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Data entered into this eCRF are automatically saved
The contributor will also be able to return at a future date to view and/or edit the eCRF should new information regarding the patient/family become available
Part 1
Part 2
Part 3
Part 4
Part 5
Part 6
Upload Family Pedigree
Part 7 - Behavioural/Environmental history using: PD RFQ-U – PHYSICAL ACTIVITY & SLEEP
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The minimal dataset is not complete yet. Please be reminded that to complete the minimal dataset is mandatory in order to have samples processed for genetic analysis. Please continue or come back when you can complete at least the minimal dataset.
The following questions will ask you about the time you spent doing different types of physical activity, and how long you slept. Please answer all questions even if you do not consider yourself to be a physically active person. When answering these questions consider “vigorous activity” to be activities that produce a large increase in breathing and heart rate; and “moderate activity” to be activities that produce a moderate increase in breathing and heart rate. While answering these questions, please consider physical activity at your work, such as lifting boxes; at your home, such as vacuuming or gardening; and in your hobbies or recreational activities
Date Part 7 form completed:
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1. From age 12 through age 17, in a typical week how many hours of:
a. vigorous physical activity did you engage in?
less than 1 hour
1-4 hours
5-10 hours
More than 10 hours/week
b. moderate physical activity did you engage in?
less than 1 hour
1-4 hours
5-10 hours
More than 10 hours/week
c. sleep did you get on an average night?
less than 5 hours
5-6 hours
6-7 hours
7-8 hours
more than 8 hours
2. From age 18 through age 25, in a typical week how many hours of:
a. vigorous physical activity did you engage in?
less than 1 hour
1-4 hours
5-10 hours
More than 10 hours/week
b. moderate physical activity did you engage in?
less than 1 hour
1-4 hours
5-10 hours
More than 10 hours/week
c. sleep did you get on an average night?
less than 5 hours
5-6 hours
6-7 hours
7-8 hours
more than 8 hours
3. From age 26 through age 35, in a typical week how many hours of:
a. vigorous physical activity did you engage in?
less than 1 hour
1-4 hours
5-10 hours
More than 10 hours/week
b. moderate physical activity did you engage in?
less than 1 hour
1-4 hours
5-10 hours
More than 10 hours/week
c. sleep did you get on an average night?
less than 5 hours
5-6 hours
6-7 hours
7-8 hours
more than 8 hours
Is your current age less than 36?
no
yes
4. From age 36 through age 45, in a typical week how many hours of:
a. vigorous physical activity did you engage in?
less than 1 hour
1-4 hours
5-10 hours
More than 10 hours/week
b. moderate physical activity did you engage in?
less than 1 hour
1-4 hours
5-10 hours
More than 10 hours/week
c. sleep did you get on an average night?
less than 5 hours
5-6 hours
6-7 hours
7-8 hours
more than 8 hours
Is your current age less than 46?
no
yes
5. From age 46 through age 55, in a typical week how many hours of:
a. vigorous physical activity did you engage in?
less than 1 hour
1-4 hours
5-10 hours
More than 10 hours/week
b. moderate physical activity did you engage in?
less than 1 hour
1-4 hours
5-10 hours
More than 10 hours/week
c. sleep did you get on an average night?
less than 5 hours
5-6 hours
6-7 hours
7-8 hours
more than 8 hours
Is your current age less than 56?
no
yes
6. From age 56 through age 65, in a typical week how many hours of:
a. vigorous physical activity did you engage in?
less than 1 hour
1-4 hours
5-10 hours
More than 10 hours/week
b. moderate physical activity did you engage in?
less than 1 hour
1-4 hours
5-10 hours
More than 10 hours/week
c. sleep did you get on an average night?
less than 5 hours
5-6 hours
6-7 hours
7-8 hours
more than 8 hours
Is your current age less than 66?
no
yes
7. From age 66 and above, in a typical week how many hours of:
a. vigorous physical activity did you engage in?
less than 1 hour
1-4 hours
5-10 hours
More than 10 hours/week
b. moderate physical activity did you engage in?
less than 1 hour
1-4 hours
5-10 hours
More than 10 hours/week
c. sleep did you get on an average night?
less than 5 hours
5-6 hours
6-7 hours
7-8 hours
more than 8 hours
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