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.
In general, your healthy conditions is？
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？
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 | |
| （1）重体力活动，如：跑步、举重物、参加剧烈运动等Heavy physical activity, such as running, lifting weights, participating in strenuous sports, etc | |||
| （2）适度的活动，如：移动一张桌子、扫地、打太极拳、做简单体操等Moderate activities, such as moving a table, sweeping the floor, playing Taiji, doing simple gymnastics, etc | |||
| （3）手提日用品，如买菜、购物等Portable daily necessities,Such as buying vegetables, shopping,etc | |||
| （4）上几层楼梯Go up several flights of stairs | |||
| （5）上一层楼梯Go up one flight of stairs | |||
| （6）弯腰、曲膝、下蹲Bend 、Bend knees、squat down | |||
| （7）步行 1600m以上的路程Walk more than 1600m distance | |||
| （8）步行 800m以上的路程Walk more than 800m distance | |||
| （9）步行 100m以上的路程Walk more than 100m distance | |||
| （10）自己洗澡、穿衣Wash and dress by yourself |
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 | |
| （1）减少了工作或活动的时间Reduce time spent on work or activities | ||
| （2）本来想要做的事情只能完成一部分Complete part of what you want to do | ||
| （3）想要做的工作和活动的种类受到限制Limit the types of work and activities you want to do | ||
| （4）完成工作或其他活动困难增多（比如需要额外的努力）Finish work and other activities is more difficult(Extra effort) |
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 | |
| （1）减少了工作或活动的时间Reduce time spent on work or activities | ||
| （2）本来想要做的事情只能完成一部分Complete part of what you want to do | ||
| （3）做事情不如平时仔细Do things not as carefully as usual |
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 | |
| （1）在过去的四个星期里，您的健康或情绪不好在多大程度上影响了您与家人、朋友、邻居或集体的正常社会交往？In the past four weeks,what extent does your poor health or mood affect your normal social interaction with your family, friends, neighbors or group? | |||||
| （2）过去四个星期里，您有身体疼痛吗？In the past four weeks,do you have physical pain? | |||||
| （3）过去四个星期里，身体疼痛影响您的工作和家务事吗？In the past four weeks,does physical pain affect your work and housework? |
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 | |
| （1）您觉得生活充实You feel the life is full | ||||||
| （2）您是一个敏感的人You are a sensitve person | ||||||
| （3）您情绪非常不好，什么事都不能使您高兴You are in a bad mood that nothing can cheer you up | ||||||
| （4）您心里很平静You have peace of mind | ||||||
| （5）您做事精力充沛You are full of energy | ||||||
| （6）您的情绪低落You feel depress | ||||||
| （7）您觉得精疲力尽You feel exhausted | ||||||
| （8）您是个快乐的人You are a happy person | ||||||
| （9）您感觉厌烦You feel bored | ||||||
| （10）不健康影响了您的社会活动（如走亲访友等）Poor health affects your social activities(Visite friends and relatives) |
What's 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 | |
| （1）我好像比别人容易生病I seem to get sick more easily than others | |||||
| （2）我跟周围人一样健康Im as healthy as people around me | |||||
| （3）我认为我的健康状况在变坏I think my health is getting worse | |||||
| （4）我的健康状况非常好Im in excellent health |
If you have notes or comments, please write below：
10题 | 被引用6次