iii. early teen interview other okay, great. so, let’s start the ... · early teen interview...
TRANSCRIPT
Project Viva (IN12)
03/10/2014
1
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)?
1 YES
2 NO
i. IF YES: How old were you when you were first diagnosed:
____ ____ years or
In what year?
____ ____ ____ ____
9 DK
b) Asthma? 1 YES
2 NO
i. IF YES: How old were you when you were first diagnosed:
____ ____ years or
In what year?
____ ____ ____ ____
9 DK
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.)
1 YES
2 NO
c) Hay fever, seasonal allergies or allergic rhinitis?
1 YES
2 NO
i. IF YES: How old were you when you were first diagnosed:
____ ____ years or
In what year?
____ ____ ____ ____
9 DK
A. IF YES: Have you had any symptoms in the past 12 months?
1 YES
2 NO
I. STUDY NUMBER___________________
II. EVENT ____________
II. TODAY’S DATE __ __ / __ __ / __ __
III. RA INITIALS ____ ____ ____
IV. SITE 1 KENMORE 2 HOME 9 OTHER
3 OTHER
3 OTHER
Project Viva (IN12)
03/10/2014
2
A1. Has a health professional, such as a doctor, physician assistant, or nurse practitioner, ever told you that you had…
d) Eczema (Atopic dermatitis)?
1 YES
2 NO
i. IF YES: How old were you when you were first diagnosed:
____ ____ years or
In what year?
____ ____ ____ ____
9 DK
A. IF YES: Have you had any symptoms in the past 12 months?
1 YES
2 NO
e) High blood pressure (hypertension) during a time when you were not pregnant?
1 YES
2 NO
i. IF YES: How old were you when you were first diagnosed:
____ ____ years or
In what year?
____ ____ ____ ____
9 DK
f) High blood pressure (hypertension) during a time when you were pregnant?
1 YES
2 NO
i. IF YES: How old were you when you were first diagnosed:
____ ____ years or
In what year?
____ ____ ____ ____
9 DK
g) A heart attack, heart bypass surgery, or angioplasty (heart balloon procedure)?
1 YES
2 NO
i. IF YES: How old were you when you were first diagnosed:
____ ____ years or
In what year?
____ ____ ____ ____
9 DK
h) A stroke?
(includes Transient Ischemic Attack, or TIA)
1 YES
2 NO
i. IF YES: How old were you when you were first diagnosed:
____ ____ years or
In what year?
____ ____ ____ ____
9 DK
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)
1 YES
2 NO
i. IF YES: How old were you when you were first diagnosed:
____ ____ years or
In what year?
____ ____ ____ ____
9 DK
Project Viva (IN12)
03/10/2014
3
A1. Has a health professional, such as a doctor, physician assistant, or nurse practitioner, ever told you that you had…
j) High cholesterol? 1 YES
2 NO
i. IF YES: How old were you when you were first diagnosed:
____ ____ years or
In what year?
____ ____ ____ ____
9 DK
k) Diabetes mellitus (also known as just diabetes)? 1 YES
2 NO
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 diagnosed:
____ ____ years or
In what year?
____ ____ ____ ____
9 DK
l) Gestational Diabetes (diabetes first diagnosed when you were pregnant)?
1 YES
2 NO
i. IF YES: How old were you when you were first diagnosed:
____ ____ years or
In what year?
____ ____ ____ ____
9 DK
Project Viva (IN12)
03/10/2014
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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?
1 YES
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 by a health professional, such as a doctor, physician assistant, or nurse practitioner?
a) Thyroid disease?
1 YES
2 NO
9 DK
b) Asthma? 1 YES
2 NO
9 DK
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.)
1 YES
2 NO
9 DK
c) Hay fever, seasonal allergies or allergic rhinitis?
1 YES
2 NO
9 DK
i. IF YES: Has he had any symptoms in the past 12 months?
1 YES
2 NO
9 DK
d) Eczema (Atopic dermatitis)?
1 YES
2 NO
9 DK
i. IF YES: Has he had any symptoms in the past 12 months?
1 YES
2 NO
9 DK
Project Viva (IN12)
03/10/2014
5
B1. Has the biological father of your child ever had any of the following conditions diagnosed by a health professional, such as a doctor, physician assistant, or nurse practitioner?
e) High blood pressure (hypertension)?
1 YES
2 NO
9 DK
i. IF YES, At what age did he first have it?
1 Younger than 60
2 60 or Older
9 DK
f) Heart attack, heart bypass surgery, or angioplasty (heart balloon procedure)?
1 YES
2 NO
9 DK
i. IF YES, At what age did he first have it?
1 Younger than 60
2 60 or Older
9 DK
g) Stroke? 1 YES
2 NO
9 DK
i. IF YES, At what age did he first have it?
1 Younger than 60
2 60 or Older
9 DK
h) Any other cardiovascular disease [like heart failure or peripheral vascular disease (blocked arteries in neck or legs)]?
1 YES
2 NO
9 DK
i. IF YES, At what age did he first have it?
1 Younger than 60
2 60 or Older
9 DK
i) High cholesterol? 1 YES
2 NO
9 DK
j) Diabetes mellitus (also known as just diabetes)?
1 YES
2 NO
9 DK
i. IF YES, What type of diabetes?
1 Type I, juvenile-onset
2 Type II, adult-onset
9 DK
Project Viva (IN12)
03/10/2014
6
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? 1 YES
2 NO
b) An ear infection (otitis media)?
1 YES
2 NO
i. IF YES: In the past 12 months, how many ear infections has your child had?
___ ___
ear infections
c) Pneumonia? 1 YES
2 NO
i. IF YES: In the past 12 months, was your child ever kept in the hospital overnight for pneumonia?
1 YES
2 NO
d) Bronchitis? 1 YES
2 NO
i. IF YES: In the past 12 months, was your child ever kept in the hospital overnight for bronchitis?
1 YES
2 NO
ii. IF YES: In the past month, have you been told by a health care professional that your child had Bronchitis?
1 YES
2 NO
iii. In the past 2 weeks, have you been told by a health care professional that your child had Bronchitis?
1 YES
2 NO
e) Any other respiratory infection?
1 YES
2 NO
i. IF YES: In the past 12 months, was your child ever kept in the hospital overnight for any other respiratory infection?
1 YES
2 NO
ii. IF YES: In the past month, have you been told by a health care professional that your child had any other respiratory infection?
1 YES
2 NO
iii. In the past 2 weeks, have you been told by a health care professional that your child had any other respiratory infection?
1 YES
2 NO
Project Viva (IN12)
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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?
1 YES
2 NO
C3. In the past week, what medications has your child taken? Please include over-the-counter medications and herbal supplements as well as prescriptions.
Name of Medication:
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
Project Viva (IN12)
03/10/2014
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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 1 YES
2 NO
i. IF YES: ___ ___ / ___ ___ ___ ___
ii. What type of congenital heart disease?
_________________________
b. Inflammatory bowel disease (Crohn disease or ulcerative colitis)
1 YES
2 NO
i. IF YES: ___ ___ / ___ ___ ___ ___
c. Spina bifida (meningomyelocele)
1 YES
2 NO
i. IF YES: ___ ___ / ___ ___ ___ ___
d. Diabetes mellitus (also known as just diabetes)
1 YES
2 NO
i. IF YES: ___ ___ / ___ ___ ___ ___
ii. What type of diabetes?
1 Type I, juvenile-onset 2 Type II, adult on-set
e. Cancer (including leukemia) 1 YES
2 NO
i. IF YES: ___ ___ / ___ ___ ___ ___
ii. What type of cancer?
_________________________
iii. Is it in remission? 1 YES 2 NO
f. Juvenile rheumatoid arthritis
1 YES
2 NO
i. IF YES: ___ ___ / ___ ___ ___ ___
ii. What type of juvenile rheumatoid arthritis?
_________________________
iii. Is it persistent? 1 YES
2 NO
Project Viva (IN12)
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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]).
1 YES
2 NO
i. IF YES: ___ ___ / ___ ___ ___ ___
ii. What type of autism spectrum disorder?
_________________________
h. Celiac Disease (gluten-sensitive enteropathy)
1 YES
2 NO
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?
1 YES
2 NO
i. IF YES: ___ ___ / ___ ___ ___ ___
ii. What type of other medical condition?
_________________________
iii. Is this a persisting condition?
1 YES 2 NO
Project Viva (IN12)
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10
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.
Does
your c
hild e
at this
food cu
rren
tly?
Rea
ctio
ns
No re
actio
n
Hiv
es o
n one
body par
t
Hiv
es o
n mor
e th
an o
ne
body par
t
Nau
sea/
vomiti
ng
Dia
rrhea
Whee
zing
Trouble
bre
athin
g
Itch
y thro
at o
r mouth
Cou
ghing
Sneezz
ing,
runny o
r
stuff
y nose
Loss o
f consc
iousn
ess
Eczem
a or w
orse
ning
ecze
ma
Oth
er, p
leas
e sp
ecify
a) Egg 1 Yes
No
A B C D E F G H I J K LM Please specify:
_________________
b) Milk 1 Yes
No
A B C D E F G H I J K LM Please specify:
_________________
c) Peanut 1 Yes
No
A B C D E F G H I J K LM Please specify:
_________________
d) Other nuts 1 Yes
No
A B C D E F G H I J K LM Please specify:
_________________
e) Wheat 1 Yes
No
A B C D E F G H I J K LM Please specify:
_________________
f) Soy 1 Yes
No
A B C D E F G H I J K LM Please specify:
_________________
g) Shellfish 1 Yes
No
A B C D E F G H I J K LM Please specify:
_________________
h) Other, please
specify:
____________
________
1 Yes
No
A B C D E F G H I J K LM Please specify:
_________________
i) Other, please
specify:
____________
________
1 Yes
No
A B C D E F G H I J K LM Please specify:
_________________
Please mark the boxes below indicating which
food(s) your child is allergic to, then mark the
reactions to the right
Project Viva (IN12)
03/10/2014
11
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 by a health professional, such as a doctor, physician assistant, or nurse practitioner?
a) High blood pressure (hypertension)?
1 YES
2 NO
9 DK
i) IF YES, your biological mother?
1 YES
2 NO
9 DK
A. IF YES, at what age did she first have it?
1 Younger than 60
2 60 or Older
9 DK
ii) IF YES, your biological
father?
1 YES
2 NO
9 DK
A. IF YES, at what age did he first have it?
1 Younger than 60
2 60 or Older
9 DK
iii) IF YES, your biological
siblings?
1 YES
2 NO
9 DK
A. IF YES, at what age did he/she first have it?
1 Younger than 60
2 60 or Older
9 DK
b) Heart attack, heart bypass surgery, or angioplasty (heart balloon procedure)?
1 YES
2 NO
9 DK
i) IF YES, your biological
mother?
1 YES
2 NO
9 DK
A. IF YES, at what age did she first have it?
1 Younger than 60
2 60 or Older
9 DK
ii) IF YES, your biological
father?
1 YES
2 NO
9 DK
A. IF YES, at what age did he first have it?
1 Younger than 60
2 60 or Older
9 DK
iii) IF YES, your biological
siblings?
1 YES
2 NO
9 DK
A. IF YES, at what age did he/she first have it?
1 Younger than 60
2 60 or Older
9 DK
Project Viva (IN12)
03/10/2014
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D1. Has anyone in your immediate family ever had any of the following conditions diagnosed by a health professional, such as a doctor, physician assistant, or nurse practitioner?
c) A stroke?
1 YES
2 NO
9 DK
i) IF YES, your biological mother?
1 YES
2 NO
9 DK
A. IF YES, at what age did she first have it?
1 Younger than 60
2 60 or Older
9 DK
ii) IF YES, your biological
father?
1 YES
2 NO
9 DK
A. IF YES, at what age did he first have it?
1 Younger than 60
2 60 or Older
9 DK
iii) IF YES, your biological siblings?
1 YES
2 NO
9 DK
A. IF YES, at what age did he/she first have it?
1 Younger than 60
2 60 or Older
9 DK
d) Any other cardiovascular disease [like heart failure or peripheral vascular disease, (blocked arteries in neck or legs)]?
1 YES
2 NO
9 DK
i) IF YES, your biological mother?
1 YES
2 NO
9 DK
A. IF YES, At what age did she first have it?
1 Younger than 60
2 60 or Older
9 DK
ii) IF YES, your father?
1 YES
2 NO
9 DK
A. IF YES, At what age did he first have it?
1 Younger than 60
2 60 or Older
9 DK
iii) IF YES, your siblings?
1 YES
2 NO
9 DK
A. IF YES, At what age did he/she first have it?
1 Younger than 60
2 60 or Older
9 DK
Project Viva (IN12)
03/10/2014
13
D1. Has anyone in your immediate family ever had any of the following conditions diagnosed by a health professional, such as a doctor, physician assistant, or nurse practitioner?
e) High cholesterol?
1 YES
2 NO
9 DK
i) IF YES, your biological mother?
1 YES
2 NO
9 DK
ii) IF YES, your biological father?
1 YES
2 NO
9 DK
iii) IF YES, your biological siblings?
1 YES
2 NO
9 DK f) Diabetes
mellitus (also known as just diabetes)?
1 YES
2 NO
9 DK
i) IF YES, Your biological mother?
1 YES
2 NO
9 DK
A. IF YES, What type of diabetes?
1 Type I, juvenile-onset
2 Type II, adult-onset
3 Gestational
9 DK
ii) IF YES, your biological father?
1 YES
2 NO
9 DK
A. IF YES, What type of diabetes?
1 Type I, juvenile-onset
2 Type II, adult-onset
9 DK
iii) IF YES, your biological siblings?
1 YES
2 NO
9 DK
A. IF YES, What type of diabetes?
1 Type I, juvenile-onset
2 Type II, adult-onset
3 Gestational
9 DK
h) Thyroid disease?
1 YES
2 NO
9 DK
i) IF YES, Your biological mother?
1 YES
2 NO
9 DK
ii) IF YES, your biological father?
1 YES
2 NO
9 DK
iii) IF YES, your biological siblings?
1 YES
2 NO
9 DK
Project Viva (IN12)
03/10/2014
14
D1. Has anyone in your immediate family ever had any of the following conditions diagnosed by a health professional, such as a doctor, physician assistant, or nurse practitioner?
i) Asthma? 1 YES
2 NO
9 DK
i) IF YES, Your biological mother?
1 YES
2 NO
9 DK
ii) IF YES, your biological father?
1 YES
2 NO
9 DK
iii) IF YES, your biological siblings?
1 YES
2 NO
9 DK
j) Hay fever, seasonal allergies or allergic rhinitis?
1 YES
2 NO
9 DK
i) IF YES, Your biological mother?
1 YES
2 NO
9 DK
ii) IF YES, your biological father?
1 YES
2 NO
9 DK
iii) IF YES, your biological siblings?
1 YES
2 NO
9 DK
k) Eczema (Atopic dermatitis)?
1 YES
2 NO
9 DK
i) IF YES, Your biological mother?
1 YES
2 NO
9 DK
ii) IF YES, your biological father?
1 YES
2 NO
9 DK
iii) IF YES, your biological siblings?
1 YES
2 NO
9 DK
Project Viva (IN12)
03/10/2014
15
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 by a health professional, such as a doctor, physician assistant, or nurse practitioner?
a) High blood pressure (hypertension)?
1 YES
2 NO
9 DK
i) IF YES, his biological
mother?
1 YES
2 NO
9 DK
A. IF YES, at what age did she first have it?
1 Younger than 60
2 60 or Older
9 DK
ii) IF YES, his biological father?
1 YES
2 NO
9 DK
A. IF YES, at what age did he first have it?
1 Younger than 60
2 60 or Older
9 DK
iii) IF YES, his biological
siblings?
1 YES
2 NO
9 DK
A. IF YES, at what age did he/she first have it??
1 Younger than 60
2 60 or Older
9 DK
b) Heart attack, heart bypass surgery, or angioplasty (heart balloon procedure)?
1 YES
2 NO
9 DK
i) IF YES, His biological mother?
1 YES
2 NO
9 DK
A. IF YES, at what age did she first have it?
1 Younger than 60
2 60 or Older
9 DK
ii) IF YES, his biological
father?
1 YES
2 NO
9 DK
A. IF YES, at what age did he first have it?
1 Younger than 60
2 60 or Older
9 DK
iii) IF YES, his biological siblings?
1 YES
2 NO
9 DK
A. IF YES, at what age did he/she first have it??
1 Younger than 60
2 60 or Older
9 DK
Project Viva (IN12)
03/10/2014
16
E1. Has any member of the father’s family ever had any of the following conditions diagnosed by a health professional, such as a doctor, physician assistant, or nurse practitioner?
c) Stroke? 1 YES
2 NO
9 DK
i) IF YES, his biological mother?
1 YES
2 NO
9 DK
A. IF YES, at what age did she first have it?
1 Younger than 60
2 60 or Older
9 DK
ii) IF YES, his biological father?
1 YES
2 NO
9 DK
A. IF YES, at what age did he first have it?
1 Younger than 60
2 60 or Older
9 DK
iii) IF YES, his biological
siblings?
1 YES
2 NO
9 DK
A. IF YES, at what age did he/she first have it?
1 Younger than 60
2 60 or Older
9 DK
d) Any other cardiovascular disease [like heart failure or peripheral vascular
disease (blocked arteries in neck or legs)]?
1 YES
2 NO
9 DK
i) IF YES, his biological mother?
1 YES
2 NO
9 DK
A. IF YES, at what age did she first have it?
1 Younger than 60
2 60 or Older
9 DK
ii) IF YES, his biological father?
1 YES
2 NO
9 DK
A. IF YES, at what age did he first have it?
1 Younger than 60
2 60 or Older
9 DK
iii) IF YES, his biological
siblings?
1 YES
2 NO
9 DK
A. IF YES, at what age did he/she first have it?
1 Younger than 60
2 60 or Older
9 DK
e) High cholesterol?
1 YES
2 NO
9 DK
i) IF YES, his biological mother?
1 YES
2 NO
9 DK ii) IF YES, his biological father?
1 YES
2 NO
9 DK iii) IF YES, his biological
siblings?
1 YES
2 NO
9 DK
Project Viva (IN12)
03/10/2014
17
E1. Has any member of the father’s family ever had any of the following conditions diagnosed by a health professional, such as a doctor, physician assistant, or nurse practitioner?
f) Diabetes mellitus (also known as just diabetes)?
1 YES
2 NO
9 DK
i) IF YES, his biological mother?
1 YES
2 NO
9 DK
a. IF YES, what type of diabetes?
1 Type I, juvenile-onset
2 Type II, adult-onset
3 Gestational
9 DK
ii) IF YES, his biological father?
1 YES
2 NO
9 DK
a. IF YES, what type of diabetes?
1 Type I, juvenile-onset
2 Type II, adult-onset
9 DK
iii) IF YES, his biological siblings?
1 YES
2 NO
9 DK
a. IF YES, what type of diabetes?
1 Type I, juvenile-onset
2 Type II, adult-onset
3 Gestational
9 DK
g) Thyroid disease?
1 YES
2 NO
9 DK
i) IF YES, His biological mother?
1 YES
2 NO
9 DK ii) IF YES, his biological father?
1 YES
2 NO
9 DK
iii) IF YES, his biological siblings?
1 YES
2 NO
9 DK
i) Asthma? 1 YES
2 NO
9 DK
i) IF YES, his biological mother?
1 YES
2 NO
9 DK
ii) IF YES, his biological father?
1 YES
2 NO
9 DK
iii) IF YES, his biological siblings?
1 YES
2 NO
9 DK
Project Viva (IN12)
03/10/2014
18
E1. Has any member of the father’s family ever had any of the following conditions diagnosed by a health professional, such as a doctor, physician assistant, or nurse practitioner?
j) Hay fever, seasonal allergies or allergic rhinitis?
1 YES
2 NO
9 DK
i) IF YES, his biological mother?
1 YES
2 NO
9 DK
ii) IF YES, his biological father?
1 YES
2 NO
9 DK
iii) IF YES, his biological siblings?
1 YES
2 NO
9 DK
k) Eczema (Atopic dermatitis)?
1 YES
2 NO
9 DK
i) IF YES, his biological mother?
1 YES
2 NO
9 DK
ii) IF YES, his biological father?
1 YES
2 NO
9 DK
iii) IF YES, his biological siblings?
1 YES
2 NO
9 DK
STOP TIME ___ ___ : ___ ___ (00:00-23:59)