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NINDS CDE Notice of Copyright
Short Form 36-Item Health Survey (SF-36)
Please visit this website for more information about the instrument: Short From 36 Item Health Survey
Copyright holder: RAND Corporation - Please read Terms and Conditions for Using the 36-Item Short Form Health Survey
Please note: The original SF-36 (i.e., SF-36 v1) is freely available in the public domain. The SF-36-version 2 is separately validated and copyrighted from SF-36v1. CDEs are not posted for the SF-36v2 since the NINDS does not have permission to post the content of this version of the instrument. Please contact the copyright holders for permissions for use.
The Medical Outcomes Trust (MOT), Health Assessment Lab (HAL), and Quality Metric Health Outcomes Solutions, co-copyright holders of all SF-36v2®, SF-12v2®and SF-8™ Health Surveys, have merged their licensing and user registration programs, with the objectives of simplifying licensing and user registration and better meeting the needs of the many new academic, commercial, and other licensees. Use of SF-36 v2 and other SF Health Surveys versions require a signed license agreement.
Licensing agreement information for the SF-36v2®, SF-12v2® and SF-8™ Health Surveys can be found on the Quality Metric website: Quality Metric PRO Health Surveys
NeuroRehab Supplemental - Highly Recommended
Recommendations for Use: Indicated for studies requiring a Generic Health-Related Quality of Life measure.
Supplemental - Highly Recommended: *Mitochondrial Disease (Mito), **Parkinson's Disease (PD)
*Recommendations for use: Indicated for interventional studies requiring a measure of quality of life. Either the EuroQoL-5D-5L or SF-36/SF-12 is recommended.
**Recommendations for use: Indicated for studies as a Generic Health-Related Quality of Life measure.
Supplemental: Amyotrophic Lateral Sclerosis (ALS), Chiari Malformation (CM), Facioscapulohumeral Muscular Dystrophy (FSHD), Friedreich's Ataxia (FA), Headache, Huntington's Disease (HD), Multiple Sclerosis (MS), Myalgic encephalomyelitis/Chronic fatigue syndrome (ME/CFS), Myasthenia Gravis (MG), Myotonic Muscular Dystrophy (DM), Neuromuscular Diseases (NMD), Spinal Muscular Atrophy (SMA), Sport-Related Concussion (SRC) Persistent/Chronic (3 months and greater post-concussion), Stroke, and Traumatic Brain Injury (TBI)
Exploratory: Cerebral Palsy (CP), Sport-Related Concussion (SRC) Subacute (after 72 hours to 3 months), Spinal Cord Injury (SCI)-Pediatric, and Unruptured Cerebral Aneurysms and Subarachnoid Hemorrhage (SAH)
Short Description of Instrument
Construct measured: Health-related quality of life
Generic vs. disease-specific: Generic
Means of administration: Interview or Self-Administered
Intended respondent: Patient
# of items: 36
# of subscales and names of sub-scales: 8 - Physical Functioning, Role-Physical, Bodily Pain, General Health, Vitality, Social Functioning, Role-Emotional, Mental Health
# of items per sub-scale: Varies
Comments/Special Instructions
The CDEs posted with this version of the SF-36 are specific to the Multiple Sclerosis Quality of Life Inventory (MSQLI). The National Institute of Health Neurological Disorder and Stroke (NINDS) received permission to post only the SF-36 version 1 questions that are used on the MSQLI.
The Short Form-36 was derived from the General Health Survey of the Medical Outcomes Study by Stewart and colleagues (1988). It is one of the most widely used generic measures of health-related quality of life and has been shown to discriminate between participants with different chronic conditions and between participants with different severity levels of the same disease. This instrument addresses health concepts that are relevant to patients from the patient's perspective.
A 12-item version, the Short Form-12 (SF-12) is also widely used. It was created by the developer of the SF-36 and found to have good reliability and validity (Ware J et al., 1996).
Scoring and Psychometric Properties
Scoring: There are 36 items and measures of health across three domains - functional status, well-being, and overall perceptions of health. The scoring system for the SF-36 is relatively complex and generates subscale scores for physical functioning, role limitations due to physical problems, bodily pain, general health perceptions, vitality, social functioning, role-limitations due to emotional problems, and mental health.
There is no single overall score for the SF-36; instead, it generates two summary scores (physical health and mental health) and 8 subscales. There are weighted sums of the questions in their section. Each scale is transformed into a 0-100 scale. The lower the score, the worse the disability. Scores are also converted to z scores for comparison with the general population.
For SF-36 v1, scoring instructions are publicly available from the Rand Corporation.(Medical Outcomes Study: 36-Item Short Form Survey Scoring Instructions)
Psychometric Properties: The SF-36 is highly validated. The SF-36 has been widely used to assess patients with PD. It shows good reliability and discriminative validity. The SF-36 was partially responsive to change over time and intervention. In one study, it was more responsive than PDQ-39 and PDQUALIF. The minimal detectable change has been determined.
To date the properties of the SF-36 have not been evaluated in the mitochondrial disease population. In a multiple sclerosis (MS) population, the Cronbach's alphas for the various subscales of the SF-36 range from 0.67 to 0.94. There is considerable evidence for the validity of the SF-36 in a variety of populations including MS. (Vickrey et al., 1995) In this study, the physical functioning and role limitations due to physical problems subscales were the ones that best discriminated between MS patients and the normative U.S. population.
Strengths: The SF-36 is easy to administer, covers a broad range of domains of health-related quality of life, and is among the most widely used of such measures. It is available in multiple languages. Availability of population-based normative data makes the SF-36 useful for comparative purposes. The availability of several subscales may be useful to investigators interested in testing hypotheses concerning these different areas of function. The SF-36 is the most extensively evaluated health status survey, it is brief, and data can be compared to the U.S. normative population and across disease states. To keep the instrument brief, some health status concepts are missing, e.g., family functioning, sexual functioning, cognitive functioning, and sleep disorders. It is suitable for self-administration, computerized administration, or administration by a trained interviewer in person or by telephone.
It has been previously used in multiple myotonic dystrophy clinical trials; however, its responsiveness to change and relevance to this population is still unknown. The response rate for the population over age 65 is low.
Administration: Administration time is approximately 10 minutes. The SF-36 is a structured, self-report questionnaire that the participant can generally complete with little or no intervention from an interviewer. However, participants with visual or upper extremity impairments may need to have the SF-36 administered by a trained interviewer.
Sport-Related Concussion-Specific:
Strengths: Generic 36-item quality of life measure that include subscales for physical function, role limitations due to physical and emotional health, energy, emotional well- being, social functioning, pain and general health. Publicly available through RAND corp. Subscales are reliable. Intuitive 100 point-based scoring system for each subscale.
Weaknesses: Measure is lengthy - 36 items (12 item scale may be more appropriate for sport concussion). Scoring conversion is challenging for the administrator and complicated. Lack of overall score. Clinical cut-off scores unavailable at this time. Subpopulations: Intended for adult patients.
Strengths: As a generalized questionnaire, it does a good job of characterizing differences in ME/CFS reported measures compared to healthy individuals and other pathological or fatiguing conditions.
Clearly separates mental issues from physical issues - the SF-36 shows that the pain, loss of vitality, physical functioning and fatigue are not accompanied by mental problems. Provides objective measures for reduced functional status, bodily pain, functional impairment, and fatigue severity that are characteristic of ME/CFS. There are enough published studies available to compare results - given the heterogeneity of the illness/comorbidities such as FMS - it is nice to be able to have a relative abundance of studies to compare measures.
Weaknesses: Not designed to capture the post-exertional malaise characteristic of the illness. May have a "floor effect" that makes it hard to determine when there is a symptom flare that reduces dimensions of health over a shorter period of time. Does not describe the full range of symptoms ME/CFS patients experience such as cognitive, fatigability, PEM and sleep problems. Consider the DePaul Symptom Questionnaire for better evaluation between and among ME/CFS patients.
Mitochondrial Disease-Specific:
Strengths: This instrument can be used to estimate the cost of illness in post-market studies. It is used as a clinical care outcome measure.
Weaknesses: Not validated but has been used in trials.
Key References:
Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992 Jun;30(6):473-83.
Hays RD. (1994). The Medical Outcomes Study (MOS) Measures of Patient Adherence. Santa Monica, CA: RAND Corporation Retrieved from
Hays RD, Shelbourne CD, Mazel R. (1995). User's Manual for the Medical Outcomes Study (MOS) Core Measures of Health-Related Quality of Life. Santa Monica, CA: RAND corporation.
McHorney CA, Ware JE Jr, Raczek AE. The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Med Care. 1993 Mar;31(3):247-63.
Stewart AL, Hays RD, Ware JE Jr. The MOS short-form general health survey. Reliability and validity in a patient population. Med Care. 1988 Jul;26(7):724-35.
Ware JE Jr. (2001). SF-36 Physical and Mental Health Summary Scales: A Manual for Users of Version 1 (2nd Edition ed.). Lincoln, RI: Quality Metric Inc.
Ware JE Jr, Kosinski M, Dewey JE. (2000). How to Score Version 2 of the SF-36® Health Survey. Retrieved from Lincoln, RI: Quality Metric Inc.
Ware JE Jr, Kosinski M, Keller SD. (1994). SF-36® Physical and Mental Health Summary Scales: A Users' Manual. Boston, MA: The Health Institute.
Ware J Jr, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996 Mar;34(3):220-33.
Ware JE Jr, Snow KK, Kosinski M, Gandek B. (1993). SF-36 Health Survey: Manual and Interpretation Guide. Boston, MA: The Health Institute.
Additional References:
Andresen EM, Gravitt GW, Aydelotte ME, Podgorski CA. Limitations of the SF-36 in a sample of nursing home residents. Age Ageing. 1999 Oct;28(6):562-6.
Hayes V, Morris J, Wolfe C, Morgan M. The SF-36 health survey questionnaire: is it suitable for use with older adults? Age Ageing. 1995 Mar;24(2):120-5.
Ruta DA, Hurst NP, Kind P, Hunter M, Stubbings A. Measuring health status in British patients with rheumatoid arthritis: reliability, validity and responsiveness of the short form 36-item health survey (SF-36). Br J Rheumatol. 1998 Apr;37(4):425-36.
Vickrey BG, Hays RD, Harooni R, Myers LW, Ellison GW. A health-related quality of life measure for multiple sclerosis. Qual Life Res. 1995 Jun;4(3):187-206.
ME/CFS-Specific References:
Buchwald D, Pearlman T, Umali J, Schmaling K, Katon W. Functional status in patients with chronic fatigue syndrome, other fatiguing illnesses, and healthy individuals. Am J Med. 1996 Oct;101(4):364-70.
Haywood KL, Staniszewska S, Chapman S. Quality and acceptability of patient-reported outcome measures used in chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME): a systematic review. Qual Life Res. 2012 Feb;21(1):35-52.
Jason L, Brown M, Evans M, Anderson V, Lerch A, Brown A, Hunnell J, Porter N. Measuring substantial reductions in functioning in patients with chronic fatigue syndrome. Disabil Rehabil. 2011;33(7):589-98.
Komaroff AL, Fagioli LR, Doolittle TH, Gandek B, Gleit MA, Guerriero RT, Kornish RJ 2nd, Ware NC, Ware JE Jr, Bates DW. Health status in patients with chronic fatigue syndrome and in general population and disease comparison groups. Am J Med. 1996 Sep;101(3):281-90.
Myotonic Dystrophy-Specific References:
Antonini G, Soscia F, Giubilei F, De Carolis A, Gragnani F, Morino S, Ruberto A, Tatarelli R. Health-related quality of life in myotonic dystrophy type 1 and its relationship with cognitive and emotional functioning. J Rehabil Med. 2006 May;38(3):181-5.
Laberge L, Mathieu J, Auclair J, Gagnon E, Noreau L, Gagnon C. Clinical, psychosocial, and central correlates of quality of life in myotonic dystrophy type 1 patients. Eur Neurol. 2013;70(5-6):308-15.
Peric S, Nisic T, Milicev M, Basta I, Marjanovic I, Peric M, Lavrnic D, Rakocevic Stojanovic V. Hypogonadism and erectile dysfunction in myotonic dystrophy type 1. Acta Myol. 2013 Oct;32(2):106-9.
Peric S, Rakocevic-Stojanovic V, Stevic Z, Basta I, Pavlovic S, Vujanac V, Marjanovic L, Lavrnic D. Health-related quality of life in patients with myotonic dystrophy type 1 and amyotrophic lateral sclerosis. Acta Neurol Belg. 2010 Mar;110(1):71-7.
Peric S, Stojanovic VR, Basta I, Peric M, Milicev M, Pavlovic S, Lavrnic D. Influence of multisystemic affection on health-related quality of life in patients with myotonic dystrophy type 1. Clin Neurol Neurosurg. 2013 Mar;115(3):270-5.
Tieleman AA, Jenks KM, Kalkman JS, Borm G, van Engelen BG. High disease impact of myotonic dystrophy type 2 on physical and mental functioning. J Neurol. 2011 Oct;258(10):1820-6.
Parkinson's Disease-Specific References:
Banks P, Martin CR. The factor structure of the SF-36 in Parkinson's disease. J Eval Clin Pract. 2009 Jun;15(3):460-3.
Brown CA, Cheng EM, Hays RD, Vassar SD, Vickrey BG. SF-36 includes less Parkinson Disease (PD)-targeted content but is more responsive to change than two PD-targeted health-related quality of life measures. Qual Life Res. 2009 Nov;18(9):1219-37.
Chrischilles EA, Rubenstein LM, Voelker MD, Wallace RB, Rodnitzky RL. The health burdens of Parkinson's disease. Mov Disord. 1998 May;13(3):406-13.
Den Oudsten BL, Van Heck GL, De Vries J. The suitability of patient-based measures in the field of Parkinson's disease: a systematic review. Mov Disord. 2007 Jul 30;22(10):1390-1401.
Hagell P, Toernqvist AL, Hobart J. Testing the SF-36 in Parkinson's disease. Implications for reporting rating scale data. J Neurol. 2008 Feb;255(2):246-54.
Hobson P, Meara J. Self-reported functioning and well-being in patients with Parkinson's disease: comparison of the Short-Form 36 and the Parkinson's Disease Questionnaire. Age Ageing. 1996 Jul;25(4):334-5.
Jenkinson C, Peto V, Fitzpatrick R, Greenhall R, Hyman N. Self-reported functioning and well-being in patients with Parkinson's disease: comparison of the short-form health survey (SF-36) and the Parkinson's Disease Questionnaire (PDQ-39). Age Ageing. 1995 Nov;24(6):505-9.
Kuopio AM, Marttila RJ, Helenius H, Toivonen M, Rinne UK. The quality of life in Parkinson's disease. Mov Disord. 2000 Mar;15(2):216-23.
Rubenstein LM, Voelker MD, Chrischilles EA, Glenn DC, Wallace RB, Rodnitzky RL. The usefulness of the Functional Status Questionnaire and Medical Outcomes Study Short Form in Parkinson's disease research. Qual Life Res. 1998 May;7(4):279-90.
Schrag A, Spottke A, Quinn NP, Dodel R. Comparative responsiveness of Parkinson's disease scales to change over time. Mov Disord. 2009 Apr 30;24(6):813-8.
Siderowf A, Jaggi JL, Xie SX, Loveland-Jones C, Leng L, Hurtig H, Colcher A, Stern M, Chou KL, Liang G, Maccarone H, Simuni T, Baltuch G. Long-term effects of bilateral subthalamic nucleus stimulation on health-related quality of life in advanced Parkinson's disease. Mov Disord. 2006 Jun;21(6):746-53.
Steffen T, Seney M. Test-retest reliability and minimal detectable change on balance and ambulation tests, the 36-item short-form health survey, and the unified Parkinson disease rating scale in people with parkinsonism. Phys Ther. 2008 Jun;88(6):733-46. Erratum in: Phys Ther. 2010 Mar;90(3):462.
Stroke-Specific References:
Anderson C, Laubscher S, Burns R. Validation of the Short Form 36 (SF-36) health survey questionnaire among stroke patients. Stroke. 1996 Oct;27(10):1812-6.
Hobart JC, Williams LS, Moran K, Thompson AJ. Quality of life measurement after stroke uses and abuses of the SF-36. Stroke. 2002 May;33(5):1348-56.
Lai SM, Perera S, Duncan PW, Bode R. Physical and social functioning after stroke: comparison of the Stroke Impact Scale and Short Form-36. Stroke. 2003 Feb;34(2):488-93.
O'Mahony PG, Rodgers H, Thomson RG, Dobson R, James OF. Is the SF-36 suitable for assessing health status of older stroke patients? Age Ageing. 1998 Jan;27(1):19-22.
Williams LS. Health-related quality of life outcomes in stroke. Neuroepidemiology. 1998;17(3):116-20.
Huntington's Disease-Specific References:
Ho AK, Gilbert AS, Mason SL, Goodman AO, Barker RA. Health-related quality of life in Huntington's disease: Which factors matter most? Mov Disord. 2009 Mar 15;24(4):574-8.
Ho AK, Robbins AO, Walters SJ, Kaptoge S, Sahakian BJ, Barker RA. Health-related quality of life in Huntington's disease: a comparison of two generic instruments, SF-36 and SIP. Mov Disord. 2004 Nov;19(11):1341-8.
Tabrizi SJ, Langbehn DR, Leavitt BR, Roos RA, Durr A, Craufurd D, Kennard C, Hicks SL, Fox NC, Scahill RI, Borowsky B, Tobin AJ, Rosas HD, Johnson H, Reilmann R, Landwehrmeyer B, Stout JC; TRACK-HD investigators. Biological and clinical manifestations of Huntington's disease in the longitudinal TRACK-HD study: cross-sectional analysis of baseline data. Lancet Neurol. 2009 Sep;8(9):791-801.
Tabrizi SJ, Scahill RI, Durr A, Roos RA, Leavitt BR, Jones R, Landwehrmeyer GB, Fox NC, Johnson H, Hicks SL, Kennard C, Craufurd D, Frost C, Langbehn DR, Reilmann R, Stout JC; TRACK-HD Investigators. Biological and clinical changes in premanifest and early stage Huntington's disease in the TRACK-HD study: the 12-month longitudinal analysis. Lancet Neurol. 2011 Jan;10(1):31-42.
Subarachnoid Hemorrhage-Specific References:
Anderson C, Rubenach S, Mhurchu CN, Clark M, Spencer C, Winsor A. Home or hospital for stroke rehabilitation? results of a randomized controlled trial : I: health outcomes at 6 months. Stroke. 2000 May;31(5):1024-31.
de Haan R, Aaronson N, Limburg M, Hewer RL, van Crevel H. Measuring quality of life in stroke. Stroke. 1993 Feb;24(2):320-7.
McDowell I. (2006) Measuring Health: A Guide to Rating Scales and Questionnaires. 3rd Edition. New York: Oxford University Press.
Sport-Related Concussion-Specific References:
Chiang CC, Guo SE, Huang KC, Lee BO, Fan JY. Trajectories and associated factors of quality of life, global outcome, and post-concussion symptoms in the first year following mild traumatic brain injury. Qual Life Res. 2016 Aug;25(8):2009-19.
Kuehl MD, Snyder AR, Erickson SE, McLeod TC. Impact of prior concussions on health-related quality of life in collegiate athletes. Clin J Sport Med. 2010 Mar;20(2):86-91.
Valier AR, Welch Bacon CE, Bay RC, Houston MN, Valovich McLeod TC. Validity of Single-Item Patient-Rated Outcomes in Adolescent Football Athletes With Concussion. Arch Phys Med Rehabil. 2016 Jul;97(7):1202-5.
Document last updated March 2024