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Table 2 Questionnaires

From: The Durham Initiative for Stomach Health (DISH): a pilot community-based Helicobacter pylori education and screening study

Category Variables
Baseline Questionnaire
 Demographics Age, race, ethnicity, education, income, occupation
 Gastric Symptoms Stomach ache, heartburn, acid reflux, hunger pains, nausea, rumbling in stomach, feeling bloated, burping, passing gas, constipation, diarrhea, loose stools, hard stools, urgent need to have bowel movement, not completely emptying bowels
 Family History Cancer, 1st degree relatives, if occurred before age 50; stomach ulcers, gastritis, H. pylori
 Medication Use Use of antibiotics, aspirin, acetaminophen, peptic ulcer medication, pills for diabetes, insulin, allergy pills, asthma
 Medical History Heart trouble, high blood pressure, anemia, asthma, hayfever, skin allergy, food allergy, emphysema, COPD, stomach ulcer, duodenal ulcer, IBD, gastritis, H. pylori, GERD, heartburn, pancreatitis, TB, hepatitis, HPV, MS, diabetes
 Cancer Screening Women (pap smear, mammogram, sigmoidoscopy, colonoscopy), men (digital rectal exam, PSA blood test, sigmoidoscopy, colonoscopy)
 Smoking Smoking status, number per day, age first smoked, number of years; chewing tobacco, snuff/dip, pipes, cigars
 Alcohol Current use, type of drink, amount and how often
 Physical Activity Average sleep during week/week-end, vigorous and moderate activity, walking, sitting
 Height and weight Self-reported height/weight
Follow-up Questionnaire
 Gastric Symptoms Same as those in the baseline questionnaire (Table 2above)
 Family History Any 1st degree relatives during the past six months being diagnosed with cancer, ulcers, gastritis, H. pylori
 Medical History Changes in the past 6 months regarding anemia, stomach ulcer, duodenal ulcer, IBD, gastritis, GERD, diabetes
 Interaction with doctor Hp + only - communication with doctor about infection (in person, over the phone, via email), timeline from diagnosis to doctor’s visit, did doctor re-test prior to treatment, did doctor retest after treatment, what was prescribed (number of pills/day/duration), adherence to prescribed medication, cost
 Experience with physician Scale of very poor, poor, fair, good, very good; friendliness, explanation about their condition, concern about questions/worries, involvement in decision making, information about medications, follow-up care, amount of time spent with provider, confidence in provider, recommend provider
 Height and weight Self-reported height/weight