I. MYSELF (W15, 2004)
I1 How strongly do you agree or disagree with each of the following statements? Circle one number for each
1 Strongly disagree
2 Disagree
3 Agree
4 Strongly Agree
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MEI1A15 I feel I have a number of good qualities.
MEI1B15 I certainly feel useless at times.
MEI1C15 I feel I do not have much to be proud of.
MEI1D15 There is really no way I can solve some of the problems I have.
MEI1E15 I take a positive attitude toward myself.
MEI1F15 On the whole, I am satisfied with myself.
MEI1G15 Sometimes I feel that I'm being pushed around in life.
MEI1H15 I have little control over the things that happen to me.
MEI1I15 I can do just about anything I really set my mind to do.
MEI1J15 What happens to me in the future mostly depends on me.
MEI1K15 I often feel helpless in dealing with the problems of life.
MEI1L15 There is little I can do to change many of the important things in my life.
MEI1M15 At times I think I am no good at all.
MEI1N15 I wish I could have more respect for myself.
HEALTH15 I2 In general, would you say your health is (Circle one number):
1 Excellent
2 Very good
3 Good
4 Fair
5 Poor
I3 What is your current height and weight?
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Height: HIGHFT15 _____ feet and HIGHIN15 _____ inches
Weight: WEIGHT15_____ pounds
1 Not at all
2 Slightly
3 Moderately
4 Quite a bit
5 Extremely
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1 Not at all
2 Slightly
3 Moderately
4 Quite a bit
5 Extremely
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1 Not at all
2 Slightly
3 Moderately
4 Quite a bit
5 Extremely
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PSPAIN15 I7 How much physical pain have you had during the past 4 weeks?
1 None
2 Very mild
3 Mild
4 Moderate
5 Severe
6 Very severe
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I8 Have you ever been told by a doctor that you have any of the following?
1 Yes
2 No
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HIGHBP15 |
High blood pressure |
Yes |
No |
HEART15 |
Heart condition |
Yes |
No |
DIABET15 |
Diabetes |
Yes |
No |
DEPRES15 |
Prolonged anxiety, depression or other mental health problems |
Yes |
No |
CANCER15 |
Cancer |
Yes |
No |
LUNG15 |
Chronic Lung Disease (Emphysema, Asthma, Chronic Bronchitis) |
Yes |
No |
BONE15 |
Fractures or broken bones |
Yes |
No |
DIGEST15 |
Chronic digestive disease (ulcer, colitis, liver problems) |
Yes |
No |
EPILEP15 |
Epilepsy or a seizure disorder |
Yes |
No |
BACKPB15 |
Chronic back problems |
Yes |
No |
DEVELP15 |
Developmental problems |
Yes |
No |
I8OTH15 |
Any other major disease, disability or handicap |
Yes |
No |
MASCUL15 I9 How masculine would you say you are?
1 Not at all masculine
2 Somewhat masculine
3 About average
4 Very masculine
5 Extremely masculine
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FEMINI15 I10 How feminine would you say you are?
1 Not at all feminine
2 Somewhat feminine
3 About average
4 Very feminine
5 Extremely feminine
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SEXORI15 I11 Has anyone ever assumed you were a different sexual orientation than you are?
1 No
2 Yes
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I12 DURING THE PAST MONTH, HOW MUCH OF THE TIME:
Circle one number for each.
1 None of the time
2 A little of the time
3 Some of the time
4 Most of the time
5 All of the time
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MEI12A15 Have you felt that the future looks hopeful and promising?
MEI12B15 Have you been under any strain, stress, or pressure?
MEI12C15 Have you been anxious or worried?
MEI12D15 Have you generally enjoyed the things you do?
MEI12E15 Have you felt tired, worn out, or exhausted?
MEI12F15 Have you felt calm and peaceful?
MEI12G15 Have you felt downhearted and blue?
MEI12H15 Have you felt tense or “high strung”?
MEI12I15 Have you felt cheerful, lighthearted?
MEI12J15 Have you been moody or brooded about things?
MEI12K15 Have you felt depressed?
MEI12L15 Have you been in low or very low spirits?
MEI12M15 Have you felt lonely?
MEI12N15 Has your daily life been full of things that are interesting to you?
MEI12O15 Do you wake up feeling fresh and rested?
I13TER15 I13 How worried are you that you or someone in your family will become a victim of terrorism?
1 Very Worried
2 Somewhat Worried
3 Not Too Worried
4 Not Worried at All
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I14SAT15 I14 How satisfied are you with the way things are going for the US in the war on terrorism?
1 Very Satisfied
2 Somewhat Satisfied
3 Not too Satisfied
4 Not Satisfied at All
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|
Typical Week |
Number of HoursPer Week |
|
Indoor household chores (cleaning, cooking, etc.) |
INDRLO15INDRHI15 |
Outdoor household chores (gardening, lawn care, shoveling snow, etc.) |
OUDRLO15 OUDRHI15 |
Repairs and renovations (of house, car, etc.) |
REPRLO15 REPRHI15 |
Time alone with my spouse or partner |
SPSLO15 SPSHI15 |
Care for my child/children |
CRCHLO15 CRCHHI15 |
Caring for a sick or elderly relative |
CRSILO15 CRSIHI15 |
Studying and attending classes (as a student) |
STUDLO15 STUDHI15 |
Clubs and organizations (political, religious, civic, PTA, etc.) |
CLUBLO15 CLUBHI15 |
Watching television |
TVLO15 TVHI15 |
Reading (books, magazines, newspapers, etc.) |
READLO15 READHI15 |
Active sports and exercise (walking, jogging, swimming, basketball, etc.) |
SPTLO15 SPTHI15 |
On the internet (email with family and friends, chat groups, games, shopping, etc.) |
INTELO15 INTEHI15 |
Other recreational activities (spectator sports, movies, concerts, etc.) |
OTHRLO15 OTHRHI15 |
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