Form 1 MSE-Medication Use Survey -Eng

Public reporting burden for this collection of information is estimated to average 04
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.

OMB#: 0925-0584
Exp. xx/xx/xxxx

HCHS/SOL- Visit 2- Medication Use Survey
FORM CODE: MSE
VERSION: 1, 12/10/13

ID NUMBER:

Contact
Occasion

0

2

SEQ #

ADMINISTRATIVE INFORMATION
0a.

Completion Date:

/

/

0b.

Staff ID:

Instructions: Enter the answer given by the participant for each response. Use the CDART Notelog window to code
'Don’t know/refused, Missing, etc.' for those questions that do not list these as an option.

Reported medication use for specified conditions (Add to medical Hx. Questionnaire)

I. Medication Use Interview
Now I would like to ask about a few specific medications.
1. Were any of the medications you took during the last four weeks for:
a. Asthma
a1.

How long have you been taking this medication?

b. Chronic bronchitis or emphysema
b1.

f.

No 0

How long have you been taking this medication?

h. Heart failure
h1.

No 0

How long have you been taking this medication?

g. Abnormal heart rhythm
g1.

No 0

How long have you been taking this medication?

Chest pain or angina
f1.

No 0

How long have you been taking this medication?

e. High blood cholesterol
e1.

No 0

How long have you been taking this medication?

d. High blood pressure or hypertension
d1.

No 0

How long have you been taking this medication?

c. High blood sugar or diabetes
c1.

No 0

No 0

How long have you been taking this medication?

MSE-Medication Use Survey-12-10-2013.docx

Yes 1
< 1 year,
Yes 1
< 1 year,
Yes 1
< 1 year,
Yes 1
< 1 year,
Yes 1
< 1 year,
Yes 1
< 1 year,
Yes 1
< 1 year,
Yes 1
< 1 year,

Unknown 9
1-5 years,

> 5 years

Unknown 9
1-5 years,

> 5 years

Unknown 9
1-5 years,

> 5 years

Unknown 9
1-5 years,

> 5 years

Unknown 9
1-5 years,

> 5 years

Unknown 9
1-5 years,

> 5 years

Unknown 9
1-5 years,

> 5 years

Unknown 9
1-5 years,

> 5 years

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FORM CODE: MSE
VERSION: 1, 12/10//2013

ID NUMBER:
i.

Blood thinning
i1.

j.

No 0

j1.

No 0

l.

No 0

Yes 1
< 1 year,
Yes 1

How long have you been taking this medication?

Leg pain while walking or claudication
l1.

< 1 year,

How long have you been taking this medication?

k. Mini-stroke or TIA
k1.

Yes 1

How long have you been taking this medication?

Stroke

No 0

< 1 year,
Yes 1

How long have you been taking this medication?

m. Depression

No 0

< 1 year,
Yes 1

m1. How long have you been taking this medication?
n. Anxiety
n1.

No 0

o1.

No 0

Yes 1
< 1 year,
Yes 1

How long have you been taking this medication?

p. A disease of the thyroid
p1.

< 1 year,

How long have you been taking this medication?

o. Glaucoma

No 0

Contact
Occasion

< 1 year,
Yes 1

How long have you been taking this medication?

< 1 year,

0

2

SEQ #

Unknown 9
1-5 years,

> 5 years

Unknown 9
1-5 years,

> 5 years

Unknown 9
1-5 years,

> 5 years

Unknown 9
1-5 years,

> 5 years

Unknown 9
1-5 years,

> 5 years

Unknown 9
1-5 years,

> 5 years

Unknown 9
1-5 years,

> 5 years

Unknown 9
1-5 years,

> 5 years

2. During the last four weeks, did you take any aspirin or aspirin-containing products including Alka-Seltzer,
cold and allergy medication or headache powder? This excludes acetaminophen (for example, Tylenol),
ibuprofen (for example, Advil, Motrin or Nuprin), and naproxen (for example, Aleve).
Show participant List #1: Commonly Used Aspirin or Aspirin-Containing Products
No
Yes
Unknown

0
1
9

 GO TO QUESTION 5
 GO TO QUESTION 5

3. How many days during the last four weeks did you take aspirin or aspirin-containing medication?
Number of days

If number of days equals “00”  GO TO QUESTION 5

4. For what purpose are you taking aspirin? (Interviewer: Do NOT read choices.)
Participant mentioned avoiding heart attack or stroke

1

Participant did not mention avoiding heart attack or stroke 2

MSE-Medication Use Survey-12-10-2013.docx

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FORM CODE: MSE
VERSION: 1, 12/10//2013

ID NUMBER:

Contact
Occasion

0

2

SEQ #

5. During the past four weeks, did you take any [other] medication for arthritis, fever, or muscle aches and
pains, or cramps? (Read bracketed “other” unless no medications were reported.)
No

0

Yes

1

Unknown

9

6. Excluding aspirin, acetaminophen (for example, Tylenol), and corticosteroids (for example prednisone),
are you NOW taking other anti-inflammatory or arthritis medications on a regular basis?
Common
examples are shown on this list.
Show participant List #2: Commonly Used Non-Steroidal Anti-Inflammatory Drugs, NSAIDS
No
Yes
Unknown

0
1
9

 END QUESTIONNAIRE
 END QUESTIONNAIRE

MSE-Medication Use Survey-12-10-2013.docx

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