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mdxp
[p. 167]

Section M - MEDICAL DEVICE

Section M1 - MEDICAL DEVICE IMPLANT SCREENING

CHECK ITEM 1
Enter person number of respondent

Respondent person number ____

These next questions are about medical devices that are SURGICALLY implanted in the body to help the body function or treat an illness or injury.


1a. Does anyone in the family now have an artificial joint, such as an artificial hip, knee or finger joint?

1[] Yes
2[] No (2)
9[] DK (2)

b. Who is this?

Record name and person number in table MDI. Mark "JOINT" box. ____

c. Anyone else?

1 [] Yes (Reask 1b and c)
2 [] No


2a. Does anyone in the family NOW have any implants, such as pins, screws, nails, wires, rods, or plates that have been surgically inserted into the body?

1[] Yes
2[] No (3)
9[] DK (3)

b. Who is this?

Record name and person number in table MDI. Mark "FIX" box. ____

c. Anyone else?

1 [] Yes (Reask 2b and c)
2 [] No


3a. Does anyone in the family now have an artificial heart valve?

1[] Yes
2[] No (4)
9[] DK (4)

b. Who is this?

Record name and person number in table MDI. Mark "HV" box. ____

c. Anyone else?

1 [] Yes (Reask 3b and c)
2 [] No


4a. Sometimes the lenses of the eyes can be replaced with artificial ones called intraocular lenses, which are sewn into place during surgery.
Does anyone in the family NOW have a lens implant? Do not include corneal transplants.

1[] Yes
2[] No (5)
9[] DK (5)

b. Who is this?

Record name and person number in table MDI. Mark "IL" box.____

c. Anyone else?

1 [] Yes (Reask 4b and c)
2 [] No


5a. Silicone implants are used to reconstruct parts of the body, such as breasts, ears, chin, or a nose.
Does anyone in the family NOW have a silicone implant? Do not include silicone injections.

1[] Yes
2[] No (6)
9[] DK (6)

b. Who is this?

Record name and person number in table MDI.
Enter SILICONE IMPLANT in "Other" column.____

c. Anyone else?

1 [] Yes (Reask 5b and c)
2 [] No


6a. Does anyone in the family now have a pacemaker?

1[] Yes
2[] No (7)
9[] DK (7)

b. Who is this?

Record name and person number in table MDI. Mark "PACE" box.____

c. Anyone else?

1 [] Yes (Reask 6b and c)
2 [] No

[p. 168]

Section M1 - MEDICAL DEVICE IMPLANT SCREENING - Continued


7a. Ear vent tubes are often implanted in the eardrums of children and adults who get frequent ear infections.
Does anyone in the family now have ear vent tubes?

1[] Yes
2[] No (8)
9[] DK (8)

b. Who is this?

Record name and person number in table MDI. Enter EAR VENT TUBES in "Other" column. ____

c. Anyone else?

1 [] Yes (Reask 7b and c)
2 [] No


8a. Infusion pumps are implants that pump medications such as insulin or chemotherapy into the body.
Does anyone in the family NOW have an infusion pump?

1[] Yes
2[] No (9)
9[] DK (9)

b. Who is this?

Record name and person number in table MDI. Enter INFUSION PUMP in "Other" column. ____

c. Anyone else?

1 [] Yes (Reask 8b and c)
2 [] No


9a. Does anyone in the family now have a shunt that drains fluid away from the brain or spinal column?

1[] Yes
2[] No (10)
9[] DK (10)

b. Who is this?

Record name and person number in table MDI. Enter SHUNT in "Other" column. ____

c. Anyone else?

1 [] Yes (Reask 10b and c)
2 [] No


10a. Does anyone in the family now have any other type of shunt or catheter implanted in the body?

Read if necessary: A shunt is a man-made tube through which blood or body fluid is diverted from its natural path.

Read if necessary: A catheter is a flexible tube implanted in the body to remove or put in fluid.

1[] Yes
2[] No (11)
9[] DK (11)

b. Who is this?

Record name and person number in table MDI. Enter SHUNT or CATHETER in "Other" column.____

c. Does anyone else have any other type of shunt or catheter implanted in the body?

1 [] Yes (Reask 10b and c)
2 [] No


11a. Does anyone in the family now have any other kind of medical device that has been implanted in the body during surgery? Some examples are artificial arteries and veins, ligaments, and dental implants.

1[] Yes
2[] No (Check item 2)
9[] DK (check item 2)

b. Who is this?

Record name and person number in table MDI. ____

c. What kind of implant does -- have?

Enter type of implant in "Other" column. ____

d. Does anyone else have any other type of medical device implanted in the body?

1 [] Yes (Reask 11b - d)
2 [] No (Check Item 2)

CHECK ITEM 2
Mark appropriate box

1 [] One or more MDI's (Table MDI)
2 [] No MDI's (Next Supplement)
[p.169]

SECTION M1 - MEDICAL DEVICE IMPLANT SCREENING - Continued

TABLE MDI
Complete the appropriate Medical Device Sections for each person and each device entered below.
(TABLE MDI contains lines for 8 different people; all of the headings (Name, Person number, etc...) are found on the same horizontal line.)

a. Name ____
b. Person number ____
c. Joint (pg.6) ____
1[]
d. Fix (pg. 12) ____
2[]
e. HV (pg. 18) ____
3[]
f. Il (pg. 24) ____
4[]
g. Pace (pg. 30) ____
5[]
h. Other (pg. 36) ____
1. ____
2. ____
3. ____