Form 1 MHE-Personal Medical History-Eng

Public reporting burden for this collection of information is estimated to average 10
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 (0925-0584). Do not return the completed form to this address.

OMB#: 0925-0584
Exp. xx/xx/xxxx

HCHS/SOL Visit 2- Personal Medical History
FORM CODE: MHE
VERSION: 1, 1/6/2014

ID NUMBER:

ADMINISTRATIVE INFORMATION
/
/
0a. Completion Date:
0c. Participant Gender:
(F=female, M=male)

Contact
Occasion

0

2

SEQ #

0b. Staff ID:
0d.Age:

Instructions: Enter the answer given by the participant for each response. Use the CDART Notelog window to
code 'Don’t know/refused, Missing, etc.' for those questions that do not list these as an option.

A. Since the first SOL visit, have you had any of the following medical problems?
No
1. Heart attack?
0

Yes Unsure
1

9

2. A balloon angioplasty, a stent, or bypass surgery to the arteries in your heart
to improve the blood flow to your heart?
3. Angina?

0

1

9

0

1

9

4. Heart Failure?

0

1

9

5. Stroke?

0

1

9

6. A mini-stroke or TIA (transient ischemic attack)?

0

1

9

7. A balloon angioplasty or surgery to the arteries of your neck to prevent or
correct a stroke?
8. An aortic aneurysm, an AAA, or ballooning of your aorta?

0

1

9

0

1

9

0

1

9

0

1

9

0

1

9

9. Peripheral arterial disease (problems with circulation, blocked arteries to the
legs)?
9.a (IF YES TO PAD) A balloon angioplasty, a stent, or an amputation for
this condition?
If No/unsure to liver disease then Go to #11
10. Liver disease?
IF YES to liver disease, then what type of liver disease?
10a. Hepatitis

No
Yes

0
1

10b. What type?

Type A
Type B
Type C
Don’t know

1
2
3
9

10c. Cirrhosis

No
Yes

0
1

MHE-Personal Medical History_1-06-2014.doc

 GO TO QUESTION 10c

Page 1 of 7

FORM CODE: MHE
VERSION: 1, 1/6/2014

ID NUMBER:

Contact
Occasion

0

2

SEQ #

11. Has a doctor ever said that you have cancer or a malignant tumor?
No
Yes

 GO TO QUESTION 12

0
1

11a. What type?

No
a1. Lung
a2. Breast
a3. Cervical
a4. Blood/lymph glands
a5. Testes/scrotum
a6. Bone
a7. Melanoma
a8. Skin (not melanoma)
a9. Brain
a10. Stomach
a11. Colon
a12. Uterine
a13. Prostate
a14. Liver
a15. Kidney/renal
a16. Other

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

Yes
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

12. Do you currently have a pacemaker or automatic defibrillator (AICD) for a heart rhythm problem?
No
0
Yes, pacemaker
1
Yes, automatic defibrillator (AICD) 2
Yes, both pacemaker,
and automatic defibrillator (AICD)
3
Not sure
9
B. Since your last telephone interview on (date), have you had any of the following problems?
No
Yes
Unsure
13. Do you often have swelling in your feet or ankles at the end of the
1
9
0
day?
14. Are there times when you wake up at night because of difficulty
1
9
0
breathing?
15. Are there times when you stop for breath when walking at your own
0
1
9
pace on level ground?
16. Are there times when you have difficulty breathing when you are not
0
1
9
walking or active?

MHE-Personal Medical History_1-06-2014.doc

Page 2 of 7

FORM CODE: MHE
VERSION: 1, 1/6/2014

ID NUMBER:

Contact
Occasion

0

2

SEQ #

17. Have you ever been told by a doctor or health professional that you had/have any of the following
conditions that effect the brain?
No

Yes

Unsure

Parkinson’s Disease

0

1

9

Dementia

0

1

9

Alzheimers Disease

0

1

9

C. Urinary Incontinence
Many people have leakage of urine. The next few questions ask about urine leakage.
(Other terms for urinary leakage are not being able to hold your urine until you can reach a toilet, not being able to
control your bladder, loss of urine control.)

18. How often do you have urinary leakage? Would you say…
1

Go to question 20

2
3
4
5
Unsure / Refused 9

Go to question 20

Never
Less than once a month
A few times a month
A few times a week,
Every day and/or night

19. How much urine do you lose each time? Would you say…
Drops 1
Small splashes 2
More 3
Unsure / Refused 9
20. During the past 12 months, have you leaked or lost control of even a small amount of urine with an
activity like coughing, lifting or exercise?
Go to question 21
No 0
Yes 1
Go to question 21
Unsure / Refused 9
20a. How frequently does this occur? Would you say this occurs . . .
Less than once a month 1
A few times a month 2
A few times a week 3
Every day and/or night 4
Unsure / Refused 9
21. During the past 12 months, have you leaked or lost control of even a small amount of urine with an
urge or pressure to urinate and you couldn’t get to the toilet fast enough?
No 0
Yes 1
Unsure / Refused 9
MHE-Personal Medical History_1-06-2014.doc

Go to question 22
Go to question 22
Page 3 of 7

ID NUMBER:

FORM CODE: MHE
VERSION: 1, 1/6/2014

Contact
Occasion

0

2

SEQ #

21a. How frequently does this occur? Would you say this occurs. . .
Less than once a month 1
A few times a month 2
A few times a week 3
Every day and/or night 4
Unsure / Refused 9
22. During the past 12 months, have you leaked or lost control of even a small amount of urine without an
activity like coughing, lifting, or exercise, or an urge to urinate?
Go to question 23
No 0
Yes 1
Go to question 23
Unsure / Refused 9
22a. How frequently does this occur? Would you say this occurs . . .
Less than once a month 1
A few times a month 2
A few times a week 3
Every day and/or night 4
Unsure / Refused 9
23. During the past 12 months, how much did your leakage of urine bother you? Please select one of the
following choices:
Not at all 1
Only a little 2
Somewhat 3
Very much 4
Greatly 5
Unsure/ Refused 9
24. During the past 12 months, how much did your leakage of urine affect your day-to-day activities?
Please select one of the following choices:
Not at all 1
Only a little 2
Somewhat 3
Very much 4
Greatly 5
Unsure/ Refused 9

MHE-Personal Medical History_1-06-2014.doc

Page 4 of 7

FORM CODE: MHE
VERSION: 1, 1/6/2014

ID NUMBER:

Contact
Occasion

0

2

SEQ #

25. During the past 30 days, how many times per night did you most typically get up to urinate, from the
time you went to bed at night until the time you got up in the morning. Would you say..
1 time
2 times
3 times
4 times
5 or more times
Unsure/ Refused

1
2
3
4
5
9

D. Kidney
26. Have you ever been told by a doctor or other health professional that you had weak or failing kidneys?
Do not include kidney stones, bladder infections, or incontinence.
No 0
Yes 1
Unsure / Refused 9

Go to question 28
Go to question 28

27. In the past 12 months, have you received dialysis (either hemodialysis or peritoneal dialysis)?
No 0
Yes 1
Unsure / Refused 9
28. Have you ever had kidney stones?
No 0
Yes 1
Unsure / Refused 9

Go to question 29
Go to question 29

28a. How many times have you passed a kidney stone?

ENTER NUMBER OF TIMES

E. Tuberculosis Screening
29. Since visit 1, have you been told that you had active tuberculosis or TB?
No 0
Yes 1
Unsure / Refused 9
29a.

Go to question 30
Go to question 30

Since visit 1, have you been prescribed any medicine to treat active tuberculosis or TB?
No 0
Yes 1
Unsure / Refused 9

30. Since visit 1, have you been given a TB or tuberculosis skin test (e.g., PPD)?
No 0
Yes 1
Unsure / Refused 9
MHE-Personal Medical History_1-06-2014.doc

 For men, go to 31; for women, END of questionnaire
Go to question 30b
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FORM CODE: MHE
VERSION: 1, 1/6/2014

ID NUMBER:
30a. Was it:

Positive
Negative
Unsure /Ref.

1
2
9

Contact
Occasion

0

2

SEQ #

For men, go to #31; for women, END of questionnaire

30b. For this TB skin test, were you prescribed any medicine to keep you from getting sick with
TB?
No
0
Yes
1
For WOMEN, END of questionnaire
Unsure/ Refused 9
F. Men only
The next set of questions is about men’s health including urinary and prostate problems. The prostate is a
gland located just below the bladder.
For men less than 40 years of age, go to question 33.
31. For men age 40 years and older only: Do you usually have trouble starting to urinate (pass water)?
No 0
Yes 1
Unsure / Refused 9
32. For men age 40 years and older only: After urinating (passing water), does your bladder feel empty?
No 0
Yes 1
Unsure / Refused 9
The remainder is for men of all ages:
33. Have you ever been told by a doctor or health professional that you have any disease of the prostate?
This includes an enlarged prostate.
No 0
Yes 1
Unsure / Refused 9
34. Have you ever been told by a doctor or health professional that you had an enlarged prostate gland?
No 0
Yes 1
Unsure / Refused 9
34a.

Go to question 35
Go to question 35

Was it a benign enlargement – that is, not cancerous, also called benign prostatic
hypertrophy?
No 0
Yes 1
Unsure / Refused 9

MHE-Personal Medical History_1-06-2014.doc

Page 6 of 7

FORM CODE: MHE
VERSION: 1, 1/6/2014

ID NUMBER:
34b.

Contact
Occasion

0

2

SEQ #

How old were you when you were first told that you had benign enlargement of the prostate
gland?
Enter age in years

34c.

Was the enlargement due to cancer?
No 0
Yes 1
Unsure / Refused 9

35. Have you ever had a blood test that your doctor told you was being used to check for prostate cancer,
called PSA, or Prostate Specific Antigen?
No 0
Yes 1
Unsure / Refused 9
36. Have you ever had a rectal examination? A rectal exam is when a finger is inserted in the rectum or
bottom to check for problems.
No 0
Yes 1
Unsure / Refused 9

Go to question 37
Go to question 37

36a.

Was this done to check for prostate cancer?
No 0
Yes 1
Unsure / Refused 9

36b.

Was this done to check for blood?
No 0
Yes 1
Unsure / Refused 9

37. Many men experience problems with sexual intercourse. How would you describe your ability to get
and keep an erection adequate for satisfactory intercourse? Would you say that you are..
Verbal Instruction: Always able or almost always able to get and keep an erection? Usually able to get and keep
an erection? Sometimes able to get and keep an erection? Never able to get and keep an erection?]

Always or almost always able
Usually able
Sometimes able
Never able
Unsure/ Refused

MHE-Personal Medical History_1-06-2014.doc

3
2
1
0
9

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