Baseline Questionnaire - GeroNet

O3base16.fmBASELINE QUESTIONNAIRE TABLE OF CONTENTSIn order of administrationIA = interviewer administeredSA = self administered__________Name ofScale_________________________________________# of items1) IA Baseline Characteristics--2) SA Yesavage Geriatric Depression Scale30(administered only if depression is failed onscreener)3) IA Folstein Mini Mental Status Exam (MMSE)8*(administered to make sure participant issuitable)(Copy in file cabinet only)4) SA Health Status Questionnaire (MOS SF-36)365) SA NHIS Disability Days26) SA Patient Satisfaction Questionnaire207) IA Perceived Efficacy in Patient-PhysicianInteractions (PEPPI)108) IA Quality of Well-Being (QWB)479) IA Illness Self Mastery510) IA NIA Battery Administration Protocol3*11) IA Physical Performance Test7** Tasks, rather than questions, to be completedAssemble packets as follows:1) Baseline Characteristics + Yesavage + Folstein2) MOS + NHIS + Patient Satisfaction3) PEPPI + QWB + Illness Self Mastery + NIA + PPT

Name:___________________________________ID#________________SADate:____/____/____HEALTH STATUS QUESTIONNAIRE (SF-36)The following questions are about activities you might doduring a typical day. Does your health now limit you inthese activities, if so, how much?1. Does your health now limit you in vigorous activities,such as running, lifting heavy objects, orparticipating in strenuous sports?___ Yes, limited a lot___ Yes, limited a little___ No, not limited at all2. Does your health now limit you in moderate activities,such as moving a table, pushing a vacuum cleaner,bowling, or playing golf?___ Yes, limited a lot___ Yes, limited a little___ No, not limited at all3. Does your health now limit you in lifting or carryinggroceries?___ Yes, limited a lot___ Yes, limited a little___ No, not limited at all4. Does your health now limit you in climbing severalflights of stairs?___ Yes, limited a lot___ Yes, limited a little___ No, not limited at all

5. Does your health now limit you in climbing one flightof stairs?___ Yes, limited a lot___ Yes, limited a little___ No, not limited at all6. Does your health now limit you in bending, kneeling, orstooping?___ Yes, limited a lot___ Yes, limited a little___ No, not limited at all7. Does your health now limit you in walking more than amile?___ Yes, limited a lot___ Yes, limited a little___ No, not limited at all8. Does your health now limit you in walking severalblocks?___ Yes, limited a lot___ Yes, limited a little___ No, not limited at all9. Does your health now limit you in walking one block?___ Yes, limited a lot___ Yes, limited a little___ No, not limited at all10. Does your health now limit you in bathing or dressingyourself?___ Yes, limited a lot___ Yes, limited a little___ No, not limited at all

During the past 4 weeks, have you had any of the followingproblems with your work or other regular daily activities asa result of your physical health?11. During the past 4 weeks, have you cut down the amountof time you spent on work or other activities as aresult of your physical health?___ Yes___ No12. During the past 4 weeks, have you accomplished lessthan you would like as a result of your physicalhealth?___ Yes___ No13. During the past 4 weeks, were you limited in the kindof work or other activities as a result of yourphysical health?___ Yes___ No14. During the past 4 weeks, did you have difficultyperforming your work or other activities (for example,it took extra effort) as a result of your physicalhealth?___ Yes___ NoDuring the past 4 weeks, have you had any of the followingproblems with your work or other regular daily activities asa result of any emotional problems (such as feelingdepressed or anxious)?15. During the past 4 weeks, have you cut down the amountof time you spent on work or other activities as aresult of emotional problems?___ Yes___ No16. During the past 4 weeks, have you accomplished lessthan you would like as a result of emotional problems?___ Yes___ No

17. During the past 4 weeks did you do work or otheractivities less carefully than usual as a result ofemotional problems?___ Yes___ NoThese questions are about how you feel and how things havebeen with you during the past 4 weeks. For each question,please give the one answer that comes closest to the way youhave been feeling.18. During the past 4 weeks, how much of the time did youfeel full of pep?___ All of the time___ Most of the time___ A good bit of the time___ Some of the time___ A little of the time___ None of the time19. During the past 4 weeks, how much of the time have youbeen a very nervous person?___ All of the time___ Most of the time___ A good bit of the time___ Some of the time___ A little of the time___ None of the time20. During the past 4 weeks, how much of the time have youfelt so down in the dumps that nothing could cheer youup?___ All of the time___ Most of the time___ A good bit of the time___ Some of the time___ A little of the time___ None of the time

21. During the past 4 weeks, how much of the time have youfelt calm and peaceful?___ All of the time___ Most of the time___ A good bit of the time___ Some of the time___ A little of the time___ None of the time22. During the past 4 weeks, how much of the time did youhave a lot of energy?___ All of the time___ Most of the time___ A good bit of the time___ Some of the time___ A little of the time___ None of the time23. During the past 4 weeks, how much of the time have youfelt downhearted and blue?___ All of the time___ Most of the time___ A good bit of the time___ Some of the time___ A little of the time___ None of the time24. During the past 4 weeks, how much of the time did youfeel worn out?___ All of the time___ Most of the time___ A good bit of the time___ Some of the time___ A little of the time___ None of the time

25. During the past 4 weeks, how much of the time have youbeen a happy person?___ All of the time___ Most of the time___ A good bit of the time___ Some of the time___ A little of the time___ None of the time26. During the past 4 weeks, how much of the time did youfeel tired?___ All of the time___ Most of the time___ A good bit of the time___ Some of the time___ A little of the time___ None of the time27. During the past 4 weeks, how much of the time has yourphysical health or emotional problems interfered withyour social activities (like visiting with friends,relatives, etc.)?___ All of the time___ Most of the time___ Some of the time___ A little of the time___ None of the time28. During the past 4 weeks, to what extent has yourphysical health or emotional problems interfered withyour normal social activities with family, friends,neighbors, or groups?___ Not at all___ Slightly___ Moderately___ Quite a bit___ Extremely

29. How much bodily pain have you had during the past 4weeks?___ None___ Very mild___ Mild___ Moderate___ Severe___ Very severe30. During the past 4 weeks, how much did pain interferewith your normal work (including both work outside the homeand housework)?___ Not at all___ A little bit___ Moderately___ Quite a bit___ ExtremelyPlease choose the answer that best describes how true orfalse each of the following statements is for you.31. I seem to get sick a little easier than other people.___ Definitely true___ Mostly true___ Not sure___ Mostly false___ Definitely false32. I am as healthy as anybody I know.___ Definitely true__ Mostly true___ Not sure___ Mostly false___ Definitely false

33. I expect my health to get worse___ Definitely true___ Mostly true___ Not sure___ Mostly false___ Definitely false34. My health is excellent___ Definitely true___ Mostly true___ Not sure___ Mostly false___ Definitely false35. In general, would you say your health is...___ Excellent___ Very good___ Good___ Fair___ Poor36. Compared to one year ago, how would you rate yourhealth in general now?___ Much better now than one year ago___ Somewhat better now than one year ago___ About the same___ Somewhat worse now than one year ago___ Much worse now than one year ago

SAO3BASE15.FMID#__________NHIS DISABILITY DAYS1. In the past four weeks, did you cut down the things youusually do, such as going to work or working around thehouse, because of illness or injury?___ No___ YesIf yes, How many days did you cut down on the thingsyou usually do because of illness or injury?_____ days2. In the past four weeks, did you ever stay in bedbecause of an illness or injury?___ No___ YesIf yes, How many days did you stay in bed at least halfthe day because of illness or injury?_____days

ID#________IAPATIENT SATISFACTION QUESTIONNAIREOn the following pages are some things people say aboutmedical care. Please read each one carefully, keeping inmind the medical care you are receiving now. (If you havenot received care recently, think about what you wouldexpect if you needed care today.) We are interested in yourfeelings, good and bad, about the medical care you havereceived.How strongly do you AGREE or DISAGREE with each of thefollowing statements?1. Doctors are good about explaining the reason formedical tests.___ Strongly disagree__ Disagree___ Uncertain___ Agree___ Strongly agree2. The doctors who treat me should give me more respect.___ Strongly disagree___ Disagree___ Uncertain___ Agree___ Strongly agree3. The medical care I have been receiving is just aboutperfect.___ Strongly disagree___ Disagree___ Uncertain___ Agree___ Strongly agree

4. Sometimes doctors use medical terms without explainingwhat they mean.___ Strongly disagree___ Disagree___ Uncertain___ Agree___ Strongly agree5. During my medical visits, I am always allowed to sayeverything that I think is important.___ Strongly disagree___ Disagree___ Uncertain___ Agree___ Strongly agree6. There are things about the medical system I receive mycare from that need to be improved.___ Strongly disagree___ Disagree___ Uncertain___ Agree___ Strongly agree7. The doctors who treat me have a genuine interest in meas a person.___ Strongly disagree___ Disagree___ Uncertain___ Agree___ Strongly agree8. Sometimes doctors make me feel foolish.___ Strongly disagree___ Disagree___ Uncertain___ Agree___ Strongly agree

9. All things considered, the medical care I receive isexcellent.___ Strongly disagree___ Disagree___ Uncertain___ Agree___ Strongly agree10. Doctors act too businesslike and impersonal toward me.___ Strongly disagree___ Disagree___ Uncertain___ Agree___ Strongly agree11. There are some things about the medical care I receivethat could be better.___ Strongly disagree___ Disagree___ Uncertain___ Agree___ Strongly agree12. My doctors treat me in a very friendly and courteousmanner.___ Strongly disagree___ Disagree___ Uncertain___ Agree___ Strongly agree13. Those who provide my medical care sometimes hurry toomuch when they treat me.___ Strongly disagree___ Disagree___ Uncertain___ Agree___ Strongly agree

14. I am very satisfied with the medical care I receive.___ Strongly disagree___ Disagree___ Uncertain___ Agree___ Strongly agree15. Doctors sometimes ignore what I tell them.___ Strongly disagree___ Disagree___ Uncertain___ Agree___ Strongly agree16. Doctors listen carefully to what I have to say.___ Strongly disagree___ Disagree___ Uncertain___ Agree___ Strongly agree17. When I am receiving medical care, they should pay moreattention to my privacy.___ Strongly disagree___ Disagree___ Uncertain___ Agree___ Strongly agree18. Doctors usually spend plenty of time with me.___ Strongly disagree___ Disagree___ Uncertain___ Agree___ Strongly agree

19. I am dissatisfied with some things about the medicalcare I receive.___ Strongly disagree___ Disagree___ Uncertain___ Agree___ Strongly agree20. Doctors always do their best to keep me from worrying.___ Strongly disagree___ Disagree___ Uncertain___ Agree___ Strongly agree

May be eliminatedID#__________GLOBAL SELF MASTERYHow strongly do you agree or disagree with the followingstatements?1. I am generally able to take care of a health problemthrough my own efforts.___ Strongly disagree___ Disagree___ Somewhat disagree___ Somewhat agree___ Agree___ Strongly agree2. If I become sick, I have the power to make myself wellagain.___ Strongly disagree___ Disagree___ Somewhat disagree___ Somewhat agree___ Agree___ Strongly agree3. I have a lot of confidence in my ability to cure myselfonce I get sick.___ Strongly disagree___ Disagree___ Somewhat disagree___ Somewhat agree___ Agree___ Strongly agree4. When I have a health problem, I am usually able to copewith it on my own.___ Strongly disagree___ Disagree___ Somewhat disagree___ Somewhat agree___ Agree___ Strongly agree

ID#__________IAQUALITY OF WELL-BEING:ModifiedB. For each of the following symptoms or problemsdetermine if the patient experienced this problemyesterday."I'm going to ask you about a few symptoms you may haveexperienced in the past day." (Check all that apply)"Did you have this symptom or problem yesterday?"1. Loss of consciousness___ Yes___ No2. Trouble remembering or thinking clearly___ Yes___ No3. Pain in the stomach___ Yes___ No4. Pain or other discomfort in the chest___ Yes___ No5. Groin pain, bleeding, itching or abdominaldischarge___ Yes___ No6. Pain in your joints, like your neck, back, arms orlegs___ Yes___ NoIf any symptoms or problems were endorsed in this section,skip to Section D.

C. If none of the symptoms were experienced in Section B.determine if the patient experienced any of the followingproblems in the past day. Continue down the list until aproblem is identified (if any). Once a problem isidentified, skip to Section D."Did you have this symptom or problem yesterday?"1. Difficulty with bowel movements or any pain ordiscomfort in the rectal area___ Yes___ No2. Difficulty urinating___ Yes___ No3. Upset stomach, vomiting or diarrhea___ Yes___ No4. General tiredness, weakness, or weight loss___ Yes___ No5. Cough, wheezing, or shortness of breath___ Yes___ No6. Spells of feeling upset, depressed or crying___ Yes___ No7. Headache___ Yes___ No8. Dizziness, or ringing in ears___ Yes___ No9. Spells of feeling hot, nervous, or shaky___ Yes___ No10. Burning or itching rash on large areas of the body___ Yes___ No

11. Trouble talking (e.g. lisp, stuttering, hoarseness, orbeing unable to speak)___ Yes___ No12. Any trouble seeing with or without glasses or contactlenses___ Yes___ No13. Burning itching or pain in one or both eyes___ Yes___ No14. A problem with being overweight or underweight___ Yes___ No15. Any very noticeable skin imperfections, many warts orlarge scars___ Yes___ No16. Trouble hearing with or without a hearing aid___ Yes___ No17. A stuffy or runny nose___ Yes___ No18. A sore throat___ Yes___ No19. An earache___ Yes___ No20. A toothache___ Yes___ No21. Sore lips, tongue, or gums___ Yes___ No22. A problem with missing or crooked teeth___ Yes___ No

23. Were you supposed to take prescribed medication orfollow a prescribed diet for health reasons (This asksif one or both were prescribed, not what the patientdid.)___ Yes___ No24. Wore glasses or contact lenses___ Yes___ No25. A problem with breathing smog or unpleasant air___ Yes___ No26. Any other symptoms, health complaints, or pains thathave not been mentioned?(Describe:___________________________________)___ Yes___ NoD. MOBILITY

1. Did you drive or ride in a car yesterday?___ YesIf yes: Did you use help from another person in orderto drive a car yesterday? If so, why?___ Yes, health related___ Yes, not health related___ No___ NoIf no: Were the reasons you did not drive yesterdayrelated in any way to your health?___ Yes___ No2. Did you use any public transportation yesterday?___ YesIf yes: Did you use help from another person to usepublic transportation yesterday? If so, why?___ Yes, health related___ Yes, not health related___ No___ NoIf no: Were the reasons you did not use public transportationyesterday related in any way to your health?___ Yes___ NoIf no: If you HAD used public transportation yesterday,would you have used help from another person? If so,why?___ Yes, health related___ Yes, not health related___ No

E. PHYSICAL ACTIVITY: your level of physical activityyesterday1. Did you spend more than half of yesterday in awheelchair?___ YesIf yes: Did you move or control the movement of thewheelchair without help most of the time yesterday?___ Yes___ No. Skip to Section F.___ No2. Did you spend more than half of yesterday in bed? Ifso, why?___ Yes, health related. Skip to Section F.___ Yes, not health related. Skip to Section F.___ No4. Did you spend more than half of yesterday in a chair?If so why?___ Yes, health related___ Yes, not health related___ No5. Did you limp or use a cane, crutch or walker yesterday?___ Yes___ No

F. DAILY ACTIVITIES:1. Did you use help from another person with your personalcare needs? (such as eating, bathing, dressing, orgetting around your home.) If so, why?___ Yes, health related___ Yes, not health related___ No2. Did you use help from another person in handling yourroutine needs? (such as everyday chores, doingnecessary business, shopping, or getting around forother purposes).___ Yes, health related___ Yes, not health related___ No3. Did you do any household activities? (such as workingin or around the house or yard, caring for children,cooking, or cleaning)___ YesIf yes: Were you limited in any way in the amount orkind of household activities you did? (such as notdoing certain tasks or strenuous work, or takingspecial rest periods or working only part of the day)___ Yes___ No___ NoIf no: Was the reason you did not do any householdactivities related in any way to your health?___ Yes___ NoIf no: If you HAD done household activities, would youhave been limited in any way in the amount or kind ofwork done? (such as not doing certain tasks orstrenuous work, or taking special rest periods)___ Yes, health related___ Yes, not health related___ No

4. Were you limited in any activities other than householdactivities, such as hobbies, shopping, recreational,social, or religious activities? If so, why?___ Yes, health related___ Yes, not health related___ NoIA

ID#___________NIA BATTERY ADMINSTRATION PROTOCOL: longI. Summary Performance ScaleStanding BalanceTimed 8 Foot WalkTimed Repeat Chair StandsTOTALTimexxxxxxSCORECategoryScoreII. Standing BalanceA. No aids, such as walker or cane, may be used forthis task.B. Start with semi-tandem stand.1. Do full tandem if subject holds semi-tandem for10 seconds.2. Do side by side if subject fails to hold semitandemfor 10 seconds.c. Score is determined by highest level successfullycompleted.Example 1: Score is 3 if subject holds semi-tandem for10 seconds and full tandem for 5 seconds.Example 2: Score is 1 if subjects fails to hold semitandemfor 10 seconds but holds side by side for 10seconds.CategoryScorea. Side by Side:Feet parallel andtouching.b. Semi-Tandem:Heel of one foot toside of big toe ofother foot.c. Full Tandem:Heel of one foottouches big toe oother foot.(circle)Time: ________secs.0 Held 0-9 seconds ortried but unable ornot attempted.Time: ________secs.Held 0-9 seconds ortried but unable ornot attempted. Tryside by side ifappropriate.1 Held 10 seconds. Held 0-9 seconds ortried by unable ornot attempted.Time:_________sec2 Held 10 seconds. Held 0-2 secondstried but unablenot attempted.3 Held 10 seconds. Held 3-9 seconds4 Held 10 seconds. Held 10 seconds.

III. Timed 8 Foot WalkA. Use tape measure to mark 8 feet and 25 feet withmasking tape. The course must be straight andunobstructed. Allow at least a couple of feet ofclearance at either end.B. Instruct subject to "walk to the first mark at yourusual speed, just as if you were walking down thestreet to go to the store." The subject may use awalking aid, if necessary.C. Time the 8 foot walk. Repeat the walk a second timeunless the subject performs the first walk in less than4 seconds.D. Use the best performance for determining thecategory score.CategoryScore(circle)First 8 foot walk:Time:________secs.Second 8 foot walk:Time:________ secs.0 Unable to complete Unable to complete1 More than 5.6 secs More than 5.6 secs.2 4.1 thru 5.6 secs. 4.1 thru 5.6 secs.3 2.0 thru 4.0 secs. 2.0 thru 4.0 secs.4 Less than 2.0 secs Less than 2.0 secs.IV. Timed Repeat Chair StandsA. Place an armless, firm, straight-backed chairagainst a wall.B. Have the subject sit in the chair with arms foldedacross his/her chest then stand up. Arms must remainfolded, and no aids may be used. If the subjectdoesn't keep arms folded or touches the chair note onthe form, repeat the instructions and try again.C. If successful, ask the subject to stand up and sitdown five times as quickly as possible. Time from theinitial sitting position to the final standingposisition at the end of the fifth stand.D. Record the time, and select the appropriate categoryscore.Category 5 Chair StandsScore(circle) Time:_______ secs.0 Unable to complete1 More than 16.7 secs.2 13.7 thru 16.7 secs.3 11.2 thru 13.6 secs.4 Less than 11.2 secs.Repeat?Walking aid used?If yes, specify.

IAID#__________NIA BATTERY ADMINSTRATION PROTOCOL: shortPERFORMANCE SCALE Time ScoreStanding BalanceTimed 8 Foot WalkTimed Repeat Chair StandsTOTALxxxxxxSCORESTANDINGBALANCEScore(circle)a. Side by Side:Time:________secs.b. Semi-Tandem:Time: ________secs.c. Full Tandem:Time:_________secs.0 Held 0-9 secs,tried & unable,not tried.Held 0-9 secs, tried& unable, not tried.1 Held 10 seconds. Held 0-9 secs, tried& unable, not tried.2 Held 10 seconds. Held 0-2 secs, tried& unable, not tried3 Held 10 seconds. Held 3-9 seconds.4 Held 10 seconds. Held 10 seconds.8FT WALKScore(circle)First 8 Foot Walk:Time:________secs.Second 8 Foot Walk:Time:________ secs.Walking aid used?If yes, specify.0 Unable to complete Unable to complete1 More than 5.6 secs More than 5.6 secs.2 4.1 thru 5.6 secs. 4.1 thru 5.6 secs.3 2.0 thru 4.0 secs. 2.0 thru 4.0 secs.4 Less than 2.0 secs Less than 2.0 secs.Score(circle)5 CHAIR STANDSTime:_______ secs.0 Unable to complete1 More than 16.7 secs.2 13.7 thru 16.7 secs.3 11.2 thru 13.6 secs.4 Less than 11.2 secs.Repeat?

Health Status Questionnaire (SF-36) responses for Q's 1-10Yes, limited a lotYes, limited a littleNo, not limited at allHealth Status Questionnaire (SF-36) responses for Q's 18-27All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the timeHealth Status Questionnaire (SF-36) responses for Q's 28,30Not at allSlightlyModeratelyQuite a bitExtremelyHealth Status Questionnaire (SF-36) responses for Q 29NoneVery mildMildModerateSevereVery severe

Health Status Questionnaire (SF-36) responses for Q's 31-34Definitely trueMostly trueNot sureMostly falseDefinitely falseHealth Status Questionnaire (SF-36) responses for Q 35ExcellentVery goodGoodFairPoorHealth Status Questionnaire (SF-36) responses for Q's 31-34Much better than one year agoSomewhat better now than one year agoAbout the sameSomewhat worse than one year agoMuch worse now than one year agoPatient Satisfaction Questionnaire reponses for all Q'sStrongly disagreeDisagreeNeither agree nor disagreeAgreeStrongly agreeQuality of Well-Being responses for:Physical Activity Q's 3, 4Social Activity Q's 1, 2, 3 subsection, 4Yes, health relatedYes, not health relatedNo

Perceived Efficacy in Physician-Patient Interactions (PEPPI)responses for all Q'sC O N F I D E N C EL E V E L1..........2.........3..........4.........5Not at allConfidentVeryConfidento3base15.fm