QUESTIONNAIRE FOR STUDY: BONE MINERAL DENSITY
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1 Jean Mayer Human Nutrition Research Center on Aging at Tufts University QUESTIONNAIRE FOR STUDY: BONE MINERAL DENSITY HNRC#: Date: / / Month Day Year PR#
2 Instructions: The following questions refer to your place of residence and your migration history over the past years.. 10 Years 1a. Based on the past ten years, how many years or months have you lived in the Northeastern United States (Massachusetts, New York, etc.)? years months 1b. Based on the past ten years, how many years or months have you lived in Puerto Rico, the Southern United States, or another area with a similar climate? years months Past Year (12 Months) 2a. In the past (1) year, how many months have you lived in the Northeaster United States (Massachusetts, New York, etc)? months 2b. In the past (1) year, how many months have you lived in Puerto Rico, the Southern United States, or another area with a similar climate? 3. On average, how many hours per week do you spend outdoors during the summer? (DO NOT include time spent inside vehicles / cars / buses) OR hours per day (If Don t Know, write 98 ) hours per week 4a. When you spend time outdoors during the summer, what parts of your skin are usually exposed to the sun? (Choose only one answer) a. Face only b. Face and hands c. Face, hands and arms d. Face, hands, arms and legs e. Not applicable 4b. When you go out, do you normally use sunscreen/spf? 99 = Not Applicable 1
3 Instructions: The following questions refer to falls and fractures that you may have suffered during the past year. 5. During the past year, did you accidentally fall to the ground? (Choose if the accident occurred during a sports activity) (If No, go to question #8) (If Yes, continue with question #6) (If Don t Know, continue with question #6) 6. If Yes or Don t Know : How many times did you suffer (or think you suffered) a fall during the last year? times 7. Did any of your falls during the last year result in the following? Outcome Yes No Don t Know a. Fracture b. Skin cut c. Blow to the head requiring medical attention d. Dislocation Bruise, sprain (twisting of ligaments), or skin cut not requiring medical e intervention 8. From age 20 until now, has your physician ever told you if you have suffered a fracture or broken bone? (If No, go to question #10) (If Yes, continue with question #9) (If No, continue with question #9) 9. In how many of the following bones did you ever suffer (or think your doctor told you that you suffered) a fracture, and at what age? (If any bones were broken more than once, indicate the age at the time of the first fracture) (Specify left or right side inside the appropriate box) (If you don t know what side, write 98 in the Left and Right boxes) (If you don t know the age, write 98 in the Age box) Bone Yes No Left Right a. Hip 1 0 b. Humerus (arm bone above the elbow) 1 0 Cubitus or radius (forearm bones below the elbow), c. or wrist 1 0 d. Hand 1 0 e. Collarbone 1 0 f. Spinal column 1 0 g. Pelvis 1 0 h. Leg 1 0 Age (of first fracture) 2
4 i. Foot 1 0 j. Toe(s) 1 0 k. Other; specify: 1 0 Instructions: The following questions refer to falls and fractures that any members of your family may have suffered after the age of Did your mother ever suffer a bone fracture after age 20? (Refer to your biological mother) (If No go to question #11) (If Don t Know go to question #11) 10a. If Yes : Please indicate each bone where your mother suffered a fracture and her age at the time. (If any bones were broken more than once, indicate the age at the time of the first fracture) (Specify left or right side inside the appropriate box) (If you don t know what side, write 98 inside the Left and Right boxes) (If you don t know the age, write 98 inside the Age box) Bone Yes No Left Right Age a. Hip 1 0 b. Humerus (arm bone above the elbow) 1 0 Cubitus or radius (forearm bones below the elbow), c. 1 0 or wrist d. Hand 1 0 e. Collarbone 1 0 f. Spinal column 1 0 g. Pelvis 1 0 h. Leg 1 0 i. Foot 1 0 j. Toe(s) 1 0 k. Other; specify: Did your father ever suffer a bone fracture after age 20? (Refer to your biological father) (If No go to question #12) 98 = Don t know (If Don t know go to question #12) 3
5 11a. If Yes : Please indicate each bone where your father suffered a fracture and his age at the time. (If any bones were broken more than once, indicate the age at the time of the first fracture) (Specify left or right side inside the appropriate box) (If you don t know what side, write 98 in the Left and Right boxes) (If you don t know the age, write 98 in the Age box) Bone Yes No Left Right Age a. Hip 1 0 b. Humerus (arm bone above the elbow) 1 0 Cubitus or radius (forearm bones below the elbow), c. 1 0 or wrist d. Hand 1 0 e. Collarbone 1 0 f. Spinal column 1 0 g. Pelvis 1 0 h. Leg 1 0 i. Foot 1 0 j. Toe(s) 1 0 k. Other; specify: How many biological sisters do you have? (Make sure to include any deceased sisters. DO NOT include step-sisters, adopted sisters, or any sisters who are not biologically related to you) sisters (If zero, write 0 and go to question #13) 12a. Did any of your biological sisters ever break or fracture her hip after age 20? 12b. Did any of your biological sisters ever break or fracture her wrist or forearm after age 20? 13. How many biological brothers do you have? (Make sure to include any deceased brothers. DO NOT include step-brothers, adopted brothers, or any brothers who are not biologically related to you) brothers (If zero, write 0 and go to question #14) 13a. Did any of your biological brothers ever break or fracture his hip after age 20? 4
6 13b. Did any of your biological brothers ever break or fracture his wrist or forearm after age 20? Instructions: The following questions refer to your weight and size / height, and any prescription medications that you may have taken to treat certain medical conditions. 14. What was your average weight at age 25? (Women: DO NOT include your weight during pregnancy. If you do not remember, give your best estimate) lbs. 15. What was your size / height, without shoes, at age 25? (If you do not remember, give your best estimate) feet inches 16. What was your average weight at age 50? (Women: DO NOT include your weight during pregnancy. If you do not remember, give your best estimate) lbs. (If the subject s current age is less than 50, write 999 ) 17. Are you currently taking any of the following prescription medications to treat osteoporosis? Medication Name No Yes Length of Use a. Calcitonin by injection (Calcinar, Miacalcin) <1yr yrs 3. >5yrs b. Nasal Calcitonin (Miacalcin) <1yr yrs 3. >5yrs c. Fosamax (Alendronate) <1yr yrs 3. >5yrs d. Didronal (Etidronate) <1yr yrs 3. >5yrs e. Calcium + Vitamin D <1yr yrs 3. >5yrs f. Calcium <1yr yrs 3. >5yrs g. Vitamin D <1yr yrs 3. >5yrs h. Cod liver oil <1yr yrs 3. >5yrs i. Other: <1yr yrs 3. >5yrs 5
7 WOMEN only 18. Are you currently taking any of the following estrogen preparations, either orally or via a patch? (Do not include vaginal creams) Medication Name No Yes Length of Use a. Premarin <1yr yrs 3. >5yrs b. Prempro <1yr yrs 3. >5yrs c. Premphase <1yr yrs 3. >5yrs d. Estratab <1yr yrs 3. >5yrs e. Menest <1yr yrs 3. >5yrs f. Estrace <1yr yrs 3. >5yrs g. Ogen, Ortho-Est <1yr yrs 3. >5yrs h. Estraderm, Vivelle <1yr yrs 3. >5yrs i. Evista <1yr yrs 3. >5yrs j. Other; specify: <1yr yrs 3. >5yrs Instructions: The following questions are in regards to restless leg syndrome and sleep patterns. 19a. Do you have unpleasant sensations in your legs, such as leg tingling, electric current or burning in your legs, combined with a feeling of urgency or the need to move your legs? (if No, go to question #20) 19b. Do these sensations/symptoms occur only when you are resting? (if No, go to question #20) 19c. Do these sensations/symptoms ammeliorate if you move? (if No, go to question #20) 1 = Si 19d. Are these sensations/symptoms worse at night when compared to during the morning? (if No, go to question #20) 1 = Si 19e. How frequently do these sensations/symptoms take place? 1 = Less than once per month / Once per month 2 = 2-4 times per month 6
8 3 = 2-3 times per week 4 = 4-5 times per week 5 = 6-7 times per week 20a. Please indicate the total number of hours that you really sleep, typically, during a 24 hour period: 1 = 5 hours or less 2 = 6 hours 3 = 7 hours 4 = 8 hours 5 = 9 hours 6 = 10 hours or more 20b. What time do you usually go to bed? : a.m. / p.m. 20c. The following questions explore your sleeping patterns: How frequently do you have difficulty falling asleep? How frequently do you have trouble with waking up at night? How frequently do you have trouble with waking up too early in the morning and not being able to fall asleep again? How frequently do you feel so sleepy during the day or night that you need to take a nap? Most of the Time Sometimes Almost Never or Never How frequently do you feel truly tired when you wake up in the morning? d. Do you snore? (if you have a partner or share your bedroom with another person, please ask him/her) 1 = Every night 2 = Most nights 3 = A few nights a week 4 = Occasionally 5 = Almost never 20e. Did you respond to the previous question about snoring alter asking your partner or bedroom-mate? 1 = Si 7
9 Thank you for your participation! 8
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