I.MYSELF (W18, 2009)

1 Strongly disagree

2 Disagree

3 Agree

4 Strongly agree

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MEI1A18 I feel I have a number of good qualities.

MEI1B18 I certainly feel useless at times.

MEI1C18 I feel I do not have much to be proud of.

MEI1D18 In my community people trust each other.

MEI1E18 There is really no way I can solve some of the problems I have.

MEI1F18 I take a positive attitude toward myself.

MEI1G18 On the whole, I am satisfied with myself.

MEI1H18 Sometimes I feel that I'm being pushed around in life.

MEI1I18 In my community people are careful about whom they trust.

MEI1J18 I have little control over the things that happen to me.

MEI1K18 I can do just about anything I really set my mind to do.

MEI1L18 What happens to me in the future mostly depends on me.

MEI1M18 I often feel helpless in dealing with the problems of life.

MEI1N18 There is little I can do to change many of the important things in my life.

MEI1O18 At times I think I am no good at all.

MEI1P18 I wish I could have more respect for myself.

MEI218 I2 How successful do you feel in your work life?

1 Not successful at all

2 Somewhat unsuccessful

3 Somewhat successful

4 Very successful

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MEI318 I3 How successful do you feel in your family or personal life?

1 Not successful at all

2 Somewhat unsuccessful

3 Somewhat successful

4 Very successful

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MEI418 I4 How successful do you feel in balancing work and family/personal life?

1 Not successful at all

2 Somewhat unsuccessful

3 Somewhat successful

4 Very successful

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MEI5HE18 I5 In general, would you say your health is (Circle one number only.)

1 Excellent

2 Very good

3 Good

4 Fair

5 Poor

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I6 What is your current height and weight?

Height: feet-MEI6FE18 and inches-MEI6IN18

MEI7PH18 I7 During the past 4 weeks, have physical health problems caused you difficulty in doing your work or other daily activities?

1 Not at all

2 Slightly

3 Moderately

4 Quite a bit

5 Extremely

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MEI8EM18 I8 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

2 Slightly

3 Moderately

4 Quite a bit

5 Extremely

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MEI9SO18 I9 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

2 Slightly

3 Moderately

4 Quite a bit

5 Extremely

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MEI1018 I10 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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I11 Have you ever been told by a doctor that you have the following?

0 No

1 Yes

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MEI11A18 High blood pressure

MEI11B18 Ischemic heart disease, heart attack, MI

MEI11C18 Stroke

MEI11D18 Hepatitis/jaundice

MEI11E18 Diabetes

MEI11F18 Prolonged anxiety, depression or other mental health problems

MEI11G18 Cancer

MEI11H18 Chronic Lung Disease (Emphysema, Asthma, Chronic Bronchitis)

MEI11I18 Fractures or broken bones

MEI11J18 Chronic digestive disease (ulcer, colitis, liver problems)

MEI11K18 Epilepsy or a seizure disorder

MEI11L18 A chronic back problem

MEI11M18 A developmental problem

MEI11N18 An allergy

MEI11O18 Any other major disease, disability or handicap

In an average week how many days do you:

Min=0 Max=7 times per week

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MEI1218 I12 Eat breakfast

MEI1318 I13 Do moderate physical activity for at least 30 minutes (e.g. walking, biking)?

MEI1418 I14 Do vigorous physical activities for at least 30 minutes(e.g. running, football, swimming)?

MEI1518 I15 How many hours of sleep do you usually get in a 24 hour period?

1 Less than five

2 Five

3 Six

4 Seven

5 Eight

6 Nine

7 More than nine

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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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MEI16A18 Have you felt that the future looks hopeful and promising?

MEI16B18 Have you been under any strain, stress, or pressure?

MEI16C18 Have you been anxious or worried?

MEI16D18 Have you generally enjoyed the things you do?

MEI16E18 Have you felt tired, worn out, or exhausted?

MEI16F18 Have you felt calm and peaceful?

MEI16G18 Have you felt downhearted and blue?

MEI16H18 Have you felt tense or “high strung”?

MEI16I18 Have you felt cheerful or lighthearted?

MEI16J18 Have you been moody or brooded about things?

MEI16K18 Have you felt depressed?

MEI16L18 Have you been in low or very low spirits?

MEI16M18 Have you felt lonely?

MEI16N18 Has your daily life been full of things that are interesting to you?

MEI16O18 Do you wake up feeling fresh and rested?

MEI1718 I17 Do you have issues regarding sadness or other mental health problems that you would like some help with?

0 No

1 Yes

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