RAND Health Survey Form

RAND Health Survey
Choose one option for each questionnaire item.
1 - Excellent2 - Very good3 - Good4 - Fair5 - Poor
1 - Much better now than one year ago2 - Somewhat better now than one year ago3 - About the same4 - Somewhat worse now than one year ago5 - Much worse now than one year ago
The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

Rows	Yes, limited a lot	Yes, limited a little	No, not limited at all
3. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports
4. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
5. Lifting or carrying groceries
6. Climbing several flights of stairs
7. Climbing one flight of stairs
8. Bending, kneeling, or stooping
9. Walking more than a mile
10. Walking several blocks
11. Walking one block
12. Bathing or dressing yourself

During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

Rows	Yes	No
13. Cut down the amount of time you spent on work or other activities
14. Accomplished less than you would like
15. Were limited in the kind of work or other activities
16. Had difficulty performing the work or other activities (for example, it took extra effort)

During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?

Rows	Yes	No
17. Cut down the amount of time you spent on work or other activities
18. Accomplished less than you would like
19. Didn't do work or other activities as carefully as usual

1 - Not at all2 - Slightly3 - Moderately4 - Quite a bit5 - Extremely
1 - None2 - Very mild3 - Mild4 - Moderate5 - Severe6 - Very severe
1 - Not at all2 - A little bit3 - Moderately4 - Quite a bit5 - Extremely

These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks...*

Rows	All of the time	Most of the time	A good bit of the time	Some of the time	A little of the time	None of the time
23. Did you feel full of pep?
24. Have you been a very nervous person?
25. Have you felt so down in the dumps that nothing could cheer you up?
26. Have you felt calm and peaceful?
27. Did you have a lot of energy?
28. Have you felt downhearted and blue?
29. Did you feel worn out?
30. Have you been a happy person?
31. Did you feel tired?

1 - All of the time2 - Most of the time3 - Some of the time4 - A little of the time5 - None of the time

How TRUE or FALSE is each of the following statements for you.*

Rows	Definitely true	Mostly true	Don't know	Mostly false	Definitely false
33. I seem to get sick a little easier than other people
34. I am as healthy as anybody I know
35. I expect my health to get worse
36. My health is excellent

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RAND Health Survey

Choose one option for each questionnaire item.

The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?