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201605147

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VR-12

VR-12 - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires





Instructions: This questionnaire 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.

Answer every question by marking the answer as indicated. If you are unsure how to answer a question, please give the best
answer you can.
(Circle one number on each line)
1. In general, would you say your health is:

EXCELLENT

VERY GOOD

GOOD

FAIR

POOR

1

2

3

4

5

2. 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?

YES,
LIMITED
A LOT

YES,
LIMITED
A LITTLE

NO,
NOT
LIMITED
AT ALL

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

1

2

3

b. Climbing several flights of stairs?


1

2

3

3. 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?



NO,
NONE
OF THE
TIME

YES,
A LITTLE
OF THE
TIME

YES,
SOME
OF THE
TIME

YES,
MOST
OF THE
TIME

YES,
ALL
OF THE
TIME

a. Accomplished less than you would like.

1

2

3

4

5

b. Were limited in the kind of work or other
activities.

1

2

3

4

5

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 any emotional problems (such as feeling depressed or anxious)?



NO,
NONE
OF THE
TIME

YES,
A LITTLE
OF THE
TIME

YES,
SOME
OF THE
TIME

YES,
MOST
OF THE
TIME

YES,
ALL
OF THE
TIME

a. Accomplished less than you would like.

1

2

3

4

5

b. Didn't do work or other activities as carefully as
usual.

1

2

3

4

5


THE VETERANS RAND 12 ITEM
HEALTH SURVEY (VR-12)






5. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and house
work)?

NOT AT ALL

A LITTLE BIT

MODERATELY

QUITE A BIT

EXTREMELY

1

2

3

4

5

These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please
give the one answer that comes closest to the way you have been feeling.

6. How much of the time during the past 4 weeks:



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

a. Have you felt calm and
peaceful?

1

2

3

4

5

6

b. Did you have a lot of
energy?

1

2

3

4

5

6

c. Have you felt downhearted
and blue?

1

2

3

4

5

6



7. 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

1

2

3

4

5

Now, we'd like to ask you some questions about how your health may have changed.

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

MUCH BETTER

SLIGHTLY BETTER

ABOUT THE SAME

SLIGHTLY WORSE

MUCH WORSE

1

2

3

4

5

9. Compared to one year ago, how would you rate your emotional problems (such as feeling anxious, depressed or irritable)
now?

MUCH BETTER

SLIGHTLY BETTER

ABOUT THE SAME

SLIGHTLY WORSE

MUCH WORSE

1

2

3

4

5





PLEASE PLACE THE COMPLETED QUESTIONNAIRE IN THE ENVELOPE WE SENT YOU.
NO STAMP IS REQUIRED: SIMPLY PLACE THE ENVELOPE IN ANY MAILBOX.


YOUR ANSWERS ARE IMPORTANT.
THANK YOU FOR COMPLETING THIS QUESTIONNAIRE.