programa escuchar proxy baseline … · l | loop from 1 to [preload number of hh members] do |...

PROGRAMA ESCUCHAR

PROXY BASELINE QUESTIONNAIRE INDIVIDUAL-LEVEL SURVEY

| 4 DOESN'T DO | | IF FH002 = 1 THEN | | | | FH004 | | Does [SELECTED HH MEMBER] have difficulty walking one block? | | 1 YES | | 2 NO | | 3 CAN'T DO | | 4 DOESN'T DO | | | ENDIF | | FH006 | Does [SELECTED HH MEMBER] have difficulty getting up from a chair after sitting for long periods? | 1 YES | 2 NO | 3 CAN'T DO | 4 DOESN'T DO | | FH009 | Does [SELECTED HH MEMBER] have difficulty stooping, kneeling, bending, or crouching? | 1 YES | 2 NO | 3 CAN'T DO | 4 DOESN'T DO | | FH010 | Does [SELECTED HH MEMBER] have difficulty reaching or extending her/his arms above shoulder level? | 1 YES | 2 NO | 3 CAN'T DO | 4 DOESN'T DO | | FH012 | Does [SELECTED HH MEMBER] have difficulty lifting or carrying objects weighing over 5 kg, like a heavy bag of groceries? | 1 YES | 2 NO | 3 CAN'T DO | 4 DOESN'T DO | | FH013 | Does [SELECTED HH MEMBER] have difficulty picking up a 1 peso coin from the table? | 1 YES | 2 NO | 3 CAN'T DO | 4 DOESN'T DO | | FH016 | Please tell me if [SELECTED HH MEMBER] has any difficulty with each of the activities I mention. If she/he does not do any of the following | activities, simply tell me. Do not include difficulties that you believe will last less than three months. | | FH014 | Does [SELECTED HH MEMBER] have difficulty dressing (including putting on shoes)? | 1 YES | 2 NO | 3 CAN'T DO | 4 DOESN'T DO | | FH017 | Does [SELECTED HH MEMBER] have any difficulty walking across a room? | 1 YES | 2 NO | 3 CAN'T DO | 4 DOESN'T DO | | IF FH017 = 1 THEN | | | | FH022 | | Does [SELECTED HH MEMBER] ever use equipment or devices such as a cane, walker or wheelchair when walking across a room? | | 1 Yes | | 2 No | | | ENDIF | | FH018 | Does [SELECTED HH MEMBER] have any difficulty bathing or showering? | 1 YES

| 2 NO | 3 CAN'T DO | 4 DOESN'T DO | | FH019 | Does [SELECTED HH MEMBER] have any difficulty eating, such as cutting her/his food? | 1 YES | 2 NO | 3 CAN'T DO | 4 DOESN'T DO | | FH020 | Does [SELECTED HH MEMBER] have any difficulty getting into or out of the bed or hammock? | 1 YES | 2 NO | 3 CAN'T DO | 4 DOESN'T DO | | IF FH020 = 1 THEN | | | | FH023 | | Does [SELECTED HH MEMBER] ever use equipment or devices such as a cane, walker or wheelchair when getting | | into or out of bed or hammock? | | 1 Yes | | 2 No | | | ENDIF | | FH021 | Does [SELECTED HH MEMBER] have any difficulty using the toilet, including getting on and off the toilet or squatting? | 1 Yes | 2 No | 3 Can't do | | FH038 | Now I am going to mention other activities. Please tell me if [SELECTED HH MEMBER] has any difficulty with the activities that I mention to you. | If she/he does not do any of the following activities, simply tell me. Do not include difficulties that you believe will last less than three months | | FH039 | Does [SELECTED HH MEMBER] have any difficulty preparing a hot meal? | 1 YES | 2 NO | 3 CAN'T DO | 4 DOESN'T DO | | FH040 | Does [SELECTED HH MEMBER] have any difficulty shopping for groceries? | 1 YES | 2 NO | 3 CAN'T DO | 4 DOESN'T DO | | FH041 | Does [SELECTED HH MEMBER] have any difficulty taking medications (if she/he take any or needed to do so)? | 1 YES | 2 NO | 3 CAN'T DO | 4 DOESN'T DO | | FH042 | Does [SELECTED HH MEMBER] have any difficulty managing her/his money? | 1 YES | 2 NO | 3 CAN'T DO | 4 DOESN'T DO | | IF FH002 = 1 OR FH004 = 1 OR FH006 = 1 OR FH009 = 1 OR | FH010 = 1 OR FH012 = 1 OR FH013 = 1 OR FH014 = 1 OR FH017 = 1 OR FH018 = | 1 OR FH019 = 1 OR FH020 = 1 OR FH021 = 1 OR FH039 = 1 OR FH040 = 1 OR | FH041 = 1 OR FH042 = 1 THEN | | | | FH154_1 | | You mentioned that [SELECTED HH MEMBER] has difficulty with one or more of the activities we just asked you about. | | Please tell me who helps her/him with these activities? | | 1 [Names of people] | | 2 [Names of people] | | 3 [Names of people] | | 4 [Names of people]

programa escuchar proxy baseline … · l | loop from 1 to [preload number of hh members] do |...

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