21 Well Being

The Hispanic Community Health Study/ Study of Latinos (HCHS/SOL)(NHLBI)

Wellbeing_5-25-07

Clinic Questionaires

OMB: 0925-0584

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ID NUMBER:









FORM CODE: WBE

VERSION: A 5/17/07


Contact

Occasion



SEQ #








OMB#: 0925-XXXX

Exp. XX/XXXX




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OMB#: 0925-XXXX

Exp. XX/XXXX

CHS/SOL Well-Being Questionnaire



ID NUMBER:










FORM CODE: WBE

VERSION: A 5/17/07


Contact

Occasion



SEQ #





Acrostic:












Administrative Information

0a. Completion Date: // 0b. Staff ID:

Instructions: Mark the appropriate box for the response. Unless instructed, mark ONLY one response.


A. CES-D 10

Below is a list of some of the ways you may have felt or behaved. Please indicate how often you have felt this way during the past week. (Mark only one on each line)

Rarely or Some or Occasionally

none of a little of or a moderate All of

the time the time amount of time the time

(<1 day) (1-2 days) (3-4 days) (5-7 days)

1. I was bothered by things that usually

don’t bother me. 0 1 2 3

2. I had trouble keeping my mind on what

I was doing. 0 1 2 3


3. I felt depressed. 0 1 2 3


4. I felt that everything I did was an effort. 0 1 2 3


5. I felt hopeful about the future. 0 1 2 3


6. I felt fearful. 0 1 2 3


7. My sleep was restless. 0 1 2 3


8. I was happy. 0 1 2 3


9. I felt lonely. 0 1 2 3


10. I could not “get going”. 0 1 2 3

B. Spielberger Trait Anxiety Scale

Choose the appropriate response for each statement that indicates how you generally feel. Do not spend too much time on any one statement but give the answer which seems to describe how you generally feel.

Almost Almost

never Sometimes Often always


11. I feel nervous and restless. 0 1 2 3

12. I feel satisfied with myself. 0 1 2 3

13. I wish I could be as happy as

others seem to be. 0 1 2 3


14. I feel like a failure. 0 1 2 3


15. I worry too much over something 0 1 2 3

that really doesn’t matter.


16. I lack self-confidence. 0 1 2 3


17. I feel secure. 0 1 2 3


18. I feel inadequate. 0 1 2 3


19. I am a steady person. 0 1 2 3


20. I get in a state of tension or turmoil 0 1 2 3

as I think over my recent concerns

and interests.



Well-Being Form (WBE) Page 0 of 2

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File TitleHCHS (INSERT NAME) Questionnaire
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Last Modified Byuccpxg
File Modified2007-08-17
File Created2007-07-25

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