ANNUAL FOLLOW-UP QUESTIONNAIRE

Transcription

1 SLEEP HEART HEALTH STUDY - TUCSON ANNUAL FOLLOW-UP QUESTIONNAIRE Dear Sleep Heart Health Study participant: Today s Date: / / Month Day Year Please take the time to complete and return this short questionnaire now. We ask you to complete one at the beginning of each calendar year. The sleep study which you undertook is only the first part of this important nationwide study. We must now determine your health status for several years, using this questionnaire. Again, thanks. Instructions: Using a pencil or pen, please put an X in the box to indicate your response to multiple-choice questions. IMPORTANT: Unless otherwise specified, questions refer to your health during the 2003 calendar year only (January through December, 2003). 1. Compared to other people your age, would you say that your health has been: Excellent 1 Fair 3 Good 2 Poor 4 b. How many times did you see a medical doctor in 2003? 2. During 2003, did you ever have a severe pain across the front of your chest lasting for half an hour or more? (if no, skip to question 3) a. Did you see a doctor because of this pain? b. If yes, what did the doctor say it was? Heart Attack 1 Something Else 2 Page 1 of 8

2 3. During 2003, did you have any pain or discomfort in your chest? (if no, skip to question 4) a. Do you get it when you walk uphill or hurry? I never hurry or walk uphill 8 b. Do you get it when you walk at an ordinary pace on a level surface? c. Was it relieved within a few minutes when you rested? d. Did you see a doctor because of this chest pain or discomfort? e. If yes, what did the doctor say caused it? Angina 1 Heart Attack 2 Other Heart Disease 3 Chronic Lung Disease 4 Other 5 4. During 2003, did you have pain in either leg while walking? (if no, skip to question 5) a. If yes, what did you do? Stop or slow down 1 Keep Walking 2 Other 3 b. What happened to the pain if you stood still? Relieved 1 Not Relieved 2 c. Did this pain ever begin when you were standing still or sitting? d. Did you get it if you walked uphill or hurried? I never hurried or walked uphill 8 e. Did the pain ever disappear while you were walking? Page 2 of 8

3 5. During the LAST FOUR WEEKS, were you able to do the following WITHOUT help from another person? (check all that apply) a. 1 Heavy work around the house, like vacuuming, or washing windows, walls or floors? b. 1 Walk up and down two flights of stairs? c. 1 Walk half a mile? (8 blocks) d. 1 Do your usual activities, such as work around the house or recreation? e. Were you able to go to work? I don t work 8 f. If you were not able to do your normal activities or work, was a heart problem the main cause? Not applicable 8 6. Do you usually cough on most days for as much as 3 months of the year? 7. Do you bring up phlegm, sputum or mucus from your chest on most days for as much as 3 months of the year? 8. Does your chest ever sound wheezy or whistling? 8a. If yes, do you get this even when you don t have a cold? 9. Have you ever had attacks of wheeze, shortness of breath, or chest tightness? 9a. If yes, during 2003, how many attacks of shortness of breath with wheezing did you have? 1 None. 2 A few (1-3) 3 Several (4-12) 4 Many (13 or more) 5 Almost every day. Page 3 of 8

4 10. During 2003, how often were you unable to do your usual activities because of illnesses such as chest colds, bronchitis, or pneumonia? (not head colds) Never 1 During 2-5 such illnesses 3 During one such illness 2 During 6 illnesses or more During 2003, were you told that you have or had: (check all that apply) a. Angina Pectoris (chest pain due to heart disease) b. Myocardial infarction or heart attack c. Coronary artery bypass surgery (cabbage) d. Cardiac (heart) catheterization, or angiography e. Angioplasty / stent f. An episode of congestive heart failure g. A stroke (cerebrovascular accident) h. A temporary or slight stroke (transient ischemic attack, TIA) i. Leg pain from artery blockage (intermittent claudication) j. COPD (emphysema, chronic bronchitis, or bronchiectasis) k. Asthma l. Carotid Endarterectomy 12. In 2003, were you told for the first time that you now have high blood pressure? Unsure Do you currently take any medications for: a. Your heart? If yes, what medications? b. High Blood Pressure? If yes, what medications? c. Breathing or Lung problems? If yes, what medications? Page 4 of 8

5 14. Please list any physicians you visited during 2003 for hypertension or heart problems: Name City State 15. Please list any physicians you visited during 2003 for any breathing or lung problems: Name City State 16. During 2003, how many times were you hospitalized (at least for one night)? If so, please tell us about them: Month Reason Hospitalized Hospital Name City/State Physician Name 17. In the past three years, have you had a chest x-ray? Unsure 8 17a. If yes, what were the results? Normal 1 Abnormal 0 Don t know 8 Page 5 of 8

6 18. Please indicate how often you experience each of the following (check one box for each in items a - g) ALMOST NEVER RARELY SOMETIMES OFTEN ALWAYS (0) (1x/month (2-4x/ (5-15x/ (16-30x/ or less) month) month) month) a. Have trouble falling asleep b. Wake up during the night and have difficulty getting back to sleep c. Wake up too early in the morning and be unable to get back to sleep d. Feel unrested during the day no matter how many hours of sleep you had e. Feel excessively (overly) sleepy during the day f. Do not get enough sleep g. Take sleeping pills or other medication to help you sleep How often do you snore now? (check one) Do not snore 0 (if no, skip to question 20) Rarely (less than one night a week) 1 Sometimes (1 or 2 nights a week) 2 Frequently (3 to 5 nights a week) 3 Always or almost always (6 or 7 nights a week) 4 Don t know 5 19a. How loud is your snoring? (check one) Only slightly louder than heavy breathing 0 About as loud as mumbling or talking 1 Louder than talking 2 Extremely loud (can be heard through a closed door) 3 Don t know 4 Page 6 of 8

7 20. What is the chance that you would doze off or fall asleep (not just feel tired ) in each of the following situations? (check one box for each situation. If you are never or rarely in the situation, please give your best guess for what would happen.) NO SLIGHT MODERATE HIGH CHANCE CHANCE CHANCE CHANCE a. Sitting and reading b. Watching TV c. Sitting inactive in a public place (such as a theater or a meeting) d. Riding as a passenger in a car for an hour without a break e. Lying down to rest in the afternoon when circumstances permit f. Sitting and talking to someone g. Sitting quietly after a lunch without alcohol h. In a car, while stopped for a few minutes in traffic i. At the dinner table j. While driving Are there times when you stop breathing during your sleep? (if no or don t know, skip to question 22) Don t know 8 21a. If yes, how often do you have times when you stop breathing during sleep? Rarely (less than one night a week) 1 Sometimes (1 or 2 nights a week) 2 Frequently (3 to 5 nights a week) 3 Always or almost always (6 or 7 nights a week) 4 Don t know 5 Page 7 of 8

8 22. Have you ever had somnoplasty, laser treatment, or surgery as treatment for snoring or sleep apnea? 23. Have you ever been told by a doctor that you have a sleep disorder (other than sleep apnea)? (if no, skip to question 24) 23a. What other sleep disorder? (check all that apply) Insomnia 1 Restless legs 2 Narcolepsy 3 Other 4 Specify other: 24. In 2003, did you change your smoking habits? I have never smoked 8 b. If your smoking habits did change, did you: 1. Stop smoking 1 2. Reduce smoking 2 3. Start smoking 3 Current number of cigarettes per day? 4. Increase smoking What is your current weight? pounds. 26. Do you plan to move during 2004? a. If yes, to what city?_ 27. May we have the name and phone number of someone who will know how to contact you next year, if we are unable to locate you? Name Phone Relationship Page 8 of 8

9 Thank-you for completing the survey! Page 9 of 8