























What is your husband/wife or partner’s highest level of qualification?


What is the full title of your current main job?
Please use precise terms, for example ‘primary school teacher’ rather than ‘teacher’, ‘production engineer’ rather than ‘engineer’, ‘chartered accountant’ rather than ‘accountant’. For government or civil service, please provide grade. For armed forces, please provide rank.

What is the full title of your husband/wife or partner's current main job?
Please use precise terms, for example ‘primary school teacher’ rather than ‘teacher’, ‘production engineer’ rather than ‘engineer’, ‘chartered accountant’ rather than ‘accountant’. For government or civil service, please provide grade. For armed forces, please provide rank.


Please circle one number for each activity. If you do not take part in the activity, please circle ‘0’
- | |
---|---|
3 - Weekly 2 - Monthly 1 - Less often 0 - Never |
|
Church-related group or religious activities, e.g. board/standing committee, men’s/ women’s group | |
Job-related association, e.g. trade union or business/professional organisation | |
Recreational groups, e.g. bowling league, golf club or other sports club; chess, bridge or other game-based group; book reading or creative-writing group; art, music or craft based group | |
Civic-political group, e.g. political party club, Chamber of Commerce, local government, parent-teacher association or other school-based work | |
Other voluntary work | |
Other groups or clubs, including Lions or Rotary | |
Other social activities, e.g. going to pubs, cinema, theatre or concerts with others |

Please circle one number for each question
- | |
---|---|
1 - Yes, limited a lot 2 - Yes, limited a little 3 - No, not limited at all |
|
Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports | |
Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf | |
Lifting or carrying groceries | |
Climbing several flights of stairs | |
Climbing one flight of stairs | |
Bending, kneeling or stooping | |
Walking more than one mile | |
Walking half a mile | |
Walking one hundred yards | |
Bathing and dressing yourself |
Please circle one number for each question
Please circle one number for each question
Please circle one number for each question
- | |
---|---|
1 - All of the time 2 - Most of the time 3 - A good bit of the time 4 - Some of the time 5 - A little bit of the time 6 - None of the time |
|
Did you feel full of life? | |
Have you been a very nervous person? | |
Have you felt so down in the dumps that nothing could cheer you up? | |
Have you felt calm and peaceful? | |
Did you have a lot of energy? | |
Have you felt downhearted and low? | |
Did you feel worn out? | |
Have you been a happy person? | |
Did you feel tired? |
Please circle one number for each question









nshd_06_pq
_admission < 7
_illness < 7
please give details in the table below. Use one row for each prescribed medication.
Name of prescribed medicine | What is it for? | |
---|---|---|
Generic textGeneric textGeneric textGeneric text | Generic textGeneric textGeneric textGeneric text | |
1 | ||
2 | ||
3 | ||
4 | ||
5 | ||
6 | ||
7 | ||
8 | ||
9 | ||
10 |
_child < && (_child <= qc_30_b) && _child <= 3
please indicate how often you have taken part in these activities in the last 12 months.
- | |
---|---|
3 - Weekly 2 - Monthly 1 - Less often 0 - Never |
|
Church-related group or religious activities, e.g. board/standing committee, men’s/ women’s group | |
Job-related association, e.g. trade union or business/professional organisation | |
Recreational groups, e.g. bowling league, golf club or other sports club; chess, bridge or other game-based group; book reading or creative-writing group; art, music or craft based group | |
Civic-political group, e.g. political party club, Chamber of Commerce, local government, parent-teacher association or other school-based work | |
Other voluntary work | |
Other groups or clubs, including Lions or Rotary | |
Other social activities, e.g. going to pubs, cinema, theatre or concerts with others |
The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
- | |
---|---|
1 - Yes, limited a lot 2 - Yes, limited a little 3 - No, not limited at all |
|
Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports | |
Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf | |
Lifting or carrying groceries | |
Climbing several flights of stairs | |
Climbing one flight of stairs | |
Bending, kneeling or stooping | |
Walking more than one mile | |
Walking half a mile | |
Walking one hundred yards | |
Bathing and dressing yourself |
During the past four weeks have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
- | |
---|---|
1 - Yes 0 - No |
|
Cut down the amount of time you spent on work or other activities | |
Accomplished less than you would like | |
Were limited in the kind of work or other activities you could do | |
Had difficulty performing the work or other activities (for example, it took extra effort) |
During the past four weeks have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
- | |
---|---|
1 - Yes 0 - No |
|
Cut down the amount of time you spent on work or other activities | |
Accomplished less than you would like | |
Didn’t do work or other activities as carefully as usual |
How much of the time during the past four weeks…
- | |
---|---|
1 - All of the time 2 - Most of the time 3 - A good bit of the time 4 - Some of the time 5 - A little bit of the time 6 - None of the time |
|
Did you feel full of life? | |
Have you been a very nervous person? | |
Have you felt so down in the dumps that nothing could cheer you up? | |
Have you felt calm and peaceful? | |
Did you have a lot of energy? | |
Have you felt downhearted and low? | |
Did you feel worn out? | |
Have you been a happy person? | |
Did you feel tired? |
Please choose the answer that best describes how TRUE or FALSE each of the following statements is for you:
- | |
---|---|
1 - Definitely true 2 - Mostly true 3 - Don’t know 4 - Mostly false 5 - Definitely false |
|
I seem to get sick a little easier than other people | |
I'm as healthy as anyone I know | |
I expect my health to get worse | |
My health is excellent |
2006-2010 Clinic Study Postal Questionnaire