View in Courier 12 pt. with .25" right and left margins

               1996 Behavioral Risk Factor Questionnaire
                           Optional Modules

Module 1:  Diabetes

1.  How old were you when you were told you have diabetes?  (172-173)

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

            Don't know/Not sure                             7  7

            Refused                                         9  9

2.  Are you now taking insulin?                             (174)

        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?          (175-177)

        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.
                                                            (178-180)

        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"?    (181)

        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?  (182-183)

        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"?                                (184-185)

        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?         (186-187)

        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.                                           (188)

            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?                    (189)

    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?                                              (190)

    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?                                             (191)

    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 12 months, with how many people have you had
    sexual intercourse?                                     (192-193)

        a.  Number                                          __ __     

        b.  None Go to Next Module                          8  8

            Don't know/Not sure                             7  7

            Refused                                         9  9

2.  During the last week, how many times have you had sexual
    intercourse?                                            (194-195)

        a.  Number                                          __ __      

        b.  None                                            8  8

            Don't know/Not sure                             7  7

            Refused                                         9  9

3.  Was a condom used the last time you had sexual intercourse?
                                                            (196)

        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.  The last time you had sexual intercourse, was the condom used ...  
                                                            (197)
            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

            Don't know/Not sure                             7    

            Refused                                         9

5.  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?                (198) 

        a.  Yes                                             1

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9

6.  In the past five years, have you been treated for a sexually
    transmitted or venereal disease?                        (199)

        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.  Were you treated at a health department STD clinic?     (200)

        a.  Yes                                             1

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9
            
            
Module 3: Health Care Coverage

I asked you previously about your health care coverage.

    If "Dk/Ns" or "Refused" to core Q. 5, go to Q. 5.  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? 
                                                            (201-202)

        a.  Lost job or changed employers
            Go to Q. 5                                      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 Q. 5                                      0 2

        c.  Became divorced or separated  Go to Q. 5        0 3

        d.  Spouse or parent died  Go to Q. 5               0 4

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

        f.  Employer doesn't offer or stopped offering
            coverage  Go to Q. 5                            0 6

        g.  Cut back to part time or became temporary
            employee  Go to Q. 5                            0 7

        h.  Benefits from employer or former employer ran
            out  Go to Q. 5                                 0 8

        i.  Couldn't afford to pay the premiums
            Go to Q. 5                                      0 9

        j.  Insurance company refused coverage
            Go to Q. 5                                      1 0

        k.  Lost Medicaid or Medical Assistance eligibility
            Go to Q. 5                                      1 1  
    
        l.  Other  Go to Q. 5                               8 7

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

            Refused  Go to Q. 5                             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?
                                                            (203)
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 Q. 5

3.  During the past 12 months, was there any time that you did not
    have any health insurance or coverage?                  (204)

        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.  What was the main reason you were without health care coverage? 
                                                            (205-206)

        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
            
            
Now I am going to ask you some questions about your doctor or other
health professional and the health care you receive.

5.  How would you rate your satisfaction with your overall health
    care?                                                   (207)
    
    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

6.  Is there one particular doctor or health professional who you
    usually go to when you need medical care?               (208)

If "more than a.  Yes, only one                             1
one," ask "Is
there one you b.  More than one  Go to Q. 9                 2
usually go to
for routine   c.  No  Go to Q. 9                            3
care?"  Code                                                          
"only one" if     Don't know/Not sure  Go to Q. 9           7
"yes"   
                  Refused  Go to Q. 9                       9
                  
                  
7.  When did you last change doctors?                       (209)

            Read only if necessary
    
"Doctors"      a.  Within the past year (1 to 12 months ago)     1
includes other
health         b.  Within the past 2 years (1 to 2 years ago)    2
professionals
               c.  Within the past 3 years (2 to 3 years ago)    3

               d.  Within the past 5 years (3 to 5 years ago)    4

               e.  5 or more years ago                           5

               f.  Never   Go to Q. 9                            8

                   Don't know/Not sure                           7

                   Refused                                       9
  

8.  Why did you change doctors that last time?              (210-211)
    
"Doctors"      a.  Changed residence or moved               0 1
includes other
health         b.  Changed jobs                             0 2
professionals
               c.  Changed health care coverage             0 3

               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
                   
                   
The next question is about the PLACE you usually go to for your own
medical care. 

9.  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?                                                  (212)

    Would you say: Please read

        a.  Excellent                                       1

        b.  Very Good                                       2

        c.  Good                                            3

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

            Refused                                         9
            

Module 4:  Smokeless Tobacco Use

1.  Have you ever used or tried any smokeless tobacco products such as
    chewing tobacco or snuff?                               (213)

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 Next Module              4

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

            Refused  Go to Next Module                      9  

2.  Do you currently use any smokeless tobacco products such as
    chewing tobacco or snuff?                               (214)

"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
                
                
Module 5: Arthritis

1.  During the past 12 months, have you had pain, aching, stiffness or
    swelling in or around a joint?                          (215)

        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?
                                                            (216)

        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?                                               (217)

        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?
                                                            (218)

        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?     (219-220)
    
        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?
                                                            (221)

        a.  Yes                                             1
 
        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9
            
            
Module 6: 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?                           (222)     

        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?                                             (223-224)

        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?                     (225-227)

        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?         (228)     

        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?                              (229)

        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?                                          (230-231)

        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?                                (232-233)

        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?                             (234-235)      
        
        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?                       (236-237)

        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?                        (238-239) 

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

            Don't know/Not sure                             7  7

            Refused                                         9  9
            
            
Module 7:  Health Care Utilization

1.  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?                                      (240)

        a.  Yes  Go to Q. 3                                 1

        b.  More than one place                             2

        c.  No  Go to Q. 4                                  3

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

            Refused  Go to Next Module                      9

2.  Is there one of these places that you go to most often when you
    are sick or need advice about your health?              (241)

        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
            

3.  What kind of place is it -- a clinic, a health center, a hospital,
    a doctor's office, or some other place?                 (242-243)

        a.  Doctor's office or private clinic               
            Go to Next Module                               0 1

        b.  Company or school health clinic/center
            Go to Next Module                               0 2

        c.  Community/migrant/rural clinic/center
            Go to Next Module                               0 3

        d.  County/city/public hospital outpatient clinic
            Go to Next Module                               0 4

        e.  Private/other hospital outpatient clinic
            Go to Next Module                               0 5

        f.  Hospital emergency room  Go to Next Module      0 6

        g.  HMO/prepaid group  Go to Next Module            0 7

        h.  Psychiatric hospital or clinic
            Go to Next Module                               0 8

        i.  VA hospital or clinic  Go to Next Module        0 9

        j.  Military health care facility
            Go to Next Module                               1 0

        k.  Some other kind of place  Go to Next Module     1 1

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

            Refused  Go to Next Module                      9 9
            

4.  What is the main reason you do not have a usual source of medical
    care?                                                   (244-245)

        a.  Two or more usual places                        0 1

        b.  Have not needed a doctor                        0 2

        c.  Do not like/trust/believe in doctors            0 3

        d.  Do not know where to go                         0 4

        e.  Previous doctor is not available/moved          0 5

        f.  No insurance/cannot afford                      0 6

        g.  Speak a different language                      0 7

        h.  No place is available/close enough/convenient   0 8

        i.  Other                                           0 9

            Don't know/Not sure                             7 7

            Refused                                         9 9
            

Module 8:  Oral Health

1.  How long has it been since you last visited the dentist or a
    dental clinic?                                          (246)

        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?                                              (247-248)

        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.                (249)

        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?                
                                                            (250) 

        a.  Yes                                             1

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9
            
            
Module 9: Preventive Counseling Services

The next series of questions is 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?                       (251)
    
If yes,       a.  Yes, within the past 12 months (1 to 12 months ago) 1
ask "About
how long ago  b.  Yes, within the past 3 years (1 to 3 years ago)     2
was 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?                    (252)
    
If yes,       a.  Yes, within the past 12 months (1 to 12 months ago) 1
ask "About
how long ago  b.  Yes, within the past 3 years (1 to 3 years ago)     2
was 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?                                        (253)
        
If yes,       a.  Yes, within the past 12 months (1 to 12 months ago) 1
ask "About
how long ago  b.  Yes, within the past 3 years (1 to 3 years ago)     2
was 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?                                       (254)
    
If yes,       a.  Yes, within the past 12 months (1 to 12 months ago)   1
ask "About
how long ago  b.  Yes, within the past 3 years (1 to 3 years ago)       2
was 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?                                      (255)
    
If yes,       a.  Yes, within the past 12 months (1 to 12 months ago)   1
ask "About
how long ago  b.  Yes, within the past 3 years (1 to 3 years ago)       2
was 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. 25 or "Not at all" to core Q. 26, go to Q. 7

6.  (Has a doctor or other health professional) ever advised you to
    quit smoking?                                           (256) 
    
If yes,       a.  Yes, within the past 12 months (1 to 12 months ago) 1
ask "About
how long ago  b.  Yes, within the past 3 years (1 to 3 years ago)     2
was 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?      (257)

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

              d.  No                                                  4

                  Don't know/Not sure                                 7

                  Refused                                             9
                  
                  
Module 10:  Hypertension Awareness

1.  About how long has it been since you last had your blood pressure
    taken by a doctor, nurse, or other health professional? (258)

            Read Only if Necessary

        a.  Within the past 6 months  (1 to 6 months ago)   1

        b.  Within the past year  (6 to 12 months ago)      2    

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

        d.  Within the past 5 years  (2 to 5 years ago)     4

        e.  5 or more years ago                             5         
            
            Don't know/Not sure                             7

            Never  Go to Next Module                        8

            Refused                                         9

2.  Have you ever been told by a doctor, nurse, or other health
    professional that you have high blood pressure?         (259)

        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

3.  Have you been told on more than one occasion that your blood
    pressure was high, or have you been told this only once?
                                                            (260)

        a.  More than once                                  1

        b.  Only once                                       2

            Don't know/Not sure                             7

            Refused                                         9
            
            
Module 11:  Cholesterol Awareness

1.  Blood cholesterol is a fatty substance found in the blood. Have
    you ever had your blood cholesterol checked?            (261)

        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.  About how long has it been since you last had your blood
    cholesterol checked?                                    (262)

            Read Only if Necessary

        a.  Within the past year  (1 to 12 months ago)      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                             7

            Refused                                         9

3.  Have you ever been told by a doctor or other health professional
    that your blood cholesterol is high?                    (263)

        a.  Yes                                             1

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9
            
            
Module 12: 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    (264)

    b.  Exercise more                1         2         7         9    (265)

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     (266)

    b.  Exercising more?             1      2      7       9     (267)

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     (268)

    b.  Angina or coronary heart disease 1      2      7       9     (269)
 
    c.  Stroke                           1      2      7       9     (270)

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?           (271)

        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?                                 (272)

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

                 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     (273)

    b.  To reduce the chance of a
        heart attack                     1      2      7       9     (274)

    c.  To reduce the chance of a stroke 1      2      7       9     (275)

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. 65 or if respondent is age 65 or older, go to Q.
8. 

7.  Have you gone through or are you now going through menopause?
                                                            (276)

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?
                                                            (277)

        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?                                 (278)

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?                (279)

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  (280)

    b.  To treat or prevent bone
        thinning, bone loss,
        or osteoporosis                1     2     7      8     9  (281)

    c.  To treat symptoms of menopause
        such as hot flashes            1     2     7      8     9  (282)
        
        
Module 13:  Immunization

1.  During the past 12 months, have you had a flu shot?     (283)

        a.  Yes                                             1

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9

2.  Have you ever had a pneumonia vaccination?              (284)

        a.  Yes                                             1

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9
            
            
Module 14:  Colorectal Cancer Screening

If respondent 40 years or older, continue with this module. 
Otherwise, go to next module.

1.  A digital rectal exam is when a doctor or other health
    professional inserts a finger in the rectum to check for cancer
    and other health problems.  Have you ever had this exam?
                                                            (285)

        a.  Yes                                             1

        b.  No  Go to Q. 3                                  2

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

            Refused  Go to Q. 3                             9

2.  When did you have your last digital rectal exam?        (286)

            Read Only if Necessary

        a.  Within the past year  (1 to 12 months ago)      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                             7

            Refused                                         9

3.  A blood stool test is a test that may use a special kit at home to
    determine whether the stool contains blood.  Have you ever had
    this test using a home kit?                             (287)

        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.  When did you have your last blood stool test using a home kit?
                                                            (288)

            Read Only if Necessary

        a.  Within the past year  (1 to 12 months ago)      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                             7

            Refused                                         9

 
5.  A sigmoidoscopy or proctoscopy is when a tube is inserted in the
    rectum to view the bowel for signs of cancer and other health
    problems.  Have you ever had this exam?                 (289)

        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

6.  When did you have your last sigmoidoscopy or proctoscopy?
                                                            (290)

            Read Only if Necessary

        a.  Within the past year  (1 to 12 months ago)      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                             7

            Refused                                         9
            

Module 15:  Injury Control

1.  How often do you use seatbelts when you drive or ride in a car?
                                                            (291)
    Would you say:   Please Read

        a.  Always                                          1

        b.  Nearly Always                                   2

        c.  Sometimes                                       3

        d.  Seldom                                          4
            or
        e.  Never                                           5

Do not      Don't know/Not sure                             7
read these
responses   Never drive or ride in a car                    8

            Refused                                         9

If core Q. 45a, b, and c are all "None," go to Q. 5

2.  What is the age of the oldest child in your household under the
    age of 16?                                              (292-293)
Code
<1 yr.  a.  Code age in years                                __ __      
as "01"
        b.  No children under age 16  Go to Q. 5             8  8

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

            Refused  Go to Q. 5                              9  9
            
            
3.  How often does the [fill in age from Q. 2]-year-old child in your
    household use a...                                      (294)

    car safety seat [for child under 5]

    seatbelt [for child 5 or older]

    ...when they ride in a car?  
    
    Would you say:   Please Read

        a.  Always                                          1

        b.  Nearly always                                   2

        c.  Sometimes                                       3

        d.  Seldom                                          4
            or
        e.  Never                                           5
        
Do not      Don't know/Not sure                             7
read these
responses   Never rides in a car                            8

            Refused                                         9

If oldest child 5 years or older, continue with Q. 4.  Otherwise, go
to Q. 5.

4.  During the past year, how often has the [fill in age from Q. 2]-year-old 
    child worn a bicycle helmet when riding a bicycle?
                                                            (295)

    Would you say:  Please Read

        a.  Always                                          1

        b.  Nearly Always                                   2

        c.  Sometimes                                       3

        d.  Seldom                                          4
            or
        e.  Never                                           5

            Don't know/Not sure                             7
Do not
read these  Never rides a bicycle                           8
responses
            Refused                                         9
            

5.  When was the last time you or someone else deliberately tested all
    of the smoke detectors in your home, either by pressing the test
    buttons or holding a source of smoke near them?         (296)

            Read Only if Necessary

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

        b.  Within the past 6 months (1 to 6 months ago)    2

        c.  Within the past year (6 to 12 months ago)       3

        d.  One or more years ago                           4

        e.  Never                                           5

        f.  No smoke detectors in home                      6

            Don't know/Not sure                             7

            Refused                                         9
            
            
Module 16:  Alcohol Consumption

1.  During the past month, have you had at least one drink of any
    alcoholic beverage such as beer, wine, wine coolers, or liquor?
                                                            (297)

        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.  During the past month, how many days per week or per month did you
    drink any alcoholic beverages, on the average?          (298-300)

        a.  Days per week                                   1 __ __      

        b.  Days per month                                  2 __ __      

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

            Refused  Go to Q. 4                             9  9  9

3.  A drink is 1 can or bottle of beer, 1 glass of wine, 1 can or
    bottle of wine cooler, 1 cocktail, or 1 shot of liquor.  On the
    days when you drank, about how many drinks did you drink on the
    average?                                                (301-302)

            Number of drinks                                 __ __     

            Don't know/Not sure                              7  7

            Refused                                          9  9

4.  Considering all types of alcoholic beverages, how many times
    during the past month did you have 5 or more drinks on an
    occasion?                                               (303-304)

        a.  Number of times                                  __ __     

        b.  None                                             8  8

            Don't know/Not sure                              7  7

            Refused                                          9  9
            

5.  During the past month, how many times have you driven when you've
    had perhaps too much to drink?                          (305-306)

        a.  Number of times                                  __ __     

        b.  None                                             8  8

            Don't know/Not sure                              7  7

            Refused                                          9  9
            
            
Module 17: 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.                                                (307)

        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?                                              (308)

        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?
                                                            (309)

        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?                                                   (310)

     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?                                           (311)

        a.  Yes                                             1

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9

Read following if "employed" or "self-employed" on core Q. 47. 
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?   (312)

        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?
                                                            (313)

        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?                              (314)

        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?                             (315)

        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?                                             (316)

        a.  Yes                                             1

        b.  No                                              2

            Don't know/Not sure                             7

            Refused                                         9
            
            
Module 18: Social Context

These next questions are about your daily life.

1.  How safe from crime do you consider your neighborhood to be?
                                                            (317)

    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?                           (318)

        a.  Own                                             1

        b.  Rent                                            2

            Refused                                         9

3.  How long have you lived at your current address?        (319)

            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?        (320)

        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?                            (321)

        a.  Yes                                             1

        b.  No                                              2

            Don't know/Not Sure                             7

            Refused                                         9