生活质量评价量表SF-36(short form 36 questionnaire)[复制]

* 1、时间Time

2、Name:

3、Age:

4、MR #:

* 5、 总体来讲,您的健康状况是？In general, would you say your health is:
Response Type: Select one answer

* 6、跟1年以前比您觉得自己的健康状况是？Compared to one year ago, how would you rate
your health in general now?
Response Type: Select one answer

* 7、重体力活动。如跑步举重、参加剧烈运动等Do you engage in heavy physical activities, such as running weight lifting, strenuous exercise?

* 8、适度的活动。如移动一张桌子、扫地、打太极拳、做简单体操等:Do you engage in moderate activities, such as moving a table, sweeping, Tai Chi, doing simple gymnastics, etc?

* 9、手提日用品。如买菜、购物等:Do you engage in any simple daily life activity, such as grocery shopping, shopping, etc?

* 10、上几层楼梯:Up a few stairs:

* 11、上一层楼梯:Up one stair:

* 12、弯腰、屈膝、下蹲:Stoop, squat, bend:

* 13、步行1500米以上的路程:Walk 1500 meters above the distance:

* 14、步行1000米的路程:Walk 1000 meters:

* 15、步行100米的路程:Walk 100 meters:

* 16、自己洗澡、穿衣:Bathe and dress:

* 17、减少了工作或其他活动时间:(权重或得分依次为1,2;下同)Reduced the work or other activity time: (weight or score is 1,2; similarly hereinafter)

* 18、本来想要做的事情只能完成一部分:What you want to do can only be done:

* 19、想要干的工作或活动种类受到限制:The type of work or activity you want to do is limited:

* 20、完成工作或其他活动困难增多(比如需要额外的努力):Difficulty in completing work or other activities (such as extra effort):

* 21、减少了工作或活动时间:(权重或得分依次为1,2;下同)Reduced work or activity time: (weight or score is 1,2; the same below)

* 22、本来想要做的事情只能完成一部分:What you want to do can only complete part:

* 23、干事情不如平时仔细:Things are not as good as usual:

* 24、在过去4个星期里,您的健康或情绪不好在多大程度上影响了您与家人、朋友、邻居或集体的正常社会交往?(权重或得分依次为5,4,3,2,1)Over the past 4 weeks, how much of your health or emotional distress has affected your normal social interactions with family, friends, neighbors, or groups (weight or score in turn is 5,4,3,2,1)

* 25、在过去4个星期里,您有身体疼痛吗?(权重或得分依次为6,5.4,4.2,3.1,2.2,1)Have you had any physical pain in the past 4 weeks (weight or score in turn 6,5.4,4.2,3.1,2.2,1)

* 26、在过去4个星期里,您的身体疼痛影响了您的工作和家务吗?(如果25无26无,权重或得分依次为6,4.75,3.5,2.25,1.0;如果为25有26无,则为5,4,3,2,1)In the past 4 weeks, your physical pain has affected your work and household chores (if there is no 26 No, weight or score in turn is 6,4.75,3.5,2.25,1.0; if there are no more than 25 for the, then 5,4,3,2,1)

* 27、您觉得生活充实:(权重或得分依次为6,5,4,3,2,1)You feel full of life: (weight or score in turn 6,5,4,3,2,1)

* 28、您是一个敏感的人:(权重或得分依次为1,2,3,4,5,6)You are a sensitive person: (weight or score is 1,2,3,4,5,6)

* 29、您的情绪非常不好,什么事都不能使您高兴起来:(权重或得分依次为1,2,3,4,5,6)Your mood is very bad, nothing can make you happy: (weight or score is 1,2,3,4,5,6)

* 30、您的心理很平静:(权重或得分依次为6,5,4,3,2,1)Your mind is very calm: (weight or score order 6,5,4,3,2,1)

* 31、您做事精力充沛:(权重或得分依次为6,5,4,3,2,1)You are energetic: (weight or score in turn 6,5,4,3,2,1)

* 32、您的情绪低落:(权重或得分依次为1,2,3,4,5,6)Your mood is low (weight or score is 1,2,3,4,5,6)

* 33、您觉得筋疲力尽:(权重或得分依次为1,2,3,4,5,6)You feel exhausted: (weight or score is 1,2,3,4,5,6)

* 34、您是个快乐的人:(权重或得分依次为6,5,4,3,2,1)You are a happy person: (weight or score is 6,5,4,3,2,1)

* 35、您感觉厌烦:(权重或得分依次为1,2,3,4,5,6)You feel bored: (weight or score is 1,2,3,4,5,6)

* 36、不健康影响了您的社会活动(如走亲访友):(权重或得分依次为1,2,3,4,5)Don't influence your health and social activities (such as zouqingfangyou): (weight or score: 1,2,3,4,5)

* 37、我好象比别人容易生病:(权重或得分依次为1,2,3,4,5)I seem to be more vulnerable than others: (weight or score in turn 1,2,3,4,5)

* 38、我跟周围人一样健康:(权重或得分依次为5,4,3,2,1)I am as healthy as the people around me: (weight or score is 5,4,3,2,1)

* 39、我认为我的健康状况在变坏:(权重或得分依次为1,2,3,4,5)I think my health is getting worse: (1,2,3,4,5)

* 40、我的健康状况非常好:(权重或得分依次为5,4,3,2,1)My health is very good: (weight or score is 5,4,3,2,1)