Respondent ID Number
Time to Complete Interview (in Minutes)
Did a proxy complete the survey for R?
Overall evaluations of health
Health now compared to last year
Severity of pain in past seven days
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
No# of doctor visits in last year
No# of emergency room visits in last year
No# of hospital stays in last year
No# of times admitted to care facility last year
No# of prescription medications currently taking
Had pneumonia vaccine
Flu vaccine in past 12 months
Been a caregiver in the past 12 months
Was caregiving difficult?
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
Condition: Angina or heart condition
Condition: Diabetes or high blood sugar
Condition: Digestive problems
Condition: Anxiety problems
Condition: High blood pressure
Condition: Arthritis
Condition: Previous hip fracture
Condition: Previous stroke
Condition: Bladder or bowel control problems
Condition: Breathing problems
Condition: Serious memory loss
Condition: Cancer
Condition: Skin ulcers or bed sores
Condition: Chronic pain
Condition: Depression
Condition: Leak urine
Frequency of accidents
Condition: Other health problems
Condition: Types of other health problems
No# of times fallen in past 12 months
Limit going out because of fear of falling
Help: Shopping and running errands
Help: Light housekeeping
Help: Doing laundry
Help: Using transportation
Help: Using the telephone
Help: Taking medications
Help: Managing finances
Help: Bathing
Help: Dressing
Help: Getting out of bed
Help: Getting out of a chair
Help: Walking around the house
Help: Eating
Help: Using the toilet
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
Reside: Alone in own residence
Reside: With significant other
Reside: With other family members
Reside: With paid caregiver
Reside: In senior housing
Reside: In a care facility
Reside: Refused
Reside: Don't know
Reside: No Answer
Reside: EXIT
Frequency of contact with others
R has advanced health care directive
R's report of date
Date correct?
Fact: Day of week
Day correct?
R at care facility?
Telephone number correct?
Age
R's report of birthdate
R's report of current president
Current president correct?
R's report of previous president
Previous president correct?
R's answer to math problem
Interviewer comments