4 Clinical Exam Mental Health Questionnaire

National Institute of Environmental Health Sciences (NIEHS) Version 1.0 (07/02/2013) GuLF STUDY
OMB#0925-XXXX
EXP. XX/XXXX

Clinical Exam:
Mental Health Questionnaire
(Estimated Burden: 40 minutes)

Public reporting burden for this collection of information is estimated to average 40 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a currently
valid OMB control number. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to: NIH, Project Clearance Branch,
6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0626). Do not return the
completed form to this address.

U.S. Department of Health and Human Services
National Institutes of Health
National Institute of Environmental Health Sciences

Table of Contents
Section A: General Health ........................................................................................................................ 3
Section B: Resiliency ................................................................................................................................. 6
Section C: Faith/Religiosity ....................................................................................................................... 8
Section D: Current Housing .................................................................................................................. 10
Section E: Traumatic Events Scale ....................................................................................................... 12
Section F: Finances ................................................................................................................................. 17
Section G: Mental Health Service Utilization .................................................................................... 21
Section H: Barriers to Access to Care ................................................................................................ 23
Section I. Social Support Scale............................................................................................................ 26
Section J: Depression .............................................................................................................................. 28
Section K: Affect ....................................................................................................................................... 31

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Section A: General Health
(Source: SF-12)
This survey asks for your views about your health. This information will help keep track of how you feel
and how well you are able to do your usual activities.
If you are unsure about how to answer a question, please give the best answer you can.
A1. In general, would you say your health is…
Excellent ........................ 1
Very good ...................... 2
Good.............................. 3
Fair ................................ 4
Poor ............................... 5
DON’T KNOW ............... 8
REFUSED ..................... 9
The following questions are about activities you might do during a typical day. In the past month (4
weeks), has your health limited you in ...
A2. Moderate activities such as moving a table, pushing a vacuum cleaner, or carrying groceries. Would
you say…
Yes, limited a lot ............ 1
Yes, limited a little ......... 2
No, not limited at all....... 3
DON’T KNOW ............... 8
REFUSED ..................... 9
A3. Climbing several flights of stairs. Would you say…
Yes, limited a lot ............ 1
Yes, limited a little ......... 2
No, not limited at all....... 3
DON’T KNOW ............... 8
REFUSED ..................... 9
For the next 4 questions, the answer choices are All of the time, Most of the time, some of the time, A little
of the time, and none of the time.
A4. During the past 4 weeks, how much of the time have you accomplished less than you would like as a
result of your physical health…
All of the time ................ 1
Most of the time............. 2
Some of the time ........... 3
A little of the time........... 4
None of the time ............ 5
DON’T KNOW ............... 8
REFUSED ..................... 9

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A5. During the past 4 weeks, how much of the time have you been limited in the kind of work or other
activities you could do as a result of your physical health…
All of the time ................ 1
Most of the time............. 2
Some of the time ........... 3
A little of the time........... 4
None of the time ............ 5
DON’T KNOW ............... 8
REFUSED ..................... 9
A6. During the past 4 weeks, how much of the time have you accomplished less than you would like as
a result of any emotional problems (such as feeling depressed or anxious)…
All of the time ................ 1
Most of the time............. 2
Some of the time ........... 3
A little of the time........... 4
None of the time ............ 5
DON’T KNOW ............... 8
REFUSED ..................... 9
A7. During the past 4 weeks, how much of the time did you do work or other activities less carefully
than usual as a result of any emotional problems (such as feeling depressed or anxious)…
All of the time ................ 1
Most of the time............. 2
Some of the time ........... 3
A little of the time........... 4
None of the time ............ 5
DON’T KNOW ............... 8
REFUSED ..................... 9
A8. During the past 4 weeks how much did pain interfere with your normal work, including work outside
the home and housework…
Not at all ........................ 1
A little bit ........................ 2
Moderately .................... 3
Quite a bit ...................... 4
Extremely ...................... 5
DON’T KNOW ............... 8
REFUSED ..................... 9
How much of the time during the past 4 weeks…
A9. Have you felt calm and peaceful…
All of the time ................ 1
Most of the time............. 2
Some of the time ........... 3
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A little of the time........... 4
None of the time ............ 5
DON’T KNOW ............... 8
REFUSED ..................... 9
A10. Did you have a lot of energy…
All of the time ................ 1
Most of the time............. 2
Some of the time ........... 3
A little of the time........... 4
None of the time ............ 5
DON’T KNOW ............... 8
REFUSED ..................... 9
A11. Have you felt downhearted and depressed…
All of the time ................ 1
Most of the time............. 2
Some of the time ........... 3
A little of the time........... 4
None of the time ............ 5
DON’T KNOW ............... 8
REFUSED ..................... 9
A12. During the past 4 weeks, how much of the time has your physical health or emotional problems
interfered with your social activities, like visiting friends or relatives…
All of the time ................ 1
Most of the time............. 2
Some of the time ........... 3
A little of the time........... 4
None of the time ............ 5
DON’T KNOW ............... 8
REFUSED ..................... 9

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Section B: Resiliency
(Source: Abbreviated 10-item Connor-Davidson Scale)
For each item, please indicate how much you agree with the following statements as they apply to you
over the last month. If a particular situation has not occurred recently, answer according to how you
think you would have felt
B1. I am able to adapt when changes occur.
Not true at all ........................................... 1
Rarely true ............................................... 2
Sometimes true ....................................... 3
Often true ................................................ 4
True nearly all of the time........................ 5
DON’T KNOW ......................................... 8
REFUSED ............................................... 9
B2. I can deal with whatever comes my way.
Not true at all ........................................... 1
Rarely true ............................................... 2
Sometimes true ....................................... 3
Often true ................................................ 4
True nearly all of the time........................ 5
DON’T KNOW ......................................... 8
REFUSED ............................................... 9
B3. I try to see the humorous side of things when I am faced with problems.
Not true at all ........................................... 1
Rarely true ............................................... 2
Sometimes true ....................................... 3
Often true ................................................ 4
True nearly all of the time........................ 5
DON’T KNOW ......................................... 8
REFUSED ............................................... 9
B4. Having to cope with stress can make me stronger.
Not true at all ........................................... 1
Rarely true ............................................... 2
Sometimes true ....................................... 3
Often true ................................................ 4
True nearly all of the time........................ 5
DON’T KNOW ......................................... 8
REFUSED ............................................... 9
B5. I tend to bounce back after illness, injury, or other hardships.
Not true at all ........................................... 1
Rarely true ............................................... 2
Sometimes true ....................................... 3
Often true ................................................ 4
True nearly all of the time........................ 5
DON’T KNOW ......................................... 8
REFUSED ............................................... 9
B6. I believe I can achieve my goals, even if there are obstacles.
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Not true at all ........................................... 1
Rarely true ............................................... 2
Sometimes true ....................................... 3
Often true ................................................ 4
True nearly all of the time........................ 5
DON’T KNOW ......................................... 8
REFUSED ............................................... 9
B7. Under pressure, I stay focused and think clearly.
Not true at all ........................................... 1
Rarely true ............................................... 2
Sometimes true ....................................... 3
Often true ................................................ 4
True nearly all of the time........................ 5
DON’T KNOW ......................................... 8
REFUSED ............................................... 9
B8. I am not easily discouraged by failure.
Not true at all ........................................... 1
Rarely true ............................................... 2
Sometimes true ....................................... 3
Often true ................................................ 4
True nearly all of the time........................ 5
DON’T KNOW ......................................... 8
REFUSED ............................................... 9
B9. I think of myself as a strong person when dealing with life's challenges and difficulties.
Not true at all ........................................... 1
Rarely true ............................................... 2
Sometimes true ....................................... 3
Often true ................................................ 4
True nearly all of the time........................ 5
DON’T KNOW ......................................... 8
REFUSED ............................................... 9
B10. I am able to handle unpleasant or painful feelings like sadness, fear and anger.
Not true at all ........................................... 1
Rarely true ............................................... 2
Sometimes true ....................................... 3
Often true ................................................ 4
True nearly all of the time........................ 5
DON’T KNOW ......................................... 8
REFUSED ............................................... 9

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Section C: Faith/Religiosity
(Source: Multiple Sources)
The next sets of questions are about religion or spirituality.
C1. How important to you is religion or spirituality? Is it...
Very important ............... 1
Somewhat important ..... 2
Slightly important ........... 3
Not at all important ........ 4
DON’T KNOW ............... 8
REFUSED ..................... 9
C2. How often, if at all, do you attend church, synagogue, a mosque, or other religious or spiritual
services?
Never ............................. 1
Less than once a year ... 2
A few times a year......... 3
About once a month ...... 4
Once a week ................. 5
Everyday ....................... 6
DON’T KNOW ............... 8
REFUSED ..................... 9
C3. What is your present religion, if any?
Protestant (Baptist, Methodist, Non-denominational, Lutheran, Presbyterian, Pentecostal,
Episcopalian Reformed, Church of Christ, Jehovah’s Witness, etc.)
1
Roman Catholic (Catholic)
2
Mormon (LDS/Church of Jesus Christ of Latter-day Saints)
3
Orthodox (Greek, Russian, or some other orthodox church)
4
Jewish (Judaism) ....................................
5
Muslim (Islam) .........................................
6
Buddhist ..................................................
7
Hindu .......................................................
8
Atheist (do not believe in God) ................
9
Agnostic (not sure if there is a God) .......
10
Something else .......................................
11 [GO TO C3a]
Nothing in particular ................................
12
(DO NOT READ) Christian......................
13
(DO NOT READ) Unitarian (Universalist)
14
DON'T KNOW ........................................
88
REFUSED ...............................................
99
C3a. Specify: __________________________
C4. How often, if at all, do you pray or meditate?
Never ............................. 1
Less than once a year ... 2
A few times a year......... 3
About once a month ...... 4
Once a week ................. 5
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Everyday ....................... 6
DON’T KNOW ............... 8
REFUSED ..................... 9

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Section D: Current Housing
(Source: Multiple Sources)

The next questions are about your current housing.
D1. Would you describe your current residence as…?
Single family home .................................. 1 [GO TO D2]
Trailer or mobile home ............................ 2 [GO TO D1b]
Apartment, condominium ........................ 3 [GO TO D2]
Hotel or motel .......................................... 4 [GO TO D2]
Other ....................................................... 5 [GO TO D1a]
DON’T KNOW ......................................... 8 [GO TO D2]
REFUSED ............................................... 9 [GO TO D2]
D1a. Specify other: ___________________________ [GO TO D2]
D1b. Who owns the property on which the trailer is located?
Respondent (or other household member) ................... 1
Other family member ..................................................... 2
Friend ............................................................................. 3
Other .............................................................................. 4
DON’T KNOW................................................................ 8
REFUSED...................................................................... 9
D2. When did you move to this residence?
[MONTH]/ [YEAR]
DON’T KNOW .................... 8
REFUSED .......................... 9
D3. Do you think you might have to move within the next 3 months?
Yes ..................................... 1 [GO TO D3b1]
No ....................................... 2
DON’T KNOW .................... 8
REFUSED .......................... 9
D3a. Do you think you might have to move within the next year?
Yes ................................... 1
No ..................................... 2 [GO TO D4]
DON’T KNOW .................. 8 [GO TO D4]
REFUSED ........................ 9 [GO TO D4]
D3b1. Why do you think you might have to move?
[TEXT] _________________________________
DON’T KNOW .......... 8
REFUSED ................ 9
D4. Do you currently own this or any other house, mobile home, or condo?
Yes ..................................... 1
No ....................................... 2
DON’T KNOW .................... 8
REFUSED .......................... 9
D4a. Is that where you are currently living?
Yes .............................. 1
No ................................ 2
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DON’T KNOW ............. 8
REFUSED ................... 9
For the next couple of questions, we will be asking about stable and permanent housing.
D5. Since 2010, have you lived, at any time, in a place that you consider permanent and stable?
Yes ..................................... 1
No ....................................... 2 [GO TO D6]
DON’T KNOW .................... 8 [GO TO D6]
REFUSED .......................... 9 [GO TO D6]
D5a. When did you move to this permanent and stable housing?
[MONTH]/[YEAR]
DON’T KNOW ......................................................8
REFUSED ............................................................9
D5b. Is that where you live now?
Yes .............................. 1
No ................................ 2
DON’T KNOW ............. 8
REFUSED ................... 9

D6. Since the last time we spoke to you in [DATE FILL], how many times have you moved?
[NUMBER OF TIMES]
DON’T KNOW .................... 8
REFUSED .......................... 9

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Section E: Traumatic Events Scale
(Source: BTQ)
Now I would like to ask you some questions about traumatic events you may have experienced in your
lifetime. Please tell me if you have experienced them and how many times they have occurred.
E1. Have you ever served in a war-zone or in a noncombat job that exposed you to war-related
casualties, such as working as a medic or on graves registration duty?
NEVER ......................... 1 [GO TO E2]
ONCE ............................ 2
TWICE ........................... 3
3 TIMES ........................ 4
4 TIMES ........................ 5
5 TIMES ........................ 6
MORE THAN 5 TIMES.. 7
DON’T KNOW .............. 8 [GO TO E2]
REFUSED .................... 9 [GO TO E2]
E1a. How old were you when this first happened?
I__II__I AGE
DON’T KNOW ....... 8
REFUSED ............. 9
E2. Have you ever been in a serious car accident, or serious accident at work or somewhere else?
NEVER .......................... 1 [GO TO E3]
ONCE ............................ 2
TWICE ........................... 3
3 TIMES ........................ 4
4 TIMES ........................ 5
5 TIMES ........................ 6
MORE THAN 5 TIMES.. 7
DON’T KNOW ............... 8 [GO TO E3]
REFUSED ..................... 9 [GO TO E3]
E2a. How old were you when this first happened?
I__II__I AGE
DON’T KNOW ....... 8
REFUSED ............. 9
E3. Have you ever been in a major natural disaster, such as a fire, tornado, hurricane, flood, or
earthquake?
NEVER .......................... 1 [GO TO E4]
ONCE ............................ 2
TWICE ........................... 3
3 TIMES ........................ 4
4 TIMES ........................ 5
5 TIMES ........................ 6
MORE THAN 5 TIMES.. 7
DON’T KNOW ............... 8 [GO TO E4]
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REFUSED ..................... 9 [GO TO E4]
E3a. How old were you when this first happened?
I__II__I AGE
DON’T KNOW ....... 8
REFUSED ............. 9
E4. Have you ever had a life-threatening illness, such as cancer, a heart attack, leukemia, AIDS, multiple
sclerosis, and so forth?
NEVER .......................... 1 [GO TO E5]
ONCE ............................ 2
TWICE ........................... 3
3 TIMES ........................ 4
4 TIMES ........................ 5
5 TIMES ........................ 6
MORE THAN 5 TIMES.. 7
DON’T KNOW ............... 8 [GO TO E5]
REFUSED ..................... 9 [GO TO E5]
E4a. How old were you when this first happened?
I__II__I AGE
DON’T KNOW ....... 8
REFUSED ............. 9
E5. Have you ever been attacked, beaten up, or mugged by anyone, including friends, family members,
or strangers?
NEVER ................................ 1[GO TO E6]
ONCE .................................. 2
TWICE ................................. 3
3 TIMES .............................. 4
4 TIMES .............................. 5
5 TIMES .............................. 6
MORE THAN 5 TIMES........ 7
DON’T KNOW ..................... 8 [GO TO E6]
REFUSED ........................... 9 [GO TO E6]
E5a. How old were you when this first happened?
I__II__I AGE
DON’T KNOW ....... 8
REFUSED ............. 9
E6. As a child, were you ever physically punished or beaten by a parent, caretaker, or teacher so that you
were very frightened; or you thought you would be injured; or you received bruises, cuts, welts,
lumps, or other injuries?
NEVER ................................ 1[GO TO E7]
ONCE .................................. 2
TWICE ................................. 3
3 TIMES .............................. 4
4 TIMES .............................. 5
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5 TIMES .............................. 6
MORE THAN 5 TIMES........ 7
DON’T KNOW ..................... 8 [GO TO E7]
REFUSED ........................... 9 [GO TO E7]
E6a. How old were you when this first happened?
I__II__I AGE
DON’T KNOW ..... 8
REFUSED ........... 9
E7. Have you ever been in a situation in which someone made or pressured you into having some type of
unwanted sexual contact?
NEVER .......................... 1 [GO TO E8]
ONCE ............................ 2
TWICE ........................... 3
3 TIMES ........................ 4
4 TIMES ........................ 5
5 TIMES ........................ 6
MORE THAN 5 TIMES.. 7
DON’T KNOW ............... 8 [GO TO E8]
REFUSED ..................... 9 [GO TO E8]
E7a. How old were you when this first happened?
I__II__I AGE
DON’T KNOW ..... 8
REFUSED ........... 9
E8.Have you ever been in any other situation in which you were seriously injured or in which you feared
you might be seriously injured or killed?
YES ............................... 1
NO ................................. 2 [GO TO E9]
DON’T KNOW ............... 8 [GO TO E9]
REFUSED ..................... 9 [GO TO E9]
E8a. How old were you when this first happened?
I__II__I AGE
DON’T KNOW ..... 8
REFUSED ........... 9
E9. Have you ever witnessed a situation in which someone with whom you were very close was seriously
injured or killed, or in which you feared someone would be seriously injured or killed?
NEVER .......................... 1 [GO TO E10]
ONCE ............................ 2
TWICE ........................... 3
3 TIMES ........................ 4
4 TIMES ........................ 5
5 TIMES ........................ 6
MORE THAN 5 TIMES.. 7
DON’T KNOW ............... 8 [GO TO E10]
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REFUSED ..................... 9 [GO TO E10]
E9a. How old were you when this first happened?
I__II__I AGE
DON’T KNOW ..... 8
REFUSED ........... 9
E10. Have you ever witnessed a situation in which someone with whom you were not so close was
seriously injured or killed or in which you feared someone would be seriously injured or killed?
NEVER .......................... 1 [GO TO E11]
ONCE ............................ 2
TWICE ........................... 3
3 TIMES ........................ 4
4 TIMES ........................ 5
5 TIMES ........................ 6
MORE THAN 5 TIMES.. 7
DON’T KNOW ............... 8 [GO TO E11]
REFUSED ..................... 9 [GO TO E11]
E10a. How old were you when this first happened?
I__II__I AGE
DON’T KNOW ............... 8
REFUSED ..................... 9
E11. Have any close family members or friends died violently, for example, in a serious car crash,
mugging, or attack?
NEVER .......................... 1 [GO TO E12]
ONCE ............................ 2
TWICE ........................... 3
3 TIMES ........................ 4
4 TIMES ........................ 5
5 TIMES ........................ 6
MORE THAN 5 TIMES.. 7
DON’T KNOW ............... 8 [GO TO E12]
REFUSED ..................... 9 [GO TO E12]
E11a. How old were you when this first happened?
I__II__I AGE
DON’T KNOW......... 8
REFUSED............... 9
E12. Have you experienced the death of any of your children?
NEVER .......................... 1 [GO TO E13]
ONCE ............................ 2
TWICE ........................... 3
3 TIMES ........................ 4
4 TIMES ........................ 5
5 TIMES ........................ 6
MORE THAN 5 TIMES.. 7
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DON’T KNOW ............... 8 [GO TO E13]
REFUSED ..................... 9 [GO TO E13]
E13. Have you experienced a seriously traumatic event not already covered in any of these questions?
YES ............................... 1
NO ................................ 2 [GO TO NEXT SECTION]
DON’T KNOW .............. 8 [GO TO NEXT SECTION]
REFUSED .................... 9 [GO TO NEXT SECTION]
E13a. Please describe your experience.
[FREE TEXT FIELD]
DON’T KNOW .... 8
REFUSED .......... 9

E13b. How old were you when this happened?
I__II__I AGE
DON’T KNOW .... 8
REFUSED .......... 9

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Section F: Finances
(Source: Financial Events Scale)
Now I would like to ask you some questions regarding your finances.
During the past 12 months have you…
F1. Been evicted due to not paying rent?
YES ............................... 1
NO ................................ 2
DON’T KNOW............... 8
REFUSED..................... 9
F2. Received assistance from non-government organizations such as church or community groups?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9
F3. Applied for federal government disability benefits?
YES...................................................................... 1
NO ....................................................................... 2 [GO TO F4]
DON’T KNOW ..................................................... 8 [GO TO F4]
REFUSED ........................................................... 9 [GO TO F4]
F3a. Did you receive these disability benefits?
Yes ............................................. 1
No............................................... 2
Awaiting decision on application 3
DON’T KNOW ............................ 8
REFUSED ................................. 9
F4. Borrowed money from friends or family to help pay bills?
YES...................................................................... 1
NO, YOU ASKED BUT WERE TURNED DOWN
NO, YOU DIDN’T ASK ........................................ 3
NO (NO DETAIL PROVIDED) ............................ 4
DON’T KNOW ..................................................... 8
REFUSED ........................................................... 9

2

F5. Sold possessions or property to raise money?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9
During the past 12 months has your…
F6. Spouse or partner began to work outside of the home?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9
F7. Spouse or partner stopped working outside of the home?
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YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9
During the past 12 months have you…

F8. Cashed in life insurance?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9
F9. Changed residence to save money, for example, moving somewhere with lower rent, sleeping on a
couch with friends or family, living on a boat, etcetera?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9
F10. Took in a housemate to increase income?
YES……………………. 1
NO……………………… 2
DON’T KNOW………… 8
REFUSED………………9
F11. Reduced medical insurance?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9
F12. Eliminated medical insurance?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9
During the past 12 months have you…
F13. Changed food shopping habits to save money?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9
F14. Changed eating habits to save money?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9
F15. Postponed paying property tax?
YES............................... 1
NO ................................ 2
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DON’T KNOW .............. 8
REFUSED..................... 9
F16. Postponed paying rent?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9
F17. Received shut-off warning(s) regarding utilities such as electricity, gas, water, phone, o r cable
due to late payment?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9
During the past 12 months,
F18. Were your utilities actually shut-off due to late payment or non-payment?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9
During the past 12 months have you…
F19. Cut back on social activities and entertainment expenses?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9
F20. Postponed major household purchases?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9
F21. Postponed clothing purchases?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9
F22. Changed transportation patterns to save money?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9
F23. Cut back on charitable donations and/or tithing?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9

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F24. Reduced household utility use?
YES............................... 1
NO ................................ 2
DON’T KNOW .............. 8
REFUSED..................... 9

During the past 12 months…
F25. Have you taken on additional employment to help meet expenses?
Yes ........................................................................................................................... 1
No, you sought additional employment, but didn’t find any ..................................... 2
No, you didn’t try to find any .................................................................................... 3
DON’T KNOW.......................................................................................................... 8
REFUSED................................................................................................................ 9

F26. Has your s pous e taken on additional employment to help meet expenses?
YES .......................................................................................................................... 1
NO, HE/SHE SOUGHT ADDITIONAL EMPLOYMENT, BUT DIDN’T FIND ANY .. 2
NO, HE/SHE DIDN’T TRY TO FIND ANY ............................................................... 3
N/A ........................................................................................................................... 4
DON’T KNOW.......................................................................................................... 8
REFUSED................................................................................................................ 9
F27. Has your c hil d taken on additional employment to help meet expenses?
YES .......................................................................................................................... 1
NO, HE/SHE SOUGHT ADDITIONAL EMPLOYMENT, BUT DIDN’T FIND ANY .. 2
NO, HE/SHE DIDN’T TRY TO FIND ANY ............................................................... 3
N/A ........................................................................................................................... 4
DON’T KNOW.......................................................................................................... 8
REFUSED................................................................................................................ 9

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Section G: Mental Health Service Utilization
(Source: Multiple Sources)
G1. In the past 6 months, have you wanted to speak with anyone about any emotional or psychological
issues?
YES ............................................ 1
NO .............................................. 2 [GO TO SECTION H]
DON’T KNOW ........................... 8 [GO TO SECTION H]
REFUSED .................................. 9 [GO TO SECTION H]
G1a. Did you talk with any professional or provider about any of these issues?
YES ............................ 1 [GO TO G1c]
NO.............................. 2
DON’T KNOW ........... 8 [GO TO SECTION H]
REFUSED ................. 9 [GO TO SECTION H]
G1b. Why not? [CHECK ALL THAT APPLY]
Don’t know where to go ...................... 1 [GO TO SECTION H]
No insurance ........................................ 2 [GO TO SECTION H]
Insurance doesn’t cover it ................... 3 [GO TO SECTION H]
No transportation ................................. 4 [GO TO SECTION H]
No child care ....................................... 5 [GO TO SECTION H]
Other .................................................... 6
DON’T KNOW ..................................... 8 [GO TO SECTION H]
REFUSED ........................................... 9 [GO TO SECTION H]
G1b1. Specify other: _______________________________
[GO TO SECTION H]
G1c. What type or types of provider were they? [CHECK ALL THAT APPLY]
Psychologist...................................................................... 1
Psychiatrist ....................................................................... 2
Case manager, case worker, or outreach worker ............. 3
Social worker .................................................................... 4
Nurse ................................................................................ 5
Physician .......................................................................... 6
Clergy................................................................................ 7
School counselor or guidance counselor......................... 8
Other ................................................................................. 9
DON’T KNOW .................................................................. 88 [GO TO SECTION H]
REFUSED ........................................................................ 99 [GO TO SECTION H]
G1c1. Specify other: __________________________
[IF G1c = NONE OF 1,2,4,5,6, GO TO SECTION H (I.E., IF NO HEALTH PROFESSIONALS/SOCIAL
WORKERS REPORTED IN G1c, THEN GO TO SECTION H)]
[IF G1c = ONLY ONE OF 1,2,4,5,6, GO TO G3 (I.E., IF ONLY ONE HEALTH PROFESSIONAL/SOCIAL
WORKER REPORTED IN G1c, THEN GO TO G3)]
G2. Let's talk about the mental health care professional you most recently visited. What type of provider
were they?
Psychologist ....................................................................................... 1
Psychiatrist ......................................................................................... 2
Social worker ...................................................................................... 4
Nurse .................................................................................................. 5
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Physician ............................................................................................ 6
Other ................................................................................................... 9
DON’T KNOW .................................................................................... 88 [GO TO SECTION H]
REFUSED .......................................................................................... 99 [GO TO SECTION H]
G2a. Specify other: __________________________
[IF G2=9, GO TO SECTION H]
G3. Thinking back to the first time you went to this [INSERT ANSWER FROM G2, IF ASKED, ELSE G1c;
RESTRICT TO CHOICES 1,2,4,5, or 6 (I.E., DO NOT INCLUDE OPTIONS 3,7,8, OR 9)], did you go
on your own, did someone refer you, were you just taken there, or were you there for something
else?
ON YOUR OWN ................................................................... 1 [GO TO G3b]
WERE REFERRED .............................................................. 2
WERE JUST TAKEN THERE .............................................. 3 [GO TO G3b]
WERE THERE FOR SOMETHING ELSE ............................ 4 [GO TO G3b]
DON’T KNOW ...................................................................... 8 [GO TO G3b]
REFUSED ............................................................................ 9 [GO TO G3b]
G3a. Who referred you to this [INSERT ANSWER FROM G2, IF ASKED, ELSE G1c; RESTRICT
TO CHOICES 1,2,4,5, or 6 (I.E., DO NOT INCLUDE OPTIONS 3,7,8, OR 9)]?
A friend, relative, or acquaintance ....................... 1
Another medical provider ..................................... 2
A case manager ................................................... 3
Someone else ...................................................... 4
DON’T KNOW ..................................................... 8
REFUSED ............................................................ 9
G3b. Overall, how satisfied are you with the care that you get from this [INSERT ANSWER
FROM G2, IF ASKED, ELSE G1c; RESTRICT TO CHOICES 1,2,4,5, or 6 (I.E., DO NOT
INCLUDE OPTIONS 3,7,8, OR 9)] in terms of psychological counseling or support?
Very satisfied ........................................................ 1 [GO TO G4]
Somewhat satisfied .............................................. 2 [GO TO G4]
Somewhat dissatisfied ......................................... 3
Very dissatisfied ................................................... 4
DON’T KNOW ...................................................... 8 [GO TO G4]
REFUSED ............................................................ 9 [GO TO G4]
G3b1. Could you briefly explain why you are dissatisfied?
[TEXT]
DON’T KNOW………… 8
REFUSED……………… 9
G4. Is there anything else you feel is important to tell me about your mental health care provider?
[TEXT]
DON’T KNOW ........................... 8
REFUSED .................................. 9

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Section H: Barriers to Access to Care
(Source: Multiple Sources)
Sometimes people have difficulties in getting services they need.
At any time in the last 6 months, did you ever delay or not get the assistance you thought you needed…
H1. Because the staff at the office or clinic do not speak your language?
YES ............................................ 1
NO .............................................. 2 [GO TO H2]
DON’T KNOW ........................... 8 [GO TO H2]
REFUSED .................................. 9 [GO TO H2]
H1a. Did this happen when you needed medical services, social services, or both?
MEDICAL ...................... 1
SOCIAL ......................... 2
BOTH ............................ 3
DON’T KNOW .............. 8
REFUSED..................... 9
H2. Because it cost too much or it wasn't covered by insurance?
YES ............................................ 1
NO .............................................. 2 [GO TO H3]
DON’T KNOW ........................... 8 [GO TO H3]
REFUSED .................................. 9 [GO TO H3]
H2a. Did this happen when you needed medical services, social services, or both?
MEDICAL ...................... 1
SOCIAL ......................... 2
BOTH ............................ 3
DON’T KNOW .............. 8
REFUSED..................... 9
H3. Because you felt the staff at the office or clinic was not competent to deal with your problem?
YES ............................................ 1
NO .............................................. 2 [GO TO H4]
DON’T KNOW ........................... 8 [GO TO H4]
REFUSED .................................. 9 [GO TO H4]
H3a. Did this happen when you needed medical services, social services, or both?
MEDICAL ...................... 1
SOCIAL ......................... 2
BOTH ............................ 3
DON’T KNOW .............. 8
REFUSED..................... 9
H4. Because you didn't know or weren't sure where to go?
YES ............................................ 1
NO .............................................. 2 [GO TO H5]
DON’T KNOW ........................... 8 [GO TO H5]
REFUSED .................................. 9 [GO TO H5]
H4a. Did this happen when you needed medical services, social services, or both?
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MEDICAL ...................... 1
SOCIAL ......................... 2
BOTH ............................ 3
DON’T KNOW .............. 8
REFUSED..................... 9
H5. Because it was difficult to get transportation there?
YES ............................................ 1
NO .............................................. 2 [GO TO H6]
DON’T KNOW ........................... 8 [GO TO H6]
REFUSED .................................. 9 [GO TO H6]
H5a. Did this happen when you needed medical services, social services, or both?
MEDICAL ...................... 1
SOCIAL ......................... 2
BOTH ............................ 3
DON’T KNOW .............. 8
REFUSED..................... 9
H6. Because the staff at the office or clinic are often not polite, are disrespectful, or are insensitive to
your needs?
YES ............................................ 1
NO .............................................. 2 [GO TO H7]
DON’T KNOW ........................... 8 [GO TO H7]
REFUSED .................................. 9 [GO TO H7]
H6a. Did this happen when you needed medical services, social services, or both?
MEDICAL ...................... 1
SOCIAL ......................... 2
BOTH ............................ 3
DON’T KNOW .............. 8
REFUSED..................... 9
H7. Because you weren't sure that the staff at the office or clinic would understand your problems?
YES ............................................ 1
NO .............................................. 2 [GO TO H8]
DON’T KNOW ........................... 8 [GO TO H8]
REFUSED .................................. 9 [GO TO H8]
H7a. Did this happen when you needed medical services, social services, or both?
MEDICAL ...................... 1
SOCIAL ......................... 2
BOTH ............................ 3
DON’T KNOW .............. 8
REFUSED..................... 9
H8. Because you felt that the staff is not good at listening to your problems or needs?
YES ............................................ 1
NO .............................................. 2 [GO TO H9]
DON’T KNOW ........................... 8 [GO TO H9]
REFUSED .................................. 9 [GO TO H9]
H8a. Did this happen when you needed medical services, social services, or both?
MEDICAL ...................... 1
SOCIAL ......................... 2
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BOTH ............................ 3
DON’T KNOW .............. 8
REFUSED..................... 9
H9. Because you needed someone to take care of your children?
YES ............................................ 1
NO .............................................. 2 [GO TO H10]
DON’T KNOW ........................... 8 [GO TO H10]
REFUSED .................................. 9 [GO TO H10]
H9a. Did this happen when you needed medical services, social services, or both?
MEDICAL ...................... 1
SOCIAL ......................... 2
BOTH ............................ 3
DON’T KNOW .............. 8
REFUSED..................... 9
H10. Because you were nervous or afraid of what the doctor/service provider might say?
YES ............................................ 1
NO .............................................. 2 [GO TO NEXT SECTION]
DON’T KNOW ........................... 8 [GO TO NEXT SECTION]
REFUSED .................................. 9 [GO TO NEXT SECTION]

H10a. Did this happen when you needed medical services, social services, or both?
MEDICAL ...................... 1
SOCIAL ......................... 2
BOTH ............................ 3
DON’T KNOW .............. 8
REFUSED..................... 9

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Section I. Social Support Scale
(Source: NHANES Social Support Questionnaire 2005-2006)
Now I would like to ask a few questions about your friends and family.
I1. Can you count on anyone to provide you with emotional support such as talking over problems or
helping you make a difficult decision?
YES ............................................ 1
NO .............................................. 2
I DON’T NEED HELP ................ 3
DON’T KNOW ........................... 8
REFUSED .................................. 9
I2. In the last 12 months, who has been helpful in providing you with emotional support?
[CHECK ALL THAT APPLY]
SPOUSE .......................................... 01
DAUGHTER ..................................... 02
SON.................................................. 03
SISTER/BROTHER.......................... 04
PARENT ........................................... 05
OTHER RELATIVE .......................... 06
NEIGHBORS .................................... 07
CO-WORKERS ................................ 08
CHURCH MEMBERS ...................... 09
CLUB MEMBERS ............................ 10
PROFESSIONALS ........................... 11
FRIENDS ......................................... 12
OTHER ............................................. 13
NO ONE ........................................... 14
DON'T KNOW .................................. 88
REFUSED ........................................ 99
I3. In the last 12 months, could you have used more emotional support than you received?
YES ............................................ 1
NO .............................................. 2 [GO TO I4]
DON’T KNOW ............................ 8 [GO TO I4]
REFUSED .................................. 9 [GO TO I4]
I3a. Concerning emotional support, would you say that you could have used…?
A lot more ......................... 1
Some more ....................... 2
A little more ...................... 3
DON’T KNOW .................. 8
REFUSED ........................ 9
I4. How often do you attend church or religious services?
I__II__II__I NUMBER OF TIMES
PER DAY ................................... 1
PER WEEK ................................ 2
PER MONTH ............................. 3
PER YEAR................................. 4
DON’T KNOW ........................... 8
REFUSED .................................. 9
I5. Is there someone you could count on to help you if you were sick, for example, to take you to the
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doctor or help you with daily chores?
YES ......................................................... 1
NO ........................................................... 2
YES, BUT I WOULDN’T ACCEPT IT..... 3
DON’T KNOW ........................................ 8
REFUSED ............................................... 9
I6. If you need some extra help financially, could you count on anyone to help you, for example, by
paying any bills, housing costs, medical expenses, or providing you with food or clothes?
YES ......................................................... 1
NO ........................................................... 2
YES, BUT I WOULDN’T ACCEPT IT..... 3
DON’T KNOW ........................................ 8
REFUSED ............................................... 9
I7. In general how many close friends do you have?
[INTERVIEWER PROBE: By “close friends” I mean relatives or non-relatives that you feel at ease
with, can talk to about private matters, and can call on for help]
I__II__I NUMBER OF CLOSE FRIENDS
DON’T KNOW ........................... 8
REFUSED .................................. 9

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Section J: Depression
(Source: CES-D and CES-D interviewer administered version 1997)
Below is a list of the ways you might have felt or behaved. Please tell me how often you have felt this way
during the past week.
J1. You were bothered by things that do not usually bother you. On how many days during the past week
did you feel this way?
Rarely or Not at all (< less than1 day) ........................................... 1
Some or a little of the time (1-2 days) ............................................ 2
Occasionally or a moderate amount (3-4 days) ............................. 3
Most or all of the time (5-7days) .................................................... 4
DON’T KNOW ................................................................................ 8
REFUSED ...................................................................................... 9
J2. You did not feel like eating, or your appetite was poor.
Rarely or Not at all (< less than1 day) ........................................... 1
Some or a little of the time (1-2 days) ............................................ 2
Occasionally or a moderate amount (3-4 days) ............................. 3
Most or all of the time (5-7days) .................................................... 4
DON’T KNOW ................................................................................ 8
REFUSED ...................................................................................... 9
J3. You felt that you could not shake off the blues, even with help from family or friends.
Rarely or Not at all (< less than1 day) ........................................... 1
Some or a little of the time (1-2 days) ............................................ 2
Occasionally or a moderate amount (3-4 days) ............................. 3
Most or all of the time (5-7days) .................................................... 4
DON’T KNOW ................................................................................ 8
REFUSED ...................................................................................... 9
J4. You felt that you were just as good as other people.
Rarely or Not at all (< less than1 day) ........................................... 1
Some or a little of the time (1-2 days) ............................................ 2
Occasionally or a moderate amount (3-4 days) ............................. 3
Most or all of the time (5-7days) .................................................... 4
DON’T KNOW ................................................................................ 8
REFUSED ...................................................................................... 9
J5. You had trouble keeping your mind on what you were doing.
Rarely or Not at all (< less than1 day) ........................................... 1
Some or a little of the time (1-2 days) ............................................ 2
Occasionally or a moderate amount (3-4 days) ............................. 3
Most or all of the time (5-7days) .................................................... 4
DON’T KNOW ................................................................................ 8
REFUSED ...................................................................................... 9
J6. You felt depressed.
Rarely or Not at all (< less than1 day) ........................................... 1
Some or a little of the time (1-2 days) ............................................ 2
Occasionally or a moderate amount (3-4 days) ............................. 3
Most or all of the time (5-7days) .................................................... 4
DON’T KNOW ................................................................................ 8
REFUSED ...................................................................................... 9
J7. You felt hopeful about the future.
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Rarely or Not at all (< less than1 day) ........................................... 1
Some or a little of the time (1-2 days) ............................................ 2
Occasionally or a moderate amount (3-4 days) ............................. 3
Most or all of the time (5-7days) .................................................... 4
DON’T KNOW ................................................................................ 8
REFUSED ...................................................................................... 9
J8. You felt your life had been a failure.
Rarely or Not at all (< less than1 day) ........................................... 1
Some or a little of the time (1-2 days) ............................................ 2
Occasionally or a moderate amount (3-4 days) ............................. 3
Most or all of the time (5-7days) .................................................... 4
DON’T KNOW ................................................................................ 8
REFUSED ...................................................................................... 9
J9. You felt fearful.
Rarely or Not at all (< less than1 day) ........................................... 1
Some or a little of the time (1-2 days) ............................................ 2
Occasionally or a moderate amount (3-4 days) ............................. 3
Most or all of the time (5-7days) .................................................... 4
DON’T KNOW ................................................................................ 8
REFUSED ...................................................................................... 9
J10. Your sleep was restless.
Rarely or Not at all (< less than1 day) ........................................... 1
Some or a little of the time (1-2 days) ............................................ 2
Occasionally or a moderate amount (3-4 days) ............................. 3
Most or all of the time (5-7days) .................................................... 4
DON’T KNOW ................................................................................ 8
REFUSED ...................................................................................... 9
J11. You were happy.
Rarely or Not at all (< less than1 day) ........................................... 1
Some or a little of the time (1-2 days) ............................................ 2
Occasionally or a moderate amount (3-4 days) ............................. 3
Most or all of the time (5-7days) .................................................... 4
DON’T KNOW ................................................................................ 8
REFUSED ...................................................................................... 9
J12. You talked less than usual.
Rarely or Not at all (< less than1 day) ........................................... 1
Some or a little of the time (1-2 days) ............................................ 2
Occasionally or a moderate amount (3-4 days) ............................. 3
Most or all of the time (5-7days) .................................................... 4
DON’T KNOW ................................................................................ 8
REFUSED ...................................................................................... 9
J13. You felt lonely.
Rarely or Not at all (< less than1 day) ........................................... 1
Some or a little of the time (1-2 days) ............................................ 2
Occasionally or a moderate amount (3-4 days) ............................. 3
Most or all of the time (5-7days) .................................................... 4
DON’T KNOW ................................................................................ 8
REFUSED ...................................................................................... 9
J14. People were unfriendly.
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Rarely or Not at all (< less than1 day) ........................................... 1
Some or a little of the time (1-2 days) ............................................ 2
Occasionally or a moderate amount (3-4 days) ............................. 3
Most or all of the time (5-7days) .................................................... 4
DON’T KNOW ................................................................................ 8
REFUSED ...................................................................................... 9
J15. You enjoyed life.
Rarely or Not at all (< less than1 day) ........................................... 1
Some or a little of the time (1-2 days) ............................................ 2
Occasionally or a moderate amount (3-4 days) ............................. 3
Most or all of the time (5-7days) .................................................... 4
DON’T KNOW ................................................................................ 8
REFUSED ...................................................................................... 9
J16. You had crying spells.
Rarely or Not at all (< less than1 day) ........................................... 1
Some or a little of the time (1-2 days) ............................................ 2
Occasionally or a moderate amount (3-4 days) ............................. 3
Most or all of the time (5-7days) .................................................... 4
DON’T KNOW ................................................................................ 8
REFUSED ...................................................................................... 9
J17. You felt sad.
Rarely or Not at all (< less than1 day) ........................................... 1
Some or a little of the time (1-2 days) ............................................ 2
Occasionally or a moderate amount (3-4 days) ............................. 3
Most or all of the time (5-7days) .................................................... 4
DON’T KNOW ................................................................................ 8
REFUSED ...................................................................................... 9
J18. You felt that people disliked you.
Rarely or Not at all (< less than1 day) ........................................... 1
Some or a little of the time (1-2 days) ............................................ 2
Occasionally or a moderate amount (3-4 days) ............................. 3
Most or all of the time (5-7days) .................................................... 4
DON’T KNOW ................................................................................ 8
REFUSED ...................................................................................... 9
J19. You could not get “going”.
Rarely or Not at all (< less than1 day) ........................................... 1
Some or a little of the time (1-2 days) ............................................ 2
Occasionally or a moderate amount (3-4 days) ............................. 3
Most or all of the time (5-7days) .................................................... 4
DON’T KNOW ................................................................................ 8
REFUSED ...................................................................................... 9

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Section K: Affect
(Source: PANAS – Positive and Negative Affect Scale)
This scale consists of a number of words that describe different feelings and emotions. Read each item
and then indicate to what extent you felt this way in the past week.
K1. Interested
Slightly or None .............. 1
A little .............................. 2
Moderately ...................... 3
Quite a Bit ....................... 4
Extremely ........................ 5
DON’T KNOW ................. 8
REFUSED ....................... 9
K2. Distressed
Slightly or None .............. 1
A little .............................. 2
Moderately ...................... 3
Quite a Bit ....................... 4
Extremely ........................ 5
DON’T KNOW ................. 8
REFUSED ....................... 9
K3. Excited
Slightly or None .............. 1
A little .............................. 2
Moderately ...................... 3
Quite a Bit ....................... 4
Extremely ........................ 5
DON’T KNOW ................. 8
REFUSED ....................... 9
K4. Upset
Slightly or None .............. 1
A little .............................. 2
Moderately ...................... 3
Quite a Bit ....................... 4
Extremely ........................ 5
DON’T KNOW ................. 8
REFUSED ....................... 9
K5. Strong
Slightly or None .............. 1
A little .............................. 2
Moderately ...................... 3
Quite a Bit ....................... 4
Extremely ........................ 5
DON’T KNOW ................. 8
REFUSED ....................... 9
K6. Guilty
Slightly or None .............. 1
A little .............................. 2
Moderately ...................... 3
Quite a Bit ....................... 4
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Extremely ........................ 5
DON’T KNOW ................. 8
REFUSED ....................... 9
K7. Scared
Slightly or None .............. 1
A little .............................. 2
Moderately ...................... 3
Quite a Bit ....................... 4
Extremely ........................ 5
DON’T KNOW ................. 8
REFUSED ....................... 9
K8. Hostile
Slightly or None .............. 1
A little .............................. 2
Moderately ...................... 3
Quite a Bit ....................... 4
Extremely ........................ 5
DON’T KNOW ................. 8
REFUSED ....................... 9
K9. Enthusiastic
Slightly or None .............. 1
A little .............................. 2
Moderately ...................... 3
Quite a Bit ....................... 4
Extremely ........................ 5
DON’T KNOW ................. 8
REFUSED ....................... 9
K10. Proud
Slightly or None .............. 1
A little .............................. 2
Moderately ...................... 3
Quite a Bit ....................... 4
Extremely ........................ 5
DON’T KNOW ................. 8
REFUSED ....................... 9
K11. Irritable
Slightly or None .............. 1
A little .............................. 2
Moderately ...................... 3
Quite a Bit ....................... 4
Extremely ........................ 5
DON’T KNOW ................. 8
REFUSED ....................... 9
K12. Alert
Slightly or None .............. 1
A little .............................. 2
Moderately ...................... 3
Quite a Bit ....................... 4
Extremely ........................ 5
DON’T KNOW ................. 8
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REFUSED ....................... 9
K13. Ashamed
Slightly or None .............. 1
A little .............................. 2
Moderately ...................... 3
Quite a Bit ....................... 4
Extremely ........................ 5
DON’T KNOW ................. 8
REFUSED ....................... 9

K14. Inspired
Slightly or None .............. 1
A little .............................. 2
Moderately ...................... 3
Quite a Bit ....................... 4
Extremely ........................ 5
DON’T KNOW ................. 8
REFUSED ....................... 9
K15. Nervous
Slightly or None .............. 1
A little .............................. 2
Moderately ...................... 3
Quite a Bit ....................... 4
Extremely ........................ 5
DON’T KNOW ................. 8
REFUSED ....................... 9
K16. Determined
Slightly or None .............. 1
A little .............................. 2
Moderately ...................... 3
Quite a Bit ....................... 4
Extremely ........................ 5
DON’T KNOW ................. 8
REFUSED ....................... 9
K17. Attentive
Slightly or None .............. 1
A little .............................. 2
Moderately ...................... 3
Quite a Bit ....................... 4
Extremely ........................ 5
DON’T KNOW ................. 8
REFUSED ....................... 9
K18. Jittery
Slightly or None .............. 1
A little .............................. 2
Moderately ...................... 3
Quite a Bit ....................... 4
Extremely ........................ 5
DON’T KNOW ................. 8
REFUSED ....................... 9
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K19. Active
Slightly or None .............. 1
A little .............................. 2
Moderately ...................... 3
Quite a Bit ....................... 4
Extremely ........................ 5
DON’T KNOW ................. 8
REFUSED ....................... 9
K20. Afraid
Slightly or None .............. 1
A little .............................. 2
Moderately ...................... 3
Quite a Bit ....................... 4
Extremely ........................ 5
DON’T KNOW ................. 8
REFUSED ....................... 9

V1.0 (07/02/2013)

Mental Health Questionnaire for the Clinical Exam

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