Health ABC Questionnaire Measures And Frequency (Revised 9 .
Health ABC Questionnaire Measures and Frequency(Revised 9/24/2013)Y1(19971998)Questionnaire / Interview MeasuresAppetite and eating behavior- Appetite and eating behavior- Resources for & access to food- Condition that interferes with ability to eat- Condition that interferes with appetite- Appetite, desire to eat- Special diet for health- Eats meals alone- Eating pleasure- Enough food to satisfy hungerBereavement and serious life events- Serious accident or illness - close friend orrelative past 12 mo / [# months since lastinterview]- Death of child, grandchild, close friend, relativespouse, past 12 mo / [# months since lastinterview]- Inventory of Complicated Grief (ICG)Cognitive assessment- CLOX 1- Digit Symbol Substitution Test (DSST)- Exit 15- Rapid Estimate of Adult Literacy in Medicine (REALM)- Teng Mini-Mental State Exam (3MS)- Cognitive Vitality Substudy- Buschke Selective Reminder Test (SRT)- Boxes test- Digit copying test- Pattern comparison test- Letter comparison test- Simple reaction time test- Digit digit test- Digit symbol test- Controlled Oral Word Association (COWA)- Telephone Interview for Cognitive Status (TICS)Contact informationDemographics- age- education- ethnicity- genderDental history / oral health- Edentulism, remaining teeth- Denture use, problems- Chewing difficulty, frequency- Oral health, care for teeth- Oral health, pain, disease, problemsDepression- CES-D- Geriatric Depression Scale (GDS)- Depression, treated, ever- Depression (two items from PHQ-9)Falls- Number of falls, past 6 months, injured,hospitalized, fractures- Number of falls, past 12 monthsFamily history- Mother / father still living- Brothers, sisters, cousins, spouses in HABC e 1 of 8XXXXXXXXX
Health ABC Questionnaire Measures and Frequency(Revised 9/24/2013)Y1(19971998)Fatigue / energy level- Weakness, liveliness, sleepinessnumerical scale- Unusual tiredness- Amount of energy, numerical scaleFemale history- Pregnancy, hormones, menopause,hysterectomy, oophorectomy, mammograms- Mammogram, past 12 monthsFinances- Personal family income- Own house / own apartment- Needs met by income- Personal assets- Medical care delayed because of moneyproblems, past 12 months- Medications not taken because of moneyproblems, past 12 months- Money, enough for food by end of month- Money, making ends meet, by end of monthFlu- Flu/cold, bed-bound, fever, past 6 months- Flu shot, past 12 months- Flu symptoms, days in bed, fever,hospitalizationsFood- Alcohol consumption history- Block food frequency (modified)Fractures- Broke or fractured a boneFunctional status (ADLs and IADLs)- Difficulty walking quarter mile- Difficulty walking up 10 steps- Have to use cane or other special equipment- Difficulty getting in and out of bed or chairs- Difficulty bathing or showering- Difficulty dressing- Difficulty standing up from chair withoutusing arms- Difficulty doing heavy work around house- Difficulty shopping for food, preparing meals- Difficulty taking managing money- Difficulty taking medications- Difficulty lifting/carrying something weighing10 pounds- Difficulty stooping, crouching, kneeling- Difficulty pushing, pulling large objects- Difficulty using fingers to grasp- Difficulty raising arms overhead- Receive help shopping, preparing food,light housework, heavy houseworkHealth care utilization- Where participant goes for health care- Saw doctor, nurse practitioner, or otherhealth care provider, since [# months sincelast interview]- Went to emergency room or urgent carecenter, since [# months since last interview]- Nursing home/rehab overnight stay,past 6 months / [# months since lastinterview]- Visiting nurse, home health care aide athome, past 6 months / [# months since 3X13X13XXXXXXXXXXXXXXXXXXXXXXXXXXX13X13X13Page 2 of 8
Health ABC Questionnaire Measures and Frequency(Revised 9/24/2013)Y1(19971998)Health insurance- Supplemental health care coverage (besides- Supplemental health care coverage(besides Medicare) for prescription drugsHealth status / concerns and symptoms- General health- Overall quality of life- Bed, all or most of day, including hospital,past 6 months / [# months since lastinterview]- Activity reduced due to illness or injury,past 6 months / [# months since lastinterview]- Anything about health that causes you concern- Nausea [since # months since last interview]- Constipation [since # months since last interview]- Shortness of breath [since # months since lastinterview]- Difficulty concentrating [since # months since lastinterview]- Difficulty swallowing [since # months since lastinterview]Hearing- Frequent ear infections- Buzzing or ringing in ear, which ear- Ear surgery, which ear- Hearing aid- Hear well enough to carry conversation in crowdedroom- Hearing difficulty that hampers personal/sociallife- Hearing difficulty and distractions that could haveinterfered with cognitive assessments over thetelephone- Job / hobby so noisy had to raise voice toInformed care/decision making/preferences- Informed care- Anyone accompany to health care provider[since # months since last interview][who/relationship]- Provider checked to see if you understoodcondition/care- Amount of information from heallth careprovider- New medicines ordered [opportunity to askquestions, express concerns, getinformation regarding side effects]- New tests ordered [opportunity to askquestions, express concerns, getinformation regarding side effects]- New treatments ordered [opportunity to askquestions, express concerns, getinformation regarding side effects]- You/someone else get health info on 13X13X13X13X13X13X13X13XXXXXXXXXXXXXXXPage 3 of 8
Health ABC Questionnaire Measures and Frequency(Revised 9/24/2013)Y1(19971998)- Decision-making and preferences- Made decisions about medical care[since # months since last interview] [what][family participation]- Medical care - preferences regardingdecision making- Types of care preferences- CPR- Ventilator- Feeding tube- Kidney dialysis- Open-heart surgery- Implanted defibrillator- Biopsy- MRI, ultrasound, angiogram- Talked with doctor regarding life-sustainingtreatments- Had procedures didn't want- Power of attorney designated- Living will- Hospice (heard of; want; talked with family)Medical conditions- Arthritis and joint symptoms- Arthritis (all kinds), diagnosed by doctor, ever- Arthritis, OA dx by doctor, past 12 months,knee/hip take meds?- Arthritis, referred to arthritis specialist or surgeon,treatment of arthritis- Arthritis, rheumatoid signs & symptoms- Arthritis, treatments, attitudes- Hip/knee replacement, attitudes- Stiffness, knee/hip- WOMAC, physical function knee/hip, past 7- Cancer- Cancer, past 3 years, type, treatment- Cancer, past 6 months- Cardiovascular history / heart conditions- Myocardial infarction, angina, CHF,intermittent claudication, TIA, stroke, valvularheart disease, hypertension, ever had,diagnosed by doctor- CABG, angioplasty, carotid endarterectomy,bypass, pacemaker, aortic aneurysm repair,heart valve replacement, ever had- Cardiovascular disease symptoms, chest(Rose)- Heart attack, angina, chest pain,past 6 months- Stroke, ever- Stroke, mini-stroke, TIA, past 6 months- Congestive heart failure, past 6 months- Hypertension, past 12 months- Cardiovascular disease symptoms, legs- Diabetes- Diabetes, ever- Diabetes, past 12 months (time interval varies)- Diabetes, medications- Osteoporosis (also see Fractures)- Osteoporosis, diagnosed by doctor, ever- Fractured bone after age 45(hip, age at fracture)- Vertebral Page 4 of 8XXXXXX8XX8
Health ABC Questionnaire Measures and Frequency(Revised 9/24/2013)Y1(19971998)- Neuropathy- Muscle cramps, legs & feet, past 12 months- how often, where, day/night, when,worse at night- worse/better when walking- Symptoms, urges to move legs, strangefeelings, leg jerks, while sitting, lying down- which bother most, how often,worse at night- better when walking- Numbness, legs or feet- Stabbing, burning, deep aching, legs or feet- Leg pain when walking- standing or sitting, walking uphill or hurry- walking at ordinary pace or level surface- after stop- in calf- hospitalized for problem in legs- Open sore or gangrene, legs or feet- Pulmonary- Pneumo-vax (vaccination), past 12 months- Pneumonia, ever- Pneumonia, past 6 months- Pulmonary conditions, disease(chronic bronchitis, COPD, emphysema)- Pulmonary conditions, disease, asthma- Other- Condition that might be life threatening, ever- Fainted, lost consciousness, past 12 months- Gallstones, dx and/or surgery, ever- Gout, ever- Kidney disease, ever- Parkinson's, ever- Shingles, ever- Thyroid - high or low, ever- Ulcer, stomach/intestines, dx and/orsurgery, ever- Other illness, past [6 months / or since lastinterviewed]- Surgery/hospitalization- Hospitalization overnight, other reason,past 6 months- Same day outpatient surgery ( specificallyblocked artery, gallbladder, cataract,TURP), past 6 mo- Surgery to repair hernia, ever- Surgery to replace hip, ever- Surgery to replace knee, everMedications- Prescription medications, inventory- Non-prescription (OTC) medications, inventory- Prescription medication for Parkinson's- Prescription medications for Alzheimer'sPain- Pain [since # months since last interview]- Ankle- Back- Bodily- Feet, toes, ankles- Hands- Hip- Knee (includes stiffness)- Knee- Neck- ShoulderPhysical activity and exercise- Light work at least 10 times, past 12 months- Heavy chores 10 times, past 12 3X10X10X108XXX8X8X8X8XXXX2XX5X5XXXXXXXXPage 5 of 8XXXX
Health ABC Questionnaire Measures and Frequency(Revised 9/24/2013)- Grocery shopping 10 times, past 12 months- Laundry, do or help at least 10 times,past 12 months- Television watching, hours per week- Reading, hours per week- Sitting upright, hours per day- Sedentary activities (television and reading)- Detailed activity instrument, including physicalactivities- Detailed activity instrument, mostly sedentary- Walking regularly, in a typical week,when age 50- Walk at least 10 times, past 12 months- Walk for exercise, past 2 weeks- Walk, other type, past 2 weeks- Walk up flight stairs at least 10 times, past 12months- Moderate-intensity exercise, past 2 weeks- Moderate-intensity exercise at least 10 times,past 12 months- Weight training, past 2 weeks- Weight training at least 10 times,- Aerobics, past 2 weeks- Aerobics at least 10 times, past 12 months- High-intensity exercise, past 2 weeks- High-intensity exercise at least 10 times,past 12 months- Vigorous exercise at least 1 hour per week,in a typical week, when age 50Psychology- Attitudes about pain & coping mechanisms- Attitudes and traits- Apathy(adapted from Apathy Evaluation Scale)- Anxiety, past week- Personal mastery- Personality assessment- Resilience assessmentReligion- Religion, spirituality, religiousservices/activitiesReliability of participant's responsesSleep- Sleeping, lying down, hours per day- Sleeping, hours per night- Napping 5 or more minutes, times per week- Snoring, past and present, how often- Sleep problems- Difficulty sleeping [since # months since lastinterview]Smoking habits- Currently smoke cigarettes, how many- Cigarettes (at least 100), ever, how long, current- Pipe, ever, how long, current- Cigar, ever, how long, X3XXXXXXXXXXXXXXXXXXXXPage 6 of 8XXXXXX
Health ABC Questionnaire Measures and Frequency(Revised 9/24/2013)Y1(19971998)Social support and network- Type of residence (home, facility, etc.)- Marital status- Household, number who live in- Household, who else lives in- Household, head of- Household, pets- Lubben Social Network Scale- Friends and neighbors get together,typical week, how often- Children or other relatives get together,typical week, how often- Relied on for shopping, cooking, etc. for other- Social contact- Social activities, frequency- Happiness and social support, numeric scaleUrinary / fecal history- Urination frequency, per day- Urinary tract infection, past 12 months, how manytimes- Leak urine, past 12 months, how many times- Leak urine, past 7 days, how many times- Symptoms related to enlarged prostate, past 30days, men only- Fecal incontinence, past 12 monthsVision- Glasses or contact lenses- Eye conditions (cataracts, glaucoma,- Eyesight with glasses/contacts- Eyesight, worry- Difficulty reading with glasses/contacts- Difficulty w/close work/hobbies, withglasses/contacts- Difficulty recognizing people across room,with glasses/contacts- Difficulty going down steps, curbs, in dim lightwith glasses/contacts- Difficulty noticing objects off to the side whilewalking with glasses/contacts- Limited daily activities due to vision- Currently driving, if not stopped due to eyesightWeight- Weight history- Weight, self-reported, XXXXXXXXX- Weight, satisfaction with- Weight, change of 5 or more pounds, gain/loss,trying, past 6 months- Weight, change of 5 or more pounds, gain/lossat any one time, trying, past 12 months- Have scale, how often weigh yourself- Weight, currently trying to loseX- Weight, currently trying to gain- Weight, eat less because of concern aboutweight- Cause of weight XXXXXXXXXXXXXX6XXXXXXXXXXXXXXXXXXX6XX6Page 7 of 8XXX
Health ABC Questionnaire Measures and Frequency(Revised 9/24/2013)Y1(19971998)Work, volunteer, and caregiving activities- Work for pay most of adult life, type position- Work for pay currently, [number of hours,type activity]- Work, volunteer, [number of hours, type] activity- Provide care to child or disabled adult- Work and caregiving 3X2X31Short versionHome only3Cognitive Vitality Substudy4Flu Substudy5Knee/Hip Pain Substudy6Weight Change Substudy7Energy Expenditure Substudy8Healthy Brain Substudy9Quarterly Interviews10Quarterly Interviews - Quarter 1 only11Quarterly Interviews - Quarter 2 only12Quarterly Interviews - Quarters 1 and 3 only13Quarterly Interviews - Quarters 1 through 414Quarterly Interviews - Quarters 2 and 4 only15Memphis only - administered during clinic/home visit (not part of Quarterly inverview)2Page 8 of 8XXXXXXX3XXXXXXXXXXX
- Digit digit test X3 X3 X3 X3 - Digit symbol test X3 X3 X3 X3 - Controlled Oral Word Association (COWA) X12 X12 X12 - Telephone Interview for Cognitive Status (TICS) X14 X14 X14 Contact information X X XX X X X X X X X X X X X X X X X X X X X X X X X12 X12 X12 Demographics - age X - educatio
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