78 (78)    MH REPORT (601.93)

.| .|  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