Biometric Measures Age 12-17

YOUTH BIOMETRIC MEASURES (Ages 12-17)

Interviewer_______________ Study ID # - - Date of Completion ___________

Time of Completion___________

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

YOUTH BIOMETRIC MEASURES

(Ages 12-17)

Public reporting burden of this collection of information is estimated to average 20 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)

Now I'm going to begin with some general questions about your health that relate to the biometric measures we will be collecting today

PART A.

WEIGHT

1. How do you describe your weight? Would you say….

A. Very underweight

B. Slightly underweight

C. About the right weight

D. Slightly overweight

E. Very overweight

DON’T KNOW

REFUSED

2. Which of the following are you trying to do about your weight?

A. Lose weight

B. Gain weight

C. Stay the same weight

D. I am not trying to do anything about my weight

DON’T KNOW

REFUSED

3. During the past 30 days, did you go without eating for 24 hours or more (also called fasting) to lose weight or to keep from gaining weight?

A. Yes

B. No

DON’T KNOW

REFUSED

4. During the past 30 days, did you take any diet pills, powders, or liquids without a doctor's advice to lose weight or to keep from gaining weight? (Do not include meal replacement products such as Slim Fast.)

A. Yes

B. No

DON’T KNOW

REFUSED

5. During the past 30 days, did you vomit or take laxatives to lose weight or to keep from gaining weight?

A. Yes

B. No

DON’T KNOW

REFUSED

6. During the past 30 days, have you gainedweight?

A. Yes – How many pounds? ______ lbs

B. No

C Don’t know

D Refused

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

A. Yes – How many pounds? ______ lbs

B. No

C Don’t know

D Refused

TOBACCO SMOKE/EXPOSURE

Now I’m going to ask you questions about smoking. I will ask the question and you can tell me the number on the card that shows what your answer is. I will be asking these questions of everybody whether or not they say they smoke.

8. During the past 7 days, on how many days were you in the same room with somebody who was smoking cigarettes?

ENTER NUMBER OF DAYS: _________________

DON’T KNOW

REFUSED

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

9aHow 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

_____ Months ago

_______ Never used

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

_____ Months ago

_____Never used

RECENT FOOD INTAKE

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

13a. what time was that food eaten? ________________AM/PM___

14. Are you currently fasting?

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

RECENT ILLNESS

14. 15. 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

DON’T KNOW

REFUSED

14. Do you have braces?

Yes

No

DON’T KNOW

REFUSED

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

Time: _________________ AM/PM18a 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

REFUSED

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

Yes

No

DON’T KNOW

REFUSED

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

Yes

No

DON’T KNOW

REFUSED

RECENT MEDICATION USE

21.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.

PART B.

1.

CHILD HEIGHT

MEASURED CM .

RF 9999

2.

CHILD WAIST CIRCUMFERANCE

MEASURED CM... .

RF 9999

3.

CHILD WEIGHT

MEASURED KG... .

RF 9999

5.

SALIVA SAMPLE COLLECTED

YES/NO

5a.

SALIVA SAMPLE #

ID - -

5b.

SALIVA SAMPLE SHIPPING #

ID - -

6. CHILD ACCELEROMETRY STUDY PARTICIPANT?

YES/NO

6a. ACCELEROMETER ID #

ID - -

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