Page 1 Thank you for taking part in this study! We ask that you complete this questionnaire as well. The information will be used in research for preventive health care. Some of the questions are similar to questions you answered on the questionnaire that you completed at home and took with you when you attended the health examination. It is important that you answer all the questions on this questionnaire. The completed questionnaire should be returned in the enclosed pre-stamped envelope. All information will be treated in strict confidence.
The Norwegian Institute of Public Health
If you do not wish to answer the questionnaire, put an X here and return the form. As a result, you will not receive a reminder.
COMPLETION Date of completion of the questionnaire: ___/___ 19___
CHILDHOOD What town did you live in when you were 1 year old? If you were not living in Norway, write the country instead of the town. If you are or have been gainfully employed, please specify which of the following categories your occupation best falls under. (If you are not currently employed, give your last occupation.)(Two answer columns: you and your spouse/partner) Semi-skilled, unskilled worker Skilled worker, artisan, foreman Non-professional occupation (shop, office, public service) Lower professional occupation (e.g. nurse, technician, teacher) Management position in public or private enterprise Farmer or forest owner Fisherman Self-employed professional (e.g. dentist, lawyer) Self-employed businessperson Have not been gainfully employed If your spouse/partner is or has been gainfully employed, please specify which occupational category his/her work falls under. (If not currently employed, give last occupation.) Semi-skilled, unskilled worker Skilled worker, artisan, foreman Non-professional occupation (shop, office, public service) Lower professional occupation (e.g. nurse, technician, teacher) Management position in public or private enterprise
Farmer or forest owner Fisherman Self-employed professional (e.g. dentist, lawyer) Self-employed businessperson Have not been gainfully employed
If you are not CURRENTLY gainfully employed or you do not do full-time housework, then go to HOUSING.
During the last 12 months, have you been on sick leave: <yes, no> without a medical certificate with a medical certificate
If YES: How long altogether? Only one X 2 weeks or less 2-8 weeks More than 8 weeks During the last 12 months, have you considered changing your career or job? <yes, no> Is your work so physically demanding that you are often physically worn out after a day’s work? Only one X Yes, nearly always Quite often Seldom Never, or almost never Does your work require so much concentration and attention that you often feel worn out after a day’s work? Yes, nearly always Quite often Seldom Never, or almost never All things considered, how much do you enjoy your work? A great deal A fair amount Not much Not at all HOUSING Who do you live with? Put an X for each line and write in the number Spouse/partner <yes, no> Other people over the age of 18 <yes, no> Number ____ People below the age of 18 <yes, no> Number ____ How many of the children attend day care? Number ____ What type of housing do you live in?X one box only Single-family house/villa Farm Flat in block or terraced block of flats Terraced house/2-4 family housing Other accommodations How large is your home? <Square metres ____> Are there fitted carpets in the living room? <yes, no> Are there fitted carpets in your bedroom? <yes, no> Is there a cat in the home? <yes, no> Is there a dog in the home <yes, no> Are there other animals with fur or birds in the home? <yes, no> FINANCES Do you receive any of the following public welfare benefits? <yes, no> Sick pay/rehabilitation benefits Retraining benefits Disability pension Retirement/old age pension Family income supplement Unemployment benefits Transitional benefits Widow’s pension Other benefits During the last year, has it at any time been difficult to meet the costs of food, transportation, housing and such?Only one X Yes, often Yes, sometimes Yes, though seldom No, never FRIENDS How many good friends do you have? Number ____ Count those with whom you can confidentially talk and who can help you when you are in need. Do not include those with whom you live, but include other relatives. Do you feel that you have enough good friends? <yes, no> How often do you usually participate in social activities such as a sewing club, athletic club, political association, religious or other groups? Never, or only a few times a year 1-2 times a month About once a week More than once a week Page 2 WHERE YOU LIVE Answer with regard to your environment, i.e. neighbourhood/group of farms. One X for each statement <Strongly agree, Somewhat agree, Not sure, Somewhat disagree, Strongly disagree> I feel a strong sense of community with the people who live here Even if someone takes the initiative, no one participates in the things going on here If I move from here, I will want to return We do not trust each other here If something has to be done here, it is easy to get people involved It is difficult to get to know people here There is a sense of unity here Nobody bothers to take initiative here anymore People like living here People here can have major problems without the neighbours knowing anything about it Somebody always takes the initiative to do what needs to be done here People here don’t talk much to each other
ILLNESS IN THE FAMILY Put an X for the relatives who have or have had any of the following illnesses. If none of your relatives has had a particular disease, put an X in the box for Nobody on that line. Possibly several Xs on each line <Mother, Father, Brother, Sister, Child, Nobody> Stroke or cerebral haemorrhage Heart attack before the age of 60 Asthma Allergy Cancer High blood pressure Mental health problems Osteoporosis Diabetes Age when he/she got diabetes Years old____ Do you have hay fever or nasal allergies? <yes, no> USE OF HEALTH SERVICES During the last 12 months, have you visited any of the following: <yes, no> One X for each line General practitioner (community doctor, private doctor, intern) Company physician Doctor at hospital (without being hospitalized) Another doctor Physiotherapist Chiropractor Homoeopath Other treatment provider (naturopath, reflexologist, laying on of hands, healer, psychic, etc.) Have you been hospitalized during the last 5 years? <yes, no> ALCOHOL If you are a non-drinker, go to DIET One X for each question Have you ever felt that you should reduce your alcohol intake? <yes, no> Have other people ever criticised your use of alcohol? <yes, no> Have you ever felt bad or guilty because of your use of alcohol? <yes, no> Have you ever had a drink first thing in the morning as a pick-me-up or to calm your nerves or to cure a hangover? <yes, no> DIET How many meals do you usually eat a day (dinner and meals with bread)? Number ____ How many days a week do you have a warm dinner? Number ____ What kind of bread (bought or homemade) do you usually eat?No more than two Xs The bread type is most like… <White, White multigrain (finely ground), Wholemeal (medium ground), Multigrain wholemeal (coarsely ground), Crispbread> What kind of fat is usually used in your household? One X for cooking and one X for bread < For cooking, On bread> Do not use butter or margarine Dairy butter Hard margarine Soft margarine Butter/margarine blend Low fat margarine Oils
USE OF MEDICINE During the last 12 months, have you taken anymedicines daily or almost daily? <yes, no>
If YES, Indicate for how many months you used the following medicines: Write 0 if you have not used these medicines. No. of months ____ Analgesics (pain relief medicine) Sleep medicine Sedatives Medicine for depression Allergy medicine Asthma medicine Heart medicine (not blood pressure medicine) Other medicine Dietary supplements: Iron tablets Vitamin supplements Cod liver oil/fish oil How often have you taken tranquilizers/sedatives or sleep medication in the last month? Daily Weekly, but not every day Not as often as every week Never Page 3 HEADACHES Have you had headaches in the last 12 months? Yes, in attacks (migraines) Yes, other types of headaches No Number of headaches in the last 12 months ____ About how many days per month do you have a headache? Less than 7 days 7 to 14 days More than 14 days How long do the headaches last each time? Less than 4 hours 4 hours - 3 days More than 3 days How often is the headache characterised by or accompanied by: One X for each line <Seldom or never, Now and again, Often> Throbbing, thumping pain Pressing pain Pain on one side of the head, always the same side Pain on one side of the head, alternating left and right sides Pain in entire head Nausea Hypersensitivity to light and/or noise Worsening with physical activity Visual disturbance before onset of headache How many tablets/suppositories of these medicines have you used altogether in the last month? Put 0 of you have not used any of these medicines Cafergot Anervan Imigran
MUSCULOSKELETAL CONDITIONS Have you had discomfort (pain, aching) in your muscles/limbsin the last month? <yes, no>
If YES, Where did you have the discomfort (one or more Xs) and for about how many days altogether were you troubled? Number of days ____ Discomfort/pain (put a cross): Neck Shoulders/upper arms Upper back Elbows Lower back Wrists/hands Hips Knees Ankles/feet
If there are several Xs, put a ring around the X for the area that bothered you the most. Did the discomfort hinder you in carrying out your everyday activities in the last month? <yes, no> At work During leisure time
Two versions were given: one had VISION section instead of LEG PAIN section Have you ever had any of the following eye conditions? <Yes, No, Don’t know> Cataract Glaucoma (raised eye pressure) Do you wear glasses? <yes, no> Do you wear contact lenses? <yes, no> Are you able to read small print (such as this text): <yes, no> without glasses/contact lenses/magnifying glass with glasses/contact lenses/magnifying glass Are you able to see quite far: <Yes, No, Don’t know> without glasses/contact lenses with glasses/contact lenses If you wear glasses or contact lenses, is this because: Shortsightedness/myopia (minus glasses) Farsightedness/hyperopia (plus glasses) Old age (reading glasses) How old were you the first time that you were prescribed glasses or contact lenses? Years old ____ LEG PAIN 2ND version sent out had LEG PAIN section instead of VISION Do you have an ulcer(s) on your toes, foot or ankle that will not heal? <yes, no> Do you have pain in one or both legs when you walk? <yes, no> Have you seen a doctor because of pain in your legs? <yes, no>
If you answered NO to the above questions, then skip to URINARY TRACT AND PROSTATE PROBLEMS
Can you walk further than 50 metres? <yes, no> Does the pain go away if you stand still a while? <yes, no> Do you have to sit down so that the pain passes? <yes, no> Where does it hurt the most? Foot Leg Thigh Hip Do you have pain in your legs when you are resting? <yes, no> Is the pain worse when you lay in bed? <yes, no> Is your sleep disturbed because of the pain? <yes, no> Do you have less pain when you elevate your legs? <yes, no> Do you have less pain if you have your legs lower, such as over the edge of the bed? <yes, no> Does it lessen the pain if you get up and walk a little? <yes, no>
URINARY TRACT AND PROSTATE PROBLEMS One X for each line Have you ever been told by a doctor that you have: <yes, no> An enlarged prostate Prostate cancer Have you had any of the following procedures done: <yes, no> Vasectomy A tissue sample (biopsy) of the prostate taken Prostatectomy (prostate removal - whole or partial) The next questions apply to the last month Only one X for each question How often have you had the feeling that your bladder is not completely empty after you have finished urinating? Never About 1 out of 5 times About 1 out of 3 times About every other time About 2 out of 3 times Almost always How often have you had to urinate again less than 2 hours after urinating? Never About 1 out of 5 times About 1 out of 3 times About every other time About 2 out of 3 times Almost always How often have you had to stop and start several times when urinating? Never About 1 out of 5 times About 1 out of 3 times About every other time About 2 out of 3 times Almost always How often has it been difficult to hold back when you felt the need to urinate? Never About 1 out of 5 times About 1 out of 3 times About every other time About 2 out of 3 times Almost always How often have you had a weak urine flow? Never About 1 out of 5 times About 1 out of 3 times About every other time About 2 out of 3 times Almost always How often have you had to push or press to start urinating? Never About 1 out of 5 times About 1 out of 3 times About every other time About 2 out of 3 times Almost always How many times do you usually get up during the night to urinate? Never Once Twice Thrice 4 times 5 times or more If you had to live the rest of your life with the urination problems that you have now, how would you feel about it? Very satisfied Satisfied Mostly satisfied Mixed feelings Mostly dissatisfied Dissatisfied Very dissatisfied
Page 4 MOOD AND WELLBEING One X for each line How you have felt in the last month? <Never, Sometimes, Quite often, Mostly> in a good mood in a bad mood Are you quick to understand that something is funny? Very slow Quite slow Quite quick Very quick Do you agree that there is something irresponsible about people who constantly try to be funny? No, not at all To some extent Quite agree Yes, absolutely Are you a cheerful person? No, not at all To some extent Quite cheerful Yes, absolutely
TEMPER Put an X by the answer that best describes you in regards to the two statements below:
I express my anger, and other people know that I am angry. Almost never Sometimes Quite often Almost always I boil with anger, but I don’t show it to others. Almost never Sometimes Quite often Almost always
REST AND RELAXATION How many hours do you usually spend lying down during a 24 hour period? How many hours do you usually spend sitting down during a 24 hour period? Work, mealtimes, TV, car, etc., Number of hours ____ How often do you suffer from insomnia? Never or a few times a year 1-2 times a month About once a week More than once a week During the last year, have you been troubled by insomnia to such adegree that it affected your work? <yes, no> Have you had difficulty falling asleep in the last month?Only one X Almost every night Often Now and again Never During the last month, have you woken too early and not been able to get back to sleep? Only one X Almost every night Often Now and again Never During the last month, have you felt nervous (irritable, anxious, tense or restless)? Almost all the time Often Now and again Never
HOW YOU FELT During your life, have there been periods of 2 consecutive weeks or more when you: <yes, no> Felt depressed, sad and down Had appetite problems or ate too little Felt weak (adynamic) or lacked extra energy Really reproached yourself and felt worthless Had problems concentrating or had difficulty making decisions Had at least three of the above mentioned problems simultaneously
HOW YOU SEE YOURSELF People see themselves in different ways. For each statement, put an X to indicate how much or how little you agree with it. One X for each line <Strongly agree, Agree, Disagree, Strongly disagree> I have a positive opinion of myself. I feel really useless at times. I feel that I do not have much to be proud of. I feel that I am a valuable person, at least equal to others. Do you feel that you have a meaningful life? <yes, no> Do you feel that you live life to its fullest? <yes, no>
HOW YOU FEEL Put an X in the box by the answer that best describes your feelings last week. Only one X Would you say you are usually cheerful or downhearted? Very downhearted Downhearted Somewhat downhearted Some of both Somewhat cheerful Cheerful Very cheerful Do you by and large feel calm and good? Almost all the time Often Sometimes Never Do you feel, for the most part, strong and fit or tired and worn out? Very strong and fit Strong and fit Somewhat strong and fit Somewhat in between Somewhat tired and worn out Tired and worn out Very tired and worn out Place the completed questionnaire in the enclosed reply envelope and post it as soon as possible! The postage is paid. Many thanks for your help!
Neurology Asia 2004; 9 (Supplement 1) : 118 – 119 A comparative study of seizure frequency and neuroimaging changes in patients with neurocysticercosis with and without albendazole therapy K Das, S Basu, GP Mondal, BB Mukherjee, KK Dey, B Mukherjee Neurology Department, Burdwan Medical College and Hospital, Burdwan, West Bengal, India Objective: Neurocysticercosis is a common cause of a
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