CIA-RDP96-00788R001700210075-0

Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210075-0
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
asu felt this best week.
Mark your answer choices, like this:
X
Answer choices
2
3
DURING THE PAST WEEK,
HAVE YOU FELT
Rarely
Some-
times
Often
4
Almost
Always
Vigorous?
1
Alert?
2
Full of pep?
3
Happy?
Calm and relaxed?
5
Content?
6
Secure?
7
Confidence in yourself?
8
Inner calm and peace?
9
Answer choices
2
3
4
DURING THE PAST WEEK,
HAVE YOU FELT
Never
Rarely
Some-
times
Often
Discouraged?
10
Uneasy ?
11
unhappy ?
12
On edge?
13
Gloomy?
14
Disappointed in people
38
Blue?
15
Like crying?
16
Worried?
17
Tense?
18
Bored?
19
Annoyed, irritated?
20
No one seemed interested in how I
really feel inside
43
*Copyright 1975, INSTITUTE FOR PROGRAM EVALUATION
1
2
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
A lack of order around me
30
Dissatisfied with myself
31
Critical of others
32
Annoyed, irritated
33
An impulse to hurt someone
34
Left out of things
35
That people treated me unfairly
36
Bothered by sloppiness around me
37
Worried about debts
39
Uncertain about who I really am
40
Unhappy about the work i do
41
My family finds fault with me
42
BOX 4654, ROANOKE, VIRGINAPPLOMed For Release 2003/09/10 : CIA-RDP96-00788R001700210075-0
:
Sub3. #
(B) PERSONAL EXPERIENCES
---
Rarely
1

Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210075-0
(C) PHYSICAL HEALTH INVENTORY
Please mark one answer for each question below.
Mark your answer like this:
X
or this
V
(D) PERSONAL BELIEFS
1
3
Answer choices
2
IT IS MY OPINION THAT .
(Please answer each statement below)
Not
Agree
Not
Sure
Agree
4
Agree
Strongly
DURING THE LAST MONTH, HAVE YOU
.
Never
Some-
times
Often
Had headaches? (Past month)
44
Felt faint?
45
Felt hot, feverish?
46
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
Had difficulty breathing?
51
Felt physically ill?
52
Had back pains?
53
Problems in life are really opportunities
to learn and grow
2
People create their own reality by the kinds
of thoughts they let themselves have
3
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 . . .
Not
Agree
2
Not
Sure
3
Agree
Agree
Strongly
More money for scientific research
More formal education for people
5
60
Redistributing the wealth
6
61
A return to organized religion
7
Been constipated (hard stools) ?
62
Social reform through better laws
8
63
Daily meditation
9
64
Spiritual reawakening (personal enlightment)
10
Protecting the environment, natural resources
11
66
67
68
A person's soul or spirit continues after death
69
People will be reborn to live again on earth
70
71
Mental telepathy (ESP) is a reality
People have out of body experiences (astral travel)
72
There are spiritual or non-physical forces
acting in today's world
76
Subj #
1
80
It's wrong to kill any living thing
1
Been bothered by itching?
Had coughing spells ?
54
Had trouble with your vision?
58
Felt exhausted, fatigued?
59
Waken from sleep feeling tired?
Had a poor appetite?
Had an upset stomach ?
Had nausea (sick to stomach) ?
Had indigestion?
Had stomach pain after eating?
Had trouble digesting food?
Had diarrhea (loose bowels) ?
Answer choices
2
3
1
Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210075-0
7
4
73
---
65

Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210075-0
(E) LIFE STYLE
(E) LIFE STYLE (CONT'D)
Answer choices
7-2
3-5
Times
/Week
Times
/ Week
Each
Day
Spent time with a close friend?
12
Shared personal problems with a friend?
13
Attended meetings of civic, or other
organizations?
35
Washed the dishes?
14
Done household cleaning?
15
16
Spent time outdoors enjoying nature?
38
Played cards or other table games?
39
Done physical exercise?
18
Taken part in active sports?
19
141
20
42
21
43
22
44
23
45
2ª
$6
25
47
26
48
27
49
23
50
Eaten fresh fruits (apoles, oranges,
etc. )?
29
Eaten natural foods (dried fruit, nuts,
whole grains ) ?
i
30
Kept up with current events, (read news-
paper, magazines, watch TV news )?
31
Read something about mystical,
spiritual or psychic things ?
1
32
Read something about personal
psychological growth?
33
DURING THE LAST MONTH, HAVE YOU . . .
Never
1-2 times 1-2 times
per month per week
4
Almost
Daily
Gone to parties for social activities
outside the home?
34
Entertained friends in your home?
36
Attended a religious service?
37
Prepared meals ?
Washed clothes?
17
Listened to music you enjoy?
Taken time to be by yourself?
Medicated?
Enjoyed contact with animals?
Taken care of house plants?
Eaten red meat (beef, pork ) ?
Eaten fish or poultry?
Visited with the neighbors?
Done grocery shopping?
Danced?
Read fiction for enjoyment?
Participated in a study group?
Taken medication for headache?
Taken medication to help you sleep?
Ta. em medication for your stomach?
Taken medication for a cold or allergy?
Taken tranquilizers?
Taken laxatives?
Used alcohol or nonprescription drugs ?
Gotten high on alcohol or drugs?
52
DURING THE LAST MONTH, HAS ALCOHOL CR
DRUG USE CAUSED PROBLEMS .
Between you and family members?
53 .
With work (difficulty working well
or going to work)?
With your physical health?
In your thinking clearly?
54
55
56
Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210075-0
Answer choices
2
3
DURING THE PAST MONTH, HOW OFTEN HAVE YOU. . . Rarely
(Please answer each question below)
or
Never
Eaten Sweets (candy, cake, pie, etc. )?
Drunk soft drinks (Coke, etc. ) ?
51
40

Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210075-0
(F) ARE YOU CURRENTLY LIVING WITH A PARENT, SPOUSE, OR SOMEONE ELSE IN A CLOSE
RELATIONSHIP?
No
(If you marked "No", skip to Section G below)
Yes ( if you marked "Yes", answer the 5 questions below!
57
(I) BACKGROUND
76
(
Subj #
)
80
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
. 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
FROM WORKING, DID YOU EARN AN ADEQUATE AMOUNT OF MONEY LAST MONTH?
(Mark one)
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
5. SMOKE CIGARETTES?
(1)
Not at all
(2)
Less than 2 pack per day
(3)
About $2 pack per day
(4)
About ) pack per day
(5)
Over 14 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
8. AVERAGE HOURS OF SLEEP
(1)
4-5 hours
1. Spent time talking with each other?
57
2. Spent time doing things together?
58
3. Openly expressed feelings to each other?
69
4. Treated each other with respect?
70
5. Felt close to each other?
6. Done things for each other?
72
(H) DO YOU HAVE ENOUGH MONEY TO
.
Pay your bills? (Mark one)
Rarely
Some-
times
3
Usually
4
Always!
73
Handle unexpected expenses? (Mark one)
74
1
Answer choices
2
3
4
DURING THE PAST MONTH, HAVE YOU AND YOUR
SIGNIFICANT OTHER (spouse, parent, etc. )
Rarely
Often
Almost
Always
1. Shared personal feelings with each other?
58
2. Been able to talk it through when angry?
59
60
67
62
53
64
65
(S) ARE THERE CHILDREN WHERE YOU LIVE? (Mark one)
No ( If you marked "No", skip to Section H below)
(2)
Yes ( If you marked "Yes", answer the next 6 questions)
66
1
3
Answer choices
2
4
DURING THE LAST MONTH, HAVE YOU AND THE
CHILD ( REN) . . .
Some-
times
Often
Almost
Always
Rarely
Some-
times
3. Agreed about finances and budget?
4. Spent enjoyable times together?
5. Discussed important matters?
J. Felt close to each other?
7. Agreed about social activities and
friends ?
8. Shared daily events that happened to
each of you?
71
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.
Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210075-0