Vida Institute

SF36 Health Survey

 

sf3 Health Survey - Instructions: This is a standard form survey that facilitates comparison with the results of other studies. Please answer all questions to the best of your ability.

1.

In general, would you say your health is: (Please tick one box.)

 

Excellent Very Good Good Fair Poor

 

2.

Compared to one year ago, how would you rate your health in general now? (Please tick one box.)

Much better than one year ago Somewhat better now than one year ago About the same as one year ago Somewhat worse now than one year ago Much worse now than one year ago

 

3.

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?
 

 

Activities

Yes, Limited A Lot

Yes, Limited A Little

Not Limited At All

3(i)

Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports

  

 

 

 

  

 

3(ii)

 Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf  

 

  

 

  

 

3(iii)

Lifting or carrying groceries

  

 

  

 

  

 

3(iv)

Climbing several flights of stairs

  

 

  

 

  

 

3(v)

Climbing one flight of stairs

  

 

  

 

  

 

3(vi)

Bending, kneeling, or stooping

  

 

  

 

  

 

3(vii)

Walking more than a mile

  

 

  

 

  

 

3(viii)

Walking several blocks

  

 

  

 

  

 

3(ix)

Walking one block

  

 

  

 

  

 

3(x)

Bathing or dressing yourself

  

 

  

 

  

 

4.

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 your physical health?
    YES NO

4(i)

Cut down on the amount of time you spent on work or other activities

  

 

  

 

4(ii)

Accomplished less than you would like

  

 

  

 

4(iii)

Were limited in the kind of work or other activities

  

 

  

 

4(iv)

Had difficulty performing the work or other activities (for example, it took extra effort)

  

 

  

 

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)?
 

(Please circle one number on each line.)

Yes

No

5(i)

Cut down on the amount of time you spent on work or other activities

  

 

  

 

5(ii)

Accomplished less than you would like

  

 

  

 

5(iii)

Didn’t do work or other activities as carefully as usual

  

 

  

 

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, neighbours, or groups?

Not at all Slightly Moderately Quite a bit Extremely

 

7.

How much physical pain have you had during the past 4 weeks? (Please tick one box.)

None Very mild Mild Moderate Severe 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)? (Please tick one box.)

Not at all A little bit Moderately Quite a bit Extremely

9.

These questions are about how you feel and how things have been with you during the past 4 weeks. Please give the one answer that is closest to the way you have been feeling for each item.
  (Please circle one number on each line.)

All of the Time

Most of the Time

A Good Bit of the Time

Some of the Time

A Little of the Time

None of the Time

9(i)

Did you feel full of life?

  

 

  

 

  

 

  

 

  

 

  

 

9(ii)

Have you been a very nervous person?

  

 

  

 

  

 

  

 

  

 

  

 

9(iii)

Have you felt so down in the dumps that nothing could cheer you up?

  

 

  

 

  

 

  

 

  

 

  

 

9(iv)

Have you felt calm and peaceful?

  

 

  

 

  

 

  

 

  

 

  

 

9(v)

Did you have a lot of energy?

  

 

  

 

  

 

  

 

  

 

  

 

9(vi)

Have you felt downhearted and blue?

  

 

  

 

  

 

  

 

  

 

  

 

9(vii)

Did you feel worn out?

  

 

  

 

  

 

  

 

  

 

  

 

9(viii)

Have you been a happy person?

  

 

  

 

  

 

  

 

  

 

  

 

9(ix)

Did you feel tired?

  

 

  

 

  

 

  

 

  

 

  

 

10.

During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives etc.) (Please tick one box.)

All of the time Most of the time Some of the time A little of the time None of the time

11.

How TRUE or FALSE is each of the following statements for you?
 

(Please circle one number on each line.)

Definitely True

Mostly True

Don’t Know

Mostly False

Definitely False

11(i)

I seem to get sick a little easier than other people

  

 

  

 

  

 

  

 

  

 

11(ii)

I am as healthy as anybody I know

  

 

  

 

  

 

  

 

  

 

11(iii)

I expect my health to get worse

  

 

  

 

  

 

  

 

  

 

11(iv)

My health is excellent

  

 

  

 

  

 

  

 

  

 
     

First Name:    

Middle Name:

Last Name:    

Ethnic Group:

Height (cm):  

Weight (Kg)  

 

Birthdate:      

Sex:                 M    F

Marital Status:  S     M

Email:          

Phone:         

Todays date:

If you have started the Asc2P regimen,

please provide the following:

Start Date:                     

Days Regimen Followed:

Days Regimen Missed:   

Days only one taken:      

Participants in the trial are asked to follow the trial regimen of two capsules per day, one in the morning, and the other before going to bed, for at least three months in order to obtain meaningful results.

Please keep track of the number of days that you have followed the Asc2P regimen, as well as the number of days that were missed, and days when only one capsule was taken. You will receive a followup survey form 90 days from the date that we receive your first order for Asc2P.

When you click on the SUBMIT button below, you will be taken to the Asc2P order page.