34.6 Survey

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

42MFamilyMedicalHistorySupplemental

42-Month Interview

OMB: 0925-0593

Document [docx]
Download: docx | pdf

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Family Medical History Supplemental SAQ, Phase 2g

OMB Specification


Family Medical History Supplemental 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 Supplemental SAQ



TABLE OF CONTENTS





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Family Medical History Supplemental 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.





SECOND FULL SIBLING


SFS00100. Please complete this supplemental form if you have more than one full brother or full sister.

 

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.

 

Have any of your full siblings ever been diagnosed with or had any of the following:

 

Begin with the second oldest full sibling.


SFS01000/(FMH_S2_ASTHMA). Asthma?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


SFS02000/(FMH_S2_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)


SFS03000/(FMH_S2_ALLERGY). Allergies?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


SFS04000/(FMH_S2_AUTOIMMUNE). Auto-immune disease?


Label

Code

Go To

Yes

1


No

2

FMH_S2_HIGHBP

Don't Know

-2

FMH_S2_HIGHBP


SOURCE

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


SFS05000/(FMH_S2_AUTOIMMUNE_TYP). 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)


SFS06000/(FMH_S2_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)


SFS07000/(FMH_S2_DIABETES). Diabetes?


Label

Code

Go To

Yes

1


No

2

FMH_S2_HIGHCHOL

Don't Know

-2

FMH_S2_HIGHCHOL


SOURCE

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


SFS08000/(FMH_S2_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)


SFS09000/(FMH_S2_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)


SFS10000/(FMH_S2_HIGHCHOL). High cholesterol?


Label

Code

Go To

Yes

1


No

2


Don't know

-2



SOURCE

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


SFS11000/(FMH_S2_HEART). A heart attack?


Label

Code

Go To

Yes

1


No

2

FMH_S2_CATH

Don't Know

-2

FMH_S2_CATH


SOURCE

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


SFS12000/(FMH_S2_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)


SFS13000/(FMH_S2_CATH). An angioplasty or coronary bypass surgery?


Label

Code

Go To

Yes

1


No

2

FMH_S2_CANCER

Don't Know

-2

FMH_S2_CANCER


SOURCE

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


SFS14000/(FMH_S2_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)


SFS15000/(FMH_S2_CANCER). Any type of cancer?


Label

Code

Go To

Yes

1


No

2

FMH_S2_THYROID

Don't Know

-2

FMH_S2_THYROID


SOURCE

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


SFS16000/(FMH_S2_CANCER_TYPE). What type of cancer was he/she diagnosed with?

 

_________________________________________________________________


SOURCE

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


SFS17000/(FMH_S2_THYROID). Thyroid disease?


Label

Code

Go To

Yes

1


No

2

FMH_S2_ADD

Don't Know

-2

FMH_S2_ADD


SOURCE

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


SFS18000/(FMH_S2_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)


SFS19000/(FMH_S2_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)


SFS20000/(FMH_S2_THY_DIS). Was he/she diagnosed with some other thyroid disease?


Label

Code

Go To

Yes

1


No

2

FMH_S2_ADD

Don't Know

-2

FMH_S2_ADD


SOURCE

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


SFS21000/(FMH_S2_THY_DIS_OTH). If yes, specify thyroid disease:

 

___________________________________________________________


SOURCE

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


SFS22000/(FMH_S2_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)


SFS23000/(FMH_S2_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)


SFS24000/(FMH_S2_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)


SFS25000/(FMH_S2_ALCOHOL). Alcoholism?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


SFS26000/(​FMH_S2_BIPOLAR). Bipolar disorder?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


SFS27000/(​FMH_S2_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)


SFS28000/(​FMH_S2_SCHIZOPHR). Schizophrenia?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


SFS29000/(​FMH_S2_ANXIETY). Anxiety disorder, such as generalized anxiety disorder (GAD) or obsessive compulsive disorder (OCD)?


Label

Code

Go To

Yes

1


No

2

FMH_S2_COGDIS

Don't Know

-2

FMH_S2_COGDIS


SOURCE

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


SFS30000/(​FMH_S2_ANXIETY_TYPE). What type of anxiety disorder was he/she diagnosed with?

 

___________________________________________________________________________


SOURCE

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


SFS31000/(​FMH_S2_COGDIS). Intellectual disability?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


SFS32000/(​​FMH_S2_BIRTH_DEF). A birth defect?


Label

Code

Go To

Yes

1


No

2

​​FMH_S2_GENETIC

Don't Know

-2

​​FMH_S2_GENETIC


SOURCE

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


SFS33000/(​​FMH_S2_BIRTH_DEF_TYPE). What type of birth defect did he/she have?

 

___________________________________________________________________________


SOURCE

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


SFS34000/(​​FMH_S2_GENETIC). Genetic disease?


Label

Code

Go To

Yes

1


No

2

​​FMH_S2_MEDS

Don't Know

-2

​​FMH_S2_MEDS


SOURCE

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


SFS35000/(​​FMH_S2_GENETIC_TYPE). What type of genetic disease was he/she diagnosed with?

 

_______________________________________________________________________________________________


SOURCE

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


SFS36000/(​​FMH_S2_MEDS). Is he/she taking any medications?


Label

Code

Go To

Yes

1


No

2

TFS00100

Don't Know

-2

TFS00100


SOURCE

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


SFS37000/(​​FMH_S2_MEDS_TYPE). What type of medications is he/she taking?

 

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


SOURCE

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



THIRD FULL SIBLING


TFS00100. Next, has your next oldest full sibling ever been diagnosed with, or had any of the following:


TFS01000/(FMH_S3_ASTHMA). Asthma?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


TFS02000/(FMH_S3_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)


TFS03000/(FMH_S3_ALLERGY). Allergies?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


TFS04000/(FMH_S3_AUTOIMMUNE). Auto-immune disease?


Label

Code

Go To

Yes

1


No

2

FMH_S3_HIGHBP

Don't Know

-2

FMH_S3_HIGHBP


SOURCE

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


TFS05000/(FMH_S3_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)


TFS06000/(FMH_S3_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)


TFS07000/(FMH_S3_DIABETES). Diabetes?


Label

Code

Go To

Yes

1


No

2

FMH_S3_HIGHCHOL

Don't Know

-2

FMH_S3_HIGHCHOL


SOURCE

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


TFS08000/(FMH_S3_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)


TFS09000/(FMH_S3_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)


TFS10000/(FMH_S3_HIGHCHOL). High cholesterol?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


TFS11000/(FMH_S3_HEART). A​ heart attack?


Label

Code

Go To

Yes

1


No

2

FMH_S3_CATH

Don't Know

-2

FMH_S3_CATH


SOURCE

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


TFS12000/(FMH_S3_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)


TFS13000/(FMH_S3_CATH). An angioplasty or coronary bypass surgery?


Label

Code

Go To

Yes

1


No

2

FMH_S3_CANCER

Don't Know

-2

FMH_S3_CANCER


SOURCE

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


TFS14000/(FMH_S3_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)


TFS15000/(FMH_S3_CANCER). Any type of cancer?


Label

Code

Go To

Yes

1


No

2

FMH_S3_THYROID

Don't Know

-2

FMH_S3_THYROID


SOURCE

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


TFS16000/(FMH_S3_CANCER_TYPE). What type of cancer was he/she diagnosed with?

 

______________________________________________________________________________________


SOURCE

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


TFS17000/(FMH_S3_THYROID). Thyroid disease?


Label

Code

Go To

Yes

1


No

2

FMH_S3_ADD

Don't Know

-2

FMH_S3_ADD


SOURCE

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


TFS18000/(FMH_S3_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)


TFS19000/(FMH_S3_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)


TFS20000/(FMH_S3_THY_DIS). Was he/she diagnosed with some other thyroid disease?


Label

Code

Go To

Yes

1


No

2

FMH_S3_ADD

Don't Know

-2

FMH_S3_ADD


SOURCE

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


TFS21000/(FMH_S3_THY_DIS_OTH). If yes, specify thyroid disease:

 

____________________________________________________________________________


SOURCE

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


TFS22000/(FMH_S3_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)


TFS23000/(FMH_S3_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)


TFS24000/(FMH_S3_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)


TFS25000/(FMH_S3_ALCOHOL). Alcoholism?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


TFS26000/(FMH_S3_BIPOLAR). Bipolar disorder?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


TFS27000/(FMH_S3_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)


TFS28000/(FMH_S3_SCHIZOPHR). Schizophrenia?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


TFS29000/(FMH_S3_ANXIETY). ​Anxiety disorder, such as generalized anxiety disorder (GAD) or obsessive compulsive disorder (OCD)?


Label

Code

Go To

Yes

1


No

2

FMH_S3_COGDIS

Don't Know

-2

FMH_S3_COGDIS


SOURCE

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


TFS30000/(FMH_S3_ANXIETY_TYPE). What type of anxiety disorder was he/she diagnosed with?

 

___________________________________________________________________________


SOURCE

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


TFS31000/(FMH_S3_COGDIS). Intellectual disability?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


TFS32000/(FMH_S3_BIRTH_DEF). B​irth defect?


Label

Code

Go To

Yes

1


No

2

FMH_S3_GENETIC

Don't Know

-2

FMH_S3_GENETIC


SOURCE

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


TFS33000/(FMH_S3_BIRTH_DEF_TYPE). What type of birth defect did he/she have?

 

___________________________________________________________________________


SOURCE

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


TFS34000/(FMH_S3_GENETIC). Genetic disease?


Label

Code

Go To

Yes

1


No

2

FMH_S3_MEDS

Don't Know

-2

FMH_S3_MEDS


SOURCE

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


TFS35000/(FMH_S3_GENETIC_TYPE). What type of genetic disease was he/she diagnosed with?

 

_______________________________________________________________________________________________


SOURCE

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


TFS36000/(FMH_S3_MEDS). Taking any medications?


Label

Code

Go To

Yes

1


No

2

FFS00100

DON'T KNOW

-2

FFS00100


SOURCE

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


TFS37000/(FMH_S3_MEDS_TYPE). What type of medications is he/she taking?

 

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


SOURCE

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



FOURTH FULL SIBLING


FFS00100. Next, has your next oldest full sibling ever been diagnosed with, or had any of the following:


FFS01000/(FMH_S4_ASTHMA). Asthma?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


FFS02000/(FMH_S4_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)


FFS03000/(FMH_S4_ALLERGY). Allergies?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


FFS04000/(FMH_S4_AUTOIMMUNE). Auto-immune disease?


Label

Code

Go To

Yes

1


No

2

FMH_S4_HIGHBP

Don't Know

-2

FMH_S4_HIGHBP


SOURCE

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


FFS05000/(FMH_S4_AUTOIMMUNE_TYPE). What was he/she diagnosed with?


Label

Code

Go To

Rheumatoid arthritis

1


Lupus

2


Other auto-immune disease

3


Don't Know

-2



SOURCE

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


FFS06000/(FMH_S4_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)


FFS07000/(FMH_S4_DIABETES). Diabetes?


Label

Code

Go To

Yes

1


No

2

FMH_S4_HIGHCHOL

Don't Know

-2

FMH_S4_HIGHCHOL


SOURCE

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


FFS08000/(FMH_S4_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)


FFS09000/(FMH_S4_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)


FFS10000/(FMH_S4_HIGHCHOL). High cholesterol?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


FFS11000/(FMH_S4_HEART). A heart attack?


Label

Code

Go To

Yes

1


No

2

FMH_S4_CATH

Don't Know

-2

FMH_S4_CATH


SOURCE

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


FFS12000/(FMH_S4_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)


FFS13000/(FMH_S4_CATH). An angioplasty or coronary bypass surgery?


Label

Code

Go To

Yes

1


No

2

FMH_S4_CANCER

Don't Know

-2

FMH_S4_CANCER


SOURCE

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


FFS14000/(FMH_S4_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)


FFS15000/(FMH_S4_CANCER). Any type of cancer?


Label

Code

Go To

Yes

1


No

2

FMH_S4_THYROID

Don't Know

-2

FMH_S4_THYROID


SOURCE

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


FFS16000/(FMH_S4_CANCER_TYPE). What type of cancer was he/she diagnosed with?

 

_____________________________________________________________________________________________


SOURCE

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


FFS17000/(FMH_S4_THYROID). Thyroid disease?


Label

Code

Go To

Yes

1


No

2

FMH_S4_ADD

Don't Know

-2

FMH_S4_ADD


SOURCE

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


FFS18000/(FMH_S4_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)


FFS19000/(FMH_S4_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)


FFS20000/(FMH_S4_THY_DIS). Was he/she diagnosed with some other thyroid disease?


Label

Code

Go To

Yes

1


No

2

FMH_S4_ADD

Don't Know

-2

FMH_S4_ADD


SOURCE

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


FFS21000/(FMH_S4_THY_DIS_OTH). If yes, specify thyroid disease:

 

______________________________________________________________________________________________


SOURCE

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


FFS22000/(FMH_S4_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)


FFS23000/(FMH_S4_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)


FFS24000/(FMH_S4_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)


FFS25000/(FMH_S4_ALCOHOL). Alcoholism?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


FFS26000/(FMH_S4_BIPOLAR). Bipolar disorder?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


FFS27000/(FMH_S4_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)


FFS28000/(FMH_S4_SCHIZOPHR). Schizophrenia?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


FFS29000/(FMH_S4_ANXIETY). ​Anxiety disorder, such as generalized anxiety disorder (GAD) or obsessive compulsive disorder (OCD)?


Label

Code

Go To

Yes

1


No

2

FMH_S4_COGDIS

Don't Know

-2

FMH_S4_COGDIS


SOURCE

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


FFS30000/(FMH_S4_ANXIETY_TYPE). What type of anxiety disorder was he/she diagnosed with?

 

_____________________________________________________________________________________________


SOURCE

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


FFS31000/(FMH_S4_COGDIS). Intellectual disability?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


FFS32000/(FMH_S4_BIRTH_DEF). A birth defect?


Label

Code

Go To

Yes

1


No

2

FMH_S4_GENETIC

Don't Know

-2

FMH_S4_GENETIC


SOURCE

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


FFS33000/(FMH_S4_BIRTH_DEF_TYPE). What type of birth defect did he/she have?

 

________________________________________________________


SOURCE

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


FFS34000/(FMH_S4_GENETIC). Genetic disease?


Label

Code

Go To

Yes

1


No

2

FMH_S4_MEDS

Don't Know

-2

FMH_S4_MEDS


SOURCE

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


FFS35000/(FMH_S4_GENETIC_TYPE). What type of genetic disease was he/she diagnosed with?

 

____________________________________________________________________________________________


SOURCE

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


FFS36000/(FMH_S4_MEDS). Taking any medications?


Label

Code

Go To

Yes

1


No

2

FFS38000

Don't Know

-2

FFS38000


SOURCE

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


FFS37000/(FMH_S4_MEDS_TYPE). What type of medications is he/she taking?

 

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


SOURCE

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


FFS38000. For additional siblings, please fill out additional 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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