|
Q1-1
|
 |
Care for a sick or disabled adult? |
|
Q1-2
|
|
Do activities with grandchildren, nieces/ nephews, or neighborhood children? |
|
Q1-3
|
|
Do volunteer work with children or young people? |
|
Q1-4
|
|
Do any other volunteer or charity work? |
|
Q1-5
|
|
Attend an educational or training course? |
|
Q1-6
|
|
Go to a sport, social, or other club? |
|
Q1-7
|
|
Attend meetings of non-religious organizations, such as political, community, or other interest groups? |
|
Q1-8
|
|
Pray privately in places other than a church or synagogue? |
|
Q1-9
|
|
Read books, magazines, or newspapers? |
|
Q1-10
|
|
Watch television? |
|
Q1-11
|
|
Do word games such as crossword puzzles or Scrabble? |
|
Q1-12
|
|
Play cards or games such as chess? |
|
Q1-13
|
|
Do writing (such as letters, stories, or journal entries)? |
|
Q1-14
|
|
Use a computer for e-mail, Internet or other tasks? |
|
Q1-15
|
|
Do home or car maintenance or gardening? |
|
Q1-16
|
|
Bake or cook something special? |
|
Q1-17
|
|
Make clothes, knit, embroider, etc.? |
|
Q1-18
|
|
Work on a hobby or project? |
|
Q1-19
|
|
Play sports or exercise? |
|
Q1-20
|
|
Walk for 20 minutes or more? |
|
Q1-21
|
|
Participate in a local community arts group such as a choir, dance, photography, theatre, or music group? |
|
Q2-1
|
|
In most ways my life is close to ideal. |
|
Q2-2
|
|
The conditions of my life are excellent. |
|
Q2-3
|
|
I am satisfied with my life. |
|
Q2-4
|
|
So far, I have gotten the important things I want in life. |
|
Q2-5
|
|
If I could live my life again, I would change almost nothing. |
|
Q3
|
|
Do you have a husband, wife, or partner with whom you live? (Mark (X) one.) |
|
Q4-1
|
|
How much do they really understand the way you feel about things? |
|
Q4-2
|
|
How much can you rely on them if you have a serious problem? |
|
Q4-3
|
|
How much can you open up to them if you need to talk about your worries? |
|
Q4-4
|
|
How often do they make too many demands on you? |
|
Q4-5
|
|
How much do they criticize you? |
|
Q4-6
|
|
How much do they let you down when you are counting on them? |
|
Q4-7
|
|
How much do they get on your nerves? |
|
Q5
|
|
How close is your relationship with your partner or spouse? |
|
Q5a
|
|
Overall, how enjoyable is the time you spend together with your spouse/partner? (Mark (X) one.) |
|
Q5b
|
|
In your free time, do you and your spouse mostly do things together or separately? |
|
Q6
|
|
Do you have any living children? |
|
Q7-1
|
|
How much do they really understand the way you feel about things? |
|
Q7-2
|
|
How much can you rely on them if you have a serious problem? |
|
Q7-3
|
|
How much can you open up to them if you need to talk about your worries? |
|
Q7-4
|
|
How often do they make too many demands on you? |
|
Q7-5
|
|
How much do they criticize you? |
|
Q7-6
|
|
How much do they let you down when you are counting on them? |
|
Q7-7
|
|
How much do they get on your nerves? |
|
Q8-1
|
|
Meet up (include both arranged and chance meetings) |
|
Q8-2
|
|
Speak on the phone |
|
Q8-3
|
|
Write or email |
|
Q8-4
|
|
Communicate by Skype, Facebook, or other social media |
|
Q9
|
|
How many of your children would you say you have a close relationship with? |
|
Q10
|
|
Do you have any OTHER IMMEDIATE FAMILY, for example, any brothers or sisters, parents, cousins or grandchildren? |
|
Q11
|
|
How much do they really understand the way you feel about things? |
|
Q11-2
|
|
How much can you rely on them if you have a serious problem? |
|
Q11-3
|
|
How much can you open up to them if you need to talk about your worries? |
|
Q11-4
|
|
How often do they make too many demands on you? |
|
Q11-5
|
|
How much do they criticize you? |
|
Q11-6
|
|
How much do they let you down when you are counting on them? |
|
Q11-7
|
|
How much do they get on your nerves? |
|
Q12-1
|
|
Meet up (include both arranged and chance meetings) |
|
Q12-2
|
|
Speak on the phone |
|
Q12-3
|
|
Write or email |
|
Q12-4
|
|
Communicate by Skype, Facebook, or other social media |
|
Q13
|
|
How many of these family members would you say you have a close relationship with? (Please write a number in the box.) |
|
Q13a
|
|
Besides the people living with you, do you have any relatives living in your neighborhood? |
|
Q14
|
|
Do you have any friends? |
|
Q15-1
|
|
How much do they really understand the way you feel about things? |
|
Q15-2
|
|
How much can you rely on them if you have a serious problem? |
|
Q15-3
|
|
How much can you open up to them if you need to talk about your worries? |
|
Q15-4
|
|
How often do they make too many demands on you? |
|
Q15-5
|
|
How much do they criticize you? |
|
Q15-6
|
|
How much do they let you down when you are counting on them? |
|
Q15-7
|
|
How much do they get on your nerves? |
|
Q16-1
|
|
Meet up (include both arranged and chance meetings) |
|
Q16-2
|
|
Speak on the phone |
|
Q16-3
|
|
Write or email |
|
Q16-4
|
|
Communicate by Skype, Facebook, or other social media |
|
Q17
|
|
How many of your friends would you say you have a close relationship with? (Please write a number in the box.) |
|
Q17a
|
|
Do you have any good friends living in your neighborhood? |
|
Q18-1
|
|
Most people dislike putting themselves out to help other people |
|
Q18-2
|
|
Most people will use somewhat unfair means to gain profit or an advantage rather than lose it. |
|
Q18-3
|
|
No one cares much what happens to you. |
|
Q18-4
|
|
I think most people would lie in order to get ahead. |
|
Q18-5
|
|
I commonly wonder what hidden reasons another person may have for doing something nice for me. |
|
Q18-6
|
|
If something can go wrong for me, it will. |
|
Q18-7
|
|
I’m always optimistic about my future. |
|
Q18-8
|
|
In uncertain times, I usually expect the best. |
|
Q18-9
|
|
Overall, I expect more good things to happen to me than bad. |
|
Q18-10
|
|
I hardly ever expect things to go my way. |
|
Q18-11
|
|
I rarely count on good things happening to me. |
|
Q18-12
|
|
I feel it is impossible for me to reach the goals that I would like to strive for. |
|
Q18-13
|
|
The future seems hopeless to me and I can’t believe that things are changing for the better. |
|
Q18-14
|
|
I don’t expect to get what I really want. |
|
Q18-15
|
|
There’s no use in really trying to get something I want because I probably won’t get it. |
|
Q19-1
|
|
You lack companionship? |
|
Q19-2
|
|
Left out? |
|
Q19-3
|
|
Isolated from others? |
|
Q19-4
|
|
That you are “in tune” with the people around you? |
|
Q19-5
|
|
Alone? |
|
Q19-6
|
|
That there are people you can talk to? |
|
Q19-7
|
|
That there are people you can turn to? |
|
Q19-8
|
|
That there are people who really understand you? |
|
Q19-9
|
|
That there are people you feel close to? |
|
Q19-10
|
|
Part of a group of friends? |
|
Q19-11
|
|
That you have a lot in common with the people around you? |
|
Q21-1
|
|
I often feel helpless in dealing with the problems of life. |
|
Q21-2
|
|
Other people determine most of what I can and cannot do. |
|
Q21-3
|
|
What happens in my life is often beyond my control. |
|
Q21-4
|
|
I have little control over the things that happen to me. |
|
Q21-5
|
|
There is really no way I can solve the problems I have. |
|
Q22-1
|
|
I can do just about anything I really set my mind to. |
|
Q22-2
|
|
When I really want to do something, I usually find a way to succeed at it. |
|
Q22-3
|
|
Whether or not I am able to get what I want is in my own hands |
|
Q22-4
|
|
What happens to me in the future mostly depends on me. |
|
Q22-5
|
|
I can do the things that I want to do. |
|
Q23
|
|
Using a 0 to 10 scale where 0 means “no control at all” and 10 means “very much control,” how would you rate the amount of control you have over your health these days? |
|
Q24
|
|
Using a 0 to 10 scale where 0 means “no control at all” and 10 means “very much control,” how would you rate the amount of control you have over your social life these days? |
|
Q25
|
|
Using a 0 to 10 scale where 0 means “no control at all” and 10 means “very much control,” how would you rate the amount of control you have over your financial situation these days? |
|
Q25a
|
|
Has the amount of control you have over your financial situation changed in the last year? |
|
Q25b
|
|
How confident are you filling out medical forms by yourself? |
|
Q26-1
|
|
Afraid? |
|
Q26-2
|
|
Upset? |
|
Q26-3
|
|
Determined? |
|
Q26-4
|
|
Enthusiastic? |
|
Q26-5
|
|
Guilty? |
|
Q26-6
|
|
Active? |
|
Q26-7
|
|
Proud? |
|
Q26-8
|
|
Interested? |
|
Q26-9
|
|
Scared? |
|
Q26-10
|
|
Frustrated? |
|
Q26-11
|
|
Happy? |
|
Q26-12
|
|
Bored? |
|
Q26-13
|
|
Hostile? |
|
Q26-14
|
|
Jittery? |
|
Q26-15
|
|
Ashamed? |
|
Q26-16
|
|
Attentive? |
|
Q26-17
|
|
Content? |
|
Q26-18
|
|
Nervous? |
|
Q26-19
|
|
Sad? |
|
Q26-20
|
|
Inspired? |
|
Q26-21
|
|
Hopeful? |
|
Q26-22
|
|
Alert? |
|
Q26-23
|
|
Distressed? |
|
Q26-24
|
|
Calm? |
|
Q26-25
|
|
Excited? |
|
Q27-1
|
|
I believe in a God who watches over me. |
|
Q27-2
|
|
The events in my life unfold according to a divine or greater plan. |
|
Q27-3
|
|
I try hard to carry my religious beliefs over into all my other dealings in life. |
|
Q27-4
|
|
I find strength and comfort in my religion. |
|
Q28a
|
|
Many people feel older or younger than they actually are. What age do you feel? (Write in a number.) |
|
Q28b-1
|
|
Things keep getting worse as I get older. |
|
Q28b-2
|
|
I have as much pep as I did last year. |
|
Q28b-3
|
|
The older I get, the more useless I feel. |
|
Q28b-4
|
|
I am as happy now as I was when I was younger. |
|
Q28b-5
|
|
As I get older, things are better than I thought they would be. |
|
Q28b-6
|
|
So far, I am satisfied with the way that I am aging. |
|
Q28b-7
|
|
The older I get, the more I have had to stop doing things that I liked. |
|
Q28b-8
|
|
Getting older has brought with it many things that I do not like. |
|
Q29-1
|
|
You are treated with less courtesy or respect than other people. |
|
Q29-2
|
|
You receive poorer service than other people at restaurants or stores. |
|
Q29-3
|
|
People act as if they think you are not smart. |
|
Q29-4
|
|
People act as if they are afraid of you. |
|
Q29-5
|
|
You are threatened or harassed. |
|
Q29-6
|
|
You receive poorer service or treatment than other people from doctors or hospitals. |
|
Q30
|
|
If any of the above (in Q29.) have happened to you, what do you think were the reasons WHY these experiences happened to you? (Mark (X) all that apply.) |
|
Q31-1
|
|
Outgoing |
|
Q31-2
|
|
Helpful |
|
Q31-3
|
|
Reckless |
|
Q31-4
|
|
Moody |
|
Q31-5
|
|
Organized |
|
Q31-6
|
|
Friendly |
|
Q31-7
|
|
Warm |
|
Q31-8
|
|
Worrying |
|
Q31-9
|
|
Responsible |
|
Q31-10
|
|
Lively |
|
Q31-11
|
|
Caring |
|
Q31-12
|
|
Nervous |
|
Q31-13
|
|
Creative |
|
Q31-14
|
|
Hardworking |
|
Q31-15
|
|
Imaginative |
|
Q31-16
|
|
Softhearted |
|
Q31-17
|
|
Calm |
|
Q31-18
|
|
Self-disciplined |
|
Q31-19
|
|
Intelligent |
|
Q31-20
|
|
Curious |
|
Q31-21
|
|
Active |
|
Q31-22
|
|
Careless |
|
Q31-23
|
|
Broad-minded |
|
Q31-24
|
|
Impulsive |
|
Q31-25
|
|
Sympathetic |
|
Q31-26
|
|
Cautious |
|
Q31-27
|
|
Talkative |
|
Q31-28
|
|
Sophisticated |
|
Q31-29
|
|
Adventurous |
|
Q31-30
|
|
Thorough |
|
Q31-31
|
|
Thrifty |
|
Q32a-1
|
|
I like to have the responsibility of handling a situation that requires a lot of thinking. |
|
Q32a-2
|
|
I really enjoy a task that involves coming up with new solutions to problems. |
|
Q32a-3
|
|
The notion of thinking abstractly is appealing to me. |
|
Q32a-4
|
|
I would rather do something that requires little thought than something that is sure to challenge my thinking abilities. |
|
Q32a-5
|
|
I try to anticipate and avoid situations where there is likely a chance I will have to think in depth about something. |
|
Q32a-6
|
|
I only think as hard as I have to. |
|
Q33-1
|
|
I enjoy making plans for the future and working to make them a reality. |
|
Q33-2
|
|
My daily activities often seem trivial and unimportant to me. |
|
Q33-3
|
|
I am an active person in carrying out the plans I set for myself. |
|
Q33-4
|
|
I don’t have a good sense of what it is I’m trying to accomplish in life. |
|
Q33-5
|
|
I sometimes feel as if I’ve done all there is to do in life. |
|
Q33-6
|
|
I live life one day at a time and don’t really think about the future. |
|
Q33-7
|
|
I have a sense of direction and purpose in my life. |
|
Q34-1
|
|
The condition of the place where you live (house or apartment)? |
|
Q34-2
|
|
The city or town you live in? |
|
Q34-3
|
|
Your daily life and leisure activities? |
|
Q34-4
|
|
Your family life? |
|
Q34-5
|
|
Your present financial situation? |
|
Q34-6
|
|
The total income of your household? |
|
Q34-7
|
|
Your health? |
|
Q34a-1
|
|
On the whole, I am satisfied with myself. |
|
Q34a-2
|
|
At times I think I am no good at all. |
|
Q34a-3
|
|
I feel that I have a number of good qualities. |
|
Q34a-4
|
|
I am able to do things as well as most other people. |
|
Q34a-5
|
|
I feel I do not have much to be proud of. |
|
Q34a-6
|
|
I certainly feel useless at times. |
|
Q34a-7
|
|
I feel that I’m a person of worth, at least on an equal plane with others. |
|
Q34a-8
|
|
I wish I could have more respect for myself. |
|
Q34a-9
|
|
All in all, I am inclined to feel that I am a failure. |
|
Q34a-10
|
|
I take a positive attitude toward myself. |
|
Q35
|
|
How difficult is it for (you/your family) to meet monthly payments on (your/your family’s) bills? |
|
Q35a-1
|
|
Ongoing health problems (in yourself) |
|
Q35a-2
|
|
Ongoing physical or emotional problems (in spouse or child) |
|
Q35a-3
|
|
Ongoing problems with alcohol or drug use in family member |
|
Q35a-4
|
|
Ongoing difficulties at work |
|
Q35a-5
|
|
Ongoing financial strain |
|
Q35a-6
|
|
Ongoing housing problems |
|
Q35a-7
|
|
Ongoing problems in a close relationship |
|
Q35a-8
|
|
Helping at least one sick, limited, or frail family member or friend on a regular basis |
|
Q35b-1
|
|
Been upset because of something that happened unexpectedly? |
|
Q35b-2
|
|
Felt that you were unable to control the important things in your life? |
|
Q35b-3
|
|
Felt nervous and “stressed”? |
|
Q35b-4
|
|
Felt confident about your ability to handle your personal problems? |
|
Q35b-5
|
|
Felt that things were going your way? |
|
Q35b-6
|
|
Found that you could not cope with all the things that you had to do? |
|
Q35b-7
|
|
Been able to control irritations in your life? |
|
Q35b-8
|
|
Felt that you were on top of things? |
|
Q35b-9
|
|
Been angered because of things that were outside of your control? |
|
Q35b-10
|
|
Felt difficulties were piling up so high that you could not overcome them? |
|
Q35c-1
|
|
I had fear of the worst happening. |
|
Q35c-2
|
|
I was nervous. |
|
Q35c-3
|
|
I felt my hands trembling |
|
Q35c-4
|
|
I had a fear of dying. |
|
Q35c-5
|
|
I felt faint. |
|
Q37
|
|
Has your position on the ladder changed within the last two years? |
|
Q38
|
|
What day of the week was it yesterday? (Mark (X) one box.) |
|
Q39
|
|
What was the date yesterday? (Please write a number in the boxes.) |
|
Q40
|
|
What time did you wake up yesterday? [For example, if you woke up at 4:00 AM, please write 04 in the hour boxes, 00 in the minute boxes, and AM in the last boxes.] |
|
Q41
|
|
What time did you go to sleep at the end of the day yesterday? [For example, if you went to sleep at 11:30 PM, please write 11 in the hour boxes, 30 in the minute boxes, and PM in the last boxes. Remember that midnight and later times are AM.] |
|
Q42-1
|
|
Frustrated |
|
Q42-2
|
|
Sad |
|
Q42-3
|
|
Enthusiastic |
|
Q42-4
|
|
Lonely |
|
Q42-5
|
|
Content |
|
Q42-6
|
|
Worried |
|
Q42-7
|
|
Bored |
|
Q42-8
|
|
Happy |
|
Q42-9
|
|
Angry |
|
Q42-10
|
|
Tired |
|
Q42-11
|
|
Stressed |
|
Q43
|
|
Yesterday, did you feel any pain? |
|
Q44
|
|
Did you feel well-rested yesterday morning (that is you slept well the night before)? |
|
Q45
|
|
How was your health yesterday |
|
Q46
|
|
Was yesterday a normal day for you or did something unusual happen? |
|
Q47
|
|
Yesterday, did you watch TV? |
|
Q48
|
|
How much time did you spend watching TV yesterday? (For example, if you spent 1 and a half hours, write 01 in the hours boxes, and 30 in the minutes boxes.) |
|
Q49-1
|
|
Happy |
|
Q49-2
|
|
Interested |
|
Q49-3
|
|
Frustrated |
|
Q49-4
|
|
Sad |
|
Q49-5
|
|
Content |
|
Q49-6
|
|
Bored |
|
Q49-7
|
|
Pain |
|
Q50
|
|
Yesterday, did you work or volunteer? (Mark (X) one.) |
|
Q51
|
|
How much time did you spend working or volunteering yesterday? [For example, if you spent 9 and a half hours, write 09 in the hours boxes and 30 in the minutes boxes.] |
|
Q52-1
|
|
Happy |
|
Q52-2
|
|
Interested |
|
Q52-3
|
|
Frustrated |
|
Q52-4
|
|
Sad |
|
Q52-5
|
|
Content |
|
Q52-6
|
|
Bored |
|
Q52-7
|
|
Pain |
|
Q53
|
|
Where did you work or volunteer yesterday? (Mark (X) one.) |
|
Q54
|
|
Yesterday, did you walk or exercise? (Mark (X) one.) |
|
Q55
|
|
How much time did you spend walking or exercising yesterday? |
|
Q56-1
|
|
Happy |
|
Q56-2
|
|
Interested |
|
Q56-3
|
|
Frustrated |
|
Q56-4
|
|
Sad |
|
Q56-5
|
|
Content |
|
Q56-6
|
|
Bored |
|
Q56-7
|
|
Pain |
|
Q57
|
|
Yesterday, did you do health-related activities other than walking or exercising (e.g., visiting a doctor, taking medications, doing treatments)? |
|
Q58
|
|
How much time did you spend doing health-related activities yesterday? |
|
Q59-1
|
|
Happy |
|
Q59-2
|
|
Interested |
|
Q59-3
|
|
Frustrated |
|
Q59-4
|
|
Sad |
|
Q59-5
|
|
Content |
|
Q59-6
|
|
Bored |
|
Q59-7
|
|
Pain |
|
Q60
|
|
Yesterday, did you travel or commute (e.g., by car, train, bus)? |
|
Q61
|
|
How much time did you spend traveling or commuting yesterday? |
|
Q62-1
|
|
Happy |
|
Q62-2
|
|
Interested |
|
Q62-3
|
|
Frustrated |
|
Q62-4
|
|
Sad |
|
Q62-5
|
|
Content |
|
Q62-6
|
|
Bored |
|
Q62-7
|
|
Pain |
|
Q63
|
|
Yesterday, did you socialize with friends, neighbors, or family (not counting your spouse or partner)? |
|
Q64
|
|
How much time did you spend socializing with friends, neighbors, or family yesterday? |
|
Q65-1
|
|
Happy |
|
Q65-2
|
|
Interested |
|
Q65-3
|
|
Frustrated |
|
Q65-4
|
|
Sad |
|
Q65-5
|
|
Content |
|
Q65-6
|
|
Bored |
|
Q65-7
|
|
Pain |
|
Q66
|
|
Yesterday, did you spend time at home by yourself (without your spouse, partner, or anyone else present)? |
|
Q67
|
|
How much time did you spend at home by yourself yesterday? |
|
Q68
|
|
Happy |
|
Q68-2
|
|
Interested |
|
Q68-3
|
|
Frustrated |
|
Q68-4
|
|
Sad |
|
Q68-5
|
|
Content |
|
Q68-6
|
|
Bored |
|
Q68-7
|
|
Pain |
|
Q69
|
|
PainYesterday, did you run errands (e.g., go shopping, get gas or supplies, pick up or deliver something)? |
|
Q70
|
|
How much time did you spend running errands yesterday? |
|
Q71-1
|
|
Happy |
|
Q71-2
|
|
Interested |
|
Q71-3
|
|
Frustrated |
|
Q71-4
|
|
Sad |
|
Q71-5
|
|
Content |
|
Q71-6
|
|
Bored |
|
Q71-7
|
|
Pain |
|
Q72
|
|
Are you currently working? (Mark (X) one.) |
|
Q73-1
|
|
You need the money? |
|
Q73-2
|
|
You need health insurance? |
|
Q75-1
|
|
My work schedule makes it difficult to fulfill personal responsibilities. |
|
Q75-2
|
|
Because of my job, I don’t have the energy to do things with my family or other important people in my life. |
|
Q75-3
|
|
Job worries or problems distract me when I am not at work. |
|
Q75-4
|
|
My home life keeps me from getting work done on time on my job. |
|
Q75-5
|
|
My family or personal life drains me of the energy I need to do my job. |
|
Q75-6
|
|
I am preoccupied with personal responsibilities while I am at work. |
|
Q75-7
|
|
My work leaves me enough time to attend to my personal responsibilities. |
|
Q75-8
|
|
My work gives me energy to do things with my family and other important people in my life. |
|
Q75-9
|
|
Because of my job, I am in a better mood at home. |
|
Q75-10
|
|
My personal responsibilities leave me enough time to do my job. |
|
Q75-11
|
|
My family or personal life gives me energy to do my job. |
|
Q75-12
|
|
I am in a better mood at work because of my family or personal life. |
|
Q76
|
|
All things considered, I am satisfied with my job. |
|
Q77
|
|
Were the questions in this booklet answered by the person whose first name is written on the front cover? (Mark (X) one.) |