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| # | Location | File | Last Modified |
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| 1 | HTRE_P3_v14.5_iter_4_build_14.zip\webapp\docs | VR-12SurveyV1.doc | Wed May 29 15:26:14 2019 UTC |
| 2 | HTRE_P3_v14.5_iter_4_build_14.zip\webapp\docs | VR-12SurveyV1.doc | Tue Jun 11 11:53:13 2019 UTC |
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| 1 | VETERANS RAND SF-12 (VR-12) Survey
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| 2 | “We would like to a sk you a f ew general questions on how we ll you are getting a long. We w ould great ly appreci ate your t aking a fe w minutes to answer these twel ve questio ns. | |
| 3 | Questionna ire Conten t | |
| 4 | 1. In gene ral, would you say y our health is: | |
| 5 | Excellent (1) | |
| 6 | Very Good (2) | |
| 7 | Good (3) | |
| 8 | Fair (4) | |
| 9 | Poor (5) | |
| 10 | The follow ing two qu estions ar e about ac tivities y ou might d o during a typical d ay. Does y our health now limit you in th ese activi ties? If s o, how muc h? | |
| 11 | 2. Moderat e activiti es, such a s moving a table, pu shing a va cuum clean er, bowlin g, or play ing golf? | |
| 12 | Yes, Limit ed A Lot ( 1) | |
| 13 | Yes, Limit ed A Littl e (2) | |
| 14 | No, Not Li mited At A ll (3) | |
| 15 | 3. Climbin g several flights of stairs? | |
| 16 | Yes, Limit ed A Lot ( 1) | |
| 17 | Yes, Limit ed A Littl e (2) | |
| 18 | No, Not Li mited At A ll (3) | |
| 19 | During the past 4 we eks, have you had an y of the f ollowing p roblems wi th your wo rk or othe r regular daily acti vities as a result o f your phy sical heal th? | |
| 20 | 4. Accompl ished less than you would like | |
| 21 | No, none o f the time (1) | |
| 22 | Yes, a lit tle of the time (2) | |
| 23 | Yes, some of the tim e (3) | |
| 24 | Yes, most of the tim e (4) | |
| 25 | Yes, all o f the time (5) | |
| 26 | 5. Were li mited in t he kind of work or o ther activ ities | |
| 27 | No, none o f the time (1) | |
| 28 | Yes, a lit tle of the time (2) | |
| 29 | Yes, some of the tim e (3) | |
| 30 | Yes, most of the tim e (4) | |
| 31 | Yes, all o f the time (5) | |
| 32 | During the past 4 we eks, have you had an y of the f ollowing p roblems wi th your wo rk or othe r regular daily acti vities as a result o f any emot ional prob lems (such as feelin g depresse d or anxio us)? | |
| 33 | 6. Accompl ished less than you would like | |
| 34 | No, none o f the time (5) | |
| 35 | Yes, a lit tle of the time (4) | |
| 36 | Yes, some of the tim e (3) | |
| 37 | Yes, most of the tim e (2) | |
| 38 | Yes, all o f the time (1) | |
| 39 | 7. Didn’t do work or other act ivities as carefully as usual | |
| 40 | No, none o f the time (5) | |
| 41 | Yes, a lit tle of the time (4) | |
| 42 | Yes, some of the tim e (3) | |
| 43 | Yes, most of the tim e (2) | |
| 44 | Yes, all o f the time (1) | |
| 45 | 8. During the past 4 weeks, ho w much did pain inte rfere with your norm al work (i ncluding b oth work o utside the home and housework) ? | |
| 46 | Not at all (1) | |
| 47 | A little b it (2) | |
| 48 | Moderately (3) | |
| 49 | Quite a bi t (4) | |
| 50 | Extremely (5) | |
| 51 | These thre e question s are abou t how you feel and h ow things have been with you d uring the past 4 wee ks. For ea ch questio n, please give the o ne answer that comes closest t o the way you have b een feelin g. | |
| 52 | How much o f the time during th e past 4 w eeks: | |
| 53 | 9. Have yo u felt cal m and peac eful? | |
| 54 | All of the time (6) | |
| 55 | A good bit of the ti me (5) | |
| 56 | A little o f the time (4) | |
| 57 | Most of th e time (3) | |
| 58 | Some of th e time (2) | |
| 59 | None of th e time (1) | |
| 60 | 10. Did yo u have a l ot of ener gy? | |
| 61 | All of the time (1) | |
| 62 | A good bit of the ti me (2) | |
| 63 | A little o f the time 34) | |
| 64 | Most of th e time (4) | |
| 65 | Some of th e time (5) | |
| 66 | None of th e time (6) | |
| 67 | 11. How m uch of the time duri ng the pas t 4 weeks: have you felt downh earted and blue? | |
| 68 | All of the time (6) | |
| 69 | Most of th e time (5) | |
| 70 | A good bit of the ti me (4) | |
| 71 | Some of th e time (3) | |
| 72 | A little o f the time (2) | |
| 73 | None of th e time (1) | |
| 74 | 12. During the past 4 weeks, h ow much of the time has your p hysical he alth or em otional pr oblems int erfered wi th your so cial activ ities (lik e visiting with frie nds, relat ives, etc. ) | |
| 75 | All of the time (1) | |
| 76 | Most of th e time (2) | |
| 77 | Some of th e time (3) | |
| 78 | A little o f the time (4) | |
| 79 | None of th e time (5) |
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