PHI stands for "Protected Health Information" (Y = Yes, N = No)
| Display | Field | Phi | Field type | Condition choices | Field note | Header | |
|---|---|---|---|---|---|---|---|
| - | lfq_a | N | checkbox | 0, If you never spend time with your friends, or if you have no friends, indicate so by placing a checkmark in the box. | - | How much difficulty have you had in the following areas over the past month? (Please indicate by marking the box that best describes your degree of difficulty, if any, over the past month)._x000D_ _x000D_ Leisure time with friends | |
| 1. Time: amount of time spent with friends | lfq_1 | N | radio | 1, No problems | 2, Mild | 3, Moderate | 4, Severe | - | Degree of difficulty functioning | |
| 2. Conflict: getting along with friends | lfq_2 | N | radio | 1, No problems | 2, Mild | 3, Moderate | 4, Severe | - | - | |
| 3. Enjoyment: enjoying time spent together | lfq_3 | N | radio | 1, No problems | 2, Mild | 3, Moderate | 4, Severe | - | - | |
| If you are having ANY difficulty, what do you think is the cause? | lfq_a_difficulty | Y | text | - | - | - | |
| - | lfq_b | N | checkbox | 0, If you never spend time with your family, or if you have no family, indicate so by placing a checkmark in the box. | - | Leisure time with family | |
| 4. Time: amount of time spent with family | lfq_4 | N | radio | 1, No problems | 2, Mild | 3, Moderate | 4, Severe | - | Degree of difficulty functioning | |
| 5. Conflict: getting along with family | lfq_5 | N | radio | 1, No problems | 2, Mild | 3, Moderate | 4, Severe | - | - | |
| 6. Enjoyment: enjoying and having an interest in family | lfq_6 | N | radio | 1, No problems | 2, Mild | 3, Moderate | 4, Severe | - | - | |
| If you are having ANY difficulty, what do you think is the cause? | lfq_b_difficulty | Y | text | - | - | - | |
| - | lfq_c | N | checkbox | 0, If you have no duties at home, or are homeless, indicate so by placing a checkmark in the box. | - | Duties at home (e.g. housework, paying bills, grocery shopping, mowing lawn, childcare tasks, car repairs) | |
| 7. Time: amount of time spent performing | lfq_7 | N | radio | 1, No problems | 2, Mild | 3, Moderate | 4, Severe | - | Degree of difficulty functioning | |
| 8. Conflict: can you perform these duties without undue friction with others? | lfq_8 | N | radio | 1, No problems | 2, Mild | 3, Moderate | 4, Severe | - | - | |
| 9. Enjoyment: enjoying and having an interest in home duties | lfq_9 | N | radio | 1, No problems | 2, Mild | 3, Moderate | 4, Severe | - | - | |
| 10. Performance: quality of work (doing a good job; getting the job done) | lfq_10 | N | radio | 1, No problems | 2, Mild | 3, Moderate | 4, Severe | - | - | |
| If you are having ANY difficulty, what do you think is the cause? | lfq_c_difficulty | Y | text | - | - | - | |
| - | lfq_d | N | checkbox | 0, (If you are not working or not in school, indicate this by placing a checkmark in the box) | - | Duties at work, school, or activity center | |
| 11. Time: amount of time spent at work, school, etc | lfq_11 | N | radio | 1, No problems | 2, Mild | 3, Moderate | 4, Severe | - | Degree of difficulty functioning | |
| 12. Conflict: getting along with co-workers and supervisors | lfq_12 | N | radio | 1, No problems | 2, Mild | 3, Moderate | 4, Severe | - | - | |
| 13. Enjoyment: enjoyment/satisfaction and interest from work | lfq_13 | N | radio | 1, No problems | 2, Mild | 3, Moderate | 4, Severe | - | - | |
| 14: Performance: quality of work | lfq_14 | N | radio | 1, No problems | 2, Mild | 3, Moderate | 4, Severe | - | - | |
| If you are having ANY difficulty, what do you think is the cause? | lfq_d_difficulty | Y | text | - | - | - | |
| A. Work | lfq_15 | N | radio | 1, 1. Not Applicable | 2, 2. 0-5 Days | 3, 3. 6-10 Days | 4, 4. 11-20 Days | 5, 5. Over 20 Days | - | How many days did you miss over this last month at work or school due to your mental illness? | |
| B. School | lfq_16 | N | radio | 1, 1. Not Applicable | 2, 2. 0-5 Days | 3, 3. 6-10 Days | 4, 4. 11-20 Days | 5, 5. Over 20 Days | - | - | |
| Did any of the following factors cause you difficulties at work this month, or cause you to work less than full-time, or not at all? (Please mark all that apply for this month.) | lfq_17 | N | checkbox | 1, 1. Too depressed most the time | 2, 2. Too manic most of the time | 3, 3. Couldn't get my mood stable long enough to work - too up and down | 4, 4. Afraid to work at usual level because afraid of precipitating another episode | 5, 5. Wanted to work but the kind of job that I could get due to my broken resume (i.e. gaps in work history) was too demeaning for my educational level | 6, 6. Mood OK and wanted to work but couldn't get a job due to my broken resume (i.e. gaps in work history) | 7, 7. Couldn't get along with others | 8, 8. Wanted my old job but couldn't get it | 9, 9. Could get my old job but felt embarrassed to go back | 10, 10. Disability check was greater than could have made otherwise | 11, 11. Didn't have a job for a long time prior to this most recent episode | 12, 12. Physical symptoms (e.g. difficulty concentrating, blurred vision, fatigue/sedation) interfered with my functioning | 13, 13. Didn't need to work (retired, supported by someone else, etc), but I could if need be | 14, 14. Medication side effects with functioning | 15, 15. Other | - | - | |
| 15. Other, please specify | lfq_17_other | Y | text | - | - | - | |
| Competitive Job | lfq_18 | N | checkbox | 1, 1. Full-time at same or higher job level than that held prior to most recent episode | 2, 2. Part-time at same or higher job level than that held prior to most recent episode | 3, 3. Full-time at lower job level than that held prior to most recent episode | 4, 4. Part-time at lower job level than that held prior to most recent episode | - | Work situation this month: (Please mark only those boxes that apply in the last 30 days) | |
| Transitional Job | lfq_19 | N | checkbox | 5, 5. Full-time | 6, 6. Part-time | - | - | |
| Work training | lfq_20 | N | checkbox | 7, 7. Work training | - | - | |
| Sheltered workshop | lfq_21 | N | checkbox | 8, 8. Sheltered workshop | - | - | |
| Volunteer | lfq_22 | N | checkbox | 9, 9. Full-time | 10, 10. Part-time | - | - | |
| Student | lfq_23 | N | checkbox | 11, 11. Full-time | 12, 12. Part-time | - | - | |
| Housewife/husband | lfq_24 | N | checkbox | 13, 13. As full time job | 14, 14. As part time job | - | - | |
| Not working in job, school, or home | lfq_25 | N | checkbox | 15, 15. Not working in job, school, or home | - | - | |
| 16. Other (please explain) | lfq_26 | Y | text | - | - | - | |
| Work | lfq_27 | N | radio | 0, 0 | 1, 1 | 2, 2 | 3, 3 | 4, 4 | 5, 5 | 6, 6 | 7, 7 | - | How many DAYS per week are you scheduled to attend: | |
| School | lfq_28 | N | radio | 0, 0 | 1, 1 | 2, 2 | 3, 3 | 4, 4 | 5, 5 | 6, 6 | 7, 7 | - | - | |
| Day Hospital | lfq_29 | N | radio | 0, 0 | 1, 1 | 2, 2 | 3, 3 | 4, 4 | 5, 5 | 6, 6 | 7, 7 | - | - | |
| Activity Center | lfq_30 | N | radio | 0, 0 | 1, 1 | 2, 2 | 3, 3 | 4, 4 | 5, 5 | 6, 6 | 7, 7 | - | - | |
| Living situation over last six months (Please <b>mark all</b> that apply) | lfq_31 | N | checkbox | 1, 1. Hospital | 2, 2. Skilled nurse facility - 24-hour nursing service | 3, 3. Intermediate care facility - less than 24-hour nursing care facility | 4, 4. Supervised group living (long-term) | 5, 5. Transitional group home (halfway or quarterway house) | 6, 6. Family foster care | 7, 7. Cooperative apartment, supervised (staff on premises) | 8, 8. Cooperative apartment, unsupervised (staff not on premises) | 9, 9. Board and care home (private proprietary home for adults, with program and supervision) | 10, 10. Boarding house (includes meals, no program or supervision) | 11, 11. Rooming or boarding house or hotel (includes single room occupancy, no meals are provided, cooking facilities may be available) | 12, 12. Private house or apartment | 13, 13. Shelter | 14, 14. Jail | 15, 15. No residence (that is, you often need to live/sleep on the streets, or other areas not generally intended for residence) | - | - | |
| Financial situation over last six months (Please mark all that apply): | lfq_32 | N | checkbox | 1, 1. Received no pay (fully supported by someone else; e.g. parents, spouse, etc.) | 2, 2. Received wages for work performed | 3, 3. Received SSI (Supplemental Security Income) or SSD (Social Security Disability) | 4, 4. Retirement Benefits | 5, 5. Other (Please specify) | - | - | |
| 5. Other, please specify: | lfq_32_specify | Y | text | - | - | - | |
| When did you last work full-time? | lfq_33 | N | radio | 1, 1. I work full-time now | 2, 2. I have never worked full-time | 3, 3. Within last 2 years | 4, 4. 2-5 years ago | 5, 5. 5-10 years ago | 6, 6. Over 10 years ago | - | - | |
| How long were you working full-time the last time you worked full-time? | lfq_34 | N | radio | 1, 1. Less than 1 month | 2, 2. Less than 6 months | 3, 3. Less than 1 year | 4, 4. 1 year or more | - | - | |
| 1. Mental illness | lfq_stopwork_1 | N | checkbox | 1, 1 | 2, 2 | 3, 3 | 4, 4 | 5, 5 | 6, 6 | - | C. Why did you stop working full-time? (If more than one reason, please rank in order of importance 1-6) | |
| 2. Physical illness | lfq_stopwork_2 | N | checkbox | 1, 1 | 2, 2 | 3, 3 | 4, 4 | 5, 5 | 6, 6 | - | - | |
| 3. Children | lfq_stopwork_3 | N | checkbox | 1, 1 | 2, 2 | 3, 3 | 4, 4 | 5, 5 | 6, 6 | - | - | |
| 4. Couldn't find job after leaving/being laid off | lfq_stopwork_4 | N | checkbox | 1, 1 | 2, 2 | 3, 3 | 4, 4 | 5, 5 | 6, 6 | - | - | |
| 5. Retired | lfq_stopwork_5 | N | checkbox | 1, 1 | 2, 2 | 3, 3 | 4, 4 | 5, 5 | 6, 6 | - | - | |
| 6. Other | lfq_stopwork_6 | N | checkbox | 1, 1 | 2, 2 | 3, 3 | 4, 4 | 5, 5 | 6, 6 | - | - | |
| 6C Explanation: | lfq_stopwork_5creason | Y | text | - | - | - | |
| Notes | lfq_notes | Y | notes | - | - | - |