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$sitecode
User:
System Date:
Mode: Production
Site Name:
Female Questionnaire (OHF)
Version: 1.02; 01-19 -06
OMB# 0925-0543
Exp. 06/30/2010
Public reporting burden for this collection of information is estimated to average 25 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection
of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch,
6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0543).
Thank you for agreeing to participate in the LIFE Study. As you know, this important study focuses on the effects of lifestyle and the
environment on reproductive health. Your participation is voluntary and you are free to withdraw from the study at any time for
whatever reason. We do, however, hope that you will want to continue to participate. As a reminder, all information that you provide
will be kept strictly confidential and used for medical research purposes only. It is our duty to ensure your privacy.
I am first going to ask you some questions about your occupation and then I will ask some questions about your medical
and pregnancy history, and finally some questions about your lifestyle.
Occupational History
1.
Are you currently employed? This includes part-time
and full-time jobs, jobs at home, on a farm, or outside
your home that are paid or military service.
Interviewer, read if necessary: Students,
homemakers/parents, temporarily unemployed and the
disabled are not considered "currently employed".
0-No
1-Yes
Does your current job involve any of the following:
a.
Night work:
Interviewer, read if necessary: Work schedule in
which most hours (>50%) are in the evening
(between 4pm and midnight) or at night (between
midnight and 8am).
0-No
1-Yes
b.
Rotating shifts:
Interviewer, read if necessary: Work schedule in
which the work time changes between days,
evenings and/or nights.
0-No
1-Yes
c.
Whole body vibration:
Interviewer, read if necessary: Vibration
associated with driving a car, truck, bus, van, fork lift,
earth moving equipment, tractor, train, helicopter,
etc.
0-No
1-Yes
d.
Noise:
Interviewer, read if necessary: Loud or very loud
noise experienced in the work environment while
performing job (for example: lawn equipment, large
earth-moving equipment, jack hammer work, airport
0-No
1-Yes
field area, rock concert stage) or (if you have to
shout to be heard by a person 3 feet away from you)
generally >85 decibels.
e.
Extreme heat:
Interviewer, read if necessary: A work
environment that is warmer than 100o F. Examples
include kitchen jobs, jobs in the dry cleaning
industry, and summer construction work.
0-No
1-Yes
f.
Heavy exertion or lifting:
Interviewer, read if necessary: Exerting in excess
of 50 pounds of force occasionally, and/or in excess
of 25 pounds of force frequently, and/or in excess of
10 pounds of force constantly to move objects.
Force may involve lifting, carrying, pushing, or
pulling.
0-No
1-Yes
g.
Prolonged standing:
Interviewer, read if necessary: Remaining on one's
feet in an upright position at a workstation with little
or no movement for 4 or more hours per day.
0-No
1-Yes
LIFE
$sitecode
User:
System Date:
Mode: Production
Site Name:
Female Medical History A (FMA)
Version: 1.03; 08-15 -06
The next few questions ask about your overall medical history.
1. Have you ever been told by a doctor that you have any of the following health conditions:
a.
Hypothyroid disease (under-active thyroid) :
Are you currently receiving medical treatment for
this condition?
b.
c.
d.
e.
f.
g.
Hyperthyroid disease (over-active thyroid) :
0-No
1-Yes
0-No
1-Yes
0-No
1-Yes
Are you currently receiving medical treatment for
this condition?
0-No
1-Yes
High blood pressure when you were not pregnant:
0-No
1-Yes
Are you currently receiving medical treatment for
this condition?
0-No
1-Yes
0-No
1-Yes
Are you currently receiving medical treatment for
this condition?
0-No
1-Yes
Diabetes (also known as 'sugar') when you were
not pregnant:
Are you currently receiving medical treatment for
this condition?
Does the treatment include:
Diet:
0-No
1-Yes
0-No
1-Yes
High cholesterol:
0-No
1-Yes
Pills:
0-No
1-Yes
Insulin:
0-No
1-Yes
0-No
1-Yes
0-No
1-Yes
0-No
1-Yes
Gestational diabetes - diabetes when you were
pregnant:
Kidney condition:
What specific kidney condition do you have?
Are you currently receiving medical treatment for
this condition?
h.
Liver condition:
0-No
1-Yes
Are you currently receiving medical treatment for
this condition?
0-No
1-Yes
Eating disorder such as anorexia nervosa,
bulimia, or binge eating disorder:
Are you currently receiving medical treatment for
this condition?
0-No
1-Yes
0-No
1-Yes
Anxiety disorder:
Interviewer, read if necessary: Anxiety Disorders are
defined as a group of disorders characterized by
persistent anxiety that is severe enough to interfere
with a person's daily activities.
Do you have:
Agoraphobia:
Interviewer, read if necessary: Anxiety about
being in places or situations from which escape
might be difficult (or embarrassing) or in which
help may not be available.
Obsessive-compulsive disorder (OCD):
Interviewer, read if necessary: ObsessiveCompulsive Disorder is characterized by
uncontrollable obsessions and compulsions
which the sufferer usually recognizes as being
excessive or unreasonable. Obsessions are
recurring thoughts or impulses that are intrusive
or inappropriate and cause the sufferer anxiety
Panic disorder:
Interviewer, read if necessary: Panic Disorder
is defined as condition in which individuals
experience recurrent panic attacks. Panic attacks
are characterized by the abrupt onset of an
episode of intense fear or discomfort.
Post traumatic stress disorder (PTSD):
Interviewer, read if necessary: Posttraumatic
Stress Disorder is a disorder that can occur
following the experience or witnessing of lifethreatening events such as military combat,
natural disasters, terrorist incidents, serious
accidents, or violent personal assaults like rape.
People who suffer from PTSD often relive the
experience through nightmares and flashbacks,
have difficulty sleeping, and feel detached or
estranged.
Social anxiety disorder:
Interviewer, read if necessary: Social Anxiety
Disorder is characterized by an intense fear of
situations, usually social or performance
situations, where embarrassment may occur.
Generalized anxiety disorder:
Interviewer, read if necessary: Generalized
anxiety disorder is characterized by a pattern of
frequent, persistent worry and anxiety for six
months or more, about several different events or
activities.
Are you currently receiving medical treatment for
any of these conditions?
0-No
1-Yes
0-No
1-Yes
0-No
1-Yes
0-No
1-Yes
0-No
1-Yes
0-No
1-Yes
0-No
1-Yes
0-No
1-Yes
What specific liver condition do you have?
i.
j.
k.
l.
m.
n.
Mood disorder:
Interviewer, read if necessary: Mood Disorders are
defined as a group of disorders characterized by a
disturbance in one's emotional state.
Do you have:
Major depression:
Interviewer, read if necessary: Major
depression is defined as a period of at least two
weeks during which a person loses pleasure in
nearly all activities and/or exhibits a depressed
mood.
Bipolar disorder:
Interviewer, read if necessary: Bipolar Disorder
is characterized by the occurrence of one or more
major depressive episodes accompanied by at
least one manic episode.
Other:
0-No
1-Yes
0-No
1-Yes
0-No
1-Yes
0-No
1-Yes
Are you currently receiving medical treatment for
any of these conditions?
0-No
1-Yes
Uterine fibroids:
Interviewer, read if necessary: Uterine fibroids are
benign (not cancerous) tumors growing in or around a
woman's uterus/womb
Are you currently receiving medical treatment for
this condition?
0-No
1-Yes
0-No
1-Yes
Polycystic ovarian syndrome:
Interviewer, read if necessary: This condition is
characterized by irregular menstrual cycles, body hair,
multiple small cysts on the ovaries (polycystic ovaries),
and infertility. Many women who have this condition
also have diabetes with insulin resistance.
Are you currently receiving medical treatment for
this condition?
0-No
1-Yes
0-No
1-Yes
Endometriosis:
Interviewer, read if necessary: Endometriosis is a
condition where the uterine lining attaches to other
places, such as the ovaries, fallopian tubes, or
abdominal cavity.
Are you currently receiving medical treatment for
this condition?
0-No
1-Yes
0-No
1-Yes
LIFE
$sitecode
User:
System Date:
Mode: Production
Site Name:
Female Medical History B (FMB)
Version: 1.02; 01-19 -06
1.
Have you ever had pelvic inflammatory disease (PID)
or an infection in your pelvis involving your tubes or other
female organs?
a.
0-No
1-Yes
How many times have you been diagnosed with
PID in your lifetime?
Now I am going to ask you about each infection, starting with the last one you experienced.
Infection Number
1
2
3
4
5
2.
In what year was the
infection diagnosed?
(yyyy)
(yyyy)
(yyyy)
(yyyy)
(yyyy)
Have you ever had gynecological surgery or surgery
How was this infection treated?
Treated without hospitalization:
0-No
1-Yes
Hospitalized for medical treatment:
0-No
1-Yes
Hospitalized for surgical treatment:
0-No
1-Yes
Treated without hospitalization:
0-No
1-Yes
Hospitalized for medical treatment:
0-No
1-Yes
Hospitalized for surgical treatment:
0-No
1-Yes
Treated without hospitalization:
0-No
1-Yes
Hospitalized for medical treatment:
0-No
1-Yes
Hospitalized for surgical treatment:
0-No
1-Yes
Treated without hospitalization:
0-No
1-Yes
Hospitalized for medical treatment:
0-No
1-Yes
Hospitalized for surgical treatment:
0-No
1-Yes
Treated without hospitalization:
0-No
1-Yes
Hospitalized for medical treatment:
0-No
1-Yes
Hospitalized for surgical treatment:
0-No
1-Yes
0-No
1-Yes
on your female organs, other than for PID?
a.
How many gynecological surgeries have you had?
Now I am going to ask you about each surgery, starting with the last one that you had.
Surgery Number
What was the surgery for?
When did you have this surgery?
1
(yyyy)
2
(yyyy)
3
3.
(yyyy)
Have you ever been diagnosed with cancer?
a.
0-No
1-Yes
With how many types of cancer have you been
diagnosed?
Now I am going to ask you about each cancer diagnosis, starting with the last one with which you were diagnosed.
Cancer Number
1
2
3
With what type of cancer were you diagnosed?
In what year were you diagnosed?
(yyyy)
(yyyy)
(yyyy)
LIFE
$sitecode
User:
System Date:
Mode: Production
Site Name:
Female Medical History C (FMC)
Version: 2.01; 08-15 -06
1.
Are you currently taking any prescription medications,
including prescription vitamins?
a.
0-No
1-Yes
How many prescription medications?
May I please see your prescription medication bottles so that I can record the names of the medications that you are taking?
Prescription Medication
Prescription Bottle Available
for Confirmation
1
0-No
1-Yes
2
0-No
1-Yes
3
0-No
1-Yes
4
0-No
1-Yes
5
0-No
1-Yes
6
0-No
1-Yes
7
0-No
1-Yes
8
0-No
1-Yes
9
0-No
1-Yes
Interviewer: Advise the woman that she may want to discuss her current medication use with her doctor in relation to becoming
pregnant.
Generic Name
Brand Name
Bismuth Subsalicylate
Metronidazole Tetracycline
hydrochloride
Helidac
Demeclocycline hydrochloride
Declomycin
Meclocycline sulfosalicylate
Meclan
Minocycline hydrochloride
Arestin, Dynacin, Minocin, Vectrin
Tetracycline hydrochloride
b.
Achromycin, Achromycin V, Actisite, Ala-Tet, Aureomycin, Bristacycline, Brodspec,
Cyclopar, Emtet-500, Panmycin, Retet, Robitet, Sumycin, Tetra 500, Tetracap,
Tetrachel, Tetracon, Tetracyn, Tetramed, Tetrex, Topicycline
Interviewer: Is the woman taking any of the
tetracyclines listed above that are contraindicated for
the fertility monitor?
c.
0-No
1-Yes
Specify how many:
d. I see you are currently taking (specify drug name from list), can you please tell me what month and year you began taking this
medication?
Interviewer: Be sure to inform the woman that her fertility monitor may not work correctly while she is taking this medication. Advise
the woman that she may want to dicuss her current medication use with her doctor in relation to becoming pregnant.
Tetracycline Drug Name
Month Initiated
1
2
3
4
5
2.
In the past 3 months, did you take a multivitamin such
as One-a-Day, Theragran -M, or Centrum (as pills, liquids,
or packets) more than once a week?
0-No
Year Initiated
(mm)
(yyyy)
(mm)
(yyyy)
(mm)
(yyyy)
(mm)
(yyyy)
(mm)
(yyyy)
1-Yes
3. In the past 3 months, did you take any of the following supplements more than once a week?
Interviewer: Hand show card to participant.
a.
Fish oil (omega-3 fatty acids):
0-No
1-Yes
b.
Echinacea:
0-No
1-Yes
c.
Ginko biloba:
0-No
1-Yes
d.
Kava, Kava:
0-No
1-Yes
e.
St. John's Wort:
0-No
1-Yes
f.
Protein shakes:
0-No
1-Yes
g.
Steroids:
0-No
1-Yes
h.
Creatine:
0-No
1-Yes
i.
Other supplements:
0-No
1-Yes
What supplements are you taking?
Note to Interviewer: Up to seven other
supplements may be entered as needed.
Now I'd like to ask you a few questions about your body shape and weight over the years.
4.
What is your current age?
a. Not including pregnancies, which of the body shapes (1 through 9) on this card do you feel most resembles your body shape
when you were:
Interviewer: Hand show card to participant
Copyrighted images are reproduced with permission of Dr. AJ Stunkard from Stunkard AJ, Sorenson T, Schulsinger F. Use of the
Danish Adoption Register for the study of obesity and thinness. In: SS Kety, LP Rowland, RL Sidman, SW Matthysse (Eds.) The
Genetics of Neurological and Psychiatric Disorders. New York: Raven Press, 1983, pp. 115-120.
Age
Shape Number
15 to 19 years old
20 to 24 years old
25 to 29 years old
30 to 34 years old
35 to 40 years old
b. Not including pregnancies, what was your average weight when you were:
Age
15 to 19 years old
20 to 24 years old
25 to 29 years old
30 to 34 years old
35 to 40 years old
Weight
(lbs)
(lbs)
(lbs)
(lbs)
(lbs)
5.
What is the most you weighed in the past 12 months?
6.
What is the least you weighed in the past 12 months?
(lbs)
(lbs)
LIFE
$sitecode
User:
System Date:
Mode: Production
Site Name:
Gynecologic History (GHF)
Version: 1.02; 08-15 -06
The next few questions relate to your gynecologic history. If you're not sure of an answer, please tell me your best
estimate.
1.
How old were you when you had your first menstrual
period?
a.
Interviewer, if unknown ask:
What grade of school were you in when you had your
first menstrual period?
2.
When was the first day of your last menstrual period?
Interviewer: Provide calendar, as needed.
3.
In the past 12 months, which of the following best
describes the regularity of your menstrual periods?
(yrs)
(mm/dd/yyyy)
1-Regular - can predict within a few days
2-Not regular - hard to predict
3-It varies
LIFE
$sitecode
User:
System Date:
Mode: Production
Site Name:
Female Reproductive History (RF2)
Version: 2.00; 04-28 -06
The next few questions ask about your reproductive history.
1.
Have you ever been pregnant, regardless of the
outcome of a particular pregnancy?
a.
How many times have you been pregnant?
0-No
1-Yes
Note to Interviewer: Ask the following question if there was at least one live birth.
2.
Are you currently breastfeeding?
0-No
1-Yes
3.
Are you currently using any form of birth control (for
example, pills, IUDs, condoms, or withdrawl)?
0-No
1-Yes
01-Birth control pills
02-Birth control patch
03-Intrauterine device (IUD)
04-Condoms
05-Diaphragm
06-Cervical cap
07-NuvaRing
08-Spermicidal foam or jelly
09-Vaginal sponge
10-Withdrawal
11-Abstinence
12-Rhythm/natural family planning
13-Monitoring your temperature
14-Monitoring your cervical mucus
15-Morning after pill
16-Other method
What other method are you using?
4.
In which month and year did you or your
husband/partner last use any form of birth control?
month (mm)
year (yyyy)
LIFE
$sitecode
User:
System Date:
Mode: Production
Site Name:
Female Pregnancy (PRF)
Version: 2.01; 08-15 -06
Pregnancy Number:
This form is to be completed each time there is a pregnancy reported on the Female Reproductive History section.
1.
Age at beginning of pregnancy:
2.
Was this a planned pregnancy:
a.
3.
0 -No
1 -Yes
How many months did it take for you to achieve pregnancy:
Was this a multiple pregnancy?
a.
4.
(yrs)
0 -No, singleton pregnancy
How many babies were there?
(babies)
How much weight did you gain during the pregnancy?
What was
the
outcome
of this
pregnancy?
1-Live Birth
2Miscarriage
3-Stillbirth
4-Abortion
5Ectopic/tubal
6-Molar
pregnancy
Date of Birth or
Loss
(mm/dd/yyyy)
1 -Yes, multiple pregnancy
How many
weeks
did you
carry
this
pregnancy?
*
(wks)
(lbs)
Was the
baby a girl
or boy?
1-Male
2-Female
How much
did
this child
weigh?
(lbs)
How much
did
this child
weigh?
(oz)
Which of the
following
best
describes
how the
baby was
delivered?
Did You
Breastfeed
This
Child?
For how
long?
(months)
0-No
1-Yes
1-Vaginal
birth after
natural onset
of labor
2-Vaginal
birth after
labor
induction
3-Planned c section
4-Unplanned
c-section
Fetus
A
Fetus
B
Fetus
C
Fetus
D
Fetus
E
* Interviewer: Number of weeks the fetus was carried prior to outcome; the average is 40 weeks long.
5.
6.
What is the name of the hospital or birthing center at which you
delivered?
In which city and state is that hospital or birthing center located?
city:
state:
(xx)
Comments:
LIFE
$sitecode
User:
System Date:
Mode: Production
Site Name:
Female Family Health History (FHF)
Version: 1.01; 01-19 -06
The next few questions relate to your birth. Please answer these questions to the best of your knowledge.
1.
How much did you weigh when you were born?
2.
When you were born, were you:
(lbs)
(oz)
1-Premature-more than 3 weeks early (<37 weeks gestation)
2-Postterm-more than 2 weeks late (>42 weeks gestation)
3-Full term (37-42 weeks gestation)
3.
Were you a twin or a triplet?
1-No, singleton
2-Yes, twin, triplet, or higher order
LIFE
$sitecode
User:
System Date:
Mode: Production
Site Name:
Female Lifestyle Factors (LFF)
Version: 1.03; 01-19 -06
The next set of questions ask about your lifestyle. Please give me your best answer even if you are not entirely sure
about your answer.
1.
During the past 12 months, have you followed a
regular vigorous exercise program? By vigorous
exercise, I mean a leisure time physical activity that
made you sweat and your heart beat faster, such as
tennis, running, bicycling, aerobics, basketball,
swimming, or brisk walking.
Interviewer: Regular is defined as at least once a week
over the past 12 months.
a.
0-No
1-Yes
0-No
1-Yes
0-No
1-Yes
How many days on average do you exercise per
week?
2.
Do you or a member of your household catch fish or
shellfish in local waters including lakes, rivers, streams,
and the Great Lakes?
3.
Do you or a member of your household catch fish or
shellfish in local waters including lakes, rivers, bays, ship
channels, local ocean waters and the Gulf of Mexico?
4. On average, during the past 12 months, how often did you eat each of the following fish or shellfish? As I read each category,
please tell me whether you ate fish or shellfish: Never or almost never, Less than once a month, About once or twice a month,
About once a week, Two or more times a week.
a.
Canned tuna fish
0-Never or almost never
1-Less than once a month
2-About once or twice a month
3-About once a week
4-Two or more times a week
b.
Fish caught in an unknown location (other than
canned tuna fish) that was given to you or purchased
from a vendor, grocery store or restaurant. Please
include both fresh and frozen fish.
0-Never or almost never
1-Less than once a month
2-About once or twice a month
3-About once a week
4-Two or more times a week
c.
Crabs, shrimp or other shellfish caught in an
unknown location that was given to you or purchased
from a vendor, grocery store or restaurant. Please
include both fresh and frozen shellfish.
0-Never or almost never
1-Less than once a month
2-About once or twice a month
3-About once a week
4-Two or more times a week
d.
Fish caught in this area including lakes, rivers,
streams, and the Great Lakes. Please include fish
caught by you or someone you know as well as
locally-caught fish purchased from grocery stores,
vendors, or restaurants.
0-Never or almost never
1-Less than once a month
2-About once or twice a month
3-About once a week
4-Two or more times a week
e.
Fish caught in this area including lakes, rivers,
bays, ship channels, local ocean waters and the Gulf
of Mexico. Please include fish caught by you or
someone you know as well as locally-caught fish
purchased from grocery stores, vendors, or
restaurants.
0-Never or almost never
1-Less than once a month
2-About once or twice a month
3-About once a week
4-Two or more times a week
f.
Crabs, shrimp or other shellfish caught in this area
including lakes, rivers, streams, and the Great Lakes.
Please include fish caught by you or someone you
know as well as locally-caught fish purchased from
grocery stores, vendors, or restaurants.
0-Never or almost never
1-Less than once a month
2-About once or twice a month
3-About once a week
4-Two or more times a week
g.
Crabs, shrimp or other shellfish caught in this area
including lakes, rivers, bays, ship channels, local
ocean waters and the Gulf of Mexico. Please include
fish caught by you or someone you know as well as
locally-caught fish purchased from grocery stores,
vendors, or restaurants.
0-Never or almost never
1-Less than once a month
2-About once or twice a month
3-About once a week
4-Two or more times a week
5.
Out of the past 10 years, how many years have you
eaten fish or shellfish that were caught in local waters,
including lakes, rivers, streams and the Great Lakes?
Please include fish caught by you or someone you know
as well as locally-caught fish purchased from grocery
stores, vendors or restaurants.
6.
Out of the past 10 years, how many years have you
eaten fish or shellfish that were caught in local waters,
including lakes, rivers, bays, ship channels, local ocean
waters and the Gulf of Mexico? Please include fish
caught by you or someone you know as well as locallycaught fish purchased from grocery stores, vendors or
restaurants.
7.
(yrs)
(yrs)
How many types of fish or shellfish caught from this
area did you eat most often over the past 12 months?
Please list the top three types and where they were
caught.
Interviewer: Provide a reference map to help participant
determine where fish were caught.
Type of Fish or Shellfish
1.
2.
Water Body Where Caught
3.
8.
On average during the past 12 months,
approximately how many caffeinated beverages did you
drink in a typical day? (One caffeinated beverage equals
a small cup of coffee or tea, or a can of cola or other
caffeinated soft drink such as Mountain Dew.)
Interviewer: Fill in "0" if none.
(drinks per day)
I am now going to ask you about your use of tobacco and alcohol products. Please give me your best answer even if you
are not entirely sure about your answer.
9.
Have you smoked more than 100 cigarettes
(5 packs) during your lifetime?
10.
How old were you when you first started smoking
regularly, that is daily or nearly everyday?
Interviewer: Fill in "99" if participant never smoked
regularly.
0-No
1-Yes
1-Yes
11.
Have you smoked in the last 12 months?
0-No
12.
Do you smoke now?
0-No
a.
13.
1-Yes
Approximately how many cigarettes do you smoke
on a typical day?
Interviewer: If less than one per day, fill in "1".
When you last smoked, approximately how many
cigarettes did you smoke on a typical day?
Interviewer: If less than one per day, fill in "1".
14.
How old were you when you quit smoking regularly?
15. Have you used any of the following tobacco products at least 20 times in your entire life?
a.
Smoked a pipe?
0-No
1-Yes
b.
Smoked cigars?
0-No
1-Yes
0-No
1-Yes
0-No
1-Yes
c.
Used snuff such as Skoal, Skoal Bandit or
Copenhagen?
d.
Used chewing tobacco such as Redman, Levi
Garrett or Beechnut?
16.
Do you currently smoke a pipe?
0-No
1-Yes, some days
2-Yes, every day
a.
17.
How many pipefuls of tobacco do you typically
smoke per day?
Interviewer: If less than one per day, fill in "1".
Do you currently smoke cigars?
0-No
1-Yes, some days
2-Yes, every day
a.
18.
How many cigars do you typically smoke per day?
Interviewer: If less than one per day, fill in "1".
Do you currently use snuff?
0-No
1-Yes, some days
2-Yes, every day
a.
19.
How many "pinches", "dips", or "rubs" of snuff do
you typically use per day?
Interviewer: If less than one per day, fill in "1".
Do you currently use chewing tobacco?
0-No
1-Yes, some days
2-Yes, every day
a.
20.
How many "plugs," "wads," or "chaws" of chewing
tobacco do you typically use per day?
Interviewer: If less than one per day, fill in "1".
In the past 12 months, have you had at least 12
drinks of any kind of alcoholic beverage?
Interviewer, read if necessary: Alcoholic beverages
include beer, wine, wine coolers, or liquor.
a.
Approximately how often did you drink some kind
of alcoholic beverage?
0-No
1-Yes
1-Less than once a month
2-Once a month
3-Two or three days a month
4-Once a week
5-Two or three times a week
6-Four to six times a week
7-Every day
b.
Approximately how many alcoholic drinks did you
have on a typical occasion?
Interviewer, read if necessary: One drink equals a
can or bottle of beer, a glass of wine, a shot of liquor,
or a mixed drink.
Interviewer: If less than one, fill in "1".
1-One drink
2-Two drinks
3-Three drinks
4-Four drinks
5-Five drinks or more
c.
Was there ever a single occasion during which you
drank five or more alcoholic drinks?
Interviewer, read if necessary: Again, one drink
equals a can or bottle of beer, a glass of wine, a shot
of liquor, or a mixed drink.
0-No
1-Yes
The next four questions ask about your feelings and thoughts during the last month. In each case, please tell me how
often you felt or thought a certain way.
21.
In the last month, how often have you felt that you
were unable to control the important things in your life?
Did you feel that way...
0-Never
1-Almost never
2-Sometimes
3-Fairly often
4-Very often
22.
In the last month, how often have you felt confident in
your ability to handle your personal problems? Did you
feel that way...
0-Never
1-Almost never
2-Sometimes
3-Fairly often
4-Very often
23.
In the last month, how often have you felt that things
were going your way? Did you feel that way...
0-Never
1-Almost never
2-Sometimes
3-Fairly often
4-Very often
24.
In the last month, how often have you felt difficulties
were piling up so high that you could not overcome
them? Did you feel that way...
0-Never
1-Almost never
2-Sometimes
3-Fairly often
4-Very often
LIFE
$sitecode
User:
System Date:
Mode: Production
Site Name:
Female Demographics (DMF)
Version: 3.00; 08-15 -06
Before the end of the interview, I'd like to ask you seven final questions.
1.
2.
What is your date of birth ?
Which of the following categories best describes your
current level of education?
(mm/dd/yyyy)
1-Less than high school graduate
2-High school graduate/GED
3-Some college or technical school
4-College graduate or higher
3.
Which of the following best describes your ethnicity?
1-Hispanic or Latino
2-Not Hispanic or Latino
4. Which of the following best describes your race? (Please indicate all that apply)
a.
American Indian or Alaska Native:
0-No
1-Yes
b.
Asian:
0-No
1-Yes
c.
Black or African American:
0-No
1-Yes
d.
Native Hawaiian or Other Pacific Islander:
0-No
1-Yes
e.
White:
0-No
1-Yes
f.
Other:
0-No
1-Yes
What race best describes you?
5. Please look at this card and tell me which letter best represents your household income (either annual or monthly) before taxes in
the last 12 months, including income from wages, salaries, social security or retirement benefits, help from relatives and other
sources of income. This includes income from all individuals living in your home.
Interviewer: Hand show card to participant.
a - Less than $10,000 (less than $833 per month)
b - $10,000-$19,999 ($833-$1,666 per month)
c - $20,000-$29,999 ($1,667-$2,499 per month)
d - $30,000-$39,999 ($2,500-$3,332 per month)
e - $40,000-$49,999 ($3,333-$4,166 per month)
f - $50,000-$59,999 ($4,167-$4,999 per month)
g - $60,000-$69,999 ($5,000-$5,832 per month)
h - $70,000-$79,999 ($5,833-$6,666 per month)
i - $80,000-$89,999 ($6,667-$7,499 per month)
j - $90,000-$99,999 ($7,500-$8,332 per month)
k - $100,000 or over ($8,333 and over per month)
6.
How many people live in your household?
7.
Do you currently have a source of health insurance?
(e.g. private health insurance, Medicaid, or military or VA
health insurance)
8.
Do you have access to a computer with an Internet
connection?
Please indicate all that apply (read choices):
0-No
0-No
1-Yes
1-Yes
at home
at work
friend or relative
library
Now that we have completed the questionnaire, I am going to take your weight and several other body measurements.
Later I will instruct you in the use of the fertility monitors and the home pregnancy test kits, as well as your daily diary.
Thank you again for your cooperation.
First Measurement
9. Weight:
(kg)
10. Height:
(cm)
11. Waist:
(cm)
12. Hip:
(cm)
Second
Measurement
Third Measurement
Self Reported Weight
(If the participant will not stand on the
scale or if weight is beyond scale limit
of 330 lbs)
(xxx lbs)
(xxx.xx)
(xxx.xx)
(xxx.xx)
(xxx.x)
(xxx.x)
(xxx.x)
(xxx.x)
(xxx.x)
(xxx.x)
(xxx.x)
(xxx.x)
(xxx.x)
Thank you for your cooperation in answering all of my questions. For future purposes, such as sending you newsletters
and providing you with the results of the study, I would like to get some additional contact information from you.
Thank you.
After saving, be sure to obtain the participant's complete contact information.
| File Type | application/pdf |
| File Title | file://K:\DMFFF\seths\PDF_forms\OHF.html |
| Author | seths |
| File Modified | 2008-03-25 |
| File Created | 2008-03-19 |