OLDER ADULT SELF-REPORT FOR AGES 60 AND ABOVE For office use only

Please print your answers. ID#

YOUR First Middle Last USUAL TYPE OF WORK, even if retired or not
FULL working now. Please be specific—for example, auto
NAME mechanic; high school teacher; homemaker; laborer;
YOUR GENDER YOUR ETHNIC lathe operator; shoe salesman; army sergeant.
Male Female AGE GROUP Your
OR RACE work
TODAY’S DATE YOUR BIRTHDATE Spouse or partner’s
Mo. Date Yr. Mo . Date Yr. work

PLEASE CHECK YOUR HIGHEST EDUCATION Please fill out this form to reflect
1. No high school diploma and no GED 7.Some graduate school your views, even if other people
2. General Equivalency Diploma (GED) but no graduate degree might not agree. You need not spend
3. High school graduate 8. Master’s Degree a lot of time on any item. Feel free
4. Some college but no college degree 9. Doctoral or Law Degree to print additional comments. Be
5. Associate’s Degree Other education (specify): sure to answer all items.
6. Bachelor’s or RN Degree _________________________

I. FRIENDS:

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A. About how many close friends do you have? (Do not include family members.)
None 1 2 or 3 4 or more

letters, e-mail.)

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Less than 1 1 or 2 3 or 4

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B. About how many times a month do you have contact with any close friends? (Include in-person contacts, phone,
5 or more

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C. How well do you get along with your close friends?
Not as well as I’d like Average Above average Far above average

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D. About how many times a month do friends or family visit you?
Less than 1 1 or 2 3 or 4 5 or more

II. SPOUSE OR PARTNER:

What is your marital status? Never been married Married but separated from spouse
Married, living with spouse Divorced
Widowed Other—please describe:

At any time in the past 2 months, did you live with your spouse or partner?
No—please skip to page 2.
Yes—Please circle 0, 1, or 2 beside items A-F to describe your relationship during the past 2 months:

0 = Not True 1 = Somewhat or Sometimes True 2 = Very True or Often True

0 1 2 A. I get along well with my spouse or 0 1 2 D. My spouse or partner and I enjoy
partner. similar activities.
0 1 2 B. My spouse or partner and I have trouble 0 1 2 E. I have trouble with my spouse or
sharing responsibilities. partner’s family.
0 1 2 C. I feel satisfied with my spouse or partner. 0 1 2 F. I like my spouse or partner’s friends.
Copyright 2004 T. Achenbach & P. Newhouse Please be sure you have answered all items.
ASEBA, University of Vermont Then see other side.
1 South Prospect St., Burlington, VT 05401-3456
www.ASEBA.org 6-04 Edition - 011
UNAUTHORIZED COPYING IS ILLEGAL
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 Please print your answers. Be sure to answer all items.
III. Below is a list of items that describe people. For each item, please circle 0, 1, or 2 to describe yourself
over the past 2 months. Please answer all items as well as you can, even if some do not seem to
apply to you.
0 = Not True 1 = Somewhat or Sometimes True 2 = Very True or Often True
0 1 2 1. I make good use of my time 0 1 2 36. I hear sounds or voices that others
0 1 2 2. I argue a lot think are not there (describe): ______
0 1 2 3. I have difficulty getting things done ______________________________
0 1 2 4. I take care of my appearance 0 1 2 37. I act without thinking
0 1 2 5. I use too much medication 0 1 2 38. I would rather be alone than with
0 1 2 6. I am self-confident others
0 1 2 7. I have trouble concentrating or paying 0 1 2 39. I do things that others don’t like
attention 0 1 2 40. I am nervous or tense
0 1 2 8. I can’t get my mind off certain thoughts 0 1 2 41. Parts of my body twitch or make
(describe):______________________ nervous movements (describe): ____
_______________________________ ______________________________
_______________________________ 0 1 2 42. I lack self-confidence
0 1 2 9. I have trouble sitting still (describe): 0 1 2 43. I am not liked by others
_______________________________ 0 1 2 44. I can do certain things better than

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other people

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0 1 2 10. I am too dependent on others
0 1 2 45. I am fearful or anxious

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0 1 2 11. I feel lonely 0 1 2 46. I feel dizzy or lightheaded
0 1 2 12. I feel confused or in a fog
0 1 2 47. I am bothered by a guilty conscience

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0 1 2 13. I cry a lot 0 1 2 48. I feel tired without good reason
0 1 2 14. I am too concerned about getting old

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49. Physical problems not due to known
0 1 2 15. I am mean to others physical cause or medication:

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0 1 2 16. I sit around and don’t do much
0 1 2 a. I have aches or pains (not stomach or
0 1 2 17. I deliberately try to hurt or kill myself headaches)
0 1 2 18. I try to get a lot of attention 0 1 2 b. I have headaches
0 1 2 19. I damage or destroy things 0 1 2 c. I feel nauseous or sick
0 1 2 20. I forget people’s names 0 1 2 d. I can’t see well, even with glasses
0 1 2 21. I worry about my future (describe):_____________________
0 1 2 22. I don’t get along with other people ______________________________
0 1 2 23. I feel too guilty 0 1 2 e. I have itching or rashes
0 1 2 24. I am jealous of others 0 1 2 f. I have stomachaches or cramps
0 1 2 25. I get along badly with my family 0 1 2 g. I vomit or throw up
0 1 2 26. I am afraid of certain situations or 0 1 2 h. My heart pounds or races
places (describe): ________________ 0 1 2 i. Parts of my body tingle or feel
_______________________________ numb
0 1 2 27. My relations with neighbors are poor 0 1 2 j. I am short of breath or I breathe hard
0 1 2 28. I am afraid I might think or do some- 0 1 2 k. Other physical problems not listed
thing bad (describe): _____________________
0 1 2 29. I have difficulty preparing my meals ______________________________
0 1 2 30. I feel that no one cares about me 0 1 2 50. I physically attack people
0 1 2 31. I feel that others are out to get me 0 1 2 51. I worry about my appearance
0 1 2 32. I feel worthless or inferior
0 1 2 52. I have trouble finishing things I
0 1 2 33. I feel sick a lot of the time should do
0 1 2 34. I feel restless or fidgety
0 1 2 53. There is very little that I enjoy
0 1 2 35. I like to have things my own way
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 Please print your answers. Be sure to answer all items.
0 = Not True 1 = Somewhat or Sometimes True 2 = Very True or Often True
0 1 2 54. My performance at tasks is poor 0 1 2 85. I lose my temper
0 1 2 55. I am poorly coordinated or clumsy
0 1 2 86. I think about sex too much
0 1 2 56. I avoid talking 0 1 2 87. I threaten to hurt people
0 1 2 57. I repeat certain acts over and over
0 1 2 88. I like to help others
(describe): _____________________ 0 1 2 89. I am too concerned about being neat
_______________________________ or clean
0 1 2 58. I have trouble making or keeping friends 0 1 2 90. I have trouble sleeping
0 1 2 59. I scream or yell a lot 0 1 2 91. I think about the past too much
0 1 2 60. I am secretive or keep things to myself 0 1 2 92. I don’t have much energy
0 1 2 61. I see things other people think are not 0 1 2 93. I am unhappy, sad, or depressed
there (describe): _________________ 0 1 2 94. I am louder than others
_______________________________ 0 1 2 95. I like to make others laugh
_______________________________ 0 1 2 96. I try to be fair to others
0 1 2 62. I am self-conscious or easily 0 1 2 97. I feel that I can’t succeed at
embarrassed things
0 1 2 63. I am being punished for what I have

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0 1 2 98. I like to try new things

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done 0 1 2 99. I keep from getting involved with
others

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0 1 2 64. I meet my responsibilities to others
0 1 2 65. I show off 0 1 2 100. I worry a lot
0 1 2 66. I am too shy or timid 0 1 2 101. I wake up too early

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0 1 2 67. My behavior is irresponsible 0 1 2 102. I worry too much about my health

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0 1 2 68. I sleep more than most people during 0 1 2 103. I have nightmares
the day

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0 1 2 104. I have trouble dressing myself
0 1 2 69. I have trouble making decisions 0 1 2 105. I don’t like to use the telephone
0 1 2 70. I have trouble talking 0 1 2 106. I have trouble bathing or grooming
0 1 2 71. I stand up for my rights 0 1 2 107. I feel younger than my age
0 1 2 72. I worry about my family 0 1 2 108. I like to read
0 1 2 73. I steal things 0 1 2 109. I am too concerned about death
0 1 2 74. I do things that other people think are 0 1 2 110. I have trouble remembering things I
strange (describe): _______________ am told
0 1 2 111. I have soiling accidents
_______________________________
0 1 2 75. I have thoughts that other people would 0 1 2 112. I make my own meals
0 1 2 113. I do my own laundry
think are strange (describe):________
_______________________________ 0 1 2 114. If I don’t write things down, I forget
them
0 1 2 76. I am stubborn, sullen, or irritable 0 1 2 115. I am bored
0 1 2 77. My moods or feelings change suddenly
0 1 2 116. I do my own shopping
0 1 2 78. I enjoy being with people 0 1 2 117. I get too tired from doing my daily tasks
0 1 2 79. I am suspicious 0 1 2 118. I am a happy person
0 1 2 80. I drink too much alcohol or get drunk 0 1 2 119. I believe that people trust me
0 1 2 81. I think about killing myself 0 1 2 120. I make good use of opportunities
0 1 2 82. I do things that may cause trouble 0 1 2 121. I feel that I am a burden on
with the law (describe):____________ others
_______________________________ 0 1 2 122. I worry too much about my
memory
0 1 2 83. I talk too much
0 1 2 84. I seem to irritate people 0 1 2 123. I have a good sense of humor

Page 3 Please be sure you have answered all items.

Then see other side.
 Please print your answers. Be sure to answer all items.
124. In the past 2 months, about how many times per day did you use tobacco (including smokeless tobacco)?
___________ times per day.
125. In the past 2 months, on how many days did you have 5 or more alcoholic drinks? ________ days.
126. In the past 2 months, on how many days were you drunk? ________ days.
127. In the past 2 months, on how many days did you use drugs for nomedical purposes (including marijuana,
amphetamines, and other drugs except alcohol and nicotine)? ________ days.

IV. Do you have any illness, disability, or handicap?

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No Yes—please describe:

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V. Please check each of the following that describes where you live:

Own home

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Retirement community

Other - please describe:

Relative’s home

Assisted living
Senior apartment

Nursing home

VI. Please describe any concerns or worries you have about your living situation, relationships, or
other things: No concerns

VII. Please describe the best things about yourself:

VIII. Please write down anything else that describes your feelings, behavior, interests, spiritual
experiences, or other things that are important to you:

Page 4 Please be sure you have answered all items.