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Quality of Life Survey

Winter 2000/2001

As part of this issue of CRIA Update, we thought it would be interesting to learn something about the quality of life of our readers. The questions included in the survey represent two different approaches to measuring quality of life -- a standard scale where people rate items provided by researchers, and an open-ended scale where people rate themselves on their own dimensions.

We have also included background questions to help us better understand the quality of life concerns of different members of our audience. Please take a few minutes to complete this anonymous survey. We will present a summary of the results in a future issue of CRIA Update.

We want to hear from as many of you as possible. Thanks for participating!

  
PERSONAL GOALS AND QUALITY OF LIFE
  
Quality of life means different things to different people at different times. To better understand what matters to you, please answer each of the questions below. Try to be specific. It is much more meaningful to say, "I'd like to spend more time with friends" or "I'd like to meet some new friends" than to just say "friends."

As you answer these questions, consider how close you are to reaching these goals (Distance).
Please rate the distance of each goal from 0 (Very Close) to 10 (Very Far).

In order to have the most satisfying life possible:

A. What different things do you want to accomplish?

Distance
Distance
Distance
Distance
Distance
 

B. What situations do you want to prevent or avoid?

Distance
Distance
Distance
Distance
Distance
 

C. What problems do you want to solve?

Distance
Distance
Distance
Distance
Distance
 

D. What things do you want to keep the way they are now?

Distance
Distance
Distance
Distance
Distance
 

E. What circumstances do you want to be able to accept?

Distance
Distance
Distance
Distance
Distance
 

F.What responsibilities or roles do you want to let go?

Distance
Distance
Distance
Distance
Distance

THE SF-12v2TM HEALTH SURVEY
Instructions for Completing the Questionnaire

Please answer every question. Some questions may look like others, but each one is different. Please take the time to read and answer each question carefully by selecting the answer that best represents your response.

Your Health in General

  1. In general, would you say your health is:
    excellent
    very good
    good
    fair
    poor

  2. The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

    1. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf
      Yes, limited a lot
      Yes, limited a little
      No, not limited at all

    2. Climbing several flights of stairs
      Yes, limited a lot
      Yes, limited a little
      No, not limited at all

  3. During the past 4 weeks, how much of the time have you had the following problem with your work or other regular activities as a result of your physical health?

    Accomplished less than you would like
    All the time
    Most of the time
    Some of the time
    A little of the time
    None of the time

  4. During the past 4 weeks, how much of the time have you had the following problem with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?

    Accomplished less than you would like
    All the time
    Most of the time
    Some of the time
    A little of the time
    None of the time

  5. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?
    Not at all
    A little bit
    Moderately
    Quite a bit
    Extremely

  6. These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.

    How much of the time during the past 4 weeks . . .

    1. have you felt calm and peaceful
      All the time
      Most of the time
      Some of the time
      A little of the time
      None of the time

    2. did you have a lot of energy
      All the time
      Most of the time
      Some of the time
      A little of the time
      None of the time

    3. have you felt downhearted and depressed
      All the time
      Most of the time
      Some of the time
      A little of the time
      None of the time

  7. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting old friends, relatives, etc.)?
    All the time
    Most of the time
    Some of the time
    A little of the time
    None of the time


BACKGROUND INFORMATION (optional)
Date of Birth:
mmddyyyy
  

Gender:
Female  Male

How do you describe yourself, in terms of your racial or ethnic identity?

What is your highest level of education?
Grade School
Some High School
High School Graduate
Some College
Earned Two Year College Degree
Earned Four Year College Degree
Some Graduate School
Earned Advanced Degree

What is or was your main job or occupation?

Have you been diagnosed with HIV?
Yes  No
IF yes, when?
mmyyyy
 

Current HIV-related involvement (please check all that apply to you):
Buddy/Volunteer
Activist
Caregiver
Professional Care Provider
Researcher
Agency Donor

Thank you for completing this survey.


Back to the CRIA Update Winter 2000/2001 Contents Page.




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