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Project Viva (IN7Y)
01/02/2008 1
AGE 7 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.
VI. TIME START ___ ___ : ___ ___ (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. How old were you when you were first diagnosed:
____ ____ years or
In what year?
____ ____ ____ ____
�9 DK
b) Asthma �1 YES
�2 NO
i. 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. 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 _______________________________
III. TODAY’S DATE __ __ / __ __ / __ __
IV. RA INITIALS ____ ____ ____
V. SITE �1 KENMORE �2 HOME �9 OTHER
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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. 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. 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. 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. How old were you when you were first diagnosed:
____ ____ years or
In what year?
____ ____ ____ ____
�9 DK
h) A stroke?
(includes TIA)
�1 YES
�2 NO
i. 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. How old were you when you were first diagnosed:
____ ____ years or
In what year?
____ ____ ____ ____
�9 DK
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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. How old were you when you were first diagnosed:
____ ____ years or
In what year?
____ ____ ____ ____
�9 DK
k) Type I, Juvenile-onset Diabetes?
�1 YES
�2 NO
i. How old were you when you were first diagnosed:
____ ____ years or
In what year?
____ ____ ____ ____
�9 DK
l) Type II, Adult-onset Diabetes? �1 YES
�2 NO
i. How old were you when you were first diagnosed:
____ ____ years or
In what year?
____ ____ ____ ____
�9 DK
m) Gestational Diabetes (diabetes first diagnosed when you were pregnant)?
�1 YES
�2 NO
i. How old were you when you were first diagnosed:
____ ____ years or
In what year?
____ ____ ____ ____
�9 DK
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A2. In the past week, what medications have you taken? Please include over-the-counter medications and herbal supplements as well as prescriptions.
A3. Since your 7-year-old child was born, have you become pregnant?
�1 YES
�2 NO (SKIP TO B1)
A3a) Are you currently pregnant?
�1 YES
�2 NO
Name of Medication:
a) ______________________________________________________________________________
b) ______________________________________________________________________________
c) ______________________________________________________________________________
d) ______________________________________________________________________________
e) ______________________________________________________________________________
f) ______________________________________________________________________________
g) ______________________________________________________________________________
h) ______________________________________________________________________________
i) ______________________________________________________________________________
j) ______________________________________________________________________________
i) What is your due date?
___ ___ / ___ ___ / ___ ___ ___ ___ EDC or M M D D Y Y Y Y ii) When was the first day of your last menstrual period?
___ ___ / ___ ___ / ___ ___ ___ ___ LMP or M M D D Y Y Y Y iii) How many weeks pregnant are you now? ____ ____ WEEKS
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A3b) Please tell me about your pregnancies after the birth of your 7-year-old child, starting with your most recent pregnancy. (But not including your current pregnancy).
In what month and year did your pregnancy end?
What was the outcome of your pregnancy?
i. __ __ / __ __ __ __
�1 Live birth ↓ 1. Did you breastfeed your baby?
�1 YES → a. For how long?
___ ___ �1 DAYS �2 WKS �3 MNTHS
� Still breastfeeding
�2 NO
�2 Stillbirth �3 Miscarriage or abortion
ii __ __ / __ __ __ __
�1 Live birth ↓ 1. Did you breastfeed your baby?
�1 YES → a. For how long?
___ ___ �1 DAYS �2 WKS �3 MNTHS
� Still breastfeeding
�2 NO
�2 Stillbirth �3 Miscarriage or abortion
iii.
__ __ / __ __ __ __
�1 Live birth ↓ 1. Did you breastfeed your baby?
�1 YES → a. For how long?
___ ___ �1 DAYS �2 WKS �3 MNTHS
� Still breastfeeding
�2 NO
�2 Stillbirth �3 Miscarriage or abortion
iv.
__ __ / __ __ __ __
�1 Live birth ↓ 1. Did you breastfeed your baby?
�1 YES → a. For how long?
___ ___ �1 DAYS �2 WKS �3 MNTHS
� Still breastfeeding
�2 NO
�2 Stillbirth �3 Miscarriage or abortion
v.
__ __ / __ __ __ __
�1 Live birth ↓ 1. Did you breastfeed your baby?
�1 YES → a. For how long?
___ ___ �1 DAYS �2 WKS �3 MNTHS
� Still breastfeeding
�2 NO
�2 Stillbirth �3 Miscarriage or abortion
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SECTION B. PATERNAL MEDICAL HISTORY
Now I’m going to ask you some questions about the medical history of your 7-year-old child’s biological father.
B1. Has the biological father of your 7-year-old 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. IF YES: Has he had any symptoms in the past 12 months?
�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
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
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B1. Has the biological father of your 7-year-old child ever had any of the following conditions diagnosed by a health professional, such as a doctor, physician assistant, or nurse practitioner?
i) High cholesterol? �1 YES
�2 NO
�9 DK
j) Type I, Juvenile-onset Diabetes �1 YES
�2 NO
�9 DK
k) Type II, Adult-onset Diabetes? �1 YES
�2 NO
�9 DK
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. In the past 12 months, how many ear infections has your child had?
___ ___
ear infections
c) Pneumonia? �1 YES
�2 NO
i. 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. In the past 12 months, was your child ever kept in the hospital overnight for bronchitis?
�1 YES
�2 NO
ii. In the past month, have you been told by a health care professional that your child had Bronchitis?
�1 YES
�2 NO
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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. In the past 12 months, was your child ever kept in the hospital overnight for any other respiratory infection?
�1 YES
�2 NO
ii. 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
f) In the past 2 weeks, have you been told by a doctor, physician assistant or nurse practitioner that your child had any other infection?
�1 YES
�2 NO
C2. Have you ever been told by a health care professional, such as a doctor, physician assistant or nurse practitioner, that your child has…
a) Eczema (atopic dermatitis)? �1 YES
�2 NO
b) Hay fever, seasonal allergies or allergic rhinitis (runny nose due to allergies)?
�1 YES
�2 NO
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c) Asthma? �1 YES
�2 NO
d) Wheezing or reactive airways? �1 YES
�2 NO
i. Has your child had wheezing in the past 2 weeks?
�1 YES
�2 NO
C3. In the past 12 months, has your child taken any of the following medications?
a) Albuterol (Proventil, Ventolin) by nebulizer or inhaler
�1 YES
�2 NO
i. Has your child taken this in the past month?
�1 YES
�2 NO
b) Prednisone, Prelone, Orapred, or other steroids by mouth
�1 YES
�2 NO
i. Has your child taken this in the past month?
�1 YES
�2 NO
c) Flovent, Pulmicort, or other inhaled steroids
�1 YES
�2 NO
i. Has your child taken this in the past month?
�1 YES
�2 NO
ii. Has your child taken this in the past 3 days?
�1 YES
�2 NO
d) Cromolyn (Intal) or Nedocromil (Tilade) by nebulizer or inhaler
�1 YES
�2 NO
i. Has your child taken this in the past month?
�1 YES
�2 NO
e) Singulair (Montelukast) �1 YES
�2 NO
i. Has your child taken this in the past month?
�1 YES
�2 NO
ii. Has your child taken this in the past 24 hours?
�1 YES
�2 NO
RA NOTE: IF NO TO BOTH OF THESE QUESTIONS, SKIP TO C6 ON PAGE 12. OTHERWISE, (IF YES TO EITHER C OR D) PLEASE CONTINUE TO C3.
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f) Theophylline �1 YES
�2 NO
i. Has your child taken this in the past 24 hours?
�1 YES
�2 NO
g) Salmeterol (Serevent, Advair), Formoterol (Foradil, Symbicort) or other long-acting bronchodilator
�1 YES
�2 NO
i. Has your child taken this in the past 24 hours?
�1 YES
�2 NO
ii. Has your child taken this in the past 12 hours?
�1 YES
�2 NO
h) In the past 12 months, has your child taken any other medications for asthma, wheezing or reactive airways?
�1 YES
�2 NO (SKIP TO
C4)
A) Has your child taken any of these other medications for asthma, wheezing, or reactive airways in the past month?
�1 YES
�2 NO
C4. Do you have a nebulizer at home for your child’s inhaled asthma treatment?
�1 YES
�2 NO
i) What other medication(s) has your child taken? ______________________________________________
1) What other medication(s) has your child taken in the past month? ______________________________________________
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C5. In the past 12 months, how many times has your child been…
Never Once 2-3 times More than 3 times
a) Kept out of (or sent home from) school or childcare for asthma, wheezing, or reactive airways
�1 �2 �3 �4
b) To doctor’s office visits for urgent treatment for asthma, wheezing or reactive airways �1 �2 �3 �4
c) To the emergency room to be treated for asthma, wheezing or reactive airways
�1
�2
�3
�4
d) Kept in the hospital overnight for asthma wheezing or reactive airways,
i) What was the name of the hospital?
________________________________
ii) How old was your child?
____ ____ Years or
iii) In what month and year was the hospital stay?
____ ____ / ____ ____ ____ ____ M M Y Y Y Y
�1
�2
�3
�4
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C6. In the past week, what medications has your child taken? Please include over-the-counter medications and herbal supplements as well as prescriptions.
Now I'm going to ask you some questions about medical conditions that [CHILD] may have.
C7. 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?
a. Congenital heart disease �1 YES
�2 NO
___ ___ / ___ ___ ___ ___
What type of congenital heart disease?
_________________________
b. Other congenital anomalies (e.g. Tuberous sclerosis, Cornelia de Lange’s syndrome, cleft lip or palate).
�1 YES
�2 NO
___ ___ / ___ ___ ___ ___
What type of congenital anomaly?
_________________________
c. Chromosomal anomalies (e.g. Down Syndrome, Turner Syndrome, Klinefelter Syndrome).
�1 YES
�2 NO
___ ___ / ___ ___ ___ ___
What type of chromosomal anomaly?
_________________________
Name of Medication:
a) ________________________________________________________________________
b) ________________________________________________________________________
c) ________________________________________________________________________
d) ________________________________________________________________________
e) ________________________________________________________________________
f) ________________________________________________________________________
g) ________________________________________________________________________
h) ________________________________________________________________________
i) ________________________________________________________________________
j) ________________________________________________________________________
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C7. 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?
d. Cystic fibrosis �1 YES
�2 NO
___ ___ / ___ ___ ___ ___
e. Cerebral palsy �1 YES
�2 NO
___ ___ / ___ ___ ___ ___
f. Inflammatory bowel disease (Crohn disease or ulcerative colitis)
�1 YES
�2 NO
___ ___ / ___ ___ ___ ___
g. Spina bifida (meningomyelocele)
�1 YES
�2 NO
___ ___ / ___ ___ ___ ___
h. Diabetes mellitus (also known as just diabetes)
�1 YES
�2 NO
___ ___ / ___ ___ ___ ___
i. Cancer (including leukemia) �1 YES
�2 NO
___ ___ / ___ ___ ___ ___
What type of cancer?
_________________________
Is it in remission?
�1 YES
�2 NO
j. Juvenile rheumatoid arthritis �1 YES
�2 NO
___ ___ / ___ ___ ___ ___
What type of juvenile rheumatoid arthritis?
_________________________
Is it persistent?
�1 YES
�2 NO
Project Viva (IN7Y) 01/02/2008
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_________________________
j. Juvenile rheumatoid arthritis �1 YES
�2 NO
___ ___ / ___ ___ ___ ___
What type of juvenile rheumatoid arthritis?
_________________________
Is it persistent?
�1 YES
�2 NO
Project Viva (IN7Y) 01/02/2008
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k. Autism or autism spectrum disorder (e.g. Asperger syndrome, pervasive developmental delay [PDD]).
�1 YES
�2 NO
___ ___ / ___ ___ ___ ___
What type of autism spectrum disorder?
_________________________
l. Celiac Disease (gluten-sensitive enteropathy)
�1 YES
�2 NO
___ ___ / ___ ___ ___ ___
m. 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
___ ___ / ___ ___ ___ ___
What type of other medical condition?
_________________________
Is this a persisting condition?
�1 YES
�2 NO
C8. Do you consider your child to be:
�1 Right-handed
�2 Mostly right-handed
�3 Ambidextrous (equally left- and right-handed)
�4 Mostly left-handed
�5 Left-handed
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Project Viva (IN7Y) 01/02/2008
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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) Your biological mother?
�1 YES
�2 NO
�9 DK
A. At what age did she first have it?
�1 Younger than 60
�2 60 or Older
�9 DK
ii) Your biological father?
�1 YES
�2 NO
�9 DK
A. At what age did he first have it?
�1 Younger than 60
�2 60 or Older
�9 DK
iii) Your biological siblings?
�1 YES
�2 NO
�9 DK
A. 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) Your biological mother?
�1 YES
�2 NO
�9 DK
A. At what age did she first have it?
�1 Younger than 60
�2 60 or Older
�9 DK
ii) Your biological father?
�1 YES
�2 NO
�9 DK
A. At what age did he first have it?
�1 Younger than 60
�2 60 or Older
�9 DK
iii) Your biological siblings?
�1 YES
�2 NO
�9 DK
A. At what age did he/she first have it?
�1 Younger than 60
�2 60 or Older
�9 DK
Project Viva (IN7Y) 01/02/2008
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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) Your biological mother?
�1 YES
�2 NO
�9 DK
A. At what age did she first have it?
�1 Younger than 60
�2 60 or Older
�9 DK
ii) Your biological father?
�1 YES
�2 NO
�9 DK
A. At what age did he first have it?
�1 Younger than 60
�2 60 or Older
�9 DK
iii) Your biological siblings?
�1 YES
�2 NO
�9 DK
A. 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) Your biological mother?
�1 YES
�2 NO
�9 DK
A. At what age did she first have it?
�1 Younger than 60
�2 60 or Older
�9 DK
ii) Your biological father?
�1 YES
�2 NO
�9 DK
A. At what age did he first have it?
�1 Younger than 60
�2 60 or Older
�9 DK
iii) Your biological siblings?
�1 YES
�2 NO
�9 DK
A. At what age did he/she first have it?
�1 Younger than 60
�2 60 or Older
�9 DK
Project Viva (IN7Y) 01/02/2008
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e) High cholesterol?
�1 YES
�2 NO
�9 DK
i) Your biological mother?
�1 YES
�2 NO
�9 DK
ii) Your biological father?
�1 YES
�2 NO
�9 DK
iii) Your biological siblings?
�1 YES
�2 NO
�9 DK f) Type I,
Juvenile-onset Diabetes?
�1 YES
�2 NO
�9 DK
i) Your biological mother?
�1 YES
�2 NO
�9 DK
ii) Your biological father?
�1 YES
�2 NO
�9 DK
iii) Your biological siblings?
�1 YES
�2 NO
�9 DK g) Type II, Adult-
onset Diabetes?
�1 YES
�2 NO
�9 DK
i) Your biological mother?
�1 YES
�2 NO
�9 DK
i) Your biological father?
�1 YES
�2 NO
�9 DK
iii) Your biological siblings?
�1 YES
�2 NO
�9 DK
Project Viva (IN7Y) 01/02/2008
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h) Thyroid disease?
�1 YES
�2 NO
�9 DK
i) Your biological mother?
�1 YES
�2 NO
�9 DK
ii) Your biological father?
�1 YES
�2 NO
�9 DK
iii) Your biological siblings?
�1 YES
�2 NO
�9 DK
i) Asthma? �1 YES
�2 NO
�9 DK
i) Your biological mother?
�1 YES
�2 NO
�9 DK
ii) Your biological father?
�1 YES
�2 NO
�9 DK
iii) Your biological siblings?
�1 YES
�2 NO
�9 DK
j) Hay fever, seasonal allergies or allergic rhinitis?
�1 YES
�2 NO
�9 DK
i) Your biological mother?
�1 YES
�2 NO
�9 DK
ii) Your biological father?
�1 YES
�2 NO
�9 DK
iii) Your biological siblings?
�1 YES
�2 NO
�9 DK
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k) Eczema (Atopic dermatitis)?
�1 YES
�2 NO
�9 DK
i) Your biological mother?
�1 YES
�2 NO
�9 DK
ii) Your biological father?
�1 YES
�2 NO
�9 DK
iii) Your biological siblings?
�1 YES
�2 NO
�9 DK
SECTION E. PATERNAL FAMILY MEDICAL HISTORY
The following questions are about the medical history of your 7-year-old 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) His biological mother?
�1 YES
�2 NO
�9 DK
A. At what age did she first have it?
�1 Younger than 60
�2 60 or Older
�9 DK
ii) His biological father?
�1 YES
�2 NO
�9 DK
A. At what age did he first have it?
�1 Younger than 60
�2 60 or Older
�9 DK
iii) His biological siblings?
�1 YES
�2 NO
�9 DK
A. At what age did he/she first have it??
�1 Younger than 60
�2 60 or Older
�9 DK
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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?
b) Heart attack, heart bypass surgery, or angioplasty (heart balloon procedure)?
�1 YES
�2 NO
�9 DK
i) His biological mother?
�1 YES
�2 NO
�9 DK
A. At what age did she first have it?
�1 Younger than 60
�2 60 or Older
�9 DK
ii) His biological father?
�1 YES
�2 NO
�9 DK
A. At what age did he first have it?
�1 Younger than 60
�2 60 or Older
�9 DK
iii) His biological siblings?
�1 YES
�2 NO
�9 DK
A. At what age did he/she first have it??
�1 Younger than 60
�2 60 or Older
�9 DK
c) Stroke? �1 YES
�2 NO
�9 DK
i) His biological mother?
�1 YES
�2 NO
�9 DK
A. At what age did she first have it?
�1 Younger than 60
�2 60 or Older
�9 DK
ii) His biological father?
�1 YES
�2 NO
�9 DK
A. At what age did he first have it?
�1 Younger than 60
�2 60 or Older
�9 DK
iii) His biological siblings?
�1 YES
�2 NO
�9 DK
A. At what age did he/she first have it?
�1 Younger than 60
�2 60 or Older
�9 DK
Project Viva (IN7Y) 01/02/2008
23
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?
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) His biological mother?
�1 YES
�2 NO
�9 DK
A. At what age did she first have it?
�1 Younger than 60
�2 60 or Older
�9 DK
ii) His biological father?
�1 YES
�2 NO
�9 DK
A. At what age did he first have it?
�1 Younger than 60
�2 60 or Older
�9 DK
iii) His biological siblings?
�1 YES
�2 NO
�9 DK
A. 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) His biological mother?
�1 YES
�2 NO
�9 DK
ii) His biological father?
�1 YES
�2 NO
�9 DK
iii) His biological siblings?
�1 YES
�2 NO
�9 DK
f) Type I, Juvenile-onset Diabetes?
�1 YES
�2 NO
�9 DK
i) His biological mother?
�1 YES
�2 NO
�9 DK
ii) His biological father?
�1 YES
�2 NO
�9 DK
iii) His biological siblings?
�1 YES
�2 NO
�9 DK
Project Viva (IN7Y) 01/02/2008
24
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?
g) Type II, Adult-onset diabetes?
�1 YES
�2 NO
�9 DK
i) His biological mother?
�1 YES
�2 NO
�9 DK
ii) His biological father?
�1 YES
�2 NO
�9 DK
iii) His biological siblings?
�1 YES
�2 NO
�9 DK h) Thyroid disease?
�1 YES
�2 NO
�9 DK
i) His biological mother?
�1 YES
�2 NO
�9 DK
ii) His biological father?
�1 YES
�2 NO
�9 DK
iii) His biological siblings?
�1 YES
�2 NO
�9 DK i) Asthma? �1 YES
�2 NO
�9 DK
i) His biological mother?
�1 YES
�2 NO
�9 DK
ii) His biological father?
�1 YES
�2 NO
�9 DK
iii) His biological siblings?
�1 YES
�2 NO
�9 DK
Project Viva (IN7Y) 01/02/2008
25
j) Hay fever, seasonal allergies or allergic rhinitis?
�1 YES
�2 NO
�9 DK
i) His biological mother?
�1 YES
�2 NO
�9 DK
ii) His biological father?
�1 YES
�2 NO
�9 DK
iii) His biological siblings?
�1 YES
�2 NO
�9 DK
k) Eczema (Atopic dermatitis)?
�1 YES
�2 NO
�9 DK
i) His biological mother?
�1 YES
�2 NO
�9 DK
ii) His biological father?
�1 YES
�2 NO
�9 DK
iii) His biological siblings?
�1 YES
�2 NO
�9 DK
TIME STOP ___ ___ : ___ ___ (00:00-23:59)
