SCQ. Self Completion Questionnaire

SCQ. Self Completion Module of JSTAR 2013

item label type description
SCQ1 Question Which of the following statements most accurately describes the current status of your overall health condition? (Circle only one.)
SCQ2-1 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. (Circle only one.)
SCQ2-2 Question How often do you do light exercise (e.g., ground golf, gateball [like croquet], jogging, radio calisthenics)?
SCQ2-3 Question How often do you do garden, grow vegetables, or care for animals?
SCQ2-4 Question How often do you do fairly strenuous exercise (e.g., tennis, soccer, swimming)?
SCQ3-1 Question Do you regularly use tobacco, or did you use it in the past? (Circle only one answer.)
SCQ3-2 Question About how many cigarettes do you smoke per day? (Answer in number of cigarettes or number of packs.)
SCQ4 Question How often did you drink alcoholic beverages in the past month? Select one from the options below. If you did, please also indicate how much you drank on average per occasion.
SCQ5-1 Question We would like to ask about your sleeping habits in the past month. How many hours do you usually sleep at night? If you have different shifts at work, please think about when you are on a day shift.
SCQ5-2 Question In the past month, how long did it take on average for you to fall asleep after going to bed?
SCQ5-3 Question In the past month, how often did you wake up in the middle of the night and have difficulty going back to sleep?
SCQ5-4 Question In the past month, how often did you wake up in the early hours and have difficulty going back to sleep?
SCQ5-5 Question In the past month, did you sleep well at night?
SCQ5-6 Question In the past month, did your family or anyone else complain about your snoring?
SCQ5-7 Question How often do you wake up at night to urinate?
SCQ6 Question In the past month, were you able to perform the following everyday activities without difficulty? Circle 1 to indicate “yes” if you had no difficulty, and 2 to indicate “no” if any difficulty.
SCQ6-1 Question Going out alone using public transportation such as buses and trains
SCQ6-2 Question Shopping for daily necessities
SCQ6-3 Question Boiling water in a kettle
SCQ6-4 Question Paying bills
SCQ6-5 Question Making deposits in and withdrawals from your bank or postal account
SCQ6-6 Question Filling out documentation such as pension forms
SCQ6-7 Question Reading newspapers
SCQ6-8 Question Reading books and magazines
SCQ6-9 Question Taking interest in newspaper/magazine articles and TV programs featuring health
SCQ6-10 Question Visiting friends’ homes
SCQ6-11 Question Giving advice to family members, friends, etc.
SCQ6-12 Question Visiting sick family members, friends, etc.
SCQ6-13 Question Talking to young people
SCQ6-14 Question Making phone calls without help
SCQ6-15 Question Taking medicine without help
SCQ7 Question This section asks about what activities you are trying to incorporate into your daily life. To what extent does each of the following statements apply to you? For each statement, circle the number corresponding to the answer that best applies to you.
SCQ7-1 Question Trying to eat breakfast everyday
SCQ7-2 Question Trying to eat vegetables as often as possible
SCQ7-3 Question Trying to avoid taking too much salt
SCQ7-4 Question Trying to purchase pesticide-free, organically-grown vegetables and additive-free foods
SCQ7-5 Question Trying to read newspapers and books
SCQ7-6 Question Trying to use the hands and fingers
SCQ7-7 Question Trying to move around rather than sitting still
SCQ7-8 Question Trying to take interest in various things
SCQ8 Question This question asks about your physical and emotional conditions. Did you experience the following symptoms in the past week, and, if you did, how long did the symptom last?
SCQ8-1 Question Feeling uneasy about things you would usually not be concerned about
SCQ8-2 Question Poor appetite
SCQ8-3 Question Feeling depressed and unable to dispel the gloom despite encouragement from family and friends
SCQ8-4 Question Feeling capable of doing what an average person can do
SCQ8-5 Question Unable to concentrate on what you are doing
SCQ8-6 Question Feeling depressed
SCQ8-7 Question Feeling troublesome to do something you would usually do effortlessly
SCQ8-8 Question Feeling optimistic about the future
SCQ8-9 Question Feeling that your life has been a failure
SCQ8-10 Question Feeling fearful
SCQ8-11 Question Poor sleep
SCQ8-12 Question Feeling happy
SCQ8-13 Question Talking less than usual
SCQ8-14 Question Feeling lonely
SCQ8-15 Question Feeling that people are unfriendly
SCQ8-16 Question Feeling fun
SCQ8-17 Question Crying or feeling like crying
SCQ8-18 Question Feeling sad
SCQ8-19 Question Feeling that people dislike you
SCQ8-20 Question Feeling low on energy and finding everything takes effort
SCQ9 Question Are you satisfied or unsatisfied with your current life? (Circle only one.)
SCQ10A Question Did you or any of your family member(s) put off doctor or dentist visits during the past 12-month period despite being in need of treatment?
SCQ10A-1 Question (Please answer this question only if you selected answer 1 in question 10A) What services or treatment did you or your family member(s) put off receiving? Select all that apply.
SCQ10A-2 Question (Please answer this question only if you selected answer 1 in question 10A) Why did you or your family member(s) put off receiving the services or treatment? Select all that apply.
SCQ10B Question Did you or any of your family member(s) put off receiving or fail to receive necessary care services during the past two-year period?
SCQ10B-1 Question (Please answer this question only if you selected answer 1 in question 10B.) What services did you or your family member(s) put off receiving or fail to receive? Select all that apply.
SCQ10B-2 Question (Please answer this question only if you selected answer 1 in question 10B.) Why did you or your family member(s) put off receiving or fail to receive the services?
SCQ11 Question Do you think your family, relatives, friends, etc. would sympathize and care for you if you have concerns or worries? For each category, circle the number corresponding to the answer that best describes your thoughts.
SCQ11-1 Question Spouse
SCQ11-2 Question Family member(s) living together (except for spouse)
SCQ11-3 Question Son(s)/daughter(s) living separately or relatives
SCQ11-4 Question Friends, acquaintances, neighbors, etc.
SCQ12 Question Do you think your family, relatives, friends, etc. would take care of you and run errands for you if you get sick and become bedridden? For each category, circle the number corresponding to the answer that best describes your thoughts.
SCQ12-1 Question Spouse
SCQ12-2 Question Family member(s) living together (except for spouse)
SCQ12-3 Question Son(s)/daughter(s) living separately or relatives
SCQ12-4 Question Friends, acquaintances, neighbors, etc.
SCQ13 Question Would you take care of your family, relatives, friends, etc. or be asked to run errands for them if they get sick and become bedridden? For each category, circle the number corresponding to the answer that best describes your thoughts.
SCQ13-1 Question Spouse
SCQ13-2 Question Family member(s) living together (except for spouse)
SCQ13-3 Question Son(s)/daughter(s) living separately or relatives
SCQ13-4 Question Friends, acquaintances, neighbors, etc.
SCQ14 Question Would you be able to go to the following places alone or would you require assistance? For each, circle the number corresponding to the answer that best describes your situation.
SCQ14-1 Question Bank or ATM
SCQ14-2 Question Grocery or supermarket
SCQ14-3 Question Clinic or hospital
SCQ14-4 Question Municipal government or its branch office
SCQ15-1 Question We would like to ask you about your frater consanguineous. How many siblings do/did you have? Please include half brothers or sisters and those who may have passed away.
SCQ15-2 Question Please indicate the time when the person of the same sex who is (was) closest in age was born.
SCQ15-3 Question Please select the relation between that person and you.
SCQ15-4 Question Is that person in good health?
SCQ15-5 Question Please indicate the sort of business which that person pursue(d) mainly currently or previously.
SCQ15-6 Question Please indicate the educational background of that person. Include dropping out.
SCQ16 Question This question asks about how you spent your time on your average work days and non-work days during the past month. Approximately how much time did you spend on each of the following activities per day?
SCQ16-1 Question Commuting
SCQ16-2 Question Working
SCQ16-3 Question Sleeping
SCQ16-4 Question Housework, shopping for daily necessities
SCQ16-5 Question Taking care of son(s)/daughter(s) or grandchildren
SCQ16-6 Question Providing care for parent(s), spouse, or other family member(s) in need
SCQ16-7 Question Sports, walking, or other exercise activities
SCQ16-8 Question Studying, learning, etc.
SCQ16-9 Question Community, religious, or political activities
SCQ16-10 Question Hobbies, leisure activities, socializing, etc.
SCQ16-11 Question Resting or relaxing (except for sleeping)
SCQ17 Question In the past month, did you engage in any non-work activities with someone other than your family and friends? (Circle only one.)
SCQ17-1 Question (Please answer this and subsequent supplementary questions if you selected answer 1 in question 17. Otherwise please proceed to question 18. ) What kinds of activities did you engage in? Please select all that apply.
SCQ17-2 Question Which of the activities selected above did you engage in most frequently? Enter the number corresponding to the activity.
SCQ17-3 Question How often did you engage in the activity selected in question 17-2? (Circle only one.)
SCQ18 Question How closely do you associate with your neighbors? Select the answer that best describes your relationships with your neighbors.
SCQ19 Question Approximately how many neighbors do you associate with? (Circle only one.)
SCQ20 Question How often do you usually associate with your friends and acquaintances outside of the workplace?
SCQ21 Question Approximately how many times a year do your relatives gather for rites such as Buddhist memorial services for deceased relatives?
SCQ21-1 Question How much does it cost per year to hold the rites?
SCQ22 Question Did you give any donations to charities during the past year? If so, how much did you donate? A rough estimate is fine.
SCQ23 Question Do you and your spouse (or common-law spouse) manage household finances together or separately?
SCQ24 Question What was your approximate income last year after taxes and social insurance deductions? Please include all income you received.
SCQ25 Question We would now like to ask about any taxes or social insurance premiums paid in your name.
SCQ25-1 Question In the past year, approximately how much did you pay altogether in taxes and social insurance premiums?
SCQ26 Question We would now like to ask about your spouse’s (or common-law spouse’s) income.
SCQ27 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.
SCQ27-1 Question In the past year, approximately how much did your spouse (or common-law spouse) pay altogether in taxes and social insurance premiums?
SCQ28 Question Do you and your spouse (or common-law spouse) manage assets together or separately?
SCQ29 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?
SCQ29-1 Question (Please answer this question only if you answered “Yes” to question 29.) How much do you have in total in those accounts?
SCQ30 Question Do you hold any fixed income securities in your name?
SCQ30-1 Question (Please answer this question only if you answered “Yes” to question 30.) How much do you have in your account?
SCQ31 Question Do you hold any equity securities that can be sold through brokers in your name?
SCQ31-1 Question (Please answer this question only if you answered “Yes” to question 31.) If you are to sell all of those securities today, how much would you expect to receive?
SCQ32 Question Does your spouse have any deposits in his/her name with any bank or similar financial institution whether in the form of savings or time deposits?
SCQ32-1 Question (Please answer this question only if you answered “Yes” to question 32). How much does he/she have in total in those accounts?
SCQ33 Question Does your spouse hold any fixed income securities in his/her name? Fixed income securities include: investment trusts, discount bank debentures, coupon bank debentures, government bonds, corporate bonds, etc.?
SCQ33-1 Question (Please answer this question only if you answered “Yes” to question 33) How much does your spouse have in his/her account?
SCQ34 Question Does your spouse (or common-law spouse) hold any equity securities that can be sold through brokers in his/her name?
SCQ34-1 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?
SCQ35 Question This concludes the questionnaire. Did you answer this questionnaire by yourself or did anyone (family member, caregiver, etc.) help you? (Circle only one.)
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