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pdf25-3. AHS Phase IV Health Follow-Up Paper & Pen Participant Survey
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Version date:
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Attachment 25-3: Agricultural Health Study - Phase IV
Participant Follow-Up Questionnaire
Instructions:
● Please use DARK BLUE OR BLACK BALLPOINT PEN.
● Mark only one answer for each question unless otherwise indicated.
● Follow the arrow from your response to find the next question.
● Only write comments in the spaces provided.
● Please keep this questionnaire clean, flat, and dry.
● Do not fold or tear any of the pages.
Fill in the bubbles COMPLETELY for each of the questions in this form.
Like this: Yes
Not like this:
If you have to change an answer, please mark a single horizontal line through it and
then bubble in the correct answer completely.
Like this: Yes
Not like this: YES
When we ask for dates or ages, if you can’t remember the exact year, or how old
you were when something happened, it’s fine to give us your best guess.
When we ask how many years you did something, please round to the nearest
whole number.
OMB No.: 0925-0406
Expiration Date: 09/30/2016
Collection of this information is authorized by The Public Health Service Act ( 2
4 USC 285l). 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 kept private to the extent provided by law. Names and other identifiers will not appear in
any report of the study. Information provided will be combined for all study participants and reported as summaries. You are being contacted by mail to
complete this health follow-up survey because as a member of the Agricultural Health Study your continued involvement can help us learn more about how
agricultural and environmental factors may affect the health of farmers and their families.
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 (0925-0406). Do not return the completed form to this
address.
1
AG1. Is your current home located on a farm? A farm is defined as any place from which
$1,000 or more of agricultural products would normally be sold during the year.
〇 No
Go to AG3
〇 Yes
AG2. In the past 12 months, how many total acres of crops were grown on this farm?
〇 None
〇 Less than 5 acres
〇 5–49 acres
〇 50–199 acres
〇 200–499 acres
〇 500–999 acres
〇 More than 1,000 acres
AG3. What is your primary source of drinking water at your current home?
〇 Private well
〇 Spring
〇 Public or community supply
〇 Bottled water
〇 Rural water
AG4. How many years has this been your primary source of drinking water at your current
house? Please round to the nearest year.
|__|__|__|
# Years
AG5. If you currently use a private well for drinking water, how deep is your private well ?
〇 Less than 50 feet
〇 50–100 feet
〇 101–150 feet
〇 More than 150 feet
〇 Don’t know
〇 Do not use a private well
Page 2 of 40
AG6. In the past 12 months have you personally performed farm work?
〇 No
〇 Yes
Go to AG8
AG7. When was the last year you personally performed farming activities?
|__|__|__|__|
Year
OR
〇 Never did farm work
AG8. In the past 12 months, what major income producing crops did you personally grow,
excluding gardens for personal use? Mark all that apply:
〇 None
〇 Peanuts
〇 Apples
〇 Peppers
〇 Alfalfa
〇 Potatoes
〇 Barley
〇 Pumpkins
〇 Bermuda grass
〇 Rye
〇 Blueberries
〇 Snap beans
〇 Cabbage
〇 Sorghum
〇 Christmas trees
〇 Soybeans
〇 Corn, field
〇 Strawberries
〇 Corn, pop
〇 Sweet potatoes
〇 Corn, seed
〇 Tomatoes
〇 Corn, sweet
〇 Tobacco
〇 Cotton
〇 Wheat
〇 Cucumbers
〇 Other vegetables
〇 Grapes
〇 Other fruits
〇 Hay or forage
〇 Other crops
〇 Melons
〇 Nursery crops
〇 Oats
〇 Peaches
Page 3 of 40
AG9. In the past 12 months, what poultry or livestock did you personally raise for sale?
Mark all that apply:
〇 None
Go to AG12
〇 Beef cattle
〇 Dairy cattle
〇 Hogs/swine
〇 Poultry
〇 Poultry for eggs
〇 Sheep or goats
〇 Horses
〇 Other animals
AG10. In the past 12 months, how many livestock in total (cattle, hogs, sheep, goats, horses),
did you personally raise for sale? Report the most livestock you had at any one time in
the past 12 months.
〇 None
〇 Less than 50
〇 50–99
〇 100–499
〇 500–999
〇 1,000 or more
AG11. In the past 12 months, how many poultry did you personally raise for sale? Report the
most poultry you had at any one time in the past 12 months.
〇 None
〇 Less than 50
〇 50–99
〇 100–499
〇 500–999
〇 1,000–10,000
〇 More than 10,000
Page 4 of 40
AG12. The next questions are about your use of pesticides including herbicides, insecticides,
fungicides, fumigants, or other chemicals used to kill plants, insects, fungi, molds, or
rodents. Please do not include the use of antibiotics, sanitizers, antimicrobial soaps or
fertilizers.
Have you ever personally mixed, loaded, or applied any pesticides for use on crops,
animals, or any other purpose NOT including home and garden use?
〇 No
Go to AG16
〇 Yes
AG13. How many years in your lifetime did you personally mix, load, or apply
pesticides?
|__|__|__|
# Years
AG14. How many days per year on average did you personally mix, load, or apply
pesticides?
|__|__|__|
# Days per year
AG15. In the past 12 months, have you personally mixed, loaded, or applied pesticides?
〇 No
〇 Yes
AG16. Since you started farming, have you ever produced or grown any crops, vegetables,
fruits, livestock, or poultry for sale without using conventional pesticides?
〇 Did not farm
〇 No
Go to AG18
Go to AG18
〇 Yes
AG17. What percent (by acreage) of your current operation does not use conventional
pesticides?
〇 None
〇 Less than 10%
〇 10 to 25%
〇 More than 25%
〇 Not currently farming
Page 5 of 40
AG18. Do you currently have a job other than working on a farm? If you are retired, mark ‘No.’
〇 No
Go to AG20
〇 Yes
AG19. About how many years have you had this job?
〇 Less than 1 year
〇 1 to 5 years
〇 5 to 10 years
〇 10 to 20 years
〇 More than 20 years
AG20. What is your current marital status? Please choose the one response that best
describes your situation.
〇 Single
〇 Married
〇 Living as married
〇 Divorced or separated
〇 Widowed
Tobacco and Alcohol
TA1. Have you smoked a total of 100 cigarettes or more during your lifetime?
〇 No
Go to TA6
〇 Yes
TA2. How old were you when you first started smoking cigarettes?
|__|__|__|
Age
TA3. Do you currently smoke cigarettes?
〇 No
〇 Yes
Go to TA5
Page 6 of 40
TA4. How old were you when you last smoked cigarettes?
|__|__|__|
Age
TA5. Thinking about all the years that you smoked, about how many cigarettes per day
did you usually smoke on days when you smoked?
|__|__|__|
# Cigarettes/day
TA6. Have you ever used chewing tobacco for 6 months or longer?
〇 No
Go to TA10
〇 Yes
TA7. How old were you when you first started using chewing tobacco?
|__|__|__|
Age
TA8. How many total years did you use chewing tobacco?
Please round to the nearest year. If it was less than 1 year, enter ‘1’.
|__|__|__|
# Years
TA9. Do you currently use chewing tobacco?
〇 No
〇 Yes
TA10. Have you ever used snuff for 6 months or longer?
〇 No
Go to TA14
〇 Yes
TA11. How old were you when you first started using snuff?
|__|__|__|
Age
Page 7 of 40
TA12. For how many total years did you use snuff? Please round to the nearest year.
If it was less than 1 year, enter ‘1’.
|__|__|__|
# Years
TA13. Do you currently use snuff?
〇 No
〇 Yes
TA14. The following questions ask about drinking alcoholic beverages including beer or ale,
wine, wine coolers, champagne, mixed drinks, and liquor. When you are asked about a
“drink,” think about a 12-ounce bottle or can of beer, a 5-ounce glass of wine or
champagne, one wine cooler, one shot of liquor, or one mixed drink or cocktail.
Did you ever drink any type of alcoholic beverage?
〇 No
Go to Height and Weight, next page
〇 Yes
TA15. How old were you when you last consumed an alcoholic beverage?
|__|__|__|
Age
TA16. In the past 12 months, how often did you drink any type of alcoholic beverage?
〇 About every day
〇 3 to 5 days a week
〇 1 to 2 days a week
〇 2 to 3 days a month
〇 About once a month
〇 Less than once a month
〇 Never
Go to Height and Weight, next page
Page 8 of 40
TA17. In the past 12 months, on days when you drank alcoholic beverages, how many
drinks did you usually have?
〇 1 to 2
〇 3 to 5
〇 6 to 8
〇 9 to 11
〇 12 or more
TA18. In the past 12 months how often have you had [4 or more (women) / 5 or more
(men)] drinks on a single occasion?
〇 2 or more times per week
〇 About once a week
〇 2 to 3 times a month
〇 Once a month or less
〇 Never
Height and Weight
HW1. What is your current height? Please answer in feet and inches, and round to the nearest
inch.
|__|__|
Feet
|__|__|
Inches
HW2. What is your current weight?
|__|__|__|
# Pounds
HW3. In the past three years, have you lost more than 5 pounds without intending to?
〇 No
Go to Family Medical History, next page
〇 Yes
HW4. In the past three years, how many pounds did you lose without intending to?
|__|__|__|
# Pounds
Page 9 of 40
Family Medical History
FH1. Has anyone in your immediate family related to you by blood (mother, father, sisters,
brothers, or children) ever been diagnosed with asthma?
〇 No
〇 Yes
FH2. Has anyone in your immediate family related to you by blood (mother, father, sisters,
brothers, or children) ever been diagnosed with Parkinson’s Disease?
〇 No
〇 Yes
FH3. Has anyone in your immediate family related to you by blood (mother, father, sisters,
brothers, or children) ever had cancer?
〇 No
Go to Pain Relievers, next page
〇 Yes
FH4. What type(s) of cancer? Mark all that apply.
〇 Bladder
〇 Lymphoma
〇 Bone
〇 Melanoma
〇 Brain
〇 Multiple myeloma
〇 Breast
〇 Ovarian
〇 Cervical
〇 Pancreatic
〇 Colon or rectal
〇 Prostate
〇 Esophagus
〇 Stomach
〇 Kidney
〇 Thyroid
〇 Leukemia
〇 Uterine or endometrial
〇 Liver
〇 Other type of cancer
〇 Lung
〇 Don’t know type
Page 10 of 40
Pain Relievers
PR1. The next questions are about some common pain relievers.
Have you ever taken aspirin regularly (at least twice per week for 6 months or longer)?
〇 No
Go to PR6
〇 Yes
PR2. Do you currently take aspirin regularly (at least twice per week)?
〇 No
〇 Yes
PR3. How many years in total have you taken aspirin regularly (at least twice per
week)?
〇 Less than 1 year
〇 1 to 5 years
〇 5 to 10 years
〇 10 to 15 years
〇 More than 15 years
PR4. When you took aspirin regularly, typically how many days per week did you take
it?
〇 Every day
〇 5 to 6 days per week
〇 3 to 4 days per week
〇 1 to 2 days per week
PR5. Did you typically take baby aspirin or regular aspirin?
〇 Baby aspirin
〇 Regular aspirin
〇 Both
〇 Don’t know
Page 11 of 40
PR6. The next questions are about the pain reliever ibuprofen. Common brand names
include Motrin, Advil, and Nuprin.
Have you ever taken ibuprofen regularly (at least twice per week for 6 months or
longer)?
〇 No
Go to PR10
〇 Yes
PR7. Do you currently take ibuprofen regularly (at least twice per week)?
〇 No
〇 Yes
PR8. How many years in total have you taken ibuprofen regularly (at least twice per
week)?
〇 Less than 1 year
〇 1 to 5 years
〇 5 to 10 years
〇 10 to 15 years
〇 More than 15 years
PR9. When you took ibuprofen regularly, typically how many days per week did you
take it?
〇 Every day
〇 5 to 6 days per week
〇 3 to 4 days per week
〇 1 to 2 days per week
Page 12 of 40
PR10. Have you ever taken Tylenol or acetaminophen regularly (at least twice per week for 6
months or longer)?
〇 No
Go to General Health
〇 Yes
PR11. Do you currently take Tylenol or acetaminophen regularly (at least twice per
week)?
〇 No
〇 Yes
PR12. How many years in total have you taken Tylenol or acetaminophen regularly (at
least twice per week)?
〇 Less than 1 year
〇 1 to 5 years
〇 5 to 10 years
〇 10 to 15 years
〇 More than 15 years
PR13. When you took Tylenol or acetaminophen regularly, typically how many days per
week did you take it?
〇 Every day
〇 5 to 6 days per week
〇 3 to 4 days per week
〇 1 to 2 days per week
General Health
GH1. About how long has it been since you last saw or talked to a doctor or other health care
professional about your health? Would you say...
〇 Never
〇 Less than 1 year ago
〇 1 to 2 years ago
〇 2 to 5 years ago
〇 More than 5 years ago
Page 13 of 40
GH2a. MEN: When did you last have a PSA test (a blood test used to check men for prostate
cancer) or a digital rectal exam to examine the prostate gland?
GH2b. WOMEN: When did you last have a mammogram (an x-ray of each breast to look for
breast cancer)?
〇 Never
〇 Less than 1 year ago
〇 1 to 2 years ago
〇 2 to 5 years ago
〇 More than 5 years ago
The next few questions ask about colon and bowel health.
GH3. When did you last have a sigmoidoscopy or colonoscopy, exams in which a tube is
inserted in the rectum to view the colon for signs of cancer or other health problems?
〇 Never
〇 Less than 1 year ago
〇 1 to 2 years ago
〇 2 to 5 years ago
〇 More than 5 years ago
GH4. Have you ever taken any over-the-counter or prescribed medicines more than a few
times a year to help with bowel movements?
〇 No
〇 Yes
GH5. Typically, how often do you have bowel movements?
〇 Two or more times per day
〇 Once per day
〇 5 to 6 times per week
〇 3 to 4 times a week (about once every other day)
〇 Less than three times per week
Men go to Health Conditions on page 19.
Women go to Women’s reproductive health on the next page.
Page 14 of 40
Women’s reproductive health
RH1. How many times have you been pregnant in your lifetime? Please include live and
stillbirths as well as any pregnancies that ended in a loss of pregnancy or abortion.
If you have never been pregnant, please enter ‘0’.
|__|__|
# Pregnancies
〇 None
Go to RH5
RH2. How many of your pregnancies ended in live birth or still birth? If none, please
enter ‘0’.
|__|__|
# births
〇 None
Go to RH5
RH3. How old were you the first time you had a pregnancy ending in a live birth or
stillbirth?
|__|__|__|
Age
RH4. How old were you the last time you had a live birth or stillbirth?
|__|__|__|
Age
RH5. Have you ever had any of the following surgeries?
Mark an answer for each row below:
No
Yes
a. hysterectomy (a surgical procedure to remove the uterus)
without removing ovaries
〇
〇
b. hysterectomy (a surgical procedure to remove the uterus)
with removal of one or more ovaries
〇
〇
c. Separate surgery to remove one or both ovaries
〇
〇
Page 15 of 40
RH6. Have you had a menstrual period in the past 12 months?
〇 No
〇 Yes
Go to RH9
FOR WOMEN WHO HAVE NOT HAD A PERIOD IN THE PAST 12 MONTHS:
RH7. Why did your periods stop? Please choose the one response that best describes your
situation.
〇 My periods stopped on their own (naturally)
〇 My periods stopped after my uterus or ovaries were removed
〇 My periods stopped due to radiation or chemotherapy
〇 My periods stopped because I am using the kind of birth control that
eliminates periods
〇 My periods stopped because I am pregnant or breastfeeding
〇 My periods stopped for some other reason
RH8. How old were you when you had your last menstrual period?
|__|__|__|
Age
Go to RH11
Page 16 of 40
FOR WOMEN WHO HAVE HAD A PERIOD IN THE PAST 12 MONTHS:
RH9. What statement best describes you?
〇 My periods have not stopped and I am not taking
hormone replacement therapy
Go to RH11
〇 My periods have not stopped but I am taking
hormone replacement therapy
Go to RH11
〇 My periods stopped, but restarted when I began hormone
replacement therapy
Go to RH11
〇 My periods stopped sometime in the last 12 months
RH10. IF PERIODS STOPPED IN PAST 12 MONTHS: Why did they stop sometime
in the last 12 months? Please choose the one response that best describes
your situation.
〇 My periods stopped on their own (naturally)
〇 My periods stopped after my uterus or ovaries were removed
〇 My periods stopped due to radiation or chemotherapy
〇 My periods stopped because I am using the kind of birth control that
eliminates periods
〇 My periods stopped because I am pregnant or breastfeeding
〇 My periods stopped for some other reason
RH11. Have you ever used estrogen or progesterone for hormone replacement therapy?
Common brand and generic names include Premarin, Estrace, estradiol, Provera, and
medroxyprogesterone.
〇 No
Go to RH17
〇 Yes
RH12. How old were you when you first used prescribed hormone replacement therapy?
|__|__|__|
Age
Page 17 of 40
RH13. How many years altogether have you used prescribed hormone replacement
therapy? Do not count years that you stopped. Please round to the nearest year.
If it was less than 1 year, enter ‘1’.
|__|__|__|
# Years
RH14. Are you currently using prescribed hormone replacement therapy?
〇 No
〇 Yes
RH15. Was the prescribed hormone replacement that you took the most often...
〇 A combination of estrogen and progesterone
〇 Estrogen only
〇 Progesterone only
〇 Something else
〇 Don’t know
RH16. Have you ever taken birth control pills for any reason?
〇 No
Go to Health Conditions, next page
〇 Yes
RH17. How old were you when you first took birth control pills?
|__|__|__|
Age
RH18. How many years altogether did you take birth control pills? Do not count years
that you stopped. Please round to the nearest year. If it was less than 1 year,
enter ‘1’.
|__|__|
# Years
Page 18 of 40
Health Conditions
These questions are about medical conditions you may have had. Please only report
conditions that were diagnosed by a doctor or other health professional. We are interested in
what age you were diagnosed with a specific condition. If you do not know your exact age,
please give us your best guess.
HC1. Have you ever been diagnosed with Parkinson’s disease?
〇 No
Go to HC6
〇 Yes
HC2. How old were you when you were first diagnosed with Parkinson’s disease?
|__|__|__|
Age
HC3. Was the diagnosis made or confirmed by a neurologist or movement disorder
specialist?
〇 No
〇 Yes
HC4. Do you currently take any prescribed medicines for Parkinson’s disease?
Examples include:
Carbidopa or levodopa (brand names such as Sinemet, Stalevo, or Parcopa);
Mirapex or Pramipexole; Requip or Ropinirole; Permax or Pergolide
〇 No
Go to HC6
〇 Yes
HC5. Did your symptoms ever improve after taking any of these medicines?
〇 No
〇 Yes
Page 19 of 40
HC6. Have you ever been diagnosed with depression?
〇 No
Go to HC9
〇 Yes
HC7. How old were you when you were first diagnosed with depression?
|__|__|__|
Age
HC8. Are you currently taking any prescribed medicines for depression?
〇 No
〇 Yes
HC9. Have you ever been diagnosed with high blood pressure or hypertension?
(WOMEN: Please do not count this condition if it occurred only during pregnancy.)
〇 No
Go to HC12
〇 Yes
HC10. How old were you when you were first diagnosed with high blood pressure or
hypertension?
|__|__|__|
Age
HC11. Do you currently take any prescribed medicines for high blood pressure or
hypertension?
〇 No
〇 Yes
Page 20 of 40
HC12. Have you ever been diagnosed with a heart attack (or myocardial infarction)?
〇 No
Go to HC14
〇 Yes
HC13. How old were you when you were first diagnosed with a heart attack (or
myocardial infarction)?
|__|__|__|
Age
HC14. Have you ever been diagnosed with heart failure?
〇 No
Go to HC16
〇 Yes
HC15. How old were you when you were first diagnosed with heart failure?
|__|__|__|
Age
HC16. Have you ever been diagnosed with a stroke? Do not include TIAs or mini-strokes.
〇 No
Go to HC18
〇 Yes
HC17. How old were you when you were first diagnosed with a stroke?
|__|__|__|
Age
HC18. Have you ever been diagnosed with asthma?
〇 No
Go to HC23
〇 Yes
HC19. How old were you when you were first diagnosed with asthma?
|__|__|__|
Age
Page 21 of 40
HC20. Do you still have asthma?
〇 No
〇 Yes
Go to HC22
HC21. How old were you when your asthma stopped?
|__|__|__|
Age
HC22. During the past 12 months, have you used any prescribed medicines for asthma,
including an inhaler?
〇 No
〇 Yes
HC23. Have you ever been diagnosed with Farmer’s Lung?
〇 No
Go to HC25
〇 Yes
HC24. How old were you when you were first diagnosed with Farmer’s Lung?
|__|__|__|
Age
HC25. Have you ever been diagnosed with idiopathic pulmonary fibrosis?
〇 No
Go to HC27
〇 Yes
HC26. How old were you when you were first diagnosed with idiopathic pulmonary
fibrosis?
|__|__|__|
Age
Page 22 of 40
HC27. Have you ever been diagnosed with emphysema?
〇 No
Go to HC29
〇 Yes
HC28. How old were you when you were first diagnosed with emphysema?
|__|__|__|
Age
HC29. Have you ever been diagnosed with chronic bronchitis?
〇 No
Go to HC31
〇 Yes
HC30. How old were you when you were first diagnosed with chronic bronchitis?
|__|__|__|
Age
HC31. Have you ever been diagnosed with chronic obstructive pulmonary disease
(COPD)?
〇 No
Go to HC33
〇 Yes
HC32. How old were you when you were first diagnosed with chronic obstructive
pulmonary disease (COPD)?
|__|__|__|
Age
Page 23 of 40
HC33. Have you ever been diagnosed with diabetes (WOMEN: other than when pregnant)?
〇 No
Go to HC37
〇 Yes
HC34. How old were you when you were first diagnosed with diabetes?
|__|__|__|
Age
HC35. Do you currently take any prescribed medicines for diabetes?
〇 No
Go to HC37
〇 Yes
HC36. Do you currently take insulin?
〇 No
〇 Yes
HC37. Have you ever been diagnosed with thyroid disease or thyroid problems?
〇 No
Go to HC46
〇 Yes
HC38. Have you ever been diagnosed with an overactive thyroid (hyperthyroidism)?
〇 No
Go to HC42
〇 Yes
HC39. How old were you when you were first diagnosed with an overactive
thyroid?
|__|__|__|
Age
Page 24 of 40
HC40. Was this Graves’ disease or some other type of thyroid condition that
caused the overactive thyroid gland?
〇 Graves’ disease
〇 Other overactive thyroid condition
〇 Don’t know
HC41. Do you currently take any prescribed medicines for an overactive thyroid?
〇 No
〇 Yes
HC42. Have you ever been diagnosed with an underactive thyroid (hypothyroidism)?
〇 No
Go to HC46
〇 Yes
HC43. How old were you when you were first diagnosed with an underactive
thyroid (hypothyroidism)?
|__|__|__|
Age
HC44. Was this thyroiditis, sometimes called Hashimoto’s thyroiditis, or was this
some other type of thyroid condition that caused the underactive thyroid
gland?
〇 Thyroiditis (also called Hashimoto’s thyroiditis)
〇 Other underactive thyroid condition
〇 Don’t know
HC45. Do you currently take any prescribed medicines for an underactive
thyroid?
〇 No
〇 Yes
Page 25 of 40
HC46. Have you ever been diagnosed with kidney stones?
〇 No
Go to HC49
〇 Yes
HC47. How old were you when you were first diagnosed with kidney stones?
|__|__|__|
Age
HC48. How many times have you had kidney stones?
|__|__|__|
# Times
HC49. Have you ever been diagnosed with kidney disease? Do not include kidney stones.
〇 No
Go to HC53
〇 Yes
HC50. How old were you when you were first diagnosed with kidney disease?
|__|__|__|
Age
HC51. Have you ever been treated with dialysis?
〇 No
Go to HC53
〇 Yes
HC52. How old were you when you were first treated with dialysis?
|__|__|__|
Age
Page 26 of 40
HC53. Have you ever been diagnosed with rheumatoid arthritis (an autoimmune disease)?
Do not include osteoarthritis (the most common type of arthritis).
〇 No
Go to HC58
〇 Yes
HC54. How old were you when you were first diagnosed with rheumatoid arthritis?
|__|__|__|
Age
HC55. Did you see a rheumatologist (a physician who specializes in bone, joint, and
skin diseases) for rheumatoid arthritis?
〇 No
〇 Yes
HC56. Have you ever taken any of the following medicines for rheumatoid arthritis?
Mark an answer for each row below:
No
Yes
Don’t
know
a. Hydroxychloroquine or chloroquine (Plaquenil),
Methotrexate (Rheumatrex or Trexall)
〇
〇
〇
b. Leflunomide (Arava), Sulfasalazine (Azulfidine)
〇
〇
〇
c. Biologics, given by infusion or injection, such as
infliximab (Remicade), adalimumab (Humira),
etanercept (Enbrel), rituximab (Rituxan).
Do not include steroid injections in the joints)
〇
〇
〇
HC57. Are you currently taking any of these medicines for rheumatoid arthritis?
〇 No
〇 Yes
Page 27 of 40
HC58. Have you ever been diagnosed with lupus?
〇 No
Go to HC63
〇 Yes
HC59. How old were you when you were first diagnosed with lupus?
|__|__|__|
Age
HC60. Did you see a rheumatologist (a physician who specializes in bone, joint, and
skin diseases) for lupus?
〇 No
〇 Yes
HC61. Have you ever taken any of the following medicines for lupus?
Mark an answer for each row below:
No
Yes
Don’t
know
a. Hydroxychloroquine or chloroquine (Plaquenil),
Methotrexate (Rheumatrex or Trexall)
〇
〇
〇
b. Azathioprine (Imuran), Cellcept, Cytoxan, or
Cyclosporine
〇
〇
〇
c. Biologics, given by infusion or injection, such as
belimumab (Benlysta). Do not include steroid
injections in the joints or skin)
〇
〇
〇
HC62. Are you currently taking any of these medicines for lupus?
〇 No
〇 Yes
Page 28 of 40
HC63. Have you ever been diagnosed with Sjögren’s disease?
〇 No
Go to HC68
〇 Yes
HC64. How old were you when you were first diagnosed with Sjögren’s disease?
|__|__|__|
Age
HC65. Did you see a rheumatologist (a physician who specializes in bone, joint, and
skin diseases) or ear, nose and throat specialist for Sjögren’s disease?
〇 No
〇 Yes
HC66. Have you ever taken any of the following medicines for Sjögren’s disease?
Mark an answer for each row below:
No
Yes
Don’t
know
a. Hydroxychloroquine or chloroquine (Plaquenil),
or Methotrexate (Rheumatrex or Trexall)
〇
〇
〇
b. Pilocarpine (Salagen) or Cevimeline (Evoxac),
or Cyclosporine Opthalmic (Restasis)
〇
〇
〇
c. Biologics, given by infusion or injection, such
as Rituximab (Rituxan)
〇
〇
〇
HC67. Are you currently taking any of these medicines for Sjögren’s disease?
〇 No
〇 Yes
Page 29 of 40
HC68. Have you ever been diagnosed with sarcoidosis?
〇 No
Go to HC70
〇 Yes
HC69. How old were you when you were first diagnosed with sarcoidosis?
|__|__|__|
Age
HC70. Have you ever been diagnosed with pesticide poisoning?
〇 No
Go to HC73
〇 Yes
HC71. How old were you when you were first diagnosed with pesticide poisoning?
|__|__|__|
Age
HC72. How many times have you been poisoned by pesticides?
|__|__|
# Times
HC73. Have you ever had a head injury requiring medical attention?
〇 No
Go to HC77
〇 Yes
HC74. Have you ever had a head injury that resulted in loss of consciousness (got
knocked out)?
〇 No
Go to HC77
〇 Yes
HC75. How old were you the first time you lost consciousness from a head
injury?
|__|__|__|
Age
Page 30 of 40
HC76. How many times have you had a head injury with loss of consciousness?
|__|__|
# Times
HC77. Have you ever had hay fever, seasonal allergies or allergic rhinitis, whether or not it
was diagnosed by a doctor?
〇 No
Go to Symptoms
〇 Yes
HC78. In the past 12 months have you taken any prescribed or over-the-counter
medicines for these allergies?
〇 No
〇 Yes
Symptoms
SM1. The next few questions ask about respiratory symptoms that you may have experienced
in the past 12 months.
Do you usually cough during the day or at night, four or more days per week?
〇 No
Go to SM4
〇 Yes
SM2. Do you usually cough like this at least three months per year?
〇 No
〇 Yes
SM3. How many years have you had this cough?
|__|__|__|
# Years
SM4. Do you usually bring up phlegm when you cough? Don’t count phlegm from your nose
as a result of seasonal allergies or colds.
〇 No
〇 Yes
Page 31 of 40
SM5. During the past 12 months, about how many days of wheezing or whistling in your chest
have you had?
〇 None
〇 1 to 2 days
〇 3 to 6 days
〇 7 to 12 days
〇 13 or more days
SM6. Are you troubled by shortness of breath when hurrying on level ground or walking up a
slight hill or up a flight of stairs?
〇 No
〇 Yes
SM7. Do your hands shake or tremble?
〇 No
〇 Yes
SM8. Do your arms or legs shake?
〇 No
〇 Yes
SM9. Is your handwriting smaller than it once was?
〇 No
〇 Yes
SM10. Is your voice softer than it once was?
〇 No
〇 Yes
Page 32 of 40
SM11. Do your feet shuffle when you walk?
〇 No
〇 Yes
SM12. Do you have trouble rising from a chair?
〇 No
〇 Yes
SM13. Do you suffer from a loss of sense of smell or a significantly decreased sense of smell?
〇 No
Go to SM15
〇 Yes
SM14. When did you start losing your sense of smell?
〇 Less than 1 year ago
〇 1 to 5 years ago
〇 5 to 10 years ago
〇 More than 10 years ago
SM15. Have you ever been told, or suspected yourself, that you seem to “act out your dreams”
while sleeping? For example, punching or flailing arms in the air, shouting, or screaming
while asleep.
〇 No
Go to SM18
〇 Yes
SM16. When did you first “act out your dreams”?
〇 Less than 1 year ago
〇 1 to 5 years ago
〇 5 to 10 years ago
〇 More than 10 years ago
Page 33 of 40
SM17. How often have you “acted out your dreams”?
〇 Less than 3 times in your life
〇 Less than once a month
〇 1 to 3 times a month
〇 Once a week
〇 More than once per week
〇 Don’t know
SM18. Have you ever had joint swelling in your wrists, fingers, elbows, or knees lasting six or
more weeks?
〇 No
〇 Yes
SM19. Have you ever had joint stiffness in the mornings, lasting at least 1 hour, for at least six
weeks? Do not include stiffness that is related to or due to an injury or surgery.
〇 No
〇 Yes
SM20. Have you ever in your life had a period lasting two weeks or longer when most of the
day you felt uninterested in things (like hobbies, work, or other things you usually enjoy)
for most of the day?
〇 No
〇 Yes
SM21. Did you ever have a time in your life when you were a “worrier” – that is, when you
worried a lot more about things than other people with the same problems as you?
〇 No
〇 Yes
Page 34 of 40
SM22. Over the last two weeks, how often
have you been bothered by...
Not at
all
Several
days
More than
half the
days
Nearly
every
day
a. having little interest or pleasure in doing
things
〇
〇
〇
〇
b. feeling down, depressed, or hopeless
〇
〇
〇
〇
c. having trouble falling or staying asleep, or
sleeping too much
〇
〇
〇
〇
d. feeling tired or having little energy
〇
〇
〇
〇
e. feeling nervous, anxious, or on edge
〇
〇
〇
〇
f. not being able to stop or control worrying
〇
〇
〇
〇
SM23. How many hours of sleep do you get each night?
〇 Less than 6 hours
〇 6 hours to 6 hours and 59 minutes
〇 7 hours to 7 hours and 59 minutes
〇 8 hours to 8 hours and 59 minutes
〇 9 hours or more
SM24. How often do you feel sleepy most of the day?
〇 Never
〇 Less than one day per month
〇 1 to 3 days per month
〇 1 to 2 days per week
〇 3 to 5 days per week
〇 6 to 7 days per week
Page 35 of 40
SM25. Do you nap during the day?
〇 No
Go to SM27
〇 Yes
SM26. How long do you nap?
〇 Less than 30 minutes
〇 30 minutes to 1 hour
〇 More than 1 hour
SM27. Date this form was completed:
|__|__| / |__|__| / |__|__|__|__|
Month
Day
Year
Page 36 of 40
Contact Information
We would like to make sure that our records include your accurate contact information should
we need to contact you in the future.
1.
Please provide your updated phone numbers and e-mail address.
Phone Numbers:
HOME:
CELL:
OTHER:
(|__|__|__|)
(|__|__|__|)
(|__|__|__|)
|__|__|__| - |__|__|__|__|
|__|__|__| - |__|__|__|__|
|__|__|__| - |__|__|__|__|
□ Home
What is the best number to reach you?
□ Cell
□ Other
E-mail Address: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
E-mail Address: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
E-mail Address: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
What is your preferred method of contact?
2.
□ Phone
□ Email
□ Mail
Our records indicate that your current address is:
XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX
Is this correct?
□
□
No Please enter corrections in the space provided below
Yes Question 3
|__|__|__|__|__|__|__|__|__|
Street Number
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Street Name
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
City
In what year did you move into your current address?
Page 37 of 40
|__|__|__|__|__|__|
Apt. Number
|__|__|
State
|__|__|__|__|
Year
|__|__|__|__|__|
Zip Code
3.
In case we are unable to reach you, please list the name and contact information for two
people who do not live with you but will know how to reach you in case you move. It is best
to give the name of someone who is about your age or younger.
Person 1:
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
First name
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Last name
Relationship to you: ___________________________________________________________
Phone Numbers:
HOME:
CELL:
OTHER:
(|__|__|__|)
(|__|__|__|)
(|__|__|__|)
|__|__|__| - |__|__|__|__|
|__|__|__| - |__|__|__|__|
|__|__|__| - |__|__|__|__|
Address:
|__|__|__|__|__|__|__|__|__|
Street Number
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Street Name
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
City
|__|__|__|__|__|__|
Apt. Number
|__|__|
State
|__|__|__|__|__|
Zip Code
Person 2:
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
First name
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Last name
Relationship to you: ___________________________________________________________
Page 38 of 40
Person 2 (continued):
Phone Numbers:
HOME:
CELL:
OTHER:
(|__|__|__|)
(|__|__|__|)
(|__|__|__|)
|__|__|__| - |__|__|__|__|
|__|__|__| - |__|__|__|__|
|__|__|__| - |__|__|__|__|
Address:
|__|__|__|__|__|__|__|__|__|
Street Number
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Street Name
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
City
Page 39 of 40
|__|__|__|__|__|__|
Apt. Number
|__|__|
State
|__|__|__|__|__|
Zip Code
4.
Lastly, we are interested in hearing about what you would like to gain from the Agricultural
Health Study. What findings are you interested in learning about from this study?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Page 40 of 40
| File Type | application/pdf |
| File Title | Microsoft Word - AHSPhaseIV_OMB_TitlePage_PptPaperPen_21Mar2016 |
| Author | erevak |
| File Modified | 2016-03-21 |
| File Created | 2016-03-21 |