QUESTIONNAIRES ADMINISTERED ORALLY TO PARTICIPANTS DURING CLINICAL ASSESSMENT AT MEMORIAL HOSPITAL OF RHODE ISLAND
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Table of Contents Smoking…………………………………………………………………………3 Cognitive Assessment……………………………………………………………5 Depressive Symptomatology……………………………………………………21 Respiratory Tract Infection……………………………………………………...22 Sexual Preference………………………………………………………………..22 Self-Efficacy……………………………………………………………………..23 Parental Bonding Instrument…………………………………………………….24 Perceived Stress………………………………………………………………….27 Altruism Scale……………………………………………………………………29 Religiosity………………………………………………………………………..30 Social Support………....…………………………………………………………31 Medications……………………………………………………………………....32
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LEAP ID: L __ __ __ __ STAFF ID:
__ __ __ __
SURVEY DATE:
Introduction We appreciate you taking the time to be here today and participating in this project. Next, I’ll be asking you a series of questions on various aspects of your health, health behaviors, family, and other life circumstances. This interview should take approximately 45 minutes. Please keep in mind that you can refuse to answer any question(s) that you are not comfortable with. Also, if any question is unclear or if you need additional clarification, please let me know. Do you have any questions before we begin? Let’s get started. *Note to interviewer: Under circumstances where the interview needs to be completed very quickly, modules marked with this symbol: are critical to obtain. Smoking (SM) I would now like to ask you a few questions about cigarette smoking. SM1.
Have you smoked at least 100 cigarettes in your entire life?
SM2.
Did you ever become a daily smoker (that is, smoke every day or nearly every day for two months or longer)?
SM3.
Yes No Don’t know Prefer not to answer
Yes No skip to SM6 Don’t know Prefer not to answer
How old were you when you first began smoking daily? Age ______ (in years)
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Don’t know
Prefer not to answer
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SM4.
When you began smoking daily, how many cigarettes did you smoke per day (on average)? Average cigarettes per day: ________ Pipes and/or cigars only Don’t know Prefer not to answer
SM5.
How old were you when you last smoked daily? Age ______ (in years) Don’t know
SM6.
Prefer not to answer
Still smoking daily
Do you smoke cigarettes now?
SM6a.
Yes No skip to next section (CA) on page 3 Don’t know Prefer not to answer
How many cigarettes per day do you smoke? (One pack equals 20 cigarettes) Number of cigarettes ________ Don’t know Prefer not to answer
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CA (CA) CA: Section I Now, I’d like to ask you some questions about your memory and thinking style. For this portion of the interview I’d like to use a tape recorder to be sure that we administer the questions in a consistent fashion. The tape recordings will later be reviewed by a member of the research staff to be sure that all participants were administered this section of the interview in the same manner and to confirm that responses were recorded accurately. Are you ready to begin? (IF PARTICIPANT REFUSES THE AUDIO-RECORDING: Okay, if you’re not comfortable with the audio-recording, I will not record this section.)
CA1.
First, how would you rate your memory at the present time? Would you say it is excellent, very good, good, fair or poor? Excellent Very good Good Fair Poor Don’t know Refused
CA2.
Compared to 2 years ago, would you say your memory is better now, about the same, or worse now than it was then? Better Same Worse Don’t know Refused
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Now I’m going to read a set of 10 words and ask you to recall as many as you can. We have purposely made the list long so that it will be difficult for anyone to recall all the words----most people recall just a few. Please listen carefully as I read them. When I finish, I will ask you to recall aloud as many of the words as you can, in any order. Is this clear? PROBE AS NEEDED FOR UNDERSTANDING OF TASK. STATE THE WORD LIST AT A SLOW RATE, CLEARLY STATING A WORD EVERY TWO SECONDS. HOTEL RIVER TREE SKIN GOLD MARKET PAPER CHILD KING BOOK Now tell me the words you can recall. ALLOW UP TO TWO MINUTES FOR SUBJECT TO RECALL AS MANY WORDS AS POSSIBLE. NOTE ALL WORDS RECALLED, BOTH CORRECT AND INCORRECT ON THE LINE BELOW. IF SUBJECT STATES THEY CANNOT REMEMBER ANY WORDS OR IF THEY REFUSE TO SAY IF THEY RECALL ANY WORDS, CHECK THE APPROPRIATE LINE BELOW AND FOLLOW THE SKIP INSTRUCTION.
CA3a) None recalled
_____ Skip to Section II
CA3b) Refused
_____ Skip to Section II
CA3) CIRCLE WORDS RECALLED: HOTEL RIVER TREE SKIN GOLD
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MARKET PAPER CHILD KING BOOK
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CODE AT END OF COGNITIVE ASSESSMENT
CA4. PLEASE INDICATE IF ANY OF THE FOLLOWING PROBLEMS OCCURRED IN RELATION TO WORD RECALL, CHOOSE ALL THAT APPLY: Subject had difficulty hearing any of the words Interruption occurred while you were reading the list Other problem (please specify) No problems occurred
CODE AT END OF COGNITIVE ASSESSMENT
CA5. PLEASE INDICATE WHETHER THE SUBJECT WROTE DOWN ANY OF THE WORDS OR USED SOME KIND OF AID TO REC ALL THE WORDS IN THE LIST DURING THE WORD RECALL TEST. CHOOSE THE MOST APPROPRIATE ANSWER: Subject definitely used aid Suspect that subject used aid, but not certain No reason to think that subject used aid
CODE AT END OF COGNITIVE ASSESSMENT *WHEN FULL INTERVIEW IS COMPLETED RECORD THE TOTAL # OF CORRECT WORDS RECALLED AND WRONG WORDS SAID ON THE APPROPRIATE LINE BELOW
CA6. # of correct words recalled
____________ (Correct)
CA7. # of wrong words said ______________ (Wrong)
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CA - Section II Now I am going to do a task that's quite a bit different. I'm going to read some numbers to you, and when I am done I would like you to rearrange the numbers from the lowest number I say to the highest number I say, and then say them back to me. For example, if I said "4, 0, 2", you would say, "0, 2, 4". I can only say the numbers once, so that's why it's important that you are able to hear me clearly. This is designed to be a little hard. We don't expect everyone to get everything right, but we really want you to try your best, OK? Is this clear? (IF THE SUBJECT NEEDS ADDITONAL EXPLANATION: I am going to say a series of numbers, and I want you to say the same numbers back but in order from the lowest number I say to the highest number. In other words, if I say "2 1 3"you would say "1 2 3", because 1 is the lowest number I said and 3 is the highest. OK?”) ONLY PROVIDE ONE CORRECT ANSWER, AFTER THE FIRST INCORRECT RESPONSE. CA7.
Okay, the first string of numbers is: 4, 8, 1. ENTER RESPONSE___________________
IF THEY DID NOT PROVIDE THE CORRECT ANSWER: The correct answer is: 1, 4, 8.
CA8.
Okay, the next string of numbers is: 6, 9, 5. ENTER RESPONSE___________________
IF THEY DID NOT PROVIDE THE CORRECT ANSWER: The correct answer is: 5, 6, 9.
CA9.
Okay, the next string of numbers is: 7, 8, 3, 0. ENTER RESPONSE___________________
IF THEY DID NOT PROVIDE THE CORRECT ANSWER: The correct answer is: 3, 7, 8.
CA10.
Okay, the next string of numbers is: 6 3 4 2.
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ENTER RESPONSE___________________ IF THEY DID NOT PROVIDE THE CORRECT ANSWER: The correct answer is: 2, 3, 4, 6.
CA11.
Okay, the next string of numbers is: 9 5 8 2 4. ENTER RESPONSE___________________
IF THEY DID NOT PROVIDE THE CORRECT ANSWER: The correct answer is: 2, 4, 5, 8, 9.
CA12. Okay, the next string of numbers is: 3 9 1 6 7. ENTER RESPONSE___________________ IF THEY DID NOT PROVIDE THE CORRECT ANSWER: The correct answer is: 1, 3, 6, 7, 9.
CA13. Okay, the next string of numbers is: 6 0 1 4 9 2. ENTER RESPONSE___________________ IF THEY DID NOT PROVIDE THE CORRECT ANSWER: The correct answer is: 0, 1, 2, 4, 6, 9.
CA14. Okay, the next string of numbers is: 3 8 6 1 5 4. ENTER RESPONSE___________________ IF THEY DID NOT PROVIDE THE CORRECT ANSWER: The correct answer is: 1, 3, 4, 5, 6, 8.
CA15.
Okay, the next string of numbers is: 2 9 8 1 7 0 5.
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ENTER RESPONSE___________________ IF THEY DID NOT PROVIDE THE CORRECT ANSWER: The correct answer is: 0, 1, 2, 5, 7, 8, 9.
CA16. Okay, the next string of numbers is: 1 6 7 3 0 8 5 2. ENTER RESPONSE___________________ IF THEY DID NOT PROVIDE THE CORRECT ANSWER: The correct answer is: 0,1, 2, 3, 5, 6, 7, 8.
CA17. Okay, the next string of numbers is: 3 8 2 9 1 4 5 7. ENTER RESPONSE___________________ IF THEY DID NOT PROVIDE THE CORRECT ANSWER: The correct answer is: 1, 2, 3, 4, 5, 7, 8, 9.
You did well! Or A lot of people find that hard, you did just fine, Or Great! “Thank you. That's all we have for that task.
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CA – Section III IFCA3a or CA3b on page ___ above is checked, skip to section IV A little while ago, I read you a list of words and you repeated the ones you could remember. Please tell me any of the words that you remember now. ALLOW UP TO 2 MINUTES FOR SUBJECT TO RECALL AS MANY WORDS AS POSSIBLE
CA18.
CA17a.
None
CA17b.
Refused
recalled
skip to section IV on page___
skip to section IV on page___
CIRCLE WORDS RECALLED: HOTEL RIVER TREE SKIN GOLD
MARKET PAPER CHILD KING BOOK
CODE AT END OF COGNITIVE ASSESSMENT *WHEN FULL INTERVIEW IS COMPLETED RECORD THE TOTAL # OF CORRECT WORDS RECALLED AND WRONG WORDS SAID ON THE APPROPRIATE LINE BELOW
CA18c. # of correct words recalled
____________(Correct)
CA18d. # of wrong words said ______________(Wrong)
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CA - Section IV Now I’m going to ask you to tell me the meanings of some words. THE INTERVIEWER WILL PLACE WORD LIST IN FRONT OF THE SUBJECT. WHEN PRONOUNCING THE WORD, POINT TO IT ON THE WORD LIST. RECORD, VERBATIM, THE SUBJECT’S RESPONSE TO EACH ITEM ON THE LINE BELOW EACH QUESTION. OCCASIONALLY IT IS DIFFICULT TO DETERMINE IF A SUBJECT DOES OR DOES NOT KNOW THE MEANING OF A WORD. IN SUCH CIRCUMSTANCES YOU PROBE FURTHER AND SAY “TELL ME MORE ABOUT IT” OR “EXPLAIN WHAT YOU MEAN”. CA19a.
What is the meaning of the word “repair”? ____________________________ Don’t know Refused
CA19b.
What is the meaning of the word “fabric”? _____________________________ Don’t know Refused
CA19c.
What is the meaning of the word “domestic”? Don’t know Refused
CA19d.
What is the meaning of the word “remorse”? Don’t know Refused
CA19e.
What is the meaning of the word “plagiarize”? Don’t know Refused
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CA - Section V PROVIDE THE SUBJECT WITH A PENCIL AND SHEET OF PAPER FOR THIS SECTION. Next I'm going to read you several numbers and I'd like you to write them down. There will be a blank number in the series that I read to you. For each number series problem I would like you to tell me what number goes in the blank. For example: CA20a. If I said the numbers “1 2 BLANK 4,” then what number would go in the blank? CORRECT RESPONSE: 3 IF THE RESPONDANT DOES NOT GIVE THE CORRECT RESPONSE (3) THEN SAY: The number 3 goes in the blank because the correct order is 1 2 3 4. (PROBE TO CHECK THE RESPONDANT UNDERSTANDS) Correct answer given (Continue to “START SERIES”) Incorrect answer (Go to CA20b) Doesn’t understand instructions (Go to CA20b) CA20b. Let’s try another one. I’m going to read you a series of numbers. There will be a blank number in the series that I will read to you. I would like you to tell me what number goes in the blank. CORRECT RESPONSE: 8 2 . . . 4 . . . 6 . . .blank Correct answer given (Continue to “START SERIES”) Incorrect answer (Go to CA20c) Doesn’t understand instructions (Go to CA20c) CA20c. The sequence is 2 4 6 8. 8 would be the correct answer because the numbers increase by 2. (PROBE TO CHECK THAT THE RESPONDANT UNDERSTANDS THE TASK) Respondant appears to understand task (Continue to”START SERIES”) Respondant seems confused or does not understand task (see directions below) IF RESPONDANT SEEMS CONFUSED OR DOES NOT UNDERSTAND TASK, STATE: Let’s go on to something else…. (Skip to section VI)
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START SERIES: I am now going to ask you a few more questions like the one you just did. Some of the problems may be easy but others may be hard. Just do the best you can. There is no credit for answering quickly - it is more important to answer the item correctly, but it is okay if you do not know the answer because some of the items are intended to be very difficult. You can go on to the next item at any time. Are you ready to begin? CLARIFY INSTRUCTIONS FOR THE SUBJECT IF NECESSARY FOR EACH ITEM IN THIS SECTION, CIRCLE THE RESPONSE OPTION THAT APPLIES PERMIT AS MUCH TIME AS SUBJECT WISHES FOR EACH QUESTION. IF THE SUBJECT HAS NOT GIVEN AN ANSWER AFTER ABOUT A MINUTE, ASK: "WOULD YOU JUST LIKE TO GO ON TO THE NEXT QUESTION?" FOR ALL OF THE ITEMS BELOW, DO NOT PROVIDE FURTHER PROMPTS, AND DO NOT GIVE THE CORRECT ANSWER OR TELL THE RESPONDENT IF HIS OR HER ANSWER IS CORRECT CA20.
Please write down the following numbers: 23 . . . 26. . . 30. . . 35. . . BLANK
Now look at the numbers that you just wrote down and tell me the number that belongs in the blank. CORRECT RESPONSE: 41 Correct answer given Incorrect answer Don’t know Refused
CA21.
Next, please write down the following numbers: 18 . . . 10 . . . 6. . . BLANK . . . 3.
Now look at the numbers that you just wrote down and tell me the number that belongs in the blank. CORRECT RESPONSE: 4 Correct answer given Incorrect answer Don’t know Refused LEAP Clinic Survey, Version 1.2, July 27, 2010
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CA22.
Next, please write down the following numbers: 17 . . . BLANK . . . 12 . . . 8.
Now look at the numbers that you just wrote down and tell me the number that belongs in the blank. CORRECT RESPONSE: 15 Correct answer given Incorrect answer Don’t know Refused ADD THE NUMBER OF CORRECT RESPONSES (0 – 3) AND NOTE HERE__________. THEN FOLLOW THE DIRECTIONS BELOW: IF # CORRECT =0 THEN CONTINUE WITH V-4: CA23 IF # CORRECT =1 THEN SKIP TO V-7: CA26 IF # CORRECT =2 THEN SKIP TO V-10: CA29 IF # CORRECT =3 THEN SKIP TO V-13: CA32
CA23.
Next, please write down the following numbers: 6 . . . 7 . . . BLANK . . . 9.
Now look at the numbers that you just wrote down and tell me the number that belongs in the blank. CORRECT RESPONSE: 8 Correct answer given Incorrect answer Don’t know Refused
CA24.
Next, please write down the following numbers: 6 . . . BLANK . . . 4 . . . 3.
Now look at the numbers that you just wrote down and tell me the number that belongs in the blank. CORRECT RESPONSE: 5 Correct answer given Incorrect answer Don’t know Refused LEAP Clinic Survey, Version 1.2, July 27, 2010
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CA25. Next, please write down the following numbers: 5 . . . 8 . . . 11 . . . BLANK. Now look at the numbers that you just wrote down and tell me the number that belongs in the blank. CORRECT RESPONSE: 14 Correct answer given Incorrect answer Don’t know Refused SKIP TO SECTION VI
CA26. Next, please write down the following numbers: 8 . . . BLANK . . . 12 . . . 14. Now look at the numbers that you just wrote down and tell me the number that belongs in the blank. CORRECT RESPONSE: 10 Correct answer given Incorrect answer Don’t know Refused
CA27. Next, please write down the following numbers: BLANK . . . 4 . . . 6 . . . 8. Now look at the numbers that you just wrote down and tell me the number that belongs in the blank. CORRECT RESPONSE: 2 Correct answer given Incorrect answer Don’t know Refused
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CA28.
Next, please write down the following numbers: 1 . . . 3 . . . 3 . . . 5 . . . 7 . . . 7 . . . BLANK.
Now look at the numbers that you just wrote down and tell me the number that belongs in the blank. CORRECT RESPONSE: 9 Correct answer given Incorrect answer Don’t know Refused SKIP TO SECTION VI
CA29. Next, please write down the following numbers: 10 . . . BLANK . . . 3 . . . 1. Now look at the numbers that you just wrote down and tell me the number that belongs in the blank. CORRECT RESPONSE: 6 Correct answer given Incorrect answer Don’t know Refused
CA30. Next, please write down the following numbers: 18 . . . 17 . . . 15 . . . BLANK . . . 8. Now look at the numbers that you just wrote down and tell me the number that belongs in the blank. CORRECT RESPONSE: 12 Correct answer given Incorrect answer Don’t know Refused
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CA31. Next, please write down the following numbers: 17 . . . 16 . . . 14 . . . 10 . . . BLANK. Now look at the numbers that you just wrote down and tell me the number that belongs in the blank. CORRECT RESPONSE: 2 or 3 Correct answer given Incorrect answer Don’t know Refused
SKIP TO SECTION VI
CA32. Next, please write down the following numbers: BLANK . . . 20 . . . 26 . . . 38. . .62 Now look at the numbers that you just wrote down and tell me the number that belongs in the blank. CORRECT RESPONSE: 17 Correct answer given Incorrect answer Don’t know Refused CA33. Next, please write down the following numbers: 5. . . BLANK. . . 11 . . . 19 . . . 35. Now look at the numbers that you just wrote down and tell me the number that belongs in the blank. CORRECT RESPONSE: 7 Correct answer given Incorrect answer Don’t know Refused
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CA34.
Next, please write down the following numbers: 70 . . . BLANK . . . BLANK . . . 84.
Now look at the numbers that you just wrote down and tell me the number that belongs in the blank. CORRECT RESPONSE: 72, 76 or 78, 82 Correct answer given Incorrect answer Don’t know Refused
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CA - Section VI Next I would like to ask you some questions which assess how people use numbers in everyday life. CA35.
If the chance of getting a disease is 10 percent, how many people out of 1000 would be expected to get the disease? ________________________ Don’t know Refused
CA36.
If 5 people all have the winning numbers in a lottery and the prize is 2 million dollars, how much will each of them get? ________________________ Don’t know Refused
IF THE SUBJECT RESPONDED INCORRECTLY TO CA34 AND CA35 ABOVE, STATE That’s the end of this section, you did a good job! AND SKIP TO NEXT SECTION (CE) ON PAGE18 CA37. Let’s say you have $200 in a savings account. The account earns 10 percent interest per year. How much would you have in the account at the end of two years? ________________________ Don’t know Refused
That’s the end of this section, you did a good job!
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CES-D10 (CE) I am going to read some other statements about how you may have you have felt or behaved during the past week. After each statement please tell me how often you have felt this way during the past week: rarely or none of the time; some or little of the time; occasionally or a moderate amount of time; or all of the time. (Show CESD10 Response Card to participant) Rarely or none of the time (less than 1 day)
Some or little of the time (1-2 days)
Occasionally or a Moderate amount of time (3-4 days)
All of the time (5-7 days)
Don’t know
prefer not to answer
0
1
2
3
7
8
0
1
2
3
7
8
0
1
2
3
7
8
0
1
2
3
7
8
0
1
2
3
7
8
CE6. I felt fearful.
0
1
2
3
7
8
CE7. My sleep was restless.
0
1
2
3
7
8
CE8. I was happy.
0
1
2
3
7
8
CE9. I felt lonely.
0
1
2
3
7
8
CE10. I could not “get going".
0
1
2
3
7
8
During the past week:
CE1. I was bothered by things that usually don’t bother me. CE2. I had trouble keeping my mind on what I was doing. CE3. I felt depressed. CE4. I felt that everything I did was an effort. CE5. I felt hopeful about the future.
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RT (RT) RT1. Do you currently have any sort of respiratory infection that may be affecting your lungs, such as a cold or flu (do not include asthma)?
Yes No Don’t know Prefer not to answer
SP (SP) Now I am going to ask you a couple of questions about relationships. SP1. Are you CURRENTLY in a relationship?
SP1a.
Yes No skip to SP2 Don’t know Prefer not to answer
Is this relationship with a man or a woman? Man Woman Don’t know Prefer not to answer
SP2. If you were to be in a relationship in the future, would it be with a man, woman, or either?
Man Woman Either Don’t know Prefer not to answer
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SE (SE) The next few statements are about certain ways you may feel about your life. Please indicate how strongly you agree or disagree with each of the following statements: Strongly agree; Agree; Neutral, Disagree, or Strongly disagree (Show SE Response Card to participant)
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
Don’t know
prefer not to answer
SE1. I have little control over the things that happen to me.
1
2
3
4
5
7
8
SE2. There is really no way I can solve some of the problems I have.
1
2
3
4
5
7
8
SE3. There is little I can do to change many of the important things in my life.
1
2
3
4
5
7
8
SE4. I often feel helpless in dealing with the problems of life.
1
2
3
4
5
7
8
SE5. Sometimes I feel that I am being pushed around in life.
1
2
3
4
5
7
8
SE6. What happens to me in the future mostly depends on me.
1
2
3
4
5
7
8
SE7. I can do just about anything I really set my mind to do.
1
2
3
4
5
7
8
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PBI (PB) The following questions are about your relationships with your primary caretakers until the time you were 16 years old. PB1. Was there a woman who helped raise you up through age 16?
Yes No Skip to PB4 Don’t know Prefer not to answer
PB2. Which woman would you say most took care of you up through age 16? Biological mother Adopted mother Step-mother Aunt Grandmother
Father's girlfriend Mother's girlfriend Other female relative Other (Please explain)____________ Don’t know Prefer not to answer
I will now read out a number of statements that describe mothers and other female caretakers. Please answer how much you disagree or agree with each statement about your female caretaker during the first 16 years of your life: disagree a lot, disagree a little, agree a little, agree a lot. (Show PBI Response Card to participant) Please circle ONE number for each statement. My mother (other FEMALE caretaker)… PB3a. was affectionate to me PB3b. understood my problems and worries PB3c. liked when I made my own decisions PB3d. let me decide things for myself PB3e. tried to control everything I did PB3f. was overly protective of me PB3g. did not understand what I needed or wanted PB3h. was emotionally cold to me
Disagree a lot
Disagree a little
Agree a little
Agree a lot
Don’t know
prefer not to answer
1
2
3
4
7
8
1
2
3
4
7
8
1
2
3
4
7
8
1
2
3
4
7
8
1
2
3
4
7
8
1
2
3
4
7
8
1
2
3
4
7
8
1
2
3
4
7
8
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PB4. Was there a man who helped raise you up through age 16?
Yes No Skip to PB7 Don’t know Prefer not to answer
PB5. Which man would you say most took care of you up through age 16? Biological father Adopted father Step-father Uncle Grandfather
Mother's boyfriend Father's boyfriend Other male relative Other (Please explain)________________ Don’t know Prefer not to answer
I will now read some statements that describe fathers and other male caretakers. Please let me know how much you disagree or agree with each statement about your male caretaker during the first 16 years of your life: disagree a lot, disagree a little, agree a little, agree a lot. (show PBI Response Card to participant)
Please circle ONE number for each statement. My father (other MALE caretaker)…
PB6a. was affectionate to me PB6b. understood my problems and worries PB6. liked when I made my own decisions PB6d. let me decide things for myself PB6e. tried to control everything I did PB6f. was overly protective of me PB6g. did not understand what I needed or wanted PB6h. was emotionally cold to me
Disagree a lot
Disagree a little
Agree a little
Agree a lot
Don’t know
prefer not to answer
1
2
3
4
7
8
1
2
3
4
7
8
1
2
3
4
7
8
1
2
3
4
7
8
1
2
3
4
7
8
1
2
3
4
7
8
1
2
3
4
7
8
1
2
3
4
7
8
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PB7. Did you have any other major parent figures or caretakers during the first 16 years of your life other than those that you have described in the questions above?
Yes No Skip to next section (PS) on page 28 Don’t know Prefer not to answer
PB8. Who was this other parent figure or caretaker during the first 16 years of your life? Biological mother Biological father Adopted mother Adopted father Step-mother Step-father Aunt Uncle Grandmother
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Grandfather Mother’s boyfriend Mother's girlfriend Father's girlfriend Father's boyfriend Other female relative Other male relative Other (please explain): ___________________ Don’t know Prefer not to answer
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Think about the other major parent figure or caretaker that you felt closest to. Please answer how much you disagree or agree with each of the following statements about this primary caretaker during the first 16 years of your life: disagree a lot, disagree a little, agree a little, agree a lot. (show PBI Response Card to participant) Please circle ONE number for each statement. Disagree a lot
Disagree a little
Agree a little
Agree a lot
Don’t know
prefer not to answer
PB9a. was affectionate to me
1
2
3
4
7
8
PB9b. understood my problems and worries
1
2
3
4
7
8
PB9c. liked when I made my own decisions
1
2
3
4
7
8
1
2
3
4
7
8
1
2
3
4
7
8
1
2
3
4
7
8
PB9g. did not understand what I needed or wanted
1
2
3
4
7
8
PB9h. was emotionally cold to me
1
2
3
4
7
8
My Caretaker..
PB9d. let me decide things for myself PB9e. tried to control everything I did PB9f. was overly protective of me
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PSC (PS) The questions in the next section ask about your feelings and thoughts during the past month. In each case, please indicate how often you felt or thought a certain way: never, almost never, sometimes, fairly often, or very often. (show PSC Response Card to participant)
Never
Almost never
Some times
Fairly often
Very often
Don’t know
prefer not to answer
PS1. In the last month, how often have you felt that you were unable to control the important things in your life?
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PS2. In the last month, how often have you felt confident about your ability to handle your personal problems?
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PS3. In the last month, how often have you felt that things were going your way?
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PS4. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?
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AS (AS) These next statements describe various acts and behaviors. Please Indicate how often these acts or behaviors have applied to you: never, once, more than once, often, or very often. (show AS Response Card to participant) Never
Once
More than once
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AS3. I have made change for a stranger.
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AS4. I have given money to charity.
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AS8. I have donated blood.
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AS9. I have helped carry a stranger's belongings, such as books, parcels, etc.
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AS1. I have helped push a stranger's car out of the snow. AS2. I have given directions to a stranger.
AS5. I have given money to a stranger who needed it (or asked me for it). AS6. I have donated goods or clothes to a charity. AS7. I have done volunteer work for a charity.
AS10. I have delayed an elevator and held the door open for a stranger. AS11. I have allowed someone to go ahead of me in a lineup (such as at a photocopy machine, in the supermarket). AS12. I have given a stranger a lift in my car AS13. I have pointed out a clerk's error, such in a bank or at the supermarket, in undercharging me for an item. AS14. I have let a neighbor whom I didn't know too well borrow an item of some value to me, such as a dish, tools, etc. AS15. I have bought 'charity' Christmas cards deliberately because I knew it was a good cause. AS16. I have helped a classmate who I did not know that well with a homework assignment when my knowledge was greater than his or hers. AS17. I have before being asked, voluntarily looked after a neighbor’s pets or children without being paid for it. AS18. I have offered to help a handicapped or elderly stranger across a street. AS19. I have offered my seat on a bus or train to a stranger who was standing. AS20. I have helped an acquaintance to move households. LEAP Clinic Survey, Version 1.2, July 27, 2010
Often
Very often
Don’t know
prefer not to answer
Page 29 of 56
REL (RE) The next few questions are about your religious views and practices.
RE1. Do you consider yourself a religious person?
Yes No Don’t know Prefer not to answer
RE2. Do you go to church or temple or another place of worship?
Yes No skip to RE3 Don’t know Prefer not to answer
RE2a.
How often do you go to church, temple or another place of worship? _______ days per month Less than once per month Don’t know Prefer not to answer
RE3. Do you belong to any church or religious groups, such as choir, bible study, or a social service group?
3a.
Yes No skip to next section (ISEL) on page 31 Don’t know Prefer not to answer
Have you been a leader in any of these groups? Yes No Don’t know Prefer not to answer
LEAP Clinic Survey, Version 1.2, July 27, 2010
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ISEL (IS) The next few statements ask for your view about the role of other people in your life. Please indicate how true or false the following statements are: definitely false, probably false, probably true, or definitely true. (Show ISEL Response Card to participant) Definitely Probably Probably Definitely Don’t false false true true know IS1. If I wanted to go on a trip for a day (for example, to the country or mountains), I would have a hard time finding someone to go with me. IS2. I feel that there is no one I can share my most private worries and fears with. IS3. If I were sick, I could easily find someone to help me with my daily chores. IS4. There is someone I can turn to for advice about handling problems with my family. IS5. If I decide one afternoon that I would like to go to a movie that evening, I could easily find someone to go with me. IS6. When I need suggestions on how to deal with a personal problem, I know someone I can turn to. IS7. I don't often get invited to do things with others. IS8. If I had to go out of town for a few weeks, it would be difficult to find someone who would look after my house or apartment (the plants, pets, garden, etc.). IS9. If I wanted to have lunch with someone, I could easily find someone to join me. IS10. If I was stranded 10 miles from home, there is someone I could call who could come and get me. IS11. If a family crisis arose, it would be difficult to find someone who could give me good advice about how to handle it. IS12. If I needed some help in moving to a new house or apartment, I would have a hard time finding someone to help me. LEAP Clinic Survey, Version 1.2, July 27, 2010
prefer not to answer
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Page 31 of 56
Medications (ME) Now I’m going to ask you about your use of prescription medications, over-the-counter drugs, and vitamins. We will review any medications, drugs, and vitamins that you brought with you today, as well as any others that you might have forgotten to bring.
ME1.
Do you take any prescription medications, over-the-counter drugs, and vitamins?
No skip to end of survey Yes ME2.
Don’t know Prefer not to answer
Do you take any vitamins?
No skip to ME7a Yes ME3.
Don’t know Prefer not to answer
Do you take a multivitamin?
No skip to ME4 Yes note amount………………B9: _________ mcg Don’t know B12: _________ mcg Prefer not to answer ME3a. How frequently do you take it?
_________ times per day _________ times per week _________ times per
Don’t know Prefer not to answer
month
ME4.
Do you take a folic acid supplement, also known as folate or vitamin B9?
No skip to ME5 Yes note amount ……………...B9: Don’t know Prefer not to answer
_________ mcg
ME4a. How frequently do you take it?
_____ times per day _____ times per week _____ times per month
LEAP Clinic Survey, Version 1.2, July 27, 2010
Don’t know Prefer not to answer
Page 32 of 56
ME5.
Do you take a vitamin B12 supplement?
No skip to ME6 Yes note amount ……………...B12: _________ mcg Don’t know Prefer not to answer ME5a. How frequently do you take it?
_____ times per day _____ times per week _____ times per month ME6.
Don’t know Prefer not to answer
Do you take a mixed B-vitamin supplement?
No skip to ME7 Yes note amount …………….. B9: _________ mcg Don’t know B12: _________ mcg Prefer not to answer ME6a. How frequently do you take it?
_________ times per day _________ times per week _________ times per
Don’t know Prefer not to answer
month
ME7.
Do you take any prescription medications or over-the-counter drugs?
No skip to end of survey Yes
Don’t know Prefer not to answer
What is the name of the first prescription medication or over-the-counter drug that you take?
ME7a. Label product name: ______________________________________________________________________
Label generic name: ______________________________________________________________________
Don’t know
Prefer not to answer
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ME7b. What is the dosage form?
Oral
Pill, tablet, or capsule Sublingual or orally-disintegrating tablet Liquid solution or suspension (drink, syrup)
Powder
Inhaled
Inhaler or nebulizer Injected
Injection Suppository
Topical
Liquid, cream, gel, or ointment Ear drops (otic) Eye drops (ophthalmic) Skin patch (transdermal)
Rectal (e.g., enema) Vaginal (e.g., douche, pessary) Other:
Don’t know Prefer not to answer
ME7c. How frequently do you take it?
_________ times per day _________ times per week _________ times per month
Don’t know Prefer not to answer
ME7d. What is the strength? (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME7d1. Total dosage per day. (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME7e. Do you take it regularly or only as needed?
Regularly Only as needed
LEAP Clinic Survey, Version 1.2, July 27, 2010
Don’t know Prefer not to answer
Page 34 of 56
ME7f.
For how long have you been taking it?
For _________ days For _________ weeks For _________ months
For _________ years Don’t know Prefer not to answer
ME7g. Interviewer comments: ________________________________________________________________________
ME7h. Do you take any other prescription medications or over-the-counter drugs?
No skip end of survey Yes
Don’t know Prefer not to answer
What is the name of the next prescription medication or over-the-counter drug that you take? ME8a.
Label product name: ______________________________________________________________________
Label generic name: ______________________________________________________________________
Don’t know
Prefer not to answer
ME8b. What is the dosage form? Oral
Pill, tablet, or capsule Sublingual or orally-disintegrating tablet Liquid solution or suspension (drink, syrup)
Powder
Inhaled
Inhaler or nebulizer Injected
Injection Suppository
Topical
Liquid, cream, gel, or ointment Ear drops (otic) Eye drops (ophthalmic) Skin patch (transdermal)
Rectal (e.g., enema) Vaginal (e.g., douche, pessary) Other:
Don’t know Prefer not to answer
ME8c. How frequently do you take it?
_________ times per day _________ times per week _________ times per month
LEAP Clinic Survey, Version 1.2, July 27, 2010
Don’t know Prefer not to answer
Page 35 of 56
ME8d. What is the strength? (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME8d1. Total dosage per day. (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME8e. Do you take it regularly or only as needed?
Regularly Only as needed ME8f.
Don’t know Prefer not to answer
For how long have you been taking it?
For _________ days For _________ weeks For _________ months
For _________ years Don’t know Prefer not to answer
ME8g. Interviewer comments: ________________________________________________________________________
ME8h. Do you take any other prescription medications or over-the-counter drugs?
No skip to end of survey Yes
Don’t know Prefer not to answer
What is the name of the next prescription medication or over-the-counter drug that you take?
ME9a. Label product name: ______________________________________________________________________
Label generic name: ______________________________________________________________________
Don’t know
Prefer not to answer
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ME9b. What is the dosage form? Oral
Pill, tablet, or capsule Sublingual or orally-disintegrating tablet Liquid solution or suspension (drink, syrup)
Powder
Inhaled
Inhaler or nebulizer Injected
Injection Suppository
Topical
Liquid, cream, gel, or ointment Ear drops (otic) Eye drops (ophthalmic) Skin patch (transdermal)
Rectal (e.g., enema) Vaginal (e.g., douche, pessary) Other:
Don’t know Prefer not to answer
ME9c. How frequently do you take it?
_________ times per day _________ times per week _________ times per month
Don’t know Prefer not to answer
ME9d. What is the strength? (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME9d1. Total dosage per day. (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME9e. Do you take it regularly or only as needed?
Regularly Only as needed
LEAP Clinic Survey, Version 1.2, July 27, 2010
Don’t know Prefer not to answer
Page 37 of 56
ME9f.
For how long have you been taking it?
For _________ days For _________ weeks For _________ months
For _________ years Don’t know Prefer not to answer
ME9g. Interviewer comments: ________________________________________________________________________ ME9h. Do you take any other prescription medications or over-the-counter drugs?
No skip to next section Yes
Don’t know Prefer not to answer
What is the name of the next prescription medication or over-the-counter drug that you take? ME10a.
Label product name: ______________________________________________________________________
Label generic name: ______________________________________________________________________
Don’t know
Prefer not to answer
ME10b. What is the dosage form? Oral
Pill, tablet, or capsule Sublingual or orally-disintegrating tablet Liquid solution or suspension (drink, syrup)
Powder
Inhaled
Inhaler or nebulizer Injected
Injection Suppository
Topical
Liquid, cream, gel, or ointment Ear drops (otic) Eye drops (ophthalmic) Skin patch (transdermal)
Rectal (e.g., enema) Vaginal (e.g., douche, pessary) Other:
Don’t know Prefer not to answer
ME10c. How frequently do you take it?
_________ times per day _________ times per week _________ times per month
LEAP Clinic Survey, Version 1.2, July 27, 2010
Don’t know Prefer not to answer
Page 38 of 56
ME10d. What is the strength? (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME10d1. Total dosage per day. (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME10e. Do you take it regularly or only as needed?
Regularly Only as needed
Don’t know Prefer not to answer
ME10f. For how long have you been taking it?
For _________ days For _________ weeks For _________ months
For _________ years Don’t know Prefer not to answer
ME10g. Interviewer comments: ________________________________________________________________________
ME10h. Do you take any other prescription medications or over-the-counter drugs?
No skip to end of survey Yes
Don’t know Prefer not to answer
What is the name of the next prescription medication or over-the-counter drug that you take? ME11a.
Label product name: ______________________________________________________________________
Label generic name: ______________________________________________________________________
Don’t know
Prefer not to answer
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ME11b. What is the dosage form? Oral
Pill, tablet, or capsule Sublingual or orally-disintegrating tablet Liquid solution or suspension (drink, syrup)
Powder
Inhaled
Inhaler or nebulizer Injected
Injection Suppository
Topical
Liquid, cream, gel, or ointment Ear drops (otic) Eye drops (ophthalmic) Skin patch (transdermal)
Rectal (e.g., enema) Vaginal (e.g., douche, pessary) Other:
Don’t know Prefer not to answer
ME11c. How frequently do you take it?
_________ times per day _________ times per week _________ times per month
Don’t know Prefer not to answer
ME11d. What is the strength? (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME11d1. Total dosage per day. (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME11e. Do you take it regularly or only as needed?
Regularly Only as needed
LEAP Clinic Survey, Version 1.2, July 27, 2010
Don’t know Prefer not to answer
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ME11f. For how long have you been taking it?
For _________ days For _________ weeks For _________ months
For _________ years Don’t know Prefer not to answer
ME11g. Interviewer comments: ________________________________________________________________________
ME11h. Do you take any other prescription medications or over-the-counter drugs?
No skip to next section Yes
Don’t know Prefer not to answer
What is the name of the next prescription medication or over-the-counter drug that you take? ME12a.
Label product name: ______________________________________________________________________
Label generic name: ______________________________________________________________________
Don’t know
Prefer not to answer
ME12b. What is the dosage form? Oral
Pill, tablet, or capsule Sublingual or orally-disintegrating tablet Liquid solution or suspension (drink, syrup)
Powder
Inhaled
Inhaler or nebulizer Injected
Injection Suppository
Topical
Liquid, cream, gel, or ointment Ear drops (otic) Eye drops (ophthalmic) Skin patch (transdermal)
Rectal (e.g., enema) Vaginal (e.g., douche, pessary) Other:
Don’t know Prefer not to answer
ME12c. How frequently do you take it?
_________ times per day _________ times per week _________ times per month
LEAP Clinic Survey, Version 1.2, July 27, 2010
Don’t know Prefer not to answer
Page 41 of 56
ME12d. What is the strength? (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME12d1. Total dosage per day. (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME12e. Do you take it regularly or only as needed?
Regularly Only as needed
Don’t know Prefer not to answer
ME12f. For how long have you been taking it?
For _________ days For _________ weeks For _________ months
For _________ years Don’t know Prefer not to answer
ME12g. Interviewer comments: ________________________________________________________________________
ME12h. Do you take any other prescription medications or over-the-counter drugs?
No skip to end of survey Yes
Don’t know Prefer not to answer
What is the name of the next prescription medication or over-the-counter drug that you take? ME13a.
Label product name: ______________________________________________________________________
Label generic name: ______________________________________________________________________
Don’t know
Prefer not to answer
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ME13b. What is the dosage form? Oral
Pill, tablet, or capsule Sublingual or orally-disintegrating tablet Liquid solution or suspension (drink, syrup)
Powder
Inhaled
Inhaler or nebulizer Injected
Injection Suppository
Topical
Liquid, cream, gel, or ointment Ear drops (otic) Eye drops (ophthalmic) Skin patch (transdermal)
Rectal (e.g., enema) Vaginal (e.g., douche, pessary) Other:
Don’t know Prefer not to answer
ME13c. How frequently do you take it?
_________ times per day _________ times per week _________ times per month
Don’t know Prefer not to answer
ME13d. What is the strength? (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME13d1. Total dosage per day. (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME13e. Do you take it regularly or only as needed?
Regularly Only as needed
LEAP Clinic Survey, Version 1.2, July 27, 2010
Don’t know Prefer not to answer
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ME13f. For how long have you been taking it?
For _________ days For _________ weeks For _________ months
For _________ years Don’t know Prefer not to answer
ME13g. Interviewer comments: ________________________________________________________________________
ME13h. Do you take any other prescription medications or over-the-counter drugs?
No skip to next section Yes
Don’t know Prefer not to answer
What is the name of the next prescription medication or over-the-counter drug that you take? ME14a.
Label product name: ______________________________________________________________________
Label generic name: ______________________________________________________________________
Don’t know
Prefer not to answer
ME14b. What is the dosage form? Oral
Pill, tablet, or capsule Sublingual or orally-disintegrating tablet Liquid solution or suspension (drink, syrup)
Powder
Inhaled
Inhaler or nebulizer Injected
Injection Suppository
Topical
Liquid, cream, gel, or ointment Ear drops (otic) Eye drops (ophthalmic) Skin patch (transdermal)
Rectal (e.g., enema) Vaginal (e.g., douche, pessary) Other:
Don’t know Prefer not to answer
ME14c. How frequently do you take it?
_________ times per day _________ times per week _________ times per month
LEAP Clinic Survey, Version 1.2, July 27, 2010
Don’t know Prefer not to answer
Page 44 of 56
ME14d. What is the strength? (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME14d1. Total dosage per day. (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME14e. Do you take it regularly or only as needed?
Regularly Only as needed
Don’t know Prefer not to answer
ME14f. For how long have you been taking it?
For _________ days For _________ weeks For _________ months
For _________ years Don’t know Prefer not to answer
ME14g. Interviewer comments: ________________________________________________________________________ ME14h. Do you take any other prescription medications or over-the-counter drugs?
No skip to next section Yes
Don’t know Prefer not to answer
What is the name of the next prescription medication or over-the-counter drug that you take?
ME15a. Label product name: ______________________________________________________________________
Label generic name: ______________________________________________________________________
Don’t know
Prefer not to answer
LEAP Clinic Survey, Version 1.2, July 27, 2010
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ME15b. What is the dosage form? Oral
Pill, tablet, or capsule Sublingual or orally-disintegrating tablet Liquid solution or suspension (drink, syrup)
Powder
Inhaled
Inhaler or nebulizer Injected
Injection Suppository
Topical
Liquid, cream, gel, or ointment Ear drops (otic) Eye drops (ophthalmic) Skin patch (transdermal)
Rectal (e.g., enema) Vaginal (e.g., douche, pessary) Other:
Don’t know Prefer not to answer
ME15c. How frequently do you take it?
_________ times per day _________ times per week _________ times per month
Don’t know Prefer not to answer
ME15d. What is the strength? (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME15d1. Total dosage per day. (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME15e. Do you take it regularly or only as needed?
Regularly Only as needed
LEAP Clinic Survey, Version 1.2, July 27, 2010
Don’t know Prefer not to answer
Page 46 of 56
ME15f. For how long have you been taking it?
For _________ days For _________ weeks For _________ months
For _________ years Don’t know Prefer not to answer
ME15g. Interviewer comments: ________________________________________________________________________ ME15h. Do you take any other prescription medications or over-the-counter drugs?
No skip to end of survey Yes
Don’t know Prefer not to answer
What is the name of the next prescription medication or over-the-counter drug that you take?
ME16a. Label product name: ______________________________________________________________________
Label generic name: ______________________________________________________________________
Don’t know
Prefer not to answer
ME16b. What is the dosage form? Oral
Pill, tablet, or capsule Sublingual or orally-disintegrating tablet Liquid solution or suspension (drink, syrup)
Powder
Inhaled
Inhaler or nebulizer Injected
Injection Suppository
Topical
Liquid, cream, gel, or ointment Ear drops (otic) Eye drops (ophthalmic) Skin patch (transdermal)
Rectal (e.g., enema) Vaginal (e.g., douche, pessary) Other:
Don’t know Prefer not to answer
ME16c. How frequently do you take it?
_________ times per day _________ times per week _________ times per month
LEAP Clinic Survey, Version 1.2, July 27, 2010
Don’t know Prefer not to answer
Page 47 of 56
ME16d. What is the strength? (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME16d1. Total dosage per day. (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME16e. Do you take it regularly or only as needed?
Regularly Only as needed
Don’t know Prefer not to answer
ME16f. For how long have you been taking it?
For _________ days For _________ weeks For _________ months
For _________ years Don’t know Prefer not to answer
ME16g. Interviewer comments: ________________________________________________________________________
ME16h. Do you take any other prescription medications or over-the-counter drugs?
No skip to end of survey Yes
Don’t know Prefer not to answer
What is the name of the next prescription medication or over-the-counter drug that you take?
ME17a. Label product name: ______________________________________________________________________
Label generic name: ______________________________________________________________________
Don’t know
Prefer not to answer
LEAP Clinic Survey, Version 1.2, July 27, 2010
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ME17b. What is the dosage form? Oral
Pill, tablet, or capsule Sublingual or orally-disintegrating tablet Liquid solution or suspension (drink, syrup)
Powder
Inhaled
Inhaler or nebulizer Injected
Injection Suppository
Topical
Liquid, cream, gel, or ointment Ear drops (otic) Eye drops (ophthalmic) Skin patch (transdermal)
Rectal (e.g., enema) Vaginal (e.g., douche, pessary) Other:
Don’t know Prefer not to answer
ME17c. How frequently do you take it?
_________ times per day _________ times per week _________ times per month
Don’t know Prefer not to answer
ME17d. What is the strength? (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME17d1. Total dosage per day. (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME17e. Do you take it regularly or only as needed?
Regularly Only as needed
LEAP Clinic Survey, Version 1.2, July 27, 2010
Don’t know Prefer not to answer
Page 49 of 56
ME17f. For how long have you been taking it?
For _________ days For _________ weeks For _________ months
For _________ years Don’t know Prefer not to answer
ME17g. Interviewer comments: ________________________________________________________________________ ME17h. Do you take any other prescription medications or over-the-counter drugs?
No skip to end of survey Yes
Don’t know Prefer not to answer
What is the name of the next prescription medication or over-the-counter drug that you take?
ME18a. Label product name: ______________________________________________________________________
Label generic name: ______________________________________________________________________
Don’t know
Prefer not to answer
ME18b. What is the dosage form? Oral
Pill, tablet, or capsule Sublingual or orally-disintegrating tablet Liquid solution or suspension (drink, syrup)
Powder
Inhaled
Inhaler or nebulizer Injected
Injection Suppository
Topical
Liquid, cream, gel, or ointment Ear drops (otic) Eye drops (ophthalmic) Skin patch (transdermal)
Rectal (e.g., enema) Vaginal (e.g., douche, pessary) Other:
Don’t know Prefer not to answer
ME18c. How frequently do you take it?
_________ times per day _________ times per week _________ times per month
LEAP Clinic Survey, Version 1.2, July 27, 2010
Don’t know Prefer not to answer
Page 50 of 56
ME18d. What is the strength? (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME18d1. Total dosage per day. (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME18e. Do you take it regularly or only as needed?
Regularly Only as needed
Don’t know Prefer not to answer
ME18f. For how long have you been taking it?
For _________ days For _________ weeks For _________ months
For _________ years Don’t know Prefer not to answer
ME18g. Interviewer comments: ________________________________________________________________________ ME18h. Do you take any other prescription medications or over-the-counter drugs?
No skip to next section Yes
Don’t know Prefer not to answer
What is the name of the next prescription medication or over-the-counter drug that you take?
ME19a. Label product name: ______________________________________________________________________
Label generic name: ______________________________________________________________________
Don’t know
Prefer not to answer
LEAP Clinic Survey, Version 1.2, July 27, 2010
Page 51 of 56
ME19b. What is the dosage form? Oral
Pill, tablet, or capsule Sublingual or orally-disintegrating tablet Liquid solution or suspension (drink, syrup)
Powder
Inhaled
Inhaler or nebulizer Injected
Injection Suppository
Topical
Liquid, cream, gel, or ointment Ear drops (otic) Eye drops (ophthalmic) Skin patch (transdermal)
Rectal (e.g., enema) Vaginal (e.g., douche, pessary) Other:
Don’t know Prefer not to answer
ME19c. How frequently do you take it?
_________ times per day _________ times per week _________ times per month
Don’t know Prefer not to answer
ME19d. What is the strength? (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME19d1. Total dosage per day. (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME19e. Do you take it regularly or only as needed?
Regularly Only as needed
Don’t know Prefer not to answer
ME19f. For how long have you been taking it?
For _________ days For _________ weeks For _________ months LEAP Clinic Survey, Version 1.2, July 27, 2010
For _________ years Don’t know Prefer not to answer Page 52 of 56
ME19g. Interviewer comments: ________________________________________________________________________
ME19h. Do you take any other prescription medications or over-the-counter drugs?
No skip to end of survey Yes
Don’t know Prefer not to answer
What is the name of the next prescription medication or over-the-counter drug that you take?
ME20a. Label product name: ______________________________________________________________________
Label generic name: ______________________________________________________________________
Don’t know
Prefer not to answer
ME20b. What is the dosage form? Oral
Pill, tablet, or capsule Sublingual or orally-disintegrating tablet Liquid solution or suspension (drink, syrup)
Powder
Inhaled
Inhaler or nebulizer Injected
Injection Suppository
Topical
Liquid, cream, gel, or ointment Ear drops (otic) Eye drops (ophthalmic) Skin patch (transdermal)
Rectal (e.g., enema) Vaginal (e.g., douche, pessary) Other:
Don’t know Prefer not to answer
ME20c. How frequently do you take it?
_________ times per day _________ times per week _________ times per month
LEAP Clinic Survey, Version 1.2, July 27, 2010
Don’t know Prefer not to answer
Page 53 of 56
ME20d. What is the strength? (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME20d1. Total dosage per day. (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME20e. Do you take it regularly or only as needed?
Regularly Only as needed
Don’t know Prefer not to answer
ME20f. For how long have you been taking it?
For _________ days For _________ weeks For _________ months
For _________ years Don’t know Prefer not to answer
ME20g. Interviewer comments: ________________________________________________________________________ ME20h. Do you take any other prescription medications or over-the-counter drugs?
No skip to next section Yes
Don’t know Prefer not to answer
What is the name of the next prescription medication or over-the-counter drug that you take?
ME21a. Label product name: ______________________________________________________________________
Label generic name: ______________________________________________________________________
Don’t know
Prefer not to answer
LEAP Clinic Survey, Version 1.2, July 27, 2010
Page 54 of 56
ME21b. What is the dosage form? Oral
Pill, tablet, or capsule Sublingual or orally-disintegrating tablet Liquid solution or suspension (drink, syrup)
Powder
Inhaled
Inhaler or nebulizer Injected
Injection Suppository
Topical
Liquid, cream, gel, or ointment Ear drops (otic) Eye drops (ophthalmic) Skin patch (transdermal)
Rectal (e.g., enema) Vaginal (e.g., douche, pessary) Other:
Don’t know Prefer not to answer
ME21c. How frequently do you take it?
_________ times per day _________ times per week _________ times per month
Don’t know Prefer not to answer
ME21d. What is the strength? (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME21d1. Total dosage per day. (Record strength of how it is actually taken, not how it is prescribed.)
_________ % _________ mg _________ mcg _________ grams _________ I.U.
_________ Other unit: _____________
Don’t know Prefer not to answer
ME21e. Do you take it regularly or only as needed?
Regularly Only as needed
Don’t know Prefer not to answer
ME21f. For how long have you been taking it?
For _________ days For _________ weeks For _________ months For _________ years LEAP Clinic Survey, Version 1.2, July 27, 2010
Don’t know Prefer not to answer
Page 55 of 56
ME21g. Interviewer comments:
LEAP Clinic Survey, Version 1, April 8 2010
Page 56 of 56
