Data Dictionary for mp2int
Number of Blaise fields: 1123
| Seq # | Var | Question | Data Type/Coding |
|---|---|---|---|
| 1 | ivisit | visit | |
| 2 | projid | MAP 2001 Baseline Interview (v6.0 Rev 02/21/2022) Project ID number. | String[8] |
| 3 | folder | Type in folder color. F/U YearFolder Baseline(manilla) | String[8] |
| 4 | visit | Enter visit code (check folder color): CODEF/U YearFolder 00=Baseline(manilla) | String[2] |
| 5 | vervisit | Please verify visit and folder color. visit = ^visitnumfolder = ^folder1 Is this correct? If not, please page up and correct folder color. | 1= Yes |
| 6 | formno | Form Number. | String[6] |
| 7 | version | Version number | String[4] |
| 8 | autodate | Automatic Date. | Date type |
| 9 | autotime | Automatic Time. | TimeType |
| 10 | autolog | Automatic Logged Date. | Date type |
| 11 | intid | CLINICIAN ID. | 100 .. 997 |
| 12 | compid | Laptop ID | String[20] |
| 13 | dateint | Date of evaluation. | Date type |
| 14 | autotm | [COMPUTER CLOCK TIME] | String[8] |
| 15 | gender | Enter participant's gender. | 1= Male 2= Female |
| 16 | pfname | Participant First name | String[12] |
| 17 | pmiddl | Participant Middle initial [HIT ENTER IF NOT APPLICABLE] | String[1] |
| 18 | plname | Participant Last name | String[18] |
| 19 | paddnum | Participant's PERMANENT ADDRESS Street number | String[6] |
| 20 | pdir | PERMANENT ADDRESS Street direction [HIT ENTER IF NOT APPLICABLE] | String[2] |
| 21 | pstreet | PERMANENT ADDRESS Street name | String[55] |
| 22 | punit | PERMANENT ADDRESS Apartment/Unit/Room number [HIT ENTER IF NOT APPLICABLE] | String[5] |
| 23 | pcity | PERMANENT ADDRESS City or Town | String[18] |
| 24 | pstate | PERMANENT ADDRESS State | String[2] |
| 25 | pzip | PERMANENT ADDRESS Zip Code | String[5] |
| 26 | preskind | PERMANENT ADDRESS What kind of residence is this? | 1= Home [Single family dwelling] 2= Apartment/Condominium [even if affiliated with CCRC] 3= Retirement home/CCRC-independent living 4= Assisted living/Sheltered care 5= Nursing home - unskilled care 6= Nursing home - skilled care 7= Other |
| 27 | sptypp | Specify: | String[40] |
| 28 | phphone | PERMANENT ADDRESS Home telephone including area code [Use '-' to separate] | String[20] |
| 29 | pwphone | PERMANENT ADDRESS Work telephone including area code [Use '-' to separate] [HIT ENTER IF NOT APPLICABLE] | String[20] |
| 30 | pcphone | PERMANENT ADDRESS Cell/mobile telephone inlcluding area code [Use '-' to separate] [Press enter if none.] | String[12] |
| 31 | pemail | PERMANENT ADDRESS E-mail address? [Press enter if none.] | String[50] |
| 32 | tempor | Are you currently staying at an address that is different from your permanent address? | 1= Yes 2= No |
| 33 | taddnum | Participant's TEMPORARY ADDRESS Street number | String[6] |
| 34 | tdir | TEMPORARY ADDRESS Street direction [HIT ENTER IF NOT APPLICABLE] | String[2] |
| 35 | tstreet | TEMPORARY ADDRESS Street name | String[55] |
| 36 | tunit | TEMPORARY ADDRESS Apartment/Unit/Room number [HIT ENTER IF NOT APPLICABLE] | String[5] |
| 37 | tcity | TEMPORARY ADDRESS City or Town | String[18] |
| 38 | tstate | TEMPORARY ADDRESS State | String[2] |
| 39 | tzip | TEMPORARY ADDRESS Zip Code | String[5] |
| 40 | treskind | TEMPORARY ADDRESS What kind of residence is this? | 1= Home [Single family dwelling] 2= Apartment/Condominium[even if affiliated with CCRC] 3= Retirement home/CCRC-independent living 4= Assisted living/Sheltered care 5= Nursing home - unskilled care 6= Nursing home - skilled care 7= Other |
| 41 | sptypt | Specify: | String[40] |
| 42 | thphone | TEMPORARY ADDRESS Home telephone including area code [Use '-' to separate] | String[20] |
| 43 | twphone | TEMPORARY ADDRESS Work telephone including area code [Use '-' to separate] [HIT ENTER IF NOT APPLICABLE] | String[20] |
| 44 | 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 |
| 45 | q5loc | What is your social security number? | 0 .. 999999999 |
| 46 | q5aloc | [ENTER R. SOCIAL SECURITY NUMBER AGAIN] | 0 .. 999999999 |
| 47 | q6loc | What is your medicare number? Please show me your card. | String[11] |
| 48 | q6aloc | [ENTER R. MEDICARE NUMBER AGAIN] | String[11] |
| 49 | validated | ||
| 50 | validateerror | ||
| 51 | errorposition | ||
| 52 | validated_hicn_cms | ||
| 53 | validated_rrb_pre1964 | ||
| 54 | validated_rrb_post1964 | ||
| 55 | hicnformats | ||
| 56 | hicn_alpha | ||
| 57 | hicn_numbers | ||
| 58 | strlen | ||
| 59 | hicn_trimmed | ||
| 60 | 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 |
| 61 | ssn | What is your social security number? [INTERVIEWER: Please enter the SSN in 000-00-0000 format.] | String[11] |
| 62 | ssn_c | [ENTER R. SOCIAL SECURITY NUMBER AGAIN] | String[11] |
| 63 | 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 |
| 64 | 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] |
| 65 | hicn_c | [ENTER R. MEDICARE NUMBER(HICN) AGAIN] | String[11] |
| 66 | hicn_type | HICN Type: ^hicnFormats | String[15] |
| 67 | 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 |
| 68 | 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] |
| 69 | mbi_c | [ENTER R. MEDICARE NUMBER(MBI) AGAIN] | String[13] |
| 70 | cntry | DEMOGRAPHICS First, we would like to get some general information about your background. 1. In what state or country were you born? | 1= U.S.A. 2= Other 3= Argentina 4= Belize 5= Bolivia 6= Brazil 7= Chile 8= Colombia 9= Costa Rica 10= Cuba 11= Dominican Republic 12= Ecuador 13= El Salvador 14= French Guiana 15= Guatemala 16= Guyana 17= Haiti 18= Honduras 19= Mexico 20= Nicaragua 21= Panama 22= Paraguay 23= Peru 24= Puerto Rico 25= Suriname 26= Uruguay 27= Venezuela |
| 71 | specfy | Specify Country: | String[30] |
| 72 | howlong | How many years have you lived in the United States? | 1 .. 130 |
| 73 | state | In what state were you born? | String[30] |
| 74 | city | 2. In what city or town? | String[30] |
| 75 | county | 3. And in what county (or province) were you born? | String[30] |
| 76 | addnumbr | Street Address at Birth I'd like you to tell me the street address where you lived when you were born, or the first street address that you remember where you lived? Participant's birth address Street number | String[6] |
| 77 | dirbr | Participant's birth address Street direction [HIT ENTER IF NOT APPLICABLE] | String[2] |
| 78 | streetbr | Participant's birth address Street name | String[18] |
| 79 | unitbr | Participant's birth address Apartment/Unit number [HIT ENTER IF NOT APPLICABLE] | String[5] |
| 80 | addcom | Participant birth address [Interviewer: If the address is not complete, ask participant to describe location, e.g. cross streets, nearby public buildings/facilities, etc.] [Press enter if none.] | String[250] |
| 81 | firstres | How old were you when you moved into this residence? | 0 .. 18 |
| 82 | race | 7. With which group do you most closely identify yourself? | 1= White 2= Black, Negro, African-American 3= Native American, Indian 4= Eskimo 5= Aleut 6= Asian or Pacific Island |
| 83 | q4dem | What is your date of birth? (mo/day/yr) | Date type |
| 84 | spanish | : Are you of Spanish, Hispanic or Latino origin? That is, having origins from a Spanish-speaking or Latin American country? | 1= Yes 2= No |
| 85 | hispor | Are you of Mexican/Chicano/Mexican American, Puerto Rican, Cuban, Dominican, Central American, or South American origin? | 1= Mexican/Chicano/Mexican American 2= Puerto Rican 3= Cuban 4= Dominican 5= Central American(Belizean, Costa Rican, Guatemalan, Honduran, Nicaraguan, Panamanian, Salvadorian) 6= South American(Argentinian, Bolivian, Brazilian, Chilean, Columbian, Ecuadorian, Paraguayan, Peruvian, Uruguayan, Venezuelan) 50= Other |
| 86 | hisporx | Other (specify, please write in English): | String[30] |
| 87 | racepri | What is your race? [Please read options 1-5 to the participant] | 1= White 2= Black or African-American 3= American Indian or Alaska Native 4= Native Hawaiian or Other Pacific Islander 5= Asian 6= Other 7= Unknown |
| 88 | raceprix | Other, specify | String[30] |
| 89 | racesec_br | Did the participant indicate a second race? [You are not to ask this question of the participant. Only click yes to this question if the participant offered this information to you during the previous question.] | 1= Yes 2= No |
| 90 | racesec | Indicate the participant's second race | 1= White 2= Black or African-American 3= American Indian or Alaska Native 4= Native Hawaiian or Other Pacific Islander 5= Asian 6= Other 7= Unknown |
| 91 | racesecx | Other, specify | String[30] |
| 92 | raceter_br | Did the participant indicate a third race? [You are not to ask this question of the participant. Only click yes to this question if the participant offered this information to you during the previous question.] | 1= Yes 2= No |
| 93 | raceter | Indicate the participant's third race | 1= White 2= Black or African-American 3= American Indian or Alaska Native 4= Native Hawaiian or Other Pacific Islander 5= Asian 6= Other 7= Unknown |
| 94 | raceterx | Other, specify | String[30] |
| 95 | heart | MEDICAL HISTORY - CARDIOVASCULAR DISEASE Now, I have some questions about a number of specific medical conditions. 1. Have you ever 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 |
| 96 | multiple | 1a. Did you have only one or more than one? | 1= Only one 2= More than one |
| 97 | inhosp | 1b Were you hospitalized overnight or longer for this (last one)? | 1= Yes 2= No |
| 98 | chf | CONGESTIVE HEART FAILURE Have you ever been told by a doctor, nurse or therapist that you had congestive heart failure? | 1= Yes 2= Suspect or possible 3= No |
| 99 | chfhosp | Were you hospitalized overnight or longer for this? | 1= Yes 2= No |
| 100 | chfnum | How many times have you been hospitalized for this? | 0 .. 10 |
| 101 | cancer | CANCER OR MALIGNANCY 1. Have you ever 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 |
| 102 | ca1a | 1a. Where was it? [OR: Where was the most recent cancer that you had?] [SPECIFY] | String[20] |
| 103 | diabetes | DIABETES Have you ever been told by a doctor, nurse or therapist that you had ... 1. Diabetes, or sugar in the urine, or high blood sugar? | 1= Yes 2= Suspect or possible 3= No |
| 104 | db1 | 2. Has a doctor, nurse or therapist, ever told you to take insulin or injections for your high blood sugar? | 1= Yes 2= No |
| 105 | db3 | 3 Has a doctor, nurse, or therapist ever told you to take medicine by mouth for your high blood sugar? | 1= Yes 2= No |
| 106 | highbp | HIGH BLOOD PRESSURE Have you ever been told by a doctor, nurse or therapist that you had ... 1. High blood pressure? | 1= Yes 2= Suspect or possible 3= No |
| 107 | bp3 | 2 Has a doctor, nurse, or therapist ever told you to take medicine by mouth for your high blood pressure? | 1= Yes 2= No |
| 108 | thyroid | THYROID DISEASE Have you ever been told by a doctor, nurse or therapist that you had ... 1. Thyroid disease? | 1= Yes 2= Suspect or possible 3= No |
| 109 | th3 | 2. Has a doctor, nurse, or therapist ever told you to take medicine by mouth for your thyroid condition? | 1= Yes 2= No |
| 110 | arthritis | Arthritis Have you ever been told by a doctor, nurse or therapist that you had osteoarthritis? | 1= Yes 2= Suspect or possible 3= No |
| 111 | gout | Have you ever been told by a doctor, nurse or therapist that you had gout? | 1= Yes 2= Suspect or possible 3= No |
| 112 | osteoporosis | Have you ever been told by a doctor, nurse or therapist that you had osteoporosis? | 1= Yes 2= Suspect or possible 3= No |
| 113 | joint_disease | Have you ever been told by a doctor, nurse or therapist that you had other joint disease (excluding cancer)? | 1= Yes 2= Suspect or possible 3= No |
| 114 | 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. Did you ever take 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 |
| 115 | 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 |
| 116 | shot | 3. injection (shot) | 1= Yes 2= Suspect 3= No |
| 117 | cos | 4. vaginal cream or suppository | 1= Yes 2= Suspect 3= No |
| 118 | patch | 5. skin patch | 1= Yes 2= Suspect 3= No |
| 119 | agefirst | 6. How old were you when you first took this/these medications? | 1 .. 115 |
| 120 | current | 7. Are you currently taking this/these medications? | 1= Yes 2= No |
| 121 | agelast | 7a. How old were you when you last took this/these medications? | 1 .. 115 |
| 122 | mensage | 8. At what age did you begin menstruating? | 1 .. 99 |
| 123 | menoage | 9. At what age did you stop menstruating? | 1 .. 99 |
| 124 | natura | 10. Was your menopause natural or caused by surgery? | 1= Natural 2= Surgery |
| 125 | whatwas | 10a. What was the surgery? | 1= Full Hysterectomy 2= Hysterectomy (partial) 3= Other |
| 126 | othspe00 | 10b. Specify: | String[40] |
| 127 | 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 |
| 128 | pressure | 1a. Do you get pressure or heaviness in your chest? | 1= Yes 2= No |
| 129 | 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 |
| 130 | level0 | 3. Do you get this pain (or discomfort) when you walk at an ordinary pace on level ground? | 1= Yes 2= No |
| 131 | legpain | CLAUDICATION Now some questions about pains in your legs. 1. Do you get pain in either leg while walking? | 1= Yes 2= No |
| 132 | standsit | 2. Does this pain ever begin when you are standing still or sitting? | 1= Yes 2= No |
| 133 | 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 |
| 134 | shrtbrth | 9. Do you get short of breath at night if you sleep flat or only on one pillow? | 1= Yes 2= No |
| 135 | pillows | 9a. How many pillows do you need to sleep on to not be short of breath? | 1 .. 9 |
| 136 | grspbrth | 9b. Do you wake up at night gasping for breath? | 1= Yes 2= No |
| 137 | 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 |
| 138 | headinj | HEAD INJURY Now I have some questions about injuries. 1. Have you EVER had a head injury? | 1= Yes 2= No |
| 139 | headyear | 2. What year was the last time? | 1878 .. 2020 |
| 140 | lostcons | 3. Have you EVER lost consciousness because of a head injury? | 1= Yes 2= Suspect or possible 3= No |
| 141 | howmany | 3a. How many times? | 1 .. 50 |
| 142 | lasttime | 3b. What year was the last time? | 1878 .. 2020 |
| 143 | howlong1 | 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 |
| 144 | hihosp | 4. Were you EVER hospitalized overnight or longer for a head injury? | 1= Yes 2= No |
| 145 | same1 | 4a. Was this the same event we just spoke about? | 1= Yes 2= No |
| 146 | hihospyr | 4b. When was it? [ENTER YEAR] | 1878 .. 2020 |
| 147 | hihospnm | 4c. What was the name of the (last) hospital? [HOSPITAL NAME] | String[40] |
| 148 | hihosloc | [LOCATION:] | String[40] |
| 149 | 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 |
| 150 | speech0 | 2. Language or speech change? | 1= Yes 2= Suspect 3= No |
| 151 | weaknes0 | 3. Weakness or paralysis of face, arms or legs? | 1= Yes 2= Suspect 3= No |
| 152 | side0 | 3a. Which side(s)? | 1= right only 2= left only 3= both |
| 153 | other00 | 4. Were there any other signs or symptoms associated with this (last) event? | 1= Yes 2= Suspect 3= No |
| 154 | othspe01 | 4a. Specify | String[40] |
| 155 | hiscan | 5. Did you EVER have a CT, MRI or other type of brain scan because of a head injury? | 1= Yes 2= No |
| 156 | same2 | Was this the same event we just spoke about? | 1= Yes 2= No |
| 157 | hiscanyr | 5a. When was this (the last time)? [ENTER YEAR] | 1878 .. 2020 |
| 158 | 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] |
| 159 | hiscanlc | [LOCATION:] | String[40] |
| 160 | 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 |
| 161 | speech1 | 2. Language or speech change? | 1= Yes 2= Suspect 3= No |
| 162 | weaknes1 | 3. Weakness or paralysis of face, arms or legs? | 1= Yes 2= Suspect 3= No |
| 163 | side1 | 3a. Which side(s)? | 1= right only 2= left only 3= both |
| 164 | other01 | 4. Were there any other signs or symptoms associated with this (last) event? | 1= Yes 2= Suspect 3= No |
| 165 | othspe02 | 4a. Specify | String[40] |
| 166 | troubles | 6. Do you have any left over troubles from your head injury(s)? | 1= Yes 2= Suspect 3= No |
| 167 | specify | 6a Specify? | String[40] |
| 168 | hdrvehicle | ||
| 169 | hdrhitbyobject | ||
| 170 | hdrfalling | ||
| 171 | hdrsports | ||
| 172 | hdrabuse | ||
| 173 | hdrmilitary | ||
| 174 | hdrother | ||
| 175 | prevbisqdone | BRAIN INJURY SCREENING QUESTIONNAIRE Have the BISQ questions been previously completed for this participant? ^prevBisqDoneText | 1= Yes 2= No |
| 176 | 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 |
| 177 | bisqvehnum | ^hdrVehicle How many times did you receive a blow to the head, in a vehicle accident? | 1 .. 30 |
| 178 | bisqvehloc | ^hdrVehicle Did you lose consciousness? | 1= Yes 2= No |
| 179 | bisqvehlocnum | ^hdrVehicle How many times have you lost consciousness? | 1 .. 30 |
| 180 | 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. |
| 181 | bisqvehlocyr1 | ^hdrVehicle In what year did this occur (1)? | 1900 .. 2050 |
| 182 | bisqvehlocyr2 | ^hdrVehicle In what year did this occur (2)? | 1900 .. 2050 |
| 183 | bisqvehlocyr3 | ^hdrVehicle In what year did this occur (3)? | 1900 .. 2050 |
| 184 | bisqvehlocyr4 | ^hdrVehicle In what year did this occur (4)? | 1900 .. 2050 |
| 185 | bisqvehlocyr5 | ^hdrVehicle In what year did this occur (5)? | 1900 .. 2050 |
| 186 | bisqvehdaze | ^hdrVehicle Were you dazed or confused? | 1= Yes 2= No |
| 187 | bisqvehdazenum | ^hdrVehicle How many times have you been dazed or confused? | 1 .. 30 |
| 188 | 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. |
| 189 | bisqvehdazeyr1 | ^hdrVehicle In what year did this occur (1)? | 1900 .. 2050 |
| 190 | bisqvehdazeyr2 | ^hdrVehicle In what year did this occur (2)? | 1900 .. 2050 |
| 191 | bisqvehdazeyr3 | ^hdrVehicle In what year did this occur (3)? | 1900 .. 2050 |
| 192 | bisqvehdazeyr4 | ^hdrVehicle In what year did this occur (4)? | 1900 .. 2050 |
| 193 | bisqvehdazeyr5 | ^^hdrVehicle In what year did this occur (5)? | 1900 .. 2050 |
| 194 | bisqhit | ^lastInterviewText1en 2. Hit by an object?(ex: equipment, falling object) | 1= Yes 2= No |
| 195 | bisqhitnum | ^hdrHitByObject How many times did you receive a blow to the head, from a falling object? | 1 .. 30 |
| 196 | bisqhitloc | ^hdrHitByObject Did you lose consciousness? | 1= Yes 2= No |
| 197 | bisqhitlocnum | ^hdrHitByObject How many times have you lost consciousness? | 1 .. 30 |
| 198 | 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. |
| 199 | bisqhitlocyr1 | ^hdrHitByObject In what year did this occur (1)? | 1900 .. 2050 |
| 200 | bisqhitlocyr2 | ^hdrHitByObject In what year did this occur (2)? | 1900 .. 2050 |
| 201 | bisqhitlocyr3 | ^hdrHitByObject In what year did this occur (3)? | 1900 .. 2050 |
| 202 | bisqhitlocyr4 | ^hdrHitByObject In what year did this occur (4)? | 1900 .. 2050 |
| 203 | bisqhitlocyr5 | ^hdrHitByObject In what year did this occur (5)? | 1900 .. 2050 |
| 204 | bisqhitdaze | ^hdrHitByObject Were you dazed or confused? | 1= Yes 2= No |
| 205 | bisqhitdazenum | ^hdrHitByObject How many times have you been dazed or confused? | 1 .. 30 |
| 206 | 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. |
| 207 | bisqhitdazeyr1 | ^hdrHitByObject In what year did this occur (1)? | 1900 .. 2050 |
| 208 | bisqhitdazeyr2 | ^hdrHitByObject In what year did this occur (2)? | 1900 .. 2050 |
| 209 | bisqhitdazeyr3 | ^hdrHitByObject In what year did this occur (3)? | 1900 .. 2050 |
| 210 | bisqhitdazeyr4 | ^hdrHitByObject In what year did this occur (4)? | 1900 .. 2050 |
| 211 | bisqhitdazeyr5 | ^hdrHitByObject In what year did this occur (5)? | 1900 .. 2050 |
| 212 | bisqfall | ^lastInterviewText2en 3. Falling? (ex: down stairs, during a fainting spell, from a high place) | 1= Yes 2= No |
| 213 | bisqfallnum | ^hdrFalling How many times did you receive a blow to the head, in a fall? | 1 .. 30 |
| 214 | bisqfallloc | ^hdrFalling Did you lose consciousness? | 1= Yes 2= No |
| 215 | bisqfalllocnum | ^hdrFalling How many times have you lost consciousness? | 1 .. 30 |
| 216 | 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. |
| 217 | bisqfalllocyr1 | ^hdrFalling In what year did this occur (1)? | 1900 .. 2050 |
| 218 | bisqfalllocyr2 | ^hdrFalling In what year did this occur (2)? | 1900 .. 2050 |
| 219 | bisqfalllocyr3 | ^hdrFalling In what year did this occur (3)? | 1900 .. 2050 |
| 220 | bisqfalllocyr4 | ^hdrFalling In what year did this occur (4)? | 1900 .. 2050 |
| 221 | bisqfalllocyr5 | ^hdrFalling In what year did this occur (5)? | 1900 .. 2050 |
| 222 | bisqfalldaze | ^hdrFalling Were you dazed or confused? | 1= Yes 2= No |
| 223 | bisqfalldazenum | ^hdrFalling How many times have you been dazed or confused? | 1 .. 30 |
| 224 | 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. |
| 225 | bisqfalldazeyr1 | ^hdrFalling In what year did this occur (1)? | 1900 .. 2050 |
| 226 | bisqfalldazeyr2 | ^hdrFalling In what year did this occur (2)? | 1900 .. 2050 |
| 227 | bisqfalldazeyr3 | ^hdrFalling In what year did this occur (3)? | 1900 .. 2050 |
| 228 | bisqfalldazeyr4 | ^hdrFalling In what year did this occur (4)? | 1900 .. 2050 |
| 229 | bisqfalldazeyr5 | ^hdrFalling In what year did this occur (5)? | 1900 .. 2050 |
| 230 | bisqsprt | ^lastInterviewText3en 4. Sports/Leisure?(ex: sports, biking, skiing, on the playground) | 1= Yes 2= No |
| 231 | bisqsprtnum | ^hdrSports How many times did you receive a blow to the head, during a sports or leisure activity? | 1 .. 30 |
| 232 | bisqsprtloc | ^hdrSports Did you lose consciousness? | 1= Yes 2= No |
| 233 | bisqsprtlocnum | ^hdrSports How many times have you lost consciousness? | 1 .. 30 |
| 234 | 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. |
| 235 | bisqsprtlocyr1 | ^hdrSports In what year did this occur (1)? | 1900 .. 2050 |
| 236 | bisqsprtlocyr2 | ^hdrSports In what year did this occur (2)? | 1900 .. 2050 |
| 237 | bisqsprtlocyr3 | ^hdrSports In what year did this occur (3)? | 1900 .. 2050 |
| 238 | bisqsprtlocyr4 | ^hdrSports In what year did this occur (4)? | 1900 .. 2050 |
| 239 | bisqsprtlocyr5 | ^hdrSports In what year did this occur (5)? | 1900 .. 2050 |
| 240 | bisqsprtdaze | ^hdrSports Were you dazed or confused? | 1= Yes 2= No |
| 241 | bisqsprtdazenum | ^hdrSports How many times have you been dazed or confused? | 1 .. 30 |
| 242 | 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. |
| 243 | bisqsprtdazeyr1 | ^hdrSports In what year did this occur (1)? | 1900 .. 2050 |
| 244 | bisqsprtdazeyr2 | ^hdrSports In what year did this occur (2)? | 1900 .. 2050 |
| 245 | bisqsprtdazeyr3 | ^hdrSports In what year did this occur (3)? | 1900 .. 2050 |
| 246 | bisqsprtdazeyr4 | ^hdrSports In what year did this occur (4)? | 1900 .. 2050 |
| 247 | bisqsprtdazeyr5 | ^hdrSports In what year did this occur (5)? | 1900 .. 2050 |
| 248 | bisqphys | ^lastInterviewText4en 5. Physical Abuse/Assault?(ex: mugged) | 1= Yes 2= No |
| 249 | bisqphysnum | ^hdrAbuse How many times did you receive a blow to the head, from abuse or assault? | 1 .. 30 |
| 250 | bisqphysloc | ^hdrAbuse Did you lose consciousness? | 1= Yes 2= No |
| 251 | bisqphyslocnum | ^hdrAbuse How many times have you lost consciousness? | 1 .. 30 |
| 252 | 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. |
| 253 | bisqphyslocyr1 | ^hdrAbuse In what year did this occur (1)? | 1900 .. 2050 |
| 254 | bisqphyslocyr2 | ^hdrAbuse In what year did this occur (2)? | 1900 .. 2050 |
| 255 | bisqphyslocyr3 | ^hdrAbuse In what year did this occur (3)? | 1900 .. 2050 |
| 256 | bisqphyslocyr4 | ^hdrAbuse In what year did this occur (4)? | 1900 .. 2050 |
| 257 | bisqphyslocyr5 | ^hdrAbuse In what year did this occur (5)? | 1900 .. 2050 |
| 258 | bisqphysdaze | ^hdrAbuse Were you dazed or confused? | 1= Yes 2= No |
| 259 | bisqphysdazenum | ^hdrAbuse How many times have you been dazed or confused? | 1 .. 30 |
| 260 | 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. |
| 261 | bisqphysdazeyr1 | ^hdrAbuse In what year did this occur (1)? | 1900 .. 2050 |
| 262 | bisqphysdazeyr2 | ^hdrAbuse In what year did this occur (2)? | 1900 .. 2050 |
| 263 | bisqphysdazeyr3 | ^hdrAbuse In what year did this occur (3)? | 1900 .. 2050 |
| 264 | bisqphysdazeyr4 | ^hdrAbuse In what year did this occur (4)? | 1900 .. 2050 |
| 265 | bisqphysdazeyr5 | ^hdrAbuse In what year did this occur (5)? | 1900 .. 2050 |
| 266 | bisqmil | ^lastInterviewText5en 6. Military Service?(ex: training, blast injury) | 1= Yes 2= No |
| 267 | bisqmilnum | ^hdrMilitary How many times did you receive a blow to the head, during military service? | 1 .. 30 |
| 268 | bisqmilloc | ^hdrMilitary Did you lose consciousness? | 1= Yes 2= No |
| 269 | bisqmillocnum | ^hdrMilitary How many times have you lost consciousness? | 1 .. 30 |
| 270 | 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. |
| 271 | bisqmillocyr1 | ^hdrMilitary In what year did this occur (1)? | 1900 .. 2050 |
| 272 | bisqmillocyr2 | ^hdrMilitary In what year did this occur (2)? | 1900 .. 2050 |
| 273 | bisqmillocyr3 | ^hdrMilitary In what year did this occur (3)? | 1900 .. 2050 |
| 274 | bisqmillocyr4 | ^hdrMilitary In what year did this occur (4)? | 1900 .. 2050 |
| 275 | bisqmillocyr5 | ^hdrMilitary In what year did this occur (5)? | 1900 .. 2050 |
| 276 | bisqmildaze | ^hdrMilitary Were you dazed or confused? | 1= Yes 2= No |
| 277 | bisqmildazenum | ^hdrMilitary How many times have you been dazed or confused? | 1 .. 30 |
| 278 | 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. |
| 279 | bisqmildazeyr1 | ^hdrMilitary In what year did this occur (1)? | 1900 .. 2050 |
| 280 | bisqmildazeyr2 | ^hdrMilitary In what year did this occur (2)? | 1900 .. 2050 |
| 281 | bisqmildazeyr3 | ^hdrMilitary In what year did this occur (3)? | 1900 .. 2050 |
| 282 | bisqmildazeyr4 | ^hdrMilitary In what year did this occur (4)? | 1900 .. 2050 |
| 283 | bisqmildazeyr5 | ^hdrMilitary In what year did this occur (5)? | 1900 .. 2050 |
| 284 | bisqoth | ^lastInterviewText6en 7. In any other circumstances? | 1= Yes 2= No |
| 285 | bisqothsp | ^hdrOther Please specify: | String[255] |
| 286 | bisqothnum | ^hdrOther How many times did you receive a blow to the head, in a situation I have not mentioned? | 1 .. 30 |
| 287 | bisqothloc | ^hdrOther Did you lose consciousness? | 1= Yes 2= No |
| 288 | bisqothlocnum | ^hdrOther How many times have you lost consciousness? | 1 .. 30 |
| 289 | 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. |
| 290 | bisqothlocyr1 | ^hdrOther In what year did this occur (1)? | 1900 .. 2050 |
| 291 | bisqothlocyr2 | ^hdrOther In what year did this occur (2)? | 1900 .. 2050 |
| 292 | bisqothlocyr3 | ^hdrOther In what year did this occur (3)? | 1900 .. 2050 |
| 293 | bisqothlocyr4 | ^hdrOther In what year did this occur (4)? | 1900 .. 2050 |
| 294 | bisqothlocyr5 | ^hdrOther In what year did this occur (5)? | 1900 .. 2050 |
| 295 | bisqothdaze | ^hdrOther Were you dazed or confused? | 1= Yes 2= No |
| 296 | bisqothdazenum | ^hdrOther How many times have you been dazed or confused? | 1 .. 30 |
| 297 | 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. |
| 298 | bisqothdazeyr1 | ^hdrOther In what year did this occur (1)? | 1900 .. 2050 |
| 299 | bisqothdazeyr2 | ^hdrOther In what year did this occur (2)? | 1900 .. 2050 |
| 300 | bisqothdazeyr3 | ^hdrOther In what year did this occur (3)? | 1900 .. 2050 |
| 301 | bisqothdazeyr4 | ^hdrOther In what year did this occur (4)? | 1900 .. 2050 |
| 302 | bisqothdazeyr5 | ^hdrOther In what year did this occur (5)? | 1900 .. 2050 |
| 303 | 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 |
| 304 | diarya | 10. In the last ten years, did you ever keep a diary or journal? | 1= Yes 2= No |
| 305 | diaryb | 10a. How many years? [Estimate total years.] | 1 .. 120 |
| 306 | museum | 11. In the last ten years, how many times did you visit a museum? | 1= Never 2= 1-2 times 3= 3-9 times 4= 10-19 times 5= More than 20 times |
| 307 | concer | 12. In the last ten years, how many times did you attend a concert, play, or musical? | 1= Never 2= 1-2 times 3= 3-9 times 4= 10-19 times 5= More than 20 times |
| 308 | lib | 13. In the last ten years, 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 |
| 309 | newpap | 14. Thinking of the last year, how often do 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 |
| 310 | 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 |
| 311 | 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 |
| 312 | 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 |
| 313 | 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 |
| 314 | 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 |
| 315 | 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 |
| 316 | 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 |
| 317 | 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 |
| 318 | 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 |
| 319 | 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 |
| 320 | 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 |
| 321 | 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] |
| 322 | 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 |
| 323 | q1aphy | 1a. How many times in the past 14 days did you go walking for exercise? [ENTER NUMBER OF TIMES] | 1 .. 87 |
| 324 | 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 |
| 325 | 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 |
| 326 | q11aphy | 2a. How many times in the past 14 days did you go walking like that? [ENTER NUMBER OF TIMES] | 1 .. 87 |
| 327 | 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 |
| 328 | q3phy | (In the past 14 days have you done) 3. Gardening or yard work? | 1= Yes 2= No |
| 329 | q3aphy | 3a. How many times in the past 14 days did you do gardening or yard work? [ENTER NUMBER OF TIMES] | 1 .. 87 |
| 330 | 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 |
| 331 | q5phy | (In the past 14 days have you done) 5. Calisthenics or general exercise? | 1= Yes 2= No |
| 332 | q5aphy | 5a. How many times in the past 14 days did you do calisthenics or general exercise? [ENTER NUMBER OF TIMES] | 1 .. 87 |
| 333 | 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 |
| 334 | q8phy | (In the past 14 days have you done) 8. Bicycle riding (including stationary bikes)? | 1= Yes 2= No |
| 335 | q8aphy | 8a. How many times in the past 14 days did you go bicycle riding? [ENTER NUMBER OF TIMES] | 1 .. 87 |
| 336 | 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 |
| 337 | q9phy | (In the past 14 days have you done) 9. Swimming or water exercises? | 1= Yes 2= No |
| 338 | q9aphy | 9a. How many times in the past 14 days did you go swimming or do water exercises? [ENTER NUMBER OF TIMES] | 1 .. 87 |
| 339 | 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 |
| 340 | 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 |
| 341 | q101phy | 10.1 [SPECIFY] | String[40] |
| 342 | q10aphy | 10a. How many times in the past 14 days did you do this? [ENTER NUMBER OF TIMES] | 1 .. 87 |
| 343 | 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 |
| 344 | joints | JOINTS Now a few questions about your joints. 1. In the past year, that is, since ^yearago have you had pain or aching in any of your joints on most days for at least one month? | 1= Yes 2= No |
| 345 | neckpain | 2. ...Pain in your neck or back on most days for at least one month? | 1= Yes 2= No |
| 346 | neckpain2 | 2. ...Pain in your neck on most days for at least one month? | 1= Yes 2= No |
| 347 | backpain | 2a. ...Pain in your back on most days for at least one month? | 1= Yes 2= No |
| 348 | 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 |
| 349 | 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 |
| 350 | 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 |
| 351 | 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 |
| 352 | feetpain | 7. ...Pain or aching in either of your feet on most days for at least one month? | 1= Yes 2= No |
| 353 | 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 |
| 354 | q1neuro | Now I have some questions about numbness and tingling. 1. 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 |
| 355 | q2neuro | 2. Was this ___ on the right side, left side, or both sides? | 1= Right 2= Left 3= Both |
| 356 | q3neuro | 3. 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 |
| 357 | q4neuro | 4. Was this ___ on the right side, left side, or both sides? | 1= Right 2= Left 3= Both |
| 358 | q1cervi | 1. Now I have some questions about neck pain. Have you ever had neck pain that lasted days, weeks or months? | 1= Yes 2= Suspect 3= No |
| 359 | q2cervi | 2. 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 |
| 360 | q3cervi1 | 3. Which of these problems did you have, pain, numbness or tingling, or weakness? | 1= Pain 2= Numbness or tingling 3= Weakness |
| 361 | q3cervi2 | 3. Which of these problems did you have, pain, numbness or tingling, or weakness? | See previous question |
| 362 | q3cervi3 | 3. Which of these problems did you have, pain, numbness or tingling, or weakness? | See previous question |
| 363 | q4cervi | 4. Did this ___ occur on the right side, left side, or both sides? | 1= Right 2= Left 3= Both |
| 364 | q5cervi | 5. 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 |
| 365 | q6cervi | 6. How many different times have you had neck pain? enter number ___ ___ ___ | 1 .. 999 |
| 366 | q7cervi | 7. 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 |
| 367 | q8cervi | 8. Have you ever seen a doctor because of neck pain? | 1= Yes 2= No |
| 368 | q9cervi | 9. Have you ever had an x-ray or scan [CT or MRI] of the neck because of pain? | 1= Yes 2= No |
| 369 | q9acervi | 9a. When was the last time? ENTER YEAR ____ | 1928 .. 2040 |
| 370 | q9bcervi | What was the name of the place (doctor's office, hospital or other place) at which the scan was performed? NAME ________________________________________ | String[40] |
| 371 | q9ccervi | LOCATION________________________________________ | String[40] |
| 372 | q1lumbar | 1. Now some questions about low back pain. Have you ever had low back pain that lasted days, weeks or months? | 1= Yes 2= Suspect 3= No |
| 373 | q2lumbar | 2. 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 |
| 374 | q3lumba1 | 3. Which of these problems did you have, pain, numbness or tingling, or weakness? | 1= Pain 2= Numbness or tingling 3= Weakness |
| 375 | q3lumba2 | 3. Which of these problems did you have, pain, numbness or tingling, or weakness? | See previous question |
| 376 | q3lumba3 | 3. Which of these problems did you have, pain, numbness or tingling, or weakness? | See previous question |
| 377 | q4lumbar | 4. Did this occur on the right side, left side, or both sides? | 1= Right 2= Left 3= Both |
| 378 | q5lumbar | 5. Now, when you have low back pain, how long, on average, does the low back pain typically last? Would you say less than a week, between one week and one months, 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 |
| 379 | q6lumbar | 6. How many different times have you had low back pain? enter number ___ ___ ___ | 1 .. 999 |
| 380 | q7lumbar | 7. 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 |
| 381 | q8lumbar | 8. Have you ever seen a doctor because of low back pain? | 1= Yes 2= No |
| 382 | q9lumbar | 9. Have you ever had an x-ray or scan [CT or MRI] of the low back because of pain? | 1= Yes 2= No |
| 383 | q9alumba | 9a. When was the last time? ENTER YEAR ____ | 1928 .. 2040 |
| 384 | q9blumba | What was the name of the place (doctor's office, hospital or other place) at which the scan was performed? NAME ________________________________________ | String[40] |
| 385 | q9clumba | LOCATION________________________________________ | String[40] |
| 386 | falls | 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 |
| 387 | 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 |
| 388 | fallhelp | 3. When you fell this past year were you ever not able to get up without help from someone? | 1= Yes 2= No |
| 389 | 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 |
| 390 | brokenhp | BROKEN HIP 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 |
| 391 | hip6a | 1a. Were you ever hospitalized overnight or longer for this? | 1= Yes 2= No |
| 392 | 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 |
| 393 | q2slp | 2. How often are you troubled by waking up during the night? | 1= Very Often 2= Often 3= Sometimes 4= Rarely 5= Never |
| 394 | 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 |
| 395 | 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 |
| 396 | q6slp | 5. In the past month, how many hours do you usually sleep at night? [ENTER AVERAGE HOURS] | 0 .. 24 |
| 397 | 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 |
| 398 | q2md | 2. My sleep was restless. (Have you felt this way much of the time during the past week?) | 1= Yes 2= No |
| 399 | q3md | 3. I felt depressed. (Have you felt this way much of the time during the past week?) | 1= Yes 2= No |
| 400 | q4md | 4. I was happy. (Have you felt this way much of the time during the past week?) | 1= Yes 2= No |
| 401 | q5md | 5. I felt lonely. (Have you felt this way much of the time during the past week?) | 1= Yes 2= No |
| 402 | q6md | 6. People were unfriendly. (Have you felt this way much of the time during the past week?) | 1= Yes 2= No |
| 403 | q7md | 7. I enjoyed life. (Have you felt this way much of the time during the past week?) | 1= Yes 2= No |
| 404 | q8md | 8. I felt sad. (Have you felt this way much of the time during the past week?) | 1= Yes 2= No |
| 405 | 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 |
| 406 | q10md | 10. I could not get 'going'. (Have you felt this way much of the time during the past week?) | 1= Yes 2= No |
| 407 | 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 |
| 408 | 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 |
| 409 | sleep | 3. A change in your pattern of sleeping. | 1= Yes 2= No |
| 410 | enrgy | 4. A decrease in your energy level. | 1= Yes 2= No |
| 411 | concen | 5. Trouble concentrating. | 1= Yes 2= No |
| 412 | guilt | 6. Felt extremely guilty or worthless. | 1= Yes 2= No |
| 413 | restls | 7. Felt extremely restless or agitated. | 1= Yes 2= No |
| 414 | activt | 8. Lost your interest in favorite activities. | 1= Yes 2= No |
| 415 | living | 9. Felt that life was not worth living. | 1= Yes 2= No |
| 416 | teldoc | 9a. Did you tell a doctor or any other professional about it? | 1= Yes 2= No |
| 417 | 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 |
| 418 | recogfr2 | 2. (When wearing eyeglasses/contact lenses) Can you see well enough to recognize a friend across the street? | 1= Yes 2= No |
| 419 | 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 |
| 420 | hearing2 | 4. (With/without a hearing aid) How often do you have difficulty understanding people over the telephone? | 1= Almost always 2= Occaisonally 3= Rarely or never |
| 421 | 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 |
| 422 | 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 |
| 423 | trial1a | 2a. Second trial: 20/100 | 1= All three correct 2= Two correct 3= One correct 4= None correct |
| 424 | trial1b | 2b. Third trial: 20/200 | 1= All three correct 2= Two correct 3= One correct 4= None correct |
| 425 | trial1c | 2c. Fourth trial: 20/400 | 1= All three correct 2= Two correct 3= One correct 4= None correct |
| 426 | trial2 | 3. Second trial: 20/50 | 1= All three correct 2= Two correct 3= One correct 4= None correct |
| 427 | trial3 | 3a. Third trial: 20/40 | 1= All three correct 2= Two correct 3= One correct 4= None correct |
| 428 | 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 |
| 429 | midfore | 1a. MID FOREARM CIRCUMFERENCE [IN cm] | 10.0 .. 78.0 |
| 430 | midleg | 1b. MID LEG CIRCUMFERENCE [IN cm] | 15.0 .. 99.0 |
| 431 | tricep1 | 2. FIRST TRICEPS SKINFOLD MEASUREMENT [IN mm] CODE 72 IF MEASUREMENT >= 67 mm] | 1 .. 72 |
| 432 | 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 |
| 433 | tricep2 | 4. SECOND TRICEPS SKINFOLD MEASUREMENT [IN mm] [CODE 72 IF MEASUREMENT >=67mm] | 1 .. 72 |
| 434 | pulsept | 5. PULSE OBLITERATION POINT [IN mmHg] | 50 .. 270 |
| 435 | pul | THE PEAK INFLATION LEVEL IS ^pulse [HIT ENTER FOR NEXT QUESTION] | 80 .. 300 |
| 436 | 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] |
| 437 | bp2 | 7. SECOND SITTING BLOOD PRESSURE READING [INTERVIEWER: ENTER SYSTOLIC/DIASTOLIC] | String[7] |
| 438 | 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] |
| 439 | weight | 9. MEASURED WEIGHT [IN LBS] [CODE 333 IF MEASUREMENT IS >=300 lbs. CODE 888 IF PHYSICALLY UNABLE TO WEIGH] | 30 .. 888 |
| 440 | height | 10. MEASURED HEIGHT [IN FEET & INCHES] [CODE 888 IF PHYSICALLY UNABLE TO MEASURE HEIGHT] | String[5] |
| 441 | 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] | |
| 442 | 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] | |
| 443 | 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] | |
| 444 | 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] | |
| 445 | 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] | |
| 446 | 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] | |
| 447 | 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] | |
| 448 | 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] | |
| 449 | 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] | |
| 450 | 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] | |
| 451 | gaitquip | Is the Gait Test Equipment Available? | 1= Yes 2= No |
| 452 | domove2 | [Interviewer, Is the Gait Test Equipment being worn by the participant during these exercises?] | 1= Yes 2= No |
| 453 | dynaid | DynaPort Device id | String[10] |
| 454 | diskid | Disk ID | String[10] |
| 455 | 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) |
| 456 | move7b | Time (seconds): | 1.0 .. 60.0 |
| 457 | move7c | Number of steps taken: | 1 .. 60 |
| 458 | 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) |
| 459 | move7d | Time (seconds): | 1.0 .. 60.0 |
| 460 | move7e | Number of steps taken: | 1 .. 60 |
| 461 | 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 |
| 462 | move7a1 | [SPECIFY] | String[20] |
| 463 | 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) |
| 464 | 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) |
| 465 | move6f | Number of steps taken: | 1 .. 60 |
| 466 | move6e | Time (seconds): | 1.0 .. 60.0 |
| 467 | 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) |
| 468 | move6h | Number of steps: | 1 .. 60 |
| 469 | move6g | Time (seconds): | 1.0 .. 60.0 |
| 470 | move6i | Record Aid used for 360 turn: | 1= No Aid 2= Quad Cane 3= Other Cane 4= Walker 5= Wheelchair 6= Other |
| 471 | move6i1 | [SPECIFY] | String[20] |
| 472 | 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) |
| 473 | 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) |
| 474 | 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) |
| 475 | getaid | Record Aid used for GET UP AND GO: | 1= No Aid 2= Quad Cane 3= Other Cane 4= Walker 5= Wheelchair 6= Other |
| 476 | getaid_specify | [SPECIFY] | String[20] |
| 477 | 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) |
| 478 | move8 | Interviewer: Record number of errors, e.g. Sidesteps: | 0 .. 60 |
| 479 | tandaid | Record Aid used for Tandem Walk: | 1= No Aid 2= Quad Cane 3= Other Cane 4= Walker 5= Wheelchair 6= Other |
| 480 | tandaid_specify | [SPECIFY] | String[20] |
| 481 | 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) |
| 482 | walk8aid | Record Aid used for BACK AND FORTH WALK: | 1= No Aid 2= Quad Cane 3= Other Cane 4= Walker 5= Wheelchair 6= Other |
| 483 | walk8aid_specify | [SPECIFY] | String[20] |
| 484 | 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) |
| 485 | move6 | Time (seconds) : | 1.0 .. 10.0 |
| 486 | 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) |
| 487 | move6a | Time (seconds) : | 1.0 .. 10.0 |
| 488 | 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) |
| 489 | move6c | Time (seconds) : | 1.0 .. 10.0 |
| 490 | 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) |
| 491 | 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) |
| 492 | 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] |
| 493 | 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] |
| 494 | 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] |
| 495 | 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] |
| 496 | trial11 | 1. Trial 1, Right Hand [ENTER NUMBER OF PEGS CORRECTLY PLACED] | 0 .. 25 |
| 497 | 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 |
| 498 | 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 |
| 499 | 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 |
| 500 | self12 | HANDEDNESS 1. Which hand do you usually use to write a letter? | 1= Right 2= Left 3= Both |
| 501 | self13 | 2. Which hand do you usually use to cut paper or cloth with scissors? | 1= Right 2= Left 3= Both |
| 502 | games6 | In order to learn how experiences early in life affect health later in life, we are asking questions about experiences at different points in your life. Childhood - Age 6 - My first questions are about when you were 6 years old, or thereabouts. I know it may be hard to remember that far back; I just want your best recollection. 1. When you were 6, how often did you play games like tic-tac-toe, checkers, or other board games, cards, or word 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 |
| 503 | read6 | 2. How often did someone in your home read to you when you were 6? 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 |
| 504 | stories6 | 3. How often did someone in your home tell you stories when you were 6? 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 |
| 505 | read12a | Teens - Age 12 Now I have some questions about when you were 12 years old, or thereabouts. 1. When you were 12, about how much time did 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 |
| 506 | read12b | 1a. How much of this reading was for school? | 1= None 2= Some 3= Half 4= Most 5= All |
| 507 | news12 | 2. Did you family subscribe to a daily newspaper when you were 12? | 1= Yes 2= No |
| 508 | mag12 | 3. Did your family subscribe to any magazines when you were 12? | 1= Yes 2= No |
| 509 | dict12 | 4. Did your family have a dictionary when you were 12? | 1= Yes 2= No |
| 510 | ency12 | 5. Did your family have an encyclopedia when you were 12? | 1= Yes 2= No |
| 511 | atlas12 | 6. Did your family have a world atlas when you were 12? | 1= Yes 2= No |
| 512 | globe12 | 7. Did your family have a globe when you were 12? | 1= Yes 2= No |
| 513 | libcar12 | 8. Did you or a member of your family have a library card when you were 12? | 1= Yes 2= No |
| 514 | books12 | 9. When you were 12, about how many books do you think were in your family home? Would you say less than 20, 20-49, 50-100, 101-250, or more than 250? | 1= Less than 20 2= 20 - 49 3= 50 - 100 4= 101 - 250 5= More than 250 |
| 515 | lib12 | 10. When you were 12, 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 |
| 516 | newpap12 | 11. When you were 12, 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 |
| 517 | magaz12 | 12. When you were 12, 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 |
| 518 | read12c | 13. When you were 12, 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 |
| 519 | letter12 | 14. When you were 12, 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 |
| 520 | games12 | 15. When you were 12, how often did 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 |
| 521 | homwk12a | 16. When you were 12, how much time did you spend on homework each day? Would you say none, less than 1/2 hour, 1/2 hour to less than 1 hour, 1 hour to less than 2 hours, or 2 or more hours? | 1= None 2= Less than 1/2 hour 3= 1/2 hour to less than 1 hour 4= 1 hour to less than 2 hours 5= 2 or more hours |
| 522 | homwk12b | 17. How often did a parent or older sibling help you with your homework when you were 12? Would you say none of the time, some of the time, half of the time, most of the time, or all of the time? | 1= None 2= Some 3= Half 4= Most 5= All |
| 523 | teamsp12 | 18. When you were 12, how often did play team sports, such as basketball, baseball, football, softball, soccer, or hockey? 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 |
| 524 | othspr12 | 19. When you were 12, how often did you engage in other sports or physically active games of any kind? 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 |
| 525 | calis12 | 20. When you were 12, how often did you engage in activities like calisthenics, running, or weight lifting? 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 |
| 526 | dust12 | 21. When you were 12, how often did you do household work like dusting, sweeping, or laundry? 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 |
| 527 | kitch12 | 22. When you were 12, how often did you do kitchen work like preparing food or washing dishes? 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 |
| 528 | yard12 | 23. When you were 12, how often did you do yard work like raking, weeding, gardening, or cutting grass? 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 |
| 529 | walk12a | 24. When you were 12, how often did you walk or ride a bike to school? 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 |
| 530 | walk12b | 25. About how far was it from your home to school when you were 12? Would you say less than 1/2 mile, 1/2 mile to less than 1 mile, 1 mile to less than 2 miles, 2 miles to less than 3 miles, or more than 3 miles? | 1= Less than 1/2 mile 2= Half mile to less than 1 mile 3= 1 mile to less than 2 miles 4= 2 miles to less than 3 miles 5= 3 or more miles |
| 531 | phys12 | 26. How physically active were you when you were 12? Would you say were one of the most physically active, above average, average, less than average, or one of the least physically active? | 1= One of the most physically active 2= Above average 3= Average 4= Less than average 5= One of the least physically active |
| 532 | lang18a | Teens - Age 18 Now, I have some questions about when you were 18 years old, or thereabouts. 1. By the age of 18, had you received any instruction in a foreign language? | 1= Yes 2= No |
| 533 | lang18b | 1a. How many years? [Estimate total years.] | 1 .. 18 |
| 534 | music18a | 2. By the age of 18, had you taken any music lessons? | 1= Yes 2= No |
| 535 | music18b | 2a. How many years? [Estimate total years.] | 1 .. 18 |
| 536 | art18a | 3. By the age of 18, had you taken any art, dance, or theater lessons? | 1= Yes 2= No |
| 537 | art18b | 3a. How many years? [Estimate total years.] | 1 .. 18 |
| 538 | diary18a | 4. By the age of 18, had you ever kept a diary or journal? | 1= Yes 2= No |
| 539 | diary18b | 4a. How many years? [Estimate total years.] | 1 .. 18 |
| 540 | museum18 | 5. By the age of 18, how many times had you visited a museum? | 1= Never 2= 1-2 times 3= 3-9 times 4= 10-19 times 5= More than 20 times |
| 541 | concer18 | 6. By the age of 18, how many times had you attended a concert, play, or musical? | 1= Never 2= 1-2 times 3= 3-9 times 4= 10-19 times 5= More than 20 times |
| 542 | read18a | 7. When you were 18, about how much time did 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 |
| 543 | read18b | 7a. How much of this reading was for school? | 1= None 2= Some 3= Half 4= Most 5= All |
| 544 | lib18 | 8. When you were 18, 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 |
| 545 | newpap18 | 9. When you were 18, 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 |
| 546 | magaz18 | 10. When you were 18, 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 |
| 547 | read18c | 13. When you were 18, 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 |
| 548 | letter18 | 14. When you were 18, 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 |
| 549 | games18 | 15. When you were 18, how often did 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 |
| 550 | friend18 | How many of the friends you had when you were 18 graduated from high school? | 1= None 2= Some 3= Half 4= Most 5= All |
| 551 | read40a | Adulthood - Age 40 Now I have some questions about when you were 40 years old, or thereabouts. 1. When you were 40, about how much time did 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 |
| 552 | read40b | 1a. How much of this reading was work-related? | 1= None 2= Some 3= Half 4= Most 5= All |
| 553 | news40 | 2. Did you or a member of your family subscribe to a daily newspaper when you were 40? | 1= Yes 2= No |
| 554 | mag40 | 3. Did you or a member of your family subscribe to any magazines when you were 40? | 1= Yes 2= No |
| 555 | libcar40 | 4. Did you or a member of your family have a library card when you were 40? | 1= Yes 2= No |
| 556 | dict40 | 5. Did your home have a dictionary when you were 40? | 1= Yes 2= No |
| 557 | ency40 | 6. Did your home have an encyclopedia when you were 40? | 1= Yes 2= No |
| 558 | atlas40 | 7. Did your home have a world atlas when you were 40? | 1= Yes 2= No |
| 559 | globe40 | 8. Did your home have a globe when you were 40? | 1= Yes 2= No |
| 560 | books40 | 9. About how many books do you think were in your home when you were 40? Would you say less than 20, 20-49, 50-100, 101-250, or more than 250? | 1= Less than 20 2= 20 - 49 3= 50 - 100 4= 101 - 250 5= More than 250 |
| 561 | diary40a | 10. From age 30 to 40, had you ever kept a diary or journal? | 1= Yes 2= No |
| 562 | diary40b | 10a. How many years? [Estimate total years.] | 1 .. 40 |
| 563 | museum40 | 11. From age 30 to 40, how many times did you visit a museum? | 1= Never 2= 1-2 times 3= 3-9 times 4= 10-19 times 5= More than 20 times |
| 564 | concer40 | 12. From age 30 to 40, how many times did you attend a concert, play, or musical? | 1= Never 2= 1-2 times 3= 3-9 times 4= 10-19 times 5= More than 20 times |
| 565 | lib40 | 13. From age 30 to 40, 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 |
| 566 | newpap40 | 14. When you were 40, 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 |
| 567 | magaz40 | 15. When you were 40, 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 |
| 568 | read40c | 16. When you were 40, 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 |
| 569 | letter40 | 17. When you were 40, 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 |
| 570 | games40 | 18. When you were 40, 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 |
| 571 | 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 |
| 572 | 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 |
| 573 | q1edu | EDUCABILITY 1. Did you have difficulty attending regular schools, i.e., did you ever attend special schools or special classes in school? [INTERVIEWER: IGNORE SPECIAL SCHOOLS OR CLASSES RELATED TO HIGH ACADEMIC ACHIEVEMENT, E.G., ADVANCED PLACEMENT.] | 1= No problem in schools 2= Attended special classes 3= Attended special schools |
| 574 | 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 |
| 575 | q2func | 2. Are you able to walk up and down stairs to the second floor without help? | 1= Yes 2= No |
| 576 | q3func | 3. Are you able to walk a half mile without help? | 1= Yes 2= No |
| 577 | 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 |
| 578 | 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 |
| 579 | 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 |
| 580 | 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 |
| 581 | 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 |
| 582 | 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 |
| 583 | 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 |
| 584 | 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 |
| 585 | 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 |
| 586 | 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 |
| 587 | 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 |
| 588 | 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 |
| 589 | 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 |
| 590 | 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 |
| 591 | 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 |
| 592 | 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 |
| 593 | 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 |
| 594 | 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 |
| 595 | 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 |
| 596 | 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 |
| 597 | 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 |
| 598 | married | SOCIAL NETWORK Now some questions about your social network. Have you ever been married? | 1= Yes 2= No |
| 599 | married2 | Are you now married, separated, divorced, or widowed? | 1= Married 2= Separated 3= Divorced 4= Widowed |
| 600 | livewith | Does your spouse/significant other live with you? | 1= Yes 2= No |
| 601 | spfname | Spouse What is his/her name? First Name: | String[12] |
| 602 | spmiddl | Spouse Middle intial: [Press enter if none.] | String[2] |
| 603 | splname | Spouse Last Name: | String[18] |
| 604 | q2soci | 1. How many members, other than yourself, are in your household? | 0 .. 30 |
| 605 | 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 |
| 606 | q2sn | How many of your children do you see at least once a month? [ENTER No. OF CHILDREN] | 0 .. 30 |
| 607 | q2asn | Do you see your child at least once a month? | 1= Yes 2= No |
| 608 | 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 |
| 609 | q3asn | How many of these close relatives do you usually see at least once a month? [ENTER No. OF CLOSE RELATIVES] | 0 .. 76 |
| 610 | q3bsn | Do you see your close relative at least once a month? | 1= Yes 2= No |
| 611 | 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 |
| 612 | q4asn | How many of these close friends do you see at least once a month? [ENTER No. OF CLOSE FRIENDS] | 0 .. 15 |
| 613 | q4bsn | Do you see your close friend at least once a month? | 1= Yes 2= No |
| 614 | spanishbr | Is the participant of Spanish/Hispanic origin? | 1= Yes 2= No |
| 615 | spanish_fluent | Are you fluent in Spanish? | 1= Yes 2= No |
| 616 | safe_accult_6 | Ask question #6 in the SAFE - Acculturation Stress Scale? | 1= Yes 2= No |
| 617 | description_acc | Acculturation Although you may speak many languages, the following questions refer to only English and Spanish. [PRESS ENTER TO CONTINUE] | |
| 618 | 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 |
| 619 | 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 |
| 620 | 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 |
| 621 | 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 |
| 622 | 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 |
| 623 | 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 |
| 624 | 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 |
| 625 | 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 |
| 626 | 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 |
| 627 | 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 |
| 628 | 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] | |
| 629 | 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 |
| 630 | 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 |
| 631 | 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 |
| 632 | 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 |
| 633 | 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 |
| 634 | 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 |
| 635 | 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] | |
| 636 | 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) |
| 637 | 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) |
| 638 | 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) |
| 639 | 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) |
| 640 | 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) |
| 641 | 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) |
| 642 | 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) |
| 643 | 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) |
| 644 | 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) |
| 645 | 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) |
| 646 | 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) |
| 647 | 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) |
| 648 | pnes_howlong_year | How long have you lived in your neighborhood? _____ years, | 0 .. 199 |
| 649 | pnes_howlong_month | and/or _____ months | 0 .. 11 |
| 650 | pnes_howlong1_year | How long have you lived at your current address? _____ years, | 0 .. 199 |
| 651 | pnes_howlong1_month | and/or _____ months | 0 .. 11 |
| 652 | 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 |
| 653 | 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 |
| 654 | 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] | |
| 655 | 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 |
| 656 | 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 |
| 657 | 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 |
| 658 | 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 |
| 659 | 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 |
| 660 | 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 |
| 661 | 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 |
| 662 | 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 |
| 663 | 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? 1. 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 |
| 664 | q2supx | 2. 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 |
| 665 | q5supx | 5. 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 |
| 666 | q10supx | 10. 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 |
| 667 | worrier | PERSONALITY-NEO Now I'd like to read some statements that may or may not describe you as a person. For each statement, please tell me how well you think the statement describes you. 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? I am not a worrier. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 668 | people | I like to have a lot of people around me. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 669 | waste | I don't like to waste my time daydreaming. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 670 | courtes | I try to be courteous to everyone I meet. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 671 | belong | I keep my belongings neat and clean. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 672 | inferior | I often feel inferior to others. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 673 | laugh | I laugh easily. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 674 | talking | I really enjoy talking to people. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 675 | tense | I often feel tense and jittery. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 676 | alone | I usually prefer to do things alone. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 677 | getangry | I often get angry at the way people treat me. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 678 | cheerful | I am a cheerful, high-spirited person. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 679 | discourg | Too often, when things go wrong, I get discouraged and feel like giving up. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 680 | helpless | I often feel helpless and want someone else to solve my problems. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 681 | active | I am a very active person. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 682 | 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 |
| 683 | 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 |
| 684 | 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 |
| 685 | purpos4 | 4. I have a sense of direction and purpose in life. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 686 | purpos5 | 5. My daily activities often seem trivial and unimportant to me. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 687 | 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 |
| 688 | 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 |
| 689 | 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 |
| 690 | 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 |
| 691 | 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 |
| 692 | emptins | SOCIAL ISOLATION I experience a general sense of emptiness. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 693 | misspeop | I miss having people around. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 694 | friends | I feel like I don't have enough friends. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 695 | abandon | I often feel abandoned. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 696 | missfrnd | I miss having a really close friend. | 1= Strongly disagree 2= Disagree 3= Neutral 4= Agree 5= Strongly Agree |
| 697 | q1mdb | DISCRIMINATION In your daily life how often have you had the following experiences: 1. You are treated with less courtesy than other people. Would you say that you have had this experience...? | 1= Often 2= Sometimes 3= Rarely 4= Never |
| 698 | q2mdb | 2. You are treated with less respect than other people. [OPTIONAL: Would you say that you have had this experience...?] | 1= Often 2= Sometimes 3= Rarely 4= Never |
| 699 | q3mdb | 3. You receive poorer service than other people at restaurants or stores. [OPTIONAL: Would you say that you have had this experience...?] | 1= Often 2= Sometimes 3= Rarely 4= Never |
| 700 | q4mdb | 4. People act as if they think you are not smart. [OPTIONAL: Would you say that you have had this experience...?] | 1= Often 2= Sometimes 3= Rarely 4= Never |
| 701 | q5mdb | 5. People act as if they are afraid of you. [OPTIONAL: Would you say that you have had this experience...?] | 1= Often 2= Sometimes 3= Rarely 4= Never |
| 702 | q6mdb | 6. People act as if they think you are dishonest. [OPTIONAL: Would you say that you have had this experience...?] | 1= Often 2= Sometimes 3= Rarely 4= Never |
| 703 | q7mdb | 7. People act as if they're better than you are. [OPTIONAL: Would you say that you have had this experience...?] | 1= Often 2= Sometimes 3= Rarely 4= Never |
| 704 | q8mdb | 8. You or your family members are called names or insulted. [OPTIONAL: Would you say that you have had this experience...?] | 1= Often 2= Sometimes 3= Rarely 4= Never |
| 705 | q9mdb | 9. You are threatened or harassed. [OPTIONAL: Would you say that you have had this experience...?] | 1= Often 2= Sometimes 3= Rarely 4= Never |
| 706 | q10mdb | 10. People ignore you or act as if you are not here. [OPTIONAL: Would you say that you have had this experience...?] | 1= Often 2= Sometimes 3= Rarely 4= Never |
| 707 | 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 |
| 708 | 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 |
| 709 | 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 |
| 710 | 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 |
| 711 | 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 |
| 712 | lifesp6 | During the past week, have you been to places outside your town or community? | 1= Yes 2= No |
| 713 | drive1 | DRIVING Are you currently licensed to drive? | 1= Yes 2= No |
| 714 | drive2 | Have you driven in the past 12 months? | 1= Yes 2= No |
| 715 | drive3 | Approximately how many days during a typical week are you likely to drive? | 1= 6 or 7 days 2= 3 to 5 days 3= 1 or 2 days 4= less than once per week |
| 716 | q1smo | SMOKING We are interested in whether smoking or drinking beverages containing alcohol are linked to certain health problems and also whether they may have some beneficial effects. First, some questions about smoking. 1. Do you smoke cigarettes now? | 1= Yes 2= No |
| 717 | q1asmo | 1a. On the average, how many cigarettes a day do you usually smoke? [ENTER NUMBER OF CIGARETTES: 1 PACK = 20 CIGARETTES] | 1 .. 200 |
| 718 | q1bsmo | 1b. How old were you when you first smoked cigarettes regularly? [ENTER AGE] | 0 .. 115 |
| 719 | q2smo | 2. Did you ever smoke cigarettes regularly? | 1= Yes 2= No |
| 720 | q2asmo | 2a. On the average, how many cigarettes a day did you usually smoke? [ENTER NUMBER OF CIGARETTES: 1 PACK = 20 CIGARETTES] | 1 .. 200 |
| 721 | q2bsmo | 2b. How old were you when you last smoked cigarettes regularly? [ENTER AGE] | 0 .. 115 |
| 722 | q2csmo | 2c. How old were you when you first smoked cigarettes regularly? [ENTER AGE] | 0 .. 115 |
| 723 | q3smo | 3. During that period of your life when you were smoking the most, about how many cigarettes a day did you usually smoke? [ENTER NUMBER OF CIGARETTES: 1 PACK = 20 CIGARETTES] | 1 .. 200 |
| 724 | q4smo | 4. Altogether, about how many years did you smoke this much? [ENTER YEARS: 01 = 1 YEAR OR LESS] | 1 .. 115 |
| 725 | q1alc | ALCOHOL USE We also have some questions on beverages that contain alcohol which may have good or bad effects on health. Included among alcoholic beverages are beer, wine and liquor, such as whiskey, rum, gin, or vodka, or any other type of alcoholic beverages. 1. In your entire life, have you had at least 12 drinks of any kind of alcoholic beverage? | 1= Yes 2= No |
| 726 | q2alc | 2. In the past 12 months, did you have at least 12 drinks of any kind of alcoholic beverage? | 1= Yes 2= No |
| 727 | q3alc | There are different types of alcoholic beverages and we would like to talk about one type at a time.3. During the past 12 months, on average, how much beer did you drink? Six or more bottles or cans per day, 4 to 5 bottles or cans per day, 2 to 3 bottles or cans per day, 1 bottle or can per day, 5 to 6 bottles or cans per WEEK, 2 to 4 bottles or cans per week, 1 bottle or can per week, 1 to 3 bottles or cans per MONTH, or less than one bottle or can per month? | 1= 6+ bottles or cans per day 2= 4-5 bottles or cans per day 3= 2-3 bottles or cans per day 4= 1 bottle or can per day 5= 5-6 bottles or cans per week 6= 2-4 bottles or cans per week 7= 1 bottle or can per week 8= 1-3 bottles or cans per month 9= Less than one bottle or can per month |
| 728 | q4alc | 4. During the past 12 months, on average, how much wine did you drink? Six or more 4-oz. glasses per day, 4 to 5 4-oz. glasses per day, 2 to 3 4-oz. glasses per day, 1 4-oz. glass per day, 5 to 6 4-oz. glasses per WEEK, 2 to 4 4-oz. glasses per week, 1 4- oz. glass per week, 1 to 3 4-oz. glasses per MONTH, or less than one 4-oz. glass per month? | 1= 6+ glasses per day 2= 4-5 glasses per day 3= 2-3 glasses per day 4= 1 glass per day 5= 5-6 glasses per week 6= 2-4 glasses per week 7= 1 glass per week 8= 1-3 glasses per month 9= Less than one glass per month |
| 729 | q5alc | 5. During the past 12 months, on average, how much liquor did you drink? That is, drinks made with whiskey, vodka, gin, brandy or liqueurs. | 1= 6+ drinks per day 2= 4-5 drinks per day 3= 2-3 drinks per day 4= 1 drink per day 5= 5-6 drinks per week 6= 2-4 drinks per week 7= 1 drink per week 8= 1-3 drinks per month 9= Less than one drink per month |
| 730 | q6alc | 6. In your entire life, when you drank the most, about how often did you drink any type of alcoholic beverage, including beer, wine and liquor? | 1= 6+ drinks per day 2= 4-5 drinks per day 3= 2-3 drinks per day 4= 1 drink per day 5= 5-6 drinks per week 6= 2-4 drinks per week 7= 1 drink per week 8= 1-3 drinks per month 9= Less than one drink per month |
| 731 | myob | PARENTAL HISTORY Now some questions about your natural or biologic parents. 1. In what year was your mother born? [ENTER YEAR] | 1840 .. 1960 |
| 732 | mfname | PARENTAL HISTORY Now some questions about your natural or biologic parents. What is/was your mother's full name? [ENTER LAST/FIRST/MIDDLE/ MAIDEN NAME] | String[40] |
| 733 | mage_bir | 1a. How old was your mother when you were born? [ENTER YEARS OF AGE] | 10 .. 50 |
| 734 | mage_br2 | 1b. Do you know if she was less than 15 years old, 15 to 20 years, in her 20's, 30's or in her 40's? | 1= Less than 15 years 2= 15 to 20 years 3= 20's 4= 30's 5= 40's |
| 735 | mlive | 2. Is your mother still living? | 1= Yes 2= No |
| 736 | myod | 2a. In what year did she die? [ENTER YEAR] | 1893 .. 2040 |
| 737 | mage_die | 2b. How old was your mother when she died? [ENTER YEARS OF AGE] | 10 .. 115 |
| 738 | mage_cur | 2c. How old is she now? [ENTER YEARS OF AGE] | 75 .. 115 |
| 739 | cmyob2 | Calculated year of birth for mother | 1829 .. 1919 |
| 740 | children | 3. How many children did your mother have? [PROBE: Please include only those children born alive.] | 1 .. 30 |
| 741 | oldersib | 4. How many of these children were older than you? | 0 .. 30 |
| 742 | mwork | 5. What kind of work did your mother do most of her life?(What was her job called?) [SPECIFY] | String[30] |
| 743 | meduc | 6. What was the highest grade or year of regular school your mother completed? Elementary 0 1 2 3 4 5 6 7 8 High School 9 10 11 12 College 13 14 15 16 Graduate Professional 17 18 19 20 21 ... | 0 .. 30 |
| 744 | meduc2 | 6a. Would you say that she had no schooling, a few years, finished grammar school, had any high school, or any college? | 1= No schooling 2= A few years 3= Finished grammar school 4= Any high school 5= Any college |
| 745 | mpark | 7. ^diddoesm your natural or biologic mother have Parkinson's disease with shaking tremors of the hands and/or slowness in walking and moving? | 1= Yes 2= Suspect or possible 3= No |
| 746 | mdement2 | 8. ^diddoesm she (your natural or biologic mother) have a problem with memory loss, confusion, dementia, or hardening of the arteries? | 1= Yes 2= Suspect or possible 3= No |
| 747 | ffname | What is/was your father's full name? [ENTER LAST/FIRST/MIDDLE] | String[30] |
| 748 | fyob | 9. In what year was your father born? [ENTER YEAR] | 1810 .. 1960 |
| 749 | fage_bir | 9a. How old was your father when you were born? [ENTER YEARS OF AGE] | 10 .. 115 |
| 750 | fage_br2 | 9b. Do you know if he was less than 15 years old, 15 to 20 years, in his 20's, 30's, 40's, or 50 or older? | 1= Less than 15 years 2= 15 to 20 years 3= 20's 4= 30's 5= 40's 6= 50+ |
| 751 | flive | 10. Is your father still living? | 1= Yes 2= No |
| 752 | fyod | 10a. In what year did he die? [ENTER YEAR] | 1820 .. 2040 |
| 753 | fage_die | 10b. How old was your father when he died? [ENTER YEARS OF AGE] | 10 .. 115 |
| 754 | fage_cur | 10c. How old is he now? [ENTER YEARS OF AGE] | 75 .. 115 |
| 755 | cfyob2 | Calculated year of birth for father | 1764 .. 1919 |
| 756 | fwork | 11. What kind of work did your father do most of his life?(What was his job called?) [SPECIFY] | String[30] |
| 757 | feduc | 12. What was the highest grade or year of regular school your father completed? Elementary0 1 2 3 4 5 6 7 8 High School 9 10 11 12 College 13 14 15 16 Graduate Professional17 18 19 20 21 ... | 0 .. 30 |
| 758 | feduc2 | 12a. Would you say that he had no schooling, a few years, finished grammar school, had any high school, or any college? | 1= No schooling 2= A few years 3= Finished grammar school 4= Any high school 5= Any college |
| 759 | fpark | 13. ^diddoesf your natural or biologic father have Parkinson's disease with shaking tremors of the hands and/or slowness in walking and moving? | 1= Yes 2= Suspect or possible 3= No |
| 760 | fdement2 | 14. ^diddoesf he (your natural or biologic father) have a problem with memory loss, confusion , dementia, or hardening of the arteries? | 1= Yes 2= Suspect or possible 3= No |
| 761 | school | How important was it to your parents that you be successful in school? | 1= Extremely important 2= Moderately important 3= Somewhat important 4= Not at all important |
| 762 | sibnum | How many natural or biological brothers and sisters did you have? [Interviewer: Include those currently living and those who have already died.] | 0 .. 30 |
| 763 | sibpark1 | Did any of your natural or biological siblings have Parkinson's disease with shaking tremors of the hands and/or slowness in walking and moving? | 1= Yes 2= Suspect or Possible 3= No |
| 764 | sibpark2 | How many? | 1 .. 9 |
| 765 | sibmem1 | Did any of your natural or biological siblings have a problem with memory loss, confusion, dementia, or hardening of the arteries? | 1= Yes 2= Suspect or Possible 3= No |
| 766 | sibmem2 | How many? | 1 .. 9 |
| 767 | currjob | OCCUPATION 1. The kind of work we do can also affect our health, so we would like to get some information about your occupations. We would like to know if you are currently working at a job? | 1= Yes 2= No |
| 768 | ftpt | 2. Full-time or part-time? | 1= Part-time 2= Full-time |
| 769 | cjobname | 3. What kind of work are you doing? (What is your job called?) (For example, registered nurse, personnel manager, supervisor, a teacher...) [JOB NAME] | String[30] |
| 770 | cjobduty | 4. What are your most important activities or duties? (For example, patient care, directing hiring policies, supervising, teaching...) [SPECIFY] | String[60] |
| 771 | retired | 5. Are you retired? (from a job?) | 1= Yes 2= No |
| 772 | yr_ret | 5a. In what year did you retire? | 1894 .. 2040 |
| 773 | lifejob | 6. What kind of work have you done most of your life? (What was your job called?) (For example, registered nurse, personnel manager, supervisor, teaching...) | 1= Same as current occupation 2= Not currently working; occupation specified 3= Different occupation from current one; 4= Never worked/disabled |
| 774 | ljobname | 6a. Specify occupation | String[30] |
| 775 | ljobduty | 6b. What were your most important activities or duties? (For example, patient care, directing hiring policies, supervising, teaching...) [SPECIFY] | String[60] |
| 776 | jobsuper | 7. Considering the time when you worked most recently and thinking of the person in your organization who had the most control over what you did on the job - which of these statements best describes how closely you were supervised - my supervisor decided both what I did and how I did it; my supervisor decided WHAT I did, but I decided HOW to do it; I had some freedom in deciding both what I did and how to do it; I was my own boss within general policies. | 1= Supervisor decided both what I did and how I did it. 2= Supervisor decided what I did, but I decided how to do it. 3= I had some freedom in deciding what I did and how to do it. 4= I was my own boss within general policies. |
| 777 | jobfree | 8. How free ^dodid you feel to disagree with him or her? Would you say you ^feelfelt completely free to disagree, quite a bit free to disagree, a little bit free to disagree or hardly free at all to disagree? | 1= Completely free 2= Quite a bit free 3= A little bit free 4= Hardly free at all |
| 778 | work30 | 9. What kind of work did you do when you were 30 years of age? (What is your job called?) (For example, registered nurse, personnel manager, supervisor, teacher...) | 1= Same as current occupation 2= Same as work done most of life 3= Different occupation from job(s) described previously 4= Other, not working |
| 779 | job30 | 9a. [SPECIFY OCCUPATION] | String[30] |
| 780 | oth30 | 9b. [SPECIFY REASON FOR NON-WORKING STATUS AT 30 YEARS OF AGE] | String[30] |
| 781 | duty30 | 9c. What were your most important activities or duties? (For example, patient care, directing hiring policies, supervising, teaching...) [SPECIFY] | String[60] |
| 782 | addnum40 | What was your street address when you were 40? Street number | String[6] |
| 783 | dir40 | Street direction [HIT ENTER IF NOT APPLICABLE] | String[2] |
| 784 | street40 | Street name | String[55] |
| 785 | unit40 | Apartment/Unit number [HIT ENTER IF NOT APPLICABLE] | String[5] |
| 786 | city40 | City or Town | String[18] |
| 787 | state40 | State | String[2] |
| 788 | zip40 | Zip Code | String[5] |
| 789 | q40inc | In order for us to have a clear understanding about what kinds of things affect our health, we need to get some information about income. This information will help us understand why some people do not get the health services they need. Please look at this card. Which of these income groups represents your household income at age 40? Just give me the letter that best represents your income category at that age.[ENTER LETTER] | 1= Q 2= R 3= S 4= T 5= U 6= V 7= W 8= X 9= Y 10= Z |
| 790 | q1inc | Which of these income groups represents ^husbwife2 personal income for the past month or year? Include income from all sources such as wages, salaries, social security or retirement benefits, help from relatives, rent from property, and so forth. Just give me the letter that represents your income category.[ENTER LETTER] | 1= Q 2= R 3= S 4= T 5= U 6= V 7= W 8= X 9= Y 10= Z |
| 791 | c1fname | CONTACT PERSON: In the event that we are unable to contact you, can you give me the name, address, and phone number of two people who would have information about you? Please, think of people who do not live in the same household as you. First Contact Person First name [ENTER DONTKNOW IF NONE.] | String[12] |
| 792 | c1middl | First Contact Person Middle initial [HIT ENTER IF NOT APPLICABLE] | String[1] |
| 793 | c1lname | First Contact Person Last name | String[18] |
| 794 | c1gender | ^c1fname ^c1lname First Contact Person's gender | 1= Male 2= Female |
| 795 | c1live | Does ^c1heshe live with you? | 1= YES 2= NO |
| 796 | c1see | How often do you see ^c1himher? | 1= <2 days per week 2= 2-3 days per week 3= 4-5 days per week 4= 6-7 days per week |
| 797 | c1addnum | ^c1fname ^c1lname First Contact Person's current address Street number | String[6] |
| 798 | c1dir | ^c1fname ^c1lname Street direction [HIT ENTER IF NOT APPLICABLE] | String[2] |
| 799 | c1street | ^c1fname ^c1lname Street name | String[55] |
| 800 | c1unit | ^c1fname ^c1lname Apartment/Unit number [HIT ENTER IF NOT APPLICABLE] | String[5] |
| 801 | c1city | ^c1fname ^c1lname City or Town | String[18] |
| 802 | c1state | ^c1fname ^c1lname State | String[2] |
| 803 | c1zip | ^c1fname ^c1lname Zip Code | String[5] |
| 804 | c1hphone | ^c1fname ^c1lname Home Telephone including area code [Use '-' to separate] | String[20] |
| 805 | c1wphone | ^c1fname ^c1lname Work Telephone including area code [Use '-' to separate] [HIT ENTER IF NOT APPLICABLE] | String[20] |
| 806 | c1relshp | ^c1fname ^c1lname First Contact Person's relationship to the participant? | 1= Spouse 2= Son/daughter (including stepchildren) 3= Son-in-law/ Daughter-in-law 4= Grandchild 5= Parent 6= Brother or sister 7= Other |
| 807 | c1relspc | ^c1fname ^c1lname Specify | String[40] |
| 808 | c2fname | Second Contact Person [THIS PERSON MAY NOT RESIDE AT THE SAME ADDRESS AS THE PARTICIPANT OR THE FIRST CONTACT PERSON] First name [ENTER DONTKNOW IF NONE.] | String[12] |
| 809 | c2middl | Second Contact Person Middle initial [HIT ENTER IF NOT APPLICABLE] | String[1] |
| 810 | c2lname | Second Contact Person Last name | String[18] |
| 811 | c2gender | ^c2fname ^c2lname Second Contact Person's gender | 1= Male 2= Female |
| 812 | c2live | Does ^c2heshe live with you? | 1= YES 2= NO |
| 813 | c2see | How often do you see ^c2himher? | 1= <2 days per week 2= 2-3 days per week 3= 4-5 days per week 4= 6-7 days per week |
| 814 | c2addnum | ^c2fname ^c2lname Second Contact Person's current address Street number | String[6] |
| 815 | c2dir | ^c2fname ^c2lname Street direction [HIT ENTER IF NOT APPLICABLE] | String[2] |
| 816 | c2street | ^c2fname ^c2lname Street name | String[55] |
| 817 | c2unit | ^c2fname ^c2lname Apartment/Unit number [HIT ENTER IF NOT APPLICABLE] | String[5] |
| 818 | c2city | ^c2fname ^c2lname City or Town | String[18] |
| 819 | c2state | ^c2fname ^c2lname State | String[2] |
| 820 | c2zip | ^c2fname ^c2lname Zip Code | String[5] |
| 821 | c2hphone | ^c2fname ^c2lname Home Telephone including area code [Use '-' to separate] | String[20] |
| 822 | c2wphone | ^c2fname ^c2lname Work Telephone including area code [Use '-' to separate] [HIT ENTER IF NOT APPLICABLE] | String[20] |
| 823 | c2relshp | ^c2fname ^c2lname Second Contact Person's relationship to the participant? | 1= Spouse 2= Son/daughter (including stepchildren) 3= Son-in-law/ Daughter-in-law 4= Grandchild 5= Parent 6= Brother or sister 7= Other |
| 824 | c2relspc | ^c2fname ^c2lname Specify | String[40] |
| 825 | study1 | STUDY INFORMATION We think that it's important for your family and friends to know about the study. Is it OK for us to send these people information about the study such as an information packet and newsletter? | 1= Yes 2= No |
| 826 | study2 | Are there any other family members and/or friends that we can send information about the study? If yes, how many? [Enter number from 1 to 9] [If none, enter 0 and continue.] | 0 .. 9 |
| 827 | fname | Can you give me their name and address? First name | String[12] |
| 828 | middl | Middle initial [HIT ENTER IF NOT APPLICABLE] | String[1] |
| 829 | lname | Last name | String[18] |
| 830 | gender2 | Gender | 1= Male 2= Female |
| 831 | live | Does he/she live with you? | 1= YES 2= NO |
| 832 | addnum | Current address Street number | String[6] |
| 833 | dir | Street direction [HIT ENTER IF NOT APPLICABLE] | String[2] |
| 834 | street | Street name | String[55] |
| 835 | unit | Apartment/Unit number [HIT ENTER IF NOT APPLICABLE] | String[5] |
| 836 | city2 | City or Town | String[18] |
| 837 | state2 | State | String[2] |
| 838 | zip | Zip Code | String[5] |
| 839 | relshp | Person's relationship to the participant? | 1= Spouse 2= Son/daughter (including stepchildren) 3= Son-in-law/ Daughter-in-law 4= Grandchild 5= Parent 6= Brother or sister 7= Other |
| 840 | relspc | Specify | String[40] |
| 841 | fname2 | Can you give me their name and address? First name | String[12] |
| 842 | middl2 | Middle initial [HIT ENTER IF NOT APPLICABLE] | String[1] |
| 843 | lname2 | Last name | String[18] |
| 844 | gender3 | Gender | 1= Male 2= Female |
| 845 | live2 | Does he/she live with you? | 1= YES 2= NO |
| 846 | addnum2 | Current address Street number | String[6] |
| 847 | dir2 | Street direction [HIT ENTER IF NOT APPLICABLE] | String[2] |
| 848 | street2 | Street name | String[55] |
| 849 | unit2 | Apartment/Unit number [HIT ENTER IF NOT APPLICABLE] | String[5] |
| 850 | city3 | City or Town | String[18] |
| 851 | state3 | State | String[2] |
| 852 | zip2 | Zip Code | String[5] |
| 853 | relshp2 | Person's relationship to the participant? | 1= Spouse 2= Son/daughter (including stepchildren) 3= Son-in-law/ Daughter-in-law 4= Grandchild 5= Parent 6= Brother or sister 7= Other |
| 854 | relspc2 | Specify | String[40] |
| 855 | fname3 | Can you give me their name and address? First name | String[12] |
| 856 | middl3 | Middle initial [HIT ENTER IF NOT APPLICABLE] | String[1] |
| 857 | lname3 | Last name | String[18] |
| 858 | gender4 | Gender | 1= Male 2= Female |
| 859 | live3 | Does he/she live with you? | 1= YES 2= NO |
| 860 | addnum3 | Current address Street number | String[6] |
| 861 | dir3 | Street direction [HIT ENTER IF NOT APPLICABLE] | String[2] |
| 862 | street3 | Street name | String[55] |
| 863 | unit3 | Apartment/Unit number [HIT ENTER IF NOT APPLICABLE] | String[5] |
| 864 | city4 | City or Town | String[18] |
| 865 | state4 | State | String[2] |
| 866 | zip3 | Zip Code | String[5] |
| 867 | relshp3 | Person's relationship to the participant? | 1= Spouse 2= Son/daughter (including stepchildren) 3= Son-in-law/ Daughter-in-law 4= Grandchild 5= Parent 6= Brother or sister 7= Other |
| 868 | relspc3 | Specify | String[40] |
| 869 | fname4 | Can you give me their name and address? First name | String[12] |
| 870 | middl4 | Middle initial [HIT ENTER IF NOT APPLICABLE] | String[1] |
| 871 | lname4 | Last name | String[18] |
| 872 | gender5 | Gender | 1= Male 2= Female |
| 873 | live4 | Does he/she live with you? | 1= YES 2= NO |
| 874 | addnum4 | Current address Street number | String[6] |
| 875 | dir4 | Street direction [HIT ENTER IF NOT APPLICABLE] | String[2] |
| 876 | street4 | Street name | String[55] |
| 877 | unit4 | Apartment/Unit number [HIT ENTER IF NOT APPLICABLE] | String[5] |
| 878 | city5 | City or Town | String[18] |
| 879 | state5 | State | String[2] |
| 880 | zip4 | Zip Code | String[5] |
| 881 | relshp4 | Person's relationship to the participant? | 1= Spouse 2= Son/daughter (including stepchildren) 3= Son-in-law/ Daughter-in-law 4= Grandchild 5= Parent 6= Brother or sister 7= Other |
| 882 | relspc4 | Specify | String[40] |
| 883 | fname5 | Can you give me their name and address? First name | String[12] |
| 884 | middl5 | Middle initial [HIT ENTER IF NOT APPLICABLE] | String[1] |
| 885 | lname5 | Last name | String[18] |
| 886 | gender6 | Gender | 1= Male 2= Female |
| 887 | live5 | Does he/she live with you? | 1= YES 2= NO |
| 888 | addnum5 | Current address Street number | String[6] |
| 889 | dir5 | Street direction [HIT ENTER IF NOT APPLICABLE] | String[2] |
| 890 | street5 | Street name | String[55] |
| 891 | unit5 | Apartment/Unit number [HIT ENTER IF NOT APPLICABLE] | String[5] |
| 892 | city6 | City or Town | String[18] |
| 893 | state6 | State | String[2] |
| 894 | zip5 | Zip Code | String[5] |
| 895 | relshp5 | Person's relationship to the participant? | 1= Spouse 2= Son/daughter (including stepchildren) 3= Son-in-law/ Daughter-in-law 4= Grandchild 5= Parent 6= Brother or sister 7= Other |
| 896 | relspc5 | Specify | String[40] |
| 897 | fname6 | Can you give me their name and address? First name | String[12] |
| 898 | middl6 | Middle initial [HIT ENTER IF NOT APPLICABLE] | String[1] |
| 899 | lname6 | Last name | String[18] |
| 900 | gender7 | Gender | 1= Male 2= Female |
| 901 | live6 | Does he/she live with you? | 1= YES 2= NO |
| 902 | addnum6 | Current address Street number | String[6] |
| 903 | dir6 | Street direction [HIT ENTER IF NOT APPLICABLE] | String[2] |
| 904 | street6 | Street name | String[55] |
| 905 | unit6 | Apartment/Unit number [HIT ENTER IF NOT APPLICABLE] | String[5] |
| 906 | city7 | City or Town | String[18] |
| 907 | state7 | State | String[2] |
| 908 | zip6 | Zip Code | String[5] |
| 909 | relshp6 | Person's relationship to the participant? | 1= Spouse 2= Son/daughter (including stepchildren) 3= Son-in-law/ Daughter-in-law 4= Grandchild 5= Parent 6= Brother or sister 7= Other |
| 910 | relspc6 | Specify | String[40] |
| 911 | fname7 | Can you give me their name and address? First name | String[12] |
| 912 | middl7 | Middle initial [HIT ENTER IF NOT APPLICABLE] | String[1] |
| 913 | lname7 | Last name | String[18] |
| 914 | gender8 | Gender | 1= Male 2= Female |
| 915 | live7 | Does he/she live with you? | 1= YES 2= NO |
| 916 | addnum7 | Current address Street number | String[6] |
| 917 | dir7 | Street direction [HIT ENTER IF NOT APPLICABLE] | String[2] |
| 918 | street7 | Street name | String[55] |
| 919 | unit7 | Apartment/Unit number [HIT ENTER IF NOT APPLICABLE] | String[5] |
| 920 | city8 | City or Town | String[18] |
| 921 | state8 | State | String[2] |
| 922 | zip7 | Zip Code | String[5] |
| 923 | relshp7 | Person's relationship to the participant? | 1= Spouse 2= Son/daughter (including stepchildren) 3= Son-in-law/ Daughter-in-law 4= Grandchild 5= Parent 6= Brother or sister 7= Other |
| 924 | relspc7 | Specify | String[40] |
| 925 | fname8 | Can you give me their name and address? First name | String[12] |
| 926 | middl8 | Middle initial [HIT ENTER IF NOT APPLICABLE] | String[1] |
| 927 | lname8 | Last name | String[18] |
| 928 | gender9 | Gender | 1= Male 2= Female |
| 929 | live8 | Does he/she live with you? | 1= YES 2= NO |
| 930 | addnum8 | Current address Street number | String[6] |
| 931 | dir8 | Street direction [HIT ENTER IF NOT APPLICABLE] | String[2] |
| 932 | street8 | Street name | String[55] |
| 933 | unit8 | Apartment/Unit number [HIT ENTER IF NOT APPLICABLE] | String[5] |
| 934 | city9 | City or Town | String[18] |
| 935 | state9 | State | String[2] |
| 936 | zip8 | Zip Code | String[5] |
| 937 | relshp8 | Person's relationship to the participant? | 1= Spouse 2= Son/daughter (including stepchildren) 3= Son-in-law/ Daughter-in-law 4= Grandchild 5= Parent 6= Brother or sister 7= Other |
| 938 | relspc8 | Specify | String[40] |
| 939 | fname9 | Can you give me their name and address? First name | String[12] |
| 940 | middl9 | Middle initial [HIT ENTER IF NOT APPLICABLE] | String[1] |
| 941 | lname9 | Last name | String[18] |
| 942 | gender10 | Gender | 1= Male 2= Female |
| 943 | live9 | Does he/she live with you? | 1= YES 2= NO |
| 944 | addnum9 | Current address Street number | String[6] |
| 945 | dir9 | Street direction [HIT ENTER IF NOT APPLICABLE] | String[2] |
| 946 | street9 | Street name | String[55] |
| 947 | unit9 | Apartment/Unit number [HIT ENTER IF NOT APPLICABLE] | String[5] |
| 948 | city10 | City or Town | String[18] |
| 949 | state10 | State | String[2] |
| 950 | zip9 | Zip Code | String[5] |
| 951 | relshp9 | Person's relationship to the participant? | 1= Spouse 2= Son/daughter (including stepchildren) 3= Son-in-law/ Daughter-in-law 4= Grandchild 5= Parent 6= Brother or sister 7= Other |
| 952 | relspc9 | Specify | String[40] |
| 953 | primphyf | 3. What is the first name of your primary physician? [ENTER FIRST NAME. NO MD or DR.] | String[15] |
| 954 | primphym | 3. What is the middle initial of your primary physician? [ENTER M.I.] | String[1] |
| 955 | primphyl | 3. What is the last of your primary physician? [ENTER LAST NAME. NO MD or DR.] | String[20] |
| 956 | phaddnum | Physician- ^primphyf ^primphyl Physician's current address Street number | String[6] |
| 957 | phdir | Physician- ^primphyf ^primphyl Street direction [HIT ENTER IF NOT APPLICABLE] | String[2] |
| 958 | phstreet | Physician- ^primphyf ^primphyl Street name | String[55] |
| 959 | phunit | Physician- ^primphyf ^primphyl Suite or office number [HIT ENTER IF NOT APPLICABLE] | String[5] |
| 960 | phcity | Physician- ^primphyf ^primphyl City or Town | String[18] |
| 961 | phstate | Physician- ^primphyf ^primphyl State | String[2] |
| 962 | phzip | Physician- ^primphyf ^primphyl Zip Code | String[5] |
| 963 | physophn | Physician- ^primphyf ^primphyl Telephone Number including area code [Use '-' to separate] [HIT ENTER IF NOT APPLICABLE] | String[20] |
| 964 | physhphn | 8. Physician's home phone? [HIT ENTER IF NOT APPLICABLE] | String[20] |
| 965 | phyvisit | 9. How often do you usually see him/her? | 1= Every 6 months 2= Every 6 to 12 months 3= Less than once/year |
| 966 | livingwl | 10. Do you have a living will or Durable Power of Health Care? | 1= Yes 2= No |
| 967 | represen | 11. Who have you designated as you representative? [ENTER NAME] | String[30] |
| 968 | liklyhos | 12. If you were to become ill and require hospitalization, which hospital would you most likely use? [ENTER HOSPITAL NAME:] | String[20] |
| 969 | lhosaddr | 13. Hospital's Address? | String[30] |
| 970 | wherlive | 14. If you were unable to care for yourself, where would live? (i.e. intermediate care) [ENTER LOCATION] | String[30] |
| 971 | funerhme | 15. At the time of your death, what funeral home would you most likely use? [ENTER FUNERAL HOME NAME] | String[20] |
| 972 | faddnum | Funeral Home Address? Address Number | String[6] |
| 973 | fdir | Funeral Home Address? Direction: [Press enter if none.] | String[4] |
| 974 | fstreet | Funeral Home Address? Street: | String[55] |
| 975 | funit | Funeral Home Address? Department, Building, or Office Number: [Press enter if none.] | String[25] |
| 976 | fcity | Funeral Home Address? City: | String[18] |
| 977 | fstate | Funeral Home Address? State: | String[2] |
| 978 | fzip | Funeral Home Address? Zip Code: | String[5] |
| 979 | fphone | What is the Funeral Home telephone number (including area code)? [Use '-' to separate] | String[20] |
| 980 | agreeaut | Has the participant agreed to autopsy in this study? [Check the participant data sheet in the chart.]? | 1= Yes 2= No |
| 981 | toldfam | Have you told your family, other relatives, any friends, or your power of attorney about your participation in this study? | 1= Yes 2= No |
| 982 | funname | Has the participant given us a name and address of a funeral home they intend to use? | 1= Yes 2= No |
| 983 | arrange | Has the participant made pre-arrangements with this funeral home? | 1= Yes 2= No |
| 984 | giveperm | Has the participant already given us permission to contact their funeral home of choice? [Check the participant data sheet in the chart.] | 1= Yes 2= No |
| 985 | contfun | Is it OK with you if we contact this funeral home and let them know that you are a participant in the study, so we can give them information about the study? | 1= Yes 2= No |
| 986 | 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 |
| 987 | hearimp | 2. Does the participant have a substantial hearing impairment? | 1= Yes 2= No |
| 988 | 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 |
| 989 | 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 |
| 990 | comments | Enter any comments. [PRESS ENTER IF NONE.] | String[150] |
| 991 | vegsign | 0 .. 8 | |
| 992 | mvegsign | 0 .. 8 | |
| 993 | cesd | 0 .. 10 | |
| 994 | mcesd | 0 .. 10 | |
| 1000 | 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 |
| 1001 | formpart | Was participant reluctant, and/or does participant have special needs? | 1= Yes 2= No |
| 1002 | formcomm | Please explain reluctance or any other factors which may have affected this data. [Press enter if no comment needed.] | String[120] |
| 1003 | statid | Please enter you staff id. | 100 .. 997 |
| 1004 | formch | Has the form been modified? | 1= Yes 2= No |
| 1005 | revidate | Enter the date that the form was modified. | Date type |
| 1006 | revintd | Enter your staff id number. | 100 .. 997 |
| 1007 | anydev | Are there any protocol deviations or missing data items to enter? | 1= Yes 2= No |
| 1008 | numdev | How many total protocol deviations and tests with missing items to enter? | 1 .. 20 |
| 1009 | reas00 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 1010 | test00 | Enter test or procedure. | String[15] |
| 1011 | item00 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 1012 | code00 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 1013 | oth00 | Enter other code used. | String[20] |
| 1014 | expl00 | Explain what happened | String[100] |
| 1015 | reas01 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 1016 | test01 | Enter test or procedure. | String[15] |
| 1017 | item01 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 1018 | code01 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 1019 | oth01 | Enter other code used. | String[20] |
| 1020 | expl01 | Explain what happened | String[100] |
| 1021 | reas02 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 1022 | test02 | Enter test or procedure. | String[15] |
| 1023 | item02 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 1024 | code02 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 1025 | oth02 | Enter other code used. | String[20] |
| 1026 | expl02 | Explain what happened | String[100] |
| 1027 | reas03 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 1028 | test03 | Enter test or procedure. | String[15] |
| 1029 | item03 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 1030 | code03 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 1031 | oth03 | Enter other code used. | String[20] |
| 1032 | expl03 | Explain what happened | String[100] |
| 1033 | reas04 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 1034 | test04 | Enter test or procedure. | String[15] |
| 1035 | item04 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 1036 | code04 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 1037 | oth04 | Enter other code used. | String[20] |
| 1038 | expl04 | Explain what happened | String[100] |
| 1039 | reas05 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 1040 | test05 | Enter test or procedure. | String[15] |
| 1041 | item05 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 1042 | code05 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 1043 | oth05 | Enter other code used. | String[20] |
| 1044 | expl05 | Explain what happened | String[100] |
| 1045 | reas06 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 1046 | test06 | Enter test or procedure. | String[15] |
| 1047 | item06 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 1048 | code06 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 1049 | oth06 | Enter other code used. | String[20] |
| 1050 | expl06 | Explain what happened | String[100] |
| 1051 | reas07 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 1052 | test07 | Enter test or procedure. | String[15] |
| 1053 | item07 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 1054 | code07 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 1055 | oth07 | Enter other code used. | String[20] |
| 1056 | expl07 | Explain what happened | String[100] |
| 1057 | reas08 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 1058 | test08 | Enter test or procedure. | String[15] |
| 1059 | item08 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 1060 | code08 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 1061 | oth08 | Enter other code used. | String[20] |
| 1062 | expl08 | Explain what happened | String[100] |
| 1063 | reas09 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 1064 | test09 | Enter test or procedure. | String[15] |
| 1065 | item09 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 1066 | code09 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 1067 | oth09 | Enter other code used. | String[20] |
| 1068 | expl09 | Explain what happened | String[100] |
| 1069 | reas10 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 1070 | test10 | Enter test or procedure. | String[15] |
| 1071 | item10 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 1072 | code10 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 1073 | oth10 | Enter other code used. | String[20] |
| 1074 | expl10 | Explain what happened | String[100] |
| 1075 | reas11 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 1076 | test11 | Enter test or procedure. | String[15] |
| 1077 | item11 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 1078 | code11 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 1079 | oth11 | Enter other code used. | String[20] |
| 1080 | expl11 | Explain what happened | String[100] |
| 1081 | reas12 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 1082 | test12 | Enter test or procedure. | String[15] |
| 1083 | item12 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 1084 | code12 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 1085 | oth12 | Enter other code used. | String[20] |
| 1086 | expl12 | Explain what happened | String[100] |
| 1087 | reas13 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 1088 | test13 | Enter test or procedure. | String[15] |
| 1089 | item13 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 1090 | code13 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 1091 | oth13 | Enter other code used. | String[20] |
| 1092 | expl13 | Explain what happened | String[100] |
| 1093 | reas14 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 1094 | test14 | Enter test or procedure. | String[15] |
| 1095 | item14 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 1096 | code14 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 1097 | oth14 | Enter other code used. | String[20] |
| 1098 | expl14 | Explain what happened | String[100] |
| 1099 | reas15 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 1100 | test15 | Enter test or procedure. | String[15] |
| 1101 | item15 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 1102 | code15 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 1103 | oth15 | Enter other code used. | String[20] |
| 1104 | expl15 | Explain what happened | String[100] |
| 1105 | reas16 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 1106 | test16 | Enter test or procedure. | String[15] |
| 1107 | item16 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 1108 | code16 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 1109 | oth16 | Enter other code used. | String[20] |
| 1110 | expl16 | Explain what happened | String[100] |
| 1111 | reas17 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 1112 | test17 | Enter test or procedure. | String[15] |
| 1113 | item17 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 1114 | code17 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 1115 | oth17 | Enter other code used. | String[20] |
| 1116 | expl17 | Explain what happened | String[100] |
| 1117 | reas18 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 1118 | test18 | Enter test or procedure. | String[15] |
| 1119 | item18 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 1120 | code18 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 1121 | oth18 | Enter other code used. | String[20] |
| 1122 | expl18 | Explain what happened | String[100] |
| 1123 | reas19 | Protocol Deviation or Missing Data? | 1= Protocol Deviation 2= Missing Data |
| 1124 | test19 | Enter test or procedure. | String[15] |
| 1125 | item19 | List items involved. [SEPARATE BY A COMMA] | String[20] |
| 1126 | code19 | Enter data code used. | 1= Don't Know 2= Refusal 3= other |
| 1127 | oth19 | Enter other code used. | String[20] |
| 1128 | expl19 | Explain what happened | String[100] |