[p.182]
Section M6 - PACEMAKER PAGE
Check item 15
Enter name and person number from Table MDI
Person No. ____
These next questions are about your pacemaker.
1a. Is the pacemaker you have NOW a replacement for a previous pacemaker?
2 [] No (2)
b. How many times has your pacemaker been replaced?
c. Why did you have the pacemaker replaced (the LAST time)?
Mark first three mentioned.
If "Mechanical failure/problem" probe: What kind of mechanical [failure/problem]?
01 [] Battery failure
02 [] Lead failure (Leed)
03 [] Other mechanical failure
04 [] Infection
05 [] Healing problem
06 [] Pain
88 [] Some other reason - Specify ____
Ask for each entry in 1c, except "Normal growth"
d. How long after that pacemaker was implanted was this (entry in 1c) first noticed? Was it less than 30 days, 30 to 90 days, or more than 90 days?
2 [] 30-90 days
3 [] More than 90 days
2 [] 30-90 days
3 [] More than 90 days
2 [] 30-90 days
3 [] More than 90 days
2 [] 30-90 days
3 [] More than 90 days
2 [] 30-90 days
3 [] More than 90 days
2 [] 30-90 days
3 [] More than 90 days
2 [] 30-90 days
3 [] More than 90 days
e. How was that pacemaker monitored - by telephone, at a doctor's office, at the hopsital, or in some other way?
Mark all mentioned.
02 [] Telephone
03 [] Doctor's office
04 [] Hospital
88 [] Other - Specify ____
f. How long did you have that pacemaker before it was replaced with the one you have NOW?
98 [] 6-11 months
Years ____
g. In what month and year did you get it?
Year 19____
0000 [] Before 1968
9898 [] 1968 or later
[p.183]
Section M6 - PACEMAKER PAGE - Continued
2a. How long have you had the pacemaker you have NOW?
98 [] 6-11 months
Years ____
b. In what month and year did you get this one?
Year 19____
0000 [] Before 1968
9898 [] 1968 or later
3. How is this pacemaker monitored - by telephone, at a doctor's office, at the hospital, or in some other way?
Mark all mentioned.
02 [] Telephone
03 [] Doctor's office
04 [] Hospital
88 [] Other - Specify ____
4. Can the pacemaker you have NOW be programmed or adjusted without surgery?
2 [] No
9 [] DK
Please tell me if you have had any of the following problems or complications with or as a result of the pacemaker you have NOW.
5a. Have you had an infection?
2 [] No (5c)
9 [] DK (5c)
b. How long had you had your pacemaker when the infection was first noticed? Was it less than 30 days, 30 to 90 days, or more than 90 days?
2 [] 30-90 days
3 [] More than 90 days
c. Have you had any healing problems (with the pacemaker you have NOW)?
2 [] No (5e)
9 [] DK
d. How long had you had your pacemaker when the healing problem was first noticed? Was it less than 30 days, 30 to 90 days, or more than 90 days?
2 [] 30-90 days
3 [] More than 90 days
e. Other than discomfort generally associated with surgery and healing, have you had any other pain with the pacemaker you have NOW?
2 [] No (5g)
9 [] DK (5g)
f. How long had you had your pacemaker when the pain was first noticed? Was it less than 30 days, 30 to 90 days, or more than 90 days?
2 [] 30-90 days
3 [] More than 90 days
g. How you had any irregular heartbeat with your pacemaker?
2 [] No (5i)
9 [] DK (5i)
h. How long had you had your pacemaker when the irregular heart beat was first noticed? Was it less than 30 days, 30 to 90 days, or more than 90 days?
2 [] 30-90 days
3 [] More than 90 days
i. Have you had any mechanical problems (with the pacemaker you have NOW), such as battery failure or lead (leed) failure?
2 [] No (5l)
9 [] DK (5l)
j. What kind of mechanical problem did it have?
Mark all mentioned.
02 [] Lead failure
88 [] Other mechanical problem - Specify ____
Ask for each entry in 5j
k. How long had you had your pacemaker when the (entry in 5j) was first noticed? Was is it less than 30 days, 30 to 90 days, or more than 90 days?
2 [] 30-90 days
3 [] More than 90 days
2 [] 30-90 days
3 [] More than 90 days
2 [] 30-90 days
3 [] More than 90 days
[p.184]
Section M6 - PACEMAKER PAGE
5l. Have you had any other problems or complications (with or as a result of the pacemaker you have NOW)?
2 [] No (Check Item 16)
9 [] DK (check item 16)
m. What were they?
Record first three mentioned.
02[] ____
03[] ____
Ask for each entry in 5m
n. How long had you had the pacemaker when the (entry in 5m) was first noticed? Was it less than 30 days, 30 to 90 days, or more than 90 days?
[option for 3 entries in the original document -01 to 03- not presented here]
Comment: 01 -03
2 [] 30-90 days
3 [] More than 90 days
Check item 16
Mark appropriate respondent box and enter relationship to MDI person if proxy.
2 [] Self - telephone
3 [] Proxy - personal
Go to next device in Table MDI.