34.4 Survey

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

42M_ChronicMedicalHistorySAQ

42-Month Interview

OMB: 0925-0593

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OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Chronic Medical History SAQ, Phase 2g

OMB Specification


Chronic 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:

3 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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Chronic Medical History SAQ



TABLE OF CONTENTS





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Chronic 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 TO CHILD


RTC00100. Please complete the Chronic Medical History Questionnaire as best you can.


RTC01000/(CMH_CHILD_RELAT). What is your relationship to 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)



MEDICAL CONDITIONS


MC00100. These questions are about medical conditions or health problems you might have now or may have had in the past.

 

Have you ever been diagnosed with or had any of the following?


MC01000/(CMH_ASTHMA). Asthma?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


MC02000/(CMH_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)


MC03000/(CMH_ALLERGIES). Allergies?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


MC04000/(CMH_AUTOIMMUNE). Auto-immune disease?


Label

Code

Go To

Yes

1


No

2

CMH_HIGHBP

Don't Know

-2

CMH_HIGHBP


SOURCE

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


MC05000/(CMH_AUTOIMMUNE_TYP). What were you 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)


MC06000/(CMH_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)


MC07000/(CMH_DIABETES). Diabetes?


Label

Code

Go To

Yes

1


No

2

CMH_HIGHCHOLEST

Don't Know

-2

CMH_HIGHCHOLEST


SOURCE

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


MC08000/(CMH_CHILD_DIABETES). Were you diagnosed with diabetes as a child?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


MC09000/(CMH_INSULIN). Have you 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)


MC10000/(CMH_HIGHCHOLEST). High cholesterol?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


MC11000/(CMH_HEARTATTACK). A heart attack?


Label

Code

Go To

Yes

1


No

2

CMH_CATH_CABG

Don't Know

-2

CMH_CATH_CABG


SOURCE

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


MC12000/(CMH_ATTACK_AGE). Did you 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)


MC13000/(CMH_CATH_CABG). An angioplasty or coronary bypass surgery?


Label

Code

Go To

Yes

1


No

2

CMH_CANCER

Don't Know

-2

CMH_CANCER


SOURCE

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


MC14000/(CMH_CABG_AGE). Did you 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)


MC15000/(CMH_CANCER). Any type of cancer?


Label

Code

Go To

Yes

1


No

2

CMH_THYROID

Don't Know

-2

CMH_THYROID


SOURCE

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


MC16000/(CMH_CANCER_TYPE). What type of cancer were you diagnosed with?

 

___________________________


SOURCE

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


MC17000/(CMH_THYROID). Thyroid disease?


Label

Code

Go To

Yes

1


No

2

CMH_ADD

Don't Know

-2

CMH_ADD


SOURCE

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


MC18000/(CMH_UNDERACTIVE). Were you diagnosed with underactive thyroid?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


MC19000/(CMH_OVERACTIVE). Were you diagnosed with overactive thyroid?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


MC20000/(CMH_THYROID_DIS). Were you diagnosed with some other tyroid disease?


Label

Code

Go To

Yes

1


No

2

CMH_ADD

Don't Know

-2

CMH_ADD


SOURCE

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


MC21000/(CMH_THYROID_DIS_OTH). Specify:  ______________________________________


SOURCE

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


MC22000/(CMH_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)


MC23000/(CMH_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)


MC24000/(CMH_EATING_DISORDER). 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)


MC25000/(CMH_ALCOHOLISM). Alcoholism?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


MC26000/(CMH_BIPOLAR). Bipolar disorder?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


MC27000/(CMH_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)


MC28000/(CMH_SCHIZOPHRENIA). Schizophrenia?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


MC29000/(CMH_ANXIETY). Anxiety disorder, such as generalized anxiety disorder (GAD), or obsessive compulsive disorder (OCD)?


Label

Code

Go To

Yes

1


No

2

CMH_COG_DISABILITY

Don't Know

-2

CMH_COG_DISABILITY


SOURCE

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


MC30000/(CMH_ANXIETY_TYPE). What type of anxiety disorder were you diagnosed with?

 

___________________________________________________________


SOURCE

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


MC31000/(CMH_COG_DISABILITY). Intellectual disability?


Label

Code

Go To

Yes

1


No

2


Don't Know

-2



SOURCE

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


MC32000/(CMH_BIRTH_DEFECT). A birth defect?


Label

Code

Go To

Yes

1


No

2

CMH_GENETIC_DISORDER

Don't Know

-2

CMH_GENETIC_DISORDER


SOURCE

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


MC33000/(CMH_BIRTH_DEF_TYPE). What type of birth defect did you have?

 

_________________________________________________


SOURCE

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


MC34000/(CMH_GENETIC_DISORDER). Genetic disease?


Label

Code

Go To

Yes

1


No

2

CMH_MEDICATIONS

Don't Know

-2

CMH_MEDICATIONS


SOURCE

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


MC35000/(CMH_GENETIC_DIS_TYPE). What type of genetic disease were you diagnosed with?

 

___________________________________________________________________________


SOURCE

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


MC36000/(CMH_MEDICATIONS). Are you taking any medications?


Label

Code

Go To

Yes

1


No

2

MC38000

Don't Know

-2

MC38000


SOURCE

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


MC37000/(CMH_MEDICATIONS_TYPE). What type of medications are you taking?

 

_______________________________________________________________

 

_______________________________________________________________


SOURCE

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


MC38000. 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 3 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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