| Question | Score | |||||||||
| −4 | −3 | −2 | −1 | 0 | 1 | 2 | 3 | 4 | ||
| 1 | Your physical health | □ | □ | □ | □ | □ | □ | □ | □ | □ |
| 2 | Your mental health | □ | □ | □ | □ | □ | □ | □ | □ | □ |
| 3 | Your way of entertainment | □ | □ | □ | □ | □ | □ | □ | □ | □ |
| 4 | Your family harmony | □ | □ | □ | □ | □ | □ | □ | □ | □ |
| 5 | Your neighbourhood interaction | □ | □ | □ | □ | □ | □ | □ | □ | □ |
| 6 | Your interaction with relatives and friends | □ | □ | □ | □ | □ | □ | □ | □ | □ |
| 7 | Your residential environment | □ | □ | □ | □ | □ | □ | □ | □ | □ |
| 8 | Your working or studying environment | □ | □ | □ | □ | □ | □ | □ | □ | □ |