Pre-ABPM Form

Attachment 1d

National Health and Nutrition Examination Survey (NHANES)

Ambulatory Blood Pressure Monitoring (ABPM) Feasibility Study

Pre ABPM Questionnaires

Form Approved

OMB No. 0920-0950

Exp. Date 12/31/2017

Assurance of confidentiality – All information which would permit identification of an individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

Public reporting burden of this collection of information is estimated to average 30 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333. ATTN: PRA (0920-0950).

This attachment captures the time needed for participants to have three resting blood pressure measurements, and be fitted with both the ABPM and the Actigraph GT3X-plus Activity Monitor. It also captures the pre ABPM questionnaires which includes sleep quality and demographic questionnaires that participants will fill out (see below).

Pre ABPM Questionnaires

DEMOGRAPHIC QUESTIONS FOR 24 HOUR AMBULATORY BLOOD PRESSURE FEASIBILITY STUDY

Are you Hispanic, Latino/a, or Spanish origin (One or more categories may be selected)

a. ____No, not of Hispanic, Latino/a, or Spanish origin

b. ____Yes, Mexican, Mexican American, Chicano/a

c. ____Yes, Puerto Rican

d. ____Yes, Cuban

e. ____Yes, Another Hispanic, Latino/a or Spanish origin

What is your race? (One or more categories may be selected)

a. ____White

b. ____Black or African American

c. ____American Indian or Alaska Native

d. ____Asian Indian

e. ____Chinese

f. ____ Filipino

g. ____Japanese

h. ____Korean

i. ____ Vietnamese

j. ____ Other Asian

k. ____Native Hawaiian

l. ____ Guamanian or Chamorro

m. ___ Samoan

n. ____Other Pacific Islander

What is the highest education completed:

􀁔 less than high school 􀁔 high school graduate or GED 􀁔 more than high school

Are you currently (check 􀀖only one):

􀁔 married 􀁔 separated 􀁔 widowed􀁔 single 􀁔 divorced

Do you have a chronic condition(s), or condition(s) you take medications for: YES or NO

If yes, please specify condition(s):__________________

Would you say in general, your health is…

􀁔 excellent 􀁔 very good 􀁔 good 􀁔 fair 􀁔 poor 􀁔 don’t know 􀁔 refused

Do you currently have high blood pressure? YES or NO

Richards-Campbell Sleep Questionnaire (RCSQ)

Measure	Questiona
1. Sleep depth	My sleep last night was: light sleep (0) ... deep sleep (100)
2. Sleep latency	Last night, the first time I got to sleep, I: just never could fall asleep (0) ... fell asleep almost immediately (100)
3. Awakenings	Last night, I was: awake all night long (0) ... awake very little (100)
4. Returning to sleep	Last night, when I woke up or was awakened, I: couldn't get back to sleep (0) ... got back to sleep immediately (100)
5. Sleep quality	I would describe my sleep last night as: a bad night's sleep (0) ... a good night's sleep (100)
6. Noiseb	I would describe the noise level last night as: very noisy (0) ... very quiet (100)

AM

Subject’s Initials ID# Date Time PM

PITTSBURGH SLEEP QUALITY INDEX (PSQI)

INSTRUCTIONS:

The following questions relate to your usual sleep habits during the past month only. Your answers should indicate the most accurate reply for the majority of days and nights in the past month.

Please answer all questions.

1. During the past month, what time have you usually gone to bed at night?

BED TIME

2. During the past month, how long (in minutes) has it usually taken you to fall asleep each night? NUMBER OF MINUTES

3. During the past month, what time have you usually gotten up in the morning?

GETTING UP TIME

4. During the past month, how many hours of actual sleep did you get at night? (This may be different than the number of hours you spent in bed.)

HOURS OF SLEEP PER NIGHT

For each of the remaining questions, check the one best response. Please answer all questions.

5. During the past month, how often have you had trouble sleeping because you . . .

1. Cannot get to sleep within 30 minutes

Not during the Less than Once or twice Three or more

past month

once a week

a week

times a week

2. Wake up in the middle of the night or early morning

Not during the Less than Once or twice Three or more

past month

once a week

a week

times a week

3. Have to get up to use the bathroom

Not during the Less than Once or twice Three or more

past month

once a week

a week

times a week

4. Cannot breathe comfortably

Not during the Less than Once or twice Three or more

past month

once a week

a week

times a week

5. Cough or snore loudly

Not during the Less than Once or twice Three or more

past month

once a week

a week

times a week

6. Feel too cold

Not during the Less than Once or twice Three or more

past month

once a week

a week

times a week

7. Feel too hot

Not during the Less than Once or twice Three or more

past month

once a week

a week

times a week

8. Had bad dreams

Not during the Less than Once or twice Three or more

past month

once a week

a week

times a week

9. Have pain

Not during the Less than Once or twice Three or more

past month

once a week

a week

times a week

10. Other reason(s), please describe

How often during the past month have you had trouble sleeping because of this?

Not during the Less than Once or twice Three or more

past month

once a week

a week

times a week

6. During the past month, how would you rate your sleep quality overall? Very good

Fairly good

Fairly bad

Very bad

7. During the past month, how often have you taken medicine to help you sleep (prescribed or "over the counter")?

Not during the Less than Once or twice Three or more

past month

once a week

a week

times a week

8. During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity?

Not during the Less than Once or twice Three or more

past month

once a week

a week

times a week

9. During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done?

No problem at all

Only a very slight problem

Somewhat of a problem

A very big problem

10.	Do you have a bed partner or room mate? No bed partner or room mate
	Partner/room mate in other room
	Partner in same room, but not same bed Partner in same bed

If you have a room mate or bed partner, ask him/her how often in the past month you have had . . .

1. Loud snoring

Not during the Less than Once or twice Three or more

past month

once a week

a week

times a week

2. Long pauses between breaths while asleep

Not during the Less than Once or twice Three or more

past month

once a week

a week

times a week

3. Legs twitching or jerking while you sleep

Not during the Less than Once or twice Three or more

past month

once a week

a week

times a week

4. Episodes of disorientation or confusion during sleep

Not during the Less than Once or twice Three or more

past month

once a week

a week

times a week

5. Other restlessness while you sleep; please describe

Not during the Less than Once or twice Three or more

past month

once a week

a week

times a week

© 1989, University of Pittsburgh. All rights reserved. Developed by Buysse,D.J., Reynolds,C.F., Monk,T.H., Berman,S.R., and Kupfer,D.J. of the University of Pittsburgh using National Institute of Mental Health Funding.

Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ: Psychiatry Research, 28:193-213, 1989.