I've been studying a few facts about depression. I would like to
ask you a few questions about depression. Don't feel like you have
to answer any question you don't want to answer.
| 1. What year were you
born? |
|
| YEAR OF BIRTH |
| DON'T KNOW |
| REFUSE |
|
| 2. What is the
highest grade or year of school you have completed? [Read choices if
necessary.] |
|
| Eighth grade or less |
| Some high school |
| High school graduate or GED
certificate |
| Some post high school |
| College graduate (Associate or
Bachelor's) |
| Post graduate education or degree |
| Other (Specify) |
| DON'T KNOW |
| REFUSE |
|
| 3. What is the
highest grade or year of school that anyone else in your
household has completed? [Read choices if
necessary.] |
|
| Eighth grade or less |
| Some high school |
| High school graduate or GED
certificate |
| Some post high school |
| College graduate (Associate or
Bachelor's) |
| Post graduate education or degree |
| Other (Specify) |
| DON'T KNOW |
| REFUSE |
|
| 4. Are you currently:
[List the choices.] |
|
| Employed or self-employed full-time |
| Employed or self-employed part-time |
| Homemaker or caregiver |
| Out of work or unable to work |
| Student |
| Student and employed |
| Retired |
| Something else (Specify) |
| REFUSE |
|
| 5. Are you currently:
[Pick
one from the list that you feel best describes your current status.”] |
|
| Married |
| Partnered |
| Divorced |
| Widowed |
| Separated |
| Never married |
| Other (Specify) |
| DON'T KNOW |
| REFUSE |
|
| 6. Do you have a
history of depression in your family? |
|
|
| 7. Do you ever feel
hopeless? If so, do you know why? |
|
|
| 8. Have you
experienced a traumatic or emotional even recently? If so,
how have you felt since it happened? |
|
|
| 9. Have you lost
someone close to you recently? If so, how have you felt
since it happened? |
|
|
| Most of the time, do people say you are a pessimist or an optimist? |
|
| Optimist |
| Pessimist |
| Id you don't know, which do you think you are
more like? |
|
| 10.What is your energy
level most of the time? |
|
| Very high |
| High |
| Medium |
| Low |
| Very low |
|
| 11.Did you know that depression is
a very common illness in the United States? |
|
|
| 12.When you feel down,
depressed, or blue, what help you feel good again? |
|
|
| 13.What do you think
causes depression in people? |
|
|