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PROGRAMS AND COLLECTION PROCEDURE5

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Series 1

Number 8

plan and operation of a

Health Examination Survey

of U.S. Youths

12-17 Years of Age

A description of the Health Examination Survey’s third cycleexaminations of a probability sample of United States youths

12-17 years of age.

DHEW Publication No. (HRA) 75-1018

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

Public Health Service

Health Resources Administration

National Center for Health Statistics

Rockville, Md. September 1974
NATIONAL CENTER FOR HEALTH STATISTICS

THEODORE D. WOOLSEY, Director

PHILIP S. LAVRENCE, Sc.D., Associate Director

OSWALD K. SAGEN, PH.D.,, Assistant Director for Health Statistics Development

WALT R. SIMMONS, M.A., Assistant Director /or Research and Scientific Development ’

ALICE M. WATERHOUSE, M.D., Medical ConsuZtant

JAMES E. KELLY, D.D.S., Dental Advisor

EDWARD E. MINTY, Executive Officer

MARGERY R. CUNNINGHAM, Information Officer

DIVISION OF HEALTH EXAMINATION STATISTICS

ARTHUR J. MCDOWELL, Director

PAUL T. BRUYERE, M.D., Deputy Director

JAMES T. BAIRD, JR., Chief, Analysis and Reports Branch

HENRY W. MILLER, Chief, Operations and Quality Control Branch

PETER v. v. HAMILL, M.D., Medical Advisor

JAMES E. KELLY, D.D.S., Dental Advisor

HAROLD J. DUPUY, Ph.D., Psychological Advisor

Public Health Service Publication KCL IOOO-Series ?-NO. 8

Library of Congress Catalog Card Number 76-602407
PREFACE

.This report presents a detailed descriptionof the “third cycle” plan

and operation of the Health Examination Survey. It is intended primarily

to serve as a necessary foundation for understanding and use of the substantive findings to be published later in the vital a:& Health Statistics,

Series 11 reports of theNational Center for Health Statistics. It is hoped

that it will also serve as a useful guide or aid to others in the planning

of health examination surveys.

In the planning and operation of the “third cycle,” valuable assistance was received from many individuals and groups. Space does not

permit the recognition of all who participated in the planning, development, and conduct of the many and varied aspects of the survey. Their

assistance is, however, gratefully acknowledged. Mention should be made,

however, of the important role played by the U.S. Bureau of the Census.

Under a contractual arrangement they have participated in certain aspects of the sample selection, conduct of initial household interviews,

and in most of the processing of thedata. The overall responsibility for

planning the program was that of Mr. Arthur J. McDowell, Director,

Division of Health Examination Statistics. The primary responsibility

for the content and coordination of the various parts of the examination

was that of Dr. Peter V, V. Hamill, Medical Advisor for the children and

youth programs of the Division of Health Examination Statistics (DHES).

Other members of the DHES staff who had responsibility in specific

areas were Dr. James E. Kelly, Dental Advisor to the National Center

for Health Statistics; Dr. Lawrence E. Van Kirk, Jr., formerly Dental

Advisor to DHES; Miss Jean Roberts, Supervisory Statistician (DHES);

and Dr. Lois R. Chatham, formerly Psychological Advisor to DHES.

This report was prepared by Henry W. Miller.

. . .

III
CONTENTS

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CONTENTS--Con.

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Appendix IC, Health Habits and Historymm-o--ooo-mooo-.--mmom~~~~m~mm~m~ v 49

Appendix ID. Supplemental InformationFromSchool---------------------- 55
THIS REPORT IS a detailed description of the third prouam of the

Health Examination Suruey. The actual collection of data for this program began in Mavch 1966 and will be completed early in calendar year

1970, It involves the selection and examination of a nationwide probability sample of the civilian, noninstitutionulixedpopulation of the United

States between the ages of 12 and 17 years. The exam&&ion focuses

primarily on factors relating to growth and development. It includes

examination by a physician-, a dental examination, a variety of tests,

procedures, measurements, and a battery of psychological tests. This

report describes the development of the survey plan, the examination

content, the logistics of operations, and procedures employed to assure

the quality of the data.

During the course of the survey, 40 locations throughout the United States

will be visited. Approximately 7,500 youths will be in the sample; of this

number 90.0 percent aye expected to be examined. A unique feature of

the present pyogram is the sample design whichutilixes the same sample areas and housing units as the previous survey popam. That program conducted during 1963-65, examined 7,119 children between the

ages of 6 and 11 years. As a result of this feature, examination data of

a long2tudinal nuture will also beavailableforapproximately2,2QO youths.
, 7 ‘ s

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PLAN AND OPERATION OF A

HEALTH EXAMINATION SURVEY OF US

YOUTHS 12-17

INTRODUCTION

The Health Examination Survey is one of the

major programs of the National Center for Health

Statisiics (NCHS). It is a part of the National Health

Survey, authorized in 1956 by the 84th Congress as

a continuing Public Health Service activity,

The National Health Survey employs three

different programs to accomplish its 0bjectives.l

One of these is the Health Interview Survey which

collects information about health and disability

of the civilian, noninstitutionalized population

through a continuous sampling and interviewing

program. The second program, Health Resources,

obtains health data and health resource and utilization information through surveys of hospitals,

nursing homes, clinics, physicians’ offices, laboratories, related facilities, and the entire range

of personnel in the health occupations. The third

major program of the National Health Survey is

the Health Examination Survey (HES).

The Health Examination Survey collects data

by drawing samples of the civilian, noninstitutionalized population of the United States and, by

means of medical and dental examinations and various tests and measurements, undertakes to characterize the population under study. This is the

most accurate way to obtain definite diagnostic

data on the prevalence of certain medically defined

illnesses. It is the only way to obtain information

on un.recogni.zed and undiagnosed conditions-in

some cases, even nonsymptomatic condition 6, It

is also the only way to obtain distributions of the

population by a variety of physical,

and psychological measurements.

physiological,

YEARS OF AGE

In addition to the data collected by the examining, measuring, and testing procedures, a

wide range of other data is collected concerning

each of the sample persons examined. Therefore,

it is not only po~ssible to study the many potential

Yelationships of the examination findings to one

another, but also to investigate the relationships

of the examination findings to demographic and

socioeconomic factors.

HES GENERAL PROGRAM

Basic Characteristics

The overall plan of the Health Examination

Survey is to conduct successive, separate programs of medical and dental examinations, tests,

and measurements in specific age segments of

the civilian, noninstitutionalized US. population.

These successive programs are referred to as

“cycles” and as such, each has a specific age segment for the target population and is concerned

with certain specified health aspects of that subpopulation.

All HES cycles make use of a nationwide probability sample of the population. This makes it

possible to obtain the desired information efficiently and in such a manner that the statistical

reliability of results is determinable, These

factors, together with the fact that the examination and measurement processes are highly

standardized and closely controlled, enable the

results of the surveys to describe the entire population of the United States on the basis of relatively small samples.
The approach to each cycle is necessarily

multidisciplinary in nature. Each draws on and

combines the talents of statisticans, physicians

of various specialties, dentists, psychologists,

nurses, educators, sociologists, management specialists, and others. In addition, each cycle involves interagency collaboration. The Bureau of

the Census is a partner in several phases of the

survey. Other Federal agencies such as the National Institutes of Health, the Office of Education,

and the Children’s Bureau, as well asnongovernment agencies such as,’ schools of public health,

medical research centers, and survey research

agencies, also advise and assist the survey.

The data collected are a cross section of a

national sample of the civilian, noninstitutionalized population. The size of the sample permits

some analysis of the data by broad geographic

region, population density groups, or other major

subgroups of the total sample, but it does not permit analysis by smaller breakdowns, such as by

State, The data are analyzed and the findings are

made available to interested persons as rapidly

as possible. This is done primarily through the

publication of reports prepared in a form usable

by large numbers of consumers of health statistics. The reports are limited to objective, scientific presentation of the particular findings,

including estimated levels of prevalence and relevant discussion of various observed relationships.

They do not include discussion of program implications of these findings, nor do they present value

judgments concerning their implications to public

health. The principal reports are published in

the various Vital and Health Statistics series of

the National Center for Health Statistics.

Any information which permits the identification of an examinee is held in strict confidence,

is not disclosed or released to others, and is

used only by persons engaged in the survey for

the purposes of the survey,

Programs to Date

The first program, or “cycle,” of the Health

Examination Survey was conducted between November 1959 and December 1962 and was directed

toward the civilian, noninstitutionalized U.S. population between the ages of 18 and79 years inclusive. The examination was focused primarily on

2

certain chronic diseases, cardiovascular disease,

arthritis and rheumatism, and diabetes. Also included were a dental examination, tests for visual

and auditory acuity, X-ray, electrocardiographic

tracings, blood chemistry tests, and numerous

body measurements. The sample size of that cycle

was 7,710 persons of which 6,672 (86.5 percent)

were examined. Details of the plan of that program are described in an earlier report.” Reports of various methodological studies 3-11 and

of the findings 12-43 are also available.

The target population of the second cycle of

the Health Examination Survey consiste,d of children between the ages of 6 and 11 years inclusive.

That cycle became operational in July. I963 and

was concluded in December 1965, The primar;-

focus of the examination was on various parameters of growth and development, but it als:’

screened for heart disease, congenital abnormalities, ENT diseases, and neuromusculoskeletal

abnormalities. The size of the sample was 7,417

of which 7,119 (96.0 percent) were examined. A

detailed report of the plan, operation, and response

results, as well as several methodological reports, have been published.14-48 Reports of findings are becoming available and will increase

rapidly now that the analysis of the first cycle

data is virtually completed.

The third cycle,. which is described in this

report, is concerned with youths .12-17 years of

age inclusive. This survey was begun in March

1966 and will be concluded early in calendar year

1970.

The operation of the Health Examination Survey at this time, therefore, is actually proceeding

on three different levels. First, data are being

collected in Cycle III. Second, analysis and publication of data from Cycle11 is being performed,

Third, plans and preparations for Cycle IV are

being made so that when Cycle III data collection

is completed, Cycle IV examinations can be

started. There are a number of reasons for this

three-level concept of operation, but the principal

one is to avoid complete dismantling andrebuilding of the field organization between examining

phases of successive cycles. It also avoids the

loss of highly trained field and headquarterspersonnel whose skills are unique and difficult to

replace.
DEVELOPMENT OF CYCLE Ill

The- Target Population

The age segment to be examined in Cycle III

had been fairly well defined at the time the target

population of Cycle II was determined. Theoriginal concept of the second cycle was that the sample

k would consist of persons between the ages of 6 and

17 years inclusive. As the detailed planning proceeded, it became apparent that the differences

in the health, mental, and behavioral characteristics of the youths within this age range were great

enough to warrant separate programs. Such matter.s as feasibility of self-administered tests,

motivational approaches to be used, sizes of certain supplies and equipment, and adverse effect

on participation on the part of teenagers in a

program that seemed to be a “children’s” examination led to a decision to limit the age range. It

was then decided that the target population for

Cycle II would be children between the ages of 6

and 11 years inclusive and the subsequent Cycle

III program would include youths between the ages

of 12 and 17 years.

Aside from age, the other specifications of

the Cycle III target pqpulation are quite similar

to those in Cycle II. Specifications for Cycle III

include the following:

I.

2.

3.

4.

5.

Be between the ages of 12 and 17 years

inclusive, regardless of whether they were

attending school.

Married youths of eligible age are to be

included.

Not confined to an institution.

Be a resident of the United States (including Alaska and Hawaii).

Not residing upon any of the reservation

lands set aside for use of American Indians.

Determination of General Objectives

It was clear earlyin the planning stages that

the general objectives of the third cycle should be

similar to those of Cycle II. Measures of growth

and development as well as statistics on other

health characteristics needed to be made available for the entire continuum of childhood through

adolescence. However + for reasons mentioned

previously and from the experience of the previous cycle, some modifications and refinements

of the Cycle II collection techniques and procedures were indicated. In addition, data related

specifically to adolescent health were desired. It

was very important, therefore, that all reasonable

items for inclusion in Cycle III be fully investigated and appraised as to their importance and

feasibility.

The determination of these refinements and

the specific data desired which was obtainable

by the HES type of examination was made only \

after extensive consultation and evaluation. Four

distinct types of consultation werp inv,Tolved. Planning the general aspects involved a continuing

advisory panel of experts from various institutions across the country who were noted for their

expertise on problems related to adolescent medicine and to the examination of children and youths.

These individuals were recognized authorities in

the fields of pediatrics, maternal and child health,

anatomy, child psychology, epidemiology and biostatistics, preventive medicine, and growth and

development. It was the function of this panel to

examine each proposed item for inclusion or exclusion in the examination portion of the survey;

the final responsibility, of course, remained with

the Division of Health Examination Statistics. The

persons who constituted this panel are:

Dr. Peter V. V. Hamill, Chief Medical Advisor, Health Examination Survey, U.S. Public

Health Service, Chairman

Dr. Forrest H. Adams, Professor, Pediatrics

(Cardiology), University of California at Los

Angeles

Dr. Nicholas G. Alexiou, Associate Professor, Maternal and Child Health, Johns Hopkins School of Hygiene and Public Health

Dr. Robert Haggerty , Chairman, Department

of Pediatrics, University of Rochester

Dr. Paul Harper, Chairman, Department of

Maternal and Child Health, Johns Hopkins.

University

Dr. Felix Heald, Chairman, Department of

Pediatrics (Adolescent Medicine), George

Washington University
Dr. Robert W. McCammon, Director ofChild

Research Council, University of Colorado

Dr. Sarah Idell Pyle, Anatomy (Brush Foundation), Case Western Reserve University

Dr. Robert Reed, Professor of Biostatistics

(Harvard Growth Study), Harvard University

School of Public Health

Dr. Kenneth Rogers, Professor of Preventive

Medicine, University of Pittsburgh

Dr. Carl S. Shultz, U.S. Public Health Service (School Health)

The second type of constiltation involved a

series of ad hoc meetings on the more specialized

aspects of the examination. Included were one or

more meetings on examinations of vision, endocrine assay, body architecture, nutritional appraisal, and exercise capacity. These meetings

generally involved one or more of the experts on

the continuing panel with numbers of other experts in connection with specific fields. These

persons were drawn from other parts of thePublit Health Service and other government agencies,

as well as from universities, and research institutes throughout the country.

The third type of consultation involved many

visits by individual HES staff members to specific

individuals and institutes across the country in

order to discuss problems with regard to particular, proposed parts of the examination.

The fourth type of consultation was with the

Advisory Committee to the Surgeon General on

the National Health Survey. This is a formally

constituted body, represented by a wide range of

interests in the health field.

Development of Specific Areas

In the consideration of items for inclusion or

exclusion in the physician’s examination and other

specific areas, certain guidelines were established. These were as follows:

1. Procedures should be included which will

identify youths who are not physically

qualified to participate in certain parts of

the overall examination.

2. Diseases or deformities with an expected

frequency of less than 1 percent should

3.

4.

5.

not be included. An item of such a small

expected frequency would be subject to too

great a sampling error and, in addition,

would not return a yield justifying the

money and effort.

All items should be judged from thepractical side with respect to time required

for administration; personnel requirements with respect to type, number, and

special training required; space; equipment maintenance and service; impact on

the examinee; and cost.

The item should be of specialinterest and

applicable to the entire sample.

Proposed items should be evaluated to

identify those which may affect or be related to other data included in the examination.

Many items were suggested for inclusion.

Those that met the above criteria were subjected

to further consultation and to preliminary studies

and tests, some of which were quite involved and

others, fairly limited. In a few instances, it was

possible to take advantage of work that had already been! done in some other connection. Thus,

one of the important areas of interest concerned

the levels of auditory acuity. It had been recognized

that there was need for new standards with respect

to hearing levels in youths just as there was for

younger children. The American Academy of

Ophthalmology and Otolaryngology Subcommittee

on Hearing in Children, under the Chairmanship

of Dr. Raymond E. Jordan, continued to work on

the development of such new standards. This

group had carried out a series of studies of school

children and youths in the Pittsburgh area, had

developed the detailed content and form of the

examination and kinds of equipment required, and

had acquired considerable experience in measuring auditory acuity in children and youths. This

group continued their interest in the survey because of the opportunity to establish norms for

the total national population.

From the viewpoint of the Health Examination

Survey, the work which this subcommittee had

completed provided extremely valuable developmental work. Arrangements were continued from

Cycle II for the executive director of the Sub-
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committee on Hearing in Children, Dr. Eldon

Eagles, and later for Dr. Jordan, to serve as

consultant to the Health Examination Survey. The

audiometric portion of the third cycle, as well

as the second cycle examination, was based on

the work done in the Pittsburgh studies. Dr. Leo

Doerfler, working with the Subcommittee on Hearing in Children in this study, supervised the training of technicians for the Health Examination

Survey. Mr. Kenneth Stewart, in charge of the

Acoustics Laboratories, University of Pittsburgh,

agreed to continue, as in Cycle II, the calibration

of the instruments to be used and to do the field

sound pressure level surveys as needed. Various

other benefits have accrued to the program as

a result of the cooperative arrangement. In this

instance the survey had essentially no developmental work to do because this had been done in

connection with the subcommittee activity.

Because of reportedly large increase in the

incidence of myopia at or around puberty, it was

decided to enlarge the visual acuity test used in

Cycle II, to include the use of a set of trial lenses

to obtain estimates of the prevalence and severity

of myopia and to test for both uncorrected acuity

and acuity with the existing correction (for which

the prescription is obtained objectively by a lensometer). This new battery of tests was worked

out with the help and counsel of Dr. J. Theodore

Schwartz, ophthalmologist-epidemiologist at the

National Institute of Neurologic Disease and Blindness, and Dr. Herbert A. Urweider of George

Washington University School of Medicine. A feasibility study of this new battery of tests was done

at the National Training School for Boys in Washington, D.C. under Dr. Urweider’s direction. Also

under Dr. Urweider’s direction, validation studies

of both the trial lens test for myopia and the lateral phoria tests were done midway in Cycle III,

in Chicago, Illinois. Each of the approximately

100 youths in the study was given the regular Cycle III examination and then a thorough clinical

examination for lateral phoria and myopia, the

latter under cycloplegics, to’ determine the extent

of agreement between a regular clinical examination and the survey tests.

It was decided to continue for adolescents the

measures relevant to intellectual and personality

growth and development that were comparable to

those used in the children’s examinations of Cycle

II with only slight modifications for the difference

in age. Hence, much of the developmental work

started in Cycle II was applicable or could be

continued in Cycle III. For example, the contract

study to develop recommended methods of evaluating and analyzing the results of the modified

Thematic Apperception Test started in Cycle II

was continued. This study is being done under the

direction of Dr. S. B. Sells of the Institute of Behavioral Research, Texas Christian University.

A contract study to further validate the Wide

Range Achievement Test for children 6-17 years

of age was completed under the direction of Dr.

K. Warner Schaie of West Virginia University.

Results of the study have been published in the

methodological series of reports from the NCHS.*’

Because of the interest indicated indetermination of the level of illiteracy in various sections

of this country and the lack of an instrument suitable for survey use, a special brief reading and

writing test of literacy was developed by Thomas

F. Donlon and W. Miles McPeek of the Education

Testing Service at Princeton, New Jersey under

contract with the HES. This test is described in

another publication in the methodological series

of the Center.*’

In 1962, with the national interest in physical

fitness of U.S. children, it was decided to try to

measure the physical fitness of the Cycle II subjects utilizing a bicycle ergometer.*6 For a variety of reasons, this test did not prove to be entirely satisfactory for use in Cycle III. Under a

contract from the HES, Dr. Henry Taylor and his

staff at the University of Minnesota Laboratory

of Physiologic Hygiene, developed a new “submaximal exercise tolerance test” involving walking on a treadmill at a 10 percent grade at 3.5

miles per hour, with the subject’s pulse rate and

electrocardiographic response continuously monitored by a cardiotachometer connected to the

subject by precordial leads. Further calibration

and validation of this test is continuing at the present time.

Ia

The body measurements chosen

nd II were mostly determined by thos

for Cycles

e interested

in human engineering data. However, it was decided for Cycle III that accurate biologic data on

growth and development in U.S. children had a

higher priority than human engineering data, so

the battery of body measurements is basicallythe

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traditional anthropometry used in the longitudinal

studies of growth and development conducted in

this country over the past 40 years. This new battery was constructed after several ad hoc meetings of those most experienced in the field of anthropometry and growth and development with the

advice of Dr. Francis E. Johnston, Department of

Anthropology, University of Texas. After some

feasibility and validation studies undertaken by

Dr. Johnston as consultant to the survey in anthropometry, Dr. Johnston also trained the technicians and periodically supervises their perfor -

mance.

Altering the primary objective of the body

measurements created a conflict of interest because it was also desired to maintain continuity

of data from ages 6 through 79 years. The compromise reached was to develop regression equations to predict the human engineering parameters

used in Cycles I and II from the new set of more

biologically oriented measurements. A few of

those which defied good prediction were carried

on in the Cycle III battery.

Investigations were conducted regarding the

problem of developing a satisfactory blood collection technique for this age group andexamination setting. The optimum amount which wouldnot

have an emotional impact upon the examinee and

which would not affect his performance in any of

the procedures to follow, was desired. The amount

of usable blood that could be drawn posed a limiting factor on the number of blood chemistry tests

that could be performed and made a difference in

accepting or rejecting an entire possible area of

the examination such as the nutritional assessment. Logistical problems also had to be resolved

involving the handling, separating, and packaging

of drawn blood so that there would be a minimum

of blood loss and packaging error. For the refrigerated but unfrozen bloods, time from shipment

to delivery was critical, so that arrangements had

to be made with postal authorities to assure prompt

delivery to the laboratories in order to avoid

spoilage.

Drs. Bernice Cohen and Wilma Bias of the

Johns Hopkins Immunogenetics Laboratory and

Dr. Gerald Cooper at the Communicable Disease

Center, Atlanta, Georgia, assisted the HES by

advising and participating in feasibility studies

and providing their laboratory facilities under

contract for the subsequent determinations.

Early in the planning and development of Cycle III, it was recognized that an accurate nutritional appraisal would be a valuable and useful

piece of information to develop. Consequently an

extensive series of ad hoc meetings, consultations, and pilot studies of feasibility and validation was undertaken. The uniqueness of this adolescent age group added a special interest to the

undertaking because of the increased nutritional

demands associated with the rapid growth of

adolescents coupled with the legendary poor dietary habits and erratic sleep and energy expenditure patterns of adolescents. On the other hand,

however, the great physiologic and maturational

heterogeneity of this group would greatly multiply

the problems arising from sample size in subsequent analysis of the data.

A full nutritional profile would have three

main parts: a biochemical appraisal, of blood and

urine specimens, a clinical appraisal, and a dietary intake survey. The first two constitute the

assessment of the subject’s current nutritional

status, while the latter attempts to reconstruct

the dietary pattern of the individual for the past

x months or years. After extensive study and

exploration of all available leads it was finally

decided to drop the full nutritional profile from

the Cycle III examination for reasons both logistical and technical. Although rejecting the full1

appraisal as neither precise enough nor workable

on our sample size, a variety of items are obtained

in the examination which more or less impinge

upon this question and which can eventually be

drawn into a unified report: namely, hemoglobin

and hematocrit; skeletal age and bone density; extensive anthropometry (especially height, weight,

and skinfolds); general assessment by a trained

physician looking especially for stigmata of malnutrition; total serum cholesterol, protein bound

iodine, and special evaluation for goiter; and a

general clinical assessment of stage of maturation and general growth.

Because of the problem in silent urinary

tract infections in women and the greatly increasing frequency at puberty, a screening test for girls

was devised with consultation and assistance from

Dr. Calvin M. Kunin, University of Virginia. Dr.

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Kunin also provides the necessary continuing supervision and his laboratory facilities are used

for identifying and typing the resultant organisms.

Another area of considerable interest, which

after considerable study had to be limited in scope,

was a full endocrine profile, Because of the cost,

difficulty in ensuring adequate laboratory determinations, and several severe logistical obstacles, this was reduced to determination of protein

bound iodine and the future determination of plasma testosterone in boys. The principal logistical

stumbling block was obtaining a 24.hour or even

a 6- or &hour urine specimen of reliable quality

in our operation.

A final example of “failure” after much study

was an exercise tolerance test which would provide a direct measure of maximum oxygen consumption and production of carbon dioxide in order

to obtain the respiratory quoti.ent as an index of

the metabolic load placed on the subject. This procedure had to be dropped from inclusion in the

examination because the testing equipment proved

to be too bulky for the trailers, too complex to

maintain, and too delicate to withstand the rigors

of transportation.

The areas of health information and attitudes,

behavior standards, educational goals, and opinions of self are but a few amongmany’areas per- . .

tinent to any study of adolescent health,, A set of

three questionnaires to obtain these and other data

was developed by the HES staff along with consultation and advice of the advisory panel to the survey and others, such as persons from the National

Institute of Mental Health. The resulting questionnaires were the Medical History of Youth-Parent

(appendix I B) , Health Habits and History-Youth

(appendix IC), and Health Behavior (appendix TE).

The key factors leading to the decision to utilize

three questionnaires was the realization that for

some items of information. the parent would be the

best provider of information, while for others it

would be the youth. In addition, certain items asked

of the youth would ‘be better answered at the examination center. It would also be possible to provide for study, similarities and differences between youth and parent on certain “comparison”

items such as educational goals and behavior

standards e Following the pretest at Detroit, Michigan, discussed in the following section, a contract

was entered into for further testing and developmental work of these forms.

Pilot Testing

In July 1964, the first of three separate pilot

test operations was conducted in the New York

area, the nineteenth location in Cycle II. It was

acknowledged by this time that the tests, procedures, and forms for the third cycle would be

similar, in many respects, to those of Cycle II.

One purpose of this first pretest was to determine particular Cycle II procedures or tests

which might be inappropriate or require further

investigation or development and modification

prior to a later and more formal pretest when the

other examination elements were more firm. An

additional purpose was to obtain a rough indication of what might be expected in the Cycle III age

group with respect to response and cooperativeness. Information from this would indicate the

desirability of initiating methodological research

into factors affecting motivation of teenage youths

in participating in a health examination survey

program.

Ninety-three youths were examined in the

New York pilot test. Among the procedures that

were new from Cycle II .was a venipuncture to

determine. the feasibility of this operation in the

12-17 year age group; a revised medical history

form; a group of questions in the area of personal

health habits and behavior to determine thereaction of youths to these questions and to establish

whether any such set of questions should be included in the third cycle; and a brief (2 to 3 minutes) exit interview, conducted by a consultant on

adolescent behavior, which consisted of asking the

examinee his or her reaction to the tests administered and what portions of the examination the

examinee felt should be eliminated or modified to

make it generally acceptable to the Cycle III age

group.

The objectives of this pretest were fully realized. In addition, other important aspects relative

to planning the third cycle which had not been anticipated were also brought to light.. Important

among these was need for changes in furniture,

equipment, and space requirements within the

examination center; changes in the wearing ap-
pare1 for the examination; desirable scheduling

arrangements; and optimal conditions for obtain&

ing cooperation.

In April and May 1965, a second pretest of

the survey was carried out in Detroit, Michigan.

The examination in the trailers had two main objectives: to solve internal logistics problems such

as length and sequence of different items of the

examination (and the effect of one procedure on a

subsequent one, for example, the exercise and the

psychological tests) and to field test various examination procedures. First among these were

various procedures for the collection of O urine

specimens for bacteruria among the girls; the atd

tempted collection of an accurate timed and ret

liable 6-hour urine specimen for nutritional and

endocrine determinations; various parts of the

highly structured physician’s examination such as

nutritional appraisal, acne grading, and objective

assessment of stage of sexual msituration; field

testing the new treadmill and cardiotachometer

(the instrument aspect and also varying duration

and intensity of the test); and the testing of a vard

iety of techniques for optimal blood collection and

handling and packaging. A complete testing ~a8

conducted of ail field procedures relating to

sample identification, Bureau of the Census household interviewing, foliowup interviewing and per u

suasion by Health Examinatiori Representatives

(HER’s), administrative records control,? transw

portation, and collection of data from schools. A

medical h&tory questionnaire to be completed by

the parent and two questionnaires invoiving health

history and behavior to be completed by the youth

were also tested. A total of 131 youths were ex*

amined during this pretest,

Following completion of the developmental

work, indicated as a result of the first two Poetests, a fulLscale pretest was conducted in Wils

mington, Delaware, during January and February

1966, at which time 163 youths were examined,

As will be discussed in a later section, the sample

design of’ Cycle III for various reasons called for

the utilization of the same sample areas andhouab

ing units of the previous cycle, Wilmington, which

in March and April 1963 had been the final pretest area for Cycle II, was therekw$ ideally suited

fey the final pretest of Cycle III, As such, it wws

powible tb obtain some irr&ghr Mto problems of

rcspome amociatti with persons subjected t0

both surveys; an estimate of the number of Cycle

II sample youths who would fall into Cycleril; the

reaction of local societies and school officials to

a second survey after about 3 years; and an estimate of the number of sample youths that could

be produced from the Cycle II sample design. The

conditions under which this pretest was conducted

attempted to simulate the operation of a regular

Cycle III location,

Between this pretest and the first location of

the actual Cycle III data collection, the technicians

received further training in the areas of body

measurements and audiometry and in techniques

of the use of special equipment to record on magnetic tape the results of eiectrocardiograms and

spirograms. The nurse also received further

training in the collection and culturing procedures

of the urine specimen, A “dress rehearsal” of examination procedures was held at the firststand of

Cycle III, Charleston, South Carolina; at this time,

46 youths were examined. Members of the-advisory

panel visited the examination center to observe

and give their final approval to the operation.

THE SAMPLE DESIGN

Simildfity to Cycle II

The sample design of Cycle III is similar to

that of Cycle II in that it utilizes the same 40

sample areas and the same segments. The de&

sion to incorporate this feature into Cycle XII was

not made prior to the selection of the second cycle

sample although it is consistent with the early

concept of a single program for 6-17 year olds,

The final decision to utilize this identical sampling

frame was made during the operation of the second

cycle program. This decision was based on the

following considerations:

1, There would be an increase of infoz?matisn,

since some of the children examined in

Cycle II would also be examined in Cycle

Ill, The graup of examinees included in

the overlap would provide longitudinal datd

which would add greatly to the study of

growth changes, It wa8 recognized that the

loss of some individuals through populau

tion mobility would keep the subset ~tsxamined fn both cycles from being a corn-
2.

3.

4,

pletely unbiased sample, but it was felt

the advantages outweighed this.

Cost of selecting a new sample would be

eliminated.

An expected high correlation within the

segments between the expected number of

youths in Cycle III and the number of

sample children in Cycle II,

Gains would be produced in the case of

field operations. Addresses would be

known, a large number of the sites used

for examination centers in Cycle II would

be available, and contacts with State and

local officials, to explain our program

and obtain their approval, could be made

by mail rather than by personal visit.

The sample design has been essentially similar for all three cycles in that each has been a

multistage, stratified probability sample of clusters of households in land-based segments. The

successive elements for this sample design are

primary sampling unit, census enumeration dis;

trict, segment (a cluster of households), household, eligible youths and finally, the sample youth.

Every eligible youth within the defined population

has a known and approximately equal chance for

selection into the sample,

A description of the Cycle II sampledesign is

presented in another report.“* It also discusses

the problems of and consideration given to other

types of sampling frames, cluster versus random

sampling, and whether or not to control the selection of siblings. It is felt, therefore, that an abbreviated discussion of the Cycle II sample design

and the minor modifications required for Cycle

III is- sufficient for the purpose of this report.

The Cycle II sample. design was developed

from a set of specifications which described the

requirements and limitations placed on it. The

general factors dictating the design specifications

were those relevant to the specific survey objectives and operational considerations. Those of

primary importance and relevant to both Cycles

II and Ill included the following:

1. The target population will be defined as the

civilian, noninstitutional population of the

United States, including Alaska and Hawaii, between the ages of 6 and 11 years

2.

3.

4.

5.

6 .

7.

8.

for Cycle. II, 12 and 17 years for Cycle III,

with the special exclusion of children residing on any reservation lands set aside

for the use of American Indians. This exclusion is due to operational problems encountered in Cycle I.

The time period of data collection should

be limited to about 3 years.

The examination objectives will be primarily concerned with factors of physical

and intellectual growth and development.

The length of an individual examination

will be between 2 and 3 hours. Approximately 12 examinations will be done each

day.

Examinations will be conducted in a specially constructed mobile examination

center.

Ancillary data will be collected through

the use of questionnaires and other records. These will consist of a household

questionnaire, medical history questionnaire, school questionnaire, and copy of

the birth certificate.

The size of the sample must be sufficiently

large to yield reliable survey findings. The

numbers involved will permit a general

analysis by broad geographic region, population density groups, and other major

subgroups such as age, sex, and limited

sociodemographic factors of the total

sample.

The size of the sample will also be influenced by certain administrative considerations and by the available budget which,

in addition to conducting collection activities, must permit simultaneous activity in

analysis and publication of findings from

other cycles and preliminary planning for

the next cycle.

The steps of drawing the sample were carried out jointly with the Bureau of the Census. The

starting points were the 1960 decennial census

lists of addresses and the nearly 1,900 primary

sampling units (PSU’s) into which the entire United

9
States was divided. Each PSU is either a standard

metropolitan statistical area (SMSA), a county, or

a group of two or three contiguous counties. These

PSU’s were grouped into 40 strata so that each

stratum had an average size of about 4.5 million

persons. This grouping was done in a manner

which maximized the degree of homogeneity within

strata with regard to the population size of the

PSU’s, degree of urbanization, geographic proximity, and degree of industrialization, The 40

strata were then classified into,4 broad geographic

regions of 10 strata each and then within each region, cross-classified by four population density

classes and rates of population change from 1950

to 1960. Using a modified Goodman-Kish controlled-selection technique, one PSU was drawn

from each of the 40 strata.

The sampling within PSU’s was carried out

in several steps, The first was the selection of

census enumeration districts (ED’s). These ED’s

are small, well-defined areas of about 250 housing

units into which the entire Nation was divided for

the 1960 population census. Each ED was assigned

a “measure of size” equal to the rounded whole

number resulting from a “division by nine” of the

number of children, aged 5-9, in the EDat the time

of the 1960 census. A sample of 20 ED’s in the

sample PSU were selected according to a systematic sampling technique with each EDhaving a

probability of selection proportional to the population of children 5-9 years at the time of the 1960

census date. From each ED a random selectionof

one measure of size (segment) was taken.

Minor changes required in the Cycle III design

were that it be supplemented for new construction

to a greater extent than had been necessary in

Cycle II, and that reserve segments be added.

Although it was the plan for Cycle III to use the

Cycle II segments, it was recognized that within

several PSU’s additional reserve segments would

be needed to avoid the risk of having an insufficient number of examinees. This was prompted

by the fact that four of the PSU’s in Cycle II had

yields of less than 165 eligible children and several others were marginal in their yield. In addition, there was a 3-year interval betweencycle

II and Cycle III, so that it was quite possible for

some segments to have been completely demolished to make room for highway construction or

urban redevelopment.

Subsampling

The time available for examinations at a particular location, or stand as they have been designated, is necessarily set far in advance of any

preliminary field work at the stand. Therefore,

the number of examinations that can be performed

at a particular location is dependent upon the

number of examining days available. At the

majority of locations the number of days available, excluding Saturdays, is 17. At the rate of

12 examinations each day, this provides for 204

examination slots. Examinations are conducted

on Saturdays if, for some reason, it is necessary.

Because of rescheduling for cancellations or noshows the maximum number of youths that is

considered for inclusion in the sample is 200.

When the number of eligible youths exceeds this

number, subsampling is performed to reduce the

number to manageable limits. This is accomplished through the use of a master list which is

a listing of all eligible youths in order by segment, serial (household order within segment),

and column number (order in the household by

age). After the subsampling rate has been determined, every n th name on the list is deleted,

starting with the y th name, Y being a number between 1 and n selected randomly, Youths who are

deleted from the Cycle III sample but who were

examined in Cycle II as well as’ any twin who may

have been deleted are, if time permits, scheduled

for an examination for inclusion in the longitudinal

study portion or twin study portion of the survey.

OTHER SAMPLING ASPECTS

Sampling Features of the Examination

The sampling aspects of the survey are not

restricted to choosing the sample persons and

having them participate in the examination. The

conduct of the examination itself has numerous

sampling features which should be mentioned

here.

Examinations will be conducted in 40 different locations throughout the United States by approximately 35 different physicians and five dentists. There will be approximately 12 technicians I

performing various procedures and 12 psycholo10
Table 1, Cycle III schedule of stand operations, HE3, 1966-70

Stand

number

1

2

3

4

5

6$

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

Location

-

Charleston, South Carolina------------

Ashtabula, Ohio-ww-LIIIIwwwwwwwwwwww~~

Poughkeepsie, New York----------------

Portland, Maine -ww”~1wwww~wwwwww~ww”ww

Boston, Massachusetts-----------------

Philadelphia, Pennsylvania------------

Ottumwa , d Towa -w-t3~~rw-rrwr~~~wr~wwwww

Denver, Colorado-ww~rrrwwwwwwrw~rwr~~"

Lamar, Colorado-~r~r-r-r-w~rrrrr~rrrrr .

Los Angeles, California---------------

Los Angeles, California---------C----wSan Francisco, California-------------

Mariposa, California-----------------~-

Moses Lake, Washington----------------

Minneapolis, Minnesota----------------

Neillsville, Wisconsin----------------

New York, New Yorkrrwr-rr~rwww"~r*w~"~

New York, New York -r-r~wwww-w-~~C~Crr~

Baltimore, Ma~y~and---wwsr-~------~w~~

Sarasota 3 Florida ~rrwr"r~wrrwrwn~rrw~~

Atlanta, Georg~~-w------~--------~wwww

Birmingham, A~aba~~-----w--w---------w

Barbourville, Kentucky-~--------------

Cleveland, 0hi.o w--r--wC~~~wCwwww~~~w~~

Chicago, ~~~~n~~s----uw~w~-----~-w-w-w

Grand Rapids, Michigan----------------

Des Moines ~“u~b--dRCFwCw~-nrw**rL

Wlchnca K~n~~~ _

. .

-~~rur-~scrr-rw-*-*-~w”

Mark& Tree, Arkansas------------*-----

San Benito, Texas -www~cwIIwww"IIc~"lww

Houston, Texasrr-r-wrrr~rwrrr~rr*~~ww~

Detroit, Michigan--C-~CICw-C---"ICLwwI

port HuT:on, ~~~h~gan---~-r-----~--ww-w

Beattyville and West Liberty,KentuckyAllentown, Pennsylvania---------------

Manchester and Bristol, Connecticut---

Newark, New Jersey-www~wwwwwwwwww-wwww

Jersey City, New Jersey---------------

Georgetown, De~aware---w--------Ccrrrr

Columbia, South Carolina--------------

Date of field operations

March-April 1966

April-May

May-June

June-July

July-August

August-September

September-October

October-November

November-December

December-January-February 1967

January-February-March

February-March-April

March-April-May

April-May-June

M&y-June-July

June-July-August

August-September-October

September-October-November

November-December

January-February 1968

February-March

March-April

April-May

May-June

June-July-August

August-September

September-October

October-November

November-December

January-February 1969

January-February-March

March-April

April-May

May-June-July

July-August

August-September-October

September-October-November

October-November-December

January-February 1970

February-March

'Stand locations are cities or towns in which trailers were located. Sample areas

from which examinees are drawn for the stand consisted of the PSU’s which may have included severa 1 counties.

gists administering psychometric tests. Ideally,

each examinee should be assigned to the particular

parts of the examination on a random basis with

respect to time, place, and examiner, This is

obviously impossible. Therefore, if there are any

peculiarities in the conduct of a part or parts of

the examination procedures, difficulties with

equipment, or changes in the standards of the laboratories doing blood chemistry analysis, they

may be reflected in the examination findings as a

place peculiarity.

Stand Sequencing and Scheduling

In all+ cycles of the Health Examination Survey , the scheduling of stands has been deliberately

arranged so that the North is avoided in winter

and the South in summer. This is a fairly obvious

operational necessity as it wouldbequiteimpractical to conduct a mobile examination survey such

as this in the northern States in the middle of the

winter. The schedule of stands for the third cycle

is shown in table 1.

11
While this type of scheduling is desirable

from an operational point of view, it can produce

certain limitations on the examination data. Any

characteristic under study which may have a seasonal variation will be difficult to interpret by

geographic region. For example, if persons inall

parts of the country weigh more in winter than in

summer, the mean weight of northerners would be

underestimated and that of southerners overestimated. Possibilities such as these must be taken

into account in analysis of the data. The seriousness invoked by such a scheduling arrangement,

however, is not considered to be too serious a

limitation in either Cycle II or Cycle III. Most of

the characteristics of the examination in the 6-

17 age group are not likely to exhibit any marked

seasonal variation, Even in Cycle I, where the

focus of the examination was on chronic conditions in the adult population, this was not considered to be too serious a problem. This would

not be true if the examination, in any of the cycles,

attempted to obtain estimates of acute conditions

such as respiratory disorders. \

An important consideration in sequencing

stands was economy of operation. Efforts were - made to follow the seasonal pattern described

above, with a minimal amount of travel necessary

in moving from one stand to the next by sequencing

with regard to geographic proximity. Another consideration was to minimize the range of the time

interval between the collection of Cycle II and the

Cycle III data at each location. The map (fig. 1)

shows the sample areas and itinerary of Cycle III.

Individual stand time schedules, featuring the various operational aspects involved in conducting the

examinations at a particular stand, were alsore-

/

Figure I. Map showing sample areas and itinerary: Health Examination Survey Cycle III,

12
quired in the development of the sequencing. Time

allowances were based on the distance between

stands and therefore the time required for movement of the trailers and personnel between stands,

the time required for Census Interviewing, HER

followup, trailer setup, staff setup and dry runs,

staff vacation periods, and at most stands, 17 days

for examinations, Schedules for three of the stands

are shown in table 2.

ADVANCE ARRANGEMENTS

Professional Rekations

Before the interviewing or examination procedures of the Health Examination Survey can be

started in a sample area, certain types of advance arrangements are necessary, Essentially,

they are of three different types involving professional relations, public relations, and arrangements for the logistical requirements of the

survey.

The conduct of the survey in any specific

area is the responsibility of the US. Public

Health Service, as distinct from the State or local

health authorities, or others in the area, In all

three cycles, however, it has been our policy to

fully acquaint the State and local health departmerits, and the medical, dental, and osteopathic

professional organizations in the States and in

the communities with the ’ HES objectives and

method of operation. In addition, since both Cycles

IT and III involve the examination of school children, the State and local officials concerned with

public schools are also contacted, as are the appropriate local and diocesan officials of the parachia1 schools.

In Cycle II, contacts were made initially by

letter or telephone giving some information about

the program and arranging for a personal visit

to discuss the plan in detail, A senior medical

advisor to the survey visited the State medical

societies, health authorities, and educational officials, The dental advisor informed the officials

of the dental association by mail and frequently

arranged a personal visit as well, The visits to

the State school officials were always preceded by

a general information and introductory letter from

the U.S. Office of Education, which had been kept

informed throughout the planning of the program,

Table 2, Excerpt from HES=+JI schedule

of stands

Stand #30 - San Benito, Texas l/3-2/14

(944 miles)

Qfflce setup m-a---wcl--aL l/3 Friday

Census interviewing------- 1/6.Monday

HER followup ---ccI---cc-~ 1113 Monday

TratJ.er arrival----------- 1114 Tuesday

Trailer setup------------- l/15 Wednes- a

day Staff setup and training-- l/20 Monday

Dry rum3 rc~rmr-r-w--rlr~ra

Examinations

l/21 T'gsd&y

a-C------C-Lwm l/22 Wgdnesday-2/13

Thursday

’ Dismantle ~wL-r-w--Ca~Ow-CI z/14 Friday

Xn transit ~-~~~-w-c..cl~w-c 2114 Friday

Stand #31 - Houston, Texas l/31-3/19

(353 miles)

Office setup w-----c-----C~ l/31 Friday

Census interviewing------- 2/3 Monday

HER followup ----m-~-rerCIL z/lo Monday

Trailer arrival----------- 2117 Monday

Trailer setup------------- 2/18 Tuesday

Staff setup and training-- 2/19 Wednesday

Dry runs ------------yL-wbw

Examinzkions

2/z(‘) Thursday

-wmFc-=--cq-mr 2124 Mondaya.

3118 Tuesday

Dismantle --------Cw---waLq 3119 Wedngsday

Pn transit~~~-cl--~----C-n 3/19 Wednesday

Stand #32 - Detroit, Michigan 3/7-4/Z

(iJ74 miles)

Office setup ----wr-r-w~rrr 317 Friday

Census interviewing------- 3/10 Monday

HER follotJup*-3-r--o----~~ 3/17 Monday

Trailer arrival------*---- 3124 Monday

Trailer setup-~----------~ 3124 Monday

Staff setup and training-- 3/25 Tuesday

Dry runs -~p--r-~r-rwnr--nC 3/26 We&esda

Examinations amwmmmmwww-wwq 3/2 '; Thursday-4118

Friday

Dismantle r-rwrCIRwI--rrrrr 4/2l Monday

In trans,t wra--rrnr-l-mr 4/21 Monday

It has been mentioned previously that the

sample areas in Cycle XI are also being used in

Cycle III, In the present cycle, therefore, it was

felt that personal visits to the above officials were

not required in all cases. Instead, letters are

13
mailed approximately 8 weeks before interviewing procedures are to begin, explaining the program and reminding them that the HES hadvisited

the sample area several years before to collect

similar information on the health of children ages

6-11 years. Also included is a copy of a resolution

passed by the American Medical Association

House of Delegates expressing their approval of

the survey and recommending cooperation, A second followup letter with supplemental information

about the survey is mailed about 1 week before

interviewing begins. At this time, letters and literature describing the survey are also mailed to

local officials such as the mayor, the Chamber of

Commerce, and law enforcement officers.

At the State and local levels, support of the

survey has been manifested in the cooperation obtained in informing physicians of the survey.

Frequently this is done by means of an article in

a professional publication distributed to all physicians in the area such as the monthly bulletin

of the county medical society. Correspondingly,

communications from the dental society are usually sent to its members, and the superintendent

of schools will usually send letters to school

officials who will be contacted later by a representative of the survey.

Public Relations

General news releases explaining the program are prepared for each sample area and are

distributed to local news media. The release is

timed to coincide with the start of Census interviewing. As a result, local newspapers at most of

the locations publish items concerning the program. No special effort is made tohaveradio and

television stations publicize the survey, but at

some locations, members of the staff have been,

interviewed by these media and film has been

taken to be shown on television. Under no circumstances, however, are pictures or films taken

of any sample examinee since this would be a

breach of our promise of confidentiality.

Sample households having a mailable address

(house or post office box number) are sent an

“advance” postcard by the Bureau of the Census

several days before the Census personnel begin

interviewing. This card informs the household

members that a Bureau of the Census interviewer

Logistical Arrangements

Four to b-weeks prior to the. start of a stand

a member of the HES field staff, the Field Operations Manager (FOM), visits the sample area to

make physical arrangements for the Mobile Examination Center and -the administrative office,

to personally contact local health and school officials, and to initiate the many logistical actions

required for the survey. The selection of locations for the examination center and administrative office are considerably simplified in Cycle

III, since in most sample areas the same sites

used in Cycle II are available. If for some reason

the previous examination site is not suitable, the

following items are considered in the selection

of a new one:

1.

2.

3.

4.

5.

6.

7,

Location of sample households and transportation arteries.

Community attitude (if any) toward the

location.

Proximity to power, water, and sewer

connection.

Reasonably free from noise and/or excessive vibration.

Availability of living accommodations for

the staff within a reasonable distance.

.Adequate space to accommodate trailers

and cars of staff.

Availability of office space for the administrative office in close proximity to

the examination site.

During this visit to the sample area, the FOM

also arranges for power hookup and services for

electricity, water, sewerage, telephone, transportation, and laundry. Any other logistical arrangements required before the arrival of the mobile

examination center and the staff, are also taken

care of at this time. Within the time allowed, he

visits as many as possible of the city and county

school superintendents whose authority extends

over schools which the sample youths attend.

14

/

-. ‘(

1

. .+

L., ‘-

* I>

. : --

’ .
PROCEDURES

EWING

Census Interviewing

Trained Bureau of the Census personnel call

on all housing units contained in the segments of

the sample area to determine their household composition and to obtain demographic and other data

if the household contains any eligible youths between 12 and 17 years inclusive. They pave the

way for the HES interviewers who subsequently

visit the household. Each of the households should

have received the advance postcard from the Bureau of the Census informing th-em of this visit.

The front of the household questionnaire, shown 3 1

as appendix IA, contains standard Census identification entries related to the housing unit, space

for recording information on calls, and a section

concerning a Medical History Form which is left

if the household contains any eligible youths. On

the inside of the questionnaire, questions l-6

identify all persons living in the household, their

relationship -to the head of the household, and their

age, race, and sex:If the household doesnot contain any youths between the ages of 12 and 17 inelusive, the interview-is concluded;

If the household does contain a youth eligible

for inclusion in the sur’vey, the remaining questions are asked only of the parent or guardian of

the youth. A callback is made by the Census interviewer if a parent or guardian is not present

initially. At the end of the interview, the interviewer leaves a medical history form with the

parent or guardian to be completed for each eligible youth. This form is shown as appendix IB.

The interviewer explains that a representative of

the U.S. Public Health Service will come to the

house in a week or so to pick up the completed

form. The interviewer also inquires as to the best

time of day for the representative to pick up the

form.

Occasionally the Census interviewer will interview a household which contains an eligible

youth 12 through 17 years of age but in which the&

are no parents or guardians, e.g., a 16 or 17 year

old who is married and living with his/her spouse.

In such instances, only the identification items of

the housing unit are completed on the front of the

questionnaire (question 14 is omitted), and on the

inside and back of the form only questions 1-7,

items C and E, and questions 13-16. It is explained

that the Public Health Service would like to send

the medical history form to the parents of the eligible youth concerning his medical history and

some questions concerning his mother. The eligible youth is asked for his parent’s name, complete address, and telephone number. This information is then given to the HES staff to followup

and mail the questionnaire. The role of the Census

interviewers is ended after all household questionnaires have been edited by the Census supervisor

for omissions or inconsistencies and then turned

over to the HES field management office.

HES Interviewing

From the household questionnaires a master

list is prepared which lists the name, age, sex,

and household identification of each eligible youth.

An eligible number (1, 2, 3, 4, etc.) is assigned

to each youth. If the number of eligible youths

does not exceed the maximum number allowable,

then sample numbers are assigned beginning with

the first youth on the list. If the number of eligible

youths exceeds the number allowable, then the subsampling procedure described in an earlier section is performed. Youths remaining after subsampling are then given Cycle III sample numbers.

If examination time allows, as many as possible of

the youths deleted from the sample through the

subsampling procedure who were (a) examined in

Cycle 11 or (b) are a twin whose twin sibling is a

sample youth, are also given sample numbers but

in a different series from the Cycle III numbers.

The former group of youths (a) are examined as

part of the longitudinal study aspect which Cycle

III presents, and the latter group (b) as part of a

smaller study of twin characteristics,

A few days after all Census interviewing is

completed and the master list prepared, HES

representatives (HER’s) visit all households containing eligible youths. This visit is designed to

accomplish several things. The medical history

form which was left by the Census interviewer

to be completed is carefully reviewed for completeness and-consistency. If the form is not completed, the HER attempts, with the parent’s help,

to complete it at that time. Except to answer any

questions that the parent might have about the

15
survey, there is no further responsibility placed pending on whether a contact was made during

upon the HER with respect to the youths deleted

from the Cycle III sample and not included in the

longitudinal or twin studies. For the sample youths

in Cycle III, deleted youths who were examined in

Cycle II, and deleted twins, there is much more

involved in this visit. At an appropriate point in

the visit, the HER explains the program to the

parent. She must be able to answer many questions about the survey such as the purpose of the

survey, how the sample was selected, examination

content, value of the examination to the individual,

and others. Obtaining agreement to cooperate by

participation in the examination has not been a

great problem in either Cycles II or III. Signed

consents of the parent are obtained for the youth’s

participation in the survey, for the survey to

transport the youth to and from the rnobile examination center, and for the survey to obtain

additional information from school personnel,

from a physician’s, dentist’s, or hospital’s records, and from other official sources such as

State registrars. A school excuse form is also

signed by the parent. The HER indicates to the

parent that the Public Health Service will be glad

to forward to the youth’s physician or dentist the

findings of the medical and dental examination if

the parents so wish. ,A marital history of the parents is obtained and a Health Habits and History

form is left with instructions that it becompleted

by the youth and be returned to the survey in the

envelope provided before he arrives for the examination. This form is shown as appendix IC, The

characterization of twins as identical or fraternal

is also established, Scheduling restrictions are

determined and recorded for later use by the administrative office in setting up appointments.

Finally, it is explained to the parent that he will

be notified by the survey of the date and time of

the examination. Also a leaflet is left which describes the program (fig. 2).

APPOINTMENT AND

TRANSPORTATION PROCEDURES

After all Census questionnaires have been

received, the schoolls attended by the sample

youths are identified and grouped. The Field

Operations Manager contact8 the School Superintetim either in per-n or by tele$une deadvance arrangements. They are informed that the

program is underway in the area, which of the

schools under their jurisdiction are involved, and

the number of youths. If the Superintendent has

not previously informed the school principals

under his jurisdiction of the survey, he is asked

at this time to contact those principals of the

schools which contain sample youths.

The scheduling and notifications of examination are worked out by the field management office. In preparing the schedule of youths to be

examined on any particular day, consideration is

given to any restrictions determined at the time

of the HER interview, the distance to the examination center, the school groupings, and any considerations the school officials may have introduced with regard to particular days or times.

Efforts are made to minimize the transportation

workload. At least 3 days before the date of the

examination, an appointment slip and covering

letter are- mailed to the home. Entered on the appointment slip is the time, day, and date of the

examination, where and when the youth will be

picked up, and when he will be returned. Youths

examined in the morning are usually scheduled

to be picked up at home and then taken to school

after the examination and a light lunch at the

center. Those examined in the afternoon are

scheduled to be picked up at school and taken home

after completion of the examination. Escorts are

provided for all youths. Usually these are carefully selected persons residing in the sample area

with transportation secured from taxi, limousine,

or small bus companies, or HER’s or other HES

administrative staff using government cars.

There are always a number of youths who for

one reason or another cancel their appointment,s

or are not available at the time they are to be

brought to the center. Those who cancel are fairly

easily rescheduled for another time. Those who

fail to appear without any notice of their intention

to do so or change their mind about participating

are followed up as soon as possible, preferably

the same day. Immediate followup of these youths

helps to reinforce in the sample youth’s mind the

importance placed on his participation. In many

cases, the youth can I thus be brought to the examination center only a little later than the other

examinees.
The Health Examination Survey is part of the U.S. Maional

Health Survey authorized by Congress in 1% to collect information about the health of Americans, Some information

is collected by asking people questions aboutthemaelvesand

their health. Other needed data can only .be obtained ‘by an

actual health examination.

All information obtained from individual6 by interview and

through the examination is held strictly confidential.. A report of the significant medical and dental findings is sent

to the exarninee’a physician and #dentist .on request. Rep.orts

of overall findings are published $or use by medical researchers, educators, physician6, dentists, and ,man.y:public

and private *agencies.

h 1%2, the *Health Examination Survey completed a ,6tudy

of health conditions of persons 1’8-79 years of age. About

7,000 adults throughout the United States .particdpated .in

,J&E special health examination which was a put of that

survey. In a second cycle of the HealthExamination Surv.ey,,

some S,,OOO children aged 6-11 year6 .participated .in a

health examination \designed to provide information about

growth and development during these years. Thin <was oompleted in December 1965.

Jn this cycle, we will be concentrating,on yyou young people

from 12-17 years of age. Some of you who .were examined

as 6-11 year olds may now be eligible for reexamination

as part of this older group. In any <event we are concerne.d

with the health aspects of your growth and development

during these important years.

The U.S. Bureau of the Census, working with the Health

Examination Survey, has selected 40 areas in the United

State.s which, taken altogether, represent the entire Nation.

Each of these areas consists of one or more cownties located in the northern, eastern, southern, and western parts

of the country. Some are urban and some are rural.

Within .eac.h of these 40 areas,.about 600 houses are 6elected

by scientific sampling methods. This is how .we ‘happened to

come to your home. Every person L&17 *years old, living

in one of these houses, automatically .becomes a part of the

national sample. This consists of .some &9,000 :young-persons

on w.hom we will obtain medical histories. This ifigure will

then be reduced *by another sampling procedure to give us

a sample of ab.out 8,000 persons to be examined.

The lexamination, which should .be an interesting and enjoyable experience for you, consists of the following:

A special examination by a physician of the eyes, ears,

nose and throat, heart, and nerve and muscle systems.

An electrocardiogram and a phonocardiogram of the

heart. (Type recordings of electrical impulses in the

<heart and of the heart sounds)

An examination by a dentist of the teeth and mouth.

Recordings of blood pressure.

Measurements of verbal, .perceptual, and social skill6

by a psychologist.

Audiometric tests for hearing performed in a specially

constructed soundproof room.

Tests of vision and visual acuity.

An X-ray of the chest and one of the.hand an,d wrist.

An exercise test walking on a treadmill, and a grip

strength test.

Biological and biochemical tests on a blood sample.

Measurement of breathing capacity.

Height, weight, and other measurements of growth and

develqpmen t .

The examination lasts about 3.5 hours. There are two examining periods each .day, morning and,afternoon. Occasionally there will be an evening session scheduled. Six youths

will be examined during each period. ,Ordinarily, there

will be other young people from your-neighborhoodor school

in your group.

The examination is given in our mobile “Health Examination

Center” which consists of foyr specially built trailers.

Transportation ,to and .from the Center will be provided by

-the .Public Health Service. There is no cost to you for any

part sfthis. If you are scheduled forthe examination during

school :hours, arrangements .will have been made with the

proper sch,ool officials in advance.

There are some 22 million young-people between the ages

of 12 and 17 in the United States. NaturaIly we.cannot examine all of them. As a participant,therefore, you represent

about 3,000 youths in your age ,group. .Whether you have

been asked simply to complete .the .medical history or

whether you have been asked to participate in the health

examination as well,, you p.lay an essential partin the success

of the survey.

Both you and your parents have been asked P O fill out a

que6tionnaire concerning YOUR health. If you are one of

those chosen, you have also been asked -to participate in the

examination. For this, of course, we need the written consent of your parents since, legally, you are a minor.
At the time sample youths are picked up or

returned to the schools, the escorts leave with

the school principal a form, Supplemental Information From School, for each sample youth in the

school. The principal has been notified of this

aspect of the survey before delivery of the forms

and has been asked to have the form completed

by the youth’s teacher or whoever he believes to

be the best informed respondent. Each form has

the name and address of the sample youth already

entered, and a preaddressed envelope is provided

for its return to the survey. This form is shown

as appendix ID. In those locations visited during

the summer months, when school is not in session, the questionnaires are mailed to the school

in the early fall with a request that they be completed and returned.

EXAMINATION CENTER AND

FlEiD STAFF

As in the previous two cycles, examinations

are carried out in a specially constructed mobile

examination center. The center used for Cycle II

req.uired some modifications and renovations to be

performed between cycles to adapt for changes in _

examination procedures, but the basic scheme is

the same. Four large trailers are used, two are

35 feet long by 8 feet wide and two are 45 feet in

length by 8 feet wide. The individual trailers are

drawn by detachable truck tractors when making

moves from one area to another. These trailers

are set up side by side and connected by covered

passageways to make the examination center. Figure 3 shows the four trailers and the floor plan

of each. A minimum space of 60 feet by 60 feet is

required to accommodate the trailers. The sites

on which the trailers are located must be as level

as possible to avoid any effect on certain examination procedures and must also be accessible

to the truck tractors. Heating and air conditioning

units have been installed to help provide a standardized environment for conduct of the examinations.

The field staff necessary to carry out the

operations of the survey may be considered to

consist of three elements. The first is the team

of Census interviewers (usually five to seven persons) and a supervisor. Their work, which is

described elsewhere in this report, begins on a

Monday, takes about 5 days to complete, and is

usually 2 to 3 weeks in advance of the examinations. The second element consists of the administrative and management personnel and the HES

interviewers. The administrative staff arrive at

the location and set up their office on the Friday

before Census interviewing, with the HES interviewers arriving 1 week later. The administrative staff consists of two field office managers

and two administrative assistants. The administrative staff includes duplicate positions since

their operations at a new sample area begin before

all examinations at a preceding area are completed. This period of overlap is in most cases

2 or 3 weeks. The third element is the examining

staff operating within the mobile examination

center. These include a physician, a nurse, a

dentist, two psychologists, four laboratory X-ray

technicians (one with supervisory responsibilities), and a clerical assistant.

With the exception of the physician, all other

members of the field staff are Civil Service employees or Commissioned Officers of the Public

Health Service. The examining physician is either

a senior resident or a fellow in pediatrics recruited from selected medical centers, medical

schools, or hospitals and is generally employed

only for a single sample area.

A medical advisor to the survey, a Public

Health Service commissioned officer, is present

during the first few days of each stand to supervise examinations by the new physician and to

provide consultation on any of the other various

medical aspects of the examination.

EXAMINATION PROCEDURES

General

As discussed previously, the content of the

examination was developed after extensive planning , consultation, and methodologic and pilot

studies. As such, it is a special examination tailored to the objectives and limitations of the survey and is not intended to be a complete medical

examination. The fact that the exa.mination is not

a substitute for a visit to one’s own physician and

dentist is explained to the parents of each sample

youth. The findings of the physical examination are

not disclosed to the youth or parent but, with the

18 .

.(

. ‘.
EXAMIN EE

ENTRANCE

r

--e--w ---- l

I

I

I AUDIOMETRY 1

I

L

<

M e ---- ---

WAITING AREA

WAITING

AREA

I ROOM

II I I I

-I

------a

PSYCHOLOGICAL

EXAMINATION

FLOOR PLAN

J DENTAL EXAMINATION

J

Figure 3. Mobile examination center.
parent% signed’ consent, a reporx i.s sent to the

physician named by the parent. A report of the

dental examinarion is likewise sent to their dentist. The reports make no specific tre&m-enn.ti retommendations except to: suggest, when it appears

desirable, that the youth be seen Before his next

regular appointment. A.11 forms being. used in the

examination, with the exception of those in the

psychological area, are shown as appendix IF.

flow of Examinees

The pattern o.f scheduling examinees inCycle

III is very similar- to th-at. of Cycle II, In the early

pibt test work of Cycle 11 it was observed that

the< children. were more at ease if a number of

th.em came in for the examination at the same

time., Another advantage of this type of scheduling

was tA,e fact that since most: of the children were

attending school, the problem of transportation

would be. facilitated if a number could be picked

mp at school or transported back to school at the

same time. In&vidual, scheduling of examinations

would greatly complicate the problem of trans.

porTaUon.

Six examination slots are available in the

morning and six in the afternoon. Because of this

it is necessary to vary the sequence of examinations, for example, the &ix could not be examined

by one physician at the samepointinthe sequence

of examination elements if aI1 examinees started

tog.ether y After screening all history forms, the’

physician sees and examines. beforehand any examinee whose history for cardiac or other reasons indicates he may be unable to tolerate the

exercise test, and wiQE excMe him from the test

jf oecessary. Equallly important is the fact that

pregnancies among females be identified so they

will be omitted from the treadmill test and from

the chest X-ray.

z When the examinees arrive at the mobile

units, the nurse and the clerical assistant provide

a short resume’ of the examination to assure the

examinees that no internal or painful tests are involved and to place them at ease as much as possible, Temperatures are then taken and any examfnee with a temperature of 1MP or over is seen

immediately by the physician and may be sent home

at the physician’s discretion. The& will be rescheduled for another date. Name cards showing

the examinee’s name and sample number are worn

during the entire examination. Special clothes are

also provided. These consist of gymnasium-type

shorts, a terry cloth robe, andcotton socks. Girls

are also provided with a specially designed blouse.

These uniforms were designed to facilitate and

stan.dardize various elements of the examination

such as the physician’s examination, the body

measurements, and the X-rays.

The flow of examinees is controlled by the

daily flow chart which is designed for efficient utilization of staff time by specifying the sequence in

which the youths are examined. The daily flow

charts, one for morning and one for afternoon, are

made up by the clerical assistant. In the preparation of these charts, numbers I through VI are assigned to the examinees. These numbers, as can be

seen from the chart (fig. 4), determine the sequence of examination procedures for each examinee. In the event there are fewer than six examinees, any of the six numbers may be omitted to

obtain the examination sequence which permits

best utilization of staff members. The clerical

assistant has the responsibility to insure that the

flow chart is followed.

In addition to those discussed above, : other

responsibilities of the clerical assistant which

should be mentioned here include recording data

from the dental examination, maintaining a daily

log of unusual events, reviewing completed case

records for completeness and consistency, preparing examinee lunches and snacks, and seeing

that each examinee completes a self-administered

Health Behavior form (appendix IE) during some

free time in the examination if ‘it has not been

completed during the psychological testing.

The Examination by Physician and Nurse

Prior to joining the field staff, each examining physician receives brief training in special

areas, especially in adolescent medicin (including maturation grading), otolaryngology , and dermatology. A medical advisor of the survey conducts this training with the aid of consultants in

medical institutions in the Washington, D.C. area.

Each Medical History of Youth form (appendix IB) and Health Habits and History-Youth

form (appendix IC) is reviewed by the examining

physician on the day before the scheduled exami20
0 hour 2

1st hour

2nd hour

HEALTH EXAMINATION SURVEY-CYCLE III

Examinee Flow Chart

Date

3rd hour

1

,'X and 11

Psychology Psychology

T-l T-2

1

T-2 I T-l

Physician Dental

and and

Nurse Vision

Dental

and

Vision

Physician

and

Nurse

Physician Dental

and and

Nurse Vision

T-l 1

T-2

Dental Physician

and and T-2 T-l

Vision Nurse

1' Physician Dental

and and

Nurse Vision

Psychology 1 Psychology 1-e

will be boys, _

zTemps.,'

tests).

change-clothes (except 1 and IX who change clothes after the psychological

L%

NOTE: T-i= treadmill, body measurements and grips, X-ray, height-weight.

T-2= audio, spirometer, ECG and phonocardiogram, secretor specimen.

figure 4. Examinee flow chart.
nation a Speciit i attention is paid to any entries

which suggest a limitation Oil the youth’s ability

to perform any of the tests or procedures and to

items which may require further followup in the

course of the examination.

It may be argued that a preexamination review

of these forms would result in the physician’s examination not being quite the same for every examinee. A blind-type design in which the physici

did not see amedical history woul.d produce somewhat different results in some cases. It was felt,

however, that the advantages of an examination

procedure more nearly like that in clinical practice outweighed these disadvantages. The physician’s examination includes an eye, ear, nose,

and throat examination, check for goiter, musculoskeletal and neurological evaluation, cardiovascular examination, grading of facial acne, assessement of sexual maturation, and an appraisal

of nutrition.

The nurse is present during the examination

and in addition to drawing a sample of blood and

questionnaire concerning the menses and collection of a urine specimen for culture of bacteriuria.

A “repeat” urine collection is indicated if the culture shows 100,000 organisms or more per cc.

The examinee is rescheduled for two return visits

as soon as possible and on consecutive days if

convenient to the examinee.

If the first repeat specimen shows less than

100,000 organisms per cc. the second visit may be

cancelled. All cultures having 60,000 organisms

or more per cc. are sent to the University of Virginia School of Medicine for organism identification and serotyping.

The eye examination includes a careful, general inspection for evidence of abnormal conditions of the lids, conjunctivae, sclerae, pupils, and

irides; a cover test for the presence of any tropia;

an inspection of the conjugate gaze; and determination of the focusing or dominant eye.

For a variety of practical reasons a lengthy,

highly structured, carefully standardized neurological exam.ination is not part of the physician’s

examination. Instead, after reviewing the total

hi.story, and testing am.inimal number of reflexes,

the physician performs as many neurological tests

as he feels are necessary either to satisfy himself that no significant neurological abnormality

exists or to delineate clearly the nature and extent of any such abnormality, much as he would

do in a clinical setting. Likewise, he uses a number of simple prescribed procedures to. obtain

clues about possible musculoskeletal problems., I

such as loss of range of motion in a joint<ormus--

cle weakness. These minimal. screening tech- ,

niques, coupled with the physician’s judgment and

skill in undertaking and interpreting any further

tests, allows him to consider the child as normal

in these respects or to obtain with reasonable

accuracy and effort a coherent explanation of any

neuromuscular or skeletal problem.

The musculoskeletal examination consists of

having the examinee put his wrists, elbows, shoulders, hips, knees, and ankles through a full range

of motions by a series of actions such as bending

forward, abducting legs and arms, and squatting

and touching toes. If he is unable to perform any

one or more of these procedures, further examination is given. For example, if he is unable to

squat or fully abduct his legs, then the hip is investigated by performing the Thomas test. Both

tibia1 tuberosities are palpated for tenderness and

swelling as definite evidence of past or present

Osgood-Schlatter disease. Hand and foot dominance are determined by having the examinee state

and demonstrate the preferred side.

Prior to joining the field staff, the physician

is given specific training in performing the ear,

nose, and throat examination. This examination

is of special interest because of the relevance of

these findings to the audiometric data. The examination consists of a general inspection of the

external ear, routine otoscopic examination of the

external auditory canals and tympanic membranes, pneumatic otoscopy, and examination of

anterior nares, tonsils, and oral pharynx.

The breast examination in males is performed

by inspection of both areolae and palpation of

breast tissue for gynecomastia and tenderness.

For females, maturation is graded and the breasts

and axillae are palpated for masses.

The genital examination for both sexes consists of evaluation of stage of maturation based on

presence and distribution of the pubic hair. Further examination of males involves an inspection

of the genitalia for circumcision and grade of ma22

* . _

/

I

. . 1

, .

i .
turation, the usual check for hernia, and palpation

of the testicles for masses.

The cardiovascular examination is a routine

auscultation of the heart. If findings are present

which are felt to be significant or even possibly

significant, a .tentative diagnosis is made. E3ecause

there is no recourse to trained cardiologists, all

diagnoses based on cardiac auscultatory findings

are considered “tentative” or likely but not definite. Three blood pressure readings are takenthe first at the beginning of the physical examination with the youth supine, the second with him

supine after the examination, and the third immediately thereafter with the youth sitting on the

edge of the examination table.

The blood sample is taken to determine hematocrit and hemoglobin, levels of- cholesterol, uric

acid, serologic tests for syphilis, testosterone

levels (in boys), protein-bound iodine, and to make

extensive genotype determinations of the blood

groups.

For each youth, the parents are asked to name

a physician (or clinic or other health facility) responsible for the youth’s medical care. This physician later receives a summary of the youth’s

examination and many related tests, including a

photographic copy of the chest X-ray. The examining physician notes on this summary sheet any

condition (such as serious intercurrent illness or

new complication of known disease) of which he

believes the physician may not be aware. In those -

few exceptional cases where it is warranted, the

examining physician provides for prompt or immediate referral of an acutely ill youth to his physician for indicated care, and may appropriately

discuss the problem with the individual’s physician.

More directly important to the survey is a

parallel summary of findings which the examining

physician makes for the survey records. Using

his training and clinical judgment, the youth’s

medical history, his own examination, the hearing

and vision tests, and the other data available to

him from the other examination procedures, he

decides whether or not the adolescent is basically

healthy. Excluding from consideration mild, transient problems such as minor cuts or bruises,

fractured bones that healed without complication,

and colds, he decides whether the youth before

him has been and is developing satisfactorily and

growing normally. Because of the small size of

the survey sample, the number of cases of abnormality traceable to any single given cardiovascular, orthopedic, or other disease will be

small. Nevertheless, data are available for adolescents who either are or are not normal and

healthy in the opinion of well-trained pediatricians. In addition, he assigns specific medical

explanations for those youths who have or have

had significant disturbances in health or development. These impressions are useful in studying

the prevalences of causes, or at least, groups of

causes, of exceptions to the usual patterns of

growth in this age group.

Dental Examination

The dental examiners derive their findings on

a uniform basis by following, as closely as possible, a written set of objective standards; The

standards are guidelines which, in effect, narrow

the range of examiner variability by eliminating

many of the borderline or questionableconditions \

that are frequently a source of disagreement. To

avoid other sources which might result in systematic bias, the dentist does not dry or isolate

teeth during the examination, remove oral debris

and calculus, or probe any tooth surface that does

not have an overt sign of decay.

The dentist dictates to a. trained recorder the

condition of each tooth that is present. Teeth are

classified as sound, filled, decayed, filled-defective, or nonfunctional. Missing permanent teeth

are also noted and each is classified under one of

four groups: unerupted, carious extraction, accidental loss, and orthodontic extraction. The examination form also provides a means of recording the presence of artificial teeth, unshed primary

teeth, and root remnants.

The next step of the examination is an assessment of the periodontal structures and-the status

of oral hygiene. A periodontal index score is entered for each tooth. The score ranges from O-8,

depending on the absence or on the presence and

extent of gingival inflammation and pocket formation. An oral hygiene score, ranging from O-6, is

recorded for all or any of six predesignatedteeth

that are present. The score is an estimate of the

amount of debris and the amount of calculus on

selected surfaces. Fluoride and nonfluoride opac23
ities and fractures of the anterior are also recorded,

The dental examination ends with a detailed

assessment of the occlusion and alignment of teeth.

The relationship between upper and lower incisors

is described by measuring the vertical and horizontal distance separating them. The occlusal relationship of posterior teeth is described by recording the anteroposterior position of the upper to

the lower teeth and the number of upper teeth in

crossbite. All displaced and rotated teeth are

counted and recorded.

An adjustable examining chair, a standard

light source, and a mouth mirror and explorer are

used in the examination of the teeth and gums. The

examination is usually completed in less than 10

minutes. At the request of parents and with their

authorization, the examining dentist fills out a

brief report form which is sent to the youth’s private dentist.

A saliva sample is collected by the dentist

to provide an estimate of the number of youths

who secrete blood group antigens, It is collected

on all examinees except those who have bleeding

gums, Waxes or other substances to stimulate

salivation’ are not used.

Vision Examination

The vision test battery is administered by the

examining dentist, since this member of the examining team has the requisite time available,

The result is to have these procedures carried

out by a professional person who, once the necessary special training has been given, is highly

adept at administering the examination.

Included in the vision examination are tests

for color deficiency (Ishihara’s screening test

followed by Hardy-Rand-Rittler ‘s test to establish’

fact) type, and degree of deficiency); tests for

mopocular and binocular visual acuity at distance

and near (Bausch and Lomb Master Orthorater

with special Armed Forces plates supplemented

_ by Landolt ring charts for illiterates); tests for

distance and near lateral phoria; trial lens test for

myopia for any examinee scoring less than 20/20

(Snellen notation) at distance; aad lensometer

readings for the glasses or contact lenses worn by

the examinee, Color vision, visual acuity at distance, the trial lens test for myopia, and the lateral

phoria tests at distance and near are given both

with and without glasses for the youths who normally wear them. Administration of these tests

usually requires about 10 minutes.

Psychological Testing

In line with the recommendations made by

child psychologists from five universities and the

National Institute of Mental Health, it was decided

to continue the same test battery used for the children’s examination, with slight modifications, to

assess the mental health aspects of growth and

development, This makes it possible to evaluate

intellectual and emotional growth and development

on a comparable basis throughout childhood and

adolescence,

After the pilot test, it was decided to use the

following test battery in the survey,

1.

2.

3.

4.

5.

6 .

Vocabulary subtest from the Wechsler

Intelligence Scale for Children

Block design subtest from the Wechsler

Scale

Human figure drawing administered as a

modified Goodenough-Harris Drawing

Test with drawings made of a person and

a self-drawing of the examinee

Selected cards from the Thematic Apper- ’ ception Test

Wide Range Achievement Test-the reading and arithmetic subtests of the 1963

version

A brief reading and writing test of literacy

The psychometric battery is administered by

psychologists who have been trained at least at

the level of the master’s degree and whohave had

some experience in administering tests to adolescents. The time required to test a single youth

is approximately 70 minutes. All but the literacy

test forms, which were developed under special

contract for the Health Examination Suvery, 4g are

available commercially, Except for the Thematic

Apperception Test, the test forms include space

for the required answers or entries. In the case

of stories produced on the basis of the Thematic

Apperception Test cards, the psychologist makes

24
tape ’ recordings which are IaM transcribed aiid

made available for reading and evaluation.

Procedures Perkwmed by Technicians

Four technicians conduct the following operations of the examination: an audiometric test, Xray of the chest, X-ray of the hand and wrist,

measurement of height and weight, spirometry,

electrocardiogram, test of grip strength, a series

of body and skinfold measurements, and an exercise tolerance test,

The audiometric testing iS done in aspecially constructed, acoustically treated room large

enough for both the technician and the youth being

examined, Because of space limitations it was also

necessary to install another testing instrument- ,

the Data Acquisition Unit (DAU)-in this room,

The hearing tests are always done when the DAU

is not in use, Special sound pressure level surveys are conducted to be sure that ambient noise

in the test room is sufficiently attenuated to allow for accurate testing.

Each youth is tesied at eight different frequencies with the 4,000 c.p,s, frequency repeated

a second time, For each frequency the sound is

presented separately to each ear in the randomized

order prescribed on the recording form. Alternation of presentation to each ear varies between

examinees according to whether the examine&s

sample number is odd or even. This is arranged

so that for half of the youths the first ear tested

is the right and for the other youths it is the left.

The threshold recorded for each frequency is the

lowest decibel level at which 50 percent or more

of the responses are obtained, that is, two out of

three or three out of five trials (fig. 5). Any condition such as earache, cold, or unusual behavior

which may affect the test results is also recorded,

Two X-ray films are taken. One is a 14x17

posterior=-anterior film of the chest at a distance

of 72 inches,, and the other is a 8x10 film of the

right hand and wrist for the determination of skeletal age and bone density. All recommended precautions to minimize radiation hazard are taken,

including the use of a special “no scatter” cone,

use of lead-rubber apron shields, and the wearing

of radiation badges by the technicians. New radiation badges are provided at the kginning of each

location, Periodic dosimetry field surveys are

Figure 5. Audiometric testing.

conducted by the Radiological Health Division of

the U.S. Public Health Service.

After the X-ray films are developed, they are

reviewed by the physician before the -examinees

are released from the trailers so that inadequate

films can be repeated. No formal readings of the

X-rays are done at the mobile examination center.

However, the physician does screen the chest Xray for abnormalities prior to recording his summary of findings. Readings of the hand-wrist Xrays for assessment of bone age are being done

by medical students with special training in this

area, at Case Western Reserve University under

the supervision of Dr. S. Idell Pyle.

The results of a 12.lead electrocardiogram

and spirogram are recorded on magnetic tape by

use of a Data Acquisition Unit. Under terms of an

agreement with the Medical Systems Development

Laboratory, National Center for Health Services

Research and Development, U.S. Public Health

Service, the tapes are fowarded to their facilities

for processing. For each examinee, the Health

Examination Survey is provided with tabular printouts and digital computer tapes of all basic data.

For the electrocardiogram, this consists of the

amplitudes and durations of various waves in each

of the 12 leads, as well as such data as QRS and

a axes, rates, and so forth. Basic data for the

spirogram will consist of measurements from

three or four trials of maximal forced expiratory
Figure 5. Testing lung capacity.

volume, the forced expiratory volumes at 1,2, and

3 seconds, the maximum expiratory flow rate, the

maximum midexpiratory flow rate, and various

peak flow rates (fig, 6).

A test of grip strength is made using a dynamometer -three separate tests for each hand.

The examinee is also questioned to determinehis

“handedness .‘! ,- A special self-balancing scale is used to record the examinee’s weight directly on the record

form. Following this, the examinee steps off the

weight scale and stands on the platform of the

height scale. The examinee is positioned with his

back and heels against a vertical bar to which an

adhesive strip wit5 his examination number is

fastened. He is asked to stand with feet together

and head facing straight ahead in the Frankfort

plane. After he has been positioned, a movable

horizontal arm is adjusted to fit snugly on top of

the examinee’s head. The technician then presses

a button attached to a camera mounted on the

Figure 7.

movable arm which is focused on the scale and a

pointer arrow indicating the height. A finished

print is available shortly thereafter which becomes a part of the examinee’s record (fig. 7).

In addition to the weight and standing height,

36 other body measurements are made. Seventeen of these are similar to measurements taken

in Cycle II. Various heights, breadths, and girths

Figure 8. Taking body measurements.

26

*-

.-

-, ?-

: .f ’ 3

* .- .

.

i , I,

.

. ’ I
are all taken on the right side of the body with one

exception, the medial calf s kinfold. Skinfold thickness measurements are recorded to the nearest

half millimeter while other measurements are

recorded to the nearest millimeter.

The measurements are made with one of the

technicians performing the procedures and another acting as a recorder. A recorder is essential for the recording of anthropometric data to

insure the optimum accuracy in the collection of

data and to assist in the correct positioning of

the examinee. Since the recorder has had the same

training as the examining technician, any errors

noticed in the measurement procedures are called

to the attention of the technician taking themeasurements. As a measurement is read, it is reported to the recorder, who repeats the number,

records it in the proper space, and gives the name

of the next measurement (fig. 8).

The exercise tolerance test is carried out by

the use of a treadmill. The test consists of a 5-

minute walk at a speed of 3.5 miles per hour. The

grade of incline during the first 2 minutes is zero,

i.e., treadmill surface is level, after which it is

raised to a lo-percent grade for the remaining 3

minutes. The result of the test is the recording of

the examinee’s pulse rate. This is monitored and

recorded by means of precordial leads going to a

cardiotachometer which records both the electrocardiogram and instantaneous pulse rate (fig. 9).

Since reasonably constant ambient temperature

and humidity are a very important part of this

procedure, the room in which this test is administered is kept between 70 and 74 degrees Fahr-

-enheit and between 50 and 60 percent relative

humidity.

The technicians perform a duplicate hematocrit on each subject and are also responsible for

the preparation and packaging of bloods sent to

the independent laboratories for analysis. ‘Bloods

for the serologic tests for syphilis aresent to the

Venereal Disease Research Laboratory, Communicable Disease Center, Public Health Service.

Each specimen is tested by the VDRL and the

FTA-ABS methods. Determinations of total serum

cholesterol, uric acid, and protein-bound iodine

are made by the Lipid Standardization Laboratory

of the Laboratory Branch, Communicable Disease

Center, Public Health Service. Hemoglobin content (MCHC) and blood typing are done by the ImFigure 9. Exercise tolerance test.

munogenetics Laboratory, Johns Hopkins University. A 2pecimen of plasma is frozen and stored

for possible future determination of testosterone

levels in the boys.

SUPPLEMENTAL DATA

Reasons for Collection

In earlier sections of this report, reference

has been made to the questionnaires obtained as

supplemental data to the examination portion of

the survey. Among these were the household questionnaire administered by the Census interviewer,

a youth medical history questionnaire completed

by the parent and another by the youth, a health

behavior questionnaire completed by the youth in

the examination center, a marital history questionnaire administered by the HER to the parents,

and a questionnaire completed by the youth’s

school teacher or other school officials acquainted

with the school record of the youth. A copy of the

27
birth certificate of each youth is requested from

the appropriate State or city registrar’s office.

These supplemental data are collected for

various purposes which can essentially be grouped

into the following categories:

1. To provide a demographic frame against

which the examination findings may be

viewed.

2. To assist the physician in his examination

of the youth by alerting him to certain

conditions necessitating further special

examinations or to limitations requiring

special handling in one or several of the

procedures in the overall examination.

3. To facilitate subsequent survey operations. (An example of this is information

on grade and school of the youth.)

4. To relate health history, achievement,

behavior, and other questionnaire data to

specific findings of the examination.

5. To verify such information as date of birth

or grade placement obtained from another

source.

Description of Supplemental Documents

The household questionnaire, which was developed jointly by members of the HES staff and

Bureau of the Census personnel, is the basic

source document of demographic data concerning

the population sample; it also serves in the final

stage of sample selection. The administration of

this form by the Bureau of the Census interviewer

has been described previously. In addition to obtaining the age, race, and sex of all household

members, a variety of other data is obtained from

all households containing an eligible youth. These

data include information on the school attended

and the grade for each eligible youth, as well as

information for each parent or guardian concerning their education, country of birth, handedness,

working status, and marital status. Information

about the status .of any other children from the

present or previous marriage who are not presently living in the household is asked of the parents only. The total family income and whether

any language other than English is spoken in the

home are also determined, Parents or guardians

are also asked three questions concerning the occurrence of certain specified episodes such as

death in the family, which might be regarded as

potentially traumatic in the life of the youth.

The Medical History of Youth questionnaire

(appendix TB) completed by the parent or guardian,

is primarily intended, as its name implies, to

obtain data on the health history of the youth. In

this respect, its value lies in several directions,

It alerts the examining physician to certain conditions which may require him to administer further special examinations or to preclude the examinee from participating in certain procedures

of the overall examination, It also provides data

which can be related to findings of the various

procedures in the examination. For example, it

provides information concerning injuries or operations to the ear, or earaches and similar items

which can be analyzed in relation to the results of

the audiometric testing. The greater portion of

the last page of the form is applicable to girls

only and pertains to their menarche,

The Health Habits and History questionnaire

(appendix IC), left at the home to be completed by

the youth, contains those items of health information which it is felt are best answered by the

youth. For example, while the parent could surely

answer whether the youth wears glasses or contact lenses, the youth would be better able to answer questions related to the necessity for glasses

and, if glasses are worn but not all day, the occasions when he does use them. As in the case of

the medical history completed by the parent, it

also alerts the physician to certain conditions for

further special examination procedures-or to conditions which may preclude the examinee from

participating in certain procedures, Several items

are included which are also contained in the history

questionnaire completed by the parent. These

“comparison” type questions have been included

where the agreement or disagreement between

parent and youth is of interest, Examples of these

are some medical history items, opinions of general health and physical growth, eating habits, and

time since last saw a doctor and dentist,

The Health Behavior questionnaire is completed by the youth while in the examination center.

The form is shown as appendix IE. Some of the

questions on this form parallel those on the health

28
history completed by the <parent. Examples are

items concerning educational goals, behavior

standards, amount of parental involvement in certain decisions concerning activities of the youth,

and the importance attached to certain medical

conditions. Other questions concern smoking habits, difficulties with law officials, and the importance of attention to certain dental conditions.

Marital history information of the parents is

obtained by the HER during her visittothe household. The data collected is a record of all marriage

dates and the reasons for; and dates of termination

in the case of broken or multiple marriages of

either parent.

Another piece of supplemental information is

that obtained from the school at which the youth is

a student. This form, Supplemental Information

From School, is shown as appendix ID. Mention has

been made previously concerning the delivery,

completion, and return of the form to the survey.

A mail followup is made when the questionnaire is

not received within a reasonable time.

The school form serves to provide official

information on the youth’s grade placement, an

item collected from the parent but subject to potential error, It collects other purely objective

data such as date of birth, grades skipped or repeated, absenteeism, and disciplinary problems.

It obtains the teacher’s evaluation of the youth’s

behavior, ability, and performance. It also identifies any youths whose health problems or differences (including mental ability) have come to the

attention of the teachers or other school officials.

Thus, for example, the youth who is known to have

a vision or hearing problem is identified. It also

provides data on the availability and utilizationof

special resources needed. Most important, while1

the battery of psychometric tests provides valuable information on the youth’s personality growth

and development and on general levels of intellectual ability, the questionnaire will provide some

comparative information which will give an indication of the youth’s actual accomplishment and

performance in his real life situation.

The final piece of supplemental data to be

collected is the birth certificate of the youth. This

document was also a part of the data collected in

Cycle II and therefore will already be available

for some of the Cycle III examinees. Data obtained on the household questionnaire and the medical history completed by the parent provide the

necessary information to make the request from

the appropriate State or city registrar’s office,

Permission to acquire this information is obtained

during the course of the HER interview. A copy

of the birth certificate is desired for several reasons. It is important, particularly in connection

with the scoring of psychological tests and for the

analysis of all the growth and development data,

to have the exact and correct age for each child.

It is also felt that the mother’s age at the birth of

the child could be obtained more accurately from

this document than from reconstruction from the

age reported in the household interview along with

the child’s age, Finally, the birth certificateprovides some information relating to the child at

birth (birth weight, congenital conditions noted at

that point, and complications of delivery) which

can be related to some of the findings of the survey examination.

QUALITY CONTROL

The efforts of the quality control program

extend to all phases of the operation-from the

beginning of the Census interview until all collected data has been coded, edited, and plac;td on’

magnetic tape for computer use. The goal of the

program is to assure that the national estimates

of ,the various characteristics collected by the

survey represent data of the highest attainable

accuracy and precision within the limitation imposed by reasonable procedures and costs.

In the Health Examination Survey, as in all

sample surveys, there are two sources of error

to be considered-sampling error and nonsampling or measurement error. Sampling error, that

is, error due to making measurements on a sample

rather than on the entire population, can be quantified and is the concern of all statisticians in

sample survey design and in analysis. During the

data-collection phase, problems due to this type

of error are minimal. The nonsampling error is

of constant concern during the data-collection

phase and considerable attention, time, and effort

of the HES personnel are devoted toward minimizing and measuring this type of error.

One type of nonsampling error which occurs

in voluntary surveys such as the HES is the bias

introduced by nonresponse, The amount of bias

29
introduced by nonresponse generally, but not necessarily, varies with the amount of nonresponse.

Even if the sample is perfectly representative of

the population, bias will result if the nonrespondents differ from the respondents with respect to

the characteristics being measured. The response

rate of a survey such as the HES is-, therefore,

very critical. Fortunately, the low proportion of

sample persons not examined in the various HES

programs to date has not produced any serious

-effects on the validity of the data. Response rates

for Cycles I and II were 86.5 and 96.0 percent,

respectively. Approximately 90.0 percent of the

sample youths in Cycle III will be examined. These

high response rates may be attributed to various

methodological studies, 4-8 to advance s planning

and publicity, to much diligent work by the Health

Examination Representatives, and to proper handling of examinees by the entire staff. ’ Another type of nonsampling error which is

of great concern in the quality control program is

the measurement error which inevitably occurs

during the examination procedure. Its importance

is easily recognized when one considers that, in

the present cycle, each sample youth has a representative sample weight of approximately 3,000.

Therefore, any blemish on the survey findings for

a particular youth is greatly enlarged in the final

analysis of the larger universe. Not only is it important to control and minimize this error but it

is also equally important to measure, wherever

possible, the amount of error.

In the Health Examination Survey several procedures are relied upon to accomplish these objectives. Prior to the collection of data it was necessary to define precisely what is to bemeasured

and to obtain instruction as to how the measurement should be performed. Advisors, both from

within the staff of the HES and from outside

sources, were instrumental in constructing the

necessary definitions and instructions, Intensive

specialized training is given to each examination

staff member in the specific procedures performed by them in the survey. The special advisors within the HES provide training in their

respective areas with additional training in other

areas obtained from various outside sources.

Although precise definitions and good initial

training -are necessary, they are generally not

L sufficient in a lengthy .survey such as the HES.

The time factor creates a problem that does not

occur when data are gathered in a shortperiod of

time. It is important to be consistent throughout

the entire survey. In order to accomplish this,

detailed written instructions are provided on all

aspects of the examination, forms are structured,

and retraining is provided. The latter may range

from a few minutes for a single item up to several

days for an entire area such as body measuremerits,

In further efforts to attack measurement error, mechanical equipment is employed wherever

feasible to obtain a “hard document.” These are

obtained through the use of such devices as tape

recorders, automatic recording of weight, photographs of height, X-rays, and the recording of

spirometry and electrocardiograms on magnetic

tape. As such, the reading and interpretation of

these records can be done independently more

than once. The use of instruments for measuring

as well as for recording introduces another source

of possible variation; thus, systematic calibration is necessary. All instruments are calibrated

at the beginning of each stand and also periodically throughout the stand, some before each examination. In some instances, audiometers for

example, resources are not available in the examining center and machines must be sent away for

calibration. Other instruments also receive periodic maintenance and service through special contract arrangements with the manufacturers.

Environment is also an important factor in

achieving valid and standardized data. Good lighting, heating, and air conditioning are essential.

For example, it is very important to be able to

standardize temperature and humidity in the room

where the exercise tolerance test is given. Similarly, it is essential that the room in which the

hearing test is given be soundproof.

The subject being examined can also introduce error into the measurement. If the examinee

fails to stand up straight for a height measure-,

ment, is uncooperative during the psychological

examination, or does not understand the directions

given for the audiometry test-to give only a few

examples-error will occur. It is, therefore, very

important that staff members be aware of such

possibilities and see that the examinee fully understands what he is to do and thathis fullest cooperation is obtained.

30
Despite all precautions, there is a degree of

inherent variable measurement error that cannot

be eliminated. Another objective of the quality

control program, therefore, is the determination

of the extent of this error. In the HES this is determined by replicate measurements. Replicate

data are obtained basi’cally in two ways: by rcevaluation or rereading a hard document, or by

reproduction of an actual measurement. Although

hard documents such as the X-ray or the weight

and height measurements are reevaluated, the

replicate program is primarily concerned with

reproducing actual measurements in a replicate

examination.

During the actual operation of the survey, the

primary use of replicate data is in indicating areas

where retraining or reevaluation of procedures is

needed. When the reports of findings of the survey ’ are published, data from the replicates will be

used to apprise the reader of the extent to which

the data may be affected by measurement error

and to call his attention to this problem.

There are several sources of replicate data

in the HES. The single most important source is

the full-scale replicate examination where a previously examined youth is returned to the examination center for a second examination, complete

except for the X-rays, blood sample, and urine

culture. The number of youths replicated at a location varies between 12 and 18 depending on the

number of examination slots available. These are

randomly drawn by segment from thoseexamined

during the first 2 weeks of the examinations.

Scheduling and other necessary arrangements do

not permit sufficient time to select youths for

replicates who are examined at a later date. In

performing these replicates, the examining staff

does not have access to any original records except the medical histories. The examiners have

been instructed to use the same techniques as they

use in a regular examination andnot to try to collect any ‘*better” data than they wouldina routine

examination, No efforts are made to assign a particular youth to a particular examiner but as always, the examiner is identified: thus, both intraand inter-observer variability can be studied.

Although for-various reasons it has not beenpossible to. do full-scale replicate examinations at

all stands, the total for the first 31 stands of this

cycle is 231, with an estimated number of 325 for

all 40 stands.

Aside from the full-scale replicates, replicate data is obtained from several specific areas

of the examination. One of these is inbody measurements. Replicate body measurements are performed on a systematic basis on “dry runs” day

at the beginning of each location. ‘!Dry runs” day

is a half day set aside for the examination of four

youths not in the sample to check all equipment

at the beginning of each stand. The examination

content is the same as that for the sample youths

and the records of findings are sent to their physician and dentist. During the course of the examinations, two of the dry-run examinees are used

for replicate body measurements. Each technician

performs measurements on one of the examinees,

thereby providing two sets of replicate data. The

pairing of technicians alternates from location to

location so that after every three locations, each

technician will have been paired with the other

three. Technicians are not allowed to observethe

other technician’s procedures or review results

of the measurements of the sample youths on whom

they are to take replicate measurements. After all

replicates have been performed, the supervisory

technician compares the two sets of measurements

for each youth. If the differences for any measurement are greater than the allowable tolerances,

these measurements are repeated on the youth by

both technicians in the presence of the supervisory

technician who observes theirprocedures and resolves any technical variations. Any changes in a

technician’s measurements resulting from this

procedure are recorded.’ However, in the analysis

of this replicate data, the original measurements

are used since they provide the best estimates of

the intertechnician measurement error. Replicate

body measurements are also made to obtain estimates of intratechnician error. This is accomplished by having each technician repeat his own

measurements on one examinee during the course

of a stand.

Although blood is not drawn during replicate

examinations, replicate determinations are made

for the blood chemistry tests. Replicate readings

of hematocrit for all examinees are made in the

examining center by using split samples. Replicate determinations on the other blood chemistries

performed by independent laboratories are obtained by drawing additional blood samples on 30

regular examinees at each location, splitting each

sample, and assigning sample numbers so that the

31
t’wo cannot be related by the laboratory, In additio;n, each laboratory also has fts owti quality control procedures which include the useof replicate

determinatfons, _ Several measures are taken to .assure cornpleteness and consistency in the recording proce8s. All questionnaires are reviewed for omissions and inconsistencies, With the exception of

the Health Behavior questionnaire which is completed in the examining center, all are reviewed

by personnel in the -field management office. If

errors are noted, correct Information is obtained

by phone or from the examinee when he comes in

for the examination, Errors in recording body

measurements and results of the dentalexamination are reduced by having a secondpersonact as

a recorder. In addition, afl data gathered in the

examining center are reviewed by the clerical

assistant before the examinees leave.

There are numerou6 quality control procedures involved in the psychological testing area.

Tests are exchanged daily by the psychologists

and checked for errors in counting items, computing age, recording scaled scores on the WISC,

and recording grade levels on the WRAT. Once

each week, six WISC tests, chosen at random from

those given by each psychologist during the week,

are exchanged and restored. Scoring disagreements are marked and discussed, If, through discu6sion, the original scorer decidesthat his scoring was in error, the score is changed accordingly.

All human figure drawings, which are scored by

Dr. James L. McCary, University of Houston, are

independently scored by two persons, Each week

an audit tape on one domplete testing session is

recorded, This tape serves as a quality control

device not only for the psychological advisor at

headquarters, but also for the field psychologist

who needs to observe his own performance at

regular intervals. A list of any unusual occurrences which may affect the,. validity of the data

is also maintained.

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*, . , ’ _ . .

\ . .

, ,

%S L I ’

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_,’ P.

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,

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30National Center for Health Statistics: Age at menopause. United States, 19604962. T/ital and Health StaGstics,

P;IS Pub. No. lOOO-Series 110No. 19. Public Iiealth Service.

Washington. U.& Government Printing Office, Oct. 1966.

31Xational -Center for Health Statistics: Osteoarthritis in

adults by selected demographic characteristics, United States,

19604962. Vital and Health Statistics. PHS Pub, No. X000-

Series ll*No. 20. Public Health Service. Washington. U.S.

Government Printing Office, Nov. 1966.

32!iational Center for Health Statistics: Childbearing and

diabetes melljtus, United States, 196001962. Vital and Health

Statistics. PHS Pub. No. IOOO-Series 1 l-No. 21, Public Health

Service, Washington. U.S. Government Printing Office, Nov.

1966.

33National Center for IIealth Statistics: Serum cholesterol

levels of adults: United States? 1960-1962. Vital and Heatfh

Statistics. PHS Pub. No. lOOO=Serics ll=No. 22. Public Health

Service. H‘ashington. U.S. Government Printing Office, Mar.

1967.

34Nat,ional Center for Health Statistics: Decayed, missin::.

and filled teeth in adults, United States, 1960-1962. Vital and

iiealtll Statistics. PHS Pub. No. 1000Series II-No. 23. Public I-Iealth Service. Washington. U.S. Government Printing

Office, Feb. 1967.

35Nationa.l Center for Health Statistics: Mean blood hematocrit of adults, United States, 1960-1962, Vita2 and Healfh

Statistics. PKS Pub, No. 1000~Series l&No. 24. Public Health

Service, Washington. U.S. Government Printing Office, Apr.

1967.

36National Center for Health Statistics: %nocular visual

acuity of adults by region and selected demographic charactpjst,ics. United States, 1960-1962. ‘I’iial and IIeaZLh Statistics, piis f’ub. No, l()OO~Series ll-No. 25, Publk IIeallfh

Service, M-ashington. U.S. Government Printing Office, JUIIP

1967.

33
37National Center for Health Statistics: Hearing levels of

adults, by race, region, and area of residence, United States,

19604962. Vital and Heaalth Statistics. PIIS Pub. No. lOOOSeries 11-No. 26. Public Health ‘*Service, Washington. U.S.

Government Printing Office, Sept. 196’7.

38 National Center for Health Statistics: Total loss of

teeth in adults, United States, 19604962. Vital and Health

Statistics. PHS Pub. No. 1000~Series 11-No. 27, Public Health

Service. Washington, U.S. Government Printing Office, Oct.

1967.

3gNational Center for He&> Statistics: IIistory and cxamination findings related to visual acuity among adults, United

States, 19604962. VilaZ and tl’ealth Statistics. PI-IS Pub. No.

lOOO-Series 110No. 28. Public Health Service. \Yashington.

U.S. Government Printing Office, Mar. 1968.

*ONational Center for Zealth Statistics: Osteoar*thritis and

body measurements. Vital and Health Statistics. l?I3S Pub. No.

1000~Series ll&No. 29. Public ’ Xealth Service. ;?l’ashington.

U.S. Government Printing Office, Apr. 1968.

41National Center for Health Statistics: Monocular-binocular visual acuity of adults, United States, 1960-1962. Vital

and Health Statistics. PHS Pub. No. 1000~Series ll-No. 30.

Public Health Service. Washington. U.S. Government Printing

Office, Apr. 1968.

Q2National Center for Health Statistics: Hearing levels of

adults, by education, income, and occupation, United States,

1960-1962. Vital and HeaZth Statistics. PIIS Pub. No. 1000”

Series 11-No. 3’1. Public Health Service. Washington. U.S.

Government Printing Office, May 1968.

43National Center for Health Statistics: Hearing status

and ear examination: findings among adults, United States,

19604962. Vital and Health Statistics. PIQS Pub. No. 1000-

Series ll-No. 32. Public Health Service. Washington. U.S,

Government Printing Office, Nov. 1968. c

44National Center for Health Statistics: Plan, operation,

and response results of a program of children’s examinations.

Vita2 and Health Statistics. PI-IS Pub. No. 1000~Series I-No.

5. Public Health Service. Washington. U.S. Government Printing Office, Oct. 1967.

45National Center for Health Statistics: Evaluation of

psychological measures used in the health examination sur=

vey of children ages 6-11. Vital and Health Statistics. PIE

Pub. Xo. 1000~Series ~-NO. 15. Public Health Service. M’ashington. U.S. Government Printing Office, Mar. 1966.

46National Center for Health Statistics: Calibration of two

bicycle ergometers used by the health examination survey.

VilaZ and Heatth Statistics. PHS Pub. No. 1000~Series 240.

21. Public Health Service. Washington. U.S. Government Printing Office, Feb. 1967.

47National Center for Health Statistics: A study of the

achievement test used in the health examination surveys of’

persons aged 6-17 years. Vital and HeaZlh Statistics. I’IX

Pub. No. 1000~Series ~-NO, 24. Public Health Service. Washington. U.S. Government Printing Office, June 1967.

48National Center for Health Statistics: Orthodontic trcatment priority index. Vital and HeaZth Statistics. PHS Pub. No.

1000~Series ~-NO. 25. Public Health Service. Washington. U.S.

Government Printing Office, Dec. 1967.

4gNational Center for Health Statistics: Dcvclopment of

the brief test of literacy. Vital and Health Sla.tis tics. PIIS

Pub. No. 1000~Series ~-NO, 27. Public Health Service. Kashin&on. U.S. Government Printing Office, Mar. 1968.

000

34
, ’

. h .

.

I ~

* . .

APPENDIX I A

NOTICE - All information which would permit identification of the individual will be held in strict confidence,

will be used only by persons engaged in and for the purposes of the survey, and will not be disclosed or re- BUDGET BUREAU NO. 68-RI 700

leased to others for any purpose, APPROVAL EXPIRES JULY 31, 1970

;O,R~M~~/IEHES-~ U.S. DEPI~RTMENT OF COMMERCE

s . BUREAU OF THE CENSUS

ACTING AS COLLECTING AGENT FOR THE

U.S. PUBLIC HEALTH SERVICE 1, Questionnaire

HEALTH EXAMINATION SURVEY of Questionnaires

!a. Address or description of location (Number and street, city, State) 3. Identifica- 4. PSU 5. Segment number 6. Serial number

tion code number

If this questionnaire is for an “EXTRA” unit in a B or

I NTA Sec#ment,. enter;

!b. Mailing address if not shown in 2a OR 0 Same as shown in 2a Serial number

E

If in NTA Segment, also

of original

1t;m ;U,,,,,

.

enter for FIRST unit

Sample Unit ‘found listed on property

Segment List

Sheet No. Line No.

/’

Ic. Name of special dwelling place 1 Code 7. Type of living quarters - Check one box

I 0 Housing unit 0 Other unit

For questions ZO- 12, ask only the questions checked:

1 0 All other-Skip to /tern 10 :i 0 00 NOT ASK QUESTIONS IO - 12. Go to question 13.

8. Do you own or rent this place?

0 Own 0 Rent 0 Rent free

.:: 10. 0 Are there any occupied or vacant living quarters BESIDES YOUR OWN

.. in this building?

Ask 9a Ask 96 Ask 9a

ga. If Own or Rent free, task: Does this place have 10 L- INO

or more acres?

L_IYes - S

b. If Rent, ask; Does the place you rent hove 10 or

Fill Table X for each quarters NOT listed.

more acres?

ll.~Aretherean

0 Yes L.-lNo .:

J occupied or vacant living quarters BESIDES YOUR OWN

on this floor.

1 1

UYes - S L- INO

I c. During the past 12 I d. During the past 12 Fill Table x for each quarters NOT listed.

months did soles of I months did soles of ”

crops, livestock, and I crops, livestock, and 12. u Is there any other building on this property for people to live in - either

other form products

if

other farm products ..’ occupied or vacant?

from the place omount rom the place amount ..‘.

to $50 or more? I to $250 or more? L- INO

I

0 Yes - SW-,

3 0 Yes 5nNo :I

Fill Table X for each quarters NOT fisted.

2 0 Yes 4 0 No

I Telephone No.

,.I: 12. What is the telephone number here? -

. . . . .‘. I’ _‘. ..I.

Y” ‘. ., 1,. ./.:. . .

: .. ., .‘_’ i. ._. CR n No telephone

14. /NT&V/EWE/?: If eligible youth in household enter’youthPs name, -

.

Column No.(s).of EY(s) for whom Column No. and relationship of

Cycle IZZ segment, setial, and column numbers on

Medical History Form.

I Medical History Form(s) were

P

erson with whom form(s)w

left: eft:

-------Wm.-------------------------.

n addition to the Information you hove olready given me, I would like to

eave this form to be filled out about - -. A representatlva of the Public .

iealth Service will come by to pick up the form in a week or so* What Best time to call:

vould be the best time of day for her to come? __--.-

5. RECORD OF CALLS AT HOU&HOLD

Item I 1 Corn. 2 Corn. 3 Corn. 4 Corn. 5 Corn.

Entire household

Date

Time

6. REASON FOR NON-INTERVIEW

TYPE 1 A B C 2 (Partial interview)

I n Refusal --Describe in footnotes

I

31 0 Vacant -s-Non-seasonal 41 0 Demolished Interview not obtoined for

2 El No one at home - repeated

calls Go to 32 n v

acant - - seasonal 42 0 In sample by mistake

Cols. ----

3 L_1 Temporarily absent 17

.33 0 Usual residence elsewhere 43 0 Eliminated in sub-sample

34 0 Other - Specify 44 0 Other - Specify because:

4 0 Other - Specify

1

170. For #*final” Type A noninterviews enter names and approximate ages of household members. 18. Signature of interviewer

Name Age Name Age

1. 4. 19. Code

2. 5.

3. 6. WASHINGTON USE ONLY

b. Who supplied this information? (Name and address) ?ersons EY’s SY’S

CO Are there any EY’s in this Type A household? 0 Yes

__-_,_

0 No m DK(Explain on page 4)

35
reetse? . . . . . . . . . . . . . .

0 DIFFERENT househoId

j--J No Cycle II questionnaire Go to item E 0 New household member

(GUARDIANS)

OF EY AND 70. What is the highest grade -- ottended in school? . . . . ..**.........r......*........

------e

finish this grade (year)?. . . ,,..,,,.,,..,,..,,.......,,.....‘,...~..~.

Ask only for EY:

c. What is the name and location of the schocll-- goes to? ; . . . . . . . . . . . . . . . . . . . .I. . . . . . . .

If “Not in school”’ ask:

What is the reason -0 is not to school? .

0 0 Not in school

. . . . . . . ..‘.......... Entet reasott above.

(for males): working or doing something else? l l . l l l l l l 9 l * l l l l l *

(for females): keeping house, working or doing something else? . l . l l .

‘..........,,~,.~..r.*....~.,

If “Keeping house’* OR ##Doing something else,“’ ask:

work at a job or business at any time during the past THREE months? , . , . , i , , . . . . . ,

If “Married, ” ask:

b. Hove you (your husband) been married more than ones? .~*.,.,**.‘I*...,~.,~‘*.‘.~~*

120. Besides (read names of children entered in question 1) heve you and your husband

(wife)everhad any other ehildreri (in this morriogi or in a previous morrioge)?

If “Yea ” ask:

b. What ar6 their names? Enter names in colttmn (a).

c. How old is --? Wliat is hii dafe of blah? Enter age AND date of birth. If deceased enter I -

“deceased” in colu&z (c), date of birth iri column

(d), and Month and year of death in c~~lumf~ (e).

db *here doe& Re (she) live how? Enter piegent whereabouts

.* ,.,:. . . _. . .

36

>’ .

’ t
-------e-eFirst name

3 I

Last name

--I----------

First name 1

. . . . . . .’

,j ‘_

-..,

’

. ..I

.,;. 5 : ,‘_ ’ I-.’ l ~ ;;-y

w

Last name

4 .‘, , ‘.‘

II

,ast name Last name

.-------b--e-

;irst name

-----

First name

m---s

First name

selationship Relationship Relationship Relationship

I UWhite 2 0 Negro

3 n Other

I UWhite 2 INegro

3 0 Other

I IWhite 2 INegro

3 0 Other

I IWhite 2 nNegro

, 3 0 Other

I 0 Male 2 0 Female I 0 Male 2 0 Female I 0 Male 2 (-‘J Female I IMale 2 LIJFemale

Age 0 Under

1 year

Month Day Year

Age

Month

0 Under

-1 year

Day Year

Age

Month

0 Under

1 year

Day Year

be 0 Under

1 year

dent h Day Year

Age

Month

0 Under

1 year

Day Year

L_I Same as column

on Cycle II

questionnaire

0 Same as column

on Cycle II

questionnaire

0 Same as column

on Cycle II

questionnaire

1 Same as column

on Cycle II

questionnaire

0 Same as column

on Cycle II

questionnaire

17 New household member ( New household member 0 New household member 0 New household member 0 New household member

I 0 EY 2j--JNot Ek I f-J EY 2 0 Not EY

I

’ CJ EY 2 C-J Not EY to EY 2 17-J Not Ek I a EY 2 q Not EY

00 0 None

I Elem. . . 12345678

2 High. . . 1 2 3 4

3 College. 1 2 3 4 5 +

------------

Ia Yes 2L_lNo

m--------e--.

Name and location

00 0 None

I Elem. . . 12345678

2 High. . . 1 2 3 4

3 College. 1 2 3 4 5 +

--------a--

In Yes 2nNo

------s-----wName and location

00 U None

I Elem. . . 12345678

2 High. . . 1 2 3 4

3 College. 1 2 3 4 5+

---------w-BI (Yes 2uNo

.------------

Name and location

00 0 None 00 0 None

I Elem. . . 1234567t

2 High. . . 1 2 3 4

3 College. 1 2 3 4 5 t

I Elem. . . 12345678

2 High. . . 1 2 3 4

3 College. 1 2 3 4 5 +

------w--w---

I 0 Yes 2f--JNo l IYes 2 0 No

mm---e-------s

Name and location Name and location

0 0 Not in school

ti

Enter reason above.

I aYes=U.S. 2[No

.----e---a---

Foreign country

0 u Not in school

Enter reason above.

0 0 Not in school

Enter reason above.

0 0 Not in school

Enter reason above.

0 [I Not in school

Enter reason above.

,113 Yes - U.S. 2 0 No ------a---

Foreign country

,IaYes -U.S. 2 0 NO

e-e- ----em.

Foreign country

IJJ Yes- U.S. 2 ~--&NE-

-----e

Foreign country

I 0 Yes-U.S. 2 Q No

-w-----w ---

Foreign country

I 0 Right 2 0 Left

3 0 Both

I 0 Right 2 L.7 Left

3 L_I Both

I 0 Right 2 (-J Left

3 0 Both

I 0 Right 2 0 Left

3 0 Both I

I 0 Right 2 0 Left 9

3 C-- Both

C-J Working IKeepinp

house

u Something else

---,,-,---*4-

0 Working 0Keepin

house

(‘-J Something else

a Working IKeeping

house

0 Something else

0 Working DKeepin,

house

0 Something else

0 Working 0 Keeping

house

0 Something else

----------e-e

I

d------------ we--------- ------m--e- ------------

a Yes I No

.------e----e 1

n Yes cl No

-L------B-----

[ Fulltime

rJ Parttime

0 Yes INO

,-------e---e

(--J Fulltimer--J Parttime 1

CJ Yes UN0 ----------se-

‘i--J Fulltime cl f$- A

m---w---------

0 Yes CJNO

0 Fulltime0 Parttime

0 Fulltime

0 Parttime

I IMarried 3 0 Divorced

2 0 Widowed 4 0 Separated I

I IMarried 3 ho Divorcee

2 0 Widowed 4 c JSeparatec

I IMarried 3 0 Divorce1

2 D Widowed 4 DSeparatel

1 IMarried 3nDivorcec

2 OWidowed 40 Separates

.------------.

0 Yes I No

.

I LMarried 3 ODivorcec

2 0 Widowed 4 DSeparsted

m-w----------

0 Yes INO

.

IYes CJNO

Relationship to both or either parent - Specify

(bl -

37
I

130. Since (name of oldest EY was born has anyone in the fomily been in o hospital, an institution, or any

similar place for MORE r’HAN A THREE MONTH PERIOD? , . . . . . . . . . . ..s.........*...... 11 Yes

A----

0 No - GO to 13b

I

If “Yes” ask: Who was this? Enter name and relationship to parent of EY in cofs. (b) and (c).

When was this? Enter calendar year in col. (d).

What is the nome of the place he was in? (Enter in col. (8).

b. During that period, has anyone in the family been unable to work or carry on his usual activities for

MORE THAN A SIX MONTH PERIOD because of ill-health? ..,,..~....................... /-J Y&s

If *6Yesg’ ask: Who was this? Enter name and relationship to parent of EY in cols. (b) and (c).

When was this? Enter calendar year in cof. (d).

c* Since -0 was born has any relative of yours died WHILE LIVING IN YOUR HOUSEHOLD? . . . . . . . . . . C-J Yes

I-- No - Co to 13c

0 NO - Go to 14

I

If “Yes” ask: Who was this? Enter name and relationship to parent of EY in cots. (b) and (c).

When was this? Enter calendar year in col. (d). I

Question No. Name Relationsh$yto Cal. Year(s) L

parent of

(a) (b) (cl (4

FILL FOR 73a ONLY

Na&e of the place

(e)

, 140. Is any language other than English spoken here in your home? . . . . . . . . . i 0 Yes

If ‘*Yest ” ask..

2010

b. What language(s)? Language(s) spoken

,

Fill ftom item C, page 2:

i SAME household - Complete question 15

* n DIFFERENT household

0 No Cycle II questionnaire Skip to question 26

0 Noninterview in Cycle II

15. If no one has left household, check: 0 All household members are the same --Go to question 16

For each person who was listed originally a& a household

column number (from Cycle ZZ questionnaire) and ask:

member but is not listed on this questionnaire, enter his name and

Complete front page of questionnaire

Footnotes and comments: Include here any information which might be useful to the PUS representative when she calls to pick up the

Medical History Form.

TABLE X - LIVING QUARTERS DETERMINATIONS AT LISTED ADDRESS

USE OF CHARACTERISTICS CLASSIFICATION IF HU IN B SEGMENT, ASK

Are these

(Specify locetfo”) Occupied All Quarters Not a Fill In what year

.

g

quarters for more separate were these

than one group

Location of unit Do the occu- DO these (S~~CUY~OC~, sepapants of these tion) quarters have: rate question- (Specify location)

(If before July 1960)

. al

g .i of people? (Specify loca- 1 unit naire and

, (Examples:

quarters

z Basement,

tlon) quarters Direct oc- A kitchen CAdd interview created? What was the name of

Q) Yes No live and eat cess from or cooking occu- (If 1959 or 1960, the household head

u

‘2 .; 2nd floor, etc.) with any other the outside equipment

group of

aleo Specify “F” of these quarters on

h:

(Fill one if first half or

&

tine for people?

or through for exciu- yty:,

0 common rive use? 1“L** if last half)

April 1, 1960?

hoii?

queseach tiongroup)

HU Other

Yes No Yes No Yes No naire) unit

(1) (2) __ $4 __ (3b) (4) (54 (5b) (Gal (GM (74 UN 03) @a) (9b) ( 10) (11)

1

2

38

I,, - . ,

I -. ‘t

, ( l

í I / .

í 6 .
APPENDIX I B

-------___I_ _-e-e------

CONFIDENTIAL - All information which would permit rdentifrcation oI thtq Individual will be held strictly

confidential, will be used only by persons engaged in and for the purposes of the survey and will not

be disclosed or released to others for any other purposes (22 FR 1687).

- -

DEPARTMENT OF

HEALTH, EDIJCATION, AND WELFARE

PUBLIC HEALTH SERVICE

NATIONAL HEALTH SURVEY

MEDICAL HISTORY OF YOUTH Sample number

Parent’s Questionnaire

NAME OF CHILD (La+-t, First, Middle) SEGMENT SERIAL COL. NO.

NOTE: Please answer the questions by checking the correct boxes or by filling in the blanks,

as required. If a question is unclear leave the answer blank and draw a line around the question. A representative of the Public Health Service will collect your filled in questionnaire

in a few days and she wili help you answer the unclear questions. Thank you for your

cooperation.

1.

4.

5.

6.

7.

8.

Was this youth born in a hospital? 1 q Yes 2 cl No 3 0 Don’t know

Did you ( the mother) have unusual medical problems or complications while pregnant or

giving birth’to this youth? 1

P

Yes 2 c l No 3 0 Don’t know

IF YES: What was wrong?

I I

Was anything wrong with him or her at birth?

1 Yes 2 q No 3 0 Don’t know

IF YES:

a. What was it?

b. What did the doctor say caused this?

Was there anything wrong with this child as a baby (that is, before he or she was one

year old)? 1

P

Yes 2 q No 3 0 Don’t know

YES: IF

a. What was the matter?

b. Did you see a doctor about it? 1 0 Yes 2 0 No 3 0 Don’t know

FOR PUBLIC HEALTH SERVICE USE ONLY

1 0 Mother

This form completed by: 2 0 Father

3 0 Other (Specijy)

9. Has there been any serious health problem since he or she was one year old?

1

51

Yes 2 q No

IF YES: What and when?

3 c l Don’t know

10. Is there anything about hisor her health that worries you now?

1

4

Yes 2 c l No

\

IF.YES: What is it?

11. How would you describe his or her present health?

1 c l Poor 2 Fair 3 0 Good

t

IF POOR OR FAIR: What is the matter?

4 c l Very Good 5 c l Excellent

39
12. Does he or she now use any medicine regularly (not counting vitamins)?

1

7

Yes 2 q No 3 a Don’t know

IFYES:

a. What is the name of the medicine? i c l Don’t know

b. What is it for? 2 c l Don’t know

c. Did a doctor say he or she should use it?

I q lYes 2 c l No 3 c l Don’t know

d. How long has he or she been using it?

13. Has he or she evet broken any bones?

1 nYes 2 c l No 3 Cl Don’t know

14. Has he or she ever had any other serious injuries or accident?

1

Fl

Yes x 0 No (IF NO, SKIP TO QUESTION 15)

IF YES:

a. How many? c l One 0 Two Cl Three 0Four or more

h. As a result of any accident did he or she have to stay in a hospital (overnight or longer)?

I 0 Yes 2 0 No

c. What lasting handicaps or damages, if any, did the accident(s) produce?

15. Has he or she ever been unconsci

1 Yes 2 0 No

IF YES: For how long?

3 cl Don’t know

1 c l One hour ot less 3 c l A day or more

2 Cl More than an hour 4 c l Don’t know

but less than a day

16. Which of the following operations or surgery has he or she had? (Check all that appEy.)

4

9

17. Has

1

cl

0

cl

cl

Tonsils and/or adenoids taken out

Appendix taken out

Hernia (Rupture)

Other; what?

Cl None

he or she ever been in a hospital (overnight or longer)?

2 ONo

(IF NO, SKIP TO QUESTION 18)

IF YES:

a. What was the longest time he or she ever spent in a hospital?

1 Cl A night to a wee&

2 c l Over one week but less than six months

3 c l Six months or longet

b. How old was he or she at that time? years

c. Why was he or she there?- ,

d. Did an adult family member spend the night with him (her) in the hospital most of the time?

1 Cl Yes 2 bo

40
18. Has he or she ever h nA (CYIX’K YES OR K IN EVERY LINE).

a. Measles 1 El Yes 2 c l No

b. Mumps 1 cl Yes 2 Cl No

i

c. Chickenpox 1 c l Yes 2 cl Nil

d. Whooping cough 1 cl Yes 2 cl No

e . Scarlet fever 1 cl Yes 2 0 N o

f. Asthma 1 q Yes 2 cl No

g. Hay fevet

h. Other allergies

i, Kidney trouble

1 cl Yes 2 c l No

1 c l Yes 2 c l NO

1 c l Yes 2 cl No

j. Heart murmur or anything else wrong

with the heart I c l Yes 2 0No

k. Fit, convulsion, or seizure

1. Pneumonia

1 Cl Yes 2 t l No

1 III Yes 2 0 No

19. Beiow is a list OP other diseases. Please read through it carefuIly and check the YES

box if he or she ever’ had any of the following:

(a) Diabetes or sugar diabetes

(b) Rheumatic fever

(c)’ Polio (Infantile Paralysis)

(d) Epilepsy

(e) Chorea or St. Vitus dance

(f) Diphtheria

(g) Tuberculosis (T.B.)

(h) Cerebral palsy

(i) Meningitis or sleeping sickness

1 $I Yes 2 c l None of these

IF’ YES: Which?

20. What in the most serious illness .or disease he ot she has ever had?

a. How old was he or she when it started? years

6, What did the doctor say about it?

The doctor said it was:

1 cl a mild case 4 a I don’t remember what he said

2 cl .a moderate case 5 c l No doctor saw the child

3 c l a severe (critical) case

c. Did the illness (disease) leave any lasting effects?

1 Cl Yes 2 0 No 3 cl

t

Hard to say

IF YES: What were or are they?

21. Has he or she wet the bed during the past year?

-

1 Cl Yes 2 0 No 3 c l Don’t kndw

22. Does he or she wear glasses or contact lenses?

1 Cl Yes, glasses 3 cl Yes, contaCt lenses

2 cl No, don’t wear either

IF I+@: Do you think he or she needs glasses?

1 cl Y’es 2 c l No 3 0 Don’t know

41
i

n ,,s he or she ever had eye trouble (except wAat is corrected by glasses or contact lenses)?

I

7

Yes 2 0 No

iF YES: What was it?

r. .

ii +. Has he or she ever had an eye operation?

2 c l No

IF YE.S: What was it .for?

25. Have his (her) ears ever been damaged or injured in any way?

1

7

Yes 2 0 No

IF YES: In what way?

26 . Have hi? {her) ear Clru~q -ver been opened or lanced?

I Yes X 0 No

IF YES:

a. How many times: 1 cl Once 2 c l More than once

b. In which ear? 1 q Left 2 0 Right 3 0Both 4 q I don’t remember

21. Has he or she ever had any other kind of ear operation?

1

P

Yes 2 c l N O

IF YES: a. What was it for?

28.

b. Which ear’?

Has he or she ever had a running ear or any discharge from the ears jezcept wax in the

ears)?

1

?

Yes X 0 No

IF YES:

a. How often? 1 a Once 2 c l More than once

b. From which ear? 1 0 Left 2 0 Right 3 0 Both 4 fl I don’t remember

29. In the past year has he or she had an earache?

1 c l Yes 7 iho

30. Does he or she have any difficulty hearing?

1 cl Yes 2 q No

31. Has he or she had any other ear trouble?

1 Yes 2 q No

IF YES: What?

32. Does he or she have any speech defect (like stuttering, stammpting, lisping, etc.)?

1 c l Yes 2 0 No

33.

34.

Does he or she have a limp or other trouble walking?

1 0Yes 2 c l No

Is there anything that prevents complete use of his (her) legs?

1

P

Yes 2 Cl No

IF YES: What is it?

‘.,-. ’

-, 4

‘\ , \ <,

. .

;‘;., _

- .

.

:

‘*. (..
35. Is there anything that prevents complete use of his (her) arms?

1

P

Yes 2 0 No

IF YES: What is it? -

36. Is he or she now prevented for reasons of health from taking part in hard exercise or ?

I

Y

Yes X 0 No (IF NC, CQ ON TO QUESTION 37)

IF YES:

a. What are the reasons? *J-zb. Did the doctor advise this?

1 cl Yes 2 0 No

37. Was he or she ever prevented for reasons of health from taking part in hard exercise oi ‘ay?

1 c l Yes 2 0 No 3 c l Don’t know

38. Have his (her) teeth been straightened or have bands been put on them?

1 El Yes 2

51

No

IF NO:

- -

a. Do you think they need straightening?

1 c l Yes 2 0 No

b. Has a dentist said they need straightening?

1 cl Yes 2 c l No

39. At the present time is he or she:

1 c l Underweight 2 . Cl About the right weight 3 0 Overweight

40. As far as physical growth is concerned, is he or she coming along:

1 cl- Too slowly 2 c l At about the right rate 3 cl Too fast

41. As far as mental development is concerned, is he or she coming along:

1 c l Too slowly 2 c l .At about the right rate 3 Cl Too fast

42. How often has he or she stayed overnight at a friend’s house?

I cl Never 2 c l Only once or twice 3 0 Quite a few times

HERE ARE SOME QUESTIONS ABOUT SCHOOL:

43. Did this youth go to-nursery school?

1 a Yes 2 the

44. Did he or she go to kindergarten?

1

‘7

Yes 2 0 No

IF YES: Was it: 1 c l Compulsory 2 c l Voluntary

45, At what age did he or she start first grade?

Cl Five or younger OSix cl Seven or older

43
46, What was his or her reaction to school during the first few weeks of 1st grade?

1 c l Was quite happy

2 c l Was a little upset

3 c l Was quite upset

4 c l Was so upset, he or she got sick

5 cl I. don’t remember don’t kn0.w

47. fn general, how easily does he or she make friends?

1 q Easily

2 E l Has a little trouble

3 q Has a lot of trouble

48. How many of his or her friends do you know well?

1 Cl Most of them

2 n Half .or less

,

3 cl Almost none

49. How much trouble was he or she to bring up?

i a None

2 0 Just.a little

3 cl Some

4 q A lot

5 Cl Don’t know

50. Some people are calm, others are nervous (tense, high-&wag). Which describes him or

her best?

1 c l Not nervous at all

2 c l Somewhat nervous

3 a Very nervous

51. Has this youth ever been to a mental hospital or guidance clinic?

1 c l Yes, within past year 3 aNo

2 El Yes, but not within past year 4 0 Don’t know

52. Has he (she) ever seen a psychiatrist, or a psychologist, or have you talked to one about

him (her)?

1 Q Yes, within past year 3 n No

2 El Yes, but not within past year 4 0,Don’t know

HERE ARE THREE QUESTIONS ABOU’T EATING HABITS:

53. Would you say he or she eats:

1 c l Too much

l2 l-l About the right amount

3 c l Tooli ttle

54, How fussy an eater is he (she):

1 0 Not fussy at all

2 0a A little fussy

3 Cl Very fussy

55. On a usual day (that is, school or work day), how many meals does he or she eat with adult

family members?

1 q Two or more 2 E l Only one 3 c l None

44

_ . .

I \ .

1 .
56. Who makes most of the decisions on the following: @heck 07~ e Zn -each row),

a. Choosing his/her clothes

4’

* I ..

b. How to spend his/her monq

c. Which friends to go out with

d. How late he/she can stay out

F

57, Does he or she get an allowance? (So much money pet week, for enzmple.)

1

P

Ye8 2

P

NO

IF YES: Who decides how much? iF, y’: Doss he or she earn money from work?

.

a_

2 cl Yes 3 cl No

58. Looking ahead, what would you like him or her to do &out schod? ($‘A& one on@.)

1 0 Quit school as soon as possible

2 cl Finish high school

3 cl Get some college or other training after high a&w1

4 cl Finish college and get a college degree

5 n Finish college and take further training (medic& I-, or other profeoeiad acAd, etc.)

59. What do you think will happen, as far as school goes? (Check OM enly,)

1 0 Quit school as soon as possible

2 cl Finish high school

3 0 Get some college or other training after high school

4 0 Finish college and get a college degree
60. How important do you think it is for a young person to have each of the qualities or

characteristics listed below? (Put one check mark in each row.)

a. To be neat and clean

Extremely Slightly

Important Important Important Unimportant

: (‘I) (2) (3) (4)

b. To be able to defend,oneself

c. To have self-control

d. To be happy

e. To obey one’s parents

f. To be dependable

g. To be considerate of others

h. To face life’s problems

calmly

i. To obey the law

j. To be ambitious

k. To know how to keep in good

health

61. If he or she had any of the following conditions, what would you want to do? (Place one

check mark in each row.)

If my child had this condition I would:

a. Stomach ache

d. Stiff neck or back

e. Headache

I

f. Vomit (throw up)

I g. Loss of appetite

I

h. Overtiredness

46

Definitely want to

get in touch

with a doctor

(1)
62. Some people when they are sick talk as if they are sicker than they really are, that is, they

exaggerate a little. How often does he or she do this when he is sick?

1 E l Pretty often 3 0 Almost never

2 c l Not very often 4 c l Never

63. As far as you are concerned, how often is it ail right for him (her) to exaggerate a little

bit when he (she) is sick?

1 c l Pretty often 3 q Almost never

2 c l Not very often 4 0 Never

64. When did a doctor last see him (her) for a check-up (routine examination)?

1 cl In the last year 4 0 Never r2 c l One-two years ago 5 0 Don’t remember or don’t know

3 c l Over two years ago

65. When did a doctor last see him (her) for treatment?

1 c l In the last year 4 a Never

2 c l One-two years ago 5 c l Don’t remember or don’t know

3 c l Over two years ago

66. What is the name and address of the doctor he/she goes to (or clinic if there is no regular

family doctor)?

Name

Street

City and State

2 Cl None

67. When did he (she) last see a dentist for a check-up (routine examination)?

1 q In the last year 4 c l Never

2 0 One-two years ago 5 q Don’t remember or don’t know

300ver two years ago

68. When did he (she) last see a dentist for treatment?

1 cl In the last year 4 q Never !

2 c l One-two years ago 5 c l Don’t remember or don’t know

3 Cl Over two years ago

69. What is the name and address of the dentist or dental clinic he/she goes to?

Name c l None

Street

City and State

47
FOR GIRLS ONLY

70. Have her monthly periods (inenstruation) started?

1

P

Yes 2 D No (iE NQ, OMIT QUESTIONS BELOIN)

IF YES:

a. Had she been told about th@m before hers begati?

1 0 Yes i cl No 3 c l Don’t know

b. How old pas she when they started?L,Years.P Months

c. Does ghe have pain or distromfot’t?

1

P

Yes 2 No 3

4

Don’t know

(IF &O OR DON’T KNOW, OMIT

d. ff there is pain or discomfort,

RI%? OF ~UESi‘IONS)

i-s it: -w

1 c l Vkdy often 2 c l Occasionally

is it:

1 c l Mild 2 c l. Moderate 3 13 Severe

e, At that time, doe& she Reqtietitly: (Check aI2 that apply)

1 cl Take medicine 4 cl Stay home. fpom school

2 c l Go to the sick rtiani ot nurse 5ClNone of these

3 c l StaJi in bed

f: Has she talked to 4 doctor &out painful menstruation?

1 0 Yes 2 Cl -.. No 3 0 Don’t know

. . . . _ .

.ooo,

40

1

. . .
APPENDIX K

~\ _; .

A- es

\.’ .,

v. . ‘h

‘. ’

.: ,

9.

, _I i

CONFIDENiIAL - Ail inlormation tuhich would permit identification of the individual will be held

sttictiy confidential, will be used only by persons engaged in and for the Qutposes of the ~~ruey and

will not be discfosed or released to others for any othet QutQoses (22 FR 1687).

-

DEPARTMENTOF

HEALTH, EDUCATION, AND WELFARE

PtJBLlC HEALTH SERVICE

NATIONAL HEALTH SURVEY

HEALTH HABITS AND #llstO??~ - Yodh

Sample No.

Natne (Last, Fitst, Middle) SEGMENT SERIAL COL. NO.

INSTRL!CTIONSt On the following pages you will find a set of questiaris dealilig with your

health, Since evety person is different, there are no “qtandard” answet-s tc, the questions;

just answer them as fully and honestly as you can. Your answers will be kept confidential.

Do your best to pick the.most likely answer from among the choices given. Only if you

really don’t know the answer check “Don’t kfrow.” WHEN YOU HAVE COMPLETED THE

QUESTIONNAIRE, P’L&:ASE MAIL IT BACK TO THE SURVEY IN THE ENVELOPE WE

LEFT WITH YOU &THERE tS NO POSTAGE NECESSARY IF YOU USE OUti ENVSi,OPk

1. SEX

I q Male 2 q Female

2. AGE 3. DATE OF BIRTHfMonfh, Dayi Year)

I I

4, How would you describe your present health?

1 Poor 2 P Fair 3 c l Good

IF ,pCK)R O&FAIR: What is wrong?

4 0 very gbod 5 0 Excel&t

Y

5. Do you have any problems you might like to talk over with a doctor?

1

P

Yes 2 GINO

IF YES: what are they? _.

6. Do YOU now ude any medicine regularly, nut counting-vitsr;lins?

2 c l No 3 c l won’t know

-

a. What is its n&me? .. - 2u Don’t know _

b. what is it for?

. .- ._-. .2 n Don’t know

ci Did a doctor say you should use it?

1 c l Yes 2 c l No 3 III Don’t kndw

d, How long have you been using it?

7. Have you avet broken any bones?

1

P

Yes 2 ONo 30 Don’t knaw

j.. ,YB&

a. Bow many times? (Several bories broken &t the same time croudt trs once .)

1 clOnce 2 0 Twice 3 0 Three times or mole

b. Hoti did it happen? ._ .., . .

49
,!

iave you ever had any other injuries or accidents?

1

P

Yes 2 a No

IF YES: What happened? /

ti. As a result of an accident, a blow, a fall, or other such cause, have you ever been

unconscious?

1 q Yes 2 0 No 3 q Don’t know

10. Have you ever stayed in a hospital (ovenight OT longer)?

1

2

F

Yes, just once 3 q N o

Yes, more than once 4 q Don’t know

IF YES: What was the longest time you ever spent in Zr hospital, and for what

reason?

How long: Reason

11. What was the most serious illness or disease you had in your life?

a. How old were you when it started? years

b. Did you have to stay in a hospital overnight or longer?

1 c l Yes 2 0 No 3 0 Don’t remember

c. What lasting effects did it leave?

HERE ARE A FEW QUESTIONS ABOUT YOUR EYES AND EARS.

12. Do you ever wear glasses or contact lenses?

1

s

Yes, glasses

2 Yes, contact lenses

YES: IF

a. With your gl asses

(or contact lenses)

can you see as well

as most people?

1 0 Yes 2 0 No

b. Do you think you need new glasses?

1 c l Yes 2 q No

c. When do you wear them?

1

51

Not all day 2 q All day

IF NOT ALL DAY:

d. When? (Check & that apply)

1 For seeing at a distance

2 c l For reading

3 0 For TV

4 u Other (Specify)

3 No

IF NO:

Is there anything wrong with your eyes (except whet is corrected by your glasses OIcontact lenses)?

1 Yes 2 bo

IF YES: What?

50
14. Do you have any difficulty hearing?

I n Yes 2 n No

15. Were your ears ever damaged or injured in any way?

1 PY@S 2. c l No 3 a Don’t know

a. IF YES: a. In what way and when? ~

b. Which ear(s)?~ - - -. L16. In the past year, how often did you have earaches?

1 III Not at all (1 can’t remember any)

2 b‘7 Not very often (about once a month or Eess)

3 a Quite often (more than once a mcnth)

17. Have you ever had any other kind of trouble with your ears?

1 Yes 2 n. No

IF YES: What was it? __ - -

18. Do you think your teeth need straightening?

1 q Yes 2 ~No 30 Don’t know

19. Do you have any difficulty talking or speaking-(like stuttering or lisping)?

1

1 L’ Yi’cs 2 n No

20. Is there anything wrong with the way you walk?

I

ci

Yes 2 0 No

IF YES: What? P1

21. Is there anything that prevents your c:omplete use of your legs?

1

P

Yes 2 bo

IF YRS: What?

22. Is there anything that prevents your complete useof your arms?

1

51

Yes 2 q No

IF YES: What?

23. Have you ever been prevented for reasons of health from taking part in hard (physical)

work, exercise, or games?

1 Yes x 0 No

IF YES:

a. Why?-

b. Did a doctor advise this?

1 Cl Yes 2 ~NO 30 Don’t know

forbidden to do some of these things?

1 c l Yes 2 UNo

51
24. At the present time, do you think you are!

1 c l Underweight

2 a About the right weight

3 c l Overweight

25. Would you say that you appear to be:

1 a Thinner than most persons of your age

2 q About the same as most persons your age

3 c l Heavier than most persons of your age

26. At this time, would you like to be:

1 c l Thinner than you are

2 c l About the same weight as you are

3 c l Heavier than you are

27. At this

.

1 a

2 q

3 c l

time, would you like to be:

Less tall than you are

About as tall as you are

Taller t11an you are

28. Jn the last year or two, have you had any backaches?

1 a Yes, quite often

2 a Yes, occasionally

3 0 No

29. Do you sleep alone in your own room?

1 cl Yes 2

P

No

IF NO:

Who else sleeps in the room?

1 cl Brother(s) 3 a i?atner

3 u Sister(s) 4 c l Mother

5 a Other person(s)

30, How often do you have trouble getting to sleep or staying asleep?

1 c l Very often 2 q Only from time to time 3 c l Never

31. How often dQ you have bad dreams or nightmares?

1 a Quite frequently ? Only from time q to time 3 Cl Never

32. As far as you know, have you walked in your sleep in the last year or so?

1 a Yss 2 cl No

32

i-

,.
,

,- .

_-c ‘.’

,. - . \

I

*a . 1

,I

“.I., ,

,

I , - ,

3 3. Do you have acne (pimples or bZqckhet&)?

1

51

Yes X III No

YES: IF

a. At what age did it start?-.-----years

b. Do you use any treatment for it? I a Yes

c. Have you seen a doctor about it? 1 a Yes

2 cl No

2 III No

d. How much does it bother or worry you?

1 0 Quite a lot 2 q Some but not t& much

4 Cl Not at all

3 a Very little

34. Have you ever been away from your family (home) for at least two months?

1 Yes, once X q No

2 Yes, more than once

IF YES:

a. Where did you stay? (Check all that appj~)

1 0Camp 4 q With a relative

2 III Boarding school 5 III Elsewhere

3 0 Hospital

b. How old were you when this happened for the Pirst time?-- __ years

35. Are you going to school? (If you are now on vacqt$an q~+d wiE2 retqrp to achoal, check “Yes.“)

1

P

Yes

IF YES:

a. During the school year, how many

hours do you work? (not counting

homework for school)

1 0 I don’t week (GO TO QUESTION

36).

,

2 cl l-4 hours a week

3 c l 5-9 hours a week

4 c l lo-20 hours a week

5 E l Over 20 hours a week

6 cl I work, but can’t tell how many

hours

b. What kinds of work do you do?

c, Do you get paid for this work?

:

2

NO! IF_

__ . , _^._ i- _>. I_ .- _ . ?

aa. Do you have a job?

7 El Yes I

8 El No, but I am looking far one.

L-, No, and 1 am not looking for one,

(AFTER THIB AhJM’EB, GO TG QUESTIGN 37).
36. Do you work during vacatioh time?

1 c l Yes, full-time 2 0 Yes, part-time 3 cl No

37. DO you get an allowance from your family (so much money per week, for example)?

. ‘P

Yes X 0 No

IF YES: (IF NO, GO ON TO QUESTION 38)

a. Who decides the amount you are to get?

1 Cl Father 2 0Mother 3 c l Both parents 4 Cl Someone else

(Specify)

b. Who do you think should decide about it?

1 Cl Father 2 0Mother 3 Cl Both parents 4 0 Someone else /

(Specify)

c. Are there duties or chores you have to perform to get this allowance?

1 0 Yes 2 0 No

d. Is your allowance ever held back as a punishment?

1 q Yes 2 c l No

38. Now about your eating habits, do you think you eat

1 c l Too much 2 cl About the right amount 3 0 Too little

39. When did you last see a doctor for a checkup (routine examination)?

1 c l In the last year 4 c l Never

2 Cl One-two years ago 5 q I don’t remember

3 c l Over two years ago

40. When did you last see a doctor for treatment?

1 cl In the last year 4 a Never

2 0One-two years ago 5 Cl I don’t remember

3 Cl Over two years ago

41. When did you last see a dentist for a checkup (routine examination)?

1 c l In the last year 4 c l Never

2 c l OneJtwo years ago 5 c l I don’t remember

3 Cl Over two years ago

42. When did you last see a dentist for treatment?

1 Cl In the last year 4 q Newi

2 Cl One-two years ago 5 c l I don’t remember

3 c l Over two years ago

ONE LAST QUESTION

43. About how much time would you guess you spend in theusual day (enter number of hours

or fraction of hours, or zero, as appropriate)?

a. Watching television

. b. Listening’to radio

c. Reading newspapers, comics, magazines

d. Reading books (except comic books)

000

54
\ /

.

.

,.- -

APPENDIX I D

PHS-4733-S (PAGE 1)

R E V . Q-66 DEPARTMENTOF

HEALTH, EDUCATION, AND WELFARE

PUBLIC HEALTH SERVICE

NATIONAL CENTER FOR HEALTH STATISTICS

HEALTH EXAMINATION SURVEY

Form Approved:

Budget Bureau No. &J-K1700

SUPPLEMENTAL INFORMATION FROM SCHOOL

The student whose name appears below is one of the sample of students being studied in the Health Examination Survey.

This student’s parent or guardian has given us written authorization to obtain information from the school. Please complete this form on the basis of school records and/or information the student’s teacher or other school official may have.

A pre-addressed envelope, requiring no postage, is furnished for your convenience in returning this form.

‘<AME OF YOUTH &W3t) (Fir4li.l (Middle)

SAMPLE NUMBER

1

-L-

-HOME ADDRESS

‘For identification)

4

1. BIRTH DATE

(Month) (Dav) (Year)

2. WHAT IS THE PRESFbT GRADE PLACEMENT OF THIS STUDENT? grade.

5. IF GRADES WERE REPEATED, WHAT WAS THE MAiN REASON?

(Check only one)

1 g EXCESSIVE ABSENTEEISM fencused)

2 c; TRUANCY

3 a MOVED INTO MORE DIFFtCULY SCHOOL SYSTEM

4 0 SOCIAL IMMATURITY

S a ACADEMIC FAILURE

S c] OTHER (explain)

6. HAS THIS STIJDENT BEEN ABSENT FROM SCHOOL AN UNUSUAL NO. OF DAYS DURING THE MOST RECENTLY COMPLETEO

SCHOOL YEAR?

2 0 NO 3 0 DON’T KNOW

1 0 YES e IF YES, WHAT IS THE MAIN REASON FOR THE ABSENCES? (Check on/y one)

1 Cl Student’s illness

2 0 Illness in student’s family

3 O DW to wak (either away from home OP at home /or reasons other than famiiy illness)

4 0 T-y

5 Cl C&S (explain)

5 5
7. HOW FREQUENTLY IS ANY SPECIFIC OISCIPLINARY ACTION REQUIRED FOR THIS STUDENT?

1 u FREQUENTLY

2 17 OCCASIONALLY

sa NEVER

40 NO BASIS FOR JUDGING WHICH OF THE ABOVE FlTS THls STUDENT

8. ARE SPECIAL RESOURCES NEEDED OR CURRENTLY BEING USE3 FOR THIS STUDENT?

2 0 NO (SKIP TO QUESTlOW 9)

f a YES--+ IF YES, complete the following only for those special resources needed or currently being used

by this youth:

a. For the gifted

b. For the mentally retarded

I I

c. For “slow learners” not

classed as mentally

retarded

d. For emotionally disturbed

e. For orthopedically handicapped

I I I

f. Special facilities for the

“hard of hearing”

I I 1

g. Special facilities for the

visually handicapped

h. Speech therapy

i. Remedial reading

. I 1

j. English for students from

non-english speaking

environments

1

k. Remedial training in

special subject area(s)

1. Other resources needed

(specify) I I I

REASON FUR NON-USE

(Check prlmmy moron)

9. IN TERMS OF ADJUSTMENT, WHICH OF THE FOLLOWING BEST OESCRIEIES THIS STUDENT?

1 fi SEEMS WELL ADJUSTED.

cl SEEMS SOMEWHAT MALADJUSTeD.

3 0 SEEMS SERIOUSLY MALADJUSTED.

4 0 NO BASIS FOR JUDGING WHlCH OF THE ABOVE FITS THIS STUDENT.

56
. I

10. IN TERMS OF INTELLECTUAL ABILITY, WHICH OF THE FOLLOWING BEST DESCRIBES THIS STUDENT?

1 0 ABOVE AVERAGE

2 q AVERAGE

3 0 BELOW AVERAGE

4 0 DON’T KNOW STUDENT WELL ENOUGH TO JUDGE.

11. IN TERMS OF ACADEMIC ACHIEVEMEN T, IS THIS STUDENT:

1 q IN THE UPPER THIRD OF HIS CLASS

2 q IN THE MIDDLE THIRD OF HIS CLASS

3 O-IN THE LOWER THIRD OF HIS CLASS

4 0 DON’T KNOWll)c/F DON’T KNOW, Specify leaSOn

12. IN TERMS OF POPULARITY WITH OTHER STUDENTS, IS THIS STUDENT:

1 0 ABOVE AVERAGE IN POPULARITY

2n ABOUT AVERAGE IN POPULARITY

3cl BELOW AVERAGE IN POPULARITY

4 113 DON’T KNOW

13. HOW LONG HAVE YOU KNOWN THIS STUDENT?

1 q LESS THAN ONE S EMESTER

2 CI*MORE T H A N ONE S E M E S T E R B U T LES S T H A N ON E YEAR

3 c] MORE THAN ONE YEAR BUT LESS THAN TWO YEARS.

4 0 MORE THAN TWO YEARS

SIGNATURE OF PERSON COMPLETING THIS FORM

OFFICIAL TITLE DATE FORM COMPL ETEO

ooo57
APPENDIX I E

CONFIDENTIAL - All information which would permit identification of the individual will be held strictly

COP htial, will be used only by persons engaged in and for the purposks of the survey and will not be disclc or released to others for any other purposes (22 FR 1687).

DEPARTMENTOF

HEALTH,EDUCATION,,A.NDWELFARE

PUBLIC HEALTH SERVICE

NATIONAL HEALTH SURVEY

HEALTH BEHAVIOR

I==---

NAME OF YOUTH (Last, First, Middle)

I

SEX AGE

Ohle 0Fed=

INSTRUCTIONS: On the following pages you will find a set of questions dealing with your health

behavior. Since every person is different, there are no “standard” answers to the questions; just

answer them as fully and honestly as you can. Your answers will be kept confidential. Do your

best to pick the most likely answer from among the choices given. Only if you really don”t know

the answer check “Don’t know.”

1. Looking ahead, what would you like to do about school? (Check one only) .

1 q Quit school as soon as possible .- 4 q Finish college and get a college degree

2 cl Finish high school 5 c l Finish college and take further training

cl

(medical, ‘I aw or other professional

‘3 Get some college or other training school, etc.)

after high school

2. What do you think will happen about school? (CHECK ONE ONLY)

1 cl Quit school as soon as possible

2 c l Finish high school

3 cl Get some college or other training after high school

4 c l Finish college and get a college degree

5 cl Finish college and take further training (medicat, law or other professional school, etc.)

3. Have you ever had a date? (That is, a boy and girl going out together, whether or not anyone else

was along .)

1

51

Yes X 0 No

IF YES: How old were you when you first had a date?-years

5 8

‘\* :

: . c

. .
,

I ’

. h‘

4. Who makes most of the decisions on the following: (CAeck one in each TOW.)

a. Choosing your clothes

b. How to spend your money

c. Which friends to go out

with

I

d. How late you can stay late you can stay out outi

(4) (W (6) (7)

I

I

I I I I I H---i I I I

tj. How many times have you run away from home? (That means, leaving OT staying away 01;

purpose, knowing uou would be missed, intending to stuy away from home, at least for .5

time .)

1

P

Once 2 More than once 3 c l Nearer

IF ONCE OR MORE:

How old were you then? .-years

‘6. How many time s have you had anything to do with police, sheriff, or juvenile officers for

something you did or they thought you did?

1

7

Once 2 Tw ice 3 -.

P

More than twice 4 cl Never

IF ONCE OR MORE:

a. What was wrong?

b. Were you arrested? 1 c l Yes 2 q No 3 c l Don’t know

c. In what way were you punished?

2 u Not at all

7. How old were you when you smoked for the first time?.- Years

0 Never tried (SKIP TO QUESTION 10)

8. How old were you when you began smoking regularly?-Years

c l Never have smoked regularly

9. About how many cigarettes do you smoke per day?

1 cl I don’t smoke at all

2 cl I don’t smoke cigarettes (but I smoke a pipe or cigars)

3 cl Less than l/2 pack

4 cl l/2 pack but less than

5 cl 1 pack but less than 2

6 c l 2 packs or more

1 pack

packs

59
10. At what hour do you usually go to bed when the next day is a school or work day?

60

11. DO you ever feel tense, nervous, or fidgety?

1 c l Yes, often I

2 cl Yes, sometimes

3 q Yes, but rarely

4 c l Never

12. How important do you think it is for a young person to have each of the qualities ot

characteristics listed below? (Put one check-mark in each row .) \

. 1

Extremely Slightly

Important Important Important Unimportant

(1) (2) (3) (4)

a. To be neat and clean

b..To be able to defend oneself

c. To have self-control

d. To be happy

e. To obey one’s parents

f. To be dependable

g. To be considerate of others

1

h. To face life’s problems calmly

i. To obey the law

-

j. To be ambitious

k. To know how to keep in

good health

’ .

, I

’ .

. I \

* . . ,.
13. If you had any of the following contlitrons, would you want a clor:toT ;.J I\lio\\ about it.:

(Includes your seeing him or a telephone call about t.) (PI ace.: one checkmark in each

-_-

TOW. )

If I had this condition, I would:

Definitely want to Probably want to Not want to

see a doctor see a doctor see a doctor

(1) (2) (3) L ._

a. Stomach ache

t

b. Sore throat

c. Hurt all over

d. Stiff neck or back

e. Headache

f. Vomit (tArow up)

r

g. Loss of appetite

L

h. Overtiredness

i. Pain in chest

j. Lump in stomach or

abdomen

‘k. Blood in urine or bowel

movement

F

1. Nervousness

14. If you had any of the following conditiou,u, would you want tA) see a denlist about it’?

(Place one chPvkmark ir, e!ach TOW .)

If I had this condition, I would:

Definitely want to Probably want to

see a dentist see a dentist

(1) (2)

Not want to

see a dentist

(3

------

a. Crooked teeth

c

b. &Sore gums

,

c. Bad breath

d. A toothAche

, 1

e. Sores in the mouth

I

I .

1. Stains on the ti that

would not brush off

I A . 7

g . Hole or cavity in a tootheven though it did nd hurt

t I J

.

000 61
APPENDIX I F

Corrjdemtiaiity has brm arrnred the iadiuidnal as set fortb in 22 FR 1687

DEPARTMENT OF

HEALTH, EDUCATION, AND WELFARE

lrUBLlC HEALTH SERVICE

NAtiONAL CENTER FOR HEAL’TH STATISTICS

WASHINGTON, D.C. 20201

H&ALlH f3AMillr3TIOW SURVEY-III

CONTttOL RECORD

Fofm Approved.

TIME IN ludgot lurtw k.

PROCEDURE, OR PART OF OVERALL

PROCEDURE NOT DONE

REASON FOR NON-COMPLETION

PROCEDURE

AUDIOMETRY

ECG and PHONO.

SPIROMETER

TREADMILL, : <II I

SECRETOR iEST ;

BODY MEASUREthENTS 1

and

GRIP STRENGTH I I

HEIGHT-WEIGHT

X-RAYS (CHEST,

HAND)

HE OUT DENTAL

EXAMINATION

VISION

PHYSICIAN’S

EXAMINATION

VENIPUNCKJRE

I I

NURSE’S

QUESTIONNAIRE 1 1

PSYCHOLOGICAL

PROCEDURES

BEHAVIORAL

QUESTIONNAIRE I I

EXAMINATION DATE (mo., day, )r.) BIRTH DATE (mo., rhy, yr.) SEX TEMPERATURE

11 q ]nm2Ot

NAME 04 (f int) , (Initial) SEQUENCE NUMBER

.

62

I

” ,

t

f. . ,
HEALTH E#AMI#ATICIW SURVEY -Ill

USE THIS SEtilON WHEN

SAMPLE NO. IS EVEN

CPS

40: R Tfl L

1000: R ,+-l L

t

6000: R

ri----lL

t

500: R 171 L

2000: R

t

250: R jI L

4000: R +,L

t

8000: R

3000: R &-jL

AUDIOMETRY

CARD

COL. NOS.

(12-15)

(?a-roI, v

Cps

USE THIS SECTION WHEN

SAMPLE NO. IS ODD

400;: ;( jl1

\2

: ;OOO: .‘R rjL

6000: R +, L

t

500: R j/j L

s

2000:

t

250: R TI L

4000: R +, L

8000: R +, L

3000: R

CONDITIONS AFFECTING TEST RESUbTSz (Check)

CONDITIONS AFFECTING TEST RESULTS

1 0 Cold at present 4 0 Cold within post week

2 0 Ear discharge SEEarache within past week

3 E Equipment defective* 6 E Behavior’ 7 E Other’

l Specify frequency (cps.) if only certain one(i) affected, and describe:
HEALTH kXMlttATlQ~ $UttVEY-ItI

IIODY MEASUREMENTS

o-11

12-15

I 10-19

0

20-23

24.27

lb-31

33-35

S-10

11-l;)

14-11)

17-19

20-22

ELBOW-ELBOW BREADTH --#-

SEAT BREADTH --*---

FOOT LENGTH --*-

25-25 BIACROMIAL BREADTH

26-211 blCRISTA1 BREADTH

BITROCHANTERIC BREADTH

UPPER ARM GIRTH

FOREARM GIRTH

as-41 CHEST GIRTH

WAIST GIRTH

$4~49 HIP GIRTH

CALF GlRTH

TRICEPS SKINFOLD (mm.)

SUB5CAPULAR SKINFOLD (mm .)

59-41 LATERAL

CHEST 5KlNFOCP (mm.)

S’IANPINO

CERVICALE HEIGHT --v.e..w*-

ACROMIAI HEiGHT ---@-.----

RADIAL HEIGHT - --@..R-..”

STYLION t%tGHT ---#-n-eILIAC CREST t&IGHT ---q---

TROCHANTER I :F!GHT ---.-

TIBIAL HEIGHT - - ---*- -4P---

-•---

-O-

-@-

----*-----

-e----

-*I)--

-*-

-e-

-e-----

---e3649 -+-...m-----+----

4%43

43-45

46.48

$P

so-52

53-55

W-58

59-41

62

63-4)

64-w

MEASl

THIGH CLEARANCE

SPHYRION HEIGHT

FOOT BREADTH -o_8---

1st TOE RELATIVE

TO 2nd TOE

ANKLE BREADTH

KNEE BREADTH --M..-q#---aw

ELBOW BREADTH --Qw.wWRIST BREADTH --cp ---*- ---e---

-*---

-*-

2nd (Indo*) FINGER

RELATIVE TO

u Longer

c l Shorter

42-64

I

SUPRA-ILIAC SKINFOLD (mm.)

66-48 WEtGHT (lbs.) 4th (Ring) FINGER

$KINFOLD (mm.) -.-m-w*----

STANDING HEIGHT

-. . . . . . .,.... --. m..-.

REMiNTS NOT DQNE OR ‘SIbE

. . . ..-

%WED-q

64

.I..

r .I : ..-

, ’

*. -.,*

ií l _ ë,

.Cí * , .

’ *

. *
HEAlTH EXAWC?lO# $URYEY-III

TREADMI 11

OBSERVER ROOM TEMPERATURE (F’) HUMIDITY

WAS TEST SATISFACTORY? 1 0 YES

2 0 NO MIF NO, explain

SPIROMETER I

ROOM TEMPERATURE

- . .

(Co) WAS TEST SATISFACTORY? ’

1 q ]YES 2 UN0 4 IF NO, explain

l

-_. ._.~ _ __ . _ .- . . . _

Gtii P STRENGTH

RIGHT LEFT YOUTH IS:

1 . 1 . 1 u RIGHT-HANDED ,

2 . 2, 2 0 LEFT-HANDED

3. _ 3. 3 0 USES BOTH HANDS ABOUT SAME AMOUNT

Max. I Max. I

WAS TEST SATISFACTORY?

1 /-J YES

2 0 NO ‘PIF, ,W, explsin

. hc ,:. -

SAwlE No. (I-$
HEALTH EXAMINATIONSURVEV-III

COLOR VISION /

EXAMINER 40 REPORT

-a

Wears 30s for test: cl g! 2 COLOR VISION TEST NO. 2-H-R-R (Continued)

Wears contact lenses for test: 2 0

PLATE I

7 v

H0

8

9

‘0 0

X

m

II

q0

0 None

Ill

Vq

X

a

0 None

X

H

0

El3

H

0

V q

EEI Y

El3 0

EEIV

IV

0 Other

0 Other

q Other

q Other

0 Other

q Other

m Other

q Other

Wears neither for test:

COLOR VISION TEST NO, 1 - lrhihara binocular test

PLATE READ AS

--- - -

0’2 i IOther

08 [ 03 mother

05 i 0 2 0 O*er

04 i 0 Other

05 i q Other

q Other j 05

Cl 42 ; 02 042

; 04 042

,

i q Other

:

Mi.

R-G

Mod,

SCORE: (If total score for plates 2-1 7 is 6 skip to page 2 of Vision R-G

Form) _

CO&OR VISION TEST NUMBER 2-H-R-R

Sev.

R-G ’

16 0

\ H

V

PLATE I II

q Other

B-Y

i 2 IsI q Other SCORE: (7 through 16) _~

High = fJ Proton q Deutan

/J Other

4 ov - q q Other

5 O

H

0 Other

q Other

Sev.

1

1b m m m mother

‘-’ 20 m m 14 0 Other -

R-G

SCORE: (17 through 20) pHigh = q Triton c] Tetorton

SAMPLE NO. (1-5)

SCORE ( l-6):

66
, -.

* . .

s

I

l , I .

6 *

A”,

’ ?

HEALTH tXMBATIoII SURVET-III

DKTANCE VISION-WITHOUT CORRECTION

VISON TESTS

-,

Check tests given first. 0 Far 0 Near (Odd numbers distance first; even numbers near firr 1

DIAL

1. BINOCULAR LATERAL PHORIA-DISTANCE (Check number nearest arrow)

0 left of 1 01 02 03 0 4 05 106 07 08 09 010.

q 11 0 12 0 13 0 14 0 15 c] 16 / 0 17 q 18 0 19 0 20 q 21

q Right of 21 0 Arrow or number not visible. .ode -

2. MONOCULAR DISTANCE-SMALL’

line

5

6

6

7

8

9

10

11

12

Right eye Score

(Check)

VHDNS OZKRC _- 50

DVZNC SRHK~ .-40

KNZCO SRDHV -30

KNDRS ZVCOH 2 5

VZCHD KNRSO-20

KZSVN HCRDO - 17

RCSNV KDHOZ -, 15

ROKHZ NSCVD - 12

I

----

,eft eye Score

CDZNO KSRVH ,- 50

CNRKH ZVSDO- 40

DVHCK OZNSR- 30

CDKRO SZVNH -25

CVHSZ ORKDN- 20

DNVHS OKRCZ- 17

ZHODC SVNKR- 15

KHOZD CSNVR - 12

3. MONOCULAR DISTANCE-LARGE l (Omi: if xoll ou IX+.! 21

Line

1

2

2

1

3

4

Right eye Score left eye $k:;,.t9

SDK - -400 VNC -400

RCSZO

1

- 200

OZNKS

I

-.200

KNtdDV DRHCV

HNZOS KRCVD -100 RZOHC KSNDV, iO0

ZHODC SVNKR - 70 RKNCZ HSDVO 70

CODE - CODE _ITRIAL LENS FOR MYOPIA (score in lines l-8, Plates 2, 3-OMIT IF CONTACT LENSES ARE WORN.)

Right eye q cl q q q q q q SCORE ______

left eye

3A. BINOCULAR DISTANCE-SMALL*

line

5 OSDNH VKZCR 7 50

6 RHZCD OSVKN - 40

7 SVNHO KCRDZ - 30

8 RHSCK OZDVN - 25

9 OZRVN HSCKD - 20

10 DRHVN ZSKCO - 17

11 OSKCV RZHDN - 15

12 SKHDN OCVRZ - 12

---

Score

T

4A. BINOCULAR DISTANCE-LARGE’ fOIlpit i/-scorr on Dial 3A)

Line

1

2

I

2J

3

4

KDS - - 400

ZSKCO

1

- 200

VRHDN

ZNSKH VDRCO - 100

OZCRH NSKDV - 70

Code -

*Diagonal line through each letter missed; horizontal line through sections of line not attempted and through top full line not attempted.

67
HEALTH EXAMIWATIOM SURVEY-III

NEAR VISION-WITHOUT CORRECTION

6. BINOCULAR LATERAL PHORIA-NEAR (Check number nearest arrow)

OLeftofl 01 02 03 04 r]5 06 u7/08 09 010 011 012 013 014

0 15 0 16 [rl 17 Iz) 18 / [71 19 [z1 20 0 21 q 22 Is] 23 0 24 [II 25 0 26 m 27 0 28 q 29

0 30 0 31 0 32 0 33 0 Right of 33 CODE..

7. MONOCULAR NEAR-SMALL’

Line Right eye Stare

(Check)

5 CVRZS DKHNO -50

6 VZKCO HRSDN -40

7 HSZKN OVCDR - 30

8 OVRHS CNDZK - 23

9 ZHCOR VDNSK - 20

16 RHCVN SDKZO - 17

11 CNZSR OHKDV - 15

12 ODCNH VRSKZ - 12

Left eye Score

ZKCRV OHSDN lly.rr 50

SDKVO ZRHNC - 40

DHZRV SOKNC A 30

DKOSN RVZCH - 25

RKZVD OSNCH - 20

OKSRN bHVCt - 17

VRCHN OZKSD - 15

ROHKS VDNCZ - 12

9. BINOCULAR NEAR-SMALL l

line

5

6

7

8

9

10

11

12

-

OCVKR tNSDH -50

ZHOCV NDRKS - 40

SDOVK HRNZC - 30

DNHKO ZSRVC - 25

DSVKH ZNOCR - 20

NZHKO RCVDS - 17

SNCtO RKVHD - 15

DHNVO SCZKR - 12

B. MONOCULAR NEAR--LARGE’ (Omit //scotr on LW 7)

Line

1

2

2 i

3

4

Right eye

NCV

HNRCD ]

Score

- 400

- 200

VOSZK

NDOCV RSZKH - 100

VRCNZ OSDHK - 70

CODE - CODE _

left eye

DSK

CRStO

NDVHK I

OKZHS NCVRD

RCOVN DHKSZ

Score

- 400

- 200

-100

- 70

c(SS. BINOCULAR NEAR--LARGE l (Omit i/ score OH D$d 9)

1 NVC: -400

2 1 CZHSN 1

21 DKORV ] -200

3 KSDVO NHZCR - 100

4 VfOCS HRNKD - 70

CODE -

*Diagonal line through each letter missed; horizontal line through sections of line not attempted and through top full line not attempted.

NEAR VISION-WITH CORRECTION

6. BINOCULAR LATERAL PHORIA-NEAR (Check number nearest arrow)

DLeftofl 01 02 03 04 05 06 U7/U8 r]9 010 011 012 013 014

015 016 017 nl8/n19 020 021 022 TT]23 024 a25026 027 028029

030 m31 032 1733 0 Rightof [7 Arrow or number not visible CODE -

.

SAMPl.f NO. (1-5)

68

I, 3
DISTANCE VISION-WITH CORRECTION 1 r--J with &%3r*

2 0 with eentoet IoMQe

W”’ .~ --‘..‘.

VrwN TIWS

PIAL

1, 6lNOCUlAR LATERAL PHORIA-DISTANCE (Check number nearest afrciw)

tlLeftof1 cl1 02 cl3 04 05 /cl6 cl7 LIEI III9 a10

q ll 012 cl13 014 015 016 / Or7 cl16 a19 020 lJ21

Line Right eye Store

(Check: Line Right eye Scare Left eye I Score

5 $OZNV SWROCe...3l 1 SbK -4Oo’ VNC 31rll. 400

6 VKkN~ CODHS -46 2

I

RCSZO

- 200 - 200

7 HSbRt NCVC)K -30 2 KNHDV

0 ZOVCS NRKDH -25 3 HNZOS KRCVD,, 160 RZOHCf: KSNDV- 100

9 RH$bK ONCVZ -20 4 ZHODC SVNKR - 70 RKNCZ HSDVO- 70

10 KNRZO OHVCS _j I7 I

11 KZOOR HNStV - 1.5 I

CODE -,_ CODE -

4A. lNOCULAR DISTANCC--LARGE’ (omit ;f ~carc on m,d 3~)

12 RVNSZ KCbOH ,-ml2

L

ldt eye Scote

CRNDO SVllHK LcI JO

ZVCOH DRBNK - 40

ZKHSC) VCDRN - 30

HNVI?S CKRW - 25

RHCVN OOSZK - 20

KRNHC OSPVZ- 17

SChZb VKNRO- 15

CNDZK 0HRVS - 12

LL*

Line

1

Line

5

6

7

8

9

10

11

1%

a Right af-’ 21 * -.. ‘. L . a cc’

c] Arrow or number not vialble. Code -

5A, MONOtlJLAR bISTANCE-SMAL&

- .. ‘ - ‘.- * ’ -. .

. ..,,,_._,_

3. MONOCULAR DISTANCE-LARGE’ (Omit y~core on Did 5A)

Score

OSbNH VKZCR -50

RHZCb OSV’KN -40

SVNHO KCRbZ we30

RHSCK CXbVN -25

CSZRVN HSCKD -20

bRHVN jtSKC0

OfiKtV RZHbN

SKHON OCVRt

L_ 17

-1s

-12

2 Z&KC%

I

- 200

2 VRHDN

3 ZHQ#H VDRCO I_ 100

4 OXRH NSKDV * 70

+biagonaI line thrtkth each fetter mlrbcd; hotitaatrl line through rtttions of llhe not atnmpttd and thtbugh top full llnt not attempted.

)tight eye Cl Cl tl q cl cl cl cl SCC)REH- .‘..

0 1 1.5 2 3 4 5 MA,

Lefteye tl Cl Cl El Cl Cl Cl Cl &OR& - .

w-- -” -“-
LINE (Code) RIGHT EYE

2

3

4

5

6

7

8

8

10

11

WITHOUT CORRECTION

200 El

100 c l

71.4 c l

50 0

39.3 cl

28.6 n

25 cl

21.4 0

17.9 cl

14.3 c1

10.7 q

CODE

I

LEFT EYE

.

200 q

loo cl

71.4 q

50 0

39.3 0

28.6 q

25 c l

21.4 q

17.9 c-3

14.3 c l

10.7 a

eDISTANCE’ (at 10 feet)

WITH CORRECflOM

I q With Giasses

2 q With Contact lenses

BINBCWLAR LINE (Code) RIGHT EYE

200 E l

100 cl

71.4 El

50 El

39.3 u

28.6 q

25 E l

21.4 0

17.9 q

14.3 c l

10.7 c l

200 Cl

100 III

71.4 c l

50 a

39.3 0

28.6 0

25 q

CODE

LER EYE

200 c l

100 cl

71.4 c l

50 El

39.3 c l

28.6 q

25 q

21.4 r]

17.9 c l

14.3 q

10.7 q

BINOCULAR

---

200 0

100 El

71.4 0

50 a

39.3 cl

28.6 n

25 q

21.4 0

17.9 cl

14.3 0

10.7 cl

-~

TRIAL LENS TEST FOR MYOPIA-without correction (Score in lines l-8 Monocular Distance -Omit if contact lenses are worn)

Right eye 0 q a cl cl q cl cl SCORE

SCORE

NEAR’ (at 14 inches)

-- --

LINE (Code) RIGHT EYE

1 200 cl

a 160 q

3 125 q

4 100 q

5 80 tl

6 60 c]

7 50 q

8 40 q

9 30 cl

10 25 0

11 20 cl

CODE -

-

LEFT EYE

200 cl

160 a

125 q

100 0

80 q

60 n

50 cl

40 c l

30 a

25 cl

~-20 0

+CQrcA acuity level rtachrd.

TRIAL LENS TEST FOR MYOPIA-with correction (Score ------I .

in lines l-8, Monocular Distance)

BINOCULAR

100 cl I Right eye q 0 r] SCORE

80 q

60 5

50 El

4 5 N.A.

id eye 0 Cl Cl SCORE

LEWSOMETER READINGS (glosser, contact lenses)

SAMPLE NO. (1-S)

70

. -

.‘li ’

.t’ .
HEALTH EXAMATIOH SURVEY- Ill

MT EXAMINATION

I? L R L

EXTERNAL EAR (Except Canal) cl 1 0 NO FINDINGS cl 1 0 OPERATIVE SCAR

cl 2 0 FINDINGS ) 20 2 0 OTHER (Describe):

:{

2. Occluded: Occluded By:

,L R L R L R L

AUDITORY cl 1 q NO FINDING3 Cl 1 q PARTIALLY cl 1 0 CERUMEN

CANAL 20 2 0 FINDINGS----+- 20 2 0 COMPLETELY 20 2 0 OTHER (Describe):

DRUM

R L

a 1 q NO FINDINGS

20 2 0 FINDINGS...,

a

3 0 NOT VISIBLE

R L

cl ’ 0 ~%Q”E)

cl 2 G TRANSPARENT

‘cl 1 0 BULGING

2 0 2 0 RETRACTED

R L Perfomted:

cl 1 q RED R L

DRRUM M?B1LE cl 1 0 YES

20 2 0 NO

TONSILS:

1 0 NOT VISIBLE

a cl PNEUMATIC OTOSCOPY

UNSATISFACTORY

ORAL PHARYNX

2 q TONSILLAR TAGS PRESENT

1 0 NO FINDINGS 3 q TONSILS PRESENT-GRADE l

2 0 FINDINGS (Qescribe):

(Within Tonsillor Pillors)

4 0 TONSILS PRESENT-GRADE II

(Outride fonrillor Pillars but not Meeting in Midline)

5 n TONSILS PRESENT-GRADE Ill

1

(Meeting in Midline)

NARES

R L

cl 1 13 NO FINDINGS

cl 2 0 FINDINGS-r

OBSTRUCTION:

R L,s

CJ 1 0 ACUTE

20 2 n CHRONIC

OTHER SIGNIFICANT FINDINGS:

R L

cl 10 NO

a 2 q YES (Describe)

SAMPLE NUMBER (l-5)

71
HEALTH EXAMINATION SURVEY-III

PHYSICAL EXAMINATION

EYES: d-i, LIDS, CONJUNCTIVAE AND SCLERAE

i R L

I Describe:

I i--J 1 0 NO FINDINGS I

I

c-ii 2 0 FINDINGS ------I

I

B. PUPILS AND IRIDES

R L

cl 1 u NO FINDINGS

cl 2 0 FINDINGS (Describe):

C. TROPIA (indicate direction)

NORMAL I N OUT UP DOWN

R lr] cl 42 a cl

D. EXTRAOCULAR MUSCLES AND CONJUGATE GAZE

R L

I

cl 1 0 NORMAL 1 Describe: _L___

L 1rJ 2p 30 40 50 cl 2 c] ABNORMAL ,-bI

______--.-..---~

E. OTHER EYE ABNORMALITIES

‘0 NO 2 0 YES (hscribo)

THY ROIO: GOlTER CLAS$IPICATION

Of-J GPCXJP 0 2 q GROUP 2

1 0 GRQU~~ I 3 0 GROUP 3

IS.., d .a

BREAST:

R L MALE

cl 1 q NO FINDINGS

20 2 0 FINDINGS:

t

QY NECOMASTIA: R L

CLASS I - WITH TENDERNESS 1 m cl

- NO TENDERNESS 2cl 90

CLASS II - WITH TENDERNESS 42 30

- NO TENDERNESS a 4c.l

OTHER FINDINGS: R L

cl 20

Describe _---

HEART:

OTHER THYROID FINDINGS

MATURATION STAGE: 1

II Ill IV V

R: li 20 30 40 50

1: 10 cl cl cl cl

.-----------------------ill---------------------

OTHER BRRAST FINDINGS:

1 q NO FINDINGS

2 q FINDINGS

R ’ L

1D 10 MASS

2 0 20 Other (hwib4 - -

?.&I, INTCRSPACB: 04 cl5 cb 1 TT] NOT FELT

10 NO 2 0 YES (Describe)

FEMALE

MlDCLAVlCULAR LINE 1 [L3AT 20 INSIDE 30 OUTSIDE 40 NOT FELT

------ -App-- -

TllRllLS: 1 qABSENT i 1 u SYSTOLIC 02 DIASTOLIC

2 [3 PRESENT ) ! 1 u BASE 3[3 AfEX

HRART

SOUNDS

c

1st HEART SOUND

2nd HEART SOUND

1 m NORMAL

10 NORMAL

2 0 OTHER (Dwcribo):

2 c] OTHER (Dercribe):

MURMUR 1 OTHRR MURMURS:

I

1 r] AUSENT 2 q PRESENT

I

I

DESCRIBE (As Before): ----

I

Describe Murmur (Location intensity, pitch, quality, duration, time, transtnisrion): I

-____-_____--

- -

I--

l ---

I

OTHER CARDIAC OR CARDIOVASCULAR FINDINGS I r] NO 2 q YES (Dercribs) - -

I

SAMPLE NO. (1-5)

72
PHYSiCAL f3AMlNATION (Continue4

ABDOMINAL: I

i

1 0 NO FINDINGS

2 q FINDINGS -----d

(Check all items I

i that apply)

1 1 0 APPENDECTOMY HERNIORRAPHY (inquinal)

I 1 0 RIGHT 2 0 LEFl

OTHER SURGICAL 2 0 SCARS (Describe): _-

I

-~

GENITALIA:

PUBIC HAIR MATURATION (Stage):

I II Ill

‘cl a 3cl

t 0 OTHER ABDOMINAL FINDINGS

IV V

40 a

MALE: A. GENITAL MATURATION (grade}:

‘Cl1 q-J II 3q Ill 40 IV CIV

B. CIRCUMCISION 10 YES 2 0 NO

c. OTHER GENITAL FINDINGS:

1 q NO FINDINGS 2 0 FINDINGS *

~ R L

1 0 1 q UNDESCENDED 1ESTlCl.E

2 q 2 a OTHER (Chcribe):

MUSCULO-SKELETAL 1 0 NO FlNDlsS 2 0 FfNDlNGS (list and Describej:

SKlN FACIAL ACNE-GRADE OTHER SKIN FINDINGS: 1 0 NO FINDINGS 2 0 FINDINGS (Describe):

0 I II Ill IV

00 ‘cl 20 cl cl --

PREFERENCES: VARIABLE

RIGHT (PREDOMINANTLY) LEFT (PREDOMINANTLY)

OR

EQUAL UNSATISFACTORY

HAND ‘0 20 30 40

EYE ‘I 20 jcl ‘El

FOOT ’ 0 ‘I 3cl 4cl

ABNORMAL NEUROLOGICAL FINDINGS

1 0 NONE 2 0 YES (CkscrihJ:

-

&HER SYSTEMS (Reticula endothelial, G.I., etc.)

1 c] No FiNDINGS 2 c] FINDINGS (Describe):

NUTRITIONAL APPRAISAL (Your own subjective appraisal)

10 NORMAL 2 0 UNDERWEIGHT 3 0 MODERATELY OBESE 4 0 VERY OBESE

BLOOD PRESSURE TIME SYSTOLIC DIASTOLIC

SAMPLE NO. (1-5)

73
NEALTN WINATION SURVEY-III

SUMMARY OF DIAGNOSTIC IMPRESSIONS

--

-.-

DIAGNOSTIC IMPRESSION

NEUROLOGICAL CONDITIONS

1 0 NO FINDINGS

2 0 NEUROLOGICALLY SUSPICIOUS BUT NO DEFINITE ABNORMALITIES (list and Describe):

3 a NEUROLOGICALLY ABJ+JORMAL (list and Describe):

.,

MUSCULO-SKELETAL

1 0 NO FINDINGS

2 0 FINDINGS (fist and Describe):

DIAGNOSTIC IMPRESSION -

OTHER SYSTEMS

1 0 NO FINDINGS

2 [7 FINDINGS (Describe):

DIAGNOSTIC IMPRESSION

74

I .

. ,

d
- J.

. I

. ..I ,

’

HEALTH EXAMINATION SURVEY --II I

, (To be asked of female examinees only)

NURSE’S QUESTIONNAIRE

--

1. HAVE YOUR MONTHLY PERIODS STARTED, THAT IS, HAVE YOU BEGUN TO MENSTRUATE:

1 0 YES 2 0 NO 3 0 DON’T KNOW

J. J 4

(If YfS, skip to (If NO or DON’T KNOW, ask Question 2 and discontinue interview.)

Question 3.)

,

2. HAVE YOU BEEN TOLD ABOUT MENSTRUATION IN GIRLS? T 0 YES 2 0 NO 3 q DON’T K; Y~J‘

IF “YES,” ask: WHO WAS IT THAT GAVE YOU YOUR FIRST REAL INFORMATION ABOUT THIS?

1 q Your Mother

2 0 Older Sister

3 0 Other Member of Family

4OY our Doctor or Nurse

5 c] School Program Person

6 0 Girl Friend

7 q Other (specify who):

3. WERE YOU TOLD ABOUT MENSTRUATION IN GIRLS before the time WHEN YOUR PERIODS BEGAN?

1 0 YES 2 0 NO 3 0 DON’T KNOW.

A. FROM WHOM DID YOU GET YOUR FIRST REAL INFORMATION ABOUT THIS?

1 0 Your Mother 5 0 School Program Person

2 0 Older Sister 6 0 Girl Friend

3 0 Other Member of Family 7 0 Other (Specify who):

4 0 Your Doctor or Nurse

B. WHOM WOULD YOU PREFER TO HAVE GIVEN YOU THIS INFORMATION?

1 0 Your Monther 4 q School Program Person

2 0 Older Sister

3OYour Doctor or Nurse

5 0 Girl Friend

6 0 Other (Specify who): -~____-____-~-

4. HOW 01D WERE YOU WHEN YOU STARTED? 15. ‘\YHi-N DID YOU HAVE YOUR LAST PERIOD?

years ____- months I _______ days ago

6. HOW LONG DOES YOUR PERIOD USUALLY

LAST? -__--~--- - - Days

i 7. HOW MANY DAYS ARE THERE BETWEEN YOUR PERIODS?

i

Days

8. DO YOU SOMETIMES HAVE DISCOMFORT OR PAIN IN CONNECTION WITH YOUR MENSTRUAL PERIOD?

1 c YES ____) IF YES, then ask:

2 c NO A. DO YOU HAVE THIS DISCOMFORT 1 q Most periods 2 0 Occasionally

B. IS THIS DISCOMFORT 1 0 Mild 2 0 Moderate 3 q Severe

c. DOES THIS FREQUENTLY CAUSE 1 0 YES+/F YES, what kind?

YOU TO TAKE MEDICINE? 2 0 NO

D. DOES THIS CAUSE YOU TO GO TO THE SICK ROOM OR NURSE? 1 0 YES 2 q NO

E. IS THIS FREQUENTLY SEVERE ENOUGH TO CAUSE YOU TO STAY

HOME FROM SCHOOL (OR WORK)? 1 q YES 2 0 NO

F. HAVE YOU TALKED TO A DOCTOR ABOUT THIS? 1 q YES 2 0 NO

75
Cottfidetttirrlity hd, been rtssured the purertts us stt forth in 22 I;.R. 168~

DEPARTMENT OF

HEALTH, EDUCATION, AND WELFARE

PUBLIC HEALTH SERVICE

NATIONAL CENTER FOR HEALTH STATISTICS

WASHINGTON, D.C. 20201

HEALTH EXAMINATION SURVEY-ill

REPORT OF FINDINGS

form Approvtd

Budqet Bureau No 6B-RI700

EXAMINEE’S NAME AND ADDRESS AGE DATE OF EXAMINATION NAME AND ADDRESS OF PHYSICIAN

-.--__--_ -_--

HEIGHT (inch) ’ WEIGHT (Ibc ) .

COLOR VISION

q No defect

TYPE

0 Red-Green

q Not tested

DEFICIENCY

SEVERITY

0 Mild

VISUAL ACUITY (Distance)

RESULTS ARE: fi WITH GLASSES

0 WITH CONTACT LENSES

q WITHOUT CORRECTION

0 NOT TESTED

/J Green-Red 0 Moderate

q Blue-Yellow q Severe

HEARING:

(audiogram)

CHEST X-RAY

q COPY ENCLOSED

q NOT PERFORMED

-----_-------

BACTERIURIA (Females only)

(POSITIVE-more than 100,000 colonies/cc)

1 st Specimen

n Pos. /-J Neg. q Not Performed

2nd Specimen (date performed -___------__- 1

0 Pos. 0 Neg. q Not Performed

PBI (Serum) -__- --- _- _- .___ -____ micro gms %

CHOLESTEROL (Serum) ._ ----_-____-__ mgms %

URIC ACID (Serum) --.------______ mgms %

SEROLOGY:

VDRL q Neg. i--J WR q Pos.

FTA-ABS q Neg. 0 WR 0 Pos.

_.. __--___-- -----.----___- ._-__----

SIGNIFICANT MEDICAL FINDINGS-f or which parent gave no history and which may require medical follow-up:

__--_----_-- ----____--.--__-~~--_-___.._---_-__--.--

~--_____-_ ----_--- __---

See enclosed Form for rooter on tests used,

RIGHT EYE __---

LEFT EYE _---

20/ 20/

BLOOD CHEMlSTRY

HEMATOCRIT -__-- __-_.-_------_- --_-- -%

76

EXAMPLE NO (l-5)
,! _ .

’ I

: - , ,sConfidentiality has beem urrrrred the plrreprts us ret forth in 22 F.R. 1687

DEPARTMENT OF

HEALTH, EDUCATION, AND WELFARE

PUBLIC HEALTH SERVICE

NATIONAL CENTER FOR HEALTH STATISTICS

WASHINGTON, D.C. 20201

form Approved

Budget Burtou Wo 6B41700

HEALTH EXAMlNATlON SURVEY-III

REPORT OF DENTAL FINDINGS

EXAMINEE’S NAME AND ADDRESS AGE DENTIST NAMED BY PARENT

DATE OF EXAM.

THE INDEX ASSESSMENTS USED IN THE SURVEY REVEAL:

._-----

a No conditions which suggest that the Examinee should be seen by you before the next regular appointment.

ONE or MORE of the FOLLO WING CONDITIONS that suggest

not treatment is needed before the next regular appointment.

a clinical examination is desirable to determine whether or

0 DECAYED TEETH

q GINGIVITIS and/or PERIODONTAL DISEASE

0 ORAL DEBRIS and/or CALCULUS

0 MALOCCLUSION

0 OTHER CONDITIONS (specify)

COMMENTS

STUDY NO. (l-5)

GPO. 19970-217-997

77
Confidentiality hos been ossured the individual O S set forth In 22 FR 1687

-

-

DtPAA lMEMT OF -

-

HEALTH EDUCATION AND WELFARE Form Approved: -

PHS-4611-5 PIJBLIC HEALTH SEHVICC Budget Bureau No. 68-R620-S4.5 -

3-65 NA:lOh(AL CENTER FOR HEALTH STATISTICS :-

iI -

I--

DENTAL EXAMINATION - HEALTH EXAMINATION SURVEY Z - al l-l-

-

Name

-

- -

-

Dote of Birth: .

-

M O DAY YEAR I . SAMPLE NUMBER e -

\1

-

-

-

-

-

-

-

-

-

-

_-

-

-

-

--

3 . EDENTULOUS ARCHES -DENTURE STATUS 0 I : I.- rZ-1 -:s--- .-4: I.5

Absent Present Defective

Upper :..:. .___ __--. __- .- 0 : 1:: -3: :$I- :;6- -13:

Examinee

Lower _ _ 0: r-t- --2 -3 - 4 :-5:

_-

4, STATUS OF TOOTH SPACES j.PERIODONTAL No ___..

I

__--.

INDEX P.I. Permanent Teeth Misstng

USC 0 C S-X R

Tooth

Space

Quadrant

UPPER

ARCH

RIGHT

.

Tooth

Space

3rd Molar

2nd Molar

1st Molar

2nd 81

1st Bi

Cuspid

Lateral

p

Central

:: \..L’.’ ‘_ . . . . .

.‘.~.‘_~.~.~.~.‘.~_~.‘.~.‘.‘.‘.~,~,~.~,~ :. :::::..‘.~,~.~.~.‘.‘.‘.‘_‘.~.’ . . . . .‘.~.‘.~.‘.~.~.‘.‘,‘.~

Central

Loterol

Cuspid

1st Bi

2nd 81

1st Molar

2nd Molor

f

3rd Molor

.‘.‘.~_‘.‘.‘.~.~.~.~.~.~,‘.~.~.‘.’.~.~.’ _‘.~.‘.~.~.~.~.~.~.~.~.~.~.~.~.~.~,~.~.. . . . . . . . . . . . . . . . . . . . . . . . . . . .._.......... .‘.~.~.‘.‘.~.‘.‘.‘.~.~.~.‘.‘.~.‘.~.’.’.’

3rd Molar

2nd Molar

1st Molar

2nd,Bi

1st Bi

Cuspid

Lateral

Central

Loteral

Cusp Id

1st Bi

2nd Bi

1st Molar

2nd Molar

3rd Molar

3rd Molar

2nd Molar

1st Molar

2nd Bi

1st Bi

Cuspid

Lateral

P

Central

.~.~.‘.~.‘.‘.~.~.~.~.~.~.~.~.~.‘.’.~.~.~ .‘.~.‘.~.‘.~.~.‘.~.~.~.~.‘.~.‘.~.’.~.~.’ .‘.‘.‘.‘.‘.~.‘.‘.‘.~.~.~.‘.~.~.‘.~.~.~.’ . . . . . . . . . . . . . . . . . . . .

Central

Loteral

Cuspid

1st Bi

2nd Bi

1st Molar

2nd Molor

3rd Molar

.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:

:.:.:.:.:.:.:.:.:.:.:.:.~:.:.:.:.:.:.:.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3rd Molar

2nd Molar

1st Molar

2nd f3i

1st Bi

Cuspid

Loteral

Central

:::.:.:.:.::::::::::::::::::::::::::::

.:.:.~~~:.:.:.:.:.:.:.~:.:.:,~~:.:

. . . . . . . . . . . . . . . . . . . .

Central

Lateral

Cuspid

1st Bi

2nd Bi

1st Molar

2nd Molar

3rd Molar

::z:-12ndMoloj

:&I 1st Molo

-

-

-

-

-

-

-

-

-

-

-

-

-

--

-

-

-

-

-

-

.-

-

-

-

-

-

-

-

-

-

-

_-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

_-

-

-

-

-

-

-

‘vt.SC 0 C S-X R I 2 6 8

~19:: Central

-IO- Lateral

UPPER

ARCH

LEFT

P XP XR R

. .

N D F XD X R

. . . . . . . . . . . . . . . . f;;;:$;:;:;:i:;:;;

. . . . . . . . . . . .

I

3 8-I 2ndMolai

LOWER

ARCH

LEFT

LOWER

ARCH

RIGHT

IN D F XD )( R

>:*..:.>:.:.:.>:.:.:

1A::::: .:: . . . . . . . . . . . . . . . . >:.:.:

I

I 2 6 8

25: Central

26: Lateral

2T: Cusptd

28: 1st Bi

-291&d B i

30I 1st Molo~

13 t I 2nd Mola

S- 3rd Mola,

-

-

-

-

78

,

. ’ .

* \. ’

<

. . ,’ I

, I

1
DENTAL EXAMINATION - HEALTH EXAMINATION SURVEY

SAMPLE NUMBER _____,

&

Upper Arch II- Lower Arch ‘-I1

Anterior I I

Left

I I

Right

ATIONSHIP

-------------------

Debris Calculus1 CalculusI Calculus1

None

7. FRACTURES OF ANTERIOR TEETH 8. OPACITIES

Upper Teeth

I

Lower Teeth -

Non-

(None Dentin Pulp Treated NA 1 (None Dentin Pulp Treated NA fluoride

Moderatesevere

N A

9. BUCCAL SEGMENT RELATION IO. POSTERIOR CROSSBITE I I. INCISOR REL

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

- Left

2-4

o-2

Overbite (mm)

Inc 3rd

Mid 3rd

Gin 3rd

Impinging Overblte

I

- Not Applicable -

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

12. HLD INDEX (Handicapping Lablo-lingual Deviations)

Labio-lingua

Spread

PHS-4611-5

3-65 (Page 2)

79
DENTAL EX: ION - HEALTH EXAMINATION SURVEY

--

13. LOWER NCISOR WIDT HS (mm and tenths) 14. INCISAL OVERLAP (mm) 15. SPACE (mm)

16. DISTANCE FROM LATERAL TO MOLAR (mm) 17, MALALIGNED TEETH

-Upper --Lower - Upper p Lower -

-

_ -. 16. MAXILLARY ARCH WIDTH (mm) 19. ORTHODONTIC APPLIANCES REMARKS: _-_ _ Present

I

Molar

I I

Cuspid

I

:I:.-: None

1:::: Active- Fixed

III:: Active Removable

----- Retainer -___-

----- Space Maintainer ----_

TT:II 0 t her (describe)

.-w-c-.-- -

- -

--- -

-- ’ ink -I=I

PHS-4611-5

3-65

(Page 3)

ooo80