Family Health History - Male Version

Family Health History – Male Version

Question

Number

Verbatim Question Response categories and comments

What is your birthdate?

Month ____

Year______

1b What state were you born in?

State __________

enter two letter state code

DC=District of Columbia

I was born outside the U.S. 1 = box checked

2 What is your sex? 1=male

2=female

3a What is your race? 1=asian

2=black

3=white

4=american indian

5=other

9=multiple boxes checked

3b Are you of Mexican, Latino, or

Hispanic origin?

1=yes

2=no

4 Please check how far you’ve gone

in school....

(Choose one)

1=Didn’t go to high school

2=Some high school

3=High school graduate or GED

4=Some college or technical school

5= 4 year college graduate

9=Multiple boxes checked

5 What is your current marital status?

Are you now...

1=married

2=not married, but living together

with a partner

3=widowed

4=separated

5=divorced

6=never married

9=multiple answers checked

6a How many times have you been

married?

1=1

2=2

3=3

4=4 or more

5=never married

9=multiple boxes checked

FHH Male

Question

Number

Verbatim Question Response categories and comments

6b During what month and year were

you first married?

Month___

Range: 1-12

Year___ Range: 10-96

Never married 1=never married

7a Which of the following best

describes your employment status?

1=full time (35 hours or more)

2=part-time (1-34 hours)

3=Not employed outside the home

9=multiple items checked

7b If you are employed full time (35

hours per week or more):

Range: 0-30

How many days of work did you

miss in the past 30 days due to

stress or feeling depressed?

How many days of work did you

miss in the past 30 days due to poor

physical health?

For most of your childhood, did your

family own their home?

1=yes

2=no

9a During your childhood, how many

times did you move residences,

even in the same town?

# of times ________

Range: 0-999

9b How long have you lived at your

current residence?

1=Less than 6 months

2=Less than 1 year

3=Less than 2 years

4=2 or more years

9=Multiple boxes checked

10 How was your mother when you

were born?

Age________

Range:0-99

FHH Male

Question

Number

Verbatim Question Response categories and comments

11a How much education does/did your

mother have? (Choose one)

1=Didn’t go to high school

2=Some high school

3=High school graduate or GED

4=Some college or technical school

5=4 year college degree graduate or higher

9=Multiple boxes checked

11b How much education does/did your

father have? (Choose one)

1=Didn’t go to high school

2=Some high school

3=High school graduate or GED

4=Some college or technical school

5= 4 year college graduate or higher

9=Multiple boxes checked

12a Have you smoked at least 100

cigarettes in your entire life?

1=yes

2=no

12b How old were you when you began

to smoke cigarettes fairly regularly?

Age______

Range: 0-99

12c Do you smoke cigarettes now? 1=yes

2=no

12d If yes, on average, about how many

cigarettes a day do you smoke?

Number of cigarettes___

Range: 0-99

13a If you used to smoke cigarettes but

don’t smoke now, about how many

cigarettes a day did you smoke?

Range:00-99

13b How old were you when you quit?

Age ________

Range:00-99

14a During your first 18 years of life did

your father smoke?

1=yes

2=no

14b During your first 18 years of life did

your mother smoke?

1=yes

2=no

15a During the past month, about how

many days per week did you

exercise for recreation or to keep in

shape?

______ days per week

Range: 0 - 7

FHH Male

Question

Number

Verbatim Question Response categories and comments

15b During the past month, when you

exercised for recreation or to keep

in shape, how long did you usually

exercise (minutes)?

______minutes

0=0

1=1-19

2=20-29

3=30-39

4=40-49

5=50-59

6=60 or more

16a How old were you when you had

your first drink of alcohol other than

a few sips?

Age_______

Range:00-99

Never drank alcohol 1=Box Checked

During each of the following age

intervals, what was your usual

number of drinks of alcohol per

week?

16b1 Age 19-29 1=None

2=Less than 6 per wk

3=7-13 per wk

4=14 or more per wk

9=multiple responses

16b2 Age 30-39 1=None

2=Less than 6 per wk

3=7-13 per wk

4=14 or more per wk

9=multiple responses

16b3 Age 40-49 1=None

2=Less than 6 per wk

3=7-13 per wk

4=14 or more per wk

9=multiple responses

16b4 Age 50 and older 1=None

2=Less than 6 per wk

3=7-13 per wk

4=14 or more per wk

9=multiple responses

16c During the past month, have you

had any beer, wine, wine coolers,

cocktails or liquor?

1=yes

2=no

FHH Male

Question

Number

Verbatim Question Response categories and comments

16d During the past month, how many

days per week did you drink any

alcoholic beverages on average?

Range: 0 - 7

16e On the days when you drank, about

how many drinks per day did you

have on average?

1=1

2=2

3=3

4=4 or more

5=didn’t drink in past month

16f Considering all types of alcoholic

beverages, how many times during

the past month did you have 5 or

more drinks on an occasion?

Number of times_______

Range:0-999

16g During the past month, how many

times have you driven when you’ve

had perhaps too much to drink?

Number of times_______

Range:0-999

16h During the past 30 days, how many

times did you ride in a car or other

vehicle driven by someone who had

been drinking alcohol?

Number of times______

Range:0-999

17 Have you ever had a problem with

your use of alcohol?

1=yes

2=no

18 Have you ever considered yourself

to be an alcoholic?

1=yes

2=no

19a During your first 18 years of life did

you live with anyone who was a

problem drinker or alcoholic?

1=yes

2=no

19b If “yes” check all who were:

father 1=if boxed checked

mother 1=if boxed checked

brothers 1=if boxed checked

other relative 1=if boxed checked

other non-relative

1=if boxed checked

FHH Male

Question

Number

Verbatim Question Response categories and comments

sisters 1=if boxed checked

20 Have you ever been married to

someone (or lived with someone as

if you were married) who was a

problem drinker or alcoholic?

1=yes

2=no

21a Have you ever used street drugs? 1=yes

2=no

21b If “yes” how old were you the first

time you used them?

Age___________

Range:0-99

21c About how many times have you

used street drugs?

0=0

1=1-2

2=3-10

3=11-25

4=26-99

5=100+

9=multiple responses

21d Have you ever had a problem with

street drugs?

1=yes

2=no

21e Have you ever considered yourself

to be addicted to street drugs?

1=yes

2=no

21f Have you ever injected street

drugs?

1=yes

2=no

22 Have you ever been under the care

of a psychologist, psychiatrist, or

therapist?

1=yes

2=no

23a Has a doctor, nurse, or health

professional ever asked you about

family or household problems

during your childhood?

1=yes

2=no

23b How many close friends or relatives

would help you with your emotional

problems or feelings if you needed

it?

1=none

2=one

3=two

4=3 or more

9=multiple responses

During your first 18 years of life,

was anyone in your household...

24 Did you live with anyone who used

street drugs?

1=yes

2=no

25a Were your parents ever separated

or divorced?

1=yes

2=no

FHH Male

Question

Number

Verbatim Question Response categories and comments

25b Did you ever live with a

stepfather?

1=yes

2=no

25c Did you ever live with a

stepmother?

1=yes

2=no

26 Were you a foster child? 1=yes

2=no

27a Did you ever run away from home

for more than one day?

1=yes

2=no

27b Did your brothers or sisters run

away from home for more than one

day?

1=yes

2=no

28 Was anyone in your household

depressed or mentally ill?

1=yes

2=no

29 Did anyone in your household

attempt to commit suicide?

1=yes

2=no

30a Did anyone in your household go to

prison?

1=yes

2=no

30b Did anyone in your household ever

commit a serious crime?

1=yes

2=no

31a What is the most you have ever

weighed?

Weight in pounds______

Range: 000-999

31b How old were you then?

age:_______

Range:18-99

32a Have you ever attempted to commit

suicide?

1=yes

2=no

32b If “yes”, how old were you the first

time you attempted suicide?

Age______

Range:1-99

32c If “yes”, how old were you the last

time you attempted suicide?

Age______

Range:1-99

32d How many times have you

attempted suicide?

# of times_________

Range:01-99,

32e Did any suicide attempt ever result

in an injury, poisoning, or overdose

that had to be treated by a doctor or

nurse?

1=yes

2=no

FHH Male

Question

Number

Verbatim Question Response categories and comments

In order to get a more complete

picture of the health of our patients,

the next three questions are about

voluntary sexual experiences.

33a How old were you the first time you

had sexual intercourse?

Years______

Never had intercourse 1=box checked

33b With how many different partners

have you ever had sexual

intercourse?

Number of partners_____

number of intercourse partners, lifetime

Range: 0-999

33c During the past year, with how

many different partners have you

ever had sexual intercourse?

# of partners_______

number of intercourse partners, past year

Range: 0-999

34a Have you ever gotten someone

pregnant?

If “Yes”:

1=yes

2=no

34b How old were you the first time you

got someone pregnant?

age:______

Range:00-99

Never got someone pregnant 1=box checked

34c What was the age of the youngest

woman you ever got pregnant?

Range:00-99

Never got someone pregnant 1=box checked

34d How old were you then? Range:00-99

Sometimes physical blows occur

between parents. While you were

growing up in your first 18 years of

life, how often did our father (or

stepfather) or mother’s boyfriend do

any to these things to your mother

(or stepmother)?

FHH Male

Question

Number

Verbatim Question Response categories and comments

35a Push, grab, slap or throw something

at her?

1=never

2=once, twice

3=sometimes

4=often

5=very often

9=multiple responses

35b Kick, bite, hit her with a fist, or hit

her with something hard?

1=never

2=once, twice

3=sometimes

4=often

5=very often

9=multiple responses

35c Repeatedly hit her over at least a

few minutes?

1=never

2=once, twice

3=sometimes

4=often

5=very often

9=multiple responses

35d Threaten her with a knife or gun, or

use a knife or gun to hurt her?

1=never

2=once, twice

3=sometimes

4=often

5=very often

9=multiple responses

Sometimes parents spank their

children as a form of discipline.

While you were growing up during

your first 18 years of life:

36a How often were you spanked? 1=never

2=once or twice

3=a few times a year

4=many times a year

5=weekly or more

9=multiple responses

36b How severely were you spanked? 1=not hard

2=a little hard

3=medium

4=quite hard

5=very hard

9=multiple responses

36c How old were you the last time you

remember being spanked?

age:______

Range:18-99

FHH Male

Question

Number

Verbatim Question Response categories and comments

While you were growing up, during

your first 18 years of life, how true

were each of the following

statements:

37 You didn’t have enough to eat? 1=never true

2=rarely true

3=sometimes true

4=often true

5=very often true

9=multiple responses

38 You knew there was someone to

take care of you and protect you?

1=never true

2=rarely true

3=sometimes true

4=often true

5=very often true

9=multiple responses

39 People in your family called you

things like “lazy” or “ugly”?

1=never true

2=rarely true

3=sometimes true

4=often true

5=very often true

9=multiple responses

40 Your parents were too drunk or high

to take care of the family?

1=never true

2=rarely true

3=sometimes true

4=often true

5=very often true

9=multiple responses

41 There was someone in your family

who helped you feel important or

special?

1=never true

2=rarely true

3=sometimes true

4=often true

5=very often true

9=multiple responses

42 You had to wear dirty clothes? 1=never true

2=rarely true

3=sometimes true

4=often true

5=very often true

9=multiple responses

FHH Male

Question

Number

Verbatim Question Response categories and comments

43 You felt loved? 1=never true

2=rarely true

3=sometimes true

4=often true

5=very often true

9=multiple responses

44 You thought your parents wished

you had never been born?

1=never true

2=rarely true

3=sometimes true

4=often true

5=very often true

9=multiple responses

45 People in your family looked out for

each other?

1=never true

2=rarely true

3=sometimes true

4=often true

5=very often true

9=multiple responses

46 You felt that someone in your family

hated you?

1=never true

2=rarely true

3=sometimes true

4=often true

5=very often true

9=multiple responses

47 People in your family said hurtful or

insulting things to you?

1=never true

2=rarely true

3=sometimes true

4=often true

5=very often true

9=multiple responses

48 People in your family felt close to

each other?

1=never true

2=rarely true

3=sometimes true

4=often true

5=very often true

9=multiple responses

49 You believe that you were

emotionally abused?

1=never true

2=rarely true

3=sometimes true

4=often true

5=very often true

9=multiple responses

FHH Male

Question

Number

Verbatim Question Response categories and comments

50 There was someone to take you to

the doctor if you needed it?

1=never true

2=rarely true

3=sometimes true

4=often true

5=very often true

9=multiple responses

51 Your family was a source of

strength and support?

1=never true

2=rarely true

3=sometimes true

4=often true

5=very often true

9=multiple responses

Sometimes parents or other adults

hurt children. While you were

growing up, that is, during your first

18 years of life, how often did a

parent, step-parent, or adult living in

your home:

52a Swear at you, insult you, or put you

down?

1=never

2=once, twice

3=sometimes

4=often

5=very often

9=multiple responses

52b Threaten to hit you or throw

something at you, but didn’t do it?

1=never

2=once, twice

3=sometimes

4=often

5=very often

9=multiple responses

52c Actually push, grab, shove, slap

you, or throw something at you?

1=never

2=once, twice

3=sometimes

4=often

5=very often

9=multiple responses

52d Hit you so hard that you had marks

or were injured?

1=never

2=once, twice

3=sometimes

4=often

5=very often

9=multiple responses

FHH Male

Question

Number

Verbatim Question Response categories and comments

52e Act in a way that made you afraid

that you might be physically hurt?

1=never

2=once, twice

3=sometimes

4=often

5=very often

9=multiple responses

Some people, while growing up in

their first 18 years of life, had a

sexual experience with

an adult or

someone at least five years older

than themselves. These

experiences may have involved a

relative family friend or stranger.

During the first 18 years of life, did

an adult or older relative, family

friend or stranger ever:

53a Touch or fondle your body in a

sexual way?

If “Yes”:

1=yes

2=no

The first time this happened, how

old were you?

age:_____

Range:00-99

The first time, did this happen

against your wishes?

1=yes

2=no

The last time this happened, how

old were you?

age:_____

Range:00-99

About how many times did this

happen to you?

# times:_____

Range:00-99

How many different people did this

to you?

# people______

Range:00-99

What was the sex of the person(s)

who did this?

1=male

2=female

3=both

9=multiple responses

54a Have you touch their body in a

sexual way?

If “Yes”:

1=yes

2=no

FHH Male

Question

Number

Verbatim Question Response categories and comments

The first time this happened, how

old were you?

age:_____

Range:00-99

The first time, did this happen

against your wishes?

1=yes

2=no

The last time this happened, how

old were you?

age:______

Range:00-99

About how many times did this

happen to you?

# times:_____

Range:00-99

How many different people did this

to you?

# people:______

Range:00-99

What was the sex of the person(s)

who did this?

1=male

2=female

3=both

9=multiple responses

55a

Attempt to have any type of sexual

intercourse (oral, anal, or vaginal)

with you?

If “Yes”:

1=yes

2=no

The first time this happened, how

old were you?

age:______

Range:00-99

The first time, did this happen

against your wishes?

1=yes

2=no

The last time this happened, how

old were you?

age:______

Range:00-99

About how many times did this

happen to you?

# times:______

Range:00-99

How many different people did this

to you?

# people:_____

Range:00-99

What was the sex of the person(s)

who did this?

1=male

2=female

3=both

9=multiple responses

FHH Male

Question

Number

Verbatim Question Response categories and comments

56a

Actually have any type of sexual

intercourse with you (oral, anal, or

vaginal) with you?

If “Yes”:

1=yes

2=no

The first time this happened, how

old were you?

age:______

Range:00-99

The first time, did this happen

against your wishes?

1=yes

2=no

The last time this happened, how

old were you?

age:______

Range:00-99

About how many times did this

happen to you?

# times:______

Range:00-99

How many different people did this

to you?

# people:_______

Range:00-99

What was the sex of the person(s)

who did this?

1=male

2=female

3=both

9=multiple responses

If you answered “No” to each of the

last 4 questions (54a-57a) about

sexual experiences with older

people, please skip to question 62a.

Did any of these sexual experiences

with an adult or person at least 5

years older than you involve:

57a A relative who lived in your home? 1=yes

2=no

57b A non-relative who lived in your

home?

1=yes

2=no

57c A relative who didn’t live in your

home?

1=yes

2=no

57d A family friend or person who you

knew, and who didn’t live in your

home?

1=yes

2=no

57e A stranger? 1=yes

2=no

FHH Male

Question

Number

Verbatim Question Response categories and comments

57f Someone who was supposed to be

taking care of you?

1=yes

2=no

57g Someone you trusted? 1=yes

2=no

Did any of these sexual experiences

involve:

58a Trickery, verbal persuasion, or

pressure to get you to participate?

1=yes

2=no

58b Being given alcohol or drugs? 1=yes

2=no

58c Threats to harm you if you didn’t

participate?

1=yes

2=no

58d Being physically forced or

overpowered to make you

participate?

1=yes

2=no

59a Have you ever told a doctor, nurse,

or other health professional about

these sexual experiences?

1=yes

2=no

59b Has a therapist of counselor ever

suggested to you that you were

sexually abused as a child?

1=yes

2=no

60 Do you think that you were sexually

abused as a child?

1=yes

2=no

Apart from the other experiences

you have already told us about,

while you were growing up

during

your first 18 years of life:

61a Did a boy or group of boys about

your own age, ever force or

threaten you with harm in order

have sexual contact?

1=yes

2=no

61b If yes did the contact involve

someone touching your sexual parts

or trying to have intercourse with

you (oral or anal)?

1=yes

2=no

FHH Male

Question

Number

Verbatim Question Response categories and comments

61c If yes how many times did someone

do this to you?

1=once

2=twice

3=3-5 times

4=6-10 times

5=more than 10 times

9=multiple responses

61d Did the contact involve a person

actually having intercourse with you

(vaginal, oral or anal)?

1=yes

2=no

61e If yes how many times did someone

do this to you?

1=once

2=twice

3=3-5 times

4=6-10 times

5=more than 10 times

9=multiple responses

62a

As an adult, (age 19 or older) has

anyone ever physically forced or

threaten you to have sexual

contact?

1=yes

2=no

62b If yes did the contact involve

someone touching your sexual parts

or trying to have intercourse with

you (vaginal, oral or anal)?

1=yes

2=no

62c If yes how many times has

someone done this to you?

1=once

2=twice

3=3-5 times

4=6-10 times

5=more than 10 times

9=multiple responses

62d Did the contact involve a person

actually having intercourse with you

(vaginal, oral or anal)?

1=yes

2=no

62e If yes how many times did someone

do this to you?

1=once

2=twice

3=3-5 times

4=6-10 times

5=more than 10 times

9=multiple responses

FHH Male