Formative - Developmental

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  `	STUDY ID:   __ __ __ __ __
	DATE:   __ __ / __ __ / __ __ (dd/mm/yy)
	INTERVIEWER: __ __ 
 
Demographic and Health Questionnaire
 
“These questions are about [your child]. They will only be used for scientific purposes. Please answer each question as carefully as possible. ALL INFORMATION THAT YOU GIVE WILL BE KEPT STRICTLY CONFIDENTIAL.” 
 
(Note to interviewer: do not record “uncertain” as an answer unless the subject absolutely cannot answer.  “Uncertain” should not be offered as a choice of answer. If the subject insists on responding uncertain/unsure, make a note of this response next to the questions, or fill with “999…” all numeric fields.)  

DEMOGRAPHICS: 
    1. 
What is your relationship to [the child]?
 1 - Biological mother 
 2 - Biological father  
 3 - Stepmother 
 4 - Stepfather 
 5 - Grandparent 
 6 - Sibling  
 7 - Legal guardian 
 8 - Other  
 
1A If “other”: Please specify? 
___________________ 
2.
What is [your child]’s date of birth?
__ __ / __ __ / __ __ __ __
3.
[Child]’s gender:
 1 - male
 2 - female 
4. 
Was [the child] born in the U.S.?
 1 - yes          0 - no 
5.
What is [your child]’s ethnicity?
 1 - Hispanic 
 2 - not Hispanic
-1 – Refused
-2 – Don’t know
6.
Race of [the child]:
 1 - White 
 2 - Black or African American
 3 – American Indian or Alaska Native
 4 – Asian, or Native Hawaiian or other Pacific Islander
 5 – Some other race
-1 – Refused
-2 – Don’t know 
7. 
Highest level of education completed by parent or legal guardian in the household:
 1 – Less than a HS diploma or GED 
 2 - HS diploma (or GED)
 3 - some college but no degree
 4 – associate degree 
 5 – bachelor’s degree 
 6 – post graduate degree
-1 – Refused
-2 – Don’t know
PREGNANCY AND PERINATAL PERIOD: 
8. 
Was [the child] born prematurely? (less than 37 weeks) 
 
 1 - Yes 0 - No 
9.
How many weeks pregnant were you when the child was born? 
__ __ weeks 
10. 
Was [the child] in the intensive care unit (NICU)? 
If no: Skip to question #11  
 1 - Yes 0 - No 
 
10A. In the NICU, did [the child] need a ventilator or a tube in his/her  
         lungs to help him/her breathe? 
 1 - Yes 0 - No 
 
10B. Did [the child] need oxygen at home after leaving the NICU? 
 
 1 - Yes 0 - No 
 
10C. Did [the child] need a monitor at home after leaving the NICU? 
 1 - Yes 0 - No 
ASTHMA QUESTIONS: 
11.
Has [the child]'s mom and/or dad ever been diagnosed with asthma by a doctor? 
 1 - Yes 0 - No 
12.
Has [the child] ever been diagnosed with eczema by a doctor? 
 1 - Yes 0 - No 
13.
Has [the child] ever been diagnosed with allergic rhinitis or hay fever by a doctor? 
 1 - Yes 0 - No 
14.
Does [the child] have wheezing in the chest apart from when he/she is sick with a cold or the flu? 
 1 - Yes 0 - No 
15. 
Has [the child] ever been tested by a doctor and found to have food allergies? 
 1 - Yes 0 - No 
16.
Does [your child] have a wheeze or cough after exercise? 
 1 - Yes 0 - No 
17.
Does [your child] have wheeze, chest tightness, or cough after exposure to airborne allergens or pollutants? 
 1 - Yes 0 - No 
18.
Do [your child]’s “go to the chest” or take more than 10 days to resolve? 
 1 - Yes 0 - No 
19.
Are symptoms improved by anti-asthma treatment? 
 1 - Yes 0 - No 
OTHER PERSONAL/MEDICAL HISTORY: 
20.
Has [the child] ever been diagnosed with any of the following? 



20A) Bronchiolitis / RSV
1 - Yes0 - No

20B) Pneumonia
1 - Yes0 - No

20C) Recurrent pneumonia
1 - Yes0 – No

20D) Eczema
1 - Yes0 – No

20E) Allergic rhinitis / hay fever
1 - Yes0 - No

20F) Cystic fibrosis
1 - Yes0 - No

20G) Chronic lung disease
1 - Yes0 – No
FAMILY / SOCIAL HISTORY: 
21.
Has [the child]'s mother ever been diagnosed with:


25A) Asthma
1 - Yes0 – No

25B) Allergic rhinitis or hay fever
1 - Yes0 – No

25C) Eczema
1 - Yes0 – No

25D) Emphysema or COPD
1 - Yes0 – No
22.
Has [the child]'s father ever been diagnosed with: 


26A) Asthma
1 - Yes0 – No

26B) Allergic rhinitis or hay fever
1 - Yes0 – No

26C) Eczema
1 - Yes0 – No

26D) Emphysema or COPD
1 - Yes0 – No
23.
Have any of [the child]'s siblings ever been diagnosed with:
1 - Yes0 – No

23A) Asthma    
1 - Yes0 – No

23B) Allergic rhinitis or hay fever
1 - Yes0 – No

23C) Eczema   
1 - Yes0 – No