Approved For Release 2003/09/10 : CIA-RDP96-00788ROO1700210037-2 PROFILE OF ADAPTATION TO LIFE (B) PERSONAL EXPERIENCES (A) MOOD SCALE DURING LAST WEEK, INCLUDING TODAY, HOW OFTEN HAVE YOU FELT . . . Ptev_6e mcftk the answeA Jot each que6tion that be,6t de6cA"Ie6 how 1 V you @dt ;Uti6 p"t wQek. Matk youA an,5weA choicez, tike thiZ: I Answer choices DURING THE PAST WEEK, HAVE YOU FELT . . . Rarely Some- times Often Almost Always Vigorous? = Alert? [71 E7 2 Full of pep? 3 Happy? F__1 4 Calm and relaxed? 5 Content? 6 Secure? 7 Confidence in yourself? 8 Inner calm and peace? 9 Answer choices --- 1 2 3 DURING THE PAST WEEK, HAVE YOU FELT . . . Never Rarely Some- times Often Discouraged? 10 Uneasy? 11 Unhappy? F-1 12 On edge? 17 13 Gloomy? 14 Blue? 15 Like crying? 16 Worried? Li 17 Tense? 18 Bored? 19 Annoyed, irritated? 20 DURING THE PAST MONTH, I'VE (Ptea6e answeA each statement befow) Enjoyed talking with others Felt trusting of people Found work useful and interesting Enjoyed people I live with Found people accept me as I am Been involved, interested in things Felt needed and useful S_UFJ_ Some- Rarely times Often Almost Always F_ 1 21 F --- I F__1 22 r 23 24 E@ 25 E@ 26 EL 27 Controlled my negative thinking and increased my positive thinking 28 Found things I've needed comin2 to me by "coincidence" or "chance 29 DURING THE PAST MONTH, I'VE FELT A lack of order around me Dissatisfied with myself Critical of others Annoyed, irritated An impulse to hurt someone Left out of things That people treated me unfairly Bothered by sloppiness around me Disappointed in people Worried about debts Uncertain about who I really am Unhappy about the work,I do My family finds fault with me No one seemed interested in how I really feel inside Never Rarely times Often F-1 r_1 1---] EJ F_ H 30 31 32 33 34 35 36 37 38 39 40 41 42 F7 El 43 *Copyright 1975, INSTITUTE FOR PROGRAM EVALUATION BOX 4654, ROANOKE, VIRGX%r64Ve'il For Release 2003/09/10 CIA-RDP96-00788 ROO 1700210037-2 Approved For Release 2003/09/10 : CIA-RDP96-00788ROO1700210037-2 (C) PHYSICAL HEALTH INVENTORY (D) PERSONAL BELIEFS Pteaze ma&k one anzweA 6ot each on betow. q Ma&k youA answe)L Zike thi.6 or this Ov Answer choices 1 2 3 Some- DURING THE LAST MONTH, HAVE YOU . . t th) d h ? (P . Never times Often 44 as mon es Had hea ac Felt faint? 45 feverish? lt hot F F_ F-1 46 e , lls of dizziness? H d F] 47 a spe Had difficulty falling asleep? L 48 Had chest pains? D 01 49 Noticed your heart beating fast? 50 Had difficulty breathing? 51 Felt physically ill? 52 Had back pains? F-1 53 Been bothered by itching? 54 Had coughing spells? LA 0 F-1 55 Had neck or shoulder pains? I I i I 1 1 56 Had pains in legs or arms? F-1 F-1 F-1 57 Had trouble with yout, vision? 58 Felt exhausted, fatigued? 59 Waken from sleep feeling tired? 60 Had a poor appetite? 61 Been constipated (hard stools)? 62 Had an upset stomach? 63 Had nausea (sick to stomach)? 64 Had indigestion? 65 H d t h i ft ti ? F] 66 a s omac n a er ea pa ng bl di sti food? H d t o F] 67 a r u e ge ng Had diarrhea (loose bowels)? 1= 68 IT IS MY OPINION THAT . . . (Please answer each statement below) A person's soul or spirit continues after death People will be reborn to live again on earth Mental telepathy (ESP) is a reality People have out of body experiences (astral travel) There are spiritual or non-physical forces acting in today's world Sooner or later people will treat you as you've treated others Spiritual or psychic healing is often as effective as medical treatment It's wrong to kill any living thing Problems in life are really opportunities to learn and grow People create their own reality by the kinds of thoughts they let themselves have IT IS MY OPINION THAT THE SOLUTIONS TO MAN'S PROBLEMS IN LIVING WILL BE FOUND IN More money for scientific research More formal education for people Redistributing the wealth A return to organized religion Social reform through better laws Daily meditation Spiritual reawakening (personal enlightment) Protecting the environment, natural resources Agree Sure A ree 9 trongly 69 F-1 70 71 72 73 E] 74 F-1 E:1 75 _T6__ El Subj 0 80 LJ 1 2 El D D 3 Agree Sure Agree S-`-- trongly F-1 Ll F-7 F7 4 H F7 5 6 F__] 7 8 F-1 9 71 F-1 10 F7 11 Approved For Release 2003/09/10 CIA-RDP96-00788ROO1700210037-2 Approved For Release 2003/09/10 CIA-RDP96-00788ROO1700210037-2 (E) LIFE STYLE (E) LIFE STYLE (CONT-D) 1XJRING THE PAST MONTH, HOW OFTEN HAVE YOU.-Rarely (Pte"e answeA each quut@on betow) or Never d? f i l en r ose Spent time with a c i nd? f ith l a r e ems w Shared personal prob ? h di es s Washed the ? ld l i c ean Done househo ng Prepared meals? Washed clothes? Done physical exercise? Taken part in active sports? ? i j c you en Listened to mus oy Taken time to be by yourself? Meditated? Enjoyed contact with animals? Taken care of house plants? Eaten red meat (beef, pork)? Eaten fish or poultry? Eaten sweets (candy, cake, pie, etc.)? Drunk soft drinks (Coke, etc.)? Eaten fresh fruits (apples, oranges, etc.)? Eaten natural foods (dried fruit, nuts, whole grains)? Kept up with current events, (read news- paper, magazines, watch TV news)? Read something about mystical, spiritual or psychic things? Read something about personal psychological growth? I-L Times /Week J_J Times /Week Each Day = = 12 FJ 1-1 13 P 14 15 16 F-1 17 H 18 19 =1 20 21 F-1 1__@ 22 23 24 F-1 25 F1 17 F-1 26 27 28 F7 29 30 F-7 = 31 71 = = 32 33 DURING THE LAST MONTH, HAVE YOU . . . Gone to parties for social activities outside the home? Attended meetings of civic, or other organizations? Entertained friends in your home? Attended a religious service? Spent time outdoors enjoying nature? Played cards or other table games? 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? Takem medication for your stomach? Takem medication for a cold or allergy? Taken tranquilizers? Taken laxatives? Never 1-2 times per month J-Z times per week L-] Daily 34 E]35 36 37 38 39 =40 =41 =42 7@43 =44 =45 L-146 =47 =48 7149 50 51 Used alcohol or nonprescription drugs? Gotten high on alcohol or drugs? 52 DURING THE LAST MONTH, HAS ALCOHOL OR DRUG USE CAUSED PROBLEMS . . . Between you and family members? 53 With work (difficulty working well or going to work)? '54 With your physical health? 55 In your thinking clearly? 56 Approved For Release 2003/09/10 CIA-RDP96-00788ROO1700210037-2 Approved For Release 2003/09/10 (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 I 1 Ans er 2 choices 3 _ 4 DURING THE PAST MONTH, HAVE YOU AND YOUR SIGNIFICANT OTHER (spouse, parent, etc.) . . . 1. Shared personal feelings with each other? 2. Been able to talk it through when angry? Rarely Some- times Often A1 most Always 58 59 3. Agreed about finances and budgetT 4. Spent enjoyable times together? 5. Discussed important matters? 6. Felt close to each other? 60 F-1 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 (1) No (If you marked "No", skip to (2)_ Yes (If you marked "Yes", answer one) Section 1i the next below) 6 questions) 66 1 Answer choices 2 3 - 4 DURING THE LAST MONTH, HAVE YOU AND THE CHILD(REN) . . . 1. Spent time talking with each other? 2. Spent time doing things together? 3. Openly expressed feelings to each other? 4. Treated each other with respect? 5. Felt close ro each other? 6. Done things for each other? Rarely Some- times H Often Almost Always 67 68 69 F-i 70 71 72 CIA-RDP96-00788 ROO 170021 OO@TT2 BAC KGROU ND S-ubj 80 1. MAJOR SOURCE OF INCOME? e answer) (Check only one (1 )_ Money.earned from work I do now (2) From spouse, relative, or friend (3) Investments or inheritance (4)_ Welfare or public assistance (51 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) M- Currently married (2) Separated, divorced, or _ widowed (3) Never married 3. SEX (Check one) M- Male (2)_ Female 4. EDUCATION (Check one) M_ Less than high school (2) High school graduate (3) Some college (4) College graduate (Type of de 5. SMOKE CIGARETTES? (1) Not at all (2)_ Less than pack per day (3)_ About 12 pack per day M_ About 1 pack per day (5)_ Over 1-1,. pack per day 6. DRINK COFFEE? M_ None or rare cup (2)_ About 1-2 cups.per day (3) 3-4 cups per day W_ 5 or more cups per day 7. WATCH TV? (1)_ None or rarely (2) Less than I 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 M_ 4-5 hours (2)_ 5-6 hours (3)_ 6-7 hours (4) 7-8 hours (5) 8 or more hours AGE 9-10 TODAY'S DATE: 17-22 (H) DO YOU HAVE ENOUGH MONEY TO . . . times Usually AlW@yjs HEIGHT feet in. 11-13 Pay your bills? (Mark one) _171- 73 WEIGHT pounds 14-16 Month Day Year Handle unexpected expenses? (Mark one) F 74 FROM WORKING, DID YOU EARN AN ADEQUATE AMOUNT OF MONEY LAST MONTH? (Mark one) 76 Subj 80 (1) Earned no money from working last month Thank you 6o@L compt-eting the questionnaEAe. YouA hefp Zs vety much (2)_ Earned enough to take care of my personal needs (spending money) appAeciated. Ptea.6e check back to make zvAe you have not Ze6t any (3)_ Earned enough to partially support a family que,5tions unan6weAed. W_ Earned enough to adequately support a family 75 Mo&?MrfttgLgLgroF'AWW&2fflXQLW1-OP.(6AEPAR.ft"- AWCAWTAW29020-2