Study Number:
BRITISH REGIONAL HEART STUDY
2007 QUESTIONNAIRE
Thank you very much for taking the time to complete this questionnaire,
which will bring us up to date with your present health and lifestyle. All the
information will be treated as strictly confidential and will only be seen by
the Research Team.
Most questions can be answered by ticking the correct box ;
Please check that you have answered as many questions as you can and
return it to us in the envelope provided – you do not need to use a stamp.
If you have any trouble answering the questions, or would like a large-print
copy, please phone us on 020 7830 2335 and give us your telephone
number. We will then call you back to answer your query.
THANK YOU FOR YOUR HELP
Department of Primary Care & Population Sciences
Royal Free & University College Medical School
University College London
Hampstead Campus
Rowland Hill Street
London NW3 2PF
DATES
1.0
Please enter today’s date
______ _____ 2007
day
month
1.1
Please give your Date of Birth
______ ______ 19 ______
day
month
year
(This information is necessary for us to ensure that you are the correct recipient).
Conditions affecting the heart or circulation
2.0
Have you ever been told by a doctor that you have or have had any of the following conditions?
If Yes, please give the year this last happened.
Yes
No
Year of last occurrence
(coronary thrombosis or myocardial infarction)
________
b
Heart failure
________
c
Angina
________
d
Other heart trouble
________
e
High blood pressure
________
f
High blood cholesterol
________
g
Aortic Aneurysm
________
h
Narrowing or hardening of the leg arteries
________
________
________
Yes
No
Year
________
a
Heart attack
(including claudication)
i
Deep Vein Thrombosis
(clot in the deep leg vein)
j
Pulmonary Embolism
(clot on the lung)
2.1
Do you have any other problems of the heart and
circulation
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If Yes, please give details:
Stroke
3.0
3.1
3.2
3.3
Have you ever been told by a doctor that you have
had a stroke?
If Yes,
Did the symptoms last for more than 24 hours?
Have you made a complete recovery from your
stroke?
Following your stroke, do you still need any
help in carrying out everyday activities?
Yes
No
Year of last occurrence
________
Investigations and special treatment for conditions affecting the heart and circulation
4.0
Have you ever had one of the following?
Yes
No
Year of last occurrence
a
A referral to a heart specialist
________
b
A referral to a chest pain clinic
________
c
An exercise ECG (“stress” or “treadmill”) test
________
(using a dye)
________
Angioplasty
(balloon treatment of coronary artery for angina)
________
(“heart bypass” or “CABG”)
________
Other tests, investigations or operations on
the heart, arteries or veins?
________
d
Angiogram or X-ray of coronary arteries
e
f
Coronary artery bypass graft operation
g
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If Yes, please give details:
Diabetes
5.0
5.1
Have you ever been told by a doctor that you have or have
had diabetes?
If Yes,
Do you have any complications of diabetes affecting your
Yes
No
Year of diagnosis
________
(Please tick whichever apply)
feet …1
kidneys …1
nerves …1
eyes …1
Cancer
6.0
6.1
Have you ever been told by a doctor that you have or have
had cancer?
If Yes, please give the Cancer Site (parts of the body affected)
Yes
No
Year of diagnosis
________
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Liver Disease
7.0
Have you ever been told by a doctor that you have an
illness or disease affecting the liver?
Yes
No
Year of diagnosis
________
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If Yes, please give the name of the condition
Other medical conditions
8.0
Have you ever been told by a doctor that you have or have had any of the following conditions?
If Yes, please give the year this last happened.
a
Asthma
Bronchitis
Cataract
Depression
Emphysema
Gall bladder disease
Gastric, peptic or duodenal ulcer
Glaucoma
Gout
Osteoporosis
Parkinson’s disease
Pneumonia
Prostate trouble
Chronic Kidney disease
Other conditions, please give details
b
c
d
e
f
g
h
i
j
k
l
m
N
o
Yes
No
Year
________
________
________
________
________
________
________
________
________
________
________
________
________
________
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________
________
Arthritis
9.0
9.1
Have you ever been told by a doctor that you have or have
had arthritis?
No
Year of diagnosis
________
If Yes, please give the type of arthritis if known,:
Osteoarthritis
Rheumatoid arthritis
Other (please give details)
9.2
Yes
1
2
Which joints are affected: (Please tick whichever apply)
Knees …1
Back …1
Hips …1
Neck …1
Feet …1
Shoulders …1
Other (please specify)
Hands and / or wrists …1
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Joint pain, swelling or stiffness
10.0
During the past year have you had pain, aching, stiffness or swelling on most days for at least
one month, in your: (Please tick whichever apply)
Knees
Hips
Feet
Hands and / or wrists
Back
Neck
Shoulders
1
1
1
1
1
1
1
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Other (please specify)
Lower back pain
Yes
11.0
11.1
Have you ever had pain in your lower back on most days for
at least one month?
If Yes, have you had this in the last year?
No
Fractures and falls
Yes
No
Please give year
Have you ever fractured your wrist?
____________
____________
Have you had a fall in the last year?
12.0
Have you ever fractured your hip?
12.1
12.2
12.3
If Yes, how many times
12.4
Did you receive medical attention for any of these falls?
___ ___
Yes
No
Operations
13.0
Have you had any major operations in the last 2 years?
If Yes, please give details:
Yes
No
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Chest Pain
Yes
No
14.0
Do you ever have any pain or discomfort in your chest?
Yes
No
Unable to walk on level
14.1
If Yes,
When you walk at an ordinary pace on the level, does
this produce the pain?
1
2
3
Yes
No
Unable to walk uphill
1
2
3
14.2
When you walk uphill or hurry, does this produce the
pain?
Breathlessness
Yes
No
Unable to walk
15.0
Do you ever get short of breath walking with other people
of your own age on level ground?
1
2
3
15.1
On walking uphill or upstairs, do you get more breathless
than people of your own age?
1
2
3
15.2
Do you ever have to stop walking because of
breathlessness?
15.3
In the past year have you at any time been awoken at
night by an attack of shortness of breath?
Yes
No
Cough and Wheeze
15.4
Do you usually bring up phlegm (or spit) from your chest
first thing in the morning in the winter?
15.5
Do you bring up phlegm like this on most days for as much
as 3 months in the winter each year?
15.6
In the past two years have you had a period of increased cough and phlegm lasting for 3 weeks
or more?
Yes, once …1
Yes, twice or more …2
Never …3
Yes
No
15.7
Does your chest ever sound wheezy or whistling?
15.8
If Yes, does this happen on most days or nights?
15.9
How many times in the past year have you had a chest infection requiring antibiotic
treatment from your doctor?
None …1
Once …2
More than once …3
Eyesight
Yes
No
Using glasses or corrective lenses if needed, can you see
well enough to recognise a friend at a distance of 12 feet/
four yards (across a road)?
16.1
If No, can you see well enough to recognise a friend at a
distance of one yard?
16.2
In the past two years has your sight:
16.0
deteriorated …1
improved …2
stayed the same …3
Hearing
Yes
No
16.3
Is your hearing good enough to follow a TV programme at a volume
others find acceptable (using a hearing aid if needed)?
16.4
If No, can you follow a TV programme with the volume turned up?
16.5
In the past two years has your hearing:
16.6
deteriorated …1
improved …2
stayed the same …3
Do you use a hearing aid?
Yes
No
Occasionally
1
2
3
Leg Pain
17.0
17.1
Do you get pain or discomfort in your leg or legs when you walk?
If Yes,
Do you know the cause of the pain?
Yes
No
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If Yes, please state cause
17.2
Does this pain ever begin when you are standing still or sitting?
Yes
No
Yes
No
Unable to
walk
17.3
Do you get the pain if you walk uphill or hurry?
1
2
3
17.4
Do you get the pain walking at an ordinary pace on the level?
1
2
3
17.5
What happens to the pain if you stand still?
Usually continues more than 10 minutes …1
Usually disappears in 10 minutes or less …2
17.6
Please mark on the diagram below where you get the pain.
FRONT
BACK
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L
R
RIGHT
SIDE
LEFT
SIDE
LEFT
SIDE
RIGHT
SIDE
Weight
18.0
What is your present weight (indoor clothes, without shoes)?
___ ___ Stones ___ ___ Pounds
18.1
18.2
___ ___ ___ Kilograms
If you have no scales and have made an estimate please tick here
or
Have you tried to lose weight in the last two years?
If Yes, did you:
Yes
No
(Please tick whichever apply)
Change your diet? …1
Take more exercise? …1
18.3
Have you been advised by a doctor or other health
professional to lose weight in the last two years?
18.4
Has your weight changed in the last two years?
Not changed
Increased
Decreased
Both increased and decreased
Don’t know
Yes
No
1
2
3
4
5
If your weight has changed in the last two years…
18.5
By what amount has your weight changed?
18.6
Was this change intentional?
18.7
Was it the result of
18.8
Do you consider your present weight to be
____ Stones ____ Pounds
Yes
No
or ____ Kilograms
Personal choice …1
Medical advice …1
Illness or ill health …1
about right …1
too high …2
too low …3
Cigarette smoking
19.0
19.1
Do you smoke cigarettes at present?
If yes,
How many cigarettes a day do you smoke at present?
Yes
No
___ ___
Pipe and cigar smoking
20.0
20.1
Do you currently smoke a pipe?
Do you currently smoke cigars?
Yes
No
Alcohol Intake
21.0
Would you describe your present alcohol intake as
Daily/most days
Weekends only
Occasionally once or twice a month
Special occasions only
None
1
2
3
4
5
Alcohol Intake, continued
One drink is HALF A PINT of beer/lager/cider, a SINGLE whisky, gin, etc. or ONE GLASS (small,
125ml) of wine or sherry
21.1
How much do you usually drink on the days when you drink alcohol?
More than 6 drinks
5-6 drinks
3-4 drinks
1-2 drinks
21.2
How many alcoholic drinks do you have during an average week?
21.3
What type of drink do you usually take?
___ ___
Beers, Lagers
Wines, Sherry
Spirits
Combination of Beers, Wines or Spirits
Low alcohol drinks
21.4
1
2
3
4
1
1
1
1
1
What is your usual consumption of these alcoholic beverages?
(please tick boxes)
PER WEEK
Never /
hardly ever
Less than 1
1-6
7-13
14-20
21+
Beer or Lager pints
Red Wine single glass
White Wine single glass
Spirits 1 drink / shot
Type of Drink
21.5
Is the alcohol which you drink usually taken……
(Please tick whichever apply)
before meals
with meals
after meals
separate from meals
1
1
1
1
Yes
No
Have you reduced your alcohol intake in the last two years?
Was this due to:
(please tick whichever apply)
Personal choice …1
Doctor’s advice …1
Illness or ill-health …1
Health precaution …1
Being on medication …1
Financial reasons …1
Other …1
Yes
No
21.8
Have you ever felt you ought to cut down on your drinking?
21.9
Have people annoyed you by criticizing your drinking?
21.10
Have you ever felt bad or guilty about your drinking?
21.11
Have you ever had a drink first thing in the morning (eye-opener) to
steady your nerves or get rid of a hangover?
21.6
21.7
Your overall health
Please indicate which statements best describe your health TODAY.
Please tick only one box
22.0
General Health
22.1
Pain/Discomfort
22.2
Mobility
22.3
Anxiety/Depression
22.4
Excellent
Good
Fair
Poor
1
2
3
4
I have no pain or discomfort …1
I have moderate pain or discomfort …2
I have extreme pain or discomfort …3
I have no problems in walking about …1
I have some problems in walking about …2
I am confined to a chair/wheelchair …3
I am not anxious or depressed …1
I am moderately anxious and/or depressed …2
I am extremely anxious and/or depressed …3
Sleeping patterns
On average, how many hours of sleep do you have in a 24 hour period?
___ ___
Please include day-time and night-time sleep
22.5
During the last month, did you have difficulties falling asleep?
almost never …1
sometimes …2
often …3
22.6
During the last month, how often did you wake up during the night?
almost never …1
sometimes …2
often …3
22.7
22.8
Your Memory
In the past year, how often did you have trouble remembering things?
never
rarely
sometimes
often
hours
1
2
3
4
Health Scale
We have drawn a health scale (rather like a thermometer) on which perfect health is 100 and
very poor health is 0.
Please put a cross (X) on the scale to reflect how good or bad your health is today.
Worst Imaginable
Health State
0
Best Imaginable
Health state
10
20
30
40
50
60
70
80
90
100
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Physical activity
23.0
Do you make regular journeys every day or most days either walking or cycling?
No …1
Walk …2
Cycle …3
Both …4
23.1
How many hours do you normally spend walking e.g. on errands or
for leisure in an average week?
23.2
___ ___
hours
Which of the following best describes your usual walking pace?
Slow …1
Steady average …2
Fast …3
___ ___
23.3
How long do you spend cycling in an average week?
23.4
Compared with a man who spends two hours on most days on activities such as: walking,
gardening, household chores, DIY projects, how physically active would you consider yourself?
Much more active …1
More active …2
Similar …3
Less active …4
Much less active …5
23.5
Do you take active sporting physical exercise such as running, swimming, dancing, golf, tennis,
squash, jogging, bowls, cycling, hiking, etc.?
No …1
Occasionally less than once a month …2
Frequently once a month or more …3
23.6
If you ticked frequently please state type of activities:
23.7
hours
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How many times a month on average do you take part in these activities?
(please give overall total)
In winter
___ ___
times
In summer
___ ___
times
Yes
No
23.8
Do you engage in exercises to increase muscle strength and
endurance such as lifting weights, doing push-ups, using exercise
machines?
23.9
If Yes, on average how many hours per week do you engage in these exercises?
___ ___
Hours
Disability
24.0
Do you have any long-standing illness, disability or infirmity?
Yes
No
“long-standing” means anything which has troubled you over a period of time or is likely to do so
If Yes,
a
b
24.1
Yes
No
Does this illness or disability limit your activities in any way?
Do you receive a disability allowance?
Do you currently have difficulty carrying out any of the following activities on your own as a result
of a long term health problem?
a
b
c
d
e
f
24.2
Yes
No
Yes
No
1
2
Going up or down stairs
Bending down
Straightening up
Keeping your balance
Going out of the house
Walking 400 yards
Is your present state of health causing problems with any of the following:-
a
Job at work paid employment
Household chores
Social life
Sex life
Interests and hobbies
Holidays and outings
b
c
d
e
f
Does not
apply
3
Present circumstances
25.0
Are you at present:-
25.1
If you are widowed or divorced/separated, please give the year when this occurred:- ________
25.2
25.3
single
married
widowed
divorced or separated
other
Are you at present:-
living
alone
living with a partner or spouse
living with other family members
living with other people
Your accommodation
Are you:an owner occupier
renting privately
living in a nursing home
other please give details
1
3
5
7
1
2
3
4
5
1
2
3
4
renting from the local authority …2
living in a residential home …4
living in sheltered accommodation …6
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During the winter, is your accommodation usually:
Very warm
Warm
Medium
Cold
Very cold
1
2
3
4
5
Yes
No
25.5
Do you have a car available for your own use?
25.6
Do you have private medical insurance?
25.7
Which of the following phrases best describes how you are managing financially these days?
manage very well …1
manage quite well …2
get by alright …3
don't manage very well …4
have some financial difficulties …5
have severe financial difficulties …6
25.8
What type of financial support do you currently have?
25.4
State pension
1
Private Personal Pension
Stakeholder pension
Group Personal Pension
Earnings from paid employment
1
1
1
1
(Please tick whichever apply)
Employer provided occupational pension
scheme
Retirement Annuity pensions pre 86 PPPs
S226 plan self-employed personal pension
Other retirement saving scheme
1
1
1
1
Your family - grandparents
We would like to know a bit more about your family history.
When were your grandparents born? And where? And at what age did they die? If you do not
know precisely please give as much detail as possible
Place of birth:
a) Year
b) City or town c) County
d) Country
e) Age at
of birth
or village
death
26.0
Your
grandmother
(father’s
side)
26.1
Your
grandfather
(father’s
side)
26.2
Your
grandmother
(mother’s
side)
26.3
Your
grandfather
(mother’s
side)
Office
use
Time spent on various activities
27.0
Approximately how many hours each week (if any) do you spend:
Hours per week
a
Looking after wife/partner
____ ____
b
Looking after other adult family member or friend
____ ____
c
Looking after grandchildren
____ ____
d
Spending time with family, friends and neighbours
____ ____
e
Talking with friends/relatives on the telephone
____ ____
f
In paid work
____ ____
g
In voluntary work
____ ____
h
On housework
____ ____
i
On gardening
____ ____
j
In a pub or club
____ ____
k
Attending religious services
____ ____
l
Playing cards, games, or bingo
____ ____
m
Visiting the cinema/restaurants/sporting events
____ ____
n
Watching television/videos/DVD’s
____ ____
o
Reading
____ ____
p
Attending class or course of study
____ ____
q
Using a computer
____ ____
28.0
Do you go on day or overnight trips?
Never
Sometimes
Often
28.1
Have you been on holiday in the last year?
28.2
Do you use the internet and or email?
1
2
3
Yes
No
Yes
No
Activities of daily living
The following questions will help us to understand difficulties people may have with various everyday
activities
29.0
What is the furthest you can walk on your own without stopping and without discomfort?
200 yards or more
1
More than a few steps but less than 200 yards
2
Only a few steps
3
29.1
Can you walk up and down a flight of 12 stairs without resting?
Yes
Only if I hold on and take a rest
Not at all
29.2
30.0
1
2
3
Can you, when standing, bend down and pick up a shoe from the floor?
Yes
1
No
2
Please indicate if you have difficulty doing any of the following
activities:
No
difficulty
Some
difficulty
Unable to
do or need
help
1
2
3
a
Reaching or extending your arms above shoulder level
b
Pulling or pushing large objects like a living room chair
c
Walking across a room
d
Getting in and out of bed on your own
Getting in and out of a chair on your own
Dressing and undressing yourself on your own
Bathing or showering
Feeding yourself, including cutting food
Getting to and using the toilet on your own
j
Lifting and carrying something as heavy as 10 lbs, for
example a bag of groceries
k
Shopping for personal items such as toilet items
or medicine by yourself
l
Doing light housework such as washing up
Preparing your own meals by yourself
n
Using the telephone by yourself
o
Taking medications by yourself
Managing money (e.g. paying bills etc)
Using public transport on your own
Driving a car on your own
Gripping with hands (eg. opening a jam jar)
e
f
g
h
i
m
p
q
r
s
During the past week
31.0
Below is a list of some of the ways you may have felt or behaved. Please indicate how often you have
felt this way during the past week (please tick one box on each line)
Rarely or none
of the time
Some or a
little of the
Time
Occasionally
or a moderate
amount of the
time
All of the
time
(less than 1 day)
(1-2 days)
(3-4 days)
(5-7 days)
a
I was bothered by things that
usually don’t bother me
1
2
3
4
b
I had trouble keeping my mind on
what I was doing
1
2
3
4
c
I felt depressed
1
2
3
4
d
I felt that everything I did was an
effort
1
2
3
4
e
I felt hopeful about the future
1
2
3
4
f
I felt fearful
1
2
3
4
g
My sleep was restless
1
2
3
4
h
I was happy
1
2
3
4
j
I felt lonely
1
2
3
4
m
I could not “get going”
1
2
3
4
Office use
31.1
Office use
Office use
If you ticked that you have experienced any of the problems mentioned in the above question at
least 1 day this week, please can you tell us how difficult these problems made it for you to do
your work, take care of things at home, or get along with other people?
Not difficult at all
1
Somewhat difficult
2
Very difficult
3
Extremely difficult
4
Preventive Health Care
32.0
Approximately how many times in the last year have you consulted your GP about a health
problem?
___ ___ times
32.1
If none, in what year did you last consult a GP about a health problem?
32.2
Have you had any of the following in the last two years:
Yes
______
No
a
Blood pressure check
b
Blood cholesterol check
c
Flu vaccination
Medicines
33.0
a
Yes
No
Do you take any regular medication?
If Yes, do you take any of the following medicines regularly?
Treatment for any form of heart disease
Yes
No
Year started
______
b
Treatment to lower blood pressure
______
c
Treatment to lower blood cholesterol
______
d
Treatment to lower triglycerides
33.1
If you are on treatment to lower your blood cholesterol:Office Use
a
Please give the name of this medicine:
b
Please give the amount you take each day:
(details of the amount in each tablet should be on the bottle)
___ ___ ___ mg
Aspirin
33.2
a
b
Do you take aspirin regularly?
If Yes,
Is this prescribed by your doctor?
What dose do you take?
(details of the amount in each tablet should be on the bottle)
c
d
How often do you take it?
Why do you take it?
Yes
No
Year started
______
___ ___ ___ mg
Daily …1
Every other day …2
Weekly …3
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Details of ALL medicines
34.0
Please write down details of all medicines– including tablets, injections, inhalers, eye-drops etc
– which you take regularly. Please also include any medications which you buy for yourself.
Name of medicine
Reason for taking
(if known)
Year
started
Is this
prescribed?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
1
2
3
4
5
6
7
8
9
10
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Vitamins, minerals and complementary therapies
35.0
Do you regularly take any vitamins, minerals and complementary
therapies?
Yes
No
If Yes, please give details: please include homeopathic and herbal treatments
Name of medicine
Reason for taking
(if known)
Year
started
1
2
3
4
5
6
Thank you very much for completing the questionnaire.
Please return it to us in the envelope provided. No stamp is needed.
Department of Primary Care & Population Sciences
Royal Free & University College Medical School
University College London
Hampstead Campus
Rowland Hill Street
London NW3 2PF
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