• Generic health status measure that was introduced in 1992 and has been translated into various languages and is used world-wide.
  • Designed to be applied to all health conditions and assess health concepts which represent basic human values and were relevant to a person’s functional status and well-being.
    • contains 36 questions covering eight domains:
      1) Physical functioning
      2) Role limitations due to physical health problems
      3) Bodily pain
      4) General health
      5) Vitality
      6) Social functioning
      7) Role limitations due to emotional problems
      8) Mental health
  • The responses are based on a Likert scale. Both standard (4 week) and acute (1 week) recall versions are used.  Version 2 of the SF-36 was released in 1996 and some modifications were made to the format, the wording of the questions and to the response options.

Clinical Considerations

  • The SF-36 is the most widely used health survey and has been used in SCI. It has been used extensively to discriminate, evaluate and predict outcomes in various health conditions, but more work is required to study the validity of the questions and the proposed modifications to the questions for SCI patient population.
  • The questions related to walking and climbing stairs are seen to be insensitive to individuals with a complete SCI.

ICF Domain

Quality of Life


Administered by interviewer or self-administered.

Number of Items





  • The manual (which must be purchased) has a scoring algorithm to transform item scores to a 0-100 scoring system.
  • Norm based scoring, where the mean score for the general population is 50 with a standard deviation of 10, is also used (scoring algorithm in manual).
  • The SF-36 can also be scored using two summary scores, a physical and a mental component score, which are norm based.


The SF-36 has been translated into over 50 languages.

Training Required



Can be found by contacting Quality Metric (www.qualitymetric.com). There is a cost to buy the manuals as well as to use the tools (depending on how they will be used).

# of studies reporting psychometric properties: 11


MCID: not established in SCI, but for a sample of patients with osteoarthritis of the lower extremities (n=142, mean age: 65.1 yrs, 70.5% female, 61.5% had knee osteoarthritis, 35.2% used NSAIDS or analgesics):

SF-36 subscales: MCID for worsening MCID for improvement
Bodily pain 7.2 7.8
Physical function 5.3 3.3
Physical component summary 2.0 2.0

Reference: Angst et al. 2001. “Smallest detectable and minimal clinically important differences of rehabilitation intervention with their implications for required sample sizes using WOMAC and SF-36 quality of life measurement instruments in patients with osteoarthritis of the lower extremities” Arthritis Care & Research, 45(4),  384–391. SEM & MDC: SF-36 score SEM and MDC (calculated from data in Lin et al. 2007):

SF-36 subscales: SEM MDC
Physical functioning 21.4 59.4
Role physical 14.7 40.8
Bodily pain 7.4 20.6
General health 7.9 21.8
Vitality 4.6 12.7
Social functioning 5.9 16.3
Role emotional 4.1 11.3
Mental health 7.4 20.6
  • There is published data and norms available for some health conditions as well as for the general population (Canada and United States).
  • Higher scores indicate higher levels of health.
  • Further research is needed on using the SF-36 for individuals with SCI to understand how they are answering the questions to ensure the data is valid.
  • Normative data for the SCI population have not been reported at this time
  • Published data on the SCI population is available for comparison (see Interpretability section of the Study Details sheet).


  • Internal consistency ranges from moderate to high for total SF-36 (Cronbach’s a = 0.82) and subscales:
    • Physical Functioning (Cronbach’s a = 0.91-0.98)
    • Role Physical (Cronbach’s a = 0.94)
    • Bodily Pain (Cronbach’s a = 0.79)
    • General Health (Cronbach’s a = 0.79-0.82)
    • Vitality (Cronbach’s a = 0.76)
    • Social Functioning (Cronbach’s a = 0.72)
    • Role Emotional (Cronbach’s a = 0.89)
    • Mental Health (Cronbach’s a=0.78)
  • Inter-rater and intra-rater reliability ranges from moderate to high for the SF-36 subscales: (Inter-rater ICC, intra-rater ICC)
    • Physical Functioning (0.67, 0.71)
    • Role Physical (0.90, 0.89)
    • Bodily Pain (0.70, 0.87)
    • General Health (0.41, 0.87)
    • Vitality (0.86, 0.93)
    • Social Functioning (0.52, 0.93)
    • Role Emotional (0.98, 0.99)
    • Mental Health (0.57, 0.77)

(Forchheimer et al. 2004, King & Roberts 2002, Lin 2007, Luther et al. 2006, Van Leeuwen et al. 2012)


  • Correlation of the SF-36 mental summary is high with Behavioural Risk Factor Surveillance System items (Pearson’s r=-0.650 to -0.761), low with the Quality of WellBeing (Pearson’s r=0.116), and low with the Instrumental Activities of Daily Living (Pearson’s r=0.262).
  • Correlation of the SF-36 physical summary is moderate with the Behavioural Risk Factor Surveillance System items (Pearson’s r=-0.458 to -0.489), the Quality of WellBeing (Pearson’s r=0.417) and the Instrumental Activities of Daily Living (Pearson’s r=-0.357)
  • The ability of the SF-36 to discriminate among subgroups with respect to age, education, marital status, employment, time since injury, level of injury, and self-care ability was tested using the Mann-Whitney U-test.
  • The domains of the SF-36 had significant discriminant validity between employment and self-care ability; the discriminant ability differed with other characteristics. Overall, the SF-36 domains significantly discriminated between subgroups in terms of 2-4 characteristics.

(Forchheimer et al. 2004, King & Roberts 2002, Lin 2007, Luther et al. 2006, Van Leeuwen et al. 2012, Andresen et al. 1999, Bonne-Lee et al. 2008, Miller et al. 2008, Raichle et al. 2006, Anton et al. 2006, Horner-Johnson et al. 2010)


  • Significantly lower scores for individuals with SCI than the nondisabled group were reported on the Physical Functioning, Bodily Pain and Role-Physical domains.
  • However, all Vitality subscale items showed significant positive differential functioning for people with SCI when controlling for total physical health scores.

(Lin 2007, Bonne-Lee et al. 2008, Horner-Johnson et al. 2010)

Floor/Ceiling Effect

  • Floor effects and ceiling effects reported for the SF-36.
  • 3 subscales (role physical, social functioning, role emotion) exhibited ceiling effects between 22.5 and 75.3%.
  • 2 subscales (physical functioning and role physical) exhibited floor effects 24.2% and 36.3%, respectively.

(King & Roberts 2002, Van Leeuwen et al. 2012, Andresen et al. 1999, Lin 2007, Bonne-Lee et al. 2008)


Dr. Ben Mortenson, Brodie Sakakibara, John Zhu, Jeremy Mak, Risa Fox

Date Last Updated

24 July 2020

Andresen EM, Fouts BS, Romeis JC, Brownson CA. Performance of health-related quality-of-life instruments in a spinal cord injured population. Arch Phys Med Rehabil, 1999; 80: 877-84.

Anton HA, Miller WC, Townson AF. Measuring fatigue in persons with spinal cord injury. Arch Phys Med Rehabil 2008; 89: 538-542.

Ataoğlu E, Tiftik T, Kara M, Tunç H, Ersöz M, Akkuş S. Effects of chronic pain on quality of life and depression in patients with spinal cord injury. Spinal Cord. 2013;51(1):23-6.

Bonne-Lee B, King MT, Simpson JM, Haran MJ, Stockler MR, Marial O, Salkeld G. Validity, responsiveness, and minimal important difference for the SF-6D Health Utility Scale in a spinal cord injured population. Value in Health, 2008; 11(4): 680-688.

Forchheimer M, McAweene M, Tate DG. Use of the SF-36 among persons with spinal cord injury. Am J Phys Med Rehabil, 2004; 83: 390-395.

Golhasani-keshtan F, Ebrahimzadeh MH, Fattahi AS, Soltani-moghaddas SH, Omidi-kashani F. Validation and cross-cultural adaptation of the Persian version of Craig Handicap Assessment and Reporting Technique (CHART) short form. Disabil Rehabil. 2013;35(22):1909-14.

Horner-Johnson W, Krahn GL, Suzuki R, Peterson JJ, Roid G, Hall T, the RRTC Expert Panel on Health Measurement. Differential performance of SF-36 items in healthy adults with and without functional limitations. Arch Phys Med Rehabil 2010;91:570-5.

King JT and Roberts MS. Validity and reliability of the Short Form-36 in cervical spondylotic myelopathy. J Neurosurg (Spine 2), 2002; 97:180-185.

Lee BB, Simpson JM, King MT, Haran MJ, Marial O. The SF-36 walk-wheel: a simple modification of the SF-36 physical domain improves its responsiveness for measuring health status change in spinal cord injury. Spinal Cord. 2009;47(1):50-5.

Lin M-R, Hwang H-F, Chen C-Y, Chiu W-T. Comparisons of the Brief Form of the World Health Organization Quality of Life and Short Form-36 for Persons with Spinal Cord Injuries. Am J Phys Med Rehabil 2007;86:104–113.

Luther SL, Kromrey J, Powell-Cope G, Rosenberg D, Nelson A, Ahmed S, Quigley P. A pilot study to modify the SF-36V physical functioning scale for use with veterans with spinal cord injury. Arch Phys Med Rehabil 2006; 87: 1059-1066.

McHorney C, Ware JJ, Lu R, CD S. The MOS 36-Item Short-Form Health Survey (SF-36): III. Tests of Data Quality, Scaling Assumptions, and Reliability Across Diverse Patient Groups. Med Care 1994;32:40-66.

Miller WC, Anton HA, Townson AF. Measurement properties of the CESD scale among individuals with spinal cord injury. Spinal Cord 2008; 46: 287-292.

Raichle KA, Osborne TL, Jensen MP, Cardenas D. The reliability and validity of pain interference measures in people with spinal cord injury. The Journal of Pain, 2006; 7(3): 179-186.

Silveira E, Taft C, Sundh V, Waern M, Palsson S, Steen B. Performance of the SF-36 health survey in screening for depressive and anxiety disorders in an elderly female Swedish population. Qual Life Res. 2005;14(5):1263-74.

Tramonti F, Gerini A, Stampacchia G. Individualised and health-related quality of life of persons with spinal cord injury. Spinal Cord. 2014;52(3):231-5.

Unalan H, Misirlioglu TO, Erhan B, Akyuz M, Gunduz B, Irgi E, Arslan HE, Baltacı A, Aslan S, Palamar D, Kutlu A, Majlesi J, Akarırmak U, Karamehmetoglu SS. Validity and reliability study of the Turkish version of Spinal Cord Independence Measure-III. Spinal Cord. 2015;53(6):455-60.

van Leeuwen CMC, van der Woude LHV, Post MWM. Validity of the mental health subscale of the SF-36 in persons with spinal cord injury. Spinal Cord, 2012; 00:1-7.

Ware JJ, Sherbourne C. The MOS 36-Item Short-Form Health Survey (SF-36)-I. Conceptual framework and item selection. Med Care 1992;30:473-483.

Ware JE, Kosinski M, Keller SF. SF-36 Physical and Mental Health Summary Scales: A User’s Manual. Boston, MA: The Health Institute, 1994