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Name
Label/Question

ID

A1. Study ID#:

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 2 Screener.

VISIT#

A2. Visit #:

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 2 Screener.

DOES SUBJECT CONFIRM HIS FULL NAME

B1. Is your name (FULL NAME)?

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 2 Screener.

GENDER

B2. Are you male or female?

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 2 Screener.

DOES SUBJECT CONFIRM HIS FULL ADDRESS

B3. Is your address (FULL ADDRESS)?

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 2 Screener.

AGE ELIGIBLE

B4a. IS SUBJECT?S AGE WITHIN 6 WEEKS OF 65th BIRTHDAY OR OLDER TODAY? (USE AGE ELIGIBILITY TABLE)

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 2 Screener.

MARITAL STATUS

B5. What is your marital status? [READ RESPONSE CATEGORIES IF UNABLE TO ANSWER]

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 2 Screener.

LEVEL OF EDUCATION

B6. What is the highest grade of school or level of education that you completed? [CODE ONLY ONE RESPONSE]

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 2 Screener.

RACE OR ETHNIC GROUP

B7. What race do you consider yourself? (PROBE: White, Black/African American, Asian, Native Hawaiian/Pacific Islander, American Indian/Alaskan Native, or another race?) ... (view details)

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 2 Screener.

HISPANIC/LATINO

B7a. Are you Hispanic or Latino?

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 2 Screener.

GLASSES

B8. The next questions are about your vision. Do you wear glasses or contact lenses to read?

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 2 Screener.

READING DIFFICULTY WITH GLASSES

B8a. How much difficulty do you have reading ordinary print in the newspaper with your glasses or contact lenses? Would you say...

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 2 Screener.

READING DIFFICULTY WITHOUT GLASSES

B8b. How much difficulty do you have reading ordinary print in the newspaper? Would you say...

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 2 Screener.

HEARING LOSS

B9. Now I would like to ask you about your hearing. Do you feel you have a hearing loss?

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 2 Screener.

HEARING AID

B9a. Do you wear a hearing aid?

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 2 Screener.

HEARING LOSS WHEN HEARING AID IS USED

B9b. Do you feel you have a hearing loss when wearing your hearing aid?

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 2 Screener.

DRESSING ACTIVITY

B10. First I am going to ask you about dressing. By dressing I mean getting clothes from closet and drawers and putting clothes on, including shoes and socks. Thinking back over the last 7 days, including the last 24 hours, how much dressi... (view details)

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 2 Screener.

DRESSING HELP - # OF TIMES

B10b. How many times in the last 7 days did you receive this help? ___ ___ # TIMES

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 2 Screener.

DRESSING SCORE

B10c. DRESSING SCORE:

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 2 Screener.

PERSONAL HYGIENE ACTIVITY

B11. The next questions are about personal hygiene. By personal hygiene I mean activities such as combing hair, brushing teeth, shaving, applying makeup, washing and drying face and hands. It does not include bathing and showering. Thinkin... (view details)

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 2 Screener.

PERSONAL HYGIENE HELP - # OF TIMES

B11b. How many times in the last 7 days did you receive this help? ___ ___ # TIMES

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 2 Screener.

PERSONAL HYGIENE SCORE

B11c. PERSONAL HYGIENE SCORE: ____

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 2 Screener.

BATHING ACTIVITY

B12. Now I am going to ask you about bathing. By bathing I mean getting soap and water and washing and drying the whole body. This includes getting in and out of the tub or shower. Thinking back over the last 7 days, including the last 24 ... (view details)

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 2 Screener.

BATHING SCORE

B12b. BATHING SCORE: ____

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 2 Screener.

ACTIVITY SCORE INELIGIBLE

B13. DID SUBJECT RECEIVE A SCORE OF 4 OR 5 IN ANY ONE OR MORE DAILY ACTIVITIES (B10c, B11c, B12b)? OR DID SUBJECT SCORE AN (8) IN ALL THREE DAILY ACTIVITIES (B10c, B11c, B12b)? ... (view details)

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 2 Screener.

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