Elbow Patient History Form Page 8
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S F-12
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C heck
O NLY
O NE
a nswer
f or
e ach
q uestion
Instructions: This survey asks for your views about your health. This information
will help keep track of how you feel and how well you are able to do your usual
activities. Please answer every question by marking one box. If you are unsure
about how to answer, please give the best answer you can.
1. In general, would you say your health is:
1 Excellent
2 Very good
3 Good
4 Fair
5 Poor
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?
Yes, Limited
Yes, Limited
No, Not
A Lot
A Little
Limited At
All
2. Moderate activities, such as moving a table,
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3
pushing a vacuum cleaner, bowling,
or playing golf
3. Climbing several flights of stairs
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3
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?
4. Accomplished less than you would like
1-Yes
2-No
5. Were limited in the kind of work or other activities
1-Yes
2-No
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)?
6. Accomplished less than you would like
1-Yes
2-No
7. Didn't do work or perform other activities
as carefully as usual
1-Yes
2-No
8. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside
the home and housework)?
1--Not at all
2--A little bit
3--Moderately
4--Quite a bit
5—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.
All of
Most of
A good
Some
A Little
None
the
the
bit of the
of the
of the
of the
time
time
time
time
time
time
9. Have you felt calm and peaceful?
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10. Did you have a lot of energy?
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11. Have you felt downhearted and blue?
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12. During the past 4 weeks, how much
of the time has your physical or emotional
problems interfered with your social activities
(like visiting with friends, relatives, etc)?
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Parent category: Medical