C1a.

Now I'd like to know how strongly you agree or disagree with these statements about yourself.

I feel that I'm a person of worth, at least on an equal basis with others. Do you strongly agree, somewhat agree, somewhat disagree or strongly disagree?

 
C1b.

I feel I have a number of good qualities.

(Do you strongly agree, somewhat agree, somewhat disagree or strongly disagree?)

 
C1c.

All in all, I feel that I am a failure.

(Do you strongly agree, somewhat agree, somewhat disagree or strongly disagree?)

 
C1d.

I am able to do things as well as most other people.

(Do you strongly agree, somewhat agree, somewhat disagree or strongly disagree?)

 
C1e.

I feel I do not have much to be proud of.

(Do you strongly agree, somewhat agree, somewhat disagree or strongly disagree?)

 
C1f.

I take a positive (good) attitude toward myself.

(Do you strongly agree, somewhat agree, somewhat disagree or strongly disagree?)

 
C1g.

On the whole, I am satisfied with myself.

(Do you strongly agree, somewhat agree, somewhat disagree or strongly disagree?)

 
C1h.

I wish I could have more respect for myself.

(Do you strongly agree, somewhat agree, somewhat disagree or strongly disagree?)

 
C1i.

I certainly feel useless at times.

(Do you strongly agree, somewhat agree, somewhat disagree or strongly disagree?)

 
C1j.

At times I think I am no good at all.

(Do you strongly agree, somewhat agree, somewhat disagree or strongly disagree?)

 
C1k.

I feel that it is impossible to reach the goals I would like to strive for.

(Do you strongly agree, somewhat agree, somewhat disagree or strongly disagree?)

 
C1l.

The future seems hopeless to me and I can't believe that things are changing for the better.

(Do you strongly agree, somewhat agree, somewhat disagree or strongly disagree?)

 
C2a.

Now I'd like to know how strongly you agree or disagree with these other statements about yourself.

There is really no way I can solve some of the problems I have. Do you strongly agree, somewhat agree, somewhat disagree or strongly disagree?

 
C2b.

Sometimes I feel that I'm being pushed around in life.

(Do you strongly agree, somewhat agree, somewhat disagree or strongly disagree?)

 
C2c.

I have little control over the things that happen to me.

(Do you strongly agree, somewhat agree, somewhat disagree or strongly disagree?)

 
C2d.

I can do just about anything I really set my mind to.

(Do you strongly agree, somewhat agree, somewhat disagree or strongly disagree?)

 
C2e.

I often feel helpless in dealing with the problems of life.

(Do you strongly agree, somewhat agree, somewhat disagree or strongly disagree?)

 
C2f.

What happens to me in the future mostly depends on me.

(Do you strongly agree, somewhat agree, somewhat disagree or strongly disagree?)

 
C2g.

There is little I can do to change many of the important things in my life.

(Do you strongly agree, somewhat agree, somewhat disagree or strongly disagree?)

 
C2h.

I look to God for strength, support and guidance.

(Do you strongly agree, somewhat agree, somewhat disagree or strongly disagree?)

 
C3.

(RB, PG 8)

Please look at the ladder on page 8 in your respondent booklet. The steps on the ladder stand for 10 possible steps in your life. The tenth step stands for the best possible way of life for you and the first step stands for the worst possible way of life for you. What step number best describes where you are now?

 
C4.

(RB, PG 8)

Will you please tell me the step number that best describes where you would like to be a few years from now?

 
C5.

(RB, PG 9)

How likely is it that you will actually reach step [(STEP # IN C4). Would you say highly likely, somewhat likely, somewhat unlikely, or highly unlikely?

1 HIGHLY LIKELY

2 SOMEWHAT LIKELY

3 SOMEWHAT UNLIKELY

4 HIGHLY UNLIKELY

 
C6.

(RB, PG 10)

How disappointed would you be if you found out that you could never reach step [(STEP # IN C4)]? Would you be very disappointed, fairly disappointed, slightly disappointed or not at all disappointed?

 
C7a.

READ SLOWLY PAUSING AS NEEDED

Which of the following things do you feel might keep you from getting to step [(STEP # IN C4)]? As I read each one, please answer yes or no.

Did lack of ability keep you from getting to step [(STEP # IN C4)]?

 
C7b.

(Which of the following things do you feel might keep you from getting to step [(STEP # IN C4)])?

How about lack of opportunity?

 
C7c.

(Which of the following things do you feel might keep you from getting to step [(STEP # IN C4)])?

...lack of effort?

 
C7d.

(Which of the following things do you feel might keep you from getting to step [(STEP # IN C4)])?

...just bad luck?

 
C7f.

(Which of the following things do you feel might keep you from getting to step [(STEP # IN C4)])?

...your race?

 
C7g.

(Which of the following things do you feel might keep you from getting to step [(STEP # IN C4)])?

...your gender?

 
C8a.

(RB, PG 11)

How would you rate the overall condition of your teeth, gums and mouth at the present time? (Would you say it is excellent, very good, good, fair or poor?)

 
C9.

(RB, PG 12)

Compared to one year ago, would you rate your health in general now as much better than one year ago, somewhat better, somewhat worse, or much worse now than one year ago?

 
C10a.

Here is a list of health problems. After each one, please indicate whether a doctor or health professional has ever told you that you have that problem. Has a doctor or health professional ever told you that you have... arthritis or rheumatism?

 
C11a.

Currently, how much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all?

 
C10b.

(Please indicate whether a doctor or health professional has ever told you that you have...)

ulcers?

 
C11b.

Currently how much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all?

 
C10c.

(Please indicate whether a doctor or health professional has ever told you that you have...)

cancer?

 
C11c.

Currently how much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all?

 
C10d.

(Please indicate whether a doctor or health professional has ever told you that you have...)

hypertension or 'high blood pressure'?

 
C11d.

Currently how much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all?

 
C10e.

(Please indicate whether a doctor or health professional has ever told you that you have...)

diabetes or 'sugar'?

 
C11e.

Currently how much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all?

 
C10f.

(Please indicate whether a doctor or health professional has ever told you that you have...)

a liver problem or 'liver trouble'?

 
C11f.

Currently how much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all?

 
C10g.

(Please indicate whether a doctor or health professional has ever told you that you have...)

a kidney problem or 'kidney trouble'?

 
C11g.

Currently how much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all?

 
C10h.

(Please indicate whether a doctor or health professional has ever told you that you have had a...)

stroke?

 
C11h.

Currently how much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all?

 
C10i.

(Please indicate whether a doctor or health professional has ever told you that you have...)

asthma?

 
C11i.

Currently how much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all?

 
C10j.

(Please indicate whether a doctor or health professional has ever told you that you have...)

chronic lung disease?

 
C11j.

Currently how much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all?

 
C10k.

(Please indicate whether a doctor or health professional has ever told you that you have...)

a blood circulation problem or 'hardening of the arteries'?

 
C11k.

Currently how much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all?

 
C10l.

(Please indicate whether a doctor or health professional has ever told you that you have...)

sickle cell disease?

 
C11l.

Currently how much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all?

 
C10m.

(Please indicate whether a doctor or health professional has ever told you that you have...)

heart trouble or have had a heart attack?

 
C11m.

Currently how much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all?

 
C10o.

(Please indicate whether a doctor or health professional has ever told you that you have...)

glaucoma?

 
C11o.

Currently how much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all?

 
C10q.

(Please indicate whether a doctor or health professional has ever told you that you have...)

fertility problems, that is, problems with having a baby?

 
C11q.

Currently how much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all?

 
C10r.

(Please indicate whether a doctor or health professional has ever told you that you have...)

osteoporosis?

 
C11r.

Currently how much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all?

 
C10s.

(Please indicate whether a doctor or health professional has ever told you that you have...)

fibroid tumors?

 
C11s.

Currently how much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all?

 
C10t.

(Please indicate whether a doctor or health professional has ever told you that you have...)

anemia?

 
C11t.

Currently how much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all?

 
C10u.

(Please indicate whether a doctor or health professional has ever told you that you have...)

anorexia, bulimia or any other eating disorder?

 
C11u.

Currently how much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all?

 
C10v.

(Please indicate whether a doctor or health professional has ever told you that you are...)

going through menopause or the change?

 
C11v.

Currently how much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all?

 
C12a.

Here are some more health problems. Have you had any of these in the past 12 months?

Very bad headaches or migraines?

 
C13a.

How much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all?

 
C12b.

(In the past 12 months)

have you had serious hearing problems?

 
C13b.

How much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all?

 
C12c.

(In the past 12 months)

have you had serious vision problems?

 
C13c.

How much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all?

 
C12d.

(In the past 12 months)

have you had bad allergies or infections?

 
C13d.

How much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all?

 
C12e.

(In the past 12 months)

have you had serious back problems?

 
C13e.

How much does this health problem keep you from working or carrying out your daily tasks? Would you say a great deal, only a little or not at all?

 
C14a.

The next questions are about activities you may do.

Please tell me how often you typically do each of the following things.

How often do you work in the garden or the yard? Would you say often, sometimes, rarely or never?

 
C14b.

How often do you engage in active sports or exercise?

(Would you say often, sometimes, rarely or never?)

 
C14c.

How often do you take walks?

(Would you say often, sometimes, rarely or never?)

 
C19.

Are you currently trying to lose weight?

 
C20.

(RB, PG 13)

Do you consider yourself very overweight, somewhat overweight, only a little overweight, just about right or underweight?

 
C21.

Now I'm going to ask about who you go to for medical help. Is there one place or person you usually go to when you are sick or need medical advice?

 
C21a.

Where or who is that?

 
C22a.

Here is a list of people one might go to for medical help. Please indicate if you have ever gone to any of the following people.

Have you ever gone to a faith healer?

 
C22b.

(Here is a list of people one might go to for medical help. Please indicate if you have ever gone to any of the following people.)

Have you ever gone to a person who heals with roots or herbs or a person who reads tea leaves or palms?

 
C22c.

(Here is a list of people one might go to for medical help. Please indicate if you have ever gone to any of the following people.)

Have you ever gone to a person who practices astrology, reads zodiac signs, or is a psychic?

 
C23.

Are you currently covered by any federal government health insurance programs, such as Medicare, Medicaid, or CHAMPUS, VA, or other military programs?

 
C23b.

Does it cover treatment of problems with emotions, nerves or mental health?

 
C24.

Are you covered by health insurance through your employer, or former employer or union, such as Blue Cross-Blue Shield or an HMO?

 
C24a.

How many such health plans do you have?

 
C24b.

[(Do any/Does it)] cover treatment of problems with emotions, nerves or mental health?

1 YES

5 NO

 
C24c.

Are you covered by health insurance through your family's employer, or former employer or union, (such as Blue Cross-Blue Shield or an HMO)? (By family I mean husband/wife/partner or parents.)

 
C24d.

Does it cover treatment of problems with emotions, nerves or mental health?

 
C25.

Do you have any type of health insurance coverage, Medigap or other supplemental coverage, or long-term care insurance that is purchased directly from an insurance company or through a membership organization such as AARP (the American Association of Retired Persons)?

 
C26.

When you see a doctor in his or her office or clinic, how much do you (or your family) have to pay out of your own pocket before you leave?

 
C26cs.

Please tell me, what is the dollar amount?

 
C26_iwr

INTERVIEWER CHECKPOINT: (SEE C23, C24, C24c, C25)

1 1+=1 IN C23-25

2 ALL OTHERS