Baseline Questionnaire Children

The Green Housing Study

Appendix D4 - Baseline (for Children 7-12 years) 5-10-11

Baseline Questionnaire for Children

OMB: 0920-0906

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Green Housing Study ID# _______________

Baseline (Child 7-12 with asthma) House ID# _____________





Green Housing Study







Baseline Questionnaire (Children 7-12 with asthma)




Public reporting burden of this collection of information is estimated to average 15 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Interviewer Initials _______ Date: ___________



Demographics


1. Is [Child’s name] Hispanic or Latino? Yes No

2. Which one or more of the following would you say is [Child’s name] race?

(Check all that apply)


2.1 White

2.2 Black or African American

2.3 Asian

2.4 Native Hawaiian or Other Pacific Islander

2.5 American Indian or Alaska Native

3. Does [Child’s name] attend childcare? Yes No

If YES, please specify

  1. Childcare facility

  2. Private residence

  3. Both


Health Care Access

4. Is [Child’s name] currently covered by any kind of health insurance or some other health care plan?

Yes No Don’t know


If YES, then ask:


4.1 Which of the following types of health care insurance is it?

(Please circle one)

  1. employer or union either through yourself or another family member

  2. Medicaid or any government-assistance plan for those with low incomes or a disability

  3. TRICARE, VA, or other military health care

  4. Indian Health Service

  5. Medicare, for people with certain disabilities

  6. Any other type of health insurance or health coverage plan

  7. Don’t know


5. Do you have one person you think of as your personal doctor or health care provider?


Probe if answer is NO: “Is there more than one, or is there no person who you think of as your personal doctor or health care provider?”


1. Yes, only one

2. More than one

3. No

4. Don’t know


6. Has a doctor or other health professional ever told you that [Child’s name] has allergies?


Yes No Don’t know



7. Does [Child’s name] have any kind of food allergy?

Y N DK


8. How old was [Child’s name] when you were first told by a doctor, nurse, or other health professional that he/she had asthma?

_________ years (insert 0 if less than 1 year)


9. During the past 3 months, did [Child’s name] have any of these conditions?

(If YES to any of the following, enter number of episodes in space provided)

Number

  1. Flu or cold Y N DK ______

(Defined by at least 3 of the following: feverish, stuffy/runny nose, cough, sore throat, body aches or tiredness, for more than 24 hours)



(If YES, then ask)

9.1.1 During these illness episodes, did [Child’s name] asthma get worse? Y N DK


9.1.2 Did [Child’s name] receive Tamiflu® or oseltamivir [o sel TAM i veer] or an inhaled medicine called Relenza® or zanamivir [za NA mi veer] to treat this illness?


Y N DK


9.1.3 Was [Child’s name] prescribed antibiotics? Y N DK



  1. Pneumonia Y N DK ______

  2. Bronchitis Y N DK ______


Enter frequency by circling one choice

  1. Sneezing, runny/stuffed nose (without a cold)

Never Once/Twice Monthly Weekly Daily

  1. Wheezing Never Once/Twice Monthly Weekly Daily

  2. Cough (without a cold) Never Once/Twice Monthly Weekly Daily

  3. Shortness of breath Never Once/Twice Monthly Weekly Daily


10. During the past 3 months, has [Child’s name] had an episode of asthma or an asthma attack?

Yes No Don’t know

If NO, then SKIP to Question 19, “Regular schedule of medicines”

If YES, how many asthma episodes or attacks?


10.1 ______ Number of times


11. During the past 3 months, did [Child’s name] have an emergency department or urgent care visit because of asthma? Yes No

If NO, Skip to Question #13

If YES, did [Child’s name] visit the following?


    1. Emergency department Y N ____ Number of visits

    2. Urgent care center Y N ____ Number of visits

    3. Urgent visit to doctor’s office Y N ____ Number of visits

If child went to Emergency department (11.1 is one or more visits), then ask:


11.4 Did [Child’s name] travel by ambulance? Yes No


If YES, how many times?

11.4.1 ____ Number of times


12. During the past 3 months, has [Child’s name] stayed in the hospital overnight because of asthma? (In other words, admitted to hospital; Do not include an overnight stay in the emergency room.)

Yes No

If YES, how many different times was [Child’s name] admitted to the hospital?

12.1 ____ Number of visits


(If # of visits equals 1, then min = max)


12.2 ____ Minimum number of days in hospital


12.3 ____ Maximum number of days in hospital


12.4 ____ Total number of days in hospital



13. During the past 3 months, was [Child’s name] unable to attend school because of asthma? Yes No


If YES, then ask: How many days did [Child’s name] miss school?

13.1.1_____ Number of days [Child’s name] missed school

[Include only days school was in session.]



13.2 Did this occur in the past 2 weeks? Yes No


If YES, how many times?

13.2.1_____ Number of days [Child’s name] missed school

[Include only days school was in session.]


14. During the past 3 months, were YOU unable to attend work or carry out your usual activities because of [Child’s name] asthma?

Yes No

If YES, then ask


14.1 _____ Total number of days (use your best guess)


14.1.1 _____ Of these, how many work days did you miss?


14.2 Did this occur in the past 2 weeks? Yes No


If YES, then ask

14.2.1_____ Number of days you missed work (if applicable)


14.2.2_____ Number of days you missed other activities


15. In the past 3 months, did [Child’s name] wake up at night because of asthma?

Yes No

If YES, then ask

15.1 ______ Number of nights (use your best guess)


15.2 Did this occur in the past 2 weeks? Yes No


If YES, then ask


15.2.1 ______ Number of nights


16. During the last 3 months, did [Child’s name] take medication when he/she had an asthma episode or attack? Y N DK

If YES, then ask the following:

16.1 Please tell me which medicines

(Interviewer: Place a mark in the “Emergency” column next to each identified medicine on the med sheet on the last two pages of this questionnaire)

16.2 Did this occur in the past 2 weeks? Y N DK


17. During the last 3 months, did [Child’s name] take prescription asthma medications by inhaler? Y N DK

If YES, then ask all of the following:

17.1 How long did [Child’s name] take them?

1. ≤ 1 month

2. 2 months

3. 3 months

17.2 Please tell me which medicines

(Interviewer: Place a mark in the “Inhaler” column next to each identified medicine on the med sheet on the last two pages of this questionnaire)

17.3 Please tell me how many canisters were used up in the past 3 months

(Interviewer: Enter number next to each identified medicine on the med sheet on the last two pages of this questionnaire)

17.4 Did [Child’s name] take prescription asthma medications by inhaler in the past 2 weeks? Y N DK


18. During the last 3 months, has [Child’s name] taken any prescription medicine in pill or syrup form for his/her asthma? Y N DK

If YES, then ask the following:


    1. Please tell me which medicines

(Interviewer: Place a mark in the “Pill/Syrup” column next to each identified medicine on the med sheet on the last two pages of this questionnaire)

    1. Did this occur in the past 2 weeks? Y N DK


19. During the last 3 months, did [Child’s name] take any medicine on a regular schedule everyday for his/her asthma? Y N DK

If YES, then ask the following:


    1. What was the medication?

(Interviewer: Place a mark in the “Regular Schedule” column next to each identified medicine on the med sheet on the last two pages of this questionnaire)

    1. Did this occur in the past 2 weeks? Y N DK


  1. Did [Child’s name] receive a flu shot (probe: or seasonal flu vaccine?) during the past year?

Y N DK

Emergency/rescue

Inhaler/ nebulizer

Pill/Syrup

Regular (Daily-use) schedule

# Canisters used in last 3 months

Visual Confirmation


Emergency/rescue

Inhaler/ nebulizer

Pill/Syrup

Regular (Daily-use) schedule

# Canisters used in last 3 months

Visual Confirmation








Accolate







Nedocromil







Acetaminophen







Pediapred







Advair







Prednisolone







Advil







Prednisone







Aerobid







Proventil







Aerolate







Pirbuterol







Aerospan HFA







Primatene Mist







Albuterol







Pro-Air HFA







Allegra







Proventil







Alupent







Pulmicort Turbuhaler







Asmanex







QVAR







Atrovent







Respid







Azmacort







Robitussin







Beclomethasone dipropionate







Salbutamol







Beclovent







Salmeterol







Bitolterol







Serevent







Brethaire







Singulair







Brethine







Slo-phyllin







Budesonide







Symbicort







Choledyl







Terbutaline







Claritin







Theo-24







Combivent







Theochron







Cromolyn







Theoclear







Deltasone







Theo-Dur







Elixophyllin







Theophylline







Flovent







Theospan







Flovent Rotadisk







Tilade







Flunisolide







Tornalate







Fluticasone







T-Phyl







Foradil







Triamcinolone acetonide







Formoterol







Tylenol







Ibuprophen







Uniphyl







Intal







Vanceril







Ipratropium Bromide







Ventolin







Levalbuterol tartate







Volomax







Loratidine







Xolair







Maxair







Xopenex HFA







Medrol







Zafirlukast







Metaprel







Zileuton







Metaproteronol







Zyflo Filmtab







Methylpredinisolone







Zyrtec







Montelukast







Other:







Mometasonefuroate







Other:







Mucinex







Other:




2

DK = Don’t know R = Refused NA = Not applicable


File Typeapplication/msword
File Title2008 Behavioral Risk Factor Surveillance System Questionnaire (English version)
Subject2008 Behavioral Risk Factor Surveillance System Questionnaire (English version)
AuthorCDC
Last Modified ByGinger Lin Chew
File Modified2011-05-10
File Created2011-05-10

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