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Hello:
You are invited to participate in our Pain Research survey. In this survey, approximately 10 people will be asked to complete a survey that asks questions about the pain they experience and how much they would value pain relief. It will take approximately 15 minutes to complete this questionnaire.
Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. It is very important for us to learn your opinions.
Your survey responses will be strictly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. If you have questions at any time about the survey or the procedures, you may contact Anne Marciniak at 07956563896 or by email at the email address specified below.
Thank you very much for your time and support. Please start with the survey now by clicking on the Continue button below.
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| How would you describe your practice of sports? |
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| Have you experienced pain over the past 4 weeks? |
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| What is the origin of the pain you have experienced during the past 4 weeks? (if you have several pains please answer for the most intense) |
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| Have you experienced physical pain in the past (before the currrent pain)? |
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| Thinking about the most painful of the past pain episodes, how was the pain compared to your current pain? |
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The Medical Outcomes Study Pain Measures
The following questions are about the pain or pains you experienced in the past 4 weeks. If you had more than one pain, answer the questions by describing your feelings of pain in general. |
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| 1. How much bodily pain have you generally had during the past 4 weeks? |
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| 2. During the past 4 weeks, how often have you had pain or discomfort? |
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| 3. When you had pain during the past 4 weeks, how long did it usually last? |
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| 4. During the past 4 weeks, how much did pain interfere with the following things?
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| 5. During the past 4 weeks, how many days did pain interfere with the things you usually do? (your answer may range from 0 to 28 days) WRITE IN # OF DAYS | | |
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6. Please select the one number that best describes your pain on the average over the past 4 weeks.
0= No Pain
20= Pain As Bad As You Can Imagine |
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7. Please select the one number that best describes your pain at its worst over the past 4 weeks.
0= No Pain
20= Pain As Bad As You Can Imagine |
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| From Stewart AL, Ware JE Jr. Measuring functioning and well-being: the Medical Outcomes Study approach. Durham, North Carolina: Duke University Press, 1992:374,378-379. |
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Short-Form McGill Pain Questionnaire (SF-MPQ) UK English version
Copyright R. Melzack, 1984, 1987
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| A. PLEASE DESCRIBE YOUR PAIN DURING THE LAST 7 DAYS
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| B. RATE YOUR PAIN DURING THE PAST 7 DAYS |
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| Please enter a number between 0 (No pain) and 100 (Worst possible pain) | | |
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| B. PRESENT PAIN INTENSITY |
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What is the average level of pain you experience during training?
0= No pain
10= Pain as bad as you can imagine |
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| Trading time to get rid of pain |
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PLEASE READ THESE INSTRUCTIONS CAREFULLY
In many of the following questions you will be asked to imagine that you have pain rated on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine. Most people would describe mild pain as being between 1-3, moderate pain (for example a headache) 4-6, severe pain (for example a toothache or an acute fracture) above 7.
The following exercise uses a technique known as time trade-off to ascertain the value in years of life that you place on being pain free. In the following four questions you will be asked to imagine that you have 20 years left to live and for those 20 years you will constantly be in a particular level of pain. You will be asked how many years of excellent health free of pain or ailments are equivalent to 20 years in pain.
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| If you had 20 years to live in constant pain as intense as you experienced during your training, how many years in excellent health without the pain is the equivalent? | | |
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| If you had 20 years to live in constant pain half as intense as you experienced during your training, how many years in excellent health without the pain is the equivalent? | | |
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If you had 20 years to live in constant pain of level 4 on a 0-10 pain scale where 0 is no pain and 10 is pain as bad as you can imagine, how many years in excellent health without the pain is the equivalent?
Years without the pain |
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| If you had 20 years to live constantly with a pain of level 7 on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine, how many years would you rather live WITHOUT the pain? | | |
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If you had 20 years to live in constant pain of level 2 on a 0-10 pain scale where 0 is no pain and 10 is pain as bad as you can imagine, how many years in excellent health without the pain is the equivalent?
Year without the pain |
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| Willingness to pay to get rid of Pain |
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Again in many of the following questions you will be asked to imagine that you have pain rated on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine. Most people would describe mild pain as being between 1-3, moderate pain (for example a headache) 4-6, severe pain (for example a toothache or an acute fracture) above 7.
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PLEASE READ HYPOTHETICAL SCENARIO 1 BELOW
Lets imagine.
You are in a pain of level 4 on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine. The pain will last continuously for one year. The pain is caused by a condition which is not life threatening. There is no cure for the condition but there is a ‘magic pill’ that suppresses the pain immediately and has no side effects.
If you are an athlete, you may be interested to know that this pill is legal for athletes and will have no consequences on your training (you will not be able to train harder) and performance. It will only work on your pain.
It is available without a prescription but you need to pay for it yourself. You take it once a month and its effects last one month exactly.
What is the maximum amount that you would you be willing to pay for such a pill every month? |
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PLEASE READ HYPOTHETICAL SCENARIO 2 BELOW
Lets imagine.
You are in a pain of level 4 on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine. The pain will last continuously for one year. The pain is caused by a condition which is not life threatening. There is no cure for the condition but there is a ‘magic pill’ that decreases the pain immediately to half of what it was. The pill has no side effects.
If you are an athlete, you may be interested to know that this pill is legal for athletes and will have no consequences on your training (you will not be able to train harder) and performance. It will only work on your pain.
It is available without a prescription but you need to pay for it yourself. You take it once a month and its effects last one month exactly.
What is the maximum amount that you would you be willing to pay for such a pill every month? |
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PLEASE READ HYPOTHETICAL SCENARIO 3 BELOW
Lets imagine.
You are in a pain of level 7 on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine. The pain will last continuously for one year. The pain is caused by a condition which is not life threatening. There is no cure for the condition but there is a ‘magic pill’ that suppresses the pain immediately and has no side effects.
If you are an athlete, you may be interested to know that this pill is legal for athletes and will have no consequences on your training (you will not be able to train harder) and performance. It will only work on your pain.
It is available without a prescription but you need to pay for it yourself. You take it once a month and its effects last one month exactly.
What is the maximum amount that you would you be willing to pay for such a pill every month? |
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PLEASE READ HYPOTHETICAL SCENARIO 4 BELOW
Lets imagine.
You are in a pain of level 7 on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine. The pain will last continuously for one year. The pain is caused by a condition which is not life threatening. There is no cure for the condition but there is a ‘magic pill’ that decreases the pain immediately to half of what it was. The pill has no side effects.
If you are an athlete, you may be interested to know that this pill is legal for athletes and will have no consequences on your training (you will not be able to train harder) and performance. It will only work on your pain.
It is available without a prescription but you need to pay for it yourself. You take it once a month and its effects last one month exactly.
What is the maximum amount that you would you be willing to pay for such a pill every month? |
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PLEASE READ HYPOTHETICAL SCENARIO 5 BELOW
Lets imagine.
You are in a pain of level 2 on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine. The pain will last continuously for one year. The pain is caused by a condition which is not life threatening. There is no cure for the condition but there is a ‘magic pill’ that suppresses the pain immediately and has no side effects.
If you are an athlete, you may be interested to know that this pill is legal for athletes and will have no consequences on your training (you will not be able to train harder) and performance. It will only work on your pain.
It is available without a prescription but you need to pay for it yourself. You take it once a month and its effects last one month exactly.
What is the maximum amount that you would you be willing to pay for such a pill every month? |
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PLEASE READ HYPOTHETICAL SCENARIO 6 BELOW
Lets imagine.
You are in a pain of level 2 on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine. The pain will last continuously for one year. The pain is caused by a condition which is not life threatening. There is no cure for the condition but there is a ‘magic pill’ that decreases the pain immediately to half of what it was. The pill has no side effects.
If you are an athlete, you may be interested to know that this pill is legal for athletes and will have no consequences on your training (you will not be able to train harder) and performance. It will only work on your pain.
It is available without a prescription but you need to pay for it yourself. You take it once a month and its effects last one month exactly.
What is the maximum amount that you would you be willing to pay for such a pill every month? |
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PLEASE READ HYPOTHETICAL SCENARIO 7 BELOW
Lets imagine.
You are in a pain as intense as the one you experienced during your training. However the pain will last continuously for one year. The pain is caused by a condition which is not life threatening. There is no cure for the condition but there is a ‘magic pill’ that suppresses the pain immediately and has no side effects.
If you are an athlete, you may be interested to know that this pill is legal for athletes and will have no consequences on your training (you will not be able to train harder) and performance. It will only work on your pain.
It is available without a prescription but you need to pay for it yourself. You take it once a month and its effects last one month exactly.
What is the maximum amount that you would you be willing to pay for such a pill every month? |
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PLEASE READ HYPOTHETICAL SCENARIO 8 BELOW
Lets imagine.
You are in a pain as intense as the one you experienced during your training. However the pain will last continuously for one year. The pain is caused by a condition which is not life threatening. There is no cure for the condition but there is a ‘magic pill’ that decreases the pain immediately to half of what it was. The pill has no side effects.
If you are an athlete, you may be interested to know that this pill is legal for athletes and will have no consequences on your training (you will not be able to train harder) and performance. It will only work on your pain.
It is available without a prescription but you need to pay for it yourself. You take it once a month and its effects last one month exactly.
What is the maximum amount that you would you be willing to pay for such a pill every month? |
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| Trading time to get rid of pain |
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PLEASE READ THESE INSTRUCTIONS CAREFULLY
In many of the following questions you will be asked to imagine that you have pain rated on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine. Most people would describe mild pain as being between 1-3, moderate pain (for example a headache) 4-6, severe pain (for example a toothache or an acute fracture) above 7.
The following exercise uses a technique known as time trade-off to ascertain the value in years of life that you place on being pain free. In the following four questions you will be asked to imagine that you have 20 years left to live and for those 20 years you will constantly be in a particular level of pain. You will be asked how many years of excellent health free of pain or ailments are equivalent to 20 years in pain.
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| If you had 20 years to live in constant pain as intense as the pain you have experienced during the past 4 weeks, how many years in excellent health without the pain is the equivalent? | | |
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| If you had 20 years to live in constant pain half as intense as the pain you have experienced during the past 4 weeks, how many years in excellent health without the pain is the equivalent? | | |
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If you had 20 years to live in constant pain of level 4 on a 0-10 pain scale where 0 is no pain and 10 is pain as bad as you can imagine, how many years in excellent health without the pain is the equivalent?
Years without the pain |
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| If you had 20 years to live constantly with a pain of level 7 on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine, how many years would you rather live WITHOUT the pain? | | |
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If you had 20 years to live in constant pain of level 2 on a 0-10 pain scale where 0 is no pain and 10 is pain as bad as you can imagine, how many years in excellent health without the pain is the equivalent?
Year without the pain |
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| Willingness to pay to get rid of Pain |
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Again in many of the following questions you will be asked to imagine that you have pain rated on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine. Most people would describe mild pain as being between 1-3, moderate pain (for example a headache) 4-6, severe pain (for example a toothache or an acute fracture) above 7.
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PLEASE READ HYPOTHETICAL SCENARIO 1 BELOW
Lets imagine.
You are in a pain of level 4 on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine. The pain will last continuously for one year. The pain is caused by a condition which is not life threatening. There is no cure for the condition but there is a ‘magic pill’ that suppresses the pain immediately and has no side effects.
If you are an athlete, you may be interested to know that this pill is legal for athletes and will have no consequences on your training (you will not be able to train harder) and performance. It will only work on your pain.
It is available without a prescription but you need to pay for it yourself. You take it once a month and its effects last one month exactly.
What is the maximum amount that you would you be willing to pay for such a pill every month? |
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PLEASE READ HYPOTHETICAL SCENARIO 2 BELOW
Lets imagine.
You are in a pain of level 4 on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine. The pain will last continuously for one year. The pain is caused by a condition which is not life threatening. There is no cure for the condition but there is a ‘magic pill’ that decreases the pain immediately to half of what it was. The pill has no side effects.
If you are an athlete, you may be interested to know that this pill is legal for athletes and will have no consequences on your training (you will not be able to train harder) and performance. It will only work on your pain.
It is available without a prescription but you need to pay for it yourself. You take it once a month and its effects last one month exactly.
What is the maximum amount that you would you be willing to pay for such a pill every month? |
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PLEASE READ HYPOTHETICAL SCENARIO 3 BELOW
Lets imagine.
You are in a pain of level 7 on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine. The pain will last continuously for one year. The pain is caused by a condition which is not life threatening. There is no cure for the condition but there is a ‘magic pill’ that suppresses the pain immediately and has no side effects.
If you are an athlete, you may be interested to know that this pill is legal for athletes and will have no consequences on your training (you will not be able to train harder) and performance. It will only work on your pain.
It is available without a prescription but you need to pay for it yourself. You take it once a month and its effects last one month exactly.
What is the maximum amount that you would you be willing to pay for such a pill every month? |
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PLEASE READ HYPOTHETICAL SCENARIO 4 BELOW
Lets imagine.
You are in a pain of level 7 on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine. The pain will last continuously for one year. The pain is caused by a condition which is not life threatening. There is no cure for the condition but there is a ‘magic pill’ that decreases the pain immediately to half of what it was. The pill has no side effects.
If you are an athlete, you may be interested to know that this pill is legal for athletes and will have no consequences on your training (you will not be able to train harder) and performance. It will only work on your pain.
It is available without a prescription but you need to pay for it yourself. You take it once a month and its effects last one month exactly.
What is the maximum amount that you would you be willing to pay for such a pill every month? |
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PLEASE READ HYPOTHETICAL SCENARIO 5 BELOW
Lets imagine.
You are in a pain of level 2 on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine. The pain will last continuously for one year. The pain is caused by a condition which is not life threatening. There is no cure for the condition but there is a ‘magic pill’ that suppresses the pain immediately and has no side effects.
If you are an athlete, you may be interested to know that this pill is legal for athletes and will have no consequences on your training (you will not be able to train harder) and performance. It will only work on your pain.
It is available without a prescription but you need to pay for it yourself. You take it once a month and its effects last one month exactly.
What is the maximum amount that you would you be willing to pay for such a pill every month? |
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PLEASE READ HYPOTHETICAL SCENARIO 6 BELOW
Lets imagine.
You are in a pain of level 2 on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine. The pain will last continuously for one year. The pain is caused by a condition which is not life threatening. There is no cure for the condition but there is a ‘magic pill’ that decreases the pain immediately to half of what it was. The pill has no side effects.
If you are an athlete, you may be interested to know that this pill is legal for athletes and will have no consequences on your training (you will not be able to train harder) and performance. It will only work on your pain.
It is available without a prescription but you need to pay for it yourself. You take it once a month and its effects last one month exactly.
What is the maximum amount that you would you be willing to pay for such a pill every month? |
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PLEASE READ HYPOTHETICAL SCENARIO 7 BELOW
Lets imagine.
You are in a pain as intense as the pain you have experienced during the past 4 weeks. However the pain will last continuously for one year. The pain is caused by a condition which is not life threatening. There is no cure for the condition but there is a ‘magic pill’ that suppresses the pain immediately and has no side effects.
If you are an athlete, you may be interested to know that this pill is legal for athletes and will have no consequences on your training (you will not be able to train harder) and performance. It will only work on your pain.
It is available without a prescription but you need to pay for it yourself. You take it once a month and its effects last one month exactly.
What is the maximum amount that you would you be willing to pay for such a pill every month? |
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PLEASE READ HYPOTHETICAL SCENARIO 8 BELOW
Lets imagine.
You are in a pain as intense as the one you have experienced during the past 4 weeks. However the pain will last continuously for one year. The pain is caused by a condition which is not life threatening. There is no cure for the condition but there is a ‘magic pill’ that decreases the pain immediately to half of what it was. The pill has no side effects.
If you are an athlete, you may be interested to know that this pill is legal for athletes and will have no consequences on your training (you will not be able to train harder) and performance. It will only work on your pain.
It is available without a prescription but you need to pay for it yourself. You take it once a month and its effects last one month exactly.
What is the maximum amount that you would you be willing to pay for such a pill every month? |
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| Have you experienced physical pain in the past? |
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| Trading time to get rid of pain |
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PLEASE READ THESE INSTRUCTIONS CAREFULLY
In many of the following questions you will be asked to imagine that you have pain rated on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine. Most people would describe mild pain as being between 1-3, moderate pain (for example a headache) 4-6, severe pain (for example a toothache or an acute fracture) above 7.
The following exercise uses a technique known as time trade-off to ascertain the value in years of life that you place on being pain free. In the following four questions you will be asked to imagine that you have 20 years left to live and for those 20 years you will constantly be in a particular level of pain. You will be asked how many years of excellent health free of pain or ailments are equivalent to 20 years in pain.
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If you had 20 years to live in constant pain of level 4 on a 0-10 pain scale where 0 is no pain and 10 is pain as bad as you can imagine, how many years in excellent health without the pain is the equivalent?
Years without the pain |
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| If you had 20 years to live constantly with a pain of level 7 on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine, how many years would you rather live WITHOUT the pain? | | |
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If you had 20 years to live in constant pain of level 2 on a 0-10 pain scale where 0 is no pain and 10 is pain as bad as you can imagine, how many years in excellent health without the pain is the equivalent?
Year without the pain |
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| Willingness to pay to get rid of Pain |
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PLEASE READ HYPOTHETICAL SCENARIO 1 BELOW
Lets imagine.
You are in a pain of level 4 on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine. The pain will last continuously for one year. The pain is caused by a condition which is not life threatening. There is no cure for the condition but there is a ‘magic pill’ that suppresses the pain immediately and has no side effects.
If you are an athlete, you may be interested to know that this pill is legal for athletes and will have no consequences on your training (you will not be able to train harder) and performance. It will only work on your pain.
It is available without a prescription but you need to pay for it yourself. You take it once a month and its effects last one month exactly.
What is the maximum amount that you would you be willing to pay for such a pill every month? |
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PLEASE READ HYPOTHETICAL SCENARIO 2 BELOW
Lets imagine.
You are in a pain of level 4 on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine. The pain will last continuously for one year. The pain is caused by a condition which is not life threatening. There is no cure for the condition but there is a ‘magic pill’ that decreases the pain immediately to half of what it was. The pill has no side effects.
If you are an athlete, you may be interested to know that this pill is legal for athletes and will have no consequences on your training (you will not be able to train harder) and performance. It will only work on your pain.
It is available without a prescription but you need to pay for it yourself. You take it once a month and its effects last one month exactly.
What is the maximum amount that you would you be willing to pay for such a pill every month? |
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PLEASE READ HYPOTHETICAL SCENARIO 3 BELOW
Lets imagine.
You are in a pain of level 7 on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine. The pain will last continuously for one year. The pain is caused by a condition which is not life threatening. There is no cure for the condition but there is a ‘magic pill’ that suppresses the pain immediately and has no side effects.
If you are an athlete, you may be interested to know that this pill is legal for athletes and will have no consequences on your training (you will not be able to train harder) and performance. It will only work on your pain.
It is available without a prescription but you need to pay for it yourself. You take it once a month and its effects last one month exactly.
What is the maximum amount that you would you be willing to pay for such a pill every month? |
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PLEASE READ HYPOTHETICAL SCENARIO 4 BELOW
Lets imagine.
You are in a pain of level 7 on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine. The pain will last continuously for one year. The pain is caused by a condition which is not life threatening. There is no cure for the condition but there is a ‘magic pill’ that decreases the pain immediately to half of what it was. The pill has no side effects.
If you are an athlete, you may be interested to know that this pill is legal for athletes and will have no consequences on your training (you will not be able to train harder) and performance. It will only work on your pain.
It is available without a prescription but you need to pay for it yourself. You take it once a month and its effects last one month exactly.
What is the maximum amount that you would you be willing to pay for such a pill every month? |
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PLEASE READ HYPOTHETICAL SCENARIO 5 BELOW
Lets imagine.
You are in a pain of level 2 on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine. The pain will last continuously for one year. The pain is caused by a condition which is not life threatening. There is no cure for the condition but there is a ‘magic pill’ that suppresses the pain immediately and has no side effects.
If you are an athlete, you may be interested to know that this pill is legal for athletes and will have no consequences on your training (you will not be able to train harder) and performance. It will only work on your pain.
It is available without a prescription but you need to pay for it yourself. You take it once a month and its effects last one month exactly.
What is the maximum amount that you would you be willing to pay for such a pill every month? |
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PLEASE READ HYPOTHETICAL SCENARIO 6 BELOW
Lets imagine.
You are in a pain of level 2 on a 0-10 scale where 0 is no pain and 10 is pain as bad as you can imagine. The pain will last continuously for one year. The pain is caused by a condition which is not life threatening. There is no cure for the condition but there is a ‘magic pill’ that decreases the pain immediately to half of what it was. The pill has no side effects.
If you are an athlete, you may be interested to know that this pill is legal for athletes and will have no consequences on your training (you will not be able to train harder) and performance. It will only work on your pain.
It is available without a prescription but you need to pay for it yourself. You take it once a month and its effects last one month exactly.
What is the maximum amount that you would you be willing to pay for such a pill every month? |
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GENERAL HEALTH QUESTIONNAIRE
Please read this carefully
We should like to know if you have had any medical complaints, and how your health has been in general, over the past few weeks. Please answer ALL the questions simply by ticking the answer which you think most nearly applies to you. Remember that we want to know about present and recent complaints, not those you had in the past. It is important that you try to answer ALL questions.
Thank you very much for your co-operation. |
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| 1- been able to concentrate on whatever you're doing? |
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| 2- lost much sleep over worry? |
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| 3- felt that you are playing a useful part in things? |
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| 4- felt capable of making decisions about things? |
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| 5- felt constantly under strain? |
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| 6- felt you couldn't overcome your difficulties? |
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| 7- been able to enjoy your normal day-to-day activities? |
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| 8- been able to face up to your problems? |
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| 9- been feeling unhappy and depressed? |
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| 10- been losing confidence in yourself? |
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| 11- been thinking of yourself as a worthless person? |
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| 12- been feeling reasonably happy, all things considered? |
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Copyright David Goldberg, 1958
All rights reserved. This work may not be reproduced by any means, even within the terms of a Photocopying License, without the written permission of the publisher. Photocopying without permission may result in legal action.
Published by GL Assessment Limited
The Chiswick Centre 414 Chiswick High Road, London W4 5TF, UK
This edition published 1992.
GL Assessment is part of the Granada Learning Group Code 0090002365 3(1.08)
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THE GENERAL WELL-BEING SCHEDULE
READ: This section of the questionnaire contains questions about how you feel and how things have been going for you over the past month. For each question choose the answer which best applies to you |
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| 1. How have you been feeling in general during the past month? |
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| 2. How often were you bothered by any illness, infirmity, aches or pains during the past month? |
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| 3. Did you feel depressed during the past month? |
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| 4. Have you been in firm control of your behaviour, thoughts, emotions or feelings during the past month? |
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| 5. Have you been bothered by nervousness or your "nerves" during the past month? |
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| 6. How much energy or vitality did you have or feel during the past month? |
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| 7. I felt downhearted and low during the past month. |
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| 8. Were you generally tense or did you feel any tension during the past month? |
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| 9. How happy, satisfied or pleased have you been with your personal life during the past month? |
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| 10. Did you feel healthy enough to carry out things you like to do or had to do during the past month? |
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| 11. Have you felt so low, discouraged, hopeless, or had so many problems that you wondered if anything was worthwhile during the past month? |
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| 12. I woke up feeling fresh and rested during the past month. |
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| 13. Have you been concerned, worried, or had any fears about your health during the past month? |
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| 14. Have you had any reason to wonder if you were losing your mind, your memory or losing control over the way you act, talk, think, feel during the past month? |
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| 15. My daily life was full of things that were interesting to me during the past month. |
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| 16. Did you feel active, vigorous, or dull, sluggish during the past month? |
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Very active, vigorous every day
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Mostly active, vigorous - never really dull, sluggish
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Faily active, vigorous - seldom dull, sluggish
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Fairly dull, sluggish - seldom active, vigorous
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Mostly dull, sluggish - never really active, vigorous
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Very dull, sluggish every day
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| 17. Have you been anxious, worried or upset during the past month? |
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| 18. I was emotionally stable and sure of myself during the past month. |
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| 19. Did you feel relaxed, at ease or agitated, on edge or wound up during the past month? |
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| 20. I felt cheerful, lighthearted during the past month. |
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| 21. I felt tired, worn out, used up or exhausted during the past month. |
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| 22. Have you been under of felt you were under any strain, stress or pressure during the past month? |
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| PGWBI - UK/English - Sep 04 - Mapi Research Institute |
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SF-12v2TM Health Survey Standard version
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This survey asks for your views about your health. This information will help you keep track of how you feel and how well you are able to do your usual activiies. Thank you for completing the survey!
For easch of the following questions, please click the circle that best describes your answer. |
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| 1) In general, would you say your health is: |
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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. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf |
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| b.Climbing several flights of stairs |
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3) During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activties as a result of your physical health?
a. Accomplished less than you would like |
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| b. Were limited in the kind of work or other activities |
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4) During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular dialy activities as a result of any emotional problems (such as feelling depressed or anxious)?
a. Accomplished less than you would like |
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| b. Did work or activities less carefully than usual |
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| 5) During the past 4 weeks, how much did pain interfere with your normal activities (including both work outside the home and housework)? |
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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 come closest to the way you have been feeling. How much of the time during the past 4 weeks...
a. Have you felt calm and peaceful? |
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| b. Did you have a lot of energy? |
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| c. Have you felt downhearted and depressed? |
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| 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.)? |
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| What is your mother language? |
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| What is your ethnic origin? |
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| Where do you currently live? |
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| What is your level of monthly income? |
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| How would you describe your health today? |
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| How would you describe your health on average over the past month? |
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