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X1
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Overall, in the last 30 days, how much pain or bodily aches did you have? |
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X2
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In the last 30 days, how much difficulty did you have with sleeping such as falling asleep, waking up frequently during the night or waking up too early in the morning? |
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X3
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Overall, in the last 30 days, how much of a problem did you have with moving around? |
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X4
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Overall, in the last 30 days, how much difficulty did you have with concentrating or remembering things? |
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X5
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In the last 30 days, how much of a problem did you have because of shortness of breath? |
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X6
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Overall, in the last 30 days, how much of a problem did you have with feeling sad, low, or depressed? |
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X7
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Do you have any impairment or health problem that limits the kind or amount of work you can do? |
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X8
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Paul has a headache once a month that is relieved after taking a pill. During the headache he can carry on with his day-to-day affairs. Overall, in the last 30 days, how much of a problem did Paul have with bodily aches or pains? |
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X9
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Maria takes about two hours every night to fall asleep. She wakes up once or twice a night feeling panicked and takes more than one hour to fall asleep again. In the last 30 days, how much difficulty did Maria have with sleeping, such as falling asleep, waking up frequently during the night or waking up too early in the morning? |
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X10
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Henry has pain that radiates down his right arm and wrist during his day at work. This is slightly relieved in the evenings when he is no longer working on his computer. Overall, in the last 30 days, how much of bodily aches or pains did Henry have? |
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X11
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Karen wakes up almost once every hour during the night. When he wakes up in the night, it takes around 15 minutes for her to go back to sleep. In the morning she does not feel well-rested. In the last 30 days, how much difficulty did Karen have with sleeping such as falling asleep, waking up frequently during the night or waking up too early in the morning? |
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X12
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Charles has pain in his knees, elbows, wrists and fingers, and the pain is present almost all the time. Although medication helps, he feels uncomfortable when moving around, holding and lifting things. Overall, in the last 30 days, how much of bodily aches or pains did Charles have? |
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X13
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Alice falls asleep easily at night, but two nights a week she wakes up in the middle of the night and cannot go back to sleep for the rest of the night. In the last 30 days, how much difficulty did Alice have with sleeping, such as falling asleep, waking up frequently during the night or waking up too early in the morning? |
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X14
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Tom has a lot of swelling in his legs due to his health condition. He has to make an effort to walk around his home as his legs feel heavy. Overall, in the last 30 days, how much of a problem did Tom have with moving around? |
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X15
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Lisa can concentrate while watching TV, reading a magazine or playing a game of cards or chess. Once a week she forgets where her keys or glasses are, but finds them within five minutes.Overall, in the last 30 days, how much difficulty did Lisa have with concentrating or remembering things? |
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X16
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Kevin does not exercise. He cannot climb stairs or do other physical activities because he is obese. He is able to carry the groceries and do some light household work. Overall, in the last 30 days, how much of a problem did Kevin have with moving around? |
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X17
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Sue is keen to learn new recipes but finds that she often makes mistakes and has to reread several times before she is able to do them properly. Overall, in the last 30 days, how much difficulty did Sue have with concentrating and remembering things? |
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X18
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Rob is able to walk distances of up to 200 metres without any problems but feels tired after walking one kilometre or climbing more than one flight of stairs. He has no problems with day-to-day activities, such as carrying food from the market. Overall, in the last 30 days, how much of a problem did Rob have with moving around? |
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X19
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Eve cannot concentrate for more than 15 minutes and has difficulty paying attention to what is being said to her. Whenever she starts a task, she never manages to finish it and often forgets what she was doing. She is able to learn the names of people she meets. Overall, in the last 30 days, how much difficulty did Eve have with concentrating or remembering things? |
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X20
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Mark has no problems with walking slowly. He gets out of breath easily when climbing uphill for 20 meters or a flight of stairs. In the last 30 days, how much of a problem did Mark have because of shortness of breath? |
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X21
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Anna feels depressed most of the time. She weeps frequently and feels hopeless about the future. She feels that she has become a burden on others and that she would be better dead. Overall, in the last 30 days, how much of a problem did Anna have with feeling sad, low or depressed? |
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X22
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Paul suffers from respiratory infections about once every year. He is short of breath 3 or 4 times a week and had to be admitted in hospital twice in the past month with a bad cough that required treatment with antibiotics. In the last 30 days, how much of a problem did Paul have because of shortness of breath? |
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X23
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Maria feels nervous and anxious. She worries and thinks negatively about the future, but feels better in the company of people or when doing something that really interests her. When she is alone she tends to feel useless and empty. Overall, in the last 30 days, how much of a problem did Maria have with feeling sad, low or depressed? |
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X24
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Henry has been a heavy smoker for 30 years and wakes up with a cough every morning. He gets short of breath even while resting and does not leave the house anymore. He often needs to be put on oxygen.In the last 30 days, how much of a problem did Henry have because of shortness of breath? |
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X25
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Karen enjoys her work and social activities and is generally satisfied with her life. She gets depressed every 3 weeks for a day or two and loses interest in what she usually enjoys but is able to carry on with her day-to-day activities.Overall, in the last 30 days, how much of a problem did Karen have with feeling sad, low or depressed? |
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X26
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Alice has almost constant pain in her back and this sometimes prevents her from doing her work. How much is Alice limited in the kind or amount of work she could do? |
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X27
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Kevin suffers from back pain that causes stiffness in his back especially at work but is relieved with low doses of medication. He does not have any pains other than this generalized discomfort. How much is Kevin limited in the kind or amount of work he could do? |
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X28
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Lisa has pain in her back and legs, and the pain is present almost all the time. It gets worse while she is working. Although medication helps, she feels uncomfortable when moving around, holding and lifting things at work. How much is Lisa limited in the kind or amount of work she could do? |
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X29
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Tom feels worried all the time. He gets depressed once a week at work for a couple of days in a row, thinking about what could go wrong and that his boss will disapprove of his condition. But he is able to come out of this mood if he concentrates on something else. How much is Tom limited in the kind or amount of work he could do? |
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X30
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Tamara has mood swings on the job. When she gets depressed, everything she does at work is an effort for her and she no longer enjoys her usual activities at work. These mood swings are not predictable and occur two or three times during a month. How much is Tamara limited in the kind or amount of work she could do? |
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X31
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Anthony generally enjoys his work. He gets depressed every 3 weeks for a day or two and loses interest in what he usually enjoys but is able to carry on with his day-to-day activities on the job.How much is Anthony limited in the kind or amount of work he could do? |
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X32
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Eve has had heart problems in the past and she has been told to watch her cholesterol level. Sometimes if she feels stressed at work she feels pain in her chest and occasionally in her arms.How much is Eve limited in the kind or amount of work she could do? |
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X33
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Mark has been diagnosed with high blood pressure. His blood pressure goes up quickly if he feels under stress. Mark does not exercise much and is overweight. How much is Mark limited in the kind or amount of work he could do? |
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X34
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Anna has undergone triple bypass heart surgery. She is a heavy smoker and still experiences severe chest pain sometimes. How much is Anna limited in the kind or amount of work she could do? |
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X35a
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please state your gender |
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X35b
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please state your birth year |