I. Physical Measures
I. Physical Measures module of HRS 2012
Start of I. Physical Measures
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NV800
MODE OF INTERVIEW FOR PHYSICAL MEASURES
@/@S@WW@W ENTER CURRENT MODE OF INTERVIEW@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Phone
2 F-t-f
@/@S@WW@W ENTER CURRENT MODE OF INTERVIEW@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Phone
2 F-t-f
If NX090_R = ENHANCEDFTF »
|
If MODE OF INTERVIEW FOR PHYSICAL MEASURES (NV800) = 2 F-t-f and R IN NURSING HOME (NA028) = NO and LANGUAGE = SPANISH or ENGNVSH »
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NV802
PHYSICAL MEASURES CONSENT
@/@S@WW@W DID R SIGN THE PHYSICAL MEASURES CONSENT FORM?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
@/@S@WW@W DID R SIGN THE PHYSICAL MEASURES CONSENT FORM?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| |
If PHYSICAL MEASURES CONSENT (NV802) = 1 Yes »
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NV854
Blood Pressure Complete
@/BLOOD PRESSURE@/@/@S@WW@W DID R COMPLETE AT LEAST ONE BLOOD PRESSURE MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
@/BLOOD PRESSURE@/@/@S@WW@W DID R COMPLETE AT LEAST ONE BLOOD PRESSURE MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| | |
If Blood Pressure Complete (NV854) = 5 No »
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NV855
Reason Blood Pressure Not Complete
@/BLOOD PRESSURE
@/@/@S@WW@W WHY DIDN'T R COMPLETE THE BLOOD PRESSURE MEASUREMENT?
@/@WW@W (SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the test
4 R tried but was unable to complete test
5 R did not understand the instructions
6 R had a rash, cast, edema, etc. on arm; other health reason
7 No suitable space
8 Problem with equipment or supplies
97 Other (specify)
@/BLOOD PRESSURE
@/@/@S@WW@W WHY DIDN'T R COMPLETE THE BLOOD PRESSURE MEASUREMENT?
@/@WW@W (SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the test
4 R tried but was unable to complete test
5 R did not understand the instructions
6 R had a rash, cast, edema, etc. on arm; other health reason
7 No suitable space
8 Problem with equipment or supplies
97 Other (specify)
| | |
ElseIf Blood Pressure Complete (NV854) = 1 Yes »
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NV857
BLOODPRESSURE TIME
@/BLOOD PRESSURE - 1ST TIME
@/@/@WW@W@SFIRST READING TIME OF READING
@/@/@WW@W ENTER HOUR, COLON, MINUTES, AND EITHER 'AM' OR 'PM'. E.G., FOR A
TIME OF 1:23PM, ENTER '1' FOLLOWED BY ':' FOLLOWED BY '23' FOLLOWED BY 'PM'.
PLEASE CHECK TO MAKE SURE ENTRY DISPLAYS CORRECTLY BEFORE PROCEEDING.@S
@/BLOOD PRESSURE - 1ST TIME
@/@/@WW@W@SFIRST READING TIME OF READING
@/@/@WW@W ENTER HOUR, COLON, MINUTES, AND EITHER 'AM' OR 'PM'. E.G., FOR A
TIME OF 1:23PM, ENTER '1' FOLLOWED BY ':' FOLLOWED BY '23' FOLLOWED BY 'PM'.
PLEASE CHECK TO MAKE SURE ENTRY DISPLAYS CORRECTLY BEFORE PROCEEDING.@S
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NV859
BLOODPRESSURE 1 SYSTOLIC (mmHg)
@/BLOOD PRESSURE - 1ST SYSTOLIC
@/@/@WW@W@SFIRST READING SYSTOLIC
@/@/@WW@WENTER 993 IF R TRIED BUT WAS UNABLE TO DO IT.
@/@WW@WENTER 999 IF R CHOSE NOT TO DO IT.@S
- - - - - - - - - - - - - - - - - - - - - - - - -
-999999999..999999999
@/BLOOD PRESSURE - 1ST SYSTOLIC
@/@/@WW@W@SFIRST READING SYSTOLIC
@/@/@WW@WENTER 993 IF R TRIED BUT WAS UNABLE TO DO IT.
@/@WW@WENTER 999 IF R CHOSE NOT TO DO IT.@S
- - - - - - - - - - - - - - - - - - - - - - - - -
-999999999..999999999
| | | |
If BLOODPRESSURE 1 SYSTOLIC (mmHg) (NV859) != 9993 and BLOODPRESSURE 1 SYSTOLIC (mmHg) (NV859) != 999 »
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NV860
BLOODPRESSURE 1 DIASTOLIC (mmHg)
@/BLOOD PRESSURE - 1ST DIASTOLIC
@/@/@WW@W@SFIRST READING DIASTOLIC@S
- - - - - - - - - - - - - - - - - - - - - - - - -
-999999999..999999999
@/BLOOD PRESSURE - 1ST DIASTOLIC
@/@/@WW@W@SFIRST READING DIASTOLIC@S
- - - - - - - - - - - - - - - - - - - - - - - - -
-999999999..999999999
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NV861
BLOODPRESSURE 1 Pulse (bpm)
@/BLOOD PRESSURE - 1ST PULSE
@/@/@WW@W@SFIRST READING PULSE @S
- - - - - - - - - - - - - - - - - - - - - - - - -
-999999999..999999999
@/BLOOD PRESSURE - 1ST PULSE
@/@/@WW@W@SFIRST READING PULSE @S
- - - - - - - - - - - - - - - - - - - - - - - - -
-999999999..999999999
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NV862
BLOODPRESSURE2 TIME
@/BLOOD PRESSURE - 2ND TIME
@/@/@WW@W@SSECOND READING TIME OF READING
@/@/@WW@W ENTER HOUR, COLON, MINUTES, AND EITHER 'AM' OR 'PM'. E.G., FOR A TIME OF 1:23PM,
ENTER '1' FOLLOWED BY ':' FOLLOWED BY '23' FOLLOWED BY 'PM'. PLEASE CHECK TO MAKE SURE ENTRY
DISPLAYS CORRECTLY BEFORE PROCEEDING.@S
@/BLOOD PRESSURE - 2ND TIME
@/@/@WW@W@SSECOND READING TIME OF READING
@/@/@WW@W ENTER HOUR, COLON, MINUTES, AND EITHER 'AM' OR 'PM'. E.G., FOR A TIME OF 1:23PM,
ENTER '1' FOLLOWED BY ':' FOLLOWED BY '23' FOLLOWED BY 'PM'. PLEASE CHECK TO MAKE SURE ENTRY
DISPLAYS CORRECTLY BEFORE PROCEEDING.@S
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NV864
BLOODPRESSURE 2 SYSTOLIC (mmHg)
@/BLOOD PRESSURE - 2ND SYSTOLIC
@/@/@WW@W@SSECOND READING SYSTOLIC
@/@/@WW@WENTER 993 IF R TRIED BUT WAS UNABLE TO DO IT.
@/@WW@WENTER 999 IF R CHOSE NOT TO DO IT.@S
- - - - - - - - - - - - - - - - - - - - - - - - -
-999999999..999999999
@/BLOOD PRESSURE - 2ND SYSTOLIC
@/@/@WW@W@SSECOND READING SYSTOLIC
@/@/@WW@WENTER 993 IF R TRIED BUT WAS UNABLE TO DO IT.
@/@WW@WENTER 999 IF R CHOSE NOT TO DO IT.@S
- - - - - - - - - - - - - - - - - - - - - - - - -
-999999999..999999999
| | | | |
If BLOODPRESSURE 2 SYSTOLIC (mmHg) (NV864) != 9993 and BLOODPRESSURE 2 SYSTOLIC (mmHg) (NV864) != 999 »
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NV865
BLOODPRESSURE 2 DIASTOLIC (mmHg)
@/BLOOD PRESSURE - 2ND DIASTOLIC
@/@/@WW@W@SSECOND READING DIASTOLIC@S
- - - - - - - - - - - - - - - - - - - - - - - - -
-999999999..999999999
@/BLOOD PRESSURE - 2ND DIASTOLIC
@/@/@WW@W@SSECOND READING DIASTOLIC@S
- - - - - - - - - - - - - - - - - - - - - - - - -
-999999999..999999999
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NV866
BLOODPRESSURE 2 Pulse (bpm)
@/BLOOD PRESSURE - 2ND PULSE
@/@/@WW@W@SSECOND READING PULSE @S
- - - - - - - - - - - - - - - - - - - - - - - - -
-999999999..999999999
@/BLOOD PRESSURE - 2ND PULSE
@/@/@WW@W@SSECOND READING PULSE @S
- - - - - - - - - - - - - - - - - - - - - - - - -
-999999999..999999999
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NV867
BLOODPRESSURE 3 TIME
@/BLOOD PRESSURE - 3RD TIME
@/@/@WW@W@STHIRD READING TIME OF READING
@/@/@WW@W ENTER HOUR, COLON, MINUTES, AND EITHER 'AM' OR 'PM'. E.G., FOR A TIME OF 1:23PM,
ENTER '1' FOLLOWED BY ':' FOLLOWED BY '23' FOLLOWED BY 'PM'. PLEASE CHECK TO MAKE SURE ENTRY
DISPLAYS CORRECTLY BEFORE PROCEEDING.@S
@/BLOOD PRESSURE - 3RD TIME
@/@/@WW@W@STHIRD READING TIME OF READING
@/@/@WW@W ENTER HOUR, COLON, MINUTES, AND EITHER 'AM' OR 'PM'. E.G., FOR A TIME OF 1:23PM,
ENTER '1' FOLLOWED BY ':' FOLLOWED BY '23' FOLLOWED BY 'PM'. PLEASE CHECK TO MAKE SURE ENTRY
DISPLAYS CORRECTLY BEFORE PROCEEDING.@S
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NV869
BLOODPRESSURE 3 Systolic (mmHg)
@/BLOOD PRESSURE - 3RD SYSTOLIC
@/@/@WW@W@STHIRD READING SYSTOLIC
@/@/@WW@WENTER 993 IF R TRIED BUT WAS UNABLE TO DO IT.
@/@WW@WENTER 999 IF R CHOSE NOT TO DO IT.@S
- - - - - - - - - - - - - - - - - - - - - - - - -
-999999999..999999999
@/BLOOD PRESSURE - 3RD SYSTOLIC
@/@/@WW@W@STHIRD READING SYSTOLIC
@/@/@WW@WENTER 993 IF R TRIED BUT WAS UNABLE TO DO IT.
@/@WW@WENTER 999 IF R CHOSE NOT TO DO IT.@S
- - - - - - - - - - - - - - - - - - - - - - - - -
-999999999..999999999
| | | | | |
If BLOODPRESSURE 3 Systolic (mmHg) (NV869) != 9993 and BLOODPRESSURE 3 Systolic (mmHg) (NV869) != 999 »
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NV870
BLOODPRESSURE 3 DIASTOLIC (mmHg)
@/BLOOD PRESSURE - 3RD DIASTOLIC
@/@/@WW@W@STHIRD READING DIASTOLIC@S
- - - - - - - - - - - - - - - - - - - - - - - - -
-999999999..999999999
@/BLOOD PRESSURE - 3RD DIASTOLIC
@/@/@WW@W@STHIRD READING DIASTOLIC@S
- - - - - - - - - - - - - - - - - - - - - - - - -
-999999999..999999999
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NV871
BLOODPRESSURE 3 Pulse (bpm)
@/BLOOD PRESSURE - 3RD PULSE
@/@/@WW@W@STHIRD READING PULSE @S
- - - - - - - - - - - - - - - - - - - - - - - - -
-999999999..999999999
@/BLOOD PRESSURE - 3RD PULSE
@/@/@WW@W@STHIRD READING PULSE @S
- - - - - - - - - - - - - - - - - - - - - - - - -
-999999999..999999999
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NV872
BLOODPRESSURE ARM
@/BLOOD PRESSURE - ARM
@/@/@WW@W@SWHICH ARM WAS USED TO CONDUCT THE MEASUREMENTS?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Left arm
2 Right arm
@/BLOOD PRESSURE - ARM
@/@/@WW@W@SWHICH ARM WAS USED TO CONDUCT THE MEASUREMENTS?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Left arm
2 Right arm
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NV873
BLOODPRESSURE Compliance
@/BLOOD PRESSURE - COMPLIANCE
@/@/@WW@W@SHOW COMPLIANT WAS R DURING THIS MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R was fully compliant
2 R was prevented from fully complying due to illness, pain, or other symptoms or discomforts
3 R was not fully compliant, but no obvious reason for this
@/BLOOD PRESSURE - COMPLIANCE
@/@/@WW@W@SHOW COMPLIANT WAS R DURING THIS MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R was fully compliant
2 R was prevented from fully complying due to illness, pain, or other symptoms or discomforts
3 R was not fully compliant, but no obvious reason for this
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NV874
BLOODPRESSURE Position
@/BLOOD PRESSURE - POSITION
@/@/@WW@W@SWHAT WAS R'S POSITION FOR THIS TEST?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Standing
2 Sitting
3 Lying down
@/BLOOD PRESSURE - POSITION
@/@/@WW@W@SWHAT WAS R'S POSITION FOR THIS TEST?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Standing
2 Sitting
3 Lying down
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NV875
BLOODPRESSURE Smoke Etc
@/BLOOD PRESSURE - SMOKE ETC.
@/@/@WW@W@SDID R SMOKE, EXERCISE, CONSUME ALCOHOL OR FOOD WITHIN THE 30
MINUTES PRIOR TO COMPLETING THE BLOOD PRESSURE TEST?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
@/BLOOD PRESSURE - SMOKE ETC.
@/@/@WW@W@SDID R SMOKE, EXERCISE, CONSUME ALCOHOL OR FOOD WITHIN THE 30
MINUTES PRIOR TO COMPLETING THE BLOOD PRESSURE TEST?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
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NV804
Breath COMPLETE AT LEAST ONE TRIAL
@/BREATHING TEST
@/@/@S@WW@W DID R COMPLETE AT LEAST ONE TRIAL OF THE BREATHING TEST?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
@/BREATHING TEST
@/@/@S@WW@W DID R COMPLETE AT LEAST ONE TRIAL OF THE BREATHING TEST?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| | |
If Breath COMPLETE AT LEAST ONE TRIAL (NV804) != 1 Yes »
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NV805
Breath Test REASON NOT COMPLETE
@/BREATHING TEST
@/@/@S@WW@W WHY DIDN'T R COMPLETE THE BREATHING TEST? (SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the test
4 R tried but was unable to complete test
5 R did not understand the instructions
6 R could not participate due to health reasons
7 No suitable space
8 Problem with equipment or supplies
97 Other (specify)
@/BREATHING TEST
@/@/@S@WW@W WHY DIDN'T R COMPLETE THE BREATHING TEST? (SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the test
4 R tried but was unable to complete test
5 R did not understand the instructions
6 R could not participate due to health reasons
7 No suitable space
8 Problem with equipment or supplies
97 Other (specify)
| | |
If Breath COMPLETE AT LEAST ONE TRIAL (NV804) = 1 Yes »
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NV807
Puff Test 1 (L/min)
@/BREATHING TEST
@/@/FIRST READING:
@/@/SECOND READING:
@/@/THIRD READING:
@/@/@S@WW@W ENTER 993 IF R TRIED BUT WAS UNABLE TO DO IT.
@/@WW@W ENTER 999 IF R CHOSE NOT TO DO IT.@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
@/BREATHING TEST
@/@/FIRST READING:
@/@/SECOND READING:
@/@/THIRD READING:
@/@/@S@WW@W ENTER 993 IF R TRIED BUT WAS UNABLE TO DO IT.
@/@WW@W ENTER 999 IF R CHOSE NOT TO DO IT.@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
| | | | ========================================================================
| | | |
NV808
Puff Test 2 (L/min)
@/BREATHING TEST
@/@/FIRST READING: Puff Test 1 (L/min)
@/@/SECOND READING:
@/@/THIRD READING:
@/@/@S@WW@W ENTER 993 IF R TRIED BUT WAS UNABLE TO DO IT.
@/@WW@W ENTER 999 IF R CHOSE NOT TO DO IT.@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
@/BREATHING TEST
@/@/FIRST READING: Puff Test 1 (L/min)
@/@/SECOND READING:
@/@/THIRD READING:
@/@/@S@WW@W ENTER 993 IF R TRIED BUT WAS UNABLE TO DO IT.
@/@WW@W ENTER 999 IF R CHOSE NOT TO DO IT.@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
| | | | ========================================================================
| | | |
NV809
Puff Test 3 (L/min)
@/BREATHING TEST
@/@/FIRST READING: Puff Test 1 (L/min)
@/@/SECOND READING: Puff Test 2 (L/min)
@/@/THIRD READING:
@/@/@S@WW@W ENTER 993 IF R TRIED BUT WAS UNABLE TO DO IT.
@/@WW@W ENTER 999 IF R CHOSE NOT TO DO IT.@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
@/BREATHING TEST
@/@/FIRST READING: Puff Test 1 (L/min)
@/@/SECOND READING: Puff Test 2 (L/min)
@/@/THIRD READING:
@/@/@S@WW@W ENTER 993 IF R TRIED BUT WAS UNABLE TO DO IT.
@/@WW@W ENTER 999 IF R CHOSE NOT TO DO IT.@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
| | | | ========================================================================
| | | |
NV810
R BREATHING TEST effort
@/BREATHING TEST
@/@/@S@WW@W HOW MUCH EFFORT DID THE R GIVE TO THIS TEST?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R gave full effort
2 Full effort prevented by illness, pain, or other symptoms or discomforts
3 Full effort not given, but no obvious reason for this
@/BREATHING TEST
@/@/@S@WW@W HOW MUCH EFFORT DID THE R GIVE TO THIS TEST?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R gave full effort
2 Full effort prevented by illness, pain, or other symptoms or discomforts
3 Full effort not given, but no obvious reason for this
| | | | ========================================================================
| | | |
NV811
BREATHING TEST R position
@/BREATHING TEST
@/@/@S@WW@W WHAT WAS THE R'S POSITION FOR THIS TEST?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Standing
2 Sitting
3 Lying down
@/BREATHING TEST
@/@/@S@WW@W WHAT WAS THE R'S POSITION FOR THIS TEST?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Standing
2 Sitting
3 Lying down
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| | |
NV812
HAND STRENGTH COMPLETE AT LEAST ONE TRIAL
@/HAND STRENGTH TEST
@/@/@S@WW@W DID R COMPLETE AT LEAST ONE TRIAL OF THE HAND STRENGTH TEST?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
@/HAND STRENGTH TEST
@/@/@S@WW@W DID R COMPLETE AT LEAST ONE TRIAL OF THE HAND STRENGTH TEST?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| | |
If HAND STRENGTH COMPLETE AT LEAST ONE TRIAL (NV812) != 1 Yes »
| | | | ========================================================================
| | | |
NV813
HAND STRENGTH TEST REASON NOT COMPLETE
@/HAND STRENGTH TEST
@/@/@S@WW@W WHY DIDN'T R COMPLETE THE HAND STRENGTH TEST? (SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the test
4 R tried but was unable to complete test
5 R did not understand the instructions
6 R could not participate due to surgery, swelling, etc.; other health reason
7 No suitable space
8 Problem with equipment or supplies
97 Other (specify)
@/HAND STRENGTH TEST
@/@/@S@WW@W WHY DIDN'T R COMPLETE THE HAND STRENGTH TEST? (SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the test
4 R tried but was unable to complete test
5 R did not understand the instructions
6 R could not participate due to surgery, swelling, etc.; other health reason
7 No suitable space
8 Problem with equipment or supplies
97 Other (specify)
| | |
Else If HAND STRENGTH COMPLETE AT LEAST ONE TRIAL (NV812) = 1 Yes »
| | | | ========================================================================
| | | |
NV815
grip dominant hand
@/HAND STRENGTH TEST
@/@/@S@WW@W RECORD R'S DOMINANT HAND.@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Right hand
2 Left hand
3 Both hands equally dominant
@/HAND STRENGTH TEST
@/@/@S@WW@W RECORD R'S DOMINANT HAND.@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Right hand
2 Left hand
3 Both hands equally dominant
| | | | ========================================================================
| | | |
NV816
Left first (kg)
@/HAND STRENGTH TEST
@/@/@S@WW@W @ULEFT@U HAND, FIRST MEASUREMENT@S.
@/@/@S@ULEFT HAND, FIRST MEASUREMENT:@U@S
@/@SRIGHT HAND, FIRST MEASUREMENT:@S
@/@SLEFT HAND, SECOND MEASUREMENT:@S
@/@SRIGHT HAND, SECOND MEASUREMENT:@S
@/@/@WW@W ENTER THE RESULT TO THE NEAREST 0.5 KILOGRAM.
@/@/@WW@W ENTER 993 IF R WAS UNABLE TO PERFORM THIS MEASUREMENT
@/ENTER 999 IF R CHOSE NOT TO DO IT@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
@/HAND STRENGTH TEST
@/@/@S@WW@W @ULEFT@U HAND, FIRST MEASUREMENT@S.
@/@/@S@ULEFT HAND, FIRST MEASUREMENT:@U@S
@/@SRIGHT HAND, FIRST MEASUREMENT:@S
@/@SLEFT HAND, SECOND MEASUREMENT:@S
@/@SRIGHT HAND, SECOND MEASUREMENT:@S
@/@/@WW@W ENTER THE RESULT TO THE NEAREST 0.5 KILOGRAM.
@/@/@WW@W ENTER 993 IF R WAS UNABLE TO PERFORM THIS MEASUREMENT
@/ENTER 999 IF R CHOSE NOT TO DO IT@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
| | | | ========================================================================
| | | |
NV851
RIGHT first (kg)
@/HAND STRENGTH TEST
@/@/@S@WW@W @URIGHT@U HAND, FIRST MEASUREMENT@S.
@/@/@SLEFT HAND, FIRST MEASUREMENT:@S Left first (kg)
@/@S@URIGHT HAND, FIRST MEASUREMENT:@U@S
@/@SLEFT HAND, SECOND MEASUREMENT:@S
@/@SRIGHT HAND, SECOND MEASUREMENT:@S
@/@/@WW@W ENTER THE RESULT TO THE THE NEAREST 0.5 KILOGRAM.
@/@/@WW@W ENTER 993 IF R WAS UNABLE TO PERFORM THIS MEASUREMENT
@/ENTER 999 IF R CHOSE NOT TO DO IT@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
@/HAND STRENGTH TEST
@/@/@S@WW@W @URIGHT@U HAND, FIRST MEASUREMENT@S.
@/@/@SLEFT HAND, FIRST MEASUREMENT:@S Left first (kg)
@/@S@URIGHT HAND, FIRST MEASUREMENT:@U@S
@/@SLEFT HAND, SECOND MEASUREMENT:@S
@/@SRIGHT HAND, SECOND MEASUREMENT:@S
@/@/@WW@W ENTER THE RESULT TO THE THE NEAREST 0.5 KILOGRAM.
@/@/@WW@W ENTER 993 IF R WAS UNABLE TO PERFORM THIS MEASUREMENT
@/ENTER 999 IF R CHOSE NOT TO DO IT@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
| | | | ========================================================================
| | | |
NV852
left second (kg)
@/HAND STRENGTH TEST
@/@/@S@WW@W @ULEFT@U HAND, @USECOND@U MEASUREMENT@S.
@/@/@SLEFT HAND, FIRST MEASUREMENT:@S Left first (kg)
@/@SRIGHT HAND, FIRST MEASUREMENT:@S RIGHT first (kg)
@/@S@ULEFT HAND, SECOND MEASUREMENT@U:@S
@/@SRIGHT HAND, SECOND MEASUREMENT:@S
@/@/@WW@W ENTER THE RESULT TO THE THE NEAREST 0.5 KILOGRAM.
@/@/ENTER 993 IF R WAS UNABLE TO PERFORM THIS MEASUREMENT
@/ENTER 999 IF R CHOSE NOT TO DO IT@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
@/HAND STRENGTH TEST
@/@/@S@WW@W @ULEFT@U HAND, @USECOND@U MEASUREMENT@S.
@/@/@SLEFT HAND, FIRST MEASUREMENT:@S Left first (kg)
@/@SRIGHT HAND, FIRST MEASUREMENT:@S RIGHT first (kg)
@/@S@ULEFT HAND, SECOND MEASUREMENT@U:@S
@/@SRIGHT HAND, SECOND MEASUREMENT:@S
@/@/@WW@W ENTER THE RESULT TO THE THE NEAREST 0.5 KILOGRAM.
@/@/ENTER 993 IF R WAS UNABLE TO PERFORM THIS MEASUREMENT
@/ENTER 999 IF R CHOSE NOT TO DO IT@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
| | | | ========================================================================
| | | |
NV853
RIGHT Second (kg)
@/HAND STRENGTH TEST
@/@/@S@WW@W @URIGHT@U HAND, @USECOND@U MEASUREMENT@S.
@/@/@SLEFT HAND, FIRST MEASUREMENT:@S Left first (kg)
@/@SRIGHT HAND, FIRST MEASUREMENT:@S RIGHT first (kg)
@/@SLEFT HAND, SECOND MEASUREMENT:@S left second(kg)
@/@S@URIGHT HAND, SECOND MEASUREMENT@U:@S
@/@/@WW@W ENTER THE RESULT TO THE THE NEAREST 0.5 KILOGRAM.
@/@/ENTER 993 IF R WAS UNABLE TO PERFORM THIS MEASUREMENT
@/ENTER 999 IF R CHOSE NOT TO DO IT@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
@/HAND STRENGTH TEST
@/@/@S@WW@W @URIGHT@U HAND, @USECOND@U MEASUREMENT@S.
@/@/@SLEFT HAND, FIRST MEASUREMENT:@S Left first (kg)
@/@SRIGHT HAND, FIRST MEASUREMENT:@S RIGHT first (kg)
@/@SLEFT HAND, SECOND MEASUREMENT:@S left second(kg)
@/@S@URIGHT HAND, SECOND MEASUREMENT@U:@S
@/@/@WW@W ENTER THE RESULT TO THE THE NEAREST 0.5 KILOGRAM.
@/@/ENTER 993 IF R WAS UNABLE TO PERFORM THIS MEASUREMENT
@/ENTER 999 IF R CHOSE NOT TO DO IT@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
| | | | ========================================================================
| | | |
NV817
GRIP R EFFORT
@/HAND STRENGTH TEST
@/@/@S@WW@W HOW MUCH EFFORT DID THE R GIVE TO THIS TEST?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R gave full effort
2 Full effort prevented by illness, pain, or other symptoms or discomforts
3 Full effort not given, but no obvious reason for this
@/HAND STRENGTH TEST
@/@/@S@WW@W HOW MUCH EFFORT DID THE R GIVE TO THIS TEST?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R gave full effort
2 Full effort prevented by illness, pain, or other symptoms or discomforts
3 Full effort not given, but no obvious reason for this
| | | | ========================================================================
| | | |
NV818
HAND STRENGTH TEST R POSITION
@/HAND STRENGTH TEST
@/@/@S@WW@W WHAT WAS THE R'S POSITION FOR THIS TEST?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Standing
2 Sitting
3 Lying down
@/HAND STRENGTH TEST
@/@/@S@WW@W WHAT WAS THE R'S POSITION FOR THIS TEST?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Standing
2 Sitting
3 Lying down
| | | | ========================================================================
| | | |
NV819
HAND STRENGTH rest arm
@/HAND STRENGTH TEST
@/@/@S@WW@W DID THE R REST THEIR ARM ON A SUPPORT WHILE PERFORMING THIS TEST?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
@/HAND STRENGTH TEST
@/@/@S@WW@W DID THE R REST THEIR ARM ON A SUPPORT WHILE PERFORMING THIS TEST?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| | | ========================================================================
| | |
NV876
BALANCE TEST - SEMI-TANDEM STAND
@/BALANCE TEST - SEMI-TANDEM STAND
@/@/@S@WW@W DID R COMPLETE THE SEMI-TANDEM STAND?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
@/BALANCE TEST - SEMI-TANDEM STAND
@/@/@S@WW@W DID R COMPLETE THE SEMI-TANDEM STAND?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| | |
If BALANCE TEST - SEMI-TANDEM STAND (NV876) != 1 Yes »
| | | | ========================================================================
| | | |
NV877
BALANCE TEST SEMI-TANDEM REASON NOT COMPLETE
@/BALANCE TEST - SEMI-TANDEM STAND
@/@/@S@WW@W WHY DIDN'T R COMPLETE THE SEMI-TANDEM STAND?
@/@WW@W SELECT ALL THAT APPLY@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the test
4 R tried but was unable to complete test
5 R did not understand the instructions
6 R had surgery, injury, or other health condition that prevented R from completing the test
7 No suitable space
8 Problem with equipment or supplies
97 Other (specify)
@/BALANCE TEST - SEMI-TANDEM STAND
@/@/@S@WW@W WHY DIDN'T R COMPLETE THE SEMI-TANDEM STAND?
@/@WW@W SELECT ALL THAT APPLY@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the test
4 R tried but was unable to complete test
5 R did not understand the instructions
6 R had surgery, injury, or other health condition that prevented R from completing the test
7 No suitable space
8 Problem with equipment or supplies
97 Other (specify)
| | |
ElseIf BALANCE TEST - SEMI-TANDEM STAND (NV876) = 1 Yes »
| | | | ========================================================================
| | | |
NV879
BALANCE TEST SEMI-TANDEM Hold Full Time
@/BALANCE TEST - SEMI-TANDEM STAND
@/@/@S@WW@W DID R HOLD SEMI-TANDEM STAND FOR FULL 10 SECONDS WITHOUT STEPPING OUT OF PLACE OR GRABBING HOLD OF ANYTHING?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
993 R tried but was unable
999 R chose not to do it
@/BALANCE TEST - SEMI-TANDEM STAND
@/@/@S@WW@W DID R HOLD SEMI-TANDEM STAND FOR FULL 10 SECONDS WITHOUT STEPPING OUT OF PLACE OR GRABBING HOLD OF ANYTHING?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
993 R tried but was unable
999 R chose not to do it
| | | |
If BALANCE TEST SEMI-TANDEM Hold Full Time (NV879) = 1 Yes »
| | | | | ========================================================================
| | | | |
NV880
BALANCE TEST SEMI-TANDEM Time
@/BALANCE TEST - SEMI-TANDEM STAND
@/@/@S@WW@W RECORD TIME IN SECONDS TO TWO DECIMAL PLACES@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
@/BALANCE TEST - SEMI-TANDEM STAND
@/@/@S@WW@W RECORD TIME IN SECONDS TO TWO DECIMAL PLACES@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
| | | |
If BALANCE TEST SEMI-TANDEM Hold Full Time (NV879) != 999 R chose not to do it and BALANCE TEST SEMI-TANDEM Hold Full Time (NV879) != 993 R tried but was unable »
| | | | | ========================================================================
| | | | |
NV881
BALANCE TEST SEMI-TANDEM Compensatory
@/BALANCE TEST - SEMI-TANDEM STAND
@/@/@S@WW@W DID R USE ANY COMPENSATORY MOVEMENTS OF HIS/HER TRUNK, ARMS OR LEGS TO STEADY HIM/HERSELF DURING SEMI-TANDEM STAND?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
@/BALANCE TEST - SEMI-TANDEM STAND
@/@/@S@WW@W DID R USE ANY COMPENSATORY MOVEMENTS OF HIS/HER TRUNK, ARMS OR LEGS TO STEADY HIM/HERSELF DURING SEMI-TANDEM STAND?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| | |
If BALANCE TEST - SEMI-TANDEM STAND (NV876) = 5 No or BALANCE TEST SEMI-TANDEM Hold Full Time (NV879) != 1 Yes »
| | | | ========================================================================
| | | |
NV883
BALANCE TEST S-B-S Complete
@/BALANCE TEST - SIDE-BY-SIDE STAND
@/@/@S@WW@W DID R COMPLETE THE SIDE-BY-SIDE STAND? @S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
@/BALANCE TEST - SIDE-BY-SIDE STAND
@/@/@S@WW@W DID R COMPLETE THE SIDE-BY-SIDE STAND? @S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| | | |
If BALANCE TEST S-B-S Complete (NV883) != 1 Yes »
| | | | | ========================================================================
| | | | |
NV884
BALANCE TEST S-B-S STAND REASON NOT COMPLETE
@/BALANCE TEST - SIDE-BY-SIDE STAND
@/@/@S@WW@W WHY DIDN'T R COMPLETE THE SIDE-BY-SIDE STAND?
@/@WW@W SELECT ALL THAT APPLY@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the test
4 R tried but was unable to complete test
5 R did not understand the instructions
6 R had surgery, injury, or other health condition that prevented R from completing the test
7 No suitable space
8 Problem with equipment or supplies
97 Other (specify)
@/BALANCE TEST - SIDE-BY-SIDE STAND
@/@/@S@WW@W WHY DIDN'T R COMPLETE THE SIDE-BY-SIDE STAND?
@/@WW@W SELECT ALL THAT APPLY@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the test
4 R tried but was unable to complete test
5 R did not understand the instructions
6 R had surgery, injury, or other health condition that prevented R from completing the test
7 No suitable space
8 Problem with equipment or supplies
97 Other (specify)
| | | |
ElseIf BALANCE TEST S-B-S Complete (NV883) = 1 Yes »
| | | | | ========================================================================
| | | | |
NV886
BALANCE TEST S-B-S Hold Full Time
@/BALANCE TEST - SIDE-BY-SIDE STAND
@/@/@S@WW@W DID R HOLD SIDE-BY-SIDE STAND FOR FULL 10 SECONDS WITHOUT STEPPING OUT OF PLACE OR GRABBING HOLD OF ANYTHING?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
993 R tried but was unable
999 R chose not to do it
@/BALANCE TEST - SIDE-BY-SIDE STAND
@/@/@S@WW@W DID R HOLD SIDE-BY-SIDE STAND FOR FULL 10 SECONDS WITHOUT STEPPING OUT OF PLACE OR GRABBING HOLD OF ANYTHING?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
993 R tried but was unable
999 R chose not to do it
| | | | |
If BALANCE TEST S-B-S Hold Full Time (NV886) = 1 Yes »
| | | | | | ========================================================================
| | | | | |
NV887
BALANCE TEST SIDE-BY-SIDE Time
@/BALANCE TEST - SIDE-BY-SIDE STAND
@/@/@S@WW@W RECORD TIME IN SECONDS TO TWO DECIMAL PLACES@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
@/BALANCE TEST - SIDE-BY-SIDE STAND
@/@/@S@WW@W RECORD TIME IN SECONDS TO TWO DECIMAL PLACES@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
| | | | |
If BALANCE TEST S-B-S Hold Full Time (NV886) != 993 R tried but was unable and BALANCE TEST S-B-S Hold Full Time (NV886) != 999 R chose not to do it »
| | | | | | ========================================================================
| | | | | |
NV888
BALANCE TEST SIDE-BY-SIDE Compensatory
@/BALANCE TEST - SIDE-BY-SIDE STAND
@/@/@S@WW@W DID R USE ANY COMPENSATORY MOVEMENTS OF HIS/HER TRUNK, ARMS OR LEGS TO STEADY HIM/HERSELF DURING SIDE-BY-SIDE STAND?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
@/BALANCE TEST - SIDE-BY-SIDE STAND
@/@/@S@WW@W DID R USE ANY COMPENSATORY MOVEMENTS OF HIS/HER TRUNK, ARMS OR LEGS TO STEADY HIM/HERSELF DURING SIDE-BY-SIDE STAND?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| | | | | | ========================================================================
| | | | | |
NV889
BALANCE TEST S-B-S Floor Surface
@/BALANCE TEST - SIDE-BY-SIDE STAND
@/@/@S@WW@W RECORD TYPE OF FLOOR SURFACE@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Linoleum/tile/wood
2 Low-pile carpet
3 High-pile carpet
4 Concrete
5 Not sure
7 Other (specify)
@/BALANCE TEST - SIDE-BY-SIDE STAND
@/@/@S@WW@W RECORD TYPE OF FLOOR SURFACE@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Linoleum/tile/wood
2 Low-pile carpet
3 High-pile carpet
4 Concrete
5 Not sure
7 Other (specify)
| | | | | | ========================================================================
| | | | | |
NV891
BALANCE TEST S-B-S Compliance
@/BALANCE TEST - SIDE-BY-SIDE STAND
@/@/@S@WW@W HOW COMPLIANT WAS R DURING THIS MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R was fully compliant
2 R was prevented from fully complying due to illness, pain, or other symptoms or discomforts
3 R was not fully compliant, but no obvious reason for this
@/BALANCE TEST - SIDE-BY-SIDE STAND
@/@/@S@WW@W HOW COMPLIANT WAS R DURING THIS MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R was fully compliant
2 R was prevented from fully complying due to illness, pain, or other symptoms or discomforts
3 R was not fully compliant, but no obvious reason for this
| | |
Else
| | | | ========================================================================
| | | |
NV893
BALANCE TEST Full Tandem Complete
@/BALANCE TEST - FULL TANDEM STAND
@/@/@S@WW@W DID R COMPLETE THE FULL TANDEM STAND? @S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
@/BALANCE TEST - FULL TANDEM STAND
@/@/@S@WW@W DID R COMPLETE THE FULL TANDEM STAND? @S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| | | |
If BALANCE TEST Full Tandem Complete (NV893) != 1 Yes »
| | | | | ========================================================================
| | | | |
NV894
BALANCE TEST Full Tandem STAND REASON NOT COMPLETE
@/BALANCE TEST - FULL TANDEM STAND
@/@/@S@WW@W WHY DIDN'T R COMPLETE THE FULL -TANDEM STAND?
@/@WW@W SELECT ALL THAT APPLY@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the test
4 R tried but was unable to complete test
5 R did not understand the instructions
6 R had surgery, injury, or other health condition that prevented R from completing the test
7 No suitable space
8 Problem with equipment or supplies
97 Other (specify)
@/BALANCE TEST - FULL TANDEM STAND
@/@/@S@WW@W WHY DIDN'T R COMPLETE THE FULL -TANDEM STAND?
@/@WW@W SELECT ALL THAT APPLY@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the test
4 R tried but was unable to complete test
5 R did not understand the instructions
6 R had surgery, injury, or other health condition that prevented R from completing the test
7 No suitable space
8 Problem with equipment or supplies
97 Other (specify)
| | | |
Else
| | | | | ========================================================================
| | | | |
NV896
BALANCE TEST FULL TANDEM Hold Full Time
@/BALANCE TEST - FULL TANDEM STAND
@/@/@S@WW@W DID R HOLD FULL TANDEM STAND FOR FULL 30.0 SECONDS WITHOUT STEPPING OUT OF PLACE OR GRABBING HOLD OF ANYTHING?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
993 R tried but was unable
999 R chose not to do it
@/BALANCE TEST - FULL TANDEM STAND
@/@/@S@WW@W DID R HOLD FULL TANDEM STAND FOR FULL 30.0 SECONDS WITHOUT STEPPING OUT OF PLACE OR GRABBING HOLD OF ANYTHING?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
993 R tried but was unable
999 R chose not to do it
| | | | |
If BALANCE TEST FULL TANDEM Hold Full Time (NV896) = 1 Yes and R CURRENT AGE CALCULATION (NA019) > 70 »
| | | | | | ========================================================================
| | | | | |
NV897
BALANCE TEST FULL TANDEM Time
@/BALANCE TEST - FULL TANDEM STAND
@/@/@S@WW@W RECORD TIME IN SECONDS TO TWO DECIMAL PLACES@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
@/BALANCE TEST - FULL TANDEM STAND
@/@/@S@WW@W RECORD TIME IN SECONDS TO TWO DECIMAL PLACES@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
| | | | |
If BALANCE TEST FULL TANDEM Hold Full Time (NV896) != 993 R tried but was unable and BALANCE TEST FULL TANDEM Hold Full Time (NV896) != 999 R chose not to do it »
| | | | | | ========================================================================
| | | | | |
NV898
BALANCE TEST FULL TANDEM Compensatory
@/BALANCE TEST - FULL TANDEM STAND
@/@/@S@WW@W DID R USE ANY COMPENSATORY MOVEMENTS OF HIS/HER TRUNK, ARMS OR LEGS TO STEADY HIM/HERSELF DURING FULL TANDEM STAND?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
@/BALANCE TEST - FULL TANDEM STAND
@/@/@S@WW@W DID R USE ANY COMPENSATORY MOVEMENTS OF HIS/HER TRUNK, ARMS OR LEGS TO STEADY HIM/HERSELF DURING FULL TANDEM STAND?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| | | | | | ========================================================================
| | | | | |
NV899
BALANCE TEST FULL TANDEM Floor Surface
@/BALANCE TEST - FULL TANDEM
@/@/@S@WW@W RECORD TYPE OF FLOOR SURFACE@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Linoleum/tile/wood
2 Low-pile carpet
3 High-pile carpet
4 Concrete
5 Not sure
7 Other (specify)
@/BALANCE TEST - FULL TANDEM
@/@/@S@WW@W RECORD TYPE OF FLOOR SURFACE@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Linoleum/tile/wood
2 Low-pile carpet
3 High-pile carpet
4 Concrete
5 Not sure
7 Other (specify)
| | | | | | ========================================================================
| | | | | |
NV902
BALANCE TEST FULL TANDEM Compliance
@/BALANCE TEST - FULL TANDEM STAND
@/@/@S@WW@W HOW COMPLIANT WAS R DURING THIS MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R was fully compliant
2 R was prevented from fully complying due to illness, pain, or other symptoms or discomforts
3 R was not fully compliant, but no obvious reason for this
@/BALANCE TEST - FULL TANDEM STAND
@/@/@S@WW@W HOW COMPLIANT WAS R DURING THIS MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R was fully compliant
2 R was prevented from fully complying due to illness, pain, or other symptoms or discomforts
3 R was not fully compliant, but no obvious reason for this
| | |
If R CURRENT AGE CALCULATION (NA019) > 64 »
| | | | ========================================================================
| | | |
NV820
WALKING TEST COMPLETE AT LEAST ONE TRIAL
@/WALKING TEST
@/@/@S@WW@W DID R COMPLETE AT LEAST ONE TRIAL OF THE WALKING TEST? @S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
@/WALKING TEST
@/@/@S@WW@W DID R COMPLETE AT LEAST ONE TRIAL OF THE WALKING TEST? @S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| | | |
If WALKING TEST COMPLETE AT LEAST ONE TRIAL (NV820) != 1 Yes »
| | | | | ========================================================================
| | | | |
NV821
WALKING TEST REASON NOT COMPLETE
@/WALKING TEST
@/@/@S@WW@W WHY DIDN`T R COMPLETE THE WALKING TEST? (SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the test
4 R tried but was unable to complete test
5 R did not understand the instructions
6 R had surgery, injury, or other health condition that prevented R from walking
7 No suitable space available
8 Problem with equipment or supplies
97 Other (specify)
@/WALKING TEST
@/@/@S@WW@W WHY DIDN`T R COMPLETE THE WALKING TEST? (SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the test
4 R tried but was unable to complete test
5 R did not understand the instructions
6 R had surgery, injury, or other health condition that prevented R from walking
7 No suitable space available
8 Problem with equipment or supplies
97 Other (specify)
| | | |
Else
| | | | | ========================================================================
| | | | |
NV823
T walk 1st trial time (seconds)
@/WALKING TEST - TIME FROM FIRST TRIAL
@/@/@S@WW@W RECORD TIME IN SECONDS TO TWO DECIMAL PLACES
@/@/@UFIRST TRIAL:@U
@/@/SECOND TRIAL:
@/@/ENTER 993 IF R WAS UNABLE TO DO IT
@/ENTER 999 IF R CHOSE NOT TO DO IT@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
@/WALKING TEST - TIME FROM FIRST TRIAL
@/@/@S@WW@W RECORD TIME IN SECONDS TO TWO DECIMAL PLACES
@/@/@UFIRST TRIAL:@U
@/@/SECOND TRIAL:
@/@/ENTER 993 IF R WAS UNABLE TO DO IT
@/ENTER 999 IF R CHOSE NOT TO DO IT@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
| | | | |
If T walk 1st trial time (seconds) (NV823) != 993 and T walk 1st trial time (seconds) (NV823) != 999 »
| | | | | | ========================================================================
| | | | | |
NV824
T walk 2nd trial time (seconds)
@/WALKING TEST - TIME FROM SECOND TRIAL
@/@/@S@WW@W RECORD TIME IN SECONDS TO TWO DECIMAL PLACES
@/@/FIRST TRIAL: T walk 1st trial time (seconds)
@/@/@USECOND TRIAL:@U
@/@/ENTER 993 IF R WAS UNABLE TO DO IT
@/ENTER 999 IF R CHOSE NOT TO DO IT@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
@/WALKING TEST - TIME FROM SECOND TRIAL
@/@/@S@WW@W RECORD TIME IN SECONDS TO TWO DECIMAL PLACES
@/@/FIRST TRIAL: T walk 1st trial time (seconds)
@/@/@USECOND TRIAL:@U
@/@/ENTER 993 IF R WAS UNABLE TO DO IT
@/ENTER 999 IF R CHOSE NOT TO DO IT@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
| | | | | | ========================================================================
| | | | | |
NV825
T walk floor surface
@/WALKING TEST
@/@/@S@WW@W RECORD TYPE OF FLOOR SURFACE@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Linoleum/tile/wood
2 Low-pile carpet
3 High-pile carpet
4 Concrete
5 Not sure
7 Other (specify)
@/WALKING TEST
@/@/@S@WW@W RECORD TYPE OF FLOOR SURFACE@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Linoleum/tile/wood
2 Low-pile carpet
3 High-pile carpet
4 Concrete
5 Not sure
7 Other (specify)
| | | | | | ========================================================================
| | | | | |
NV828
walking aid type
@/WALKING TEST
@/@/@S@WW@W RECORD TYPE OF AID USED@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 NONE
2 Walking stick or cane
3 Elbow crutches
4 Walking frame
7 Other (specify)
@/WALKING TEST
@/@/@S@WW@W RECORD TYPE OF AID USED@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 NONE
2 Walking stick or cane
3 Elbow crutches
4 Walking frame
7 Other (specify)
| | | | | | ========================================================================
| | | | | |
NV830
walk R effort
@/WALKING TEST
@/@/@S@WW@W HOW COMPLIANT WAS R DURING THIS MEASUREMENT@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R was fully compliant.
2 R was prevented from fully complying due to illness, pain, or other symptoms or discomforts
3 R was not fully compliant, but no obvious reason for this
@/WALKING TEST
@/@/@S@WW@W HOW COMPLIANT WAS R DURING THIS MEASUREMENT@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R was fully compliant.
2 R was prevented from fully complying due to illness, pain, or other symptoms or discomforts
3 R was not fully compliant, but no obvious reason for this
| | | ========================================================================
| | |
NV831
MEASURE R HEIGHT
@/HEIGHT
@/@/@S@WW@W WERE YOU ABLE TO MEASURE R`S HEIGHT? @S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
@/HEIGHT
@/@/@S@WW@W WERE YOU ABLE TO MEASURE R`S HEIGHT? @S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| | |
If MEASURE R HEIGHT (NV831) != 1 Yes »
| | | | ========================================================================
| | | |
NV832
HEIGHT REASON NOT COMPLETE
@/HEIGHT
@/@/@S@WW@W WHY WEREN'T YOU ABLE TO MEASURE R`S HEIGHT? (SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the measurement
4 R tried but was unable to complete measurement
5 R did not understand the instructions
6 R is not able to stand; other health reason
7 No suitable space available
8 Problem with equipment or supplies
9 R too tall, interviewer could not reach
97 Other (specify)
@/HEIGHT
@/@/@S@WW@W WHY WEREN'T YOU ABLE TO MEASURE R`S HEIGHT? (SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the measurement
4 R tried but was unable to complete measurement
5 R did not understand the instructions
6 R is not able to stand; other health reason
7 No suitable space available
8 Problem with equipment or supplies
9 R too tall, interviewer could not reach
97 Other (specify)
| | |
Else
| | | | ========================================================================
| | | |
NV834
HEIGHT MEASURMENT (inches)
@/HEIGHT
@/@/@S@WW@W ENTER RESPONDENT'S HEIGHT IN INCHES. ROUND TO THE NEAREST QUARTER INCH.@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..99
@/HEIGHT
@/@/@S@WW@W ENTER RESPONDENT'S HEIGHT IN INCHES. ROUND TO THE NEAREST QUARTER INCH.@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..99
| | | | ========================================================================
| | | |
NV835HEIGHTFLOORING
HEIGHT floor surface
@/HEIGHT
@/@/@S@WW@W RECORD TYPE OF FLOOR SURFACE@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Linoleum/tile/wood
2 Low-pile carpet
3 High-pile carpet
4 Concrete
5 Not sure
7 Other (specify)
@/HEIGHT
@/@/@S@WW@W RECORD TYPE OF FLOOR SURFACE@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Linoleum/tile/wood
2 Low-pile carpet
3 High-pile carpet
4 Concrete
5 Not sure
7 Other (specify)
| | | | ========================================================================
| | | |
NV837
HEIGHT wearing shoes
@/HEIGHT
@/@/@S@WW@W WAS R WEARING SHOES DURING MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
@/HEIGHT
@/@/@S@WW@W WAS R WEARING SHOES DURING MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| | | | ========================================================================
| | | |
NV903
HEIGHT wearing shoes
@/HEIGHT
@/@/@S@WW@W HOW COMPLIANT WAS R DURING THIS MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R was fully compliant
2 R was prevented from fully complying due to illness, pain, or other symptoms or discomforts
3 R was not fully compliant, but no obvious reason for this
@/HEIGHT
@/@/@S@WW@W HOW COMPLIANT WAS R DURING THIS MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R was fully compliant
2 R was prevented from fully complying due to illness, pain, or other symptoms or discomforts
3 R was not fully compliant, but no obvious reason for this
| | |
If WEIGHT IN POUNDS (NC139) < 300 »
| | | | ========================================================================
| | | |
NV838
WEIGHT ABLE TO MEASURE
@/WEIGHT
@/@/@S@WW@W WERE YOU ABLE TO MEASURE R`S WEIGHT? @S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
@/WEIGHT
@/@/@S@WW@W WERE YOU ABLE TO MEASURE R`S WEIGHT? @S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| | | |
If WEIGHT ABLE TO MEASURE (NV838) != 1 Yes »
| | | | | ========================================================================
| | | | |
NV839
WEIGHT REASON NOT COMPLETE
@/WEIGHT
@/@/@S@WW@W WHY WEREN'T YOU ABLE TO MEASURE R`S WEIGHT? (SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the measurement
4 R tried but was unable to complete the measurement
5 R did not understand the instructions
6 R is not able to stand or balance on scale; other health reason
7 No suitable space available
8 Scale did not work; other problem with equipment or supplies
97 Other (specify)
@/WEIGHT
@/@/@S@WW@W WHY WEREN'T YOU ABLE TO MEASURE R`S WEIGHT? (SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the measurement
4 R tried but was unable to complete the measurement
5 R did not understand the instructions
6 R is not able to stand or balance on scale; other health reason
7 No suitable space available
8 Scale did not work; other problem with equipment or supplies
97 Other (specify)
| | | |
Else
| | | | | ========================================================================
| | | | |
NV841
Weight Measurment (lbs)
@/WEIGHT
@/@/@S@WW@W ENTER RESPONDENT'S WEIGHT IN POUNDS AS RECORDED ON SCALE (TO THE NEAREST
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
@/WEIGHT
@/@/@S@WW@W ENTER RESPONDENT'S WEIGHT IN POUNDS AS RECORDED ON SCALE (TO THE NEAREST
- - - - - - - - - - - - - - - - - - - - - - - - -
0..1000
| | | | | ========================================================================
| | | | |
NV842
WEIGHT floor surface
@/WEIGHT
@/@/@S@WW@W RECORD TYPE OF FLOOR SURFACE@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Linoleum/tile/wood
2 Low-pile carpet
3 High-pile carpet
4 Concrete
5 Not sure
7 Other (specify)
@/WEIGHT
@/@/@S@WW@W RECORD TYPE OF FLOOR SURFACE@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Linoleum/tile/wood
2 Low-pile carpet
3 High-pile carpet
4 Concrete
5 Not sure
7 Other (specify)
| | | | | ========================================================================
| | | | |
NV844
WEIGHT wearing shoes
@/WEIGHT
@/@/@S@WW@W WAS R WEARING SHOES DURING MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
@/WEIGHT
@/@/@S@WW@W WAS R WEARING SHOES DURING MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| | | | | ========================================================================
| | | | |
NV947
WEIGHT Compliance
@/WEIGHT
@/@/@S@WW@W HOW COMPLIANT WAS R DURING THIS MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R was fully compliant
2 R was prevented from fully complying due to illness, pain, or other symptoms or discomforts
3 R was not fully compliant, but no obvious reason for this
@/WEIGHT
@/@/@S@WW@W HOW COMPLIANT WAS R DURING THIS MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R was fully compliant
2 R was prevented from fully complying due to illness, pain, or other symptoms or discomforts
3 R was not fully compliant, but no obvious reason for this
| | | ========================================================================
| | |
NV904
WAIST Complete
@/WAIST CIRCUMFERENCE
@/@/@S@WW@W WERE YOU ABLE TO MEASURE R'S WAIST CIRCUMFERENCE?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
@/WAIST CIRCUMFERENCE
@/@/@S@WW@W WERE YOU ABLE TO MEASURE R'S WAIST CIRCUMFERENCE?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| | |
If WAIST Complete (NV904) != 1 Yes »
| | | | ========================================================================
| | | |
NV905
Waist Why Not Complete
@/WAIST CIRCUMFERENCE
@/@/@S@WW@W WERE YOU ABLE TO MEASURE R'S WAIST CIRCUMFERENCE? (SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the measurement
4 R tried but was unable to complete measurement
5 R did not understand the instructions
6 R is not able to stand; other health reason
7 No suitable space available
8 Problem with equipment or supplies
97 Other (specify)
@/WAIST CIRCUMFERENCE
@/@/@S@WW@W WERE YOU ABLE TO MEASURE R'S WAIST CIRCUMFERENCE? (SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the measurement
4 R tried but was unable to complete measurement
5 R did not understand the instructions
6 R is not able to stand; other health reason
7 No suitable space available
8 Problem with equipment or supplies
97 Other (specify)
| | |
Else
| | | | ========================================================================
| | | |
NV907
Waist Measurment (inches)
@/WAIST CIRCUMFERENCE -MEASUREMENT
@/@/@S@WW@W ENTER RESPONDENT'S WAIST MEASUREMENT TO THE NEAREST QUARTER INCH.
@/@/@WW@W ENTER 993 IF R TRIED BUT WAS UNABLE TO DO IT.
@/@WW@W ENTER 999 IF R CHOSE NOT TO DO IT.@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..999
@/WAIST CIRCUMFERENCE -MEASUREMENT
@/@/@S@WW@W ENTER RESPONDENT'S WAIST MEASUREMENT TO THE NEAREST QUARTER INCH.
@/@/@WW@W ENTER 993 IF R TRIED BUT WAS UNABLE TO DO IT.
@/@WW@W ENTER 999 IF R CHOSE NOT TO DO IT.@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0..999
| | | |
If Waist Measurment (inches) (NV907) != 993 and Waist Measurment (inches) (NV907) != 999 »
| | | | | ========================================================================
| | | | |
NV908
Waist Difficulties
@/WAIST CIRCUMFERENCE -MEASUREMENT
@/@/@S@WW@W WHAT DIFFICULTIES OCCURRED DURING THIS MEASUREMENT?@S
@/@S@WW@W SELECT ALL THAT APPLY@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 None
2 R had breathing difficulties
3 R was unable to hold breath at end of exhale
4 R was prevented from giving full effort by illness, pain, or other symptoms or discomforts
5 R did not appear to give full effort, but no obvious reason for this.
6 Had difficulty or unable to locate navel
97 Other (specify)
@/WAIST CIRCUMFERENCE -MEASUREMENT
@/@/@S@WW@W WHAT DIFFICULTIES OCCURRED DURING THIS MEASUREMENT?@S
@/@S@WW@W SELECT ALL THAT APPLY@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 None
2 R had breathing difficulties
3 R was unable to hold breath at end of exhale
4 R was prevented from giving full effort by illness, pain, or other symptoms or discomforts
5 R did not appear to give full effort, but no obvious reason for this.
6 Had difficulty or unable to locate navel
97 Other (specify)
| | | | | ========================================================================
| | | | |
NV910
Waist Compliance
@/WAIST CIRCUMFERENCE
@/@/@S@WW@W HOW COMPLIANT WAS R DURING THIS MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R was fully compliant
2 R was prevented from fully complying due to illness, pain, or other symptoms or discomforts
3 R was not fully compliant, but no obvious reason for this
@/WAIST CIRCUMFERENCE
@/@/@S@WW@W HOW COMPLIANT WAS R DURING THIS MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R was fully compliant
2 R was prevented from fully complying due to illness, pain, or other symptoms or discomforts
3 R was not fully compliant, but no obvious reason for this
| | | | | ========================================================================
| | | | |
NV911
Waist Who Measured
@/WAIST CIRCUMFERENCE
@/@/@S@WW@W WHO COMPLETED THE MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R completed the measurement
2 IWER completed the measurement
@/WAIST CIRCUMFERENCE
@/@/@S@WW@W WHO COMPLETED THE MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R completed the measurement
2 IWER completed the measurement
| | | | | ========================================================================
| | | | |
NV912
Waist Bulky Clothes
@/WAIST CIRCUMFERENCE
@/@/@S@WW@W WAS R WEARING BULKY CLOTHING DURING THIS MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
@/WAIST CIRCUMFERENCE
@/@/@S@WW@W WAS R WEARING BULKY CLOTHING DURING THIS MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| | ========================================================================
| |
NV913
Saliva Consent
@/@SSALIVA SAMPLE@S
@/@/@S@WW@W DID R SIGN THE CONSENT FORM FOR THE SALIVA SAMPLE?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
@/@SSALIVA SAMPLE@S
@/@/@S@WW@W DID R SIGN THE CONSENT FORM FOR THE SALIVA SAMPLE?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| |
If Saliva Consent (NV913) = 5 No »
| | | ========================================================================
| | |
NV941
Why No Consent Saliva
@/@SSALIVA SAMPLE @S
@/@/@S@WW@W WHY DIDN'T R SIGN THE SALIVA CONSENT FORM? (SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the measurement
4 R tried but was unable to complete measurement
5 R did not understand the instructions
6 R could not complete the measurement due to health reasons
7 No suitable space
8 R ate, drank, smoked, or brushed teeth in last 30 minutes
97 Other (specify)
@/@SSALIVA SAMPLE @S
@/@/@S@WW@W WHY DIDN'T R SIGN THE SALIVA CONSENT FORM? (SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the measurement
4 R tried but was unable to complete measurement
5 R did not understand the instructions
6 R could not complete the measurement due to health reasons
7 No suitable space
8 R ate, drank, smoked, or brushed teeth in last 30 minutes
97 Other (specify)
| |
Else
| | | ========================================================================
| | |
NV915
Saliva Complete
@/SALIVA SAMPLE
@/@/@S@WW@W DID R COMPLETE THE SALIVA SAMPLE?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
@/SALIVA SAMPLE
@/@/@S@WW@W DID R COMPLETE THE SALIVA SAMPLE?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| | |
If Saliva Complete (NV915) != 1 Yes »
| | | | ========================================================================
| | | |
NV916
Saliva Why Not Complete
@/SALIVA SAMPLE
@/@/@S@WW@W WHY DIDN'T R COMPLETE THE SALIVA SAMPLE? (SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the measurement
4 R tried but was unable to complete measurement
5 R did not understand the instructions
6 R could not complete the measurement due to health problems
7 No suitable space available
8 Problem with equipment or supplies
97 Other (specify)
@/SALIVA SAMPLE
@/@/@S@WW@W WHY DIDN'T R COMPLETE THE SALIVA SAMPLE? (SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the measurement
4 R tried but was unable to complete measurement
5 R did not understand the instructions
6 R could not complete the measurement due to health problems
7 No suitable space available
8 Problem with equipment or supplies
97 Other (specify)
| | |
Else
| | | | ========================================================================
| | | |
NV918
Saliva Fill Vial
@/SALIVA SAMPLE
@/@/@S@WW@W DID R FILL THE VIAL TO THE DESIRED LEVEL?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
@/SALIVA SAMPLE
@/@/@S@WW@W DID R FILL THE VIAL TO THE DESIRED LEVEL?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| | | | ========================================================================
| | | |
NV919
Saliva Problems
@/SALIVA SAMPLE
@/@/@S@WW@W WHAT, IF ANY, PROBLEMS OCCURED?
@/(SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 None
2 Solution in cover leaked before vial was sealed
3 Saliva spilled
4 R was unable to produce enough saliva
5 Collection container leaked; other problem with equipment or supplies
97 Other (specify)
@/SALIVA SAMPLE
@/@/@S@WW@W WHAT, IF ANY, PROBLEMS OCCURED?
@/(SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 None
2 Solution in cover leaked before vial was sealed
3 Saliva spilled
4 R was unable to produce enough saliva
5 Collection container leaked; other problem with equipment or supplies
97 Other (specify)
| | | | ========================================================================
| | | |
NV921
Saliva Compliance
@/SALIVA SAMPLE
@/@/@S@WW@W HOW COMPLIANT WAS R DURING THIS MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R was fully compliant
2 R was prevented from fully complying due to illness, pain, or other symptoms or discomforts
3 R was not fully compliant, but no obvious reason for this
@/SALIVA SAMPLE
@/@/@S@WW@W HOW COMPLIANT WAS R DURING THIS MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R was fully compliant
2 R was prevented from fully complying due to illness, pain, or other symptoms or discomforts
3 R was not fully compliant, but no obvious reason for this
| | ========================================================================
| |
NV922
BLOOD Consent
@/@SBLOOD SAMPLE@S
@/@/@S@WW@W DID R SIGN THE BLOOD SAMPLE CONSENT FORM?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
@/@SBLOOD SAMPLE@S
@/@/@S@WW@W DID R SIGN THE BLOOD SAMPLE CONSENT FORM?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| |
If BLOOD Consent (NV922) = 5 No »
| | | ========================================================================
| | |
NV943
Why No Consent Blood
@/@SBLOOD SAMPLE@S
@/@/@S@WW@W WHY DIDN'T R SIGN THE BLOOD CONSENT FORM? (SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the measurement
4 R tried but was unable to complete measurement
5 R did not understand the instructions
6 R has hemophilia or is on medication that thins the blood (anticoagulant); other health reason
7 No suitable space
8 R ate, drank, smoked, or brushed teeth in last 30 minutes
97 Other (specify)
@/@SBLOOD SAMPLE@S
@/@/@S@WW@W WHY DIDN'T R SIGN THE BLOOD CONSENT FORM? (SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the measurement
4 R tried but was unable to complete measurement
5 R did not understand the instructions
6 R has hemophilia or is on medication that thins the blood (anticoagulant); other health reason
7 No suitable space
8 R ate, drank, smoked, or brushed teeth in last 30 minutes
97 Other (specify)
| |
Else
| | | ========================================================================
| | |
NV923
Blood Complete
@/BLOOD SAMPLE
@/@/@S@WW@W DID R COMPLETE THE BLOOD SAMPLE?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
@/BLOOD SAMPLE
@/@/@S@WW@W DID R COMPLETE THE BLOOD SAMPLE?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
5 No
| | |
If Blood Complete (NV923) != 1 Yes »
| | | | ========================================================================
| | | |
NV924
Blood Why Not Complete
@/BLOOD SAMPLE
@/@/@S@WW@W WHY DIDN'T R COMPLETE THE BLOOD SAMPLE? (SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the measurement
4 R tried but was unable to complete measurement
5 R did not understand the instructions
6 R has hemophilia or is on medication that thins the blood (anticoagulant); other health reason
7 No suitable space
8 Problem with equipment or supplies
97 Other (specify)
@/BLOOD SAMPLE
@/@/@S@WW@W WHY DIDN'T R COMPLETE THE BLOOD SAMPLE? (SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R felt it would not be safe
2 IWER felt it would not be safe
3 R refused or was not willing to complete the measurement
4 R tried but was unable to complete measurement
5 R did not understand the instructions
6 R has hemophilia or is on medication that thins the blood (anticoagulant); other health reason
7 No suitable space
8 Problem with equipment or supplies
97 Other (specify)
| | |
Else
| | | | ========================================================================
| | | |
NV926
Blood What Problems
@/BLOOD SAMPLE
@/@/@S@WW@W WHAT, IF ANY, PROBLEMS OCCURRED DURING THE COLLECTION OF THE BLOOD SAMPLE?
@/(SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 None
2 R became lightheaded, fainted, or became nauseous
3 R had difficulty getting finger to stop bleeding
4 Unable to obtain enough blood
5 Problem with equipment or supplies
97 Other (specify)
@/BLOOD SAMPLE
@/@/@S@WW@W WHAT, IF ANY, PROBLEMS OCCURRED DURING THE COLLECTION OF THE BLOOD SAMPLE?
@/(SELECT ALL THAT APPLY)@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 None
2 R became lightheaded, fainted, or became nauseous
3 R had difficulty getting finger to stop bleeding
4 Unable to obtain enough blood
5 Problem with equipment or supplies
97 Other (specify)
| | | | ========================================================================
| | | |
NV928
Blood Who Measured
@/BLOOD SAMPLE
@/@/@S@WW@W WHO PRICKED THE R'S FINGER(S)?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R pricked own finger(s)
2 IWER pricked R's finger(s)
3 Both R and Iwer pricked R
@/BLOOD SAMPLE
@/@/@S@WW@W WHO PRICKED THE R'S FINGER(S)?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R pricked own finger(s)
2 IWER pricked R's finger(s)
3 Both R and Iwer pricked R
| | | | ========================================================================
| | | |
NV929
Blood Fill Spots
@/BLOOD SAMPLE
@/@/@S@WW@W HOW MANY CIRCLES WERE FILLED ON THE FIRST CARD? @S
- - - - - - - - - - - - - - - - - - - - - - - - -
0 Zero
1 One
2 Two
3 Three
@/BLOOD SAMPLE
@/@/@S@WW@W HOW MANY CIRCLES WERE FILLED ON THE FIRST CARD? @S
- - - - - - - - - - - - - - - - - - - - - - - - -
0 Zero
1 One
2 Two
3 Three
| | | | ========================================================================
| | | |
NV945
Blood Fill Spots
@/BLOOD SAMPLE
@/@/@S@WW@W HOW MANY CIRCLES WERE FILLED ON THE STORAGE CARD?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0 Zero
1 One
2 Two
3 Three
@/BLOOD SAMPLE
@/@/@S@WW@W HOW MANY CIRCLES WERE FILLED ON THE STORAGE CARD?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
0 Zero
1 One
2 Two
3 Three
| | | | ========================================================================
| | | |
NV930
Blood Pricks
@/BLOOD SAMPLE
@/@/@S@WW@W HOW MANY TIMES DID THE R'S FINGER HAVE TO BE PRICKED IN ORDER TO FILL THE CARDS?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 One time
2 Two times
3 Two times but the R was unable to fill all of the collection areas
@/BLOOD SAMPLE
@/@/@S@WW@W HOW MANY TIMES DID THE R'S FINGER HAVE TO BE PRICKED IN ORDER TO FILL THE CARDS?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 One time
2 Two times
3 Two times but the R was unable to fill all of the collection areas
| | | | ========================================================================
| | | |
NV931
Blood Compliance
@/BLOOD SAMPLE
@/@/@S@WW@W HOW COMPLIANT WAS R DURING THIS MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R was fully compliant
2 R was prevented from fully complying due to illness, pain, or other symptoms or discomforts
3 R was not fully compliant, but no obvious reason for this
@/BLOOD SAMPLE
@/@/@S@WW@W HOW COMPLIANT WAS R DURING THIS MEASUREMENT?@S
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R was fully compliant
2 R was prevented from fully complying due to illness, pain, or other symptoms or discomforts
3 R was not fully compliant, but no obvious reason for this
End of I. Physical Measures