Survey on Living with Chronic Diseases in Canada (SLCDC)- Respiratory Component

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Table of Contents

Survey Introduction (XINT)

Survey Introduction (XINT) - Question identifier:XINT_R01

This survey is conducted under the authority of the Statistics Act in collaboration with the Public Health Agency of Canada. You may remember recently completing the Canadian Community Health Survey - this is a follow-up to that survey. The purpose of this survey is to collect information on Canadians with chronic health conditions. Data from the survey will be used by health professionals and public health programs, with the aim of improving health outcomes for Canadians with chronic conditions.

Diagnosis and family history (XDHR)

Diagnosis and family history (XDHR) - Question identifier:XDHR_R01

Now I would like to ask some questions about breathing problems.

Diagnosis and family history (XDHR) - Question identifier:XDHR_Q01

To begin, do you have ^DT_CON1E that has been diagnosed by a health professional?

1. Yes
2. No

Diagnosis and family history (XDHR) - Question identifier:XDHR_Q02

Has a health professional ever told you that you have ^DT_CON1E?

1. Yes
2. No

Diagnosis and family history (XDHR) - Question identifier:XDHR_Q03

Have you ever had to use a puffer or inhaler to help you with your breathing?

1. Yes
2. No

Diagnosis and family history (XDHR) - Question identifier:XDHR_Q04

Have you ever visited a hospital emergency room because of problems with your breathing?

1. Yes
2. No

Diagnosis and family history (XDHR) - Question identifier:XDHR_Q05

During the CCHS interview, it was reported that you have ^DT_CON1E that has been diagnosed by a health professional but this time it was reported that you do not. Is this because you control your ^DT_CON1E through medication or changes to your lifestyle, because you never had an official diagnosis, or because of something else?

1. Error in CCHS - never had ^DT_CON1E
2. ^DT_CON1EC was never diagnosed by a health professional
3. Feels better - doesn't think he/she still has ^DT_CON1E
4. Takes medication that controls ^DT_CON1E
5. Has respiratory condition other than ^DT_CON1E
6. Other
DK, RF

Diagnosis and family history (XDHR) - Question identifier:XDHR_R06

You have said that you don't feel that you have ^DT_CON1E anymore because you are able to control it. Even though your ^DT_CON1E is controlled, we are still interested in hearing about your experiences.

Diagnosis and family history (XDHR) - Question identifier:XDHR_Q06

Which condition do you have?

1. Chronic bronchitis
2. Emphysema
3. Chronic obstructive pulmonary disease (COPD)
DK, RF

Diagnosis and family history (XDHR) - Question identifier:XDHR_Q07

How old were you when you were first diagnosed with ^DT_CONDE?

Minimum: 0 Maximum: 130

Diagnosis and family history (XDHR) - Question identifier:XDHR_Q08

Do you have a blood relative, that is, a mother, father, sister, brother, or child who has ever been diagnosed with asthma, chronic bronchitis, emphysema, or chronic obstructive pulmonary disease (COPD)?

1. Yes
2. No
DK, RF

Diagnosis and family history (XDHR) - Question identifier:XDHR_R09

Since this survey applies only to people with ^DT_CON1E, you are not eligible to participate in today's survey. Thank you for your time.

Symptoms and severity (XSSR)

Symptoms and severity (XSSR) - Question identifier:XSSR_R01

Now some questions about the severity of your ^DT_CONDE.

Symptoms and severity (XSSR) - Question identifier:XSSR_Q01

I am going to ask you some questions about shortness of breath. But first, are you unable to walk due to a condition other than shortness of breath?

1. Yes
2. No
DK, RF

Symptoms and severity (XSSR) - Question identifier:XSSR_Q02

What type of condition is this?

1. A disease or illness
2. Ageing
3. A condition caused by an accident or injury
DK, RF

Symptoms and severity (XSSR) - Question identifier:XSSR_Q03

Are you short of breath when dressing or undressing?

1. Yes
2. No
DK, RF

Symptoms and severity (XSSR) - Question identifier:XSSR_Q04

Do you ever have to stop for breath after walking about 100 m (or the length of a soccer field) on level ground?

1. Yes
2. No
DK, RF

Symptoms and severity (XSSR) - Question identifier:XSSR_Q05

Do you ever have to stop for breath when walking at your own pace on level ground?

1. Yes
2. No
DK, RF

Symptoms and severity (XSSR) - Question identifier:XSSR_Q06

Do you have to walk slower than people of your age on level ground because of shortness of breath?

1. Yes
2. No
DK, RF

Symptoms and severity (XSSR) - Question identifier:XSSR_Q07

Do you experience shortness of breath when hurrying on level ground or walking up a slight hill?

1. Yes
2. No
DK, RF

Symptoms and severity (XSSR) - Question identifier:XSSR_Q08

On average, how many days per week do you experience symptoms such as shortness of breath, cough, chest tightness, or wheeze during the day?

Minimum: 0 Maximum: 7

Symptoms and severity (XSSR) - Question identifier:XSSR_Q09

On average, how many nights per week do you experience symptoms such as shortness of breath, cough, chest tightness, or wheeze?

Minimum: 0 Maximum: 7

Symptoms and severity (XSSR) - Question identifier:XSSR_Q10

During the past year, that is, from (date one year ago) to yesterday, have you had a cough where you brought up phlegm that lasted 3 months or more?

1. Yes
2. No
DK, RF

Symptoms and severity (XSSR) - Question identifier:XSSR_Q11

During the previous year, that is, from (date two years ago) to (date one year ago), did you have a cough where you brought up phlegm that lasted 3 months or more?

1. Yes
2. No
DK, RF

Triggers (XTRR)

Triggers (XTRR) - Question identifier:XTRR_R01

Now I'd like to ask about things that may cause the symptoms of your ^DT_CONDE to get worse.

Triggers (XTRR) - Question identifier:XTRR_Q01

I'm going to read you a list of items. Do any of the following bring on your ^DT_CONDE symptoms or make them worse?

1. Dust
2. Feathers in items such as pillows, quilts or duvets
3. Dampness or humidity
4. Mold or mildew
5. Furry or feathered pets (for example, cats, dogs, rabbits, birds)
6. Pollen
7. Certain foods
8. Certain medicines
9. Colds or chest infections
10. Exercise/ physical activity
11. Laughing or crying
12. Stress
13. Cold air
14. Fumes from a WOOD stove or wood furnace
15. Outdoor air pollution
16. Tobacco smoke
17. A change in temperature or weather
18. Perfumes or colognes
19. Chemical fumes or gases (for example, chlorine, gasoline, paint or cleaners)
20. Other
21. No triggers
DK, RF

Health care utilization (XHUR)

Health care utilization (XHUR) - Question identifier:XHUR_Q01

Which of the following health professionals or practitioners do you consider most responsible for treating your ^DT_CONDE?

1. Family doctor, general practitioner or pediatrician
2. Other medical doctor or specialist
3. Asthma, COPD or respiratory educator
4. Nurse or nurse practitioner
5. Pharmacist
6. Other health professional
7. No health professional responsible for treating breathing problems
DK
RF

Health care utilization (XHUR) - Question identifier:XHUR_Q02

Has a health care professional given you a breathing test where you blew into a small tube attached to a machine?

1. Yes
2. No
DK, RF

Health care utilization (XHUR) - Question identifier:XHUR_R03

Now I'd like to ask about your contacts with various health professionals about your ^DT_CONDE during the past 12 months.

Health care utilization (XHUR) - Question identifier:XHUR_Q03

In the past 12 months, have you seen, or talked to any of the following health professionals about your ^DT_CONDE:

... A family doctor or general practitioner?

1. Yes
2. No
DK, RF

Health care utilization (XHUR) - Question identifier:XHUR_Q04

In the past 12 months, have you seen, or talked to:

... Any other medical doctor or specialist about your ^DT_CONDE?

1. Yes
2. No
DK, RF

Health care utilization (XHUR) - Question identifier:XHUR_Q05

(In the past 12 months, have you seen, or talked to:)

... an asthma or respiratory educator about your ^DT_CONDE?

1. Yes
2. No
DK, RF

Health care utilization (XHUR) - Question identifier:XHUR_Q06

(In the past 12 months, have you seen, or talked to:)

... a pharmacist about your ^DT_CONDE?

1. Yes
2. No
DK, RF

Health care utilization (XHUR) - Question identifier:XHUR_Q07

(In the past 12 months, have you seen, or talked to:)

... a complementary or alternative health care practitioner such as a massage therapist, a naturopath or herbalist about your ^DT_CONDE?

1. Yes
2. No
DK, RF

Health care utilization (XHUR) - Question identifier:XHUR_Q08

In the past 12 months, how many times have you visited a general practitioner or specialist for your ^DT_CONDE? Do not include doctors seen in an emergency room.

Minimum: 0 Maximum: 130

Health care utilization (XHUR) - Question identifier:XHUR_Q09

How many times, in the past 12 months, have you visited a hospital emergency room because of your ^DT_CONDE?

Minimum: 0 Maximum: 130

Health care utilization (XHUR) - Question identifier:XHUR_Q10

In the past 12 months, how many nights have you spent in hospital because of your ^DT_CONDE?

Minimum: 0 Maximum: 130

Medication use (XMER)

Medication use (XMER) - Question identifier:XMER_R01

Now I'd like to ask a few questions about your use of medications for your ^DT_CONDE. Be sure to include medicines that are used on a regular basis, as well as those used only for attacks.

Medication use (XMER) - Question identifier:XMER_Q01

Currently, are you taking any prescribed medication for your ^DT_CONDE such as inhalers (puffers), nebulizers (pumps), pills, liquids, or needles?

1. Yes
2. No
DK, RF

Medication use (XMER) - Question identifier:XMER_Q02

What are the reasons that you are not currently taking any prescription medications for your ^DT_CONDE?

1. No medication prescribed from a doctor or health professional
2. Do not want to take medication at this time
3. Side-effects caused by medication
4. Medication not working/need more medication
5. Ran out of medication
6. Too costly / financial constraints
7. Breathing problems controlled without medication
8. Other
DK, RF

Medication use (XMER) - Question identifier:XMER_R03

Now I am going to ask about reliever and controller medications you might take to help control your ^DT_CONDE.

Medication use (XMER) - Question identifier:XMER_Q03

In the past month, did you take a reliever or rescue medication for your ^DT_CONDE? This medication generally comes in a solid blue or grey puffer (inhaler).

1. Yes
2. No
DK, RF

Medication use (XMER) - Question identifier:XMER_Q04

When do you take your reliever or rescue medication? Is it:

1. ... when having an attack or difficulty breathing?
2. ... before exercise or doing something which might cause an attack?
3. ... every day, on a regular basis to help control symptoms?
4. ... every day during certain times of the year?
5. Other
DK, RF

Medication use (XMER) - Question identifier:XMER_Q05

In the past month, how many days per week on average did you use your reliever medication? Do not include when you took it for exercise.

Minimum: 0 Maximum: 7

Medication use (XMER) - Question identifier:XMER_Q06

In the past month did you take a controller medication for your ^DT_CONDE? This medication generally comes in a red and white, orange, burgundy, purple or green and white inhaler (puffer).

1. Yes
2. No
DK, RF

Medication use (XMER) - Question identifier:XMER_Q07

When do you take your controller medication? Is it:

1. ... when having an attack or difficulty breathing?
2. ... before exercise or doing something which might cause an attack?
3. ... every day, on a regular basis to help control symptoms?
4. ... every day during certain times of the year?
5. Other
DK, RF

Medication use (XMER) - Question identifier:XMER_Q08

Thinking about how often you take your controller medication, on average, would you say you:

1. ... take it as often as prescribed?
2. ... take it more often than prescribed?
3. ... take it less often than prescribed?
4. ... occasionally miss a dose?
5. ... do not take the controller medication at all.
DK, RF

Medication use (XMER) - Question identifier:XMER_Q09

What are the reasons that you are not taking your controller medication for your ^DT_CONDE exactly as prescribed?

1. Forget to take medication
2. Side-effects caused by medication
3. Medication not working
4. Symptoms are not controlled with prescribed amount of medication
5. Ran out of medication
6. Too expensive
7. Breathing problems controlled without medication
8. Not confident in the prescribed treatment
9. Do not know how to take medication properly
10. Too embarrassed to use inhaler
11. Other
DK, RF

Medication use (XMER) - Question identifier:XMER_Q10

Has a health professional ever watched you use your inhaler or puffer?

1. Yes
2. No
DK, RF

Medication use (XMER) - Question identifier:XMER_Q11

In the past 12 months, have you taken corticosteroid pills such as Prednisone to treat your ^DT_CONDE?

1. Yes
2. No
DK, RF

Medication use (XMER) - Question identifier:XMER_Q12

In the past 12 months, on how many occasions have you taken corticosteroid pills for your ^DT_CONDE?

Minimum: 0 Maximum: 99

Medication use (XMER) - Question identifier:XMER_Q13

In the past 12 months, have you taken antibiotics to treat your ^DT_CONDE?

1. Yes
2. No
DK, RF

Medication use (XMER) - Question identifier:XMER_Q14

In the past 12 months, on how many occasions have you taken antibiotics for your ^DT_CONDE?

Minimum: 0 Maximum: 99

Medication use (XMER) - Question identifier:XMER_Q15

Do you currently use oxygen therapy to help manage your ^DT_CONDE?

1. Yes
2. No
DK, RF

Medication use (XMER) - Question identifier:XMER_Q16

On average, how many hours per day do you use oxygen therapy?

Minimum: 0 Maximum: 24

Medication use (XMER) - Question identifier:XMER_Q17

Have you ever been given a WRITTEN action plan? This is a plan that has been developed with the aid of a doctor or other health professional and tells you how to adjust the amount of medicine you take depending on the severity of symptoms and when to seek medical care.

1. Yes
2. No
DK, RF

Health conditions (XHCR)

Health conditions (XHCR) - Question identifier:XHCR_R01

Now I'd like to ask about other health conditions which you may have.

Health conditions (XHCR) - Question identifier:XHCR_Q01

Have you been told by a health professional that you have sleep apnea?

1. Yes
2. No
DK, RF

Health conditions (XHCR) - Question identifier:XHCR_Q02

Have you ever been referred to a sleep lab for overnight testing?

1. Yes
2. No
DK, RF

Health conditions (XHCR) - Question identifier:XHCR_Q03

Have you ever been prescribed Continuous Positive Airway Pressure (CPAP) treatment for your sleep apnea?

Health conditions (XHCR) - Question identifier:XHCR_Q04

Do you currently use Continuous Positive Airway Pressure (CPAP) treatment for your sleep apnea?

1. Yes
2. No
DK, RF

Health conditions (XHCR) - Question identifier:XHCR_Q05

Have you been told by a health professional that you have osteoporosis?

1. Yes
2. No
DK, RF

Health conditions (XHCR) - Question identifier:XHCR_Q06

Have you been told by a health professional that you have heart failure?

1. Yes
2. No
DK, RF

Health conditions (XHCR) - Question identifier:XHCR_Q07

Do you ever experience ^DT_SYMPTOM?

1. Yes
2. No
DK, RF

Allergies (XALR)

Allergies (XALR) - Question identifier:XALR_R01

Now I would like to ask some questions about allergies.

Allergies (XALR) - Question identifier:XALR_Q01

Have you ever had allergy tests?

1. Yes
2. No
DK, RF

Allergies (XALR) - Question identifier:XALR_Q02

What type of allergy tests did you have?

1. Skin testing
2. Blood testing
3. Other
DK, RF

Allergies (XALR) - Question identifier:XALR_Q03

As a result of the allergy tests, were you told that you have allergies?

1. Yes
2. No
DK, RF

Allergies (XALR) - Question identifier:XALR_Q04

What did your health professional say you were allergic to?

1. Certain foods
2. Certain animals
3. Dust mites
4. Mold
5. Pollen
6. Other
DK, RF

Allergies (XALR) - Question identifier:XALR_Q05

Were you told by a health professional that you have hay fever or nasal allergy?

1. Yes
2. No
DK, RF

Allergies (XALR) - Question identifier:XALR_Q06

Have you ever received allergy shots?

1. Yes
2. No
DK, RF

Allergies (XALR) - Question identifier:XALR_Q07

Were you given allergy shots for your asthma?

1. Yes
2. No
DK, RF

Allergies (XALR) - Question identifier:XALR_Q08

Do you currently have a prescription for an epinephrine injection (such as Epipen or Twinject)?

1. Yes
2. No
DK, RF

Restriction of activities (XRAR)

Restriction of activities (XRAR) - Question identifier:XRAR_R01

The next few questions deal with any limitations in your usual activities caused by your breathing problems. By breathing problems we mean wheezing or whistling in the chest, shortness of breath, difficulty breathing, chest tightness and cough.

Restriction of activities (XRAR) - Question identifier:XRAR_Q01

In the past 12 months, how much did your breathing problems limit you:

... in getting a good night's sleep?

1. A lot
2. A little
3. Not at all
DK
RF

Restriction of activities (XRAR) - Question identifier:XRAR_Q02

In the past 12 months, how much did your breathing problems limit you:

... in bathing or dressing yourself?

1. A lot
2. A little
3. Not at all
DK, RF

Restriction of activities (XRAR) - Question identifier:XRAR_Q03

(In the past 12 months, how much did your breathing problems limit you:)

... in getting around the house?

1. A lot
2. A little
3. Not at all
DK, RF

Restriction of activities (XRAR) - Question identifier:XRAR_Q04

(In the past 12 months, how much did your breathing problems limit you:)

... in doing household chores?

1. A lot
2. A little
3. Not at all
DK, RF

Restriction of activities (XRAR) - Question identifier:XRAR_Q05

(In the past 12 months, how much did your breathing problems limit you:)

... in running errands or shopping?

1. A lot
2. A little
3. Not at all
DK, RF

Restriction of activities (XRAR) - Question identifier:XRAR_Q06

(In the past 12 months, how much did your breathing problems limit you:)

... in exercise and/or playing sports?

Restriction of activities (XRAR) - Question identifier:XRAR_Q07

(In the past 12 months, how much did your breathing problems limit you:)

... in activities such as recreation, leisure, hobbies or social activities?

1. A lot
2. A little
3. Not at all
DK, RF

Restriction of activities (XRAR) - Question identifier:XRAR_Q08

Overall, how much do your breathing problems affect your life?

1. Not at all
2. A little bit
3. Moderately
4. Quite a bit
5. Extremely
DK, RF

Restriction of work-related activities (XRWR)

Restriction of work-related activities (XRWR) - Question identifier:XRWR_R01

The next questions concern your work activities.

Restriction of work-related activities (XRWR) - Question identifier:XRWR_Q01

Are you currently working for pay at a job or business?

1. Yes
2. No
DK
RF

Restriction of work-related activities (XRWR) - Question identifier:XRWR_Q02

Have you ever worked for pay at a job or business?

1. Yes
2. No
DK, RF

Restriction of work-related activities (XRWR) - Question identifier:XRWR_Q03

Did you have ^DT_CONDE while you were working?

1. Yes
2. No
DK, RF

Restriction of work-related activities (XRWR) - Question identifier:XRWR_R04

Now some questions about your current and past work environments.

Restriction of work-related activities (XRWR) - Question identifier:XRWR_Q04

Because of your ^DT_CONDE, did you ever:

... change the number of hours you ^DT_WORK or the type of work you ^DT_DODID at your job?

1. Yes
2. No
DK, RF

Restriction of work-related activities (XRWR) - Question identifier:XRWR_Q05

Because of your ^DT_CONDE, did you ever:

... stop work permanently?

1. Yes
2. No
DK, RF

Restriction of work-related activities (XRWR) - Question identifier:XRWR_Q06

Has a health professional ever told you that you have work-related ^DT_CONDE?

1. Yes
2. No
DK, RF

Restriction of work-related activities (XRWR) - Question identifier:XRWR_Q07

Have you ever worked in jobs where you were exposed to dust, fumes or gases?

1. Yes
2. No
DK, RF

Restriction of educational activities (XRER)

Restriction of educational activities (XRER) - Question identifier:XRER_R01

The next questions concern educational activities.

Restriction of educational activities (XRER) - Question identifier:XRER_Q01

Are you currently attending a school, college, or university?

1. Yes
2. No
DK, RF

Restriction of educational activities (XRER) - Question identifier:XRER_Q02

Because of your ^DT_CONDE, did you ever:

... change the number of hours or the type of activities you do at school?

1. Yes
2. No
DK, RF

Restriction of volunteer activities (XRVR)

Restriction of volunteer activities (XRVR) - Question identifier:XRVR_R01

Now, some questions about any volunteer activities that you do without pay. Please include any unpaid help you may provide to groups or organizations such as schools, sports teams or leagues, religious organizations or community associations.

Restriction of volunteer activities (XRVR) - Question identifier:XRVR_Q01

Are you currently doing any volunteer work, for example organizing events, fundraising, or helping out with office work?

1. Yes
2. No
DK, RF

Restriction of volunteer activities (XRVR) - Question identifier:XRVR_Q02

Have you ever done any volunteer work?

1. Yes
2. No
DK, RF

Restriction of volunteer activities (XRVR) - Question identifier:XRVR_Q03

Did you have ^DT_CONDE while you were volunteering?

1. Yes
2. No
DK, RF

Restriction of volunteer activities (XRVR) - Question identifier:XRVR_Q04

Because of your ^DT_CONDE, did you ever:

... change the number of hours or the type of volunteer work you ^DT_TODO, or stop doing volunteer work altogether?

1. Yes
2. No
DK, RF

Self-management (XSMR)

Self-management (XSMR) - Question identifier:XSMR_R01

The next questions are about things that a doctor or other health professional may have suggested you do to help manage your breathing problems. By manage, we mean things that may help you cope with your breathing problems, improve any symptoms you may have, or keep further problems from developing.

Self-management (XSMR) - Question identifier:XSMR_Q01

Has a doctor or other health professional ever suggested:

... visiting an asthma, COPD, or respiratory educator to help you manage your ^DT_CONDE?

1. Yes
2. No
DK
RF

Self-management (XSMR) - Question identifier:XSMR_Q02

Have you ever visited an asthma, COPD, or respiratory educator to learn how to manage problems related to your ^DT_CONDE?

1. Yes
2. No
DK, RF

Self-management (XSMR) - Question identifier:XSMR_Q03

Has a doctor or other health professional ever suggested:

... participating in a supervised pulmonary rehabilitation program for your ^DT_CONDE?

1. Yes
2. No
DK, RF

Self-management (XSMR) - Question identifier:XSMR_Q04

Have you ever participated in a supervised pulmonary rehabilitation program for your ^DT_CONDE?

1. Yes
2. No
DK, RF

Self-management (XSMR) - Question identifier:XSMR_Q05

Has a doctor or other health professional ever suggested:

... changing your home environment to help you control your ^DT_CONDE, for example by covering your mattress or changing your flooring?

1. Yes
2. No
DK, RF

Self-management (XSMR) - Question identifier:XSMR_Q06

Have you ever made any of the following changes to your environment to help manage your ^DT_CONDE:

1. Changed floor coverings
2. Changed window coverings in your bedroom
3. Covered mattress with a dust mite proof anti-allergy (plastic) cover
4. Covered pillows in dust mite proof anti-allergy (plastic) cover
5. Changed heating source
6. Installed air conditioning
7. Installed humidifier
8. Installed dehumidifier
9. Used an air cleaning device (air purifier)
10. Gave up a pet
11. Other
12. None of the above
DK, RF

Support and well-being (XSWR)

Support and well-being (XSWR) - Question identifier:XSWR_R01

The next few questions are about support and emotional well-being.

Support and well-being (XSWR) - Question identifier:XSWR_Q01

Are your family or friends supportive when it comes to helping you manage problems related to your ^DT_CONDE if you need it?

1. Yes
2. No
3. Not applicable
DK
RF

Support and well-being (XSWR) - Question identifier:XSWR_Q02

Was there ever a time when you felt that you needed help for your emotions, stress, or your mental health, in order to manage your ^DT_CONDE?

1. Yes
2. No
DK, RF

Support and well-being (XSWR) - Question identifier:XSWR_Q03

Has a doctor or other health professional ever suggested reducing your level of stress to help you control your ^DT_CONDE?

1. Yes
2. No
DK, RF

Support and well-being (XSWR) - Question identifier:XSWR_Q04

Has a doctor or other health professional ever suggested you talk to a mental health professional (for example, a psychologist, counsellor, social worker or psychiatrist) to help you manage problems related to your ^DT_CONDE?

1. Yes
2. No
DK, RF

Support and well-being (XSWR) - Question identifier:XSWR_Q05

Have you ever sought help from a mental health professional (for example, a psychologist, counsellor, social worker, psychiatrist) to help you manage problems related to your ^DT_CONDE?

1. Yes
2. No
DK, RF

Support and well-being (XSWR) - Question identifier:XSWR_Q06

Have you ever talked to your family members about your wishes for care should your ^DT_CONDE worsen and you require hospitalization?

1. Yes
2. No
DK, RF

Support and well-being (XSWR) - Question identifier:XSWR_Q07

Have you ever talked to your doctor about your wishes for care as your ^DT_CONDE progresses?

1. Yes
2. No
DK, RF

Smoking History (XSHR)

Smoking History (XSHR) - Question identifier:XSHR_R01

The next questions are about your smoking history.

Smoking History (XSHR) - Question identifier:XSHR_Q01

Including cigarettes, cigars and pipes, at any time since you were first diagnosed with ^DT_CONDE, did you smoke?

1. Yes
2. No
DK
RF

Smoking History (XSHR) - Question identifier:XSHR_Q02

As a result of being diagnosed with ^DT_CONDE, did you ever quit or cut down on smoking to help control your breathing problems?

1. Yes
2. No
DK, RF

Smoking History (XSHR) - Question identifier:XSHR_Q03

What are the reasons why you did not try to quit or cut down on smoking to help control your breathing problems?

1. Does not want to quit / cut down on smoking
2. Lack of will power / self-discipline
3. Tried to quit / cut down on smoking - didn't work
4. Already quit /cut down on smoking for other reasons
5. Does not think that quitting / cutting down on smoking is important
6. Other
7. No reason for not quitting / cutting down on smoking
DK, RF

Smoking History (XSHR) - Question identifier:XSHR_Q04

In your lifetime, have you smoked a total of 100 or more cigarettes (about 4 or 5 packs)?

1. Yes
2. No
DK, RF

Smoking History (XSHR) - Question identifier:XSHR_Q05

Was there ever a period where you were a daily smoker, that is, you smoked at least one cigarette per day?

1. Yes
2. No
DK, RF

Smoking History (XSHR) - Question identifier:XSHR_Q06

For how many years were you a daily smoker?

Minimum: 0 Maximum: 130

Smoking History (XSHR) - Question identifier:XSHR_Q07

During this period, how many cigarettes would you usually smoke each day?

Minimum: 0 Maximum: 99

Smoking History (XSHR) - Question identifier:XSHR_Q08

Do you currently smoke cigarettes daily?

1. Yes
2. No
DK, RF

Smoking History (XSHR) - Question identifier:XSHR_Q09

Was there ever a period where you were an occasional smoker, that is, you smoked, but not everyday?

1. Yes
2. No
DK, RF

Smoking History (XSHR) - Question identifier:XSHR_Q10

For how many years were you an occasional smoker?

Minimum: 0 Maximum: 130

Smoking History (XSHR) - Question identifier:XSHR_Q11

During this period, in a typical month, on how many days would you smoke one or more cigarettes?

Minimum: 0 Maximum: 30

Smoking History (XSHR) - Question identifier:XSHR_Q12

During this period, how many cigarettes would you usually smoke per day, on the days that you smoked?

Minimum: 0 Maximum: 99

Smoking History (XSHR) - Question identifier:XSHR_Q13

Do you currently smoke cigarettes occasionally?

1. Yes
2. No
DK, RF

Smoking History (XSHR) - Question identifier:XSHR_Q14

Have you ever smoked any of the following?

1. Cigars
2. Cigarillos
3. Marijuana
4. Pipes
5. None of the above
DK, RF

Smoking History (XSHR) - Question identifier:XSHR_Q15

For how many years have you smoked these products?

Minimum: 0 Maximum: 130

Smoking History (XSHR) - Question identifier:XSHR_Q16

Do you currently smoke any of the following?

1. Cigars
2. Cigarillos
3. Marijuana
4. Pipes
5. None of the above
DK, RF

Smoking History (XSHR) - Question identifier:XSHR_Q17

In the past month, on how many days did you smoke these products?

Minimum: 0 Maximum: 30

Smoking cessation (XSCR)

Smoking cessation (XSCR) - Question identifier:XSCR_Q01

Does your doctor know that you smoke?

1. Yes
2. No
3. Does not have a regular doctor
DK
RF

Smoking cessation (XSCR) - Question identifier:XSCR_Q02

In the past 12 months, did your doctor advise you to quit smoking?

1. Yes
2. No
DK, RF

Smoking cessation (XSCR) - Question identifier:XSCR_Q04

What type of help did the doctor give?

1. Referral to a one-on-one cessation program
2. Referral to a group cessation program
3. Recommended use of nicotine patch or nicotine gum
4. Recommended zyban or other prescription medication
5. Provided self-help information (for example, pamphlet, referral to website)
6. Own doctor offered counselling
7. Other
DK, RF

Smoking cessation (XSCR) - Question identifier:XSCR_Q05

Are you seriously considering quitting smoking within the next 30 days?

1. Yes
2. No
DK, RF

Smoking cessation (XSCR) - Question identifier:XSCR_Q06

In the past 12 months, did you stop smoking for at least 24 hours because you were trying to quit?

1. Yes
2. No
DK, RF

Smoking cessation (XSCR) - Question identifier:XSCR_Q07

In the past 12 months, have you done any of the following to help you stop smoking?

1. Use a nicotine patch
2. Use nicotine gums such as « Nicorette »
3. Use a product such as Champix, Nortriptyline, or zyban
4. Hypnosis
5. Acupuncture
6. Biofeedback
7. Other
8. None of the above
DK, RF

Smoking cessation (XSCR) - Question identifier:XSCR_Q08

What are the reasons that you did not use a product such as Champix, Nortriptyline, or Zyban to help you stop smoking in the past 12 months?

1. Health professional did not prescribe/recommend it
2. Did not want to take medication at this time
3. Side-effects of medication
4. Too expensive/ financial constraints
5. Not confident the medication will work
6. Other
DK, RF

Smoking cessation (XSCR) - Question identifier:XSCR_R09

The next questions are about cigarette smoke you may be exposed to at home.

Smoking cessation (XSCR) - Question identifier:XSCR_Q09

Do other members of your household smoke?

1. Yes
2. No
3. Not applicable - lives alone
DK, RF

Smoking cessation (XSCR) - Question identifier:XSCR_Q10

Has a doctor or other health professional ever suggested:

... that other members of your household quit or cut down smoking to help you control your ^DT_CONDE?

1. Yes
2. No
DK, RF

Administration (XADM)

Administration (XADM) - Question identifier:XADM_R01A

The next few questions are about linking the information from today's interview to your information from the Canadian Community Health Survey and sharing this information with other government organizations.

We will be asking your parent or guardian the same questions after you have answered them.

Administration (XADM) - Question identifier:XADM_R01B

In 2010, you responded to the Canadian Community Health Survey. At that time, you gave permission for ^DT_QUEBECHNE to link information from that survey to your health services information. You also gave us your provincial health number to assist in linking this information.

Administration (XADM) - Question identifier:XADM_R01C

In order to reduce the number of questions on today's survey, Statistics Canada would like to link information from this interview with your information from the 2010 Canadian Community Health Survey.

Administration (XADM) - Question identifier:XADM_Q01

The linked information will be kept strictly confidential and used only for statistical purposes.

Do we have your permission?

1. Yes
2. No
DK, RF

Administration (XADM) - Question identifier:XADM_R02

Statistics Canada would like your permission to share the linked survey data, that is your information from today's interview and your information from the Canadian Community Health Survey, with the Public Health Agency of Canada, Health Canada^DT_SHAREE.

Administration (XADM) - Question identifier:XADM_Q02

Information from both surveys will be kept confidential and used only for statistical purposes.

Do you agree to share the linked information?

1. Yes
2. No
DK, RF

Administration (XADM) - Question identifier:XADM_R03

Although you do not agree to link the information collected in today's interview to the 2010 Canadian Community Health Survey, we would like your permission to share only the information collected today with the Public Health Agency of Canada, Health Canada^DT_SHAREE.

Administration (XADM) - Question identifier:XADM_Q03

Your personal identifiers such as name, address and telephone number will not be shared. All information will be kept confidential and used only for statistical purposes.

Do you agree to share the information from today's interview?

1. Yes
2. No
DK, RF

Administration (XADM) - Question identifier:XADM_Q04

Your personal identifiers such as name, address and telephone number will not be shared. All information will be kept confidential and used only for statistical purposes.

Do you agree to share the information from today's interview?

1. Yes
2. No
DK, RF

Administration (XADM) - Question identifier:XADM_R06

For the last few questions, I would like to speak with one of your parents or your guardian.

Administration (XADM) - Question identifier:XADM_Q06

Is one of your parents or guardian available?

1. Yes
2. No
3. Parent or guardian refuses to participate

Administration (XADM) - Question identifier:XADM_R07

This completes your portion of the interview. On behalf of Statistics Canada, I would like to thank you very much for your time.

Administration (XADM) - Question identifier:XADM_R08

This completes your portion of the interview. On behalf of Statistics Canada, I would like to thank you very much for your time. I would now like to try and find the best time to speak with one of your parents or guardian.

Administration (XADM) - Question identifier:XADM_R09

This completes your portion of the interview. On behalf of Statistics Canada, I would like to thank you very much for your time. I would now like to speak with one of your parents or guardian.

Administration (XADM) - Question identifier:XADM_R10

Hello, My name is ... I've just completed the main portion of the interview with ^FNAME. At this point I would like to ask you a few administrative questions to finish the interview.

Administration (XADM) - Question identifier:XADM_R11A

In 2010, ^FNAME responded to the Canadian Community Health Survey. At that time, you gave permission for ^DT_QUEBECHNE to link information from that survey to ^FNAME's health services information. You also gave us ^FNAME's provincial health number to assist in linking this information.

Administration (XADM) - Question identifier:XADM_R11B

In order to reduce the number of questions on today's survey, Statistics Canada would like to link information from this interview with ^FNAME's information from the 2010 Canadian Community Health Survey.

Administration (XADM) - Question identifier:XADM_Q11

The linked information will be kept strictly confidential and used only for statistical purposes.

Do we have your permission?

1. Yes
2. No
DK, RF

Administration (XADM) - Question identifier:XADM_R12

Statistics Canada would like your permission to share the linked survey data, that is ^FNAME's information from today's interview and ^FNAME's information from the Canadian Community Health Survey, with the Public Health Agency of Canada, Health Canada^DT_SHAREE.

Administration (XADM) - Question identifier:XADM_Q12

Information from both surveys will be kept confidential and used only for statistical purposes.

Do you agree to share the linked information?

1. Yes
2. No
DK, RF

Administration (XADM) - Question identifier:XADM_R13

Although you do not agree to link ^FNAME's information collected in today's interview to the 2010 Canadian Community Health Survey, we would like your permission to share only the information collected today with the Public Health Agency of Canada, Health Canada^DT_SHAREE.

Administration (XADM) - Question identifier:XADM_Q13

^FNAME's personal identifiers such as name, address and telephone number will not be shared. All information will be kept confidential and used only for statistical purposes.

Do you agree to share the information from today's interview?

1. Yes
2. No
DK, RF

Administration (XADM) - Question identifier:XADM_R14

Although you do not agree to share ^FNAME's linked survey information, we would like your permission to share only the information collected in today's interview with the Public Health Agency of Canada, Health Canada^DT_SHAREE.

Administration (XADM) - Question identifier:XADM_Q14

^FNAME's personal identifiers such as name, address and telephone number will not be shared. All information will be kept confidential and used only for statistical purposes.

Do you agree to share the information from today's interview?

1. Yes
2. No
DK, RF

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