Comprehensive Health Assessment Survey: Vision, Hearing, Mobility, Pain, Cognition, Affect, and Fatigue

1. The BI-Mark 12007

2. Vision Do you wear glasses or contact lenses? How much difficulty do you have in clearly seeing someone’s face across a room (when wearing your glasses or contacts)? How much difficulty do you have in clearly seeing printed text in a newspaper (when wearing your glasses or contacts) For Qs 2 and 3: No difficulty A little difficulty A lot of difficulty Unable General instructions to interviewer: If respondent asks about time frame, say: “Please answer according to how you have been during the past week.”

3. Hearing 1. Do you wear a hearing aid? 2. How much difficulty do you have hearing what is said in a conversation with one other person in a noisy room where there are several other conversations going on (when using your hearing aid)? 3. How much difficulty do you have hearing what is said in a conversation with one other person in a quiet room (when using your hearing aid)? For Qs 2 and 3: No difficulty A little difficulty A lot of difficulty Unable

4. Mobility 1. Do you use any aids or equipment for walking or moving around? If yes, read list of aids. 2. How much difficulty do you have walking 500 metres on level ground, that would be about (insert country-specific example) (without using your aids)? Would you say… Note: Allow for country equivalents to 500 metres. 3. How much difficulty do you have walking 100 metres on level ground, that would be about (insert country-specific example) (without using your aids)? Would you say… Note: Allow for country equivalents to 100 metres. 4. How much difficulty do you have walking up and down a flight of stairs (without using your aids)? Would you say… For Qs 2, 3 and 4: No difficulty A little difficulty A lot of difficulty Unable

5. Pain and Cognition Overall, during the past week, how much physical pain or physical discomfort did you have? Would you say…. If asked: Please answer according to whatever medication you were taking. None at all A little Moderate A lot Extreme How much difficulty do you have remembering important things? Would you say… No difficulty A little difficulty A lot of difficulty Unable

6. Affect Overall, during the past week, how worried, nervous, or anxious did you feel? Would you say… 2. Overall, during the past week, how sad, low, or depressed did you feel? Would you say… For both Qs: Not at all Slightly Moderately A lot Extremely Interviewer: If R asks whether they are to answer about their emotional states after taking mood-regulating medications, say “Please answer according to whatever medication you were taking.” Note: Translators should use culturally appropriate terms to convey a spectrum of mood.

7. Question-SpecificIssues for Testing Use of aids: glasses, hearing aids, mobility aids, railings, etc. Time period: past 30 days, two weeks Terminology and translation issues: walking, depression, anxiety, chronic Activity references: newspaper, coins, noisy/quiet rooms, level ground, stairs or steps or hill, jug vs. bottle, learning vs. using information, remembering important things, etc. Distances: 100 vs. 500, meters vs. yards vs. blocks Use of medications (capacity or performance): anxiety, depression, pain Frequency, duration, severity/intensity issues: anxiety, depression, pain

8. Changes to BI-M1 from Round 2 Vision: 1) Difficulty clearly seeing A) someone’s face across a room and B) the picture on a coin. 2) Glasses question before each. Hearing: 1) Difficulty hearing what is said in a conversation with one other person A) in a quiet room and B) in a noisier room. 2) Unable to A skips B. Mobility: 1) New – Do you have difficulty moving around inside your home? 2) The following asked twice, once with and once without aids: 100 metres, 500 metres and steps. 3) Unable to 100 metres skips 500. 4) Difficulty walking up “or down 12 steps”.

9. Changes to BI-M1 To Date Cognition: 1) Dropped “important things”. 2) Screener Q – Difficulty remembering or concentrating. 3) If yes to remembering: how often do you have diff and diff remembering a few things, a lot of things or both. 4) if yes to concentrating: how much diff concentrating for 10 minutes. Affect: 1) For both worried, nervous or anxious and depressed, added A) how often, B) take medication, C) thinking about the last time, how would you describe level of feelings. Pain: 1) Dropped “physical pain or physical discomfort” and replaced with Do you have frequent pain? 2) Added A) how often in past 3 months, B) thinking about the last time, how long did it last, and C) thinking about the last time, how much pain did you have.

10. Changes to BI-M1 To Date Fatigue: Previously excluded from BI-M1. In past 3 months, how often did you feel very tired or exhausted? Followed by, thinking about the last time A) how long did it last and B) how would you describe your level of tiredness. New domains: As part of the joint work with the WG, now testing upper body, communication and learning domains. New response categories: In some places, new responses are being tested. Different recall periods: Only pain and fatigue, in past 3 months. Use of aids or medication: Collect information in vision, hearing, mobility and affect.