Golestan cohort study
Health and lifestyle questionnaire
May 2003
1. Study participant’s information
1.1. Identification number: |__||__||__||__||__||__||__|
1.2. First name: ……………………………………………………………………………………..
1.3. Last Name: …………………………………………………………………………………...
1.4. Place of interview: ………………………………………………………………...
1.5. Date of interview
1.6. (Iranian date): |__||__||__||__||__||__|
1.7. Current address and phone number (Code and number):……………………………………...
……………………………………………………………………………………………………….
1.7 Name of the head of the house: ……………………………………………………………….
1.8 Address 2 (a relative or a friend) and phone number (Code and number): …………………
……………………………………………………………………………………………………….
[This page must be removed and filed separately prior to data entry. Before removal, please verify that the match between name and ID number and verify that the correct ID number is present on each page of this questionnaire.]
ID: |__||__||__||__||__||__||__|
1.9 Gender: (1) Male |__| (2) Female |__|
1.10 Date of birth (Iranian date) |__||__||__||__||__||__|
1.11 Age (completed years): |__||__|
1.12 Ethnicity:
(1) Turkoman (2) Fars (3) Turk (4) Sistani (5) Baluch |__|
(6) Kurd (7) Afghani (8) Other: …………………………
1.12.1. If Turkoman, please specify the tribe:
(1) Yamoot (2) Googlan (3) Tekeh (4) Other (specify) |__|
1.13. Marital status:
(1) Unmarried (2) Married (3) Widowed
(4) Divorced / separated | (5) Other |__|
1.14. Highest level of education received:
(1) Nil (2) Less or equal than 5th Std. (3) 6th-8th Std. (4) High school
(5) College / Graduation |__|
ID: |__||__||__||__||__||__||__|
2. Tobacco and opiate use
2.1 Have you ever smoked cigarettes regularly (at least weekly over a 6 month period)?
(if No, go to 2.5)
(1) Yes (2) No |__|
2.2 Do you still smoke cigarettes now? (1) Yes (2) No |__| 2.3 If no, how old were you when you stopped smoking regularly? |__||__|
2.4 List cigarette consumption beginning with when you started to smoke regularly:
| From age | To age | *Type | Number per day | Days per week |
| |__||__| | |__||__| | |__| | |__||__| | |__| |
| |__||__| | |__||__| | |__| | |__||__| | |__| |
| |__||__| | |__||__| | |__| | |__||__| | |__| |
| |__||__| | |__||__| | |__| | |__||__| | |__| |
| |__||__| | |__||__| | |__| | |__||__| | |__| |
*Type: 1=Filter; 2=No filter; 3=Rolled tobacco
ID: |__||__||__||__||__||__||__|
2.5 Have you ever used Nass, Hooka, Calumet, or Pipe regularly? (if No, go to 2.6 ) (at least weekly over a 6 month period) (1) Yes (2) No |__|
2.5.1 If yes, list consumption:
Product | Ever used (1)Yes (2) No | If ever used |
| | | Age when first smoked | Age when last smoked | Usual number per day | Days/week |
| Nass | |__| |__| |__| | |__||__| |__||__| |__||__| | |__||__| |__||__| |__||__| | |__||__| |__||__| |__||__| | |__||__| |__||__| |__||__| |
| Calumet (traditional pipe) | |__| |__| |__| | |__||__| |__||__| |__||__| | |__||__| |__||__| |__||__| | |__||__| |__||__| |__||__| | |__||__| |__||__| |__||__| |
| Pipe | |__| |__| |__| | |__||__| |__||__| |__||__| | |__||__| |__||__| |__||__| | |__||__| |__||__| |__||__| | |__||__| |__||__| |__||__| |
| Hooka | |__| |__| |__| | |__||__| |__||__| |__||__| | |__||__| |__||__| |__||__| | |__||__| |__||__| |__||__| | |__||__| |__||__| |__||__| |
ID: |__||__||__||__||__||__||__|
2.6 Have you ever used opium regularly? (if No, go to 2.7)
(at least weekly over a 6 month period)
(1) Yes (2) No |__|
2.6.1 If yes, please specify:
Product | Ever used (1)Yes (2) No | If ever used |
| | | Age when first smoked | Age when last smoked | Route of administration | Usual number per day | Days/week |
| Opium |
