National Archive of Computerized Data on Aging

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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 3 Baseline Individual Assessment, Part 1.

VISIT#

A2. Visit #:

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 3 Baseline Individual Assessment, Part 1.

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 3 Baseline Individual Assessment, Part 1.

GENDER

B2. Are you male or female?

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 3 Baseline Individual Assessment, Part 1.

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 3 Baseline Individual Assessment, Part 1.

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 3 Baseline Individual Assessment, Part 1.

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 3 Baseline Individual Assessment, Part 1.

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 3 Baseline Individual Assessment, Part 1.

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 3 Baseline Individual Assessment, Part 1.

HISPANIC/LATINO

B7a. Are you Hispanic or Latino?

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 3 Baseline Individual Assessment, Part 1.

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 3 Baseline Individual Assessment, Part 1.

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 3 Baseline Individual Assessment, Part 1.

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 3 Baseline Individual Assessment, Part 1.

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 3 Baseline Individual Assessment, Part 1.

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 3 Baseline Individual Assessment, Part 1.

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 3 Baseline Individual Assessment, Part 1.

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 3 Baseline Individual Assessment, Part 1.

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 3 Baseline Individual Assessment, Part 1.

DRESSING SCORE

B10c. DRESSING SCORE:

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 3 Baseline Individual Assessment, Part 1.

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 3 Baseline Individual Assessment, Part 1.

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 3 Baseline Individual Assessment, Part 1.

PERSONAL HYGIENE SCORE

B11c. PERSONAL HYGIENE SCORE: ____

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 3 Baseline Individual Assessment, Part 1.

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 3 Baseline Individual Assessment, Part 1.

BATHING SCORE

B12b. BATHING SCORE: ____

Taken from: ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999-2001 [United States] - Form 3 Baseline Individual Assessment, Part 1.

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 3 Baseline Individual Assessment, Part 1.

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