English translation; Mrs. Anne Clancy and Mr. KevinMcCafferty
Togetlier itithIhe invitalion to attendyou received a questionnairefroni Ihe National Mass Radiography Service. Yoti a’elivered thisqnesrionnaireatilie exaniinalion.
Cardiovascular diseases are, however, a complex group ofdiseases. The causes are stil1 partly unknown. in Tromso we are therefore tlying to ohlaina more complele descr,p1ion offaclors whicjz may be ofimportance fortlie course ofthese diseases, such as diet, psychologicalpressure (“siress‘), social conditions, and occurrence ofdisease in relatives. We hope you will take the Ironbie to coniplele ihis qnestionnaire as weR and reiuriz it to the Tromso Board ofHealth in the enclosed envelope.
All iiJbrrnation in connection with 11w niass .r—ray examination will be trealed as stricily coifldeniial.
1 YOUR OWN DIET
1.Whai typeofbread do you usually eat?
Tick Ihe most appropriate box; }‘es White bread (e.g. French bread) LI Ordinary bread (light texture) LI Whole meal (brovn) bread LI Home-made (brown) bread El
2. What type of butter or margarine do you usually eat?
Tick the most appropriate bor; Yes
Butter LI
Ordinarv margarine LI
Plant margarine El
Soft margarine spread LI
3. l-low many slices ofbread do ou usually eat daily?
Tiek Ihe most appropriate box;
Less than two slices 2-6 slices
7-12 slices 13 or more slices
4. What type of milk do you usually drink?
Tick Ihe tnost appropriate box; Tes
Do not drink milk fl
Full cream milk: ordinarytype
orcurdled fl
Skimmed milk: ordinarv type
orcurdled fl
Mixture of full cream and skimmed
milk Li
5. The drawings below show cubes of butter or margarine(actual size).
Tick ihe bor above the cube which best resembles the amount ou spread ona slice of bread.
Ifin doubt. tr buuering a slice.
Do not use butter or nmrgarine LI
Yes LI fl fl LI
1. fl 2. LI 3. fl 4. El
Tick the Inos appropriate bor Do not drink milk, or drink less tirnn I glass/cup
1-2 glasses 3-4 glasses/cups 5 or more glasses/cups
7. How many cups of coffee do you usually drink daily?
Tick the most appropriale box Do not drink coffee or drink less t.han i cup
I-4 cups 5-8 cups 9 or more cups
8. Areyou a teetotaller?
If “\‘‘
Ho’ often do you usually drink beer?
Tick the Inost appropriate box Never or just a few times a vear Once or twice a month About once a week 2-3 times a week More or less daily
How often do vou usually drink wine?
Tick ilie most appropriate bor Never orjust a few times a vear Once or twice a month About once a week 2-3 times a week More or less daily
How often do you usually drink spirits?
Tick the ,nosl appropriate box Never or a just few times a vear Once or twice a month About once a veek 2-3 tinles a week More or less daily
spirits that vou gol drunk?
Tick the iirost appropriote bor
Li Have never been drunk. or have not ïes Li been dnmk during the past vear
Li A fewtimes during tlie last year O Once or twice a month
Once or twice a week 3 or more times a week
10. How often does your main meal consist Yes offish or fish dishes?
Tick the !,zost appropriate bor Yes
Less than once a week LI
Li Once or twice a week Li
3-4 times a week Li
O 5 -6 times a week Li
7 days a week Li
11. How often do you eat fruit or vegctables?
Li Li Tick the ,nost appropriate bor }‘es Never eat fruit or vegetables Li
A few times a year Li
Once or twice a month Li
About once a week Li
2to3 timesaweek Li
More or less daily fl
12. How many times a month do you eat boiled sausages or fried meat balis, processed meat, etc.?
Tick the niost appropriate bor ïes Never nr less than once a nionth Li
Once or twice a month Li
Li 3 -4 times a nionth (up to once a week) Li -i 5 -8 times a monffi (up to twice a week) Li
More than 8 times a month, (more than
Li twice a week) Li
13. Have ou made anv changes in your diet during the last 5 earsas regards tie following food items?
Tick each ile,n in the appropriote bor
\ç More before now Ordinarv margarine or butter: 0 LI
Skinimed milk: Li Li
Leanmeat:
Full cream milk:
Soya margarine (sofi):
Fatty meat:
TIck Ilie appropriare hox ‘Yes” ar 14. Have vou ever bad ?
-Sudden paralysis or numbness on one side of vour face or body, in vour hand or foot
-Sudden loss of ability to speak -Sudden loss of evesighi, complete or partial. or sudden onset of double
15. Have you bad a peptic ulcer?
Do vou often have a gnawing pain in the upper part of vour stomach? 0 0 Do vou suffer much from hearibum or regurgitation ofgastricjuices? LI 0 Do you suffer much from vind
and rumbling in vour stomach?
Do you often get cramps in your stomach?
Have you ever had your large intestine x-raved?
Have you ever had gall stones?
16. Have you bad kidney stones or stones in 11e urinary tract?
Ifyes, how many times?
and
18. Do vou have, orhave bad vou tbe skin
disease psoriasis? Yes .Vo
00 19. Have vou bad allergv-induced eczema on your hands during the last ïesVo
l2months? LI LI
20. Have you been on sick leave, or bccn unable to work due to allergic eczema on vour harids at anv time during the past 3 vears?
l’es .Vo LI:
21. Have vou ever bad arthritis?
(chronic rheumatoid arthritis)
25. Have you had any infectious disease during the past 14 days?
(influenza. comrnon cold, vomiting. diarrhoea, etc.) 26. Have you taken iron tablets during Ute past 14 days?
27. How often do vou take painkillers such as Globoid, Novid, Dispril, Albyl. etc.?
Tick ihe appropriate box 1 -3 times a week
-3 times a monilt Seldom or never
Have ou used such painkillers duringthe past 14 davs?
28. Have you changed Lite amount ofphysical exercise you take in leisure during time r.he last five years?
TIck the tnost appropriate box.
As before More ilian before Less than before
les ,Vo [LI
vision
Yes No
22. Have you suffered from back pain during the past 12 months lasting for more than 4
0 0 weeks? ls No
00 00
If “Yes did Lite back pain 0 0 improve if you exercised?
fes Vo 00 23. Have you suffered from morning stiffness Yes No in your back lasting more than Yes No
0 0 30 minutes? 0 LI
Lii
24. Have you suffered from pains lasting more than 3 months, in lite joints listedbelow duringlite last 3 vears? }s No
Knees: 0 LI
Elbows: 0 0
Innermost finger joints: 0 0
0 0 Offierjoints: 0 0
0 0 If ‘Yes‘, did you suffer from stiffjoints in Ute 0 0 mornings lasting more than Yes No
30 minutes? LI LI
Yes No 00
Whendid you have your last attack? Year 17. Have you ever bad cancer?
If “yes”, in what vear was the disease discovered?
IV SOCIAL CONDITIONS AND PSYCHOLOGICAL PRESSURE (“STRESS”)
30. How many vears schooling have you had? (including secondary and folk high schools) nuniber of vears
31. What was your familys financial situation when vou were growing up?
Tick the appropriale box Veiy good
Good Poor Very poor
32 .Do you suffer fl-om sleeplessness?
33. Have you had difficulty sleeping in the past couple ofweeks?
Tick the inost appropriate box Yes
Not at all fl
No more than usual fl
Rather more than usual fl
Much more than usual fl
34. Have you felt unliappvand depressed Yes during ihe past couple of weeks?
fl Tick ilie appropriate box Yes
o
Notatall flO No more than usual 0
o
Rather more than usual flMuch more than usual fl ïes Vo
If “yes‘,at what time ofthe year do you suffer from sleeplessness?
Tick the appropriate box Yes
No particular time 0
Especially during tlie ‘dark tinie 0 Especially during the arctic summer
(midnight sun) fl
Especiallv in spring and autumn [1
35. Have vou felt unable to cope with your difficulties during the past couple ofweeks?
Tick rhe appropriale bor Yes
Notatall fl
No more thaii usual Ratlier more t.han usual Much more Ilian usual
What form our sleeplessness take?
Tick tlie inost appropriale bor Yes Difficult to fall asleep at night? fl Wake up a lot during ilie night? 0 Wake upverv earlv in the moming? fl
Cerebral stroke or brain haemorrhage fl 0 0 Li
Diabetes LI fl fl fl
Anhritis (chronic rheumatoid art.hritis) 0 0 0 0
Cancer 0 fl fl fl
Kidnev stones or stone in urinan’ tract fl fl 0 0
Psoriasis fl fl 0 LI
Pepticulcer fl 0 0 0
None ofthe above-mentioned ilinesses fl fl fl fl
fl fl fl
TiEtr 1L 5ER LDEU1DE KLSE