Notes During 2016 and 2017, 9,007 valid surveys were returned by members of the ALSWH birth cohort. These were all done online.
|
|
- Erick Fowler
- 5 years ago
- Views:
Transcription
1
2
3 Data book for the fourth survey of the cohort (aged years) This work is copyright. Permission to use or reproduce material in this book for the purpose of free distribution is not required, provided that proper acknowledgement of the source is given. For other uses, apart from any permitted use under the Copyright Act 1968, no part may be reproduced by any process without written permission from the Director, Australian Longitudinal Study on Women s Health, University of Queensland. Acknowledgements This study is funded by the Australian Government Department of Health. This document was prepared by Hsiu-Wen Chan and David Fitzgerald, with help from the data management group of the Australian Longitudinal Study on Women s Health (ALSWH) at the Universities of Queensland and Newcastle. The research team would like to thank all participants who contributed to the project. Notes During 2016 and 2017, 9,007 valid surveys were returned by members of the ALSWH birth cohort. These were all done online. This data book is ordered by the order the questions occurred in the questionnaire. Some derived variables are given in place of the questionnaire items or immediately after them. The frequencies in this data book have not been weighted. For information on the derived variables refer to the ALSWH website ( The ALSWH website has general information about the project; the investigators and staff; publications and presentations; information for participants; surveys; and information for potential data users. If you have any queries, please contact us at: Australian Longitudinal Study on Women s Health The University of Newcastle Research Centre for Gender, Health & Ageing University Drive Callaghan NSW 2308 Phone: Fax: info@alswh.org.au The University of Queensland School of Public Health Herston Road Herston QLD 4006 Phone: Fax: sph-wha@sph.uq.edu.au 1
4 Which of the following prompted you to do this survey? In general, would you say your health is: Compared to one year, how would you rate your health in general now The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? Vigorous activities such as running, lifting heavy objects, participating in strenuous sports The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf INFO001 SF36001 SF36002 SF36003 SF invitation / reminder SMS / text message Newsletter Mailed invitation / reminder Facebook Phone call Other social media (Please specify) Other (Please specify) Missing. 78 Excellent Very good Good Fair Poor Much better Somewhat better About the same Somewhat worse Much worse Missing. 77 Limited a lot Limited a little Not limited Missing. 81 Limited a lot Limited a little Not limited Missing. 83 2
5 The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? Lifting or carrying groceries The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? Climbing several flights of stairs The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? Climbing one flight of stairs The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? Bending, kneeling or stooping The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? Walking more than one kilometre The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? Walking half a kilometre The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? Walking 100 metres SF36005 SF36006 SF36007 SF36008 SF36009 SF36010 SF36011 Limited a lot Limited a little Not limited Missing. 85 Limited a lot Limited a little Not limited Missing. 86 Limited a lot Limited a little Not limited Missing. 89 Limited a lot Limited a little Not limited Missing. 93 Limited a lot Limited a little Not limited Missing. 89 Limited a lot Limited a little Not limited Missing. 88 Limited a lot Limited a little Not limited Missing. 86 3
6 The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? Bathing or dressing yourself During the past four weeks, have you had any of the following problems with your work (including your work outside the home and housework) or other regular daily activities as a result of your physical health? Cut down on the amount of time you spent on work or other activities During the past four weeks, have you had any of the following problems with your work (including your work outside the home and housework) or other regular daily activities as a result of your physical health? Accomplished less than you would like During the past four weeks, have you had any of the following problems with your work (including your work outside the home and housework) or other regular daily activities as a result of your physical health? Were limited in the kind of work or other activities During the past four weeks, have you had any of the following problems with your work (including your work outside the home and housework) or other regular daily activities as a result of your physical health? Had difficulty performing the work or other activities (for example it took extra effort) During the past four weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? Cut down on the amount of time you spent on work or other activities During the past four weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? Accomplished less than you would like During the past four weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? Didn't do work or other activities as carefully as usual SF36012 SF36013 SF36014 SF36015 SF36016 SF36017 SF36018 SF36019 Limited a lot Limited a little Not limited Missing. 86 Yes No Missing. 112 Yes No Missing. 112 Yes No Missing. 114 Yes No Missing. 114 Yes No Missing. 117 Yes No Missing. 120 Yes No Missing
7 During the past four weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbours or groups? How much bodily pain have you had during the past four weeks? During the past four weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past four weeks: Did you feel full of life? For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past four weeks. Have you been a very nervous person SF36020 SF36021 SF36022 SF36023 SF Not at all Slightly Moderately Quite a bit Extremely Missing. 119 No bodily pain Very mild Mild Moderate Severe Very severe Missing. 126 Not at all A little bit Moderately Quite a bit Extremely Missing. 126 All the time Most of the time A good bit of the time Some of the time Little of the time None of the time Missing. 182 All the time Most of the time A good bit of the time Some of the time Little of the time None of the time Missing. 182
8 For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past four weeks. Have you felt so down in the dumps that nothing could cheer you up For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past four weeks. Have you felt calm and peaceful For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past four weeks. Did you have a lot of energy For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past four weeks. Have you felt down SF36025 SF36026 SF36027 SF36028 All the time Most of the time A good bit of the time Some of the time Little of the time None of the time Missing. 182 All the time Most of the time A good bit of the time Some of the time Little of the time None of the time Missing. 181 All the time Most of the time A good bit of the time Some of the time Little of the time None of the time Missing. 181 All the time Most of the time A good bit of the time Some of the time Little of the time None of the time Missing
9 For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past four weeks. Did you feel worn out For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past four weeks. Have you been a happy person For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past four weeks. Did you feel tired During the past four weeks, how much of the time have your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc)? How true or false is each of the following statements for you? I seem to get sick a little easier than other people SF36029 SF36030 SF36031 SF36032 SF All the time Most of the time A good bit of the time Some of the time Little of the time None of the time Missing. 185 All the time Most of the time A good bit of the time Some of the time Little of the time None of the time Missing. 183 All the time Most of the time A good bit of the time Some of the time Little of the time None of the time Missing. 183 All the time Most of the time Some of the time Little of the time None of the time Missing. 185 Definitely true Mostly true Don't know Mostly false Definitely false Missing. 186
10 How true or false is each of the following statements for you? I am as healthy as anybody I know How true or false is each of the following statements for you? I expect my health to get worse How true or false is each of the following statements for you? My health is excellent Have you ever been sexually active? Have you ever had vaginal sex? Do you have a Health Care Card? This is a card that entitles you to discounts and assistance with medical expenses. This is not the same as a Medicare card. SF36034 SF36035 SF36036 REPH286 REPH272 HSRV079 Definitely true Mostly true Don't know Mostly false Definitely false Missing. 188 Definitely true Mostly true Don't know Mostly false Definitely false Missing. 188 Definitely true Mostly true Don't know Mostly false Definitely false Missing. 188 Yes No Missing. 191 Yes No I prefer not to answer Missing. 807 Yes No Missing
11 How often do you currently smoke cigarettes or any tobacco products? If you smoke daily, on average how many cigarettes do you smoke each day? In your lifetime, would you have smoked at least 100 cigarettes (or equivalent)? How often do you usually drink alcohol? On a day when you drink alcohol, how many standard drinks do you usually have? SMOK007 SMOK016 SMOK018 ALCS009 ALCS010 Daily At least weekly(but not daily) Less often than weekly Not at all Missing. 191 Mean 8.77 Std Error 0.22 N 658 N Missing 8349 Yes No Missing. 408 I never drink alcohol Less than once a month Less than once a week On 1 or 2 days a week On 3 or 4 days a week On 5 or 6 days a week Every day Missing. 193 Never drink or 2 drinks per day or four drinks per day to 8 drinks per day or more drinks per day Missing
12 How often do you have five or more standard drinks of alcohol on one occasion? How many times would you have had five or more standard drinks of alcohol on one occasion in the last 12 months? Have you ever had reason to believe that you may have had your drink spiked in the past? ALCS011 ALCS034 ALCS040 Never Less than once a month About once a month About once a week More than once a week Missing or more Missing Yes No Unsure Missing
13 How many pieces of fresh fruit do you usually eat per day? (Count 1/2 cup of diced fruit, berries or grapes as one piece) How many serves of vegetables do you usually eat each day? (A serve = half a cup of cooked vegetables or a cup of salad vegetables) Over the last 12 months, on average, how often did you drink the following? Cola drinks/not diet (e.g. Coke) FFQV001 EATS063 EATS041 I don't eat fruit Less than 1 piece of fruit per day 1 piece of fruit per day 2 pieces of fruit per day 3 pieces of fruit per day 4 or more pieces of fruit per day Missing. 201 None Less than one serve serve serves serves serves serves or more Missing. 201 Never Less than once per month times per month time per week times per week times per week times per week time per day times per day times or more per day Missing
14 Over the last 12 months, on average, how often did you drink the following? Diet cola drinks (e.g. Diet coke) Over the last 12 months, on average, how often did you drink the following? Other carbonated (e.g. fizzy/soft drinks) EATS042 EATS043 Never Less than once per month times per month time per week times per week times per week times per week time per day times per day times or more per day Missing. 223 Never Less than once per month times per month time per week times per week times per week times per week time per day times per day times or more per day Missing
15 Over the last 12 months, on average, how often did you drink the following? Other diet carbonated drinks (e.g. diet lemonade) Over the last 12 months, on average, how often did you drink the following? Non-carbonated diet cordials, fruit or sport drinks EATS056 EATS057 Never Less than once per month times per month time per week times per week times per week times per week time per day times per day times or more per day Missing. 223 Never Less than once per month times per month time per week times per week times per week times per week time per day times per day times or more per day Missing
16 Over the last 12 months, on average, how often did you drink the following? Cordials, fruit or sport drinks Over the last 12 months, on average, how often did you drink the following? Milk or Soya Milk (including flavoured varieties) EATS044 EATS045 Never Less than once per month times per month time per week times per week times per week times per week time per day times per day times or more per day Missing. 224 Never Less than once per month times per month time per week times per week times per week times per week time per day times per day times or more per day Missing
17 Over the last 12 months, on average, how often did you drink the following? Fruit or vegetable juices Over the last 12 months, on average, how often did you drink the following? Tea EATS046 EATS047 Never Less than once per month times per month time per week times per week times per week times per week time per day times per day times or more per day Missing. 225 Never Less than once per month times per month time per week times per week times per week times per week time per day times per day times or more per day Missing
18 Over the last 12 months, on average, how often did you drink the following? Herbal tea Over the last 12 months, on average, how often did you drink the following? Coffee EATS048 EATS049 Never Less than once per month times per month time per week times per week times per week times per week time per day times per day times or more per day Missing. 227 Never Less than once per month times per month time per week times per week times per week times per week time per day times per day times or more per day Missing
19 Over the last 12 months, on average, how often did you drink the following? Water (including soda or plain mineral water) How many times did you do each type of activity last week? Walking briskly How many times did you do each type of activity last week? Moderate leisure activity How many times did you do each type of activity last week? Vigorous leisure activity How many times did you do each type of activity last week? Vigorous household or garden chores EATS050 EXER004 EXER005 EXER006 EXER011 Never Less than once per month times per month time per week times per week times per week times per week time per day times per day times or more per day Missing. 215 Mean 5.85 Std Error 0.07 N 8753 N Missing 254 Mean 1.37 Std Error 0.03 N 8752 N Missing 255 Mean 1.64 Std Error 0.03 N 8753 N Missing 254 Mean 1.67 Std Error 0.04 N 8752 N Missing
20 In total minutes, how much time did you spend altogether walking briskly? In total minutes, how much time did you spend altogether on moderate leisure activities? In total minutes, how much time did you spend altogether on vigorous leisure activities? In total minutes, how much time did you spend altogether on vigorous household or garden chores? Metabolic minutes Exercise Status Grouped Have you ever had a partner or spouse? WALKBRISKTOTMIN MODLEISTOTMIN VIGLEISTOTMIN VIGCHORETOTMIN metmin exgrp FAMF209 Mean Std Error 4.78 N 8636 N Missing 371 Mean Std Error 2.42 N 8637 N Missing 370 Mean Std Error 2.92 N 8638 N Missing 369 Mean Std Error 2.68 N 8645 N Missing 362 Mean Std Error N 8676 N Missing 331 Inactive Low Moderate High Missing. 331 Yes No Missing
21 This question asks about situations you may have experienced with current or past partners. My Partner: Told me that I was ugly, stupid or crazy, or that I wasn't good enough or that no one would ever want me This question asks about situations you may have experienced with current or past partners. My Partner: Followed me or harassed me around my neighbourhood / work. This question asks about situations you may have experienced with current or past partners. My Partner: Tried to turn my family, friends or children against me or tried to convince them I was crazy This question asks about situations you may have experienced with current or past partners. My Partner: Kicked, bit, slapped or hit me with a fist or tried to hit me with something CASC136 CASC139 CASC128 CASC129 Never Last 12 months only More than 12 months Last 12 months and more than 12 months Missing Never Last 12 months only More than 12 months Last 12 months and more than 12 months Missing Never Last 12 months only More than 12 months Last 12 months and more than 12 months Missing Never Last 12 months only More than 12 months Last 12 months and more than 12 months Missing
22 This question asks about situations you may have experienced with current or past partners. My Partner: Forced me to take part in unwanted sexual activity. This question asks about situations you may have experienced with current or past partners. My partner: Tried to keep me from seeing or talking to my family, friends or children, or didn't want me to socialise This question asks about situations you may have experienced with current or past partners. My partner: Pushed, grabbed, shoved, shook or threw me This question asks about situations you may have experienced with current or past partners. My Partner: Blamed me for causing their violent behaviour CASC138 CASC121 CASC122 CASC132 Never Last 12 months only More than 12 months Last 12 months and more than 12 months Missing Never Last 12 months only More than 12 months Last 12 months and more than 12 months Missing Never Last 12 months only More than 12 months Last 12 months and more than 12 months Missing Never Last 12 months only More than 12 months Last 12 months and more than 12 months Missing
23 This question asks about situations you may have experienced with current or past partners. My partner: Harassed me over the telephone, , Facebook or internet This question asks about situations you may have experienced with current or past partners. My partner: Used a knife or gun or other weapon or beat me up This question asks about situations you may have experienced with current or past partners. My Partner: Became upset if dinner/ housework wasn t done when they thought it should be This question asks about situations you may have experienced with current or past partners. My partner: Refused to let me work outside the home or took my wallet and left me stranded. Have you ever been in a violent relationship with a partner/spouse? CASC133 CASC134 CASC137 CASC135 FAMF023 Never Last 12 months only More than 12 months Last 12 months and more than 12 months Missing Never Last 12 months only More than 12 months Last 12 months and more than 12 months Missing Never Last 12 months only More than 12 months Last 12 months and more than 12 months Missing Never Last 12 months only More than 12 months Last 12 months and more than 12 months Missing Yes No Missing
24 In the last 12 months, have you had any injury for which you received medical treatment? Did any of the injuries that you received medical treatment for: Involve a car, bus, motorbike, pushbike, boat or other form of transport? Did any of the injuries that you received medical treatment for: Involve you getting burnt or scalded? Did any of the injuries that you received medical treatment for: Happen because you fell? Did any of the injuries that you received medical treatment for: Happen because someone meant to hurt you at the time? Did any of the injuries that you received medical treatment for: Happen while you were playing sport, a game or in the water? Have you been feeling that life isn't worth living? MEDH458 MEDH459 MEDH460 MEDH461 MEDH462 MEDH463 PWEL005 Yes No Missing. 303 Yes No NA Missing. 305 Yes No NA Missing. 305 Yes No NA Missing. 305 Yes No NA Missing. 306 Yes No NA Missing. 306 Never Last 12 months only More than 12 months Last 12 months and more than 12 months Missing
25 Have you deliberately hurt yourself or done anything that you knew might have harmed or even killed you? In the past 4 weeks:about how often did you feel tired out for no good reason? In the past 4 weeks:about how often did you feel nervous In the past 4 weeks:about how often did you feel so nervous that nothing could calm you down? In the past 4 weeks:about how often did you feel hopeless? PWEL006 KTEN001 KTEN002 KTEN003 KTEN004 Never Last 12 months only More than 12 months Last 12 months and more than 12 months Missing. 317 None of the time A little of the time Some of the time Most of the time All of the time Missing. 260 None of the time A little of the time Some of the time Most of the time All of the time Missing. 266 None of the time A little of the time Some of the time Most of the time All of the time Missing. 267 None of the time A little of the time Some of the time Most of the time All of the time Missing
26 In the past 4 weeks:about how often did you feel restless or fidgety? In the past 4 weeks:about how often did you feel so restless you could not sit still? KTEN005 KTEN006 In the past 4 weeks:about how often did you feel depressed? KTEN007 In the past 4 weeks:about how often did you feel that everything is an effort? In the past 4 weeks:about how often did you feel so sad that nothing could cheer you up? KTEN008 KTEN009 None of the time A little of the time Some of the time Most of the time All of the time Missing. 342 None of the time A little of the time Some of the time Most of the time All of the time Missing. 318 None of the time A little of the time Some of the time Most of the time All of the time Missing. 356 None of the time A little of the time Some of the time Most of the time All of the time Missing. 324 None of the time A little of the time Some of the time Most of the time All of the time Missing
27 In the past 4 weeks:about how often did you feel worthless? Kessler Psychological Distress Scale (K10) Score Over the last 12 months, how stressed have you felt about the following areas of your life: Own health Over the last 12 months, how stressed have you felt about the following areas of your life: Health of other family members Over the last 12 months, how stressed have you felt about the following areas of your life: Work/Employment KTEN010 k10 STRS001 STRS002 STRS003 None of the time A little of the time Some of the time Most of the time All of the time Missing. 279 Mean Std Error 0.08 N 8735 N Missing 272 Not applicable Not at all stressed Somewhat stressed Moderately stressed Very stressed Extremely stressed Missing. 327 Not applicable Not at all stressed Somewhat stressed Moderately stressed Very stressed Extremely stressed Missing. 331 Not applicable Not at all stressed Somewhat stressed Moderately stressed Very stressed Extremely stressed Missing
28 Over the last 12 months, how stressed have you felt about the following areas of your life: Living arrangements Over the last 12 months, how stressed have you felt about the following areas of your life: Study Over the last 12 months, how stressed have you felt about the following areas of your life: Money Over the last 12 months, how stressed have you felt about the following areas of your life: Relationship with parents STRS004 STRS005 STRS006 STRS007 Not applicable Not at all stressed Somewhat stressed Moderately stressed Very stressed Extremely stressed Missing. 329 Not applicable Not at all stressed Somewhat stressed Moderately stressed Very stressed Extremely stressed Missing. 331 Not applicable Not at all stressed Somewhat stressed Moderately stressed Very stressed Extremely stressed Missing. 332 Not applicable Not at all stressed Somewhat stressed Moderately stressed Very stressed Extremely stressed Missing
29 Over the last 12 months, how stressed have you felt about the following areas of your life: Relationship with partner/spouse Over the last 12 months, how stressed have you felt about the following areas of your life: Relationship with other family members Over the last 12 months, how stressed have you felt about the following areas of your life? Relationship with friends Over the last 12 months, how stressed have you felt about the following areas of your life: Motherhood/children Mean of Multi-item summed score for perceived stress. From 0 to 4. Higher values means more stressed. STRS008 STRS010 STRS030 STRS031 mnstrs Not applicable Not at all stressed Somewhat stressed Moderately stressed Very stressed Extremely stressed Missing. 329 Not applicable Not at all stressed Somewhat stressed Moderately stressed Very stressed Extremely stressed Missing. 329 Not applicable Not at all stressed Somewhat stressed Moderately stressed Very stressed Extremely stressed Missing. 329 Not applicable Not at all stressed Somewhat stressed Moderately stressed Very stressed Extremely stressed Missing. 332 Mean 1.04 Std Error 0.01 N 8678 N Missing
30 Are you currently pregnant? How tall are you without shoes? How much do you weigh without clothes or shoes? Body Mass Index BMI group REPH132 htcm wtkg BMI BMIGROUP No Less than 3 months to 6 months More than 6 months Don t know Missing. 327 Mean Std Error 0.08 N 8892 N Missing 115 Mean Std Error 0.19 N 8669 N Missing 338 Mean Std Error 0.07 N 8572 N Missing 435 Underweight, BMI < 18.5 Healthy weight, 18.5 <= BMI < 25 Overweight, 25 <= BMI < Obese, 30 <= BMI Missing
31 What is the highest level of education you have completed? Are you currently unemployed and actively seeking work? DEMO154 EMPL033 Are you currently employed and actively seeking more work? EMPL095 In a usual week, how many hours do you spend doing paid work? EMPL093 Year 10 or below Year 11 or equivalent Year 12 or equivalent Certificate I / II Certificate III / IV Advanced Diploma / Diploma Bachelor degree Graduate diploma / Graduate certificate Postgraduate degree Missing. 254 No Yes, unemployed for less than 6 months Yes, unemployed for 6 months or more Missing. 331 No Yes Missing or more Missing
32 In a usual week, how many hours do you spend studying? In a usual week, how many hours do you spend doing work without pay? How do you manage on the income you have available? What is your current relationship status? EMPL094 EMPL092 DEMO013 DEMO or more Missing or more Missing. 334 It is impossible It is difficult all the time It is difficult some of the time It is not too bad It is easy Missing. 332 I am single I am in a relationship (not living together) I am living with a partner I am engaged I am married I am divorced I am separated I am widowed Missing. 333
33 What are your living arrangements? I live alone What are your living arrangements?i live with one or both parents What are your living arrangements?i live with other adults What are your living arrangements?i live with my male partner What are your living arrangements?i live with my female partner What are your living arrangements? Live with children In a seven day week, on how many DAYS would you say you are AT WORK (paid or unpaid)? DEMO156 DEMO157 DEMO158 DEMO159 DEMO160 DEMO161 TIME047 No Yes Missing. 256 No Yes Missing. 256 No Yes Missing. 256 No Yes Missing. 256 No Yes Missing. 256 No Yes Missing Missing
34 On average, on days when you are AT WORK (paid or unpaid), how many hours per day do you work? Please estimate how much time you spent sitting in each of the following activities on your last working day and on your last non working day (weekend day or day off) For transport ( eg in car, bus, train etc) WORK DAY Please estimate how much time you spent SITTING in each of the following activities on your last working day and on your last non working day (weekend day or day off) For transport ( eg in car, bus, train etc) NON WORK DAY Please estimate how much time you spent sitting in each of the following activities on your last working day and on your last non working day (weekend day or day off) At work (e.g. sitting at a desk or using a computer) WORK DAY Please estimate how much time you spent SITTING in each of the following activities on your last working day and on your last non working day (weekend day or day off) At work (e.g. sitting at a desk or using a computer) NON WORK DAY Please estimate how much time you spent sitting in each of the following activities on your last working day and on your last non working day (weekend day or day off) Watching TV WORK DAY Please estimate how much time you spent SITTING in each of the following activities on your last working day and on your last non working day (weekend day or day off) Watching TV NON WORK DAY TIME048 SITWDTOTMIN1 SITNWDTOTMIN1 SITWDTOTMIN2 SITNWDTOTMIN2 SITWDTOTMIN3 SITNWDTOTMIN3 Mean 6.85 Std Error 0.04 N 8668 N Missing 339 Mean Std Error 1.05 N 5640 N Missing 3367 Mean Std Error 1.19 N 5567 N Missing 3440 Mean Std Error 2.22 N 7059 N Missing 1948 Mean Std Error 1.62 N 5344 N Missing 3663 Mean Std Error 1.10 N 7036 N Missing 1971 Mean Std Error 1.40 N 7596 N Missing
35 Please estimate how much time you spent sitting in each of the following activities on your last working day and on your last non working day (weekend day or day off) Using a computer at home ( , games, information, chatting) WORK DAY Please estimate how much time you spent SITTING in each of the following activities on your last working day and on your last non working day (weekend day or day off) Using a computer at home ( , games, information, chatting) NON WORK DAY Please estimate how much time you spent sitting in each of the following activities on your last working day and on your last non working day (weekend day or day off) Other leisure activities (socializing, movies, etc, but NOT including TV or computer use) WORK DAY Please estimate how much time you spent SITTING in each of the following activities on your last working day and on your last non working day (weekend day or day off) Other leisure activities (socializing, movies, etc but NOT including TV or computer use) NON WORK DAY SITWDTOTMIN4 SITNWDTOTMIN4 SITWDTOTMIN5 SITNWDTOTMIN5 Mean Std Error 1.50 N 6876 N Missing 2131 Mean Std Error 1.64 N 7420 N Missing 1587 Mean Std Error 1.09 N 6328 N Missing 2679 Mean Std Error 1.41 N 7422 N Missing
36 We would like to know your main occupation now: Did someone help you fill in this survey? Age at time survey returned TIME040 FAMF206 AGE Manager or administrator Professional Associate professional Tradesperson or related worker Advanced clerical or service worker Intermediate clerical, sales or service worker Intermediate production or transport worker Elementary clerical, sales or service worker Labourer or related worker No paid job Missing. 340 No Yes, but I told them the answers I wanted Yes, but the helper answered for me using his / her own judgement Missing. 364 Mean Std Error 0.02 N 9007 N Missing 0 34
37 State participant resides in at the completion of each survey What is your postcode? Mark here if living overseas Smoking status - smokst Alcohol status- NHMRC (AlcNHMRC) Alcohol pattern (AlcPAtt) state DEMO142 smokst alcnhmrc alcpatt NSW Vic Qld SA WA Tas NT ACT Missing. 349 Yes No Missing. 449 Never smoked Ex-smoker Smoker <10 c/d Smoker c/d Smoker > = 20 c/d Missing. 192 Low risk drinker Non-drinker Rarely drinks Risky drinker High risk drinker Missing. 195 Low long-term risk, drinks at short-term risk less than weekly Non-drinker Low long-term risk, drinks at short-term risk weekly or more Risky/high risk drinker Missing
38 Marital status (marital) ARIA+ Grouped Type of survey completed (full or short phone). Modified Monash Model HT - Health Transition Subscale marital ariapgp source MMM ht Married De Facto Separated Divorced Widowed Never married Missing. 333 Major cities Inner regional Outer regional Remote Very remote Missing. 405 Full online survey Short telephone survey Major cities Large regional Medium Large regional Medium regional Small regional Remote Very remote Missing. 390 Mean 2.68 Std Error 0.01 N 8930 N Missing 77 36
39 SF36 Physical Functioning SF36 Role Physical SF36 Pain Index SF36 General Health Perceptions SF36 Vitality SF36 Social Functioning SF36 Role Emotional PF RP BP GH VT SF RE Mean Std Error 0.18 N 8922 N Missing 85 Mean Std Error 0.35 N 8895 N Missing 112 Mean Std Error 0.22 N 8881 N Missing 126 Mean Std Error 0.24 N 8819 N Missing 188 Mean Std Error 0.22 N 8825 N Missing 182 Mean Std Error 0.26 N 8888 N Missing 119 Mean Std Error 0.43 N 8889 N Missing
40 SF36 Mental Health Index MH Mean Std Error 0.21 N 8825 N Missing
For each question you will be asked to fill in a bubble in each line: 1. How strongly do you agree or disagree with each of the following statements?
Appendix A: SF-36 Version 2 (modified for Australian use*) The SF-36v2 Health Survey Instructions for Completing the Questionnaire Please answer every question. Some questions may look like others, but
More informationHEALTH STATUS QUESTIONNAIRE 2.0
HEALTH STATUS QUESTIONNAIRE 2.0 Mode of Collection Self-Administered Personal Interview Telephone Interview Mail Other Patient: Date: Patient ID#: Instructions: This survey asks for your views about your
More informationPatient Follow-up Form - Version 1.1
Physician: [Last Name GO PROJECT Patient Follow-up Form - Version 1.1 Thank you for participating in the Glioma Outcomes Project. To continue participating in this important project, complete or correct
More informationPlease complete ALL 6 pages of the form in blue/black ink. Patient Acct # Provider # BMI # Height Weight
Please complete ALL 6 pages of the form in blue/black ink. Patient Acct # Provider # BMI # Height Weight f-25-n (08-07-13) ( 11-02-12) 0 10 Spine Questionnaire (continued) OFFICE USE ONLY Patient Acct
More informationSHOULDER Survey Packet for Measuring Your Improvement
SHOULDER Survey Packet for Measuring Your Improvement YOUR NAME: DATE: Record number: Surgeon: Dr. John Skedros A. How bad is your pain today (mark line with an X)? No pain at all Pain as bad as it can
More informationAustralian Longitudinal Study on Women s Health
Australian Longitudinal Study on Women s Health 1946-51 COHORT SUMMARY 1996 2013 April 2015 Table of Contents 1 EXECUTIVE SUMMARY... 1 2 INTRODUCTION AND BACKGROUND... 3 3 COHORT TRAJECTORIES 1996 2013...
More informationLIST CHANGES IN YOUR MEDICATION OR SUPPLEMENTS INTAKE (add new meds, changes in old meds or meds you stopped taking) Are you taking it?
Date Patient name: LIST YOUR THREE MAIN COMPLAINTS FOR THIS VISIT - - - New med Old med LIST CHANGES IN YOUR MEDICATION OR SUPPLEMENTS INTAKE (add new meds, changes in old meds or meds you stopped taking)
More informationElbow and Forearm Pain Form
Elbow and Forearm Pain Form Last Name First Name Date RIGHT LEFT My dominant hand? Right Left Does your elbow hurt? Yes No Yes No Does your forearm hurt? Yes No Yes No When did the problem start? Did you
More informationAppendix A. DePaul Symptom Questionnaire. Please answer the following questions.
Page 1 ID# Date Appendix A DePaul Symptom Questionnaire Please answer the following questions. 1. What is your height? 2. What is your weight? 3. What is your date of birth? 4. What is your gender? 5.
More informationSleep Health Center. You have been scheduled for an Insomnia Treatment Program consultation to further discuss your
Sleep Health Center You have been scheduled for an Insomnia Treatment Program consultation to further discuss your sleep. In the week preceding your appointment, please take the time to complete the enclosed
More informationPATIENT SURVEY FOR ADMINISTRATIVE USE ONLY. TO BE COMPLETED BY STUDY COORDINATOR.
PATIENT SURVEY FOR ADMINISTRATIVE USE ONLY. TO BE COMPLETED BY STUDY COORDINATOR. DATE OF VISIT: / / PATIENT ID: REGULAR PROVIDER: SITE OF VISIT: Cleveland Houston Manhattan Pittsburgh Thank you for agreeing
More informationGood. Poor [ ] [ ] Yes, at all [ A ] Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf [ ] [ ]
PATIENT I.D. This survey asks for your views about your health. This information will help keep track of how you feel and how well you are able to do your usual activities. For each of the following questions,
More informationMedical History. Instructions. My telephone number is: 1 Tools Medical History
Medical History Instructions To do the best possible job with your heart failure, the doctor needs details about your history, including current and past medical problems, medications, health habits, and
More informationDiabetes Care Profile
ID# Name Today s Date Diabetes Care Profile Michigan Diabetes Research and Training Center DCP2.0 1998 The University of Michigan 1 Section I Demographics Please answer each of the following questions
More informationComparative study of health status in working men and women using Standard Form -36 questionnaire.
International Journal of Pharmaceutical Science Invention ISSN (Online): 2319 6718, ISSN (Print): 2319 670X Volume 2 Issue 3 March 2013 PP.30-35 Comparative study of health status in working men and women
More informationVoice & Swallow Clinics
University of Wisconsin-Madison Voice & Swallow Clinics Medical Intake Form for Voice Patients (re-visit) Date MRN (Staff Input) Name: Date of Birth: Please indicate if your occupation has changed since
More informationADULT QUESTIONNAIRE. Date of Birth: Briefly describe the history and development of this issue from onset to present.
ADULT QUESTIONNAIRE Name: Address: Preferred phone number to reach you: Is it okay to leave a message? Yes No (Please check one) Date of Birth: Reason(s) for seeking treatment at this time? Briefly describe
More informationNAME OF PATIENT: STREET ADDRESS: CITY: STATE: ZIP: SEX: Male Female AGE: BIRTHDATE: MARITAL STATUS: PATIENT EMPLOYED BY: BUSINESS ADDRESS:
DATE: HOME PHONE: NAME OF PATIENT: (Last name) (First name) (Middle) RESPONSIBLE PARTY (if a minor): STREET ADDRESS: CITY: STATE: ZIP: SEX: Male Female AGE: BIRTHDATE: MARITAL STATUS: PATIENT EMPLOYED
More informationCBT Intake Form. Patient Name: Preferred Name: Last. First. Best contact phone number: address: Address:
Patient Information CBT Intake Form Patient Name: Preferred Name: Last Date of Birth: _// Age: _ First MM DD YYYY Gender: Best contact phone number: Email address: _ Address: _ Primary Care Physician:
More informationDate of Birth (mm/dd/year): 2. How much would you like to weigh (desired weight)?
MFA Weight Management Practice Initial Consultation Survey Name: Date of Birth (mm/dd/year): I. Weight History 1. What is the main reason you want to lose weight? _ 2. How much would you like to weigh
More informationMedicare Wellness Visit
of Birth: Today s : Medicare Wellness Visit Dear Patient, Your Medicare benefits include an Annual Wellness Visit to assist in preventing illness or detect illness at an early stage. Your Annual Wellness
More informationCHECK LIST FORM-MONTH 42 (Please note Month 42 is from enrolment not randomisation)
CHECK LIST FORM-MONTH 42 (Please note Month 42 is from enrolment not randomisation) Date of Birth: Evaluation Date: Were the following forms completed for this visit? Follow Up Form Done t Done BVASWG
More informationDANCER INTAKE FORM. 9. Do you teach dance? Yes No. If yes, how many hours a week do you teach? 10. Nightly sleep: Average of hours of sleep per night
DANCER INTAKE FORM 1. What is your primary style of dance? 2. How long have you been dancing in your primary style? 3. What is your current company or dance academy/school? 4. How long have you been at
More informationAll subjects who had baseline evaluations, including all randomized subjects Visits Baseline Visits 1-3, Month 6, Month 12, Month 24 VISIT codes
Trial CALERIE 2 Dataset (Rand SF-36 QOL instrument) Description RAD SF-36 QOL data from CRF. Includes responses to each item in the questionnaire and derived scores using SF-36 scoring algorithm (see QOL
More informationStroke Impact Scale VERSION 3.0
Stroke Impact Scale VERSION 3.0 The purpose of this questionnaire is to evaluate how stroke has impacted your health and life. We want to know from YOUR POINT OF VIEW how stroke has affected you. We will
More informationColombia (Bogota Oficial) Survey
1-3 SITE Site Code 4-13 SCHOOL School Codes 14-16 CLASS Class Codes 17-17 Q1 Q1 How old are you? 1 11 years old or younger 2 12 years old 3 13 years old 4 14 years old 5 15 years old 6 16 years old or
More informationHealth Appraisal Please complete all information to the best of your ability
Health Appraisal Please complete all information to the best of your ability Patient Information Legal Name (Last, First, Middle) Preferred Name: Cell # ( ) - Home # ( ) - Email Address YES! I would like
More informationHealthy Ageing. 12 years of results from the Australian Longitudinal Study on Women s Health (ALSWH) Professor Julie Byles
Healthy Ageing 12 years of results from the Australian Longitudinal Study on Women s Health (ALSWH) Professor Julie Byles SCHOOL OF POPULATION HEALTH THE UNIVERSITY OF QUEENSLAND Life in your years, not
More informationIf you arrive at the office without these forms, your visit may need to be rescheduled.
Dear, Your Appointment for the Welcome to Medicare Visit OR Annual Wellness Visit is scheduled on at There is NO CO-PAY for this visit, so it is free for you. The goal of this visit is to provide time
More informationDesigning a life of wellness. Evaluation of the demonstration program at the Wilder Humboldt campus
Designing a life of wellness Evaluation of the demonstration program at the Wilder Humboldt campus F E B R U A R Y 2 0 0 3 Designing a life of wellness Evaluation of the demonstration program at the Wilder
More informationFollow-up Questionnaire Page 1 of 10
(FQ1) Plate #330 Seq #005 Page 1 of 10 To s Date Demographics 1 What is your highest level of schooling or education? Primary or grammar school Some high school Graduated from high school Some college
More informationThese questions are about the physical problems which may have occurred as a result of your stroke. Quite a bit of strength
PhenX Measure: Functionality after Stroke (#820700) PhenX Protocol: Stroke Impact Scale (SIS) - Adults (#820701) Date of Interview/Examination (MM/DD/YYYY): _ Stroke Impact Scale VERSION 3.0 The purpose
More informationSTEPS Instrument for NCD Risk Factors (Core and Expanded Version 1.4)
WHO/NMH/CCS/03.03 Version.4 DISTRIBUTION: LIMITED STEPS Instrument for NCD Risk Factors (Core and Expanded Version.4) The WHO STEPwise approach to Surveillance of noncommunicable diseases (STEPS) ncommunicable
More informationThe first section of this booklet will help you think about what alcohol can do to your health.
6 5 4 3 2 Your doctor or health worker has advised you that you are drinking at a level which can cause problems. Do you think your health or any part of your life may suffer because of your drinking?
More informationSample Health Risk Assessment
Sample Health Risk Assessment The HRA questions outlined below are provided as examples. They represent one HRA model. Use of this model is not a requirement for the Medicare Annual Wellness Visit HRA,
More informationYour Goals and Expectations:
New Member Information: Aligned Health Chiropractic Dr. Jennifer Carauddo, D.C. 987 University Avenue, Suite 28 Los Gatos, CA 95032 (408) 371-6003 Fax (408) 371-6009 Today s Date / / Name Birth Date /
More informationFunctional Status Questionnaire & Pain Catastrophizing Scale. A Presentation by: Jacob leroux, NAM NGUYEN & DEREK TITUS
Functional Status Questionnaire & Pain Catastrophizing Scale A Presentation by: Jacob leroux, NAM NGUYEN & DEREK TITUS Objectives 1. Understand and employ the functional status questionnaire; 2. Define
More information1 3/04/15. University of California Global Food Initiative - Got Food? Survey. 1) Where do you currently live? Agree a lot.
1) Where do you currently live? o Campus residence hall o Fraternity or sorority house college/university housing o Parent/guardian s home off-campus housing o With a friend until I find other housing
More informationINSOMNIA SEVERITY INDEX
Name: Date: INSOMNIA SEVERITY INDEX For each of the items below, please circle the number that most closely corresponds to how you feel. 1. Please rate the CURRENT (i.e. last 2 weeks) severity of your
More informationHealth Behavior Survey
Name: PIN: Date: Starting Time: Ending Time: Health Behavior Survey This survey asks about your physical activity, fruits and vegetables consumption, fiber consumption, dietary fat intake, and other eating
More informationIF YOU RE SICK OF: YOU RE READY TO QUIT! Hint: Quitting chewing tobacco and snuff is a lot like
IF YOU RE SICK OF: Coughing all the time Spending your money on cigarettes Smelling like an ashtray People hassling you about smoking Hurting your health Cigarettes screwing up your life... YOU RE READY
More informationUse, access to, and impact of Medicare services for Australian women: Findings from the Australian Longitudinal Study on Women s Health Julie Byles
Use, access to, and impact of Medicare services for Australian women: Findings from the Australian Longitudinal Study on Women s Health Julie Byles See alswh.org.au This presentation Introduce ALSWH Latest
More informationWestminster IAPT Primary Care Psychology Service. Opt-In Questionnaire
Westminster IAPT Primary Care Psychology Service Opt-In Questionnaire In order to get a better idea of your difficulties, we would be grateful if you could complete the attached registration form and questionnaire.
More informationA naturalistic observational study of Western herbal medicine practice in self-reported anxiety and depression
INFORMATION SHEET (PATIENT PARTICIPANT) A naturalistic observational study of Western herbal medicine practice in self-reported anxiety and depression WHO IS DOING THE RESEARCH? Our names are Dr Jon Wardle,
More informationDepression. Northumberland, Tyne and Wear NHS Trust (Revised Jan 2002) An Information Leaflet
Depression Northumberland, Tyne and Wear NHS Trust (Revised Jan 2002) An Information Leaflet practical ldren 1 7XR isle, d n. ocial These are the thoughts of two people who are depressed: I feel so alone,
More informationHEALTH RISK ASSESSMENT FOR ANNUAL PHYSICALS
HEALTH RISK ASSESSMENT FOR ANNUAL PHYSICALS Patient Name: DOB: PHYSICAL INACTIVITY/LACK OF EXERCISE How many days a week do you usually exercise? days per week On days when you exercise, for how long do
More information05/26/2011 Page 1 of 15
Number of IYS 2010 Respondents N Total Grade 198 203 401 Avg Age N Avg How old are you? 11.9 198 13.9 203 Gender % N % N Female 4 96 5 115 Male 5 99 4 87 Race/Ethnicity N % N % N White 8 165 8 176 Black
More information05/26/2011 Page 1 of 15
Number of IYS 2010 Respondents N Total Grade 101 102 203 Avg Age N Avg How old are you? 11.8 101 13.7 102 Gender % N % N Female 4 43 5 52 Male 5 57 4 50 Race/Ethnicity N % N % N White 9 97 9 99 Black /
More information05/27/2011 Page 1 of 15
Number of IYS 2010 Respondents N Total Grade 218 194 412 Age Avg N Avg How old are you? 11.9 218 13.8 193 Gender % N % N Female 5 112 5 103 Male 4 99 4 88 Race/Ethnicity N % N % N White 7 164 8 158 Black
More informationAPPENDIX: question text and additional data tables
Attitudes to obesity APPENDIX: question text and additional data tables Questionnaire CAPI interview Q343 [MaleObes] CARD WITH MALE BODY IMAGES I'm going to show you a card that uses computer images of
More informationSouth Australian Health & Wellbeing Survey
South Australian Health & Wellbeing Survey DECEMBER 2000 Eleonora Dal Grande Anne Taylor David Wilson Centre for Population Studies in Epidemiology South Australian Department of Human Services ACKNOWLEDGMENTS
More informationQuality of Life in Epilepsy for Adolescents: QOLIE-AD-48 (Version 1)
Quality of Life in Epilepsy for Adolescents: QOLIE-AD-48 (Version 1) QOLIE-AD-48 1999, QOLIE Development Group. All rights reserved. Today's Date / / Name: INSTRUCTIONS The QOLIE-AD-48 is a survey of health-related
More informationWeight Loss- Medical History Form
Weight Loss- Medical History Form Name: Age: Sex: M F Family Physician: Phone: May we contact this practitioner? Yes No Present Status: 1. Are you in good health at the present time to the best of your
More informationWelcome to NHS Highland Pain Management Service
Welcome to NHS Highland Pain Management Service Information from this questionnaire helps us to understand your pain problem better. It is important that you read each question carefully and answer as
More informationSupplementary Materials:
Supplementary Materials: Depression and risk of unintentional injury in rural communities a longitudinal analysis of the Australian Rural Mental Health Study (Inder at al.) Figure S1. Directed acyclic
More information05/26/2011 Page 1 of 26
Number of IYS 2010 Respondents N Total Grade 52 53 60 165 Age Avg N Avg N Avg How old are you? 14.1 52 16.0 53 17.9 60 Gender % N % N % N Female 5 29 4 23 4 27 Male 4 21 5 29 5 33 Race/Ethnicity N % N
More informationChatham. Student Survey Report 2016
Chatham Student Survey Report 2016 3/10/2017 2 Introduction The need for such a survey is clear. The drug problem and the context within which substance use and abuse occurs will not improve without intervention.
More informationFollow Up Patient Questionnaire
Follow Up Patient Questionnaire Adult Reconstruction & Joint Replacement Patient Information: First Name: M.I. Last Name: Date of Birth: Today's Date: Chief Complaint (select all that apply): Location/Laterality:
More informationFOREVER FREE STOP SMOKING FOR GOOD. Stop Smoking. For Good. Smoking, Stress, & Mood
B O O K L E T 6 Stop Smoking For Good Smoking, Stress, & Mood Contents What Causes Stress? 2 What is Stress? 4 How is Stress Related to Smoking? 4 So, Why Not Smoke When Stressed? 6 Better Ways to Deal
More informationWyoming Prevention Needs Assessment Survey
Wyoming Prevention Needs Assessment Survey 1. Thank you for agreeing to participate in this survey. The purpose of the survey is to learn how students in our schools feel about their community, family,
More informationIndicator Interpretation Guide 2014/15. New Zealand Health Survey
Indicator Interpretation Guide 2014/15 New Zealand Health Survey Released 2015 health.govt.nz Authors This interpretation guide was written by Sharon Cox, Deepa Weerasekera, Hilary Sharpe and Bridget Murphy
More informationSandra Bell, Christina Lee, Jennifer Powers and Jean Ball. Health of other family members. Living arrangements
Age Cohorts Surveys Derived Variable Definition Source Items Statistical form Index Number Younger, Mid-age and Older All Young, Mid-age, Older 1 and 2 only MNSTRS Multi-item summed score for perceived
More informationGENDER, ALCOHOL, AND CULTURE: AN INTERNATIONAL STUDY (GENACIS)
1 NOTE. THE CORE QUESTIONNAIRE SHOULD BE USED ONLY IN CIRCUMSTANCES WHERE TIME AND RESOURCES FOR INCLUDING ALCOHOL-RELATED QUESTIONS ARE LIMITED. NOVEMBER 2001 CASE ID: INTERVIEWER ID: GENDER, ALCOHOL,
More informationNew Zealand Smoking Monitor (NZSM) Questionnaire 2011/12
New Zealand Smoking Monitor (NZSM) Questionnaire 2011/12 Screeners (S1-S5): S1) Can I just check, in the last (#), have you taken part in a telephone survey conducted by the Ministry of Health around smoking
More informationModule A. Middle School Questionnaire
2009-2010 This survey asks about your behavior, experiences, and attitudes related to health, well-being, and schooling. It includes questions about use of alcohol, tobacco, and other drugs; bullying and
More informationBEHAVIORAL RISK FACTORS
EXAMPLES OF QUESTIONS IN AN HRA BEHAVIORAL RISK FACTORS PHYSICAL INACTIVITY/LACK OF EXERCISE How many days a week do you usually exercise? days per week On days when you exercise, for how long do you usually
More informationLevel 1 Award in Health Improvement
Level 1 ward in Health Improvement Specimen Examination Paper INSTRUTIONS TO NITES 1 ttempt to answer every question. 2. Enter your answers on the accompanying answer sheet. Each question has only ONE
More informationPRE-VISIT QUESTIONNAIRE FOR NEW PATIENTS
UF Health Senior Care PO Box 100383 Gainesville, FL 32608 352-265-0615 Fax 352-294-5803 PRE-VISIT QUESTIONNAIRE FOR NEW PATIENTS Please complete this questionnaire at home and bring it with you to the
More informationPoll 9 - Kids and Food: Challenges families face December 2017
Poll 9 - Kids and Food: Challenges families face December 2017 The below questions were reported on in the ninth RCH National Child Health Poll Kids and food: Challenges families face. As a parent or carer,
More informationHealth & Wellness Assessment. Name Date of Birth. List the names of any doctors, medical providers, nurses, or medical suppliers that you have:
1 Health & Wellness Assessment Name Date of Birth List the names of any doctors, medical providers, nurses, or medical suppliers that you have: Name Phone Services You Receive General Health In general,
More informationName: Age: Sex: M F. 1. Are you in good health at the present time to the best of your knowledge? Yes No
Medical History Form Name: Age: Sex: M F Family Physician: Phone: Present Status: 1. Are you in good health at the present time to the best of your knowledge? Yes No 2. Are you under a doctor s care at
More informationYOUR SLEEP PATTERNS (for week 0 and week 12)
ID: Page 1 of 1 rev Aug 6, 2014 YOUR SLEEP PATTERNS (for week 0 and week 12) 1. How many hours of sleep do you normally get each night? Typical week night Typical weekend night 2. Do you work at night?
More informationINTAKE FORM ID: 1. I have the following conditions:
. I have the following conditions: Anemia Arthritis Ashma/Rhinitis/Sinusitis Cáncer Depressión Diabetes Migraines Anxiety High Cholesterol High Blood Pressure INTAKE FORM ID: Problems with your lungs Problems
More informationALVIN C. BURSTEIN, MD PATIENT CLIENT INFORMATION
ALVIN C. BURSTEIN, MD PATIENT CLIENT INFORMATION LEGAL Name Date of Birth (must match insurance card) Address City State Zip Mailing Address City State Zip (If different) Phone: Cell Home Appt. reminders
More information11/04/2011 Page 1 of 16
Survey Validity % N Invalid 5 Valid 96% 116 Valid surveys are those that have 4 or more of the questions answered, report no derbisol use, and indicate that the respondent was honest at least some of the
More information11/03/2011 Page 1 of 16
Survey Validity % N Invalid 5 Valid 9 181 Valid surveys are those that have 4 or more of the questions answered, report no derbisol use, and indicate that the respondent was honest at least some of the
More informationASSOCIATED PRESS-LIFEGOESSTRONG.COM BOOMERS SURVEY JUNE 2011 CONDUCTED BY KNOWLEDGE NETWORKS July 18, 2011
Interview dates: June 3 June 12, 2011 Interviews:1,416 adults, 1,078 boomers Sampling margin of error for a 50% statistic with 95% confidence is: ±4.4 for all adults; ±3.3 for boomers 2100 Geng Road Suite
More informationGENERAL BEHAVIOR INVENTORY Self-Report Version Never or Sometimes Often Very Often
GENERAL BEHAVIOR INVENTORY Self-Report Version Here are some questions about behaviors that occur in the general population. Think about how often they occur for you. Using the scale below, select the
More informationSUPPLEMENT MATERIALS. Appendix A: Cleveland Global Quality of Life (CGQL) [0 being the WORST and 10 being the BEST]
SUPPLEMENT MATERIALS Appendix A: Cleveland Global Quality of Life (CGQL) [0 being the WORST and 10 being the BEST] Q1. Current Quality of Life: Circle one 6 7 8 9 10 Q2. Current Quality of Health: Circle
More informationKAISER PERMANENTE SPINE
KAISER PERMANENTE SPINE The following forms are specially designed to give your doctor valuable information about the health of your spine. The same way an EKG gives us information about your heart. It
More informationName: Date of Birth: Age: Grade: ID Number: Bob M Jones 4/21/ Gender: Sexual Orientation: Sex at Birth: Preferred Pronoun:
JUST HEALTH PATIENT REPORT Name: Date of Birth: Age: Grade: ID Number: Bob M Jones 4/21/2000 17 12 1234567 Gender: Sexual Orientation: Sex at Birth: Preferred Pronoun: Femal Gay or Lesbian Female No pronouns,
More informationPHARMACY INFORMATION:
Patient Name: Date of Birth: Referred by: Reason for Visit: Current psychiatric medications and doses: PHARMACY INFORMATION: Name of Pharmacy: Phone Number: Fax Number: Address: PRIMARY CARE PHYSICIAN
More informationIndicator Interpretation Guide 2013/14. New Zealand Health Survey
Indicator Interpretation Guide 2013/14 New Zealand Health Survey Citation: Ministry of Health. 2014. Indicator Interpretation Guide 2013/14: New Zealand Health Survey. Wellington: Ministry of Health. Published
More informationEGEA MEDICAL WEIGHT LOSS CENTER. Name: Age: Sex: M F. 6. History of Diabetes? Yes No At what age:
EGEA MEDICAL WEIGHT LOSS CENTER Medical History Form Name: Age: Sex: M F Primary Care Physician: Home Phone : Present Status: 1. Are you in good health at the present time to the best of your knowledge?
More informationYour Guide to a Smoke Free Future
Your Guide to a Smoke Free Future If you smoke, or if you have quit within the past 2 months, then ask for our detailed handout which provides information on how to begin and maintain a smoke-free lifestyle.
More informationDespite substantial declines over the past decade,
19 The journey to quitting smoking Margot Shields Abstract Objectives This article outlines smoking trends over the past 10 years among the population aged 18 or older. Factors associated with smoking
More informationdid you feel sad or depressed? did you feel sad or depressed for most of the day, nearly every day?
Name: Age: Date: PDSQ This form asks you about emotions, moods, thoughts, and behaviors. For each question, circle YES in the column next to that question, if it describes how you have been acting, feeling,
More informationThe Road to Food Security: Creating a Food and Resource Center in Stillwater. By: Katelyn McAdams. Data Report
The Road to Food Security: Creating a Food and Resource Center in Stillwater By: Katelyn McAdams Data Report July 2016 1 *blank=no response 70-74 6% CURRENT AGE 75+ 9% 3% 18-24 4% 25-29 6% 30-34 5% 35-39
More informationMetro SHAPE MN State Epidemiological Outcomes Workgroup June 20 th, Updated on June 27, 2016
Metro SHAPE 2014 MN State Epidemiological Outcomes Workgroup June 20 th, 2016 Updated on June 27, 2016 Survey Background An on-going public health surveillance and assessment of the health of Hennepin
More informationParent Pain Questionnaire Understanding your child s pain
Parent Pain Questionnaire Understanding your child s pain This questionnaire is to help us learn about your child's pain problems. All information obtained from this questionnaire and in interviews will
More informationAdding Activity to Your Lifestyle
MINTO PREVENTION & REHABILITATION CENTRE CENTRE DE PREVENTION ET DE READAPTATION MINTO Adding Activity to Your Lifestyle About This Kit An important long-term goal of the Heart Institute Prevention and
More informationIf you have any difficulties in filling out the forms, please contact our team administrator on
Westminster IAPT Primary Care Psychology Service Lisson Grove Health Centre Gateforth Street London NW8 8EG Team Administrator Tel: 07971315596 Dear Sir/Madam Thank you for requesting this opt-in pack
More informationGENDER, ALCOHOL, AND CULTURE: AN INTERNATIONAL STUDY (GENACIS)
NOVEMBER 2001 CASE ID: INTERVIEWER ID: 1 GENDER, ALCOHOL, AND CULTURE: AN INTERNATIONAL STUDY (GENACIS) EXPANDED CORE QUESTIONNAIRE: DEMOGRAPHICS 1. What is your gender? Male 1 Female 2 2. What is your
More informationG L O B A L S C H O O L - B A S E D S T U D E N T H E A L T H S U R V E Y R E S U L T S. Cambodia Survey. Public Use Codebook
17-17 Q1 Q1 How old are you? 1 11 years old or younger 12 0.4 2 12 years old 78 2.1 3 13 years old 451 11.8 4 14 years old 643 18.8 5 15 years old 640 18.6 6 16 years old 521 14.8 7 17 years old 585 14.3
More informationContents. Smoking. Staying stopped. Preparing to stop. Relapsing. Stopping
Contents Stage 1: Preparing to stop smoking 1 Stage 2: Stopping 3 Stage 3: Staying stopped 5 Nicotine replacement therapy 7 Non-nicotine treatments 10 Where to get help and advice 11 Stopping smoking isn't
More information11/02/2011 Page 1 of 16
Survey Validity % N Invalid 10 Valid 9 201 Valid surveys are those that have 4 or more of the questions answered, report no derbisol use, and indicate that the respondent was honest at least some of the
More information9 in 10 Australian young people don t move enough. Make your move Sit less Be active for life! years
AUSTRALIA S PHYSICAL ACTIVITY AND SEDENTARY BEHAVIOUR GUIDELINES 9 in 10 Australian young people don t move enough Make your move Sit less Be active for life! 13-17 years What s it all about? As you move
More informationORIENTATION SAN FRANCISCO STOP SMOKING PROGRAM
ORIENTATION SAN FRANCISCO STOP SMOKING PROGRAM PURPOSE To introduce the program, tell the participants what to expect, and set an overall positive tone for the series. AGENDA Item Time 0.1 Acknowledgement
More informationMENTAL HEALTH 2011 SURVEY RESULTS REPORT. and Related Behaviors. Figure 1 n Trends in mental health indicators, Grades 9 12, New Mexico,
2011 SURVEY RESULTS REPORT MENTAL HEALTH and Related Behaviors 50 40 30 20 Persistent sadness or hopelessness Percent (%) 10 0 2003 2005 2007 2009 2011 31.9 28.7 30.8 29.7 29.1 Seriously considered suicide
More informationIllinois Youth Survey 2010 Lake County - All Students
Schools Represented in this Report Count School Total CARL SANDBURG MIDDLE SCHOOL CARMEL CATHOLIC HIGH SCHOOL FREMONT MIDDLE SCHOOL MUNDELEIN CONS HIGH SCHOOL WEST OAK MIDDLE SCHOOL Grade level Total 182
More information