The 17 items of the Duke questionnaire
| Yes, describes me exactly | Somewhat describes me | No, doesn't describe me at all | |
|---|---|---|---|
| 1. I like who I am | |||
| 2. I am not an easy person to get along with | |||
| 3. I am basically a healthy person | |||
| 4. I give up too easily | |||
| 5. I have difficulty concentrating | |||
| 6. I am happy with my family relationships | |||
| 7. I am comfortable being around people | |||
| TODAY would you have any physical trouble or difficulty: | None | Some | A lot |
| 8. Walking up a flight of stairs? | |||
| 9. Running the length of a football field? | |||
| DURING THE PAST WEEK, how much trouble have you had with: | None | Some | A lot |
| 10. Sleeping? | |||
| 11. Hurting or aching in any part of your body? | |||
| 12. Getting tired easily? | |||
| 13. Feeling depressed or sad? | |||
| 14. Nervousness? | |||
| DURING THE PAST WEEK, how often did you: | None | Some | A lot |
| 15. Socialise with other people (talk or visit with friends or relatives)? | |||
| 16. Take part in social, religious, or recreation activities (meetings, church, movies, sports, parties)? | |||
| DURING THE PAST WEEK, how often did you: | None | 1–4 days | 5–7 days |
| 17. Stay in your home, a nursing home, or hospital because of sickness, injury, or other health problem? |