156 Supplemental Questionaire

Form 156 – Supplemental Questionnaire

OMB #0925-0414

Exp XX/XX

This questionnaire asks about you, your home, your phone and computer use, and your health
care. Your answers will help us understand the health of women like you.
Office Use Only

1.

What year was your mother born? ___ ___ ___ ___

2.

What year was your father born?

___ ___ ___ ___

3.

What is your current weight?

___ ___ ___ lbs

0

1-2

3-4

5-6

7-9

10 or more

4.

How many close friends do you have?

0

1

2

3

4

5

5.

How many close relatives do you have?

0

1

2

3

4

5

6.

As people grow older they sometimes need to make changes to their home so that it is a safer
and easier place to live. Please read the list below and mark any changes or additions you have
made to your home for yourself or someone else. Be sure to mark all that apply.
1 Railings or banisters

6 Decreasing clutter

2 Grab bars

7 Increasing lighting

3 Indoor or outdoor ramps

8 Sink/counter heights

4 Non-slip surfaces

9 Other

5 Tacking down carpets/rugs

10 No changes

7.

In the last year, did you fall at home?

1 Yes

0 No

8.

Do you wear a device around your neck or wrist for
contacting emergency help?

1 Yes

0 No

Public reporting for this collection of information is estimated to average 8.5 minutes per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the information needed and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a
person is not required to respond to a collection of information unless it is displays a currently valid OMB control number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge
Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0414). Do not return the completed form to this address.

BAR CODE HERE

OFFICE USE ONLY

Date Received:

Month

Language:

Day

Year

Reviewed By:

1
S 2
E



RCR

SERIAL #
PLEASE MAKE NO MARKS IN THIS AREA

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Form 156 – Supplemental Questionnaire
No

Don’t know/
Yes
Not sure

0

1

2

10. A pneumonia shot or pneumococcal vaccine is usually given only
once or twice in a person's life and is different from the flu shot.
Have you ever had a pneumonia shot?

0

1

2

11. Have you had the shingles vaccine (also known as the zoster vaccine)?

0

1

2

9.

During the past 12 months, have you had a seasonal flu shot?

12. As an adult, have you had pneumonia diagnosed by a physician?
1 Yes

12.1

0 No
2 Don't know/

Not sure

How long ago was your last pneumonia diagnosed?
1 Less than 6 months

3 6 to 12 months ago

2 1 to 3 years ago

4 Greater than 3 years ago

13. Has a health care provider ever told you that you had a urinary tract infection (bladder infection,
cystitis, kidney infection, pyelonephritis)?
1 Yes

13.1

0 No
2 Don't know/

Not sure
14.

How long ago was your last urinary tract infection?
1 Less than 6 months

3 6 to 12 months ago

2 1 to 3 years ago

4 Greater than 3 years ago

Have you ever had shingles?
1 Yes

14.1

0 No
2 Don't know/

Not sure

How long ago did you have shingles?
1 Less than 6 months

3 6 to 12 months ago

2 1 to 3 years ago

4 Greater than 3 years ago

15. When was the last time you saw an eye doctor?
1 1 year ago

3 More than 2 years ago

2 1-2 years ago

4 I do not see an eye doctor

16. Have you ever been told by an eye doctor that you have glaucoma?
1 Yes
0 No

16.1

How old were you when diagnosed with glaucoma?
1 <55

16.2

2 55-64

3 65-74

4 75-84

5 ≥ 85

Has your glaucoma been treated with any of the following?
(Mark all that apply.)
1 Eye drops

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2 Laser treatment

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8 Other surgery

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Form 156 – Supplemental Questionnaire
17.

Have you ever had surgery to remove cataracts?
1 Yes
0 No

17.1

How old were you when you had your first cataract extraction surgery?
1 <45

2 45-54

3 55-64

4 65-74

5 75-84

6 ≥ 85

18. Have you ever been told by an eye doctor that you have diabetic retinopathy?
1 Yes
0 No

18.1

How old were you when diagnosed with diabetic retinopathy?
1 <55

18.2

2 55-64

3 65-74

4 75-84

5 ≥ 85

Has your retinopathy been treated with any of the following?
(Mark all that apply.)

1 Laser treatment

2 Surgery/vitrectomy

3 Nutritional supplement

19. Have you ever been told by an eye doctor that you have dry eye syndrome?
1 Yes
0 No

19.1

How old were you when diagnosed with dry eye syndrome?
1 <55

19.2

2 55-64

3 65-74

4 75-84

5 ≥85

Has your dry eye been treated with any of the following?
(Mark all that apply.)

1 Over-the-counter artificial tears

©

2 Medicating drops (e.g., Restasis )

3 Fish oil or omega-3

supplements

The next set of questions asks about advanced health care planning. This can cover becoming
too sick to live on your own, being very sick and you cannot speak for yourself, or being near the
end of your life and you cannot speak for yourself.
20. Have you chosen a specific person you trust to make health care decisions for you in case you
cannot speak for yourself? (Mark one.)
1 Yes
0 No

20.1

Who did you choose to make health care decisions for you? (Mark one.)
1 My spouse or partner

4 A friend or non-family member

2 Another family member

5 My doctor

3 My family as a group

20.2

Have you talked to the person you chose about the type of health care
you want if you were very sick or near the end of your life? (Mark one.)
1 Yes, we had a very detailed discussion about my wishes
2 Yes, but we just had a general discussion
3 No, because I assume my decision maker knows what I want
4 No, for other reason

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Form 156 – Supplemental Questionnaire
21. Have you made plans for what should happen if you become too sick to live on your own?
(Mark one.)
1 Yes, I have made plans.

3 No, I don’t have plans but I have thought

2 No, I haven’t given it much thought.

about it.

22. An Advance Directive or Living Will are documents that let a person choose how she wants to be
treated if she gets very sick and is near the end of her life. Have you filled out a written Advance
Directive or Living Will?
1 Yes

0 No

2 Not sure

23. In the past year, has a health care provider refused to have you as a patient
because you are on Medicare?
1 Yes

0 No

2 Don't know / Not sure

3 Not on Medicare

The next five questions are about your eating habits.
No

Yes

24. I eat fewer than 2 meals per day.

0

1

25. I eat alone most of the time.

0

1

26. I have tooth or mouth problems that make it hard for me to eat.

0

1

27. I am not always physically able to shop, cook and/or feed myself.

0

1

28. I don’t always have enough money to buy the food I need.

0

1

No

Yes

31. Even if you do not use a computer, do you use a “Smart phone,” iPad,
or other device for email or the internet?

0

1

32. Do you use the internet to look for health information?

0

1

33. Have you looked at the WHI website (www.whi.org)?

0

1

This last set of questions is about your use of phones and computers.
29.

Do you own a cell phone?
1 Yes
0 No

29.1

Do you send or receive text messages on your phone?
0 No

1 Yes

30. Do you use a computer (either at home or away from home)?
1 Yes
0 No

30.1

Do you use it for e-mail?

0 No

1 Yes

30.2

Do you use it for the internet?

0 No

1 Yes

Thank you. Please take a moment to review any questions you may have missed.
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