QDS Version
START TIME
Date 30 days ago
Subject
Site Code
Visit Code
What is your gender?
How old are you?
What is your current marital or partnership status?
Please specify other marital or partnership status:
Which of the following best describe your race?
Please specify other race:
What is your date of birth?
In the past year, has a health care provider recommended that you receive a flu vaccine?
How would you rate your current state of health?
Medical care rating
How long since last medical appointment
Nervousness or shakiness inside
Faintness
What time do you usually wake up in the morning?
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 smoked a cigarette
During the past 7 days, how many cigarettes did you smoke?
How many cigarettes did you smoke yesterday?
When you smoke, how soon after you wake up do you have your first cigarette?
Have you ever tried to quit smoking?
Do you want to quit smoking cigarettes?
Do you have any additional comments?
ENDTIME
White: Which of the following best describe your race?
Black or African American: Which of the following best describe your race?
Asian: Which of the following best describe your race?
Native Hawaiian or Pacific Islander: Which of the following best describe your race?
American Indian or Alaska Native: Which of the following best describe your race?
Other: Which of the following best describe your race?
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 appointment
Months: How long since last medical appointment
Days: How long since last medical appointment
Hour: What time do you usually wake up in the morning?
Minutes: What time do you usually wake up in the morning?
Hour: What time do you usually go to sleep?
Minutes: What time do you usually go to sleep?
Eating out: Favorite recreational activities
Movies or theatre: Favorite recreational activities
Dancing: Favorite recreational activities
Hiking: Favorite recreational activities
Exercising at the gym: Favorite recreational activities
Running: Favorite recreational activities
Playing sports: Favorite recreational activities
Watching sports: Favorite recreational activities