PROGRAMS AND COLLECTION PROCEDURES Series 1

Number 14

Plan and Operation of the

HANES I Augmentation

Survey of Adults 25-74 Years

United States, 1974-1975

DHEW Publication No. (PHS) 78-1314

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

Public Health Service

National Center for Health Statistics

Hyattsville, Md. June 1978
NATIONAL CENTER FOR HEALTH STATISTICS

DOROTHY P. RICE, Director

ROBERT A. ISRAEL, Deputy Director

JACOB J. FELDMAN, Ph.D., Associate Director for Ad’ysis

GAIL F. FISHER, Ph.D., Associate Director for the Cooperative He&h Stutistics System

ELIJAH L. WHITE, Associate Director for Data Systems

JAMES T. BAIRD, JR., Ph.D., Associate Director fib International Statistics

ROBERT C. HUBER, Associate Director for Management

MOdROE G. SIRKEN, Ph.D., AssociateDirector for Ma thema tical S ta tistics

PETER L. HURLEY, Associate Director for Operations

JAMES M. ROBEY, Ph.D., Associate Director for Program Development

PAUL E. LEAVERTON, Ph.D., Associate Director for Research

ALICE HAYWOOD, Information Officer

DIVISION OF HEALTH EXAMINATION STATISTICS

MICHAEL A. W. HATTWICK, M.D., Director

JEAN ROBERTS, Chief, Medical Statistics Branch

SIDNEY ABRAHAM, Chief, Nutritional Statistics Branch

LINCOLN OLIVER, Chief, Psychological Statistics Brunch

ROBERT S, MURPHY, Chief Survey Pkznning and Development Branch

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 U.S. Bureau of the Census participated in the design and selection of the sample and

carried out the household interview stage of the data collection and certain parts of the statistical processing.

The Center for Disease Control acted as laboratory consultants and performed a series of

biochemical, hematological, and serological assessments on blood speciments of persons participating in the survey.

The U.S. Environmental Protection Agency supervised the chemical analyses of the water

samples collected at each household.

Vital and Health Statistics-Series l-No. 14

DHEW Publication No. (PHS) 78-1314

Library of Congress Catalog Card Number 78406016
ACKNOWLEDGMENTS

Special acknowledgment is due Mr. Arthur J. McDowell,

former Director of the Division of Health Examination Statistics, and Dr. Jean-Pierre Habicht, former Special Assistant to

the Director, for their guidance in the formulation bf the

HANES I Augmentation Survey.

. . .

III
,. .I.

11 _ . 3 *,’ ,

CONTENTS

Acknowledgments ......................................................................................................................................

Introduction ..............................................................................................................................................

New Procedures .........................................................................................................................................

Hearing Test for Speech........................................................................................................................

Vision Testing.......................................................................................................................................

Water Sample Collaborative Study (HANES-National Institutes of Health-Environment Protection

Agency) .............................................................................................................................................

Additional Questionnaire Material ........................................................................................................

Additional Laboratory Procedures ........................................................................................................

Sample Design............................................................................................................................................

Selection of Primary Sampling Units ....................................................................................................

Sample Selection Within Primary Sampling Units .................................................................................

Data Collection ..........................................................................................................................................

Plans for Analysis and Publication of Data.................................................................................................

References .................................................................................................................................................

Appendixes

I. Technical Notes on the Sample Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

II. Sample Locations of the Health and Nutrition Examination Survey of Adults, by Region,

County, State, and Probability Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

III. Questionnaires and Examination Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

LIST OF FIGURES

1. Sample Person Selection Sheet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2. Quality control review form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . .

ill

1

2

2

3

3

3

4

4

4

5

5

9

10

12

14

16

6

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SYMBOLS

Data not available ,,,,,,,,,,,,-,,--,,------------------~--- W-B

Category not applicable --__--___----_----_------------- . . .

Quantity zero --_--_-------_-----_____________________------- e

Quantity more than 0 but less than 0.05.----- 0.0

Figure does not meet standards of

reliability or precision ------_-__-_-----_------------ *
PLAN AND

AUGMENTATION

OPERATION OF THE HANES I

SURVEY OF ADULTS 25-74 YEARS

Arnold Engel, M.D., Robert S. Murphy, Kurt Maurer, and Everette Collins,

Division of Health Examination Statistics

INTRODUCTION

In the Health Examination Survey (HES), a

major program of the National Center for Health

Statistics (NCHS), data are collected by direct

physical examination, tests, and measurements

performed on the sample population studied.

The National Health Survey was authorized

under the National Health Survey Act of 1956

by the 84th Congress to be a continuous public

health service activity to monitor the health

status of the American population. Information

has been obtained on the prevalence of certain

medically defined illnesses and the distribution

of a variety of physical, physiological, and

psychological measurements. The Survey provides this information for the U.S. civilian

noninstitutionalized population and simultaneously provides the demographic and socioeconomic data necessary for analysis. In recent

years, procedures to measure either directly or

indirectly the impact of the environment on

individuals and to delineate met and unmet

health care needs have been employed in the

Survey.

The first three national surveys conducted

between 1959 and 1970 had specific age groupings as their target populations. These were

adults ages 18-79 years, children ages 6-l 1, and

youths ages 12-17. lW3 The fourth survey program, the first Health and Nutrition Examination Survey (HANES I) was conducted between

April 197 1 and June 1974 on a probability

sample of the U.S. noninstitutionalized civilian

population, ages l-74. An extensive nutrition

examination and sPe cial exam

ophthalmologi sts, dermat010gists 9

inations bv

and dentists

were given to every sample person who was

examined. Additional examination components

focused on other aspects of health were administered to a subsample of adults (25-74 years),

about one-fifth of all the examinees. These

additional components were designated as the

“detailed” components, in contrast with the

somewhat simpler nutrition examinations.

A reduction in the magnitude of resources

available for conducting the field operation

made it necessary to cut back the number of

field teams from three to two in January 1973.

It had originally been anticipated that the

detailed components would be continued into a

second HANES program. Due to the reduction

in field teams, HANES I required 3 years instead

of 2. In order to speed up the availability of the

data from detailed components, it was decided

to devote the 15-month period, July 1974

through September 1975, to approximately

double the number of people examined for the

detailed health component. The larger sample

size would facilitate analysis of the examination

findings by smaller demographic groupings. In

addition, the prolonged period of data collection

would also provide more time for planning the

design of the next projected Health and Nutrition Examination Survey (HANES II) so as to

take greater advantage of information and experience gained from HANES I. This 15.month

operation was referred to as the “Augmentation

Survey” for the detailed component.
For the 15-month augmentation phase of

the detailed component of HANES I, a number

of changes were made in both the content of the

examination and the sample design. The operation of the survey proceeded in roughly the same

manner as it did in the first part of HANES I.

The purpose of this report is to supplement the

program description of HANES I4 by describing

the modifications in procedures, program content, sampling, and other data collection activities that were made for the augmentation phase

of HANES I. Stand sequencing, scheduling,

professional and public relations, logistical

arrangements, household interviewing, appointment procedures, quality control, examination

procedures, and the composition of the field

staff are described in the HANES I program

report. Most of the components of the detailed

examination were continued with little or no

modification. For a detailed discussion of the

components in the following listing, reference to

the HANES I program description4 is advised. A

description of the nutrition and special examinations given in HANES I and copies of the forms

used in HANES I are also included. Copies of

the forms used in the HANES I Augmentation

Survey are found in appendix III of this report.

Detailed instructions and procedures used in

HANES I and the HANES I Augmentation Survey are described in the staff instruction manuals, which are available upon request?7

Components of the HANES I Detailed Ex8. A schedule for measuring psychological

well-being.

Hand-wrist

density an

amination Survey that were continued in the

HANES I Augmentation Survey include:

1. A physician’s examination.

2. Spirometry.

3. Single-breath carbon

pulmonary diffusion.

monoxide test for

4. A 12-lead electrocardiogram (ECG).

5. Pure-tone audiometry at 500, 1,000,

2,000, and 4,000 cycles.

6. Anthropometric measurements.

7. Medical History, General Medical History Supplement, Health Care Needs,

Arthritis, Respiratory, and Cardiovascular questionnaires.

9 .

.d

X-rays precessed for bone

cortical thickness and hip

and knee X-ray

of arthritis.

s assessed for thepre sence

10. Laboratory tests--Serum: Measurements

of SCOT, alkaline phosphatase, bilirubin, uric acid, folates, cholesterol, calcium, phosphorus, and serology tests for

measles, German measles, polio, tetanus,

diphtheria, and amebiasis were performed. Whole blood: Hematocrit,

hemoglobin, red and white cell counts,

and white cell differential count were

continued. Hemoglobinopathy screening

that was instituted during the conduct of

HANES I was also continued in the

Augmentation Survey.

NEW PROCEDURES

Hearing Test for Speech

The purpose of this test was to provide a

measure of the ability of the U.S. population to

hear and understand conversational speech.

test

Recommendations for the addition of the

came from a number of speech and hearing

authorities who attended an advisory meeting at

NCHS. These included Hallowell Davis, Central

Institute for the Deaf; Leo Doeffler, Stanley

Zerling, and Ralph Nauton, University of Chicago; and Eldon Eagles, Associate Director for the

National Institute of Neurological and Communicative Disorders and Stroke, National Institutes of Health.

‘- The stimuli used in the test consisted of the

revised Central Institute for the Deaf Sentences

supplied by Dr. Davis. The material was developed by a working group of the Committee on

Hearing and Bioacoustics of the National Research Council. The following criteria were

followed in developing 10 lists of 10 sentences

each:

Vocabulary appropriate to adults.

Words that appear with high frequency as

cited in one or more of the well-known word

counts of the English language.

2
Exclusion of proper names and proper

nouns.

Free use of common nonslang idioms and

constructions.

Avoidance of phonetic loading and tongue

twisting.

High redundancy.

Low level of abstraction.

Grammatical construction that varies freely.

The sentences in each list contained 50

keywords (appendix III, forms Q and R). The

keywords are shown in capital letters in each of

the sentences. The recordings of the sentences

made under contract at the University of Maryland by Dr. G. Donald Causey were examined at

the National Bureau of Standards and judged to

be of excellent technical quality.

In the test format, the initial list of sentences was presented at a level lo-15 decibels

(dB) below the lOOcycle pure-tone threshold

unless that threshold was 25 dB or lower. In that

case, testing always began at the 20.dB level.

Depending on the results of the initial presentation, the next list was presented at either 10 dB

higher or 10 dB lower. The end-point for

terminating the test was the correct identification of 90 percent of the keywords in a particular list. A different list was presented at each lodB level within the range of 20 dB to 80 dB, as

determined by the degree of hearing loss.

Vision Testing

The inclusion of visual acuity tests in the

HANES I Augmentation Survey was for the pur

pose of comparing objective tests of visual

disability with a series of questions designed for

the same purpose. The near-vision test used in

the examination was designed to measure one’s

ability to read printed selections. Keeney and

Sloan cards had different style typefaces and

different reading selections. Using both Keeney

and Sloan cards together provided a wide range

of type sizes for testing near-vision acuity. An

adaptation of the test provided some information on near vision for illiterate persons.

Distance visual acuity was measured in previous examination programs by using devices that

simulated the recommended 20.foot distanceby optical methods such as the use of mirrors.

Since some inaccuracies are introduced by the

use of distance simulation devices, it was

decided to use Good-lite charts at an actual

20-foot distance. Carefully controlled direct and

background lighting was used to ensure accuracv. Both binocular and monocular distance

vision were tested.

Water Sample Collaborative Study (HAN ESNational Institutes of Health-Environmental

Protection Agency)

This study was undertaken to evaluate the

possible relationships among bulk constituents,

hardness, and trace metals in household tapwater with certain risk factors of cardiovascular

disease. Water samples were collected from taps

or wells and from public water distribution

supplies. The samples are being analyzed by the

Environmental

their hardness,

Protection

alkalinity,

Agency to measure

and the total amount

of solute present. They are also being tested for

the presence

bers of trace

sizable

to the

and concentration of

minerals. In addition

questi.onnaire

stered to the s

numwater

sample collection, a

form C) was admini

(appendix III,

ample persons

detailing personal consumption of water and the

source of the water supplied to the household.

The water pipes under the sink were examined

to determine their camposition.

Additional Questionnaire Material

During the Health Interview Survey (HIS),

conducted annually by NCHS, approximately

40,000 households are interviewed to obtain a

wide variety of health information. Sets of

questions on vision and hearing developed for

HIS were included in the HANES exam. This

would enable HIS to provide a better

interpretation of the relationship of a

basis for

person’s

answers to questionnaires in these fields to

clinical findings. In short, the questionnaire

items provide a scaled index of impairment for

hearing, distance visual acuity, and reading

ability (appendix III, form B).

A portion of the 1975 HIS schedule on

hypertension was included so that it could be

correlated with the clinical data obtained in the

HANES I Augmentation Survey. A final addition
was a 20-question depression scale that the

National Institute of Mental Health recommended to be included. This scale had been used

in two large community studies. Since depression is an exceedingly common and important

condition for study, the epidemiological relationship of it to various other health factors is of

considerable interesL

Additional Laboratory Procedures

Because of continuous interest in monitoring

the prevalence of venereal disease in the U.S.

population, serological tests for syphilis were

added to the survey. These tests, performed at

the Center for Disease Control consisted of the

ART, VDRL, and FTA. Another study subject

was hemoglobinopathies. Tests for hemoglobinopathies were actually begun on a special pilot

basis at the 37th location of HANES I. Although

considerable information is available from local

studies, interest was shown in developing estimates for the U.S. population. The laboratory

procedure performed involved the phenotyping

of red cells. On the SMA 12/60, the additional

determinations of blood urea nitrogen (BUN),

creatinine, sodium, and potassium were done.

The BUN and serum creatinine levels served as

indicators of kidney impairment in the population.

SAMPLE DESIGN

The sample design for the HANES I Augmentation Survey of Adults had two basic

requirements : The sample of persons selected

for examination in locations 66-100 would

constitute a national probability sample of the

target population and, when considered jointly

with those receiving the detailed examination in

HANES I locations l-65, the sample would be a

lOO-PSU (primary sampling unit), national probability sample. All 100 of the HANES sample

locations are listed in appendix II by geographic

region and probability design. As indicated in

appendix II, 10 of the PSU’s were included in

both the Augmentation Survey sample and in

the initial 65-PSU design, so that actually there

were only 90 distinct sample PSU’s. The sample

design specifications, selection procedures, and

data collection procedures for the first 65 PSU’s

are described elsewhere .4 Definitions relating to

the sample design and selection of locations remained constant throughout the 100 survey

locations.

The HANES I Augmentation Survey sample

was designed to meet the following goals:

1 .

2 .

G 3 .

4 .

5 .

To examine a national probability sample

of adults 25-74 years of age which represents the civilian noninstitutionalized

population of the contiguous United

States, excluding those living on lands

set aside for use by American Indians.

To complete the survey of approximately 4,300 sample persons in a 12- to

15-month period.

To sample the target population in proportion to its representation in the population-with no oversampling of special

groups.

To produce two kinds of estimates from

the survey: (a) distributions of the population by specified characteristics such as

blood pressure and selected biochemical

determinations; and (b) prevalence in the

population of selected chronic conditions, particularly arthritic, respiratory,

and cardiovascular conditions.

To set maximum tolerances for variability for these key statistics permitting a

general analysis by broad geographic

regions and by other major demographic

subgroups such as income, race, age, and

sex.

Selection of Primary Sampling Units

The program description of HANES I4 describes the contiguous United States as divided

into 1,900 geographic areas or PSU’s. These

1,900 PSU’s were collapsed into 357 strata for

HIS and collapsed again into 40 superstrata for

HANES. Of these 40 superstrata, 15 are composed of only 1 very large metropolitan area of

more than 2 million people and were drawn into

the HANES 650PSU design with certainty. How- I

ever, in the Augmentation Survey only five of
them were drawn into the sample with certainty :

Essex, Morris, Union, Somerset, Hudson,

Middlesex, N. J.

Essex, Middlesex, Norfolk, Plymouth, Suffolk, Mass.

Allegheny, Beaver, Washington, Westmoreland, Pa.

Macomb, Oakland, Wayne, Mich.

Alameda, Contra-Costa, San Mateo, San

Francisco, Solano, Calif.

The other 10 superstrata that were drawn

into the 65.PSU design with certainty were

collapsed into 5 groups of two each, only 1 of

which was chosen for the Augmentation Survey

with a probability of 0.5:

Nassau, Queens, Suffolk, N.Y.

Bronx, N.Y.

Bucks, Chester, Delaware, Montgomery,

Philadelphia, Pa.

Lake, Porter, Cook, Will, Kane, Ill.

Orange, Los Angeles, Calif.

However, when these five locations are

considered as part of the lOO-PSU design they

are selected with certainty.

In each of the 25 remaining noncertainty

strata, defined as they were for the HANES I

65-PSU design,” a selection of a PSU was made

with probability proportional to size in a controlled selection procedure, independent of its

selection status in the 65.PSU design. Only two

PSU’s in the noncertainty strata were included

in both surveys:

St. Bernard, Jefferson, Orleans, La.

Hancock, Hamblen, Hawkins, Claiborne,

Tenn.

Sample Selection Within Primary Sampling Units

Within PSU’s, using 1970 census data, enu-

.meration districts (ED’s) were divided into segments of an expected eight housing units each.

In urban areas where listing units were well defined in 1970, tilis division was quite accurate,

since the .c;a.nrpJG- +, frame was comprised of listings that resuited from the 19 70 census. For

ED’s not covered by the listing books, area sampling was employed, and consequently, some

variation in segment size occurred. To make the

sample representative of the current population

of the United States, the listed segments were

supplemented by a sample of housing units that

had been constructed since 1970. Then a systematic sample of segments in each PSU was

selected. Randomly selected reserve segments

were drawn to provide a minimum of 105 sample persons per PSU.

After the sample segments had been identified, a list of all current addresses within the

segment boundaries was made, and the household interviews were conducted to determine

the age of each household member, as well as to

obtain other demographic and socioeconomic

information required for the survey. After listing

the household members according to specified

rules of relationship to the head of the household, those 25-74 years of age were then added

to the appropriate Sample Person Selection

Sheet (figure 1) from which one of every two

eligible persons was selected for participation in

the survey. The sheet illustrates one of two

possible sampling patterns with selection of the

first listed person in the segment, third, and so

forth. The patterns were randomly assigned to

segments in order to effectively remove sampling

bias from the selection process. The census

interviewer P

appointment

roceeded to arrange an ex

for all sample persons

amin

who

ation

indicated a willingness to be examined.

Logistical arrangements, household interviewing procedures, appointment and transportation procedures, and general mobile examination center procedures are described elsewhere.4

DATA COLLECTION

Census interviewers replaced Health Examination Representatives in administering most of

the material in the medical history forms as a

part of the initial household interview phase of

the survey. Because of this change in interviewers, the task of asking certain “sensitive”

questions (e.g., those relating to kidney and

5
FORM HES-28A (Cycle l\F) U.S. DEPARTMENT OF COMMERCE a. HES Stand Name b. HES Stand Number

(5-l 3-74) BUREAU OF THE CENSUS

. SAMPLE PERSON SELECTION SHEET c. Interviewer’s Name

HEALTH EXAMINATION SURVEY

Part I - SAMPLE PERSON SELECTION

I 1 I I I

Line I IHH EP’s Serial

I I

Segment Line HH EP’s Serial Segment Line Serial Segment

No. Line No. No. No. I I

No. Line No. No. I INo. I I

No. HLEeENpbs ’ , No. I INo. I

(1) (2) (3) (4) (1) (2) (3) (4) (1) (2) (3) (4)

01 029

2 16 30

-03 017 031

4 18 32

,O5 019 033

6 20 34

I @I I I IO I 035

36

I

I I I I I

. I

09 037

I II I 381I ! ! 1

,O11 025 039

12 26 40

28

Segment

No.

(1)

Serial

No.

(2)

- CALL BACK HOUSEHOLDS (c

EP’s Segment Serial EP’s

(Est.) No. No. (Est.)

(3) (1) (2) (3)

Segment

No.

(1)

Serial

No.

(2)

E P’s Remarks

(Est.)

(3)

\

Figure 1. Sample Person Selection Sheet

6

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-\, .
bowel function) was given to the examining

physician. There were also small modifications

in the mobile units, such as the installation of

‘special lighting and recording equipment. In

place of scheduling 10 examinees (2 for the

detailed and 8 for the nutrition exams scheduled

for each of the 2 daily sessions of HANES I), 6

examinees, all for the detailed, were scheduled

for each session. The average number of examinees scheduled at each location in the Augmentation Survey was 120. The lengths of time

spent in different locations were roughly equal,

in contrast to HANES I in which some locations

had a much larger sample size than others and so

required a longer stay. Because of the dropping

of the dental, dermatological, and ophthalmological exams, none of the personnel responsible for

these parts of the exam was present in the

detailed Augmentation Survey. Nutritionists

were also not needed, since the Augmentation

Survey did not include a dietary history.

Quality control measures were in general

similar to those outlined in Plan and Operation

of the Health and Nutrition Examination Survey,

Series 1, No. lOa. Some additional procedures

had been worked out during HANES I and were

applied in the detailed exam for the Augmentation Survey sample as follows:

1. X-ray technique: Chest X-ray films were

reviewed by a supervisory technician

who furnished a checklist of particular

errors of technique (figure 2). These

were used for further instruction of the

technicians. The hip and knee X-rays

were graded for quality by one of the

expert readers at the same time the film

was being examined for pathology. In

addition, listings of errors in technique

in hip and knee films and in the handwrist X-ray films were also provided by

the respective contractors on a regular

I POSTER IOR-ANTER IOR CHEST FILM I

Figure 2. Quality control review form

7
2 .

3 .

4 .

5 .

6 .

basis. Field evaluations of the X-ray

units included checking the horizontal

accuracy of the X-ray beams at the

beginning of a stand and using metal

wedges and bone phantoms for checking

the calibration of the X-ray machines for

the hand and wrist bone density determinations.

Spirometry: The spirometry output was

monitored on an oscilloscope. Based on

morphology and reproducibility of the

forced expiration trials, various corrective actions were undertaken by the

technician. About 4 months after the

continuation exams began, the acquisition of two-channel Gould Records provided the means of ensuring a more

accurate check on the quality of the

recordings.

Carbon monoxide (CO) diffusion test:

The tracings from the test were reviewed

to determine whether the trials were

acceptable. The trials were reviewed for

such items as inspiration time, breathholding time, inspired volume/vital

capacity ratio, minimum dead space

washout, minimum volume of gas collected, presence of inhalation artifacts.

ECG tracings: These tracings were

checked for “noise,” correct lead placement, machine problems, calibration

standards, and baseline shift in the field,

and also on a spot basis at headquarters.

Body measurements:

ments were replicated

locations of HANES

random assignment

technicians within a

B

as

I.

of

OdY measurein the first 65

In addition, a

examinees

field team

to

was

coupled with computer monitoring to

compare results among technicians for

bodv measurements.

Audiometry: The random assignment of

examinees to technicians and the monitoring of technician differences were also

used to compare pure-tone audiometry

results. In addition, the results of the

speech test were reviewed at headquarters for each stand on a regular basis

and compared with the results of the

pure-tone audiometry.

7. Leg length measurements: This X-ray

determination was part of the arthritis

exam. In order to ensure the accuracy of

leg length determinations by X-ray, a

metal stand on which the examinee

stood was verified as level every day by

means of two spirit levels. A computer

program was used for monitoring this by

comparing left and right leg measurements for each stand.

8. General Well-Being Schedule: Each copy

of the General Well-Being (GWB) questionnaire was reviewed at headquarters.

In addition, every form was checked in

the field, and an examiner’s observation

sheet was filled out giving reasons for

not obtaining a full, acceptable GWB.

Also

pressi

included

on of the

-

was the interviewer’s

degree of comprehen

imsion

of the interviewee in filling out the

GWB.

9. Laboratory procedures: Generally, a lopercent nonrandom sample of blind

duplicates was selected for all blood

chemistries and serologies. The single

e;,ception was the T3 T, determinations

for which the lo-percent sample of blind

duplicates was chosen in a random fashion. (The nonrandom selection was from

the first batch of blood specimens in the

first daily session.) The quality control

procedures in hematology included the

use of Coulter controls. Control results

were plotted daily. Blood indices were

calculated and used in quality control.

The data collection of the Augmentation

Survey was completed in September 1975 with

medical histories and household information

completed on 94 percent of the 4,288 sample

persons; 71 percent of sample persons were

examined.

The nonexamined sample persons are of

major concern in interpreting the results of the

survey. The potential biasing effects of excluding information for nonexamined sample persons are evaluated in the development of each I

. ’ ,

‘1
..* ,” ’ .* ’ I

I .

-‘?

. .f : -

- -q

-I I I

report, and the findings are presented in published reports. In the development of national

estimates, imputation procedures to estimate

’ missing data are selected to minimize potential

bias in the final results. Imputation procedures

used on the data are presented in substantive

reports to inform the user of the amount of

missing data for which estimated values were

substituted and how the values were estimated.

PLANS FOR ANALYSIS AND

PUBLICATION OF DATA

Analytical and descriptive reports published

by NCHS on HANES findings are usually written by the analytical staff of the Division of

Health Examination Statistics, often in collaboration with experts in particular fields.

Before the data are ready for analysis,

several preliminary steps must be taken. In some

cases, such as reading X-rays, further processing

of a data unit is necessary. Data must then be

reduced to machine-readable form. A considerable amount of time is usually spent editing

data to detect errors in data collection and

preparation. For example, examination of cholesterol data in HANES I revealed a large

number of greatly elevated cholesterol values in

one location. An extra serum vial for these

persons was used to repeat the tests; the original

values were found to be erroneous, and the

repeated tests values were used instead. Editing

may also involve comparison of results for

variables that are highly correlated, such as body

measurements or hematocrit-hemoglobin determinations.

Because of the large amount of data available, it is to be expected that everything cannot

be analyzed and published very soon after the

end of the survey. Priorities for analyses are

governed by such factors as the importance of

the data, the necessity of timeliness of publication of particular data, the degree of interest of

different groups in the data, and the relative

difficulties involved in editing data. Some reports involving the relationships of several data

items will require processing of all the involved

items before analysis. Most of them should be

published in the 5 years following completion of

the survey. As in other HES cycles, a set of

cornputer tapes contain ing the edited data

bein g Prepared for the use of investigators at

organizations other than NCHS, for example,

universities and other Government agencies. In

general, NCHS publishes the results in the Vital

and Health Statistics Series 2 and 11 reports. To

a lesser extent, information is made available in

journal articles and in papers presented at

professional meetings.

000
REFERENCES

‘National Center for Health Statistics: Plan and

initial program of the Health Examination Survey. VzkzZ

and Health Statistics. PHS Pub. No. lOOO-Series l-No. 4.

Public Health Service. Washington. U.S. Government

Printing Office, July 1965.

*National Center for Health Statistics: Plan, operation, and response results of a program of children’s

examinations. Vital and Health Statistics. Series l-No. 5.

DHEW Pub. No. (HSM) 73-1251. Health Services and

Mental Health Administration. Washington. U.S. Government Printing Office, Oct. 1967.

3National Center for Health Statistics: Plan and

operation of a Health Examination Survey of U.S.

youths, 12-17 years of age. Vital and Health Statistics.

PHS No. lOOO-Series l-No. 8. Public Health Service.

Washington. U.S. Government Printing Office, Sept.

1969.

4National Center for Health Statistics: Plan and

operation of the Health and Nutrition Examination

Survey, United States, 19714973. Vital and Health

Statistics. Series 1-Nos. 1Oa and lob. DHEW Pub. No.

(HSM) 7 3-l 310. Health Services and Mental Health

Administration. Washington. U.S. Government Printing

Office, Feb. 1973.

5 National Center for Health Statistics: HANES,

examination staff procedures manual for the Health and

Nutrition Examination Survey, 1971-1973. NCHS Instruction Manual, Part 15a. Health Services and Mental

Health Administration. Washington. U.S. Government

Printing Office, June 1972.

6National Center for Health Statistics: Field staff

operations manual. NCHS Instruction Manual, Part 15b.

Health Services and Mental Health Administration.

Washington. U.S. Government Printing Office, Sept.

1972.

‘National Center for Health Statistics: Examination

staff procedures manual for the Health Examination

Survey, 1974-1975. NCHS Instruction Manual, Part 15~.

Health Resources Administration. Washington. U.S.

Government Printing Office, Apr. 1975.

8U.S. Bureau of the Census: Standard metropolitan

statistical areas in the United States as defined on May 1,

1967, with populations in 1960 and 1950. Current

Population Reports. Series P-23, No. 23. Washington.

U.S. Government Printing Office, Oct. 9, 1967.

gNational Center for Health Statistics: Sample design

and estimation procedures for a national health examination survey of children. VitaZ and Health Statistics.

Series Z-No. 43. DHEW Pub. No. (HSM) 72-1005. Health

Services and Mental Health Administration. Washington.

U.S. Government Printing Office, Aug. 1971.

’ oGoodman, R., and Kish, L.: Controlled selection-a

technique in probability sampling. J.Am. Stat. Assoc.

45(251): 350-373, Sept. 1950.

10
I.

APPENDIXES

CONTENTS

Technical Notes on the Sample Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Definition of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

II. Sample Locations of the Health and Nutrition Examination Survey of Adults, by Region, County,

State, and Probability Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

III. Questionnaires and Examination Forms.............................................................................................

A. Household Card ......................................................................................................................

B. Sample Person Supplement .....................................................................................................

C. Water Usage Supplement .........................................................................................................

D. Health Care Needs Questionnaire ............................................................................................

E. General Well-Being Questionnaire............................................................................................

F. Supplement A-Arthritis .........................................................................................................

G. Supplement B-Respiratory ....................................................................................................

H. Supplement C-Cardiovascular................................................................................................

J. Body Measurements .................................................................................................................

K. General Medical Examination .................................................................................................

L. Audiometry (Air) ....................................................................................................................

M. Respiratory Function Tests ....................................................................................................

N. Physician’s Supplement...........................................................................................................

0. Report of Physical Findings ....................................................................................................

P. Vision Test ..............................................................................................................................

Q. Speech Test (20-60 decibels)...................................................................................................

R. Speech Test (70-80 decibels)...................................................................................................

16

16

18

34

38

46

52

64

72

78

79

88

89

90

93

95

101

106

LIST OF APPENDIX TABLES

I. State groups by geographic region. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

12

12

II. Ranges for rate-of-population-change control groups by geographic region, 1950-l 960 . . . . . . . . . . . . . . . . . . . . . 13

11
APPENDIX 1

TECHNICAL NOTES ON THE SAMPLE DESIGN

Definition of Terms

Standards metropolitan statistical area

(SMSA).-An SMSA consists of a county or

group of contiguous counties (except in New

England) which contains at least one central city

of 50,000 people or more, or “twin cities” with

a combined population of at least 50,000

population. In addition, other contiguous

counties are included in an SMSA if, according

to certain criteria, they are socially and economically integrated with the central city.

Definitions of SMSA’s which identify the composition and structure of each appear in a U.S.

Bureau of the Census publication.8

Geographic regions. -For purposes of HES,

the 48 contiguous States and the District of

Columbia are divided into 4 regions of about the

same population size, shown in table I.

Controlled selection.-This term refers to a

scheme that permits some element of subjective

determination in obtaining a “better balanced”

or “more representative” sample, while retaining

all the elements of true probability sampling.

The procedure is described in a number of

publications. g J * The control variables used for

this sample design are “State groups” and “rate

of population change” and are defined as follows:

Separate groups were formed within geographic regions, as shown in table I. To form

the State groups, the HIS design strata were

classified as belonging to the State in which

the HIS sample PSU was located. If a sample

PSU was within two States, it was put in the

State with the greater proportion of the

population.

NOTE: A list of references follows the text.

12

Table I. State groups by geographic region

-?

Region

Northeast.. .........

Midwest .............

South .................

West . . . . . . . . . . . . . . . . . . .

State

group

number

1

2

3

6

1

1

2

3

States in group

New York

Pennsylvania and New Jersey

Maine, New Hampshire, Vermont,

Massachusetts, Connecticut,

and Rhode Island

Ohio

Michigan

Indiana and Illinois

Missouri

Kansas, Nebraska, Iowa, and

North Dakota

Wisconsin and Minnesota

Maryland, Delaware, and District of Columbia

Virginia and West Virginia

Kentucky and Tennessee

North Carolina and South Carolina

Georgia

Alabama and Mississippi

Florida

Arkansas, Louisiana, and Texas

California and Nevada

Texas

Washington, Oregon, Idaho,

and Montana

Oklahoma, Arkansas, and

Louisiana

Wyoming, Utah, Colorado,

New Mexico, and Arizona

North Dakota, South Dakota,

Nebraska, Kansas, Minnesota,

and Missouri

Rate of population change. -Groups were

defined differently for each region as indicated in

table II. In the Northeast Region, for example,

PSU’s with less than a S-percent increase in

population between 1950 and 1960 were classified in group 1, while this class in the Midwest
Table I I. Ranges for rate-of-population-change control groups by geographic region, 1950-60

Rate-of-population-change group number

1 .,..................,.,................,....,...,......,..,....................,......,....,..........,.,....

2 .............................................................................................................

3 .............................................................................................................

4 .............................................................................................................

5 .............................................................................................................

A

tj .............................................................................................................

7 .............................................................................................................

8 .............................................................................................................

Region

Northeast I Midwest I South West

Percent population change, 195060

L

3 and under

5-I 1

12-23

25-58

0 and under

1-15

16-23

24-30

34-8 1

-

1-10 and under

-9-o

1-8

9-16

19-26

27-36

37-47

50-301

-5 and under

-2-o

4-21

24-39

40-59

73-167

Region included only those PSU’s with a loss or

with no gain in population.

Population density groups. -In general, this

term refers to the proportion of the population

that lives in urban areas. The density groups are

defined somewhat differently for each geographic region.* For the very large SMSA’s,

except those in the South Region, the criterion

for inclusion was population size; these SMSA’s

were chosen for the sample with certainty. In

the South Region, the largest SMSA’s were

defined in the same way as “other large

SMSA’s,” but were put in a different stratum for

sampling puposes.

000

13
APPENDIX I I

SAMPLE LOCATIONS OF THE HEALTH AND NUTRITION

EXAMINATION SURVEY OF ADULTS, BY REGION, COUNTY, STATE,

AND PROBABILITY DESIGN

Region, county,’ and State

Probability design

l-35 1-65 66400

Northeast

Essex, Morris, Union, Somerset, Hudson, Middlesex, N.J . ...................................................................................

Nassau, Queens, Suffolk, N.Y ..............................................................................................................................

Bronx, N.Y ..........................................................................................................................................................

Kings, Richmond, N.Y .........................................................................................................................................

Westchester, Rockland, N.Y.: Bergen, Passaic, N.J . .............................................................................................

Bucks, Chester, Delaware, Montgomery, Philadelphia, Pa ....................................................................................

Philadelphia, Pa: Camden, Gloucester, Burlington, N.J .......................................................................................

Essex, Middlesex, Norfolk, Plymouth, Suffolk, Mass ...........................................................................................

Allegheny, Beaver, Washington, Westmoreland, Pa. ..........................................................................................

Albany, Schenectady, Rensselaer, Saratoga, N.Y. ...............................................................................................

Lac kawanna, Pa. .................................................................................................................................................

Holyoke, Chicopee, Springfield, Mass. ................................................................................................................

Bristol, Newport, Providence, Kent, Washington, R.I. ........................................................................................

Hartford, Tolland, Conn. ....................................................................................................................................

Chemung, Tioga, Tompkins, N.Y ........................................................................................................................

Mercer, Pa ...........................................................................................................................................................

Bedford, Fulton, Pa. ...........................................................................................................................................

Monroe, N.Y .......................................................................................................................................................

Blair, Pa. .............................................................................................................................................................

Middlesex, New Haven, Conn. ............................................................................................................................

Warren, N.Y . .......................................................................................................................................................

Midwest

Lake, Porter, Cook, Will, Kane, Ill. .....................................................................................................................

Cook, DuPage, Kane, Lake, McHenry, Ill . ...........................................................................................................

Macomb, Oakland, Wayne, Mich .........................................................................................................................

Milwaukee, Wau kesha, Wis ..................................................................................................................................

Hennepin, Ramsey, Anoka, Dakota, Washington, Minn. .....................................................................................

Lake, Cuyahoga, Ohio ........................................................................................................................................

Franklin, Ohio ....................................................................................................................................................

Buchanan, MO.....................................................................................................................................................

Cass, N.Dak.: Clay, Minn. ...................................................................................................................................

Jefferson, St. Charles, St. Louis, MO.: Madison, St. Clair, Ill ...............................................................................

Bay, Mich. ..........................................................................................................................................................

DeKalb-Stueben, Ind.: Branch, Mich. .................................................................................................................

Cass, St. Joseph, Mich .........................................................................................................................................

Fayette, Ross, Ohio ............................................................................................................................................

LaPorte, Marshall, Starke, Ind. ...........................................................................................................................

Boone, Greene, Iowa ..........................................................................................................................................

‘County, parish, or borough.

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

X

X

X

X

II

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

14

1 . , (~ * ;’

. .-

. !

,.‘C -

*, I’ *
Region, county,’ and State

Probability design

l-35 1-65 66400

Midwest-Con.

Howard, Iowa: Fillmore, Minn. ..........................................................................................................................

Cass, Clay, Jackson, Platte, MO. ..........................................................................................................................

Marion, Ind .........................................................................................................................................................

Montgomery, Greene, Miami, Ohio .....................................................................................................................

Jackson, Mich. ....................................................................................................................................................

Jefferson, Leavenworth, Kans.: Platt, MO. ..........................................................................................................

Brown, Clinton, Ohio .........................................................................................................................................

Rusk, Wis. ...........................................................................................................................................................

South

St. Bernard, Jefferson, Orleans, La. ....................................................................................................................

Washington, D.C.: Fairfax, Arlington, Va.: Prince Georges, Montgomery, Md. ..................................................

Richland, Lexington, SC. ...................................................................................................................................

Knox, Anderson, Blount, Tenn ...........................................................................................................................

Roanoke, Va. ......................................................................................................................................................

Chatham, Ga. ......................................................................................................................................................

Hillsborough, Pinellas, Fla. .................................................................................................................................

Palm Beach, Fla. .................................................................................................................................................

Natchitoches, La. ................................................................................................................................................

Lamar, Marion, Miss. ..........................................................................................................................................

Cabarrus, Stanley, Union, N.C. ...........................................................................................................................

Hancock, Hamblen, Hawkins, Claiborne, Tenn. ..................................................................................................

Barbou r, Ala. ......................................................................................................................................................

Bullock. Jenkins, Ga. ..........................................................................................................................................

Sussex, Del .: Worcester, Md................................................................................................................................

Fayette, W. Va. ...................................................................................................................................................

Greenville, S.C. ...................................................................................................................................................

New Castle, Del. .................................................................................................................................................

Jefferson, Ala. ....................................................................................................................................................

Volusia, Fla. .......................................................................................................................................................

Edgefield, Saluda, S.C. ........................................................................................................................................

Clay, Calhoun, Roane, W. Va. .............................................................................................................................

West

Orange, Los Angeles, Calif. .................................................................................................................................

Los Angeles, Calif. ..............................................................................................................................................

Alameda, Contra-Costa, San Mateo, San Francisco, Solano, Calif. ......................................................................

Collin, Denton, Dallas, Ellis, Tex. .......................................................................................................................

Bexar, Tex. .........................................................................................................................................................

Pima, Ariz . ..........................................................................................................................................................

Douglas, Nebr.: Pottawattamie, Iowa ..................................................................................................................

San Diego, Calif. .................................................................................................................................................

Fresno, Cal if. ......................................................................................................................................................

Monterey, Calif . ..................................................................................................................................................

Clallum, San Juan, Wash. ....................................................................................................................................

Grant, Wash. .......................................................................................................................................................

Gila, Ariz. ...........................................................................................................................................................

Avoyel les, La. .....................................................................................................................................................

Ottertail, Minn . ...................................................................................................................................................

Adams, Arapahoe, Denver, Jefferson, Boulder, Colo. .........................................................................................

Sacramento, Cal if. ..............................................................................................................................................

Hunt, Rains, Tex. ...............................................................................................................................................

Mason, Thurston, Wash . ......................................................................................................................................

Greeley, Nance, Nebr . .........................................................................................................................................

Camadian, Cleveland, Oklahoma, Okla. ..............................................................................................................

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

kounty, parish, or borough.

15
APPENDIX Ill

QUESTIONNAIRES AND EXAMINATION FORMS

A. Household Card

\~,F$~ES-SA (CYCLE IV)

. .

NOTICE - All information which would permit identification of the indrvidual will be held

U.S. DEPARTMENT OF COMMERCE in strict confidence, will be used only by persons engaged in and for the Purposes of the

SOCIAI. AND ECONOMIC STATISTICS ADMINlSTRATlON survey, and WIII not be disclosed or released to others for any purposes.

BUREAU OF THE CENSUS

ACTING AS COLLECTING AGENT FOR THE 1. Stand 2. ldentifrcatton 3. Control number 4. Card

U.S. PUBLIC HEALTH SERVICE number code

HOUSEHOLD CARD PSU Segment Serial II_ of

HEALTH EXAMINATION SURVEY cards

5a. What is your exact address? (Include House No., Apt. No., or other identification and I Listing 14. Noninterview reason

ZIP cooej 1 Sheet

---------------------------------------------~ , Sheet

J TYPE A

’ No.

1’. 1 Refusal - Descrrbe tn a tootnote

I ------__________--------------- [I; No one at home - repeated calls

I State

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

: Line Fill items

City 1 ZIP code [;: Temporarily absent - Footnote 6-8. lla-c as

I

I

I

I N0.e.e-a applicable

l

I r-1 Other fspecify)

3 I

73-15 and 18

b. IS this your mailing address? 1: 1 Same as 5a

Mark box or specify If different. Include ZIP code.

TYPE 6

_-----_______----------------------------------------- [; ivacant -nonseasonal

,

[- i Vacant - seasonal

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

City 1 State 7 ^zI-p-~-d; - - - - 7 Usual residence elsewhere Fill items

I I

I I

[y j Armed Forces

6-8. 1 la-c as

applicable,

*-- -

c. Special place name I Sample unit number Type code I KT’ Other (Specify)3

13-15

1

I

I

+ ,

6. YEAR BUILT - Ask

When was this structure zally built?

i-. Do NOT Ask

TYPE C

17; Unused line of llstrng sheet ’

: Before 4-l-70 (- . After 4-l-70 (Go lo 8c, complete r Demo1 ished

lContrnue rntervrew~ rl required and end rnfervrewl ; 1-i Merged

’ : : Outside segment Fill items

7. Type of living quarters ’ : Housing unit 2 i- OTHER unit 8c if marked,

and 13-15 I

i: * Built after April 1, 1970

8. Area segments ONLY 11 i Other fspecrfyj

3 1

; -’ a. Are there any occupied or vacant living quarters besides your own in this building?

Y (till Table XI N

-----------------------------------------------------. I

- b. Are there any occupied or vacant living quarters besides your own on this floor? 15. Record of calls

Y f/r/l Table XI N Time

____ ______ -_-- _______ - ____ -- _______ ---_--___-__---- __-___ Date Beginnrng Endtng Completed

- c. Is there any other building on this property for people to live in - either occupied or vacant? . ---- .’ ---

Y ‘fill Tdble XI N

I-----~------------------_---------__-_-_----__------.. I-. 1

a.m. a.m.

p.m. p.m.

I

‘- d. NolIe 2

a.m. I ;:?I:

L

rgn.~.

 3 I a.m. a.m.

9. Land use 2, -’ RURAL ‘Go to 10) I - ALL OTHER 119, back) I p.m. p.m.

I l Regular units coded 82 or 84 in item 2. 4

I

a.m. a.fl1.

1

p. 111. p.m.

aSpecial place units coded 82 or 84 in item 2 AND coded 85-89 in item SC. 5 I a.m. a.m.

A I P.m. p.n1.

IO. Do you own or rent this place? Own ; Rent I Rent for flee 6

I

;:I:

a.m.

I p.m.

Ila. Does thts place you fawn ,rent rent for free) have 10 acres or more? 1 Y 2 N (IICI

16. List line numbers of sample persons

b. During the past 12 months did sales of crops, livestock, and

not Interviewed during lnrtral Interview.

other farm products from this place amount to $50 or more? I Y (19 back) 2 N (19 back) ; None

- -

c. During the past 12 months did sales of crops, livestock, and

other farm products from this place amount to 5250 or more? 1 Y 2N Line number

1 17. Record of fiddlttonal personal calls

) GO TO QUESTION 19 ON THE REVERSE SIDE

12, What is the telephone number here?

b

NOTE: EEFORE LEAVING HOliSEHOLD, CHECK THAT 16 HAS AN ENTRY.

Determine the best time for callbacks for Supplements and sample persons,

FOOTNOTES

approxlrllate ages, and sex of household members, r

Name Age Sex

I

--s-w --u---u2

---.---m._.-.- . .- .-

3 r YI.w-.--.*Ab..-., . -...,-.. __. & _

4

I.. I- I...“-..- .- _.- .I5

I

6 -

I

--t:

-.-PW.. __.

Total number W$ij~M~N of personr

Total number of

s.rmpled person:

16

’ -.

: ..-

.I’

;’ , $1

. I

. I .,’
--

LI 

>2--

------->2 ----

‘.: 86

IA

1,II)1J.

!?;D.iL:I:
B. Sample Person Supplement

18

FORM HES-SB (CYCLE iv)

(10.2674)

U.S. DEPARTMENT OF COMMERCE

SOCIAL AND ECONOMIC STATISTICS ADMINISTRATION

BUREAU OF THE CENSUS’

ACTING AS COLLECTING A G E N T FOR THE

U.S. PUB L I C HEALTH SERVICE

SAMPLE PERSON SUPPLEMENT

HEALTH EXAMINATION SURVEY

Form Approved

O.M.B. No. 6&RI 184

NOTICE -All information which woult

permit identification of the individua

will be held in strict confidence,wiIl bc

used only by persons engaged in ant

for the purposes of the survey, and wil

not be disclosed or released to other!

for any purposes.

a. PSU b. Segment number C. Serial number d. Person number c. NCHS SERIAL NUMBER

Comments

-
1. In what State were you born? 1. ! State or foreign country

Enter the name of the State or foreign country. I

j@ I I

2a. What is the highest grade or year of regular

school you have ever attended?

2a.I@ o 0 None

I

I Elementary 12345678

I

I High School 9 IO II I2

160,>

I

College I 2 3 4 St

b. Did you finish the -- grade (year)? lJ.1 @

I

i [z1 Yes

20 N o

I

3. What is your origin or descent?

3* P

o 0 German 8 0 Mexican

I

2( Italian 8 0 Mexican0

f

t 0 Irish 7 0 Puerto Rican

t

s a French 7 q Cuban

I

4 173 Polish 7 c] Central or

s q Russian South American

I 7 q Other Spanish

f

6 q English

I

I s 0 Scottish

12 0 Negro

12 0 Black

f 1sq Welsh 1s 0 Other -

8 0 Mexican-American

SPecify 7

I

I 8 c] Chicano I

la. Jtiny;;e you doing MOST of the past 4% 1

(For male:): working or doing something else?

10lo) I 0 Working (4d)

(For females): keeping house, working, or i

2 q Keeping house (4~)

doing something else? f

3 c] Something else

b. What were you doing? b.1 @ 0 q Layoff

I 1 0 Retired

I

2 q Student

I

4 q III

I

s q Staying home

I

6 c] Looking for work

I

7 q Unable to work

1

s [23 Other - Specify

c. Did you work at a lob or business AT ANY

TIME during the past 3 months?

A@)

I

1UYes

I

2 0 No (Sb)

d. When you were working, did you usually work

full time or port time?

d.@ I q Full time

! 2 13 Part time

I

ia. Did you work at any time last week or the

week before?

SO.@ 1 0 Yes (6)

(For females): not counting work around the house? I 2lNo

b. Even though you did not work during that time, i

do you have a lob or business?

b.,(iii) 1 c) Yes

I

2fyo

I

c. Were you looking for work or on layoff from a lob? c.I 112

I

0

i q Yes

I

2 0 No (Instructions for Q-6)

d. Which - looking for work or on layoff from a lob? d’I@ I 0 Looking

I

2 0 Layoff

I

I

3 /--J Both

4sk for all 6a. For whom did you work? Name 60.: Employer

)ersons with of company, business, orgoni- I

1 “Yes” in zation, or other employer. I

I 5a, b, or c.

b. What kind of business or industry

I

b. I Industry

‘f “Yes” in is this? For example, TV and I

5c only, radio manufacturing, retail shoe

questions 6a store, State Labor Department, farm. j@

:hrough 6d I

I I I

apply to this c. What kind of work were you doing?

For example, electrical engineer,

c.; Occupation

)erson’s LAST

‘ull-time stock clerk, typist, farmer.

civilian job. 10 r-j-T-j

d. Class of worker (Fill from

entries in 60-c; if not clear,

q @ 1 0 Private paid

read list.) I

2 q Gov. Federal (7)

I

3 0 Gov. other )

I 4(Own

I s 0 Nonpaid

I >

6 0 Never worked (7)

If self-employed in “OWN” business and not a farm, ask:f ,,,

I 0 i 0Yes

e. Is the business incorporated? e.I 20No

19
Now I have some questions about your I

20

7. Would you say your health in general is

excellent, very good, good, fair, or poor?

7. 1 q Excellent

I

I

2 q Very good

3 0 Good

I 4 0 Fair

1 5 0 Poor

8a. Do you have any health problems now that

you would like to talk to a doctor about?

&i. $ij

/ I q Yes

I 2 0 No (9)

b. What are the problems?

90. Have you had a cold, flu, or “the virus”

during the past month?

b. Do you still have it?

b. :

1

)DATA PREPARATION USE ONLY4

I 0120 1r-J @cl

1 * 2u * 21

9;s 9;;

I

31 cl cl cl

I

I

cl 41 41

9a. I@ i q Yes

I 2 0 No (IO)

b. j@ 1 0 Yes

2 n No

I

I

10. IN THE PAST 5 YEARS have you had a 10.

back injury?

;(iiJ 1 q Yes

I

I

20 No I

)ow I have some questions about HEARING. i

, I

rl la. At any time over the past few years, have you

ever noticed ringing in your ears, or have you

lla. i ,27 0 t u Yes

been bothered by other funny noises in your ears? I 20 No (12)

I

b. How often - every few days or less often? b. $j I [13 Every few days

I

I

2 0 Less often

c. When it does occur, does it bother you quite c. ; 129

a bit, just a little, or not at all?

0

I 0 Quite a bit

I

i

20 Just a little

I

3 c] Not at all

12a. Have you EVER had a running ear or any

discharge from your ears (not counting wax

120. ( @J

in the ears)?

I

10 Yes

2(No

1

9 0 DK (13)

rb. How often have you had a running ear or

any discharge from your ears?

c. Did you visit a doctor because of

this condition?

d. Did a doctor give you anything for

this condition?

b. 1 @ I 0 Once only

I

2 0 Twice

i

3 0 3 or more times

I 9DDDK

I

13a. Have you EVER had deafness or trouble

hearing with one or both ears? Do not

include any problems which lasted just a

short period of time such as colds.

b. Did you ever see a doctor about it?

c. How old were you when you first began

having trouble hearing?

c. i@ I 0 O-4 years old

I

I 2 0 5-9 years old

i

I

3 c] IO- I9 years old

4 q 20-29 years old

I 5 c] 30-39 years old

I 6 q 40-49 years old

I 7 q 50 years old or older

d. Since this trouble began, has it gotten worse, d. !@ 1 q Gotten worse

better, or stayed about the same? I 2 c] Gotten better

I 3 q Stayed about the same

e. Was the cause of your hearing trouble or e. i

deafness - (Read list) I Yes

Ear infection. , . . . . . . . . . . . . . . . . !@I cl

Born with ft. . . . . . . . . . . . . . , , . . . ’ *

I 20 * 20 * 21

Loud noise such as that from machinery, i

gunfire blasts, or explosions , . . . . . . 1 cl NII 30 I

Ear surgery , , . , . . . . . . . . . . . . l . l

I 40 4 0 40

Ear injury . . . . . . . . . . . . . . . . . . . .

I

I

Kl cl 511

Other - Specify I

I cl fm cl
, .

b. I

‘., “, .

.

. ‘5) . , .)

.

? ‘=

\ r

-,,. ,‘9 I

HEARING - Continued

131. How would you rate your hearing in your RIGHT

ear - good, a little decreased, a lot decreased,

or are you deaf?

g. How would you rate

J

our hearing in your LEFT

ear - good, a little ecreased, a lot decreased,

or are you deaf?

h. Have you ever attended d school or class for

those with poor hearing or a school for the deaf?

i. Have you ever had any training in

I ip reading?

i. Have you ever had any training in speech or in

speech correction because of poor hearing?

k. Have you ever had any training in how to

use your hearing?

I. Have you ever had an operation on your ears?

m. Have you ever had your hearing tested?

n. How old were you when your hearing was

first tested?

o. How often do you now have your

hearing tested?

p. Have you ever used a hearing aid? P*

q. Which ear?

r. Do you use a hearing aid now?

s. How well satisfied are you with your present

hearing aid? Does it help a lot, a little,

very little, or not at all?

13f. j @j 10 Good

I 2 0 A little decreased

3 0 A lot decreased

I

h. i @ I 0 Yes

I

20 No

I

i. I’ @ i 0 Yes

I

I

2(-J No

i.1 @ 10 Yes

2( N o

I

k. i (rr;, 10 Yes

I

I

20 N o

I. / (;?;> i q Yes

I

2\ N o

I

I m. I (GJ 10 Yes

I 20 No (13~)

4 (;s;, I q Helps a lot

I

I 2 0 Helps a little I

3 !-J Helps very little

4 0 Does not help at all

0 If “Yes” in l3p ask 140-g using the parenthetical

phrase “Without a hearing aid.”

14a. (Without a hearing aid) Can you usually HEAR AND

UNDERSTAND what a person says without seeing his

face if that person WHISPERS to you from across a

quiet room?

I

I

I

14a. i

I @ i cl\ Yes (IS)

I

I 20 N o

I

b. (Without a hearing aid) Can you usually HEAR AND

UNDERSTAND what a person says without seeing his

face if that person TALKS IN A NORMAL VOICE to

you from across a quiet room?

c. (Without a hearin

R

aid) Can you usually HEAR AND

UNDERSTAND w at a person says without seeing his

face if that person SHOUTS to you from across

a quiet room?

d. (Without a hearing aid) Can you usually HEAR AND

UNDERSTAND a person if that person SPEAKS

LOUDLY into your better ear?

e. (Without a hearin

R

aid) Can you usually tell the

of speech from ot er sounds and noises ?

sound

b. /

/ (154) 1 0 Yes (IS)

I 2[ N o

C. i

I

1 @ 1 0 Yes (15)

I 20 No

d. ;

I

056) i 0 Yes (IS)

I 2( N o

I

e. I (157) i 0 Yes (IS)

I 20 N o

f. b’: ‘ithout a hearing aid)

noise from another?

Can you usually tell one kind f . iI 0158 i 0 Yes

21-1 N o

(15)

g. (Without a hearing aid) Can you hear loud noises?

21
The following series of questions will be about specific

medical problems or conditions you might have had in

the past or might even have at the present time. Please

answer “Yes” or “No” to each question.

Have you EVER had -

150. Pain or aching in any of your joints on most days for

AT LEAST 1 MONTH?

b. Pain in your neck or back on most days for AT LEAST

1 MONTH?

c. Pain in or around either hip joint including the

buttock, groin, and side of the upper thigh on most

days for AT LEAST 1 MONTH?

d. Pain in or around the knee including the back of the

knee on most days for AT LEAST 1 MONTH?

e. Swelling at a joint, with pain present in the joint when

touched on most days for AT LEAST 1 MONTH?

f. Stiffness in the joints and muscles when getting out of

bed in the morning lasting for AT LEAST 15 MINUTES?

Have you EVER had -

g. Trouble with recurring persistent cough attacks?

h. A cough first thing in the morning in the winter?

(Count a cough with first smoking or on first going

out of doors; exclude clearing of throat or a single cough.)

i. A cough first thing in the morning in the summer?

i. Any phlegm from your chest first thing in the morning

in the winter? (Count phlegm with the first smoke or

on going out of doors; exclude phlegm from the nose.

Count swallowed phlegm.)

k. Any phlegm from your chest the first thing in the

morning in the summer?

I. During the past 3 years have you had a period of

inc’reased cough and phlegm lasting for 3 weeks

or more?

Have you EVER had -

m. Trouble with shortness of breath, when hurrying

on the level or walking up a slight hill?

n. Wheezy or whistling sounds in your chest?

o. Trouble with any pain or discomfort in your chest?

p. Trouble with

your chest?

any pressure or heavy sensation in

q. Severe pain across the front of your chest lasting

for half an hour or more?

r. Pains in either leg when walking?

15a. j @ i 0 Yes

I

I

2 0 N o

b. i@ i 0 Yes

I 20 N o

c* @ i 0 Yes

I

I

20 No

d. @ I 0 Yes

I

2r-J N o

e. ,O\ 164 1 n Yes

I

I

2 0 No

f. j@ 1 q Yes

II 2 Cl No

I

I

g . 0j 166 1 IJ Yes

I 20 No

I

h. /@ i fl Yes

I 2[No

1

i, I@I10 Yes

I

i. 1

20 No

.

j@ i 0 Yes

I

I 2[ No

I

k. @ i 0 Yes

I

I 20 No

I 0 Yes - How 2 n No (l5m)

many times?

7

If 0172 i 0 I time

II 2 0 2 times

II 3 0 More than 2 times

0.: 0175 I 0 Yes

I

20 No I

;

P* ,@ I q Yes

I

I 2 0 No I

I

q.1 177 ,O i 0 Yes

; 2f-J No I

r. /@ 10 Yes

I

I

20 N o

s. Heart failure, or “weak heart” of any degree

of severity?

t. Infections of the kidneys or bladder?

u. Loss of vision or blindner

minutes to severa I days?

S lasting

v. Difficulty in speaking or very s lurred speech

lasting from several minutes to several days?

u.I 181

I 0 i 0 Yes

I

20 No

v.; @

I

i 0 Yes

I

2[-j No

22
I ’

,-

* ‘ ,

. . * ’ , , ‘I

_

.’ .

. ’ 1

.” . . -

‘a .

) 5’

Have you EVER had -

15w. Prolonged weakness or paralysis of one or both

sides of the body lasting up to several months?

X. Lass of sensation or numbness or tingling sensations

lasting several minutes to several days?

I

I

l&v. I (ISB

I

i 0 Yes

I

20 N o

x. ; @ 10 Yes

I

2 0 N o

I

y. A severe head injury leading to unconsciousness

lasting for more than 5 minutes?

b DIABETES

160. Do you have any reason to think that you may have

diabetes, sometimes called sugar diabetes or

sugar disease?

b. Did a doctor tell you that you had it?

c. How long ago did you start having it?

y. I @ 10 Yes

I

I

20 N o

I

16a. f Oes> 1 0 Yes

20 No (17)

b. i @ i 0 Yes

I

I 2 0 No (I 7)

c. I 0 Less than I year ago

I 2 0 l-4 years ago

I 3 0 5 or more years ago

I

d. Do you take insulin shots? d. 1 @ i 0 Yes

20 N o

e. Do you take any medicine by mouth for diabetes? e. i @ i 0 Yes

I 2(No (17)

) GOITER/THYROID

170. Have you ever had a goiter or any other

thyroid trouble?

b. Who told you that you had goiter or

thyroid trouble?

c. Is, or was, your thyroid: Overactive (hyperactive) or

underactive (hypoactive)?

d. How long ago did you first have this trouble?

I

170. I @ 1 0 Yes

I

I

2 0 No (18)

b. ; (192) I 0 A doctor

I 2 q A nurse

I

I

I

3 0 Other

I

c. 1 193 ,O i 0 Overactive

I

I

2 0 Underactive

I

3 0 Neither

I

I

9 0 DK

d. ‘@

I

I 0 Less than I year ago

I

2 0 l-4 years ago

I

I 3 0 5-9 years ago

I

I

I

4 0 IO or more years ago

e. Have you been treated by a doctor for goiter or

for thyroid trouble?

f. Were you treated for this condition by a

doctor with - (Reod list and mark a//

that apply)

e. j @ 10 Yes

i 2 0 No (18)

1

f. ;@ I 0 Medicines

I *

I

2 0 Surgery

I

I

3 0 Radiation

I 4 0 Anything else - Specify

I J

I

I

I

g. Are you currently being treated for this problem? g. I(;;;;) i q Yes

I

20 N o

I

h. Are you currently taking any pills or medicino

to help you lose or gain weight?

h. / @i$ 1 0 Yes

I

I 20 N o

I

i. When was the last time you saw a doctor about

goiter or thyroid trouble?

i. j @ I 0 Less than I month ago

I

I 2 0 l-3 months ago

I

I

I

3 0 4-6 months ago

I

I 4 0 7-l I months ago

I

I

5 0 I or more years ago

I

9nDK

23
) NOW I would like to qsk you some questions about I

your TEETH.

I

I

180. Have you lost all your teeth from your upper iaw? 180. I @ i 0 Yes

I

I 2 0 No (19)

I

b. Da you have a plate for your upper iaw?

.

C. How long have you had your plate?

b- 1 (GJ I 0 Yes

I

I

2 u No (l8d)

d. Have you ever had a dental plate for your upper jaw?

C. 1bO202 I q Less than I year

I 2 0 I-4 years

I

I 3 0 5-9 years (19)

I 4 c7 IO-19 years

I

I

I

5 0 20 or more years

I

l . HOW long has it been since you had any natural or false

teeth to chew with in your upper iaw?

d. ; oo,> I 0 Yes

I

2 0 No

t

e. i @ I 0 Less than I year

I 2 0 I-4 years

I 3 0 5-9 years

I 4 0 IO-19 years

I

I 5 0 20 or more years I

190. Have you lost all your teeth from your lower law? 190. I (ZJ 1 0 Yes

I

I 2 0 No (20)

I

b. Do you have a plate for your lower iaw?

c. How long have you had your plate?

I

I

2q No (l9d)

c. iIO207 I q Less than I year

I 2 0 I-4 years

I

I

3 0 5-9 years (20)

I

I

4 0 IO?19 years

I

I

5 0 20 or more years

I

d. Have you ever had a dental plate fo; your lower jaw?

e. How long has it beon since you had any natural or false

teeth to chew with in your lower jaw?

da 1 @ I 0 Yes

I 2 I-J N o

e. i10209 I q Less than I year

I

2 0 I-4 years

I

I 3 0 5-9 years

I

I 4 q IO-19 years

I

I 5 0 20 or more years

I

@If “Yes” in 18b or 19b ask question 20; otherwise skip

to instructions above question 21.

200. Do you usually wear your plate(s) while eating? 200. j 210 0 I 0 Yes

f

2 0 N o

I

b. Do you usually wear your plate(s) when not eating?

c. Do you usually use denture powder or cream to help

keep your plate(s) in place? ’ I

I

2 f-J N o

I

d. DO you think you need a new plate or that the one(s)

you have noed( s) refitting?

l /f “Yes” to questions 18~1 ond 190, GO to question 32;

otherwise ask:

de i @ 1 (-J No

i

I

2 q Yes, one

I

I

3 CJ Yes, both

f

90 DK

I

I

I

21. How would you describe the condition of your TEETH - 21. i 214 0 1 0 Excellent

excellent, good, fair, or poor? I 2 0 Good

I 3 0 Fair

I 4 0 Poor

I

I

22. HOW would you doscribo the condition of your GUMS -

l xcollont, good, fair, or poor?

23. How many times a day do you usually brush

your teeth?

22. i @ I 0 Excellent

I

I

2 q Good

I

I

3 0 Fair

I 4 0 Poor

I

I

23. ;

,O’ 2H Times

24
TEETH - Continued

Do you think that you ought to go to a dentist now

or very soon for a checkup?

1 i

1 0217 q Yes24. No

I 920c] DK I

25. Do you now have an appointment to see a dentist? 25. I @J 1 OYes

I 21No

26. Do you think you have any teeth that need filling? 26. i (219) I 0 Yes

I

I

2 0N o

I

I s=DK

27a. Do you think you have any teeth that need to be pulled?

b. Do you think that all of them need to be pulled?

28a. Have you ever had your teeth cleaned by a dentist

or dental hygienist?

280. I @

I

i 0 Yes

2 0 No (28~)

b. When was the last time they were cleaned?

c. Do you think that your teeth need cleaning now

by a dentist or dental hygienist?

I

29. Do you have a dentist you usually go to? 29. / @ i q Yes II

20 No

30. How long has it been since you last saw a

dentist about yourself?

i

30. ; 026) O R Months

I

I 227 ,O eYears (32)

I

I

o [7 Less than I month

I 77 q Never (32)

I

31. Do you go to a dentist AS OFTEN as once

every year?

31. j@ iuYes

I

21N o

320. Do you have an illness which has recently cut

down your appetite?

34. Have you over had yellow ioundico (which made 7

your skin or l yor turn yellow)?

34. 1 @

I

1 /-J Yes

I 2 133 N o

I

350. Have you ever had an abdominal operation for -

(Red list and murk oil thcrt Opply)

35. f @ 1 0 Ulcers

I

I

2 0 Gal istones

i

3 0 Hiatus hernia of the diaphragm

I

4 n Any other condition - SpecifyJ

i

0 None

I

36a. In the past y#ar have you rtayed in a

hospital overnight or longer?

360.~ @ lOYes !

I

2 0 No (37)

b. For what condition?

(1) First

(2) Second

(3) Third

c* How long were you in the hospital?

(1) First condition . . . . . . . . . . . . . . . . . . . . .

(2) Second condition . . . . . . . . . . . . . . . . . . . .

i

$3 Weeks

I o 0 Less than I week

I

(3) Third condition I@ -

Weeks . . . . . . . . . . . . . . . . . . . .

I

o 0 Less than I week

I

25
370. Has a doctor ever told you

that you had any of the

370. i

following conditions?

I-/’ . 0 If “Yes” co any of the following

conditions, ask 37b and 3.7~ for

those conditions.

I

I

Yes No

Arthritis . . . . . . . . . . ,.. . . . . . . . . ..I @ 0 20

1 Gout . . . . . . . . . . . . . . . . . . . . . . . ..I

I

@lo cl

Asthma.., . . . . . . . . . . . . . . . . . . . . .I @

I

c] 20

Chronic bronchitis or emphysema . . . . . . . i @cl cl

I Tuberculosis . . . . . . . . . . . . . . . . . . . . , @o 20

I Rheumatic fever . . . . . . . . . . . . . . . . . . I @cl 4Il I

I _--------------------------------j---------~----~

.

I

Heart murmur . . . . . . . . . . . . . . . . . . . . i @cl cl

I

Heart failure . . . . . . . . . . . . . . . . . . . . i

I

@Kl cl

Heartattack . . . . . . . , . . . . . . . . . . . .I 056) 0(37c)2[

I

Stroke ..,..................... 1I

@I q (37c) 2(--J

A peptic, stomach, or duodenal ulcer. , . . . @jo 20

I

Recurrent or chronic enteritis. . . . . . . . . . I @o 20

I

t

----------_-----------~--~~---~---~--~--~------ I

I

Colitis (spastic colon, I mucous colitis). . . . . . . . . . . . . . . . . . . ; @cl a

Gallstones.. . . . . . . . . . . . . . . . . . . . . / @ q 20

I

Hepatitis. . . . . . . . . . . . . . . . . . . . . . .I @ r] 20

I

Chronic cough. . . . . . . . . . . . . . . . . . . .I @

i

q 2 q

Pleurisy . . . . . . . . . . . . . . . . . . . . . . .I @o cl

Low blood pressure . . . . . . . . , . . . . . . .I

I

@o cl

----__-__-__--_--_------------------------------ I

Hay fever. f

.,..............*.....,

I

@o cl

Allergies to food. . . . . . . . . . . . , . . . . . I

I

630 c.l

Hives . . . . . . . . . . . . . . . . . . . . . . . . ..I @hII a

Other allergies . . . . . . . . . . . . . . . . . . . 1

I

@go c.l

Polio or paralysis . . . . . . . . . . . . . . . . . i @ [z1 2 u

I

I

Hiatus hernia of the diaphragm. . . . .- . . . . I @

1

0 2 0

Ic-------------------------------4 ____-___------

Kidney disease or kidney stones. ....... [ De) 0 2 0

Malignont tumor or growth ............ j @ 0 2 [3

Benign tumor, growth, or cyst

I

(except fat or skin). I

................ , @o 21

Trouble with blood not I

clotting properly .................. r@Jo , 211)

Nervous breakdown .................j (296) 0 2(

---------_-__---_------------------------------- I

Fracture of hip . . . . . . . . . . . . . . . . . . . Ij@o 21

Fracture of wrist. . , . . . , . . . . . . . . . . . , 4i90 20

I

Fracture of spine. . . . . . . . . . . . . . . . . . i

I

@lo cl

Fracture of any other bone. . . . . . . . . . . . I

1

@go cl

I

Do you still have it?

I

37~. How many

years ago did I

I

you first

have it? I

Yes No Dk

cl cl cl

10 cl cl

cl 31 cl

cl cl cl

cl cl 90

cl cl cl

0241 -

0243 -

0245 -

0247 -

0249 -

0251 -

--_-----__-_------ cl cl cl

cl cl 90 -

0

257 ,-

0

259 -

cl cl 911 Q6iJcl 31-1 cl 0263 -

1

----v-------------e

t

__--------

cl cl cl

cl cl gel

cl cl cl

cl cl cl

cl cl 91

10 30 cl

--_--------m-y----

cl cl cl

cl cl cl

cl cl cl

cl cl 90

0265 .-,

0267 -

0269 -

0271 -

0273 ~--

0275

.-------_

0277 -

0279

0281

0283

0285 -

cl a cl 0287 -

____________------- --e-s---__

cl cl cl 0289 -

cl cl 91 0291 -

10 31 cl 0293 -

0295

0297 -

0 299 -

0 301 -

0 303 -

0 305 -

26

‘_

.

,L”. L

.

’ */

, “.

\ I

! , *
.~ ‘J. \_ . ,

‘, I

*

I 1 ‘* .

’

ANEMIA

Have ou ever had anemia, sometimes called

“low ilood?”

I

b. How long ago did you first have it? Years

oo 0 Less than I year

I 99 c] Don’t remember

c. Did o doctor ever tell you that you had anemia? c. I @ i q Yes I1 2 0 No (39)

d. Was the anemia caused by - (Read list) d ’ l I Yes

r@ fcl

N o DK

Poor diet. . . . . . . . . . . . . . . . . . . . . . . . . . . @isJo @la

Childbirth , , . . . . . . . . . . . . . . . . . . . . . . . . I * 2cl * a * a

Accidental loss of blood . . . . . . . . . . . . . . . .,.

I cl cl cl

Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I

I

cl 40 cl

Surgery ,.,......................... cl cI.l cl I Any other cause - Specify I cl cl 61

e. Were you bated for this condition by o doctor? e* j @j -10 Yes

I

I 2 /--J No (39)

f. Wos the treatment you used a - (Read list and mark

all that apply)

f*; @j

( *

1 0 Better diet

I

2 0 Iron pills

I

3 0 Iron shots

I 4 q Vitamin pills

I

I

,s q Vitamin shots

I

I

6 0 Transfusions

I

7 0 Any other treatment - Sptciiv 3

I

i

I I

g. Are you still being treated for this condition?

Now I have some questions about HYPERTENSION

a. Have you EVER been told by o doctor that you had

high blood pressure?

i O* I 0

312 i 0 Yes

I

I

20 N o

1

390.1

(313) 1 0 Yes (39~)

2[ N o

I

b. Another name for high blood pressure is hypertension.

Hove you EVER been told by o doctor that you

hod hypertension?

C. About how long ago were you FIRST told by o doctor .

that you hod (high blood pressure/hypertension)?

40. During the post 12 months about how many timos how

you seen or talked to o doctor about your (high blood

presrure/hyperten8ion)?

40. [ 9,7

0

Times

i o 0 None

41. Has a doctor EVER advised you to loso woi

BECAUSE OF (HIGH BLOOD PRESSURE?

ht 41. I @ 10 Yes

HYPERTENSION)? I

I

21 No

420. Do you now use more salt, less salt, or about the same

I

amount of salt slnco you lootnod you hod (hlgh blood

42a. / (119) 1 0 More

prossuro/hyportonslon)? I 2( Less

I 3 0 Same

I

.

b, Wore you EVER advised by o doctor, nurse,

or other modi potron to use loss salt?

b.; @ij t 0 Yet

i

. nONo

430, Has Q doctor EVER proscribed modicina for

your (high blood pnssuroihyportonslon)?

430.1 @zJ 1n1Yes

I

I 2 q No (44) I

b. Are you now taklng on

doctor for your (high

modIcIno proscribed by o

b ood r pnssuro/hyportonsIon)?

c. How ofton ore you supposed to take this

madicIno - more than onto a day, onto a day,

or loss than onto a day?

c.j @ cl More than once a dry

/

2 /J Once a dry

I 8 0 Las than once a dry

d, How often do you toko your medlclno whm

you ore supposed to - all the time,

often, onto In o whllo, or now?

I d., @ rm All thotlmo

I

I 2 cz) Ofton

I a [3 Onca In I whllr

I

/

40 New

8 t] other - Spclfyp

I

2 7
f

HYPERTENSION - Continued

44. ABOUT how many da s during the past 12 months has

(high blood pressureiF;

or most of the day?

ypsrtension) kept you in bed all

I

44* i 325 0

-Days

I

I o 0 None

l If “No longer has high blood pressure” in 43b, I

GO to 45d; otherwise ask: I

45a. How often does your (high blood pressure/hypertension) 45o.i @ I 0 All the time

bother you - all the time, often, once in a while,

or never? I

2 0 Often

I 3 0 Once in a while

I

I

4 0 Never (45~)

I s q Other -Specify7

I

I

b. When it does bother you, are you bothered a great

deal, some, or very little?

b.; @ I [3 Great deal

i

2q Some

I

I 3 0 Very little

I

I

I

4 0 Other - Specify3

l If “All the time” in 45a, GO to 46; otherwise ask:

c. Do you still have (high blood pressure/hypertension)?

i

c./ @ I 0 Yes (46)

I

I 2(-J No

I 9 /--J DK

I

I d., @

c

d. Is this condition completely cured or is it under control? I 0 Cured (47)

I

I 2 0 Under control

46. Can you tell when your blood pressure is high -

that is, do you have any symptoms?

I

46. i @ 10 Yes

I 20 N o

470.

b.

Has a doctor EVER talked to you about problems that

con be caused by high blood pressure or hypertension?

470.11 Yes (48)

I

0 331 t 0

I

I 20 No

Has a nurse or other medical person EVER talked to

you about problems that can be caused by high blood

pressure or hypertension?

b./ 332

I 0 i q Yes

I

I

2 0 No (48)

c. What type of medical person was this? c.I @

I 1 q Nurse

I

2 0 Other - Specify?

I

I

I

48. ABOUT how long has it been since you LAST hod your 48. 1 o 0 Less than I month

blood pressure taken? i

I@ Months

I

I@ (51) Years

I

I

77 c] Never (51)

I

49. Were you told that your reading was high, low, normal, 49. j @ I 0 High

or were you not told? I

I

20 Low

3 0 Normal

4 0 Not told

s 0 Other - Specify/

I

I

I I

50. During the post 12 months, how many times was your

aYI.1,..., times while ‘** 1 / m Times

510. ABOUT how long has it been since ou had an

electrocardiogram, which involves T

on the chest dnd arms?

p acing wires

b. ABOUT how long has it been since you hod o

chest X-ray?

b.1 o 0 Less than I year

I

I 339 0 -Years

I 77 0 Never

0.

.’ ‘ .

-‘,,

I.

:a . .

*

, -,’

‘., .

.

-‘.

. .
Now, I have some questions about VISION.

Are you blind in one or both eyes?

1

52. j @J 10 Yes

I 2(No

530. Do you now have any of the following conditions:

Cataracts, glaucoma, detached retina, or

any other condition of the retina?

530. j @J 1 0 Cataracts

I * 2 0 Glaucoma

I

I

s 0 Detached retina

I

4 123 Other condition of retina

s 0 No condition I

Do you now have any (other) trouble seeing in one

or both eyes even when wearing eyeglasses ?

540. Do you wear eyeglasses? i 540. I @J 10 Yes

I

I 20 No

b. Do you wear contact lenses?

l If BOTH 540 and 54b ore “No,” enter 8-2 in box

in upper right corner and SKIP to Check Item I;

otherwise continue with question 55.

b* 1 344 0

10 Yes

I

I

20 No

I

I

55. How often do you use your (eyeglasses/contact lenses), 55.

all of the time, most of the time, some of the time,

I @ 1 q All of the time (Enter A-l in box

I in upper right corner and GO to

hardly ever, or never? i Check Item I.)

I

2 0 Most of the time

I 3 c] Some of the time

I

I

4 0 Hardly ever

I s q Never (Enter B-2 in box ond

I GO to Check Item I.)

I

-1

56. Do you use your (eyeglasses/contact lenses) for reading 56.

and other close work?

i @ I 0 Yes - A

I

I

~~No-B

I

57. Do you use your (eyeglasses/contact lenses) for seeing 57.

distant obiects better?

‘@

f 1 q Yes - 1

I 2010-2

If both 56 and 57 ore “No” enter B-2 in the box and osk

58; otherwise record the letter and number from 56 and 57

in the box in upper right corner and GO to Check ltem 1.

Why do you wear (eyeglasses/contact lenses)?

b CHECK ITEM I r) i

I

l If A-l, or A-2, or 8-l is entered in upper right box, READ: 1 These first questions ore about how well you can see

even when wearing eyeglasses or contact lenses.

1

(Reod the phrase “When wearing eyeglasses/con tact I

I

lenses” in each of the following questions.) I

l If B-2 READ: I

These first questions are about how well you con see. I

590. (When wearing eyeglasses/contact lenses) How much 590.

1 @ I (-J A lot of trouble

trouble do you have seeing with your LEFT eye - I

20 A little trouble W a lot of trouble, o little trouble, or no trouble at all? I

3 c] No trouble

I

b. Are you blind in the left eye? b. / @ I q ]~es

I 2 f--J No

60a. (When wearing eyeglasses/contact lenses) How much

trouble do you have seeing with your RIGHT eye -

o let of trouble, a little trouble, or no trouble at all?

b. Are you blind in the right eye?

l If Yes” in 59b and 606, GO to question 62; otherwise osk:

610. (When wearing l yeglosses/contoct lenses) In terms of

total vision, how much trouble do you have seeing -

a lot of trouble, a little trouble, or no trouble at all?

b. Are you blind?

620. About how long have you had trouble seeing?

b. Has it been less than 3 months, or 3 months or more?

29
) CHECK ITEM II 4

l If A-l or 6-l in upper right box on page 12, READ:

The next questions are about how well you can see in

recognizing o friend from different distances. (Reod the

phrase “When wearing eyeglasses/contact lenses” in

each of the following questions.)

l If A-2 or B-2 in box, READ:

The next questions are about how well you can

recognizing o friend from different distances.

see in

63. (When wearing eyeglasses/contact lenses) Can you SEE

well enough to recognize a friend if you get close to

his face?

63. I

I

I

ass) iq yes

I 2 /-J No

64. (When wearing eyeglasses/contact lenses) Can you SEE

well enough to recognize a friend who is an arms

64. I Js9

I 0

i 0 Yes

length away? I

2 r] No (Check Item Ill)

I

65. (When wearing eyeglasses/contact lenses) Can you SEE 65.

well enough to recognize a friend across a room?

1

lO

360 I 0 Yes

I 2 123 No (Check Item Ill)

I

66a. (When wearing eyeglasses/contact lenses) Can you SEE

well enough to recognize o friend across a street?

66a. / (361) 1 0 Yes

I 2 0 No (Check Item /II) I

I

I

I I

I

b. Do you have any problems seeing distant objects? b. / @ I q yes

I

I

2 0 No (Check Item Ill) I

b CHECK ITEM Ill 4

l If A-l or A-2 in the box, READ:

Now I’m going to ask about how well you con see things

that are near to you. Please answer these questions in

terms of when you are wearing glasses. (Read the phrase

“When wearing eyeglosses/contoct lenses” in each of

the following questions where appropriate.)

l If 0-l or B-2 in box, READ:

Now I’m going to ask about how well you con see things

that are near to you.

I

67a. Do you reod any newspapers, mogazines, or books?

I 343

67a. I 0

i 0 Yes

I 2 0 No (67~)

(When wearing eyeglasses/contact

any trouble at all seeing the print?

lenses) Do you have

I

c. Is this because you have trouble seeing?

b. / @ 1 0 Yes (68)

I 2 0 No (70) I I

I

C. / @ 10 Yes

I

I

20 No

680. (When wearing eyeglasses/contact lenses) Can you SEE

well enough to read ordinary newspaper print?

b. (When wearing eyeglasses/contact lenses) Con you

SEE well enough to recognize letters in ordinary

newsoauer orint?

69a. In order to (read/recognize) ordinary newspaper print,

must you use a hand magnifying glass? I------ b. Can you see well enough to read or recognize ordinary

newspaper print if you use a hand magnifying glass?

l if 67c is “Yes,” GO to 70b; otherwise ask:

70a. Do you have any problem seeing ORDINARY NEWSPAPER print (even when wearing eyeglasses)?

b. What types of problems do you have in seeing the print?

I

720. If you are in a room, con you see well enough to tell

if a light is on or off?

72a. j @ 1 0 Yes

2 0 No (73)

I I

I

b. Can you see welt enough to tell where the light is

coming from?

b.; @ q----&s

I
I

73. During the past 6 months, have you used any medicine, 73.

drugs, or pills internally for the following? (Include

;

any over-the-counter medicine or prescription drugs.)

I

I Regularly Occasionally No I

Sleep problems or insomnia . . . . . . . . . . . . . . .

Headache. . . . . . . . . . . . . . . . . . . , . . . . . . .

Other pains . . . . . . . . . . . . . . . . . . . . . . . . .

Upset stomach or indigestion, , . . . , . , . , . , . . cl 31-I

Weakheart . . . . . ,.,...,, . . . . . . . . . . . . . @ 10

I

21 3cl

Allergies. . . . . . . . . . . . . . . . . . . . . . . . . . . I@ 10 cl 311

Nerves . . . , . . . . . . . . . . . . . . . . . . . . . . . . ‘@ 10 cl 31

Lack of pep (except thyroid pi Ils) . . . . . . . . . . .

‘0I381 10 21 31

Convulsions. . . . . . . . . . . . . . . . . . . . . . . . . I@ 10 cl cl

Skin conditions. . . . . . . . . . . . . . . . . . . . . . .

‘0I383 10

Fluid pills for water loss . . . , . . . . . . . . . , . .

I

21 cl

I384 10

I

0 20 31

Weight loss (except fluid pills). . , . . . . . ; . . . . 1385 10

I 0 cl cl

Infection (antibiotic or sulfa pills or shots only) . / 386 ,o lo 21 cl

I

74a. Are you on a special diet? 74a. r@ i 0 Yes

I

I

2 q No (75)

b. Is this diet - (Reod list ond mark all that apply) b. $iij I q To lose weight

i *

I

2 0 For diabetes

I

3 0 For kidney failure

I

40 For ulcers

I

I

5 0 For allergies

I

6 q For heart’ trouble or high

I

‘0

blood pressure

1 389 I c] For pregnancy

I *

I

2 j--J For any other reason - Specify 7

c. Is this diet - (Read list ond mark o/l that apply) c* j@ i 0 Low fat

I *

I

2 0 Low protein

I

I

3( Low salt

I

I

4 0 Low carbohydrate

I

5 0 Low calorie

I

I

6 q Some other type - Specifyfl

d. Was this diet ordered by a doctor?

75. In your usual day, arid. from recreation, are you

physically vary active, moderately active, or

_ . _ a

d. j@ 1OYes

I

I

20No

75. i @ i 0 Very active

I

I 2 ll Moderately active

I

quite inactive? I ,

I

I

3 Ej Quite inactive I

76. In things you do for rocriation, for l xamplo: sports,

hiking, dancing, and so forth, do you got much

exorcise, moderato exercisei or llttlo or no •XWC~SO?

76. I 393

I

c> 1 0 Much exercise

2 0 Moderate exercise

I 8 fJ Little or no exercise

Theso next questions are about the use of TOBACCO.

I

I

77a. Have you smoked at Ioast 100 cigarottos during your 770, I 394 i c] Yes

l ntiro lit.7 I 0

I 2 /-J No (78) I

b. Do you smoke cigarettes now?

I

b. ’

I

$3 1 q Yes

I

I

2 0 No (77d)

I

c. On the average, about how many a day do you smoke? C* I@ -Cigarettes per day (77e)

d. How long has it been since you smoked cigarettes

fairly regularly?

d. ;

I 397

I 0

-Years (77f)

I 77 0 Under one year

’

I

aa 0 Never smoked cigarettes

I

regularly (78)

; ssn DK

31
770. On the average, about how many cigarottos a day

wore you smoking 12 months ago?

770. I

I 398

I

0 Cigarettes per day

a8 q Did not smoke

I 99 q DK

J

f. During tha period when you wwo smoking the

most about how many cigarcrttos o day did you

usuohy rmoko?

f. 1

I@ Cigarettes per day

I eemDK

I

g* About how old wore you when you first stortod

smoking cigorottor fairly rogulorly?

780. Have you smoked at loost 50 cigars during

your entire life?

b, Do you smoke cigars now?

C. About how many cigars o day do you smoke?

d. About how long has it been since you smoked

throw or more cigars a week?

l . Twolvo months ago, about how many cigars a day

9. /

I 400

I 0 -Years old

I

aa c] Never smoked regularly

I

I

99 f-J DK

780. I 401

I 0 i q Yes

I

2 q Nd (79)

b . 43 i 0 Yes

I

2 q No (78d) t

I

did you usually smoke?

c. ;@I Cigars per day (78e)

I

I

(IF LESS THAN 7 PER DAY)

I

I

aa 0 3 to 6 per week (78e)

I

9s (-J Less than 3 per week

I

d. ;

$9 Years (79)

I

77 0 Under I year

I

I

ea Iz] Never smoked 3 or more

cigars a week (79)

I 99 0 DK

I l . I

79a. Have you smoked at least throw packages of pipe

tobacco during your entire lifo?

I

I 405 ‘0 -Cigars per day

I

i

I

t-‘IF LESS THAN 7 PER DAY)

77 0 3 to 6 per week

I

I

ae 0 Less than 3 per week

I

99 0 Did not smoke cigars

I

790. f @ 1 0 Yes

I

I

2 f-J No (80)

I

b. Do you smoke a pipe now?

co About how many pipesful of tobacco a day do you

usually smoke?

b. 1 @ 1 0 Yes

I 2 0 No (79d)

I

C* I @J

I

-Pipesful per day (79e)

1

(IF LESS THAN 7 PER DAY)

i

77 q 3 to 6 per week (79e)

I aa q Less than 3 per week

I

d. About how long has it been since you smoked

three or more pipesful a week?

eD Twelve months ago, about how many

pipesful a day did you smoke?

80. Do you presently use - (Read list and mark

all thot apply)

d* I 409

I

0

-Years (80)

I

77 0 Under I year

I

a8 0 Never smoked 3 or more pipesful

I

a week (80)

I

ssnDK

I

“‘I@ -Pipesful per day

I

I

I

t (IF LESS THAN I PER DAY)

I

77 0 3 to 6 per week

I

aa q Less than 3 per week

1

I

99 c] Did not smoke a pipe

80. I @iJ 1 Cl Snuff

I

2 0 Chewing tobacco

I

3 0 Any other form of tobacco -Specify 3

I

I 0 None

32

, ~’

?

.

I ’

f -I -

‘* , .

I .-. .
..

,,) . .

,

: .

81. How important do you think it is for people to have a 81. 18

i

I q Very important

regular physical check-up, very important, fairly

important, or hardly important at all?

I

2 q Fairly important

I

3 c] Hardly important

I snDK

,

82. Is there ONE petiicular doctor or place you usually

go to when you are sick or when you need advice

8% ; @iiJ 1 •J Yes

about your health? I

I

2 [7 No (84)

83. Where do you go for this care or advice, to a clinic,

hospital, doctor’s office, or some other place?

83. $g

I

I 0 Private doctor’s office

I 2 0 Home

If Hospital: Is this an outpatient clinic or the

emergency room?

If Clinic: Is this a hospital outpatient clinic,

a company clinic, or some other kind of clinic?

3 0 Doctor’s clinic

4 q Group practice

5 [3 Hospital Outpatient Clinic

6 0 Hospital Emergency Room

7 0 Company or industry Clinic

8 q Other - specify 7

84. How long has it been since you last talked to any

doctor about yourself?

85. Do you get check-ups from a doctor AS OFTEN

as once every 2 years?

84. j

’ 413

I

0

-Months O R

@J -Years

1 o 0 Less than I month

I 77 r] Never (Check Item IV)

I

I

85. I @ I 0 .Yes

I

I

2010

1 ‰ CHECK ITEM IV 4 I

I

Ask questions 86, 87, and 88 only once for each I

family, If already asked for this household, I mark (X)-the box and end questions. *a,I

86a. Is any language other than English frequently spoken

here in this home?

86~~ ; @ i j-J Yes

1

2 q No (87)

b. What language(s)? b. 1 Language(s) spoken 1 87. Please look at this card - (Show Flashcard) 87. ) Group

Which of these Income groups represents yours, your -I’S

etc., total combined family income for the past ‘12 months; j@ 11 q A 15nlE 190 I

that is, sine (date) a year ago? Include income 1208 1sn F 20 •J J

from all sources such as wa 1

or retirement benefits, help 0

es, salaries, social security

rom relatives, rent from f 13(C 17 q G 210 K

property, and so forth. I

140 0 ram H 220 L

1

88. May I see your box of table salt? 88. I@ 1 0 Iodized

I

I 2 q Not iodized

33
6. Water Usage Supplement

FORM HES-SC

tlo-24-74) U.S. DEPARTMENT OF COMMERCE

SOCIAL AND ECONOMIC STATISTICS ADMINISTRATION

BUREAU OF THE CENSUS

ACTING AS COLLECTING AGENT FOR THE

U.S. PUBLIC HEALTH SERVICE

NOTICE - All information which

would permit identification of the

I

individual will be held strictly

confidential, wiI I be used only by

persons engaged in and for the

WATER USAGE SUPPLEMENT

HEALTH EXAMINATION SURVEY I

purposes of the survey, and will

not be disclosed or released to

others for any other purposes.

. .PSU b. Segment number C. Serial number d. Person number e. NCHS Serial number

I I I 1

READ-Th k’d f e t In o wa er a person drinks may affect his health. Each house has different water depending

on such things as the pipes in the house and the service line to the house. I would like to ask you

about your u;e of drinking water.

l These next four questions are about water and drinks that la.

you make from a faucet at this house. Do NOT include

drinks made from water at other locations.

la. About ho w many glasses of water do you drink here per day?

b. About how many glasses of cold drinks made from water

such as powdered milk, Kool aide, Tang, frozen juice,

iced tea, whiskey with water, etc.,do you drink per-day?

b.

c. About how many cups of coffee do you drink per day? c.

d. About how mony cups of other hot drinks such as tea, soup,

etc.,do you drink per day?

d.

e. How long have you lived at this address? e.

l Now we have some questions about drinks made from faucets 2a.

at other locations such as work, restaurants, and so forth.

2a. About how many glasses of water do you drink per day at

these places?

b. About how many glasses of cold drinks made from water such b.

as powdered milk, Kool aide, Tang, frozen juice, iced tea,

whiskey with water, etc.,do you drink per day?

c. About how many cups of coffee do you drink per day? c.

d. About how many cups of other hot drinks such as tea, soup,

etc.,do you drink per day?

d.

.

0101 glass(es)

o q None

0102 glass(es)

o q None

01.03 CUP(S)

o q None

.

.

0104 CUP(S)

o q None

010s month(s)

0106 year(s)

I

0107 glass(es)

o l-l None

0108 glass(es)

o q None

0109 CUP(S)

o 0 None

0110 cu PW

o q None

b lf an entry of glasses or cups in item 2a through d ask questions e and f; otherwise go to item 3.

e. What is the address of the place thot you used most in the e. Address

last month? (Include number, street, city, Stote, &id

ZIP code)

f. How long hove you used woter ot . . . ? f. 0112 month(s)

-0113 ,--year(s)

34

c .I

L i =, ;

,

:. .

.

$3 . 4

?

‘ ?I

, -
l NOW we have some questions about drinks made from 30.

commercioJ bottled water. 114 glass(es)

a. About how many glasses of commercial bottled water do you

0

drink per day?

0 0 None

b. About how many glasses of cold drinks made from co.mmerciaI b.

bottled woter such OS powdered milk, Kool aide, Tang, frozen I @ .d wW

juice, iced tea, whiskey with water, etc.,do you drink per day? o 0 None

c. About how many cups of coffee do you drink per day? c.

0

116 cup(s)

o 0 None

d. About how many cups of other hot drinks such as tea, soup,

etc.,do you drink per day?

d. 0117 cuPW

o 0 None

b If an entry of glasses or cups in item 3a through d ask questions e, f, and g; otherwise to to ite’m 4.

e. Whot brand of bottled water do you use? a. Brand name

f. What type of water is this (e.g., mineral, distilled, etc.)? f. 0118 I 0 Mineral

.

2 0 Distilled

3 0 Other (Specify) 7

g. How long have you used this type of water? 9* 0119 month(s)

0120 year(s)

l The next questions are about drinks made from other sources 40.

such OS a well, cistern, spring, etc., on the property but not

connected to the house. 0121 glass(es)

#a. How many glasses of water do you drink per day?

o 0 None

b. About how many glasses of cold drinks made from water such b.

as powdered milk, Kool aide, Tong, frozen juice, iced tea, 122

whiskey with water, etc.,do you drink per day? 0 glass(es)

o 0 None

c. About how many cups of coffee do you drink per day? C. 0123 CUP(S)

o 0 None

d. About how many cups of other hot drinks such as teo, soup,

etc.,do you drink per day?

d.

0124 CUP(S)

o 0 Norie

B If an entry of glasses or cups in item 4a through d ask questions e and f; otherwise go to item 5,

e. What type of source not eonneeted to a faucet have you l .

used most in the last moGth (e.g., well, cistern, spring, etc.) 0125 1 0 Well

2 0 Cistern

3 0 Spring

4 0 Other (Specify) 3

f, Is this source located at home? f. r,126 I 0 Yes

2 0 No

35
CHECK ITEM I

Ask questions 5 through IO once for a household. If already asked for this

household, mark (X) the box, end questions and go to Check Item II.- c l

5. Does your faucet water come from u public water system 5.

or your own woter supply? 0127 7 D,No faucet water in structure (IO)

2 0 Public water

3 0 Own supply (7)

Sa. What is the name of the water company that supplies

your house?

b. How long have you used water from this company?

7. What type of water line runs from your own water supply

to the house?

Mark (X) one box after reading list.

&a. 0128 Name of company

I I 1 I

b. 0129 month(s)

0 >

(8)

130 war(s)

7. 0131 I 0 Black iron 7 0 Cement

2 ( Galvanized 8 0 Other

3 0 Plastic (SW fY) jJ

4 q Lead

5 0 Brass 9 0 Don’t know

6 q Copper

80. Do you have a water softener or conditioner connected

to the hot or cold water?

8a. 0132 I 0 Yes

dzlN0 (9)

9 q Don’t know (9)

b. Which one? b. 0133 10Hot

2 q Cold

3 q Both

c. What brand is it?

9a. l would like to check the pipes where they are not

painted or chrome-plated. May I check under the

kitchen sink?

9 0 Don’t know where connected

C . Brand name

9a. 0134 I 0 Kitchen

2 0 At water heater

3 0 Other location (Specify) 7

(134) 4 L_1 Not checked (Enter reason) J

b. Mark (X) the type of pipe. b. 0136 I 0 Black iron

2 m Galvanized

3 q Plastic

4 q Lead

5 q Brass

6 0 Copper

7 0 Other (Specify) 3

9 0 Don’t know

36

:..

v’

<,‘,’

- 1

. .

-_ r

\

I

’ I-

,

. x
.

;

\

. r, .

_. 4r ;

’ ” I*’ I_ ‘...

. \

* . - -

TO, We will be analyridg the water available to peoplcr for 10. SAMPLE OBTAINED

drinking or cooking in their homes. M a

the water from your kitchen faucet (we1 r

I take u sample of @ I a Household faucet

, cistern, spring, etc.)? 2 n Source not connec.ted to a faucet

SAMPLE NOT OBTAINED

3 0 Use bottled water only

4 0 Other (Specify) 3

I

CHECK ITEM II

READ 77-E FOLLOWING:

Thank you very much for answering the questions about yourseif. To determine more completely

and precisely the health status and needs of the adult U.S. population, the U.S. Public Heolth

Service also needs actual measurements and tests that can only be obtained by a health exominotion. For this, a special examination center has been set up and examinations will be conducted

on the dates and times indicated on the sheet I will give you. The examination thot is given

is very thorough and there are no procedures, such as an internal examination, that ore in uny

way embarrassing.

We very carefully select a sample of people to be representative of all parts of the population.

You have been selected from many thousands of people similar to you with respect to your age,

race,and sex,and the fact that we cannot substitute any other person for you makes yourporticipation in the examination very important.

The examination is entirely free and you will receive a fee of $10.00 as on expression of

appreciation for your help in this important survey and as compensation for your time:and for any

inconvenience. We provide transportation to and from the examination center or we reimburse you

if you decide to drive your own car.

None of the results from the examination or answers to the questions l have just asked, will ever

be disclosed to anyone for any purpose without the individual’s written consent; this is required

by law. However, since a valuable examination is being given, most people do request that the

examination results be sent to their physician. I would very much like to make an appointment

for you at a time that is convenient.

0 Appointment made

q Appointment not made (Specify)

3

Notes

37
D. Health Care Needs Questionnaire

BIRJ,--~~-~ (F'ORMFXLY 119+43-l-@

0-75

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

PUBLIC HEALTH SERVICE

HEALTH RESOURCES ADMINISTRATION

NATIONAL CENTER FOR HEALTH STATISTICS

HEALTH AND NUTRITION EXAMINATION SlJRVEY

HEALTH CARE NEEDS

Form Approved

O.M.B. No. 680RI I84

L ASSURANCE OF CONFIDENTIALITY

All information which would permit

identification of the indlvldual will

be held strictly confidential, will be

used only by persons engaged in

and for the purposes of the survey,

and will not be disclosed or released

to others for any other purposes

(22 I= R 1607).

I. Name (Lost, first, middle)

1. Deck No. c. Sample No. d. Segment No. l . Seri al No. f. Column N’o.

181 --Be- -w---- -- --

{EAD - I need to ask you a number of questions about doctors, dentists, hospitils, and other people who might give

you medical core, just how you use them, ond what your opinion is on some questions about health core.

Your answers will be kept confidential.

I

) DOCTORS I

I

2 but

1. When was the last time you tolked 1. I

LSSS 6 2 5

than Weeks through less

2

through or

to o doctor obout your own health . . 1 Never I I than

through

4

weeks 5 more

months months 2 years

I years

years

ago

ago

ago ago

f

am ago

I

at a private doctor’s office? . . . . .

I@ cl 21 a 41 cl cl 71-1

1

at a hospital outpatient clinic? . . . 1002 10

I 0 21 cl cl 50 cl 7 I

at a city clinic? . . . . . . . . . l . . . @ cl cl cl cl cl cl 7lz!

1

at a clinic at work? . . . . . . . . . . . @ 10

f

cl cl cl cl cl 71

ot another type clinic? l . . . . . . . . 1005 0 la cl 31 cl cl cl cl

I

at a hospital emergency room? . . . . . @ cl ’ a cl 41 cl cl cl

ot home? .

I

. . . . . . . . . . . . . . . . . IO070 10 cl cl 41 51 cl Kl

1 over the telephone?. . . . . . . . . . . 1@ cl c.l 30 cl 50 cl 7 Cl

in another woy? - Specify

f

1

21 cl 41 cl cl 7El

sickness or illness --What was the problem?

last visit with a doctor? (Check

only one.) t

I

I

2 0 An injury- Whot was the problem?

I

f

I

3 0 A follow-up visit

I

4 0 A regular checkup

I 5 0 An injection

1

t

6 0 For a prescription

I 7 q Some other reason

I I

38
3a. For this lost visit, how long was it

from the time you decided you should

see o doctor until you actually sow him:

b. Did you have an appointment to see him? b. i@ I 0 Yes - Ask c

I

I 2 ( No - SKIP to 4 I

c. How long was it from the time ou made

the appointment until you saw I im?

C . j 013 0 I 0 Less than one day

i

i

2m 14days

I

I 3 0 I but less than 2 weeks

I

I 4 0 2-3 weeks

I s 0 l-2 months

1I 6 0 3 months or more

I

I

9 q Don’t remember

30. 1 @ I 0 Less than one day

I 20 l-6 days

f 3 C I but less than 2 weeks

I

I 4

I

0 2-3 weeks

i

s 0 l-2 months

I 6 q 3 months or more

I

I 9 0 Don’t remember

b

d. War this time longer thon you would

have liked?

d. i @ iCYei

I

I

2 0 No

I 9 q Don’t remember

4. From whot place did you leave to go

to the doctor?

4. I 015 I 0 From home

I 0I 2 q From work

3 l_j From some other place

5. How did you get from there to the doctor? 5. @ 1~Walked

I 21 Bus

I 3 0 Own car

I 4 0 Someone else’s car

I

I s 0 Cab

I

I 6 q Ambulance

I

I 7 0 Other means t 1

6. How long did it take to get there? & I @iJ i 0 Less than I5 minutes I

I

I

20 IS-29 minutes

I

3 0 So-59 minutes

I

I

4 q I hour or mork

I

I 9 0 Don’t remember

70. At this last visit, about how many 70. 1

minutes did you have to wait before I

being seen by the doctor? I

I@--- minutes

I A

b. Do you think this woit was too long? be I @ I OYes

I 2 0 No

L I 1

8. How well satisfied were you with 8.

this visit?

f‘0020 I q Satisfied

f 2 q Not completely satisfied

I

t

3 q Dissatisfied

I 4 0 No opinion I

39
90. During the past 12 months, have you

hod o health problem which ou would

have liked to see a doctor ar;out but

did not for some reascin?

9a.Il @ I q Yes - Ask b

I

;I

I 2 q No - SKIP to 10

(1

b. What was the reason you did not see b.‘;

a doctor? I’

I

I

Yqs No

Lack of confidence in available

doctors . . . . . . . . . . . . . . . . . . . . . . $&r-J cl

Didn’t have time . . . . . . . . . . . . . . . . . . . @Q--J cl

Would cost too much. . . . . . . . . . . . . . . . . 1 @ I 0 cl

I

Couldn’t get an appointment. . . . . . . . . . . . @lo cl

Would have to travel too far . . . . . . e . . . . . I@10

I 2cl

Didn’t have a way tq get there . . . . . . . . . . i@lO c.l

Was afraid of finding out what

I

was wrong . . . . . . . . . . . . . . . . . . .

;@&a cl

Didn’t have anyone to care for I

children or other family members . . . . . I@10 21

Other - Specify -I@ ‘cl 2c3

I

I

I1

loo. When did you last have a general checkup

or examination, not counting exams made

lo*@I

I 0 Never - SK/P to 13

during a visit for an illness?

I

I

2 [ Less than 6 months ago

I

I 3 0 6-1 I months ago

I

I 4 [ I but less than 2 years ago

I

I 5 0 2 years ago of more

I

I 9 q Don’t remember

1

11. Where did you get-this general examination ?

1 1 . ) (032) I 0 Doctor’s office

I

I 2 0 Hospital clinic

I

I 3 0 Another clinic

I

I

I

4 0 Some other place -Specify

I

I

I

12. During this lost general examination, were

you given -

12. f

I

I

Yes No

a cardiogram? . . . . . . . . . . . . . . . . . . . . .

I

I@10 cl d

a blood pressure check? . . . . . . . . . . . . . . p10 20

a chest x-ray? . . . . . . . . . . . . . . . . . . . . ;@q---J cl

blood tests? . . . . . . . . . . . . . . . . . . . . . .

I

; @ Q---J cl

a urinalysis? . ‘. . . . . . . . . . . . . . . . . . . . ;@(-J 21

vision tests? . . . . . . . . . . . . . . . . . . . . . @lo cl

hearing tests? . . . . . . . . . . . . . . . . . . . . ~@lO c.l

a rectal examination? . . . . . . . . . . . . . , . . I@10 21

an internal examination (FEMALES ONLY)? . &lo 21 8 [ Not applicable

I

1

40
. :’ .

’ I

. .

,.

e ,

I .,

13a. When was the lost time you received

any shots, immunizations or voccinotions

to prevent on illness, excluding shots

for allergy?

b. Why did you get this shot?

130.1 @ I 0 Never - SKIP to 14

I 2 q Less than 6 months ago

1 3 0 6-l I months ago

I

I 4 1 I-2 years ago

I

Is 0 3-5 years ago

I

I

6 0 6-9 years ago

I

1

7 0 IO years ago or more

I

9 0 Don’t remember

r

b, 1 @ t L^] Foreign travel

i

2 0 During military service

I

I

3LJ Participation in community or workI

sponsored immunization campaign

I

(for example, polio or flu)

I

I

4 q Other - Specify

I

140. Is there o particular doctor you see

regularly or whom you would go to if

something were bothering you?

i 140.1 0

044I q Yes - Ask b I

I

2 0 No - SKIP to 15

,

I

b. If you couldn’t see this doctor, is there

some other particular doctor you would

want to see if something were bothering

you?

ba i (045) i 0 Yes

I

I 2110

I

I 9 0 Don’t know

15. Except in an emergency, do you need to

have on appointment in order to see a

15* i 046 10 Yes

I 0

doctor? I

I

2 ( No

16. When you go to a doctor, do you like the

doctor to talk to you about your condition

or do you like him iust to treot it?

17. Do the doctors you usually see talk

to you obout your condition?

16. I

i @ I 0 Talk

I

I

2 0 Just treat

I

I

17. 

I

I@ q--JYtg

I

2 0 No

. L

18. Do you try out home remedies or any 18* that you can get without a prescription jlO049 i m Yes often v

before going to your doctor about a I 2 0 Yes, sometimes

problem? I

I 3 0 No 1

NOTES
I

b DENTIST

19. Do you hove a dentist you

usuolly go to?

i

19 I

l \ 0OS0 1 0 Yes

I 2 n No

20. When wos the lost time you

visited or talked with o

10. /

I

dentist obout yourself. . . . .

ot a dentist’s office?. . . . . . . .

at a hospital dental clinic? . . .

at o hospital emergency

clinic? . . . . . . . . . . . . .

I

I OS1

I

0

;@

I

I

I

I 053

I 0

ot another clinic (work, school,

etc.) . . . . . . . . . . . . . . . .

over the telephone? . . . . . . . . .

I

1

I OS4

I 0

I

I@

in another way? - Specify @

Never

Less

than

6

months

ago

20

20

cl

20

a

20

6

through

I I

months

ago

- -

3 0

3cl

cl

30

cl

30

I

but

less

than

2

years

agO

2 5

through 0t

4 more

years years

ato ago

cl

=cl

cl

cl

=El

cl

6 PI’1

cl

cl

cl

cl

cl

21. What was the MAIN reason for

your lost visit or talk with o

dentist at either his office or

at a clinic?

21. i @ I f Adjustment or repair of dental plate I

I

1

I

I

I

I

I

I

I

I

I

I

I

I

I

I

2 0 To have a dental plate made

3 1 loathache

4 E] Tooth pulled or other surgery

s 1-1 Trouble with gums

6 m Regular checkup visit

7 0 For cleaning teeth

e 0 To have teeth fi I led

9 n For a prescription

o 0 Some other reason - Specify . -

22. For this last visit, how long was

it from the time you decided you

22. f @) I 0 Less than one c)ay

I

needed or wanted to see o dentist

I

until you actually saw him? I

20 Mdays

I

I

I

3 0 I week but less than 2 weeks

4 C] 2-3 weeks

s 0 l-2 months

6 0 3 months or more

9 0 Don’t remember

42
. -

. ’ .’

: : i

. . I.’ ,

a 7

. . .a’ .(

m

..*- _.I

?-,I’ ,’

\

I 8 .

~230. At the time of this lost visit or

talk with a dentist did you hove

an appointment?

23a. @lOYesf

Ask 23b

I 2 0 No - SKIP to 24

I

b. How long wos it from the time

you mode the appointment until

you sow him?

c. Was this wait longer threra you

would hove liked it?

b. f‘0060 I q Less than one day

I

20 I-6 days

I

I

3 fl I week but less than 2 weeks

I

I

4 q 2-3 weeks

I s 0 l-2 months

I

I

6 q 3 months or more

I 9 0 Don’t remember

- -

C . I 061 I 0 Yes

I

0

1

2010

I 9 0 Don’t remember

24. How did you get to the dentist’s

off ice?

24. /@ ‘cl

I

I 2(-1

I

I 31

I

I

41-1

I

I

cl

i

Walked

Bus or subway

Car

Cab

Other means - Specify -

25. How long did it take to get there? 25. i @ I 0 Less than IS minutes

I

I 2

I

q 15-29 minutes

I 3 0 30-59 minutes

I

4 q l hour or more

II 9 0 Don’t remefnber

-260. At this last visit with a dentist,

about how many minutes did you

have to wait before being seen by

the dentist?

b. Do you think this woit wos too long?

I

27. How well satisfied were you with this

visit?

i 260. 1

I

I,O064 minutes ---

b. 1 (6$ 1 q ë(es II 2I_1No I

w . I 0066 I 0 Satisfied

I

I

2 ( Not completely satisfied

I

I 3 c Dissatisfied

I

I

I

4 q No opinion

28. Does your dentist or dentol clinic call

you or send you o note to remind you

when your next regular checkup is due?

28. j @ 1 m Yes

I 2 0 No

9 0 Don’t know

296. During the past 12 months, have you hod

a dental problem which you would have

liked to see o dentist about but you didn’t

see the dentist?

290. I

j (068) 1 q Yes - Ask 29b

I

I 2 f--J No - SKIP to 30

I

I

I

I

I

I

I

43
29b. Why didn’t you sea bim? 29b. i Yes

Didn’t have time . . . . . . . . . . . . . .

1

l . . .

@to

Would cost too much . . . . . . . . . . . . . . .

I @lo

CouIdn’t get on appointment . . . . . . . . . . I

, @cl

Would have to troval too for . . . . . . . . . .

i @IO

Didn’t have a way to get there . . . . . . . . .

i

1 073 1 r--J

I 0

Didn’t have anyone to care for i

children or other family members . . . . l 1 @cl

Some other reason . . . . . . . . . . . . . . . . .

II 07501 n

No

cl

2-1

20

ncl

20

21

ncl

HOSPITAL

30.

:

When was the lost time you stayed in

a hospital overnight or longer?

i

I 076 I 0 Never - SKIP to 36

30. ; 0

1

2 u Less than I month ago

I 3 0 l-5 months ago

I

I

4 q 6-l I months ago

1

5 0 One year ago or more

I

I 9 0 Don’t remember

1

- -

31. Was this stay in the hospital on account

of on emergency 01 was it planned in

31* i @ I q Planned

I

advance? I 2 m Emergency I

32. What was theMAlNreoson you went into

the hospital that time?

32* 1 @ I m Sickness or illness

i

1

2 a Injury

I

30 wwY

I 4 0 Child birth

I s 0 Checkup >

SKIP to 34

1

6 n Some other reason - Specify ond SKIP to 34

I

I

b. How long was it from the time it was

decided you needed to go into the

Lspital until you went in?

b, i

I

I

I

I

I

I

I

I

t

I m Less than one day

2-) 1-6days

3 u I but less than 2 weeks

4 q 2-3 weeks

5 (J l-2 months

6 q 3 months or more

s q Don’t remember

340. What part of the doctlr:‘r bill did you

or your family have b pay out of

own pocket for the trecrtment the I

our

actor

gave you while you were in the hospital?

b. Did you get any of this money bock

from your health insurance?

%d @ I LJ None - SKIP to 35

I

I

2 q Less than half

I

I

3 n More tharl half, but not all

I

I

411 All

I

I

s q Don’t know - SK/P to 35

t

b.1 @ 3 0 Yes

I 2 r-1 No

44

‘1 P

.: ‘- .

, ‘

I ,

‘J I
3Sa. What part of this hospital

bill did you or your family

3h 1 0082 I 0 None - SKIP to 36

have to pay out of your own I 2 0 Less than half

pot ket? I 3 0 More than half, but not all

I

I

41 All

I s q Don’t know - ‘SKIP to 36

1

b. Did you get any of this money

back from your health insurance?

bei @ i 0 Yes

1

I

I 2nNo

360. When you see a doctor at his 360. 1 0$4

office or at a clinic, whot

I q Never been to a doctor - SKIP to 37

I 0

port of the cost do you or

I 2 0 None - SKIP to 37

I

your family usually hove to I

3 0 Less than half

pay out of your own pocket? I

I

4 n More than half, but not all

I

I

so All

I 9 0 Don’t know - SKIP to 37

b. Do you get any of this money

back from your health insurance? I

I

2010

370. Whenever you see o dentist

at either his office or at a

370.‘0I m1I 0 Never been to a dentist - SKIP to 38

clinic, what part of the cost

I

I

2 0 None - SKIP to 38

do you or your family have I 3 fl Less than half

to pay out of your own pocket?

I

I 4 0 More than half, but not all

I

I

50 AlI

I

1

9 i--J Don’t know - SKIP 10 38

b. Do ou get any of this money

b oc Ifrom your he&h insurance?

b. i @ 1 0 yes

i

I

2lNo

1 380. What part of the cost of drugs

ond medicines prescribed by

%J @ I q No drugs or medicines ever prescribed - SKIP to 39 I

I

your doctor do you poy out of I 2 n None - SKIP to 39

your own pocket? I

I

3 0 Less than half

I 4 [ More than half, but not all

I

I 5( All

I

I 9 0 Don’t know - SKIP to 39

Ib. Do you get any of this money

back from-your health insurance?

b-I@ l(1Yes

I

I 2aNo

39. Do you have insurance or 39. i

covetage for medical care

:

39b. What port of your medical bills

under . . . .

I

yer ’ ~~~oelY::ay? M$;;;yn - *,, Don’t knOIh

than

I half not all

Medicare (for elderly) ? . . . . . . . Iwo 10 8

cl 0098 I 0 zcl 31 cl

Private medical insurance?. . . . . )Wh(l 20 0099 1IJ 20 3cl scl

Insumnce through your ploceof work? 1 092 1 q

i

0 2 D @ 10 2cl 30 gi7

Medicaid (for all ages) ?. . . . . . . @cl 21 0101 1 r-J a 31 cl

Retired military privileges?. . . 169410 2n

8

102 1 [

8

20 3n cl

Veterans medical care? . . . . . . . 109510 20

I

103 1 0 2n 30 scl

Some other government assistance

program? - Specify ;@cl 21 @ ‘cl 2cl 3c1 glzl

I

I

Some 06er way? . . . . . .

I

l *.**e 1 0

097 q---J 20 0105 11 a cl 90 I

I 1

45
E. General Well-Being Questionnaire

H RA-1 l-7 (Formerly HSM-411-7)

I-74

Form Approved

O.M.B. No. 68-R I I84

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

PUBLIC HEALTH SERVICE

HEALTH RESOURCES ADMINISTRATION

NATIONAL CENTER FOR HEALTH STATISTICS

HEALTH EXAMINATION SURVEY

ASSURANCE OF CONFIDENTlALITY

All information which would permit

identification of the individual will

be held strictly confidential, will be

used only by persons engaged in

and for the purposes of the survey,

GENERAL WELL-BEING I

and will not be disclosed or released

to others for any other purposes

(22 FR 1687).

O. Name (Lost, first, middle) b. Deck No. c. Sample No. d. Sex e. Age

171

1 pI Male

----- 2 0 Female - -

READ - This section of the exominotion contains questions about how you feel ond how things hove been

going with you. For each question, mark (X) the onswer which best applies to-you.

1

1. How hove you been feeling in general? (DURING

THE PAST MONTH)

1. 1 (001) 1 q In excellent spirits

I 2 q In very good spirits

I

1

3 0 In good spirits mostly

I

4 n I have been up and down in spirits a lot

I

1

5 q In low spirits mostly

I 6 q In very low spirits

2. Have you been bothered by nervousness or your

“nerves”? (DURING THE PAST MONTH)

2. i @ I q Extremely so -- to the point where I

I could not work or take care of things

I

I

2 0 Very much so

1

3 0 Quite a bit

I 40 Some-- enough to bother me

s q A little

6 0 Not at all

.3. Have you been in firm control of your behavior,

thoughts, emotions OR feelings? (DURING THE

3. I @ I q Yes, definitely so

I

PAST MOWH) I 2 0 Yes, for the most part

I

I 3 q Generally so

;

I

4 0 Not too wel I

I

5 q No, and l am somewhat disturbed

I

I

6 0 No, and I am very disturbed

4. Have you felt so sod, discouraged, hopeless, or I Extremely so -- to the point that I have

had so many problems that you wondered if I just about given up

anything wos worthwhile? (DURING THE PAST

MONTH)

1

I 2 q Very much so

I 3 q Quite a bit

I

!

4 q Some - - enough to bother me

I 5 q A little bit

I

I 6 0 Not at all

5. Have you been under or felt you were under any 5. 1 @ i 0 Yes - - almost more than I could bear

strain, stress, or pressure? (DIJRUVG THE PAST or stand

MONTH) I

I

I 2nYes -- quite a bit of pressure

I

I 3 0 Yes -0 some - more than usual

1 4 0 Yes -- some - but about usual

I 5 0 Yes - a little

I

I

6 r-J Not at all

46

1

I
6. How hoppy, satisfied, or pleased hove you

been with your personal life? (DURING THE

PAS7 MONTH)

I

6. I @ I q Extremely happy -could not have been

f more satisfied or pleased

I 2 0 v.ery WPY

I

1

3 0 Fairly happy

I

f

4 0 Satisfied -- pleased

f

5 0 Somewhat dissatisfied

I

6 0 Very di ssati sfi ed

7. Hove you had any reason to wonder if you

were losing your mind, or losing control over

the way you act, talk, think, feel, or of your

memory? (DURING THE PAS7 MONTH)

7

7 i @ I q Not at all

l I

I

2 q Only a little

3( Some-- but not enough to be concerned

or worried about

4 q Some and I have been a little concerned

5 q Some and I am quite concerned

6 0 Yes, very much so and I am very concerned

8. Have you been anxious, worried, or upset?

(DURING THE PAS7 MONTH)

8. / @ I 0 Extremely so -- to the point of being sick

I or almost sick I

2 q Very much so

3 0 Quite a bit

4nSome-- enough to bother me

5 q A little bit

6 q Not at all

9. Hove you been woking up fresh ond rested?

(DURWG THE PAS7 MONTH)

i

9. I 009 I q Every day

I 0

I

2 q Most every day

f

3 0 Fairly often

I

I

4 q Less than half the time

I

I

5 0 Rarely

I

I

6 q None of the time

10. Hove you been bothered by any illness, bodily 10. / I q All the time

disorder, poins, or fears obout your heolth? I

(DURING THE PAS7 MONTH) I 2 0 Most of the time

I

I

3 0 A good bit of the time

I

I

4 0 Some of the time

I

I

5 0 A little of the time

I 6 0 None of the time

I 11. Has your doily life been fuII of things that were 11. 1 011 1 q Ail the time

interesting to you? (DURING THE PAS7 MONTH) 1 0

I

2 q Most of the time

I

I

3 0 A good bit of the time

II

4 0 Some of the time

I

I

5 q A little of the time

I

I

6 0 None of the time

12. Hove you felt down-hearted and blue.3

THE PAS7 MONTH)

(DURING 12. ) @ I L_I All of the time

I

I

2 q Most of the time

\

3 q A good bit of the time

4 0 Some of the time

5 0 A little of the time

6 0 None of the time

47
13. Have you been feeling emotionally stable

and sure of yourself? (DURING THE PAS7

MONTH)

i

1% I 0130I 0 All of the time

I

I

2 0 Most of the time

I

3 0 A good bit of the time

i

I

4 0 Some of the time

5 0 4 little of the time

t 6 0 None of the time

I q

14. Have you felt tired, worn out, used-up, or I q All of the time

exhausted? (DURING THE PAS7 MONTH)

I

2 0 Most of the time

I

3 q A good bit of the time

4 0 Some of the time

5 0 A I ittle of the time

6 q None of the time

For each of the four stoles below, note that the

words ot each end of thq 0 to 10 scale describe

opposite feelings. Circle any number along the

bar which seems closest to how you have generolly felt DURING THE PAST MONTH.

15. How concerned or worried about your HEALTH

hove you been? (DURING THE PASTMONTH)

15*j@ 0 1 2 3 4 5 6 7 8 9 10

I

I

I

I

Not Very

I concerned concerned

at all

16. HOW RELAXED or TENSE hove you been?

(DURING THE PAS7 MONTH)

16.@ o I 2 3 4 5 6 7 8 9 ‘0

I

I

I I I I \

I

Very Very

I

relaxed tense

17. HOW much ENERGY, PEP, VITALITY have

YOU felt? (DURING THE PAST MONTH)

i

17.@ o I 2 3 4 5 6 7 8 9 ‘0

I

I d

I

I No energy Very

I

I

AT ALL, ENERGETIC,

I I i stless dynamic

I

I

18. How DEPRESSED or CHEERFUL have hove 0 1 2 3 4 5 6 7 8 9 10

you

been? (DURING THE PAS7 MONTH) la./@

I

I . A \

I

I Very Very

I depressed cheerfu I

19. Have you had severe enough personol,

emotional, behavior, or mentol problems

that you felt you needed help DURING

THE PAS7 YEAR?

1% 1 019 I q Yes, and I did seek professional help

I 0I

2 0 Yes, but I did not seek professional

I help

I

I

3 q I have had (or have now) severe

r

personal problems, but have not felt

I needed professional help

1

4 q I have had very few personal problems

I of any serious concern

I

I

5 0 I have not been bothered at all by

I

personal problems during the past year

48
‘ *. -.

. *

.

.

:’ Ia “ I

, .

I .

: .

. ,+:- :’ -

\ \

‘,. - .

9

20. Have you ever felt that you were going to

have, or were close to having, a nervous

breakdown?

2&i@ 10 Yes -- during the past year

I

2 0 Yes -- more than a year ago

1

anlo

21. Have you ever had a nervous

breakdown?

21, t @ 10 Yes -- during the past year

I

I

2)Yes -- more than a year ago

I

30 No

I

22. Have you ever been a patient (or outpatient) 22.1 @ 10 Yes -- during the past year

at a mental hospital, a mental health ward of

a hospital, or a mental health clinic, for any I 2 0 Yes -- more than a year ago

personal, emotional, behavior, or mental problemI I, 30 No

23. Have you ever seen o psychiatrist, psychologist, 23. 1 @ 1 l---J Yes -- during the past year

or psychoanalyst about any personal,

emotional, behavior, or mental problem I 2 q Yes -- more than a year ago

I

concerning yourself? II 3010

24. H ave you talked with or had any connection

with any of the following about some personal,

emotional, behavior, mental problem, worries,

or “nerves” CONCERNING YOURSELF DURIK

7-H PAST YEAR?

a. Regular medical doctor

(except for definite physical

conditions or routine check-ups) . . . . l . . . .

24a. f

I1,O024 i 0 Yes

b. Brain or nerve specialist . . . . . . . . . . . . . be! (025) l[YeS

c. Nurse (except for routine

medical conditions) . . . . . . . . . . . . . . . . .

d. Lawyer (except for routine

legal services) . . . . . . . . . . . . . . . . . . . .

e. Police ( except for simple

traffic violations) . . . . . . . . . . . . . . . . . .

f. Clergyman, minister, priest,

rabbi, etc. . . . . . . . . . . . . . . . . . . . . . . .

2010

20 No

g. Marriage Counselor . ..*.** .a*?**. l l .

h. Social Worker. . . . , . . . . . . . . . . . . . . . .

0.

f, j (GJ I 0 Yes

I

go 1 030 1 IYes

I 0

h. ) (031) I 0 Yes

2 0 No

2110

2110

2mNo i

i. Other formal assistance:. . . . . . . . . . . . . . i. 1 0320I q Yes - What kind?

I

I

I

I 2010

I

25. Do you discuss your problems with ony members 25. - and it helps a lot

of your family or friends?

I @lOYes

I 2 0 Yes - and it helps some.

I

I

3 0 Yes - but it does not help at all

I

4 q No - I do not have anyone I can talk

I with about my problems

I 5 0 No - no one cares to hear about my

I problems

I

i

6 0 No - I sdo not care to talk about my

problems with anyone

7 q No - I do not have any problems

49
Circle the number for each statement which best describes how often you felt

or behaved this way-DURING THE PAST’WEEK.

50

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

44.

45.

DURING THE PAST WEEK:

I was bothered by things that usually don’t

bother me . . . . . . . . . . . . . .

I did not feel like eating; my appetite was

poor . . . . . . . . . . . . . . . .

I felt that I could not shake off the blues even

with help from my family or friends . . . .

I felt that I was just as good as other people .

I had trouble keeping my mind on what I

was doing . . , . . . . . . . . . . .

I felt depressed. . . . . . . . . . . . .

I felt that everything I did was an effort . . .

I felt hopeful about the future . . . . . .

I thought my life had been a failure . . .

I felt fearful . . . . . . . . . . . . . .

My sleep was restless . . . . . . . . . .

I was happy . . . . . . . . . . . . . .

I talked less than usual . . . . . . . l .

I felt lonely . . . . . . . . . . . . . .

People were unfriendly . . . . . . . . .

I enjoyed life . . . . . . . . . . . . .

I had crying spells . . . . . . . . . . .

lfeltsad ...............

I felt that people disliked me .......

I could not get “going” . . . . . . . . .

Rarely or

None of

the Time

(Less than

1 DaYI

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

Some or a

Little of

the Time

(1-2 Days)

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Occasionaily

or a Most or

Moderate All of

Amount of the Time

Time

(3-4 Days) (5-7 Days

2 3

2 3

2 3

2 3

2 3

2 3

2 3

2 3

2 3

2 3

2 3

2 3

2 3

2 3

2 3

2 3

2 3

2 3

2 3

2 3
I

t-IRA-1 l-7A

12/74

I

EXAMINER OBSItRVA’l’ION SHEET

( Circle the number for the most appropriate observation for each alphabet set )

A. Test qualifications

1. Refused at least one item

2. Couldn’t comprehend at least one item

3. Simple error - missed item, skipped page, etc.

4, Time called, page missing, other non-examince factor

5. Feel this is a poor quality record of questionable value (other than above)

6. Other (describe)

*7 . None - record complete, no qualifications

B. Reasons for not obtaining full, acceptable GW13 ( asscssmcnl limitations)

1. Lack of interviewers

2. Lack of time

3. Examinee failed to return to complete exam

4. Examinee too ill, drunk, etc.

5. Foregin language barrier

6. Seemed to be mentally retarded

7. Mental functioning or verbal comprehension too limited (o/t 5, 6)

8. Confused mental state, senile, etc.

9. Too emotionally disturbed or upset

10. Refused, non-cooperative, “difficult”

11. Other (describe)

* 12. None: obtained full, acceptable GWB

C. Indicatiqns of current problems from examinee

I-- 49. ‘I‘cchnician Obser\*ation

C.

1. Direct reference to a current psychologic problems, i.e., under treatment

for “nerves”, taking tranquilizers, sedatives, sleeping pills, memory loss,

delusions, senile. brain damage, retarded

2. Death of someone mentioned as negative affect or distressing

3. Distressing or limiting medical problem or condition mentioned

4. Medica or psychologic problem of someone else mentioned

5. Reference to problems of living, i.e., money, drug use or reaction, alcohol,

limited physical movement, lonely, unhappy, job loss, unhappy love/sex

condition, problems with children or spouse, etc.

6. Reference to problems of other family members, close friends, close

associates

7. More than 2 year history mentioned for questions 20-23

8. Other (describe)

*9. No apparent problems

6 .

7.

8.

*9.

D. Interviewer impression of subjective distress or state (Any personal, situation, I).

-2, .

. ,I

i . l . -.

., . 4 l i

I_ . .\ :. 3

Form Approved

O.M.B. No. 68-R118

rst, hliddle

AGE:

48. GWB examiner number

(If t-to examiner number, leave blank)

(:omtnents:

‘)

-.

3 .

4.

. . 5

or condition mentioned or behavior, appearance, suggesting well being - distress)

0. Mentally or emotionally disturbed

1. Severely distressed

2. Moderately distressed

3. Mild distress

4. Some problems but apparently coping well or not distressed

5. Overly euphoric, hyperactive, or “pushing”

6. Highly restrained, tense, apprehensive, uncertain

7. Other (describe)

*8. Mild positive affect (feeling tone or state)

9. Strong positive affect

E. Interviewer impression of comprehension of task (filling-out GWB)

0.

1.

2.

3.

4. Comments:

5.

6.

7.

*8.

9.

I41 .

0. Could not do task (do not consider negative refusal)

1. Comprehension low

2. Comprehension questionable

3. Translator used or foreign language noted

4. Literacy level seemed low

5. Dialect or non-mainstream American-English

6. Mental seemed slow, uncertain processes

7. Speech slurred or hardly audible-difficult to understand

8. Some other problem (describe)

*9. No apparent limitations

0. 4

1.

9-.

3.

4.

5.

6.

7.

8. --

*9. 50. Technician’s Examiner No.

51
F. Supplement A-Arthritis

HRA-1 l-2 (FORMERLY HSM-41 l-2)

6-75

Form Approved

O.M.B. No. 68.kI 184

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE ASSURANCE OF CONFIDENTIALITY

PUBLIC HEALTH SERVICE Al I InformatIon which would perrrl~t

HEALTH RESOURCES ADMINISTRATION ldentlflcatlon of the lndivIdual Will

NATIONAL CENTER FOR HEALTH STATISTICS

be held strictly cor\fidential, ~111 be

II red only by persons cngnged Ill

Hf Al 1 I I ANU NU’I RI I ION LXAMINAT ION SUfaVfi y ,111tj for ttre purpo>cs of ItIC su~vt*y,

SUPPLEMENT A - ARTHRITIS

,lll(i WI I I r\ot I,- (11 \( IOSVC~ or rf*lt*,I\I*(i

11) 01 t\c1 v. I or i\llt’ c,tlrc*t ()III()O\V’b

(I) I ii IMl/).

.

Name (Lust, first, mrddle) Deck No. Smplc No.

121 -----

READ - Earlier you mentioned having had either pain in a joint or in the back or neck, swelling of a joint, or

morning stiffness in the joints or muscles, Here are some additional questions about it.

l

la, Have you had pain in either the back or neck la, ‘0I 001 I q Yes - Ask b

on most days for at least one month? I z q No - SKIP to k~ I

b. Has this pain in the back or neck been

present on any one occasion for at least

six weeks?

b ,; 002 ,O 1; Yes

I z /-J No

I

c. Where is the pain usually located?

r

c. :

I Yes N o

Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . j,O003 I 0 cl

Upper back . . . . . . . . . . . . . . . . . . . . . . . . ‘ ; @ I q 2cl I

Mid-back. . . . . . . . . . . . . . . . . . . . . . . . . . j

’ @ cl 20

I

Lower back.. . . . . . . . . . . . . . . . . . . . . . . jiO006 ’ cl cl

d.8 When you have this pain, where is it most intense? d.; Yes No

Neck . . . . . ......,.r.....,........ $iij cl a

Upper back . . . . . . . . . . . . . . . . . . . . . . . . j @ I a

2cl

I

Mid-back. . . . . . . . . . . . . . . . . . . . . . . . . .

0

009 1 cl *cl

Lower back. . . . . . . . . . . . . . . . . . . , . . . . ; @cl cl

e. Is the pain present when you are resting

at night?

e.: (6j-i) 1 q Yes

I 20 No

,

f. When you have the pain, does it awaken

you from sleep at night?

f.! @ 1 /-JYVes

I 211 No

I

9. Does the pain in the back ever seem 013

to spread?

gas 0

10 Yes

2aNo

30 Not apphcable, no pain in bxk

h. Where doe; it spread to? h . Yes No

To the back of the right leg . . . . . . . . . . . . . , @ I 0

4zl

To the back of the left leg . . . . . . . . . , , . . .

,OIO15 cl cl

To the back of both legs . . . . . . . . . , . . . . ,

;O, 016 1 I 20

To the top of the head . . . . . . . . . . . . . . . . . ; @ I q *cl

To the sides of the body . . C . . . . . . . . . . , , ; @ I 0

cl

I
Item I (Continued)

i, Hos pain in the neck ever seemed to spread?

i 1 @ i IYes

’ I 2 0 No

I

I

3 0 Not applicable, no pain in neck

\

i. Where does it spread to? ie I Yes No

To the top and bock of the head. . . . . . . . . . / @ 10 cl

I

To either shoulder area . . . . . . . . . . . . . . . ; @ ln cl

To the arms or bonds. . . . . . . . . . . . . . . . .

I

I@ ‘cl 20

I

Other - Specify - I @ cl 21

I

I

k. Is your bock or neck pain made worse - k. 1 Yes No

by coughing, sneezing, or deep breathing?. . . i@lO 2)

with bending or twisting motion? . . . . . . . . . /@a 21

I

after prolonged activity? . . . . . . . . . . . . . . I@ cl 21

I

after prolonged sitting? . . . . . . . . . . . . . . .

after prolonged standing?. . . . . . . . . . . . . .

I. How old were you when you first experienced

20

a

Less than 20 years old

this recurring back or neik pain?

m. When was the last time you had this pain?

n. What is the longest episode of back or

neck pain you have ever had?

o. Does this back or neck poin occur more

frequently now than it used to occur?

p. Have you ever had a sprained back due to

some type of physical activity?

q. Have you ever had a “whiplash” injury

of the neck?

I

I 2 u 20 - 29 years old

i 3030- 39 years old

I

i

I 4040- 49 years old

I

I S~IO- 59 years old

I

I

I

6 q 60 years old or older

----

m. / @I q Now

; 2 @ Less than I year ago but not now

I

I

I cl’ - 2 years ago

1I

413- 5 years ago

I

i

I

5 ) 6 years ago or more

I

n. i @ I q Less than one month

II

I z 0 One but less than two months

I

I

302- 3 months

414- 5 months I

I

I q 6 months or more

I

I 9 1 Don’t remember

I

0. / @ i 0 Yes

1

I

2 0 No

pB j @ i IYes

I

I 2 q No I

q. j @ 1 IYes

I 2nNo

53
lr, Hove you ever had a ruptured disc in either

your bock or neck?

lr. ;1 035 0 I q Yes -Ask s

II

.2 u No - SK/P to v

s. At what age?

+

5. ; 0

036

I

I - - years

t. Were you in traction?

U. Wos surgery necessary?

tb ) @ 1 0 Yes

I

I 2 0 No

@ i 0 Yes

1

I

2 UNo

V. Hove you ever stayed overnight in a hospital

for bock or neck pain?

V. , @ 1 I yes I

I

! 2 q No

20. Hove you had pain in or oround eithes hip joint

(including the buttock, groin, and side of the

upper thigh) on most days for at least one

month?

b. Has this pain in the hip area been present on

any one occasion for at leost six weeks?

c. Where did you first notice it?

d. In the hip orea, where is the pain usually

most intense?

Right buttock .....................

Left buttock .....................

Both buttocks. ....................

Right groin .....................

Left groin .......................

Both groins .....................

Side of right thigh .................

Side of left thigh. ..................

Sides of both upper thighs. ............

20. i @ I u Yes -Ask b

I 2

I 0 No - SKIP to 3a

I

b.i @i) 1 0 Yes

I1 2 UNo

C* / @ I q Left hip

II 2 0 Right hip

I

I 3 q Both hips

d. 1 I

. I

I Yes No

; @ ‘cl 21

IIO044 ’ cl 2(1

I

I 045 I 0 ’ cl 20

I 0 046 ’ u 21 I

I

I 0 047 1 n 21 I '0I 048 ’ 0 2!1

I

I @ ‘(1 2(1

I

Other - Specify

e. Frem the hip, has the pain tended to spreod to - er

the inside of your leg? . . . . . . . . . . . . . . .

the front of your leg? . . . . b’ . . . . . . . . . .

the outside of your leg? . . . . . . . . . . . . . .

the back of your leg? . . . . . . . . . . . . . . .

f. Hove you hod pain

either coughing or

in or oround the hip when f.

sneezing?

1 0 Yes

2 0 No

g. When this hip pain is present, does it

hurt at rest as well as when moving?

9. i 0058 i IYes

II 2 q No

54
2h. How old were you when you first

experienced this recurring pain

in the hip?

i. When was the last time you had the pain?

i. What is the longest episode of hip pain

you have ever had?

k. Have you ever had a fractured hip?

I. Which hip was broken?

m. How old were you when it happened?

n. Was the hip in traction?

o. Was there surgery?

p. Have you ever had o dislocated hip?

q. Which hip was dislocated?

r. How old were you when it happened?

s. Wos the hip in traction?

t. Was there surgery?

I 0 Less than 20 years old

2 0 20 - 29 years old

3rJ30- 39 years old

4140- 49 years old

s 0 50 - 59 years old

6 0 60 years old or older

i. iI

I

0 060 ,~Now

2 0 Less than I year ago but not now

I cl’ - 2 years ago

1 403- 5 years ago

I

I s 0 6 years ago or more

i*l a 1n Less than one month

I 2 0One but less than 2 months

I

! 302-- 3 months

I

4/-J4- 5 months

II 5 06 months or more

I 9 0 Don’t remember

k. j @ 10 Yes - Ask I

I

I 2 0 No - SKIP to p

I

I. ( @ I q Right

I 2 0 Left

1 3 0 Both

I

me/ (i&i)- _ Years

n. j @i q Yes

I

I

2q No

0. ’ @

I

10 Yes

I 2 0 No

L

p / @ 1 q Yes - Ask q

I-2 0 No - SKIP to 30

-

q* I

I 0068 I m Right

2 q Left

3 q Both

r.

5.

;i @ii& _ Years

b .--

1 0070 i IYes

I

I C-JNo

30. Have you hod pain in or oround the knee

(including the back of the knee) on most

days for at least one month?

3a. i @ I 0 Yes - Ask b

I 2 ! No - SKIP to 40

I

b. Has this pain in the knee area been present

on any one occasion for at least six weeks?

b. i @I q Yes

I

I

I 2 0 No

55
3c, In which knee did you first have it? 3c. ; , 0074 I q Left knee

I z 0 Right knee

3 q Both knees

9 q Don’t remember

de HOW old were you when you first experienced

recurring pain in the knee?

d. ; @ I q Less than 20 years old

I

I 2 0 20-29 years old

I

1

3 0 30-39 years old

II4 0 40-49 years old

I s q SO-59 years old

I

I 6 0 60 years old or older

e. When this knee pain is present, where is it ; e* I

most intense? I Yes

- -

N O

Rightknee.. ....................... ; 0076 1 q 21

Left knee ......................... II@ cl 20

Both knees ........................ \,O078 í q 20

Behind the right knee .................. I1 079 0' Cl 20

Behind the left knee .................. I@ ‘0 20

Behind both knees ................. .e.;@) ‘cl 21

f. When this knee pain is present, does it hurt

at rest as well as when moving?

f. :I @ i IJ Yes

I 2 l-l No

g. When this knee pain is present, is there also

swelling of the knee joint?

h. When this pain is present, have you every had

“locking” of the knee?

i, Has either knee ever “given way” under you?

I 2 (No

r@ 1 (Yes

I 2 !--I No

i* %I 0 Yes - As& j

I

I 2 u No - SK/P to k

i. Which knee? i* ,

I@ I q Right

2 I_ Left

3 ! Both

k. When was the last time you had this knee pain?

I. What was the longest episode of knee pain you

have ever had?

k. ; @ 1 INow

I

I 2 a Less than I year ago but not now

I

I 3 @ I-2 years ago

I

I 4 0 3-5 years ago

I

;s n 6.years ago or more

I, ;,O088 I n Less than one month

2 I One but less than 2 months I

3 !-J 2-3 months

4 ( 4-5 months

5 i 6 months or more

9 0 Don’t remember

m, Have you ever hod Q fractured knee?

n, Which knee?

m. I@ I !-J Yes - Ask n

I

I 2 f-J No - SKIP to o

n. i@ t r-J Right

I

I 2 ( Left

I

I

3 q Both

56

_ I’ ,. . ,. .

‘,

I-

*‘- 0.:‘

_ i

I -
4 - +

\, -

,

. .

‘. _ , - .‘.

#. .

3’ .

. .*l )

. . _ _

30, Have you ever had a severe twisting of 091 I 0 Yes - Ask p

either knee with resultant sprain or swelling

30. ‘01

-

I

I 2 0 No - SUP to Q

1

p. 1 @ I n Right

I

I

I

2 [I] Left

I

I

3 m Both

I

lasting more than two weeks?

p. Which knee?

q. Have you ever hod any other knee injury? q. 1 @ I 0 Yes - Ask r

I

I 2 a No - SKIP to 40

I

r. Which knee?

40. Have you ever had hip, knee, or back

disease treated by an operation?

b, Which joint?

IF HIP:

(1) Which hip?

IF KNEE:

(2) Which knee?

c. What was the operation or procedure?

Sped fy

r. j 0094 I 0 Right

I

I

2 m Left

I

3 q Both

I

40. ;@ I 0 Yes - Ask b

I

I 2 0 No - SKIP to 50

I ,

b, 1 @ 1 q Hip

I

4 q Hip and knee

I

2 0 Knee 5 m Back and knee

I

3 n Back 6 q Hip and back

I

I

7 m ALL

r

(1) ; @I I 0 Right

I

I 2 q Left

I

I 3 0 Both

I

(2) I @ I q Right

I

I

I

2 q Left

I

I

3 /-J Both

r

I

II

I

I

I

So. Have you had pain or aching in any joint

other than the hip, back, or knee on most

days for at least six weeks?

b. Which joints were painful?

So. ;

-

I

b. & c.

Fingers . . . . . . . . . . . . . . . . . . . . . . . .

~~~;,~- I

Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . ;@ ‘I 20 @ ‘0 20 30

Elbow. . . . . . . . . . . . . . . . . . . . . . . . . '

'0104 ' u 2 0

i - 0105 '0 20 310

Shoulder. . . . : . . . . . . . . . . . . . . . . . , . I@ ‘j 21 @ ‘0 2/ 3irIl I Ankle. l . . . . . . . . . . . . . . . . . . . . . . . . gg1l-J 2@ @ ‘0 2I-J 311

Foot...............,.........,., 1 (iiJ ‘I 2) @iJ ‘0 2j 31

I

60. Hove you ever had ony swelling of joints

with pain present when the joint was touched

on most days for at least one month?

60. 'l 112 0 I 0 Yes - Ask b

I

I 2 0 No - SKIP to 7a

1

b. Has this swelling been present on any one

occasion for at leost six weeks?

I b. ; @1 q Yes

I

I

2 q No

57
6c. Which joints ore usually involved whenever

; k&d. I e

you have this swelling and tenderness on I

touching?

I

I Yes No

Fingers. . . . . . . . . . . . . . . . . . . . . . . . . . .

I(ii-&o 2/

I

I Wrists.. . . . . . . . . . . . . . . . . . . . . . . . l l g giYJ’0 4.3

Elbows ,........ , . . . . . . . . . . . . l ..*.

I

Shoulders . . . . . . , . . . . . . . . . , , . l l . b . e ;@1o 2j

I

Hips......... . . . . . . . . . . . . . . . . . . . .

I@'0 20

I

Knees . . . . . . . . ..P................

I

Ankles . . . . . . . . . . . . . . . . . . . . . . . . . . . ;(G&o 20

Feet . . . . . . . . . . . . . . . . . . . . . . . . . . . .

I

I@'0 2(

I

- -

-

6d, If “Yes,” - Which?

Right Left Both 0115 q-J 21 31

0117 11 qJ 31

0119 10 20 3j

0 121 11 21 30

0123 '0 20 30

0125 10 2( 30

0127 ‘0 2( 3j

0129 10 2/ 30

-.-

6e. How old were you when you first experienced

this swelling of the joints?

*./ @ I q Less than 20 years old

I

I

2 0 20 - 29 years old

I

I

3(30- 39 years old

I

I 4040- 49 years old

I

I SrJIO- 59 years old

6 q 60 years old or older

f. When was the last time you hod this? f. j @3 1 q Now

I 2 1 Less than I year ago bgt not now

70.

b.

C.

cl~ - 2 years ago

4(J3-- 5 years ago

5 06 years ago or mote

Have you had stiffness in your joints and

muscles when first getting out of bed in

the morning on most mornings for at least

7a. / @ I C Yes - Ask b

I 2 E No - SK/P ro &I

I one month?

Has this morning stiffness been present on

any one occasion for at least six weeks?

h. i (ii 1 0 Yes

I

I

2 0 No

I - -

Which joints are usually involved whenever C.&d. 1 L

you have this morning stiffness) I I

I YCS N 0

Fingers. . . . . . . . . . , . . . . . . . . . . . . . . . . ; @ ‘f-J 21

Wrists.. . . . . . . . . . , . . . . . . . . . . . . . . . . i(ijJ'G 7;

Elbows. . . . . . . . . . . . . . . . . . . . . . . . . . . ,I& li 2i

I Shoulders . . . . . . . . . . . . . . , . . . . . . . . . , ; (j-g) 1 ( 2 Q

I -

Hips . . . . . . . . . . . . . . . . . . . . . . . . . . . . j &j) ll 2;

Knees . , . . . . . . . . . . . . . . . . . . . . . . . . . j@) ‘0 2z

Ankles. . . . . , . . . . . . . . . . . . . . . . . . . . . 1 (ijig 10 21

Feat . . . . . . . . . . . . , . . . . . . . . . . . . . . . +-i&c 2z

Back. . . . . . . . . . . . . . . . . . . . . . . a.... j (g-9 ’ 0 g--J

76, If “Yes,” - Which?

Ri gtlt Left Both

’ I

. .

. -.
r .- _ I

~ , ,

j

‘... ’

. .1’ ”

. ,F ._ ; -, ,

.’ - ” *

,.’ .-

:

’ ,I.,

76. How long after getting up and moving

around does the morning stiffness last?

i 7e. ,

,O152 I a Less than 15 minutes

I z @ 15 minutes to one half hour

3 q More than one half hour but less

than all day

4nAlI day

f. How old were you when you first experienced

this morning stiffness of joints?

I q Less than 20 years old

2 rJ 20 -- 29 years old

3@30- 39 years old

4040- 49 years old

5j-J150- 59 years old

6 E 60 years old or older

I

g. When was the lost time you hod this? 9* I

:0154 1 0 Now

I 2 @ Less tha n

I I

I year ago but not now

3l.m - 3 years ago

404 - 9 years ago

5 q IO years ago or more

80. Have you ever had pain, swelling, or stiffness

in a joint as the result of an accident or injury?

8a. / @ I 0 Yes - Ask h

II 2 q No - SK/P to 9

b, Was this the cause of the pain, swelling,

or stiffness mentioned previously, do

you think?

c. ,ls this the cause of any pain, swelling, or

stiffness which might still be present, do

you think?

- -

l

b.: @ I E Yes

II 2j‘No

I 9 q Don’t know

1 (Yes

I 2110

I

9 0 Don’t kriow

9 . Have you ever been treated by any of the 9. I

following people for your joint troubles? I Yes NO

Genera I practitioner. . . . . . . . . . . . . . . . . . .

I@)17 cl

Internist , . . . . . . . . . . . . . . . . . . . . . . . . . ;@I0 2z

Rheumatologist . . . . . . . . . . . . . . . . . . . . .

; (i,jGj ’ ;

LE

Orthopedist . . . . . . . . . . . . . . . . z - . . . . . .

/ (@) a

2!-J

.-- I Chiropractor . . . . . . . . . . . . . . . . . . . . . . .

,O162 ’ : cl

Osteopoth . . . . . . . . . . . . . . . . . . . . . . . . (iii) 1 q 2 @

Foot doctor (chiropodist or podiatrist). . . . . . .

, r(g) ’ 1

-

2l I

-- /

Physical therapist . , . . . . . . . . . . . . . . . . . (163 ! ‘5 2

-

:

- -

Occupational therapist. . . . . . . . . . . . . . . . ,

10

166 lj '> 1 I

Other - Specify

:-I

,‘/rd7 1ig 2'1

Never been treuted . . . . . . . . . . . . .

59
100. Are you currently being treated by a doctor

for the troubles you have just described?

lOa. i @ I r-3-- Yes - Ask b

I

I

2 [ -] No - SKIP to I lo .-

b, What type of doctor is he?

c. What did he soy the problem was?

b. 1

IO170 I [:I General practitioner

I

I

2 [J Internist

I

I

3 I:-) Rheumatologist

I 4 [ye 1 Orthopedist

I

I

I

5 1-y ) Chiropractor

I 6 [::I Osteopath

1 7 C-3 Other specialist

I

I

I

8 [-__I Other - Specify

I

I

I

t

c. I DATA PREPARATION USE ONLY

i

I 0

171 ' r-Y.3 0

174 ' El

I

I

I

I

0

172 1 t.1 0

175 ' LII

I

d, When was the last time you saw him?

e, Who originally referred you to this doctor?

I

I(;;;> cl 0

176 ' [:I

I

d.j @ I [-y-l Less than I month ago

I 2[“] I - 3 months ago

I

I

I

3 [ I:] 4 - 6 months ago

I

I 4 L-1 7 -’ I I months ago

I -.

I

I

5 L 3 I year ago or more

I

9 [.J Don’t know

}p----a

e.; @ I [-I] No one

1 2 i-111 He’s the regular doctor

I

I 3 [I:] Another doctor

I

I

I

4 Is--j Family

;

5 1-L-i Cln~ic

I

I

6 1 -1 Health nurse

I

I

7 i-1 1 Friend

I

I

e [- 11 Other - Specify-.----

l

I

I i

__l_---____ __- -____I_ I

f, Where do you usually see him?

g. How long will it be until your next

visit to him?

t

-_.__~_-.- -------- ---.-----

f. ; @ I 1. 1 His office

I 2 1 -j Ata clinic

I 3 1 _ _I At home 1I

I 4 1 - i Ottret

I------_----------- .- --- -- ----- --

9,: @ 1 I--, 1 l,ess than I month

I

I

2 L-II’j I - 2 months

I 3 ;. .] 3 - 6 months

II 4 [-Y ] -7 I I months

I 5 rI-1 I year or more

I

I g r.-j Don’t know

60

\ (‘I

.

. . . . .,

I .

1 ,

I ‘v * -

i ._’ .b

. ‘.I,’ \ \
. . \

. .

. .d

I

110. Have you ever used any of the following 110. 1

kinds of treatment for your joint troubles? f

t

Ilib. Did it do you

any good?

Yes Yes No

Splints or casts . . . . . . . . . . . . . . . . . . . . I , (GJ q---J 2 L-1 0182 I [--I - 2 1'13

I

. Braces. . . . . . . . . . . . . . . . . . . . . . . . . . i@ ‘lzl 2 c-2 0184 1 1-1-- 2 Ll I

Diathermy or paraffin. . . . . . . . . . . . . . . . . ; @ 1(--j-- 2 lx-1 0186 1 [--I 2 L-l

I

Hot packs or heating pads. . . . . . . . . . . . . . I @ ‘Kl 2 1-J 0188

' Ll 2c:1 I

Cold packs or ice. . . . . . . . . . . . . . . . . . . I 189

' r-II 2 r3 190 q--l_- 2 r-r-1 I. 0 0

Rest . . . . . . . . . . . . . . . . . . . . . . . . . . . ; @ ‘El 2m 0192

' El 2 r-3

Traction . . . . . . . . . . . . . . . . . . . . . . . . .

II 0193 1 crl 2 crl 0194 1 ITT7 2 CI I

Exercises or ph,ysical therapy . . . . . . . . . . . I @ 1 Cl 2 II.2 196

' l:J 2 III I 0

Aspirin. . . . . . . . . . . . . . . . . . . . . . . . . . I

, @ cl 2 Cl 0198 10 2 111 I

Cane . . . . . . . . . . . . . . . . . . . . . . . . . . .

IIO199

' crl 2 L] 0200 'III 2 III

Crutch . . . . . . . . . . . . . . . . . . . . . . . . . .

I

I 201 0 1 II1 2 czl @ ’ CII 2 I3

Stiff mattress. . . . . . . . . . . . . . . . . . . . . .

I

1 @ ’ c3 2 E-J 0204

' [:I 2 r-1 1

I

Bed board. . . . . . . . . . . . . . . . . . . . . . . . ; @ ’ CII 2 1-:-i 2 L-l

I

--c

I

c. If “Yes” to I la or I Ib - Do you use it regularly? I

c* I Yes No

I Splints or casts . . . . . . . . . . . . . . . . . . . . I @ q-J 2 C-l

I

Braces . . . . . . . . . . . . . . . . . . . . . . . . . . I @ c-l 2 c. 1

Diathermy or paraffin. . . . . , . . . . . . . . . . .

I

; @ ‘IT3 213

Hot packs or heating pads. . . . . . . . . . . . . . / @9 JrI 41 I

Cold packs or ice . . . . . . . . . . . . . . . . . . .

I

; @ii ‘1’1 21’ I

Rest . . . . . . . :. . . . . . . . . . . . . . . . . . . I @ 11.1 21-I

I

Traction.. . , . . , , . . . . , . . . . . . . . . . . . / @j-g 11’I 21 I

Exercises or physical therapy . . , . , , , . , . . i (i=GJ 11. 1 2L I

Aspirin..,...,.....,.,,... . . . . . . . / ($) 1 I - I WI I

. . . r-ane . . . . . . . . . . . . . . . . . . . . . . . . . . .

I

; @ii) 11.1 2 I -_ I

Crutch . . , , , . . . . . , . . , . . . . . , , . . . . . ; (izj 1 c-1 I 4 I

Stiff mattress, . . . . . , , . . . V . . , . . . , . . . I & m 2r: 1

I

Bed board. . , . . . . . . . . . . . . . . . . . . , . , 1 @ 11-1 Cl

1

120. Hove you ever hod injections into any

of your joint,?

120.; @ I 1'; IYes - Ask b

I

b. Did they do you any good?

I--- . --. ---_._-__

2 I-‘] No -- SW to 13~1

b. 1 (@ I 1-13 Yes

II 2 I -.- I N 0

WW61
62

130, Have you ever taken any of the following 130. / Yes No Don’t know

medications for your joints?

Any cortisone-like medicine by mouth . . . . .

I

’ 222 0 1 r--J 2 Ll g I-.: -1

Butazolidin . . . . . . . . . . . . . . . . . . . . . .

I

; @ 1 c-1- 2 1:: I g L-1

Darvon or Tylenol. . . , . . . . . . . . . . , . . . i @ ‘l-3- 2 1.: I 9 c.1 I

I

Indocin.. . . . . . . . . . . . . . . . . . . . . . . .

i1 225 1 [ -1- _ 2 r-. I 9 I. I -1 t-Q

b, If “Yes” - Did it do any good? b. ’

Any cortisone-like medicine by mouth . . . . .

I

Yes NO

I@ cl 4: I

Butazolidin . . . , . . . . . . . . . . . . . . . . . . 1, @ cl 2 Cl

Darvon or Tylenol. . . . . . , . . . . . . . . . . ,

I

; @ 1l.l 2 c13

Indocin.. . . . . . . . . . . . . . . . . . . . . . . . I&n 1

2 1111

1 14. Con you do the following things without

the help of someone else or the help of

14. ;

some special device? I Yes No

I

Go up or down stairs . . . . . . . . . . . . . . . . ; @I cl 2 L-.-I

I

Get into or out of a car . . . . . . . . . . . . . . I@ cl 2 L-2

I

Use washing facilities. . . . . . . . . . . . . . . ; @ ‘s-3 2 l-II

I

Dress yourself . . . . . . . . . . . . . . . . . . . . ) @ Cl 2 1 :-I

I

Feed yourself , . . . . . . . . . . . . . . . . . . . ; @ 1L-3 2l-I I

Get into or out of bed. . . . . . . . . . . . . . . . c-1

15. At the present time, does your joint

condition restrict your physical activity

15. j @ 1 n-

 Very little

I

very little, quite a bit, or a whole lot?

2 0 Quite a bit

-

3 u A whole lot

I

16. Have you ever had to stoy in bed at home for 16. 1

long periods of time because of your joints?

I 0237 I [.-J Yes

I

I

2 r--l No

17. Have you ever stayed overnight in a

hospital because of joint problems?

17. i @iJ 1 r--l Yes I

.--

I 2 [I--] No

18. With respect to your joint trouble, would

you say your condition is mild, moderate,

18. / @ I [rl-.- Mild

I

I 2 17 Moderate

or severe?

19. What was your lob status one month before 19.

I

I

you first developed your joint condition?

lo240 I [-J Retired because of age

I 2 [I Retired because of disability

i

I

3 11-1 Unemployed

I

4 [J Working full-time

I

I

5 [I Working part-time

I

I

6 [:I] Housewife with ful I duties

I

7 [r] Housewife with partial or no duties

I 8 [I] Other - Specify

I

I

I ---A--

I

I ----

I

;.’ ._

í l ,

6 .

1
I

, I ” i

. *

-a 1 . , ,

I .’ :*

200. As o result of your joint condition, has

there been a change in your job stotus?

200. / @ I L_IYes -Ask b

I

2 0 No - SKlP to 21

b. What is it now? b*l @ cl Retired because of di sabi Ii ty

2 q Unemployed

3 L-J Changed to easier job

4 17.1 Working

s [: ] Housewife with partial duties

6 r-1 Housewife with no duties

7 a Other - Specify

I

I

21. How many work days do you estimate that 21.

you lost during the past 12 months as a result

i@ I L_J None

I

of your joint condition? I

2 0 I - 4 days

I 3 n 5 - 9 days

4cj IO - 14 days

5l 15- 19days

6 q 20 - 29 days

7 LJ 30 days or more

i

1 244 ,o

I 0245

I

NOTES

63
G. Supplement B-Respiratory

RRA-11-3 (Formerly HSM-411-j)

4/75

Form Approved

O.M.B. No. 68-RI 184

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

PUBLIC HEALTH SERVICE

HEALTH RESOURCES ADMINISTRATION

NATIONAL CENTER FOR HEALTH STATISTICS

HEALTH AND NUTRITION EXAMINATION SURVEY

SUPPLEMENT B - RESPIRATORY

a. Name (Last, first, middle)

ASSURANCE OF CONFIDENTIALITY

All information which would permit

identification of the individual will

be held strictly confidential, will be

used only by persons engaged in

and for the purposes of the survey,

and will not be disclosed or released

others for any other purposes

;,o, FR 1687).

b. Deck No. c. Sample No.

131 -----

READ - Earlier you mentioned having had either persistent cough, phlegm, wheezing, shortness of breath, asthma, or

hay fever. Here are some additional questions about this trouble.

I

b PERSISTENT COUGHING 10001 1 L_J Yes - Ask b

la. Was your problem that of persistent coughing? la, i ~/NO- SKIP to 20 I

b. How long have you had this condition? b. -Less than I year

I

I 2 [ l-3 years

I

I

I 3 0 4-9 years

I

I 4 [ IO years or more

I

I

c. Have you been bothered by this w,ithin the

past year?

c. j,O003 1 L_J Yes

I 2 [No

I

t

d. When you have this trouble, do you also

have chest pains?

d. i @ I 0 Yes - Ask e

I

I

I

2 j--J No - SKIP to f

L

e. Where?

I

e. I Yes No

Upper back . . , . . . . . . . . . , . . . . , , . . . I @ f •I 2cl

I

Lower back.. . . . . . . . . . . . . . . . . . . . . 1IO006 ’ cl 2[1

Upperchest.. . . . . . . . . . . . . . . . . .-e 10i 007 ' cl 2cl

Along the rib edge . . . . . . . . . . . . . . . . I@T 20

I On the sides . . . . . , . . . . . . . . . . . . , . . I (&GJ 1 q cl II

f. Do you bring up phelgm with the cough? f. I, @ f L_J Yes

I

I

2 0 No

I

g. Do you cough persistently like this on

most days for as much as. THREE

months each year?

h. Do any medicines you take help relieve

the cough?

i. What time of year do these coughing

attacks seem at their worst?

9* ;‘0011 1 a Yes

i

2 q NO

h. i @ 1 u Yes

I

I 2 ElNo

I

t

i. i:0013 1 0 Winter

I

I 2 q Summer

I

I 3 n No difference

I

I
l

Ií ë,

p , .ë, d

î ,

I 1.. .- , .

. ,,._._

20.

b.

C.

d.

e.

h.

b, How long have you had this condition? b’-

* I -

I 2 q l-3 years

I

I

I

3 0 4-9 years

I

I

4 q IO years or more

I

I 9 0 Don’t know

I

.

I

Have you had trouble with coughing spells when 20. ;

you first get up in the early morning? (Count 1 014 0 1 q Yes - Ask b

a cough with first smoke or on first going out

I

of doors; exclude clearing of throat or a

I

2 q No - SKIP to 30

single cough.)

I

I

I

HOW long have you had this particular condition? be 1 @ , 0 ~~~~ than 1 year

I

I

I

2 0 I-3 years

I 3 q 4-9 years

I

I

4 q IO years or more

I

.I

9 q Don’t know

t

Do you have chest pains when you have CA @g I q Yes - Ask d

morning coughing spells? I

I 2 q No - SKIP to e

I

Where? d. i

I

Yes No

Upper back . . . . . . . . . . . , . . . , . . . . . . I 017

I 0 I q 20

Lower back.. . . . . . . . . . . . . . . . . . . . . i @ I q 20 I

Upper chest. . . . . . . . . . . . . . . . . l . . l l I@jlU

I

2u

Along the rib edge. . . . . . . . . . . . . . . . . . 1 0020 I 0 au

I

On the sides . . . . . . . . . . . . . . . . . . . l . i @

I

1 q 2cl

What time of year are these morning coughing

spells at their worst?

I

e./ @ i q Winter

I 2 0 Summer

t

I

3 q No difference

Do you have a morning cough like this on

most days for as much as THREE months

each year?

Do you usually have a persistent cough at

other times during the day or at night in the

winter? (IGNORE AN OCCASIONAL COUGH.)

Do you usually have a persistent cough at

other times during the day or at night in the

summer? (IGNORE AN OCCASIONAL COUGH.)

i

f. ; @ i UYes

I

I

2 q No

I

I

9.1 @ i UYes

I

I

2 q No

h.iI

IO025 i IYes

I

I

I

2 /‘-JNo

F PHLEGM ;

30, Do you usually bring up any phlegm from your 30. ; 0026 I 0 Yes - Ask b

chest first thing in the morning? (Count phelgm

with the first smoke or on going out of doors. I

I 2 0 No - SKIP to 40

Exclude phlegm from the nose. Count I swallowed phlegm.) I

ha 1n Less than I year

65
c. What color is the phlegm? C.j Yes No

Green. . . . . . . . . . . . . . . . . . . . . . . . . . . . ; (028) ‘El 2[_1

I

Yellow. . . . . . . . . . . . . . . . . . . . . . . . . . . ;@pcl 2lIl

I

Clear . . . . . . . . . . . . . . . . . . . . . . . . . . . ;@Kl 2cl

I Blood-streaked. . . . . . . . . . . . . . . . . . . . . . 1 @ 1 0 21

d. Do you also bring up any phlegm from your chest d. )

at other times during the day or at night, in the I @ 1 IYes

winter? (At least two times or more) I

I 2 ~NO

I

e. Do you also bring up any phlegm from your chest I

during the day, or at night, in the summer? e*[ @ 1 (Yes

(At least two times or more) I

I

I

2 UNo

f. What time of year do you seem to bring up the

most phlegm from your chest?

f, [ @ 1 0 Winter

I

I

2 11 Summer

I

I 3 0 No difference

I

g. If you have brought up phlegm, do you bring it

up on most days for as much as THREE months

9.1 @ 1 0 Yes

I

each year? I

2 ONo

-

) SHORTNESS OF BREATH

40, Have you had shortness of breath either when

I

1 @ I q Yes - Ask b

40, I

hurrying on the level or walking up ,a slight hill? i 2 f-J No - SKIP to Sc(

L

b. Have you had this problem most days for as much b, i 0037 * q Yes I as TH-REE months‘each year? -

i 2 ~NO

I

c. Do you get short of breath when walking with

other people at an ordinary pace on the level?

I ~ ~~- - -

c.; (GiiJ * l-J Yes

I

I

2 UNo

d. Do you have to stop for breath when%valking

at your own pace on the level?

e. Do you have to stop for breath after walking

about 100 yards or after a few minutes on the

level?

f. How long ago did you first have this trouble

with shortness of breath?

g. Have you gotten chest pains along with the

shortness of breath?

h. Where?

Upper chest. . . . . . . . . . . . . . . . . . . . . . . a

i d, I @ 1 q Yes

I

I 2 0 No

1

e l II (GJ 1 0 Yes

I

I 2 q No

Less than I year ago

2 U I-3 years ago

3 0 4-9 years ago

4 q IO years ago or more

9 I-J Don’t know

9.1 @ i LJ Yes - Ask h

1

I

I

2 0 No - SK/P to i

h, i Yes

I

I @‘cl

No

2(1

Upper back . . . . . . . . . . . . , . . . . . . . . . . . I, @ 1 q

I

21

Lower back.. . . . , . . . . . . . . . . . . . . . . . .

i

, @lo 21

Along the lower ribs . . . . . . . . . . . . . . . . . . j@cl xl

I

On the sides . . . . . . . . . . . . . . . . . . . . . . . ; @‘cl 21
di. Do you develop wheezing as well as shortness

of breath?

4i. i (048) 1 q Yes

I 2q No

i. Have you ever felt like you were going to pass

out from the shortness of breath?

i. 1 @ i C]!Yes

I 2 0 No

I

) WHEEZING I

1 050

50. Has your chest ever sounded wheezy or 50, ) 0 I f--J Yes - Ask b

whistling? I

2 m No - SKIP to 6a

b. How long have you had this condition? b. I

f 0OS1 I n Less than I year

I

2 0 l-3 years

I

I

3 c_1 4-9 years

I

I

4 L-j IO years or more

I

I--

-.--

c. Do you get this wheezing or whistling with colds? c. i 0OS2 i IYes

I

2 KIN0

; -*._ - - _. .----I---.-

d. Do you get this occasionally apart from colds? d. 1 0053 i DYes

I

I

l--.--~nN”

e. Does this usually occur daily?

I

e. I 0054 i IYes

I ;L m No

I

-a--

f. What time of year does it seem worst? f, I 05s

I

0 i q Winter

I

2 0 Summer

I

I

3 n No difference

I -.--

g. Is this wheeziness present on most days for as g. i q Yes

much as THREE months each year?

I@

II---..-_2 q No

h. Do you take any medicines for wheezing? h. 

I

1 @ I IYes -Aski

I

I

2 L_1 No - SKIP to 6a

I

i. Do they help relieve the wheezing? i. I@ I q Not at all

I

I 2 q A small amount

I

I 3 q A great deal

I

b ASTHMA i‘0059 I 0 Yes - Ask b

50. Have you had, or do you now have asthma? 60. II 2 q No - SKIP to 7a

I b. What is it related to or due to? b. ; Yes

I Dust............................. I@ q--J

I

Foods . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 @ ‘cl

Animal contacts . . . . . . . . . . . . . . . . . . . . . i@‘cl

I

Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . f @ ‘I

Pollens. . . . . . . . . . . . . . . . . . . . . . . . . . . j @ ‘cl

Molds . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 @ ’ q

Other - Specify I @ lo

t

Don’t know . . . . . . . . . . . . . . . . . . . . . . .

I@ cl

I

I

No

2c.l

2cl

cl

21

cl

21

20

67
6~. HOW long have you had this condition?

I 4

I

6c. 1lo068 I q Less than I year - SKIP to e

2 0 I-3 years - SKIP to e

3 q 4-9 years ago - SKIP to e

d, Since you were a child?

I

I 4 q IO years or more - Go to d

I

I

d.; @ i IYes

I

I 2 0 N o

I

t

e. Do you have asthma symptoms on most days for e.: 0070 i (Yes

as much as THREE months each year? II

2 q No

What time of year is it worst?

I

f. I Yes No

i

Spring . . . . . . . . . . . . . . . . . . . . l . . . . . .

I

I 0071 1 r--J 21

I Summer . . . . . . . . . . . . . . , . . . . . . . . . . . I 0072 1 r-J cl

I Foll~.....~,....~....~...,..,.,,, ; @ , q 2c.l I

Winter . . . . . , . . . . . . . . e.. . . . . . . . . . . IOI

I

074 1 r--J

Do you take any medicines for it?

t 2n1

g.l 0075 i (Yes

I

I

2 a N o

I

) HAYFEVER I 076

‘a. Have you had, or do you now have, hayfever? IO 1 q Yes - Ask b

70.;

I

2 q No - SKIP to 80

I

b. What is it related to or due to? b’ Yes No

‘ I

Dust . . . . . . . . . . . . . ..a.......... I@ ‘I 21

I

Foods . . . . . . . . . . . . . . . . . . . . , . . . , , i@ ‘U cl

I Animal contacts . . . , . . . . . . . . . . . . . . . . I@ ‘U 20

I Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . I@ ‘cl cl

I Pollens.. . . . . . . . . , . . . . . . . . . . . . . . .

I10081 ‘0 cl

Molds . . . . . . . . . . . . . . . . . . . . . . . . . . /O082 1 q cl

Air conditioners . . . . . . . . . . . . . . . . . . . . i@ q--J 2n

I

I

Other - Specify ;@ q---J 20

I

Don’t know . . . . . . . . . . . . . . . . . . . , , . ) @ q---J

I----

C* How long have you had this condition? 9‘0086 1 q Less than I year - SKIP to e

I

I 2 11_1 l-3 years - SKIP to e

,

3 L_14-9 years - SKIP to e

d. Since you were a child?

I

I

4 u IO years or more - Ask d

d.; @ i nYes

I

I 2 [No

68

, * ,_’ ’

,s. . ‘

’ ,

: I __ --. ’ I

c

; . .

* 1.

I’ .

3

J ”
7e. Do you have hayfever symptoms on most days 7e. i ,O088

for as much as THREE months each year?

1 Cl Yes

I 2 NO

I

I f. What time of the year is it worst? f, ; Yes No I

Spring.. . . . . . . . . . . . . . . . . . . . . . . . . . .

i@ ’ Lzl

I 2cl

Summer. . . . . . . . . . . . . . . . . . . . . . . . . . . 1@ ‘I 2cl

I

Fall . . . . . . . . . . . . . ,.. . . . . . . . . . ,..

I,@ ‘cl 2cl

Winter . . . . . . . . . . . . . . . . . . . . . . . . . . . I@ q--j 21

Iye--

I g. Do you take any medicines for it? 9* I@ 1 u Yes

I

I 2 n No 1I

b MEDICAL CARE ;(094) I m Yes - Ask b

8a. Have you ever been tested for TB (tuberculosis)? 80. 1

2[10- SKIP to 9a

b. How were you tested? b. i

A skin test . . . . . . . . . . . , . . . . . . . . . . . .

I@

I

Chest x-ray . . . , . . . , . . . . . . . . . . .\. . . . .

;@

I

Sputum examination . . . . . . . . . . . . . . . . . .

I@

Don’t know . . . . . . . . . . . . . . . . . . . . . . . .

j@

Yes

‘cl

1 CT1

'El

g Cl

No

2cl

21

2cl

c. How often are you tested?

I

I

C. ;@ 1 L_1 Once every year

I

I 2 n Once every two years

I1

3 0 Once every 3-5 years

I 4 !-J Less often than once every 5 years

I

d. How long ago were you last tested?

I d./ @j I r-1 Less than I year ago

I 2 0 I-2 years ago

I

I 3 q 3-5 years ago

I

I

I 4 m 6-9 years ago

I

I 5 q IOyearsa go or more

, 9 0 Don’t know

90, Have you seen a doctor or anyone else

about the chest or lung conditions you

mentioned previously?

b, What is the name of the doctor you see?

c. What type of doctor is he?

:@ 11] General Practitioner

C@ ; 2 9 Internist

3 LJ Osteopath

4 iJ Surgeon

5 (._ Lung specialist

6 q Allergist

7 K-1 Other - Specify---.---.----

d, Who inrtially referred you to this doctor? d,; @ 1 q No one

I 2 7 He’s the regular doctor

3 u Another physician

I

/ 4 a Health nurse

5 [ Clinic

6 m Family

I 7 m Other - Specify I

69
9e. How long after you first developed the problem 9s.

did you see him?

/ @ I q I-6 days

I

I z 0 l-7 weeks

I

I 3 0 2-6 months

I

I 4 0 7-l I months

I

I 5 q One year or more

I

I 9 0 Don’t know I

f. What did he say the condition or conditions fB I DATA PREPARATION USE ONLY

affecting your chest were? j@ ‘0 @ ‘El (;;;)‘O

j@ ‘cl (IiiJ ‘cl

I

I@ ‘cl @‘cl

i@ ‘cl @‘cl

I

I

I 0109 ' cl

I 0114 ' cl

g. When you see the doctor about your chest

condition, how often do you receive a

chest x-ray?

6, I (116) I E At every visit

.

t

i 0 At every other visit

I

f

d a Less often than every other visit

h, Does he prescribe the medicine for

the condition?

ho / @ I q Yes - Ask i

1 2 0 No - SKIP to j

i, How ir the medicine taken? i. Yes No

I

Swallowed ,bb,,b,,,bbbbbbbObbbbbbbb ;I 0li8 1 0 2(1

I 6 rea&ed bbbbbbbbbbbbbbbbbbbbbbbbb I@ 10 2cl

I

Iniected b-bbbbbbbbbbbbbbbbbbbbbbbb L I@ ‘0 a

I

Other - Specify

ib Has he told you to do ony of these other things ib

for it? I

I Yes

Breathing exercises bbbbbbbbbabbbbbbbbb I@ ‘cl

I Use a breathing machine b b b b b b b b . bbbbbb I@ ‘I

Stop smoking b . b b b

I

bbbbbbb.b.aObb b b b b I124 'cl ,O

Decrease smoking b b b b b b b b b b b b b b b b l . b 1 (;r;> 1 q

I Regular checkup. b b b b . b b . . b b b b b 6 . b b b b 1 @ 1 m

Lots of rest . 4’ b . bb.bb.b bbbbb,bbbb.b IIO127 '[1

Decrease activity b.bb..bbbbb..b.bb.b @-J ‘cl

Other - Speciiy

I

;@ ‘I

No

20

2cl

cl

2cl

21

20

20

cl

k. When was the lost time you saw him? k. j 030) I q Less than I month ago I

2 0 l-3 months ago

3 q 4-6 months ago

4 q 7-l I months ago

5 0 I year ago or more

9 q Don’t know

70
. . c’ - ’

. . . *

. .,’ ’

.--

91. Where do you usually see him? 91. / (GJ I 1_1 At his office

I

I

2 1 At a clinic

I 3 0 At home

I

I 4 q Other - Specify

m. How long will it be until your next

appointment?

10. Within the past 12 months, has your chest

condition gotten worse, gotten better, or

stayed about the same?

d @

I

I j--J Less than I month

I

I 2 0 l-3 months

I

I 3 ( 4-6 months

I

4 0 7-l I months

I

I

5 q I year or more

I

I 9 LJ Don’t know

I

10. 1 @ i 0 Gotten worse

I

2 q Gotten better

3 c7] Stayed about the same

Have you ever stayed overnight in a hospital 12. ;I (135)

because of a chest condition?

1 L_I Yes

I

I 2 I. No

13. What was your iob status one month before

you first had a problem with a chest or

13. [ @ I 0 Retired because of age

I

lung condition? I

I

2 m Retired because of disability

I

I

3 m Unemployed

I

4 0 Working ful I-time

I

I S 0 Working part-time

I 6 a Housewife with full duties

14a. As a result of your chest or lung condition,

has there been a change in your job status?

I

I 7 q Housewife with partial or no duties

I

I 8 Ll Other - Specify

I

I

I

I

I

14a. i @ I q Yes - Ask b

I

I 2 !--J No -SKIP to IS

I b. What is it now? b I ’ IlO138 I 1_1 Retired because of di sabi I i ty

I

I

2 a Unemployed

I

I

3 [ Working only part-time

II

4 m Changed to easier job

I

I s fl Housewife with partial duties

I

I 6 m Housewife with no duties

7 l-1 Other - Specify

I I I

I 1

.

15. How many work days would you estimate you

have lost during the past 12 months because

15. ; @I I 9 None

I

of your chest or lung condition, excluding I

2 q l-4 days

colds or flu?

I

I 3 I_J 5-9 days

I

I 4 q IO-14 days

; 5 0 IS-19 days

I

I

I

6 q 20-29 days

I 7 0 30 days or more

71
H. Supplement C-Cardiovasdular

HS&411-4 \PAG E 1)

REV. 5/71

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

PUBLIC HEALTH SERVICE

HEALTH SERVICES AND MENTAL HEALTH ADMlNlSTRATlON

NATIONAL CENTER FOR HEALTH STATISTICS

HEALTH AND NUTRITION EXAMINATION SURVEY

SUPPLEMENT C - CARDIOVASCULAR

a. Name (Last, first, middle)

Form Approved

O.M. B. No. 68-R I 184

ASSURANCE OF CONFIDENTIALITY

All information which would permit

identification of the individual will

be held strictly confidential, will be

used only by persons engaged in

and for the purposes of the survey,

and will not be disclosed or released

others for any other purposes

;,o, FR 1687).

b. Deck No. C. Sample No.

141 - ----

READ - Earlier you mentioned having a history of either chest pains, chest discomfort or heaviness, leg pains

while walking, or heart failure. Here are some additional questions about it.

la. Was the problem that of chest pains, chest

discomfort, pressure, or heaviness?

la. j @ I 0 Yes - Ask b

I

2 0 No - SKIP to 2a

b. How would you best describe this pain b.j

or discomfort? I Yes No

I

Heaviness.,........................ I 002 11 2llIl I 0

I

Burning sensation. . . . . . . . . . . . . . . . . . . . . I:O003 1 r--J 21

Tightness,. . . . . . . . . . . . . . . . . . . . . . . . . 1'0004 1 r--J 2cl

Stabbing pain.. . . . . . . . . . . . . . . . . . . . . . .

I

IlO005 I q 2cl

Pressure.. . . . . . . . . . . . . . . . . . . . . . . . . . ;0l 006 10 21

. Sharppain . . . . . . , . . . . . . . . . . . . . , . . . . . IOI

I

007 1 r-J 21

Shooting pains . . . . . . . . . . . . . . . . . . . . . . .

IIO008 I 0 cl

c. Have you had it more than THREE times?

d. Have you been bothered by this within the

past 12 months?

e, How old were you when you first had it?

f. Do you get it if you walk at an ordinary

pace on level ground?

g. Do you get it if you walk uphill

or hurry?

c.;:0m!J 1 q Yes

I

I 2 1_1 No

I

d.1 0010 1 q Yes

I

I 2 q No

I

I

e.; (iiiiJ q-Jo- I9 years old

I

1

2020- 29 years old

I

I 3r---JlO- 39 years old

I

I 4140- 49 years old

I

I

I

5n50- 59 years old

I

I 6 0 60 years old or older

I

I

f ’ I ’ (GJ 1 m Yes

I

I

2 q No

I

I

+I 0013 I q Yes - Ask h

2 q No - SKIPto k

I

72
0 ’ . .

,. ,’

\- .

. \.

.

-, . r

’ t _,..I _

lh. What do you do if you get it while walking? lh, f

I

I

Yes No 1

stop. . . . . . . . . . . . . . . . . be~**~*o**e** ;@ ‘U cl

I

Slow down I,..*..,......,..,......... I 0015 ‘cl 21

I

Continue at same pace. . .

I

. . . . . . . . . l ..**. 1

I 0

016 ‘0 cl

Take medicine. . . . . . . . . . . . . . . . . . . . . . . i @ij ‘0 cl

i. If you do stop or slow down, is it relieved i.j @ I q Relieved - Ask j

or not?

2 0 Not relieved - SKIP to k

I

j. How soon? i* I 0019 I q Less than IO minutes

I

I 2 q IO minutes or more

I

k. When you get pain or discomfort, where

is it located?

k ’ l I

I

I

I

Yes No

Upper middle chest , . , . . . . . . . . 0 . . . . . . . . I@ ‘cl 20

I Lower middle chest. . . .**~***oo**.*ee** +J ‘0

Left side of chest. . . . . . . . . . . . . l l **.*e* : @. ëcl

I

Left arm

I

,......,,............. . . . . . 1,@ ‘cl

Right side of chest

I

....... ............. I

,@ ‘cl

Other - Specify

I

1

I

025 0 í q

I. Do any of these things tend to bring it on? I. i Yes

I

cl

cl

21

21

21

No

Excitement or emotion . . . . . **a********** ;@1o 20

Stooping over 0027 ‘cl 21

Eating a heavy meal . . . . . . . . . l *.***.*s* I@ 10 2u

I

I

Coughing spells . . . . . . . . , . . . . . . . . . . . . . ; @ 10 21

I

Cold wind . . . . . . . . . . . . l ,e~e*oo*e* 0 . 0 ;@ 10 21

I

Exertion ..e.....,..,..e* 6 l . . , . . . , . I@ ëI 21

I

2a. Have you ever had severe pain across the

front of your chest lasting for half an hour

or more?

b. How many of these attacks have you had?

c. What was the date of your last attack?

2a.j @J I q ’ Yes - Ask b

I

I

2 0 No - SKIP to 3a

1 q One

I

I 202-3

I

I

3 u 4 or more

c.; @ Month Year

I -- -m

I

d, What was the duration of the pain during

your last attack?

d. I @ I q 30 - 59 minutes

I

I 2 qI - 2 hours

I 3 0 3 - 5 hours

I

I 4 0 6 - I I hours

I

I 50 12-23 hours

I

I 6 24 q - 47 hours

I

I

7 q 2 days or more

L

73
.J

2e. Did you see a doctor about this lost attack? 2e. I @ I U Yes -Ask f

i

I

2 E] No - SUP to 3a

f. What did he say it was? f . I1 DATA PREPARATlON USE ONLY

1 @ 1 [-J 0 041 1 1_11

[@q--JI 0 042 I / I

;@lo 0043

' 1_1 I

i@lO 0 044 ’ L-l - I

3a. Do you get pain or discomfort in either leg

while walking?

I a h ) @ I u Yes - Ask b

i

2 c--J No - SKIP to 4a

b, Do you also get this pain in your legs

while standing still?

I

c, In what parts of your leg do you feel

this pain?

1 i Lower part (calf)

2 q Upper part (thigh)

3 r-J Both lower and upper parts

d. Do you get the pain in your legs while

quiet or while sitting?

e. Do you get it when you walk up a hill

in a hurry?

da I @ 1 U Yes

I

I 2 t--J No

I

e. i @ 1 L_1 Yes

I

I 2ElNo

f, Do you get it when you walk at an

ordinary pace on level ground?

g. Does the pain in your legs come on after

you have taken a few steps?

h. Does the pain disappear while you ore

still walking?

i

90 1 @ ’ u yes

I

I

2 u No

I

ho 1 (052) 1 r_7 Yes

I

I 2 u ho

.-

i, What do you do when you get‘it while

you are walking?

i, /

I Yes No

stop. ,,,..~*B~om~o@eob~~ .~,~e~eooo

;@

I

‘cl uzl

I

Slow down *~~oe~o@Do~~~*e. eo*eeaeo*m IO ‘[--I cl

Continue at same pace. •~~~~~~ooo*oeo~~b I @ 11-J

I

._ uzl

Take medicine. l . . . . . . . . . . . . . . . , . . , , . iIO056 ‘u uzl

j. If you stop, is it relieved or not? i” 1 @ I [I] Relieved - Ask k

I

I

2 U Not relieved - SK/P to I

k. How soon after stopping? k. /

lo058 1 q Less than IO minutes

I

I

2 L__I IO minutes or more

I. Is the pain more likely to occur when you

are hurrying than when you are walking

at a slower, more even pace?

I 4 0059 1 UYes

I

I

2 u No

I

I i

74
c :’ . r ‘

^ ’

,’ I c

. ..r&.- .

. .- ‘. . .

I

4a. Have you ever seen a doctor about chest pains,

chest discomfort, pains in the legs while

h 1 @ I U Yes - Ask b

walking, or heart failure? I

2 q No - SKIP to 5

I -- -..... . .._ ., _-“_. ._.__._

b. What is the name of the doctor? I

I

I

I-- ---- p

--- ---- . ..-

c. What type of doctor is he? C.1 @iJ 1 q General practitioner

I

I

2 q Osteopath

I

I

3 0 Heart specialist

I 4 U Other specialist

I

I 5 q Other - Specify

I

I

I 9 i---J Don’t know

d. Who initially referred you to this doctor? d. ; Yes

No one. . . . . . . . . . . . . . . . . . . . . . . . . . . .

; @ l]

I

No

21

He’s the regular doctor . . . . . . . . . . . . . . . . . I @ l[

I

i

Another doctor . . . . . . . . . . . . . . . . . . . . . . . 1 0064 I q.

I

Family.. . . . . . . . . . . . . . . . . . . . . . . . . . . I@‘U

Clinic.. . . . . . . . . . . . . . . . . . . . . . . . . . . .

II 0066

’ cl

Health nurse . . . . . . . . . . . . . . . . . . . . . . . . I @ q---J 2 cl

I

f. At that time, what did he say the problem was?

Other - Specify

How long after this trouble first started did

you first visit your doctor about it?

i

IlO069 I r-1 Less than I day

I

2 L-j 4 - 2 days

I

I 3 i---J 3 - 6 days

I

I

4 i--J I - 3 weeks

I CII- 5 months

I

I 6L--j6- I I months

I

I

7 IJ I year or more

I

I 9 c_Tl Don’t remember

----- -...-.___ -... -

I

---

I -_ I

I I

g. Did you have a cardiogram at the first visit?

h. Did you have one at a later visit? h.i@ , I [ _ 1 Yes - Ask i

I

I

2 i 1-j No - SKIP to 4j

i. How long was it from the time of the

first visit?

I ---

i. ,’ 0072 1 I--i I -

;3

2 days

I

I 2 I.-r. I - 6 days

II

3 i--j I - 3 weeks

I 4 F--l L -J I - 5 months

I

I 5 1116 - I I months I

I

I 6 C-J I year or more

1

I 9 [:I] Don’t know

75
4j. Did you have a chest X-ray at the first visit? 4j. / (ZJ 1 IYes

I

I 21/o

k. i @ I 1_1] Yes - Ask I

I

I

I 2 u No - SK/P to m

k. Did you have one at a later visit?

I

I. How long was it from the time of the

first visit?

I. i @ I L_1 I - 2 days

I

I 2 1_J 3 - 6 days

I

I

I

I

I

I

I

II

I

3 m I - 3 weeks

4 L-II 1 -

5 months

5i76- I I months

6 [I I year or more

9 L._1 Don’t know

m. Have you had any other tests for this

condition? (such as blood or urine)

n. Did the doctor prescribe medicines to take

for your condition?

m.1 @ l(JYes

I

I 2L.iNo

t

n. 1 @ I L]Yes -Ask o

I

I 2 1_.1 No - SKIP to p

o. How do you take the medicine? 0. / Yes

Swallowed. . . . . . . . . . . . . . . . . . . . . . . . . . ( @ q---J

I

Under the tongue . . . . . . . . . . . . . . . . . . . . . I@ ’ El

I

Injected . . . . . . . . . . . . . . . . . . . . . . . . . . . I@10

Other - Specify ~

i

I,O081 ’ n

N o

~cl

2 El

2 cl

2 El

p. Has he told you to do any of these other things? p. 1 Yes

Make regular visits . . . . . . . . . . . . . . . . . . . . I:0082 I n

I Have regular cardiograms . . , , , , . , . . , , . , . , I

l@ ‘L-zl

Decrease activity . . . . . . . . . . . . . . . . . . . . . 1IO084 I 0

No

2a

2 [II

Rest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . r@) ’ i_.i I

I Do exercises . . . . . . . . . . . . . . . . . . . . . . . . 1, @ 1g

I Stop smoking, . . , . . . . , , , , , . . , . , , . . . . . I 088 0 I I-1

Other - Specify 0089 ’ t?J 2 L_i

q. When was the last time you saw him? I [[I Less than I month ago

2ElI- 3 months ago

3 [-2 4 - 6 months ago

4r-37 - I I months ago

5 [2 I year ago or more

9 I, Don’t remember

r. Where do you usually see him? r. j 0091 I L--J At his office

I

I

2 i At a clinic

I 3 [J At home

I

I 4 L-J Other - Specify
I ,I

, * i

. .r ,.’

8 ;

” - *

IS. How long will it be until your next visit? 4s. / @ I 0 Less than I month

1 21_1l- 3 months

I

3[4- 6 months

I 417- I I months

I

I 5 0 I year or more

I

I 9 0 Don’t know

c

t. Would you say that the treatments you have

had have done you any good?

t. i @ I q No, not at all

I

I 2 a Yes, partly

I

I

I

3 0 Yes, quite a bit

5. Within the past 12 months, would you say that 5. I (094) I r_l Gotten worse

your condition has gotten worse, gotten better, I

or stayed about the same? I

2 0 Gotten better

I

3 0 Stayed about the same

I

5. Have you ever been disabled because of chest

pain, leg pain, or heart failure?

6, i @ I q Yes

I

I 2 q No I

I. Have you ever stayed overnight in a hospital

because of chest pain, leg pain, or heart

7. I (i@ 1 IYes

I

failure? I 2 0 No

i

3. What was your job status one month before you

first developed chest pain, leg pain, or

8. I (097) I q Retired because of age

I

heart fa i I ure? I

2 L_I Reti red because of di sabi Ii ty

I

I

3 0 Unemployed

I

I

4 q Working full-time

I

I

5 0 Working part-time

I 6 0 Housewife with ful I duties

I

I 7 q Housewife with partial or no duties

I

I 8 0 Other - Specify

I

I

I

I

I

I

3a. As a result of your condition, has there been

a change in your job status?

9a. i @ I q Yes - Ask b

I

I 2nNo- SKIP to IO

I

b. What is it now?

10. How many work days would you estimate you

have lost during the past 12 months because

of your heart condition?

b,

I

i @ I 0 Retired because of disabi Ii ty

I

I

2 0 Unemployed

I

I 3 [ Working only part-time

I

I 4 0 Changed to easier job

I

I 5 q Housewife with partial duties

I

I 6 0 Housewife with no duties

I

I 7 q Other - Specify

I

I

I

I1

10. 1 @ I 0 None

I

I 2 m I - 4 days

II 3 q 5 - 9 days

I

I1

40 IO - I4 days

I

I

50 I5 - I9 days

I

I

6 q 20 - 29 days

I

I

7 0 30 days or more
J. Body Measurements

--_ - _- ._- --

4Rji. 1 r?. ‘A (F ormerly I-+SM-425-7A)

‘-74

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

PUBLIC HEALTH SERVICE

HEALTH RESOURCES ADMINISTRATION

NATIONAL CENTER FOR HEALTH STATISTICS

HEALTH EXAMINATION SURVEY

60DY MEASUREMENTS I

and will not be disclosed or released

to others for any other purposes

1 (22 FR 1687).

Q. Deck No. b. Examiner No. C . Recorder No.

111 --

> Measuremknt in cm. unless otherwise specified.

NOTE

Measure left side also if the last digit of examinee’s sample number is 3 or 6.

1. Bitrochanteric breadth

I

1. !@j--.-

2. Elbow breadth

3. Upper arm girth

Chest circumference

4a. Full expiration

i

!O

RIGHT SIDE LEFT SIDE

2. I 001 - - . - 0ooze-.-

I

I

RIGHT SIDE LEFT SIDE

’ 3. 1 0003 - - . - 0ooJ,,.- I

b. Full inspiration b.

I

I@--- i RIGHT SIDE LEFT SIDE

5. Triceps skinfold (mm.) 5. I, 0005 sm. - 0006 w-eI RIGHT SIDE 0008

LEFT SIDE

6. Subscapular skinfold (mm.) --.-

7. Sitting height

I

7. I@ --.-

~~~~~~~

When both sides ore measured

8. Is examinee right or left handed?

1

i 016 I q Right handed

8. ;

0

2 c Left handed

I

I 3 0 Uses both hands about the same

I 4 0 Not sure

I

I

a u Not applicable

9. Weight (Ibs.)

I

I 9. 1 013 ,O - --.-w

10a. Standing height (cm.) 1Oa. ,Oh ---.-

b. Standing heig?t (inches)

I

b.: --/

Sample Number

1

N‘? 98743

- ) ‘_

- ;

: 3

I

.

I
: . ’ t

,

’ I:: _ .

t *

.- ..,

K. General Medical Examination

HRA-12-3

FORMERLY HSM-425-3

(7/74)

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

PUBLIC HEALTH SERVICE

HEALTH RESOURCES ADMINISTRATION

NATIONAL CENTER FOR HEALTH STATISTICS

Form Approved

O.M.6. No. 680Rf 184

ASWRANCE OF CONFIDENTIALITY

All information which would permit

identification of the individual will

be held strictly confidential, will be

GENERAL MEDICAL EXAMINATION - AGES 25-74

used only by persons engaged in

and for the purposes of the stirvey,

HEALTH EXAMINATION SURVEY

and will not be disclosed or released

to others for any other purposes

(22 FR 1687).

aa Name (Last, first, middle) b, Deck No. C* Pulse d, Blood pressure

Systol i c Diastolic

231 @ 002 003 --- 0 --- 0 ---

1. HEAD, EYES, EARS, NOSE, 1‘0004 I m Findings 4. ABDOMINAL EVALUATION:

AND THROAT:

i @ I q Findings

I

If findings, mark applicable t

2 0 No If findings, mark applicable ! 20 No

box and continue with a. i

findings box and continue with a. I

I

findings

If no findings, SKIP to 20. Yes If no findings, SKIP to 5.

I

Yes

a. Conjunctival injection . . . . . l j @q--J a. Hepatomegaly. . . . . . . . . . . . $$I0 ,

b. Fi Ii form papi I lary atrophy 1 @q--J b. Splenomegaly . . . . . . . . . . . . I@,0

of tongue . . . . . . . . . . . . . . I I

I C. Uterine enlargement . . . . . . . I 0051 1 L_1

C. Fungi form papi I I ary hyper- ; @q-J d. Umbilical hernia. . . . . . . . . .

I

trophy of tongue . . . . . . . . . . I

I

0052 1 r-J

d. Fissures of tongue . . . . . . .

I e. Mass(es) . . . . . . . . . . . . . . . 054

I 0022 1 q

; 0 I LJ

e. Serrations or swelling of tongue 1 0023 1 r-J

(1) Area(s) - Enter number(s) ;@j--v--

f. Scarlet beefy tongue . . . . . . . I @ 1 L_I (2) Other findings - DescribeJ I, @IO

go Other - Specify I

I

I t

1 @L-j I

I f. Surgical scars . . . . . . . . . . . I 057 i 0

20. THYROID EVALUATION:

(WHO Classification)

i @ 1 q Group 0

0

(1) Area(s) - Enter number(s) I

I

2 u Group I

, @j-----

3 q Group 2 (2) Other findings -

I 4 I_J Group 3

DescribeJ j @ I q

I

b. OTHER THYROID

FINDINGS:

(1) Tenderness. . . . . . . . . . .

(2) Ncdule.. . . . . . . . . . . . .

(4) Other - Describe

3. CARDIOVASCULAR

EVALUATIONS:

If findings, mark ap@icable

box and continue with Q.

If no findings, SKIP to 4.

a. Cyanosis . . . . . . . . . . . . . .

b. Irregular pulse. . . . . . . . . . .

j @Ia

‘SAMPLE

I,O045 1 q N ? 98143 I

79
5. MUSCUCOSKELETAL

EVALUATION:

, 06201 q Findings

/f findings, murk applicable I 2( No

box and describe.

I

findings

If no findings, SKIP to 6. I

I

Yes

Findings - DescribeJ I@ q---J

I

f

i

I

I

I

6. NEUROLOGICAL I

EVALUATION: I

0067 1 q Findings

If findings, mark applicable 1

2/ No

box ond continue with u.

;

findings

If no findings, SK/P to 7.

I Yes

a. Absent knee jerks . . . . . . . 1 0068 1 q

b. Absent ankle jerks . . . . . . . i @ I q

c. Other findings - Describe

J

; @ q--J

I

I

I

I

I

I

I

Comments

7. SKIN EVALUATION:

t

0074 I i--J Findings

If findings, murk applicable 2 f-J No

box and continue with a. ! findings

If no findings, SKIP to 8. i

. Yes

a. Petechiae - Describe

J

/@q--J

I

b. Ecchymoses - DescribeJ i

I@ cl

I

I

C. Other findings - Describe I

3

I@‘0

I

8a.Obesity . . . . . . . . . . . l . . I 0093 10

I b. No obesity . . . . . . . . . . . . , 2111

_-~~ --

9. Name of physician

SAMPLE NUMBER

N ? 98743
L

I

’ +

i >. .\

.’ I

-,

-IRA-12-4 (Page 1) (Formerly HSM-425-4 (Page 1))

7-74

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

PUBLIC HEALTH SERVICE

HEALTH RESOURCES ADMINISTRATION

NATIONAL CENTER FOR HEALTH STATISTICS

HEALTH EXAMINATION SURVEY

GENERAL MEDICAL EXAMINATION

) A. EXTERNAL EAR i

(Except canal)

I

I

I Right Left

1. No findings -

I

SKIPtoB. . . . . .1. I@ 1 q @ 10

2. Findings -

I

Continue with 3 . . 2. I 21 20 r-------w-----w__

3. Operative scar . . . 3. t @ i 0 @ ! q

c 4. Other - Describe . 4. i W,-;-/j---&-,-O

I 0 0

L a------------__-

I 5. Pierced ears . . . . 5. I,O007 I 0 Yes 2 IN

F 8. AUDITORY CANAL I

I Right Left

1. No findings -

I

SKlPtoC . . . . ..I* 1 @ ln @ I~

I

2. Findings -

I

Continue with 3 . . 2. f 20 cl

+-------------------

3. Occluded: I

a. Partially . . . . . 30. j 010

I C l 0 0011 1 fl

b. Comp!etely . . . . b. I 20 21i

r

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

4. Occluded by: I

a. Cerumen . . . . .4a. I

I

(012) in (013)lLl

b. Other - Describe b.1 20 2cl

P C. DRUM IRight Left

I

1. No findings -

SKIPtoD . . . . . . 1.

1014 cl @cl

; 0

2. Findings -

I

I

Continue with 4. . . 2. ! 2n 211

3. Not visible . . . . . 3. 1 3n 30

L-----------------

4. Dull (Opaque). f l . 4. I @ 1 u @ 1 0

5. Transparent . . . . . 5. 1 20 cl

I--------------___

6. Bulging ....... 6. ; 0

018 , rJ 0019 1 cl

7. Retracted ...... 7. 211 20

8. Calcium plaques . . 8. I :@10 @lo

9. Other findings - I -- ------ __________

Describe . . . . . . . 9. ) @ I 0 @ 1 n

,

I

Form Approved

O.M.B. No. 680RI 184

ASSURANCE OF CONFIDENTIALITY

All information which would permit

identification of the individual will

be held strictly confidential, will be

used only by persons engaged in

and for the purposes of the survey,

and wi II not be disclosed or released

to others for any other purposes

(22 FR 1687).

1 Deck No. 232

FC. DRUM - Continued I

I Right Left

10. Red . . . . . . . . .lO. f @ 1 0

I

i-

@ 1 0

11. Other discolorations 11.

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

2 0 20

12. Fluid . . . . . . . .12. j @ 1 q @ I q

13. Scars . . . . . . . .13. I@10 @IO

14. Perforated ~-~--------~~~~--

a. With discharge 140.10 030 1 00 031 1 q

b. Without discharge . b.; cl 21

,D. NARES I

I Right Left

1. No findings -

I

SKIPtoE . . . . . . 1. i@(o (&J

2. Findings -

I

I

Continue with 3 . . 2. i 21 cl r

----em.-----------

3. Obstruction I

a. Acute . . . . . . . 30. I@)cl @cl

I

b. Chronic . . . . . . b. 1

L

21 21

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

4. Other significant I

I

findings -

I

a. Deviated septum . 40. $&--J l-------w------e__ @IO

I

b. Swol len turbinates b. 1 @ 1 r~ @q-J

I

----------.-----a__

c. Chronic inflammationc.0i 040 1 g 0041 í q a-------_

d. Other -Describe . d. ‘-@-I-E @I n

) E. NECK i

I

1. No findings -

I

I

SK/Pro F . . . . . . 1. @Q-J

2. Findings -

I

I

Continue with 3 . . 2. ! 21

3. Adenopathy . . . . . 3. ;@10

4. Tracheal deviation. 4. i @ 1 z

I

5. Other - Describe. . 5. 1&+3 I

I

Sample Number

N? 98743
I

IF. CHEST Dimin.

brth. ) Absent Branch ial Rales Rhorxh i Wheeze

1. Auscultation I b,s. sounds ,

. .

L 0

Right chest I m t 0 No findings -

SKlPtoG /I==;‘;b; @; i 1: i;: g;z z-z

2 0 Findings I

i

Lower lobe 0059 10 I~0 @cl @cl @cl@pc I I

Left chest 0

1

Upper lobe _

064 11 ; 20 @cl @cl @a@1e I

Lower lobe *o069 cl ;2cl ! @ijcl @cl @~lo@C

2. Other chest findings

0074 1 0 None 2 q Findings

4. HEART I

1.P.M.I. . . . . . . . . . . . . . . . . . . . . 1. 1 @ tnFelt 2 0 Not felt

I

I

2. Interspace . . . . . . . . . . . . . . . . . . 2. 1, @cl VII cl 7u

I

3. Midclavicular line . . . . . . . . . . . . . 3. 1 @ I 0 At 2 0 Inside 3 q Outside

I

4. Thrills . . . . . . . . . . . . . . . . . . . . 4. f @ I m Absent I2 0 Present

I

a.Systolic. . . . . . . . . . . . . . . . . . a. I 0079 1 m Base 2 q Apex

I

I

b. Diastolic . . . . . . . . . . . . . . . . . b.

I@

1 I 0 Base 2 0 Apex

I

5. Heart sounds I

I a. I st heart sound . . . . . . . . . . . . So. i 0~1 I 0 Normal 2 0 Accentuated 3 m Diminished

I

b. 2nd heart sound . . . . . . . . . . . . b. i @ I i-J Normal I

2 0 Accentuated 3 m Diminished

I

6. Murmurs . . . . . . . . . . . . . . . . . . . 6. 1I 0~3 I q None -Skip to 7

I- -------_-_---_____-_---~------------------- I

‘0

SYSTOLlCMURMUR(S) DIASTOLIC MURMUR(S)

a.Type.... . . . . . . . . . . . . . . . . CJ. 1 064 I 0 Functional (~5 I 17 Functional

I

I 2 0 Organic 0 2 ( Organic

I

I 9 0 Don’t know 9 f Don’t know

b. Location

r

------------------------------------------_

I GRADE GRADE

(1)Apex .- . . . . . . . . . . . . . . . b(l)/ @ lfl2i3i415[16j @ 1~12’3L-j4j15~16~

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

I

I

(2) Midprecordium . . . . . . . . . . . (2); @ 1~2~3(4~Sfl6~ @lfl2~3~4cI]S~6~

~-------------------------------------------

I

(3) Left base. . . . . . . . . . . . . . .

(3); @ 1~2~3~4jIS~6~ @32~3~4=)5~6~

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

I

I

(4) Right base . . . . . . . . . . . . . (4); @ li2~3~4~S(6j @1~2~334~S5]6~

I

Sample Number

Continue with 6c, “Origin” on Page 3

N !? 98743

82

’ ‘

. .l

? .
1

‘G. HEART - Continued I

I . -

6. Murmurs - Continued I

I

c. Origin I

Systolic Diastolic Both

(1) Mitral . . . . . . . . . . . . . . . . 6c.(l) j @ 1 0 2cl uzl

(2) Aortic. . . . . . . . *. . . . . . l

I

(2) 1 000s l[ 21 UII

(3) Tricuspid. . . . . . . . . . . . . . (3) I

I 0096 I 11 211 uzl

(4) Pulmonic (4) I

: : : : : : : : : : : : :

I 0097 1 0 21 3lIl

(5) AS0

(6) VSD : : : . . . . . . . . . . . . .

(5) 1

1

098 1 0

,8

21 cl

(61 I

099 10 2cl 31

(7) Other . . . . . . . . . . . . . . . . (7) i 1~ I 0 cl 30

(8) Don’t know . . . . . . . . . . . . (8) I

I

101 9 El

7. Other cardiac or I

cardiovascular findings I

I

I 0102 1 0 No - Skip to /j 2DYes - Continue with 70

a. Edema . . . . . . . . . . . . . . . . . 70. I

i

0103 1 0

b. Other - Describe . . . . . . . . . . b. I @ 1 0

I

I

I

I

I

I

C. Neck vein distension . . . . . . . . C. 1 010s 1 0

I

I

b H. PULSE - ARTERIAL EVALUATION I

1. Palpation

I Sclerotic and

I Normal Sclerotic

I

Tortuous Tortuous

a. Right radial . . . . . . . . . . . . . . la. i 0106 10 cl cl 41

b. Right femoral . . . . . . . . . . . . . b. i @ I 0 21 31 41-1

C. Right dorsalis pedis D . . . . . . . c.

I

I

I 0108 10 cl uzl 4El

d. Left radial . . . . . . . . . . . . . . . d. ) @ 1 0 20 cl uzl

e. Left femoral . . . . . . . . . . . . . e. i

I @ 1 0 20 cl 40

f. Left dorsalis pedis . . . . . . . . . f. 1 @ 1 m 21 cl 4c.l

I

2. Pulsations

I

I Normal Diminished

I Bounding Absent

o. Right radial . . . . . . . . . . . . . .2a. i

i

0112 1 r-J 21 cl cl

b. Right femoral . . . . . . . . . . . . . b.

I

@ 1 0 cl 30 4cl

C. Right dorsalis pedis . . . . . . . . c. I 0114 1 cl 2cl cl 4cl

d. Other - Describe . . . . . . . . . . d. 1

I 0115 l cl 21 cl 40

I

I

I

I

I

I

c. Left radial . . . . . . . . . . . . . . . C. 1 116 10

f. Left femoral . . . . . . . . . . . . . f. I 8

cl cl 41

117 1 0 20 cl 41

9. Left dorsalis pedis . . . . . . . . . 9, I m cl cl cl 4cl

II. Other - Describe . . . . . . . ., . . . h. i

I

I

20

Sample Number

hl-? 98743

83
) I. KNEES I 1~ 1 0 Findings - Continue with I

I

0 2 ! No findings - Skip to J

1. Bony irregularity I R L Both

a. Genu varum I................ lo. I 0121 10 2cl cl

b. Genu valgum ............... b. i @ I q 211 uzl

c. Genu recurvatum c. I.............

i 0123 10 2cl 3cl

d. Fixed flexion ............... d. I 0124 t 0 2cl 3cl

e. Other - Describe. ............ e. 1 0125 1 0 20

I

30

II

I

2. Pain on motion

I

I

Act. Pas. Both Tenderness

a. Right medial ............... 20. i 0126 1 0 21 cl 0127 10

b, Right lateral .............. b./ (GiJ 10 20 AII 0129 10

C. Right diffuse .............. c.; @ 10 cl dzl 0131 1 j-J

d. Left medial ............... d*I @ 1 q cl 3cl 133 10

e. Left lateral ............... e.; @ 10

0

21 cl 0135 cl

f. Left diffuse ............... f* 1 @ 1 cl 21 30 0137 cl

9. Right suprapatel lar I

.......... g.l ................................ 138 Kl

h. Left suprapatellar ........... h. 1

0 ................................

0

139 Kl

i. Right infrapatellar ........... i. / ................................ 0140 cl

i. Left infrapatellar. ........... 1. i ................................

I 0141 l cl

3. Other findings

I

I R L Both

I

a. Swelling ................. 30.; 142 0 1 0 2cl 3 cl*

b. Fluid ................... b.; @ 10 21 cl

c. Soft tissue proliferation ....... c*j @ lcl 2cl 31

d. Subpatellar crepitus. ......... d.1 (145) 1 Cl cl cl

e. Muscular wasting thigh ........ e. .I @ 1 Cl 21 31

f. Other - Describe ........... f*‘@ lcl 20 cl I

I

I

I

) 1. HIPS 1 @ 1 0 Findings - Continue with I

I

I 2 0 No findings - Skip to K

1. Pain on motion

0. Exterjsion ................

b. Flexion. .................

c. Abduction ................

d. Adduction .................

e. Ext. rot. .................

f. Int. rot ..................

I

I R

I

lo. ; 0149 cl

b.l (r;;> lcl

c-1 @ cl

d./ (155) 10

4 @ 10

f. / 0159 'cl

ACTIVE

L Both

2cl 3cl

21 uzl

AIl 3cl

21 3cl

2cl 31

dzl 3cl

PASSIVE

R L Both

11 2[1 cl

lcl 21 cl

cl 21 cl

lcl 21 dIl

10 2cl cl

11 2cl 31

Sample Number

J N ? 98743

, 1:
'...V. ,f:.:.:>>:.~.:.:.>

:~.~y.~.~.y.;~.~.:

:.>:.:y..y*.:.::: m32

.. . . . . . ..A * ...I... . . . . . . . . . .. :.:

.:.:....>:.:*:.: >>>.:*:>>:.y.>:. .. . * . ,::::::~..::::::~.~.~. . . . . . . . . .*.. '...'i.... . . . . . :.>.a. . . . ::::z)>.*.:.:.:; .. . . . . . . 9.. . . .. .> .>$$.:::$$.>,. .. . . .. . . . .*.x.: * *........ ::>*.:.:.:.:*~*.~.:+ *.a. . . ..* . . . .. . :.:.:.y..:.:.,

.>:'.....

~.$g$$$

::';:.:*>>*'::::::.:

y~~.:yJ$~*:y

-...:. . . . . . .,.::..~:.:'::.(.:.'.: :.:.:.:.:.:.>~.:.~.: .. . . . . . . *. . .*.... . . . :::p,.:.:::+:. . . . .i. . . . .*.*.... .. . . . . -2. .*.*..

.:'..:..:.:.:.:.y :.>~::$+:.:.y :>.::.:r.::::::.:.:. .. . . . . ..*. .. . .. . . . . . . 5:

clm-

>.::::::y:.:::::y* 32

-N

ilo

&-I m

dd r; C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . h l í - -

85
BACK

1. scoliosis .......... 1.

2. Kyphosis ........... 2.

3. Lordosis ............ 3.

4. Tenderness

a. Sciatic notch ....... 40.

b. Sacroiliac ......... b.

c. Other - Describe

5. Limitation of motion

a. Cervical spine . . . . . . Sa.

b. Thoracic spine . . . . . . b.

c. Lumbar spine flexion . . c.

d. Lumbar spine, right

lateral flexion. . . . . d.

e. Lumbar spine, left

lateral flexion . . . . e.

f. Full extension . . . . . . f.

6. Pain on motion . . . . . . . . 6.

7. Flexion . . . . . . . . . . . . 7.

8. Extension . . . . . . . . . . . 8.

9. Right lateral bending . . . 9.

0. Left lateral bending . . . . 10.

1. Right rotation. . . . . . . . . 11.

2. Left rotation . . . . . . . . . 12.

0234 1 0

cl

0235 1 q

0236 ‘Cl

0237 ’ 0

0238 ‘0

0239 1 q

0 240 1 q

0241 1 m

0242 1 0

0243 1 0

0244 I q

@lo

0246 I 0

0247 I 111

Cervical

No findings - Skip to M

Findings - Continue with 1

R GIL cl

R dY= dIl

Negative

Thoracic

LIP

Low back

0 2sO 10

025s 1 0

0260 ’ 0

0265 ’ 0

0270 í q

0 275 ’ 0

Both

Both

ositive

Diffuse Uncertain

252 1 q 8257 I n

i

M. STRAIGHT-LEG-RAISING TEST ;

I

1. Right leg. . . . . . . . . . . . 1. 1 0

278 I 11 Neg. 2 q Pos.

2. Left leg . . . . . . . . . . . . 2. 1 @ 1 L._I Neg. 2 0 Pos.

3. Increase -

I

I a. On ankle (right leg) . . . 3a. I 0

279 I q Yes 20 No

I b. Dorsiflexion (Left leg) I 0281 1 q Yes 2 0 No

. I

N. OTHER SYSTEMS 1 q No findings - Skip to 0

(Reticula endcthelial, G.I., etc.)

0282

2 0 Findings - Describe’-/

L7

86

\/ . L

.

, ,

. <

I I

.

’ ,

. .

~ *m
) 0. BLOOD PRESSURE I

I TIME SYSTOLIC DIASTOLIC

I

1. Recumbent. . . . . . . . . . . . . . 1. I I@ I 0 A.M. 0 204 -we

o-m:--

0 285 -v2. Sitting . . . . . . . . . . . . . . . . 2.1 2 0 P.M. --s - -- I 0 207 0 288

I

) P. SUMMARY OF DIAGNOSTIC

IMPRESSIONS

; @$ I q Normal; no abnormal findings

I 2 0Abnormal;significant findingsnotedbelow I

II Severity Certainty ICD code 1. Cardiovascular I

I Min. Mod. Sev. (o-9)

a. la. I I @lo 20 cl 0 291 - 0292 ---

I

b. 30 0 294 - 0 295 - v -

-

b.1 1 @lo 20

I

I

c. c. 1 @cl I 20 cl 0297 - 0298 - - -

I

I

I 2. Musculoskeletal I

a. 20.1 @I 1 Cl 20 30 0 300 *- 0 301 ---

l

b. b.1i @ ‘0 20 cl 0 303 - 0304 - - -

I

I

C. f @lo

c. I 20 30 0306 - 0307 - - -

I

-. I 3. Respiratory I

a. I

I

b. b. / 0 311 '0 cl 30 0312 s 0313 ---

I

c. Ee; @$n 20 cl 0315 - 0316 - - -

I

I

I

4. Other systems - Specify I

I

0, 4a,; @i&u 2 Cl cl 0318 - 0319 - - -

I

I

b, b 0321 - 0322 - - -

I

I

c. -- Cl 3 Cl 0324 - 0 325 - - -

I

I

I

5. I

I ’ III 3r-J 327 - 328 - - -

a. 50. I 026) 2u 0 0

I

b,

C.

Name of physician

0330 - 0331 ---

II c * ) @m - 20 3u 0333 - 0334 - - -

I

I Sample Number

N !i’ 98743

87
L. Audiometry (Air)

HRA-12-10

FORMERLY HSM-425-10

(7-74)

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

PUBLIC HEALTH SERVICE

Form Approved

O.M.B. No. 68-RI 184

ASSURANCE OF CONFIDENTIALITY

HEALTH RESOURCES ADMlNlSTRATlON

Al I information which would permit

NATIONAL CENTER FOR HEALTH STATISTICS identification of the individual will

be held strictly confidential, will be

AUDIOMETRY (AIR)

used only by persons engaged in and

for the purposes of the survey, and

will not be disclosed or released

HEALTH EXAMINATION SURVEY others for any other purposes

;;2 FR 1687).

a. Deck No. b. Audio No. C. Examiner No.

241 0001 --m-- 0002 - -

b START HERE IF SAMPLE NUMBER EVEN START WERE IF SAMPLE NUMBER ODD

1. AIR CONDUCTION - RIGHT EAR 2. AIR CONDUCTION - LEFT EAR

Retest R with Frequency

masking on L* 0-w Hearing level

Retest L with Frequency

masking on R* U-W Hearing level

(a) (b) w (a) (b) 6)

0003

0009

3015

3

021

3027

3. CONDITION AFFECTING TEST RESULTS *Retest poorer ear with A/C masking on better ear only if

. differences in A/C+L between the two ears is 40 df3 or more

Mark (X) only one

3

** Specify frequ encies affected and describe

OS9 I q None 3

2 q Cold or sinusitis now

3 0 Ear discharge

. .

4 n Ringing or other noises in ears

5 q Equipment defect**

6 q Cold or sinusitis within one week

7 j--J Earache within week

8 [ Other - Describe; +*

7

Iomments

t

SAMPLE NUMBER

w.? 98743

88

_<-c -

,. - ‘i ‘I

I -

‘,.

. ‘.*

.

. I J

I .

. l I

I
M. Respiratory Function Tests

-IRA-12-9 (Formerly HSM-425-g) Form Approved

‘-74 O.M.B. No. 680RI 184

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE I -ASSURANCE OF CONFIDENTIALITY

PUBLIC HEALTH SERVICE All information which would permit

HEALTH RESOURCES ADMINISTRATION

NATIONAL CENTER FOR HEALTH STATISTICS

identification of the individual will

be held strictly confidential, will be

HEALTH EXAMINATION SURVEY used only by persons engaged in

RESPIRATORY FUNCTION TESTS

and for the purposes of the survey,

and will not be disclosed or released

for any

;,o, F”kh”lk’87).

other purposes

leek No. Room temperature

251 0001 -- oc

. A. SPIROMETER I

I

1. Was test satisfactory? . . . . . . . . . . . . . . . 1. i @ 1 q Yes 2 [ No - Explain

I 7

I

I

I

II

I

I

) B. SINGLE BREATH DIFFUSING CAPACITY I

I

I

1. inspired Co.. . . . . . . . . . . . . . . . . . . . . 1. 1 -

1 0 0% --

I

2. Small spirometer temperature . . . . . . . . . . 2. 1 @ - -OC

30. Uncorrected barometric pressure . . . . . . . 30. / @ ---.-mm.Hg.

b. Barometer temperature . . . . . . . . . . . . . b. i 021 - -OC

I 0

I TRIAL #l TRIAL #2

I

TRIAL #3

4. inspired helium. . . . . . . . . . . . . . . . . . . 4. ; @--.-- @--.-- @--.--

5. Expired helium percent. . . . . . . . . . . . . . 5. I @ii&,-- @ii&.-- @ -.--

I

6. Expired Co meter reading . . . . . . . . . . . . 6. ; a--.- (012)~-.- @iJ--.-

7. Breath holding time *cm . . . . . . . . . . . . . 7. ) @ii+-- @ --.- @ --.-

8. Volume inspired V.C. (ATPS) ml . . . . . . . 8. i @-- -- 0014 - - - - 019 0 - - --

9. Was test satisfactory? . . . . . . . . . . . . . . 9. ;@ i 0 Yes 2 C] No - Explain ‘-/

I

I

l From tracing - 1/2 inspiration point

measured to onset of expiration I

I

NOT ES

Sample Number

N ? 98743

89
N. Physician’s Supplement

RA-12.24

/74)

DEPARTMENT OF HEALiH, EDUCATION, AND WELFARE

PUBLlC HEALTH SERVICE

HEALTH RESOURCES ADMINISTRATION

NATIONAL CENTER FOR HEALTH STATISTICS’

PHYSICIAN’S SUPPLEMENT

HEALTH EXAMINATION SURVEY

Form Approved

0,M.B. No. 68-W 184

ASSURANCE OF CONFIDENTIALITY

All information which would permit

identification of the individual will

be held strictly confidential, will be

used only by persons engaged in

and for the purposes of the survey,

and will not be disclosed or released

to pthers for any other purposes

(22 FR 1687).

Deck No. 082

1. Ocular fundi

I

I Right Left Both

a. Normai la. ;(GJ ‘0 2cl

3 u+ If box 3 marked,

I

SKIP to za

b. Fundus not visualized b. I@ ‘0 21 SKI

If box(es) I, 2, or 3

I marked, SKIP to Im

c. Globe absent C. ‘@ l(

I

20

3 o+ If box 3 marked,

SKIP to 2u

d. Increased light reflex d.i@rg 2f-J 30

e. N&row orterioles e. /@ ‘0 cl 30

f, Tortuous arterioles f, I@

I

10 cl 30

g. AV compression 9@ 1 107 10

h. Hemorrhage h,

I

0 cl 3c.l

@ ‘0 21 31

i. Exudate i. / 109 0 q--J 2cl 3cl

i. Venous engorgement ie Ill0 10 Zcl. 30

k. Popilledema k.

I 0

I111 0 10 20 30

I. Disc obnormol I.

II112 '[ 21 31

I 0

m. Lens opacities m. Ill3 0 10 21 31

I

n. Iritis n. 1114 0 '0 2. 31

0. Othei - SpecifY7

I

0. Ill5 '0 a 31

I

0

I1

20. Did a doctor ever tell you that you had 2% I

protein, olbumin, blood or sugar in @ I 0 Yes - Ask b

your urine? I

1

2 q No - SKIP to 3

b. Which? b. ;

I

Yes No

Protein . . . . . ., . . . . . . . . . . . . . . . . I 117 1 r-J

Alb

I 0 4zl

umir.. . . . . . . . . . . . . . . . . . . . . . 1118 0 10 cl

Blood . . . . . . . . . . . . . . . . . . . . . . .

1

I 0119 10 20

Sugar . . . . , . . . . . . . . ..,....,.. I@ ‘cl 20

,

I

3. During the past 6 months have you had 3.

parasites or worms in your stools?

) 121

I 0 i 0 Yes SAMPLE NUMBER

I

21 No

I 9 q Don’t know hl-v 98743

I

9 0

‘1 ;

, I

l? -r

,

, A *, . -

\,. I . .

\ ..’
, , 8 ,

, i _

.4a. Do you have trouble with your bowels 40. 1@ i q Yes - constipated

which makes you constipated or gives 1

you diarrhea? 1

2 0 Yes - diarrhea

t

4

3nNo

b. How often do you usually have a b.

bowel movement?

1 @

I

I 0 Once a week or less often

I

2 0 2-3 times a week

I

3 0 4-6 times a week

t

1

4 0 Once a day

I s 0 2-3 times a day

I 6 q

I------

4 or more times a day

c. Have your movements ever been white, c.

gray, dark black, or streaked with blood?

@ I q Yes - Ask d

I 2 q No - SKIP to 5a

4

d. Which? d. ;

I

Yes No

White . . . . . . . . . . . . . . . . . . . . . . .

I 012s 10 21

Gray . . . . . . . . . . . . ..*........ ;(iiJ 10 21

I Dark block . . . . . . . . . . . . . . . . . . . I@ 10 21

Streaked with blood . . . . . . . . . . . . . i@ l/-J 21

I

5a. Has a doctor ever told you that you had

loss of blood from the stomach or bowels?

b. Do you still have it?

50. I@

I

I q Yes - Ask b

I 2 q NO - SKIP to 6a

I

b. ‘@

I

i 0 Yes

I

2nNo

I s 0 Don’t know

I

I

c. How many years ago did you first have it? c. I, 131 - -Years ago .O

60, Have you ever had an abdominal operotion? 6CJ. /@ 1 m Yes - Ask b

1

2 q No - SKIP to 7

b. Was it for . . . b, 1

Tumor of the stomach, bowel, or colon? j@ T’;i :“o

Tumor or cyst of the womb or ovaries? j@ 10 20

7. Do you have episodes (or “spells”) of pain

1 7. 1

or discomfort in your crbdomen or stomach of

at least 3 days per month? (Don’t count

ones that go with a cold, sore throat, flu,

or (for women) menstrual periods.)

8. Do you have episodes (or “spells”) of

vomiting of at least 3 days per month?

(Don’t count ones that go with colds,

sore throats, flu, or (for women)

menstrual periods.)

8. ; SAMPLE NUMBER

I

I@ 1 q Yes

f

I

2nNo N? 98743 ,

91
90. During the past year, have ou had at least

one drink of beer, wine, or riquor?

b, How often do you drink?

90. I@

f

I 0 Yes - Ask b

I 2 q No - SKIP to Check Item I

ba j@ I 0 Every day

i

1

2 q Just about every day

I

30 About 2 or 3 times a week

!

4 u About l-4 times a month

I

s q More than 3 but less than I2

times a year

6 q No more than 2 or 3 times a year -

SKIP to Check Item

c, Which do you most frequently drink --

beer, wine, or liquor?

C . I

I 0139 I 0 Beer

r

2 q Wine

I 3 q Liquor

d. When you drink (beer/wine/liquor), how much

do you usually drink over 24 hours? (Enter

an amount only for the one marked in 94

d I- .

, 0140 - -Classes of beer

I

I

- - Glasses of wine

l

i m-Drinks of liquor

CHECK ITEM

I@ I q Female -Ask IOa

1

I

I 20 Male - UVD OF QUESTIONNAIRE

100. How old were you when your periods or

menstrual cycles started?

10a. i

I 142 Years - Ask b

I 0

I

02 0 Haven’t started yet -

I END Of QUESTIONNAIRE

b. Have they entirely stopped? b. ;@

I

I q Yes - Ask c

I 2 q No - SKIP to I la

c. At what age? C . j@ - -Years I

Ilo. Have you taken birth control pills during

the past 6 months?

b. Are you taking them now?

1 la. I@)

I

I 0 Yes - Ask b

I

20 No - SKIP to IZa

1 b, I

I 146 0 10 Yes

I 20 No

120. Are you or have you ever been pregnant?

b. What is the totol number of pregnancies

you have had?

c. What is the total number of miscarriages

you have had?

d. What is the total number of live births

you have had?

120. I L_1 Yes - Ask b

I

20 No - END Of QUESTIONNAIRE

b. 1

1 148 - -Number

c. I

0

I@ - -Number

d. 1

1 @ - -Number

e. Are you pregnant now?

f. Which month of pregnancy are you in?

I e. I 151 In Yes -Ask f

I

0

I 2[1-. No

I 9 I-1- -

 Don’t know

I

I

I SAMPLE NiiJMBE R

I

f. i (F;i> - -Month N !’ 98743

92
0. Report of Physical F indings

Confidentiality has been assured examinees as set forth in 22 F.R

DEPARTMENT OF HEALT-H, EDUCATION, AND WELFARE

PUBLIC HEALTH SERVICE

NATIONAL CENTER FOR HEALTH STATISTICS

ROCKVILLE, MD. 20852

HEALTH EXAMINATION SURVEY

. 1687

REPORT OF PHYSICAL FINDINGS

Dear Doctor:

Recently the person named below was a sample person who voluntarily participated as an examinee in the Health

Examination Survey conducted at special facilities of the U.S. Public Health Service. The objectives of the Survey

are to obtain information on the health status of the U.S. population. The examination is not, and was not intended

to be, a substitute for a visit to the examinee’s physician, par was it intended to be a complete examination. At the

request of the examinee, however, we do send a report of certain selected procedures to his/her physician.

Reported below are physical findings which our physicians thought were significant and should be brought to your

attention (i.e., for which no treatment had been sought and/or no history given). Also reported are some test reports

and/or laboratory data. Although we are not engaged in follow-up or treatment of our findings, we appreciate the

cooperation of our examinees and hope that we can contribute to their medical care by making this information

available to you.

In addition to items listed below a separate letter will be sent reporting any significant conditions found on knee

and hip X-rays if any are present.

Sincerely,

Arnold Engel, M.D.

Medical Advisor

Date of Age Height Chest X-ray EKG

Examinee’s examination

name and

1

. , 0 Encl.

Weight 17 Not done

0 Encl.

address - Sex q Not done

1

MEDICAL VISUAL ACUITY BLOOD PRESSURE

[ No new signitlcant flndlngs R Eye L Eye Systolic Diastolic

20 /- 20 /-

q Without glasses AUDIOGRAM - Decibels

0 With glasses CPS 500 1000 2000 4000

q With contacts Right

L_I Not tested Left

Hematocrit URINEvol% NV TR 1 2 3 4

Albumin

Hemoglobin gm% Sugar

RBC count mill/cc Ph 05 06 07 n-18 09 SAMPLE NUMBER

WBC count thou/cc Blood q Pos cl Neg N? 98743

c l SEE REVERSE SIDE FOR NOTES ON TESTS AND PROCEDURES

93
94

NOTES ON TESTS AND PROCEDURES

Medical Examination - The physician’s examination included the head and neck, chest (cardiopulmonary), abdomen, and

extremities (musculoskeletal and neurological) - however, rectal, pelvic, and breast examinations

were excluded.

X-Rays and EKG - A 12 lead EKG and A-P plus Lateral Chest X-rays were taken unless contraindicated. Knee and

hip plus low back A-P X-rays were taken except on females age 49 or less. Copies enclosed are

without interpretation - I-IES interpretations will be made later and used only as survey data.

Hematology - Screening limits *

Micro- Cyanmet- Coulter Coulter

Determination hematocrit hemoglobin counter counter

Vol. % Hgb Gm% RBC/cc WBC/cc I 1

Adult Males 41 - 52 14.0 - 16.5 4.6 - 6.2 mill. 4.3 - 10 thou.

, Adult Females 36 - 48 12.0 - 14.5 4.2 - 5.4 mill. 4.3 - 10 thou.

1 Pregnant Females I 33 - 42 I 10.5 - 14.0 I 3.7 - 4.9 mill. I 5.0 - 1 2 thou. I

Urinalysis - Dip and read method using Ames Multistix.

Audiometry - Air conduction readings are reported in decibels with respect to audiometric zero (IS0 - 1964), which is

considered normal.

ROUGH GUIDELINES FOR dB REPORT AT 500 - 2000 cps.

25 d6 01 less - Hearing normal or more acute

30 - 40 dB - Near normal (difficulty with faint speech)

45 - 55 de - Mild (difficulty with normal speech)

60 - 70 dB - Moderate (difficulty with loud speech)

75 - 100 dB - Severe (hears only amplified speech)

105 or more - Profound (usually cannot understand amplified speech)

Clinical Chemistry - Laboratory tests on blood are performed by a central laboratory. Results shown below, if any, are

those received from the laboratory prior to the time this report was mailed. Additional results, if

any, will be forwarded to you promptly when received.

I BLOOD I

Test I

Folate (s)

Vitamin C (P)

Cholesterol

.

BUN

Creatinine

Sodium

Potassium

T 3

Euthy.

HYPO.

Hyper.

1

Result Screening limits * Test Result Screening limits *

, mug% 5 - 30 mug% T4 3.0 - 7.5 mcg%

Murph -Pattee Test

mg% 0.2 - 4.0 mg% (if in&at ed) 5.0 - 14.5 mcg%

mg% 260 or less Total bilirubin (S) mg% 0.2 - 1.0 mg%

mg% 30 mg% or less SGOT (S) units 10 - 40 units

w% 1.50 mg% or less Alk. phos. (S) I.U. 30-o 80 I.U. (SMA)

mEg/l 135 - 155 Uric acid (S) . mg% 2.5 - 7.0 mg%

mEg/l 3.5 - 5.0 Calcium (S) mg% 9.0 - 11.0 mg%

0.88 - 1.10 Phosphrous (SorP) mg% 2.5 - 4.8 mg%

Over - 1.10

Less - 0.88 (P) = Plasma (S) = Serum

I

I * Results outside the screening limits are considered to warrant further investigation of the examinee. I
-
9 6

1 1. With or without correction:

0

105 i LJ Wears glasses for test

2 m Wears contact lenses for test

3 ( Forgot (glasses, contact lenses)

4 !_. Does not wear either glasses or contact lenses

B. NEAR VISION

’ 2. Test us

Selection

(4

500

350

250

200

150

125

100

7 5

50

b

--

 3. Test us

Selection

(a)

I30

120

8 5

6 5

50

40

30

20

ng Sloan reading cards (both eyes) - Put horizontal I ine through words read correctly.

Smaliest selection

Attempted Distance (cm) read sati sfactori I y Number wrong

Mark (X) one

--- w w ----Cd) w

0 106 f E-1 0 107 -- - - 0 108 1 [ 0 109 ---

@ CJ 0 111 --- 0 112 1 c-l 0 113 - --

0 114 ' CT-I 0 115 - - - 0 116 1( 0 117 ---

0 118 1 [ .--j 0 119 --- 0 120 q---J 0 121 ---

0 122 1 1.1 0 123 - __ - 0 124 ’ r-1 0 125 ---

0 126 ‘:‘.I 0 127 ---- 0 128 1 iTl 0 129 --e

0 130 Vi,_-__, 0 131 -- -- 0 132 ’ i-l 0 133 ----

0 135 --- I 0 136 ' s-3 0 137 ---

/0138 'i..‘! 0139 - - ~-- 0140 ' n 0141 ---

ng Keeney reading cards (both eyes) - Put horizontal linethroughwordsreadcorrectl,y.

----.--Pp.-

Attempted

- -_____--- w ---. -

0 142 11 !

' 0 146 1: -1! 0 150 1 1 --j

01541!--/-'

c.3 l-i8 ! L . . .

0

'

:32I[-;

0 166 1 '-- '- !

0170 1 i-.3

) 4. Conditions interfering with test: 0 174 I 1-J Cannot read English

2 [.-J Cannot read

Distance (cm)

0 143 - - - 0 144 ! r-y -'

0 147 ---- 0 148 ' !I-.1

0 151 __ - .- 0 152 'I--1.-.1

0 155 ---- 0 156 1 Iy-1

0 159 ~ - -~ 0 163 1 y---j

0 163 - - - 0 164 ' n

0 167 F-m 0 168 ' CT3

0 171 - - - @ 'cl

3 I_T] Difficulty speaking

4 Cl Other - Specify

Number wrong

(4

0 145 .- -

G149 --

0 153 --

0 157 --

0 161 - -

0 165 - m

0 169 -v

0 173 - -
” ^ ‘,\ ‘,‘i

*.

,\ I I

’ .

^ ..\I .

.! .

. *

. ..- ., * :

C. NEAR VISION (FOR NON-ENGLISH OR ILLITERATES)

) 1. With or without correction: 0175 i m Wears glasses for test 3 0 Forgot (glasses, contact lenses)

2 q Wears contact lenses for test 4 m Does not wear either glasses or contact lenses

) 2. Test using Sloan letters (both eyes)

SI oan letters

Selection Distance (cm) Draw a diagonal line through every letter missed. Draw a horizontal line Errors Score

through sections of line not attempted and through top full line not attempted. allowed Mark (X) one

(4 W (cl (4 (e)

so0 0176 - - - IT IS VY HT IN TE SN TY 4 @lo

350 0178 e - - CR T E T P W H CR CS AD BN 4 0179cl

250 0180 me - HE YU MD TE LR YU WE T O 4 0 181 1 0

200 0182 -- - OE IN LG W E AS GT TT HE 4 0183 1 0

IS0 0184 - - - TE W R BU FS CR TS FR T T 4 0185 10

12s 0186 --- TE FS AE ED TO CE FM TE . 4 0187 1 q

100 0188 --- OE D Y MY NR AD ME IF HD 4 0189 I(1

7s 0190 --- VS T O FA CS GE AE ON AD 4 0 191 1 cl

so 0192 --- B W TS AE OF TO KS TE T T 4 0 193 1 u

1

) 3. Test using Keeney letters (both eyes)

Keeney letters

Selection Distance (cm) Draw a diagonal line through every letter missed. Draw a horizontal line Errors Score

through sections of line not attempted and through top full iine not attempted. al lowed Murk (X) one

(a) W (4 W W

130 0194 --- W N IN TE CE GF HN ES IT 4 0195 10

I20 01% - v m OE PE TO DE TE PL BS W H 4 0197II-‘1

85 0198 m -- WH AR AD TO AE AG TE PS '4 019910

60 0200 --- W H TE LS OF NE AD OF NS 4 @lo

so 0202 --- CS W H IL TM TO TE SN W E 4 0203 l cl

40 0204 e v - RS T T AG TE AE LE LY - AD 4 020s l cl *

30 0206 m_ - T T W R AY FO OF GT BS DE 4 @po

20 0208 --- ET TR SY AD HS PE ID WL’ 4 0209 1 q

97
NAME SAMPLE NUMBER

130 WHEN IN THE COURSE OF HUMAN EVENTS, IT BECOMES NECESSARY FOR

120 ONE PEOPLE TO DISSOLVE THE POLITICAL BANDS WHICH HAVE CONNECTED THEM

85 WITH ANOTHER, AND TO ASSUME AMONG THE POWERS OF THE EARTH, THE SEPARATE

AND EQUAL STATION TO

60

50

40

30

20

WHICH THE LAWS OF NATURE AND OF NATURE'S GOD ENTITLE THEM, A DECENT

RESPECT TO THE OPINIONS OF MANKIND REQUIRES THAT THEY SHOULD DECLARE THE

CAUSES WHICH IMPEL THEM TO THE SEPARATION. WE HOLD THESE TRUTHS TO BE

SELF-EVIDENT, THAT ALL MEN ARE CREATED EQUAL, THAT THEY ARE ENDOWED BY

THEIR CREATOR WITH CERTAIN UNALIENABLE

RIGHTS, THAT AMONG THESE ARE LIFE, LIBERTY, AND THE PURSUIT OF HAPPINESS.

THAT TO SECURE THESE RIGHTS, GOVERNMENTS ARE INSTITUTED AMONG MEN,

DERIVING THEIR JUST POWERS FROM THE CONSENT OF THE GOVERNED

THAT, WHENEVER ANY FORM OF GOVERNMENT BECOMES DESTRUCTIVE OF THESE ENDS,

IT IS THE RIGHT OF THE PEOPLE TO ALTER OR TO ABOLISH IT, AND TO

INSTITUTE NEW GOVERNMENT, LAYING ITS FOUNDATION ON SUCH PRINCIPLES AND

ORGANIZING ITS POWERS IN SUCH FORM, AS TO THEM SHALL SEEM MOST LIKELY TO

EFFECT THEIR SAFETY AND HAPPINESS. PRUDENCE INDEED, WILL DICTATE

THAT GOVERNMENTS LONG ESTABLISHED SHOULD NOT BE CHANGED FOR LIGHT AND

TRANSIENT CAUSES, AND ACCORDINGLY ALL EXPERIENCE HATH SHOWN, THAT

MANKIND ARE MORE DISPOSED TO SUFFER, WHILE EVILS ARE SUFFERABLE, THAN

TO RIGHT THEMSELVES BY ABOLISHING THE FORMS TO WHICH THEY ARE ACCUSTOMED.

NEAR VISION TEST CARD

BUT WHEN A LONG TRAIN OF ABUSES AND USURPATIONS
, .

”

- .

’ . . .

I

NAME --. SAMPLE NUMBCI1

I

SLOAN NEAR VISJON TEST CARD

so0 IT IS VERY HOT IN THE SUN TODAY

350 COVER 'THE TOP WITH CRACKER CRUMBS AND BROWN IN A HOT OVEN.

250 HAVE YOU MAILED THE LETTER YOU WROTE TO YOUR NEPHEW? HE WILL

EXPECT TO HE.-1R FROM YOU TOblORftO\J.

200 ONCE IN A LONG MHILE, AS A GREAT TREAT, HE TOOK ME DOI'JN TO HIS OFFICE;

THIS COULD H:"\I'PEN ONLY ON A SATURDAY FIORYING WHEN THERE WAS NO SCHOOL.

150 THE WEATHER BIJREAU FORKASTS COLDER TEMPERATURES FOR TONIGHT AND

TO!MMKOI~, ii'Il'H 11 h'ARMTNG TREND SETTING IN BY THURSDAY. LOI'; TEMPERATURES

TONIGHT WLL BE IX THE LOW 30’S IN THIS AREA. TOMORROW’S HIGH WILL

HIT ABOUT 37 11EGREES.

125 THE FUNDS ARE EXPECJ'ED TO CO21E FRO>! THE SALE OF A TRACT OF LAND IN

HEKRIKG PARK. '1 IIlY MCNI3 \+I LI, ?'O'f‘ BECoxi: AVAI'LABLE UNTIL THE FIRST

OF NEXT YEAR B11'f' OFF XC IALS STATE THAT THEY CAN BEGIN ON SO% PARTS

OF 'J-HE i'ROJECT AT ONCE.

3 00 ONE DAY I’dY NEIGHBOR ASKE’D I’d13 I F I HAD MT THE WIDOW WO HAD ,JUST MOVED

INTO ‘I’M-i Nl’XT HI,C;CK. THAT NIGIIT J HOBNED I-)Oh’N T!4E STREET AND KNOCKED

UPON 11131 DOOR . I EXf'EC'l'I:D TO FINT, SO,!clE SWFE,'f', ALTHOUGH TOTTERING, LADY

OF 80, BUT h?IA'I‘ OI'fINED THE DOOR KAS THIS BLONDE . I I'ROPOSCD TO HER

TMx1H :"\'I'EI,Y , SHE HAD R BETTLR l'EI,EVISICN SET IN HER HOUSE THAN THE ONE

1 f LAD 1 N MY CO’l’TkGE .

75 VlWI’ORS TO 11 FLORJDA CITRUS GROVE ARE OFTEN AhfAZED TO SEE FULLY RIPE

ORANGES MIW I’JCKM FRO)! A TREE WHICH 1s ALSO FILLED KITH CLUSTERS OF

FRAGIUWI’ WHITE ORANGE BLOSSO\1S--A GRAPHIC ILLUSTRATION OF THE TIME NATURE

KEQUIKrlS TO PRODLJCE CITRUS FRUIT. UNLIKE MOST O'l'f-il'ft TYPES OF FRUIT, KHKH

USUAtLY NEED ONLY THREE TO FOUR MONTHS TO CO;4PLETE THEIR CYCLE FROb1 BLOSSOM

TO MKI1JIiI'l'Y, CITRUS FRIJ ITS RiQJIRE TEN TO TWELVE MONTHS--AND THEY HAVE TO

BE MQN'f'flS OF SUNSHINE. THA'l IS WHY A RELA'I'fVELY SMALL SECTION, KNOk'N AS

THE "CITR1IS BELT," WHICH EXTENDS ACROSS THE WAIST OF FLORJ:DA--AND h'HERE

THE SUN SHINES ALMOST EVERY DAY IN THE YEAR-PROL1UCES NEARLY TWO-THIRDS

OF ALL THE CITRUS FRUIT CONSUMED IN THE U .S.

.

99
50 BOW TIES ARE OF TWO KINDS, THOSE THAT ARE RMDY TIED AKD THOSE THAT

HAVI: TO BE TIED. BOW' TIES TMT HAVE TO BE TIED ARE PREFERRED, SINCE

THE READY TIED ARE TOO PERFKT. I:~IPERFECl'IOXS IN THE TIE 'I‘MT HAS TO

BE TIED SIIOh '1‘HKI' IT IS NOT MKHINE-MDE BUT I1AXLbWROIJWI'. KHILE THE

TIE THAT MS l'0 BE TIED IS IWERFKT IT WOULD NOT BE TOO IblPERFEiT.

THAT IS TO SAY, ONE SIDE SHOULD NOT BE LONGER THAN THE OTHER SIDE, AND

THE TIE SHOlJLD SIT HORIX'Xf^\LLY AhD NOT AT A!'i ANGLE OF 45 DEGREES.

TYING A BOW WI' UQLiS NOT COME NATUKALLY.
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o U. S. GOVERNMENT PRINTING OFFICE : 1978 X0-937/15

.,.

* \

.I .

I . . .

>’ . ‘. *_ ;
VITAL AND HEALTH STATISTICS PUBLICATIONS SERIEaS

Series 1.

Series 2.

Series 3.

Series 4.

Formerly Public Health Service Publication No. 1000

Programs and Collection fiocedures. -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.

Data Evaluation and Methods Research. -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.

Analytical Studies. -Reports presenting analytical or interpretive studies based on vital and health

statistics, carrying the analysis further than the expository types of reports in the other series.

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 porn the Health Interview Survey. -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 jkom the Health Examination Survey.-Data from direct examination, testing, and measurement

of national samples of the civilian, noninstitutionalized 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 characteristics; and (2) analysis of” relationships among the various measurements without reference to an

explicit finite universe of persons.

Series 12. Data from the Institutionalized Population Surveys. -Discontinued effective 1975. Future reports from

these surveys will be in Series 13.

Series 13. Data on Health Resources Utilization .-Statistics on the utilization of health manpower and facilities

providing long-term care, ambulatory care, hospital care, and family planning services.

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 Mortality.-Various statistics on mortality other than as included in regular annual or monthly

reports. Special analyses by cause of death, age, and other demographic variables; geographic and time

series analyses; and statistics on characteristics of deaths not available from the vital records, based on

sample surveys of those records.

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. Special analyses by demographic variables;

geographic and time series analyses; studies of fertility; and statistics on characteristics *of births not

available from the vital records, based on sample surveys of those records.

Series 22. Data from the National Mortality and Natality Surueys. -Discontinued effective 19 7 5. Future reports

from these sample surveys based on vital records will be included in Series 20 and 21, respectively.

Series 23..Data jkom the National Survey of Family Growth. -Statistics on fertility, family formation and dissolution, family planning, and related maternal and infant health topics derived from a biennial survey of

a nationwide probability sample of ever-married women 1544 years of age.

I

For a list of titles of reports published in these series, write to: Scientific and Technical Information Branch

National Center for Health Statistics

Public Health Service

Hyattsville, Md. 20 782