Yes (Please specify) _____________________ Cancer? No Unsure Yes Immune disorders such as lupus, No rheumatoid arthritis, or HIV? Unsure Yes Neurological conditions such as Parkinson’s No disease or multiple sclerosis? Unsure Yes (Please specify) _____________________ Any other medical conditions? No Unsure Prior to the incident, were you taking any medicines? This includes medicines prescribed by a health care provider and those you might have gotten without a prescription from stores, pharmacies, friends, or relatives. Yes No Go to Question F4 Don’t Know Go to Question F4 What medicines were you taking? If respondent does not know the name of the medication, ask: What was the medicine for? Do you currently smoke cigarettes, cigars, or pipes? Yes Go to instruction box before Question F7 No
Cancer? Yes (Please specify) _____________________ No Unsure Immune disorders such as lupus, rheumatoid arthritis, or HIV? Yes No Unsure Neurological conditions such as Parkinson’s disease or multiple sclerosis? Yes No Unsure Any other medical conditions? Yes (Please specify) _____________________ No Unsure Prior to the incident, were you taking any medicines? This includes medicines prescribed by a health care provider and those you might have gotten without a prescription from stores, pharmacies, friends, or relatives. Yes No Go to Question F4 Don’t Know Go to Question F4 What medicines were you taking? If respondent does not know the name of the medication, ask: What was the medicine for? Do you currently smoke cigarettes, cigars, or pipes? Yes Go to instruction box before Question F7 No
ACE_General_Survey.docx