| Social resources | |
| 1. Are you single (never married), married, widowed, divorced, or separated? | |
| 1 | Single (never married) |
| 2 | Married |
| 3 | Widowed |
| 4 | Divorced |
| 5 | Separated |
| – | Not answered |
| (If "2" ask a.) | |
| a. Does your spouse live here also? | |
| 1 | Yes |
| 0 | No |
| – | Not answered |
| 2. In the past year about how often did you leave here to visit your family and/or friends for weekends or holidays, or to go on shopping trips or outings? | |
| 4 | Once a week or more |
| 3 | One to three times a month |
| 2 | Less than once a month or only on holidays |
| 1 | Never |
| – | Not answered |
| 3. How many people do you know well enough to visit with in their homes? | |
| 3 | Five or more |
| 2 | Three or four |
| 1 | One or two |
| 0 | None |
| – | Not answered |
| 4. About how many times did you talk to someone - friends, relatives, or others - on the telephone in the past week (either you called them or they called you)? (If subject has no phone, question still applies.) | |
| 3 | Once a day or more |
| 2 | Two to six times |
| 1 | Not at all |
| – | Not answered |
| 5. How many times in the past week did you visit with someone, either with people who live here or people who visited you here? | |
| 3 | Once a day or more |
| 2 | Two to six times |
| 1 | Once |
| 0 | Not at all |
| – | Not answered |
| 6. Do you have someone you can trust and confide in? | |
| 1 | Yes |
| 0 | No |
| – | Not answered |
| 7. Do you find yourself feeling lonely quite often, sometimes, or almost never? | |
| 0 | Quite often |
| 1 | Sometimes |
| 2 | Almost never |
| – | Not answered |
| 8. Do you see your relatives and friends as often as you want to, or not? | |
| 1 | As often as wants to |
| 0 | Not as often as wants to |
| – | Not answered |
| 9. Is there someone outside this place who would give you any help at all if you were sick or disabled, for example your husband/wife, a member of your family, or a friend? | |
| 1 | Yes |
| 0 | No one is willing and able to help |
| – | Not answered |
| (If "Yes" ask a. and b.) | |
| a. Is there someone outside this place who would take care of you as long as needed, or only for a short time, or only someone who would help you now and then (for example, taking you to the doctor, or fixing lunch occasionally, etc)? | |
| 3 | Someone who would take care of subject indefinitely (as long as needed) |
| 2 | Someone who would take care of subject for a short time (a few weeks to six months) |
| 1 | Someone who would help the subject now and then (taking him/her to the doctor or fixing lunch, etc) |
| – | Not answered |
| b. Who is this person? | |
| Name: | |
| Relationship: | |
| Code: Spouse = 1, Sibling = 2, Offspring = 3, Grandchild = 4, Other kin = 5, Friend = 6, Other = 7 | |
