Questionaire Packets

Form Approved

OMB NO. __________

Exp. Date __________

Survey of Gastrointestinal Function

Appendix E 12

Public Reporting Burden Statement

Public reporting burden of 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)

The following questions will ask about your child’s dietary habits and stool patterns. Please circle your response and place the code for the response to the right of question on the lines provided.

1.	Do you feel like [CHILD]’s diet is...Please read choices below.			_____ _____
	01 = Good 02 = Limited 03 = Poor 98 = Refused 99 = Don’t know
2.	Does your [CHILD] currently have any diet restrictions?			_____ _____
	01 = Yes 02 = No [Go to question 6] 98 = Refused [Go to question 6] 99 = Don’t know [Go to question 6]
	3.	If yes, what are the diet restrictions? Please list all.
	4.	Is [CHILD]’s diet…		_____ _____
		01 = Self restricted 02 = Parent restricted 03 = Medically prescribed 98 = Refused 99 = Don’t know
	5.	Why does [CHILD] have diet restrictions? Please describe symptoms that are affected by food.
		Some examples of symptoms affected by food are stool consistency or frequency (please describe), rash, and behavior.
6.	Has [CHILD] ever had difficulty swallowing on a regular basis? By regular, I mean difficulty swallowing for 2-3 weeks.			_____ _____
	01 = Yes 02 = No [Go to question 11] 98 = Refused [Go to question 11 99 = Don’t know [Go to question 11]
	7.	At what age did [CHILD] have this problem? Please record the age of [CHILD] for each instance that child had this problem.
		a. _____ _____ months or _____ _____years b. _____ _____ months or _____ _____years c. _____ _____ months or _____ _____years
	8.	What consistencies of food did [CHILD] have difficulty swallowing?
		Yes No Refused Don’t know Liquid 01 02 98 99 Solid 01 02 98 99 Nectar 01 02 98 99
	9.	Has your [CHILD] ever had a swallow study?		_____ _____
		01 = Yes 02 = No [Go to question 11] 98 = Refused [Go to question 11] 99 = Don’t know [Go to question 11]
	10.	Was the result of the study normal or abnormal for…
		Normal Abnormal Refused Don’t know Thin liquids 01 02 98 99 Solids 01 02 98 99 Nectar consistency 01 02 98 99
11.	Has your [CHILD] ever rejected certain textures of food for more than 2 to 3 weeks?			_____ _____
	01 = Yes 02 = No [Go to question 14] 98 = Refused [Go to question 14] 99 = Don’t know [Go to question 14]
	12.	At what age? Please record the age of [CHILD] for each instance that [CHILD] rejected textures.
		a. _____ _____ months or _____ _____years b. _____ _____ months or _____ _____years c. _____ _____ months or _____ _____years
	13.	What textures of food did [CHILD] reject?
		Yes No Refused Don’t know Hard to chew 01 02 98 99 (tough meat or raw carrot) Crunchy 01 02 98 99 Mushy 01 02 98 99 Sticky 01 02 98 99 Lumps 01 02 98 99 Mixed texture 01 02 98 99 (mixture of at least one or two of above textures) Other 01 02 98 99 [specify]
14.	Do you feel that your [CHILD] currently has gastrointestinal (bowel) problems on a regular basis? By regular basis I mean more than twice a month.			_____ _____
	01 = Yes 02 = No [Go to question 18] 98 = Refused [Go to question 18] 99 = Don’t know [Go to question 18]
	15.	Does [CHILD] have any of the following gastrointestinal problems?
		Yes No Refused Don’t know Vomiting 01 02 98 99 Diarrhea 01 02 98 99 Loose stools 01 02 98 99 Constipation 01 02 98 99 Loose stools alternating with constipation 01 02 98 99 Abdominal pain with meals 01 02 98 99 Abdominal pain relieved by defecation 01 02 98 99 Pain on stooling 01 02 98 99 Gaseousness 01 02 98 99 Other 01 02 98 99 [specify]
		If yes for any condition in question 15, please complete questions 16 and 17. If no, refused or don’t know for all the above conditions, go to question 18.
	16.	How old was [CHILD] when problem started? Please refer back to the conditions listed in question 16 and place the letter of the condition under “Condition Code” .
		CONDITION CODE AGE PROBLEM STARTED a. _____ _____ months or _____ _____ years b. _____ _____ months or _____ _____ years c. _____ _____ months or _____ _____ years d. _____ _____ months or _____ _____ years e. _____ _____ months or _____ _____ years
		98 = Refused 99 = Don’t know
	17.	How often did [CHILD] have the (PROBLEM)? Would you say it was… (Please refer to the frequency code list below in the shaded box).
		CONDITION CODE FREQUENCY CODE a. _____ _____ b. _____ _____ c. _____ _____ d. _____ _____ e. _____ _____
		01 = 2-4 times 02 = 1 to 2 times per week 03 = 3-6 times per week 04 = Daily 98 = Refused 99 = Don’t know
18.	Do you feel that your [CHILD] had gastrointestinal symptoms in the past that are not present now?			_____ _____
	01 = Yes 02 = No [go to question 21] 98 = Refused [go to question 21] 99 = Don’t know [go to question 21]
	19.	At what age did the symptoms go away?	_____ _____ months or _____ _____ years
	20.	What did you do that made the symptoms go away? Please be specific.
21.	In the past 30 days, has [CHILD] used stool softeners, laxatives or fiber supplements?
		01 = Yes 02 = No [Go to question 11] 98 = Refused [Go to question 11 99 = Don’t know [Go to question 11]
	22.	What was the name of the product(s)
		____________________________________________________
	23.	How many times during the month did [CHILD] use the product?
		Product 1 __________ Product 2___________ Product 3___________
24.	Does your [CHILD] vomit more than once a month when not associated with an illness?			_____ _____
	01 = Yes 02 = No [go to question 23] 98 = Refused [go to question 23] 99 = Don’t know [go to question 23]
	25.	What seems to be causing the vomiting?		_____ _____
		01 = Crying 02 = Stress 03 = Certain smells 0 Cause #1: Cause #2: Cause #3: 4 = Eating too quickly 05 = Eating too much 06 = Reflux 0 7 = Other [specify] 98 = Refused 99 = Don’t know
26.	Is there ever any blood in [CHILD]’s stool?			_____ _____
	01 = Yes 02 = No 98 = Refused 99 = Don’t know
27.	Has there ever been a time when [CHILD]’s stools were greasy, mucousy, frothy, or more foul smelling than usual, more than one time per week for a long period of time?
	Yes No Refused Don’t know Greasy 01 02 98 99 Mucousy 01 02 98 99 Frothy 01 02 98 99 More foul smelling 01 02 98 99
	If yes for any condition in question 24, please answer question 25. If no, refused or don’t know for all conditions, please go to question 26.
	28.	At what age(s)? Please refer to the letter of the conditions in question 24 and place that letter under “Condition Code”.
		CONDITION CODE AGE PROBLEM STARTED a. _____ _____ months or _____ _____ years b. _____ _____ months or _____ _____ years c. _____ _____ months or _____ _____ years d. _____ _____ months or _____ _____ years e. _____ _____ months or _____ _____ years
		98 = Refused 99 = Don’t know
29.	Has your [CHILD] ever had a severe episode of dehydration requiring medical intervention?			_____ _____
	01 = Yes 02 = No [go to question 29] 98 = Refused [go to question 29] 99 = Don’t know [go to question 29]
	30.	How many times has [CHILD] had these dehydration episodes?		_____ _____ # times
	31.	What type of medical intervention did [CHILD] receive during these episodes?
		Episode 1: ___________________________________________ Episode 2: ___________________________________________ Episode 3: ___________________________________________

We are interested in getting some more information about your [CHILD]’s current stool patterns.

32.	How many stools does [CHILD] have per day? Would you say it is…		_____ _____
	01 = 0-1 stools 02 = 2-3 stools 03 = more than 3 stools 98 = Refused 99 = Don’t know
33.	How many stools does [CHILD] have per week? Would you say it was…		_____ _____
	01 = less than 3 stools 02 = 3-7 stools 03 = more than 7 stools 98 = Refused 99 = Don’t know
34.	Does [CHILD] currently wear diapers?		_____ _____
	01 = Yes [ go to question 32 and refer to LIST A] 02 = No [go to question 32 and refer to LIST B] 98 = Refused 99 = Don’t know
	35.	What is the typical consistency of your [CHILD]’s stools? Would you say it was….	_____ _____
		LIST A (use this list if child wears diapers) 01 = Separate hard lumps, like nuts or rabbit pellets 02 = Sausage-shaped but lumpy 03 = Like a sausage or snake but with cracks on its surface, form may be changed slightly by sitting on stool 04 = Like a sausage or snake, smooth and soft, may be deformed by sitting on stool 05 = Soft blobs with clear cut edges, never a sausage 06 = Runny, no form 07 = Watery, no solid pieces, soaks into diaper 98 = Refused 99 = Don’t know LIST B (use this list if child does not wear diapers) 01 = Separate hard lumps, like nuts 02 = Sausage-shaped but lumpy 03 = Like a sausage or snake but with cracks on its surface 04 = Like a sausage or snake, smooth and soft 05 = Soft blobs with clear-cut edges 06 = Fluffy pieces with ragged edges, a mushy stool 07 = Watery, no solid pieces 98 = Refused 99 = Don’t know
36.	Are [CHILD]’s stools like separate hard lumps, fluffy pieces with ragged edges (mushy stool), or watery with no solid pieces two or more times per week?		_____ _____
	01 = Yes 02 = No 98 = Refused 99 = Don’t know
37.	Does [CHILD] alternate between loose stools and hard stools?		_____ _____
	01 = Yes 02 = No 98 = Refused 99 = Don’t know

Survey of GI Function

Appendix E12 Page 8 of 8