Form 12 Demographic & Health Questionnaire

Attachment 12: Demographic and Health Questionnaire – FEAST

NCI Food and Eating Assessment Study: Demographic and Health Questionnaire

OMB Control Number: 0925-0605

Expiry Date: 10/31/2011

STATEMENT OF CONFIDENTIALITY

Collection of this information is authorized by The Public Health Service Act, Section 412 (42 USC 285 a-1). Rights of study participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The information collected in this study will be held in professional confidence. Names and other identifiers will be separated from information provided and will not appear in any report of the study. Information provided will be combined for all study participants and report as statistical summaries.

NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN

Public reporting burden for this collection of information is estimated to average 10 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 (0925-0605).

We have a few questions for you. This should take only a few minutes to answer.

1. In general, how would you describe your health? When answering this question, think about how you feel generally.

Excellent …..
Very Good …
Good …………
Fair ……………
Poor ………….

2. What is your current height without shoes on?

Feet Inches

|__| |__|__|

3. What is your current weight without shoes on?

Pounds |_|_|_|

4. During the past 12 months, did you take any vitamin or mineral supplements of any kind? Include vitamin or mineral pills, liquids, or tinctures. Do NOT include vitamin fortified foods.

Yes …………
No ………….

5. Do you get much exercise in things you do for recreation (sport, or hiking, or anything like that), or hardly any exercise, or in between?

Much exercise …………
Moderate exercise ….
Little or no exercise …

5. In your usual day, aside from recreation, are you physically very active, moderately active, or quite inactive?

Very active ……………..
Moderately active …..
Quite inactive …………

5. Have you smoked 100 or more cigarettes during your entire life?

No ………….

Y es ………… Do you currently smoke cigarettes or have you stopped?

Currently smoke……

Stopped …………………

How long ago did you stop?

< 1 year ago………..……..

1-4 years ago ……….……

5-9 years ago …………..…

10 or more years ago …

5. Over the past 12 months, did you drink alcoholic beverages such as beer, wine or wine coolers, liquor or mixed drinks?

No …………. (SKIP TO QUESTION 9)

Y es ………… How often did you drink alcoholic beverages?

Never …….…………………....…..

1 time per month or less …..

2-3 times per month .….…..…

1-2 times per week ……………

1 time per day ………….….…

2-3 times per day …….…….…

4-5 times per day ……….………

5. In the past 7 days, how many times did you eat fast food? Include fast food meals eaten at work, at home, or at fast-food restaurants, carryout or drive through.

__________# OF TIMES IN PAST 7 DAYS

5. What is your current marital status or domestic relationship?

Married ………………………………………………………..
Living as married, in a civil union or domestic partnership … ……………………………………………….
Divorced or separated and not living with a spouse or partner …………………………………………
Widowed ……………………………………………………..
Single, never married …………………………………..

5. What is your current living arrangement?

Alone …………………………………………………………
With spouse/partner … ……………………………..
With other family member or person ………..
Nursing home/Assisted living facility …………
Other ………………………………………………………..

5. What is the highest level of education you have completed?

8^th grade or less

Some high school

Earned GED (Graduate Equivalency Degree)

Completed high school

Some college

Post high-school training other than college (for example vocational or technical training)

Completed a two-year college degree (Associates Arts or Associate Sciences Degree)

Completed a four-year college degree (for example BA, BS, RN degree)

Some graduate or professional school after college but no degree …

Completed graduate/professional school after college …………

5. What is your current annual household income?

Less than $25,000 ………………………………………………….
$25,000 – $49,999 …………………………………………………
$50,000 – $74,999 …………………………………………………
$75,000 – $99,999 …………………………………………………
$100,000 - $149,999 ………………………………………………
$150,000 and more ……………………………………………….

Thank you!