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Table 1 Personal happiness form, adapted from the combine study [33]

From: Outpatient treatment of alcohol use disorders among subjects 60+ years: design of a randomized clinical trial conducted in three countries (Elderly Study)

Personal happiness form

 

How happy or satisfied are you with each of these areas of your life? (circle only one number for each item)

If unsatisfied, (= < 5), what is the reason? Please mark more than one if appropriate*

Life areas

Completely dissatisfied

Somewhat dissatisfied

Somewhat satisfied

Mostly satisfied

Completely satisfied

Doesn’t apply (IR)

Loss

Loneliness

Loss of ability due to aging

Something else, please note

Growing old*

1

2

3

4

5

6

7

8

9

10

IR

0 = no

0 = no

0 = no

 

1 = yes

1 = yes

1 = yes

9 = irr.

9 = irr.

9 = irr.

Inter personal relations

               

 Relationship with partner/spouse

1

2

3

4

5

6

7

8

9

10

IR

0 = no

0 = no

0 = no

 

1 = yes

1 = yes

1 = yes

9 = irr.

9 = irr.

9 = irr.

 Friends and social life

1

2

3

4

5

6

7

8

9

10

IR

0 = no

0 = no

0 = no

 

1 = yes

1 = yes

1 = yes

9 = irr.

9 = irr.

9 = irr.

 Family relationships

1

2

3

4

5

6

7

8

9

10

IR

0 = no

0 = no

0 = no

 

1 = yes

1 = yes

1 = yes

9 = irr.

9 = irr.

9 = irr.

 Love and affection

1

2

3

4

5

6

7

8

9

10

IR

0 = no

0 = no

0 = no

 

1 = yes

1 = yes

1 = yes

9 = irr.

9 = irr.

9 = irr.

 Sex life

1

2

3

4

5

6

7

8

9

10

IR

0 = no

0 = no

0 = no

 

1 = yes

1 = yes

1 = yes

9 = irr.

9 = irr.

9 = irr.

Social life

               

 Leisure time and fun

1

2

3

4

5

6

7

8

9

10

IR

0 = no

0 = no

0 = no

 

1 = yes

1 = yes

1 = yes

9 = irr.

9 = irr.

9 = irr.

 Giving/caring for others

1

2

3

4

5

6

7

8

9

10

IR

0 = no

0 = no

0 = no

 

1 = yes

1 = yes

1 = yes

9 = irr.

9 = irr.

9 = irr.

 Personal safety, security

1

2

3

4

5

6

7

8

9

10

IR

0 = no

0 = no

0 = no

 

1 = yes

1 = yes

1 = yes

9 = irr.

9 = irr.

9 = irr.

Life circumstances

               

 Job/work/pension

1

2

3

4

5

6

7

8

9

10

IR

0 = no

0 = no

0 = no

 

1 = yes

1 = yes

1 = yes

9 = irr.

9 = irr.

9 = irr.

 Where I live

1

2

3

4

5

6

7

8

9

10

IR

0 = no

0 = no

0 = no

 

1 = yes

1 = yes

1 = yes

9 = irr.

9 = irr.

9 = irr.

 Money, financial security

1

2

3

4

5

6

7

8

9

10

IR

0 = no

0 = no

0 = no

 

1 = yes

1 = yes

1 = yes

9 = irr.

9 = irr.

9 = irr.

Physical health

               

 Physical health

1

2

3

4

5

6

7

8

9

10

IR

0 = no

0 = no

0 = no

 

1 = yes

1 = yes

1 = yes

9 = irr.

9 = irr.

9 = irr.

 Physical activities, exercise

1

2

3

4

5

6

7

8

9

10

IR

0 = no

0 = no

0 = no

 

1 = yes

1 = yes

1 = yes

9 = irr.

9 = irr.

9 = irr.

 Daily routine, the small tasks during the day

1

2

3

4

5

6

7

8

9

10

IR

0 = no

0 = no

0 = no

 

1 = yes

1 = yes

1 = yes

9 = irr.

9 = irr.

9 = irr.

 Eating, weight

1

2

3

4

5

6

7

8

9

10

IR

0 = no

0 = no

0 = no

 

1 = yes

1 = yes

1 = yes

9 = irr.

9 = irr.

9 = irr.

Psychological health

               

 Mood and self-esteem

1

2

3

4

5

6

7

8

9

10

IR

0 = no

0 = no

0 = no

 

1 = yes

1 = yes

1 = yes

9 = irr.

9 = irr.

9 = irr.

 Stress and anxiety

1

2

3

4

5

6

7

8

9

10

IR

0 = no

0 = no

0 = no

 

1 = yes

1 = yes

1 = yes

9 = irr.

9 = irr.

9 = irr.

 Anger and arguments

1

2

3

4

5

6

7

8

9

10

IR

0 = no

0 = no

0 = no

 

1 = yes

1 = yes

1 = yes

9 = irr.

9 = irr.

9 = irr.

 Spirituality

1

2

3

4

5

6

7

8

9

10

IR

0 = no

0 = no

0 = no

 

1 = yes

1 = yes

1 = yes

9 = irr.

9 = irr.

9 = irr.

 Memory

1

2

3

4

5

6

7

8

9

10

IR

0 = no

0 = no

0 = no

 

1 = yes

1 = yes

1 = yes

9 = irr.

9 = irr.

9 = irr.

 Mental ability

1

2

3

4

5

6

7

8

9

10

IR

0 = no

0 = no

0 = no

 

1 = yes

1 = yes

1 = yes

9 = irr.

9 = irr.

9 = irr.

  1. *Added a question about aging in general and if dissatisfaction in any domain is reported, then is it because of factors related to aging
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BMC Psychiatry

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