(View in Courier New, 10 pt.)

     1997 Behavioral Risk Factor Surveillance System Questionnaire
                           Optional Modules

Module 1:  Diabetes

1.  How old were you when you were told you have diabetes?  (149-150)

            Code age in years  [76=76 and older]            __ __     

            Don't know/Not sure                             7  7

            Refused                                         9  9

2.  Are you now taking insulin?                             (151)

        a.  Yes                                             1

        b.  No  Go to Q. 4                                  2

            Refused  Go to Q. 4                             9

3.  Currently, about how often do you use insulin?          (152-154)

        a.  Times per day                                   1  __ __     

        b.  Times per week                                  2  __ __    

        c.  Use insulin pump                                3  3  3

            Don't know/Not sure                             7  7  7

            Refused                                         9  9  9   

4.  About how often do you check your blood for glucose or sugar? 
    Include times when checked by a family member or friend, but do
    not include times when checked by a health professional.
                                                            (155-157)

        a.  Times per day                                   1  __ __    

        b.  Times per week                                  2  __ __    

        c.  Times per month                                 3  __ __    

        d.  Times per year                                  4  __ __    

        e.  Never                                           8  8  8

            Don't know/Not sure                             7  7  7

            Refused                                         9  9  9
            
            
5.  Have you ever heard of glycosylated hemoglobin [gli-KOS-ilated HE-mo-glo-bin] or
hemoglobin "A one C"?    (158)

        a.  Yes                                             1

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9

6.  About how many times in the last year have you seen a doctor,
    nurse, or other health professional for your diabetes?  (159-160)

        a.  Number of times                                 __ __     

        b.  None  Go to Q. 9                                8  8

            Don't know/Not sure  Go to Q. 9                 7  7

            Refused  Go to Q. 9                             9  9

    If "No," "Dk/Ns," or "Refused" to Q. 5, go to Q. 8.

7.  About how many times in the last year has a doctor, nurse, or
    other health professional checked you for glycosylated hemoglobin
    or hemoglobin "A one C"?                                (161-162)

        a.  Number of times                                 __ __     

        b.  None                                            8 8

            Don't know/Not sure                             7 7

            Refused                                         9 9

8.  About how many times in the last year has a health professional
    checked your feet for any sores or irritations?         (163-164)

        a.  Number of times                                 __ __     

        b.  None                                            8 8

            Don't know/Not sure                             7 7

            Refused                                         9 9
            
            
9.  When was the last time you had an eye exam in which the pupils
    were dilated?  This would have made you temporarily sensitive to
    bright light.                                           (165)

            Read Only if Necessary

        a.  Within the past month (0 to 1 month ago)        1

        b.  Within the past year (1 to 12 months ago)       2

        c.  Within the past 2 years (1 to 2 years ago)      3

        d.  2 or more years ago                             4

        e.  Never                                           8

            Don't know/Not sure                             7

            Refused                                         9

I would now like to ask you three questions about how well you see
with your glasses or contacts on if you use them.

10. How much of the time does your vision limit you in recognizing
    people or objects across the street?                    (166)

    Would you say:  Please Read

        a.  All of the time                                 1

        b.  Most of the time                                2

        c.  Some of the time                                3

        d.  A little bit of the time                        4
            or
        e.  None of the time                                5

Do not      Don't know/Not sure                             7
read these
responses   Refused                                         9

11. How much of the time does your vision limit you in reading print 
    in a newspaper, magazine, recipe, menu, or numbers on the
    telephone?                                              (167)

    Would you say:  Please Read

        a.  All of the time                                 1

        b.  Most of the time                                2

        c.  Some of the time                                3

        d.  A little bit of the time                        4
            or
        e.  None of the time                                5

Do not      Don't know/Not sure                             7
read these
responses   Refused                                         9

12. How much of the time does your vision limit you in watching
    television?                                             (168)

    Would you say:  Please Read

        a.  All of the time                                 1

        b.  Most of the time                                2

        c.  Some of the time                                3

        d.  A little bit of the time                        4
            or
        e.  None of the time                                5

Do not      Don't know/Not sure                             7
read these
responses   Refused                                         9

Module 2: Sexual Behavior

If respondent 50 years old or older, go to next module

1.  During the past twelve months, with how many people have you had
    sexual intercourse?                                     (169-170)

        a.  Number                                          __ __     

        b.  None Go to Next Module                          8  8

            Don't know/Not sure                             7  7

            Refused                                         9  9

2.  Was a condom used the last time you had sexual intercourse?
                                                            (171)

        a.  Yes                                             1

        b.  No Go to Q. 4                                   2

            Don't know/Not sure  Go to Q. 4                 7

            Refused  Go to Q. 4                             9

3.  The last time you had sexual intercourse, was the condom used ...  
                                                            (172)
            Please Read

        a.  To prevent pregnancy                            1

        b.  To prevent diseases like syphilis, gonorrhea,
            and AIDS                                        2

        c.  For both of these reasons                       3
            or
        d.  For some other reason                           4

Do not      Don't know/Not sure                             7    
read these
responses   Refused                                         9

4.  Some people use condoms to keep from getting infected with HIV
    through sexual activity.  How effective do you think a properly
    used condom is for this purpose?                        (173)

    Would you say:  Please Read

        a.  Very effective                                  1

        b.  Somewhat effective                              2
            or
        c.  Not at all effective                            3

            Don't know how effective                        4
Do not
read these  Don't know method                               5
responses
            Refused                                         9

5.  How many new sex partners did you have during the past twelve
    months?                                                 (174-175)
A new sex
partner is  a. Number [76 = 76 or more]                     __ __
someone
the respon- b. None                                         8  8
dent had sex
with for the   Don't know/Not sure                          7  7
first time in
the past 12    Refused                                      9  9
months

6.  I'm going to read you a list.  When I'm done, please tell me if
    any of the situations apply to you.  You Don't need to tell me
    which one.

    You have used intravenous drugs in the past year

    You have been treated for a sexually transmitted or venereal
    disease in the past year

    You tested positive for having HIV, the virus that causes AIDS

    You had anal sex without a condom in the past year

    Do any of these situations apply to you?                (176) 

        a.  Yes                                             1

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9

7.  In the past five years, have you been treated for a sexually
    transmitted or venereal disease?                        (177)

        a.  Yes                                             1

        b.  No Go to Next Module                            2

            Don't know/Not sure Go to Next Module           7

            Refused Go to Next Module                       9

8.  Were you treated at a health department STD clinic?     (178)

    
        a.  Yes                                             1

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9
            
            
Module 3: Health Care Coverage

    If "Dk/Ns" or "Refused" to core Q. 5, go to next module.

I asked you previously about your health care coverage.

    If "None" to core Q. 7a or core Q. 7b, continue.  Otherwise, go to
    Q. 2.

1.  What is the main reason you are without health care coverage? 
                                                            (179-180)

            Reason Code                                    __ __      

        a.  Lost job or changed employers
            Go to Next Module                               0 1

        b.  Spouse or parent lost job or changed employers
            [includes any person who had been providing
            insurance prior to job loss or change]
            Go to Next Module                               0 2

        c.  Became divorced or separated  Go to Next
            Module                                          0 3

        d.  Spouse or parent died  Go to Next Module        0 4

        e.  Became ineligible because of age or because
            left school  Go to Next Module                  0 5

        f.  Employer doesn't offer or stopped offering
            coverage  Go to Next Module                     0 6

        g.  Cut back to part time or became temporary
            employee  Go to Next Module                     0 7

        h.  Benefits from employer or former employer ran
            out  Go to Next Module                          0 8

        i.  Couldn't afford to pay the premiums
            Go to Next Module                               0 9

        j.  Insurance company refused coverage
            Go to Next Module                               1 0

        k.  Lost Medicaid or Medical Assistance eligibility
            Go to Next Module                               1 1  
    
        l.  Other  Go to Next Module                        8 7

            Don't know/Not sure  Go to Next Module          7 7

            Refused  Go to Next Module                      9 9
            
            
2.  Other than [fill in type (Medicare/Medicaid/the health coverage
    which pays for most of your medical care) from core Q. 6, Q. 7a,
    or Q. 7b], do you have any other type of health care coverage?
                                                            (181)
Do not
include     a.  Yes                                         1
plans that
only cover  b.  No                                          2
one type of
service or      Don't know/Not sure                         7
care
                Refused                                     9

If respondent 66 years old or older, go to next module.

3.  During the past 12 months, was there any time that you did not
    have any health insurance or coverage?                  (182)

        a.  Yes                                             1

        b.  No   Go to Next Module                          2

            Don't know/Not sure   Go to Next Module         7

            Refused  Go to Next Module                      9
            
            
4.  What was the main reason you were without health care coverage? 
                                                            (183-184)

            Reason Code                                     __ __     

        a.  Lost job or changed employers                   0 1

        b.  Spouse or parent lost job or changed employers
            [includes any person who had been providing
            insurance prior to job loss or change]          0 2

        c.  Became divorced or separated                    0 3

        d.  Spouse or parent died                           0 4

        e.  Became ineligible because of age or because
            left school                                     0 5

        f.  Employer doesn't offer or stopped offering
            coverage                                        0 6

        g.  Cut back to part time or became temporary
            employee                                        0 7

        h.  Benefits from employer or former employer ran
            out                                             0 8

        i.  Couldn't afford to pay the premiums             0 9

        j.  Insurance company refused coverage              1 0

        k.  Lost Medicaid or Medical Assistance eligibility 1 1
    
        l.  Other                                           8 7

            Don't know/Not sure                             7 7

            Refused                                         9 9
            
            
Module 4: Health Care Utilization

Now I am going to ask you some questions about the health care you
receive.

1.  How would you rate your satisfaction with your overall health
    care?                                                   (185)
    
    Would you say: Please Read
    
        a.  Excellent                                       1

        b.  Very Good                                       2

        c.  Good                                            3

        d.  Fair                                            4
            or
        e.  Poor                                            5

Do not      Not applicable/don't use any health services    8
read these
responses   Don't know/Not sure                             7  

            Refused                                         9

2.  Is there one particular clinic, health center, doctor's office, or
    other place that you usually go to if you are sick or need advice
    about your health?                                      (186)

        a.  Yes  Go to Q. 5                                 1

        b.  More than one place  Go to Q. 4                 2

        c.  No                                              3

            Don't know/Not sure  Go to Next Module          7

            Refused  Go to Next Module                      9
            
            
3.  What is the main reason you do not have a usual source of medical
    care?                                                   (187-188)

            Reason Code                                     __ __     

        a.  Two or more usual places                        0 1

        b.  Have not needed a doctor Go to Next Module      0 2

        c.  Do not like/trust/believe in doctors
            Go to Next Module                               0 3

        d.  Do not know where to go  Go to Next Module      0 4

        e.  Previous doctor is not available/moved
            Go to Next Module                               0 5

        f.  No insurance/cannot afford Go to Next Module    0 6

        g.  Speak a different language Go to Next Module    0 7

        h.  No place is available/close enough/convenient
            Go to Next Module                               0 8

        i.  Other Go to Next Module                         0 9

            Don't know/Not sure Go to Next Module           7 7

            Refused Go to Next Module                       9 9

4.  Is there one of these places that you go to most often when you
    are sick or need advice about your health?              (189)

        a.  Yes                                             1

        b.  No  Go to Next Module                           2

            Don't know/Not sure  Go to Next Module          7

            Refused  Go to Next Module                      9
            
            
5.  What kind of place is it -- a clinic, a health center, a hospital,
    a doctor's office, or some other place?                 (190-191)

            Facility Code                                   __ __     

        a.  Doctor's office or private clinic               0 1

        b.  Company or school health clinic/center          0 2

        c.  Community/migrant/rural clinic/center           0 3

        d.  County/city/public hospital outpatient clinic   0 4

        e.  Private/other hospital outpatient clinic        0 5

        f.  Hospital emergency room                         0 6

        g.  HMO/prepaid group                               0 7

        h.  Psychiatric hospital or clinic                  0 8

        i.  VA hospital or clinic                           0 9

        j.  Military health care facility                   1 0

        k.  Some other kind of place                        1 1

            Don't know/Not sure                             7 7

            Refused                                         9 9

6.  Thinking of the distance or time you travel to get to the place
    you usually go to, how would you rate the convenience of that
    place?                                                  (192)

    Would you say: Please Read

        a.  Excellent                                       1

        b.  Very Good                                       2

        c.  Good                                            3

        d.  Fair                                            4
            or
        e.  Poor                                            5
    
Do not      Don't have usual place                          6
read these
responses   Don't know/Not sure                             7  

            Refused                                         9
            
            
7.  Is there one particular doctor or health professional who you
    usually go to when you need routine medical care?       (193)

If "no," ask    a.  Yes, only one                           1
"Is there more
than one or is  b.  More than one  Go to Next Module        2
there no usual
doctor who you  c.  No  Go to Next Module                   3
go to?"                                                          
                    Don't know/Not sure  Go to Next Module  7

                    Refused  Go to Next Module              9

8.  When did you last change doctors?                       (194)

                Read only if necessary
    
"Doctors"   a.  Within the past year (1 to 12 months ago)   1
includes
other       b.  Within the past 2 years (1 to 2 years ago)  2
health
profes-     c.  Within the past 3 years (2 to 3 years ago)  3
sionals
            d.  Within the past 5 years (3 to 5 years ago)  4

            e.  5 or more years ago                         5

            f.  Never  Go to Next Module                    8

                Don't know/Not sure  Go to Next Module      7

                Refused  Go to Next Module                  9
            
            
9.  Why did you change doctors that last time?              (195-196)

                Reason Code                                 __ __     
    
"Doctors"   a.  Changed residence or moved                  0 1
includes
other       b.  Changed jobs                                0 2
health
profes-     c.  Changed health care coverage                0 3
sionals
            d.  Provider moved or retired                   0 4

            e.  Dissatisfied with former provider
                or liked new provider better                0 5

            f.  Former provider no longer reimbursed
                by my health care coverage                  0 6

            g.  Owed money to former provider               0 7

            h.  Medical care needs changed                  0 8

            i.  Other                                       8 7

                Don't know/Not sure                         7 7

                Refused                                     9 9
                
                
Module 5:  Oral Health

1.  How long has it been since you last visited the dentist or a
    dental clinic?                                          (197)

            Read Only if Necessary

        a.  Within the past year (1 to 12 months ago)
            Go to Q. 3                                      1

        b.  Within the past 2 years (1 to 2 years ago)      2

        c.  Within the past 5 years (2 to 5 years ago)      3

        d.  5 or more years ago                             4

            Don't know/Not sure  Go to Q. 3                 7

            Never                                           8

            Refused  Go to Q. 3                             9

2.  What is the main reason you have not visited the dentist in the
    last year?                                              (198-199)

            Reason code                                     __ __     

            Read only if necessary

        a.  Fear, apprehension, nervousness, pain,
            dislike going                                   0 1

        b.  Cost                                            0 2

        c.  Do not have/know a dentist                      0 3

        d.  Cannot get to the office/clinic (too far away,
            no transportation, no appointments available)   0 4

        e.  No reason to go (no problems, no teeth)         0 5

        f.  Other priorities                                0 6

        g.  Have not thought of it                          0 7

        h.  Other                                           0 8

            Don't know/Not sure                             7 7

            Refused                                         9 9
            
            
3.  How many of your permanent teeth have been removed because of
    tooth decay or gum disease?  Do not include teeth lost for other
    reasons, such as injury or orthodontics.                (200)

        a.  5 or fewer                                      1

        b.  6 or more but not all                           2

        c.  All                                             3

        d.  None                                            8

            Don't know/Not sure                             7

            Refused                                         9

4.  Do you have any kind of insurance coverage that pays for some or
    all of your routine dental care, including dental insurance,
    prepaid plans such as HMOs, or government plans such as Medicaid?                
                                                            (201) 

        a.  Yes                                             1

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9
            
            
Module 6: Preventive Counseling Services

The next questions are about counseling services related to prevention
that you might have received from a doctor, nurse, or other health
professional.

1.  Has a doctor or other health professional ever talked with you
    about your diet or eating habits?                       (202)
    
If yes,     a.  Yes, within the past 12 months 
ask "About      (1 to 12 months ago)                            1
how long
ago was     b.  Yes, within the past 3 years (1 to 3 years ago) 2
it?" 
            c.  Yes, 3 or more years ago                        3

            d.  No                                              4

                Don't know/Not sure                             7

                Refused                                         9

2.  Has a doctor or other health professional ever talked with you
    about physical activity or exercise?                    (203)
    
If yes,     a.  Yes, within the past 12 months 
ask "About      (1 to 12 months ago)                            1
how long
ago was     b.  Yes, within the past 3 years (1 to 3 years ago) 2
it?" 
            c.  Yes, 3 or more years ago                        3

            d.  No                                              4

                Don't know/Not sure                             7

                Refused                                         9

3.  (Has a doctor or other health professional ever talked with you)
    about injury prevention, such as safety belt use, helmet use, or
    smoke detectors?                                        (204)
        
If yes,     a.  Yes, within the past 12 months 
ask "About      (1 to 12 months ago)                            1
how long
ago was     b.  Yes, within the past 3 years (1 to 3 years ago) 2
it?" 
            c.  Yes, 3 or more years ago                        3

            d.  No                                              4

                Don't know/Not sure                             7

                Refused                                         9

4.  (Has a doctor or other health professional ever talked with you)
    about drug abuse?                                       (205)
    
If yes,     a.  Yes, within the past 12 months 
ask "About      (1 to 12 months ago)                            1
how long
ago was     b.  Yes, within the past 3 years (1 to 3 years ago) 2
it?" 
            c.  Yes, 3 or more years ago                        3

            d.  No                                              4

                Don't know/Not sure                             7

                Refused                                         9
    

5.  (Has a doctor or other health professional ever talked with you)
    about alcohol use?                                      (206)
    
If yes,     a.  Yes, within the past 12 months 
ask "About      (1 to 12 months ago)                            1
how long
ago was     b.  Yes, within the past 3 years (1 to 3 years ago) 2
it?" 
            c.  Yes, 3 or more years ago                        3

            d.  No                                              4

                Don't know/Not sure                             7

                Refused                                         9

If "No" to core Q. 26 or "Not at all" to core Q. 27, go to Q. 7

6.  (Has a doctor or other health professional) ever advised you to
    quit smoking?                                           (207) 
    
If yes,     a.  Yes, within the past 12 months 
ask "About      (1 to 12 months ago)                            1
how long
ago was     b.  Yes, within the past 3 years (1 to 3 years ago) 2
it?" 
            c.  Yes, 3 or more years ago                        3

            d.  No                                              4

                Don't know/Not sure                             7

                Refused                                         9
            
            
If respondent 65 years old or older, go to next module

7.  (Has a doctor or other health professional) ever talked with you
    about your sexual practices, including family planning, sexually
    transmitted diseases, AIDS, or the use of condoms?      (208)

    
If yes,     a.  Yes, within the past 12 months 
ask "About      (1 to 12 months ago)                            1
how long
ago was     b.  Yes, within the past 3 years (1 to 3 years ago) 2
it?" 
            c.  Yes, 3 or more years ago                        3

            d.  No                                              4

                Don't know/Not sure                             7

                Refused                                         9
            

Module 7: Cardiovascular Disease

1.  To lower your risk of developing heart disease or stroke, has a
    doctor advised you to...

            Please Read                       Yes    No   Dk/Ns   Ref    
                                             
    a.  Eat fewer high fat
        or high cholesterol foods              1      2      7     9    (209)

    b.  Exercise more                          1      2      7     9    (210)

2.  To lower your risk of developing heart disease or stroke, are you?

            Please Read                       Yes    No   Dk/Ns   Ref
                                             
    a.  Eating fewer high fat
        or high cholesterol foods?             1      2     7      9    (211)

    b.  Exercising more?                       1      2     7      9    (212)

3.  Has a doctor ever told you that you had any of the following?

            Please Read                       Yes    No   Dk/Ns   Ref

    a.  Heart attack or myocardial
        infarction                             1      2     7      9    (213)

    b.  Angina or coronary heart disease       1      2     7      9    (214)
 
    c.  Stroke                                 1      2     7      9    (215)

If respondent 35 years old or older continue with Q. 4.  Otherwise, go
to next module.

4.  Do you take aspirin daily or every other day?           (216)

        a.  Yes  Go to Q. 6                                 1

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9
            
            
5.  Do you have a health problem or condition that makes taking
    aspirin unsafe for you?                                 (217)

If yes, ask a.  Yes, not stomach related  Go to Q. 7        1
"Is this a
stomach     b.  Yes, stomach problems  Go to Q. 7           2
condition?"
Code upset  c.  No  Go to Q. 7                              3
stomachs as
stomach         Don't know/Not sure  Go to Q. 7             7
problems
                Refused  Go to Q. 7                         9

6.  Why do you take aspirin?

            Please Read                       Yes    No   Dk/Ns   Ref    

    a.  To relieve pain                        1      2     7      9    (218)

    b.  To reduce the chance of a
        heart attack                           1      2     7      9    (219)

    c.  To reduce the chance of a stroke       1      2     7      9    (220)

If respondent is male or is female and pregnant, go to next module.

The next few questions are about menopause, or what some women refer
to as the "change of life."

If "yes" to core Q. 59 or if respondent is age 65 or older, go to Q.
8. 

7.  Have you gone through or are you now going through menopause?
                                                            (221)

Probe   a.  Yes, have gone through menopause                1
for
which   b.  Yes, now going through menopause                2

        c.  No Go to Next Module                            3

            Don't know/Not sure  Go to Next Module          7

            Refused  Go to Next Module                      9
            
            
8.  Estrogens such as Premarin and progestins such as Provera are
    female hormones that may be prescribed around the time of
    menopause, after menopause, or after a hysterectomy.  Has your
    doctor discussed the benefits and risks of estrogen with you?
                                                            (222)

        a.  Yes                                             1

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9

9.  Other than birth control pills, has your doctor ever prescribed
    estrogen pills for you?                                 (223)

Do not   a.  Yes                                            1
include
estrogen b.  No  Go to Next Module                          2
patches
            Don't know/Not sure Go to Next Module           7

            Refused  Go to Next Module                      9

10. Are you currently taking estrogen pills?                (224)

Do not   a.  Yes                                            1
include
estrogen b.  No                                             2
patches
             Don't know/Not sure Go to Next Module          7

             Refused Go to Next Module                      9
             
             
11. Why...

        are you taking...[if "Yes" to Q. 10]

        did you take...[if "No" to Q. 10]

        ...estrogen pills?

                                                           Never
                    Please Read            Yes  No  Dk/Ns  took   Ref

    a.  To prevent a heart attack           1    2    7      8     9    (225)

    b.  To treat or prevent bone
        thinning, bone loss,
        or osteoporosis                     1    2    7      8     9    (226)

    c.  To treat symptoms of menopause
        such as hot flashes                 1    2    7      8     9    (227)
        
        
Module 8: Arthritis

1.  During the past 12 months, have you had pain, aching, stiffness or
    swelling in or around a joint?                          (228)

        a.  Yes                                             1
 
        b.  No  Go to Q. 4                                  2

            Don't know/Not sure  Go to Q. 4                 7

            Refused  Go to Q. 4                             9

 
2.  Were these symptoms present on most days for at least one month?
                                                            (229)

        a.  Yes                                             1
 
        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9

    
3.  Are you now limited in any way in any activities because of joint
    symptoms?                                               (230)

        a.  Yes                                             1
 
        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9

4.  Have you ever been told by a doctor that you have arthritis?
                                                            (231)

        a.  Yes                                             1
 
        b.  No   Go to Next Module                          2

            Don't know/Not sure  Go to Next Module          7

            Refused    Go to Next Module                    9

5.  What type of arthritis did the doctor say you have?     (232-233)

            Type Code                                       __ __     
    
            Read Only if Necessary

        a.  Osteoarthritis/degenerative arthritis           0 1

        b.  Rheumatism                                      0 2
    
        c.  Rheumatoid Arthritis                            0 3

        d.  Lyme disease                                    0 4

        e.  Other(specify)                                  0 7

        f.  Never saw a doctor                              8 8

            Don't know/Not sure                             7 7
        
            Refused                                         9 9

6.  Are you currently being treated by a doctor for arthritis?
                                                            (234)

        a.  Yes                                             1
 
        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9
            
            
Module 9: Quality of Life

    These next questions are about limitations you may have in your
    daily life.

1.  Are you limited in any way in any activities because of any
    impairment or health problem?                           (235)     

        a.  Yes                                             1
    
        b.  No  Go to Q. 6                                  2

            Don't know/Not sure  Go to Q. 6                 7

            Refused  Go to Q. 6                             9

2.  What is the major impairment or health problem that limits your
    activities?                                             (236-237)

            Reason Code                                     __ __     

        a.  Arthritis/rheumatism                            0 1

        b.  Back or neck problem                            0 2

        c.  Fractures, bone/joint injury                    0 3

        d.  Walking problem                                 0 4

        e.  Lung/breathing problem                          0 5

        f.  Hearing problem                                 0 6

        g.  Eye/vision problem                              0 7

        h.  Heart problem                                   0 8

        i.  Stroke problem                                  0 9

        j.  Hypertension/high blood pressure                1 0

        k.  Diabetes                                        1 1

        l.  Cancer                                          1 2

        m.  Depression/anxiety/emotional problem            1 3

        n.  Other impairment/problem                        1 4

            Don't know/Not sure                             7 7

            Refused                                         9 9
            
            
3.  For how long have your activities been limited because of your
    major impairment or health problem?                     (238-240)

        a.  Days                                            1  __ __    

        b.  Weeks                                           2  __ __    

        c.  Months                                          3  __ __    

        d.  Years                                           4  __ __    

            Don't know/Not Sure                             7  7  7

            Refused                                         9  9  9

4.  Because of any impairment or health problem, do you need the help
    of other persons with your PERSONAL CARE needs, such as eating,
    bathing, dressing, or getting around the house?         (241)     

        a.  Yes                                             1    

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9

5.  Because of any impairment or health problem, do you need the help
    of other persons in handling your ROUTINE needs, such as everyday
    household chores, doing necessary business, shopping, or getting
    around for other purposes?                              (242)

        a.  Yes                                             1    

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9
            
            
6.  During the past 30 days, for about how many days did pain make it
    hard for you to do your usual activities, such as self-care, work,
    or recreation?                                          (243-244)

        a.  Number of days                                  __ __     

        b.  None                                            8  8

            Don't know/Not sure                             7  7

            Refused                                         9  9

7.  During the past 30 days, for about how many days have you felt
    sad, blue, or depressed?                                (245-246)

        a.  Number of days                                  __ __          
        
        b.  None                                            8  8

            Don't know/Not sure                             7  7

            Refused                                         9  9

8.  During the past 30 days, for about how many days have you felt
    worried, tense, or anxious?                             (247-248)      
    
        a.  Number of days                                  __ __          
        
        b.  None                                            8  8

            Don't know/Not sure                             7  7

            Refused                                         9  9

9.  During the past 30 days, for about how many days have you felt you
    did not get enough rest or sleep?                       (249-250)

        a.  Number of days                                  __ __          

        b.  None                                            8  8

            Don't know/Not sure                             7  7

            Refused                                         9  9
            

10. During the past 30 days, for about how many days have you felt
    very healthy and full of energy?                        (251-252) 

        a.  Number of days                                  __ __          
        
        b.  None                                            8  8

            Don't know/Not sure                             7  7

            Refused                                         9  9
            

Module 10:  Fruits and Vegetables

These next questions are about the foods you usually eat or drink. 
Please tell me how often you eat or drink each one, for example, twice
a week, three times a month, and so forth.  Remember, I am only
interested in the foods you eat.  Include all foods you eat, both at
home and away from home.

1.  How often do you drink fruit juices such as orange, grapefruit, or
    tomato?                                                 (253-255)

        a.  Per day                                         1  __ __      

        b.  Per week                                        2  __ __      

        c.  Per month                                       3  __ __      
 
        d.  Per year                                        4  __ __      

        e.  Never                                           5  5  5

            Don't know/Not sure                             7  7  7

            Refused                                         9  9  9

2.  Not counting juice, how often do you eat fruit?         (256-258)

        a.  Per day                                         1  __ __      

        b.  Per week                                        2  __ __      

        c.  Per month                                       3  __ __      
 
        d.  Per year                                        4  __ __      

        e.  Never                                           5  5  5

            Don't know/Not sure                             7  7  7

            Refused                                         9  9  9

3.  How often do you eat green salad?                       (259-261)

        a.  Per day                                         1  __ __      

        b.  Per week                                        2  __ __      

        c.  Per month                                       3  __ __      
 
        d.  Per year                                        4  __ __      

        e.  Never                                           5  5  5

            Don't know/Not sure                             7  7  7

            Refused                                         9  9  9

4.  How often do you eat potatoes not including french fries, fried
    potatoes, or potato chips?                              (262-264)

        a.  Per day                                         1  __ __      

        b.  Per week                                        2  __ __      

        c.  Per month                                       3  __ __      
 
        d.  Per year                                        4  __ __      

        e.  Never                                           5  5  5

            Don't know/Not sure                             7  7  7

            Refused                                         9  9  9

5.  How often do you eat carrots?                           (265-267)

        a.  Per day                                         1  __ __      

        b.  Per week                                        2  __ __      

        c.  Per month                                       3  __ __      
 
        d.  Per year                                        4  __ __      

        e.  Never                                           5  5  5

            Don't know/Not sure                             7  7  7

            Refused                                         9  9  9
            
            
6.  Not counting carrots, potatoes, or salad, how many servings of
    vegetables do you usually eat?                          (268-270)

Example:    a.  Per day                                     1  __ __       
A serving of
vegetables  b.  Per week                                    2  __ __       
at both
lunch and   c.  Per month                                   3  __ __      
dinner would
be two      d.  Per year                                    4  __ __      
servings
            e.  Never                                       5  5  5

                Don't know/Not sure                         7  7  7

                Refused                                     9  9  9
                
                
Module 11:  Exercise

The next few questions are about exercise, recreation, or physical
activities other than your regular job duties.

1.  During the past month, did you participate in any physical
    activities or exercises such as running, calisthenics, golf,
    gardening, or walking for exercise?                     (271)

        a.  Yes                                             1

        b.  No  Go to Next Module                           2

            Don't know/Not sure  Go to Next Module          7

            Refused  Go to Next Module                      9

2.  What type of physical activity or exercise did you spend the most
    time doing during the past month?                       (272-273)

            Activity (specify):                             __ __     
                                See coding list A

            Refused  Go to Q. 6                             9  9

Ask Q. 3 only if answer to Q. 2 is running, jogging, walking, or
swimming.  All others, go to Q. 4.

3.  How far did you usually walk/run/jog/swim?              (274-276)

See coding    Miles and tenths                              __ __.__  
list B if
response is   Don't know/Not sure                           7  7  7
not in miles
and tenths    Refused                                       9  9  9

4.  How many times per week or per month did you take part in this
    activity during the past month?                         (277-279)

        a.  Times per week                                  1  __ __    

        b.  Times per month                                 2  __ __    

            Don't know/Not sure                             7  7  7

            Refused                                         9  9  9
            
            
5.  And when you took part in this activity, for how many minutes or
    hours did you usually keep at it?                       (280-282)

            Hours and minutes                               __:__ __     

            Don't know/Not sure                             7  7  7

            Refused                                         9  9  9 

6.  Was there another physical activity or exercise that you
    participated in during the last month?                  (283)

        a.  Yes                                             1

        b.  No  Go to Next Module                           2

            Don't know/Not sure  Go to Next Module          7

            Refused  Go to Next Module                      9

7.  What other type of physical activity gave you the next most
    exercise during the past month?                         (284-285)

            Activity (specify):                                  
                                 See coding list A          __ __

            Refused  Go to Next Module                      9  9

Ask Q. 8 only if answer to Q. 7 is running, jogging, walking, or
swimming.  All others go to Q. 9.

8.  How far did you usually walk/run/jog/swim?              (286-288)

See coding  Miles and tenths                                __ __.__  
list B if
response is Don't know/Not sure                             7  7  7
not in miles
and tenths  Refused                                         9  9  9

9.  How many times per week or per month did you take part in this
    activity?                                               (289-291)

        a.  Times per week                                  1  __ __     

        b.  Times per month                                 2  __ __     

            Don't know/Not sure                             7  7  7

            Refused                                         9  9  9

10. And when you took part in this activity, for how many minutes or
    hours did you usually keep at it?                       (292-294)

            Hours and minutes                               __:__ __     

            Don't know/Not sure                             7  7  7

            Refused                                         9  9  9
            
            
            Activity List for Common Leisure Activities
                            Coding List A

Code Description
 
01. Aerobics class
02. Backpacking
03. Badminton
04. Basketball
05. Bicycling for pleasure
06. Boating (canoeing, rowing,
     sailing for pleasure or
     camping)
07. Bowling
08. Boxing
09. Calisthenics
10. Canoeing/rowing - in
     competition
11. Carpentry
12. Dancing-aerobics/ballet
13. Fishing from river bank or   
     boat
14. Gardening (spading, weeding,
     digging, filling)
15. Golf
16. Handball
17. Health club exercise
18. Hiking - cross-country
19. Home exercise
20. Horseback riding
21. Hunting large game - deer, elk
22. Jogging
23. Judo/karate
24. Mountain climbing
25. Mowing lawn
26. Paddleball
27. Painting/papering house
28. Racketball
29. Raking lawn
30. Running
31. Rope skipping
32. Scuba diving
33. Skating - ice or roller
34. Sledding, tobogganing
35. Snorkeling
36. Snowshoeing
37. Snow shoveling by hand
38. Snow blowing
39. Snow skiing
40. Soccer
41. Softball
42. Squash
43. Stair climbing
44. Stream fishing in waders
45. Surfing
46. Swimming laps
47. Table tennis
48. Tennis
49. Touch football
50. Volleyball
51. Walking
52. Waterskiing
53. Weight lifting
54. Other______________
55. Bicycling machine exercise 
56. Rowing machine exercise

                             Coding List B

Lap Swimming
                         
Size pool/Laps

50 ft. pool:  10 laps = .1 mile
100 ft. pool:  5 laps = .1 mile
50 meter pool: 3 laps = .1 mile

Running/Jogging/Walking

1/2 mile = .5 mile
1/4 mile = .3 mile
1/8 mile = .1 mile
 1 block = .1 mile
 

Module 12: Weight Control

1.  Are you now trying to lose weight?                      (295)

        a.  Yes Go to Q. 3                                  1

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9

2.  Are you now trying to maintain your current weight, that is to
    keep from gaining weight?                               (296)

        a.  Yes                                             1

        b.  No  Go to Q. 6                                  2

            Don't know/Not sure  Go to Q. 6                 7

            Refused  Go to Q. 6                             9

3.  Are you eating either fewer calories or less fat to...

    lose weight? [if "Yes" on Q. 1]

    keep from gaining weight? [if "Yes" on Q. 2]            (297)

Probe   a.  Yes, fewer calories                             1
for
which   b.  Yes, less fat                                   2

        c.  Yes, fewer calories and less fat                3

        d.  No                                              4

            Don't know/Not sure                             7

            Refused                                         9
            
            
4.  Are you using physical activity or exercise to... 

    lose weight? [if "Yes" on Q. 1]

    keep from gaining weight? [if "Yes" on Q. 2]            (298)

        a.  Yes                                             1

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9

5.  How much would you like to weigh?                       (299-301)

            Weight                                          __ __ __        
                                                             pounds

            Don't know/Not sure                             7  7  7

            Refused                                         9  9  9

6.  In the past 12 months, has a doctor, nurse, or other health
    professional given you advice about your weight?        (302)

Probe   a.  Yes, lose weight                                1
for
which   b.  Yes, gain weight                                2

        c.  Yes, maintain current weight                    3

        d.  No                                              4

            Don't know/Not sure                             7

            Refused                                         9
            
            
Module 13: Folic Acid

1.  Do you currently take any vitamin pills or supplements? (303)

Include a.  Yes                                             1
liquid
supple- b.  No  Go to Q. 5                                  2
ments
            Don't know/Not sure  Go to Q. 5                 7

            Refused  Go to Q. 5                             9

2.  Are any of these a multivitamin?                        (304)

        a.  Yes  Go to Q. 4                                 1

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9

3.  Do any of the vitamin pills or supplements you take contain folic
    acid?                                                   (305)

        a.  Yes                                             1

        b.  No Go to Q. 5                                   2

            Don't know/Not sure Go to Q. 5                  7

            Refused Go to Q. 5                              9

4.  How often do you take this vitamin pill or supplement?  (306-308)

        a.  Times per day                                   1  __ __    

        b.  Times per week                                  2  __ __    

        c.  Times per month                                 3  __ __    

            Don't know/Not sure                             7  7  7

            Refused                                         9  9  9
            
            
If respondent 45 years old or older, go to next module

5.  Some health experts recommend that women take 400 micrograms of
    the B vitamin folic acid, for which one of the following
    reasons...                                              (309)

            Please Read

        a.  To make strong bones                            1

        b.  To prevent birth defects                        2

        c.  To prevent high blood pressure                  3
            or
        d.  Some other reason                               4

Do not      Don't know/Not sure                             7
read these
responses   Refused                                         9

Module 14: Firearms

The next questions are about safety and firearms.  Firearms include
weapons such as pistols, shotguns, and rifles.  In answering the
questions, do not include BB guns, starter pistols, or guns that
cannot fire.

1.  Are any firearms now kept in or around your home?  Include those
    kept in a garage, outdoor storage area, car, truck, or other motor
    vehicle.                                                (310)

        a.  Yes                                             1

        b.  No Go to Next Module                            2

            Don't know/Not sure Go to Next Module           7

            Refused Go to Next Module                       9

2.  Are any of the firearms handguns, such as pistols or revolvers?   
                                                            (311)

        a.  Yes                                             1

        b.  No Go to Q. 4                                   2

            Don't know/Not sure                             7

            Refused                                         9

3.  Are any of the firearms long guns, such as rifles or shotguns?
                                                            (312)

        a.  Yes                                             1

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9
            
            
4.  What is the main reason that there are firearms in or around your
    home?                                                   (313)

     Would you say for...

            Please Read

        a.  Hunting or sport                                1

        b.  Protection                                      2

        c.  Work                                            3
            or
        d.  Some other reason                               4

            Don't know/Not sure                             7

            Refused                                         9

5.  Is there a firearm in or around your home that is now both loaded
    and unlocked?                                           (314)

        a.  Yes                                             1

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9

Read the following if "employed" or "self-employed" on core Q. 42. 
Otherwise, go directly to Q. 6.

The next three questions are about using firearms.  If you are a
police officer or have another occupation that requires and authorizes
you to use a firearm, do not include firearm-use associated with your
job.

6.  During the last 30 days, have you carried a loaded firearm on your
    person, outside of the home for protection against people?
                                                            (315)

        a.  Yes                                             1

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9
            
            
7.  During the last 30 days, have you driven or been a passenger in a
    motor vehicle in which you knew there was a loaded firearm?
                                                            (316)

        a.  Yes                                             1

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9

8.  During the last 12 months, have you confronted another person with
    a firearm, even if you did not fire it, to protect yourself, your
    property, or someone else?                              (317)

        a.  Yes                                             1

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9

9.  In the past three years, have you attended a firearm safety
    workshop, class, or clinic?                             (318)

        a.  Yes                                             1

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9

10. Do any of the firearms kept in or around your home belong to you,
    personally?                                             (319)

        a.  Yes                                             1

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9
            
            
Module 15: Social Context

These next questions are about your daily life.

1.  How safe from crime do you consider your neighborhood to be?
                                                            (320)

    Would you say:  Please Read

        a.  Extremely safe                                  1

        b.  Quite safe                                      2

        c.  Slightly safe                                   3

        d.  Not at all safe                                 4

            Don't know/Not sure                             7

            Refused                                         9

2.  Do you own or rent your home?                           (321)

        a.  Own                                             1

        b.  Rent                                            2

            Refused                                         9

3.  How long have you lived at your current address?        (322)

            Read Only if Necessary

        a.  Less than six months (1 to 6 months)            1

        b.  Less than one year (6 to 12 months)             2

        c.  Less than two years (1 to 2 years)              3

        d.  2 or more years                                 4

            Don't know/Not sure                             7

            Refused                                         9
            
            
4.  How many close friends or relatives would help you with your
    emotional problems or feelings if you needed it?        (323)

        a.  3 or more                                       1

        b.  2                                               2

        c.  1                                               3

        d.  None                                            4

            Don't know/Not Sure                             7

            Refused                                         9

5.  In the past 30 days, have you been concerned about having enough
    food for you or your family?                            (324)

        a.  Yes                                             1

        b.  No                                              2

            Don't know/Not Sure                             7

            Refused                                         9
            
            
Module 16:  Smokeless Tobacco Use

1.  Have you ever used or tried any smokeless tobacco products such as
    chewing tobacco or snuff?                               (325)

Probe for a.  Yes, chewing tobacco                          1
chewing
tobacco,  b.  Yes, snuff                                    2
snuff,
or both   c.  Yes, both                                     3

          d.  No, neither  Go to Closing Statement          4

              Don't know/Not sure  Go to Closing Statement  7

              Refused  Go to Closing Statement              9  

2.  Do you currently use any smokeless tobacco products such as
    chewing tobacco or snuff?                               (326)

"Yes"   a.  Yes, chewing tobacco                            1
includes
occa-   b.  Yes, snuff                                      2
sional
use     c.  Yes, both                                       3

        d.  No, neither                                     4

            Don't know/Not sure                             7

            Refused                                         9