Beruflich Dokumente
Kultur Dokumente
IDENTITAS RESPONDEN
1. Nama
2. Jenis Kelamin
3. Tempat, Tanggal, Lahir
4. Alamat
5. Pekerjaan
6. Penghasilan Keluarga
7. Jumlah Anggota Keluarga dalam Rumah
8. Penghasilan per Kapita
9. Asuransi
10. No. Hp
11. Tipe Stroke
12. Frekuensi Stroke Berulang
II. KUALITAS HIDUP
: .................................................................................
: Laki-laki/Perempuan
: .................................................................................
: .................................................................................
.................................................................................
: .................................................................................
: .................................................................................
: ................orang
: .................................................................................
: Ya , Jenis Asuransi: ............................................
Tidak
: .................................................................................
: 1. Stroke Penyumbatan
2. Stroke Perdarahan
: ... bulan
Excellent
Very Good
Good
Fair
Poor
Somewhat better
now than one year
ago
Somewhat worse
now than one year
ago
The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
1
1
1
2
2
2
3
3
3
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?
13. Cut down the amount of time you spent on work or other activities
14. Accomplished less than you would like
15. Were limited in the kind of work or other activities
16. Had difficulty performing the work or other activities (for example, it took extra effort)
Yes
No
1
1
2
2
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)?
Yes
No
17. Cut down the amount of time you spent on work or other activities
18. Accomplished less than you would like
19. Didn't do work or other activities as carefully as usual
20. During the past 4 weeks, to what extent has your physical health or emotional problems
interfered with your normal social activities with family, friends, neighbors, or groups?
21. How much bodily pain have you had during the past 4 weeks?
22. During the past 4 weeks, how much did pain interfere with your normal work (including both
work outside the home and housework)?
1
1
2
2
Not at
all
Slightly
Moderatel
y
Quite a
bit
Extremely
None
Very
Mild
Mild
Moderat
e
Severe
Very
Severe
Not at
all
A little
bit
Moderatel
y
Quite a Extremely
bit
4
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 of the time during the past 4 weeks . . .
All of
A Good
A Little
None
Most of
Some of
the
Bit of the
of the
of the
the Time
the Time
time
Time
Time
Time
23. Did you feel full of pep?
1
2
3
4
5
6
24. Have you been a very nervous person?
1
2
3
4
5
6
25. Have you felt so down in the dumps that nothing could cheer you up?
1
2
3
4
5
6
32. During the past 4 weeks, how much of the time has your physical health or emotional
problems interfered with your social activities (like visiting with friends, relatives, etc.)?
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
4
4
4
4
4
4
5
5
5
5
5
5
6
6
6
6
6
6
All of
the
time
Most of
the time
Some
of the
time
A little
of the
time
None
of the
time
Definitel
y
1
1
1
1
Mostly
True
2
2
2
2
Dont
Know
3
3
3
3
Mostly
False
4
4
4
4
Definitel
y False
5
5
5
5
3. DUKUNGAN KELUARGA
Almost
Some of
Hardly
Always
the Time
Ever
1. I am satisfied that I can turn to my family for help when something is troubling me.
2. I am satisfied with the way my family talks over things with me and shares problem with me.
3. I am satisfied that my family accepts and supports my wishes to take on new activities or directions.
4. I am satisfied with the way my family expresses affection and responds to my emotions, such as anger, sorrow, and love.
5. I am satisfied with the way my family and I share time together.
Cimahi, ... Desember 2015
Responden
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