I.MYSELF (W16, 2005)
1 Strongly disagree
4 Strongly agree
MEI1A16 I feel I have a number of good qualities.
MEI1B16 I certainly feel useless at times.
MEI1C16 I feel I do not have much to be proud of.
MEI1D16 There is really no way I can solve some of the problems I have.
MEI1E16 I take a positive attitude toward myself.
MEI1F16 On the whole, I am satisfied with myself.
MEI1G16 Sometimes I feel that I'm being pushed around in life.
MEI1H16 I have little control over the things that happen to me.
MEI1I16 I can do just about anything I really set my mind to do.
MEI1J16 What happens to me in the future mostly depends on me.
MEI1K16 I often feel helpless in dealing with the problems of life.
MEI1L16 There is little I can do to change many of the important things in my life.
MEI1M16 At times I think I am no good at all.
MEI1N16 I wish I could have more respect for myself.
MEI1O16 I like to take the lead when a group does things together.
MEI1P16 I enjoy convincing others of my opinions.
MEI1Q16 I like to assume responsibility.
MEI2RA16 I2 What is your primary ethnic and/or racial identity?
MEI3HE16 I3 In general, would you say your health is (Circle one number only.)
2 Very good
I4 What is your current height and weight?
Height: feet-MEI4FE16 and inches-MEI4IN16
MEI5PH16 I5 During the past 4 weeks, have physical health problems caused you difficulty in doing your work or other daily activities?
1 Not at all
4 Quite a bit
MEI6EM16 I6 During the past 4 weeks, have emotional problems (such as feeling depressed or anxious) led you to accomplish less than you would like in your work or other daily activities?
1 Not at all
4 Quite a bit
MEI7SO16 I7 During the past 4 weeks, have physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?
1 Not at all
4 Quite a bit
MEI8PA16 I8 How much physical pain have you had during the past 4 weeks?
2 Very mild
6 Very Severe
I9 Have you ever been told by a doctor that you have the following?
MEI9A16 High blood pressure
MEI9B16 Heart condition
MEI9D16 Prolonged anxiety, depression or other mental health problems
MEI9F16 Chronic Lung Disease (Emphysema, Asthma, Chronic Bronchitis)
MEI9G16 Fractures or broken bones
MEI9H16 Chronic digestive disease (ulcer, colitis, liver problems)
MEI9I16 Epilepsy or a seizure disorder
MEI9J16 Chronic back problems
MEI9K16 Developmental problems
MEI9M16 Any other major disease, disability or handicap
MEI1016 I10 Is there one particular clinic, health center, or doctor’s office that you usually go to if you are sick or need advice about your health?
In an average week how many days do you:
Min=0 Max=7 times per week
MEI1116 I11 Eat breakfast
MEI1216 I12 Do moderate physical activity for at least 30 minutes (e.g. walking, biking)?
MEI1316 I13 Do vigorous physical activities for at least 30 minutes(e.g. running, football, swimming)?
MEI1416 I14 How many hours of sleep do you usually get in a 24 hour period?
1 Less than five
7 More than nine
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
MEI15A16 Have you felt that the future looks hopeful and promising?
MEI15B16 Have you been under any strain, stress, or pressure?
MEI15C16 Have you been anxious or worried?
MEI15D16 Have you generally enjoyed the things you do?
MEI15E16 Have you felt tired, worn out, or exhausted?
MEI15F16 Have you felt calm and peaceful?
MEI15G16 Have you felt downhearted and blue?
MEI15H16 Have you felt tense or “high strung”?
MEI15I16 Have you felt cheerful or lighthearted?
MEI15J16 Have you been moody or brooded about things?
MEI15K16 Have you felt depressed?
MEI15L16 Have you been in low or very low spirits?
MEI15M16 Have you felt lonely?
MEI15N16 Has your daily life been full of things that are interesting to you?
MEI15O16 Do you wake up feeling fresh and rested?
I16 We'd like you to consider how things are going in various areas of your life and whether you would like to change them.
1 No change
2 Some change
3 A great deal of change
4 Not applicable
MEI16A16 Relationship with my spouse or partner
MEI16B16 Relationship with my parents
MEI16C16 Relationship with my child or children
MEI16D16 My job or career
MEI16E16 Religious or spiritual aspects of my life
MEI16F16 Involvement in a neighborhood group
MEI16G16 Involvement in my community
MEI16H16 Other: (specification-MEI16I16)
I17 People often feel more or less like “an adult” in different situations or areas of their lives. In answering the following questions, please consider how you usually feel in these situations and place an “X” in the appropriate box.
1 Not at all like an adult
2 Somewhat like an adult
3 Entirely like an adult
4 Does not apply/never do this
MEI17A16 When I am at school
MEI17B16 When I am at work
MEI17C16 When I am participating in a community organization (civic, religious, etc.)
MEI17D16 When I am doing active sports or exercising
MEI17E16 When I am doing other recreational activities (going to a museum, concert, sports event, etc.)
MEI17F16 When I am with my friends
MEI17G16 When I am taking care of my house/apartment
MEI17H16 When I am with my child/children
MEI17I16 When I am with my parent(s)
MEI17J16 When I am with a romantic partner
MEI17K16 When I am doing volunteer work
MEI17L16 When I donate money
MEI17M16 When I vote
MEI17N16 When I limit my drinking because I am driving or serving as a “designated driver”
MEI17O16 When I do something I know is wrong
MEI17P16 When I do something that might be against the law
MEI17Q16 Most of the time
I18 Please record whether you have experienced each event listed below.
· If you HAVE experienced the event, indicate how “early,” “on time,” or “late” you were when you did it.
· If you think the event WILL occur in the future, indicate how “early,” “on time,” or “late” it will be when it happens.
· If you NEVER want or expect to experience the event (for example, you know that you never want to become a parent), mark "Event Not Expected.”
· If you do not think being early, on time, or late are relevant considerations, mark “Timing Not Relevant.”
|Has this event happened?||Estimate of timing|
1=Very early 2=Somewhat early 3=Right on time 4=Somewhat late 5=Very late 6= Timing not relevant 7= Event not expected -9=Missing
|Cohabit with a partner or spouse||ME18A116||ME18A216|
|Own a home||ME18C116||ME18C216|
|Become a parent||ME18D116||ME18D216|
|Get a full-time job||ME18F116||ME18F216|
|Become finanically independent||ME18G116||ME18G216|
|Start a "career"||ME18H116||ME18H216|
H. Life Events (W16, 2005)
J. Drinking and Smoking (W16, 2005)