No number Appendix E.12 GI questionaire

Form Approved

OMB NO. 0920-0741

Exp. Date 6/30/2007

Study to Explore Early Development

Survey of Gastrointestinal Fuction

The following questions will ask about your child’s dietary habits and stool patterns. Please check your responses.

1. Do you feel like your child’s diet is…

□ Good

□ Limited

□ Poor

□ Don’t know

2. Does your child currently have any diet restrictions?

□ Yes

□ No (go to question 6)

□ Don’t know (go to question 6)

3. If yes, what are the diet restrictions? Please list all.

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

4. Is your child’s diet… Check all that apply

□ Self restricted

□ Parent restricted

□ Medically prescribed

□ Don’t know

5. Why does your child have diet restrictions? Please describe symptoms that are affected by food, such as stool consistency, stool frequency, rash, or behavior.

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

6. Has your child ever had difficulty swallowing on a regular basis (for 2-3 weeks)?

□ Yes

□ No (go to question 11)

□ Don’t know (go to question 11)

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 (0920-0741)

7. At what age did your child have this problem? Please record the age of your child for each instance he/she had this problem.

1^st instance: _______ months or _______ years

2^nd instance: _______ months or _______ years

3^rd instance: _______ months or _______ years

8. What consistencies of food did your child have difficulty swallowing?

Yes No Don’t know

a. Liquid……... □ □ □

b. Solid.……… □ □ □

c. Nectar……… □ □ □

9. Has your child ever had a swallow study?

□ Yes

□ No (go to question 11)

□ Don’t know (go to question 11)

10. Was the result of the study normal or abnormal for…

Normal Abnormal Don’t know

a. Thin liquids………....□ □ □

b. Solids.………………□ □ □

c. Nectar consistency….□ □ □

11. Has your child ever rejected certain textures of foods for more than 2 to 3 weeks?

□ Yes

□ No (go to question 14)

□ Don’t know (go to question 14)

12. At what age did your child reject textures? Please record the age of your child for each instance he/she rejected textures.

1^st instance: _______ months or _______ years

2^nd instance: _______ months or _______ years

3^rd instance: _______ months or _______ years

13. What textures of food did your child reject?

Yes No Don’t know

a. Hard to chew ……………... ………… …. □ □ □

(tough meat or raw carrot)

b. Crunchy………………….... ………… …. □ □ □

c. Mushy…………………….. ………… …. □ □ □

d. Sticky …………………...... ………… …. □ □ □

e. Lumps …………………..... ………… …. □ □ □

f. Mixed texture …….............. ………… …. □ □ □

(mixture of at least two of the above textures)

g. Other ……………………... ………… …. □ □ □

Specify: _______________________________

14. Do you feel that your child currently has gastrointestinal (bowel) problems on a regular basis (more than twice a month)?

□ Yes

□ No (go to question 18)

□ Don’t know (go to question 18)

15. Does your child have any of the following gastrointestinal problems?

Yes No Don’t know

a. Vomiting …………………………………... □ □ □

b. Diarrhea …………………………………… □ □ □

c. Loose stools ……………………………….. □ □ □

d. Constipation ……………………………… □ □ □

e. Loose stools alternating with constipation … □ □ □

f. Abdominal pain with meals ……………… □ □ □

g. Abdominal pain relieved by defecation …. □ □ □

h. Pain on stooling …………………………. □ □ □

i. Gaseousness ……………………………… □ □ □

j. Other ……………………………………… □ □ □

Specify ______________________

If yes for any condition in question 15, please complete questions 16 and 17.

If no or don’t know for all the above conditions, go to question 18.

16. How old was your child when the problem started? Please refer back to the conditions listed in question 15 and write the name of the condition under “Condition”.

Condition Age Problem Started

Example: __diarrhea__ ___32__ months or _______ years

1. _________________ _______ months or _______ years

2. _________________ _______ months or _______ years

3. _________________ _______ months or _______ years

4. _________________ _______ months or _______ years

5. _________________ _______ months or _______ years

17. How often did your child have each problem? Please refer back to the conditions listed in question 15 and write the name of the condition under “Condition”.

2-4 times 1-2 times 3-6 times

Condition per month per week per week Daily Don’t know

1. ________________________ □ □ □ □ □

2. ________________________ □ □ □ □ □

3. ________________________ □ □ □ □ □

4. ________________________ □ □ □ □ □

5. ________________________ □ □ □ □ □

18. Do you feel that your child had gastrointestinal symptoms in the past that are not present now?

□ Yes

□ No (go to question 21)

□ 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 your child used stool softeners, laxatives or fiber supplements?

□ Yes

□ No (go to question 24)

□ Don’t know (go to question 24)

22. What was the name of the product(s)?

____________________________________________________________________________

____________________________________________________________________________

23. How many times during the month did your child use the product(s)?

Product 1 _________

Product 2 _________

Product 3 _________

24. Does your child vomit more than once a month when not associated with an illness?

□ Yes

□ No (go to question 26)

□ Don’t know (go to question 26)

25. What seems to be causing the vomiting? Check all that apply.

□ Crying

□ Stress

□ Certain smells

□ Eating too quickly

□ Eating too much

□ Reflux

□ Other: ______________________________________________

□ Don’t know

26. Is there ever any blood in your child’s stool?

□ Yes

□ No

□ Don’t know

27. Has there ever been a time when your 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 Don’t know

a. Greasy …………………….. □ □ □

b. Mucousy …………………. □ □ □

c. Frothy …………………….. □ □ □

d. More foul smelling ………. □ □ □

If yes for any condition in 27, please answer question 28.

If no or don’t know for all conditions, please go to question 29.

28. At what age(s)? Please refer to the conditions in question 27 and write the name of the condition under “Condition”.

Condition Age Problem Started

Example: __greasy__ ___32__ months or _______ years

1. _________________ _______ months or _______ years

2. _________________ _______ months or _______ years

3. _________________ _______ months or _______ years

4. _________________ _______ months or _______ years

29. Has your child ever had a severe episode of dehydration requiring medical intervention?

□ Yes

□ No (go to question 32)

□ Don’t know (go to question 32)

30. How many times has your child had these dehydration episodes?

________ times

31. What type of medical intervention did your 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 your child have per day? Would you say it is…

□ 0 – 1 stools

□ 2 – 3 stools

□ more than 3 stools

□ Don’t know

33. How many stools does your child have per week? Would you say it is…

□ less than 3 stools

□ 3 – 7 stools

□ more than 7 stools

□ Don’t know

34. Does your child currently wear diapers?

□ Yes (go to question 35 and refer to LIST A)

□ No (go to question 35 and refer to LIST B)

□ Don’t know

35. What is the typical consistency of your child’s stools? Would you say it is…

LIST A (use this list if your child wears diapers)

□ Separate hard lumps, like nuts or rabbit pellets

□ Sausage-shaped but lumpy

□ Like a sausage or snake but with cracks on its surface, form may be changed slightly by sitting on stool

□ Like a sausage or snake, smooth and soft, may be deformed by sitting on stool

□ Soft blobs with clear cut edges, never a sausage

□ Runny, no form

□ Watery, no solid pieces, soaks into diaper

□ Don’t know

LIST B (use this list if your child does not wear diapers)

□ Separate hard lumps, like nuts

□ Sausage-shaped but lumpy

□ Like a sausage or snake but with cracks on its surface

□ Like a sausage or snake, smooth and soft

□ Soft blobs with clear-cut edges

□ Fluffy pieces with ragged edges, a mushy stool

□ Watery, no solid pieces

□ Don’t know

36. Are your 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?

□ Yes

□ No

□ Don’t know

37. Does your child alternate between loose stools and hard stools?

□ Yes

□ No

□ Don’t know

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