34.5 Survey

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

GENERAL PROGRAMMER INSTRUCTIONS: 1

RELATIONSHIP WITH CHILD 3

BIOLOGICAL PARENTS & SIBLINGS 4

HISTORY - BIOLOGICAL MOTHER 7

HISTORY - BIOLOGICAL FATHER 15

HISTORY SIBLING 1 23

FOR OFFICIAL USE 31

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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.