Q0001 调查点代码:
Surveyed site number:
1
Q0002 调查对象编号:
Respondent ID:
Q0003 是初次调查还是再次调查？ 1.初次 2.再次
Is this the initial or retest interview? 2. Retest
Q0003a 如果是再次调查，请指明两次调查间的间隔天数：(天)
If retest interview, indicate number of days between initial and
retest: (Days)
Q0004 调查员编号
Interviewer ID
Q0005 调查员姓名
Interviewer name
______________2
Q0006 调查完成日期(年/月/日)
Date of finish(Year/Month/Day)
/ /
Q0007 调查结果： 1.完成 2.部分完成 3.失访
Final result 1. Finished 2. Part finished 3. Missing
Q0008 督导员审核日期(年/月/日)
Date of audit(Year/Month/Day)
/ /
督导员签字
Signature of Supervisor
______________
AstraZeneca R&D Mölndal
第二军医大学卫生统计学教研室
1 每个空格处填写一个数字
2 请用大写英文字母填写
上海预调查
A pilot survey in general population, Shanghai
尊敬的参与者：
您好。
您已被随机地选为本次研究的调查对象，我们将对您作有关调查。本次研究是阿斯利康
国际药业公司与第二军医大学卫生统计学教研室联合开展的一项预调查研究，由专业人员进
行调查。您所提供的信息仅用于了解影响您健康的一些问题，整个调查约需 30 分钟。
您提供的信息不会泄漏给任何人，只用于研究目的。您的姓名、地址和其他个人信息将
从调查表中删去，仅用代码与您的姓名和您的回答相联系，单从调查表不能认出是您本人。
调查组在必要时可能会再次与您联系。
您的参与是自愿的，并且可以在调查过程中退出。您可以拒绝回答调查问卷中的任何一
个问题。
在调查过程中，如果您有任何问题，可直接问调查员或直接与第二军医大学卫生统计学
教研室的督导员联系。
签字表示您已了解您在本次调查中需要做的事情并愿意参加本次调查。
Dear Participant,
You have been randomly selected to be part of this survey and we would, therefore, like to
interview you. This survey is a pilot study conducted by the AstraZeneca International
Pharmaceutical Company and Department of Health Statistics, Second Military Medical
University (SMMU), and will be carried out by professional interviewers. The information you
provide will only be used to understand the main things that affect your health. The interview
will take approximately 30 minutes.
The information you provide is totally confidential and will not be disclosed to anyone. It
will only be used for research purposes. Your name, address, and other personal information
will be removed from the questionnaire, and only a code will be used to connect your name
and your answers without identifying you. The Survey Team may contact you again only if it is
necessary to complete the information on the survey.
Your participation is voluntary and you can withdraw from the survey after having
agreed to participate. You are free to refuse to answer any question that is asked in the
questionnaire.
If you have any questions about this survey you may ask interviewer or contact Principal
Investigator of Department of Health Statistics, SMMU..
Signing this consent indicates that you understand what will be expected of you and are
willing to participate in this survey.
调查对象签名： 日期：
Sign of respondent: ______________ Date: / /
联系电话：___________________
知情同意书
Consent Form
填写答案处
Answer
Q1001 姓名(请用汉语拼音填写) Full name (Please fill with English) __________3
Q1002 性别: 1-女性 2-男性 Sex:: 1-Female 2-Male 4
Q1003 年龄 (岁) Age (yrs)
Q1003a 如果记不清具体年龄，请选择您所在的年龄段：
1. 18~19 岁 2. 20~29 岁 3. 30~39 岁
4. 40~49 岁 5. 50~59 岁 6. 60~69 岁 7. 70+
If you don't know/don’t want to tell me your age could you tell me the age range:
1. 18~19yrs 2. 20~29yrs 3. 30~39yrs
4. 40~49yrs 5. 50~59ysr 6. 60~69ysr 7. 70+
Q1004 体重(公斤) Weight(kg)
Q1005 身高(厘米) Height(cm)
Q1006 婚姻状况: 1-已婚 2-未婚
Current marital status: 1- Married 2-Unmarried
Q1007 最高学历: 1-小学以下 2-小学 3-初中 4-高中 5-大专/大学 6-硕士 7-博士
The highest level of education: 1-Less than primary school 2-Primary school
completed 3-Secondary school completed 4-High school (or equivalent) completed
5-College / pre-university / University completed 6-Master degree 7-Doctor degree
Q1008 您总共接受过多少年学校教育(包括复读时间)？
How many years of school education have you completed (including repeated grades)?
Q1009 民族(请用汉语拼音填写) Nationality (Please fill with English) ___________
Q1010 职业: 1-公务员 2-专业技术人员(军人除外) 3-工人
4-农、林、牧、渔业从业者 5-服务行业人员 6-在校学生 7-军人
Current job: 1-Government employee 2-Professional or technician (excluding armed
forces) 3-Blue-collar worker 4-Agricultural or fisheries Worker
5-Personal services, marketing, or sales 6-Student in school 7-Armed forces
Q1011 家庭月收入: 1-1999 元以下 2-2000~4999 元 3-5000~9999 元 4-10000 元以上
Total income of family per month: 1-less than 1999 Yuan 2-2000~4999 Yuan
3-5000~9999 Yuan 4-10000 Yuan or above
Q1012 吸烟情况:
1-不吸 2-1~5 支/天 3-6~10 支/天
4-11~15 支/天 5-16~20 支/天 6-21 支/天 以上
Do you currently smoke?
1-No 2-1~5pieces/day 3-6~10pieces/day
4-11~15pieces/day 5-16~20pieces/day 6-21pieces/day or above
Q1012a 如果您吸烟，请说明您大概吸了多少年了？
If you smoke, for how many years are you have been smoking?
Q1013 饮酒情况: 1-不饮酒 2.-每月少于 4 次 3-每周至少一次 4-每天至少一次
Do you currently drink?: 1-No 2-Less than 4 times per month
3-At least 1 time per week 4-At least 1 time per day
Q1013a 如果您饮酒，请说明您大概饮酒多少年了？
If you drink, for how many years are you have been drinking?
Q1014 请选择您平时进行体育运动的频率:
1-不运动 2-每月少于 4 次 3-每周至少一次 4-每天至少一次
How often do you take physical activities?
1-Never 2- Less than 4 times per month
3-At least 1 time per week 4-At least 1 time per day
Q1015 总体来说，您的健康状况: 1-非常好 2-好 3-一般 4-差 5-很差
3 横线处请用大写字母填写。
4 每个空格处填写一个数字，带有小数者请四舍五入。
第一部分：基本情况
Part I: General Information)
In general, how would you rate your health? 1-Very good 2-Good 3-Moderate
4-Bad 5-Very Bad
Q1016 总体来说，您从事日常活动的能力: 1-非常好 2-好 3-一般 4-差 5-很差
Overall, how would you rate your daily activity? 1-Very good 2-Good
3-Moderate 4-Bad 5-Very Bad
Q1017 总体来说，您从事工作的能力: 1-非常好 2-好 3-一般 4-差 5-很差
Overall, how would you rate your daily work?: 1-Very good 2-Good 3-Moderate
4-Bad 5-Very Bad
Q1018 总体来说，您的精神状态: 1-非常好 2-好 3-一般 4-差 5.-很差
Overall, how would you rate your spirit? 1-Very good 2-Good 3-Moderate
4-Bad 5-Very Bad
Q1019 总体来说，您的社会交往情况: 1-非常好 2-好 3-一般 4-差 5-很差
Overall, how would you rate your interpersonal activities? 1-Very good 2-Good
3-Moderate 4-Bad 5-Very Bad
Q1020 你是否被医生诊断为以下情况/疾病？（如果是，最早做出这一诊断是在您多大年纪
时？）
Have you been diagnosed by a physician with any of the following
conditions/diseases?？（If yes, at which age was it first diagnosed）
年龄（岁）
Age（yrs）
Q1020a 高血压 Hypertension
Q1020b 缺血性心脏病 Ischemic heart disease
Q1020c 脑血管功能异常 Cerebrovascular disorder
Q1020d 糖尿病 Diabetes
Q1020e 慢性阻塞性肺病 COPD
Q1020f 哮喘 Asthma
Q1020g 肾功能异常 Renal disorder
Q1020h 肝功能异常 Liver disorder
Q1020i 风湿性关节炎 Rheumatoid arthritis
Q1020j 骨关节炎 Osteoarthritis
Q1020k 焦虑症 Anxiety
Q1020l 抑郁症 Depression
Q1021 您现在正在服下列药吗？如果有，请在后面写出已服用了多久
Are you taking following drugs currently? If yes, please write the duration that you
have taken them?
时间(月)
Duration(mont
hs)
Q1021a 皮质类固醇 Corticosteroids
Q1021b 荷尔蒙替代品 Hormone replacement
Q1022 现在服用的其它药物一，名称： Others (name)： __________5
Q1022a 服用了多少时间(月) Duration of treatment(months)
Q1023 现在服用的其它药物二，名称： Others (name)： ___________
Q1023a 服用了多少时间(月) Duration of treatment(months)
Q1024 现在服用的其它药物三，名称： Others (name)： ___________
Q1024a 服用了多少时间(月) Duration of treatment(months)
5 如不知英文名，可用中文填写。
本调查涉及你对自身健康的观点。这些信息将有助于追踪你从事日常活动的能力及自身
感觉。请回答所有问题，在方框内填下你所选择的的数字。如果你对答案不确定，请给出你
认为最接近的答案。
This survey asks for your views about your health. This information will help keep track of
how you feel and how well you are able to do your usual every question by
marking the answer as indicated. If you are unsure about how to answer a question, please give the
best answer you can.
Q6001
总的来说，你认为你的健康状况： 1-棒极了 2-很好 3-好 4-过得去 5-糟糕
In general, would you say your health is: 1-Excellent 2-Very good 3-Good 4-Fair 5-Poor
Q6002
与一年前相比，你如何评价现在的健康状况？
1-比一年前好多了 2-比一年前好一点 3-和一年前差不多
4-比一年前差一点 5-比一年前差多了
Compared to one year ago, how would you rate your health in general now?
1-Much better now than one year ago 2-Somehwat better now than one year ago 3-About the same
as one year ago 4-Somewhat worse
now than one year ago 5-Much worse now than one year ago
Q6003
下列项目是你平常在一天中可能做的事情。你现在的健康限制你从事这些活动吗？如果是的话，
程度如何？
选择项:
1-是，很受限 2-是，稍受限 3-不，完全不受限
The following items are about activities you might do during a typical day. Does your health now limit
you in these activities? Is so, how much?
Selection:
1-Yes, limited a lot 2-Yes, limited a little 3-No, not limited at all
Q6003a
高强度活动，如跑步、举重物、参与剧烈运动：
Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports:
Q6003b
中等度活动，如移动桌子，推动真空吸尘器（或拖地板）、打保龄球、打高尔夫球（或打太极
拳）：
Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf:
Q6003c
举或搬运杂物：
Lifting or carrying groceries:
Q6003d
爬数层楼梯：
Climbing several flights of stairs:
Q6003e
爬一层楼梯：
Climbing one flight of stairs:
Q6003f
弯腰、屈膝：
Bending, kneeling, or stooping:
Q6003g
步行 1500 米以上：
Walking more than a mile:
Q6003h
步行几个路口：
Walking several blocks:
Q6003i
步行一个路口：
Walking one block:
Q6003j
自己洗澡或穿衣：
Bathing or dressing yourself:
第二部分：SF-36 健康调查问卷
Part Ⅱ: SF-36
Q6004
在过去 4 周，你是否因为生理健康原因，在工作或从事其他日常活动时有下列问题？
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?
Q6004a
减少了工作或从事其他活动的时间：1-是 2-否
Cut down on the amount of time you spent on work or other activities: 1-Yes 2-No
Q6004b
减少了工作量或活动量：1-是 2-否
Accomplished less than you would like：1-Yes 2-No
Q6004c
从事工作或其他活动的种类受限：1-是 2-否
Were limited in the kind of work or other -Yes 2-No
Q6004d
从事工作或其他活动有困难（例如，费劲）：1-是 2-否
Had difficulty performing the work or other activities (for example, it took extra effort): 1-Yes 2-No
Q6005
在过去 4 周，你是否因为任何情感问题（如感到抑郁或焦虑），在工作或从事其他日常活动时有
下列问题？
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)
Q6005a
减少了工作或从事其他活动的时间：1-是 2-否
Cut down on the amount of time you spent on work or other activities: 1-Yes 2-No
Q6005b
减少了工作量或活动量：1-是 2-否
Accomplished less than you would like：1-Yes 2-No
Q6005c
不能象平常那么专心地从事工作或其他活动：1-是 2-否
Didn’t do work or other activities as carefully as usual：1-Yes 2-No
Q6006
在过去 4 周，你的生理健康或情感问题在何种程度上干扰了你与家人、朋友、邻居、或团体的正
常社会活动？ 1-完全没有 2-轻度 3-中度 4-重度 5-极度
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?
1-Not at all 2-Slightly 3-Moderately 4-Quite a bit 5-Extremely
Q6007
在过去 4 周，你经受了多少躯体疼痛？
1-完全没有 2-很轻微 3-轻微 4-中等 5-严重 6-极严重
How much bodily pain have you had during the past 4 weeks?
1-None 2-Very mild 3-Mild 4-Moderate 5-Severe 6-Very severe
Q6008
在过去 4 周，疼痛在多大程度上干扰了你的正常工作（包括户外工作和家务劳动）？
1-完全没有 2-一点点 3-中度 4-重度 5-极度
During the past 4 weeks, how much did pain interfere with your normal work (including both work
outside the home and housework)?
1-Not at all 2-A little bit 3-Moderately 4-Quite a bit 5-Extremely
Q6009
这些问题将问及你在过去4周的感觉和情感体验。对每一问题，请给出与你想法最接近的一个答
案。在过去4周，有多少时间…
选择项:
1-所有时间 2-绝大多数时间 3-很多时间 4-一些时间 5-一点时间 6-没有时间
These questions are about how you feel and how things have been with you during the past 4 weeks.
For each question, please give the one answer that comes closest to the way you have been feeling.
How much of the time during the past 4 weeks
Selection:
1- All of the time 2-Most of the time 3-A good bit of the time
4-Some of the time 5-A little of the time 6-None of the time
Q6009a
你觉得干劲十足？
Did you feel full of pep?
Q6009b
你是一个非常紧张的人？
Have you been a very nervous person?
Q6009c
你感到情绪低落、沮丧，怎么也快乐不起来？
Have you felt so down in the dumps that nothing could cheer you up?
Q6009d
你觉得平静、安适？
Have you felt calm and peaceful?
Q6009e
你觉得精力旺盛？
Did you have a lot of energy?
Q6009f
你感到闷闷不乐、心情忧郁？
Have you felt downhearted and blue?
Q6009g
你觉得累极了？
Did you feel worn out?
Q6009h
你是一个快乐的人？
Have you been a happy person?
Q6009i
你觉得疲劳？
Did you feel tired?
Q6010
在过去 4 周，有多少时间你的社会活动（如访问朋友，亲戚等）受你的生理健康或情感问题的影
响动？1-所有时间 2-绝大多数时间 3-一些时间 4-一点时间 5-没有时间
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.)?
1- All the time 2-Most of the time 3- Some times 4-A little time 5-None of the time
Q6011
下列每一种情形与你实际情况符合的程度如何?
How TRUE or FALSE is each of the following statements for you?
Q6011a
和其他人相比，我似乎更容易生病：
1-全部符合 2-大部分符合 3-不知道 4-大部分不符合 5-全部不符合
I seem to get sick a little easier than other people
1-Definitely true 2-Mostly true 3-Don’t know 4-Mostly false 5-Definitely false
Q6011b
我和我认识的人一样健康：
1-全部符合 2-大部分符合 3-不知道 4-大部分不符合 5-全部不符合
I am as healthy as anybody I know
1-Definitely true 2-Mostly true 3-Don’t know 4-Mostly false 5-Definitely false
Q6011c
我预计我的健康状况将变得更差：
1-全部符合 2-大部分符合 3-不知道 4-大部分不符合 5-全部不符合
I expect my health to get worse
1-Definitely true 2-Mostly true 3-Don’t know 4-Mostly false 5-Definitely false
Q6011d
我的身体棒极了：
1-全部符合 2-大部分符合 3-不知道 4-大部分不符合 5-全部不符合
My health is excellent
1-Definitely true 2-Mostly true 3-Don’t know 4-Mostly false 5-Definitely false
