Initial Questionnaire of the NIOSH Occupational Asthma Identification Project ID #: INS - AZ - ________________ Location: ___________________________ Date: ____/____/________ **** General Tips before You Start **** This questionnaire will ask you mainly about your health. Read the whole question before making an answer. Try to answer all questions unless you are told to skip them. If you cannot decide whether to answer YES or NO, leave the question blank. If there are several responses, select the one which best describes your situation or symptoms, unless you are told to choose multiple answers. IDENTIFICATION 1) NAME: _________________ _______________________ ___________ (Last) (First) (Middle Initial) 2) SOCIAL SECURITY #: _________ _____ _________ 3) BIRTH DATE: _____/______/_____ (Month/Day/Year) 4) CURRENT ADDRESS: ____________________________________________ (Number, Street, or Rural Route) ____________________________________________ ____________________________________________ (City or Town, State, Zip Code) 5) HOME PHONE: (_________) _________ - _________________ 6) SEX 1. MALE 2. FEMALE 7) RACE 7a) Are you of hispanic origin? 0. White 1. NO 1. Black 2. YES 2. Asian/Pac. 3. Am Ind/Eskimo 4. other 8) STANDING HEIGHT 9) WEIGHT __________(inches) ________(lbs) 10) WHAT WAS THE HIGHEST GRADE OF SCHOOL YOU COMPLETED? __________(years) (Mark 12 if you have a high school diploma, 13 to 15 if you also have technical or associate training, 16 for a college degree, etc.) 11) This may be the last time we see you, but we would like to be able to keep you up to date on the results of the study. If you move, is there someone who would know your new address? (For example: parents, child, friend) NAME: ___________________________ RELATIONSHIP: _________________ ADDRESS: ____________________________________________ (Number, Street, or Rural Route) ____________________________________________ (City or Town, State, Zip Code) PHONE NUMBER: (_________) _________ - _________________ ABOUT YOUR HEALTH 1. Have you ever had asthma? 1. NO 2. YES 2. Have you ever had an asthmatic attack? 1. NO 2. YES IF YOU ANSWERED NO TO BOTH QUESTIONS 1 AND 2, SKIP TO QUESTION NUMBER 3 IF YOU ANSWERED "YES" TO EITHER OF THE ABOVE, PLEASE ANSWER QUESTIONS 2a, 2b and 2c. 2a) About what age did the asthma start? __________ age in years or ____ don't know 2b) Was asthma confirmed by a doctor? 1. NO 2. YES 2c) Do you still have asthma? 1. NO: How old were you when it stopped? __________ age in years 2. YES: Do you now take any pills, capsules, or liquids, including non-prescription medications for asthma? 1. NO 2. YES (List the names: _________________ _________________________________) 3. Does your chest ever sound wheezing or whistling? 1. NO 2. YES: If "YES", 3a) Do you get this only when you have a cold? 1. NO 2. YES occasionally apart from cold? 1. NO 2. YES most days or nights each week? 1. NO 2. YES 3b) Does the wheezing always clear after you cough? 1. NO 2. YES 4. Have you ever had attacks of shortness of breath with wheezing or whistling? 1. NO 2. YES: If "YES", was your breathing absolutely normal between attacks? 1. NO 2. YES 5. During the past 12 months, have you had an attack of shortness of breath or coughing that came on when you were just lying in bed or not doing any special effort? 1. NO 2. YES 6. During the past 12 months, has your chest ever felt tight for longer than a minute? 1. NO 2. YES 7. During the past 12 months, have you had an attack of shortness of breath or coughing that came on shortly after you stopped exercising? 1. NO 2. YES IF YOU ANSWERED NO TO ALL THE QUESTIONS FROM 3 TO 7, THEN SKIP TO QUESTION 19. IF YOU ANSWERED "YES" TO ANY OF THE QUESTIONS FROM 3 TO 7, PLEASE ANSWER ALL THE FOLLOWING QUESTIONS. 8. Which of the following best describes your breathing? 1. I never or only rarely get trouble with my breathing. 2. I get repeated trouble with my breathing, but it always gets completely better. 3. My breathing is never quite right. 9. What have been the most troublesome chest symptom or symptoms? 1. wheezing or whistling 2. attacks of shortness of breath 3. chest tightness 4. attacks of cough 5. other (Specify: _____________________) Please answer the following questions about your most troublesome chest symptom(s): 10. About how often have you had these symptoms? 1. Only once 2. Only a few days ever 3. A few days each year 4. A few days each month 5. A few days each week 6. Usually at least once each day or night 11. About what age did the symptoms first start? ___________ age in years 12. About what age did they last occur? ___________ age in years or ____ I still get them. 13. During the years that you had the chest symptoms, have you ever had a break in your symptoms for as long as a year or more? 1. NO 2. YES: IF "YES", 13a) Did you always take breathing medications during the breaks in your symptoms? 1. NO 2. YES 13b) Since your last break, how long have you had the symptoms? _____________ years 14. Are/were your symptoms worse during a particular season of the year? 1. NO, about the same in all seasons 2. YES: IF "YES", which is/was the worst season? 1. Winter 2. Spring 3. Summer 4. Fall 15. Are/were your symptoms worse at any particular time of day or night?: 1. NO, not worse at any particular time of day or night 2. YES: IF "YES", when are/were they worse? 1. When you first wake up? 2. While at work? 3. After leaving work? 4. While lying in bed? 16. When you are off work on weekend or vacation, do/did your symptoms get: 1. no change. 2. better. 3. worse. 17. After you have returned to work from leave or vacation, do/did your symptoms get: 1. no change. 2. better. 3. worse. 18. Regarding the most troublesome chest symptoms mentioned above, are/were they brought on by, or made worse by (choose all that apply): Contact with animals/pets? 1. NO 2. YES Heavy exercise? 1. NO 2. YES Plants or pollens 1. NO 2. YES Exposure to insects at work? 1. NO 2. YES Dusts, gases, or fumes at work? 1. NO 2. YES Dusts or fumes in the home? 1. NO 2. YES Exposure to tobacco smoke? 1. NO 2. YES 19. Do you have any nerve, muscle, or bone problem or heart trouble that makes walking quite difficult for you? 1. NO 2. YES (please specify: ____________________________ ____________________________) 20. Are you troubled by shortness of breath when hurrying on level ground or walking up a slight hill? 1. NO: IF NO, SKIP TO QUESTION 21. 2. YES: IF "YES", 20a) Do you get short of breath walking with other people of your own age on level ground? 1. NO: IF NO, SKIP TO QUESTION 21. 2. YES: IF "YES", 20a1) Do you have to stop for breath when walking at your own pace on level ground? 1. NO 2. YES 21. Do you usually cough on getting up, or first thing in the morning in the winter? (Count a cough with first smoke or on first going out-of-doors. Exclude clearing throat or a single cough.) [usually] means 4 or more days per week 1. NO 2. YES 22. Do you usually cough during the day - or at night - in the winter? (Ignore an occasional cough.) [usually] means 4 or more days per week 1. NO 2. YES IF YOU ANSWERED NO TO BOTH QUESTIONS 21 AND 22, SKIP TO QUESTION 23 IF YOU ANSWERED "YES" TO EITHER OF THE ABOVE, PLEASE ANSWER QUESTIONS 22a and 22b. 22a) Do you cough like this on most days - or nights - for as much as three months during the year? 1. NO 2. YES 22b) How many years have you coughed like this? _________ YEARS 23. Do you usually bring up any phlegm from your chest on getting up, or first thing in the morning in the winter? (Count phlegm with first smoke or on first going out of doors. Exclude phlegm from the nose. Count swallowed phlegm.) [usually] means 4 or more days per week 1. NO 2. YES 24. Do you usually bring up any phlegm from your chest during the day - or at night - in the winter? (If twice or more in a day, mark YES.) [usually] means 4 or more days per week 1. NO 2. YES IF YOU ANSWERED NO TO BOTH QUESTIONS 23 AND 24, SKIP TO QUESTION 25. IF YOU ANSWERED "YES" TO EITHER OF THE ABOVE, PLEASE ANSWER QUESTIONS 24a and 24b. 24a) Do you bring up phlegm like this on most days - or nights - for as much as three months during the year? 1. NO 2. YES 24b) How many years have you brought up phlegm like this? _________ YEARS 25. Do you usually have a stuffy nose, or drainage at the back of your nose? 1. NO 2. YES 26. During the past 12 months, have you had two or more episodes of blocked, itchy, or runny nose? 1. NO 2. YES IF YOU ANSWERED NO TO BOTH QUESTIONS 25 AND 26, SKIP TO QUESTION 27 IF YOU ANSWERED "YES" TO EITHER OF THE ABOVE, PLEASE ANSWER QUESTIONS 26a thru 26e. 26a) Do you usually have these nose symptoms at any particular time of year? 1. NO, about the same in all seasons 2. YES: IF "YES", which is the worst season? 1. Winter 2. Spring 3. Summer 4. Fall 26b) When you have nose symptoms, do you usually have fever, headache, or general body ache? 1. NO 2. YES 26c) Were these nose symptoms mainly due to one of the following? 1. cold or flu 2. hay fever 3. other allergies 4. something else (specify:____________________) 26d) At what age did you first notice the nose symptoms? _______ years in age 26e) Do the nose symptoms seem better or worse when you were away from work, on vacation, sick leave, or a lay-off? 1. NO, neither better nor worse away from work 2. YES, better away from work 3. YES, worse away from work 27. During the past 12 months, have your eyes been red, itchy, or watery more than twice? 1. NO 2. YES IF YOU ANSWERED NO TO QUESTION 27, SKIP TO QUESTION 28. IF YOU ANSWERED "YES", PLEASE ANSWER QUESTIONS 27a thru 27f. 27a) Over the past year, about how often have you noticed this? 1. less than 1 - 2 days altogether 2. less than 7 days 3. less than 30 days 4. more than 30 days 27b) Do you usually have these eye symptoms at any particular time of year? 1. NO, about the same in all seasons 2. YES: IF "YES", which is the worst season? 1. Winter 2. Spring 3. Summer 4. Fall 27c) When you have eye symptoms, do you usually have fever, headache, or general body ache? 1. NO 2. YES 27d) Were these eye symptoms mainly due to one of the following? 1. contact lenses 2. cold or flu 3. hay fever 4. other allergies 5. something else (specify:______________) 27e) At what age did you first notice the eye symptoms? _______ years in age 27f) Did/does the eye symptom seem better or worse when you were away from work, on vacation, sick leave, or a lay-off? 1. NO, neither better nor worse away from work 2. YES, better away from work 3. YES, worse away from work 28. During the last 12 months, have you had a skin rash, dermatitis, hives, or eczema? [ Mark NO if your skin looks normal or is only dry. ] 1. NO 2. YES IF YOU ANSWERED NO TO QUESTION 28, SKIP TO QUESTION 29. IF YOU ANSWERED "YES", PLEASE ANSWER QUESTIONS 28a thru 28d. 28a) What parts of your body were affected? (Check ( ) all that apply) AFFECTED BODY PART Scalp ( ) Trunk ( ) Face or neck ( ) Groin or private part ( ) Hands or arms ( ) Feet or legs ( ) Other (Specify:_____________________________) 28b) Did any of the following substances cause rashes on your skin? (Check ( ) all that apply) Jewelry ( ) Tapes, glues ( ) Clothing, gloves, shoes, undergarments ( ) Cosmetics, perfume, deodorant, after shave ( ) Hairdyes/colorings ( ) Soaps, detergents ( ) Skin medicine (ointment, lotion, etc.) ( ) Poison ivy/oak ( ) Oils, greases ( ) Solvents ( ) Chemicals ( ) Others (Specify: _________________________________) 28c) At what age did you first notice these skin changes? _______ years in age 28d) Did/does your skin seem better or worse when you were away from work, on vacation, sick leave, or a lay-off? 1. NO, neither better nor worse away from work 2. YES, better away from work 3. YES, worse away from work 29. Have you ever smoked cigarettes regularly? 1. NO 2. YES IF YOU ANSWERED NO TO QUESTION 29, SKIP TO QUESTION 30. IF YOU ANSWERED "YES" TO QUESTION 29, PLEASE ANSWER QUESTIONS 29a thru 29d. 29a) How old were you when you first started smoking cigarettes regularly? __________ YEARS OLD (AGE) 29b) Do you still smoke cigarettes? 1. NO: IF "NO", how old were you when you last gave up smoking? __________ YEARS OLD (AGE) 2. YES 29c) During the years that you smoked, did you ever quit for 6 months or more? 1. NO 2. YES: IF "YES", how long did you quit for altogether? __________ YEARS 29d) Over the years that you smoked, on the average approximately how many cigarettes per day did you smoke? __________ Cigarettes per day. 30. Do you now smoke a pipe or cigar? 1. NO 2. YES 31. Since childhood, have you ever had (Mark an X in appropriate area) Yes, in Yes, in No Unknown the past the present Hay fever? Emphysema? Tuberculosis? Bronchitis? Pneumonia? Any Allergies to: Foods? Metals? Chemicals? Medicines? Dusts? Animals? Others? (Specify: ________________________) 32. Have you seen a doctor for any problem in the past year? 1. NO 2. YES: (Please specify):____________________________________________ __________________________________________________________________ 33. Do you take any medications, including non-prescription medicine, aside from vitamins? 1. NO 2. YES: (Please specify):____________________________________________ __________________________________________________________________ ABOUT YOUR FAMILY INDICATE ANY BLOOD RELATIVES WHO EVER HAD ANY OF THE FOLLOWING: (Do not include relatives by marriage.) If family history is completely unknown (subject is adopted, etc.), mark this space ( ) and leave the following blank. (Mark an X in appropriate area) PROBLEM PARENTS GRAND BROTHER/ CHILDREN UNKNOWN PARENTS SISTER IN FAMILY ANY KIND OF ALLERGIES? Hay Fever Eczema Asthma Sinus Problem Other Allergies ANY LUNG DISEASES SUCH AS: Emphysema? Tuberculosis? Chronic Bronchitis? Pneumonia? Other lung trouble?