Download:
pdf |
pdf 3. Has a doctor ever told you that you have high blood pressure?
1
Yes
3a. If yes, has a doctor ever prescribed any medicine for high blood pressure?
1
Yes
2
No
3
Don’t know
3b. Are you now taking any medicine for high blood pressure?
1
2
No
3
Don’t know
Yes
2
No
3
Don’t know
4. Has a doctor ever told you that you had any of the following? (check yes or no for each one)
1
Yes
2
No
Addison’s Disease
1
Yes
2
No
Asthma
1
Yes
2
No
Celiac disease
1
Yes
2
No
Hyperthyroidism (high thyroid)
1
Yes
2
No
Hypothyroidism (low thyroid)
1
Yes
2
No
Vitiligo (white skin patches)
5. Has a doctor said that diabetes has affected your kidneys?
1
Yes
2
No
3
Don’t know
6. Has a doctor said that diabetes has damaged the back of your eyes, that is, the retina?
1
Yes
6a. If yes, did this require laser treatment of the retina?
2
No
3
Don’t know
1
Yes
2
No
SEARCH 3 Cohort Study - Health Questionnaire – Young Adult Version – 12-09-10
2 of 19
7. Have you had any other major illness or medical conditions that we have not asked about?
1
Yes
2
No
If yes, please describe:
Questions 8 and 9 are for FEMALES only.
8. Have you already had your first period?
1
Yes
8a. If yes, how old were you when you had your first
period?
1
2
No
3
Don’t know
years old
Don’t know
9. Has a doctor ever told you that you have polycystic ovaries (PCO, PCOS)?
1
Yes
2
No
3
Don’t know
MEDICAL HISTORY
The next few questions are about emergency room and hospital visits you may have had.
10. In the last 6 months, have you been to the emergency room for any reason?
1
Yes
2
No
10a. How many times were you in the emergency room?
SEARCH 3 Cohort Study - Health Questionnaire – Young Adult Version – 12-09-10
# of times
3 of 19
11. In the last 6 months, have you had one or more night’s hospital stay for any reason?
1
Yes
2
No
11a. How many times were you in the hospital for
one or more nights?
# of times
12. In the past 6 months, have you had any severe hypoglycemia, that is, very low blood sugar that required
you to get help?
1
2
Yes
12a. How many times?
# of times
12b. How many times were you given an injection
of glucagon – for hypoglycemia (low blood
sugar)?
# of times
12c. How many times was“911” or life squad/
paramedics called for hypoglycemia?
# of times
12d. How many times did you go to an emergency
room for hypoglycemia?
# of times
12e. How many times did you need to stay
overnight at a hospital?
# of times
No
13. In the past 6 months, have you had ketoacidosis (often called DKA, frequently with high blood sugar,
vomiting and shortness of breath)?
1
Yes
13a. How many times?
13b. How many times did this result in an
emergency room visit?
13c. How many times did this result in one or more
night’s hospital stay?
2
# of times
# of times
# of times
No
SEARCH 3 Cohort Study - Health Questionnaire – Young Adult Version – 12-09-10
4 of 19
MEDICATION INVENTORY
Insulin Use
14. Were you ever treated with insulin (shots/pumps) since you were diagnosed?
1
No (skip to question 20)
2
Yes
15. If yes, when were insulin shots/pump started?
1
At diagnosis
2
Less than 1 month after diagnosis
3
Within 1-6 months after diagnosis
4
Within 6-12 months after diagnosis
5
1 year or more after diagnosis
16. Did you ever stop taking insulin?
1
No (skip to question 20)
2
Yes
17. If yes, did that happen…
1
Less than 1st month after diagnosis
2
1-6 months after diagnosis
3
6-12 months after diagnosis
4
1 year or more after diagnosis
18. How long were you off insulin?
1
Less than 1 month
2
1-6 months
3
6-12 months
4
1 year or more
SEARCH 3 Cohort Study - Health Questionnaire – Young Adult Version – 12-09-10
5 of 19
19. Did you ever have any episodes of ketoacidosis (DKA) when insulin was stopped?
Yes
2 No
3 Don’t know
1
20. How do you currently treat your diabetes? Do you use: (check yes or no for each)
20a. Diabetes tablets (pills)
1
Yes
2
No
20b. Insulin shots, pump, or pen
1
Yes
2
No
20c. Diet (meal plan)
1
Yes
2
No
20d. Exercise
1
Yes
2
No
20e. Other (what?)
21. If you are currently taking insulin, how often do you take insulin each day on average? (if you are not
currently taking insulin, go to question 24)
1
1 time a day
4
More than 3 times a day
2
2 times a day
5
Insulin pump
3
3 times a day
22. How do you take insulin? (check all that apply)
1
22a. With a syringe (needle)
2
22b. With an insulin pump
3
22c. With an insulin pen
Worksheet
23. We would like to know the dose of insulin (number of units)
that you took yesterday. (If you use an insulin pump, record
the bolus amounts in 23a – 23e, and record the total 24-hour
basal dose in 23f. This may require filling out a worksheet of
hourly basal rates to determine the total basal dose.)
23a.
Breakfast
.
23b.
Lunch
.
23c.
Dinner
.
23d.
Bedtime
.
23e.
Other
23f.
Pump
.
.
Total insulin:
SEARCH 3 Cohort Study - Health Questionnaire – Young Adult Version – 12-09-10
6 of 19
Prescribed Medications
24. Are you taking prescribed medication(s) including insulin?
1
Yes (If Yes, document up to 10 medications below. If you are taking insulin, be certain to include all types
No (if No, skip to question 25)
or preparations.)
2
1.
______________________________________________
2.
______________________________________________
3.
______________________________________________
4.
______________________________________________
5.
______________________________________________
6.
______________________________________________
7.
______________________________________________
8.
______________________________________________
9.
______________________________________________
10.
______________________________________________
Diabetes Education
The next few questions are about what you have been taught about diabetes.
25. In the past 12 months have you met with a diabetes
nurse or diabetes educator?
1
Yes
2
No
3
Don’t know
26. In the past 12 months have you met with a dietician or nutritionist, or talked to someone in detail about
your diet?
1
2
Yes
26a. When you were staying one or
more nights in the hospital
1
Yes
2
No
3
Don’t know
26b. As an outpatient
1
Yes
2
No
3
Don’t know
No
SEARCH 3 Cohort Study - Health Questionnaire – Young Adult Version – 12-09-10
7 of 19
27. In the past 12 months, which of the following types of diabetes information have you received from your
doctor’s office or health care plan? (check all that apply)
1
Information about diabetes camp
1
Information about diabetes support groups
1
Written materials about diabetes such as pamphlets or newsletters
1
Videos or audio tapes
1
Reminder about upcoming appointments
1
A copy or explanation of diabetes laboratory or test results
1
Diabetes information or advice by telephone
1
Diabetes information or advice in person
1
How to get diabetes information on the internet
1
Information about diabetes research studies other than this study
28. How would you rate your diabetes control: Would you say:
Excellent
2 Good
3 Fair
4 Needs much work
1
Home Diabetes Care
Here are some questions about your diabetes care outside of the doctor’s office.
29. Do you live or stay in more than one home on a regular basis? For example, if your parents are separated,
this would include spending the weekend with your other parent. It would also include other relatives you
might live or stay with on a regular basis (at least once per month).
1
2
Yes
29a. If yes, do you live in:
1
2 households
2
3 or more households
3
Don’t know
No, live in one household
SEARCH 3 Cohort Study - Health Questionnaire – Young Adult Version – 12-09-10
8 of 19
30. How much of your own diabetes care do you do for yourself? Would you say: (check one response)
None
2 Less than 25%
3 25-75%
4 More than 75%
5 All (skip to question 32)
1
31. Who helps you with your diabetes care?
31a. Parent/step parent/guardian
1
Yes
2
No
31b. Grandparent
1
Yes
2
No
31c. Brother/sister
1
Yes
2
No
31d. Another person
1
Yes
2
No
32. Do you test your blood sugar or glucose at home or any place other than the doctor’s office?
1
Yes
No (if
no, go to
question 33)
2
32a. How often is your blood sugar checked with a glucose meter (glucometer)? (check one)
Less than once a week
2 Less than once a day
3 1-2 times a day
4 3 times a day
5 4-6 times a day
6 7 or more times a day
7 Only when you are sick
1
SEARCH 3 Cohort Study - Health Questionnaire – Young Adult Version – 12-09-10
9 of 19
32b. Do you use a continuous glucose monitor (CGM) to measure your glucose?
Yes
2 No (if no go to 32c)
1
32b(1). If yes, how do you use the CGM?
1
I have used it through my doctor’s office
How often have you
used it?
2
1 time
2 2 or more times
3 Don’t know/not sure
1
I have a CGM for use at home
How often do you use it?
1 Rarely (0-19% of the time)
Occasionally (20-39% of the time)
3 About half the time (40-59% of the time)
4 Usually (60-79% of the time)
5 Most of the time (80-99% of the time)
6 Always (100% of the time)
7 Don’t know/not sure
2
32c. What do you usually do when the blood sugar test results are running too high or too low?
32c(1). Make changes to the diabetes treatment (insulin
dose or other medications, diet or exercise
1
Yes
2
No
32c(2). Call your diabetes doctor
1
Yes
2
No
32c(3). Talk to your diabetes doctor at the next visit
1
Yes
2
No
SEARCH 3 Cohort Study - Health Questionnaire – Young Adult Version – 12-09-10
10 of 19
Provider Care
These questions are about the doctors or health care providers that you see.
33. Who do you usually see for your diabetes care? (Check only one response)
2
3
4
5
6
7
8
9
10
1
11
13
12
Pediatric endocrinologist/diabetologist (diabetes specialist)
Pediatrician
Family practice doctor
General practice doctor
Adult endocrinologist/diabetologist (diabetes specialist)
Internist
Nurse practitioner/physician’s assistant
Nurse diabetes educator
Traditional medicine man, healer, or curandero/curandera
Dietician/Nutritionist
Other (specify)
Don’t know/unsure of what kind of doctor
None/no source of medical care
34. Who do you usually see for your medical needs not related to diabetes? (Check only one response)
2
3
4
5
6
7
8
9
10
11
12
13
1
Pediatric endocrinologist/diabetologist (diabetes specialist)
Pediatrician
Family practice doctor
General practice doctor
Adult endocrinologist/diabetologist (diabetes specialist)
Internist
Nurse practitioner/physician’s assistant
Nurse diabetes educator
Traditional medicine man, healer, or curandero/curandera
Dietician/Nutritionist
Other (specify)
Don’t know/unsure of what kind of doctor
None/no source of medical care
SEARCH 3 Cohort Study - Health Questionnaire – Young Adult Version – 12-09-10
11 of 19
Below are some questions about how often you see various medical providers.
35. Who provides medical care for you? (For each provider checked, indicate the number of visits you had with
this provider in the past 6 months.)
35a.
1
Yes
2
No
Pediatric endocrinologist/
diabetologist (diabetes specialist)
# of visits in the
last 6 months
35b.
1
Yes
2
No
Pediatrician
# of visits in the
last 6 months
35c.
1
Yes
2
No
Family practice doctor
# of visits in the
last 6 months
35d.
1
Yes
2
No
General practice doctor
# of visits in the
last 6 months
35e.
1
Yes
2
No
Adult endocrinologist/
diabetologist (diabetes specialist)
# of visits in the
last 6 months
35f.
1
Yes
2
No
Internist
# of visits in the
last 6 months
35g.
1
Yes
2
No
Nurse practitioner/physician’s
assistant
# of visits in the
last 6 months
35h.
1
Yes
2
No
Nurse diabetes educator
# of visits in the
last 6 months
35i.
1
Yes
2
No
Traditional medicine man, healer,
or curandero/curandera
# of visits in the
last 6 months
35j.
1
Yes
2
No
Dietician
# of visits in the
last 6 months
35k.
1
Yes
2
No
Eye doctor (optometrist,
ophthalmologist)
35l.
1
Yes
2
No
Psychiatrist, psychologist, or
mental health counselor
35m.
1
Yes
2
No
Other
(specify)
SEARCH 3 Cohort Study - Health Questionnaire – Young Adult Version – 12-09-10
# of visits in the
last 6 months
# of visits in the
last 6 months
# of visits in the
last 6 months
12 of 19
Insurance and Cost of Diabetes Supplies
36. What kind of health insurance or health care plan do you have?
36a. Medicaid/Medicare/State-funded/ other Federally-funded
1
Yes
2
No
36b. Private insurance, through employer
1
Yes
2
No
36c. Private insurance, purchased on your own
1
Yes
2
No
36d. Military
1
Yes
2
No
36e. School-based insurance
1
Yes
2
No
36f. Tribe/Indian Health Service
1
Yes
2
No
36g. Any other or type unknown
1
Yes
2
No
36h. None (if none, go to question 38)
1
Yes
2
No
37. Does your health insurance or health care plan pay for any of your… (check yes, no or don’t know for each one)
37a. Diabetes medicine/insulin
1
Yes
2
No
3
Don’t know
37b. Syringes/pens/needles
1
Yes
2
No
3
Don’t know
37c. Insulin pump and supplies
1
Yes
2
No
3
Don’t know
37d. Home glucose monitor
1
Yes
2
No
3
Don’t know
37e. Monitor strips and related supplies
1
Yes
2
No
3
Don’t know
37f. Diabetes education
1
Yes
2
No
3
Don’t know
37g.
Not applicable
38. About how much do you spend, on average, in a typical month on diabetes medicine and supplies? (This
does not include costs that are covered or later reimbursed by your insurance plan.)
1
$0 (none)
2
$1 - $19
3
$20 - $49
4
$50 - $99
5
$100 - $199
6
$200 or more
7
Don’t know
SEARCH 3 Cohort Study - Health Questionnaire – Young Adult Version – 12-09-10
13 of 19
39. How satisfied are you with your current insurance coverage? Would you say:
1
Very satisfied
2
Satisfied
3
Somewhat satisfied
4
Not satisfied
40. Has your main health insurance plan changed in the last 6 months?
1
Yes (if yes, go to question 40a)
2
No (if no, go to question 41)
Don’t know
4 Don’t want to answer
3
40a. What were the reasons your health insurance plan changed? (check all that apply)
1
Employer stopped offering this plan
1
Doctor left this plan
1
Unhappy with benefits/coverage
1
Too difficult to get care
1
Moved
1
Change in jobs
1
Other
1
Don’t know
1
Don’t want to answer
(specify)
41. Has your main diabetes provider changed in the last six months?
1
Yes (if yes, go to question 41a)
2
No (if no, go to question 42)
3
Don’t know
4
Don’t want to answer
SEARCH 3 Cohort Study - Health Questionnaire – Young Adult Version – 12-09-10
14 of 19
What were the reasons you had a change in diabetes provider? (check all that apply)
41a.
1
No longer covered by health plan
Too difficult to get care
1 Not satisfied with care
1 Moved
1 Other (specify)
1
1
Don’t know
1
Don’t want to answer
These questions deal with your parents’ education.
42. What is the highest degree or level of school your mother/guardian has COMPLETED?
No schooling completed
th
2 Nursery school to 4 grade
th
th
3 5 grade or 6 grade
th
th
4 7 grade or 8 grade
th
5 9 grade
th
6 10 grade
th
7 11 grade
th
8 12 grade, NO DIPLOMA
9 High school graduate (high school diploma) or equivalent (for example: GED)
10 Business/technical school
11 Some college credit but less than 1 year
12 1 or more years of college, no degree
13 Associate degree (for example: AA, AS) (2-year)
14 Bachelor’s degree (for example: BA, AB, BS) (4-year)
15 Master’s degree (for example: MA, MS, MEng, MEd, MSW)
1
Professional or doctorate degree (for example: MD, DDS, JD, PhD, EdD)
17 Don’t know
16
SEARCH 3 Cohort Study - Health Questionnaire – Young Adult Version – 12-09-10
15 of 19
43. What is the highest degree or level of school your father/guardian has COMPLETED?
1
No schooling completed
2
Nursery school to 4th grade
3
5th grade or 6th grade
4
7th grade or 8th grade
5
9th grade
6
10th grade
7
11th grade
8
12th grade, NO DIPLOMA
9
High school graduate (high school diploma) or equivalent (for example: GED)
10
Business/technical school
11
Some college credit but less than 1 year
12
1 or more years of college, no degree
13
Associate degree (for example: AA, AS) (2-year)
14
Bachelor’s degree (for example: BA, AB, BS) (4-year)
15
Master’s degree (for example:
16
Professional or doctorate degree (for example: MD, DDS, JD, PhD, EdD)
17
Don’t know
MA, MS, MEng, MEd, MSW)
44. Which of these categories best describes the total income of all persons living in your household, including
yourself for the past 12 months? (Check only one category.)
1
Less than $5,000
6
$35,000 through $49,999
2
$5,000 through $11,999
7
$50,000 through $74,999
3
$12,000 through $15,999
8
$75,000 through $99,999
4
$16,000 through $24,999
9
$100,000 and greater
5
$25,000 through $34,999
10
Don’t know
11
Prefer not to answer
SEARCH 3 Cohort Study - Health Questionnaire – Young Adult Version – 12-09-10
16 of 19
45. How many people are currently living in your household, including yourself?
45a. Total number of people
45b. Number of children (less
than 18)
45c. Number of adults
45c(1). Of the number of adults, how many bring income into the household?
46. Are you participating in another research study?
1
Yes
2
No
46a. If yes, what study?
As a part of the study, we will be contacting you in the future. It would be helpful to us if
you could provide us with the names, addresses, and phone numbers of two people who
could contact you even if you move.
Name
Relationship
Address:
P.O. Box
City
Street
Apt. #
State
Zip Code
Email Address
SEARCH 3 Cohort Study - Health Questionnaire – Young Adult Version – 12-09-10
17 of 19
Phone # (best)
(
(area code)
ext.
(area code)
ext.
(area code)
ext.
Phone # (other)
Phone # (other)
Name
Relationship
Address:
P.O. Box
Street
City
Apt. #
State
Zip Code
Email Address
Phone # (best)
(
(area code)
ext.
(area code)
ext.
(area code)
ext.
Phone # (other)
Phone # (other)
Thank you for completing this questionnaire.
SEARCH 3 Cohort Study - Health Questionnaire – Young Adult Version – 12-09-10
18 of 19
FOR STUDY USE ONLY
Interview Assessment:
1. How much difficulty did the Patient have in understanding the questions?
None
Slight
Moderate
A Great Deal
Don’t know
2. Were there significant problems with the interview?
Yes
No
If yes describe:
Date Completed
Completed by
Month
Mode of Administration
Day
1
In-Person
Year
2
Telephone
Reviewer Code
Date Reviewed
Month
Day
Year
Date Entered
Data Entry Code
Month
Day
Year
SEARCH 3 Cohort Study - Health Questionnaire – Young Adult Version – 12-09-10
19 of 19
| File Type | application/pdf |
| File Title | Microsoft Word - Health_Questionnaire - Young Adult 18 and over_ 11-18-10 revised 12-09-10 |
| Author | stmoxley |
| File Modified | 2011-05-10 |
| File Created | 2010-12-09 |