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  • Publicado : 26 de septiembre de 2010
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Health Survey for Dialysis Patients (SF36)
Today’s Date:__________

Name: Last:_______________________ First: _______________ Date of Birth: __________

This survey asks for your views about your health. This information will help keep track of how you feel and how well you are able to do your usual activities.

Please answer these questions by“check-marking” your choice. Please select only one choice for each item.

1- In general, would you say your health is:
› 1. Excellent › 2. Very good › 3. Good › 4. Fair › 5. Poor

2- Compared to ONE YEAR AGO, how would you rate your health in general NOW?
› 1. MUCH BETTER than one year ago.
› 2. Somewhat BETTER now than one year ago.
› 3. About the SAME as one year ago.
› 4. SomewhatWORSE now than one year ago.
› 5. MUCH WORSE now than one year ago.

3- The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
Activities
1. Yes, Limited A Lot
2. Yes, Limited
A Little
3. No,
Not Limited At All
a) Vigorous activities, such as running, lifting heavy objects, participating instrenuous sports?
› 1. Yes, limited a lot
› 2. Yes, limited a little
› 3. No, not limited at all
b) Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf?
› 1. Yes, limited a lot
› 2. Yes, limited a little
› 3. No, not limited at all
c) Lifting or carrying groceries?
› 1. Yes, limited a lot
› 2. Yes, limited a little
› 3. No, not limitedat all
d) Climbing several flights of stairs?
› 1. Yes, limited a lot
› 2. Yes, limited a little
› 3. No, not limited at all
e) Climbing one flight of stairs?
› 1. Yes, limited a lot
› 2. Yes, limited a little
› 3. No, not limited at all
f) Bending, kneeing or stooping?
› 1. Yes, limited a lot
› 2. Yes, limited a little
› 3. No, not limited at all
g) Walking more than a mile?› 1. Yes, limited a lot
› 2. Yes, limited a little
› 3. No, not limited at all
h) Walking several blocks?
› 1. Yes, limited a lot
› 2. Yes, limited a little
› 3. No, not limited at all
i) Walking one block?
› 1. Yes, limited a lot
› 2. Yes, limited a little
› 3. No, not limited at all
j) Bathing or dressing yourself?
› 1. Yes, limited a lot
› 2. Yes, limited a little
›3. No, not limited at all

4- During the past 4 weeks, have you had any of the following problems with your work or other regular activities as a result of your physical health?

Yes
No
a) Cut down on the amount of time you spent on work or other activities?
› 1. yes
› 2. No
b) Accomplished less than you would like?
› 1. yes
› 2. No
c) Were limited in the kind of work or otheractivities?
› 1. yes
› 2. No
d) Had difficulty performing the work or other activities (for example it took extra effort)?
› 1. yes
› 2. No
5. 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)?

Yes
No
a) Cut down on the amount of time you spenton work or other activities?
› 1. yes
› 2. No
b) Accomplished less than you would like?
› 1. yes
› 2. No
c) Didn’t do work or other activities as carefully as usual?
› 1. yes
› 2. No

6. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?
› 1. Not at all ›2. Slightly › 3. Moderately › 4. Quite a bit › 5. Extremely

7. How much bodily pain have you had during the past 4 weeks?
› 1. None › 2. Very mild › 3. Mild › 4. Moderate › 5. Severe › 6. Very severe

8. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?
› 1. Not at all ›...
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