Forms SF-12 Patient Questionnaire

Consultation Questionnaire SF-12

Questionnaire to keep track of how you feel and how well you are able to do you usual activities

The SF-12 form is to be completed by all our patients scheduled for surgery. It quantifies the effects of your pain on your psyche related to general activities of daily life. We will ask you to complete this after surgery at intervals as part of your followup. Thank You.

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Name *

First

Last

Date of Birth

Today's date

SF-12®: This information will help your doctors keep track of how you feel and how well you are able to do your usual activities. Answer every question by clicking the star indicating the appropriate answer. It is not specific for arthritis. If you are unsure about how to answer a question, please give the best answer you feel is applicable.

1. In general, would you say your health is:

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.Excellent 2.Very Good 3.Good 4.Fair 5.Poor

The following two questions are about activities you might do during a typical day. Does YOUR HEALTH NOW LIMIT YOU in these activities? If so, how much?

2. MODERATE ACTIVITIES, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf:

Rate 1 out of 3Rate 2 out of 3Rate 3 out of 3

1.Yes, Limited a Lot 2.Yes, Limited A Little 3.No, Not Limited At All

3. CLIMBING SEVERAL FLIGHTS OF STAIRS:

Rate 1 out of 3Rate 2 out of 3Rate 3 out of 3

1.Yes, Limited a Lot 2.Yes, Limited A Little 3.No, Not Limited At All

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?

4. ACCOMPLISHED LESS than you would like:

Rate 1 out of 2Rate 2 out of 2

1.Yes 2.No

5. Were limited in the KIND of work or other activities:

Rate 1 out of 2Rate 2 out of 2

1.Yes 2.No

During the PAST 4 WEEKS, were you limited in the kind of work you do or other regular activities AS A RESULT OF ANY EMOTIONAL PROBLEMS (such as feeling depressed or anxious)?

6. ACCOMPLISHED LESS than you would like:

Rate 1 out of 2Rate 2 out of 2

1.Yes 2.No

7. Didn’t do work or other activities as CAREFULLY as usual:

Rate 1 out of 2Rate 2 out of 2

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)?

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.Not at all 2.A little bit 3.Moderately 4.Quite a bit 5.Extremely

The next three questions are about how you feel and how things have been 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 –

9. Have you felt calm and peaceful?

Rate 1 out of 6Rate 2 out of 6Rate 3 out of 6Rate 4 out of 6Rate 5 out of 6Rate 6 out of 6

1.All of the time 2.Most of the time 3.A good bit of the time 4.Some of the time 5.A little of the time 6.None of the time

10. Did you have a lot of energy?

Rate 1 out of 6Rate 2 out of 6Rate 3 out of 6Rate 4 out of 6Rate 5 out of 6Rate 6 out of 6

1.All of the time 2.Most of the time 3.A good bit of the time 4.Some of the time 5.A little of the time 6.None of the time

11. Have you felt downhearted and blue?

Rate 1 out of 6Rate 2 out of 6Rate 3 out of 6Rate 4 out of 6Rate 5 out of 6Rate 6 out of 6

1.All of the time 2.Most of the time 3.A good bit of the time 4.Some of the time 5.A little of the time 6.None of the time

12. During the PAST 4 WEEKS, how much of the time has your PHYSICAL HEALTH OR EMOTIONAL PROBLEMS interfered with your social activities (like visiting with friends, relatives, etc.)?

Rate 1 out of 6Rate 2 out of 6Rate 3 out of 6Rate 4 out of 6Rate 5 out of 6Rate 6 out of 6

1.All of the time 2.Most of the time 3.A good bit of the time 4.Some of the time 5.A little of the time 6.None of the time

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Forms SF-12 Patient Questionnaire

Consultation Questionnaire SF-12

Questionnaire to keep track of how you feel and how well you are able to do you usual activities

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