Baseline Health and Exposure Questionnaire

A

Form Approved:

OMB No. 0920-xxxx Exp. Date __xx/xx/2011

TTACHMENT 3

Interviewer initials: ______ Date of interview: ___ /___ /______

Subject ID: _____________

Atlanta Commuter Exposure Study:

Baseline Health and Exposure Questionnaire

Section A: DEMOGRAPHICS

First, I would like to collect some background information about you.

A1. What is your date of birth?	(mm/dd/yyyy): _ _ / _ _ / _ _ _ _
A2. If don’t know or refused A1, what is your age?			_____ years
A3. What is your sex?	 Male  Female
A4. Do you consider yourself to be of Hispanic or Latino origin?	 Yes  No
A5. Which one of these groups would you say best represents your race? (choose one or more categories)	 White  Black or African American  Asian  Native Hawaiian or other Pacific Islander  American Indian or Alaskan native
A6. What is the highest grade or year of school you completed?	 Less than HS graduate  HS graduate or equivalent  Some college  College grad or more  Refused
A7. What is your annual household income from all sources?	 less than $25,000  $45-$74,999  Don’t know  $25-$44,999  $75,000 or more
A8. How tall are you without shoes?		____ feet ____ inches  Don’t know
A9. How much do you weigh without shoes?		______ pounds  Don’t know

We also need to know the address of your residence and workplace to determine distance to major sources of outdoor air pollution (such as highways, power plants and industrial facilities) and to determine your normal commute time and distance. We will not use these addresses for any other purpose.

A10. What is the street address of your primary residence?	Street ______________________________________________ City __________________________ Zip code ______________
A11. What is the street address of your primary workplace?	Street ______________________________________________ City __________________________ Zip code ______________  Don’t know – Ask: What is the nearest intersection? ________________________ and __________________________

Public reporting burden of this collection of information is estimated to average 20 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).

Section B. HEALTH STATUS

I would know like to ask you some questions about your health.

B1. Would you say that in general your health is excellent, very good, good, fair, or poor?  Excellent  Very good  Good  Fair  Poor  Don’t know  Refused
	Yes	No	Don’t know
Has a doctor, nurse, or other health professional EVER told you that you had any of the following?
B2. high blood pressure?			
B3. if yes and female, Ask: Was this only when you were pregnant?			
B4. high blood cholesterol?			
B5. a heart attack, also called a myocardial infarction?			
B6. angina or coronary heart disease?			
B7. a stroke?			
B8. any kind of heart condition or heart disease (other than the ones I just asked about)?			
if yes, describe: __________________________________________________
B9. emphysema?			
B10. asthma?			
B11. chronic obstructive pulmonary disease (COPD)?			
B12. hay fever or other nasal allergies?			
B13. atopy or eczema?			
B14. During the past 12 MONTHS, have you been told by a doctor, nurse, or other health professional that you had chronic bronchitis?
			
B15. During the past TWO WEEKS, have you had a head cold or chest cold?
			

Section C. ASTHMA

The following questions are related to your asthma symptoms and medication usage.

	Yes	No	Don’t know
C1. Do you still have asthma?			
C2. During the past 12 MONTHS, have you had an episode of asthma or an asthma attack?			
C3. During the past 3 MONTHS, have you had an episode of asthma or an asthma attack?			
C4. During the past 12 MONTHS, how many times did you see a doctor, nurse, or other health professional for a routine checkup for your asthma?	Number of visits: _______		
C5. Symptoms of asthma include cough, wheezing, shortness of breath, chest tightness and phlegm production when you don’t have a cold or respiratory infection. During the past 30 DAYS, how often did you have any symptoms of asthma? Would you say —  Not at any time  Don’t know  Less than once a week  Once or twice a week  More than 2 times a week, but not every day  Every day, but not all the time  Every day, all the time

Now I'm going to ask you about two different kinds of ASTHMA medicine. One is for quick relief. The other does not give quick relief but protects your lungs AND PREVENTS SYMPTOMS OVER THE LONG TERM.

	Yes	No	Don’t know
C6. During the PAST 3 MONTHS, have you used the kind of prescription inhaler that gives QUICK relief from asthma symptoms? [Common brand names for these inhalers are AccuNeb, ProAir, Proventil, and Ventolin.]			
C7. During the PAST 3 MONTHS did you use more than three canisters of this type of inhaler?			
C8. Have you EVER been prescribed a preventive asthma medicine that is taken in pill form every day to PREVENT asthma attacks?			
C9. If Yes to C8: Are you NOW taking this medication?			
C10. Have you EVER been prescribed a preventive asthma medicine that comes in an inhaler and is used every day to PREVENT asthma attacks? [Common brand names are Advair, Flonase, and Flovent.]			
C11. If Yes to C10: Are you NOW taking this medication? If so, how much are you taking?			
dose: ________ µg/day

Section D. FAMILY HISTORY

The next section of questions asks about your family history of disease. We are interested in your close blood relatives, including your father, mother, sisters, and brothers.

	Yes	No	Don’t know
Were any of your close blood relatives, including both living and deceased, EVER told by a doctor, nurse, or other health professional that they had any of the following?
D1. high blood pressure (not associated with pregnancy)?			
D2. heart disease?			
D6. a stroke?			
D7. asthma?			

Section E. MEDICATION

Please provide a list of the medications (including both prescription and over the counter) you have used in the past 3 MONTHS and how often you used the medication. (e.g., include medicine to treat high blood pressure, high blood cholesterol, asthma, allergies, pain, etc.)

Drug Name
E1. Drug name: _____________________________________ Symptoms treated: _______________________________ Dose:   per day OR   per week
E2. Drug name: _____________________________________ Symptoms treated: _______________________________ Dose:   per day OR   per week
E3. Drug name: _____________________________________ Symptoms treated: _______________________________ Dose:   per day OR   per week
E4. Drug name: _____________________________________ Symptoms treated: _______________________________ Dose:   per day OR   per week
E5. Drug name: _____________________________________ Symptoms treated: _______________________________ Dose:   per day OR   per week

Section F. LIFESTYLE

The following questions ask about your level or physical activity or exercise.

F1. During the past month, other than your regular job, did you participate in any physical

activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?

 Yes  No  Don’t know

F2. When you are at work, which of the following best describes what you do? Would you say—

(If respondent has multiple jobs, include all jobs.)

 Mostly sitting or standing  Don’t know

 Mostly walking

 Mostly heavy labor or physically demanding work

We are interested in two types of physical activity - vigorous and moderate. Vigorous activities cause large increases in breathing or heart rate while moderate activities cause small increases in breathing or heart rate.

F3. Not counting activities you do while at work, how many days in a typical week do you perform some type of moderate exercise for at least 10 minutes at a time? Examples of moderate exercise include brisk walking, bicycling, vacuuming, gardening, or anything else that causes some increase in breathing or heart rate?

___ Days per week  Don’t know

F4. On days when you perform moderate exercise for at least 10 minutes at a time, how much total time per day do you spend doing this?

_:_ _ Hours and minutes per day  Don’t know

F5. Not counting activities you do while at work, how many days in a typical week do you perform vigorous exercise for at least 10 minutes at a time? Example of vigorous exercise include running, aerobics, heavy yard work, or anything else that causes large increases in breathing or heart rate?

___ Days per week  Don’t know

F6. On days when you perform vigorous exercise for at least 10 minutes at a time, how much total time per day do you spend doing this?

_:_ _ Hours and minutes per day  Don’t know

The next questions ask about your smoking behavior and your exposure to secondhand smoke.

	Yes	No	Don’t know
F9. Have you smoked at least 100 cigarettes in your entire life? (NOTE: 5 packs = 100 cigarettes)			
F10. Do you smoke cigarettes now?			
If yes, how often:  every day  some days  not at all
F11. Currently, are you typically exposed to secondhand smoke either at home, at work, or in social situations?			
If yes, how often:  daily  weekly  monthly  less often

Section G. DRIVING BEHAVIOR

G1. How do you normally commute to and from work?	 personal vehicle (single-occupancy)  carpool or vanpool  public transportation (MARTA)  bicycle  walk  other _____________________________
G2. What is the one-way distance between your home and your primary workplace?		________ miles		 Don’t know
G3. How many miles do you drive in a typical week or a typical month?		________ miles per week ________ miles per month		 Don’t know
G4. Please describe the route you normally follow to get to work. Be specific enough that we may trace this route on a map. Include regular stop points (e.g., coffee shop, school, day care center, etc) along your route.	____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
G5. What time do you typically start your commute from home to work?		___ : ______ am pm		 Don’t know
G6. How many minutes did it usually it take you to get from home to work last week?		________ minutes		 Don’t know
G7. What time do you typically start your commute from work to home?		___ : ______ am pm		 Don’t know
G8. How many minutes did it usually it take you to get from work to home last week?		________ minutes		 Don’t know
G9. On a typical weekday, what is the average amount of time that you spend inside your home, inside your workplace, inside a car or other vehicle, inside at another location, or outside each day? (Note: the total number of hours should equal 24.)
Inside your home			_____ hours
Inside your workplace			_____ hours
Inside a car or other vehicle			_____ hours
Inside other location (e.g., gym, store)			_____ hours
Outside			_____ hours
TOTAL			_____ hours

Section H. HOUSEHOLD EXPOSURES

Now I have a few questions about your home.

H1. Do you live in a:

 Single family detached house

 Single family attached house

 A building with 2 or more apartments or condos

 A mobile home or trailer

 Other: _______________

	Yes	No	Don’t Know
H2. In the past 30 days, has anyone seen or smelled mold or a musty odor inside your home? Do not include mold on food.			
H3. Does your household have pets such as dogs, cats, hamsters, birds or other feathered or furry pets that spend time indoors?			

Section I. WORKPLACE EXPOSURES

Now I have some questions about your job and your primary workplace.

I1. Describe the type of work that you do, including job title and primary activities during your workday.	_______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________
		Yes	No	Don’t Know
I2. Is your workplace air conditioned?				
I3. At your present job, are you currently exposed to loud noise?				
I4. On average, for how many hours per day are you currently exposed to this loud noise?		_______ hours		
I5. Did you ever wear protective hearing devices while you were exposed to loud noise in that job?				

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