I_BM. BIOMARKERS (BM)

I_BM. BIOMARKERS (BM) of LASI pilot 2016

item label type description
BM001 Question [Equipment needed: Omron HEM-780N Monitor, Batteries, Stopwatch] I would like to measure your blood pressure and pulse using this monitor and cuff which I will secure around your left arm. I would like to take three blood pressure measures. I will ask you to relax and remain seated and quiet, with legs uncrossed and feet flat on the floor, during the measurements. First, I will place the cuff on your left arm. Once the cuff is placed appropriately on your arm and we are ready to begin, I will ask you to lay your arm on a flat surface, palm facing up, so that the center of your upper arm is at the same height as your heart. I will then press the start button. The cuff will inflate and deflate automatically. It will squeeze your arm a bit, but won't hurt. After we have completed all three measures, I will give you your results. Do you understand these directions and are you willing to provide this measurement?
BM002 Question Did you smoke, exercise, or consume alcohol or food within the 30 minutes prior the blood pressure test?
BM003 Question Do you have a rash, a cast, edema (swelling) in the left arm, open sores or wounds, or a significant bruise where the blood pressure cuff will be in contact?
BM004 Question [Ask only if BM003=1]Do you have a rash, a cast, edema (swelling) in the right arm, open sores or wounds, or a significant bruise where the blood pressure cuff will be in contact?
BM005_intro Question When the device is in the correct position and the R is relaxed, press the button to Start. Measure blood pressure and pulse three times with one minute gap between each of the measurements. No need to remove the cuffs and the device between the measurements. Record measurements in chart: (Enter 993 in first systolic reading if R tried but was unable to do it/if an unresolvable equipment problem occurs. Enter 999 if R chose not to do it.) If the lowest reading obtained is greater than 140 systolic or greater than 90 diastolic, fill out the High-Blood Pressure Card and leave it with the respondent. [Soft Check: Systolic: BM006=>90 or =<250; BM010=>90 or =<250; BM014=>90 or =<250] [Diastolic: BM007=>40 or =<150; BM011=>40 or =<150; BM015=>40 or<=150] [Pulse: BM008, BM012, BM016=>60 or <=150] [Hard check: BM006
BM005 Question Time of Reading __ __:__ __ am/pm
BM006 Question Systolic Reading ___ mmHg
BM007 Question Diastolic Reading ___ mmHg
BM008 Question Pulse ___ Beats/min
BM009 Question Time of Reading __ __:__ __ am/pm
BM010 Question Systolic Reading___ mmHg
BM011 Question Diastolic Reading___mmHg
BM012 Question Pulse ___ Beats/min
BM013 Question Time of Reading __ __:__ __ am/pm
BM014 Question Systolic Reading___ mmHg
BM015 Question Diastolic Reading___mmHg
BM016 Question Pulse ___ Beats/min
BM017 Question Systolic Reading ___mmHg
BM018 Question Diastolic Reading ___mmHg
BM019 Question Pulse __ Beats/min
BM020 Question Which arm was used to conduct the measurements?
BM021 Question What was R's position for this test?
BM022 Question How compliant was R during this measurement?
BM023 Question [Equipment needed: Dynamometer, Stopwatch] Now I would like to assess the strength of your hand in a gripping action. I will ask you to squeeze this handle as hard as you can, just for a couple of seconds and then let go. I will take alternately two measurements from your right and your left hand. Begin the test with the left hand.
BM024 Question Before we begin, I would like to make sure it is safe for you to do this measurement. Have you had surgery or experienced any swelling, inflammation, severe pain, or injury in one or both hands within the last 6 months?
BM025 Question In which hand (have you had surgery or experienced any swelling, inflammation, severe pain, or injury in the last 6 months)?
BM026 Question Which is your dominant hand?
BM027_intro Question [Note: Conduct one practice with R's [right/left] hand]: We can practice with your [right/left] hand Start measurement from Left hand first. Take 30 second-rests between two measurements. Record measurements to the nearest 0.5 kilogram in the table below. Record 993 if R tried but was unable/if an irresolvable equipment problem occurs. Record 999 if R chose not to do it] [Soft check: BM028, BM029, BM030, BM031 =>5 or <= 60 kg][Hard check: There should be a 30 second gap between each reading]
BM028 Question 1st Left hand [(Ask if BM024=1 & BM025=3) or BM024=2] ____._ kg
BM029 Question 1st Right Hand [(Ask if BM024=1 & BM025=2) or BM024=2] ____._ kg
BM030 Question 2nd Left hand [(Ask if BM024=1 & BM025=3) or BM024=2] ____._ kg
BM031 Question 2nd Right Hand [(Ask if BM024=1 & BM025=2) or BM024=2] ____._ kg
BM032 Question How much effort did R give to this test?
BM033 Question What was R's position for this test?
BM034 Question Did R rest their arm on a support while performing the test?
BM035 Question [Equipment needed: Stopwatch, Show Card] I would now like you to try to stand in different positions. I will first describe and show each position to you. Then, I would like you to try to do it. If you cannot do a particular position, or if you feel it would be unsafe to try to do it, tell me and we will move on to the next one. Let me emphasize that I do not want you to try to do any activity that you feel might be unsafe. For the first one, I want you to try to stand with the side of the heel of one foot touching the big toe of the other foot for about 10 seconds. You may put either foot in front, whichever is more comfortable for you. Like this... Demonstrate the measurement. Stand and place the heel of one foot touching the big toe of the other foot.
BM036 Question Before we begin, do you have any problems from recent surgery, injury or other health conditions that might prevent you from standing up from a chair and balancing?
BM037 Question Discuss with him/her whether s/he should attempt each measurement given his/her physical problems after describing each measurement. Do not assume a respondent is too physically limited to attempt a measurement without discussing it with him/her. Do you understand these directions and are willing to provide this measurement?
BM038 Question Did R hold semi-tandem stand for a full 10 seconds without stepping out of place or grabbing hold of anything?
BM040 Question Did R use any compensatory movements of his/her trunk, arms or legs to steady him/herself during semi-tandem stand?
BM041 Question [Equipment needed: Stopwatch, Show Card] Now I will show you next movement. I want you to try to stand with your feet together, side-by-side for about 10 seconds. You may use your arms, bend your knees, or move your body to maintain your balance, but try not to move your feet. Try to hold this position until I tell you to stop. Like this... Demonstrate the measurement Stand with feet together. Do you understand these directions and are you willing to do this test?
BM042 Question Did R hold side-by-side stand for a full 10 seconds without stepping out of place or grabbing hold of anything?
BM044 Question Did R use any compensatory movements of his/her trunk, arms or legs to steady him/herself during side-by-side stand?
BM045 Question Record the type of floor surface that the balance measures were conducted on.
BM046 Question How compliant was R during the balance measurement?
BM047 Question [Equipment needed: Stopwatch, Show Card] Record eligible time If R's age is >=70, tandem time is 30 seconds. If R's age is <70, tandem time is 60 seconds. The full-tandem time for which R is eligible:
BM048 Question Now I want you to try to stand with the heel of one foot in front of and touching the toes of the other foot for about [30/60] seconds. You may put either foot in front, whichever is more comfortable for you. You may use your arms, bend your knees, or move your body to maintain your balance, but try not to move your feet. Try to hold this position until I tell you to stop. Like this.. Demonstrate the measurement. Stand and place the heel of one foot touching the toes of the other foot. Do you understand these directions and are you willing to do this test?
BM049_IWER Question Did R hold full-tandem stand for a full [30/60] seconds without stepping out of place or grabbing hold of anything?
BM051_IWER Question Did R use any compensatory movements of his/her trunk, arms or legs to steady him/herself during the full-tandem stand?
BM052 Question Record the type of floor surface that the balance measures were conducted on.
BM053_IWER Question How compliant was R during the balance measurements?
BM054 Question Next, I would like to assess whether you can walk a very short distance comfortably (using a walking stick or other aid if necessary). First, I want to make sure it is safe to carry out the measurement. Do you have any problems from recent surgery, injury, or other health conditions that might prevent you from walking?
BM055 Question Now let's find a place where we can conduct the measurement. We will need a clear space about 4 meters long in a non-carpeted area, if possible. I'm going to place the measuring tape alongside the space where the walk will take place. Set up the course (4meters) This is our walking course. I am going to time you as you walk the course. I will be asking you to walk the course two times. I will walk along side you the whole time during the measurement. Now, I would like to demonstrate how to do the measurement. You will start by lining your feet up at the starting point. Demonstrate the measurement Do you understand these directions and are you willing to do this test?
BM056_ intr... Question I will be asking you to walk the course at your usual pace a total of two times. I will walk alongside you the whole time during the measurement. I would like you to stand here with your feet lined up. Start walking when I say ÒBeginÓ. Walk all the way past the other end of the tape before you stop. Are you ready to go now? Begin. [Repeat the measurement]: ÒNow I want you to repeat the walk. Remember to walk at your usual pace and go all the way past the other end of the course. I would like you to stand here with your feet lined up. Start walking when I say ÒBeginÓ. Are you ready to go now? Begin. [Instructions for Interviewer: Record measurements in table below. Record 993 if R tried but was unable. Record 999 if R chose not to do it.] [Record up to 2 decimal points: Example 10.15 seconds]
BM056 Question 1st Walking Speed Time ___.__ seconds
BM057 Question 2nd Walking Speed Time ___.__ seconds
BM058 Question Record type of aid used
BM059 Question How compliant was R during this measurement?
BM060 Question [Equipment needed: CAPI, Flexible steel measuring tape, Sticky tape] We are now going to test your distance vision and near vision. Can you see light and count the fingers of hand held 2 feet in front of your face with one eye open and when wearing your glasses or contacts?
BM060a Question Left
BM060b Question Right
BM061_Intro Question [Distance vision] [Instructions for Interviewer: Start with using CAPI screen placed at 3 meters distance] We will start with your distance vision - and with your left eye. Would you please cover your Right eye with the palm of your Right- hand? Indicate if the "E" is facing Up, Down, Left or Right. Please read .. [Instructions for Interviewer: Set the Mini Laptop (CAPI Device) at eye level. For the displayed orientations, mark the responses given by 'R', as ÒcorrectÓ or ÒincorrectÓ. Once the test is completed the test results will be displayed on CAPI device & recorded automatically] Now please cover your left eye with your left-hand so we can test your right eye. Please read... [Instruction for CAPI: Record acuity in BM061-BM062
BM061 Question Distance Vision - Left Eye Distance Vision
BM062 Question Distance Vision - Right Eye Distance Vision
BM063_Intro Question Okay, now we would like to test your near vision at 40cm - starting again with your Left eye - please cover your Right eye with your Right hand. Indicate if the "E" is facing up, down, left or right. Please read... Now cover your left eye with your left hand so I can test your right eye. Please read... [Ask respondent to stand or sit 40 centimetres from the monitor. Set the Mini Laptop (CAPI Device) at eye level. Then place the palm over the eye with the same hand. Responses will be verbal (Up, Down, Left, Right). Interviewer will mark correct or incorrect response] [Instruction for CAPI: Record acuity in BM063-BM064]
BM063 Question Near Vision - Left Eye Near Vision
BM064 Question Near Vision - Right Eye Near Vision
BM065 Question How compliant was R during this measurement?
BM066 Question [Equipment needed: Stadiometer] Can the respondent stand?
BM067 Question Record R's height in centimetres __._ cm [Hard check: 50>=BM067>250]
BM068 Question Was R wearing any artificial limbs or orthosis during the measurement?
BM069 Question How compliant was R during this measurement?
BM070 Question [Equipment needed: Weighing Scale] Next, I would like to measure your weight. To complete this measurement, I will be asking you to remove bulky clothing and to take off your shoes during weight measurements. Stand up and look straight ahead. [Instruction for Interviewer: Demonstrate the measurement]
BM071 Question [Instruction for Interviewer: Record measurement in kilograms in table below: Enter 993 if R tried but received an error message. Record R's weight up to 2 decimal points] ___._ _ [Soft check: 25<=BM071<=250]
BM072 Question Was R wearing an artificial limb or orthosis during the measurement?
BM074 Question How compliant was R during this measurement?
BM075 Question [Equipment needed: Soft tape measure] Next I am going to ask you to perform a simple measurement of your waist circumference. For this measurement it is important for you to be standing. I will ask you to identify where on your body your navel (belly button) is located. I will then ask you to place this soft measuring tape around your waist, over your clothing, holding it securely at the level of your navel. Once the tape measure is placed appropriately around your waist then we are ready to begin. I will ask you to take a normal breath and exhale, holding your breath at the end of the exhale. I will then record the measurement.
BM076_intro Question Record measurement in table below: Enter 999 if R chose not to do it. Record R's waist circumference to the nearest 0.1 cm
BM076 Question Waist Measurement ______ [Soft check: BM076 >=50 or <150]
BM077 Question Was R wearing bulky clothing during this measurement?
BM078 Question [Equipment needed: Soft tape measure] Next I am going to ask you to perform a simple measurement of your hip circumference. For this measurement it is important for you to be standing. I will ask you to identify where the maximum circumference of your hip. I will then ask you to place this soft measuring tape around your hip, over your clothing, holding it securely. Once the tape measure is placed appropriately around your hip and parallel to floor then we are ready to begin. I will ask you to take a normal breath and exhale, holding your breath at the end of the exhale. I will then record the measurement.
BM079 Question Record measurement in table below: Enter 999 if R chose not to do it. Record R's Hip Circumference to the nearest 0.1 cm ______ [BM079>=50 or <150]
BM080 Question What difficulties occurred during this measurement? [Multiple answers are allowed][Instructions for CAPI: if BM080=a then freeze other options]
BM081 Question Who conducted this measurement?
BM082 Question Do you have any of the following condition? [Instruction for CAPI: If any of questions BM082a to BM082e=1, then skip to BM088]
BM082a Question Active Tb or Upper Respiratory tract infection (cough)
BM082b Question Eye surgery in last 3months
BM082c Question Abdominal Surgery in last 3 months
BM082d Question Myocardial Infarction in last 3 month
BM082e Question [If DM003 =2 & DM005 < 55] Pregnancy ( any trimester)
BM083 Question Have you used any Inhalers in the last 6 hours?
BM084 Question [Equipment needed: Spirometer, Disposable mouthpiece] Next I am going to ask you to perform a simple task of taking a deep breath and then blowing as long and hard as you can into a small tube attached to this machine. The machine measures how long it takes you to blow out all the air from your lungs. I would like you to perform the measurement few times. When we are ready to begin, I will ask you to sit up straight. Open your mouth and close your lips firmly around the outside of the mouthpiece. Take as deep a breath as possible and then blow as hard and as fast as you can into the mouth piece followed by deep inhalation again like this.... Demonstrate the measurement. Sit up, place lips around the outside of the mouth piece. Take a deep breath, and then blow as hard and as fast as you can. Do you understand these directions and are you willing to provide this measurement?
BM085 Question [Instruction for Interviewer: CAPI should be connected with Spirometry instrument. Perform the test; and the spirometry readings will be automatically recorded in the CAPI] [Instruction for Interviewer: Step1: CAPI should be connected with Spirometry inst
BM086 Question What was R's position for this test?
BM087 Question How much effort did R give to this test?
BM088 Question I would like to collect a small sample of your blood using just a finger prick. We would be very grateful if you would agree to provide us with a sample of blood. This is an important part of the study, as the analysis of blood samples will tell us a lot about the health of the population. Before we begin, I would like to read this consent form. Longitudinal Ageing Study in India (LASI) International Institute for Population Sciences (IIPS) Additional Consent Form for Blood Sample Collection for Storage and Future Use This is in continuation with your individual consent that you have already given. Further, we would like to inform you that as a part of this longitudinal ageing study, we want to collect few drops of your blood sample using finger prick. The blood sample will be used to test anemia, diabetes, and chronic infections. Your blood sample will be extremely useful to plan special health care services for the older population in the country. The test uses new, disposable sterile instruments that are clean and completely safe in use. I will prick your finger to draw few drops of blood. These drops will be soaked on a piece of filter paper. These pieces of paper will be used to check various health conditions. The blood sample will be sent to National AIDS Research Institute (NARI), which is a premier institute devoted to health research for analysis and storage. The information you will provide will be kept strictly confidential. The results of the blood test will only be used for research and planning purposes without any personal identification. However, if you decide not to provide a blood sample, it is your right and we will respect your decision. Should you have any question about the survey please feel free to ask me or contact the concerned authority (Interviewer: Provide Card). Director / Project Coordinators International Institute for Population Sciences (IIPS) Govandi Station Road, Deonar, Mumbai-400 088. Tel: 022-42372-682/ 401/ 682/ 417/ 422, Fax: 022-42372401. Do you agree to provide consent for giving few drops of blood sample? (Circle one of the response)
BM089_intro Question [Equipment needed: Black spread sheet, DBS Kit, Gloves, Small Biohazard Container, Barcode Scanner and Barcode label, drying rack with Box]
BM089 Question Date ___date(dd/mm/yyyy)
BM090 Question Time ____:____ am/pm(12hour clock
BM091 Question Instructions for IWER:Step 1. Scan the barcode. Step 2. Enter the Barcode number twice: BM091a & BM091b CAPI will check BM091a=Bm091b If not, re-enter.BM091a Sample Barcode number:______BM091b Sample Barcode number:______[BM091 up to 14 digits]
BM092 Question What, if any, problems occurred during the collection of the blood sample? [Multiple answers are allowed] [Instruction for CAPI: BM092=a then freeze other options]
BM093 Question How many circles were filled on the DBS card?
BM094 Question [For the Health Investigator]DBS quality assessment by the health investigator, which is to be completed after they have collected blood spots. What is the quality of the blood spots that have been collected?
BM095 Question How many times did the R's finger need to be pricked in order to get 5 drops of blood?
BM096 Question How compliant was R during this measurement?
BM097 Question Thank you for your cooperation. This concludes the physical measure and biomarkers portion of the survey.
Start of I_BM. BIOMARKERS (BM)
 
BM001

[Equipment needed: Omron HEM-780N Monitor, Batteries, Stopwatch] I would like to measure your blood pressure and pulse using this monitor and cuff which I will secure around your left arm. I would like to take three blood pressure measures. I will ask you to relax and remain seated and quiet, with legs uncrossed and feet flat on the floor, during the measurements. First, I will place the cuff on your left arm. Once the cuff is placed appropriately on your arm and we are ready to begin, I will ask you to lay your arm on a flat surface, palm facing up, so that the center of your upper arm is at the same height as your heart. I will then press the start button. The cuff will inflate and deflate automatically. It will squeeze your arm a bit, but won't hurt. After we have completed all three measures, I will give you your results. Do you understand these directions and are you willing to provide this measurement?

[EQUIPMENT NEEDED: OMRON HEM-780N MONITOR, BATTERIES, STOPWATCH] I WOULD LIKE TO MEASURE YOUR BLOOD PRESSURE AND PULSE USING THIS MONITOR AND CUFF WHICH I WILL SECURE AROUND YOUR LEFT ARM. I WOULD LIKE TO TAKE THREE BLOOD PRESSURE MEASURES. I WILL ASK YOU TO RELAX AND REMAIN SEATED AND QUIET, WITH LEGS UNCROSSED AND FEET FLAT ON THE FLOOR, DURING THE MEASUREMENTS. FIRST, I WILL PLACE THE CUFF ON YOUR LEFT ARM. ONCE THE CUFF IS PLACED APPROPRIATELY ON YOUR ARM AND WE ARE READY TO BEGIN, I WILL ASK YOU TO LAY YOUR ARM ON A FLAT SURFACE, PALM FACING UP, SO THAT THE CENTER OF YOUR UPPER ARM IS AT THE SAME HEIGHT AS YOUR HEART. I WILL THEN PRESS THE START BUTTON. THE CUFF WILL INFLATE AND DEFLATE AUTOMATICALLY. IT WILL SQUEEZE YOUR ARM A BIT, BUT WON'T HURT. AFTER WE HAVE COMPLETED ALL THREE MEASURES, I WILL GIVE YOU YOUR RESULTS. DO YOU UNDERSTAND THESE DIRECTIONS AND ARE YOU WILLING TO PROVIDE THIS MEASUREMENT?
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If [Equipment needed: Omron HEM-780N Monitor, Batteries, Stopwatch] I would like to measure your blood pressure and pulse using this monitor and cuff which I will secure around your left arm. I would like to take three blood pressure measures. I will ask you to relax and remain seated and quiet, with legs uncrossed and feet flat on the floor, during the measurements. First, I will place the cuff on your left arm. Once the cuff is placed appropriately on your arm and we are ready to begin, I will ask you to lay your arm on a flat surface, palm facing up, so that the center of your upper arm is at the same height as your heart. I will then press the start button. The cuff will inflate and deflate automatically. It will squeeze your arm a bit, but won't hurt. After we have completed all three measures, I will give you your results. Do you understand these directions and are you willing to provide this measurement? = 1 Yes 2 No  »
 
   
 
BM002

Did you smoke, exercise, or consume alcohol or food within the 30 minutes prior the blood pressure test?

DID YOU SMOKE, EXERCISE, OR CONSUME ALCOHOL OR FOOD WITHIN THE 30 MINUTES PRIOR THE BLOOD PRESSURE TEST?
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BM003

Do you have a rash, a cast, edema (swelling) in the left arm, open sores or wounds, or a significant bruise where the blood pressure cuff will be in contact?

DO YOU HAVE A RASH, A CAST, EDEMA (SWELLING) IN THE LEFT ARM, OPEN SORES OR WOUNDS, OR A SIGNIFICANT BRUISE WHERE THE BLOOD PRESSURE CUFF WILL BE IN CONTACT?
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If Do you have a rash, a cast, edema (swelling) in the left arm, open sores or wounds, or a significant bruise where the blood pressure cuff will be in contact? = 1 Yes 2 No  »
 
     
   
BM004

[Ask only if BM003=1]Do you have a rash, a cast, edema (swelling) in the right arm, open sores or wounds, or a significant bruise where the blood pressure cuff will be in contact?

[ASK ONLY IF BM003=1]DO YOU HAVE A RASH, A CAST, EDEMA (SWELLING) IN THE RIGHT ARM, OPEN SORES OR WOUNDS, OR A SIGNIFICANT BRUISE WHERE THE BLOOD PRESSURE CUFF WILL BE IN CONTACT?
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If [Ask only if BM003=1]Do you have a rash, a cast, edema (swelling) in the right arm, open sores or wounds, or a significant bruise where the blood pressure cuff will be in contact? = 2 »
 
       
     
BM005

Time of Reading __ __:__ __ am/pm

TIME OF READING __ __:__ __ AM/PM
       
     
BM006

Systolic Reading ___ mmHg

SYSTOLIC READING ___ MMHG
       
     
BM007

Diastolic Reading ___ mmHg

DIASTOLIC READING ___ MMHG
       
     
BM008

Pulse ___ Beats/min

PULSE ___ BEATS/MIN
       
     
BM009

Time of Reading __ __:__ __ am/pm

TIME OF READING __ __:__ __ AM/PM
       
     
BM010

Systolic Reading___ mmHg

SYSTOLIC READING___ MMHG
       
     
BM011

Diastolic Reading___mmHg

DIASTOLIC READING___MMHG
       
     
BM012

Pulse ___ Beats/min

PULSE ___ BEATS/MIN
       
     
BM013

Time of Reading __ __:__ __ am/pm

TIME OF READING __ __:__ __ AM/PM
       
     
BM014

Systolic Reading___ mmHg

SYSTOLIC READING___ MMHG
       
     
BM015

Diastolic Reading___mmHg

DIASTOLIC READING___MMHG
       
     
BM016

Pulse ___ Beats/min

PULSE ___ BEATS/MIN
       
     
BM017

Systolic Reading ___mmHg

SYSTOLIC READING ___MMHG
       
     
BM018

Diastolic Reading ___mmHg

DIASTOLIC READING ___MMHG
       
     
BM019

Pulse __ Beats/min

PULSE __ BEATS/MIN
       
     
BM020

Which arm was used to conduct the measurements?

WHICH ARM WAS USED TO CONDUCT THE MEASUREMENTS?
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BM021

What was R's position for this test?

WHAT WAS R'S POSITION FOR THIS TEST?
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BM022

How compliant was R during this measurement?

HOW COMPLIANT WAS R DURING THIS MEASUREMENT?
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BM023

[Equipment needed: Dynamometer, Stopwatch] Now I would like to assess the strength of your hand in a gripping action. I will ask you to squeeze this handle as hard as you can, just for a couple of seconds and then let go. I will take alternately two measurements from your right and your left hand. Begin the test with the left hand.

[EQUIPMENT NEEDED: DYNAMOMETER, STOPWATCH] NOW I WOULD LIKE TO ASSESS THE STRENGTH OF YOUR HAND IN A GRIPPING ACTION. I WILL ASK YOU TO SQUEEZE THIS HANDLE AS HARD AS YOU CAN, JUST FOR A COUPLE OF SECONDS AND THEN LET GO. I WILL TAKE ALTERNATELY TWO MEASUREMENTS FROM YOUR RIGHT AND YOUR LEFT HAND. BEGIN THE TEST WITH THE LEFT HAND.
 
BM024

Before we begin, I would like to make sure it is safe for you to do this measurement. Have you had surgery or experienced any swelling, inflammation, severe pain, or injury in one or both hands within the last 6 months?

BEFORE WE BEGIN, I WOULD LIKE TO MAKE SURE IT IS SAFE FOR YOU TO DO THIS MEASUREMENT. HAVE YOU HAD SURGERY OR EXPERIENCED ANY SWELLING, INFLAMMATION, SEVERE PAIN, OR INJURY IN ONE OR BOTH HANDS WITHIN THE LAST 6 MONTHS?
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If Before we begin, I would like to make sure it is safe for you to do this measurement. Have you had surgery or experienced any swelling, inflammation, severe pain, or injury in one or both hands within the last 6 months? = 1 Yes 2 No  »
 
   
 
BM025

In which hand (have you had surgery or experienced any swelling, inflammation, severe pain, or injury in the last 6 months)?

IN WHICH HAND (HAVE YOU HAD SURGERY OR EXPERIENCED ANY SWELLING, INFLAMMATION, SEVERE PAIN, OR INJURY IN THE LAST 6 MONTHS)?
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BM026

Which is your dominant hand?

WHICH IS YOUR DOMINANT HAND?
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If (Before we begin, I would like to make sure it is safe for you to do this measurement. Have you had surgery or experienced any swelling, inflammation, severe pain, or injury in one or both hands within the last 6 months? = 1 Yes 2 No and In which hand (have you had surgery or experienced any swelling, inflammation, severe pain, or injury in the last 6 months)? = 3) or Before we begin, I would like to make sure it is safe for you to do this measurement. Have you had surgery or experienced any swelling, inflammation, severe pain, or injury in one or both hands within the last 6 months? = 2 »
 
   
 
BM028

1st Left hand [(Ask if BM024=1 & BM025=3) or BM024=2] ____._ kg

1ST LEFT HAND [(ASK IF BM024=1 & BM025=3) OR BM024=2] ____._ KG
   
 
BM030

2nd Left hand [(Ask if BM024=1 & BM025=3) or BM024=2] ____._ kg

2ND LEFT HAND [(ASK IF BM024=1 & BM025=3) OR BM024=2] ____._ KG
   
ElseIf (Before we begin, I would like to make sure it is safe for you to do this measurement. Have you had surgery or experienced any swelling, inflammation, severe pain, or injury in one or both hands within the last 6 months? = 1 Yes 2 No and In which hand (have you had surgery or experienced any swelling, inflammation, severe pain, or injury in the last 6 months)? = 2) or Before we begin, I would like to make sure it is safe for you to do this measurement. Have you had surgery or experienced any swelling, inflammation, severe pain, or injury in one or both hands within the last 6 months? = 2 »
 
   
 
BM029

1st Right Hand [(Ask if BM024=1 & BM025=2) or BM024=2] ____._ kg

1ST RIGHT HAND [(ASK IF BM024=1 & BM025=2) OR BM024=2] ____._ KG
   
 
BM031

2nd Right Hand [(Ask if BM024=1 & BM025=2) or BM024=2] ____._ kg

2ND RIGHT HAND [(ASK IF BM024=1 & BM025=2) OR BM024=2] ____._ KG
   
BM032

How much effort did R give to this test?

HOW MUCH EFFORT DID R GIVE TO THIS TEST?
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BM033

What was R's position for this test?

WHAT WAS R'S POSITION FOR THIS TEST?
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BM034

Did R rest their arm on a support while performing the test?

DID R REST THEIR ARM ON A SUPPORT WHILE PERFORMING THE TEST?
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BM035

[Equipment needed: Stopwatch, Show Card] I would now like you to try to stand in different positions. I will first describe and show each position to you. Then, I would like you to try to do it. If you cannot do a particular position, or if you feel it would be unsafe to try to do it, tell me and we will move on to the next one. Let me emphasize that I do not want you to try to do any activity that you feel might be unsafe. For the first one, I want you to try to stand with the side of the heel of one foot touching the big toe of the other foot for about 10 seconds. You may put either foot in front, whichever is more comfortable for you. Like this... Demonstrate the measurement. Stand and place the heel of one foot touching the big toe of the other foot.

[EQUIPMENT NEEDED: STOPWATCH, SHOW CARD] I WOULD NOW LIKE YOU TO TRY TO STAND IN DIFFERENT POSITIONS. I WILL FIRST DESCRIBE AND SHOW EACH POSITION TO YOU. THEN, I WOULD LIKE YOU TO TRY TO DO IT. IF YOU CANNOT DO A PARTICULAR POSITION, OR IF YOU FEEL IT WOULD BE UNSAFE TO TRY TO DO IT, TELL ME AND WE WILL MOVE ON TO THE NEXT ONE. LET ME EMPHASIZE THAT I DO NOT WANT YOU TO TRY TO DO ANY ACTIVITY THAT YOU FEEL MIGHT BE UNSAFE. FOR THE FIRST ONE, I WANT YOU TO TRY TO STAND WITH THE SIDE OF THE HEEL OF ONE FOOT TOUCHING THE BIG TOE OF THE OTHER FOOT FOR ABOUT 10 SECONDS. YOU MAY PUT EITHER FOOT IN FRONT, WHICHEVER IS MORE COMFORTABLE FOR YOU. LIKE THIS... DEMONSTRATE THE MEASUREMENT. STAND AND PLACE THE HEEL OF ONE FOOT TOUCHING THE BIG TOE OF THE OTHER FOOT.
 
BM036

Before we begin, do you have any problems from recent surgery, injury or other health conditions that might prevent you from standing up from a chair and balancing?

BEFORE WE BEGIN, DO YOU HAVE ANY PROBLEMS FROM RECENT SURGERY, INJURY OR OTHER HEALTH CONDITIONS THAT MIGHT PREVENT YOU FROM STANDING UP FROM A CHAIR AND BALANCING?
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If Before we begin, do you have any problems from recent surgery, injury or other health conditions that might prevent you from standing up from a chair and balancing? = 1 Yes 2 No  »
 
   
 
BM037

Discuss with him/her whether s/he should attempt each measurement given his/her physical problems after describing each measurement. Do not assume a respondent is too physically limited to attempt a measurement without discussing it with him/her. Do you understand these directions and are willing to provide this measurement?

DISCUSS WITH HIM/HER WHETHER S/HE SHOULD ATTEMPT EACH MEASUREMENT GIVEN HIS/HER PHYSICAL PROBLEMS AFTER DESCRIBING EACH MEASUREMENT. DO NOT ASSUME A RESPONDENT IS TOO PHYSICALLY LIMITED TO ATTEMPT A MEASUREMENT WITHOUT DISCUSSING IT WITH HIM/HER. DO YOU UNDERSTAND THESE DIRECTIONS AND ARE WILLING TO PROVIDE THIS MEASUREMENT?
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If Discuss with him/her whether s/he should attempt each measurement given his/her physical problems after describing each measurement. Do not assume a respondent is too physically limited to attempt a measurement without discussing it with him/her. Do you understand these directions and are willing to provide this measurement? = 1 Yes 2 No  »
 
     
   
BM038

Did R hold semi-tandem stand for a full 10 seconds without stepping out of place or grabbing hold of anything?

DID R HOLD SEMI-TANDEM STAND FOR A FULL 10 SECONDS WITHOUT STEPPING OUT OF PLACE OR GRABBING HOLD OF ANYTHING?
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If Before we begin, do you have any problems from recent surgery, injury or other health conditions that might prevent you from standing up from a chair and balancing? = 1 Yes 2 No  »
 
   
 
BM038

Did R hold semi-tandem stand for a full 10 seconds without stepping out of place or grabbing hold of anything?

DID R HOLD SEMI-TANDEM STAND FOR A FULL 10 SECONDS WITHOUT STEPPING OUT OF PLACE OR GRABBING HOLD OF ANYTHING?
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BM040

Did R use any compensatory movements of his/her trunk, arms or legs to steady him/herself during semi-tandem stand?

DID R USE ANY COMPENSATORY MOVEMENTS OF HIS/HER TRUNK, ARMS OR LEGS TO STEADY HIM/HERSELF DURING SEMI-TANDEM STAND?
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BM041

[Equipment needed: Stopwatch, Show Card] Now I will show you next movement. I want you to try to stand with your feet together, side-by-side for about 10 seconds. You may use your arms, bend your knees, or move your body to maintain your balance, but try not to move your feet. Try to hold this position until I tell you to stop. Like this... Demonstrate the measurement Stand with feet together. Do you understand these directions and are you willing to do this test?

[EQUIPMENT NEEDED: STOPWATCH, SHOW CARD] NOW I WILL SHOW YOU NEXT MOVEMENT. I WANT YOU TO TRY TO STAND WITH YOUR FEET TOGETHER, SIDE-BY-SIDE FOR ABOUT 10 SECONDS. YOU MAY USE YOUR ARMS, BEND YOUR KNEES, OR MOVE YOUR BODY TO MAINTAIN YOUR BALANCE, BUT TRY NOT TO MOVE YOUR FEET. TRY TO HOLD THIS POSITION UNTIL I TELL YOU TO STOP. LIKE THIS... DEMONSTRATE THE MEASUREMENT STAND WITH FEET TOGETHER. DO YOU UNDERSTAND THESE DIRECTIONS AND ARE YOU WILLING TO DO THIS TEST?
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If [Equipment needed: Stopwatch, Show Card] Now I will show you next movement. I want you to try to stand with your feet together, side-by-side for about 10 seconds. You may use your arms, bend your knees, or move your body to maintain your balance, but try not to move your feet. Try to hold this position until I tell you to stop. Like this... Demonstrate the measurement Stand with feet together. Do you understand these directions and are you willing to do this test? = 1 Yes 2 No  »
 
   
 
BM042

Did R hold side-by-side stand for a full 10 seconds without stepping out of place or grabbing hold of anything?

DID R HOLD SIDE-BY-SIDE STAND FOR A FULL 10 SECONDS WITHOUT STEPPING OUT OF PLACE OR GRABBING HOLD OF ANYTHING?
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BM044

Did R use any compensatory movements of his/her trunk, arms or legs to steady him/herself during side-by-side stand?

DID R USE ANY COMPENSATORY MOVEMENTS OF HIS/HER TRUNK, ARMS OR LEGS TO STEADY HIM/HERSELF DURING SIDE-BY-SIDE STAND?
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BM045

Record the type of floor surface that the balance measures were conducted on.

RECORD THE TYPE OF FLOOR SURFACE THAT THE BALANCE MEASURES WERE CONDUCTED ON.
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BM046

How compliant was R during the balance measurement?

HOW COMPLIANT WAS R DURING THE BALANCE MEASUREMENT?
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BM047

[Equipment needed: Stopwatch, Show Card] Record eligible time If R's age is >=70, tandem time is 30 seconds. If R's age is <70, tandem time is 60 seconds. The full-tandem time for which R is eligible:

[EQUIPMENT NEEDED: STOPWATCH, SHOW CARD] RECORD ELIGIBLE TIME IF R'S AGE IS >=70, TANDEM TIME IS 30 SECONDS. IF R'S AGE IS <70, TANDEM TIME IS 60 SECONDS. THE FULL-TANDEM TIME FOR WHICH R IS ELIGIBLE:
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BM048

Now I want you to try to stand with the heel of one foot in front of and touching the toes of the other foot for about [30/60] seconds. You may put either foot in front, whichever is more comfortable for you. You may use your arms, bend your knees, or move your body to maintain your balance, but try not to move your feet. Try to hold this position until I tell you to stop. Like this.. Demonstrate the measurement. Stand and place the heel of one foot touching the toes of the other foot. Do you understand these directions and are you willing to do this test?

NOW I WANT YOU TO TRY TO STAND WITH THE HEEL OF ONE FOOT IN FRONT OF AND TOUCHING THE TOES OF THE OTHER FOOT FOR ABOUT [30/60] SECONDS. YOU MAY PUT EITHER FOOT IN FRONT, WHICHEVER IS MORE COMFORTABLE FOR YOU. YOU MAY USE YOUR ARMS, BEND YOUR KNEES, OR MOVE YOUR BODY TO MAINTAIN YOUR BALANCE, BUT TRY NOT TO MOVE YOUR FEET. TRY TO HOLD THIS POSITION UNTIL I TELL YOU TO STOP. LIKE THIS.. DEMONSTRATE THE MEASUREMENT. STAND AND PLACE THE HEEL OF ONE FOOT TOUCHING THE TOES OF THE OTHER FOOT. DO YOU UNDERSTAND THESE DIRECTIONS AND ARE YOU WILLING TO DO THIS TEST?
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If Now I want you to try to stand with the heel of one foot in front of and touching the toes of the other foot for about [30/60] seconds. You may put either foot in front, whichever is more comfortable for you. You may use your arms, bend your knees, or move your body to maintain your balance, but try not to move your feet. Try to hold this position until I tell you to stop. Like this.. Demonstrate the measurement. Stand and place the heel of one foot touching the toes of the other foot. Do you understand these directions and are you willing to do this test? = 1 Yes 2 No  »
 
     
   
BM052

Record the type of floor surface that the balance measures were conducted on.

RECORD THE TYPE OF FLOOR SURFACE THAT THE BALANCE MEASURES WERE CONDUCTED ON.
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BM054

Next, I would like to assess whether you can walk a very short distance comfortably (using a walking stick or other aid if necessary). First, I want to make sure it is safe to carry out the measurement. Do you have any problems from recent surgery, injury, or other health conditions that might prevent you from walking?

NEXT, I WOULD LIKE TO ASSESS WHETHER YOU CAN WALK A VERY SHORT DISTANCE COMFORTABLY (USING A WALKING STICK OR OTHER AID IF NECESSARY). FIRST, I WANT TO MAKE SURE IT IS SAFE TO CARRY OUT THE MEASUREMENT. DO YOU HAVE ANY PROBLEMS FROM RECENT SURGERY, INJURY, OR OTHER HEALTH CONDITIONS THAT MIGHT PREVENT YOU FROM WALKING?
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If Next, I would like to assess whether you can walk a very short distance comfortably (using a walking stick or other aid if necessary). First, I want to make sure it is safe to carry out the measurement. Do you have any problems from recent surgery, injury, or other health conditions that might prevent you from walking? = 1 No apparent restriction 2 Yes, recent surgery 3 Yes, injury 4 Yes, other health condition  »
 
   
 
BM055

Now let's find a place where we can conduct the measurement. We will need a clear space about 4 meters long in a non-carpeted area, if possible. I'm going to place the measuring tape alongside the space where the walk will take place. Set up the course (4meters) This is our walking course. I am going to time you as you walk the course. I will be asking you to walk the course two times. I will walk along side you the whole time during the measurement. Now, I would like to demonstrate how to do the measurement. You will start by lining your feet up at the starting point. Demonstrate the measurement Do you understand these directions and are you willing to do this test?

NOW LET'S FIND A PLACE WHERE WE CAN CONDUCT THE MEASUREMENT. WE WILL NEED A CLEAR SPACE ABOUT 4 METERS LONG IN A NON-CARPETED AREA, IF POSSIBLE. I'M GOING TO PLACE THE MEASURING TAPE ALONGSIDE THE SPACE WHERE THE WALK WILL TAKE PLACE. SET UP THE COURSE (4METERS) THIS IS OUR WALKING COURSE. I AM GOING TO TIME YOU AS YOU WALK THE COURSE. I WILL BE ASKING YOU TO WALK THE COURSE TWO TIMES. I WILL WALK ALONG SIDE YOU THE WHOLE TIME DURING THE MEASUREMENT. NOW, I WOULD LIKE TO DEMONSTRATE HOW TO DO THE MEASUREMENT. YOU WILL START BY LINING YOUR FEET UP AT THE STARTING POINT. DEMONSTRATE THE MEASUREMENT DO YOU UNDERSTAND THESE DIRECTIONS AND ARE YOU WILLING TO DO THIS TEST?
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If Now let's find a place where we can conduct the measurement. We will need a clear space about 4 meters long in a non-carpeted area, if possible. I'm going to place the measuring tape alongside the space where the walk will take place. Set up the course (4meters) This is our walking course. I am going to time you as you walk the course. I will be asking you to walk the course two times. I will walk along side you the whole time during the measurement. Now, I would like to demonstrate how to do the measurement. You will start by lining your feet up at the starting point. Demonstrate the measurement Do you understand these directions and are you willing to do this test? = 1 Yes 2 No  »
 
     
   
BM056

1st Walking Speed Time ___.__ seconds

1ST WALKING SPEED TIME ___.__ SECONDS
     
   
BM057

2nd Walking Speed Time ___.__ seconds

2ND WALKING SPEED TIME ___.__ SECONDS
     
   
BM058

Record type of aid used

RECORD TYPE OF AID USED
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BM059

How compliant was R during this measurement?

HOW COMPLIANT WAS R DURING THIS MEASUREMENT?
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BM060

[Equipment needed: CAPI, Flexible steel measuring tape, Sticky tape] We are now going to test your distance vision and near vision. Can you see light and count the fingers of hand held 2 feet in front of your face with one eye open and when wearing your glasses or contacts?

[EQUIPMENT NEEDED: CAPI, FLEXIBLE STEEL MEASURING TAPE, STICKY TAPE] WE ARE NOW GOING TO TEST YOUR DISTANCE VISION AND NEAR VISION. CAN YOU SEE LIGHT AND COUNT THE FINGERS OF HAND HELD 2 FEET IN FRONT OF YOUR FACE WITH ONE EYE OPEN AND WHEN WEARING YOUR GLASSES OR CONTACTS?
 
BM061

Distance Vision - Left Eye Distance Vision

DISTANCE VISION - LEFT EYE DISTANCE VISION
 
BM062

Distance Vision - Right Eye Distance Vision

DISTANCE VISION - RIGHT EYE DISTANCE VISION
 
BM063

Near Vision - Left Eye Near Vision

NEAR VISION - LEFT EYE NEAR VISION
 
BM064

Near Vision - Right Eye Near Vision

NEAR VISION - RIGHT EYE NEAR VISION
 
BM065

How compliant was R during this measurement?

HOW COMPLIANT WAS R DURING THIS MEASUREMENT?
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BM066

[Equipment needed: Stadiometer] Can the respondent stand?

[EQUIPMENT NEEDED: STADIOMETER] CAN THE RESPONDENT STAND?
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BM067

Record R's height in centimetres __._ cm [Hard check: 50>=BM067>250]

RECORD R’S HEIGHT IN CENTIMETRES __._ CM [HARD CHECK: 50>=BM067>250]
 
BM068

Was R wearing any artificial limbs or orthosis during the measurement?

WAS R WEARING ANY ARTIFICIAL LIMBS OR ORTHOSIS DURING THE MEASUREMENT?
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BM069

How compliant was R during this measurement?

HOW COMPLIANT WAS R DURING THIS MEASUREMENT?
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BM070

[Equipment needed: Weighing Scale] Next, I would like to measure your weight. To complete this measurement, I will be asking you to remove bulky clothing and to take off your shoes during weight measurements. Stand up and look straight ahead. [Instruction for Interviewer: Demonstrate the measurement]

[EQUIPMENT NEEDED: WEIGHING SCALE] NEXT, I WOULD LIKE TO MEASURE YOUR WEIGHT. TO COMPLETE THIS MEASUREMENT, I WILL BE ASKING YOU TO REMOVE BULKY CLOTHING AND TO TAKE OFF YOUR SHOES DURING WEIGHT MEASUREMENTS. STAND UP AND LOOK STRAIGHT AHEAD. [INSTRUCTION FOR INTERVIEWER: DEMONSTRATE THE MEASUREMENT]
 
BM071

[Instruction for Interviewer: Record measurement in kilograms in table below: Enter 993 if R tried but received an error message. Record R's weight up to 2 decimal points] ___._ _ [Soft check: 25<=BM071<=250]

[INSTRUCTION FOR INTERVIEWER: RECORD MEASUREMENT IN KILOGRAMS IN TABLE BELOW: ENTER 993 IF R TRIED BUT RECEIVED AN ERROR MESSAGE. RECORD R'S WEIGHT UP TO 2 DECIMAL POINTS] ___._ _ [SOFT CHECK: 25<=BM071<=250]
 
BM072

Was R wearing an artificial limb or orthosis during the measurement?

WAS R WEARING AN ARTIFICIAL LIMB OR ORTHOSIS DURING THE MEASUREMENT?
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BM074

How compliant was R during this measurement?

HOW COMPLIANT WAS R DURING THIS MEASUREMENT?
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BM075

[Equipment needed: Soft tape measure] Next I am going to ask you to perform a simple measurement of your waist circumference. For this measurement it is important for you to be standing. I will ask you to identify where on your body your navel (belly button) is located. I will then ask you to place this soft measuring tape around your waist, over your clothing, holding it securely at the level of your navel. Once the tape measure is placed appropriately around your waist then we are ready to begin. I will ask you to take a normal breath and exhale, holding your breath at the end of the exhale. I will then record the measurement.

[EQUIPMENT NEEDED: SOFT TAPE MEASURE] NEXT I AM GOING TO ASK YOU TO PERFORM A SIMPLE MEASUREMENT OF YOUR WAIST CIRCUMFERENCE. FOR THIS MEASUREMENT IT IS IMPORTANT FOR YOU TO BE STANDING. I WILL ASK YOU TO IDENTIFY WHERE ON YOUR BODY YOUR NAVEL (BELLY BUTTON) IS LOCATED. I WILL THEN ASK YOU TO PLACE THIS SOFT MEASURING TAPE AROUND YOUR WAIST, OVER YOUR CLOTHING, HOLDING IT SECURELY AT THE LEVEL OF YOUR NAVEL. ONCE THE TAPE MEASURE IS PLACED APPROPRIATELY AROUND YOUR WAIST THEN WE ARE READY TO BEGIN. I WILL ASK YOU TO TAKE A NORMAL BREATH AND EXHALE, HOLDING YOUR BREATH AT THE END OF THE EXHALE. I WILL THEN RECORD THE MEASUREMENT.
 
BM076

Waist Measurement ______ [Soft check: BM076 >=50 or <150]

WAIST MEASUREMENT ______ [SOFT CHECK: BM076 >=50 OR <150]
 
BM077

Was R wearing bulky clothing during this measurement?

WAS R WEARING BULKY CLOTHING DURING THIS MEASUREMENT?
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BM078

[Equipment needed: Soft tape measure] Next I am going to ask you to perform a simple measurement of your hip circumference. For this measurement it is important for you to be standing. I will ask you to identify where the maximum circumference of your hip. I will then ask you to place this soft measuring tape around your hip, over your clothing, holding it securely. Once the tape measure is placed appropriately around your hip and parallel to floor then we are ready to begin. I will ask you to take a normal breath and exhale, holding your breath at the end of the exhale. I will then record the measurement.

[EQUIPMENT NEEDED: SOFT TAPE MEASURE] NEXT I AM GOING TO ASK YOU TO PERFORM A SIMPLE MEASUREMENT OF YOUR HIP CIRCUMFERENCE. FOR THIS MEASUREMENT IT IS IMPORTANT FOR YOU TO BE STANDING. I WILL ASK YOU TO IDENTIFY WHERE THE MAXIMUM CIRCUMFERENCE OF YOUR HIP. I WILL THEN ASK YOU TO PLACE THIS SOFT MEASURING TAPE AROUND YOUR HIP, OVER YOUR CLOTHING, HOLDING IT SECURELY. ONCE THE TAPE MEASURE IS PLACED APPROPRIATELY AROUND YOUR HIP AND PARALLEL TO FLOOR THEN WE ARE READY TO BEGIN. I WILL ASK YOU TO TAKE A NORMAL BREATH AND EXHALE, HOLDING YOUR BREATH AT THE END OF THE EXHALE. I WILL THEN RECORD THE MEASUREMENT.
 
BM079

Record measurement in table below: Enter 999 if R chose not to do it. Record R's Hip Circumference to the nearest 0.1 cm ______ [BM079>=50 or <150]

RECORD MEASUREMENT IN TABLE BELOW: ENTER 999 IF R CHOSE NOT TO DO IT. RECORD R'S HIP CIRCUMFERENCE TO THE NEAREST 0.1 CM ______ [BM079>=50 OR <150]
 
BM080

What difficulties occurred during this measurement? [Multiple answers are allowed][Instructions for CAPI: if BM080=a then freeze other options]

WHAT DIFFICULTIES OCCURRED DURING THIS MEASUREMENT? [MULTIPLE ANSWERS ARE ALLOWED][INSTRUCTIONS FOR CAPI: IF BM080=A THEN FREEZE OTHER OPTIONS]
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BM081

Who conducted this measurement?

WHO CONDUCTED THIS MEASUREMENT?
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BM082

Do you have any of the following condition? [Instruction for CAPI: If any of questions BM082a to BM082e=1, then skip to BM088]

DO YOU HAVE ANY OF THE FOLLOWING CONDITION? [INSTRUCTION FOR CAPI: IF ANY OF QUESTIONS BM082A TO BM082E=1, THEN SKIP TO BM088]
 
BM082A

Active Tb or Upper Respiratory tract infection (cough)

ACTIVE TB OR UPPER RESPIRATORY TRACT INFECTION (COUGH)
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BM082B

Eye surgery in last 3months

EYE SURGERY IN LAST 3MONTHS
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BM082C

Abdominal Surgery in last 3 months

ABDOMINAL SURGERY IN LAST 3 MONTHS
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BM082D

Myocardial Infarction in last 3 month

MYOCARDIAL INFARCTION IN LAST 3 MONTH
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BM082E

[If DM003 =2 & DM005 < 55] Pregnancy ( any trimester)

[IF DM003 =2 & DM005 < 55] PREGNANCY ( ANY TRIMESTER)
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BM083

Have you used any Inhalers in the last 6 hours?

HAVE YOU USED ANY INHALERS IN THE LAST 6 HOURS?
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BM084

[Equipment needed: Spirometer, Disposable mouthpiece] Next I am going to ask you to perform a simple task of taking a deep breath and then blowing as long and hard as you can into a small tube attached to this machine. The machine measures how long it takes you to blow out all the air from your lungs. I would like you to perform the measurement few times. When we are ready to begin, I will ask you to sit up straight. Open your mouth and close your lips firmly around the outside of the mouthpiece. Take as deep a breath as possible and then blow as hard and as fast as you can into the mouth piece followed by deep inhalation again like this.... Demonstrate the measurement. Sit up, place lips around the outside of the mouth piece. Take a deep breath, and then blow as hard and as fast as you can. Do you understand these directions and are you willing to provide this measurement?

[EQUIPMENT NEEDED: SPIROMETER, DISPOSABLE MOUTHPIECE] NEXT I AM GOING TO ASK YOU TO PERFORM A SIMPLE TASK OF TAKING A DEEP BREATH AND THEN BLOWING AS LONG AND HARD AS YOU CAN INTO A SMALL TUBE ATTACHED TO THIS MACHINE. THE MACHINE MEASURES HOW LONG IT TAKES YOU TO BLOW OUT ALL THE AIR FROM YOUR LUNGS. I WOULD LIKE YOU TO PERFORM THE MEASUREMENT FEW TIMES. WHEN WE ARE READY TO BEGIN, I WILL ASK YOU TO SIT UP STRAIGHT. OPEN YOUR MOUTH AND CLOSE YOUR LIPS FIRMLY AROUND THE OUTSIDE OF THE MOUTHPIECE. TAKE AS DEEP A BREATH AS POSSIBLE AND THEN BLOW AS HARD AND AS FAST AS YOU CAN INTO THE MOUTH PIECE FOLLOWED BY DEEP INHALATION AGAIN LIKE THIS.... DEMONSTRATE THE MEASUREMENT. SIT UP, PLACE LIPS AROUND THE OUTSIDE OF THE MOUTH PIECE. TAKE A DEEP BREATH, AND THEN BLOW AS HARD AND AS FAST AS YOU CAN. DO YOU UNDERSTAND THESE DIRECTIONS AND ARE YOU WILLING TO PROVIDE THIS MEASUREMENT?
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If [Equipment needed: Spirometer, Disposable mouthpiece] Next I am going to ask you to perform a simple task of taking a deep breath and then blowing as long and hard as you can into a small tube attached to this machine. The machine measures how long it takes you to blow out all the air from your lungs. I would like you to perform the measurement few times. When we are ready to begin, I will ask you to sit up straight. Open your mouth and close your lips firmly around the outside of the mouthpiece. Take as deep a breath as possible and then blow as hard and as fast as you can into the mouth piece followed by deep inhalation again like this.... Demonstrate the measurement. Sit up, place lips around the outside of the mouth piece. Take a deep breath, and then blow as hard and as fast as you can. Do you understand these directions and are you willing to provide this measurement? = 1 Yes 2 No  »
 
   
 
BM085

[Instruction for Interviewer: CAPI should be connected with Spirometry instrument. Perform the test; and the spirometry readings will be automatically recorded in the CAPI] [Instruction for Interviewer: Step1: CAPI should be connected with Spirometry inst

[INSTRUCTION FOR INTERVIEWER: CAPI SHOULD BE CONNECTED WITH SPIROMETRY INSTRUMENT. PERFORM THE TEST; AND THE SPIROMETRY READINGS WILL BE AUTOMATICALLY RECORDED IN THE CAPI] [INSTRUCTION FOR INTERVIEWER: STEP1: CAPI SHOULD BE CONNECTED WITH SPIROMETRY INSTRUMENT. STEP2: SCAN THE BARCODE ON MOUTHPIECE STEP3: ENTER THE BARCODE NUMBER TWICE: BM085_1&BM085_2 CAPI WILL CHECK BM085_1=BM085_2 IF NOT, RE-ENTER STEP4: PERFORM THE TEST; AND RECORD THE SPIROMETRY READINGS IN BM085A, BM085B & BM085C] BM085_1 BARCODE NUMBER:……………………………….
BM085_2 BARCODE NUMBER:………………………………
BM085_1 & BM085_2 UP TO 14 DIGITS
BM085A: FVC _____.___ ___
BM085B: FEV1_____.______
BM085C: PEF______.______
   
 
BM086

What was R's position for this test?

WHAT WAS R'S POSITION FOR THIS TEST?
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BM087

How much effort did R give to this test?

HOW MUCH EFFORT DID R GIVE TO THIS TEST?
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BM088

I would like to collect a small sample of your blood using just a finger prick. We would be very grateful if you would agree to provide us with a sample of blood. This is an important part of the study, as the analysis of blood samples will tell us a lot about the health of the population. Before we begin, I would like to read this consent form. Longitudinal Ageing Study in India (LASI) International Institute for Population Sciences (IIPS) Additional Consent Form for Blood Sample Collection for Storage and Future Use This is in continuation with your individual consent that you have already given. Further, we would like to inform you that as a part of this longitudinal ageing study, we want to collect few drops of your blood sample using finger prick. The blood sample will be used to test anemia, diabetes, and chronic infections. Your blood sample will be extremely useful to plan special health care services for the older population in the country. The test uses new, disposable sterile instruments that are clean and completely safe in use. I will prick your finger to draw few drops of blood. These drops will be soaked on a piece of filter paper. These pieces of paper will be used to check various health conditions. The blood sample will be sent to National AIDS Research Institute (NARI), which is a premier institute devoted to health research for analysis and storage. The information you will provide will be kept strictly confidential. The results of the blood test will only be used for research and planning purposes without any personal identification. However, if you decide not to provide a blood sample, it is your right and we will respect your decision. Should you have any question about the survey please feel free to ask me or contact the concerned authority (Interviewer: Provide Card). Director / Project Coordinators International Institute for Population Sciences (IIPS) Govandi Station Road, Deonar, Mumbai-400 088. Tel: 022-42372-682/ 401/ 682/ 417/ 422, Fax: 022-42372401. Do you agree to provide consent for giving few drops of blood sample? (Circle one of the response)

I WOULD LIKE TO COLLECT A SMALL SAMPLE OF YOUR BLOOD USING JUST A FINGER PRICK. WE WOULD BE VERY GRATEFUL IF YOU WOULD AGREE TO PROVIDE US WITH A SAMPLE OF BLOOD. THIS IS AN IMPORTANT PART OF THE STUDY, AS THE ANALYSIS OF BLOOD SAMPLES WILL TELL US A LOT ABOUT THE HEALTH OF THE POPULATION. BEFORE WE BEGIN, I WOULD LIKE TO READ THIS CONSENT FORM. LONGITUDINAL AGEING STUDY IN INDIA (LASI) INTERNATIONAL INSTITUTE FOR POPULATION SCIENCES (IIPS) ADDITIONAL CONSENT FORM FOR BLOOD SAMPLE COLLECTION FOR STORAGE AND FUTURE USE THIS IS IN CONTINUATION WITH YOUR INDIVIDUAL CONSENT THAT YOU HAVE ALREADY GIVEN. FURTHER, WE WOULD LIKE TO INFORM YOU THAT AS A PART OF THIS LONGITUDINAL AGEING STUDY, WE WANT TO COLLECT FEW DROPS OF YOUR BLOOD SAMPLE USING FINGER PRICK. THE BLOOD SAMPLE WILL BE USED TO TEST ANEMIA, DIABETES, AND CHRONIC INFECTIONS. YOUR BLOOD SAMPLE WILL BE EXTREMELY USEFUL TO PLAN SPECIAL HEALTH CARE SERVICES FOR THE OLDER POPULATION IN THE COUNTRY. THE TEST USES NEW, DISPOSABLE STERILE INSTRUMENTS THAT ARE CLEAN AND COMPLETELY SAFE IN USE. I WILL PRICK YOUR FINGER TO DRAW FEW DROPS OF BLOOD. THESE DROPS WILL BE SOAKED ON A PIECE OF FILTER PAPER. THESE PIECES OF PAPER WILL BE USED TO CHECK VARIOUS HEALTH CONDITIONS. THE BLOOD SAMPLE WILL BE SENT TO NATIONAL AIDS RESEARCH INSTITUTE (NARI), WHICH IS A PREMIER INSTITUTE DEVOTED TO HEALTH RESEARCH FOR ANALYSIS AND STORAGE. THE INFORMATION YOU WILL PROVIDE WILL BE KEPT STRICTLY CONFIDENTIAL. THE RESULTS OF THE BLOOD TEST WILL ONLY BE USED FOR RESEARCH AND PLANNING PURPOSES WITHOUT ANY PERSONAL IDENTIFICATION. HOWEVER, IF YOU DECIDE NOT TO PROVIDE A BLOOD SAMPLE, IT IS YOUR RIGHT AND WE WILL RESPECT YOUR DECISION. SHOULD YOU HAVE ANY QUESTION ABOUT THE SURVEY PLEASE FEEL FREE TO ASK ME OR CONTACT THE CONCERNED AUTHORITY (INTERVIEWER: PROVIDE CARD). DIRECTOR / PROJECT COORDINATORS INTERNATIONAL INSTITUTE FOR POPULATION SCIENCES (IIPS) GOVANDI STATION ROAD, DEONAR, MUMBAI-400 088. TEL: 022-42372-682/ 401/ 682/ 417/ 422, FAX: 022-42372401. DO YOU AGREE TO PROVIDE CONSENT FOR GIVING FEW DROPS OF BLOOD SAMPLE? (CIRCLE ONE OF THE RESPONSE)
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If I would like to collect a small sample of your blood using just a finger prick. We would be very grateful if you would agree to provide us with a sample of blood. This is an important part of the study, as the analysis of blood samples will tell us a lot about the health of the population. Before we begin, I would like to read this consent form. Longitudinal Ageing Study in India (LASI) International Institute for Population Sciences (IIPS) Additional Consent Form for Blood Sample Collection for Storage and Future Use This is in continuation with your individual consent that you have already given. Further, we would like to inform you that as a part of this longitudinal ageing study, we want to collect few drops of your blood sample using finger prick. The blood sample will be used to test anemia, diabetes, and chronic infections. Your blood sample will be extremely useful to plan special health care services for the older population in the country. The test uses new, disposable sterile instruments that are clean and completely safe in use. I will prick your finger to draw few drops of blood. These drops will be soaked on a piece of filter paper. These pieces of paper will be used to check various health conditions. The blood sample will be sent to National AIDS Research Institute (NARI), which is a premier institute devoted to health research for analysis and storage. The information you will provide will be kept strictly confidential. The results of the blood test will only be used for research and planning purposes without any personal identification. However, if you decide not to provide a blood sample, it is your right and we will respect your decision. Should you have any question about the survey please feel free to ask me or contact the concerned authority (Interviewer: Provide Card). Director / Project Coordinators International Institute for Population Sciences (IIPS) Govandi Station Road, Deonar, Mumbai-400 088. Tel: 022-42372-682/ 401/ 682/ 417/ 422, Fax: 022-42372401. Do you agree to provide consent for giving few drops of blood sample? (Circle one of the response) != 3 Consent Refused »
 
   
 
BM089

Date ___date(dd/mm/yyyy)

DATE ___DATE(DD/MM/YYYY)
   
 
BM090

Time ____:____ am/pm(12hour clock

TIME ____:____ AM/PM(12HOUR CLOCK
   
 
BM091

Instructions for IWER:Step 1. Scan the barcode. Step 2. Enter the Barcode number twice: BM091a & BM091b CAPI will check BM091a=Bm091b If not, re-enter.BM091a Sample Barcode number:______BM091b Sample Barcode number:______[BM091 up to 14 digits]

INSTRUCTIONS FOR IWER:STEP 1. SCAN THE BARCODE. STEP 2. ENTER THE BARCODE NUMBER TWICE: BM091A & BM091B CAPI WILL CHECK BM091A=BM091B IF NOT, RE-ENTER.BM091A SAMPLE BARCODE NUMBER:______BM091B SAMPLE BARCODE NUMBER:______[BM091 UP TO 14 DIGITS]
   
 
BM092

What, if any, problems occurred during the collection of the blood sample? [Multiple answers are allowed] [Instruction for CAPI: BM092=a then freeze other options]

WHAT, IF ANY, PROBLEMS OCCURRED DURING THE COLLECTION OF THE BLOOD SAMPLE? [MULTIPLE ANSWERS ARE ALLOWED] [INSTRUCTION FOR CAPI: BM092=A THEN FREEZE OTHER OPTIONS]
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BM093

How many circles were filled on the DBS card?

HOW MANY CIRCLES WERE FILLED ON THE DBS CARD?
expand
   
 
BM094

[For the Health Investigator]DBS quality assessment by the health investigator, which is to be completed after they have collected blood spots. What is the quality of the blood spots that have been collected?

[FOR THE HEALTH INVESTIGATOR]DBS QUALITY ASSESSMENT BY THE HEALTH INVESTIGATOR, WHICH IS TO BE COMPLETED AFTER THEY HAVE COLLECTED BLOOD SPOTS. WHAT IS THE QUALITY OF THE BLOOD SPOTS THAT HAVE BEEN COLLECTED?
expand
   
 
BM095

How many times did the R's finger need to be pricked in order to get 5 drops of blood?

HOW MANY TIMES DID THE R'S FINGER NEED TO BE PRICKED IN ORDER TO GET 5 DROPS OF BLOOD?
expand
   
 
BM096

How compliant was R during this measurement?

HOW COMPLIANT WAS R DURING THIS MEASUREMENT?
expand
   
BM097

Thank you for your cooperation. This concludes the physical measure and biomarkers portion of the survey.

THANK YOU FOR YOUR COOPERATION. THIS CONCLUDES THE PHYSICAL MEASURE AND BIOMARKERS PORTION OF THE SURVEY.
 
End of I_BM. BIOMARKERS (BM)
Start of I_BM. BIOMARKERS (BM)

========================================================================
BM001
[Equipment needed: Omron HEM-780N Monitor, Batteries, Stopwatch] I would like to measure your blood pressure and pulse using this monitor and cuff which I will secure around your left arm. I would like to take three blood pressure measures. I will ask you to relax and remain seated and quiet, with legs uncrossed and feet flat on the floor, during the measurements. First, I will place the cuff on your left arm. Once the cuff is placed appropriately on your arm and we are ready to begin, I will ask you to lay your arm on a flat surface, palm facing up, so that the center of your upper arm is at the same height as your heart. I will then press the start button. The cuff will inflate and deflate automatically. It will squeeze your arm a bit, but won't hurt. After we have completed all three measures, I will give you your results. Do you understand these directions and are you willing to provide this measurement?

[EQUIPMENT NEEDED: OMRON HEM-780N MONITOR, BATTERIES, STOPWATCH] I WOULD LIKE TO MEASURE YOUR BLOOD PRESSURE AND PULSE USING THIS MONITOR AND CUFF WHICH I WILL SECURE AROUND YOUR LEFT ARM. I WOULD LIKE TO TAKE THREE BLOOD PRESSURE MEASURES. I WILL ASK YOU TO RELAX AND REMAIN SEATED AND QUIET, WITH LEGS UNCROSSED AND FEET FLAT ON THE FLOOR, DURING THE MEASUREMENTS. FIRST, I WILL PLACE THE CUFF ON YOUR LEFT ARM. ONCE THE CUFF IS PLACED APPROPRIATELY ON YOUR ARM AND WE ARE READY TO BEGIN, I WILL ASK YOU TO LAY YOUR ARM ON A FLAT SURFACE, PALM FACING UP, SO THAT THE CENTER OF YOUR UPPER ARM IS AT THE SAME HEIGHT AS YOUR HEART. I WILL THEN PRESS THE START BUTTON. THE CUFF WILL INFLATE AND DEFLATE AUTOMATICALLY. IT WILL SQUEEZE YOUR ARM A BIT, BUT WON'T HURT. AFTER WE HAVE COMPLETED ALL THREE MEASURES, I WILL GIVE YOU YOUR RESULTS. DO YOU UNDERSTAND THESE DIRECTIONS AND ARE YOU WILLING TO PROVIDE THIS MEASUREMENT?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No


If [Equipment needed: Omron HEM-780N Monitor, Batteries, Stopwatch] I would like to measure your blood pressure and pulse using this monitor and cuff which I will secure around your left arm. I would like to take three blood pressure measures. I will ask you to relax and remain seated and quiet, with legs uncrossed and feet flat on the floor, during the measurements. First, I will place the cuff on your left arm. Once the cuff is placed appropriately on your arm and we are ready to begin, I will ask you to lay your arm on a flat surface, palm facing up, so that the center of your upper arm is at the same height as your heart. I will then press the start button. The cuff will inflate and deflate automatically. It will squeeze your arm a bit, but won't hurt. After we have completed all three measures, I will give you your results. Do you understand these directions and are you willing to provide this measurement? (BM001) = 1 Yes 2 No  »

| ========================================================================
BM002
Did you smoke, exercise, or consume alcohol or food within the 30 minutes prior the blood pressure test?

DID YOU SMOKE, EXERCISE, OR CONSUME ALCOHOL OR FOOD WITHIN THE 30 MINUTES PRIOR THE BLOOD PRESSURE TEST?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No


| ========================================================================
BM003
Do you have a rash, a cast, edema (swelling) in the left arm, open sores or wounds, or a significant bruise where the blood pressure cuff will be in contact?

DO YOU HAVE A RASH, A CAST, EDEMA (SWELLING) IN THE LEFT ARM, OPEN SORES OR WOUNDS, OR A SIGNIFICANT BRUISE WHERE THE BLOOD PRESSURE CUFF WILL BE IN CONTACT?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No


If Do you have a rash, a cast, edema (swelling) in the left arm, open sores or wounds, or a significant bruise where the blood pressure cuff will be in contact? (BM003) = 1 Yes 2 No  »

| | ========================================================================
| | 
BM004
[Ask only if BM003=1]Do you have a rash, a cast, edema (swelling) in the right arm, open sores or wounds, or a significant bruise where the blood pressure cuff will be in contact?

[ASK ONLY IF BM003=1]DO YOU HAVE A RASH, A CAST, EDEMA (SWELLING) IN THE RIGHT ARM, OPEN SORES OR WOUNDS, OR A SIGNIFICANT BRUISE WHERE THE BLOOD PRESSURE CUFF WILL BE IN CONTACT?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No


| | If [Ask only if BM003=1]Do you have a rash, a cast, edema (swelling) in the right arm, open sores or wounds, or a significant bruise where the blood pressure cuff will be in contact? (BM004) = 2 »

| | | ========================================================================
| | | 
BM005
Time of Reading __ __:__ __ am/pm

TIME OF READING __ __:__ __ AM/PM

| | | ========================================================================
| | | 
BM006
Systolic Reading ___ mmHg

SYSTOLIC READING ___ MMHG

| | | ========================================================================
| | | 
BM007
Diastolic Reading ___ mmHg

DIASTOLIC READING ___ MMHG

| | | ========================================================================
| | | 
BM008
Pulse ___ Beats/min

PULSE ___ BEATS/MIN

| | | ========================================================================
| | | 
BM009
Time of Reading __ __:__ __ am/pm

TIME OF READING __ __:__ __ AM/PM

| | | ========================================================================
| | | 
BM010
Systolic Reading___ mmHg

SYSTOLIC READING___ MMHG

| | | ========================================================================
| | | 
BM011
Diastolic Reading___mmHg

DIASTOLIC READING___MMHG

| | | ========================================================================
| | | 
BM012
Pulse ___ Beats/min

PULSE ___ BEATS/MIN

| | | ========================================================================
| | | 
BM013
Time of Reading __ __:__ __ am/pm

TIME OF READING __ __:__ __ AM/PM

| | | ========================================================================
| | | 
BM014
Systolic Reading___ mmHg

SYSTOLIC READING___ MMHG

| | | ========================================================================
| | | 
BM015
Diastolic Reading___mmHg

DIASTOLIC READING___MMHG

| | | ========================================================================
| | | 
BM016
Pulse ___ Beats/min

PULSE ___ BEATS/MIN

| | | ========================================================================
| | | 
BM017
Systolic Reading ___mmHg

SYSTOLIC READING ___MMHG

| | | ========================================================================
| | | 
BM018
Diastolic Reading ___mmHg

DIASTOLIC READING ___MMHG

| | | ========================================================================
| | | 
BM019
Pulse __ Beats/min

PULSE __ BEATS/MIN

| | | ========================================================================
| | | 
BM020
Which arm was used to conduct the measurements?

WHICH ARM WAS USED TO CONDUCT THE MEASUREMENTS?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Left arm
2 Right arm


| | | ========================================================================
| | | 
BM021
What was R's position for this test?

WHAT WAS R'S POSITION FOR THIS TEST?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Standing
2 Sitting
3 Lying down


| | | ========================================================================
| | | 
BM022
How compliant was R during this measurement?

HOW COMPLIANT WAS R DURING THIS MEASUREMENT?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R was fully compliant
2 R was prevented from fully complying due to illness, pain, or other symptoms or discomfort
3 R was not fully compliant[Grip Strength/Hand Strength]


========================================================================
BM023
[Equipment needed: Dynamometer, Stopwatch] Now I would like to assess the strength of your hand in a gripping action. I will ask you to squeeze this handle as hard as you can, just for a couple of seconds and then let go. I will take alternately two measurements from your right and your left hand. Begin the test with the left hand.

[EQUIPMENT NEEDED: DYNAMOMETER, STOPWATCH] NOW I WOULD LIKE TO ASSESS THE STRENGTH OF YOUR HAND IN A GRIPPING ACTION. I WILL ASK YOU TO SQUEEZE THIS HANDLE AS HARD AS YOU CAN, JUST FOR A COUPLE OF SECONDS AND THEN LET GO. I WILL TAKE ALTERNATELY TWO MEASUREMENTS FROM YOUR RIGHT AND YOUR LEFT HAND. BEGIN THE TEST WITH THE LEFT HAND.

========================================================================
BM024
Before we begin, I would like to make sure it is safe for you to do this measurement. Have you had surgery or experienced any swelling, inflammation, severe pain, or injury in one or both hands within the last 6 months?

BEFORE WE BEGIN, I WOULD LIKE TO MAKE SURE IT IS SAFE FOR YOU TO DO THIS MEASUREMENT. HAVE YOU HAD SURGERY OR EXPERIENCED ANY SWELLING, INFLAMMATION, SEVERE PAIN, OR INJURY IN ONE OR BOTH HANDS WITHIN THE LAST 6 MONTHS?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No


If Before we begin, I would like to make sure it is safe for you to do this measurement. Have you had surgery or experienced any swelling, inflammation, severe pain, or injury in one or both hands within the last 6 months? (BM024) = 1 Yes 2 No  »

| ========================================================================
BM025
In which hand (have you had surgery or experienced any swelling, inflammation, severe pain, or injury in the last 6 months)?

IN WHICH HAND (HAVE YOU HAD SURGERY OR EXPERIENCED ANY SWELLING, INFLAMMATION, SEVERE PAIN, OR INJURY IN THE LAST 6 MONTHS)?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Both hands
2 Left hand only
3 Right hand only


========================================================================
BM026
Which is your dominant hand?

WHICH IS YOUR DOMINANT HAND?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Right hand
2 Left hand
3 Both hands equally dominant


If (Before we begin, I would like to make sure it is safe for you to do this measurement. Have you had surgery or experienced any swelling, inflammation, severe pain, or injury in one or both hands within the last 6 months? (BM024) = 1 Yes 2 No and In which hand (have you had surgery or experienced any swelling, inflammation, severe pain, or injury in the last 6 months)? (BM025) = 3) or Before we begin, I would like to make sure it is safe for you to do this measurement. Have you had surgery or experienced any swelling, inflammation, severe pain, or injury in one or both hands within the last 6 months? (BM024) = 2 »

| ========================================================================
BM028
1st Left hand [(Ask if BM024=1 & BM025=3) or BM024=2] ____._ kg

1ST LEFT HAND [(ASK IF BM024=1 & BM025=3) OR BM024=2] ____._ KG

| ========================================================================
BM030
2nd Left hand [(Ask if BM024=1 & BM025=3) or BM024=2] ____._ kg

2ND LEFT HAND [(ASK IF BM024=1 & BM025=3) OR BM024=2] ____._ KG

ElseIf (Before we begin, I would like to make sure it is safe for you to do this measurement. Have you had surgery or experienced any swelling, inflammation, severe pain, or injury in one or both hands within the last 6 months? (BM024) = 1 Yes 2 No and In which hand (have you had surgery or experienced any swelling, inflammation, severe pain, or injury in the last 6 months)? (BM025) = 2) or Before we begin, I would like to make sure it is safe for you to do this measurement. Have you had surgery or experienced any swelling, inflammation, severe pain, or injury in one or both hands within the last 6 months? (BM024) = 2 »

| ========================================================================
BM029
1st Right Hand [(Ask if BM024=1 & BM025=2) or BM024=2] ____._ kg

1ST RIGHT HAND [(ASK IF BM024=1 & BM025=2) OR BM024=2] ____._ KG

| ========================================================================
BM031
2nd Right Hand [(Ask if BM024=1 & BM025=2) or BM024=2] ____._ kg

2ND RIGHT HAND [(ASK IF BM024=1 & BM025=2) OR BM024=2] ____._ KG

========================================================================
BM032
How much effort did R give to this test?

HOW MUCH EFFORT DID R GIVE TO THIS TEST?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R gave full effort
2 R was prevented from giving full effort by illness, pain, or other symptoms or discomforts
3 R did not appear to give full effort, but no obvious reason for this


========================================================================
BM033
What was R's position for this test?

WHAT WAS R'S POSITION FOR THIS TEST?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Standing
2 Sitting
3 Lying down


========================================================================
BM034
Did R rest their arm on a support while performing the test?

DID R REST THEIR ARM ON A SUPPORT WHILE PERFORMING THE TEST?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No


========================================================================
BM035
[Equipment needed: Stopwatch, Show Card] I would now like you to try to stand in different positions. I will first describe and show each position to you. Then, I would like you to try to do it. If you cannot do a particular position, or if you feel it would be unsafe to try to do it, tell me and we will move on to the next one. Let me emphasize that I do not want you to try to do any activity that you feel might be unsafe. For the first one, I want you to try to stand with the side of the heel of one foot touching the big toe of the other foot for about 10 seconds. You may put either foot in front, whichever is more comfortable for you. Like this... Demonstrate the measurement. Stand and place the heel of one foot touching the big toe of the other foot.

[EQUIPMENT NEEDED: STOPWATCH, SHOW CARD] I WOULD NOW LIKE YOU TO TRY TO STAND IN DIFFERENT POSITIONS. I WILL FIRST DESCRIBE AND SHOW EACH POSITION TO YOU. THEN, I WOULD LIKE YOU TO TRY TO DO IT. IF YOU CANNOT DO A PARTICULAR POSITION, OR IF YOU FEEL IT WOULD BE UNSAFE TO TRY TO DO IT, TELL ME AND WE WILL MOVE ON TO THE NEXT ONE. LET ME EMPHASIZE THAT I DO NOT WANT YOU TO TRY TO DO ANY ACTIVITY THAT YOU FEEL MIGHT BE UNSAFE. FOR THE FIRST ONE, I WANT YOU TO TRY TO STAND WITH THE SIDE OF THE HEEL OF ONE FOOT TOUCHING THE BIG TOE OF THE OTHER FOOT FOR ABOUT 10 SECONDS. YOU MAY PUT EITHER FOOT IN FRONT, WHICHEVER IS MORE COMFORTABLE FOR YOU. LIKE THIS... DEMONSTRATE THE MEASUREMENT. STAND AND PLACE THE HEEL OF ONE FOOT TOUCHING THE BIG TOE OF THE OTHER FOOT.

========================================================================
BM036
Before we begin, do you have any problems from recent surgery, injury or other health conditions that might prevent you from standing up from a chair and balancing?

BEFORE WE BEGIN, DO YOU HAVE ANY PROBLEMS FROM RECENT SURGERY, INJURY OR OTHER HEALTH CONDITIONS THAT MIGHT PREVENT YOU FROM STANDING UP FROM A CHAIR AND BALANCING?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No


If Before we begin, do you have any problems from recent surgery, injury or other health conditions that might prevent you from standing up from a chair and balancing? (BM036) = 1 Yes 2 No  »

| ========================================================================
BM037
Discuss with him/her whether s/he should attempt each measurement given his/her physical problems after describing each measurement. Do not assume a respondent is too physically limited to attempt a measurement without discussing it with him/her. Do you understand these directions and are willing to provide this measurement?

DISCUSS WITH HIM/HER WHETHER S/HE SHOULD ATTEMPT EACH MEASUREMENT GIVEN HIS/HER PHYSICAL PROBLEMS AFTER DESCRIBING EACH MEASUREMENT. DO NOT ASSUME A RESPONDENT IS TOO PHYSICALLY LIMITED TO ATTEMPT A MEASUREMENT WITHOUT DISCUSSING IT WITH HIM/HER. DO YOU UNDERSTAND THESE DIRECTIONS AND ARE WILLING TO PROVIDE THIS MEASUREMENT?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No


If Discuss with him/her whether s/he should attempt each measurement given his/her physical problems after describing each measurement. Do not assume a respondent is too physically limited to attempt a measurement without discussing it with him/her. Do you understand these directions and are willing to provide this measurement? (BM037) = 1 Yes 2 No  »

| | ========================================================================
| | 
BM038
Did R hold semi-tandem stand for a full 10 seconds without stepping out of place or grabbing hold of anything?

DID R HOLD SEMI-TANDEM STAND FOR A FULL 10 SECONDS WITHOUT STEPPING OUT OF PLACE OR GRABBING HOLD OF ANYTHING?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No (Time in seconds): BM039__[Soft check: BM039<10]


If Before we begin, do you have any problems from recent surgery, injury or other health conditions that might prevent you from standing up from a chair and balancing? (BM036) = 1 Yes 2 No  »

| ========================================================================
BM038
Did R hold semi-tandem stand for a full 10 seconds without stepping out of place or grabbing hold of anything?

DID R HOLD SEMI-TANDEM STAND FOR A FULL 10 SECONDS WITHOUT STEPPING OUT OF PLACE OR GRABBING HOLD OF ANYTHING?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No (Time in seconds): BM039__[Soft check: BM039<10]


========================================================================
BM040
Did R use any compensatory movements of his/her trunk, arms or legs to steady him/herself during semi-tandem stand?

DID R USE ANY COMPENSATORY MOVEMENTS OF HIS/HER TRUNK, ARMS OR LEGS TO STEADY HIM/HERSELF DURING SEMI-TANDEM STAND?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No


========================================================================
BM041
[Equipment needed: Stopwatch, Show Card] Now I will show you next movement. I want you to try to stand with your feet together, side-by-side for about 10 seconds. You may use your arms, bend your knees, or move your body to maintain your balance, but try not to move your feet. Try to hold this position until I tell you to stop. Like this... Demonstrate the measurement Stand with feet together. Do you understand these directions and are you willing to do this test?

[EQUIPMENT NEEDED: STOPWATCH, SHOW CARD] NOW I WILL SHOW YOU NEXT MOVEMENT. I WANT YOU TO TRY TO STAND WITH YOUR FEET TOGETHER, SIDE-BY-SIDE FOR ABOUT 10 SECONDS. YOU MAY USE YOUR ARMS, BEND YOUR KNEES, OR MOVE YOUR BODY TO MAINTAIN YOUR BALANCE, BUT TRY NOT TO MOVE YOUR FEET. TRY TO HOLD THIS POSITION UNTIL I TELL YOU TO STOP. LIKE THIS... DEMONSTRATE THE MEASUREMENT STAND WITH FEET TOGETHER. DO YOU UNDERSTAND THESE DIRECTIONS AND ARE YOU WILLING TO DO THIS TEST?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No


If [Equipment needed: Stopwatch, Show Card] Now I will show you next movement. I want you to try to stand with your feet together, side-by-side for about 10 seconds. You may use your arms, bend your knees, or move your body to maintain your balance, but try not to move your feet. Try to hold this position until I tell you to stop. Like this... Demonstrate the measurement Stand with feet together. Do you understand these directions and are you willing to do this test? (BM041) = 1 Yes 2 No  »

| ========================================================================
BM042
Did R hold side-by-side stand for a full 10 seconds without stepping out of place or grabbing hold of anything?

DID R HOLD SIDE-BY-SIDE STAND FOR A FULL 10 SECONDS WITHOUT STEPPING OUT OF PLACE OR GRABBING HOLD OF ANYTHING?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No (Time in seconds) BM043__ [Soft check : BM043<10]


| ========================================================================
BM044
Did R use any compensatory movements of his/her trunk, arms or legs to steady him/herself during side-by-side stand?

DID R USE ANY COMPENSATORY MOVEMENTS OF HIS/HER TRUNK, ARMS OR LEGS TO STEADY HIM/HERSELF DURING SIDE-BY-SIDE STAND?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No


| ========================================================================
BM045
Record the type of floor surface that the balance measures were conducted on.

RECORD THE TYPE OF FLOOR SURFACE THAT THE BALANCE MEASURES WERE CONDUCTED ON.
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Wood/ Tile/ Linoleum
2 Concrete
3 Kutchha/ Mud


| ========================================================================
BM046
How compliant was R during the balance measurement?

HOW COMPLIANT WAS R DURING THE BALANCE MEASUREMENT?
- - - - - - - - - - - - - - - - - - - - - - - - -
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


| ========================================================================
BM047
[Equipment needed: Stopwatch, Show Card] Record eligible time If R's age is >=70, tandem time is 30 seconds. If R's age is <70, tandem time is 60 seconds. The full-tandem time for which R is eligible:

[EQUIPMENT NEEDED: STOPWATCH, SHOW CARD] RECORD ELIGIBLE TIME IF R'S AGE IS >=70, TANDEM TIME IS 30 SECONDS. IF R'S AGE IS <70, TANDEM TIME IS 60 SECONDS. THE FULL-TANDEM TIME FOR WHICH R IS ELIGIBLE:
- - - - - - - - - - - - - - - - - - - - - - - - -
1 30 seconds full-tandem balance measurement
2 60 seconds full-tandem balance measurement


| ========================================================================
BM048
Now I want you to try to stand with the heel of one foot in front of and touching the toes of the other foot for about [30/60] seconds. You may put either foot in front, whichever is more comfortable for you. You may use your arms, bend your knees, or move your body to maintain your balance, but try not to move your feet. Try to hold this position until I tell you to stop. Like this.. Demonstrate the measurement. Stand and place the heel of one foot touching the toes of the other foot. Do you understand these directions and are you willing to do this test?

NOW I WANT YOU TO TRY TO STAND WITH THE HEEL OF ONE FOOT IN FRONT OF AND TOUCHING THE TOES OF THE OTHER FOOT FOR ABOUT [30/60] SECONDS. YOU MAY PUT EITHER FOOT IN FRONT, WHICHEVER IS MORE COMFORTABLE FOR YOU. YOU MAY USE YOUR ARMS, BEND YOUR KNEES, OR MOVE YOUR BODY TO MAINTAIN YOUR BALANCE, BUT TRY NOT TO MOVE YOUR FEET. TRY TO HOLD THIS POSITION UNTIL I TELL YOU TO STOP. LIKE THIS.. DEMONSTRATE THE MEASUREMENT. STAND AND PLACE THE HEEL OF ONE FOOT TOUCHING THE TOES OF THE OTHER FOOT. DO YOU UNDERSTAND THESE DIRECTIONS AND ARE YOU WILLING TO DO THIS TEST?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No


If Now I want you to try to stand with the heel of one foot in front of and touching the toes of the other foot for about [30/60] seconds. You may put either foot in front, whichever is more comfortable for you. You may use your arms, bend your knees, or move your body to maintain your balance, but try not to move your feet. Try to hold this position until I tell you to stop. Like this.. Demonstrate the measurement. Stand and place the heel of one foot touching the toes of the other foot. Do you understand these directions and are you willing to do this test? (BM048) = 1 Yes 2 No  »

| | ========================================================================
| | 
BM052
Record the type of floor surface that the balance measures were conducted on.

RECORD THE TYPE OF FLOOR SURFACE THAT THE BALANCE MEASURES WERE CONDUCTED ON.
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Wood/ Tile/ Linoleum
2 Concrete
3 Kutchha/ Mud


========================================================================
BM054
Next, I would like to assess whether you can walk a very short distance comfortably (using a walking stick or other aid if necessary). First, I want to make sure it is safe to carry out the measurement. Do you have any problems from recent surgery, injury, or other health conditions that might prevent you from walking?

NEXT, I WOULD LIKE TO ASSESS WHETHER YOU CAN WALK A VERY SHORT DISTANCE COMFORTABLY (USING A WALKING STICK OR OTHER AID IF NECESSARY). FIRST, I WANT TO MAKE SURE IT IS SAFE TO CARRY OUT THE MEASUREMENT. DO YOU HAVE ANY PROBLEMS FROM RECENT SURGERY, INJURY, OR OTHER HEALTH CONDITIONS THAT MIGHT PREVENT YOU FROM WALKING?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 No apparent restriction
2 Yes, recent surgery
3 Yes, injury
4 Yes, other health condition


If Next, I would like to assess whether you can walk a very short distance comfortably (using a walking stick or other aid if necessary). First, I want to make sure it is safe to carry out the measurement. Do you have any problems from recent surgery, injury, or other health conditions that might prevent you from walking? (BM054) = 1 No apparent restriction 2 Yes, recent surgery 3 Yes, injury 4 Yes, other health condition  »

| ========================================================================
BM055
Now let's find a place where we can conduct the measurement. We will need a clear space about 4 meters long in a non-carpeted area, if possible. I'm going to place the measuring tape alongside the space where the walk will take place. Set up the course (4meters) This is our walking course. I am going to time you as you walk the course. I will be asking you to walk the course two times. I will walk along side you the whole time during the measurement. Now, I would like to demonstrate how to do the measurement. You will start by lining your feet up at the starting point. Demonstrate the measurement Do you understand these directions and are you willing to do this test?

NOW LET'S FIND A PLACE WHERE WE CAN CONDUCT THE MEASUREMENT. WE WILL NEED A CLEAR SPACE ABOUT 4 METERS LONG IN A NON-CARPETED AREA, IF POSSIBLE. I'M GOING TO PLACE THE MEASURING TAPE ALONGSIDE THE SPACE WHERE THE WALK WILL TAKE PLACE. SET UP THE COURSE (4METERS) THIS IS OUR WALKING COURSE. I AM GOING TO TIME YOU AS YOU WALK THE COURSE. I WILL BE ASKING YOU TO WALK THE COURSE TWO TIMES. I WILL WALK ALONG SIDE YOU THE WHOLE TIME DURING THE MEASUREMENT. NOW, I WOULD LIKE TO DEMONSTRATE HOW TO DO THE MEASUREMENT. YOU WILL START BY LINING YOUR FEET UP AT THE STARTING POINT. DEMONSTRATE THE MEASUREMENT DO YOU UNDERSTAND THESE DIRECTIONS AND ARE YOU WILLING TO DO THIS TEST?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No


If Now let's find a place where we can conduct the measurement. We will need a clear space about 4 meters long in a non-carpeted area, if possible. I'm going to place the measuring tape alongside the space where the walk will take place. Set up the course (4meters) This is our walking course. I am going to time you as you walk the course. I will be asking you to walk the course two times. I will walk along side you the whole time during the measurement. Now, I would like to demonstrate how to do the measurement. You will start by lining your feet up at the starting point. Demonstrate the measurement Do you understand these directions and are you willing to do this test? (BM055) = 1 Yes 2 No  »

| | ========================================================================
| | 
BM056
1st Walking Speed Time ___.__ seconds

1ST WALKING SPEED TIME ___.__ SECONDS

| | ========================================================================
| | 
BM057
2nd Walking Speed Time ___.__ seconds

2ND WALKING SPEED TIME ___.__ SECONDS

| | ========================================================================
| | 
BM058
Record type of aid used

RECORD TYPE OF AID USED
- - - - - - - - - - - - - - - - - - - - - - - - -
1 None
2 Walking stick or cane
3 Elbow crutches
4 Walking frame
5 Other, please specify________________


| | ========================================================================
| | 
BM059
How compliant was R during this measurement?

HOW COMPLIANT WAS R DURING THIS MEASUREMENT?
- - - - - - - - - - - - - - - - - - - - - - - - -
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


========================================================================
BM060
[Equipment needed: CAPI, Flexible steel measuring tape, Sticky tape] We are now going to test your distance vision and near vision. Can you see light and count the fingers of hand held 2 feet in front of your face with one eye open and when wearing your glasses or contacts?

[EQUIPMENT NEEDED: CAPI, FLEXIBLE STEEL MEASURING TAPE, STICKY TAPE] WE ARE NOW GOING TO TEST YOUR DISTANCE VISION AND NEAR VISION. CAN YOU SEE LIGHT AND COUNT THE FINGERS OF HAND HELD 2 FEET IN FRONT OF YOUR FACE WITH ONE EYE OPEN AND WHEN WEARING YOUR GLASSES OR CONTACTS?

========================================================================
BM061
Distance Vision - Left Eye Distance Vision

DISTANCE VISION - LEFT EYE DISTANCE VISION

========================================================================
BM062
Distance Vision - Right Eye Distance Vision

DISTANCE VISION - RIGHT EYE DISTANCE VISION

========================================================================
BM063
Near Vision - Left Eye Near Vision

NEAR VISION - LEFT EYE NEAR VISION

========================================================================
BM064
Near Vision - Right Eye Near Vision

NEAR VISION - RIGHT EYE NEAR VISION

========================================================================
BM065
How compliant was R during this measurement?

HOW COMPLIANT WAS R DURING THIS MEASUREMENT?
- - - - - - - - - - - - - - - - - - - - - - - - -
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


========================================================================
BM066
[Equipment needed: Stadiometer] Can the respondent stand?

[EQUIPMENT NEEDED: STADIOMETER] CAN THE RESPONDENT STAND?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No


========================================================================
BM067
Record R's height in centimetres __._ cm [Hard check: 50>=BM067>250]

RECORD R’S HEIGHT IN CENTIMETRES __._ CM [HARD CHECK: 50>=BM067>250]

========================================================================
BM068
Was R wearing any artificial limbs or orthosis during the measurement?

WAS R WEARING ANY ARTIFICIAL LIMBS OR ORTHOSIS DURING THE MEASUREMENT?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No


========================================================================
BM069
How compliant was R during this measurement?

HOW COMPLIANT WAS R DURING THIS MEASUREMENT?
- - - - - - - - - - - - - - - - - - - - - - - - -
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


========================================================================
BM070
[Equipment needed: Weighing Scale] Next, I would like to measure your weight. To complete this measurement, I will be asking you to remove bulky clothing and to take off your shoes during weight measurements. Stand up and look straight ahead. [Instruction for Interviewer: Demonstrate the measurement]

[EQUIPMENT NEEDED: WEIGHING SCALE] NEXT, I WOULD LIKE TO MEASURE YOUR WEIGHT. TO COMPLETE THIS MEASUREMENT, I WILL BE ASKING YOU TO REMOVE BULKY CLOTHING AND TO TAKE OFF YOUR SHOES DURING WEIGHT MEASUREMENTS. STAND UP AND LOOK STRAIGHT AHEAD. [INSTRUCTION FOR INTERVIEWER: DEMONSTRATE THE MEASUREMENT]

========================================================================
BM071
[Instruction for Interviewer: Record measurement in kilograms in table below: Enter 993 if R tried but received an error message. Record R's weight up to 2 decimal points] ___._ _ [Soft check: 25<=BM071<=250]

[INSTRUCTION FOR INTERVIEWER: RECORD MEASUREMENT IN KILOGRAMS IN TABLE BELOW: ENTER 993 IF R TRIED BUT RECEIVED AN ERROR MESSAGE. RECORD R'S WEIGHT UP TO 2 DECIMAL POINTS] ___._ _ [SOFT CHECK: 25<=BM071<=250]

========================================================================
BM072
Was R wearing an artificial limb or orthosis during the measurement?

WAS R WEARING AN ARTIFICIAL LIMB OR ORTHOSIS DURING THE MEASUREMENT?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes, then record the weight of the artificial limb BM073 ___._
2 No


========================================================================
BM074
How compliant was R during this measurement?

HOW COMPLIANT WAS R DURING THIS MEASUREMENT?
- - - - - - - - - - - - - - - - - - - - - - - - -
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


========================================================================
BM075
[Equipment needed: Soft tape measure] Next I am going to ask you to perform a simple measurement of your waist circumference. For this measurement it is important for you to be standing. I will ask you to identify where on your body your navel (belly button) is located. I will then ask you to place this soft measuring tape around your waist, over your clothing, holding it securely at the level of your navel. Once the tape measure is placed appropriately around your waist then we are ready to begin. I will ask you to take a normal breath and exhale, holding your breath at the end of the exhale. I will then record the measurement.

[EQUIPMENT NEEDED: SOFT TAPE MEASURE] NEXT I AM GOING TO ASK YOU TO PERFORM A SIMPLE MEASUREMENT OF YOUR WAIST CIRCUMFERENCE. FOR THIS MEASUREMENT IT IS IMPORTANT FOR YOU TO BE STANDING. I WILL ASK YOU TO IDENTIFY WHERE ON YOUR BODY YOUR NAVEL (BELLY BUTTON) IS LOCATED. I WILL THEN ASK YOU TO PLACE THIS SOFT MEASURING TAPE AROUND YOUR WAIST, OVER YOUR CLOTHING, HOLDING IT SECURELY AT THE LEVEL OF YOUR NAVEL. ONCE THE TAPE MEASURE IS PLACED APPROPRIATELY AROUND YOUR WAIST THEN WE ARE READY TO BEGIN. I WILL ASK YOU TO TAKE A NORMAL BREATH AND EXHALE, HOLDING YOUR BREATH AT THE END OF THE EXHALE. I WILL THEN RECORD THE MEASUREMENT.

========================================================================
BM076
Waist Measurement ______ [Soft check: BM076 >=50 or <150]

WAIST MEASUREMENT ______ [SOFT CHECK: BM076 >=50 OR <150]

========================================================================
BM077
Was R wearing bulky clothing during this measurement?

WAS R WEARING BULKY CLOTHING DURING THIS MEASUREMENT?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No


========================================================================
BM078
[Equipment needed: Soft tape measure] Next I am going to ask you to perform a simple measurement of your hip circumference. For this measurement it is important for you to be standing. I will ask you to identify where the maximum circumference of your hip. I will then ask you to place this soft measuring tape around your hip, over your clothing, holding it securely. Once the tape measure is placed appropriately around your hip and parallel to floor then we are ready to begin. I will ask you to take a normal breath and exhale, holding your breath at the end of the exhale. I will then record the measurement.

[EQUIPMENT NEEDED: SOFT TAPE MEASURE] NEXT I AM GOING TO ASK YOU TO PERFORM A SIMPLE MEASUREMENT OF YOUR HIP CIRCUMFERENCE. FOR THIS MEASUREMENT IT IS IMPORTANT FOR YOU TO BE STANDING. I WILL ASK YOU TO IDENTIFY WHERE THE MAXIMUM CIRCUMFERENCE OF YOUR HIP. I WILL THEN ASK YOU TO PLACE THIS SOFT MEASURING TAPE AROUND YOUR HIP, OVER YOUR CLOTHING, HOLDING IT SECURELY. ONCE THE TAPE MEASURE IS PLACED APPROPRIATELY AROUND YOUR HIP AND PARALLEL TO FLOOR THEN WE ARE READY TO BEGIN. I WILL ASK YOU TO TAKE A NORMAL BREATH AND EXHALE, HOLDING YOUR BREATH AT THE END OF THE EXHALE. I WILL THEN RECORD THE MEASUREMENT.

========================================================================
BM079
Record measurement in table below: Enter 999 if R chose not to do it. Record R's Hip Circumference to the nearest 0.1 cm ______ [BM079>=50 or <150]

RECORD MEASUREMENT IN TABLE BELOW: ENTER 999 IF R CHOSE NOT TO DO IT. RECORD R'S HIP CIRCUMFERENCE TO THE NEAREST 0.1 CM ______ [BM079>=50 OR <150]

========================================================================
BM080
What difficulties occurred during this measurement? [Multiple answers are allowed][Instructions for CAPI: if BM080=a then freeze other options]

WHAT DIFFICULTIES OCCURRED DURING THIS MEASUREMENT? [MULTIPLE ANSWERS ARE ALLOWED][INSTRUCTIONS FOR CAPI: IF BM080=A THEN FREEZE OTHER OPTIONS]
- - - - - - - - - - - - - - - - - - - - - - - - -
1 None
2 R had breathing difficulties
3 R was unable to hold breath at the end of the 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
7 Other, please specify ___________


========================================================================
BM081
Who conducted this measurement?

WHO CONDUCTED THIS MEASUREMENT?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R conducted the measurement
2 IWER conducted the measurement


========================================================================
BM082
Do you have any of the following condition? [Instruction for CAPI: If any of questions BM082a to BM082e=1, then skip to BM088]

DO YOU HAVE ANY OF THE FOLLOWING CONDITION? [INSTRUCTION FOR CAPI: IF ANY OF QUESTIONS BM082A TO BM082E=1, THEN SKIP TO BM088]

========================================================================
BM082A
Active Tb or Upper Respiratory tract infection (cough)

ACTIVE TB OR UPPER RESPIRATORY TRACT INFECTION (COUGH)
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No


========================================================================
BM082B
Eye surgery in last 3months

EYE SURGERY IN LAST 3MONTHS
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No


========================================================================
BM082C
Abdominal Surgery in last 3 months

ABDOMINAL SURGERY IN LAST 3 MONTHS
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No


========================================================================
BM082D
Myocardial Infarction in last 3 month

MYOCARDIAL INFARCTION IN LAST 3 MONTH
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No


========================================================================
BM082E
[If DM003 =2 & DM005 < 55] Pregnancy ( any trimester)

[IF DM003 =2 & DM005 < 55] PREGNANCY ( ANY TRIMESTER)
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No


========================================================================
BM083
Have you used any Inhalers in the last 6 hours?

HAVE YOU USED ANY INHALERS IN THE LAST 6 HOURS?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No


========================================================================
BM084
[Equipment needed: Spirometer, Disposable mouthpiece] Next I am going to ask you to perform a simple task of taking a deep breath and then blowing as long and hard as you can into a small tube attached to this machine. The machine measures how long it takes you to blow out all the air from your lungs. I would like you to perform the measurement few times. When we are ready to begin, I will ask you to sit up straight. Open your mouth and close your lips firmly around the outside of the mouthpiece. Take as deep a breath as possible and then blow as hard and as fast as you can into the mouth piece followed by deep inhalation again like this.... Demonstrate the measurement. Sit up, place lips around the outside of the mouth piece. Take a deep breath, and then blow as hard and as fast as you can. Do you understand these directions and are you willing to provide this measurement?

[EQUIPMENT NEEDED: SPIROMETER, DISPOSABLE MOUTHPIECE] NEXT I AM GOING TO ASK YOU TO PERFORM A SIMPLE TASK OF TAKING A DEEP BREATH AND THEN BLOWING AS LONG AND HARD AS YOU CAN INTO A SMALL TUBE ATTACHED TO THIS MACHINE. THE MACHINE MEASURES HOW LONG IT TAKES YOU TO BLOW OUT ALL THE AIR FROM YOUR LUNGS. I WOULD LIKE YOU TO PERFORM THE MEASUREMENT FEW TIMES. WHEN WE ARE READY TO BEGIN, I WILL ASK YOU TO SIT UP STRAIGHT. OPEN YOUR MOUTH AND CLOSE YOUR LIPS FIRMLY AROUND THE OUTSIDE OF THE MOUTHPIECE. TAKE AS DEEP A BREATH AS POSSIBLE AND THEN BLOW AS HARD AND AS FAST AS YOU CAN INTO THE MOUTH PIECE FOLLOWED BY DEEP INHALATION AGAIN LIKE THIS.... DEMONSTRATE THE MEASUREMENT. SIT UP, PLACE LIPS AROUND THE OUTSIDE OF THE MOUTH PIECE. TAKE A DEEP BREATH, AND THEN BLOW AS HARD AND AS FAST AS YOU CAN. DO YOU UNDERSTAND THESE DIRECTIONS AND ARE YOU WILLING TO PROVIDE THIS MEASUREMENT?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No


If [Equipment needed: Spirometer, Disposable mouthpiece] Next I am going to ask you to perform a simple task of taking a deep breath and then blowing as long and hard as you can into a small tube attached to this machine. The machine measures how long it takes you to blow out all the air from your lungs. I would like you to perform the measurement few times. When we are ready to begin, I will ask you to sit up straight. Open your mouth and close your lips firmly around the outside of the mouthpiece. Take as deep a breath as possible and then blow as hard and as fast as you can into the mouth piece followed by deep inhalation again like this.... Demonstrate the measurement. Sit up, place lips around the outside of the mouth piece. Take a deep breath, and then blow as hard and as fast as you can. Do you understand these directions and are you willing to provide this measurement? (BM084) = 1 Yes 2 No  »

| ========================================================================
BM085
[Instruction for Interviewer: CAPI should be connected with Spirometry instrument. Perform the test; and the spirometry readings will be automatically recorded in the CAPI] [Instruction for Interviewer: Step1: CAPI should be connected with Spirometry inst

[INSTRUCTION FOR INTERVIEWER: CAPI SHOULD BE CONNECTED WITH SPIROMETRY INSTRUMENT. PERFORM THE TEST; AND THE SPIROMETRY READINGS WILL BE AUTOMATICALLY RECORDED IN THE CAPI] [INSTRUCTION FOR INTERVIEWER: STEP1: CAPI SHOULD BE CONNECTED WITH SPIROMETRY INSTRUMENT. STEP2: SCAN THE BARCODE ON MOUTHPIECE STEP3: ENTER THE BARCODE NUMBER TWICE: BM085_1&BM085_2 CAPI WILL CHECK BM085_1=BM085_2 IF NOT, RE-ENTER STEP4: PERFORM THE TEST; AND RECORD THE SPIROMETRY READINGS IN BM085A, BM085B & BM085C] BM085_1 BARCODE NUMBER:……………………………….
BM085_2 BARCODE NUMBER:………………………………
BM085_1 & BM085_2 UP TO 14 DIGITS
BM085A: FVC _____.___ ___
BM085B: FEV1_____.______
BM085C: PEF______.______

| ========================================================================
BM086
What was R's position for this test?

WHAT WAS R'S POSITION FOR THIS TEST?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Standing
2 Sitting
3 Lying down


| ========================================================================
BM087
How much effort did R give to this test?

HOW MUCH EFFORT DID R GIVE TO THIS TEST?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R gave full effort
2 R was prevented from giving full effort by illness, pain, or other symptoms or discomfort.
3 R did not appear to give full effort, but no obvious reason for this


========================================================================
BM088
I would like to collect a small sample of your blood using just a finger prick. We would be very grateful if you would agree to provide us with a sample of blood. This is an important part of the study, as the analysis of blood samples will tell us a lot about the health of the population. Before we begin, I would like to read this consent form. Longitudinal Ageing Study in India (LASI) International Institute for Population Sciences (IIPS) Additional Consent Form for Blood Sample Collection for Storage and Future Use This is in continuation with your individual consent that you have already given. Further, we would like to inform you that as a part of this longitudinal ageing study, we want to collect few drops of your blood sample using finger prick. The blood sample will be used to test anemia, diabetes, and chronic infections. Your blood sample will be extremely useful to plan special health care services for the older population in the country. The test uses new, disposable sterile instruments that are clean and completely safe in use. I will prick your finger to draw few drops of blood. These drops will be soaked on a piece of filter paper. These pieces of paper will be used to check various health conditions. The blood sample will be sent to National AIDS Research Institute (NARI), which is a premier institute devoted to health research for analysis and storage. The information you will provide will be kept strictly confidential. The results of the blood test will only be used for research and planning purposes without any personal identification. However, if you decide not to provide a blood sample, it is your right and we will respect your decision. Should you have any question about the survey please feel free to ask me or contact the concerned authority (Interviewer: Provide Card). Director / Project Coordinators International Institute for Population Sciences (IIPS) Govandi Station Road, Deonar, Mumbai-400 088. Tel: 022-42372-682/ 401/ 682/ 417/ 422, Fax: 022-42372401. Do you agree to provide consent for giving few drops of blood sample? (Circle one of the response)

I WOULD LIKE TO COLLECT A SMALL SAMPLE OF YOUR BLOOD USING JUST A FINGER PRICK. WE WOULD BE VERY GRATEFUL IF YOU WOULD AGREE TO PROVIDE US WITH A SAMPLE OF BLOOD. THIS IS AN IMPORTANT PART OF THE STUDY, AS THE ANALYSIS OF BLOOD SAMPLES WILL TELL US A LOT ABOUT THE HEALTH OF THE POPULATION. BEFORE WE BEGIN, I WOULD LIKE TO READ THIS CONSENT FORM. LONGITUDINAL AGEING STUDY IN INDIA (LASI) INTERNATIONAL INSTITUTE FOR POPULATION SCIENCES (IIPS) ADDITIONAL CONSENT FORM FOR BLOOD SAMPLE COLLECTION FOR STORAGE AND FUTURE USE THIS IS IN CONTINUATION WITH YOUR INDIVIDUAL CONSENT THAT YOU HAVE ALREADY GIVEN. FURTHER, WE WOULD LIKE TO INFORM YOU THAT AS A PART OF THIS LONGITUDINAL AGEING STUDY, WE WANT TO COLLECT FEW DROPS OF YOUR BLOOD SAMPLE USING FINGER PRICK. THE BLOOD SAMPLE WILL BE USED TO TEST ANEMIA, DIABETES, AND CHRONIC INFECTIONS. YOUR BLOOD SAMPLE WILL BE EXTREMELY USEFUL TO PLAN SPECIAL HEALTH CARE SERVICES FOR THE OLDER POPULATION IN THE COUNTRY. THE TEST USES NEW, DISPOSABLE STERILE INSTRUMENTS THAT ARE CLEAN AND COMPLETELY SAFE IN USE. I WILL PRICK YOUR FINGER TO DRAW FEW DROPS OF BLOOD. THESE DROPS WILL BE SOAKED ON A PIECE OF FILTER PAPER. THESE PIECES OF PAPER WILL BE USED TO CHECK VARIOUS HEALTH CONDITIONS. THE BLOOD SAMPLE WILL BE SENT TO NATIONAL AIDS RESEARCH INSTITUTE (NARI), WHICH IS A PREMIER INSTITUTE DEVOTED TO HEALTH RESEARCH FOR ANALYSIS AND STORAGE. THE INFORMATION YOU WILL PROVIDE WILL BE KEPT STRICTLY CONFIDENTIAL. THE RESULTS OF THE BLOOD TEST WILL ONLY BE USED FOR RESEARCH AND PLANNING PURPOSES WITHOUT ANY PERSONAL IDENTIFICATION. HOWEVER, IF YOU DECIDE NOT TO PROVIDE A BLOOD SAMPLE, IT IS YOUR RIGHT AND WE WILL RESPECT YOUR DECISION. SHOULD YOU HAVE ANY QUESTION ABOUT THE SURVEY PLEASE FEEL FREE TO ASK ME OR CONTACT THE CONCERNED AUTHORITY (INTERVIEWER: PROVIDE CARD). DIRECTOR / PROJECT COORDINATORS INTERNATIONAL INSTITUTE FOR POPULATION SCIENCES (IIPS) GOVANDI STATION ROAD, DEONAR, MUMBAI-400 088. TEL: 022-42372-682/ 401/ 682/ 417/ 422, FAX: 022-42372401. DO YOU AGREE TO PROVIDE CONSENT FOR GIVING FEW DROPS OF BLOOD SAMPLE? (CIRCLE ONE OF THE RESPONSE)
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Consent given along with signature/ thumb impression for blood sample collection
2 Consent given but without signature/thumb impression for blood sample collection
3 Consent Refused

If I would like to collect a small sample of your blood using just a finger prick. We would be very grateful if you would agree to provide us with a sample of blood. This is an important part of the study, as the analysis of blood samples will tell us a lot about the health of the population. Before we begin, I would like to read this consent form. Longitudinal Ageing Study in India (LASI) International Institute for Population Sciences (IIPS) Additional Consent Form for Blood Sample Collection for Storage and Future Use This is in continuation with your individual consent that you have already given. Further, we would like to inform you that as a part of this longitudinal ageing study, we want to collect few drops of your blood sample using finger prick. The blood sample will be used to test anemia, diabetes, and chronic infections. Your blood sample will be extremely useful to plan special health care services for the older population in the country. The test uses new, disposable sterile instruments that are clean and completely safe in use. I will prick your finger to draw few drops of blood. These drops will be soaked on a piece of filter paper. These pieces of paper will be used to check various health conditions. The blood sample will be sent to National AIDS Research Institute (NARI), which is a premier institute devoted to health research for analysis and storage. The information you will provide will be kept strictly confidential. The results of the blood test will only be used for research and planning purposes without any personal identification. However, if you decide not to provide a blood sample, it is your right and we will respect your decision. Should you have any question about the survey please feel free to ask me or contact the concerned authority (Interviewer: Provide Card). Director / Project Coordinators International Institute for Population Sciences (IIPS) Govandi Station Road, Deonar, Mumbai-400 088. Tel: 022-42372-682/ 401/ 682/ 417/ 422, Fax: 022-42372401. Do you agree to provide consent for giving few drops of blood sample? (Circle one of the response) (BM088) != 3 Consent Refused »

| ========================================================================
BM089
Date ___date(dd/mm/yyyy)

DATE ___DATE(DD/MM/YYYY)

| ========================================================================
BM090
Time ____:____ am/pm(12hour clock

TIME ____:____ AM/PM(12HOUR CLOCK

| ========================================================================
BM091
Instructions for IWER:Step 1. Scan the barcode. Step 2. Enter the Barcode number twice: BM091a & BM091b CAPI will check BM091a=Bm091b If not, re-enter.BM091a Sample Barcode number:______BM091b Sample Barcode number:______[BM091 up to 14 digits]

INSTRUCTIONS FOR IWER:STEP 1. SCAN THE BARCODE. STEP 2. ENTER THE BARCODE NUMBER TWICE: BM091A & BM091B CAPI WILL CHECK BM091A=BM091B IF NOT, RE-ENTER.BM091A SAMPLE BARCODE NUMBER:______BM091B SAMPLE BARCODE NUMBER:______[BM091 UP TO 14 DIGITS]

| ========================================================================
BM092
What, if any, problems occurred during the collection of the blood sample? [Multiple answers are allowed] [Instruction for CAPI: BM092=a then freeze other options]

WHAT, IF ANY, PROBLEMS OCCURRED DURING THE COLLECTION OF THE BLOOD SAMPLE? [MULTIPLE ANSWERS ARE ALLOWED] [INSTRUCTION FOR CAPI: BM092=A THEN FREEZE OTHER OPTIONS]
- - - - - - - - - - - - - - - - - - - - - - - - -
1 None
2 R became light-headed, fainted, or nauseous
3 R had difficulty getting finger to stop bleeding
4 Unable to obtain enough blood
5 Problem with equipment or supplies
6 Other, please specify: ________________________


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BM093
How many circles were filled on the DBS card?

HOW MANY CIRCLES WERE FILLED ON THE DBS CARD?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 0
2 1
3 2
4 3
5 4
6 5


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BM094
[For the Health Investigator]DBS quality assessment by the health investigator, which is to be completed after they have collected blood spots. What is the quality of the blood spots that have been collected?

[FOR THE HEALTH INVESTIGATOR]DBS QUALITY ASSESSMENT BY THE HEALTH INVESTIGATOR, WHICH IS TO BE COMPLETED AFTER THEY HAVE COLLECTED BLOOD SPOTS. WHAT IS THE QUALITY OF THE BLOOD SPOTS THAT HAVE BEEN COLLECTED?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Good (will yield five to six 3-mm punches per spot)
2 Fair (will yield three to four 3-mm punches per spot)
3 Poor (will yield one to two 3-mm punches per spot)
4 Spots are unusable


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BM095
How many times did the R's finger need to be pricked in order to get 5 drops of blood?

HOW MANY TIMES DID THE R'S FINGER NEED TO BE PRICKED IN ORDER TO GET 5 DROPS OF BLOOD?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 One time
2 Twice
3 Twice but the R was unable to get 5 drops of blood


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BM096
How compliant was R during this measurement?

HOW COMPLIANT WAS R DURING THIS MEASUREMENT?
- - - - - - - - - - - - - - - - - - - - - - - - -
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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BM097
Thank you for your cooperation. This concludes the physical measure and biomarkers portion of the survey.

THANK YOU FOR YOUR COOPERATION. THIS CONCLUDES THE PHYSICAL MEASURE AND BIOMARKERS PORTION OF THE SURVEY.

End of I_BM. BIOMARKERS (BM)