1.3 Goal 1 Demographic and Health

ID: ________________________

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Demographic Health Behavior Questionnaire

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1. Sex Male Female (Circle one)

2. Are you Hispanic, Latino/a or Spanish origin (One of more categories may be selected)

 1. No, not Hispanic, Latino/a, or Spanish Origin

 2. Yes, Mexican, Mexican American, Chicano/a

 3. Yes, Puerto Rican

 4. Yes, Cuban

 5. Yes, Another Hispanic, Latino/a or Spanish origin

3. What is your race? (Choose all that apply)

 1. White

 2. Black or African American

 3. American Indian or Alaska Native

 4. Asian Indian

 5. Chinese

 6. Filipino

 7. Japanese

 8. Korean

 9. Vietnamese

 10. Other Asian

 11. Native Hawaiian

 12. Guamanian or Chamorro

 13. Samoan

 14. Other Pacific Islander

4. How old are you? _______ years _____ months

5. Have you had a fever in the past 3 days?

0=No

1=Yes

6. In the last 2 days (48 hours), have you taken any over-the-counter medicines or prescription medication (other than contraceptives)?

0=No (Skip to 5)

1=Yes (Continue)

DK=Don’t Know (Politely explain that, as described in the recruitment, screening, and consent processes, prescription medication use (other than contraception) disqualifies individuals from participating in the study. As individual is unsure, participation in the study is not possible. Thank the individual for his/her time and end the interview.)

What did you take?

Name: Time taken: Dose

__________________ ­­­­­­­­­­­­­­

What were the medications for? (check all that apply)

___ for pain (e.g. Tylenol, Motrin, Aspirin)

___for a cough or cold? (e.g. Robitussin, Sudafed, Triaminic)

___to control their behavior? (e.g. Ritalin, Adderall, Concerta, Risperadol)

___for asthma? (e.g. Albuterol, Serevent , Rhinocort)

___other

____specify reason for ‘other’ medication

If prescription medications (other than birth control) are included above: Politely explain that, as described in the recruitment, screening, and consent processes, prescription medication use (other than contraception) disqualifies individuals from participating in the study. Thank the individual for his/her time and end the interview.)

If no prescription medications other than birth control are included above: Continue to question 6.

7. Do you have any oral health problems? For example, cuts or sores in your mouth, untreated cavities, or gum disease?

0=No

1=Yes

8. Have you ever been diagnosed with periodontitis or gingivitis?

0=No

1=Yes

9. When you brush your teeth, do you see "red-pinkish" color when you spit into the sink?

0=No

1=Yes

10. How many times a day do you brush your teeth? _______

11. How many times per week do you floss your teeth? _____

12. Do you smoke?

0=No (Skip to 12)

1=Yes (Continue)

8a. How many years have you smoked? _________(years)

8b. How many cigarettes a day? ______ (Number)

8c. How many in the last 12 hours? ____(Number)

13. Do you use any smokeless tobacco products , or products with nicotine (Gum, water)?

0=No (Skip to 13)

1=Yes

If yes continue: Have you used any of these products in the last 24 hours?

0=No

1=Yes

14. Are there other people who smoke in your household?

0=No

1=Yes

[SKIP to 19 if Male]

15. Are you pregnant?

0=No

1=Yes (Politely explain that, as described in the recruitment, screening, and consent processes, pregnancy disqualifies individuals from participating in the study. Thank the individual for her time and end the interview.)

DK=Don’t Know

16. Are you breastfeeding?

0 = No

1 = yes (If yes, How many months have you been breastfeeding? ___ (Months)

17. Have you had your period in the last three months?

0=No

1=Yes

18. How many days ago did your period end?

______# of days

______ I am currently having my period

DK=Don’t Know

19. Are you currently using “the pill” or "the patch" contraceptives?

0=No

1=Yes

20. Are you currently under the care of a physician for any chronic condition?

If yes, name ___________________________________________________

21. On a typical day, how many hours of sleep do you get ? (Record in hours AND minutes)

_______ # of hours AND ______ # of minutes

22. What is your typical bedtime (Record in hours AND minutes.)

_______ Circle ONE: AM or PM

23. What is your typical Wake time (Record hours AND minutes)

________ Circle ONE: AM or PM

24. How would you rate the quality of your sleep? 

___1: Excellent

___2: Very Good

___3: Good

___4: Fair

___5: Poor

25. Compared to other adults your age, would you say your health in the last two days has been:

___1: Excellent

___2: Very Good

___3: Good

___4: Fair

___5: Poor

26. Your access to oral health care is

___1: Excellent

___2: Very Good

___3: Good

___4: Fair

___5: Poor

27. How many servings of fresh fruit and vegetables have you had in the past 3 days?

_____ (number)

28. How many servings of dairy products have you had in the past 3 days?

_____(number)

29. How many servings of beef have you had in the past 3 days?

_____(number)

30. What is your height? ____(inches)_

31. What is your weight? ____ (lbs)

Thank you very much!

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