Forms for the Balance Vestibular Visual Function Pilot S

Attachment 1b

National Health and Nutrition Examination Survey (NHANES)

Balance / Vestibular/ Visual Function Pilot Study

Data Collection Forms

Form Approved

OMB No. 0920-0950

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Public reporting burden of this collection of information is estimated to average 22 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection review Office, 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333. ATTN: PRA (0920-0950).

Expires: 12/31/2019

NHANES Balance / Vestibular / Visual Function

(ages 40 years and older)

SP ID______________ Tech ID_______________

SAFETY EXCLUSION QUESTIONS

1. Can you stand on your own? ___YES ___NO

2. Do you have amputations of your legs or feet, other than toes? ___YES ___NO

3. Where is the amputation? RIGHT LEG LEFT LEG RIGHT FOOT LEFT FOOT

4. Do you have a leg brace? ___YES ___NO

5. How much do you weight without shoes or clothes? _____ LBS

6. Have you had a problem in the last 24 hours with dizziness, lightheadedness, feeling as if you are going to pass out or fainting? ___YES ___NO

7. Have you fallen in the past 12 months due to a problem with dizziness or balance ___YES ___NO

If a person says “Yes” to questions 1, 2, or 3 above or “Yes” to both 5 and 6 above then s/he is ineligible.

BALANCE TEST RESULTS

Test 1 complete ___ Yes ___No

Result for (eyes open, stand on firm surface) ___Passed ___Failed (not still 20 seconds)

Accelerometer vector magnitude score (for swaying) ____

Test 2 complete ___ Yes ___No

Result for (eyes closed, stand on firm surface) ___Passed ___Failed (not still 20 seconds)

Accelerometer vector magnitude score (for swaying) ____

Test 3 complete ___ Yes ___No

Result for (eyes open, stand on soft surface) ___Passed ___Failed (not still 20 seconds)

Accelerometer vector magnitude score (for swaying) ____

Test 4 complete ___ Yes ___No

Result for (eyes closed, stand on soft surface) ___Passed ___Failed (not still 20 seconds)

Accelerometer vector magnitude score (for swaying) ____

Test 5 complete ___ Yes ___No

Result for (eyes closed, stand on soft surface, head moving) ___Passed ___Failed (not still 20 seconds)

Accelerometer vector magnitude score (for swaying) ____

REASONS BALANCE TEST INCOMPLETE OR NOT DONE

Physical limitation

Participant refusal

Participant ill/emergency

Out of time

Equipment failure

Communication problem

DYNAMIC VISUAL ACUITY TEST RESULTS

Test 1 complete ___ Yes ___No

Corrected bioptic visual acuity (while head is still) ___/___ (for example 20/20 vision)

Test 2 complete ___ Yes ___No

Corrected bioptic visual acuity (while head is moving side to side) ___/___ (for example 20/80 vision)

REASONS DYNAMIC VISUAL ACUITY TEST INCOMPLETE OR NOT DONE

Physical limitation

Participant refusal

Participant ill/emergency

Out of time

Equipment failure

Communication problem

QUESTIONS ABOUT CORRECTIVE LENSES

If the participant is wearing glasses, the health technician will ask the following questions:

1. Are the glasses you are wearing single vision or multi-vision?

single vision

multi-vision

IF YES TO QUESTION 1,

1a) what type of multi-vision glasses are they?

bi-focals

tri-focals

progressives

1b) Do you usually wear those glasses during the day?

yes

no

1c) Have you been wearing the glasses continually for the past hour or more??

yes

no

If the participant is not wearing glasses, the health technician will ask the following questions instead:

1) Are you currently wearing contact lenses?

yes

no

IF YES TO QUESTION 1,

1a) Are the contacts you are wearing single vision or multi-vision?

single vision

multi-vision

1b) Do you usually wear contacts during the day?

yes

no

1c) Have you been wearing the contacts continually for the past hour or more?

yes

no

Example Contrast Senstivity form