Document V3jJ6N1pYOwVwBOJzLy5ZyYMw

Study ID Number _ _ _ __ Name _ _ __ Interview START TIME_ _ _ __ Part 1. Demographic information DIO. Interview Location: _ In hospital interview room _ Bedside in subject's room or ward _ Subject's home _ Other (specify) _ _ _ _ _ _ _ _ __ DI 1 Interviewee relationship to patient: D Self D Spouse D Child D Other (specify)____ (Parent, grandparent, cousin, uncle, aunt, neighbor, friend) DI2 National ID number _ _ _ _ _ _ _ _(to be obtained from Clinical Coordinator) DB Gender: Male D Female D DI4 Birth date _ _ _ _ _ _ _ _ __ DI5 Birth place (country, province, city, other) DI6 Ethnicity: Han D Hui D Man D Bai D Tibet D Other _ _ __ DI7 Marital status: Never married D Married D Divorced D Widowed D DI8 Height CM DI9 Weight Kg DIlO Education, Highest level completed: None D Primary D Middle D High D University D Postgraduate D Do Not Know [J DIll Current address- - - - - - - - - - - - - - - - - - - - - - - - DIllS At this address since _ _ _ _ _ _ _ __ DIll T Home telephone _ _ _ _ _ __ DI 12 Is there another address that we could contact you at in the future? DIl2T Home telephone _ _ _ _ _ __ Version 24 February 2004 CC_DP Questionnaire 2 of 15 SH ELL-MCCLU RG-059280