4. During the past 4 weeks , have you had any of the following problems with your work or other regular activities as a result of your physical health (circle the appropriate number for each question)?
Yes
No
▪ Cut down on the amount of time you spent on work or other activities.
1 1 1
2 2 2
▪ Accomplished less than you would like.
▪ Were limited in the kind of work or other activities.
▪ Had difficulty performing the work or other activities (for example, requiring an extra effort)? 5. During the past four weeks , have you had any of the following problems with your work or other regular daily activities as result of any emotional problems (such as feeling depressed or anxious) (circle the appropriate number for each question)?
1
2
Yes
No
▪ Cut down on the amount of time you spent on work or other activities.
1
2
▪ Accomplished less than you would like.
1
2
▪ Didn’t do work or other activities as carefully as usual.
1
2
6. During the past 4 weeks , to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors or groups (circle one)?
1 - Not at all 2 - Slightly 3 - Moderately 4 - Quite a bit 5 - Extremely 1 - None 2 - Very mild 3 - Mild 4 - Moderate 5 - Severe 6 - Very severe 1 - Not at all 2 - A little bit 3 - Moderately 4 - Quite a bit 5 - Extremely
7. How much bodily pain have you had during the past 4 weeks (circle one)?
8. During the past 4 weeks , how much did pain interfere with your normal work (including both work outside the home and housework) (circle one)?
9. 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 (circle one number on each line): 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
▪ Did you feel full of pep?
1
2
3
4
5
6
▪ Have you been a very nervous person? ▪ Have you felt so down in the dumps that nothing could cheer you up? ▪ Have you felt calm and peaceful? ▪ Did you have a lot of energy? ▪ Have you felt downhearted and blue?
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
▪ Did you feel worn out?
1
2
3
4
5
6
▪ Have you been a happy person?
1
2
3
4
5
6
▪ Did you feel tired?
1
2
3
4
5
6
10. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives etc.) (circle one)?
1 - All of the time. 2 - Most of the time. 3 - Some of the time. 4 - A little of the time. 5 - None of the time.
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EliteLearning.com/Physical-Therapy
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