BCS70 Age 46 Survey
Self-completion questionnaire
First Draft for consultation
November 2014
Page 2
Warwick Edinburgh Mental Well-Being Scale
Below are some statements about feelings and thoughts. For each statement, please
choose the option that best describes your experience of each over the last 2 weeks.
None of
the time
I’ve been feeling
optimistic about the
future
I’ve been feeling useful
I’ve been feeling relaxed
I’ve been feeling
interested in other people
I’ve had energy to spare
I’ve been dealing with
problems well
I’ve been thinking clearly
I’ve been feeling good
about myself
I’ve been feeling close to
other people
I’ve been feeling
confident
I’ve been able to make
up my own mind about
things
I’ve been feeling loved
I’ve been interested in
new things
I’ve been feeling cheerful
Rarely
Some of
the time
Often
All of the
time
Page 3
SF-36
The following items are about activities you might do during a typical day.
Q1 Does your health limit you in these activities? If so, how much?
Yes, limited a lot
Yes, limited a
little
No, not limited
at all
Vigorous activities, such as
running, lifting heavy objects,
participating in strenuous sports
Moderate activities, such as
moving a table, pushing a vacuum
cleaner, bowling, or playing golf
Lifting or carrying groceries
Climbing several flights of stairs
Climbing one flight of stairs
Bending, kneeling or stooping
Walking more than one mile
Walking half a mile
Walking 100 yards
Bathing or dressing yourself
Q2 During the past 4 weeks, have you had any of the following problems with your
work or other regular daily activities as a result of your physical health?
Have you…
Yes
Cut down the amount of time you spent on
work or other activities?
Been limited in the kind of work or other
activities you were able to do?
Accomplished less than you would like?
Had difficulty performing work or other
activities (for example, it took extra effort)?
No
Page 4
Q3 During the past 4 weeks, have you had any of the following problems with your
work or other regular daily activities as a result of any emotional problems (such as
feeling depressed or anxious)?
Have you…
Yes
No
Cut down the amount of time you spent on
work or other activities?
Accomplished less than you would like?
Not done your work or other activities as
carefully as usual?
Q4 During the past 4 weeks, to what extent has your physical health or emotional
problems interfered with your normal social activities with family, friends, neighbours,
or groups?
1 Not at all
2 Slightly
3 Moderately
4 Quite a bit
5 Extremely
Q5 How much bodily pain have you had during the past 4 weeks?
1 None
2 Very mild
3 Mild
4 Moderate
5 Severe
6 Very severe
Page 5
Q6 During the past 4 weeks, how much did pain interfere with your normal work
(including both work outside the home and housework)?
1 Not at all
2 Slightly
3 Moderately
4 Quite a bit
5 Extremely
Q7 These questions are about how you feel and how things have been with you
during the past 4 weeks. For each question, please give the one answer that comes
closest to the way you have been feeling.
How much time during the past four weeks...
All of
the
time
Did you feel full of life?
Have you been a very nervous person?
Have you felt so down in the dumps
nothing could cheer you up?
Have you felt calm and cheerful?
Did you have a lot of energy?
Have you felt downhearted and low?
Did you feel worn out?
Have you been a happy person?
Did you feel tired?
Has your health limited your social
activities (like visiting friends, relatives,
etc.)?
Most
of the
time
Some
of the
time
A
good
bit of
the
time
A
little
of
the
time
None
of
the
time
Page 6
Q8 For each of the following statements please choose one answer that best
describes how true or false it is for you.
Definitely Mostly Don’t Mostly Definitely
false
true
true
know false
I seem to get ill a little easier than other
people
I am as healthy as anybody I know
I expect my health to get worse
My health is excellent
Cambridge Physical Activity Questionnaire
The next set of questions are designed to find out about your physical activity in your
everyday life.
Section A – Home Activities
Average over the past year
At what time do you
normally get up?
At what time do you
normally go to bed?
On a week day
On a weekend day
Which form of transport do you use most often apart from your journey to and from work?
Distance of
journeys
Less than one
mile
1–5 mile(s)
More than 5 miles
Usual mode of transport
Car
Walk
Public
transport
Page 7
TV OR VIDEO VIEWING
Hours of TV
or Video
watched per
day
Average over the last 12 months
None
Less than 1 1 to 2
hour a day
hours a
day
Comment [ICS1]: Note that categories
differ to those used at 42
2 to 3 hours
a day
3 to 4
hours a
day
More
than 4
hours a
day
On a weekday
before 6 pm
On a weekday
after 6 pm
On a weekend
day before 6
pm
On a weekend
day after 6 pm
ACTIVITIES IN AND AROUND THE HOME
Approximate
number of hours
each week
Preparing food,
cooking and
washing up
Shopping for food
and groceries
Shopping and
browsing in shops
for other items (e.g.
clothes,toys)
Cleaning the house
Doing the laundry
and ironing
Caring for preschool children or
babies at home (not
as paid
employment)
Caring for
handicapped,
elderly or disabled
people at home (not
as paid
employment)
Average over the last 12 months
None
Less than 1 to 3
3 to 6
1 hour a
hours a
hours a
week
week
week
6 to 10
hours
a week
10 to
15
hours
a week
More
than
15
hours
a
week
Page 8
STAIR CLIMBING AT HOME
Number of
times you
climbed up a
flight of
stairs
(approx 10
steps) each
day at home
On a weekday
On a weekend
Average over the last 12 months
None
1 to 5 times
6 to 10
a day
times a
day
Comment [ICS2]: Note that stair q
moved to follow activities to maximise use
of space
11 to 15
times a day
16 to
20
times a
day
More
than 20
times a
day
SECTION B – ACTIVITY AT WORK
NEED TO ADD APPROPRIATE INSTRUCTIONS RE: ROUTING
ACTIVITY LEVELS AT YOUR WORK
Now we would like you to take the total number of hours you worked per week in each job
and divide them up according to your activity level.
Job 1
No
Yes
Hours per
week
Sitting — light work
e.g. desk work, or driving a car or truck
Sitting — moderate work
e.g. working heavy levers or riding
a mower or forklift truck
Standing — light work
e.g. lab technician work or working
at a shop counter
Standing — light/moderate work
e.g. light welding or stocking shelves
Standing — moderate work
e.g. fast rate assembly line work or
lifting up to 50 lbs every 5 minutes
for a few seconds at a time
Standing — moderate/heavy work
e.g. masonry/painting or lifting more
than 50 lbs every 5 minutes for a few
seconds at a time
Walking at work — carrying
nothing heavier than a briefcase
e.g. moving about a shop
Walking — carrying something
Heavy
Moving, pushing heavy objects
objects weighing over 75lbs
Page 9
STAIR OR STEP CLIMBING AT HOME
Average over the last 12 months
None
1 to 5 times
6 to 10
a day
times a
day
11 to 15
times a day
16 to
20
times a
day
More
than 20
times a
day
Number of
times you
climbed up a
flight of stairs
(10 steps) at
work
Number of
times you
climbed up a
ladder at work
KNEELING AND SQUATTING AT WORK
In an average working day did you:
No
Yes
kneel for more than one hour in total?
squat for more than one hour in total?
get up from kneeling or squatting more than 30 times?
TRAVEL TO AND FROM WORK
Roughly how many miles was it from home to your job?
How many times a week did you travel from home to your job?
How did you
normally travel to
your job?
By car
By works or public
transport
By bicycle
Walking
Always
Usually
Occasionally
Never
Don’t know
Page 10
SECTION C
The following questions ask about how you spent your leisure time. Please indicate
how often you did each activity on average over the past 12 months.
For activities that are seasonal, e.g. cricket or mowing the lawn, please put the average
frequency during the season when you did the activity.
Please indicate the average length of time that you spent doing the activity on each
occasion.
None
Swimming —
competitive
Swimming —
leisurely
Backpacking or
mountain climbing
Walking for pleasure
— you should not
include
walking as a means of
transportation as this
was
included in Sections A &
B
Racing or rough
terrain cycling
Cycling for pleasure
— you should not
include
cycling as a means of
transportation
Mowing the lawn
— during the grass
cutting
season
Watering the lawn or
garden in the summer
Digging, shovelling or
chopping wood
Weeding or pruning
DIY e.g. carpentry,
home
or car maintenance
Less
than
once
a
mont
h
Once
a
mont
h
2 to
3
time
sa
mont
h
Once
a
week
2 to
3
time
sa
week
4 to
5
time
sa
week
6
time
sa
week
or
more
Hour
s
Mins
Page 11
None
High impact aerobics
or step aerobics
Other types of aerobics
Exercises with weights
Conditioning exercises
e.g. using an exercise
bike
or rowing machine
Floor exercises
e.g. stretching, bending,
keep fit or yoga
Dancing
e.g. ballroom or disco
Competitive running
Jogging
Bowling
— indoor, lawn or 10
pin
Tennis or badminton
Squash
Table tennis
Golf
Football, rugby or
hockey (during the
season)
Cricket (during the
season)
Rowing
Netball, volleyball or
basketball
Fishing
Horse-riding
Snooker, billiards or
darts
Musical instrument
playing or singing
Ice-skating
Sailing, wind-surfing
or boating
Martial arts, boxing or
wrestling
Less
than
once
a
mont
h
Once
a
mont
h
2 to
3
time
sa
mont
h
Once
a
week
2 to
3
time
sa
week
4 to
5
time
sa
week
6
time
sa
week
or
more
Hour
s
Mins
Page 12
CES-D 10 item
For each of the following statements, please check the box that best describes how
often you felt or behaved this way during the past week.
Rarely or
none of the
time (less
than 1 day)
Some or a
little of the
time (1-2
days)
I was bothered by
things that usually
don’t bother me
I had trouble keeping
my mind on what I was
doing.
I felt depressed.
I felt that everything I
did was an effort.
I felt hopeful about the
future.
I felt fearful.
My sleep was restless.
I was happy.
I felt lonely.
I could not get “going”.
Malaise – 9 item
Yes
Do you feel tired most of
the time?
Do you often feel
miserable or depressed?
Do you often get worried
about things?
Do you often get in a
violent rage?
Do you often suddenly
become scared for no
good reason?
Are you easily upset or
irritated?
Are you constantly
keyed up and jittery?
Does every little thing
get on your nerves and
wear you out?
Does your heart often
race like mad?
No
Occasionally
or moderate
amount of
time (3-4
days)
Most or all of
the time (5-7
days)
Page 13
Sleep
During the last four weeks, how long did it usually take for you to fall asleep?
0-15 minutes

16-30 minutes
31-45 minutes



46-60 minutes
More than 60 minutes
During the past four weeks, how many hours did you sleep each night on average?
WRITE YOUR ANSWER IN HOURS TO THE NEAREST HOUR IN THE BOX
During the past four weeks, how often did you awaken during your sleep time and have
trouble falling back to sleep again?
All of the time 
Most of the time

A good bit of the time
Some of the time

A little of the time

None of the time

During the past four weeks, how often did you get enough sleep to feel rested upon waking in
the morning?
All of the time 
Most of the time

A good bit of the time
Some of the time

A little of the time

None of the time

Do you snore?
Yes
No
Don’t Know
Comment [ICS3]: Not found a
question on noise yet
Page 14
Rose Angina Scale
Do you ever get pain in your chest?
Yes
No
Where do you get this pain or discomfort? Please mark X on the appropriate place.
When you walk at an ordinary pace on the level does this produce the pain?
Yes
No
When you walk uphill or hurry does this produce the pain?
Yes
No
When you get any pain or discomfort in your chest on walking, what do you do?
Stop
Slow down
Continue at same pace
Not applicable
Does the pain or discomfort in your chest go away if you stand still?
Yes
No
How long does it take to go away?
10 minutes or less
More than 10 minutes
Page 15
Below is a list of things that people value. For each one we’d like to know on a scale from 1 to
10 how important each one is to you, where '1' equals 'Not important at all', and '10' equals
‘Very important’.
Your health
Having a lot
of money
Having
children
Having a
fulfilling job
Being
independent
Owning your
own home
Having a
good
marriage or
partnership
Having good
friends
Not important at
all
1
2
3
4
5
6
7
8
9
Very important
10
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