8 F155 Lifestyle

Form 155 – Lifestyle Questionnaire (Draft)

OMB #0925-0414 Exp X/XXXXX

This booklet has questions about your behavior, feelings, and experiences. Please answer each
question as honestly as you can. No one will see your answers except for the scientists and staff at
WHI. Your answers will be kept secret and will never be put with your name in a report. Please
answer using you first thoughts about each question. Do not go back later to ‘figure out’ answers.
Your answers will help us to understand the health of women like you. Thank you for your help.

MARKING INSTRUCTIONS
•
•
•
•

Use a No. 2 pencil only.
Darken the oval completely next to the answer you choose.
Erase cleanly any marks you wish to change.
Do not make any stray marks on this form.

INCORRECT MARKS

CORRECT MARK

Public reporting for this collection of information is estimated to average 25 minutes per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the information needed and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a
person is not required to respond to a collection of information unless it is displays a currently valid OMB control number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive,
MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0414). Do not return the completed form to this address.

OFFICE USE ONLY

1. Date Received:
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AFFIX LABEL BETWEEN LINES

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2.

Reviewed By:

Day

Year

3. Contact Type
1 Phone
2 Mail
8 Other

FCA

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5. Language:
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SERIAL #

PLEASE MAKE NO MARKS IN THIS AREA

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DRAFT: 11/18/09

Form 155 – Lifestyle Questionnaire (Draft)
Please answer each question below as accurately as possible.
Excellent
1.

In general, would you say your health is:

2.

Compared to one year ago, how
would you rate your health in general
now?

3.

1

Very
good

Good

Fair

Poor

2

3

4

5

Much
better now
than 1 year
ago

Somewhat
better now
than 1 year
ago

About
the same

Somewhat
worse now
than 1 year
ago

Much
worse
now than
1 year ago

1

2

3

4

5

Overall, how would you rate your quality of life? (Mark one box below.)
0

1

2

3

4

Worst

5

6

7

8

9

Halfway

Best

As bad or worse
than being dead
4.

5.

10

Best quality
of life

How would you describe (Mark one box for
each line.)

Excellent Very good Average

Poor

Very
poor

4.1

Your hearing?

1

2

3

4

5

4.2

The condition of your mouth and teeth?

1

2

3

4

5

4.3

Your vision (corrected with glasses or
lenses as needed)?

1

2

3

4

5

4.4

Your appetite?

1

2

3

4

5

4.5

Your balance?

1

2

3

4

5

Have you lost 10 pounds or more in the past year?

0 No
1 Yes
6.

7.

Do you smoke cigarettes now?
0 No
1 Yes

6.1

If yes, how many cigarettes do you usually smoke each day?
1 Less than 1
5 25 - 34
2 1 - 4
6 35 - 44
3 5 - 14
7 45 or more
4 15 - 24

Are you taking a calcium supplement such as Oscal, Viactiv, or Tums?
0 No
1 Yes

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Form 155 – Lifestyle Questionnaire (Draft)
The next question is about female hormones you got with a doctor’s prescription in the last year, even
if you are not taking them right now.
8.

In the past year, did you use any of the following female hormones—ESTROGEN, PROGESTERONE
(also called PROGESTIN), or TESTOSTERONE—that were prescribed by a doctor? (These may have
been in the form of a pill; skin patch; shot; cream; vaginal ring, pellet, or suppository, or bioidentical
compound.)
0 No
1 Yes
9 Don't know

9.

In the past 3 months, how often have you had drinks containing alcohol?
0 Never

1
2
3
4

less than once per week
1 or 2 times per week
3 or 4 times per week
Everyday

The next questions are about your living conditions.
10.

11.

Who lives with you? (Answer No or Yes for each line.)
No

Yes

10.1

0

1

I live alone

10.2

0

1

I live with my husband or partner

10.3

0

1

I live with my children

10.4

0

1

I live with other relatives

10.5

0

1

I live with friends

10.6

0

1

Other (please describe):
__________________________________

Does the place where you live have special services for older people (such as help with meals,
medicines, bathing, or transportation)?

0 No

1 Yes

11.1

Are you currently receiving any of these services?

0 No
12.

In the past year, have you stayed in a nursing home?

0 No

1 Yes

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Pg. 3 of 17

1 Yes

Form 155 – Lifestyle Questionnaire (Draft)
The following are questions about a typical (or usual) day's activities. Does your health now limit you
in these activities and, if so, how much? (Mark one box for each question.)
No,
not limited
at all

Yes,
limited
a little

Yes,
limited
a lot

13.

Vigorous activities, such as running,lifting
heavy objects, or strenuous sports

3

2

1

14.

Moderate activities, such as moving a table,
vacuuming, bowling, or golfing

3

2

1

15.

Lifting or carrying groceries

3

2

1

16.

Climbing several flights of stairs

3

2

1

17.

Climbing one flight of stairs

3

2

1

18.

Bending, kneeling, stooping

3

2

1

19.

Walking more than a mile

3

2

1

20.

Walking several blocks

3

2

1

21.

Walking one block

3

2

1

22.

Bathing or dressing yourself

3

2

1

23.

What aid, if any, do you
usually use to walk on a level
surface? (Mark one.)

I do not
use any aid

I use a
cane

I use
crutches

I use a
walker

I use a
wheelchair

1

2

3

4

5

These next questions ask about how much help (if any) you need to do routine activities for yourself.
Help can be defined as getting assistance from another person or using a device. (Mark one box for
each question)
Completely
By myself
With some
I can do this activity:
unable to do this
without help
help
by myself
24. Can you feed yourself?
1
2
3
25. Can you dress and undress yourself?

1

2

3

26. Can you get in and out of bed yourself?

1

2

3

27. Can you take a bath or shower?

1

2

3

28. Can you do your own grocery shopping?

1

2

3

29. Can you keep track of and take your medicines?

1

2

3

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Form 155 – Lifestyle Questionnaire (Draft)
The next questions ask about your physical activity.
30.

Think about the walking you do outside the home. How often do you walk outside the home for more
than 10 minutes without stopping? (Mark only one)

1
2
3
4
5
6

Rarely or never
1 to 3 times each month
1 time each week
2 to 3 times each week
4 to 6 times each week
7 or more times each week

When you walk outside the home for more than 10 minutes without stopping,
30.1

For how many minutes do you usually walk?

1
2
3
4
30.2

31.

Less than 20 minutes
20 to 39 minutes
40 to 59 minutes
1 hour or more

What is your usual speed?
1 Casual strolling (2 miles per hour)
2 Average or normal (2-3 miles per hour)
3 Fairly fast (3-4 miles per hour)
4 Very fast (more than 4 miles per hour)
5 Don’t know

Not counting walking outside the home, how often each week (7 days) do you usually do the exercises
listed below?
31.1

Moderate or strenuous exercise. For example, biking outdoors, using an exercise machine
(like a stationary bike or treadmill), aerobics, swimming, folk or popular dancing, jogging,
tennis.
1 No
31.2 How long do you usually exercise
2 1 day per week
like this at one time?
3 2 days per week
1 Less than 20 minutes
4 3 days per week
2 20 to 39 minutes
5 4 days per week
3 40 to 59 minutes
6 5 or more days per week
4 1 hour or more

Go to the next page

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Form 155 – Lifestyle Questionnaire (Draft)
31.3

Mild exercise. For example, slow dancing, bowling or golf.
1 No
2 1 day per week
31.4 How long do you usually exercise
3 2 days per week
like this at one time?
4 3 days per week
1 Less than 20 minutes
5 4 days per week
2 20 to 39 minutes
6 5 or more days per week
3 40 to 59 minutes
4 1 hour or more

Now some questions about your social activities. How often, if at all, do you do any of the following
activities? (Check one box on each line.)
At least
Several
Once a Rarely or
once per times per
month
never
week
month
32.

Eat out of the house

1

2

3

4

33.

Go shopping

1

2

3

4

34.

Go to a cultural event such as a movie, concert, play
or lecture

1

2

3

4

35.

Meet with family or friends who do not live with you

1

2

3

4

36.

Communicate with family or friends by phone or
email

1

2

3

4

37.

Go to a church or other religious center

1

2

3

4

With growing older, we may rely on others more to help us with everyday care (meals or bathing or
transportation, etc.).
38.

How often in the past 4 weeks have you felt that people you rely on for everyday care have neglected
your needs?

0
1
2
3

Does not apply. I don't need help with my everyday care
Almost no problems with obtaining everyday care
Occasional problems with obtaining everyday care
Frequent problems with obtaining everyday care

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Form 155 – Lifestyle Questionnaire (Draft)
Questions 39-43 ask about your feelings during the past week. For each of the statements, please
indicate the choice that tells how often you felt this way.
Rarely or none
of the time
(less than
1 day)

Some or Occasionally or Most or all
a little of
a moderate
of the time
the time amount of time (5-7 days)
(1-2 days)
(3-4 days)

39. You felt depressed (blue or down)

1

2

3

4

40. Your sleep was restless

1

2

3

4

41. You enjoyed life

1

2

3

4

42. You felt sad

1

2

3

4

43. You felt that people disliked you

1

2

3

4

44.

In the past year, have you had 2 weeks or more during which you felt sad, blue or depressed, or lost
pleasure in things that you usually cared about or enjoyed?

0 No
45.

1 Yes

Have you had 2 years or more in your life when you felt depressed or sad most days, even if you
felt okay sometimes?
45.1 If yes, have you felt depressed or sad much of the time
0 No
1 Yes
in the past year?

0 No

46. During the past 4 weeks, how much
bodily pain have you had?

47. During the past 4 weeks, how much did
pain interfere with your normal work
(both outside your home and at home)?

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1 Yes

None

Very
mild

Mild

Moderately
(Medium)

Severe

1

2

3

4

5

Not at
all

A little
bit

Moderately
(Medium)

Quite
a bit

Extremely
(A lot)

1

2

3

4

5

Pg. 7 of 17

Form 155 – Lifestyle Questionnaire (Draft)
Questions 48-56 ask about how you feel and how things have been during the past 4 weeks. Give one
answer that comes closest to the way you have been feeling.
How much of the time during the past 4 weeks…
All
of the
time

Most
of the
time

A good
bit of the
time

Some
of the
time

A little
of the
time

None
of the
time

48. Did you feel full of pep?

1

2

3

4

5

6

49. Did you have a lot of energy?

1

2

3

4

5

6

50. Did you feel worn out?

1

2

3

4

5

6

51. Did you feel tired?

1

2

3

4

5

6

52. Have you been a very nervous
person?

1

2

3

4

5

6

53. Have you felt so down in the dumps
that nothing could cheer you up?

1

2

3

4

5

6

54. Have you felt calm and peaceful?

1

2

3

4

5

6

55. Have you felt downhearted and
blue?

1

2

3

4

5

6

56. Have you been happy?

1

2

3

4

5

6

During the past 4 weeks, how often have you been bothered by any of the following problems?
Not
at all

Several
days

More than half
the days

57. Feeling nervous, anxious, on edge, or worrying a lot
about different things

1

2

3

58. Feeling restless so that it is hard to sit still

1

2

3

59. Trouble concentrating on things, such as reading a
book or watching TV

1

2

3

60. Having an anxiety attack—suddenly feeling fear or
panic

1

2

3

61. Getting tired very easily

1

2

3

62. Muscle tension aches or soreness

1

2

3

63. Trouble falling asleep or staying asleep

1

2

3

64. Becoming easily annoyed or irritable

1

2

3

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Form 155 – Lifestyle Questionnaire (Draft)
The following questions are about emotions you may have been feeling. Please mark one box for each
statement
How true have the following been for you in this past week (7 days)?
Not
at all

A little
bit

Somewhat

Quite
a bit

Very
much

65. I am not interested in activities that will
expand my horizons.

0

1

2

3

4

66. I think it is important to have new
experiences that challenge how you
think about yourself and the world.

0

1

2

3

4

67. When I think about it, I haven't really
improved much as a person over the
years.

0

1

2

3

4

68. I have the sense that I have developed a
lot as a person over time.

0

1

2

3

4

69. For me, life has been a continuous
process of learning, changing, and
growth

0

1

2

3

4

70. I gave up trying to make big
improvements or changes in my life a
long time ago.

0

1

2

3

4

71. I do not enjoy being in new situations
that require me to change my old
familiar ways of doing things

0

1

2

3

4

72. I live life one day at a time and don't
really think about the future.

0

1

2

3

4

73. I have a sense of direction and purpose
in life.

0

1

2

3

4

74. I don't have a good sense of what it is
I'm trying to accomplish in life.

0

1

2

3

4

75. My daily activities often seem trivial
and unimportant to me.

0

1

2

3

4

76. I enjoy making plans for the future and
working to make them a reality.

0

1

2

3

4

77. I am an active person in carrying out
the plans I set for myself.

0

1

2

3

4

78. Some people wander aimlessly through
life, but I am not one of them.

0

1

2

3

4

79. I sometimes feel as if I've done all there
is to do in life.

0

1

2

3

4

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Pg. 9 of 17

Form 155 – Lifestyle Questionnaire (Draft)
Below are some hard things that sometimes happen to people. Please try to think back over the past
year to remember if any of these things happened. Mark the answer that seems best.
Yes, and it upset me:
Not too Moderately Very
much
(Medium) much

Over the past year:

No

80.

Did your spouse or partner have a serious illness?

0

1

2

3

81.

Did you have any major problems with money?

0

1

2

3

82.

Did you have a major conflict with children or
grandchildren?

0

1

2

3

83.

Were you physically abused by being hit, slapped,
pushed, shoved, punched or threatened with a
weapon by a family member or close friend?

0

1

2

3

84.

Were you verbally abused by being made fun of,
severely criticized, told you were a stupid or
worthless person, or threatened with harm to
yourself, your possessions, or your pets, by a
family member or close friend?

0

1

2

3

85.

Did a close friend or family member die or have a
serious illness (other than your spouse or partner)?

0

1

2

3

86.

Did you have a divorce or break-up with a spouse
or partner?

0

1

2

3

87.

Did a family member or close friend have a
divorce or break-up?

0

1

2

3

88.

Did you have any major accidents, disasters,
mugging, unwanted sexual experiences, robberies,
or similar events?

0

1

2

3

89.

Did you or a family member or close friend lose
their job or retire?

0

1

2

3

90.

Did a pet die?

0

1

2

3

91.

Did your spouse or partner die?

0

1

2

3

If you answered yes to Question 91, please mark
the answer that best describes how you feel right
now about the person who died.

Never Rarely

Sometimes

Often Always

91.1 I feel myself longing or yearning for my
spouse or partner who died--I miss them so
much it’s hard to care about anything else.

0

1

2

3

4

91.2 I think about this person so much that it’s
hard for me to do the things I normally do.

0

1

2

3

4

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Pg. 10 of 17

Form 155 – Lifestyle Questionnaire (Draft)
Questions 92-100 are about your sleep habits and experiences.
how often you experienced the situation in the past 4 weeks.

Pick the answer that best describes

No,
not in
past 4
weeks

Yes,
less than
once a
week

Yes,
1 or 2
times
a week

Yes,
3 or 4
times
a week

Yes,
5 or more
times a
week

92. Did you take any kind of medication or
alcohol at bedtime to help you sleep?

0

1

2

3

4

93. Did you fall asleep during quiet activities
like reading, watching TV, or riding in a
car?

0

1

2

3

4

94. Did you nap during the day?

0

1

2

3

4

95. Did you have trouble falling asleep?

0

1

2

3

4

96. Did you wake up several times at night?

0

1

2

3

4

97. Did you wake up earlier than you planned
to?

0

1

2

3

4

98. Did you have trouble getting back to sleep
after you woke up too early?

0

1

2

3

4

99.

About how many hours of sleep did you get on a typical night during the past 4 weeks?
5 or less
6
7
8
9
10 or more
hours
hours
hours
hours
hours
hours

1

2

3

4

5

100. Overall, was your typical night's sleep during the past 4 weeks:
Very sound
Sound or
Average
or restful
restful
quality
Restless

5

4

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3

Pg. 11 of 17

2

6

Very
restless

1

Form 155 – Lifestyle Questionnaire (Draft)

Never

Almost
never

Sometimes

Fairly
often

Very
often

101. That you were unable to control the important things
in your life?

0

1

2

3

4

102. Confident about your ability to handle your personal
problems?

0

1

2

3

4

103. That things were going your way?

0

1

2

3

4

104. That difficulties were piling up so high that you could
not overcome them?

0

1

2

3

4

In the past 4 weeks, how often have you felt:

Strongly
disagree

Disagree
somewhat

Disagree
slightly

Agree
slightly

Agree
somewhat

Agree
strongly

105. I tend to bounce back quickly
after hard times.

1

2

3

4

5

6

106. It does not take me long to
recover from a stressful event.

1

2

3

4

5

6

107. I have a hard time making it
through stressful events.

1

2

3

4

5

6

In general…

During the past 4 weeks, how intensively did you suffer from the following?
Not at all

Symptom occurred and was:
Mild

Moderate

Severe

108. Cold hands or feet

0

1

2

3

109. Feeling too warm

0

1

2

3

110. Perspiring (without exercise)

0

1

2

3

111. "Gooseflesh" or shivering

0

1

2

3

112. Generally uncomfortable with the
temperature

0

1

2

3

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Form 155 – Lifestyle Questionnaire (Draft)
Below is a list of symptoms women sometimes have as they become older or after menopause. For each
item, mark the one box that best describes how bothersome the symptom was over the past year. Be sure to
mark one box on each line.
If you did not have the problem, please mark the box under “symptom did not occur.” If you
had the symptom, use the following key to indicate how bothersome it was:
Mild
Moderate
Severe

= symptom did not interfere with usual activities
= symptom interfered somewhat with usual activities
= symptom was so bothersome that usual activities could not be performed
Symptom
did not
occur

Mild

Moderate

Severe

Symptom occurred and was:

113.

Night sweats

0

1

2

3

114.

General aches or pains

0

1

2

3

115.

Breast tenderness

0

1

2

3

116.

Hot flashes

0

1

2

3

117.

Mood swings

0

1

2

3

118.

Irritability

0

1

2

3

119.

Feeling tired

0

1

2

3

120.

Forgetfulness

0

1

2

3

121.

Skin dryness or scaling

0

1

2

3

122.

Headaches or migraines

0

1

2

3

123.

Difficulty concentrating

0

1

2

3

124.

Joint pain or stiffness

0

1

2

3

125.

Uncontrolled leaking of urine

0

1

2

3

126.

Uncontrolled leaking of feces

0

1

2

3

127.

Vaginal or genital irritation or itching

0

1

2

3

128.

Vaginal or genital dryness

0

1

2

3

129.

Other (Specify): ________________

0

1

2

3

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Pg. 13 of 17

Form 155 – Lifestyle Questionnaire (Draft)

People sometimes look to others for help, friendship, or other types of support. Next are some
questions about the support that you have. How often is each of the following kinds of support
available to you if you need it?
None
A little
Some
Most
All
of the
of the
of the
of the
of the
time
time
time
time
time
130. Someone to give you good advice about a
1
2
3
4
5
problem
131. Someone to take you to the doctor if you
1
2
3
4
5
need it
132. Someone to have a good time with

1

2

3

4

5

133. Someone to love you and make you feel
wanted
134. Someone you can count on to listen to
you when you need to talk
135. Someone to help you understand a
problem when you need it
136. Someone to help with daily chores if you
are sick
137. Someone to share your most private
worries and fears

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

138. Someone to do something fun with

1

2

3

4

5

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Pg. 14 of 17

Form 155 – Lifestyle Questionnaire (Draft)

How true have the following been for you in the past week (7 days)?
Not
at all

A little
bit

Somewhat

Quite
a bit

Very
much

139. I felt peaceful.

0

1

2

3

4

140. I had a reason for living.

0

1

2

3

4

141. My life has been productive.

0

1

2

3

4

142. I had trouble feeling peace of mind.

0

1

2

3

4

143. I felt a sense of purpose in my life.

0

1

2

3

4

144. I was able to reach down deep into
myself for comfort.

0

1

2

3

4

145. I felt a sense of harmony within
myself.

0

1

2

3

4

146. My life lacked meaning and
purpose.

0

1

2

3

4

147. I found comfort in my faith or
spiritual beliefs.

0

1

2

3

4

148. I found strength in my faith or
spiritual beliefs.

0

1

2

3

4

149. I am always hopeful about my
future.

0

1

2

3

4

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Pg. 15 of 17

Form 155 – Lifestyle Questionnaire (Draft)
The last questions are about emotions you may have been feeling. Please mark one box for each
statement.
Mark the answer that best corresponds to how much you agree with each statement.
Strongly
Disagree
disagree

Slightly
disagree

Neither Slightly
agree or agree
disagree

Agree

Strongly
Agree

150. In most ways my life is close
to my ideal.

1

2

3

4

5

6

7

151. The conditions of my life are
excellent.

1

2

3

4

5

6

7

152. I am satisfied with my life.

1

2

3

4

5

6

7

153. So far I have gotten the
important things I want in life.

1

2

3

4

5

6

7

154. If I could live my life over, I
would change almost nothing.

1

2

3

4

5

6

7

Please take a few minutes to review this form for any questions you may have missed.
Thank you for taking the time to complete this questionnaire
Add any comments you may have here.

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Pg. 16 of 17

Form 155 – Lifestyle Questionnaire (Draft)
Form 155
Spanish translation under way.
Instructions to WHI staff under way.

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Pg. 17 of 17