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pdf These next questions are about watching TV.
5. On each weekday, about how much time do you usually spend watching TV?
6. On each weekend day, about how much time do you usually spend watching TV?
Each weekday
Each weekend day
1
None
1
None
2
Less than 1 hour
2
Less than 1 hour
3
1 hour
3
1 hour
4
2 hours
4
2 hours
5
3 hours
5
3 hours
6
4 hours
6
4 hours
7
5 or more hours
7
5 or more hours
These questions are about using the computer for fun.
7. On each weekday, about how much time do you usually spend on the computer for fun, including
playing video or computer games? Please do not include time on the computer for school or work.
8. On each weekend day, about how much time do you usually spend on the computer for fun, including
playing video or computer games? Please do not include time on the computer for school or work.
Each weekday
Each weekend day
1
None
1
None
2
Less than 1 hour
2
Less than 1 hour
3
1 hour
3
1 hour
4
2 hours
4
2 hours
5
3 hours
5
3 hours
6
4 hours
6
4 hours
7
5 or more hours
7
5 or more hours
SEARCH 3 Cohort Study – Supplemental Questionnaire for Age 10 or Older – 11-01-10
Page 2 of 15
Diabetes Care/Control
The following questions are about your diabetes care and diabetes control. When the
questions say “doctor”, this means doctor or any other health care provider such as a nurse.
9. How would you rate your diabetes care overall? Would you say:
1
Excellent
2
Good
3
Fair
4
Poor
10. How would you rate your diabetes care: (check the appropriate boxes)
Excellent
Good
Fair
Poor
Not Applicable
1
2
3
4
5
10b. Getting answers to your
diabetes questions
1
2
3
4
5
10c. Access during emergencies
1
2
3
4
5
10d. Getting an explanation of lab
results
1
2
3
4
5
10e. Courtesy/personal
communication style of your
doctor
1
2
3
4
5
10a. Diabetes care from your doctor
11. How often do you miss your diabetes medicine including insulin?
1
Don’t take diabetes medicine (skip to question 13)
2
Never (skip to question 13)
3
1-3 times a month
4
1-5 times a week
5
1 time a day
6
More than 1 time a day
SEARCH 3 Cohort Study – Supplemental Questionnaire for Age 10 or Older – 11-01-10
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12. When you miss your diabetes medicine is it because: (check Yes, No, or Not applicable)
Yes
No
Not applicable
1
2
3
12b. Thought it would help to lose weight
1
2
3
12c. Worried about low blood sugar
1
2
3
12d. Cannot afford insulin supplies or other medicine
1
2
3
12e. Don’t want to give insulin when others are around
1
2
3
12f. Tired of shots
1
2
3
12g. Afraid of needles
1
2
3
12h. Other reason (specify)
1
2
3
12a. Forgot
The following questions ask about what you usually do to take care of your
diabetes. There are no right or wrong answers. Please think about the past 3
months and select the answer that comes closest to what you have done.
13. Do you wear or carry anything that identifies you as having diabetes,
like a card or bracelet?
1
Wear necklace, bracelet or charm
2
Carry billfold identification card only
3
Have identification but do not wear or carry it
4
Do not have identification about diabetes
SEARCH 3 Cohort Study – Supplemental Questionnaire for Age 10 or Older – 11-01-10
Page 4 of 15
Please think about what you usually did about low blood sugar reactions in the
past 3 months.
14. Do you keep something with you to eat in case your blood sugar gets too low?
Yes
2 No
3 Do not have low blood sugars/no prescribed diabetes medicationsÎ(Go to Question 17)
1
15. If you think you have a low blood sugar, how often do you test before treating?
Always
2 More than half the time
3 Half the time
4 Less than half the time
5 Never
6 Do not have low blood sugars/no prescribed diabetes medications
1
16. If you think you have a low blood sugar, do you eat until you feel better?
Yes Î 16a. If Yes, do you take extra insulin for the food eaten while feeling low?
1 No
2 Yes - Always
3 Yes – If more that 15 grams of carbohydrates eaten
4 Yes – If more than 30 grams of carbohydrates eaten
2 No
1
3
Do not have low blood sugars/no prescribed diabetes medications
SEARCH 3 Cohort Study – Supplemental Questionnaire for Age 10 or Older – 11-01-10
Page 5 of 15
17. People with diabetes receive different dietary recommendations, depending on their own individual
needs. Please indicate below which of the dietary recommendations you have received from health
care providers, and how frequently each method is currently used.
Dietary recommendations
keep track of calories
count carbohydrates
choose low glycemic index foods
use dietary exchanges
keep track of fat grams
limit sweets
limit high fat foods
drink more milk
eat more fruits and vegetables
eat more fiber and whole grains
18.
Have you ever received
this recommendation?
Yes
No
Don’t know
How frequently do you
currently use this method?)
Often
Sometimes
Never
Have you been taught about how to adjust your insulin depending on how much or what kinds of
food you eat?
1
Yes Î
18a. If YES, how often do you adjust insulin based on what you have eaten?
1
Often
2
Sometimes
3
Never
2
No
3
Does not apply - insulin not prescribed
The following questions have to do with your habits when it comes to testing
blood sugar. Please think about the past 3 months and choose the answer that is
closest to what you have done.
19.
In the past 3 months, how often have you tested your blood sugar?
6 or more times daily
2 4 or 5 times daily
3 2 or 3 times daily
4 At least once daily
5 Do not test, or test less than once a day
1
SEARCH 3 Cohort Study – Supplemental Questionnaire for Age 10 or Older – 11-01-10
Page 6 of 15
20.
How often has your diabetes care provider suggested that you test your blood sugar?
6 or more times daily
2 At least 4 or 5 times daily
3 At least 2 or 3 times daily
4 At least once daily
5 Don’t know
1
Transition from Pediatric to Adult Care
21. Are you 12 years of age or older?
1
Yes
2
No
- (skip to question 33)
22. Which of the following best describes your current diabetes provider?
1
He/She is a pediatric provider, who treats mainly children
2
He/She is an adult provider who treats mainly adults, except for a few children
(skip to
question 30)
3
He/She is an adult and pediatric provider, who treats patients of all ages (skip to question 33)
4
Not sure how to describe my current diabetes provider
23. Have they talked with you about having you eventually see doctors or other health care providers
who treat adults?
1
Yes (skip to question 25)
2
No
3
Not sure
24. Would a discussion about doctors who treat adults have been helpful to you?
Yes
2 No
3 Not sure
1
25. Have your doctors or other health care providers talked with you about your health care needs as you
become an adult?
1
Yes (skip to question 27)
2
No
3
Not sure
SEARCH 3 Cohort Study – Supplemental Questionnaire for Age 10 or Older – 11-01-10
Page 7 of 15
26. Would a discussion about your health care needs have been helpful?
1
Yes
2
No
3
Not sure
27. Eligibility for health insurance often changes as children reach adulthood. Has anyone discussed with
you how to obtain or keep some type of health insurance coverage as you become an adult?
Yes (skip to question 29)
2 No
3 Not sure
1
28. Would a discussion about health insurance have been helpful to you?
Yes
2 No
3 Not sure
1
29. How often do your doctors or other health care providers encourage you to take responsibility for
your health care needs, such as taking medication, checking blood sugars, understanding your
health, or following medical advice?
Never
2 Sometimes
3 Usually
4 Always
5 Don’t know
1
Questions 30-32 ask about transition to adult diabetes care. If you have not
already changed to adult diabetes care, please skip to question 33.
30. Since you have changed to adult diabetes providers, have you experienced an interruption of 3
months or longer in receiving:
a. any primary care that you needed?
b. any diabetes care that you needed?
c. any medications that you needed?
d. any medical insurance coverage that you needed?
Yes
1 Yes
1 Yes
1 Yes
1
SEARCH 3 Cohort Study – Supplemental Questionnaire for Age 10 or Older – 11-01-10
No
2 No
2 No
2 No
2
Page 8 of 15
31. How satisfied are you with the support you received from any health professionals for transferring to
adult diabetes care?
0
1
2
3
4
5
6
7
8
9
Very/
somewhat
satisfied
10
Very/
somewhat
dissatisfied
32. How easy or difficult was it for you to change from pediatric to adult diabetes care?
1
0
2
3
4
5
6
7
8
9 10
Very/
somewhat
easy
33.
Very/
somewhat
difficult
In the last 12 months, how often did your doctors or health providers:
Never Sometimes Usually Always
33a. Listen carefully to you?
1
2
3
4
33b. Explain things in a way you could
understand?
1
2
3
4
33c. Show respect for what you had to say?
1
2
3
4
33d. Spend enough time with you?
1
2
3
4
SEARCH 3 Cohort Study – Supplemental Questionnaire for Age 10 or Older – 11-01-10
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Education
The next set of questions concerns your education.
34. Are you currently in school?
1
Yes
2
No
35. What is the highest degree or level of school you have COMPLETED?
1
No schooling completed
2
Nursery school to 4th grade
3
5th grade or 6th grade
4
7th grade or 8th grade
5
9th grade
6
10th grade
7
11th grade
8
12th grade, NO DIPLOMA
9
High school graduate (high school diploma) or equivalent (for example GED)
10 Business/technical school
11 Some college credit but less than 1 year
12 1 or more years of college, no degree
13 Associate degree (for example: AA, AS)
14 Bachelor’s degree (for example: BA, AB, BS)
15 Master’s degree (for example: MA, MS, MEng, MEd, MSW, MBA)
16 Professional or doctorate degree (for example MD, DDS, JD, PhD, EdD)
17 Don’t know
SEARCH 3 Cohort Study – Supplemental Questionnaire for Age 10 or Older – 11-01-10
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Tobacco Use
This section contains questions about tobacco use. These questions are confidential and will not
be shared with your parent/guardian.
36. Does anyone who lives in your household smoke cigarettes, cigars, or pipes anywhere inside the home?
1
Yes
2
No
3
Don’t know
4
I do not want to answer
37. Have you ever tried cigarette smoking, even one or two puffs?
Yes
2 No (if no, go to question 41)
3 I do not want to answer (go to question 41)
1
38. How old were you when you smoked a whole cigarette for the first time?
1
I have never smoked a whole cigarette
2
8 years old or younger
3
9 or 10 years old
4
11 or 12 years old
5
13 or 14 years old
6
15 or 16 years old
7
17 years old or older
8
I do not want to answer
39. Have you ever smoked cigarettes daily, that is, at least one cigarette every day for 30 days?
1
Yes
2
No
3
I do not want to answer
SEARCH 3 Cohort Study – Supplemental Questionnaire for Age 10 or Older – 11-01-10
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40. During the past 30 days, on how many days did you smoke cigarettes?
1
None
2
1 or 2 days
3
3 to 5 days
4
6 to 9 days
5
10 to 19 days
6
20 to 29 days
7
All 30 days
8
I do not want to answer
41. During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip, such as
Redman, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen?
1
None
2
1 or 2 days
3
3 to 5 days
4
6 to 9 days
5
10 to 19 days
6
20 to 29 days
7
All 30 days
8
I do not want to answer
42. During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?
1
None
2
1 or 2 days
3
3 to 5 days
4
6 to 9 days
5
10 to 19 days
6
20 to 29 days
7
All 30 days
8
I do not want to answer
SEARCH 3 Cohort Study – Supplemental Questionnaire for Age 10 or Older – 11-01-10
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43. Has your health care provider or another health care worker asked
you if you used tobacco or smoked?
1
Yes
2
No
44. Has a doctor or nurse counseled you to not smoke or to stop
smoking?
1
Yes
2
No
Alcohol Use
This section contains questions about alcohol use. These questions are confidential and will
not be shared with your parent/guardian.
45. During the past 30 days, have you had at least one drink of any alcoholic beverage such as beer,
wine, a malt beverage or liquor?
Yes
2 No (go to question 50)
3 Don’t know / Not sure (go to question 50)
4 I do not want to answer (go to question 50)
1
46. During the past 30 days, how many days per week or per month did you have at least one drink of
any alcoholic beverage?
____ Days per week
OR
_____ Days per month
No drinks in past 30 days (go to question 50)
2 Don’t know / Not sure
3 I do not want to answer
1
47. One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of
liquor. During the past 30 days, on the days when you drank, about how many drinks did you drink on
the average?
NOTE: A 40 ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2
drinks.
_____ Number of drinks (write in the number)
Don’t know / Not sure
2 I do not want to answer
1
SEARCH 3 Cohort Study – Supplemental Questionnaire for Age 10 or Older – 11-01-10
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48a. (For males only) Considering all types of alcoholic beverages, how many times during the past
30 days did you have 5 or more drinks on an occasion?
_____ Number of times (write in the number)
1 None
2
3
Don’t know / Not sure
I do not want to answer
48b. (For females only) Considering all types of alcoholic beverages, how many times during the
past 30 days did you have 4 or more drinks on an occasion?
_____ Number of times (write in the number)
1 None
Don’t know / Not sure
3 I do not want to answer
2
49. During the past 30 days, what is the largest number of drinks you had on any occasion?
_____ Number of drinks
1 Don’t know / Not sure
2
I do not want to answer
Pregnancy (for females only)
This question is confidential and will not be shared with your parent/guardian.
50. Have you ever been pregnant?
1
Yes
2
No
3
I do not want to answer
This is the end of this questionnaire. Thank you very much for taking the time to complete the
questionnaire.
SEARCH 3 Cohort Study – Supplemental Questionnaire for Age 10 or Older – 11-01-10
Page 14 of 15
FOR STUDY USE ONLY
Date
Completed
Date
Reviewed
Date
Entered
Month
Month
Month
Day
Day
Day
Year
Year
Year
Completer
Code
Reviewer
Code
Data Entry
Code
SEARCH 3 Cohort Study – Supplemental Questionnaire for Age 10 or Older – 11-01-10
Page 15 of 15
| File Type | application/pdf |
| File Title | Microsoft Word - Suppl - ds _3_ _review with Debbie_ 11-01-10 f_ds _3_ FINAL FINAL |
| Author | stmoxley |
| File Modified | 2011-05-10 |
| File Created | 2010-11-05 |