Adult Biometric Measures

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

ADULT BIOMETRIC MEASURES

Public reporting burden of this collection of information is estimated to average 30 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx)

PART A.

I'm going to begin with some general questions about you, your health and recent activities that are related to the biometric measures we will be collecting today

DEMOGRAPHICS

1. What is your age?

_ _ Code age in years

7. Don‘t know / Not sure

9. Refused

ASK ONLY IF FEMALE:

2. To your knowledge, are you now pregnant?

1 Yes

2 No

7 Don‘t know / Not sure

7. Refused

BLOOD PRESSURE

3. Since we last interviewed you on [DATE], Have you been told by a doctor, nurse, or other health professional that you have high blood pressure?
   If “Yes” and respondent is female, ask: “Was this only when you were pregnant?”

1 Yes
2 Yes, but female told only during pregnancy [Go to next section]
3 No [Go to next section]
4 Told borderline high or pre-hypertensive [Go to next section]
7 Don‘t know / Not sure [Go to next section]
9 Refused [Go to next section]

4. Since we last interviewed you on [DATE], (Have you) changed your eating habits (to help lower or control your high blood pressure)?

1 Yes
2 No
7 Don‘t know / Not sure
9 Refused

5. Since we last interviewed you on [DATE], (Have you) cut down on salt (to help lower or control your high blood pressure)?

1 Yes
2 No
3 Do not use salt
7 Don‘t know / Not sure
9 Refused

6. Since we last interviewed you on [DATE], (Have you) reduced alcohol use (to help lower or control your high blood pressure)?

1 Yes
2 No
3 Do not drink
7 Don‘t know / Not sure
9 Refused

7. Since we last interviewed you on [DATE], (Are you) exercising (to help lower or control your high blood pressure)?

1 Yes
2 No
7 Don‘t know / Not sure
9 Refused

4. 8. Since we last interviewed you on [DATE], Are you taking medicine for your high blood pressure?

1 Yes (list)_________________
2 No
7 Don‘t know / Not sure
9 Refused

TOBACO SMOKE/EXPOSURE

9. Do you currently smoke cigarettes, cigarillos, cigars or pipe?

1. Yes

2. No – skip to question 10

DON’T KNOW – SKIP TO QUESTION 10

REFUSED – SKIP TO QUESTION 10

9a. How much do you usually smoke per day?

-----------

________Cigarettes

Cigarillos

Cigars

Pipes

DON’T KNOW

REFUSED

10. How long has it been since you last smoked a cigarette, cigarillo, cigar or pipe, even one or two puffs?

Hours ago

Days ago

Months ago

Never smoked

DON’T KNOW

REFUSED

11. Do you currently use chewing tobacco, snuff, or dip such as Redman, Skoal, or Copenhagen?

1. Yes

2. No – SKIP TO QUESTION 12

DON’T KNOW – SKIP TO QUESTION 12

REFUSED – SKIP TO QUESTION 12

11a Approximately how long ago did you last use any of those?

_____ Hours ago

______Days ago

______Weeks ago

______Months ago

DON’T KNOW

REFUSED

12. Are currently using anything to help you quit smoking like a nicotine patch, nicotine gum, nasal spray or inhaler?

Yes

No – SKIP TO QUESTION 13

DON’T KNOW – SKIP TO QUESTION 13

REFUSED – SKIP TO QUESTION 13

12a. When did you last use any of these things that are designed to help you quit smoking?

_____ Currently using (e.g. patch)

Hours ago

Days ago

______Weeks ago

______Months ago

DON’T KNOW

REFUSED

13.(not counting yourself) Does anyone who lives here smoke cigarettes, cigars, or pipes anywhere inside this home?

Yes

No – skip to question16

Don’t know – skip to question 16

Refused – skip to question 16

14. How many cigarettes per day [do you/does anyone in the house] usually smoke anywhere inside the home?

___ number of cigarettes total

DON’T KNOW

REFUSED

14. In the past 7 days, on how many days did anyone smoke cigarettes, cigars or pipes anywhere inside your home?

Enter a number from 1-7.

14. During the past 7 days, that is since <DATE>, not counting at home, on how many days did you breathe smoke from someone else who was smoking in an indoor public place? Include the place you work if people smoke indoors there.

IF NEEDED, SAY: Examples of indoor public places are indoor areas of stores, restaurants, bars, casinos, clubs, and sports arenas.

_____ NUMBER OF DAYS

DON’T KNOW

REFUSED

WEIGHT

14. {Do you} consider {yourself now to be…

1 overweight
2 underweight
3 about right
7 Don‘t know / Not sure
9 Refused

14. During the past 12 months, {have you} tried to lose weight?

1 Yes
2 No
7 Don‘t know / Not sure
9 Refused

14. During the past 30 days, {have you} gained weight?

1 Yes - How many pounds?_________ lbs./kg
2 No
7 Don‘t know / Not sure
9 Refused

14. During the past 30 days, have you lost weight?

1 Yes - How many pounds?_________ lbs./kg
2 No
7 Don‘t know / Not sure
9 Refused

RECENT FOOD INTAKE

14. What food or foods did <you> eat during your last meal or snack?Please list all the food and drinks you had during your last meal or snack.

21a. what time was that food eaten? ___________________

14. Are you currently fasting?

1 Yes
2 No
7 Don‘t know / Not sure
9 Refused

RECENT ILLNESS

14. List any cold, flu or other illness you have had in the last 2 weeks. For each one, please tell me how recently the illness occurred.

If no illness in last 2 weeks, check here: _______

Illness

Today Last 2 days

Last 2 weeks

1) _______________________ □ □ □

2) _______________________ □ □ □

3) _______________________ □ □ □

4) _______________________ □ □ □

5) _______________________ □ □ □

The next few questions will help us understand the results of your saliva sample.

14. Has a doctor or dentist told you that you had periodontal disease (that is, an infection of the soft tissues and bones surrounding the teeth)?

Yes

No

14. Before this visit, when was the last time you brushed your teeth?

Time: ____________ AM/PM

24a The last time you brushed your teeth, did you see any pink or reddish color when you spit into the sink?

Yes

No

Don’t know

14. In the past 24 hours have you had any injuries to your mouth or any dental work that caused bleeding?

Yes

No

14. Do you have any open sores or cuts in your mouth?

Yes

No

QUES: RECENT MEDICATION USE

1. What medications are you currently taking? (Prescription medications, OTC, vitamins, dietary supplements etc.)

INTERVIEWER INSTRUCTION – IF THE PERSON IS CURRENTLY TAKING THE MEDICATION, INDICATE “ONGOING” FOR THE STOP DATE AND MARK “ONGOING” AS YES.

_____ No medication

NAME (brand/generic)	DOSE (Mg etc.)	FREQUENCY (1X, 2X etc.)	ROUTE (Oral, shot etc.)	INDICATION (Hypertension etc.)	START DATE (MM/YR)	STOP DATE (MM/YR)	ONGOING? (Yes/No)
Example: Norvasc/Amlodipine	5mg	1X	oral	High Blood Pressure	3/2008	ongoing
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

DON’T KNOW

REFUSED

PART B.

I would like to start measurements by taking your pulse and blood pressure. I will take your pulse and blood pressure with three consecutive readings with 30 sec intervals between each reading. (Have respondent rest for 5 minutes if they left seat prior to BP readings)

PREPARE SUBJECT FOR BLOOD PRESSURE MEASUREMENT ACCORDING TO

INSTRUCTIONS

			ADULT BLOOD PRESSURE						ARM RT or LT MID ARM CIRCUMFERANCE IN . CUFF SIZE Small (7-9 inches) …………..…………………...1 Medium (9-13 inches)……………………………2 Large (13-17 inches) ……………………………..3 Extra-large (17-20 inches) ……………………… 4 HEART RATE per min .... SYSTOLIC mmHg... .... DIASTOLIC mmHg ... .... RF 9999
			ADULT HEIGHT						MEASURED CM . RF 9999
			ADULT WAIST CIRCUMFERANCE						MEASURED CM... . RF 9999
			ADULT WEIGHT						MEASURED KG... . RF 9999
		SALIVA SAMPLE COLLECTED					YES/NO
		6a. SALIVA SAMPLE #					ID - -
		6b. SALIVA SAMPLE SHIPPING #					ID - -
ADULT ACCELEROMETRY STUDY						YES/NO

7a.. ACCELEROMETER ID #

ID - -