Packet 4
Before you continue, please write the current time: ______
How Do Others See You?
In this section, we would like to learn how others see you.
What would the people who know you say about you? For each of the following, please indicate where they would place you on the scale below.
On this scale, a -3 means that this is much less characteristic of you than of other people. A 0 means that others would see you as about average. A +3 means it is much more characteristic of you than of others. Please circle the number between -3 and +3 that best describes what others would say about you.
Much less About Much more
than others average than others
enthusiastic...... -3-2-10+1+2+3
optimistic...... -3-2-10+1+2+3
laughs easily...... -3-2-10+1+2+3
always sees the bright side...... -3-2-10+1+2+3
comfortable everywhere...... -3-2-10+1+2+3
enjoys good food...... -3-2-10+1+2+3
enjoys being with people...... -3-2-10+1+2+3
pessimistic...... -3-2-10+1+2+3
often worries for nothing...... -3-2-10+1+2+3
a bit depressed...... -3-2-10+1+2+3
often angry...... -3-2-10+1+2+3
tense and uncomfortable...... -3-2-10+1+2+3
Next, we would like to know how much pleasure and pain you experience in different parts of life. Some parts of your life are pleasant and enjoyable, whereas others may be miserable and painful. But sometimes, the part that gives us the most pleasure may also provide us with the most pain. Below we first ask you how much pleasure or joy you get from various parts of your life. Then, we ask you similar questions about pain or misery.
How muchpleasure and joy do you get from each of these domains of life?
No joy at all Lots of joy
Spiritual and religious life...... 0123456
Your neighborhood...... 0123456
Work...... 0123456
Television...... 0123456
Children...... 0123456
Family relationships...... 0123456
Friends...... 0123456
Financial security...... 0123456
Thoughts about the future...... 0123456
Nature, outdoor activities...... 0123456
Activity in the community...... 0123456
Hobbies around house & garden....0123456
Sex, intimate relations...... 0123456
Love and relationships...... 0123456
Your house and home...... 0123456
Food and eating...... 0123456
Your physical condition, health.....0123456
Your future career...... 0123456
Physical activities, sports...... 0123456
Your looks...... 0123456
Your weight...... 0123456
Travel, vacations...... 0123456
Reading...... 0123456
Taking walks...... 0123456
Art, music...... 0123456
Animals, pets...... 0123456
The respect you get from others....0123456
Getting older...... 0123456
Your parents...... 0123456
Meals with friends...... 0123456
Regular activities with friends...... 0123456
Regular family occasions...... 0123456
And how much pain or unhappiness do you experience in these domains of life?
No pain Lots of
at all pain
Spiritual and religious life...... 0123456
Your neighborhood...... 0123456
Work...... 0123456
Television...... 0123456
Children...... 0123456
Family relationships...... 0123456
Friends...... 0123456
Financial security...... 0123456
Thoughts about the future...... 0123456
Nature, outdoor activities...... 0123456
Activity in the community...... 0123456
Hobbies around house & garden....0123456
Sex, intimate relations...... 0123456
Love and relationships...... 0123456
Your house and home...... 0123456
Food and eating...... 0123456
Your physical condition, health.....0123456
Your future career...... 0123456
Physical activities, sports...... 0123456
Your looks...... 0123456
Your weight...... 0123456
Travel, vacations...... 0123456
Reading...... 0123456
Taking walks...... 0123456
Art, music...... 0123456
Animals, pets...... 0123456
The respect you get from others....0123456
Getting older...... 0123456
Your parents...... 0123456
Meals with friends...... 0123456
Regular activities with friends...... 0123456
Regular family occasions...... 0123456
Was there a particular thought that you had several times today, which made you sad or angry?
__ yes__ no
Was there a particular thought that you had several times today, which made you want to smile?
__ yes__ no
How often do you worry about each of the following things?
not at all rarely often
my health….……………….……….………______
health of my family………………………______
relationship…………….……………..……______
my financial future………….………..….______
my marriage.………………………………______
keeping my job.………………………..…______
my enjoyment of work……………….…______
my children……………….…………..……______
Food and diet………….…………….……______
the politics of the country………..……______
How much would you agree or disagree with the following statement:
“Eating is one of life’s great pleasures”?
__ disagree entirely __ somewhat disagree __ agree, some __ agree entirely
Which of the following two statements would you agree most with (or disagree least)?
__ I am happier than most
__ I am unhappier than most
A few additional questions about you
How often do you go to church or other places of worship?
___Several times a week ___Once a week __Occasionally ___Never
In general, how important are religious activities in your life?
__ very important __ fairly important __ slightly important __ not at all important
During the past month, how would you rate your overall sleep quality?
__very good __ fairly good __ fairly bad __very bad
During the past month, on average how many hours of actual sleep did you get at night?
Average hours of sleep per night ______
Last night, how many hours of actual sleep did you get? [CF1]
Hours of sleep last night ______
During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done?
__ no problem at all
__ only a very slight problem
__ somewhat of a problem
__ a very big problem
How satisfied are you with your health these days? Are you
__ very satisfied __ satisfied __ not very satisfied __ not at all satisfied
Do you take sleeping pills?
__ Never
__ Seldom
__ Occasionally
__ Often
In the last year or so, have you been taking any medication for depression, anxiety or another mental state?
__ Yes
__ No
Are you currently on any medical treatment?
__ Yes
__ No
Are you currently dieting for your weight?
__ Yes
__ No
Are you currently dieting for medical reasons?
__ Yes
__ No
Your weight: _____ Your height: _____
Please write the current time: ______
Thank you very much!
Please return this packet to the envelope labeled “Packet 4”. Make certain that all three packets (Packets 1, 3, and 4) are in the large envelope and that you have completed all the questions. When you are finished, take the materials to the lobby.
[CF1]Re-inserted by DK