Demographic Questionnaire

Today's Date:
Month/Day/Year
/ /

Wave Wave 1
Wave 2
Wave 3
ID Number:

Your age (in years):

Your gender: Male
Female
Missing
What is your current marital status?
Single
Living together
Married
Separated
Divorced
Widowed
Missing
What is your Ethnicity/Race?
White/Caucasian
Black/African-American
Hispanic
Native American
Asian/Pacific Islander
Other
Missing
If you selected Other, please specify Ethnicity/Race here:

What is your highest education level?
Less than high school
Completed high school
Completed some college
Completed 2-year college degree
Completed 4-year college degree
Completed some work toward graduate degree
Completed masters degree
Completed doctoral-level degree
Missing
Indicate your heart-related medical diagnoses during your most recent hospitalization or doctor's visit:
Yes      No
Heart Attack
      

Angina
      

Coronary artery disease
      

High blood pressure
      

Congestive heart failure
      

Other
      

Was this question skipped or Missing?
      
If you selected Other, please specify Diagnoses here:

Indicate whether you had any of the following procedures done with your most recent hospitalization:
Yes      No
Cardiac catheterization
      

Coronary angioplasty or stent
      

Coronary artery bypass surgery
      

Heart valve surgery
      

Other
      

Missing
      
If you selected Other, please specify procedures here:
Please indicate the date of your most recent heart-related hospitalization:
Month/Day/Year
/ /

Are you currently participating in an outpatient cardiac rehab exercise program?
Yes
No
Wave 1/2
Are you currently doing a cardiac rehab exercise program at home or in another setting?
Yes
No
Wave 1/2
Are you currently doing any type of rehab program Yes
No
Missing

 

Thoughts about the Future


RIGHT NOW...
    Strongly disagree Disagree Agree Strongly agree Missing
Today, it is difficult for me to imagine my future.  
Today, I believe I can not make a difference.  
Today, I believe that things will improve.  
Today, I believe I am powerless to change my future.  
Today, I see my future as gloomy.  
Today, I believe I will accomplish what I set out to do.  
Today, I believe I can help improve things.  
Today, I feel giving up would be easier.  
Today, I believe I can overcome obstacles.  
Today, things don't work out as I would like.  

 


GENERALLY...
    Strongly disagree Disagree Agree Strongly agree Missing
Typically, things don't work out as I would like.  
Typically, I believe I can overcome obstacles.  
Typically, I see myself as fortunate.  
Typically, I see my future as gloomy.  
Typically, negative things seem to happen to me.  
Typically, it is difficult for me to imagine my future.  
Typically, I believe I can help improve things.  
Typically, I feel giving up would be easier.  
Typically, I believe that I will accomplish what I set out to do.  
Typically, I believe that things will improve.  
Typically, I believe I can not make a difference.  
Typically, I doubt that anything is worthwhile.  
Typically, I believe that I am powerless to change my future.