Form 1 Well Being

Public reporting burden for this collection of information is estimated to average 04
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 (0925-0584). Do not return the completed form to this address.

OMB#: 0925-0584
Exp. xx/xx/xxxx

HCHS/SOL- Visit 2- Well-Being Questionnaire
FORM CODE: WBE
VERSION: 1, 12/10/2013

ID NUMBER:

Contact
Occasion

0

2

SEQ #

ADMINISTRATIVE INFORMATION
0a.

Completion Date:

/

/

0b.

Staff ID:

Instructions: Enter the answer given by the participant for each response. The special value, "Q", is allowed for cases
where the response 'Don’t know/refused' is not listed as an option.

A. CES-D 10

I am going to read a list of some of the ways you may have felt or behaved. Please indicate how
often you have felt this way during the past week. Respond by saying “rarely or none of the time’,
meaning less than one day during the past week, ‘some or a little of the time’, meaning one to two
days during the past week, ‘occasionally or a moderate amount of time, meaning three to four
days, or ‘all of the time’ meaning five to seven days. Choose only one of these categories for each
item statement I read.
Rarely or none
of the time
(<1 day)

Some or a little
of the time
(1-2 days)

Occasionally or
a moderate
amount of time
(3-4 days)

All of the time
(5-7 days)

1. I was bothered by things that usually
don’t bother me.

0

1

2

3

2. I had trouble keeping my mind on what I
was doing.

0

1

2

3

3. I felt depressed.

0

1

2

3

4. I felt that everything I did was an effort.

0

1

2

3

5. I felt hopeful about the future.

0

1

2

3

6. I felt fearful.

0

1

2

3

7. My sleep was restless.

0

1

2

3

8. I was happy.

0

1

2

3

9. I felt lonely.

0

1

2

3

10. I could not “get going”.

0

1

2

3

WBE-Well Being-CESD_GAD-12-10-2013.docx

1

ID NUMBER:

FORM CODE: WBE
VERSION: 1, 12/10/2013

Contact
Occasion

0

2

SEQ #

B. GAD-7

Over the last 2 weeks, how often have you been bothered by the following problems?

Not at all

Several
days

More than
half the
days

Nearly
every
day

1. Feeling nervous, anxious or on edge

0

1

2

3

2. Not being able to stop or control worrying

0

1

2

3

3. Worrying too much about different things

0

1

2

3

4. Trouble relaxing

0

1

2

3

5. Being so restless that it is hard to sit still

0

1

2

3

6. Becoming easily annoyed or irritable

0

1

2

3

7. Feeling afraid as if something awful might happen

0

1

2

3

WBE-Well Being-CESD_GAD-12-10-2013.docx

2