patient questionnaire - niddk central repository

ACTIVE/ADIPOSE

Patient Questionnaire

Study ID#: D -DJ-1 I I I

Reason if data are not available

1. In the past 12 months, have you lost more than 10 pounds unintentionally? (i.e. not due to dieting or exercise)

2. Do you now smoke cigarettes everyday, some days or not at all?

3. Are you living alone?

r Yes /

r No .:;

r Not sure r Refuse .3 7

I r Everyday 3 r Not at all Yr Refuse

..2 r Some days f r Don't know

/ c Yes ..z r No y r Refuse

4. Are you living in a nursing home, assisted living facility or personal care home? I r Yes ...2. r No 'l r Refuse

Sa. Are you now able to work for pay?

Sb. Are you now working for pay (receiving taxable wages)?

I r Yes full-time .J r No ¥r Don't know

2 r Yes part-time j' r Refuse

/ r Yes full-time .J r No

~ r Yes part-time '1 r Refuse

6. Thinking of all the activity you get in a non-dialysis day, would/ r Less than 30 minutes on most or all days you say that you are moving around, being active for:

.._"'> r About 30 minutes on most or all days

1

.---------------""''"""'1 r More than 30 minutes on most or all days

•

• f' r Refuse

6a. If more than 30 mins,

7. In the past 12 months, have you received :

a. Physical therapy services?

b. Occupational therapy services?

c. Cardiac rehabilitation?

minutes I day or hours/ day

I r Yes ..< s 7

r No r Not sure r Refuse

If YES, for what: I . .. / r Yes ~ r No .3 r Not sure l"r Refuse

..._I ___ ~., If YES, for what:

r Yes /

r No r Not sure o{ 3

r Refuse

7

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ACTIVE/ ADIPOSE


Study ID#: D-CD-1 I I I 7 :2 .3 7

8. In the past 12 months, have you had a fall (a fall is defined as unintentionally coming to rest on the ground, floor or other lower level)?

r Yes r No r Not sure r Refuse

~ I f YES, number of falls in the past year:

I "'2 3 9. In the past 12 months, have you had any fractures (broken bones)?~ Yes r No r Not sure

7 r Refuse

If YES, please describe:

10. Have you had to stay overnight in the hospita l during / r No hospitalizations in the past 12 months

the past 12 months? c.2 r one or more in the past 12 months

if 'one or more ~ please complete hospitalization information below

Hospitalization 1

Month/Year r Approximate number of nights

Hospitalization 2

Month/Year

Approximate number of nights

Hospitalization 3

Month/Year


Hospitalization 4

Reason

Reason

Reason

Month/Year Reason

Approximate number of nights r--Hospitalization 5

Month/Year


Attach separate page(s) for additional Hospitalizations

Reason

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ACTIVE/ADIPOSE


Study ID#: D-CD-1 I I I 11. At the present time. do you need help from another person ...

1. To bathe (wash and dry your whole body)? .2' No / r Yes .3 f'. r Unable to do r Refuse

If you need help or are unable to do, what is the main symptom or condition Jthat causes you to have difficulty or prevents you from doing the activity?

2. To dress (like putting on a shirt or shoes, buttoning, and zipping)? 2 r No I r Yes 3r Unable to do 7 r Refuse

If you need help or are unable to do, what is the main symptom or condition

that causes you to have difficulty or prevents you from doing the activity?

3. To get in and out of a chair? ,.< r No I r Yes 3 r Unable to do / r Refuse



4. To walk around your home or apartment .,,.( r No I r Yes .3 r Unable to do f r Refuse



12. I am oin which activities ou have done in th st two weeks: Select a choice below How often What is the average How many (Yes; No; Not Sure/ have you amount of time that you months per

Refuse) name spent per session? {hours year do you activity in and/or minutes) name the last activitY!

two weeks?

1 r Yes I a. walking for exercise? min .,). r No times hr months '1 r Not sure / Refuse

b. moderately strenuous Ir Yes min household chores? ,< r No times hr months (for example, scrubbing or 't r Not sure / Refuse vacuuming?)

c. mowing the lawn? / r Yes min o< r No times hr months ? r Not sure I Refuse

d. raking the lawn? I r Yes min o{ r No times hr months 7 r Not sure I Refuse

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ACTIVE/ ADIPOSE


Study ID#: D-OJ-1 I I I 12. continued ..

I am going to read a list of activities. Please tell me which activities you have done in the past two weeks:

Select a choice below How often What is the average How many (Yes; No; Not Sure I have you amount of time t hat you months per

Refuse) name spent per session? (hours year do you acti vity in and/or minutes) name the last activir:y?

two weeks?

/ ,-- min e. gardening? r Yes I I hr I ~ r No times months ? r Not sure / Refuse

f. hiking? / r Yes I I hr ! min I .,< r No times months 7 r Not sure / Refuse

g. jogging? / r Yes I I hr I min I ,? r No times months 'l r Not sure / Refuse

h. biking? I r Yes I I hr I min I ..2 r No times months ? r Not sure / Refuse

i. exercise cycle? / r Yes I I hr I min I ~ r No times months 7 r Not sure / Refuse

j. dancing? / r Yes I I hr I min I .2 r No times months 7 r Not sure / Refuse

k. aerobics/aerobic dance? I r Yes I t hr ! min I .,,( r No times months 'l r Not sure / Refuse

I -- ··--··- ·

I. bowling? r Yes l I hr I min l ~ r No times months r r Not sure / Refuse

m. golf? / r Yes I I hr I min I ,,.{ r No times months

7 r Not sure / Refuse

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ACTIVE/ AD I POSE Patient Questionnaire

Study ID#: o -rn-1 I I I 12. continued ...

I am going to read a list of activit ies. Please tell me which activities you have done in the past two weeks:

Select a choice below How often What is the average How many (Yes; No; Not Sure I have you amount of time that you months per

Refuse) name spent per session? (hours year do you activity in and/or minutes) name activit'f/

the last two weeks?

~ n. swimming? r Yes I I hr I min I ~ r No times months ? r Not sure / Refuse

o. calisthenics/general I r Yes I I hr [ min ! exercise? ~ r No times months

'i r Not sure / Refuse

p. singles tennis? / r Yes l I hr I min r .:? r No times months 'i r Not sure / Refuse

q. doubles tennis? I r Yes I I hr r-- min I .,< r No times months 9 r Not sure / Refuse

r. racquetball? / r Yes t I hr l min I ,,,.< r No times months 7 r Not sure / Refuse

13. How many hours of sleep do you usually get at night? (hours) I (XX.X hours)

14. How often do you have trouble falling asleep? / r All or most of the time 3r A little of the time 9'r Refuse v< r Some of the time ,yr None of the time

15. How often do you have t rouble with waking up / r All or most of the time 3 r A little of the time 7~ Refuse during the night? .2 r Some of the time i r None of the time

16. How often do you have trouble with waking up / r All or most of the time 3 r A little of the time ~ r Refuse too early and not being able to fall asleep again? ~ r Some of the time f r None of the time

17. Do you have creepy-crawly feelings in your legs that make r Yes you want to move your legs? /

r No o?

r Not sure r Refuse 3 7

if yes, a. Do these feelings happen mainly when you stay still and / r Yes .:{' No 3 r Not sure c;f' Refuse get better when you move?

b. Are these feelings in your legs worse in the evening or at / r Yes ,,...: r No 3 r Not sure 'fr Refuse night than in the morning?

c. How often do you experience these feelings?

/ r Once a month or less 3r 5 to 15 times a month ...( r 2 to 4 times a month ~ r 16 or more times a month

<j r Refuse

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AmVE/ADIPOSE


Study ID #: D ·OJ -I I I I if yes, continued •• d. Overall, how severe were these feelings over/ r Very severe ~r Mild the last month? ,,< r Severe

3 r Moderate S r Not bothersome at all '1 r Refuse

18. These questions are about how things have been going. How much of the time during the past 4 weeks ...

1. Did you react slowly to things that / r None of the time were said or done? ..< r A little of the time

3 <"" Some of the time

~ r A good bit of the time 5" r Most of the t i me

'l' r Refuse

6 r All of the time

2. Did you have difficulty concentrating I r None of the tim~ or thinking? ..< r A little of the time

.3 r Some of the time

.//' r A good bit of the time ..>'" r Most of the time

? I Refuse

(, r All of the t ime

3. Did you become confused? / r None of the time .2 r A little of the time .3 r Some of the time

71' r A good bit of the t ime ..) r Most of the time

f r Refuse

.b r All of the time

19. The following items are about activities vou might do during a typical dav. Does vour health now limit vou in these activities? If so, how much?

1. Vigorous activities, such as running, lifting heavy I' r Yes limited a lot objects, participating in strenuous sports .< r Yes limited a little

2. Moderate activities, such as moving a table, pushing/ I Yes limited a lot a vacuum cleaner, bowling, or playing golf ~ r Yes limited a little

3. Lifting or carrying groceries

4. Climbing several flights of stairs

5. Climbing one flight of stairs

6. Bending, kneeling, or stooping

7. Walking more than a mile

8. Walking several hundred yards

9. Walking one hundred yard

10. Bathing or dressing yourself

/ r Yes limited a lot .,.< r Yes limited a little

I r Yes limited a lot <>< r Yes limited a little

I' r Yes limited a lot ...? r Yes limited a little

/ r Yes limited a lot o< r Yes limited a little

/ r Yes limited a lot ~ r Yes limited a little

/ r Yes limited a lot P( r Yes limited a little

/ r Yes limited a lot ol r Yes limited a little

/ r Yes limited a lot o2 r Yes limited a little

3 r· No not limited at all l' r Refused

.3 r No not limited at all ? r Refused

..3 r No not limited at all '.r r Refused

..3 r No not limited at all i' r Refused

3 r No not limited at all 9 r Refused

.3 r No not limited at all 7' r Refused

3 r No not limited at all ? r Refused

.3 r No not limited at all ? r Refused

.3 r No not limited at all 'j' r Refused

.3 r No not limited at all 7 r Refused

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AcnVE/ ADIPOSE


Study ID #: D · ITJ -I I I I

20. These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.

How much of the time during the past 4 weeks ...

1. Did you feel full of life? I r All of the time ~ r Most of the time 3 r Some of the time

2. Did you have a lot of energy? I r All of the time .2 ( Most of the time 3 r Some of the time

3. Did you feel worn out? / r All of the time .,{ r Most of the time ..3 r Some of the time

4. Did you feel ti red? / r All of t he time ..< r Most of the time .3 r Some of the t ime

21. Below is a list of the ways you might have felt or behaved.

Please tell me how often vou have felt this wav during the oast week.

7"' r A little of the t ime ..J r None of the t ime 'l r Refuse

,Y r A little of the time ..J r None of the time '1 r Refuse

7/' r A little of the time .r r None of the t ime 'J r Refuse

~ r A little of the t ime .r r None of the time 'l r Refuse

1. I was bothered by things that usually don't bother me.

0 r Rarely or none of the time (less than 1 day) I r Some or little of the time (1·2 days) ~ r Occasionally or a moderate amount of time (3·4 days) ..J r Most or all of the time (5·7 days) 'j r Refuse

2. I did not feel like eating; my appetite was poor. O r Rarely or none of the time (less than 1 day) I r Some or little of the time (1-2 days)

..2 r Occasionally or a moderate amount of t ime (3-4 days) .3 r Most or all of the time (5-7 days) '1 r Refuse

3. I felt that I could not shake off the blues even O r Rarely or none of the time (less than 1 day) with help from my family or f riends. / r Some or little of the time (1-2 days)

4. I felt I was just as good as other people.

,.< r Occasionally or a moderate amount of time (3-4 days) .3 r Most or all of the t ime (5-7 days) 7 r Refuse

O r Rarely or none of the time (less than 1 day) I r Some or little of the time (1-2 days)

.,,< r Occasionally or a moderate amount of time (3-4 days)

..3 r Most or all of the time (5-7 days) 9 r Refuse

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ACTIVE/ ADIPOSE


Study ID#: D ·CD· I I I I

21. continued. .. Please tell me how often vou have felt this wav during the past week.

5. I had trouble keeping my mind on what I was doing . 12. I was happy. 0 r Rarely or none of the time (less than 1 day) 0 r Rarely or none of the time (less than 1 day) / r Some or little of the time (1-2 days) / i Some or little of the time (1-2 days)

,l!... r Occasionally or a moderate amount of time (3-4 days) .J r Occasionally or a moderate amount of time (3-4 days) ...3 i Most or all of the time (5-7 days) .3 r Most or all of the time (5-7 days) 'f t Refuse / r Refuse

6. I felt depressed. 0 r Rarely or none of the time (less than 1 day) / r Some or little of the time (1-2 days) ..z r Occasionally or a moderate amount of time (3-4 days) .3 r Most or all of the time (5·7 days) '7 r Refuse

7. I felt that everything I did was an effort. 0 (" Rarely or none of the t ime (less than 1 day) / r Some or little of the time (1-2 days)

.2 r Occasionally or a moderate amount of time (3-4 days) 3 r Most or all of the time (5-7 days)

9 r Refuse

8. I felt hopeful about the future. 0 r Rarely or none of the time (less than 1 day) / r Some or little of the time (1-2 days)

..z r Occasionally or a moderate amount of time (3-4 days) .3 r Most or all of the time (5-7 days) 9 r Refuse

9. I thought my life had been a failure. 0 r Rarely or none of the time (less than 1 day) I r Some or little of the time (1-2 days)

..2 r Occasionally or a moderate .amount of time (3-4 days) 3 r Most or all of the time (5-7 days) 7 r Refuse

10. I felt fearful. 0 r Rarely or none of the time (less than 1 day) / r Some or little of the time (1-2 days)

.,)_ r Occasionally or a moderate amount of time (3·4 days) 3 r Most or all of the time (5-7 days) 'j' r Refuse

11. My sleep was restless. 0 r Rarely or none of the time (less than 1 day) / r Some or little of the time (1-2 days) ~ r Occasionally or a moderate amount of time (3-4 days) 3 r Most or all of the time (5-7 days) 9 r Refuse

13. I talked less than usual. 0 r Rarely or none of the time (less than 1 day) / r Some or little of the time (1-2 days) .2 r Occasionally or a moderate amount of time (3-4 days) 3 r Most or all the time (5-7 days) 9 r Refuse

0 14. I felt lonely. r Rarely or none of the t ime (less than 1 day)

/ r Some or little of the time (1-2 days) .2 r Occasionally or a moderate amount of time (3-4 days) .3 r Most or all of the time (5-7 days) 7 r Refuse

0 15. People were unfriendly. r Rarely or none of the time (less than 1 day)

I r Some or little of the time (1-2 days) ..2 r Occasionally or a moderate amount of time (3-4 days)

r Most or all of the time (5-7 days) 3 ~ r Refuse

16. I enjoyed life. 0 r Rarely or none of the time (less than 1 day) / r Some or little of the time (1-2 days) ..2 r Occasionally or a moderate amount of time (3-4 days) .3 r Most or all of the time (5-7 days) '7 r Refuse

17. I had crying spells. 0 r Rarely or none of the t ime (less than 1 day) I r Some or little of the time (1-2 days) ..l r Occasionally or a moderate amount of time (3-4 days) .3 r Most or a II of the time ( 5-7 days) 9 r Refuse

18. I felt sad. 0 r Rarely or none of the time (less than 1 day) / r Some or little of the time (1-2 days)

..2 r Occasionally or a moderate amount of time (3-4 days) 3 r Most or all of the time (5-7 days) 7 r Refuse

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Q

/ .2 3 7

ACTIVE/ ADIPOSE


Study ID #: D·CD·I I I I

21. continued ... Please tell me how often vou have felt this wavduring the past week.

19. I felt that people disliked me. r Rarely or none of the time (less than 1 day) r Some or little of the time (1-2 days) r Occasionally or a moderate amount of time (3-4 days) r Most or all of the time (5-7 days) ,- Refuse

20. I could not get "going." 0 r Rarely or none of the time (less than 1 day) / r Some or little of the time (1-2 days)

..2 r Occasionally or a moderate amount of time (3-4 days) 3 r Most or all of the time (5-7 days) 5> C' Refuse

22. We are interested in knowing if any of these reasons may limit your participation in physical activity. I am going to read a list of possible reasons. Please tell me if a reason limits your physical activity. (If necessary, ask after each: " Is this a reason you limit your physical activity?'')

a. You feel too sick / r Yes ,;,l r No .Jr Not sure Y' r Refuse

b. You feel too tired I r Yes o< r No 3 r Not sure ?r Refuse

c. You feel sad / r Yes ,,? (' No .3 r Not sure 'lr Refuse

d. You don't have time / r Yes .,,,( r No 3 r Not sure <Jr Refuse

e. You are just not motivated I r Yes .:? r No .3 r Not sure 7 r Refuse

f. You don't have any place to exercise or any exercise / r Yes ~ r No ..3 r Not sure 7r Refuse equipment

g. You don't know what to do / r Yes ...( (" No .3 r Not sure J r Refuse

h. You don't think it is good for you / r Yes ~ r No 3 r Not sure 7'r Refuse

i. You are in too much pain / r Yes t:-l r No .3 r Not sure ? r Refuse

j. You are afraid of getting hurt / r Yes :; r No 3 r Not sure 7 r Refuse

k. Your family doesn't think you should / r Yes ..< r No .3 r Not sure 7r Refuse

I. Your doctor doesn't think you should I r Yes .:? r No 3 r Not sure 7 r Refuse

23. Is there anything that we haven't asked that you think would be helpful for the researchers to know?

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patient questionnaire - niddk central repository

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