Data Dictionary for mp2intfu
Number of Blaise fields: 683
| Seq # | Var | Question | Data Type/Coding |
|---|---|---|---|
| 1 | ivisit | visit | |
| 2 | projid | MAP 2001 FOLLOW-UP Interview (v6.0 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 | baseyear | Enter year of baseline from face sheet: | 1993 .. 2025 |
| 5 | formno | INTRODUCTION Form Number | String[8] |
| 6 | version | version Number. | String[4] |
| 7 | autodate | Automatic Date. | Date type |
| 8 | autotime | Automatic Time. | TimeType |
| 9 | autolog | Automatic Logged Date. | Date type |
| 10 | intid | INTERVIEWER ID | 100 .. 997 |
| 11 | compid | Laptop ID | String[20] |
| 12 | dateint | Date of interview | Date type |
| 13 | datlas | Date of previous MAP questionnaire | Date type |
| 14 | gender | 1. Record participant's sex. | 1= Male 2= Female |
| 15 | phone | Was this interview completed on telephone or in person? | 1= In-person 2= Telephone |
| 16 | autotm | [COMPUTER CLOCK TIME] | String[8] |
| 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 | heart | 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 |
| 44 | multiple | 1a. Did you have only one or more than one? | 1= Only one 2= More than one |
| 45 | inhosp | 1b Were you hospitalized overnight or longer for this (last one)? | 1= Yes 2= No |
| 46 | 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 |
| 47 | chfhosp | Were you hospitalized overnight or longer for this? | 1= Yes 2= No |
| 48 | chfnum | How many times have you been hospitalized for this since your last interview on [last interview date]? | 0 .. 10 |
| 49 | cancer | 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 |
| 50 | ca1a | 1a. Where was it? [OR: Where was the most recent cancer that you had?] [SPECIFY] | String[20] |
| 51 | diabetes | 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 |
| 52 | db1 | 2. Has a doctor, nurse or therapist, told you to take insulin or injections for your high blood sugar? | 1= Yes 2= No |
| 53 | db3 | 3. Has a doctor, nurse, or therapist told you to take medicine by mouth for your high blood sugar? | 1= Yes 2= No |
| 54 | highbp | 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 |
| 55 | bp3 | 2 Has a doctor, nurse, or therapist told you to take medicine by mouth for your high blood pressure? | 1= Yes 2= No |
| 56 | thyroid | 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 |
| 57 | brokenhp | 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 |
| 58 | hip6afix | 1a. Were you hospitalized overnight or longer for this? | 1= Yes 2= No |
| 59 | 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 |
| 60 | 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 |
| 61 | 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 |
| 62 | 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 |
| 63 | hormones | 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. 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 |
| 64 | pill | 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 |
| 65 | shot | 3. injection (shot) | 1= Yes 2= Suspect 3= No |
| 66 | cos | 4. vaginal cream or suppository | 1= Yes 2= Suspect 3= No |
| 67 | patch | 5. skin patch | 1= Yes 2= Suspect 3= No |
| 68 | current | 6. Are you currently taking this/these medications? | 1= Yes 2= No |
| 69 | chespain | CHEST PAIN Now some questions about pains in your chest. 1. Do you get pain or discomfort in your chest? | 1= Yes 2= No |
| 70 | pressure | 1a. Do you get pressure or heaviness in your chest? | 1= Yes 2= No |
| 71 | uphill0 | 2. Do you get this pain (or discomfort) when you walk uphill or hurry? | 1= Yes 2= No 3= Never walks uphill or hurries |
| 72 | level0 | 3. Do you get this pain (or discomfort) when you walk at an ordinary pace on level ground? | 1= Yes 2= No |
| 73 | legpain | CLAUDICATION Now some questions about pains in your legs. 1. Do you get pain in either leg while walking? | 1= Yes 2= No |
| 74 | standsit | 2. Does this pain ever begin when you are standing still or sitting? | 1= Yes 2= No |
| 75 | 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 |
| 76 | shrtbrth | 9. Do you get short of breath at night if you sleep flat or only on one pillow? | 1= Yes 2= No |
| 77 | pillows | 9a. How many pillows do you need to sleep on to not be short of breath? | 1 .. 9 |
| 78 | grspbrth | 9b. Do you wake up at night gasping for breath? | 1= Yes 2= No |
| 79 | hoftshrt | 9c. About how often did you have shortness of breath at night in the last month? | 1= Several times/week 2= Once every night 3= A few times a week 4= Less often than once a week |
| 80 | joints | 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 |
| 81 | neckpain | 2. ...Pain in your neck or back on most days for at least one month? | 1= Yes 2= No |
| 82 | neckpain2 | 2. ...Pain in your neck on most days for at least one month? | 1= Yes 2= No |
| 83 | backpain | 2a. ...Pain in your back on most days for at least one month? | 1= Yes 2= No |
| 84 | hippain | 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 |
| 85 | kneepain | 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 |
| 86 | swelling | 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 |
| 87 | stiff | 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 |
| 88 | feetpain | 7. ...Pain or aching in either of your feet on most days for at least one month? | 1= Yes 2= No |
| 89 | handpain | 8. ...Pain or aching in either of your hands, wrists or fingers on most days for at least one month? | 1= Yes 2= No |
| 90 | q1neur | NEUROPATHY Now I have some questions about numbness and tingling. In the past month, have you had numbness or tingling [or asleep or burning] feeling of your feet or toes? | 1= Yes 2= Suspect 3= No |
| 91 | q2neur | Was this ___ on the right side, left side, or both sides? | 1= Right 2= Left 3= Both |
| 92 | q3neur | In the past month, have you had numbness or tingling [or asleep or burning] feeling of your hands or fingers? | 1= Yes 2= Suspect 3= No |
| 93 | q4neur | Was this ___ on the right side, left side, or both sides? | 1= Right 2= Left 3= Both |
| 94 | q5neur | CERVICAL RADICULAPATHY Now I have some questions about neck pain. Since your interview on [last interview date], have you had neck pain that lasted days weeks, or months? | 1= Yes 2= Suspect 3= No |
| 95 | q6neur | 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 |
| 96 | q7neur1 | 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 |
| 97 | q7neur2 | Which of these problems did you have, pain, numbness or tingling, or weakness? [LIST ALL THAT APPLY] | See previous question |
| 98 | q7neur3 | Which of these problems did you have, pain, numbness or tingling, or weakness? [LIST ALL THAT APPLY] | See previous question |
| 99 | q8neur | Did this ___ occur on the right side, left side, or both sides? | 1= Right 2= Left 3= Both |
| 100 | q9neur | 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 |
| 101 | q10neur | How many different times have you had neck pain? | 1 .. 50 |
| 102 | q11neur | 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 |
| 103 | q12neur | Have you seen a doctor because of neck pain since your last interview on [last interview date]? | 1= Yes 2= No |
| 104 | q13neur | Have you had an x-ray or scan [CT or MRI] of the neck because of the pain since your last interview on [last interview date]? | 1= Yes 2= No |
| 105 | q14neur | When was the last time? [ENTER YEAR] @ @ @ @ | 1900 .. 2040 |
| 106 | q15neur | What was the name of the place (doctor's office, hospital or other place) at which the scan was performed? [ENTER NAME] | String[40] |
| 107 | q16neur | [ENTER LOCATION] | String[40] |
| 108 | q17neur | 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 |
| 109 | q18neur | At a time while you were having low back pain, did you also have pain, numbness or tingling, or weakness in the feet or toes? | 1= Yes 2= Suspect 3= No |
| 110 | q19neur1 | 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 |
| 111 | q19neur2 | Which of these problems did you have, pain, numbness or tingling, or weakness? [LIST ALL THAT APPLY] | See previous question |
| 112 | q19neur3 | Which of these problems did you have, pain, numbness or tingling, or weakness? [LIST ALL THAT APPLY] | See previous question |
| 113 | q20neur | Did this ___ occur on the right side, left side, or both sides? | 1= Right 2= Left 3= Both |
| 114 | q21neur | Now, when you have low back pain, how long, on average, does the 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 |
| 115 | q22neur | How many different times have you had low back pain? | 1 .. 50 |
| 116 | q23neur | 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 |
| 117 | q24neur | Have you seen a doctor because of low back pain since your last interview on [last interview date]? | 1= Yes 2= No |
| 118 | q25neur | Have you had an x-ray or scan [CT or MRI] of the low back because of the pain since your last interview on [last interview date]? | 1= Yes 2= No |
| 119 | q26neur | When was the last time? [ENTER YEAR] @ @ @ @ | 1900 .. 2040 |
| 120 | q27neur | What was the name of the place (doctor's office, hospital or other place) at which the scan was performed? [ENTER NAME] | String[40] |
| 121 | q28neur | [ENTER LOCATION] | String[40] |
| 122 | q1md | MOODS Now let me ask some questions about your current moods and feelings. 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 |
| 123 | q2md | 2. My sleep was restless. (Have you felt this way much of the time during the past week?) | 1= Yes 2= No |
| 124 | q3md | 3. I felt depressed. (Have you felt this way much of the time during the past week?) | 1= Yes 2= No |
| 125 | q4md | 4. I was happy. (Have you felt this way much of the time during the past week?) | 1= Yes 2= No |
| 126 | q5md | 5. I felt lonely. (Have you felt this way much of the time during the past week?) | 1= Yes 2= No |
| 127 | q6md | 6. People were unfriendly. (Have you felt this way much of the time during the past week?) | 1= Yes 2= No |
| 128 | q7md | 7. I enjoyed life. (Have you felt this way much of the time during the past week?) | 1= Yes 2= No |
| 129 | q8md | 8. I felt sad. (Have you felt this way much of the time during the past week?) | 1= Yes 2= No |
| 130 | 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 |
| 131 | q10md | 10. I could not get 'going'. (Have you felt this way much of the time during the past week?) | 1= Yes 2= No |
| 132 | q1slp | SLEEP Now I would like to get some information about how well you sleep. 1. How often do you have trouble falling asleep? Would you say it is - very often, often, sometimes, rarely or never? | 1= Very Often 2= Often 3= Sometimes 4= Rarely 5= Never |
| 133 | q2slp | 2. How often are you troubled by waking up during the night? | 1= Very Often 2= Often 3= Sometimes 4= Rarely 5= Never |
| 134 | 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 |
| 135 | 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 |
| 136 | q6slp | 5. In the past month, how many hours do you usually sleep at night? [ENTER AVERAGE HOURS] | 0 .. 24 |
| 137 | howfeel | DEPRESSION Now I have a few more questions about how you feel. 1. In the past month, has there been a period of 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 |
| 138 | aptite | During this period during which you felt depressed, did you experience any of the following problems? 2. A change in your appetite | 1= Yes 2= No |
| 139 | sleep | 3. A change in your pattern of sleeping. | 1= Yes 2= No |
| 140 | enrgy | 4. A decrease in your energy level. | 1= Yes 2= No |
| 141 | concen | 5. Trouble concentrating. | 1= Yes 2= No |
| 142 | guilt | 6. Felt extremely guilty or worthless. | 1= Yes 2= No |
| 143 | restls | 7. Felt extremely restless or agitated. | 1= Yes 2= No |
| 144 | activt | 8. Lost your interest in favorite activities. | 1= Yes 2= No |
| 145 | living | 9. Felt that life was not worth living. | 1= Yes 2= No |
| 146 | teldoc | 9a. Did you tell a doctor or any other professional about it? | 1= Yes 2= No |
| 147 | headinj | HEAD INJURY Now I have some questions about injuries. 1. Since [last interview date], have you had a head injury? | 1= Yes 2= No |
| 148 | lostcons | 3. Have you lost consciousness because of a head injury that occurred since [last interview date]? | 1= Yes 2= Suspect or possible 3= No |
| 149 | howmany | 3a. How many times? | 1 .. 50 |
| 150 | howlong0 | 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 |
| 151 | hihosp | 4. Since your interview on [last interview date], were you hospitalized overnight or longer for a head injury? | 1= Yes 2= No |
| 152 | same1 | 4a. Was this the same event we just spoke about? | 1= Yes 2= No |
| 153 | hihospnm | 4c. What was the name of the (last) hospital? [HOSPITAL NAME] | String[40] |
| 154 | hihosloc | [LOCATION:] | String[40] |
| 155 | memory0 | Were any of the following signs/symptoms associated with this (last) event? [INTERVIEWER: `Last' event refers to the most recent hospitalization, or, if not hospitalized, most recent event with loss of consciousness.] 1. Memory loss or forgetfulness? | 1= Yes 2= Suspect 3= No |
| 156 | speech0 | 2. Language or speech change? | 1= Yes 2= Suspect 3= No |
| 157 | weaknes0 | 3. Weakness or paralysis of face, arms or legs? | 1= Yes 2= Suspect 3= No |
| 158 | side0 | 3a. Which side(s)? | 1= right only 2= left only 3= both |
| 159 | othspec0 | 4. Specify any other signs or symptoms associated with this (last) event? [PRESS ENTER IF NONE.] | String[40] |
| 160 | leftove0 | 6. Specify left over troubles from your head injury(s)? [PRESS ENTER IF NONE.] | String[40] |
| 161 | hiscan | 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 |
| 162 | same2 | Was this the same event we just spoke about? | 1= Yes 2= No |
| 163 | hiscanam | 5b. What was the name of the place (doctor's office, hospital or other place) at which the scan was performed? [NAME:] | String[40] |
| 164 | memory1 | Were any of the following signs/symptoms associated with this (last) event? [INTERVIEWER: `Last' event refers to the event associated with the CT, MRI, or brain scan.] 1. Memory loss or forgetfulness? | 1= Yes 2= Suspect 3= No |
| 165 | speech1 | 2. Language or speech change? | 1= Yes 2= Suspect 3= No |
| 166 | weaknes1 | 3. Weakness or paralysis of face, arms or legs? | 1= Yes 2= Suspect 3= No |
| 167 | side1 | 3a. Which side(s)? | 1= right only 2= left only 3= both |
| 168 | othspec1 | 4. Specify any other signs or symptoms associated with this (last) event? [PRESS ENTER IF NONE.] | String[40] |
| 169 | leftove1 | 6. Specify left over troubles from your head injury(s)? [PRESS ENTER IF NONE.] | String[40] |
| 170 | specify | 6. Specify left over troubles from your head injury(s)? [PRESS ENTER IF NONE.] | String[40] |
| 171 | hdrvehicle | ||
| 172 | hdrhitbyobject | ||
| 173 | hdrfalling | ||
| 174 | hdrsports | ||
| 175 | hdrabuse | ||
| 176 | hdrmilitary | ||
| 177 | hdrother | ||
| 178 | prevbisqdone | BRAIN INJURY SCREENING QUESTIONNAIRE Have the BISQ questions been previously completed for this participant? ^prevBisqDoneText | 1= Yes 2= No |
| 179 | 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 |
| 180 | bisqvehnum | ^hdrVehicle How many times did you receive a blow to the head, in a vehicle accident? | 1 .. 30 |
| 181 | bisqvehloc | ^hdrVehicle Did you lose consciousness? | 1= Yes 2= No |
| 182 | bisqvehlocnum | ^hdrVehicle How many times have you lost consciousness? | 1 .. 30 |
| 183 | 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. |
| 184 | bisqvehlocyr1 | ^hdrVehicle In what year did this occur (1)? | 1900 .. 2050 |
| 185 | bisqvehlocyr2 | ^hdrVehicle In what year did this occur (2)? | 1900 .. 2050 |
| 186 | bisqvehlocyr3 | ^hdrVehicle In what year did this occur (3)? | 1900 .. 2050 |
| 187 | bisqvehlocyr4 | ^hdrVehicle In what year did this occur (4)? | 1900 .. 2050 |
| 188 | bisqvehlocyr5 | ^hdrVehicle In what year did this occur (5)? | 1900 .. 2050 |
| 189 | bisqvehdaze | ^hdrVehicle Were you dazed or confused? | 1= Yes 2= No |
| 190 | bisqvehdazenum | ^hdrVehicle How many times have you been dazed or confused? | 1 .. 30 |
| 191 | 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. |
| 192 | bisqvehdazeyr1 | ^hdrVehicle In what year did this occur (1)? | 1900 .. 2050 |
| 193 | bisqvehdazeyr2 | ^hdrVehicle In what year did this occur (2)? | 1900 .. 2050 |
| 194 | bisqvehdazeyr3 | ^hdrVehicle In what year did this occur (3)? | 1900 .. 2050 |
| 195 | bisqvehdazeyr4 | ^hdrVehicle In what year did this occur (4)? | 1900 .. 2050 |
| 196 | bisqvehdazeyr5 | ^^hdrVehicle In what year did this occur (5)? | 1900 .. 2050 |
| 197 | bisqhit | ^lastInterviewText1en 2. Hit by an object?(ex: equipment, falling object) | 1= Yes 2= No |
| 198 | bisqhitnum | ^hdrHitByObject How many times did you receive a blow to the head, from a falling object? | 1 .. 30 |
| 199 | bisqhitloc | ^hdrHitByObject Did you lose consciousness? | 1= Yes 2= No |
| 200 | bisqhitlocnum | ^hdrHitByObject How many times have you lost consciousness? | 1 .. 30 |
| 201 | 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. |
| 202 | bisqhitlocyr1 | ^hdrHitByObject In what year did this occur (1)? | 1900 .. 2050 |
| 203 | bisqhitlocyr2 | ^hdrHitByObject In what year did this occur (2)? | 1900 .. 2050 |
| 204 | bisqhitlocyr3 | ^hdrHitByObject In what year did this occur (3)? | 1900 .. 2050 |
| 205 | bisqhitlocyr4 | ^hdrHitByObject In what year did this occur (4)? | 1900 .. 2050 |
| 206 | bisqhitlocyr5 | ^hdrHitByObject In what year did this occur (5)? | 1900 .. 2050 |
| 207 | bisqhitdaze | ^hdrHitByObject Were you dazed or confused? | 1= Yes 2= No |
| 208 | bisqhitdazenum | ^hdrHitByObject How many times have you been dazed or confused? | 1 .. 30 |
| 209 | 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. |
| 210 | bisqhitdazeyr1 | ^hdrHitByObject In what year did this occur (1)? | 1900 .. 2050 |
| 211 | bisqhitdazeyr2 | ^hdrHitByObject In what year did this occur (2)? | 1900 .. 2050 |
| 212 | bisqhitdazeyr3 | ^hdrHitByObject In what year did this occur (3)? | 1900 .. 2050 |
| 213 | bisqhitdazeyr4 | ^hdrHitByObject In what year did this occur (4)? | 1900 .. 2050 |
| 214 | bisqhitdazeyr5 | ^hdrHitByObject In what year did this occur (5)? | 1900 .. 2050 |
| 215 | bisqfall | ^lastInterviewText2en 3. Falling? (ex: down stairs, during a fainting spell, from a high place) | 1= Yes 2= No |
| 216 | bisqfallnum | ^hdrFalling How many times did you receive a blow to the head, in a fall? | 1 .. 30 |
| 217 | bisqfallloc | ^hdrFalling Did you lose consciousness? | 1= Yes 2= No |
| 218 | bisqfalllocnum | ^hdrFalling How many times have you lost consciousness? | 1 .. 30 |
| 219 | 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. |
| 220 | bisqfalllocyr1 | ^hdrFalling In what year did this occur (1)? | 1900 .. 2050 |
| 221 | bisqfalllocyr2 | ^hdrFalling In what year did this occur (2)? | 1900 .. 2050 |
| 222 | bisqfalllocyr3 | ^hdrFalling In what year did this occur (3)? | 1900 .. 2050 |
| 223 | bisqfalllocyr4 | ^hdrFalling In what year did this occur (4)? | 1900 .. 2050 |
| 224 | bisqfalllocyr5 | ^hdrFalling In what year did this occur (5)? | 1900 .. 2050 |
| 225 | bisqfalldaze | ^hdrFalling Were you dazed or confused? | 1= Yes 2= No |
| 226 | bisqfalldazenum | ^hdrFalling How many times have you been dazed or confused? | 1 .. 30 |
| 227 | 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. |
| 228 | bisqfalldazeyr1 | ^hdrFalling In what year did this occur (1)? | 1900 .. 2050 |
| 229 | bisqfalldazeyr2 | ^hdrFalling In what year did this occur (2)? | 1900 .. 2050 |
| 230 | bisqfalldazeyr3 | ^hdrFalling In what year did this occur (3)? | 1900 .. 2050 |
| 231 | bisqfalldazeyr4 | ^hdrFalling In what year did this occur (4)? | 1900 .. 2050 |
| 232 | bisqfalldazeyr5 | ^hdrFalling In what year did this occur (5)? | 1900 .. 2050 |
| 233 | bisqsprt | ^lastInterviewText3en 4. Sports/Leisure?(ex: sports, biking, skiing, on the playground) | 1= Yes 2= No |
| 234 | bisqsprtnum | ^hdrSports How many times did you receive a blow to the head, during a sports or leisure activity? | 1 .. 30 |
| 235 | bisqsprtloc | ^hdrSports Did you lose consciousness? | 1= Yes 2= No |
| 236 | bisqsprtlocnum | ^hdrSports How many times have you lost consciousness? | 1 .. 30 |
| 237 | 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. |
| 238 | bisqsprtlocyr1 | ^hdrSports In what year did this occur (1)? | 1900 .. 2050 |
| 239 | bisqsprtlocyr2 | ^hdrSports In what year did this occur (2)? | 1900 .. 2050 |
| 240 | bisqsprtlocyr3 | ^hdrSports In what year did this occur (3)? | 1900 .. 2050 |
| 241 | bisqsprtlocyr4 | ^hdrSports In what year did this occur (4)? | 1900 .. 2050 |
| 242 | bisqsprtlocyr5 | ^hdrSports In what year did this occur (5)? | 1900 .. 2050 |
| 243 | bisqsprtdaze | ^hdrSports Were you dazed or confused? | 1= Yes 2= No |
| 244 | bisqsprtdazenum | ^hdrSports How many times have you been dazed or confused? | 1 .. 30 |
| 245 | 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. |
| 246 | bisqsprtdazeyr1 | ^hdrSports In what year did this occur (1)? | 1900 .. 2050 |
| 247 | bisqsprtdazeyr2 | ^hdrSports In what year did this occur (2)? | 1900 .. 2050 |
| 248 | bisqsprtdazeyr3 | ^hdrSports In what year did this occur (3)? | 1900 .. 2050 |
| 249 | bisqsprtdazeyr4 | ^hdrSports In what year did this occur (4)? | 1900 .. 2050 |
| 250 | bisqsprtdazeyr5 | ^hdrSports In what year did this occur (5)? | 1900 .. 2050 |
| 251 | bisqphys | ^lastInterviewText4en 5. Physical Abuse/Assault?(ex: mugged) | 1= Yes 2= No |
| 252 | bisqphysnum | ^hdrAbuse How many times did you receive a blow to the head, from abuse or assault? | 1 .. 30 |
| 253 | bisqphysloc | ^hdrAbuse Did you lose consciousness? | 1= Yes 2= No |
| 254 | bisqphyslocnum | ^hdrAbuse How many times have you lost consciousness? | 1 .. 30 |
| 255 | 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. |
| 256 | bisqphyslocyr1 | ^hdrAbuse In what year did this occur (1)? | 1900 .. 2050 |
| 257 | bisqphyslocyr2 | ^hdrAbuse In what year did this occur (2)? | 1900 .. 2050 |
| 258 | bisqphyslocyr3 | ^hdrAbuse In what year did this occur (3)? | 1900 .. 2050 |
| 259 | bisqphyslocyr4 | ^hdrAbuse In what year did this occur (4)? | 1900 .. 2050 |
| 260 | bisqphyslocyr5 | ^hdrAbuse In what year did this occur (5)? | 1900 .. 2050 |
| 261 | bisqphysdaze | ^hdrAbuse Were you dazed or confused? | 1= Yes 2= No |
| 262 | bisqphysdazenum | ^hdrAbuse How many times have you been dazed or confused? | 1 .. 30 |
| 263 | 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. |
| 264 | bisqphysdazeyr1 | ^hdrAbuse In what year did this occur (1)? | 1900 .. 2050 |
| 265 | bisqphysdazeyr2 | ^hdrAbuse In what year did this occur (2)? | 1900 .. 2050 |
| 266 | bisqphysdazeyr3 | ^hdrAbuse In what year did this occur (3)? | 1900 .. 2050 |
| 267 | bisqphysdazeyr4 | ^hdrAbuse In what year did this occur (4)? | 1900 .. 2050 |
| 268 | bisqphysdazeyr5 | ^hdrAbuse In what year did this occur (5)? | 1900 .. 2050 |
| 269 | bisqmil | ^lastInterviewText5en 6. Military Service?(ex: training, blast injury) | 1= Yes 2= No |
| 270 | bisqmilnum | ^hdrMilitary How many times did you receive a blow to the head, during military service? | 1 .. 30 |
| 271 | bisqmilloc | ^hdrMilitary Did you lose consciousness? | 1= Yes 2= No |
| 272 | bisqmillocnum | ^hdrMilitary How many times have you lost consciousness? | 1 .. 30 |
| 273 | 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. |
| 274 | bisqmillocyr1 | ^hdrMilitary In what year did this occur (1)? | 1900 .. 2050 |
| 275 | bisqmillocyr2 | ^hdrMilitary In what year did this occur (2)? | 1900 .. 2050 |
| 276 | bisqmillocyr3 | ^hdrMilitary In what year did this occur (3)? | 1900 .. 2050 |
| 277 | bisqmillocyr4 | ^hdrMilitary In what year did this occur (4)? | 1900 .. 2050 |
| 278 | bisqmillocyr5 | ^hdrMilitary In what year did this occur (5)? | 1900 .. 2050 |
| 279 | bisqmildaze | ^hdrMilitary Were you dazed or confused? | 1= Yes 2= No |
| 280 | bisqmildazenum | ^hdrMilitary How many times have you been dazed or confused? | 1 .. 30 |
| 281 | 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. |
| 282 | bisqmildazeyr1 | ^hdrMilitary In what year did this occur (1)? | 1900 .. 2050 |
| 283 | bisqmildazeyr2 | ^hdrMilitary In what year did this occur (2)? | 1900 .. 2050 |
| 284 | bisqmildazeyr3 | ^hdrMilitary In what year did this occur (3)? | 1900 .. 2050 |
| 285 | bisqmildazeyr4 | ^hdrMilitary In what year did this occur (4)? | 1900 .. 2050 |
| 286 | bisqmildazeyr5 | ^hdrMilitary In what year did this occur (5)? | 1900 .. 2050 |
| 287 | bisqoth | ^lastInterviewText6en 7. In any other circumstances? | 1= Yes 2= No |
| 288 | bisqothsp | ^hdrOther Please specify: | String[255] |
| 289 | bisqothnum | ^hdrOther How many times did you receive a blow to the head, in a situation I have not mentioned? | 1 .. 30 |
| 290 | bisqothloc | ^hdrOther Did you lose consciousness? | 1= Yes 2= No |
| 291 | bisqothlocnum | ^hdrOther How many times have you lost consciousness? | 1 .. 30 |
| 292 | 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. |
| 293 | bisqothlocyr1 | ^hdrOther In what year did this occur (1)? | 1900 .. 2050 |
| 294 | bisqothlocyr2 | ^hdrOther In what year did this occur (2)? | 1900 .. 2050 |
| 295 | bisqothlocyr3 | ^hdrOther In what year did this occur (3)? | 1900 .. 2050 |
| 296 | bisqothlocyr4 | ^hdrOther In what year did this occur (4)? | 1900 .. 2050 |
| 297 | bisqothlocyr5 | ^hdrOther In what year did this occur (5)? | 1900 .. 2050 |
| 298 | bisqothdaze | ^hdrOther Were you dazed or confused? | 1= Yes 2= No |
| 299 | bisqothdazenum | ^hdrOther How many times have you been dazed or confused? | 1 .. 30 |
| 300 | 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. |
| 301 | bisqothdazeyr1 | ^hdrOther In what year did this occur (1)? | 1900 .. 2050 |
| 302 | bisqothdazeyr2 | ^hdrOther In what year did this occur (2)? | 1900 .. 2050 |
| 303 | bisqothdazeyr3 | ^hdrOther In what year did this occur (3)? | 1900 .. 2050 |
| 304 | bisqothdazeyr4 | ^hdrOther In what year did this occur (4)? | 1900 .. 2050 |
| 305 | bisqothdazeyr5 | ^hdrOther In what year did this occur (5)? | 1900 .. 2050 |
| 306 | reada | Present Time Now I have some questions about how you spend your time. 1. About how much time do you spend reading each day? | 1= None 2= Less than one hour 3= One to less than two hours 4= Two to less than three hours 5= Three or more hours |
| 307 | diary2 | 10. Since your last interview on [last interview date], have you kept a diary or journal? | 1= Yes 2= No |
| 308 | museum2 | 11. Since your last interview on [last interview date], have you visited a museum? | 1= Yes 2= No |
| 309 | concer2 | 12. Since your last interview on [last interview date], have you attended a concert, play, or musical? | 1= Yes 2= No |
| 310 | lib2001 | 13. Thinking of the last year, how often did you visit a library? Would you say every day or almost every day, several times a week, several times a month, several times a year, or once a year or less? | 1= Every day or almost every day 2= Several times a week 3= Several times a month 4= Several times a year 5= Once a year or less |
| 311 | newpap | 14. During the past year, how often did you read newspapers? Would you say every day or almost every day, several times a week, several times a month, several times a year, or once a year or less? | 1= Every day or almost every day 2= Several times a week 3= Several times a month 4= Several times a year 5= Once a year or less |
| 312 | magaz | 15. During the past year, how often did you read magazines? Would you say every day or almost every day, several times a week, several times a month, several times a year, or once a year or less? | 1= Every day or almost every day 2= Several times a week 3= Several times a month 4= Several times a year 5= Once a year or less |
| 313 | readc | 16. During the past year, how often did you read books? Would you say every day or almost every day, several times a week, several times a month, several times a year, or once a year or less? | 1= Every day or almost every day 2= Several times a week 3= Several times a month 4= Several times a year 5= Once a year or less |
| 314 | letter | 17. During the past year, how often did you write letters? Would you say every day or almost every day, several times a week, several times a month, several times a year, or once a year or less? | 1= Every day or almost every day 2= Several times a week 3= Several times a month 4= Several times a year 5= Once a year or less |
| 315 | games | 18. During the past year, how often did you play games like checkers or other board games, cards, puzzles, word games, mind teasers, or any other similar games? Would you say every day or almost every day, several times a week, several times a month, several times a year, or once a year or less? | 1= Every day or almost every day 2= Several times a week 3= Several times a month 4= Several times a year 5= Once a year or less |
| 316 | q9act | 9. During the past year, how often did you go to restaurants, sporting events or teletract, or play bingo? | 1= Every day or almost every day 2= Several times a week 3= Several times a month 4= Several times a year 5= Once a year or less |
| 317 | q10act | 10. During the past year, how often did you go on day trips or overnight trips? | 1= Every day or almost every day 2= Several times a week 3= Several times a month 4= Several times a year 5= Once a year or less |
| 318 | q11act | 11. During the past year, how often did you do unpaid community/volunteer work? | 1= Every day or almost every day 2= Several times a week 3= Several times a month 4= Several times a year 5= Once a year or less |
| 319 | q12act | 12. During the past year, how often did you do paid community work? | 1= Every day or almost every day 2= Several times a week 3= Several times a month 4= Several times a year 5= Once a year or less |
| 320 | q13act | 13. During the past year, how often did you visit at relatives' or friends' houses? | 1= Every day or almost every day 2= Several times a week 3= Several times a month 4= Several times a year 5= Once a year or less |
| 321 | q14act | 14. During the past year, how often did you participate in groups (such as senior center, VFW, Knights of Columbus, Rosary Society or something similar)? | 1= Every day or almost every day 2= Several times a week 3= Several times a month 4= Several times a year 5= Once a year or less |
| 322 | q15act | 15. During the past year, how often did you attend church or religious services? | 1= Every day or almost every day 2= Several times a week 3= Several times a month 4= Several times a year 5= Once a year or less |
| 323 | introp | 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] |
| 324 | q1phy | In the past 14 days, have you done any of the following exercises, sports, or physically active hobbies: 1. Walking for exercise? | 1= Yes 2= No |
| 325 | q1aphy | 1a. How many times in the past 14 days did you go walking for exercise? [ENTER NUMBER OF TIMES] | 1 .. 87 |
| 326 | q1bphy | 1b. 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 |
| 327 | q11phy | In addition to walking for exercise, in the past 14 days, have you done any other walking, for example, to go to the store, to visit someone in the neighborhood, or to go to church? | 1= Yes 2= No |
| 328 | q11aphy | 2a. How many times in the past 14 days did you go walking like that? [ENTER NUMBER OF TIMES] | 1 .. 87 |
| 329 | q11bphy | 2b. 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 |
| 330 | q3phy | (In the past 14 days have you done) 3. Gardening or yard work? | 1= Yes 2= No |
| 331 | q3aphy | 3a. How many times in the past 14 days did you do gardening or yard work? [ENTER NUMBER OF TIMES] | 1 .. 87 |
| 332 | q3bphy | 3b. 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 |
| 333 | q5phy | (In the past 14 days have you done) 5. Calisthenics or general exercise? | 1= Yes 2= No |
| 334 | q5aphy | 5a. How many times in the past 14 days did you do calisthenics or general exercise? [ENTER NUMBER OF TIMES] | 1 .. 87 |
| 335 | q5bphy | 5b. 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 |
| 336 | q8phy | (In the past 14 days have you done) 8. Bicycle riding (including stationary bikes)? | 1= Yes 2= No |
| 337 | q8aphy | 8a. How many times in the past 14 days did you go bicycle//riding? [ENTER NUMBER OF TIMES] | 1 .. 87 |
| 338 | q8bphy | 8b. 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 |
| 339 | q9phy | (In the past 14 days have you done) 9. Swimming or water exercises? | 1= Yes 2= No |
| 340 | q9aphy | 9a. How many times in the past 14 days did you go swimming or do water exercises? [ENTER NUMBER OF TIMES] | 1 .. 87 |
| 341 | q9bphy | 9b. 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 |
| 342 | q10phy | 10. Have you done any other exercises, sports, or physically active hobbies in the past 2 weeks other than the ones listed above? | 1= Yes 2= No |
| 343 | q101phy | 10.1 [SPECIFY] | String[40] |
| 344 | q10aphy | 10a. How many times in the past 14 days did you do this? [ENTER NUMBER OF TIMES] | 1 .. 87 |
| 345 | q10bphy | 10b. 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 |
| 346 | 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 |
| 347 | 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 |
| 348 | recogfr1 | VISION/HEARING Now I have some questions about your vision and hearing. 1. (When wearing eyeglasses/contact lenses) Can you see well enough to recognize a friend across a room? | 1= Yes 2= No |
| 349 | recogfr2 | 2. (When wearing eyeglasses/contact lenses) Can you see well enough to recognize a friend across the street? | 1= Yes 2= No |
| 350 | hearing1 | 3. (With/without a hearing aid) Can you usually hear and understand what a person says without seeing his face if that person talks in a normal voice to you in a quiet room? | 1= Yes 2= No |
| 351 | hearing2 | 4. (With/without a hearing aid) How often do you have difficulty understanding people over the telephone? | 1= Almost always 2= Occasionally 3= Rarely or never |
| 352 | glasses | [If subject uses glasses, instruct him or her to wear them during test.] 1. Test taken with: | 1= Glasses 2= Contact lenses 3= Neither |
| 353 | trial1 | Now I would like to check your eyesight. [INTERVIEWER: Visual acuity should be checked with both eyes open. Hold card 14 inches from subject and ask him or 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 |
| 354 | trial1a | 2a. Second trial: 20/100 | 1= All three correct 2= Two correct 3= One correct 4= None correct |
| 355 | trial1b | 2b. Third trial: 20/200 | 1= All three correct 2= Two correct 3= One correct 4= None correct |
| 356 | trial1c | 2c. Fourth trial: 20/400 | 1= All three correct 2= Two correct 3= One correct 4= None correct |
| 357 | trial2 | 3. Second trial: 20/50 | 1= All three correct 2= Two correct 3= One correct 4= None correct |
| 358 | trial3 | 3a. Third trial: 20/40 | 1= All three correct 2= Two correct 3= One correct 4= None correct |
| 359 | 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 |
| 360 | midfore | 1a. MID FOREARM CIRCUMFERENCE [IN cm] | 10.0 .. 78.0 |
| 361 | midleg | 1b. MID LEG CIRCUMFERENCE [IN cm] | 15.0 .. 99.0 |
| 362 | tricep1 | 2. FIRST TRICEPS SKINFOLD MEASUREMENT [IN mm] CODE 72 IF MEASUREMENT >= 67 mm] | 1 .. 72 |
| 363 | 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 |
| 364 | tricep2 | 4. SECOND TRICEPS SKINFOLD MEASUREMENT [IN mm] [CODE 72 IF MEASUREMENT >=67mm] | 1 .. 72 |
| 365 | pulsept | 5. PULSE OBLITERATION POINT [IN mmHg] | 50 .. 270 |
| 366 | pul | THE PEAK INFLATION LEVEL IS ^pulse [HIT ENTER FOR NEXT QUESTION] | 80 .. 300 |
| 367 | bp11 | 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] |
| 368 | bp2 | 7. SECOND SITTING BLOOD PRESSURE READING [INTERVIEWER: ENTER SYSTOLIC/DIASTOLIC] | String[7] |
| 369 | 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] |
| 370 | weight | 9. MEASURED WEIGHT [IN LBS] [CODE 333 IF MEASUREMENT IS >=300 lbs. CODE 888 IF PHYSICALLY UNABLE TO WEIGH] | 30 .. 888 |
| 371 | height | 10. MEASURED HEIGHT [IN FEET & INCHES] [CODE 888 IF PHYSICALLY UNABLE TO MEASURE HEIGHT] | String[5] |
| 372 | gaitremind | For each exercise: Say, 'Remember to look straight ahead and stay as still as possible until I say, Begin. Ready? Begin.' Say, 'Begin' and press the forward button on the remote to start the measurement (time will start on the program) Count Steps (when applicable) Say, 'Stop' and press the Forward button a second time to end the measurement. Stop Stopwatch (when applicable) If the measurement was accurately performed, press the Slideshow button on the remote to move onto the next measurement (once Slideshow button is pressed, you CANNOT repeat the measurement) If the measurement needs to be repeated, press the Back button on the remote or select 'cancel current trial' on the computer screen. Check device to ensure green light is still flashing. [Press enter to continue] | |
| 373 | dynaintro | Say I'm going to place this belt around your waist. The belt contains a recording device that will track your movements. I'm going to press a button on a remote before and after each task. It is important that you don't begin the task until I say 'Begin' and don't stop until I say 'stop'. Before starting each task I want you to look straight ahead and stay as still as possibel until I say 'Begin' [Press enter to continue] | |
| 374 | walkint1 | 8 foot walk (trial 1) Place the DynaPort device around the waist of the participant, like a belt. DynaPort device should be located on the waistline, in center of the participant's back. Insert the scan disk with the participant's ID number labeled on it into the DynaPort device. Check that the green light on the DynaPort is on and then slide the device into the belt. Open the Dyrector MT program on your computer. Select the Perform tab. Make sure the COM port is selected and you have selected 'gait' under protocol. When you are ready to begin the gait test, select 'Start Measurement'. Check that the green light on the DynaPort is blinking. [Press enter to continue] | |
| 375 | walkint2 | 8 foot walk (trial 1) Now I am going to observe how you walk at your normal pace. This is our walking course. I want you to walk to the other end of the course at your usual speed, just as if you were walking to the store. I want you to walk all the way past this line until I say 'Stop.' Let me show you what my normal pace would be if I were to walk the course. [Demonstrate and then ask the participant:] Do you feel it would be safe for you to walk this course with me? [Have the participant stand with both feet together on top of the line.] Remember to look straight ahead and stay as still as possible until I say 'Begin'. Ready? Begin. [Press enter to continue] | |
| 376 | sidebysintro | POSTURAL STANDS: SIDE BY SIDE STAND-EYES OPEN For the next exercise, I would like you to place one foot beside the other in a comfortable position in front of this line. [Demonstrate the position.] [Optional prompt if needed:] You may use your arms, bend your knees, or move your body to maintain your balance, but try not to move your feet. Now you try it. [Extend hands palm side up for the participant to use for balance.] I'm going to support your arms while you get into the position. Try to hold this position until I say 'Stop'. [Once the position is attained, the examiner's place is to the side and slightly behind the participant.] [Press enter to continue] | |
| 377 | turn1intro | 360� TURN Now I would like you to make a complete turn at your normal walking pace and turn until you reach your starting point. [Demonstrate] Now you try it. Line your feet on top of the tape and begin turning when I say 'Begin' and turn until you reach your starting point. Remember to look straight ahead and stay as still as possible until I say 'Begin'. Ready? Begin. [Press enter to continue] | |
| 378 | poststndintro | POSTURAL STANDS: SIDE BY SIDE STAND-EYES CLOSED Now I want you to do this again, but this time I want you to do it with your eyes closed. I'm going to support your arms while you get into the position. Try to hold the position until I say 'Stop.' [Press enter to continue] | |
| 379 | getup1intro | GET UP AND GO (trial 1) Place a chair behind the start line for the eight foot walk. Now I'm going to have you walk this course again but this time you're going to be seated in this chair with your back rested agains the back of the chair. Then, you're going to stand up from this chair, walk to the other end of the course at your normal pace past the line, turn around, walk back to the chair and sit down. [Demonstrate exercise] [Press enter to continue] | |
| 380 | tandemintro | TANDEM WALK (HEEL-TOE WALK) Now I want you to walk this course again but this time I want you to place one foot in front of the other with the heel touching the toe of the other foot like this, alternating feet. [Demonstrate exercise.] If you feel you are losing your balance, step out like this and then resume walking again. I want you to continue this walk all the way past this line before you stop. Participant should start with both feet on top of the line of tape. Remind participant to stay as still as possible until you say 'begin'. Ready? Begin [Press enter to continue] | |
| 381 | walk8intro | BACK AND FORTH 8 FOOT WALK TWICE I would like you to walk this course again. I want you to walk to the other end of the course at your usual speed, just as if you were walking to the store. This time, however, I want you to walk all the way past this line, turn around and walk back to the starting line. When you pass the starting line I want you to turn around and walk to the other end of the course, turn around and walk back. [Demonstrate] Do you feel it would be safe for you to walk this course with me? Participant should start with both feet on top of the line of tape. Remeber to look straight ahead and stay as still as possible until I say 'Begin'. Ready? Begin. [Press enter to continue] | |
| 382 | gaitquip | Is the Gait Test Equipment Available? | 1= Yes 2= No |
| 383 | domove2 | [Interviewer, Is the Gait Test Equipment being worn by the participant during these exercises?] | 1= Yes 2= No |
| 384 | dynaid | DynaPort Device id | String[10] |
| 385 | diskid | Disk ID | String[10] |
| 386 | walk1 | 8 foot Walk (trial 1) Press M on the DynaPort device to start recording Say, 'Ready? Begin.' Start Stopwatch Count Steps Say, 'Stop'. Press M to stop recording Check device to ensure green light is still flashing. Is test performed? | 1= Yes (Pt. completed gait test) 2= Refused (Pt is able, but refused to complete test), 3= Unable (Pt. is physically/mentally unable to complete test) |
| 387 | move7b | Time (seconds): | 1.0 .. 60.0 |
| 388 | move7c | Number of steps taken: | 1 .. 60 |
| 389 | walk2 | 8 foot Walk (trial 2) Is test performed? | 1= Yes (Pt. completed gait test) 2= Refused (Pt is able, but refused to complete test), 3= Unable (Pt. is physically/mentally unable to complete test) |
| 390 | move7d | Time (seconds): | 1.0 .. 60.0 |
| 391 | move7e | Number of steps taken: | 1 .. 60 |
| 392 | move7a | Record Aid used for 8 foot walk: | 1= No Aid 2= Quad Cane 3= Other Cane 4= Walker 5= Wheelchair as walking aid 6= Other |
| 393 | move7a1 | [SPECIFY] | String[20] |
| 394 | sidebys | POSTURAL STANDS: SIDE BY SIDE STAND-EYES OPEN Press M on the DynaPort device to start recording Say, 'Ready? Begin.' Start timing with the stopwatch Say, 'Stop'. Stop the stopwatch after 20 seconds or participant falls out of position. Press M on the DynaPort device when move has ended. Check device to ensure green light is still flashing. Is the test performed? | 1= Yes (Pt. completed gait test) 2= Refused (Pt is able, but refused to complete test), 3= Unable (Pt. is physically/mentally unable to complete test) |
| 395 | turn1 | 360� TURN Press M on the DynaPort device to start recording Say, 'Ready? Begin.' Start timing with the stopwatch Say, 'Stop'. Press M on the DynaPort device when the turn is completed. Check device to ensure green light is still flashing. Is the test performed? | 1= Yes (Pt. completed gait test) 2= Refused (Pt is able, but refused to complete test), 3= Unable (Pt. is physically/mentally unable to complete test) |
| 396 | move6f | Number of steps taken: | 1 .. 60 |
| 397 | move6e | Time (seconds): | 1.0 .. 60.0 |
| 398 | turn2 | 360� TURN Second trial Is test performed? | 1= Yes (Pt. completed gait test) 2= Refused (Pt is able, but refused to complete test), 3= Unable (Pt. is physically/mentally unable to complete test) |
| 399 | move6h | Number of steps: | 1 .. 60 |
| 400 | move6g | Time (seconds): | 1.0 .. 60.0 |
| 401 | move6i | Record Aid used for 360 turn: | 1= No Aid 2= Quad Cane 3= Other Cane 4= Walker 5= Wheelchair 6= Other |
| 402 | move6i1 | [SPECIFY] | String[20] |
| 403 | poststnd | POSTURAL STANDS: SIDE BY SIDE STAND-EYES CLOSED Press M on the DynaPort device to start recording Say, 'Ready? Begin.' Start timing with the stopwatch Say, 'Stop'. Stop the stopwatch after 20 seconds or participant falls out of position. Press M on the DynaPort device when move has ended. Check device to ensure green light is still flashing. Is the test performed? | 1= Yes (Pt. completed gait test) 2= Refused (Pt is able, but refused to complete test), 3= Unable (Pt. is physically/mentally unable to complete test) |
| 404 | getup1 | GET UP AND GO (trial 1) Press M on the DynaPort device to begin recording Say, 'Ready? Begin.' Press M on the DynaPort device when the participant has returned and sat back down in the chair. Check device to ensure green light is still flashing. Is the test performed? | 1= Yes (Pt. completed gait test) 2= Refused (Pt is able, but refused to complete test), 3= Unable (Pt. is physically/mentally unable to complete test) |
| 405 | getup2 | GET UP AND GO (trial 2) Is the test performed? | 1= Yes (Pt. completed gait test) 2= Refused (Pt is able, but refused to complete test), 3= Unable (Pt. is physically/mentally unable to complete test) |
| 406 | getaid | Record Aid used for GET UP AND GO: | 1= No Aid 2= Quad Cane 3= Other Cane 4= Walker 5= Wheelchair 6= Other |
| 407 | getaid_specify | [SPECIFY] | String[20] |
| 408 | tandem | TANDEM WALK (HEEL-TOE WALK) Press M on the DynaPort device to begin recording Say, 'Ready? Begin.' Say, 'Stop' when participant has returned to starting point Press M on the DynaPort to stop recording Check device to ensure green light is still flashing. Is the test performed? | 1= Yes (Pt. completed gait test) 2= Refused (Pt is able, but refused to complete test), 3= Unable (Pt. is physically/mentally unable to complete test) |
| 409 | move8 | Interviewer: Record number of errors, e.g. Sidesteps: | 0 .. 60 |
| 410 | tandaid | Record Aid used for Tandem Walk: | 1= No Aid 2= Quad Cane 3= Other Cane 4= Walker 5= Wheelchair 6= Other |
| 411 | tandaid_specify | [SPECIFY] | String[20] |
| 412 | walk8 | BACK AND FORTH 8 FOOT WALK TWICE Press M on the DynaPort device to begin recording Say, 'Ready? Begin.' Say, 'Stop' when participant has returned to starting point Press M on the DynaPort to stop recording Check device to ensure green light is still flashing. Is the test performed? | 1= Yes (Pt. completed gait test) 2= Refused (Pt is able, but refused to complete test), 3= Unable (Pt. is physically/mentally unable to complete test) |
| 413 | walk8aid | Record Aid used for BACK AND FORTH WALK: | 1= No Aid 2= Quad Cane 3= Other Cane 4= Walker 5= Wheelchair 6= Other |
| 414 | walk8aid_specify | [SPECIFY] | String[20] |
| 415 | sttoeopen | Toe Stand (Eyes Open) Describe the position while demonstraiting. Once the participant is ready: Press M on the DynaPort device to begin recording Say, 'Ready? Begin.' Start timing with stopwatch Stop timing if the participant falls out of position or max time of 10 seconds is reached. Press M on the DynaPort device Maximum time is 10 seconds. Is the test performed? | 1= Yes (Pt. completed gait test) 2= Refused (Pt is able, but refused to complete test), 3= Unable (Pt. is physically/mentally unable to complete test) |
| 416 | move6 | Time (seconds) : | 1.0 .. 10.0 |
| 417 | strlopen | Standing on Right Leg (Eyes Open) Describe the position and demonstrate. Once the participant is ready: Press M on the DynaPort device to begin recording Say, 'Ready? Begin.' Start timing with stopwatch Stop timing if the participant falls out of position or max time of 10 seconds is reached. Press M on the DynaPort device Maximum time is 10 seconds. Is the test performed? | 1= Yes (Pt. completed gait test) 2= Refused (Pt is able, but refused to complete test), 3= Unable (Pt. is physically/mentally unable to complete test) |
| 418 | move6a | Time (seconds) : | 1.0 .. 10.0 |
| 419 | stllopen | Standing on Left Leg (Eyes Open) Describe the position and demonstrate. Once the participant is ready: Press M on the DynaPort device to begin recording Say, 'Ready? Begin.' Start timing with stopwatch Stop timing if the participant falls out of position or max time of 10 seconds is reached. Press M on the DynaPort device Maximum time is 10 seconds. Is the test performed? | 1= Yes (Pt. completed gait test) 2= Refused (Pt is able, but refused to complete test), 3= Unable (Pt. is physically/mentally unable to complete test) |
| 420 | move6c | Time (seconds) : | 1.0 .. 10.0 |
| 421 | pegboardrt | PURDUE PEGBOARD Is the test performed with right hand? | 1= Yes (Pt. completed gait test) 2= Refused (Pt is able, but refused to complete test), 3= Unable (Pt. is physically/mentally unable to complete test) |
| 422 | pegboardlt | PURDUE PEGBOARD Is the test performed with left hand? | 1= Yes (Pt. completed gait test) 2= Refused (Pt is able, but refused to complete test), 3= Unable (Pt. is physically/mentally unable to complete test) |
| 423 | 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] |
| 424 | 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] |
| 425 | admin3 | 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 LEFT HAND IN LEFT-HAND COLUMN.] Now for practice you try it with your left 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] |
| 426 | admin4 | [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 LEFT-HAND COLUMN] with your LEFT 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] |
| 427 | trial11 | 1. Trial 1, Right Hand [ENTER NUMBER OF PEGS CORRECTLY PLACED] | 0 .. 25 |
| 428 | 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 |
| 429 | 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 |
| 430 | 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 |
| 431 | q1func | 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. 1. Are you able to do heavy work around the house, like washing windows, walls, or floors without help? | 1= Yes 2= No |
| 432 | q2func | 2. Are you able to walk up and down stairs to the second floor without help? | 1= Yes 2= No |
| 433 | q3func | 3. Are you able to walk a half mile without help? | 1= Yes 2= No |
| 434 | q4func | Next, I would like to know if you need help do some different kinds of activities. At the present time, do you need help either from another person or a special equipment or device... 4. Walking across a small room? | 1= No help 2= Help 3= Unable to do |
| 435 | q4bfunc | 4b. How much difficulty, on average, do you have walking across a small room? | 1= No difficulty at all 2= Some difficulty 3= A lot of difficulty 4= Refused 5= Dont know |
| 436 | q5func | 5. Do you need help, either from another person or a special equipment or device... Bathing, either a sponge bath, tub bath or shower? | 1= No help 2= Help 3= Unable to do |
| 437 | q5bfunc | 5b. How much difficulty, on average, do you have bathing? | 1= No difficulty at all 2= Some difficulty 3= A lot of difficulty 4= Refused 5= Dont know |
| 438 | q6func | 6. Do you need help, either from another person or a special equipment or device... Dressing, like putting on a shirt, buttoning and zipping, or putting on shoes? | 1= No help 2= Help 3= Unable to do |
| 439 | q6bfunc | 6b. How much difficulty, on average, do you have dressing? | 1= No difficulty at all 2= Some difficulty 3= A lot of difficulty 4= Refused 5= Dont know |
| 440 | q7func | Do you need help, either from another person or a special equipment or device... 7. Eating like holding a fork, cutting food, or drinking from a glass? | 1= No help 2= Help 3= Unable to do |
| 441 | q7bfunc | 7b. How much difficulty, on average, do you have eating? | 1= No difficulty at all 2= Some difficulty 3= A lot of difficulty 4= Refused 5= Dont know |
| 442 | q8func | Do you need help, either from another person or a special equipment or device... 8. Getting from a bed to a chair? | 1= No help 2= Help 3= Unable to do |
| 443 | q8bfunc | 8b. How much difficulty, on average, do you have getting from a bed to a chair? | 1= No difficulty at all 2= Some difficulty 3= A lot of difficulty 4= Refused 5= Dont know |
| 444 | q9func | Do you need help, either from another person or a special equipment or device... 9. Using the toilet? | 1= No help 2= Help 3= Unable to do |
| 445 | q9bfunc | 9b. How much difficulty, on average, do you have using the toilet? | 1= No difficulty at all 2= Some difficulty 3= A lot of difficulty 4= Refused 5= Dont know |
| 446 | q10func | Now I have a few more questions about activities people may or may not do. Although some things may acutually be performed by someone else, just tell me whether you think you are able to do them. 10. 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 |
| 447 | q12func | 12. 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 |
| 448 | q13func | 13. Are you able to do routine light housekeeping completely by yourself or does someone else help you? | 1= No help 2= Help 3= Unable to do |
| 449 | q14func | 14. Are you able to do periodic heavy housekeeping completely by yourself or does someone else help you? | 1= No help 2= Help 3= Unable to do |
| 450 | q16func | 16. 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 |
| 451 | q17func | 17. 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 |
| 452 | q20func | 20. 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 |
| 453 | q21func | 21. 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 |
| 454 | q1urin | 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. URINARY INCONTINENCE 1. How often during the last month have you leaked urine or lost control of your urine - almost everyday (5-7 days/week), several times a week (2-4 days/week), several times a month (2-4 days/month), once a month less than once a month, or never? | 1= Almost everyday (5-7 days/week) 2= Several times a week (2-4 days/week) 3= Several times a month (2-4 days/month) 4= Once a month 5= Less than once a month 6= Never |
| 455 | falls | FALLING 1. How many times would you say you have fallen over the past year? That is, how many times have you unintentionally come to rest on the ground or floor? | 0 .. 99 |
| 456 | fallinj | 2. Did you suffer any injury that required you to go to your doctor, an emergency room or an urgent care center? | 1= Yes 2= No |
| 457 | fallhelp | 3. When you fell this past year were you ever not able to get up without help from someone? | 1= Yes 2= No |
| 458 | fallnear | 6. Have you had any near falls in the past year? That is, where you almost fell but were able to catch yourself or stop the fall? | 1= Yes 2= No |
| 459 | married | SOCIAL NETWORK Now some questions about your social network. I know that we asked you these questions last year, but we need to ask again for our records. Have you ever been married? | 1= Yes 2= No |
| 460 | married2 | Are you now married, separated, divorced, or widowed? | 1= Married 2= Separated 3= Divorced 4= Widowed |
| 461 | livewith | Does your spouse/significant other live with you? | 1= Yes 2= No |
| 462 | q2soci | 1. How many members, other than yourself, are in your household? | 0 .. 30 |
| 463 | q1sn | How many living children do you have? Please include adopted children as well as children you have raised. [ENTER No. OF CHILDREN] | 0 .. 30 |
| 464 | q2sn | How many of your children do you see at least once a month? [ENTER No. OF CHILDREN] | 0 .. 30 |
| 465 | q2asn | Do you see your child at least once a month? | 1= Yes 2= No |
| 466 | q3sn | Now I'd like to ask you about your other relatives (besides your spouse and children), people that you are related to by blood or marriage. Please include grandchildren, brothers, sisters, sons-in-law and daughters-in-law, parents, aunts and uncles, and cousins. How many relatives do you have that you feel really close to - people you feel at ease with, can talk to about private matters or call upon for help? [ENTER No. OF CLOSE RELATIVES] | 0 .. 76 |
| 467 | q3asn | How many of these close relatives do you usually see at least once a month? [ENTER No. OF CLOSE RELATIVES] | 0 .. 76 |
| 468 | q3bsn | Do you see your close relative at least once a month? | 1= Yes 2= No |
| 469 | q4sn | Besides people that you are related to, how many close friends do you have; that is, people that you feel at ease with, can talk to about private matters and can call upon for help? [ENTER No. OF CLOSE FRIENDS] | 0 .. 76 |
| 470 | q4asn | How many of these close friends do you see at least once a month? [ENTER No. OF CLOSE FRIENDS] | 0 .. 15 |
| 471 | q4bsn | Do you see your close friend at least once a month? | 1= Yes 2= No |
| 472 | spanishbr | Is the participant of Spanish/Hispanic origin? [CHECK RELEASE SHEET] | 1= Yes 2= No |
| 473 | spanish_fluent | Is the participant fluent in Spanish? [CHECK RELEASE SHEET] | 1= Yes 2= No |
| 474 | safe_accult_6 | Ask question #6 in the SAFE - Acculturation Stress Scale | 1= Yes 2= No |
| 475 | description_acc | Acculturation Although you may speak many languages, the following questions refer to only English and Spanish. [PRESS ENTER TO CONTINUE] | |
| 476 | 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 |
| 477 | 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 |
| 478 | 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 |
| 479 | 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 |
| 480 | 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 |
| 481 | 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 |
| 482 | 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 |
| 483 | 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 |
| 484 | 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 |
| 485 | 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 |
| 486 | 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] | |
| 487 | 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 |
| 488 | 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 |
| 489 | 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 |
| 490 | 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 |
| 491 | 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 |
| 492 | 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 |
| 493 | pnes_description | PNES Perception I'm going to read you a list of statements about neighborhoods. Please tell me how much you agree or disagree with each statement as it relates to the neighborhood you live in now. In answering these questions, please think of your neighborhood as the area within about a 20 minute walk (or about a mile) from your house. [PRESS ENTER TO CONTINUE] | |
| 494 | pnes_wellmaintain | 1. In my neighborhood the buildings and homes are well-maintained. | 1= Strongly Agree 2= Agree 3= Neutral (neither agree or disagree) 4= Disagree 5= Strongly Disagree 0= Does not apply (lives in group /retirement home setting) |
| 495 | pnes_attractive | 2. My neighborhood is attractive. | 1= Strongly Agree 2= Agree 3= Neutral (neither agree or disagree) 4= Disagree 5= Strongly Disagree 0= Does not apply (lives in group /retirement home setting) |
| 496 | pnes_noise | 3. There is a lot of noise in my neighborhood. | 1= Strongly Agree 2= Agree 3= Neutral (neither agree or disagree) 4= Disagree 5= Strongly Disagree 0= Does not apply (lives in group /retirement home setting) |
| 497 | pnes_freshproduce | 4. A large selection of fresh fruits and vegetables is available in my neighborhood. | 1= Strongly Agree 2= Agree 3= Neutral (neither agree or disagree) 4= Disagree 5= Strongly Disagree 0= Does not apply (lives in group /retirement home setting) |
| 498 | pnes_fastfood | 5. There are many opportunities to purchase fast foods in my neighborhood. | 1= Strongly Agree 2= Agree 3= Neutral (neither agree or disagree) 4= Disagree 5= Strongly Disagree 0= Does not apply (lives in group /retirement home setting) |
| 499 | pnes_active | 6. My neighborhood offers many opportunities to be physically active. | 1= Strongly Agree 2= Agree 3= Neutral (neither agree or disagree) 4= Disagree 5= Strongly Disagree 0= Does not apply (lives in group /retirement home setting) |
| 500 | pnes_facilities | 7. Local sports clubs and other facilities in my neighborhood offer many opportunities to get exercise. | 1= Strongly Agree 2= Agree 3= Neutral (neither agree or disagree) 4= Disagree 5= Strongly Disagree 0= Does not apply (lives in group /retirement home setting) |
| 501 | pnes_walk | 8. It is pleasant to walk in my neighborhood. | 1= Strongly Agree 2= Agree 3= Neutral (neither agree or disagree) 4= Disagree 5= Strongly Disagree 0= Does not apply (lives in group /retirement home setting) |
| 502 | pnes_traffic | 9. My neighborhood has heavy traffic. | 1= Strongly Agree 2= Agree 3= Neutral (neither agree or disagree) 4= Disagree 5= Strongly Disagree 0= Does not apply (lives in group /retirement home setting) |
| 503 | pnes_help | 10. People around here are willing to help their neighbors. | 1= Strongly Agree 2= Agree 3= Neutral (neither agree or disagree) 4= Disagree 5= Strongly Disagree 0= Does not apply (lives in group /retirement home setting) |
| 504 | pnes_getalong | 11. People in my neighborhood generally get along with each other. | 1= Strongly Agree 2= Agree 3= Neutral (neither agree or disagree) 4= Disagree 5= Strongly Disagree 0= Does not apply (lives in group /retirement home setting) |
| 505 | pnes_trusted | 12. People in my neighborhood can be trusted. | 1= Strongly Agree 2= Agree 3= Neutral (neither agree or disagree) 4= Disagree 5= Strongly Disagree 0= Does not apply (lives in group /retirement home setting) |
| 506 | pnes_howlong_year | How long have you lived in your neighborhood? _____ years, | 0 .. 199 |
| 507 | pnes_howlong_month | and/or _____ months | 0 .. 11 |
| 508 | pnes_howlong1_year | How long have you lived at your current address? _____ years, | 0 .. 199 |
| 509 | pnes_howlong1_month | and/or _____ months | 0 .. 11 |
| 510 | pnes_safe1 | 13. How safe from crime would you say your neighborhood is? | 1= Very Safe 2= Fairly Safe 3= Somewhat Safe 4= Not too safe 5= Not Safe at all 0= Does not apply |
| 511 | pnes_safe2 | 14. Thinking about the building (house) you live in, how safe from crime would you say it is? | 1= Very Safe 2= Fairly Safe 3= Somewhat Safe 4= Not too safe 5= Not Safe at all 0= Does not apply |
| 512 | safe_description | I'm going to read you a list of statements describing some potentially stressful experiences. Regardless of whether you've experienced these situations yourself, please tell me how stressful you might find each situation. [PRESS ENTER TO CONTINUE] | |
| 513 | safe_pressure | 1. People pressuring you to fit in. | 1= Not stressful 2= Mildly stressful 3= Neutral (neither stressful or stress free) 4= Stressful 5= Extremely Stressful |
| 514 | safe_stereo | 2. People having stereotypes about your culture or ethnic group and treating you as if they are true. | 1= Not stressful 2= Mildly stressful 3= Neutral (neither stressful or stress free) 4= Stressful 5= Extremely Stressful |
| 515 | safe_credit | 3. Not getting enough credit for the work you do. | 1= Not stressful 2= Mildly stressful 3= Neutral (neither stressful or stress free) 4= Stressful 5= Extremely Stressful |
| 516 | safe_exlude | 4. Being excluded from participating in things. | 1= Not stressful 2= Mildly stressful 3= Neutral (neither stressful or stress free) 4= Stressful 5= Extremely Stressful |
| 517 | safe_custom | 5. Being looked down upon for practicing customs of your culture | 1= Not stressful 2= Mildly stressful 3= Neutral (neither stressful or stress free) 4= Stressful 5= Extremely Stressful |
| 518 | safe_english | 6. People thinking you are unfriendly when in fact you have trouble communicating in English. | 1= Not stressful 2= Mildly stressful 3= Neutral (neither stressful or stress free) 4= Stressful 5= Extremely Stressful |
| 519 | safe_loosen | 7. People pressuring you to loosen ties with your cultural background. | 1= Not stressful 2= Mildly stressful 3= Neutral (neither stressful or stress free) 4= Stressful 5= Extremely Stressful |
| 520 | safe_ignore | 8. Feeling ignored by people who are supposed to assist you. | 1= Not stressful 2= Mildly stressful 3= Neutral (neither stressful or stress free) 4= Stressful 5= Extremely Stressful |
| 521 | q1supx | SOCIAL SUPPORT Now we are interested in knowing how you feel about the following statements. Please indicate how much you agree or disagree with each statement. Please use this card to help with your responses. [READ FIRST STATEMENT, THEN ASK: Do you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree that this statement describes you? There is a special person who is around when I am in need. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 522 | q2supx | There is a special person with whom I can share joys and sorrows. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 523 | q5supx | I have a special person who is a real source of comfort to me. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 524 | q10supx | There is a special person in my life who cares about my feelings. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 525 | purpos1 | PURPOSE IN LIFE 1. I feel good when I think of what I've done in the past and what I hope to do in the future. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 526 | purpos2 | 2. I live life one day at a time and don't really think about the future. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 527 | purpos3 | 3. I tend to focus on the present, because the future nearly always brings me problems. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 528 | purpos4 | 4. I have a sense of direction and purpose in life. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 529 | purpos5 | 5. My daily activities often seem trivial and unimportant to me. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 530 | purpos6 | 6. I used to set goals for myself, but that now seems like a waste of time. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 531 | purpos7 | 7. I enjoy making plans for the future and working them to a reality. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 532 | purpos8 | 8. I am an active person in carrying out the plans I set for myself. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 533 | purpos9 | 9. Some people wander aimlessly through life, but I am not one of them. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 534 | purpos10 | 10. I sometimes feel as if I've done all there is to do in life. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 535 | emptins | SOCIAL ISOLATION I experience a general sense of emptiness. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 536 | misspeop | I miss having people around. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 537 | friends | I feel like I don't have enough friends. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 538 | abandon | I often feel abandoned. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 539 | missfrnd | I miss having a really close friend. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 540 | lifesp1 | LIFE SPACE For the next set of questions, please think of all the places you have been during the past week. During the past week, have you been to other rooms of your apartment (or home) besides the room where you sleep? | 1= Yes 2= No |
| 541 | lifesp2 | During the past week, have you been to an area immediately outside your apartment (or home) such as your porch, deck, or patio, hallway or garage? | 1= Yes 2= No |
| 542 | lifesp3 | During the past week, have you been to an area outside your apartment building (or home) such as the courtyard, yard, driveway, or parking lot? | 1= Yes 2= No |
| 543 | lifesp4 | During the past week, have you been to places within your immediate neighborhood but beyond your own apartment building or property? | 1= Yes 2= No |
| 544 | lifesp5 | During the past week, have you been to places outside your immediate neighborhood, but within your own town or community? [INTERVIEWER: For persons living in CCRC's or other facilities with multiple buildings, this means beyond the buildings on the facility's property. We're looking for other places beyond walking distance, e.g., more than half a mile.] | 1= Yes 2= No |
| 545 | lifesp6 | During the past week, have you been to places outside your town or community? | 1= Yes 2= No |
| 546 | howwell | 1. INTERVIEWER OBSERVATIONS How well do you think the participant understood the questions? | 1= Quite well 2= Fairly well 3= Somewhat 4= Very Little 5= Not at all |
| 547 | hearimp | 2. Does the participant have a substantial hearing impairment? | 1= Yes 2= No |
| 548 | visimp | 3. Does the participant have a SUBSTANTIAL visual impariment? | 1= Yes, completely blind 2= Yes, very poor 3= Yes, poor 4= No, not substantial |
| 549 | phyeffrt | 4. How great an effort do you think the participant put into the physical function items? | 1= A great deal 2= A considerable amount 3= A moderate amount 4= A little bit 5= Hardly any |
| 550 | comments | Enter any comments. [PRESS ENTER IF NONE.] | String[150] |
| 551 | vegsign | 0 .. 8 | |
| 552 | mvegsign | 0 .. 8 | |
| 553 | cesd | 0 .. 10 | |
| 554 | mcesd | 0 .. 10 | |
| 559 | 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 |
| 560 | formpart | Was participant reluctant, and/or does participant have special needs? | 1= Yes 2= No |
| 561 | formcomm | Please explain reluctance or any other factors which may have affected this data. [Press enter if no comment needed.] | String[120] |
| 562 | statid | Please enter you staff id. | 100 .. 997 |
| 563 | formch | Has the form been modified? | 1= Yes 2= No |
| 564 | revidate | Enter the date that the form was modified. | Date type |
| 565 | revintd | Enter your staff id number. | 100 .. 997 |
| 566 | anydev | Are there any protocol deviations or missing data items to enter? | 1= Yes 2= No |
| 567 | numdev | How many total protocol deviations and tests with missing items to enter? | 1 .. 20 |
| 568 | reas00 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 569 | test00 | Enter test or procedure. | String[15] |
| 570 | item00 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 571 | code00 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 572 | oth00 | Enter other code used. | String[20] |
| 573 | expl00 | Explain what happened | String[100] |
| 574 | reas01 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 575 | test01 | Enter test or procedure. | String[15] |
| 576 | item01 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 577 | code01 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 578 | oth01 | Enter other code used. | String[20] |
| 579 | expl01 | Explain what happened | String[100] |
| 580 | reas02 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 581 | test02 | Enter test or procedure. | String[15] |
| 582 | item02 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 583 | code02 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 584 | oth02 | Enter other code used. | String[20] |
| 585 | expl02 | Explain what happened | String[100] |
| 586 | reas03 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 587 | test03 | Enter test or procedure. | String[15] |
| 588 | item03 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 589 | code03 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 590 | oth03 | Enter other code used. | String[20] |
| 591 | expl03 | Explain what happened | String[100] |
| 592 | reas04 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 593 | test04 | Enter test or procedure. | String[15] |
| 594 | item04 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 595 | code04 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 596 | oth04 | Enter other code used. | String[20] |
| 597 | expl04 | Explain what happened | String[100] |
| 598 | reas05 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 599 | test05 | Enter test or procedure. | String[15] |
| 600 | item05 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 601 | code05 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 602 | oth05 | Enter other code used. | String[20] |
| 603 | expl05 | Explain what happened | String[100] |
| 604 | reas06 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 605 | test06 | Enter test or procedure. | String[15] |
| 606 | item06 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 607 | code06 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 608 | oth06 | Enter other code used. | String[20] |
| 609 | expl06 | Explain what happened | String[100] |
| 610 | reas07 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 611 | test07 | Enter test or procedure. | String[15] |
| 612 | item07 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 613 | code07 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 614 | oth07 | Enter other code used. | String[20] |
| 615 | expl07 | Explain what happened | String[100] |
| 616 | reas08 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 617 | test08 | Enter test or procedure. | String[15] |
| 618 | item08 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 619 | code08 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 620 | oth08 | Enter other code used. | String[20] |
| 621 | expl08 | Explain what happened | String[100] |
| 622 | reas09 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 623 | test09 | Enter test or procedure. | String[15] |
| 624 | item09 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 625 | code09 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 626 | oth09 | Enter other code used. | String[20] |
| 627 | expl09 | Explain what happened | String[100] |
| 628 | reas10 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 629 | test10 | Enter test or procedure. | String[15] |
| 630 | item10 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 631 | code10 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 632 | oth10 | Enter other code used. | String[20] |
| 633 | expl10 | Explain what happened | String[100] |
| 634 | reas11 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 635 | test11 | Enter test or procedure. | String[15] |
| 636 | item11 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 637 | code11 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 638 | oth11 | Enter other code used. | String[20] |
| 639 | expl11 | Explain what happened | String[100] |
| 640 | reas12 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 641 | test12 | Enter test or procedure. | String[15] |
| 642 | item12 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 643 | code12 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 644 | oth12 | Enter other code used. | String[20] |
| 645 | expl12 | Explain what happened | String[100] |
| 646 | reas13 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 647 | test13 | Enter test or procedure. | String[15] |
| 648 | item13 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 649 | code13 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 650 | oth13 | Enter other code used. | String[20] |
| 651 | expl13 | Explain what happened | String[100] |
| 652 | reas14 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 653 | test14 | Enter test or procedure. | String[15] |
| 654 | item14 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 655 | code14 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 656 | oth14 | Enter other code used. | String[20] |
| 657 | expl14 | Explain what happened | String[100] |
| 658 | reas15 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 659 | test15 | Enter test or procedure. | String[15] |
| 660 | item15 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 661 | code15 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 662 | oth15 | Enter other code used. | String[20] |
| 663 | expl15 | Explain what happened | String[100] |
| 664 | reas16 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 665 | test16 | Enter test or procedure. | String[15] |
| 666 | item16 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 667 | code16 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 668 | oth16 | Enter other code used. | String[20] |
| 669 | expl16 | Explain what happened | String[100] |
| 670 | reas17 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 671 | test17 | Enter test or procedure. | String[15] |
| 672 | item17 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 673 | code17 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 674 | oth17 | Enter other code used. | String[20] |
| 675 | expl17 | Explain what happened | String[100] |
| 676 | reas18 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 677 | test18 | Enter test or procedure. | String[15] |
| 678 | item18 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 679 | code18 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 680 | oth18 | Enter other code used. | String[20] |
| 681 | expl18 | Explain what happened | String[100] |
| 682 | reas19 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 683 | test19 | Enter test or procedure. | String[15] |
| 684 | item19 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 685 | code19 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 686 | oth19 | Enter other code used. | String[20] |
| 687 | expl19 | Explain what happened | String[100] |