National Survey of Health and Development
2006-2010 (Age 60-64)
2006-2010 Clinic Study Postal Questionnaire
nshd_06_pq
STRICTLY CONFIDENTIAL
MRC NATIONAL SURVEY OF HEALTH AND DEVELOPMENT
MRC Unit for Lifelong Health & Ageing
Royal Free & University College Medical School
Department of Epidemiology and Public Health
Postal Questionnaire 2008
This questionnaire is about your health and about your family and work life.
When completing the questionnaire please use a pen to circle the appropriate response to each question and provide further details where requested either in boxes or in the space provided. Some questions don’t apply to everybody. Where you should skip questions that do not apply to you it tells you which question to go to next at the side of the answer you have circled (i.e. go to Q2). Otherwise please continue through each question in turn.
If you wish to provide further information in relation to any of the questions, please use the space provided at the back of the questionnaire booklet. At the end of the questionnaire you will also be asked to fill in a consent form that will allow us to access your hospital and GP records. If you have changed address recently or are about to do so, please provide your new address in the space on the back of the consent form.
All information you give us will be treated in the strictest confidence. If you have any queries do not hesitate to telephone us
When you have finished filling in the questionnaire and the consent form on page 25 please use the prepaid envelope provided to post it back to us. Thank you very much for your time and co-operation.
Please enter the date you completed this questionnaire:
Questions 1 to 24 are about your health. Some ask about your current health and some about your health since 1999.
How is your health in general?
(circle one)
Compared to one year ago, how would you rate your health in general now?
(circle one)
Do you ever have any pain or discomfort in your chest?
Do you get this pain or discomfort when you walk uphill or hurry?
Do you get it when you walk at an ordinary pace on the level?
What do you do if you get this pain while walking?
(circle one)
Does the pain or discomfort in your chest go away if you stand still?
Where do you get this pain or discomfort? Mark the place(s) with an X on the diagram.
Did you see a doctor because of this pain or discomfort?
what did they say it was?
Since 1999 have you had a severe pain across the front of your chest lasting half an hour or more?
Do you get pain in either leg on walking?
Does this pain ever begin when you are standing still or sitting?
In what part of your leg do you feel it?
(circle all that apply)
Do you get it if you walk uphill or hurry?
Do you get it when you walk at an ordinary pace on the level?
Does the pain ever disappear while you are walking?
Since 1999 has a doctor told you that you have had angina?
Since 1999 has a doctor told you that you have had a heart attack (myocardial infarct/coronary thrombosis)?
Since 1999 have you had any other heart trouble suspected or confirmed? (e.g. valve disease, congenital heart disease or irregular heart beat)
please specify:
Since 1999 have you had a sudden speech problem which got better after a day?
Since 1999 have you had sudden sight problems which got better after a day?
Since 1999 have you had a sudden weakness in an arm or leg which got better after a day?
Since 1999 have you been told by a doctor that you have blood pressure problems?
Since 1999 have you been told by a doctor that you have had a stroke?
Since 1999 have you been told that you have diabetes?
How old were you when you were first told that you had diabetes? Age ... years
Is your diabetes controlled by
(circle all that apply)
Since 1999 have you been told by a doctor that you have a thyroid disorder?
What kind of thyroid disorder have you had?
Have you had any treatment for your thyroid disorder?
Since 1999 have you been told by a doctor that you have fits or epilepsy?
Since 1999 have you been told by a doctor that you have cancer?
please specify site:
Since 1999 have you suffered from any other troublesome health problem(s) which has been diagnosed by a medical doctor?
please list below:
Since 1999 have you been knocked unconscious?
Do you usually cough first thing in the morning in the winter?
Do you usually cough during the day or night in winter?
If you answered ‘No’ to both 16a and 16b go to Q17a
Do you cough like this on most days for as much as 3 months each year?
Do you usually bring up any phlegm (spit from the chest) first thing in the morning in winter?
Do you usually bring up any phlegm during the day or at night in winter?
If you answered ‘No’ to both 17a and 17b go to Q18
Do you bring up phlegm on most days for as much as 3 months each year?
In the past 3 years, have you had a period of cough and phlegm lasting for 3 weeks or more?
Does your chest ever sound wheezy or whistling?
During the past 3 years have you had any chest illness, for example, bronchitis or pneumonia, which has kept you off work or indoors for a week or more?
How many illnesses like this have you had in the last 3 years?
Did you consult a doctor about this during the last 3 years?
These questions concern any test(s) or treatment(s) you may have had in hospital for chest pain or heart disease.
If you answer ‘Yes’ to a question please fill in the requested details.
Have you ever had an exercise/stress ECG heart tracing whilst walking or running on a treadmill?
Hospital name/ town:
Name of consultant:
Were you an NHS or private patient?
Date of test:
Have you ever had an angiogram or X-ray of your coronary arteries (a dye test of the arteries)?
Hospital name/ town:
Name of consultant:
Were you an NHS or private patient?
Date of test:
Have you ever had angioplasty of coronary arteries (balloon treatment for angina) or insertion of a stent?
Hospital name/ town:
Name of consultant:
Name of ward:
Were you an NHS or private patient?
Date of admission to hospital:
Length of stay in hospital: Number of days
Have you ever had a coronary artery bypass graft (CABG) operation?
Hospital name/ town:
Name of consultant:
Name of ward:
Were you an NHS or private patient?
Date of admission to hospital:
Length of stay in hospital: Number of days
Have you ever had an admission to hospital with chest pain, angina or heart attack?
Hospital name/ town:
Name of consultant:
Name of ward:
Were you NHS or private patient?
Date of admission to hospital:
Length of stay in hospital: Number of days
Have you ever had other heart tests or operations or admissions to hospital for other heart trouble?
Please specify test, operation or reason for hospital admission (e.g. 24 hour ECG, pacemaker, thallium scan, echocardiogram, or resting ECG)
Hospital name/ town:
Name of consultant:
Name of ward:
Were you an NHS or private patient?
Date of admission to hospital or date of test/procedure:
Length of stay in hospital: Number of days
IN-PATIENT HOSPITAL ADMISSIONS
Since 1999 have you been admitted to hospital as an in-patient (that is you spent at least one night in hospital) for any other reason not already mentioned in question 21?
please fill in details of each hospital admission in the table below, starting from the earliest admission. Please use one column for each hospital admission and fill in the details requested in the boxes provided. REMEMBER YOU DO NOT NEED TO REPEAT INFORMATION ALREADY PROVIDED IN QUESTION 21.
_admission < 7
_admission < 7
Hospital Name/Town:
Name of Consultant:
Name of Ward:
Were you an NHS or private patient?
Date of admission.
How many days did you stay in hospital? Number of days
Why were you admitted to hospital?
Please specify the reason you were admitted and the diagnosis you were given.
Was this problem the result of an injury?
please specify cause of injury
What treatment(s) did you have?
Please specify all operations or treatments that you had during your stay in hospital.
Have you had any other hospital admissions since 1999?
HOSPITAL DAY SURGERY AND OUTPATIENT TREATMENTS
Since 1999, have you been to hospital for treatment or surgery and then come home again on the same day (that is you did not spend a night in hospital)?
please fill in details of each illness or condition in the table below. Please use one column for each illness or condition (even if you visited the hospital more than once for treatment for the same problem).
_illness < 7
_illness < 7
Why did you go to hospital?
Please specify the reason you were admitted and the diagnosis you were given.
Was this problem the result of an injury?
please specify cause of injury
Were you an NHS or private patient?
Date of beginning of treatment:
How many times did you visit the hospital for treatment for this illness/condition? Number of visits
What treatment did you have at the hospital?
Please specify all operations or treatments that you had at the hospital.
Do you regularly take any medicines, tablets, tonics or pills prescribed by a doctor?
The following questions are about your family.
Does your household own or rent your accommodation?
How many people in total live in your household, including yourself? Include those who live in the household but are away e.g. working away or a student. Number
Do you have a husband/wife or partner living in this household?
What is your husband/wife or partner’s highest level of qualification?
Since 1999 have you been married, remarried, separated, divorced or widowed?
(circle all that apply)
In what year were you married/ remarried? Year
When did you stop living together? Year
When did your husband/wife or partner die? Year
So, are you currently
Since 1999, have you lived with a partner for more than a year?
Since 1999, have you had any children?
How many children have you had since 1999? Number of children
Please fill in details of each child below.
Do you have any grandchildren?
How many grandchildren do you have? Number of grandchildren
In what year was your first grandchild born? Year
The following questions are about work and retirement.
Have you retired from your main occupation, even if you are now doing other paid work?
At what age do you plan to retire from your main occupation? Age ... years
How old were you when you retired from your main occupation? Age ... years
What was the reason you retired from your main occupation?
Are you currently in paid work, including part-time work and self-employment?
What is the full title of your current main job?
Please use precise terms, for example ‘primary school teacher’ rather than ‘teacher’, ‘production engineer’ rather than ‘engineer’, ‘chartered accountant’ rather than ‘accountant’. For government or civil service, please provide grade. For armed forces, please provide rank.
What are the main things you do in the job.
If this is self-explanatory, please write 'as above'.
What does the firm/organisation you work for mainly make or do (at the place where you work)?
Please describe fully e.g., manufacturing or processing or distributing etc and main goods produced, materials used, wholesale or retail, etc.
Are you working as an employee or self-employed?
Do you have any managerial duties, or are you supervising any other employees?
How many employees are there at the place where you work?
Are you working on your own or do you have employees?
How many people do you employ at the place where you work?
Do you work full time or part-time?
How many hours a week do you usually work in this job, including regular overtime? Hours
Does your employer contribute towards your pension?
In what year did you start this job? Year
As well as this job, do you have a second job?
Now go to question 44
Are you seriously looking for any kind of paid work?
What is the main reason you are not looking for paid work?
(circle one)
Since 1999 have you had any paid work?
Since 1999, how many jobs have you had altogether, including any job held in 1999 and any current job? Number of jobs
Since 1999, have you had any spells of a month or more when you were not in any kind of paid work? (please include spells out of work in 1999)
Has your husband/wife or partner retired from their main occupation, even if they are now doing other paid work?
At what age does your husband/ wife or partner plan to retire from their main occupation? Age ... years
How old was your husband/ wife or partner when they retired from their main occupation? Age ... years
What was the reason they retired from their main occupation?
Is your husband/wife or partner currently in paid work, including part-time work and self-employment?
What is the full title of your husband/wife or partner's current main job?
Please use precise terms, for example ‘primary school teacher’ rather than ‘teacher’, ‘production engineer’ rather than ‘engineer’, ‘chartered accountant’ rather than ‘accountant’. For government or civil service, please provide grade. For armed forces, please provide rank.
What are the main things they do in the job?
If this is self-explanatory, please write 'as above'.
What does the firm/organisation they work for mainly make or do (at the place where they work)?
Please describe fully e.g., manufacturing or processing or distributing etc and main goods produced, materials used, wholesale or retail, etc.
Are they working as an employee or are they self-employed?
Do they have any managerial duties, or are they supervising any other employees?
How many employees are there at the place where they work?
Since 1999 has your husband/wife or partner had any paid work?
These questions are about your smoking habits.
Do you smoke cigarettes at all nowadays?
How many cigarettes a day do you usually smoke? If you smoke roll-ups, please give the equivalent number of cigarettes. Number of cigarettes
What is the main brand of cigarettes you smoke? Please specify brand:
At what age did you start smoking? ... Years
Now go to question 56a
Have you ever smoked cigarettes regularly, by which we mean at least one cigarette a day for 12 months or more?
Do you smoke a pipe?
How much pipe tobacco do you usually smoke per week? Amount
Is that grams or ounces?
What brand of tobacco do you smoke? Please specify brand:
Do you smoke cigars?
How many cigars do you smoke per week? Number of cigars
What brand of cigars do you smoke? Please specify brand:
In your spare time are you involved in any of the following activities?
Please circle one number for each activity. If you do not take part in the activity, please circle ‘0’
The final questions are about how you have been feeling recently and your quality of life.
Please circle one number for each question
Please circle one number for each question
Please circle one number for each question
During the past four weeks to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbours or groups?
Please circle one
How much bodily pain have you had during the past four weeks?
Please circle one
During the past four weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?
Please circle one
Please circle one number for each question
During the past four weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, etc)?
Please circle one
Please circle one number for each question
If you would like to give further details to any questions or make any comments about the questionnaire, please feel free to do so in the space below:
Thank you very much for the time you have spent filling in this questionnaire.
Please could you now fill in the consent form on page 25 and, if you have moved house recently, turn to the back page of the questionnaire and provide us with your new address. Please put the questionnaire in the pre-paid envelope and post it back to us.
STRICTLY CONFIDENTIAL
MRC National Survey of Health and Development Royal Free & University College Medical School Department of Epidemiology and Public Health
CONSENT: ACCESS TO HOSPITAL AND GP RECORDS
We may need to obtain additional details about your health from your hospital records and from your general practitioner (GP). In order to do this we need to ask your permission. Please complete the following:
I ... give my consent for the MRC National Survey of Health and Development to access my hospital and GP records. I understand that all information provided will be treated in the strictest confidence and used for medical research purposes only.
Date
Please give details of your GP: GP’s name
Please give details of your GP: Address
Please give details of your GP: Postcode.
If you have recently changed your address or are about to do so, please will you provide your new address and telephone number below.
New address:
I am now living at this address
I will be living at this address from ... (please give date)
New telephone number:
If you do not wish to complete the questionnaire we would be grateful if you could tell us why and return the uncompleted questionnaire to us in the pre-paid envelope:
Please give your reason for not completing the questionnaire:
nshd_06_pq
_admission < 7
_illness < 7
_child < && (_child <= qc_30_b) && _child <= 3
2006-2010 Clinic Study Postal Questionnaire