Adult Changes in Thought Study

ACT Form 77 Summary

Data Description

ACT Form 77 collects self-reported medical history information on ACT participants. A high-level overview of the content areas is shown below.

Perceived Health

  • Self-rated health
  • Hospitalizations
  • Use of adult day care, home health, nursing home, rehab hospital, or handivan / handicab services

Cardiovascular History

  • Chest pain, including context (when walking, duration, etc.)
  • Sudden weakness / paralysis / loss of sensation of arm or leg
  • Vision, speech, or balance disturbance

Diabetes History

  • Diabetes and treatment info (insulin, pills, duration)
  • Complications of diabetes (coma, kidney disease, circulation, amputation, blindness, other)

Medications

  • Prescription medications for blood pressure and cholesterol (including duration)
  • Medication inventory (OTC, prescriptions) and pharmacy utilization
  • Vitamin or dietary supplements (A, C, E, multi, minerals / calcium, fish oil, other)

Physical Activity

  • Days per week of activity (walking, hiking, cycling, calisthenics, swimming, water aerobics, strength training, other) for at least 15 minutes at a time

Women's Health

  • Completion of Breast Cancer Screening Questionnaire (BCSQ)
  • Age at menarche, age at menopause (natural, artificially induced)
  • Hysterectomy information
  • Pregnancies
  • Hormones, birth control 

Fractures

  • Fracture of the hip, spine, forearm, and/or other (including year)

Special Diets

  • Low salt, low cholesterol, and/or diabetic diet

Sleep

  • Snoring, cramps at night, cold feet

Other Diagnoses/ Hospitalizations

  • Neurological (epilepsy, Parkinson’s disease, Huntington’s Chorea, sleep apnea, other)
  • Viral (mononucleosis, shingles, meningitis / encephalitis, other)
  • Joint disease (osteoarthritis, gout, osteoporosis, other)
  • Allergies (hay fever, eczema, hives, food or drug)
  • Digestive problems (cholecystitis, hepatitis / cirrhosis, diverticulosis / diverticulitis, polyps, ulcers)
  • Thyroid disease (hyperthyroid, hypothyroid, goiter)
  • Coronary (congestive heart failure, myocardial infarction, angina, hypertension, stroke / TIA, coronary bypass surgery, angioplasty, surgery, heart rhythm, pacemaker)
  • Respiratory (acute / chronic bronchitis, pneumonia, emphysema, asthma, tuberculosis)
  • Other (prostate, kidney, cancer, tonsil, congenital defects, migraines, hearing /vision, venereal, other)

Important Note: Form contents have changed over the years so all the above items may not be collected over the full duration of the ACT study. 

Data Structure 

This Form 77 dataset contains one row per visit at which the study form was collected . 

 

Historical Data Collection Forms

For Baseline and Biennial Visits (PDFs)