22 survey

OMB#: 0925-0584

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 02 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 (0925-0584). Do not return the completed form to this address.

H

OMB#: 0925-0584

Exp. X/XX/XXXX

CHS/SOL Claudication Questionnaire

ID NUMBER:

FORM CODE: CLE VERSION: A 2/25/08

Contact Occasion

SEQ #

Acrostic:

Administrative Information

0a. Completion Date: // 0b. Staff ID:

Month Day Year

Instructions: Enter the answer given by the participant for each response. The special value, "Q", is allowed for cases where the response 'Don’t know/refused' is not listed as an option.

1. Are you age 45 or older?

No 0  END QUESTIONNAIRE

Yes 1

2. Do you get pain or discomfort in either leg on walking?

No 0  END QUESTIONNAIRE

Yes 1

2a. In which leg(s)?

Right leg 1  ADMINISTER QUESTION 3 – QUESTION 7

Left leg 2  GO TO QUESTION 8

Both legs 3  ADMINISTER QUESTION 3 – QUESTION 12

A. Right Leg

3. Does this pain ever begin when you are standing still or sitting?

No 0

Yes 1

4. Does this pain include your calf/calves?

No 0

Yes 1

5. Do you get it when you walk at an ordinary pace on the level?

No 0

Yes 1

6. What do you do if you get it when you are walking?

Stop or slow down 1

Continue on 2

7. What happens to the pain if you stand still?

(Interviewer: response categories refer to pain)

Lessened or relieved 1

Unchanged 2

B. Left Leg

8. Does this pain ever begin when you are standing still or sitting?

No 0

Yes 1

9. Does this pain include your calf/calves?

No 0

Yes 1

10. Do you get it when you walk at an ordinary pace on the level?

No 0

Yes 1

11. What do you do if you get it when you are walking?

Stop or slow down 1

Continue on 2

12. What happens to the pain if you stand still?

(Interviewer: response categories refer to pain)

Lessened or relieved 1

Unchanged 2

Claudication Form (CLE) Page 1 of 2