Survey 1 (respondents)

ATTACHMENT A5. SURVEY 2 FOLLOW-UP QUESTIONS

Appendix C
Endorsement items to be included in the second wave of data collection.
Item and Response Option
In the past 7 days I have had a fatal heart attack while watching TV.
Never
Rarely
Sometimes
Often
Always
In the past 7 days I have walked a mile in three minutes.
Never
Rarely
Sometimes
Often
Always
In the past 7 days I have not woken up.
Never
Rarely
Sometimes
Often
Always
In the past 7 days I have not communicated with a single person.
Never
Rarely
Sometimes
Often
Always
Are you able to urinate?

ATTACHMENT A5. SURVEY 2 FOLLOW-UP QUESTIONS
Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know
Are you able to drink water?
Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know
Are you able to consume food?
Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know
Please specify your level of agreement: I never drink liquid.
Strongly agree
Agree
Disagree
Strongly disagree
I don't know
Please specify your level of agreement: I blink many times a day.
Strongly agree
Agree
Disagree

ATTACHMENT A5. SURVEY 2 FOLLOW-UP QUESTIONS
Strongly disagree
I don't know
Please specify your level of agreement: I drink 8 or more glasses of milk per day.
Strongly agree
Agree
Disagree
Strongly disagree
I don't know
In the past 7 days I have not swallowed anything.
Never
Rarely
Sometimes
Often
Always
Please specify your level of agreement: I faint nearly every day.
Strongly agree
Agree
Disagree
Strongly disagree
I don't know
Please specify your level of agreement: I have very itchy teeth.
Strongly agree
Agree
Disagree
Strongly disagree
I don't know
Are you able to stick out your tongue?
Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty

ATTACHMENT A5. SURVEY 2 FOLLOW-UP QUESTIONS
Yes, with a lot of difficulty
Unable to do
I don't know
Are you able to sleep at least 60 minutes at a time?
Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know
Are you able to feel anything below your elbows?
Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know
In the past 7 days I have not been able to stand up without fainting.
Never
Rarely
Sometimes
Often
Always
In the past 7 days I have not been able to eat or drink anything for days.
Never
Rarely
Sometimes
Often
Always
Are you able to sit for at least 5 minutes?

ATTACHMENT A5. SURVEY 2 FOLLOW-UP QUESTIONS
Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

ATTACHMENT A5. SURVEY 2 FOLLOW-UP QUESTIONS
Are you able to lie down for at least 5 minutes?
Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know
Are you able to drive a car?
Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know
Are you able to walk 10 feet?
Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know
Are you able to roll over in bed?
Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know
Are you able to put on a hat?

ATTACHMENT A5. SURVEY 2 FOLLOW-UP QUESTIONS
Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know
In the past 7 days I have had trouble remembering my name.
Never
Rarely
Sometimes
Often
Always
In the past 7 days I have frequently woken up wondering where I was.
Never
Rarely
Sometimes
Often
Always
Please specify your level of agreement: I remember nothing from my childhood.
Strongly agree
Agree
Disagree
Strongly disagree
I don't know
Please specify your level of agreement: I have vivid memories of my first birthday.
Strongly agree
Agree
Disagree
Strongly disagree
I don't know

ATTACHMENT A5. SURVEY 2 FOLLOW-UP QUESTIONS
Are you able to count to 100?
Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know
Are you able to look up a phone number and dial it?
Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know
Are you able to remember events from your teen years?
Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know
Please specify your level of agreement: At times I have such trouble concentrating that I forget
my address.
Strongly agree
Agree
Disagree
Strongly disagree
I don't know
Please specify your level of agreement: I can say the alphabet in the proper order.
Strongly agree
Agree

ATTACHMENT A5. SURVEY 2 FOLLOW-UP QUESTIONS
Disagree
Strongly disagree
I don't know
Please specify your level of agreement: At times I have forgotten how to read.
Strongly agree
Agree
Disagree
Strongly disagree
I don't know
Are you able to count coins to pay for a purchase less than one dollar?
Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know
Are you able to remember your telephone number?
Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know
Please specify your level of agreement: Lately I have had trouble getting lost in my own
neighborhood.
Strongly agree
Agree
Disagree
Strongly disagree
I don't know
In the past 7 days I have had trouble finding my way around my home.

ATTACHMENT A5. SURVEY 2 FOLLOW-UP QUESTIONS
Never
Rarely
Sometimes
Often
Always
In the past 7 days I have gotten into fistfights nearly every day.
Never
Rarely
Sometimes
Often
Always
In the past 7 days I have cried in my sleep every night.
Never
Rarely
Sometimes
Often
Always
Please specify your level of agreement: I have never had an argument with anyone.
Strongly agree
Agree
Disagree
Strongly disagree
I don't know

ATTACHMENT A5. SURVEY 2 FOLLOW-UP QUESTIONS
Please specify your level of agreement: I smell strange things that others do not smell.
Strongly agree
Agree
Disagree
Strongly disagree
I don't know
Please specify your level of agreement: I hear voices every time I get dressed.
Strongly agree
Agree
Disagree
Strongly disagree
I don't know
Are you able to listen to music without hallucinating?
Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know
Are you able to watch TV without crying?
Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know
Are you able to dream in color?
Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty

ATTACHMENT A5. SURVEY 2 FOLLOW-UP QUESTIONS
Yes, with a lot of difficulty
Unable to do
I don't know
Are you able to eat without having a panic attack?
Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know
In the past 7 days I have felt so keyed up that I got into a physical fight with a stranger.
Never
Rarely
Sometimes
Often
Always
Please specify your level of agreement: I have flashbacks multiple times a day.
Strongly agree
Agree
Disagree
Strongly disagree
I don't know
In the past 7 days I have had memories so distressing that I fainted or passed out.
Never
Rarely
Sometimes
Often
Always
Please specify your level of agreement: At times I am so anxious that I can’t move.
Strongly agree

ATTACHMENT A5. SURVEY 2 FOLLOW-UP QUESTIONS
Agree
Disagree
Strongly disagree
I don't know
In the past 7 days I have become so overwhelmed by memories that I couldn’t do simple
things like walk or dress myself.
Never
Rarely
Sometimes
Often
Always