Form 9 Medication Use

ID NUMBER:

FORM CODE: MUE VERSION: A 7/02/07

Contact Occasion

SEQ #

OMB#: 0925-XXXX

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 06 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 Medication Use Questionnaire

ID NUMBER:

FORM CODE: MUE VERSION: A 7/02/07

Contact Occasion

SEQ #

Acrostic:

Administrative Information

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

Month Day Year

Instructions: This form should be completed during the participant’s visit. Affix the participant ID label above. Whenever numerical responses are required, enter the number so that the last digit appears in the rightmost box. Enter leading zeroes where necessary to fill all boxes. If a number is entered incorrectly, mark through the incorrect entry with an “=”. Code the correct entry clearly above the incorrect entry.

A. Reception

As you know, HCHS/SOL is recording all prescription and over-the-counter medications used by participants in the past four weeks, including cold and allergy medications, vitamins, herbal remedies, and other supplements. These medications include solid and non-solid formulations that you may swallow, inhale, apply to the skin or hair, inject, implant, or place in the ears, eyes, nose, mouth, or any other part of the body. The letter you received about this appointment included a plastic bag for all your current medications and asked you to bring them to the clinic.

1. Did you bring all the medications that you used in the past four weeks, or their containers?

Yes, all of them 1  GO TO SECTION B, QUESTION 5

No, some of them 2  GO TO SECTION A, QUESTION 3

No, none of them 3

2. Is this because you forgot, because you have not taken any medications at all in the last four weeks, or because you could not bring your medications?

Took no medication 1  GO TO SECTION C, QUESTION 34

Forgot or was unable

to bring medication 2

That’s alright. Since the information on medications is so important, we would still like to ask you about it during the interview.

3. May we follow up on this after the visit so that we can get the information from the other medication labels? (Explain follow-up options)

No or not applicable 0  Scan/transcribe what you can in

Section B and attempt to convert

refusals; indicate this on tracking form

Yes 1

4. Describe method of follow-up to be used:_______________________________________________

B. Medication Record

Copy the MEDICATION UPC / NDC from each medication label. For each medication, begin with the left-most space in fields a-c and the rightmost space in field d. Using upper case letters, carefully copy the MEDICATION NAME. Using periods to indicate decimal points, copy the formulation STRENGTH (weight for solids and concentration for non-solids). Using upper case letters and standard abbreviations, copy the UNITS used to measure strength. For combination medications, use a forward slash (/) to separate active ingredients, corresponding strengths, and units.

#	(a) Medication UPC / NDC		Medication name (b)
5.
	(c) Strength	(d) Units
6.
	(c) Strength	(d) Units
7.
	(c) Strength	(d) Units
8.
	(c) Strength	(d) Units
9.
	(c) Strength	(d) Units
10.
	(c) Strength	(d) Units
11.
	(c) Strength	(d) Units
12.
	(c) Strength	(d) Units
13.
	(c) Strength	(d) Units
14.
	(c) Strength	(d) Units
#	(a) Medication UPC		Medication name (b)
15.
	(c) Strength	(d) Units
16.
	(c) Strength	(d) Units
17.
	(c) Strength	(d) Units
18.
	(c) Strength	(d) Units
19.
	(c) Strength	(d) Units
20.
	(c) Strength	(d) Units
21.
	(c) Strength	(d) Units
22.
	(c) Strength	(d) Units
23.
	(c) Strength	(d) Units
24.
	(c) Strength	(d) Units
25.
	(c) Strength	(d) Units

#	(a) Medication UPC		Medication name (b)
26.
	(c) Strength	(d) Units
27.
	(c) Strength	(d) Units
28.
	(c) Strength	(d) Units
29.
	(c) Strength	(d) Units

30. Total number of medications in bag

31. Number of medications unable to scan or transcribe

32. HCHS/SOL ID number(s) of person scanning / transcribing medications and interviewing the participant:

a. Scanner / transcriber:

b. Date of scanning / transcription: / /

Month Day Year

C. Medication Use Interview

Now I would like to ask about a few specific medications.

33. Were any of the medications you took during the last four weeks for: (If “Yes”, verify that the medication NAME is on the medication record.)

No Yes Unknown

a. Asthma 0 1 9

b. Chronic bronchitis or emphysema 0 1 9

c. High blood sugar or diabetes 0 1 9

d. High blood pressure or hypertension 0 1 9

e. High blood cholesterol 0 1 9

f. Chest pain or angina 0 1 9

g. Abnormal heart rhythm 0 1 9

h. Heart failure 0 1 9

i. Blood thinning 0 1 9

j. Stroke 0 1 9

k. Mini-stroke or TIA 0 1 9

l. Leg pain while walking or claudication 0 1 9

34. During the last four weeks, did you take any aspirin or aspirin-containing products including Alka- Seltzer, cold and allergy medication or headache powder? This excludes acetaminophen (for example, Tylenol), ibuprofen (for example, Advil, Motrin or Nuprin), and naproxen (for example, Aleve).

Show participant List #1: Commonly Used Aspirin or Aspirin-Containing Products

No 0  GO TO QUESTION 37

Yes 1

Unknown 9  GO TO QUESTION 37

35. How many days during the last four weeks did you take aspirin or aspirin-containing medication? Number of days

If number of days equals “00”  GO TO QUESTION 37

36. For what purpose are you taking aspirin? (Interviewer: Do NOT read choices.)

Participant mentioned avoiding heart attack or stroke 1

Participant did not mention avoiding heart attack or stroke 2

37. During the past four weeks, did you take any [other] medication for arthritis, fever, or muscle aches and pains, or cramps? (Read bracketed “other” unless no medications were reported.)

No 0

Yes 1

Unknown 9

38. Excluding aspirin, acetaminophen (for example, Tylenol), and corticosteroids (for example prednisone), are you NOW taking other anti-inflammatory or arthritis medications on a regular basis? Common examples are shown on this list.

Show participant List #3: Commonly Used Non-Steroidal Anti-Inflammatory Drugs, NSAIDS

No 0  END QUESTIONNAIRE

Yes 1

Unknown 9  END QUESTIONNAIRE

39. Unless already recorded in Items B5-B29, record the following information for the medication identified by Item 38.

Already recorded 1

(a) Medication UPC		Medication name (b)
(c) Strength	(d) Units

40. How many pills per week are you taking, on average?

Number of pills per week

Medication Use Form (MUE) Page 2 of 6