Spinal Cord Injury Research Questionnaire
Part I. General Spinal Cord Injury Information
Please fill in all fields.
1. Do you have a spinal cord injury? Yes No
If you answered "Yes" to the previous question, please continue to question 2. If you answered "No," thank you for your participation but this questionnaire is only for spinal cord injured persons.
2. If known, please provide your spinal cord injury level or area on your spinal cord that was injured (cervical, thoracic, lumbar, or sacral area)?
3. When and how did you acquire a spinal cord injury? Please provide the year and if possible, the month that this occurred.
4. How long was your recovering hospital stay?
5. Have you sought out rehabilitation since your injury? If you went to an inpatient rehabilitation facility, how long was your stay? If you went to an outpatient rehabilitation facility, how frequently were your visits?
6. Do you live with anyone or do you live alone?
7. Do you work or attend college? If so, what is your major?
8. Do you own a ramp van? If so, do you drive yourself?
9. Optional: Would you like to share any struggles or difficulties you face being spinal cord injured?
10. Optional: What do you miss most from life without a spinal cord injury?
________________________________________________________
11. Are you male or female? Male Female
12. What is your age? 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 89 90
13. What is your marital status? Single Married In a relationship Separated/Divorced Widowed
14. What is place of residence? Home Apartment Nursing Home Other
Part II. Mood Scale
Please read the following statements and select the best answer for how you have felt over the last month.
1. Have you felt hopeless, down, or depressed? Not at all 1-5 days 6-10 days 11-15 days Nearly every day Every day
2. Have you felt tired and had a lack of energy? Not at all 1-5 days 6-10 days 11-15 days Nearly every day Every day
3. Do you feel satisfied with your life? Not at all 1-5 days 6-10 days 11-15 days Nearly every day Every day
4. Are you usually in good spirits? Not at all 1-5 days 6-10 days 11-15 days Nearly every day Every day
5. Do you laugh and still find humor in things? Not at all 1-5 days 6-10 days 11-15 days Nearly every day Every day
6. Do you live a healthy lifestyle? Not at all 1-5 days 6-10 days 11-15 days Nearly every day Every day
7. Do you feel that your life has value? Not at all 1-5 days 6-10 days 11-15 days Nearly every day Every day
8. Do you easily get upset? Not at all 1-5 days 6-10 days 11-15 days Nearly every day Every day
9. Do you find interest and enjoyment in doing things? Not at all 1-5 days 6-10 days 11-15 days Nearly every day Every day
10. Do you feel happy? Not at all 1-5 days 6-10 days 11-15 days Nearly every day Every day
11. Are you positive for the most part? Not at all 1-5 days 6-10 days 11-15 days Nearly every day Every day
12. How often do you worry? Not at all 1-5 days 6-10 days 11-15 days Nearly every day Every day
13. How often do you feel angry? Not at all 1-5 days 6-10 days 11-15 days Nearly every day Every day
14. Do you feel regret? Not at all 1-5 days 6-10 days 11-15 days Nearly every day Every day
15. Do you prefer to stay home? Not at all 1-5 days 6-10 days 11-15 days Nearly every day Every day
16. How often do you have fun? Not at all 1-5 days 6-10 days 11-15 days Nearly every day Every day
17. Do you ever feel helpless? Not at all 1-5 days 6-10 days 11-15 days Nearly every day Every day
18. Have you felt suicidal or wished you were not alive? Not at all 1-5 days 6-10 days 11-15 days Nearly every day Every day
19. Have you felt stressed or annoyed? Not at all 1-5 days 6-10 days 11-15 days Nearly every day Every day
20. Do you enjoy life? Not at all 1-5 days 6-10 days 11-15 days Nearly every day Every day
21. Do you feel hopeful about the future? Not at all 1-5 days 6-10 days 11-15 days Nearly every day Every day
Part III. The 14-Item Resilience Scale™ (RS-14™)
Please read the following statements. To the right of each you will find seven numbers, ranging from "1" (Strongly Disagree) on the left to "7" (Strongly Agree) on the right. Circle the number which best indicates your feelings about that statement. For example, if you strongly disagree with a statement, circle "1". If you are neutral, circle "4", and if you strongly agree, circle "7", etc.
1
2
3
4
5
6
7
NOTE: By clicking the Submit button below, you agree to allow us to use your ANSWERS ONLY in future published studies on Resilience, which we hope you will find useful and beneficial. We will keep your responses in a large database and will only report aggregate data; we do not keep data to identify you.
Would you like to be contacted? Yes No
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Questions or Comments:
Created February 26, 2011