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pdfTHE LONGITUDINAL INVESTIGATION OF GENDER,
HEALTH, AND TRAUMA SURVEY (LIGHT Survey)
Time 1
Over one’s lifetime, people experience a wide range
of significant life events. We are specifically
interested in the unique experiences Veterans have
during their lives. This survey will ask you questions
about life experiences, health, attitudes, and
emotions, as well as how you have been supported
and how you generally cope. Thank you in advance
for completing this survey.
Q1
What is your age?
Q2
Are you of Hispanic, Latino/a, or Spanish
origin?
Yes
No
If you wish to participate PLEASE GO TO
QUESTION 1.
Q3
How do you describe your race? Select all that
apply.
Native American or Alaska Native
If you do not wish to participate PLEASE MAIL
BACK THE OPT-OUT FORM TO STOP FUTURE
REQUESTS TO COMPLETE THE SURVEY. You
may also contact our helpdesk at 1-855-462-7577.
Black
INSTRUCTIONS
• Choose one answer for each question unless the
instructions say otherwise.
• Read each question carefully. Different questions
ask about different timeframes.
Other Pacific Islander
Asian
West Asian, Middle Eastern, or North African
Native Hawaiian
White/European
Other: (Please describe)
Q4
What is the highest degree or level of
education you have completed?
Some high school but no diploma or GED
High school diploma / GED
Post-high school vocational or technical
training
This number preserves your confidentiality and allows us to mail you
the incentive as a thank you for your time.
Some college credit, no degree
Associate’s degree (for example, AA, AS)
Bachelor’s degree (for example, BA, BS)
Master’s, Doctorate or professional degree (for
example, MA, MSW, MBA, PhD, MD, JD)
Q5
How many children do you have (both your
biological children and other children for whom
you have parenting responsibilities)?
Number of children:
I do not have any children → Go to question 6
Light Survey - Time 1 (F)
1
Q5b If you have children, what are their ages in
years?
Q7
What is your current living situation?
Rent an apartment, house, or room
Own my house or apartment
Child 1
Live with a relative or friend and not paying
rent
Live in a car, on the street, or in a homeless
shelter
Other (Please describe)
Child 2
Child 3
Child 4
Child 5
Child 6
Q8
Have you ever been homeless?
Yes
Child 7
No
Child 8
Q9
Child 9
Chilid 10
What is your current employment status?
Select all the apply.
Working for pay full-time (≥30 hours/week)
Working for pay part-time (<30 hours/week)
Yes
Not working for pay but actively looking for
paid work
Full-time care of children under the age of 18
or adult (for example, disabled adult
child/parent/spouse)
Full-time homemaker without full-time child or
elder care responsibilities
Retired
No
Disabled
Q5c Would you consider yourself the or one of the
primary caregivers for your child/children?
Q6
Do you have family members who are veterans
of the armed services? Select all that apply.
No, I do not have an immediate or extended
family member who served/serves in the
military
Yes, my grandfather and/or grandmother
served in the military
Yes, my mother and/or father served/serves in
the military
Yes, I have a sibling that served/serves in the
military
Yes, I have a child who served/serves in the
military
Yes, I have an extended family member (e.g.,
aunt, uncle) who served/serves in the military
Light Survey - Time 1 (F)
Q10 Please provide an estimate of your
HOUSEHOLD’S yearly income before taxes
are taken out. Include all sources of income
from all earners in your household. If you do
not know the answer, please make your best
guess.
No income
Less than $15,000 per year
$15,000 – 24,999
$25,000 – 34,999
$35,000 – 44,999
$45,000 - 54,999
$55,000 – 74,999
$75,000 – 99,999
$100,000 - $149,999
$150,000 or more per year
2
Q11 How many people are supported by this
HOUSEHOLD income, including yourself, your
significant other (if you have one), and anyone
else partially or fully supported by this income
whether or not they live with you?
Q18 What was your paygrade on your last day of
military service (for example, E-5, O-6)?
Q19 What was your primary military occupation
during your military service?
Q12 Have you ever been incarcerated for longer
than 24 hours?
Yes
No
Now we will ask you about your military
history and experiences
Combat arms
Combat support
Service support
Q20 Which of the following describes your
discharge from military service?
Honorable
General under honorable conditions
Active Duty
Under another category besides honorable
(for example, Other Than Honorable (OTH),
Bad Conduct Discharge (BCD), Dishonorable)
Medical
Reserve
Not sure
Q13 In what component(s) have you served? Select
all the apply.
National guard
Q14 In which branch of the military have you spent
the most time?
Army
Marine Corps
Navy
Air Force
Q21 Did you ever deploy overseas?
Yes
No
→ Go to question 22
If YES, please answer the following questions
about your deployments. If you never deployed
please skip to question 22.
Q21a How many times were you deployed?
Coast Guard
Q15 How long were you in the military?
Years
Q21b How many total months were you deployed
out of country?
Months
Q16 At what age did you enlist?
Q17 At what age did you separate from military
service?
Light Survey - Time 1 (F)
Q21c Did you experience a deployment in support of
the following wars? Select all that apply.
Operation Enduring Freedom/Operation Iraqi
Freedom/Operation New Dawn
(OEF/OIF/OND)
Gulf War (1990-1991)
Other: (Please describe)
3
The statements below are about your combat experiences during your military service.
Please select the response that best fits your answer.
Q22 During your military service…
Never
Once or Twice
Several times
Many times
a. You encountered land or water mines, booby traps, or
roadside bombs (for example, IEDs).
b. You saw refugees who had lost their homes or
belongings.
c. You fired your weapon at enemy combatants
d. You saw civilians after they had been severely
wounded or disfigured.
e. You were involved in searching and/or disarming
potential enemy combatants.
f. You went on combat patrols or missions.
g. You personally witnessed someone from your unit or
an ally unit being seriously wounded or killed.
h. You were exposed to hostile incoming fire.
i. You saw the bodies of dead enemy combatants.
The statements below are about your relationships with other military personnel during your
military service. As used in these statements, the term “unit” refers to those you lived and
worked with on a daily basis during your military service. Please mark how much you agree
or disagree with each statement.
Q23 While I was in the military…
Strongly
Disagree
Somewhat
Disagree
Neither
Agree nor
Disagree
Somewhat
Agree
Strongly
Agree
a. My unit was like family to me.
b. People in my unit were trustworthy.
c. My fellow unit members appreciated my efforts.
d. I felt valued by my fellow unit members.
e. Members of my unit were interested in my well-being.
f. My fellow unit members were interested in what I
thought and how I felt about things.
g. My unit leader(s) were interested in what I thought and
how I felt about things.
h. I felt like my efforts really counted to the leaders in my
unit.
i. My service was appreciated by the leaders in my unit.
j. I could go to unit leaders for help if I had a problem or
concern.
k. The leaders of my unit were interested in my personal
welfare.
l. I felt valued by the leaders of my unit.
Light Survey - Time 1 (F)
4
The next set of questions is about your relationships with others (for example, other unit
members, other unit leaders, civilians) during your military service. Please mark how often
you experienced each circumstance.
Q24 While I was in the military, the people I worked with…
Never
Once or twice
Several times
Many times
a. Treated me in an overly critical way.
b. Behaved in a way that was uncooperative when
working with me.
c. Treated me as if I had to work harder than others to
prove myself.
d. Questioned my abilities or commitment to perform my
job effectively.
e. Acted as though my mistakes were worse than
others’.
f. Tried to make my job more difficult to do.
g. “Put me down” or treated me in a condescending way.
h. Threatened my physical safety.
i. Made crude and offensive sexual remarks directed at
me, either publicly or privately.
j. Spread negative rumors about my sexual activities.
k. Tried to talk me into participating in sexual acts when I
didn’t want to.
l. Used a position of authority to pressure me into
unwanted sexual activity.
m. Offered me a specific reward or special treatment to
take part in sexual behavior.
n. Threatened me with some sort of retaliation if I was
not sexually cooperative (for example, the threat of a
negative review or physical violence).
o. Touched me in a sexual way against my will.
p. Physically forced me to have sex.
Light Survey - Time 1 (F)
5
Now we will ask you about experiences you have had starting in your childhood.
Q25 The sentences below refer to your relationship with your family WHEN YOU WERE GROWING UP.
Please describe how much you agree or disagree with each statement by marking the response
that best fits your choice. If you spent time in more than one family setting, please answer these
questions about the family in which you spent the greatest part of your childhood.
Strongly
disagree
Somewhat
disagree
Neither
agree or
disagree
Somewhat
agree
Strongly
agree
a. I got along well with my family members.
b. I felt like I fit in with my family.
c. Family members knew what I thought and how I felt
about things.
d. I felt like my contributions to my family were
appreciated.
e. I shared many common interests and activities with
family members.
f. My opinions were valued by other family members.
g. I was affectionate with family members.
h. I played an important role in my family.
i. I spent as much of my free time with family members
as possible.
j. Family members told me when they were having a
problem.
k. I could be myself around family members.
l. My input was sought on important family decisions.
The following questions ask about experiences you may have had in your life. Please mark
the number of times you experienced these events in each age range. If the event does not
apply to you, mark “Not at all.”
Q26a Serious accident (for example, car/boat accident, accident at work)
Not at all
Once or twice
Several times
Many times
Several times
Many times
Childhood (birth – age 17)
Age 18 to enlistment (if applicable)
During military service
After military service until end of May 2018
In the last 3 months
Q26b Exposure to toxic substance (for example, dangerous chemicals, radiation)
Not at all
Once or twice
Childhood (birth – age 17)
Age 18 to enlistment (if applicable)
During military service
After military service until end of May 2018
In the last 3 months
Light Survey - Time 1 (F)
6
Q26c Witnessed sudden, violent death or aftermath (for example, homicide, suicide)
Not at all
Once or twice
Several times
Many times
Once or twice
Several times
Many times
Once or twice
Several times
Many times
Once or twice
Several times
Many times
Once or twice
Several times
Many times
Childhood (birth – age 17)
Age 18 to enlistment (if applicable)
During military service
After military service until end of May 2018
In the last 3 months
Q26d Sudden, unexpected death of someone close to you
Not at all
Childhood (birth – age 17)
Age 18 to enlistment (if applicable)
During military service
After military service until end of May 2018
In the last 3 months
Q26e Serious injury, harm, or death you caused to someone else
Not at all
Childhood (birth – age 17)
Age 18 to enlistment (if applicable)
During military service
After military service until end of May 2018
In the last 3 months
Q26f Captivity (for example, being kidnapped, held hostage, prisoner of war)
Not at all
Childhood (birth – age 17)
Age 18 to enlistment (if applicable)
During military service
After military service until End of May 2018
In the last 3 months
Q26g Community violence: terrorist attack, bombing, riots.
Not at all
Childhood (birth – age 17)
Age 18 to enlistment (if applicable)
During military service
After military service until end of May 2018
In the last 3 months
Light Survey - Time 1 (F)
7
This section is about violent attacks against you by someone who is NOT a romantic partner
or spouse
Q26h Sexual assault by anyone who is NOT an intimate partner (rape, attempted rape, made to perform any
sexual act through force or threat of harm)
Not at all
Once or twice
Several times
Many times
Childhood (birth – age 17)
Age 18 to enlistment (if applicable)
During military service
After military service until end of May 2018
In the last 3 months
Q26i Serious physical assault by anyone who is NOT an intimate partner (attacked with or without a weapon,
threatened with a weapon)
Not at all
Once or twice
Several times
Many times
Childhood (birth – age 17)
Age 18 to enlistment (if applicable)
During military service
After military service until end of May 2018
In the last 3 months
This section is about violence against you by someone who WAS/IS a romantic partner or
spouse
Q26j Physical assault (pushed, grabbed, shaken, hit, beat up) by a significant other/spouse
Not at all
Once or twice
Several times
Many times
Childhood (birth – age 17)
Age 18 to enlistment (if applicable)
During military service
After military service until end of May 2018
In the last 3 months
Q26k Unwanted sexual experience by a significant other/spouse (pressured or forced to do sexual things you
didn’t want to do)
Not at all
Once or twice
Several times
Many times
Childhood (birth – age 17)
Age 18 to enlistment (if applicable)
During military service
After military service until end of May 2018
In the last 3 months
Light Survey - Time 1 (F)
8
Q26l Emotional mistreatment by significant other/spouse (name-calling, criticized, not allowed to see
friends/family, humiliated, or denied money)
Not at all
Once or twice
Several times
Many times
Not at all
Once or twice
Several times
Many times
Childhood (birth – age 17)
Age 18 to enlistment (if applicable)
During military service
After military service until end of May 2018
In the last 3 months
Q26m Other traumatic event: please specify.
Please describe the event:
Childhood (birth – age 17)
Age 18 to enlistment (if applicable)
During military service
After military service until end of May 2018
In the last 3 months
Q27 Think about things that may have happened to you throughout your life that are unusually or especially
frightening, horrible, or traumatic. If you have had one of these experiences, which experience causes
you the most distress? If you have not had an experience like this, please select “I did not have an
experience like this” and proceed to question 30. Check one only.
Combat/ exposure to warzone
Physical assault
Sexual assault
Accident
Natural disaster
Seen someone killed or seriously injured
Death of loved one through homicide or suicide
I did not have an experience like this → Go to question 30
Other: (Please describe)
Q28 How old were you when this most distressing trauma occurred?
Light Survey - Time 1 (F)
9
Below is a list of problems that people sometimes have in response to a very stressful
experience. Please read each problem carefully and then choose one of the responses to
the right to indicate how much you have been bothered by that problem in the past month.
Please base your answers on problems related to the experience you named as the worst in
question 27
Q29 Thinking about the experience you named in question 27, in the past month, how much were you
bothered by:
Not at all
A little bit
Moderately
Quite a bit
Extremely
a. Repeated, disturbing, and unwanted memories of the
stressful experience?
b. Repeated, disturbing dreams of the stressful
experience?
c. Suddenly feeling or acting as if the stressful
experience were actually happening again (as if you
were actually back there reliving it)?
d. Feeling very upset when something reminded you of
the stressful experience?
e. Having strong physical reactions when something
reminded you of the stressful experience (for example,
heart pounding, trouble breathing, sweating)?
f. Avoiding memories, thoughts, or feelings related to the
stressful experience?
g. Avoiding external reminders of the stressful
experience (for example, people, places, conversations,
activities, objects, or situations)?
h. Trouble remembering important parts of the stressful
experience?
i. Having strong negative beliefs about yourself, other
people, or the world (for example, having thoughts such
as: I am bad, there is something seriously wrong with
me, no one can be trusted, the world is completely
dangerous)?
j. Blaming yourself or someone else for the stressful
experience or what happened after it?
k. Having strong negative feelings such as fear, horror,
anger, guilt, or shame?
l. Loss of interest in activities that you used to enjoy?
m. Feeling distant or cut off from other people?
n. Trouble experiencing positive feelings (for example,
being unable to feel happiness or have loving feelings for
people close to you)?
o. Irritable behavior, angry outbursts, or acting
aggressively?
p. Taking too many risks or doing things that could cause
you harm?
q. Being “superalert” or watchful or on guard?
r. Feeling jumpy or easily startled?
s. Having difficulty concentrating?
t. Trouble falling or staying asleep?
Light Survey - Time 1 (F)
10
Q30 The next set of items ask about potentially stressful situations you may be currently experiencing. Think
about whether or not the stressful situation described happened in the last month. If the situation IS NOT
occurring for you, choose "N/A" and go to the next item. If the situation IS occurring, please rate the
extent to which it is NOW stressful/distressing to you on a scale from 1-10.
N/A
Not at all
distressing
1
2
3
4
Somewhat
distressing
5
6
7
8
9
Extremely
distressing
10
a. Laid off or fired from work
b. At risk for losing your
home
c. Caring of seriously ill
and/or disabled dependents
(e.g., children, elders)
d. Divorce or separation
from romantic partner
e. Legal problems, court
proceedings, ongoing
litigation
f. Major negative change in
financial status
g. Major problems at
school/At risk of losing spot
at school or Veteran
subsidies
h. Major health problem
i. Major problem with your
significant other or child(ren)
Q31 Over the last two weeks how often have you been bothered by any of the following problems?
Not at all
Several days
More than half Nearly every
the days
day
a. Little interest or pleasure in doing things
b. Feeling down, depressed, or hopeless
c. Trouble falling or staying asleep, or sleeping too much
d. Feeling tired or having little energy
e. Poor appetite or overeating
f. Feeling bad about yourself – or that you are a failure or
have let yourself or your family down
g. Trouble concentrating on things, such as reading the
newspaper or watching television
h. Moving or speaking so slowly that other people could have
noticed. Or the opposite – being so fidgety or restless that
you have been moving around a lot more than usual
i. Thoughts that you would be better off dead, or of hurting
yourself
j. Feeling nervous, anxious, or on edge
k. Not being able to stop or control worrying
l. Worrying too much about different things
m. Trouble relaxing
n. Being so restless that it's hard to sit still
o. Becoming easily annoyed or irritable
p. Feeling afraid as if something awful might happen
Light Survey - Time 1 (F)
11
Q32
Have you ever been diagnosed with any of
the following emotional/mental health
conditions? Select all that apply.
Post-traumatic Stress Disorder (PTSD)
Depression
Anxiety Disorder (for example, panic disorder,
generalized anxiety disorder)
Other mental health problem (please specify):
Q33b How often have you thought about killing
yourself in the past year? Check one only.
Never
Rarely (1 time)
Sometimes (2 times)
Often (3-4 times)
Very often (5 or more times)
Q33c Have you ever told someone that you were
going to commit suicide, or that you might do
it? Check one only.
Please check the one box beside the
statement or phrase that best applies to
you.
No
Yes, at one time, but did not really want to die
Yes, at one time, and really wanted to die
Yes, more than once, but did not want to do it
Q33a Have you ever thought about or attempted to
kill yourself? Check one only.
Never
Yes, more than once, and really wanted to do
it
Q33d How likely is it that you will attempt suicide
someday? Check one only.
It was just a brief passing thought
Never
I have had a plan at least once to kill myself
but did not try to do it
I have had a plan at least once to kill myself
and really wanted to die
I have attempted to kill myself, but did not
want to die
I have attempted to kill myself, and really
hoped to die
No chance at all
Rather unlikely
Unlikely
Likely
Rather likely
Very likely
Having thoughts of hurting yourself can be a common response to feeling distressed. We
want you to know that help is available. We recommend that you contact your primary care
provider or call the Veterans Crisis Hotline (1-800-273-8255) if you are experiencing suicidal
thoughts.
Q34 Thinking over the past month, check the option that best describes the amount of time you felt
that way.
None or
All or almost
almost none A little of the Some of the Most of the all of the
of the time
time
time
time
time
a. I found myself getting angry at people or situations.
b. When I got angry, I got really mad.
c. When I got angry, I stayed angry.
d. When I got angry at someone I wanted to hit them.
e. My anger prevented me from getting along with people
as well as I'd have liked to.
Light Survey - Time 1 (F)
12
Q35
What is your current marital status?
Q36
Are you currently in a romantic relationship?
Currently in a relationship and living as a
couple
Currently in a relationship but not living as a
couple
Not currently in a relationship → Go to
question 38
Never married
Married - first and only marriage → Go to
question 37
Married - second or later marriage → Go to
question 37
Separated
Divorced
Widowed
If you are married or currently in a romantic relationship, please answer the following
questions. If you are not married or in a romantic relationship, please skip to question 38:
Q37 Over the last month, how often have you done the following in your romantic relationship:
Never
Rarely
Sometimes
Often
Most or all of
the time
a. Provided your significant other with the emotional
support they sought
b. Shared your intimate thoughts and feelings
c. Done your fair share of day-to-day tasks. (for example,
grocery shopping, errands, planning activities)
d. Initiated leisure time activities that both you and your
significant other enjoy.
e. Made effort to work through disagreements
respectfully.
f. Expressed interest and/or willingness to engage in
regular sexual or physical intimacy.
If you currently have parenting responsibilities for any children 18 or under please answer
the following questions. If not, please skip to question 39.
Q38 All parents have strengths and weaknesses. Over the last month, how often have you:
Never
Rarely
Sometimes
Often
Most or all
of the time
a. Provided a healthy environment for your children. (for
example, preparing healthy meals, caring for their health,
keeping them safe)
b. Been a good example for your children. (for example,
being respectful during disagreements with others,
taking good care of your own health).
c. Been actively involved in your child(ren)’s activities.
(for example, regularly attending sporting and school
events, giving your full attention during time together)
d. Met your children’s needs for physical affection and
emotional support. (for example, giving them hugs, being
sympathetic to their problems)
e. Been able to successfully manage your child(ren)’s
unique challenges. (for example, effectively disciplining
children)
Light Survey - Time 1 (F)
13
The following questions ask about your neighborhood and community.
Q39 How long have you lived in your current neighborhood (Years / Months)?
Years:
Months:
Q40 Over the course of your adult life, how often have you been involved in….
Never
Rarely
Sometimes
Often
Most or all
of the time
a. Activities that address political topics at the local, state, or
national level (for example, political rallies or fundraisers,
groups that focus on specific political point of views, etc.)
b. Volunteer activities for non-political organizations (for
example, red cross, local organization)
c. Religious or spiritual communities
d. Culture, recreational, or leisure group activities (for
example, sport, music, craft, etc.)
Q41 To what extent do you think these groups or organizations above would offer you help if you request it?
Not involved in these groups/organizations
Very unlikely
Unlikely
Neither likely nor unlikely
Likely
Very likely
Q42 How likely are these things to happen in your neighborhood…
Very
Unlikely
Unlikely
Neither likely
nor unlikely
Likely
Very likely
a. People around here are willing to help their neighbors.
b. This is a close-knit neighborhood.
c. People in this neighborhood can be trusted.
d. People in this neighborhood generally don’t get along
with each other.
e. People in this neighborhood do not share the same
values.
Q43 On the whole, how much do you like this neighborhood as a place to live?
Not at all
A little
Somewhat
A great deal
Light Survey - Time 1 (F)
14
Q44 We are interested in how you feel about the following statements. Read each statement carefully.
Indicate how you feel about each statement.
Strongly
Disagree
Disagree
Agree
Strongly
Agree
a. There is a lot of graffiti in my neighborhood.
b. My neighborhood is noisy.
c. Vandalism is common in my neighborhood.
d. There are a lot of abandoned buildings in
my neighborhood.
e. My neighborhood is clean.
f. People in my neighborhood take good care of their
houses and apartments.
g. There are too many people hanging around on
the streets near my home.
h. There is a lot of crime in my neighborhood.
i. There is too much drug use in my neighborhood.
j. There is too much alcohol use in my neighborhood.
k. I’m always having trouble with my neighbors.
l. In my neighborhood, people watch out for each other.
m. My neighborhood is safe.
Q45 In the last year, how often have you heard
gunshots associated with crime or violence in
your neighborhood?
Never
Q49 Have you ever seen someone shot with a gun
in the neighborhood?
Yes
No
Once or twice
Three to five times
More than five times
Q46 How common would you say it is for people to
belong to street gangs in your neighborhood?
Very common
Q50 If a fight were to break out near your home,
how likely is it that your neighbors would
attempt to break it up?
Somewhat common
Very likely
Somewhat uncommon
Somewhat likely
Very uncommon
Somewhat unlikely
Q47 How common do you think it is for people to
carry guns in the neighborhood?
Very unlikely
Very common
Somewhat common
Somewhat uncommon
Very uncommon
Q48 Have you ever seen someone threatened with
a gun in the neighborhood?
Q51 If a fight were to break out near your home,
how likely is it that the police would be called?
Very likely
Somewhat likely
Yes
Somewhat unlikely
No
Very unlikely
Light Survey - Time 1 (F)
15
Q52 How safe do you feel…
Very
safe
Q58
Some
what
safe
Some
what
Very
unsafe unsafe
a. Alone inside your
house?
b. Outside in your
neighborhood during the
day?
c. Outside in your
neighborhood at night?
d. Walking alone toward
a group of people that
you don’t know?
Q53
In this neighborhood, it is sometimes
necessary for people to carry guns to protect
themselves or their family.
Strongly agree
Agree
Disagree
Strongly Disagree
Q54
Agree
Disagree
Strongly disagree
The following questions ask about your
health.
Q55
Hours of sleep per night:
Q59
How often do you exercise for 30 minutes or
more?
Daily or almost daily
3 to 4 times per week
2 to 3 times per week
1 to 2 times per week
Fewer than once per week
Please answer the following questions
related to your current and history of
substance use. Skip any questions that are
irrelevant to you.
Q60
In this neighborhood, it is sometimes
necessary for people to join a gang to protect
themselves or their family.
Strongly agree
During the past month, how many hours of
actual sleep did you get at night? (This may
be different from the number of hours you
spent in bed.)
How many cigarettes did you smoke on an
average day in the last month (if you do not
smoke write 0)?
For alcohol, one drink equals:
• 4 oz. wine
• 1 wine cooler
• 12 oz. beer
• 1 cocktail with 1 oz. hard liquor
Q61
During the past month, what time have you
usually gone to bed at night (hh:mm)?
How often do you currently have a drink
containing alcohol?
Never
Monthly or less
:
2-4 times a month
Q56
2-3 times a week
During the past month, how long, has it
usually taken you to fall asleep each night?
Number of Hours:
Number of minutes:
4 or more times a week
Q62
How many standard drinks containing alcohol
do you have on a typical day?
1 or 2
3 or 4
Q57
During the past month, what time have you
usually gotten up in the morning (hh:mm)?
:
Light Survey - Time 1 (F)
5 or 6
7 to 9
10 or more
16
Q63
On average, how often do you have 5 or more
drinks on one occasion?
Never
Less than monthly
Monthly
Q64
Weekly
No
Daily or almost daily
Yes
Times in a week:
Have you ever been diagnosed with alcohol
abuse or dependence in the past?
No
Yes
Q65
Q66 In the past month, did you use other drugs,
other than alcohol or marijuana? If YES, how
many times in a typical week did you use, if at
all? This includes cocaine, crack, heroin, acid,
speed, ecstasy, methamphetamines, steroids,
and medicines prescribed for someone else.
Q66a Does your use of drugs other than alcohol or
marijuana cause any problems?
Yes
In the past month, did you use marijuana? If
YES, how many times in a typical week?
No
N/A, I do not use drugs, not including alcohol
or marijuana
No → Go to question 66
Yes
Times in a week:
Q65a Does your marijuana use cause any
problems?
Q66b Did anyone else think your use of drugs other
than alcohol or marijuana cause a problem?
Yes
No
Yes
N/A, I do not use drugs, not including alcohol
or marijuana
No
N/A, I do not use marijuana
Q65b Did anyone else think your marijuana use
caused a problem?
Yes
Q67
Have you ever been diagnosed with drug
(including prescription drugs) abuse or
dependence in the past?
No
No
N/A, I do not use marijuana
Yes
If you are prescribed pain medication please answer the following questions, otherwise skip
to item 69.
Q68 In the past 3 months…
Never
Rarely
Sometimes
Often
Almost
Always
a. I abused prescription pain medication
b. I ran out of my prescription pain medication early
c. I got prescription pain medication from someone other
than my healthcare provider
d. I used more of my prescription pain medication than I
was supposed to
e. I experienced cravings for pain medication
f. I used more pain medication before the effects wore
off
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Q68a In the past 3 months…
Not at all
A little bit
Somewhat
Quite a bit
Very much
When my prescription for pain medication ran out, I felt
anxious
The following questions are about food and eating behavior
Q69
Please answer yes or no to the following questions:
No
Yes
a. Do you make yourself sick because you feel uncomfortably full?
b. Do you worry that you have lost control over how much you eat?
c. Have you recently lost more than 14 lbs in a 3-month period?
d. Do you believe yourself to be fat when others say you are too thin?
e. Would you say that food dominates your life?
Q70
What is your current height not wearing shoes?
'
Q71
"
What is your current weight (if you are currently pregnant please put your pre-pregnancy weight)?
lbs
Q72 Please indicate whether you are currently diagnosed with any of the following conditions:
No
Yes
a.Sleep problem or disorder (for example, insomnia, sleep apnea)
b. Chronic pain or pain related disorder (for example, knee, back, migraines)
c. Sexually transmitted disease
d. Other chronic physical problem (please specify)
Q73
Have you ever experienced any of the
following events? Select all that apply.
Blast or explosion (IED, RPG, Landmine,
Grenade, etc)
Vehicular accident/crash (any vehicle
including aircraft)
Fragment wound or bullet wound above the
shoulders
Fall
Blow to the head (head hit by falling/flying
object, head hit by another person, head hit
against something, etc)
Strangulation
Q74
Did you have any of these immediately after
any of the events in Q73? Select all that
apply.
Losing consciousness/”knocked out”
Being dazed, confused, or “seeing stars”
Not remembering the event
Concussion
Head injury that resulted in broken bones in
head, neck, face, damaged teeth, or ruptured
eardrum
None of the above
Shaken violently
None of the above → Go to question 77
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18
Q75
Did any of the following problems begin or get
worse afterwards? Select all that apply.
Q77b Did you become pregnant eventually?
No, and I have stopped trying
Memory problems or lapses
No, but I am still trying
Balance problems or dizziness
Yes, I became pregnant naturally
Sensitivity to bright light
Yes, I became pregnant with medical
intervention (i.e. IVF)
Irritability
Headaches
Sleep problems
None of the above
Q78
Are you currently pregnant?
No
Yes
Q76
In the past week, have you had any of the
symptoms from question 73? Select all that
apply.
Q78a If YES, how many weeks pregnant are you?
Memory problems or lapses
Balance problems or dizziness
Sensitivity to bright light
Irritability
Headaches
Sleep problems
None of the above
Q77
Have you ever tried, for a period of 12 months
or longer, to become pregnant?
Yes, I have tried for 12 months or longer to
become pregnant
No → Go to question 78
N/A → Go to question 78
Q77a If YES, Did a doctor identify any of the
following reasons for your difficulties in
becoming pregnant? Select all that apply.
I did not see a doctor for this problem
No reason identified
Cervical factor
Tubal factor
Q78b If NO, are you currently trying to get
pregnant?
No → Go to question 79
Yes
Q78c If YES, how many months have you been
trying to become pregnant?
Q79 Have you ever been pregnant? Please include
live births, stillbirths, miscarriages, induced
abortions, and tubal and other ectopic
pregnancies.
No → Go to question 81
Yes
Q79a If YES, how many times have you been
pregnant? Please include live births, stillbirths,
miscarriages, induced abortions, and tubal
and other ectopic pregnancies.
Ovulation factor
Semen or sperm factor
Hormonal factor
Other (please specify)
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Q79b If YES, how many live or stillborn births have
you had?
19
Q79c Have you had any pregnancies that did NOT
lead to a birth, either live or stillborn, such as
an abortion or miscarriage? If YES, how
many?
Q79d Have you ever had an ectopic/tubal
pregnancy?
No
Yes
No
Yes
Number of Abortions:
Number of miscarrages:
Age at first miscarrage:
Please answer the following questions about your pregnancy history, thinking about
pregnancies that led to either a LIVE or STILLBORN birth, including any current pregnancy.
Q80a Did your pregnancy lead to (Select all that apply):
1st
Pregnancy
2nd
3rd
4th
5th
6th
7th
8th
Pregnancy
Currently Pregnant
Live Birth
Stillborn
Twins/Triplets
Other
Q80b Was this pregnancy planned?
1st
Pregnancy
2nd
3rd
4th
5th
6th
7th
8th
Pregnancy
Yes
No
Do not remember
Q80c If planned, how long did it take you to get pregnant?
1st Pregnancy
Months
5th
Months
2nd
Months
6th
Months
3rd
Months
7th
Months
4th
Months
8th Pregnancy
Months
Q80d How old were you when you got pregnant?
Age
Age
1st Pregnancy
5th
2nd
6th
3rd
7th
4th
8th Pregnancy
Light Survey - Time 1 (F)
20
Q80e Did you see a doctor regularly during your pregnancy?
1st
Pregnancy
2nd
3rd
4th
5th
6th
7th
8th
Pregnancy
Yes
No
Q80f Did you have any of the following medical conditions during your pregnancy? (Select all that apply)
1st
Pregnancy
2nd
3rd
4th
5th
6th
7th
8th
Pregnancy
No conditions
High blood pressure
Gestational diabetes
Sexually transmitted
disease(s)
Depression and/or
anxiety
Other
Q80g Did you use any of the following substances and/or medications during this pregnancy? (Select all that
apply)
1st
Pregnancy
2nd
3rd
4th
5th
6th
7th
8th
Pregnancy
6th
7th
8th
Pregnancy
None
Prenatal Vitamins
Cigarettes
Alcohol
Opiod pain medication
Other non-prescribed
substance(s)
Other prescribed
substance(s)
Q80h What kind of delivery did you have? Do not include current pregnancies.
1st
Pregnancy
2nd
3rd
4th
5th
Vaginal (spontaneous)
Vaginal (induced)
Planned c-section
Emergency c-section
Non-emergency c-section
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21
Q80i How many weeks did the pregnancy last? Do not include current pregnancies.
Weeks
Weeks
1st Pregnancy
5th
2nd
6th
3rd
7th
4th
8th Pregnancy
Q80j What was the birth weight of the baby? Do not include current pregnancies.
Lbs
Oz
Lbs
Oz
1st Pregnancy
/
5th
/
2nd
/
6th
/
3rd
/
7th
/
4th
/
8th Pregnancy
/
Q80k Were you prescribed pain medication after this pregnancy? Do not include current pregnancies.
1st
Pregnancy
2nd
3rd
4th
5th
6th
7th
8th
Pregnancy
Yes
No
Q80l Did you suffer from postpartum depression and/or anxiety after this pregnancy? Do not include current
pregnancies.
1st
Pregnancy
2nd
3rd
4th
5th
6th
7th
8th
Pregnancy
Yes
No
Q80mHave you had more than 8 pregnancies
leading to a live or stillborn birth?
Yes
No
Q81 Within the past couple of years, has your
menstrual period been regular? Please think
about those times you were not using
hormonal contraceptives.
Yes
Additional number of births:
No
Additional number of stillbirths:
Cannot say because I was taking hormonal
contraceptives most of the time.
N/A, I no longer have menstrual periods
Light Survey - Time 1 (F)
22
Q82 Thinking about the time(s) when you have not
used hormonal contraceptives, what is the
average number of days from the first day of
one period to the first day of your next period?
For example, if you cycle ranges from 26-28
days, you would write 27 days.
Q85d If YES, what type of hormonal birth control are
you on?
The pill
The patch
The shot
Vaginal ring
IUD/Implant
Q83 How would you classify the total amount of
your menstrual flow?
Light (10 or fewer pads or tampons per
period)
Moderate (11 to 20 pads or tampons per
period)
Moderate/heavy (21-30 pads or tampons per
period)
Heavy (more than 30 pads or tampons per
period)
Q84 How much pain do you usually have with your
menstrual period? Please focus on the times
when you were not using hormonal
contraceptives.
None
Mild cramps, with medication seldom needed
Moderate cramps, with medication usually
needed
Severe cramps, with medications and bed rest
required
Q85 Have you ever used hormonal birth control (for
example, the pill, hormonal IUD)?
Q86 Have you ever been diagnosed or do you
suffer with (Select all that apply):
Fibroids in womb
Chronic pelvic pain
Polycystic Ovary Syndrome or PCO/PCOS
Pelvic Inflammatory Disease
Q86a At what age did this begin or were you
diagnosed?
Fibroids in womb
Chronic pelvic pain
Polycystic Ovary Syndrome or
PCO/PCOS
Pelvic Inflammatory Disease
Q87 Have you had a hysterectomy (surgical
removal of your uterus)?
No → Go to question 88
Yes, and kept ovaries
Yes
Yes, both ovaries removed
No → Go to question 86
Yes, one ovary removed
Q85a At what age did you first use hormonal birth
control?
Q87a If YES, why did you have a hysterectomy?
Abdominal bleeding
Pain
Q85b How many years have you been on hormonal
birth control over your lifetime (If less than one
year, write 0)?
Q85c Are you on hormonal birth control now?
Cancer
Other:
Q88 During the past three years, have you had a
Pap smear?
Yes
Yes
No → Go to question 86
No
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23
Q89 Has a doctor ever told you that you had an
abnormal Pap smear?
Q92a If NO, why not?
Not eligible
Yes
Distance to VA facilities/transportation
concerns
My VA does not provide the services I need.
No → Go to question 90
Q89a If YES, did you have a colposcopy with
cervical biopsies or a procedure to remove
cervical tissue known as LEEP?
I don’t feel comfortable seeking services at
the VA.
Preference for my current healthcare
providers
Other (please specify):
Yes
No
Not sure
Q90 Did you see an OB/GYN or gynecologist
during the past three years?
Q93
Yes
No
I think that I am suffering from mental health
problems (for example, feeling anxious
depressed, or too angry).
True
Q90a If YES, did you use a VA provider for this
care?
Yes
False
Q94
No
True
Q91 Please place an “x” in the box that best
describes your feelings about pelvic exams (the
internal physical exam performed by your
doctor):
Not at MinimModer- ExtreMildly
all
ally
ately
mely
a. Do you experience
emotional distress
during pelvic exams?
b. Do you experience
physical discomfort
during pelvic exams?
c. Are you afraid of
the examiner?
d. How much does it
matter to you if the
doctor is male or
female?
The following questions ask about your use
of healthcare and thoughts about mental
health treatment.
I think that I might benefit from mental health
treatment.
False
Q95
Are you currently receiving mental health
services (for example, seeing a therapist,
counselor, or medications) to help with
distress?
Yes → Go to question 96
No
Q95a If NO, what prevents you from seeking mental
health treatment? Select all that apply.
Concern for job security
Judgment from others
Distance/transportation to mental healthcare
providers
Don’t think it will help me
Q92
Do you get any healthcare (physical and/or
mental health) at Veterans’ Administration
(VA) hospitals or clinics?
Yes → Go to question 93
No insurance coverage
I don't need mental health treatment
Other (please specify):
No
Light Survey - Time 1 (F)
24
Q96 If I thought that I were suffering from serious
depression, anxiety, anger, or fear, I would
seek assistance from (Select all that apply):
Good female friends
Good male friends
Spouse or intimate partner
Family member (brother, sister, mother, father,
etc.)
Coworker
Religious leader (e.g. pastor, priest, rabbi)
Medical doctor (primary care doctor)
Therapist or counselor
Information on the internet
Self-help books or magazine articles
Other (please specify):
Q97 We are interested in your use of mental health services in the past 12 months. If you received any
help (even if it was only once or for a little while), please mark where you received this help. Mark
the no column only if you did not receive any of that type of help in the past 12 months.
No, I did not
get this kind
of help
Yes, from
a VA provider
Yes, from a
community
(non-VA)
provider
Yes, from both
a VA and a
community
provider
a. Medication for a mental health problem (e.g., an
antidepressant)
b. Individual counseling or therapy for a mental health
program
c. Group counseling or therapy for a mental health
problem
d. Family therapy
e. Inpatient or partial hospitalization program for a mental
health problem
f. Another type of mental health treatment (please
specify):
Q98
Q99
If you felt as though you needed mental
health treatment, do you feel your health care
provider could get it for you?
Q100 If you have received any mental health
treatments, how helpful was this care in
reducing your distress?
Yes
Not at all helpful
No
Slightly helpful
N/A
Moderately helpful
If you have received any mental health
treatments, how satisfied were you with the
care you received?
Very helpful
Extremely helpful
N/A
Not at all satisfied
Slightly satisfied
Moderately satisfied
Very satisfied
Extremely satisfied
N/A
Light Survey - Time 1 (F)
25
Q101 If you have received any mental health treatments, how difficult was it to find a therapist and schedule
your mental health appointments?
Very difficult
Difficult
Moderately difficult
Neutral
Easy
Very easy
N/A
Q102 How likely would you be to use the following services if they were offered by the VA?
Not at all likely
Slightly likely
Moderately likely
Very likely
Extremely likely
a. Family Education
b. Help with children
c. Help with marriage/
relationship
Q103 Were you aware that the VA offers services to support the family, including marital, couples, and family
therapy?
Yes
No
The next set of questions ask you about your current support system and coping strategies.
Q104 We are interested in how you feel about the following statements. Read each statement carefully.
Indicate how you feel about each statement.
Very
strongly
disagree
Strongly
disagree
Mildly
disagree
Neutral
Mildly
agree
Strongly
agree
Very
strongly
agree
a. There is a special person who is around
when I am in need.
b. There is a special person with whom I can
share my joys and sorrows.
c. My family really tries to help me.
d. I get the emotional help and support I
need from my family.
e. I have a special person who is a real
source of comfort to me.
f. My friends really try to help me.
g. I can count on my friends when things go
wrong.
h. I can talk about my problems with my
family.
i. I have friends with whom I can share my
joys and sorrows.
j. There is a special person in my life who
cares about my feelings.
k. My family is willing to help me make
decisions.
l. I can talk about my problems with my
friends.
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26
Q105 Please indicate how many times you have done each of these things to someone else in the past six
months.
Once
Twice
Not in the
past 6
months,
but it did This has
More than happen
never
3-5 times 6-10 times 11-20 times 20 times
before
happened
a. I insulted, swore, shouted
or yelled at someone.
b. I pushed, shoved, or
slapped someone.
c. I punched, kicked, or beatup someone.
d. I destroyed something
belonging to someone else or
threatened to hit someone.
Q106 Please indicate the extent to which you agree with each of the following statements.
Strongly
Disagree
Disagree
Neutral
Agree
Strongly Agree
a. You tend to bounce back quickly after
hard times.
b. You have a hard time making it through
stressful events.
c. It does not take you long to recover from a
stressful event.
d. It is hard for you to snap back when
something bad happens.
e. You usually come through difficult times
with little trouble.
f. You tend to take a long time to get over set
-backs in your life.
Q107 In your day-to-day life, how often do any of the following things happen to you?
Almost
At least A few times A few times Less than
everyday once a week a month
a year
once a year
Never
a. You are treated with less courtesy than
other people are.
b. You are treated with less respect than
other people are.
c. You receive poorer service than other
people at restaurants or stores.
d. People act as if they think you are not
smart.
e. People act as if they are afraid of you
f. People act as if they think you are
dishonest.
g. People act as if they’re better than you
are.
h. You are called names or insulted.
i. You are threatened or harassed.
Light Survey - Time 1 (F)
27
Please answer the following question if you answered “a few times a year” or more
frequently to any of the above questions.
Q108 What do you think is the main reason for these experiences? Select all that apply.
Your Ancestry or National Origins
Your Gender
Your Race
Your Age
Your Religion
Your Height
Your Weight
Some other Aspect of Your Physical Appearance
Your Sexual Orientation
Your Education or Income Level
Q109 What is your biological sex?
Male
Female
Q111 How would you describe your current sexual
orientation?
Heterosexual/straight
Homosexual/gay or lesbian
Bisexual
Uncertain
Other (please specify):
Q110 What is your gender identity?
Male
Female
Transgender
Other (please specify):
Q112 There may be opportunities for you to
participate in other studies. May we use your
contact information to inform you about these
opportunities?
Yes
No, not at this time
THANK YOU FOR YOUR PARTICIPATION IN THIS SURVEY.
PLEASE RETURN YOUR SURVEY IN THE ENCLOSED ENVELOPE.
ONCE WE RECEIVE THE SURVEY, $20 WILL BE MAILED TO YOU.
Light Survey - Time 1 (F)
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| File Type | application/pdf |
| File Modified | 2019-06-28 |
| File Created | 2018-08-08 |