SilverOakHealth HrQoL

2. Compared to one year ago, how would you rate your health in general now?

Much better now 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 items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports	Yes, limited a lot Yes, limited a little No, not limited at all
Moderate activities, such as moving a table, sweeping the floor, folding clothes or throwing a ball	Yes, limited a lot Yes, limited a little No, not limited at all
Lifting or carrying groceries	Yes, limited a lot Yes, limited a little No, not limited at all
Climbing several flights of stairs	Yes, limited a lot Yes, limited a little No, not limited at all
Climbing one flight of stairs	Yes, limited a lot Yes, limited a little No, not limited at all
Bending, kneeling, or stooping	Yes, limited a lot Yes, limited a little No, not limited at all
Walking more than a mile	Yes, limited a lot Yes, limited a little No, not limited at all
Brisk walking for 5 minutes	Yes, limited a lot Yes, limited a little No, not limited at all
Brisk walking for 1 minute	Yes, limited a lot Yes, limited a little No, not limited at all
Bathing or dressing yourself	Yes, limited a lot Yes, limited a little 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 daily activities as a result of your physical health?

Cut down the amount of time you spent on work or other activities	Yes No
Accomplished less than you would like	Yes No
Were limited in the kind of work or other activities	Yes No
Had difficulty performing the work or other activities (for example, it took extra effort)	Yes 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)?

Cut down the amount of time you spent on work or other activities	Yes No
Accomplished less than you would like	Yes No
Didn't do work or other activities as carefully as usual	Yes 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?

Not at all Slightly Moderately Quite a bit Extremely

7. How much bodily pain have you had during the past 4 weeks?

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)?

Not at all A little bit Moderately Quite a bit Extremely

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.)?

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

Please fill out the following.

Name *

Year of Birth *

Gender *

City *

Employment Status *

Email *

Disclaimer : All the information shared by you is kept strictly confidential. This information is only used to analyse data at a group level.

Did you feel full of enthusiasm?	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
Have you been a very nervous person?	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
Have you felt so down in the dumps that nothing could cheer you up?	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
Have you felt calm and peaceful?	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
Did you have a lot of energy?	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
Have you felt downhearted and blue?	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
Did you feel worn out?	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
Have you been a happy person?	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
Did you feel tired?	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

I seem to get sick a little easier than other people	Definitely true Mostly true Don't know Mostly false Definitely false
I am as healthy as anybody I know	Definitely true Mostly true Don't know Mostly false Definitely false
I expect my health to get worse	Definitely true Mostly true Don't know Mostly false Definitely false
My health is excellent	Definitely true Mostly true Don't know Mostly false Definitely false

Health related Quality of Life Assessment