SCQ. Self Completion Questionnaire

SCQ. Self Completion Module of JSTAR 2011

Label Type Description
SCQ1 Question Which of the following statements most accurately describes the current status of your overall health condition?
SCQ2-1 Question Are you able to perform the following everyday activities without difficulty?Going out alone using public transportation such as buses or trains
SCQ2-2 Question Are you able to perform the following everyday activities without difficulty?Shopping for daily necessities
SCQ2-3 Question Are you able to perform the following everyday activities without difficulty?Boiling water in a kettle
SCQ2-4 Question Are you able to perform the following everyday activities without difficulty?Paying bills
SCQ2-5 Question Are you able to perform the following everyday activities without difficulty?Making deposits in and withdrawals from your bank or postal account
SCQ2-6 Question Are you able to perform the following everyday activities without difficulty?Filling out documentation such as pension forms
SCQ2-7 Question Are you able to perform the following everyday activities without difficulty?Reading newspapers
SCQ2-8 Question Are you able to perform the following everyday activities without difficulty?Reading books and magazines
SCQ2-9 Question Are you able to perform the following everyday activities without difficulty?Taking interest in newspaper/magazine articles and TV programs featuring health
SCQ2-10 Question Are you able to perform the following everyday activities without difficulty?Visiting friends' homes
SCQ2-11 Question Are you able to perform the following everyday activities without difficulty?Giving advice to family members, friends, etc.
SCQ2-12 Question Are you able to perform the following everyday activities without difficulty?Visiting sick family members, friends, etc.
SCQ2-13 Question Are you able to perform the following everyday activities without difficulty?Talking to young people
SCQ2-14 Question Are you able to perform the following everyday activities without difficulty?Making phone calls without help
SCQ2-15 Question Are you able to perform the following everyday activities without difficulty?Taking medicine without help
SCQ3 Question How much do you walk per day? Please include not only the time spent on walking for leisure or exercise but also that spent on walking for shopping, commuting to work, and running errands.
SCQ4 Question Do you regularly smoke or did you do so in the past?I smoke regularly now (Go to question 4-1).......1
SCQ4-1 Question At about what age did you begin smoking regularly?
SCQ4-2 Question How much do you smoke (or did you used to smoke) per day?
SCQ4-3 Question At about what age did you quit smoking?
SCQ5 Question How often did you drink alcoholic beverages (beer, whiskey, shochu, sake, wine, etc.) in the past six months?
SCQ5-1 Question What did you usually drink and how much per occasion? If you drank more than one kind, please indicate the total quantity per day.
SCQ6 Question Are you currently concerned about your health?
SCQ7 Question Are you confident that you will be healthy three years from now?
SCQ8-1 Question Did you experience the following symptoms in the past week?Feeling uneasy about things you would usually not be concerned about
SCQ8-2 Question Did you experience the following symptoms in the past week?Poor appetite
SCQ8-3 Question Did you experience the following symptoms in the past week?Feeling depressed and unable to dispel the gloom despite encouragement from family and friends
SCQ8-4 Question Did you experience the following symptoms in the past week?Feeling capable of doing what an average person can do
SCQ8-5 Question Did you experience the following symptoms in the past week?Unable to concentrate on what you are doing
SCQ8-6 Question Did you experience the following symptoms in the past week?Feeling depressed
SCQ8-7 Question Did you experience the following symptoms in the past week?Feeling troublesome to do something you would usually do effortlessly
SCQ8-8 Question Did you experience the following symptoms in the past week?Feeling optimistic about the future
SCQ8-9 Question Did you experience the following symptoms in the past week?Feeling that your life has been a failure
SCQ8-10 Question Did you experience the following symptoms in the past week?Feeling fearful
SCQ8-11 Question Did you experience the following symptoms in the past week?Poor sleep
SCQ8-12 Question Did you experience the following symptoms in the past week?Feeling happy
SCQ8-13 Question Did you experience the following symptoms in the past week?Talking less than usual
SCQ8-14 Question Did you experience the following symptoms in the past week?Feeling lonely
SCQ8-15 Question Did you experience the following symptoms in the past week?Feeling that people are unfriendly
SCQ8-16 Question Did you experience the following symptoms in the past week?Feeling fun
SCQ8-17 Question Did you experience the following symptoms in the past week?Crying or feeling like crying
SCQ8-18 Question Did you experience the following symptoms in the past week?Feeling sad
SCQ8-19 Question Did you experience the following symptoms in the past week?Feeling that people dislike you
SCQ8-20 Question Did you experience the following symptoms in the past week?Feeling low on energy and finding everything takes effort
SCQ9 Question Are you satisfied or unsatisfied with your current life?
SCQ10-1 Question Spouse (or common-law spouse).Do you think they would sympathize and care for you if you have concerns or worries?
SCQ10-2 Question Family member(s) living together (except for spouse).Do you think they would sympathize and care for you if you have concerns or worries?
SCQ10-3 Question Son(s)/daughter(s) living separately or relatives.Do you think they would sympathize and care for you if you have concerns or worries?
SCQ10-4 Question Friends, acquaintances,neighbors, etc..Do you think they would sympathize and care for you if you have concerns or worries?
SCQ11-1 Question Spouse (or common-law spouse).Do you think they would take care of you and run errands for you if you get sick and become bedridden?
SCQ11-2 Question Family member(s) living together (except for spouse).Do you think they would take care of you and run errands for you if you get sick and become bedridden?
SCQ11-3 Question Son(s)/daughter(s) living separately or relatives.Do you think they would take care of you and run errands for you if you get sick and become bedridden?
SCQ11-4 Question Friends, acquaintances,neighbors, etc..Do you think they would take care of you and run errands for you if you get sick and become bedridden?
SCQ12-1 Question Spouse (or common-law spouse).Would you sympathize and care for them if they have concerns or worries?
SCQ12-2 Question Family member(s) living together (except for spouse).Would you sympathize and care for them if they have concerns or worries?
SCQ12-3 Question Son(s)/daughter(s) living separately or relatives.Would you sympathize and care for them if they have concerns or worries?
SCQ12-4 Question Friends, acquaintances,neighbors, etc..Would you sympathize and care for them if they have concerns or worries?
SCQ13-1 Question Spouse (or common-law spouse).Would you take care of them or be asked to run errands for them if they get sick and become bedridden?
SCQ13-2 Question Family member(s) living together (except for spouse).Would you take care of them or be asked to run errands for them if they get sick and become bedridden?
SCQ13-3 Question Son(s)/daughter(s) living separately or relatives.Would you take care of them or be asked to run errands for them if they get sick and become bedridden?
SCQ13-4 Question Friends, acquaintances,neighbors, etc..Would you take care of them or be asked to run errands for them if they get sick and become bedridden?
SCQ14-1 Question Who is or was primarily responsible for the following tasks?Taking care of children
SCQ14-2 Question Who is or was primarily responsible for the following tasks?Earning income
SCQ14-3 Question Who is or was primarily responsible for the following tasks?Preparing meals, cleaning house, and doing laundry
SCQ14-4 Question Who is or was primarily responsible for the following tasks?Providing care for elderly family member(s)
SCQ14-5 Question Who is or was primarily responsible for the following tasks?Managing household budgets
SCQ14-6 Question Who is or was primarily responsible for the following tasks?Making decisions on major purchases
SCQ15 Question How satisfied are you overall with your relationship with your spouse (or common law spouse)?
SCQ16-1 Question Men should work outside and women should run the household
SCQ16-2 Question Boys and girls should be raised differently
SCQ16-3 Question Women are more suited for housework and childcare than men
SCQ17A Question Who do you think should be responsible for Livelihood
SCQ17B Question Who do you think should be responsible for Medical and nursing care
SCQ17-2 Question (ONLY FOR HIRISHIMA STUDY) Do you have an Atomic Bomb Survivor's Certificate?
SCQ18-1 Question Both the pharmacy store(s) and clinic(s)/hospital(s) are located nearby
SCQ18-2 Question Stores selling groceries and daily necessities are located nearby
SCQ18-3 Question A park where you feel safe walking and exercising is located nearby
SCQ18-4 Question No train stations or bus stops are located nearby
SCQ18-5 Question Having pollution, noise, or other environmental problems
SCQ18-6 Question Having neighborhood safety concerns such as a rise in crime and violence
SCQ18-7 Question An appropriate place for gathering and meeting with friends is available nearby
SCQ19-1 Question What do you think of the people living in your area?Most people can be trusted
SCQ19-2 Question What do you think of the people living in your area?Other people (except your family) would take advantage of you if given the opportunity
SCQ19-3 Question What do you think of the people living in your area?Most people try to be helpful to others
SCQ20 Question When you read the term "your area" in the previous question, which of the following came to mind?
SCQ21-1 Question Time spent Commuting
SCQ21-2 Question Time spent Working
SCQ21-3 Question Time spent Housework, shopping for daily necessities
SCQ21-4 Question Time spent Taking caring of son(s)/daughter(s) or grandchildren
SCQ21-5 Question Time spent Providing care for parent(s), spouse, or other family member(s) in need
SCQ21-6 Question Time spent Sports, walking, or other exercise activities
SCQ21-7 Question Time spent Studying, learning, etc.
SCQ21-8 Question Time spent Community, religious, or political activities
SCQ21-9 Question Time spent Hobbies, leisure activities, socializing
SCQ21-10 Question Time spent Resting or relaxing (except for sleeping)
SCQ21-11 Question Time spent Sleeping
SCQ22-1 Question Male friends.Know from childhood or school days. How many friends in all?
SCQ22-2 Question Male friends.Know from childhood or school days. Number of those with whom you would share concerns, etc.
SCQ22-3 Question Male friends.Know from childhood or school days. Number of those you could ask for help if you were sick, injured or had some other problem?
SCQ22-4 Question Male friends.Know from work. How many friends in all?
SCQ22-5 Question Male friends.Know from work. Number of those with whom you would share concerns, etc.
SCQ22-6 Question Male friends.Know from work. Number of those you could ask for help if you were sick, injured or had some other problem?
SCQ22-7 Question Male friends.Know from hobby or volunteer activity. How many friends in all?
SCQ22-8 Question Male friends.Know from hobby or volunteer activity. Number of those with whom you would share concerns, etc.
SCQ22-9 Question Male friends.Know from hobby or volunteer activity. Number of those you could ask for help if you were sick, injured or had some other problem?
SCQ22-10 Question Male friends.Know through spouse or children. How many friends in all?
SCQ22-11 Question Male friends.Know through spouse or children. Number of those with whom you would share concerns, etc.
SCQ22-12 Question Male friends.Know through spouse or children. Number of those you could ask for help if you were sick, injured or had some other problem?
SCQ22-13 Question Male friends.Met through friend after graduating from school. How many friends in all?
SCQ22-14 Question Male friends.Met through friend after graduating from school. Number of those with whom you would share concerns, etc.
SCQ22-15 Question Male friends.Met through friend after graduating from school. Number of those you could ask for help if you were sick, injured or had some other problem?
SCQ22-16 Question Male friends.Live nearby. How many friends in all?
SCQ22-17 Question Male friends.Live nearby. Number of those with whom you would share concerns, etc.
SCQ22-18 Question Male friends.Live nearby. Number of those you could ask for help if you were sick, injured or had some other problem?
SCQ22-19 Question female friends.Know from childhood or school days. How many friends in all?
SCQ22-20 Question female friends.Know from childhood or school days. Number of those with whom you would share concerns, etc.
SCQ22-21 Question female friends.Know from childhood or school days. Number of those you could ask for help if you were sick, injured or had some other problem?
SCQ22-22 Question female friends.Know from work. How many friends in all?
SCQ22-23 Question female friends.Know from work. Number of those with whom you would share concerns, etc.
SCQ22-24 Question female friends.Know from work. Number of those you could ask for help if you were sick, injured or had some other problem?
SCQ22-25 Question female friends.Know from hobby or volunteer activity. How many friends in all?
SCQ22-26 Question female friends.Know from hobby or volunteer activity. Number of those with whom you would share concerns, etc.
SCQ22-27 Question female friends.Know from hobby or volunteer activity. Number of those you could ask for help if you were sick, injured or had some other problem?
SCQ22-28 Question female friends.Know through spouse or children. How many friends in all?
SCQ22-29 Question female friends.Know through spouse or children. Number of those with whom you would share concerns, etc.
SCQ22-30 Question female friends.Know through spouse or children. Number of those you could ask for help if you were sick, injured or had some other problem?
SCQ22-31 Question female friends.Met through friend after graduating from school. How many friends in all?
SCQ22-32 Question female friends.Met through friend after graduating from school. Number of those with whom you would share concerns, etc.
SCQ22-33 Question female friends.Met through friend after graduating from school. Number of those you could ask for help if you were sick, injured or had some other problem?
SCQ22-34 Question female friends.Live nearby. How many friends in all?
SCQ22-35 Question female friends.Live nearby. Number of those with whom you would share concerns, etc.
SCQ22-36 Question female friends.Live nearby. Number of those you could ask for help if you were sick, injured or had some other problem?
SCQ23 Question Overall, are you satisfied with your current friendships?
SCQ24 Question In the past month, did you engage in any non-work activities with someone other than your family and friends?
SCQ24-1 Question What kinds of activities did you engage in? Please select all that apply.
SCQ24-2 Question Which of the activities selected above did you engage in most frequently? Enter the number corresponding to the activity.
SCQ24-3 Question How often did you engage in the activity selected in question 24-2?
SCQ25 Question Did you give any donations to charities during the past year?
SCQ25-1 Question How much did you donate? A rough estimate is fine.
SCQ26 Question Do you and your spouse (or common-law spouse) manage household finances together or separately?
SCQ27 Question What was your approximate income last year after taxes and social insurance deductions? Please include all income you received, i.e., income from work, pension benefits, as well as interest and returns on financial assets (time deposits, government bonds, etc.) and investments in real estate held in your name. If you are receiving any financial support for living expenses from anyone other than your spouse (son(s), daughter(s), parents, etc.), please include the amount you received last year as well. In the case you received such support in non-cash form such as meals, include its estimated value. If you had no individual income, please enter 0.
SCQ28 Question We would now like to ask about any taxes or social insurance premiums paid in your name. Did you pay any tax (national/local income taxes, local business tax, real estate tax, automobile tax, inheritance tax, etc.) or social insurance premiums (public pension, health, and long-term care insurance premiums) out of your income last year?
SCQ28-1 Question In the past year, approximately how much did you pay altogether in taxes and social insurance premiums? If possible, please provide breakdown figures for taxes and social insurance premiums. Circle the applicable number and indicate the amount(s) as appropriate.I paid something but don't know how much..........1
SCQ29 Question We would now like to ask about your spouse's (or common-law spouse's) income. What was his/her approximate income last year after taxes and social insurance deductions? Please include all income he/she received (i.e., income from work, pension benefits, as well as interest and returns on financial assets (time deposits, government bonds, etc.) and investments in real estate held in his/her name. If he she had no individual income, please enter 0.
SCQ30 Question We would now like to ask about any taxes or social insurance premiums paid in your spouse's (or common-law spouse's) name. Did he/she pay any tax (national/local income taxes, local business tax, real estate tax, automobile tax, inheritance tax, etc.) or social insurance premiums (public pensions, health, and long-term care insurance premiums) out of your income last year?
SCQ30-1 Question In the past year, approximately how much did your spouse (or common-law spouse) pay altogether in taxes and social insurance premiums? If possible, please provide breakdown figures for taxes and social insurance premiums. Circle the appropriate number and indicate the amount(s) as appropriate.I paid something but don't know how much..........1
SCQ31 Question Do you and your spouse (or common-law spouse) manage assets together or separately?
SCQ32 Question Do you have any deposits held in your name with any bank or similar financial institution (including the Japan Post Bank, credit banks and unions, agricultural cooperatives, and trust banks) whether in the form of savings or time deposits?
SCQ32-1 Question How much do you have in total in those accounts?
SCQ33 Question Do you held any fixed income securities in your name? Fixed securities include: investment trusts (money market funds, medium-term government bond funds, foreign investment trusts, etc.), discount bank debentures, coupon bank debentures, government bonds, corporate bonds, etc.
SCQ33-1 Question How much do you have in your account?
SCQ34 Question Do you hold any equity securities that can be sold through brokers in your name?
SCQ34-1 Question If you are to sell all of those securities today, how much would you expect to receive?
SCQ35 Question Does your spouse (or common-law spouse) have any deposits in his/her name with any bank or similar financial institution (including the Japan Post Bank, credit banks and unions, agricultural cooperatives, and trust banks) whether in the form of savings or time deposits?
SCQ35-1 Question How much does your spouse have in his/her account?
SCQ36 Question Does your spouse (or common-law spouse) hold any fixed income securities in his/her name? Fixed income securities include: investment trusts (money market funds, medium-term government bond funds, foreign investment trusts, etc.), discount bank debentures, coupon bank debentures, government bonds, corporate bonds, etc.
SCQ36-1 Question How much does your spouse have in his/her account?
SCQ37 Question Does your spouse (or common-law spouse) hold any equity securities that can be sold through brokers in his/her name?
SCQ37-1 Question If your spouse (or common-law spouse) is to sell all of those securities today, how much do you expect he/she would receive?
SCQ38 Question This concludes the questionnaire. Did you answer this questionnaire by yourself or did anyone (family member, caregiver, etc.) helpyou?
SCQ38-1 Question From whom did you have help?