Before you begin we would like you to answer a few general questions about yourself: by selecting the correct answer or by filling in the space provided.
What is your gender? Male Female
What is your date of birth? 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
What is the highest education you've received? None at all Primary school Secondary school Tertiary (further and higher education)
What is your marital status? Single Married Living as married Separated Divorced Widowed
Are you currently ill? Yes No
If something is wrong with your health what do you think it is? Please write your illness(es) or problem(s) here:
(maximum 255 characters)
This questionnaire asks how you feel about your quality of life, health and other areas of your life. Please answer all the questions. If you are unsure about which response to give to a question, please choose the ONE that appears most appropriate. This can often be your first response.
Please keep in mind your standards, hopes, pleasures and concerns. We ask that you think about your life in the last two weeks. You should select the option that best fits how you feel about what happened over the last two weeks.
Please read each question, assess your feelings, and select the option on the scale for each question that gives the best answer for you.
The following questions ask about how much you have experienced certain things in the last two weeks.
The following questions ask about how completely you experience or were able to do certain things in the last two weeks.
The following questions ask you to say how good or satisfied you have felt about various aspects of your life over the last two weeks.
The following question refers to how often you have felt or experienced certain things in the last two weeks.
How would you describe your ethnic group? White Black Caribbean Black African Black (other) Indian Pakistani Bangladeshi Chinese Other - Asian Other ethnic background (not Asian)
Do you currently live in Britain? Yes No
Where is your home located? Centre of a town or city Suburbs of a town or city In the countryside
Have you consulted a doctor in the last 2 weeks? Yes No
Did someone help you to fill out this form? Yes No
How long did it take you to fill out this form? minutes
Do you have any comments about this questionnaire?
Thank you for your help.
