09 ANNUAL FOLLOW-UP RESPONSE CARDS
(Version Date: 01/15/2005)
RESPONSE CARDS Page 1 of 20
ANNUAL FOLLOW-UP 9
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RESPONSE CARD A
DON’T TAKE ANY
1-3 DAYS PER WEEK
4-6 DAYS PER WEEK
EVERYDAY
ANNUAL FOLLOW-UP INTERVIEW
QUESTION B25 (a to n), B29a
ABBREVIATED PLUS FOLLOW-UP INTERVIEW
QUESTION B25 (a to n), B29a
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RESPONSE CARD B
NONE OR FEWER THAN ONE A WEEK
1 PER WEEK
2 PER WEEK
3-4 PER WEEK
5-6 PER WEEK
7 OR MORE PER WEEK
ANNUAL FOLLOW-UP INTERVIEW
QUESTION B30-B32
ABBREVIATED PLUS FOLLOW-UP INTERVIEW
QUESTION B30-B32
RESPONSE CARDS Page 3 of 20
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RESPONSE CARD C
A. HEART DISEASE
B. OSTEOPOROSIS
C. MENOPAUSAL SYMPTOMS
D. STAY YOUNG-LOOKING
E. IMPROVE MEMORY
F. REGULATE PERIODS
G. GENERAL HEALTH
H. LOSE WEIGHT OR STAY THE SAME WEIGHT
I. ADVICE FROM HEALTH CARE PROVIDER
J. OTHER REASON (SPECIFY)
ANNUAL FOLLOW-UP INTERVIEW
QUESTION C1-C21
ABBREVIATED PLUS FOLLOW-UP INTERVIEW
QUESTION C1-C21
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RESPONSE CARD D
MEDICAL DOCTOR (MD) ................................................. 1
DOCTOR OF OSTEOPATHY (DO) ................................... 2
CHIROPRACTOR (DC) ..................................................... 3
REGISTERED NURSE (RN) ............................................. 4
NURSE PRACTITIONER (NP) .......................................... 5
PHYSICIAN ASSISTANT (PA) .......................................... 6
OTHER (SPECIFY) ........................................................... 7
ANNUAL FOLLOW-UP INTERVIEW
QUESTION D13
ABBREVIATED PLUS FOLLOW-UP INTERVIEW
QUESTION D16
BREAK FRACTURE EVENT FORM
QUESTION E2
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RESPONSE CARD E
BECOME FARTHER APART ............................................ 1
BECOME CLOSER TOGETHER ...................................... 2
OCCURRED AT MORE VARIABLE
INTERVALS ....................................................................... 3
STAYED THE SAME ......................................................... 4
BECOME MORE REGULAR ............................................ 5
ANNUAL FOLLOW-UP INTERVIEW
QUESTION E4
ABBREVIATED PLUS FOLLOW-UP INTERVIEW
QUESTION E4
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RESPONSE CARD F
LIVE BIRTH ....................................................................... 1
STILL BIRTH ..................................................................... 2
MISCARRIAGE ................................................................. 3
ABORTION ........................................................................ 4
TUBAL/ECTOPIC PREGNANCY ...................................... 5
STILL PREGNANT ............................................................ 6
ANNUAL FOLLOW-UP INTERVIEW
QUESTION E6a
ABBREVIATED PLUS FOLLOW-UP INTERVIEW
QUESTION E6a
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ANNUAL FOLLOW-UP 9
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RESPONSE CARD G
0 1 2 3 4 5 6 7 8 9 10
WORST BEST
POSSIBLE POSSIBLE
QUALITY QUALITY
ANNUAL FOLLOW-UP INTERVIEW
QUESTION F1
ABBREVIATED PLUS FOLLOW-UP INTERVIEW
QUESTION G1
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RESPONSE CARD H
NEVER .............................................................................. 1
ALMOST NEVER .............................................................. 2
SOMETIMES ..................................................................... 3
FAIRLY OFTEN ................................................................. 4
VERY OFTEN .................................................................... 5
ANNUAL FOLLOW-UP INTERVIEW
QUESTION F4 (a to d)
ABBREVIATED PLUS FOLLOW-UP INTERVIEW
QUESTION G2 to G5
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RESPONSE CARD I
RARELY OR NONE OF THE TIME
(LESS THAN 1 DAY) ......................................................... 1
SOME OR A LITTLE OF THE TIME
(1-2 DAYS)......................................................................... 2
OCCASIONALLY OR A MODERATE AMOUNT
OF THE TIME (3-4 DAYS) ................................................. 3
MOST OR ALL OF THE TIME (5-7 DAYS) ....................... 4
ANNUAL FOLLOW-UP INTERVIEW
QUESTION F5 (a to t)
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RESPONSE CARD J
NONE OR LESS THAN ONE PER MONTH
1-3 PER MONTH
1 PER WEEK
2-4 PER WEEK
5-6 PER WEEK
1 PER DAY
2-3 PER DAY
4 PER DAY
5 OR MORE PER DAY
ABBREVIATED PLUS FOLLOW- UP INTERVIEW
QUESTION F2 –F4
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RESPONSE CARD K
NOT AT ALL TRUE
A LITTLE BIT TRUE
MODERATELY TRUE
QUITE A BIT TRUE
EXTREMELY TRUE
ABBREVIATED PLUS FOLLOW-UP INTERVIEW
QUESTION G6
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RESPONSE CARD L
STRONGLY AGREE
AGREE
NEITHER AGREE NOR DISAGREE
DISAGREE
STRONGLY DISAGREE
ABBREVIATED PLUS FOLLOW-UP INTERVIEW
QUESTION G7
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ANNUAL FOLLOW-UP 9
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RESPONSE CARD M
NEVER OR LESS THAN 1 HOUR A WEEK
AT LEAST 1 HOUR/WEEK BUT LESS THAN 1 HOUR/DAY
1 – 2 HOURS A DAY
2 – 4 HOURS A DAY
MORE THAN 4 HOURS A DAY
ABBREVIATED PLUS FOLLOW-UP INTERVIEW
QUESTION G8
RESPONSE CARDS Page 14 of 20
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RESPONSE CARD N
NEVER OR LESS THAN 5 MINUTES PER DAY
5 – 15 MINUTES PER DAY
16 – 30 MINUTES PER DAY
31 – 45 MINUTES PER DAY
MORE THAN 45 MINUTES PER DAY
ABBREVIATED PLUS FOLLOW-UP INTERVIEW
QUESTION G9
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ANNUAL FOLLOW-UP 9
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RESPONSE CARD O
NO
YES, NOT AT ALL UPSETTING
YES, SOMEWHAT UPSETTING
YES, VERY UPSETTING
YES, VERY UPSETTING AND STILL UPSETTING
ABBREVIATED PLUS FOLLOW-UP INTERVIEW
QUESTION H1 (a to f)
RESPONSE CARD P
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ANNUAL FOLLOW-UP 9
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NOT AT ALL
1-5 DAYS
6-8 DAYS
9-13 DAYS
EVERYDAY
ABBREVIATED PLUS FOLLOW-UP INTERVIEW
QUESTION I1 (a to s)
RESPONSE CARDS Page 17 of 20
ANNUAL FOLLOW-UP 9
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RESPONSE CARD X
AFTER A FALL FROM A HEIGHT ABOVE THE GROUND
GREATER THAN SIX INCHES
IN A MOTOR VEHICLE ACCIDENT
WHILE MOVING FAST, LIKE RUNNING, BICYCLING, OR
SKATING
WHILE PLAYING SPORTS
BECAUSE SOMETHING HEAVY FELL ON YOU OR STRUCK
YOU
BREAK FRACTURE EVENT FORM
QUESTION B2a
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RESPONSE CARD Y
YOURSELF ................................................................. 1
MOTHER OR SISTER ................................................. 2
OTHER FAMILY MEMBER.......................................... 3
FRIEND........................................................................ 4
PRIMARY CARE PROVIDER...................................... 5
GYNECOLOGIST ........................................................ 6
OTHER HEALTH CARE PROVIDER .......................... 7
OTHER (SPECIFY)...................................................... 8
HYSTERECTOMY PARTICIPANT FORM
QUESTION C1
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RESPONSE CARD Z
STRONGLY AGREE
AGREE
NEITHER AGREE NOR DISAGREE
DISAGREE
STRONGLY DISAGREE
HYSTERECTOMY PARTICIPANT FORM
QUESTION C13
RESPONSE CARDS Page 20 of 20
ANNUAL FOLLOW-UP 9
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