LIFESTYLE RESEARCH QUESTIONNAIRE
Copyright © 1985 by Al Louis Ripskis
We are conducting an in-depth survey of people's lifestyles in various parts of the world, and how well they like living there. Please circle the most appropriate response. For responses where you need more space please use a separate sheet of paper. Just jot down the question number (such as 2.E.3.) and your answer; no need to write out the question. When asked to rate (1-10), 1 means the least or the most negative, while 10 is highest or the most positive. If you don't want to answer a question put an "X" in front of it and proceed to the next one. If don't know, put "DK." If you are really pressed for time and can't respond to the entire questionnaire, then just answer the question with bold, underlined Roman numerals (I, IV, etc.)
The name of the place and country for which you are answering this questionnaire: _______________________________________________ Today's date__________
I. A. How long have you lived here?____ B.How do you find the climate __________ ?C. Is it objectionable during any time of the year, such as being excessively hot, cold, rainy, humid, windy or other ______________________.
II. A. What is your work status? 1. Employed full-time. 2. Part-time 3. Self-employed
4. Student 5. Househusband/Housewife. 6. Retired. 7. Unemployed. 8. Welfare
9. Volunteer work 10. Other, specify _________________________________________________
B. What do you find satisfying about your work? __________________________________________
C. What do you want to get from work and are you getting it? ______________________________
D. How would you summarize what you do?
E. How would you characterize what you do? 1. Stimulating; 2. Challenging; 3. Varied; 4. Routine; 5. Boring; 6. Other _____________________________________________________________
F. On average, how many hours a week do you work? _____
III. A. Marital status_____ (S=single; M=married;D=divorced; W=widowed; SP=separated) B.Number of children living with you __ C. Is this a good place to bring them up?(1-10)_____ Quality of Schools? ______ D. Your Education_____(years of schooling completed) E. Degree(s) obtained______ F. Total gross household income range: 1. Under $15,000; 2. $15,000 - $25,000; 3. $25,001 - $50,000; 4. $50,001 - $100,000; 5. Over $100,000
G. 1. Monthly Rent/Mortgage ____________; 2. Monthly utilities ___________.
IV.Earlier I mentioned the term "quality of life." What does that mean to you specifically?
A. What is a satisfactory standard of living for you? ______________________________________
B. How easy (1 = very easy; 10 = very difficult) is it here to earn sufficient income to maintain that standard of living?_________ B. Do you need to work overtime or have a second job? 1.Yes; 2.No. C.How do you find the cost of the following (1=very low; 5=reasonable; 10=very high) 1.Rent or mortgage payments?_________; 2.Food?_________; 3.Transportation?________;
V. In the area where you live, how many neighbors do you know?_____ 2. How well do you know them? ___________________________________________________________________________ ______
3. What activities do you participate in with your neighbors? _______________________________
4. How would you describe the neighborhood atmosphere? Friendly, cooperative, tense, angry, indifferent, other _____________________________
VI. A.If you were not born here, how easy or difficult was it to be accepted when you first arrived here?___ (10=very easy, 1=very difficult)
B.How long was it before they invited you to their home? _________________________________
VII. A. How many close friends do you have here? _____ B. How many of them would accept you unconditionally? _____ C. Where did you meet your friends? 1.School; 2.Work; 3.Socially; 4.Other________________
VIII. A. How satisfied (1-10) are you with the following aspects of your housing arrangement? 1.Size_____; 2.Quality_____; 3.Cost____ 4.Neighborhood__
B. What is your present housing arrangement? 1.Do you rent (R) Own (O)____? 2. Board (B) or share (S) housing expenses with someone_____?
C. Is there wide economic disparity where you live? 1.Yes; 2.No; 3. DK (Don't Know) D.Slums? 1.Yes; 2.No; 3.DK. E.High unemployment? l.Yes;
2.No ;3.DK. F. Widespread alcoholism? 1.Yes ; 2.No; 3.DK. G.High drug use? 1.Yes; 2.No; 3.DK. 4. If yes, what type? _______________ I.High suicide rate? 1.Yes; 2.No; 3.DK.
IX. A.1. To what extend (1-10) are you afraid for your personal safety while in public _____; 2. Robbery ______; 3. Pickpockets ______; 5. Fear the loss of your personal property while it's unattended where you are staying ______;5. If you have any other crime or personal safety concerns, please explain:
B. If you were to experience a medical emergency in public, how likely do you think strangers would get involved in assisting you (1-10) _____?
X. Now turning to recreation and play. A.What activities are you involved with? _________________ 1.Family; 2.Politics; 3.Sports; 4.Social life;
5.Special projects; 6.Religion; 7.Hobbies; 7.Arts & Crafts; 8.Other, explain ___________
B. Are you involved in any regular physical exercise program? 1=Yes; 2=No; If yes, what?____________________________; How often per week?_____
[FOR ANSWERING ITEMS "C" THROUGH "M" PLEASE USE A SEPARATE PIECE OF PAPER]
C.1.What provides you the greatest satisfaction and enjoyment in your life?
2.How much time do you devote to these activities? (hours per week)
D. When do you feel the happiest? How often do you find yourself happy?
E. What do you value most in life?
F. What has been your most exciting experience?
G. What has been your most moving experience?
H. What major changes have happened in your life and how did you feel about what was happening?
I. What moved you to make these major changes in your life?
J. Can you describe the periods in your life when you felt anguish, confusion and pain?
K. Are you worried or concerned about anything?
L. When do you feel most scared?
M. What's the most outrageous thing you have ever done?
N. Are you involved in any volunteer work? 1.Yes; 2.No; 3.If yes, what kind?__________________________________4.How many hours a week? _______
O. How would you describe your social life? a.Very active; b.Active; c.Inactive; d. Nonexistent. 2.What do you do? ________________________________________________________
P. Think of the last time you got together with your friends. What did you do or talk about? 1.Politics; 2.Sports; 3.Work; 4.Interpersonal relations; 5.Family events; 6.Books; 7.Movies; 8.Other ______________________________________________________________________
Q. 1.On average, how many hours a week do you watch TV?______ 2.What do you think of the quality of the programs in general? (1-10) _____
R. 1.Is there much in the way of live theater? a.Yes; b.No. 3. Quality 1-10______. S. Quality of movies available ______________________________________________________________________
XI. A. As to the intellectual aspects of your life--how often during the week do you get together with intellectually stimulating people? ____ B. Who? ________________________________________
C. Where? ___________________ D. Do you read much? 1.Y 2.N; 3.What were the last 3 books you read? _______________________________________________________________________
E. Is there a library that's accessible 1.Yes; 2.No; 3.Rate it 1-10 _______
F. How often do you read newspapers? 1.Every day; 2.Weekends; 3.Now and then; 4. Almost never. 5.Which? _______________________________________________________________
G. Are you involved in any other intellectually-related activities?
XII. A. Think back when you got up this morning. What was your mood?___________________ B. Was there anything you either looked forward to or dreaded? 1.Yes; 2.No; 3. If, yes, what?
C. What's your mood most days? ______________________________________ 1. Happy? 2. Neutral? 3. Mixed? 3. Bored? 4 Anxious? 5. Fearful?
6. Frustrated? 7. Depressed 8. Varies considerably from being_______________________ one day to being ____________________________ the next.
XIII. A. Over-all are you doing what's really important to you?
B. What are your core interests (activities, projects, persons) that you are committed to?
C. What other interests and hobbies do you have?
XIV. Do you have any specific short-term or long-term goals that you are working toward? 1.Y; 2.N; 3.If so, how would you describe them?
XV. How would you describe the pace of your life? A.Leisurely. B. Hectic. C. Comfortable. D. Stressful. E. Other _________
XVI. Describe your daily routine, if there is one. Get up at ...
XVII. Are you stuck in any important area of your life? (Stuck = strong, continuing dissatisfaction about some aspect your life which you have repeatedly attempted to change unsuccessful.) 1.Yes 2.No 3. If yes, please describe.
XVIII. A. Are you currently involved in a primary relationship? 1.Yes; 2.No; 3.If so, what do you find especially satisfying about this relationship?
4. Anything dissatisfying?
B. Are you at an impasse or stuck in any major way in that relationship? 1.Yes; 2.No C.How long have you been in this relationship? _____________________
D. If you are not currently involved in a primary relationship, how important is it for you to be in such a relationship? (1-10) _______
E. How difficult has it been in the past for you to find such a relationship? 1-10 _____. F. How often does your choice turn out badly? 1. Seldom; 2. Sometimes; 3. Often; 4. Most of the time; XIX. Your risk taking quotient. A. Smoke? 1.Yes; 2.No. 3. If, yes, how many cigarettes a day?______ B. Do you have more than 2 alcoholic drinks a day? 1.Yes; 2.No. C. Are you within 10% of your optimum weight? 1.Yes; 2.No. D. During the last 5 years have you been ticketed for excessive speed, reckless driving, or been involved in any accidents? 1.Yes; 2.No. 3. If yes how many times? ____? E. Circle any high-risk activities you have been involved in the last 5 years: Sky-diving, hand- gliding, unprotected sex with an untested person? Other ______________ _______________________.
F.On the 1-10 scale how would you rate yourself in terms of needing excitement in your life?________
XX. A. How would you rate your current state of happiness? 1-10 _____ B. Is there anything specific you attribute your happiness/unhappiness to?
XXI. A. What has been your experience with the local health care system-- doctors/hospitals? 1-10 _____ B.Overall, how would you rate the health care system: 1-10 _____ C.Your personal experience (1-10) in dealing with 1. local____; 2. state_____; 3. federal government agencies_____
XXII. A. Why did you move here, if you were not born here? 1.Work; 2. Other
B. What do you like most about living here?
XXIII. A. On the 1-10 scale how well or badly does the total environment support your lifestyle and activities you especially enjoy?
B. Are you mismatched or at odds in any significant way with your environment? 1.Yes;
2.No; 3.If, yes, explain.
C. Do the people here support your values? 1.Yes; 2.No; 3.If, no, explain
D. Are you comfortable with the pace of life? 1.Yes; 2.No; 3. If, no, explain ______________
E. If you had the power to change anything about this place, what would that be?
F. If you could live anywhere in the world, where would that be?
1.___________________________ 2. Why?
G. What would be your ideal lifestyle?
XXIV. Is there anything that we didn't cover in this questionnaire that seriously affects how well you like or dislike living here? If yes, please elaborate.