J-9 Medical History Questionnaire.pdf

General Instruc�ons

Instruc�ons to the interviewer are in square brackets in bold text:• [go to next ques�on]

Speeches introducing new sec�ons will be forma�ed as, “courier new font.”• “Thank you for your continuing participation in the World Trade Center Medical Monitoring Program.”

BACKGROUND

General Instruc�ons

Check only one response for mul�ple choice ques�ons, unless otherwise indicated.• All dates are MM/YY, unless otherwise indicated.• DK = Don’t Know; R = Refused.• Ques�ons that are associated with ‘ac�on triggers’ are shaded.•

World Trade Center Responder Health Program

Health Assessment Examina�on Comprehensive Medical History

BACKGROUND

"Thank you for your continuing participation in the World Trade Center Medical Monitoring Program. I am now going to ask you some questions about how your health has been and any changes in your health since we last saw you on [Periodic Visit Date]. Please try to answer all questions to the best of your ability. Please stop me if anything I ask you isn’t clear, or if you need to stop for any other reason. This part of the program will take about [X] minutes."

Pa�ent Name (Last, First) Date of Birth (MM/DD/YY) Current Address

Current Home Telephone Current Work Telephone

Current Cell Telephone Current E-mail Address Exam Loca�on

World Trade Center Number Visit Date (MM/DD/YY)

Interviewer Name (Last, First) Today’s Date (MM/DD/YY)

Hispanic or La�no descent? � Yes � No � Refused � White or Caucasian � American Indian or Alaskan Na�ve

� Black or African-American � Other (Specify ______________________________________________ )

� Asian � I refuse to answer

� Na�ve Hawaiian or other Pacific Islander

ADDITIONAL CONTACTS

If you have not already done so, please provide us with the names of two or more addi�onal people who do not live in your household who will always know how to contact you. All informa�on provided to us will be kept strictly confiden�al.

1.

Name (Last, First) Rela�on to You Current Address

Home Telephone Work Telephone

Cell Telephone E-mail Address

2.

Name (Last, First) Rela�on to You Current Address

Home Telephone Work Telephone

Cell Telephone E-mail Address

3.

Name (Last, First) Rela�on to You Current Address

Home Telephone Work Telephone

Cell Telephone E-mail Address

Background 20080925.1 1

What kind of work have you been doing since your last exam?

From [MM/YY] To [MM/YY] Job Title

What is your current work status?

� Working F/T � Disabled or on Medical Leave because of a non-work-related health problem or injury

� Working P/T � Laid Off or Unemployed

� F/T Student/No Paid Work � Retired

� Working but taking more than 8 days/month Sick Leave on avg. � Other

� Disabled or on Medical Leave because of a WTC-related health problem or injury � Don’t Know

� Disabled or on Medical Leave because of a work-related, but not WTC-related health problem or injury � Refused

What is your occupa�on now?

� Construc�on � Office/Administrative/Professional � News Agency � Other [Specify]

� Public Sector-Blue Collar � Law Enforcement � Federal Employee

� Transportation � Technical and Utilities � Don’t Know

� Volunteer � Cleaning/Maintenance � Refused

� Healthcare � Firefighter (Non FDNY) � N/A

Family History For each family member below, check medical condi�ons they have or had:

If living, present age

If deceased age at death

Diabetes Asthma Cancer Hypertension Coronary Artery Disease

Other [specify]

Mother ___ ___ � � � � � � Father ___ ___ � � � � � � Sibling 1 ___ ___ � � � � � � Sibling 2 ___ ___ � � � � � � Sibling 3 ___ ___ � � � � � � Sibling 4 ___ ___ � � � � � �

Background / Family History 20080925.1 2

Sec�on 1 Medica�ons, Allergies Current Health Condi�ons and Concerns

1.1 Medica�on History

1.1.1 Are you currently taking any prescrip�on, non-prescrip�on or herbal medica�ons?

� Y � N � DK � R

[Proceed] [Next Page] [Next Page] [Next Page]

[If the responder started, stopped, and then re-started a medica�on, complete a row on the table below for the most recent �me that the responder started the medica�on. You will be entering the details of ‘start-stop’ medica�on use on the table of Ques�on 1.1.2. Please write medica�on name legibly.]

Medica�on A. Reason(s) for taking medica�on B. When did you start taking? [MM/YY]

1.1.1.1 Alterna�ve, herbal, homeopathic

or other medicines

1.1.1.2

1.1.1.3

1.1.1.4

1.1.1.5

1.1.1.6

1.1.1.7

[If responder is currently taking more than 7 medica�ons, complete one or more “Supplemental Current Medica�ons”.]

� Check here if one or more supplemental sheets are used. Click here to go to the “Supplemental Current Medica�ons” sheet.

Medica�ons, Allergies Current Health Condi�ons and Concerns 20080925.1 3

1.1.2 Have you taken any prescrip�on, non-prescrip�on or herbal medica�ons for WTC-related condi�ons or symptoms since your last examina�on that you are no longer taking?

� Y � N � DK � R

[Proceed] [Next Page] [Next Page] [Next Page]

[If the responder started but stopped a medica�on more than once, complete one row for each �me the responder both started and stopped the medica�on. Please write medica�on name legibly.]

Medica�on [Examples of common medica�ons are listed here]

A. Reason(s) for taking medica�on B. How long did you take it? [complete one]

1.1.2.1 An�bio�cs for cough or breathing _______ Days � DK

� R _______ Months

_______ Years

1.1.2.2 Bronchodilators (ex. Albuterol ; Proven�l Atrovent; Combivent) _______ Days � DK

� R _______ Months

_______ Years

1.1.2.3 Steroids by pill, tablet, or injec�on (prednisone; medrol) _______ Days � DK

� R _______ Months

_______ Years

1.1.2.4 Inhaled steroids (Advair; Pulmicort; Azmacort; Flovent) _______ Days � DK

� R _______ Months

_______ Years

1.1.2.5 Nebulized medica�ons _______ Days � DK

� R _______ Months

_______ Years

1.1.2.6 Sinus/nasal decongestants (pills, syrups, non-steroid sprays – _______ Days � DK

� R Saline; Afrin; Neosynephrine; Astelin; Atrovent) _______ Months

_______ Years

1.1.2.7 Sinus/Nasal steroid sprays (Rhinocort; Nasalcort; Nasonex; Flonase; others) _______ Days � DK

� R _______ Months

_______ Years

1.1.2.8 Acid inhibitors tablets or pills (Pepcid; Zantac; Prilosec; Nexium; Aciplex; Protonics) _______ Days � DK

� R _______ Months

_______ Years

1.1.2.9 Frequent use of Antacids (Maalox; Mylanta; Tums; Rolaids; Milk of Magnesia; _______ Days � DK

� R Pepto-Bismol) _______ Months

_______ Years

1.1.2.10 Other _______ Days � DK

� R _______ Months

_______ Years

[If responder is currently taking more than 9 medica�ons, complete one or more “Supplemental Stopped Medica�ons”.]

� Check here if one or more supplemental sheets are used. Click here to go to the “Supplemental Stopped Medica�ons” sheet.

Medica�ons, Allergies Current Health Condi�ons and Concerns 20080925.1 4

1.2 Allergy History

1.2.1 Do you have any allergies to medica�ons? Yes [please list]

� N [Next]

� DK

[Next]

� R [Next]

Do you currently have any allergies to the items below?

Did you have this allergy before working on WTC?

When did this allergy first develop?

Since you began working on the WTC effort, has the allergy…

Has the allergy been confirmed by skin or blood tests?

1.2.1.1 Latex

� Yes

� No

� DK

� Yes

� No

� DK

MM/YY

� Worsened

� Stayed about the same

� Improved

� DK

� Yes

� No

� DK

1.2.1.2 Animals (e.g. cats, dogs, horses)

� Yes

� No

� DK

� Yes

� No

� DK

MM/YY

� Worsened

� Stayed about the same

� Improved

� DK

� Yes

� No

� DK

1.2.1.3 Outdoor allergens (e.g. pollens, trees, weeds)

� Yes

� No

� DK

� Yes

� No

� DK

MM/YY

� Worsened

� Stayed about the same

� Improved

� DK

� Yes

1.2.1.4 Indoor allergens (e.g. mold, dust, cockroaches)

� Yes

� No

� DK

� Yes

� No

� DK

MM/YY

� Worsened

� Stayed about the same

� Improved

� DK

� Yes

� No

� DK

1.2.1.5 Other:

[specify]

� Yes

� No

� DK

� Yes

� No

� DK

MM/YY

� Worsened

� Stayed about the same

� Improved

� DK

� Yes

1.3 Health Concerns

“We will now be asking you various symptoms, any testing or treatments you may have had related to your breathing, heart, ears, nose, throat and sinuses, the stomach, muscles and joints and other body systems. Many of the symptoms are common and you may or may not have ex-perienced them since the last time we saw you. If you have any questions, we can discuss them as we go along.”

1.3.1 Are there any specific health concerns related to your WTC experience that you would like to tell us about? � Y [Specify]

� N [Next page]

� DK

[Next page]

� R [Next page]

Please specify in the space below.

Medica�ons, Allergies Current Health Condi�ons and Concerns 20080925.1 5

Sec�on 2 Pulmonary

2.1 Lower Respiratory Symptoms

“Now I am going to ask you some questions about symptoms you may have had in your chest. I am interested in hearing about these symptoms if you have experienced them when you did not have a chest cold, flu or upper respiratory infection. Some of these symptoms we asked about during your last visit. We are interested in knowing whether you have had any of these symptoms in the past 12 months.”

A. Symptom “Apart from when you had a cold, have you had…”

B. In the past 12 months, have you had [symptom] C. Over the past 12 months, on average, how much of a problem has [symptom] been?

D. How o�en, on average, in the past 4 weeks have you had [symptom] while you were awake?

2.1.1 A regular cough

4 or more coughs/day

4 or more days/week, 4 or more consecu�ve weeks

� Y [B1]

� N [2.1.2]

� DK

[2.1.2]

� R [2.1.2]

Severity: _________ [D]

� DK [D]

� Refused [D]

2 = mild or slight problem

[check only one]

� Not at all [2.1.2]

_____ days/wk. [2.1.2]

� I had a chest cold, flu or upper � respiratory infec�on in the past 4 weeks

� DK/not sure [2.1.2]

� Refused [2.1.2]

[If <1 day/wk., code as 01 day/wk.]

B1. Which of the following statements best describes your frequent or regular cough?

� My cough is usually dry (does not bring up mucous or phlegm) [C]

� My cough is usually wet (does bring up mucous or phlegm) [B2]

� My cough is some�mes dry and some�mes wet [B2]

� DK [B2]

� Refused [B2] 3 = moderate problem 4 = severe problem 5 = problem ‘as bad as it can be’

B2. Have you had this cough for 3 months in a row in each of the past 2 years?

� Y [B3]

� N [B3]

� DK

[B3]

� R [B3]

B3. Apart from when you had a cold, when you have a wet cough, where does the mucous or phlegm usually comes from?

� the back of my throat [C]

� my chest [C]

� both [C]

� not sure [C]

� Refused [C] for for

Pulmonary Lower Respiratory 20080925.1 6

A. Symptom “Apart from when you had a cold, have you had…”

B. In the past 12 months, have you had [symptom] C. Over the past 12 months, on average, how much of a problem has [symptom] been?

[Use Problem Severity Prompt Card]

D. How o�en, on average, in the past 4 weeks have you had [symptom] while you were awake?

[If <1 day/wk., code as 01 day/wk.]

2.1.2 Wheezing or whistling in

your chest

� Yes [C] Severity: _________ [D]

� DK [D]

� Refused [D]

� Not at all [2.1.3]

_____ days/wk. [2.1.3]

� DK/not sure [2.1.3]

� Refused [2.1.3]

� No [2.1.3]

� DK [2.1.3]

� Refused [2.1.3]

2.1.3 Shortness of breath

� Yes [C] Severity: _________ [D]

� DK [D]

� Refused [D]

� Not at all [2.1.4]

_____ days/wk. [2.1.4]

� DK/not sure [2.1.4]

� Refused [2.1.4]

� No [2.1.4]

� DK [2.1.4]

� Refused [2.1.4]

2.1.4 Chest �ghtness

� Yes [C] Severity: _________ [D]

� DK [D]

� Refused [D]

� Not at all [next]

_____ days/wk. [next]

� DK/not sure [next]

� Refused [next]

� No [next]

� DK [next]

� Refused [next]

[If No to ALL of the above, go to Ques�on 2.2, Lower Respiratory Condi�on] [If Yes to ANY of the above,

2.1.5 How o�en has your sleep been prevented or interrupted by cough, wheezing, shortness of breath, and/or chest �ghtness in the past 4 weeks? [check only one] � Not at all _____Nights/Wk � DK � R

2.1.6 Did you see a doctor or health professional for the cough, wheezing, shortness of breath or chest �ghtness? � Y � N � DK � R

2.1.7 Did you take any medica�ons for the symptoms? � Y � N [2.1.9] � DK [2.1.9] � R [2.1.9]

2.1.8 If you take/took inhaled steroids (and/or oral steroids) or Singulair for at least four con-secu�ve weeks for your lower respiratory symptoms, do you think that it helped? � Y � N � DK � R

2.1.9 Overall, how do you feel your symptoms have been since we saw you last? � Resolved � Worsened

� Improved � Symptoms vary too much to decide

� Feel normal with treatment � Refused

� Stayed about the same � N/A

2.1.10 Clinical Comments

Pulmonary Lower Respiratory 20080925.1 7

A. Diagnosis (ever) by Health Care Provider reported at ini�al or periodic visit

B. Since we last saw you, have you been diagnosed with [condi�on]?

C. You reported that a physician had diagnosed you with [condi�on] in a prior visit. Do you s�ll have [condi�on]?

D. Are you currently taking medica�on and/ or seeing a health professional regularly for [condi�on]?

2.2.1 Asthma/RADS

� Yes [A1] � Yes [B1]

� No [2.2.2]

� DK [2.2.2]

� Refused [2.2.2]

B1. When? ___________ [MM/YY]

� DK

� Refused B2. Do you still have [condition]?

� Yes [D]

� No [B3]

� DK [D]

� Refused [D] B3. When did it resolve? ___________ [MM/YY] [next]

� DK [2.2.2]

� Refused [2.2.2]

� Yes [D] � Yes [2.2.2]

� No [B] � No [C1]

� DK [D]

� Refused [D]

� No [2.2.2]

� DK [2.2.2] � DK [B]

� Refused [2.2.2] A1. When? C1. When did it resolve?

___________ [MM/YY] [C] ___________ [MM/YY] [2.2.2]

� DK [2.2.2]

� Refused [2.2.2]

2.2.2 Emphysema or Chronic Obstruc�ve Pulmonary Disease (COPD) or Chronic Bronchi�s

� Yes [A1] � Yes [B1]

� No [2.2.3]

� DK [2.2.3]

� Refused [2.2.3]

B1. When? ___________ [MM/YY]

� DK

� Refused B2. Do you still have [condition]?

� Yes [D]

� No [B3]

� DK [D]

� Refused [D] B3. When did it resolve? ___________ [MM/YY] [next]

� DK [2.2.3]

� Refused [2.2.3]

� Yes [D] � Yes [2.2.3]

� No [B] � No [C1]

� DK [D]

� Refused [D]

� No [2.2.3]

� DK [2.2.3] � DK [B]

� Refused [2.2.3] A1. When? C1. When did it resolve?

___________ [MM/YY] [C] ___________ [MM/YY] [2.2.3]

� DK [2.2.3]

� Refused [2.2.3]

2.2 Lower Respiratory Condi�ons

“Now I would like to ask you about Lower Respiratory conditions that have been diagnosed by a physician. You may have either reported these at your first visit, a subsequent visit, or received a diagnosis more recently.”

Pulmonary Lower Respiratory 20080925.1 8

[Column headings have changed to reflect the acute condi�ons being discussed below]

A. Diagnosis (ever) by Health Care Provider reported at ini�al or periodic visit

B. Since we last saw you, have you been diagnosed with [condi�on]?

C. You reported that a physician had diagnosed you with [condi�on] in a prior visit.

How many episodes of [condi�on] have you had since we last saw you?

2.2.3 Acute Bronchi�s

� Yes [A1] � Yes [B1] Number of episodes? ___________

� No [B] � No [2.2.4] [if 0, go to next condition, otherwise got to C1]

� DK [B] � DK [2.2.4] � DK

� Refused [2.2.4] � Refused A1. When? B1. How many episodes? ___________

___________ [MM/YY] [C] � DK [B2] C1. Any in the last 4 weeks?

� Refused [B2] � Yes [2.2.4]

� No [2.2.4] B2. Any in the last 4 weeks? � DK [2.2.4]

� Yes [2.2.4] � Refused [2.2.4]

� No [2.2.4]

� DK [2.2.4]

� Refused [2.2.4]

2.2.4 Pneumonia

� Yes [A1] � Yes [B1] Number of episodes? ___________

� No [B] � No [2.2.5] [if 0, go to next condition, otherwise go to C1]

� DK [B] � DK [2.2.5] � DK

� Refused [2.2.5] � Refused A1. When? B1. How many episodes? ___________

___________ [MM/YY] [C] � DK C1. Any in the last 4 weeks?

� Refused � Yes [2.2.5]

� No [2.2.5] B2. Any in the last 4 weeks? � DK [2.2.5]

� Yes [2.2.5] � Refused [2.2.5]

� No [2.2.5]

� DK [2.2.5]

� Refused [2.2.5] If No to ALL of the above, go to Lower Respiratory or Cardiac Procedures & Treatments, ques�on 2.3.1.

If Yes to ANY of the above:

2.2.5 How has your work situa�on been affected by asthma/RADS, emphysema, COPD, pneumonia, and/or bronchi�s?

� Not affected � Le� usual job

� Missed work � Not working for other reason

� Modified/ light duty/restricted duty � Refused

Pulmonary Lower Respiratory 20080925.1 9

2.3 Lower Respiratory or Cardiac Procedures & Treatments

2.3.1 Since your last examina�on on (visit date), have you had any medical tests or treatments, including hospitaliza�ons, or Emergency Room (ER) visits for medical condi�ons involving your chest?

� Yes [A] � No [Go to next sec�on] � DK [Go to next sec�on] � Refused [Go to next sec�on]

A. ER visits or hospital stays because of chest problem(s)

B. Diagnos�c Procedures (any) C. Treatments/Procedures (any) D. Other treatments (any) E. S�ll using ‘other’ treatment?

� Yes [A1]

� DK [B]

� No [B]

� R [B]

� Yes [complete below, and go to (C)]

� No [C]

� DK [C]

� R [C]

� Yes [complete below and go to (D)]

� No [D]

� DK [D]

� R [D]

� Yes [complete below and go to (E)]

� No

� DK

� R Any abnormal?

A1.

ER visits:

total number

� DK � R

A2.

Overnight hospital stays:

total number [B]

� DK � R

B1. � Skin tes�ng for allergy � Yes

� DK

� No

� R

C1. � ER nebulizer

C1. � DK � R

# Times � Allergy shots

� Yes

� DK

� No

� R

B2. � Methacholine challenge � Yes

� DK

� No

� R

C2. � IV/PO

(Intravenous or oral) steroids

C1. � DK � R

# Times � Home Nebulizer

� Yes

� DK

� No

� R

B3. � Chest CT scan � Yes

� DK

� No

� R

� Other [specify]

� Yes

� DK

� No

� RC3. � Injected Adrenaline

C1.� DK � R

# Times

B4. � Bronchoscopy � Yes

� DK

� No

� R C4. � Intuba�on

C1. � DK � R

# Times

B5. � Full PFT (in lab, not � desktop spirometer)

� Yes

� DK

� No

� R C5. � Other [specify]

# Times

B6. � Chest x-ray � Yes

� DK

� No

� R

B7. � EKG

� Yes

� DK

� No

� R

B8. � Other [specify]

� Yes

� DK

� No

� R

2.3.2 Clinical Comments

Pulmonary Lower Respiratory 20080925.1 10

2.4 Provocability

“Now I am going to ask you some questions about how specific situations or exposures might influence certain respiratory symptoms.”

[Ask 2.4.2 - 2.4.5 for all pa�ents.]

2.4.1 Have you experienced wheezing or chest �ghtness in the past 12 months when?

A. Situa�on B. Response C. Have you had this reac�on in the past 4 weeks? D. When did it stop?

2.4.2 you were doing exercise or physical ac�vity

� Yes [C]

� No [next]

� DK [next]

� R [next]

� No exercise [next]

� Yes [next]

� No [D]

� DK [D]

� R [D]

� No exercise [D]

MM/YY

2.4.3 you were exposed to smoke or fumes (cigare�e smoke, vehicle exhaust) or dust other than house dust?

� Yes [C]

� No [next]

� DK [next]

� R [next]

� Not exposed [next]

� Yes [next]

� No [D]

� DK [D]

� R [D]

� Not exposed [D]

MM/YY

2.4.4 you were exposed to animals, trees, weeds, house dust or pollen?

� Yes [C]

� No [next]

� DK [next]

� R [next]

� Not exposed [next]

� Yes [next]

� No [D]

� DK [D]

� R [D]

� Not exposed [D]

MM/YY

2.4.5 you were exposed to very hot or very cold condi�ons, (for example, extremes of temperature?)

� Yes [C]

� No [next]

� DK [next]

� R [next]

� Not exposed [next]

� Yes [next]

� No [D]

� DK [D]

� R [D]

� Not exposed [D]

MM/YY

[If no symptoms above, please go to Sec�on 2.5 Tolerance for Physical Effort.]

2.4.6 Over the past 12 months, how much of a problem are wheezing, shortness of breath, or chest �ghtness when triggered by physical ac�vity, smoke, fumes, dust, or very hot or very cold condi�ons?

[use prompt card]

Severity: _________

� DK

� Refused

2 = mild or slight problem 3 = moderate problem 4 = severe problem 5 = problem ‘as bad as it can be’

2.4.7 Did you see a doctor or health professional for the wheezing, shortness of breath or chest �ghtness? � Yes � No � DK � R

2.4.8 Did you take any medica�ons for these symptoms? � Yes � No [skip to 2.4.10] � DK [skip to 2.4.10] � R [skip to 2.4.10]

2.4.9 If you take/took medicine for at least four weeks and/or underwent treatment for your provocability symptoms, do you think that it helped?

� Yes � No � DK � R

2.4.10 Overall, how do you feel your (provocability) symptom(s) (that I have just been asking about) has(have) been since we saw you last?

� Resolved

� Improved

� Feel normal

� Stayed about the same

� Worsened

� Symptoms vary too much to decide

� Refused

� N/A

Pulmonary Provocability 20080925.1 11

2.5 Tolerance for Physical Effort

“Now I am going to ask you a few more questions about your tolerence to physical effort.”

2.5.1 Are you troubled by shortness of breath

when hurrying on level ground or walking up a slight hill?

� Yes

� No [Go to next sec�on]

� DK

� Refused

� Respondent unable to perform because of

� other physical limita�on

2.5.2 When walking on the level, have you had to

walk more slowly than people of your own age because of breathlessness?

� Yes

� No [Go to next sec�on]

� DK

� Refused

� Respondent unable to perform because of

� other physical limita�on

2.5.3 Have you had to stop for breath a�er

walking more than 100 yards when walking at your own pace on the level?

� Yes

� No [Go to next sec�on]

� DK

� Refused

� Respondent unable to perform because of

� other physical limita�on

2.5.4 Have you had to stop for breath a�er

walking less than 100 yards (or a�er a few minutes) when walking at your own pace on the level?

� Yes

� No [Go to next sec�on]

� DK

� Refused

� Respondent unable to perform because of

� other physical limita�on

2.5.5 Have you been too breathless to leave

the house or been breathless on dressing or undressing?

� Yes

� No [Go to next sec�on]

� DK

� Refused

� Respondent unable to perform because of

� other physical limita�on

2.5.6 Have you been breathless or short of

breath at rest?

� Yes

� No [Go to next sec�on]

� DK

� Refused

� Respondent unable to perform because of

� other physical limita�on

2.6 Upper Respiratory Symptoms & Condi�ons

“These next questions are about upper respiratory symptoms that you may have had since we last saw you. Some of these questions may sound familiar to you, as we have asked you about some of these symptoms before. Presently, we are interested in learning how your health has been since we last saw you, apart from when you have had a respiratory infection, cold or the flu.”

A. Apart from when you have had a respiratory infec�on, cold or the flu

B. Have you had [symptom] in the past 12 months?

C. In the past 12 months, did you have [symptom] for 3 or more consecu�ve months?

D. In the past 4 weeks have you had [symptom]?

2.6.1 frequent headaches � Yes [C]

� DK [Next]

� No [Next]

� R [Next]

� Yes [D]

� DK [D]

� No [D]

� R [D]

� Yes [Next]

� DK [Next]

� No [Next]

� R [Next]

2.6.2 sinus or face pain or pressure or sinus conges�on

� Yes [C]

� DK [Next]

� No [Next]

� R [Next]

� Yes [D]

� DK [D]

� No [D]

� R [D]

� Yes [Next]

� DK [Next]

� No [Next]

� R [Next]

Pulmonary Physical Effort / Upper Respiratory 20080925.1 12

A. Apart from when you have had a respiratory infec�on, cold or the flu

B. Have you had [symptom] in the past 12 months?

C. In the past 12 months, did you have [symptom] for 3 or more consecu�ve months?

D. In the past 4 weeks have you had [symptom]?

2.6.3 runny nose/blowing nose more than usual, stuffy nose, and/or postnasal drip

� Yes [B1]

� DK [Next]

� No [Next]

� R [Next]

� Yes [D]

� DK [D]

� No [D]

� R [D]

� Yes [Next]

� DK [Next]

� No [Next]

� R [Next]

B1. What was the color of the nasal discharge [check all that apply]:

� Yellow/Green[B2]

� Clear [B2]

� Black/Grey [B2]

B2. What was the consistency of the nasal discharge

[check whichever apply]:

� Thick [C]

� Thin [C]

2.6.4 Hoarseness of voice or voice change � Yes [C]

� DK [Next]

� No [Next]

� R [Next]

� Yes [D]

� DK [D]

� No [D]

� R [D]

� Yes [Next]

� DK [Next]

� No [Next]

� R [Next]

[Note �me-frame change; these ques�ons do not ask about ‘3 consecu�ve months’.]

A. Symptom (apart from when you have a cold)

B. Have you had [symptom] in the past 12 months? C. Over the past 4 weeks, have you had [symptom]?

2.6.5 Sore throat or throat irrita�on � Y

[C]

� N [Next]

� DK

[Next]

� R [Next]

� Y [Next]

� N [Next]

� DK

[Next]

� R [Next]

2.6.6 Nose irrita�on, soreness or burning � Y

[C]

� N [Next]

� DK

[Next]

� R [Next]

� Y [Next]

� N [Next]

� DK

[Next]

� R [Next]

2.6.7 Suffered uncontrollable nosebleed � Y

[C]

� N [Next]

� DK

[Next]

� R [Next]

� Y [Next]

� N [Next]

� DK

[Next]

� R [Next]

2.6.8 Throat closure or throat spasms

� Y [B1]

� N [Next]

� DK

[Next]

� R [Next]

� Y [Next]

� N [Next]

� DK

[Next]

� R [Next]

B1. Is your throat spasm/closure brought on by: [check all that seem to bring on or cause throat closure/spasm] [C]

� Animals

� Dust

� Exercise

� Extreme cold

� Extreme heat

� Pollen

� Strong odors

� Trees

� When you lie down

� Your usual work

� DK

� Refused [If NO to all of the above (2.6.1-2.6.8), Skip to 2.7 “Snoring/Sleep Apnea”] [If yes, complete next set of ques�ons]

Pulmonary Upper Respiratory 20080925.1 13

[Complete the following ques�ons, if YES to 2.6.1, 2.6.2, 2.6.3, 2.6.6, and/or 2.6.7 otherwise skip to instruc�ons above 2.6.14]

2.6.9 Over the past 12 months, how much of a problem are your sinus/nasal symptoms? Severity: _________

� DK

� Refused

2 = mild or slight problem 3 = moderate problem 4 = severe problem 5 = problem ‘as bad as it can be’

2.6.10 Did you see a doctor or health professional for the frequent headaches, sinus pain, runny nose, post-nasal drip or nasal irrita�on? � Yes � No � DK � R

2.6.11 Did you take any medica�ons for these symptoms? � Yes � No [skip to 2.6.13] � DK [skip to 2.6.13] � R [skip to 2.6.13]

2.6.12 If you take/took nasal steroids (and/or oral steroids) for at least four consecu�ve weeks and/or underwent treatment for your sinus/nasal symptoms, do you think that it helped? � Yes � No � DK � R

2.6.13 Overall, how do you feel your (sinus/nasal) symptom(s) (that I have just been asking about) has(have) been since we saw you last?

� Resolved

� Improved

� Feel normal with treatment

� Stayed about the same

� Worsened

� Symptoms vary too much to decide

� Refused

� N/A

[complete the following ques�ons, if YES to 2.6.4, 2.6.5 and/or 2.6.8; otherwise skip to 2.7.1]

2.6.14 Over the past 12 months, how much of a problem are hoarseness of voice, throat irrita�on or throat spasms?

Severity: _________

� DK

� Refused

2 = mild or slight problem 3 = moderate problem 4 = severe problem 5 = problem ‘as bad as it can be’

2.6.15 Did you see a doctor or health professional for the sore throat/throat irrita�on, hoarseness of voice, or voice change or throat spasms? � Yes � No � DK � R

2.6.16 Did you take any medica�ons for these symptoms? � Yes � No [skip to 2.6.18] � DK [skip to 2.6.18] � R [skip to 2.6.18]

2.6.17 If you take/took medicine for at least four weeks and/or underwent treatment for your throat symptoms, do you think that it helped? � Yes � No � DK � R

2.6.18 Overall, how do you feel your (throat) symptom(s) (that I have just been asking about) has(have) been since we saw you last? [check one]

� Resolved

� Improved

� Feel normal with treatment

� Stayed about the same

� Worsened

� Symptoms vary too much to decide

� Refused

� N/A

2.7 Snoring/Sleep Apnea

2.7.1 During the past 12 months did you usually snore (louder than talking) at least 3 �mes a week? � Yes � No � DK � R

2.7.2 During the past 12 months, have you stopped breathing in your sleep at least once a month? � Yes � No � DK � R

2.7.3 Do you have uncontrollable or excessive day�me sleepiness: for example falling asleep when si�ng inac�ve in a public place, si�ng and talking to someone, or in a car while stopped for a few minutes in traffic? � Yes � No � DK � R

Pulmonary Upper Respiratory 20080925.1 14

A. Diagnosis (ever) by Health Care Provider reported at ini�al or periodic visit.

B. Since we last saw you, have you been diagnosed with [condi�on]?

C. You reported that a physician had diagnosed you with [condi�on] in a prior visit. Do you s�ll have [condi�on]?

D.

2.7.4 Sinusi�s

� Yes [A1]

� No [B]

� DK [B]

� Yes [B1] � DK [next]

� No [next] � Refused [next]

B1. How many episodes? ___________ or � constant [D]

B2. Date of last? ___________ [D]

[MM/YY]

� DK [D]

� Refused [D]

Do you still have [condition]?

� Yes [Go to number of episodes]

� No [C1] � DK [D] � Refused [D]

Number of episodes? ___________ or � constant [if 0, go to next condition, otherwise go to C1]

� DK [D] � Refused [D]

C1. Date of last? ___________

[MM/YY]

� DK [D] � Refused [D]

D. Have you been evaluated by an ENT?

� Yes [next]

� No [next]

� DK [next]

� Refused [next]

A1. When?

___________ [MM/YY] [C]

2.7.5 Nasal Inflamma�on/Rhini�s

� Yes [A1]

� No [B]

� DK [B]

� Yes [B1] � DK [next]

� No [next] � Refused [next]

B1. How many episodes? ___________ or � constant [D]

B2. Date of last? ___________ [D]

[MM/YY]

� DK [D]

� Refused [D]

Do you still have [condition]?

� Yes [Go to number of episodes]

� No [C1] � DK [D] � Refused [D]

Number of episodes? ___________ or � constant [if 0, go to next condition, otherwise go to C1]

� DK [D] � Refused [D]

C1. Date of last? ___________

[MM/YY]

� DK [D] � Refused [D]

D. Have you been evaluated by an ENT?

� Yes [next]

� No [next]

� DK [next]

� Refused [next] A1. When?

___________ [MM/YY] [C]

2.7.6 Sleep Apnea

� Yes [A1]

� No [B]

� DK [B]

A1. When?

___________ [MM/YY] [C]

� Yes [D]

� No [next]

� DK [next]

� Refused [next]

Do you still have [condition]?

� Yes [D] � DK [D]

� No [C1] � Refused [D]

C1. When did it resolve?

___________ [MM/YY] [D]

� DK [next]

� Refused [next]

D. Are you currently under the care of a doctor for sleep apnea?

� Yes [next]

� No [next]

� DK [next]

� Refused [next]

[If No to ALL of the above, go to Upper Respiratory Procedures & Treatments, ques�on 2.8.1. If Yes to ANY of the above complete ques�on 2.7.7.]

2.7.7 How has your work situa�on been affected by sinusi�s, nasal inflamma�on, rhini�s, or sleep apnea?

� Not affected

� Missed work

� Modified/light duty/restricted duty

� Le� usual job

� Not working for other reason

� Refused

� DK

“Now I would like to ask you about upper respiratory conditions that have been diagnosed by a physician. You may have either reported these at your first visit, periodic visit, or received a diagnosis more recently.”

Pulmonary Upper Respiratory 20080925.1 15

2.8 Upper Respiratory or Cardiac Procedures & Treatments

2.8.1 Since your last examina�on on (visit date), have you had any medical tests or treatments, including hospitaliza�ons, or Emergency Room (ER) visits for medical condi�ons involving your ears, nose, sinuses or throat? � Yes [A] � No [Go to next sec�on] � DK [Go to next sec�on] � Refused [Go to next sec�on]

A. ER visits or hospital stays because of ear, nose, sinus or throat problem(s)

� Yes [A1]

� No [B]

� DK [B]

� R [B]

B. Diagnos�c Procedures (any)

� Yes [complete below, and

� go to (C)] � No [C]

� DK [C]

� R [C]

C. Treatments/Procedures (any)

� Yes [complete below and go to (D)]

� No [D]

� DK [D]

� R [D]

D. Other treatments (any)

� Yes [complete below and go to (E)]

� No

� DK

� R

E. S�ll using ‘other’ treatment?

Any abnormal?

A1.

ER visits:

total number

� DK � R

A2.

Overnight hospital stays: total number [B]

� DK � R

B1. � Sinus CT scan � Yes

� DK

� No

� R C1. � Sinus or nose surgery

C1. � DK � R

# �mes � Allergy shots

� Yes

� DK

� No

� R

B2. � Rhinoscopy/ laryngoscopy B2. � (scope into nose or throat but B2. � not stomach)

� Yes

� DK

� No

� R C5. � Other [specify]

# �mes � Nasal saline irriga�on

� Yes

� DK

� No

� R

B3. � Endoscopy (scope into B2. � stomach or food pipe)

� Yes

� DK

� No � R

� CPAP/BIPAP

� Yes

� DK

� No

� R

B4. � Biopsy

� Nasal

� Vocal chord

� Esophagus/stomach

� Yes

� DK

� No

� R � Other [specify]

� Yes

� DK

� No

� R

B5. � Skin tes�ng for allergy � Yes

� DK

� No

� R

B6. � Overnight sleep study � Yes

� DK

� No

� R

B7. � Other [specify] � Yes

� DK

� No

� R

[If No condi�ons above, go to next sec�on]

2.8.2 How do you feel your (Upper Respiratory) condi�on(s) (that I have just been asking about) has(have) been since we saw you last?

[check one]

� Resolved

� Improved

� Feel normal with treatment

� Stayed about the same

� Worsened � Don’t know

� R � N/A

Clinical Comments [Please include approximate dates of any abnormal diagnos�c procedure results and any addi�onal comments on the abnormal diagnos�c procedure results recorded in column B.]

Pulmonary Upper Respiratory 20080925.1 16

Sec�on 3 Cardiovascular

3.1 Chest Burning Pressure or Pain

[‘Don’t Know’ is not an op�on for these ques�ons; if the pa�ent “doesn’t know”, probe and record in Clinical Comments.]

A. In the past 12 months, have you had? B. Do you have the symptom(s) at this moment?

3.1.1 Chest Burning?

� Yes [B]

� No [next]

� R [next]

� Yes [Refer immediately for clinical assessment]

� No [next]

� R [next]

3.1.2 Chest Pressure?

� Yes [B]

� No [next]

� R [next]

� Yes [Refer immediately for clinical assessment]

� No [next]

� R [next]

3.1.3 Chest Pain?

� Yes [B]

� No [next]

� R [next]

� Yes [Refer immediately for clinical assessment]

� No [next]

� R [next]

3.1.4 Heart Palpita�ons or an irregular heartbeat

� Yes [B]

� No [next]

� R [next]

� Yes [Refer immediately for clinical assessment]

� No [next]

� R [next]

3.1.5 Notes Regarding Referral, if applicable

[Complete this sec�on if “Yes” to any of the above.] Chest Burning Chest Pressure Chest Pain Heart Palpita�ons or Irregular Heart Beat

3.1.6 Did this symptom worsen in frequency or severity over the past 12 months?

� Yes

� No

� Yes

� No

� Yes

� No

� Yes

� No

3.1.7 When did you last have the symptom?

MM/YY

MM/YY

MM/YY

MM/YY

3.1.8 Do you have the symptoms at rest?

� Yes

� No

� Yes

� No

� Yes

� No

� Yes

� No

3.1.9 Do you get the symptom when you walk up a hill in a hurry?

� Yes

� No

� Yes

� No

� Yes

� No

� Yes

� No

3.1.10 Do you get the symptom when you are walking at an ordinary pace on level ground?

� Yes

� No

� Yes

� No

� Yes

� No

� Yes

� No

3.1.11 Did you see a doctor or health professional for the symptom?

� Yes

� No

� Yes

� No

� Yes

� No

� Yes

� No

3.1.12 Do/Did you take any medica�ons for the symptom?

� Yes

� No

� Yes

� No

� Yes

� No

� Yes

� No

3.1.13 If you take/took medicine and/or underwent treatment for symptom for at least 4 weeks, do you think that it helps/helped?

� Yes

� No

� Yes

� No

� Yes

� No

� Yes

Cardiovascular 20080925.1 17

Sec�on 4 Gastrointes�nal

4.1 Gastrointes�nal Symptoms

“Now I am going to ask you some questions about how specific situations or exposures might influence certain respiratory symptoms.”

[We are only interested in knowing whether you have had these symptoms when you did not have a cold or respiratory infec�on, flu or stomach virus.]

B. Have you had [symptom] in the past 12 months? C. Over the past 4 weeks have you had [symptom]?

4.1.1 Frequent difficulty or inability to taste � Y

[C]

� N [next]

� DK

[next]

� R [next]

� Y [next]

� N [next]

� DK

[next]

� R [next]

4.1.2 Difficulty smelling or no ability to smell � Y

[C]

� N [next]

� DK

[next]

� R [next]

� Y [next]

� N [next]

� DK

[next]

� R [next]

4.1.3 Frequent difficulty swallowing – feels like food gets stuck � Y [C]

� N [next]

� DK

[next]

� R [next]

� Y [next]

� N [next]

� DK

[next]

� R [next]

4.1.4 Frequent sour or acid taste in mouth � Y

[C]

� N [next]

� DK

[next]

� R [next]

� Y [next]

� N [next]

� DK

[next]

� R [next]

4.1.5 Coughing a�er you lie down or eat � Y

[C]

� N [next]

� DK

[next]

� R [next]

� Y [next]

� N [next]

� DK

[next]

� R [next]

4.1.6 Reflux/regurgita�on into mouth or throat � Y

[C]

� N [next]

� DK

[next]

� R [next]

� Y [next]

� N [next]

� DK

[next]

� R [next]

4.1.7 Frequent heartburn/indiges�on � Y

[C]

� N [next]

� DK

[next]

� R [next]

� Y [next]

� N [next]

� DK

[next]

� R [next]

4.1.8 Frequent nausea � Y

[C]

� N [next]

� DK

[next]

� R [next]

� Y [next]

� N [next]

� DK

[next]

� R [next]

4.1.9 A. In the past 12 months have you experienced wheezing, shortness of breath, or chest �ghtness when you were lying down? B. Have you had this reac�on in the past 4 weeks?

� Yes [B]

� No [next]

� DK [next]

� Refused [next]

� Yes [next]

� No, when did it stop? __________ [MM/YY] [next]

� DK [next]

� Refused [next]

[If NO to ALL of the above symptoms, skip to 4.1.15 “Acid Reflux or Gastro-Esophageal Reflux Disease.”] If Yes to ANY of the above:

4.1.10 A. Over the past 12 months, how much of a problem are sour/acid taste, coughing a�er you lie down or eat, reflux/regurgita�on, heartburn/indiges�on, nausea and/or breathing difficul�es when lying down?

Severity: _________

� DK

� Refused

2 = mild or slight problem 3 = moderate problem 4 = severe problem 5 = problem ‘as bad as it can be’

4.1.11 Did you see a doctor or health professional for the above symptoms? � Y � N � DK � R

4.1.12 Did you take any medica�ons for these symptoms? � Y [Proceed] � N [4.1.14] � DK [4.1.14] � R [4.1.14]

4.1.13 If you take/took medicine for at least four weeks and/or underwent treatment for the above symptoms, do you think that it helped? � Y � N � DK � R

4.1.14 How do you feel your (G.I. & Other Respiratory) symptom(s) (that I have just been asking about) has(have) been since we saw you last? [check one]

� Resolved

� Improved

� Feel normal with treatment

� Stayed about the same

� Worsened � Don’t know

� R � N/A

Gastrointes�nal 20080925.1 18

“Now I would like to ask you about Acid reflux or GERD that has been diagnosed by a physician. You may have either reported these at your first visit, second visit, or received a diagnosis more recently.”

A. Diagnosis (ever) by Health Care Provider reported at ini�al or periodic visit.

B. Since we last saw you, have you been diagnosed with [condi�on]?

C. You reported that a physician had diagnosed you with [condi�on]. Do you s�ll have [condi�on]?

D. Are you currently under the care of a doctor for [condi�on]?

E. How has your work situa�on been affected by [condi�on]?

4.1.15 Acid Reflux or Gastro-Esophageal Reflux Disease (GERD)

� Yes [A1]

� No [B]

� DK [B]

A1. When?

___________ [MM/YY] [C]

� Yes [B1] � DK [next]

� No [next] � Refused [next]

B1. When?

___________ [MM/YY] [B2]

� DK [D]

� Refused [D]

B2. Do you still have [condition]?

� Yes [D] � DK [D]

� No [B3] � Refused [D]

B3. When did it resolve?

___________ [MM/YY] [E]

� DK [E]

� Refused [E]

� Yes [D] � DK [D]

� No [C1] � Refused [D]

C1. When did it resolve?

___________ [MM/YY] [E]

� DK [E]

� Refused [E]

� Yes [E] � DK [E]

� No [E] � Refused [E]

� Not affected

� Missed work

� Modified/ light duty/restricted duty

� Le� usual job

� Not working for other reason

� Refused

� DK

4.1.16 Clinical Comments

Gastrointes�nal 20080925.1 19

4.2 Acid Reflux or Gastro-Esophageal Reflux Disease (GERD) Procedures & Treatments

4.2.1 Since your last examina�on on (visit date), have you had any medical tests or treatments, including hospitaliza�ons, or Emergency Room (ER) visits for GERD, indiges�on or heartburn?

� Yes [A] � No [Go to next sec�on] � DK [Go to next sec�on] � Refused [Go to next sec�on]

A. ER visits or hospital stays because of indiges�on or heartburn problem(s)

� Yes [A1]

� DK [B]

� No [B]

� R [B]

B. Diagnos�c Procedures (any)

� Yes [Complete below, and go to (C)] � No [C]

� DK [C]

� R [C]

C. Treatments/Procedures (any)

� Yes [complete below and go to (D)]

� No [D]

� DK [D]

� R [D]

D. Other treatments (any)

� Yes [complete below and go to (E)]

� No

� DK

� R

E. S�ll using ‘other’ treatment?

Any abnormal?

A1.

ER visits:

total number

� DK � R

A2.

Overnight hospital stays:

total number [B]

� DK � R

B1. � Endoscopy/Gastroscopy � Yes

� DK

� No

� R

�Surgery

[MM/YY]

� Diet modifica�on � Yes

� DK

� No

� R

B2. � 24h or night-�me pH monitoring � Yes

� DK

� No

� R � Other [specify]

� Eleva�ng head of bed � Yes

� DK

� No

� R

B3. � Laryngoscopy � Yes

� DK

� No � R

[MM/YY]

� Other [specify]

� Yes

� DK

� No

� R

B4. � Other [specify]

� Yes

� No

� R

4.2.2 Clinical Comments

Gastrointes�nal 20080925.1 20

Sec�on 5 Musculoskeletal Condi�ons

5.1 Have you been evaluated/treated for an injury or a muscle, joint or disc problem that was WTC related? � Yes [Specify] ______________________________________� No � DK � R

5.1.1 Has a physician or healthcare provider diagnosed you with any musculoskeletal condi�on since 9/11? � Yes [A] � No � DK � R [Skip to 6.1]

A. Type of Musculoskeletal condi�on See chart below.

B. Date of onset? C. Do you s�ll have condi�on?

D. Are you currently under the care of a doctor for [condi�on]?

E. What treatment has been used for this condi�on (check all that apply)?

F. How do you feel your condi�on(s) has(have) been since we saw you last? [select one]

Condi�on 1

Code _________

__________ [MM/YY] [C]

� DK [C]

� Refused [C]

� Yes [D]

� No [next]

� DK [next]

� R [next]

� Yes [E]

� No [next]

� DK [next]

� R [next]

� Rest

� Equipment specify ________________

� Physical therapy

� Medica�on(s) specify ________________

� Surgery

[Go to F]

� Resolved

� Improved

� Normal with treatment

� Stayed about the same

� Worsened

� Refused

� N/A Don’t know

Condi�on 2

Code _________

__________ [MM/YY] [C]

� DK [C]

� Refused [C]

� Yes [D]

� No [next]

� DK [next]

� R [next]

� Yes [E]

� No [next]

� DK [next]

� R [next]

� Rest

� Equipment specify ________________

� Physical therapy

� Medica�on(s) specify ________________

� Surgery

[Go to F]

� Resolved

� Improved

� Normal with treatment

� Stayed about the same

� Worsened

� Refused

� N/A Don’t know

Condi�on 3

Code _________

__________ [MM/YY] [C]

� DK [C]

� Refused [C]

� Yes [D]

� No [next]

� DK [next]

� R [next]

� Yes [E]

� No [next]

� DK [next]

� R [next]

� Rest

� Equipment specify ________________

� Physical therapy

� Medica�on(s) specify ________________

� Surgery

[Go to F]

� Resolved

� Improved

� Normal with treatment

� Stayed about the same

� Worsened

� Refused

� N/A Don’t know

Codes for Common Musculoskeletal Condi�ons

01 Cervical disk hernia�on 05 Cubital tunnel syndrome 09 Lumbo-sacral disk hernia�on 13 Foot disorder (e.g., heel spur, plantar fascii�s)

02 Cervical disk rediculopathy (pinched neck nerve) 06 Tendoni�s of forearm/wrist 10 Lumbo-sacral rediculopathy (pinched nerve in lower back) 14 Bursi�s (specify where)

03 Rotator Cuff tear/injury 07 Carpal Tunnel syndrome 11 Low back pain/strain diagnosed by MD 15 Spinal Stenosis

04 Epicondyli�s (tennis/golfers elbow) 08 Trigger Finger 12 Knee disorder (e.g., torn car�lage/ligament, strain or tear) 16 Other

Musculoskeletal Condi�ons 20080925.1 21

5.1.2 Do you have any muscle or joint symptoms that appear to be related to or worsened by your work? � Yes [Specify] ______________________________________� No � DK � R

5.2 Clinical Comments:

Sec�on 6 Review of Systems

6.1 Other Diagnosed Condi�ons, Non-Cancer

“Now I am going to ask you about other physician-diagnosed medical conditions that you may ever have had.”

Condi�on A. Since we last saw you, has a doctor, nurse prac��oner or physician’s assistant ever told you that you have [condi�on]?

B. When were you diagnosed with [condi�on]?

C. Are you currently under the care of a doctor for [condi�on]?

6.1.1 Arthritis

� Reported at ini�al or periodic visit

[If reported either in ini�al or periodic visit, go to C] [If not reported in ini�al or periodic visit, go to A]

� Yes [A1] � DK [next]

� No [next] � Refused [next]

A1. If Yes, which type of arthritis was it?

[check one] [B]

___________ [MM/YY] [C]

� DK [C]

� Refused [C]

� Yes � DK

� No � Refused

� Rheumatoid

� Lupus

� Osteoarthri�s

Psoria�c

� Post-trauma�c

Scleroderma

� Poly(dermato)myosi�s

� Ankylosing spondyli�s

� Other

� DK

� Refused

6.1.2 High blood pressure including borderline

� Reported at ini�al or periodic visit

[If reported either in ini�al or periodic visit, go to C] [If not reported in ini�al or periodic visit, go to A]

� Yes [B] � DK [next]

� No [next] � Refused [next]

___________ [MM/YY] [C]

� DK [C]

� Refused [C]

� Yes � DK

� No � Refused

6.1.3 Heart trouble: Reported at ini�al visit or subsequent visit: � Yes � No

6.1.4 Since we last saw you, have you been told by a doctor you had any type of trouble with your heart? � Yes � No [6.1.11] � DK � R

Musculoskeletal / Review of Systems 20080925.1 22

Condi�on A. Since we last saw you, has a doctor, nurse prac��oner or physician’s assistant ever told you that you have [condi�on]?

B. When were you diagnosed with [condi�on]?

C. Are you currently under the care of a doctor for [condi�on]?

6.1.5 Coronary artery disease, Angina (also called

angina pectoris), and/or Heart attack

� Reported at ini�al or periodic visit

[If reported either in ini�al or periodic visit, go to C] [If not reported in ini�al or periodic visit, go to A]

� Yes [B] � DK [next]

� No [next] � Refused [next]

___________ [MM/YY] [C]

� DK [C]

� Refused [C]

� Yes � DK

� No � Refused

6.1.6 Heart Attack

� Reported at ini�al or periodic visit

[If reported either in ini�al or periodic visit, go to B] [If not reported in ini�al or periodic visit, go to A]

� Yes [B] � DK [next]

� No [next] � Refused [next] Most recent diagnosis ___________ [MM/YY]

Earliest diagnosis ___________ [MM/YY] � DK � Refused

Total # of heart a�acks ___________

6.1.7 Abnormal or irregular heart beat/heart rhythm

� Reported at ini�al or periodic visit

[If reported either in ini�al or periodic visit, go to C] [If not reported in ini�al or periodic visit, go to A]

� Yes [A1] � DK [next]

� No [next] � Refused [next]

A1. [Specify] ___________________________________

___________ [MM/YY] [C]

� DK [C]

� Refused [C]

� Yes � DK

� No � Refused

6.1.8 Heart murmur or valve problem

� Reported at ini�al or periodic visit

[If reported either in ini�al or periodic visit, go to C] [If not reported in ini�al or periodic visit, go to A]

� Yes [B] � DK [next]

� No [next] � Refused [next]

___________ [MM/YY] [C]

� DK [C]

� Refused [C]

� Yes � DK

� No � Refused

6.1.9 Congestive heart failure or cardiomyopathy

� Reported at ini�al or periodic visit

[If reported either in ini�al or periodic visit, go to C] [If not reported in ini�al or periodic visit, go to A]

� Yes [B] � DK [next]

� No [next] � Refused [next]

___________ [MM/YY] [C]

� DK [C]

� Refused [C]

� Yes � DK

� No � Refused

6.1.10 Other heart disease

� Reported at ini�al or periodic visit

[If reported either in ini�al or periodic visit, go to C] [If not reported in ini�al or periodic visit, go to A]

� Yes [B] � DK [next]

� No [next] � Refused [next]

___________ [MM/YY] [C]

� DK [C]

� Refused [C]

� Yes � DK

� No � Refused

Review of Systems 20080925.1 23

B. When were you diagnosed with [condi�on]?

C. Are you currently under the care of a doctor for [condi�on]?

6.1.11 Asbestos-related scarring of the lung or the

lining of the lung

� Reported at ini�al or periodic visit

[If reported either in ini�al or periodic visit, go to C] [If not reported in ini�al or periodic visit, go to A]

� Yes [B] � DK [next]

� No [next] � Refused [next]

___________ [MM/YY] [C]

� DK [C]

� Refused [C]

Does your doctor know about your [condition]?

� Yes � DK

� No � Refused

C1. Are you monitored for this at least annually?

� Yes � DK

� No � Refused

6.1.12 Pleurisy or pleural fluid/effusion

� Reported at ini�al or periodic visit

[If reported either in ini�al or periodic visit, go to C] [If not reported in ini�al or periodic visit, go to A]

� Yes [B] � DK [next]

� No [next] � Refused [next]

___________ [MM/YY] [C]

� DK [C]

� Refused [C]

� Yes � DK

� No � Refused

6.1.13 Sarcoidosis

� Reported at ini�al or periodic visit

[If reported either in ini�al or periodic visit, go to C] [If not reported in ini�al or periodic visit, go to A]

� Yes [B] � DK [next]

� No [next] � Refused [next]

___________ [MM/YY] [C]

� DK [C]

� Refused [C]

� Yes � DK

� No � Refused

6.1.14 Tuberculosis

� Reported at ini�al or periodic visit

[If reported either in ini�al or periodic visit, go to C] [If not reported in ini�al or periodic visit, go to A]

� Yes [B] � DK [next]

� No [next] � Refused [next]

___________ [MM/YY] [C]

� DK [C]

� Refused [C]

� Yes � DK

� No � Refused

6.1.15 Diabetes

� Reported at ini�al or periodic visit

[If reported either in ini�al or periodic visit, go to C] [If not reported in ini�al or periodic visit, go to A]

� Yes [B] � DK [next]

� No [next] � Refused [next]

___________ [MM/YY] [C]

� DK [C]

� Refused [C]

� Yes � DK

� No � Refused

6.1.16 Elevated Cholesterol

� Reported at ini�al or periodic visit

[If reported either in ini�al or periodic visit, go to C] [If not reported in ini�al or periodic visit, go to A]

� Yes [B] � DK [next]

� No [next] � Refused [next]

___________ [MM/YY] [B1]

� DK [B1]

� Refused [B1]

� Yes � DK

Review of Systems 20080925.1 24

B. When were you diagnosed with [condi�on]?

C. Are you currently under the care of a doctor for [condi�on]?

6.1.17 Elevated triglycerides

� Reported at ini�al or periodic visit

[If reported either in ini�al or periodic visit, go to C] [If not reported in ini�al or periodic visit, go to A]

� Yes [B] � DK [next]

� No [next] � Refused [next]

___________ [MM/YY] [C]

� DK [C]

� Refused [C]

� Yes � DK

� No � Refused

6.1.18 Stroke [use “other conditions” for transient

ischemic attack (TIA)-Q.6.4.13]

� Reported at ini�al or periodic visit

[If reported either in ini�al or periodic visit, go to C] [If not reported in ini�al or periodic visit, go to A]

� Yes [B] � DK [next]

� No [next] � Refused [next]

Most recent diagnosis

___________ [MM/YY] [B1]

� DK [B1]

� Refused [B1]

B1. Earliest diagnosis

___________ [MM/YY] [C]

� DK [C]

� Refused [C]

� Yes � DK

� No � Refused

6.1.19 Thyroid problem (not cancer)

� Reported at ini�al or periodic visit

[If reported either in ini�al or periodic visit, go to C] [If not reported in ini�al or periodic visit, go to A]

� Yes [A1] � DK [next]

� No [next] � Refused [next]

___________ [MM/YY] [C]

� DK [C]

� Refused [C]

� Yes � DK

� No � Refused

A1. [Specify which type] ____________________________ [B]

� DK [B] � Refused [B]

6.1.20 Kidney disease (not cancer)

� Reported at ini�al or periodic visit

[If reported either in ini�al or periodic visit, go to C] [If not reported in ini�al or periodic visit, go to A]

� Yes [B] � DK [next]

� No [next] � Refused [next]

___________ [MM/YY] [C]

� DK [C]

� Refused [C]

� Yes � DK

� No � Refused

6.1.21 Hepatitis

� Reported at ini�al or periodic visit

[If reported either in ini�al or periodic visit, go to C] [If not reported in ini�al or periodic visit, go to A]

� Yes [A1] � DK [next]

� No [next] � Refused [next]

Most recent diagnosis

___________ [MM/YY]

Earliest diagnosis

___________ [MM/YY]

� DK

� Refused

Total # of Diagnoses _______

� Yes � DK

� No � Refused

A1. [Specify which type] ____________________________ [B]

� DK [B] � Refused [B]

Review of Systems 20080925.1 25

B. When were you diagnosed with [condi�on]?

C. Are you currently under the care of a doctor for [condi�on]?

6.1.22 Crohn’s disease/Ulcerative Colitis

� Reported at ini�al or periodic visit

[If reported either in ini�al or periodic visit, go to C] [If not reported in ini�al or periodic visit, go to A]

� Yes [B] � DK [next]

� No [next] � Refused [next]

Most recent diagnosis

___________ [MM/YY] [B1]

� DK [B1]

� Refused [B1]

B1. Earliest diagnosis

___________ [MM/YY] [C]

� DK [C]

� Refused [C]

� Yes � DK

� No � Refused

6.1.23 Cirrhosis

� Reported at ini�al or periodic visit

[If reported either in ini�al or periodic visit, go to C] [If not reported in ini�al or periodic visit, go to A]

� Yes [B] � DK [next]

� No [next] � Refused [next]

Most recent diagnosis

___________ [MM/YY] [B1]

� DK [B1]

� Refused [B1]

B1. Earliest diagnosis

___________ [MM/YY] [C]

� DK [C]

� Refused [C]

� Yes � DK

� No � Refused

6.1.24 Chronic Laryngitis

� Reported at ini�al or periodic visit

[If reported either in ini�al or periodic visit, go to C] [If not reported in ini�al or periodic visit, go to A]

� Yes [B] � DK [next]

� No [next] � Refused [next]

[Specify which type] __________________________________

___________ [MM/YY] [C]

� DK [C]

� Refused [C]

� Yes � DK

� No � Refused

6.1.25 Chronic Tonsillitis

� Reported at ini�al or periodic visit

[If reported either in ini�al or periodic visit, go to C] [If not reported in ini�al or periodic visit, go to A]

� Yes [B] � DK [next]

� No [next] � Refused [next]

___________ [MM/YY] [C]

� DK [C]

� Refused [C]

� Yes � DK

� No � Refused

6.1.26 Autoimmune Disease

� Reported at ini�al or periodic visit

[If reported either in ini�al or periodic visit, go to C] [If not reported in ini�al or periodic visit, go to A]

� Yes [B] � DK [next]

� No [next] � Refused [next]

[Specify which type] __________________________________

___________ [MM/YY] [C]

� DK [C]

� Refused [C]

� Yes � DK

Review of Systems…