Detailed evaluation of mental and physical health related quality of life

The SF-36 questionnaire is a validated tool for generic evaluation of patients’ physical and mental health. Its 36 items cover multiple dimensions, such as physical functioning, bodily pain, general health, vitality, social functioning and mental health. Owing to the high number of items, health assessment with the SF-36 is very detailed and precise, but might take patients—especially elderly people—more time to complete than other generic measure tools will .

This questionnaire has been used in various studies in different medical disciplines, including in patients with compression fractures (orthopedics), stroke (neurology) and asthma (pulmonology).


This instrument was developed for the generic evaluation of patients’ physical and mental health. It is one of the most common instruments in health-related quality of life assessment. Various studies have included the SF-36 in their evaluation, such as research in orthopedics 1 2 3 on patients with compression fractures, in neurology on stroke patients 4 and in pulmonology on patients with asthma 5.

Items - Dimensions - Completion time

The 36 items must be answered by selecting 1 of 2–6 response options.

The questionnaire covers 8 dimensions: physical functioning (10 items), role limitations due to physical health problems (4 items), bodily pain (2 items), general health (5 items), vitality (4 items), social functioning (2 items), role limitations due to personal or emotional problems (3 items) and mental health (5 items). There is 1 item on perceived change in health. 6

In a publication including elderly patients, the completion time varied from 4 to 30 minutes, the median being 8 minutes, and 84% completed the survey in 10 minutes. 7

Scoring method

Versions 1.0 and 2.0 are scored differently.

Version 1.0 (RAND Health Care):

Each response for each item is scored from 0 to 100, 100 being the best possible health condition and 0 the worst. The points of the responses for each dimension are averaged to calculate the dimension score (0–100). There is no total score.
Items skipped are not taken into account, and the scoring mechanism remains the same (only completed items are included in calculating the average score per dimension).

Version 2.0 (QualityMetric):

The results are represented by 1 physical component score and 1 mental component score. The physical component score includes the items on parameters of physical functioning and pain, whereas the mental component score includes the mental health items. The patient’s responses can be submitted on qualitymetric.com, where an API will score the raw data. Each answer is linked with an indicator variable and different regression weights during the score calculation, and norm-based scoring is employed. 8 9

Score interpretation

For both versions, the higher the score, the better the patient’s health.

For version 2.0, each subscore as well as the physical component score and mental component score can be interpreted individually. A score of 50 represents the average in comparison with the U.S. reference population employed. The standard deviation is 10 (a score of 60 equals 1 standard deviation above the U.S. average).

The SF-36 has been validated in several languages, and an English version is available. 10 11 12 13
Version 1.0: RAND Health Care (Santa Monica, Calif., U.S.) 14 Version 2.0: QualityMetric (Johnston, R.I., U.S.) Version 2.0 has simpler instructions and items , better comparability with widely used translations and more 5-level response options in place of dichotomous response options. 8
The RAND Health Care 36-item health survey (version 1.0 of the SF-36) can be used without a license fee. QualityMetric’s SF-36v2 health survey (version 2.0 of the SF-36) requires a survey license and costs are to be expected.
The SF-36 allows a very detailed health status assessment owing to the high number and diversity of items. The SF-36 has wide international use and acceptance in several medical disciplines. For version 2.0, statistical analysis is easily and intuitively possible through translation into T scores according to a reference population .
Since there is no total or general health score for the SF-36 intended in its original publication, many researchers have sought to generate a total score by averaging or summing the response scores. 15 The tool can take a long time to answer and has a complicated scoring mechanism, making it difficult to implement in the clinical routine.

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  1. Zoarski, Gregg H., et al. “Percutaneous vertebroplasty for osteoporotic compression fractures: quantitative prospective evaluation of long-term outcomes.” Journal of Vascular and Interventional Radiology 13.2 (2002): 139-148.
  2. Copay, Anne G., et al. “Minimum clinically important difference in lumbar spine surgery patients: a choice of methods using the Oswestry Disability Index, Medical Outcomes Study questionnaire Short Form 36, and pain scales.” The Spine Journal 8.6 (2008): 968-974.
  3. Glassman, Steven D., et al. “Defining substantial clinical benefit following lumbar spine arthrodesis.” JBJS 90.9 (2008): 1839-1847.
  4. Anderson, Craig, Sara Laubscher, and Richard Burns. “Validation of the Short Form 36 (SF-36) health survey questionnaire among stroke patients.” Stroke 27.10 (1996): 1812-1816.
  5. Bousquet, Jean, et al. “Quality of life in asthma. I. Internal consistency and validity of the SF-36 questionnaire.” American journal of respiratory and critical care medicine 149.2 (1994): 371-375.
  6. Hays, Ron D., Cathy Donald Sherbourne, and Rebecca M. Mazel. “The rand 36‐item health survey 1.0.” Health economics 2.3 (1993): 217-227.
  7. Hayes, Victor, et al. “The SF-36 health survey questionnaire: is it suitable for use with older adults?.” Age and ageing 24.2 (1995): 120-125.
  8. Ware Jr, John E. “SF-36 health survey update.” Spine 25.24 (2000): 3130-3139.
  9. Ellert, U., and B. M. Kurth. “Methodological views on the SF-36 summary scores based on the adult German population.” Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz 47.11 (2004): 1027-1032.
  10. Montazeri, Ali, et al. “The Short Form Health Survey (SF-36): translation and validation study of the Iranian version.” Quality of life research 14.3 (2005): 875-882.
  11. Fukuhara, Shunichi, et al. “Translation, adaptation, and validation of the SF-36 Health Survey for use in Japan.” Journal of clinical epidemiology 51.11 (1998): 1037-1044.
  12. Grevitt, Michael, et al. “The short form-36 health survey questionnaire in spine surgery.” The Journal of bone and joint surgery. British volume 79.1 (1997): 48-52.
  13. Bullinger, Monika. “German translation and psychometric testing of the SF-36 health survey: preliminary results from the IQOLA project.” Social science & medicine 41.10 (1995): 1359-1366.
  14. https://www.rand.org/health-care/surveys_tools/mos/36-item-short-form.html
  15. Lins, Liliane, and Fernando Martins Carvalho. “SF-36 total score as a single measure of health-related quality of life: Scoping review.” SAGE open medicine 4 (2016): 2050312116671725.