Start
nshd_99_scq
MRC NATIONAL SURVEY OF HEALTH AND DEVELOPMENT
University College London Medical School Department of Epidemiology and Public Health
SELF-COMPLETION BOOKLET 1999

INTERVIEW DATE

Generic date
How often do you normally eat the following types of foods?
-

1 - Most days

2 - Sometimes

3 - Hardly ever or never

Apples or pears
Biscuits or cakes
Carrots
Crisps or savoury snacks
Chocolate or other confectionary
Coffee
Chips
Fish
Fruit juice (not squash or fizzy)
Green leafy vegetables or salad
Meat (beef, lamb, pork, bacon, ham)
Onions
Oranges or other citrus fruit
Tea

Are you on any special diet at the moment?

1
Yes
0
No
If No to question 2a GO TO QUESTION 3
qc_2_a == 0
Else

Is your diet:

1
low salt/salt free
2
low fat
3
high fibre/high residue
4
low protein
5
diabetic
6
weight reduction
7
gluten-free
8
other (please describe)
Other

Was it recommended by a doctor?

1
Yes
0
No

Are you a vegetarian?

1
Yes
0
No

When you eat a main meal or any other food is salt generally added to it: during cooking?

1
Yes
0
No

When you eat a main meal or any other food is salt generally added to it: at table?

1
Yes
0
No

Have you drunk alcohol in the last year?

0
No
1
Only on special occasions
2
More often
If No to question 5 GO TO QUESTION 11
qc_5 == 0
Else

In the last seven days have you had any of the following drinks? Spirits or liqueurs (e.g. whisky, gin, brandy, vodka)

1
Yes
0
No
If Yes to question 6a
qc_6_a == 1

How many measures?

How many

In the last seven days have you had any of the following drinks? Wine, sherry, martini or port

1
Yes
0
No
If Yes to question 6b
qc_6_b == 1

How many glasses?

How many

In the last seven days have you had any of the following drinks? Beer lager, cider or stout

1
Yes
0
No
If Yes to question 6c
qc_6_c == 1

How many 1/2 pints?

How many

In the last year, have you felt you ought to cut down on your drinking? DO NOT INCLUDE DIETING

1
Yes
0
No

In the last year, have people ever annoyed you by criticising your drinking?

1
Yes
0
No

In the last year, have you ever felt bad or guilty about your drinking?

1
Yes
0
No

In the last year, have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?

1
Yes
0
No

Do you usually wear glasses or contact lenses for distance vision (e.g. for driving a car or watching television)?

1
Yes
0
No

Do you have difficulty recognising a friend across the road (4 yards)? (without distance vision glasses or contact lenses if you have them)

1
Yes
0
No

Do you wear a hearing aid?

1
Yes
0
No

Do you find it very difficult to follow a conversation if there is background noise, such as TV, radio, children playing? (without a hearing aid if you have one)

1
Yes
0
No

In your spare time do you do any of the following activities? Constructive activities, making things with your hands

1
Yes
0
No
If Yes to question 15a
qc_15_a == 1

How often do you take part?

1
weekly
2
monthly
3
less often

In your spare time do you do any of the following activities? Musical, artistic or creative activities

1
Yes
0
No
If Yes to question 15b
qc_15_b == 1

How often do you take part?

1
weekly
2
monthly
3
less often

Thinking about the person you have felt closest to in the last 12 months please answer the following questions: Is this person your ...

1
husband/wife/partner
2
boyfriend/girlfriend
3
parent
4
brother/sister
5
son/daughter
6
other relative
7
neighbour
8
friend from work
9
other friend
10
other (please describe)
11
No-one
Other
If No-one to question 16a GO TO QUESTION 17
qc_16_a == 11
Else

How much in the last 12 months did this person make you feel good about yourself?

0
Not at all
1
A little
2
Quite a lot
3
A great deal

How much in the last 12 months did you share interests, hobbies and fun with this person?

0
Not at all
1
A little
2
Quite a lot
3
A great deal

How much in the last 12 months did this person give you worries, problems and stress?

0
Not at all
1
A little
2
Quite a lot
3
A great deal

How much in the last 12 months did you confide in this person?

0
Not at all
1
A little
2
Quite a lot
3
A great deal

How much in the last 12 months would you have liked to have confided more in this person?

0
Not at all
1
A little
2
Quite a lot
3
A great deal

How much in the last 12 months did talking to this person make things worse?

0
Not at all
1
A little
2
Quite a lot
3
A great deal

Overall, do you think you have enough opportunity to talk openly and share your feelings about things?

1
Yes
0
No
Please answer ALL the following questions about how you have been feeling over the past few weeks. Remember that we want to know about your present and recent complaints, not those you had in the past.

HAVE YOU RECENTLY: Been feeling perfectly well and in good health?

1
Better than usual
2
Same as usual
3
Worse than usual
4
Much worse than usual

HAVE YOU RECENTLY: Been feeling in need of a good tonic?

1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual

HAVE YOU RECENTLY: Been feeling run down and out of sorts?

1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual

HAVE YOU RECENTLY: Felt that you are ill?

1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual

HAVE YOU RECENTLY: Been getting any pains in your head?

1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual

HAVE YOU RECENTLY: Been getting a feeling of tightness or pressure in your head?

1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual

HAVE YOU RECENTLY: Been having hot or cold spells?

1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual

HAVE YOU RECENTLY: Lost much sleep over worry?

1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual

HAVE YOU RECENTLY: Had difficulty staying asleep once you are off?

1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual

HAVE YOU RECENTLY: Been managing to keep yourself busy and occupied?

1
More so than usual
2
Same as usual
3
Rather less than usual
4
Much less than usual

HAVE YOU RECENTLY: Been taking longer over the things you do?

1
Quicker than usual
2
Same as usual
3
Longer than usual
4
Much longer than usual

HAVE YOU RECENTLY: Felt on the whole you were doing things well?

1
Better than usual
2
About the same as usual
3
Less well than usual
4
Much less well

HAVE YOU RECENTLY: Been satisfied with the way you've carried out your task?

1
More satisfied
2
About the same as usual
3
Less satisfied than usual
4
Much less satisfied

HAVE YOU RECENTLY: Felt that you are playing a useful part in things?

1
More so than usual
2
Same as usual
3
Less useful than usual
4
Much less useful

HAVE YOU RECENTLY: Felt capable of making decisions about things?

1
More so than usual
2
Same as usual
3
Less so than usual
4
Much less capable

HAVE YOU RECENTLY: Felt constantly under strain?

1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual

HAVE YOU RECENTLY: Been able to enjoy your normal day-to-day activities?

1
More so than usual
2
Same as usual
3
Less so than usual
4
Much less than usual

HAVE YOU RECENTLY: Been getting edgy and bad-tempered?

1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual

HAVE YOU RECENTLY: Been getting scared or panicky for no good reason?

1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual

HAVE YOU RECENTLY: Found everything getting on top of you?

1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual

HAVE YOU RECENTLY: Been thinking of yourself as a worthless person?

1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual

HAVE YOU RECENTLY: Felt that life is entirely hopeless?

1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual

HAVE YOU RECENTLY: Been feeling nervous and strung-up all the time?

1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual

HAVE YOU RECENTLY: Felt that life isn't worth living?

1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual

HAVE YOU RECENTLY: Thought of the possibility that you might make away with yourself?

1
Definitely not
2
I don't think so
3
Has crossed my mind
4
Definitely have

HAVE YOU RECENTLY: Found at times you couldn't do anything because your nerves were too bad?

1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual

HAVE YOU RECENTLY: Found yourself wishing you were dead and away from it all?

1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual

HAVE YOU RECENTLY: Found that the idea of taking your life kept coming into your mind?

1
Definitely not
2
I don't think so
3
Has crossed my mind
4
Definitely has
These next five questions are about how you have been feeling over the past year.

Over the past year, have there been times when you felt very happy indeed without a break for days on end?

2
Yes
1
Unsure
0
No

Over the past year, have you felt that your thoughts were directly interfered with or controlled by some outside force or person?

2
Yes
1
Unsure
0
No

Over the past year, have there been times when you felt people were against you?

2
Yes
1
Unsure
0
No

Over the past year, have there been times when you felt that something strange was going on?

2
Yes
1
Unsure
0
No

Over the past year, have there been times when you heard or saw things that other people couldn't?

2
Yes
1
Unsure
0
No
MEN ONLY
Many men suffer from bladder problems. We would like to find out more about these common problems and we would be grateful if you would answer these questions.

During the last month how long have you usually been able to go during the daytime, without passing water? ... hours ... minutes

Hours Minutes
During the last month have you:
-

1 - Never

2 - Less than 1 time in 5

3 - Less than halft the time

4 - About half the time

5 - More than half the time

6 - Always or almost always

Had to get up in the night to pass water?
Have you found it difficult to wait to pass water once you feel the need?
Once you are ready to pass water have you had to wait before urine comes?
Has your stream stopped and then started again?
Have you had a weak urinary stream?
Have you had a sensation of not emptying your bladder completely after you've finished?
Have you had a burning feeling while passing water?
Have you dripped urine or wet your clothes in a way you couldn't control?
If you haven't dripped urine or wet your clothes in a way you couldn't control during the last month, go to Question 54. Otherwise answer Questions 53a-g.
qc_52_a-h$1;8 != 1
Else

How often do you leak urine?

3
Several times a day
2
Several times a week
1
Less often

Do you usually leak?

1
A few drops?
2
Enough to wet your underpants?
3
So that it wets your trousers?

Do you leak urine when you make a physical effort, like lifting, running, coughing, sneezing or laughing?

1
Yes
0
No

When you feel an urgent need to pass water do you leak urine before you can get to the toilet?

2
Yes, every time
1
Yes, sometimes
0
No
If No to question 53d go to question 53f
qc_53_d == 0
Else

What makes you leak when the need is urgent?

1
Standing up
2
Washing your hands
3
Hearing running water

Do you leak urine ...

1
without urgency or warning?
2
when you are asleep?
3
after you've finished passing water?
4
during intercourse?

Do you take precautions to deal with urine leakage, for example using pads?

1
Yes
0
No
If Yes,
qc_53_h == 1

describe methods you use:

Generic text

Have you ever consulted a doctor about urinary problems?

0
No
1
Yes
If No to question 54a GO TO QUESTION 55
qc_54_a == 0
Else

How old were you when you: first consulted? ... Age

Age

How old were you when you: last consulted? ... Age

Age

During the last month, has any urinary problem kept you from doing the kind of things you usually do?

1
None of the time
2
A little of the time
3
Some of the time
4
Most of the time
5
All the time

If your current urinary problem were to last, would you feel

0
No problem
1
Happy
2
Pleased
3
Satisfied
4
Mixed
5
Dissatisfied
6
Unhappy
7
Desperate
WOMEN ONLY

Have you ever had any of the following operations? (FOR EACH OPERATION CIRCLE O (No) or 1 (Yes). Removal of uterus (womb) and both ovaries (hysterectomy & bilateral oopherectomy)

0
No
1
Yes
IF YES,
qc_57a == 1

give dates of all operations. If you cannot remember the month and year, give your age at the time of the operation.) Month … Year ... or Age at the time … yrs

Generic date

Have you ever had any of the following operations? (FOR EACH OPERATION CIRCLE O (No) or 1 (Yes). Removal of uterus (womb) only (hysterectomy)

0
No
1
Yes
IF YES,
qc_57b == 1

give dates of all operations. If you cannot remember the month and year, give your age at the time of the operation.) Month … Year ... or Age at the time … yrs

Generic date

Have you ever had any of the following operations? (FOR EACH OPERATION CIRCLE O (No) or 1 (Yes). Removal of uterus (womb) and one ovary (hysterectomy and oopherectomy)

0
No
1
Yes
IF YES,
qc_57c == 1

give dates of all operations. If you cannot remember the month and year, give your age at the time of the operation.) Month … Year ... or Age at the time … yrs

Generic date

Have you ever had any of the following operations? (FOR EACH OPERATION CIRCLE O (No) or 1 (Yes). Removal of both ovaries only (bilateral oophorectomy)

0
No
1
Yes
IF YES,
qc_57d == 1

give dates of all operations. If you cannot remember the month and year, give your age at the time of the operation.) Month … Year ... or Age at the time … yrs

Generic date

Have you ever had any of the following operations? (FOR EACH OPERATION CIRCLE O (No) or 1 (Yes) Removal of one ovary only (oopherectomy)

0
No
1
Yes
IF YES,
qc_57e == 1

give dates of all operations. If you cannot remember the month and year, give your age at the time of the operation.) Month … Year ... or Age at the time … yrs

Generic date

In the last 12 months have you had a period or menstrual bleeding?

0
No
1
Yes
IF NO,
qc_58 == 0

were your periods stopped by:

1
Surgery?
2
Chemotherapy or radiation therapy
3
Pregnancy or breastefeeding
4
No obvious reason/menopause?
5
Other reason, please specify
Other

In the last 3 months have you had a period or menstrual bleeding?

0
No
1
Yes

When was your last period? (Include current period if bleeding now.) Month ...Year … If you cannot remember the month and year please give your age at the time. ... yrs

Generic date
Age
These questions are for all women answering this section.

If you are still having periods, tell us about the most recent changes. If your periods have stopped, tell us about the changes before your last period. In the last few years (in the years before your last period) did your periods:

1
become more regular?
2
become less regular?
3
remain about the same? (i.e. as regular/irregular as before)
If remain about the same? (i.e. as regular/irregular as before) to question 61a go to Question 62
qc_61_a == 3
Else

If more regular or less regular, when did you first notice this change?

1
Up to 1 year before last period
2
Up to 2 years before last period
3
Up to 3 years before last period
4
Up to 4 years before last period
5
More than 4 years before last period

Have you ever had hormone replacement therapy (HRT)?

0
No
1
Yes
If No to question 62 (go to end)
qc_62 == 0
Else

When did you first start HRT? Month ... Year … If you cannot remember the month and year please give your age at the time. ... yrs

Generic date
Age

Before you first started HRT had your menstrual periods stopped?

0
No
1
Yes
If yes,
qc_64 == 1

what was the date of your last period before starting HRT? Month ... Year … If you cannot remember the month and year please give your age at the time. … yrs

Generic date
Age

Have you ever stopped HRT and then started again?

0
No
1
Yes

Are you currently on HRT?

0
No
1
Yes
End

nshd_99_scq

MRC NATIONAL SURVEY OF HEALTH AND DEVELOPMENT
University College London Medical School Department of Epidemiology and Public Health
SELF-COMPLETION BOOKLET 1999
INTERVIEW DATE
Generic date

How often do you normally eat the following types of foods?

-

1 - Most days

2 - Sometimes

3 - Hardly ever or never

Apples or pears
Biscuits or cakes
Carrots
Crisps or savoury snacks
Chocolate or other confectionary
Coffee
Chips
Fish
Fruit juice (not squash or fizzy)
Green leafy vegetables or salad
Meat (beef, lamb, pork, bacon, ham)
Onions
Oranges or other citrus fruit
Tea
Are you on any special diet at the moment?
1
Yes
0
No
Is your diet:
1
low salt/salt free
2
low fat
3
high fibre/high residue
4
low protein
5
diabetic
6
weight reduction
7
gluten-free
8
other (please describe)
Other
Was it recommended by a doctor?
1
Yes
0
No
Are you a vegetarian?
1
Yes
0
No
When you eat a main meal or any other food is salt generally added to it: during cooking?
1
Yes
0
No
When you eat a main meal or any other food is salt generally added to it: at table?
1
Yes
0
No
Have you drunk alcohol in the last year?
0
No
1
Only on special occasions
2
More often
In the last seven days have you had any of the following drinks? Spirits or liqueurs (e.g. whisky, gin, brandy, vodka)
1
Yes
0
No
How many measures?
How many
In the last seven days have you had any of the following drinks? Wine, sherry, martini or port
1
Yes
0
No
How many glasses?
How many
In the last seven days have you had any of the following drinks? Beer lager, cider or stout
1
Yes
0
No
How many 1/2 pints?
How many
In the last year, have you felt you ought to cut down on your drinking? DO NOT INCLUDE DIETING
1
Yes
0
No
In the last year, have people ever annoyed you by criticising your drinking?
1
Yes
0
No
In the last year, have you ever felt bad or guilty about your drinking?
1
Yes
0
No
In the last year, have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?
1
Yes
0
No
Do you usually wear glasses or contact lenses for distance vision (e.g. for driving a car or watching television)?
1
Yes
0
No
Do you have difficulty recognising a friend across the road (4 yards)? (without distance vision glasses or contact lenses if you have them)
1
Yes
0
No
Do you wear a hearing aid?
1
Yes
0
No
Do you find it very difficult to follow a conversation if there is background noise, such as TV, radio, children playing? (without a hearing aid if you have one)
1
Yes
0
No
In your spare time do you do any of the following activities? Constructive activities, making things with your hands
1
Yes
0
No
How often do you take part?
1
weekly
2
monthly
3
less often
In your spare time do you do any of the following activities? Musical, artistic or creative activities
1
Yes
0
No
How often do you take part?
1
weekly
2
monthly
3
less often
Thinking about the person you have felt closest to in the last 12 months please answer the following questions: Is this person your ...
1
husband/wife/partner
2
boyfriend/girlfriend
3
parent
4
brother/sister
5
son/daughter
6
other relative
7
neighbour
8
friend from work
9
other friend
10
other (please describe)
11
No-one
Other
How much in the last 12 months did this person make you feel good about yourself?
0
Not at all
1
A little
2
Quite a lot
3
A great deal
How much in the last 12 months did you share interests, hobbies and fun with this person?
0
Not at all
1
A little
2
Quite a lot
3
A great deal
How much in the last 12 months did this person give you worries, problems and stress?
0
Not at all
1
A little
2
Quite a lot
3
A great deal
How much in the last 12 months did you confide in this person?
0
Not at all
1
A little
2
Quite a lot
3
A great deal
How much in the last 12 months would you have liked to have confided more in this person?
0
Not at all
1
A little
2
Quite a lot
3
A great deal
How much in the last 12 months did talking to this person make things worse?
0
Not at all
1
A little
2
Quite a lot
3
A great deal
Overall, do you think you have enough opportunity to talk openly and share your feelings about things?
1
Yes
0
No
Please answer ALL the following questions about how you have been feeling over the past few weeks. Remember that we want to know about your present and recent complaints, not those you had in the past.
HAVE YOU RECENTLY: Been feeling perfectly well and in good health?
1
Better than usual
2
Same as usual
3
Worse than usual
4
Much worse than usual
HAVE YOU RECENTLY: Been feeling in need of a good tonic?
1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual
HAVE YOU RECENTLY: Been feeling run down and out of sorts?
1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual
HAVE YOU RECENTLY: Felt that you are ill?
1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual
HAVE YOU RECENTLY: Been getting any pains in your head?
1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual
HAVE YOU RECENTLY: Been getting a feeling of tightness or pressure in your head?
1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual
HAVE YOU RECENTLY: Been having hot or cold spells?
1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual
HAVE YOU RECENTLY: Lost much sleep over worry?
1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual
HAVE YOU RECENTLY: Had difficulty staying asleep once you are off?
1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual
HAVE YOU RECENTLY: Been managing to keep yourself busy and occupied?
1
More so than usual
2
Same as usual
3
Rather less than usual
4
Much less than usual
HAVE YOU RECENTLY: Been taking longer over the things you do?
1
Quicker than usual
2
Same as usual
3
Longer than usual
4
Much longer than usual
HAVE YOU RECENTLY: Felt on the whole you were doing things well?
1
Better than usual
2
About the same as usual
3
Less well than usual
4
Much less well
HAVE YOU RECENTLY: Been satisfied with the way you've carried out your task?
1
More satisfied
2
About the same as usual
3
Less satisfied than usual
4
Much less satisfied
HAVE YOU RECENTLY: Felt that you are playing a useful part in things?
1
More so than usual
2
Same as usual
3
Less useful than usual
4
Much less useful
HAVE YOU RECENTLY: Felt capable of making decisions about things?
1
More so than usual
2
Same as usual
3
Less so than usual
4
Much less capable
HAVE YOU RECENTLY: Felt constantly under strain?
1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual
HAVE YOU RECENTLY: Been able to enjoy your normal day-to-day activities?
1
More so than usual
2
Same as usual
3
Less so than usual
4
Much less than usual
HAVE YOU RECENTLY: Been getting edgy and bad-tempered?
1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual
HAVE YOU RECENTLY: Been getting scared or panicky for no good reason?
1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual
HAVE YOU RECENTLY: Found everything getting on top of you?
1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual
HAVE YOU RECENTLY: Been thinking of yourself as a worthless person?
1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual
HAVE YOU RECENTLY: Felt that life is entirely hopeless?
1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual
HAVE YOU RECENTLY: Been feeling nervous and strung-up all the time?
1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual
HAVE YOU RECENTLY: Felt that life isn't worth living?
1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual
HAVE YOU RECENTLY: Thought of the possibility that you might make away with yourself?
1
Definitely not
2
I don't think so
3
Has crossed my mind
4
Definitely have
HAVE YOU RECENTLY: Found at times you couldn't do anything because your nerves were too bad?
1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual
HAVE YOU RECENTLY: Found yourself wishing you were dead and away from it all?
1
Not at all
2
No more than usual
3
Rather more than usual
4
Much more than usual
HAVE YOU RECENTLY: Found that the idea of taking your life kept coming into your mind?
1
Definitely not
2
I don't think so
3
Has crossed my mind
4
Definitely has
These next five questions are about how you have been feeling over the past year.
Over the past year, have there been times when you felt very happy indeed without a break for days on end?
2
Yes
1
Unsure
0
No
Over the past year, have you felt that your thoughts were directly interfered with or controlled by some outside force or person?
2
Yes
1
Unsure
0
No
Over the past year, have there been times when you felt people were against you?
2
Yes
1
Unsure
0
No
Over the past year, have there been times when you felt that something strange was going on?
2
Yes
1
Unsure
0
No
Over the past year, have there been times when you heard or saw things that other people couldn't?
2
Yes
1
Unsure
0
No
Many men suffer from bladder problems. We would like to find out more about these common problems and we would be grateful if you would answer these questions.
During the last month how long have you usually been able to go during the daytime, without passing water? ... hours ... minutes
Hours Minutes

During the last month have you:

-

1 - Never

2 - Less than 1 time in 5

3 - Less than halft the time

4 - About half the time

5 - More than half the time

6 - Always or almost always

Had to get up in the night to pass water?
Have you found it difficult to wait to pass water once you feel the need?
Once you are ready to pass water have you had to wait before urine comes?
Has your stream stopped and then started again?
Have you had a weak urinary stream?
Have you had a sensation of not emptying your bladder completely after you've finished?
Have you had a burning feeling while passing water?
Have you dripped urine or wet your clothes in a way you couldn't control?
How often do you leak urine?
3
Several times a day
2
Several times a week
1
Less often
Do you usually leak?
1
A few drops?
2
Enough to wet your underpants?
3
So that it wets your trousers?
Do you leak urine when you make a physical effort, like lifting, running, coughing, sneezing or laughing?
1
Yes
0
No
When you feel an urgent need to pass water do you leak urine before you can get to the toilet?
2
Yes, every time
1
Yes, sometimes
0
No
What makes you leak when the need is urgent?
1
Standing up
2
Washing your hands
3
Hearing running water
Do you leak urine ...
1
without urgency or warning?
2
when you are asleep?
3
after you've finished passing water?
4
during intercourse?
Do you take precautions to deal with urine leakage, for example using pads?
1
Yes
0
No
describe methods you use:
Generic text
Have you ever consulted a doctor about urinary problems?
0
No
1
Yes
How old were you when you: first consulted? ... Age
Age
How old were you when you: last consulted? ... Age
Age
During the last month, has any urinary problem kept you from doing the kind of things you usually do?
1
None of the time
2
A little of the time
3
Some of the time
4
Most of the time
5
All the time
If your current urinary problem were to last, would you feel
0
No problem
1
Happy
2
Pleased
3
Satisfied
4
Mixed
5
Dissatisfied
6
Unhappy
7
Desperate
Have you ever had any of the following operations? (FOR EACH OPERATION CIRCLE O (No) or 1 (Yes). Removal of uterus (womb) and both ovaries (hysterectomy & bilateral oopherectomy)
0
No
1
Yes
give dates of all operations. If you cannot remember the month and year, give your age at the time of the operation.) Month … Year ... or Age at the time … yrs
Generic date
Have you ever had any of the following operations? (FOR EACH OPERATION CIRCLE O (No) or 1 (Yes). Removal of uterus (womb) only (hysterectomy)
0
No
1
Yes
give dates of all operations. If you cannot remember the month and year, give your age at the time of the operation.) Month … Year ... or Age at the time … yrs
Generic date
Have you ever had any of the following operations? (FOR EACH OPERATION CIRCLE O (No) or 1 (Yes). Removal of uterus (womb) and one ovary (hysterectomy and oopherectomy)
0
No
1
Yes
give dates of all operations. If you cannot remember the month and year, give your age at the time of the operation.) Month … Year ... or Age at the time … yrs
Generic date
Have you ever had any of the following operations? (FOR EACH OPERATION CIRCLE O (No) or 1 (Yes). Removal of both ovaries only (bilateral oophorectomy)
0
No
1
Yes
give dates of all operations. If you cannot remember the month and year, give your age at the time of the operation.) Month … Year ... or Age at the time … yrs
Generic date
Have you ever had any of the following operations? (FOR EACH OPERATION CIRCLE O (No) or 1 (Yes) Removal of one ovary only (oopherectomy)
0
No
1
Yes
give dates of all operations. If you cannot remember the month and year, give your age at the time of the operation.) Month … Year ... or Age at the time … yrs
Generic date
In the last 12 months have you had a period or menstrual bleeding?
0
No
1
Yes
were your periods stopped by:
1
Surgery?
2
Chemotherapy or radiation therapy
3
Pregnancy or breastefeeding
4
No obvious reason/menopause?
5
Other reason, please specify
Other
In the last 3 months have you had a period or menstrual bleeding?
0
No
1
Yes
When was your last period? (Include current period if bleeding now.) Month ...Year … If you cannot remember the month and year please give your age at the time. ... yrs
Generic date
Age
These questions are for all women answering this section.
If you are still having periods, tell us about the most recent changes. If your periods have stopped, tell us about the changes before your last period. In the last few years (in the years before your last period) did your periods:
1
become more regular?
2
become less regular?
3
remain about the same? (i.e. as regular/irregular as before)
If more regular or less regular, when did you first notice this change?
1
Up to 1 year before last period
2
Up to 2 years before last period
3
Up to 3 years before last period
4
Up to 4 years before last period
5
More than 4 years before last period
Have you ever had hormone replacement therapy (HRT)?
0
No
1
Yes
When did you first start HRT? Month ... Year … If you cannot remember the month and year please give your age at the time. ... yrs
Generic date
Age
Before you first started HRT had your menstrual periods stopped?
0
No
1
Yes
what was the date of your last period before starting HRT? Month ... Year … If you cannot remember the month and year please give your age at the time. … yrs
Generic date
Age
Have you ever stopped HRT and then started again?
0
No
1
Yes
Are you currently on HRT?
0
No
1
Yes
Name

1999 Self-Completion Questionnaire