VR-12 Health Survey

SOR Physical Therapy

This questionnaire asks for your views about your health. This information will help you 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.

Completion Status: 0 of 10 sections completed

Patient Identification

Required for patient record verification and CRM contact matching.

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth *

1. In general, how would you rate your health?

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?

Select one option for each activity. Both 2a and 2b are required. *

Questions	Yes, Limited a Lot	Yes, Limited a Little	No, Not Limited at All
2a. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf?
2b. Climbing several flights of stairs?

2a. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf?

2b. Climbing several flights of stairs?

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?

Select one option for each item. Both 3a and 3b are required. *

Questions	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
3a. Accomplished less than you would like
3b. Were limited in the kind of work or other activities

3a. Accomplished less than you would like

3b. Were limited in the kind of work or other activities

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)?

Select one option for each item. Both 4a and 4b are required. *

Questions	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
4a. Accomplished less than you would like
4b. Didn't do work or other activities as carefully as usual

4a. Accomplished less than you would like

4b. Didn't do work or other activities as carefully as usual

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

6. 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: *

Questions	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
6a. Have you felt calm and peaceful?
6b. Did you have a lot of energy?
6c. Have you felt downhearted and blue?

6a. Have you felt calm and peaceful?

6b. Did you have a lot of energy?

6c. Have you felt downhearted and blue?

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.)?

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

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

VR-12 Health Survey (Veterans RAND 12-Item Health Survey)