Whs observational 9 (18916 - activated, traditional)

HEALTH STUDY
PLEASE USE A BALL-POINT PEN WHEN COMPLETING THIS QUESTIONNAIRE. IT IMPROVES THE QUALITY OF OUR DATA.
1. Birth date:
Last 6 digits of SSN:
(optional)
2. WITHIN THE PAST 2 YEARS, have you been NEWLY DIAGNOSED with any of the following illnesses or had any of the following
procedures? Please answer NO or YES on each line. IF YES, indicate the date (month/year) of the diagnosis or the procedure.
DIAGNOSIS OR PROCEDURE
IF YES, PROVIDE MO/YR IN BOXES BELOW
a. Acute coronary syndrome/unstable angina If YES, confirmed by: angiogram/cardiac cath? d. Coronary angioplasty (PTCA or PCI) or stent i. Peripheral artery disease (not varicose veins) n. Carotid artery surgery (endarterectomy) t. Other cancer (not including any of the above cancers) HEALTH STUDY
2. (continued) NEWLY DIAGNOSED IN LAST 2 YEARS?
IF YES, PROVIDE DATE (MO/YR) IN BOXES BELOW
RIGHT eye
RIGHT eye
RIGHT eye
ee. Elevated cholesterol (NEW dx by a clinician) kk. Fibrocystic or other benign breast disease 3. In general, would you say your health is:
4. What is your CURRENT TOTAL CHOLESTEROL (mg/dl) if checked within the past 2 years?
5. What is your CURRENT HDL-CHOLESTEROL (mg/dl) if checked within the past 2 years?
6. Do you CURRENTLY smoke cigarettes?
If YES: On average, how many cigarettes/day 7. What is your CURRENT weight?
8. What is your CURRENT blood pressure (mmHg)?
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HEALTH STUDY
9. DURING THE PAST YEAR, what was your approximate
AVERAGE TIME PER WEEK
AVERAGE TIME PER WEEK spent at each of the following
recreational activities?
hours hours
a. Walking or hiking (include walking to work) e. Aerobic exercise / aerobic dance / exercise machines f. Lower intensity exercise / yoga / stretching / toning j. Other: Please specify activity: _____________________ 10. ON AVERAGE, how many FLIGHTS of stairs (not individual steps) do you climb DAILY?
11. What is your usual walking pace outdoors?
AVERAGE TIME PER WEEK
12. DURING THE PAST YEAR, on average, how many
HOURS PER WEEK did you spend:
a. Sitting at work or away from home or while driving b. Sitting at home while watching TV/VCR/DVD c. Other sitting at home (e.g., reading, meal times, at desk) 13. IN THE PAST 2 YEARS, have you used female hormones?
a. IF YES, in the PAST 2 YEARS, for how many months have you used female hormones? b. Are you CURRENTLY using them (within the last month)? c. Mark the type(s) of hormones you have used the longest in the PAST 2 YEARS: d. If you used oral conjugated estrogens (e.g., Premarin) what dose did you usually take? HEALTH STUDY
14. IN THE PAST MONTH, on approximately how many DAYS did you take any
DAYS USED IN THE PAST MONTH
of the following? Please answer on each line.
a. Acetaminophen (e.g., Tylenol, Excedrin P.M.) b. Aspirin (e.g., Bayer, Bufferin, Anacin, Excedrin, Ecotrin) c. Medications containing aspirin (e.g., Alka-Seltzer, Doan's Pills, Fiorinal) d. Other non-steroidal, anti-inflammatory agents (e.g., Motrin, Advil, Aleve) f. SINGLE supplements of omega-3 fatty acids (fish oil) g. SINGLE supplements of calcium (include elemental calcium in Tums) h. SINGLE supplements of vitamin D (in calcium supplements or separately) 15. Are you CURRENTLY taking any of the following medications REGULARLY? Please indicate NO/YES for each.
a. Antihypertensives (e.g., diuretic, calcium channel blockers, angiotensin receptor or b-blockers, ACE inhibitor) b. Statin cholesterol-lowering medications (e.g., Lipitor, Zocor, Mevacor, Pravachol, Crestor, Lescol) c. Other non-statin lipid-lowering medications (e.g., niacin, Lopid, Questran, Colestid, Zetia) d. Fosamax or other bisphosphonates for prevention/treatment of bone loss If YES, for how many years have you been regularly taking this bone loss med.? 16. IN THE PAST YEAR, have you had any of the following?
(Please answer on
(Please answer on
each line)
each line)
symptoms screening
symptoms screening
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NAME: ________________________________________________
STREET: ______________________________________________
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Neighbor

Source: http://whs.bwh.harvard.edu/images/WHS%20observational%209%20(18916%20-%20Activated,%20Traditional).pdf