34.5 Survey

Continuation of National Children's Study Vanguard (Pilot) Study Data Collection: Study Visits through 60-Months and Sibling Birth Enrollment

42M_FamilyMedicalHistorySAQ

42-Month Interview

OMB: 0925-0593

Document [docx]
Download: docx | pdf

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Family Medical History SAQ, Phase 2g

OMB Specification


Family Medical History SAQ


Event Category:

Time-Based

Event:

42M

Administration:

N/A

Instrument Target:

Biological Mother; Biological Father

Instrument Respondent:

Biological Mother; Biological Father

Domain:

Questionnaire

Document Category:

Questionnaire

Method:

Self-Administered

Mode (for this instrument*):

In-Person, PAPI

OMB Approved Modes:

In-Person, PAPI;
Phone, PAPI;
Web-Based, CAI

Estimated Administration Time:

6 minutes

Multiple Child/Sibling Consideration:

Per Event

Special Considerations:

N/A

Version:

1.0

MDES Release:

4.0


*This instrument is OMB-approved for multi-mode administration but this version of the instrument is designed for administration in this/these mode(s) only.


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Family Medical History SAQ



TABLE OF CONTENTS





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Family Medical History SAQ



GENERAL PROGRAMMER INSTRUCTIONS:

WHEN PROGRAMMING INSTRUMENTS, VALIDATE FIELD LENGTHS AND TYPES AGAINST THE MDES TO ENSURE DATA COLLECTION RESPONSES DO NOT EXCEED THOSE OF THE MDES. SOME GENERAL ITEM LIMITS USED ARE AS FOLLOWS:


DATA ELEMENT FIELDS

MAXIMUM CHARACTERS PERMITTED

DATA TYPE

PROGRAMMER INSTRUCTIONS

ADDRESS AND EMAIL FIELDS

100

CHARACTER


UNIT AND PHONE FIELDS

10

CHARACTER


_OTH AND COMMENT FIELDS

255

CHARACTER

  • Limit text to 255 characters

FIRST NAME AND LAST NAME

30

CHARACTER

  • Limit text to 30 characters

ALL ID FIELDS

36

CHARACTER


ZIP CODE

5

NUMERIC


ZIP CODE LAST FOUR

4

NUMERIC


CITY

50

CHARACTER


DOB AND ALL OTHER DATE FIELDS (E.G., DT, DATE, ETC.)

10

NUMERIC


CHARACTER



  • DISPLAY AS MM/DD/YYYY

  • STORE AS YYYY-MM-DD

  • HARD EDITS:

MM MUST EQUAL 01 TO 12

DD MUST EQUAL 01 TO 31

YYYY MUST BE BETWEEN 1900 AND CURRENT YEAR.

TIME VARIABLES

TWO-DIGIT HOUR AND TWO-DIGIT MINUTE, AM/PM DESIGNATION

NUMERIC

  • HARD EDITS:

HOURS MUST BE BETWEEN 00 AND 12;

MINUTES MUST BE BETWEEN 00 AND 59


Instrument Guidelines for Participant and Respondent IDs:

PRENATALLY, THE P_ID IN THE MDES HEADER IS THAT OF THE PARTICIPANT (E.G. THE NON-PREGNANT WOMAN, PREGNANT WOMAN, OR THE FATHER).


POSTNATALLY, A RESPONDENT ID WILL BE USED IN ADDITION TO THE PARTICIPANT ID BECAUSE SOMEBODY OTHER THAN THE PARTICIPANT MAY BE COMPLETING THE INTERVIEW. FOR EXAMPLE, THE PARTICIPANT MAY BE THE CHILD AND THE RESPONDENT MAY BE THE MOTHER, FATHER, OR ANOTHER CAREGIVER. THEREFORE, MDES VERSION 2.2 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID (RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT. THIS WILL ALLOW ROCs TO INDICATE WHETHER THE RESPONDENT IS SOMEBODY OTHER THAN THE PARTICIPANT ABOUT WHOM THE QUESTIONS ARE BEING ASKED.



A REMINDER:

ALL RESPONDENTS MUST BE CONSENTED AND HAVE RECORDS IN THE PERSON, PARTICIPANT, PARTICIPANT_CONSENT AND LINK_PERSON_PARTICIPANT TABLES, WHICH CAN BE PRELOADED INTO EACH INSTRUMENT. ADDITIONALLY, IN POST-BIRTH QUESTIONNAIRES WHERE THERE IS THE ABILITY TO LOOP THROUGH A SET OF QUESTIONS FOR MULTIPLE CHILDREN, IT IS IMPORTANT TO CAPTURE AND STORE THE CORRECT CHILD P_ID ALONG WITH THE LOOP INFORMATION. IN THE MDES VARIABLE LABEL/DEFINITION COLUMN, THIS IS INDICATED AS FOLLOWS: EXTERNAL IDENTIFIER: PARTICIPANT ID FOR CHILD DETAIL.





RELATIONSHIP WITH CHILD


RWC00100. ​Please complete the Family Medical History Questionnaire as best you can.  If you don't know the answer to a question or do not have all the information you need to complete a question, please contact your biological mother, biological father, full brothers and sisters, or other family members and ask them to help you complete the question.  By full brothers and sisters, we mean brothers or sisters who have the same biological mother and father as you.


RWC01000/(FMH_CHILD_RELATE). What is your relationship with the child?


Label

Code

Go To

Biological (or Birth) Mother

1


Adoptive Mother

2


Biological Father

3


Adoptive Father

4


Grandparent

5


Other Relative

6


Other Non-Relative

7



SOURCE

National Health and Nutrition Examination Survey (NHANES) (modified)



BIOLOGICAL PARENTS & SIBLINGS


BPS00100. ​The following questions are about your biological parents and full siblings.


BPS01000/(FMH_WHO_RAISED). Were you raised by your biological parent or parents, other relatives, adoptive parent(s), or foster parent(s)?  (Check all that apply.)


Label

Code

Go To

Biological parent(s)

1


Adoptive parent(s)

2


Foster parent(s)

3


Other

-5


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


PROGRAMMER INSTRUCTIONS

  • IF FMH_WHO_RAISED = ANY COMBINATION OF RESPONSES 1 - 3 AND OTHER, GO TO FMH_WHO_RAISED_OTH.

  • IF FMH_WHO_RAISED = ANY COMBINATION OF RESPONSES 1 - 3 ONLY, GO TO FMH_HEALTH.

  • OTHERWISE, IF FMH_WHO_RAISED = -2, DO NOT ALLOW THE SELECTION OF ADDITIONAL RESPONSES AND GO TO FMH_HEALTH.


BPS02000/(FMH_WHO_RAISED_OTH). Please specify:

 

____________________________________________________


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


BPS03000/(FMH_HEALTH). Do you know anything about the health conditions of your biological parents or full siblings?


Label

Code

Go To

Yes

1


No

2

HS138000

Don't Know

-2



SOURCE

National Health and Nutrition Examination Survey (NHANES) (modified)


BPS04000/(FMH_FULL_SIBLINGS). How many full siblings do you have?  By full siblings, we mean brothers or sisters who have the same biological mother and father as you.

 

|_____|_____|

NUMBER OF FULL SIBLINGS


Label

Code

Go To

No full siblings

1


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


BPS05000/(FMH_M_ALIVE). Is your biological mother still living?


Label

Code

Go To

Yes

1

FMH_F_ALIVE

No

2


Don't know

-2

FMH_F_ALIVE


SOURCE

National Health and Nutrition Examination Survey (NHANES) (modified)


BPS06000/(FMH_M_DEATH_CAUSE). What was the cause of her death?

 

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Label

Code

Go To

Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


BPS07000/(FMH_M_DEATH_AGE). How old was she when she died?  If you aren't sure how old she was when she died, please make your best guess.

 

|_____|_____|

AGE


Label

Code

Go To

Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


BPS08000/(FMH_F_ALIVE). Is your biological father still living?


Label

Code

Go To

Yes

1

HBM00100

No

2


Don't Know

-2

HBM00100


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


BPS09000/(FMH_F_DEATH_CAUSE). What was the cause of his death?

 

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Label

Code

Go To

Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


BPS10000/(FMH_F_DEATH_AGE). How old was he when he died?  If you aren't sure how old he was when he died, please make your best guess.

 

|_____|_____|

AGE


Label

Code

Go To

Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)



HISTORY - BIOLOGICAL MOTHER


HBM00100. These next questions are about medical conditions or health problems your biological parents, as well as any full brothers or sisters might have had in the past.

 

First, has your biological mother​ ever been diagnosed with, or had any of the following:


HBM01000/(FMH_M_ASTHMA). Asthma?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM02000/(FMH_M_ECZEMA). Eczema or atopic dermatitis?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM03000/(FMH_M_ALLERGY). Allergies?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM04000/(FMH_M_AUTOIMMUNE). Auto-immune disease?


Label

Code

Go To

Yes

1


No

2

FMH_M_HIGHBP

Don't Know

-2

FMH_M_HIGHBP


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM05000/(FMH_M_AUTOIMMUNE_TYP). What was she diagnosed with?


Label

Code

Go To

Rheumatoid arthritis

1


Lupus

2


Other

3


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM06000/(FMH_M_HIGHBP). High blood pressure?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM07000/(FMH_M_DIABETES). Diabetes?


Label

Code

Go To

Yes

1


No

2

FMH_M_HIGHCHOL

Don't Know

-2

FMH_M_HIGHCHOL


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM08000/(FMH_M_CHILD_DM). Was she diagnosed with diabetes as a child or a teenager?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM09000/(FMH_M_INSULIN). Has she ever used insulin shots or an insulin pump to treat diabetes?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM10000/(FMH_M_HIGHCHOL). High cholesterol?


Label

Code

Go To

Yes

1


No

2


Don't know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM11000/(FMH_M_HEART). A heart attack?


Label

Code

Go To

Yes

1


No

2

FMH_M_CATH

Don't Know

-2

FMH_M_CATH


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM12000/(FMH_M_HEART_AGE). Did she have a heart attack before age 55?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM13000/(FMH_M_CATH). An angioplasty or coronary bypass surgery?


Label

Code

Go To

Yes

1


No

2

FMH_M_CANCER

Don't Know

-2

FMH_M_CANCER


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM14000/(FMH_M_CATH_AGE). Did she have an angioplasty or coronary bypass surgery before age 55?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM15000/(FMH_M_CANCER). Any type of cancer?


Label

Code

Go To

Yes

1


No

2

FMH_M_THYROID

Don't Know

-2

FMH_M_THYROID


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM16000/(FMH_M_CANCER_TYPE). What type of cancer was she diagnosed with?

 

_________________________________________________________________


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM17000/(FMH_M_THYROID). Thyroid disease?


Label

Code

Go To

Yes

1


No

2

FMH_M_ADD

Don't Know

-2

FMH_M_ADD


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM18000/(FMH_M_UNDERACTIVE). Was she diagnosed with an underactive thyroid?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM19000/(FMH_M_OVERACTIVE). Was she diagnosed with an overactive thyroid?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

National Health and Nutrition Examination Survey (NHANES) (modified)


HBM20000/(FMH_M_THY_DIS). Was she diagnosed with some other thyroid disease?


Label

Code

Go To

Yes

1


No

2

FMH_M_ADD

Don't Know

-2

FMH_M_ADD


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM21000/(FMH_M_THY_DIS_OTH). If yes, specify thyroid disease:

 

___________________________________________________________


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM22000/(FMH_M_ADD). Attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD)?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM23000/(FMH_M_AUTISM). Autism, Asperger syndrome, or other autism spectrum disorder?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM24000/(FMH_M_EATDIS). An eating disorder, such as anorexia or bulimia?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM25000/(FMH_M_ALCOHOL). Alcoholism?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM26000/(​FMH_M_BIPOLAR). Bipolar disorder?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM27000/(​FMH_M_DEPRESSION). Depression other than bipolar disorder?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM28000/(​FMH_M_SCHIZOPHR). Schizophrenia?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM29000/(​FMH_M_ANXIETY). Anxiety disorder, such as generalized anxiety disorder (GAD) or obsessive compulsive disorder (OCD)?


Label

Code

Go To

Yes

1


No

2

FMH_M_COGDIS

Don't Know

-2

FMH_M_COGDIS


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM30000/(​FMH_M_ANXIETY_TYPE). What type of anxiety disorder was she diagnosed with?

 

___________________________________________________________________________


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM31000/(​FMH_M_COGDIS). Intellectual disability?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM32000/(​​FMH_M_BIRTH_DEF). A birth defect?


Label

Code

Go To

Yes

1


No

2

​​FMH_M_GENETIC

Don't Know

-2

​​FMH_M_GENETIC


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM33000/(​​FMH_M_BIRTH_DEF_TYPE). What type of birth defect did she have?

 

___________________________________________________________________________


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM34000/(​​FMH_M_GENETIC). Genetic disease?


Label

Code

Go To

Yes

1


No

2

​​FMH_M_MEDS

Don't Know

-2

​​FMH_M_MEDS


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM35000/(​​FMH_M_GENETIC_TYPE). What type of genetic disease was she diagnosed with?

 

_______________________________________________________________________________________________


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM36000/(​​FMH_M_MEDS). Is he/she taking any medications?


Label

Code

Go To

Yes

1


No

2

HBF00100

Don't Know

-2

HBF00100


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBM37000/(​​FMH_M_MEDS_TYPE). What type of medications is she taking?

 

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


SOURCE

National Health and Nutrition Examination Survey (NHANES) (modified)



HISTORY - BIOLOGICAL FATHER


HBF00100. Next, has your biological father​ ever been diagnosed with, or had any of the following:


HBF01000/(FMH_F_ASTHMA). Asthma?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

National Health and Nutrition Examination Survey (NHANES) (modified)


HBF02000/(FMH_F_ECZEMA). Eczema or atopic dermatitis?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF03000/(FMH_F_ALLERGY). Allergies?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF04000/(FMH_F_AUTOIMMUNE). Auto-immune disease?


Label

Code

Go To

Yes

1


No

2

FMH_F_HIGHBP

Don't Know

-2

FMH_F_HIGHBP


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF05000/(FMH_F_AUTOIMMUNE_TYPE). What was he diagnosed with?


Label

Code

Go To

Rheumatoid arthritis

1


Lupus

2


Other

3


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF06000/(FMH_F_HIGHBP). High blood pressure?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF07000/(FMH_F_DIABETES). Diabetes?


Label

Code

Go To

Yes

1


No

2

FMH_F_HIGHCHOL

Don't Know

-2

FMH_F_HIGHCHOL


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF08000/(FMH_F_CHILD_DM). Was he diagnosed with diabetes as a child or a teenager?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF09000/(FMH_F_INSULIN). Has he ever used insulin shots or an insulin pump to treat diabetes?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF10000/(FMH_F_HIGHCHOL). High cholesterol?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF11000/(FMH_F_HEART). A​ heart attack?


Label

Code

Go To

Yes

1


No

2

FMH_F_CATH

Don't Know

-2

FMH_F_CATH


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF12000/(FMH_F_HEART_AGE). Did he have a heart attack before age 55?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF13000/(FMH_F_CATH). An angioplasty or coronary bypass surgery?


Label

Code

Go To

Yes

1


No

2

FMH_F_CANCER

Don't Know

-2

FMH_F_CANCER


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF14000/(FMH_F_CATH_AGE). Did he have an angioplasty or coronary bypass surgery before age 55?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF15000/(FMH_F_CANCER). Any type of cancer?


Label

Code

Go To

Yes

1


No

2

FMH_F_THYROID

Don't Know

-2

FMH_F_THYROID


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF16000/(FMH_F_CANCER_TYPE). What type of cancer was he diagnosed with?

 

______________________________________________________________________________________


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF17000/(FMH_F_THYROID). Thyroid disease?


Label

Code

Go To

YEes

1


No

2

FMH_F_ADD

Don't Know

-2

FMH_F_ADD


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF18000/(FMH_F_UNDERACTIVE). Was he diagnosed with an underactive thyroid?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF19000/(FMH_F_OVERACTIVE). Was he diagnosed with an overactive thyroid?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF20000/(FMH_F_THY_DIS). Was he diagnosed with some other thyroid disease?


Label

Code

Go To

Yes

1


No

2

FMH_F_ADD

Don't Know

-2

FMH_F_ADD


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF21000/(FMH_F_THY_DIS_OTH). If yes, specify thyroid disease:

 

____________________________________________________________________________


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF22000/(FMH_F_ADD). ​Attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD)?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF23000/(FMH_F_AUTISM). ​Autism, Asperger syndrome, or other autism spectrum disorder?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF24000/(FMH_F_EATDIS). ​An eating disorder, such as anorexia or bulimia?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF25000/(FMH_F_ALCOHOL). Alcoholism?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF26000/(FMH_F_BIPOLAR). Bipolar disorder?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF27000/(FMH_F_DEPRESSION). Depression other than bipolar disorder?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF28000/(FMH_F_SCHIZOPHR). Schizophrenia?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF29000/(FMH_F_ANXIETY). ​Anxiety disorder, such as generalized anxiety disorder (GAD) or obsessive compulsive disorder (OCD)?


Label

Code

Go To

Yes

1


No

2

FMH_F_COGDIS

Don't Know

-2

FMH_F_COGDIS


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF30000/(FMH_F_ANXIETY_TYPE). What type of anxiety disorder was he diagnosed with?

 

___________________________________________________________________________


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF31000/(FMH_F_COGDIS). Intellectual disability?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF32000/(FMH_F_BIRTH_DEF). A b​irth defect?


Label

Code

Go To

Yes

1


No

2

FMH_F_GENETIC

Don't Know

-2

FMH_F_GENETIC


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF33000/(FMH_F_BIRTH_DEF_TYPE). What type of birth defect did he have?

 

___________________________________________________________________________


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF34000/(FMH_F_GENETIC). Genetic disease?


Label

Code

Go To

Yes

1


No

2

FMH_F_MEDS

Don't Know

-2

FMH_F_MEDS


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF35000/(FMH_F_GENETIC_TYPE). What type of genetic disease was he diagnosed with?

 

_______________________________________________________________________________________________


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF36000/(FMH_F_MEDS). Taking any medications?


Label

Code

Go To

Yes

1


No

2

HS100100

DON'T KNOW

-2

HS100100


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HBF37000/(FMH_F_MEDS_TYPE). What type of medications is he taking?

 

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)



HISTORY SIBLING 1


HS100100. ​Next, has your oldest full sibling (by full sibling, we mean brother or sister who has the same biological mother and father as you) ever been diagnosed with, or had any of the following:


HS101000/(FMH_S1_ASTHMA). Asthma?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS102000/(FMH_S1_ECZEMA). Eczema or atopic dermatitis?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS103000/(FMH_S1_ALLERGY). Allergies?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS104000/(FMH_S1_AUTOIMMUNE). Auto-immune disease?


Label

Code

Go To

Yes

1


No

2

FMH_S1_HIGHBP

Don't Know

-2

FMH_S1_HIGHBP


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS105000/(FMH_S1_AUTOIMMUNE_TYPE). What was he/she diagnosed with?


Label

Code

Go To

Rheumatoid arthritis

1


Lupus

2


Other

3


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS106000/(FMH_S1_HIGHBP). High blood pressure?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS107000/(FMH_S1_DIABETES). Diabetes?


Label

Code

Go To

Yes

1


No

2

FMH_S1_HIGHCHOL

Don't Know

-2

FMH_S1_HIGHCHOL


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS108000/(FMH_S1_CHILD_DM). Was he/she diagnosed with diabetes as a child or a teenager?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS109000/(FMH_S1_INSULIN). Has he/she ever used insulin shots or an insulin pump to treat diabetes?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS110000/(FMH_S1_HIGHCHOL). High cholesterol?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS111000/(FMH_S1_HEART). A heart attack?


Label

Code

Go To

Yes

1


No

2

FMH_S1_CATH

Don't Know

-2

FMH_S1_CATH


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS112000/(FMH_S1_HEART_AGE). Did he/she have a heart attack before age 55?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS113000/(FMH_S1_CATH). An angioplasty or coronary bypass surgery?


Label

Code

Go To

Yes

1


No

2

FMH_S1_CANCER

Don't Know

-2

FMH_S1_CANCER


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS114000/(FMH_S1_CATH_AGE). Did he/she have an angioplasty or coronary bypass surgery before age 55?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS115000/(FMH_S1_CANCER). Any type of cancer?


Label

Code

Go To

Yes

1


No

2

FMH_S1_THYROID

Don't Know

-2

FMH_S1_THYROID


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS116000/(FMH_S1_CANCER_TYPE). What type of cancer was he/she diagnosed with?

 

_____________________________________________________________________________________________


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS117000/(FMH_S1_THYROID). Thyroid disease?


Label

Code

Go To

Yes

1


No

2

FMH_S1_ADD

Don't Know

-2

FMH_S1_ADD


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS118000/(FMH_S1_UNDERACTIVE). Was he/she diagnosed with an underactive thyroid?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS119000/(FMH_S1_OVERACTIVE). ​Was he/she diagnosed with an overactive thyroid?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS120000/(FMH_S1_THY_DIS). Was he/she diagnosed with some other thyroid disease?


Label

Code

Go To

Yes

1


No

2

FMH_S1_ADD

Don't Know

-2

FMH_S1_ADD


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS121000/(FMH_S1_THY_DIS_OTH). If yes, specify thyroid disease:

 

______________________________________________________________________________________________


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS122000/(FMH_S1_ADD). Attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD)?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS123000/(FMH_S1_AUTISM). Autism, Asperger syndrome, or other autism spectrum disorder?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS124000/(FMH_S1_EATDIS). An eating disorder, such as anorexia or bulimia?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS125000/(FMH_S1_ALCOHOL). Alcoholism?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS126000/(FMH_S1_BIPOLAR). Bipolar disorder?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS127000/(FMH_S1_DEPRESSION). Depression other than bipolar disorder?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS128000/(FMH_S1_SCHIZOPHR). Schizophrenia?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS129000/(FMH_S1_ANXIETY). ​Anxiety disorder, such as generalized anxiety disorder (GAD) or obsessive compulsive disorder (OCD)?


Label

Code

Go To

Yes

1


No

2

FMH_S1_COGDIS

Don't Know

-2

FMH_S1_COGDIS


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS130000/(FMH_S1_ANXIETY_TYPE). What type of anxiety disorder was he/she diagnosed with?

 

_____________________________________________________________________________________________


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS131000/(FMH_S1_COGDIS). Intellectual disability?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS132000/(FMH_S1_BIRTH_DEF). A birth defect?


Label

Code

Go To

Yes

1


No

2

FMH_S1_GENETIC

Don't Know

-2

FMH_S1_GENETIC


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS133000/(FMH_S1_BIRTH_DEF_TYPE). What type of birth defect did he/she have?

 

________________________________________________________


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS134000/(FMH_S1_GENETIC). Genetic disease?


Label

Code

Go To

Yes

1


No

2

FMH_S1_MEDS

Don't Know

-2

FMH_S1_MEDS


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS135000/(FMH_S1_GENETIC_TYPE). What type of genetic disease was he/she diagnosed with?

 

____________________________________________________________________________________________


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS136000/(FMH_S1_MEDS). Taking any medications?


Label

Code

Go To

Yes

1


No

2

HS138000

Don't Know

-2

HS138000


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS137000/(FMH_S1_MEDS_TYPE). What type of medications is he/she taking?

 

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


SOURCE

​​National Health and Nutrition Examination Survey (NHANES) (modified)


HS138000. For additional siblings, please fill out the Family Medical History Supplemental Questionnaire(s).

 

Thank you for participating in the National Children's Study and for taking the time to complete this survey.



FOR OFFICIAL USE


FOU01000/(P_ID). Participant ID:_________________________________________


FOU02000/(R_P_ID). Respondent ID:___________________________________


Public reporting burden for this collection of information is estimated to average 6 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593*). Do not return the completed form to this address.

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