AGING & WELL-BEING
I'd like to ask you some common questions about yourself and your living situation.... 1. Sex:   male    female   2. When were you born? ____month _____day _______year   3. What was your highest level of schooling completed?  
    8th grade       some high school        high school diploma or GED
    some college/vocational training        college degree          advanced degree 4. How would you describe your ethnic background?     African-American    American Indian    Asian    Hispanic/Latino    White 
    Other (please specify) 5. a.) What is your present marital status?     never married    married    separated    divorced    widowed     b.) If ever married, how long have you been/were you together? _______ years 
    c.) How many times have you been married altogether? _______ times   6. a.) In what state or country were you born? _______________________
    b.) If bom in another country, what year did you come to the United States?______


OARS: Self Reported Physical Health
Let's talk about your health now....

1. About how many times have you seen a doctor during the past 6 months other than as an in-patient in a hospital? (EXCLUDE PSYCHIATRISTS.)   _________ times 2. During the past six months how many days were you sick that you were unable to carry on 
your usual activities - such as going to work or working around the house? 0      None
1      A week or less
2      More than a week but less than one month
3      1-3 months
4      4-6 months
--      Not answered


3. How many days in the past six months were you in a hospital for physical health problems?
                    __________________ days

 4. How many days in the past six months were you in a nursing home or rehabilitation center for physical health problems?
                    __________________ days 5. Do you feel that you need medical care or treatment beyond what you are receiving at this time?
                    1     Yes
                    0      No
                    --      Not answered

6. I have a list of common medicines that people take. Would you please tell me if you've taken any of the following in the past month. Ask the name of the mediation, and write it in.
(Mark the approriate box for EACH MEDICINE.)

 
Y N
  Arthritis medication
  Prescription pain killer (other than above)
  High blood pressure medicine
  Pills to make you lose water or salt (water pills)
  Digitalis pills for the heart
  Nitroglycerin tablets for chest pain
  Blood thinner medicine (anticoagulants)
  Drugs to improve circulation
  Insulin injections for diabetes
  Pills for diabetes
  Prescription ulcer medicine
  Seizure medications (like Dilantin)
  Thyroid pills
  Cortisone pills or injections
  Antibiotics
  Tranquilizers or nerve medicine
  Prescription sleeping pills (once a week or more)
  Hormones, male or female (including birth control pills)
7. What other prescription drugs have you taken in the past month? 
(Record the "others". Later enter them in appropriate the categories above,
if possible.)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
 
 
 
 
 
 
 
 
 
 

8. Do you have any of the following illnesses at the present time? 
   (Check the appropriate "YES"/"NO" box for each illness.)

    IF YES, please tell me whether the condition interferes with your activities 
    "Not at all", "A little", or "A great deal".
Y N Not at all A little Greatly
  Arthritis or rheumatism
 
 
 
  Glaucoma
 
  
  Asthma
 
 
 
  Emphysema or chronic bronchitis 
 
 
 
  Tuberculosis
 
 
 
  High blood pressure 
 
 
 
  Heart trouble 
 
 
 
  Circulation trouble in arms or legs
 
 
 
  Diabetes
 
 
 
  Ulcers (of the digestive system)
 
 
  Other stomach or intestinal disorders 
      or gall bladder problems
 
 
 
  Liver disease
 
 
 
  Kidney disease 
 
 
 
  Other urinary tract disorders 
     (including prostate trouble)
 
 
 
  Cancer or leukemia 
 
 
 
  Anemia
 
 
 
  Effects of stroke 
 
 
 
  Parkinson's disease 
 
 
 
  Epilepsy
 
 
  Cerebral palsy
 
 
 
  Multiple sclerosis
 
 
 
  Muscular dystrophy
 
 
 
  Effects of polio
 
 
 
  Thyroid or other glandular disorders
 
 
 
  Skin disorders such as pressure 
    sores, leg ulcers or severe bums
 
 
 
  Speech impediment or impairment
 
 
 


9. Do you have any physical disabilities such as a total or partial paralysis, missing or non-functional limbs, or broken bones?

no
total paralysis
partial paralysis
missing or non-functional limbs
broken bones
not answered 10. How is your eyesight (with glasses or contacts), excellent, good, fair, poor, or are you totally blind? excellent
good
fair
poor
totally blind
not answered


11. How is your hearing, excellent, good, fair, poor, or are you totally deaf?.

excellent
good
fair
poor
totally deaf
not answered


12. Do you have any other physical problems or illnesses at the present time that seriously affect your health?

yes, if YES specify________________________________
no
not answered   13. How would you rate your overall health at the present time -- excellent, good, fair, or poor? excellent
good
fair
poor
not answered


14. Is your health now better, about the same, or worse than it was five years ago?

better
about the same
worse 
not answered


15. How much do your health troubles stand in the way of your doing the things you want to do not at all, a little (some), or a great deal?

a great deal 
a little (some)
not at all 
not answered ADL/IADL: EVERYDAY FUNCTIONING AND ACTIVITIES

Read instruction: Now I'd like to ask you about some of the activities of daily living, things that we all need to do as a part of our daily lives. I would like to know if you can do these activities without any help at all, or if you need some help to do them, or if you can't do them at all.

Be sure to READ ALL ANSWER CHOICES if application in Questions 16 through 29 to respondent.

1. Can you use the telephone....
without help, including looking up numbers and dialing
with some help (can answer phone or dial operator in an emergency, but need a special phone or help in getting the number or dialing.
or are you completely unable to use the telephone?
not answered
2. Can you get to places out of walking distance..... without help (can travel alone on buses, taxis, or drive your own car)
with some help (need someone to help you or go with you when traveling)
or are you unable to travel unless emergency arrangements are made for a specialized vehicle like an ambulance?
not answered 3. Can you go shopping for groceries or clothes (ASSUMING elder has transportation).. without help (taking care of all shopping needs yourself, assuming you had transportation)
with some help (need someone to go with you on all shopping trips)
or are you completely unable to do any shopping
not answered 4. Can you prepare your own meals..... without help (plan and cook full meals yourself)
with some help (can prepare some things but unable to cook full meals yourself)
or are you completely unable to prepare any meals?
not answered 5. Can you do your housework..... without help (can scrub floors, etc.)
with some help (can do light housework but need help with heavy work)
or are you completely unable to do any housework?
not answered 6. Can you take your own medicine..... without help (in the right doses at the right time)
with some help (able to take medicine if someone prepares it for you and/or reminds you to take it)
or are you completely unable to take your medicines?
not answered 7. Can you handle your own money..... without help (write checks, pay bills, etc.)
with some help (manage day-to-day buying but need help with managing your checkbook and paying your bills)
or are you completely unable to handle money?
not answered 8. Can you eat..... without help (able to feed yourself completely)
with some help (need help with cutting, etc.)
or are you completely unable to feed yourself?
not answered 9. Can you dress and undress yourself.... without help (able to pick out clothes, dress and undress yourself)
with some help
or are you completely unable to dress and undress yourself.?
not answered 10. Can you take care of your own appearance, for example combing your hair and (for men) shaving without help
with some help
or are you completely unable to maintain your appearance yourself.?
not answered 11. Can you walk..... without help (except from a cane)
with some help from a person or with the use of a walker, or crutches, etc.
or are you completely unable to walk?
not answered 12. Can you get in and out of bed..... without any help or aids
with some help (either from a person or with the aid of some device)
or are totally dependent on someone else to lift you?
not answered 13. Can you take a bath or shower..... without help
with some help (need help getting in and out of the tub, or need special attachments on the tub)
or are you completely unable to bathe yourself?
not answered


14. Do you ever have trouble getting to the bathroom on time.....

no
yes
have a catheter or colostomy
not answered 15. Is there someone who helps you with such things as shopping, housework, bathing, dressing, and getting around? yes
no
not answered