Baseline Questionnaire - GeroNet

Name:___________________________________ID#________________SADate:____/____/____HEALTH STATUS QUESTIONNAIRE (SF-36)The following questions are about activities you might doduring a typical day. Does your health now limit you inthese activities, if so, how much?1. Does your health now limit you in vigorous activities,such as running, lifting heavy objects, orparticipating in strenuous sports?___ Yes, limited a lot___ Yes, limited a little___ No, not limited at all2. Does your health now limit you in moderate activities,such as moving a table, pushing a vacuum cleaner,bowling, or playing golf?___ Yes, limited a lot___ Yes, limited a little___ No, not limited at all3. Does your health now limit you in lifting or carryinggroceries?___ Yes, limited a lot___ Yes, limited a little___ No, not limited at all4. Does your health now limit you in climbing severalflights of stairs?___ Yes, limited a lot___ Yes, limited a little___ No, not limited at all