Demographic factors

What is your age?

Gender

How many years have you been in full time education?

What is your marital status?

Country of residence

Leisure activities

Recent activities
Please look at the list of activities below

Have you done any of the following activities in the past twelve months?

Done voluntary of charity work

Attended an educational or training course

Gone to a sport, social or other kind of club

Taken part in a political or community-related organization

Read books, magazines or newspapers

Did word or number games such as crossword puzzles or Sudoku

Played cards or games such as chess

Difficulties in everyday activities (1)

Please look at the list of activities below

Do you have any difficulty doing each of these everyday activities? Please exclude any difficulties that you expect to last less than three months

Walking 100 metres

Sitting for about two hours

Getting up from a chair after sitting for long periods

Climbing several flights of stairs without resting

Climbing one flight of stairs without resting

Stooping, kneeling, or crouching

Reaching or extending your arms above shoulder level

Pulling or pushing large objects like a living room chair

Lifting or carrying weights over 10 pounds/5 kilos, like a heavy bag of groceries

Picking up a small coin from a table

Difficulties in everyday activities (2)

Please look at the list of activities below

Have you any difficulty in the following activities?

Dressing, including putting on shoes and socks

Walking across a room

Bathing or showering

Eating, such as cutting up your food

Getting in or out of bed

Using the toilet, including getting up or down

Using a map to figure out how to get around in a strange place

Preparing a hot meal

Shopping for groceries

Making telephone calls

Taking medication

Doing work around the house or garden

Managing money, such as paying bills and keeping track of expenses

Physical symptoms and perceptions

Are you troubled with pain?

For the past six months at least, have you been bothered by dizziness, faints or blackouts?

For the past six months at least, have you been bothered by fatigue?

On a scale from 0 to 10, how satisfied are you with your life?

How often do you think your age prevents you from doing the things you would like to do?

How often do you feel that what happens to you is out of your control?

How often do you feel left out of things?

How often do you think that family responsibilities prevent you from doing what you want to do?

How often do you feel full of energy these days?

How often do you feel that the future looks good for you?

How much of the time do you feel lonely?

Depressive symptoms

In the last month, have you been sad or depressed?

Do you have hopes for the future?

In the last month, have you felt that you would rather be dead?

Do you tend to blame yourself or feel guilty about anything?

Have you had trouble sleeping recently?

In the last month, have you lost interest in things?

Have you been irritable recently?

Has your appetite diminished in the last month?

In the last month, have you had too little energy to do the things you wanted to do?

Do you have problems concentrating (e.g. following a television programme or reading)?

Have you enjoyed doing any activity recently?

In the last month, have you cried at all?

Demographic factors

Leisure activities

Recent activities Please look at the list of activities below

Difficulties in everyday activities (1)

Please look at the list of activities below

Difficulties in everyday activities (2)

Please look at the list of activities below

Physical symptoms and perceptions

Depressive symptoms

Recent activities
Please look at the list of activities below