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Name
Label/Question
1. AID

ID

A1. Study ID#:

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


Name
Label/Question
2. VISIT

VISIT#

A2. Visit #:

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


Name
Label/Question

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.


Name
Label/Question

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.


Name
Label/Question

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.


Name
Label/Question

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.


Name
Label/Question

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.


Name
Label/Question

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.


Name
Label/Question
9. RACE

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.


Name
Label/Question

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.


Name
Label/Question
11. GLASES

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.


Name
Label/Question
12. VISION

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.


Name
Label/Question

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.


Name
Label/Question

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.


Name
Label/Question

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.


Name
Label/Question

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.


Name
Label/Question

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.


Name
Label/Question

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.


Name
Label/Question

DRESSING SCORE

B10c. DRESSING SCORE:

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


Name
Label/Question

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.


Name
Label/Question

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.


Name
Label/Question

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.


Name
Label/Question

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.


Name
Label/Question

BATHING SCORE

B12b. BATHING SCORE: ____

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


Name
Label/Question

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.


Name
Label/Question

ARTHRITIS

B14. Has a doctor or a nurse ever told you that you have: a. arthritis

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


Name
Label/Question

DIABETES

B14. Has a doctor or a nurse ever told you that you have: b. diabetes

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


Name
Label/Question

HEART DISEASE

B14. Has a doctor or a nurse ever told you that you have: c. heart attack or myocardial infarction

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


Name
Label/Question

ALZHEIMER'S DISEASE

B14. Has a doctor or a nurse ever told you that you have: d. Alzheimer's Disease

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


Name
Label/Question
30. STROKE

STROKE

B14. Has a doctor or a nurse ever told you that you have: e. a stroke within the past year

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


Name
Label/Question
31. CANCER

CANCER

B14. Has a doctor or a nurse ever told you that you have: f. cancer, other than skin cancer, within the past 5 years

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


Name
Label/Question

LUNG CANCER

B14g. What kind of cancer (site of the cancer) is it? CODE ALL SUBJECT MENTIONS. LUNG

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


Name
Label/Question

STOMACH CANCER

B14g. What kind of cancer (site of the cancer) is it? CODE ALL SUBJECT MENTIONS. STOMACH CANCER

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


Name
Label/Question
34. LIVER

LIVER CANCER

B14g. What kind of cancer (site of the cancer) is it? CODE ALL SUBJECT MENTIONS. LIVER CANCER

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


Name
Label/Question

PANCREAS CANCER

B14g. What kind of cancer (site of the cancer) is it? CODE ALL SUBJECT MENTIONS. PANCREAS CANCER

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


Name
Label/Question

ESOPHAGUS CANCER

B14g. What kind of cancer (site of the cancer) is it? CODE ALL SUBJECT MENTIONS. ESOPHAGUS CANCER

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


Name
Label/Question

OTHER CANCER

B14g. What kind of cancer (site of the cancer) is it? CODE ALL SUBJECT MENTIONS. OTHER CANCER

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


Name
Label/Question

CHEMOTHERAPY

B14h. Are you currently receiving chemotherapy or radiation treatment for this (these) cancer(s)?

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


Name
Label/Question

PLANNING TO MOVE

C1. Are you planning to move out of the area (county) in the next year or so?

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


Name
Label/Question

PLANNING TO BE AWAY

C2. In the next year or so, do you plan to be away for an extended period of time, such as one or more months at a time? (PROBE: For example, do you regularly go (south in the winter / north in the summer) for several months?) ... (view details)

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


Name
Label/Question
41. TRIPS

TRIPS

C2b. Are you planning any short trips for several days or a week in the next 3 months?

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


Name
Label/Question

STUDY CONFLICT

C2d. BASED ON SUBJECT’S REPLIES TO C2 - C2c AND SITE’S TESTING AND TRAINING SCHEDULE, CODE BELOW.

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


Name
Label/Question
43. COMMIT

COMMITMENTS

C3. This study offers a program on 2 to 3 mornings or afternoons a week for 5 weeks. Do you have any commitments such as employment, caregiving or volunteering that could not be rearranged and thus would affect your availability to partici... (view details)

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


Name
Label/Question

RESEARCH STUDY

C4. In the past 2 years, have you participated in any research study or educational training program for older adults to improve thinking, memory or problem solving? ... (view details)

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


Name
Label/Question
45. WHORAN

WHO RAN THE MEMORY STUDY

C4b. Who ran this study or training program? DO NOT READ CHOICES BELOW. IF NEEDED, USE SITE SPECIFIC PROGRAM NAME AS A PROBE.

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


Name
Label/Question

STUDY SIMILAR TO ACTIVE

C4d. BASED ON C4a-c, CODE:

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


Name
Label/Question

DAILY SKILLS STUDIES

C5. In the past 2 years, have you participated in a research study to help you handle everyday activities like paying the bills, using the telephone, or taking your medications? ... (view details)

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


Name
Label/Question

MAKING SELF UNDERSTOOD SCORING

USING THE SCORING CRITERIA ON THE NEXT PAGE, CODE YOUR ASSESSMENT OF SUBJECT’S ABILITY TO MAKE SELF UNDERSTOOD AND TO UNDERSTAND OTHERS. D1. MAKING SELF UNDERSTOOD ... (view details)

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


Name
Label/Question

ABILITY TO UNDERSTAND OTHERS SCORING

D2. ABILITY TO UNDERSTAND OTHERS

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


Name
Label/Question

INELIGIBLE BECAUSE OF COMMUNICATION

D3. DID SUBJECT RECEIVE A SCORE OF A 2 OR 3 IN EITHER ITEM (D1 OR D2)?

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

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