34.6 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Family Medical History Supplemental SAQ, Phase 2g

OMB Specification

Family Medical History Supplemental SAQ

Event Category:	Time-Based
Event:	42M
Administration:	N/A
Instrument Target:	Biological Mother; Biological Father
Instrument Respondent:	Biological Mother; Biological Father
Domain:	Questionnaire
Document Category:	Questionnaire
Method:	Self-Administered
Mode (for this instrument*):	In-Person, PAPI
OMB Approved Modes:	In-Person, PAPI; Phone, PAPI; Web-Based, CAI
Estimated Administration Time:	6 minutes
Multiple Child/Sibling Consideration:	Per Event
Special Considerations:	N/A
Version:	1.0
MDES Release:	4.0

*This instrument is OMB-approved for multi-mode administration but this version of the instrument is designed for administration in this/these mode(s) only.

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Family Medical History Supplemental SAQ

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

SECOND FULL SIBLING 3

THIRD FULL SIBLING 11

FOURTH FULL SIBLING 19

FOR OFFICIAL USE 27

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Family Medical History Supplemental SAQ

GENERAL PROGRAMMER INSTRUCTIONS:

WHEN PROGRAMMING INSTRUMENTS, VALIDATE FIELD LENGTHS AND TYPES AGAINST THE MDES TO ENSURE DATA COLLECTION RESPONSES DO NOT EXCEED THOSE OF THE MDES. SOME GENERAL ITEM LIMITS USED ARE AS FOLLOWS:

DATA ELEMENT FIELDS	MAXIMUM CHARACTERS PERMITTED	DATA TYPE	PROGRAMMER INSTRUCTIONS
ADDRESS AND EMAIL FIELDS	100	CHARACTER
UNIT AND PHONE FIELDS	10	CHARACTER
_OTH AND COMMENT FIELDS	255	CHARACTER	Limit text to 255 characters
FIRST NAME AND LAST NAME	30	CHARACTER	Limit text to 30 characters
ALL ID FIELDS	36	CHARACTER
ZIP CODE	5	NUMERIC
ZIP CODE LAST FOUR	4	NUMERIC
CITY	50	CHARACTER
DOB AND ALL OTHER DATE FIELDS (E.G., DT, DATE, ETC.)	10	NUMERIC CHARACTER	DISPLAY AS MM/DD/YYYY STORE AS YYYY-MM-DD HARD EDITS: MM MUST EQUAL 01 TO 12 DD MUST EQUAL 01 TO 31 YYYY MUST BE BETWEEN 1900 AND CURRENT YEAR.
TIME VARIABLES	TWO-DIGIT HOUR AND TWO-DIGIT MINUTE, AM/PM DESIGNATION	NUMERIC	HARD EDITS: HOURS MUST BE BETWEEN 00 AND 12; MINUTES MUST BE BETWEEN 00 AND 59

Instrument Guidelines for Participant and Respondent IDs:

PRENATALLY, THE P_ID IN THE MDES HEADER IS THAT OF THE PARTICIPANT (E.G. THE NON-PREGNANT WOMAN, PREGNANT WOMAN, OR THE FATHER).

POSTNATALLY, A RESPONDENT ID WILL BE USED IN ADDITION TO THE PARTICIPANT ID BECAUSE SOMEBODY OTHER THAN THE PARTICIPANT MAY BE COMPLETING THE INTERVIEW. FOR EXAMPLE, THE PARTICIPANT MAY BE THE CHILD AND THE RESPONDENT MAY BE THE MOTHER, FATHER, OR ANOTHER CAREGIVER. THEREFORE, MDES VERSION 2.2 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID (RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT. THIS WILL ALLOW ROCs TO INDICATE WHETHER THE RESPONDENT IS SOMEBODY OTHER THAN THE PARTICIPANT ABOUT WHOM THE QUESTIONS ARE BEING ASKED.

A REMINDER:

ALL RESPONDENTS MUST BE CONSENTED AND HAVE RECORDS IN THE PERSON, PARTICIPANT, PARTICIPANT_CONSENT AND LINK_PERSON_PARTICIPANT TABLES, WHICH CAN BE PRELOADED INTO EACH INSTRUMENT. ADDITIONALLY, IN POST-BIRTH QUESTIONNAIRES WHERE THERE IS THE ABILITY TO LOOP THROUGH A SET OF QUESTIONS FOR MULTIPLE CHILDREN, IT IS IMPORTANT TO CAPTURE AND STORE THE CORRECT CHILD P_ID ALONG WITH THE LOOP INFORMATION. IN THE MDES VARIABLE LABEL/DEFINITION COLUMN, THIS IS INDICATED AS FOLLOWS: EXTERNAL IDENTIFIER: PARTICIPANT ID FOR CHILD DETAIL.

SECOND FULL SIBLING

SFS00100. Please complete this supplemental form if you have more than one full brother or full sister.

 

Please complete the Family Medical History Questionnaire as best you can. If you don't know the answer to a question or do not have all the information you need to complete a question, please contact your biological mother, biological father, full brothers and sisters, or other family members and ask them to help you complete the question. By full brothers and sisters, we mean brothers or sisters who have the same biological mother and father as you.

 

Have any of your full siblings ever been diagnosed with or had any of the following:

 

Begin with the second oldest full sibling.

SFS01000/(FMH_S2_ASTHMA). Asthma?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS02000/(FMH_S2_ECZEMA). Eczema or atopic dermatitis?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS03000/(FMH_S2_ALLERGY). Allergies?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS04000/(FMH_S2_AUTOIMMUNE). Auto-immune disease?

Label	Code	Go To
Yes	1
No	2	FMH_S2_HIGHBP
Don't Know	-2	FMH_S2_HIGHBP

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS05000/(FMH_S2_AUTOIMMUNE_TYP). What was he/she diagnosed with?

Label	Code	Go To
Rheumatoid arthritis	1
Lupus	2
Other	3
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS06000/(FMH_S2_HIGHBP). High blood pressure?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS07000/(FMH_S2_DIABETES). Diabetes?

Label	Code	Go To
Yes	1
No	2	FMH_S2_HIGHCHOL
Don't Know	-2	FMH_S2_HIGHCHOL

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS08000/(FMH_S2_CHILD_DM). Was he/she diagnosed with diabetes as a child or a teenager?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS09000/(FMH_S2_INSULIN). Has he/she ever used insulin shots or an insulin pump to treat diabetes?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS10000/(FMH_S2_HIGHCHOL). High cholesterol?

Label	Code	Go To
Yes	1
No	2
Don't know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS11000/(FMH_S2_HEART). A heart attack?

Label	Code	Go To
Yes	1
No	2	FMH_S2_CATH
Don't Know	-2	FMH_S2_CATH

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS12000/(FMH_S2_HEART_AGE). Did he/she have a heart attack before age 55?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS13000/(FMH_S2_CATH). An angioplasty or coronary bypass surgery?

Label	Code	Go To
Yes	1
No	2	FMH_S2_CANCER
Don't Know	-2	FMH_S2_CANCER

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS14000/(FMH_S2_CATH_AGE). Did he/she have an angioplasty or coronary bypass surgery before age 55?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS15000/(FMH_S2_CANCER). Any type of cancer?

Label	Code	Go To
Yes	1
No	2	FMH_S2_THYROID
Don't Know	-2	FMH_S2_THYROID

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS16000/(FMH_S2_CANCER_TYPE). What type of cancer was he/she diagnosed with?

 

_________________________________________________________________

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS17000/(FMH_S2_THYROID). Thyroid disease?

Label	Code	Go To
Yes	1
No	2	FMH_S2_ADD
Don't Know	-2	FMH_S2_ADD

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS18000/(FMH_S2_UNDERACTIVE). Was he/she diagnosed with an underactive thyroid?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS19000/(FMH_S2_OVERACTIVE). Was he/she diagnosed with an overactive thyroid?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS20000/(FMH_S2_THY_DIS). Was he/she diagnosed with some other thyroid disease?

Label	Code	Go To
Yes	1
No	2	FMH_S2_ADD
Don't Know	-2	FMH_S2_ADD

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS21000/(FMH_S2_THY_DIS_OTH). If yes, specify thyroid disease:

 

___________________________________________________________

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS22000/(FMH_S2_ADD). Attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD)?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS23000/(FMH_S2_AUTISM). Autism, Asperger syndrome, or other autism spectrum disorder?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS24000/(FMH_S2_EATDIS). An eating disorder, such as anorexia or bulimia?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS25000/(FMH_S2_ALCOHOL). Alcoholism?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS26000/(​FMH_S2_BIPOLAR). Bipolar disorder?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS27000/(​FMH_S2_DEPRESSION). Depression other than bipolar disorder?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS28000/(​FMH_S2_SCHIZOPHR). Schizophrenia?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS29000/(​FMH_S2_ANXIETY). Anxiety disorder, such as generalized anxiety disorder (GAD) or obsessive compulsive disorder (OCD)?

Label	Code	Go To
Yes	1
No	2	​FMH_S2_COGDIS
Don't Know	-2	​FMH_S2_COGDIS

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS30000/(​FMH_S2_ANXIETY_TYPE). What type of anxiety disorder was he/she diagnosed with?

 

___________________________________________________________________________

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS31000/(​FMH_S2_COGDIS). Intellectual disability?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS32000/(​​FMH_S2_BIRTH_DEF). A birth defect?

Label	Code	Go To
Yes	1
No	2	​​FMH_S2_GENETIC
Don't Know	-2	​​FMH_S2_GENETIC

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS33000/(​​FMH_S2_BIRTH_DEF_TYPE). What type of birth defect did he/she have?

 

___________________________________________________________________________

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS34000/(​​FMH_S2_GENETIC). Genetic disease?

Label	Code	Go To
Yes	1
No	2	​​FMH_S2_MEDS
Don't Know	-2	​​FMH_S2_MEDS

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS35000/(​​FMH_S2_GENETIC_TYPE). What type of genetic disease was he/she diagnosed with?

 

_______________________________________________________________________________________________

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS36000/(​​FMH_S2_MEDS). Is he/she taking any medications?

Label	Code	Go To
Yes	1
No	2	TFS00100
Don't Know	-2	TFS00100

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

SFS37000/(​​FMH_S2_MEDS_TYPE). What type of medications is he/she taking?

 

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

THIRD FULL SIBLING

TFS00100. Next, has your next oldest full sibling ever been diagnosed with, or had any of the following:

TFS01000/(FMH_S3_ASTHMA). Asthma?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS02000/(FMH_S3_ECZEMA). Eczema or atopic dermatitis?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS03000/(FMH_S3_ALLERGY). Allergies?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS04000/(FMH_S3_AUTOIMMUNE). Auto-immune disease?

Label	Code	Go To
Yes	1
No	2	FMH_S3_HIGHBP
Don't Know	-2	FMH_S3_HIGHBP

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS05000/(FMH_S3_AUTOIMMUNE_TYPE). What was he/she diagnosed with?

Label	Code	Go To
Rheumatoid arthritis	1
Lupus	2
Other	3
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS06000/(FMH_S3_HIGHBP). High blood pressure?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS07000/(FMH_S3_DIABETES). Diabetes?

Label	Code	Go To
Yes	1
No	2	FMH_S3_HIGHCHOL
Don't Know	-2	FMH_S3_HIGHCHOL

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS08000/(FMH_S3_CHILD_DM). Was he/she diagnosed with diabetes as a child or a teenager?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS09000/(FMH_S3_INSULIN). Has he/she ever used insulin shots or an insulin pump to treat diabetes?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS10000/(FMH_S3_HIGHCHOL). High cholesterol?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS11000/(FMH_S3_HEART). A​ heart attack?

Label	Code	Go To
Yes	1
No	2	FMH_S3_CATH
Don't Know	-2	FMH_S3_CATH

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS12000/(FMH_S3_HEART_AGE). Did he/she have a heart attack before age 55?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS13000/(FMH_S3_CATH). An angioplasty or coronary bypass surgery?

Label	Code	Go To
Yes	1
No	2	FMH_S3_CANCER
Don't Know	-2	FMH_S3_CANCER

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS14000/(FMH_S3_CATH_AGE). Did he/she have an angioplasty or coronary bypass surgery before age 55?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS15000/(FMH_S3_CANCER). Any type of cancer?

Label	Code	Go To
Yes	1
No	2	FMH_S3_THYROID
Don't Know	-2	FMH_S3_THYROID

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS16000/(FMH_S3_CANCER_TYPE). What type of cancer was he/she diagnosed with?

 

______________________________________________________________________________________

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS17000/(FMH_S3_THYROID). Thyroid disease?

Label	Code	Go To
Yes	1
No	2	FMH_S3_ADD
Don't Know	-2	FMH_S3_ADD

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS18000/(FMH_S3_UNDERACTIVE). Was he/she diagnosed with an underactive thyroid?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS19000/(FMH_S3_OVERACTIVE). Was he/she diagnosed with an overactive thyroid?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS20000/(FMH_S3_THY_DIS). Was he/she diagnosed with some other thyroid disease?

Label	Code	Go To
Yes	1
No	2	FMH_S3_ADD
Don't Know	-2	FMH_S3_ADD

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS21000/(FMH_S3_THY_DIS_OTH). If yes, specify thyroid disease:

 

____________________________________________________________________________

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS22000/(FMH_S3_ADD). ​Attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD)?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS23000/(FMH_S3_AUTISM). ​Autism, Asperger syndrome, or other autism spectrum disorder?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS24000/(FMH_S3_EATDIS). ​An eating disorder, such as anorexia or bulimia?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS25000/(FMH_S3_ALCOHOL). Alcoholism?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS26000/(FMH_S3_BIPOLAR). Bipolar disorder?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS27000/(FMH_S3_DEPRESSION). Depression other than bipolar disorder?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS28000/(FMH_S3_SCHIZOPHR). Schizophrenia?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS29000/(FMH_S3_ANXIETY). ​Anxiety disorder, such as generalized anxiety disorder (GAD) or obsessive compulsive disorder (OCD)?

Label	Code	Go To
Yes	1
No	2	FMH_S3_COGDIS
Don't Know	-2	FMH_S3_COGDIS

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS30000/(FMH_S3_ANXIETY_TYPE). What type of anxiety disorder was he/she diagnosed with?

 

___________________________________________________________________________

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS31000/(FMH_S3_COGDIS). Intellectual disability?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS32000/(FMH_S3_BIRTH_DEF). B​irth defect?

Label	Code	Go To
Yes	1
No	2	FMH_S3_GENETIC
Don't Know	-2	FMH_S3_GENETIC

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS33000/(FMH_S3_BIRTH_DEF_TYPE). What type of birth defect did he/she have?

 

___________________________________________________________________________

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS34000/(FMH_S3_GENETIC). Genetic disease?

Label	Code	Go To
Yes	1
No	2	FMH_S3_MEDS
Don't Know	-2	FMH_S3_MEDS

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS35000/(FMH_S3_GENETIC_TYPE). What type of genetic disease was he/she diagnosed with?

 

_______________________________________________________________________________________________

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS36000/(FMH_S3_MEDS). Taking any medications?

Label	Code	Go To
Yes	1
No	2	FFS00100
DON'T KNOW	-2	FFS00100

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

TFS37000/(FMH_S3_MEDS_TYPE). What type of medications is he/she taking?

 

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FOURTH FULL SIBLING

FFS00100. Next, has your next oldest full sibling ever been diagnosed with, or had any of the following:

FFS01000/(FMH_S4_ASTHMA). Asthma?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS02000/(FMH_S4_ECZEMA). Eczema or atopic dermatitis?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS03000/(FMH_S4_ALLERGY). Allergies?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS04000/(FMH_S4_AUTOIMMUNE). Auto-immune disease?

Label	Code	Go To
Yes	1
No	2	FMH_S4_HIGHBP
Don't Know	-2	FMH_S4_HIGHBP

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS05000/(FMH_S4_AUTOIMMUNE_TYPE). What was he/she diagnosed with?

Label	Code	Go To
Rheumatoid arthritis	1
Lupus	2
Other auto-immune disease	3
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS06000/(FMH_S4_HIGHBP). High blood pressure?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS07000/(FMH_S4_DIABETES). Diabetes?

Label	Code	Go To
Yes	1
No	2	FMH_S4_HIGHCHOL
Don't Know	-2	FMH_S4_HIGHCHOL

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS08000/(FMH_S4_CHILD_DM). Was he/she diagnosed with diabetes as a child or a teenager?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS09000/(FMH_S4_INSULIN). Has he/she ever used insulin shots or an insulin pump to treat diabetes?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS10000/(FMH_S4_HIGHCHOL). High cholesterol?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS11000/(FMH_S4_HEART). A heart attack?

Label	Code	Go To
Yes	1
No	2	FMH_S4_CATH
Don't Know	-2	FMH_S4_CATH

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS12000/(FMH_S4_HEART_AGE). Did he/she have a heart attack before age 55?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS13000/(FMH_S4_CATH). An angioplasty or coronary bypass surgery?

Label	Code	Go To
Yes	1
No	2	FMH_S4_CANCER
Don't Know	-2	FMH_S4_CANCER

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS14000/(FMH_S4_CATH_AGE). Did he/she have an angioplasty or coronary bypass surgery before age 55?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS15000/(FMH_S4_CANCER). Any type of cancer?

Label	Code	Go To
Yes	1
No	2	FMH_S4_THYROID
Don't Know	-2	FMH_S4_THYROID

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS16000/(FMH_S4_CANCER_TYPE). What type of cancer was he/she diagnosed with?

 

_____________________________________________________________________________________________

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS17000/(FMH_S4_THYROID). Thyroid disease?

Label	Code	Go To
Yes	1
No	2	FMH_S4_ADD
Don't Know	-2	FMH_S4_ADD

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS18000/(FMH_S4_UNDERACTIVE). Was he/she diagnosed with an underactive thyroid?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS19000/(FMH_S4_OVERACTIVE). ​Was he/she diagnosed with an overactive thyroid?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS20000/(FMH_S4_THY_DIS). Was he/she diagnosed with some other thyroid disease?

Label	Code	Go To
Yes	1
No	2	FMH_S4_ADD
Don't Know	-2	FMH_S4_ADD

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS21000/(FMH_S4_THY_DIS_OTH). If yes, specify thyroid disease:

 

______________________________________________________________________________________________

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS22000/(FMH_S4_ADD). Attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD)?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS23000/(FMH_S4_AUTISM). Autism, Asperger syndrome, or other autism spectrum disorder?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS24000/(FMH_S4_EATDIS). An eating disorder, such as anorexia or bulimia?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS25000/(FMH_S4_ALCOHOL). Alcoholism?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS26000/(FMH_S4_BIPOLAR). Bipolar disorder?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS27000/(FMH_S4_DEPRESSION). Depression other than bipolar disorder?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS28000/(FMH_S4_SCHIZOPHR). Schizophrenia?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS29000/(FMH_S4_ANXIETY). ​Anxiety disorder, such as generalized anxiety disorder (GAD) or obsessive compulsive disorder (OCD)?

Label	Code	Go To
Yes	1
No	2	FMH_S4_COGDIS
Don't Know	-2	FMH_S4_COGDIS

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS30000/(FMH_S4_ANXIETY_TYPE). What type of anxiety disorder was he/she diagnosed with?

 

_____________________________________________________________________________________________

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS31000/(FMH_S4_COGDIS). Intellectual disability?

Label	Code	Go To
Yes	1
No	2
Don't Know	-2

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS32000/(FMH_S4_BIRTH_DEF). A birth defect?

Label	Code	Go To
Yes	1
No	2	FMH_S4_GENETIC
Don't Know	-2	FMH_S4_GENETIC

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS33000/(FMH_S4_BIRTH_DEF_TYPE). What type of birth defect did he/she have?

 

________________________________________________________

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS34000/(FMH_S4_GENETIC). Genetic disease?

Label	Code	Go To
Yes	1
No	2	FMH_S4_MEDS
Don't Know	-2	FMH_S4_MEDS

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS35000/(FMH_S4_GENETIC_TYPE). What type of genetic disease was he/she diagnosed with?

 

____________________________________________________________________________________________

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS36000/(FMH_S4_MEDS). Taking any medications?

Label	Code	Go To
Yes	1
No	2	FFS38000
Don't Know	-2	FFS38000

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS37000/(FMH_S4_MEDS_TYPE). What type of medications is he/she taking?

 

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)

FFS38000. For additional siblings, please fill out additional Family Medical History Supplemental Questionnaire(s).

 

Thank you for participating in the National Children's Study and for taking the time to complete this survey.

FOR OFFICIAL USE

FOU01000/(P_ID). Participant ID:_________________________________

FOU02000/(R_P_ID). Respondent ID:_______________________________________

Public reporting burden for this collection of information is estimated to average 6 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 (0925-0593*). Do not return the completed form to this address.