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Health Related Quality of Life Questions—BRFSS

1. Would you say that in general your health is:
   
   Please read
   1 Excellent
   2 Very Good
   3 Good
   4 Fair or
   5 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?
   
    _ _ Number of days
   8 8 None
   7 7 Don’t know / Not sure
   9 9 Refused
    
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?
   
   _ _ Number of days
   8 8 None
   7 7 Don’t know / Not sure
   9 9 Refused
    

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?

   _ _ Number of days
   8 8 None
   7 7 Don’t know / Not sure
   9 9 Refused

Page last reviewed: September 25, 2008
Page last modified: June 13, 2007
Content Source: Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion

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