Baseline - children - Chinese

Green Housing Study ID# _______________

Baseline (Child 7-12 with asthma) House ID# _____________

Green Housing Study

綠色住房研究

Baseline Questionnaire (Children 7-12 with asthma)

基礎問卷（7-12嵗由哮喘的兒童）

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

這個數據收集所造成的回答負擔大約在１5分鐘左右，其中包括閲讀指示，搜索現有信息庫，集合和保持所需數據，以及完成並檢查收集的數據。任何單位不能進行或贊助，任何人也沒有必要回答沒有國家管理和經費預算辦公室（OMB）批復編號的數據收集問卷。發送有關回答負擔的評論或者建議到美國疾病控制與方中心(CDC/ATSDR)信息收集審查辦公室：1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXX).

Interviewer Initials _______ Date: ___________

訪問員名字： 日期：

Demographics 人口情況

1. Is [Child’s name] Hispanic or Latino? Yes No

1. [小孩名字]是西班牙後裔或者是拉丁人嗎？ 是 否

2. Which one or more of the following would you say is [Child’s name] race?

(Check all that apply)

2．以下哪個（些）選項是[小孩名字]的種族？

2.1 White

2.2 Black or African American

2.3 Asian

2.4 Native Hawaiian or Other Pacific Islander

2.5 American Indian or Alaska Native

2.1 白種人

2.2 黑人或者美國黑人

2.3 亞洲人

2.4 夏威夷土著或者其他太平洋島土著

2.5．美洲印第安人或者阿拉斯加土著

3. Does [Child’s name] attend childcare? Yes No

3．[小孩名字]去幼兒園嗎？ 是 否

If YES, please specify

1. Childcare facility

2. Private residence

3. Both

如果是，請説明

1. 幼兒園

2. 私人住宅

3. 兩個多有

Health Care Access

4. Is [Child’s name] currently covered by any kind of health insurance or some other health care plan?

Yes No Don’t know

4．[小孩名字]現在有健康保險或者其他的醫療計劃嗎？ 有 沒有 不知道

If YES, then ask:

4.1 Which of the following types of health care insurance is it?

(Please circle one)

1. employer or union either through yourself or another family member

2. Medicaid or any government-assistance plan for those with low incomes or a disability

3. TRICARE, VA, or other military health care

4. Indian Health Service

5. Medicare, for people with certain disabilities

6. Any other type of health insurance or health coverage plan

7. Don’t know

如果有，繼續問：

4.1 是以下哪個(些)健康保險？ （請選一）

1．你或者其他家人的工作單位或者工會保險

2．Medicaid 或者任何政府針對低收入或殘障所進行補補助的計劃

3．TRICARE，VA, 或者其他軍隊健康保險

4．印第安健康保險

5．Medicare， 針對有殘障的人群

6．其他任何健康保險或者醫療保險計劃

7．不知道

5. Do you have one person you think of as your personal doctor or health care provider?

5．有沒有某一個人你認爲是你的個人醫生或者醫療提供者？

Probe if answer is NO: “Is there more than one, or is there no person who you think of as your personal doctor or health care provider?”

1. Yes, only one

2. More than one

3. No

4. Don’t know

如果回答是“否”，提示：是有多個人，或者沒有任何人你認爲是你的個人醫生或者醫療提供者？

1. 是，只有 一個人

2. 有多個人

3. 否

4. 不知道

　

6. Has a doctor or other health professional ever told you that [Child’s name] has allergies?

Yes No Don’t know

6．有醫生或者其他健康衛生工作者在任何時候告訴過你[小孩名字]有過敏症嗎？

有 沒有 不知道

7. Does [Child’s name] have any kind of food allergy?

Y N DK

7．[小孩名字]對任何食物過敏嗎？ 有 沒有 不知道

8. How old was [Child’s name] when you were first told by a doctor, nurse, or other health professional that he/she had asthma?

_________ years (insert 0 if less than 1 year)

8．第一次有醫生，護士或者其他健康工作者告訴你[小孩名字]有氣喘時，他/她又多大？

_________嵗(如果不滿周歲填0)

9. During the past 3 months, did [Child’s name] have any of these conditions?

(If YES to any of the following, enter number of episodes in space provided)

9．在過去的3個月中， [小孩名字]有以下的症狀嗎？

（如果有以下任何症狀，在提供的空間裏填入症狀發作次數）

Number 數量

1. Flu or cold Y N DK ______

9.1 流感或者感冒 是 否 不知道

(Defined by at least 3 of the following: feverish, stuffy/runny nose, cough, sore throat, body aches or tiredness, for more than 24 hours)

（以至少以下三种症狀為基準：持續24小時以上的發燒， 鼻塞/流鼻涕，咳嗽，喉嚨發炎，身體疼痛或者發軟，

(If YES, then ask)如果有，繼續問

9.1.1 During these illness episodes, did [Child’s name] asthma get worse? Y N DK

9．1.1 在這些症狀發生時，[小孩名字]的氣喘有加重嗎？ 有 沒有 不知道

9.1.2 Did [Child’s name] receive Tamiflu® or oseltamivir [o sel TAM i veer] or an inhaled medicine called Relenza® or zanamivir [za NA mi veer] to treat this illness?

Y N DK

9.1.2 [小孩名字]有用Tamiflu，oseltamivir或者另外一種叫Relenza，zanamivir 來治療症狀嗎 ？

9.1.3 Was [Child’s name] prescribed antibiotics? Y N DK

9.1.3 [小孩名字]有用抗生素嗎？ 有 沒有 不知道

2. Pneumonia Y N DK ______

3. Bronchitis Y N DK ______

9.2 肺炎 有 沒有 不知道 次數_____

9.3 支氣管炎 有 沒有 不知道 次數_____

Enter frequency by circling one choice選擇相應的頻率

4. Sneezing, runny/stuffed nose (without a cold)

Never Once/Twice Monthly Weekly Daily

5. Wheezing Never Once/Twice Monthly Weekly Daily

6. Cough (without a cold) Never Once/Twice Monthly Weekly Daily

7. Shortness of breath Never Once/Twice Monthly Weekly Daily

9.4 打噴嚏，流鼻涕/鼻塞 （沒有感冒） 從來沒有 一兩次 每月 每週 每日

9.5 喘息 從來沒有 一兩次 每月 每週 每日

9.6 咳嗽（沒有感冒） 從來沒有 一兩次 每月 每週 每日

9.7 氣緊 從來沒有 一兩次 每月 每週 每日

10. During the past 3 months, has [Child’s name] had an episode of asthma or an asthma attack?

Yes No Don’t know

10．在過去的3個月中， [小孩名字]有出現過氣喘或者氣喘症狀嗎？ 有 沒有 不知道

If NO, then SKIP to Question 19, “Regular schedule of medicines”

If YES, how many asthma episodes or attacks?

10.1 ______ Number of times

如果沒有，跳到第19題

如果有，有幾次氣喘？

10．1 ________次數

11. During the past 3 months, did [Child’s name] have an emergency department or urgent care visit because of asthma? Yes No

11．在過去的3個月中， [小孩名字]有因爲氣喘而到過急救中心或者急救部門嗎？ 有 沒有

If NO, Skip to Question #13 如果沒有，跳到第13題

If YES, did [Child’s name] visit the following? 如果有，[小孩名字]到過以下哪些地方？

1. Emergency department Y N ____ Number of visits

2. Urgent care center Y N ____ Number of visits

3. Urgent visit to doctor’s office Y N ____ Number of visits

11.1 急救科 有 沒有 次數

11.2 急診中心 有 沒有 次數

11.3 緊急到醫生辦公室 有 沒有 次數

If child went to Emergency department (11.1 is one or more visits), then ask:

如果小孩去了急救科，繼續問：

11.4 Did [Child’s name] travel by ambulance? Yes No

If YES, how many times?

11.4.1 ____ Number of times

11.4 有救護車載[小孩名字]嗎？ 有 沒有

如果有，有幾次？

11.4.1 ________次數

12. During the past 3 months, has [Child’s name] stayed in the hospital overnight because of asthma? (In other words, admitted to hospital; Do not include an overnight stay in the emergency room.)

Yes No

12．在過去的3個月中，[小孩名字]有因爲氣喘而在醫院留宿嗎？ （換句話說，住院；不包括在急救室呆的晚上）

If YES, how many different times was [Child’s name] admitted to the hospital?

12.1 ____ Number of visits

如果有， [小孩名字]一共有多少次住院？

12.1 _________次數

(If # of visits equals 1, then min = max) （如果住院次數=1, 最少=最多）

12.2 ____ Minimum number of days in hospital

12.3 ____ Maximum number of days in hospital

12.4 ____ Total number of days in hospital

12.2 最少住院時間

12.3 最多住院時間

12．4 縂住院時間

13. During the past 3 months, was [Child’s name] unable to attend school because of asthma? Yes No

13．在過去的3個月中，[小孩名字]有因爲氣喘而無法上學嗎？ 有 沒有

If YES, then ask: How many days did [Child’s name] miss school?

13.1.1_____ Number of days [Child’s name] missed school

[Include only days school was in session.]

如果有，繼續問：[小孩名字]一共缺席多少天？

13.1______[小孩名字]缺席的天數 （只包括學校開的日子）

13.2 Did this occur in the past 2 weeks? Yes No

13.2 [小孩名字]在過去的2個星期裏缺席了嗎？ 有 沒有

If YES, how many times?

13.2.1_____ Number of days [Child’s name] missed school

[Include only days school was in session.]

如果有，有多少次？

13.2.1 _____[小孩名字]缺席的天數 （只包括學校開的日子）

14. During the past 3 months, were YOU unable to attend work or carry out your usual activities because of [Child’s name] asthma?

Yes No

14．在過去的3個月裏，你有因爲小孩的氣喘而無法上班或者進行日常的活動嗎？ 有 沒有

If YES, then ask

14.1 _____ Total number of days (use your best guess)

14.1.1 _____ Of these, how many work days did you miss?

如果有，繼續問：

14.1 ______縂天數 （最好的估計）

14.1.1 其中有________天你無法上班

14.2 Did this occur in the past 2 weeks? Yes No

14.2 你在過去的2周裏有因爲孩子的氣喘而無法上班嗎？ 有 沒有

If YES, then ask

14.2.1_____ Number of days you missed work (if applicable)

14.2.2_____ Number of days you missed other activities

如果有，繼續問

14.2.1 有_____天你無法上班（如果適用）

14.2.2．有_____天你無法進行其他活動

15. In the past 3 months, did [Child’s name] wake up at night because of asthma?

Yes No

15．在過去的3 個月裏，[小孩名字]有因爲氣喘而半夜突然醒來嗎？ 有 沒有

If YES, then ask

15.1 ______ Number of nights (use your best guess)

15.2 Did this occur in the past 2 weeks? Yes No

If YES, then ask

15.2.1 ______ Number of nights

如果有，繼續問：

15.1 ______晚上

15.2 這個/些再過去的2周裏出現過嗎？ 有 沒有

如果有，再問：

15.2.1 ________晚上

16. During the last 3 months, did [Child’s name] take medication when he/she had an asthma episode or attack? Y N DK

16．在過去的3個月中，[小孩名字]有在出現氣喘症狀的時候吃葯嗎？ 有 沒有 不知道

If YES, then ask the following:

16.1 Please tell me which medicines

(Interviewer: Place a mark in the “Emergency” column next to each identified medicine on the med sheet on the last two pages of this questionnaire)

16.2 Did this occur in the past 2 weeks? Y N DK

如果有，繼續問：

16．1 請告訴我這些藥品

（採訪員：在“緊急”這個縱列裏對每個提到的藥品划Ｘ）

17. During the last 3 months, did [Child’s name] take prescription asthma medications by inhaler? Y N DK

17. 在過去的3個月中，[小孩名字]有吸入針對氣喘的處方藥嗎？

If YES, then ask all of the following:

17.1 How long did [Child’s name] take them?

1. ≤ 1 month

2. 2 months

3. 3 months

如果有，問以下所有：

17.1 [小孩名字]使用了多久了？

1．小於一個月

2．兩個月

3．3個月

17.2 Please tell me which medicines

(Interviewer: Place a mark in the “Inhaler” column next to each identified medicine on the med sheet on the last two pages of this questionnaire)

17.2 請告訴有哪些藥品

（採訪員：在“吸入藥品”這個縱列裏對每個提到的藥品划Ｘ

17.3 Please tell me how many canisters were used up in the past 3 months

(Interviewer: Enter number next to each identified medicine on the med sheet on the last two pages of this questionnaire)

17.3 請告訴我在過去的三個月中一共有了多少罐？

17.4 Did [Child’s name] take prescription asthma medications by inhaler in the past 2 weeks? Y N DK

17.4 在過去的2周裏，[小孩名字]有吸入過針對氣喘的處方藥嗎？

18. During the last 3 months, has [Child’s name] taken any prescription medicine in pill or syrup form for his/her asthma? Y N DK

18．在過去的3個月中，[小孩名字]有吃過顆粒狀或者液體狀的氣喘葯嗎？ 有 沒有 不知道

If YES, then ask the following:

1. Please tell me which medicines

(Interviewer: Place a mark in the “Pill/Syrup” column next to each identified medicine on the med sheet on the last two pages of this questionnaire)

2. Did this occur in the past 2 weeks? Y N DK

如果有，繼續問：

18.1 請告訴我有哪些藥品（採訪員：在“顆粒/液體葯”這個縱列裏對每個提到的藥品划Ｘ）

18．2 小孩又在過去的2周裏吃過嗎？

19. During the last 3 months, did [Child’s name] take any medicine on a regular schedule everyday for his/her asthma? Y N DK

19．在過去的3個月裏，[小孩名字]有每天定時吃氣喘的葯嗎？ 有 沒有 不知道

If YES, then ask the following:

1. What was the medication?

(Interviewer: Place a mark in the “Regular Schedule” column next to each identified medicine on the med sheet on the last two pages of this questionnaire)

2. Did this occur in the past 2 weeks? Y N DK

如果有，繼續問：

19.1 是什麽藥品？

（採訪員：在 “定時藥品”這個縱列裏對每個提到的藥品划Ｘ）

19.2 小孩在在過去的2周裏有定時吃葯嗎？ 有 沒有 不知道

20. Did [Child’s name] receive a flu shot (probe: or seasonal flu vaccine?) during the past year?

Y N DK

20．在過去的一年裏，[小孩名字]有打過流感預防針嗎？ 有 沒有 不知道

Emergency/rescue	Inhaler/ nebulizer	Pill/Syrup	Regular (Daily-use) schedule	# Canisters used in last 3 months	Visual Confirmation		Emergency/rescue	Inhaler/ nebulizer	Pill/Syrup	Regular (Daily-use) schedule	# Canisters used in last 3 months	Visual Confirmation
						Accolate							Nedocromil
						Acetaminophen							Pediapred
						Advair							Prednisolone
						Advil							Prednisone
						Aerobid							Proventil
						Aerolate							Pirbuterol
						Aerospan HFA							Primatene Mist
						Albuterol							Pro-Air HFA
						Allegra							Proventil
						Alupent							Pulmicort Turbuhaler
						Asmanex							QVAR
						Atrovent							Respid
						Azmacort							Robitussin
						Beclomethasone dipropionate							Salbutamol
						Beclovent							Salmeterol
						Bitolterol							Serevent
						Brethaire							Singulair
						Brethine							Slo-phyllin
						Budesonide							Symbicort
						Choledyl							Terbutaline
						Claritin							Theo-24
						Combivent							Theochron
						Cromolyn							Theoclear
						Deltasone							Theo-Dur
						Elixophyllin							Theophylline
						Flovent							Theospan
						Flovent Rotadisk							Tilade
						Flunisolide							Tornalate
						Fluticasone							T-Phyl
						Foradil							Triamcinolone acetonide
						Formoterol							Tylenol
						Ibuprophen							Uniphyl
						Intal							Vanceril
						Ipratropium Bromide							Ventolin
						Levalbuterol tartate							Volomax
						Loratidine							Xolair
						Maxair							Xopenex HFA
						Medrol							Zafirlukast
						Metaprel							Zileuton
						Metaproteronol							Zyflo Filmtab
						Methylpredinisolone							Zyrtec
						Montelukast							Other:
						Mometasonefuroate							Other:
						Mucinex							Other:

0

DK = Don’t know R = Refused NA = Not applicable