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Lampiran

I. IDENTITAS RESPONDEN

1. Nama : .................................................................................

2. Jenis Kelamin : Laki-laki/Perempuan3. Tempat, Tanggal, Lahir : .................................................................................

4. Alamat : .................................................................................

.................................................................................

. Peker!aan : .................................................................................

". Penghasilan Keluarga : ............. ............... .............. ............... .............. ..........

#. Jumlah Angg$ta Keluarga %alam &umah

'. Penghasilan per Kapita

: ................$rang

: .................................................................................

(. Asuransi : )a , Jenis Asuransi: ............................................

Ti%ak

1*. N$. +p11. Tipe tr$ke

12. rekuensi tr$ke erulang

: .................................................................................: 1. tr$ke Penum0atan

2. tr$ke Per%arahan

: ... 0ulan

II. KUALITAS HIDUP

Circle One Number on Each Line

ellent er 5$$% 5$$% air P$$r

1. 6n general, 7$ul% $u sa $ur

health is:1 2 3 4

8uh 0etter n$7than $ne ear ag$

$me7hat 0etter

n$7 than $ne ear

ag$

A0$ut the same

$me7hat 7$rse

n$7 than $ne ear

ag$

8uh 7$rse n$7 than$ne ear ag$

2. Compared o one !ear a"o,

h$7 7$ul% $ur rate $ur health in

general no#9

1 2 3 4

The $ll$7ing items are a0$ut ati;ities $u might %$ %uring a tpial %a.

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)es, Limite% a L$t )es, Limite% a LittleN$, N$t limite% at

All

3. $i"orou% aci&iie%, suh as running, liting hea; $0!ets, partiipating in strenu$us

sp$rts1 2 3

4. 'oderae aci&iie%, suh as m$;ing a ta0le, pushing a ;auum leaner, 0$7ling, $r

plaing g$l

1 2 3

. Liting $r arring gr$eries 1 2 3

". >lim0ing %e&erallights $ stairs1 2 3

#. >lim0ing onelight $ stairs 1 2 3

'. en%ing, kneeling, $r st$$ping1 2 3

(. =alking more han a mile 1 2 3

1*. =alking %e&eral bloc(% 1 2 3

11. =alking one bloc( 1 2 3

12. athing $r %ressing $ursel 1 2 3

ut %$7n the am$unt $ time $u spent $n 7$rk $r $ther ati;ities1 2

14. Accompli%hed le%%than $u 7$ul% like1 2

1. =ere limite% in the (ind$ 7$rk $r $ther ati;ities 1 21". +a% di**icul!per$rming the 7$rk $r $ther ati;ities ?$r eample, it t$$k etra e$rt@ 1 2

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1#. >ut %$7n the amoun o* ime$u spent $n 7$rk $r $ther ati;ities1 2

1'. Accompli%hed le%%than $u 7$ul% like 1 2

1(.

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2". +a;e $u elt alm an% peaeul9 1 2 3 4 "

2#. imahi, ...

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