| 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 | |
| 2. Who lives with you? | ||
| Yes | No | |
| 1 | 0 | No one |
| 1 | 0 | Husband or wife |
| 1 | 0 | Children |
| 1 | 0 | Grandchildren |
| 1 | 0 | Parents |
| 1 | 0 | Grandparents |
| 1 | 0 | Brothers and sisters |
| 1 | 0 | Other relatives (does not include in-laws covered in the above categories) |
| 1 | 0 | Friends |
| 1 | 0 | Non-related paid* helper |
| 1 | 0 | Other (specify): |
| 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 | Once | |
| 0 | Not at all | |
| - | Not answered | |
| 5. How many times during the past week did you spend time with someone who does not live with you; that is, you went to see them or they came to visit you, or you went out to do things together? | ||
| 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 willing and able to help | |
| - | Not answered | |
| (If "Yes" ask a. and b.) | ||
| a. Is there anyone 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 | ||
