all, 2=a little bit, 3=moderately, 4=quite a bit, 5=extremely)
General Health
1. In general, would you say your health is: (1=very good, 2=very good, 3=good, 4=fair, 5=poor)
2. I seem to get sick a little easier than other people. (1=definitely true, 2=
mostly true, 3=don’t know, 4=mostly false, 5=definitely false)
3. I am as healthy as anybody I know. (1=definitely true, 2= mostly true, 3=don’t know, 4=mostly false, 5=definitely false)
4. I expect my health to get worse. (1=definitely true, 2= mostly true, 3=don’t
know, 4=mostly false, 5=definitely false)
5. My health is excellent. (1=definitely true, 2= mostly true, 3=don’t know, 4=mostly false, 5=definitely false)
Mental Health
Description: These questions are about how you feel and how things have been with you during the past month. For each question, please circle a number for the one answer that comes closest to the way you have been feeling.
Kessler-6: Non-specific Psychological Distress
The following questions ask about how you have been feeling during the past 30 days. For each
question, please circle the number that best describes how often you had this feeling.
About how often (1=none of the time, 2=a little of the time, 3=some of the time, 4=most of the time, 5=all of the time) during the past 30 days did you feel …
1. Nervous? 2. Hopeless?
3. Restless or fidgety?
4. So depressed that nothing could cheer you up? 5. That everything was an effort?
6. Worthless?
Emotional well-being (1=none of the time, 2=a little of the time, 3=some of the
time, 4=most of the time, 5=all of the time)
1. Have you been a very nervous person?
2. Have you felt so down in the dumps that nothing could cheer you up? 3. Have you felt calm and peaceful?
4. Have you felt downhearted and blue? 5. Have you been a happy person?
Positive Affect (MOS HEALTH-RELATED QUALITY OF LIFE)
1. How happy, satisfied, or pleased have you been with your personal life during the past month? (1=extremely happy, could not have been more satisfied or
pleased, 2=very happy most of the time, 3=generally satisfied, pleased, 4=generally dissatisfied, unhappy, 5=very dissatisfied, unhappy most of the time)
2. During the past month, how much of the time have you generally enjoyed the things you do? (1=none of the time, 2=a little of the time, 3=some of the
time, 4=most of the time, 5=all of the time)
3. How much of the time, during the past month, has your daily life been full of things that were interesting to you? (none of the time to all of the time) 4. During the past month, how much of the time has living been a wonderful
adventure for you? (none of the time to all of the time)
5. How much of the time, during the past month, have you felt cheerful, lighthearted? (none of the time to all of the time)
Physical Health: Secondary Conditions
Below, please check conditions you have experienced in the past 12 months as a result of your primary impairment. For conditions you experienced, please mark how big of a problem it was.
Chronic pain in muscles or joints? □ Yes □ No
If YES, how big of a problem was it? (circle a number) Not problematic Slightly
problematic Somewhat problematic Very problematic Extremely problematic 1 2 3 4 5
Sleep problems? □ Yes □ No
If YES, how big of a problem was it? (circle a number) Not problematic Slightly
pro lematic Somewhat problematic Very problematic Extremely problematic 1 2 3 4 5
Weight or eating problems? □ Yes □ No
If YES, how big of a problem was it? (circle a number) Not problem tic Slightly
pro lematic Somewhat p oblematic Very problematic Extr mely problematic 1 2 3 4 5
Skin problems (including pressure sores or pressure ulcers)? □ Yes □ No If YES, how big of a problem was it? (circle a number)
Not problematic
Slightly pr blematic
Somewhat problematic Very p oblematic
Extremely problematic
1 2 3 4 5
Muscle spasms? □ Yes □ No
If YES, how big of a problem was it? (circle a number) Not problematic Slightly
problematic Somewhat problematic Very problematic Extremely probl matic 1 2 3 4 5
Bowel/bladder problems? □ Yes □ No
If YES, how big of a problem was it? (circle a number) Not problematic Slightly
p oblematic Somewhat proble atic Very problematic Extremely problematic 1 2 3 4 5
Appendix D Participant Demographics
Below are questions about you. Please by marking your responses (with a check, an X, or by circling your answers).
1. What is your gender? __ Male __Female __Other (Please specify:_________)
2. How old are you? ____ years 3. What is your race/ethnicity?
__ American Indian and Alaska Native __Asian
__Non-Hispanic Black/African American __Hispanic
__Native Hawaiian/Other Pacific Islander __Non-Hispanic White/Caucasian
__Some Other Race/Ethnicity (Please specify :____________) 4. What is your relational or sexual orientation?
__Gay __Lesbian __Bisexual __Ambiguous __Asexual __Straight
__Other (Please specify:_________________) 5. What is your political leaning?
__Strong liberal __Liberal
__Moderate, leaning towards liberal __Moderate
__Moderate, leaning towards conservative __Conservative
__Strong conservative
6. Was your disability acquired (that is, did it happen after birth)? __Yes __No
7. What type of disability do you have? __ Physical
__Sensory __ Cognitive
__Other (specify: _______)
8. Do you use a wheelchair? __Yes __No
9. If you have a physical disability, what type of disability is it? __Quadriplegia (unable to fully use all four limbs)
__Paraplegia (able to use arms and hands) __Don’t know
10. What is the cause of your disability (e.g., spinal cord injury, stroke, brain injury, amputation, other)? ____________________
11. In what year did the injury that resulted in your disability happen? _____ 12. How many years/months have you had your disability? ___ years/___
months
13. Do you receive any source of assistance listed below? (Please check all that apply.)
__Supplemental Security Income (SSI)
__Social Security Disability Insurance (SSDI) __Medicare
__Medicaid
14. What is your source of monthly income? _________ __Supplemental Security Income (SSI) only
__Social Security Disability Insurance (SSDI) only __Employment only
__Both SSI and employment __Both SSDI and employment
__Other (Please specify source of income if none of the above: ____________________)
15. What is your monthly income? $________
16. Which of the following best describes your family’s social class or the social class of the household in which you grew up?
__Very economically disadvantaged (lower class)
__Neither economically disadvantaged nor advantaged (working class) __Moderately advantaged (middle class)
__Economically advantaged (upper middle class) __Very economically advantaged (upper class)
17. What is the highest level of education that you completed? __Less than high school diploma
__High school graduate
__Some college, but no degree __Associate’s degree
__Bachelor’s degree
Appendix E