I 

I 

PROGRAMS AND COLLECTION PROCEDURES	 Series 1 

Number 11 

Health InterviewSurvey 

Procedure 

1957=1974 

DHEW Publication No. (HRA) 75-1311 

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

Public Health Service 

Health ResourcesAdministration 

National Center for Health Statistics 

Rockville, Md. April 1975 
Library of Congress Cataloging in Publication Data 

United States. National Center for Health Statistics. Health interview survey, 1957-1974. 

(Its Vital and health statistics: Series 1, Programs and collection procedures; no. 11) 

(DHEW publication no. (HRA) 75-131 1) 

1. Health surveys–United States. 1. Title. II. Series. III. Series: United States. Dept. of 

Health, Education and Welfare. DHEW publication no. (HRA) 75-1311. 

RA409.U44 no. 11 312’.07’23s [312’.O7’23J 74-32057 ISBN 0-8406 -0037-2 
NATIONAL CENTER FOR HEALTH STATISTICS 

EDWARD B. PERRIN, Ph.D., Director 

PHILIP S. LAWRENCE, SC.D., Deputy Director


GAIL F. FISHER, Associate Directorfor the Cooperative Health Statistics System


ELIJAH L. WHITE, Associate Director for Data Systems


IWAO M, MORIYAMA, Ph. D., Associate Director forlnternationa~ Statistics


EDWARD E. MINTY, Associate Director for Management


ROBERT A, ISRAEL, Associate Director for Operations


QUENTIN R. REMEIN, Associate Director for Program Development 

ALICE HAYWOOD, Information Officer 

DIVISION OF HEALTH INTERVIEW STATISTICS 

ROBERT R. FUCHS BERG, Director 

PETER RIES, Ph. D., Chief Illness and Disability Statistics Branch


KINZO YAMAMOTO, Ph.D., Chiej Utilization and Expenditure Statistics Branch


CLINTON E, BURNHAM, Chiej Swuey Planning and Development Branch


COOPERATION OF THE BUREAU OF THE CENSUS 

Under the legislation establishing the National Health Survey, the Public 

Health Service is authorized to use, insofar as possible, the services or facilities of 

other Federal, State, or private agencies. 

In accordance with specifications established by the National Center for Health 

Statistics, the Bureau of the Census, under a contractual arrangement, participated 

in planning the survey and collecting the data. 

Vital and Health Statistics-Series l-No. 11 

DHEW Publication No. (HRA) 75-1311 

Library of Congress Catalog Card Number 74-32057 
CONTENTS


Page 

Introduction . ...0.0... . . . . . . . . . . . . . . . . . . . . . *..*****. . . . . . . . . . . . . 1


History of the Interview Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1


Background of the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Concepts Usedinthe Health Interview Suwey . . . . . . . . . . . . . . . . . . . . . . . :


Technical Aspects of the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4


Statistical Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...*. 4


Estimating Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5


Reliability of Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7


Errors Due to Sampling Variability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7


Questionnaire Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8


History of the Questionnaire Format . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9


The Basic Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11


Supplements to the Basic Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . 39


Appendix I. Rotating Supplements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41


Health Insurance Coverage, .


FY 1960 (July-December 1959) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41


FY 1963 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41


FY and CY 1968 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42


CY 1970 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42


CY 1972 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...* 43


CY 1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44


Hearing Ability, :,

.


FY 1963 . . . . . . . . . . . . . . . . . . . . . ...*.. . ...*...* . . . . . . . . . . . 45


CY 1971 . . . . . . . . . . . . . . . . . . . ...0.... . . . . . . . . . . . . . . . . . . � . 49


Loss of Income,


FY and CY 1968 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51


CY 1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52


Nursing Care and/or Special Aids,


FY 1959 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .* 54


FY 1967-68 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54


CY 1969 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .0 57


Personal Health Expenses,


FY 1963 (July-December 1962) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58


FY 1966 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61


CY 1971 . . . . . . . . . . . . ...**... . . . . . . . . . . . . . . . . . . . . � .*...* 64

.

CONTENTS.-Lon. 

Prescribed and Nonprescribed Medicines,


FY 1965 . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . .


CY 1973 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Smoking Habits,


FY 1965-66 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


CY 1970 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Vision Impairment and Use of Corrective Lenses,


FY 1963 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


FY 1966 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


CY 1971 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


X-Ray Visits,


FY 1961 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


FY 1964 (April-June 1964) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


CY 1970 (Apnl-September I 970) . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Appendix II. One-Time or SingIe Supplements . . . . . . . . . . . . . . . . . . . . . . . . . .


Acute Conditions: CY 1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Arthritis: CY 1969 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Blood Donorship: CY 1973 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . � . . . . . .


Diabetes: FY 1965 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Hypertension: CY 1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Medical Care Availability: CY 1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Motor Vehicle Accidents: CY 1968 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Orthodontic Care: CY 1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Pregnancy: CY 1973 . ...0..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Preventive Care: CY 1973 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Specialists’ Services and Routine Checkups: FY 1964 . . . . . . . . . . . . . . . . .


Appendix III. Definition of Certain Terms Usedin the Health 

Interview Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Terms Relating to Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Terms Relating to Disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Terms Relating to Persons Injured . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Terms Relating to Class of Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Terms Relating to Hospitalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Terms Relating to Dental Visits . ...0..... . . . . . . . . . . . . . . . . . . . . . . . .


Terms Relating to Physician Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Terms Relating to Special Aids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Terms Relating to Home Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Family and Related Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Terms Relating to Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Terms Relating to Acquisition and Cost of Medicines . . . . . . . . . . . . . . . . .


Terms Relating to Corrective Lenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Terms Relating to Cigarette Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Demographic Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Page 

68 

69 

70 

71 

72 

82 

82 

83 

84 

86 

87 

87 

95 

103 

104 

112 

115 

119 

124 

124 

125 

126 

127 

127 

130 

132 

134 

135 

136 

136 

138 

138 

139 

140 

140 

141 

142 

142 

iV 
CONTENTS.–Con. 

Page 

Appendix IV. Checklists for Selected Chronic Conditions: 1968-73 . . . . . . . . . . 148


Conditions of the Digestive System: 1968 . . ...*.... . . . . . . . . . . . . . . . . 148


Conditions of the Bones, Joints, Muscles, and Skin: 1969 . . . . . . . . . . . . . . 149


Conditions of the Respiratory System: 1970 . . . . . . . . . . . . . . . . . . . . . . . . 150


Impairments: 1971 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151


Conditions of the Cardiovascular System: 1972 . . . . . . . . . . . . . . . . . . . . . . 152


Conditions Affecting the Nervous System, Glandular Disorders,


and Conditions of the Genitourinary System: 1973 . . . . . . . . . . . . . . . . . 153

HEALTH INTERVIEW SURVEY PROCEDURE 

1957-1974 

INTRODUCTION 

The Health Interview Survey, one of a variety 

of programs conducted by the National Center 

for Health Statistics to gather information on 

the health of the American people, has been in 

operation since July 1957. The survey consists 

of a continuous sampling and interviewing of the 

civilian, noninstitutional population of the 

United States. 

In addition to the collection of information 

and the production of health statistics, research 

studies relating to survey methodology and 

improved techniques in data collection have 

been carried out since the beginning of the 

survey. As a result of these studies and of the 

experience gained in the collection process, 

many changes have occurred in the format, 

content, and administration of the questionnaire, the collection document used in the 

survey. 

This report outlines the changes that have led 

to the improvement of data collection in the 

household survey since its inception. The expansion of the survey is also examined to provide 

for the gathering of information on supplemental health-related topics. 

An earlier reportl published in 1964 covers 

the measurement concepts, the questionnaire 

development, and definitions used during the 

first 7 years of the survey. Certain components 

of the survey, particularly those dealing with the 

structure of the interview, the respondent, and 

the time references of the interview, are 

described in great detail. Since the present 

report is not directed primarily to the ideological and behavioral aspects of the survey, the 

reader with interests in these areas is referred to 

the earlier report and to some of the methodological studiesz-1 A released by the National 

Center for Health Statistics. However, in order 

to present a chronological description of changes 

in the survey, the timespan 1957-74 will be 

covered in the present report. 

HISTORY OF THE INTERVIEW 

SURVEY 

Background of the Suwey 

Legislation authorizing the U.S. Public Health 

Service to conduct surveys of illness and disability was enacted in July 1956 (Public Law 

652, 84th Congress). The Health Interview 

Survey, the first of a number of data-collection 

sy stems implementing the legislation, was 

organized during the fall and winter of 1956. 

The resources of the Bureau of the Census were 

obtained through contractual arrangement to 

prepare a sample design and to provide services 

for the collection and processing phases of the 

program. During February 1957, the procedures 

were pretested in the Washington, D.C., area and 

in Charlotte, N.C. From the findings of this 

pretesting, revisions were made in the collection 

procedures, and a national sample was pretested 

1

during May and June 1957. Collection of data 

started officially on July 1, 1957, and has 

continued without interruption since that time. 

However, prior to the planning of the interview questionnaire and the construction of a 

sample design, it was necessary to develop some 

concepts relating to the kinds of information to 

be collected. In the development of concepts, 

survey personnel relied heavily on the experiences of researchers who had used the interview 

as a data-collection method. Early in the 1920’s, 

certain populations in Hagerstown, Md., were 

selected for epidemiological studies and the 

measurement of levels of selected health characteristics in a local population. These studies 

continued during the next several decades. During 1935-36, a major nationwide health survey 

was carried out with 737,000 urban households 

visited by interviewers. Both of these studies 

contributed to the knowledge concerning the 

basic kinds of health data that can be collected 

by household interview. Since 1936, with the 

development and refinement of sampling techniques and procedures, the interview method has 

been used as a means of data collection in a 

number of local studies of morbidity. Foremost 

among these are surveys conducted in Baltimore, 

Md.; Pittsburgh, Pa.; Hunterdon County, N.J.; 

Kansas City, Me.; New York City; and the State 

of California. 

Concepts Used in the Health Interview Survey 

Even though plans for the Health Interview 

Survey could be based on the experience and 

findings of many researchers, concepts and 

definitions have continued to develop with the 

expansion and growth of the survey. From 

information gathered in interviews, an attempt is 

made to describe the social, demographic, and 

economic aspects of illness, disability, and the 

use of medical services. Since interview data 

measure these health items in terms of the 

impact they have on the lives of individuals 

rather than in terms of medical criteria, the 

concepts of morbidity, disability, and the use of 

services differ basically from those used in 

scientific and medical studies. 

Morbidity. –Morbidity is considered as a 

departure from a state of physical or mental 

well-being, resulting from disease or injury, of 

which the affected individual is aware. Awareness connotes a degree of measurable impact on 

the individual or his family in terms of the 

restrictions and disabilities caused by the 

morbidity. Morbidity includes not only active or 

progressive disease but also impairments, that is, 

chronic or permanent defects that are static in 

nature, resulting from disease, injury, or congenital malformation. The existence of 

morbidity in an individual caused by a particular 

disease, injury, or impairment is called a “morbidity condition,” or simply a “condition.” 

During the course of this condition, there 

may be one or more periods when the affected 

individual considers himself to be “sick” or 

“injured.” These periods are spoken of as 

episodes of illness. The period or periods of 

illness may coincide with the period during 

which the condition exists, or they may cover 

only a part of that period. A condition may 

involve no illness, in the usual sense of the word. 

Hence, illness is only one form of evidence of 

the existence of a morbidity condition. Other 

evidence might be a decrease in, or complete loss 

of, ability to perform various functions, particularly those of the musculoskeletal system or 

the sense organs; or a change in the appearance 

of the body, such as a rash or lump, believed to 

be abnormal by the person affected. 

For the purposes of this survey, the concept 

of a morbidity condition is usually further 

limited by specifying that it includes only 

conditions as a result of which the person has 

taken one or more various actions. Such actions 

might be the restricting of usual activities, bed 

disability, work loss, the seeking of medical 

advice, or the taking of medicines. 

The start, or onset, of the condition is 

conceived to be the time when the person first 

becomes aware of it. If there is an illness 

associated with the condition, the start, or 

onset, is usually the time when the illness begins 

or the injury occurs. In many instances, it may 

be the time when a physician tells the person 

that he has a condition of which he was 

previously unaware. 

In the statement of this concept, there has 

been reference to the individual’s awareness of 

his condition and to the individual’s actions as a 

result of the condition. Obviously, in the case of 

children, the statement must be modified. It is 

2 
not always the child’s awareness or the child’s 

action that establishes the existence of a morbidity condition. Instead, it is the awareness and 

action of the people responsible for the care of 

the child, usually the parents. A simikir modification applies to adults who are not competent 

to care for themselves. 

Disability. –The term “disability” has several 

common uses. For example, a “disability” often 

means a condition that interferes with ability to 

work. Also, conditions are frequently classified 

as producing temporary partial, temporary total, 

permanent partial, or permanent total “disability.” In this sense, the various degrees of 

“disability” have some legal or official definition 

that is related to compensation. 

There is also the term “disabling,” which has 

been used in illness surveys for many years to 

describe a condition that prevents the individual 

from carrying on his usual activities for 1 or 

more days. It has been observed that speaking of 

a “disabling condition,” as the term has been 

used in surveys, meant to some people no less 

than severe chronic disability, despite the fact 

that the range of conditions covered might 

include such minor disability as the case of the 

common cold that laid the person up for a day 

or two. 

Because the other uses had gained such wide 

acceptance in certain fields, it was decided not 

to employ the term “disability” in this survey 

except in a very general sense where it is 

intended to cover the whole field of interference 

with activities caused by disease, injury, or 

impairment (in much the same way that the 

term “morbidity” is used for a generic rather 

than a specific concept) and also where other 

words used with it make clear the desired 

meaning, as in “bed disability.” For other 

specific indexes of disability, new terms that are 

more descriptive of the concepts of the survey 

have been and will be introduced. Furthermore, 

it was decided that the Health Interview Survey 

needed not one, but several different, specifically defined indexes of disability to serve 

different purposes. These are presented in 

appendix III. 

The disability terms used in this survey may 

be grouped into the following three categories: 

(1) terms describing the individual’s status during a specified day, or number of days, which 

are equally applicable to acute conditions or 

chronic conditions, to all members of the 

population, and to any day of the week, for 

example, restricted-activity day and bed-disability day; (2) terms describing the individual’s 

status during a specified day, or number of days, 

which apply to both acute and chronic conditions but only to certain members of the 

population on days when they would have been 

working at a job or business, or going to school, 

if it had not been for their condition, for 

example, work-loss day and school-loss day; and 

(3) terms applying only to chronic conditions, 

or persons with one or more chronic conditions, 

which describe their usual status “at the present 

time,” meaning in this case during recent 

months, for example, “chronic activity limitation” and “chronic mobility limitation.” 

Since these terms were devised for use in this 

survey and have special meanings, it is especially 

important that the user of statistics from the 

survey become familiar with the concepts that 

the terms represent. 

Medical services and facilities.–The personaI 

interview can be used as a medium for determining how illnesses, injuries, and impairments 

affect people—the restrictions and disabilities 

they suffer and the medical care they receive. 

This latter term may be broadly interpreted to 

encompass the concept of utilization of medical 

services and facilities. It might be so broadly 

defined as to include everything that people use 

to care for their well-being, including such items 

as health sanitation, personal hygiene, and food 

intake. The Health Interview Survey measures 

the utilization of medical services and facilities 

in terms of medical attention, dental care, and 

hospitalization; use of X-ray facilities, preventive 

care services, nursing care services, and prosthetic appliances and devices; self-treatment; and 

other similar components of medical care or 

services. 

The use of the concept of medical attendance 

necessitates defining the term “physician” and 

also defining what is meant by “talking to” or 

consulting a physician. The definitions are contained in appendix III. Medical attendance is 

broadly defined; it does not imply continued 

attendance or consuhation, nor does it require 

that the physician give the advice in person. The 

emphasis is on the fact that the condition was 

3 
brought to the attention of a physician and that 

the initial action necessary to set in motion the 

procedure of diagnosis and treatment was taken. 

Any definition more restrictive than this would 

involve the question of what constitutes adequate care-a question that is not a part of the 

subject matter of the survey. 

Two of the principal concepts in the area of 

medical care included in the interview are the 

physician visit and the classification of visits by 

type of service. These are closely paralleled by 

similar concepts in the area of dental care. In 

both of these areas, the following rules apply: 

(1) Included in the statistics are visits during 

which the service is given, not by the physician 

or dentist himself, but by some other person 

such as a nurse or dental hygienist acting under 

the physician’s or dentist’s supervision, and (2) 

excluded are visits during which the service 

consisted of a single procedure administered 

identically to a number of people who all came 

for the same purpose, as in a glaucoma or 

diabetes screening program. 

The first rule was adopted because it was 

believed to give a more useful measure of the 

total volume of care provided and because the 

concept as defined corresponded more closely to 

what the layman thinks of as a visit to the 

physician or dentist. The second rule, on the 

other hand, was introduced because certain 

types of service, particularly in the field of mass 

preventive care, seemed remote from the 

personalized care that is implied by the terms 

“physician visit” and “dental visit.” If a 

physician administered a test of-hearing to every 

child in a school classroom, It hardly seemed 

appropriate that every child be counted as 

having had one “physician visit.” Therefore, it 

was decided that the counting of such services 

could be better handled as a separate inquiry 

into the volume and type of preventive care 

services. 

The average layman responding in an interview cannot give accurate detailed information 

about the nature of the service performed at 

each visit. Consequently, visits have been classified in broad groups according to the type of 

service. The definitions and method of classifying physician visits and the terms dealing with 

the classification of hospitalization are presented 

in appendix III. The use of X-ray facilities has 

been measured in terms of visits to X-ray 

facilities, the part-of-body X-rayed, and the 

place of service. 

The extent of personal and nursing care 

received at home has been the subject of inquiry 

in terms of the condition causing the requirement, the duration of the care, who performed 

the service, and whether it was constant or part 

time. The use of prosthetic appliances and other 

devices has been concerned with the use of 

hearing aids, artificial limbs, braces, and wheel 

chairs. The condition causing the use of the 

appliance was determined, as was the extent of 

use. The use of home remedies and other forms 

of self-treatment, the extent of preventive care, 

the availability of medical care, and attitudes 

regarding medical care are items that have 

recently been added to the survey questionnaire. 

TECHNICAL ASPECTS OF THE 

SURVEY 

Statistical Design 

The sampling plan of the survey follows a 

multistage probability design, which permits a 

continuous sampling of the civilian, noninstitutionalized population of the United States. The 

sample is designed in such away that the sample 

of households interviewed each week is representative of the target population and that 

weekly samples are additive over time. This 

feature of the design permits both continuous 

measurement of characteristics of samples and 

more detailed analysis of less common characteristics and smaller categories of health-related 

items. The continuous collection has administrative and operational advantages as well as technical assets since it permits fieldwork to be 

handled with an experienced, stable staff. 

In the first stage of the sampling process, 

primary sampling units (PSU’S) are selected from 

a universe of 1,900 such units, which are 

geographically defined and collectively cover the 

50 States and the District of Columbia. Each 

PSU consists of a standard metropolitan 

statistical area (SMSA) or one or two contiguous 

counties. In a series of successive sampling steps, 

a final sampling unit is selected, which consists 

typically of a cluster of neighboring households, 

4 
called a “segment.” (Segments of 4, 6, and 9 

households have been used at various times.) 

A basic design has persisted throughout the 

existence of the survey, but among the modifications, four have been sufficiently distinct to be 

identified by design dates: the designs of 1957, 

1959, 1963, and 1973. In the original 1957 

design, 372 PSU’S were selected from the universe. Approximately 36,000 households within 

these sampling units were assigned for interviewing, with the average size of assignment being 12 

households per interviewer. In the 1959 design, 

the number of selected PSU’S was increased to 

503, with a corresponding increase to 38,000 

households per year and to 13.5 households per 

average assignment. Both the 1957 and the 1959 

designs were based on population figures from 

the 1950 Decennial Census. 

In 1963, when population data from the 1960 

census became available, many changes were 

made to increase the efficiency of design. The 

number of PSU’S was decreased from 372 to 

357. The structure of segments and assignments 

was modified in three important respects: (1) 

segment size was changed from an expected six 

households to an expected nine households; (2) 

the nine households were alternate ones in a 

cluster of about 18 neighboring households, 

whereas, earlier, the six had been a compact 

cluster of six adjacent households; and (3) 

assignments in a given week consisted of paired 

neighboring segments in 1963, while, earlier, an 

assignment attempted to pair unlike segments. 

In the new design, heterogeneity is obtained by 

giving the same interviewer different types of 

segments in successive weekly assignments. One 

result accompanying these changes was an 

increase in the average size of assignment from 

13.5 households to 16 households. The manner 

of selecting specific segments was changed for 

about two-thirds of the total sample, from area 

sampling to list sampling, using the 1960 census 

registers as the list frame. Most of the remaining 

third of the sample continued as an area sample. 

Finally, the evidence from better estimates of 

components of variance, plus the above changes, 

together with the benefits from joint designing 

with the Census/Bureau of Labor Statistics 

Current Population Survey led to a reduction 

from 503 to 357 PSU’S and an increase from 

38,000 to 42,000 sample households. In July 

1968, segment size was changed to six households. In January 1973, the sample design was 

modified to reflect the 1970 Decennial Census. 

The number of PSU’S was increased from 357 to 

376, and segment size was changed from six 

adjacent households to four adjacent 

households. 

Estimating Procedures 

Since the design of the interview survey is a 

complex multistage probability sample, it is 

necessary to use complex procedures in the 

derivation of estimates. The following four basic 

operations are involved: 

1. Infiation by the reciprocal of the probability o~selection.—The probabilityy of selection 

is the product of the probabilities of selection 

from each step of selection in the design (PSU, 

segment, and household). 

2. Nonresponse adjustment.–The estimates 

are inflated by a multiplication factor, which has 

as its numerator the number of sample households in a given segment and as its denominator 

the number of households interviewed in that 

segment. 

3. First-stage ratio adjustment. –Sampling 

theory indicates that the use of auxiliary information that is highly correlated with the variables being estimated improves the reliability of 

the estimates. To reduce the variability between 

PSU’S within a region, the estimates are ratio 

adjusted to the 1960 populations within six 

color-residence classes. 

4. Poststratz’’cata’on by age-sex-color.–The 

estimates are ratio adjusted within each of” 60 

age-sex-color cells to an independent estimate of 

the population of each cell for the survey 

period. These independent estimates are prepared by the Bureau of the Census. Both the 

first-stage and poststratified ratio adjustments 

take the form of multiplication factors applied 

to the weight of each elementary unit (person, 

household, condition, and hospitrdization). 

The contribution of decedents to a total 

inventory of events, conditions, or services can 

be estimated. Since the sample of households is 

preselected for an entire collection year, it can 

be assumed that the continuous sampling produces results that are analogous to those that 

would be obtained (with adjustment for seasonal 

5 
variation) if all sample persons were interviewed 

on a single day during the year. If it is also 

assumed that the death rate throughout the year 

is fairly constant and that the vast majority of 

deaths occur in the civilian, noninstitutionalized 

population, a complete survey conducted on 

July 1, for example, would include the experience of approximately one-half of the decedents 

during a given year. Thus, the conditions, events, 

and services for the remaining half of the 

decedents are missing from the interview data 

regardless of whether the reference period of the 

interview item is 2 weeks or a complete year. 

In 1972, there were 1,962,000 deaths in the 

~llited States. Estimates of the experience 

attributable to approximately 981,000 of these 

persons are missing from the interview survey. It 

has been established through methodological 

studies and from statistics provided by the 

Hospital Discharge Survey that individuals 

experience higher rates of disability and hospital 

episodes and receive a greater number of medical 

services during the last year of life than do 

persons in the general population.1s 31G!I T On 

the basis of these findings, it can be estimated 

that as a maximum the rates among the 

decedents missed in the survey might be three 

times as high as those for the surveyed population. Table A provides, for selected items, a 

rough estimate of the underestimation caused by 

the exclusion from the survey of the experience 

of decedents. 

In 1972, there were approximately 28 million 

discharges from short-stay hospitals, a rate of 

13.9 discharges per 100 persons. If the rate of 

discharges among decedents were three times 

that in the general population, or 40 discharges 

per 100 persons, then 392,000 were omitted 

from the survey. The inclusion of these would 

have increased the rate of discharges to 14.1 per 

100 persons. 

The effect of the ratio-estimating process is to 

make the sample more closely representative of 

the civilian, noninstitutionalized population by 

age, sex, color, and residence, which thereby 

reduces sampling variance. 

As noted, each week’s sample represents the 

population living during that week and characteristics of the population. Consolidation of 

samples over a time period, for example, a 

calendar quarter, produces estimates of average 

characteristics of the U.S. population for the 

calendar quarter. Similarly, population data for 

a year are averages of the four quarterly figures. 

For prevalence statistics, such as number of 

persons with speech impairments or number of 

persons classified by time interval since last 

physician visit, figures are first calculated for 

each calendar quarter by averaging estimates for 

all weeks of interviewing in the quarter. Prevalence data for a year are then obtained by 

averaging the four quarterly figures. 

For other types of statistics–namely, those 

measuring the number of occurrences during a 

specified time period—such as incidence of acute 

conditions, number of disability days, or 

number of visits to a doctor or dentist, a similar 

computational procedure is used, but the statistics are interpreted differently. For these 

items, the questionnaire asks for the respondent’s experience over the 2 calendar weeks 

prior to the week of interview. In such instances, 

the estimated quarterly total for the statistic is 

6.5 times the average 2-week estimate produced 

by the 13 successive samples taken during the 

period. The annual total is the sum of the four 

quarters. Thus, the experience of persons interviewed during a year–experience that actually 

Table A. Estimation of the effect of the exclusion of decedent experience on in :erview survey data (1972 estl ,ates) 

Survey data 

Intervievd item Number Rate 

(in per 

thousands) parson 

Beddisability days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,,, . 1,319,566 6.5 

Physician visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,016,548 5.0 

Persons injured . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64,259 0.3 

Decedent data 

Estimated 

Estimatad number 

rate per missed in 

decedant survey data 

(in thousands) 

19.5 19,130 

15.0 14,715 

0.9 883 

Survay rate 

adjusted to 

include 

decedent 

expariance 

6.6 

5,1 

0.3 

6 
occurred for each person in a 2-calendar-week 

interval prior to week of interview-is treated as 

though it measured thy total of such experience 

during the year. Such mterpretation leads to no 

significant bias. 

Rounding of numbers.–The original tabulations on which the data in reports are based 

show all estimates to the nearest whole unit. All 

consolidations were made from the original 

tabulations using the estimates to the nearest 

unit. In the final published tables, the figures are 

rounded to the nearest thousand, although these 

are not necessarily accurate to that detail. 

Devised statistics such as rates and percent 

distributions are computed after the estimates 

on which these are based have been rounded to 

the nearest thousand. 

Population figures. -Some of the published 

tables include population figures for specified 

categories. Except for certain overall totals by 

age, sex, and color, which are adjusted to 

independent estimates, these figures are based 

on the sample of households in the Health 

Interview Survey. These are given primarily to 

provide denominators for rate computation, and 

for this purpose are more appropriate for use 

with the accompanying measures of health 

characteristics than other population data that 

may be available. With the exception of the 

overall totals by age, sex, and color mentioned 

above, the population figures differ from figures 

(which are derived from different sources) published in reports of the Bureau of the Census. 

Official population estimates are presented in 

Bureau of the, Census reports in Series P-20, 

P-25, and P-60. 

Reliability of Estimates 

There are limitations to the accuracy of 

diagnostic and other information collected in 

household interviews. For diagnostic information, the household respondent can usually pass 

on to the interviewer only the information the 

physician has given to the family. For conditions 

not medically attended, diagnostic information 

is often no more than a description of 

symptoms. However, other facts, such as the 

number of disability days caused by the condition, can be obtained more accurately from 

household members than from any other source, 

since only the persons concerned are in a 

position to report this information. 

The population covered by the sample for the 

Health Interview Survey is the civilian, noninstitutionalized population of the United States 

living at the time of the interview. The sample 

does not incilude members of the Armed Forces 

or U.S. nationals living in foreign countries. It 

should also be noted that the estimates shown 

do not represent a complete measure of any 

given topic during the specified calendar period, 

since data are not collected in the interview for 

persons who died during the reference period. 

For many types of statistics collected in the 

survey, the reference period covers the 2 weeks 

prior to the interview week. For such a short 

period, the contribution by decedents to a total 

inventory of conditions or services should be 

very small. However, the contribution by 

decedents during a long reference period (e.g., 1 

year) might be sizable, especially for older 

persons. 

Since about 38 percent of all deaths are 

attributable to diseases of the heart, at least 

373,000 cases of heart diseases are missed in the 

survey. The prevalence estimates of other causes 

of death, with lower mortality rates, may be 

affected to a lesser extent by the exclusion of 

decedents. 

Errors Due to Sampling Variability 

Since the statistics presented in a report are 

based on a sample, they will differ somewhat 

from the figures that would have been obtained 

if a complete census had been taken using the 

same schedules, instructions, and interviewing 

personnel and procedures. 

As in any survey, the results are also subject 

to reporting and processing errors and errors due 

to nonresponse. To the extent possible, these 

types of errors were kept to a minimum by 

methods built into survey procedures. Although 

it is very difficult to measure the extent of bias 

in the Health Interview Survey, a number of 

studies have been conducted to examine this 

problem. The results have been published in 

several reports. 

The standard error is primarily a measure of 

sampling variabiIit y; that is, the variations that 

might occur by chance because ordy a sample of 

7 
the population is surveyed. As calculated for a 

report, the standard error also reflects part of 

the variation that arises in the measurement 

process. It does not include estimates of any 

biases that might be in the data. The chances are 

about 68 out of 100 that an estimate from the 

sample would differ from a complete census by 

less than the standard error. The chances are 

about 95 out of 100 that the difference would 

be less than twice the standard error and about 

99 out of 100 that it would be less than 2?4 

times as large. 

The relative standard error of an estimate is 

obtained by dividing the standard error of the 

estimate by the estimate itself and is expressed 

as a percentage of the estimate. For a report, 

asterisks are shown for any cell with more than a 

30-percent relative standard error. Included in 

the appendix of all HIS reports are charts from 

which the relative standard errors can be determined for estimates shown in the report. In 

order to derive relative errors that would be 

applicable to a wide variety of health statistics 

and that could be prepared at a moderate cost, a 

number of approximations were required. As a 

result, the charts provide an estimate of the 

approximate relative standard error rather than 

the precise error for any specific aggregate or 

percentage. 

The following three classes of statistics for the 

health survey are identified for purposes of 

estimating variances: 

1. Narrow range.–This class consists of (1) 

statistics that estimate a population attribute, 

for exampIe, the number of persons in a 

particular income group and (2) statistics for 

which the measure for a single individual during 

the reference period used in data collection is 

usually either O or 1, or on occasion may take 

on the value 2 or, very rarely, 3. 

2. Medium range.–This class consists of other 

statistics for which the measure for a single 

individual during the reference period used in 

data collection will rarely lie outside the range 

o-5. 

3. Wide range.–This class consists of statistics 

for which the measure for a single individual 

during the reference period used in data collection can range from O to a number in excess of 

5, for example, the number of days of bed 

disability. 

8 

In addition to classifying variables according 

to whether they are narrow, medium, or wide 

range, statistics in the survey are further defined 

as: 

Type A. Statistics on prevalence and incidence 

for which the period of reference in 

the questionnaire is 12 months. 

Type B. Incidence-type statistics for which the 

period of reference in the questionnaire is 2 weeks. 

Type C. Statistics for which the reference 

period is 6 months. 

Type D. Statistics for which the reference period is 3 months. 

QUESTIONNAIRE DEVELOPMENT 

The health interview questionnaire consists of 

a core of questions concerning items about 

which information has been collected each year. 

These basic items include acute conditions and 

injuries, chronic conditions, days of disability 

due to acute or chronic conditions, limitation of 

activity caused by chronic conditions or impairment, hospitalization, and the social, economic, 

and demographic characteristics of the interviewed sample persons. During recent years, 

medical care provided by physicians and dental 

care have become core items. 

Information on certain other health-related 

items has been collected in the survey periodically, usually at intervals from 2 to 5 years. In the 

early years of the survey, these topics were 

described as rotating items and consisted of 

measures such as mobility limitation due to 

chronic ilIness, dental care, and the proportion 

of hospital bills paid by insurance. As the survey 

developed, there was an increasing demand for 

more detailed information about some of the 

core items, such as detailed data on types of 

injuries, the duration of activity limitation, the 

accessibility of physicians’ services, and convalescence folIowing hospitalization. The need for 

this information led to the expansion of certain 

areas of the basic questionnaire to provide for 

the collection of these data at periodic intervals, 

introducing a slightIy different category of 

rotating items. 

In addition, the questionnaire for a given year 

has usuaUy included one or more special supplements. While most of the supplements were 

originally planned for a l-year collection period, 
some of them deal with topics for which trend 

information is needed. Since the interview is the 

most efficient method of collecting this type of 

data, certain items are added to the basic 

questionnaire on a planned schedule. These 

items, which might be described as rotating 

supplements, include such topics as smoking 

habits, health insurance coverage, X-ray exposure, home care, the use of special aids, and 

personal health expenses. Other supplements, 

particularly those dealing with specific chronic 

conditions or impairments, have been added to 

the questionnaire on a less regular basis. 

This arrangement of expanded core items, 

rotating items, and supplements allows the 

survey to respond to changing needs for data 

and to cover a greater variety of topics, and at 

the same time provide for continuous information on certain fundamental topics. 

History of Questionnaire Format 

During the planning phase of the interview 

survey in 1956-57, two general questionnaire 

formats were considered. The one referred to as 

“alternative B“ was designed to elicit information about conditions through the reporting of 

actions a person might have to take as a result of 

illness. For example, a respondent would be 

asked if he had to (1) cut out or reduce all or 

part of his activities regularly or from time to 

time, (2) change his activities, (3) change his 

diet, (4) take medicine or treatment over a long 

period of time, or (5) wear or use some special 

device. 

After a positive response to any of the above 

statements, the respondent would be asked, 

“What was the matter?” While the original 

intent of this proposed format was to elicit 

information about chronic conditions, the same 

general approach was applicable to both chronic 

and acute conditions. 

The other format, the one actually used 

during the first 10 years of the Health Interview 

Survey (July 1957-June 1967), provided for the 

reporting of all kinds of morbidity conditions 

through a series of direct questions designed to 

encourage the reporting of illnesses and injuries. 

In contrast to alternative B, no attempt at the 

time the condition was initially reported was 

made to determine if some action had been 

taken by the person because of the condition. 

This format was used to maximize the number 

of conditions reported regardless of their impact 

or severity and to apply the criteria of medical 

attention, restricted activity, or limitation of 

activity during the coding and transcribing of 

the collected data. 

The selection of this questionnaire format, 

which is usually identified as the condition 

approach, was influenced by its general acceptance in earlier health surveys. Illness-recall 

questions, which had been formulated and used 

successfully in the collection of health data in 

earlier surveys, served as a prototype for the first 

questionnaire used in the Health Interview 

Survey. Using a tested collection procedure 

made it possible to begin the interviewing phase 

of the survey much earlier than would have been 

the case if a completely untested procedure such 

as alternative B had been adopted. 

The wording of the introduction to the 

illness-probe questions—”We are interested in all 

kinds of illness, whether serious or not”­

indicates the comprehensive nature of this 

section of the questionnaire. These questions 

were structured to elicit information about any 

departure from a state of physical or mental 

well-being resulting from disease or injury, that 

is, a morbidity condition. The questions that 

were limited to occurrences during the last week 

or the week before were designed primarily to 

aid in the reporting of acute conditions. MI 

reported conditions were recorded regardless of 

which type of question had prompted the reply. 

Whether these conditions were chronic was 

established later in the interview on the basis of 

a series of questions relating to the nature of the 

disease and its duration. 

During the succeeding years of the interview 

survey, the section of the questionnaire dealing 

with acute and chronic illness underwent certain 

changes. Progressive experience in survey collection procedures on the part of the Health 

Interview Survey staff and the findings produced 

from continuing studies on survey methodology 

led to periodic changes, which in turn led to 

some improvement in the reporting of illness by 

the respondent. These changes included variations in the order in which illness-recall questions were asked, introduction of a small 

calendar outlining the recall period for the 

convenience of the respondent, restructuring of 

9 
the checklists of chronic diseases and impairments, the identification of the condition(s) 

causing either limitation of activity or limitation 

of mobility, and format changes to accommodate revised data-processing procedures. 

Despite these changes in the questionnaire, 

certain kinds of health-related information continued to be underreported in the survey, 

although to a lesser extent than in the first years 

of the survey when, on the basis of research 

studies comparing interview data with medical 

records, it had been established that chronic 

conditions were not completely reported in the 

interview. For example, the prevalence of 

selected chronic conditions has increased with 

changes in the questionnaire formats. 

Early in 1963, after 6 years of data collection 

and in accordance with a long-range plan set up 

during the early years of the survey, a general 

evaluation of the design and format of the 

survey was undertaken. A timetable was prepared, which provided for considering proposed 

changes, deciding whether to accept, reject, or 

modify the proposed changes, and pretesting 

and evaluating the approved changes. A target 

date of July 1, 1967, was established for the 

completion of the evaluation and for the introduction of any new procedures in the collection 

phase of the survey. During the 4-year evaluative 

period 1963-67, the ongoing survey continued in 

line with collection procedures developed during 

the early years of the survey. Evaluation of the 

survey in terms of questionnaire content and 

format led to major changes that were 

introduced in July 1967. 

The new questionnaire introduced as a datacollection instrument in July 1967 resembled 

the approach suggested by the alternative B 

method of data collection considered at the 

beginning of the interview survey. The illnessrecall questions, with a 2-week reference period, 

were replaced with probe questions pertaining to 

health-related actions during the period–for 

example, cutting down on usual activities, 

spending days in bed, losing time from work or 

school, or seeking medical attention. Information about conditions responsible for such 

actions was obtained from persons with positive 

response to the health-related action-probe 

questions. 

Methodological studies, which had been 

conducted since the beginning of the survey, 

showed that chronic conditions are generally 

underreported in interviews. They also indicated 

that the expansion of a checklist of chronic 

conditions to include as many descriptive titles 

as possible will increase the probability of a 

person reporting a condition, assuming that he is 

aware of its existence. These findings led to the 

decision to restrict the collection of prevalence 

data on chronic conditions to specific types of 

conditions during a given collection year. This 

change in collection procedure was independent 

of the approach suggested by the alternative B 

method of data collection. However, since both 

procedural changes were experimental during 

the collection year July 1967-June 1968, they 

were tested on the new questionnaire introduced 

in the field. 

Concentrating on a group of chronic conditions involving a specific system of the body 

(e.g., those affecting the digestive system) rather 

than on the entire spectrum of chronic conditions not only improves the quality of response 

but also permits the collection of more detailed 

diagnostic information related to that body 

system. The survey plan calls for the collection 

of different types of conditions each year, so 

that within 5 or 6 years after the initiation of 

this plan, information on the prevalence of 

virtually all chronic conditions will have been 

obtained. 

Once the decision had been made to modify 

the collection procedure for chronic conditions 

by emphasizing a specific type of condition 

during a given year, it was necessary to develop, 

at the same time, procedures that would provide 

comparable data for other measures of morbidity that had been derived previously from data 

collected on all types of chronic conditions. One 

of these measures, the number of persons with 

limitation of activity (long-term disability), had 

previously been generated by consolidating the 

data on activity limitation attributable to 

specific chronic conditions reported by an individual to represent the activity limitation status 

of that individual. The most obvious alternative 

to this consolidation was to build a person-data 

foundation in terms of the degree of activity 

limitation and then ascertain the conditions 

10 
responsible for the activity limitation status of 

the individual. 

The Basic Questionnaire 

The many procedural changes in the format 

and administration of the questionnaire during 

the course of the survey preclude a discussion of 

the content according to the sequence of the 

interview. For this reason, the description of the 

changes that have occurred will be presented on 

a topical basis covering the major areas of the 

questionnaire. 

Social, economic, and demopaphic characteristics. —After the interviewer identifies herself as 

a representative of the Bureau of the Census, the 

agency that serves as collection agent for the 

interview survey, she verifies the address as the 

one assi~ed on the first page of the questionnaire and then starts the interview by asking 

questions to determine the social, economic, and 

demographic characteristics of the sample 

persons. Since the beginning of the survey, many 

changes in the wording of the questions designed 

to elicit this type of information have been 

made in order to improve their specificity and to 

increase the accuracy of the information 

obtained (figure 1). The transferring of 

questions relating to education, military service, 

employment, and marital status to a later 

section of the interview, as indicated by the 

numbering of the questions in the 1974 questionnaire, made it possible to obtain data on 

health-related items nearer the beginning of the 

interview. Questions on personal characteristics 

that have been added, deleted, or included on an 

irregular basis follow: 

1. PIace of birth was asked for fiscal years 

1958 and 1959 only. 

2. Current activity status was added as a basic 

item to the questionnaire beginning in 

fiscal year 1960. 

3. Questions relating to occupation and 

industry were included in the questionnaire 

for fiscal years 1962 and 1963 and were 

incorporated as a continuing item 

beginning in fiscal year 1966. 

4. During calendar years 1968 and 1969, the 

question on income status was expanded to 

obtain information about the receipt of 

public assistance, relief, or weIfare payments to any of the family members. 

5. On the calendar year 1973 and 1974 

questionnaires, an attempt was made to 

check the accuracy of the questions on age 

and income by ascertaining the year of 

birth and the amount of income for each 

family member. 

6. During calendar year 1973, information on 

the number of times married was obtained 

for all persons who had ever been married. 

Illness and injury recalL-Because of the new 

approach in eliciting information on acute and 

chronic conditions introduced during the 

interim period, July 1967-December 1968, it is 

necessary to divide the description of the development of the illness-recall questions into 

two chronological periods: (1) the first 10 years 

of the survey, ending in June 1967, and (2) the 

foIlowing years beginning in July 1967 and 

continuing through calendar year 1974. 

1. July 1957-June 1967: From a comparison 

of the illness and injury recall for fiscal years 

1958 and 1967, it becomes obvious that several 

changes in questionnaire format occurred (figure 

2). During the introduction to the probe 

questions in the later questionnaire, the respondent was given a small calendar on which the 

2-week period referred to in the succeeding 

questions was outlined in red. This innovation 

was introduced on the fiscal year 1965 questionnaire to aid the respondent in identifying the 

reference period for all “2-week questions.” 

Minor changes in wording and emphasis were 

made to stress the reference period and the 

presence of recurrent or seasonal conditions. 

A revision of the checklists of chronic conditions and impairments and the division of cards 

A and B into two parts were initiated on the 

fiscal year 1966 questionnaire and retained 

during fiscal year 1967. These changes were 

made in an effort to increase the reporting of 

chronic illness, an area of underreporting that 

had been identified by methodological studies 

conducted since the beginning of the survey. 

2. July 1967-December 1974: As described 

earlier, the questionnaire introduced as a datacollection instrument in July 1967 resembled 

11

-------

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

--

--

--

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

--

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

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

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

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

--

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

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

--

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

--

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

--

w 1964 W 1S74 

. ,.,kc,. I& .-1., ,. M .* *,. -m ,., . . ..” 1...,,, ..1-!, -1- l.. MI. I {. ~. . . ...1 IA. h-t.1 th!. h..soh.ld? - Entecnamein fmt column. 

,,, -u .“ n. .900., *I .Lbu “- * n“ h.rwl <,,.% .:1 “t..” .s. h, tit .,. lh. mm. .f .11.th.t p,... wh. 11.. h.,.? - List .11 pusm. n+. Ilve here. Yes” No ““,,, ,,!. . . . . . “4 .,, “t,.” .,”,., k,, *. h... . . ..”} .,”. .t . . I h.v. Ilstd (Read mm+..) Is tk.r. �.Y... .1s. SI.YI.S hr. n.w. such .s frl.nk 1.1011..s, of mnws? CJ Cl ,..!’..e. .1...,.,.. ,!.! -“. “rot.. 1.1$. ““.ri~ -~.,J Ma 1.1 b - 1.!s.0 1.-.. — n. h.-.! 0. or. ..1— d. ff.v. I miss.{ ..pm. wfI. USUALLY 11..s hr. but IS n. .W.Y Ir.m ho..? . . . . . . . . . . . . . . . . . . . . •l O 

.. D...y.fh. pw.l.lm*is h..sA.ldh... hm. *..wh . ...l*.7 . . . . . . . . . . . . . . . . . . . . . . . . . . � O -G-,-.-&--------- *W 

If any adult male, listed. ask “AW IWu:+dd murAtIshiP ml... 20 

f.	 A,. my J III. �s.”, 4. MS hous.h.1~. . . . . fwll.thm , 01 

..11,. J.lv witK th. A-d F.,<.. .1 I,. U.IIA 3+.1.s? . . . . . . . . . I Y cd(s) .—(De!@ z N SEX 

2. R.$.tlm,bl, it! 

~

z. D.....*:Yn “I.-i t. b u .1 U. -m ,.,.,r.1.,1”..!. t“! 

?. Hew IS -- rol.td t. [Head of hwsebold)? 

NEAD ,F ..”. . . . . . . ..ch!.r. S.*.-. “!..,-’.. t”. *, . . . . Id-r. t. ..”,

1.4.!- .,,....... I 

n WK. 0 ml” 3. MIm is --,s dat..1 bltih? (Emf dataandAze,.4 circle Racemd Sex) 3. ?kmUi 0.,. v“< 

% m ,0.a -. b“ l., “h “,.”1 0 .I.. Uund.. 17 I if 17yews old .r 0“.,, .sk 

00 � Nm. 135J

(l/P) 

‘ . . ,m.c, “. * m. “d ““”, 0 -!. 0 n-l. k Sk* is *. M*..! gmd. w fw .W.M M sc!Io*l? 34. ~lm: 12345678 

. n 94.. 

%U.a.nl-. m=rl-u-, , mu H,dx 9 10 II 12 

Col!.g.: t 2345 6* 

c. =.” ““ - -I.? (=.,, .,.,. “ -,.- -“,,J, ., f.,.,. -., b. 014-- HrJ.h St. 3-J. (m.r)? b. *Y ,11 

,r ,4,.”..1’ .r . . . . “k 

7, h.w.-..mlh.JA.JA a?.lwc -U. mnar-ruw n 

a 

-,. 

..”. 

n-l.. ,* ,..” 

O*t..n* 

0 -* 

A3k for ,!1 rn,le%17 ,*”, or .“.,: 

k. Dld .“*, ,*IW [“”lb Amd F“..* �I *. U“ltd %,,? $k*Y , N (HP) 

,CI,,, . . ).. f.. ..a “r.-) Owe, -,,.4 b. m.” JIJ h. WV.? VlemmI Em (Am .64 m w-m). . . . VN b. 

,, ,4 ,..r. .14 .r “r. -: 091,, ,, ,.U. Circle CC& !. descmdtnzorderof r.rlm!ty. l’hus If 

mm. served [n VI*!MI -d In Km., clrch VN. 

K.r.m W= (June ,3Q-Jm. ,55) . . . . . KW 

W,r!d !%, II (3ePI, .40-J,IY .47J . . . . WWll 

,“!4 

II zKW 

4WM 

s02 

WorldWW I (A+,il ‘17-No,. ‘IV. . . . . why 

n ,“. Otlmr service (all ocherperiods). . . . . 0S ,WM, ‘OK 

,, .,. ..4 *4 >-r. .14 ., “... “1: n- ..-. xn.. 

s. (.lltdn= . ..t--t.t b---- --,~- .5’?..-....= -H...- II 17y.”. old 0, 0“,,, -k � U.da 17(NPJ 

, f -,... - “.:€

,,, &.s.. .am. u.dndu-m.m -u....—? h. Did -- w.rk .I w Il.. I.st w..k w h w-k b.fu. -(For fem,lesJ! .OI C.W.!IW workKMInd tko km? 24. J-~-@:.~---~-~------.


,,, -r”... ..,.1. ,,!. “r... fr” e.*,””!r., — cl,.. 0-

b. Evcathqh --ilimi w-k JAW the,. 2 w-k,, &., hoh,. . Iob w bu.lmss? 

1.1 r- -a .1 s... � - 1$-*- -Ifl -~ :: ------~ ;.:.::-! l-:J:?_------:!------.


U -.,.. .“:€

ypc.;~,~,.:~ .M 0“!. M“.= %,: G w., b Ink!”, h, “orb 0? on lq.fr fmm � lob? . . tY * N (an
 cl”-, -------------.-----. 

1 ~ Lmk,n, qg Bnh 

,., “ w ., Jn, .ti” 9.-.9 *. at IN .41-” ‘n, 19$? 0 ,.s Om. i. mid! -141”, . W.*., .“ I.”.rr h . lob? ,, z ~ L,,o,t 

,, .,. ”. .14 .r . ..r. “.. 

.f m. w- m-*... 0 “,.,., 

00s4., , . . . . . m I.. m. ~-s (w] wmk k? ,7A E“wl.,.r 

m. (.) -“ 1---- .* ,“, tie. .,,, ,,. -*t.h 1.-1.. I.. -* ..-1” -w” .1-? 01.*3., ,., “,* 

,W,w.o”rlw .*t.r. 10M:..I.*-*. ~-$=-. -*fu-~w*l- 0,,.,,.. .“” ,,ye,,, 

,“, .bmr.” , -,,. .!.’ t. -1 w � ,” -Ii,.’ .,8.? o 0.s.. t. .*”1 l.deslry 

,, .-..U1.’ . . . . . .“.,.4 “4 “,.- i. “ ,..,. .M ., .!.r. “w n --t,,., .1s. 

,S6a. b,orc. k,k%,! kind d kw.lm,s w MW,W IS INS? . . . . . . . . . . . . . . . ?’,,- in 34. -------------------. IIy, Westio.s 

1. hrwth 37d c. W1.t klmdC4wwk IS (w.,) /.1.,? . Ou”,.tbn 

>P!y10 hi. 

,,s.”% LAST 

.Ie=, ask IIwne dvlllm Fl!! 37d t ~ P“% ,d. s n Me-@. frommules in 37.-37G If not ,a b“. F.d. ‘U N... -t& d. Cl,,, of worker IId sn~v..lh. 

, ,401 bf{mt./m..h I t. ,h. Y

b..hos. I 1...,8.O.O N 

Pi”,. Id al lbls <,,4 (E&M C“d 1) Gs+v .srJcl .rrJ* 1. WMehof th.s. I.COM. sm. , ,.p,,s.m YOU,total c.mbl*J hmll? lnc.m. f.r fh. ,a*t 12 m.lhs - tkt 1. 30. .og A .4r]E ,,L]I �“,*, y.”, --,, .1..? !“< “d. he-. ft.. .11 sow... ,“ch .s .,,.., ‘.1.ri.., .tcl.l SUwlry W r.mt..-t K.m.f[,s, ,t~a o,OF 08CIJ h.l,fm,.lo,,v~, rontfr.mpq”y,.nd s. f“th. 

,20C o,~G ,,L1, 

),. WMch(.rh.r) I.mlly m-b,,, ,-,1,.d ,,.. 1“.... 4wlM&vst 12mmths? 3!.. 

Mtrk %cm.”. L-axin P,,SO,.S column. ~ w,­

b. Dii �y .th.r family m.mbas r.mlv .mYi,mmm &,ln3 th, past 12 mmths? Y [Red 3% md b) 34 

If WTlyone m,,.. WI.A %cme.e tax mstked,C. w Q. 41. Gm.9 .,I-Jo .71:]1 

If 2 m mare personswit)! ‘Vncome.etax marked,ask Q. 40 for ..& @onA a,rJE 00CII 

1.	!+lI,h .1 IJI*,, I“c...,,a,. rqr,mn,, --,’ 1“<.”, for lb p,t 12 -“WI*? ,0. 0,r]5 OSL-IF o.(1J 

e*LIc .*n G tor:l, 

If 17ye,,. old or o.,,, ask. ,fTLhd” 17(NPI 

1. 1.-. “ml . . . ..J. “,i.wd, dlw,, d, ..e,.,d, w m“., W,,ld? - Muk 0“. box for esch*WM.. ,,. tHW,cd - ,-s. ,,.$.!, 

‘ � W.n,ad- w,. .b,o”t 

~ � w,d-* 

4rJo,w,d 

, In S,”.(C4 

, [1 N.”” W“ti lNP1 

H*WWY *I... h.. b,” “Irld? 42. —T,. , 

Figure 1. Questions relating to social, economic. ?nd demographic characteristics, fiscal year 1958 and calendar Year 1974. 
--

---

c MD .- HAVEA_mj~G US. 9URIHG YSAT2.SSSSPSMOO* 

* LASTWSORwmsx 9Emm cm TAREM7 ME34CMEORrsmmmr OYm Om 

w 1s0s 

,..”,” * *,, In” I.. i,-.,, *, -1.” n.,, - W,.. ,, ~ -* 

n, w A, ,, M ,.., I... m.. -!- -..* “SW.* “ “m “1- ~,, “, f- -11 

.“ .$.- 1, “, ,,.0., ,,,- -r “,,.., .,* . . 

., n. “a “IIm ,,, m WI ma ON,-*., lq.rl.q ●,*” “ 

,. u“ “ ., n. - w.” m l.. I., “ ,,, .,,* h - ,.,!,., 

(U -ml” .1., I u ,-u~-~:. ml” . * 1...., 0.. u -. a.. ..MU-mwn 19 m-. 0. 

1~ -*L ..-1,1- y .*tt*”, ,.”4 “J .ti,,,- “,,,.. ,. ,“ ,.,,- “ ,,, “,,”, 

,,, il. $-. m,hl”h ,”- .,m”. ti,,,- 0 ,“ 0.. 

161.LMTKSALW7SEWJ SSYCRSMD.- WEdJYMC10S#T3011tSJMESI OY*a ❑ * 

= . ND -. HAVEMY OISES ACUDSS7SORl#JUMSSDUSISC7sAT 2.lKS YEl 

u,, 040.. m IIAVEAS14XV07SER)ACCIGSSTOR lUURVIMI SllLLSC~SR! CIYM O N- S W&J.g Cudmm “cd m h. cd”m e?+Ud.mn “+snd

13, Tw. !oCC,6.B nrd Rccdtok,dn d Cmd 8 (S.1, 8.?), ,crd,,,mkywd,,,m, OY” 0N4 

mead !“ h!, edc.m m+ CMA!lm, *A id !h W!* Is 

1 

Ill. Cnmti p.~kvi am Awom, aAimws,OR PRMLEV$SITS 13Y. CNb

k mATl&TR&mMl [Ricdtib!bwl! Ml ptn+ Uhnbtnak M. 

= 

{w *.4 m. . ..4.,,” “ .*,,,”, .,,* “, ,d,,,-

.“,,-” ,, ,,, .,,.. ,“ ,$, .,,”, 

L.Id& 

M,,.,,, “Ii,” 9u,$t, 

Cb..b u,, ., C+.”ts ,“,,,,.,. 

.tili, ,,.“-* .,,,, 

1. * .N,ra *S. A., .,,,. am,. .-h ,-,. 

1. ?“bwc.lcd. ,* “M!” ,,MC, or out, ,,*” t,..!


1, .3K+l, tmaa,u. :; prlhr:,.%~.


1. “,M!M .U.,i. of .Inw VW,,!


,, m-t,, ,,,,, ,,. M.-t”


,, wd”,., ., ,,, .,”,,,, a mm,, ,Iw,!, ., -,,.,


1, n!,” mad ,W,”rt 2,. mtl,m, m CC.lwl.ka, ., m ,M 

1. INIrt tw,l, n. MM ., “m, ttil, 

, MM, 2?. n.mtd trm,l. vu W or .,,” 

. Trt.bl, .lth ,,riw “la, x. k, ., C.”C,, 

,*rrb$,i. ., ,,,” *,. mm,, .U. tn.,,. 

-,,,,.44,, ., ,,,,, m.b,. n. -n!. or r“,.” 

M , nhnwn 9s,Lm SU,m 

ash U.* .1 I.”:””u 

1. mm”. w “r:- 1-1. .1* b-m. 

a. t.tl.”1 trnb!. .1L4 -!.. .l.a .1-, 1-

:. yJc+ ,n9”t ,19M MM. d “ .Im “1.” ., .1* 

,. m-,,., or .0,, ,*,. .,,, ,* 

i. M.#l., fl.””, i-d. ., m 

c. [i!.!., Ian, 10M. c1 1“ 7. Rnbrll m,lJ 

8. ?U.IJ91* .C w Uh /&”w-w”: .Utfna * d8bm1tJ ●f lb! fnt * M. Ilmc”. 

.MYOTSSS PsOslLKmTs si$ssNnR 

Gu.*tlm 12 

Slow l% WI., IO rmd e list d cwdltlm, -

PI-S* I*N m. if ,Ou, y.”, --, ●*., k.”. 

had any .1 th,s, cmdNlms GURING THE 

PAST 12 MONTHS? 

L Ash.? 

2 cHmNlc hcbili.? 

3. REPEATED att,cks .1 sir... trouble? 

4. TROUBLE with varicose veins? 

S HemtrbrJd* or @kS? 

6. Hay f.vm? 

7. Tumor, cyst, w snmb?


S CHRONIC .ssNblad&r o, liver Mbk?


9. S!omcb ulcer?


10. Any other CHRONIC mm,cb tmubk?


11. ~i~g+tcam m CHROtNC tidmy


1. Tabwculos[a?


Z Smphysemt?


:S. Ikrdenlng of tbe mtuim?


s.(km,? 

6. N,,II trouble? 

7. Stroke? 

s She”m.lk Iavcr? 

9. ArthrK$s w rb,mmllsm? 

so. mental illness? 

lL Oi,ktes? 

1S. Epilepsy? 

Gu*:!lm 12 

k2 Hew y.., ywr ●tc., h.d em.1 Ih. cnndi!im, 00RNIG 7SS PAST 12 AiSt47Sk$? 

12 Ttwmid umbse c+ Pi:e,? 

13. Ar.7 .Nqy? 

14. CHR03!C ~UW41S Imbk? 

15. CHRLMIC skim wwbk? 

16. Palsy? 

17. P-17.!. d m, bkd? 

18. REPEATED tmnbk wok back m splae? 

19. Ckrtpalm? 

as.Any sptck &f&

21.HmhIWNPWC? 

32 Pm.t*tc tmubk? 

Gun!lm 13: 

&t	 Do you, ywr--, QIC., HAVEmI~ .lfS** 

conditions? 

1.	 Lk.fmss c+ sERIOUS 1PM. hearhs 

WI* One 0, Mb Un? 

4. ANSSI.S I“W Or W&y (or bmlll)? 

E. Club k-n? 

6.	 PERNANS74T s!iffaess c+ eny defc+mhy 

of M, Iek I@cm, armor bwb? 

A-1 

Figure 2. Questions relating to illness and injury recall, fiscal years 1958 and 1967. 

13 
the approach suggested by the alternative B 

method of collection considered at the 

beginning of the survey. The illness and injury 

recal questions, with a 2-week reference period, 

were replaced with questions pertaining to 

health-related actions taken during the reference 

period. Information about conditions responsible for such actions was obtained from persons 

giving positive responses to these questions 

(figures 3aand 3b). 

The 18-month period, July 1967-December 

1968, was considered as a trial period for the 

new “person” approach in data collection. 

Because of this decision, it was felt that information on one-half of the sample population 

should be collected on the new questionnaire 

and that information on the other half should be 

elicited by means of the “condition” approach 

used in the first 10 years of the survey. 

Estimates based on the two samples are 

described and compared in Vital and Health 

Statistics report, Series 2, Number 4811. It was 

found that no drastic changes in levels and 

relationships of health measures resulted from 

the adoption of the “person” approach. The 

designation of these 18 months as an interim 

experimental period made it possible for revisions to be made during this time by adding, 

deleting, or rewording questions. It also provided for an orderly transfer of the data-collection period for a given questionnaire from a 

fiscal to a calendar year basis (beginning in 

January 1969). This change in the collection 

period was initiated in order to make the data 

from the interview survey more comparable to 

other health-related statistics. 

During the interim period, two new areas 

were added to the 2-week recall questions in an 

attempt to elicit certain kinds of conditions: one 

related to dental visits for the treatment of oral 

conditions and the other was directed to 

hospitalization during the 2-week period for 

emergency or other types of care. However, 

neither of these areas produced a sufficient 

number of reportable conditions to justify 

including them on a permanent basis; the dental 

probe question relating to conditions was 

dropped from the questionnaire for calendar 

year 1971, and the hospital probe question was 

deleted on the calendar year 1970 questionnaire. 

Other revisions in the illness recall area during 

the trial period, shown in figure 4, included (1) 

the expansion of the introduction to the 2-week 

recall questions to inform the respondent of the 

purpose of the survey, the areas of questioning, 

and the beginning and concluding dates of the 

period outlined on the calendar, (2) the rearrangement of questions relating to disability 

caused by reportable conditions to obtain information on work- and school-loss days prior to 

information on activity-restricting days, and (3) 

an addition in the area of 2-week physician visits 

to elicit illnesses due to pregnancy. All of these 

three changes in format proved to be quite 

effective and have remained practically 

unchanged through 1974. 

A gradual decline in the number of injuries 

reported in the survey during the late 1960’s and 

during 1970 led to the addition of a specific area 

related to injury recall on the calendar years 

1971-74 questionnaires. 

The decision to restrict the collection of 

prevalence data to specific types of chronic conditions during a given collection year was implemented by the collection of data on digestive 

conditions during the interim period July 1967-

December 1968. The collection schedule for this 

type of information during succeeding years 

follows: 

Calendar year 1969–Conditions of the bones, 

joints, muscles, and skin 

Calendar year 1970–Conditions of the respiratory system 

Calendar year 197 l–Impairments 

Calendar year 1972–Conditions of the cardiovascular system 

CaIendar year 1973–Conditions affecting the 

nervous system, glandular disorders, and 

conditions of the genitourinary system 

Calendar year 1974–No chronic condition list 

The specific conditions and illnesses included for 

each of these are shown in appendix IV. 

Descra@ion of conditions and related disability.–Dunng the first 8 years of the survey, 

fiscal years 1958-65, the format of the questionnaire provided for the entering of each illness or 

injury on a separate line of questionnaire table I 

14 
Figure 3a. Questions relating to illness and injury recall, fiscal year 1968. 

15 
-- ------------------------------------------------------------------------------- ---

--

--

--

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

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

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

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

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

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

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

--

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

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

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

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

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

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

--

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

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

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

--

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

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

� 

I 

,.,. 

TM. sum. 1, him, . ..Jw..J t. <.11.<, !J.t,m,h. . . lk. N,,i.m,s h“l!h. 1.111 .sk..h.”t ,1s1” !. 

doclm .“ I d.”,l ,18, 111”.s, 1. III. l.m,l,, ..4 .th,, h“lth ,.l,ld ,,”,. (HAND CALENDAR) 

Th. “.xt f.w ,-*,!oRs ,.Iw * if,. p,, 2 . ..k.. h. 2 w..k, �,llmd 1. 1A .n ,M c.!.mda, 

b.,lnmlms Uani.y. (d,,,) , .nd Arms hi. P., $..d.r, (dam) . Y (db) 

. . hrl”s *.,. 2 w..i,, iii .IEy 1“ kd k..,, of ..y 111..,s �, 1,1.ly? 4.. 0, “	 1,.,.: 17.~5/6, 

b. DU,im, W 2.w,,k w,I,J, how am.y &y, W .- ,ISy I. M .IL,, .,s, .1 ,k dq? h — m,, } Lw,,6(8, 

i hi., 1A.,.
2 w..k,, h.. m,., &y. did 111..,s .r lmIwy k“, --b w.rk? % _wl. 4.,*01 (For fenules)! “.1 c.vntl,, w.* �ud th, h.,,,? C4n “e”. (8) 

I. b]”, III.,. 2“.,k., h. Hsy d.,s di~ III,”, .! ln[,!y k“, k s,bwl? 6. _SL ..,% 

=0”-. (81 -

— c.,. 

,.	 0“ h. -“Y �f h,,. &r, I** I f?n W - ,!s, 1. ksd .11 .,.,,? �I lb. &y? 7. ~~llm. ““0’’’$’”””4’’; 01”’” ,mb, { =1 } 

k.	 (HOT COUNTING !h, J+) 1. nY 

{ R&:::$., } ‘ 

Wor. A.- ..7 (.(+,,) 4+ id., h. P..,2 w“ks lb! ..! 4..”.. dm iii”,. z N(9J t.. “.udlr J.” k..,. �I 111”.s. �r r.l”rr? -.. --.-----------------

i“ M 

b.	 (A@., -1 .H.11”, lb. d+) ~ —m,. { R2:::’., } ) .Olim Du,l,, thst ,.,1.4, h,. mcm~ (.!h.r) d.p did h. <u! d... h, .s m.ch .s , d.y! 

If one w MM. dap 1.9’$.4-2, axk % aht.wise ZO to nut $+rson, 

““m’-’’’’’”n’”u’d--” { iii%’ }&rrn’h”’’*’2-k” ‘- ‘“’”’%’7’’”’-’ 

b. Did,”, .lk.r ,mdlll.. c..,. ht. IS 

{=:’ } ‘“’’n’k’’’”d’ L :.PJ 

Em” cAIAl;Tb ,“ ,Io”, c c. hi CSd[lbn? c. 

m 

k. D“rr”s ,h. p.,, 2 w-k, d,d .“,... 1“ tk. Idly, ,h.t h pm, 

7..,	 --, *.., h.,. �.r M.<) .C<ld.”ls � I.1.i.s? .---------- .-------_ -------------------y------.------------N-!'-'!-. 

b. h w. this? - mk ,<Acddcnt w I, IuIY, t-ax In persc.n,s column. 10L imum”t “ I*JW 

,.,.,7 

c. Wht “.s fh. l,[wy? ._-”. 

i. Dli cap,, k,,, ,n~ .!b,r ,,,1/,,1, at I.IWIO* d.tlni I!+*I pedcd! Y (Reak 10b and,) N 

For euh mrsm with aaAcddtnt w I“lwy; , ask Y (Em.t I“,* 1.8.. c) 

,. A, . mul, �l h .<cldmt, dld --,... J.cf.r.r dli b. ..1 A.” on h W.” h. “SWIIY dots? . N 

. 

. Dwl”g lh. PI 2 w..ks [A, 2 w,.k, .utlln.d lm rcd . . M c.l,mA,I h,w -“Y 13- O* � “m. II.., dii s... AM kh,? _N”ah,.,v,,,t, } ‘NPJ 

(0.sId,, ihe,. ,1,1,,) 

. D.,lng ,1., 2.w.,k p.,1.d dld..y,m, 1. I!+. hilly g.,. , 4,,,.,>, ,ffl,. ,, Y 

<M. fsr shot., x.my,, t..,,, . . .Xa.z..m.%? N [IS) -. 

b. W. w., ,M,? - Mwk ,,Dcaw ,1,1,., box 1“ Per,.”., ..1..”. 14L � co.,., “$,,, 

c.	 Asp. .[..? Y (Rta,k 14b md .) 

II 

k7%-l;lG%ity,:iCC 

d. N.. mn,y ,1... 4d --,1,1, h d..!., dwl.g IW P,rld? & _ Il””bu.l”,%!m ,.,, 

,, D.,!., lk., p,rled, did ..7... in h. 1..1[7 @my .,di,,! ,4,1<, Gom Y 

. id., . ...*, ,.1.?h.”.? N (16) -_ 

b. tie w.. tk. ,ho”, ..11 ,hu,? - M,k .sPhoc+ call,, b+. [n F+,,,.% cofunm. 

t. Amy ,,11s .bm., ..!.”. .1s.? Y (Reo,k 15b .“6 c1 

N 

If ‘,PhMe <,,,,., ,,k 

i H* -“y ,.1***”. ..11,..” MA 10 !0! mdi<.1 .4”1,. .icd ! d. — llht al =11s (NPJ 

Si ~ 

FIU ,tem C. [C.3CTOR1. from Q.e, 13-85 f- all ,.r~.. ‘=J ‘i’’’’’” %“.=1641 Ask Q. 16. for exh P,c,on w,th vi%l” 1“ DOCTOR b+% 

,. F., wk., co,i[lhn dl 4 --,,.., “Ik to . Aclw duti., *. p,, 2 w+,? ,6* � **S”= W16.1 

� Na CC.?d,tk.l -

k Dld--,..., tdk h . d.dw.bw, �y xpdfk ..,JIH..? -! ---y-.-----J-,!p-J---, c. Mm .ond[H.m? H. . En,.? .dd:wd~,lt.m c

-----------------, 

L WI,, PA pfi,d, dld ,“ .,t.!k % , JtiIor .ko.l.ny �!h,, ..”411[..? Y (M@ “ (“n, 

--~ .----------------, 

0. DWIm, k. px?2 w-k, W, ,lck km.s. .! h.r,m~~? . Ii .- ---y-------~--f!:!--. 

f. m! m, *, M*,? f. E“.< <dn,w ,.,,,.” c ,,6 

1 ..- k. ..-

,.	 WRlffi THE PAST 12 M+ITHS, dl~ .mysn. 1. th. I.milr 

{r.”, Vu! --, �.) ha,. - C&yddy 

,, .7,,.,. ~xk ~ and . 

k. Wh..,, M.? Enternm. d cmdltlm 91dlener of 11”, C. Cy,fl< flkr.,l,? J vkfe,,~,md 1“ 8w.,cf.,IMe w,,”% COIMI” 1“ film C. D. Am.l,? 

c.	 Du,lnz NICW,I 12 .oAJ, dli woo. .1,. ho . . . ? 

E. Eplt.,sy? 

F. MJII,I, ,cl.msls? 

G. Ml,,.] n.? 

~}==” J. N.pk,x,ls? 

K. Krdn.y ,,...s? 

L. AM” A,, kihy ,m,b[.? cmm:~pv 

M. BIOJJ,, ,,.”M.? 

N. P,.,,.- ,m.b!.? 

0. Dls.,,. .f i+;u,,m, ,, ,vow?” 

P. A*Y .*., f,..l. ,“”M,? 1 

Figure 3b. Questions relating to illnass and injury recall, fiscal year 1974. 

16 
-- -------

-- ------

--

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

-- -----

-- ------

-- ---

----- --

---

(This ( 8u~ IS king conducted to cellcct infannation an the Natien’s heolti. I wiU ask ~~ut “isitz to dwtor~ gnd

tdwffsts, ii {rmss in tbo family, mrd .thr health rehd items.) (HAND CALENDAR) BD 

The 1 first few questions refer to the past twa wcoks, that is, tbo 2 weeks outlined in red on that calandar, 

boglnnlng 1 Monday, , and ending this past Sunda5 ~ ~CS (5b) 

50. During tbosc two w~ks, did stay in bed because of any illness or iniwy? 5a. m N. (5c o,d) __ ______________ _______________________________________________ 

b. During that two-week period, how many days did stay in btd all or most of the day? b. days (se. or d) __ ______________ ______ ___________________________________________ 

If 1’7yearn old or over ask: m No.. ~~:m c.	 During tbosc two weeks, baw many days did illness or inpry keep fram work? c. 

For femalead& Not cwntirrgworkmarmdtlmhowc. _days } 

.--~f%:l%;c;:oid-a;k; mNom (SU 

d.	 During Wos@*owccks, howmany &ysdidillness eriniu~k~p fim school? _ _* _-.aYsL5SL---- _________________________________________________ 

Aak only if bed days AND work loss or school 10SS. aNone ~f 

____cL@_h~w_ma_ny ~f&~sl=-_daas Iostfiom work (scheel) did sta Lin_ M_aLI =r_m_st_ol A_e_dg9~ __ _ _q _-q________ 1 __________ 

“-f: &:lDES the days in bcd and days last from work, school)werc rfrere any dnys during the past 2 weeks f. mYes(5gl had to cut down on tlw things he usually does b-cause of health? __ ______________ lgNof6a) . - - - ________________________________________________ 

g.	 (A oin, notceunting ~e&ysin kdanddays lost frmwa&, schml), how many 9. a None (&p; 

(o&r) days did hc have to cut down far .s much as a day? days’(6.) 

Ml+ dnysin Q.5, wrk6,


othcrwiae Sotoncxl person Enter ccmditi.ms fn Item C


60. Wbatcondition coused--ti {$5’ } duringthepast2wccks? 6a. Ask 6b and c 

_-, ______________ _________________________________________________ 

b. Didanyoth@rcondition caus*him ~(stiyin b4, miss we&, miss schwl, c.tdown)d.,ing fiat Petiod? b. myes(sc) mN.00sao.NP; ___ . - __________________________________________________ 

c. What cenditian? c, En?Zr-cG$&J’6~ ZeZ E ‘-

Figure 4. Questions relating to illness and injury recall, as revised during tha interim period July 1867-Decamber 1888. 

(see figure 5). Questions in table I were designed 

to elicit information relating to (1) whether the 

condition had ever been attended by a 

‘physician, (2) the most accurate description the 

respondent could give about the nature of the 

condition, (3) days of restricted activity, bed 

disability, and work- or school-loss days caused 

by the condition, and (4) certain facts about the 

onset of the condition to determine whether it 

was acute or chronic. The principal change in 

this portion of the questionnaire through fiscal 

year 1965 was not in the wording of the specific 

questions in the table, but in the interviewers’ 

instructions included in the heading of the table. 

These instructions were expanded in the 

questionnaires for fiscal years 1960 and 1961 

and were then unchanged through fiscal year 

1965. 

In the computer processing of the data for 

fiscal years 1966 and 1967, a photographic 

process, identified as FOSDIC: was used by the 

Bureau of the Census, the agency that carried 

out the statistical processing of the interview 

data through fiscal year 1968. With this procedure, it was not feasible to use the questionnaire table I format, so each reported condition 

was carried through a separate “condition page,” 

which also included questions on accidents 

‘Filmed Optical Sensing Device for Input to Computers. 

resulting in injury and on activity and mobility 

limitation. The wording of the questions relating 

to conditions and the interviewers’ instructions 

were not changed to a great extent, but the 

questionnaire format was quite different. The 

“condition page” concept has been continued 

through calendar year 1974. 

With the introduction of restricting the collection of information on chronic conditions to 

those affecting a specific system (beginning in 

July 1967), it was felt that the amount of data 

relating to the history, treatment, and development of such conditions should be increased. 

Since the new “person approach” called for the 

collection of information on activity and mobility limitation on a person basis, as described 

earlier, the questions relating to limitation were 

transferred to another area on the questionnaire, 

and detailed information on specific chronic 

conditions was obtained by adding a section 

identified as AA to each condition page. Section 

M was revised to some extent during the trial 

period (July 1967-December 1968) and has 

remained as an integral part of the condition 

page through calendar year 1973 (figure 6). 

Limitation of activsly.–During the first 8 

years of the survey, through June 1965, information on limitation of activity due to chronic 

conditions was obtained from questions at the 

end of questionnaire table I. After competing 

17 
Figure 5. Development of segments of questionnaire table 1, fiscal years 1956-1965. 
--

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

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

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

--

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

--

--

......

--

--

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

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

--

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

-- ew.d?

CONDITION2 

1. r,,,,” ““mh,, N.- ,f c,.dlt!,m 0, C.In -- s,, ..11 ,,,qh 1. ,.sd �rdl,m, n,w,pop, 

1 

i WI,. did t,,+,..., talk,,. d,.,,, abo., h!, . ..? { -

E. Flr,t notlud d,rl,: 6, p,,, 2 week,? 

(Quc.tlon 9) . . . . . . . . . . . Y N (AA} 

b. Doctor seen o, talked ta d,rlns tie P,,, 2 week,? 

(lhsIIm 2) . . . . . . . . . .. Y(FlJl N A4 w f-) 

G 0“. or .we cut.don days? 

CARD C (Quesu’an % . . . . . . . . .. Y(Frl! N (w M“, &n) 

Do M, s,k for Csn.z,, FOOTNOTES 

b, W%,* w,, th. ,.”,. �I . ..? 

a Accld,,t c+ I“IUIY (A?) Conditions reported for which questions 3a-3e 

need not be asked: If tie .nuy 1,3, or M Ind,d,s th, wcidx 

All.,,, C..d,,l.n D,,,,4, T,.A,.


A...,. ~:<, jy, & Acne Laryngitis
 Aa,h.. A*k c


A,,,A mm,.,, R“,.,. 

} Appendicitis Migraine 

G Wht kl.d .1 . . . I, at? Contln.o b .zmdltl.ns Ilsttd O, reported In wobe que%tlon 3!, 

A .tiwwIsc,,.toA5. Formt**(nzex”mb..s .r.r,*ns.t.ufi. Arteriosclerosis Migraine headache � Do”.r seen (12) m Ooaor not *,,” (It) 

PJrlilZ;tJ-JZiSki~ i/kI 1!. Dwl., $k. P.,, 12 mo”lhs who! dld --d... !ok. for his . ..? {Write I.> I Athlete’s foot Mumps L Now do,, 1A. .11,,,” (,1,.k.l .If..l M.? 

dnfibl”$ .1..? (18) Bronchitis (any kind) Normal delivery 

1 how

I Af!.r fiml “all-d s...thing . . . “raw abed 1.”s “n% H

-------..... b.lm. h. rnlkcd t. . d.,,., about h? Bunions Phlebitis 

For an lcwalrnmnt m any at the fol!awnz u,tr!tix (P,c.b< W., !1 . .ell,r of clap, .uk,, ., months?) (Thrombophlebitis) Ah,<.,; h“,,. r.”!,,,. 

Ash, (,,.,p, $,,,, d,.) Omw+h 

-

R.,.,, .0. � Dl,cavertd by tiant (14.) )—weeks Bursitis 

Pneumonia 81..41., H,m,,d,,,, 2..


ml,.d .!., 8“!,.,,.. ~“rmy ,,, � Less NW o“, day ,_I’bnti* Calluses


c.,! !“h”m.t,tm 

lx.., 

Ask c -0.7% *—Y.-, Chicken pox Pregnancy CM,., N.”,.!,,. 

C::::.gq, p“:] ,,, V.,,-.. “,”, 13. BEFORE talk.d +. . dr.ct.r .kout hls . . . . did h. do ., Iok. Sciatica V..k } a.r+hl.. 1., i,? Cold C,** P.I,. WA”.,, !’Y” *“N Sinus ,.WI pi d tk, kdr 1, ,If.<t,d? Mo. Do., NOW take any rn.dl<lne w troatawnf for III, . . .? Corns 

Sinus trouble Croup 

b. w., w.1 M. ..dkr..., h-mni r..”. o.d.d hY. docl.r? Diabetes ............. I '-'----------:-u-`'z----------------------------i (Sinusitis) L.ll. -. I.. f.,. !Y *N 

B.,u,,,..hl. b,, . . . . . . . . . . . . . . . .. .,a,., ,..., 12. H.. k. . . . . hsd‘w-y 6, thisc-d!tfie.? Epilepsy SCrJpptrepcmm) E.,.,.”. . . . . . . . . . . . . . . . . ..”..rb.h 

Am . . . . . . . . . . . . . . . . . . . ..~~.. h.hh.!~i.uyr. ,Y ,N lI_=Ll i, Y’, N 

tar IM* eo.dmo.? 

r Gallstones Tonsillitis L,, . . . . . . . . . . . . . . . . . . . ..$n... b..h. hlp.k”... 1s. W., h. .,., he,,ltallzcd 

Goiter 17. 9.,1. ,h. P.,, 12 mnn,h,, akeut how mmy ,1.. s h., s“” a Ulcer (duodenal, lh;;~lnntlnf,;lona will b, ,,k,d ,s qProPrl,t, I., IJI, f.lk. .l 1. a doctor mheut ht. . . .? 

I (De ..1 count VISII, whll. , p,!l.,t [n e ho,plrnl.) Hardening of stomach, peptic 

k2 � 1,.. I � Q.3b � Q. 3d the arteries or gastric only) 

� 0.3. u Q, 3. Hay fever Vasectomy 4. DWI.S Ih. pant 2 w-b., drd hl, . . . . ..s. hla I hl. I. k.d .11 or ..,, of rho da,? I 1. cut do.,.. d,, ,ht.,, h. u,uelly dv.,t ,Y *N(7) 

—Dw m. � Nom Hemorrhoids or pi Ies Warts 5, DA. ,601 p.,l,d, how .on”d,p 4!4 k. cm! 

k“ k,., �uch �s . dqr _ D*YS 79.. How oft,. do., his . . . kthc, him -.11 of th, II.., .hom, enc. In . Hernia (All types) Whooping cough o,ONon, (9)	 “h I l., ., “.”..? 

, � All the II.. , � Often 

6. D.N,s that 2.w..k ,,,1,/, h,. .,,y & , did 

h!.	 . . . k.op hlm 1“ k.d .(1 ., m,,, .1, i . d.~? _cl*y, 00 Ne”cI N 9.) . n Ouler - ., u Non. 

b. Wh.. u d... Wh.r h&.#~$m~Ihti.d Ask if 17+ W,,X , � Great deal 7.	 How ..my d.y. dl~ III, . . . k.., kl. f,,. work _D,y* (9) du,ln, ,k, 2.w,.k p,A,d7 tFo, re.,l,,k n., ,, � N,”, (9] . Ig Olher -s*cIf” ,.untl,g we,k mm,,d th. h.,,.? 

A,k If 6-16 p,,,, � All tie %(.c In 19. (AS) 

0,	 How ..my day, dld Id,,, , k,. him fro. _D,ys c. Dot, still hmv. Ihl, <o.dl!lom? 

,stmd dwlng lhal 1...,4 PI, r ? o, � No,, , Y (As) N 

9.	 Wh.. d[d 11,,, ,.,1.. hl, . . .? 

, Ig 2 lw,ks-3 ..”*S d. 1, ,hl, .ondlw.m cawl.bly a-d I � Last w,tk 

— z � cured , ~ Week b,for, s n 0“,, 3-11 M“*, 

I � P.,, 2 we,k*-DK IAIlcb . � hr. **” 12 mall!, .1. . � other - slMclf, 

(W., 1, du,lm, th. ,,,,12 mn!h, ., k,fm. that ,1..?) &ui 1,.. 10., did he,. ,M, c.ndl,lo. 

, � once In * *M!, Kidney stones Sm.lf, 

a s-.1 d.d, m.!,., vw Iml.1 

, � v-y 11.1. 

.,1, 1, .nd.r <..,IQI? 

, � Under . . . . . I (AS) 

(A5f 

. . bs7w. 1, . . ------------1 .

(W.. w dutlmt tho PII 3 rm.thn *r k.hr. Nml w..?) 

(W,, 1, dw,lm, ,i, “,! 2 w-k, ., k.fw. lkl w..?] 

Figure 6. Sample “condition page:’ calendar year 1973. (Excluded 

Figure 15,) 

questionnaire table I for the final condition reported for a sample individual, the interviewer 

handed a card to the respondent and asked her 

to look at the statements printed thereon. She 

was then asked to select the degree of limitation 

that was most descriptive of the sample person 

(figure 7). By means of interviewer instructions 

keyed to the duration of conditions and checklists of conditions, these questions were limited 

to those persons for whom chronic conditions 

are questions on accidents resulting in injury, which appear in 

were reported. The respondent was then asked 

to identify the reported condition(s) that caused 

the specific degree of activity Imitation. During 

the period July 1965-June 1967, the questions 

remained virtually unchanged, but the transfer 

in format from questionnaire table I to the 

“condition page” led to a corresponding change 

in the format of the questions on limitation of 

activity. During the entire period, July 1957-

June 1967, estimates of the number of limited 

19 
CAR DSC.F (FY 1958 AND FY 1959) OR DJ3 (FY 1%71 

FY 1959 CARD Q Patons osher than howwiws and childrmn CARD F: Childnn d.16 Yom 

T. A.k .f#e. ec+ui., l“, 

FY 1950 r.!=. <“M= fei c.eh *..-: I 

L!vi N..*. U*,2 ,, ,. l.!?r- Fl,uo .1”,0 la .t n d. 1.4 “ e.,{. .,,, 1. NOT ABLE TO WORKAT ALL. 1. NOT ABLE TO GO TO SCHOOL AT ALL. ~ :$-, {k, 1. *I. d. ,,) ,. 

:bk@ .4 ~ ::~:, mu “d ..4 ~yco : 

.-,,,,.0 .-E. or ,,. :=
 :;y;. ;&- .( .“,


:t::, m y,m*pg j, ~ “. *,,* .& ~,,~ 2. ABLE TO WORKBUT LIMITEDIN 2. ABLE TO GO TO SCHOOLBUT LIMITED


., cud. .,.,1. ~~1~, “’”- ,,.”’ AMOUNTOF WORKOR KINDOF WORK. TO CERTAIN TYPES OF SCHOOLSOR


:0:, :,?, ;.ntJf: :4: :“”y ::, (z.. IN SCHOOLATTENDANCE. !. x o,,,!. i.. ,*.. * A-B, ,*. !.!4 .0 ,:. * m	 y,: c- ~:=y ~: c. 4.., ~, 3. ABLE TO WORK BUT LIMITEDIN KIND .wr.-

STOP F.”l.] .:* IN OTHER ACTIVITIES.

(“1 1.1 

4, NOT LIMITEDIN ANY OF THE 

(..) (0 1.) (0 ABOVE WAYS. 4. ;]I)SLIMITED IN ANY OF TRE ABOVE 

,,,,,,, .,,, .&. OR AMOUNTOF OTHER ACTIVITIES. 3. ABLE TO GO TO SCHOOLBUT LIMITED 

I CARD E Housewife CARD G Childrm utulw6yun 

I 

L NOT ABLE TO KEEP HOUSEAT ALL. 1. NOT ABLE TO TAKE PART AT ALL IN 

FY 196T ORDINARY PLAY IMTIIOTNER 

ShW Cord D, E, F, w G, OS ; lB. PLEASE LOOK AT EACH STATEMENT ON THIS CARD (CARD O, E, F, G). CIIILOREN. 

.mcwm,e Lined m WIWIIY : TNEN TELL MEWHICHSTATEMENTFITS .- BESTIN TERMSOF HEALTH, ~1>34.c.. = v 2. ABLE TO KEEP HOUSEBUT LIMITEO ,Imm V.qc. ,)/4 “,.,,.,”, . ..6.,)* 0000 0 IN AMOUNTOR KINDOF HOUSEWORK. 

II1,2. a 3 nnrked 19. IS nls BECAUSEOF AHY OF THE COWOITIONS YOU HAVE TOLO ME ABOUT? WASHINGTON USE 2. ABLE TO PLAY WITIIOTIIER CIIILDREN 

1.18 c.sk, “. n. — BUT LIMITED IN AMOUNT OK KIND OF . . . . . . .. . . . . . . . . . .. . .. .. . . . . . . . . . . . . . . . .. . .. .. . . . . . . . .0 : PLAY. 114nurkd m 18 golo~. \ 

; � y- ~.w~Lc~~:::y&t.r.r..+l.g.J..q~<f.).................................... 3. ABLE TO KEEP HOUSE BUT LIMITEO 

MC-w. IN KINDOR AMOUNTOF OTHER ~ 000 ACTIVITIES. 

: D No * K;L:&;\t; (z.,,, ..,,,) ,.. 4. NOT LIMITEDIN ANY OF TIIE ABOVE 

WAYS. 

4. ~OTJIMITED IN ANY OF THE ABOVE 

I I 

Figure 7. Questions relating to limitation of activity, f iscal years 1958,1959, and 1967. 
persons and the number of conditions causing 

limitation were derived during the data-processing phase of the survey. 

In the questionnaire format adopted in JuIy 

1967, the restriction regarding the presence of 

chronic condition(s) was removed, and questions 

relating to the degree of activity limitation were 

asked for all sample persons. This change was 

necessary because it was no Ionger possible to 

derive complete estimates of limitation status 

from previously reported conditions when only 

specific body systems were included in the 

checklists of chronic conditions. Other major 

changes in administering the questions relating 

to activity limitation were as follows: (1) instead 

of asking the respondent to select the appropriate limitation status from a printed card, the 

interviewer read the options to the respondent, 

and (2) the questions relating to the usual activity of the sample persons were moved from the 

section on personal characteristics to an area 

immediately preceding the limitation of activity 

questions. The latter change was necessary 

because the options from which the respondent 

selects the appropriate Imitation status are 

keyed to the usual activity of the sample person 

(figure 8). 

During the 18-month period ending in December 1968, many changes were made in the wording, format, and arrangement of the questions 

on limitation of activity, The interviewing problems and data-processing difficulties were not 

completely resolved until 1970 when a satisfactory series of questions was obtained. Unlike 

other health-related items, such as physician or 

dental visits that are objective by nature, limitation of activity represents an opinion or attitude 

on the part of the respondent. Because the 

questions require a subjective judgment by the 

respondent, even minor changes in the wording 

or the sequence of the questions may cause 

marked variation in response. The format used 

in the questionnaire fielded in January 1970 has 

been retained with few changes through 

December 1974. 

During fiscal years 1960 and 1961, information on the duration of limitation of activity was 

obtained for all persons who were either unable 

to carry on their usual activity or limited in the 

amount or kind of usual activity, In addition, 

those 17 years or over were asked if they had 

been working up until the time the limitation 

started. Questions relating to the duration of 

limitation of activity were not asked again until 

January 1969. During that year, all persons with 

any degree of limitation were asked: 

About how long has he: 

Been limited in._. 

Been unable to 

Had to go to a certain type of school? 

H Less than 1 month 

_ months — years 

This question has continued to be on the 

questionnaire through December 1973. 

Hospitalization. –Similar to the procedure 

used in recording illness and injury, questions 

on hospitalization are asked in two stages: (1) 

hospitalization recall questions asked during 

the early part of the interview (figure 9) and 

(2) questions regarding the cause, duration, and 

place of hospitalization. Changes in format for 

recording information on hospitalizations are 

also quite similar to those for recording illness 

data in that an area of questionnaire table II 

(see figure 10), analogous to questionnaire 

table I, was used during the fiscal years 

1958-65, and a hospital page, comparable to 

the condition page, has been used during fiscal 

year 1966 through calendar year 1974. 

An early methodological study, the findings 

of which were published in Vital and Health 

Statistics report, Series 2, Number 7,4 revealed 

that hospitalizations during the year prior to 

the week of interview are underreported in the 

household interview. In an attempt to improve 

the completeness and accuracy of reporting, 

the following two major changes were made in 

the hospitalization recall area: (1) an additional 

question, inserted for fiscal year 1961 and 

retained thereafter, reminds the interviewer to 

inquire about hospitalizations for deliveries 

when a child under 1 year of age is listed as a 

household member, and (2) beginning in fiscal 

year 1963, there was a change in the time 

reference for the recall questions. This latter 

change consisted of the addition of an extra 

period of recall extending the period to the 1st 

of the month preceding the 12-month period 

prior to interview. For example, respondents 

21

----

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

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

--

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

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

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

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

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

--

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

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

--

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

----

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

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

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

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

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

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

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

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

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

--

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

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

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

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

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

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

w 19W 

* Igl”,,,, b“” (

H %...,,,., .1”,, -4 s..... .1 .s, “t, 

‘1%’ k 1,. -”,1.0 , OU,,IA ,,,, 4n c.!.,. .*”1 Go, w 1074 n -.-W’ .1”,. d ..4” 4s ,..” d . . “ h * 1s. “b 

. m., .,, 4.,s+? , n 17+.”*1.Z .1.. m, 2%. Wm.! w., --AM MOST OF THE PAST 12 WIITHS - (For msl,,b WWH”so, d,lmg UA+IE+.1,.? m. --._-- ,06-1’ ..mw.’ .!.e (,,, If %.eti,.t ,1,.. - .,k (For fomd.sb ko#&ww\&w.dm ,ttiw ~:, :: ::”:@k-:. ~u, 

l,.	 m.. .,, -.4.t”i “,,.16. ?.,, 12..”*, - “I,q -.*1 ..i.,”1 . . ..*I.I.!”, y: b. mat “.. u.,? 

II --.4.,.1..- “k! ,, ~, ~=, M was M, !%CA,.ZC)) clk,,o,nt bus,,)) w C,!OIM m XhOd,)) .Sk ,0”,!,.4, b“,lh (M, 

. . IS — r.,lmd? , n ““,,4 ..”,,,, %: L m., . . --&l”l, d. M WU,ed:s “k Did h. ,.,1,. b.,.”,. .1 MS Im.l$h? lo wm. ,+0, w, I II :~~ 21.. 

[f %mmhl.gd$.,,j ask 

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

>06-,’ !W”,h,.,.,’. ,m, 

h?,., . d+ MOST OF WE PAST 12 MONTHS - wt., t. SAMI w 4.1., ,.#hl,s .1,.? .0 (>, -w., .,.. (24, 

I M. 1“ ,.-s .th.4DL i. --*1.1. i.k.,.nm 41 c. .48”-.1” .8* . . ..ehw.”? I 15.1 b,!&J-~l=:-dq~- - -------. 

In.. (,$*, t 0 h’. m, “:f::6 - --:Jl:t~~, 

‘K
 k. ,. h. 1,.1,.I **. MA.,...””, .,d.r k.”,. .’M.,..I*, L * my., n,> la.,. --.,,. 1. Wt. m u d! (“ C.WCUV P!.? “M A,, chlldfw? Lzl.j Y !“@, 

t II �“. .-c. Io”.,, p.”m b. Is h. t,.,,.d i. lie k,fd cfPlo, he <m & b.”.,. .Ihi. h,.hh? ‘ @J

,’. ,,-- I(.W 1“ -, -.T,..-,M,h Mdlb,lb, ,,. I or..,,,., ..1. ho 1,.1,.d i. h .#nLm, .1 ploy b.,,..,.d h,, h“lth! . ,,(?0 “(a, 

~,~syv. . 1“ +., -v l,h. II*,,* -*,,, .lgll. -c6,..w - 22+. Is 11.lld 1..“y ..y k.”.. .1 ht.6“!*? .?. _z__...MLw. 

L 1“ -k, ..” IS h. II-M? Recad Ilmkattm. rat cwdttlom . (20) 

-,.,, 

. . . . . ..-------—---—— ------—- L!L? _.____4 

24.. Do,, h“!,h “.. k.., hr. h- ..,+1.,? 

17. ,. !.,., .,hllh m *I. “ “*, ,,. .’.:. J. Lfx..._.L_­

b. Is h. [1.1,4 la the kind of M h. COvld & boc..s. .1 ht. b“lli? � . . mu 9an. (21, -----.- .__--&. --’- ?-f-z------- !----­

------.-------- . . !, h. Ilmltd 1“ the omom! of wk he ce+ld de b...... .1 hls h“llh? 

L !, --1,.,,4 i.*. kn.d “-..., .1 “*L. -.14+ i.”...d M. hdbl 

--L ---.---------------..-.---------------.---------------------------------------l-?J-:-:-RJ-...---!-----l 

d. Is h, 1,.,,.4 M tie k,nd w .-, .(ahar 0<,1”1,{,s b,,..,. .1 MS h..!k? zah. eo on. am 2%. D,,, IIOW h.... jab? , (la) . ..---------— . . . . . . . . . . . . _!___ 1,. ,,-- [MM h h. k,”,,, -,.1 (“!k. k...)h)h. .-J. h.c-s..t M. h..ltit 1,. b. 1“ ,,rm .1 h..l,b, ,, NOWQM. 1. [-k - k,,P h+”,,) .,.11? 

� 7.. ,,#b> (,,,> H ml. --h _L ___ J-!-%

--, .-------------- G 1, k. 11.1,.d I. tit k,ndof (-k -ho”’eti) h, m“ do b,,,.,. .1 M. k,.llh? ---1-:J.2-Y.RJ......-!-----I L 1, --d.!. (“rI& k,.? k.,,,)., .!11 d. 1, h. Ilmi,,d 1. the m,., of(mk -hw,wc.kj h, <.” & b,<.,,. .1 MS hm!,h? --.-... ----.-------.-----... ------------.---.- .--------.-.---------------------l-+J-<-x-RJ-------E-----l qa.. ,,,, , DN. “,, ..hh Iiml,.d I“ tha kind mown, o(o!hc, ..,1,1 ,1.’ b.,.,,. of h!. h,,d,k? I ., s Y ,1,, “ ,,,, ..-----_-__-_.--

-1’-- 1,.,!,d 1“ h Md ., -w”, .1 .*,! ,C,l”,+r.. b.$w.. .1,1. i..l*? “ ! nY.. w) 26. 1. ,.,m, d b.dlh w.,ld b.d. ,. s ,0 ,d,ml? m. v !“(a) 

40H. -C.,..”, ”.”- 27.. D.,, [wldl he..,. w IO . <.M. tip. at ‘chad b,c..m .1 hls h.dth?	 n.. * Y ,20, ..-. --------------! 

w. ,“ ,,-s .( h,.m ,--- AI. 1.,. “ mh,l, 1,. b. 1, h, (..,IJ h. b.) 11.11.d 1. schcat atttcdmce b.”... .1 hi. k..!lh? b *Yml --------------! 

� . . “o> 9D+. (21, ..1. ho Ilml+d 1“ th khd w .mcu!t d CUIUactivities h-us..1ht. hnlth? . . “ (29, N 

n. c.., (“w)h. h”. 1. w . . ..s,.,” W..t .4..1 h.c. .. ..ihs. L..m ?0. 28..1, — I!mlt.d i. ANY WAY bus’. .1. dl.nblllly m h.dlh? a. .Y. ”,w, . . . 

2DY.. “,, on. @m> b. 1. “M “my !s h. Ii.1,.d? Rucid Iimltsrlco. not ceodltim. L 

- i i.i;Gtih; i.i L?,i i-.c-Gl-.GGGbY-ZF.iihiihi i.>ii ”--- -i b... [,.,,.4 1. — ~ *n L...-,-* %. Abw, ho. be, h., h. h..” “nob!. 10-- mm. m, 0)!. m, { h.t la 9s ,.. ..rl.l. *. .1 .Ch”!l } , _ M,. z _,,,, - .--------___--- -----.- . -.. 

C.	 1, 1,.1,,4 k lb. m{ “ . . .-.1.$.,, ..(,,,,.. b...”” .f il. h“w b. ~., (oth,l <mdi,t.. . ..s.s AI. U.11.H..7 b. ‘“M w!!% ..* ‘* ‘- 3 rw.. m, 

40!(. --!....,-- M Wd .,*,, Mr. “k 1, M. 11.ltalm c.u,.d by.ny ,p,dfk msdt!t”? -- ---n.~!-~..::.-(ff~--- ­

..1.1!.1!.,1.. *,. t%., C.”,,!N” ..”,.. *,, ,W,.11.m? z,. !$1, CS.SQ4 b ..” .*., Cnditloal v %%, “ 

i Ma tax w .$* � -h t ~,..” 

. . ,, w. ,(.,,.,,.” .W.., * .“, A., C..’,,. ”,, 

- , .-------___J--- J d. M%,<h .1 ,b,,. c.ndrtr..s w,uld y.. ,ar [s ti. MAIN c.,’. d MS Ild.llod . ,.,., .“. ““,,,,- -

� Y.. “,., 

- . nu,*-?l.”2?.”-K! 

. m“ C“*,!.”,? -47 . . ..’...1}...? . 

� Y.. 0,. 

Figure 8. Questions relating to limitation of activity, fiscal year 1968 and calendar year 1974. 

c 
--------------- --

-------

--

--

. .

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

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

--

--

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

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

FY 1958 

blOSPIIAL CABE 

S& (Q)stm2suatm Ms2 z~humch~fdwtia~tumtlla bmitd awml J t or Icuws If 7,s”: 

(b) h- mu tlna n“ m h th Mdtd? 

30.	 m plr:grtbb~~’lz,-s ku - h tm fmli * a Duimtm
� aminr 

If7,s,, (b) mm .W time. TW8 ymnZms utdEs d or mttuh? 

CY 1974 

In r- (ml, 11) mm 

m.*tlm9 

or-(lull.
 n) all.
 --------\-
 ~. oft-


280, Was a pntitnt in a hospital at any time since ..-.-------------_ --_.. ___._-_____L?!!--?J::L:`!!________________________________ ?+’:____L____wE5L

b, How many timas was in a hospital since (date) a year ago? b. . Timas (Item C) —“.- - ~. . ‘h’ ) ,. ,,,,.,..,.,. ., . ., .. ,,,,, , ._% .:~ 

29a. Was anyon. in the fmnilyi;ea nursing home, cmwolescent home, or 

similar plact sine* a year ago? Y N (30) -—-

b, Who was this? - Circle “Y” in person’s column. 29b. Y —-- —— — 

For each “Y” circled, ask 

c. During that period, how mony times was in a nursing home or similar place? c. _ Times (he” C) 

Ask for each child I year old or under if date of birth is on or after reference date. II I 300. Was born in o hospital? 30.. 

If “Yes,” and no hoapitallzations entered in his and/or mother’s colunm, enter “’l” i“ 28b ~d item c. Y N (NP) 

If “Yes,” and a hospitalization is entered for the mother and/or baby, ask 30b for each. 

~-------------------------------------------------- b. Is this hospitalization included in the number you gave me for ? b. If” No,” correct entries in Q. 28 and item C for mother and/or baby. 11 Y N 

Figure 9. Recall questions relating to hospitalization, fiscal year 1958 and calendar year 1974. 

interviewed during July 1963 were asked about 

hospitalizations occurring since June 1, 1962. 

However, only hospitalizations within the 12-

month period were used for the derivation of 

estimates for hospital episodes. These revisions 

have continued with only minor wording 

changes through December 1974 (figure 9). 

The wording in questionnaire table II, dealing with the cause, duration, and place of 

hospitalization , remained virtually unchanged 

from July 1958 through June 1965 (figure 10). 

However, the instructions to the interviewer 

pertaining to the administration of this area of 

the questionnaire were expanded in order to 

increase their specificity. In keeping with the 

format change from questionnaire table II to 

the “hospital page,” to accommodate the 

FOSDIC method of data processing in fiscal 

years 1966 and 1967, the hospital page has 

been retained on the questionnaire through 

December 1974 with only minor changes in 

question location and interviewer instructions 

(figure 11). 

During the period January 1968 through 

December 1970, a question was added to 

ascertain if the hospital episode was the first 

admission for the designated cause of hospitalization. This question was not retained because 

it was confusing to the respondent and the 

information obtained was of questionable 

value. 

During certain years of the survey, either 

questionnaire table II or the “hospital page” 

has been expanded to obtain information on 

topics specifically related to hospitalizations. 

These topics–the portions of the hospital and/ 

or surgical bills paid by insurance and convalescence following hospitalization-were not 

planned originally as rotating items. However, 

their importance and timeliness have led to 

their inclusion on a rotating basis. 

Questions pertaining to the part of the bill 

paid by insurance were asked during fiscal 

years 1959, 1960, 1964, 1967, and 1968 

(figure 12). During the years 1959, 1960, and 

1964, the questions relating to insurance cover23 
--

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

!s? 

FY196S 

?,bl, 1I - SUMTALIZAtlW WIRE PA#? 1S DltlM T.bl. 11 - Wsrmmlumox -Ill! mm 11 Wnns 

W mUmyh$*www nm “wS#W”hyw.8~ &Uc uLO*mmsLlcm 98mb991u x-m 

i g ~ E!?w, %*’ %%: ‘=pil& EM!? m9#.mi=uti= .l’-Ju.u. Wud r.rmnhl. ,, .rI..l (U* -, .W “ n-w. - u..> i 

J s w w, “.-ul. ”ti, .”.w. lu”. U..*,,,*.*) ; 

i!&% ,,, 

,.) m (.) la ,., ,1, m (1 I 

.— Oul ., 0,. + 

, *_ _- A —- :: 0. , 

FY 1W8 

cd. w.. USE YOUR CALENDAR F...M .dlttal 4147- .“*r I+” w.” .“, .P-$rl.m pad RI y- d.li., mu, 1. *b ..” A &m.. d tlm Iinpl”l Vu ..m l.? 

N.. d.. Y.. ..!4 *k, rw mm 1. tb Co 1,<s frca -ml.. !. ..1s, (c) .nd (d)i h.plld --J. “.. Lmw ill. .4A non? M. S*Y .1 th. h“,ll.l? 

.1 No,	 h“mml (.”=., 1-1.., .1..) dwhs %:% .r,%n- .lmrs.k A qne.!i.~. 

,* put y“, y.. 1. th. (If .4..1 mm. * k.wo, .Imr If W=.,-, .sk: (Ent.r till w dh01E4t.1, .*.I Orhuhm” al UN* 1: 1* I8U1OA 

“ E Im’pll.al? p.”,=y: ~ ::my: ~ :~ fm~h, rr,pwdms, d.scwni.r..) .Ily ad SM. 11au” .C4 k?- ml., N’.u,.l j Wm84[4 7.. amt”llm h“?ltd p.. y,: ,..+ , ‘ W&m h,,:.1 Cu % W.* vu Ilm -m. .Ith. OloMltm? 

oh. h,, ,1”17 :~h;:ti 3 ~ 12 .mh.? :kwzYL .,httin %W$”+%%x’dn?i”” & Any oh, wmhn.? 

(EC4.,..MW d.y and m.. U knm, rcqtimd ,. T.bl. 0 : 

j .X.c, d.l. ”.t Alcm, Obuh .Cc.$+ tit Ihh:Afl .5 

.! “,1*.J .Slk’at.,j —? 

(.) (b) (.) (d) (.) (o (s) (h> o) (1) 

rj Y.. la v.. la N. N“. .1 b.s,iul 

1 ;,:’7 ~zfi2>;,----.-.-- 1 _ ~ ~ — . . Nm. NM. NM. ~ N. 

SOURCE DATEOF AOMIMlON LENGTHOFSTAY CAULXOFADMISSION(DIAGNosIN *ERAT10t+6 NAMEOF NOWTAL 

Figure 10. Questions relating to hospitalization (tabla 11), fiscal years 1958 and 1965. 
--

--

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

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

--

--

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

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

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

HOSPITAL PAGE 1. Person number 

You saldthot wa~ in the hospital (nursing home) during the past year. USE YOUR CAL@’NOAR Month D.Y Year 

L Whan did �nter the hospital (nursing home) (the last time)? Make sure thC YEAR IS correct 2. 19_ 

Name 

Street 1. Whotisth*nanc andaddress ofthishospital (nursing home)? 3. 

City (or county) State 

1. Howmony nights was-- lnth. hospital (nursing home)? 4. _N i;hts 

Complete Q.5 from entries lnQ.’s2and4; Ifnotcle?,r, ask the questions, 

io. Hew many of these nights were during the past 12 months? 5.. ~lghts 

b.	 How many of these nights were during the post 2 w~eks? b. _Nigh!s ,. ___ ___ -_ 

c. Wes still in the hospitol (nursing home) last Sunday night for this hospitalization (stay)? c, Y N 

For whet condition did ~ter he hospitol (nursing home) - do you knew the medical name? 6. a Normal delivery � Normal at birth 

If medical name unknown, enter an adquate description. Condition 

I For delivery ask: 1 Show CAUSE, KIND, and ~:”< F-----__ -a-6icza6c ___________ 

Was this a ntmnal dalivety? If “No:’ aSk 

/ PART OF BODY in same ________________________________ 

Fornewborn, ask What was the mower? ! detai I as required for the Kind 

Was the baby notrnal at birth? 1 Condition page. 

} I ~;t:;f-b;~y 

a.	 War* any operations performed on during fhis stay at the hospital (nursing home)? 70. Y 0 N (8) . ___ ___ 

b. Whet waa the nom. of the operation? b. 

If name of operation Is not knowm, describe what was done. 

Y (Describe) 

7N 

c. Any otffar operations during this stay? e. 

.	 NOTE: If the condition in Q.6 or 7 is in Q.31 or there is 1’ I” or more ntghts in Q.5b, a Condition page 

is required. If there is no Condition page, fill one after completing columns for all required hospitalizations. 

Figure 11. Questions on the “hospital page;’ calandar year 1974. 

age were comparatively simple and straightforward. In fiscal year 1967, an attempt was 

made to determine- the actu~ sources ;f payment and the amount paid by each source. The 

information obtained was found to be incomplete and of questionable accuracy since many 

respondents did not have records available or 

had never been informed about the sources or 

amounts of payment. Nevertheless, the same 

format was continued during fiscal year 1968. 

Since the period July-December 1968 was a 

part of the experimental period for the 

“person approach” method of data collection, 

it was felt that a new format on insurance 

payments could be tested during that period. 

As a result, the source options, as shown in 

figure 12, were combined into four groups, but 

the questions were further complicated by the 

addition of questions pertaining to surgical 

bills. During this period, the information was 

collected on a supplemental document to the 

questionnaire. The data collected on this topic 

durinq 1967 and 1968 did not provide adequate-information for the derivation of reliable 

estimates. 

During calendar year 1972, the most recent 

year for which data on hospitzd expense have 

been collected, information on the actual 

amount of payment for the hospital stay was 

limited to that paid by the family (out-ofpocket expense). By returning to the concept 

used in the early years of the survey, information was elicited about the proportion of the 

bill paid by insurance. To obtain information 

on the sources of payment, the respondent was 

handed card H and was asked to select those 

sources that had paid any part of the hospital 

bill. The options on card H, which were much 

more definitive than those on the 1967 

questionnaire, consisted of the following: 

1.	 Total or partial payment by self or 

family 

2. Social Security Medicare 

25 
------------------------------

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

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

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

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

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

---

------ ---

.

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

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

WA911NGTONUSE 

1 WHATW ‘i%ETOIALmUNT OF THE(HD2FITALINUE!IUC fWEj Eif.1 FOR THIS$TAY7 1 ~~ j G.+* I‘:k’’-mmwmm’’m’c . .

I I 

k

‘ti-DIFiTICOfWOf-MfWAIIEWAV-4RVPAW#-”----”-” ‘----”---—----—--------. ”------”””’”—­

kMTISTIfEfUME 0F2HE INSURANCEFun? * 

c 010WILL)ANYOIHCRHEALTHINSU.WCE PIAII 

siE.,., ,..1- raubtfalth .,ua~ in lIn. A 

lW. WHOPN9illLL ?AY27t!E[REUUH0ER0F TIE) 

k DIDAAYOTiiERPOS2M OR.mfcY PAYNW ..- ‘:-==:;’= 

� Y.a. m Jk fJ NO. c.l. ]m c1 w+,,. d,. hamddd t=------”---”” . . . . . . . . . . . . . . . . . . . . . . . . ..-—. . 0,,,,..,. 

c. 2110W THIS7 W W aterxy nmW .00.0 0000. 1. . . .

‘-- . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . m Fred ! m.

00 

#. VHAT1fl ?HE#.WHTPAlD2Y ..7 

(E.. M PM who .WWW. cmog~,) . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NTERVEtiR: 

Add-..”9d[! r&&&woWm!m! Pad h 

w Ih .,..m.)wd m!” n TOTAL b, ,1.. 

m! ~ d % f.! ,&m b=.... 

, 

Figure 12. Questions relating to portion of hospital (and/or 

July-December 1968, and calendar year 1972. 

4! ILWDEC2MBER 1-

Eats. lb. pus.. .mmber ad lb. d,- .1 .Dtrf 

12. Ask qm.tim. 18 threugb 18 for ed eompl.t.d ho.piti!mt!.o 

Muk a,. to, 

13.	 W1.t W9. 1A* *IQI ..w”t �I lb. !..,,lml bill far I@ shy? 

De .,11. cIu4. .,Y dnctc.r% ., .vrqmn,, bill,. � 2.,1”,., b,ll “..,..4 i-J rub.,., Ml .* “4..4 I-J r,- W 

N“. .11.s””.. +
 Ml.,. c.,,. 1A Dld (.[11) hcdth i,swrmmc. PV .*Y @ +1 it. b.wltdW? Ei%.L_/ 

— . d. What w. &. am.mt paid by --? I 

.&fwlqE2i cff~ rlpdd . n H. .P4r.,h [,9, ,0 OP!m,i” ., ddiv.q ,,’., cdl.,. C..l. 

..* m. box 

W.	 WI.* f., “.s 

,h!,the ..w”I *1 the swsnn,s (dsctw’s) = E,, I.,,.. b,ll ,,..,,.4 = E,,I..,., MII . . . r...id O Fmm bill bill �pma,roa (d.l{,oryl? 

b.ls2h. $ — for fh. SWS.C4S (doc!m%fblll Ind.d.d III Aw $_ ,mov,t yc+ qnv. forth, hespl~l bill? 

, m Y..	 1.. low.,i.d!e.m tb. .u”I ““M of tie h-y-l L!ll .!1.. d.d.=tl.’ xh. SW,-% Wmw.d 4 Cl !!. (17> lok.kh k.,. .y.k.f.. i.tk. . . . . ..t.F.I b,k.hk r. . . . . . . . . .!b . . . ..m..JSn..-.I.S i. q,t.,iou 1, d 1 id, . Pp..,. k. .XP.S.S .!h.r O.. tk. b.sph.l bill.) (17) 

17.. D14 (.1111 hca!lh i.suramc. pay �m>part .$ IA. N... .1 !4..”... PI” DoIi.” ce.t. 

S“,W,+S (d.eloisl b!l 1? -_-210glo--- Ely- ) f 1 b. ~~1~.~~.~~:o~lk.~v=mac: E+JL . . Dld(.!11] any mhoc hmlih I“.”* . . . . ,!.. w 

pm! .i,h. surstds (docfe, -s) bill? BE?::::-.: 

A.k f.r.mc~bdb I..tuan.. PI.. �mcd, tbs. . t. 18b. d. WI., ..s [.111 b.) th..maunt mid by (..me of p1 ..)? 

Enter katal . . ..N p.ld by h..hh in.u=mce i. Ii.. A s.,,. .[ pm.., D.!].,. c..!. 

Fit,, an . . . . . . aid by Saimf SGcu,i,y Medicare lm line B. 

18.. W%* @ 15(will pay $h. %w.c.+s (dnc!.r,s) bill? ‘“ ‘ D :%’W%%”, MOd’a.”, . b. Did (W a) .mf .Ihtr p.rson � SW*CY y .*Y .Ih,,	 -____ (doctor,,) bll~
 --------_pat of ,h. ,ww.#, --_----------BGz”?ir:::. ::~5:’!2:YL’:’Ev-_--- .------


CV !222 f2n2mt fcfti H.) 

‘7A. fdl.wim W,.IIWS � r. mbsut !+. bill fst tbls h..plt.l stq - @ .bwt -y .op<rn. bill fmm 1234 S67S9 

Am docto r., SW,,””. PI-.. l-k ,1 this ecrd (Straw Card H). 10($..1*)7

.ma .f lb.,. sow,.. ,.14., =$: ,92 .“7 �f ht. h.s,ll.f bill? 

b. Did., *II my .IA,, UUIS. WY w .1 W, h.s,ltd bill? 

e !4mh SW?C*? 1d. Oldg::==:-=:Eg:El12;z-E w trlfl m � you f“ifr PV q pm! .1 IAI. b..plhl bill WI �I Y.., � w. ~tk,i? 

,. H-@m~c-b-,-f -h-1~-h~~p~l-olill I dld ., will YO* ~r-Y-q~f-s~~l~-~ ~gt-o-J-~r I . .“” p<k.t? ._*. --!----------------. 

If h.awit,l l,$u~= w90ttd (“3,0 clr&d 1. 88). .Sk , � L.,, OIa,Tt,.lf (9, 

f. W! PWI .t th. b.wild bill ..S �will b. ,44 by h,s,tld I.wmc+, I,ulfmi+f armnbaff �r_? L *fain. - —------— 

If only .3,, i, dr.ld 1.8., **K 

m Old.. “111 b.spltd tmwmme. w �ll �I I+.. h.wild bll!? ,. ,Y *N 

surgical) bill paid by insurance, fiscal years 1959 and 1960,1964,1967, 
--------------------------------------------------------------------------------------------------------------

--

--

--------

--

--

--

3. 

4. 

5. 

6. 

7. 

8. 

9. 

10. 

Hospital insurance or doctor visit


insurance


Workmen’s Compensation


Accident insurance carried by family or


someone outside the family


Armed Forces Dependent Care


(CHAMPUS)


Veteran’s benefits


Medicaid


Welfare


Other (some other source)


seems to be the most satisfactory to date; the 

questions are set up to elicit the kind of information that can be collected on this topic in a 

household interview with some degree of 

accuracy. 

Supplementary questions pertaining to convalescence following hospitalization were added 

to the survey questionnaire during fiscal years 

1961 and 1967, and during the interim period, 

July 1967-December 1968 (figure 13). In 

1961, only those persons who had undergone 

surgery, had a child, or had a fracture set were 

asked - -the convalescence questions that were

added to hospital table II. Only the following 

The questionnaire format of the hospital bill 

payment items on the 1972 questionnaire 

FY 1S61 

F.n completed h..pimIiz.tions (-’No” in Cd. (.rJ of pecso.s 6 years old ..d over who show an opm.cio.,. seuing of. fr.cmre, cr. delivery in CA. (h) or(l): 

ft.w rnmy nl*hts w.,. Aft., . . M the he,. ff “still umj~ in (k> 

g:fpz::~. PM, ow monydnys 

How long ho. 1*b,,. 

tlon d.11-ry, .?.. ?	 %4%%% ST”.. ,.”1.,,,,. .Olviti,, 1“11.tlm? hosplt.al? 

o) (k) (1) 

No. of ni.ghu_ No. d days R%:tm%w 

n Still ur,.ble ~,y— Month. 

FY 1967 I 

.4sK QUESTIONS II. 13 IF PERSOfV/s S5 YE,4m OLD OR OVER (Sfwk o.* circle)— -=;””’” ~;” 

ha. WHEN-- LEFT (Name of hospital/nursing home), II Home -co (. (k,ti.n 12 WASHINGTON USE 

010 NE RETURN HOME OR GO SOME OTHER PLACE? •l Sores o!her p[oce - Ask Q..ati.. llb 119. 

b, WHAT KIND OF PLACE DID --GO TO? (Spscify) + ~ ::% 

INTERVIEWER: � HosPN.I Page Filled (STOP) 

[f lb “Ploce” in 1 lb IS a Hospital, Nwsl~ Hc.ma � HcepNol POW * fillsd (FM H.+.. FO.Wfor .nreportcd stoy..) w a slm{lor PICC., wos o Hospital Poge 

Ilk! fct that stay? (fAurk era box.) 

12, AFTER LEAVING THE f HOSPITAL/ NURSfNG HOME,) HOW MANY OAYS DIO HAVE TO S,tll. w.,z.. ”, o t!... 0% REMAIN IN BED ALL OR MOST OF THE OAY? ( Mark Wry) .,. 00 ,.:, .-. 

.. :.,.; :. 

13. (ALTOGETHER) HOWMANY OAYS WAS_ CONFINEO To THE HOUSE AFTER RETURNING HOME FROM 3<1!4.+.- o km THE ( HOSPITAL/ NURSING HOME.)? (Mark entry) ,:: 0 ,: ::.,: . . . 

.: ::,.., ... . 

14. NOTE TO INTERVIEWER 

If the ccodition in questionS or 6 Is on Card A (A-1, A-2) or B (S.1, &2) or there is ‘f” or morenights in quesffon4b, 

{he condition must have a complelti Condftfonpage. If the conditiondoes not have a Condition page, fill one after 

completingalf requiredHospital pages, .m -: “’ 

CY 1966 [ 

9a. Whan left (nam. of hospit.1/nursing home) did he return home or o some other plac.? 

3 a Home (10) 4 Cl Some other place (J b) ___________________________________________________________ 

b. What kind of pfa.. did g. to? (Specify) 

Interviewer: If the place in 9b is a hospital, n.ming home or similar ptace, was a hospital page filled for that stay? 

m Hospital page filled (Stop) a Hospital page not filled (Fifl hospital page for unreported stay) 

fO, After Icavlng th. h.spit.l (nursing home) how many days did 

have to r.main in b.d all or most of the day? 0000 None XXIU Still i“ bed Ddays 

11. Af.1’OGETffER how many days was confined to the house 

after returning homt from the hospital (nursing hem.)? 0000 )&e xx I u Still co.fimd to house Odays 

Figure 13. Questions relating to convalescence following hospitalization, fiscal years 1961 and 1967, and calendar year 
two items of information about the convalescence were obtained: (1) the number of 

davs before a person returned to his usual 

ac~ivities full ti~e after he left the hospital, 

and (2) for a person still unable to pursue his 

usual activities, the number of days since he 

was discharged from the hospital. During the 

interim period July 1967-December 1968, this 

area of the cmestionnaire was administered to 

all persons 55 years of age and older for each 

hospital discharge during the year prior to 

interview. In addition, information was 

obtained on place of convalescence, number of 

days spent in bed, and number of days conFY 195S 

fined to the house following discharge from 

the hospital. 

Accidents resulting in injury. —During the 

interview, injuries due to accidents are usually 

reported in response to the illness and injury 

recall questions. From July 1957 through June 

1967, there were specific recall questions reIating to injuries occurring during the 2 weeks 

prior to interview week and to the presence of 

>ffects of old injuries. Through ‘fiscal year 

1965, in addition to entering each injury on a 

separate line in table I of the questionnaire, 

the interviewer also completed for each injury 

a “table A,” which described the class and 

TABLE A (Accidents and Iniuri.s) 

Lls&No. 1. Wwl PM .1 lka ti W’S hurl? Whti kl,d 4 lniwy W- N? Anythlms.1s.? �	 Ac.idmt hammed dui.g 

past 2 web 

H 

~ Accldmc happened during 

2. Wbmdld N hQPwn7 Yew _ (Eater wth .1.. if the yes! is 19S? u 1958) Momb p.., 2 weeks 

S. Whw. iii Nm ac.ld.nt ha-? 

n At b- ~~~~dio~~~j~~=h~~~~) r IWbN. in Armed %N!cCS o se C&t place 

4. w... w, buck, bus u Otkw *W WM.!. 

Iav,lvod 1“ tfm ac.ldmt 1“-Y NV? � Ycs n No 

5.	 Wm you ei work e! YSW Iok w bwlnw. whsm 

(g Yes n No a Usdec 14 years., Iimc.[ accident Ii!. -.lAIII IIqmm4? 

:Y 1%5 

T.bla A - ACClDENTS AND INJURIES 

Li&No. 1. Whrn dld *O accldom hopprn? 2. At the time of tho accid.nt, what Prt of th. body was hurt? what kind of Iniury was N? Anything .Ia.? 

Table 1 Yew ~ Pat(s) of body Kind of injury (injuries) 

&;;Cd � ~ 

last week Month Fe ~wme:k 

(Go ;. Q. $) 

3 a. W.. a .ar, tm.k, b... or oyb.r motor vMcl. involwd in th. aceidrnt In any WV? . . . . . . . . . . . . . . . . . . . . . O Yes o No [o. (. Q. 4) 

bWa, mo,e~m~o ~to, v&lcl, Innlv,d? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . mYes(Mm,thu~,) o No 

C.wdslt (.lh.,m.)m”[”gatyh. ilk.? .,...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1=1 Yes o No 

4 c. Whm dld tfw accident hoppm- OYhem, or some OYIW PISCS? 

t a At home (inside bousc) 2 n At home (djacent premisec) m Some .3&c plsce 

ff %mc other plmce,ot ..k 

b.	 M@ kind of place was It? 

3 n Street md I@hway (inclwhs rosdway) 6 � School (inch!dcs school wmkes) 

40FuM 7 � Place of recreation and sports, except at school 

S O fduxrial pIace (include* premises) O� Other (SP.CNY fho Ph.. whor. ..cfd,nt h.P&?,..d) 

S. WermYou at wurk OYyour Iob or business den the occid.nt happened? 

1 U Yes 213N0 3 H While in Armed services 4 = Under 17 at time of accident 

INTERVIEWER: Return to Table I and complete tbe rem of ZMShe. 

Figure 14. Questions relating to accidental injuries (table A), fiscal years 1958 and 1865. 

, 

28 
---------------- --------------------------------

--

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

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

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

place of accident (figure 14). Essentially the 

same information needed to classify the injury 

was obtained each year. However, the 

questions on the 1965 questionnaire were more 

specific and more detailed than those on the 

1958 document. 

Beginning in July 1965, the equivalent of questionnaire table A, a section on each condition 

page, was completed if an injury was reported. 

The questions on the condition page were worded 

quite similarly to those on questionnaire table A, 

and this same format has been used through December 1974 (figure 15). 

A5 � Accident cminjury � Other (NC) 

la. Did the accident happan during tho past 2 yaars or Mom that time? 

U During the past 2 years (20b) � Before 2 years (210) 

b, %~;;~ti;~;;:c~~G; ~;fi;;~----------------------------­

� Last wesk � Over 3-12 months 

D Week before � I-2 years 

� 2 weeks-3 months 

10.	 At tht Nnw of the accident what port of the body was hurt? 

What kind of In[ury was it? Anything �lse? 

Pan(s) of body Kind of Injury 

. 

If accident happenad more than 3 months ago, ask 

b.	 What part of the body IS affected now? 

How is his affected? Is he affcctad in any other way? 

Part(s) of body Present effects 

Wher* did tho occidrnt happan?


t U At home (inside house)


z 0 At home (adjacent premises)


s � Streat and highway (Includes roadway and public sidewalk)


40 Farm 

s � Industrial place (Includes premises) 

6 � School (includes premises) 

7 � Place of recreation and sports, except at school 

s I_J Other - Specifyv 

1. Was -- et work ot his @b or business when the accident happened? 

tY s � While in Armed Services 

2N t � Under 17 at time of accident 

(a.	 Was a car, truck, bus, or other motor vcbicl. 

involvod in tlw accident in any way? lY z N (NC) 

b. Was mere tbms mw vehicle involvad? Y N 

c. Was it (*lthas arm) moving of S%0time? !Y 2N 

Figure 15. Questions on the “condition pagan which relate to 

accidental injury, calendar year 1973 (first part of this page is 

shown in Figure 6). 

As in other areas of the questionnaire, the 

section describing accidents resulting in injury has 

been expanded during certain years of the survey 

in order to obtain detailed information on accidents. During calendar years 1969 and 1970, a 

question relating to objects causing accidents or 

injuries was added. In fiscal years 1960 and 1961, 

and again in calendar years 1971 and 1972, this 

area of the questionnaire was extended to obtain 

information on the circumstances of the accident 

and the resulting injury (figure 16). While the 

questions for the two collection periods were 

quite simikr, the format differed slightly. During 

both periods, the classification of the type of 

accident was made by the interviewer on the basis 

of the description and details provided by the 

respondent. 

Physician Visits. –Two types of information on 

physician visits are collected in the survey. One, 

the number of visits to a physician during the 

2-week period prior to the week of the interview, 

is used to derive estimates of the total number of 

visits during the year for which the questionnaire 

is administered. The other, number of visits during the year prior to the interview and/or the 

length of time since a physician was seen, is the 

basis for estimates of frequency distributions of 

the population according to the annual number of 

physician visits (excluding hospital patient visits) 

and according to the interval since the physician 

was last seen. The development of the questionnaire area on medical attention from fiscal year 

1958 through fiscal year 1964 is shown in figure 

17. 

While information on physician visits during 

the 2 weeks prior to interview is usually considered as a basic core item in the survey, it has not 

been collected continuously in the survey. During 

fiscal years 1960-63, 1965, and the first half of 

1966, no data on physician visits were collected. 

(January-June 1966 data were collected as a supplement. See Vital and Health Statistics, Series 

10-Number 49, p. 4.) However, in January 1968, 

when the person approach method of data collection was introduced for the recalI of illness and 

injury, recent medical attention (during the 2 

weeks prior to interview) was established as a 

necessary continuing item and thus became apart 

of the basic core of questions. While the information on annual visits and the interval since last 

physician visit is not required for the person ap29 

L 
. . .------- ..”. 

Table A. (Accidmts and Inluries) 

L/r~mNo. 1. Wh.n did th. .aceid.mthapp,n? 2. At th. Nm. OFth. a..ld..t, what pm of th. bc+ w.. h.rf? Whrd kind of 1.IWY vm. N? 

AnythlnS .1s.? T.ble 1 l%!fs) of bed, Kind of &iiw(S) rear: I 

(If 1%0 cm1%1 .fs. ems the mcab) .— Accident 

;:;~d 

II Month: week oc week hcfore (00 ,0 q. 3> 

3. (o) W... ..r. fr..kt bus O, d- mow which Inv.lv.d 1. th* o.cid.m t. any way? m Yes o No (0. to S..1Ion B) 

(b) WIJSmm. thm on. motor v.hl.l. I“v.1,.d? � Yes (mme than one) n No 

(.) Was N (*!th*r on*) moving at tht Nm.? � Yes a No (0. 10 S..tfwt B) 

2. m Geuin,g in m out 

4.	 W.ra you outsld. AI. v.hlcl., g.tNng In or out .f N, e p.ass.npw or w“. you th. dtiv.,? 1.0 Outside 3. El P*.=.SS, ~q::)s.=t{en 4. n Driver 

SecfIon A. (Motor Vehicle Accidmts) Swtion B . (Non.hbtor V*hiclc Accidmts) 

ff “Outside’” im q. 4, �sh 7. ffcoW did th. occld.r,t hopp.n? 

5. (a) How did th. sccld.nt hoppcn? Al. D Amy injury involving .n uncontrolled fire m explosion 

1.	 U A..id..t ~~e.. UUtOC~ebi.1. *ad P-... .i~% 2. Cl ~y tiIUY ~.Olvi.g the ~s.~g. of a f~e=rm on bicycle, in streetcti, M railro.d tmin, on horse 

dr.wn vehicle 3. � Any injxy from an ..ciderit involving . non-mmm Tehicle in racsica (su.xcmr, mifmxd 

train, airplane, bmc, bicycle, boz.e-&.wn vehicle) 

2. a Accident between mcca vAicIe �nd pet..aa who was walking, r.dag, LX.t.ading B.4. f=I Any infury c.u.ed by trmchirmry (Mc m amttn &i.em) while i. opemtim 

3.	 n other [SP.C1O h.” I.% .C.id,”t h.ppen,d) 

(SP,.llY kind .1 m.chl”.,y) 

5.	 U Any ini~y ca=,d by ed~e cc Point of knife, scissor., tail e odxr CW& u 

piercing implemerx 

(b) Whof kind(s) of motot v.blel. w.. Iwml..d? 6.0 AUYi.i~r ....~ by f=eisa b~y ~ CYC,w~dpiw ccah= MX.e. 

l.n~ 2. a Taxi 3. m En. ~. U AUYWIY ..~.d by .n~sl = ~S=C 

4. U T,.ck 3. U Motorcycle 6. n Other fsp..,f~j 8. U A.Y f@Y C.US~ by pOi.~~ ..~m.c= .w.llawcd fsmifr ..b*tan..J 

C.9. � Fell on suir’ m stew ct froma height 

10. D All atber falIs 

11. n Bumped into object or pxson (conrs *11collisions between person. including strikfng, 

23 %ctcir,s in or cutS1 *,P.ssengez” u “Dsiver,” in q. 4, ask puncbiig, kiqking, etc.) 

6.	 (a) How dld tiw a;cldant hapf+n? 12. n Struck by moving object (include ck.j.cts held in own band m b.cd of .tba per’.., .lSO 

falling, flying, .x thrown cA@cs) 

1.0	 A..id..c ~cw.e. WI. = m=e motor -bicl.. m tcadwa, 13. = Hu,dfing cc stepping on sharp cu m.gh object. s.cb .s .tcaes, .pfint.r., broken 

d.*s, w+,et.. 

2. U A..ident ~~,cu ~tOC vehi.1= ad ~m= .tb= obje.c	 .xI rwdw,r 14. a Ck.ght in, pinched u crushed between two moving objects ~ between � moving mud. 

station-y object 

(Sp.dfy .bj.oo 

15. � Came is contact with hot cbject m submance c+ OP.XIffur.. 

3. a Motor ~ebicle cmme t. sudden soap on f~dw.y 16. n one-time lifcfn~ w otbcr .xm-titx exezcica 

4. n fdoox rack Ian off mdwty 

17. a Twidng, .rumbIi.g, etc. 

5.	 U Other (SS+.W bow Ifi. . .. Id..t JI.PP...O D. IS. n Other (sp.rdfy how .ccfd..t h.PP...dJ 

m Ace. m m.dw.y 

n A... .Ot m ,08dW*y 

(b)	 What kind of I@.. v.hld. w.r. y.. 1. (g.ttlng I.) (g.tll.g 

.ut of) wh.n th. mcldomthoppsn.d? 

1.0 C.r 2. a Taxi 3. D Bus 

4. U Truck 5. a bfOtKCyCk 6. D Other(SP.clfYJ 

ASK FOR ALL ACCIDENTS 

8. (a) Whet. dld the accld.nt happm--at bomcu maw oths, $X.? 

1. a At home (knside house) 2. a At bomc (adjacent ptmaises) � Some .th~ PI.., 

S3*%UW .xbcr place,” ask 

(b) Wh.t kind of P!.C* W., N? 

3. a Street �nd Mghw.y (include’ romdway) 6. U School fincludm scbo.al ~mf,es) 

4.0 F.IIU 7. n place Of ,..r=tion .nd SPORS, except at scb..l 

5. a lnduxri.I pl.ce (includes rxemise.) 8.0 Other (Smelly th. PI... wh.r. .csld.n, h.pp.”.d) 

9. Wor. y.. OYwork of your 10b or busln*ss vdwn th* accldcnt happ.ncd? 

I. � Ye8 2. � No 3. n While & Armed 2cmices 4. U U.d.r 17 .t time cd .ccidcti 

Figure 16. Questions relating to accidental injury as revised for fiscal years 1960 and 1961, and calendar years 1971 and 1972. 

30 
------------------------------------------------

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

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

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

--

--

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

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

CY 1971 AND 1972 

� Other (A3) 

160. Did the accidant happen during the past 2 ye.rs or before that time? 

D fXtrinE the past 2 years (16b) l_JBefore2ycars (17a) 

b.	 Whondld th*accidenthappen? 

� Lsst week Whattime of day � 0ver3-12 months 

� Week before } was It?_ � 1-2 years 

� 2 weeks-3 months 

170.	 Atthotimc of the accident what ortofthe body wosh.rt? 

Whatkind ofiniuWwos it? Anyt [ mgels.? 

I P,rt[s) of bodv I Ki”dof i“i.rv 

lfaccident happened more than 3 months ago, ask: 

b.	 What port ofthcbody isaffectedn.w? 

Howlshis--affectcd? Isheaffect.d inanyotherw.y? 

Pmt.) of body I Prcs.m elfeccs 

I

f--.-+---­

1 1 

18. Whcrcdld th*accidenthappwt? 

t mAchome (inside house) 

2 � At home (adjacent premi ses) 

I U Street and highway (includes roadway and public sidewalk) 

4 � Farm 

s � Industrial place (includes premises) 

a � .School(includes premises) 

7 i_JPIaceof recreation and sports, except M school 

naother f.%ccify)~ 

190	 Was -- at ~ork gt his iob or busineis when the accident hoppenad? 

lY 3 � V/Me in Armed Services 

2N ~ U Under 17 m time of accident 

20a. Was o car, truck, bus, or .th.r motor vchiclc 

CARD Y 

MOTOR VEHICLE ACCIDENTS 

How did the accident happen? 

Outside motor vehfcle 

1. Accident between motor vehicle and person 

riding on bicycle, in streetcar, on rai Iroad 

train, on horsedrawn vehicle 

2. Accident betweenmotorvehicle endperson 

whowas walking, running,or standing 

3. Other way (Specify how) 

Inside motorvehkle or gettiog in or out 

4. Accident between two or mere motor vehicles 

on roadway 

5. Motor vehicle came to suddeti stop on 

roadway 

6. Motor vehicle ran off roadway 

7.	 Accident between motor vehicle and some 

other object on roadway (Specify object) 

8.	 Other way (Svecifr how) 

CARD Z 

NONMOTOR VEHICLE ACCIDENTS 

involvad in tht occident in any way? lY 2 N (22/ 

b.	 WCISmore than one vehiclo Involved? Y N How did the accident happen? 

. 

c. Was It (ciiher one) moving at the time? !Y 2N I I. Any injury involving an uncontrolled fire or explosion 

21.a. Wttt outside the vehicle, getting in or out of it, a passenger 12. Any injury involving the discharge of a firearm or was the drivw?


I u Outside (b] s D Passenger (c) 13. Any iniury from an accident invcdvi”g a m!nmotor


vehicle in motion (streetcar, railroad train, airplane, z ~ Gemin~ in & out (c) ~ � Driver (c) boat, bicycle, horse-drawn vehicle) 

b.	 What kind(s) of motor vohiclc was involved? 14. Arty iniury inflicted by machinery (belt or motor 1 I-J car (22) 2 D Taxi (22) 3 � Bus (22) driven) while in operation (Specify machinq) 

4 � T~ck W s � f.motorcycle (ZZ) 6 � other (Swih) ..-. 15. Any injury inflicted by edge m point of knife,

:-:. scissors, n ail m other cutting or piercing implement 

C.	 What kind of motor vehiclo was in (getting in or out of)? 16. Any injury inflicted by foreign body in eye, I � Car z n Tsxi 3 � Bus windpipe, or other orifices 4 � Tmck s 0 M-cycle 6 n Other @pecify) 17. Any injury inflicted by animal m insect 

?2. How did the accident h.appwt? 

For motor vehicle accident, refer m Card Y and circle 

number for mswer given. 

If “Outside “ -

1 2 3* (Specify) 

If “Inside” or “Getting 

in or out of” -

4 5 6 7* (Specify object) 

8	 � Accident on roadway 

u Accident not on roadway } (sP’cifY how) 

For nonmotor vehicle accident, refer m Card Z and circle 

number for answer given. 

11 12 13 14* 15 16 17 18* 19 20 21 22 

23 24 25 26 27 28* 

*(Specify) 

18. Any injury inflicted by poisonous substance 

swallowed (Speci~ substance) 

19. Fell on stairs m steps or from a height 

20. Al I other falls 

21.	 Bumped into object or person (covers all co!! Is ions 

between persons including striking, punching, 

kicking, etc.) 

22.	 Struck by moving object (include objecrs held 

in own hand or hand of other person, also falling, 

flying or thrown objects) 

23.	 Handling or stepping on sharp or rough object 

(include wounds from splinters, broken glass, etc.) 

24.	 Caught in, pinched m crushed (i.e., beoveen two 

moving objects or between a moving and a 

stationary obiect) 

25.	 Came in contact with hot obiect or substance of 

open flame 

26. Lifting m other exertion 

27. Twisting or stumbling 

28. Other (Specify how accident happened) 

Figure 16. Questions relating to accidental injury as revised for fiscal years 1960 and 1961, and calendar yaars 1971 and 

1972-Con. 

31

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

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

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

--

Y 195s 

fg Yes O No SO.LAST WEEK OR THE WEEK BEFORE did aoy.n. In th. fmnlly folk to a I WERVIEWEK DDNOTCOUNT doctors,eea doctor or w b o doctot”s office er clinic? whtle . . ,r,p.uent d. . hospital _ No. of times Last Week 

If “Yes,’’-ask: _No. of rhea WeekBefore (.) who was this? Place p~..= 

(b) Anyone �Is*? Hem- = At borne O/T = IN-g. or uem- Phcc Pmpmc -

Off. = At office mat 1 For EACH per.m with “Y..*’ box checked, ask Questions 20S.) dmush (&. ClI.. = Oup.tic.t Nat. = %&St !Mtlf ~ 

(.) How nwny Nrn.s did y.. . . . m talk f.. &.tor LAST WEEK? ~;{:d G,.. = :%,1 check-up (6I How monytim.s did you S- or t.lk to. dncforfhe WEEK BEFORE LASTY a. = ~ompmy or w = k@mu.ww8cc. 3 

Ask for EACH *isit t.s dcctccin I.st 2 weeks: industry EYI =EY e Emrn. 4 1.1. = tier telephc-- . . . ,ss.s) 

(.) WhQC*did ye. tdk to ih. d.cfor Oh. last time, th. Mm. Lwfor., d..)? 0?. = C&r (SP..1’7, . . . l“: “,. .

-.4.4,1 !-? (Sp..lf?) 5 

(dl whydld Y.. g. 10 (..11) th. doctor(that wm.)? ml ~~6 “- ~

0 Under 6 mos. El 6-11 � ., . SS“’N9” to Question 20, *sk: 

21. ABOUT howlongh.. N b.rn sin.o you how SCM w Mksd t. a doctor? No. of yCUS_ ig Never 

FY 19S4 t 

MEDICAL CARZ 

U, I.) SA5Yml!xm INSmm smms did WM. 18 th fmlb - yea mr-., da.. talk or- �NOON to. *tar or m to. *ctOr% .111* a .Ueic? Wm. ~m? 

lf “7*,” 

(b) W mmstzses&rkss tka sast 2 tOck* m, 8YN-

(.) m,im did x tafk ta tb. &ctor? a 2@L 

(d) m. - tlma *t (b, offlm. elialc# �t- )? At. .. ...... .. ..... — 

(MC.,~ t.%.l .wb,r or tlm., 1,, .,ch W. .1 91s!.)	 ACO!ll” . .. . . . . . . . . .. _ 

mm d .11,1 . . . . . .. . _ 

Cmpm ., 1c49t”. . . _ 

cm, I.lohmo . . . . . . . . _ 

CdLlr (*..1 *)....... _ 

i 

L I 

Figure 17. Development of questions relating to medical attention, fiscal years 1958-1964. 

preach, both items continue to be included on the 

questionnaire since January 1969. 

In a similar format to that for conditions, 

injuries, and hospitalizations, questions relating 

to medical attention are asked in two stages: 

(1) the recall of visits fairly early in the interview and (2) the circumstances of the visit on 

the “doctor visit” page. This format, which has 

been in general use since fiscal year 1967, is 

shown as it appears on the questionnaire for 

calendar year 1974 (figure 18). 

During several years of the survey, the 

“doctor \isit” page has been expanded to 

include questions on related items. From July 

1966 through December 1968, information was 

elicited on the amount of the bill (or expected 

bill) for each physician visit during the 2 weeks 

prior to week of interview. In calendar year 

1969, the following three questions pertaining 

to the availability of medical care were added: 

1. About how long did it take to get 

there for the visit? 

2. Did have an appointment for that 

visit? 

3. Once he got there, about how long did 

wait to see the doctor? 

During calendar year 1972, a complete page 

was included in the questionnaire to obtain 

information on the most recent physician visit 

during the past 12 months for all persons who 

had not seen a physician during the 2-week 

period prior to week of interview (figure 19). 

An additional question was included on the 

doctor visit page during 1974 to determine if 

the respondent’s blood pressure was taken during the visit. This question was in conjunction 

with a special supplement on hypertension that 

was administered to respondents in 1974. 

Dental visits.–Dunng the first 10 years of 

the survey, questions regarding dental visits 

were on the questionnaire only during fiscal 

years 1958, 1959, and 1964. Information 

about dental care during the 2 weeks prior to 

week of interview was elicited for all 3 years. 

32 
------------------------------------------------------------------------- --

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

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

--

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

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

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

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

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

--

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

--

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

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

---

--

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

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

-------

RECALL QUESTIONS 

\ d. How mmy wm.s did -- ,I,lt th. doctorduringthot p.rlod? 

1%	 DwlnS M pfod, did onpno In th, family @my m.dlcol odwlc. fwm Y 

, d,cfa, .w, th, M.ph, n,? N (16] 

b. N. ~, *h. ph... ,.11 .kt? - brk w%c.ne all,- box ImVrson% CO!umn. . 

c. A,y .,11s .64 asyon. ,1s.? J (Reosk 155.“4 c1 

If ,qPhme <.!l,,S ,,k 

d, How me,y mlephon. CONSWI. mad. lo ml msdlcalcd,].. abmf ? 

F!ll I!an C, (DOCTOR), lean!9:s 13-15 for all P*lSOnS. b A&Q, 16afar each personwith visits In wCTOR bw. � Pmt”mw (16.) lda. F., who!cnndltiondld .- ,“ or mfk m a doctor dutlngtfw psi 2 wnks? 16- a N. CW.4UM . 

b. Did -- ,“ ., Mb h . alder about,,y ,pelflc .mdllfor,? ---------------. ______-_y---_N_<!p_Jp_J---_­

c. S%.1COndlll.”? . . E“,.? <W~~;~,~ h.”, C 

___ 

d, DU,I,S that ~,l,d, did ,“ w fnfk @ a doctor ak+vt w ok <ond[tlm? d. Y [16c) N (NP) 

� . Lklng ffm poit 2 w-k, W, .Ick k+ca,s. ef Imr prq.mncy? . . ----y--__ -_-N- lI:L ____ 

1. w.! w..*. $Aiw? L E.*, <md],lw in ,f.m C (!6.4 

17,. O,tIW Ih. pst 12 months,(M i. ,1”,, 17. 000I-J My tim in bo.pi”, 

talk in. m,dk.al do<ta,? (Do net countdocta,, _Ii%P%~t%’f%,%r .-m flms did . ,Vrn~ 0,0 � Nm. (lt.l~c ~ ,,,,ti ~. af,wdy told m, Au,.) _ Numb or .3s[” 

-b­

. ASOUT h.w 1,.s ha, w h. ,1.., LAST sw ., Ialktd fo . mcdlcmld.cti,? k. tf-f-kov \ 

, 

2.WEEKS OOCTOR VISITS PAGE 1. 

Earll.r, ye. told m. that -- hsd s“. a tii+.cd b. 

Q&to, du,l,s +h. wst 2 wnks. I 

‘h. O“ what (+.,) dm.s duringth.t 2.w”k pwlod did -- 2.a 

======+ 

e, 

If Hospital: 

Ih. .m.rg.ncy 

Was 

.-? 

it lb. c.wl#9n? .11.1. 

I 

+E?+ If Cllnlc: WosM a hO*FM avtpt!mt 

cl!n!e,. companyclinic, a sow.. .Ih.r 

bind ef clinic? 

b. W.,. ih.m any ,k,, doctor,1.11s for himdwlng q-_-~--------_

o OW$I. ,“P,I.”z 1“ h.s,iul (N... W 

“ .11”!., hospital, dOdW’S offk., M sari. 0; � Pk.? , a km?:, .Ifm (m.p P.”l.. w 

4. Is*, doctora **”*ml p,e.lltl.”.t .,. ,Peci.11.l? 

~ 

5.	 2$lh#J; “lslt (..11) did -- .ctuolly ,- (tilk *) . 

60. why did h. VISII (call) th. doctoron 

===1

, fl Dhz. or.eauam [6,1 - * � Geneml*-M (&b) 

z � Pm c. PO,,”.!.! cu. 

4 � E,. em. (s1.ss.,) 

s � Imnlz.llca (W.- w> 

*m’wl*r _ } 

b. Wqsfbls for my ,pdflc conditlor? Y (E..w cmdltl.n 1.6. N (N.ti W) 

:q”~%%.q, Wlw. 

. ----------------------------—----—-- --------------------— 

Mark boxw �sk m tkdlxlm “FU1.d 1, ti 

G F., whet condttlo. dld ,1s11 +ho dmfor m J@)_ ? e. 

Figure 18. Questions relating to medical attention, calendar year 1974. 

33 
--

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

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

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

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

--

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

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

� 2-week D.V. (NPJ 

12-MONTHS DOCTOR VISITS PAGE 1. � No12-mon,h D.V. (NPJ 

Eodier, you told me th.t had seen or talked to a doctor during the post 12 months. ~ ‘. lnwhatmonth during thepast 12months did-- lo.tvisit ortalkto a doctor? 2. r-t.mol Year 

Where did he last se. the doctor in (month) ,ata


clinic, hc.spit.al, doctor’s office, m mm. other place? 3. ‘oa:h;!,~:;mc } (STOP,


0! � Docto,. safflcm 

If Hospital: Wositthe outpatient clinic (zrwp pract,cc or 

or the emergency room? Do.,.,.. Clinic) 

10 � Telephone 

If Clinic: Wasitahospital o.tpafient 20 � f&;.1 Outr..tleat
 clinic, a company .Iinic, or some other


kind of clinic?
 30 � Home 

4oa HosPltal EmuencyR, wn 

50nC0~~cmy or I“d”stfy 

60 � Other (Specl,$) 

7 

. Isthed.ctor ageneral pmctitioner oraspe.iolist? 4. olm General pr.ct,tloner 

a. Was this visit for emergency care? 

b. Wasthis visit forsurgeV orpreor Postsurgi.al 

a.	 Why did he visit (call) the doctor in (nlo”th) 

Write in reason 

Mark appropriate box(es) 

b. Was fhis for any sptcific cc.nditien? 

Mark box or ask: 

c.	 For what condition did visit the doctor in 

Pleas. /ook at this card - (Show Card H) 

� Specialist - Whm kind of 

sp..la list [s h.? 

7 

5.. lY 2N .-------------------

core? b. lY 2N 

? 60. 

3 � D1.:. .rtreaunent(6cJ 

3= Ge”eral checkup 

2mPceoc Postnatal care 

4 � Eye exam. (zlasses) 

5 � Imm+mtzatlor, (7, 

6 � Other . 

Y(Enwccmd. intq N (71 CIW.7, to ,JDq. 

b. ., Ir,omlen t,,) -__, 

� Condition ,qmrted ,“ 6. 

(month) ? . . 

123456789 

0. Which of those sources did or will pay any of the doctor’s bill for this visit? 7., 10(speci&) 7 

b.	 Did or will any other source pay any of the doctor’s bill for thi. visit? b. lY 2 N (NP) ____ .

c. Which source? c. Circle oddtrlond ,..,.,, in 70 

I I 

CARD H 

1. Total or partial payment by self or fami Iy 

2. Social Security Medicare 

3. Hospital insurance or Doctor Visit insurance 

4. Workmen’s Compensation 

5.	 Accident insurance carried by fami Iy or someone outs ide the fami Iy 

6. Armed Forces Oependent Care (CHAMPUS) 

7. Veteran’s Benefits 

8. Medicaid 

9. Welfare 

10.Other (Some other source) 

Figure 19. Format of the “1 2-months doctor visits page: calendar year 1972. 

1 
In addition, information about the interval 

since last dental visit was obtained in fiscal 

years 1958 and 1964, and about the frequency 

of dental visits during the past 12 months in 

fiscal year 1959 (figure 20). 

Information about dental visits during the 

2-week period prior to the week of interview 

became a standard item in calendar year 1968 

and has been used through December 1974, 

From responses to these questions, it was 

possible to derive estimates of the total 

number of dental visits made during the year. 

During calendar year 1968, with the new 

“person approach” on illness recall, an additional question was added to the 2-week dental 

section for the purpose of eliciting oral or 

dental conditions. These questions were retained through caIendar year 1970. The 1971 

FY 1958 

questionnaire included questions relating to the 

type of dental service received. During calendar 

years 1970-74, data were collected that provided estimates relating to the interval since 

the last dental visit and the frequency of visits 

during the 12 months prior to the interview. 

During 2 years of the survey, fiscal year 

1958 and calendar year 1971, a question that 

provided information relating to edentulous 

persons was added to the questionnaire. During 

1958 a single question, “Is there anyone in the 

family who has lost all of his teeth?” elicited 

this kind of information. During 1971, this 

question was followed by additional ones pertaining to ownership, use, and adequacy of 

upper and/or lower dentures (figure 21.) 

Limitation of mobility. –Information on the 

ability of sample persons to get around freely 

-— 1 DENTAL CABE 

XL y; &z:,nDkor tba wesA btfore did mimim tie aifa m tas demtist? ~ .222? n 109 

..-------J3A!! 

(b) SO, .W tfma arkmg ‘b. B@ z n&’f M.eth 

2s, mat did v ban tin? (1) (2) (a) 

U aor. tbs. .m. .islt: 88 8%5 ti- = Otk 

-W7 

Ztnfmti 

~“~d-’’--’+a ‘i’’” —t f. m 

02SMIU tutk m -r (29-W) 

If ~o,, to q, 21., “P. —=. - _222. 

zf. sOmlmcbs itk8imm Ya-t toa-tfst? Olmskl.. Cffimr 

ad, 1* mm -011 M f-lb* m Ioct all of M- tntk? n s- aw


FY 1959 

19. (o) L-f w-k or th. w.+ b.fom did anmn. In th. fOMIiiYgo 10 a d.n!lst? hYOM �IS*? n Y** Ofde 

u .Y..* ————. _____ _ 

(b) How manyilm.. dwltw *h* PO** 2 w-k.? ~o. of Ciis 

n one n Ike 

20.	 H.w many t!m.. .Itoz+..r 1. th. P..* 12 m.mhs did YOU0.18. d.ntlst7 a Two U FoR.-

0 Nom. 

Y 1964 

18, LAST WEEK OR TNE WEEK BEFORE did anyone in ih. fmily ss to . dentist? = Yes --—. — —-——. o No 

No. of times 

If “Yes,” ash ----— -——. 

(1) (2) (3) 

(o) Mo WOS thl s? m n o Filfings 

o 0 0 Extractions w 

(b) AIlyd”$ �ISO? cdl., .5Urgeq 

o 0 m Scrafghtain 

(ORbcdoncla“$ For each person with “Yes” checked, ask o 0 0 Trestmerd for smuts 

0 U 0 Cfeuzing teeth (.) How many times did y.. visit th. d.nti.t LAST WEEK OR THE WEEK BEFORE? o D o ExtimtioII 

o 0 n Denture work (dl what did you how dome (th. last time, th. time h-for., etc.)? o 0 0 Other (SP.CIW -7 

(c) Anything .1s.? 

If “No” to Question 18, asic o Under 6 MOS. m 6-12 m.% 

9. ABOUT Iwv/ long hm it boon since yO” wont to o dmtist? No. of ycaKs_ o Never 

–~ I 

Figure 20. Questions relating to dental visits, fiscal years 1958, 1959, and 1964. 

35 
----------------------------------------------------------------------------- --- ------ ----

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

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

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

--

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

--

--

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

has been collected on a rotating basis. During 

the first 4 years of the survey, fiscal years 

1958-61, a single question regarding mobility 

limitation was asked at the end of questionnaire table I (figure 22). This question was 

asked only for those persons for whom some 

degree of activity limitation had been reported. 

During the period July 1964 through June 

1967, the next interval during which mobility 

Imitation data were collected, this restriction 

was removed and all persons with one or more 

chronic conditions were queried about their 

ability to move about; also, a question pertaining to the cause of the limitation was added. 

In keeping with the introduction of the “condition page” in July 1965, the format of this 

question changed but the wording remained 

essentially the same through June 1967. During 

calendar year 1971, a concerted effort was 

made to obtain definitive information on 

mobility limitation. Instead of asking the 

respondent to select the appropriate statement 

from a card, the interviewer read the options 

to the respondent and recorded the most suitable degree of limitation for each sample 

Ila. Is thrre gnyone in the family who has lost ALL of hfs teeth? 

b. Who is this? Anyone �lse? 

For each person with “NO teeth,” ask 

c, Does have false teeth? 

d, Does have �n upper plate, a lower plate, or both? ---_ --_------------------a 

the upper .. DoeS USWJIIy )wgr the lower plate(s) while eating? {1 both

:----------------------------------------------------

person. However, this procedure produced 

inconsistent results; therefore, a modified flashcard version was used again in 1972 (figure 

23). 

Control items.–At the completion of the 

health interview, the interviewer turns to page 

1 of the survey questionnaire to ask certain 

questions about the living quarters in the 

sample household. The front page of the 

questionnaire serves the following purposes: (1) 

to provide space for a record of the calls made 

to obtain the interview and the Iength of the 

completed interview; (2) to obtain information 

about the size of the place and the annual 

amount of produce, data that are necessary in 

classifying the sample persons by place of 

residence (farm, nonfarm, etc.); (3) to record 

the number of rooms in the home (not all 

years); (4) to record the telephone number in 

case additional information is needed later by 

the interviewer; and (5) to provide information 

regarding the reason for noninterview in those 

assigned households where no interview was 

conducted. 

For certain years, additional items have been 

Y N (12) 

-H —--- ----, I 

-L’!IDN”’”” ------------_---__- J 

. Y N (NPJ 

� Upper � Both 

d. � Lower 

H 

IIe. Y N

I 

the upper 

f. Does usually wmr the lower plate(s) when not eating? f. Y N 

{} ----------------~-------J----------------------------------------------------+--4--------------------l 

both 11

g. Does need new false teeth? 9. Y (NP) N 

____________________ 

h. Do the oneshe has needrefitting? H h. y N 

Figure21. Questionsrelating
to loss of teeth and use of dentures, calendar year 197’1. 

s 
--

-------

FY 1958.61 

If “1,”
 u “’2”


u “3” card 6


h ‘4.
 (r) ask


NATIONAL 3SEALUI SIIRVSS 

Plras* 

look at W’ 1. Cm fined ta the house =11 the tine, except in emrgencics. 

card md : � 

r cad 

�ach g 2. can go outside but need the helD of another Perscm In 

stuts- getting arcund outside. 

mant 

Thrn .3

A 

t 011 mm which 

stat. 

3. Cm go outside alme but hwe trouble in cettin; around 

freekf. 

m ont 

f its you b .St. 4. Not Mnited in w of these SVS. 

g+&wG) 

r ) 

FY 1986-67 

20. PLEASE LOOK AT THE BLUE CARD, CARD H. WHICH ONE OF t2345bsl.#v 

THOSE STATEMENTS FITS BEST IN TERMS OF HEALTH? MEA statement nmbw + 0000 00 0 

If 1,2,3,4, m S m.ark,d t X. IS THIS 6ECAUSE OF ANY OF THE CONDITtONS YOU HAVE TOLD ME ABoOR .“-’- “’: WASHINGTONUSE ‘ - ‘“ 

in 20, wk: , 

Y“llov 

If6 marked, omit 21 d ~ � Yes+ WHICH? ----------------------$------g------------- 0 0 0 -_--_ --___ g~t<~~g.<g~<~&g. <g”-”&--q~--..”. ”----

@10 M,! pw$om. 1 bhmrn , 00 00 c WNAT ODES CAUSE \ ~ No- ~ls LIMIT~~OH~ .= ,. ;::.;::: E“t,r cm.. 

I 

CARD H 

For: Mobility 

1. MUSTSTAYINBEDALLOR MOSTOF 

THETIME. 

2.MUSTSTAYINTHEHOUSEALLOR


MOSTOF THETIME.


3.NEEDTHEHELPOF ANOTHERPERSON


INGETTINGAROUNDINSIDE
 OR


OUTSIDE
THEHOUSE.


4.NEEDTHEHELPOF SOMESPECIAL 

AID,SUCHASA CANEOR WHEELCHAIR, 

IN GETTINGAROUNDINSIDEOR


OUTSIDE
THEHOUSE.


5.DOESNOTNEEDTHEHELPOF


ANOTHERPERSONOR A SPECIAL
AID


BUTHASTROUBLEINGETTING


AROUNDFREELY.


6.NOTLIMITED
INANYOF THEABOVE


WAYS.


Figure 22. Questions relating to limitation of mobility, fiscal years 1958-1861, and 1866-1967. 

37

--

--

--

---

--

--

--

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

, ~’ ‘: 

?. 

3 (24.)

Please look at this card (Hand respondent Card M) 4 

Which one of these statements fits best in terms of health? (Circle appropriate number) 5‘/ __________________________________________________________________________ .__. 

If respondent does not understand or is unable to read the card, ask questions I Y-23 for each person. 6 (NP) .. 

[9. In terns of health must stay IN BED ~lj or most of tie tjme?	 9. I Y (240) N — 

!0. In terms of health must stay IN THE HOUSE all or most of the time? D. 2 Y (240) N 

!1. Does need the help of ANOTHER PERSON in getting around inside or outside the house? 1. s Y (24.s) N 

!2. Does need the help of some SPECIAL AID, such as a cane or wheelchair in getting around L 

inside or outside the house? — 4 Y (240) N

!3.	 Although do-s not need the help of another person or a special aid, does he have trouble 3. 

getting around freely? s Y (24.) 6 N (NP) 

Ask for each personwith a Iimitation reportedin item M or in questions 19-23: 

(1) hodto stay in bed because of health? 000 � Less chn I month 

(2) had to stay in the house because of health? !40. About how long has 10. 1 —Ftos. 2 _Yrs, (3-4) needed help getting around inside or outside the house? 

{ (5) had trouble getting around freely? / ______________________________________________________________________________ .. b. What (other) condition causes this? b. En fer Co:myayk,; t tam C 

If “old age” only, ask: Is this caused by any specific condition? � Old .;. only (NP) ______________________________________________________________________________ .- ___________________ 

Y ~R:::k, N c.	 Is this caused by any other condition? ______________________________________________________________________________ .’: ___________________ 

Mark boxor ask � Only I condlclon 

d. Whichof these conditionswouldyou say is the MAIN causeof his limitation? d. Enter main conditlcm 

CARD M 

In terms of health: 

1. MUST STAY IN BED ALL OR MOST OF 

THE TIME. 

2.	 MUST STAY IN THE HOUSE ALL OR 

MOST OF THE TIME. 

3.	 NEED THE HELP OF ANOTHER PERSON 

IN GETTING AROUND INSIDE OR 

OUTSIDE THE HOUSE. 

4.	 NEED THE HELP OF SOME SPECIAL 

AID, SUCH AS A CANE OR WHEELCHAIR, 

IN GETTING AROUND INSIDE OR 

OUTSIDE THE HOUSE 

S.	 DOES NOT NEED THE HELP OF 

ANOTHER PERSON OR A SPECIAL AID 

BUT HAS TROUBLE IN GETTING 

AROUND FREELY. 

6.	 DOES NOT HAVE TROUBLE GETTING 

AROUND FREELY. 

Figure 23. Questions releting to limitation of mobility, calendar year 19 

included on the covering page. In most pages, or table A on accidents and injuries, to 

instances, these items were added to remind determine if appropriate supplements had been 

the interviewer to check certain areas of the completed for persons with conditions that 

questionnaire, such as table I, the condition requ;red supplements for a specific year. In 

38 
calendar year 1970, during which the collection of prevalence data on chronic conditions 

was limited to those affecting the respiratory 

system, a household item relating to the type 

of heating and air conditioning in the home 

was added to the first page of the questionnaire. 

Supplements to the Basic Questionnaire 

Supplements to the questionnaire used in 

the Health Interview Survey are of the following two types: (1) rotating supplements, defined as those on the same general topic that 

have appeared during more than one collection 

interval, and (2) one-time or single supplements, described as those that have appeared 

during a single collection interval. As previously noted, some of the rotating supplements were included according to a planned 

schedule; others, originally intended as onetime items, became rotating supplements when 

their timeliness and importance indicated a 

need for trend data. 

In table B, the special supplements are outlined according to type of supplement and the 

period during which data were collected. Some 

of the supplements were included within the 

format of the basic questionnaire, while others 

were on separate documents. In appendixes 

and II, the actual configuration of the supplements is shown. 

Table B. Supplements to the basic questionnaire used in the Health Interview Survey 

Fiscal year Calendar year 

— — — — Type of supplement


I 959 1960 1961 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974


Rotating supplements 

1. Health insurance . .


2. Hearing impairment 

3. Lossof income . . .


4.	 Nursing care and/or


special aids . . .


5.	 Personal haalth


expenses . . . . .


6.	 Prescribed and


nonprascribed


medicines ,.. .


7. Smoking habits . . . 

8,	 Vision impairment 

and useof 

corractiva 

Manses. . . . . . . .


9. X-rey visits . . . . . . 

Ona-time supplements 

1, Acute condition . .


2, Arthritis .,, .,...


3, Blood donorship . .


4. Diabetes . . . . . . . .


6. Hypartanslon ., , .


6. Medical care


availability . . . .


7,	 Motor vehicle


accidants , . . . .


8. Orthodontic care .


9. Pregnancy . . . . . . .


10. Pravantive care . . .


11.	 Specialists’ services


and routina


checkups . . . . .


— — — 

x x x x x x 

x	 ) 

x x 

x x x x 

x x x 

x x


x x x x


x x x


x x x


x x x x 

x 

x 

x 

x 

x 

x 

x 

x 

ooo — . 

39 

I 
REFERENCES


lNational Cater for Heal& Statistics: Health Survey Procedure: Concepts, Questionnaire Development, and Definitions 

in the Health Interview Survey. Vital and Health Statistics. 

PHs Pub. No. 1000-Series l-No. 2. Public Health Service. 

Washington. U.S. Government Printing Office, May 1964. 

‘National Center for Health Statistics: Measurement of 

Personal Health Expenditures. Vital and Health Statz’sties.PHs 

Pub. No. 1000-Series 2-No. 2. Public Health Service. Washington.U.S. Government Printing Office, June 1963. 

3National Center for Health Statistics: Reporting of 

Hospitalization in the Health Interview Survey. Vital and 

Health Statistics. PHS Pub. No. 1000-Series 2-No. 6. Public 

Health Service. Wasldmgton. U.S. Government Printing Office, 

Jdy 1965. 

4National Center for Health Statistics: HeaIth Interview 

Responses Compared WMs Medical Records. “Vital and Health 

Statirtlcs. PHS Pub. No. 1000-Series 2-No. 7. Public Health 

Hlce. Washington. U.S. Government Printing Office, July 

1965. 

5Nationsl Center for Health Statistics: Interview Response 

on Health Insurance Compared Wkh Insurance Records, U.S., 

1960. Vital and Health Statistics. PHS Pub. No. 1000-Series 

2-No. 18. Public Health Service. Washington. U.S. Government 

Printing Office, Aug. 1966. 

6Nationzd Center for Health Statistics: Interview Data on 

Chronic Conditions Compared WMs Information Derived From 

Medical Records. Vital and Health Stat&tics. PHS Pub. No. 

1000+5enes 2-No. 23. Public Health Service. Washington. U.S. 

Government Printing Office, May 1967. 

7National Center for Health Statistics: The Influence of 

Interviewer and Respondent Psychological and Behavioral 

Variables on the Reporting in’ Household Interviews. Vital and 

Health Statistics. PHS Pub. No. 1000-Series 2-No. 26. Public 

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

Mar. 1968. 

8Nationrd Center for Health Statistics: Development and 

Evaluation of an Expanded Hearing Loss Scale Questionnaire. 

Vital and Health Statz%tics.PHS Pub. No. 1000-Seties 2-No. 

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

Printing Office, Apr. 1970. 

‘National Center for Health Statistics: Effect of Some 

Experimental Interviewing Techniques on Reporting in the 

Health Interview Survey. Vital and Health Statistics. PHS Pub. 

No. 1000-Series 2-No. 41. Public Health Service. Washington. 

U.S. Government Printing Office, May 1971. 

l%ationzd Center for Health Statistics: Reporting Health 

Events in Household Interviews: Effects of Reinforcemen~ 

40 

Question Length, and Reintemiews. Vital and Health Statistics. 

PHS Pub. No. 1000-Series 2-No. 45. Public Health Service. 

Washington. U.S. Government Printing Office, Mar. 1972. 

1lNational Center for Health Statistics: Interviewing 

Methods in the Health Interview Survey. Vital and Health 

Statistics. PHS Pub. No. 1000-Series 2-No. 48. Public HeaIth 

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

1972. 

12Nation~ Center for Health Statistics: Reporting Health 

Events in Household Interviews: Effects of an Extensive 

Questionnaire and a Diary Procedure. Vital and Health 

Statktics. PHS Pub. No. 1000-Series 2-No. 49. Public Herdth 

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

1972. 

13National Center for Health Statistics: Optimum Recall 

Period for Reporting Persons Injured in Motor Vehicle Accidents. Vital and Health Statistics. PHS Pub. No. 1000-Series 

2-No. 50. Public Health Service. Washington. U.S. Government 

Printing Office, Apr. 1972. 

l?National Center for Health Statistics: Net Differences in 

Interview Data on Chronic Conditions and Information Derived 

From Medical Records. Vital and Health Statistics. PHS Pub. 

No. 1000-Serks 2-No. 57. Public Health Service. Washington; 

U.S. Government Printing Office, June 1973. 

15Nationrd Center for Health Statistics: Hospital UtWzation 

in the Last Year of Life. Vitaland Health Statistics. PHS Pub. 

No. 1000-Senes 2-No. 10. Public Health Service. Washington. 

U.S. Government Printing Office, July 1965. 

16National Center for Health Statistics: Hospitalization in 

the Last Year of Life, United States, 1961. Vital and Health 

Statktics. PHS Pub. No. 1000-Senes 22-No. 1. Public Health 

Service. Washington. U.S. Government IMnting Office, Sept. 

1965. 

17Nation~ Center for Health Statistics: Episodes md 

Duration of HospitaHzation in the Last Year of Life, United 

States, 1961. Vital and Health Statistics. PHS Pub. No. 

1000-Senes 22-No. 2. Public Health Service. Washington. U.S. 

Government Printing Office, June 1966. 

18Nationaf Center for Health Statistics: E@hth Revision 

International Class~ication of Diseases,Adapted for Use in the 

United States. PHS Pub. No. 1693. Public Health Service. 

Washington. U.S. Government Printing Office, 1967. 

19National Center for Health Statistics: Impairments Due to 

Injury, United States, 1971. Vital and Health Statistics. Series 

1O-NO. 87. DHEW Pub. No. (HRA) 741514. Public Health 

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

1973. 
-------------

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

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

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

. 

APPENDIX 1 

ROTATING SUPPLEMENTS 

The health insurance supplements were incIuded within the format of the basic questionnaire in 

fiscal years 1960, 1963, and 1968 and calendar years 1968, 1970, 1972, and 1974. 

Fy 1960(July-December 1959) 

l,.(.)I hmv. s.-. qw,tl.ns about hwlth I“s.,enc.. W. d.n”t wm”t w I.rl.d. i.s.,onu that P07S 

ONLY h. ..eldonts, bui w. or. lnt.r-t.d 4. ON mh.. kl.d.. . . D. y.., 7.”,---, h“. 

u Y,. I-J No ODK 

l.,uram. tfmt w, UN or ,mr ,1 h MN, wh.. y.. v t. th. Iwsp!t.l? N.me(s) 

U “Y*.,” 

(b) Whor Is * .-!0 .1 Ifw plan (or plans)? Any mh.t plnn.? 

(c)h is -v-d bY this PI- (.o,h Plan) ? 

(Check W-.” in 18(.) dx e,ch PCCS- c.a,er,d\ 

(i) O**. fh. PI- (.lth.r pled psy my Parr.1 th. ,.,S-.’. bill for 

al ..”ml..? I-J Yes o No n 2X 

1?,(.) AM .xeludlng lnsuww. thmf P.7S 0NL% ia accldmls, de you, your--- how lnsumri- O Y., a No igDK 

lh.1 P.YS ON ., POfl .1 lfw bill Io, d+clor” VI.il. M hem at al his OtilC*? If “y..,!) 

(h) Whm Is the ..M .1 fha P!.. (OI pk-) ? Amy arhot Plnns? 

N.LM,> 

(c) Who 1. -v-d by thl. Plnn (-h PIMI)? 

(Check “Yes ,” i. 1X.) fot ..ch Persca co..md) 

E.t.t i. each wsca’. c.alumn.whethm m not h. responded I., him=.lf (W w.*:i..* 18 *.d 19 m Respond-f for self 

RI auf U he did.% (1) show the column number cd the person who responded IW him m (2) tk GA No._was tcspmde.t 

,, 10, 19 (mm tbnt. Fum NH8-3(.) which c.-cd fiIO W*S l*ft. m FOIUI NHS-3 (.) I=fr 

FY 1963


B. (o) I hava sam. questions about h.olfb lnsuran.m We don’t wont to Mud. I. IUFOIIC* that Poy. ONLY for m Yes o No 

accldowts, but wo am In!wostcd In all oflmr kinds. Do you, your . .. CYC.,hav. Insurnncs that paYs all or POIY 

ef tlm bills when you go to ihc hospital? Name of plan($) 

.-

If “YCS,” d3 

(b) Who Is eovcml by hosp[t.1 l.s.ranet? (Check die ‘ ‘Yes” box fn 18(s) fm e.ch person covered) 

(c) WIIOt is th. nom of the plm (W plans)? Any orfmr plan.? 

9, (o) Excluding Insurme. that pay.ONLYfor accidents, do you, your .-, tic. h.v. Insurarrcc thof pays 011 or part of m Yes 0 No 

the surgmn’s bill for on ovratlen? Name Of pk!($) 

If “Yes,” ask 

(b) WiIo Is covmd by I.uwancc for surpaom’ bills? (Check the “Yes” box in U(a) foc each person cowed) 

(c) WhatIs th. nom. of th. Plon (or plms)? Any oth.r plan.? 

a Yes o No 

D. (a) Do you, YOU?-., �tc., havo Insurmco that pays any part of doctors’ bills for home calls and OHICC visits? Name of Phn(s) 

If “Yes,” ask 

(b) Who [. w-ad by Inauron.c fwr doctors’ bills? (Check the “yes” bOx in Ms) fOt each person cOY~ed) 

(c) What Is tlm rmmc of riw Plm (or plans)? Any othw plans? 

(d) Do.. It (.m.h plan) poy far hem. calls and office visits for m..t kinds .f .l.fcII.ss? 0 Yes u No 

41

---- ----

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

--

--

--

--

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

--

--

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

--

--

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

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

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

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

--

Wand CY 1968’ 

These ntxt questions are abaut health insurancs. W* are interested in all kinds of health insumnce plans •xc~t thosr which pay only fur accidents. 

12a. (Not counting SOci.al Security Medicare), is anyone in the family covered by hospital ~ Yes (32b,c) ~ No (32d) 

insumnce, that is, a health insurance plan which pays any part of a hospital bill? ,_______________________________________________________________________ 

b. What is the name of the plan? (Ilccord in Tnbl. 11.[.) _____________________________________________ _________________ 

C.	 (Again not co.ntin Medicare), is anyone in the family covered by any other n Yes (32b,c] n No (32d) hcalfh insurance $an which pays a~ part of o hospital bill? — ---------------- ___________ — ____________ 

d. (Besides Mvdicwrc und the plan(s) you already told me about)is anyone in the family m Yes (.32e,f) n r$ffpjk.s 

covered by any health insurance plan which pays any part of o doctor s or surgeon’s bill? (Complete 

go< Q.33) Table H.1. 

$vrah �. Whet is the namo of the plan? (Ihwmd in Tuhle 11.1.) 

f.	 Do.s anyotm in tht famil y have any other heolth insurance p!on (besides Medicare)? a Yes (32e,f) n No 

} 

If 65 or over, ask: on Und,65(ffP) @ 

33, These next questions arc about Social Security Medicare. Does have o Medicare card? 33, � YMS(NP) � N. (NP) 

If “Yes” for one or more persons in Q. 33, ask:	 Fmra 1 � Hospital 

card: 2 Ofdcdical } NP 34. It would be helpful if I could see (and --) Mdicare card (s) to detwmine what !ype 34. -

of	 coverage he has (they hove). May I please see this (those) card(s)? No 4 nCm’tlOc. 

card: 

(Transcribe the information from tle card or check the appropriate “NO csrd” box.) 60 Other 

For each person with “No” in Q.33 or “No card” in Q.34, ask: 

15& Is covered by that part of Social Security Medicare which pays for hospital bills? 350. c1 y,. DNo 

‘b~~-----------------: covtrcd b that part of Medicare which‘------ pays for doctor7------------------------- s bills, - i< 

that is, the Ma z icarcplan krwhich heorsomo agtncymust pay$3.00 a month? mYes(NP) 0No(N29 

For each person check Table H.1. and Q. 34 and 35 and determine On Covered (NP) 

if ’’Covered” by insurance or frfe.dicareor’’NotC.wered;l by either. n Not covered (36) 

36.	 (Many prnplcdo notcarW healtbinsumnce ~rvarious reasons). 36. 

Would you mind telling me wby dots not have health insurance? ,., ” 

CY 1970 

Thtse nexi �stions are about health insurance. � tJnd. 6S fNP) . 

IF 65 310. Is covered by that part of Social Security Medicare which Pys for hospital bills? IY 2N 9 DU OR OVER, X 

ASIC b. Is cevcred by that rtof Medicare which poys fordoctor’s bills, s Oh 

that is, the Medicare pran for which he or some agency must pay $5.SO a month? b. L;) :!) fNP) 

For each person with “DK” in Q. 31a w b. ask: 

32. Mayl plenses~c --(and ) $ociol $cc.rity Medicaro card(s) to determirw 32. 1 � Hospit*l the	 type of coverage? Zet.tedlcal (NP] 

I fJranscribe the infonnrttion from the card of mark the “Card not seen” box.) I 3D Card not see” } 

We are interested in all kinds of henlth insuranca plans �xc@pt th.asc which p+y only foi accidents. 

(Not counting Medicare) 

33a. IS anyone i. the family ccwrad by hospital Insurance, that is, a haoltb 

insurance Dlon . which ways . . anv sat of a hosDital bill? Y L?lb. c1 . . . _____ .... —.- N (33d) 

b. Whnt is the name of the plan? (Rccfxd in Table HZ.) 

c. fs anyone in the fami Iy covered by any othtr hospital insurance plan? Y (33b, C) N (33d) 

d. Is anyone in tht family covcrtd by a (any other) health insurance plan which 

pays	 any fwrt of a doctor’s or surgeon’s bill? Y N (Cornplef. Table H& 

for each plan. If no :::q:e~ted, go .- ~...., _______________________________________________________________________________________________________ 

�. What is the name of the plan? (Record in Table H.I.: reask 33d) 

TABLE H.1.	 Whi.h members of the fomily W.. Ihi. D... --PO) ,0.$ pay Do.sthispl.an Dc+sthi. plan 

.,. c.ve,.d by (name of i“.”,. ”.. any’ purf of . ny W* of a p.y..y Part PO Ony pmt. 

plan)? plo” hospital bill c@.,,, bill .rg. o.,. bill? of a doctor.. a c?

obmlrmd bi II for .ffic. f., Offl.. VIsn 

“i.!+’ orhom...alls Circle colunm nurnt-ms through . . Call’? whom. aft*ro c*,laln Name of plan	 employer, 

u.ion, or ammmt has 

Is anyone else in the family place of b... paid by 

cover.d under this policy? work? tho fondly? 

3) 5 6 7 

Y (Next pl.nJ ~ 

A YNN N

(1) 

12345678910 

(?.) 1 (4) =l=E . 

Y (NMpl.”) BI ! 12345678910 * YN N y N 

lThe format of thk supplement onhealth insurance wasrevisedseveraf times during theexperimental period, JuIy 1967-December 

1968. The format shown here was according to the final revision dated April 25,1968. 

42 

I 
--- --

----------

--

--

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

--

----------

GT lY/L 

~haso next quastions arc about hoohh insurance. � Und. 65 (NP) ___________________ 

F 65 

)R OVER, la, IS ~ov.red bY that pcrtof S~cIal security Modicore which pays for hospital bills?“ _ 1“. IY ZN 9 DK -—— .-------- — 

\SK: b. IS ~ovarad by that art of M-&care which pays for doctor’s bills, 9 DK 

that is, the Mcdicore pf an for which ho or somo agmrcy must pay a ccrfain amount �ach month? b. ;N:) :N:) (NP) 

For each person with “’DK” in Q. I a or b, ask: 1 � Hospital 

2. May I pleas. sat tho Social S~curity Modicaro card(s) for (and --) to detwminc 2. 2 � Medical (NP) tho fypO of covoragc? 

(Transcribe the information from the card or mark the “Card not seen” box,) 3 � Card not SCM 1 

Wo arc intorostod In cdl kinds of health insurance plans except thosa which pay only for occidents. 

o, (Not counting Medlcarc) ls anyona in tho family cave red by hospital insurance, that i Sr a health 

Insumnca plan which pays any part of a hospital bill? Y (3b, C) N (3dJ _________________________________________________________________________________________________________ 

b, What is ths nom. of the plan? (Record in Table H .1,) 

c.	 Is any.mw in the family covered by any other hospital insurance plan? Y (3b, c) N (34 ______________________________________ __________________________________________________________________ 

Y N (Complete Table H.L 

d. Is anyone ln the family covcrcd by a (any othor) health insurance plan which for each plan. If no 

pays my part of a doctor’s or surgaon’s bill? plana reported, go toIj ________________________________________________________________________________________________________ 

�. what Is the nama of tho plan? (Record in Table H.I.; reask 3d) 

Whichrmmbws cdtha tamlly Wasfhls In*urancoplan Is this plan NOWcarrlsd thmuch To rccslvc SWVICOSundw TABLE H.L are covcrcdby (nzmc of plan)? obtalnadthroughan � gMllp M aS 2n Indlvldual ph? this plan mustye+!and your 

Circle person mmbera amployar,unl.zn,or som famliy go to cwtaln cllnics 

othergroup? m doctors? 

covaradundu Nils policy? 

(a) (b) (c) (d) (e) 

A 12345678910 1Y2?4 9 DK t � Group 2nlnd.9DDK 1Y2N 9 OK 

B 12345678910 1Y2N 9 DK 1 � Group 2 � Ind. 9 � OK 1Y2N 9 OK 

c 12345678910 1Y2N 9 DK t � Group 20 lnd. 9 � DK 1Y2N s DK 

D 12345678910 !Y2N 9 DK 1 � Group 2alnd. 90DK 1Y2N 9 DK 

E t 2345678910 1Y2N s DK 1 � Group 2nlnd.9a DK !Y2N s DK 

Narhe of plan Is anyoneGISOIn tho family 

9W fkls - m dez this plan cy any Ooes this Ian pty Wh4fdoyOU(does—) Whatdoyell (dots —) Wh3nwas tho last tima zny 

w any part 0f l“:fl~azr” &&*if&b,,, ;::fi::~for Ilka mostcboutthis — Ilko lcsst 6bc41t:hls ~cbw of yew fcmlly used 

Mpllal cxpenM3? surnon% bills hc+neCatIS? Ofnc* VISNS2+ for 0watlens7 ham calls afwr a cwtaln amounthas bean paid by tfm 

f2mNy? 

(f) (;) (h) (1) (i) (k) (1) 

plan? — pfan? — plan? 

000 � Nev. used 2_ Wks. 

YzNs DK IY2N9DK !Y(j)2N9DK 1Y2N9DK 3_Mos. 4_ Yrs. 

000 � Nev. used 2_ Wks. 

Y2N9DK 1Y2N9DK tY(j)2N9DK 1Y2N9DK 3_M0S. 4_ Yrs. 

000 � Nev. used 2—Wks. 

Y2N9DK 1Y2N9DK 1Y(j)2N9DK 1Y2N9DK 3—MOs. 4_ Yrs. 

000 � !Nev. used 2_ Wks. 

Y2N9DK 1Y2N9DK lY(j)2N9DK !Y2N9DK 3— Mos. 4—Yrs. 

000 � NOV. used 2_ Wks. 

Y2Ns DK 1Y2N9DK 1Y(j)2N9DK 1Y2N9DK 3_M0s. 4_ Yrs. 

~~ l-? .. / a 

~ [~~orhp’arson, review Q’s. I and 2 and Table H.I. and determine if I 1 � Covered (NPJ 

erad” by either Medicare or insurance or “Not covered.” 2 � Not covered (NP) 

Ask for each person ‘ ‘Ndt covered” I 23456 

(Men P*O 19 do not carry health insurance for various rmsons) 7 (Specify) Whit lRoft 9se ttat9mcnts (Hand Card N) best descfibes why 4. 7 

‘ is not covarad by any boolth insurance plan? Any other reason? Circle al I reasons given 

a. Is trnyono in tho family covorad by an insurance plan which pays any part ,. ,, 

of a dmrtist bill for mutino or regular care? !Y 2 N (41) __________________ ~ _______________________ ________ =, —-. 

b. Which mombors of thg family arg covgred? - Anyono else? 5b. � Covered 

43 
--------------------

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

--

--

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

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

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

----------

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

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

--

--

CY 1974 

HEALTH INSURANCE PAGE 

These next questions are about health insurance. ❑ Und. 65 (NP) 

IF 65 la. Is ~ov=red by that part of Social Security Medicare which pays for hospital bills? 10. tY2N 9 DK 

OR 

OVER b. IS covered by that part of Medicare which pays for doctor’s bills, that is, b. 2N 9 DK 

ASK the Medicare plan for which he or some agency must pay o certain amount each month? :N;) (NP) (NP) 

For each person with “OK” in la or b, ask 2. 1 I_J Hospital 

2.	 Moy I please see the Social Security Medicare card(s) for (and --) to determine the type of coverage? 2 ❑ Medical 

(Transcribe the information form the card or mark the “Card not seen” box.) 3 I_J Card not seen 

--;,’.:., ~ “ ~ 

We are interested in all kinds of health insurance 

plans except those which pay only for occidents. 

4.	 I ❑ Covered (NP) 

2 ❑ Not covered (NP) 

Y N (3d) 

b. Whet is the name of the plan? (Record in Table H.I.) 

c. Is anyone in the family covered by any other hospital insurance plan? 

Y (Reask 3b and c) N 

~ DK ~:, .,.>” ~~ : ,,::$: 

d. [s anyone in the family covered by any. (other) health insurance plan 

which pays any part of a DOCTOR’S or SURGEON’S bill? 4. 1 ❑ Covered (NP) 

2 u Not covered (NP) 

Y N (4) 

●. What is the name of the plan? (Record in Table H.I., reask 3d) 

rEEemployer, union, or some other group? 

b. Does this plan pay any part of hospital ●xpenses? 

c. Does this plan pay any part of doctor’s 

L_-SLZ’?!%?Is ~lls-for~pe,ations? ~ ~h:uw, IML 

I d. Doe. this plan rIav anv Dart of a doctor’s bill for 

_.,?f2,,i:z;:iii::::::::::: ‘:::;;:’’;’”;! 

●. Does this plan pay any part of a doctor’s bill for d. DR. VISIT 1 Y(4) 2N office visits or home calls AFTER A CERTAIN ______________________________ :: i AMOUNT has been oaid bv the familv? 11. a. DEDIICTI 13-E I Y 2N 

I For each person, review I and 2 and 4 for each plan and determine if “’Covered” by either 

Medicare or insurance, or “Not covered.*’ I Rn2’f;NP, 

Ask for each person “’Not covered.” 123456 

Mony people do not carry health insurance for various reasons (Hand Card N) 

da. Which of those statements describes why 

is not covered by any health Insurance plan? Any other reason? --_-__-_____-__---:-----_--------__--_----_________________?::'::!:!:E::!?:!e_ .:. _::::::__---

❑ Only me reason 

Mark box or ask 123456 

b. What is the MAIN reoson is not covered by any health insurance plon? b, Other (Spec/fy)7 

II 

44 

I 
HEARING ABILITY 

w 1963 

HEARING ABILITY SUPF4.EMENTARY QUESTIONNAIRE 

B&,, k“. No. d&R6$Q.2t+ A$+IE.4 Zqlrc. ~ 30. lx 

CONFIDENTIAL. 2’M. infarsmim is collected fcf the u.2- Public Ifedtb S-i..+, .utb~i,z .f P’MIc LV 652 

.1 dm Mth G.OFC.. (70 &.t 42% 42 U.SC. 30s). All infcmaci.an wbkh would per-t Idmul!cx,om of the Isdddwl will be held .tr,.dr .or,fidc.tid, will be used only by pec.on. e. .ged i. d 1-&. -H. of the .mey -d will 

mot & dklmed m ml--d to mhet. f- may othra -.,s (22 f R 1Cd7h 

pm:lNs2.1 

U.S. OLWARTMEMTOF CWUERCC ,“”.. ” ., T“* CK!lsus 

A=,,”. .S C~LLSC’?WO A*UNT VOm ?IIK 

us. � UBLIC RtALTU scnvic~ 

mu 

NATIONAL HEALTH SURVEY ~ 

(HM,IIW Abillfy) 

ml m. OoL 

lameof person for whom cM. form should be filled out 

GENERAL lNSTRUCTfOf4S 

Please .nswer *1I of theq.estions im this form tfmt apply co you. Km of the questionsun be answered 

by checking one of the boxes, like this: ti. In some of the questions, mc+e tfmn on. box m.y be 

checked for your answer. h � few questions, s number (such as age) is �sked for. da � few c.dm?a, 8 

written deacri~ ionof explann!im is required. 

If the pa$m for whom the information is requested is � child, a puenc IX g..udka shcufd saswa the 

quewimm for him or her. 

SECTIONA 

(Pleeac & nut omit my pat of ~esffe.. 1 d 2 . . . . cbo h am, or mom .ffke .IaMImfs xmy not 

qpear 10 be directly related to yew pre8e.t ability Id hem.7 

1.WITNWT using � hearfn~ old, what em YOU km? Yes No 

(-1 . . . . chock the ,8Y..,8 ., a,NamIbe. �ft,, �ach =1.lMwIL> 

I cm hear lourf noises. 

MOMof the time I can tell one kind of noise fcom znother. 

M Xhem a sound, IMSr of the time I can tell if it is . person’s roice of nor. 

1 cm h-a and wrkrstrnds few words. person siys if I CM see his face -d lip-. 

I cm how cad wvdcrsfatd . few words � person s.ys without seeing his face md Iips. 

I cm hcet md u.dwsfmd most of the things � pm says if I cm see his face and lips. 

[CM h-w and mdortfa~ IDOX of the rhinBs a person SSYS without seeing his face and fips. 

Moat of the time I CM fwar ad undasfand a discusaioo between severmf people witbow 

se.i.g their faces ond lips. 

1 c~n hmt ad undcrs~d � telephone con~ersstfrn on an ordinuy telephcme (tb.c is n telephone without nn .mplifier). 

L PI..se descriix how well y.” c.. hesr, wi!hout ..[.s . hd.s afd, by checking .-of the smmmts 

below fat �a-shear. For �xunpl=, a person who is de.f in his left esr ..d h.. -d hcsrin’ in his right 

cm would check the follovia~. fn left �sr. box (dk fn rifit esx-box (e). 

I 

I 

fnldfew I In rlyh? CW t 

(I) ~ \fy hcsrin~ is # : (e) m fdy hearing is@ 

(b) El I h.v. � litde wcuble hearing ~ (0 Cl I h.~s littfe tikde hcnris~ 

(c) n 1 have. lot of trouble he~ing \ W CZ I hive * 10Cof rrcutde hcsting 

I (d) OImo&#d I (h) Clx Mdaf t 

f YOUhcve checked dmt your hecdng is # in kdfh ears - (I) and (e) checked, *kip the quedoas an Pages 2 

md38ndcwm m2ectim Dca Pa~ 4. 

f y.. have say troukh hemrn~ at afl, please p M rnd mswer &e qwc.ti.ws tfm M.= en %pe 2 med 3. 

45 
3.	 ff~” eld WOm you when ye” began te have hrnrins troubl. e, 9MW dtaf? 

(Pt.,., ch,ck the fi,,t box that ,RPN,, end .“1., ye,, ., ,PPr.aPrM..J 

a At birth O I was about —ye- O1d. 

a 1 was less !h.n one ye.r old. U; ~ntt sure, but I know it was before 

_ye.rs old. 

4.(0)	 Since your hearing trouble began, has your hearing gotttn WORSE, has N improved, or IS it [ust about 

tbc SOIM? (PI,.,. ehack one box.> 

~ My hmrin~ is now worse than when 1 first hpn to have hearing trouhlo. 

~ A.y he.cin~ is now b.ttw ch.n when 1 fim k~m to have hearing cm.hle. 

a Pdyhesring is just about th. zamc .s when I first tegan to have he.ring trouble. 

(N you h.., eh,ck,d that yore, he,,fng II,. #ott,” we,’., PI.,,. �new., the following q“m,tlm.) 

(b)	 How old w.r. you wh.n it@ .s poor .s it i, now? 

(Plea,. check th, fi,,t box th,l ,PPNe, end �nter )’..,,, �PPr.aPrMe.) 

m I am not sum, but 1 know it W.S before I was _yC8rS old. 

a Neither of tbe above applies - -it is gemin~ worse �ll the time. 

i.	Wt.ot “as th. caus. of your hearing trouble or ddnass? 

a k W.S cmsed by a sickness, illness or disease, ~ I wns barn deaf or with pour 

What illness? hearin~. 

~ Snr,,etlti”g else caused it. 

~	 It was caused by an .ccidem or injuty. (n,..’, w.,,,,t,e ,,, 

What kind ef inlwy was N? 

POW did N h.app.m? : ~. 1,$.n’c h..... n’hac caused it. 

i. Bcsidct yew h-ring trwbl. or d.afn..s, d. ye. h.v. any .th.. tr..bl. wilh y... . . . . . 

~ Yes ~] No 

II ., Y..,** 

Whet kind ef wovbl.? ,P!.a,. cheek a. EI,ny box., � . .Ppw.j 

~ Noises or ringing in the head or e.r a Dizzfness 

= Earache. or pmins in the e.r n Any ocher trouble. What kind? 

~ Running ears 

‘.(.)	 At work ar lchool and at honw, what am .11 iht W.YI y6. .s. to M other p.opl. wh.t y.. want? 

(Plea.. chink. ,chwy that you .,..) 

u [ talk co thcnl. a I use sign Ia.pge. 

a f write .@es. O%mec.therw.y. H.w? 

= I spell with my fingers, 

(b) Please put . circl. mound th. way you US. A. me,t. 

l.(a) AI work er school ..d at hem., whet m-e .11 th. ways oth.r p.opl. use ie 1*JI yau what they want? 

[Pleaaech,ek �ach w,r,hat the” we.) 

~ They talk to me. n TheyusesignIangtqe. ~ Theywitsnotes. O.someotherway. How? 

G They spell widt ct,eir fingers. 

(b) PIeose put a ciult mound the way thty use ihc mest. 

9.	 ffclVC you �V07 attendad a school orekss far those <h 

poor bsotinq or a schoal or class for tht deaf? m Yes n No 

10, HGVOyou cvor had any tmlning in lip raadlng a Yes n No (spcach reading)? 

1. !hv. yew .wr had any ?mlning in spaoch w $Wtch rcormctton bccauso of your poor bowing �r dcahmss? m Yes UN. 

12. Eavo you �vm had any tmlnlng in haaring (Iossons t. n Yes m No help y.. .ndorst.md batter wh.t you h-r)? 

POW “MS.*, {,.1,.,11 
(The question. in ;hi. section r&f. the . ...{ hewing and..) 

13. Pfavc you Wm trf.d. homing old? l_JYes mNog::eN;j’’ .klp S.#ionDon D.. 

15.	 (c) If YoU hav. a h..rfng aid NOW, +10 chwk hws * m 

AND chd on. of fh. kox.s below h Indl.ato whm you gmt it. 

If yOU IJO NOT hmv. a homing aid NOW, PIM8Q cfmsk h- —El


AND ch~k WI* of tfm kOXOS below Pa Indbah whm YOU yot tfic bt am YOU hod.


Mm	 did YOU get It? 

~ ‘l’his YCU (1962) n Ii -10 years ago 

~ Last year (1961) ~NOrerha. 10yenrs.g. 

m 2-5 years .80 

Therem.ining pmtsof Qnescion 15spply toyourpresent hearing aidifyou haveoocn@w. Ifyoudonof 

have n hearin~ nid now, they ripply to the last henring �id you had. 

(c)	 Whcm arc (wars) tho ompliffcr and bottorbs warn wh- you usc (used) tlw hearing aid? 

fP1 . . . . .h..k o“. b..) 

~ Above the neck ~ Mow the neck 

(.$	 WIIYdid yo. chc+s. Ads (that) parffe.1.r kidd of hwring old? 

(PI...* Ch,ck on. tax) 

11 It wns prescribed by m medicnl doctor m It WASnfbismf by n hearing nid dealer


n It was prescribed bj m hearing clinic ~ time ocher reason (PI . . . . .XPI.I.)


~ A friend or osbcive cold m. .fm.c it


~ I saw it �dvertised


(.) About how long did N Yak. to got usd to N? (PJ . . . . .h.ck on. box]


U Less than one month ~ kbre than six momhs


~ One to six months ~ Ne?et have gotten used m it


16.(0) f)a y.t! usc a hcorkng aid NW? ~ Yes m No $N4;~j **.klp t. S..11.. D.. 

(b)	 %W much & y.” u%. it? (PI..,. ch.ck . . . &z on .ach Ii”.) 00.s NOsc *CC (If y.. d. “.1 work, @ 1. ..h..f, �t.., cheek the **Do., “d “Ot of he ina Newx �pply *, Co rum..) Spply time while 

At work? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

At school? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

At church? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Attherrmvies? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Lissming coradio or TV? . . . . . . . . . . . . . . . . . . . . . . . . 

At home? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , .-

(e) HOW Wdl satisfbd am you With th Acaring aid yOU am now using? (P1.a.. ch.ck .“. doxJ 

~ V.IY well satisfied ~ Fairly well satisfied ~ Not satisfied �t .23 

Q.98*1.. 17 of %ctlw C 0. F%~ 4 

“SCOIM-DC,,$,3..1 
17.wlTwwdlurfngafd# Wilafc= y- had (Pm- Ch*ck MO-.tt or‘,N.l) box dtu Yes Yo ueb statmmtJ HIculfwumdmadmfmd � few WC+3S� pcrsan scys if I csa see his fsce and lips. 

IcMhosc#ad Aomfmd s k wrchs pcraoo IV with- seeing his facesad lips. 

lcmhwdmdwsfmd rmx of khe this@* LXWOUsays if I CMIsee his face and lips. II 

I can h- and wndonfmd moa of tfe thingss pcrsca nys without seeiag his face 

md fip. 

Mm of the time I cm hat and undrrstmd a dkussion het.rern seven] pcepk without 

seeing dmir faces ~d tips. 

I cm h- A Awsfand * tekphcme crnwrsufca on any tele#wae. 

I 

(a) Abe@ how lm~ age was ybur hwring LAST mafd by a rmdlcd doctor? (p[ . . . . ch..k . . . box) 

n l%is yeu (1%2) ~4-5yenrssga 

n LRst y- (1961). ~ 6-10 y,,,, n= 

~ 2-3 years ago ~ %fe thin 10 ycuk ago 

(b) w-s th. docfsrmhokt fcd ywf hmrfng an w SfldOht Of was ho . OMWd fdy dokto,? 

fPIum ch.ck mm box) . 

n fktor who was an e- spe.iafiat n I dcu’t km. 

~ Genersl fmnily dacca 

(cS About hOW�ld wwo YOUA- your hwfq !-s FIRST *sM by � Al-f dsdkr? 

1 was �but — years Ol& 

I dan’c km, fanit -* before I wns_ ye=. 014. 

19.	 Is yOuYIWlljg *shd Mgilldy, * �lllp4*, kn- w 

twk � ma? n Yes ~ No 

Cmmmts - (Ptu.. us. khh .Pa.. or .llach �m addltlonhl .h.*t of paper for an? �ddltl.n.l mm.rka YOU =.7 

ha,. �bout ye., h..tfa~.) 

Name of person who filIed out this form Teleflwrm No. 

*ORM..!-0.1 m.ac.sm “scc+n4-. . ****A 

48 
--

--

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

--

--

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

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

--

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

--

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

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

--

--

--

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

CY 1971 

1.Rccozd the number of Doctor Visits and Hospitalizations. DOCTOR HOSP. 

c —W=2 (NP) 

2.	 Record each condition in the person’s column, with the question numbeds) where it was reported. Q. no. Condition 

I 

Reference dates 

I 

2.week period , P I 

Dentist and Doctor I visit probe I 

I Hospital probe I 

I 

L 1 1 1 I I J 

For persona 19 years old or over, show wbn respunded for (or was present during the asking of) Q.’s s-37. 1 � Responded for seIf-entixely

RI If persons responded for seIf, show whether entirely or partly. For persons under 19 show who responded 2 n Responded for self-partly 

Q.’s 5-37 for them. Person — was respondent 

For each person with an entry of’ ‘A,” “B,’]or ‘’37” in C2, ask Q.’s 3s-41. 

]80 Hos .Vcr “s.d a karing Old? 38. Y N 

Little Lot of Plcaso look at this cord - (Show Card H) Good trouble ,n.auble Deaf 

190. Which stutamtnt best doscribcs ‘5 hcuring in his LEFT car (without o hcuring aid)? 390. In 20 130s 41-S . -------—- L________ 

i 

b. Which statcmmrt hst describas ‘s hwtring in his RIGHT sar (without a hearing aid)? b. II-J zig 13US 4ns 

If under 3, go to 41a 

10tI. (Without a hearing aid) Can “SUtIllY HEAR AND UNDERSTAND whet a person says without 400. Y (42aj N 

sdng his face if that person WHISPERS to him from acro~s a quiet room? 

b.	 (Wl~out o hwr[ng ~ld) can ..- usually HEAR AND UNDERSTAND what a person says without b. Y (41a> ,/ 

sedng his faco if that person TALKS IN A NORhfAL VOICE to him from across a quiet room? —---

~.	 (without a h.aring ~id) can usually HEAR AND UNDERSTAND what a person soys without e. Y (41b> N 

scsing his fncc if that person SHOU~S to him from across a quiet room? -— — — 

d. (Without a Iwaring aid) Can usually HEAR AND UNDERSTAND a person if that persan d. Y (41bj N 

SPEAKS	 LOUDLY into his L@ter �or? ___ ___________________ 

. . (without a hmr[ng aid) Can usually tell the sound of sp+ech from other sounds and noises? --% _ Y (41b) N 

f.	 (Withaut a hcarl~ aid) Can usually tell onc kind of noise from another? f. Y (41bj N _______________________________________________________________________________ ___ __________________ 

g. (without o ~rh aid) can hear Laud noisos? 9. Y f41b> N (41b> 

� At birth


I_J Less than 1 year


— Ye.= old Ila, Haw old was whtn h. began ta havo traublo h.aring? 4l; � DK 

b. � No trouble b. How old was when ho began to IWO serious troublo hearing or bwxwnc deaf? 

Camplete Q. 41c from entty in 41a and b ar age. If “DK)’ in Q.’s 41a and b AND 21 or older, ask: � Before 21 

c. Wag it bdora or aftw --’s twenty-first birthday? .. � Afmr 21 fR2) 

%“ in BOTH ears in Q. 39? A. Y N 

“’N” in Q. 40b? B. Y N 

F 

If “Y” in A or B fill Hearing Supplement after the interview. � Hearfng Supplement 

R2 For persons 19 years old or over, show who responded for (or was present during the asking nf) Q.’s 38-41. I a Responded for self-entirely 

If persons responded z%rself, show whecber entirely or partly. Far persons under 19 show who 2 � Responded for self-partly 

Q:, 38-41 tespanded for them. Person —was respondent 

HEARING 

UPPLEMENT 

;HECK ITEM Number of supplement~. Enter number here and in Item N on Household page. 

49 
CARD H


Which statement best describes your hearing in 

your LEFT ear (without a hearing aid)? 

1. HEARING IS GOOD 

2. LITTLE TROUBLE HEARING 

3. LOT OF TROUBLE HEARING 

4. DEAF 

Which statement best describes your hearing in 

your RIGHT ear (without a hearing aid)? 

1. HEARING IS GOOD 

2. LITTLE TROUBLE HEARING 

3. LOT OF TROUBLE HEARING 

4. DEAF 
-- ---------------------------------------- --------

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

--

-- --

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

--

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

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

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

--

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

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

---------

------

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

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

------

-------

---------

LOSS OF 

FYand CY 1968 

I Ask for all persons with a “Yes” in 36a, 36b, or 36.. Employer If “Yes” in 36c 

only, questions 37a I1 37a, Who doss (did) work fOr? —— ­ throu,qh 97d apply to I Industry c this person’s LAST I 

full-time civilian job. I b. Wh.t kind of business or i.d.sfry ——---—-- is this? —- —-- —- ——— — ------ —-----— —----- Occupation c 

I c. What kind of work is (was) doing? ,---- --e-- -----,, -------------------------—--—---------------—-- -

I Filf 37d from entries in 37a-37c, if not clear, ask: on%t pd. 31goW’n 

I t DGov. Fed. 4mNon-pd. 

d. Class of worker zE!Gov. Oth. 5 l_JNev. wOrke 

INTERVIEWER CHECK fTEhh I 4DNoI in f-ahor FOrce or Under 17 

Ifperson is under 17 years, or not in LaborForce (Q. 37 a-d blank) check ‘“NOt ~ Labnr FOrce.” o � NO work-loss days-in LF Go m next-person 

ff in Labor Force (Q. 37 filled) refer to Question Se and make appropriate entry. aW&;fo.& days — 

Earner you sold thot lost days from work during the post 2 week. - (If self-employed, ask b; for other workers, ask a) ! DYes-.4:k nNo-A:k 

380. was paid ony wages by his employer for the days that he lost? 

z nYes-Ask 3uNo-Ask


,----------------------------------------------------------- b. Do.s h.vc any tnsurnnca that pays him for the Income he lost on these days? ---..-=- *.=-.%” .

1 nYes-A;k Z= No-Ask e. Dldho recelv. hi% full day”s pay for all of these days he lost? d&e ,----- .----4 --.”-

d, In total, how much income did 1.s, because of the days he lost from work? 

� . Is this bafore or after taxes? 

f, f+.w ~u.h does us”.lly .orn per week? $ -. . - ”.,------

g.	 Is thls before or after taxes? t ~Before zaAfter -----. .!.,. -. 

h, Did - - C.C.IW this Incorn. for these days through a sick Ie.ave plan, loss-of-pay Insurance, or some other way? t � .Sick leave plan 

z OLOss+ f-pay insur~ce 

3 mother - Specify 

51 
--

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

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

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

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

--

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

(2V -, 1974 ._. .

Person number ! � Not 5P (E2) #ark one box: 

E1 : ~ ~~~~~;:;w;$;~il. (E2) EZ :: ;:;;:-;:::::;:J 

CURRENTLY EMPLOYED PERSON PAGE 

(Next CE Page) 

Earlier it was reportad that losttime from work during thepast2 weeks. (Hand calendar) 

1.	 Onwhich days during *at2-week period outlined inreddid helosefime from work hcause of illness 

oriniury or becavse hewosn’t feeling well? (Circle all days reported in Table WL-1) 

Hand calendar 

?0. L&ring the post 2 weeks (the 2.week period outlined in red on that calendar) 

“ --lose any(other) time from work because hewassick oriniuredor 

because he wasn’t feeling well? lY 2 N (3) 

b.onwhich days didhelose time from work? (Circle alldays reported in Table WL-1 andreask 2a.) 

3a. (Besides this time) During the post 2 weeks, did he lose any (other) time 

from work to visit a doctor, dentist, or other medical person for himself? lY 2 N (WL-1) 

-. 

b. On which days did he lose time from work for this reason? (Circle all days reported in Table WL-I and reask 3a.) 

Days circled in WL.l? TABLE WL-1 WL-I Y N (7) 

Week before Last week 

For EACH circled day, ask 4a and b Mon Tue Wed Thu Fri Sat sun t-ton Tue Wed Thu Fri Sat Sun 

40. How many hours did he lose from 

workon (day) ?, . . . . . . . . . . . . . . . — — — . — — — — — — . — . . 

Hours Hours Hours Hours Hours Hews HCWS Hours Hwrs Hwrs Hours Hours Hwrs Hours I � Self employed (Ask 40 only) 

1 Full 

b. Will his employer pay him in _____ ______ ______ .-----

full, in part, or not at 0[1 for 2 Part this time lost from work? .----- —--

0 Name 

i 

%. (III addition to his �mployer) Oid or will receive any income from 10ss d pay insuronce 

or income from any other source for al I or part o: this time lost from work? Y O N (6) . 

b.	 what source is this? (Specify) 

7 

If ONLY “Full” marked in 4b, go to 7; otherwise ask 

Dollars ! Cents 6.	 How much income did he lose BEFORE DEDUCTIONS because of this I time lost from work? $ ! 0000 � None 

FOOTNOTES 
------

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

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

--

--

--

--

70.	 (Bcsldes this time you hove iust told me about) During the past 2 weeks, 

did he IOS* any time from work because someone �lse was sick or to take 

somsonc �lso to a doctor, dentist, or for other heolth care? lY 2 N (1/) 

_______________________________________________________________________________________________________ 

b.	 On which days did he lose time from work for this mason? (Circle all days reported in Table WL-2.) _________________________________________________________________________________________________ 

c. During the ptmt 2 weeks did he lose any other time from work for this reason? Y (Red 7b) N 

TABLE WL-2 

Week before Last week 

For EACH circled day, ask 8a and b Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun 

80. How many hours did he lose from 

work on (day)?.. . . . . . . . . . . . . . — . . . — — 

Hwrs Hours Hwrs iim % — HWrS — HWfS — Hwrs —Hwr2 Hwrs Hours How2 Hwrs iizz ! I_J Self employed (ask 8a only) 

1 Full 

b. Will mployer pay him in .----- —-—--- ____ ______ ______ _____ ______ ______ _____ 

full, in part, or not at all for 2 Part this time lost from work? ______ ______ ,_____ _____ ______ ______ _____ ______ ______ _____ 

his �

0 None 

9a.	 (In addition ta his em Ioyer) Did or will receive any incame from loss of pay insurance 

or income from any at Ecr source for all ar part of this time lost from work? Y a N (/0) 

_______________________________________________________________________________________________________ 

b. What source is this? (Specify) ~ 

, 

If ONLY “Full” marked in 8b, go to II; atherwise ask Collars I cents 

O. How much income did be lose BEFORE DEDUCTIONS because af this I 

tlmc lost fram work? $ I 0000 u None 

If days circled in Table WL-I or WL-2 ash otherwise go to 12. 

la. How many days pcr week does USUALLY work? Days _______________________________________________________________________________________________________ 

b.	 How many hours per week does he USUALLY work? Hows _______________________________________________________________________________________________________ 

Dol Iars I Cents 

c. Wlwn he warks hours, how much does he earn per week BEFORE DEDUCTIONS? s I

I 

If “Self employed,” go to next CE; otherwise aslc 

2a.	 When is ill and loses time from work does he continue to receive any wages 

or solary directly fram his employer? tY 2 N (NP) _______________________________________________________________________________________________________ 

b. Under this arrangement is be �ntitled ta a ccrtoin number of days of sick Iaave each yeor? Y a N (NP) _________________________________	 _____________________________________________________________________ J 

C. How many days of sick leave is he allawed each year? Days 

53 

I 
--

--

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

NURSING CARE AND/OR SPECIAL AIDS 

Cv 1 aEa 1 t 8UUU 

SUPPLEMENTARY QUESTION ON PERSONAL CARE AT HOME 

)3. IS tharw orryono In the fomily who mquiros constant help.or nursing care? Is there anyone in the a Yes - Constant a No 

fomily who’rmquireshelp or nursing core only partof tho time, such os help in dressing, �ating, n Yes - Pert-time 

tollot acthdtios, �te.? Condition: 

(Do not record ‘Yes” for normsl care for infsnts or children) 

(a) For whetcondition? —Yesrs — Months 

(b) How long hos he requiredthis core? (Years; or months if less thsn 1 yesr) n Household members 

(e) Whohslps withthis care? o Other relative 

m Trained (registered) nurse 

(Check sll boxes thst apply. If “Other” specify in footnotes) m Practical nurse 

U Other (sps.ify) 

SUPPLEMENTARY QUESTION ON SPECIAL AIDS 

14. Does anyone in the family hove a hearing aid? An artificial armor ieg? A brace of any kind? O Yes n No 

(o) For what cmrditbr? Condition: 

(b) Is it used 011the time, most of tho time, only occrrsionolly,or novsr used now? o All n Occssionslly

7 A whaei ehtrir? Type of &d: 

If -acasionallys or ‘Never used novr,” ask: m Most O Never used 

(c) Why is it thot you rmveruse it? Verbatim 

or 

Why is it thot you US- it only ocaosionnliy? 

FY 1967-68 

If oerson is 55 vears old or river. ask: 

THE FOLLOtiNG (JJEStiONS REFER TO DIFFERENT KINDS OF PERSONAL CARE SOME D Under55 (Stop) 

PEOPLE NEED AT HOME


22a.DOES NEED ANY HELP IN BATHING, DRESSING OR PUTTING ON HIS SHOES? � Yes (Stop) � No


b. OOES -_ NEED ANY HELPAT HOMEWITHINJECTION$SHOTSOR OTHER 

TREATMENTS? � Yes (Stop) � No 

c.00ES NEEDANY ONE’SHELPWHENWALKINGUPSTAIRSOR GElllNG 

FROMROOMTO ROOM? 

-------.-------------------------7c---,i-------------------------------------- -~!!!:!%’!! � No . 

If questmns 220, 22b ard 22c are ~ No ask: 

d. 00ES -- NEEOANY HELPAT ALL INCARINGFOR HIM3ELF? El Yes (StOp) � No 

23a. OURINGTHE PAST12MONTHS, HAS--RECEIVEDANY CAREATHOMEFROMA NURSE’ � Yes (Ask 23b, d fl No (Stop ___________________________________________________________________________ 

b.OURINGTHIS12MONTHPERIOD,ABOUTHOWMANYVISITS DIO A NURSE 

MAKETO CARE FOR-.? ‘-=ac.WEREANY OF THESEVISITSDURINGTHE PAST2-WEEKS? � ’fes � No � DK 

54 
--- --

--

fOyA-NU#HIS.2 (FY 67) Bud&et But.,. NO. 68-R160(


U.S. DEPARTMENT OF COMMERCE AppmvsI Expire. Match 31, 1961
 BuREAu OF THE CENSUS


ACTIN. AS COlleCting AcENcy FOR THE 

U.S. PUBLIC HEALTH SERVICE 

HOME CARE SUPPLEMENT 

Name of person Person No. Age Psu Segment No. Serial No. Sample 

B


FOOTNOTES 

Name of interviewer Code Respondent No. 

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 released to others for any purposes. 

For each ‘“Yes, ” answer to la, Ask: 

Earlier in the interview you mentioned that --needed help of No Yas i
 some kind hero at home. I am going to read a list of different lb. Who helps ? I Does anyone else help ? 

kinds of parsonal care some paople need in the home. Please 

tell m. if nacds help in any of the following ways. I


I
 la. Does --need help -
 ~ in walking up stairs orgetting from roomto room? — 

Undressing orputtingorr shoes? . . . . . . . . . . . — I


I
 Does --need help - I
 —
 in bathing (shaving) or ether toilet activities? I


Ineoting orhaving meols served in bed?. . . . . . — I


Dams --nerd help - 1 

— I with changing bandages? . . . . . . . . . . . . . . . . 

— I in receiving infections? . . . . . . . . . . . . . . . . . 

with othertreatments?. . . . . . . . . . . . . . . . . . I


I
 If ’’Yes,’’ask: What kinds oftreotment? I


I
 Specify


Dbc$--n.. d help - I


i
 —
 in changing bed positions? . . . . . . . . . . . . . . .


In �xerci sing or physical therapy? . . . . . . . . . . — I


incuttingtoenoi}s? . . . . . . . . . . . . . . . . . . . — I


I
 Dois--gct any OTHER help or care here at home? . . . .
 ~
 If “Yea,” osk: What kinds of other help or core?
 —
 I


~ Specl f y 

IF PERSON IS NOT RECEIVING CARE	 (All “No’s” to question la), reconcile differences between answers in Q. 22 or 23c and Q. la above or describe 

the situation cmthe front of this form. 

Z, For ~hat ~ond[tlon(s)does-- receivethis help or care?
 —. \ Specify condition(s) I

--

--

--

--

--

-- -------

�

3. HOW long has received help or care at home? Mark one box: a I month or less n Over I to 6 months a Over 6 to 12 months 

n Over I to 3 years I_J Over 3 to 5 years D Over 5 years 

DAII of the time 

4. Because of - -’S heolth, must someone be in the house with him D Part of the time all of the time, part of the time, or only when providing the 

needed help or care? n Only when providing the needed help or care 

For each person, other than a nurse, listed in lb, ask: Determine the ty~e(s) of person(s) 5a. IS a nurse, a physical therapist, or some other kind of health worker? providing the care in question 5 

If “Nurse” reported in Q. I b or 50, osk: and mark appropriate box in 

5b. Is the nurse that cares for a registered nurse, a practical nurse, or some other kind of nurse? \ column (1) of Table H. 

., ‘TABLE H $. 

During the past two weeks, About how many hours a day does receive Is (relative, nurse, 

on about how many days help or care from (relative, nurse, �tc.)? �tc.) paid for theso did receive help or core services? “ Type of persons providing care from (relative, nurse, 

tc.)? 

(2) (3) (4) 

(1) Daya Don’t know Hours Less than I hour Don’t know Yes No 

NON-HEALTH A. n Related household members WORKERS 

B. � Related persons not in 

household 

C. a Friend or neighbor 

D. a Other 

Specify 

HEALTH


WORKERS E. I_J Nurse - Registered


F. a Nurse - Practical or other 

G. n Physical therapist 

H. 1=1 Other -<- .,~t, 

Specjfy 

INTERVIEWER: M2rk the n Person 65 + and “’Yes” in column (4). Ask Q% 6,7, and 8. 

OPProPr;Ote box before 80inE-+ D Person 55-64 and “Yes” in column (4). Ask Q’s 7 and 8. 

to Q’s 6-8. ~ All “No’s” in column (4) or only “A” checked in column (1) of Table H. Skip to question 8. 

6. Are any of these services paid for by Medicare? m Yes U No D Don’t know 

70. Who pays (the remainder of the bill) for these services? n Self or family = Agency or organization 

b. Anyone �lse? ~ Other relative or friend 

(Visiting Nurses Association, etc.) 

a Welfare 

a Health insurance D Other - Specify 

n Yes - Ask 8b D No - STOP 

8a. During the past 12 months. has received any care at home from a nurse? __________________________________________ ____________________ 

Number of visits 

b. During the post 12 months, ABOUT how many visits did a nurse make to core for --? 

FOSM NH$-H192 {PY $71 (12-12-061 U~COMM.OC 
CY 1969
 . .. -,,.
e.
 i aoie 3A 170. DO*S anyone in the family now use any of the following special aids - I 

I If l-d in (b), ASK: If 3-9 in (b) ASK: 

PerE&l ?;; 

Yes No 

(a) (b) An artificial arm? . . . . . . . . . . . . . 

A.artifi.iol 

Abra.eof any 

leg? 

kind? 

. . . .

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

. 

EEL Crotches? . . . . . . . . . . . . . . . . . . . 

A cane or walking stick?.. . . . . . _ -. 

Sp.ial shoes? . . . . . . . . . . . . . . . 

A wheel chair? . . . . . . . . . . . . . . . . 

Awnlker? . . . . . . . . . . . . . . . . . . . . 

Any.other ktnd of aid for 

g.ttmgorotmd? . . . . . . . . . . . . . . . 

]f ‘iYes;; specify: 7 

For what condition does Dye:::e; ho need this_? @em C) 

(c) (d) 

10 

4-J 

Other — 

~n 

2U 

Other — 

la 

4-J 

Other — 

HOW W8S the-obtained? Was it purchased, 

rented, borrowed or a gift? 

(g) 

1m Purchased 2D Rented 30 Borrowed 40 Gift 

1a Pnmhased 20 Rented so Borrowed 4D Gift 

1 � Purchased 20 Rented SU Borrowed 4D Gift 

57 

l. 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

9. 

, b. Who is this? her in Table SA 

c. Anyone �lse? 

Is the—used all the time, most 

of the time or only occasionally? 

(e) 

I 

I 

Table 5A - Continued 

How tang has he used—? 

(f) 

D Less than 1 month 

_Months — Years 

a Less than 1 month 

— Months — Years 

D	 Less than 1 month 

_Mcmths _Years 

IUA1l Zn Most 3D Occasionally 

tnAll 2D Most 30 Occasionally 

lj_JA1l 2U Most so Occasionally 

I 
PERSONAL HEALTH EXPENSES 

FY 1963 (July-December 1962) 

Owur. w US. DEPARTMENT OF COMMERCE mdg~tBUW NO: IWR620.6 

THC DIRECTOR BURSAU OF THE CENSUS Approval Expires July 1$ 1%3 

WASHINGTON25,D.C. 

FORM NHS.6(C) 

(4.2-s2) 

Dear Friend:. 

The Bureau of the Census, as collecting sgent for the U.S. Public Health Service, is 

conducting a special survey on the cost of medical care. This study, when combined 

with other information, will serve to answer important questions about health and 

medical care costs in ourNation. 

The Census interviewer who called at your household was asked to leave this form in 

order that s1l of the family members csn tske part in answering these questions, and 

that bills, receipts, and other records can be consulted. If you cannot supply exact 

amounts from bills or records, please give the best estimate you can. 

We would appreciate your completing this form and mailing it back to US within five 

days. A self-addressed envelope which requires no postage has been provided for 

your convenience. 

Yourcooperscion
 in answering these questions will be a definite public service. The 

information will be given confidential treatment by the Bureau of the Census and the 

[J.S. Public ‘Health Service. Nothing will be published except statistical summaries. 

Thank you. 

Please return completed form to: 

U.S. Bureauof the Census 

1st F1. NW Section 

536 S. Clark Street 

Chicago 5, Illinois 

Phone:Hakrison7-7fj23,
 Ext. 523


Sincerely yours,•

Richard M. Scammon•

Ditector•

E3ureauof the Census•

CONFIDENTIAL . This information is collected for the U.S. Public Health Service aader authority Of 

Public Law6520fthe 84th Congress (70&dt. 48~42U.S.C.3O5), Allinformation whkhwouldpetmit identification of the individual will be held strictly confidemisl, will be used only by persons 

engaged in and for thepruposes of the survey, sad will not be disclosed or released to others for my 

orherpurposes(22FR 1687). 

uscolm.Qc 11711 P-es 

58

GENERAL INSTRUCTIONS 

10 The name of each related member of the household has been 

entered on a separate page of this form. Please fill all 

sections of each page for each person listed. 

2, The specific period we are asking about is the 12 month 

period from to . 

3.	 In enteritrg the total medical expenditures, count all bills 

paid (or to be paid) by the person himself, his family or 

friends 

directly 

himself, 

amount 

the total 

4. Please 

and also any part paid by insurance, whether paid 

to the hospital or doctor, or paid to the person 

or to his family. If you do not know exactly the 

paid by insurance, estimate it, and include it in 

bill. 

do not count any amounts paid (or to be paid) by: 

Workmen’s compensation


Non-profit organizations such as the


“Polio 

Charitable 

MHitary 

Veterans 

Federal, 

Foundation” 

or Welfare Organizations 

Services, including Medicare 

Administration 

State, City, or County Government 

5.	 If there are any babies in the household who were born during the past 12 months, the hospital and doctor bills relating 

to the baby’s birth should be reported on the page for the 

mother. All other medical expenditures relating to the baby’s 

health should be reported on the page for the baby. 

6. After completing all sections of this form for each person in 

the household, please indicate below the name of the person 

or persons who filled it out. 

1 2 3 4 

FOR 

OFFICE 

USE 

ONLY 

FORM NHS.6(a) (4-2-62) 

59 
COSTS FOR MEDICAL AND DENTAL CARE DURING THE PAST 12 MONTHS 

FROM: TO: 

PLEASE ANSWER THE QUESTIONS IN EACH SECTION BELOW FOR: 

Name of person 

lFEXACT AhtOUNTS ARE NOT KNOWN, PLEASE ENTER YOUR BEST ESTIMATE. 

DOCTORS’ BILLS 

l.tlowmuc hdidallo fthedactors’ (incltrding surgeons’) bills forthis person come toduring thepast12 months? 

Besura tocomrt alldoctora$ billa for: ~“] NO doctors’ 

bills 

Operations Check-rrps Pregnancy csre Laboratory fees Immunizations or shotfi 

Trestmmrts Deliveries X-rays Eye examinations Any other 

doctors’ services r 

HOSPITAL BILLS 

2. (a) Was this person in a hospital (nursing home, rest home, sanitarium, etc.) overnight or longer during the post 

12 months? 

D Yes~ n No (Go to Q.e.tion 3) 

(b) How much did all of the hospital bills come to for this person for the past 12 months? 

Be mrra to count all froapital biJ1a for: 

Room and Operating snd Anesthesia x-rays Any other


board delivery room Special treatments Tests hospital services $


MEDICINE COSTS 

3. About how much was spent for medicine for this person during the past 12 months? 

Be sure to caant costs for all kinds of medicine whether D No costs 

or not prescribed by a doctorj such aa: for medicine 

Tonics Prescript ions Ointments An other 

Pills Salves Vitamins me $“Icme 

~ 

, 

DENTISTSS BILLS 

4. How much did all of the dentists’ bills far this person come to for the past 12 months? 

Be aura to cmwrt all dental bills for: n No dentisrs* 

bills 

Fillings Cleanings Bridgework Straightening Any other 

Extractions X-rays Dental plates of teeth dental services 

F 

1 

SPECIAL MEDICAL EXPENSES 

5. How much did the bills come to for this person during the post 12 months for: 

D None D None Special braces D None 

or trusses, 

Hearing Aids? $ Corrective 

shoes? $ 

wheel chnirs or 

artificial limbs? $ 

OTHER MEDICAL EXPENSES 

6. Enter any other medical expenses incurred during the past 12 months which are not included n None above, showin the kind and amount of expenditure (for example, emergency or outpatient 

treatment in a 1 ospital or Clinic). (If no other medical experwes, check the “NrmeS* box.) I . 

Kinrk $ 

PSU No. Segment No. Serial No. I Colmrm No. FOR OFFICE 

USE ONLY 

I 1 I I I 

FORM NHS-6(S) [4.2.62) 
FY 1966


U.S. DEPARTMENT OF COMMERCE 

BURSAU OF THE CENSUS 

WASHINGTON. D.C. 20233 

BUDGET BUREAU NO. 68-R620. t2 

OFFICE QF THE DIRECTOR APPROVAL EXPIRES AUGUST 91, 1966 

The Bureau of the Censns, acting as collecting agent for the U.S. Public Health Service, is 

condtrcting a special survey on the cost of medical care. This study, when combined with the 

other information which you have jnst given our Census interviewer, will serve to answer important 

questions about health and medical care costs in our Nation. 

The Census interviewer who called at your household was asked to leave this form in order that 

all of the family members caa take part in answering these questions, and that bills, receipts, and 

other records can be consulted. If you cannot supply exact amounts from bills or records, please 

give the best estimate you can. Please read the instruction on page 2 before completing this form. 

We would appreciate yorrr completing this form and mailing it back to us witbin five daya. A selfaddressed envelope which requires no postage has been provided for your convenience. 

Your cooperation in answering these questions will be a definite public service. The information 

will be given confidential treatment by the Bureau of the Census and the U.S. Public Health 

Service. Nothing will be published except statistical summaries. 

Thank YOU, 

Sincerely years,


A. Ross Eckler


Director


Bureau of the Census


NOTICE -. All information which would permit identification of the individual will be held strictly confidential, will be used only by persons engaged frt and for the purposes of the survey, and will not be 

disclosed or releaaed to othere for any other purpose. 

1 I 

FoRM NHS-HIS-lC (FY 1966) USC OMM-DC 

( 12-6-65) 

61 
GENERAL INSTRUCTIONS 

1. The name of each related member of the household has 

been entered on a separate page of this form. Please fill 

the 4 questions on each page for each person listed. If you 

cannot give the exact amount from bills or records please 

enter the best estimate you can. 

2. In entering the medical expenditures in questions 1 

through 3, count all bills paid (or to be paid) by the person 

himself, his family or friends. Also include any part paid 

by insurance, whether paid directly to the hospital or doctor 

or paid to the person himself, or to his family. If you do 

not know exactly the amount paid by insurance, estimate it, 

and include it in the total bill. 

3. In figuring the total doctor, hospital, or dentist 

not count any amounts paid (or to be paid) by: 

Workmen’s compensation 

Non-profit organizations such as the 

“Polio Foundation” 

Charitable or Welfare Organizations 

Military Services 

Veterans Administration 

Federal, State, City, or County Government 

bills, do 

4. If there are any babies in the household who were born 

during the past 12 months, the hospital and doctor bills 

relating to the baby’s birth should be reported on the page 

for the mother. All other medical expenditures relating to 

the baby’s health should be reported an the page for the 

baby. 

1 2 3 4 

FOR 

CENSUS 

USE 

. 

FORM NHS-H!S-lC (12-6-65) USCOMM-DC 

62 
--

Please answer the following questions for ~ 

The 12-month period referred to below is from to 

IF EXACT AMOUNTSARE NOT KNOWN,PLEASE ENTER YOUR BEST ESTIMATE 

DOCTORS’ BILLS 

HOW much did all of the doctors’ (including surgeons’) bills 

“ forthis person come toduring the past 12manths? . . . . . . . . . . . . . . . . . . . . . . . . . . $ m 

Be sure to count all doctors’ bills for: u No doctors’ bills 

Operations Check-ups Pregnancy care Laboratory fees immunizations or shots 

Treatments Deliveries X-rays Eye examinations Any other doctor’s services 

HOSPITAL BILLS 

!a.	 Was this person in a hospital (nursing home, rest hame, sanitarium, etc.) 

avernight or longer during the past 12 months? 

D Yes a No (Go to question 3) 

b.	 How much did all af the hospital bills came to far this person for the 

past 12manths? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . s“. s””” .””$ m 

Be sure to count all hospital bills for: 

~lgrm and Operating and Anesthesia X-rays Any other 

delivery room Special treatments Tests hospital services 

DENTISTS’ BILLS 

1. How much did all of the dentists’ bills for this person come to for the 

past	 12 months? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...””” .“”s.””””ss c 

Be sure to count all dental bills for: D No dentists’ bills 

Fillings Cleanings Bridgework Straightening Any other 

Extractions X-rays Dental plates of teeth dental services 

DOCTOR VISITS 

L During the past 12 manths, how many times has this person visited or 

been visited byamedical doctor? . . . . . . . . . . . . . . . . . . . . . . . . . . ...” . . . . . . . . 

~ 

Count: 1.	 All visits to a doctor’s office or clinic for consultation, m None 

shots, x-rays, or for any other medical purpose. 

Z. All doctor visits made to the home. 

Do NOT count: 1. Visits to dentists. 

2.	 Any visits made to this person while he was en in atient for one or more 

nights in a hospital. (However, please note that t1 e bills for such visits 

should be included in question 1 above.) 

i. Name of person completing this page 

;omments 

FOR 

:ENSUS USE 

, ,.c.l””. ----.. ”.. ec >RM NHS-HE-IC (12-6-65) 

63 
CY 1971


DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE 

PUBLICHEALW sERvlcE 

HEALTH sERVICES AND MENTAL HEALTH ADMINISTRATION 

ROCKVILLE, MARYLAND 20852 

NATIONAL CENTER FOR 

HEALTH STATISTICS 

SURVEY OF FAMILY MEDICAL EXPENSES 

r 1


L -l 

ASSURANCE OF CONFIDENTIALITY: 

AN infom.! l.. which would parmlt Id..tlfi..tl.. of . . individual, or of.. .stabllshm. .*, will be held c.. fid..t1,l, 

will b. .s.dcmly by p.r.ons .ngag.d I. and forth. purposeofth. .u,v.y, .nd will be pr.t..t.d ag.a!n.tdkclos.r. 

i.accordmc. with provlsLms.f42CFR P.rtl. 

HSM-503-2 O.M.B. No. 68-S71011 

3-71 APPC.V.I Expires: 9-30-71 
READ AND FILL THIS PAGE FIRST 

Please list below the -s of each farhily member NOW living at home beginning with the Head of the family. 

Relationship to S.* Person’s .9. . . 

Name. of Family Members Family Head <Check one) last birthday: 

1. Head Y..,. old 

2. years old 

2. yeors old 

4 y..,. old 

5. years old 

6. w.rs old 

7. Ye.rs .Id 

8, m,, old 

9.	 c Female m.,. old 

U Mole 

10. � Female years old 

Are any family members now living at this household on full-time active duty with the Armed Forces of the United States? 

(Check one box) 

� No E Yes 

4

I Who is this? 

N.me of Faml [y Vemt,er f 

//’ Nom. of Fomi IY hlernber 

What is the highest grade or year the HEAD of the family completed in school? 

(Circle one)	 Elementary: 1 234 5678 

High School: 9 10 11 lZ 

college: 12345+ 

Besides the family members that you have listed above, is there myone else Iivi”g withycw now, such as frie”ds cwroomers? 

(Check one box) 

� N. (0. to nextpage) n Yes 

1 

Pleose list below the name of each person not related to you who is now Iivi”g 

at this household. 

Nomes of Otho, Persons 

3. 

4. 

5. 
The term “THIS FAMILY” in each of the questions on the following pages refers to all members of your family that you have 

listed in Item A on the page to the left. 

During 1970, that is, from January 1, 1970, to December 31, 1970, how much did THIS FAhflLY spend on health insurance 

premiums for plans that pay for any part of a hospital bill or a doctor’s bill? 

Q. I* 

Amount deducted from p.ycheck for healfh insurance premiums ~ Or Amount deducted from Social Security check for Medicare 

� This family did not pay any Amount paid directly to health insurance plans or to .soci.l .%.urity for Medicare 

i.sur.an.e premiums 

D.~ot i“.l. de: 

Health insurance plons that pay only in *h. case of accidents 

Employer or union contributions 

2. During 1970, did THIS FAMILY pay any medical expenses for any person who is NOT listed in Item A on the page to the left? 

This might I“cl.de expenses for children “.w away at school or par.nm, other relatives or friends now in n.rsi”g homes or .Is.wher., 

or who are deceosed. 

The.. exp.uses may include bills from dot?. r., d.”tists, optometrists, hospitals, “.rsi”g homes, heolth insurance premiums, cost of 

prescription medicine, eye glasses, and s. forth. 

(Check . . . box) 

Amount This Fomily 

TYPE OF MEDICAL EXPENSE P~id \ DOLLARS , CENTS 

$ 

DOLLARS 1CENTS 

$ 

OOLLARS IcENTS 

s m 

3. What income group best describes THIS FAMILY’S total combined income during 1970? 

(Check . . . box) 

c Less !hm $3,000 c :7,CC[J- ;9,999 

r-j $3,030-$4,999 p $)(I,{LC - $[4,999 

H $5,fM0 -:6,999	 c $ J+,L~6 - $24,99’? 

u W,cm+ 

4. Please print below the name of the person or persons who are completing this form. 

Nom. 

N.. e 
FILL ONE PAGE FOR EACH FAMILY MEMBER NOW LIVING IN THIS HOUSEliOLO WRITE IN THE PERSON’S NAME BELOW 

BEFORF ANSWERING THE QUESTIONS ABOUT HIM: 

+ 

The following medical and dental expenses were for 

Wrife i. Name of Family hfembsr 

All questions on this page should be answered even though the person may not have had any medical or dental expenses in 1970. 

If the person did not have any expense of a certain kind during 1970, be sure to make a mark in the “no bills paid” box. The 

amounts you give below should only include what THIS FAMILY paid, NOT any payments made by health insurance or some other 

person or agency. Do not include payments you made if health insurance has or will reimburse you. IF EXACT AMOUNTS ARE 

NOT KNOWN,PLEASE ENTER YOUR BEST ESTIMATE. 

INCLUDE am.unts spent for: 

Cleanings S$raighte”ing Dental surgery FJridg.w.ark 

Fillings x-ray % Extractions Dental I ob.r.t.ry fee. “’~=”~.fi~ w 

PAYMENTS MADE FOR “OTHER” MEDICAL BILLS 

&z Howmuch didTHIS FAMILYspend onother medical expenses forthis per.ond.ringl97O? 

~ 

D. not i.cl.de any expenses which yo. h.v. .lre.dy r.c.rded. Donor i“cl.de amounts spent for 

medicines of any kind. � No mn;;nt paid for 

these items n INCLUDE am.unts spent for such expenses as: 

Chlroproctor.”or Podiatrists’ fees Physic.1 or Speech Thermpy 

He.rin .id Speciol n.,sing core 

Specl. i’ broc.s, +russ. s, wheelchair Nursing Home or Convalescent 

or .rtific ial limb. Home care 

6b. What type ofmedical expense didthis person have? 

Type .fMedicol Expense 

7. Check oneofthe following boxes: 

� R. f.rr.d to reeords for .11 dollar mno.”ts entered .“ this page. 

� R. f.rmd to r.c.rds for some but “o, .11 doll.r amounts en,.md .“ this page. 

~ “id “.,,.1.,,. any records. 

67 
-----

--

--

-------

-------

-------

-- -------

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

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

PRESCRIBED AND NONPRESCRIBED MEDICINES 

FY . 1$)65

Uew I h.v. SOS+.QJ..Nens .kout Pvfcb.swsof medl. in.. Firs+, I WF+Wto ask ye. okout nudiel.es pr..crlbd by. decte+ 

h e. LAST WEEK OR THE WEEK BEFORE, dld .nyon. 1. MO fomlly buy w .kfalm any kind of modl.in. Pmscrikwd by. docwr? 

D Yes ~ No (0. 1. I?. z7J 

If a,Ycs,l* ..k: 

b.	Whet IS th. nom. of th. nwdl.1..? (Enter rum. of medicine in column (.) of Table P. 22name is uaknowr., �nter ‘IDKOh column M d 

.sk Whaf . ..dltion is i! for? Then eater tb. condition in column (b).) 

c. LAST WEEK OR THE WEEK BEFORE, did anyeno buy or obfal. any OTHER mdlclrn pms.rlhd by. doctor? 

I=i Yes (Re-a.k Q. 16b> ~ N. (2W1 mm.hlad .or.mn. et T.bl. P for . ..h m.dtm.. mP.rt.d2 

TLUS to Cud J, md .Sk 

7.	 m. LAST WEEK OR THE WEEK BEFORE, dldaw-.ln lh. f.mllybW wobtalm mm.dlcin. NOT 

v...rtb*d bdodt.r?r? Thf. (~.w~J) t.. lI.t.f SOME .f*. $tmslntil.h w..mint.r.st.d. 

D Yes � N. (O.,o Q. 18) INTERVIEWER 

If “Yc*,”~ ask %@rmcm.$, cu 

%o.ditiorm,, . . ~rd A 

&M.tlslh~-dth.mdlelm? (E.krnm, akhd.fme&ctic hcoIm(.).f T.bk~.) reponedinq.e.cian 

0,17, shoufdbec,rded 

e. USTWEEK OR THE WEEK BEFORE, dld.nym. hy.r.til..~ OTHER dl.l.. HOT~xerlkd~ed.tir? bxkm T.ble I iftbcy 

do rm .Iready .p~.~ UY.S (R*-.*k Q.17bS ON. fF1lI,.m.lnl.d c.l-..IT.bl. NPfo,..ti m.dl.fn. "Po,t.a cbem. 

g 

nblo P -PRESCRIBED MEDICINES 

Ntm. of �edicine,, Whew, if pmsc,lkmd f.,? Wbl.h -k w.. th. --bought, Wfmf candlNon IS tho for? (X”t.r a.fum” “Wlb., LAST WEEK—orlhm gf::ti:f:4k;~=:R:,.?’” 

(b) of SYcy) BEFORE LAsT? {d) 

U L.,: wmk 

-Eizo:e?-a: -(=6s 

U L.,, week 

-65 ZO:,-2;F*<7CTCP7 

.*x ==k -6O E:b7e1;:&:-(fi6ti 

0 L,. -A ~20;,;-=-&:-(rT;6 

WEEK .W mvch(e~d N cost 

cdl.,, I cent, 

U Weekbef-are I $ 

n Week bda,, I 

t 

u W.* before I 

I 

m week before , I 

Wh.m was it boug+i? 

(0 

, b!. NP - HOHFRESCRIBEO MEOICIHES 

Whm 1s rh--- Whl h Nur.e of medicine u.md fw by Z# “’””Y p:;l.f~; which w-k w.. tb. --kw,h,, 

(ff n.me i, uak.ow:,, enter fomlly? Il. -.% LAST WEEK—* *h, WEEK 

the kind of u,ed,c,ne) (E”,., ..1. “e.. BEFORE LAST? .r myc~) (.) (b) (d) 

= Last week o Week b,f.,. 

0 Before 2 weeks (STOP) 

Oust week o Weekb,f.m _______________ 

11 Before 2 weeks (sTOP) 

O L.,, “&k o Vmk bcfmc _______________ 

m B4m 2 weeks (STOP) 

O L.., week o Week before 

n B40m 2 week9 (STOP) 

) I 

How m-h dld 1?coat? 

(e) 

Dollars cents 

n Dtus s,.= m Othu (+..1{,) 

$ 

: 

I O 

n 

Grocay StO~ 

Mail oxier b.... 

I O DIUS ,wm u Otb.r [~.cIf,> 

I a Gr&eIY ,,mc 

s I n M1l ode, house 

i 

I 

= 

n 

DCJSstow 

Grocery s,cf, 

u Otbecr~+) 

$ n M*G order ho”.. 

I ~ Dnx store m abet (zpccl&j 

m Glomy store 

$ I n WII .*, bmti 

I 

Card J Medicines fnr eye, ear, or nuse cunditioua 

Vitamins 

Tonics or blood builders 

Pain reJievers, such as aspirin, headache powders, etc. First Bid items 

Remedies
 for colds sod other respiratory conditions, Antiseptics sach as cough medicine, GOSSdrops or sprays, EEC. 

AJlergy remedies Medicine fix digestive conditions or upactG, such as 

antacids, laxatives, etc. Nonprescription tranquilizers, sleeping piJls, nr 

%ray awake’> pills Remedies for skin or muscular conditions, such as 

ointments, salvea, linfmefkts, etc. Any other nonpzescfiption medicines 

16 
------

------

------

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

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

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

CY 1973 

FIRESCRi BED MEDICINES 

la.	 During th. past 2 w..ks, (thc 2 w-ks outlined in red on that calender) did ony.ne in the family, (that 

Is you, y Ir --, �tc.) buy or obtain anY (other) kind of medicine prescribed by a doctor? Y N (2). b. What i. i ,-n;;; ;f-t~; ‘=~i;~n-e~ ‘~;t= ;;m-a-;f-m-e-d~c;;e-;n-c;;.-(~)-;f-T-a-b~e-fi ‘~-~ ;;k; ‘ 

What con Non Is N for? Enter name of condition [n cot. (c) and reask I a. 

(Boald,a I* prescriptions you bavo already told me obout) 

2a. ~a:laf post 2 weeks did anyone in the family get any (other) medicint from o pharmacist or drugstore 

.sctibcd by a tdephcm. call from a doctor? Y N (3) 

b, What iS i ~;n-m-c;~;h-c-m-c~;c;;o~-~;t;; ;a-m-e-o~-m-e~~c~;e-i;-c; ~~;)-o~%%;e 'M-;n~-a; ~:--------------------------------------------"

What COn tlon is N for?. Enter name of condition in cd. (c) and reask 2a. 

(B.sld., It prescriptions ou have already told me about) k.	 Durl”g tl past 2 weeks diJ anyone in the family —-----b.ve any (other) prescription. refilled? Y N (4) ~----------------------------------------------------------------- . b. %k7i;i name of the medlcfne? Enter name of mediclne in COI. (b) of Table M and ask 

What con Non is N for? Enter name of condition in co!. (c) and reask 3a. 

(B,sid.s m prescriptions you have alrcudy told me about) 

(w During tt past two weekt did anyone in the family obtoin any (other) medicine directly from a doctor to toko at hemc? Y N (Table M) 

b, What iS ( tnam. of them.dicine? Enter name of medicine in COI. (b)of Table Mand ask 

What con Iionis it for? Enter name of condition incoi. (c)and reask 4a. 

TABLE M: omplete columns d-k as appropriate for each prescription listed. If none listed. ao to next Daae. 

I	 W.stfm --ebt.in.d last HOWw.. this medicine obtained - fhrougb week or the wrnk before? a wriffen prescripti.m, a refill, acallto J“e Q&s	 the pharmacist from the doctor, given 

by the de.tor to take at home, or was it 

obtained in some other wny? 

(d 

= I � DK 

A; s El in Past 2weeks. DKw+tich 3 � Call to the pha,nmcist

so Dr. recomme~,ded(not prescribed) 

i 4 I ~ 

TABLE M - Continued 

who WES this DLItin th, post How much did O, wiil you w yOU, Did m will may Wh.t (ot+er) sour.. paid w will What WOS th iotal cost of this prescribed for? 2WU i s>h.w family pay for this medicine? other SWIC* Pily Ony P@ cd fhi, m.dicin.? tidi.i~, including thcomount 

. ---- many dif fcrcnt Iftwoor more times in col. (I). oav mw of the Enter approprlmr. to b+ paid by all sourcas? ,er. person numb. . adt Include the w.! omouiTfor bi[l for’this I*I$ 

(f) 

t � Free from doctor (NfdJ


q@&a&al*imwance ssss � OK


t � Weifare (Incl. Medicaid) Dollars I Gilts 

Per,sonNo. — � Other - Specify .g * , 

= 

69 
--

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

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

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

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

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

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

---

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

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

SMOKING HABITS 

FV 

, , 1,“--

CIRWW““ 

t+awI have . few questions about snwking ~ ““d:,,,,,,, 

For each person 17 years old or over, ask: 

18. 0. Have you smoked at least one hundred cigarettes during your entire life? 0. n Yes m No (0. to 21) _________________ If “yes,” ask: 

b. D.ri.g the pericxl when you were smoking the most, how many .Ig.atettes a day did you .s..ally sm.ake? b. P,, day OR P.: week 

19. 0. Do you smoke cig.mette. now? 0. n Yes m NO(QO 10 20) 

If “Yes,” ask questions 19b AND 19.. If *‘No,” go to question 20: 

b.	 On the overage, about how many cigarettes e day do you smoke? b. Per day OR PCCweek 

a Smne n Didnh smoke c. Twelve months ag., how many cig.mettes a day were yo” smoking? 

c. per day OR Per week 

... . . . ., .,. Go to free, tlon 21 ,, .. .. ,, 

If “No” co question 19a, ask SOTH questions 20a AND 20b: = None 

10.	 a. On the average, about how many cigarettes a day were you smoking 12 months ago? 0. P,, day OR Per week . 

b. How long has it been sfi”ce you smoked cigarettes fairly cegularly? 

b. month, OR ye,,, 

For each nml. 17 years. old or ovec ask questions 21 ANO 22: m Fem. or under 17 

21.0. Hove you smoked at Iemst 10 cigars during your enNra life? a. m Y,. a No (Go (. 22) 

b. O.a YOUsmoke cigars now? b! O Yes (Ask c) n NO (A,k d) 

If “Yes” co 21b, ask: Per Per 

c.	 Ab-aut how many cigars m day do you “swIIy smoke.? c. -dy_-. -o@-@ 

If “No” to 21b, as!c nm”tbs _ OR Y,.,s _ 

d. About how long has it been s 1... y.. smoked 3 or mwe cigars a week? d. m NEVER smoked 30, mm. a week 

22. a. Have y.” smokmd at Iaost 3 packages of pipe tobacco during your entire life? 0. m Yes O No (STOP) 

b. Do YW smoke . pipe now? b. I_J Yes (A.k c] n NO [A.k o 

If “Yes)* to 22b, ask: Per 

=. About how many plpefuls of tobacco a day do you usually smoke? =. _ *Z....O: - -E;.k-- . 

If *’No” to 22b, as!c months _OR years_ d. About how long has N been since y.” smoked 3 or more pipef”ls o week? d. m NEVER smoked 3 or m.,. , week 

70 
--

--

--

--

--

--

--

--

--

--

--

--

---

--

--

--

.

--

--

--

--

--

--

SMOKING PAGE 

Person No. ComDlete Smokina . Pane.– for :h person 17+ years of age. 

Now, I hove a few questions about smoking: 11, Has smoked at Ieost w cigars during his �ntire life? 

1. Hos smoked at least 100 cigarettes during his entire life? lY z N (17) 9 DK 

3. 

lY 2 N (11) 9 DK 12. Does smoke cigars now? 

2, Doss smoke cigarettes now? lY 2 N (14) 9 DK (14) 

1 Y (5) 2N 9 DK 13. About how many cigars o day does usually smoke? 

If less than 1 per day: 

—No. of completed years (4,9) 90 n Never smoked regularly (11) 99 ~ DK (15) 97 � Less than 3 per week 

How long has it been since smoked cigarettes fairly regularly? —No. per day (15) 96 n 3 to 6 per week (15) 

99 � DK (8) 00 � Under I year (8) 14. About how long has it been since smoked 3 or more cigars a week? 

4. For years 1-10 ask: Which of these statements (Hand Card S) were _No. of completed years (17) 00 � Under I year ~16j reosons decided to stop smoking cigarettes? Please give me the 97 � Never smoked 3 or more per week (17) 99 a Don’t know 1 number of any statement that applies. Circle number. 

15. What size cigars does usually smoke: fu[l. sized cigars, the small 

I 2 3 4 S 6 7 8 9 10 II 12 13 (%=ify)~ cigors sometimes called cigarilles, or the very small cigars about the 

Any other reason? size of a cigarette? 

If more than one circled, ask: What was the main reason decided i n Full-sized 3 U Cigarette size 

to stop smoking cigarettes? 2 � Cigarilios 9DOK 

Enter the number of the main reason (9) 16. Twelve months ago,obc.ut how many cigars a day did usually smoke? 

5. On the average, about how many cigarettes a day does smoke? If less than 1 per day: 

—No. per day 99 DK —No. per day 96 � 3 to 6 per week 

97 � Less than 3 per week 

6. What size cigarette does usually smoke: regular size, king size, 99 � DK 99 � Did not smoke or	 �xtro long? 

... -‘,. . . . .. . .,, “,., I � Regu tar 2 n King Size 3 � Extra long s=DK 17. Has smc.k“’”ed at least 3 packages of pipe tobacco during his �ntire life’ 

7. Does usually smoke filter or nonfiiter cigarettes? 

t � Filter 2 � Nonfilter 9DDK lY 2 N (22) 9 DK 

18. Does smoke a pipe now? 

8.	 On the average, about how many cigarettes a day was 

smoking 12 months 090? lY z N (20) 9 D K (20) 

—No. per day 98 n Did not smoke 99 � DK 19. About how many pipefuls of tobacco a day does usualiy smoke? 

9.	 During the period when was smoking the most, about how many —No. per day (ZI) //less than 1 per day: 

cigarettes a day did he usually smoke? 9s � 3 to 6 per week (21) 

_No, per day 99 DK 99 � DK (21) 97 � Less than 3 per week 

20. Abmrt h,,w long has it been since smoked 3 or more pipefuls a week? 1.	 About how old WOS -- when he first started smoking cigarettes 

fairly regularly? 96 � Never smoked regularly _No. of completed years (22) 00 � Under I year 

_Age started smoking 99 � DK 97 � Never smoked 3 or more per week (22) 99 � DK 

Z1. Twelve months ago, about how mony pipefuls a day did usually smoke{ 

If less than 1 per day: 

—No. per day 96 � 3 to 6 per week 

97 

---–- m Less than 3 per week 

99HDK 98 � Did not smoke I 

22.	 Does presently use any other form of tobacco, such as 

snuff or chewing tobacco? ,, :“ Respondent for Q%, I-22 1 I-J snuff 4 � Other INTERVIEWER t � Responded for self-entirely z � Chewing tobacco 9DDK iCMECK ITEM 2 � Responded for self-partly Person —was res I anNo Fill Interviewer Check Item 

CY 1974 (See Hypertension Supplement, Appendix 11, p. 114.) 
------ ------ ------ ----- ------

VISION IMPAIRMENT AND USE OF CORRECTIVE LENSES 

FY1963 Bud&etBum.uNo.68-R620.@A ppmvalE xpiresJ.1Y15,1964 

$~ya~H5.HIS. I(b) U.S. OEPARIWENT OF COMMERCE 

� UREAU OF THE CENSUS Name Of p-On Age 

Psu Segment Serial No. Sample 

VISION SUPPLEMENT B1NATIONALHEALTtfSlfRYEY 

Column nutnber of person . . . . . . . . . . . . . . . . . . 

n Responded for self 

OR 

Column number of respondent . . . . . . . . . . . . . . . 

NTERVIEWER Complete m”fher5ccilon A orB 

Complete Section A (buff Pages 2-6), if: 

(a) Both “Yes” and ‘“No” in answer to Columns (c), (d), a“d .(e) of TabIe B 

OR 

(b) ‘“Great deal’’ or’’Some” inanswcr to Column (j)of Table B. 

Complete Section !3 (blue Wages 7- 10), if: 

“No” in answer to all of Columns (c), (d), and (e) of Table B. 

RESPONDENT RULES FOR WS1ON SUPPLEMENT 

f theperson forwhomtiw Sision S.~pplcment istobecomp!etcdis an eligible respondent according totheregular efigiblerespon. 

len:ndes, heistorespmtd f~rhimsclf. Iflieis noratbome orothcmisc notavailable, make arrangements foraretm canto 

ntervicw him. (Two additiontil calls toconcact him may be made.) 

f the person is not anelisible resp~ndent, nrisunzble torespond forhimself because ofdisaMlity orillness, complete tbehtem 

riew with any eligible respondent for him. 

EXCEPTION TO RESPONDENT RULES FOR VISION SUPPLEMENT 

f the person is an eligible fesponc!ent for himself, but definitely is not going tobe available for intetview at any time during 

ntetview week, complete the interview with any other eligible respondent for hint. In sucha case, explain the teason for the 

]se of the other respondent in a footnote. 

Footnotes and comments 

cOm- 2 com- 1 pleted pleted 

RECOROOF RETURN


CALLSTOCOMPLETE Date


SUPPLEMENT n None


Tme 

Nameofintemicwer Code 

CONFIDENTIAL . This information is collected for the U.S. PubSic Health Service under authority of Public Law 652 of the 84th 

Congress (i’o stat.485%42 U.S.C. 305). All~fOrmatiOn which wOuldpe~it identification Ofthe~divid~l wi1lbeheldstfiCtIy 

confidential, will be used only by persons engagedin and fortheputposesof thesumey, andwill not bedisclosed orrcleasedto 

others for any otbcI purposes (22 FR 16B7). 

USCOMM.DC 15188 P.#S 

72 
---

.Section A 

QUESTIONS DEFINITIONS 

a, Did your troublo with sdngcomesuddenlyordid itcomegmdually? ‘Suddenly’a would be either instantaneously .xin a very 

n Suddenly short time, usurdlyassociated 

withan injuty. 

n Gradually 

n At bictb (GO to Q..ation Z) 

b. If8’Suddenly’’0r’’Gradua fly,’’ eak: “Daily activities “.rne.ans the 

Age person’s usuel actmmes, 

depending on the age of the How old wers you when your trouble with seeing FIRST began person at the time. to Interfers with your daily activities, tbut is, your work, 

mcmotion, education, or travel ? . . . . . . . . . . . . . . . . . . . . . . . . 

i (Under 17- Go to Qu..tion 2) 

a Never interfered (GO to Que.tfon 2) 

If a,ge in lb ia 17 or ovar, ask: 

c. Waro you working at a [eb or Iwslness before you began to hovo 

trouble with seeing? 

n Yes m No 

If over 12 months, round to !. 

�y. Spcicd ist? u ward, e.~., “1%” years sI ould be recorded as “2” 

n During the past 12 months _Years I_J Never years. 

If person ia wearing $Iasaen mark thfa box j_J and ask 3b. 

If person fa not wearfng glasse.?, ask: 

When were your eyes lost examined by a physician nearest year; round % years 

a. At the presant Nit+ do you use any glasses.. that is, 

ordinary glasses or special glossax os lenses? 

D Ye. (A.k Sb) = No (Qo to Que.tiOn 4) 

If “YL96’*or if pereon is weating glaasws, ask: 

b. Whet types of glasses do you .USO or wear? 

� Ordinary glasses for distance and for reading 

n Ordinary glasses for distance alone 

n Ordinary glasses for reading alone 

D	 Spectacles with strong reading additions (such as bifocals) 

n Hand magnifying len5es 

a Protection glasses (dark or fmsred) 

n Any other type (SPO.MY) 

Footnotes and comments 

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

Mark each type -reported. If unable to class;f by type, 

mark last lmx an i descr~be. 

USCOM4.DCWto8 ?4s 

73 
--- ---

QUESTIONS DEFINITIONS 

. Do YW s-o things as if you w-m looking through a tub+ or a gun barrel? Persons with this type of 

visual defect (“Tunnel 

a Yes D No Vision”) will understand 

the question 

o. ~causo of your trouhl. s-ing, do you rnvar us. any aids ●ither in 

@tlng around tbo housa or in tmvelin outsids tho housa; such as 

a can., guide d% or a pmsm with sigt t? 

a Ye. a NO (Go to Q...tn.n 6) 

If “I%*,** aak: 

b. Which do you us.? 6u.rk each o.. nm.tion.dj 

n A cane (If m.rhd ●sk Q.e.:ior 5b(0


n A guide dog (If m.rk.d ..k Q...tIon 5b(2)


a A person with sight


n Other fsP..ffY)


If cane used, aak: 

(1) ~~n~~i~orc~:fny special instructions in tmlng or g9tting 

n Yes n No % Pecial instructions:’ means 

If gufde dcg used, aak training by a trained msttuctor 

(2)	 Hava you wor had any SIMCIOI instructions in tmv.ling with 

suidc dogs? 

I_’J Yes U No 

n. Have YOU war hoard of talking book mccmfs? If the supplement person is a 

child, 6a refers towhegber the 

U Yes a NO (Go to Qu.,tkm 7> respondent ever beard of talking book recordsi 6b to whether 

’Yen,” aak: the child is recemog them. If ●

b. #t#I&:~\w am you gatting talking bock m.otds of any kind 

n Yes n No 

a. Havo you war had any instruction in reading bmille? 

n Yes n No (Go to Qu..t1on 8) 

If ●’Yea,** aati 

b. Can you mad bmlll.? 

m Yes n NO (G. to Qu.mtf.n 8> 

Zf ““Yea,’* aak 

c. At& pmacnt tinm ON YOUreading books III bmilla? 

m Ye. m No 

‘JC4110CCSarid comments 

..— ..- . . . uscOM*Oc 1818B Pea 

74 
QUESTIONS DEFINITIONS 

Bat During an overage week, about how m.ny hors do you spend No. of hours If answer is not reported in hours 

watch ingorllstening to television ?..... . . . . . . . . . . . . . . . . . . . coqverc to hours. “An average 

week” is whatever tbe person 

considers to be a typical week. n Don’t watch or Iisren (Go to @e.tlon 9) 

No. of feet If tb.e answer is “Quite close” If some hours reported, ask: (Approximately)	 or something similar, ask ebout 

bow many feet that would be. b. When you am watching television, how close to the screen do you 

have tositin order tosectheplct.m? . . . . . . . . . . . . . . . . . . . . . . . 

m Only listen 

9. During an average week, about how many hours do you’ spend No. of hours If answer is not re r, orted in hours 

listening€ to the radio? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . convert to hours. An average 

week” is whatever tbe person 

n Don’t list.. considers to be a t~ical week. 

Oa. During an overage week, about how many hours do you spend reading No. of hours Include printed books, books in 

orlisten ing to books? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . braille and recorded books. Do 

not include time spent reading comic books, magazines or news- U None (Ask 10b) (Go f. Q&flo” 11) papers. 

If answer is not reported in 

hours, convert to bows. If ‘eNone, ‘“ ask: 

b. Is this because of your trouble with seeing? 

= Yes a No 

1.€ Do you attend any school or take any courses? Include correspondence courses 

and ni~bt school. Report 

students on summer vacation m Yes m No as *’Yes. ” 

NTERVIEWER, MARK ONE BOX. 

a Person is under 17 years of age {Skip to Que.tlon 20) 

a Person is 17 year. old or over (Contfrm. with Q.e.tim 12) 

2. Because of your trouble with seeing hove YOU ever hod any special Training received throu b any 

vocational	 or iob training? formal program designe t to 

aid or rehabilitate persons 

with visual defects. o Yes I_J No 

30, Do you have a iob or business? Accept t~e person’s answ~rs 

to Q~escIons 13b and c without 

probing. u Yes n No (GO to Question 14) 

If *“Yes, ” ask: Occupation Examples: Farmer, seamstress, 

sales clerk. 

b. What kind of work am you doing? . . . . . . . . . . 

Industry€ Examples: Farm, dress manufacturing, candy aod tobacco 

stand. c. What kind of business or industry is this? . . . . . 

d.	 Class of workec (Mark one box) If nOt indicated by entde= 

in (b) and (c), ask additional westiOns. 

~ Private - paid (works for private concern) 

m Own (owns or sbarcs ownership in own business) 

a Federal Government 

a Government - other than Federal 

n Non-paid (works only for room and board, etc.) 

lob, fairly satisfied or not satisfied at a7 1? most nearly corresponding 

the person s answer. 

to 

n Very satisfied 

D Fairly satisfied 

D Not satisfied at all 

Footnotes and comments 

e. On the whole, would you soy you are ve satisfied with your present Mark tbe box for the statement 

NHS.HIS.l(b) (5.3.69) USCOMM.DC 15! m Pas 

75 
QUESTIONS DEFINITIONS 

No. of hours Iqc!ude time spent in physical 

VISICS only, “ot telephone 

4a. 

b. 

%. 

b. 

c. 

6. 

70. 

On the avemge, about how many hours a week do you spend visiting conversations. 

with friends, either in your home or theirs? . . . . . . . . . . . . . . . . . . . If answer is not in hours, 

convert to hours. m Don’t visit 

Hos your trouble with seeing made any difference at all in hew 

often you get together with friends? 

n Yes a No 

Do you belong to any clubs or organizations?	 Include any soci+, civic, 

fratemaI, or rehglous organiza. 

a Yes (Ask 1S0 U No (A.k 15.) tions. 

If “Yeag* to Question 15a, ask: 

Has your trouble with seeing made any difference at all in your 

activity in clubs or organizations? 

D Yes D No 

[f “’No’* to Question 15.9, ask: 

IS this because of your trouble with seeing? 

m Yes = No 

Either alone or with someone Do you go to stores to do any shopping for yourself or your household? else. 

D Yes m No 

If person lives with related member(a), skip to Question 18. 

If person doee not live with any related membe<.$, ask: 

De you hove any relatives who live within ten miles of your home? 

= Ye. n No 

b.	 About hew often do you visit with your relotives, either in your 

home or the Irs? 

n Every day 

n At least once a week 

D At least once a month 

D Other (specify) 

c. Do you own your own home, rent or board? ~?c refers to sample unit, 

= Owns m Boards	 A.e:, person’s yesent 

living quarters. 

n Rents a Other (specify) 

8. How long have you lived at your present address? 

a Less than a yeat 

D One year but less than two 

D Two years but less than five 

n Five years but less than ten 

= Ten years os over 

Footnotes and comments 

USCOMM.OC 

76 
,. 

QUESTfONS 

19.	 Howlong have youliv6d in (%1s arsa)? 

(city or town) 

a Less than a yesr€

m 0.. year but 1.ss than two€

n Two yests but less tbs. five€

n Five yetus but less tbm ten€

= Ten years m ovet€

10. Bscauso of your trouble with seeing, ON you pmsenily receiving 

any fhvanclal help or othm services from public or privotn agenciss? 

D Yes n No€

Footnotes and comments€

.,. -. ““. “,. .,*, ..... ... .. .. -“m “..-”,.-.,”, 

I 

DEFINITIONS 

Insert name of city or-town -

if in turd area, substitute€ “this area.)’€

Include all. ~es. of s:rvices,

such. aS, aid m SnO mg, 

receapt of free recorT ed buoks, etc. 

“S.wu.mc 

.. .. ...- *m*an ..... m.€

77 
section B 

QUESTIONS DEFINITIONS 

1. Con you see well enough to tell if a light IS on or off? 

n Yes a No 

20. Did your trouble with seeing come suddenly or did it come gmdually? “Suddenly”’ would be either in­ stantaneously w in a very shott n Suddenly	 tim$, usually associated with 

an mjuty. 

D Gradually 

n At birth (Skip @ Question 5) 

If “Suddenly” or “Gradually,** ask:	 “Daily activities” means the person’s usual activities, 

depending on the ase of the Age (years) person at the time. 

b. How old were you when your trouble with seeing FIRST began to Interjere with y~w daily motivities, that is, your work, 

recreation, education, or travel?.,..... . . . . . . . . . . . . . . . . . . . 

-1> 

If age in Question 2b is under 6, ask: 

30. Co”Id you see cmyihing besides light when you were an Infant? 

n Yes a No (Skip to Que.tio. 5) 

If “Yes,” ask: 

b. Do you remember seeing colors? 

m Yes m No 

c, Do you remember seeing moving oblects or people’s featutes? 

= Yes = No 

(Skfp to Qu..tlon 5> 

If age in Question 2b is 17 or over, ask: 

4. Were you working at o iob or business before you began to 

hove trouble with seeing? 

= Yes m No 

5, When were your eyes lost examined by a physician �ye If over 12 months, round to 

specialist? nearest yeaq round z Ycals upward, e.g., ‘“l%” years 

n During the past 12 months —Years D Never	 should be recorded as “2°$ 

years. 

~ootnoces and comments 

FORM NHS.HIS.l (b) (5.3-63) USCOW.DC 

7% 
--

QUESTIONS DEFINITIONS 

L	Becaum of your ?41. ssolng, de ou �ver US* ony aids either in 

gcttlng around tfw house or III tmv- r ing outsid* the house; such as 

a can., guide do-, or o parson with sight? 

n Yes = No K+. to Que.tlon 7) 

If ‘gYea,’” ask: 

b. Which do you use? (Mark each on. mentioned) 

D A cane (lf marked, .s.11 Q.e.tl.an 6b(J)) 

n A guide dog m mark.d, a.k Question 6b(2)) 

n A person with sight 

a Other (sP.cIfY) 

If cme wed, ask: 

(1)Have ou �ver had any special instructions in using or getting 

aroun J with o cane? 

“sP’sial if=’’%:ion’.’” “an’ n Yes a No trammg by a trained instructor. 

‘If guide dog used, aak: 

(2) Have you war hod any qeciol instructions in tmveling with 

guldt dogs? 

m Yes m No 

I.	 Hava you ever heard of talking book records? If the supplement person is a 

child, 7s refers to whether the 

u Yes m No (Go to Que.tlon 8)	 respondent ever heard of talking 

book records; 7b to whether the 

child is receiving them. 

If Wee, “ ask: 

>..AI the present time am you getting. talkittg book records of a.y kind 

through the mail? 

a Yes a No 

:. Have you ever had any instructions in reading bmille? 

n Yes m No (Go to Que.lfo” 9) 

If �’Yea,” aak: 

>. Can you mnd braille? 

n Yes a No (Go toQ.eatfcm 9) 

If ‘“Yea, ” ask: 

:. At the present time am you reading books in bmille? 

n Yes a No 

During an average 

madingor listening 

week, about how many 

to books?.. . . . . . 

hours 

. . . . 

do you 

. . . . . 

spend 

. . . . . . . . . . . . 

No. of hours “An average week” is whatever the person considers to 

be a typical week. 

Include books in braille, 

recorded books snd printed 

m None books read by or to the person, 

but not including magazines 

&&%%%&R::% ::’ 

).	 During an average week, about how many hours do yo. spend NO of hews ~f answer noc reported 

Listening tothemdio ortelevision? . . . . . . . . . . . . . . . . . . . . . . . . m hours, convem to hours. 

a Don’t listen 

:ootnotes and comments 

. . . . . . . . . e–. ., ORM NH S-HIS.1 (b) (5.8.0s) ,.I. G”?4K-”. . . .. . .-”. 

79 
QUESTIONS DEFINITIoNs 

1. Do you attend any school or take any courses?	 Include correspondence courses and night school. Report 

l-J	 Yes a No students on summer vacation as “yes.” 

lNTERVfEWER, MARK ONE BOX. 

D Person is under 17 years of age (Skip to Qu..tim 20> 

a P.lSO. is 17 years old or over (Contlntie wffh Qu..ti.an 12) 

2.	 Because of your trouble with seeing hove you �ver had any special Training received throu h any vocational or iob tmining? formaI program designe f to 

aid or rehabilitate persons 

a Yes = No with visual defects. 

30.	 Do you have a 10b or business? Accept the person’s answers to Questions 13b and c without 

probing. a Yes m NO(Go to Q.e.tlon 14) 

-ii” Yea,’8 ask: Occupation Examples: Farmer, seamstress, sales clerk. 

b. What kind of work are you doing?. . . . . . . . . . 

Industry	 Examples: Farm, dress manw facturing, candy and tobacco 

stand. c. What kind of business or industry is this? . . . . . 

d.	 Class of workec (Mark one box) If not indicated by ~nfrje= 

in (b) and (c), ask additional questions. 

a Private - paid (works for private concern) 

� Own (owns or shares ownership in own business) 

a Federal Government 

D Government - other than federal 

= Non-paid (works only for room and board, etc.) 

�.	 On the whole, would YOU soy you are ve ~ satisfied w ith your present 

@b, fairly satisfied or not satisfied at a 1? 

Mark tbe box for the statement most nearly corresponding to 

a Very satisfied tbe person s answer. 

U Fairly satisfied 

D Not satisfied at all 

No. of hours Include time spent in physical 

4Q. On the avcmge, about how many hours a week do you spmd visiting visits only, not telephone 

with friends, �ither in your home or theirs? . . . . . . . . . . . . . . . . . . conversations. 

U Don’t visit 

b.	 Has your trouble with seeing made any difference at 011 in how 

oftan you get together with friends? 

n Yes D No 

So. Do you belong to any clubs or orgonlzations? Include any soc}a!, civic, 

a Yes (Ask Z5b) a No (Ask 25.) 

fraternal, or rehg]ous Organiza­ tions. 

If ‘*Yea ‘p to Question 15a, a8k: 

b.	 Has your trouble with seeing made any difference at all in your 

activity In clubs or organizations? 

� Yes n No 

If “N08* to Question 15a, ask: 

c. Is this because of your troublo with seting? 

u Yes D No 

‘ootnotes and comments 

FORM NHS.HIS-l(b) (S.3.0S) Uscohw.ec *VI** P. 
--

,,.,-ouwm.-

QUESTIONS , DEFINITIONS 

5.	 Do you go to stores to de any shopping for yourself or yo.rlwwsehold? Either alone or with someone 

else. 

a Yes I_J No 

If person lives with related membefs), skip to Question 18. 

“ If person does not live with any related member(s), ask: 

La. Do you have any relatives who live within ten ml le. of your home? 

a Yes n No 

b.	 About how often do YOU visit with your relatives, either in your 

home or theirs? 

n Evc1y day 

D At least once a week 

a At least once a month 

I_J Other fsPecIfY) 

c.	 Do you own your own home, rent or board? ~7c refers to sample unit, 

l.e:, person’s present u owns a Boards living quarters. 

D Rents a Other (specffy) 

How long hove you lived at your present address? 

a Less than a year 

n One year but less than two 

I_J Two years but less than five 

n Five years but less than ten 

n Ten years or over 

9. How long have you lived in Insert name of city or.town (city ~rtow”rhis are”)’ if in mral area, substitute m Less than a year 

m One yeat but less than two 

n Two years but less than five 

D Five years but less than ten 

m Ten years m over 

D.	 Because of your trouble with seeing, 

any finoncio I help or other services 

D Yes n No 

ootnotes and comments 

FORM NHS.HtS-l [b) (5-9-03) 

“this area:’ 

are you presently receiving Iriclude all tYpes of. services, 

from public or privote agencies? such as, aid m shop ing, 

receipt of free recor i ed 

books, etc. 

----..,------� ----- .*”. P., 

8? 

L 
--

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

--

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

--

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

--

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

--

--

--

--

-----

FY 1966
 Itim 0. lk.sa MXI WSdW �O akut ey,slass,s EYEGLASS PAGE h., b“. ,“,,1,s’.s . . u cmtoct 1,”s,,?

km 0 mu., b. wAcd fw P:XO P332m P31el P&l .11 p.r”l}.. 3 ymv. .16 or 

.“,,, If ““d., 3 !..,” mwk 

the “.ndrr 3“ cM..	 : Yes . Yu - Ye Yes 

:WO ?Wa :m - Ha 

c W3 - LW3 : w: r W3 

mad arnoc! lon,n. 

Cwk [of ark Wr,ol. I 

P$ll Pup Pe22 Pawn P2p Pc;-al 

: Yes Yes Ye% LB ::


CIh $’ -Ha WO


. fm3 7 und3 U,’63 lM3 IM3 c W3


F2LL WE EYEGLASS PAGE (UJESTIONS 1.61 FOR EACH PERSC4 WITH WV MARKED IN ITEM 0 FOR EYEGLASSES OR C@iTACT LENSES 

WI, t“ 1. P*f$m .& “.. --k II 

Qmtio” ~Y,Kl,M,, ~d ,.,,,,, 3 refer. 1. all . Jo. dmvJ; - qqlcsscc (CI CO,I*I inms) wcscrlkd f.. rwilms md ““n., 

l,ms,. wNch, p,,s,nhm..- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

b.h.“701 --.y@..s., (“ COnlcclIns.>) PI*Wih4 k SAW Y”’----i- - v“ 

Al-, .bl.e. ... . ..h.,?. ..................... .....--------- If ‘%8. to k.~h & ,nd 

3b, �ot 3,. 

II .,1,--- m m ..1,..4 .,.. —; 

II ..),... i. tb .“,,, .,~ ,~, —~ 

For w otk,, 

ccmbl,,tic., .1 . 

yri,,; 1;,3., mod .~ 

OWMiO” 5 r.fcr.t. the 

FIRST “i”.a! “id (.yogl...c. ., ..”,.., !.”.,.): 

that (h. p,,... g.,. 

W-1*.D o ,Clcr. 1. tn. LAW “i””d ‘id (cycglass,. ., c.”,,., 1,,s,s) 

thu the pets.. SOI. 

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

. . . . ... ... .... s. Irn91�* hi. V*,I.S1*S ~~” Olv 

(w C.”1.CI 1.”s.s) 

4m HOW.b.m do., .,, M* .PI1.i s., (emdC8M,CI I,ms.s) whll. rs.dl,g M ~,, ~,% “ 

w dol.s .1.” w,k: Al! .! ,h. ,IM, most .( +ho Ilmc, lw,dly ..-, or H,,,? . 

,.. ...... ------- .--------------------- .......... . . . . . . . . . . . . . . . . . 

b. H*- �hm d-s --w hi, ,Y,glm,s (A .enm<, I,,,,,) f“ ,WIW ~, ~,, ~,, - “ 

didcnt	 �M.ctx All al th, t!-, CU,I ,1 ,h, ,Im,, lwdly w.,, w WV,,? c 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . --. ---. .---., 

; c. Hcw �h,, de, “,, hi, �YOSI,SS,S(and ,,,IccI I,n,, sh Atd.1 A!! L?M, Wily N... v 

1A. I!M, m,,t d the time, kwdly ,,,,, w m,,? J 

i 

! 5. Abwl b.. old w., wk.. h, v 

@ hi, FIRST pair .; .Y.. 

! S1.ss.s (*r con,.<, 1..,,,)? $~~:$n 

0!+)”, 1.,, 27.”, ..4.1 ‘b 

da. Dld .Mn MS LAST p!, *1 .Y.JI..s.s (m <..1.<$ 1,.,,,) 

: d,rlnm th, 1,,12 y,w, � More that !lm.? Mul %“ 2 ,9M . . * [0) 

‘ 

A,k 6b, e, ud d , *I W ;;.”.IXJ L- L”i.J;iiIJ-+q-lii ;Ji’ - ‘-o--~;;;;-m-;:-;-;-;;) 

60,,11 p.,..., (*7 .Ont.cl 1..1..)? 

examlmd for Ua, of d.,,., ., person 

,Y,sI.s,,, dsri,6 u 

pnz 2 pm. e, Wha,. w., h. .mmlm,d? 

lame 01 @ace 

Kftd ofF&e 

h mums 

1fiV---------------------------@--------------­

1 

ll’-”””’EWL’ 

I 

I 

J -d d. Is the doe!,, (prsen) +. .xamlm,d--c, ophthalmalqfd -

� ,pmm!,rst? 

CY 1971 . 

‘o. Does anyone in the family use - l. Contact lenses?. .Y N . . . . . . . ..l 2 3 4 5 6 7 8 9 10 

If “yes,” ask b and C 

b. Who is this? Circle person’s number 2. Eyeglasses? . . ..Y N . . . . . . . ..l 2345678910 

c. Anyone else? 

3. A hearing aid? . . . Y N., . . . . . ..l 2 3 4 5 6 7 8 9 10 

For “hearing aid,” with no hearing problem reported, ask:


For what condition does he need this?


Enter condition in item C


82 

. 
----------

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

X-RAY VISITS


W 1961
 X-RAY QUESTIONS 

21, (o) We arm interested 1“ cdl kinds of X.r.ays - Did you have your teeth X-rayed during the past 

,f ,,$.~a~ths. - (that la, from.. through lost S.”day) ? 

~b) l%; many times? 

22. During tht post 3 months did you have a CHEST X-ray? 

23.	 (a) Did you havo any (othw) kind of X-ray at all during the post 3 months? 

If “Ye*, ” 

(b) What pert af *h* body wo. X-ray-d? 

24.	 (a) Durln the past 3 months, did anyone in the family have a“y X-rays for the treatment of 

a con ! ItIon? 

U “Yes:) 

(b) What port of thm body W., twined? 

(c) W., this Included In the X-ray(s) you told m. about before? 

25.	 (o) Did anyonm in the family bow a fluoroscope during tbe post 3 months? 

u “Yes, ” 

(b) Wh part of the body was this for?


(c) WOSthis Ind.dd i. the X-ray(s) YOU told me about before?


eX. FILLl !E LINE FOR EA 

D Yes n No 

No. of times 

D Yes-Chest a No 

m Yes n No 

Part(s) of body 

a Yes n No 

Part(s) of bodfi 

. . . . . . . . . . . . . . . . . . . 

n Yes D No 

n Yes m No 

Patt(s) of bc+ 

-------. m Yes m No t RY FROM QUESTIONS 22.25 

How ninny Where did you What w.. this X-roy (s) for- -0 If “both” in cccl. If “botb” or “treatment” in CO1. (f) asfc different hove the X-ray(s)? checkup or an examination or (f) ask times did you How mm X-rays for treatnmnt? have your . . . were at t Ke. (hos. How many of 

Part of body X-rayed dur- pitol, doctor’s ,he,e . . . x.,ay(~) For wfat condftion wera you b.i”g trmte ing the past .Wi.., at..)? 3 months? 

(d) 

Hospital _ D Check-up/examination


Dr. office _ Cl Treatment I I
 Ckher _


83 

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

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

--

sfleet_ Of — sheets FY 1964 (April-June 1964) Budxet Bme,u No.6.?.R620.8, AnDroval ExDi,eslulv 15. 1964 

PSU No. B. Segment No. C. Secial No. E. >monthr eferenceperiod 

Mr. FROM TO Mrs. Intervmw status F. Address of sample unit (Item 2(b) Or ( a) of NffS-HIS-1) Miss ] [m.cview (Fill km, E, F, and G) OR UNocelephone Relationship 3Nonim&p: fpa.Ny we) Heed 

AKC Race O Type B City State m Type C 

.RAY QUESTIONS 

(Exp.s.re toallki.d. .fX-r. .is. matter afp.rti..lar lntere.t tithe P.bli. He.l*Service, andlhavo a'~ewfinal questio.. &w a Yes n No X.raysand fluore.scopes.) DIK youhave your te~h X-r.yed durlngthe past 3months(thati$kom through last Sunday)? 

(If “’Yea,t* check the “Ye.” box and enter “Teeth.”) I 

During the past 3 months did you hove a chest X-ray? I n Yes n No 

~lf ,, Y=8,,, deck (h= ~Iya# boxandwter “Chest.”) 

(a) Did You have any (othcr),kind of X-ray at.1 I during the Past 3 m.nfhs? U Yes a No 

If ‘~Yes,” ask: 

(b) What partofthe b.dywos X-r.yed? @nterpati of body* persm’scSl~) 

(a) Did you have o fluoroscope during the post 3 months? � Yes � No 

If “‘Yes,” ask 

(b) Whotpart ofth. body wos it for? (Enter part of bodyinperscm’s cohmm) 

If “X-rays” in question 2or 3forthepcrson, ask: - - -

(.) Was this included in the X-rays y.. told me about before? n Yes m No 

(a) D;~t;;yo~; in the family, that is, y.., your --, et.., have .“~ X-cays’ f., the TREATMENT of a cowliti.n during the 3.momh u Yes UT through lost Sundaynig t? If ‘pYes,” ask, 

(b) Who WCS this? 

(c) Whotport ofth.eb.dy w.streated? (Enter @rCofbodyin If X-ray smquestmn. 2-4 for the person, ask: pers~’8@lm) 

(d) %s this included in the X-rays y.. told me about before? OY.. ~ nNo -

Height Wei,qht 

Whaf is your height and weight? (Feet) ~ (Inch,.) (P.a”” d.) 

I 

- “Ill. -,,. & , “m &.-l*,, rAm , “r P“”, 1-,, , m , rrm”m .x”k.z , ,“,,.7 .-d 

:01. f&s- How many 

‘0. ti.m different 

f No. times did 

er- YOU have 

on your 

P:? X-rayed 

during the 

body past 3 

months? 

(a) (h) (c) (d) 

Times 

~ I 

I 

— 

Times 

reverse side f more Ii”es eve needed. 

For de”cal X-rays, ask: What is the name and address of the (de”tlst, doctor, hospital, et=.) 

Where did you have the X.rays token - at the den. where the X-roys we,e take”? 

Nst’s of ffce or some other place? 

For X-rays other than demrd, ask 

Where did you hove the X-rays taken - at the 

doctor’s office, o hospltol, or sore. other place? 

(If “Some other place,’* determine place.) 

If more than one place given and more than o“e X-ray taken, ask: 

How many X-rays were taken at the (hospital, doctor’s office, etc.)? 

(e) 

INTERVIEWER -

For X-rays taken at hospivafs, clinics, etc., ALSO enter the name of 

the doctor. 

For X-rays taken at mobile units, enter: 

‘<Mobile unit” 0“ “mm line;


Ioc.tic.” of unit at rime of X-ray o“ ad#ress line; and
 name and address of sponsoring organ: zacion and date


of X-ray i“ foomote.


Verify mamc and address in telephone dicectory.


Enter the te!cphone “umber.


Check “Ver!fmd” box. If unable to verify, give reason in a footnote.


(f) 

Name and title m Dentist’s office . . . . . . . . . (Time.) 

n Doctor’s office . . . . . . . . . . (Time,] Address


uNos.piwd . . . . . . . . . . . . . . scar,


l_JOther (spec,fy). . . . . . . . . . —(TIM.*J


I 

‘Name and title D Dtruist’s office . . . . . . . . . _ (Tim..) 

a Doctor’s office . . . . . . . . . . —(Tim.,] M*=S 

Oiiospical . . . . . . . . . . . . . . . (2%!..> (-Jtv IState l~Other(specify, .......... +—,Tfme*~]T=~,,honeNo I 

IU Ve,ifi.d 

l— 

Name 8nd ride u f2e”tist’s office . . . . . . . . . —(T!..*) 

� Doctor’s office . . . . . . . . . . ~=,me,j Address 

l~llospitd. . . . . . . . . . . . . . ,T,m@l@ I stare 

u Ocher (.SIXI.,,Y). . . . . . . . . . ~Tt...) ==,=pho”= ~m, I 

u V.,lfl.d 

:RVIEWER - Ask .fcer compleci”g Table X for .11 related persons with X-rays. u Si,qmd O Not signed g~gfi”,
 >ywe cont.. the, (doctor d.nti.t, hospital, etc.) you have mentioned to obtain additional information about the X-rays?
 ‘re.smc form r sw..t.re) Will you please sign this form?


84 
rAtal c Y - e..., . . ..-. ,..” -.. ,m - “,, .,,,... 

‘INTERVIEWER - DO NOT ASK FOR DENTAL X-RAYS 

ihot W(W this X-rat for - If “Both” in column (g), ask: If “Treatment” or “Both” in column (gJ, ask: INTERVIEWER - Ask for each person with 

~ checkup or m .xomlnotion or HOW many of these -- X-my. 

or n trootmwnt? W.C. for tc.atnwnt? 

For whet condition were you being treated? 

2 or more lines i“ Table X after sII X-rays 

haw been recorded for a pHSOIL

(Enter -wnditlm> (DO NOT include dental X-.aya tn number of j 

X-ray visits.) : 

E 

Altqether you had -- X-rays during the past 

3 mmths. How many sepwota visits did you .: 

make to have the.. -- X.,.ays?

(g) (h) (i) (i) 

~ Checkup/Examination 

‘_J Treatment 

(Skip to column (i)) 

-J &o:: CO,m, ~h) ~d ~i)) 

Number Number of visits 

~ Checkup/Exnminntion 

~ ~;;r;o,m ~,)) 

-J fi:j CO,m, (h) ,“d ~,)) 

Number Number of visits 

_J Che.kup/Examination 

-J :f;tyy;o,m ~,)) 

-J ~:~ CO,m, ~h) ~d ~,)) 

Number Number of visits 

. INTERVIEWER - n No X-my. repormd FOOTNOTES 

After completi”~ X-ray Supplement, x-rays reported and 

check �ppropri ate box. t_J No problems (release signed, “o missing information, etc.) 

n ~:~~p::b~::l;fi:o;::,:~d, missing i“formari.”, etc.) 

1 

2 

3 

m yI#$s.HIS.l (X.,cy S“PP.) (FY-d41 X-RAY SUPPLEMENT FOR NHS-HIS-1 (FY-1964) US. OEP:R:M:NT ::: OMMERC{, 

85 
--

--

--

--

--

CY 1970 (Atxil-SefNember) 

Exposure to cII kind. of X-r. s is a matt.r of p.rN..l.zr Int.rest to tho Public Health Service, and 

I have some questions about k -rays and fluoroscopes. .39b. n Dental n Other (SPdffi 

39a. Did anyont in the family’ have his tcoth X.rayad during iho po$t 3 months, thnt IS from_ (date) through last Sunday? 

Y N (4o) 

b. Who W.. this? Mark “DentaISB in Porso”,s CO1.IM c. Anyone ,1s.? Part of body 

60a. Ouringtha past3mmths dldanyon* inthefamtly have ach*st X-roy? Y N (41) 40b. mChest nOther(Speclfy; 

b. Who was this? Mark “Chest” In person’s column c. Anyon*aIsa? Part of body 

41o. Did have any (other) kind of X-royat alldurlngthapost3 months? lf$’Yes,’’aslc 410, Y N (NP) c. b. Whotpart ofth. bodywns X-rayed? Entarpart of bcdyinpiwsrn]s column 

c.. Oid --hova any othw X-ray during the post 3 months? b. Part of body 

42a. Did havmafluorosc.pa d.tlngthm past 3 months? If “Yes,’’aslc 42a, Y N (NP> c. b. What port of the body was N for? Enter part of bcdy in person% cokm 

G Did- - have any other fluoroscope during the post 3 month.? b. Part of body 

430. D.ringthoso 3months, dIdanyona inthefomIly havaany X-ray sfortha TREATMENT ofacmditlon? Y N (43d,44) 43b. a Treatnwnt 

b. Whowasthis? Mark <<Treatment* *inpersrn%coltmm c. A“yoneefsm? 

d. What part ofth. body wastraatad? Enter part of body inperson*a column d. Part of body 

For each person with X-rays, fluoroscopes, or treatment in 39-43, ask FeetHelght,“cha~ Weight (Lbe.) 

44. What Is--”shalght ondw.igh?? 44. 

Table R- FILLONE LINEFOR EACH '' PART OF BODY' 'ENTRY FROM Questions 39-43 

Col. Ques- How many For dental X-rays, ask If more than Whet is th. nmne ond oddr.ss of the (dsntist, doctor, hospltol, de.) 

No. tlon different Whemdld heh.sve the X.roystak*n-ota one tima at whe,e the X.rays wara taken? 

of No. times did dentist’s office or some other place? anyone place, 

ask per- For X-rays taken at hospitals, clinlcs, G+slml Iar places,

his . 

hav. For X-rays other than dental, ask Were a,, ,he~e ALSO enter the name of thedoctor whotookthe X-ray%. 5 s~ 

Part 

. . Whemdld he h.oveth. X-rays token -at a X-rcy.d For X-ray stakenatmobi Ie units, enter: Itth E of d“,,no ,he doctor’s office, a h.spitol, or some other place? :;yhy’f:pe” .,Moblle ““it.. On name Ii”e; !OCatt On Of Wt[t z body post 3 (If %om. other place,,, dotennfne place.) (dentist’s .afficq of X-ray on address line; and n?.mermd address of # d.xtd. office, sponswlng wganfzation and date of X-ray In foc.mott. 

J months? [f more than one place givem, ask UC.)? Verlfyname and address Intelephone directory. foroach place: Check’’Verlfied” box. lfunable toverlfy, ~lvereason lnafootno!a.
 How many X.roys were token at the (hospNal, Enter the telephone number If available.
 doctor’s office, �te.)?


(a) (b) (c) (d) (e) (f) (:1) 

n Oent[st’s office. . . . . Times Name and title 

� Oo.tor’. office . . . ..— Times Y Address 

I � Hospital . . . . . . . . . . Times city State 21P code 

Tim,, a Other (Specify) . . . ..— Times N (gl,42) 

n Verified Teiephone No. 

n Dentist’s office. . . . . Times Name and title 

I-J Doctor”. office . . . . . Times Y Address 

2 OHOSPN.I . . . . . . . . . T[mes city State ZIP code ~ m Other (Specify) . . . . . Times N (gl, eZ> 

a Verified Teiephone No. 

m Dentist,. office . . . . . Times Name and title 

� Doctor’s office . . . . . Times Y Address 

3 OH.aspltal . . . . . . . . . Times city state ZiP coda T,m,, a Other fspecify) .....— Times N (#l, g2) 

n Veriflcd Telephone No. 

Ask after completing Table R for al I related parsons with X-rays. 

4S. Maywmccmtactthm (doctor, dentist, hospltal,atc.) youhava mantlmad toobtatnaddltional lnformaNcm about tho X-rays? n Sl;ne.d o t4y,~)ncd @.t#r 

(Present fmm for slznature) Will you P!amsm slg. this form? 

Table R - Cominu.d 

Use fc+ additional name and address DO NOT ASK FOR OENTAL X-RAYS 

What wos this X-r.ayf.ar -a How IW3”y of Ask foreach person with 20r more lines in 

checkup, an mxamlnation,or these x-rays Table Rafter all X.rayshave been recorded 

for a treatmant? were Fortreotment? for a person, DO NOT Include dental 5 X-rays Innumberofvislts.	 E 

2 

; (Not counting his dental X-rays) A Alto@her he hod -- X-rays during ths past 

3mmths. Howmony scparatc visltsdtdho 

make tohavethasm X.rays? 

(*2) (h) (1) (k) 

Vame and tide n Check. p/Examl”atlon @j 

\ddress 

:Icy I state ZIP code I_J Treatment (k) i 

Number Number of visits 

~ Verified Telephone No. a Both (i) 

000 
APPENDIX II 

ONE-TIME OR SINGLE SUPPLEMENTS 

ACUTE CONDITIONS: CY 1973 and 1974 

n“m .!. .- IY,.n,l.........F..-,---.,-... ., ,,.. v.I.,.=. I... .e. mIOVW; npprovm cxpmes marcn s 1. 17/ 

rORM llts.lA (S974) 

10.11.7a) NOTICE - Al I information which would permit identification of the Individual will be held In strict confidence, w} I I be used only by persons engaged In and U..% DEPARTMENT OF COMMERCE for the purposes of the survey, and WI II not be disclosed or relea$ed to others SOCIAL AND ECONOMIC STATISTICS for any purposes. ADMINISTRATION 

DUREAU OF THS CENSUS 

ACTINS 

U.S. PUBLIC HEALTH SERVICE number. number number person 

US. HEALTH INTERVIEW SURVEY IY 2N 

CONDITION SUPPLEMENT g. Name of condition h. Name of person 

(M~dicolly Attended) 

As COlleCting AGENT FOR THC a. Psu b. Segment c. Serial d. Sample ‘e. Person f. Sample 

L Determine if eligible respondent is available: 

i_J Eligible respondent available 

� Telephone cal I or return visit required (A5, Condition page) 

i. RECORD OF TELEPHONE CALLS ONLY k. Reason for rroninterview 

Date Beginning Ending 

time time Completed I H Refused 

a.m. a.m. 

I p.m. p.m. 2 D Not at home - repeated cat Is 

a.m. am, 

2 p.m. p.m. s � Temporari 1y absent 

a.m. a.m. 

a p.m. p.m. � Other (Specify)7 

a.m. a.m. 

4 p.m. p.m. 

a.m. a.m. s p.m. . . . . . ... , 

In an interview at our horrs~ 

INTRODUCTION: had . . . . The fol rowing questions refar to that condition. 

b I a Respondent denies having condition (RA) 

,.. . ., ., ... ., ,, 

~ 

87 
------ -----

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

1. Pleas. look at the calendar (HAND CALENDAR) I 

I and tell mew what data you first noticed I


(had) tfm. . . . ! Month Day
 I 

2. Attfrot time when wfirstnoticcd (had)tho : 1 � Very serious 

. . . . how serious J.Id you think it was - vary I 2 � Somewhat seriaus 

scriow, somewhat serious, or not *eriaus at all? I

1 

s � Not serious at all 1 

, 3a, After you first noticed (had) the condition w : 000 � Discovered by dactor (5) 

; 100 � Under 4 hours (4) *:k2z&;+xr!3P s 

i 

----= ~---------------------- i--*--?2:E_:__D:I:I---- :---?-$-:-. 

b. We are interested m th~ various reasons why ~ A. Did you wait because you couldn’t 

people wait before going to a doctor. Please I get an appointment or the doctor 

tell me whether any of the fol Iowin statemaats t

I was not available? lY 2N 

WHO reobts why WI waited (time 5 to SO* or 

I talk to a doctor about this condition -

I 

I B. Because you didn’t have the money? I Y z N 1 

I 

~ C. Because you didn’t have a way to 

,- get to the doctor? lY 2N 

{ D. Did ou wait because yau felt 

I the 1 octor couldn’t do anything 

for the condition? lY 2N I 

I 

~ E. Because you felt you cwld treat 

I the condition yourself? lY 2N 

I 

~ F. Bacause you didn’t want to bother 

I the doctor? lY 2N 

1 

~ G. Did you wait because you didn’t 

I think it was seriaus enough? lY 2N 

~ H. Because you feel uncomfortable 

I with doctars or have a fear 

of dactors? 7Y 2N 

I 

1 

I 

I I. Did yau wait for any other reasan? lY 2 N(K) 

~ J. What was the reason? 

PROBE IF RESPONSE IS INAPPROPRIATE: ; (1) (Reosk 

i (2) (Reask3 

I 

I If all “N’s” in A-1, ask otherwise, 

I go to Q. 3c: 

~ K. Why did you wait-@@-to see or talk to a 

I doctor about this . . .? Any other reasons? 

~ 

PROBE IF RESPONSE IS INAPPROPRIATE: \ (1) 

1 

i (2) ~---------- — . 

if two or mare reasons given in statements A-K, 

ask, atherwise mark box: I 

I c. Whigh of these reasans would you say was the 

MAIN reason far waiting to see a dactar for 

this condition? 

. ~ � Only I reasan 

Circie the apjxopriate stotement letter In the j otA 04 D 07 G 10 J(2) 13 K(l) 16 K(4) 

space to the right. ~ 02B os E 06 H 11 J(3) 14 K(2) 

! 03C os F 09 J(l) 12](4) Is K(3) 

FORM HIS- I A IIO. ! 1-7S1 

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

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

--

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

--

-----

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

--

--

I la.	 Before you talked to a 

doctor about this condition,! 

did you ask anyone for I 

advice about it, such as a ~ 

nurse, druggist, relative, I 

friend or someone �lse? IIY 2 N(5) 

_i__ _____ ________________ _______________ —- —___________ . 

2 � Druggist 3 � Relative � Other - Specifyz 

(Household member) 

4 ~ Relative (Nonhousehold member) 

s I_J Friend 

________________ _______________ 

b.	 Who WaS this? I I � Nurse —- —— 

c. Did you ask anyone �lse ~ 

for advice? 

Y (Recrsk 4b N[ and c) __________________________________ 

Ask for each column 

marked in Q. 4tt 

d, Did advise you to see [,Y a doctor? 2N ,.f ,N ,y ,~ ,y ,N 

— ._---------- __ —- __________ 

�. Did cdvise you h take ! 

some medicine? lY J-X.-----a_! ______.---____A!!______ Q---JL__­

f. ~ld 

sOme-%$1$~-G”4----LTz----T-E------I 

of treatment? llY 2N lY 2N lY 2N lY 2N —---- . .- —--------- —— 

9. Did give yw any other ~ Y o N (Next Y o N (Next Y o N (Next Y o N(S) 

advice? CoI.) cot.) CoI.) 

/ _____ ___ ____ ______ - ____ 

h. What advice did give ~ 

you? I 

! (Remk g) 

i.	 Plezse look at the calenda~. (HAND CALENDAR) 

On what date did you first visitor talk to 

a doctor about this condition? 

‘. On (date) where did you first see or 

talk to the doctor - at a clinic, hospital, 

doctor’s office, or some other place? 

If hospital: Was it a hospital outpatient 

clinic or the emergency room? 

If clinic: Was it a hospital outpatient clinic, 

o company clinic, or some other kind of clinic? 

.	 Had you ever gone te this doctor before 

this visit? 

.	 How did you choose this doctor - through 

onother dotter, o relative or friend, a 

medical bureou, from a telephone directory, 

or in some other way? 

a.	 Is this doctor you visited orru ate the 

doctor you would usually go to for this type 

(Remk g) (Reask g) (Reosk g) 

I 

I 

i 

i 

1 

t 

~ 

, 

I 

t 

! 

I 

i 

1 

I 

I 

I 

i 

1 

I 

I 

Month Date 

o � While inPatient in hospital (RA) 

1 U	 DOctOr”s office (group practice 

doctor’s clinic) (7) 

z a Telephone (20) 

3 � Hospital outpatient clinic (10) 

4 � Home (7) 

5 � Hospital emergency room (10) 

6 a C0mP2nY or industry clinic (IO) 

7 � Other - Specifyy 

lY 2N 

I � Another doctor 

2 � Rel ativtifri end 

3 � Medical bure3u 

4 � Telephone directory 

n Other - SpecifyT 

or 

(lo) 

(13) 

89 

of condition? i o Y(f3) -______-_-_____-______--______--__----_+-__-_-----__--__-______-_N______________ 

b.	 Why didn’t you use the doctor or place that I you would usually go to fer this type of 

condition? I 

i 
---------------------------------------

----- ---

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

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

1 

0.	 Had you ●ver gene to this place before this visit? I lY 2N
 I


1. How did you choose this placo - through arwther I I ❑ Another doctor 

doctor, a rdativo or friend, a medical bureau, I 2 ❑ Relative/friend 

from a tolcphono directory, or in some other woy? I s ❑ Medical bureau
 I
 4 ❑ Telephone directory


s ❑ Other - SpecifyT 

I


20. Is this place you visited on ~ thm ploco 

you	 would usually go to for this type of condition? ~ o Y(13) N 

~----------------------------------------

b.	 Whydidn’t ouusotho doctor orplacc that you I
 would usun r Iygotofer this typo of condition?


I


1


If ’”Home’” in Q.6, goto Q. 16. I


I
 130. Did YOU moko an omointmwrt for this visit? lY 2 N(14)


I


b.	 Did you havo ony problom rooking I
 this appointment? Y o N(14)


c.WKatweroAoPro%TSmZ?-----------------------------------------------------------------

I


I


I


I


4G. Whtn you vi~itod tha doctor on=, how I ❑ Very difficult difficult was N for you to gd thwo - was it 

very difficuh, somowhot difficult, or not at 2 m Somewhat difficult 

aHdifficuit? ! smNotat all difficult(c) <---ZZb. Why wos it difficult? I


i


, 

i


c.Abouthc.w lorrgdidit takcyoutogetthcro? 1, —Minutes 2 — Hours


15a. AftorgcttIng thorc,did oufoolthotthotimc I I ❑ Muchtoolong 

ou had to woitto sact i isdoctnr was much too I zn Somewhat too long 1ong, aomowhottaa Ioag, ornotteo long? I snNottoo long :------

I


b. About haw long did you have to woit aftw i


I
 g.tting there? 11 — Minutes 2_ Hours


I


16.	 During this vksiton (date) .,didtho 1 I ❑ Spent enough time


doctor spend ●nough tImo with you a; not I


enough time? I 2 ❑ Did not spend enough time 

I


17a. Durin this visit didthcdoctor adviso youto I


cemo~ck and s.. him forth . ...? lY 2 N(18) ---------------------------------------\----------------------------------------

b. Did w wili yeu go bock ta so. him for this i


coadition? : 1Y(18)


---------------------------------------~------------~f--------:-:~------------­ a. Why net? 

! 

90 
--------------------------------------- ----------------------

--------

---------

18a.	 During this visit on (d.ate ) , did the 1


doctor prescribe or adv, se you to get any 1


medicine for this . . .? lY 2 N(19)


~_______ .-—-----—--

1


b.	 Did you get this medicine? I 0 Y(19) N I
 ---l-----------------------------------&----------------------------------------


C. Why not? -1 

I


, I
 ! I
 I
 190. During this visit did the doctor refer you to


another doctor? I lY 2 N(28) _______--_-_-------_-------------------k----------------------------------------

I


b.	 Did or will you see this other doctor? I t Y(28) 2N 9 DK _________________________________________________________________________ 

c. Why not? 1


[ t I


(28) I


I


20.	 Hadyouever gone tothisdoctor or place 

before this call? I lY 2N 

21.	 Howdidyou choose this doctor or place- I n Another doctor 

through another doctor, a relative or friend, 

a medical bureau, from atelephorre directory, 2 � Relative/friend 

Qrin some other way? an Medical bureau 

4 � Telephone directory 

n Other - Spe.ify7 

I I


220.	 Is this doctor or place you called on _ I


the doctor or place you would usually go to for 1


this type of condition? o Y(23) N


b~Wk;~a7~;:I;;:%:l;~;;;,-~;cz:~~-----------:---------------------------------------­

you would usually go to for this type of I
 condition? 

I


I


23a. How difficult was it for you to reach the doctor t mVery difficult 

by telephone on (date) -was it very 2 � Somewhat difficult difficult, somewmcult, or not at


all difficult? 3 � Not at ail difficult (24)


----_____-_--__---_-_--— _______________ ;_____ __________________________

b. Why was It difficult? I

t 1


, I
 I
 I
 , t � .Spent enough time 24.	 During this canon $date) ,did the doctor I


srmsd enough time wlthyouar not enough time? znDid not spend enough time


I€ 25a. During this call did the doctor advise you to


comein and seehimfarthe. . . ? 1 ,y 2 N (26)


-------___---__---_— ___________________ L-----------------------------------------

I


I
 b.	 Did or will YOU go into see him for this condition? I Y(26) ________________________-_---;__________.___:-N----_--_::!_____________ 

c. Why not? I


I
 I


1 I
 I


I I
 FORM HIS-1A (!0-11-7s1 

91 
------------------------- -------------- ---------------------------------

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

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

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

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

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

I 

6a. During this call on (date) didthe doctor I prescribe oradvise~~t anymedicine for this . ..? I 

+--’J--- 2 N(27J 

1 

b. Did you get this medicirw? \ 0Y(27) N 

;------------------------------- C. Why not? t i 

I !7s. During this cal 1, did this doctor refer you to 

another doctor? : lY 2 N(28) 

---------------------------------------+----------------------------------------

I 

b.	 Did or wil I you see thie other doctor? ~ 1 Y(28) 2N 9 DK ---------------------------------------y---------------------------------------­ c. Why not? 

!80. In ywr opinion, were you satisfied or 

dissatisfied with the treatment or care yw 

reccivcd fremthis doctor on (date) ? 

b.	 Would you say that you wero very sotisfled or 

iust wmewbat satisfied? 

c.	 Would you saythot you were very dissatisfied 

or iust somewhat dissoti died? 

d.~~;~a_’fi;fi 

!9. Doywstil lhsrvoth c...? 

Show who responded for tiis supplement. 

Ifother than self-respadent, show who 

responded for him. RA - If other than self-respondent, give 

!ESPONDENT reason for accepting a proxy. 

I Show how the Information on this 

supplement was obtained. 

TYPE OF 

INTERVIEW 

i

I

I

1 I
 I


I I


i


I � Satisfied (b)
 I

I � Dissatisfied (c)
 4----------------------------------------


~ 1 � Very satisfied (29)


: zm Somewhat satisfied(d)
 +----------------------------------------

i


I 4 I_J Very dissatisfied


~ snSomewhat dissatisfied


I ‘-------------------- -------------------’
 t


I 

I 

I 

i


I


I


! I


i ,Y 2N 1 

~ I � Responded for self 

: 

Person was respondent ;-----------------------------------------

~ on Under17 

I


1 1 � Mentally incompetent


I


; 2n Physically incompetent


I


1
 I I � Completed during initial
 t


I uncompleted by return visit


: uncompleted byatelephone


GO TOA5, CONDITION PAGE 

ORM ISIS-1A1%0.1S.7S) 

92 

1 

interview 

callback 

J 

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

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

--

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

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

--

--

--

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

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

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

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

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

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

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

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

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

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

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

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

0. M. B. No.68-R16~, Approval Expires March 31, 1975 

po:n,-Hi~lB (1?74) NOTICE -All information which would permit identification of the Individual will beheld ln strict 

confidence, will be used only by persons engaged in and for purposes of the survey, and will not US. DEPARTMENT OF COMMERCE be disclosed or released to others for a“y purposes. SOCIAL AND EC0N0MlC5TATlSTlCS 

ADMINISTRATION BUREAU OF THE CENSUS a. RI u b. Segment c. Serial . Sample e. Person f. Sample 

ACTING As COk LECTING ACENT FOR THE number number number person 

U.S. PUISLIC HEALTH SERVICE lY ZN 

U.S. HEALTH INTERVIEW SURVEY g. Name of condition h. Name of person 

CONDITION SUPPLEMENT 

(Nonmedically Attended) 

. Determine if eliglble respondent is availablw � Eligible respondent available 

� Telephone call or return visit required (AS, Condition page) 

o RECORD OF TELEPHONE CALLS ONLY k. Reason for noninterview 

Date Beginning Ending Completed time time I D Refused 

a.m. a.m. 

I p.m. p.m. Z � Nat at home - repeated ca[ls 

u.m. o.m. 

2 p.m. p.m. s � Temporarily absent 

a.m. a.m. 

3 p.m. p.m. D Other (Specify) ~ 

a.m. a.m. 

4 p.m. p.m. 

a.m. a.m. 

5 p.m. p.m. 

3.. -.. — ~ 

In an interview at your household today (earlier this week) it was reported that you recently had . . . . 

INTRODUCTION: The following questions refer to that condition. 

b I a Respondent denies having candition (RB) —. J! 

. Please look at the calendar (HAND [ 

CALENDAR) and tell me on what date 

you first noticed (had) the . . . . I Month Day 

!. At that time when yau first noticed I 

I I � Very serious 

(had) the . . . . how serious did you I 2 U Somewhat seriaus think it was - very serious, somewhat I s n Not serious at all serious, or not seriaus at all? 

a. Did you ask an one for advice ( 

about this con J [tIon, such os a nurse, \ 

druggist, relative, fiend, or ~ 

someone else? ,lY 2 N (4) < 

~ I m Nurse 2 � Druggist 3 � Relative 

b. Who was this? 1 (Household member) 1

nOther - Specify7 

L 

c. Did you ask anyone else far odvice? j 4L?U%I”X3,” I Y (Reask 3b and c) N s !_J Friend 

___----------- __----------- L -------------- _______________ 

Ask for each column marked in Q. 3b: ~ I 

d.	 Did advise you to see o doctor? 2N BY 2N IY 2N lY 2?4 ;:-y 

e. Did --advise you to take I 4 

some medicine? IIY 2N BY 2N IY 2N lY 2N —--------- —--- +-------------- 1 

f. Did advise you on some other type ~ 

of treatment? IIY BY 2N IY 2N 1lY 2N _--------- _---__ --______ : _!________ :_!____ 

g. Did give you any other advice? I Y ON (Nex Y o N (Next Y o N (Next Y o N (4) 

cot.) Col.) CoI.) 

___________________________ +-------------- — _______ h. What advice did give you? I 

1 

I

1I 

I (Reask g) (Reosk g) (Reask g) (Reask g) 

‘oatnotes 
-- --------------------------

1 

4.	 Do you expect to see or talk to a doctor 

about this . . .? j I Y(5b) 2N 9 DK 

5a.	 We are interested in the various reasons why I 

people do not go to doctors. Please tell me I whether any of the following statements were ~ A. Did you not see a doctor (did you wait) reasons why you didn’t see or talk to a I because you couldn’t get an appoint. doctor about this condition - I ment or the doctor was not available? lY 2N 

b.	 We are interested in the various reasons why # 

people wait before going to a doctor. Please : tell me whether any of the following statements were reasons why you waited (time) ~ B. Because you didn’t have the money? lY 2N 

to see or talk to a doctor about this condition - 1 

1 

I C. Because you didn’t have a way to


I get to the doctor? lY 2N


~ D. Did you not see a doctor (did you wait) 

I because you felt the doctor couldn’t do 

I anything for the condition? lY 2N 

I 

I E. Because you felt you could treot 

I the condition yourself? lY 2N 

I 

j F. Because you didn’t want to bother 

I the doctor? lY 2N 

I 

j G. Did ou not see a doctor (did you 

I wad“r because you didn’t think it 

was serious enough? lY 2N I 

~ H. Because you feel uncomfortable with


I doctors or have a fear of doctors? lY 2N


I


1 

I 1. Did you not see o doctor (did you


I wait) for any other reason? tY 2 N (K)


I J. What wos the reason?


t


PROBE IF RESPONSE IS INAPPROPRIATE: ~ (1) (Reask 1) 

I 

i (2) (Reask 1) 

i If all “N’s” in A-I ask; otherwise, go to Q.5C 

~ K. Why did you (not/wait to) see or talk to a 

1 doctor about this . . .? Any other reason? 

PROBE IF RESPONSE IS INAPPROPRIATE: + (1) 

I 

(2) _______________________________________ ~_____ ____________________________________________ 

If 2 or more reasons given in statements 

A-K, askotherwi semarkbo~ ! 

1 

c. Which of these reasons would you say was the I � Only I reason 

MAIN reason for(not seeing/woiting ta.ee) 

a doctor for this condition? ;OIA 04 D 07 G 10 J(2) 13 K(l) 16 K(4) 

Circle the appropriate statement letter in ~ 02B as E a8 H II J(3) 14 K(2) 

the space to the right. / 03C as F 09 J(l) 12 J(4) 13 K(3) 

1 

! 

6. Do you still have this condition? 1 lY 2N 

Show whoresponded for this supplement. ~ I � Responded for self 

If other than self-respondent, show I 

RB __ ~~resPOnded forhim.	 I Person _was respondent ~_________________________________________________ 

If other than self-respondent, give I O � Under 17 RESPONDENT reason for accepting a proxy. i I � Mentally Incompetent 

I 

I 2 � Physically incompetent 

! 

I Show how the information I supplement was obtained. 

on this i

I 1 � Completed during initial interview 

TYPE OF z � Completed by return visit 

INTERVIEW I s � Completed by a telephone cal I back 

GO TO AS, CONDITION PAGE 
ARTHRITIS: CY 1969 

~;5Mf/S-2A (1969) BUDGET BURBAU NO. 68-R1600 APPROVAL EXPIRES MARCH 31,1970 

W% DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS Psu Segment Serial No. Sample ACTING AS cOLLECTING AGENT FOR THE 

U.S. PUBLIC HEALTH SERVICE BU.S. HEALTH INTERVIEW SURVEY Name of sample person Person No. 

ARTHRITIS SUPPLEMENT 

I fame of interviewer Code I n Responded for self I 

1 OR 

Person number of respondent+! 

Footnotes 

IOTICE - All information which would permit identification of the individual wil I be held in strict confidence, will be used 

lnly by persons engaged in and for the purposes of the survey, and will not be disclosed or released to others for anY purpose. 
I 

Earlier in the interview you told me about --’s arthritis 1 a.m. 

(rheumatism, . . .). This is a matter of special interest to the p.m. Us. public Health ~rvice, and I have same additional questions Starting time . . . J 

about it. 

a.	 During the past 12 months, have you had any STIFFNESS in 

your Iaints when first getting out of bed in the morning? t = Yes 2 n No (2) 

_a.mo H Never b. What time of day does this stiffness usually go away? _p.mo 

c.	 During the past 12 months, have your WRISTS been stiff 

when first getting out of bed in the morning? 1 = Yes znNa 

:a.	 During the past 12 months, hove you had PAIN in your 

ioints when moving them? I ~ Yes 2 n No (3) 

b.	 During that period, have your WRISTS been painful when 

you moved them? I a Yes 2=N0 

ia.	 (During the past 12 months) have you had SWELLING 

in any Iaints except in the ankles or feet? I n Yes 20 No (4) 

b. During that period, have you had any swell ing.in yatrr WRISTS? I a Yes 20N0 

a.	 (During the past 12 months) have you had PAIN or SORENESS 

when you touch or press an your Ioints? I = Yes 2 a No (5) 

b.	 During that period, hove you had any pain or soreness when 

yau touched or pressed on your WRISTS? I = Yes 2UN0 

If “YeS’” in questions I c, 2b, 3b, or qb ask 

i. Which wrist is bothered or affected by arthritis? 1 a Right 2 n Left 30 Both 

o.	 Durin ifre post 12 months, have an of the ioints in your 1 n Yes 2 D No (7) FING~RS been bothered or affecte J by arthritis? 

b. Please look at this picture of a hand. (HAND CARD D TO m I Red n 4 Gray 

RESPONDENT) Teli me what colors on this cord match n 2 Blue a None 

the	 iaints of your RIGHThrrrd ihot are bothered or affected m 3 Yellow 

by arthritis. 

c.	 Now your LEFT hand. What colors match the Ioints of your = I Red = 4 Gray 

LEFT hand that are bothered or affected by arthritis? D 2 Blue m None 

D 3 Yellow 

d. Are you right-handed .or left-handed? 1 U Right 2 a Left 3 a Both 

:oomotes 

96 
70.	 During the past 12 months, have your ELBOWS been bothered or = Yes 1 n No (8) affected in any way by arthritis? 

b. Which elbow is affected? 2 m Right 3 D Left 4 n Both 

8a.	 During the past 12 months, have your KNEES been m Yes I m No (9) affected in any way by arthritis? 

b. Which knee is affected? 2 m Right 3 n Left 4U Both 

9a.	 Do you presently have pain, swelling, or stiffness in 1 D Yes 2U No (/0) any ioint as a result of an old accident or irriury? 

b.	 Did this accident or irrirrry happen during the past 1 n During past 12 months (/0) 

12 months or before that time? z U More than 12 months ago 

c. Which ioints were hurt in this accident or in@y? Right Left 

n Neck Ankle . . 

n Upper back Elbow. . 

n Middle back Foot. . . 

m Lower back Hand. . . 

Hip. . . . 

Knee . . 

Shoulder. 

Wrist. . . 

10, Who was the FIRST person to tell you that you had arthritis? 1 n Medical doctor 

2 n Chiropractor 

3 n Friend 

41_J Relative 

a Other (Specify) 

11. When did a doctor first tell you that you had arthritis? o U Less than 12 months ago 

a n Doctor never said it was arthritis 

_ Years 

9 n Doctor never seen 

12.	 When did your arthritis bother you the most-during the past 1 u During the past 12 months 

12 months, when you first noticed it, or at some other time? 2 n When first noticed it. 

3 n Some other time 

13. Have you �ver been treated by any of the following people for your 

Arthritis­

. a foot doctor (chiropodist or podiatrist)? 

b. a physical therapist? 

c. an occupational theropi st? 

4a. Have you ever seen a social worker for your brthritis? 

b. Was the social worker from a hospital? 

1 m Yes 2=N0 

1 = Yes 2DN0 

1 = Yes zmNa 

m Yes I Q No (/S) 

2 = Yes 3DN0 

97 
--

TABLE I 

Are yau now using

15. Have yau EVER used (any of the fallowing) far for your arthritis? 

your arthritis - (1) ~ 

Where are the splints ar 

a Yes~ casts worn? (Specify) 

a. Any splints or casts? 1 u NO (b) 2n Yes 3DNo(4 

Wher& are the braces warn? 

D Yes~ (Specify) 

b. Braces of any kind? I n No (C) 2nYes 3D No(c) 

.$i ,,’:, .; m .. ’,’?’ , Yes~ 

c. Diathermy ar paraffin? lUNo(d) 2n Yes 3DN0 I ,-

? ,,: 1,, ,. 

,, ,> 

n Yes~ .’ do Hot packs, hot baths, . . .. or a heating pad? 1 n No (e) 20 Yes 3DNa ,4 ,.,, 

= Yes~ 

e.€ Cold packs ar ice treatment? Ia No(f) 20 Yes 31_JNo . 

.. 

m Yes ~ 

f. Rest recommended by a doctor? I O NO (d 2n Yes 3UN0 ,, . ,... 

g.€ Exercises recommended by a dactor = Yes ~ 

or physical therapist? 1 D No(/6) 2n Yes 3DN0 

1 n Yes zaNo (/7) 

16a. Are you now taking Aspirin, Anacin, ar Bufferin far your arthritis? 

b. Do you take it every day? I a Yes 20 No (/7) 

c. About haw many da yau usually take each day? _Number per day 

d. Do you usually take the same amaunt every day? 1 n Yes 2DN0 

o 0 Less than one month 

e. How Iang have you been taking aspirin every day? —Months —Years 

117a. Are yau presently taking any infections or shots for your arthritis? I m Yes 2DN0 (18) 

b. Are any af these infections “gold” shats? 1 a Yes 2HN0 

f‘ootnotes 
--

18a.	 Are yau presently taking any (other) drugs or medicines that 

were recommended by a medical doctor for your arthritis? I n Yes 2m No (/9) 

1 0 Butazolidin, Sterazol idin, Tandearil 

2 n Aristocort, Cortisone, Decadron, 

b.	 What are the names af these medicines? * Medrol, Prednisone 

4 D Darvon, Soma, Tylenol 

n Other 

(Specify) 

19a.	 Have you EVER used any remedies or medicines for your 

arthritis either on your own or that were recommended by 

someone OTHER than a medical doctor? 1 m Yes 2 n No (20) 

b.	 What kind af remedies or medicines did yau use? 

(Enter name or description of remedies or medicines 

in column (a) of Toble / I below.) 

c. Anything sise? m Yes (Reask (19b) u No 

TABLE II 

Have you used at Did you ever talk ta 

Remedies or medicines any time during the a medical &ctor 

past 12 months? about using --? 

(a) (b) (c) 

1. 

L 

L 

L 

L 

;. 

r. 

Footnotes 

1 = Yes 2mNo 1 m Yes 2DN0 

1 m Yes 2nNa I = Yes 2mNa 

I m Yes 2mNo I n Yes 2DN0 

1 D Yes 20N0 I m Yes 20N0 

1 m Yes 2nNa 1 a Yes 2nNa 

lmYes’ 2DN0 1 a Yes 20N0 

t m Yes 2DN0 1 D Yes 20N0 

99 
Some people need help because of artfrritisFor each “Yes” answer, ask: 

What kind of help is this - a 

person or some kind of aid? 

1 Do you use the help of anotfmr person or special aid­

(a) when getting in or out of an automobile? m Yes t n NO (5 2 n Person 3 = Aid 

(b) when going Up or down stoirs? n Yes I n No (C) 2 a Person 3HAid 

(c) when getiinginorartof a tub or shower? O Yes In No(dj 2 n Person 3 n Aid 

Do you use the help of another person or special aid-

(d) in order to completely dress yourself? a Yes I m No {e) 2 I_J Person 30 Aid 

(e) in ordor to feed yourself a complete meal? = Yes II___J No(f) 2 n Person 3 n Aid 

(f) when rolling anto your side in bed? = Yes 1 DNo(21) 2 a Person 3 D Aid 

le. Doss your ARTHRITIS cause you to sit or lie down to rest 

dt any time during the day? I ~ Yes 2 n No (e) 

Time a.m. 

b. At what time do you usually sit or lie down to rest? _ p.m. 

c. DO you rest some every day? I a Yes 2 n No (e) 

Hours	 ~.Minutes 

I d.	 How long da you ustrally rest each day? 

Time 

� . What time do you USUALLY get up in the morning? — a.m. 

ootnotes 
... . . . ..:,:, ...... . .. . .....

. .. .... ... . .... .,,,,. .. .::;.,.. ......... ,, . ,,, . ..... . ....

--

. .... ......... ... ,,,

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

--

. . . !2a. Are you PRESENTLY seeing anyone for your arthrltls?. . . . . . . . . . . . . . . . 1 m Yes (c) 2 n No (b) 

b. Could you tell me why you aren’t presently seeing anyone far your arthritis? 

t n Arthritis not severe enough (23) = Other (Record response verbatim) 

(23) 2 I_J No one can do anything for it (23) 

c. Who are you seeing? Check al I categories in Table III that apply. 

d. Are you now seeing anyone else for Then ask the appropriate questions for each 

your arthritis? category marked. 

} 

, ,,.:..’ ,:::::: ,.::::,,,,.,?,, .,:

.. “;::;. . 

,,-::,,.~ TABLE Ill .,..,,,,,.; 

rype of person m Medical doctor + 

I.	 What is the nome Name and address 

and address of the 

dactor you see? 

2. Why did you decide I n He’s a family doctor 

to go to this 2 n Referred by doctor 

for your arthritis? 3 D	 Referred by someone else 

4 I_J He’s an arthritis 

specialist 

a Other (SPecifY) ~ 

la.	 Is the doctor a 1 Cl General practitioner(4) general practitioner 

or a specialist? a Specialist 

b.	 What kind of 

specialist is he? 

4.	 When was the LAST I a Past 2 weeks 

time you saw for — Weeks 

your arthritis? _ Months 

5. k&ere did you see I a Doctor’s office 

--~ ot his offie% z m Hame (Next column) 

your home, or some 

other place? n Other (Specify) ~ 

5.	 About how long did _Minutes 

it take you to get 

to the --? _Hours 

7. HOW did yau get to t m Bus or subway 

and from the --? 2 I_J Taxi 

3 m Private car 

U Other (Specify)z 

n Medical doctor 

Name and address 

1 EIHe’s a family doctor 

z a Referred by doctor 

3 D Referred by someone else 

4 n He’s an arthritis 

specialist 

D Other (Specify) 

7 

I	 U General practitioner(4) 

n Specialist 

1 D Past 2 weeks


—Weeks


_MontJts


1 m Doctor’s office 

2 jg Home (Next column) 

D Other (Specify) ~ 

_Minutes 

_Hours 

1 n Bus or subway 

20 Taxi 

3 a Private car 

n Other (Specify)~ 

. . .. .. . .:,,:,,’, ~.,. . . .
 ~ ,,., .,
 j., . . . .. .,“, .::, ‘,
 ., ,: .,.,.... .... > .,


n Other (Specify)


.,.,‘.’;’; ;..:::., +.;.,:;.. , , ,, ,,.:, . ::.::.. .,.,,,, .,..,, ,,,,,,,,y,j. .,: ., ..::.. .+;:,.:.. ..:.,.,,.. ..,:>,, ; y,, ,...:.,. . ,,;..:? ,,,., ,.: ,., . ,.,, ,,, ,.. ,. ...:.. . .,,,,,,, 

..,,.:, .,..,,,..:.::. ::. , .::. .!..., ,,.:. >..,.,., , ,. ,,.

10 He’s a family doctor 

2 n Referred ,by doctor 

30	 Referred by someone else 

4 D	 He’s an arthritis 

specialist 

n Other [Specify)7 

,,.,,,. .:,. . . <.:{..,. ,

, .::..:.:.. .,, ,,:, ,,.,:. .,,,;. ,,,.,., . ,. ,.,’” 

I n Past 2 weeks 

—Weeks 

—Months 

20 Home (Stop) 

D Other (Specify) ~ 

_Minutes 

—Hours 

1 n Bus or subway 

2 n Taxi 

3 Ig Private car 

a Other (Specify) 

7 

101 
23a. Have yau ever had any special iob training because of your arthritis? I t= Yes 2 n No (24) 

Name of place 

b. Where did you receive this training? 

24a. Have yau �ver changed or left a iob because of yaur arthritis? ] ll_JYes(c) zl_JNa 

b.	 Have yau worked at any time since au had arthritis­

(For females add: not taunting war L araund the hause)? f a Yes 2 D Na (25) 

c. In general has yaur awn income decreased because of yaur arthritis? I tUYes ZUNO 

I n Yes 2 D No (STOf 

25a. Have you ever heard of the Arthritis Foundation? 3 m Don’t know (STOP) 

Describe 

b. Haw did yau first learn about the Arthritis Faundatian? 

c.	 Have you ever received any personal help, treatment, referral, 

or ather infarmatian fram the Arthritis Foundation? t n Yes 2 u No (STOI 

Describe 

d. What did the Arthritis Foundation do far yau? I 

Footnotes 
--

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

--

----

BLOOD DONORSHIP: CY 1973 

If 17 years old or over, ask: 

3a,	 During the past 12 months, has given or sold any blood to a blood bank, 

a hospital, tht Red Cross, or anywhere else? . _____________________________________________________________________________ 

b.	 During the past 12 months, how many times has given or sold his blood? b. I —Times 

----.-- ________________. (Los 

For each donation reported In Q, 33b, ask rime) I 2 3 4 5-spec/fy 3 

c. Which of tht raosons listed on this card (Hand Card B) best describes why c. 1 

gave blood (the last time, thetime before that, etc.)? I 2 3 4 5-specl&’ 

$ 

2 

I 2 3 4 5-specMy 

? 

3

I4 

I 2 3 4 5 -specl&z 

s. 
DIABETES: FY 1965


‘02~yIJHS-HIS-l(d) (FY.1%5) BUDGET BuRBAu NO. 68-R62O.1O 

APPROVAL EXPIRES JULY15, 1965 

U.S. DEPARTMENT OF COMMERCE Psu Segment Seritd No. Sample BUREAU OF THE CENSUS 

AcTING AS COLLECTING AGENT FOR THE B U.S. PUBLIC HEALTH SERVICE 

NATIONAL HEALTH SURVEY Nsnre of person with diabetes Age 

DIABETES SUPPLEMENT 

RESPONDENT RULES FOR DIABETES SUPPLEMENT 

If fie person for whom tbe Diabetea Supplement istobecompleted issn eligible 

respondent according to the regular eligible respondent rules, he is to respond for 

himself. Ifheisnot athomeor o&erwise notavailable, make amangements fora 

return call to interview him. (Two additional calls to contact him may be made.) 

E the person is not an eligible respondent, or isunable to respond for himself 

because of disability or illness, complete theinterview with therespondent who 

knows most about the person’s diabetes. 

If the person is not going to be available for interview at any time during interview 

week, complete the interview with the respondent who knows most about his 

condition. In either case, explain in a footnote the teason forthe use of the proxy 

respondent. 

ktotnotes and comments 

Returns Date Time Completed No tECORD OF RETURN CALLS TO rstum 1 

:OMPLETE SUPPLEMENT calls 

u ~ 

broe of interviewer Code n Responded for self 

OR 

Column number of despondent+ 

CONFIDENTIAL - T& information is collected for the U.S. Public Heslth Service under authority of Public Lsw 652 of the 84th 

tingress (70 Stat. 489; 42 U.S.C. 305). All infomtation which would pennitidentifkxionof theindividual will beheld strictly 

mnfideatial, will beusedonly bypersonsengsgedin sndforthe putposesof the survey, andwil~not bedisclosed orreleaaed to 

xhers for soy other purposes (22 FR 1687). 

uSCOMht-DC 250W P.64 

104 
--

/ 

QUESTIONS DEFINITIONS 

n the interview you (your , etc.) told me about your diabetes.. This is a motter of continung interest to the Public Health Service and I have some additional questians about it -

.	 About how old were you when a doctor first told you 

that you had diabetes? Age Estimate is acceptable 

la. Before you were (Age ,n ~ueat,on J, hod you ever 

been told by a doctor that you MIGHT HAVE, or D Yes D No MIGHT BE GETTING diabetes? 

A glucose tolerance 

test is a sweet drink 

followed by one ar 

more blood testa taken 

b. Have yau ever hod a glucose toleronce teat? m Yes I_J No the same day. 

Rand respondent Card NHS-HIS-l(C> NOTE TO INTERVIEWER 

la. Please look at that card and tell me which 

of those symptoms you had at the time you When the respondent mentions 

first fdund out that you had diabetes.	 one or more symptoms, check tbe 

‘*Yes” box fot each sym~tom 

menrioned and then ask ‘Any 

others?” Continue to ask unril 

(Check “Yes” or “No” for each symptom an answer of “No” is given. 

listed rmder “At time of diagnosis”)• Either the ‘“Yes” or “No” box must be checked for each 

symptom. 

At time of Present during , 

diagnosis past monrh 

Yes No Yes No 

Thirst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n n a 0 

Larger appetite than usual . . . . . . . . . . . . . . . . . . . n m n m 

Smaller appetite than usual . . . . . . . . . . . . . . . . . . n n n n 

Legpain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n n n n 

Extreme tiredness . . . . . . . . . . . . . . . . . . . . . . . . . . n n n n 

Eye trouble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n n c1 n 

Itching . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n n n n 

Sudden weakness (associated with trembling, 

shakiness, and cold sweats). . . . . . . . . . . . . . . . . . n n n n 

Losa of weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n .0 n n 

Frequent rrrination . . . . . . . . . . . . . . . . . . . . . . . . . . n c1 il c1 

Boils orcarbuncles . . . . . . . . . . . . . . . . . . . . . . . . . n n no 

), 

b.	 Please look at the card again. Did any of thase 

symptoms bather yau at any time during the pust 

30 days? 

~yes ‘N” Which symptoms did yau have? (Check each 81y=## Or $8NoPJ ~der f~pre~~t &ri@ 

past month”) 

la. Were yau in the haspiial at the tinre the dactor 

faund aut that yau had diabetes? a Yes D NO	 (Go to 

questfm 5) As an inpatient 

b.	 Were yau there because yau had aymptams of 

diabetes? n Yes fti to n No~=toon ~~ 

question 6s) 

FORM NHS-H IS-1(d) (FY-1 965) (4.27.641 

105 
61 

I 

1 

I 

I 

------

--

--

r ? 

OUESTIONS ~————-—-. — t Tll?FfNITIONS ——. — .- n “ 

(,Ask only if “No” in question 4a) 

5L	 At the time your diabetes was first discovered, were 

you sent to the hospital for regulation of your 

diabetes? m Yes D No As an inpatient 

10. (Not counting that first time) Have you ever been hospitalized because of your diabetes? m Yes a No:e:tfln ,a) 

b. About how many times? Number Estimate acceptable. 

Several reasons rn+y c. Have you ever been hospitalized (Ask all 4 parts) be given for any single 

hospital stsy. 

--for diabetic coma? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .I_J Yes n No 

-. fOrinsulin reaction? . . . . . . . . . . . . . . . . . . . . . . . . . . . . m Yes n No 

.. fOrgongrene? . . . . . . . . . . . . . . . . . . . . . ..o . . . . . . . . ..n yes O No 

-. forregulation? . . ..o . . . . ..o . . . . . . . . . . . . . . . ......aye~ a No 

7(‘o.	 Have you ever hod o nurse come to your home to 

help you in taking care af yaw diabetes? I_J Yes n NO(GO::on ,=) 

ib. Abaut haw many times has she visited 

you during the past 12 months? Number I_J Nose . 

c.	 I Where do yau usually go for care of your diabetes 

a clinic; a dactor’s affice; ar some other place? n CIinic I-J DOc:% 

m Some other place (specify) 

. 

d.	 Daes the doctor you go to far your diabetes 

SPECIALIZE in the treatment of diabetes? D Yes n No . 

e.4 How long have yau been going to him � Less thsn for your diabetes? Years one year 

8,a.	 Haw man brathers and sisters have you 

had --ejt1 er living or dead? Number n Non:,~: :, 

Ib.	 Did any of these brothers or 

sisters have diabetes? Number D Nane 

(

c. Did your mother hove diobetes? D Yes n No 

,

d. Did your father have diabetes? I-J Yes I_J No 

(1If “ever married, ” ask) -

Exclude stepchildren, 

9)a. Haw many chi Idren have you ever had? 

Number H N::t::;:a) sdopted chlldten, and 

foster children 

(iIf nmnber entered in question 9a, aek) - L 4. 7. 

Accept estimate, b.	 How much did eoch of your children enter answer in paunds ~eigh at birth. . starting with the 2. 5. 8. and ounces. oldest? If pounds only are given, 

3. 6. 9. this is acceptable 

;[f “1” or more in question 9a, ask)­

c. Did any of your children have diabetes? Number n None 

ti USCOMM-OC2S036 P-64 

106 
QUESTIONS DEFINITIONS 

Da. Have you overtaken insulin infections? D Yes a NOfGO t. 

question 14) 

b. Howmmvy years have you taken Roupd to nearest whole year. 

insulin	 infections? Number D Less than Estimate acceptable. one year If the respondent is not taking 

c.	 Have you been taking insulin infections daily insulin at the present time ask: 

for most of the post 12 months? D Yes a No “How many years did you take it? 

d.	 Areyou NOW taking insulin infections? ~ Yes n NO(GO to 

qvestion 14) 

la. What kinds of insulin are you NOTE TO INTER VIEWER 

now using? n Regular, plain, or crystalline How was information for lla and 1lb obtained? 

D Semi-lente m Globin a NPH (Check all that apply) 

O Respondent gave information 

a Protamine D :~-

zinc n Lente I_J Other family members gave

n a Other (Descrfbe) 

b. What strength insulin are you i-Ju40 DU80 

now using? n Other (Specify afr.ngtb) 

c. Do you usually take your insulin iniectian 

before meals? Yes n NO(GO:. 

w..tion Xle) 

* 

d.	 Which meals? (Cfreck all Umt n Breakfast a #1”~ a Supper 

aPPIY and go to question Ilf> (Evening) 

e.	 When do you usually take your insulin? 

(Enter time of day and go to questian Ilf ) Time 

f. If you delay toking your insulin 

for an haur or more does it make n Yes n Na m Never delay (Go to yau feel sick? question Ilh) 

g.	 When was the last time you 

delayed taking your insulin for m &&m D 30 days m Never delay 

or more an hour or more? 

h. Do you iniect the insulin yourself? a Y~jt~mt;2) a No 

Who iniects+the insulin? n Relative D Nurse n Other persaa 

(Check all that apply and ga to question 13a) 

2.	 Who taught you how to iniect the m Doctor n Nurse n Relative 

insu IIn? (Check appropriate box 

eud ask qaestion 13a) D Other D Not taught 

person 

30.	 During the past week, in what a One arm a Bath arms D One leg 

parts of the body hove you been 

iniecting the insulin? n Both legs D Abdomen a B.ttacks 

(Check all that apply) a Other (Describe) 

Anywhere else? 

b. How are your syringes and D Alcohol n Use disposable needle 

needles cleaned and sterilized? 

a Bail a Use disposable syringe 

(Check all that apply) 

a Other (Specify) 

4. Do you usually carr candy or fruit or sugor 

or similar items wit 1 you? a Yes m No

FORM NHS-HIS- l(dl (FY-19135) (4-27-64) 

reformat ion 

Information obtained from 

bottle or some other source 

The “past week” is the 

week ending last Sunday 

night. 

107 
QUESTIONS DEFINITIONS 

5a. Doyauknow what an irtsulin reaction IS? g Yes D No (Go to 

quedion 17) 

b.	 Have youever hadan insulin reaction? n Yes U No::t:n ~6a) Sudden weakness, trembling, 

shakiness, cold sweats 

c. Howmmry insulin reactions have you had 

during the past 30 days? Number n None 

d.	 About howmany hove you had during 

the past 12 months? Number n None 

e. Hove you ever used Glucagon? I-J Yes U No c1 D#Ji%w Glucagon: 

A drug aametimes used 

by persons with diabetes 

6a. Can an insulin reaction be to counteract insulin caused by too much food? n Yes a No n Don’t kllOW shock. 

b.	 Can an insulin rerxctionbe 

caused by too much exercise? n Yea n No n Don’t know 

c. la on insulin reaction the same 

as a diabetic cama? n Yes n No n Dan’t know 

7.	 Can a persan with diabetea n Yes n No n Dan)t know 

exercise aa much as other 

people? 

80.	 Have you ever taken diabetea pills? D Yes n No (GO to 

m’leatio” 204 

b. ~e:,many years have you been taking Numbet n ;Yesrths. Round to the n$arest 

whole year, estimate 

c.	 Have you taken them moat of the past 12 months? n Yes I--J No acceptable. 

If respondent is nat t*ing ills at preamt d.	 Are you now taking diabates pills? n Yes j_J No <GO /. time asi : queatfon 200) ,, Haw many years 

9a. How mmry pills da you take each day? Nunrber did you take them? 

b. Do you usually toke your pills before meals? Yes D No;:t;: 19 

+ 

c. Which meals? D Breskfast n &oo;h a Sapper 

(E.enfnd) 

d.	 [f you delay taking your pills far 

;;e~~;;; more does it make you D Yes n No m Never delay 

(Go toqmation 20a} 

e. When was the last time au delayed � ;:~.;rm n 30 days � Never delay 

more ? or mare 

Oa. Do you test your urine for sugar? m Yea D No::ti: ~1) Testing by persan himself 

or +s-e relative nat a 

physlclan, pharmacist, etc. 

NOTE TO INTERVIEWER 

How was ~rrfartnatian for 20b 

obtaiaed? 

takin your pills for an i our or 

b. What test da you use? n Benedict’s test D Clinitest 

(Check all fhat apply) 

� Clinisti. H Other (Spscify) � Respondent gave information 

D Oc$~r)c~i~y members gave 

a Testape n paforyoy=:nO:t:&J $00== 

USCOMM.DC 2S086 P-64 
QUESTIONS DEFINITIONS 

20c, How many times did you test your urine 

last week? Number None *tLast week*~ is tbe yeek 

(If number is enterpd, go to question 20.) endiag last Sunday n:ght 

~ 

d.	 Whmrwos thelaet time youtested it? 

(Enter verbatim) 

� .	 Do you write down any of the results of 

these tests? Yes n No(o-a to 

queatian 20& * 

This means the record or notes f. Dayoushow this to your doctor? n Yes n No of the tesuks of the tests 

9.	 Did you test your urine for anything else besides 

sugrrr at any time during the past 12msnths? Yes O-NO 

!1. About how toll are you? 

(Feet) (Inche.> 

!20. About how much do you weigh? (Pound.) 

b.	 What isthemost youhave weighed during tfre past 

12 manths? (Pounds) Not coming pregnancies 

c.	 What is the least you have weighed during tfre post 

12 months? (Pound.) 

4sk this question if perawr is 25 years old or over (if under 25, go to question 24)) Youngsters apersan O-25 years 

Overweight is weighing more than 

3rt.	 When yau werea youngster were you ever the person himself or his &ctor 

overweight? n Yes n No thinks that he should weigh. 

b. Whnt is the most you have weighed since you were 

25 years old? (Pounds) Not counting pregnancies 

c.	 What is the least you hove weighed since you were 

25 years old? (Pounds> 

4. Were either of your porents overweight? D Yes D No 

50. Who prepares most of yaur meols? n ::5:, a other (~pecify) 

(Check	 one) 

relative 

a SsIf 

b.	 Do yo or the person who fixes your meal+ use any o yes 

specla“7 recipes prepared far persons with diabetes? n No 

ia. Cnn you name some foods thnt can be substituted for meet? 

(Enter first two mentianed) 

b.	 Can yau name some drinks which have very Drinks mean non-alcahalic drinks. 

few calories? 

(Enter first twa mentiased) 

c.	 Con you name same vegetables which have 

very few colories? 

(Enter fht two mentioned) 

h.	 During the post 30 days have you eaten any P sstry made with sugar 

pastries? n Yes n Na 

b.	 During the past 30 days have you enten any 

cmrdy made with sugar? n Yes n No 

FORM NHS. HIS.l(d ) (FY.196sI (4.27-64) 

109 
2’ 

, 

QUESTIONS I DEFINITIONS 

21!8. During the past week did you The “past week” is the 

--drink any dietetic soft drinks? . . . . . . . . . . . . . . . . ..n Yes i_J No week ending last 

..eotcnydieteti CCann=df, uits? . . . . . . . . . . . . . . . . . I_J Yes n No Sunday night 

.- We any ~rtifical sw=ete”ers such as saccharin ?.. n Yes m No 

..eat any other d[etefic food .. .. . . . .. . . . .. . .. . ...0 Yes n No 

(If “Yes,” specify below) 

“Dietetic” means food 

specially prepared with 

little or no sugar 

!9. How many calories a day are you allowed? Number . 

3[10a.	 Hnve you been given o diet for your ~ Yea n No (c% t. Written, typed, or printed 

diabetes? question 350) instruction about fond 

b.	 Who taught you how to use a Doctor n Nurse a Parent 

this diet? 

n Dietitian or nutritionist 

n Not taught n Other (specify) 

Who gave you the diet? 

(Enter person’s occupation) 

c.	 How long hove you had this UIX: n 3 months n Over 

diet? to one one 

3 months yest year 

d. Do you follof+ this diet? n Yea No 

“Yes” means usually or #fJ@ (Go to qu.aatlon 3.%) most of the time 

e.	 Is the diet list used as a guide in the n Yes (.. to I_J No 

preparation of your meals? quearirn 31a) 

f.	 When did you last look at your D T&k;th n I.-lhs D Over 6 q,YouII means respondent 01 

diet list? months person prepming the meals 

3310. Does your diet give the size of food portions? Yes a No (GU to 

queatlrn 32) 

+ 

b.	 Do you measure, weigh, or 

estimate the portions? n Measure I_J Weigh m Estimate 

(Check all that apply) u 332.	 Do you have to follow your diet carefully 

in order to feel well? n Yea n No 

333a. Do you ever eat away from home? Yes 

n ‘owfii: 34a) 

+ 

b.	 Do you hove trouble foIlowing n Yea n SOme- O No your diet when eating away times from home? 

3340. Does your diet include a list of food a Yes D No (Go to 

exchanges? queetfm A food exchange list 35s) arranges foods in groups 

b.	 Without looking at the list can you tell Enter “*No.”’9*DK,”’ according to their food 

me how man bread exchmges you are JiVe:o;f::’%, Ke%y;: values pecmitring substitu­ allowed eac x day? havc yesterday? tion within each group 

(If “No’) or “DK,” go to que8tion 35. If ask~ 

number is given, enter it and a8k about 

tbe remaining food exchanges listed below. ) 

How many vegetable exchanges are in your diet?... 

How many tiuit exchanges are in your diet? . . . . . . . 

How many milk exchanges are in your diet? . . . . . . . 

How many meat exchanges are in your diet? . . . . . . . 

How mrny fat exchanges are in your diet? . . . . . . . . . 

c.	 Do ou have any problems in using your n Yes n Na 

� xc1ange list? 

What are they? 

(Enter verbatim reaponee) . 

110 
---

QUESTIONS DEFINITIONS 

35a. Here are the covers of three pamphlets. L%OW special Diabetes pampldeta) 

Have you ever had a copy of any of these


pamphlets? Yes n No


J 

b. Which? (Check all that apply) a A DB DC 

360.	 Were you taught how to take core of your feet a Yee � No (Go /. 

to avoid infection? queetfon 36c) 

b. Haw do yau take care af your feet? (Enter verbatim response) 

c. During the past 12 months have you visited 

o foot doctor? n Yes a No Podiatrist or Chiropodiac 

]70.	 Have yeubeen toadoctor tohave your eyes 

examined during the past two years? a Yea a No 

b.	 Doyousee better in the morning n Morning a Afternoon a j;f=r=nce or in the afternoon? 

18a.	 lfYauhcrd abadcold, would yOu 

talk to yaur doctor? n Yes D No 

b.	 Ifyouhad askininfecti.an, would 

you tolk to your doctor? n Yes n No 

c.	 [f you hadthrownwrp, would you 

talk to your doctor? a Yes I__J No 

)96. Have youever attended classes tolearnobout 

diobates? Yes n NOW:: ;Oa) 

b.. Who gave the classes? D Hospital a :~&$(mcaos out-patient 

n Health 

department n Other (specify) 

a Diabetes 

association 

Oa.	 Are you a menber of a diabetes association 

or similar group? Yee n No~~;” ~1) 

+ 

b. What ia the name of this group? 

1,	 What ore your most difficult problems in coring for your diabetes? 

(Enter verbatim reapocme) 

\ 

LEAVE ‘“THANK YOU” LETTER AND DEPART 

,,---..., . . . . . - FORM NHSHIS.t(d) (FY-1965) (4-27.04) “.*”mm-”* . . . . . I----. . 

111

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

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

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

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

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

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

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

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

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

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

HYPERTENSION: CY 1974


Person number ! � SP under 17 (hfed/ca/ Cam Pago) 

HYPERTENSION PAGE HP1 2D EliglMeresp. wall, (1) 

(SAMPLE PERSONS ONLY) 3nRewrn call required 

(Next Hypertenslci? Pege) 

L Have you EVER been tc.ldby adocfor fhatyou had high blood pressure? J-Y (7C) 2 N 

b.	 Another name forhigh blmdpreswm ishypertensimr. Haveyou EVER been told 

bvo doc@r-&_t~ou hadhWSIte@S~? lY 2 N (70) 

c. Abwt how Iongagowem you FlRST6~~I~;=;;t; ;fi;;~o;-h;~lfi~; ~~;~---------------------- ~oon~e*~*a” , ~mt~ 

pressure/hypertension)? 1 —Months 

2 Years 

. During the~st12montis about howmany times have ~useenortilkedha — Times 

doctor ab+ut your (high blood pressurdkypertcnsiw)? 000U None 

. H.s. doctor EVERadvised youtil.seweifit BECAUSE OF(HlGHBL~D 

PRESSURE/Hypertension)? lY ZN 

a.	 Do youngw use more salt, less salt, orobout thesame amount ofsoltsinca 1 � Mme 

you learnedyw had (high blood pressurdrypertensi. an)? 2 � Less 

3 � %.me 

D. Were you EVER advised by o doctor, nurse, or other medical person to use less salt? lY 2N 

o. Has o doctor EVER prescribed medicine for your (high blood pressudhypertcnsion)? 

b. Are you now taking an mrdicine pres.ribcd by a doctar for your (high blwd 

E=%.IE&wss.s,Jl -;-;-------------:-:;:1------

c.	 How often arc you supposed to take this medicine - more than once a cloy, once a day, 1 H More than once a day 

or IQSS then once a day? 2 I_J Once a day 

s � Less than once 8 day 

d.	 How often do you take your medicine when you arc supposed ta - all the time, often, 1 (_J All the time 

once in a whil*, or n*v9r? 2 � Oftcm 

3 � Cnce in a while 

0 � Never 

� Other (Sp3Clty) ~ 

�. Ooes your medicirm �vtr cause any side �ffccts or make you feel funny in any way? 1 Y (6) 2 N (6) 

f. Why did you stop taking the medicine? Any other reason? 1 � Doctor’s advice (5h) 

z u No longer has high blood pressure 

3 � Side effects 

� Other (.9p3c/fy) ~ 

! 

Mork all that apply 

-. 

g. Oid a doctor advise you to stop toking flw mcdicino? lY 2N 

If “Side effectc” in 5f, go to 6 otherwise ask 

h.	 Rlron you wera taking this medicine did it cauae cmy sido Acts or mokeyou feel 

funny in any way? lY 2N 

112 
------------------------------------------------------------------------- ------ ----

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

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

--

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

-- -- -------

Days 6, ABOUT how many days during the past 12 months has (high blood pressure/hypertension) 

kapt you in bed all or most of the day? 000 � None 

If “No longer has high blood pressure” in 5f, go to 7d; otherwise ask 1 � All the time 

2 � Often 70. How often does your (high blood pressurdrypertension) bother you - all the time, 3D Once In a while often,	 once in a whi I*, or never? 0 n Never (7c) 

� Other (Spsclfy) ~ 

—--- ———---—--— ——---— 

b.	 Wfmn It doss botber you, are you bothered a great deal, some, or very little? 1 � Great deal 

2 � Some 

3 � Vey I Me 

� Other (SIXWfy) ~ 

_-___________ - _ —______ . —- — 

If “All the time” in 7a, go to& otherwise ask 

c.	 Do you still have (high blood pressurdhypertension)? 1 Y (8) 2N 9 DK _________________________________________________________________________ —— — —-------

d. Is tbls condition completely cured or is it under control? I � Cured (10) 

2 � Under control 

8. Can you tell when your blood pressure is high - that is, do you hove any symptoms? lY 2N 

9. Have you �ver bean refused life insumnce or heolth insurance coverage because 

You had (high blood pressurdhypertensiort)? lY 2N 

Oa.	 Has a doctor EVER talked to YOU about problems that can be caused by high blood 1 Y (HP2) 2 N Erg~s~~c_9r-hypertension? __ ________________ –––___–_–– _____ - —----------- —- —- ————————-—-

b, Has a nurse or other medical person EVER talked to you about problems that can lY 2 N (HP2) be caused by high blood pressure or hypertension? ------———--------——--—— 

c.	 What type of medical person was this? I � Nurse 

� Ofher (Spsclfy) ~ 

� No 2-week OV in Cl (11) ., 

Refer to THIS PERSON’S doctor visit columns. ,.:. HP2 � 2-week DV in Cl If “Y” in 7a in ANY column, go to 14 otherwise .’ ,, 

} go to Il. ,: 

., ., . . 

1.ABOUT how long hos it been since you LAST had your blood pressure taken? we � Never (76) 

2. who took your blood pressure the LAST time? 

000 � Less than I month 

I_ Months 

2 Years (16) 

1 n Oocror 

2 � Nurse 

3 � Friend or relative 

4 H Orugglst 

saSclf(73b) 

� Other (Spec/fy) ~ 

13a, Wer* you told that your reoding was high, low, normal, or were you not told? 1 � High 

2 � Low 

s � NOCIT=J


4 � NoCrold (14)


H Other (SRc/fy) ~


_________________________________________________________________________ } —---- ———- — —------- b. Was your reading high, low, or normal? 1 � High 

2 � Low 

3 � Normal [15) � Other (Specify) ~ 1 ‘4. During the past 12 months, have you taken your own blood pressure? IY 2N 

5,	 During the past 12 months, how many times was your blood pressure taken? (Do not 

count times while o prrtiqt in o hospital.) —Times 

113 
------------------------------------------------------------------------- ------------------------------

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

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

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

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

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

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

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

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

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

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

----- ---

�

h.	 ABOUT how long has it been since you had an electrocardiogram, which involves 98 � Never 

placing wires on the chest and arms? 00 � Less than I year 

—Years 

b.	 ABOUT how long hos it been since you had a chest X-ray? 98 � Never 

00 � Less than I year 

—Years 

7a. ABOUT how much do you weigh? _ Pounds 

b. ABOUT how tall are you? — Feet — Inches 

c.	 Do you consider yourself overweight, underweight, or iust about right? I I_J Overwelzht 

z � Underweight (78) 

3 � About right (77e) 

d.	 Are you now trying to lose weight? 1 Y (1 7/) 2N ______________________________ 

e.	 Are you now trying to keep from gaining weight? lY 2 N (18) _________________________________________________________________________ ______________________________ 

f.	 Is this bused on advice from a doctor, nurse, or other medical person? lY 2N ______________________________ 

g.	 What ore you doing to (lose/control your) weight - watching what you eat, 1 � Diet 

xercising, or something else? Anything �lse? z � Exercise 

3 � Medication 

� Other (Specify) ~ 

Mork all that apply 

& Have you EVER been told by o doctor that you had diabetes? tY 2N 

9. Have you EVER been told by a doctor that you had heart trouble? lY 2N 

O. Have you EVER had a stroke? lY 2N 

10.	 Have you smoked at least 100 cigarettes in your entire life? !Y 2 N (Med/cn/ Care 

Pago) 

b. Do you smoke cigarettes now? lY 2 N (21e) 

c. On the average, ABOUT how many cigarettes a day do you smoke? — Clzarettes 

d. Hove you EVER tried to stop smoking? lY 2N 

e. Have you EVER been advised by o doctor to stop smoking? lY 2 N (Med/ca/ Care 

Page) _____________________________ 

f.	 Was this because of a specific condition you had ot that time? 2 N (Med/ca/ Care - ‘ y page) -

g. Matcondition was it? 

_________________________________________________________________________ ______________________________ 

h. Any other condition? Y (Raask 21g) N 

‘OOTNOTES 

114 
--------------------------------------------------------------------------

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

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

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

MEDICAL CARE AVAILABILITY: CY 1974 

MEDICAL CARE PAGE 

(SAMPLE PERSONS ONLY) Person number 

.	 18thcr@ ONEparticular doctor orplacc --usually gosstowhen heissick orwhen 

YOU nacdodvice about his health? IY 2 N (11) 

a, Whore do you go for this care or advice for --, to a clinic, hospital, doctor’s office, 1 =Privatedocmr,s office(s) 

or somcothsr place? 2 � Home (5) 

3 � Doctor’s clinic (2b) 

If Hospital: Isthisan outpatient clinic ortbe emergency room? 4m Group practice 

SD H.sPllal Outpatient Clinic 

If Clinic Isthisahospitol outpatient clinic, a company clinic, So Hospital Emergency Room 

or somtothtr kind of clinic? 7u Company or industry Cli”lc (3) � Ocher (Specify) ~ 

b.	 Is this a group practice clinic - that is, does it consist of three or more doctors 

_____________________________ 1 who share thr some equipment? lY ZN 9 OK 

o. What is the nom- of this (place) ? 

--------------------:--_--_ii&i5;;_fi;;;&;iiiiii;iii;ij________________ 

b, During the past 12 months, that is, since ‘--- “I=ic, ‘------

you s-e or talk to a doctor at this place a out 000 � None ___ ___ _____ _____

c.	 If something bothered you about --’s heclth, would you first gO to (name of place) I � Go m rezular place first 

or would you try to determine what was wrong and go to the type of place most appropriate 2 � Select most appropriate place 

for this kind of trouble? � Other (Spec/fy) ~ 

L Is thrre a PARTICULAR doctor usually sees at (name of place) ? IY 2 N (Ml) ____________ _ 

b, Is this doctor a general practitioner or a specialist? 01 u General pra.~i~io”er (Ml) 

� Speciaii.z _ 

Whet kind of speci.li.t i, he? 

7 

(Ml) 

a, what is the name of this doctor? � 2+ D.C,.,, (2b) 

.--- +------------------------ ~ 

b. During the post 12 months, that IS, s,nce (date) o year ago, how many t,mes d,d 

you	 see or talk to (name of doctor) about --? —visits 000 � None _______________________ ________________________ _____ ______

C.	 IS this doctor part of a group practice - that is, does he work with two or more other 

doctors and share the same equipment? lY 2N 9 OK 

. IS this doctor a general practitioner or o specialist? 0I � General praccicvan.c 

D	 Specialist -

What kind of spe.lolist is h=? 

7 

115 
--

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

---

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

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

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

--

--

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

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

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

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

--

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

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

7. If something bothered you about --’s health, would you first go to (name of dOctor) , or ! � Go to regular doctor first 

would	 you try to determine what was wrong and select the most appropriate specialist? 2 � Select most appropriate 

specialist 

� Other (SFZc/fy) ~ 

Ml Refer to “12klo. ISI” boxattop ofperson’s column ad rmrkss appropriate I � Ihmmh DV(8) ZCI No 12-mmth DV (17) 

8a.	 (Besides name of doctor ) During the past 12 months has seen a (ony other) 

doctor at a private doctor’s office? lY 2 N (9) . . . —-— -—------- _______________________________________ 

1 � One 

b. During thot period, how many (other) doctors has see” at o private doctor’s office? Doctors (Ed) 

___________ ______ __________ _______ -_=== —---- .- _?____ _-_ —- ________________ 

c.	 Did (name of doctor/place) EVER refer to this doctor? 1 Y (9) 2 N (9) 

-_-_ -____ - _ -- _ _ ----—---- .---= ________ .- —---

d.	 Did (name of doctor/place) EVER refer to ANY of these other doctors? lY 2 N (9) _________________________________ ________ ~ = ______________________________ —---------- ..----

e. Did (name of doctor/place) refer to ALL of these other doctors? IY 2N 

Did (name of doctorlp lace) 

refer him to this place? 

9. During 12~o”ths adoctor at (any of the hepast has seen
 (1)

following places) -

a. (A/any other) hospital �mergency room? 1 Y (Cal. 1) 2 N (9b) lY 2N + ___________ 

b.	 (A/any other) hospital outpatient clinic? 1 Y (co/. 1) 2 N (9c) lY 2N = --------------------

c. (A/any other) company or industry clinic? 1 Y (co/. 1) 2 N (gal) lY 2N ~ ------------------ -. ?---

d. (A/any other) public health clinic? 1 Y (CO1. 1) 2 N (9e) lY 2N 

e. (A/any other) neighborhood health center? 1 Y (co!. 1) 2 N (70) lY 2N 

10a. During the past 12 months hos seen a doctor at any other 

type of place? (Do not include doctors seen while a patient 

in a hospital.) lY z N (74) 

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

b.	 What type of place was this? Type of place 

IY 

(Reask 10aJ 

2N (Col. 1) _} 

Type of place 

lY 

(Reask 10a) 

(Col. 7) 2N } 
--

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

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

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

--

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

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

--

--

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

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

Il.	 Many pwple do not have ONE particular doctor. (Hand Card D) Which of those I 2 3 

sfatemtnts best describes wby you don’t have one particular doctor or place for 

medical care for --? OIher (Specify) 

M2 Refer to“12M0. DV” box at top ofpersm’s column ad mark as appropriate: t � 12 Month DV (/2) 20 No 12 Month OV (/7) 

12. During the post 12 months, has seen a doctor at any of the following places -

a. &f~i::t:j::t~~:: &::~------------ _ _ __:_Y ______ 2 N ___ 

b.	 A hospital rmergency room? lY 2N ________________________________________________________________________ 

1 

c. AhosPhal outpatlentcluuc? _---____-__:___::_______________________-__-____-__-----_---_--___

d.	 A company or industry clinic? tY 2N 

—— ______________________________ 

I 

c. A public health clinic? tY 2N 

/ 

f. A neighborhood health center? I lY 2N 

130.	 During the past 12 months, has seen a doctor at any other type of place? 

(Do not include doctors seen while a patient in o hospital.) lY 2 N (14) 

b. What typo of place was this? I TYP= of place 

(Reask 13a) 

-—--- —— . 

Type of Place 

t 

I (Reask 13a) 

14,	 During the past 12 months did you get medical advice far from ANY doctor 

over the telephone? lY 2N 

15.	 During the past 12 months has ANY doctor come to your home to give medical care? tY 2N I 

Hand Card H 12345678910 I 16a, During the past 12 months, which of those sources paid any part of --’s doctor bills? Other (Spec/fy) 

t 

b.	 During that period, did any other source pay any part of his doctor bills? Y (Reask 16a) N - — 

If “ l“ is circled in 16a, go to 17; otherwise ask 

1 

c. Durina the paxt 12 months, did YOU or Your family pay any part of --’s doctor bills? I IY ZN 

117

--

--------

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

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

--

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

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

--

--

--

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

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

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

----

Durin the past 12 

monti s, did this mo%;~~i!;h!’;~$lem 

problem ever DELAY you in �ver PREVENT you from 

17.	 During the past 12 months, have you had any problems getting medical care gettin~o~e~:,ol car* 

getting medical care for (for any of the following for --? 

reasons) - (1) (2) “ 

a.	 Because no doctor w05 available when you needed one? 1 Y (COI. 1) 2 N (17b) !Y 2N lY 2N _._- _-_- _--_ —_____________________________ ____________________ _____ _____ -

b.	 Because of how much it cost? t Y (co/. 7) 2 N (17c) lY 2N lY 2N __________________________________________ ____________________ . ____ -

c.	 Becouse you didn’t know where to go? 1 Y (Col. 1) 2 N (17d) lY 2N lY 2N --___ -__- ______________ — ____________________ ____________________ . . 

d.	 Because you didn’t have o way to get to the doctor? 1 Y (Co!. 7) 2 N (17e) lY ?.N lY 2N . .------------------- . 

e. Because the office hours weren’t convenient? 1 Y (cot. 1) 2 N (18) lY 2N lY 2N 

18. During the past 12 months, hove you had any problem 

getting an appointment for as soon as you felt he


needed one? 1 Y (co/. 1) 2 N (19) lY 2N lY 2N


190. During the past 12 months, hove you had any other 

problem getting medical care for --? lY 2 N (20) 

—— — . 

b. Whet problem did you hove? lY lY 2N (Reash 19a) 

(co!. 1) 2N } ____________________ . 

!Y 

lY 2N (Reask 19aJ 

(Cbl. 1) ZN } 

200. In general do you feel is getting as much medicol care as 

he needs? 1 Y (21) 2N ____________________________________________________ -_ 

Hand Card M 12345 

b.	 Which of tb.ase statements describes why isn’t getting enough medical care? 4 Any other reason? Circle all reasons given Other (Specify) 

21. During the past 12 months, hos received any services from any of the following persons -

a. A chiropractor? lY 2N 

b. An optometrist? ty 2N 

c. A podiatrist or chiropodist? lY 2N 

d. A physical therapist? lY 2N 

Show who responded for the Hypertension and Medical Care Pages. 1 n Responded for self 

~~ 

____________________ _iti:::i~-!Y::?:!:?--------

RESPONDENT If other than self respondent, give reason for accept) ng a proxy. 

1 � Mentally incompecem 

2 � Physically i“cmnpetent 
-----

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

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

---

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

— 

MOTOR VEHICLE ACCIDENTS: CY 1968 

Budget Bureau No.68S-66048, Approval Expires March 31, 1969 

WJw&NWflS.3 (1968) NOTICE -AI1 infomration which wonld permit identification of theindi 

vidual will beheld in strict confidence, will be used only by ersons en. gagedin and for the purposes of the survey, andwill not be i“wclosedo released to others for any purposes. U.S. DEPARTMENT OF COMMERCE 

BUREAUOF THE CENSUS 

U.S. PUBLIC HEALTH SERVICE 

US. HEALTH INTERVIEW SURVEY I I I, 

MOTOR VEHICLE ACCIDENT SUPPLEMENT 4. Sample number. 5. 

I B- I Book of books 

BEGIN SUPPLEMENT WITH QUESTION 1ON 

ACTING As COLLECTING AGENT FOR THE 1. Psu 2. Segment number 3. Serial nonrber 

210.	 What was tho main purpoaa of tho trip - working, going. tosr from work, or some 

othar pUfflOIO? 

3 � Other (b) __________ ___________________ __________ ________________ ____ 

b.	 What was tho purposa? H b. 

- —_________________ Record verbatim response 

22a, Did tha accldwrt hoppon on tha road, on the shoulder of the mad or semewhtre else? 220	 1 n OrIroad (c) 

z n On shoulder } 

3 n Other (b) ----- ________ ------ ---------- ---- ---- _______ _. ___________________ 

b, Wharo did It happsn? t b 

I 1------------------–. 

_________ --------- -. If “intersection “ ask d otherwise, do to 23 -------- ------- ---------------- ____________ -. -— __L _ __, ________ . 

c.	 Dld this accident hoppon within an intersection? c n Yes (d) 1 D No (23) -- _______________ _____ 

d.	 Did tho Intcrsoction hava a traffic control, such as a policeman, a traffic light, d 

a stop or ylcld sign or something else? 

—--- ___________ ____ _______ -- ----- ---- ------ ---- . 

s.	 What kind of traffic control was it? 8 3 n Policeman 4 m Traffic light 

5 D Stop sign 6 m Yield sign 

Check all that apply 

7 D Other (Specify) 

23a. Did tho accidant happen during daylight, dusk, dark, or dawn? ?iG I m Daylight 2 m Dusk 

----- --------------------------- _________ __ 3 n -- Dark 4 D Dawn 

b, About what timo wos it? b — A.M. O n Midnight 

— P.hl. 4 n Noon 

24.	 Did tho accident hopptn in o residcntiol or business district, in the opan country, 24. 1 a Residential z n Business 

or somewhere � 1s-? 3 D Open conntry 

— 4 n Other (Specify) 

25,	 What was tho cortdition of tho road at the time of the accident; was it wet, 25. 1 n wet 2nDry 3 D Icy 

dry, icy or somathing �ISO? 

4 a Other (Specify) 

26.€ Whet was the weather like at the time of tho accident; was it clear, rainy, foggy, 26. 1 D Clear z D Foggy 3 n Cloudy 

snowy, cfoudy, or somothing also? 4 D Rainy 5 n Snowy 

6 m Other (Specify) 

27, About haw many milas from homo did the occident happen? 27. ~ n Le== thm 1 mile — Miles 

119 
-- --

--

--

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

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

--

--

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

--

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

--

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

--

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

-- ------

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

--

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

-- ------

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

--

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

--

COMWETE A SEPARATE COLfJIW FOR EACH PERSON INVOLVED IN THIS ACCIDENT 

Enter the person number, age and name .—+ 

Record the date of the accident below. 

, # Yeu said that (and were) Month I flay I Year 

was in a motor vehicle accidcsrt on (date). I 

Interviewer: Check one box - I I 

Number of rel~ted p~rsons


rn household m acc]dent . . . � 1 person (lb) n 2+ persons (1.)


la. Were they in the some accident? a Yes (lb) � ‘“ $:: ~g$ :::;:;;’ ‘0’ 

b. Basidas was anyone else in the family in this accident? 

� Yes $~f::~,:::fi;h n No ;e:o:i::!j 

Z(I. was hurt or irriured in any way in this �ccident? 20. 

— 

b. At the time of the accident, what pnrt of his body was hurt? b. 

c. What kind of iniury was it? c. 

-— 

d. Did hove any other irriuries in this accident? d. 

!a. Did ever See or talk to a doctor because of this irriury (accident)? 30. 

-—-- —— ------ ___ - — —------

b.	 How long after the accident did see the doctor? If less than b. 

1 hour, enter number of minutes. 

da. Did the (irriury from this) occident keep In bed all or most of a day? 40. 

b,	 How many days did the (irriury from this) accident keep in b. 

bed all or most of the day? 

c,	 Even though didn’t have to remain in Imd, did this iniury (uccident) cause him c. 

to cut down on the things he usually does for os much as a day? 

d.	 In total, how many days did have to cut down on the d. 

things he usually does for as much as a day? 

—------ --—-—-

If 6-16 yeara of age, ask: 

e.	 How marry days did the irriury (accident) keep from school? ‘“ 

If 17+ years of age, ask: 

f.	 How many days did the iniury (occident) keep from work? f. 

(for females, add) not counting wOrk arOund the hOus@? 

—-------

If “no injury” AND 1 or more “cut down” days, ask: 

g. What conditinrr coused to cut down on the things he usually does? 9. 

Record verbatim response in appropriate column 

1 n Related household member injured (6) 

If “no injuries” were reported, ask 

5a. Even though (or your husband, etc.) was not irriured, was ANYONE else who was in your 

vehicle, in another vehicle, or a pedestrian, hurt or irriured in any WOY in this o=iderrt? 

_________________ ______________________________:_3y_ 

b. Did an ambulance come to the scene of the accident? 

Person number	 I Age 

I 

I 

I 

I 

Name of person 

< 

1 n Injured (2i3) 2 a Not injured (3; 

. 

Part of body Kind of injury 

1. 

2. 

3 _____ 

n ~:a~k b_d) n No (3) 

n Yes (b) xo D No (4) 

—--- ~ _____ 

. Minutes T Hours I Days 

I 

I 

/ I 

n Yes (b) UN. (C) 

e------

Numbe;$f bed days I 

I 

____________ I 

n Yes (d) 000 n No (NP) 

I Number of cut down days , 

(e, f, or g.) I 

000 n None [g) 

_______ 

Numbe;$f school 10SS dsys I 

i 

_---------_-—-- i 

. 

. 

. 

. . 

000 m None (g) 

Numbe;$f work Ioas daya	 I 

I 

_____________ I .

n Injured 6VP) 

2 a Yes ~b) 

} ______________ 

1 � Yes If “Yes” in 5a, go to 9. 

ODNO }	 If “No” in Sa, STOP; do not fill remainder of Supplement. 
--

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

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

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

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

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

--

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

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

------

-----

— 

— 

Ask for each injured household member: n Yes(b) 

6@0 D[d ,Oceive any first �ld treatment or other care at the scene of the accident? 6. o n No (NP) - — . —--- . 

b. What kind of care did he receive? 1 Write in verbatim response 

—---- c. Who provided this COrO- a doctor, an ambulance attendant, or some other parson? 

7a. Dld on ambulance come to the scene of the accident? 

1 ~ Yes (b) 

____________ :g_.w __ 

b.	 Didtheambulance toke(--, --, et) fromthehe 

scano of the accident? I_J Yes (.) 

m No (8) 

c. Who was taken? 

Mark “Taken by ambulance” box in appropriate column for each injured person. -

Ask [or each injured person “Taken by ambulance”: 

d,	 Whara did the ambulance take --, to a hospital, 

a doctor’s office, home, or some other place? 

Ask for each injored person NOT tiken by ambulance: 

8.	 Whare did go from the scene of ’the occident - to a 

hospitol, o doctor’s office, home, or some other place? 

Page 4 

—, 

c 

= 

7a 

‘b 

c 

d 

— 

8. 

— 

. -_--_-------—-- — 

--------—— L 1 m Doctor 

2 m Ambulance attendant (NP) 

3 m Other person (Specify) } 

J 

n Taken by ambulance ------------—-

1 n Hospital 1 

2 D Doctor’s office . (NP.) 

3 a Home 

4 El Some Otfrer place (Specify)x’ 

I 

s ~ Hospital 

6 a Doctor’s office (NP) 

7 D Home 

80 some other place (Specify)H 

121 
------------------ ---------------------

--

--

--

--

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

--

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

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

--

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

--

%, How many motor vahiclos were involved In this oc.idont? 

n One (b) m TWO or more (11) - Enter number+~– 

-1- ,, 

b. Wot tha motor vohiclo moving nt the time of the accident? 

0 m Yes (11) I I_J No (10) 

O. How did the accidmtt hnppr? r 

1 D Moving (11) 2 D Caught in door 

� NO;-l:wkl::y 3 n Fell getting in or out 

then STOP; + 4 m Injured while repairing vehicle 

DO NOT fill remainder of 

8upplemant. { s n Other (Specify) 

If 14 years or over aak: n Outside (12) 

1. At the time of the accidant, was outside the vehicle, getting in or out of it, 11. 3 n Getting in or out (NP) 

a Psenger, or was he the driver? 

If under 14 years, aak: m Passenger (13.) 

At the time of the occident, was outside the vehicle, getting in or outof it, 4 n Driver (13b) 

or was he a passenger? If motorcycle, go to 14 

2.	 Was on foot, on a bicycle or in some other vehicle? 12. 0 m on foot 

1 D Bicycle (NP) 

z D Other (Specify) 

fl } 

3a. was sitting i“ the frontor
back sent? 130. 5 n Front (b) 6 a Back (b) 

7 n Mohxcycle (14) E n Other (Specify (Np) 

) 

-----— . . 

b. Was wearing a seat belt? b. 1 D Yes (d) DNo (C) 

4 m Motorcycle (14.S —------ . - —- —--

c.	 Was there a seat belt where he was sitting? c. 2 U Yes (d) 3DNo (d) 

- -

d.	 Was weoring a shoulder strap or harness? d .5 D Yes (NP) U No (e) . .-

e. Was there a shoulder strap or harness where he was sitting? e . 6 m Yes (NP) 7 m No (NP) 

If on a motorcycle, ash 

14. was ~aori”g a helmet at the time of the accident? 14! 1 D Yes 20N0 

INTERVIEWER CHECK BOX Refer to questions 9 and 11 and check the appropriate box below: WASHINGTON USE 

D One motor vehicle with 1 or m&e family members inside (19) 

D Two or more motor vehicles with 1 or more family members inside (16) 

m All family members outside motor vehicle (15) 

122 
l%. -- ----------

--

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

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

---- ------

--

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

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

----- -----

---- -------

--

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

--

----- -----

--

. 

If all related household members outside motor vehicle, ask: Year I 

I 

Make 

I Whet c______________ was tha ywar and moko of the motor vehicle involved? 

_____ _______ __ 15.3. 1 I
 b.	 Was It � sodon, a convertible, a hrwdtop, a station wagon, –b. O D Sedan 1 a Convertible 

or aomo othar typs of motor vehicle? 2 m Hardtop 3 D Station wagon 

If truck, determine type: pickup, dump, etc. 4 � Other (Specify) 

c. In what Stato was this vehicla registered? c. State (?22) 

If fnside, and 2 or more motor vehicles, ask: 

160. Was tha motor vehiclt was (they were) In moving at the time of the accident? 160. 1 a ye,(c) n NO (b) _______ _____ ______ _______ _ ______ ____ _____ ____ -

b.	 Was it moving the instant bafore the accident happened? b. 2 n Yes (c) 3 I_J No (c) _____ _________ ________ _ _ _____ ______ _____ ____ 

c.	 Was tho other v.hicle moving at the time of the accident? c. 1 m Yes (17) m No (d) ________ _____ ____ __________ _______ _ ____ ________ _____ ___ 

d. Was the othor vehicle moving the instant before the accident happened? d, 2 � Yes (17) 3DNo (17) 

Hand respondent motor vehicle fIash card- Family member motor vehicle 

17a.	 Assumln this is the motor vahicle was in, in what Iettered 170. IDA 2DB 3mc 40D arur of t t!c motor vehicle did the impoct occur? sUE 6nF 71ZG EUH _________ ______ ____ ____ _ _____ ___= ______ _____ 

b. In what Iottorod aroo of the other motor vehicle did the impact occur? b. Other motor vehicle 

10A 2DB 3nc 40D 

sUE 60F 70G sUH (18) 

1Ea. What was tho year and make of the other motor vahic 10 involved? 18a. Year ~ Make 

: 

__________ __________ ____ _ I I b.	 Wos It a sedan, a convertible, a hardtop, a strrtlon wagon b. O D Sedan 1 n Convertible 

or mm- other typo of motor vehicle? 2 D Hardtop 3 m Station wagon 

4 a Other (Specify) ______ ____ ____ _____ _____ _________ _ ____ _________ ___ 

c. In what Stata was this vehicle registered? c. state (20) 

I 

If inside and 1 motor vehicle, ask 1 D Colfision with object (c) 19fl.	 How did tha accident happen; wos it a collision with some other 19a. 

obioct or did It happen in some other way? D Other way (b) _______ _____________________________ ____ ,- _ ______ ______ 

b. How did the accident happen? b. 2 n Turned over 

3 n sudden stop -NO col]ision (20) 

4 n Other (Specify) z’ } 

____________________________ ________________ -. ___ __________ ______ ~ c. What type of obicct was it? c. o bject (ZO) 

200, What was the yam and moko of motor vehicle was (they were) in? 2Oa Year 1 Make 

1 

I 

_____ ___________________ -__. . _ .1 I b.	 Was It a sedan, a convartlble, a hardtop, a stotion wagon, b. O U Sedan 1 a Convertible 

or soma othgr typo of motor vehicle? 2 D Hardtop 3 D Station wagon 

If truck, detecmine type: pickup, dump, etc. 4 a Other (Specify) . ______ ________ ___________ __________ _______ __, - _ _______________ _ — 

c. In what State was this vahlcle reglstar~d? c. State 

,---- ____________ ________ _________ _ ________ ________ — 

d. In tarms of dollars, about how much damage was d. 

dmw	 totho motor vohiclo was (they wore) in? s 

:$,,., v 

;. $$J$&>,+.:$, ,.$,*.X, ,, :}:.i.,], ‘: ;“ . . 

*+$*; Y: ~+* =Z’!s && . ~ ,y;j?s?t CONTINUE WITH QUESTION 21 ON PAGE 1 :

i 

..:. ~ 

Gm :10810- 2m-m6 

123 
-- ------------------------------------------------------------------------------ ---

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

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

-- --

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

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

--

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

--

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

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

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

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

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

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

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

--

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

--

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

--

-- -- --

--

ORTHODONTIC CARE: CY 1974 

a 2S+ yeirs (NP) 

0 Ihfarkone boxin each person,. column. c€ � 5-24 y.~. (13) 

� Under 5 years (NP) 

a.Has � v.srhad his teeth straightened or had bands on his teeth? 13., lY z N (14] . 

00 � Nme (NP) 

b. During the past 12 months, about how many visits did he moke to an orthod.antist? b _ N.rnber of visits 

00 � None (NP) 

c. How many of these visits wtre in the past two weeks - that is tlm two weeks outlined in red on tfmt calendar? Q — N.mlw of vlstts _______________________________________ 

If one or more visits In I Id, ask otherwise, go to NP. 

d.	 How many of these orthodontic visits were included in the dental visits had during the past 2 wotks 00 � None NP that you told me about eorlier? d _ Number of vlslts } 

a. DO you think --.; S teeth “Oed to JK straightened? 140 tY 2N 

(Even though you don’t think his teeth need to be straightened) 

b. Have you ever bean told by a dentist or orthodontist that his teeth needed to be st,aigAtened? b IY 2N . .--, .-------------------

If “Y” circled in 14a or b, ask otherwise, go to NP. 

c.	 We are interested in the vnrious reasons why people do not have their taeth straightened when they need ., [2345678 

this type of car.. (Hand Card O) 

Which of those statements describes why is other (s@c//y) not NOW rocciving this care? A Any other reason? Circle all reasons given � .------------------. Mark box or aslc 00 � Only me reason 

d. What is the MAIN wason 1s not NOW receiving this care? d, 12345678 

Other(SpecNy) 

PREGNANCY: CY 1973 

INTERVIEWER � No Females 17-44 yrs. old (Next poge) ‘R EGNANCY CHECK ITEM o � 1+ Females 17-44 yrs. old (1) .

!

. 

r. During the past 12 months, has anyone in the family been pregnant :,;. ~ :.,,,...,;“# ‘- *, . !, 

w *+,. or hod a miscarriage? Y . ,,;..- .; ,“~~?., ~ ~~,&.. . =.tiA 

N (Next page) i!. :, 

. . ..s. ‘ ” . . ..A-*.. 

>. Who IS this? Mark “’Was pregmmt” box in person’s column.	 � was Pre?.”a”c --.--”,~~- . ..-.%.”. 

:.	 Durin the post 12 monthz, has anyone else in the famiiy been pregnant Y (Reask N .;. ,.:, 

or hai a miscarriage? lb and c) . 

[..1. 

[f ““WasDregnant,” ask 

3. Is now pregnant? 2.. Y 

(Not ~oun+ing --s S current pregnancy) � None (NPJ 

L During the past 12 months, how many times has been pregnant, Including miscarriages? 

b’ A 

(No, counting --*% currant pregnancy) 01 � Once (NPJ 

:. How many times has EVER besn pregnant, including miscarriages? c. _Preg”ancfes . . . . . .. . . II . . . 

00 � N.”. (NPJ 

1.	 How many of these pregnancies resulted In live births? d. 

—Live births (NPJ 

“ABLE P Complete a line of Table P for each terminated pregnancy reporte lin Q.2b. Ifnoterminated pregnancies reported, go fonext page. 

Oid --’s (last pregnmwy/pregnancy before Did she see a doctor HOW many months About bow many visits Did a docfor .ver tell 

Person that)cnd inafull.term live birth, a premature at anytime during pregnant was did m.ke to a to remain in bed 

Number livG birth, a miscarriage, or what? that pregnancy? when she first saw doctor BEFORE that for two weeks or more 

o doctor? pregnoncy ended? during thot ~gnancy? 

(.) (bJ [d) [.) 

IO FUII term 

2U Premature 

3 a Miscarriage lY !Y 

~ o Stillbirth 

s � Abortion 2 N (g) —Months —Visits 2N 

6 —rl Other - $ecify 1 I 1 I 

rABLE P - Continued 

How Ionghas it been )..s intend to NOTES since th.t pregnancy ave a check-up for 

ended? hot pregnancy? 

~~ 

(1) (1) I 

! � p:”rl lY 

2 � 2+ months (NP) 2N 

124 
--

--

--

--

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

--

--

--

--

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

--

--

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

--

--

PREVENTIVE CARE: CY 1973 

sl 0 ~ Not 5P (NP) 

1 m Eligible resp. avail. (S2) 

2 [~ Return call required (NP) 

PREVENTIVE CARE 52	 ~ 40+ years (1) 

~ 17-39 years (3) 

m 3-16 years (?) 

a Under 3 years (8) 

1,About how long has it been since had an electrocardiogram, or EKG, which involves 1. 98 ❑ Neve, 

placing wires on the chest and arms? 00 I_J Less then I year 

— Years 

2,	 About how long has it been since had a test for glaucoma - this is sometimes 2. 98 m Never 

referred to as an ●ye pressure test? 00 I_J Less than I year 

—Years 

3.	 About how long has it been since had a chest X-ray? 3. 98 a Never 

00 H Less than I year 

—Year. 

ta. Does have ●yeglasses or contact lenses? 4.. 

!Y 2N 

. . 

b, About how long has it been since hod his eyes examined to see if he needed (new) glasses? b. 98 ❑ Never 

00 ❑ Less than I year 

— Years 

Ask only of FEMALES 17+ years of agq otherwise, go ta next person. 5. 98 ❑ Never 

5. About how long has it been since had o Pap smear test for cancer? 00 ❑ Less than I year 

—.— Years 

5. About haw long has it been since had a breast ●xamination by a doctor? 6. 98 ❑ Never 

00 j_J Less thm I year (NP) 

— Years }, ,. ,, 

~a. Dots have ●yeglasses or contact lenses? 7.. 

lY 2N 

. 

b.	 About how long has it been since had his eyes examined to see if he needed (new) glosses? b. 98 I_J Never 

(Include any ●ye exams given in school.) 00 ❑ Less than I year 

—Years 

la.	 During the post 12 months, was taken to a doctor for a ROUTINE physical examination, 80. 

that is, not for a particular illness but for a general checkup? 1 Y (9) 2N 

____________________ 

b. About how long has it been since was token to a doctor for a routine physical examination b. 98 ❑ Never 

or	 general checkup? 

_Y=ars 

). About how old w05 when you FIRST took him to a dentist? 9. 98 ❑ Never 

_ Years old 
SPECIALISTS’ SERVICES AND ROUTINE CHECKUPS: FY 1964 

If any children under 17 years in household, ash u 22. DURING THE PAST 12 fAONTHS WCS- (were .-, -., et..) wk.” to a doctor for a 

ROUTINE physl.ol ex.min.Non, that i., ..+ for a particular illness but for o general check-up? 017 yeus or Omr 

If “Y..,” and more than one child under 17 years, ask ~ Yes m No (.) who w.. this?


(b) AJV of th. other children?


23. DURING THE PAST 12 MONTHS has ANYONE in the family - ihnt is, you, your .-, etc., - received any + (fduk (x) S&cidist) Times 

services from any of the persons listed on this card? Please check “We.” or “’No” for each me listed. Pediatrician A 

Hand r.spo”dent pencil and card (NHS-HIS-l(a)) Obstecri+n or 

For each “Yes” box checked on tbe card, ask Gynecologist B 

(.) Who sow the (specialist) ? (Mark (X) for each specialist in person’s column.) Ophthalmologist c 

(b) About how m.ny time. did Y.. see . (specialist) during the past 12 months (not counting Otolaryngolosist o cmy vi’its while you were in the hospital)? 

(.) Old anyone else .e* a (specialist) during *he Post 12 mon*h.? 

Psycbistrist 

Ikrrat0108ist 

E 

F 

N “Yes,” ask Onboptdist G 

(d) Who W.. this? Cbiinctor H 

(e) About how m.ny time. did y.. see a (specialist) during the past 12 months 

a“y visits while you were in th. hospital)? 

(not counting optometrist I 

Podiatrist or 

Check the “Nme’* box for each person who did not am a specialist. Cbiiopodist J 

o None 

*Beginning in July 1966, information on specialists’ services has been elicited by a single question on the doctor visits page, thus 

becoming a continuing item as of that date. 

000


126

APPENDIX Ill 

DEFINITIONS OF CERTAIN TERMS USED 

IN THE HEALTH INTERVIEW SURVEYb 

Terms Relating to Conditions 

Condition.–A morbidity condition, or 

simply a condition, is any entry on the 

questionnaire that describes a departure from a 

state of physical or mental well-being. It results 

from a positive response to one of a series of 

“medical-disability impact” or “illness-recall” 

questions. In the coding and tabulating process 

conditions are selected or classified according 

to a number of different criteria such as 

whether they were medically attended, whether 

they resulted in disability, or whether they 

were acute or chomic; or according to the type 

of disease, injury, impairment, or symptom 

reported. For the purposes of each published 

report or set of tables, ordy those conditions 

recorded on the questionnaire that satisfy certain stated criteria are included. 

Conditions except impairments are classified 

by type according to the Eighth Revision of 

the International Classification of Diseases, 

Adapted for Use in the United States, 18 with 

certain modifications adopted to make the 

code more suitable for a household interview 

survey. 

Acute condition.–An acute condition is defined as a condition that has lasted less than 3 

months and that has involved either medical 

procedures used to estimate incidence, the 

acute conditions included in this report are the 

conditions that had their onset during the 2 

weeks prior to the interview week and that 

involved either medical attention or restricted 

activity during that 2-week period. However, 

certain conditions are aIways classified as 

chronic regardless of onset (see list under the 

definition of chronic condition). 

Acute condition groups. -In this report aIl 

tables that have data classified by type of 

condition employ a five-category regrouping 

plus several selected subgroups (Table I). 

Chronic condition.–A condition is considered chronic if (1) the condition is described 

by the respondent as having been first noticed 

more than 3 months bef ore the week of the 

interview or (2) it is one of the conditions 

listed below that are always considered chronic 

regardless of the date of onset. 

Allergy, any


Arthritis or rheumatism


Asthma


Cancer


Cleft palate


Clubfoot


Condition present since birth


Deafness or serious trouble with hearing


Diabetes attention or restricted activity. Because of the ~ Epilepsy 

~~e defifitiomshow in this report are those used in CY Hardening of the arteries 

1973 reports. Some of the definitions have been modified Hay fever 

through the years to improve clarity and to reflect minor Heart trouble 

methodological changes. Hemorrhoids or piles 

NOTE-A Iist of references follows the text. Hernia or rupture 

127 
Table 1. Acute condition groups and International Classification code numbers included in each category 

Condition group 

Infective andparasitic diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Common childhood diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Virus not otherwiw specified . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Other infective andparasitic diseases . . . . . . . . . . . . . . . . . . . . . . . . 

Respiratory conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Up~rmspiratov conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Common cold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Other upper respiratory conditions . . . . . . . . . . . . . . . . . . . . . . 

Influenze . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

influenza with digestive manifestations . . . . . . . . . . . . . . . . . . . 

Other influence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Other respiratory conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Bronchitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Other respiratory conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Digestive system conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Dental conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Functional and symptomatic upper gastrointastinal disorders 

not elsewhere classifiable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Other digestive system conditions . . . . . . . . . . . . . . . . . . . . . . . . . . 

Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Fractures, dislocations, sprains, and strains . . . . . . . . . . . . . . . . . . . 

Fractures and dislocations . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 

Sprains and strains . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Open wounds and lacerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Contusions and superficial injuries . . . . . . . . . . . . . . . . . . . . . . . . . 

Other current injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Allotheracute conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 

Diseasesof the ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Headaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Genitourina~ disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Deliveries and disorders of pregnancy and the prserperium . . . . . . . 

Diseasasof the skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Diseasesof the mueculoskeletal system . . . . . . . . . . . . . . . . . . . . . . 

Another acute conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

High blood pressure 

Kidney stones 

Mental illness 

Missing fingers, hand, or arm-toes, foot, or leg 

Palsy 

Paralysis of any kind 

Permanent stiffness or deformity of the foot, 

leg, fingers, arm, or back 

Prostate trouble 

Repeated trouble with back or spine 

Rheumatic fever 

Serious trouble with seeing, even when wearing 

glasses 

128 

International Classification code number 

000-136 

033,052,055,056,072


079.9


000-032,034-051,053, 054,057-071,073-136


460-4S6, 501,508-516,519,783


460-465,501,508


460


461-465,501,508


470-474


473


470-472,474


466, 4S0-486, 510-516,519,783


480-4S6


466


510-516,519,783


520.6-521.5,521.7-523.9, 525-530,535-543,560, 561,564-

577,784,785 

520.6-521.5,521.7-523.9, 525


536,784.0,784.1,784.3, 784.7,785.4 pt.


526-530,535,537,540-543, 560,561,564-577,784.2, 784.4-


7S4.6, 785 pt.


N800-N870, N872-N664, NS8C-N894, N800-N884, N886-N888


N800-N848


N800-N839


N840-N848


N870, N872-N884, N880-N894, N800-N907


N91 O-N929


N850-N869, N930-N994, N886-N999


All other acute code numbers


380-387,745.0-745.3, 781.3


791


580-628,786,788


630-678


680-708


717-733,787


Other acute code numbers


Sinus trouble, repeated attacks of


Speech defect, any


Stomach ulcer


Stroke


Thyroid troubIe or goiter


Tuberculosis


Tumor, cyst, or growth


Varicose veins, trouble with


Chronic condition grou@.–The 30 condition 

groups shown in this report and the International Classification code numbers used are 

listed in table II. 
Table 11. Chronic condition groups and the International Classification code numbers included in each category 

Condition causingactivitv limitation International Classification coda number 

Tuberculosis, all forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 010-018 

Malignant neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140-208 

Benign and unspecified neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210-239 

Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250 

Mental andnervous conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290-304,305.0,305.3, 305.5,305.6,306-308, 780.6,781.5, 

785.6,786.2,790.0,790.2 

Heart conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390-398,402,404,410-428, 782.1,782.2,782.4 

Cerebrovascular disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430-438 

Hypertension without heart involvement . . . . . . . . . . . . . . . . . . . . . . . 400,401,403 

Varicose veins...............,.. . . . . . . . . . . . . . . . . . . . . . . . . . . 454,456 

Hemorrhoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455 

Other conditions of circulatory system . . . . . . . . . . . . . . . . . . . . . . . . 440-453,457,458,782.0, 782.3,782,5-.9 

Chronic bronchitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 480,491 

Emphysema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 492 

Asthma, with or without hay fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493 

Hay fever, withwt asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507 

Chronic sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Other conditions of respiratory system . . . . . . . . . . . . . . . . . . . . . . . . 

Peptic ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Qther conditions of digestive system . . . . . . . . . . . . . . . . . . . . . . . . . . 

Diseasesofkidney andureter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Othar conditions of genitourinary system . . . . . . . . . . . . . . . . . . . . . . 

Arthritis and rheumatism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Other musculoskeletel disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Visual impairments...........,.. . . . . . . . . . . . . . . . . . . . . . . . . . . 

Hearing impairments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Paralysis, complete or partial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Impairments (except paralysis) of back or spine . . . . . . . . . . . . . . . . . . 

Impairments (except paralysis and absence) of upper extremities 

and shoulders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Impairments (except paralysis and absence) of lower extremities 

and hips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Condition not specified: 

Old age 

Other 

Im~az?ment.–Impairments are chronic or 

permanent defects, usually static in nature, 

resulting from disease, injury, or congenital 

malformation. They represent decrease or loss 

of ability to perform various functions, particularly those of the musculoskeletal system 

and the sense organs. All impairments are 

classified by means of a special supplementary 

code for impairments. Hence, code numbers 

for impairments in the International Classijlcation of Diseases are not used. In the Supplementary Code, impairments are grouped 

according to type of functional impairment 

and etiology. The impairment classification is 

shown in Vital and Health Statistics, Series 10, 

Number 87,19 

Prevalence of conditions.–In general, prevalence of conditions is the estimated number of 

conditions of a specified type existing at a 

503


470486,500-502,504-506, 508-519,783


531-534


550-553


520.3,520.4,520.6-521 .5,521 .7-523.525-530, 535-543,560-


577,784,785.0-785.5, 785.7,785.8 

581-584,590-593 

594-611,613-628,786.0, 786.1,786.3-786.7,789 

710-716,717.0,717.1, 717.9,718 

720-723,725,728-732, 733.0,733.2,733.3,733.6, 733.9,734 

See definition of impairment J

specified time or the average number existing 

during a specified interval ;f time. The prev; 

lence of chronic conditions is defined as the 

number of chronic cases reported to be present 

or assumed to be present at the time of the 

interview. Those assumed to be present at the 

time of the interview are cases described by 

the respondent in terms of one of the diseases 

on the list of conditions always considered 

chronic (see definition of chronic condition 

above) and reported to have been present at 

some time during the 12-month period prior to 

the interview. 

Incidence of conditions.–The incidence of 

conditions is the estimated number of conditions having their onset in a specified time 

period. As previously mentioned, minor acute 

conditions involving neither restricted activity 

nor medical attention are excluded from the 

129 
statistics. The incidence data shown in some 

reports are further limited to various subclasses 

of conditions, such as “incidence of conditions 

involving bed disability.” 

Onset of condition.–A condition is considered to have had its onset when it was first 

noticed. This could be the time the person first 

felt sick or became injured, or it could be the 

time when the person or his family was first 

told by a physician that he had a condition of 

which he was previously unaware. 

Persons with chronic conditions.–The estimated number of persons with chronic conditions is based on the number of persons who 

at the time of the interview were reported to 

have one or more chronic conditions. 

Activity-restricting condition.–An activityrestricting condition is one that had its onset 

in the past 2 weeks and that caused at least 1 

day of restricted activity curing the 2 calendar 

weeks before the interview week. (See “Restricted-activity day” under “Terms Relating to 

Disability.”) 

Bed-disabling condition.–A condition with 

onset in the past 2 weeks involving at least 1 

day of bed disability is called a bed-disabling 

condition. (See “Bed-disability day” under 

“Terms Relating to Disability.”) 

Medically attended condition.–A condition 

wkh onset in the past 2 weeks is considered 

medically attended if a physician has been 

consulted about it either at its onset or at any 

time thereafter. However, when the first 

medical attention for a condition does not 

occur until after the end of the 2-week period, 

the case is treated as though there was no 

medical attention. Medical attention includes 

consultation either in person or by telephone 

for ‘ treatment or advice. Advice from the 

physician transmitted to the patient through 

the nurse is counted as well as visits to 

physicians in clinics or hospitals. If during the 

course of a single visit the physician is consulted about more than one condition for each 

of several patients, each condition of each 

patient is counted as medically attended. 

Discussions of a child’s condition by the 

physician and a responsible member of the 

household are considered as medical attention 

even if the child was not seen at that time. 

For the purpose of this definition, the term 

“physician “ includes doctors of medicine and 

osteopathic physicians. 

Terms Relating to Disability 

Disability.-Disability is the general term 

used to describe any temporary or long-term 

reduction of a person’s activity as a result of 

an acute or chornic condition. 

Disability &y.–Short-term disability days 

are classified according to whether they are 

days of restricted activity, bed days, hospital 

days, work-loss days, or school-Ioss days. All 

hospital days are, by definition, days of bed 

disability; all days of bed disability are, by 

definition, days of restricted activity. The converse form of these statements is, of course, 

not true. Days lost from work and days lost 

from school are special terms that appIy to the 

working and school-age populations only, but 

these too are days of restricted activity. Hence, 

“days of restricted activity” is the most inclusive term used to describe disability days. 

Restricted-activity day.–A day of restricted 

activity is one on which a person cuts down on 

his usual activities for the whole of that day 

because of an illness or an injury. The term 

“usual activities” for any day means the things 

that the person would ordinarily do on that 

day. For children under school age, usual 

activities depend on whatever the usual pattern 

is for the child’s day, which will in turn be 

affected by the age of the child, weather 

conditions, and so forth. For retired or elderly 

persons, usual activities might consist of almost 

no activity, but cutting down on even a small 

amount for as much as a day would constitute 

restricted activity. On Sundays or holidays, 

usual activities are the things the person 

usually does on such days—going to church, 

playing golf, visiting friends or relatives, or 

staying at home and listening to the radio, 

reading, watching television, and so forth. 

Persons who have permanently reduced their 

usual activities because of a chronic condition 

might not report any restricted-activity days 

during a 2-week period. Therefore, absence of 

restncted-activit y days does not imply normal 

health. 

130 
Restricted activity does not imply complete 

inactivity, but it does imply only the minimum 

of usual activities. A special nap for an hour 

after lunch does not constitute cutting down 

on usual activities, nor does the elimination of 

a heavy chore such as cleaning ashes out of the 

furnace or hanging out the wash. If a farmer or 

housewife carries on only the minimum of the 

day’s chores, however, this is a day of 

restricted activity. 

A day spent” in bed or a day home from 

work or school because of illness or injury is, 

of course, a restricted-activity day. 

Bed-disability day.–A day of bed disability 

is one on which a person stays in bed for all or 

most of the day because of a specific illness or 

injury. All or most of the day is defined as 

more than half of the daylight hours. All 

hospital days for inpatients are considered to 

be days of bed disability even if the patient 

was not actually in bed at the hospital. 

Work-1oss day.–A day lost from work is a 

day on which a person did not work at his job 

or business for at least half of his normal 

workday because of a specific illness or injury. 

The number of days lost from work is determined only for persons 17 years of age and 

over who reported that at any time during the 

2-week period covered by the interview they 

either worked at or had a job or business. (See 

“Currently employed persons” under “llemographic Terms.”) 

School-1oss day.–A day lost from school is a 

normal school day on which a child did not 

attend school because of a specific illness or 

injury. The number of days lost from school is 

determined only for children 6-16 years of age. 

Person-day. –Person-days of restricted activity, bed disability, and so forth are days of the 

various forms of disability experienced by any 

one person. The sum of days for all persons in 

a group represents an unduplicated count of all 

days of disability for the group. 

Condition-day. –Condition-days of restricted 

activity, bed disability, and so forth are days 

of the various forms of disability associated 

with any one condition. Since any particular 

day of disability may be associated with more 

than one condition, the sum of days for 

conditions may add to more than the total 

number of person-days. 

Chronic activity limitation. –Persons arc 

classified into four categories according to the 

extent to which their activities are limited at 

present as a result of chronic conditions. Since 

the usual activities of preschool children, 

school-age children, housewives, and workers 

and other persons differ, a different set of 

criteria is used for each group. There is a 

general similarity between them, however, as 

will be seen in the following descriptions of 

the four categories: 

1. Persons unable to carry on major activity for 

their group (major activity refers to ability 

to work, keep house, or engage in school or 

preschool activities). 

Preschool children: 

Inability to take part in” ordinary play 

with other children. 

School-age children: 

Inability to go to school. 

Housewives: 

Inability to do any housework. 

Workers and all other persons: 

Inability to work at a job or business. 

2. .Persons limited in amount or kind of maior . 

activity performed (major activity refers” to 

ability to work, keep house, or engage in 

school or preschool activities). 

Preschool children: 

Limited in amount or kind of play with 

other chiIdren, e.g., need special rest 

periods, cannot play strenuous games, or 

cannot play for long periods at a time. 

School-age children: 

Limited to certain types of schools or in 

school attendance, e.g., need special 

schools or special teaching or cannot go 

to school full time or for long periods at 

a time. 

Housewives: 

Limited in amount or kind of housework, 

e.g., cannot lift children, -wash or iron, or 

do housework for long periods at a time. 

Workers and all other persons: 

Limited in amount or kind of work, e.g., 

need special working aids or special rest 

periods at work, cannot work full time or 

for long periods at a time, or cannot do 

strenuous work. 

131

3. Persons not limited in major activity but 

otherwise limited (major activity refers to 

ability to work, keep house, or engage in 

school or preschool activities). 

Preschool children: 

Not classified in this category. 

School-age children: 

Not limited in going to school but limited 

in participation in athletics or other extracurricular activities. 

Housewives: 

Not limited in housework but limited in 

other activities such as church, clubs, 

hobbies, civic projects, or shopping. 

Workers and all other persons: 

Not limited in regular work activities but 

limited in other activities such as church, 

clubs, hobbies, civic projects, sports, or 

games. 

4. Persons not limited in activities (includes 

persons whose activities are not limited in 

any of the ways described above). 

Chronic mobility limitation. –Persons are 

classified into the following five categories 

according to the extent to which their mobility 

is limited at present as a result of chronic 

conditions: 

1. Stays z%bed. Must stay in bed all or most of 

the time. 

2. Stays in the house. Must stay in the house, 

but not in bed, all or most of the time. 

3. Needs help getting around. Able to go outside but needs the help of another person or 

of a special aid such as a cane or wheelchair 

in getting around. 

4. Has trouble getting around j?eely. Does not 

need the help of another person or a special 

aid but has trouble in getting around freely. 

5. Is not limited in mobility. Not limited in 

any of the ways described above. 

Terms Relating to Persons Injured 

Injury condition.–An injury condition, or 

simply an injury, is a condition of the type 

that is classified according to the nature of 

injury code numbers (N800-N999) in the International Classification of Diseases. In addition 

to fractures, lacerations, contusions, burns, and 

so forth, which are commonly thought of as 

injuries, this group of codes includes effects of 

exposure, such as frostbite, adverse reactions to 

immunization and other medical procedures, 

and poisonings. Unless otherwise specified, the 

term “injury” is used to cover all of these. 

Since a person may sustain more than one 

injury in a single accident, e.g., a broken leg 

and laceration of the scalp, the number of 

injury conditions may exceed the number of 

persons injured. 

Statistics of acute injury conditions include 

only those injuries that involved at least 1 full 

day of restricted activity or medical attendance. 

Person injured.–A person injured is one who 

has sustained one or more injuries in an 

accident or in some type of nonaccidental 

violence. (See definition of injury condition.) 

Each time a person is involved in an accident 

or in nonaccidenta.1 violence causing injury that 

results in at least 1 full day of restricted 

activity or medical attention, he is included in 

the statistics as a separate person injured; 

hence, one person may be included more than 

once. 

The number of persons injured is not equivalent to the number of accidents for several 

reasons: (1) the term “accident” as commonly 

used may not’ involve injury at all, (2) more 

than one injured person may be involved in a 

single accident, so the number of accidents 

resulting in injury would be less than the 

number of persons injured in accidents, and (3) 

the term “accident” ordinarily implies an 

accidental origin, whereas “persons injured” as 

used in the Health Interview Survey includes 

persons whose injuries resuIted from certain 

nonaccidental violence. 

The number of persons injured in a specified 

time interval is always equal to or less than the 

incidence of injury conditions, since one 

person may incur more than one injury in a 

single accident. 

Place of accident. –Persons injured are classified according to the type of place where the 

injury occurred. 

1. Home. The place of accident is considered as 

“home” if the injury occurred either inside 

or outside the home but within the property 

132 
boundaries. “Home” includes not only the


person’s own home but also any other home


(vacant or occupied) in which he may have


been when he was injured. “Home” includes


any structure that has the primary function


of a dwelling unit and includes the structure


and premises of such places as apartment


houses and house trailers.


Inside the house:


Includes any room, attic, cellar, porch, or 

steps leading to an entrance of the house. 

However, inside the garage is not considered as inside the house. 

Outside the house: 

Includes the yard, driveway, garage, patio, 

gardens, or walks. On a farm, only the 

premises adjacent to the house are 

considered as part of the home. Injuries 

due to accidents occurring on cultivated 

land, in barns, or other similar farm 

buildings would not be considered home 

injuries. 

2. Street or highway. “Street or highway” 

means the entire area between property lines 

of which any part is open for the use of the 

public as a matter or right or custom. It 

includes the roadway, shoulder, curb, or 

public sidewalk; excluded are private driveways, lanes, or sidewalks. 

3. Farm. “Farm” as a place of accident refers 

to accidents occurring in farm buildings or 

on cultivated land but does not include 

accidents occurring in the farm home or 

premises. A ranch is considered a farm. 

4. Industn”al place. “Industrial place” is the 

term applied to accidents occurring in an 

industrial place or on the premises. Included 

are such places as factories, railway yards, 

warehouses, workshops, logging camps, 

shipping piers, oil fields, shipyards, sand and 

gravel pits, canneries, and auto repair 

garages. Construction projects such as 

houses, buildings, bridges, and new roads are 

included in this category. Buildings undergoing remodeling, with the exception of 

private homes, are classified as industrial 

places or premises. 

5. School. “School” as a place of accident 

includes all accidents occurring in school 

buildings or on the premises. This classification includes elementary schools, high 

schools, coHeges, and trade and business 

schools. 

6. Place of recreation. “Place of recreation” is 

used to describe accidents occurring in 

places organized for sports and recre~tion 

other than recreational areas located at a 

place already defined as “home,” “industrial 

place,” or “school.” Bowling alley, amusement park, football stadium, and dance hall 

are examples of “place of recreation.” In 

“place of accident” classification of injuries 

the place is significant rather than the 

activity in which the person was engaged at 

the time of accident. Hence, an injury sustained by a person at a dance hall while he 

was at work is classified as a “place of 

recreation” injury. Likewise, an injury 

occurring while a person was engaged in a 

sport in an industrial place is classified as an 

“industrial place” injury. 

7. Other. Accidents that cannot be classified in 

any of the above groups or for which the 

place is unknown are classified as “other.” 

Included in the classification are such places 

as restaurants, churches, business and professional offices, and open or wooded 

country. 

Classzj?cation of injured persons by activity 

restn”ction or medical attendance. —The classification of injured persons by activity restriction 

or medical attendance is based on the classification of the injury. (See definitions for 

activity-restricting injury, bed-disabling injury, 

work- or school-loss injury, and medicaUy 

attended injury.) For example, a person may 

have received severaI injuries in a single accident; if one of the injuries involved 1 or more 

days of restricted activity, 1 or more days in 

bed, or medical attendance, the person injured 

would correspondingly be classified as with 

restricted activity, with bed disability, or 

medically attended. 

Actz%ity-restra”cting injury. -An activityrestricting injury is an injury that has caused at 

Ieast 1 day of restricted activity. (See definition of restricted-activity day.) The incidence 

of activity-restricting injuries is estimated from 

the number of such injuries reported as having 

occurred in the 2 weeks before the interview 

week. For this reason, an injury that did not 

result in restricted activity until after the end 

133 
of the 2-week period in which it occurred is 

not classified as an activity-restricting injury. 

Bed-disabling injzwy.-An injury resulting in 

at least 1 day of bed disability is calIed a 

bed-disabling injury. (See also definition of 

activity-restricting injury.) 

Work- or school-loss injury.–An injury resulting in at least 1 day of work or school loss 

is called a work-loss injury or a school-loss 

injury. (See also definition of activity-restricting injury.) 

Medically attended injury. –An injury for 

which a physician was consulted is called a 

medically attended injury. Consulting a 

physician includes consultation in person or by 

telephone for treatment or advice. Advice from 

the physician transmitted to the patient 

through the nurse is counted as medical consultation as well as visits to physicians in 

clinics or hospitals. If at one visit the physician 

is consulted about more than one injury for 

each of several patients, each injury is counted 

as medically attended. 

A parent consulting a physician- about a 

child’s injury is counted as medical consultation about that injury even if the child was not 

seen by the physician at that time. 

For the purpose of this definition, 

“physician “ includes doctors of medicine and 

osteopathic physicians. The term “doctor” is 

used in the interview rather than “physician” 

because of popuku usage. However, the 

concept toward which all instructions are 

directed is that which is described here. 

An injury is counted as medically attended 

if a physician was consulted about it at its 

onset or at any time thereafter. However, the 

first medical attention for an injury that was 

experienced during the 2-week period prior to 

the household interview may not occur until 

after the interview. Such cases are treated as 

though there was no medical attention. 

An injury is counted as medically attended 

if a physician was consulted about it at its 

onset or at any time thereafter. However, the 

first medical attention for an injury that was 

experienced during the 2-week period prior to 

the household interview may not occur until 

after the end of the 2-week period. Such cases 

are treated ‘as though there was no medical 

attention. 

Terms Relating to Class of Accident 

Class of accident. –Injuries, injured persons, 

and resulting days of disability may be grouped 

according to class of accident. This is a broad 

classification of the types of events that resulted in personal injuries. Most of these events 

are accidents in the usual sense of the word, 

but some are other kinds of mishap, such as 

overexposure to the sun or adverse reactions to 

medical procedures, and others are nonaccidental violence, such as attempted suicide. The 

classes of accident are (1) moving motor 

vehicle accidents, (2) accidents occurring while 

at work, (3) home accidents, and (4) other 

accidents. These categories are not mutually 

exclusive. For example, a person may be 

injured in a moving motor vehicle accident that 

occurred while the person was at home or at 

work. The accident class “moving motor 

vehicle” includes “home-moving motor vehicle” 

and “while at work-moving motor vehicle.” 

Similarly, the classes “while at work” and 

“home” include duplicated counts, e.g., 

“moving motor vehicle-while at work” is 

included under “while at work.” 

Motor vehicle.–A motor vehicle is any 

mechanically or electrically powered device, 

not operated on rails, upon which or by which 

any person or property may be transported or 

drawn upon a land highway. Any object, such 

as a trailer, coaster, sled, or wagon, being 

towed by a motor vehicle is considered a part 

of the motor vehicle. Devices used solely for 

moving persons or materials within the confines of a building and its premises are not 

counted as motor vehicles. 

Moving motor vehicle accident.–The accident is classified as “moving motor vehicle” if 

at least one of the motor vehicles involved in 

the accident was moving at the time of the 

accident. This category is subdivided into 

“traffic” and “nontraffic” accidents. 

1. Traffic moving motor vehicle accident. The 

accident is in the “traf fit” category if it 

occurred on a public highway. It is considered to have occurred on the highway if 

it occurred wholly on the highway, if it 

originated on the highway, if it terminated 

on the highway, or if it involved a vehicle 

134 
partially on the highway. A public highway 

is the entire width between boundary lines 

of every way or place of which any part is 

open to the use of the public for the purposes of vehicular traffic as a matter of right 

or custom. 

2. Nontraffic moving motor vehicle accident. 

The accident is in the “nontraffic” category 

if it occurred entirely in any place othe 

than a public highway. 

Nonmoving motor vehicle accident.–If the 

motor vehicle was not moving at the time of 

the accident, the accident is considered a “nonmoving motor vehicle” accident and is classified in the “other accident” category. 

Accident while at work. –The class of accident is “while at work” if the injured person 

was 17 years of age or over and was at work at 

a job or a business at the time the accident 

happened. 

Home accident.–The class of accident is 

“home” if the injury occurred either inside or 

outside the house. “Outside the house” refers 

to the yard, buildings, and sidewalks on the 

property, “Home” includes not only the 

person’s own home but also any other home in 

which he may have been when he was injured. 

Other accident.–The class of accident is 

“other” if the occurrence of injury cannot be 

classified in one or more of the first three 

class-of-accident categories (i.e., moving motor 

vehicle, while at work, or home). This category 

therefore includes persons injured in public 

places (e.g., tripping and falling in a store or 

on a public sidewalk) and also nonaccidenta.1 

injuries such as homicidal and suicidal 

attempts. The survey does not cover the military population, but current disability of 

various types resulting from prior injury 

occurring while the person was in the Armed 

Forces is covered and is included in this class. 

The class also includes mishaps for which the 

class of accident could not be ascertained. 

Terms Relating to Hospitalization 

Hospital .–For this survey a hospital is defined as any institution meeting one of the 

following criteria: (1) named in the listing of 

hospitals in the current Guide Issue of 

Hospitals, the Journal of the American 

Hospital Association, (2) named in the Iisting 

of hospitak in the Directories of the American 

Osteopathic Hospital Association, or (3) named 

in the annual inventory of non-Federal 

hospitah submitted by the States to the Health 

Care Facilities Service, HeaIth Services and 

Mental HeaIth Administration, in conjunction 

with the HiII-Burton program. 

Short-stay hospital.–A short-stay hospital is 

one in which the type of service provided by 

the hospital is general; maternity; eye, ear, 

nose, and throat; children’s; or osteopathic; or 

it may be the hospital department of an 

institution. 

Hospital ownership. –Hospital ownership is a 

classification of hospitals according to the type 

of organization that controls and operates the 

hospital. The category to which an individual 

hospital is assigned and the definition of these 

categories follows the usage of the American 

Hospital Association. 

Hospital dizy.-A hospital day is a day on 

which a person is confined to a hospital. The 

day is counted as a hospital day only if the 

patient stays overnight. Thus a patient who 

enters the hospital on Monday afternoon and 

leaves Wednesday noon is considered to have 

had 2 hospital days. 

Hospital days dura”ngthe year.–The number 

of hospital days during the year is the total 

number for all hospital episodes in the 

12-month period prior to the interview week. 

For the purposes of this estimate, episodes 

overlapping the beginning or end of the 

12-month period are subdivided so that only 

those days falling within the period are 

included. 

Hospital episode.–A hospital episode is any 

continuous period of stay of 1 night or more 

in a hospital as an inpatient except the period 

of stay of a well newborn infant. A hospital 

episode is recorded for a family member whenever and part of his hospital stay is included in 

the 12-month period prior to the interview 

week. 

Hospital discharge.–A hospitaI discharge is 

the completion of any continuous period of 

stay of 1 or more nights in a hospital as an 

inpatient except the period of stay of a well 

newborn infant. A hospital discharge is 

recorded whenever a present member of the 

135 
household is reported to have been discharged 

from a hospital in the 12-month period prior 

to the interview week. (Estimates were based 

on discharges which occurred during the 

6-month period prior to the interview.) 

Length of hospital stay.–The length of 

hospital stay is the duration in days, exclusive 

of the day of discharge, of a hospital discharge. 

(See definition of “hospital discharge.”) 

Average length of stay.–The average length 

of stay per discharged patient is computed by 

dividing the total number of hospital days for 

a specified group by the total number of discharges for the same group. 

Type of hospital service.-Type of hospital 

service is a classification of hospitals according 

to the predominant type of cases for which 

they provide care. The category to which an 

individual hospital is assigned and the definition of these categories follows the usage of 

the American Hospital Association. 

Terms Relating to Dental Visits 

Dental visit.–A dentaI visit is defined as any 

visit to a dentist’s office for treatment or 

advice, including services by a technician or 

hygienist acting under a dentist’s supervision. 

Interval since last dental visit.–The interval 

since the last dental visit is the length of time 

prior to the week of interview since a dentist 

or dental hygienist was last visited for treatment or advice of any type. 

Edentzdous persons. –Persons who have lost 

all their permanent teeth are classed as edentu10USpersons. An edentulous person may have 

dentures but does not have any natural teeth. 

Type of dental service.-A dental service is a 

service received when a dentist or dental 

hygienist is visited. For purposes of this survey, 

dental services have been categorized into a 

number of broad types. If a single dental visit 

involves more than one type of dental service, 

each type of service is recorded. If a particular 

type of service is rendered more than once 

during a single visit, the type of service is 

nevertheless recorded only once. For example, 

if during a single dental visit one tooth is 

extracted and three teeth are filled, the types 

of services rendered during that visit are 

recorded as “extractions” and “fillings,” each 

category being recorded only once. The 

categories of type of dental service are defined 

as follows: 

1. FzWings include temporary fillings, permanent fillings, inlays, crowns, and similar procedures. 

2. Extractions include any dentzd surgery and 

related activity such as removal of stitches. 

3. Cleaning or examination includes all forms 

of dental prophylaxis, checkup, consultation, 

and X-rays. 

4. Straightening includes orthodontic treatment 

and brace work and also fitting or repair of 

braces. 

5. Gum treatment includes all periodontal work 

except prophylaxis. 

6. Denture work includes taking impressions 

for false teeth, plate fitting or repair, and 

bridge work. 

7. Other includes all types of dental service not 

listed above. 

Terms Relating to Physician Visits 

Physician visit.–A physician visit is defined 

as consultation with a physician, in person or 

by telephone, for examination, diagnosis, treatment, or advice. The visit is considered to be a 

physician visit if the service is provided directly 

by the physician or by a nurse or other person 

acting under a physician’s supervision. For the 

purpose of this definition, “physician” includes 

doctors of medicine and osteopathic 

physicians. The term “doctor” is used in the 

interview rather than “physician” because of 

popular usage. However, the concept toward 

which all instructions are directed is that which 

is described here. 

Physician visits for services provided on a 

mass basis are not included in the tabulations. 

A service received on a mass basis is defined as 

any service involving only a single test (e.g., 

test for diabetes) or a single procedure (e.g., 

smallpox vaccination) when this single service 

was administered identically to all persons who 

were at the place for this purpose. Hence obtaining a chest X-ray in a tuberculosis chest 

X-ray trailer is not included as a physician 

visit. However, a special chest X-ray given in a 

physician’s office or in an outpatient clinic is 

considered a physician visit. 

136

Physician visits to hospital inpatients are not 

included. 

If a physician is called to a house to see 

more than one person, the call is considered a 

separate physician visit for each person about 

whom the physician was consulted. 

A physician visit is associated with the 

person about whom the advice was sought, 

even if that person did not actually see or 

consult the physician. For example, if a 

mother consults a physician about one of her 

children, the physician visit is ascribed to the 

child. 

Interval since last physician visit. –The interval since the last physician visit is the length 

of time prior to the week of interview since a 

physician was last consulted in person or by 

telephone for treatment or advice of any type 

whatever. A physician visit to a hospital inpatient may be counted as the, last time a 

physician was seen. 

Place of visit.–The place of visit is a classification of the types of places at which a 

physician visit occurs. Definitions of the 

various categories are as follows: 

1. Home is defined as any place in which the 

person was staying at the time of the physician’s visit. It may be his own home, the 

home of a friend, a hotel, or any other place 

the person may have been staying (except as 

an overnight patient in a hospital). 

2. Office is defined as the office of a physician 

in private practice only. This may be an 

office in the physician’s home, an individual 

office in an office building, or a suite of 

offices occupied by several physicians. For 

purposes of this survey, physicians connected with prepayment-group-practice plans 

are considered to be in private practice. 

3. Hospital clinic is defined as an outpatient 

clinic or emergency room in any hospital. 

4. Company or _industry health unit refers to 

treatment received from a physician or 

under a physician’s supervision at a place of 

business (e.g., factory, store, office building). 

This includes emergency or first-aid rooms 

located in such places if treatment was 

received there from a physician or trained 

nurse. 

5. Telephone contact refers to advice given in a 

telephone call by the physician directly or 

through a nurse. (Calls for appointments are 

excluded.) 

6. Other refers to advice or treatment received 

from a physician or under a physician’s 

general supervision at a school, at an insurance office, at a health department clinic, or 

any other place at which a physician consultation might take place. 

Type of medical service. –A medical service 

is a service received when a physician is consulted. For the purposes of this survey, medical 

services have been categorized into several 

broad types. A single physician visit may result 

in the recording of more than one type of 

medical service (though a particular type is not 

recorded more than once for any one physician 

visit). Definitions of the types of medical 

service are as folIows: 

1. Diagnosis and treatment include (1) examinations and tests in order to diagnose an 

illness regardless of whether the examinations and tests resulted in a diagnosis and 

(2) treatment or advice given by the 

physician or under the physician’s supervision. The category includes diagnosis alone, 

treatment alone, and both combined. X-rays 

either for diagnostic purposes or for treatment are included in this class. 

2. Prenatal and postnatal care include consultations concerning the care of the mother 

during pregnancy and in the postpartum 

period. It excludes consultations for illnesses 

not related to pregnancy or delivery. 

3, General checkup includes checkups for 

general purposes and also those for a specific 

purpose such as employment or insurance. If 

a diagnosis or diagnoses are made in the 

course of a general checkup, the physician 

visit is classified to “diagnosis and treatment” as weIl as to “general checkup.” If 

the consultation is for checking up on a 

specific condition, as, for example, when a 

person goes at regular intervals for a check 

on a tuberculous or heart condition, this is 

classified as “diagnosis and treatment” and 

not as “general checkup.” 

137 
4. Immunization includes this preventive service 

when provided by a physician or under a 

physician’s supervision. A physician service 

which is for the sole purpose of receiving 

immunization ag~nst a p~ticular disease 

given at the same time and place that many 

other persons are receiving the identical 

immunization is excluded because of the 

rule for exclusion of such services in the 

definition of a physician visit. 

5. Other includes eye refractions and specific 

preventive-care services (such as vitamin 

injections) not embraced by the above type 

of service categories. Also included are all 

visits where an unknown type of service was 

reported. 

Terms Relating to Special Aids 

Special aid.–A special aid is a device used to 

compensate for defects resulting from disease, 

injury, impairment, or congenital malformation. Aids included in this survey are artificial 

limbs, braces, crutches, canes or walking sticks, 

special shoes, wheelchairs, walkers, and any 

other kind of aid for getting around, as 

follows: 

1. Artificial limb is a device to replace a missing leg, arm, hand, or foot. It does not have 

to have moving parts, but a device employed 

only for lengthening a leg where the whole 

leg or foot is present is not counted. 

2. Brace is defined as any kind of supportive 

device for the arms, hands, legs, feet, back, 

neck, or head, exclusive of temporary casts, 

slings, bandages, trusses, belts, or crutches. 

Dental braces are excluded. 

3. Crutch is a staff with a crosspiece at the top 

to support a person in walking. The point of 

support may be the axilla, upper arm, or 

forearm. For each crutch a second support is 

at hand level. 

4. Cane or walking stick is a short staff, either 

straight or cu~ed at upper end, used to 

provide some support at hand level in walking. 

5. Special shoes are shoes of special construction or desire which are used to help a 

person in get;ing around. Oversized shoe; of 

normal or usual construction are excluded. 

6. Wheelchair is a chair mounted on wheels and 

usually propelled by the occupant by means 

of handrims attached to the two large side 

wheels. 

7. Walker is a four-legged stand which provides 

support for a person. It is moved by lifting 

or by wheeling on casters. 

Terms Relating to Home Care 

Home care.–Care received at home is defined as any personal assistance or personal 

services received by a person at home as a 

result of illness, injury, impairment, or advanced age. The person providing the care may 

have received a fee for his service or the service 

may have been provided free. Excluded from 

the definition of home care is any care provided by a physician. However, care by all 

other persons whether the latter are professionzd health workers or not is included. The 

amount of care varies from constant care for 

bedridden persons to only partial or intermittent. 

Type of care provided. –Type of care provided has been classified into three general 

categories. These categories with the specific 

inclusions are as follows: 

1. Personal care 

Walking up stairs or getting from room to , 

room: 

Includes assistance either in walking from 

one room to another or in going up and 

down stairs. This would include cases 

where someone must watch or stand 

behind a person as he walks up the steps 

in case he falls or stumbles. If the person 

is bedridden or never attempts to walk 

from one room to another or to walk up 

and down stairs, this type of care is excluded since this kind of service is not 

rendered by anyone. 

Dressing or putting on shoes: 

Includes any care a person receives in 

dressing and the like because he is unable 

to dress himself without the help of 

another person because of some h-ealth 

problem. Not included is help in dressing 

that is not health related such as the wife 

138 
who ties her husband’s ties because he 

never learned how to do it property or 

the husband who hooks the back of his 

wife’s dress because it is difficult for her 

to reach. 

Bathing (shaving) or other toilet activities: 

Includes any assistance the person need in 

washing or shaving himself or in using a 

bedpan and so forth. 

Eating or having meals served in bed: 

Includes help if the person is unable to 

eat without assistance or has to have his 

meals served to him in bed. Not included 

in this definition is help in preparation of 

meals. 

2. Medically related care 

Changing bandages: 

Includes assistance in changing dressing or 

bandages. 

Receiving injections: 

Includes injections received at home from 

someone other than a doctor. 

Other treatments: 

Includes all other treatments received 

from some other person at home such as 

the application of salves or ointments, 

wetpacks, etc. 

3. Other types of care 

Changing bed positions: 

Includes assistance of another person in 

order to sit up or turn over in bed. 

Exercising or physical therapy: 

Includes receipt of physical therapy at 

home or in any exercise performed 

because of some illness, injury, or impairment. 

Cutting toenails.€

Any other type of care not specified above.€

Specifically excluded from types of care provided are (1) any care received by the person 

outside his home, e.g., physical therapy at an 

outpatient clinic, (2) any care received from a 

physician either at the person’s home or at the 

doctor’s office, a clinic, a hospital, etc., and 

(3) maid service for cleaning, laundry, or 

preparation of meak. 

Duration of care.–Duration of care is the 

length of time prior to the week of interview 

that a person received home care. 

Extent of care.–Two major categories used 

to describe the extent of care received are 

constant care and partial or intermittent care. 

1. Constant care was provided when the person 

was never left unattended or alone in the 

house even for short intervals or during the 

night. Although the person providing the 

care was immediately available at all times, 

the care did not have to be provided at all 

times. 

2. Part-time care includes any care on a parttime basis. This includes care for persons 

who required constant care during intermittent episodes of a condition. 

Provider of care.–Three categories are used 

to classify provider of home care. 

1. Related household member included any 

medical or paramedical personnel who were 

related to the individual requiring care. However, related physicians were excluded from 

this category as well as the remaining ones. 

2. Registered nurse who came to the home to 

provide care. 

3. AU other persons providing care included 

practical nurses, physical therapists, and 

social workers. 

Nurse viszls.–Home visits by nurses include 

visits from nurses in the past 12 months by 

any kind of nurse, registered or otherwise. 

Family and Related Terms 

The definitions of families and unrelated 

individuals (family units) are the same as those 

used in the 1970 census. 

Family refers to a group of two persons or 

more related by blood, marriage, or adoption 

who are living together in the same household. 

Although the usual household contains only 

the primary family, a household can contain 

secondary families as well as individuals unrelated to the family. A Iodger and his family 

who are not related to the head of the household or a resident employee and his wife living 

in are considered a secondary family and not 

139

part of the primary family. However, if the son 

of the head of the household and the son’s 

wife and children are members of the household, this subfamily is treated as part of the 

primary family. 

Individuals are persons (other than inmates 

of institutions) who are not living with any 

relatives. An unrelated individual can be (1) a 

household head living alone or with nonrelative, (2) a lodger or resident employee 

with no relatives in the household, (3) a staff 

member of an institution who has no relatives 

living with him, or (4) a resident of a dormitory, lodging house, or other shared-residence 

facility who has no relative living with him. 

Head of family is usually the person regarded as the “head” by the members of the 

group. Married women are never classified as 

heads if their husbands are living with them at 

the time of the survey except when the 

husband is a member of the Armed Forces. 

Only one person in each family can be designated as the head. Therefore the number of 

heads of families is equal to the number of 

families. 

Other family members are all persons who 

are related to the head of the family by blood, 

marriage, or adoption. The category “child 

under 17,” used as a classifier of husband-wife 

families, refers to a child of these parents and 

includes an adopted child, a foster child, or a 

ward but excludes a grandchild. 

Terms Relating to Health Insurance 

Health insurance is any plan specifically 

designed to pay all or part of the medical or 

hospital expenses of the insured individual. The 

insurance can be either a group or an indlvidual policy with the premiums paid by the 

individual, his employer, a third party, or a 

combination of these. Benefits received under 

the plan can be in the form of payment to the 

individwd or to the hospital or doctor. However, the plan must be a formal one with 

defined membership and benefits rather than 

an informal one. For example, an employer 

simply paying the hospital bill for an employee 

would not constitute a health insurance plan. 

For the Health Interview Survey, health 

insurance excludes the following kinds of 

plans: (1) plans limited to the “dread diseases” 

such as cancer and polio, (2) free care such as 

public assistance, public welfare, and Medicaid, 

care given free of charge to veterans, care given 

under Uniformed Services Dependents Medical 

Care Program, care given under the Crippled 

Children Program or similar programs, and care 

of persons admitted to a hospital for research 

purposes, (3) insurance that pays bills only for 

accidents, such as liability insurance held by a 

car or property owner, insurance that covers 

children for accidents at school or camp, and 

insurance for a worker that covers him only 

for accidents, injuries, or diseases incurred on 

the job, and (4) insurance that pays only for 

loss of income. 

Hospital z’rzsurance.-Insurance that pays all 

or part of the hospital bill for the hospitalized 

person is called hospital insurance. The hospital 

bill is limited to the biII submitted by the 

hospital itself, not the doctor’s or surgeon’s bill 

or the bill for special nurses. Such a bill always 

includes the cost of room and meak and may 

also include the cost of other services such as 

operating room, laboratory tests, and X-rays. 

Swg”cal insurance. –Insurance that pays in 

whole or part the bill of the doctor or surgeon 

for an operation whether performed in a 

hospital or in the doctor’s office is surgical 

insurance. Insurance that pays the cost of visits 

to a doctor’s office for postoperative care is 

incIuded as surgical insurance. 

Terms Relating to Acquisition 

and Cost of Medicines 

In order to obtain accurate and complete 

information relating to the acquisition and cost 

of medicines, the reference period is limited to 

the 2-week period prior to interview. The 

collected data are then appropriately weighted 

to provide annual estimates for medicine items. 

Prescribed medicine. –Prescribed medicine is 

defined as (1) any medicine obtained on a 

doctor’s written prescription, (2) any medicine 

which has been prepared on the basis of a 

doctor’s telephone call to a pharmacist, or (3) 

any medicine given by the doctor (or nurse) to 

a person to take home. Medicine obtained as a 

refill of a previous prescription is considered 

prescribed medicine. Medicines and injections 

140 
administered in a medicaI facility are excluded. 

Acquisition of prescribed medicine. –Each 

time the medicine is actually obtained on the 

basis of a prescription is considered an acquisition. If the medicine is specifically prescribed 

for two persons, it is counted as two acquisitions. Each time the prescription is refilled is 

considered a separate acquisition. 

Cost per acquisition of prescribed medicine. 

–The amount paid (or to be paid) by a person, 

his family, or friends and any part paid by 

health insurance is recorded for each acquisition of medicine for each person. If the medicine was obtained without cost, the source 

from which the medicine was obtained free of 

charge is recorded. If the medicine was obtained for two persons, haIf of the cost is 

allocated to each person. Similarly if the medicine was obtained twice for one person, half 

the total cost is allocated per acquisition. 

Nonprescn”bed medicine. –Nonprescribed medicine is defined as medicines obtained without a prescription. The term includes tonics, 

pills, salves, ointments, vitamins, first-aid items, 

and other medicines or medications. 

Users of nonprescn”bed medicine. –Persons in 

the family who used or might use each nonprescribed medicine are recorded. 

Cost of nonprescn”bed medicine during 

period per user. –The amount paid (or to be 

paid) for a given type of nonprescribed medicine actually obtained during a period of time 

is allocated equally among each user (or potential user) of the medicine. Nonprescribed medicine obtained “free from doctor” (or other 

source) is recorded as having no cost. 

Terms Relating to Corrective Lenses 

Corrective lenses.-Corrective Ienses include 

eyeglasses and contact lenses. The term is limited to visual aids worn to correct or improve 

vision and therefore excludes sunglasses worn 

only to filter light, safety glasses worn only for 

protection of the eyes, hand magnifying 

glasses, and other such devices. However, if the 

safety glasses are worn ako for correction or 

improvement of vision, they are considered 

corrective lenses as are prescription sunglasses. 

Type of correction. -Lenses are used for the 

correction of near vision, distance vision, and 

defective vision due to specific eye conditions. 

Lenses prescribed for the correction of near 

vision aid the person in reading or doing close 

work. For persons who cannot read, the term 

“close work” is defined as seeing smzdl objects 

clearly enough to recognize what they are. 

Lenses prescribed for the correction of distance 

vision aid the person in seeing distance objects 

and are used in such activities as driving a car, 

watching a moving, or seeing entries on a 

blackboard. Persons who reported having bifocals are considered as having correction for 

both near and distance vision, but the use of 

both types of lenses is verified by the interviewer. 

When the respondent reported ordy in terms 

of an eye condition such as astigmatism or 

strabismus, the type of correction is classified 

as other than correction of near or distance 

vision. 

For persons who obtained their corrective 

lenses without a prescription, the respondent’s 

reply regarding type of correction is accepted. 

Frequency of use of corrective lenses.–The 

options read to the respondent, “all of the 

time, most of the time, hardly ever, never” 

represent a descending scale of frequency of 

use. For persons who use their lenses for the 

correction of near vision only or distance 

vision only, the scale refers only to the purpose for which the lenses were prescribed or 

intended, e.g., if a person uses his lenses to 

read only the daily newspaper each morning 

and does no other reading or close work, he is 

considered as a person who uses his glasses “all 

of the time” for “reading or close work.” If a 

person has both eyeglasses and contact Ienses 

or more than one pair of either, the question 

on frequency of use applies to all lenses used, 

e.g., if a person wears contact lenses at work 

and eyeglasses at all other times, he is considered as wearing corrective lenses “all of the 

time.” 

Source of optical prescr@tion.–Prescriptions 

for corrective lenses are usually obtained from 

either an ophthalmoIogist or an optometrist. 

An ophthalmoIogist is a physician who specializes in the medical and surgical care of the 

eyes and may prescribe drugs or other treatment as well as lenses. An optometrist performs visual analysis by examining the eyes, 

141 
prescribing lenses and other vision aids, visual 

training, and orthoptics or other optical aids. 

The optometrist does not treat eye diseases or 

perform surgery. 

Terms Relating to Cigarette Smoking 

iVorzwnoker.-A person who has never 

smoked more than 100 cigarettes (five packs) 

during his entire life is considered to have 

never smoked cigarettes. Persons who have 

never smoked cigarettes are also referred to as 

“never smokers.” 

Ever smoked cigarettes.–Persons who have 

smoked more than 100 cigarettes (five packs) 

in their entire lives are classified as having ever 

smoked and are further described as present 

smokers and former smokers. They also are 

referred to as “ever smokers.” 

Present cigarette smoker.–Any person who 

reported a current rate of cigarette smoking is 

classified as a present smoker. The rate may 

range from less than one cigarette per day to 

99 or more cigarettes per day. If a person has 

stopped smoking cigarettes only temporarily 

because of illness, economic reasons, or the 

like, he is still considered a present smoker. 

Former cigarette smoker.–Any person who 

has smoked at least 100 cigarettes during his 

entire life but reports smoking no cigarettes at 

the time of the interview is classified as a 

former smoker. 

Heaviest smoking rate. –A person’s heaviest 

smoking rate is the daily rate of consumption 

during the period when he was smoking the 

most. The period of heaviest smoking can 

range from a short time to many years. 

Present smoking rate.–A person’s present 

smoking rate is the number of cigarettes he 

reports to be smoking per day at the time of 

the interview. 

Time since last snzoked.-This is a measure 

of the interval of time since a former smoker 

last smoked cigarettes fairly regularly. 

Demographic Terms 

Age.–The age recorded for each person is 

the age at last birthday. Age is recorded in 

single years and grouped in a variety of 

distributions depending on the purpose of the 

table. 

Color.–The population is divided into two 

color groups, “white” and “all other.” “AU 

other” includes Negro, American Indian, Chinese, Japanese , and any other race. Mexican 

persons are included with “white” unless definitely known to be Indian or of another race. 

Income of family or of unrelated individuals.–Each member of a family is classified 

according to the total income of the family of 

which he is a member. Within the household 

all persons related to each other by blood, 

marriage, or adoption constitute a family. Unrelated individuals are classified according to 

their own income. 

The income recorded is the total of all income received by members of the family (or 

by an unrelated individual) in the 12-month 

period preceding the week of interview. Income from all sources is included, e.g., wages, 

salaries, rents from property, pensions, and 

help from relatives. 

Education.–The categories of education 

status show the years of school completed. 

Only years completed in regular schools, where 

persons are given a formal education, are 

included. A “regular” school is one which advances a person toward an elementary or high 

school diploma or a college, university, or professional school degree. Thus education in 

vocational, trade, or business schools outside 

the regtdar school system is not counted in 

determining the highest grade of school 

completed. 

L Education of head of family or of unrelated 

individuals. Each member of a family is 

classified according to the education of the 

head “of the family of which he is a member. 

Within the household all persons related to 

each other by blood, marriage, or adoption 

constitute a family. Unrelated individuals are 

ckissified according to their own education. 

2. Education of individual. Each person aged 

17 years or older is classified by education 

in terms of the highest grade of school 

completed. 

Man”tal status. –Marital status is recorded 

only for persons 17 years of age or older. The 

marital status categories in this report are as 

follows: 

1. Under 17 includes all persons aged O-16 

regardless of their marital status. 

142 
2. Married incIudes all married persons not 

separated from their spouses. Persons with 

common-law marriage are considered as 

married. 

3. Never marrz”ed includes persons who were 

never married and persons whose only 

marriage was annulled. 

4. Separated includes married persons w~o have 

a legal separation or who have parted 

because of other reasons. This does not include persons separated from their spouses 

because of the circumstances of their 

employment or service in the Armed Forces; 

these persons are considered married. 

5. Widowed and divorced include, respectively, 

all persons who said they were either 

widowed or legaUy divorced. 

Living arrangement.-The four categories of 

living arrangements shown in this report are as 

follows: 

1. Living alone. Living alone is defined as living 

in a one-member household. 

2. Living with nonrelative. Living with nonrelative is defined as living in a household 

with another person or persons none of 

whom are related to the person by blood, 

marriage, or adoption. 

3. Living with relatives–marn”ed. This category 

includes married persons who are living in a 

household with another person or persons 

one or more of whom are related to them 

by blood, marriage, or adoption. Persons 

with common-law marriages are considered 

to be married. For purposes of this category, 

“married” excludes widowed, divorced, or 

separated. Persons whose only marriage was 

annulled are counted as “never married.” 

4. Living with relatives–other. This category 

includes children living with parents or 

relatives; it also includes persons who are 

widowed, divorced, separated, or never 

married who are living in a household with 

another person or persons one or more of 

whom are related to them by blood, marriage, or adoption. Persons whose only marriage was annulled are counted as “never 

married.” “ Separated” refers to married persons who have a legal separation or who 

have parted because of marital discord. 

Usual activity.–All persons in the population 

are chissified according to their usual activity 

during the 12-month period prior to the week 

of interview. The “usual” activity, in case more 

than one is reported, is the one at which the 

person spent the most time during the 

12-month period. Children under 6 years of 

age are classified as “preschool.” All persons 

aged 6-16 years are classified as “school age.” 

The categories of usual activity used in this 

report for persons aged 17 years and over are 

usually working, usually going to school, 

usually keeping house, retired, and other activity. For several reasons these categories are not 

comparable with somewhat similarly named 

categories in official Federal labor force statistics. First, the responses concerning usual activity are accepted without detailed questioning 

since the objective of the question is not to 

estimate the numbers of persons in labor force 

categories but to identify crudely certain population groups that may have differing health 

problems. Second, the figures represent the 

usual activity status over the period of an entire year, whereas official labor force statistics 

relate to a much shorter period, usually 1 

week. Third, the minimum age for usually 

working persons is 17 in the Health Interview 

Survey, and the official labor force categories 

include all persons aged 14 or older. Finally, in 

the definitions of specific categories which 

follow, certain marginzd groups are classified 

differently to simplify procedures. 

1. Usually working includes persons 17 years of 

age or older who are paid employees; selfemployed in their own business, profession, 

or in farming; or unpaid employees in a 

family business or farm. Work around the 

house or volunteer or unpaid work such as 

for a church is not counted as working. 

2. Usually going to school includes persons 17 

years of age or older whose major activity is 

going to school. 

3. Usually keeping house includes female 

persons 17 years of age or older whose 

major activity is described as “keeping 

house” and who cannot be classified as 

“working.” 

4. Retired includes persons 45 years old and 

over who consider themselves to be retired. 

In case of doubt, a person 45 years of age 

or older is counted as retired if he or she 

has either voluntarily or involuntarily 

stopped working, is not looking for work, 

143 
and is not described as “keeping house.” A 

retired person may or may not be able to 

work. 

5. Other activity includes all persons 17 years of 

age or older not classified as “working,” 

“retired,” or “going to school,” and females 

17 years of age or older not classified as 

“keeping house.” 

Geographic region.–For the purpose of 

classifying the population by geographic area, 

the States are grouped into four regions. These 

regions, which correspond to those used by the 

U.S. Bureau of the Census, are shown below. 

Region States included 

Northeast . . . . .	 Maine, New Hampshire, 

Vermont, Massachusetts, 

Rhode Island, Connecticut, 

New York, New Jersey, 

Pennsylvania 

North Central . .	 Michigan, Ohio, Indiana, 

Illinois, Wisconsin, 

Minnesota, Iowa, Missouri, 

North Dakota, South 

Dakota, Kansas, Nebraska 

South . . . . . . . .	 Delaware, Maryland, 

District of Columbia, 

Virginia, West Virginia, 

North Carolina, South 

Carolina, Georgia, Florida, 

Kentucky, Texas, Tennessee, 

Alabama, Mississippi, 

Arkansas, Louisiana, 

Oklahoma 

West . . . . . . . . .	 Montana, Idaho, Wyoming, 

Colorado, New Mexico, “ 

Arizona, Utah, Nevada, 

Washington, Alaska, Oregon, 

California, Hawaii 

Place of residence. –The place of residence of 

a member of the civilian, noninstitutionalized 

population is classified as inside a standard 

metropolitan statistical area (SMSA) or outside 

an SMSA either farm or nonfarm. 

1. Standard metropolitan statistical areas. The 

definitions and titles of SMSA’S are established by the U.S. Office of Management and 

Budget with the advice of the Federal Committee on Standard Metropolitan Statistical 

Areas. There were 212 SMSA’S defined for the 

1960 decennial census. The definition of an 

individuzd SMSA involves two considerations: 

first, a city or cities of specified population 

which constitute the central city and identify 

the county in which it is located as the central 

count y; second, economic and social relationships with contiguous counties (except in 

New England) which are metropolitan in 

character so that the periphery of the specific 

metropolitan area may be determined. 

SMSA’S are not limited by State boundaries. 

In New England SMSA’S consist of towns and 

cities, rather than counties. The metropolitan 

population in this report is based on SMSA’S 

as defined in the 1960 census and does not 

include any subsequent additions or changes. 

2. Central cities. Each SMSA must include at 

least one central city. The complete title of an 

SMSA identifies the central city or cities. If 

only one central city is designated, then it 

must have 50,000 inhabitants or more. The 

area title may include, in addition to the 

largest city,. up to two city names on the basis 

and in the order of the following criteria: (1) 

the additional city has at least 250,000 

inhabitants or (2) the additional city has a 

population of one-third or more of that of the 

largest city and a minimum population of 

25,000. An exception occurs where two cities 

have contiguous boundaries and constitute, 

for economic and social purposes, a single 

community of at least 50,000, the smaller of 

which must have a population of at least 

15,0000 

3. Farm and nonfarm residence. The population 

residing outside SMSA’S is subdivided into the 

farm population, which comprises all nonSMSA residents Iiving on farms, and the 

nonfarm population, which comprises the 

remaining outside SMSA population. The 

farm population includes persons living on 

places of 10 acres or more from which sales of 

farm products amounted to $50 or more 

during the previous 12 months or on places of 

less than 10 acres from which sales of farm 

products amounted to $250 or more during 

the preceding 12 months. Other persons living 

outside an SMSA were classified as nonfarm if 

144

their household paid rent for the house but 

their rent did not include any land used for 

farming. 

Sales of farm products refer to the gross 

receipts from the sale of field crops, 

vegetables, fruits, nuts, livestock and livestock 

products (milk, wool, etc.), poultry and poultry products, and nursery and forest products 

produced on the place and sold at any time 

during the preceding 12 months. 

Occupation.–A person’s occupation may be 

defined as his principal job or business. For the 

purposes of this survey, the principal job or 

business is defined in one of the following ways. 

If the person worked during the 2-week reference period of the interview, or had a job or 

business, the question concerning his occupation 

(or what kind of work he was doing) applies to 

his job during that period. If the respondent 

held more than one job, the question is directed 

to the one at which he spent the most time. For 

an unemployed person, this question refers to 

the last full-time civilian job he had. A person 

who has a job to which he has not yet reported, 

and has never had a previous job or business, is 

classified as a “new worker.” 

Shown below are the occupation classes presented in this report and their code numbers as 

OccupationClassification Census Code 

White-collorworkens 

Professional, technical, and kindred 

workers . . . . . . . . . . 001-195, N 

Managers and”administrators, except farm . 201-245 

Sales workers . . . . . . . . . 260-280 

Clerical and kindred workem . . . . . 301-395, P, Q 

Blue-collarworkers 

Craftsmen and Idndrad workers . . . . 401-580, R, S 

Operatives, except transport . . . . . 601-596, T 

Transport equipment operatives . . . . 701-715, u 

Laborers, except farm . . . . . . . 740-785, V 

Fmrs workers 

Farmars and farm managers . . . . . 801-802, W 

Farm laborers and farm foremen . . . . 821-824 

Setvice workers 

Service workers, except private household . 901-965, X, Y 

Private household workers . . . . . . 980-984, Z 

Unknown . . . . . . . . . . . 880,885 

found in the Classified Index of Occupations and 

Industries, U.S. Bureau of the Census (June 1971). 

Industry.–The industry in which a person was 

reportedly working is classified by the major 

activity of the establishment in which he 

worked. The only exceptions, the few establishments classified according to the major activity 

of the parent organization, are as follows: 

laboratories, warehouses, repair shops, and 

storage facilities. 

The industry categories presented in this 

report are shown below with the corresponding 

codes found in the Classified Index of Occupations and Industries, U.S. Bureau of the Census, 

and the Standard Industrial Classification 

ManuaZs (SIC), U.S. Office of Management and 

Budget, (1967). 

IndustryClussi~icution Census Code SIC Code 

Agricultural . . . . 017-019, A 01,07 

(except 0713) 

Forastry and fisherias . 027-028 08,09 

Mining 047-057 10-14 

Construct~on: : : : 067-077,B 15-17 

Manufacturing . . . 107-398,C 19-39,0713 

Transportation and 

public utilitias . . 407-479,D 40-49 

Wholesale and retail 

trade . . 507-598, E, F, G 50-59 

Finance, insuran;a, . . 

and real estate . . 707-718 60-67 

Services and miscalIaneous 727-897,H, J, K 7C-89 

Public admini;traho; : 907-937,L, M 91-84 

Unknown . . . . 995-988 88 

In labor force.–All persons 17 years and over 

who worked at or had a job or business or were 

looking for work or on layoff from work during 

the 2-week period prior to the week of interview 

are in the labor force. The labor force consists of 

persons currently employed and currently 

unemployed. Definitions of these categories, 

similar to those used by the Current Population 

Survey, are as follows: 

1. Currently employed. Persons 17 years of age 

and over who reported that at any time 

during the 2-week period covered by the 

interview they either worked at or had a job 

or business are currently employed. Current 

employment includes paid work as an 

employee of someone else; self-employment 

in business, farming, or professional practice, . . and unpmd work m a family business or far.,,, 

145 
Freelance workers are considered currently 

employed if they had a definite arrangement 

with one employer or more to work for pay 

according to a weekly or monthly schedule; 

those without a definite employment 

schedule are counted as employed, unemployed, or not in the labor force depending 

upon their activity during the 2-week period 

covered by the interview. Persons temporarily 

absent from a job or business because of 

illness, vacation, strike, or bad weather are 

considered employed. 

Excluded from the currently employed 

population are (1) persons receiving revenue 

from an enterprise but not participating in its 

operation, (2) persons doing housework or 

charity work for which they receive no pay, 

(3) seasonal workers during the portion of the 

year they were not working, and (4) persons 

not working even though they had a job or 

business but who were on layoff or looking 

for work. 

2. Currently unemployed. Persons 17 years and 

over who during the 2-week period prior to 

interview did not work or had no job or 

business but were looking for work and those 

who had a job but were on layoff or looking 

for work are considered currently 

unemployed. 

The number of currently employed and 

currently unemployed persons estimated from 

the Health Interview Survey (HIS) will differ 

from the estimates prepared from the Current 

Population Survey (CPS) of the U.S. Bureau of 

the Census. This occurs because of sampling 

variability and the following primary conceptual 

differences: (1) HIS estimates are for persons 17 

years of age and over, while CPS estimates are 

for persons 16 years of age and over; (2) HIS 

uses a 2-week reference period, while CPS uses a 

l-week reference period; and (3) HIS is a 

continuing survey with separate samples taken 

weekly, while CPS is a monthly sample taken for 

the survey week that includes the 12th of the 

month. 

Not in labor ~orce.–Persons not in the labor 

force are all persons under 17 years of age and 

other persons who did not at any time during 

the 2-week period covered by the interview have 

a job or business, were not looking for work, 

and were not on layoff from a job. In general, 

persons excluded from the labor force are 

youths under 17, retired persons, physically 

hardcapped persons unable to work, and housewives or charity workers who receive no pay. 

Also excluded are persons receiving revenue 

from but not participating in a business and 

seasonal or freelance workers not looking for 

work. 

Class of roorker.-Persons in the labor force 

are classified according to class of worker as 

follows: 

1. Private paid workers are persons working for a 

private employer for wages, salary, or 

commissions. This includes compensation by 

tips; piece rates or pay in kind; and wages or 

salary from settlement houses, churches, 

unions, and other nonprofit organizations. 

2. Federal Government workers are persons who 

work for any branch of the Federal Government including employees of Governmentowned bus lines and utilities, civilian 

employees of the Armed Forces, and persons 

elected to Federal offices. 

3. Other government workers are persons who 

work for any branch of government other 

than the Federal Government, e.g., State, 

city, or county. Included in this group are 

civilian employees of the National Guard, 

persons elected to paid offices, employees of 

international organizations such as the United 

Nations, and employees of foreign governments. 

4. Self-employed workers are persons working 

for profit or fees in their own business, farm, 

shop, or office. “Own business” includes 

persons who have their own tools or equipment and provide services on a contract, 

subcontract, or job basis. Officers of corporations are not classified as owning their own 

business, even though they do own all or part 

of the corporation stock; such persons are 

considered as “private paid.” A person who 

operates a farm for himself, regardless of 

whether he owns or rents the land, is 

considered self-employed. 

5. Other class of worker includes (1) persons 

working without pay on a farm or in a 

146

business operated by a relative, (2) persons Quarter.–The quarters used by the Health 

who have never worked in the past but have a Interview Survey are actually 13-week periods 

job or business which will begin in the near rather than 3 calendar months. Since each 

future, (3) persons who have not worked in 13-week period begins on a Monday and ends on 

the past but are presently looking for work, a Sunday,. . the actual dates of the beginning ~d 

and (4) persons for whom no information as end of each 13-week period may o“verlap-into 

to class of worker is available. another calendar quarter. 

000


147

APPENDIX IV 

CHECKLISTS FOR SELECTED CHRONIC CONDITIONS: 1968-73 

CONDITIONS OF THE DIGESTIVE SYSTEM: 1968 

NOW I’m going to read a list of conditionti I 

16a. During the past 12 months, has anyone in the famil y (yoa,your --, �tc.) had any of the fol lowing conditions - h I Yea No 

If “Yes? ask b and c A. Gallstones? I I b.	 Who was this? B. Any other gallbladder trouble? 

c. During the past12 months has anyone else had . . . ? 

(Enter name of condition and letter of line where 

reported in appropriate persons column(s) in Item C.) Esi!!ea

F. Hepatitis? I 

During the past 12 nronths,,has anyone in During the past 12 months has anyone in During the past 12 months has anyone in 

the family Irad - If “Yes, aak b and c ye. No the family had - If “Yes;’ ask b and F ye, No the family had - [f “Yes:’ ask b and c Yes No 

G. Yellow iaundice? N. Gastritis? U. Frequent constipation? 

H. Any ather liver trouble? 0. Frequent indigestion? V. Any other bawel trouble? 

1. Diabetes? P. Any other stomach trouble? W. Any other intestinal trouble? 

J. Any disease of the pancreas? Q. Enteritis? X. Cancer of the stomoch, colon or rectum? 

K. Ulcer? R. Diverticulitis? Y. During the post 12 months has anyone 

in the family had any other condition 

L. Hernia or ruptur~? S. Colitis? of the digestive system? 

If “Yes, ask:, Who was this? - What M. A disease of the �sophagus? T. Spastic Colon? i. d.. .m. rli+i*.? (Ii!.t.. f. It. m C) 

148 
-----

----

CONDITIONS OF THE BONES, JOINTS, MUSCLES, AND SKIN: 1969


17. Now I’m going to read a list of conditions. A-2 17. DURING THE PAST 12 MONTHS 17. DURING THE PAST 12 MONTHS, did 

Does onyone In the family (you, your-, 

ok.) HAVE any of these condit ions... 

Missing fingers, hand c+ armtces, fcmt or leg? 

Permanent stiffness or any defwmlty 

of the foot, leg, fingers, armor 

back? 

Paralysis of any kind? 

If “Yes” ask 

Who iS this? 

Does anyone �lse have...? 

did anyone in the family have...


Arthritis of any kind


Rheu;atlsm?


Gout?


Lumbago?


Osteomyelitis? (u~-tee-oh.m~-uh-lit<-lss)


A bone cyst w bone spur?


Any other disease of the bone w cartilage?


Trick knee?


A sli~d or ruptwed disc?


Curvature of the spine?


Repeated trouble.with neck, back or sp]ne?


Bwsitis w synovitis? (si#-uh-vfi&lss)


Any distase of the muscles or tendons?


If “Yes;’ ask


WhoWOSlhis? 

During the past 12 maths, 

did anyone �lse have... 

anyone in the family have... 

A tumor, cyst or growth of the skin? 

Eczema or psoriasis? (sc-ryi.uh-sis) A-3 

: Trouble with dry or inching skin? : 

Trouble with acne? / 

A skin ulcer? \ 

1 

Any kind of skin allergy? s 

Dermatitis gr any other skin trouble? ~ 

1 Trouble with Fallen arches, flatfeet o’f :

clubfoot? ~ 

Trouble with ingrown tcenails or fingernails? } 

Trouble with bunions, corns or calluses?	 : 

1 

A dfsease of the hair or scalp? 1 

Any disease of the lymph or sweat glands?	 \ 

1 

~ If ‘“Yes:’ ask 1 

who WOS this? 1 

~ During the past 12 months, / did anyone 81s. have... 1 

Exclude persons who have arthritis or 

other ‘Arthritis”’ conditions. 

17.	 (?esides —) During thep.st12m.nlhs, 

did anyone (else) in the fomily have any 

of the follow ing... 

AA.	 Anystiffness inthejoints when first 

geming out of bed in the morning?* 

BB. Pain inthejoints when they are moved?” 

CC. Swelling inanyofthe joints, excepcin 

the ankles or feet?* 

DD.	 Anypaln orsoreness intheioints when 

the~are touched or pressed on?* 

�lf “Yes, ” ask What was the cause of this? 

Record letters and cause initem C.2. 

Interviewer informaciorv 

Other “anhritis” conditions 

1. Lupus (erythematosus) 

2. Sclemderma 

3. Dermatomyosicis 

4. POlyarteritis 

5. Periarteritis 

6. Psoriatic arthritis 

7. Rheumatism 

8. Gout 

Conditfoms reported for which quesHanx 3da 

n-d not fm askd. 

Acne Hleft blocd wessure 

Hymnsica 

Arteriosclerosis Kidney stmes 

Athlete’s foot Laryngitis 

B Bronchitis (any kfnd) Migraine heatfadm 

Bursitis Mmnfn ~-----

i Chickec+mx Phlebitis 

Cold (Thruttb@hbitls) 

~ 

Corns, calluses, Pntumonfa c 1 bunlcms ot warts hmw : Crcup Sciatica 

, Olabetes Sinus utile 

4 

EPilq)sy (Sfnusitis) 

; Galist0ne5 9Ju:$reFtmccus) 

: Goiter Tcmsiliitis 4 H:e&#e:&f Ulcer (ckkxfenal, : stmn=h, ~I%iC ! 

j Hay fWU w gattrlc only) 

4 Hemetrhoids w piles Wlwoping C@ 

, Hernia 

$

; (all types) 

,

4 

4 

j 

.! 

149

--

CONDITIONS OF THE RESPIRATORY SYSTEM: 1970 

t%. Now I’m going to read a list of conditions; 

A. Bronchitis? Y N 

During the past 12 months, did anyone in the family (you, your --, �tc.) have any of these conditions -

B. Bronchiactasis? Y N 

If “Yes,”’ ask b and c 

C. Asthma? Y N b. Whowastbis ?- Enter name ofcondition and Ietterof line where 

reported	 inappropriate persons column(s)in item C. 

D. Hay fever? Y N 

c.	 During the past 12 months did onyone ekehave . . .? 

E. Nasal POIYP? Y N 

Do not circle “Y” and make no entryin item C for cold; flu; red, sore, or strep throafi 

or< ’virus” reported inanswer to question 16. 

During fhepast 12months didanyone inthe family have...? If “Yes:’askbandc 

J. Tumor, cyst, or growth of the O. Tumor, cyst, or growth of the 

F. Sinus troublo? Y N bronchial tube or lung? Y N throot, [ar.ynx, ortrachao? Y N 

P. Any work.related respiratory condition 

K. Emphysema? Y N such as dust on the lungs, 

G. De flacted or deviated nasal s@um? Y N silicosis or pnau.mo.co.n i.o.s is? Y N 

L. Pleurisy? Y N 

H. �Tonsillitis or mslargement of the Q. During the post 12 months did anyone in 

tonsi Is or adenoids? Y N the fami Iy have any other respiratory, M. Tuberculosis? Y N lung, or pulmonary condition? Y N 

If ’’Yes/’ ask: Whowssthis?-Whet 

L �Laryngitis? Y N N. Abscess of the lung? Y N wos the condition? (Enter in item C) 

�lf reported in question 160nly, aslc 

1.Howmanytimas did havs . . . in the past 12 months? - If 2+, enter in item C. 

If only I time, aslc 

2.	 How Iongdidithsst?-lf I month or Ionger, enter in item C. 

If Iess than i month, donotrecwd. 

If tonsils or adenoids removed during the past 12 months, enter in item C. 

Donotcircle c’Y’’and make no entry in item CforcoId; flu; red, sore, orstrepthroaC 

Or’’virus” reported inanswer to question 16. 

150 
IMPAIRMENTS: 1971


36a. Does anyone in the family (YOU, your --, etc.) NOW hove - A. Deafness in one or bofh ears? Y N 

If “yes,” ask b and C &	 Any other trouble hearing with 

one or both ears? Y N 

b.	 Who is this? - Enter name of condition and letter of line where 

reported in appropriate person’s column(s) in i rem C. C. Tinnitus or ringing in the eors? Y N 

c. Does anyone else have . . . ? 

D. Blindness in one or both eyes? 

-

I F. Glaucoma? Y N 

Does onyone in the family NOW have , . . ? If “’Yes,” ask b and c 

I , , 

M. A missing finger, hand, or arm, toe, S. Any TROUBLE with fallen 

L Color blindness? Y N foot, or leg? Y N arches or flat feet? Y N 

1. A detnched retina or any other 

condition of the retina? Y N N. A missing (breast), kidney, or lung? Y N T. A clubfoot? Y N 

Any other trouble seeing with one or both U. Permanent stiffness or any deformity


�yes even when wearing glasses? Y N O. Palsy or cerebral palsy? Y N of the back, foot, or leg? Y N


V. Permanent stiffness or any deformity 

, A cleft palate or harelip? Y N P. Paralysis of any kind? Y N of the fingers , hand, or arm? Y N 

:. Stammering or stuttering? Y N Q. Curvature of the spine? Y N W, Mento I retardation? Y N 

X. Any condition caused by on old 

accident or iniur ? 

,. Any other speech defect? Y N R. REPEATED trouble with bock or spine? Y N u “’Yes,” ask ~hat is the condition? Y N 

151

CONDITIONS OF THE CARDIOVASCULAR SYSTEM: 1972 

18a. Has anyons in tho family (you, your --, �tc.) EVER had -


If “Yes;’ ask b and c.


b.	 Who was this? Enter name of condition and letter of line where


reprted in appropriate person’s column(s) in item C.


c. Hot anyone �lse �ver hod. . .?


)9a. DURING THE PAST 12 MONTHS, did anyone in tho family (YOU, your --, stc.)
 have -

If “Yes,” ask b and c 

b.	 who WOS th? Enter name of condition and letter of line where


reported in appropriate perSOn’s column(s) in item C.


c. During tho post 12 months did anyona .1s8 havo. . .?


A. Rheumatic fever?


B. Rheumatic heart disease? II


C.	 Hardening of the arteries or arteriosclerosis?


I


D. Congenital heart di seose?


1


E. Coronary heart disease?


F. High blood pressure?


G. Stroke or a cerebrovascular accident?
 ~


H. Hemorrhage of the brain? I


1. Angina mctoris? II


J. Myocrxdird infarction?


K. Any other heart ottock?


L. Damagad haart valves?


M. Tachycardio or rapid ham+?


N. Heart murmur?


O. Any ether heart trouble?


P. Aneurysm


Q. Any bleed clots?


R. Gangrcno?


S. Varicosa veins?


T. Hemorrhoids or piles?


U. Phlebitis or thrombophlebitis?


V. Any other condition affecting blood circulation?


152 
CONDITIONS	 AFFECTING THE NERVOUS SYSTEM, GLANDULAR DISORDERS, AND 

CONDITIONS OF THE GENITOURINARY SYSTEM: 1973 

31.x DURING THE PAST 12 MONTHS, did anyone in the family 

(you, your --, �tc. ) hove - Glandular 

disorder 

If “Yes,” ask b and c = 

b.	 Who was this? Enter name of condition and letter of line } where reported In approprl ate person’s COIumn in item C. 

c. During the past 12 months, did anyone else have . . . ? 

B 

F. Multiple sclerosis? 

c w“,”;”.? 

H. Neuralgia or neuritis Condition affecting the la. DURING THE PAST 12 MONTHS, did anyone in the family have - nervous system 1. Sciatica? 

If “’Yes,” ask b and c J. Nephritis? 

b. Who was this? Enter in item C K. Kidney stones? 

L. Any other kidney trouble? Genito.urinary c. During the past 12 months, did anyone else hove . . . ? condition M. Bladder trouble? 

N. Prostate trouble? 

O. Oisease of the uterus or ovary? 

P. Any other female trouble? 

000


* U.S.GOVERNMENT PRINTING OFFICE: 19750-573-998

VITAL AND HEALTH STATISTICS PUBLICATION SERIES 

Formerly Public Health Service Publication No. 1000 

Series 1. Programs and collection pyoceduves. — Reports which describe the general programs of the National 

Center for Health Statistics and its offices and divisions, data collection methods used, definitions, 

and other material necessary for understanding the data. 

Swies 2.	 Dati ez.dmtion and methods veseavch. — Studies of new statistical methodology including: experimental tests of new survey methods, studies of vital statistics collection methods, new analytical 

techniques, objective evaluations of reliability of collected data, contributions to statistical theory. 

Series 3. Analytical studies. —Reports presenting analytical or interpretive studies basedon vital and health 

statishcs, carrying the analysis further than the expository types of reports in the other series. 

Series 4. Documents and committee reports. — Final reports of major committees concerned with vital and 

health statistics, and documents such as recommended model vital registration laws and revised 

birth and death certificates. 

Series 10.	 Data from the Health Interview Swuev. —Statistics on illness, accidental injuries, disability, use 

of hospital, medical, dental, and other services, and other health-related topics, based on data 

collected in a continuing national household interview survey. 

Series 11. Data jiom the Health Examination Survey. —Data from direct examination, testing, and measurement of national samples of the civilian, noninstitutional population provide the basis for two types 

of reports: (1) estimates of the medically defined prevalence of specific diseases in the United 

States and the distributions of the population with respect to physical, physiological, and psychological characterist its; and (2) analysis of relationships among the various measurements without 

reference to an explicit finite universe of persons. 

Series 12.	 Data from the Institutional Population Surueys — Statistics relating to the health characteristics of 

persons in institutions, and their medical, nursing, and personal care received, based on national 

samples of establishments providing these services and samples of the residents or patients. 

S#ies 13.	 Data from the Hospital Discharge Survey .—Statistics relating to di.ck~rged patients in short-stay 

hospitals, based on a sample of patient records in a national samPIe of hospitals. 

Series 14.	 Data on health resources: manpower and facilities. —Statistics on the numbers, geographic distribution, and characteristics of health resources including physicians, dentists, nurses, other health 

occupations, hospitals, nursing homes, and outpatient facilities. 

Series 20.	 Data on mortulity. —Various statistics on mortality other than as included in regular annual or 

montnly reports— special analyses by cause of death, age, and other demographic variables, also 

geographic and time series analyses. 

Series 21.	 Data on natality, marriage, and divorce. —Various statistics on natality, marriage, and divorce 

other than as included in regular annual or monthly reports+ pecial analyses by demographic 

variables, also geographic and time series analyses, studies of fertility. 

Seyies 22. Data f%om the National Natality and Mortality Surveys. — Statistics on characteristics of births 

and deaths not available from the vital records, based on sample surveys stemrnfng from these 

records, including such topics as mortality by socioeconomic class, hospital experience in the 

last year of life, medical care during pregnancy, health insurance coverage, etc. 

For a list of titles of reports published in these series, write to:	 Office of Information 

National Center for Health Statistics 

Public Health Service, HRA 

Rockville. Md. 20852