Table 1 Health-related quality of life questions included in survey

1.

Would you say that in general your health is: excellent, very good, good, fair or poor?

2.

Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?

3.

Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

4.

During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?

Optional HRQOL module questions (pain and activity limitation)

1.

During the past 30 days, for about how many days did PAIN make it hard for you to do your usual activities, such as self-care, work, or recreation?

2.

Are you limited in any activities because of any impairment or health problem?

3.

What is the MAJOR impairment or health problem that limits your activities?

4.

For HOW LONG have your activities been limited because of your impairment or health problem? Please give the length of time.

5.

Because of any impairment or health problem, do you need the help of other persons with your PERSONAL CARE needs, such as eating, bathing, dressing, or getting around the house?

6.

Because of any impairment or health problem, do you need the help of other persons in handling your ROUTINE needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?