MIND - Self Report Scales
(to be completed by a trained clinician)

       DATE:           TIME (24hr): 

Name: SSN: Age: Date of birth Sex Date Completed ______________________ ___________________ _______ ___/___/_____ M F ___/___/____

Instructions:
• In order to make your health evaluation more complete, please take the time to complete this questionnaire carefully and accurately.
• We realize some questions may seem repetitive, but they help us to give a thorough evaluation.

Section C: Health Functioning and Quality of Life

VR-36

C.1. In general, would you say your health is: Excellent Very Good Good Fair Poor

C.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?

A. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports B. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf C. Lifting or carrying groceries D. Climbing several flights of stairs E. Climbing one flight of stairs F. Bending, kneeling, or stooping G. Walking more than a mile H. Walking several blocks I. Walking one block J. Bathing or dressing yourself

C3. During the past 4 weeks, have you had any of the following problems with your work or other regular daily physical activities as a result of your physical health? A. Cut down the amount of time you spent on work or other activities B. Accomplished less than you would like C. Were limited in the kind of work or other activities. D. Had difficulty performing the work or other activities (for example, it took extra effort)

C.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)? A. Cut down the amount of time you spent on work or other activities B. Accomplished less than you would like C. Didn’t do work or other activities as carefully as usual

C.5. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with families, friends, neighbors, or groups? Not at all Slightly Moderately Quite a bit Extremely

C.6. How much bodily pain have you had during the past 4 weeks? None Very mild Mild Moderate Severe Very severe

C.7. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and house work)? Not at all Slightly Moderately Quite a bit Extremely

C.8 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: A. Did you feel full of pep? B. Have you been a very nervous person? C. Have you felt so down in the dumps that nothing could cheer you up? D. Have you felt calm and peaceful? E. Did you have a lot of energy? F. Have you felt downhearted and blue? G. Did you feel worn out? H. Have you been a happy person? I. Did you feel tired?

C.9. During the past 4 weeks, how much of the time have your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? All of the time Most of the time Some of the time A little of the time None of the time

C.10. Please choose the answer that best describes how true or false each of the following statements is for you.

A. I seem to get sick a little easier than other people B. I am as healthy as anybody I know C. I expect my health to get worse D. My health is excellent

C.11. Now, we would like to ask you some questions about how your health may have changed. Compared to one year ago:

A. How would you rate your health in general now? B. How would you rate your physical health in general now? C. How would you rate your emotional problems now? (such as feeling anxious, depressed or irritable)

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          Last update:  12/23/2010