Start
nshd_06_ncs
STRICTLY CONFIDENTIAL
MRC NATIONAL SURVEY OF HEALTH AND DEVELOPMENT
MRC Unit for Lifelong Health and Ageing
CLINIC STUDY 2008-10
Nurse Clinic Schedule
Version Dated: 01/05/2008
intro i

Date of birth

Date of birth
intro ii

Nurses No's.

Nurse No.
Nurse No. 2
intro iii

Interview date

Generic date
intro iv

Record the time of day (24 hour clock):

Generic time
A. NURSE INTERVIEW (1): Consents, urine and medical review
Thank participant for coming. Make sure travelling expenses have been dealt with. Collect the preassessment questionnaire and check if the participant had any problems filling it in.
Explain purpose of clinic visit and ask if participants have read the information pamphlet and if they have any questions about the study and the measures.
Explain we need to obtain their consent to be interviewed and measured today and to use information collected today and at previous times for research. Explain that even having given consent they can still decline to do any part of the interview or examination.
Explain that results of some tests (blood pressure, lung function and anthropometry) will be given to them today.
Explain we will be asking them to consent to send results to their GP that may be useful for their health care and that this will be explained at the relevant parts of the examination. Confirm the GP address already on the GP letter. If the GP details have changed use a new GP letter. If the participant does not want any results sent to their GP use the participant feedback letter rather than the GP letter.
Participant should now read and sign the general consent form. Delete any sections that the participant does not consent to (e.g. results to GP or use of blood sample for genetic aspects of health).
1 a

Are any sections of the general consent form crossed out?

1
Yes
0
No
If No to question 1a go to 1c
qc_1_a == 0
Else
If the participant does not want results sent to GP, ask them to sign the clinical advisor consent form. Explain that if this consent is not given, a blood sample cannot be drawn and certain cardiovascular tests cannot be taken.
1 b

If necessary, has the clinical advisor consent form been signed?

1
Yes
0
No
1 c

If the participant has not completed a hospital records consent form ask them to do so and record whether the form has now been signed:

1
Hospital consent form now signed
2
Hospital consent form not signed
3
Not applicable, form already signed
2 a

Have you brought your urine sample with you?

1
Yes
0
No
2 b

Have you brought the completed urine instruction sheet?

Complete a new sheet if necessary

1
Yes
0
No
3

Have you had anything to eat in the last 12 hours?

1
Yes
0
No
If yes,
qc_3 == 1
3 i

how many hours ago did you last eat? ... hours

How many
4

Besides water, have you drunk anything else in the last 12 hours?

1
Yes
0
No
If No to question 4 go to Q6
qc_4 == 0
Else
5 a

Have you drunk tea or coffee or cola in the last 12 hours?

1
Yes
0
No
If yes,
qc_5_a == 1
5 a(i)

how many hours ago did you drink tea, coffee or cola? ... hours

How many
5 b

Have you drunk anything else in the last 12 hours?

1
Yes
0
No
If yes,
qc_5_b == 1
5 b(i)

please specify

Generic text
6

Have you smoked tobacco in the last 12 hours?

1
Yes
0
No/Non-smoker
If yes,
qc_6 == 1
6 i

how many hours ago did you smoke tobacco?

How many
7

Did you do any strenuous physical activity yesterday?

1
Yes
0
No
8

Have you had any operations in the last 3 months?

1
Yes
0
No
If yes,
qc_8 == 1
8 i

please specify:

Generic text
9 a

Do you ever have any pain or discomfort in your chest?

0
No
1
Yes
If No to question 9a go to Q10
qc_9_a == 0
Else
9 b

Do you get this pain or discomfort when you walk uphill or hurry?

0
No
1
Yes
2
Never walk uphill or hurry
9 c

Do you get it when you walk at an ordinary pace on the level?

0
No
1
Yes
2
Never walk
9 d

What do you do if you get this pain while walking?

(Circle one)

1
Stop or slow down
2
Carry on
3
Carry on after using a spray or taking tablet under your tongue (nitroglycerine)
4
Not applicable
9 e

Does the pain or discomfort in your chest go away if you stand still?

0
No
1
Yes
If No to question 9e go to g
qc_9_e == 0
Else
9 f

How long does it take to go away?

1
10 minutes or less
2
More than 10 minutes
9 g

Where do you get this pain or discomfort? Mark the place(s) with an X on the diagram.

10

Check whether they have brought their regular medicines with them and ask: Have you taken any medicines, prescribed or non-prescribed, in the last 24 hours?

1
Yes
0
No
If 'Yes',
qc_10 == 1
10 i
please give details in the table below. Use one row for each medication. Be sure to include use of puffer or inhaler or any medication for breathing, and any medications bought from a pharmacy.Use spare medication sheets if necessary and attach to questionaire
Name of medicine How many hours ago did you last take the medicine? Do you take this medicine regularly? Is this medicine prescribed by your GP or consultant?
Generic textHow many

1 - Yes

0 - No

1 - Yes

0 - No

How many

1 - Yes

0 - No

1 - Yes

0 - No

Generic text

1 - Yes

0 - No

How many

1 - Yes

0 - No

Generic text

1 - Yes

0 - No

How manyGeneric text

1 - Yes

0 - No

 Generic textHow many

1 - Yes

0 - No

1 - Yes

0 - No

How many

1 - Yes

0 - No

1 - Yes

0 - No

Generic text

1 - Yes

0 - No

How many

1 - Yes

0 - No

Generic text

1 - Yes

0 - No

How manyGeneric text

1 - Yes

0 - No

 Generic textHow many

1 - Yes

0 - No

1 - Yes

0 - No

How many

1 - Yes

0 - No

1 - Yes

0 - No

Generic text

1 - Yes

0 - No

How many

1 - Yes

0 - No

Generic text

1 - Yes

0 - No

How manyGeneric text

1 - Yes

0 - No

 Generic textHow many

1 - Yes

0 - No

1 - Yes

0 - No

How many

1 - Yes

0 - No

1 - Yes

0 - No

Generic text

1 - Yes

0 - No

How many

1 - Yes

0 - No

Generic text

1 - Yes

0 - No

How manyGeneric text

1 - Yes

0 - No
1
2
3
4
5
6
7
8
9
10
11
12
13
11 a

Has a doctor told you that you have any of the following health problems? Health Problem High blood pressure

1
YES
0
NO
11 b

Has a doctor told you that you have any of the following health problems? Health Problem Diabetes

1
YES
0
NO
11 c

Has a doctor told you that you have any of the following health problems? Health Problem Bleeding or clotting disorder

1
YES
0
NO
11 d

Has a doctor told you that you have any of the following health problems? Health Problem Angina

1
YES
0
NO
11 e

Has a doctor told you that you have any of the following health problems? Health Problem Heart attack (myocardial infarct, coronary thrombosis)

1
YES
0
NO
If YES to question 11e.
qc_11_e == 1
11 e(i)

when did this (last) occur?

Generic date
11 f

Has a doctor told you that you have any of the following health problems? Health Problem Aortic aneurysm

1
YES
0
NO
11 g

Has a doctor told you that you have any of the following health problems? Health Problem Aortic stenosis

1
YES
0
NO
11 h

Has a doctor told you that you have any of the following health problems? Health Problem Myocarditis (infection of the heart)

1
YES
0
NO
11 i

Has a doctor told you that you have any of the following health problems? Health Problem Cardiomyopathy (‘large heart’ or ‘weak heart’)

1
YES
0
NO
11 j

Has a doctor told you that you have any of the following health problems? Health Problem Other heart trouble (Valvular disease, Ischaemic heart disease, tachycardia, palpitations or heart murmur, other) Please specify

1
YES
0
NO
Other
11 k

Has a doctor told you that you have any of the following health problems? Health Problem Pulmonary embolism (blood clot on the lung) or systemic embolism within the last 4 weeks

1
YES
0
NO
11 l

Has a doctor told you that you have any of the following health problems? Health Problem Do you have a pacemaker?

1
YES
0
NO
B

BLOOD SAMPLE: Record the time of day (24 hour clock):

Generic time
If participant has not consented for GP to be sent the results nor for the clinical advisor to contact them - No blood sample to be taken go to module C.
qc_1_a == 1 && qc_1_b == 0
Else
12 a

Have you given a blood sample before?

1
Yes
0
No
If yes,
qc_12_a == 1
12 b

were there any problems (e.g. fainting)? Please specify:

1
Yes
0
No
Generic text
Explain the purpose and procedure for taking blood.
13

Would you be willing to have a blood sample taken?

1
Yes
0
No
If NO,
qc_13 == 0
13 i

please give reason:

Generic text
If No to question 13 go to module C.
qc_13 == 0
Else
Collect blood sample into separate safety monovettes, appropriately labelled, with appropriate anticoagulants for different analytical purposes: lithium heparin, EDTA, fluoride oxalate, citrate and a plain tube (see detailed protocol in the manual). Then answer Q14a-d:
14 a

Was the whole blood sample obtained?

1
Yes
2
Only part
3
None
If incomplete or absent sample,
qc_14_a == 2 || qc_14_a == 3
14 a(i)

please give reason.

(Circle all that apply)

1
Collapsing/poor veins
2
Second attempt necessary
3
Participant felt faint/fainted
4
Unable to use tourniquet
5
Other (Specify)
Other
14 b

Was a butterfly used instead of a fixed needle?

1
Yes
0
No
If yes,
qc_14_b == 1
14 b(i)

please give reason for using butterfly

Generic text
14 c

Record where blood taken from. If from more than one place record on blood tracking form:

1
Right arm
2
Left arm
3
Right hand
4
Left hand
5
More than 1 place
8
Not obtained
14 d

Was participant sitting in a chair or lying down when the blood was taken?

1
Sitting in chair
2
Lying down
15

The research team will write to you to tell you when the results of the blood tests have been sent to your GP [unless consent not given] Do you want to receive a copy of the blood results?

1
Yes
0
No
If 'yes'
qc_15 == 1
15 i

please tick the appropriate box on the GP letter Please tick the box to confirm you have done this

1
Tick
Now complete the front page of the blood sample tracking form, and the time urine received and delivered on the urine tracking form.
15 ii

Hand both the blood and urine samples, and their corresponding tracking forms, to the lab staff. Please tick the box to confirm you have done this

1
Tick
15 iii

Record the time of day (24 hour clock):

Generic time
C. ECHO: (LV MASS, GLOBAL DIASTOLIC AND SYSTOLIC FUNCTION)
If participant has not consented for GP to be sent results that are directly relevant to their health nor for the clinical advisor to contact them if necessary then do not take these measures.
Else
Explain purpose and procedures for echocardiogram.
16

Would you be willing to have an echocardiogram?

1
Yes
2
Yes, but unable (e.g. arrived too late)
0
No, not willing
If no echocardiogram completed,
qc_16 == 2 || qc_16 == 0
16 i

please give reason:

Generic text
If No ECHO to be taken go to module D
qc_16 == 2 || qc_16 == 0
Else
Ask participant to undress and put on a gown.
17

Was the echocardiogram completed satisfactorily?

1
Yes
0
No
If not completed satisfactorily,
qc_17 == 0
17 i

please explain:

Generic text
If the echocardiogram was abnormal,
18 a

was a full echocardiogram carried out so a clinical report could be written?

1
Yes
0
No
18 b

Are there any reasons for not doing the step test? Please specify:

1
Yes
0
No
Generic text
D. CAROTID IMT and DISTENSIBILITY
If participant has not consented for GP to be sent results that are directly relevant to their health nor for the clinical advisor to contact them if necessary then do not take this measure.
Else
Explain purpose and procedures for the carotid IMT and distensibility measures
19

Would you be willing to have these measurements taken?

1
Yes
2
Yes, but unable (e.g. arrived too late)
0
No, not willing
If no measurements taken,
qc_19 == 2 || qc_19 == 0
19 i

please give reason:

Generic text
If no IMT/distensibility measures taken go to module E
qc_19 == 2 || qc_19 == 0
Else
20 a(i)

Echocardiographer to provide two blood pressure measurements with the participant supine: RIGHT Systolic

Systolic mmHg
20 a(i)

Echocardiographer to provide two blood pressure measurements with the participant supine: RIGHT Diastolic

Diastolic mmHg
20 a(ii)

Echocardiographer to provide two blood pressure measurements with the participant supine: LEFT Systolic

Systolic mmHg
20 a(ii)

Echocardiographer to provide two blood pressure measurements with the participant supine: LEFT Diastolic

Diastolic mmHg
20 b

Were the CAROTID IMT and DISTENSIBILITY measures completed satisfactorily?

1
Yes
0
No
If not completed satisfactorily,
qc_20_b == 0
20 b(i)

please explain:

Generic text
21

Was plaque present in the common carotid artery or the bifurcation?

1
Yes
0
No
GP LETTER (OR PARTICIPANT FEEDBACK LETTER)
21 i

Echocardiographer to complete relevant part of the letter and sign the form. Please tick the box to confirm you have done this

1
Tick
E. SELF-COMPLETION
Introduce self-completion questionnaire
“Now it’s time for breakfast and while I am getting that ready I’d like to give you this questionnaire to fill in by yourself. The questions are about how you have been feeling recently. Please check with me if any of the questions are unclear.”
22

Can I ask, would you be willing to complete this questionnaire?

1
Yes
0
No
If NO,
qc_22 == 0
22 i

please give reason:

Generic text
BREAKFAST
23

Check any uncompleted or inconsistent questions on the self-completion questionnaire and record:

1
Booklet completed independently
2
Booklet completed with assistance from interviewer
3
Booklet completed with assistance from someone else
4
Booklet not completed
23 i

Check any uncompleted or inconsistent questions on the pre-assessment questionnaire: Please tick the box to confirm you have done this

1
Tick
F

ANTHROPOMETRY: Record the time of day (24 hour clock):

Generic time
24

Would you be willing to be measured and weighed?

1
Yes
2
Yes, but unable (e.g. equipment not available)
0
No
If no,
qc_24 == 0
24 i

please give reason:

Generic text
If No anthropometric measures to be taken go to module G
qc_24 == 0
Else
25

Measure standing height. Height

Enter in centimetres to nearest mm.

Centimetres
26

Measure sitting height (participant seated on a board on a chair) Sitting height

Enter in centimetres to nearest mm.

Centimetres
27

Measure weight (using kilograms) and record scale reading Weight

Kilograms
28

Measure circumference of right arm to the nearest mm. Arm

Enter in centimetres

Centimetres
29 a

Measure the chest circumference to the nearest mm. Chest

Enter in centimetres

Centimetres
29 b

Measure the expanded chest circumference to the nearest mm. Expanded

Enter in centimetres

Centimetres
30

Measure the waist circumference to the nearest mm. Waist

Enter in centimetres

Centimetres
31

Measure the hip circumference to the nearest mm. Hip

Enter in centimetres

Centimetres
31 i

Now write the height, weight, waist and hip circumference measurements on the letter Please tick the box to confirm you have done this

1
Tick
31 ii

How were the anthropometric measures taken?:

1
On skin
2
Light clothes
3
Other (Specify, e.g. heavy clothes)
Other
31 iii

Please note below any changes to protocol for the anthropometric measurements e.g. participant sat on the floor for sitting height measurement:

Generic text
GP LETTER (OR PARTICIPANT FEEDBACK LETTER)
G. BLOOD PRESSURE (SEATED)
32

Would you be willing to have your blood pressure taken?

1
Yes
2
Yes, but unable (e.g. machine broken)
0
No
If no measure taken,
qc_32 == 2 || qc_32 == 0
32 i

please give reason:

Generic text
If No blood pressure taken go to module H
[qc_32 == 2 || qc_32 == 0
Else
32 ii

Provide machine no

Generic text
32 iii

Enter ambient temperature in Celsius to the nearest degree.

Celsius
32 iv(a)

First reading: SYSTOLIC

Systolic mmHg
32 iv(b)

First reading: DIASTOLIC

Diastolic mmHg
32 iv(c)

First reading: PULSE

Pulse
32 v(a)

Second reading: SYSTOLIC

Systolic mmHg
32 v(b)

Second reading: DIASTOLIC

Diastolic mmHg
32 v(c)

Second reading: PULSE

Pulse
GP LETTER (OR PARTICIPANT FEEDBACK LETTER)
32 vi

Now write the blood pressure measurements onto the letter (use lowest diastolic reading) Please tick the box to confirm you have done this

1
Tick
H. ECG AND HEART RATE VARIABILITY
If participant has not consented for GP to be sent results that are directly relevant to their health nor for the clinical advisor to contact them if necessary then do not take this measure
Explain purpose and procedures for ECG, heart rate variability and pulse wave velocity.
33

Would you be willing to have these measures taken?

1
All of them
2
Some of them
3
None of them
If ‘some of them’ or ‘none of them’,
qc_33 == 2 || qc_33 == 3
33 i

please give reason:

Generic text
If None of them to question 33 go to module J
qc_33 == 3
Else
34

Was the ECG completed satisfactorily?

1
Yes
0
No
If not completed satisfactorily,
qc_34 == 0
34 i

please explain:

Generic text
35 a

Was the heart rate from the ECG >= 100bpm

1
Yes
0
No
35 b

Was the heart rate from the ECG <=40bpm

1
Yes
0
No
36

Was HEART RATE VARIABILITY measured satisfactorily?

1
Yes
0
No
If not completed satisfactorily,
qc_36 == 0
36 i

please explain:

Generic text
I. PULSE WAVE VELOCITY (PWV) AND PULSE WAVE ANALYSIS (PWA)
37

Was PWV measured satisfactorily?

1
Yes
0
No
If not completed satisfactorily,
qc_37 == 0
37 i

please explain:

Generic text
38

Was PWA measured satisfactorily?

1
Yes
0
No
If not completed satisfactorily,
qc_38 == 0
38 i

please explain:

Generic text
38 ii

Please record: Distance from the suprasternal notch to the top of thigh cuff ( right) ... mm

Millimetres
38 iii

Nurse to complete the rest of the CVD section of the letter Please tick the box to confirm you have done this

1
Tick
38 iv

Record the time of day (24 hour clock):

Generic time
J. SALIVARY CORTISOL
“We are collecting saliva to measure cortisol, one of the body’s hormones. Cortisol levels are related to many aspects of our health that we are measuring in this data collection. We would like you to unscrew the cap of this salivette tube and pop the swab in your mouth without touching it. We would like you to keep the swab in your mouth and roll it around your mouth for 1-2 minutes until you feel that you can longer prevent yourself from swallowing the saliva produced. Then we want you to spit the swab back into the small container and screw the top on.”
39 a

Would you be willing to collect saliva in this way?

1
Yes
0
No
If no,
qc_39_a == 0
39 a(i)

please give reason

Generic text
No to question 39a go to module K
qc_23_a == 0
Else
39 b

Did you suffer any stress, anxiety or trauma in the hour before the sample was taken?

1
Yes
0
No
After the sample has been taken ask:
If yes,
qc_39_b == 1
39 b(i)

what was the cause of the stress?

Generic text
39 b(ii)

Now complete the saliva tracking form and hand both the form and saliva sample to the lab staff. Please tick to confirm you have done this.

1
Tick
“Cortisol levels can change between morning and night and we would like you to take some more saliva samples at home and post them back to the clinic. I’ll explain more about this at the end of the visit.”
K. ECONOMIC CIRCUMSTANCES
Introduce questions on economic circumstances:
“The next few questions are about your economic circumstances as this study and others show that things like income and your level of financial security can affect health in a number of ways.”
40 a(ii)

Do you or your husband/wife/partner receive income from any of the sources listed on this show card? Husband/wife or partner Other, please specify

(Circle all that apply)

1
Earnings from employment or self- employment
2
State pension (include basic state pension, SERPS and State 2nd pension)
3
Pension form a previous employer
4
Private pension/annuity
5
Dividends or interest from savings or investments
6
Rent from property or land
7
Health-related or disability benefits e.g. Incapacity benefit (Invalidity Benefit), Statutory Sick Pay, Severe Disablement Allowance, Disability Living Allowance, Attendance Allowance, Carer’s Allowance (Invalid Care Allowance), Industrial Injuries Disablement Benefit, War Disablement Pension.
8
General benefits e.g. Pension credit (Minimum Income Guarantee), Income Support for the over 60’s, Income Support, Job Seeker’s Allowance (Unemployment Benefit), Housing Benefit/ Rent Rebate or Allowance, Council Tax Benefit, Working Tax Credit (Working Families Tax Credit), Widow’s Pension, Widowed Mother’s Allowance, Bereavement Allowance, Child Benefit, Child Tax Credit.
9
Other, please specify
Other
40 a(i)

Do you or your husband/wife/partner receive income from any of the sources listed on this show card? Participant Other, please specify

(Circle all that apply)

1
Earnings from employment or self- employment
2
State pension (include basic state pension, SERPS and State 2nd pension)
3
Pension form a previous employer
4
Private pension/annuity
5
Dividends or interest from savings or investments
6
Rent from property or land
7
Health-related or disability benefits e.g. Incapacity benefit (Invalidity Benefit), Statutory Sick Pay, Severe Disablement Allowance, Disability Living Allowance, Attendance Allowance, Carer’s Allowance (Invalid Care Allowance), Industrial Injuries Disablement Benefit, War Disablement Pension.
8
General benefits e.g. Pension credit (Minimum Income Guarantee), Income Support for the over 60’s, Income Support, Job Seeker’s Allowance (Unemployment Benefit), Housing Benefit/ Rent Rebate or Allowance, Council Tax Benefit, Working Tax Credit (Working Families Tax Credit), Widow’s Pension, Widowed Mother’s Allowance, Bereavement Allowance, Child Benefit, Child Tax Credit.
9
Other, please specify
Other
40 b

Which of the letters on the show card represents your total net household income? Please include our own and your partner’s earned income (after deduction for income tax and national insurance), any state benefits and any other sources of income such as pension and interest. Please also include contributions from other members of your household (such as children). Please choose the period (annual, monthly or weekly) that is most convenient for you to use. Then, find the amount in pounds which represents your net household income and state the corresponding letter. Letter

Letter
41 a

On your present income do you find (as a family)

1
That it’s really quite hard to manage?
2
That you manage fairly well?
3
That you manage comfortably?
41 b

Have you or your family had to go without things you really needed in the last year because you were short of money?

1
Yes, often
2
Yes, sometimes
3
No
41 c

Have you found you have been unable to pay the bills in the last year because you were short of money?

1
Yes, often
2
Yes, sometimes
3
No
L. PERFORMANCE QUESTIONS AND TESTS
These next questions are about difficulties you may have carrying out daily activities.
42

Do you have any long-term illness, health problem or disability that limits your activities or the work you can do?

0
No
1
Yes
43

Do you have difficulty because of long-term health problems holding something heavy like a full kettle or removing a stiff lid from a jar?

0
No
1
Some difficulty
2
A lot of difficulty
44

How frequently at home or at work do you use your hands in strong movements, such as squeezing water out of a towel, playing racket sports, digging the garden, or carrying heavy items such as a suitcase, briefcase, bucket or shopping bag?

1
Several times a day
2
Once a day
3
Once or several times a week
4
Occasionally
5
Never
45

In the last 12 months, have you had sciatica, lumbago or severe backache?

0
No
1
Yes
46

In the last 12 months, have you had pain in and around your knees on most days of the month for at least 3 months?

0
No
1
Yes
47 a

Do you find it difficult to walk for a quarter of a mile on the level because of long-term health problems? (If asked: a quarter of a mile is 400 yards)

0
No
1
Yes
If yes,
qc_47_a == 1
47 b

how far can you walk without stopping or severe discomfort. Would you say...

1
More than 400 yards
2
200 to 400 yards
3
50 to 200 yards or
4
Less than 50 yards
48

Do you find it difficult walking up and down stairs, because of long-term health problems?

0
No
1
Yes
If yes,
qc_48 == 1
48 i

can you walk up and down a flight of 12 stairs in a normal manner without holding on or taking a rest?

0
No
1
Yes
49

Do you easily fall or have difficulty keeping your balance because of long-term health problems?

0
No
1
Yes
50

Do you need to hold onto something to keep your balance?

0
No
1
Occasionally
3
Often
4
Always
51

Have you fallen at all in the past 12 months?

0
No
1
Yes
If yes,
qc_51 == 1
51 i

how many times have you fallen in the past 12 months?

How many
51 ii

On how many of these occasions have you injured yourself badly enough to see a doctor?

How many
52 a

Do you have difficulty bending down and straightening up, even when holding onto something because of long-term health problems?

0
No
1
Yes
If No to question 52a go to Q53
qc_52_a == 0
Else
52 b

Can you bend down to sweep something from the floor and straighten up?

1
Yes
0
No
If Yes to question 52b go to Q53
qc_52_b == 1
Else
52 c

Can you bend down to pick up something from the floor and straighten up?

1
Yes
0
No
If Yes to question 52c go to Q53
qc_52_c == 1
Else
52 d

Can you bend down far enough to touch your knees and straighten up?

1
Yes
0
No
53 a

Is it difficult, because of long-term health problems to do any of the following activities? go shopping and carry a full bag of shopping in each hand?

1
Yes
0
No
53 b

Is it difficult, because of long-term health problems to do any of the following activities? do heavy housework?

1
Yes
0
No
53 c

Is it difficult, because of long-term health problems to do any of the following activities? prepare a hot meal?

1
Yes
0
No
54 a

Is it difficult, because of long-term health problems, for you to do any of the following activities? Washing hands and face?

0
No
1
Yes
If yes,
qc_54_a == 1
54 a(i)

can you do it without aids or personal help?

1
Yes
2
No, uses aid but no personal help
3
No, needs personal help
54 b

Is it difficult, because of long-term health problems, for you to do any of the following activities? Bathing or showering?

0
No
1
Yes
2
Bathing only
If yes,
qc_54_b == 1 || qc_54_b == 2
54 b(i)

can you do it without aids or personal help?

1
Yes
2
No, uses aid but no personal help
3
No, needs personal help
54 c

Is it difficult, because of long-term health problems, for you to do any of the following activities? Dressing and undressing?

0
No
1
Yes
If yes,
qc_54_c == 1
54 c(i)

can you do it without aids or personal help?

1
Yes
2
No, uses aid but no personal help
3
No, needs personal help
54 d

Is it difficult, because of long-term health problems, for you to do any of the following activities? Getting in and out of a chair?

0
No
1
Yes
If yes,
qc_54_d == 1
54 d(i)

can you do it without aids or personal help?

1
Yes
2
No, uses aid but no personal help
3
No, needs personal help
54 e

Is it difficult, because of long-term health problems, for you to do any of the following activities? Getting in and out of bed?

0
No
1
Yes
If yes,
qc_54_e == 1
54 e(i)

can you do it without aids or personal help?

1
Yes
2
No, uses aid but no personal help
3
No, needs personal help
54 f

Is it difficult, because of long-term health problems, for you to do any of the following activities? Getting to the toilet?

0
No
1
Yes
If yes,
qc_54_f == 1
54 f(i)

can you do it without aids or personal help?

1
Yes
2
No, uses aid but no personal help
3
No, needs personal help
54 g

Is it difficult, because of long-term health problems, for you to do any of the following activities? Using the toilet?

0
No
1
Yes
If yes,
qc_54_g == 1
54 g(i)

can you do it without aids or personal help?

1
Yes
2
No, uses aid but no personal help
3
No, needs personal help
54 h

Is it difficult, because of long-term health problems, for you to do any of the following activities? Feeding yourself, including cutting up food?

0
No
1
Yes
If yes,
qc_54_h == 1
54 h(i)

can you do it without aids or personal help?

1
Yes
2
No, uses aid but no personal help
3
No, needs personal help
55 a-d
In the last 12 months, have you had a problem with the following?
-

1 - Rarely or never

2 - Sometimes

3 - Often

4 - Very often
Sudden loss of balance?
Weakness in the arms?
Weakness in the legs?
Dizziness when standing up quickly?
56 i-iv
Have you had a problem with the following in the last 12 months?
-

1 - Rarely or never

2 - Sometimes

3 - Often

4 - Very often
Paying attention?
Finding the right word?
Remembering things?
Remembering where you put something?
57 i-vi
Have you had difficulty with the following in the last 12 months?
-

1 - No difficulty

2 - A little difficulty

3 - Some difficulty

4 - A great deal of difficulty
Reading a newspaper?
Recognizing a friend across the street?
Reading signs at night?
Hearing over the phone?
Hearing a normal conversation?
Hearing conversation in a noisy room?
58 i

In the last 12 months, have you had a problem with the following? Loss of appetite?

1
Rarely or never
2
Sometimes
3
Often
4
Very often
58 ii

In the last 12 months, have you had a problem with the following? Unexplained weight loss?

1
Rarely or never
2
Sometimes
3
Often
4
Very often
59

In the last year, have you lost more than 10 pounds unintentionally?

1
Yes
0
No
60

How often in the last week did the following apply? “I felt that everything I did was an effort” or “I could not get going”

0
Rarely or none of the time (&lt;1 day)
1
Some or a little of the time (1-2 days)
2
A moderate amount of time (3-4 days)
3
Most of the time (&gt;4 days)
60 i

Record the time of day (24 hour clock):

Generic time
FUTURE CONSENT FORM
Ask the participant if they would be willing to complete the future consent form
REACTION TIME
61 a

I would now like to see how quickly you can react. This involves pressing a key every time you see a ‘0’ or an ‘8’ appear on the screen. Are you willing to do this test?

1
Yes
2
No
3
Unable for health reasons
4
Unable, other (e.g. machine broken)
61 a(i)

Please say why unable/unwilling

Generic text
61 a(ii)

Provide machine no.

Generic text
Put your finger on this key marked ‘0’ and look at the screen. This is the only key you will need to use. Every time you see a ‘0’ or an ‘8’ on the screen press the key once as quickly as you can. We will start with a practice run to make sure you know what to do. Are you clear about it? I am going to start the machine now, so look for the ‘0’s or ‘8’s and press firmly as soon as you see one.
Press start button. Correct any error during 8 practice trials. When the ‘wait’ indicator appears, say:
That was fine. Now we can time your reactions. Every time you see a ‘0’ or an ‘8’ on the screen, press the ‘0’ key as quickly as you can.
Press start button (20 ‘0’s or ‘8’s will be displayed in turn).
61 b

When display flashes: Press Key 1 and record: Mean

Mean time
61 c

When display flashes: Press Key 2 and record: Standard deviation

Standard deviation
Then press Start to clear the screen.
I’m now going to give you a slightly harder test. This time the numbers 1, 2, 3 or 4 will appear on the screen. I want you to press the key that has the same number as that on the screen. If you see a ‘4’ on the screen, press key 4 as quickly as possible. If you see a ‘1’, press key 1, and so on.
Use both hands to do this. Put the 1st and 2nd fingers of each hand on the four keys (1, 2, 3, 4). (Other fingers can be used if necessary.)
reactiontime i

If the participant has a non-functional hand, tick here ... and go to the next test.

1
Tick
I am going to start the machine again. Remember to press the same number as the number on the screen. This is another practice run.
Press start button. Correct any error during 8 practice trials. When the ‘wait’ indicator appears, say:
Now let’s do it as a proper test. Every time you see a number on the screen, quickly press the key with the same number. Remember to press firmly.
Press start button (40 numbers will be displayed in turn).
61 d

When display flashes: Press Key 1 and record: Mean time (correct)

Mean time
61 e

When display flashes: Press Key 2 and record: Standard deviation

Standard deviation
61 f

When display flashes: Press Key 0 and record: Number of errors

How many
61 g

When display flashes: Press Key 3 and record: Mean time (errors)

Mean time
61 h

When display flashes: Press Key 4 and record: Standard deviation

Standard deviation
Switch off machine.
WORD LIST MEMORY
62 a

Now I want to see how well you remember a list of fifteen words. I will show you one word at a time and when I reach the end of the list you have one minute to write down as many words as you can. Please write the words in any order you like. It is best not to talk to anyone while you are doing this. Are you willing to do this test?

1
Yes
2
No
3
Unable for health reasons
4
Unable, other (e.g. materials not available)
62 a(i)

Please say why unable/unwilling

Generic text
Nurse: Hand over the paper test booklet turn to page 3 and make sure the participant has a pencil. Show the words at two second intervals using Word List A or B as specified on contact sheet and on front page of booklet. Make sure the last word is shown for two seconds. Tell participant to start. Start the stopwatch and time for one minute then tell the participant to finish. Turn booklet to page 5. Show the words again. Tell participant to start. Start the stopwatch and time for one minute then tell the participant to finish. Turn booklet to page 7. Show the words again. Tell participant to start. Start the stopwatch and time for one minute then tell the participant to finish.
62 b

Please record whether the word list trials were completed. Code one only.

1
All 3 trials were attempted
2
2 out of the 3 trials were attempted
3
Only one trial was attempted
4
None of the trials were attempted
VISUAL SEARCH
Nurse: Turn to letter search (page 9 of paper test booklet).
63 a

I would now like to see how quickly you can work through this list, crossing out the P's and W's. Are you willing to do this test?

1
Yes
2
No
3
Unable for health reasons
4
Unable, other (e.g. materials not available)
63 a(i)

Please say why unable/unwilling

Generic text
Start at the top left and work along the row from left to right, then go to the beginning of the next row and work from left to right again, like reading a page. Carry on this way crossing out any P's and W's with one mark of the pencil like this. (Demonstrate). Carry on until I tell you to stop. Work as quickly and as accurately as you can. Nurse: Set your stopwatch for one minute. Tell the participant to start and stop at the correct moment.
63 b

Please record whether the letter search was attempted. Code one only.

1
Letter search attempted
2
Letter search not attempted
64

Do you remember that list of 15 words I showed you earlier. I would like you to write down as many of those words as you can remember.

Nurse: Turn to page 11 of the paper test booklet. Record whether the fourth word list trial was attempted. Code one only.

1
Fourth trial attempted
2
Fourth trial not attempted
If not completed,
qc_64 == 2
64 i

please explain:

Generic text
65 a

Nurse: Did the survey member have visual difficulty during testing?

1
No difficulty
2
Mild difficulty
3
Severe difficulty
4
No tests done
65 b

Nurse: Did the survey member have hearing difficulty during testing?

1
No difficulty
2
Mild difficulty
3
Severe difficulty
4
No tests done
CHAIR RISES
66 a

I would now like you to do 10 chair rises. First I will ask you to fold your arms and, after I say, ‘And Go’, stand up from your chair and sit down again 10 times like this, as quickly as possible (demonstrate). Are you willing to do this test?

1
Yes
2
No
3
Unable for health reasons
4
Unable, other (e.g. equipment not available)
66 a(i)

Please say why unable/unwilling

Generic text
66 a(ii)

Let the participant practice then record time for chair rise test. Enter time in seconds as on stopwatch (to 1/100th second)

Minutes Seconds
BALANCE AND CO-ORDINATION
67 a

I would now like to assess your balance and co-ordination. First, I will ask you to fold your arms and, after I say ‘And Go’, stand on your dominant leg, and raise your other foot off the floor like this (demonstrate). I will ask you to hold this position for as long as you can or until I tell you to stop. Then I want you to repeat the test with your eyes closed. Are you willing to do this test?

1
Yes
2
No
3
Unable for health reasons
4
Unable, other (e.g. no room available)
67 a(i)

Please say why unable/unwilling

Generic text
67 b

Which is your dominant leg (ignoring any current injury)?

If asked: Which leg would you kick a ball with or hop on. Code one only.

1
Right leg
2
Left leg
67 c

Carry out test with participant's eyes open. Allow the participant to practice. Set stop watch for 30 seconds. Record time for balance test with eyes open. Enter time in seconds as on stopwatch (to 1/100th second) Minutes ... Seconds

Minutes Seconds
67 d

Carry out test with participant's eyes closed. Allow the participant to practice. Set stop watch for 30 seconds. Record time for balance test with eyes closed Enter time in seconds as on stopwatch (to 1/100th second)

Minutes Seconds
TIMED GET UP AND GO
68 a

Now I would like to time you while you get up from the chair and walk at a pace that is normal for you to the furthest line on the floor, turn around, walk back and sit back in the chair. Are you willing to do this test?

1
Yes
2
No
3
Unable for health reasons
4
Unable, other (e.g. no room available)
68 a(i)

Please say why unable/unwilling

Generic text
68 b

Able to walk without another person’s help?

1
Yes
0
No
68 c

Walking aid? specify (stick, frame e.t.c)

0
No
1
Yes
Generic text
68 i

Record time taken to complete walk. Enter time in seconds as on stopwatch (to 1/100th second)

Minutes Seconds
HAND GRIP
69 a

Now I would like to assess the strength of your hand in a gripping action. After I say ‘And Go’ squeeze this handle as hard as you can, just for a couple of seconds and then let go. Are you willing to do this test?

1
Yes
2
No
3
Unable for health reasons
4
Unable, other (e.g. machine broken)
69 a(i)

Please say why unable/unwilling

Generic text
69 a(ii)

Provide machine no.

Generic text
69 b

Please watch the display as you are squeezing so that you can see how well you are doing. I will take 3 measurements from your dominant hand and 3 measurements from your non dominant hand.

Record one only.

1
Participant has the use of both hands
2
Participant is unable to use right hand
3
Participant is unable to use left hand
4
Participant is unable to use either hand
69 c

Which is your dominant hand?

1
Right hand
2
Left hand
Position the participant correctly, select the correct hand grip and set the probable range on the dynamometer. Explain the procedure once again. Show the participant how to do the test.
69 d

Dominant hand, first measurement. Enter the results to one decimal place.

Grip strength
69 e

Non dominant hand, first measurement. Enter the results to one decimal place.

Grip strength
69 f

Dominant hand, second measurement. Enter the results to one decimal place.

Grip strength
69 g

Non dominant hand, second measurement. Enter the results to one decimal place.

Grip strength
69 h

Dominant hand, third measurement. Enter the results to one decimal place.

Grip strength
69 i

Non dominant hand, third measurement. Enter the results to one decimal place.

Grip strength
LUNG FUNCTION
70 a

Now I would like to measure your lung function. Can I check, have you had abdominal or chest surgery in the past three weeks?

1
Yes
0
No
If Yes to question 70a. - No lung function to be taken go to module M
qc_70_a == 1
Else
70 b

Have you been admitted to hospital for a heart complaint or stroke in the past six weeks?

1
Yes
0
No
If Yes to question 70b. - No lung function to be taken go to module M
qc_70_b == 1
Else
70 c

Are you willing to have your lung function measured?

1
Yes
2
No
3
Unable for health reasons
4
Unable, other (e.g. machine broken)
70 c(i)

Please say why unable/unwilling

Generic text
70 c(ii)

Provide machine no.

Generic text
70 d

In the past three weeks, have you had any respiratory infections such as influenza, pneumonia, bronchitis or a severe cold?

1
Yes
0
No
70 e

Do you suffer from asthma or hayfever?

1
Yes
0
No
Explain the procedure and demonstrate the test. Record the results of two blows by the participant in the boxes below. Record each blow as it is carried out. For each blow, enter measurements and code whether technique was satisfactory. If no reading obtained enter ‘0’and suppress all checks.
70 f(i)

First blow: FEV1

FEV1
70 f(ii)

First blow: FVC

FVC
70 f(iii)

First blow: FER%

FER%
70 f(iv)

First blow: PEF

PEF
70 f(v)

First blow: Technique satisfactory?

1
Yes
0
No
70 g(i)

Second blow: FEV1

FEV1
70 g(ii)

Second blow: FVC

FVC
70 g(iii)

Second blow: FER%

FER%
70 g(iv)

Second blow: PEF

PEF
70 g(v)

Second blow: Technique satisfactory?

1
Yes
0
No
GP LETTER (OR PARTICIPANT FEEDBACK LETTER)
70 i

Nurse to complete lung function measurements on the participant feedback letter (use highest). Please tick the box to confirm you have done this:

1
Tick
M. DIET DIARY
The MRC National Survey team would like you to keep this diet diary for 5 days over the following week, including both Saturday and Sunday, and then send it back in this envelope as you last did in 1999 [delete if not applicable]. The participant did not complete the diary in 1999 [delete if not applicable]
71

Would you be willing to keep the diet diary for 5 days?

1
Yes
0
No
71 i

Please say why unable /unwilling

Generic text
Nurse to use instruction sheet from manual to remind participant how to fill out the diary and how to collect the food labels.
Nurse: Attach one HNR label on the inside front cover of diary and another on the plastic folder. Explain to participant that they return the diary and labels to MRC Human Nutrition Research in Cambridge in the envelope provided in the folder.
N. STEP TEST OR WALK TEST AND HABITUAL PHYSICAL ACTIVITY
The nurse must complete the medical review to ensure participant is eligible for the step test
Medical review
The answers to question 72a-f should be completed by the nurse, based on answers given previously or on the ECG trace. If any answer to 72a-f is ‘yes’ the step test will not be performed.
72 a

Did the participant: Answer yes to Q9a and to 9b or 9c.

0
No
1
Yes
2
Yes, but different kind of pain e.g. indigestion
If Yes, but different kind of pain e.g. indigestion to question 72a go to Q72b
qc_72_a == 2
72 b

Did the participant: Report any of the following medical conditions at Q11 [aortic aneurysm, aortic stenosis, angina, myocardial infarction within last 3 months, myocarditis, cardiomyopathy, tachycardia, pulmonary or systemic embolism within the last 4 weeks] Please specify

0
No
1
Yes
Generic text
If Yes to question 72a go to Q75 walk test
qc_72_a == 1
Else
72 c

Did the participant: Echtocardiographer recommended no step test (Q18b) or heart rate No 0 on ECG was >= 100bpm or <= 40bpm (Q35)

0
No
1
Yes
If Yes to question 72c go to Q75 walk test
qc_72_c == 1
Else
72 d

Did the participant: Have a diastolic blood pressure >= 120mmHg or a systolic blood pressure of >= 200mmHg reported at Q32?

0
No
1
Yes
If Yes to question 72d go to Q75 walk test
qc_72_d == 1
Else
72 e

Did the participant: report dizziness ‘often’ or ‘very often’ on Q55d?

0
No
1
Yes
If Yes to question 72e go to Q75 walk test
qc_72_e == 1
Else
72 f

Did the participant: reported taking >= 100mg beta blocker in the medication list Q10?

0
No
1
Yes
If Yes to question 72f go to Q75 walk test
qc_72_f == 1
Else
73 a

Has a doctor ever told you that you have a bone or joint problem that could be aggravated by exercise?

0
No
1
Yes
If Yes to question 73a go to Q75 walk test
qc_73_a == 1
Else
73 b

Is there any reason you know of that means you should not follow an activity programme even if you wanted to? [if MI > 3 months ago check that participant has been approved for exercise by a physician] Please specify

0
No
1
Yes
Generic text
If Yes to question 73b go to Q75 walk test
qc_73_b == 1
Else
73 c

Do you suffer from breathlessness that prevents you climbing one flight of stairs or walking unaided on the flat for less than 10 minutes? [include breathlessness due to chronic lung disorders or unspecified valve disorders]

0
No
1
Yes
73 i

Nurse to initial box to indicate exclusion protocol is complete

Generic text
If Yes to question 73c go to Q75 walk test
qc_73_c == 1
Else
STEP TEST (for eligible participants only)
74 a

The last physical activity I would like you to do is to step on and off this step for a few minutes in time to a beat which will start at a slow pace, then get a little faster. I will stop the test after 8 minutes, or earlier if you want to stop or your heart rate reaches a certain level. Are you willing to do this test?

1
Yes
2
No
3
Unable for health reasons
4
Unable, other (e.g. equipment not available)
74 a(i)

Please say why unable/unwilling

Generic text
74 b

Record whether the step test was attempted. Code one only.

1
Step test attempted
2
Step test not attempted
74 c

Record the reason for stopping the test.

1
Participant finished the 8 minute test
2
HR reaches 90% age-predicted maximum HR or 80 % max HR for 2 mins
3
Participant not physically able to maintain the correct step frequency
4
Participant wanted to stop
Download the actiheart monitor now go to Q76
qc_72_a == 0 && qc_72_b == 0 && qc_72_c == 0 && qc_72_d == 0 && qc_72_e == 0 && qc_72_f == 0 && qc_73_a == 0 && qc_72_b == 0 && qc_72_c == 0
Else
WALK TEST (For those not eligible for the step test)
75 a

This test is very simple. I want you to walk 250 metres (about 275 yards) at your own speed and keeping a regular, consistent pace over the entire distance. It is not the aim to get there in the shortest time. Are you willing to do this test?

1
Yes
2
No
3
Unable for health reasons
4
Unable, other (e.g. no room available)
75 a(i)

Please say why unable/unwilling

Generic text
75 b

Record whether the walk test was attempted. Code one only.

1
Walk test attempted
2
Walk test not attempted or completed
75 c

Record time taken to walk the distance

Minutes Seconds
Download the actiheart monitor now
HABITUAL PHYSICAL ACTIVITY
We would like you to wear the actiheart monitor for the next 5 days while you carry out your normal activities. This would give information about your energy expenditure. The monitor is waterproof and does not need to be taken off when you bathe although you may remove it for short periods if you need to. You will be given instructions to take away with you and a box and pre-paid label for posting it back to us. If you want, we can send you information about your results.
76 a

Would you be willing to wear the actiheart monitor for 5 days?

1
Yes
0
No
76 a(i)

Please say why unable/unwilling

Generic text
76 b

Would you like us to send you information about your results?

1
Yes
0
No
If the participant has not done the step test they must do the walk test if they are to wear the actiheart monitor for 5 days.
Please set up the actiheart monitor for free-living recording if participant has agreed to this and give participant full instructions as in nurse manual.
O. COLLECTION OF SALIVARY CORTISOL AT HOME
77

We would like you to collect another three saliva samples at home, in the same way as you did earlier this morning. Would you be willing to collect these samples?

1
Yes
0
No
If No,
qc_77 == 0
77 i

please give reason

Generic text
If yes:
qc_77 == 1
“Here are the instructions for collecting these samples. We are asking you to collect one sample between 9.00-9.30p.m this evening, a second sample as soon as you wake up tomorrow morning, and a third sample 30 minutes after waking up. Each time you will need to write down on this form the actual time the sample was taken and report any stress, anxiety or trauma that occurred in the hour before the sample was taken. Then we would like you to place each salivette tube in to the transport container and place them in this pre-paid jiffy bag, and post the bag back to the lab. Thank you very much for taking the time to do this.” [If participant has a visit on a Friday, please ask them to take the first sample on Sunday night and the other two samples on Monday morning and then post them back to the lab]
P. BODY COMPOSITION SCANS
Explain purpose and procedures for bone health measurements.
78

Would you be willing to have these measurements taken?

1
Yes
2
Yes, but unable (e.g. ran out of time)
0
No, not willing
If no measurements taken,
qc_78 == 2 || qc_78 == 0
78 i

please give reason:

Generic text
GP LETTER OR PARTICIPANT LETTER AND EVALUATION FORM
gpletter i

Nurse to finish completing and sign the letter. Please check that this corresponds with the general consent form. Please tick the box to confirm you have done this

1
Tick
Go through the GP letter with the participant unless they do not wish to. Make 5 copies of this letter:
1 for the participant (unless they don’t want a copy)
1 to leave with the Department of Medical Physics
1 for the GP
1 for the CRF
1 for MRC Human Nutrition Research, Cambridge
original for NSHD
Make 2 copies of the general consent form, and 2 of the clinical advisor consent form if used:
1 for the participant (unless they don’t want a copy)
1 for the CRF
original for NSHD
Ask participant to give you their evaluation form or leave it with reception or bone density staff or send it back with their actiheart monitor.
Give arrangements for lunch or lunch voucher after bone measurements.
Thank the participant for coming.
Confirm arrangements for transport home.
gpletter ii

Record the time of day (24 hour clock):

Generic time
Nurse to finish completing and sign the letter.
Ring the Department of Medical Physics to say participant is ready to come over.
End

nshd_06_ncs

s_intro_i
STRICTLY CONFIDENTIAL
s_intro_ii
MRC NATIONAL SURVEY OF HEALTH AND DEVELOPMENT
s_intro_iii
MRC Unit for Lifelong Health and Ageing
s_intro_iv
CLINIC STUDY 2008-10
s_intro_v
Nurse Clinic Schedule
s_intro_vi
Version Dated: 01/05/2008
intro i
Date of birth
Date of birth
intro ii
Nurses No's.
Nurse No.
Nurse No. 2
intro iii
Interview date
Generic date
intro iv
Record the time of day (24 hour clock):
Generic time

A. NURSE INTERVIEW (1): Consents, urine and medical review

s_intro_vii
Thank participant for coming. Make sure travelling expenses have been dealt with. Collect the preassessment questionnaire and check if the participant had any problems filling it in.
s_intro_viii
Explain purpose of clinic visit and ask if participants have read the information pamphlet and if they have any questions about the study and the measures.
s_intro_ix
Explain we need to obtain their consent to be interviewed and measured today and to use information collected today and at previous times for research. Explain that even having given consent they can still decline to do any part of the interview or examination.
s_intro_x
Explain that results of some tests (blood pressure, lung function and anthropometry) will be given to them today.
s_intro_xi
Explain we will be asking them to consent to send results to their GP that may be useful for their health care and that this will be explained at the relevant parts of the examination. Confirm the GP address already on the GP letter. If the GP details have changed use a new GP letter. If the participant does not want any results sent to their GP use the participant feedback letter rather than the GP letter.
s_intro_xii
Participant should now read and sign the general consent form. Delete any sections that the participant does not consent to (e.g. results to GP or use of blood sample for genetic aspects of health).
1 a
Are any sections of the general consent form crossed out?
1
Yes
0
No
s_q1b
If the participant does not want results sent to GP, ask them to sign the clinical advisor consent form. Explain that if this consent is not given, a blood sample cannot be drawn and certain cardiovascular tests cannot be taken.
1 b
If necessary, has the clinical advisor consent form been signed?
1
Yes
0
No
1 c
If the participant has not completed a hospital records consent form ask them to do so and record whether the form has now been signed:
1
Hospital consent form now signed
2
Hospital consent form not signed
3
Not applicable, form already signed
2 a
Have you brought your urine sample with you?
1
Yes
0
No
2 b
Have you brought the completed urine instruction sheet?
1
Yes
0
No
3
Have you had anything to eat in the last 12 hours?
1
Yes
0
No
3 i
how many hours ago did you last eat? ... hours
How many
If yes,
4
Besides water, have you drunk anything else in the last 12 hours?
1
Yes
0
No
5 a
Have you drunk tea or coffee or cola in the last 12 hours?
1
Yes
0
No
5 a(i)
how many hours ago did you drink tea, coffee or cola? ... hours
How many
If yes,
5 b
Have you drunk anything else in the last 12 hours?
1
Yes
0
No
5 b(i)
please specify
Generic text
If yes,
6
Have you smoked tobacco in the last 12 hours?
1
Yes
0
No/Non-smoker
6 i
how many hours ago did you smoke tobacco?
How many
If yes,
7
Did you do any strenuous physical activity yesterday?
1
Yes
0
No
8
Have you had any operations in the last 3 months?
1
Yes
0
No
8 i
please specify:
Generic text
If yes,
9 a
Do you ever have any pain or discomfort in your chest?
0
No
1
Yes
9 b
Do you get this pain or discomfort when you walk uphill or hurry?
0
No
1
Yes
2
Never walk uphill or hurry
9 c
Do you get it when you walk at an ordinary pace on the level?
0
No
1
Yes
2
Never walk
9 d
What do you do if you get this pain while walking?
1
Stop or slow down
2
Carry on
3
Carry on after using a spray or taking tablet under your tongue (nitroglycerine)
4
Not applicable
9 e
Does the pain or discomfort in your chest go away if you stand still?
0
No
1
Yes
9 f
How long does it take to go away?
1
10 minutes or less
2
More than 10 minutes
9 g
Where do you get this pain or discomfort? Mark the place(s) with an X on the diagram.
10
Check whether they have brought their regular medicines with them and ask: Have you taken any medicines, prescribed or non-prescribed, in the last 24 hours?
1
Yes
0
No
10 i

please give details in the table below. Use one row for each medication. Be sure to include use of puffer or inhaler or any medication for breathing, and any medications bought from a pharmacy.Use spare medication sheets if necessary and attach to questionaire

Name of medicine How many hours ago did you last take the medicine? Do you take this medicine regularly? Is this medicine prescribed by your GP or consultant?
Generic textHow many

1 - Yes

0 - No

1 - Yes

0 - No

How many

1 - Yes

0 - No

1 - Yes

0 - No

Generic text

1 - Yes

0 - No

How many

1 - Yes

0 - No

Generic text

1 - Yes

0 - No

How manyGeneric text

1 - Yes

0 - No

 Generic textHow many

1 - Yes

0 - No

1 - Yes

0 - No

How many

1 - Yes

0 - No

1 - Yes

0 - No

Generic text

1 - Yes

0 - No

How many

1 - Yes

0 - No

Generic text

1 - Yes

0 - No

How manyGeneric text

1 - Yes

0 - No

 Generic textHow many

1 - Yes

0 - No

1 - Yes

0 - No

How many

1 - Yes

0 - No

1 - Yes

0 - No

Generic text

1 - Yes

0 - No

How many

1 - Yes

0 - No

Generic text

1 - Yes

0 - No

How manyGeneric text

1 - Yes

0 - No

 Generic textHow many

1 - Yes

0 - No

1 - Yes

0 - No

How many

1 - Yes

0 - No

1 - Yes

0 - No

Generic text

1 - Yes

0 - No

How many

1 - Yes

0 - No

Generic text

1 - Yes

0 - No

How manyGeneric text

1 - Yes

0 - No
1
2
3
4
5
6
7
8
9
10
11
12
13
If 'Yes',
11 a
Has a doctor told you that you have any of the following health problems? Health Problem High blood pressure
1
YES
0
NO
11 b
Has a doctor told you that you have any of the following health problems? Health Problem Diabetes
1
YES
0
NO
11 c
Has a doctor told you that you have any of the following health problems? Health Problem Bleeding or clotting disorder
1
YES
0
NO
11 d
Has a doctor told you that you have any of the following health problems? Health Problem Angina
1
YES
0
NO
11 e
Has a doctor told you that you have any of the following health problems? Health Problem Heart attack (myocardial infarct, coronary thrombosis)
1
YES
0
NO
11 e(i)
when did this (last) occur?
Generic date
If YES to question 11e.
11 f
Has a doctor told you that you have any of the following health problems? Health Problem Aortic aneurysm
1
YES
0
NO
11 g
Has a doctor told you that you have any of the following health problems? Health Problem Aortic stenosis
1
YES
0
NO
11 h
Has a doctor told you that you have any of the following health problems? Health Problem Myocarditis (infection of the heart)
1
YES
0
NO
11 i
Has a doctor told you that you have any of the following health problems? Health Problem Cardiomyopathy (‘large heart’ or ‘weak heart’)
1
YES
0
NO
11 j
Has a doctor told you that you have any of the following health problems? Health Problem Other heart trouble (Valvular disease, Ischaemic heart disease, tachycardia, palpitations or heart murmur, other) Please specify
1
YES
0
NO
Other
11 k
Has a doctor told you that you have any of the following health problems? Health Problem Pulmonary embolism (blood clot on the lung) or systemic embolism within the last 4 weeks
1
YES
0
NO
11 l
Has a doctor told you that you have any of the following health problems? Health Problem Do you have a pacemaker?
1
YES
0
NO
B
BLOOD SAMPLE: Record the time of day (24 hour clock):
Generic time
12 a
Have you given a blood sample before?
1
Yes
0
No
12 b
were there any problems (e.g. fainting)? Please specify:
1
Yes
0
No
Generic text
If yes,
s_q13
Explain the purpose and procedure for taking blood.
13
Would you be willing to have a blood sample taken?
1
Yes
0
No
13 i
please give reason:
Generic text
If NO,
s_q14a
Collect blood sample into separate safety monovettes, appropriately labelled, with appropriate anticoagulants for different analytical purposes: lithium heparin, EDTA, fluoride oxalate, citrate and a plain tube (see detailed protocol in the manual). Then answer Q14a-d:
14 a
Was the whole blood sample obtained?
1
Yes
2
Only part
3
None
14 a(i)
please give reason.
1
Collapsing/poor veins
2
Second attempt necessary
3
Participant felt faint/fainted
4
Unable to use tourniquet
5
Other (Specify)
Other
If incomplete or absent sample,
14 b
Was a butterfly used instead of a fixed needle?
1
Yes
0
No
14 b(i)
please give reason for using butterfly
Generic text
If yes,
14 c
Record where blood taken from. If from more than one place record on blood tracking form:
1
Right arm
2
Left arm
3
Right hand
4
Left hand
5
More than 1 place
8
Not obtained
14 d
Was participant sitting in a chair or lying down when the blood was taken?
1
Sitting in chair
2
Lying down
15
The research team will write to you to tell you when the results of the blood tests have been sent to your GP [unless consent not given] Do you want to receive a copy of the blood results?
1
Yes
0
No
15 i
please tick the appropriate box on the GP letter Please tick the box to confirm you have done this
1
Tick
If 'yes'
s_q15ii
Now complete the front page of the blood sample tracking form, and the time urine received and delivered on the urine tracking form.
15 ii
Hand both the blood and urine samples, and their corresponding tracking forms, to the lab staff. Please tick the box to confirm you have done this
1
Tick
15 iii
Record the time of day (24 hour clock):
Generic time

C. ECHO: (LV MASS, GLOBAL DIASTOLIC AND SYSTOLIC FUNCTION)

s_echo_i
Explain purpose and procedures for echocardiogram.
16
Would you be willing to have an echocardiogram?
1
Yes
2
Yes, but unable (e.g. arrived too late)
0
No, not willing
16 i
please give reason:
Generic text
If no echocardiogram completed,
s_echo_ii
Ask participant to undress and put on a gown.
17
Was the echocardiogram completed satisfactorily?
1
Yes
0
No
17 i
please explain:
Generic text
If not completed satisfactorily,
18 a
was a full echocardiogram carried out so a clinical report could be written?
1
Yes
0
No
If the echocardiogram was abnormal,
18 b
Are there any reasons for not doing the step test? Please specify:
1
Yes
0
No
Generic text

D. CAROTID IMT and DISTENSIBILITY

s_q19
Explain purpose and procedures for the carotid IMT and distensibility measures
19
Would you be willing to have these measurements taken?
1
Yes
2
Yes, but unable (e.g. arrived too late)
0
No, not willing
19 i
please give reason:
Generic text
If no measurements taken,
20 a(i)
Echocardiographer to provide two blood pressure measurements with the participant supine: RIGHT Systolic
Systolic mmHg
20 a(i)
Echocardiographer to provide two blood pressure measurements with the participant supine: RIGHT Diastolic
Diastolic mmHg
20 a(ii)
Echocardiographer to provide two blood pressure measurements with the participant supine: LEFT Systolic
Systolic mmHg
20 a(ii)
Echocardiographer to provide two blood pressure measurements with the participant supine: LEFT Diastolic
Diastolic mmHg
20 b
Were the CAROTID IMT and DISTENSIBILITY measures completed satisfactorily?
1
Yes
0
No
20 b(i)
please explain:
Generic text
If not completed satisfactorily,
21
Was plaque present in the common carotid artery or the bifurcation?
1
Yes
0
No
s_q21i
GP LETTER (OR PARTICIPANT FEEDBACK LETTER)
21 i
Echocardiographer to complete relevant part of the letter and sign the form. Please tick the box to confirm you have done this
1
Tick

E. SELF-COMPLETION

s_self-completion_i
Introduce self-completion questionnaire
s_self-completion_ii
“Now it’s time for breakfast and while I am getting that ready I’d like to give you this questionnaire to fill in by yourself. The questions are about how you have been feeling recently. Please check with me if any of the questions are unclear.”
22
Can I ask, would you be willing to complete this questionnaire?
1
Yes
0
No
22 i
please give reason:
Generic text
If NO,
s_self-completion_iii
BREAKFAST
23
Check any uncompleted or inconsistent questions on the self-completion questionnaire and record:
1
Booklet completed independently
2
Booklet completed with assistance from interviewer
3
Booklet completed with assistance from someone else
4
Booklet not completed
23 i
Check any uncompleted or inconsistent questions on the pre-assessment questionnaire: Please tick the box to confirm you have done this
1
Tick
F
ANTHROPOMETRY: Record the time of day (24 hour clock):
Generic time
24
Would you be willing to be measured and weighed?
1
Yes
2
Yes, but unable (e.g. equipment not available)
0
No
24 i
please give reason:
Generic text
If no,
25
Measure standing height. Height
Centimetres
26
Measure sitting height (participant seated on a board on a chair) Sitting height
Centimetres
27
Measure weight (using kilograms) and record scale reading Weight
Kilograms
28
Measure circumference of right arm to the nearest mm. Arm
Centimetres
29 a
Measure the chest circumference to the nearest mm. Chest
Centimetres
29 b
Measure the expanded chest circumference to the nearest mm. Expanded
Centimetres
30
Measure the waist circumference to the nearest mm. Waist
Centimetres
31
Measure the hip circumference to the nearest mm. Hip
Centimetres
31 i
Now write the height, weight, waist and hip circumference measurements on the letter Please tick the box to confirm you have done this
1
Tick
31 ii
How were the anthropometric measures taken?:
1
On skin
2
Light clothes
3
Other (Specify, e.g. heavy clothes)
Other
31 iii
Please note below any changes to protocol for the anthropometric measurements e.g. participant sat on the floor for sitting height measurement:
Generic text
s_anthropometry_ii
GP LETTER (OR PARTICIPANT FEEDBACK LETTER)

G. BLOOD PRESSURE (SEATED)

32
Would you be willing to have your blood pressure taken?
1
Yes
2
Yes, but unable (e.g. machine broken)
0
No
32 i
please give reason:
Generic text
If no measure taken,
32 ii
Provide machine no
Generic text
32 iii
Enter ambient temperature in Celsius to the nearest degree.
Celsius
32 iv(a)
First reading: SYSTOLIC
Systolic mmHg
32 iv(b)
First reading: DIASTOLIC
Diastolic mmHg
32 iv(c)
First reading: PULSE
Pulse
32 v(a)
Second reading: SYSTOLIC
Systolic mmHg
32 v(b)
Second reading: DIASTOLIC
Diastolic mmHg
32 v(c)
Second reading: PULSE
Pulse
s_q32vi
GP LETTER (OR PARTICIPANT FEEDBACK LETTER)
32 vi
Now write the blood pressure measurements onto the letter (use lowest diastolic reading) Please tick the box to confirm you have done this
1
Tick

H. ECG AND HEART RATE VARIABILITY

s_ecg_i
If participant has not consented for GP to be sent results that are directly relevant to their health nor for the clinical advisor to contact them if necessary then do not take this measure
s_ecg_ii
Explain purpose and procedures for ECG, heart rate variability and pulse wave velocity.
33
Would you be willing to have these measures taken?
1
All of them
2
Some of them
3
None of them
33 i
please give reason:
Generic text
If ‘some of them’ or ‘none of them’,
34
Was the ECG completed satisfactorily?
1
Yes
0
No
34 i
please explain:
Generic text
If not completed satisfactorily,
35 a
Was the heart rate from the ECG >= 100bpm
1
Yes
0
No
35 b
Was the heart rate from the ECG <=40bpm
1
Yes
0
No
36
Was HEART RATE VARIABILITY measured satisfactorily?
1
Yes
0
No
36 i
please explain:
Generic text
If not completed satisfactorily,

I. PULSE WAVE VELOCITY (PWV) AND PULSE WAVE ANALYSIS (PWA)

37
Was PWV measured satisfactorily?
1
Yes
0
No
37 i
please explain:
Generic text
If not completed satisfactorily,
38
Was PWA measured satisfactorily?
1
Yes
0
No
38 i
please explain:
Generic text
If not completed satisfactorily,
38 ii
Please record: Distance from the suprasternal notch to the top of thigh cuff ( right) ... mm
Millimetres
38 iii
Nurse to complete the rest of the CVD section of the letter Please tick the box to confirm you have done this
1
Tick
38 iv
Record the time of day (24 hour clock):
Generic time

J. SALIVARY CORTISOL

s_salivarycortisol_i
“We are collecting saliva to measure cortisol, one of the body’s hormones. Cortisol levels are related to many aspects of our health that we are measuring in this data collection. We would like you to unscrew the cap of this salivette tube and pop the swab in your mouth without touching it. We would like you to keep the swab in your mouth and roll it around your mouth for 1-2 minutes until you feel that you can longer prevent yourself from swallowing the saliva produced. Then we want you to spit the swab back into the small container and screw the top on.”
39 a
Would you be willing to collect saliva in this way?
1
Yes
0
No
39 a(i)
please give reason
Generic text
If no,
39 b
Did you suffer any stress, anxiety or trauma in the hour before the sample was taken?
1
Yes
0
No
s_salivarycortisol_ii
After the sample has been taken ask:
39 b(i)
what was the cause of the stress?
Generic text
If yes,
39 b(ii)
Now complete the saliva tracking form and hand both the form and saliva sample to the lab staff. Please tick to confirm you have done this.
1
Tick
s_salivarycortisol_iii
“Cortisol levels can change between morning and night and we would like you to take some more saliva samples at home and post them back to the clinic. I’ll explain more about this at the end of the visit.”

K. ECONOMIC CIRCUMSTANCES

s_economiccircumstances_i
Introduce questions on economic circumstances:
s_economiccircumstances_ii
“The next few questions are about your economic circumstances as this study and others show that things like income and your level of financial security can affect health in a number of ways.”
40 a(ii)
Do you or your husband/wife/partner receive income from any of the sources listed on this show card? Husband/wife or partner Other, please specify
1
Earnings from employment or self- employment
2
State pension (include basic state pension, SERPS and State 2nd pension)
3
Pension form a previous employer
4
Private pension/annuity
5
Dividends or interest from savings or investments
6
Rent from property or land
7
Health-related or disability benefits e.g. Incapacity benefit (Invalidity Benefit), Statutory Sick Pay, Severe Disablement Allowance, Disability Living Allowance, Attendance Allowance, Carer’s Allowance (Invalid Care Allowance), Industrial Injuries Disablement Benefit, War Disablement Pension.
8
General benefits e.g. Pension credit (Minimum Income Guarantee), Income Support for the over 60’s, Income Support, Job Seeker’s Allowance (Unemployment Benefit), Housing Benefit/ Rent Rebate or Allowance, Council Tax Benefit, Working Tax Credit (Working Families Tax Credit), Widow’s Pension, Widowed Mother’s Allowance, Bereavement Allowance, Child Benefit, Child Tax Credit.
9
Other, please specify
Other
40 a(i)
Do you or your husband/wife/partner receive income from any of the sources listed on this show card? Participant Other, please specify
1
Earnings from employment or self- employment
2
State pension (include basic state pension, SERPS and State 2nd pension)
3
Pension form a previous employer
4
Private pension/annuity
5
Dividends or interest from savings or investments
6
Rent from property or land
7
Health-related or disability benefits e.g. Incapacity benefit (Invalidity Benefit), Statutory Sick Pay, Severe Disablement Allowance, Disability Living Allowance, Attendance Allowance, Carer’s Allowance (Invalid Care Allowance), Industrial Injuries Disablement Benefit, War Disablement Pension.
8
General benefits e.g. Pension credit (Minimum Income Guarantee), Income Support for the over 60’s, Income Support, Job Seeker’s Allowance (Unemployment Benefit), Housing Benefit/ Rent Rebate or Allowance, Council Tax Benefit, Working Tax Credit (Working Families Tax Credit), Widow’s Pension, Widowed Mother’s Allowance, Bereavement Allowance, Child Benefit, Child Tax Credit.
9
Other, please specify
Other
40 b
Which of the letters on the show card represents your total net household income? Please include our own and your partner’s earned income (after deduction for income tax and national insurance), any state benefits and any other sources of income such as pension and interest. Please also include contributions from other members of your household (such as children). Please choose the period (annual, monthly or weekly) that is most convenient for you to use. Then, find the amount in pounds which represents your net household income and state the corresponding letter. Letter
Letter
41 a
On your present income do you find (as a family)
1
That it’s really quite hard to manage?
2
That you manage fairly well?
3
That you manage comfortably?
41 b
Have you or your family had to go without things you really needed in the last year because you were short of money?
1
Yes, often
2
Yes, sometimes
3
No
41 c
Have you found you have been unable to pay the bills in the last year because you were short of money?
1
Yes, often
2
Yes, sometimes
3
No

L. PERFORMANCE QUESTIONS AND TESTS

s_performancequestions_i
These next questions are about difficulties you may have carrying out daily activities.
42
Do you have any long-term illness, health problem or disability that limits your activities or the work you can do?
0
No
1
Yes
43
Do you have difficulty because of long-term health problems holding something heavy like a full kettle or removing a stiff lid from a jar?
0
No
1
Some difficulty
2
A lot of difficulty
44
How frequently at home or at work do you use your hands in strong movements, such as squeezing water out of a towel, playing racket sports, digging the garden, or carrying heavy items such as a suitcase, briefcase, bucket or shopping bag?
1
Several times a day
2
Once a day
3
Once or several times a week
4
Occasionally
5
Never
45
In the last 12 months, have you had sciatica, lumbago or severe backache?
0
No
1
Yes
46
In the last 12 months, have you had pain in and around your knees on most days of the month for at least 3 months?
0
No
1
Yes
47 a
Do you find it difficult to walk for a quarter of a mile on the level because of long-term health problems? (If asked: a quarter of a mile is 400 yards)
0
No
1
Yes
47 b
how far can you walk without stopping or severe discomfort. Would you say...
1
More than 400 yards
2
200 to 400 yards
3
50 to 200 yards or
4
Less than 50 yards
If yes,
48
Do you find it difficult walking up and down stairs, because of long-term health problems?
0
No
1
Yes
48 i
can you walk up and down a flight of 12 stairs in a normal manner without holding on or taking a rest?
0
No
1
Yes
If yes,
49
Do you easily fall or have difficulty keeping your balance because of long-term health problems?
0
No
1
Yes
50
Do you need to hold onto something to keep your balance?
0
No
1
Occasionally
3
Often
4
Always
51
Have you fallen at all in the past 12 months?
0
No
1
Yes
51 i
how many times have you fallen in the past 12 months?
How many
If yes,
51 ii
On how many of these occasions have you injured yourself badly enough to see a doctor?
How many
If yes,
52 a
Do you have difficulty bending down and straightening up, even when holding onto something because of long-term health problems?
0
No
1
Yes
52 b
Can you bend down to sweep something from the floor and straighten up?
1
Yes
0
No
52 c
Can you bend down to pick up something from the floor and straighten up?
1
Yes
0
No
52 d
Can you bend down far enough to touch your knees and straighten up?
1
Yes
0
No
53 a
Is it difficult, because of long-term health problems to do any of the following activities? go shopping and carry a full bag of shopping in each hand?
1
Yes
0
No
53 b
Is it difficult, because of long-term health problems to do any of the following activities? do heavy housework?
1
Yes
0
No
53 c
Is it difficult, because of long-term health problems to do any of the following activities? prepare a hot meal?
1
Yes
0
No
54 a
Is it difficult, because of long-term health problems, for you to do any of the following activities? Washing hands and face?
0
No
1
Yes
54 a(i)
can you do it without aids or personal help?
1
Yes
2
No, uses aid but no personal help
3
No, needs personal help
If yes,
54 b
Is it difficult, because of long-term health problems, for you to do any of the following activities? Bathing or showering?
0
No
1
Yes
2
Bathing only
54 b(i)
can you do it without aids or personal help?
1
Yes
2
No, uses aid but no personal help
3
No, needs personal help
If yes,
54 c
Is it difficult, because of long-term health problems, for you to do any of the following activities? Dressing and undressing?
0
No
1
Yes
54 c(i)
can you do it without aids or personal help?
1
Yes
2
No, uses aid but no personal help
3
No, needs personal help
If yes,
54 d
Is it difficult, because of long-term health problems, for you to do any of the following activities? Getting in and out of a chair?
0
No
1
Yes
54 d(i)
can you do it without aids or personal help?
1
Yes
2
No, uses aid but no personal help
3
No, needs personal help
If yes,
54 e
Is it difficult, because of long-term health problems, for you to do any of the following activities? Getting in and out of bed?
0
No
1
Yes
54 e(i)
can you do it without aids or personal help?
1
Yes
2
No, uses aid but no personal help
3
No, needs personal help
If yes,
54 f
Is it difficult, because of long-term health problems, for you to do any of the following activities? Getting to the toilet?
0
No
1
Yes
54 f(i)
can you do it without aids or personal help?
1
Yes
2
No, uses aid but no personal help
3
No, needs personal help
If yes,
54 g
Is it difficult, because of long-term health problems, for you to do any of the following activities? Using the toilet?
0
No
1
Yes
54 g(i)
can you do it without aids or personal help?
1
Yes
2
No, uses aid but no personal help
3
No, needs personal help
If yes,
54 h
Is it difficult, because of long-term health problems, for you to do any of the following activities? Feeding yourself, including cutting up food?
0
No
1
Yes
54 h(i)
can you do it without aids or personal help?
1
Yes
2
No, uses aid but no personal help
3
No, needs personal help
If yes,
55 a-d

In the last 12 months, have you had a problem with the following?

-

1 - Rarely or never

2 - Sometimes

3 - Often

4 - Very often
Sudden loss of balance?
Weakness in the arms?
Weakness in the legs?
Dizziness when standing up quickly?
56 i-iv

Have you had a problem with the following in the last 12 months?

-

1 - Rarely or never

2 - Sometimes

3 - Often

4 - Very often
Paying attention?
Finding the right word?
Remembering things?
Remembering where you put something?
57 i-vi

Have you had difficulty with the following in the last 12 months?

-

1 - No difficulty

2 - A little difficulty

3 - Some difficulty

4 - A great deal of difficulty
Reading a newspaper?
Recognizing a friend across the street?
Reading signs at night?
Hearing over the phone?
Hearing a normal conversation?
Hearing conversation in a noisy room?
58 i
In the last 12 months, have you had a problem with the following? Loss of appetite?
1
Rarely or never
2
Sometimes
3
Often
4
Very often
58 ii
In the last 12 months, have you had a problem with the following? Unexplained weight loss?
1
Rarely or never
2
Sometimes
3
Often
4
Very often
59
In the last year, have you lost more than 10 pounds unintentionally?
1
Yes
0
No
60
How often in the last week did the following apply? “I felt that everything I did was an effort” or “I could not get going”
0
Rarely or none of the time (&lt;1 day)
1
Some or a little of the time (1-2 days)
2
A moderate amount of time (3-4 days)
3
Most of the time (&gt;4 days)
60 i
Record the time of day (24 hour clock):
Generic time
s_performancequestions_ii
FUTURE CONSENT FORM
s_performancequestions_iii
Ask the participant if they would be willing to complete the future consent form

REACTION TIME

61 a
I would now like to see how quickly you can react. This involves pressing a key every time you see a ‘0’ or an ‘8’ appear on the screen. Are you willing to do this test?
1
Yes
2
No
3
Unable for health reasons
4
Unable, other (e.g. machine broken)
61 a(i)
Please say why unable/unwilling
Generic text
61 a(ii)
Provide machine no.
Generic text
s_reactiontime_i
Put your finger on this key marked ‘0’ and look at the screen. This is the only key you will need to use. Every time you see a ‘0’ or an ‘8’ on the screen press the key once as quickly as you can. We will start with a practice run to make sure you know what to do. Are you clear about it? I am going to start the machine now, so look for the ‘0’s or ‘8’s and press firmly as soon as you see one.
s_reactiontime_ii
Press start button. Correct any error during 8 practice trials. When the ‘wait’ indicator appears, say:
s_reactiontime_iii
That was fine. Now we can time your reactions. Every time you see a ‘0’ or an ‘8’ on the screen, press the ‘0’ key as quickly as you can.
s_reactiontime_iv
Press start button (20 ‘0’s or ‘8’s will be displayed in turn).
61 b
When display flashes: Press Key 1 and record: Mean
Mean time
61 c
When display flashes: Press Key 2 and record: Standard deviation
Standard deviation
s_reactiontime_v
Then press Start to clear the screen.
s_reactiontime_vi
I’m now going to give you a slightly harder test. This time the numbers 1, 2, 3 or 4 will appear on the screen. I want you to press the key that has the same number as that on the screen. If you see a ‘4’ on the screen, press key 4 as quickly as possible. If you see a ‘1’, press key 1, and so on.
s_reactiontime_vii
Use both hands to do this. Put the 1st and 2nd fingers of each hand on the four keys (1, 2, 3, 4). (Other fingers can be used if necessary.)
reactiontime i
If the participant has a non-functional hand, tick here ... and go to the next test.
1
Tick
s_reactiontime_viii
I am going to start the machine again. Remember to press the same number as the number on the screen. This is another practice run.
s_reactiontime_ix
Press start button. Correct any error during 8 practice trials. When the ‘wait’ indicator appears, say:
s_reactiontime_x
Now let’s do it as a proper test. Every time you see a number on the screen, quickly press the key with the same number. Remember to press firmly.
s_reactiontime_xi
Press start button (40 numbers will be displayed in turn).
61 d
When display flashes: Press Key 1 and record: Mean time (correct)
Mean time
61 e
When display flashes: Press Key 2 and record: Standard deviation
Standard deviation
61 f
When display flashes: Press Key 0 and record: Number of errors
How many
61 g
When display flashes: Press Key 3 and record: Mean time (errors)
Mean time
61 h
When display flashes: Press Key 4 and record: Standard deviation
Standard deviation
s_reactiontime_xii
Switch off machine.

WORD LIST MEMORY

62 a
Now I want to see how well you remember a list of fifteen words. I will show you one word at a time and when I reach the end of the list you have one minute to write down as many words as you can. Please write the words in any order you like. It is best not to talk to anyone while you are doing this. Are you willing to do this test?
1
Yes
2
No
3
Unable for health reasons
4
Unable, other (e.g. materials not available)
62 a(i)
Please say why unable/unwilling
Generic text
s_q62b
Nurse: Hand over the paper test booklet turn to page 3 and make sure the participant has a pencil. Show the words at two second intervals using Word List A or B as specified on contact sheet and on front page of booklet. Make sure the last word is shown for two seconds. Tell participant to start. Start the stopwatch and time for one minute then tell the participant to finish. Turn booklet to page 5. Show the words again. Tell participant to start. Start the stopwatch and time for one minute then tell the participant to finish. Turn booklet to page 7. Show the words again. Tell participant to start. Start the stopwatch and time for one minute then tell the participant to finish.
62 b
Please record whether the word list trials were completed. Code one only.
1
All 3 trials were attempted
2
2 out of the 3 trials were attempted
3
Only one trial was attempted
4
None of the trials were attempted

VISUAL SEARCH

s_visualsearch_i
Nurse: Turn to letter search (page 9 of paper test booklet).
63 a
I would now like to see how quickly you can work through this list, crossing out the P's and W's. Are you willing to do this test?
1
Yes
2
No
3
Unable for health reasons
4
Unable, other (e.g. materials not available)
63 a(i)
Please say why unable/unwilling
Generic text
s_visualsearch_ii
Start at the top left and work along the row from left to right, then go to the beginning of the next row and work from left to right again, like reading a page. Carry on this way crossing out any P's and W's with one mark of the pencil like this. (Demonstrate). Carry on until I tell you to stop. Work as quickly and as accurately as you can. Nurse: Set your stopwatch for one minute. Tell the participant to start and stop at the correct moment.
63 b
Please record whether the letter search was attempted. Code one only.
1
Letter search attempted
2
Letter search not attempted
64
Do you remember that list of 15 words I showed you earlier. I would like you to write down as many of those words as you can remember.
1
Fourth trial attempted
2
Fourth trial not attempted
64 i
please explain:
Generic text
If not completed,
65 a
Nurse: Did the survey member have visual difficulty during testing?
1
No difficulty
2
Mild difficulty
3
Severe difficulty
4
No tests done
65 b
Nurse: Did the survey member have hearing difficulty during testing?
1
No difficulty
2
Mild difficulty
3
Severe difficulty
4
No tests done

CHAIR RISES

66 a
I would now like you to do 10 chair rises. First I will ask you to fold your arms and, after I say, ‘And Go’, stand up from your chair and sit down again 10 times like this, as quickly as possible (demonstrate). Are you willing to do this test?
1
Yes
2
No
3
Unable for health reasons
4
Unable, other (e.g. equipment not available)
66 a(i)
Please say why unable/unwilling
Generic text
66 a(ii)
Let the participant practice then record time for chair rise test. Enter time in seconds as on stopwatch (to 1/100th second)
Minutes Seconds

BALANCE AND CO-ORDINATION

67 a
I would now like to assess your balance and co-ordination. First, I will ask you to fold your arms and, after I say ‘And Go’, stand on your dominant leg, and raise your other foot off the floor like this (demonstrate). I will ask you to hold this position for as long as you can or until I tell you to stop. Then I want you to repeat the test with your eyes closed. Are you willing to do this test?
1
Yes
2
No
3
Unable for health reasons
4
Unable, other (e.g. no room available)
67 a(i)
Please say why unable/unwilling
Generic text
67 b
Which is your dominant leg (ignoring any current injury)?
1
Right leg
2
Left leg
67 c
Carry out test with participant's eyes open. Allow the participant to practice. Set stop watch for 30 seconds. Record time for balance test with eyes open. Enter time in seconds as on stopwatch (to 1/100th second) Minutes ... Seconds
Minutes Seconds
67 d
Carry out test with participant's eyes closed. Allow the participant to practice. Set stop watch for 30 seconds. Record time for balance test with eyes closed Enter time in seconds as on stopwatch (to 1/100th second)
Minutes Seconds

TIMED GET UP AND GO

68 a
Now I would like to time you while you get up from the chair and walk at a pace that is normal for you to the furthest line on the floor, turn around, walk back and sit back in the chair. Are you willing to do this test?
1
Yes
2
No
3
Unable for health reasons
4
Unable, other (e.g. no room available)
68 a(i)
Please say why unable/unwilling
Generic text
68 b
Able to walk without another person’s help?
1
Yes
0
No
68 c
Walking aid? specify (stick, frame e.t.c)
0
No
1
Yes
Generic text
68 i
Record time taken to complete walk. Enter time in seconds as on stopwatch (to 1/100th second)
Minutes Seconds

HAND GRIP

69 a
Now I would like to assess the strength of your hand in a gripping action. After I say ‘And Go’ squeeze this handle as hard as you can, just for a couple of seconds and then let go. Are you willing to do this test?
1
Yes
2
No
3
Unable for health reasons
4
Unable, other (e.g. machine broken)
69 a(i)
Please say why unable/unwilling
Generic text
69 a(ii)
Provide machine no.
Generic text
69 b
Please watch the display as you are squeezing so that you can see how well you are doing. I will take 3 measurements from your dominant hand and 3 measurements from your non dominant hand.
1
Participant has the use of both hands
2
Participant is unable to use right hand
3
Participant is unable to use left hand
4
Participant is unable to use either hand
69 c
Which is your dominant hand?
1
Right hand
2
Left hand
s_handgrip_i
Position the participant correctly, select the correct hand grip and set the probable range on the dynamometer. Explain the procedure once again. Show the participant how to do the test.
69 d
Dominant hand, first measurement. Enter the results to one decimal place.
Grip strength
69 e
Non dominant hand, first measurement. Enter the results to one decimal place.
Grip strength
69 f
Dominant hand, second measurement. Enter the results to one decimal place.
Grip strength
69 g
Non dominant hand, second measurement. Enter the results to one decimal place.
Grip strength
69 h
Dominant hand, third measurement. Enter the results to one decimal place.
Grip strength
69 i
Non dominant hand, third measurement. Enter the results to one decimal place.
Grip strength

LUNG FUNCTION

70 a
Now I would like to measure your lung function. Can I check, have you had abdominal or chest surgery in the past three weeks?
1
Yes
0
No
70 b
Have you been admitted to hospital for a heart complaint or stroke in the past six weeks?
1
Yes
0
No
70 c
Are you willing to have your lung function measured?
1
Yes
2
No
3
Unable for health reasons
4
Unable, other (e.g. machine broken)
70 c(i)
Please say why unable/unwilling
Generic text
70 c(ii)
Provide machine no.
Generic text
70 d
In the past three weeks, have you had any respiratory infections such as influenza, pneumonia, bronchitis or a severe cold?
1
Yes
0
No
70 e
Do you suffer from asthma or hayfever?
1
Yes
0
No
s_lungfunction_ii
Explain the procedure and demonstrate the test. Record the results of two blows by the participant in the boxes below. Record each blow as it is carried out. For each blow, enter measurements and code whether technique was satisfactory. If no reading obtained enter ‘0’and suppress all checks.
70 f(i)
First blow: FEV1
FEV1
70 f(ii)
First blow: FVC
FVC
70 f(iii)
First blow: FER%
FER%
70 f(iv)