Form 1 NIH Diet and Health Study Questionnaire

OMB#: 0925-0587 EXP. DATE: 4/30/2011

NIH–AARP Diet and Health Study
Short Questionnaire
Survey ID #:

*00000005*

STATEMENT OF CONFIDENTIALITY
Collection of this information is authorized by The Public Health Service Act, Section 412 (42 USC 285 a-1). Rights of study participants are protected
by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal
to participate will not affect your benefits in any way. The information collected in this study will be held in professional confidence. Names and other
identifiers will be separated from information provided and will not appear in any report of the study. Information provided will be combined for all study
participants and report as statistical summaries.
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN
Public reporting burden for this collection of information is estimated to average 4 minutes per response, including the time for review 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 (0925-0587).
Do not return the completed form to this address.

GENERAL INSTRUCTIONS
Answer to the best of your ability, rather than leaving a response blank.
Be certain to completely blacken in each of your answers and do not make any stray marks.
CORRECT MARK: v
INCORRECT MARKS:
1. What is your current weight in pounds?
(Enter your current weight and mark
one circle beneath each box.)
ExAMPLE 1: If you
weigh 186 pounds,
your entry would be:

ExAMPLE 2: If you
weigh 94 pounds,
your entry would be:

POUNDS

POUNDS

186

0 0 0
V V V
1 1 1
v V V
2 2 2
V V V
3 3 3
V V V
4 4 4
V V V
5 5 5
V V V
6 6
V v
7 7
V V
8 8
v V
9 9
V V

094

0 0 0
v V V
1 1 1
V V V
2 2 2
V V V
3 3 3
V V V
4 4 4
V V v
5 5 5
V V V
6 6
V V
7 7
V V
8 8
V V
9 9
v V

Your Current
Weight

2. For each of the ages shown below, select the
diagram that best describes your body shape
at that age. (Mark one circle at each age.)
Men

POUNDS
0 0 0
V V V
1 1 1
V V V
2 2 2
V V V
3 3 3
V V V
4 4 4
V V V
5 5 5
V V V
6 6
V V
7 7
V V
8 8
V V
9 9
V V

Age 10
Age 18
Age 35
Age 50
Currently

V
V
V
V
V

V
V
V
V
V

V
V
V
V
V

V
V
V
V
V

V
V
V
V
V

V
V
V
V
V

V
V
V
V
V

V
V
V
V
V

V
V
V
V
V

V
V
V
V
V

V
V
V
V
V

V
V
V
V
V

V
V
V
V
V

V
V
V
V
V

V
V
V
V
V

V
V
V
V
V

V
V
V
V
V

V
V
V
V
V

Women

Age 10
Age 18
Age 35
Age 50
Currently

3. How many times a week do you usually do 30 minutes of moderate physical activity or walking
that increases your heart rate or makes you breathe harder than normal? (For example, brisk walking, bicycling at a regular pace, carrying light loads, mowing the lawn, or playing doubles tennis.)
V None

V 1–2 times/week

V 3–4 times/week

V 5 or more times/week

4. How many times a week do you usually do 20 minutes of vigorous physical activity that makes you
sweat or puff and pant? (For example, jogging, aerobics, weight training or lifting, or fast bicycling.)
V None

V 1–2 times/week

V 3–4 times/week

V 5 or more times/week

PLEASE TURN OVER +

5. Do you currently smoke cigarettes?
V No

V Yes

+ How many cigarettes/day?

V 1–10

V 11–20

6. Have you ever been told by a doctor that you had any
of the following conditions? (Please mark one circle
to indicate the year that you were first diagnosed.)
Condition (first Diagnosed)
High blood pressure
Diabetes
High cholesterol
Heart attack, angina, or coronary artery disease
TIA (Transient Ischemic Attack)
Stroke
Pulmonary embolus (blood clot in lungs)
COPD (Chronic Obstructive Pulmonary Disease)
Emphysema or chronic bronchitis
Hip fracture
Macular degeneration of the eye
Kidney stones
Gallstones
Colon or rectal polyps
Stomach or duodenal ulcer
Parkinson’s disease
Multiple sclerosis
ALS (Amyotrophic lateral sclerosis, Lou Gehrig’s Disease)
Depression
Cancer (any type)

7. Have you ever had any of the following procedures
performed? (Please mark one circle to indicate
the year that you were first performed.)
Coronary angioplasty
Coronary artery bypass
Gallbladder removal
Hip replacement

V 21–40

V 41 or more

No
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V

YES—YEAR CONDITION WAS fIRST DIAGNOSED
(Mark only one response per condition.)
Before
2004–
2007–
2004
2006
Present
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V

No
V
V
V
V

YES—YEAR fIRST PERfORMED
(Mark only one response per procedure.)
Before
2004–
2007–
2004
2006
Present
V
V
V
V
V
V
V
V
V
V
V
V

MEN ONLY
8. When did you last have a PSA test (a test that screens your blood for indications of prostate
cancer)? (Mark only one circle.)
V Never had one
V 5 or more years ago

V Less than 1 year ago
V Had one, but not sure when

V 1–2 years ago
V Not sure if had one

V 3–4 years ago

WOMEN ONLY
9. Have you had your uterus removed, that is, have you had a hysterectomy?
V No

V Yes

+ Date of surgery:

V Before 2004

V 2004–2006

V 2007–present

10. Have you had either of your ovaries surgically removed?
V No

V Yes

+ Date of most recent surgery: V Before 2004
+ How many ovaries do you have remaining?
THANK YOU!

V 2004–2006
V None

V 2007–present
V One

Please return the completed questionnaire in the pre-paid envelope provided.