Part I
1=Very Dissatisfied‚ 2=Moderately Dissatisfied‚ 3=Slightly Dissatisfied‚ 4=Slightly Satisfied‚ 5=Moderately Satisfied‚ 6=Very Satisfied
HOW SATISFIED ARE YOU WITH:
1. Your health?
2. Your health care?
3. The amount of pain that you have?
4. The amount of energy you have for everyday activities?
5. Your ability to take care of yourself without help?
6. The amount of control you have over your life?
7. Your chances of living as long as you would like?
8. Your family’s health?
9. Your children?
10. Your family’s happiness?
11. Your sex life?
12. Your spouse‚ lover‚ or partner?
13. Your friends?
14. The emotional support you get from your family?
15. The emotional support you get from people other than your family?
16. Your ability to take care of family responsibilities?
17. How useful you are to others?
18. The amount of worries in your life?
19. Your neighborhood?
20. Your home‚ apartment‚ or place where you live?
21. Your job (if employed)?
22. Not having a job (if unemployed‚ retired‚ or disabled)?
23. Your education?
24. How well you can take care of your financial needs?
25. The things you do for fun?
26. Your chances for a happy future?
27. Your peace of mind?
28. Your faith in God?
29. Your achievement of personal goals?
30. Your happiness in general?
31. Your life in general?
32. Your personal appearance?
33. Yourself in general?
Part II
1= Very Unimportant‚ 2=Moderately Unimportant‚ 3=Slightly Unimportant‚ 4=Slightly Important‚ 5=Moderately Important‚ 6=Very Important
HOW IMPORTANT TO YOU IS:
1. Your health?
2. Your health care?
3. having no pain?
4. having enough energy for everyday activities?
5. Taking care of yourself without help?
6. having control over your life?
7. Living as long as you would like?
8. Your family’s health?
9. Your children?
10. Your family’s happiness?
11. Your sex life?
12. Your spouse‚ lover‚ or partner?
13. Your friends?
14. The emotional support you get from your family?
15. The emotional support you get from people other than your family?
16. Taking care of family responsibilities?
17. Being useful to others?
18. having no worries?
19. Your neighborhood?
20. Your home‚ apartment‚ or place where you live?
21. Your job (if employed)?
22. having a job (if unemployed‚ retired‚ or disabled)?
23. Your education?
24. Being able to take care of your financial needs?
25. Doing things for fun?
26. having a happy future?
27. Peace of mind?
28. Your faith in God?
29. Achieving your personal goals?
30. Your happiness in general?
31. Being satisfied with life?
32. Your personal appearance?
33. Are you to yourself?
Health and Functioning Subscale‚ Social and Economic Subscale‚ Psychological/Spiritual Subscale and Family Subscale
Carol Estwing Ferrans‚ PhD‚ FAAN
University of Illinois at Chicago
College of Nursing (M/C 802)
845 S. Damen Avenue – 7th floor
Chicago‚ IL 60612 U.S.A.
Phone (312) 996-8445
Fax (312) 996-4979
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