You Have No Problems in Walking About? 01

Question:EQ5D_1

I am now going to read out some questions. Each question has a choice of five answers. Please tell me which answer best describes your health TODAY. Do not choose more than one answer in each group of questions. It may be necessary to remind the respondent regularly that the timeframe is TODAY. It may also be necessary to repeat the questions verbatim. First I'd like to ask you about mobility. Would you say that: READ SCALE.

You have no problems in walking about?...... 01

You have slight problems in walking about?...... 02

You have moderate problems in walking about...... 03

You have severe problems in walking about?...... 04

You are unable to walk about?...... 05

Note: the EQ-5D questions are used under license.

Question:EQ5D_2

Next I'd like to ask you about self-care. Would you say that: READ SCALE.

You have no problems washing or dressing yourself?...... 01

You have slight problems washing or dressing yourself?...... 02

You have moderate problems washing or dressing yourself?...... 03

You have severe problems washing or dressing yourself?...... 04

You are unable to wash or dress yourself?...... 05

Note: the EQ-5D questions are used under license.

Question:EQ5D_3

Next I'd like to ask you about your usual activities, for example work, study, housework, family or leisure activities. Would you say that: READ SCALE.

You have no problems doing your usual activities?...... 01

You have slight problems doing your usual activities?...... 02

You have moderate problems doing your usual activities?...... 03

You have severe problems doing your usual activities?...... 04

You are unable to do your usual activities?...... 05

Note: the EQ-5D questions are used under license.

Question:EQ5D_4

Next I'd like to ask you about pain or discomfort. Would you say that. READ SCALE.

You have no pain or discomfort?...... 01

You have slight pain or discomfort?...... 02

You have moderate pain or discomfort?...... 03

You have severe pain or discomfort?...... 04

You have extreme pain or discomfort?...... 05

Note: the EQ-5D questions are used under license.

Question:EQ5D_5

Finally I'd like to ask you about anxiety or depression. Would you say that: READ SCALE.

You are not anxious or depressed?...... 01

You are slightly anxious or depressed?...... 02

You are moderately anxious or depressed?...... 03

You are severely anxious or depressed?...... 04

You are extremely anxious or depressed?...... 05

Note: the EQ-5D questions are used under license.

Question:EQ5D_VAS

Now, I would like to ask you to say how good or bad your health is TODAY. I'd like you to try to picture in your mind a scale that looks rather like a thermometer. Can you do that? The best health you can imagine is marked 100 (one hundred) at the top of the scale and the worst state you can imagine is marked 0 (zero) at the bottom. I would now like you to tell me the point on this scale where you would put your health today.

Range ...... 0-100

Note: the EQ-5D questions are used under license.

Question:HRQOL4_1

The following questions ask about physical activity, social relationships and health status. By health, we mean not only the absence of disease or injury but also physical, mental and social well-being. Would you say that in general your health is: READ OPTIONS

Excellent...... 01

Very Good...... 02

Good...... 03

Fair...... 04

Poor...... 05

Question:HRQOL4_2

Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?

Range ...... 0-30

Question:HRQOL4_3

Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

Range ...... 0-30

Question:HRQOL4_4

During the past 30 days, for about how many days did poor physical and mental health keep you from doing your usual activities, such as self-care, work, or recreation?

Range ...... 0-30

Question:SATIS_1

I am now going to ask you how satisfied you feel, on a scale from 0 to 10. 0 means you feel no satisfaction at all and 10 means you feel completely satisfied. I will start by asking how satisfied you are with life. So thinking about your own life and personal circumstances, on a scale of 0 to 10, how satisfied are you with your life as a whole? Repeat if Question is unclear to Respondent Repeat above. Would you like me to go over this again for you?

0...... 00

1...... 01

2...... 02

3...... 03

4...... 04

5...... 05

6...... 06

7...... 07

8...... 08

9...... 09

10...... 10

Question:SATIS_2

How satisfied are you with your standard of living? On a scale from 0 to 10. 0 means you feel no satisfaction at all and 10 means you feel completely satisfied.

0...... 00

1...... 01

2...... 02

3...... 03

4...... 04

5...... 05

6...... 06

7...... 07

8...... 08

9...... 09

10...... 10

Question:SATIS_3

How satisfied are you with your health? On a scale from 0 to 10. 0 means you feel no satisfaction at all. 10 means you feel completely satisfied.

0...... 00

1...... 01

2...... 02

3...... 03

4...... 04

5...... 05

6...... 06

7...... 07

8...... 08

9...... 09

10...... 10

Question:SATIS_4

How satisfied are you with what you are achieving in life? On a scale from 0 to 10. 0 means you feel no satisfaction at all. 10 means you feel completely satisfied.

0...... 00

1...... 01

2...... 02

3...... 03

4...... 04

5...... 05

6...... 06

7...... 07

8...... 08

9...... 09

10...... 10

Question:SATIS_5

How satisfied are you with your personal relationships? On a scale from 0 to 10. 0 means you feel no satisfaction at all. 10 means you feel completely satisfied.

0...... 00

1...... 01

2...... 02

3...... 03

4...... 04

5...... 05

6...... 06

7...... 07

8...... 08

9...... 09

10...... 10

Question:SATIS_6

How satisfied are you with how safe you feel? On a scale from 0 to 10. 0 means you feel no satisfaction at all. 10 means you feel completely satisfied.

0...... 00

1...... 01

2...... 02

3...... 03

4...... 04

5...... 05

6...... 06

7...... 07

8...... 08

9...... 09

10...... 10

Question:SATIS_7

How satisfied are you with feeling part of your community? On a scale from 0 to 10. 0 means you feel no satisfaction at all. 10 means you feel completely satisfied.

0...... 00

1...... 01

2...... 02

3...... 03

4...... 04

5...... 05

6...... 06

7...... 07

8...... 08

9...... 09

10...... 10

Question:SATIS_8

How satisfied are you with your future security? On a scale from 0 to 10. 0 means you feel no satisfaction at all. 10 means you feel completely satisfied.

0...... 00

1...... 01

2...... 02

3...... 03

4...... 04

5...... 05

6...... 06

7...... 07

8...... 08

9...... 09

10...... 10

Question:SATIS_9

How satisfied are you with your spirituality or your religion? On a scale from 0 to 10. 0 means you feel no satisfaction at all. 10 means you feel completely satisfied.

0...... 00

1...... 01

2...... 02

3...... 03

4...... 04

5...... 05

6...... 06

7...... 07

8...... 08

9...... 09

10...... 10

Question:STS_Q1

Now a few questions about the stress in your life. In general, how would you rate your ability to handle unexpected and difficult problems, for example, a family or personal crisis? Would you say your ability is: READ OPTIONS

Excellent...... 01

Very good...... 02

Good...... 03

Fair...... 04

Poor...... 05

Question:STS_Q2

In general, how would you rate your ability to handle the day-to-day demands in your life, for example, handling work, family and volunteer responsibilities? Would you say your ability is: READ OPTIONS

Excellent...... 01

Very good...... 02

Good...... 03

Fair...... 04

Poor...... 05

Question:STS_Q3

Thinking about stress in your day-to-day life, what would you say is the most important thing contributing to feelings of stress you may have? DO NOT READ CHOICES. DO NOT PROBE. CHOOSE THE ANSWER THAT BEST MATCHES THE RESPONDENTS ANSWER

Time pressures / Not enough time...... 01

Own physical health problem or condition...... 02

Own emotional or mental health problem or condition...... 03

Financial situation (e.g., not enough money, debt)...... 04

Own work situation (e.g., hours of work, working conditions).....05

School...... 06

Employment status (e.g., unemployment)...... 07

Caring for - own children...... 08

Caring for - others...... 09

Other personal or family responsibilities...... 10

Personal relationships...... 11

Discrimination...... 12

Personal and family's safety...... 13

Health of family members...... 14

Other - Specify...... 15

Nothing...... 16

Question:RLE_1

I'd like to ask about some things that may have happened in the past 12 months, that is, from <RLE> to yesterday. Some of these experiences happen to most people at one time or another, while some happen to only a few. Now I'd like you to think just about your family, that is, yourself or your spouse/partner or children if any. Did you or someone in your family have a major financial crisis?

Yes...... 01

No...... 02

Question:RLE_2

Did you or someone in your family fail school or a training program? For this question family includes yourself or your spouse/partner or children if any

Yes...... 01

No...... 02

Question:RLE_3

Did you or someone in your family experience a change in job for a worse one? For this question family includes yourself or your spouse/partner or children if any

Yes...... 01

No...... 02

Question:RLE_4

Did you or someone in your family get demoted at work or take a cut in pay? For this question family includes yourself or your spouse/partner or children if any

Yes...... 01

No...... 02

Question:RLE_5

Did someone in your family pass away? For this question family includes yourself or your spouse/partner or children if any

Yes...... 01

No...... 02

Question:RLE_6

Were you or someone in your family beaten up or physically attacked? For this question family includes yourself or your spouse/partner or children if any

Yes...... 01

No...... 02

Question:RLE_7

Were you or someone in your family bullied? For this question family includes yourself or your spouse/partner or children if any

Yes...... 01

No...... 02

Question:NUT_1

NUTRITION (NUT)

Now some questions about your eating and drinking habits. How often do you usually drink regular (non-diet) soft drinks? READ OPTIONS

Once a day or more...... 01

4 - 6 times a week...... 02

1 - 3 times a week...... 03

Less than once a week but more than once a month...... 04

Once a month or less...... 05

Question:NUT_2

NUTRITION (NUT)

How often do you usually drink sugar sweetened fruit drinks (such as Kool-Aid and lemonade), sweet tea, and sports or energy drinks (such as Gatorade or Red Bull)? READ OPTIONS

Once a day or more...... 01

4 - 6 times a week...... 02

1 - 3 times a week...... 03

Less than once a week but more than once a month...... 04

Once a month or less...... 05

Question:NUT_3

NUTRITION (NUT)

How often do you usually drink sweetened specialty coffee or tea based drinks (such as lattes, mochacinnos, frappacinnos) READ OPTIONS

Once a day or more...... 01

4 - 6 times a week...... 02

1 - 3 times a week...... 03

Less than once a week but more than once a month...... 04

Once a month or less...... 05

Question:NUT_4

NUTRITION (NUT)

How often do you eat out at a restaurant, fast food establishment or cafeteria? READ OPTIONS

Once a day or more...... 01

4 - 6 Times a week...... 02

1 - 3 Times a week...... 03

Less than once a week but more than once a month...... 04

Once a month or less...... 05

Question:NUT_5

NUTRITION (NUT)

Now I'd like to ask you some questions about sodium or salt intake. Most of the sodium or salt we eat comes from processed foods and foods prepared in restaurants. Salt also can be added in cooking or at the table. Are you currently watching or reducing your sodium or salt intake?

Yes...... 01

No...... 02=> /NUT_7

Question:NUT_6

NUTRITION (NUT)

How long have you been watching or reducing your sodium or salt intake? Do not accept ranges, ask respondent for their best estimate.

Day(s)...... 01O

Week(s)...... 02O

Month(s)...... 03O

Year(s)...... 04O

All my life...... 05

Question:NUT_7

NUTRITION (NUT)

Has your doctor or other health professional ever advised you to reduce your sodium or salt intake?

Yes...... 01

No...... 02

Question:SED_1

SEDENTARY

Now a few questions about what you do in your leisure time, that is activities not at work or at school. In a typical week how much time do you spend playing computer games, surfing the internet, playing video games, watching television or videos? DO NOT READ SCALE. PLEASE ROUND UP.

None...... 01

Less than an hour...... 02

From 1 to 2 hours...... 03

From 3 to 5 hours...... 04

From 6 to 10 hours...... 05

From 11 to 14 hours...... 06

From 15 to 20 hours...... 07

More than 20 hours...... 08

Question:SED_2

(SEDENTARY)

In a typical week how much time do you spend reading on the Internet (e.g., the news, articles, a book), not counting at work or school? Include books, magazines, newspapers, homework DO NOT READ SCALE. PLEASE ROUND UP.

None...... 01

Less than 1 hour...... 02

From 1 to 2 hours...... 03

From 3 to 5 hours...... 04

From 6 to 10 hours...... 05

From 11 to 14 hours...... 06

From 15 to 20 hours...... 07

More than 20 hours...... 08

Question:SED_3

(SEDENTARY)

In a typical week how much time do you spend reading hard copy books, not counting work or school? Include books, magazines, newspapers, homework DO NOT READ SCALE. PLEASE ROUND UP.

None...... 01

Less than 1 hour...... 02

From 1 to 2 hours...... 03

From 3 to 5 hours...... 04

From 6 to 10 hours...... 05

From 11 to 14 hours...... 06

From 15 to 20 hours...... 07

More than 20 hours...... 08

Question:SMK_202

SMOKING (SMK)

The next set of questions is about smoking. At the present time, do you smoke cigarettes...? READ OPTIONS

Daily...... 01=

Occasionally...... 02

Not at all...... 03

Question:SMK_05D

SMOKING (SMK)

Have you ever smoked cigarettes daily? READ OPTIONS

Yes...... 01

No...... 02

Question:MD_Q01