Baseline Questionnaire

Attachment J: BASELINE MEASURES FOR MAIN STUDY (A-CASI)

Form Approved

OMB No. __0920-XXX__

Exp. Date _xx/xx/20xx_

Respondent No. ___________

A. Quality of Life: SF-12 Health Survey (Ware, Kisinski, & Keller, 1996)

Please see SF-12^® in Attachment L.

B. Disability

1. During the 30 days from { date from 30 days before baseline interview to baseline interview }, about how many days did you miss work because of an illness or injury (do not include maternity leave)? If patient delays answer, audio cues for patient to give best guess.

____ days

____ Don’t remember

____ Don’t work outside the house

2. During the 30 days from { date from 30 days before baseline interview to baseline interview }, about how many days were you unable to do your housework tasks because of an illness or injury (do not include maternity leave)?

____ days

____ Don’t remember

C. Current signs or symptoms

Are you frequently bothered by any of the following problems?
1. Arthritis or pain, aching, stiffness, or swelling in or around a joint (knee, elbow, hip, fingers, etc.)	YES	NO
2. Neck pain or low back pain	YES	NO
3. Stomach or abdominal pain	YES	NO
4. Pelvic pain	YES	NO
5. Menstrual cramps or other problems with your periods	YES	NO
6. Pain or problems during sexual intercourse	YES	NO
7. Vaginal bleeding or any kind of discharge	YES	NO
8. Vaginal or genital infection	YES	NO
9. Headaches or migraines	YES	NO
10. Nausea, gas, or indigestion	YES	NO
11. Constipation	YES	NO
12. Vomiting or diarrhea	YES	NO
13. Trouble falling asleep or staying asleep on 3 or more nights a week.	YES	NO

D. Health Care Utilization outside Bureau

1. In the past year, have you been admitted to the hospital, stayed at least one night – not just in an emergency room hospitalized in a hospital or clinic other than here at Stroger?

___ Yes  How many times? ____

___ No

2. In the past year, have you gone to an Emergency Department Room other than here at our ER room at County (Stroger)?

___ Yes  How many times? ____

 Were any of these times because of an injury (like a cut, burn, fracture, bloody nose or mouth)? ___ Yes __ NO

___ No

E. Mental Health (SRQ-20; WHO, 1994)

1. Do you often have headaches? YES NO

2. Is your appetite poor? YES NO

3. Do you sleep badly? YES NO

4. Are you easily frightened? YES NO

5. Do your hands shake? YES NO

6. Do you feel nervous, tense or worried? YES NO

7. Is your digestion poor? YES NO

8. Do you have trouble thinking clearly? YES NO

9. Do you feel unhappy? YES NO

10. Do you cry more than usual? YES NO

11. Do you find it difficult to enjoy your daily activities? YES NO

12. Do you find it difficult to make decisions? YES NO

13. Is your daily work suffering? YES NO

14. Are you unable to play a useful part in life? YES NO

15. Have you lost interest in things? YES NO

16. Do you feel you are a worthless person? YES NO

17. Has the thought of ending your life been on your mind? YES NO

18. Do you feel tired all the time? YES NO

19. Do you have uncomfortable feelings in your stomach? YES NO

20. Are you easily tired? YES NO

F. Partner Violence Screen (Feldhaus, et al., 1997) ONLY IN ARM 1

These next questions refer to violence by intimate partners. Violence is a problem for many women. Because it affects their health, we are asking our patients about it. Just so you know, your answers will not be shared with anyone unless you choose to share them.

1. Have you been hit, kicked, punched, or otherwise hurt by an intimate partner within the past year?

__ YES

__ NO

2. Do you feel safe in your current relationship?

__ YES

__ NO

3. Is there a partner from a previous relationship who is making you feel unsafe now?

__ YES

__ NO