复旦大学高原健康研究中心-云南保障前调查评估问卷

尊敬的各位领导：
       您好！欢迎参加复旦大学高原健康研究中心保障性项目。
       本问卷用于评估您的健康状态，并作为健康保障依据。问卷由个体光历史问卷、光敏感性调查问卷、匹兹堡睡眠质量指数量表、身体活动问卷、高原习服每日症状报告、路易斯湖问卷(LLS)、心脏状态调查表等部分组成，完成问卷预计耗时15分钟，感谢您的配合。

个人信息
Personal Information
您的姓名 Your name:
您的年龄 （周岁）Your age：
您的性别 Your gender
您的手机号码/邮箱 Your phone number/email address:
5. 您的身高 Your height：________  cm
6. 您的体重 Your weight：_________ kg
请输入您到达高原的日期：
您是第几次到高海拔地区工作？
您的文化程度：
您的专业  Your major：
您的视力是？
12. 您眼镜的度数是？（例如：200）
左眼：_________    右眼：_________
您的色觉情况是？
用光习惯调查问卷
Light Habits Survey
指导语：请回想并根据最近的一个月的生活情况来回答以下问题。
Instructions: Please recall and answer the following questions according to your life condition in recent one month.
第一部分：生活环境
Part I：Living environment
Q3：你的住宅在几楼？

         The floor of your house is:
Q4：你的卧室的朝向？
        The orientation of your bedroom is:
Q5：你的卧室窗户的尺寸？（平方米）
        The area of the window in your bedroom is: (square meter)
Q6：你的卧室窗户的水平视角看天空有多少被遮挡？
        How much of the sky is obscured above the horizontal view from the window of your bedroom?
Q7：你的办公室在几楼？
        The floor of your office is:
Q8：你的办公室的朝向？
         The orientation of your office is:
Q9：你的办公室窗户（距离工位最近的）的尺寸？（平方米）
         The area of the nearest window away from your workbench in your office is: (square meter)
Q10：你与办公室窗户（距离工位最近的）之间的距离？（米）
          The distance between you and the nearest window away from your workbench in your office is:（meter）
Q11：你的办公室窗户的水平视角看天空有多少被遮挡？

         How much of the sky is obscured above the horizontal view from the window of your office?
第二部分：接受日光的习惯
Part II: The habits of daylight exposure
Q12：请评价在早上睡觉睁眼前从卧室外透进房间内的太阳光线
           Please evaluate the sunray penetrating into room from outside of bedroom before opening eyes in the morning
Q13：通常情况下，一天中你会接受几个小时充足的日光照射(户外或窗口)？
          In general, how many abundant daylight hours (outdoors or beside the window) last in a whole day without using artificial light？
Q14：在以下时间段, 你会接收几个小时充足的日光照射（户外或窗口）？

           In the following time period, how many abundant daylight hours (outdoors or beside the window) last without using artificial light？

1）清晨8:00之前 before 8:00am
2）上午8:00~12:00 between 8:00~12:00
3）下午12:00~16:00 between 12:00~16:00
4）在下午16:00~20:00 between 16:00~20:00
第三部分：接受人工照明的习惯
Part III: The habits of artificial lighting exposure
Q15：日落之后，你在明亮的房间中度过的时间大概有多久？（小时）
          Duration for you to stay in bright room after sunset (hour)
Q16：请回答日落之后你所在时间最长的房间中的照明情况
           Please answer the lighting conditions of the room where you stay for the longest time after sunset
1）所在房间中使用的照明器具
      Lighting appliance used in the room
2）所在房间的照明方式是直接照明还是间接照明

      The room adopts direct lighting or indirect lighting
3）所在房间使用的照明颜色（色温度）为

      Light color (color temperature) of room
Q17：准备入睡后的卧室照明情况？
           Lighting condition of bedroom after being ready to fall asleep
第四部分：使用电子产品的习惯
Part IV: The habits of using electronic products
Q18：请回答在入睡前1小时所使用以下电子产品的时间
           Please answer the use time of the following electronic products 1 hour before falling asleep
  • 0
  • 0~10
  • 10~30
  • 30~60
1）电视（分钟） Television (minute)
2）电脑、ipad（分钟） Computer or ipad (minute)
3）手机（分钟）Mobile phone (minute)
Q19：请回答睡前1小时使用电子产品时是否开启房间的照明灯具？
           Please answer whether the light is on when you use the electronic products 1 hour before falling asleep
Q20：请回答睡前1小时使用电子产品时屏幕的亮度情况？
           Please answer the luminance condition of screen when you use the electronic devices 1 hour before falling asleep
第五部分：睡眠习惯
Part V: Sleeping habits
Q21：如果你在工作日度过了正常的一天，第二天你能完全自由地计划你的时间，
If you spend a normal day in working days and you are entirely free to plan your second day,
1）相比前一天，你会选择在晚上 ________入睡。
Compared with the day before, you want to sleep ________ at night.
提前2小时（120 分钟）(-120)
推迟3小时（180分钟）(180)
2）相比前一天，你会选择在早晨 ________起床。

Compared with the day before, you want to get up ________ in the morning.
提前2小时（120分钟）(-120)
推迟3小时（180分钟）(180)
光敏感性调查问卷
Light Sensitivity Survey
指导语：请回想并根据您的经历来回答以下问题。
Instructions: Please recall and answer the following questions according to your experience.
1. 通常来讲，您能否在开灯的环境中入睡？
2. 为了尽快入睡，您需要在睡前多少分钟关灯并放下手机？
0分钟(0)
60分钟(60)
3. 夜间起夜接受灯光照射后，您需要多长时间才能继续入睡？
0分钟(0)
60分钟(60)
4. 清晨起床后，您是否会拉开窗帘主动接受阳光照射？
5. 相比于晴朗的天气，你是否会在阴天感到困倦或情绪低落？
6. 你是否经历过光干预或光治疗？
7. 您在光干预或光治疗后感受到的效果如何？
清晨型和夜晚型问卷自评量表
MORNINGNESS-EVENINGNESS QUESTIONNAIRE
Self-Assessment Version (MEQ-SA)
指导语：在每项问题中，请选出最能形容你在过去几星期的感受的句子。
Instructions: For each question, please select the answer that best describes you by circling the answer that best indicates how you have felt in recent weeks.
1. 如果你能够完全自由地计划白天的时间，你希望大约在什么时间起床？

Approximately when would you get up if you were entirely free to plan your day?
2. 如果你能够完全自由地计划夜晚的时间，你希望大约在什么时间去睡觉？

Approximately what time would you go to bed if you were entirely free to plan your evening?
3. 如果你要在早上的某个时刻起床，你会有多么依赖闹钟来唤醒你？

If you usually have to get up at a specific time in the morning, how much do you depend on an alarm clock?
4. 在早上时, 你有多容易起床？（当你没有被突如其来的事唤醒）

How easy do you find it to get up in the morning when you are not awakened unexpectedly?
5. 早上起床后的半小时内，你有多精神？

How alert do you feel during the first half hour after you wake up in the morning?
6. 在起床后的半小时内，你感到有多肚饿？

How hungry do you feel during the first half hour after you wake up?
7. 清晨起床后的半小时内，你的感觉如何？

During the first half hour after you wake up in the morning, how do you feel?
8. 如果在第二天你没有任何约会，相比你平时习惯的时间，你会选择什么时间去睡觉？

If you had no commitments the next day, what time would you go to bed compared to your usual bedtime?
9. 假设你决定要开始做运动，你的朋友建议你应一周进行两次一小时的运动，而且在早上7-8点 (07-08 h) 为最佳时间，请谨记你只需考虑自己的生理时钟，你认为你会表现得怎么样？

You have decided to exercise. A friend suggests that you do this for one hour, twice a week, between 7-8 AM (07-08 h). Bearing in mind nothing but your own internal “clock,” how do you think you would perform?
10. 在夜晚你大约到什么时候你会感到疲倦，而且需要睡觉？

Approximately when would you go to bed if you could sleep when you felt like it?
11. 假设你希望在一项会令你精神疲累而且需持续两个小时的测试中取得最佳表现时，如果你能完全自由地计划你的时间，仅需考虑你自己的生理时钟，你会选择以下哪段考试时间？

You want to be at your peak performance for a test that you know is going to be mentally exhausting and will last two hours. You are entirely free to plan your day. Considering only your “internal clock,” which one of the four testing times would

you choose?
12．如果你要在晚上11点（23:00 h）去睡觉，你会有多疲倦？

If you went to bed at 11 PM (23 h), how tired would you be?
13. 假设因为某些原因，你比平时迟几个小时去睡觉，但又不需在第二天早上的特定时间起床，你最可能出现以下哪种情况？

For some reason you have gone to bed several hours later than usual, but there is no need to get up at any particular time the next morning. Which one of the following are you most likely to do?
14. 假设因为你要当夜更，而你要在清晨4-6点（04:00-06:00 h）时候需要保持清醒，而第二天你没有任何约会。以下哪种情况最适合你？

One night you have to remain awake between 4-6 AM (04-06 h) to carry out a night watch. You have no time commitments the next day. Which one of these alternatives would suit you best?
15. 假设你需要进行一项两小时的艰巨体力工作 你可以完全自由地计划时间，仅需考虑你自己的生理时钟，你会选择以下哪个时段？

You have two hours of hard physical work. You are entirely free to plan your day. Considering only your internal “clock,” which of the following times would you choose?
16. 假设你决定要开始做运动，你的朋友建议你应一周进行两次一小时的运动，而且在晚上10-11点（22:00-23:00 h）为最佳时间。请谨记你只需考虑自己的生理时钟，你认为你会有怎么样的表现？

You have decided to exercise. A friend suggests that you do this for one hour twice a week between 10-11 PM (22-23 h). Bearing in mind only your internal “clock,” how well do you think you would perform?
17. 假设你可以选择自己的工作时间，你每天只需工作5个小时（包括休息时间），而这项工作是很有趣的，酬金会依据你的工作表现，你会选择以下哪个时段呢？

Suppose that you can choose your own work hours. Assume that you work a fivehour day (including breaks), your job is interesting, and you are paid based on your performance. At approximately what time would you choose to begin?

18. 一天之中以下哪个时段是你的最佳时间？

At approximately what time of day do you usually feel your best?
19. 人可分为“清晨”型和“夜晚”型，你认为你自己属于哪一类型？

Are you a “morning type” or an “evening type”?
匹兹堡睡眠质量指数量表
Pittsburgh Sleep Quality Index (PSQI)
指导语：下面一些问题是关于您最近1个月的睡眠状况，请选择或填写与您近1个月实际情况的最符合的答案。请回答下列问题：
Instructions: The following questions relate to your usual sleep habits during the past month only. Your answers should indicate the most accurate reply for the majority of days and nights in the past month. Please answer all questions.
65. 1. 近1个月，晚上上床睡觉通常是：

    During the past month, when have you usually gone to bed at night?    USUAL BED TIME:

    _________ ：_________
66. 2. 近1个月，从上床到入睡通常需要: 

    During the past month, how long (in minutes) has it usually take you to fall asleep each night?  NUMBER OF MINUTES: 

    ________ 分钟 min.
67. 3. 近1个月，早上起床时间通常是：

    During the past month, when have you usually gotten up in the morning?  USUAL GETTING UP TIME:

    ________ ：_________
68. 4. 近1个月，每夜实际睡眠时间通常是（不等于卧床时间)：

    During the past month, how many hours of actual sleep did you get at night? (This may be different than the number of hours you spend in bed)  HOURS OF SLEEP PER NIGHT：

    _________ 小时 h
5. 近一个月，您有没有因下列情况而影响睡眠，请从①②③④四项中选一项：

For each of the remaining questions, check the one best response. Please answer all questions.

During the past month, how often have you had trouble sleeping because you...
  • ①无 Not during the past month
  • ②不足1次／周 Less than once a week
  • ③1-2次／周 Once or twice a week
  • ④3次或以上／周 Three or more times a week
a. 入睡困难（30分钟内不能入睡）Cannot get to sleep within 30 minutes
b. 夜间易醒或早醒 Wake up in the middle of the night or early morning
c. 夜间去厕所 Have to get up to use the bathroom
d. 呼吸不畅 Cannot breathe comfortably
e. 大声咳嗽或鼾声高 Cough or snore loudly
f. 感觉冷 Feel too cold
g. 感觉热 Feel too hot
h. 做噩梦 Had bad dreams
i. 疼痛不适 Have pain
j.其他影响睡眠的事情（请写明） Other reason(s), please describe
上一题（题5）中 j 选项需要写明的情况：

Other reason(s), please describe:
6. 近1个月您的睡眠质量

During the past month, how would you rate your sleep quality overall?
7. 近1个月您是否经常使用催眠药物才能入睡

During the past month, how often have you taken medicine (prescribed or “over the counter”) to help you sleep?
8. 近1个月您是否常感到困倦

During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity?
9. 近1个月您做事的是否精力不足

During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done?
身体活动问卷
Physical Activity Questionnaire
指导语：下面一些问题是关于您最近7天的运动状况，请选择或填写与您近1周内实际情况的最符合的答案。请回答下列问题：
Instructions: The following questions relate to your usual exercise habits during the past week only. Your answers should indicate the most accurate reply for the majority of days and nights in the past week. Please answer all questions.
1. 最近7天内，您有几天做了剧烈的体育活动，像是提重物、挖掘、有氧运动或是快速骑车？
2. 在这其中一天您通常会花多少时间在剧烈的体育活动上？
3. 最近7天内，您有几天做了适度的体育活动，像是提轻的物品、以平常的速度骑车或打双人网球？请不要包括走路。
4. 在这其中一天您通常会花多少时间在适度的体育活动上？
5. 最近7天内，您有几天是步行，且一次步行至少10分钟？
6. 在这其中一天您通常花多少时间在步行上？
7. 最近7天内，工作日您有多久时间是坐着的？
高原习服症状调查
High Altitude Acclimatization Symptom Survey
请您根据在高原上当日的感觉填写。
Please answer the following questions based on how you feel on the day of your stay at high altitude.
第一部分：每日症状报告
Part I: Daily Symptom Report
1. 您今日是否吸氧
2. 您今日吸氧的次数为
3. 您今日累计吸氧时长约为：
4. 您今日是否使用了呼吸机
5. 您今日使用呼吸机的时间段为？
6. 您今日累计使用呼吸机的时长约为：
7. 您今日是否服用药物？
8. 您今日服用过的药物是
9. 您服用的西药名称是？
10. 您服用西药的剂量是？
11. 您服用的中药主要成分是？
12. 您服用的中药的剂量是？
13. 您觉得自己是否感冒了？
14. 您感冒是否有以下症状？
15. 上高原后，您是否有受伤？
16. 上高原后，身体是否有水肿？
17. 上高原后，是否有视觉上的异常？
18. 上高原后，其他不寻常的症状为
第二部分：路易斯湖问卷（LLS）
Part II: Lake Louise Acute Mountain Sickness Score (LLS)
1. 您出现头痛的情况为?
2. 如果有，头痛的具体部位是？
3. 如果有，过去一天内，头痛的发作次数为：
4. 您是否有食欲不振/恶心/反胃的感觉?
5. 您是否出现腹泻？
6. 您是否感到疲劳、虚弱或四肢无力?
7. 过去的一天，您是否感到头晕或头昏?
8. 入睡时间比上山前有延迟吗？
9. 昨晚睡着后醒来的次数？
10. 比自己预想的时间早醒？
11. 您昨晚总体睡眠时间充足吗？
12. 您对自己昨晚的睡眠质量满意吗？
13. 您今天白天的情绪怎么样？
14. 白天身体功能(体力和精神，如记忆力、认识和注意力等)怎么样？
15. 白天有犯困、想睡觉吗？
16. 综合来看，这些症状对您生活状态影响的严重程度为？
第三部分：心脏状态调查表
Part III: Cardiac Symptom Questionnaire
1. 今天是否出现心慌、气短的现象？
2. 今天是否过出现头晕、头疼、眼前发黑，甚至突然间晕倒等？
3. 今天是否有感到心悸、胸闷、感到心脏偶有“停跳”（心律不齐），运动或激动时有明显的不适感？
4. 今天是否出现颈部，下颌，喉咙，上腹部或背部疼痛？
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