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!

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).

A. What different things do you want to accomplish?

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

C. What problems do you want to solve?

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

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

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

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
   

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