*Please enter the unique 4-digit number you have chosen for these surveys. This could be your birthday or your telephone number, but you must remember this number. Only numbers may be entered in this field This must be a number. You can not use letters. Use the same number for all of the surveys.

Please enter your course number or home if you are doing the survey from your home.

*1. In general would you say your health is: Choose only one of the following Excellent Very Good Good Fair Poor

*How much does your health now limit you when you engage in moderate activities, such as moving a table, pushing a vacuum cleaner, or playing sports? Choose only one of the following Yes, limited a lot Yes, limited a little No, not limited at all

*3. Does your health now limit you in activities such as climbing SEVERAL flights of stairs? Choose only one of the following Yes, limited a lot Yes, limited a little No, not limited at all

*4. During the past month have you accomplished less than you would like with your work or daily activities as a result of your PHYSICAL health? Yes No

*5. During the past month were you limited in the KIND of work or activities as a result of your PHYSICAL health? Yes No

*6. During the past month have you accomplished less than you would like with your work or daily activities as a result of your EMOTIONAL health? Yes No

*7. During the past month, were you limited in the KIND of work or activities as a result of your EMOTIONAL health? Yes No

*8. During the past month, how much did PAIN interfere with your normal work (include work both outside the home and housework)? Choose only one of the following Not at all A little bit Moderately Quite a bit

*9. For the past month have you felt calm and peaceful? Choose only one of the following All of the time Most of the time A good bit of the time Some of the time A little bit of the time None of the time

*10. For the past month did you have a lot of energy? Choose only one of the following All of the time Most of the time A good bit of the time Some of the time A little bit of the time None of the time

*11. For the past month have you felt downhearted and depressed? Choose only one of the following All of the time Most of the time A good bit of the time Some of the time A little bit of the time None of the time

*12. For the past month how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends or relatives)? Choose only one of the following All of the time Most of the time Some of the time A little of the time None of the time

Please enter any comments or clarifications you might have concerning the above questions.