I_BM. Biomarkers (BM)
I_BM. Biomarkers (BM) of LASI 2017-2019
Start of I_BM. Biomarkers (BM)
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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
[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
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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
DID YOU SMOKE, EXERCISE, OR CONSUME ALCOHOL OR FOOD WITHIN THE 30 MINUTES PRIOR THE BLOOD PRESSURE TEST?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No
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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?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No
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
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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? (BM003) = 1 Yes
2 No
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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
[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
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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? (BM004) = 2 »
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BM020
Which arm was used to conduct the measurements?
WHICH ARM WAS USED TO CONDUCT THE MEASUREMENTS?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Left arm
2 Right arm
WHICH ARM WAS USED TO CONDUCT THE MEASUREMENTS?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Left arm
2 Right arm
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BM021
What was R's position for this test?
WHAT WAS R'S POSITION FOR THIS TEST?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Standing
2 Sitting
3 Lying down
WHAT WAS R'S POSITION FOR THIS TEST?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Standing
2 Sitting
3 Lying down
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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]
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]
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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.
[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.
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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
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
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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
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
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BM026
Which is your dominant hand?
WHICH IS YOUR DOMINANT HAND?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Right hand
2 Left hand
3 Both hands equally dominant
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 »
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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
1ST LEFT HAND [(ASK IF BM024=1 & BM025=3) OR BM024=2] ____._ KG
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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
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 »
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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
1ST RIGHT HAND [(ASK IF BM024=1 & BM025=2) OR BM024=2] ____._ KG
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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
2ND RIGHT HAND [(ASK IF BM024=1 & BM025=2) OR BM024=2] ____._ KG
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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
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
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BM033
What was R's position for this test?
WHAT WAS R'S POSITION FOR THIS TEST?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Standing
2 Sitting
3 Lying down
WHAT WAS R'S POSITION FOR THIS TEST?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Standing
2 Sitting
3 Lying down
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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?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No
DID R REST THEIR ARM ON A SUPPORT WHILE PERFORMING THE TEST?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No
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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.
[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.
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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
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
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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
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
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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? (BM037) = 1 Yes
2 No
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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]
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
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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]
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]
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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?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No
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
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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?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No
[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
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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]
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]
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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?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No
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
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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.
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Wood/ Tile/ Linoleum
2 Concrete
3 Kutchha/ Mud
RECORD THE TYPE OF FLOOR SURFACE THAT THE BALANCE MEASURES WERE CONDUCTED ON.
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Wood/ Tile/ Linoleum
2 Concrete
3 Kutchha/ Mud
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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
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
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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:
- - - - - - - - - - - - - - - - - - - - - - - - -
1 30 seconds full-tandem balance measurement
2 60 seconds full-tandem balance measurement
[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
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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?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No
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
»
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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
RECORD THE TYPE OF FLOOR SURFACE THAT THE BALANCE MEASURES WERE CONDUCTED ON.
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Wood/ Tile/ Linoleum
2 Concrete
3 Kutchha/ Mud
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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?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 No apparent restriction
2 Yes, recent surgery
3 Yes, injury
4 Yes, other health condition
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
»
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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
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
»
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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________________
RECORD TYPE OF AID USED
- - - - - - - - - - - - - - - - - - - - - - - - -
1 None
2 Walking stick or cane
3 Elbow crutches
4 Walking frame
5 Other, please specify________________
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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
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?
[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?
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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
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
[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]
RECORD R’S HEIGHT IN CENTIMETRES __._ CM [HARD CHECK: 50>=BM067>250]
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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
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
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]
[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]
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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]
[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]
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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
WAS R WEARING AN ARTIFICIAL LIMB OR ORTHOSIS DURING THE MEASUREMENT?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes, then record the weight of the artificial limb BM073 ___._
2 No
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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
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.
[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.
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BM076
Waist Measurement ______ [Soft check: BM076 >=50 or <150]
WAIST MEASUREMENT ______ [SOFT CHECK: BM076 >=50 OR <150]
WAIST MEASUREMENT ______ [SOFT CHECK: BM076 >=50 OR <150]
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BM077
Was R wearing bulky clothing during this measurement?
WAS R WEARING BULKY CLOTHING DURING THIS MEASUREMENT?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No
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.
[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.
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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]
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]
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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 ___________
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 ___________
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BM081
Who conducted this measurement?
WHO CONDUCTED THIS MEASUREMENT?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R conducted the measurement
2 IWER conducted the measurement
WHO CONDUCTED THIS MEASUREMENT?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 R conducted the measurement
2 IWER conducted the 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]
DO YOU HAVE ANY OF THE FOLLOWING CONDITION? [INSTRUCTION FOR CAPI: IF ANY OF QUESTIONS BM082A TO BM082E=1, THEN SKIP TO BM088]
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BM082A
Active Tb or Upper Respiratory tract infection (cough)
ACTIVE TB OR UPPER RESPIRATORY TRACT INFECTION (COUGH)
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No
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
EYE SURGERY IN LAST 3MONTHS
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No
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BM082C
Abdominal Surgery in last 3 months
ABDOMINAL SURGERY IN LAST 3 MONTHS
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No
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
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
[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
HAVE YOU USED ANY INHALERS IN THE LAST 6 HOURS?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No
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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?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Yes
2 No
[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
»
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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______.______
[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______.______
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BM086
What was R's position for this test?
WHAT WAS R'S POSITION FOR THIS TEST?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Standing
2 Sitting
3 Lying down
WHAT WAS R'S POSITION FOR THIS TEST?
- - - - - - - - - - - - - - - - - - - - - - - - -
1 Standing
2 Sitting
3 Lying down
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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
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
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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)
- - - - - - - - - - - - - - - - - - - - - - - - -
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
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 »
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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]
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]
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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: ________________________
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
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
[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
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
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.
THANK YOU FOR YOUR COOPERATION. THIS CONCLUDES THE PHYSICAL MEASURE AND BIOMARKERS PORTION OF THE SURVEY.
End of I_BM. Biomarkers (BM)