World Health Survey Template Page 7
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57Q2051 In the last 30 days, how much difficulty did you have in learning a new
1. None
2. Mild
3. Moderate
4. Severe
5. Extreme/
task (for example, learning how to get to a new place, learning a new
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game, learning a new recipe etc.)?
.
Interpersonal Activities
.
Q2060 Overall in the last 30 days, how much difficulty did you have with
1. None
2. Mild
3. Moderate
4. Severe
5. Extreme/
personal relationship or participation in the community?
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Q2061 In the last 30 days, how much difficulty did you have in dealing with
1. None
2. Mild
3. Moderate
4. Severe
5. Extreme/
conflicts and tensions with others?
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.
Vision
.
Q2070 Do you wear glasses or contact lenses?
1. Yes
5. No
(If Respondent says YES to this question, preface the next 2 questions
with "Please answer the following questions taking into account your
glasses or contact lenses".)
Q2071 In the last 30 days, how much difficulty did you have in seeing and
1. None
2. Mild
3. Moderate
4. Severe
5. Extreme/
recognizing a person you know across the road (i.e. from a distance of
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about 20 meters)?
Q2072 In the last 30 days, how much difficulty did you have in seeing and
1. None
2. Mild
3. Moderate
4. Severe
5. Extreme/
recognizing an object at arm’s length or in reading?
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.
Sleep and Energy
.
Q2080 Overall in the last 30 days, how much of a problem did you have with
1. None
2. Mild
3. Moderate
4. Severe
5. Extreme
sleeping, such as falling asleep, waking up frequently during the night or
waking up too early in the morning?
1. None
2. Mild
3. Moderate
4. Severe
5. Extreme
Q2081 In the last 30 days, how much of a problem did you have due to not
feeling rested and refreshed during the day (e.g. feeling tired, not having
energy)?
.
Affect
.
Q2090 Overall in the last 30 days, how much of a problem did you have with
1. None
2. Mild
3. Moderate
4. Severe
5. Extreme
feeling sad, low or depressed?
1. None
2. Mild
3. Moderate
4. Severe
5. Extreme
Q2091 Overall in the last 30 days, how much of a problem did you have with
worry or anxiety?
WORLD HEALTH SURVEY - HEALTH STATE DESCRIPTIONS
2.2
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Parent category: Life