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Health Related Quality of Life

1. Would you say that, in general, your health is: 
	Excellent…………………………  5 
	Very good……………………….. 4 
	Good……………………………..  3 
	Fair……………………………….  2 
	Poor……………………………… 1 

2. During the past 30 days, how many days was your physical health, which includes physical illness and injury, not good? 
	0…………………………………... 6 
	1week or less……………………. 5 
	About 2 weeks…………………... 4 
	About 3 weeks……………………3 
	Almost every day…………………2 
	Every day………………………….1 

3. During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, school/work, or recreation? 
	0…………………………………... 6 
	1week or less……………………. 5 
	About 2 weeks……………………4 
	About 3 weeks……………………3 
	Almost every day…………………2 
	Every day………………………….1 

4. During the past 30 days, for about how many days did PAIN make it hard for you to do your usual activities, such as self-care, school/work, or recreation? 
	0…………………………………... 6 
	1week or less……………………. 5 
	About 2 weeks…………………... 4 
	About 3 weeks……………………3 
	Almost every day…………………2 
	Every day………………………… 1 

5. During the past 30 days, for about how many days have you felt VERY HEALTHY AND FULL OF ENERGY? 
	0…………………………………... 6 
	1week or less……………………. 5 
	About 2 weeks…………………... 4 
	About 3 weeks……………………3 
	Almost every day…………………2 
	Every day………………………… 1 

Source: Center for Disease Control