健康状况调查问卷The MOS item short from health survey（SF-36） - 问卷调查调研模板

健康状况调查问卷The MOS item short from health survey（SF-36）

本问卷将简明调查您目前的健康状况，请您在问卷中勾选最符合目前自身状况的答案，若您有不同答案，请在最后的空白处写上您的答案与注释。This questionnaire will investigate your current medical condition compendiously,please tick the best fits your current situation ,If you have a different answer, please write your answer and comments in the space at the end.

:目前您对自身健康状况的感受是？How do you feel about your health right now?

Q1:总体来讲，您的健康状况是？In general, your healthy conditions is？

非常好 Excellent

很好 Very good

好 Good

一般 General

差 Bad

Q2:跟一年前相比，您觉得您现在的健康状况是？Compared with one year ago, now your healthy conditions is？

好多了 Much better

好一些Better

好Good

一般General

更差Worse

Q3:您的日常活动是否受您目前的身体状况限制？如果有限制，程度如何？Are your daily activities limited by your current physical condition? If have,what degree?

毫无限制No limit

有些限制Some limited

限制很大Very limited

Q4:在过去四个星期里，您的工作和日常活动有无因为身体健康的原因而出现以下这些问题？In the past four weeks,do you have the following problems because of health reasons in your work and daily activities ?

是Yes

否No

Q5:在过去四个星期里，您的工作和日常活动有无因为情绪的原因（如压抑或者忧虑），而出现以下问题？In the past four weeks,do you have the following problems because of emotional reasons(such as repression or worry) in your work and daily activities ?

是Yes

否No

Q6:在过去四个星期里，您的工作和日常活动有无因为情绪的原因（如压抑或者忧虑），而出现以下问题？In the past four weeks,do you have the following problems because of emotional reasons(such as repression or worry) in your work and daily activities ?

完全没有Not at all

有一点A little

中等Moderate

严重Serious

非常严重Very serious

Q7:过去一个月里，您是否有以下感觉？您的感觉时间基本上是？In the past month,do you have following feelings?What is your feeling time?

所有时间All the time

大部分时间Most of time

比较多时间 A lot of time

一部分时间A little time

一小部分时间Little time

没有这种感觉No time

Q8:以下情况最符合您自我感觉身体状况的是？Whats the best fit for your physical condition?

绝对正确Absolutely true

大部分正确Mostly true

不能肯定Not sure

大部分错误Mostly wrong

绝对错误Absolutely wrong

Q9:如果您有注释或评论，请写在下面：If you have notes or comments, please write below：

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