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Cognitive and Emotional Health Project (CEHP)


Questionnaire

Name of Study:
Principal Investigator(s): (e.g., Jane Doe)
Grant ID#: (e.g., R01AG012345, P20MH012345, U01NS012345, N/A)

1. Population Studied and Timing of Assessments

Location/catchment area:
Community-based sampling? Yes No
Sample Description:
Community-dwelling residents
Yes No
HMO members
Yes No
Hospital in- or outpatients
Yes No
Nursing home assisted living
Yes No
Special populations
Yes No
Veterans
Yes No
Religious group (e.g., Catholic nuns)
Yes No
Occupational cohort (e.g., electrical workers)
Yes No
Health cohort (e.g., stroke survivors)
Yes No
Other
 Yes No
Other (specify) *
Sample size at the end of enrollment (actual or projected)
Calendar year at start of study (e.g., 1980)
Follow-up interval (number of years between assessments)
Number of follow-up waves as of today
Maximum time between first and last assessment (actual or projected)
Calendar year at end of study (actual or projected) (e.g., 1980)
Mortality ascertainment Yes No

2. Demographic Status

Were the following groups studied? Answer Yes or No for each group.
Age at baseline:
18-24 years
 Yes No
25-34 years
Yes No
35-44 years
Yes No
45-54 years
Yes No

55-64 years

Yes No
65-74 years
 Yes No
75-84 years
Yes No
85+ years Yes No
Gender of Participants:
Male
Yes No
Female
Yes No
Race/ethnic composition:
White
Yes No
Black
Yes No
Hispanic
Yes No
Asian
Yes No
Native American
 Yes No
Other
Yes No
Were the following variables assessed?
Handedness
Yes No
Education
Yes No
Marital status
Yes No
Occupational history
Yes No
Urban/rural residence
Yes No
Census tract of residence
Yes No
Income
Yes No

3. Medical History

DOES THE STUDY ASSESS MEDICAL HISTORY AND MEDICATIONS? Yes No
If No, Go to Section 4.
Medical History
Neurologic conditions (e.g., Alzheimer's disease, Parkinson's disease, stroke, head injury)
Yes No
Cardiovascular conditions (e.g., angina, hypertension, myocardial infarction, congestive heart failure)
Yes No
Pulmonary conditions (e.g., asthma, COPD)
Yes No
Diabetes
Yes No
Cancer
Yes No
Musculoskeletal conditions (e.g., arthritis, hip fracture)
Yes No
Sensory impairment (e.g., visual, auditory)
Yes No
Psychiatric Disorders
(e.g., depression, anxiety, PTSD, schizophrenia) 		Yes No
Medication use
Were all medications recorded?
Yes No
Were specific medications (e.g., estrogen) recorded?
Yes No
Hospitalization History
Recent (e.g., past 1 year) hospitalization history
Yes No
Lifetime hospitalization history
Yes No
Reproductive History
Menstrual history
Yes No
Pregnancy history
Yes No
Family History
Neurologic conditions
Yes No
Psychiatric conditions
Yes No
Environmental Exposures
Pesticides
Yes No
Occupational exposures
Yes No
Vaccination Yes No
Other (specify) *

4. Health Habits

DOES THE STUDY ASSESS HEALTH HABITS? Yes No
If No, Go to Section 5.
Smoking history (e.g., cigarettes) Yes No
Alcohol consumption Yes No
Vitamin use Yes No
Supplement/Nutraceutical use Yes No
Caffeine consumption Yes No
Usual dietary history Yes No
Sleep patterns Yes No
Illegal drug use (e.g., marijuana) Yes No
Other (specify) *

5. Leisure Activities

DOES THE STUDY ASSESS AT HOME, ON THE JOB, AND RECREATION ACTIVITIES? Yes No
If No, Go to Section 6.
Physical activities (e.g., active sports, walking, swimming) Yes No
Mental activities (e.g., reading, crossword puzzles, bridge) Yes No
Social activities (e.g., visiting friends, going out to dinner, movie or sporting event) Yes No
Productive activities (e.g., home maintenance, volunteer work, providing informal help to others) Yes No
Other leisure activities Yes No
Other (specify) *
Were any of these items in Section 5 assessed more than once? Yes No

6. Biomedical Assessment

DOES THE STUDY INCLUDE BIOMEDICAL ASSESSMENTS? Yes No
If No, Go to Section 7.
Lab Specimens
Were the following biological materials collected?
Blood
 Yes No
Urine
 Yes No
Brain tissue
 Yes No
CSF
 Yes No
Other (specify) *
Have samples been stored for future analysis?
Plasma
 Yes No
Cell lines
 Yes No
DNA
 Yes No
Other (specify) *
Common Tests and Procedures
Anthropometry:
Weight
 Yes No
Height
 Yes No
Body fat
 Yes No
Waist-to-hip ratio
 Yes No
Blood Pressure:
Resting
 Yes No
Orthostatic
 Yes No
Ankle-arm blood pressure ratio
 Yes No
Spirometry
 Yes No
Sleep assessment
 Yes No
Cardiac Assessment:
Electrocardiography
 Yes No
Ultrasonography
 Yes No
Echocardiography
 Yes No
Brain Imaging:
Computed Tomography
 Yes No
Magnetic Resonance Imaging
 Yes No
PET/SPECT�
 Yes No
Functional Magnetic Resonance Imaging
 Yes No
Other (specify) *
Biologic Analysis
Have the following biological analyses been performed?
Cardiovascular profile:
Lipids
 Yes No
Total serum cholesterol
 Yes No
High-density lipoprotein cholesterol
 Yes No
Triglycerides
 Yes No
Homocysteine
 Yes No
Other cardiovascular factors:
Post-challenge serum glucose, insulin
 Yes No
Plasma fibrinogen
 Yes No
Factors �VII, �VIII�
 Yes No
DHEA
 Yes No
Stress hormones (e.g., cortisol)
 Yes No
Nutrient levels (e.g., antioxidants)
 Yes No
Genetic markers
 Yes No
Other
 Yes No
Other (specify) *
Were any of these items in Section 6 assessed more than once? Yes No

7. Functional Status

DOES THE STUDY ASSESS FUNCTIONAL STATUS? Yes No
If No, Go to Section 8.
Self Report
Basic self-care tasks (e.g., activities of daily living)
 Yes No
Household management (e.g., instrumental activities of daily living)
 Yes No
Other (e.g., upper extremity function, mobility)
 Yes No
Performance-based Assessments
Postural stability (e.g., tandem, side-by-side stands, timed walk, chair stands)
 Yes No
Strength measure (e.g., lower & upper extremity strength)
 Yes No
Were any of these items in Section 7 assessed more than once? Yes No

8. Psychosocial Status

DOES THE STUDY ASSESS PSYCHOSOCIAL STATUS? Yes No
If No, Go to Section 9.
Perceived health/quality of life Yes No
Social networks Yes No
Social support (e.g., emotional, instrumental support) Yes No
Life events Yes No
Coping style/strategies Yes No
Perceived stress Yes No
Sense of control, self-efficacy, or mastery Yes No
Religiosity (strength of religious conviction) Yes No
Attendance at religious services Yes No
Hopelessness Yes No
Optimism Yes No
Housing quality Yes No
Personal security, safety Yes No
Experiences with violence:
Violence by childhood caregivers
 Yes No
Spousal violence
 Yes No
Elder violence
 Yes No
Other psychosocial measures
 Yes No
Other psychosocial measures (specify) *
Were any of these items in Section 8 assessed more than once? Yes No

9. Psychiatric Status

DOES THE STUDY ASSESS PSYCHIATRIC STATUS? Yes No
If No, Go to Section 10.
Depression or Depressive Symptoms:
Screening instrument (e.g., CES-D, BDI)
 Yes No
Structured diagnostic interview (e.g., DIS, SCID)
 Yes No
Clinical Examination
 Yes No
Anxiety Disorders or Anxiety Symptoms:
Screening instrument (e.g., Spielberger)
 Yes No
Structured diagnostic interview (e.g., DIS, SCID)
 Yes No
Clinical examination
 Yes No
Other Emotional Behavior Changes Yes No
Substance Use Disorders:
Screening instrument (e.g., alcohol use)
 Yes No
Structured diagnostic interview (e.g., DIS, SCID)
 Yes No
Clinical examination
 Yes No
Schizophrenia or Other Psychiatric Disorders:
Screening instrument (e.g., SCID screener)
 Yes No
Structured diagnostic interview (e.g., DIS, SCID)
 Yes No
Clinical examination
 Yes No
Previous history of psychiatric disorder Yes No
Were any of these items in Section 9 assessed more than once? Yes No

10. Cognitive Status

DOES THE STUDY ASSESS COGNITIVE STATUS? Yes No
If No, Go to Section 11.
 
Was whole sample tested, or subset only?
Number of times subjects were tested?
Brief Screening Instruments:
Mini-Mental State Exam (MMSE)
 Yes No Whole Subset 1X 2X 3+X
Modified Mini-Mental State Exam (3MS)
 Yes No Whole Subset 1X 2X 3+X
Telephone Interview for Cognitive Status (TICS)
 Yes No Whole Subset 1X 2X 3+X
Short Portable Mental Status Questionnaire (SPMSQ)
 Yes No Whole Subset 1X 2X 3+X
Other brief screeners
 Yes No Whole Subset 1X 2X 3+X
Neuropsychological Tests:
Memory
 Yes No Whole Subset 1X 2X 3+X
Language
 Yes No Whole Subset 1X 2X 3+X
Conceptualization, reasoning
 Yes No Whole Subset 1X 2X 3+X
Visuospatial ability
 Yes No Whole Subset 1X 2X 3+X
Other abilities
 Yes No Whole Subset 1X 2X 3+X
Dementia Evaluation, Clinical Yes No Whole Subset 1X 2X 3+X

11. Publications

Please provide us with one publication that best outlines the parameters of the study as a whole. If such a publication does not exist, please type "NA" in the box.