Instrument: Demographics

Instrument Usage:

Clinical Research

References:

Metadata content for this form includes selected measures from the PhenX Toolkit for Substance Abuse and Addiction – Core: Tier 1 (https://www.phenxtoolkit.org)

Current Quality of Life questions use standard, publicly accessible content from the Centers for Disease Control for the Healthy Days Core Module questionnaire (http://www.cdc.gov/hrqol/hrqol14_measure.htm)

Module	Module ID
Demographics	4309553
Body Mass Index	4309554
Current Quality of Life	4309556

Associated Modules

1. Demographics

Module #1 - Demographics

1. Date of Birth

2. Age

3. Gender

1 (Male)

2 (Female)

0 (Unknown)

4. Does the participant consider him- or herself to be Hispanic/Latino

2 (No)

1 (Yes)

3 (Don't know)

5. Indicate the group that represents his or her Hispanic origin or ancestry

6. What race does the participant consider him or herself to represent

7. Other Pacific Islander specify

8. Other Asian specify

9. Some other race specify

10. What is the highest grade or level of school the participant has completed or the highest degree they have received

No Formal Schooling (Never attended / kindergarten only)

1st Grade (1st Grade)

2nd Grade (2nd Grade)

3rd Grade (3rd Grade)

4th Grade (4th Grade)

5th Grade (5th Grade)

6th Grade (6th Grade)

7th Grade (7th Grade)

8th Grade (8th Grade)

9th Grade (9th Grade)

10th Grade (10th Grade)

11th Grade (11th Grade)

12th Grade No Diploma (12th Grade)

High School Graduate (High School Graduate)

General Equivalency Diploma (GED or equivalent)

Some College, No Degree (Some College)

VoTech Program (Associate's degree: occupational, technical or vocational program)

Associate Degree (Associate's degree: academic program)

Bachelor Degree (Bachelor's degree)

Master's Degree (Master's Degree Completion)

Professional Doctorate Degree (Professional school degree)

Academic Doctorate Degree (Doctoral degree)

Refused (Refuse)

Don't Know (Does Not Know)

11. We would like to know about what the participant does --is he/she working now, looking for work, retired, keeping house, a student, or what

Employed 32 hours or more per week (Working now)

Only temporarily laid off, sick leave or maternity leave (Only temporarily laid off, sick leave or maternity leave)

Unemployed (Looking for work, unemployed)

Retired (RETIRED)

Disabled (Disabled, permanently or temporarily)

Homemaker (Keeping house)

Full-time student (Student)

Other (Other)

12. Other, specify

13. Is the participant married, widowed, divorced, separated, never married, or living with a partner

Married (MARRIED)

Widowed (Widowed)

Divorced (DIVORCED)

Separated (Separated)

Never married (Never married)

Domestic Partnership (Living with partner)

I prefer not to answer (Refused)

Unknown/Not Reported (Don't know)

2. Body Mass Index

Module #2 - Body Mass Index

1. Record standing height in meters (or centimeters) or inches

2. Record current weight in pounds or kilograms

3. Body Mass Index (BMI)

3. Current Quality of Life

Module #3 - Current Quality of Life

1. Would you say that in general your health is:

Excellent (Excellent)

Very good (Very much Good)

Good (Good)

Fair (Fair)

Poor (Poor)

Not sure (Don't know/Not sure)

Refused (Refuse)

2. Thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?

0 (Day 0)

1 (Day 1)

2 (Day 2)

3 (Day 3)

4 (Day 4)

5 (Day 5)

6 (Day 6)

7 (Day 7)

8 (Day 8)

9 (Day 9)

10 (Day 10)

11 (Day 11)

12 (Day 12)

13 (Day 13)

14 (Day 14)

15 (Day 15)

16 (Day 16)

17 (Day 17)

18 (Day 18)

19 (Day 19)

20 (Day 20)

21 (Day 21)

22 (Day 22)

23 (Day 23)

24 (Day 24)

25 (Day 25)

26 (Day 26)

27 (Day 27)

28 (Day 28)

29 (Day 29)

30 (Day 30)

88 (None)

77 (Don't know/Not sure)

99 (Refused)

3. Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

0 (Day 0)

1 (Day 1)

2 (Day 2)

3 (Day 3)

4 (Day 4)

5 (Day 5)

6 (Day 6)

7 (Day 7)

8 (Day 8)

9 (Day 9)

10 (Day 10)

11 (Day 11)

12 (Day 12)

13 (Day 13)

14 (Day 14)

15 (Day 15)

16 (Day 16)

17 (Day 17)

18 (Day 18)

19 (Day 19)

20 (Day 20)

21 (Day 21)

22 (Day 22)

23 (Day 23)

24 (Day 24)

25 (Day 25)

26 (Day 26)

27 (Day 27)

28 (Day 28)

29 (Day 29)

30 (Day 30)

88 (None)

77 (Don't know/Not sure)

99 (Refused)

4. During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?

0 (Day 0)

1 (Day 1)

2 (Day 2)

3 (Day 3)

4 (Day 4)

5 (Day 5)

6 (Day 6)

7 (Day 7)

8 (Day 8)

9 (Day 9)

10 (Day 10)

11 (Day 11)

12 (Day 12)

13 (Day 13)

14 (Day 14)

15 (Day 15)

16 (Day 16)

17 (Day 17)

18 (Day 18)

19 (Day 19)

20 (Day 20)

21 (Day 21)

22 (Day 22)

23 (Day 23)

24 (Day 24)

25 (Day 25)

26 (Day 26)

27 (Day 27)

28 (Day 28)

29 (Day 29)

30 (Day 30)

88 (None)

77 (Don't know/Not sure)

99 (Refused)

5. Sum the number of unhealthy days from Questions 2 and 3.

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Instrument: Demographics

Module #1 - Demographics

Module #2 - Body Mass Index

Module #3 - Current Quality of Life