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Protocol - Personal and Family History of Respiratory Symptoms/Diseases - Child Protocol

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Description:

Age-specific questions are asked in this protocol to two different age ranges of children. For children ages 13 and 14, a set of questions is asked directly to the child. For children 6 or 7 years old, a set of questions is asked of the parents.

Specific Instructions:

None

Protocol:

Questionnaire for 13 and 14 year olds

1. Have you ever had wheezing or whistling in the chest at any time in the past?

[ ] Yes

[ ] No

IF YOU HAVE ANSWERED "NO," PLEASE SKIP TO QUESTION 6.

2. Have you had wheezing or whistling in the chest in the last 12 months?

[ ] Yes

[ ] No

IF YOU HAVE ANSWERED "NO," PLEASE SKIP TO QUESTION 6.

3. How many attacks of wheezing have you had in the last 12 months?

[ ] None

[ ] 1 to 3

[ ] 4 to 12

[ ] More than 12

4. In the last 12 months, how often, on average, has your sleep been disturbed due to wheezing?

[ ] Never woken with wheezing

[ ] Less than one night per week

[ ] One or more nights per week

5. In the last 12 months, has wheezing ever been severe enough to limit your speech to only one or two words at a time between breaths?

[ ] Yes

[ ] No

6. Have you ever had asthma?

[ ] Yes

[ ] No

7. In the last 12 months, has your chest sounded wheezy during or after exercise?

[ ] Yes

[ ] No

8. In the last 12 months, have you had a dry cough at night, apart from a cough associated with a cold or chest infection?

[ ] Yes

[ ] No

All questions are about problems which occur when you DO NOT have a cold or the flu.

9. Have you ever had a problem with sneezing, or a runny or blocked nose, when you DID NOT have a cold or the flu?

[ ] Yes

[ ] No

IF YOU HAVE ANSWERED "NO," PLEASE SKIP TO QUESTION 14.

10. In the past 12 months, have you had a problem with sneezing, or a runny or blocked nose, when you DID NOT have a cold or the flu?

[ ] Yes

[ ] No

IF YOU HAVE ANSWERED "NO," PLEASE SKIP TO QUESTION 14.

11. In the past 12 months, has this nose problem been accompanied by itchy or watery eyes?

[ ] Yes

[ ] No

12. In which of the past 12 months did this nose problem occur? (Please tick any which apply.)

[ ] January

[ ] February

[ ] March

[ ] April

[ ] May

[ ] June

[ ] July

[ ] August

[ ] September

[ ] October

[ ] November

[ ] December

13. In the past 12 months, how much did this nose problem interfere with your daily activities?

[ ] Not at all

[ ] A little

[ ] A moderate amount

[ ] A lot

14. Have you ever had hay fever?

[ ] Yes

[ ] No

15. Have you ever had an itchy rash which was coming and going for at least six months?

[ ] Yes

[ ] No

IF YOU HAVE ANSWERED "NO," PLEASE SKIP TO QUESTION 20.

16. Have you had this itchy rash at any time in the last 12 months?

[ ] Yes

[ ] No

IF YOU HAVE ANSWERED "NO," PLEASE SKIP TO QUESTION 20.

17. Has this itchy rash at any time affected any of the following places: the folds of the elbows, behind the knees, in front of the ankles, under the buttocks, or around the neck, ears, or eyes?

[ ] Yes

[ ] No

18. Has this rash cleared completely at any time during the last 12 months?

[ ] Yes

[ ] No

19. In the last 12 months, how often, on average, have you been kept awake at night by this itchy rash?

[ ] Never in the last 12 months

[ ] Less than one night per week

[ ] One or more nights per week

20. Have you ever had eczema?

[ ] Yes

[ ] No

Questionnaire for 6 and 7 year olds

21. Has your child ever had wheezing or whistling in the chest at any time in the past?

[ ] Yes

[ ] No

IF YOU HAVE ANSWERED "NO," PLEASE SKIP TO QUESTION 26.

22. Has your child had wheezing or whistling in the chest in the last 12 months?

[ ] Yes

[ ] No

IF YOU HAVE ANSWERED "NO," PLEASE SKIP TO QUESTION 26.

23. How many attacks of wheezing has your child had in the last 12 months?

[ ] None

[ ] 1 to 3

[ ] 4 to 12

[ ] More than 12

24. In the last 12 months, how often, on average, has your childs sleep been disturbed due to wheezing?

[ ] Never woken with wheezing

[ ] Less than one night per week

[ ] One or more nights per week

25. In the last 12 months, has wheezing ever been severe enough to limit your childs speech to only one or two words at a time between breaths?

[ ] Yes

[ ] No

26. Has your child ever had asthma?

[ ] Yes

[ ] No

27. In the last 12 months, has your childs chest sounded wheezy during or after exercise?

[ ] Yes

[ ] No

28. In the last 12 months, has your child had a dry cough at night, apart from a cough associated with a cold or chest infection?

[ ] Yes

[ ] No

29. Has your child ever had a problem with sneezing, or a runny or blocked nose, when he/she DID NOT have a cold or the flu?

[ ] Yes

[ ] No

IF YOU HAVE ANSWERED "NO," PLEASE SKIP TO QUESTION 34.

30. In the past 12 months, has your child had a problem with sneezing, or a runny or blocked nose, when he/she DID NOT have a cold or the flu?

[ ] Yes

[ ] No

IF YOU HAVE ANSWERED "NO," PLEASE SKIP TO QUESTION 34.

31. In the past 12 months, has this nose problem been accompanied by itchy, watery eyes?

[ ] Yes

[ ] No

32. In which of the past 12 months did this nose problem occur? (Please tick any which apply)

[ ] January

[ ] February

[ ] March

[ ] April

[ ] May

[ ] June

[ ] July

[ ] August

[ ] September

[ ] October

[ ] November

[ ] December

33. In the past 12 months, how much did this nose problem interfere with your childs daily activities?

[ ] Not at all

[ ] A little

[ ] A moderate amount

[ ] A lot

34. Has your child ever had hay fever?

[ ] Yes

[ ] No

35. Has your child ever had an itchy rash that was coming and going for at least 6 months?

[ ] Yes

[ ] No

IF YOU HAVE ANSWERED "NO," PLEASE SKIP TO QUESTION 40.

36. Has your child had this itchy rash at any time in the last 12 months?

[ ] Yes

[ ] No

IF YOU HAVE ANSWERED "NO," PLEASE SKIP TO QUESTION 40.

37. Has this itchy rash at any time affected any of the following places: the folds of the elbows, behind the knees, in front of the ankles, under the buttocks, or around the neck, ears, or eyes?

[ ] Yes

[ ] No

38. At what age did this itchy rash first occur?

[ ] Under 2 years

[ ] Age 2-4 years

[ ] Age 5 or more

39. Has this rash cleared completely at any time during the last 12 months?

[ ] Yes

[ ] No

40. In the last 12 months, how often, on average, has your child been kept awake at night by this itchy rash?

[ ] Never in the last 12 months

[ ] Less than one night per week

[ ] One or more nights per week

41. Has your child ever had eczema?

[ ] Yes

[ ] No

Protocol Name from Source:

Availability:

Publicly available

Personnel and Training Required

None

Equipment Needs

None

Requirements
Requirement CategoryRequired
Major equipment No
Major equipment No
Specialized training No
Specialized training No
Specialized requirements for biospecimen collection No
Specialized requirements for biospecimen collection No
Average time of greater than 15 minutes in an unaffected individual No
Average time of greater than 15 minutes in an unaffected individual No
Mode of Administration

Self-administered questionnaire

Life Stage:

Child, Child, Adolescent

Participants:

Children aged 13 to 14 years

Parents of children aged 6 to 7 years*

* While the parental questionnaire was used in a study of parents of children aged 6 to 7 years, the Respiratory Working Group deems it appropriate to use with parents of children under the age of 14.

Selection Rationale

The International Study of Asthma and Allergies in Childhood (ISAAC) was founded to maximize the value of epidemiological research into asthma and allergic disease by establishing a standardized methodology and facilitating international collaboration.

Language

English, English

Standards
StandardNameIDSource
Common Data Elements (CDE) Person Respiratory Symptom Family And Personal Medical History Text 2969935 CDE Browser
Logical Observation Identifiers Names and Codes (LOINC) Resp fam hx resp sympt child proto 62626-7 LOINC
Derived Variables

None

Process and Review

Not applicable.

Source
The International Study of Asthma and Allergies in Childhood (ISAAC) Manual. December 1993, 2nd Edition. Module 1.1. Questions 1-8 (questions 1-8 and 21-28). Module 1.2. Questions 1-6 (questions 9-14 and 29-34). Module 1.3. Questions 1-7 (questions 15-20 and 35-41).

General References

None

Protocol ID:

90902

Variables:
Export Variables
Variable NameVariable IDVariable DescriptionVersiondbGaP Mapping
PX090902_Asthma_Ever_13 PX090902060000 Have you ever had asthma? Variable Mapping
PX090902_Asthma_Ever_6 PX090902260000 Has your child ever had asthma? N/A
PX090902_Dry_Cough_Night_12_Months_13 PX090902080000 In the last 12 months, have you had a dry more
cough at night, apart from a cough associated with a cold or chest infection? show less
N/A
PX090902_Dry_Cough_Night_12_Months_6 PX090902280000 In the last 12 months, has your child had a more
dry cough at night, apart from a cough associated with a cold or chest infection? show less
N/A
PX090902_Eczema_Ever_13 PX090902200000 Have you ever had eczema? Variable Mapping
PX090902_Eczema_Ever_6 PX090902410000 Has your child ever had eczema? Variable Mapping
PX090902_Hay_Fever_Ever_13 PX090902140000 Have you ever had hay fever? Variable Mapping
PX090902_Hay_Fever_Ever_6 PX090902340000 Has your child ever had hay fever? N/A
PX090902_Itchy_Rash_12_Months_13 PX090902160000 Have you had this itchy rash at any time in more
the last 12 months? show less
N/A
PX090902_Itchy_Rash_12_Months_6 PX090902360000 Has your child had this itchy rash at any more
time in the last 12 months? show less
N/A
PX090902_Itchy_Rash_Affected_Sites_Places_13 PX090902170000 Has this itchy rash at any time affected any more
of the following places: the folds of the elbows, behind the knees, in front of the ankles, under the buttocks, or around the neck, ears, or eyes? show less
N/A
PX090902_Itchy_Rash_Affected_Sites_Places_6 PX090902370000 Has this itchy rash at any time affected any more
of the following places: the folds of the elbows, behind the knees, in front of the ankles, under the buttocks, or around the neck, ears, or eyes? show less
N/A
PX090902_Itchy_Rash_Cleared_Completely_13 PX090902180000 Has this rash cleared completely at any time more
during the last 12 months? show less
N/A
PX090902_Itchy_Rash_Cleared_Completely_6 PX090902390000 Has this rash cleared completely at any time more
during the last 12 months? show less
N/A
PX090902_Itchy_Rash_Ever_13 PX090902150000 Have you ever had an itchy rash which was more
coming and going for at least six months? show less
N/A
PX090902_Itchy_Rash_Ever_6 PX090902350000 Has your child ever had an itchy rash that more
was coming and going for at least 6 months? show less
N/A
PX090902_Itchy_Rash_First_Age_6 PX090902380000 At what age did this itchy rash first occur? N/A
PX090902_Itchy_Rash_Often_Awake_Night_13 PX090902190000 In the last 12 months, how often, on more
average, have you been kept awake at night by this itchy rash? show less
N/A
PX090902_Itchy_Rash_Often_Awake_Night_6 PX090902400000 In the last 12 months, how often, on more
average, has your child been kept awake at night by this itchy rash? show less
N/A
PX090902_Nose_Interfere_Activities_12_Months_13 PX090902130000 In the past 12 months, how much did this more
nose problem interfere with your daily activities? show less
N/A
PX090902_Nose_Interfere_Activities_12_Months_6 PX090902330000 In the past 12 months, how much did this more
nose problem interfere with your child's daily activities? show less
N/A
PX090902_Nose_Itchy_Eyes_12_Months_13 PX090902110000 In the past 12 months, has this nose problem more
been accompanied by itchy or watery eyes? show less
N/A
PX090902_Nose_Itchy_Eyes_12_Months_6 PX090902310000 In the past 12 months, has this nose problem more
been accompanied by itchy, watery eyes? show less
N/A
PX090902_Sneezing_Runny_Nose_12_Months_13 PX090902100000 In the past 12 months, have you had a more
problem with sneezing, or a runny or blocked nose, when you DID NOT have a cold or the flu? show less
N/A
PX090902_Sneezing_Runny_Nose_12_Months_6 PX090902300000 In the past 12 months, has your child had a more
problem with sneezing, or a runny or blocked nose, when he/she DID NOT have a cold or the flu? show less
N/A
PX090902_Sneezing_Runny_Nose_Ever_13 PX090902090000 Have you ever had a problem with sneezing, more
or a runny or blocked nose, when you DID NOT have a cold or the flu? show less
Variable Mapping
PX090902_Sneezing_Runny_Nose_Ever_6 PX090902290000 Has your child ever had a problem with more
sneezing, or a runny or blocked nose, when he/she DID NOT have a cold or the flu? show less
N/A
PX090902_Sneezing_Runny_Nose_Occurrence_Months_13_April PX090902120400 In which of the past 12 months did this nose more
problem occur? April show less
N/A
PX090902_Sneezing_Runny_Nose_Occurrence_Months_13_August PX090902120800 In which of the past 12 months did this nose more
problem occur? August show less
N/A
PX090902_Sneezing_Runny_Nose_Occurrence_Months_13_December PX090902121200 In which of the past 12 months did this nose more
problem occur? December show less
N/A
PX090902_Sneezing_Runny_Nose_Occurrence_Months_13_February PX090902120200 In which of the past 12 months did this nose more
problem occur? February show less
N/A
PX090902_Sneezing_Runny_Nose_Occurrence_Months_13_January PX090902120100 In which of the past 12 months did this nose more
problem occur? January show less
N/A
PX090902_Sneezing_Runny_Nose_Occurrence_Months_13_July PX090902120700 In which of the past 12 months did this nose more
problem occur? July show less
N/A
PX090902_Sneezing_Runny_Nose_Occurrence_Months_13_June PX090902120600 In which of the past 12 months did this nose more
problem occur? June show less
N/A
PX090902_Sneezing_Runny_Nose_Occurrence_Months_13_March PX090902120300 In which of the past 12 months did this nose more
problem occur? March show less
N/A
PX090902_Sneezing_Runny_Nose_Occurrence_Months_13_May PX090902120500 In which of the past 12 months did this nose more
problem occur? May show less
N/A
PX090902_Sneezing_Runny_Nose_Occurrence_Months_13_November PX090902121100 In which of the past 12 months did this nose more
problem occur? November show less
N/A
PX090902_Sneezing_Runny_Nose_Occurrence_Months_13_October PX090902121000 In which of the past 12 months did this nose more
problem occur? October show less
N/A
PX090902_Sneezing_Runny_Nose_Occurrence_Months_13_September PX090902120900 In which of the past 12 months did this nose more
problem occur? September show less
N/A
PX090902_Sneezing_Runny_Nose_Occurrence_Months_6_April PX090902320400 In which of the past 12 months did this nose more
problem occur? April show less
N/A
PX090902_Sneezing_Runny_Nose_Occurrence_Months_6_August PX090902320800 In which of the past 12 months did this nose more
problem occur? August show less
N/A
PX090902_Sneezing_Runny_Nose_Occurrence_Months_6_December PX090902321200 In which of the past 12 months did this nose more
problem occur? December show less
N/A
PX090902_Sneezing_Runny_Nose_Occurrence_Months_6_February PX090902320200 In which of the past 12 months did this nose more
problem occur? February show less
N/A
PX090902_Sneezing_Runny_Nose_Occurrence_Months_6_January PX090902320100 In which of the past 12 months did this nose more
problem occur? January show less
N/A
PX090902_Sneezing_Runny_Nose_Occurrence_Months_6_July PX090902320700 In which of the past 12 months did this nose more
problem occur? July show less
N/A
PX090902_Sneezing_Runny_Nose_Occurrence_Months_6_June PX090902320600 In which of the past 12 months did this nose more
problem occur? June show less
N/A
PX090902_Sneezing_Runny_Nose_Occurrence_Months_6_March PX090902320300 In which of the past 12 months did this nose more
problem occur? March show less
N/A
PX090902_Sneezing_Runny_Nose_Occurrence_Months_6_May PX090902320500 In which of the past 12 months did this nose more
problem occur? May show less
N/A
PX090902_Sneezing_Runny_Nose_Occurrence_Months_6_November PX090902321100 In which of the past 12 months did this nose more
problem occur? November show less
N/A
PX090902_Sneezing_Runny_Nose_Occurrence_Months_6_October PX090902321000 In which of the past 12 months did this nose more
problem occur? October show less
N/A
PX090902_Sneezing_Runny_Nose_Occurrence_Months_6_September PX090902320900 In which of the past 12 months did this nose more
problem occur? September show less
N/A
PX090902_Wheezing_Attack_Times_12_Months_13 PX090902030000 How many attacks of wheezing have you had in more
the last 12 months? show less
Variable Mapping
PX090902_Wheezing_Attack_Times_12_Months_6 PX090902230000 How many attacks of wheezing has your child more
had in the last 12 months? show less
Variable Mapping
PX090902_Wheezing_Limit_Speech_12_Months_13 PX090902050000 In the last 12 months, has wheezing ever more
been severe enough to limit your speech to only one or two words at a time between breaths? show less
N/A
PX090902_Wheezing_Limit_Speech_12_Months_6 PX090902250000 In the last 12 months, has wheezing ever more
been severe enough to limit your child's speech to only one or two words at a time between breaths? show less
N/A
PX090902_Wheezing_Sleep_Disturbed_12_Months_13 PX090902040000 In the last 12 months, how often, on more
average, has your sleep been disturbed due to wheezing? show less
N/A
PX090902_Wheezing_Sleep_Disturbed_12_Months_6 PX090902240000 In the last 12 months, how often, on more
average, has your child's sleep been disturbed due to wheezing? show less
N/A
PX090902_Wheezing_Whistling_Chest_12_Months_13 PX090902020000 Have you had wheezing or whistling in the more
chest in the last 12 months? show less
Variable Mapping
PX090902_Wheezing_Whistling_Chest_12_Months_6 PX090902220000 Has your child had wheezing or whistling in more
the chest in the last 12 months? show less
N/A
PX090902_Wheezing_Whistling_Chest_Ever_13 PX090902010000 Have you ever had wheezing or whistling in more
the chest at any time in the past? show less
Variable Mapping
PX090902_Wheezing_Whistling_Chest_Ever_6 PX090902210000 Has your child ever had wheezing or more
whistling in the chest at any time in the past? show less
Variable Mapping
PX090902_Wheezy_Chest_Exercise_12_Months_13 PX090902070000 In the last 12 months, has your chest more
sounded wheezy during or after exercise? show less
Variable Mapping
PX090902_Wheezy_Chest_Exercise_12_Months_6 PX090902270000 In the last 12 months, has your child's more
chest sounded wheezy during or after exercise? show less
N/A
Respiratory
Measure Name:

Personal and Family History of Respiratory Symptoms/Diseases

Release Date:

January 29, 2010

Definition

Measure to assess the history of respiratory symptoms (i.e., cough, phlegm, shortness of breath, wheezing) and respiratory diseases.

Purpose

Personal and family history of respiratory symptoms and diseases are important to assess for overall health and quality of life. Standardized approaches to assess respiratory symptoms and diseases are required to define many respiratory phenotypes.

Keywords

respiratory, lung, personal history and family history of respiratory symptoms/diseases, asthma, dyspnea, cough, chest injuries, chest illnesses, chronic obstructive pulmonary disease (COPD), emphysema, chronic bronchitis, wheezing, family history, smoking