Protocol - Assessment of Gallbladder Disease and Related Conditions

0. CHECK ITEM. REFER TO AGE OF SP.

1[ ]17–74 Years (1)

2[ ]75+ Years (16)

HAND CARD HAQ-4.

1. Please look at this diagram. During the past 12 months, have you had pain in the area shaded on the diagram? FOR FEMALES DO NOT INCLUDE MENSTRUAL PAIN.

1[ ]Y

2[ ]N (9)

9[ ]DK (9)

2. Sometimes people have more than one type of pain. I am going to ask you a few questions about the pain that has been the most uncomfortable in the past 12 months. For the pain that was most uncomfortable, please show me where the pain was located. MARK ALL AREAS INDICATED.

3. During the past 12 months, what is the longest time that one episode of this pain has lasted?

_______
Number

1[ ]Minutes

2[ ]Hours

3[ ]Days

4. On how many days in the past 12 months have you had this pain?

_______ days
Number

5. When you had this pain, was it continuous, or did it tend to come and go?

1[ ]Continuous

2[ ]Come and go

3[ ]Both

6. When you had the pain, if you moved around, did you hurt more, less, or was there no difference?

1[ ]More

2[ ]Less

3[ ]No difference

9[ ]DK

7. Have you ever seen a doctor about this pain?

1[ ]Y

2[ ]N (9)

8. What did the doctor say caused the pain?

01[ ]Gallstones/gallbladder problems (11)

02[ ]Ulcer

03[ ]Appendicitis or appendix problems

04[ ]Spastic colon or irritable bowel

05[ ]Diverticulitis or diverticulosis

06[ ]Other 07 ____________________
                    Specify

9. Has a doctor ever told you that you had gallstones?

1[ ]Y

2[ ]N (12)

9[ ]DK (12)

10. What was the reason you visited the doctor the time that he told you that you had gallstones?

1[ ]pain

2[ ]other 3 _____________________
                    Specify

11. Have you ever had medical treatment to dissolve or remove gallstones? Do not include surgery.

1[ ]Y

2[ ]N

9[ ]DK

12. Have you ever had gallbladder surgery?

1[ ]Y

2[ ]N (14)

9[ ]DK (14)

13. How old were you when you had your gallbladder surgery?

_____ age

14. CHECK ITEM. REFER TO 8, 10, AND 12.

1[ ]GALLSTONES/GALLBLADDER PROBLEMS (1) MARKED IN 8 AND YES (1) IN 12

1[ ]PAIN (1) MARKED IN 10 AND YES (1) IN 12

2[ ]OTHER (END OF PROTOCOL)

15. Did the pain that caused you to visit the doctor continue after your gallbladder surgery?

1[ ]Y (END OF PROTOCOL)

2[ ]N (END OF PROTOCOL)

9[ ]DK (END OF PROTOCOL)

16. Has a doctor ever told you that you had gallstones?

1[ ]Y

2[ ]N

9[ ]DK

17. Have you ever had gallbladder surgery?

1[ ]Y

2[ ]N (END OF PROTOCOL)

9[ ]DK (END OF PROTOCOL)

18. How old were you when you had your gallbladder surgery?

_____ age