SRD- ASS 1B

The 500 Family Study [1998-2000: United States]

ICPSR 4549

Barbara Schneider University of Chicago. National Organization for Research and Computing (NORC). Alfred P. Sloan Center on Parents, Children and Work

Linda J. Waite University of Chicago. National Organization for Research and Computing (NORC). Alfred P. Sloan Center on Parents, Children and Work

Cortisol Data Questionnaires

P.O. Box 1248 Ann Arbor, Michigan 48106

www.icpsr.umich.edu

About Research Connections

These data are made available by the Child Care and Early Education Research Connections project. Research Connections promotes high quality research in child care and early education and the use of that research in policymaking.

Research Connections is operated by the National Center for Children in Poverty at the Mailman School of Public Health, Columbia University and the Inter-university Consortium for Political and Social Research at the Institute for Social Research, University of Michigan, through a cooperative agreement with the Child Care Bureau, Office of Family Assistance and the Office of Planning, Research, and Evaluation, Administration for Children and Families in the U.S. Department of Health and Human Services.

Terms of Use The terms of use for this study can be found at:

http://www.icpsr.umich.edu/cocoon/ICPSR/TERMS/4549.xml

Health Information - Parent of Young Child ID#____________ Certain substances, lifestyle choices, medications and health states can affect people's levels of cortisol, the stress hormone that we are measuring in your saliva. We need to know about these for you and your child so we can take them into account when analyzing your stress hormone levels. Please answer the following, remembering that all of your answers are entirely confidential, and that you may skip any question you do not wish to answer. The first set of questions asks about you, then we ask you some questions about your child's health. 1. Do you regularly take any form of caffeine? (coffee, tea, caffeinated pop, caffeine pills, etc.) Yes No

� If yes, please indicate what form you take it in and how much you take each day. Form _________________ Quantity _________________ (amount/day).

2. Do you smoke or take nicotine in any other form? Yes No

� If yes, please indicate what form you take it in and how much you take each day. Form _____________ Quantity _______________ (amount/day)

☺ If male, please skip to question 6. 3. Do you currently use birth control pills or a birth control implant or injection? Yes No

If yes, please indicate type __________________________________ 4. Are you currently pregnant? Yes No

� If yes, how many weeks pregnant are you? _________ weeks

5. Do you have a monthly menstrual cycle? Yes No � If yes, how many days has it been since the beginning of your last menstrual period? _____ days � If yes, is your menstrual cycle typically regular (same number of days)? Yes No

6. Are you currently diagnosed with asthma? Yes No

� If yes, do you currently take any form of asthma medication? Yes No

� If yes, what type(s)? ___________________________________________________ 7. Do you have any allergies? Yes No

� If yes, please list ___________________________________________________________

� If yes, are you taking any medications for these allergies? Yes No

� If yes, please list medications____________________________________________________ 8. Are you currently diagnosed with depression or any other form of mental illness? Yes No

� If yes, what type(s) of mental illnes? Diagnoses _________________________________

� Are you currently taking medication for depression or another mental illness? Yes No � If yes, please list the medication(s) and the diagnosis for which each is prescribed. ___________________________________________________________________________

9. Do you currently perform any form of regular physical exercise? Yes No � If yes, please indicate what types of exercise you do and how often you do each.

_______________________________________________________________________________

10. Please list any other things you do for the purpose of promoting your physical and/or emotional health.

______________________________________________________________________________

11. What is your height and current weight? Height ________ (feet, inches) Weight _______ (pounds)

12. On average, how many hours of sleep do you get per night? _____________ (hours)

I typically go to bed between the hours of __________ and ____________

I typically get up between the hours of _________ and ____________ 13. On average, how many drinks containing alcohol (wine, beer, etc.) do you consume per week? ______ drinks. 14. To the best of your ability, please indicate the number of times you have had the following illnesses or

conditions in the last 2 months.

Cold (sore throat, congestion, runny nose) ____________

Flu (fever, pain, upset stomach) ____________

Headache (lasting more than 1 hour) ____________

Allergic reaction to food, dust or other allergen ____________

Asthma attack ____________

Lower back pain (not from menstruation or exercise) ____________

Strong mood swing ____________

Out of control temper ____________

General tiredness (fatigue) ____________

Difficulty falling asleep (insomnia) ____________

Other sleep problems (describe: ___________________ ) ____________

15. Do you have any other health conditions we should be aware of? If yes, please describe.

_______________________________________________________________________________

16. Are you taking any other medications, beyond those you’ve mentioned above? If yes, please list the medications and the medical condition for which each one is prescribed.

_______________________________________________________________________________

17. How many days of work have you missed over the past year due to illness? ______ days. How many times have you visited a physician over the last year for reasons of illness (do not include

regularly scheduled check-ups or preventative-care visits)? _______ times.

Have you been hospitalized in the last year? If so, please indicate the reason for the hospitalization and the duration of the hospital stay. Reason _______________________________ Duration____________________________

18. Basically, would you say your health is (circle one):

Excellent Above Average Average Below Average Poor

Now I'd like to ask you a few questions about the health of your child who is participating in the study (5-6 year old). 1. Please report your child's birth month and year _________, 19_____ and today’s date __________, 2000. 2. Please report your child's height and weight. Height _________ (feet, inches) Weight________ (pounds)

3. On average, how many hours of sleep per night does your child get? ____________ (hours) 4. Does your child regularly take any form of caffeine? (e.g. caffeinated pop). Yes No

� If yes, please what form of caffeine and how much. Form ____________ Quantity_______ (amount/day). 5. Is your child currently diagnosed with asthma? Yes No

� If yes, does he or she currently take any form of asthma medication? Yes No

� If yes, what type(s)? ___________________________________________________ 6. Does your child have any allergies? Yes No

� If yes, please list ___________________________________________________________

� If yes, is he/she taking any medications to control these allergies? Yes No

� If yes, please list ____________________________________________________________ 7. Is your child currently diagnosed with ADHD or any other emotional or behavioral disorder? Yes No

� If yes, what type(s) of emotional or behavioral disorder(s)? _________________________________

� Is your child currently taking any medication for this? Yes No � If yes, please list the medication(s) and the diagnosis for which each is prescribed. ______________________________________________________________________________________

8. To the best of your ability, please indicate the number of times your child has had the following illnesses or

conditions in the last 2 months.

Cold (sore throat, congestion, runny nose) ____________

Flu (fever, pain, upset stomach) ____________

Headache (lasting more than 1 hour) ____________

Allergic reaction ____________

Ear infection ____________

Asthma attack ____________

Temper tantrum ____________

General tiredness (fatigue) ____________

Difficulty falling asleep (insomnia) ____________

Other sleep problems (describe: ___________________ ) ____________

9. Has your child had any other illnesses in the last two months? If so, please list.

_____________________________________________________________________________

10. Does your child have any other medical conditions or do you have any other health concerns regarding your child that we should be aware of? If yes, please describe.

_______________________________________________________________________________

11. Is your child taking any other medications, beyond those already described above? If yes, please list the medications and the medical condition for which each medication is prescribed.

_______________________________________________________________________________ 12. How many days of kindergarten/school/day care did your child miss last year due to illness? ______ days. How many times has your child visited a physician over the last year for reasons of illness (do not include

regularly scheduled check-ups or preventative-care visits)? _______ times.

Has your child been hospitalized in the last year? If so, please indicate the reason for the hospitalization and the duration of the hospital stay. Reason _______________________________ Duration____________________________

13. Basically, would you say your child's health is (circle one):

Excellent Above Average Average Below Average Poor 12. Is anyone else in your family currently facing a serious health problem? If so, please describe.

_______________________________________________________________________________

Thank you!

Parent Health Form P. 1

Health Information - Parent of Teen ID#____________ Certain substances, lifestyle choices, medications and health states can affect people's levels of cortisol, the stress hormone that we are measuring in your saliva. We need to know about these for you and your teen so we can take them into account when analyzing your stress hormone levels. Please answer the following, remembering that all of your answers are entirely confidential, and that you may skip any question you do not wish to answer. The first set of questions asks about you, then we ask you some questions about your teen's health. 1. Do you regularly take any form of caffeine? (coffee, tea, caffeinated pop, caffeine pills, etc.) Yes No

� If yes, please indicate what form you take it in and how much you take each day. Form _________________ Quantity _________________ (amount/day).

2. Do you smoke or take nicotine in any other form? Yes No

� If yes, please indicate what form you take it in and how much you take each day. Form _____________ Quantity _______________ (amount/day)

☺ If male, please skip to question 6. 3. Do you currently use birth control pills or a birth control implant or injection? Yes No

If yes, please indicate type __________________________________ 4. Are you currently pregnant? Yes No

� If yes, how many weeks pregnant are you? _________ weeks

5. Do you have a monthly menstrual cycle? Yes No � If yes, how many days has it been since the beginning of your last menstrual period? _____ days � If yes, is your menstrual cycle typically regular (same number of days)? Yes No

6. Are you currently diagnosed with asthma? Yes No

� If yes, do you currently take any form of asthma medication? Yes No

� If yes, what type(s)? ___________________________________________________ 7. Do you have any allergies? Yes No

� If yes, please list ___________________________________________________________

� If yes, are you taking any medications for these allergies? Yes No

� If yes, please list medications______________________________________________________ 8. Are you currently diagnosed with depression or any other form of mental illness? Yes No

� If yes, what type(s) of mental illnes? Diagnoses _________________________________

� Are you currently taking medication for depression or another mental illness? Yes No � If yes, please list the medication(s) and the diagnosis for which each is prescribed. ___________________________________________________________________________

Parent Health Form P. 2

9. Do you currently perform any form of regular physical exercise? Yes No � If yes, please indicate what types of exercise you do and how often you do each.

_______________________________________________________________________________

10. Please list any other things you do for the purpose of promoting your physical and/or emotional health. _______________________________________________________________________________

11. What is your height and current weight? Height ________ (feet, inches) Weight _______ (pounds)

12. On average, how many hours of sleep do you get per night? _____________ (hours)

I typically go to bed between the hours of __________ and ____________

I typically get up between the hours of _________ and ____________ 13. On average, how many drinks containing alcohol (wine, beer, etc.) do you consume per week? ______ drinks. 14. To the best of your ability, please indicate the number of times you have had the following illnesses or

conditions in the last 2 months.

Cold (sore throat, congestion, runny nose) ____________

Flu (fever, pain, upset stomach) ____________

Headache (lasting more than 1 hour) ____________

Allergic reaction to food, dust or other allergen ____________

Asthma attack ____________

Lower back pain (not from menstruation or exercise) ____________

Strong mood swing ____________

Out of control temper ____________

General tiredness (fatigue) ____________

Difficulty falling asleep (insomnia) ____________

Other sleep problems (describe: ___________________ ) ____________

15. Do you have any other health conditions we should be aware of? If yes, please describe.

_______________________________________________________________________________

16. Are you taking any other medications, beyond those you’ve already mentioned above? If yes, please list the medications and the medical condition for which each one is prescribed.

_______________________________________________________________________________

17. How many days of work have you missed over the past year due to illness? ______ days. How many times have you visited a physician over the last year for reasons of illness (do not include

regularly scheduled check-ups or preventative-care visits)? _______ times.

Have you been hospitalized in the last year? If so, please indicate the reason for the hospitalization and the duration of the hospital stay. Reason _______________________________ Duration____________________________

18. Basically, would you say your health is (circle one):

Excellent Above Average Average Below Average Poor

Parent Health Form P. 3

Now I'd like to ask you a few questions about the health of your teenage child who is participating in the study. 1. Please report your child's birth month and year ________, 19______ and today’s date __________, 2000. 2. Please report your child's height and weight. Height _________ (feet, inches) Weight________ (pounds)

3. On average, how many hours of sleep per night does your child get? ____________ (hours) 4. Does your child regularly take any form of caffeine? (e.g. caffeinated pop). Yes No

� If yes, what form of caffeine and how much. Form ____________ Quantity__________ (amount/day). 5. Is your child currently diagnosed with asthma? Yes No

� If yes, does he or she currently take any form of asthma medication? Yes No

� If yes, what type(s)? ___________________________________________________ 6. Does your child have any allergies? Yes No

� If yes, please list ___________________________________________________________

� If yes, is he/she taking any medications to control these allergies? Yes No

� If yes, please list ____________________________________________________________ 7. Is your child currently diagnosed with ADHD or any other emotional or behavioral disorder? Yes No

� If yes, what type(s) of emotional or behavioral disorder(s)? _________________________________

� Is your child currently taking any medication for this? Yes No � If yes, please list the medication(s) and the diagnosis for which each is prescribed. ______________________________________________________________________________________

8. To the best of your ability, please indicate the number of times your child has had the following illnesses or

conditions in the last 2 months.

Cold (sore throat, congestion, runny nose) ____________

Flu (fever, pain, upset stomach) ____________

Headache (lasting more than 1 hour) ____________

Allergic reaction to food, dust or other allergen ____________

Asthma attack ____________

Lower back pain (not from menstruation or exercise) ____________

Strong mood swing ____________

Out of control temper ____________

General tiredness (fatigue) ____________

Difficulty falling asleep (insomnia) ____________

Other sleep problems (describe: ___________________ ) ____________

Parent Health Form P. 4

9. Has your child had any other illnesses in the last two months? If so, please list.

_____________________________________________________________________________

10. Does your child have any other medical conditions or do you have any other health concerns regarding your child that we should be aware of? If yes, please describe.

_______________________________________________________________________________

11. Is your child taking any other medications, beyond those already described above? If yes, please list the medications and the medical condition for which each medication is prescribed.

_______________________________________________________________________________ 12. How many days of school did your child miss last year due to illness? ______ days. How many times has your child visited a physician over the last year for reasons of illness (do not include

regularly scheduled check-ups or preventative-care visits)? _______ times.

Has your child been hospitalized in the last year? If so, please indicate the reason for the hospitalization and the duration of the hospital stay. Reason _______________________________ Duration____________________________

13. Basically, would you say your child's health is (circle one):

Excellent Above Average Average Below Average Poor 14. Is anyone else in your family currently facing a serious health problem? If so, please describe.

_______________________________________________________________________________

Thank you!

Teen Health Form P. 1

Health Information - Teen ID#____________ Certain lifestyle choices, medications and health states affect people's levels of cortisol, the stress hormone that we are measuring in your saliva. We need to know about these so we can take them into account when analyzing your stress hormone levels. We realize that many of the questions below may not be relevant to you, but we need to ask them of everybody. Please answer the following, remembering that you may skip any question you do not wish to answer, and that all of your answers are confidential. To help ensure confidentiality, please seal your questionnaire in the envelope labeled "Teen Health Form" once it is completed. Thank you! 1. Do you regularly take any form of caffeine? (coffee, tea, caffeinated pop, caffeine pills, etc.) Yes No

� If yes, please indicate what form you take it in and how much you take each day. Form _________________ Quantity _________________ (amount/day).

2. Do you smoke or take nicotine in any other form? Yes No

� If yes, please indicate what form you take it in and how much you take each day. Form _____________ Quantity _______________ (amount/day)

☺ If male, please skip to question 6. 3. Have you begun menstruating? Yes No

� If yes, how old were you when you first menstruated? Age: I was _______ years and ________ months old when I began to menstruate.

4. Do you have a monthly menstrual cycle? Yes No � If yes, how many days has it been since the beginning of your last menstrual period? _______ days

� Is yes, is your menstrual cycle typically regular (same number of days)? Yes No

5. Do you currently use birth control pills or a birth control implant or injection? Yes No

� If yes, please indicate type __________________________________

6. Are you currently diagnosed with asthma? Yes No

� If yes, do you currently take any form of asthma medication? Yes No

� If yes, what type(s)? ___________________________________________________

7. Do you have any allergies? Yes No

� If yes, please list ___________________________________________________________

� If yes, are you taking any medications for these allergies? Yes No

� If yes, please list medications _________________________________________________________

8. Are you currently diagnosed with depression or any other form of emotional or mental illness? Yes No

� If yes, what type(s) of mental illness? Diagnoses _________________________________

� Are you currently taking medication for depression or another mental illness? Yes No � If yes, please list the medication(s) and the diagnosis for which each is prescribed. ________________________________________________________________________

Teen Health Form P. 2

9. Do you currently perform any form of regular physical exercise? Yes No � If yes, please indicate what types of exercise you do how often you do each.

_______________________________________________________________________________ _______________________________________________________________________________ 10. Please list any other things you do for the purpose of promoting your physical and/or emotional health. _______________________________________________________________________________

11. On average, how many hours of sleep do you get per night? _____________ (hours)

� I typically go to bed between the hours of __________ and ____________ � I typically get up between the hours of _________ and ____________

12. How tall are you? Height: I am _______ feet and ________ inches tall. 13. How much do you weigh? Weight: I weigh ____________ pounds. 14. Do you ever consume alcoholic beverages? Yes No

� If yes, how many drinks containing alcohol (wine, beer, etc.) do you consume per week? ______ drinks. 15. To the best of your ability, please indicate the number of times you have had the following illnesses or

conditions in the last 2 months.

Cold (sore throat, congestion, runny nose) _________ Flu (fever, upset stomach) _________

Headache (lasting more than 1 hour) _________ Asthma attack _________

Allergic reaction to food, dust or other _________ Strong mood swing _________

Back pain (not from menstruation or exercise) _________ Out of control temper _________

General tiredness (fatigue) _________ Difficulty falling asleep (insomnia) _________

Other sleep problems (describe: ________________________________________________) _________

16. Do you have any other health conditions we should be aware of? Yes No

� If yes, please list.

_______________________________________________________________________________

17. Do you ever take any other medications, beyond those already described above? Yes No � If yes, please list the medications, how often you take them and for what reasons.

_______________________________________________________________________________

18. How many days of school have you missed over the past year due to illness? ______ days.

� How many times have you visited a physician over the last year for reasons of illness (do not include regularly scheduled check-ups or preventative-care visits)? _______ times.

Have you been hospitalized in the last year? Yes No � If so, please indicate the reason for the hospitalization and the duration of the hospital stay. Reason ___________________________________ Duration____________________________

19. Basically, would you say your health is (circle one):

Excellent Above Average Average Below Average Poor

Teen Health Form P. 3

Physical Development Scale – Female (please read!) The hormonal changes that girls go through during puberty affect the stress hormones that we are studying so we would like to know about your puberty changes. The following questions are about those physical changes that are occurring (or have already occurred) in your body. Some of the questions are quite personal; skip any questions you do not wish to answer. Remember that your answers are entirely confidential. Once you’re done, please seal your completed form in the envelope that is labeled “Teen Health Form”

CIRCLE ONLY ONE ANSWER FOR EACH QUESTION.

1. Would you say that your growth in height:

a. has not yet begun to spurt ("spurt" means more growth than usual) b. has barely started c. is definitely underway d. seems completed

2. And how about the growth of body hair ("body hair" means underarm and pubic hair)?

Would you say that your body hair has: a. not yet started growing b. has barely started growing c. is definitely underway d. seems completed

3. Have you noticed any skin changes, especially pimples?

a. not yet started showing changes b. have barely started showing changes c. skin changes are definitely underway d. skin changes seem completed

4. Have your breasts begun to grow?

a. not yet started growing b. has barely started changing c. breast growth is definitely underway d. breast growth seems completed

5. Do you think your development is any earlier or later than most girls your age?

a. much earlier b. somewhat earlier c. about the same d. somewhat later e. much later

Teen Health Form P. 4

Physical Development Scale – Male (please read!)

The hormonal changes that boys go through during puberty affect the stress hormones that we are studying so we would like to know about your puberty changes. The following questions are about those physical changes that are occurring (or have already occurred) in your body. Some of the questions are quite personal; skip any questions you do not wish to answer. Remember that your answers are entirely confidential. Once you’re done, please seal your completed form in the envelope that is labeled “Teen Health Form”

CIRCLE ONLY ONE ANSWER FOR EACH QUESTION. 1. Would you say that your growth in height:

a. has not yet begun to spurt ("spurt" means more growth than usual) b. has barely started c. is definitely underway d. seems completed

2. And how about the growth of body hair ("body hair" means underarm and pubic hair)?

Would you say that your body hair has: a. not yet started growing b. has barely started growing c. is definitely underway d. seems completed

3. Have you noticed any skin changes, especially pimples?

a. not yet started showing changes b. have barely started showing changes c. skin changes are definitely underway d. skin changes seem completed

4. Have you noticed a deepening of your voice?

a. not yet started changing b. has barely started changing c. voice change is definitely underway d. voice change seems completed

5. Have you begun to grow hair on your face?

a. not yet started growing hair b. has barely started growing hair c. facial hair growth is definitely underway d. facial hair growth seems completed

6. Do you think your development is any earlier or later than most other boys your age?

a. much earlier b. somewhat earlier c. about the same d. somewhat later e. much later