Form 2155 RPCV Long Term Health Outcomes Survey

Peace Corps Health Outcomes
Introduction

Peace Corps has partnered with the Centers for Disease Control and Prevention to determine the
health of returned Peace Corps Volunteers. The investigators have developed an online survey for
returned Peace Corps Volunteers to complete.

Burden Statement: Public reporting burden for this collection of information is estimated to
average 25 minutes per response. This estimate includes the time for reviewing instructions and
completing 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 [email protected] ,
Subject line: PRA (0420-####). Do not return the completed form to this email address.

OMB Control No. 0420-xxxx
Expiration Date: x/xx/20xx

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Peace Corps Health Outcomes
Purpose and Consent

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Introduction and purpose
The Centers for Disease Control and Prevention (CDC) and Peace Corps are conducting a survey to learn about the health of Peace
Corps Volunteers (PCVs). This survey will help us understand what diseases for which PCVs might be at risk. To do this, we are
conducting anonymous surveys among PCVs who served between 1995–2014. We would like to invite you to take part in this survey.

Procedures
Taking this survey is up to you. Participating will not cost you anything. If you agree, we will ask you some questions about your health
since leaving Peace Corps. You can choose not to answer any questions that you wish for any reasons. The survey will take an
average of 25 minutes to complete. Once completed, the survey results will be sent to CDC.

Confidentiality
Survey results will be compiled and analyzed as a group. Although aggregate results will be shared with Peace Corps, no information
that can identify you individually will be collected or shared. Survey data will be kept private to the extent allowed by law.

Risks/benefits
This survey has little risk. The information we collect could benefit PCVs by improving the knowledge of PCMOs on the health risks of
PCVs.

Cost
The only cost to you for being in the survey is your time. You will not be paid to take part in this survey.

Right to refuse or withdraw
It is up to you to join the assessment or to withdraw at any time. You can choose to skip any questions you do not want to answer.
While taking the survey, if you decide that you do not want to take part, you can simply stop answering questions.

Persons to contact
If, at any time, you have questions or problems related to this assessment, you may contact Kathrine Tan (404) 718-4701

,

e-mail: [email protected]

* I have read the above information and:
I consent to participate
I do NOT consent to participate

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Peace Corps Health Outcomes
Section 1: Peace Corps - Service

The following questions are about your time as a Peace Corps Volunteer.
* In what country did you serve as a Peace Corps Volunteer? If you served in more than one country, please
list the country that you served in first.

Other (please specify)

What best describes the location of your assignment?
Rural (Less than 1,000 people per square mile. Ex: village or town with dirt roads)
Urban (1,000 or more people per square mile. Ex: capital city of the country)

* When did you start (includes pre-service training) and finish (includes close of service, early termination,
medical separation, or evacuation) your Peace Corps Service in country?
Month

Year

Start
Finish

What was your primary work assignment as a Peace Corps Volunteer?
Education
Agriculture
Community economic development
Youth in development
Environment
Health
Other (please specify)

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Peace Corps Health Outcomes
Section 1: Peace Corps - Cookfires

While in Peace Corps, were you exposed to smoke from cookfires, either from wood or charcoal? (i.e. used
fire for cooking, or visited or lived in a house where cookfires were used)
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 1: Peace Corps Volunteer - Cookfire exposure

Where were you exposed (check all that apply)?
Indoors
Outdoors
Both indoors and outdoors

How often were you exposed?
Daily
Some days of the week
Rarely
Never
Don't know

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Peace Corps Health Outcomes
Section 1: Peace Corps - Water Safety

While in Peace Corps, what were the two main water safety measures, if any, did you take? (can select up
to two)
Bleach or chlorine
Aquatabs
Boiled water
Filtered water using a Peace Corps approved filter
Iodine tablets
None
Not applicable
Don't know
Other (please specify)

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Peace Corps Health Outcomes
Section 1: Peace Corps - Mosquito Avoidance Measures

What statement best describes your use of mosquito repellent during Peace Corps?
I used a DEET-containing mosquito repellent every day.
I used some type of mosquito repellent every day.
I used a DEET-containing mosquito repellent most days.
I used some type of mosquito repellent most days.
I used a DEET-containing mosquito repellent some days.
I used some type of mosquito repellent some days.
I never used a mosquito repellent.
Don't know

What statement best describes your use of mosquito nets?
I used a mosquito net every night
I used a mosquito net most nights
I used a mosquito net some nights
I used a mosguito net rarely
Don't know

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Peace Corps Health Outcomes
Section 2: Malaria Prevention During Peace Corps

* While in Peace Corps, were you prescribed a medication to prevent malaria?
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 2: Malaria Prevention During Peace Corps - Antimalarials

What was the first antimalarial you took during your Peace Corps service?
Atovaquone/proguanil (malarone)
Chloroquine or Plaquenil
Doxycycline
Mefloquine (Lariam)
Other (please specify)

What statement best describes how you took the medication while in Peace Corps:
I took the medication as prescribed.
I took the medication as prescribed most of the time.
I took the medication about half of the time.
I rarely took the medication (less than half of the time).
I never took the medication.
I stopped taking the medication and switched to another because of side effects.
I don't know.
Other (please specify)

Approximate length of time actually taking the medication (in months):

Last time this particular medication for malaria prophylaxis was taken during Peace Corps (if you
completed a trip directly after close of service in an area which required malaria prophylaxis, note the last
time it was taken for this trip)
Month

Year

Date

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Were you prescribed any other medication for malaria prophylaxis during Peace Corps?
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 2: Malaria Prevention During Peace Corps - Other Antimalarials

Why was a different medication prescribed?
Side effects from original antimalarial
Deployment to a different area requiring a different antimalarial
Other (please specify)

What antimalarial were you prescribed?
Atovaquone/proguanil (malarone)
Chloroquine
Doxycycline
Mefloquine (Lariam)
Other (please specify)

What statement best describes how you took the medication while in Peace Corps:
I took the medication as prescribed.
I took the medication as prescribed most of the time.
I took the medication about half of the time.
I rarely took the medication (less than half of the time).
I never took the medication.
I don't know.
Other (please specify)

Approximate length of time actually taking the medication (in months):

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Last time this particular medication for malaria prophylaxis was taken during Peace Corps (if you traveled
right after close of service in an area which required malaria prophylaxis, and you continued to take this
same medication note the last time it was taken for this trip).
Month

Year

Date

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Peace Corps Health Outcomes
Section 2: After Peace Corps - Other Malaria Preventive Medications

Have you taken medication for malaria prophylaxis since leaving Peace Corps?
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 2: After Peace Corps - Other Malaria Preventive Medications

Since leaving Peace Corps, have you taken more than 6 months worth of malaria prophylaxis at a time?
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 3: Health Questions

The next few questions will help us understand your health prior, during, and after Peace Corps.

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Peace Corps Health Outcomes
Section 3: Health Questions - Skin Conditions

* Have you ever been diagnosed by a health care provider with skin conditions such as:
Acne
Allergic dermatitis (allergic rash)
Contact dermatitis (rash from contact with something)
Fungal infection of skin ("ring worm")
Psoriasis
Skin cancer
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 3: Health Questions - Skin Conditions - Diagnoses

* Please indicate if you have had any of the following skin conditions. For any conditions that you have NOT
had, please indicate "never diagnosed". For any condition that you have had, please indicate if it was
present before, during, and/or after Peace Corps (select all that apply).
Never diagnosed

Before Peace Corps

During Peace Corps

After Peace Corps

Acne
Allergic dermatitis
(allergic rash)
Contact dermatitis (rash
from contact with
something)
Fungal infection of skin
(also called "ring worm")
Skin cancer
Psoriasis
Other skin condition
If "other" please specify

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Peace Corps Health Outcomes
Section 3: Health Questions - Skin Conditions - Medications Y/N

Have you ever taken medication for your skin condition(s)?
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 3: Health Questions - Skin Conditions - Medications

Please select any medications taken for your skin condition(s), and if applicable indicate when taken.
Select all that apply. Note that generic names are listed in alphabetical order with the brand name in bold.
Never taken

Before Peace Corps

During Peace Corps

After Peace Corps

Adalimumab (Humira)
Anthralin (Zithranol)
Calcipotriene (Dovonex,
Sorilux)
Doxycycline
(Vibramycin)
Hydrocortisone cream
Isotretinoin (Accutane,
Sotret)
Methotrexate
(Rheumatrex, Trexall)
Tetracycline
Other (specify below)
If "other" please specify

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Peace Corps Health Outcomes
Section 3: Health Questions - Heart Conditions

* Have you ever been diagnosed by a health care provider with heart or circulation problems?
For example:
Arrhythmia (irregular heartbeat)
Cardiomyopathy
Congestive heart failure
High cholesterol
Hypertension (high blood pressure)
Myocardial infarction (heart attack)
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 3: Health Questions - Heart Conditions - Diagnoses

* Please indicate if you have had the following heart or circulatory conditions. For any condition that you
have NOT had, please indicate "never diagnosed". For any condition that you have had, please indicate if
it was present before, during, and/or after Peace Corps (select all that apply).
Never diagnosed

Before Peace Corps

During Peace Corps

After Peace Corps

Arrhythmia (irregular
heartbeat)
Cardiomyopathy
Congestive heart failure
High Cholesterol
Hypertension (high
blood pressure)
Myocardial infarction
(heart attack)
Other heart condition
If "other" please specify

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Peace Corps Health Outcomes
Section 3: Health Questions – Heart Conditions – Medications Y/N

Have you ever taken medication for your heart or circulatory condition(s)?
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 3: Health Questions - Heart Conditions - Medications

Please select any medications taken for your heart condition(s), and if applicable indicate when taken.
Select all that apply. Note that generic names are listed in alphabetical order with the brand name in bold.
Never taken

Before Peace Corps

During Peace Corps

After Peace Corps

Aspirin
Atenolol (Tenormin)
Atorvastatin (Lipitor)
Captopril (Capoten)
Fluvastatin (Lescol)
Furosemide (Lasix)
Hydrochlorothiazide
(Aquazide H,
HydroDIURIL,
Microzide)
Lisinopril (Prinvil,
Zestril)
Losartan (Cozaar)
Lovastatin (Altocor,
Altoprev, Mevacor)
Metoprolol (Lopressor,
Toprol-XL)
Pravastatin (Pravachol)
Rosuvastatin (Crestor)
Simvastatin (Zocor)
Warfarin (Coumadin)
Other (specify below)
If "other" please specify

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Peace Corps Health Outcomes
Section 3: Health Questions - Lung Conditions

* Have you ever been diagnosed by a health care provider with lung problems?
For example:
Asthma
Chronic obstructive pulmonary disease (COPD), bronchitis or emphysema
Lung cancer
Recurrent pneumonia
Restrictive lung disease
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 3: Health Questions - Lung Conditions - Diagnoses

* Please indicate if you have had the following lung conditions. For any lung condition that you have NOT
had, please indicate "never diagnosed". For any lung condition that you have had, please indicate if it was
present before, during, and/or after Peace Corps (select all that apply).
Never diagnosed

Before Peace Corps

During Peace Corps

After Peace Corps

Asthma
Chronic obstructive
pulmonary disease
(COPD), chronic
bronchitis, or
emphysema
Chronic bronchitis
Lung cancer
Recurrent pneumonia
Restrictive lung disease
Other lung condition
If "other" please specify

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Peace Corps Health Outcomes
Section 3: Health Questions –Lung Conditions – Medications Y/N

* Have you ever taken medication for your lung condition(s)?
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 3: Health Questions - Lung Conditions - Medications

Please select any medications taken for your lung condition(s), and if applicable indicate when taken.
Select all that apply. Note that generic names are listed in alphabetical order with the brand name in bold.
Never taken

Before Peace Corps

During Peace Corps

After Peace Corps

Albuterol (Accuneb,
ProAir, Proventil,
Ventolin)
Albuterol-ipratropium
bromide (Combivent)
Fluticasone
(Fluticasone)
Metaproteranol
(Alupent)
Mometasone
(Asmanex)
Montelukast (Singulair)
Prednisone (Rayos,
Sterapred)
Prednisolone (Orapred,
Prelone)
Triamcinolone
(Azmacort)
Other (specify below)
If "other" please specify

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Peace Corps Health Outcomes
Section 3: Health Questions - Gastrointestinal/stomach problems

* Have you ever been diagnosed by a health care provider with gastrointestinal or stomach problems?
For example:
Amoebas
Crohn’s disease
Cirrhosis
Duodenal ulcers
Esophageal ulcers
Fatty liver
Gastroesophageal reflux (GERD) or heartburn
Giardia
Inflammatory bowel disease
Irritable bowel syndrome (IBS)
Liver failure
Peptic Ulcers
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 3: Health Questions – Gastrointestinal/stomach problems – Diagnoses

* Please indicate if you have had the following gastrointestinal/stomach problems. For any problem that you
have NOT had, please indicate "never diagnosed". For any problems that you have had, please indicate if
it was present before, during, and/or after Peace Corps (select all that apply).
Never diagnosed

Before Peace Corps

During Peace Corps

After Peace Corps

Amoebas
Crohn’s disease
Cirrhosis
Duodenal ulcers
Esophageal ulcers
Fatty liver
Gastroesophageal reflux
(GERD) or heartburn
Giardia
Inflammatory bowel
disease
Irritable bowel syndrome
(IBS)
Liver failure
Peptic Ulcers
Other
gastrointestinal/stomach
disease
If "other" please specify

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Peace Corps Health Outcomes
Section 3: Health Questions – Gastrointestinal/stomach problems – Medications Y/N

Have you ever taken medication for your gastrointestinal/stomach problems?
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 3: Health Questions – Gastrointestinal/stomach problems – Medications

Please select any medications taken for your gastrointestinal/stomach problem(s), and if applicable indicate
when taken. Select all that apply. Note that generic names are listed in alphabetical order with the brand
name in bold.
Never taken

Before Peace Corps

During Peace Corps

After Peace Corps

Balsalazide (Colazal,
Giazo)
Certolizumab (Cimzia)
Cimetidine (Tagamet,
Tagamet HB)
Ciprofloxacin (Cipro)
Dexamethasone
(Baycadron, Dexpak,
Zema Pak)
Esomeprazole
(Nexium)
Famotidine (Pepcid)
Infliximab (Remicade)
Lansoprazole
(Prevacid)
Maalox
Mesalamine (Apriso,
Asacol, Delzicol,
Lialda)
Methylprednisolone
Metronidazole (Flagyl)
Mylanta
Natalizumab (Tysabri)
Omeprazole (Prilosec)
Pantoprazole (Protonix)
Prednisolone (Orapred,
Prelone)
Prednisone (Rayos,
Sterapred)

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Never taken

Before Peace Corps

During Peace Corps

After Peace Corps

Ranitidine (Taladine,
Zantac)
Sulfasalazine
(Azulfidine)
Tums
Other (specify below)
If "other" please specify

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Peace Corps Health Outcomes
Section 3: Health Questions – Genital, reproductive, or urinary tract problems

* Have you ever been diagnosed by a health care provider with genital, reproductive, or urinary tract
(kidney/bladder) problems?
For example:
Kidney stones
Miscarriages
Recurrent urinary tract infections
Recurrent vaginal yeast infections
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 3: Health Questions – Genital, reproductive, or urinary tract problems – Diagnoses

* Please indicate if you have had the following genital, reproductive, urinary tract problems. For any
problems that you have NOT had, please indicate "never diagnosed". For any problems that you have had,
please indicate if it was present before, during, and/or after Peace Corps (select all that apply).
Never diagnosed

Before Peace Corps

During Peace Corps

After Peace Corps

Kidney stones
Miscarriage(s)
Recurrent urinary tract
infections (3 or more
episodes in 1 year)
Recurrent vaginal yeast
(4 or more episodes in 1
year)
Other genital,
reproductive, or urinary
tract problem
If "other" please specify

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Peace Corps Health Outcomes
Section 3: Health Questions – Genital, reproductive, urinary tract problems – Medications Y/N

* Have you ever taken medication for your genital, reproductive, or urinary tract problems?
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 3: Health Questions - Genital, reproductive, or urinary tract problems - Medications

Please select any medications taken for your genital, reproductive, or urinary tract problem(s), and if
applicable indicate when taken. Select all that apply. Note that generic names are listed in alphabetical
order with the brand name in bold.
Never taken

Before Peace Corps

During Peace Corps

After Peace Corps

Amoxicillin-clavulanate
(Augmentin)
Ciprofloxacin (Cipro)
Fluconazole (Diflucan)
Levofloxacin
(Levaquin)
Miconazole (Monistat)
Nitrofurantoin
(Macrobid,
Macrodantin)
Sulfamethoxazoletrimethoprim (Bactrim,
Septra)
Other (specify below)
If "other" please specify

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Peace Corps Health Outcomes
Section 3: Health Questions – Immunologic, rheumatologic, or oncologic problems

* Have you ever been diagnosed by a health care provider with immunologic, rheumatologic, or oncologic
(cancer) problems?
For example:
Breast cancer
Gastric cancer
Leukemia
Liver cancer
Lymphoma
Prostate cancer
Rheumatoid arthritis
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 3: Health Questions – Immunologic, rheumatologic, or oncologic problems - Diagnoses

* Please indicate if you have had the following immunologic, rheumatologic, or oncologic problems. For any
problem that you have NOT had, please indicate "never diagnosed". For any problems that you have had,
please indicate if it was present before, during, and/or after Peace Corps (select all that apply).
Never diagnosed

Before Peace Corps

During Peace Corps

After Peace Corps

Breast cancer
Gastric cancer
Leukemia
Liver cancer
Lymphoma
Prostate cancer
Rheumatoid arthritis
Other immunologic,
rheumatologic, or
oncologic problem
If "other" please specify

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Peace Corps Health Outcomes
Section 3: Health Questions – Immunologic, rheumatologic, or oncologic problem - Medications
Y/N

Have you ever taken medication for your immunologic, rheumatologic, or oncologic problems?
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 3: Health Questions - Immunologic, rheumatologic, or oncologic problems - Medications

Please select any medications taken for your immunologic, rheumatologic, or oncologic problem(s), and if
applicable indicate when taken. Select all that apply. Note that generic names are listed in alphabetical
order with the brand name in bold.
Never taken

Before Peace Corps

During Peace Corps

After Peace Corps

Chemotherapy for
cancer
Dexamethasone
(Baycadron, DexPak,
Zema Pak)
Hydroxychloroquine
(Plaquenil)
Ibuprofen (Advil,
Motrin)
Levofloxacin
(Levaquin)
Methotrexate (Trexall)
Naproxen (Aleve,
Naprosyn)
Prednisolone (Millipred,
Orapred, Prelone)
Prednisone (Rayos,
Sterapred)
Radiation therapy
Sulfasalazine
(Azulfidine, Sulfazine)
Other (specify below)
If "other" please specify

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Peace Corps Health Outcomes
Section 3: Health Questions – Infectious diseases

* Have you ever been diagnosed by a health care provider with infectious diseases?
For example:
Amoebas
Antibiotic resistant infections
Chikungunya
Dengue
Eye infection
Gastrointestinal infection
Giardia
Leishmaniasis
Malaria
Pneumonia
Positive PPD (skin test for tuberculosis)
Schistosomiasis
Skin infections
Sexually transmitted disease
Tuberculosis (active)
Urinary tract infection (kidney, bladder)
Vaginal yeast infection
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 3: Health Questions – Infectious diseases - Diagnoses

* Please indicate if you have had the following infectious diseases. For any problem that you have NOT had,
please indicate "never diagnosed". For any problems that you have had, please indicate if it was present
before, during, and/or after Peace Corps (select all that apply).
Never diagnosed

Before Peace Corps

During Peace Corps

After Peace Corps

Amoebas
Antibiotic resistant
infections
Chikungunya
Dengue
Eye infection
Gastrointestinal
infection (not listed
here)
Giardia
Malaria
Pneumonia
Positive PPD (skin test
for tuberculosis)
Skin infections
Schistosomiasis
Sexually transmitted
disease
Tuberculosis
Urinary tract infections
(kidney, bladder)
Vaginal yeast infections
Other infectious disease
If "other" please specify

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Peace Corps Health Outcomes
Section 3: Health Questions – Infectious disease - Medication Y/N

* Have you ever taken medication for your infectious disease(s)?
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 3: Health Questions - Infectious diseases - Medications

Please select any medications taken for your infectious disease(s), and if applicable indicate when taken.
Select all that apply. Note that generic names are listed in alphabetical order with the brand name in bold.
Never taken

Before Peace Corps

During Peace Corps

After Peace Corps

Amoxicillin
Amoxicillin-clavulanate
(Augmentin)
Artemether-lumefantrine
(Coartem)
Atovaquone-proguanil
(Malarone)
Azithromycin
(Zithromax, Zmax)
Cefpodoxime (Vantin)
Cefuroxime (Ceftin)
Cephalexin (Keflex)
Chloroquine (Aralen)
Ciprofloxacin (Cipro)
Clindamycin (Cleocin)
Doxycycline
(Vibramycin)
Ethambutol
(Myambutol)
Fluconazole (Diflucan)
Gatifloxacin (Tequin,
Teqpaq)
Hydroxychloroquine
(Plaquenil)
Isoniazid (Nydrazid)
Levofloxacin
(Levaquin)
Mefloquine (Lariam)
Metronidazole (Flagyl)

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Never taken

Before Peace Corps

During Peace Corps

After Peace Corps

Miconazole (Monistat)
Primaquine
Quinine (Qualaquin)
Rifampin (Rifadin,
Rimactane)
Sulfamethoxazoletrimethoprim (Bactrim)
Tetracycline (Ala-Tet,
Panmycin, Sumycin)
Other (specify below)
If "other" please specify

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Peace Corps Health Outcomes
Section 3: Health Questions – Metabolic, endocrine, or hormonal problems

* Have you ever been diagnosed by a health care provider with metabolic, endocrine, or hormonal problems
other than menopause?
For example:
Diabetes
Hyperlipidemia (high cholesterol)
Hyperthyroidism
Hypothyroidism
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 3: Health Questions – Metabolic, endocrine, or hormonal problems - Diagnoses

* Please indicate if you have had the following metabolic, endocrine, or hormonal problems. For any
problem that you have NOT had, please indicate "never diagnosed". For any problems that you have had,
please indicate if it was present before, during, and/or after Peace Corps (select all that apply).
Never diagnosed

Before Peace Corps

During Peace Corps

After Peace Corps

Diabetes
Hyperlipidemia (high
cholesterol)
Hyperthyroidism
Hypothyroidism
Other metabolic or
hormonal problem
If "other" please specify

49

Peace Corps Health Outcomes
Section 3: Health Questions – Metabolic, endocrine, or hormonal problems - Medication Y/N

Have you ever taken medication for your metabolic, endocrine, or hormonal problem(s)?
Yes
No
Don't know

50

Peace Corps Health Outcomes
Section 3: Health Questions - Metabolic, endocrine, or hormonal problems - Medications

51

Please select any medications taken for your metabolic, endocrine, or hormonal problem(s), and if
applicable indicate when taken. Select all that apply. Note that generic names are listed in alphabetical
order with the brand name in bold.
Never taken

Before Peace Corps

During Peace Corps

After Peace Corps

Alogliptin (Nesina)
Atorvastatin (Lipitor)
Cerivastatin (Baycol)
Fluvastatin (Lescol,
Lescol XL)
Glimepiride (Amaryl)
Glipizide (Glucotrol)
Glyburide (Diabeta,
Glynase, Micronase)
Insulin (any type)
Linagliptin (Tradjenta)
Lovastatin (Altocor,
Altoprev)
Metformin
(Glucophage)
Nateglinide (Starlix)
Plioglitazone (Actos)
Pravastatin (Lipostat,
Pravachol)
Repaglinide (Prandin)
Rosiglitazone (Avandia)
Rosuvastatin (Crestor)
Simvastatin (Zocor)
Sitagliptin (Januvia)
Troglitazone (Rezulin)
Other (specify below)
If "other" please specify

52

Peace Corps Health Outcomes
Section 3: Health Questions – Musculoskeletal problems

* Have you ever been diagnosed by a health care provider with musculoskeletal problems?
For example:
Fracture
Osteoporosis
Tendon rupture
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 3: Health Questions – Musculoskeletal problems - Diagnoses

* Please indicate if you have had the following musculoskeletal problems For any problem that you have
NOT had, please indicate "never diagnosed". For any problems that you have had, please indicate if it was
present before, during, and/or after Peace Corps (select all that apply).
Never diagnosed

Before Peace Corps

During Peace Corps

After Peace Corps

Fracture (specify
location below)
Tendon rupture
Osteoporosis
Other musculoskeletal
problem (specify below)
If "fracture" or "other" please specify

54

Peace Corps Health Outcomes
Section 3: Health Questions – Musculoskeletal problems - Medication Y/N

Have you ever taken medication for your musculoskeletal problem(s)?
Yes
No
Don't know

55

Peace Corps Health Outcomes
Section 3: Health Questions - Musculoskeletal problems - Medications

Please select any medications taken for your musculoskeletal problem(s), and if applicable indicate when
taken. Select all that apply. Note that generic names are listed in alphabetical order with the brand name in
bold.
Never taken

Before Peace Corps

During Peace Corps

After Peace Corps

Acetaminophen
(Tylenol)
Alendronate (Fosamax)
Aspirin
Ibandronate (Boniva,
Bondronat)
Ibuprofen (Advil,
Motrin)
Naproxen (Aleve,
Naprosyn)
Raloxifene (Evista)
Risendronate (Actonel)
Other (specify below)
If "other" please specify

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Peace Corps Health Outcomes
Section 3: Health Questions – Neurologic problems

* Have you ever been diagnosed by a health care provider with neurologic problems?
For example:
Cluster headache
Dementia
Hearing loss
Insomnia
Migraines
Neuropathy
Seizures
Tension headache
Tinnitus
Vestibular disorder (vertigo)
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 3: Health Questions – Neurologic Problems - Diagnoses

* Please indicate if you have had the following neurologic problems. For any problem that you have NOT
had, please indicate "never diagnosed". For any problems that you have had, please indicate if it was
present before, during, and/or after Peace Corps (select all that apply).
Never diagnosed

Before Peace Corps

During Peace Corps

After Peace Corps

Cluster headache
Dementia
Hearing loss
Insomnia
Migraines
Neuropathy
Seizures
Tension headache
Tinnitus
Vestibular disorder
(vertigo)
Other neurologic
problem
If "other" please specify

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Peace Corps Health Outcomes
Section 3: Health Questions – Neurologic problems - Medication Y/N

* Have you ever taken medication for your neurologic problem(s)?
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 3: Health Questions - Neurologic problems - Medications

Please select any medications taken for your neurologic problem(s), and if applicable indicate when taken.
Select all that apply. Note that generic names are listed in alphabetical order with the brand name in bold.
Never taken

Before Peace Corps

During Peace Corps

After Peace Corps

Acetaminophen
(Tylenol)
Amoxapine (Asendin)
Amitriptyline (Vanatrip,
Elavil, Endep)
Carbamazepine
(Carbatrol, Epitol,
Equetro, Tegretol,
Tegretol XR)
Clomipramine
(Anafranil)
Desipramine
(Norpramin)
Dimenhydrinate
(Dramamine,
Driminate)
Diphenhydramine
(Benadryl, Diphen)
Divalproex sodium
(Depakote, Depakote
ER)
Doxepin (Silenor)
Eslicarbazepine
(Aptiom)
Gabapentin (Neurontin)
Ibuprofen (Aleve,
Motrin)
Imipramine (Tofranil)
Meclizine (Antivert,
Bonine, Dramamine
Less Drowsy)
Naproxen (Aleve,
Naprosyn)

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Never taken

Before Peace Corps

During Peace Corps

After Peace Corps

Nortriptyline (Aventyl,
Pamelor)
Oxcarbazepine
(Oxtellar XR, Trileptal)
Phenytoin (Dilantin,
Phenytek)
Pregabalin (Lyrica)
Rizatriptan (Maxalt)
Sumatriptan (Imitrex)
Tiagabine (Gabitril)
Vigabatrin (Sabril)
Other (specify below)
If "other" please specify

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Peace Corps Health Outcomes
Section 3: Health Questions – Ophthalmologic (eye) Problems

Do you currently wear glasses or contacts?
Yes
No
Don't know

* Have you ever been diagnosed by a health care provider with ophthalmologic (eye) problems?
For example
Cataracts
Corneal ulcer
Glaucoma
Keratitis
Macular degeneration
Retinopathy
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 3: Health Questions – Ophthalmologic (eye) problems - Diagnoses

* Please indicate if you have had the following ophthalmologic (eye) problems For any problem that you
have NOT had, please indicate "never diagnosed". For any problems that you have had, please indicate if
it was present before, during, and/or after Peace Corps (select all that apply).
Never diagnosed

Before Peace Corps

During Peace Corps

After Peace Corps

Cataracts
Corneal ulcer
Glaucoma
Keratitis
Macular degeneration
Retinopathy
Other ophthalmologic
problem (specify below)
If "other" please specify

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Peace Corps Health Outcomes
Section 3: Health Questions – Ophthalmologic problems - Medication Y/N

Have you ever taken medication for your ophthalmologic problem(s)?
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 3: Health Questions - Ophthalmologic problems - Medications

Please select any medications taken for your ophthalmologic problem(s), and if applicable indicate when
taken. Select all that apply. Note that generic names are listed in alphabetical order with the brand name in
bold.
Never taken

Before Peace Corps

During Peace Corps

After Peace Corps

Betaxolol ophthalmic
(Betoptic, Betoptic S)
Latanoprost ophthalmic
(Xalatan)
Ranibizumab ophthalmic
(Lucentis)
Timolol ophthalmic
(Betimol, Istalol,
Timpoptic)
Other (specify below)
If "other" please specify

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Peace Corps Health Outcomes
Section 3: Health Questions – Psychiatric problems

* Have you ever been diagnosed by a health care provider with psychiatric problems?
For example:
Anxiety disorder
Bipolar disorder
Depression
Obsessive-compulsive disorder
Schizophrenia
Yes
No
Don't know

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Peace Corps Health Outcomes
Section 3: Health Questions – Psychiatric problems - Diagnoses

* Please indicate if you have had the following psychiatric problems For any problem that you have NOT
had, please indicate "never diagnosed". For any problems that you have had, please indicate if it was
present before, during, and/or after Peace Corps (select all that apply).
Never diagnosed

Before Peace Corps

During Peace Corps

After Peace Corps

Generalized anxiety
disorder
Bipolar disorder
Major depressive
disorder
Obsessive-compulsive
disorder
Schizophrenia
Other Psychiatric
problem (specify below)
If "other" please specify

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Peace Corps Health Outcomes
Section 3: Health Questions – Psychiatric problems - Medication Y/N

Have you ever taken medication for your psychiatric problem(s)?
Yes
No
Don't know

68

Peace Corps Health Outcomes
Section 3: Health Questions - Psychiatric problems - Medications

Please select any medications taken for your psychiatric problem(s), and if applicable indicate when taken.
Select all that apply. Note that generic names are listed in alphabetical order with the brand name in bold.
Never taken

Before Peace Corps

During Peace Corps

After Peace Corps

Amitriptyline (Elavil,
Vanatrip)
Amoxapine (Asendin)
Asenapine (Saphris)
Bupropion (Aplenzihn,
Budeprion, Buproban,
Forfivo XL, Wellbutrin,
Zyban)
Citalopram (Celexa)
Clomipramine
(Anafranil)
Clonazepam
(Klonopin)
Clozapine (Clopine,
Clozaril, Denzapine,
FazaClo, Versacloz,
Zaponex)
Desipramine
(Norpramin)
Desvenlafaxine
(Khedezla, Pristiq)
Diazepam (Valium)
Divalproex sodium
(Depakote)
Doxepin (Silenor,
Sinequan)
Droperidol (Inapsine)

Duloxetine (Cymbalta)
Escitalopram (Lexapro)
Fluoxetine (Prozac,
Sarafem, Selfemra)

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Never taken

Before Peace Corps

During Peace Corps

After Peace Corps

Fluvoxamine (Luvox)
Haloperidol (Haldol)
Imipramine (Tofranil)
Isocarboxazid
(Marplan)
Maprotiline (Ludiomil)
Midazolam (Versed)
Mirtazapine (Remeron)
Nefazodone (Serzone)
Nortriptyline (Aventyl,
Pamelor)
Olanzapine (Zyprexa)
Paroxetine (Brisdelle,
Paxil, Pexeva)
Phenelzine (Nardil)
Phenobarbital (Luminal,
Solfoton)
Pimozide (Orap)
Protriptyline (Vivactil)
Quetiapine (Seroquel)
Risperidone (Risperdal)
Selegiline (Emsam)
Sertraline (Zoloft)
Tranylcypromine
(Parnate)
Trazodone (Desyrel,
Oleptro)
Trimipramine
(Surmontil)
Venlafaxine (Effexor,
Effexor XR)
Ziprasidone (Geodon)
Other (specify below)
If "other" please specify

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71

Peace Corps Health Outcomes
Section 4: Risk Factors - Family History

This last group of questions will help us understand if you might be at higher risk for certain diseases.
Has anyone in your family (mother, father, brother, sister) ever been diagnosed with (check any that apply):
Cancer
Diabetes
Heart problems (heart attack, irregular heartbeat, congestive heart failure)
Psoriasis
Psychiatric issues (ex: generalized anxiety disorder, major depressive disorder, bipolar, or schizophrenia)

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Peace Corps Health Outcomes
Section 4: Risk Factors - Smoke

Have you smoked at least 100 cigarettes in your entire life?
NOTE: 5 packs = 100 cigarettes
Yes
No
Don't know/not sure

73

Peace Corps Health Outcomes
Section 4: Risk Factors - Smoke

Do you now smoke cigarettes every day, some days, or not at all?
Every day
Some days
Not at all
Don't know/ Not sure

During the past 12 months, have you stopped smoking for one day or longer because you were trying to
quit smoking?
Yes
No
Not applicable. I haven't smoked in the last 12 months.
Don't know / Not sure

How long has it been since you last smoked a cigarette, even one or two puffs?
Within the past month (less than 1 month ago)
Within the past 3 months (1 month but less than 3 months ago)
Within the past 6 months (less than 6 months ago)
Within the past year (6 months but less than 1 year ago)
Within the past 5 years (1 year but less than 5 years ago)
Within the past 10 years (5 years but less than 10 years ago)
10 years or more
Don't know/ Not sure

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Peace Corps Health Outcomes
Section 4: Risk Factors - Alcohol

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
No
Don't know/ Not sure

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Peace Corps Health Outcomes
Section 4: Risk Factors - Alcohol

During the past 30 days how many days per week or per month did you have at least one drink of any
alcoholic beverage such as beer, wine, a malt beverage, or liquor?
(Please enter a number 0 or greater)
Days per week
Days per month

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?
(Please enter a number 0 or greater)

Considering all types of alcoholic beverages, how many times during the past 30 days did you have 5 or
more drinks (for men) or 4 or more drinks (for women) on an occasion?
(Please enter a number, 0 or greater)
NOTE: A 40 ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.

During the past 30 days, what is the largest number of drinks you had on any occasion?
(Please enter a number, 0 or greater)

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Peace Corps Health Outcomes
Section 5: Demographics

How many days per week do you exercise moderately or vigorously (physical exertion feels somewhat
hard to hard) for at least 30 minutes? (Please enter a number 0 or greater)

What is the highest grade or year of school you completed?
Grade 12 or GED (High school graduate)
College 1 year to 3 years (Some college or technical school)
College 4 years or more (College graduate)
Graduate or Professional school

Are you currently...?
Employed for wages
Self-employed
Out of work for 1 year or more
Out of work for less than 1 year
A Homemaker
A Student
Retired
Unable to work

Are you...?
Married
Divorced
Widowed
Separated
Never married
A member of an unmarried couple

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What is your age group?
21-29
30-39
40-49
50-59
60-69
70+

Are you male, female, or other?
Male
Female
Other
Prefer not to answer

Are you Hispanic, Latino/a, or Spanish origin?
Yes
No
Don't know/ Not sure

Which one or more of the following would you say is your race?
White
Black or African American
American Indian or Alaska Native
Asian
Pacific Islander
Don't know/ Not sure
Other (please specify)

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Peace Corps Health Outcomes
End of Survey

Thank you for helping to improve Peace Corps' understanding of the long term health outcomes
among Peace Corps Volunteers.

79