Yearly Health Survey 
	University of Michigan Medical Center	
Head and Neck Surgery Division 
SECTION A
The following questions ask for your views about health.  Please answer each of the following questions by circling the answer.  If you are unsure about how to answer a question, please give the best answer you can.

Excellent	Very Good	
Good	
Fair	
Poor	
1	2	3	4	5	

Q1.	In general, would you say your health is:

Much
Better	Somewhat
Better	About the Same	Somewhat 
Worse	Much
Worse	
1	2	3	4	5	

				   	
						     
Q2.	Compared to one year ago, how would
            you rate your health in general now?                        

The following questions are about activities you might do during a typical day.

Q3.	Does your health now limit you in these activities?  If so, how much?

	Yes, Limited
A Lot	Yes, Limited
A Little	No, Not
Limited At All	
a.	Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports? 
	1	2	3	
b.	Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf?
	1	2	3	
c.	Lifting or carrying groceries?
	1	2	3	
d.	Climbing several flights of stairs?
	1	2	3	
e.	Climbing one flight of stairs?
	1	2	3	
f.	Bending, kneeling, or stooping?
	1	2	3	
g.	Walking more than a mile?
	1	2	3	
h.	Walking several blocks?
	1	2	3	
i.	Walking one block?
	1	2	3	
j.	Bathing or dressing yourself?
	1	2	3	

 
                  
Q4.	
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?

	Yes	No	
a.	Cut down on the amount of time you spent on work or other activities?
	1	2	
b.	Accomplished less than you would like?
	1	2	
c.	Were limited in the kind of work or other activities?
	1	2	
d.	Had difficulty performing the work or other activities (for example, it took extra effort)?                              
	1	2	

										    

Q5.	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)?

	Yes	No	
a.	Cut down on the amount of time you spent on work or other activities?
	1	2	
b.	Accomplished less than you would like?
	1	2	
c.	Didn’t do work or other activities as carefully as usual?
	1	2	

           

Not 
At All	
Slightly	
Moderately	Quite
A Bit	
Extremely	
1	2	3	4	5	

Q6.	During the past 4 weeks, to 
          	what extent has your physical 
          	health or emotional problems 		
          	interfered with your normal 
          	social activities with family, 
          	friends, neighbors, or groups?

				

None	Very
Mild	
Mild	Quite
A Bit	
Severe	Very
Severe	
1	2	3	4	5	6	

Q7.	How much bodily pain have you 
          	had during the past 4 weeks? 		

Q8.	
Not 
At All	
Slightly	
Moderately	Quite
A Bit	
Extremely	
1	2	3	4	5	

During the past 4 weeks, how much 
          	did pain interfere with your normal 
          	work (including both work outside 	  
          	the home and housework)?

These questions are about how you feel and how things have been with you during the past 4 weeks.  For each question, please circle the one answer that comes closest to the way you have been feeling

Q9.	How much of the time during the past 4 weeks:

	All
Of the
Time	Most
Of the
Time	A Good
Bit of
The Time	Some
Of the
Time	A Little
Of the
Time	None
Of the
Time	
a.	Did you feel full of pep? 
	1	2	3	4	5	6	
b.	Have you been a very nervous person?
	1	2	3	4	5	6	
c.	Have you felt so down in the dumps that nothing could cheer you up
	1	2	3	4	5	6	
d.	Have you felt calm and peaceful?  
	1	2	3	4	5	6	
e.	Did you have a lot of energy?
	1	2	3	4	5	6	
f.	Have you felt downhearted and blue?
	1	2	3	4	5	6	
g.	Did you feel worn out? 
	1	2	3	4	5	6	
h.	Have you been a happy person?
	1	2	3	4	5	6	
i.	Did you feel tired? 
	1	2	3	4	5	6	

Q10.	
All of
The Time	Most of
The Time	Some of
The Time	A Little of
The Time	None of
The Time	
1	2	3	4	5	

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.)?

Q11.	How TRUE or FALSE is each of the following statements for you?

	Definitely
True	Mostly
True	Don’t
Know	Mostly
False	Definitely
False	
a.	I seem to get sick a little easier than other people.
	1	2	3	4	5	
b.	I am as healthy as anybody I know.
	1	2	3	4	5	
c.	I expect my health to get worse. 	
	1	2	3	4	5	
d.	My health is excellent.	
	1	2	3	4	5	

SECTION B
The following questions are about smoking and tobacco use.  Please circle the correct answer.

Q12.	Please circle the answer that best describes your smoking status.  

1.	I CURRENTLY SMOKE CIGARETTES.
2.	I have smoked in the past, but quit within the last 1 month.
3.	I have smoked in the past, but quit within the last 6 months.
4.	I have smoked in the past, but quit within the last year.	
5.	I have smoked in the past, but quit over a year ago.
6.	I have never smoked.
7.	i CURRENTLY USE OTHER TOBACCO
8.	I HAVE USED OTHER TOBACCO IN THE PAST, BUT QUIT WITHIN THE LAST 1 MONTH
9.	I HAVE USED OTHER TOBACCO IN THE PAST, BUT QUIT WITHIN THE LAST 6 MONTHS
10.	I HAVE USED OTHER TOBACCO IN THE PAST, BUT QUIT WITHIN THE LAST YEAR
11.	I HAVE USED OTHER TOBACCO IN THE PAST, BUT QUIT OVER A YEAR AGO

If you have not smoked within the last 12 months, please skip to Question 20 on page 7.
If you currently smoke or have quit within the last year, please continue on.

Within
5 min.	Within
6–30 min.	Within
31–60 min.	After
60 min.	
1	2	3	4	

Q13.	How soon after you wake up do 	     
           	you smoke your first cigarette?	

Yes	No	
1	2	

									
Q14.	Do you find it difficult to refrain from smoking
in places where it is forbidden (e.g., in church,
at the library, in cinema, etc.)?			    

The first one
In the morning	
All others	
1	2	

Q15.	Which cigarette would you hate most to give up?

Q16.	How many cigarettes/day do you smoke?
a.	(1) 10 or LESS
b.	(2) 11–20
c.	(3) 21–30
d.	(4) 31 or MORE

	Yes	No	

Do you smoke more frequently during the first hours after waking than during the rest of the day?	……
	
1	
2	

Do you smoke if you are so ill that you are in bed most of the day? …………………………………..
	
1	
2	

a.  Have you ever tried to quit smoking?  …………
           	1	2	
If no, skip to question 20 on the next page

Q17.	

Q18.	

Q19.	

               b.  If yes, how many times have you tried to quit? _______Times

Q20.	
	Yes	No	
a.   Have you ever smoked cigarettes fairly regularly (practically every day)?	1	2	
					If no, skip to question 21 below

b.   If yes, on average how many cigarettes do/did you smoke each day?	_______

c.   During how many years have/had you smoked this amount?	____ YEARS

Q21.	
	Yes	No	
a.   Do you currently smoke cigars?
	1	2	
b.   Have you ever smoked cigars fairly regularly?
	1	2	
If no, skip to question 22 below

c.   If yes, on average how many cigars do/did you smoke each week?	_______

d.   During how many years have/had you smoked this amount?	____ YEARS
(SMOKE_CIGAR_YEARS) – code number

Q22.	
	Yes	No	
a.   Do you currently smoke pipe tobacco?
	1	2	
b.   Have you ever smoked pipe tobacco fairly regularly?
	1	2	
If no, skip to question 23 on the next page

c.   If yes, on average how many pipefuls of tobacco do/did you use each week?	______

d.   During how many years have/had you smoked this amount?		______ YEARS

Q23.	
	Yes	No	
a.   Do you currently use chewing tobacco?
	1	2	
b.   Have you ever used chewing tobacco fairly regularly?
	1	2	
If no, skip to question 24 below 

c.	If yes, on average how many plugs, wads, or chaws of chewing tobacco do/did you 
use per day?     ___###_

d.   During how many years have/had you used this amount?		____ YEARS

Q24.	
	Yes	No	
a.   Do you currently use snuff?
	1	2	
b.   Have you ever used snuff fairly regularly?
	1	2	
If no, skip to Section C below 

c.	If yes, on average how many dips, pinches, or rubs of snuff do/did you 
use per day?     ______

d.   During how many years have/had you used this amount?		_____ YEARS

SECTION C
The following questions are about drinking alcohol.  
Please CIRCLE the answer that best describes your drinking habits.

Q25.	Please circle the answer that best describes your alcohol drinking.

1.	I currently drink alcohol.
2.	I drank alcohol in the past, but quit drinking within the last 1 month.
3.	I drank alcohol in the past, but quit drinking within the last 6 months.
4.	I drank alcohol in the past, but quit drinking within the last year.
5.	I drank alcohol in the past, but quit drinking over a year ago.
6.	I have never drUnk alcohol.

If you did not drink alcohol within the last 12 months, please skip to Section D on page 10.  
If you currently drink alcohol or have quit drinking within the last year, please continue on.

Never	
Less than Monthly	2 to 4 Times a Month	2 or 3 Times a Week	4 or More Times 
a Week	
1	2	3	4	5	

Q26.	How often do you have a drink 
containing alcohol?	 

Q27.	How many drinks containing alcohol do you have on a typical day when you are drinking?	
a.	(1) 1 OR 2
b.	(2) 3 OR 4
c.	(3) 5 OR 6
d.	(4) 7 TO 9
e.	(5) 10 OR MORE

	Never	Less than Monthly	Monthly	Weekly	Daily or Almost Daily	
How often do you have six or more drinks on one occasion?
	1	2	3	4	5	
How often during the last year have you found that you were not able to stop drinking once you had started? 
	1	2	3	4	5	
How often during the last year have you failed to do what was normally expected of you because of drinking?	
	1	2	3	4	5	
How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
	1	2	3	4	5	
How often during the last year have you had a feeling of guilt or remorse after drinking? 
	1	2	3	4	5	
How often during the last year have you been unable to remember what happened the night before because you had been drinking?	 
	1	2	3	4	5	

	

Q28.	

Q29.	

Q30.	

Q31.	

Q32.	

Q33.	

	
No	Yes, but not in the last year	Yes, during the last year	
Have you or someone else been injured because of your drinking?	 ………………………………….         
	
1	
2	
3	
Has a relative or friend or a doctor or other health care worker been concerned about your drinking or suggested you cut down?  ……………………….
(CUT_DOWN_DRINKS)	
1	
2	
3	

Q34.	 

Q35.	Q38

	Yes	No	
a.   Have you ever thought you should quit drinking? …..
	1	2
	
	  If no, skip to Section D below
	
b.	If yes, have you ever tried to quit drinking? …………
	1	2	

			
Q36.	 

   

              
c.  If yes, how may times have you tried to quit drinking?   …………………..     __Times

Many, always, everyday, all my life = 5
Several = 4 
Few = 3
While Pregnant = 2
I just stopped, I did quit = 1

SECTION D
The following statements are about your feelings in the last week.  
For each of the following, please indicate how often you felt that way during the past week.

	Rarely or none of the time
(less than 1 day)	Some or a little of the time
(1 to 2 days)	Moderately or much of the time
(3 to 4 days)	Most or all of the time
(5 to 7 days)	
I felt that I could not shake off the blues even with help from my family and friends.
	1	2	3	4	
I felt depressed. 
	1	2	3	4	
I felt fearful.	
	1	2	3	4	
My sleep was restless.	
	1	2	3	4	
I felt hopeful about the future.
	1	2	3	4	

				    	        

Q37.	 

Q38.	 

Q39.	

Q40.	

Q41.	 

SECTION E
The following questions are to assess how much you are bothered by your head and neck condition and/or treatment.  Please circle the answer that best describes you.  If you are unsure about how to answer, please give the best answer you can.

Q42.	As a result of your head and neck condition or treatment, over the past four weeks, how much
            have you been bothered by your ……….

	Not 
At All	
Slightly	
Moderately
	
A lot	
Extremely
	
a.  Ability to talk to other people? …….. 
	1	2	3	4	5	
b.  Ability to talk on the phone?  ………
	1	2	3	4	5	

Q43.	Over the past four weeks, how much have you been bothered by ……….

	Not 
At All	
Slightly	
Moderately
	
A lot	
Extremely
	
a.	Concerns or worries about your appearance related to your head and neck condition or treatment?
	1	2	3	4	5	
b.	Emotional problems related to your head and neck condition or treatment? 
	1	2	3	4	5	
c.	Embarrassment about your symptoms? 
	1	2	3	4	5	
d.	Frustration about your condition?
	1	2	3	4	5	
e.	Financial worries due to medical problems? 
	1	2	3	4	5	
f.	Worries that your condition will get worse? 
	1	2	3	4	5	
g.	Physical problems related to your head and neck condition? 
	1	2	3	4	5	

						          

For this Section, 6= Feeding Tube/ Not Applicable

Please circle the answer that best describes you.  If you are unsure about how to answer, please give the best answer you can.
Q44.	As a result of your head and neck condition or treatment, over the past four weeks, how much
            have you been bothered by problems with …………

	Not
At All	Slightly	Moderately	A lot	Extremely	
a.	Volume of your voice? 
	1	2	3	4	5	
b.	Clarity of your voice? 
	1	2	3	4	5	
c.	Difficulty opening your mouth? 
	1	2	3	4	5	
d.	Dryness in your mouth while eating?
	1	2	3	4	5	
e.	Chewing food (for example, pain, difficulty opening or closing your mouth, moving food in your mouth, or teeth or denture problems)? 
	1	2	3	4	5	
f.	Swallowing liquids? 
	1	2	3	4	5	
g.	Swallowing soft foods and/or solids?
	1	2	3	4	5	
h.	Your ability to taste food (for example, loss of taste, and/or loss of appetite due to poor taste)? 
	1	2	3	4	5	
i.	Pain, burning, and/or discomfort in your mouth, jaw, or throat?
	1	2	3	4	5	
j.	Shoulder or neck pain? 
	1	2	3	4	5	
k.	Waking up frequently during the night?
	1	2	3	4	5	

					

Never	Rarely	Sometimes
	Frequently	Always
	
1	2	3	4	5	

		
Q45.	Over the past four weeks, how often
            did you take pain medication?			      

Q46.	
	Yes	No	
a.   During the 6 months prior to being diagnosed with a head and neck condition, were you ever working (employed)?...
	1	2	
	If no, skip to question 47 below	
b.   If yes, are you currently unable to work due to your head and neck condition or treatment? .……………..
	1	2	

	Not at all
	Slightly 
	Moderately
	Very
	Extremely
	
a.	For the past four weeks, please rate your overall amount of disturbance or bother as a result of your head and neck condition? 
	
1	
2	
3	
4	
5	

Q47.	

Poor	Fair	Good	Very Good	Excellent	
1	2	3	4	5	

b.	Overall how would you rate your
	       response to treatment?				

*NOTE: Skip this question in BioDBx on Baseline Survey

SECTION F
The following questions are about your sleep during the past 4 weeks.

Q48.	How often during the past 4 weeks did you…

	All of the time
	Most of the time
	A good bit of the time
	Some of the time
	A little of the time
	None of the time
	
a.	Get enough sleep to feel rested upon waking in the morning?
	1	2	3	4	5	6	
b.	Awaken short of breath or with a headache?
	1	2	3	4	5	6	
c.	Have trouble falling asleep?
	1	2	3	4	5	6	
d.	Awaken during your sleep time and have trouble falling asleep again?
	1	2	3	4	5	6	
e.	Have trouble staying awake during the day?
	1	2	3	4	5	6	
f.	Get the amount of sleep you needed?
	1	2	3	4	5	6	

SECTION G
The following questions are about your daily physical activity.  Please circle the answer that best describes you.  If you are unsure about how to answer, please give the best answer you can.
 
Leisure Time Activity – Please think about what you do in your leisure time (excluding work or chores).  

Q49.	
	Never	Seldom
 (1-2 days)	Sometimes 
(3-4 days)	Often 
(5-7 days)	
a.   Over the past 7 days, how often did you participate in sitting activities such as reading, watching TV or doing handcrafts?
	1	2	3	4	
If Never, please go to question 50 on the next page	
b.   What were these activities?
	_____ENTER TEXT_______________________________	
					
	Less than 1 hour	1-2 hours	2-4 hours	More than 4 hours	
c.   On average, how many hours per day did you engage in these sitting activities?
	1	2	3	4	

Q50.	
	Never	Seldom
 (1-2 days)	Sometimes 
(3-4 days)	Often 
(5-7 days)	
a.   Over the past 7 days, how often did you take a walk outside your home or yard for any reason?  For example, for fun or exercise, walking to work, walking the dog, etc.?
	1	2	3	4	
If Never, please go to question 51 below	
	
	Less than 1 hour	1-2 hours	2-4 hours	More than 4 hours	
b.   On average, how many hours per day did you spend walking?
	1	2	3	4	

The next four questions are about your sport and recreational activities.  Please indicate how often you participate in Light, Moderate, Strenuous and Strength Building sport and recreational activities.

Q51.	
	Never	Seldom
 (1-2 days)	Sometimes 
(3-4 days)	Often 
(5-7 days)	
a.   Over the past 7 days, how often did you engage in light sport or recreational activities such as bowling, golf with a cart, shuffleboard, fishing from a boat or pier or other similar activities?
	1	2	3	4	
If Never, please go to question 52 on the next page	
b.   What were these activities?
	_________ENTER TEXT__________________________	

	Less than 1 hour	1-2 hours	2-4 hours	More than 4 hours	
c.   On average, how many hours per day did you engage in these light sport or recreational activities?
	1	2	3	4	

Q52.	
	Never	Seldom
 (1-2 days)	Sometimes 
(3-4 days)	Often 
(5-7 days)	
a.   Over the past 7 days, how often did you engage in moderate sport and recreational activities such as doubles tennis, ballroom dancing, hunting, ice skating, golf without a cart, softball or other similar activities?
	1	2	3	4	
If Never, please go to question 53 below	
b.   What were these activities?
	_____________ ENTER TEXT________________________	

	Less than 1 hour	1-2 hours	2-4 hours	More than 4 hours	
c.   On average, how many hours per day did you engage in these moderate sport and recreational activities?
	1	2	3	4	

Q53.	
	Never	Seldom
 (1-2 days)	Sometimes 
(3-4 days)	Often 
(5-7 days)	
a.   Over the past 7 days, how often did you engage in strenuous sports and recreational activities such as jogging, swimming, cycling, singles tennis, aerobic dance, skiing (downhill or cross-country) or other similar activities?
	1	2	3	4	
If Never, please go to question 54 on the next page	
b.   What were these activities?
	____________ ENTER TEXT________________________	
					
	Less than 1 hour	1-2 hours	2-4 hours	More than 4 hours	
c.   On average, how many hours per day did you engage in these strenuous sport and recreational activities?
	1	2	3	4	

Q54.	

	Never	Seldom
 (1-2 days)	Sometimes 
(3-4 days)	Often 
(5-7 days)	
a.   Over the past 7 days, how often did you do any exercises specifically to increase muscle strength and endurance, such as lifting weights or pushups, etc.?
	1	2	3	4	
If Never, please go to question 55 below	
b.   What were these activities?
	_______________ ENTER TEXT___________________	
					
	Less than 1 hour	1-2 hours	2-4 hours	More than 4 hours	
c.   On average, how many hours per day did you engage in exercises to increase muscle strength and endurance?
	1	2	3	4	

Household Activity
	Yes	No	
Q55.	During the past 7 days, have you done any light housework, such as dusting or washing dishes? …………………….……...
	1	2	

	Yes	No	
Q56.	During the past 7 days, have you done any heavy housework or chores, such as vacuuming, scrubbing floors, washing windows, or carrying wood? ……………………………………………..
	1	2	

Q57.	During the past 7 days, did you engage in any of the following activities?  (Please answer Yes or No for each item.)
	Yes	No	
a.   Home repairs like painting, wallpapering, electrical work, etc. 
	1	2	
b.	Lawn work or yard care, including snow or leaf removal, wood chopping, etc.
	1	2	
c.	Outdoor gardening
	1	2	
d.	Caring for another person, such as children, dependent spouse, or another adult
	1	2	

Work-Related Activity

Q58.	
	Yes	No	
a.   During the past 7 days did you work for pay or as a volunteer? 	1	2	
					If no, please go to Section H below

b.	How many hours per week did you work for pay and/or as a volunteer?    ________ Hours

c.	Which of the following categories best describes the amount of physical activity required on your job and/or volunteer work? (Please circle your answer)  

1.	Mainly sitting with slight arm movements.  (Examples: office worker, watchmaker, seated assembly line worker, bus driver, etc.)	
2.	Sitting or standing with some walking.  (Examples: cashier, general office worker, light tool and machinery worker.)	
3.	Walking, with some handling of materials generally weighing less than 50 pounds.  (Examples: mailman, waiter/waitress, construction worker, heavy tool and machinery worker.)	
4.	Walking and heavy manual work often requiring handling of materials weighing over 50 pounds.  (Examples: lumberjack, stone mason, farm or general laborer.)	

SECTION H
Finally, we would like to know a few things about you.  Please provide the correct answer.

Q59.	How old are you? …..……………………………………………     _ YEARS OLD
Q60.	What is your sex?  

1.	MALE
2.	FEMALE

	Yes	No	
Q61.	Are you Hispanic or Latino?	1	2	

Q62.	
Which one of these groups would you say best represents your race?

1.	EUROPEAN AMERICAN / WHITE 
2.	AFRICAN AMERICAN / BLACK
3.	ASIAN 
4.	NATIVE HAWAIIN / PACIFIC ISLANDER
5.	AMERICAN INDIAN / ESKIMO / ALEUTIAN
6.	OTHER   Please specify. __________________________________________

Q63.	
If circled more than one, enter higher level

What is your highest level of education?

1.	LESS THAN HIGH SCHOOL
2.	HIGH SCHOOL DIPLOMA / GED
3.	SOME COLLEGE
4.	4 YEAR COLLEGE DEGREE
5.	MORE THAN COLLEGE

Q64.	What is your marital status?

1.   MARRIED 
	2.   SEPARATED
	3.   WIDOWED
	4.   DIVORCED
	      5.    NEVER MARRIED

	Yes	No	
Q65.	Are you a veteran of the U.S. armed forces?	1	2	

Q66.	About how much do you weigh without shoes?	___________ pounds

Q67.	About how tall are you without shoes?	______feet   	_____inches

Q68.	Have you ever been diagnosed or treated for any of the following health problems? 

	Yes	No	Don’t Know	
a.	Cancer (other than of the Head or Neck)
	1	2	3	
b.	Lung Disease (such as chronic bronchitis, or emphysema, or chronic asthma, or chronic wheezing, or regular use of inhalers)
	1	2	3	
c.	Heart Disease (such as a heart attack, or coronary heart disease, or chest pain due to your heart, or arrhythmia) 
	1	2	3	
d.	Stroke 
	1	2	3	
e.	Psychiatric Problems (such as Depression, or Manic-Depression, or Anxiety Attacks, or Schizophrenia)
	1	2	3	
f.	Diabetes 
	1	2	3	
g.	Arthritis 
	1	2	3	

										 Yes		 No
Q69.	In the past year, has your physician told you 
that your head/neck condition has returned?……………….	               1		  2

Q70.	What date did you complete this survey? ………………       Date: _mm__/__dd___/_yyyy__