Form 20 Weight History

ID NUMBER:

FORM CODE: WHE VERSION: A 7/03/07

Contact Occasion

SEQ #

OMB#: 0925-XXXX

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 02 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-XXXX). Do not return the completed form to this address.

H

OMB#: 0925-XXXX

Exp. XX/XXXX

CHS/SOL Weight History Questionnaire

ID NUMBER:

FORM CODE: WHE VERSION: A 7/03/07

Contact Occasion

SEQ #

Acrostic:

Administrative Information

0a. Completion Date: // 0b. Staff ID:

Month Day Year

Instructions: Mark the appropriate box for the response. Unless instructed, mark ONLY one response.

Interviewer: Ask participant his/her age. Check Question 1 below if participant is under 21 years old.

Note questions may be skipped due to participant’s age.

1. Under 21 years old  END QUESTIONNAIRE

These set of questions asks about your height and weight at different ages since age 21. If you don’t remember exactly, give your best guess.

2. How tall were you (without shoes on) at about age 21 (your tallest adult height)? (Provide in either centimeters OR feet and inches)

Centimeters OR Feet Inches

3. What was your weight at about age 21? (Women, when you were not pregnant) (Provide in either kilograms OR pounds, rounding to the nearest kilogram or pound)

Kilograms OR Pounds

4. What was your weight at about age 45? (Women, when you were not pregnant) (Provide in either kilograms OR pounds, rounding to the nearest kilogram or pound)

Kilograms OR Pounds

5 What was your weight at about age 65? (Provide in either kilograms OR pounds, rounding to the nearest kilogram or pound)

Kilograms OR Pounds

6. How much has your weight changed in the last 12 months? (Provide in either kilograms OR pounds, rounding to the nearest kilogram or pound)

No change 0  END QUESTIONNAIRE

Kilograms OR Pounds

7. Was this change a loss or a gain? Loss 1

Gain 2

8. Did you lose/gain weight because you were trying to lose/gain weight?

No 0

Yes 1

Weight History Form (WHE) Page 0 of 2