Household Interview Hand Cards

Attachment 3e

Household Interview Hand Cards

Table of Contents

Sample Person (SP) Hand Cards 2

Family Hand Cards 60

Sample Person (SP) Hand Cards

SP Hand Cards; 7/1/2018

Introductory Hand Card

Suggested script: (example)

During the interview, I will ask if I can see the containers for all the dietary supplements and prescription medication (you take/SP NAME takes) to enter them in my computer. To save time, would you please collect the containers for all of the items in this list that you take, while I set up my computer for the interview? Thank you. (Present the laminated card to the SP or proxy)

(Laminated card for participants 2 years and older)

Containers from past 30 days

Vitamins, minerals, herbals, or other dietary supplements

Antacids

Prescription medications

(Laminated card for participants 0-24 months)

Containers from past 2 weeks

Infant formulas

Toddler formulas

Containers from past 30 days

Vitamins, minerals, herbals, or other dietary supplements

Antacids

Prescription medications

MCQ1

MCQ2

FNQ1

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

FNQ2

Some difficulty

A lot of difficulty

Cannot do at all

FNQ3

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

OSQ3

Hip replacement

Knee replacement

Plates or pins to fix a broken bone

Dental implants (posts)

Metal sutures or clips Stents

Pacemakers

HEQ1

Prescribed Medicines for Hepatitis B

Adefovir

Alinia

Baraclude Entecavir

Epivir

Epivir HBV

Hepsera

Interferon / Peginterferon

Intron A

Lamivudine

Nitazoxanide

Olysio (simeprevir) Pegasys

Pegintron

Roferon-A

Sovaldi (sofosbuvir) Telbivudine

Tenofovir

Tyzeka

Vemlidy

Viread

HEQ2

Prescribed Medicines for Hepatitis C

Alinia

Boceprevir

Copegus

Daklinza (Daclatasvir)

Epclusa

Harvoni

Incivek

Infergen

Interferon / Peginterferon

Intron A

Ledipasvir

Mayvret

Nitazoxanide

Olysio (simeprevir)

Pegasys

Pegintron

Rebetol

Rebetron

Ribapak

Ribasphere

Ribatab

Ribavirin

Roferon-A

Sovaldi (sofosbuvir)

Sylatron

Technivie

Telaprevir

Victrelis

Viekira Pak

Virazole

Vosevi

Zepatier

DLQ1

No difficulty

Some difficult

A lot of difficulty

Unable to do

DIQ1

Prediabetes

Impaired fasting glucose

Impaired glucose tolerance

Borderline diabetes

DIQ3

Less than 6

Less than 7

Less than 8

Less than 9

Less than 10

Provider did not specify a goal

CDQ1

OSQ1

OSQ2

Prescribed Medicines for Osteoporosis

Fosamax, Alendronate

Boniva, Ibandronate

Actonel, Atelvia, Risedronate Reclast, Zoledronic acid

Fortical, Miacalcin, Calcitonin Evista, Raloxifene

Forteo, Teriparatide

Duavee, Bazedoxifene

Prolia, Denosumab

AUQ1

Genetic/hereditary causes

Ear infections (including fluid in ears)

Ear diseases (otosclerosis, menieres, tumor) Illness/infections (measles, meningitis, mumps) Drugs/medications

Head or neck injury/trauma

Loud brief explosive noise sounds

Noise exposure, long-term (machinery, etc.) Aging, getting older

AUQ2

Speech-language Reading

Hearing or listening skills Intellectual disability

Movement or mobility difficulties

Other developmental or disability problems

AUQ3

Always

Usually

About half the time Seldom

Never

AUQ4

Always

Usually

About half the time Seldom

Never

No noise exposure past 12 months

DEQ2

Always

Most of the time

Sometimes

Rarely

Never

OHQ1

Went in on own for check-up, examination or cleaning

Was called in by the dentist for check-up, examination or cleaning

Something was wrong, bothering or hurting

Went for treatment of a condition that dentist discovered at earlier check-up or examination

OHQ2

Could not afford the cost

Did not want to spend the money

Insurance did not cover recommended procedures

Dental office is too far away

Dental office is not open at convenient times Another dentist recommended not doing it

Afraid or do not like dentists

Unable to take time off from work

Too busy

I did not think anything serious was wrong/expected dental problems to go away

OHQ3

Very often

Fairly often Occasionally Hardly ever

Never

OHQ4

1. Full load

2. Half load

3. Pea size

4. Smear

BAQ 1

Getting up after sitting or lying down

Bending down or leaning over

Looking up or leaning head back

Looking at moving objects – passing traffic or a train

Being in a place with a lot of people moving around

Being in wide-open spaces

Motion sickness from riding in a car or moving vehicle

Quick head movement from side-to-side

Rolling over in bed

Standing on your feet for a long time

BAQ 2

Nausea or vomiting

Migraine or severe headache

Tinnitus (ringing, buzzing or roaring in ears or head)

Sinus congestion

Depression

Ear fullness, pressure or stuffed-up feeling, without pain

Hearing trouble (worse hearing)

BAQ 3

Anemia

Anxiety or panic attacks

Diabetes

Heart disease

Hormonal changes (including pregnancy)

Low blood pressure or hypotension

Low blood sugar or hypoglycemia

Stroke

None of these

BAQ 4

Auto-immune disease, such as rheumatoroid arthritis, lupus, sjogren’s

Benign positional vertigo (bpv or bppv)

Crystals—loose or dislodged in ear

Head or neck trauma or concussion

Inner ear infection, viral labrynthitis

Ménière’s (men-e-airz) disease

Migraines or headaches

Neurological condition, such as multiple sclerosis, parkinson’s

Side effects from medications, such as cancer treatments, antibiotics

None of these

BAQ 5

Exercises at home, which were not begun in a clinic

Exercises or physical therapy begun in a clinic

Bed rest for several hours or days

Head rolling or epley maneuver by a doctor or therapist

Steroid injections into the ear

Gentamicin (jen-tah-mi-sin) injections into the ear

Prescription medicines

Psychiatric or psychological treatment

Surgery to the ear

Some other type of surgery

None of these

BAQ 6

Over-the-counter medicines or drugs

Dietary restrictions: slow salt diet, avoiding certain foods or drinks, such as chocolate, coffee, or alcohol

Quitting or reducing use of tobacco or cigarettes

Massage therapy or chiropractic treatments or manipulations

Herbal remedy: feverfew leaf, ginger, ginkgo biloba, etc

Wearing magnets or acupressure wristband

Counseling or stress management

Acupuncture

None of these

BAQ 7

Anxiety or panic attacks

Auto-immune disease, such as rheumatoroid arthritis, lupus, sjogren’s

Cognitive problems, such as memory, attention, learning

Depression

Head injury or concussion

Heart rythem problems or heart failure

Migraine(s) or severe headaches

Numbness in the hands or feet lasting days or longer

Neurological disorder, such as parkinson’s, multiple scherosis, seizures

Severe head injury or concussion (with or without loss of consciousness)

No—none of these

SLQ1

Never

Rarely – 1 time a month

Sometimes – 2 to 4 times a month Often – 5 to 15 times a month

Almost always – 16 to 30 times a month

DEQ1

Always

Most of the time

Sometimes

Rarely

Never

DBQ2

Never

0-3 months

4-5 months

6-7 months

8-9 months

10-11 months

12 months or older

DBQ3

Nut butters

_________________________________________________

Nut and seed products

______________________________________________________

Nuts

__________________________________________________

Seeds

DBQ4

Never

Rarely – less than once a week

Sometimes – once a week or more, but

less than once a day

Often – once a day or more

DBQ5

A regular milk drinker for most or all

of lifetime, including childhood

Never has been a regular milk drinker

Milk drinking has varied over lifetime – sometimes has been a regular milk drinker and sometimes has not been a regular milk drinker

DBQ6

Never

Rarely – less than once a week Sometimes – once a week or more,

but less than once a day

Often – once a day or more

FSQ1

Child does not qualify for WIC (family income too high)

Child does not need WIC because family receives support from relatives or friends

Child does not need WIC because family receives support SNAP, a food bank, or another program

Never thought about applying for WIC

Parent/caregiver cannot find time to get to the WIC clinic

Parent/caregiver does not have transportation to get to WIC

The stores that accept WIC are not close to family’s home

WIC foods are difficult to find in the grocery store

Using WIC at the grocery store is uncomfortable

Another reason (describe)

FSQ2

Child no longer qualifies for WIC (family income too high)

Child no longer needs WIC because family receives support from relatives or friends

Child no longer needs WIC because family receives support from SNAP, a food bank, or another program

Parent/caregiver could not find time to go to the WIC clinic

Parent/caregiver could not find transportation to get to WIC

WIC clinic wait times were too long

The stores that accept WIC were not close to family’s home

WIC foods were difficult to find in the grocery store

Using WIC at the grocery store was uncomfortable

Checking out at the store with WIC foods took a long time

Child did not like the WIC foods

Another reason (describe)

DBQ74DBQ7

EXAMPLES OF FROZEN MEALS & FROZEN PIZZAS

WHQ1

SMQ1

ACQ1

Only Spanish

More Spanish than English

Both equally

More English than Spanish

Only English

ACQ2

English

Chinese Farsi/Persian

Hindi

Japanese

Khmer/Cambodian Korean

Tagalog/Filipino

Urdu

Vietnamese Other

DMQ1

Never attended/kindergarten only

1st grade

2nd grade

3rd grade

4th grade

5th grade

6th grade

7th grade

8th grade

9th grade

10th grade

11th grade

12th grade, no diploma High school graduate GED or equivalent

Some college, no degree

Associate degree: Occupational, technical, or vocational program

Associate degree: Academic program

Bachelor’s degree (example: BA, AB, BS, BBA)

Master’s degree (example: MA, MS, MEng, MEd, MBA)

Professional school degree (example: MD, DDS, DVM, JD)

Doctoral degree (example: PhD, EdD)

DMQ4

American Indian or Alaska

Native Asian

Black or African American

Native Hawaiian or Pacific Islander

White

DMQ5

1. Native Hawaiian

2. Guamanian or Chamorro

3. Samoan

4. Other Pacific Islander

DMQ8

Examples of what we learned when matching NHANES data to other data sources such as Medicare and Medicaid:

• How housing environment may affect the levels of lead in children’s blood

• Higher vitamin D in the blood lowers the risk of broken bones

• Consuming high amount of sugar can increase the risk of heart diseases

• People who live or work with smokers have a higher risk of heart attack

• Adults who exercise, eat healthy diets, and do not smoke have a lower chance of dying

HIQ1

Private health insurance

Medicare

Medi-gap

Medicaid

Children’s Health Insurance Program (CHIP)

Military Related Health Care: Tricare (CHAMPUS)/VA HEALTH CARE/ Champ-VA

Indian Health Service

State-sponsored health plan

Other government program

No coverage of any type

HIQ2

DSQ1b

EXAMPLES OF ANTACIDS

Tums

Rolaids Maalox Mylanta

Family Hand Cards

DMQ1

Never attended/kindergarten only

1st grade

2nd grade

3rd grade

4th grade

5th grade

6th grade

7th grade

8th grade

9th grade

10th grade

11th grade

12th grade, no diploma

High school graduate

GED or equivalent

Some college, no degree

Associate degree: Occupational, technical, or vocational program

Associate degree: Academic program

Bachelor’s degree (example: BA, AB, BS, BBA)

Master’s degree (example: MA, MS, MEng, MEd, MBA)

Professional school degree (example: MD, DDS, DVM, JD)

Doctoral degree (example: PhD, EdD)

HOQ1

A one-family house detached from any other house

A one-family house attached to one or more houses

A building with 2 apartments

A building with 3 or 4 apartments

A building with 5 to 9 apartments

A building with 10 to 19 apartments

A building with 20 to 49 apartments

A building with 50 or more apartments

A mobile home, trailer, or manufactured home

A dormitory or similar boarding house

HOQ2

Brita or other pitcher water filter

Ceramic or charcoal filter

Water softener

Aerator

Reverse osmosis

CBQ1

EXAMPLES OF PLACES OTHER THAN GROCERY STORES

Convenience Stores (7-11, Mini Mart)

Wholesale Stores (Costco, Sam’s Club,

BJ’s)

Target/ Wal-Mart/ Kmart

Dollar Store

Bakeries

Meat Markets

Vegetable stands

Farmer’s Markets

INQ1

U.	$20,000 - $20,999	JJ.	$35,000 - $39,999
V.	$21,000 - $21,999	KK.	$40,000 - $44,999
W.	$22,000 - $22,999	LL.	$45,000 - $49,999
X.	$23,000 - $23,999	MM.	$50,000 - $54,999
Y.	$24,000 - $24,999	NN.	$55,000 - $59,999
Z.	$25,000 - $25,999	OO.	$60,000 - $64,999
AA.	$26,000 - $26,999	PP.	$65,000 - $69,999
BB.	$27,000 - $27,999	QQ.	$70,000 - $74,999
CC.	$28,000 - $28,999	RR.	$75,000 - $79,999
DD.	$29,000 - $29,999	SS.	$80,000 - $84,999
EE.	$30,000 - $30,999	TT.	$85,000 - $89,999
FF.	$31,000 - $31,999	UU.	$90,000 - $94,999
GG.	$32,000 - $32,999	VV.	$95,000 - $99,999
HH.	$33,000 - $33,999	WW.	$100,000 and over
II.	$34,000 - $34,999

INQ2

A.	Less than $1,000	K. $10,000 - $10,999
B.	$1,000 - $1,999	L. $11,000 - $11,999
C.	$2,000 - $2,999	M. $12,000 - $12,999
D.	$3,000 - $3,999	N. $13,000 - $13,999
E.	$4,000 - $4,999	O. $14,000 - $14,999
F.	$5,000 - $5,999	P. $15,000 - $15,999
G.	$6,000 - $6,999	Q. $16,000 - $16,999
H.	$7,000 - $7,999	R. $17,000 - $17,999
I.	$8,000 - $8,999	S. $18,000 - $18,999
J.	$9,000 - $9,999	T. $19,000 - $19,999

INQ3

Cash

Checking account Saving accounts

CDs (Certificates of deposit)

Retirement accounts (such as IRAs, 401K, etc.) Stocks

Bonds Mutual funds

INQ4

A: $0 - $3,000

B: $3,001 - $5,000

C: $5,001 - $10,000

D: $10,001 - $15,000 E: $15,001 - $20,000

Cash

Checking account Saving accounts

CDs (Certificates of deposit)

Retirement accounts (such as IRAs, 401K, etc.) Stocks

Bonds

Mutual funds

INQ5

In my car

In a car that belongs to someone I live with

In a car that belongs to someone who lives

elsewhere

Walk

Ride bicycle

Bus, subway or other public transit

Taxi or other paid driver

Someone else delivers groceries

Other

FSQ1

Often true

Sometimes true

Never true