Number of Blaise fields: 643
Seq # | Var | Question | Data Type/Coding |
---|---|---|---|
1 | ivisit | visit | |
2 | projid | ROS FOLLOW-UP Interview (v4.0 Rev 02/21/2022) Enter project ID number. | String[8] |
3 | visit | Enter curent visit code from face sheet: CODE F/U Year CODE F/U Year CODE F/U Year CODE F/U Year 00 = Baseline 08 = 8th F/U 16 = 16th F/U 24 = 24th F/U 01 = 1st F/U 09 = 9th F/U 17 = 17th F/U 25 = 25th F/U 02 = 2nd F/U 10 = 10th F/U 18 = 18th F/U 26 = 26th F/U 03 = 3rd F/U 11 = 11th F/U 19 = 19th F/U 27 = 27th F/U 04 = 4th F/U 12 = 12th F/U 20 = 20th F/U 28 = 28th F/U 05 = 5th F/U 13 = 13th F/U 21 = 21th F/U 29 = 29th F/U 06 = 6th F/U 14 = 14th F/U 22 = 22th F/U 30 = 30th F/U 07 = 7th F/U 15 = 15th F/U 23 = 23th F/U 31 = 30th F/U ... 50 = 50th F/U | String[2] |
4 | dateint | Date of interview | Date type |
5 | baseyear | Enter year of baseline from face sheet: | 1993 .. 2025 |
6 | formno | INTRODUCTION Form Number | String[8] |
7 | version | version Number. | String[4] |
8 | autodate | Automatic Date. | Date type |
9 | autotime | Automatic Time. | TimeType |
10 | autolog | Automatic Logged Date. | Date type |
11 | intid | INTERVIEWER ID | 100 .. 997 |
12 | compid | Laptop ID | String[20] |
13 | datlas | Date of previous ROS questionnaire | Date type |
14 | sex | 1. Record participant's sex. | 1= Male 2= Female |
15 | autotm | [COMPUTER CLOCK TIME] | String[8] |
16 | phone | Was this interview completed over the telephone or in person? | 1= In-person 2= Telephone |
17 | ssnmedneeded | Do we need to obtain SSN and/or Medicare# from this participant? [INTERVIEWER: Check the face sheet. Enter NO if both SSN and Medicare# have been collected. Enter NO if participant refuses to provide both SSN and Medicare#. Enter 'Yes, both' if participant is able to provide both SSN and Medicare#. Enter 'Yes, SSN only' if participant is able to provide only the SSN. Enter 'Yes, Medicare# only' if participant is able to provide only the Medicare#.] | 2= No 1= Yes, both 3= Yes, SSN only 4= Yes, Medicare# only |
18 | q5loc | What is your social security number? | 0 .. 999999999 |
19 | q5aloc | [ENTER R. SOCIAL SECURITY NUMBER AGAIN] | 0 .. 999999999 |
20 | q6loc | What is your medicare number? Please show me your card. | String[11] |
21 | q6aloc | [ENTER R. MEDICARE NUMBER AGAIN] | String[11] |
22 | validated | ||
23 | validateerror | ||
24 | errorposition | ||
25 | validated_hicn_cms | ||
26 | validated_rrb_pre1964 | ||
27 | validated_rrb_post1964 | ||
28 | hicnformats | ||
29 | hicn_alpha | ||
30 | hicn_numbers | ||
31 | strlen | ||
32 | hicn_trimmed | ||
33 | ssn_br | Do we need to obtain SSN from this participant? [INTERVIEWER: Check the face sheet. Enter YES if participant is able to provide the SSN. Enter NO if SSN is not to be collected.] | 1= Yes 2= No, already collected 3= No, face sheet stated NOT to ask Pt 4= No, Pt does not have it available or is not eligible 5= No, Pt has mild reluctance 6= No, Pt has moderate reluctance 7= No, Pt has strong reluctance |
34 | ssn | What is your social security number? [INTERVIEWER: Please enter the SSN in 000-00-0000 format.] | String[11] |
35 | ssn_c | [ENTER R. SOCIAL SECURITY NUMBER AGAIN] | String[11] |
36 | hicn_br | Do we need to obtain the old Medicare#(HICN) from this participant? [INTERVIEWER: Check the face sheet. Enter YES if participant is able to provide the HICN. Enter NO if HICN is not to be collected.] | 1= Yes 2= No, already collected 3= No, face sheet stated NOT to ask Pt 4= No, Pt does not have it available or is not eligible 5= No, Pt has mild reluctance 6= No, Pt has moderate reluctance 7= No, Pt has strong reluctance |
37 | hicn | What is your old medicare number(HICN) ? Please show me your card. [INTERVIEWER: valid HICN formats include 000000000A, 000000000C1, A000000000 or A000000.] | String[11] |
38 | hicn_c | [ENTER R. MEDICARE NUMBER(HICN) AGAIN] | String[11] |
39 | hicn_type | HICN Type: ^hicnFormats | String[15] |
40 | mbi_br | Do we need to obtain the new Medicare#(MBI) from this participant? [INTERVIEWER: Check the face sheet. Enter YES if participant is able to provide the MBI. Enter NO if MBI is not to be collected.] | 1= Yes 2= No, already collected 3= No, face sheet stated NOT to ask Pt 4= No, Pt does not have it available or is not eligible 5= No, Pt has mild reluctance 6= No, Pt has moderate reluctance 7= No, Pt has strong reluctance |
41 | mbi | What is your new medicare number(MBI) ? Please show me your card. [INTERVIEWER: Please enter the MBI in 01EG4-TE5-MK73 format.] | String[13] |
42 | mbi_c | [ENTER R. MEDICARE NUMBER(MBI) AGAIN] | String[13] |
43 | q1qua | QUALITY OF LIFE Now I have some general questions about your health. 1. As compared to other people your own age, would you say that your health is excellent, good, fair or poor? | 1= Excellent 2= Good 3= Fair 4= Poor |
44 | q2qua | 2. Now, thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good? [ENTER NUMBER OF DAYS] | 0 .. 30 |
45 | q3qua | 3. Now, thinking about your mental health, which includes stress, depression, or problems with your emotions. For how many days during the past 30 days was your mental health not good? [ENTER NUMBER OF DAYS] | 0 .. 30 |
46 | q4qua | 4. During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation? [ENTER NUMBER OF DAYS] | 0 .. 30 |
47 | chf | CONGESTIVE HEART FAILURE Since your last interview on [last interview date], have you been told by a doctor, nurse, or therapist that you had.....congestive heart failure? | 1= Yes 2= Suspect or possible 3= No |
48 | heartfu | MEDICAL HISTORY - CARDIOVASCULAR DISEASE Now, I have some questions about a number of specific medical conditions. 1. Since your last study interview on [last interview date], have you been told by a doctor, nurse or therapist that you had a heart attack or coronary, or coronary thrombosis, or coronary occlusion, or myocardial infarction? | 1= Yes 2= Suspect or possible 3= No |
49 | multipfu | 1a. Did you have only one or more than one? | 1= Only one 2= More than one |
50 | inhospfu | 1b Were you hospitalized overnight or longer for this (last one)? | 1= Yes 2= No |
51 | hospnafu | 1d. What was the name of the (last) hospital? [SPECIFY] | String[40] |
52 | cancerfu | CANCER OR MALIGNANCY 1. Since your last interview on [last interview date], have you been told by a doctor, nurse or therapist that you had ... Cancer, malignancy or tumor of any type? | 1= Yes 2= Suspect or possible 3= No |
53 | ca1afu | 1a. Where was it? [OR: Where was the most recent cancer that you had?] [SPECIFY] | String[20] |
54 | ca1bfu | 1b. Were you hospitalized overnight or longer for this? | 1= Yes 2= No |
55 | ca1dfu | 1c. What was the name of the (last) hospital? [SPECIFY] | String[40] |
56 | diabetfu | DIABETES 1. (Since your last interview on [last interview date], have you been told by a doctor, nurse or therapist that you had ...) 2. Diabetes, or sugar in the urine, or high blood sugar? | 1= Yes 2= Suspect or possible 3= No |
57 | db1fu | 2. Has a doctor, nurse or therapist, told you to take insulin or injections for your high blood sugar? | 1= Yes 2= No |
58 | db1afu | 2a Are you currently taking insulin or injections? | 1= Yes 2= No |
59 | db3fu | 3 Has a doctor, nurse, or therapist told you to take medicine by mouth for your high blood sugar? | 1= Yes 2= No |
60 | db3afu | 3a Are you currently doing this? | 1= Yes 2= No |
61 | highbpfu | HIGH BLOOD PRESSURE (Since your interview on [last interview date], have you been told by a doctor, nurse or therapist that you had ...) 1. High blood pressure? | 1= Yes 2= Suspect or possible 3= No |
62 | bp30fu | 2 Has a doctor, nurse, or therapist told you to take medicine by mouth for your high blood pressure? | 1= Yes 2= No |
63 | bp3afu | 2a Are you currently doing this? | 1= Yes 2= No |
64 | herpesfu | HERPES ZOSTER (Since your interview on [last interview date], have you been told by a doctor, nurse or therapist that you had ...) 1. Shingles or herpes zoster? | 1= Yes 2= Suspect or possible 3= No |
65 | thyroifu | THYROID DISEASE (Since your interview on [last interview date], have you been told by a doctor, nurse or therapist that you had ...) 1. Thyroid disease? | 1= Yes 2= Suspect or possible 3= No |
66 | th5bfu | 1b. Were you hospitalized overnight or longer for thyroid disease? | 1= Yes 2= No |
67 | th5dfu | 1c. What was the name of the (last) hospital? [SPECIFY] | String[40] |
68 | brokenfu | BROKEN HIP (Since your interview on [last interview date], have you been told by a doctor, nurse or therapist that you had ...) 1. A broken or fractured hip? | 1= Yes 2= Suspect or possible 3= No |
69 | hip6afu | 1a. Were you ever hospitalized overnight or longer for this? | 1= Yes 2= No |
70 | hip6cfu | 1b. What was the name of the (last) hospital? [SPECIFY] | String[40] |
71 | arthritis | Arthritis Since your last study interview on ^IntroBlock_datlas, have you been told by a doctor, nurse or therapist that you had osteoarthritis? | 1= Yes 2= Suspect or possible 3= No |
72 | gout | Since your last study interview on ^IntroBlock_datlas, have you been told by a doctor, nurse or therapist that you had gout? | 1= Yes 2= Suspect or possible 3= No |
73 | osteoporosis | Since your last study interview on ^IntroBlock_datlas, have you been told by a doctor, nurse or therapist that you had osteoporosis? | 1= Yes 2= Suspect or possible 3= No |
74 | joint_disease | Since your last study interview on ^IntroBlock_datlas, have you been told by a doctor, nurse or therapist that you had other joint disease (excluding cancer)? | 1= Yes 2= Suspect or possible 3= No |
75 | chespafu | CHEST PAIN Now some questions about pains in your chest. 1. Since [last interview date], have you had any pain or discomfort in your chest? | 1= Yes 2= No |
76 | pressufu | 1a. Have you had any pressure or heaviness in your chest? | 1= Yes 2= No |
77 | uphil0fu | 2. Do you get this pain or discomfort when you walk uphill or hurry? | 1= Yes 2= No 3= Never walks uphill or hurries |
78 | level0fu | 3. Do you get this pain or discomfort when you walk at an ordinary pace on the level? | 1= Yes 2= No |
79 | dowha0fu | 4. What do you do if you get this pain while you are walking? [IF CONTINUED AFTER TAKING NITROGLYCERIN,RECORD AS `Stop or slow down'] | 1= Stop or slow down 2= Take a nitroglycerin 3= Continue at the same pace |
80 | stand0fu | 5. If you stand still, what happens to the pain? | 1= Relieved 2= Not relieved |
81 | howso0fu | 5a. How soon is the pain relieved? | 1= 10 minutes or less 2= More than 10 minutes |
82 | musterfu | 6a. Will you show me where it was? Sternum (middle or upper) | 1= Show 2= Not shown |
83 | lowstefu | 6b. Sternum (lower) | 1= Show 2= Not shown |
84 | lantchfu | 6c. Left anterior chest | 1= Show 2= Not shown |
85 | leftarfu | 6d. Left arm | 1= Show 2= Not shown |
86 | otherfu | 7. Did you feel it anywhere else? | 1= Yes 2= No |
87 | wherefu | 7a. Where? [SPECIFY] | String[30] |
88 | attackfu | 8. Have you had a severe pain across the front of your chest lasting half an hour or more? | 1= Yes 2= No |
89 | seedocfu | 9. Did you see a doctor because of the pain? | 1= Yes 2= No |
90 | docsaifu | 9a. What did (s)he say it was? | String[40] |
91 | howma0fu | 10. How many of these attacks have you had? | 1 .. 99 |
92 | legpain | CLAUDICATION Now some questions about pains in your legs 1. Do you get pain in either leg while walking? | 1= Yes 2= No |
93 | standsit | 2. Does this pain ever begin when you are standing still or sitting? | 1= Yes 2= No |
94 | calf | 3. In what part of your leg do you feel it? [IF CALVES NOT MENTIONED ASK: `Anywhere else?' IF STILL NOT MENTIONED, CODE 2] | 1= Pain includes calf/calves 2= Pain does not include calf |
95 | uphill1 | 4. Do you get this pain when you walk uphill or hurry? | 1= Yes 2= No 3= Never walks uphill or hurries |
96 | level1 | 5. Do you get this pain when you walk at an ordinary pace on the level? | 1= Yes 2= No |
97 | disapp | 6. Does this pain ever disappear while you are still walking? | 1= Yes 2= No |
98 | dowhat1 | 7. What do you do if you get this pain while you are walking? | 1= Stop/slacken the pace 2= Continue at the same pace |
99 | stand1 | 8. What happens to the pain if you stand still? | 1= Relieved 2= Not relieved |
100 | howsoon1 | 8a. How soon is it relieved? | 1= 10 minutes or less 2= More than 10 minutes |
101 | hormadm | HORMONE REPLACEMENT Now I'd like to ask you about hormonal medications you may have used. Hormones are sometimes used by women around the time of their change of life, after surgery on their ovaries, to control heavy or irregular menstrual periods, or for prevention of disease such as bone loss. These medications include pills, injections, vaginal creams or suppositories, or skin patches. [Please enter c for first question.] | String[1] |
102 | hormonfu | 1. Since [last interview date], have you taken any type of estrogen hormonal medication, for example Premarin, Ogen or Estrace, or progesterone hormonal medication, for example, Provera? | 1= Yes 2= Suspect 3= No |
103 | pillfu | Were these estrogen or progesterone hormones in the form of a pill, injection, vaginal cream or suppository, or skin patch? 2. pill or other oral dosage form | 1= Yes 2= Suspect 3= No |
104 | shotfu | 3. injection (shot) | 1= Yes 2= Suspect 3= No |
105 | cosfu | 4. vaginal cream or suppository | 1= Yes 2= Suspect 3= No |
106 | patchfu | 5. skin patch | 1= Yes 2= Suspect 3= No |
107 | currenfu | 6. Are you currently taking this/these medications? | 1= Yes 2= No |
108 | dizzyfu | DIZZINESS Now some questions about dizziness or lightheadedness. 1. Have you had an episode of dizziness or lightheadedness since your last interview on [last interview date]? | 1= Yes 2= Suspect 3= No |
109 | freq0fu | 2. How often, on average, do they occur? Would you say that they occur about once a year or less, several times a year, once a month, several times a month, once a week, or several times a week? | 1= once a year or less 2= several times a year 3= once a month 4= several times a month 5= once a week 6= several times a week |
110 | severifu | 3. How severe, on average, are these episodes? Would you say they are usually not severe at all, slightly severe, somewhat severe, very severe, or extremely severe? | 1= not severe at all 2= slightly severe 3= somewhat severe 4= very severe 5= extremely severe |
111 | spinfu | 4. During any of these episodes, did you definitely feel as if either you or the room was actually spinning, turning or moving? | 1= Yes 2= Suspect 3= No |
112 | numspifu | 4a. How many episodes like this have you had? Would you say one, or two to five, six to ten, or more than ten? | 1= One 2= two to five 3= six to ten 4= more than ten |
113 | timespfu | 4b. How long, on average, does a typical episode last? Would you say less than 5 seconds, between 5 seconds and 5 minutes, between 5 minutes and 1 hour, between 1 hour and 2 days, or more than 2 days? | 1= < 5 seconds 2= 5 seconds - 5 minutes 3= > 5 minutes - 1 hour 4= > 1 hour - 2 days 5= > 2 days |
114 | dzdoctfu | 4c. Since your last interview on [last interview date], have you seen a doctor because of an episode of dizziness? | 1= Yes 2= No |
115 | dzhospfu | 4d. Were you hospitalized overnight or longer for this (last one)? | 1= Yes 2= No |
116 | dzhonmfu | 4f. What was the name of the (last) hospital? | String[40] |
117 | jointsfu | JOINTS Now a few questions about your joints. 1. Since your last interview on [last interview date] have you had pain or aching in any of your joints on most days for at least one month? | 1= Yes 2= No |
118 | neckpafu | 2. ...Pain in your neck or back on most days for at least one month? | 1= Yes 2= No |
119 | neckpafu2 | 2. ...Pain in your neck on most days for at least one month? | 1= Yes 2= No |
120 | backpafu | 2. ...Pain in your back on most days for at least one month? | 1= Yes 2= No |
121 | hippaifu | 3. ...Pain in or around either hip joint including the buttock, groin, and side of the upper thigh on most days for at least one month? | 1= Yes 2= No |
122 | kneepafu | 4. ...Pain in or around the knees including the back of the knee on most days for at least one month? | 1= Yes 2= No |
123 | swellifu | 5. ...Swelling at a joint, with pain present in the joint when touched, on most days for at least one month? | 1= Yes 2= No |
124 | stifffu | 6. ...Stiffness in the joints and muscles when getting out of bed in the morning lasting for at least 15 minutes? | 1= Yes 2= No |
125 | feetpafu | 7. ...Pain or aching in either of your feet on most days for at least one month? | 1= Yes 2= No |
126 | handpafu | 8. ...Pain or aching in either of your hands, wrists or fingers on most days for at least one month? | 1= Yes 2= No |
127 | q1neurfu | NEUROPATHY Now I have some questions about numbness and tingling. Since your last interview on [last interview date], have you had numbness or tingling [or asleep or burning] feeling of your feet or toes? | 1= Yes 2= Suspect 3= No |
128 | q2neurfu | Was this ___ on the right side, left side, or both sides? | 1= Right 2= Left 3= Both |
129 | q3neurfu | In the past month, have you had numbness or tingling [or asleep or burning] feeling of your hands or fingers? [This question was replaced by q3bneufu in this form because the time frame is not within the pasy year.] | 1= Yes 2= Suspect 3= No |
130 | q4neurfu | Was this ___ on the right side, left side, or both sides? [This question was replaced by q4bneufu in this form because the time frame is not within the pasy year.] | 1= Right 2= Left 3= Both |
131 | q3bneufu | Since your last interview on [last interview date], have you had numbness or tingling [or asleep or burning] feeling of your hands or fingers? | 1= Yes 2= Suspect 3= No |
132 | q4bneufu | Was this ___ on the right side, left side, or both sides? | 1= Right 2= Left 3= Both |
133 | q5neurfu | CERVICAL RADICULAPATHY Now I have some questions about neck pain. Since your last interview on [last interview date] have you had neck pain that lasted days weeks, or months? | 1= Yes 2= Suspect 3= No |
134 | q6neurfu | At a time while you were having pain in the neck, did you also have pain, numbness or tingling, or weakness in the arms or hands? | 1= Yes 2= Suspect 3= No |
135 | q7neurf1 | Which of these problems did you have, pain, numbness or tingling, or weakness? [LIST ALL THAT APPLY] | 1= Pain 2= Numbness or tingling 3= Weakness |
136 | q7neurf2 | Which of these problems did you have, pain, numbness or tingling, or weakness? [LIST ALL THAT APPLY] | See previous question |
137 | q7neurf3 | Which of these problems did you have, pain, numbness or tingling, or weakness? [LIST ALL THAT APPLY] | See previous question |
138 | q8neurfu | Did this ___ occur on the right side, left side, or both sides? | 1= Right 2= Left 3= Both |
139 | q9neurfu | Now, when you have neck pain, how long, on average, does the neck pain typically last? Would you say less than a week, between one week and one month, between one and two months, between two and six months, or greater than six months? | 1= < a week 2= 1 week - 1 month 3= > 1 month - 2 months 4= > 2 months - 6 months 5= > 6 months |
140 | q10neufu | How many different times have you had neck pain? | 1 .. 50 |
141 | q11neufu | How severe, on average, is the neck pain? Would you say it is usually not severe at all, slightly severe, somewhat severe, very severe, or extremely severe? | 1= Not severe at all 2= Slightly severe 3= Somewhat severe 4= Very severe 5= Extremely severe |
142 | q12neufu | Since your last interview on [last interview date] have you seen a doctor because of neck pain? | 1= Yes 2= No |
143 | q13neufu | Since your last interview on [last interview date] have you had an x-ray or scan [CT or MRI] of the neck because of the pain? | 1= Yes 2= No |
144 | q14neufu | When was the last time? [ENTER YEAR] | 1900 .. 2040 |
145 | q15neufu | What was the name of the place (doctor's office, hospital or other place) at which the scan was performed? [ENTER NAME] | String[40] |
146 | q16neufu | [ENTER LOCATION] | String[40] |
147 | q17neufu | LUMBAR RADICULOPATHY Now I have some questions about low back pain. Since your last interview on [last interview date] have you had low back pain that lasted days to months? | 1= Yes 2= Suspect 3= No |
148 | q18neufu | At a time while you were having low back pain, did you also have pain, numbness or tingling, or weakness in the legs or feet? | 1= Yes 2= Suspect 3= No |
149 | q19neuf1 | Which of these problems did you have, pain, numbness or tingling, or weakness? [LIST ALL THAT APPLY] | 1= Pain 2= Numbness or tingling 3= Weakness |
150 | q19neuf2 | Which of these problems did you have, pain, numbness or tingling, or weakness? [LIST ALL THAT APPLY] | See previous question |
151 | q19neuf3 | Which of these problems did you have, pain, numbness or tingling, or weakness? [LIST ALL THAT APPLY] | See previous question |
152 | q20neufu | Did this ___ occur on the right side, left side, or both sides? | 1= Right 2= Left 3= Both |
153 | q21neufu | Now, when you have low back pain, how long, on average, does the low back pain typically last? Would you say less than a week, between one week and one month, between one and two months, between two and six months, or greater than six months? | 1= < a week 2= 1 week - 1 month 3= > 1 month - 2 months 4= > 2 months - 6 months 5= > 6 months |
154 | q22neufu | How many different times have you had low back pain? | 1 .. 50 |
155 | q23neufu | How severe, on average, is the low back pain? Would you say it is usually not severe at all, slightly severe, somewhat severe, very severe, or extremely severe? | 1= Not severe at all 2= Slightly severe 3= Somewhat severe 4= Very severe 5= Extremely severe |
156 | q24neufu | Since your last interview on [last interview date] have you seen a doctor because of low back pain? | 1= Yes 2= No |
157 | q25neufu | Since your last interview on [last interview date] have you had an x-ray or scan [CT or MRI] of the low back because of the pain? | 1= Yes 2= No |
158 | q26neufu | When was the last time? [ENTER YEAR] | 1900 .. 2040 |
159 | q27neufu | What was the name of the place (doctor's office, hospital or other place) at which the scan was performed? [ENTER NAME] | String[40] |
160 | q28neufu | [ENTER LOCATION] | String[40] |
161 | q1md | The next few questions are about your feelings during the past week. For each of the following statements, please tell me if you felt that way much of the time during the past week. 1. I felt that everything I did was an effort. Have you felt this way much of the time during the past week? | 1= Yes 2= No |
162 | q2md | 2. My sleep was restless. (Have you felt this way much of the time during the past week?) | 1= Yes 2= No |
163 | q3md | 3. I felt depressed. (Have you felt this way much of the time during the past week?) | 1= Yes 2= No |
164 | q4md | 4. I was happy. (Have you felt this way much of the time during the past week?) | 1= Yes 2= No |
165 | q5md | 5. I felt lonely. (Have you felt this way much of the time during the past week?) | 1= Yes 2= No |
166 | q6md | 6. People were unfriendly. (Have you felt this way much of the time during the past week?) | 1= Yes 2= No |
167 | q7md | 7. I enjoyed life. (Have you felt this way much of the time during the past week?) | 1= Yes 2= No |
168 | q8md | 8. I felt sad. (Have you felt this way much of the time during the past week?) | 1= Yes 2= No |
169 | q9md | 9. I felt that people disliked me. (Have you felt this way much of the time during the past week?) | 1= Yes 2= No |
170 | q10md | 10. I could not get 'going'. (Have you felt this way much of the time during the past week?) | 1= Yes 2= No |
171 | q1slp | SLEEP Now I would like to get some information about how well you sleep 1. How often you have trouble falling asleep? Would you say it is - most of the time, sometimes, or rarely or never? | 1= Very Often 2= Often 3= Sometimes 4= Rarely 5= never |
172 | q2slp | 2. How often are you troubled by waking up during the night? | 1= Very Often 2= Often 3= Sometimes 4= Rarely 5= never |
173 | q4slp | 3. How often do you get so sleepy during the day or evening that you have to take a nap? | 1= Very Often 2= Often 3= Sometimes 4= Rarely 5= never |
174 | q5slp | 4. How often do you feel really rested when you wake up in the morning? | 1= Very Often 2= Often 3= Sometimes 4= Rarely 5= never |
175 | q6slp | How many hours do you usually sleep at night? | 0 .. 24 |
176 | q1dep | DEPRESSION Now I have few more questions about how you feel. 1. In the past month, has there been two weeks or more during which you felt sad, blue, depressed, or when you lost interest and pleasure in things you usually cared about or enjoyed? | 1= Yes 2= No |
177 | q1adep | During this period, did you experience any of the following problems? 1a. A change in your appetite | 1= Yes 2= No |
178 | q1bdep | 1b. A change in your pattern of sleeping | 1= Yes 2= No |
179 | q1cdep | 1c. A decrease in your energy level | 1= Yes 2= No |
180 | q1ddep | 1d. Trouble concentrating | 1= Yes 2= No |
181 | q1edep | 1e. Felt extremely guilty or worthless | 1= Yes 2= No |
182 | q1fdep | 1f. Felt extremely restless or agitated | 1= Yes 2= No |
183 | q1gdep | 1g. Lost your interest in favorite activities | 1= Yes 2= No |
184 | q1hdep | 1h. Felt that life was not worth living | 1= Yes 2= No |
185 | q2dep | 2. Did you tell a doctor or any other professional about it? | 1= Yes 2= No |
186 | q3dep | 3. In the past year, other than the past month, have you ever had two weeks or more during which you felt sad, blue, depressed, or when you lost interest and pleasure in things you usually cared about or enjoyed? | 1= Yes 2= No |
187 | q3aadep | During this period during which you felt depressed, did you experience any of the following problems? 3a. A change in your appetite | 1= Yes 2= No |
188 | q3abdep | 3ab. A change in your pattern of sleeping | 1= Yes 2= No |
189 | q3acdep | 3ac. A decrease in your energy level | 1= Yes 2= No |
190 | q3addep | 3ad. Trouble concentrating | 1= Yes 2= No |
191 | q3aedep | 3ae. Felt extremely guilty or worthless | 1= Yes 2= No |
192 | q3afdep | 3af. Felt extremely restless or agitated | 1= Yes 2= No |
193 | q3agdep | 3ag. Lost your interest in favorite activities | 1= Yes 2= No |
194 | q3ahdep | 3ah. Felt that life was not worth living | 1= Yes 2= No |
195 | q3bdep | 3b. In the past year, how many episodes like that have you had that lasted two weeks or more? [allow for two digits] [ENTER NUMBER] | 1 .. 99 |
196 | q3cdep | 3c. Have you ever seen a doctor because this (one of these) episode(s)? | 1= Yes 2= No |
197 | q3ddep | 3d. Were you ever hospitalized overnight or longer for this (one of these) episode(s)? | 1= Yes 2= No |
198 | q3edep | 3e. When was the last time? [ENTER YEAR] | 1996 .. 2040 |
199 | q3fdep | 3f. What was the name and location of the (last) hospital? | String[40] |
200 | swall | SWALLOWING Now I have some question about chewing and swallowing 1. How much difficulty, on average, do you have swallowing your food? Would you say you have - no difficulty at all, a little difficulty, some difficulty or a lot of difficulty? | 1= No difficulty at all 2= A little difficulty 3= Some difficulty 4= A lot of difficulty |
201 | movi | 2. How much difficulty, on average, do you have moving food out of your mouth into your throat to swallow? Would you say you have - no difficulty at all, a little difficulty, some difficulty or a lot of difficulty? | 1= No difficulty at all 2= A little difficulty 3= Some difficulty 4= A lot of difficulty |
202 | cough | 3. How often do you cough or choke when drinking or eating? Would you say never, rarely, sometimes, most of the time or almost always? | 1= Never 2= Rarely 3= Sometimes 4= Most of the time 5= Almost always |
203 | bring | 4. How often do you bring up food or liquid after you have swallowed it? | 1= Never 2= Rarely 3= Sometimes 4= Most of the time 5= Almost always |
204 | headinfu | HEAD INJURY Now I have some questions about injuries. 1. Since [last interview date], have you had a head injury? | 1= Yes 2= No |
205 | lostcofu | 3. Have you lost consciousness because of a head injury that occurred since [last interview date]? | 1= Yes 2= Suspect or possible 3= No |
206 | howma1fu | 3a. How many times? | 1 .. 50 |
207 | howlo0fu | 3c. How long were you unconscious for this (last) head injury? Would you say less than 5 seconds, between 5 seconds and 5 minutes, between 5 minutes and 1 hour, between 1 hour and 2 days, or more than 2 days? | 1= < 5 seconds 2= 5 seconds - 5 minutes 3= > 5 minutes - 1 hour 4= > 1 hour - 2 days 5= > 2 days |
208 | hihospfu | 4. Since your interview on [last interview date], were you hospitalized overnight or longer for a head injury? | 1= Yes 2= No |
209 | same1fu | 4a. Was this the same event we just spoke about? | 1= Yes 2= No |
210 | hihonmfu | 4c. What was the name of the (last) hospital? [HOSPITAL NAME] | String[40] |
211 | hihoslfu | [LOCATION:] | String[40] |
212 | memor0fu | Were any of the following signs/symptoms associated with this (last) event? [INTERVIEWER: `Last' event refers to the most recent hospitalization event.] 1. Memory loss or forgetfulness? | 1= Yes 2= Suspect 3= No |
213 | speec0fu | 2. Language or speech change? | 1= Yes 2= Suspect 3= No |
214 | weakn0fu | 3. Weakness or paralysis of face, arms or legs? | 1= Yes 2= Suspect 3= No |
215 | side0fu | 3a. Which side(s)? | 1= right only 2= left only 3= both |
216 | othsp0fu | 4. Specify any other signs or symptoms associated with this (last) event? | String[40] |
217 | hiscanfu | 5. Since [last interview date], did you have a CT, MRI or other type of brain scan because of a head injury? | 1= Yes 2= No |
218 | same2fu | Was this the same event we just spoke about? | 1= Yes 2= No |
219 | hiscnmfu | 5b. What was the name of the place (doctor's office, hospital or other place) at which the scan was performed? [NAME:] | String[40] |
220 | memor1fu | Were any of the following signs/symptoms associated with this (last) event? [INTERVIEWER: `Last' event refers to the most recent hospitalization event.] 1. Memory loss or forgetfulness? | 1= Yes 2= Suspect 3= No |
221 | speec1fu | 2. Language or speech change? | 1= Yes 2= Suspect 3= No |
222 | weakn1fu | 3. Weakness or paralysis of face, arms or legs? | 1= Yes 2= Suspect 3= No |
223 | side1fu | 3a. Which side(s)? | 1= right only 2= left only 3= both |
224 | othsp1fu | 4. Specify any other signs or symptoms associated with this (last) event? | String[40] |
225 | speciffu | 6. Specify left over troubles from your head injury(s)? | String[40] |
226 | hdrvehicle | ||
227 | hdrhitbyobject | ||
228 | hdrfalling | ||
229 | hdrsports | ||
230 | hdrabuse | ||
231 | hdrmilitary | ||
232 | hdrother | ||
233 | prevbisqdone | BRAIN INJURY SCREENING QUESTIONNAIRE Have the BISQ questions been previously completed for this participant? ^prevBisqDoneText | 1= Yes 2= No |
234 | bisqveh | BRAIN INJURY SCREENING QUESTIONNAIRE Now I have some questions about head injuries. ^lastInterviewText0en 1. Vehicle accident?(ex: MVA, pedestrian accident, motorcycle/ATV crash) | 1= Yes 2= No |
235 | bisqvehnum | ^hdrVehicle How many times did you receive a blow to the head, in a vehicle accident? | 1 .. 30 |
236 | bisqvehloc | ^hdrVehicle Did you lose consciousness? | 1= Yes 2= No |
237 | bisqvehlocnum | ^hdrVehicle How many times have you lost consciousness? | 1 .. 30 |
238 | bisqvehlocdur | ^hdrVehicle What was the longest duration? | 1= Don't know 2= Less than 5 seconds. 3= Less than 1 min. 4= 1-5 mins. 5= 6-10 mins. 6= 11-20 mins. 7= 21-30 mins. 8= 31-45 mins. 9= 46-60 mins. 10= 1 hour-23 hours 11= 1-2 days 12= 2 days-1 week 13= 1 week-1 month 14= More than 1 mo. |
239 | bisqvehlocyr1 | ^hdrVehicle In what year did this occur (1)? | 1900 .. 2050 |
240 | bisqvehlocyr2 | ^hdrVehicle In what year did this occur (2)? | 1900 .. 2050 |
241 | bisqvehlocyr3 | ^hdrVehicle In what year did this occur (3)? | 1900 .. 2050 |
242 | bisqvehlocyr4 | ^hdrVehicle In what year did this occur (4)? | 1900 .. 2050 |
243 | bisqvehlocyr5 | ^hdrVehicle In what year did this occur (5)? | 1900 .. 2050 |
244 | bisqvehdaze | ^hdrVehicle Were you dazed or confused? | 1= Yes 2= No |
245 | bisqvehdazenum | ^hdrVehicle How many times have you been dazed or confused? | 1 .. 30 |
246 | bisqvehdazedur | ^hdrVehicle What was the longest duration? | 1= Don't know 2= Less than 5 seconds. 3= Less than 1 min. 4= 1-5 mins. 5= 6-10 mins. 6= 11-20 mins. 7= 21-30 mins. 8= 31-45 mins. 9= 46-60 mins. 10= 1 hour-23 hours 11= 1-2 days 12= 2 days-1 week 13= 1 week-1 month 14= More than 1 mo. |
247 | bisqvehdazeyr1 | ^hdrVehicle In what year did this occur (1)? | 1900 .. 2050 |
248 | bisqvehdazeyr2 | ^hdrVehicle In what year did this occur (2)? | 1900 .. 2050 |
249 | bisqvehdazeyr3 | ^hdrVehicle In what year did this occur (3)? | 1900 .. 2050 |
250 | bisqvehdazeyr4 | ^hdrVehicle In what year did this occur (4)? | 1900 .. 2050 |
251 | bisqvehdazeyr5 | ^^hdrVehicle In what year did this occur (5)? | 1900 .. 2050 |
252 | bisqhit | ^lastInterviewText1en 2. Hit by an object?(ex: equipment, falling object) | 1= Yes 2= No |
253 | bisqhitnum | ^hdrHitByObject How many times did you receive a blow to the head, from a falling object? | 1 .. 30 |
254 | bisqhitloc | ^hdrHitByObject Did you lose consciousness? | 1= Yes 2= No |
255 | bisqhitlocnum | ^hdrHitByObject How many times have you lost consciousness? | 1 .. 30 |
256 | bisqhitlocdur | ^hdrHitByObject What was the longest duration? | 1= Don't know 2= Less than 5 seconds. 3= Less than 1 min. 4= 1-5 mins. 5= 6-10 mins. 6= 11-20 mins. 7= 21-30 mins. 8= 31-45 mins. 9= 46-60 mins. 10= 1 hour-23 hours 11= 1-2 days 12= 2 days-1 week 13= 1 week-1 month 14= More than 1 mo. |
257 | bisqhitlocyr1 | ^hdrHitByObject In what year did this occur (1)? | 1900 .. 2050 |
258 | bisqhitlocyr2 | ^hdrHitByObject In what year did this occur (2)? | 1900 .. 2050 |
259 | bisqhitlocyr3 | ^hdrHitByObject In what year did this occur (3)? | 1900 .. 2050 |
260 | bisqhitlocyr4 | ^hdrHitByObject In what year did this occur (4)? | 1900 .. 2050 |
261 | bisqhitlocyr5 | ^hdrHitByObject In what year did this occur (5)? | 1900 .. 2050 |
262 | bisqhitdaze | ^hdrHitByObject Were you dazed or confused? | 1= Yes 2= No |
263 | bisqhitdazenum | ^hdrHitByObject How many times have you been dazed or confused? | 1 .. 30 |
264 | bisqhitdazedur | ^hdrHitByObject What was the longest duration? | 1= Don't know 2= Less than 5 seconds. 3= Less than 1 min. 4= 1-5 mins. 5= 6-10 mins. 6= 11-20 mins. 7= 21-30 mins. 8= 31-45 mins. 9= 46-60 mins. 10= 1 hour-23 hours 11= 1-2 days 12= 2 days-1 week 13= 1 week-1 month 14= More than 1 mo. |
265 | bisqhitdazeyr1 | ^hdrHitByObject In what year did this occur (1)? | 1900 .. 2050 |
266 | bisqhitdazeyr2 | ^hdrHitByObject In what year did this occur (2)? | 1900 .. 2050 |
267 | bisqhitdazeyr3 | ^hdrHitByObject In what year did this occur (3)? | 1900 .. 2050 |
268 | bisqhitdazeyr4 | ^hdrHitByObject In what year did this occur (4)? | 1900 .. 2050 |
269 | bisqhitdazeyr5 | ^hdrHitByObject In what year did this occur (5)? | 1900 .. 2050 |
270 | bisqfall | ^lastInterviewText2en 3. Falling? (ex: down stairs, during a fainting spell, from a high place) | 1= Yes 2= No |
271 | bisqfallnum | ^hdrFalling How many times did you receive a blow to the head, in a fall? | 1 .. 30 |
272 | bisqfallloc | ^hdrFalling Did you lose consciousness? | 1= Yes 2= No |
273 | bisqfalllocnum | ^hdrFalling How many times have you lost consciousness? | 1 .. 30 |
274 | bisqfalllocdur | ^hdrFalling What was the longest duration? | 1= Don't know 2= Less than 5 seconds. 3= Less than 1 min. 4= 1-5 mins. 5= 6-10 mins. 6= 11-20 mins. 7= 21-30 mins. 8= 31-45 mins. 9= 46-60 mins. 10= 1 hour-23 hours 11= 1-2 days 12= 2 days-1 week 13= 1 week-1 month 14= More than 1 mo. |
275 | bisqfalllocyr1 | ^hdrFalling In what year did this occur (1)? | 1900 .. 2050 |
276 | bisqfalllocyr2 | ^hdrFalling In what year did this occur (2)? | 1900 .. 2050 |
277 | bisqfalllocyr3 | ^hdrFalling In what year did this occur (3)? | 1900 .. 2050 |
278 | bisqfalllocyr4 | ^hdrFalling In what year did this occur (4)? | 1900 .. 2050 |
279 | bisqfalllocyr5 | ^hdrFalling In what year did this occur (5)? | 1900 .. 2050 |
280 | bisqfalldaze | ^hdrFalling Were you dazed or confused? | 1= Yes 2= No |
281 | bisqfalldazenum | ^hdrFalling How many times have you been dazed or confused? | 1 .. 30 |
282 | bisqfalldazedur | ^hdrFalling What was the longest duration? | 1= Don't know 2= Less than 5 seconds. 3= Less than 1 min. 4= 1-5 mins. 5= 6-10 mins. 6= 11-20 mins. 7= 21-30 mins. 8= 31-45 mins. 9= 46-60 mins. 10= 1 hour-23 hours 11= 1-2 days 12= 2 days-1 week 13= 1 week-1 month 14= More than 1 mo. |
283 | bisqfalldazeyr1 | ^hdrFalling In what year did this occur (1)? | 1900 .. 2050 |
284 | bisqfalldazeyr2 | ^hdrFalling In what year did this occur (2)? | 1900 .. 2050 |
285 | bisqfalldazeyr3 | ^hdrFalling In what year did this occur (3)? | 1900 .. 2050 |
286 | bisqfalldazeyr4 | ^hdrFalling In what year did this occur (4)? | 1900 .. 2050 |
287 | bisqfalldazeyr5 | ^hdrFalling In what year did this occur (5)? | 1900 .. 2050 |
288 | bisqsprt | ^lastInterviewText3en 4. Sports/Leisure?(ex: sports, biking, skiing, on the playground) | 1= Yes 2= No |
289 | bisqsprtnum | ^hdrSports How many times did you receive a blow to the head, during a sports or leisure activity? | 1 .. 30 |
290 | bisqsprtloc | ^hdrSports Did you lose consciousness? | 1= Yes 2= No |
291 | bisqsprtlocnum | ^hdrSports How many times have you lost consciousness? | 1 .. 30 |
292 | bisqsprtlocdur | ^hdrSports What was the longest duration? | 1= Don't know 2= Less than 5 seconds. 3= Less than 1 min. 4= 1-5 mins. 5= 6-10 mins. 6= 11-20 mins. 7= 21-30 mins. 8= 31-45 mins. 9= 46-60 mins. 10= 1 hour-23 hours 11= 1-2 days 12= 2 days-1 week 13= 1 week-1 month 14= More than 1 mo. |
293 | bisqsprtlocyr1 | ^hdrSports In what year did this occur (1)? | 1900 .. 2050 |
294 | bisqsprtlocyr2 | ^hdrSports In what year did this occur (2)? | 1900 .. 2050 |
295 | bisqsprtlocyr3 | ^hdrSports In what year did this occur (3)? | 1900 .. 2050 |
296 | bisqsprtlocyr4 | ^hdrSports In what year did this occur (4)? | 1900 .. 2050 |
297 | bisqsprtlocyr5 | ^hdrSports In what year did this occur (5)? | 1900 .. 2050 |
298 | bisqsprtdaze | ^hdrSports Were you dazed or confused? | 1= Yes 2= No |
299 | bisqsprtdazenum | ^hdrSports How many times have you been dazed or confused? | 1 .. 30 |
300 | bisqsprtdazedur | ^hdrSports What was the longest duration? | 1= Don't know 2= Less than 5 seconds. 3= Less than 1 min. 4= 1-5 mins. 5= 6-10 mins. 6= 11-20 mins. 7= 21-30 mins. 8= 31-45 mins. 9= 46-60 mins. 10= 1 hour-23 hours 11= 1-2 days 12= 2 days-1 week 13= 1 week-1 month 14= More than 1 mo. |
301 | bisqsprtdazeyr1 | ^hdrSports In what year did this occur (1)? | 1900 .. 2050 |
302 | bisqsprtdazeyr2 | ^hdrSports In what year did this occur (2)? | 1900 .. 2050 |
303 | bisqsprtdazeyr3 | ^hdrSports In what year did this occur (3)? | 1900 .. 2050 |
304 | bisqsprtdazeyr4 | ^hdrSports In what year did this occur (4)? | 1900 .. 2050 |
305 | bisqsprtdazeyr5 | ^hdrSports In what year did this occur (5)? | 1900 .. 2050 |
306 | bisqphys | ^lastInterviewText4en 5. Physical Abuse/Assault?(ex: mugged) | 1= Yes 2= No |
307 | bisqphysnum | ^hdrAbuse How many times did you receive a blow to the head, from abuse or assault? | 1 .. 30 |
308 | bisqphysloc | ^hdrAbuse Did you lose consciousness? | 1= Yes 2= No |
309 | bisqphyslocnum | ^hdrAbuse How many times have you lost consciousness? | 1 .. 30 |
310 | bisqphyslocdur | ^hdrAbuse What was the longest duration? | 1= Don't know 2= Less than 5 seconds. 3= Less than 1 min. 4= 1-5 mins. 5= 6-10 mins. 6= 11-20 mins. 7= 21-30 mins. 8= 31-45 mins. 9= 46-60 mins. 10= 1 hour-23 hours 11= 1-2 days 12= 2 days-1 week 13= 1 week-1 month 14= More than 1 mo. |
311 | bisqphyslocyr1 | ^hdrAbuse In what year did this occur (1)? | 1900 .. 2050 |
312 | bisqphyslocyr2 | ^hdrAbuse In what year did this occur (2)? | 1900 .. 2050 |
313 | bisqphyslocyr3 | ^hdrAbuse In what year did this occur (3)? | 1900 .. 2050 |
314 | bisqphyslocyr4 | ^hdrAbuse In what year did this occur (4)? | 1900 .. 2050 |
315 | bisqphyslocyr5 | ^hdrAbuse In what year did this occur (5)? | 1900 .. 2050 |
316 | bisqphysdaze | ^hdrAbuse Were you dazed or confused? | 1= Yes 2= No |
317 | bisqphysdazenum | ^hdrAbuse How many times have you been dazed or confused? | 1 .. 30 |
318 | bisqphysdazedur | ^hdrAbuse What was the longest duration? | 1= Don't know 2= Less than 5 seconds. 3= Less than 1 min. 4= 1-5 mins. 5= 6-10 mins. 6= 11-20 mins. 7= 21-30 mins. 8= 31-45 mins. 9= 46-60 mins. 10= 1 hour-23 hours 11= 1-2 days 12= 2 days-1 week 13= 1 week-1 month 14= More than 1 mo. |
319 | bisqphysdazeyr1 | ^hdrAbuse In what year did this occur (1)? | 1900 .. 2050 |
320 | bisqphysdazeyr2 | ^hdrAbuse In what year did this occur (2)? | 1900 .. 2050 |
321 | bisqphysdazeyr3 | ^hdrAbuse In what year did this occur (3)? | 1900 .. 2050 |
322 | bisqphysdazeyr4 | ^hdrAbuse In what year did this occur (4)? | 1900 .. 2050 |
323 | bisqphysdazeyr5 | ^hdrAbuse In what year did this occur (5)? | 1900 .. 2050 |
324 | bisqmil | ^lastInterviewText5en 6. Military Service?(ex: training, blast injury) | 1= Yes 2= No |
325 | bisqmilnum | ^hdrMilitary How many times did you receive a blow to the head, during military service? | 1 .. 30 |
326 | bisqmilloc | ^hdrMilitary Did you lose consciousness? | 1= Yes 2= No |
327 | bisqmillocnum | ^hdrMilitary How many times have you lost consciousness? | 1 .. 30 |
328 | bisqmillocdur | ^hdrMilitary What was the longest duration? | 1= Don't know 2= Less than 5 seconds. 3= Less than 1 min. 4= 1-5 mins. 5= 6-10 mins. 6= 11-20 mins. 7= 21-30 mins. 8= 31-45 mins. 9= 46-60 mins. 10= 1 hour-23 hours 11= 1-2 days 12= 2 days-1 week 13= 1 week-1 month 14= More than 1 mo. |
329 | bisqmillocyr1 | ^hdrMilitary In what year did this occur (1)? | 1900 .. 2050 |
330 | bisqmillocyr2 | ^hdrMilitary In what year did this occur (2)? | 1900 .. 2050 |
331 | bisqmillocyr3 | ^hdrMilitary In what year did this occur (3)? | 1900 .. 2050 |
332 | bisqmillocyr4 | ^hdrMilitary In what year did this occur (4)? | 1900 .. 2050 |
333 | bisqmillocyr5 | ^hdrMilitary In what year did this occur (5)? | 1900 .. 2050 |
334 | bisqmildaze | ^hdrMilitary Were you dazed or confused? | 1= Yes 2= No |
335 | bisqmildazenum | ^hdrMilitary How many times have you been dazed or confused? | 1 .. 30 |
336 | bisqmildazedur | ^hdrMilitary What was the longest duration? | 1= Don't know 2= Less than 5 seconds. 3= Less than 1 min. 4= 1-5 mins. 5= 6-10 mins. 6= 11-20 mins. 7= 21-30 mins. 8= 31-45 mins. 9= 46-60 mins. 10= 1 hour-23 hours 11= 1-2 days 12= 2 days-1 week 13= 1 week-1 month 14= More than 1 mo. |
337 | bisqmildazeyr1 | ^hdrMilitary In what year did this occur (1)? | 1900 .. 2050 |
338 | bisqmildazeyr2 | ^hdrMilitary In what year did this occur (2)? | 1900 .. 2050 |
339 | bisqmildazeyr3 | ^hdrMilitary In what year did this occur (3)? | 1900 .. 2050 |
340 | bisqmildazeyr4 | ^hdrMilitary In what year did this occur (4)? | 1900 .. 2050 |
341 | bisqmildazeyr5 | ^hdrMilitary In what year did this occur (5)? | 1900 .. 2050 |
342 | bisqoth | ^lastInterviewText6en 7. In any other circumstances? | 1= Yes 2= No |
343 | bisqothsp | ^hdrOther Please specify: | String[255] |
344 | bisqothnum | ^hdrOther How many times did you receive a blow to the head, in a situation I have not mentioned? | 1 .. 30 |
345 | bisqothloc | ^hdrOther Did you lose consciousness? | 1= Yes 2= No |
346 | bisqothlocnum | ^hdrOther How many times have you lost consciousness? | 1 .. 30 |
347 | bisqothlocdur | ^hdrOther What was the longest duration? | 1= Don't know 2= Less than 5 seconds. 3= Less than 1 min. 4= 1-5 mins. 5= 6-10 mins. 6= 11-20 mins. 7= 21-30 mins. 8= 31-45 mins. 9= 46-60 mins. 10= 1 hour-23 hours 11= 1-2 days 12= 2 days-1 week 13= 1 week-1 month 14= More than 1 mo. |
348 | bisqothlocyr1 | ^hdrOther In what year did this occur (1)? | 1900 .. 2050 |
349 | bisqothlocyr2 | ^hdrOther In what year did this occur (2)? | 1900 .. 2050 |
350 | bisqothlocyr3 | ^hdrOther In what year did this occur (3)? | 1900 .. 2050 |
351 | bisqothlocyr4 | ^hdrOther In what year did this occur (4)? | 1900 .. 2050 |
352 | bisqothlocyr5 | ^hdrOther In what year did this occur (5)? | 1900 .. 2050 |
353 | bisqothdaze | ^hdrOther Were you dazed or confused? | 1= Yes 2= No |
354 | bisqothdazenum | ^hdrOther How many times have you been dazed or confused? | 1 .. 30 |
355 | bisqothdazedur | ^hdrOther What was the longest duration? | 1= Don't know 2= Less than 5 seconds. 3= Less than 1 min. 4= 1-5 mins. 5= 6-10 mins. 6= 11-20 mins. 7= 21-30 mins. 8= 31-45 mins. 9= 46-60 mins. 10= 1 hour-23 hours 11= 1-2 days 12= 2 days-1 week 13= 1 week-1 month 14= More than 1 mo. |
356 | bisqothdazeyr1 | ^hdrOther In what year did this occur (1)? | 1900 .. 2050 |
357 | bisqothdazeyr2 | ^hdrOther In what year did this occur (2)? | 1900 .. 2050 |
358 | bisqothdazeyr3 | ^hdrOther In what year did this occur (3)? | 1900 .. 2050 |
359 | bisqothdazeyr4 | ^hdrOther In what year did this occur (4)? | 1900 .. 2050 |
360 | bisqothdazeyr5 | ^hdrOther In what year did this occur (5)? | 1900 .. 2050 |
361 | q1injfu | OTHER INJURIES 1. Since [last interview date], have you had any other accidents or injuries? | 1= Yes 2= No |
362 | q1ainjfu | 1a. Did you have one injury or more than one injury? | 1= One 2= More than one |
363 | q2injfu | [INTERVIEWER: IF MORE THAN ONE INJURY, THE FOLLOWING QUESTIONS REFER TO THE MOST SEVERE INJURY.] 2. Can you tell me where you were when the injury occurred? For example, were you in your bedroom, bathroom, dining room, or on the stairs, sidewalk, street...? | String[40] |
364 | q3injfu | 3. What event directly led to the injury? For example, did you fall either off of something or while walking, or were you struck by an object...? | String[40] |
365 | q4injfu | 4. What object or exposure directly inflicted the injury? For example, was it furniture, stairs, a wall, fire, a car...? | String[40] |
366 | q5injfu | 5. How would you describe the nature of the injury? For example, was it a cut, bruise, sprain, fracture, burn...? | String[40] |
367 | q6injfu | 6. Which part of the body was directly affected by the injury? For example, was it your eyes, hands, back...? | String[40] |
368 | q7injfu | 7. Did you have to see a doctor or other medical practitioner? | 1= Yes 2= No |
369 | q7ainjfu | 7a. Were you hospitalized? | 1= Yes 2= No |
370 | q7binjfu | 7b. What was the name of the (last) hospital? | String[40] |
371 | q1cc | COGNITIVE COMPLAINTS Now I have some questions about your memory. 1. People find that they sometimes have more trouble remembering things as they get older. About how often do you have trouble remembering things? Would you say it is very often, often, sometimes, rarely or never? | 1= Very often 2= Often 3= Sometimes 4= Rarely 5= Never |
372 | q2cc | 2. Compared to 10 years ago, would you say that your memory is much worse, a little worse, the same, a little better or much better? | 1= Much worse 2= A little worse 3= The same 4= A little better 5= Much better |
373 | q3cc | 3. How often do you have any other problems with your thinking, such as trouble concentrating or finding words in conversations? Would you say it is very often, often, sometimes, rarely or never? | 1= Very often 2= Often 3= Sometimes 4= Rarely 5= Never |
374 | q3acc | 3a. Specify | String[30] |
375 | q3bcc | 3b. Compared to 10 years ago, would you say that these problems are much worse, a little worse, the same, a little better or much better? [INTERVIEWER: 'THESE' REFERS TO ALL OF THE PROBLEMS. IF SUBJECT INSISTS ON 'WHICH ONE' INSTRUCT HIM/HER TO REFER TO THE ONE WHICH MOST TROUBLES HIM/HER.] | 1= Much worse 2= A little worse 3= The same 4= A little better 5= Much better |
376 | q1phy | PHYSICAL ACTIVITIY We are also interested in any physical activities that you do. I have a list of different types of activities that we ask of everyone, but most people do only one or two. [PRESS ENTER TO CONTINUE.] | String[1] |
377 | q1aphy | How many times in the past 14 days did you go walking for exercise? [ENTER NUMBER OF TIMES] | 0 .. 87 |
378 | q1bphy | On average, about how many minutes did you actually spend on each occasion? [ENTER NUMBER OF MINUTES] [CODE 1 Hour=60 min; 1.5 Hour=90 min; 2 Hours=120 min; 2.5 Hours=150 min; 3 Hours=180 min; 3.5 Hours=210 min; 4 Hours=240 min] | 1 .. 300 |
379 | q3aphy | How many times in the past 14 days did you do gardening or yard work? [ENTER NUMBER OF TIMES] | 0 .. 87 |
380 | q3bphy | On average, about how many minutes did you actually spend on each occasion? [ENTER NUMBER OF MINUTES] [CODE 1 Hour=60 min; 1.5 Hour=90 min; 2 Hours=120 min; 2.5 Hours=150 min; 3 Hours=180 min; 3.5 Hours=210 min; 4 Hours=240 min] | 1 .. 300 |
381 | q5aphy | How many times in the past 14 days did you do calisthenics or general exercise? [ENTER NUMBER OF TIMES] | 0 .. 87 |
382 | q5bphy | On average, bout how many minutes did you actually spend on each occasion? [ENTER NUMBER OF MINUTES] [CODE 1 Hour=60 min; 1.5 Hour=90 min; 2 Hours=120 min; 2.5 Hours=150 min; 3 Hours=180 min; 3.5 Hours=210 min; 4 Hours=240 min] | 1 .. 300 |
383 | q8aphy | How many times in the past 14 days did you go bicycle riding? [ENTER NUMBER OF TIMES] | 0 .. 87 |
384 | q8bphy | On average, about how many minutes did you actually spend on each occasion? [ENTER NUMBER OF MINUTES] [CODE 1 Hour=60 min; 1.5 Hour=90 min; 2 Hours=120 min; 2.5 Hours=150 min; 3 Hours=180 min; 3.5 Hours=210 min; 4 Hours=240 min] | 1 .. 300 |
385 | q101phy | [SPECIFY] any other exercise, sports, or physically active hobbies in the past 2 weeks | String[40] |
386 | q10aphy | How many times in the past 14 days did you do this? [ENTER NUMBER OF TIMES] | 1 .. 87 |
387 | q10bphy | On average, about how many minutes did you actually spend on each occasion? [ENTER NUMBER OF MINUTES] [CODE 1 Hour=60 min; 1.5 Hour=90 min; 2 Hours=120 min; 2.5 Hours=150 min; 3 Hours=180 min; 3.5 Hours=210 min; 4 Hours=240 min] | 1 .. 300 |
388 | q1fs | FUNCTIONAL STATUS We would also like to know how well you are able to do some physical activities that are important in day-to-day living but which many people have problems doing. First, I would like to know if you are able to do certain kinds of activities without help from another person. Are you ABLE to do heavy work around the house, like washing windows, walls, or floors without help? | 1= Yes 2= No |
389 | q2fs | Are you able to walk up and down stairs to the second floor without help? | 1= Yes 2= No |
390 | q3fs | Are you able to walk a half mile without help? | 1= Yes 2= No |
391 | q4fs | Now I'm going to ask you how difficult it is, on the average to do similar kinds of activities. For each thing, tell me whether you have: no difficulty at all, a little difficulty, some difficulty, a lot of difficulty, or just unable to do it. To begin, how much difficulty, if any, do you have pulling or pushing large objects like a living room chair? Would you say you have no difficulty at all, a little difficulty, some difficulty, a lot of difficulty or are you just unable to do it? | 1= No difficulty at all 2= A little difficulty 3= Some difficulty 4= A lot of difficulty 5= Just unable to do it |
392 | q5fs | What about stooping, crouching, or kneeling? (Do you have no difficulty at all, a little difficulty, some difficulty, a lot of difficulty, or are you just unable to do it?) | 1= No difficulty at all 2= A little difficulty 3= Some difficulty 4= A lot of difficulty 5= Just unable to do it |
393 | q6fs | Lifting or carrying weights over 10 pounds, like a very heavy bag of groceries? (Do you have no difficulty at all, a little difficulty, some difficulty, a lot of difficulty, or are you just unable to do it?) | 1= No difficulty at all 2= A little difficulty 3= Some difficulty 4= A lot of difficulty 5= Just unable to do it |
394 | q7fs | Reaching or extending arms above shoulder level? Do you have...? | 1= No difficulty at all 2= A little difficulty 3= Some difficulty 4= A lot of difficulty 5= Just unable to do it |
395 | q8fs | Either writing or handling or fingering small objects? Do you have...? | 1= No difficulty at all 2= A little difficulty 3= Some difficulty 4= A lot of difficulty 5= Just unable to do it |
396 | q9fs | Trimming, cutting or clipping your toenails? Do you have...? | 1= No difficulty at all 2= A little difficulty 3= Some difficulty 4= A lot of difficulty 5= Just unable to do it |
397 | q10fs | How much difficulty do you have finding shoes that are comfortable? Do you have...? | 1= No difficulty at all 2= A little difficulty 3= Some difficulty 4= A lot of difficulty 5= Just unable to do it |
398 | q11fs | Next, I would like to know if you need help do some different kinds of activities. At the present time, do you need help ... Walking across a small room? | 1= No Help 2= Help 3= Unable to do |
399 | q12fs | Bathing, either a sponge bath, tub bath or shower? | 1= No Help 2= Help 3= Unable to do |
400 | q14fs | Dressing, like putting on a shirt, buttoning and zipping, or putting on shoes? | 1= No Help 2= Help 3= Unable to do |
401 | q15fs | Eating like holding a fork, cutting food, or drinking from a glass? | 1= No Help 2= Help 3= Unable to do |
402 | q16fs | Getting from a bed to a chair? | 1= No Help 2= Help 3= Unable to do |
403 | q17fs | Using the toilet? | 1= No Help 2= Help 3= Unable to do |
404 | q1fun | Now I have a few more questions about activities people may or may not do. Although some things may actually be performed by someone else, just tell me whether you think you are able to do them. 1. Are you able to use the telephone - including looking up numbers and dialing - completely by yourself, or does someone else help you? | 1= No Help 2= Help 3= Unable to do |
405 | q2fun | 2. Are you able to shop for the groceries you need - either by going to the grocery store and picking them up or by having them delivered - completely by yourself, or does someone else help you? | 1= No Help 2= Help 3= Unable to do |
406 | q3fun | 3. Are you able to prepare your own meals completely by yourself, or does someone else help you? | 1= No Help 2= Help 3= Unable to do |
407 | q4fun | 4. Are you able to do the routine light housekeeping completely by yourself, or does someone else help you? | 1= No Help 2= Help 3= Unable to do |
408 | q5fun | 5. Are you able to do the periodic heavy housekeeping completely by yourself, or does someone else help you? | 1= No Help 2= Help 3= Unable to do |
409 | q6fun | 6. Are you able to do your own laundry completely by yourself, or does someone else help you? | 1= No Help 2= Help 3= Unable to do |
410 | q7fun | 7. Are you able to take your own prescribed medicines completely by yourself, or does someone else help you? | 1= No Help 2= Help 3= Unable to do |
411 | q8fun | 8. Are you able to take care of your own finances - including paying bills, writing checks, keeping track of income (but not necessarily preparing your own taxes) - completely by yourself, or does someone else help you? | 1= No Help 2= Help 3= Unable to do |
412 | q9fun | 9. Are you able to take care of your own social life - including talking to friends and relatives on the telephone, having people come in to visit, going to other people to visit - completely by yourself, or does someone else help you by making all the arrangements? | 1= No Help 2= Help 3= Unable to do |
413 | q10fun | 10. Are you able to take care of making your own doctors appointments and going to see your doctor and other health care providers completely by yourself, or does someone else help you by making the appointments or taking you there? | 1= No Help 2= Help 3= Unable to do |
414 | q11fun | 11. Are you able to do your own personal shopping, like for clothes, for personal things, or for household needs completely by yourself, or does someone else help you? | 1= No Help 2= Help 3= Unable to do |
415 | q12fun | 12. Are you able to travel around in your community to the places you might want to go, like to church or just to be outside completely by yourself, or does someone else help you? | 1= No Help 2= Help 3= Unable to do |
416 | introd | Next we would like to ask a few questions about common problems that people have as they grow older. We would appreciate your answers to these questions even though you may not have any problems. >>>>[HIT ENTER FOR NEXT QUESTION]<<<< | String[1] |
417 | q1ur | URINARY INCONTINENCE 1. How often during the last 12 months have you leaked urine or lost control of your urine - almost every day, several times a week, several times a month, once a month, less than once a month, or never? | 1= Almost everyday 2= Several times a week 3= Several times a month 4= Once a month 5= Less than once a month 6= Never |
418 | q2ur | 2. When you lose urine, how much usually leaks - a few drops, enough to wet your underwear, enough to wet your outer clothes, or enough to wet the floor? [PROBE IF PADS WORN:] Without the protection pads, how much urine would you lose?] | 1= A few drops 2= Enough to wet underwear 3= Enough to wet outer clothes 4= Enough to wet the floor |
419 | q3ur | 3. How much of a problem do you consider your urine loss to be - a big problem, a little problem, or no problem at all? | 1= A big problem 2= A little problem 3= No problem |
420 | q4ur | 4. In the past few months have you ever lost control of your bowels when you didn't want to? | 1= Yes 2= No |
421 | currjob | OCCUPATION 1. The kind of work we do can also affect our health, so we would like to get some information about your occupations. Because Nuns, Priests, and Brothers perform many different types of functions, we would like to know if you are currently working at a job? | 1= Yes 2= No |
422 | ftpt | 2. Full-time or part-time? | 1= Part-time 2= Full-time |
423 | cjobname | 3. What kind of work are you doing? (What is your job called?) (For example, registered nurse, personnel manager, supervisor, a teacher...) [JOB NAME] | String[30] |
424 | spanishbr | Is the participant of Spanish/Hispanic origin? [CHECK RELEASE SHEET] | 1= Yes 2= No |
425 | description_acc | Acculturation Although you may speak many languages, the following questions refer to only English and Spanish. [PRESS ENTER TO CONTINUE] | |
426 | acc_langreadspeak | 1. In general, what language(s) do you read and speak? | 1= Only Spanish 2= Spanish better 3= Both equally 4= English better than Spanish 5= Only English |
427 | acc_langchild | 2. What was the language(s) you used as a child? | 1= Only Spanish 2= More Spanish than English 3= Both equally 4= More English than Spanish 5= Only English |
428 | acc_langhome | 3. What language(s) do you usually speak at home? | 1= Only Spanish 2= More Spanish than English 3= Both equally 4= More English than Spanish 5= Only English |
429 | acc_langthink | 4. In which language(s) do you usually think? | 1= Only Spanish 2= More Spanish than English 3= Both equally 4= More English than Spanish 5= Only English |
430 | acc_langfriend | 5. What language(s) do you usually speak with your friends? | 1= Only Spanish 2= More Spanish than English 3= Both equally 4= More English than Spanish 5= Only English |
431 | acc_langmedia | 6. In general, what language(s) are the movies, T.V. and radio programs you prefer to watch and listen to? | 1= Only Spanish 2= More Spanish than English 3= Both equally 4= More English than Spanish 5= Only English |
432 | acc_friends | 7. Your close friends are... | 1= All Hispanic/Latino 2= More Hispanic/Latino than non-Hispanic/non-Latino 3= About half and half 4= More non-Hispanic/non-Latino than Hispanic/Latino 5= All non-Hispanic/non-Latino |
433 | acc_social | 8. You prefer going to social gatherings/parties at which people are... | 1= All Hispanic/Latino 2= More Hispanic/Latino than non-Hispanic/non-Latino 3= About half and half 4= More non-Hispanic/non-Latino than Hispanic/Latino 5= All non-Hispanic/non-Latino |
434 | acc_visitors | 9. The persons you visit or who visit you are... | 1= All Hispanic/Latino 2= More Hispanic/Latino than non-Hispanic/non-Latino 3= About half and half 4= More non-Hispanic/non-Latino than Hispanic/Latino 5= All non-Hispanic/non-Latino |
435 | acc_kidsfriend | 10. If you could choose your children's friends you would want them to be... | 1= All Hispanic/Latino 2= More Hispanic/Latino than non-Hispanic/non-Latino 3= About half and half 4= More non-Hispanic/non-Latino than Hispanic/Latino 5= All non-Hispanic/non-Latino |
436 | description_fam | Familism Please indicate how much you agree or disagree with these statements by choosing the answer from 1 (disagree a lot) to 5 (agree a lot) which best shows how you feel about each statement. [PRESS ENTER TO CONTINUE] | |
437 | fam_grandchild | 1. One should have the hope of living long enough to see his/her grandchildren grow up. | 1= Disagree a lot 2= Disagree 3= Don't disagree or agree 4= Agree 5= Agree a lot |
438 | fam_parliverel | 2. Aging parents should live with relatives. | 1= Disagree a lot 2= Disagree 3= Don't disagree or agree 4= Agree 5= Agree a lot |
439 | fam_helprel | 3. When someone has problems he/she can count on help from his/her relatives. | 1= Disagree a lot 2= Disagree 3= Don't disagree or agree 4= Agree 5= Agree a lot |
440 | fam_pleasepar | 4. Much of what a son or daughter does should be done to please the parents. | 1= Disagree a lot 2= Disagree 3= Don't disagree or agree 4= Agree 5= Agree a lot |
441 | fam_embrass | 5. One should be embarrassed about the bad things done by his/her brothers and sisters. | 1= Disagree a lot 2= Disagree 3= Don't disagree or agree 4= Agree 5= Agree a lot |
442 | fam_livepar | 6. Children should live in their parents' house until they get married. | 1= Disagree a lot 2= Disagree 3= Don't disagree or agree 4= Agree 5= Agree a lot |
443 | admin1 | PURDUE PEGBOARD -- ADMINISTRATION: [PLACE PEGBOARD IN FRONT OF R, WITH WELLS AT TOP AND PEGS IN FIRST AND LAST WELLS. SAY:] `I want to see how quickly you can place these pegs [POINT] into these holes [POINT] - like this without skipping any holes. [EXAMINER PLACES 4 PEGS WITH RIGHT HAND IN RIGHT-HAND COLUMN.] Now for practice you try it with your right hand.' [ALLOW SUBJECT TO PLACE 4 PEGS IN RIGHT COLUMN; ENCOURAGE WITH `good;' REPEAT PROCESS IF SUBJECT DOES NOT COMPLETE PRACTICE ITEMS SATISFACTORILY. THEN REPLACE PEGS.] >>>>> PRESS ENTER TO CONTINUE <<<<< | String[1] |
444 | admin2 | [SAY: ]`Good. You have the idea. Now, when I tell you to begin, pick up the pegs one at a time and place them in this column [POINT TO RIGHT-HAND COLUMN] with your RIGHT HAND as quickly as you can. Again, please do not skip any holes. Ready? Begin. '[START TIMER AS YOU SAY `BEGIN;' EACH TRIAL IS *30 SECONDS*. WATCH R; PROMPT TO PICK UP ONLY ONE PEG AT A TIME, TO USE ONLY ONE HAND AT A TIME, AND NOT TO SKIPHOLES, AS NECESSARY; IF R MAKES SIGNIFICANT ERRORS DURING TRIAL (E.G., USING BOTH HANDS, PLACING PEGS IN WRONG COLUMN, SKIPPING HOLES, ETC.) **IT IS PERMISSIBLE TO REPEAT 1 TRIAL**. IF NECESSARY, COVER ONE COLUMN OF HOLES WITH THE PANEL THAT SLIDES OVER THE WELLS. ONLY VERBALLY REMIND BEYOND THIS, HOWEVER. AT 30 SECONDS SAY:] `stop'. >>>>> PRESS ENTER FOR FIRST TRIAL <<<<< | String[1] |
445 | trial11 | 1. Trial 1, Right Hand [ENTER NUMBER OF PEGS CORRECTLY PLACED] | 0 .. 25 |
446 | trial21 | [AT COMPLETION OF TRIAL 1, REPLACE PEGS AND SAY:] `Now I want you to do the same thing with your LEFT HAND. Pick up the pegs one at a time and place them in this column [POINT TO LEFT-HAND COLUMN] with your left hand. Work as quickly as you can and do not skip any holes. Ready? Begin.' [TRIAL IS 30 SECONDS WITH SAME PROCEDURES AS TRIAL 1.] 2. Trial 2, Left Hand [ENTER NUMBER OF PEGS CORRECTLY PLACED] | 0 .. 25 |
447 | trial301 | [AT COMPLETION OF TRIAL 2, REPLACE PEGS AND SAY:] `Now I want you to do this again with your RIGHT HAND. Place the pegs one at a time in this column [POINT TO RIGHT-HAND COLUMN COLUMN] with your right hand. Work as quickly as you can and do not skip any holes. Ready? Begin.' [TRIAL IS 30 SECONDS WITH SAME PROCEDURES AS TRIAL 1.] 3. Trial 3, Right Hand [ENTER NUMBER OF PEGS CORRECTLY PLACED] | 0 .. 25 |
448 | trial4 | [AT COMPLETION OF TRIAL 3, REPLACE PEGS AND SAY:] `Now I want you to do this again with your LEFT HAND. Place the pegs one at a time in this column [POINT TO LEFT-HAND COLUMN] with your left hand. Work as quickly as you can and do not skip any holes. Ready? Begin.' [TRIAL IS 30 SECONDS WITH SAME PROCEDURES AS TRIAL 1.] 4. Trial 4, Left Hand [ENTER NUMBER OF PEGS CORRECTLY PLACED] | 0 .. 25 |
449 | glasses | VISION Now I have some questions about your eyesight and your hearing. 1. Do you wear eyeglasses, contact lenses or both? | 1= Eyeglasses 2= Contact lenses 3= Both 4= Neither |
450 | reading | 1a. Do you use ^eyes for reading and other close work? | 1= Yes 2= No |
451 | distant | 1b. Do you use ^eyes for seeing distant objects better? | 1= Yes 2= No |
452 | testaid | ^instruct 1c. Test taken with: | 1= Glasses 2= Contact lenses 3= Neither |
453 | trial10 | [INTERVIEWER: Visual acuity should be checked with both eyes open. Hold card 14 inches from subject and ask him/her to read the number on the card. Record number of correct responses.] 2. First trial: 20/70 | 1= All three correct 2= Two correct 3= One correct 4= None correct |
454 | trial1a | 2a. Second trial: 20/100 | 1= All three correct 2= Two correct 3= One correct 4= None correct |
455 | trial1b | 2b. Third trial: 20/200 | 1= All three correct 2= Two correct 3= One correct 4= None correct |
456 | trial1c | 2c. Fourth trial: 20/400 | 1= All three correct 2= Two correct 3= One correct 4= None correct |
457 | trial20 | 3. Second trial: 20/50 | 1= All three correct 2= Two correct 3= One correct 4= None correct |
458 | trial300 | 3a. Third trial: 20/40 | 1= All three correct 2= Two correct 3= One correct 4= None correct |
459 | hearaid | 4. Do you wear a hearing aid? | 1= Yes 2= No |
460 | freq1 | 4a. How often do you usually wear a hearing aid these days: practically always, frequently, occasionally, or almost never? | 1= Practically always 2= Frequently 3= Occasionally 4= Almost never |
461 | normal | 5. ^aid you usually hear and understand what a person says without seeing his or her face if that person talks in a normal voice to you in a quiet room? | 1= Yes 2= No |
462 | acrossrm | 5a. ^aid you usually hear and understand what a person says without seeing his or her face if that person shouts to you from across a quiet room? | 1= Yes 2= No |
463 | inear | 5b. ^aid you usually hear and understand what a person says without seeing his or her face if that person shouts in your better ear? | 1= Yes 2= No |
464 | htwt1fu | HEIGHT AND WEIGHT Now I have some questions about your height and weight. 1. Since your interview on [last interview date], have you gained or lost more than 10 pounds? [PROBE IF YES: Did you gain more than 10 pounds or lose more than 10 pounds or both?] | 1= Yes, lost >10 lbs 2= Yes, gained > 10 lbs 3= Yes, gained and lost > 10 lbs 4= No changes |
465 | midarm | BLOODPRESSURE Now I would like to take some arm, height and weight measurements, and blood pressure readings. 1. MID-ARM CIRCUMFERENCE [IN cm] | 15.0 .. 78.0 |
466 | midfore | 1a. MID FOREARM CIRCUMFERENCE [IN cm] | 10.0 .. 78.0 |
467 | midleg | 1b. MID LEG CIRCUMFERENCE [IN cm] | 15.0 .. 99.0 |
468 | tricep1 | 2. FIRST TRICEPS SKINFOLD MEASUREMENT [IN mm] CODE 72 IF MEASUREMENT >= 67 mm] | 1 .. 72 |
469 | cuff | BLOODPRESSURE Now I would like to take some height and weight measurements, and blood pressure readings. 3. IS CUFF SIZE AVAILABLE? [IF CUFF NOT AVAILABLE, AT END OF INTERVIEW SET UP TIME TO RETURN FOR BLOOD PRESSURE MEASUREMENT] | 1= Yes 2= No |
470 | tricep2 | 4. SECOND TRICEPS SKINFOLD MEASUREMENT [IN mm] [CODE 72 IF MEASUREMENT >=67mm] | 1 .. 72 |
471 | pulsept | 5. PULSE OBLITERATION POINT [IN mmHg] | 50 .. 270 |
472 | pul | THE PEAK INFLATION LEVEL IS ^pulse [HIT ENTER FOR NEXT QUESTION] | 80 .. 300 |
473 | bp1 | 6. FIRST SITTING BLOOD PRESSURE READING [INTERVIEWER: The subject should be seated for five minutes prior to obtaining the seated blood pressure readings. ENTER SYSTOLIC/DIASTOLIC] | String[7] |
474 | bp2 | 7. SECOND SITTING BLOOD PRESSURE READING [INTERVIEWER: ENTER SYSTOLIC/DIASTOLIC] | String[7] |
475 | bp31 | 8. STANDING BLOOD PRESSURE READING [INTERVIEWER: ASK THE SUBJECT TO STAND. WAIT 60 SECONDS THEN REPEAT BLOOD PRESSURE READING. ENTER SYSTOLIC/DIASTOLIC] | String[7] |
476 | weight | 9. MEASURED WEIGHT [IN LBS] [CODE 333 IF MEASUREMENT IS >=300 lbs. CODE 888 IF PHYSICALLY UNABLE TO WEIGH] | 30 .. 888 |
477 | height | 10. MEASURED HEIGHT [IN FEET & INCHES] [CODE 888 IF PHYSICALLY UNABLE TO MEASURE HEIGHT] | String[5] |
478 | introk | PHYSICAL MEASUREMENTS Now I would like you to try to do different movements of your body that involve your arms and legs. I will first describe and show each movement to you. Then I'd like you to try it. Please be very careful and let me know if you need help. [INTERVIEWER: BOTH THE RESEARCH ASSISTANT AND NURSE SHOULD BE PRESENT IF THE SUBJECT NEEDS ASSISTANCE WITH THESE MEASUREMENTS. DEMONSTRATE AND DESCRIBE EACH POSITION. THEN ENTER NUMBER OF SECONDS THE SUBJECT HOLDS POSITION.] >>>>> PRESS ENTER FOR NEXT QUESTION <<<<</p | String[1] |
479 | move1 | 1. SEMI-TANDEM STAND (Eyes Open) [UP TO 10 SECONDS] [INTERVIEWER: DESCRIBE THE POSITION WHILE DEMONSTRATING.] [ENTER NUMBER OF SECONDS R HOLDS POSITION] [CODE 55.5=tried but unable] | 1.0 .. 55.5 |
480 | move2 | 2. FULL TANDEM STAND (Eyes Open) [INTERVIEWER: DESCRIBE THE POSITION WHILE DEMONSTRATING.] [ENTER NUMBER OF SECONDS R HOLDS POSITION] [CODE 55.5=tried but unable] | 1.0 .. 55.5 |
481 | move3 | 3. SIDE BY SIDE STAND (Eyes Open) [INTERVIEWER: DESCRIBE THE POSITION WHILE DEMONSTRATING.] [ENTER NUMBER OF SECONDS R HOLDS POSITION] [CODE 55.5=tried but unable] | 1.0 .. 55.5 |
482 | move4 | 4. SIDE BY SIDE STAND (Eyes Closed) [INTERVIEWER: DESCRIBE THE POSITION WHILE DEMONSTRATING.] [ENTER NUMBER OF SECONDS R HOLDS POSITION] [CODE 55.5=tried but unable] | 1.0 .. 55.5 |
483 | move5 | 5. HEEL STAND (Eyes Open) [INTERVIEWER: DESCRIBE THE POSITION WHILE DEMONSTRATING.] [ENTER NUMBER OF SECONDS R HOLDS POSITION] [CODE 55.5=tried but unable] | 1.0 .. 55.5 |
484 | move6 | 6. TOE STAND (Eyes Open) [INTERVIEWER: DESCRIBE THE POSITION WHILE DEMONSTRATING.] [ENTER NUMBER OF SECONDS R HOLDS POSITION] [CODE 55.5=tried but unable] | 1.0 .. 55.5 |
485 | move6a | 6a. STANDING ON RIGHT LEG (Eyes Open) [TRIAL ONE] [INTERVIEWER: DESCRIBE THE POSITION WHILE DEMONSTRATING.] [ENTER NUMBER OF SECONDS R HOLDS POSITION] [CODE 55.5=tried but unable] | 1.0 .. 55.5 |
486 | move6b | 6b. STANDING ON RIGHT LEG (Eyes Open) [TRIAL TWO] [INTERVIEWER: DESCRIBE THE POSITION WHILE DEMONSTRATING.] [ENTER NUMBER OF SECONDS R HOLDS POSITION] [CODE 55.5=tried but unable] | 1.0 .. 55.5 |
487 | move6c | 6c. STANDING ON LEFT LEG (Eyes Open) [TRIAL ONE] [INTERVIEWER: DESCRIBE THE POSITION WHILE DEMONSTRATING.] [ENTER NUMBER OF SECONDS R HOLDS POSITION] [CODE 55.5=tried but unable] | 1.0 .. 55.5 |
488 | move6d | 6d. STANDING ON LEFT LEG (Eyes Open) [TRIAL TWO] [INTERVIEWER: DESCRIBE THE POSITION WHILE DEMONSTRATING.] [ENTER NUMBER OF SECONDS R HOLDS POSITION] [CODE 55.5=tried but unable] | 1.0 .. 55.5 |
489 | move6e | 6e. TURNING (360 degrees) [TRIAL ONE] [INTERVIEWER: DESCRIBE THE POSITION WHILE DEMONSTRATING.] [ENTER NUMBER OF SECONDS R TAKES TO COMPLETE THE TURN] [CODE 555.5=tried but unable] | 1.0 .. 555.5 |
490 | move6f | 6f. TURNING (360 degrees) [TRIAL ONE] [INTERVIEWER: DESCRIBE THE POSITION WHILE DEMONSTRATING.] [ENTER NUMBER OF STEPS R TAKES TO COMPLETE THE TURN] [CODE 55=tried but unable] | 1 .. 55 |
491 | move6g | 6g. TURNING (360 degrees) [TRIAL TWO] [INTERVIEWER: DESCRIBE THE POSITION WHILE DEMONSTRATING.] [ENTER NUMBER OF SECONDS R TAKES TO COMPLETE THE TURN] [CODE 555.5=tried but unable] | 1.0 .. 555.5 |
492 | move6h | 6h. TURNING (360 degrees) [TRIAL TWO] [INTERVIEWER: DESCRIBE THE POSITION WHILE DEMONSTRATING.] [ENTER NUMBER OF STEPS R TAKES TO COMPLETE THE TURN] [CODE 55=tried but unable] | 1 .. 55 |
493 | move6i | 6i. [INTERVIEWER: RECORD AIDS USED FOR TURNING] | 1= No aid 2= Quad Cane 3= Other Cane 4= Walker 5= Wheelchair 6= Other |
494 | move6i1 | [SPECIFY] | String[20] |
495 | move7 | 7. MEASURED WALK [INTERVIEWER: EXTEND THE RULE TO THE 8' LENGTH IN AN AREA WHICH OFFERS AT LEAST 11' AND IDEALLY 12' OF WALKING SPACE. MARK STARTING LINE AND ENDING LINE WITH 18 INCH PIECE OF TAPE. Count the number of steps required to complete the course.] Was the course 8 feet in length? | 1= Yes 2= No |
496 | move7a | 7a. [INTERVIEWER: RECORD AIDS USED IN MEASURED WALK] | 1= No aid 2= Quad Cane 3= Other Cane 4= Walker 5= Wheelchair as walking aid 6= Other |
497 | move7a1 | 7b1. [SPECIFY] | String[20] |
498 | move7b | 7b. [INTERVIEWER: RECORD TIME FOR FIRST WALK (in seconds)] [CODE 555.5=tried but unable] | 1.0 .. 555.5 |
499 | move7c | 7c. How many steps were taken? | 1 .. 55 |
500 | move8 | 8. TANDEM WALK [INTERVIEWER: RECORD NUMBER OF ERRORS, e.g. SIDESTEPS] [CODE 55=TRIED BUT UNABLE] | 0 .. 55 |
501 | move9a | 9a. CHAIR STAND. [INTERVIEWER: DESCRIBE THE CHAIR STAND AND DEMONSTRATE.] ENTER NUMBER OF ATTEMPTS TO RISE (INCLUDING ROCKING/WEIGHT SHIFTING) | 0 .. 20 |
502 | move9b | 9b. ATTEMPT TO RISE. | 1= Rises without using arms 2= Rises using arms 3= Not attempted (no suitable chair) 55= Tried but unable |
503 | move10a | 10. REPEATED CHAIR STAND [INTERVIEWER: DESCRIBE REPEATED CHAIR STANDS WHILE DEMONSTRATING.] 10a. COMPLETION. | 1= One completed 2= Two completed 3= Three completed 4= Four completed 5= Five completed 13= Not attempted, no suitable chair 55= Tried, but unable |
504 | move10b | 10b. TIME IF 5 STANDS DONE SUCCESSFULLY [IN SECONDS] | 1.0 .. 99.0 |
505 | move9c | 10c. [RECORD CHAIR HEIGHT] [ENTER INCHES FROM FLOOR TO LOWEST POINT OF SEAT] | 3 .. 48 |
506 | move9d | 10d. Did the chair have arms? | 1= Yes 2= No |
507 | move11a | EXTERNAL SHOULDER ROTATION. [DESCRIBE EXERCISE WHILE DEMONSTRATING.] 11a. RIGHT SIDE: | 1= Performed fully 2= Performed partially; hand behind head 3= Performed partially; arm raised 4= Unable to do |
508 | move11b | 11b. LEFT SIDE: | 1= Performed fully 2= Performed partially; hand behind head 3= Performed partially; arm raised 4= Unable to do |
509 | autendtm | [COMPUTER CLOCK TIME] | String[8] |
510 | comment | Comments | String[120] |
515 | vegsign | 0 .. 8 | |
516 | mvegsign | 0 .. 8 | |
517 | cesd | 0 .. 10 | |
518 | mcesd | 0 .. 10 | |
519 | formcode | Please enter status code. 11 = COMPLETE 13 = COMPLETE, portion with proxy 12 = INCOMPLETE, refused 14 = INCOMPLETE, too impaired 21 = INCOMPLETE interim, complete later 73 = NOT TESTED, out of town 31 = NOT TESTED, moved 33 = NOT TESTED, refused 75 = NOT TESTED, hospitalized 76 = NOT TESTED, other 42 = DECEASED 43 = WITHDRAWN 44 = WITHDRAWN, Autopsy OK | 11 .. 76 |
520 | formpart | Was participant reluctant, and/or does participant have special needs? | 1= Yes 2= No |
521 | formcomm | Please explain reluctance or any other factors which may have affected this data. [Press enter if no comment needed.] | String[120] |
522 | statid | Please enter you staff id. | 100 .. 997 |
523 | formch | Has the form been modified? | 1= Yes 2= No |
524 | revidate | Enter the date that the form was modified. | Date type |
525 | revintd | Enter your staff id number. | 100 .. 997 |
526 | anydev | Are there any protocol deviations or missing data items to enter? | 1= Yes 2= No |
527 | numdev | How many total protocol deviations and tests with missing items to enter? | 1 .. 20 |
528 | reas00 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
529 | test00 | Enter test or procedure. | String[15] |
530 | item00 | List items involved. [SEPARATE BY A COMMA] | String[20] |
531 | code00 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
532 | oth00 | Enter other code used. | String[20] |
533 | expl00 | Explain what happened | String[100] |
534 | reas01 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
535 | test01 | Enter test or procedure. | String[15] |
536 | item01 | List items involved. [SEPARATE BY A COMMA] | String[20] |
537 | code01 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
538 | oth01 | Enter other code used. | String[20] |
539 | expl01 | Explain what happened | String[100] |
540 | reas02 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
541 | test02 | Enter test or procedure. | String[15] |
542 | item02 | List items involved. [SEPARATE BY A COMMA] | String[20] |
543 | code02 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
544 | oth02 | Enter other code used. | String[20] |
545 | expl02 | Explain what happened | String[100] |
546 | reas03 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
547 | test03 | Enter test or procedure. | String[15] |
548 | item03 | List items involved. [SEPARATE BY A COMMA] | String[20] |
549 | code03 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
550 | oth03 | Enter other code used. | String[20] |
551 | expl03 | Explain what happened | String[100] |
552 | reas04 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
553 | test04 | Enter test or procedure. | String[15] |
554 | item04 | List items involved. [SEPARATE BY A COMMA] | String[20] |
555 | code04 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
556 | oth04 | Enter other code used. | String[20] |
557 | expl04 | Explain what happened | String[100] |
558 | reas05 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
559 | test05 | Enter test or procedure. | String[15] |
560 | item05 | List items involved. [SEPARATE BY A COMMA] | String[20] |
561 | code05 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
562 | oth05 | Enter other code used. | String[20] |
563 | expl05 | Explain what happened | String[100] |
564 | reas06 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
565 | test06 | Enter test or procedure. | String[15] |
566 | item06 | List items involved. [SEPARATE BY A COMMA] | String[20] |
567 | code06 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
568 | oth06 | Enter other code used. | String[20] |
569 | expl06 | Explain what happened | String[100] |
570 | reas07 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
571 | test07 | Enter test or procedure. | String[15] |
572 | item07 | List items involved. [SEPARATE BY A COMMA] | String[20] |
573 | code07 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
574 | oth07 | Enter other code used. | String[20] |
575 | expl07 | Explain what happened | String[100] |
576 | reas08 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
577 | test08 | Enter test or procedure. | String[15] |
578 | item08 | List items involved. [SEPARATE BY A COMMA] | String[20] |
579 | code08 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
580 | oth08 | Enter other code used. | String[20] |
581 | expl08 | Explain what happened | String[100] |
582 | reas09 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
583 | test09 | Enter test or procedure. | String[15] |
584 | item09 | List items involved. [SEPARATE BY A COMMA] | String[20] |
585 | code09 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
586 | oth09 | Enter other code used. | String[20] |
587 | expl09 | Explain what happened | String[100] |
588 | reas10 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
589 | test10 | Enter test or procedure. | String[15] |
590 | item10 | List items involved. [SEPARATE BY A COMMA] | String[20] |
591 | code10 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
592 | oth10 | Enter other code used. | String[20] |
593 | expl10 | Explain what happened | String[100] |
594 | reas11 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
595 | test11 | Enter test or procedure. | String[15] |
596 | item11 | List items involved. [SEPARATE BY A COMMA] | String[20] |
597 | code11 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
598 | oth11 | Enter other code used. | String[20] |
599 | expl11 | Explain what happened | String[100] |
600 | reas12 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
601 | test12 | Enter test or procedure. | String[15] |
602 | item12 | List items involved. [SEPARATE BY A COMMA] | String[20] |
603 | code12 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
604 | oth12 | Enter other code used. | String[20] |
605 | expl12 | Explain what happened | String[100] |
606 | reas13 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
607 | test13 | Enter test or procedure. | String[15] |
608 | item13 | List items involved. [SEPARATE BY A COMMA] | String[20] |
609 | code13 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
610 | oth13 | Enter other code used. | String[20] |
611 | expl13 | Explain what happened | String[100] |
612 | reas14 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
613 | test14 | Enter test or procedure. | String[15] |
614 | item14 | List items involved. [SEPARATE BY A COMMA] | String[20] |
615 | code14 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
616 | oth14 | Enter other code used. | String[20] |
617 | expl14 | Explain what happened | String[100] |
618 | reas15 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
619 | test15 | Enter test or procedure. | String[15] |
620 | item15 | List items involved. [SEPARATE BY A COMMA] | String[20] |
621 | code15 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
622 | oth15 | Enter other code used. | String[20] |
623 | expl15 | Explain what happened | String[100] |
624 | reas16 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
625 | test16 | Enter test or procedure. | String[15] |
626 | item16 | List items involved. [SEPARATE BY A COMMA] | String[20] |
627 | code16 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
628 | oth16 | Enter other code used. | String[20] |
629 | expl16 | Explain what happened | String[100] |
630 | reas17 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
631 | test17 | Enter test or procedure. | String[15] |
632 | item17 | List items involved. [SEPARATE BY A COMMA] | String[20] |
633 | code17 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
634 | oth17 | Enter other code used. | String[20] |
635 | expl17 | Explain what happened | String[100] |
636 | reas18 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
637 | test18 | Enter test or procedure. | String[15] |
638 | item18 | List items involved. [SEPARATE BY A COMMA] | String[20] |
639 | code18 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
640 | oth18 | Enter other code used. | String[20] |
641 | expl18 | Explain what happened | String[100] |
642 | reas19 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
643 | test19 | Enter test or procedure. | String[15] |
644 | item19 | List items involved. [SEPARATE BY A COMMA] | String[20] |
645 | code19 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
646 | oth19 | Enter other code used. | String[20] |
647 | expl19 | Explain what happened | String[100] |