34.4 Survey

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

GENERAL PROGRAMMER INSTRUCTIONS: 1

RELATIONSHIP TO CHILD 3

MEDICAL CONDITIONS 4

FOR OFFICIAL USE 12

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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.