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Please answer completely and return to Tiffany Lipsey via email (), fax (970-491-7677), or in person at least 24 hours prior to your appointment.
The following questions measure behavioral health aspects, which may be indirectly related to cardiovascular disease.
Occupational stress awareness consultation is now included in the NFPA 1582 7.7.23 (7.7.23.1-2)(2017). These questionnaires help to provide this awareness education to you. In addition, we have added sleep disturbance questionnaires to the Health History Questionnaire. Sleep disturbance screening is now include in the NFPA 1582 7.7.21 (7.7.21.1-2)(2017).
Please answer the questionnaires using your first response. Do not dwell on your answer as your first response is generally most accurate.
Read the directions carefully above each scale.
Thank You
Read each item carefully. Using the scale shown below, please select the number that best describes YOU and put that number in the box provided.
1=Definitely False 2=Mostly False 3=Mostly True 4=Definitely True
1. I can think of many ways to get out of a jam.2. I energetically pursue my goals.
3. I feel tired most of the time.
4. There are lots of ways around any problem.
5. I am easily downed in an argument.
6. I can think of many ways to get the things in life that are most important to me.
7. I worry about my health.
8. Even when others get discouraged, I know I can find a way to solve the problem.
9. My past experiences have prepared me well for my future.
10. I’ve been pretty successful in life.
11. I usually find myself worrying about something.
12. I meet the goals that I set for myself.
Indicate True or False to the following statements, as applied to you:
T F / 1. At times I feel like swearing.T F / 2. At times I feel like smashing things.
T F / 3. Often I can’t understand why I have been so irritable and grouchy.
T F / 4. At times I feel like picking a fist fight with someone.
T F / 5. I easily become impatient with people.
T F / 6. I am often said to be hotheaded.
T F / 7. I am often so annoyed when someone tries to get ahead of me in line I speak to that person about it.
T F / 8. I have at times had to be rough with people who were rude or annoying.
T F / 9. I am often sorry because I am so irritable and grouchy.
T F / 10. It makes me angry to have people hurry me.
T F / 11. I am very stubborn.
T F / 12. Sometimes I get so angry and upset I don’t know what comes over me.
T F / 13. I have gotten angry and broken furniture or dishes when I was drinking.
T F / 14. I have become so angry with someone that I have felt as if I would explode.
T F / 15. I’ve been so angry at times that I’ve hurt someone in a physical fight.
T F / 16. I almost never lose self-control.
For each statement, please indicate how often you have felt this way recently by selecting the option you most agree with.
Not at all or less than 1 day per week / 1 or 2 days per week / 3 to 4 days per week / 5 to 7 days per week / Nearly every day over the past two weeks1. My appetite is poor.
2. I could not shake off the blues.
3. I had trouble keeping my mind on what I was doing.
4. I felt depressed.
5. My sleep was restless.
6. I felt sad.
7. I could not get going.
8. Nothing made me happy.
9. I felt like a bad person.
10. I lost interest in my usual activities.
11. I slept much more than usual.
12. I felt like I was moving slowly.
13. I felt fidgety.
14. I wished I were dead.
15. I wanted to hurt myself.
16. I was tired all the time.
17. I did not like myself.
18. I lost a lot of weight without trying to.
19. I had a lot of trouble getting to sleep.
20. I could not focus on important things.
There follows a number of sentences which people have used in order to describe how they feel. There are no right or wrong answers. Try to consider which of the answers best describes how you feel at this moment. Mark the box beside the statement.
Strongly Agree / Strongly Disagree1 / 2 / 3 / 4 / 5
I feel calm
I feel tense
I feel satisfied
I’m worried in case I fail
I feel nervous
I feel shaky
I feel relaxed
I feel anxious
I feel harmonious
I feel frightened
Please answer every question below, even if you must make it a hypothetical situation in order to do so. Circle your response.
T F / 1. When I take a new job, I like to be tipped off on who should be gotten next to.T F / 2. When someone does me wrong I feel I should pay him back if I can, just for the principle of the thing.
T F / 3. I prefer to pass by school friends, or people I know but I have not seen for a long time, unless they speak to me first.
T F / 4. I have often had to take orders from someone who did not know as much as I did.
T F / 5. I think a great many people exaggerate their misfortunes in order to gain sympathy and help of others.
T F / 6. It takes a lot of argument to convince most people of the truth.
T F / 7. I think most people would lie to get ahead.
T F / 8. Someone has it in for me.
T F / 9. Most people are honest chiefly through fear of being caught.
T F / 10. Most people will use somewhat unfair means to gain profit or an advantage rather than to lose it.
T F / 11. I commonly wonder what hidden reason another person may have for doing something nice for me.
T F / 12. It makes me impatient to have people ask my advice or otherwise interrupt me when I am working on something important.
T F / 13. I feel that I have often been punished without cause.
T F / 14. I am against giving money to beggars.
T F / 15. Some of my family have habits that bother and annoy me very much.
T F / 16. My relatives are nearly all in sympathy with me.
T F / 17. My way of doing things is apt to be misunderstood by others.
T F / 18. I don’t blame anyone for trying to grab everything they can get in this world.
T F / 19. No one cares much what happens to you.
T F / 20. I can be friendly with people who do things which I consider wrong.
T F / 21. It is safer to trust nobody.
T F / 22. I do not blame a person for taking advantage of someone who lays himself open to it.
T F / 23. I have often felt that strangers were looking at me critically.
T F / 24. Most people make friends because friends are likely to be useful to them.
T F / 25. I am sure I am being talked about.
T F / 26. I am likely not to speak to people until they speak to me.
T F / 27. Most people inwardly dislike putting themselves out to help other people.
T F / 28. I tend to be on my guard with people who are somewhat more friendly than I had expected.
T F / 29. I have sometimes stayed away from another person because I feared doing or saying something that I might regret afterwards.
T F / 30. People often disappoint me.
T F / 31. I like to keep people guessing what I’m going to do next.
T F / 32. I frequently ask people for advice.
T F / 33. I am not easily angered.
T F / 34. I have often met people who were supposed to be experts who were no better than I.
T F / 35. I would certainly enjoy beating a crook at his own game.
T F / 36. It makes me feel like a failure when I hear of the success of someone I know well.
T F / 37. I have at times had to be rough with people who were rude or annoying.
T F / 38. People generally demand more respect for their own rights than they are willing to allow for others.
T F / 39. There are certain people whom I dislike so much that I am inwardly pleased when they are catching it for something they have done.
T F / 40. I am often inclined to go out of my way to win a point with someone who has opposed me.
T F / 41. I am quite often not in on the gossip and talk of the group I belong to.
T F / 42. The man who had most to do with me when I was a child (such as my father, stepfather, etc.) was very strict with me.
T F / 43. I have often found people jealous of my good ideas, just because they had not thought of them first.
T F / 44. When a man is with a woman he is usually thinking about things related to her sex.
T F / 45. I do not try to cover up my poor opinion or pity of a person so that he won’t know how I feel.
T F / 46. I have frequently worked under people who seem to have things arranged so that they get credit for good work but are able to pass off mistakes onto those under them.
T F / 47. I strongly defend my own opinions as a rule.
T F / 48. People can pretty easily change me even though I thought that my mind was already made up on a subject.
T F / 49. Sometimes I am sure that other people can tell what I am thinking.
T F / 50. A large number of people are guilty of bad sexual conduct.
How well do the following traits and qualities describe you? Place a mark in the box that describes you.
Very well / Fairly well / Somewhat / Not at all1. Being hard driving and competitive
2. Usually pressed for time
3. Being bossy and domineering
4. Having a strong need to excel in most things
5. Eating too quickly
Office use only / 1 / 2 / 3 / 4
Have you felt the following at the end of an average day of work? For housewives/men the questions concern your household work.
Yes / No6. Often felt very pressed for time
7. Work stayed with you so you were thinking about it after working hours
8. Work often stretched you to the very limits of your energy and capacity
9. Often felt uncertain, uncomfortable, or dissatisfied with how well you were doing
10. Do you get upset when you have to wait for anything?
Office use only: 1=Yes 0=No
Please answer the following questions as truthful as you can:
I have forgiven myself for things that I have done wrong. / AlwaysOften
Seldom
Never
I have forgiven those who hurt me. / Always
Often
Seldom
Never
I know that God forgives me. / Always or almost always
Often
Seldom
Never
Office use only: 1- Always, 2- Often, 3- Seldom, 4- Never
Next are some questions about the social support that is available to you.
1. About how many close friends and close relatives do you have (people you feel at ease with and can talk to about what is on your mind)?
Number of close friendsNumber of relatives
People sometimes look to others for companionship, assistance, or other types of support. How often is each of the following kinds of support available to you if you need it?
None of the time1 / A little of the time
2 / Some of the time
3 / Most of the time
4 / All of the time
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2. Someone to help you if you were confined to bed
3. Someone you can count on to listen to you when you need to talk
4. Someone to give you good advice about a crisis
5. Someone to take you to the doctor if you needed it
6. Someone who shows you love and affection
7. Someone to have a good time with
8. Someone to give you information to help you understand a situation
9. Someone to confide in or talk to about yourself or your problems
10. Someone who hugs you
11. Someone to get together with for relaxation
12. Someone to prepare your meals if you were unable to do it yourself
13. Someone whose advice you really want
14. Someone to do things with to help you get your mind off things
15. Someone to help with daily chores if you were sick
16. Someone to share your most private worries and fears with
17. Someone to turn to for suggestions about how to deal with a personal problem
None of the time
1 / A little of the time
2 / Some of the time
3 / Most of the time
4 / All of the time
5
18. Someone to do something enjoyable with
19. Someone who understands your problems
20. Someone to love and make you feel wanted
Here are a series of questions relating to various aspects of our lives. Each question has seven possible answers. Please circle the number which expresses your answer, with numbers 1 and 7 being the extreme answers. If the words under 1 are right for you, mark 1; if the words under 7 are right for you, mark 7. If you feel differently, mark the box above the number which best expresses your feeling. Please give only one answer to each question.
1. Do you have the feeling that you don’t really care about what goes on around you?1
Very seldom or never / 2 / 3 / 4 / 5 / 6 / 7
Very often
2. Has it happened in the past that you were surprised by the behavior of people whom you thought you knew well?
1
Never happened / 2 / 3 / 4 / 5 / 6 / 7
Always happened
3. Has it happened that people whom you counted on disappointed you?
1
Never happened / 2 / 3 / 4 / 5 / 6 / 7
Always happened
4. Until now your life has had:
1
No clear goals or purpose / 2 / 3 / 4 / 5 / 6 / 7
Very clear goals and purpose
5. Do you have the feeling that you’re being treated unfairly?
1
Very often / 2 / 3 / 4 / 5 / 6 / 7
Very seldom or never
6. Do you have the feeling that you are in an unfamiliar situation and don’t know what to do?
1
Very often / 2 / 3 / 4 / 5 / 6 / 7
Very seldom or never
7. Doing the things you do every day is:
1
A source of deep pleasure and satisfaction / 2 / 3 / 4 / 5 / 6 / 7
A source of pain and boredom
8. Do you have very mixed-up feelings and ideas?
1
Very often / 2 / 3 / 4 / 5 / 6 / 7
Very seldom or never
9. Does it happen that you have feelings inside you would rather not feel?
1
Very often / 2 / 3 / 4 / 5 / 6 / 7
Very seldom or never
10. Many people-even those with a strong character-sometimes feel like sad sacks (losers) in certain situations. How often have you felt this way in the past?
1
Very often / 2 / 3 / 4 / 5 / 6 / 7
Very seldom or never
11. When something happened, have you generally found that:
1
You overestimated or underestimated its importance / 2 / 3 / 4 / 5 / 6 / 7
You saw things in the right proportion
12. How often do you have the feeling that there is little meaning in the things you do in your daily life?
1
Very often / 2 / 3 / 4 / 5 / 6 / 7
Very seldom or never
13. How often do you have feelings that you’re not sure you can keep under control?
1
Very often / 2 / 3 / 4 / 5 / 6 / 7
Very seldom or never
Please circle the number that best applies to you:
1. How do you feel about life as a whole? Mark the box above the number.