| RPT |
.| .| The Veterans RAND 12-Item Health Survey| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN:
during the past 4 weeks: | 6A. Have you felt calm and peaceful?| <*Answer_5608*>| 6B. Did you have a lot of energy?| <*Answer_5609*>| 6C. Have you felt downhearted and blue?|
<*Answer_5610*>| 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.)?| <*Answer_5611*>| 8. Compared to one year ago, how would you rate your physical health in general now?| <*Answer_5612*>| 9. Compared to one year ago, how would you rate your
emotional problems (such as feeling anxious, depressed or irritable) now?| <*Answer_5613*>| | | Information contained in this note is based on a self-report assessment and is not sufficient to
use alone for diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~
<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>|| Physical Component Summary Score: <-PCS->| Higher scores indicate better health. Range is 1 to 72, Mean = 40, SD = 12.|| Mental
Component Summary Score: <-MCS-> | Higher scores indicate better health. Range is -2 to 76, Mean = 50, SD = 11.|| Questions and Answers| | 1. In general, would you say your health is:|
<*Answer_5600*>| 2. The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? | 2A. Moderate activities, such as moving
a table, pushing a vacuum cleaner, bowling, or playing golf?| <*Answer_5601*>| 2B. Climbing several flights of stairs?| <*Answer_5602*>| 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?| 3A. Accomplished less than you would like.| <*Answer_5603*>| 3B. Were limited
in the kind of work or other activities.| <*Answer_5604*>| 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)?| 4A. Accomplished less than you would like.| <*Answer_5605*>| 4B. Didn't do work or other activities as carefully as usual.|
<*Answer_5606*>| 5. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and house work)?| <*Answer_5607*>| 6. How much of the time
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