FORM - PROFILE OF ADAPTATION TO LIFE FORM

• Document Type: CREST
• Collection: STARGATE
• Document Number (FOIA) /ESDN (CREST): CIA-RDP96-00788R001700210037-2
• Release Decision: RIFPUB
• Original Classification: K
• Document Page Count: 4
• Document Creation Date: November 4, 2016
• Document Release Date: December 4, 1998
• Sequence Number: 37
• Publication Date: January 1, 1976
• Content Type: SS

Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210037-2
PROFILE OF ADAPTATION TO LIFE
Pteabe mah.k the answer bon. each que6ti.on that beat deacni eh how I V_1
you Sett ;his pat week. Matti yowc answeL choices, tike his: 1 /1 I
DURING THE PAST WEEK,
HAVE YOU FELT . . .
Answer choices
1 2 3 4
Rarely Some- Often Almost
times Always
Vigorous? I I
Alert? F7
Full of pep?
Happy?
Calm and relaxed?
Content?
Secure?
Confidence in yourself?
Inner calm and peace?
DURING THE PAST WEEK,
HAVE YOU FELT . . .
Discouraged?
Uneasy?
Unhappy?
On edge?
Gloomy?
Blue?
Like crying?
Worried?
Tense?
Bored?
Annoyed, irritated?
n 1
I n
Answer choices
1 2
Never Rarely
Some-
times
of
DURING THE PAST MONTH, I'VE
(Pkeahe anuswe1 each statement below)
Answer choices
2 3
Some-
times
Enjoyed talking with others
Felt trusting of people
Found work useful and interesting
Enjoyed people I live with
Found people accept me as I am
Been involved, interested in things
Felt needed and useful
Controlled my negative thinking
and increased my positive thinking
Found things I've needed coming to
me by "coincidence" or "chance"
A lack of order around me
Dissatisfied with myself
Critical of others
Annoyed, irritated
An impulse to hurt someone
Left out of things
That people treated me unfairly
Bothered by sloppiness around me
Disappointed in people
Worried about debts
Uncertain about who I really am
Unhappy about the work,I do
My family finds fault with me
No one seemed interested in how I
really feel inside
n
Answer choices
2 3
Su5j: #
I 27
I 28
*Copyright 1975, INSTITUTE FOR PROGRAM EVALUATION
BOX 4654, ROANOKE, VIRGlk roved For Release 2003/09/10 : CIA-RDP96-00788R001700210037-2
 Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210037-2
(C) PHYSICAL HEALTH INVENTORY
Pkease mark one answer Son each question below.
Merck yowc answer. Pike .thi.6: I X I or this
Had headaches? (Past month)
Felt faint?
Felt hot, feverish?
Had spells of dizziness?
Had difficulty falling asleep?
Had chest pains?
Noticed your heart beating fast?
Had difficulty breathing?
Felt physically ill?
Had back pains?
Been bothered by itching?
Had coughing spells?
Had neck or shoulder pains?
Had pains in legs or arms?
Had trouble with your' vision?
Felt exhausted, fatigued?
Waken from sleep feeling tired?
Had a poor appetite?
Been constipated (hard stools)?
Had an upset stomach?
Had nausea (sick to stomach)?
Had indigestion?
Had stomach pain after eating?
Had trouble digesting food?
Had diarrhea (loose bowels)?
L !
Answer choices
2 3
Some-
times
Li
Often
II
Li
Li
Li
IT IS MY OPINION THAT . . .
(Please answer each statement below)
A person's soul or spirit continues after death
People will be reborn to live again on earth
Mental telepathy (ESP) is a reality
People have out of body experiences (astral travel)
There are spiritual or non-physical forces
acting in today's world
Sooner or later people will treat you as
you've treated others
Spiritual or psychic healing is often as
effective as medical treatment
Not
Agree
i
I !
Li
El
Answer choices
2 3 4
It's wrong to kill any living thing
Problems in life are really opportunities
to learn and grow
People create their own reality by the kinds
of thoughts they let themselves have
IT IS MY OPINION THAT THE SOLUTIONS TO MAN'S
PROBLEMS IN LIVING WILL BE FOUND IN . . .
More money for scientific research
More formal education for people
Redistributing the wealth
A return to organized religion
Social reform through better laws
Daily meditation
Spiritual reawakening (personal enlightment)
Protecting the environment, natural resources
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Not
Sure
El 74
Not
Agree
E__1 I
El
2
Not
Sure
70
1 71
172
If
3
Agree
Li
4
Agree
Strongly
Li
 Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210037-2
(P!ea, answe'i each que$2Lon below) or Times Times Each
Shared personal problems with a friend? 1_
Washed the dishes? 1-7
Done household cleaning?
Prepared meals?
Washed clothes?
Done physical exercise?
Taken part in active sports?
Listened to music you enjoy?
Taken time to be by yourself?
Meditated?
Enjoyed contact with animals?
Taken care of house plants?
Eaten red meat (beef, pork)?
Eaten fish or poultry?
Eaten sweets (candy, cake, pie, etc.)?
Drunk soft drinks (Coke, etc.)?
Eaten fresh fruits (apples, oranges,
etc.)?
Eaten natural foods (dried fruit, nuts,
whole grains)?
Kept up with current events, (read news-
paper, magazines, watch TV news)?
Read something about mystical,
spiritual or psychic things?
Read something about personal
psychological growth?
L !
17
17-
F-1 l__1 I
1 32
47 033
(E) LIFE STYLE (CONT-D)
Answer choices
2 3 4
Gone to parties for social activities
outside the home?
Attended meetings of civic, or other
organizations?
Entertained friends in your home?
Attended a religious service?
Spent time outdoors enjoying nature?
Played cards or other table games?
Visited with the neighbors?
Done grocery shopping?
Danced?
Read fiction for enjoyment?
Participated in a study group?
Taken medication for headache?
Taken medication to help you sleep?
Takem medication for your stomach?
Takem medication for a cold or allergy?
Taken tranquilizers?
Taken laxatives?
37
1 138
=39
140
F-140
=41
U]
Used alcohol or nonprescription drugs? I
Gotten high on alcohol or drugs?
DURING THE LAST MONTH, HAS ALCOHOL OR
DRUG USE CAUSED PROBLEMS . . .
Between you and family members?
With work (difficulty working well
or going to work)?
With your physical health?
In your thinking clearly?
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=34
u
i~
U
P
148
149
150
151
54
 Approved For Release 2003/09/10 : CIA-RDP96-00788R00170021003Tj2 BACKGROUND
(F) ARE YOU CURRENTLY LIVING WITH A PARENT, SPOUSE, OR SOMEONE ELSE IN A CLOSE
(1) No (If you marked No, skip to Section G below)
(2) Yes (If you marked "Yes", answer the 8 questions below)
Answer choices
1
2
SIGNIFICANT OTHER (spouse, parent, etc.) . . . Rarely
times
1.
Shared personal feelings with each other? 17
F_
2.
Been able to talk it through when angry?
3. Agreed about finances and budgetT
4
ent enjoyable times together? ED
S
E
.
p
Discussed important matters?
u
C
Felt close to each other?
Agreed about social activities and
friends?
8.
Shared daily events that happened to
each of you?
Answer choices
2 3
(G) ARE THERE CHILDREN WHERE YOU LIVE? (Mark one)
(1) No (If you marked No, skip to Section H below)
(2) Yes (If you marked "Yes", answer the next 6 questions)
DURING THE LAST MONTH, HAVE YOU AND THE Some-
CHILD(REN) . . . Rarely times Often
1. Spent time talking with each other?
2. Spent time doing things together?
3. Openly expressed feelings to each other?
4. Treated each other with respect?
5. Felt close to each other?
6. Done things for each other?
3 4
Almost
Always
71
Almost
Al ways
1. MAJOR SOURCE OF INCOME? 5. SMOKE
(Check only one answer)
(1)_ Money.earned from work I
do now
(2)
From spouse, relative, or
friend
(3)
Investments or inheritance
59
(4)
Welfare or public assistance
(5)
Retirement or social security
61
(6)
Unemployment compensation
62
(7)
Scholarship or student stipend
63
(8)
Alimony or child support
U U
ome- 3
(H) DO YOU HAVE ENOUGH MONEY TO Rarely__ time s_, Usual
Pay your bills? (Mark one) 7I Q
Handle unexpected expenses? (Mark one) Li l_____
4
Alwa s
FROM WORKING, DID YOU EARN AN ADEQUATE AMOUNT OF MONEY LAST MONTH? (Mark one)
(1) Earned no money from working last month
(2) Earned enough to take care of my personal needs (spending money)
(3) Earned enough to partially support a family
(4) Earned enough to adequately support a family
u
(9)_ Veterans benefits
2. YOUR MARITAL STATUS (Check one)
(1) Currently married
Separated, divorced, or
(2)
_
widowed
(3) Never married
3. SEX (Check one)
(1) Male
(2) Female
4. EDUCATION (Check one)
(1) Less than high school
(2)_ High school graduate
(3) Some college
(4) College graduate (Type
(2) Less than 2 pack per day
(3) About i pack per day
(4) About 1 pack per day
(5) Over 1' pack per day
6. DRINK COFFEE?
(1) None or rare cup
(2) About 1-2 cups. per day
(3) 3-4 cups per day
(4)_ 5 or more cups per day
7. WATCH TV?
(1 ) None or rarely
(2) Less than 1 hour per
day
(3) 1-2 hours per day
(4) 3-4 hours per day
(5) 5+ hours per day
8. AVERAGE HOURS OF SLEEP
(1) 4-5 hours
(2) 5-6 hours
(3) 6-7 hours
(4) 7-8 hours
(5) 8 or more hours
of degree
AGE 9-10
HEIGHT feet in. 11-13
WEIGHT pounds 14-16
Month Day Year
76 Sub? # 80
Thank you bon comp-et.Ing the questi.onnai Le. you'. help .ia veny much
appneaiuted. Pteaae check back to make hune you have not Zebt any
queal%onb unavusweAed.