CIA-RDP96-00788R001700210037-2

Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210037-2
PROFILE OF ADAPTATION TO LIFE
(A) MOOD SCALE
DURING LAST WEEK, INCLUDING TODAY, HOW OFTEN HAVE YOU FELT .
.
Please mark the answer for each question that best describes how
you felt this past week.
Mark your answer choices, like this:
X
Answer choices
2
3
DURING THE PAST WEEK,
HAVE YOU FELT .
Some-
times
Often
4
Almost
Always
Vigorous?
1
Alert?
2
Full of pep?
3
Happy?
4
Calm and relaxed?
5
Content?
6
Secure?
7
Confidence in yourself?
8
Inner calm and peace?
9
A lack of order around me
30
Dissatisfied with myself
31
Critical of others
32
Annoyed, irritated
33
Discouraged?
10
Uneasy?
11
Unhappy ?
12
On edge?
13
Bothered by sloppiness around me
37
Gloomy?
14
Disappointed in people
38
Blue?
15
Worried about debts
39
Like crying?
16
Uncertain about who I really am
40
Worried?
17
Tense?
18
My family finds fault with me
42
Bored?
19
Annoyed, irritated?
20
No one seemed interested in how I
really feel inside
43
*Copyright 1975, INSTITUTE FOR PROGRAM EVALUATION
BOX 4654, ROANOKE, VIRGIN
Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210037-2
(
Subj. #
1
1
1
Answer choices
3
4
DURING THE PAST MONTH, I'VE
(Please answer each statement below)
Some-
times
Often
Almost
Always
Enjoyed talking with others
21
Felt trusting of people
22
Found work useful and interesting
23
Enjoyed people I live with
24
Found people accept me as I am
25
Been involved, interested in things
26
Felt needed and useful
27
Controlled my negative thinking
and increased my positive thinking
28
Found things I've needed coming to
me by "coincidence" or "chance"
29
1
2
Answer choices
3
4
DURING THE PAST MONTH, I'VE FELT .
Never
Rarely
Some-
times
Often
1
Never
2
3
4
Often
DURING THE PAST WEEK,
HAVE YOU FELT . . .
Rarely
Some-
times
An impulse to hurt someone
34
Left out of things
35
That people treated me unfairly
36
Unhappy about the work. I do
41
Ī
Rarely
Answer choices
(B) PERSONAL EXPERIENCES
2
Rarely

Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210037-2
(C) PHYSICAL HEALTH INVENTORY
Please mark one answer for each question below.
Mark your answer like this:
X
V
or this
(D) PERSONAL BELIEFS
Answer choices
1
2
3
4
IT IS MY OPINION THAT
.
(Please answer each statement below)
Not
Agree
Not
Sure
Agree
Agree
Strongly
A person's soul or spirit continues after death
69
People will be reborn to live again on earth
70
Mental telepathy (ESP) is a reality
71
Felt faint?
45
Felt hot, feverish?
46
There are spiritual or non-physical forces
acting in today's world
73
Had spells of dizziness?
47
Sooner or later people will treat you as
you've treated others
74
Had difficulty falling asleep?
48
Had chest pains?
49
Spiritual or psychic healing is often as
effective as medical treatment
75
Noticed your heart beating fast?
50
(
76
Subj #
-
80
Had difficulty breathing?
51
It's wrong to kill any living thing
1
Felt physically ill?
52
Had back pains?
53
Problems in life are really opportunities
to learn and grow
2
Been bothered by itching?
54
People create their own reality by the kinds
of thoughts they let themselves have
3
Had coughing spells ?
55
Had neck or shoulder pains?
56
Had pains in legs or arms?
57
IT IS MY OPINION THAT THE SOLUTIONS TO MAN'S
PROBLEMS IN LIVING WILL BE FOUND IN . . .
1
Not
Agree
2
Not
Sure
3
4
Agree
Strongly
More money for scientific research
4
Felt exhausted, fatigued?
59
More formal education for people
5
Waken from sleep feeling tired?
60
Redistributing the wealth
6
Had a poor appetite?
61
A return to organized religion
7
Been constipated (hard stools) ?
62
Social reform through better laws
8
Had an upset stomach?
63
Daily meditation
9
Had nausea (sick to stomach) ?
64
Spiritual reawakening (personal enlightment)
10
Had indigestion?
65
Had stomach pain after eating?
66
Had trouble digesting food?
67
Had diarrhea (loose bowels) ?
68
1
Answer choices
2
3
DURING THE LAST MONTH, HAVE YOU
.
.
Never
Some-
times
Often
Had headaches?
(Past month)
44
People have out of body experiences (astral travel)
72
Protecting the environment, natural resources
11
Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210037-2
Agree
Had trouble with your vision?
58

Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210037-2
(E) LIFE STYLE
(E) LIFE STYLE (CONT'D)
Answer choices
DURING THE PAST MONTH, HOW OFTEN HAVE YOU. . , Rarely
(Please answer each question below)
or
Never
1-2
Times
/Week
Times
/Week
Each
Day
Spent time with a close friend?
12
Gone to parties for social activities
outside the home?
34
Shared personal problems with a friend?
13
Attended meetings of civic, or other
organizations?
35
Washed the dishes?
14
Entertained friends in your home?
36
Done household cleaning?
15
Attended a religious service?
37
Prepared meals?
16
Spent time outdoors enjoying nature?
38
Washed clothes?
17
Played cards or other table games?
39
Done physical exercise?
18
Visited with the neighbors?
40
Taken part in active sports?
19
Done grocery shopping?
41
Listened to music you enjoy?
20
Danced?
42
Taken time to be by yourself?
21
Read fiction for enjoyment?
43
Meditated?
22
44
Enjoyed contact with animals?
23
Taken medication for headache?
45
Taken care of house plants?
24
Taken medication to help you sleep?
46
Eaten red meat (beef, pork)?
25
Takem medication for your stomach?
47
Eaten fish or poultry?
26
Takem medication for a cold or allergy?
48
Eaten sweets (candy, cake, pie, etc.)?
27
Taken tranquilizers?
49
Drunk soft drinks (Coke, etc.)?
28
Taken laxatives?
50
Eaten fresh fruits (apples, oranges,
etc. )?
29
Used alcohol or nonprescription drugs?
51
Gotten high on alcohol or drugs?
52
Eaten natural foods (dried fruit, nuts,
whole grains ) ?
30
Kept up with current events, (read news-
paper, magazines, watch TV news )?
T
31
Read something about mystical,
spiritual or psychic things ?
-
32
With work (difficulty working well
or going to work) ?
54
Read something about personal
psychological growth?
33
With your physical health?
55
In your thinking clearly?
56
3-5
DURING THE LAST MONTH, HAVE YOU
1
3
Answer choices
2
4
Never
1-2 times 1-2 times Almost
per month per week
Daily
Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210037-2
DURING THE LAST MONTH, HAS ALCOHOL OR
DRUG USE CAUSED PROBLEMS .
.
Between you and family members?
53
Participated in a study group?

Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210037-2
BACKGROUND
76
(
Subj #
1
80
DURING THE PAST MONTH, HAVE YOU AND YOUR
SIGNIFICANT OTHER (spouse, parent, etc. ) .
.
Rarely
Some-
times
Often
Almost
Always
1. Shared personal feelings with each other?
58
2. Been able to talk it through when angry?
59
3. Agreed about finances and budget?
60
61
62
63
7. Agreed about social activities and
friends?
64
8. Shared daily events that happened to
each of you?
65
(G) ARE THERE CHILDREN WHERE YOU LIVE? (Mark one)
(1)
No
( If you marked "No", skip to Section H below)
(2)
Yes (If you marked "Yes", answer the next 6 questions)
66
DURING THE LAST MONTH, HAVE YOU AND THE
CHILD (REN)
. .
Some -
times
Often
Almost
Always
1. Spent time talking with each other?
67
2. Spent time doing things together?
68
3. Openly expressed feelings to each other?
69
4. Treated each other with respect?
70
5. Felt close to each other?
71
6. Done things for each other?
72
(H) DO YOU HAVE ENOUGH MONEY TO
Rarely
Usually
Always
Pay your bills? (Mark one)
73
Handle unexpected expenses? (Mark one)
74
FROM WORKING, DID YOU EARN AN ADEQUATE AMOUNT OF MONEY LAST MONTH? (Mark one)
(1)
Earned no money from working last month
(2)
Earned enough to take care of my personal needs (spending money)
(3)
Earned enough to partially support a family
(4)
Earned enough to adequately support a family
75
1. MAJOR SOURCE OF INCOME ?
(Check only one answer)
(1)
Money earned from work I
do now
(2)
From spouse, relative, or
friend
(3)
Investments or inheritance
(4)
Welfare or public assistance
(5)
Retirement or social security
(6)
Unemployment compensation
(7)
Scholarship or student stipend
(8)
Alimony or child support
(9)
Veterans benefits
2. YOUR MARITAL STATUS (Check one)
(1)
Currently married
(2)
Separated, divorced, or
widowed
(3).
Never married
3. SEX (Check one)
(1)
Male
(2)
Female
4. EDUCATION (Check one)
(2)
5-6 hours
(1)
Less than high school
(3)
6-7 hours
(2)
High school graduate
(4)
7-8 hours
(3)
Some college
(5)
8 or more hours
(4)
College graduate (Type of degree
)
AGE
9-10
TODAY'S DATE:
17-22
HEIGHT
feet
in. 11-13
Month
Day
Year
WEIGHT
pounds 14-16
(
)
3
76
Subj #
80
Thank you for completing the questionnaire. Your help is very much
appreciated. Please check back to make sure you have not left any
questions unanswered.
MoAuerAxedue6Release 2003/08/10 p.GIAERRE96-00788R001700222920-2
5. SMOKE CIGARETTES?
(1)
Not at all
(2)
Less than 12 pack per day
(3)
About $2 pack per day
(4)
About 1 pack per day
(5)
Over 142 pack per day
6. DRINK COFFEE?
(1)
None or rare cup
(2)
About 1-2 cups. per day
(3)
3-4 cups per day
(4)
5 or more cups per day
7. WATCH TV?
(1)
None or rarely
(2)
Less than 1 hour per
day
(3)
1-2 hours per day
(4)
3-4 hours per day
(5)
5+ hours per day
1
Answer choices
2
3
4
Rarely
Some-
times
3
4
1
3
Answer choices
2
4
(F) ARE YOU CURRENTLY LIVING WITH A PARENT, SPOUSE, OR SOMEONE ELSE IN A CLOSE
RELATIONSHIP?
(1)
No
(If you marked "No", skip to Section G below)
(2)
Yes (If you marked "Yes", answer the 8 questions below)
57
4. Spent enjoyable times together?
5. Discussed important matters?
6. Felt close to each other?
8. AVERAGE HOURS OF SLEEP
(1)
4-5 hours