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II. attach PID label here. -. -. Patient ID:. Clinical Unit:. -. -. Month. Day. Year. 4. 1. 2. 1. 3. 2. 1. 2. Yes. Yes. No. No. Refused to answer. Don't know. No. Yes. Form Date:. Coordinator Code:. Visit:. 1. 1. Have you ever smoked cigarettes?.
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II attach PID label here - - Patient ID: Clinical Unit: - - Month Day Year 4 1 2 1 3 2 1 2 Yes Yes No No Refused to answer Don't know No Yes Form Date: Coordinator Code: Visit: 1 1. Have you ever smoked cigarettes? 1a. Do you smoke now? 2 How long ago did you stop smoking? years 1b. About how many cigarettes do you smoke (or did you, if no longer smoking) per day: cigarettes per day drinks 2. Are there any [other] cigarette smokers in the child's household? 2a. Number who smoke in the house: 3. Have you had an alcoholic beverage in the past 12 months? 3a. How many days per week in a typical week do you drink any alcoholic beverages (beer, wine, or liquor)? days 3b. On the days you drank alcohol, on the average, how many drinks did you have? days 3c. In the past 12 months, how many days did you have 5 or more drinks on a single day? 1 Yes 4 Refused to answer 3 Don’t know 4 Refused to answer 3 Don’t know 4 Refused to answer 3 Don’t know 2 No LIFE STYLE HISTORY For the child's primary caregiver: I have some questions about common habits of yours. OPT Form 93 V1 (1-2) JAN 06
4. Are there any [other] people who drink alcoholic beverages (beer, wine, liquor) in the child's household? 4 3 1 3 1 1 4 4 3 3 4 2 1 2 2 2 2 2 1 1 3 2 4 2 1 1 2 1 No Don't know Refused to answer Week Month Months ago Don't know Yes No Refused to answer Week Weeks ago Weeks ago Yes Refused to answer Months ago Don't know Month No No Yes Refused to answer Don't know No Refused to answer Don't know Yes Yes 4a. Number who drink alcohol in the house: 5b. When did you last smoke? 7b. When did you last use them? 5a. How often have you smoked? times per 5. Have you smoked marijuana or hash in the past year? 7. Have you ever used other street or recreational drugs (cocaine, heroin, etc.)? 7a. How often have you used them? times per 6. Are there any [other] people who smoke marijuana or hash in the child's household? 6a. Number who smoke marijuana or hash in the house: 8. Are there any [other] people who use street or recreational drugs (cocaine, heroin, etc.) in the child's household? 8a. Number who use street or recreational drugs in the house: OBSTETRICS & PERIO THERAPY STUDY II The next few questions are about your use of drugs. Remember that your answers are completely confidential. OPT Form 93 V1 (2-2) JAN 06
