ARIC MRI VITAMIN SURVEY FORM CODE: VIT Version B ID Number: Contact Year: 16 Instructions: Whenever numerical responses are required, enter the number so that the last digit appears in the rightmost box. Enter leading zeroes where necessary to fill all boxes. If a number is entered incorrectly on the paper form, mark through the incorrect entry with an "X". Code the correct entry clearly above the incorrect entry. For "multiple choice" and "yes/no" type questions, check the box next to the most appropriate response. If a box is checked incorrectly, mark through it with an "X" and check the correct response. Ask questions as written. Use vitamin containers for dosage. 1) Do you regularly take multiple vitamins? 0... No Go to Item 2 a) How many pills do you take per week? (00, if less than 1 per week) Ask, Did you bring the container with you? If the answer is Yes, copy the manufacturer s name first and brand name second from the label of the container. If the answer is No, ask, Do you know what brand you usually take and who the manufacturer is? and enter the manufacturer s name first and brand name second. Enter the brand name exactly as it appears on the container. b) Manufacturer: c) Brand Name: d) Enter 4 digit code number from the multiple vitamin code list: ARIC MRI Vitamin Survey, VIT, Vers. B: 08.11/03 Page 1 of 7
Not counting multiple vitamins, do you take any of the following preparations? (Please answer either Yes or No for each preparation) 2) Vitamin A, not including Beta-carotene: 0... No Go to Item 3 a) Do you take it seasonally or most months? 1... Seasonally 2... Monthly b) How many years have you taken it?. (00 if less than 1 year) c) How many pills do you take per week? (00 if less than 1 per week) d) Dose per pill: e) Units: 3) Vitamin C: 0... No Go to Item 4 a) Do you take it seasonally or most months? 1... Seasonally 2... Monthly b) How many years have you taken it?. (00 if less than 1 year) c) How many pills do you take per week? (00 if less than 1 per week d) Dose per pill: e) Units: ARIC MRI Vitamin Survey, VIT, Vers. B: 08.11/03 Page 2 of 7
4) Vitamin B6: 0... No Go to Item 5 5) Vitamin E: 0... No Go to Item 6 b) How many pills do you take per week? (00 if less than 1 per week ARIC MRI Vitamin Survey, VIT, Vers. B: 08.11/03 Page 3 of 7
6) Selenium: 0... No Go to Item 7 7) Iron: b) How many pills do you take per week? (00 if less than 1 per week 0... No Go to Item 8 ARIC MRI Vitamin Survey, VIT, Vers. B: 08.11/03 Page 4 of 7
8) Calcium: 0... No Go to Item 9 9) Beta-carotene: 0... No Go to Item 10 ARIC MRI Vitamin Survey, VIT, Vers. B: 08.11/03 Page 5 of 7
10) Fish oil? (including omega-3 fatty acids, EPA, cod liver oil): 0... No Go to Item 11 b) Do you take it as a pill or teaspoons? 1... Pill 2... Teaspoons c) How many pills or teaspoons do you take per week? (00 if less than 1 per week) 11) Ginkgo Biloba? (this may include supplements with Ginkgo as only one of the main ingredients): 0... No Go to Item 12 ARIC MRI Vitamin Survey, VIT, Vers. B: 08.11/03 Page 6 of 7
12) Are there other supplements that you take on a regular basis? (Please answer either Yes or No for each of the following questions.) Did you take: Yes No a) Folic acid... 1 0 b) Vitamin D.. 1 0 c) B-complex vitamin... 1 0 d) Iodine. 1 0 e) Copper.. 1 0 f) Brewer s Yeast.. 1 0 g) Magnesium... 1 0 13) Date of data collection / / M M D D Y Y Y Y 14) Staff code number of person completing this form:. ARIC MRI Vitamin Survey, VIT, Vers. B: 08.11/03 Page 7 of 7