[p. 185]
Section M7 - OTHER DEVICE PAGE
Check item 17
Enter name, person number and device from "OTHER" column of Table MDI.
Person No. ____
Refer to "MDI" in Check Item 17.
2 [] Some other device (2)
These next questions are about your infusion pump.
1a. Is the infusion pump for chemotherapy, insulin treatment, or something else?
2 [] Insulin
8 [] Other - Specify ____
b. Is the pump itself implanted inside your body, or is the pump worn on the outside?
2 [] Outside
(These next questions are about your (entry in check item 17).)
2a. In what part of the body is the (other) (entry in check item 17) located?
2[] ____
3[] ____
b. Do you have any other (entry in CHECK ITEM 17)?
2 [] No
Enter each body part in a separate column as well as name and person number and MDI type in Check Item 17.
3a. Is the (entry in check item 17) in your (entry in check item 19) a replacement for a previous one?
2 [] No (4)
b. How many times has the (entry in check item 17) in your (entry in check item 19) been replaced?
c. Why did you have the (entry in Check item 17/19) replaced (the LAST time)?
Mark first three mentioned
01 [] Infection
02 [] Defect or malfunction
03 [] Healing problems
04 [] Pain
05 [] Blood clots
06 [] Bleeding
07 [] Injury
88 [] Some other reason - Specify ____
Ask for each entry in 3c, except "Normal growth"
d. How long had you had that (entry in check item 17) when the (entry in 3c) 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
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
[p.186]
Section M7 - OTHER DEVICE PAGE - Continued
3e. How long did you have the (entry in CHECK ITEM 17/19) before it was replaced with the one you have NOW?
98 [] 6-11 months
Years ____
f. In what month and year did you get it?
Year 19____
0000 [] Before 1968
9898 [] 1968 or later
4a. How long have you had the (entry in check item 17/19) you have NOW?
98 [] 6-11 months
Years ____
b. In what month and year did you get this one?
Year ____
0000 [] Before 1968
9898 [] 1968 or later
Please tell me if you have had any of the following problems or complications with or as a result of the (entry in check item 17) you NOW have in your (entry in check item 19)?
5a. Have you had an infection?
2 [] No (5c)
9 [] DK (5c)
b. How long had you had your (entry in check item 17/19) 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 (entry check item 17/19) you have NOW)?
2 [] No (5e)
9 [] DK (5e)
d. How long had you had your (entry in check item 17/19) 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 (entry check item 17/19) you have NOW)?
2 [] No (5g)
9 [] DK (5g)
f. How long had you had your (entry in check item 17/19) 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. Have you had any defects with the (entry check item 17/19) you have NOW or has it failed to operate properly?
2 [] No (5i)
9 [] DK (5i)
h. How long had you had your (entry in check item 17/19) when this 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
i. Have you had any other problems or complications with or as a result of the (entry check item 17/19) you have NOW)?
2 [] No (6)
9 [] DK (6)
j. What were they?
Record first three mentioned
02[] ____
03[] ____
Ask for each entry in 5j
k. How long had you had the (entry in check item 17/19) when the (problem in 5j) 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 to 90 days
3 [] More than 90 days
[p. 187]
Section M7 - OTEHR DEVICE PAGE - Continued
6. Why did you need to get the (entry in check item 17/19) in the first place?
Mark all mentioned
02 [] Injury
88 [] Some other reason - Specify ____
Check item 20
Mark appropriate respondent box and enter relationship to MDI person if proxy.
2 [] Self - telephone
3 [] Proxy - personal
Go to next column or next device