Did a proxy complete the survey for R?
Overall evaluations of health
Health limit: Vigorous activities
Health limit: Moderate activities
Health limit: Lifting / carrying groceries
Health limit: Climbing several flights of stairs
Health limit: Climbing one flight of stairs
Health limit: Bending, kneeling or stooping
Health limit: Walking more than a mile
Health limit: Walking several hundred yards
Health limit: Walking one hundred yards
Health limit: Bathing or dressing yourself
Physical health: Cut down work time--FREQ
Physical health: Accomplished less--FREQ
Physical health: Limited kind of work--FREQ
Physical health: Difficulty performing work--FREQ
Emotional health: Cut down work time--FREQ
Emotional health: Accomplished less--FREQ
Emotional health: Less careful at work--FREQ
Physical / emotional health interfered w/ social activities
Amount of bodily pain
Pain interfered with normal work--FREQ
Felt calm and peaceful--FREQ
Had a lot of energy--FREQ
Felt downhearted and depressed--FREQ
Physical / emotional health interfered w/ social activities--FREQ
A/D: Office is inviting, comfortable, and pleasant
A/D: Staff truly care about me as a person
A/D: Staff are caring and compassionate
A/D: Confidence and trust in staff
A/D: Free to discuss concerns or anxieties with staff
A/D: Staff answer my questions completely
A/D: Staff are well coordinated
A/D: Staff include me in discussions of my condition
A/D: Staff keep family informed *as much as I want*
A/D: Staff involve family *as much as I want*
A/D: Quality of care at doctor's office is excellent
Difficulty of moving around home
Difficulty of using toilet
Difficulty of dressing self
Difficulty of getting out of chair
Difficulty of going grocery shopping
Difficulty of walking up flight of stairs
Difficulty of walking a block
Difficulty of doing housework
Difficulty of walking half a mile
Difficulty of put in a day's office work
Difficulty of rearranging furniture
Difficulty of running across street
Difficulty of doing two hours of yard work
Feel: My health just doesn't turn out
Feel: Difficult to find solutions to health problems
Feel: I succeed in improving my health
Feel: Able to accomplish health goals
Feel: Efforts to change health are not effective
Feel: My plans for health don't work out well
Feel: Able to do things for health as well as others
Feel: Situation is hopeless
Feel: Worry a lot about the past
Feel: Feel pretty worthless the way I am now
Feel: Frequently feel like crying
Feel: Often feel helpless
Feel: Often feel downhearted and blue
Feel: Sometimes feel that my life is empty
Feel: Dropped many of my activities and interests
Feel: Enjoy getting up in the morning
Feel: Find life very exciting
Feel: Full of energy
Level of education
Date correct?
Fact: Day of week
Day correct?
R at care facility?
Telephone number correct?
Age
Current president correct?
Previous president correct?