STRONG HEART STUDY PHASE I DATA DICTIONARY ROSE QUESTIONNAIRE FORM

QUESTION NO POSITION
4 1 2 3 4 5 6 7 7 7 7 7 8 9 10 11 12 13 14 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

VARIABLE
IDNO ROSE1 ROSE2 ROSE3 ROSE4 ROSE5 ROSE6 ROSE7A ROSE7B ROSE7C ROSE7D ROSE7E ROSE8 ROSE9 ROSE10 ROSE11 ROSE12 ROSE13 ROSE14

TYPE
Char Char Char Char Char Char Char Char Char Char Char Char Char Char Char Char Char Char Char

LENGTH
6 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

LABEL
SHS ID NUMBER PAIN/DISCOMFORT IN CHEST CHEST PAIN WALKING UPHILL, UPSTAIRS OR HURRY CHEST PAIN WALKING ORDINARY PACE ON LEVEL RESPONSE TO CHEST PAIN WHEN WALKING CHEST PAIN STANDING STILL TIME TO CHEST PAIN RELIEF LOCATION OF CHEST PAIN/STERNUM-UPPER/MID LOCATION OF CHEST PAIN/STERNUM-LOWER LOCATION OF CHEST PAIN/LT ANT CHEST LOCATION OF CHEST PAIN/LEFT ARM LOCATION OF CHEST PAIN/OTHER OTHER CHEST PAIN LOCATION SEVERE FRONT CHEST PAIN >= 30 MIN LEG PAIN WALKING LEG PAIN WHEN STILL LEG PAIN LOCATION LEG PAIN WALKING UPHILL OR HURRY LEG PAIN WALKING ORDINARY PACE ON LEVEL

RESPONSE
NUMBERS 1=YES, 2=NO 1=YES, 2=NO, 3=NEVER HURRIES OR WALKS UPHILL OR UPSTAIRS 1=YES, 2=NO 1=STOP OR SLOW DOWN, 2=CARRY ON 1=RELEIVED, 2=NOT RELIEVED 1=10 MIN OR LESS, 2=MORE THAN 10 MIN 1=YES 1=YES 1=YES 1=YES 1=YES 1=YES, 2=NO 1=YES, 2=NO 1=YES, 2=NO 1=YES, 2=NO 1=INCLUDES CALF/CALVES, 2=DOES NOT INCLUDE CALF/CALVES 1=YES, 2=NO, 3=NEVER HURRIES OR WALKS UPHILL 1=YES, 2=NO

Tuesday, June 05, 2007

Page 1 of 2

Rose Questionnaire Form

QUESTION NO
15 16 17 18

POSITION
28 29 30 31 32 35

VARIABLE
ROSE15 ROSE16 ROSE17 ROSE18 CODE DOC

TYPE
Char Char Char Char Char Num

LENGTH
1 1 1 1 3 4

LABEL
LEG PAIN EVER RELIEVED WHEN WALKING RESPONSE TO LEG PAIN WHEN WALKING LEG PAIN STANDING STILL TIME TO LEG PAIN RELIEF PERSONNEL CODE NUMBER DATE OF DATA COLLECTION

RESPONSE
1=YES, 2=NO 1=STOP OR SLOW DOWN, 2=CARRY ON 1=RELIEVED, 2=NOT RELIEVED 1=10 MIN OR LESS, 2=MORE THAN 10 MIN NUMBERS MMDDYY

Tuesday, June 05, 2007

Page 2 of 2

Rose Questionnaire Form