HEALTH SCREENING 5.0

QID.

Qgotoend. Go to end

Yes No

QStart.

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Before starting we would like some basic information about you

Q1. Are you:

Male Female

Q2. What is your date of birth?


Date

Q3. When did you first join the police force?

Q4. What is your rank and role within the force?

	Rank	Role
Full time

Q5. How many years have you served in your current role?

Q6. Section 1: We would like some information on your use of the Airwave radio system. This includes operations or control room use and direct mode use.

Do you use the Airwave Radio system?

Yes No

Q7. Which year did you first start using Airwave radios?

Q8. What make(s) of Airwave (TETRA) radio terminal do you use?
Please select all that apply.

Sepura Motorola Nokia Sepura Vehicle Cleartone Vehicle Other make and model :

Q9. While using or shortly after using your Airwave radio in PTT or PSTN mode, do you experience one or more of the following symptoms?

Q10. Please indicate and rate your concern about the effect of Airwave equipment on your personal health.


Use of Airwave Radios	No concern A little concern Moderate concern High concern Extreme concern
Proximity to Airwave masts (base stations)	No concern A little concern Moderate concern High concern Extreme concern

Q11. Please provide information on the usual location of your Airwave radio when you are using it in Press-to-talk (PTT) /transmit mode.

	Transmit mode
Personal radio with earpiece/microphone	A lot of the time Some of the time None of the time
Personal radio without earpiece/microphone	A lot of the time Some of the time None of the time
Desk mounted radio including operation/control room use	A lot of the time Some of the time None of the time
Motorcycle mounted radio	A lot of the time Some of the time None of the time
Car mounted radio	A lot of the time Some of the time None of the time
Body mounted radio (covert users)	A lot of the time Some of the time None of the time
Other	A lot of the time Some of the time None of the time

Q12. Please provide information on the usual location of your Airwave radio when you are using it in PSTN/mobile phone mode.

	Mobile phone mode
Personal radio with earpiece/microphone	A lot of the time Some of the time None of the time
Personal radio without earpiece/microphone	A lot of the time Some of the time None of the time
Desk mounted radio including operation/control room use	A lot of the time Some of the time None of the time
Motorcycle mounted radio	A lot of the time Some of the time None of the time
Car mounted radio	A lot of the time Some of the time None of the time
Body mounted radio (covert users)	A lot of the time Some of the time None of the time
Other	A lot of the time Some of the time None of the time

Q13. Please specify the other location of your Airwave radio when you are using it in either Press-to-talk (PTT)/transmit OR mobile phone mode.

Q14. While using Airwave Radio and when not wearing any earpiece, what is the usual position of your handset?

Right side of head Left side of head Both sides equally Not applicable

Q15. Please provide the start date of your last full shift when you used an Airwave radio:


Date

Q16. The start time and end time (using the 24-hour clock) of your last full shift

	HH	MM
Start
End

Q17. Please give an estimate on your use of the Airwave radio over your last full shift.

Approximate number of outgoing Radio Calls


Personal radio
Pool (or shared) radio
Vehicle mounted radio
Desk mounted radio including operation/ control room use
Body mounted radio (covert users)
Radio use in direct mode

Q18.
Approximate total duration (in minutes) of outgoing Radio Calls


Personal radio
Pool (or shared) Radio
Vehicle mounted radio
Desk mounted radio including operation/ control room use
Body mounted radio (covert users)
Radio use in direct mode

Q19. What proportion of your total radio use is with a Pool radio?

Q20. Since joining the Police Force, have you ever worked in an operations or control room?

Yes No

Q21. Since joining the Police Force, what proportion of your total working time has been spent in an operations or control room?

Q22. Have you experienced any specific health related problems while working in operations/control room?

Yes. Please specify : No

Q23. Did you ever use the old analogue radio system?

Yes No

Q24. For how many years did you use the old analogue radio system?

Q25. Are you still using the analogue radio?

Yes No

Q26. Section 2: This section is about the use of your personal or any other mobile phone (not including the use of your Airwave radio).

Do you use a mobile phone?

Yes No

Q27. In which year did you start using a mobile phone?

Q28. Not counting SMS text messaging, please estimate the total duration of phone calls you made and received on your mobile phone(s) in the last 24 hours.

	Hours	Minutes
Duration

The next questions are about your mobile phone use with hands-free equipment or a headset.

Q29. Do you use hands-free equipment or a headset with your mobile phone(s)?

Yes No

Q30. In which year did you first start using hands-free equipment or a headset?

Q31. Please estimate the proportion of time you usually spend using hands-free equipment or a handset while talking on your mobile phone(s).

Q32. When talking on your mobile phone, do you generally use it on the right or left side of your head?

Right side Left side Both/either

Q33. How often do you move the mobile phone from ear to ear during calls?

Almost never Occasionally During most calls

Q34. While using, or shortly after using your mobile phone(s), do you experience any of the following symptoms?

Q35. Section 3: This section asks you about your general health and family history

Would you say that you have had bothersome headaches in the last twelve months?

Yes No

Q36. How often do you get these bothersome headaches at the moment?

Every day Not every day, but on more days than not (more than 15 days each month) On 2 or 3 days every week Between once a month and once a week Less than once a month

Q37. Do any of these bothersome headaches fit the following descriptions?


Moderate or severe headache	All Some None
Headache on one side of the head only	All Some None
Throbbing/pulsating headache	All Some None
A headache made worse by light exercise, such as going upstairs	All Some None

Q37a. How often do you get the 'Moderate or Severe' headache?

Every day Not every day, but on more days than not (more than 15 days each month) On 2 or 3 days every week Between once a month and once a week Less than once a month

Q37b. How often do you get the headache 'on one side of the head'?

Every day Not every day, but on more days than not (more than 15 days each month) On 2 or 3 days every week Between once a month and once a week Less than once a month

Q37c. How often do you get the 'throbbing/pulsating' headache?

Every day Not every day, but on more days than not (more than 15 days each month) On 2 or 3 days every week Between once a month and once a week Less than once a month

Q37d. How often do you get the headache which is 'made worse by light exercise?

Every day Not every day, but on more days than not (more than 15 days each month) On 2 or 3 days every week Between once a month and once a week Less than once a month

Q37e. How often do these headaches last if left untreated?

Once or twice a week Once or twice a month Once or twice in the last year Not at all in the last 12 months

Q38. With any of the bothersome headaches you have described, do you get any of these other symptoms?


Do you feel sick or vomit?	Every time Sometimes Never
Does ordinary daylight bother you?	Every time Sometimes Never
Does general noise bother you?	Every time Sometimes Never

Q39. Have you ever been diagnosed by a Doctor with any of the following conditions? If the answer is yes, then please also tell us the year of diagnosis.


Cancer	Yes No
High blood pressure	Yes No
Angina	Yes No
Heart attack (MI)	Yes No
Other heart conditions	Yes No
Chronic Fatigue Syndrome/ME	Yes No
Depression	Yes No
Chronic liver disease	Yes No
Deafness/partial hearing loss	Yes No
Migraine	Yes No
Diabetes	Yes No
Chronic Obstructive Pulmonary Disease (COPD)	Yes No
Asthma	Yes No
Allergy (eczema, hay fever, rhinitis)	Yes No
Cataract	Yes No
Glaucoma or high eye pressure	Yes No
Epilepsy	Yes No
Arthritis	Yes No
Parkinson’s disease	Yes No
Stroke / transient ischaemic attack(TIA)	Yes No
Thyroid-related disorders	Yes No

Q40. You indicated that you have been diagnosed with cancer. Please tell us about the type of cancer.

Q41. Have you ever experienced loss of sight or impairment of vision in one eye, accompanied by pain around the eye caused by eye movement (opticus neuritis)?

Yes No

Q42. The next set of questions relate to pains in the chest.

In the past year, have you had any pain or discomfort in your chest?

Yes No

Q43. Do you get this pain or discomfort when you walk uphill or hurry?

Yes No

Q44. Do you get it when you walk at an ordinary pace on the level?

Yes No

Q45. When you get any pain or discomfort in your chest, what do you do?

Stop Slow down Continue at same pace

Q46. Does it go away when you stand still?

Yes No

Q47. How soon does the pain take to go away when you stand still?

In 10 minutes or less More than 10 minutes

Q48. In the past year, have you had a severe pain across the front of your chest lasting half an hour or more?

Yes No

Q49. These questions relate to your report of severe pain across the front of your chest lasting half an hour or more.

How many of these attacks have you had in the past year?

Q50. Did you consult a doctor for your chest pain?

Yes No

Q51. What was the diagnosis for your chest pain?

Q52. How many days of sickness leave have you taken in the past year?

Q53. In the past year how many times have you consulted your GP for your health problems?

Q54. The next set of statements will help us to get an impression of how you have felt during the past 2 weeks.
The assessment is on a scale of 1 to 7 with yes and no at the two extremes of the scale. Please use the scale to indicate how you have felt. For example, if you feel relaxed but not very relaxed, then select a box close to 'yes, true', such as 3.


I feel tired	Yes, true 2 3 4 5 6 No, not true
I feel very active	Yes, true 2 3 4 5 6 No, not true
Thinking requires effort	Yes, true 2 3 4 5 6 No, not true
Physically I feel exhausted	Yes, true 2 3 4 5 6 No, not true
I feel like doing all kinds of nice things	Yes, true 2 3 4 5 6 No, not true
I feel fit	Yes, true 2 3 4 5 6 No, not true
I do quite a lot within a day	Yes, true 2 3 4 5 6 No, not true
When I am doing something, I can concentrate quite well	Yes, true 2 3 4 5 6 No, not true
I feel weak	Yes, true 2 3 4 5 6 No, not true
I don't do much during the day	Yes, true 2 3 4 5 6 No, not true
I can concentrate well	Yes, true 2 3 4 5 6 No, not true
I feel rested	Yes, true 2 3 4 5 6 No, not true
I have trouble concentrating	Yes, true 2 3 4 5 6 No, not true
Physically I am in bad condition	Yes, true 2 3 4 5 6 No, not true
I am full of plans	Yes, true 2 3 4 5 6 No, not true
I get tired very quickly	Yes, true 2 3 4 5 6 No, not true
I have a low output	Yes, true 2 3 4 5 6 No, not true
I have no desire to do anything	Yes, true 2 3 4 5 6 No, not true
My thoughts easily wander	Yes, true 2 3 4 5 6 No, not true
Physically I feel in good shape	Yes, true 2 3 4 5 6 No, not true

Q55. How much sleep do you usually get over a 24 hour period?

5 hours or less 6 hours 7 hours 8 hours 9 hours or more

Q56. To help us make the most comprehensive health assessment, please complete the following questions on your family medical history.

Is your biological father still alive?

Yes No Don’t know

Q57. How old was your father when he died?

Q58. What did he die from?

Heart attack (coronary) Stroke Neurological condition Cancer. Please specify type: Another cause? Please specify : Don’t know

Q59. Is your biological mother still alive?

Yes No Don’t know

Q60. How old was your mother when she died?

Q61. What did she die from?

Heart attack (coronary) Stroke Neurological condition Cancer. Please specify type: Another cause. Please specify : Don’t know

Q62. Section 4: In this section, we would like to ask you questions about your general lifestyle habits, including questions on smoking, alcohol intake and exercise. This will help us take into account other important factors that may affect your health.

Do you currently smoke cigarettes?

Yes No

Q63. How many cigarettes a day do you smoke?

Q64. When did you first start smoking?

Q65. What kind of cigarette do you usually smoke?

Manufactured cigarettes “Roll your own” cigarettes Both of the above

Q66. If you are not a cigarette smoker now, did you ever smoke 5 or more cigarettes a day?

Yes No

Q67. How many cigarettes a day did you usually smoke?

Q68. When did you quit smoking?

Q69. How many people smoke in the household where you live (please include yourself)?

Q70. At home, about how many hours per week are you exposed to other people’s tobacco smoke?

Q71. Outside of your home, about how many hours per week are you exposed to other people’s tobacco smoke?

Q72. Do you currently drink alcohol?

Yes No

Q73. How often do you have a drink containing alcohol?

Monthly or less Two to four times a month Two or three times a week Four or five times a week Daily or almost daily

Q74. In the last seven days how many drinks have you had of each of the following?

Please remember that a drink poured at home could be equivalent to 2 or 3 pub measures.
1 bottle of wine is equivalent to 6 small glasses.

	Glasses (small/125ml)
Red Wine

Q74a.

	Glasses (small/125 ml)
White Wine/Champagne

Q74b.

	Glasses (small/125 ml)
Fortified Wine (includes sherry, port and vermouth)

Q74c.

	Pub Measures
Spirits/liqueurs (include whisky, gin, run, vodka, brandy)

Q74d.

	Pints
Beer or cider (include bitter, lager, stout, ale and Guinness)

Q75. How often do you have six or more drinks on one occasion?
(One drink = half a pint of beer, a small glass of wine (125ml), or one measure of spirits.)

Never Monthly or less Two to four times a month Two or three times a week Four or five times a week Daily or almost daily

Q76. In the last five years have you changed your drinking habits?

Yes No

Q77. Compared to your current habits, do you drink

more nowadays? less nowadays?

Q78. Did you ever drink alcohol?

Yes No

Q79. When did you stop drinking alcohol?

Q80. Why did you stop drinking/reduce the amount of alcohol?

Financial reasons Doctors advice or ill health Change of lifestyle Reduction in stress at work Change of job Other reasons. Please specify:

Q81. Concerning the amount of alcohol you drank in the past, were you:

A light drinker A moderate drinker A heavy drinker

Q81a.

Continue

Q82. The following questions will ask you about the time you spent being physically active in the last 7 days. Please think about the activities you do at work, as part of your housework and gardening, to get from place to place, and in your spare time for recreation, exercise or sport.

Think about the activities which take vigorous physical effort that you did in the last 7 days.

Vigorous activities make you breathe harder than normal and may include heavy lifting, sports activities such as squash or football, or fast cycling. Think only about those physical activities that you did for at least 10 minutes at a time.

During the last 7 days on how many days did you do vigorous physical activities?


Days

Q83. How much total time did you usually spend doing vigorous physical activities on one of those days?

	Hours	Minutes
Hours per day

Q84. If your pattern of activity varies from day to day, how much total time did you spend over the last 7 days doing vigorous physical activity?

	Hours	Minutes
Hours per week

Think about the activities which take moderate physical effort that you did in the last 7 days.

Moderate physical activity makes you breathe somewhat harder than normal and may include carrying light loads, cycling at a slow pace or slow jogging. Do not include walking. Again, think only about those activities that you did for at least 10 minutes.

Q85. During the last 7 days, on how many days did you do moderate physical activities?


Days

Q86. How much time did you usually spend doing moderate physical activities on one of those days?

	Hours	Minutes
Hours per day

Q87. If your pattern of activity varies from day to day, how much total time did you spend over the last 7 days doing moderate physical activity?

	Hours	Minutes
Hours per week

Now think about the time you spent walking in the last 7 days. This includes at work, and at home, walking to travel from place to place.

Q88. During the last 7 days, on how many days did you walk for at least 10 minutes at a time?


Days

Q89. How much time did you usually spend walking on one of those days?

	Hours	Minutes
Hours per day

Q90. Think about the total time you spent sitting on weekdays during the last 7 days. Include time spent at work, at home, and during leisure time.

	Hours
Hours per week

Q91. During the last 7 days what was the total time you spent watching television?

	Hours	Minutes
Hours per week

Q91a.

Continue

Section 5: These questions ask about your dietary and food habits.

Please include all types independent of preparation method, e.g. fresh, canned, frozen, and cooked.

Q92. Sparequestion

continue

Q93. How often do you eat oily fish (herring, kipper, mackerel, salmon, sardines or trout)?

never less than once a week once a week two to four times a week more than five times a week daily

Q94. How often do you eat white fish (cod, haddock or tinned tuna)?

never less than once a week once a week two to four times a week more than five times a week daily

Q95. How often do you eat white meat (chicken, duck, turkey, lobster, shrimp or crab)?

never less than once a week once a week two to four times a week more than five times a week daily

Q96. How often do you eat red meat (beef, veal, lamb, mutton or pork)?

never less than once a week once a week two to four times a week more than five times a week daily

Q97. What type of spread do you mainly use?

never/rarely use spread butter margarine olive oil based spread low or reduced fat spread others

Q98. How many days a week do you eat fruit and vegetables?
Please include fresh, dried, frozen and tinned foods.


Vegetables
Fruit

Q99. How many heaped tablespoons of vegetables do you eat each day on which you eat vegetables?
Please include fresh, frozen, tinned and cooked vegetables.

Q100. How many pieces or portions of fruit do you eat on a day in which you eat fruit?
One portion is one large fruit e.g. apple/pear, or two small fruits, e.g. plums/apricots.

Q101. How often do you eat nuts?

never less than once a week once a week two to four times a week more than five times a week daily

Q102. Are you following any special kind of diet right now?

Yes No

Q103. Is your diet for

Losing weight High blood pressure Diabetes Food allergy High cholesterol Other. Please specify

Q104. The following questions about your regular beverages apply to work as well as home.

How many cups of Tea do you drink every day?
(1 cup = 150 ml)

Q105. How many cups of coffee do you drink every day?
(1 cup = 150 ml)

Q106. How many cans of fizzy drinks do you drink everyday?
(1 can = 330ml)

Q107. How many cups of water (bottled or tap) do you drink every day?
(1 cup = 150 ml)

Section 6: The next sets of questions are about your work and its environment, which might have a bearing on your health in the future

Q108. How many hours per week do you usually work? (Exclude overtime)

Q109. How many hours per week of overtime do you usually work?

Q110. To what extent do you agree with the following statements about your normal day to day work for the Police Force?

Select the answer that best describes your regular, everyday job.


You have to work very hard	Strongly Agree Agree Disagree Strongly Disagree
You have an excessive amount of work to do	Strongly Agree Agree Disagree Strongly Disagree
You have a lot of say about what happens on the job	Strongly Agree Agree Disagree Strongly Disagree
You have a high level of skill	Strongly Agree Agree Disagree Strongly Disagree
You have the freedom to decide how you do your work	Strongly Agree Agree Disagree Strongly Disagree
You have the chance to be creative	Strongly Agree Agree Disagree Strongly Disagree

Q111. When you are having difficulties at work.


How often do you get help and support from your colleagues?	Often Sometimes Seldom Never
How often are your colleagues willing to listen to your work related problems?	Often Sometimes Seldom Never
How often do you get help and support from your immediate superior?	Often Sometimes Seldom Never
How often is your immediate superior willing to listen to your work related problems?	Often Sometimes Seldom Never

Q112. Taking all things into consideration how satisfied are you with your job as a whole?

Very satisfied Satisfied Dissatisfied Very dissatisfied

Q113. These questions refer to any problems, with your work or other regular daily activities ,as a result of any emotional problems such as feeling depressed or anxious. How often have you been bothered by any of the following problems over the last 2 weeks?


Little interest or pleasure in doing things	Not at All Several Days More than half the days Nearly every day
Feeling down, depressed or hopeless	Not at All Several Days More than half the days Nearly every day
Trouble falling or staying asleep or sleeping too much	Not at All Several Days More than half the days Nearly every day
Feeling tired or having little energy	Not at All Several Days More than half the days Nearly every day
Poor appetite or overeating	Not at All Several Days More than half the days Nearly every day
Feeling bad about yourself, that you are a failure or have let yourself or your family down	Not at All Several Days More than half the days Nearly every day
Trouble concentrating on things such as reading the newspaper or watching television	Not at All Several Days More than half the days Nearly every day
Moving or speaking so slowly that other people could have noticed or the opposite, being so fidgety or restless that you have been moving around a lot more than usual	Not at All Several Days More than half the days Nearly every day
Thoughts that you would be better off dead or of hurting yourself in some way	Not at All Several Days More than half the days Nearly every day

Q114. How anxious have you been in the last 2 weeks?

Do you feel tense or "wound up"?

Not at all Occasionally A lot of the time Most of the time

Q115. Do you get a sort of frightened feeling as if something awful is about to happen?

Not at all A little but it doesn’t worry me Yes, but not too badly Very definitely and quite badly

Q116. Do worrying thoughts go through your mind?

Very little Not too often A lot of the time A great deal of the time

Q117. Can you sit at ease and feel relaxed?

Not at all Not often Usually Definitely

Q118. Do you get a sort of frightened feeling like “butterflies” in the stomach?

Not at all Occasionally Quite often Very often

Q119. Do you feel restless as if you have to be on the move?

Not at all Not very much Quite a lot Very much indeed

Q120. Do you get sudden feelings of panic?

Not at all Not very often Quite often Very often indeed

Q121. When really angry or annoyed what do you do?


Get tense or worried	Very likely Somewhat likely Not too likely
Get a headache	Very likely Somewhat likely Not too likely
Feel weak	Very likely Somewhat likely Not too likely
Get nervous or shaky	Very likely Somewhat likely Not too likely
Try to act as though nothing had happened	Very likely Somewhat likely Not too likely
Keep it to yourself	Very likely Somewhat likely Not too likely
Apologise even though you are right	Very likely Somewhat likely Not too likely
Take it out on some one else	Very likely Somewhat likely Not too likely
Blame someone else	Very likely Somewhat likely Not too likely
Get it off your chest	Very likely Somewhat likely Not too likely
Talk to a friend or relative	Very likely Somewhat likely Not too likely

Q122. Police work can involve dealing with stressful and sometimes traumatic incidents. Indeed such events may be so difficult that they are hard to erase from the memory. Think about the most recent or disturbing work related incident you have dealt with in the last 6 months.

Can you think of any incident which is bothering you and which has occurred over the past 6 months?

Yes No

Q123. Can you please briefly state the event.

Q124. Please look at the events listed below. If you have experienced any of the reactions at least twice in the past week please tell us about it.

As a result of this event to what extent have you been bothered by the following:


Upsetting thoughts or memories about the event that have come to your mind against your will	Not at All A little Moderately Quite a bit Extremely
Upsetting dreams about the event	Not at All A little Moderately Quite a bit Extremely
Acting or feeling as though the event were happening again	Not at All A little Moderately Quite a bit Extremely
Feeling upset by reminders of the event	Not at All A little Moderately Quite a bit Extremely
Bodily reactions (such as fast heartbeat, stomach churning, sweatiness, dizziness) when reminded of the event.	Not at All A little Moderately Quite a bit Extremely
Difficulty falling or staying asleep	Not at All A little Moderately Quite a bit Extremely
Irritability or outbursts of anger	Not at All A little Moderately Quite a bit Extremely
Difficulty concentrating	Not at All A little Moderately Quite a bit Extremely
Heightened awareness of potential dangers to yourself and others	Not at All A little Moderately Quite a bit Extremely
Being jumpy or being startled at something unexpected.	Not at All A little Moderately Quite a bit Extremely

Q125. Have you ever sought any medical or other professional help to cope with this event?

Yes No

Q126. Section 6: We would now like to ask you some questions on you and your partner’s reproductive health. We understand that some of these questions may seem intrusive. However, we need to check thoroughly that there are no adverse reproductive health outcomes associated with Airwave use.

At any time over the past 10 years, have you and your spouse/partner ever tried to become pregnant over a period of at least a year without success?

Yes No

Q127. When did you first experience this?


Start Date

Q128. Are you still trying?

Yes No

Q129. Did you get pregnant by the end of this period?

Yes No

Q130. How long did you try to get pregnant before you gave up or became pregnant?

	Years	Months
Duration

Q131. Why did you give up?

We started using birth control again The relationship ended A pregnancy was conceived Other. Please specify:

Q132. At the beginning of this period, were you a regular smoker?

Yes No

Q133. At the beginning of this period, was your spouse or partner a regular smoker?

Yes No

Q134. Please tell us the date of birth of your spouse or partner.


Date

Q135. The following questions ask about ALL the pregnancies which have occurred.

Have you or your wife or partner (or previous wife or partner) ever been pregnant or currently pregnant?

Yes No - I have never been pregnant/have never fathered a child.

Q136. How many times have you been pregnant ? How many pregnancies have you fathered?

Include any current pregnancy.
Do not include deliberate terminations of pregnancy.

Q137. Please tell us when the first pregnancy ended or, if currently pregnant, when you/your wife/partner expect to deliver.

	Year	Month
Date

Q137a. Reason for end of pregnancy.

Still pregnant Born alive Miscarriage Still-born Other

Q137b.

Single baby? Twins? Multiple birth?

Q137c. Sex of baby

Female Male

Q137d. Weight of baby - if known.

	Measure	Pounds/Kilos	Ounces/Grams
Weight	Imperial Metric

Q137e. Delivery was

Full term Pre term Post term

Q138. Has there been a second pregnancy?

Yes No

Q138a. Please tell us when the second pregnancy ended or, if currently pregnant, when you/your wife/partner expect to deliver.

	Year	Month
Date

Q138b.
Reason for end of pregnancy

Still pregnant Born alive Miscarriage Still-born Other

Q138c.

Single baby? Twins? Multiple birth?

Q138d. Sex of baby

Female Male

Q138e. Weight of baby - if known.

		Pounds/Kilos	Ounces/Grams
Weight	Imperial Metric

Q138f.
Delivery was

Full term Pre term Post term

Q139. Has there been a third pregnancy?

Yes No

Q139a.
Please tell us when the third pregnancy ended or, if currently pregnant, when you/your wife/partner expect to deliver.

	Year	Month
Date

Q139b.
Reason for end of pregnancy

Still pregnant Born alive Miscarriage Still-born Other

Q139c.

Single baby? Twins? Multiple birth?

Q139d.
Sex of baby

Female Male

Q139e. Weight of baby - if known.

		Pounds/Kilos	Ounces/Grams
Weight	Imperial Metric

Q139f.
Delivery was

Full term Pre term Post term

Q140. Has there been a fourth pregnancy?

Yes No

Q140a.
Please tell us when the second pregnancy ended or, if currently pregnant, when you/your wife/partner expect to deliver.

	Year	Month
Date

Q140b. Reason for end of pregnancy

Still pregnant Born alive Miscarriage Still-born Other

Q140c.

Single baby? Twins? Multiple birth?

Q140d. Sex of baby

Female Male

Q140e. Weight of baby - if known.

	Measure	Pounds/Kilos	Ounces/Grams
Weight	Imperial Metric

Q140f.
Delivery was

Full term Pre term Post term

Q141. Has there been a fifth pregnancy?

Yes No

Q141a.
Please tell us when the second fifth ended or, if currently pregnant, when you/your wife/partner expect to deliver.

	Year	Month
Date

Q141b. Reason for end of pregnancy?

Still pregnant Born alive Miscarriage Still-born Other

Q141c.

Single baby? Twins? Multiple birth?

Q141d.

Sex of baby

Female Male

Q141e. Weight of baby - if known

	Measure	Pounds/Kilos	Ounces/Grams
Weight	Imperial Metric

Q141f.
Delivery was

Full term Pre term Post term

Q142. Has there been a sixth pregnancy?

Yes No

Q142a.
Please tell us when the sixth pregnancy ended or, if currently pregnant, when you/your wife/partner expect to deliver.

	Year	Month
Date

Q142b. Reason for end of pregnancy

Still pregnant Born alive Miscarriage Still-born Other

Q142c.

Single baby? Twins? Multiple birth?

Q142d. Sex of baby

Female Male

Q142e. Weight of baby - if known.

	Measure	Pounds/Kilos	Ounces/Grams
Weight	Imperial Metric

Q142f.
Delivery was

Full term Pre term Post term

Q143. Has there been a seventh pregnancy?

Yes No

Q143a.

Please tell us when the seventh pregnancy ended or, if currently pregnant, when you/your wife/partner expect to deliver.

	Year	Month
Date

Q143b. Reason for end of pregnancy?

Still pregnant Born alive Miscarriage Still-born Other

Q143c.

Single baby? Twins? Multiple birth?

Q143d. Sex of baby

Female Male

Q143e. Weight of baby - if known

	Measure	Pounds/Kilos	Ounces/Grams
Weight	Imperial Metric

Q143f. Delivery was

Full term Pre term Post term

Q144. Has there been an eighth pregnancy?

Yes No

Q144a.

Please tell us when the eighth pregnancy ended or, if currently pregnant, when you/your wife/partner expect to deliver.

	Year	Month
Date

Q144b. Reason for end of pregnancy?

Still pregnant Born alive Miscarriage Still-born Other

Q144c.

Single baby? Twins? Multiple birth?

Q144d. Sex of baby

Female Male

Q144e. Weight of baby - if known.

	Measure	Pounds/Kilos	Ounces/Grams
Weight	Imperial Metric

Q144f. Delivery was

Full term Pre term Post term

Q145. Before the first pregnancy you told us about, what was the last type of birth control that you or your spouse/partner used?

Never used birth control The pill Coil/intrauterine device Rhythm/"safe" period, or withdrawal Condom Cap Other (specify)

Q146. Did you/she/he stop this before the pregnancy started, or did the pregnancy result from a birth control failure?

We stopped it before Birth control failure Not clear

Q147. At the beginning of this period, were you a regular smoker?

Yes No

Q148. At the beginning of this period, was your spouse/partner a regular smoker?

Yes No

Q149. These questions ask about any fertility related problems and treatment taken by you or your spouse/partner.

Have you or your spouse/partner ever sought any medical help because of problems with conceiving?

Yes No

Q150. Did either of you receive any treatment for infertility?

Yes No

Q151. Please tell us which of you was affected.

You Your spouse/partner

Q151a.

deleted question

Q152. Please tell us when the treatment started.

Q153. Have either you or your spouse/partner ever had any disease, condition, medical or surgical treatment that makes it difficult or impossible for you to have children?

Yes No

Q154. Please tell us which of you was affected.

You Your spouse/partner

Q154a.

Deleted question

Q155. Please tell us when the diagnosis was made.

Q156. This section is for women only.
How old were you when your periods started?

Q157. Have you had your menopause? Have your periods stopped?

Yes No Don't know - had a hysterectomy Don't know. Please specify :

Q158. How old were you when your periods stopped?

Q159. Have you ever taken the contraceptive pill? (includes the mini-pill)

Yes No Don't know

Q160. Have you ever had hormone replacement therapy? (HRT)

Yes No Don't know

Q161. How old were you when you first used HRT?

Q166. Section 8: Finally, we would like some other information which will allow us to take into account variation in background and socio-economic factors.

Do you consider yourself to be:

Q167. Presently, are you:

Married Separated Divorced Cohabiting Single Other. Please specify:

Q168. What is the highest level of education you have completed to date?

Left school before taking O levels / GCSE’s GSCE/O-Level/CSE Vocational qualifications (NVQ1+2) A levels / Highers or equivalent (NVQ3) Bachelor Degree or equivalent (NVQ4) Postgraduate qualifications

Q169. At this time, what is the total personal, annual income you receive before tax is deducted?

Please include all sources such as wages, investments, pensions, savings, rents or property, benefits, any second or odd jobs, maintenance etc.

Less than £20,000 £20,000 - £25,999 £26,000 - £31,999 £32,000 - £37,999 £38,000 - £43,999 £44,000 - £59,999 £60,000 - £65,999 More than £66,000

Q170. What total income, including your own, has your household received in the last 12 months?

Please include all sources such as wages, investments, pensions, savings, rents or property, benefits, any second or odd jobs, maintenance etc.

Q171. How many people including yourself, contribute to your total household income?

Q172. How many people including yourself live in your household?

Q173. How many of those in your household are children under the age of 18?

Q174. All things considered how satisfied or dissatisfied are you with your standard of living?

Very dissatisfied Moderately dissatisfied A little dissatisfied No feelings either way A little satisfied Moderately satisfied Very satisfied

Thank you for taking the time to complete these questions, some of which we realise may have been difficult. We reassure you that all the information you have provided us with will be treated in strict confidence

Please press the submit button at the bottom of this page to save the results and wait for the next page to appear.

QFinish.