Approved For Release 2003/09/10 : CIA-RDP96-00788ROO1700210075-0
P R 0 F 1 LEE 0 is: ADAPTATION TO LIFE B Ni PERSONAL EXPERIENCES
(A) @tOG-u SCALE
@-AST !@-LCEK, 70-,Ay, HC.,` OFTEEN iiAVE YCu, FELT . . .
Fl:,@aje rkz@j@ z@.e a,@5.,ee- @c@ e.7,cli that be-kt ducli@,el-
Mla,.z trou,@L aiL@44,vt &,cZLL@6, @ike thi-s:
'eZt -St WQzk. 1 A
		Answer choices	
		3	4

DURI!i@ THE PAST WEEK,	
Rarely	Often
Some-	Almost

r@,Av- YOU		t i ,e s	Alway

-
			7
rous ?			7
i
			2
P,jll of DeD?			
			

;-,Ppy?			4

7-
-a@m and relaxed?			5
		F-	-T ------- -7
C @@n an t ?			
			

Secure?		1	7
			2
Conf@dence in yourself?			
			
T alm and rpeace?
rn e r c		
J	
-
tXRING THE PAST ?-M-H, VVE
@'-@eerse arswc@,L ecch zt-,Lte@meitt beiov,"
Enjoyed talking with, others
Pelt trusting of PeoPle
Found work useful and interesting
Enjoyed people I live with
Found veople accept me as I am
3 e en. involved, intereSted in things
Pelt needed and useful
'Controlled, ry negative thinking
eased my positive thinking
and jrcr
Found things I've needed coming to
me by "coincidence" or "chance"
"OR TNG THE PAST MONTH, VVE FELT
				A lack of order around me	
	
- - ---------	Answer choices
--		Dissatisfied with	
						

E,R:,V@ THE PAST WEEK,	
Never	Rarely	
- 047ten
So me		
Critical of others	
L", Y,)IJ PELT . . .			t me s			
					Annoyed, irr-@tated	
D@scouragecl?				
10		
					An impulse to hurt someone	
Ureasy?						
		71		
12	Left oit of things	
						


-d
?				
13	me unfairlv
That people treated	
ge			L			

"				
14	Bothered by sloppiness around mp	
G
00fry					l
i	
					e
n peop
Disappointed	
51 ue?

?				
16	
Worried about debts	

I
Like crying			I		
am
ll
h
I	1
				17	rea
o
Uncertain about w
y	
,@o-r4ed?						

?					Unhappy about the work ', do	
:ense					lt with me
f
fi
d	
				'19	au
n
s
My family	
Rored?						

irritated?
d
A
L			
20	No one seemed interested in how 1

id
l i
l
f	
nnoye
,					ns
e
ee
real
y	
		

-Copyright 11975.,	17 lkjl T

INST @ .- . ;RAM EVALUATION
F()q
7
1nqWd For Release 2003/09/10 CIA-RDP96-00788RO01 700210
k	

075-0
	BOX 4654, ROANOKE,	,N
V lRG	Wl			

Ra re, y	So -,Ie -
tinles Often	A I uo s t
Always
		21
		22
	------------	.............. .
23
		24
	L
------ -	
25
		26
		
	
L-	27
		28
		29
	nswer cnoices	
4
	2 3	
Never	Rarely	t i mes	Often
			30
			31
			32
			33
		1	34
		
I	135
			36
			
		
F	37
L==@j 38
			39
	I		
4-
			41
			42
			43
Approved For Release 2003/09/10 : CIA-RDP96-00788ROO1700210075-0
INVENTORY L BELIEFS
PHYSICAL HEALTH - (0) PERSONA Answer cholices
P,,'e,;sc matk one an6w@@,t @,o;i each questton
: - r-, i r, 4
qcut answe,, Zike this or this " 1 2 3
x !T IS MY OPINION THAT . . . Not .140 t Agree
Y-! S Agree S
,Please answer each statement below) Agree ure trongly
7
Answer chc- L
ices A person's soul or spirit continues after death 69
1 2 3
Some- People will be reborn to live again on earth i i7 70
DjRTNG THE LAST MONTH, HAVE YOU Never times Often
1 7 71
had headdches? (Past m-inth) I i 44 Mental telepathy (ESP) is a reality
'F-i People have out of body eAPeriences (astral *travel) t 72
'7elt faint? 45
There are spiritual or non-physical forces
46
Felt hot, feverish? acting in today's world 73
Had spells of dizziness? 47 Sooner or later people will treat you as
You've treated others 74
48
Had difficulty falling asleep-@ I
Spiritual or psychic healing is often as 7--
49 75
Had chest pains? e-ect@ve as medical treatment
51
'eart bea@ing fast?
Noticea your n I
76 S 0
breathing? 5 1----7 ubj 0 8
,Had difficulty i
Tt'S wrong to kill any living thing.
Felt physically ill? 52
Probiem, in life are really op-portun' ties
Hal. back pains? L_j 53 to learn and grow 2
Been bothered by itch ing? 54 People create their own reality by the kinds
55 of thoughts they let themselves have 3
Had coughing spells?
Had neck or shouider pains? 56
2 3 4
L IT IS MY OP'NION THAT THE SOLUTIONS TO MAN'S Not Not Agree
Had pains in legs or am-s? 57
PR,"BILEM' IN' LiVING' WILL k FOUN@ IN . . . Agree Sure Agree
S Strongly
xa@d trouble with vour vision? 58
More money for scientific research i- L--j 4
Felt exhausted, fatigued? 59
5
More formal education for people LD 1
Waken from sleep feeling tired? 1 60
Redistributing the wealth 6
Hao a poor appetite? 61 F-
A return to organized religion 7
62
Been constipated (hard stools)? Social reform through better laws 8
j--7
Had an upset stomach? 63 9
Daily meditation I
Had nausea (sick to stowach)? 64
10
Spiritual reawakening (personal enlightirient)
Had indigestion? 65
Protecting the environment, natural resources L-J
r eating?
Had stomach pain dfte 66
67
Had troutle digesting food?
Had diarrhea (loose bowels)?
Approved For Release 2003/09/10 : CIA-RDP96-00788ROO1700210075-0
Approved For Release 2003/09/10 CIA-RDP96-00788ROO1700210075-0
L E S T , L E
D,'R 1NG THE PAST MONTH, HOW OFTEN HAVE Y@X,
iPt"zr-5e anzwe,, zach quezktie< be@@v_'
@-,ent- ti,7
@e with a close friend'
Shared personal p
with a friend
-p -he disnes?
W a s h, c
Done household clear@!ic?
Prepared meals?
,@ashed c"othes?
.one physical exercise?
iak,;n Dart -@'n active sports,
Listened @o @@1;sic en_-jv?
@a@er t4mp to @e bv vo@_irse'
"ed4 -a -cd?
Enjoyed con-.act witr. anii-ais?
@are of --se pla-)@s-@
Eat@@-' rec meat @tee',
aten f-h or pcL@'-rll
sweets rcandy, za@e, pip, el
'rjn@@ soft
drinks @Cc@2, etc,"
,ater. fresh lrui@s
'apcJes, oranz@cs,
Eater natural foo@s @@dried fruit, n_-s, i
whole orainsl?
Kept up witn cvrrent events, Iread news-
paper, magazines, watch TV news)?
Read something about mysti@al,
SD@r@lual or psychic things?
Re,@d something about perscnal
:Dsychclogical; qrowt@..^,
Answer cho4ces	
Rarely	3-5	
or Ti;@,es	T ime s	Each
.
,ever /Week	/Week	Dav
		
		13
		
		14
		
		6
		1 17
		
		
	
-	25
	
7
1	2 1
		
		22
		23
		
		2r
	t	I
		2'
		23
29
i 1 30
31
32
33
'E@ LTFE STYLEE C ON 7" D
	Answer cnocic	
	2 3	4
Dlj?!NG THE LAST MMTH, HAVE Yo@	1-2 t 41r% S 11-2 ti,7es	Al most
Never	per morth per week	Daily
"!one to parties for social activities F-,		

ou's ide
the home?	L	34
Attended Teetings of civic, or other		
organ4zations'@

___j	
I
_J	
I ,35
Erterta4ned friends in your horv-,	
-	:36
_j

Attcrided a religious se,Oce?	7	
37
Scen- line o@tdcors enjoying nature?		138

Played cards cr other table cames?	r	
		
Visited with the neighbors?		
"one grocery shopping)		
47
		
'a-
nced?		42
@@ead fil-lion for en4o,@:rert?		
Part'zipated ir a study grourl-,	
J	144
		

aken medicat4on for headacne?		45
		
a-_n redicaticn, to help you sleep?		;46
-,ed4:az4IIrI 'or your Sto		
e- @ed@Cat4,n for a cold or all,--@;Y'		
		
		
7aken 'axatives?		
@'sed a-conol or nonprescription drugs?
-------------		!51
Gotten high on al@onol or drues?		
D! -tRING THE LAST MiONTH, HAS ALCOHOL OR
DRUG USE CAUSED PROBLEMS . . .
Between you and family imemoers?
With work (difficulty working well
or going to work)?
With -our P@vsical he-A' th?
F__I r
53
LI 54
:n your thinkiria clearly?
Approved For Release 2003/09/10 CIA-RDP96-00788ROO1700210075-0
Approved For Release 2003/09/10 CIA-RDP96-00788ROO1700210075-0
@1. R, LI jlij- 7 'NG A P, @,NT E'L IN A C@ S,
@!T P"
7 S,
@io If you -.arke@ No" p t o '@@ c r. he I ow
@es r-@a rked @es dnswe r m@ ns be'; c,-;'
r --no l c e s
2 3 4
'-7 r:"VE 'Ou: AND @(YjR 5,-@me - A I mo s
Z: It: TPC
OTHER (SPOLSe, parent, etc.) Rarely fi,--as Often A! ways
sharej personal 47ee', ings -,,iith each othe0
-7 58
2. Beein able to talK it through when angry?
3 .Al Q reed . t o u t f i na nc e s a n d b id @;e t-
4- S D e r, r e n14 oYa b I rti--.es tog,et@ier?
-T
Discussed Jmporta.-' :rlat-ersl
Fpl* c'cse to eact, cthcr" 63
7--i
AgrEed soc:el act-vities and
64
1:r-'ends,
Sna-ea @ai,y events tna7 r-@pnpned t o
each of YOU? 6-
S AP--- THERE WHERE YOU LiVE? (Mlark one@
.0 (If yc-, marked "tD", skip to Section H below)
N 4
Yes @-,f v,:@; marked "Yes", answer the next 6 o-jestions)
--
Answer &.o4ces
T P. E-' LAST M.0147@!, @-@IVE AND T So [,,e - Al ms t
D R E N ) . . . Rarely I me cc Often Always
Spen- tirle ta"kirg w;z1h ea-,@@ otlier-,
2. Scent t4-e doin-, t-4rgs lc;ether'
3 .Or,)enl Y excressed feel ings to ea--h otiter? Fs 9
r
4. Trea'ed each wt1l resp@---t? 1 1 -3
L - L@ 7
to each cot@,.*r?
E .Felt c`ose
72
6, Done things for each other?
I S A C KG C$1j,
	Sutj 80			
?eA-',3R	SOURICE OF I1;CCYF- S	K E		
	
(Check only one answer,'		N31 at al	
	Money earneTfrom Iiork T			
	cc now	(2,	Less -.han pack	per da@,
(2)	Fror7 spouse, relative, or			
_	frileid	"?I	About pack per	day
(3)	investments or inheritance			
		f4'	About pack cer	day
	Welfare or public assistance			
			Over 11 p31-k per	day
(5)	Retirement or social' security			
	6.	DRIN@	C0F;7E7-?	
@6i	Une@ployment compensation,		Nc,,@L cr rarE c,- P	
	'Ent sticen-
Scholarsh4p or StUU		Abct,-, 1-2 c-jL)s. per day
	Ali,--.luny or child support	13'.	2-4 cup@ @er day	
	Velerans berefits	r4,'	5 j- --,re cups per day
2. kIARTT'L STATUS (Check one)
C u rre n y ma r r i ed
2 Separated, a4vorcec, or
widowed
1
(3'._ _ Never mzrr-led
3. SEX (Check one)
Ma 1, e
(2) Femaie
4. EDuCAT I ON Check one)
Less than high scnocl
(21 High school gradua-e
(31 So-e ccllege
4 1) College graduate (7ype of degr,
7. WATCH TV?
1) None or rdrei v
(2) Less t.nan 1 hour per
0ay
(3) hours per day
'4) 3-4 hours per day
(5) 5@ hours -@er day
S. AvERAGE POURS 07 SLEEP
4-5 hciws
12) 5-6 hours
6-- hours
/4) 7-8 hours
(5) 3 or more hours
AGE 9-10 TODAY'S DATE: 17-22
(H) DO YOU HAVE -7.NCQGH MONEY TO iRarely ti rles Usually A! ",a v s!
in, 11-13
HEIGHT feet
Pay your bills? (Via r'k one) 3 1 --T Mont h. Day Year
4 GHT pounds 14-16
L i
Har;dlle unexpected expenses? i7 4
(Mark one) 76 Subi 80
FRO'A WORKING, DID YOU EARN AN ADEQUATE AMOUNT OF !CNEY LAST MONTH? (M a r k one)
1: Earned no money fron-- working last month T@' "o. hcip o vety fru, ch
latll@ UNA 10,t
Earned enou& to take care of my personall needs (spending money) app,@cciatcd. Pieasv, c;:ecp@ bac@ tu rkzk@ 4, ;,-u o @ t apvi
,3', Earned enough to Dartially sj;)I-c-t a fanilv 75
(4j- "Earned erough to --dequately support a family
Approved For Release 2003/09/10 CIA-RDP96-00788ROO1700210075-0