Did a proxy complete the survey for R?
1 = ACTUAL R
2 = R IS PROXY OR CAREGIVER

Overall evaluations of health
1 = EXCELLENT
2 = VERY GOOD
3 = GOOD
4 = FAIR
5 = POOR
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

Health limit: Vigorous activities
1 = YES, LIMITED A LOT
2 = YES, LIMITED A LITTLE
3 = NO, NOT LIMITED AT ALL
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

Physical health: Cut down work time--FREQ
1 = ALL OF THE TIME
2 = MOST OF THE TIME
3 = SOME OF THE TIME
4 = A LITTLE OF THE TIME
5 = NONE OF THE TIME
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

Physical / emotional health interfered w/ social activities
1 = NOT AT ALL
2 = SLIGHTLY
3 = MODERATELY
4 = QUITE A BIT
5 = EXTREMELY
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

Amount of bodily pain
1 = NONE
2 = VERY MILD
3 = MILD
4 = MODERATE
5 = SEVERE
6 = VERY SEVERE
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

Pain interfered with normal work--FREQ
1 = NOT AT ALL
2 = A LITTLE BIT
3 = MODERATELY
4 = QUITE A BIT
5 = EXTREMELY
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

A/D: Office is inviting, comfortable, and pleasant
1 = DISAGREE
2 = AGREE
3 = STRONGLY AGREE
4 = VERY STRONGLY AGREE
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

A/D: Staff are well coordinated
1 = DISAGREE
2 = AGREE
3 = STRONGLY AGREE
4 = VERY STRONGLY AGREE
5 = DNA: R SEES ONLY ONE PERSON
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

A/D: Staff keep family informed *as much as I want*
1 = DISAGREE
2 = AGREE
3 = STRONGLY AGREE
4 = VERY STRONGLY AGREE
5 = DNA: NO FAMILY/FRIENDS
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

Difficulty of moving around home
1 = VERY DIFFICULT
2 = DIFFICULT
3 = EASY
4 = VERY EASY
5 = SOMEWHAT DIFFICULT
6 = EASY IF EQUIPMENT USED
7 = VERY EASY IF EQUIPMENT USED
97 = REFUSED
98 = DON'T KNOW
99 = NO ANSWER

Feel: My health just doesn't turn out
1 = STRONGLY DISAGREE
2 = SOMEWHAT DISAGREE
3 = SOMEWHAT AGREE
4 = STRONGLY AGREE
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

Feel: Situation is hopeless
1 = STRONGLY DISAGREE
2 = DISAGREE
3 = AGREE
4 = STRONGLY AGREE
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

Level of education
1 = GRADE SCHOOL
2 = HIGH SCHOOL
3 = ANY EDUCATION BEYOND HS
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

Date correct?
1 = CORRECT
2 = INCORRECT

Fact: Day of week
1 = MONDAY
2 = TUESDAY
3 = WEDNESDAY
4 = THURSDAY
5 = FRIDAY
6 = SATURDAY
7 = SUNDAY
8 = OTHER --> SPECIFY
97 = REFUSED
98 = DON'T KNOW
99 = NO ANSWER

R at care facility?
1 = YES
2 = NO
8 = DON'T KNOW

115 = 115 YEARS OR MORE
997 = REFUSED
998 = DON'T KNOW
999 = NO ANSWER