March
3911
Please read the following statements. To the right of each you will find seven numbers, ranging from
"1" (Strongly Disagree) on the left to "7" (Strongly Agree) on the right. Click the circle below the
number which best indicates your feelings about that statement. For example, if you strongly
disagree with a statement, click "1". If you are neutral, click "4", and if you strongly agree, click "7",
etc.
Strongly
Disagree
1. When I make plans, I follow through with them.
2. I usually manage one way or another.
3. I am able to depend on myself more than anyone else.
4. Keeping interested in things is important to me.
5. I can be on my own if I have to.
6. I feel proud that I have accomplished things in life.
7. I usually take things in stride.
8. I am friends with myself.
9. I feel that I can handle many things at a time.
10. I am determined.
11. I seldom wonder what the point of it all is.
12. I take things one day at a time.
13. I can get through difficult times because I've experienced
difficulty before.
14. I have self-discipline.
15. I keep interested in things.
Strongly
Agree
1987 Gail M. Wagnild & Heather M. Young. Used by permission. All rights reserved. "The Resilience Scale" is an
international trademark of Gail M. Wagnild & Heather M. Young.
SF-36 baseline
37879
Subject No.
The following questions ask for your views about your health. If you are unsure about
how to answer a question, please give the best answer you can.
1. In general, would you say your health is:
Excellent
Very good
Good
Fair
Poor
Much better
Somewhat better
About the same
Somewhat worse
Much worse
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?
Yes,
limited
a lot
Yes,
limited
a little
No, not
limited
at all
SF-36 baseline
37879
Subject No.
4. During the past 4 weeks, how much of the time have you had any of the following
problems with your work or other regular daily activities as a result of your physical health?
All
of the
time
Most
of the
time
Some
of the
time
A little
of the
time
None
of the
time
5. During the past 4 weeks, how much of the time 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)?
All
of the
time
Most
of the
time
Some
of the
time
A little
of the
time
Slightly
Moderately
Quite a bit
Extremely
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None
of the
time
SF-36 baseline
37879
Subject No.
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 house work)?
Not at all
Slightly
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. For each question, please give the one answer that comes closest to the way you have
been feeling.
How much of the time during the past 4 weeks...
All
of the
time
Most
of the
time
Some
of the
time
A little
of the
time
None
of the
time
Page 3 of 4
37879
SF-36 baseline
Subject No.
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
11. Please choose the answer that best describes how true or false each of the following
statements is for you.
Definitely
true
Mostly
true
Don't
know
Mostly
false
Definitely
false
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