1. How do you feel in general?

2. What is the most prominent health concern?

3. Do you take any medications? If yes: Do you remember to take your medications at
the times prescribed?

4. How do they make you feel?

5. Do you make your own food? - If yes: do you try to eat 3 meals a day at least? - If no,
why?

6. Do you do any chores?

7. What do you do in your free time?

8. Would you engage in an activity that involves you using technology?

9. Would you mind participating in an activity with other adults?

 10. Would you rather have planned activities that you are on schedule to go to or activities
that are more lenient to participation

11. Do you feel it is possible to continue learning something new everyday?

12. What joys ,if any, do you still find in life?

13. Do you remember where you put specific items like your favorite shoes or keys to
your room.

14. Do you replace items in the same spot where you removed them from

GENERAL QUESTIONS

1. Year of birth

2. Gender Male Female

3. What ethnic group or racial group do you belong to or identify with the most?
White (not of Hispanic origin) Black (not of Hispanic origin) Hispanic
Asian or Pacific Islander Native American or American Indian, or Some other group:
Please specify Dont know
4. Marital status never married married widowed divorced

5. What is the highest level of schooling that you have completed?

0 to 8 years 9 to 12 years, no diploma high school graduate or GED

associates degree, Technical degree or some college College graduate

Graduate degree (Masters, PH. D., J. D., M.B.A.) Dont know Not applicable

<SF-12v1>
This survey asks for your views about your physical & mental health and your ability to
do your usual activities. Thank you for completing this survey!

For each of the following questions, please mark a check in the box that best describes your
answer.
1. In general, would you say your health is:
1 Excellent 2 Very good 3 Good 4 Fair 5 Poor

2. The following questions are about activities you might do during a typical day. Does your
health now limit you in these activities? If so, how much?
Yes, Yes, No,
limited a limited not
lot a little limited
at all

a. Moderate activities, such as moving a table,

pushing a vacuum cleaner, bowling, or playing
golf .. 1 2 3

b. Climbing several flights of stairs . 1 2 3

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?
Yes No

a. Accomplished less than you would like.. 1 2

b. Were limited in the kind of work or other activities.. 1 2

4. 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)?
Yes No

a. Accomplished less than you would like .. 1 2

b. Did work or other activities less carefully than

usual 1 2

5. During the past 4 weeks, how much did pain interfere with your normal work (including
both work outside the home and housework)?
Not at all A little bit Moderately Quite a bit Extremely

1 2 3 4 5

6. 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 of A little None of
the time the time bit of the the time of the the time
time time

a. Have you felt calm

and
peaceful?............ 1 2 3 4 5 6

b. Did you have a lot

of
energy?................. 1 2 3 4 5 6

c. Have you felt

downhearted &
blue? 1 2 3 4 5 6

7. 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.)?
All of the time Most of the Some of the A little of the None of the
time time time time

1 2 3 4 5

<SEBC>

Circle one number among 5 statements**

1. I currently exercise regularly and have been doing so for more than 6 months.
2. I currently exercise regularly but have begun doing so in the last 6 months.
3. I currently exercise a little but not regularly.
4. I currently do not exercise but I am thinking about starting in the next 6 months.
5. I currently do not exercise and do not intent to start in the next 6 months.