QDS Version
START TIME
Date 30 days ago
Site Code
Visit Code
What is your gender?
How old are you?
What is your current marital or partners
Please specify other marital or partners
Which of the following best describe you
Please specify other race:
What is your date of birth?
In the past year, has a health care prov
How would you rate your current state of
Medical care rating
How long since last medical appointment
Nervousness or shakiness inside
Faintness
What time do you usually wake up in the
What time do you usually go to sleep?
Favorite recreational activities
Other favorite activity:
Times movies in the last 30 days
Times 3D movies in the last 30 days
Have you ever smoked a cigarette?
How old were you the first time you smok
During the past 7 days, how many cigaret
How many cigarettes did you smoke yester
When you smoke, how soon after you wake
Have you ever tried to quit smoking?
Do you want to quit smoking cigarettes?
Do you have any additional comments?
White: Which of the following best descr
Black or African American: Which of the
Asian: Which of the following best descr
Native Hawaiian or Pacific Islander: Whi
American Indian or Alaska Native: Which
Other: Which of the following best descr
Year: What is your date of birth?
Month: What is your date of birth?
Day: What is your date of birth?
Years: How long since last medical appoi
Months: How long since last medical appo
Days: How long since last medical appoin
Hour: What time do you usually wake up i
Minutes: What time do you usually wake u
Hour: What time do you usually go to sle
Minutes: What time do you usually go to
Eating out: Favorite recreational activi
Movies or theatre: Favorite recreational
Dancing: Favorite recreational activitie
Hiking: Favorite recreational activities
Exercising at the gym: Favorite recreati
Running: Favorite recreational activitie
Playing sports: Favorite recreational ac
Watching sports: Favorite recreational a
Other activity: Favorite recreational ac