I. STUDY NUMBER II. EVENT II. TODAY S DATE / / III. RA INITIALS IV. SITE 1 KENMORE 2 HOME 9 OTHER Early Teen Interview Okay, great. So, let s start the interview. I d like to begin by stressing that there are no right or wrong answers. If you can t decide, please just answer as best as you can. O1. START TIME : (00:00-23:59) I have a few questions to update the health information about you and your child s family. First, I d like to ask you some questions about your health. A1. Has a health professional, such as a doctor, physician assistant, or nurse practitioner, ever told you that you had a) Thyroid disease (includes thyroid removal, thyroid medication and goiter)? i. IF YES: How old were you when you were first b) Asthma? c) Hay fever, seasonal allergies or allergic rhinitis? i. IF YES: How old were you when you were first i. IF YES: How old were you when you were first A. IF YES: Have you had any symptoms in the past 12 months? (Symptoms of asthma include cough, wheezing, shortness of breath, chest tightness and phlegm production when you do not have a cold or respiratory infection.) A. IF YES: Have you had any symptoms in the past 12 months? 1
A1. Has a health professional, such as a doctor, physician assistant, or nurse practitioner, ever told you that you had d) Eczema (Atopic dermatitis)? i. IF YES: How old were you when you were first A. IF YES: Have you had any symptoms in the past 12 months? e) High blood pressure (hypertension) during a time when you were not pregnant? f) High blood pressure (hypertension) during a time when you were pregnant? g) A heart attack, heart bypass surgery, or angioplasty (heart balloon procedure)? h) A stroke? (includes Transient Ischemic Attack, or TIA) i) Any other cardiovascular disease [like heart failure or peripheral vascular disease (blocked arteries in neck or legs)]? (includes angina, arrhythmia/abnormal heart rhythm, arteriosclerosis/hardened arteries, enlarged heart, hole in heart, pacemaker, tachycardia/racing heart) i. IF YES: How old were you when you were first i. IF YES: How old were you when you were first i. IF YES: How old were you when you were first i. IF YES: How old were you when you were first i. IF YES: How old were you when you were first 2
A1. Has a health professional, such as a doctor, physician assistant, or nurse practitioner, ever told you that you had j) High cholesterol? k) Diabetes mellitus (also known as just diabetes)? i. IF YES: How old were you when you were first i. IF YES: What type of diabetes? 1 Type I, juvenile-onset 2 Type II, adult-onset ii. How old were you when you were first l) Gestational Diabetes (diabetes first diagnosed when you were pregnant)? i. IF YES: How old were you when you were first 3
A2. How many total pregnancies have you had in your lifetime, including your Project Viva child? A2b) How many of these previous pregnancies were i) Live births? ii) Still births? iii) Miscarriages/terminations? A3) Are you currently pregnant? 2 NO SECTION B. PATERNAL MEDICAL HISTORY Now I m going to ask you some questions about the medical history of your 12-year-old child s biological father. B1. Has the biological father of your child ever had any of the following conditions diagnosed a) Thyroid disease? 1 YES b) Asthma? 1 YES c) Hay fever, seasonal allergies or allergic rhinitis? d) Eczema (Atopic dermatitis)? 1 YES 1 YES i. A. IF YES: Have you had any symptoms in the past 12 months? (Symptoms of asthma include cough, wheezing, shortness of breath, chest tightness and phlegm production when you do not have a cold or respiratory infection.) i. IF YES: Has he had any symptoms in the past 12 months? i. IF YES: Has he had any symptoms in the past 12 months? 1 YES 1 YES 1 YES 4
B1. Has the biological father of your child ever had any of the following conditions diagnosed e) High blood pressure (hypertension)? f) Heart attack, heart bypass surgery, or angioplasty (heart balloon procedure)? 1 YES 1 YES g) Stroke? 1 YES h) Any other cardiovascular disease [like heart failure or peripheral vascular disease (blocked arteries in neck or legs)]? 1 YES i) High cholesterol? 1 YES i. IF YES, At he i. IF YES, At he i. IF YES, At he i. IF YES, At he 1 Younger than 60 2 60 or Older 1 Younger than 60 2 60 or Older 1 Younger than 60 2 60 or Older 1 Younger than 60 2 60 or Older j) Diabetes mellitus (also known as just diabetes)? 1 YES i. IF YES, What type of diabetes? 1 Type I, juvenile-onset 2 Type II, adult-onset 5
SECTION C. CHILD MEDICAL HISTORY Now I d like to ask you some questions about [CHILD S NAME]. C1. In the past 12 months, have you been told by a health care professional, such as a doctor, physician assistant or nurse practitioner, that your child had a) A sinus infection? b) An ear infection (otitis media)? i. IF YES: In the past 12 months, how many ear infections has your child had? ear infections c) Pneumonia? i. IF YES: In the past 12 months, was your child ever kept in the hospital overnight for pneumonia? d) Bronchitis? i. IF YES: In the past 12 months, was your child ever kept in the hospital overnight for bronchitis? ii. IF YES: In the past month, have you been told by a health care professional that your child had Bronchitis? iii. In the past 2 weeks, have you been told by a health care professional that your child had Bronchitis? e) Any other respiratory infection? i. IF YES: In the past 12 months, was your child ever kept in the hospital overnight for any other respiratory infection? ii. IF YES: In the past month, have you been told by a health care professional that your child had any other respiratory infection? iii. In the past 2 weeks, have you been told by a health care professional that your child had any other respiratory infection? 6
C2) In the past 2 weeks, have you been told by a doctor, physician assistant or nurse practitioner that your child had any other infection, such as the flu, strep throat, or a bad cold? C3. In the past week, what medications has your child taken? Please include over-the-counter medications and herbal supplements as well as prescriptions. a) b) c) d) e) f) g) h) i) j) Name of Medication: 7
Now I'm going to ask you some questions about medical conditions that [CHILD] may have. C4. Have you ever been told by a health care professional, such as a doctor, physician assistant or nurse practitioner, that your child has In what month and year was he/she first diagnosed? [RA should encourage participant to approximate date if she does not remember.] a. Congenital heart disease i. IF YES: / ii. What type of congenital heart disease? b. Inflammatory bowel disease (Crohn disease or ulcerative colitis) c. Spina bifida (meningomyelocele) d. Diabetes mellitus (also known as just diabetes) i. IF YES: / i. IF YES: / i. IF YES: / ii. What type of diabetes? 1 Type I, juvenile-onset 2 Type II, adult on-set e. Cancer (including leukemia) i. IF YES: / ii. What type of cancer? iii. Is it in remission? f. Juvenile rheumatoid arthritis i. IF YES: / ii. What type of juvenile rheumatoid arthritis? 8 iii. Is it persistent?
C4. Have you ever been told by a health care professional, such as a doctor, physician assistant or nurse practitioner, that your child has In what month and year was he/she first diagnosed? [RA should encourage participant to approximate date if she does not remember.] g. Autism or autism spectrum disorder (e.g. Asperger syndrome, pervasive developmental delay [PDD]). h. Celiac Disease (glutensensitive enteropathy) i. IF YES: / ii. What type of autism spectrum disorder? i. IF YES: / i. Any other medical condition that affects your child's weight, his/her mental development or his/her ability to participate in sports or other physical activities? i. IF YES: / ii. What type of other medical condition? iii. Is this a persisting condition? 9
C5. Which of the following food(s) is your child allergic to? Specify the reaction(s) that your child had within one hour of eating them. Please check as many reactions for each food as needed. Please mark the boxes below indicating which food(s) your child is allergic to, then mark the reactions to the right Does your child eat this food currently? Reactions No reaction Hives on one body part Nausea/vomiting Hives on more than one body part Diarrhea Wheezing Trouble breathing Itchy throat or mouth Coughing Sneezzing, runny or stuffy nose Loss of consciousness Eczema or worsening eczema Other, please specify a) Egg 1 Yes No A B C D E F G H I J K L M Please specify: b) Milk 1 Yes No A B C D E F G H I J K L M Please specify: c) Peanut 1 Yes No A B C D E F G H I J K L M Please specify: d) Other nuts 1 Yes No A B C D E F G H I J K L M Please specify: e) Wheat 1 Yes No A B C D E F G H I J K L M Please specify: f) Soy 1 Yes No A B C D E F G H I J K L M Please specify: g) Shellfish 1 Yes No A B C D E F G H I J K L M Please specify: h) Other, please specify: i) Other, please specify: 1 1 Yes No A B C D E F G H I J K L M Please specify: Yes No A B C D E F G H I J K L M Please specify: 10
SECTION D. MATERNAL FAMILY MEDICAL HISTORY Now I m going to ask you some questions about the medical history of your immediate family. By your immediate family we mean your biological mother, father, and siblings (a sibling with at least one biological parent with you). D1. Has anyone in your immediate family ever had any of the following conditions diagnosed a) High blood pressure (hypertension)? i) IF YES, your biological mother? she ii) IF YES, your biological father? he iii) IF YES, your biological siblings? he/she first have it? b) Heart attack, heart bypass surgery, or angioplasty (heart balloon procedure)? i) IF YES, your biological mother? ii) IF YES, your biological father? she he iii) IF YES, your biological siblings? he/she first have it? 11
D1. Has anyone in your immediate family ever had any of the following conditions diagnosed c) A stroke? i) IF YES, your biological mother? she ii) IF YES, your biological father? he iii) IF YES, your biological siblings? he/she first have it? d) Any other cardiovascular disease [like heart failure or peripheral vascular disease, (blocked arteries in neck or legs)]? i) IF YES, your biological mother? ii) IF YES, your father? A. IF YES, At she A. IF YES, At he iii) IF YES, your siblings? A. IF YES, At he/she first have it? 12
D1. Has anyone in your immediate family ever had any of the following conditions diagnosed e) High cholesterol? i) IF YES, your biological mother? ii) IF YES, your biological father? iii) IF YES, your biological siblings? f) Diabetes mellitus (also known as just diabetes)? i) IF YES, Your biological mother? A. IF YES, What type of diabetes? 1 Type I, juvenile-onset 2 Type II, adult-onset 3 Gestational ii) IF YES, your biological father? A. IF YES, What type of diabetes? 1 Type I, juvenile-onset 2 Type II, adult-onset iii) IF YES, your biological siblings? A. IF YES, What type of diabetes? 1 Type I, juvenile-onset 2 Type II, adult-onset 3 Gestational h) Thyroid disease? i) IF YES, Your biological mother? ii) IF YES, your biological father? iii) IF YES, your biological siblings? 13
D1. Has anyone in your immediate family ever had any of the following conditions diagnosed i) Asthma? j) Hay fever, seasonal allergies or allergic rhinitis? k) Eczema (Atopic dermatitis)? i) IF YES, Your biological mother? ii) IF YES, your biological father? iii) IF YES, your biological siblings? i) IF YES, Your biological mother? ii) IF YES, your biological father? iii) IF YES, your biological siblings? i) IF YES, Your biological mother? ii) IF YES, your biological father? iii) IF YES, your biological siblings? 14
SECTION E. PATERNAL FAMILY MEDICAL HISTORY The following questions are about the medical history of your child s biological father s immediate family. This includes his biological mother, father, and siblings (a sibling with at least one biological parent in common). [In other words, your child s biological grandparents, aunts and uncles on the father s side of the family.] E1. Has any member of the father s family ever had any of the following conditions diagnosed a) High blood pressure (hypertension)? i) IF YES, his biological mother? she ii) IF YES, his biological father? he iii) IF YES, his biological siblings? he/she first have it?? b) Heart attack, heart bypass surgery, or angioplasty (heart balloon procedure)? i) IF YES, His biological mother? ii) IF YES, his biological father? she he iii) IF YES, his biological siblings? he/she first have it?? 15
E1. Has any member of the father s family ever had any of the following conditions diagnosed c) Stroke? d) Any other cardiovascular disease [like heart failure or peripheral vascular disease (blocked arteries in neck or legs)]? e) High cholesterol? i) IF YES, his biological mother? ii) IF YES, his biological father? iii) IF YES, his biological siblings? i) IF YES, his biological mother? ii) IF YES, his biological father? iii) IF YES, his biological siblings? i) IF YES, his biological mother? ii) IF YES, his biological father? iii) IF YES, his biological siblings? she first have it? he first have it? he/she first have it? she first have it? he first have it? he/she first have it? 16
E1. Has any member of the father s family ever had any of the following conditions diagnosed f) Diabetes mellitus (also known as just diabetes)? i) IF YES, his biological mother? ii) IF YES, his biological father? a. IF YES, what type of diabetes? 1 Type I, juvenile-onset 2 Type II, adult-onset 3 Gestational a. IF YES, what type of diabetes? 1 Type I, juvenile-onset 2 Type II, adult-onset iii) IF YES, his biological siblings? a. IF YES, what type of diabetes? 1 Type I, juvenile-onset 2 Type II, adult-onset 3 Gestational g) Thyroid disease? i) IF YES, His biological mother? ii) IF YES, his biological father? iii) IF YES, his biological siblings? i) Asthma? i) IF YES, his biological mother? ii) IF YES, his biological father? iii) IF YES, his biological siblings? 17
E1. Has any member of the father s family ever had any of the following conditions diagnosed j) Hay fever, seasonal allergies or allergic rhinitis? k) Eczema (Atopic dermatitis)? i) IF YES, his biological mother? ii) IF YES, his biological father? iii) IF YES, his biological siblings? i) IF YES, his biological mother? ii) IF YES, his biological father? iii) IF YES, his biological siblings? STOP TIME : (00:00-23:59) 18