Vital and 

Health Stdstics 

Questionnaires From ... . 

the National Health, 

Interview Survey, 

1985-89 

Series 1: 

Programs and Collection Procedures 

No. 31 

Thisreport is the second in a series of reports that describe questionnaires from 

the National Health Interview Survey. Thisvolume includes the questions used 

in the National Health Interview Survey from 1985 to 1989. The report contains 

the basic health and demographic questionnaires and c’urrent health topic 

questionnaires, 

U.S.DEPARTMENTOF HEALTHAND HUMANSERVICES 

Public Health Service 

Centers for Disease Control and Prevention 

National Center for Health Statistics 

Hyatkville, Maryland 

August 1993 

DHHSPublication No. (PHS)93-l 307 
Trade Name Disclaimer 

The use oftrade names is for identification only and does not imply 

endorsement by the Public Health Service. U.S. Department of Health and 

Human Services. 

Copyright lnfgrmation 

All material appearing in this report is in the public domain and may be 

reproduced or copied without permission: citation as to source, however, is 

appreciated. 

Suggested Citation 

Chyba MM, Washington LR. Questionnaires from the National Health Interview 

Survey, 198.5-99. National Center for Health Statistics. Vital Health Stat l(31). 

1993. 

Library of Congress Cataloging-in-Publication Data 

Chyba, Michele M. 

Questionnaires from theNational Health Interview Survey, 1985-39. 

p. cm. - (Vital and health statistics. Series 1. Programs and collection 

procedures : no. 31) (DHHS publication : no. (PHS) 93-1307) 

Authors: Michele M. Chyba and Linda R. Washington. 

“August 1993.” 

Includes bibliographical references. 

ISBN Ck-6406-04&30-7 

1. National Health Interview Survey (U.S.) 2. Questionnaires. 3. Public 

health-United States. 4. Health surveys-United States. 5. National Health 

Interview Survey (U.S.) I. Washington, Linda Ft. II. National Center for Health 

Statistics (U.S.) Ill. Title. IV. Series. V. Series: DHHS publication ; no. (PHS) 

93-1307. 

[DNLM: 1. Health Surveys-United States. 2. Questionnaires. W2 

A N146va no. 31 19931 

RA409U44 no. 31 

[RA407.3] 

362.1’0723 s-dc20 

[614.4’273] 

DNLM/DLC 93-854 

for Library of Congress CIP 

For sale by the U.S. Government Printing Office 

Superintendent of Documents 

Mail Stop: SSOP 

Washington, DC 20402-9328 
National Center for Health Statistics 

Manning Feinleib, M.D., &.P.H.; Director 

Jack R. Anderson, Deputy.Director. -

Jacob J. Feldman, Ph.D., Associate Director for Analysis 

and Epidemiology 7 

Gail F. Fisher, Ph.D., Associate‘Director for.ljlakning L&i 

Extramural Programs ~. 

Peter L. Hurley, Associate Director.for t/ital and’Health 

StaristicsSystems 

Robert A. Israel, Associate Director for International 

Statistics c 

Stephen E. Nieberding, Associate Dirtktor fo{ 

Management : 

Charles J. Rothwell, Associate Dtiector for Data 

P<ocessingand Services 

Monroe G. Sirken, Ph.D., Associate Director for Research 

and Methodology 

David L. Larson;h$&tant Direct& Atkirk . ” .’ ’ 

Division of Health Interview Statistics 

Owen T. Thornberry, Jr., Ph.D., Director 

Gerry E. Hendershot, Ph.D., Chief; Illness and Disability 

StatisticsBranch 

Nelma B. Keen, Chie$ Systemsand Programming Branch 

Stewart C. Rice, Jr., ChieJ SurveyPlanning and 

Development Branch 

Robert A. Wright, ChieJ Utilization and Expenditure 

StatisticsBranch 
Preface 

The National Center for Health Statistics (NCHS) 

published the first volume of a series of reports focusing 

on the current health topic questions used in the National 

Health Interview Survey (NHIS) in 1989. The first report 

included questions from 1980 through 1984. This report is . 

the second in the series and describes those current health 

topic questions used in the NHIS from 1985 through 1989. 

The report also contains the basic health and demographic 

questionnaire for 1989. The questions in the basic questionnaire have not changed since 1985. 

In 1985, however, a new sample design for the NHIS 

and a different method of presenting sampling errors were 

introduced. Information about the new sample design 

features can be found in each of the Current Estimates 

from the NHIS beginning in 1985 and in the vital and 

Health Statistics series report entitled Design and Estimation for the National Health Interview Suwey, 1985-94. 

The majority of the responses to the NHIS are available on public-use data tapes. As with the first volume, it 

should be noted that not every question included in a 

survey instrument appears on an NHIS public-use data 

tape. The information might have been excluded because 

of NCHS’ confidentiality provisions, combining of variabies as a result of recodes, or factors relating to the data’s 

reliability. Variables may also appear on the public-use 

data tape that were not in the questionnaire. 

- Public-use data tapes of NHIS surveys from 1985 

through 1989 are available for sale through the National 

Technical Information Service. These files include 

household, person condition, hospital episodes, and 

doctor visit records. A complete listing of NHIS data 

tapes can be found in NCHS’ Catalog of Electronic 

Data Products. Complimentary copies of the catalog 

are available from NCHS’ Data Dissemination Branch, 

Room 1064, Presidential Building, 6525 Belcrest Road, 

Hyattsville, Maryland 20782. 

Questionnaires on current health topics are organized 

by year, beginning with 1985. Introductions precede each 

year’s questionnaires and summarize the data collection 

activity, highlighting the main differences, if any, from 

previous years. 

Public-use data tapes-of the current health topics for 

1985 through 1989 can be,purchased from the Division of 

Health Interview Statistics at NCHS. 

iii 
Contents 

Overview of the National Health Interview Survey.......................................................... 1 

Background ......................................................................................... 1 

Purpose and scope........................... ..: .................................................... 1 

Content of questionnaires ............................................................................ 1 

Survey instruments ..................................................................................... 3 

Basic health and demographic questionnaires: 1985-89 ................................................... 3 

Changes in the NHIS basic health and demographic questionnaire: 1985-89 ................................. 3 

Current health topics: 1985-89 ........................................................................ 28 

1985 ............................................................................................. 28 

1986 ............................................................................................. 48 

1987 .............................................................................................. 69 

1988 ............................................................................................. 144 

1989 ............................................................................................. 249 

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289 

Appendixes 

I. Data collection procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2?! 

II. NHIS design and estimation structures . . . . . . . . . ..*.................... . . . . . . . . ..*..........*.*e..... 292 

A conceptual model of the NHIS ..,..........,,.,....,,,,..........,............................. 292 

Simplified NHIS design structures and variance estimation methodology . ..*..*.........*........**.*.* 293 

Variance estimation for person data using SUDAAN and the NHIS public use 

person data tapesj 1987-92 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293 

III. Response rates. . . . . . . . . . . . . . . ,............................................,..................~...... 295 

IV. Topical index to questionnaire items, by year ,..,.....,.....~‘....,.................................. 296 

Text table 

Characteristics of the current health topics of the National Health Interview Survey, 1985-89. . . . . . . . . . . . . . . . . . . . 4 

v 
- - - 

Symbols 

Data not available 

. . . Category not applicable 

Quantity zero 

0.0 Quantity more than zero but less than 

0.05 

Z Quantity more than zero but less than 

500 where numbers are rounded to 

thousands 

* Figure does not meet standard of 

reliability or precision 

# Figure suppressed to comply with 

confidentiality requirements 

vi 
Questionnaires From the 

National Health Interview 

Survey, 1985-89 

by Michele M. Chyba, Division of Health Interview 

Statistics, and Linda R. Washington, Division of Data 

Services 

Overview of the National 

Health Interview Survey 

Background 

The National Health Interview Survey (NHIS) is the 

principal source of information on the health of the 

civilian noninstitutionalized population of the United States. 

NHIS is one of the major data collection programs of the 

National Center for Health Statistics. The National Health 

Survey Act of 1956 provided for a continuing survey and 

special studies to secure accurate and current statistical 

information on the amount, distribution, and effects of 

illness and disability in the United States and the services 

rendered for or because of such conditions. The survey 

referred to in the Act, now called the National Health 

Interview Survey, was initiated in July 1957. Since 1960, 

the survey has been conducted by the National Center for 

Health Statistics, which was formed when the National 

Health Survey and the National Office of Vital Statistics 

were combined. 

Purpose and scope 

The objective of the survey is to address major current 

health issues through the collection and analysis of data 

on the civilian noninstitutionalized population of the United 

States. National data on the incidence of acute illness and 

injuries, the prevalence of chronic conditions and impairments, the extent of disability, the utilization of health 

care services, and other health-related topics are provided 

through the survey. A major strength of this survey lies in 

its ability to display these health factors by many demographic and socioeconomic characteristics. 

The NHIS data are obtained through personal interviews with household members. Interviews are conducted 

each week throughout the year in a probability sample of 

households. The households selected for interview are a 

NOTE: The authors are grateful for the assistance and support received 

in preparing this report. Support was received from Linda Purvin for 

typing. We would also like to acknowledge technical assistanceprovided by Susan S. Jack, NHIS, and response data from Michael Zukauskas, 

U.S. Bureau of the Census. Technical assistance was also provided by staff of the Systems and Programming Branch, especially Nancy Gagne. The authors are greatly appreciative of the appendix, “NHIS Design and 

Estimations Structures,” prepared by NCHS staff Steve Botman, Van 

Parsons, Randy Curtin, and John Horm. 

probability sample representative of the civilian noninstitutionalized population of the United States. Data are 

collected from approximately 50,000 households, including 

about 135,000 persons in a calendar year. Participation is 

voluntary, and confidentiality of responses is guaranteed. 

The annual response rate of NHIS is over 95 percent of 

the eligible households in the sample. The nonresponse is 

divided equally between refusals and households in which 

no eligible respondents could be found at home after 

repeated calls. 

Interviewing is performed by a permanent staff of 

interviewers employed by the U.S. Bureau of the Census. 

Data collected over the period of a year form the basis for 

the development of annual estimates of the health characteristics of the population and for the analysis of trends in 

those characteristics. Additional information about data 

collection procedures can be found in appendix I of vital 

and Health Statistics Series 10, No. 175, “Current Estimates 

From the National Health Interview Survey, 1989. ” 

The survey covers the civilian noninstitutionalized 

population of the United States living at the time of the 

interview. Because of technical and logistical problems, 

several segments of the population are not included in the 

sample or in the estimates from the survey. Persons 

excluded are patients in long-term care facilities, persons 

on. active duty with the Armed Forces (although their 

dependents are included), and U.S. nationals living in 

foreign countries. Appendix II describes the NHIS design 

and estimation structures. 

The questionnaire consists of two parts: a set of basic 

health and demographic items and one set or more of 

questions on current health topics. The basic items constitute approximately 50 percent of the questionnaire and 

are repeated each year. They provide. continuous information on basic health variables. Questions on current health 

topics facilitate a response to changing needs for data and 

coverage of a wide variety of issues. This combination 

yields a unique national health data base. 

Content of questionnaires 

Basic health and demographic questionnaire 

(formerly core) 

The questionnaire includes the following types of 

basic health and demographic questions. 
Demographic characteristics of household members, including age, sex, race, education, and family income 

Disability days, including restricted-activity and beddisability days; work and school-loss days occurring 

during the 2-week period prior to the week of interview; and bed days during the last 12 months 

Physician visits occurring in the same Z-week period, 

interval since thelast physician visit, and number of 

visits in the last 12 months 

Acute and chronic conditions responsible for these 

days and visits 

Long-term limitation of activity resulting from chronic 

disease or impairment and the chronic conditions 

associated with the disability 

Short-stay hospitalization data, including the number 

of hospital episodes during the past year and the 

number of days for each year 

Data tapes, with findings from the NHIS basic health 

and demographic questionnaire, can be purchased from 

the National Technical Information Service (703) 487-

4650. These files include household, person, condition, 

hospital episode, and doctor visit records. 
Survey instruments t 

Basic health and demographic 

questionnaires: 1985-89 

The first part of the NIBS questionnaire, the basic 

health and demographic questionnaire, contains questions 

on acute conditions, the prevalence of chronic conditions, 

persons limited in activity due to impairment or health 

problems, and utilization of health care services involving 

physician care and short-stay hospitalization. These questions more or less remain the same from year to year. 

The 1985 NHIS sample consisted of approximately 

34,844 households containing 91,531 persons. The total 

interview rate was about 4.3 percent. 

New sample design features were initiated for the 

1985-94 NHIS. One new feature is that the full NHIS 

sample can be partitioned into four panels. Each individual panel is a representative sample of the U.S. civilian 

noninstitutionalized population. Each individual panel also 

has the same sampling properties, and any combination of 

panels defines a national design. 

This feature enables large reductions in the sample 

size to be made efficiently. Additional information about 

the 1985-89 NHIS sample survey can be found in “Current 

Estimates ffom ‘the National Health Interview Survey” for 

any year beginning in 1985 (1). The redesign is also 

discussed by Massey, et al in an NCHS vital and Health 

Statistics series report (2). 

Changes in the NHIS basic health and 

demographic questionnaire: 1985-89 

There were minimal changes to the NHIS basic health 

and demographic questionnaire from 1985 through 1989. 

Since 1985, questions pertaining to the family members’ 

city and State of birth, social security number, and father’s 

last name, have been included. 

In 1989, questions were added that obtained the 

location (city, county, and State) of any physician contact 

whether by telephone or in person and for family members born in the United States, how many years have they 

lived in the State of residence and for family members 

born in a foreign country, how many years have they lived 

in the United States. Section L., “Demographic Background Page,” shows the questionnaire changes as they 

appear in 1989. Only section L6, questions 9a, b, and c are 

included on the 1989 NHIS public-use data tape. 

3 
Characteristics of the current health topics of the National Health Interview Survey, 1985-89 

Number of persons Data collection 

Persons eligible in sample on Respondent Response Period 

Year and topic for sample’ public-use tape rule2 rate3 weeks Panels4 Locaflon5 Modes 

1985 

Health promotion and disease prevention: 

Health promotion and disease One adult per family 33,830 QO.IH 52 

prevention (HPDP) . . . . . . . . . ‘. . . . 18 years and over 

Smoking history dorlng Female family members 19,700 88.1H 52 

pregnancy . . . . . . . . . . . . . . . . . . 18-44 years old 

Child safety and infant All children under 25,825 88.W 52 

feeding . . . . . . . . . . . . . . . . . . . . 18 years 

1986 

Longest job worked . . . . . . . . . . . . . . . Family members 37,917 95.8H 52 

25 years and over 

Dental health ................... All family members 62,052 95.8H 52 

Functional limitations .............. Family members 7,192 95.10 52 

65 years and over 

Vitamin and mineral intake. . . . . . . . . . . One adult 18 years 11,500 adults cd 93.6H 52 

and over and one child 1,800 children 94.5H 

2-6 years old per family 13,300 total 93.71-1 

Health insurance. . . . . . . . . . . . . . . . . All family members 62,052 C 98.OH 52 

1987 

Cancer risk factors. . . . . . . . . . . . . . . . Each household was assigned to either the cancer control or cancer 

epidemiology sample 

Cancer control. . . . . . . . . . . . . . . . . One adult per family 22.043 e 94.2H 52 4 S P 

18 years and over 

Cancer epidemiology. . . . . . . . . . . . . One adult per family 22,080 e 94.OH 52 4 S P 

I8 years and over 

.Chlld adoption . . . . . . 1 . . . . . . . . . . . Female family members 31.124 9 79.6H 52 4 C P 

20-54 years old 

Poliomyelitis. . . . . . . . . . . . . . . . . . . . Family members 26 73,574 h 91.6H 52 4 C P 

years and over 

AIDS knowledge and attitudes . . . . . . . . One adult per family 17,698 e 94.8H August- . . , S P.A 

18 years and over December 

1988 

Medical device implants . . . . . . . . . . . . All family members 122.310 I 93.OH 52 4 S 

Occupational health. . . . . . . . . . . . . . . One adult per family 44,233 e 86.58 52 4 S 

I8 years and over 

Alcohol use . . . . . . . . . . . . . , . . . . . . One adult per family 43,809 e 85.98 52 4 S 

I8 years and over 

Child health. . . . . . . . . . . . . . . . . . . . One child per family 17,110 i 88.48 52 4 S 

under I8 years 

AIDS knowledge and attitudes . . . . . . . , One adult per family 29,659 e 84.5H 52 4 S 

I8 years and over 

4 
Characteristics of the current health topics of the National Health Interview Survey, 198589-Con. 

Number of persons Data collection 

Year and topic 

1989 

Health insurance coverage. . . . . . . . . . . 

Adult immurtization . . . . . . . . . . . . . . . 

Mental health . . , . . . . . . . . . . . . . . . . 

Dental health . . . . . . . . . . . . . . . . . . . 

Diabetes: 

Diabetes (initial screening and followup 

screening questions) . . . . . . . . . . . 

Diabetes risk factors . . . . . . . . . . . . . 

Orofacial pain . . . . . . . . . . . . . . . . . 

Digestive disorders . . . . . . . . . . . . . . 

AIDS: knowledge and attitudes. . . . . . . 

Persons eligible 

for sample’ 

All family members 

Family members 18 years 

and over 

All family members 

All family members 

Family members 18 years 

and over (initial 

screening) 

Family members 18 years 

and over who were ever 

told by doctor had 

diabetes (followup 

screening) 

In one-half sample of the 

families, one adult per 

family 18 years and over, 

if nondiabetic 

One adult per family 

18 years and over 

One adult per family 

18 years and over 

One adult per family 

18 years and over 

in sample on Respondent Response Period 

public-use tape rule2 rate3 weeks Panels4 Location= Mode6 

116,929 C 92.21-1 52 4 S P 

84,572 C 92.1H 52 4 s ‘P 

116,929 C 91.9H 52 4 S P 

116,929 C 92.OH 52 4 S P 

84,572 k 87.4H 52 4’s P 

I 91.1H 52 4 S P 

20,847 m 92.1H 52 4 S P 

42,370 m 86.48 52 4 S P’ 

42,392 m 86.48 52 4 S P 

40,979 e’ 84.OH 52 4 S A 

1Sample persons were randomly selected. Unrelated individuals living in households were considered to be one-member families. 

*Respondent notes: 

a. The household respondent answered questions 1 and 2 in Section M. The remainder of Section M and the-current health topic questions were completed by the sample person. A proxy 

was not accepted. 

b, The sample person answered the questions on child safety and infant feeding for each child in the family. 

0. Any responsible adult 19 years of age and over or any married person may have answered the questions for all family members. Single persons 17 or 16 years of age may have responded 

for him/herself. 

d. The household respondent answered questions for the sample child (2-6 years). A proxy was not accepted. 

a. QuestIons were answered by the sample person. A proxy was not accepted. 

f, The sample person was the preferred respondent. A proxy was acceptable (1) at the time of the interview if the sample parson was physically or mentally incapable of responding or (2) 

after a callback if the sample person was not available. The proxy had to be a household member knowledgeable about the parson or a caregiver. 

g, Puestfons were answered by the female household respondent, the adoptive mother, or whomever adopted the child. A knowledgeable proxy was accepted. 

h. The sample person was the preferred respondent. A proxy was accepted If the sample person was available at the time of Interview. A parent or other knowledgeable parson could have 

been the proxy. The parent did not have to be in the household. 

iI Implant questions ware answered by the implant recipient unless he/she was absent or physically incapable of responding in which case a household respondent or knowledgeable person 

was accepted as a proxy. 

j. QuestIons In the Pl Section were answered by the household respondent. The remainder of the questions were answered by the preferred respondent. The preferred respondent was a 

related adult, the biological or adoptive mother, the biological father, an adult relative living with the person, legal guardian, or primary caretaker. The sample child could not respond for 

hlmlherself. The spouse could not respond for the sample child. 

k. Questions were answered by the household respondent. 

I. Questions 1 through 5 in Section Q2 were answered by the person who was Identified as a diabetic by the household respondent. After confirmation that the person was a diabetic, the 

remalnlng questions were answered by the diabetic. A proxy was not accepted. 

m. Questions in Section M through Cl1 were answered by the household respondent. The current health topic questions were completed by the sample person. A proxy was not accepted. 

3Response rate: Response rates take into account both the basic questionnaire and the current health topic questionnaire response rates. The rates are calculated by multiplying the basic 

anestlonnalre response rate by the current health topic rate. See text description for additional information. “9” refers to numbers for response rate from the Bureau of the Census: “H” refers to 

numbers for response rate from the Division of Health Interview Statistics, NCHS. 

4Number of panels in NHIS sample was reduced in some years due to budget considerations. A panel is a national probability sample consisting of one quarter of the households assigned for 

the year. 

%ocatlon of current health topic questions: “C” refers to the core/basic health and demographic questionnelre; “S” refers to the supplement/current health topics. 

6Mode: All Interviews were done in personal face-to-face interview in the home, a telephone callback was permitted. “P” refers to paper and pencil administration. “A” refers to computerassisted personal interviewing (CAPI). 

Source: Additional information about respondent rules and eligible sample persons can be found in the National Health Interview Survey Interviewer’s Manual for the years 1966-89. 

5 
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-- ----- 

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-------------_----_---------------------------I

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os~auanm not HU in rocmlng or barding house 

0.90 Unit not prminsnt in mrulent hotel, motel. et*. 

to~Unoccu.led shs for”ob”a horns. t”“sr. ortam 17. Record of additional contacts 

6 
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---- 

-- 

-- 

-- 

-- 

one of the penons who owns or rents this home. Enter name in REFERENCE PERSON column: 

b. Whet are thb names of all other persons lhring or staying hare? Enter names in columns. 

o. I have listed (reednemss1. Have I missed: .., - any bebles or small children? . . . . . . . . . . . . . . . . . ..~.................... 

- coy lodgers, bearden, or persons you employ who Ilvehere? ; . . ‘c. . . . . . 

- anyone who USUALLY lives hers but Is now iway frcm home 

tmvellng or In P hospital? . . . . . . . . . ..“..~~.....................‘.... 

- snyone she staying hem? .;.............i.......................... 

d. Do all of the persons you have named usually live hem? 0 Yes 1.3 sZi=Wb 2nNo - Number 

q No (APPLY HOUSEHOLD MEMBERSHIP 

Probe if necessary: RULES. Delete nonhousehold members C 2 

by en “X” from 7-C2 and enter r8ason.l IA - $” -1 Is- T”. :“““I iycmo. Dcas usually live somewhere else? 

3 8 8 I ,I 

Ask for,al/@ersons begioning with column 2: 

. What Is -.- rsletiLnship to (reference person)? Ii- - ‘iAT -lth’- iiNT.itfiT~li%~tikD,

I I I I II . What I? date of blrtfi? (Enter date endege endmark sex.) 1 I I I II 

REFERENCE PERIODS LA - :“ii -yv- ylycmymo 

P-WEEK PERIOD I I I I ,I 

----;--------------------- __-__-i----__---------~ 

Al ___-------____-- 12-MONTH DATE ----------------,------------------:------------- LA y 1D” yu.~CLLTRpy0N0 

* . t I1 I II 

13.MONTH HOSPITAL DATE ----------------_ LA IRA ID” ;INJ.; CLLTN;HSICONO A2 ASK CONDITION LISL. . I

I I II I .I 

A3 0 All persons 6s and owr 151 A 3 Refer to ages of a// related HH members. 0 Other 141 

.a. Am any of the psnons In this family now on full-time active 

dutv with the armed forces? q Yes 0 No (51

b. Who is this? 

Delete column numberlsl ­ ___________________________L_____----------------- by en “X” from 7-C2. ., ., ,: 1 _____----____-----. I 

c. Anyone blss? ----‘-------------------------------------~-------,-.----------,---~- 0 Yes (Reask 4b end cl q No ---. 

Ask for each person in armed forces: pd. 0 Living at hqe 

d. Where does usually live and sleep, here or somewhere else? 0 Not livingat home 

Mark box in person’s column. I Y 

If related persons 17 and over ere listed in addition to the respondent and ere not present, say: 

i. We would llke to have all adult family members who are at home take part In the Interview. 

Am (names of persons 17 end over) at home now? If “Yes, “ask: Could they Joln us? lA//ow time1 

Read.to respondent(sl: .’ This survey Is bslng conducted to collect Information on the nation’s health. I will lisk ahout 

horpltellzetlons, dlsebllity, visits to doctors, Illness In the family, and other health related items. 

HOSPITAL PRbBE 6a. I noes ia. Since (13-month hospital date1 a year ago, was a patlsnt In a hospital OVERNIGHT? 2 q No ,Me,k“HOSP.“box, THENNP, _-----__-----___-------------~---------------------. ---------__-------. b. How many dlffarsnt times did stay in any hospital overnlght or longer since‘ fMake ey!rv in 

(13-month hospiteldetel a year ago? b. ;;;tl;p,box 

Number of times I 

Ask for each child under one: 7a. 1q Yes 

‘a. Was born In a hospital? 2 0 No fNPJ 

____________________-----~-~---------~-------------------------------

Ask for mother arid child: b. 0 yes WPI 

b. Have you Included thls hospitallzatlcn In the number you gave me for --? . 0 No Gmecr 6 md “HOSP.” box, 

OOTNOTES 

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1 6. LIMITATION OF ACTIVITIES PAGE 

Bl Refer to age. B1 1 cl 18-69111 

2 0 Other INPI 

1. Whatwas - - doing MOST OF THE PAST 12 MONTHS; working at a job or business, 1. 1 0 Working 121 

keeping house, going to school, or somethlng else? 2 q Keeping house /31 

Priority if 2 or more activities reported: (1) Spent the most time doing; 121Considers the most important. 

2a. Does any impairment or health problem NOW keep from working at a job or business? 2a. 

_____-'_______--__--_------------------------------ 4--d4-_d--__--+ 

I b. Is limited in the kind OR amount of work - - can do because of any impairment or health problem? 1 b- t 2q Yes 171 3 0 No Ml 1 

3a. Does any impairment or health problem NOW keep from doing any housework at all? I3a. I

_------d---~---4 4OYf~141 q No I _---_------------_---~~-~~--~~--~~--~~--~--~~--~-- b. Is limited in the kind OR amount of housework can do because of any impairment b. 5 q Yes141 6 0 No 151 or health problem? 

4a. What (other1 condition causes this? 

Ask if injury or operation: When did [the (in-&y) occur?l- - have the operation?] 4a. IEnter condition In C2, THEN 461 

Ask if operation over 3 months ago: For what condition dld - - have the operation? 

If pregnancy/delivery or O-3 months injury or operation,-

Reask question 3 ‘where limitation reported, saying: Except for - - Icondition), . . .7 

1 q Old age (Mark “Old age” box, 

THEN 40) 

OR reask 4b/c. -----------------------_--__--__--_--i_----------- _-------d------d 

b. Besides (condition1 is there any other condition that causes this limitation? b. ; r,;yk 4s sndbl 

0 

--~----------------------------------------------- .---------------

c. Is this limitation caused by any (other) specific condition? C. ; Yes lReask 4.3 sndbl 

I t 1 UNo I __---_---__--__--~_-~~~~~~-~---~-------~---~--~--- ----d---d------

Mark box if only one condition. d. q Only 1 condition -I 

d. Which of these conditions would you say Is the MAIN cause of this limitation? 

1 I Maln cau*l! I 

5a. Does any impairment or health problem keep from working at a job or business? 15a- 1 1 q Yes171 0 No 1

__--_---_--------_--,-~--~-~~--~~--~~--~~--~~--~---. 

b. Is limited in the kind OR amount of work could do bacause of any Impairment or health problem? 

I

I82 I Refer to questions 3a and 3b. & 

6a. Is - - limited in ANY WAY in any activtties because of an Impairment or health problem? 6a. 1 Elves __-------~~_-~~_~~~_-~~---~~--~~--~~--~~-~~~~~~~-~ _------_d-d~---

2 q No 1NPl 

b. In what way is ---limited? Record limitation, not condition. b. 

Limitation I 

7a. What (other) condition causes this? 

Ask if injury or operation: When did [the (iniurv) occurll-- have the operation?] 7a. IEnter condition in C2, THEN 7bt 

Ask if operation over 3 months ago: For what condition did - - have the operation? 

If pregnancy/delivery or O-3 months injury or operation - I 0 Old age &lark “Old s&box, THEN 7~) 

Reask question 2, 5, or 6 where limitation reported, saying: Except for (condition}, . . .I 

OR reask 7b/c. -_----_---__-~~_~-~~~----~~~~~~~~~--~------------- -d-------d-_-db. Besides (condition) is there any other condition that causes this limitation? b. 0 Yes {&ask 7e mdb) 

q No (7d) __---_--------------------~~---~---~----------~~-- -------dd-d--dc. Is this limitation caused by any (other) specific condition? C. 0 Yes (Reesk 7s end bl 

q No __--------------_----~---~~~~~~~~~~~-~~~--~~-~~~~~ --------d--d--_ 

Mark box if only one condition. d. q Only 1 condition 

d. Which of these conditions would you say is the MAIN cause of this limitation? 

Main cause 

8 
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B. LIMITATION OF ACTIVITIES PAGE; Continued ; ’ . .. ‘: . ..,*, _ ~ < 

B 3 Refer to age. 

‘. ” B3 ‘:i ~,e;;::p’; i y,,“,”(NW 

owr 181 

8. What was doing MOST OF THE PAST 12 MONT’HS; working’at aJob or business; kee.ping.:. : 8.. , I q Working 

house, going to school, or something else? 2 0 Keeping house 

Priority if 2 or more activities reported: (ljspent thd most time doing; (21 Considers the most important. 3 0 Going to school 

1 4 0 Something else 

8a. Because of any impairment or health problem, does need the help of other persona’with ’ 9a. 1 Elves (131 ON0 - - personal care needs, such as eating, bathing, dressing, or genlng around this home? ____ ------,----------- -_--- --,---- - ---.----.- LA --.- ii- ----_-----_~_-_ b. Because of any impaument or health problem, does need the help of other persons m handkng b. 

routine needs, such as everyday household chores, doing necessary business, shopping, or 2 Cl Yes (13) 3 0 No 1121 

getting around for other purposes? 

Oa. Is - - able to take part AT ALL in the usual kinds of play aotivhies done by most children . -A age?’ 1 Oa; q Yes . 0 0 No (131

----,,-T---~-------------------------------~---------~ -------L------­

b. Is hmrted m the kmd OR amount of play activities can do because of any impaument I ’ .b. 

or health problem? I . ‘. 1 +ss (73). 2 0 No 1121 

,’ la. Does any impalrment or health problem NOW keep from attending school? ‘ , 1 . * . ‘_ 

Ila. 

b. 

1 q IYSS (73) CINO 

b.,Does- --------.---------.----------- --.-------- ---------. --_--------------- 217yes,r3, q lNo 

attend a epecral school or specral classes because of any Impairment or health problem? 

--------------A-.-------- -.---------- ---mL-,-----LLIL-.---L--------------- .I ,’ . 

c. Does need to attend a specral school or specral classes because of any rmpatrment or C. 

health problem? 3 0 Yes 1131 q INC

d, is----is~~~d~n-sdh,, ~&~~a&c~ ~s~~u~s-o~~1 &ih> - - - - - - - - - - - - 7 T - - -.? - r -“- ime--,-d--------L--­ 4q Yes,,3, 6ONO 

2a. la limited in ANY WAY in any activities because of an impairment or health problem? 12a. 1q IYSS 2 0 No iNpI 

_______ ------------+--------------LL-~----~-~L----L~ -.-- bswm’----‘----------­

b. In what way is limited? Record limitation, not condition. 

* ., ‘, .- ._ Limitation 

3a. What (other) condition causes this? . ; 13a. 

Ask if injury or operation: When did [the f&~l occur?/-: - have the operation?] (Enter condition in C2, THEN 73bl 

Ask if operation over 3 months ago: For what condition did have the operation? 

If pregnancy/delivery or O-3 months injury or operation - 1 0 Old age (Mark “O/d age” box, 

THEN 130) Reask question where limitation reported, saying: Except for :,- (condition), . . .1 , : OR reask 13b/c. / -

_-_-----------------------------------------------~--~ b. Besides (condition) is there any other condition that causes this limitation? b. OYes b?eask 13s and bJ 

q No 113dl _____________-----------~-~~~~~~~,~~~~~-~----------~--~---------------

c. Is thls limitation caused by any (other) specific condition? C. q Yes (Reask 13a and b) 

ON0 ________-------------------------~-~~~~~~~~----~---.--~~~~~~~~~~~~~~~~ 

Mark box if only one condition. ’ . . d- 0 Only 1 condition 

d. Which of these conditions would you say is the MAIN cause of this limitation? 

/. ‘. * I .,* ,. / 

Main cause 

:OOTNOTES :.. .i 

* ,. .. ; 

9 
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B. LIMITATION OF ACTIVITIES PAGE, Continued 

B4 o0 Under 5 //VP) 2 0 60-69 (141 B4 Refer to age. 1 0 5-59 (B51 3 0 70 and 

owe INPI 

B5 Refer to “Old age”and “‘LA” boxes. Mark first appropriate box. 

B5 0 

0 

“Old age” box marked (741 

Entry in “LA” box (741 

0 Other (NPI 

14a. Because of any impairment or health problem, does - - need the help of other persons with - - personal care needs, such as eating, bathing, dressing, orgetting around this home? -------.--~--------.---------------------------------.--~---------------

14a. 

1 0 Yes l75) ONo 

If under 78, skrp to next person; otherwrse ask: b. 

b. Because of any impairment or health problem, does need the help of other persons in handling 

routine needs, such as everyday household chores, doing necessary business, shopping, or 2 0 Yes 3 17 No INPl 

setting around for other purposes? 

15a. What (other) condition causes this? 

Ask if injury or operation: When did [the CnJ& occurll-- have the operation71 

Ask if operation over.3 months ago: For what condition did have the operetion? 

If pregrlancy/delivery or O-3 months injury or operation -

Reask question 14 where limitation reported, saying: Except for - - (condition), . . .? 

OR reask 15b/c. -----------------------------------------~--------

b. Besides (condition) is there any other condition that causes this limitation? 

-----------------------------------------,--------- c. Is this limitation caused by any (other) specific condition? 

_--_-------_---_----------------------------------

Mark box if only one bondition. 

d. Which of these conditions would you say is the MAIN cause of this limitation? 

FOOTNOTES 

IO 

15a. lEnter condition in C2, THEN 1661 

1 0 Old age (Mark “Ooldage” box, 

THEN 1601 

d. cl Only 1 condition 

I Main csuse I 
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D. RESTRICTED ACTIVITY PAGE PERSON 1 

Hand calendar. 

{The next questions refer to the 2 weeks outlined in red on that calendar 

beginning Monday, @&end ending this past Sunday(date).} 

Refer to age. 

Dl 

0 Under 5 (4, 0 5-17 (3, 0 18 and over (II 

I a. DURING THOSE 2 WEEKS, did - - work at any time at a job or 

business not counthtg work around the house? (Include unpaid 

work fn the family Cfarmlbusinesal.) 

I [7 Yes (Mark “Wa” box, THEN 2, ZUNO 

__--___---___--_---------------~~ 

b. Even though - - did not work during those 2 weeks, did - - have a job or business? 

I 0 Yes (Mark “Wb”box, THEN 2, znNo (4, 

la. During those 2 weeks, did miss any time from a job or business because of illness or injury? 

‘ClYes oo 0 No 14, 

----_----------__--------------~~ b. During that l-week period, how many days did miss more than half of the day from - - job or business because of 

illness or injury? 

INo.ofwork-lossdaysI (4, 

oo 0 None (4) 

Ba. During those 2 weeks, did miss any time from school because 

of Illness or, injury? 

q 3Yes ooq No (4, 

_---__----_----_----------~~~--~~ 

b. During that l-week period, how many days did - - miss more than half of the day from school because of illness or injury? 

1No. of school-loss days1 

ooq None 

La. During those 2 weeks, did stay in bed because of illness or injury? 

q Yes oo0 No (61 ---------------_----------------- b. During that 2-week period, how many days did - - stay in bed more than half of the day because of illness or injury? 

I#o..fbeddays (D2, 

oo 0 None (6) 

RMHls.111999l V-16-991 

Refer to 26 and 3b. D2 0 No days in 2b or 3b (61 

0 1 or more days in 2b or 3b (5) 

5. On how many of the (number in 2b or 36) days missed from 

[work/school] did - - stay in bed more than half of the day 

because of illness or injury? . 

000 None No. of days 

. . Refer to 2b, 36, and 4b. 

missed from work 

6a. (Not counting the day(s) missed from school 1, (and) in bed I 

Was there any tOTDEft) time during those 2 weeks that cut 

down on the things .- - usually does because of illness or injury? 

0 Yes .’ odn No ‘(03, 

---i----------------------------- ..’ 

missed from work 

b. (Again, not couating the bayfsj missed fromschool 1 1, (and) fn bed 

During that period, how many’(OTHER) days did cut down for more than half of the day because of illness or injury? 

oonNone 

Refer to 2 - 6. 

D 3 0 Nb days in 2-6 (Mark “No” in RD, THEN. NPI 

0 1 or more days in 2-6 (Mark “Yes”in RD, THEN 7) 

Refer to 2b, 3b, 4b, and 66. 

7a. What (other) condition caused 

(Enter condition in C2, THEN 7b, 

-I------------------_____________ 

b. Did any other condition cause - - to $~~~$~hat 

I OYes (Reask 7a and b, znNo 

:OOTNOTES 

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E. 2-WEEK DOCTOR VISITS PROBE PAGE 

Read to respondent(s): 

These next questions are about health care received during the 2 weeks outlined in red on that calendar, 

El Refer to age. 

1 a. During those 2 weeks, how many times did - - see or talk to a medical doctor? {Include all types 

of doctors, such as dermatologists, psychiatrists, and ophthalmologists, as well as general 

practitioners and osteopaths.} (Do not count times while an overnight patient in a hospital.) ____----____----____----~~~~-~---~~~-----~~-----~ 

b. During those 2 weeks, how many times did anyone see or talk to a medical doctor about ---1 

(Do not count times while an overnight patient In a hospital.) 

2a. (Besides the time(s) you just told me about) During those 2 weeks, did anyone in the family receive 

health care at home or go to a doctor’s office, clinic, hospital or some other place? Include care from a nurse or anyone working with or for a medical doctor. Do not count times while an overnight patient in a hospital. Cl Yes 0 No 13aJ ____---------------------------------------------- b. Who received this care? Mark “DR Visit” box in person’s column. 

c. Anyoneslse~- - - - - - - - - - - - - - - - - - - - - - - - odes ~R~a~k~~andol - - - - - - -

---------------------------------------------~~---

Ask for each person with “DR Visit” in 2b: 

d. How many times did receive this cere during that period? 

3a. (Besides the time(s) you already told me about) During those 2 weeks, did anyone in the family 

get any medical advice, prescriptionsor test results over the PHONE from a doctor, nurse, or 

anyone working with or for a medical doctor? Cl Yes 0 No ff2) ----___------_---_______________________---------- b. Who was the phone call about? Mark “Phone call” box in person’s column. 

----___~_____-___---____________________~~~--~~~~~ c. Were there any calls about anyone else? 0 Yes fReask 3b and c) 0 No -___---------------_____________________----------

Ask for each person with “Phone call”in 3b: 

d. How many telephone calls were made about --? 

I 

El 

la. 

and 

b. 

2b. 

d. 

3b. 

d. 

q Under 14 (lb] 

0 14 and over (Ial 

lNP1 

Number of times 

---------_-----

0 DR Visit 

--------d-_---­

-----d---~-~--d 

I)Number of times 

-----------~-~-

c] Phone call 

------~-~~-----

I Number of calls 

E* I Add numbers in 1,2d, and,3d for each person. Record total number of visits and c$ls in “2-WK. DV” box in item Cl. 

OOTNOTES 

12 
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---- ----- 

-- 

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

------ 

------ 

------ 

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

---- ,,.“.,. 

-- 

F. 2-WEEK DOCTOR VISITS PAGE DR VISIT 1 

Referto Cl. “2-WK. DV”box. PERSON NUMBER.-

0 Under 14 flbl Fl 1Refer t0 age. 0 14and over llel 

1 a. _on_w_hsl(otharrda!e 2_w_eeJsjid ==se9rJslJ s ~n$dJ@ ~Jo~~,~III& o_rd_o@o~s_as&tf@ _ _ l’a. 

b. On what (other) date(s) during those 2 weeks did anyone see or talk to a medical doctor, nurse, and Month - DateOR or doctor’s assistant about - -7 b. --------.T----~--------------------------------~- -----_____-----____ Ask after last DR vl~lt column for rhrsparson: c. 1 [7 Yes fReask 7s orb andcl 

c. Were there any other visits or calls for during thit period? Make neces~arycorrection to,bWk. DVboxin Cl. 2 0 No IAsk 2-6 for each visit1 

2. Wheredid receive health care on (date in I), at a doctor’s office, clinic, hospital, some 2. 010 Telephone 

other place, or was this a telephone call? Not in hospital: HospHal: 

/f doctor’s office: Was this office in a hospital? .; 

.)’ oz0Home 08 Cl O.P. clinic 

03 0 Doctor’s office 09 [7 Emergency room If hospital: Was it the outpatient clinic or the emergency room? d4 0 Co. oi lad. clinic 10 Cl Doctor’s office 

If clinic: Was it a hospital outpatient clinic, a company clinic, a public health clinic, or 050 Gther!dlinic 11 OLab 

some other kind of clinic? 060 Lab ‘: 12 0 Ovemigld patient(61 

If lab: Was this lab in a hospital? , . 07 0 Other (SpeciYyI j 880 Other fSpecifyl 3 What was done during this visit? (Footnote) 

Ask 3b if under 14. 3a. 1 clYesf36 , 8 q DKifM.D. f3cj 3a. Did - - actually talk to a medical doctor? and 2 0 No f3cf 9 17 DK who was seen 136 b. b~e~yone~c~u~liy~ai~t~~~e~i~ai~o~t~~a~~~~~~------------------- b. ---------,--------,--------------------------------

c. What type of medlcal person or assistant was talked to? c. 

TYPE 990 DK 

-----------------_______________________---------- .d. r---- --_--- ­

d. Does the (entry in 3~) work with or for ONE doctor or MORE than one doctor? 10 One 136 2 q More BuNone (41 90 DK --------------------------,~.------------------ ------------------_ 8. For this [visit/call] what kind of doctnr was the (entry m 3~) workmg with pr for - a general luGPf41 2ClSpecialist f3gl 9 0 DK 141 

f. Is that doctor a general practitioner or a specialist? -------------------,----------------------------~--- ---‘----L----------­

g. What kind of specialist? 6. Kind of specialist 

Ask 46 if under 14. 4a. t 0 Condition f/tern C.?, ThEN 4gf 

aa. For what condition did see or talk to the [doctor/(entryin 3cn on (date in I)? Mark first appropriate box. a;d 2 0 Pregnancy(4) ----------------------d~e-m-~-------~~--~~------y---- . 3 0 Test(s) or examination #cl 

b. For what condition did anyone see or talk to the [doctorl(entrv in 3cfl about - - on (date m I)? 8 17 Other iSpecify Mark first appropriate box. 3 ,a-, 

__---- --‘ffsL - c. iiLi&-a%%&i&if&%~a%~ ~~uitof~~~t~ssic~/~x~i~~ti~~~ - - - 0. 0 Yes f4hl ON0 ----.------~-~ -----“---.~-Z~-h~d~ --7--- d. Was thw [testlexammatlonl because of a speclflc condition d. rr~,~k-b~~~use~f~~rpr~9n~n~~~-­ e. During the past 2 weeks was e. 

f. _______----------------------------What was the matter? f. “_,1 Condition THEN 4gl -----_____________ g. b&hGtThi% ~i~iiic7l~w~s~h~t~r~e~~~~3~~t~~~ -__~-----------____-____________________~~~~~~ G&oiit\iiyq<$ea con&Go?15 - - -OIE- ____ c1EE~ ______ 

h. What was the condition? 0 Pregnancy 1481 

f/tern C2, 

Condition THEN 4gl 

Mark box if “Telephone” in 2. o 0 Telephone in 2 fNext I q Yes 2 0 No (61

5a. Did have any klnd of surgery or operation during this visit, including bone settings and stitches? 5a. Dr. visitt __------____-----_______________________------~~-- ---------_---------

b. What was the name of the surgery or operation? If name of operation not known, b. Ill 

describe what was done. (21 _______-________________________________------------------------------

c. Was there any other surgery or operation during this visit? C. 0 Yes fReask 5b andcj GINO 

6. In what city (town), county, and State is the (place in 2) located? 6. City/County 

State/ZIP Coda 

FORM twi itsas t7-16.891 

13 
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G. HEALTH INDICATOR PAGE 

i a. During the P-week period outlined in red on that calendar, has anyone in the family had an injury from an accident or other cause that you have not yet told me about? 

_____-----____------____________________-----~~~~~ q lYes q No (2) .-- __------------- b. Who was this? Mark “lnjury”box in parson’s column. lb. 01,wry -------___------____------------------------------ ----------i---­ c. What was injury? C. 

Enter injury&s) in person’s column. 

___-~__-------------____________________---------- --_------------ Injury 

d. Did anyone have any other injuries during that period? I 

-----_____--_______-------------------------------0 Yes (Reask lb, c, and d) q No ----d----_~----

Ask for each injury in 1c: e. c] Ye’s (Enter injury h CZ, THEN 

e . As a result of the (injury in lcl did C--/anyone] see or talk to a medical doctor or assistant le for next kl]wy) 

(about - - j or did - - cut down on usual activities for more than half of a day? q No lie for next Injury) 

2. During the past 12 months, {that is, since 112-month date) a year ago} ABOUT how many days did 2. OOO~None illness or injury keep in bed more than half of the day? (Include days while an overnight patient 

in a hospital.) No. of days 

3a. During the past 12 months, ABOUT how many times did [ --/anyone] see or talk to a medical 3a. OOO~None (3bl doctor or assistant (about --j? (Do not count doctors seen while an overnight patient in a 000~0nly when overnlghr hospital.) (Include the (number in 2-WK DVboxl visit(s) you already told me about.) patient in hospital (NPJ 

No. of visits ----__-_----___---______________________---------- ---------d---__ 

b. About how long has it been since [--/anyone1 last saw or talked to a medical doctor or assistant 1 q interview week fReask 36) (about --j? Include doctors seen while a patient in a hospital. 2 0 Less than 1 yr. 1fZeask3.4 

3 0 1 yr., lass than 2 yrs. 

4 Cl2 yra., less than 6 yrs. 

5 Cl 5 yrs. 0, mcr5 

0 q Never 

1. Would you say health in general is excellent, very good, good, fair, or poor? 4. 1 q Excallant 40 Fait 

2q Very good 60 Poor 

OHGood 

Mark box if under 18. 5a. 0 Under 18 (NP) 

ia. About how tall is - - without shoes? 

____---____----_________________________---------- -----__-------- Feet -Inches 

b. About how much does - - weigh without shoes? b. 

Pounds 

14 

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

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

-- 

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

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

--------- 

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

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

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

-------- 

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

------ 

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

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

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

U t?nNlWTlnN I I-CT-C 1 llNn 3 

Read to raspondentfsl and ask list specified in A2: 

Now I am going to read a list of medical conditions. Tell ma if anyone in the family has had any of these conditions, even if 

you have mentioned them before. 

1 a. Does anyone in the family {read names) NOW HAVE - 2a. Does anyone in the family {read names) NOW HAVE - If “Yes , “ask 7b and c. If “Ves , “ask 2b and c. 

b. Who is this; 

c. Does anyone else NOW have - 1 b. Who is this? 

Enter condition and letter in appropriate person’s column. c. Does anyone else NOW have - A. PERMANENT stiffness or any deformity of the 

foot, leg, fingers, arm, or back? (Permanent Enter condition and letter h appropriate person’s column. 

A-L are conditions affecting’ 

1 d. DURlnio THE PAST 12 MONTHS, did anyone in the Cbnditions M-AA are impairments. family have - If ‘Yes, “ask le and f. 

8. Who was this? 

f. DURING THE PAST 12 MONTHS, aid anyone else have -

Enter condition and letter in appropriate person’s column. 

C-L are conditions affecting the bone and muscle. Q. Palsy or cerebra! palsy? M-W are conditions affecting the skin. C . Tinnitus or ringing in (ser’a-bral) 

the ears? 

i--------------+- t 

R. Paralysis of any kind? - D. Blindness in one or both 

I eyes? I t S.Curvature of the spine? t 

N. Skin cancer? --------------_-

_-----‘-------- t II E. Cataiacts? 

0. Eczema or Psoriasis? 

(ek’se-me) or 

-

(s’o-rye’uh-sis) 

P. TROUBLE with dry or itching skin? -------------_- t ----~---------

0. A bone cyst or bone G. TROUBLE with acne? 

spur? t 

---------------_- R. A skin ulcer? H. Any other disease of the 

bone or caitilage? 

--------------_- S. Any kind of skin allergy? 

I. A slipped or ruptured disc? _____.__ 

---------------_- T. Dermatitis or any other 

skin tr.ouble? J. REPEATEDtrouble with -----------_____ neck, back, or spine? U. TROUBLE with ingrown -----------_____ toenails or fingernails? 

K . Bursitis? 

V. TROUBLE with bunions, 

corns, or callus057 

L. Any disease of the _--------- ____.__ 

muscles or tendons? W. Any.disease of ,the 

hair or scalp? 

--------A-----.--

F. Glaucoma? --------------iG. Color blindness? ------_-------_-

H. A detached.retina or any 

other condition of the 

retina? ------.--

I. Any other trouble seeing 

with one or both eyes 

EVEN when wearing glasses? _-____ --------_-

J. A Cleft palate or harelip? --------------.--

K . Stammering or stuttefing? --------------.--

L. Any other speech defect? --------------_-

M . Loss of terte or smell 

which hes lasted 3 -_ months or more? --------------_-

N. A missing finger, hand, 

or arm; toe, foot, or leg? 

_------------- - T.REPEATED trouble t 

with neck, back, or spine? _----.__--__---.-_ 

U.Any TROUBLE with 

fallen arches or flatfeet? 

V.A clubfoot? --------------.-_ 

W. A trick knee+ 

____ ---___ 

X.PERMANENT stiffness 

or any deformity of the 

foot, leg, or back? 

(Permanent stiffness -

joint5 will not move at all.) 

Y. PERMANENT‘stiffness 

or any deformity of the 

fingers, hand, or arm? 

2. Mental retardation? 

AA.Any condition caused 

by an accident or injury 

which happened more than 3 months ago? If 

“Yes “ask. What is the 

condition?’ 

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

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

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

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

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

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

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

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

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

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

------ 

-- 

-- 

-- 

-- 

-- 

-- 

-- 

-- 

-- 

-- 

-- 

---- 

H. CONDITION LISTS 3 AND 4 

Read to respondent(s) and ask list specified in AZ: 

Now I am going to read a list of medical conditions. Tell me if anyone in the family has had any of these conditions, even if 

lave mentioned them before. 

3a. DURING THE PAST 12 MONTHS, did anyone in the la. DURING THE PAST 12 MONTHS,dldanyons in the family 

family {read names) have - (read names] have -

If “Yes,” ask 3b and c. If “Yes,” ask 4b and c. 

b. Who was this? b. Who was this? 

c. DURING THE PAST 12 MONTHS, did anyone else have - c. DURING THE PAST 12 MONTHS, did anyone else have -

Enter condition and letter in appropriate person’s column. 

Make no entry in item C2 for cold; flu; red, sore, or strep 

throat; or “virus” even if reported in this list. 

Conditions affecting the digestive system. 

Enter condition and letter in appropriate person’s column, 

A-B are conditions affecting the glandular system, 

C is Y blood condition, 

D-I are conditions affecting the nervous system. J-Y are conditions affecting the genito-urinary systen 7, -

Reask 4a 

N. Any other kidney trouble7 - .-------------

,

0. Bladder trouble? .---------d--d 

P. Any disease of the 

genital organs? -... .----d-d-----­

,

0. A missing breast? .-----------_-

R. Breast dancsr? I...-d---------­

- S. *Cancer of the 

prostate? .-------------

T. *Any other 

prostate trouble? .---------d---

I

U. **Trouble with 

menstruation? - I------dd----_ 

U. **A hysterectomy? If “Yes “ask: 

For whit condition did - - have a hysterectomy 7 

.--------4----

- ‘IH. *+A tumor, cyst, or growth of the uterus or ovaries? .-------------

X. **Any other disease of 

the uterus or ovaries? 

.------d--d---

Y. **Any other female 

trouble? 

-

A. Gallstones? 

B. Any other gallbladder 

trouble? 

--7----------

C . Cirrhosis of the liver? 

D. Fatty liver? r------------

E . Hepbtitis? --------_____ 

F. Yellow jaundice? 

G . Any other liver troublei 

H. An ulcer? _--__--------

I. A hernia or rupture? ----_-------_ 

J. Any disease of the 

esophagus7 

<. Gastritis7 

l.. FREQUENT indigestion7 

M .Any other stomach 

trouble? 

RMHlSl , 

16 

Reask 3a 

N. Enteritis? _------------

0. Diverticulitis? 

(Dye-ver-tic-yoo-lye’tisl .------------

P. Colitis? .------------

L A spastic colon? 

R. FREQUENT 

constipation? _------------

B. Any other bowel 

trouble? _--------___-

T. Any other intestinal 

trouble? 

I& Cancer of the stomach 

intestines, colon, or rectum? 

Y. During the past 12 

months, did 

anyone (else) in the 

family have any 

other condition of 

the digestive 

system? 

If “Yes ” ask- Who was this? - What was the condition? 

Enter in item C2, 

THEN reask V. 

R. A goiter or other 

thyroid trouble? ------------. 

B. Diabetes? ------------. 

C. Anemia of any kind? -------_--_-. 

D. Epilepsy? ----------__. 

E. REPEATED seizures, 

convulsions, or blackouts? ------. 

F. Multiple sclerosis? ------------. 

3. Migraine? ------------. 

i. FREQUENT 

headaches? 

-Ai -_---_ 

I. Neuralgia or neuritis? --------____. 

J. Nephritis? ------------. 

K. Kidney stones? ------------. 

I.. REPEATED kidney 

infections? ----------__. 

1. A mlssing kidney? 

*Ask only if males in family. 

‘*Ask only if females in family. 
---------------- 

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

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

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

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

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

---- 

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

H. CONDITION LISTS 5 AND 6 

Read to respondent(s) and ask list specified in A2. 

Now I am going to read a list of medical conditions. Tell me if anyone in the family has had any of these conditions, even if 

you have mentioned them before. 

5a. Has anyone in the family (read names) EVER had - 6a. DURING THE PAST 12 MONTHS, did anyone in the famii 

If “Yes I “ask 5b and c* {read names) have -

If ” lW, ” ask 6b and c. b. Who wes this? 

5 c. Has anyone else EVER had 6 b. Who wes this? 

-

Enter condition and letter in appropriate person’s column. 

Conditions affecting the heart and circulatory system. 

c. DURING THE PAST 12 MONTHS, did enyone else have -

Enter condition and letter in appropriate person’s column. 

Make no entry in item C2 for cold; flu; red, sore, or strep 

throat; or “virus” even if reported in this list. 

Conditions affecting, the respiratory system. 

A. Rhaumatic fever? 

B. Rheumatic heart disease? ----------------___-___________ 

C. Hardening of the arteries or artsriosclerosis? ----__-------

D. Congenitalheart disease? -----------------__-___________ 

0. A stroke or a cerebrovascuier 

accident? 

(s&a-bro vas ku-iar) 

H. A hemorrhage of the 

brain? 

I. Angina pactorb? 

(pek’to-ris) 

J. A myocardiel _ _ _ infarction?

-

K. t;it;$er heart 

A. Bronchitis? --------------------__------__-

B. Asthme? ----------------------------__-

C. Hay fever? ---------------------_-----_~-

D. Sinus trouble? ----------------------------__-

E. A nasal polyp? -------__-----__---___--_____--

F. A deflected ot deviated 

nasal septum? --------_--__-_ 

G. +Tonsillitis or anlargement of the tonsils ot 

adenoids? 

H. *Laryngitis? 

i. A tumor oc growth of 

the throat, larynx, or 

trachea? 

___-----_---i--

J.Atumoror 

growth-of the 

t;o;cnhg;Bi tube 

*If reported in this list only, 

I. How many times did - 12 months? 

If 2 or more times, enter 

If only 1 time, ask: 

Reask 6a. 

K. A missing lung? 

I.. Lung center? 

M. Emphysema? 

N. Pleurisy? 

0. Tuberculosis? 

P. Any other workrelated respiratory 

condition, such as dust on the lungs, silicosis, 

asbestosis, or pneu-mo-co-ni-o-sis? 

-------------._-

Q. During the past 12 

months did anyone (else) in the family have 

any other respiratory, 

lung, or pulmonary 

condition? If “Yes ” 

ask: Who was this; - What was the condition? Enter in item C2, 

THEN reesk 0. 

ask: 

- have (condition) in the past 

condition in item C2. 

E. Coronary heart disease? _ - - - - - _ _ _ - - - -

F. Hypertension, 

sometimes called 

high blood 

pressure? 

5d. DURING THE PAST 

family have -

If “Yes, ” ask 5e and f. 

e. Who was this? 

12 MONTHS, did anyone in the 

f. DURING THE PAST 12 MONTHS, did anyoneelse have -

Enter condition and letter in appropriate person’s column. 

Conditions affecting the heart and circulatory system. 

L. Damaged heart valves? 

M. ;t;z*cardia or rapid 

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

N:A heart tiurmur? -----_---------_---------------

0. Any other heart trouble? 

P. An aneurysm? 

(en yoo-rizm) 

Q. Any blood clots? 

R. Varicose veins? ---‘-----------

S. Hemorrhoids ot 

piles? 

T. Phlebitis or 

thrombophiebitis? 

U. Any other condition 

affecting blood 

circulation? 

2. How long did it last? If 1 month or longer, enter in item C2. 

If less than 1 month, do not record. 

If tonsils or adenoids were removed during past 12 months, 

enter the condition causing removal in item C2. 

17 
-- 

-- 

-- 

-- 

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

-- 

-- 

J. HOSPITAL PAGE HOSPITALSTAY

-

I. Refer to CI I “HOSP . “box . 1. ‘ERSON NUMBER - !. you said earlier that was a patient in the hospital since-e) a year lonth Data YCWI, 

ego. On what data did enter the hospital ([the last time/the time before that])? 

Record each entrv date in a seoarate Hosoita/ Stav column. 2. 19-

I. How many nights was - - in the hospital? F- ~0000 None fh’ext H.9 

Nights -

1. For what condition did - - enter the hospital? 0. 1 0 Normal delivery 

l For delivery ask: l For newborn ask: 

Was this a normal delivery? Was the baby normal at birth? 

If “No ” ask* If “No ” ask* 

What wes the matter? What Las the matter? 

l For initial “No condition”ask* 

Whydid sntar the horphsl? 

l For tests, ask: 

What were the results of the teatsi 

2 0 

3 q 

0 

Normal at birth > 16) 

No condition 

Condition 

J 

If no results, ask: 

Why were the tests performed? 

Jl Refer to questions 2, 3, and 2-week reference period. 

ii I 0 At least one night in 2-week 

reference period lEnter condition 

in CL?,THEN 51 

0 No nights in P-waak refarance period /Sl 

ia. Did have any kind of surgery or operation during this stay in the hospital, 58. 10 Yes 20 No (81 including bone settings and stitches? 

_----------------------------------------------, ----d------d-----­

b. What was the name of the surgery or operation? b. ’ Ill If name of operation not known, describe what was done. 

12) 

131 

------------d~-ddc. Was there any other surgery or operation during this stay? 0, 

i. What is the name and address of this hospital? s, N 

Nlumber and street 

C:itv or County state 

-

:OOTNOTES 

18 
--------------- 

CONDITION 1 PERSON NO.- Ask 3g if there is an impairment (refer to Card CP2) or any of the 

following entries in 3b-f: 

I. Name of condition Abrcssi Damage Palsy 

Ache Iexcept head or ear) Growth Paralysis 

Mark “2-wk. ref. pd. “box without asking if “DV” or “HS” Bleeding (except menstrual) Hemorrhage Rupture 

in C2 as source. Blood clot lnfsctlon Sorelness) 

I. ybheu: did [ --/anyone] last see or talk to a doctor or assistant Boll Inflammation Stlfflne**) 

- - (condition)? Cancer Neuralgia Tumor 

0 0 Interview week f/bask 21 5 0 2 yrs., less than 5 yrs. Cramps (except menstrual) Neuritis UICW 

1 0 2-wk. ref. pd. 6 0 5 yrs. or more Cyst Paln varicose veins 

2 0 Over 2 weeks, less than 6 mos. 7 0 Dr. seen, DK when Weakbmss) 

3q 6 mm., less than 1 yr. 8 0 DK if Dr. seen 4 0 1 yr., less than 2 yrs. 9 0 Dr. never seen 1361 g. What part of the body is affected? 

Kpecifyl la. (Earlior you told me about --lconditionJ Did the doctor or assistant Show the following detail: 

call the (condition) by a more technical or specific name? Haad.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . skull, scalp, face 10 Yes ZCINO SnDK Back/spine/vertebrae . . . . . . . . . . . . . . . . . . . . . . . . . . . . upper, middle, lower --------____----____---------~~~~ 

Ask 3b if “Yes” in 3a, otherwise transcribe condition name from Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . left or right 

item 7 without asking: Ear.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . lnnerorouter;left,right,orboth 

b. What did he or she call it? EW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . left, rlght, or both 

Arm . . . . . . . . . . . . . . shoulder, upper, elbow, lower or wrist; left, right, or both -. , 0 Color Blindness (NC) 2 cl cancer 138) 

Koecifvl ,. Hand . . . . . . . . . ‘. . . . . . . . . . . . . entire hand or fingers only; left, right, or both 

Leg . . . . . . . . . . . . . . . . . . . hip, upper, knee, lower, or ankle; left, right, or both 3 [7 Normal pregnancy, 

15) 

4 q Old age /NC1 Foot . . . . . . . . . . . . . . . . . . . . entire foot, arch, or tees only; left, right, or both normal delivery. 8 0 Other 13el vasectomy > ___------_---___-_--~~~~~~-~~~--- ------------_____------~~~~~~~~~~~ 

c. What was the cause of - - (condition in 3b)? (Specify) z Except for eyes, ears, or internal organs, ask 3h if there are any of the 

following entries in 36-f: 

lnfsctkul Sore Soreness 

----~-_-~~~__----___-----~~------

Mark box if accident or injury. o cl Accident/injury 15) 1. What part of the (Dart of bodv in 36-o) is affected by the [infection/ 

sore/soreness] -‘the skin, muscle, bone, or some other part? d. Did the (condition in 3b) result from an accident or injury? 

10 Yes (5) 20No 

------__------___--______________ 

Ask 3e if the condition name in 36 includes any of the following words: (Specify) 

Ask if there are any of the following entries in 3b-f: 

Allmant ClllWb3r 

Anamla Condltlon 

Disease 

Disorder 

Problem 

Rupture 

Tumor Cyst Growth 

Asthma cyst Growth Trouble . Is this [tumor/cyst/growth] malignant or benign? Attack Dafect MIMJSIOS Tumor 

Bad UICM 1 0 Malignant 2 0 Benign SnDK 

a. When was - - (condition in 3b/3f) ] 1 q 2-wli. ref. pd. e. What kind of (condition in 3b) is it? 

(Specify) first noticed? 2 0 Over 2 weeks to 3 months 

-----_------____----_____________ -------------______ 3 0 Over 3 months to 1 year 

Ask 3f only if allergy or stroke in 36-e: i[ b. When did - - (name of injury in 3b)? 4 0 Over 1 year to 5 years 

f. How does the [allergy/stroke1 NOW affect --? (Specify) 7 5 cl Over 5 years 

Ask probes as necessary: 

(Was it on or since (first date of Z-week ref. period) 

or was it before that dete?) 

(Was it less than 3 months or more than 3 months agoi) 

For Stroke, fill remainder of this condition page for the first present (Was it less than 1 year or more than 1 year ago?) effect. Enter in item CZ and complete a separate condition page for (Was it less than 5 years or more than 5 years ago?) each additional present effect. 

,M”Is-I ,lrJ89,,7-15-W 

19 
-- 

-- 

-- -- 

-- 

Is this jcondition in 3bJ the result of the same accident you already 

accident questions first comp1eted.j - -

--z-----------------------------­ b. During that period, how many days did cut down for more than half of the day? 14. Where did the accident happen? 

10 At home linside house1 

000 None K2) -DSYS 20 At home (adjacent premises) 

7. During those 2 weeks, how many days did - - stay in bed for 3C1 Street and highway Iincludes roadway and public sidewalk) 

more than half of the day because of this condition? 40 Farm 

50 Industrial place (includes premises) 

OonNone -DSYS 60 School (includes premises1 

Ask if “Wa/Wb” box marked in Cl: 70 Place of recreation and Sports, except at school 

8. During those 2 weeks, how many days did miss more than 60 Other fSpscify1 

half of the day from - - job or business because of this condition? I 5 , I 

Mark box if under 18. q Under 18 (161 

15a. Was - - under 18 when the accident happened? 

10 Yes (16) ONo 

--------------------__3__________ 

half of the day from school because of this condition? b. Was-- in the Armed FrNes when the accident happened? 

217 Yes 176) 0 _______---------__-_-----~-d---~~ 

c. Was atworkat j ybbgNusiness when the accident happenad? 0 Condition has “CL LTR” in C2 as source WJ1 30 Yes 0 Condition does not have “CL LTR” in C2 as source lK41 

16a. Was a car, truck, bus, or other motor vehicle involved in the accidsnt 

in anv. wav?_ in bed more than half of the day? (include days 1OYe.9 20No (171 while ---------------------~-~-~~~~~~~- an overnight patient in a hospitai.j b. Was more than one vehicle involved? 

-Days 1OYes __------------------d--d---~~-d+- 20No 

o. Was tit/either one1 moving at the time? 

1OYes 20No 10 Yes 20No 

0 Missing extremity or organ IK41 17a. At the time of the accident what part of the body was hurt? _._ .__ _ a. _ ._- y3n 1 [7 Other 172) \ gnat uina nt injury was rtt 

Anything else? 

12a. Does - - still have this condition? 

I q Yes IK41 DNo Pmtbl of body l 

_-------------------------------

b. Is this condition completely cured or is it under control? 

2q Cured 6 0 Other Epecifyj 3 

L-------_--_----l--------------- 3 q Under control fK41 K4) --------,------------------------ Ask if box 3,4, or 5 marked in 0.5:

c. About how long drd - - have this condition before it was cured? b. vJi;tipti of the body is affected now? - - (part of bodv) affected? 

OOo~Less than 1 month OR - 10 Months Is affected in any other way? 

Number 1 20 Years 

_______---------____~~~~~~~~~~---

d. Was this condition present at any time during the past 12 months? 

1q Yes 20No 

I I 

1

K4 00 Not an accident/injury (NC) l Enter part of body in same detail as for 3g. 10 First accident/injury for this person (14) l l If multiple present effects, enter in C2 each one that is not the 60 Other 173) same’as 3b or C2 and complete a separate condition page for it. . FORM HIS-1 11999l17-15-991 

20 
-- 

-- 

----------- 

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

-- 

-- -- 

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

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

-- -- 

L. DEMOGRAPHIC BACKG,ROUND PAGE 

l/l Refer to age. 

I 

1 a. Did EVER serve on active duty in the Armed Forces of the United States? 

____--___----_-____------~~~~-----~~-~~----------~ .__ - ____ b. When did - - serve? Vietnam Era (Aug. ‘64 to April ‘751 . . . : . . . . VN b. 1OVN 5[7PVN 

Korean War (June ‘50 to Jan. ‘.55) . . . . . . . . . KW 20KW 900s. 

Mark box in descending order of priority. World War II (Sept. ‘40 to July ‘47) . . . . . . WWII 3clWWll SUDK thus, ifperson sewedin Vietnam endie Korea World War I (April ‘17 to NOV. ‘18) . . . . . . . . WWI 

mark VN. Post Vietnam (May ‘75 to present) . . . . . . . . PVN 4OWWI 

1 Other Service (all other periods) . . . . , . . . . . . OS 

C. 

-4 q Yes 20No(Z) -L-----.--- 7nDKL?j 1

I -___--___----______-___i_____________

d. Was ALL of active duty service related to Natfonal Guard or military reserve trainfng? d. 1uYes 30No SbK t 1 

2a. What is the highest grade or year of regular school has ever attended? 00 0 Never attended or 

kindergarten lNPl 

I I Elem: 12345678 I 

High: 9 10 11 12 

t College: 1 2 3 4 5 6 + 

____--___---_______------------------------------- .__ ---__--__------

b. Did - - finish the (number in 2a) [grade/year]? b. lOYes 2nNo 

Hand Card R. Ask first alternative for first person; ask second alternative for other persons. 

3s. ;WI;: i: the n,;rni;r of the group or groups 

1 

which represents race? 1 3a. 1 2 3 4 5 

J 

Circle all that apply 1 - Aleut, Eskimo, or American Indian 4 - White 

2 - Asian or Pacific Islander 5 - Another group not listed - Specify 

3 - Slack fSpscifyj 

I I 2 3 4 5 

b. Which of those groups; thet is, (entries in 3a) would you say BEST represents race? 

lSpscify1 ____----_---------L------------------------------- __ 

o. Mark observed race of respondent(s) only. 0. 

t row 206 300 

Hand Card 0. 

40. Are any of those groups national origin or ancestry? (Where did ancestors come from?) __-____________-____------------------------------. 

b. Please give me the number of the group. b. 

Circle all that apply. 

1 - Puerto Rican 5 - Chicano 

2 - Cuban 6 - Other Latin American 1234567 

3 - MexicanlMexicano 7 - Other Spanish 

4 - Mexican American 

21 
-- -- 

-- 

--- 

-- 

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

-- 

-- 

---- 

-- 

-- 

-- 

-- 

-- 

-- 

-- 

L. DEMOGRAPHIC BACKGROUND PAGE, Continued 

L2 Refer to “Age” and “Wa/Wb” boxes in CI. 12 

I 

5s. Earlier you said that has a job or business but did not work last week or the week before. 5a. 

Was looking for work or on layoff from a job during those 2 weeks? ----_--___----__-----~~~-----~-------------~~~----

b. E;j;rer you saip that - - didn’t have a job or business last week or the week before. b. 

looking for work or on layoff from a job during those 2 weeks? ----------------------~--------------------------­ c.Which, looking for work or on layoff from a job? C. 

6a. Earlier you said that - - worked last week or the week before. Ask 6b. 

--------------------------~-----------------

b. For whom did - - work? Enter name of company, busmess, orgamzatlon, or other employer, stz 

and --------------------------------~-------~--~~--- C. c. For whom did work at - - last full-time job or business lasting 2 consecutive weeks or more? 

Enter name of compan y, business, organization, or other employer, or mark “NEV” or ‘AF” box in person’s column, 

----_---____---- -------__-----__----~...~----~~~~~~~ 

d. What kind of business or industry is this? For example, TVand radio manufacturing, d. 

retail shoe store, State Labor Department, farm. 

If “AF” in 66/c, mark “AF” box in person’s column without askmg. e. 

e.What kind of work was doing? For example, electrical engineer, stock clerk, typist, farmer. 

------______-___________________________----------

f. What ware most important activities or duties at that job? For example, types, f. 

keeps account books, files, sells cars, operates printing press, finishes concrete. 

-----------------------~~~~~~~~---~~..~..~~~----

Complete from entries in 6b-f. If not clear, ask: 

g. Was g. An employee of a PRIVATE company, business or Sslf.amployad in OWN business, professional 

individual for wager, salary, or commlrrlon . . . . . . . . . P practics, or farm? 

A FEDERAL government employee? . . . . . . . . . . . . . . . F Ask: Is tba business Incorporated7 . 

A STATE government employee? . . . . . . . . . . . . . . . . . S Yes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 

A LOCAL government smployw? . . . . . . . . . . . . . . . . . L No . . . . . . . . . . . . . . . . ..__._.......... SE 

V$I~FA;WITHOUT PAY in family businau 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . WP 

- NEVER WORKED or navel wotimd at a fclWme 

iobIasting2wnksormon . . . . . . . . . . . . . . . NEV 

DOTNOTES 

00 Under 18 (NPI 

I 0 Wa box marked @a) 

20 Wb box marked &a) 

30 Neither box marked l6bl 

1 cl Yes 16cl 2 0 No fsbl 

----_----d-d--d 

10 Yes 2 0 Na fNPl 

-______-d--dddi 

10 Looking @cl 3 0 Both (Ebl 

20 Layoff (cib) 

---------d-dddd 

Idustry 

------------...iccupation 

OAF (NPI 

---d----d----..,­

:lass of worker 

IOP 601 

20F 6ClSE 

30s 7OWP 

4OL 8ONEV 

22 
-- 

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

LDEMOGRAPHIC BACKGROUND PAGE, Continued 

Mark box if under 14. If “*Married” refer to household composition and mark according/y. 

‘. Is now married, widowed, divorced, separated, or has - - never bean married? 

la. Was the total combined FAMILY income during the past 12 months - that is, yours, jread names, including 

Armed Forces members livina at homel more or less than $20,000? Include money from jobs, social security, 

retirement income, unemployment payments, public assistance, and so forth. Also include income from 

Interest, dividends. net income from business. farm. or rent. and anv other mcnev income received. 

Read if necessary.- Income is important in analyzing the health information we collect. For example, this 

information helps us to learn whether parsons in one income group use certain types of medical care services or have certain conditions more or less often than those in another orouo.

- .

Read parenthetical phrase if Armed Forces member living at home or if necessary. 

b. Of those income groups, which letter best represents the total combined FAMILY income 

during the past 12 months (that is, yours, head names, including Armed Forces members 

living at home))? Include wages, salaries, and other items we just talked about. 

Read if necessary: Income is important in analyzing the health information we collect. For example, 

thfs lnformation helps us to learn whether parsons in one income group use certain types of 

medical care services or have certain conditions more or lass often than those in another group. 

a. Mark first appropriate box. 

R 

b. Enter person number of respondent. 

.3 Enter person number of first parent listed or mark box. 

Enter person number of spouse or mark box. 

)OTNOTES 

64HIS.1 ,lSSS, 17-15.88, 

7. 

-

-

3a. 

b, 

-

?a. 

.-

b. 

-

L3 

-

L4 

-

0 q Under 14 

1 0 Married - spouse in HH 

2 17 Married - spouse not in HH 

3 0 Widowed 

4 0 Divorced 

5 0 Separated 

6 0 Never married 

1 0 $20,000 or more (Hand Card /I 

2 0 Less than $20,000 fHand CardJl 

OOOA 

01 q B 

020 c 

030 D 

040 E 

050; 

060G 

070 H 

060 I 

090 J 

0 0 Under 17 

1 0 Present for all questions 

2 0 Present for some questions 

3 0 Not present 

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

Parson rumbar of respondentk.1 

Person number of parent 

30 0 None in household 

Person number of spouse 

JO 0 None in household 

23 
-- 

-- 

-- 

-- 

-- 

-- 

L. DEMOGRAPHIC BACKGROUND PAGE, Continued I 

1 

L5 Refer to age. Complete a separate column fbr each nondeleted person aged 78 and over. L5 PERSON NUMBER 

Read to respondent(s): In order to determine how health practices and conditions are related to how long people live, we would like to refer to statistical 

records maintained by the National Center for Health Statistics. 

Date of birth Is-11 

L6 Enter date of birth from question 3 on Household Composition page. 

L5 /Monlhl 

w )a. In what State or country was born? Sa. 99ODK 

Print the full name of the State or mark theappropriate box if the State 

person 

02 q Virgin Islands 00q Mexico 03 0 Guam 98 OAll other 

04 0 Canada cou”trlss 

__________________------------------------------~----------------- E 

was not born in the United States. 01 Cl Puerto Rico 05 q Cuba 

If born in U.S., ask 9b; if born in foreign country, ask 9c. 1 q Less than 1 yr. 4 0 lOyrs., lassthan 16 

b. Altogether, how meny years has - - lived in (State of present residence)? b. 2 0 1 yr., less than 5 6 q 16 yrs. or more 

___-________--___-------------------------------~ 3 0 5 yrs., lass than 10 9 0 DK 

c. Altogether, how many years has lived in the United States? -T,,,,,--r,,,,,,, ., 

C. 2 0 1 yr., less than 5 6 cl16yrr,ormors 

3 q 5 yrs., less than 10 9 0 DK 

Last b 

L7 Print full name, including middle initial, from question 1 on Household Composition page. 

I.7 First 

Middle initial I 11 

Verify for males; ask for females. Father’s LAST name w 

lg. What is father’s LAST name? 10. 

VerJfy spelling. DO NOT write “Same. ” 

172--8( Read to responden,t(s): We also need Social Security Number. This information is 999999999~ DK 

voluntary and collected under the authority of the Public Health Service 

Act. There will be no effect on benefii and no information will be 

given to any other government or nongovernment agency. 11. rl-I-I-I-ill[ Read if necessary: The Public Health Service Act is title 42, United States Code, Social Security Number 

section 242k. 

Mark if number 1 q Memory 1 

II. Whatis Social Security Number? obtained from __* 2 0 Records 

1 

1 Cl Self-personal 

L8 Mark box to indicate how Social Security number was or was not obtained. I.8 2 0 Self-telephone 

3 El Proxy-personal 

4 q Proxy-telephone 

lit.4“19-l 119991,7-te-881 

24 
L. DEMOGRAPHIC BACKGROUND PAGE, Continued 

Read to Hhld. respondent: The National Center for Health Statistics may wlrh to contact you again to obtain additional health related 

information. Please give ma the name, address, and telephone number of a relative or friend who would know 

where you could be raached in case we have trouble reaching you. (Please give me the name of someone who 

is not currently living in the household.) Please print items 12- 15. 1 RT62 

12. Contact Person name 3-4 ; 126-391 ) 40 14. Area code/telephone number Is7-106 

Last 6-24 ) First i Middle 

I I initial I-T-T-l n-T--l-In-T-l 

I I 

13a. Address (Number and street). )41-66 10 None E 

2 0 Refused 

snDK 

b. City Iss-E6~ 

I 

State 1se-87izlp 18s-ee 15. Relationship to household respondent poa-109 

I 1Code I 

I 

I I 

FOOTNOTES 

25 
lOTNOTES 

26 
LISTING SHEET 

E If this questionnaire is for an 

EXTRA unit, enter Control 

Number of original sample unit I) 

If in ARE4 OR BLOCK SEGMENT, also enter for FIRST Sheet number Line number 

unit listed on property I) 

TABLE X - LIVING QUARTERS DETERMINATIONS AT LISTED ADDRESS 

ADDRESS OF ADDITIONAL LIVING QUARTERS LOCATION OF UNIT SEPARATENESS AND FACILITIES CLASSIFICATION AREA AND BLOCK PERMIT SEGMENTS SEGMENTS 

If already listed, fill sheet and line number below and Is this a unit in a special Do the occupants (or Does (address in co/. (111 

stop Table X. Otherwise: enter basic address and unit place? 

N - Not a separate unit Is this unit within the Is this unit within the have direct access from 

address, if any, OR description of location. Include on this segment boundaries? same structure as the the outside or through a questionnaire. original sample unit? 

and eat separately from common hall? 

all other persons on the Separete unit - Do 

Property? not include on this 

questionnaire. 

H U Complete the 

01 appropriate segment 

vpe column for 

m tervie wing 

instructions. I 

(11 (2) (31 ‘14) I51 (61 (71 

Sheet- Line ~ 0 Yes - Skip to co!. 151 0 Yes 0 %; ;JMerk HU in q N - Stop’ Tab/e X for 0 Yes - interview as an 0 Yes - List on first 

this line EXTRA unit svailable line of /isting ~~/~~~~~$~~ to q No - Skip to co/. 151 * 

0 No sheet. interview if in 

manual and mark N - Mark N in co/. (51 0 HU - Fi// Co/. El Or(71, q No- DO not inten/iew 

as appropriate sample. 

q No 0 OT - Fill co/. 161 or (71, q No - Donotinterview 

as appropriate 

Sheet- ­ q Yes - Skip to co!. (51 Line 0 Yes 17 L;; ;;iM”rk HU in [7 N - Stop Tab/e X for 0 Yes - interview as an 0 Yes - List on first 

~$~~~~~~~$ to 0 No - Skip to co/. (51 ’ this line EXTRA unit available line of listing 

sheet. Interview if in 

manual and mark N 0 No - Mark N in co/. 151 0 HU - Fill CO/. 161 or (7J, 0 No - DO not interview 

as appropriate sample. 

0 No 0 OT - Fill co/. (6) or (71, 0 No - Do not interview 

as appropriate 

Sheet- - 0 Yes - Skip to co!. 151 0 Yes ,- 0 ‘x’x’; EJMark HU in 0 N - Stop Tab/e X for Cl Yes - interview as an 0 Yes - List on first Line 

$/~~~~~,“,“’ to c] No - Skip to co/. (51 ’ this line EXTRA unit available line of listing 

sheet. Interview if in 

manual and mark N 0 No - Mark N in co/. (51 0 HU - Fill CO/. 161 or (71, 0 No - DO not interview 

es appropriate sample. 

0 No 0 OT - Fill co/. 161 or (71, 0 No - Donotinterview 

es appropriate 

NOTE: Be sure to continue interview for original unit after completing Table X for all lines. 

OOTNOTES 
Current health topics: 1985-89 

1985 

The 1985 NHIS included 34,844 households that 

yielded interviews with 91,531persons. Because of budgetary limitations, the NHIS sample was reduced by 25 percent 

in the 1985 data collection year. 

Health promotion and disease prevention was the, 

special health topic of interest in 1985. One adult family 

member, 18 years of age and over, was selected to participate in the questions on .health promotion and disease 

prevention. Female family members were asked questions 

concerning their smoking history during pregnancy. Children under 18 years of age were the subject of questions 

about child safety and infant feeding. 

The 1985 basic health and demographic questionnaire 

included questions that were in the survey in prior years: 

acute conditions, chronic conditions, restriction in activity, 

use of medical services, and short-stay hospitalization. 

However, the 1985 NHIS marked the.initiation of several . new design features. 

The NHIS sample design implemented with the 1985 

data collection year reflected a complete redesign from 

the previous years (1,2). The major changes covered four 

areas (1). The formation of panels of primary sampling 

units (PSU’s) was one of the changes. The total NHIS 

sample of PSU’s was subdivided into four separate panels 

such that each panel was a representative sample of the 

United States population. This design feature had a number of advantages, including flexibility for the total sample 

size. The 1985 NHIS sample included three of the four 

panels. The second change was the reduction of the 

number of primary sampling locations from 376 to 198 to 

improve sampling efficiency. The third design change 

implemented in 1985 was the oversampling of the black 

population to improve the precision of estimates, The 

oversampling resulted in an increase in the number of 

black persons in the NHIS sample by approximately 75 percent and an increase in the precision of most related 

statistics by more than 20 percent. The fourth change 

facilitated followup studies of respondents and linkage 

with other national health-related data sets such as the 

National Death Index by using an all-area frame not based 

on the decennial census. 

28 
---- 

6 

U.S. DEPARTMENTOF COMMERCE establishment in accorda ction 3081dl of the Public Health Service Act 142 USC 242m). BUREA”OFTHECENS”S ACT,NoAsCo~~ECTIHoAoENTFORTHE 

U.S. PUBLIC HEALTH SERVICE 

NATIONAL HEALTH INTERVIEW 

SURVEY 

HEALTH PROMOTION AND DISEASE PREVENTION 

SUPPLEMENT BOOKLET 

o 0 No person 18 + in this family lHouseho/d pagel 

a. Section M (Household Respondent Section) 1’a.m. Interview 

1 0 Complete interview (all appropriate items completed) 

z 0 Partial interview (some but not all appropriate items completed) (Explain in notes) 10. Interviewer identification 

Noninterview , Code 

(Exp/ain in notesl 

b. Sections N through V (Sample Person Section) 

Interview 

ondeleted family members 18 + by age 

I 0 Complete interview (all appropriate sections completed) t). Refer to sample selection label 

z 0 Partial interview (some but not all appropriate sections priate. THEN circle Person No. in 

completed) rExplain in notes) ‘SP” box on HIS-1 for the selected 

Noninterview 

3 0 Refusal (Explain in notes) 

4 0 SP temporarily absent 

s 0 SP mentally or physically incapable 76 76-77 78-71 

s q Other (Explain in noted 1 ---.----.--------_-------------

1 TRANSCRIPTION FROM COMPLETED HIS-l 1 80 

12. Telephone in household (Household page, question 17, THEN 76) 2 

i 0 Yes sUDK _--.------------------------------

zuNo _ 3

13. Education of SP (page 42, question Zal 181-82 --__----.----------------------.----

oo 0 Never attended or kindergarten 

4 

Elem: 1 2 3 4 5 6 7 8 ---.---- ----------------------.----

High: 9 10 11 12 5 ---.--_-.--------_-------------~----

College: 1 2 3 4 5 6 + 

-__---_---------------------------------------- ____ 

Finish grade/year lQuestion 2bl 83 = __-_--_-.--__---___--__________ _---

I 0 Yes 

z0No 7 ---.------------_-------------.----

4. Main Race of SP (page 42, question 3a/bl 1 84 

8 

1 2 3 4 5 - Specify 3 ---.---- ----------------------.----

9 

5. Family Income (page 46, question 86) 18s-86. 16. TELEPHONE NUMBER w 

oo 0 A 100 K 20 0 u 13 None 

01 0 B 11 q L 21 IJV Area c&e I Number 

I 02 0 c 120 M 220 w I 

I OS 0 D 130 N 23 ox FOOTNOTES 

04 0 E 1400 24 0 Y 

06 0 F 160 P 25 0 i? 

060 G 1600 28022 

070 H 17OR (Transcribe from 8a if 8d blank) 

08 0 I 1sos 27 Cl $20,000 or more OSOJ 19 UT 2s 0 Less than $20,000 

, Refer to HIS-l (SE%)page 4, questions 4a and b. Transcribe from HIS-l for the sample 

person, if required (page 20, questions 5a and b). 

29 
Section M. PREGNANCY AND SMOKING Person Number __ 

Refer to age and sex on Household Composition Page. First name 

Ml q Females 18-44 in family (Enter person number q No females 18-44 in 

and name of all females 18-44; THEN 11 family (Section N! I 

L 

Read to respondent: -

These next few questions refer to smoking and pregnancy and are asked of women aged 

18-44. In this family the questions refer to (read name& I I 

I a. Are any of these women now pregnant? q Yes 

b. Who is this? Mark box in person’s column. 1q Yes, pregnant now 

c. Anyone else? 0 Yes lReask 1b and cl 

Za. Have any of these women given birth to a live born infant in the past 5 years? I I 

q Yes q No IM21 0 DK _____------------------------------------------------- -----d--------d4----- -

b. Who is this? Mark box in person’s column. 10 Yes, child past 5 years gf-JDK L3z 

-~___----------_---_____________________~---~~---~---- ---------d---_-~~d_---~-~--

Lc. Anyone else? 0 Yes Weask 26 and cl 0 No 

I I 1 i 0 Available. “Yes” in 2b (3) E 

20 Available; “Yes” in 1 b (41

M2 1 Mark first appropriate box. 17 1 band 2b blank for all persons (Section Nj I fW? I 30 Callback required (NP) 

40 Noninterview (Coverpage, THENNPI 

80 Other (NPI 

3. In what month and year was your last child born? 3. 1 lo-la 

-119-

Month Year 

4. Have you smoked at least 100 cigarettes in your entire life? 4. I 0 Yes (Mark “Smoking asked” I-AL 

box, THEN 51 

I I 90 No (Mark “Smoking asked” 

Ija. Do you smoke cigarettes now? 5a. 10 Yes 161 LA!L I I 20 No ---_----------------------------------------------

b. About how long has it been since you last smoked cigarettes fairly regularly? 

9980 Never smoked regularly (A431 

6. 1 19-20 6. On the average, about how many cigarettes a day do you now smoke? ____ Number 

000 Less than 1 par day 

I 0 “Yes” in 1 b and “Yes” in 5a IS/ 1 

M3 Mark appropriate box. M3 20 “Yes” in 1band “No” in 5a (71 

I I 80 Other (iW4) 

7. Have you smoked cigarettes at any time during this pregnancy? 7. 10 Yes 1 

I I 20 No (M4) 

8. On the average, about how many cigarettes e day did you smoke BEFORE you 8. 1 23-24 

found out you were pregnant this time? I I -Number 

1 1 990 Did not smoke regularly 

9. On the average, about how many cigarettes a day did you smoke AFTER you 9. 1 26-26 

found out you were pregnant this time? -Number 

I I -980 Did not smoke regutarty 

~~ 1 27 

M4 Mark appropriate box. M4 10 “Yes” in 2b 110) 

80 Other (14) 1 IO. Did you smoke cigarettes at all during the 12 months before your last child 10. 10 Yes 

1 28 

1 On the average, about how many cigarettes a day did you smoke BEFORE you 11. 1 29-30 

found out you were pregnant? -Number 

980 Did not smoke regularly 

112. On the average, about how many cigarettes a day did you smoke AFTER you 12. 1 31-32 

found out you were pregnant? -Number 

980 Did not smoke regularly 

000 None (141 

was born in (month and year in 311 20 No (741 

Il. 

1 3. In general, would you say that you smoked cigarettes during MOST of 13. 10 Yes 1 

that pregnancy? I I 20 No 

80 Other (Specify1 

1 4. Did a doctor EVER advise you to quit or cut down on smoking? ‘14. 10 Yes 1 34 

20 No 

90 DK . FORMHIsI,ss, 119SSl ICZs-I 

30 
1 AT72 

Section N. GENERAL HEALTH HABITS 

I 1 3-4 I 

I Sample Person Number I 

I 

I I [7 Callback required (Hhld. page) 1 5 

Nl I z 0 Noninterview (Cover page) 

I 3 q Available (1) 

Read to respondent: I 

I 

1 6 

These questlons are about general health practices. 1 I q Almost every day 

1. How often do you eat breakfast - almost every day, 2 0 Sometimes 

sometimes, rarely or never? , 

I 3 0 Rarely or never 

2. lnnzling evening snacks, how often do you eat between i I q Almost every day L 

- almost every day, sometimes, rarely or never? i 2 0 Sometimes 

I 3 0 Rarely or never 

I 1 8 3. When you visit a doctor or other health professional for i 0 Often 

routine care, is eeting proper foods discussed often, 2 Cl Sometimes 

sometimes, rarely or never? 3 Cl Rarely or never 

4 0 Don’t visit for routine care 

.N2 ‘1 Refer to page 46 or 47, item R, of H/S-l. 1 

1 

I 0 SP is Hhld. resp. 151 

s 0 Other (41 / 

1 

4a. About how tall are you without shoes? I 

I 

1 10-12 

I - Feet ~ Inches 

-----------------------------------------~-------------------------------------+~~~~-

b. About how much do you weigh without shoes? 

I - Pounds 

18 Hand Card N 7 or read responses for telephone interview. I 

I I 0 Don’t eat at bedtime ‘I7 

6. In your opinion which of these are the TWO best ways to i 2 0 Eat fewer calories 

lore weight? 3 0 Take diet pills 

4 0 Increase physical activity 

5 0 Eat NO fat 

s 0 Eat grapefruit with each meal 

1 18 6. Are you now trying to lose weight? I lOYes 

I

I 2 0 No (91 

I 1 19 7. Am you eating fewer calories to lose weight? 1 lOYes 

! 20No 

B. Have you Increased your physical activity to lose weight? lOYes 1 

20No 

1 21 aa. Do you conslder yourself overweight, underweight, or just I 0 Overweight 

about right? 2 0 Underweight 

3 0 About right (101 

b. Would you say you are very overweight, somewhat overweight, i I 0 Very overweight m 

or only a little overweight? 1 2 0 Somewhat overweight 

1 3 0 Only a little overweight 

, 1 23-24 I. On the average, how many hours of sleep do you get in a 

24-hour period? I 

I Hours 

IOTNOTES 
Section N. GENERAL HEALTH HABITS - Continued 

11. Is there a particular clinic, health center, doctor’s office, ; I 0 Yes or other place that you usually go to if you are sick or 1 20N0 (141 need advice about your health? 

I 

12. What kind of place is it - a clinic, a health center, a i I 17 Doctor’s office (group practice or doctor’s clinic) hospital, a doctor’s office, or some other place? I 2 0 Hospital outpatient clinic 

IF HOSPITAL: Is this an outpatient clinic or the emergency room? f s 0 Sample person’s home 

I 4 q Hospital emergency room 

IF CLINIC: Is this a hospital outpatient clinic, a company 1 s 0 Company or industry clinic 

clinic, or some other kind of clinic? I s 0 Health center 

i a 0 Other (Specify) 

13. Is there ONE particular doctor you usually see at (place in 1211 I 0 Yes 

lN31 20No’ 

Hand Card N2 or read reasons for telephone interview. I 0 Have two or more usual doctors or places depending 

on what is wrong 14. Which of these is the MAIN reason you don’t have a particular 2 0 Haven’t needed a doctor place you usually go? s 0 Previous doctor no longer available 

4 0 Haven’t been able to find the right doctor 

s c] Recently moved to area 

a 0 Can’t afford medical care 

s 0 Other reason (Specify1 

N3 Refer to sex. i I q Male (Section 0) 

i z 0 Female (15) 

15. About how long has it been since you had a Pap smear test? 1 

, -Years 

’ ss ONever 

\ oo 0 Less than 1 year 1 

I6a. About how long has it been since you had a breast examination i 

by a doctor or other health professional? I -Years 

I 9s ONever 

f oo 0 Less than 1 year 

--__---__---_---__-------------- d--------*---------------------*­

b. Do you know how to examine your own breasts for lumps? 1 I q Yes 

’ 2 0 No Eection 01 

------~-------------------------~--------------------------------

c. About how many times a year do you examine your own breasts I 

for lumps? r -Times per year 

I 

r as 0 Other (Specify) 

1 ga ONever 

-0OTNOTES 

L-z1 26 

1 

1 

1 29 

1 30-31 

1 32-33 

r-34. 

f- 3=5i6 

32 
--------- 

-- 

-- 

-- 

Section 0. INJURY CONTROL AND CHILD SAFETY AND HEALTH 

I ) 37 

f z 0 No children’under 10 in family 1031 

Read to respondent: 8 1 30 

These questions are about preventing inh&u? to children. 

I a. Have you ever heard about POISON CONTROL CENTERS? 1 cl Yes 

20No G?. 

____--__-_-----_------~-~---~----~~~~--- I ,------------ ____ ---------~--- 7--fiB01 Refer to household composition. 1 10 Children under 10 in family (11 

b. Do you have the telephone number for a Poison Control I 1OYes 

Center in your area? 1 20No 

I snDK 

2. There is a medication called IPECAC (ip’ i kak) SYRUP I 

10 Yes 

1 40 

which is sometimes taken to cause vomiting after 

something poisonous is swallowed. Do you now have 20No 

any Ipecac Syrup in this household? s0DK 

I 1 41 

02 Refer to household composition. l i q Children under 5 in family (3) 

I

l 2 0 No children under 5 in family (031 

#. Have you heard about child safety seats, sometimes called I 

I 

1 42 

car safety terriers, which are designed to carry children , 1OYes 

while they are riding in a car? I 2[7No (031 

1 43 I. Did a doctor or other health professional EVER tell you 

about the importance of using car safety seats for [your) 1q Yes 

children? 20No 

I 1 44 

03 Refer to household composition. I 

1 

10 

20 

Children under 18 in family fO41 

No children under 18 in family 1101 

[ UT73 1 3-4 

Person Number __ S-6 

First name 

04 Enter person number and name of all children under 18; THEN mark box. 04 

I 0 Under 5 (51 ( 7 

206-17 (71 

5. When - - was brought home from the hospital following birth, was 5. 1q Yes 

1 8 

buckled in a car safety seat? 20 No 

s 0 Not born in hospital 

40 Didn’t ride home in “car” 

snDK 

ia. Does now have a car safety seat7 6a. lOYes 1 9 

20No 

snDK 1 (71 

_____________-__________________________---------------------------------------

b. When riding in a car, is - - buckled in a car safety seat all or most of the b. I 17 All or most of the time -Izc 

time, some of the time, once in awhile, or never? ~0 Some of the time W’I 

3 0 Once in awhile 1 4 17 Never 

snDK 1 (71 

r. When riding in a car, does wear a seat belt all or most of the time, some 7. i 0 All or most of the time 1 11 

of the time, once in awhile, or never? 20 Some of the time 

3 q Once in awhile 

4 0 Never 

5 c] Uses child safety seat 

90DK 

j 12 

05 Refer to age. 05 10 Under 5 181 

8 0 Other ‘1061 

Read to respondent: 8. 1UYes ) 13 

{These next questions are about breastfeeding.} 20No 

I. Was --ever breastfed? 9uDK 1 (061 

1 14-16 I. How old was - - when - - COMPLETELY stopped breastfeeding? 9. 0000 Still breastfed 

I q Day.s 

2 q Weeks 

3 q Months 

Age 1 4 OYears 

1 17 

06 Respondent 06 I 0 Child’s parent 

8 0 Other 

-... _. FORMHs-1,SSI,lSS51IC258 

33 
--- -- 

-- 

“l,‘B 

Section 0. INJURY CONTROL AND CHILD SAFETY AND HEALTH - Continued 

10. When driving or riding in a car, do you wear a seat belt I

1 ~OAllormostofthetime all or most of the time, some of the time, once in l 20 Someofthetime awhile, or never? I 30 Once in awhile 

1 40 Never 

I 5 0 Don’t ride in car I 

I 

Read to respondent: I 01 Cl Only 1 fl ICJ 

The next questions are about this home. I 

I la. How many smoke detectors are installed in this home? I 

1 

-Number 

000 None 

(1lbJ 

’ 9snDK I (121 

________---__---------------------------~--------------------------------------------

b. How many of them are now working? I 

I 

I -Number 17 7dJ 

I 

1 000 None UlfJ 

___ .. _________ ---------------------------1------------ __-. --_------_ __--___----. 

c. Is it now working? I 117 Yes 

; znNo 

’ s~DK 1 f77fJ 

3-4 

6 

1 6-7 

1 8-9 

p-0--

_ ___- ..___._ -------------------------------~-----------.--------- _ - _ __- ._ - - - - ., _ - - - _ _ - -

d. How do you know [it islthey are1 working? I 

I I 0 Tested it/them LIEI 

I 

I 

I I c] It/they went off because of smoke 1 

I 

I 

I 

1 0 It/they went off while cooking 1 I 

I 

I I 0 Changed the batteries I 

I 

I 

I 1OThelightison I I 

I 

I 1 0 Seeps when battery is low I 

I 

I 

I 10 Other fSpecifyJ -1 

I ----------------------------------------~--------------------------------------------

e . Any other way? I 0 Yes ff?eask 7 IdandeJ 

I 0 No ----------------------------------------~--.------------------------------------

f. [Is it/Are any of the smoke detectors1 next to a sleeping area? I lOYes -L- -1e-

’ zuNo 

j snDK 

I2a. Do you know about what the hot water temperature is in , 

I 10 Yes 

1 19 

this home? 1 2nNo113J 

-___---_----------.----------------~----- +-- -_----_---_----~---_--~ _-.___ _- _.._ 

b. About what temperature is the hot water? I 1-20-Z 

I - Temperature I 

I OR I 

I 10 High 1 1 20 Low 

I 30 Medium ----------------------------------------~-------------------------------------... 

c. How did you estimate the hot water temperature? 1 I [7 The setting on hot water heater -L2c 

I 3 [3 Tested with thermometer 

1 30 Guessed 

I 8 0 Other ISpecifyJ 

I 

3. In the past 12 months, have you (or has anyone in your I 1clYes ( 25 

household) used a thermometer to test the temperature I 20No of the hot water here? I sUDK 

1 26-29 4. ABOVE what temperature will hot water cause scald injuries? f 

I Temperature 

: 99&i DK 

‘OOTNOTES 

34 
---- 

---------- 

1 RT76 

Section P. HIGH BLOOD PRESSURE 3-4 

, 1. I am going to read a list of things which may or may not affect a 1 

person’s chances of getting HEART DISEASE. 

; Hand Card P I

I 

After I read each one, tell me if you think it definitely I 

increases, probably increases, probably does not, or I 

definitely does not increase a person’s chances of I PROBABLY DEFINITELY getting heart disease. First - I DEFINITELY PROBABLY DOES NOT DOES NOT DUN0 

; INCREASES INCREASES INCREASE INCREASE OPINION 

a. Cigarette smoking? (Give me a number from the card.) 1 lcl 20 30 40 90 1 

__----------------------------------------------------- - - - - - - _ ._ - - -. . . -. _ -

b. Worry or anxiety? 10 20 30 40 90 1 

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

c. High blood pressure? 1 10 20 30 40 90 1 

-_.--._.. -.~---~~------------I-------- .__- --_--___- ___,___________,_____, 

‘I 

I d. Diabetes? I 10 2n 30 40 90 1 

_ -_..._..- ~---__-.-__-__-_----------~- I__--_ - - - .- - - - - - _. .-. - - - - _ - - - _ _ _ _ ._ - -. -. __ -

I 

e. Being VERY overweight? ; 10 20 30 40 i: 90 ( 

-_~-------------__---------------_---__--__-___-______~__~_____~_______~, 

I 

I 

f. Overwork? I 10 20 30 40 90 ( 

----------------------------------l----------------------~-------------, I 

I 

g. Drinking coffee with caffeine? 1 10 20 30 40 90 I 

__--_--_--_-----------------------l--~---~--~~--~~~~~~-~~~~~~~~~~~~~~~~. 

I 

I 

h. Eating a diet high in animal fat? I 10 20 30 40 90 1 

_-_--_---__-______-___i__--__-----I---------__--_--__~-______-___~______. I 

i. Family history of heart disease? i lcl 20 30 40 90 I-=­

__--_---------------------------~-l--~--~~~-~~--~~~~~~-~~~~~~-~~~~~~~~~, 

I 

j. High cholesterol? I 10 20 30 40 90 lIIzic I 

1 15 I. The following conditions are related to having a STROKE. In your i I q Diabetes opinion, which of these conditions MOST increases a person’s I 2 0 High blood pressure chances of having a stroke - diabetes, high blood pressure, or I 

high cholesterol? I 3 0 High cholesterol 

I soDK I 

. Which one of the following substances in food is MOST often I 

I I 0 Sodium ( 16 

associated with HIGH BLOOD PRESSURE - sodium, I 

cholesterol or sugar? I 2 0 Cholesterol 

I 

I 3 0 Sugar 

I 8 0 Other (Specify) 

I 9nDK I 

I. Have you EVER been told by a doctor or other health professional I 1 17 

that you had hypertension, sometimes called high blood pressure? i lOYes 

20 No (721 

3 0 Only during pregnancy (121 

i. Were you told two or more DIFFERENT times that you had lOYes ) 18 

hypertension or high blood pressure? 20No 

snDK I 

i. Are you NOW taking any medicine prescribed by a doctor for I 

I 

1 0 Yes la 1 19 

your hypertension or high blood pressure? I 

I z0No 

‘a. Was any medicine EVER prescribed by a doctor for your I 

I lOYes 

1 20 

hypertension or high blood pressure? I z 0 No (81 I 

I b. Did a doctor advise you to stop taking the medicine? I lOYes 

1 21 

I 

I 20No 

I 

OOTNOTES 

35 
--- -------------------- -- 

-- 

--- -- 

Section P. HIGH BLOOD PRESSURE - Continued 

8. Because of your hypertension or high blood pressure, a. Diet to lose weight? b. Cut down on salt or c. Exercise? 

has a doctor or other health professional EVER sodium in your diet? 

advised you to - i 0 Yes (91 I ** i Cl Yes (9J 1 23 lUYYeS191 IzK 

z 13 No 18bl z 0 No (84 z 0 No (711 

9. Have you EVER followed this advice? i q lYes (70) 1 26 i Cl Yes (10) I 26 I q Yes (70) 1 zn No 18bI z 0 No 18~) 2 0 No (17) 

10. Are you NOW following this advice? 

; i ;“,” /8bj ’ *’ ; E ‘,; (8~1’ *’ 1~Yes (111 1 

I I z0No I 

I 1 31 la. Do you still have hypertension or high blood pressure? 1 10 Yes (721 

20No 

I snDK 

.._..-.- ------;-------- --.- --_--_---~_-_-_-.._-____ __._ _-- I-- 32 b. Is this condition completely cured or is it under control? ( 1 0 Cured 

I z q Under control 

I 

I snDK 

2a. ABOUT how long has it been since you LAST had your I 2 0 Days ) 33-36 

blood pressure taken by a doctor or other health I 3 fl Weeks 

professional? I 

I Number 4 c] Months 

I ( 5 El Years 

I 

9sd DK 

I 

, ooo~ Never 1 1131 

-----------------------------------+----------------------------------------~--

b. Blood pressure is usually given as one number over I 

I i 0 Yes 7--jeanother. Were you told what your blood pressure was, I 2[7No in NUMBERS? I soDK > (12dl 

-----------------------------------r I __-__------.-_------_-- ---------------------,-~~~~ 

c. What was your blood pressure, in NUMBERS? I I I 

1 99sggg~ DK 40-42 -----------------------------------t-------------------------------------------­

d. At that time, was your blood pressure high, I I 0 High 

-I 43 

low, or normal? I 

I 2OLow 

I 3 0 Normal I 

I a 0 Other (Specify) I sCjDK I 

I 

1 44 13. Do you NOW have diabetes or sugar diabetes? I 7q jYes z0No I 

I 8 0 Other (Specify1 I 

14. Have you ever been told by a doctor or other health I 

I tOYes ( 46 

professional that you had high cholesterol? I zflNo I 

15. Do you have any kind of heart condition or heart I 

I lOYes 1 46 

trouble? I 20No I 

18. Have you ever had a stroke? I I 0 Yes ( 47 

I 2[7No I 

JOTNOTES 

36 
. Section 0. STRESS ,, , 1 

Read to respondent: I 

1, 

These next questions are about stress. ; I mAlot 

1. During the past 2 weeks, would you say that you 1 z q Moderate I 

experienced a lot of stress, a moderate amount of , 3 0 Relatively little 

stress, relatively little stress, or almost no stress et all? 1 4 0 Almost none 

I s 0 DK what stress is (31 

2. In the past year, how much effect has stress had on your 1 1nAlot 1 

health - a lot, some, hardly any or none? I 2OSome 

1 s 0 Hardly any or none 

3e. In the pest year, did you think about seeking 

personal or emotional problems from family 

help for any 

or friends? I lOYes 

1 

; znNo 

_________-__--------~~~~~~~---~~~------~ ~-------------2-------~~---7--------~~~~~ 

E b. from a helping professional or a self-help group? ’ lOYes 

1 z.nNo 

I 

Ql Refer to 3a and b. f I 0 “No”in 3a and 3b (Section RI 

1 s 0 Other 14) 

1 

Qa. Did you actually seek any help? ; 

I 

tOYes 1 

, 2 0 No (Section RI 

__________________--____________________ :____-________________________“‘________----~ 

Number up to four items in the order mentioned. - relative 1541 __ Anonymous 163 

b. From whom did you seek help? I Family member or Gamblers 

Do not read list. - Friend 1551 __ Weight Watchers 164 

- Psychologist 1661 _ Counselor at work 165 

__ Psychiatrist El - Counselor at school 166 

Psychiatric social - Probation officer .’ 167 

- worker 1681 

Other (Specify) 

I Other mental 3 

I- health professional 1691 

- Medical doctor 1601 - 168 

__ Religious counselor IXI 

I 169 

Alcoholics 

I- Anonymous El 170 

I ----------------------------------------~--------------------------------------------

,c. Anyone else? / 0 Yes (Reask 4b and cl 

, q No ’ RT76 

Section R. EXERCISE 3-4 

6 ! I 0 SP is physically handicapped (Describe in footnotes, THEN 1) -

Read to respondent: I 

I 

I 

) 

These next questions are about physical exercise. Hand calendar. 1 

1 a. In the pest 2 weeks (outlined on that calendar), beginning 

Monday (datel and ending this past Sunday (datel, have you 

done anyexercises, sports, or physically active hobbies? 

I iClYes 

i znNo /3,page131 

____-____-__------------------~~----.--.---- +---- -------_-----__~_-----~~~~---~~~~~-------

RI 

I 1 s 0 Other (2) 

b. What were they? I 

I Record on next page, THEN lc. I ----------------------------------------~--------------------------------------------

c. Anything else? 1 0 Yes (Reask Ib and c) 

; 0 No 12b) 

:OOTNOTES 

MH,S.l,SB,l‘985,W25.851, 
---------------- 

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

-- 

2 q 

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

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

Cl 

----------- 

Small 

-- 

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

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

-- 

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

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

0 Moderate 

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

Handball, Small 

----------------------- ---------------- 1 0 Small 3 •i None 

----------- 

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

r Section R. EXERCISE - Continued 

NOTE - ASK ALL OF 2a BEFORE GOING TO Zb-d. NOTE: ASK Zb-d FOR EACH ACTIVITY MARKED “YES”IN 2a. 

Read to respondent: These next questions are b. How many times in c. On the average, about d. {What usually happsnad to your 

about physical exercise. Hand calendar. the past 2 weeks did how many minutes did heart rate or breathing when you 

!a. In the past 2 weeks (outlined on that celendar), you [play/go/do1 you actually spend (activity in Zaj?) Did you have a 

beginning Monday, (date), and ending this past (activity in Za)? (activity in 2a) on each small, moderate, or large InSunday, (dateh have you done any (of the occasion? crease, or no increase at all in 

following exercises, sports, or physically 1 your heart rata or breathing? 

active hobbies) - YES NO 8-8 1q Small 3q Large I l3 

(1) Walking for exercise? 10 20 (1) - Times 1 - Minutes 110-n z 0 Moderate 4 0 None 

R2 Refer to age* I 13 SP is 75+ 123) ’ ‘* 

a q Other (2) 

(2) Jogging or running? 10 20 ( 15 (2) - Times118-17 -Minutes 118-20 10 q Small 3 0 q Large 1 21 2 Moderate 4 None __--------------------- T ---__-------____- 125-27 _--______________-_.__ 22 23-24 _ 1q Small ; B I.$;: 1’ 

(3) Hiking? lcl 20 (3) -Times ~ Minutes 2 0 Moderate -------------------.---- ’ --------------------._-- _________ ______ __ _ _____ -_-- _.. - _ _ -_ 29 30-31 32-34 1q Small 3 q large /

(4) Gardening or yard work? , [7 2 0 (4i - Timc!s r37-38 ~ Minutes 2 17 Moderate 4 0 None ___---- ._.. -.-- ---..-- ______.___ ______,__________ -. _-.-- 1-

(5) Aerobics or aerobic 36 39-41 1q Small large 

dancing? 10 20 (5) - Times ___ Minutes 2 0 Moderate :B None - ..-- ----------------.--- ------.---------- _____________ _-___________..____._ _.. ._ 

(6) Other dancing? 10 20 43 (6) Times44-45 -Minutes 46-48 1 Cl Small Moderate gL$~,“lx

- -------------_----_--------------‘-----------~------~-~-~~~~~~~~--~-~~~~~-- - d - - . . s . - -

(7) Calisthenics or general 1 60 51-52 153-66 1 0 Small 3 q large LE!L. 

exercise? 10 20 (7) - Times - Minutes 2 0 Moderate 4 0 None 

__----c---------------- T 57 58-59 ---__---__-_____ 180-82 __________-_________------ 1q Small 3 0 Large LSL

(8) Golf? 10 20 2 0 7 (8) - Times --___------------Minutes __-___---_--------d--Moderate 4 0 None 

(9) Tennis? --------------------------!?-~~~~~---.~ Small lcl 20 64 65-66 Minutes 87-69 z

1 0 Moderate ; 8 lz;pc - -----------------_------e-~ 

(IO) Bowling? 113 20 ( 71 (1.0) 72-73 74-76 z1aq Moderate 3 q Large L2L 

-Times ___ Minutes 4 q None ---------_--------_--

78 79-80 81-83 1 Cl Small i 1 $r$zK 

(11) Biking? 10 20 (11) -Times - Minutes z 0 Moderate __---__---------------- ---__---_---__-- _____________________ - _-

(12) Swimming or water 85 86-87 88-90 1q Small i [ L$rpL exercises? 10 20 (12) - Times ~ Minutes z 0 Moderate -_--------------------- T ---.------------ -..-_-_------- l-.sx-d-d 

92 93-94 1q Small 3 q Large 

(13) Yoga? 10 20 (13) ___ Times M,nute~~-g7- 2 0 Moderate 4 0 None 

R3 Refer to age- 1 0 SP is 65-74 123) y; 

a 0 Other 174) 6 

8 1 7-8 1 s-11 1q Small 3 q Large 1 l2 

(14) Weight lifting or training? 1 q 2 0 (14) m ___---_---_---_---------------------~-------~----~---~~--~~---~-~-~---~~-~~~---~--- Times -Minutes 2 q Moderate 4 0 None 

13 14-15 16-18 1q SmalI 3 q Large I 

(15) Basketball? 10 20 (15) - ___-___--__--___-___--- -20-------------Times -Minutes ---.---------_~- 21-22 2 0 Moderate __--~_---_---__-__~-- T23-26 1 0 Small 4 0 None 

3 Cl Large l-X-

(1 6) Baseball or softball? 10 20 (16) ___ ___-------------------- -~7--------------2s.------------ Times ~ Minutes 2 0 Moderate ~o=~l-l-~sman _-__---_ 4 0 None ‘f3’ 

(17) Football? 10 213 (17) -Times -Minutes 2 0 Moderate ; i L,.d,gt= 

-~~------------- p6-36 - 37-~3~--,-------------d1q Small 3 Cl Largel2.I 

(18) Soccer? 10 2n (18) -Times ___ Minutes 2 0 Moderate 4 0 None -4’i-------------- --__------------ __-__-________------_ 

(19) Volleyball7 10 20 (19) ___ Times42-43 -Minutes T44-48 21 0 Small ;: 1 l$E 

--___----------- -----_-________-_---_ 

(201 or squash? racquetball, 10 20 48 (20) -Times 49-50 -Minutes 51-63 12 q 0 Moderate i 00 Laa$=

(21) Skating? 10 20 55 (21) 58-67 ---.------------ Minutes 68-80 2 0 ------___-------__i__Moderate 4 0 Large E 

- ------_---_-------__--- - _______ -zzzk!n_es _____ ------~-------------- T65-87 3 q 1argeT.K (22) Skiing? - Minutes ------_---------10-10__62_122’-~T~~~~~~-_- _______________ ~8~~~~~~10~~~ ___-_ 

(231 Have you done any (other) exercises, sports, or 

physically active hobbies in the past 2 weeks 

(that I haven’t mentioned)? Anything else? 

0 Yes - What were they? )-JN~ 169-70 71-72 73-76 1 

3 0 Small 3 0 Large

(23) ___ Times - Minutes 2 0 Moderate 4 0 None 

177-78 79-80 ---__---__--__~- 81-83 _____________________ E

1 0 Small 3 q large 

(23) - Times - Minutes 2 0 Moderate 4 0 None 

38 
----- 

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

----- 

----- 

Section R. EXERCISE - Continued 

3. Do you exercise qr play sports regularly? 1 

, 

1ElYes 1 85 

I 20 No (5) I 

I 1 88-88 4. For how long have you exercised or played I I 0 Days sports regularly? 

I z 0 Weeks 

I 3 0 Months 

I 

I 

5a. Would you say that you are physically more actitie, less 

active, or about as active as other parsons your age? I 

I 

’ 

1 0 

2 0 

More active 

Less active 

( 88 

I 3 0 About as active lR41 

’ s 0 Other (Specify1 fR41 

---------------------------_----__---__-~--------------------------------------

I Number i 4 Cl Years 

b. Is that [a lot more or a little more/a lot lass or a little less] active? 1 I 0 A lot more T 

1 2 0 A little more 

1 3q A lot less 

1 4 0 A little less 

I 1 81 

R4 Refer to “Wa/Wb” boxes in C7 on HIS- 7. 1 I 0 Wa or Wb box marked (6al 

i s 0 Other 1619 

I 

1 * 1 82 6a. How much hard physical work is required on your job? I I 0 Great deal 

Would you say a great deal, a moderate amount, a little, 1 2 q Moderate amount or none? I s 0 A little (7) 4 0 None 1 --..__..--_. -_-- -.-.-- ----I--___--___--___-------------.-.-_-.---------.--­

b. About how many hours par day do you perform hard physical 1 1 93-94 

work on your job? I Hours 171 I ~_~-~----.-------------~----~~--~~~--~~~~ +--------------------------------------

c. How much hard physical work is required in your main daily ’ I 0 Great deal 7--95-

activity? Would you say a great deal, a moderate amount, a I 2 0 Moderate amount little, or none? 

I 30 A little 171 I 4nNone I ----------------------------------------~-------------------------------~------

d. About how many hours per day do you perform hard physical I 1 86-97 

work in your main daily activity? I Hours I 

Read to respondent: I 1 98 

These next questions are about strengthening the heart Days and lungs through exercise. 

7a. How many days a week do you think a person should exarcisa 8 0 Other (Specify) 

to strengthen the heart and lungs? sODK 

----------------------------------------+--------------------------------------

b. For.how many minutes do you think a person should I 

I 

~99-101 

exercise on EACH occasion so that the heart and lungs I Minutes are strengthened? I 

1 sss0DK 

----------------------------------------~-------------------------------------- - ‘1 -ioii-- Hand card R7 

o. (During those (number in 76) minutes), How fast do you 

think a parson’s heart rata and breathing should be to 

strengthen the heart and lungs? 

Do you think that the heart and breathing rate should be - I I 0 No faster than usual 

no faster than usual, I 2 0 A little faster than usual 

a little faster than usual, I 3 [3 A lot faster but talking is possible 

a lot faster but talking is possible, I 4 [7 So fast that talking is not possible so fast that talking is not possible? I snDK 

I 

OOTNOTES 

.,.~.,._._...-. __, 

39 
---- -- 

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

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

RT78 

Section S. SMOKING a-4 

I 6 

Sl Refer to “Smoking asked” box on HIS-I. I 

! 

I 0 “Smoking asked” 

snOther (1) 

box marked (4) 

I I 

Read to respondent: I I 

These next questions are about smoking cigarettes. ’ i q Yes 

1. Have you smoked at least 100 cigarettes in your entire life? t , 20No (41 

I 

2a. Do you smoke cigarettes now? 1 I Cl Yes (3) 1 

I 20No ~~~~~~--~~~~--.~~~--~~______-____------------------- l----------------_--____--_------------------­

b. About how long has it been since you last smoked cigarettes 1 F 

fairly regularly? 

(4) 

I Number 

I 

! 888 0 Never smoked regularly (4) 

I 

3. On the average, about how many cigarettes a day do I 

1 oo q Less than 1 per day (11-1; 

you now smoke? I 

Number 

4. {These next q&ions are about smoking cigarettes.} (Hand ; 

Card S) Tell me if you think CIGARETTE SMOKING definitely PROBABLY DEFINITELY increases, probably increases, probably does not, or definitely 1 DEFINITELY PROBABLY DOES NOT DOES NOT DKINO does not increase a person’s chances of getting the following I INCREASES INCREASES INCREASE INCREASE OPINION 

problems. First - I 

a. Emphysema? (Give me a number from the card.) I I ----__---------------------------------- 1--10----c?------3-!-----2~ ____ --52. 

b. Bladder cancer? I lcl 20 30 40 3u 1 ----------------------------------------~--------------------------------------------

c. Cancer of the larynx (lar’inks) or voice box? ! lcl 20 30 4ii SO I ----------------------------------------~--------------------------------------------

d. Cataracts? I 10 20 3cl 40 SO 1 

_---__---__----------------------------- ~-----------------------------~-~---~-~~-~--~ 

e. Cancer of the esophagus? ; 10 20 30 40 90 1 

_--___----_----_------------------------ -----------_----~L-_--~----~--~--~-~--~ f----­

f. Chronic bronchitis? 1 _--___---_----------____________________ ,-2” I -----4”------3-!---~--:E------e ---_-_ 

9. Gallstones? 1 10 20 3c! 40 917 CE 

------_----___--__----~~---~----~--------~~---~----~~--~~~~-~~~~-~~~~~~~~~-~~~~~~.~~~~ 

h. Lung cancer? I 10 20 30 40 so 1 

1 

s2 Refer to age. 

1 0 SP is under 45 (4;) 

2OSPis45+ (S31 

Read to respondent: PROBABLY DEFINITELY 

Does cigarette smoking during pregnancy definitely increase, ; DEFINITELY PROBABLY DOES NOT DOES NOT DKlNO 

probably increase, probably not or definitely not increase the I INCREASES INCREASES INCREASE INCREASE OPINION 

chances of - I 

i. Miscarriage? 10 20 30 40 SO E 

----------_ -----------------------------1--------------------.-----------------------.. 

j. Stillbirth? 

k. Premature birth? j 10 20 30 40 90 1 

_--------------------------------------- 3 ---.-------.------------ - -_ 

I. Low birth weight of the newborn? I 10 20 30 40 90 1 

I 1

5a. If a woman takes birth control pills, is she more likely to have I lOYes a stroke if she smokes than if she does not smoke? ’ znNo 

631 

I 8nDK > 

l------------------------~--~----~~--~~.----~. 

b. Is she much more likely or somewhat more likely to have I

l I q Much more 1 

a stroke? 1 2 0 Somewhat more 

Refer to 1. I I Cl “Yes” in 1 (6) h!L s3 I I ’ 8 q Other (Section T) I 

6. Did a doctor EVER advise you to quit or cut down on smoking? ’ lOYes 

1 

I 20No 

; PODK 

.-- ._ FORM HIS-71SBt 11985114.26.l
---- 

Section T. ALCOHOLUSE 

Read to respondent: 

I 

I 

1 30 

I 

These next questions are about drinking alcoholic beverages. 

Included are liquor such as whiskey, rum, gin, or vodka, and 

beer, and wine, and any other type of alcoholic beverage. 

I 

I 

I 

I 

I a. In YOUR ENTIRE LIFE have you had at least 12 drinks of ANY ’ i q Yes ._. 

kind of alcoholic beverage? I zq,No (7.d) I 

----.-----------.---------------L--- ~__-I_.---_-------.------~.---- -.--­ . ,. r -51-- b. In ANY ONE YEAR have you had at least 12 drinks of ANY kind I I q lYes 

of alcoholic beverage? ’ z0No f7dl 

--..-.-----~-------------------.----r-------------- ---.------- --.­

c. Have you had at least one drink of beer, wine, or liquor during 1 lOYes@/ .Lx..l 

the PAST YEAR? 20No 

_ - ---.-.~------------------.~- :---------.----------.-.-- -.-- . . -.--.. 1 33zi4-

d. What is your MAIN reason for not drinking (in the past year)? I oo 0 No need/not necessary 

01 0 Don’t care for/dislike it 

I 02 0 Medical/health reasons 

03 0 Religious/moral reasons 

O-I q Brought up not to drink 1 (91 

05 0 Costs too much 

06 0 Family member an alcoholic or problem drinker 

1. 07 q Infrequent drinker . ’ 08 0 Other (Specify) .I,’2 

!. In the past 2 WEEKS (outlined on that calendar), beginning I 01 0 14 (Every day) 120 8-9 2303 35-36 

Monday ldatel and ending this past Sunday (dare), on ’ 02~13-14 1308 24u 2-3 

how maniys did you drink any alcoholicsrages, 

such as beer, wine, or liquor? f 

’ 

03013 

04012-13 

1407-8, 

150 7 

250 2 

260 l-2 

Use list to probe, if necessary. , 

’ 

05nl2 

06011-12 

1606-7 

170 6 

2701 

bo 0 None/Never (4) 

I 07011 ,sfl5-6 990DK 

’ 08010-11 1905 

I 09010 200 4-5 

; 1009-10 210 4 

I 1109 220 3-4 

i 37-33 I. On the (number in 2) days that you drank alcoholic beverages. I 01q Twelve or more 08 0 Three or four 

how many drinks did you have per day, on the average? 1 02 0 Seven to eleven osnThree ,, 

Use list to probe, if necessary. f 03ClSix IO 0 Two or three 

1 04 0 Five or six IIOTWO 

1 osnFive 120 Oneortwo 

1 06 0 Four or five 130 One 

, 07 OFour ss[3 DK 

la. Was the amount of your drinking during that P-WEEK 

typical of your drinking during the past 12 months? 

period I

I 

’ 

1q iYes~51 2nNo 

1 39 

_______.__ - .___ - -___ --.---------------+-- -_____. --_-----_---- _ .- - - _. - - -. - - - .-

b. Was the amount of your drinking during that 2-WEEK period I

I I q More LIz!Ei 

more or less than your drinking during the past 12 months? ' 2 q Less 

1. During the past 12 months, in how many MONTHS did you 1

I . ) 41-42 

have at least one drink of ANY alcoholic beverage? I 

I Months I 

I. During [that month/those months], on how many DAYS did you 1 1 43-46 

have 9 or more drinks of ANY alcoholic beverage? Days 

I

I oooaNoneornever I 

During [that month/those months], on how many DAYS did you 1 1 46-48 

’ have 5 or more drinks of ANY alcoholic beverage? (Include the I Days (number in 6j days you had 9 or more drinks.) I

I ooo 0 None or never I 

During the past year, how many times did you drive when I 

I 

1 49-51 

’ you had perhaps too much to drink? I Times . I

I ooonNone i /. 

1 998 q Don’t drive 

OOTNOTES 

MHIS.1ISEI118E61,4.26.86, 

41 
--- --- ---- ----- ---- 

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

------ 

-- 

--- ------ 

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

Section 1. ALCOHOL USE - Continued 

9. (Hand Card TI Tell me if you think HEAVY ALCOHOL DRINK- 1 

ING definitelv increases. orobablv increases. orobablv does , 

not, or definiiely does noiincreask a perso&‘chances of I 

getting the following problems. First - I 

I 

I PROBABLY ;E’~~l-fs”N”o: 

I DEFINITELY PROBABLY DOES NOT DUN0 

1 INCREASES INCREASES INCREASE INCREASE OPINION 

I 

I a. Throat cancer? (Give me a number from the card.) I 10 2.0 30 40 90 1 

..---- . ---.--- ;- ---... _.__ - ___ ______. _-_--. 

I 

b. Cirrhosis of the liver? I

I 10 2u 30 40 90 1 

..------ -.---. I ---._--__ .______I..___.._ - _ . ._ _ -

I 

I c. Bladder cancer? I 10 20 30 40 SC! 1 

_. --.--------.-----------------T--- I ----+e-L-_- -___._ _- .__-.-. . ..- -

I 

d. Cancer of the mouth? I 1Cl 20 30 40 90 CE 

----------------_______________I________----------------~----~-----

I e. Arthritis? I 10 20 30 40 

f --.-. -_ - __ _... __ _________._. . -_.-

f. Blood clots? 

I 

I 1 I 

Tl Refer to age. I 

I I q SP is under 45 (ggl 

I 2 q SP is 45 + lSecrion Ul 

I I 

I 

Read to respondent : I 

I 

I 

Does heavy drinking during pregnancy definitely increase, ; DEFINITELY PROBABLY FFi;pNBBoLTy m;my 

DUN0 probably increase, probably not or definitely not increase I INCREASES INCREASES INCREASE INCREASE OPlNlON the chances of - I 

I 

I 

g. Miscarriage? I 10 20 30 40 90 I 

---------------------------------~-----------------------------------

I 

I 

h. Mental retardation of the newborn? I 10 20 30 40 Du E 

---------------------------------T-------------------~--------------- I 

I 

i. Low birth weight of the newborn? I 10 20 30 40 90 1 

- _.-- -----I- -----.-_- -.--. -_c---__-- _______. ~_-

I 

j. Birth defects? I 10 20 30 40 DU l2.z 

I 

I Oa. Have you ever heard of FETAL ALCOHOL SYNDROME? I 

I 

lOYes ( 

I 

I 2 c] No (Section UI 

---------------------------------T-------------------------------- I 

b. In your opinion, which ONE of the following best describes I E 

Fetal Alcohol Syndrome - a baby is born drunk, or born I 

addicted to alcohol, or born with certain birth defects? 

I 

I I 0 Drunk 

I 2 0 Addicted to alcohol 

I 3 c] With certain birth defects I 

I-0OTNOTES 

42 
--- 

---- ------ 

------ 

---------- 

Section U. DENTAL CARE 

. This next question is about preventing TOOTH DECAY. /-/and ’ PROBABLY DEFINITELY 

Card U. After I read each of the following, tell me if you think it 1 DEFINITELY PROBABLY NOT NOT DK/NO 

is definitely important, probably important, probably not, or ; IMPORTANT IMPORTANT IMPORTANT IMPORTANT ‘OPINION 

definitely not important in preventing TOOTH DECAY. First - , 

a. Seeing a dentist regularly? .(Give me a number from the card.) / I 0 20 30 40 SO L-E. 

----_---------------_________ 4 ___________ --__----------_----.------

I 

b. Drinking water with fluoride from early childhood? ’ 10 20 30 40 9.0 1 

-------------------------------------+-------------------------~---------------

I 

I c. Regular brushing and flossing of the teeth? 10 20 30 40 90 1 

-----~--------------____________ ; ______. ----.--------___--.---.-.-----.----

I 

d. Using fluoride toothpaste or fluoride mouth rinse? I 10 20 30 40 90 m 

---. ------_____--------- -----/-- -------_-----------_---- _-..-

I 

a. Avoiding between-meal sweets? 1 10 20 30 40 90 1 

I 

Now I’m going to ask about preventing GUM DISEASE. In I 

’ your opinion, how important or not important is each of the 1 

following in preventing GUM DISEASE? First - I 

I 

a. Seeing a dentist regularly? I

I 10 20 30 40 90 1 

_- - -.--- ------------------.- A--------------.-.--------------------­

b. Drinking water with fluoride from early childhood? I 10 20 30 40 90 1 

__-__--_------------------------ 1------------------- ---.----. 

I 

c. Regular brushing and flossing of the teeth? I 

I 10 20 30 40 90 1 

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

I 

d. Using fluoride toothpaste or fluoride mouth rinse? I

I 10 20 30 40 90 1 

---_---------------------------- -j-------------------------.-----------. -

I 

e. Avoiding between-meal sweets? 1 10 40 90 1 

In your opinion, which of the following is the MAIN cause of i I 0 Tooth decay I-z 

tooth loss in CHILDREN - tooth decay, gum disease, or injury 1 2 0 Gum disease to the teeth? I 3 0 Injury to the teeth 

1 In your opinion, which of the following is the MAIN cause of ’ I q ]Tooth decay tooth loss in ADULTS - tooth decay, gum disease, or injury to 1

I 2 0 Gum disease the teeth? I 3 0 Injury to the teeth 

I 

1. Have you ever heard of DENTAL SEALANTS? I I q Yes 1 I 

I 2 q No (Section VI 

__-____-__-_-----_-------------- j------------------------------------. 

b. Which of the following BEST describes the purpose of dental I I aPrevent gum disease 1 

sealants - to prevent gum disease, to prevent tooth decay, or I 2 q Prevent tooth decay to hold dentures in place? I 

I 3 OHold dentures in place 

FORMHIS-1ISBI I19861 Id2S.W 

43 
-- -------------------- 

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

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

RT7B 

Section V. OCCUPATIONAL SAFETY AND HEALTH 3-4 

*I8 6 

VI Refer to “Wa/Wb” boxes in Cl on HIS- 1. I I 0 Wa or Wb box marked (7) 

/ 8 0 Other (Cover page) 

Read to respondent: I 

I 

1 8 

These questions are about your present job. I 

’ lOYes 

1 a. In your present job, are you exposed to any SUBSTANCES 

that could endanger your health, such as chemicals, dusts, ( znNo 

. fumes, or gases? ; 80DK > 12) 

-------_______--~--~~~~~~~~~----------~~~_----~~_____----_----~~-----~~~~~~.~~~~~--___ 

b. What substances are you exposed to that could SUBSTANCE 1 SUBSTANCE 2 endanger your health? 

Enter each substance in a separate column. 1 7-8 (17-18 

Any others? 

--_____-______------------------------------------------------------------------------

Ask Ic for each response in lb. S-16 19-26 

c. How can (response in lb) endanger your health? 

Record verbatim response(s). 

Any other way? 

88nDK 990 DK AT80 

28. In your present job, are you exposed to any WORK 3-4 

CONDITIONS that could endanger your health, such as 1 Cl Yes 

6 loud noise, extreme heat or cold, physical or mental : z[7No 131 stress, or radiation? ; sUDK I - ______ --.-- --_------- - -------------------_-----------~------------ b. What work condmons are you exposed to that could 

endanger your health? WORK CONDITION 1 WORK CONDITION 2 

Enter each work condition in a separate column. 1 6-7 p-17 

Any others? 

---.- _-.- - ---.---- --------. _-____ -__--_ ____.____. ,. _ .._. ___- Ask 2c for each response in 2b. S-16 IS--26 

c. How ten (response in 2bl endanger your health? 

Record verbatim response(s1. 

Any other way? 

-

88nDK ssnDK 

3a. In your present job are you exposed to any risks of lOYes 1 66 

accidents or injuries? ’ znNo (Cover Pagej f 90DK 1 --.-- -_-._ -.--------------2 _____ -)------ ---------I --... . --. - -.-- - . . . ,. _ 

b. Whet (other) risks of accidents or injuries are you I 67-80 

exposed to? I 

I Record verbatim responselsl. I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I _______----___----______________________- ~------------------------------------ _--_--_ 

c. Any others? 1 0 Yes IReask 3b and c) 

1 q No (Cover Page) , q DK 

44 
CARD R 

RACE 

1. Aleut, Eskimo, or American Indian 

2. Asian or Pacific islander 

3. Black 

4. White 

CARD I 

INCOME 

U . . . . $20,000 - $24,999 

V . . . . $25,000 - $29,999 

W . . . $30,000 - $34,999 

X . . . . $35,000 - $39,999 

Y . . . . $40.000 - $44.999 

2 .,.. $45,000 - $49,999 

ZZ... $50,000 and over 

CARD 0 

ORIGIN 

1. Puerto Rican 

P.Cuban 

3. Mexican/Mexican0 %

-0 

:------- I 4. Mexican American 

6. Chicano 

6. Other Latin American 

7. Other Spanish I 

j

I 

I 

CARD J 

INCOME 

A . . . . . . . Less than $1,000 iincluding loss) 

B . . . . . . . $1,000 - $1,999 

c . . . . . . . $2,000 - $2,999 

D . . . . . . . $3,000 - $3,939 

E . . . . . . . $4,000- $4,999 

F . . . . . . . $5,000 - $5,999 

G . . . . . . . $6,000- $6,999 

H . . . . . . . $7,000 - $7,999 

I . . . . . . . . $6,000 - $6,999 

J . . . . . . . M,OOO - ~9,999 

K . . . . . . . $10,000 - ~10,999 

I. . . . . . . . . *11,000-*11,999 

M . . . . . . *‘12,000- $12,999 

N . ..a... $13,000- $13,999 

0 . . . . . . . *14,000- $14,999 

P . . . . . . . $15,000- $16,999 

0 . . . . . . . tl6.000 - ~16,999 

II . . . . . . . t17.000 - $17,999 

S . . . . . . . $16,000 - W6.999 

T . . . . . . . $19,000- M9.939 

45 
CARD Nl CARD N2 

Choose two 1. Have two or more usual doctors or 

1. Don’t eat at bedtime places depending on what is wrong 

2. Eat fewer calories 2. Haven’t needed a doctor 

3. Take diet pills 3. Previous doctor no longer 

available 

4. Increase physical activity 

4. Haven’t been able to find the 

5. Eat NO fat right doctor 

6. Eat grapefruit with each meal 5. Recently moved to area 

6. Can’t afford medical care 

8. Other reason - Specify 

CARD P CARD RI 

1. Definitely increases the chances of 1. No faster than usual heart disease 

2. A little faster than usual 

2. Probably increases the chances of 

heart disease 3. A lot faster but talking is possible 

3. Probably does not increase the 4.80 fast that talking is not possible chances of heart disease 

4. Definitely does not increase the 

chances of heart disease 

9. Don’t know or no opinion 

46 
CARD S 

Clgerette smoking -

1. Definitely increases the chances 

2. Probebly increases the chances 

3. Probably does not increase the chances 

4. Definitely does not increase the chances 

9. Don’t know or no opinion. 

CARD U 

1. Definitely important 

2. Probably important 

3. Probably not important 

4:Definitely not important 

9. Don’t know or no opinion 

CARD T 

Heavy alcohol drinking -

1. Definitely increases the chances 

2. Probably increases the chances 

3. Probably does not increase the chances 

4. Definitely does not increase the chances 

9. Don’t know or no opinion 

47 
1986 

The 1986 NHIS was conducted with a sample approximately one-half the size of the full sample because of 

funding limitations. The 1986 NHIS sample included two 

of the four panels. The interview sample for 1986 was 

composed of 23,838 households in which 62,052 persons 

were interviewed. 

In 1986, as in previous years, the NHIS obtained data 

on acute conditions, episodes of persons injured, restriction in activity, limitation of activity due to chronic conditions, the prevalence of chronic conditions, respondentassessedhealth status, and the use of medical servicesincluding physician contacts and short-stay hospitalization. 

The current health topics included in the 1986 NHIS 

were vitamin and mineral intake, employment, dental 

health, functional limitations, and health insurance. Except for the health insurance questions, the 1986 health 

topics were included in a separate booklet. Questions on 

health insurance were included in the health and demographic questionnaire. 

The questions on vitamin and mineral intake inquired 

about the name of the product, the amount taken, the 

length of time the product was taken, and if the product 

was obtained with a doctor’s prescription. 

The questions pertaining to employment asked about 

the longest job worked, the kind of work the sample 

person had been doing the longest, and the kind of 

business or industry it was. 

The questions on dental health pertained to the 

number of dental visits, the reason for going to the dentist, 

the brand of toothpaste and fluoride mouthrinses used, 

the use of fluoride supplements, and the purpose of water 

fluoridation. 

The questions on functional limitations pertained to 

the activities of daily living and the instrumental activities 

of daily living. The survey instrument also included questions about the number of steps and the number of floors, 

and the need for having a walk-in shower and having a 

bathroom, bedroom, and kitchen on the same floor. 

The health insurance questions inquired about Medicare, Medicaid, military, and other health insurance plans 

and coverage; reasons for not having health insurance; 

compensation for disability; and coverage during job layoff, 

48 
-- 

-- 

-- -- 

---- 

-- 

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

-- 

-- Pn.,.,srl -- -- 

-- 

---- 

I “8 oa Section M. HEALTH INSURANCE 3-4 

I Read to respcndentlsk Medl~re is a Soclal Sscurity health hwunnca program for disabled persons and for psnons 66 

ye.” old and owe,. People covamd by Medicars have a card that looks like this. Show card. I I 

1 a. Is anyone In thla family, tbet IsJread names), now covered by Medicare? -~-------------~________________________~-------------~~~~~~~~ q Yes 0 No (4) q DK 

lb. , q Covered SnDK 1 

b. I* now covemd? 2 0 Not covered 

Ask for each person with “Ccvered”in lb: 20. 10 Yes gnDK 1 

20. la now covrmd by the part of Social Security Medicare which pays for horpital bills? 20No ---------------~-------------------------------------------------­ loyes sE.&-E 

b. Ia now covwad by that pmt of Medicare which pays for doctor’s bills? This is thi Medicam plan for which or b. soms agsncy muat pay l carbdn amount each month. 20NO 

Ask for each person with “OK” in 28 and/orb: 3. 1 0 Hospital 1 

3. May I plerw sw the Social Sscudty Medicare card(s) for (and --I to determlns tha type of coverag!? 

Transcribe the information from the card or mark the “Card N.A.” box. z 0 Medical 

3 0 Card N.A. 

4a. We me lntsmsted In all kinds of health bwurancs plans except those which pay only for 1 

accidents. INot counting Medlcwa) Is anyons In the family now covered by a health 

lnsurancs plan which pay‘ any part of a hospital, doctor’s, surgeon’s or dentist’s bill? q Yes 0 No Ml) q DK. (Ml) --------------------____________________------------------------- --_________________

b. What I* the nmne of the plan? Record in Table H.I. 

C. l~,~“~,;;~h~f~,l?;,,,,~b~,,lh,hsa~h~”~u~~h~~~~ 

pays any part of a hospital, doctor’s, surgeon’s or dentist’s bill? q ]Yes Fteaskskbandcl 0 No 

TABLE H.I. 

.- . Yes No DK 

U.-“-K--JPaY any 1 2 9 7. Is 7. ,o Covered . . . 

part of horpltal expsnsas? _________ i%iy” ------------_- 2 17 Not covered 1NPI

b. Dwsthlsplw~pay.nypart 1 3 3 this SnDK . . . . . . . of doctor’s or wrgson’s 

~IviceS other than ora1 9mployw or union? - surgwy? 

Yes No DK 

6a. Iethll ~plrnaHaalth , 2 22 7. It ci”erd , u ““.~I~” . . * I 7. I _ rl _ I y&y- OrganlmUon or 

under 20 Not covered VW ---__-_--------.-----___ this SODK . . . . . . . b. Was tbla plan obt&md throunh ’ ’ “” ’ ‘@ I -_ 

I C. la It now curled through an ~~lcer other than oral l mployw or union? , dtrgsry? 

1 33 

Yes No DK Yes No DK 60. Imthls [aame)plwi.HMth , 2 3 6a. Doesthlr&@n~Lpl~np.yany y&nmca Orgmlutlon or pwt of hospital wrpwwa.7 

, 2 3 3. 7. Is 7. , q Covered . . . COVWed ----------‘--‘---9--

I -,------------l--L-~--~ I IL Dan~thlsnl~np.y.“ypwt 1 2 

l-- under 2 0 Not covered WI 

this 9mDK . . . . . . . urgeon’* Inems) an l mplo~rrorunlon7 - 128 bills for opwatlorw? plan? ----------------,--- - _ 2 - s- C.iY..Zt~~~G&iEi~i i- 2- s--

G II It now car&d through an u?vlus othw than oral l mployrr or union? rurgwy? 132 

FOIW HIS-1 ll9BBll7-34I6l 

49 
-- 

-- 

-- 

-- 

-- 

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

1 3-4 I - -

b. ,u Covered 9nDK = ,n Covered 9mDK - lb. ,n Covered 9nDK - ,o Covered 9aDK 1 

2 q Not covered 2 17 Not covered 2 0 Not covered 2 0 Not covered 

- -

a. 1q yes 9nDK ) 20. 10 Yes 90 DK ) 

20No 20No 

b. 10 Yes 9uDK 1 1q yes 90DK 1 b. 1 Cl Yes 9nDK = 1q Yes 9aDK w 

20No 20 No 20 No 20No - - -

1 0 Hospital 1 1 17 Hospital I-L FL- 1 0 Hospital I , q Hospital 1 

2 0 Medical 2 0 Medical 2 0 Medical 2 0 Medical 

3 q Card N.A. 3 q Card N.A. 3 0 Card N.A. 3 0 Card N.A. 

- - - -

1 

----------_-_-_----_ 

1 1 1 

‘. , 0 Covered . . . , 0 Covered _ . . 7. ,a Covered . . . 10 Covered , IS 

20 Not covered fNPJ 20 Not covered (NPJ 20 Not covered fNPl 2q Not covered lNPl 

9nDK . . . . . . . 9aDK . . . . . . . > 9nDK . ..I_.. 9nDK ,,,,,.a 

l-z!­

, 0 Covered . . _ ,u Covered _ _ . ,u Covered r . . 1 0 Covered G‘, 

20 Not covered (NPJ 20 Not covered lNPl 20 Not covered (NPI 2fl Not covered iNPl 

9nDK . . . . . . . > 9nDK . . . . . . . > 9nDK . . . . . . . > 90DK rr.,,,, 

1 1 

, j--J Covered . _ _ , q Covered . _ _ ,n Covered r . . 10 Covered . , . 

20 Not covered fNP1 20 Not covered iNPJ 20 Not covered VJPI 2 0 Not covered lNP1 

9nDK . . . . . . . 9nDK . . .._.. 9nDK . . . . . . . > 9nDK ,,,l,,l > 

50 
------------- 

-- 

----- 

---- 

-- 

---- 

-- 

-- 

-- 

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

6a. Ia this ~plw~ a Health 6s. D-8 this w plan pay an Mdntenancs O~mlutlon or part of horpltal expenses? HMO7 ------------_ _-_---------_ b. Dws this plan pay any part 

b. Was this plan obtalnnd thro of doctor’s or surgwn’s 

an smploysr or union? bllls for oparatlonr? 

_---------____ c. Dws lt pay for any DENTAL C. Is It now carded through an services other than oral amployar or union? 

Yes No DK Yes No DK 

60. Im thls&i?&plana Health , 2 9 60. Does this LnameLplan pay any, 2 g 48 7. Is 7. , q Covered . . . aid,“““““” Drganlzatlon or part of hospital expenses? covered 143 --------------. .---~-- = 2 0 Not covered WI under ----------i---rsers b. Dcastblsplanpayanypart I-- 2 lhl8 9nDK ._..... 

b. War this plan obtslnad through ’ of doctor’s or surgeon’s 

an smployer crunlon7 bills for opsratlons? ----------.--‘---~-- ---------------.,-- ---8--

2 C. DcesltpsyfcranyDENTAL ’ ’ C. Is It now carried through an 145 rswicer other than oral amploysr or union? 148 w SurQsry? 

1 Ml 

, /-J Covered . . . . . . . . . . . . 

Ml Review 1 and 7 for each person and determine if “Covered” by either Medicare andlorinsurance, or “Not covered. ” 2 0 Not covered under 65 . . INPI 3 0 Not covered 65 and over 

snDK . . . . . . . . . . . . . . . . 

.w Ask for each person “Not covered” in Ml. If “Not covered 65 and over,” include “or Medicare.” 60. 

Baa (Many people do not carry health Insurance for varlow masons.} Hand Card M. 1 2 3 4 5 6 7 e3 

Which of those statements dsacrlbss why Is not covered by any health Insurancs (0~ Medicare)? 

Any othar mason? Circle all reasons given. Specify 

53-54 

55-56 -------------___________________________----------------------------------------

Mark box if only one reason. If “Not covered 65 andover”in Ml, include “orMedicare.” b. 000 Only one reason E 57-56 

b. What Is the MAIN reason Is not covered by any health Insurance (or Madlcere)? 12345678 2 

Specify 

Ask only if persons under age 20 in family: 

90. Does anyone In this family now receive assistance through 

tho “Aid to Families with Dependent Children” pmgram, q h Cl NCf70) q DK scmetlmes callad “AFDC” or “ADC”? 

----___----__----_--------------------------------------------------------------

b. Does now mcalve AFDC or ADC? Ob. E 

1OYes .snDK 

20NC 

0% Doss anyone In this family now receive the “Supplemental 

Sscurlty Income” or “SSI” check? q lY*s q No (11) q DK 

----,~-y~s----,ooK~ 

b. Does now mcslve this check? lob. 

20Nc 

RM HIS-l,lm3I W3.86, 

51 
--- 

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

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

1 41 1 41 1 41 1 

7. , 0 Covered . . . ,a Covered . . . 7. , q Covered . . . ,n Covered , , , 

2 0 Not covered INP) 2 0 Not covered 1NPl 2 0 Not covered WI 2q Not covered INP) 

90DK . . . . . . . > 9oDK . . . . . . . > 9nDK . ..-... 9nDK .a,..,, > 

1 49 1 49 1 49 1 

7. , j-J Covered . . . , [7 Covered _ _ _ 7. ,a Covered . . . , f-J Covered , , r 

2 0 Not covered INPI 2q Not covered INPl 2 0 Not covered INPJ 2 0 Not covered 1NPI 

9nDK . . . . . . . I 9[7DK _.___.. I 9nDK . ..*... > 9ndK ,.,,,a, 1 

Hl ) 50 I 50 Ml 1 60 1 

, f-J Covered . . . . . . . . . . . . ,n Covered . . . . . . . . . . . . , q Covered . . . . . . , . , . e. , j-J Covered #1#,,<*,#,,, 

2 0 Not covered under 65 . . 

3 0 Not covered 65 and over lNPl 2 0 Not covered under 65 . . 3 17 Not covered 65 and over fNPI 2 0 Not covered under 65 . . 

3q Not covered 65 end over fNP) 2 0 Not covered under 65 . , 

3 c] Not covered 66 and wer fNPI 

90DK .._............. 1 9nDK _.__..__._..._.. 1 9nDK . .._ . . . . . . . . . . . . 1 9nDK d,.,*.,d,d.~..,.. 1 

151-52 151-52 S. 151-52 151-82 8a. 

123456783 1 2 3 4 5 6 7 8$ 1 2 3 4 5 6 7 8? 1 2 3 4 6 6 7 61 

specify Specify Specify Specify 

53-54 53-54 53-54 53-64 

55-56 55-56 65-66 55-56 -----------------__-------------------------.---.-------~--~~~~~~~--------~~~~~~~-~---

b. 000 Only one reason 57-68 000 Only one reason 57-58 b. 000 Onlyonereason 67-68 000 Only one r*lwJn E57-66 

12345678 1234’5678 12345676 12346679 il 3 7 7 

Specify Specify Specify Specify 

---~--------------- ----_--_--___--_________ _-___~_---------~--- dd 

59 9b. 1 q Yes 90DK r 59 

1ElYes 9nDK 

1 5g 9b. 1UYes 90 DK 1 q Y*s gnDK r 

?.uNo ZUNO 20No 2aNo 

---__--------------- ----.---.---------------- ----------__----~-d- d 

Ob. 60 60 lob. T 80 

1 cl Yes 9nDK 1 cl Yes 90 DK 1q Yes 90 DK 1q Yes g0DK E 

20No 20No 20No 20No 

52 
--------------- 

-- 

-- 

-- 

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

-- 

-- 

-- 

-- 

-- 

Section M. HEALTH INSURANCE, Continued 

I 1 a. Them Is a natlonal prc6ram called Madicald which pays for 

health cam for psncn‘ In need. (In this State tt Is also called 

-1 

Ourlng the past 12 months, has anyone In this family received 

hG7ar.a which has b+w or will be paid for by MedicaId Ior q Yes q No 112) -CIDK ____--__----__----_-------------------------------

b. Has recslved this cam In the past 12 months? llb. 1 OYes 9uDK E 

ZONO 

l 20. Doss anyond In the fsmlly now have a hledicsld (or (name)) 

card which locks llke this? Show Medicaid cardH. q Yes UNc 1731 q DK 

---------------------------------~----------------~---------------

b. Doas now have thin card? 12b. 1q Yes SUDK E 

ZUNO ---------__---_----_____________________-------~~-

Ask for each psrson with ‘Yes” in 12b: C. r-c q Medicaid card seen 7 E. May I please see (and --I card(r)? 1q Current Mark appropriate box&?sJ in person’s column. 2 0 Expired 

3 17 No card seen 

8 0 Other card .seen 3 

Specify 

130. Is anyone In the family now covered by any other public 

q aslstance program that pay. for health care? q Yes ONo (141 q DK -1------------------------------------------------~- ------_---__-­

b. Is new covered7 lsb. 1q Yes g,-,,,K hiii 

L ZDNC 

140. Doss anycns In the family now mceiva military retlremsnt 

pmymsnts frcm any branch of the Armed Forces or a pension 

from the Veterans’ Admlnlstratlon7 Do not in&da VA 

dlaablllty compsnsatlon. q Yes 0 No 1151 q JDK -----___----_--___----------------------------~---

b. Doas - - now mcslve,mllitary mtlmment or (I VA penslon7 

~___-----_----__---_____________________----~~---~ 

Ask for each person with “Yes”in 14b: 1 0 Armed Forces 

c. Which doss mcelve - the Armed Forces rstirsmeht, the VA 

psnslon or both7 

16s. Is anyone In the family now covsmd by CHAMPUS, which I8 a 

pmgram of medical cam for depsndsnts of military penonnel7 q Yes q No(15cl q DK ____--------------------------------------------~- -,-~y~,---Bo-DK-rsib. Is ncwcovamd by CHAMPUS? 

20Nc ____-____---__------------------------------------ __--__-___-------

C. Ia anyone In the family now covered by CHAMP-VA, which is 

msdlcal Insurance for dependents or survivors of dlsnbled 

vataranal q Yes 0 No (161 q IDK ~___---------------_-------~~--~~~--~~~-~~~~~~~~~~ -,y;s-----si-D;-r 

d. ID now ccvwad by CHAMP-VA7 

‘3 ZUNC 

I6a. In w~ycns In the family now covwad by any other pm~ram that 

provides healtliban for mllitay dependents or survlvon cf 

mllituy panonh 

--------------------------------------------------~-- q Yes ONo (M2) q IDK 

b. IB now covsmd7 16b. 

20No 

NW HIS-1llSSEI 17.3.861 

53 
----------------- 

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

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

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

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

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

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

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

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

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

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

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

--------- 

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

---- 

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

---------- 

MM-­

;;b. 1 q lYes SnDK 1 1q Yes si-,,,K -,-81-+i, -----------~---- l q lYes SODK 1 6’1 -.--- I Elves SaDK 1 61 

2UN.3 ZUNC. 20No 

----.-------- ---------___ 1 rives SnDK 1 1 Elves SnDK 1 OYes SnDK 

2UN.3 20Nc. ZUNO _-

0 

0 Medicaid card seen 2 L-XL 0 Medicaid card seen 2 a 0 Medicaid card 888” 7 0 Medicaid card wen J 

1 q Current 1 q Current 1 0 Current 1 Cl Currant 

2 0 Expired 2 0 Expired 2 0 Expired 2 0 Explrad 

3 0 No card Seen 3 0 No card see” 3 0 No card we” 3 q No card seen 

9 q Other card seen 3 9 0 Other card SB~” 3 8 [7 Other card SW” 3 8 0 Other card see” 3 

I Spqcify Specify Specify spscrry 

----_-_----____-__------------

i%b. l ElYes s’-JDK -Lz 1 q lYes SODK 64 1 q Yes s~DK ’ 64 

t 20No 20No PUN0 

i;b. I ---__-----------_.--~~~~~~-~-- ---. 

l q lYes S,,DK E 1 clues SnDK 1 q Yes SUDK 1 65 1 q ~Yl3.9 SCjDK 1 66 

217No 2[7No 20No 20No 66 _.------- ---dM-dd i­

.- c. 1 0 Armed Forces 1 1 0 Armed Forces 1 17 Armed Forces 1 0 Armed Forces 65 

20VA 20VA ZOVA 20VA 

3 q Both 3 0 Both 3 0 Both 3 q Both 

1q Ye* SUDK -

20No 

1 Elves 9[7DK ’ 68 1 q Yes SUDK ’ ‘* 

ZUNO ZONCI 20No 

___---------_--- 1 -.-- v-d69 69 

1 q Yes SnDK 1 q lYes SDDK 1 q YOS SODK 

20No ZUNO 20No 

54 
-- -- 

-- 

-- 

-- 

-- 

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

-- 

-- 

-- 

Section M. HEALTH IhlSURANCE, Continued 

M2 10 AF box marked (171 1 70 

I

/ M2 Refer to ‘AF” box above person’s column. 8 0 Other fNPl 

! 170. Doss have II dlsablllty r&tad to service In the Armed Forces of the United States? 17a. 1 71 

( -----------------------------------------------------.------------- 1OYes 2 0 No (NPI 

, b. Doss now racsive compsnsatlon for this dlsablllty from the Veterans’ AdmInistration? b. r r2-

[ -_-----__-------_------------~-----------------~~--~~~---~--~~~-~~ 10 Yes (NPI 20No 

i C. Has war applied for a sswiceconnscted dbabllity rating from the Veterans’ Admlnlstradon? C. 1OYes g 0 DK lNPl r 53 

_______---__--__--______________________-------------. ~~!o!!pI------.m 

d. Was it approved or denied? d. 1 0 Approved 3 0 Pending r ~4-

/ I I 

1 Bat. During the past 12 months, that Is slnceIBmonth 

year ago, have pad names of related NH members 19 or o&l 

b. Who 

basn 

-----------------------------------------------~~-

was 

lald off 

thls? 

from aJob or lost a Job? 0 Yes 0 No (Supplement Bookfetl 0 DK69.1pplement Bookfetl .----------

Mark ‘Laid off/lostjob” box in person’s column. 1 0 Laid off/lost job -------------------------------------------~~-~~~- .----------------

o. Anyons slss? 17 Y fflessk 18b and d ON -----------------------------~~--------~----~-----

Ask 18d. c?, and f for each person with “Laid off/lost job” in 1Bb. 

d. How many tlmas has been laid off or lost a Job during the past 12 months? d. 

------------------_-------------------------------

e. a. In what month and war was - 2 lald off or did lose a J&(&he last time/the time before that I)? 

f. For ANYTIME during CthaMhosel Job layoff(s) or Job loss~asl, did rscslve unemployment insurance benefits7 f. 

I I 

t I I I 

190. Because of lnames Job layoff(s) or Job 

losslesj. dld anyone In the family lose any health insurance I covsraga that had been carried through [that/those] Job(s)? 0 Yes q No (Supplement Bookletl 0 DK fSupp/ement Booklet1 I I _-_---_---------------------------------------------~-------------

b. Who ~a. this? r SOMark ‘Lost coverage” box in person’s column. 19b. 1 q Lost coverage -----------------------------------------------~~-~~~~~~~~~~~~~~~~~~~~ 

o. Anyone ah? 0 Yes Rieask 196 and cl ON0 

I

M3 1 Cl Lost coverage 1201 1 91 

Refer to 19b and mark appropriate box. M3I 2 0 Did not lose coverage (NPJ I 

20s. For ANYTIME during [that/those1 job layoff(s) or Job loss(es), was - - without any type of health Insurance 1 92 

coversgo? (Do not include health cara programs, such as Medicaid, AFDC, or mllltary benefit programs, as health Insurance oovarags.) 20s. 1OYes 20No (21) --------------------------------------------~------- --------L---­

b. For how long W.S - - without ‘oma type of ha&h Insurance coverage? b. 00 0 Less than 1 month p3=-94 

(How many months Is that?) 

Months 

21 a. For ANYTIME during [that/those1 Job layofflsl or Job losslesl, was - - covered by any health cam program, 1 95 

such as MedIcaId, AFDC, or I) military benefit program? 21 a. 1q Yes 2nNo fNPl : ___--__---------------------------------------------~~--------~~---

b. For how long was - - covered by some health cam program? b- 00 0 Less than 1 month [vs=-97 

(How many months Is that71 Months 

_ FORM HIS.1(1066l~74.E61 

55 
“Mtl NO. “YB,-uuz,: ApprclVal 

m81jlS-I’SB’ (1986) NOTICE - lnformstion contained on this form which would permit identification of soy lndivldoal or sstsblkhment has been collected with a guarsntee that it will be held in strict confidence, will bs used only for purpour 

U.S. DEPARTMENT OF COMMERCE 

stated for this study, and will not be disclosed or released to others without the consent of the Individual or ths establishment in accordance with section 303(d) of the Public Health Service Act (42 USC 242m), 

a”REA”OFmECENS”S ACnNGA3COUEC”NCAGEWMRME Ins4 U.S. PUBLIC HEALTH SERWCE 

1. 3-7 2. R.O. Number I g-lo 3. Sample 1’1’1--‘11 

8 NATIONAL HEALTH INTERVIEW Book -of- books SURVEY 4. Control number 6. Baginnlng time 

PSU 114--1BjSwment 117--P3jsaria' 124-26 I,,-,, SUPPLEMENT BOOKLET 

1 I 2 pm 

GO TO SECTION N 

9. FINAL STATUS OF SUPPLEMENTS 

a. Sections N and 0 b. Section P EC (Household Respondent Section) (Eligible Person Section) =y 

Interview o 0 No person 65 + in this family 

I 13 Complete interview (all appropriate sections completed) I q All eligible persons interviewed 

, 2 0 Partial interview (some but not all appropriate sections completed) 2 0 Some but not all eligible parsons interviewed (Explain in noted 

(Explain in noted 

l 3 0 No eligible persons interviewed Exphin in notesj 

Noninterview I 

I 

3 0 Refusal 

1 (Explain in notesl a 0 Other 

I 

I 

I 

0. Ending time 11, Interviewer identification 

47-501 61 Name 1 Code 152-1 

1 a.m. 

2 p.m. i 

=OOTNOTES 

56 
-- -- 

-- 

-- 

1 RT65 

Section N. LONGEST JOB WORKED 

N 1 Refertoage 

N2 Refer to HIS-l pages’&, 45, q. 66/c. 

READ 70 RESPONDENT(S): 

{Now I would like to ark about work experience.} 

1. Of all the PAID jobs or businassas aver had, what kind of work was dolng the longest? (For example, electrical engineer, stock clerk, typist, farmer.) 

2., How long did do this kind of work? 

Mark box if “AF” marked in 1. 

3. What kind of business ?r Industry dlcj work In the longest as a (pn trvin TJ? . (Foyampl.s, TV and radro manufacturmg, retail shoe store, State Labor Department, 

FOOTNOTES 

PERSON 1 v’ .I 3-4 

1 

Nl 10 Under 25 (NPI 

*cl25+ fNZI 

) 6 

N2 I 0 “NE!!” marked in 6b/c fNPl 

8 0 All others (71 

0000 Neverwo;ked INPI I 7-g 

9050 AF 

1. 

Ocwpation 

1 10 

2. I q Less than 5 years 

2 0 5 years, less than 10 years 

s 0 10 years, less than 20 years 

4 Cl 20 or more years 

m 

3. 94~0 AF. , 

Industry 

57 
--- 

-- 

-- 

-- 

1Krtltl 

I Section 0. DENTAL HEALTH I I PERSON 1 1 3-4 

Now I’m going to ask you some questions about WATER FLUORIDATION. w 

1. As you understand it, what is the purpose of adding FLUORIDE to the public drinking water? 

1. 

Do not read answer categories, circle the ONE that best fits respondent’s answer. ’ vg 

1. Prevent tooth decay, protect teeth, or related response 

8. Other Epecifyl 

8. Don’t know fSpecW 

2a. Does the water that you drink at home coma or is it from another souma, such as a well? from a public water system 2a. 1 0 Public water system 

1 

8q Other source 

9uDK ______________-_----------------------------------------------- ---,oY,---‘-‘-~-T’s’ 

b. Does this drinking water have FLUORIDE in it? b. 

20No 

sUDK 

; _, 

HAND CALENDAR. “ 

These next questions am about receiving dental cam. 

3a. During the 2 weeks (outlined in red on that calender), 

beginnlng Monday (dateland ending this past Sunday 

(w, did anyone in the family go to a dentist? Include all 

types of dentists, such as orthodontists, oral surgeons, 

and all other dental specialists, as wall ae dental 

hygienists. c7 Yes 0 No 141 

_________------------------------------~~~-----------------~~~~~~~~----~~~-------

b. Who was this? T 

3b. I q Dental visit 

Mark “Dental visit” boxin person’s column. ___~_-------------__~~~~~~~~~~-------~---~~~-~~~~~~~-~~~~~~~~-~~~~~~~~~~~-~~-~~~~~~-~ 

c. During those 2 weeks, did anyone else in the 

family go to a dentist? q Yes (Reask 3b and cl 0 No 

________------------------------------------------------ -------~-~~~~~~11~~4____i E 1 Ask for each parson with “Dental visitYin 3b: 

d. During those 2 weeks, how many times did go to a dentist? d.’ 0 Number of times 

w 4 Mark box if under two years old. gsan Under 2 INPI 

4a. During the past 12 months {thet is. since (7 Z-month date) a year ago}, 4a. 

how many visits did make to a dentist- -Visits 

(Include the (Number in 3d) visit(s) you already told me about.) ooon None _____--------------------~~~----~~~~~~~~~~-~~~~~~---~~~~~-------~ ---------------T-? 

Mark “2-week dental visit” box in person’s column if visit(s) reported in 3d. 1q Past 2 weeks nor reported 

b. How long has it been since LAST went to a dentist? (Mark 3b, ask 3dl 

b. 2 0 P-week dental visit 

3 0 Over 2 weeks, less than 

6 months 

4 0 6 months, less than 1 year 

5 0 1 year, less than 2 years 

a q 2 years, less than 5 years 

7 0 5 years or more 

0q Never 

k 

01 Refer to 4b. 01 I [3 Less than 2 years in 4b (51 

80 Other fNPI 

{Some people go to the dentist because they think they have a problem; other people go Irt-1 18 

to the dentist for a check-up or to have their teeth cleaned. Sometimes when people go 

for a check-up the dentist discovers a problem that needs to be treated.} 

5. What was the MAIN REASON - - last want to the dentist? 5. 1 2 3 4 

Do not read answer categories, circle ihe ONE main reason. “3 g 

1. Went in on own for check-up, examination or cleaning. 

2. Was called in by the dentist for check-up, examination or cleaning. 

3. Something was wrong, bothering or hurting - - . 

4 Went for treatment of a condition that dentist discovered at Epeclfy) 

earlier check-up or examination. 

8. Other (Specify) 

9. Don’t know 

FOOTNOTES 

58 
p;.,S..d 

------- 

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

---- 

---- 

Section 0. DENTAL HEALTH, Continued PERSON 1 

~~,~,,‘~*;‘~<~~;+‘~k~l>;;c &~+q.‘.-;qTm>,i r. “J *,.‘,S?~~;~, 5 ,, f+T’

-$,“*z,:(, ;: Lml”;;,:>,:*,. ” ,;t .‘, ,,‘,.., i ~“:,,‘&+~~.,,:i.y<.r’ 60. Is there anyone in the family who has lost ALL of his or her ‘?*,r‘..%,; q Yes I-J No (7, ‘“j& .!k”-:-‘;~~?~-!!:-\‘:.::;-‘:~,~i-:-L-L <,.+.+ *:+4 “‘<$A .’..,f, natural teeth? --_----------_------- _______ ____________________ ‘e (. -.,r,,C;LL~~_~~~i’-i--~..$:‘,:-,:V,, 

b. Who Is this? 6b. 19 

Mark “Lost all teeth” box in person’s column. 1 0 Lost all teeth 

---------------_----------------------------------------------- ~~~~~~,:‘~“.t~.,.,:~,i: -----~-----S’;~-r?~ _.,) _, )

-. o. Anyone slse? .. ;‘::‘“*w’~ .,:*.;,G.$;‘.. ./ ;y+; ~&/;A ‘5.‘I +)Q \“. +3. : ;s’,i; .,. .{I;.), _‘” 

0 Yes fReask 6b and c) 0 No ;$i;: ., ,r:~:M’,,~,.:.;.,~,~.~~.. i;.: v;;:“; y.!.”)I 

1 20 

02 

Refer to 6b for all family members. 

02 

I 0 “Lost all teeth” marked in 6b for 

all family members (Sscrion PI 

8 0 Other (71 

.‘,‘.-~,.,b’.:...‘~-,~ .if*,.,i ._ e-x:, - ,ue-&.. ,, ., ,:.-. *cl .+:;,: :^;,., ,. ,C”,y,:’if; :.“f’*.J~$ 

Do nor ask for persons with “Lost all teeth,“,% 6b. I 0 Toothpaste 1761 ’ 

21 

70. (Now I am golng to ask about some things that people may be dolng to take care of their teeth.} 70. a 0 Other 3 

What does - - use when - - brushes - - teeth - toothpaste, tooth powder, or somsthlng else? 

fNPI 

lSpecifyj ____ 

b. What brand dld - - usa most often during she past two weeks? b. 22-23 

Do not readanswer categories, circle ONE brand. 1234568-S 

1. Crest 4. Dentagard 8. Other (Specify1 

2. Crest Tartar Control 5. Aquafresh 9. Don’t know 

3. Colgate 6. Aim [Specifyl 

: > ‘, .,,. 1 ..<*‘; :. :,,-1. * :‘J,~~~,,..~ ;: , :- :&;,;~yy,$$ :‘;-cc.;: y:,:,: , ,.;. qsr ;‘*:,,G :,“ : ‘, i,, I>:;;, L‘*” ‘.* 

Some MOUTHRINSES contaln FLUORIDE to reduce tooth decay. Others , . I 0 j

_.1* ;“,.: ;” :1 r) _ .. 

do not. ACT, Fluorlgard, Llstermint with Fluoride, StanCare and some i’ 

., .) ‘,‘,,;y‘;J: :. prascrlption brands are examples of mouthrlnses that contain FLUORIDE. i ...‘.-.A,~,,f..<‘$1:. .., -_ ,I.,,,-,. -5, ..; . 80. Does anyone 

at 

In the family now use a FLUORIDE 

mouthrlnsa 0 Yes 0 No (031 0 DK (03) .;, I,‘:’ -, .(;-‘r;;,:‘,~.~~~~~,i::;;, _’ home? ---------------------------------------------------------------~--- Liz-l-‘-L~~~L-.-­

b. Who Is this? 8b. 24 

. Mark “Fluoride mouthrhse” box in person’s column. I 0 Fluoride mouthrinse 

--------------------------------------------------------------------.~------------------------

c. Anyone slsa? 

13 Yes Beask 8b and cl q No ____ ----------------------------------------------------------------~--

Ask for each person with “Fluoride mouthrinse” in 8b: 25-26 

d. What brand dld - - use most often during the past 2 weeks? 

Do not read answer categories, circle ONE brand. d.l 2 13~ 9 

2. Prescription fluoride rinse 

1. 8. Other ISpecify) (Specify) g. Don,t know 

...‘wF , . * : I ; ,. , ; ::* .’ ,:.. 2’ .. z .’ .,: ,_ ,...!P 

1 27 

03 Refer to age. 03 I 0 Under 17 (91 

z 0 17 and over (NP) 

(Some schools have fluoride MOUTHRINSE programs.} 1 q Yes / 28 

g. Does - - now take pert In a fluoride MOUTHRINSE program at school? 9. zuNo 

snDK 

_, .$‘ .- ;: 7. ‘;’ 

Somatlmas doctors or dentists prescribe or provide pills or drops with fluoride In them. -; : Sometlmes these are given at school. ‘;‘.’_.: ” , 

_. .i-, ., . 

Oa. Does anyone In the family now take vitamins with FLUORIDE In I ; ,. i>’ ,,.QI_,’ _ them or any other kind of FLUORIDE drops, pills, or tablets, either 

at home or at school? ---------------------------------------------------------------i::- q Yes 0 No 1111 q OK1111 “; ,‘.:\-;: ] -“‘-: :::‘:.: : 

b. Who Is thlr? lob. -iFMark “Fluoride Supplements” box in person’s column. 1 0 Fluoride supplements ----------------------------------------------------------------,~---~~------------~----

c. Anyone else? f (f* ,L, ,~~,‘:, .. 

0 Yes fReask 1Ob and cf ,, No ‘;~.‘,i’::,.~~:_.,!,‘~‘:-r,; ‘- ._. .: ; _, , 

la. Dental SEALANTS era special plastic coatings that era painted 1, ..,, \I, I , _ ,;. :-..:: :li(l on the tops of the back teeth to prevent tooth decay. They are ,:,(~1 _, ,-i ‘.. .;,:. ‘.. ‘r ‘\ ^ :: 

put on by a dentist or a dental hygienist. They are DIFFERENT ;.; ‘.; ., . 4.: ,~;,, )_’ ’ 

from fillings, caps, crowns and fluoride treatments. Has anyone 0 Yes q ‘NofSection PI 0 DK (Section PI ;’ : ),‘j .’ .:” “, ‘- In the family had dental SEALANTS placed on their teeth? P’, .‘,‘Y. d *’ .: ,, )o.(, ---------------------------------------------------------------_;1,--_--~-,______ 

b. Who la this? lib. 1 30 

Mark “Dental sea/ants” box in person’s column. i 0 Dental sealants ---------------------------------------------------------------~--~~-~~--~--~,--~--,-----

c. Anyone else? .‘:.~‘;‘ _,‘i’,,I :‘;.& ‘.;,, I _I._.’ __ I / : -r v 0 Yes iReask 7 1b and cl 0 No :+:; ,;:-‘:..;,,i.~..,-,-,

: ,“; i ::* ‘._\‘. (. ‘, -.,’ ., ‘,:, I _, 

1,;; ; ;. 7: ““‘:::+< ?.‘i.~,!. .. .:I.:, .’ _ ‘_’ ^ .* 

OOTNOTES 

FORMHIS-1cm ,19&s,m-19-86, 

59 
----------------------------------------- 

Section P. FUNCTIONAL LIMITATIONS (FL) 

I UP ersons 65+ in famihl Enterperson 0 No persons 65+ In PI Refer to ages of all family members 

I number and first name of EACH parson family (Cover Pagej 

on e separate FL page) 

Person No. 1 3-4 First name 

FL1 i 0 Callback required (Hhld. page, THENNPI 0 Available (71 

I 0 Noninterview Ifootnotes, THEN NPI 

1 Read to respondent -The next questions are about how well you are abla to do cartaln l ctivltiss - by- vourself and without uslna- swolal _ aqulpmsnt. _ _ I

1. Bacausa of a health or physical 

problem, do you have ANY 

dlfflculty -

(1) 1 

Bathing or showering? 

(3) ( 

Eating? 

Ask if “Doesn’t do”: 

Is this because of a HEALTH or 1q Yes 1q Yes 

PHYSICAL problem? 

If “Yes,” mark box 1; if “No,” 

mark box 3 

20 No 3 0 Doesn’t do for other reason 

20 No 

3 0 Doesn’t do for other reason 

Ask Z-5 for each activity marked 

“Yes” in 1. 

k 

2. By yourself and without uslng special equipment, how much 

1 Cl Some 

z q A lot 

1 Cl Some 

2 0 A lot 

3 0 Unable 3 0 Unable 

3. Db you receive help from I 

anyone In fectivityl? 1OYes 1clYe.s 

z 0 No 151 2 0 No 15) 

Qa. Who gives this help? 4a. Source of help I 4b. Paid 4a. Source of help ! 4b. Paid 

1 8-11 I e 140-431 144--4; 

---------r-----

Mark the S/C/P box without 

asking if ONLY he/p is from 

spouge/children/p&ents. 

b. Is this help paid for? 

iH member I 

I 0 0 S/C/P 15) 

I 0 

0 

Relative . . . .I I 0 Yes z 0 No 

z Nonrelative . I I 0 Yes z 0 No 

I 

Uon-HH member r 

3 0 Relative. . . .I lOYes 20No 

HH member I 0 0 S/C/P (6J 

1 q Relative .,,,i lOYes 20No 

2 0 Nonrelative . I 1 0 Yes 2 0 No 

Non-HH member I 

3 0 Relative ,..,I tCI]Yes 20No 

Ask if necessary: 

Which helpers are paid? 4 0 Nonrelative .I I OYes znNo 4 0 Nonrelative ,I I OYes 20No 

I 

ia. Do you use any special aquipmentor aids in fectivfty)? 

1 

2 0 No f2 for next activity 

IO Yes 

) 

2 0 No 12 for next act/&y 

with “Yes” in 1) with “Yes” h II 

b. What special equipment or Special equipment or aids Special equipment or aids 

aids do you use? 

Anything else? 

6a. Do you have dlfflculty controlling bowels? RT68’ 6 

_ 

(2) 1 

Dressing? 

10 Yes 

20 No 

3 0 Doesn’t do for other reason 

1 

1 El Some 

2nAlot 

3 0 Unable 

1 

10 Yes 

2 [7 No (51 

4a. Source of help ! 4b. Paid 

124-271 )28--31

I HH member I 0 0 S/C/P 151 

toRelative....; inYes 2C]No 

2 0 Nonrelative . I I 0 Yes 2 0 No I 

Non-HH member 1 

3[7Relative....! 1nYe.s 20No 

t 

) 

1 Cl Yes 

4 17 Nonrelative .) toYes 20No 

2 0 No f2 for next activity 

with “Yes”in 1) 

Special equipment or aids 

your 3-4 , 

’ 1q lYes 2 0 No(&)

-----------------------------------------r--------------------------------------- I -a-­

b. How frequently do you have this dlfflculty - dally, several times a week, I 1 0 Dally 4 c] Less than once a week once a week, or less than once a week? I 2 0 Several times a week 90DK 

1 3 0 Once a week -----------------------------------------~--------------------------------------- ‘7’-

c. Do you have a colostomy or a devlca to help control bowel movements? I 1q Yes 2 0 No (71 

______----------------------------------- ;----------- ---------------------d-mm-ddTd-m- 1 0 -I 

d Do you need help from anyone in taking care of this device? 1 1 q Yes 20No 

1 1 9 

7a. Do you have difficulty controlling urination? .; 1 0 Yes 2 0 Not7c) 

r--------------------------------------d -6-b 

10 b. How frequently do you have this dllculty - daily, several times a week, 1 I 0 Daily 4 0 Less than once a week once a week, or less than once a week? r 2 0 Several times a week euDK 

1 3 0 Once a week 

-----------------------------------------lr--------------------------------------- ‘~~­

c. Do you have a urinary catheter or a device to help control urination? ; 1OYes 20 NofP21 

--_________-__---__---------------------- -------------------~~-~~~-~-~~~-~~ --de r----- 12 d. Do you need help from anyone in taking care of this device? I lOYes 20No 

1 13 ( I 0 Respondent is a proxy 3 0 Telephone interview f6l P2 Mark first appropriate box ; 2 0 Person has only been (81 4 0 All other (Page 101 seen in a bed or chair 

Mark if known I 1 14 

B. Because of a health or physical problem, do you usually -

a. Stay In bad all or most of the time? I 1 Cl Yes (Page 101 20No 

----------------------------------------~~--------------------------------------- -Tcb. Stay In a chair all or most of the time? i 1q Yes 20No 

FORMHIa- m, ,19&l, 151Psal 

60 
Reask 1 (41 ) 

Getting in and out of bed or chairs?: 

1 Cl Yes 

3 q Doesn’t do far other rea9on 

1q Some 

z 0 A lot 

3 0 Unable 

1 

10 Yes 

.z 17 No (5) 

4a. Source of help I 4b. Paid 

I66-60 I )60--8: 

4H member 1 0 0 S/C/P 151 

, 0 Relative . . . .I I 0 Yes 2 0 NC 

z 0 Nonrelative . I I [7 Yes z 0 Nc 

I 

don-HH member I 

3 q Relative . . ..I lOYes 2nNc 

4 q Nonrelative .I I q Yes 20Nc 

I 

) 

10 Yes 

2 q No (2 for next activiry 

with “Yes” in 1) 

Special equipment or aids 

RM HIS-1 WI 1199813-19-88) 

Walking7 . Getting outside? Using the toilet, including getting 

I I to the toilet? 

10 Yes 10 Yes 10 Yes I I 

2 q No 20 No 20 No 3 q Doesn’t do for other reason 3 0 Doesn’t do for 6ther reason 3 q Doesn’t do for other reason 

1 70 ( 86 , 1 

1q Some 1q Some 1q Some 2 0 A lot 2 0 A lot 2 0 A lot 

3 0 Unable 3 [7 Unable 3 0 Unable 

171 ._ 187 ” 1 

1H 

10 Yes 1q Yes 1q Yes 2 0 No 151 2 0 No 15) z [7 No 15) 

4a. Source of help I 4b. Paid 4s. Source of help ] 4b. Paid 4a. Source of help I 4b. Paid 

172-76 I 

I 176-79 Ias-91 I / sz-96 ~104-1071 1108-11’ 

member I 0q S/C/P 15) HH member I

I 0q S/C/P 151 HHmember I 0 q &C/P (51 

I 0 Relative’. . . .I I 0 Yes 2 0 No 1q Relative. . . .I lOYes 20No I 0 Relative . . . . \ 1 q Yes z 0 No 

2 0 Nonrelative . I 1 0 Yes 2 0 No 2 0 Nonrelative . I I 0 Yes 2 0 No 2 0 Nonrelative . I ‘1 0 Yes 2 17 No I I I 

Jon-HH member I . . Non-H! member 1 Non-HH member I .‘ 

3 0 Relative . . ., . I lOYes 20No 3 0 Relative . . ..I lOYes 20No 3 0 Relative . . ..I 1 q Yes 20No 

4 0 Nonrelative .( lOYes inNo 4 0 Nonrelative .I I q Yes 2[7No 4 0 Nonrelative .I I q Yes 20No 

I I ! 

1 80 1 96 1 

1q Yes 1q Yes 1q Yes 2 0 No (2 for next activity I 2 0 No (2 for next activity I 2 0 No 161 

with “Yes” in 1) with “Yes” in 7) 

I I 

Special equipment or aids Special equipment or aids Special equipment or aids 

61 
Section P. FUNCTIONAL LIMITATIONS (FL), Continued 

Read to respondent - Now I will ask about some other activities. Tell me about doing them by yourself. 

(1) 1 16 (2) 1 

3. Because of a health or physical problem, do you have ANY difficulty - Preparing your own meals? Shopphtg for personal Barns, (such 

Ask if “Doesn’t do”: as toilet items or madlchter)? 

Is this because of a HEALTH or PHYSICAL problem? 10 Yes 1q Yes 

If “Yes,“mark box 1; if “No,“mark box 3 2 0 No 20 No 

3 0 Doesn’t do for other reason 3 0 Doesn’t do for other reason 

Ask lo- 12 for each activity marked “Yes” in 9. J 17 1 

D. By yourself, how much difficulty do you have factivitv), 1 El Some 1 Cl Some 

some, a lot, or are you unable to do it? 2 0 A lot 2 0 A lot 

3 0 Unable 3 q Unable 

1. Do you receive help from anyone In WI7 i q Yes (12) 

j 18 

1 Cl Yes /12! 

( 

2 0 No (IO for next activity 2 [7 No (10 for next activity 

with “Yes” in 91 with “Yes” in 9) 

2e. Who giver this help? 12a. Source of help ! 12b. Paid 120. Source of help ! 1Zb. Paid 

119-221 123-26 130-33 I b 

I Anyone else? HH member I 0 0 S/C/P HH member I 0 q SIC/P 

---------_------------------------ ln~elative-...l lOyes 2nNo 1 Cl Relative , . *, ’ 1 q Yes 2CINo 

Mark the S/c/P box without asking if ONLY help is from spouse/children/parents, 2 q Nonrelative . ; I 0 Yes 2 0 No 2 c] Nonrelative . 1 1 q Yes 2 a No THEN 10 for next activity marked “Yes”in 9. 

Non-HH member I Non-HH member ’ 

b. Is this help paid for? 3 Cl Relative . . ..I lOYes 20No 3 q Relative ..,,I 1 aYes 2aNo 

Ask if necessary: 

Which helpers are paid? 4 [7 Nonrelative .I r[7Yes 20No 4 0 Nonrelative ,I 

I 

1 0 yes 2 q NO 

8 

1 I 

P3 Refer to 13 and 14 on other FL pages. / I 0 13and 14filledon anotherFLpage (15) 

1 8 0 Other (131 

I 1 30. Is it NECESSARY to go up or down a step to get into this fhouselapattmentl 1 , q No 

frcm the outside? I 

I Yes - If not mentioned, ask: Is lt one step or mora than one step? 

I 2 q 1 step I 

I 3 0 More than 1 step 

-----------------------------------------~---------------------------------------- E b. Counting basements and stepdown living areas es separate levels, does I

I 1q Yes 2 q No 17461 this ~ouselepartmentl have more than one floor or level? I

I w 4a. Does this [house/apartment] have a bathroom, bedroom, and kitchen I 1q lYes 20No ALL on the same floor or level? _____________----_-_--------------------- I----- _-----_--------------d------d---..--4 A-..­

b. Does this thouselapartmentl have a walk-in shower, that Is, where you I 

, 1 III Yes 20No 

T 

don’t step over the side of the tub to get into the shower? 

I 

5a. Because of a health or physical problem do YOU NEED a bathroom, I 1 

bedroom, and kitchen ALL on the SAME floor or level? I i 0 Yes 20No 

-----------------------------------------~---------------------------------------

I E 

b. Because of a health or physical problem do YOU NEED a I 1q lYes 20No walk-in shower? I 

FOOTNOTES 

62 
Managlng your money, {ruch as keeping track of axpenrsr or paying bills}? 

1 cl Yes 

20 No 

3 0 Doesn’t do for other reason 

I-E 

1q Some 

2 0 A lot 

3 0 Unable 

10 Yes 172) 

2 0 No (10 fornextectivity 

with “Yes” in 91 

126. Source of help 1 12b. Paid 

141-44 I 146-48 

4H member I 00 S/C/P 

1 0 Relative . . . .I i 0 Yes 2 0 No 

2 0 Nonrelative . I i 0 Yes 2 0 No 

I 

Jon-HH member l 

3 q Relative . . . .I lOYes znNo 

4 0 Nonrelative . 1 I 0 Yes 2 0 No 

,< ,.,. ._,, 

OOTNOTES 

Using the telephone? 

1 q Yes 

2 0 No 

3 0 Doesn’t do for other reason 

1q Some 

z 0 A lot 

3 0 Unable 

1 

1 q Yes(121 

2 0 No I10 for next activity 

with “Yes” in 91 

2a. Source of help I .12b. Paid 

152-56 I Iss-ss 

iH member I 0q S/C/P 

lnReletive....~ lOYes 20No 

2 0 Nonrelative . I I 17 Yes 2 0 No 

I 

don-HH member l 

3 [7 Relative . . ..I inYes 20No 

4 0 Nonrelative .I inYes 20No 

Dolng heavy housework, (such es scmbblng floors, or washing windows)? 

1q Yes 

2 0 No 

3 q Doesn’t do for other reason 

Doing light housework, (such as doing dishes, straightening up, or light cleaning}? 

1 Cl Yes 

20 No 

3 q Doesn’t do for other reason 

1 61 1 

1q Some 1q Some 

z 0 A lot 2 0 A lot 

3 0 Unable 3 q Unable 

1 62 1 

1q Yes1121 1q Yes(721 

2 0 No I1 0 for next activity 2 0 No (P3) 

with “Yes” in 91 

Za. Source of help 1 12b. Paid 12a. Source of help I 12b. Paid 

)63-661 I 167-70 174-77 I 178--81 

IH member I 00 S/C/P HH member I

I 0,q S/C/P 

1 0 Relative . . . . i 1 0 Yes 2 0 No tnReletive....l 1 [7Yes 20No 

2 0 Nonrelative : I I 0 Yes 2 0 No 2 0 Nonrelative . I I 0 Yes 2 0 No 

I I 

Ion-HH member l Non-HH member l 

3 q Relative . . ..I iaYes 20No 3 0 Relative . . ..I I q Yes 217No 

4 0 Nonrelative . i I 0 Yes 2 0 No 4 0 Nonrelative . 1 .I 17 Yes 2 0 No 

I 

I 

63 
[ RTd7 

Section P - FUNCTIONAL LIMITATIONS (FL), Continued 

Person No. 1 3-4 First name I 

FL2 I [7 Callback required (Hhld. page, THEN NPJ 0 Available Ill 

I 0 Noninterview (Foornotes, THEN NPI 

, Read to respondent - The next questions are about how well YOU era able to do certain acthdties - bv- vourself and without twine - l prcial . aqubment. - . 

1. Because of a health or physical (1) 1 (2) ( (31 1 

problem, do you have ANY Bathing or showering? Dressing? Eating? difficulty -

Ask if “Doesn’t do”: 1q Yes 1q Yes i q lYes 

Is this because of a HEALTH or 

PHYSICAL problem? 2[7No 2 0 No 20 No If “Yes , ” mark box I.I if “No , ” 

mark 3 0 Doesn’t do for other reason 3 0 Doesn’t do for other reason 3 0 Doesn’t do for other raason box 3 

Ask Z-5 for each activity 1 1 

marked “Yes” in 1. 

2. By yourself and without uring 1q Some 1q Some i q Some 

special equipment, how much 2 0 A lot 2 0 A lot 2 0 A lot difficulty do you have (activit@, 3 q Unable 3 0 Unable 3 0 Unable some, e lot, or are you unable 

to do it? 

3. Do you receive help from 1 

2q No 151 2 0 No (54 

4a. Who gives this help? da. Source of help i 4b. Paid 4a. Source of help ! 4b. Paid 4s. Source of help ] 4b. Paid 

1 S-11 I 112-‘16 124-27 I 128-31 140-43 I m I 

anyone in factivitvn 1 q Ye.S 1UYes 

-~--------f----~ r 

I-IH member I 0 0 S/C/P (5) IH member i 0 0 S/C/P 151 IH member i 0 El SIC/Pk3 

Mark the S/C/P box without 1 0 Relative. . . .I inYes z0No t 0 Relative . _ . .I I 0 Yes 2 q No 1 Cl Relative ,<.,; I q Yes 20No 

asking if ONLY help is from 2 0 Nonrelative . I t 0 Yes 2 0 No 2 q Nonrelative . I t 0 Yes 2 0 No 2 0 Nonrelative , I I 0 Yes 2 0 No 

spouse/children/parents. I I 

hIon-HH member I ion-HH member I Ion-HH member ! 

b. Is this help paid for? 3 0 Relative . . ..I lOYes 2nNo 3 II Relative . . ..I lOYes 20No s 0 Relative . . ..I I UYes 20No 

Ask if necessary: Which helpers era paid? 4 0 Nonrelative .I 

9 

lOYes 2[7No 4 0 Nonrelative .I 

I 

I OYes 2[7No 4 q NonreIative . 

, 

I’ 1 0 Yes 2 0 No 

5a. Do you usa any special equip- 1 q lYes ( 

10 Yes 

( 

1 Cl Yes 

E 

ment or aids in factivity)? 2 0 No (2 for next a&v@ 2 0 No 12 for next activity 2 0 No (2 for next activity 

with “Yes” in 1j with “Yes” in II with “Yes”ln 7) 

b. Whet special equipment or Special equipment or aids Special equipment or aids Special equipment or aids 

aids do you use? 

Anything else? 

, _ <. _: ; . , ._. -, 

6a. Do you have difficulty controlling your bowels? i 0 Yes 2 0 No 16cl I. 

l~~a~~--------------~~-~~~~~~n~~a-~~~----~ 

b. HOW fmquentiy do you have this difficulty - daily, several times a week, once e week, or less than once a week? 2 0 Several times a week anDK 

3 0 Once a week 

c. Do you have a colostomy or a device to help control bowel movements? 

d Do you need help from anyone in taking care of this device7 i q Yes 20No ---I 

7a. Do you have difficulty controlling urination? , Cl Yes 

10 b. How frequently do you have this difficulty - daily, several times e week, I fJ Daily 4 0 Less than once a week once a weak, or less than once a week? 

I 3 0 Once a week 2 17 Several times a week -/------------------------------vd----deddTd=7j sODK -i 

I, c. Do you have a urinary catheter or a device to help control urination? 1 i q lYes 2 0 No IP21 -__-------------------------------------- &--- _--_---__----_-------------------- dT$w 

d. Do you need help from anyone in taking care of this device? I iLlYes 20No Y 

p2I i I 0 Respondent is a proxy 3 0 Telephone interview (8) 

Mark first appropriate box ; 2 q Person has only been IS! 4 0 All other (Page141 seen in a bed or chair 

Mark if known 1 14 

I 8. Because of a health or physical problem, do you usually -

a. Stay in bed all or most of the time? I 1q Yes (Page 141 20No 

-----------------------------------------~--------------------------------------- -~~-

b. Stay in a chair all or most of the time? 1 l!IlYes 20No . . 

FORMHIS-,ISW119m l3.18.m 

64 
I 

Section P - FUNCTIONAL LIMITATIONS (FL), Continued 

Qettlng In and out of bed or chairs? Walking7 Getting outslde? Using the toilet, Including getting 

to the toilet? 

1 Cl Yes 1q Yes 1 cl Yes 1 cl Yes 

20 No z 0 No 217 No 20 No 

3 0 Doesn’t do for other reason 3 0 Doesn’t do for other reason 3 0 Doesn’t do for other reason 3 q Doesn’t do for other reason 

1 64 170 1 88 E 

1q Some 1q Some t q Some 1q Some 

2 0 A lot 20Alot 2 0 A lot 2 0 A lot 

3 0 Unable 3 0 Unable 3 0 Unable 3 0 Unable 

1 66 1 71 1 87 1 

i q Yes 1q Yes 1q Yes 1 q Yes 

2 0 No (51 2 0 No 151 2 0 No (51 2 17 No f5) 

la. Source of help 1 4b. Paid 4.a. Source of help 1 4b. Paid 40. Source of help 1 4b. Paid 40. Source of help i 4b. Paid 

IbS--69 I 180-83 172-76 I 176-79 ~88-91 I 192-95 ~104-1071 b 

I 

HH member I 0q S/C/P 151 HH member I 0 0 S/C/P 151 HH member I 0 0 S/C/P (51 HH member I 0 cl S/C/P (51 . 

l~Relatlve....~ iDYes 20No lnftelative....~ rOYas 20No t~Relativs....l tOYes 20No rnReletive....~ 1 q Yes 20No 

2 0 Nonrelative . 

I 

I 1 0 Yes 2 (7 No 2 q Nonrelative . I 

I 

1 0 Yes 2 0 No 2 0 Nonrelative . I 

I 

i 0 Yes 2 0 No 2 0 Nonrelative . I 

I 

I 0 Yes 2 0 No 

Non-HH member l Non-HH member l Non-HH member r Non-HH member r 

3 q Relative . . ..I lOYes 20No 3 0 Relative . . ..I lOYes 20No 3 0 Relative . . ..I lOYes 2nNo 3 0 Relative . . ..I 1 q Yes 20No 

4 0 Nonrelative .I tOYes 20No 4 0 Nonrelative .I inYes 20No 4 0 Nonrelative . ! I 0 Yes 2 0 No 4 0 Nonrelative . ! 1 0 Yes 2 0 No 

I 0 I I 

1q Yes ) 64 '1 q Yes 1 80 1 q Yes 1 96 1q Yes 1 

2 0 No (2 for next activity with “Yes” in 1) 

2 0 No f2 fornextactivity. 

with “Yes” in 1) 

2 0 No f2 for next activity with “Yes” in 7 J 

2 0 No (61 

Special equipment or aids Special equipment or aids Special equipment or aids Special equipment or aids 

~66-66 181-82 197-98 E 

167-68 183-84 19%100 1115-11 

, ~I,.: ,a’.* ~*,.-,<.,;,,& .:-.,,.2,-:* $,>iXf ;“)~<(<4;: .;:ii,;,;: :;: ,~.,‘::c.:,)y$ .yr;‘,; ii-‘.. T,’ ;< ..‘, .~ ‘; ., . _. ,,.. .._&‘,’ 

F;DTNOTES 
--------------------------------- 

-- 

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

Section P. FUNCTIONAL LIMITATIONS (FL), Continued 

’ Read To respondent - Now I will ask about some other activitles. Tell me about doing them by yourself. 

(1) 1 10 Ga 1 27 

3. Because of a health or physical problem, do you have ANYdifficulty - Preparing your own meals? Shopplng for personal Ifems, {ruoh 

Ask if “Doesn’t do”: es toilet Moms or medlclnes)? 

Is this because of a HEALTH or PHYSICAL problem? 1q JYes 1q Yes 

If “Yes, ” mark box 1; if “No,” mark box 3 2 0 No 20 No 

3 17 Doesn’t do for other reason 3 0 Doesn’t do for other reason 

Ask IO- 12 for each activity marked “Yes”in 9. 1 '17 1 28 

0. By yourself, how much difficulty do you have fsctivitvl. i q Some Tq Some 

some, a lot, or ara you unable to do it? 2 0 A lot 2 0 A lot 

3 0 Unable 3 0 Unable 

1. Do you receive help from anyone in -I? 1 18 1 29 

10 Yes (12) 1clYes 1121 

2 0 No (10 fornextactivity 2 0 No (10 for next activity 

with “Yes” in 9) with “Yes” In 91 

2e. Who gives this help? 12a. Source of help ! 12b. Paid 12~. Source of help i 12b. Paid 

118-221 123-28 )30-33 I jar-a7 

I Anyone else? HH member I 00 S/C/P HH member I 0 Cl S/C/P 

tORelative....; lOYes 20No r~flelative.,..) 1 OYes znNo Mark the S/C/P box without asking if ONLY help is from spouse/children/parents, 20 Nonreletive .I I UYes 20 No 2 q Nonrelative , I I 0 Yes 2 0 No THEN 10 for next activity marked “Yes” in 9. I 

Non-HH member I Non-HH member f b. Is this help paid for? 3 0 Relative . . ..I ruYes 20No 3 q Relative . . ..i 1 q Yer znNo 

Ask if necessary: 4 0 Nonrelative .I I UYes 20 No 4 0 Nonrelative . r I 0 Yes 2 0 No Which helpers are paid? t I 

;;c’. ._’ ,,. $~..,’ , : / ,I -. _ .I I‘ ’ _ -. -’ ,.I - _ I ” t I . I 1 

P3 Refer to 13 and 14 on other FL pages. I i 0 13 and 14 filled on another FL page (15) 

( 3 17 Other (131 

h 

3a. Is it NECESSARY to go up or down a step to get into this Ihousa/apartmeotl 1 , q No 1 

from the outside? I Yes - If not mentioned, ask: Is it one step or mora thsn one step? I 

I 2 0 1 step I 

3 q More than 1 step 

- -------~~--- ---.- ------------t;~-~~---------;o,,,, ,------------------E 

b. Countmg basements and stepdown Irving areas as separate levels, does 

this l’houselapartmentl have more than one floor or level? 

I 

I 1 48. Does this Ihouselapartmentl have a bathroom, bedroom, and kitchen 1

I , q Yes 20No ALL on the same floor or level? 

-----------------------------------------I -------A---------'-----------"-"T' r-­

b. Does this Ihouselapartmentl have a walk-in shower, that is, where you 1 

don’t step over the side of the tub to get into the shower? 1 i q Yes 20No 

I 

5a. Because of a health or physical problem do YOU NEED a bathroom, I 1 

bedroom, and kitchen ALL on the SAME floor or level? 1 1q lYes 20No 

------------------------------------------~--------------------------------------- m b. Because of a health or physical problem do YOU NEED a I i q Yes 20No walk-in shower? I 

FOOTNOTES 

FOAMtw-I ,98,11996113-1e.1 

66 
Reask 9 (4) 1 (5) 1 

Managlng your money, such as kasplng track of expsnser or pay\ ng blllr)? Using the telephone? Doing heavy housework, {such as scrubbing floors, or washing windows}? 

Dolng light housework, (such as dolng 

dishes, straightening up, or light cleaning)? 

1q Yes 1 q Yes 1q Yes 1q Yes 

z 0 No 2 0 No ‘20No 20 No 

3 0 Doesn’t do for other reason s 0 Doesn’t do for other reason 3 0 Doesn’t do for other reason 3 0 Doesn’t do for other reason 

1 L-E 

1q Some 1q Some 1q Some‘ 1q Some 

z 0 A lot 2 0 A lot 2 0 A lot 2 0 A lot 

3 17 Unable 3 0 Unable 3 0 Unable a 0 Unable 

HH 

1 1 - 1 I7 Yes (121 1q Yes (72) 1q Yes (12) 1q Yes (121 

2 0 No (70 for next activity 2 0 No 110 for next activity 2 0 No I10 for next activity 2nNofP3j 

with “Yes” in 91 with “Yes” in 9) with “Yes” in 9) 

12~ Source of help ] 12b. Paid I2a. Source of help 1 12b. Paid Pa. Source of help I 12b. Paid 2a. Source of help I 12b. Paid 

141-44 I 

r 

146--48 162~-66 I 

r 

b 163-66 I 

r 167--7(1 174-77 I I 

(78--81 

member I 0q S/C/P -lH member I 0q S/C/P IH member I 0 q S/C/P IH member I 0 cl S/C/P 

1q Relative . . . .I iaYes z[7Nc tORelative....’ lOYes znNo I 0 Relative. . . .I I 0 Yes z 0 No tORelative..../ iaYes 20No 

2 0 Nonrelative . I t 0 Yes 2 0 NC 2 0 Nonrelative . 1 I 0 Yes 2 0 No 2 0 Nonrelative . I I [7 Yes 2 0 No 2 0 Nonrelative . 1 t 0 Yes 2 17 No 

I 

Uon-HH member I Uon-HH member ’ Ion-HH member ’ Ion-HH member ’ 

3q Relative . . ..I 10Yt.x 20Nc 3 Cl Relative . . . .I lOYes 20No 3 0 Relative . . ..I iDYes 20No a 0 Relative . . ..I I q Yes 20No 

4 q Nonrelative . I 1 0 Yes 2 q NC 4 0 Nonrelative . / I 0 Yes 2 [7 No 4 0 Nonrelative .I lOYes 20No 4 0 Nonrelative .I lOYes 20No 

:

/. , _I, ; . ‘z ) 

:OOTNOTES 
CARD R 

RACE 

1. Abut, Eskimo, or American Indian 

2. Asian or Pacific Islander 

3. Black 

4. White 

CARD I 

INCOME 

U . ... $20,000 - $24,999 

V . ... $25,000 - $29,999 

w . .. $30,000 - $34,999 

X . ... $35,000 - $39,999 

Y . . . . $40,000 - $44,999 

z .. .. $45,000 - $49,999 

ZZ... $50,000 and over 

CARD 0 

ORIGIN 

1. Puerto Rican 

2. Cuban 

3. MaxicanlMaxicano ___--- :-

4. Mexican American I 

5. Chicano 

6. Other Latin American 

7. Other Spanish 

CARD J 

INCOME 

A .... . . l..ss than $1,000 IincludinS Iowl 

B ....... s1.000 - *1,999 

c ... . ... $2,000 - *2,999 

D ....... $3,000 - $3,099 

E ....... $4,000 - $4,999 

F ....... #5,000 - 15,999 

.G ....... $6,000 - $6,999 

H ....... $7,000 - $7,999 

I ........ ~8,000 - $8,99S 

J ....... $9,000 - $9,999 

K ....... ~10,000 - $10,999 

. ........ *11,ooo - *11,999 

M ...... tl2,009- (12,999 

N ....... W3,OOO - $13,999 

0 ....... *14,000 - w4.999 

P ....... 116,000 - *1s,999 

Q ....... M6,000- ~19,999 

R ....... ~17,000- t17,sss 

s ....... *18.000 - *19.ess 

T ....... *1s,wo - *19,999 

66 
1987 

The 1987 NHIS was conducted with a full sample that 

comprised 47,240 households containing 122,859 household members. In addition ‘to the basic health and demographic questionnaire, the 1987 survey included questions 

on the following special health topics: cancer risk factors, 

child adoption, poliomyelitis, and Acquired Immunodeficiency Syndrome (AIDS). 

The questions pertaining to cancer risk factors comprised a separate booklet. One-half of the households 

were asked the epidemiology questionnaire for cancer risk 

factors and the other one-half of the households were 

asked the cancer control study questionnaire. The Hispanic population was oversampled for the cancer risk 

factor questionnaires. The interviews in Hispanic households were conducted using a Spanish translation guide. 

The guide is not included in this report. 

The special health topic on AIDS asked questions 

concerning knowledge of AIDS and attitudes about AIDS. 

A self-response questionnaire was administered between 

August and December 1987.The interview, initially administered with a paper questionnaire, was converted to a 

computer-assisted personal interview (CAPI). 

The questions were designed to determine what a 

person knew about AIDS. The person was asked if he or 

she had ever heard of AIDS, what was their source of 

information about AIDS, true,or false statements about 

AIDS, and questions about ways a person contracts AIDS. 

Approximately 21,000 randomly selected NHIS household members 18 years of age and older responded to the 

questions. Data from the AIDS health topic were produced on a monthly basis and published in Advance Data 

reports. 

Questions concerning child adoption were included in 

the basic health and demographic questionnaire. Women 

in the family 20-54 years of agewere eligible to respond to 

the questions on child adoption. The survey instrument 

included questions that asked about the number of children adopted, how many of the adopted children were 

living in the household, the date the child began living in 

the household, the date of birth, the country of birth 

(United States or foreign country), their relation to child, 

prior to adoption, and through whom the adoption was 

arranged. 

The questions on poliomyelitis were also included in 

the basic health and demographic questionnaire. The 

questions were designed as screener questions intended to 

identify individuals having post-polio symptoms. Persons 

26 years of age and over were asked the screener questions. 

69 
------------------------ ---- 

---- 

swusa 

OME No. 0933.0161: ApprovslEx~lrsr March 31,lQQl 

m&iS-1A 119871 NOTICE - Information contaIned on this form which would permitfdsntlflcstlon of any lndivldusl or sstsblbh. 

msnt has been collected with s guarantee that it will be held in strict confldencs, will bs used only for purposss stated for this study, and will not be disclosed or released to others without the consent of ths lndlvidusl or the 

U.S. DEPARTMENT OF COMMERCE establishment In accordance with section 308fdJ of the Public Health Ssrvlce Act (42 USC 242m1, B”REA”OFTHECENSUS ACnNGASCOUECTlNeAtENTFORTHE RT 86 U.S. PUBLICHEALTHSERVICE 1. 3-7 2. R.O. number I 9-10 3. Sample m 

8 NATIONAL HEALTH INTERVIEW 

SURVEY Book -of- books 

4. Control number 6, Bsglnnlng time 

PSU m Segment ,7 p3lSerial 124-26 126-29 1 30 

CANCER CONTROL I L=l t km, 

I

I I

I 2 p.m, 

le. FAMILY’ROSTER b.Hispanic oversample & 

List sJJnonda/eted familvmembers 78 f bvaoe _ - (oldest to vounuestl. . - I 10 

;Pl 1 32 133-34 136-36 

Lina PerSOn Acre NO. No. Name “X;;fkVp 

SP2-3 

His 

line I?0, 

1 0 Hisp, 

2 q Hisp. 

3 0 Hisp. 

4 0 Hfsp. 

5 0 Hlsp. 

6 0 Hisp. 

7 0 Hlsp. 

8. q Hisp. 

9 0 Hlsp, 

1 Refer.to the appropriate section of the sample person selection Jabeland circle as applicable. THEN circle the “SPl” 

Line No. in item 6a and mark “SP” box on the HIS- 1 for the selected sample person. THEN go to Section 0. 

r. FINAL STATUS 

o 0 No parson 18 + in this family (Household Page) Noninterview 

Interview 3 0 Refusal b?xpfain in NotesJ 

4 0 SPtemporarily absent I 

t 0 Complete interview (all appropriate sections completed) 6 0 SP mentally or physically incapable 

8 0 Other - Explein 7 

2 0 Partial interview (some but not all appropriate sections 

completed1 --Explain 2 

8. Ending time 9.lntarview mode 10. Language of interview 1 44 11. Interviewer identification w 

38-411 42 

1q Personal 

1 43 I 0 English aa 80th English and Spanish Name 

I 

[Code 

t a.m. 2 p.m. 2 0 Telephone 2 0 Spanish am Other I 

, TRANSCRIPTION FROM COMPLETED HIS-1 

2. Sex of SP /Page 2 or 55, question 31. 13. Education of SP IPeg; 42 or43, qdsstion W 148-49 14. Main race of SP (Pegs 42 or 43, question 3a/bJ w 

00 0 Never attended or kindergarten 

Elem: 1 2 3 4 5 8 7 8 1 2 3 4 5 - Specify 7 

High: 9 10 11 12 

College: 1 2 3 4 5 6 + 

Finish grade&ear Kluestion 2bJ 1 60 

- _r ..... 20 Manis-d - -r---- .._ not in HH I ozuc

a 0 Widowed 030D 

4 0 Divorced I 040E 

6 0 Separated 050F 

6 0 Never married 0600 

, question 861 

osaJ 1600 

loOK 170R 

llcll. tsus 

12OY 1sUT 

130 N 2oou 

(Transcribe from Ba if 8b blankj 

27 fJ $20,000 or more 

28 q Less than $20,066 

230 x~~ I I 1Ix1 Cancer control 

240 Y 

250 Z I 

2acl zz 

PHS-T-540 

05/s/86 

70 
-------- -- --------- 

I 

I 

3 0 

RT 66 

Section 0 - ACCULTURATION 3-4 

, 6 

I t 0 Available 1021 

01 SP Status ht initial interview .I 

‘I z 0 Callback required lffouseholdpegel 

1 a q Noninterview fCoverpege1 I 

1 8 I I 0 HispaniclBnglish Supp. interview (la), 

Refer to hispanic origin from family roster and I z 0 Hispanic/Spanish Supp. interview flbl 02 expectdd language for this supplement. I 

I a 0 Other fsection PI I 

I 

1 7 

Read to respondent: 

I’m golng to be asklng questions that are related to health concerns, such as smoklng, eating practices, doctor visits and so 

forth. Before I ask these questions I would like to ask a few questions about the language you use most often. 

1 cl Yes 12) 

1 a. Do you speak sny Spanish? z q No(4) _-------- ______________ ________________________ ____________ - ______ ---------E 

Read to respondent: 

I’m going to be asking questions that are related to health concerns, such as smoking, eating practices, doctor visits and so 

forth. Before I ask these questions I would like to ask Edfew questions about the language you use most often. 

I 

b. Do you speak any English? 1 Cl Yes 

I‘ 2 0 No 14) 

1 s 2. Would you say that you speak mostly Spanish, mostly Engilsh, [ I 0 Mostly Spanish or do you speak Spanish and Englirh about the same? I 2 0 Mostly English I 3 0 Both about the same 1 1 10 3. What language do you prefer: Spanish only, mostly Spanish, i I 0 Spanish only 

mostly English, English only, or Spanish and Engilsh about z 0 Mostly Spanish squally? 3 0 Mostly English 

4 0 English only 

1 a 0 Spanish and English equally 

~ 4. Can you read Spanish? iClYes 

1 11 

i

I 20No J 1 12 5. Can you read English? I i Cl Yes 

I znNo I 

If “Yes” to both 4 and 5 ask: I I 0 Spanish 1 13 

2 0 English 

8. In which language do you read better? I 3 0 Both the same 

I lOYes 1 14 

7. Can you write in Spanish? 

I 20Nq, 

8. Can writs in 1 16 

you English? I 1fl Yes 

znNo I 

1 If “Yes” to both 7 and 8 ask: I 1 16

I t 0 Spanish 

8. In which Ianguags do you writs better? I 2 0 English 

I 3 0 Both the same 

I 1 17 

If self-reported on HIS-T, mark box without asking. I 10 Puerto Rican 6q Chicano 

I 2 0 Cuban 6 q Other Latin American 

HAND CARD 0, read categories if telephone interview. I 3 0 MexicanlMexicano 7 mother Spanish 

I 4 0 Mexican American s mother ISpecify -J 

10. VMtMS ~f;~;~c~~o;~ best describes your I 

I 

I 

11. Which of these groups best describss your I 

i 0 Puerto Rican 6 q Chicano 1 18 

mother’s ethnic idsntification? I

I 2 0 Cuban 6 mother Latin American 

I 3 0 MexicanlMexicano 7 mother Spanish 

I 4 0 Mexican American s mother fSpedfy1 3 

f 

I.I 

12. Which of these groups best describes your I 

I t 0 Puerto Rican 5q lChicano ( 19 

father’s ethnic identification? I 2 0 Cuban 6 mother Latin American 

I 4 0 MexicanlMexicano Mexican American 7 mother Spanish

e mother ISpecifyl 3 

I 

I 

FORMHIS-IAnss7, ,7-7s88, 

71 
Section 0 

- ACCULTURATION - Continued 

1 

If self-reported on HIS- 1, mark box without asking. I I Cl U.S., except Puerto Rico 

2 Cl Puerto Rico 13. In what country or state were you born? I 3 0 Cuba 

I 4 Cl Mexico 

s 0 Other (Specify) 3 

i 

I 

b 

I 4. In what country or state was your father born? I i Cl U.S., except Puerto Rico 

I 

I 2 El Puerto Rico 

I 3 0 Cuba 

I 4 cl Mexico 

1 a 0 Other ISpecifyJ I 3 

I 

1 

I 5. In what country or state was your mother born? f 1 cl U.S., except Puerto Rico 

1 2 0 Puerto Rico 

I 3 0 Cuba 

I 4 0 Mexico t

I 8 0 Other (Specify) 3 

t 

I 

Notes 

1 

1 

m 
--------- ---------- --------- 

. 

Secttibn P - MEDICAL CARE 

I 

(I’m going to be asking questions that are related to health 1 

concamr, such as smoking, eating practIcesI doctor vlrlts I l nd so forth.) I 

There questions are about medIcsI care you may have. I 

nwded in the past year. 

1a. Durlng the past 12 months, that is, since /I%month dateLo 

f 1q Yes 

year ago, hmve you NEEDED any medical care or advice? I 7.0 No 121 

_-----------------------------------------------’ l-~~~T--------- p r---­ b. During the past 12 months, was there aver a time when you ; 

did not get the mvdlcal care or advlce that you needed? 2 0 No (21

__-____~-----------~-~--~~~~~~~~~ ---------------f--------------------------------------------------~ 

c. Why didn’t you get the cam that you nssded? I I 0 ProcrastinstadlPut it off 26 

Mark all mentionad, do not probe. t 0 Care was not available when needed 27 

I 

i 

t 0 Cost too much 

I 0 Didn’t know where to go 

t 0 Didn’t know what kind of doctor to saa 

23 

20 

I i 0 Didn’t have a way to get there 31 

I 

1 

I 

t 0 Hours not convenient 

I 0 Fear of being treated rudely or unkindly 

I 0 Other reason lSpscifyl3 ,’ 

33 

~ 34 

I 

I I q ‘DK 36 

! . la thsre a particular doctor’s office, cllnlc, health center, or other place that you usually go to 11you am sick or noed advlce 

about your health? 

I 

i 

i IJYas 

2iJNo 

snDK > 14j 

1 

B. What klnd of place Is lt - a doctor’s office, a hospital, a cllnfc, l ha&h cantor, or some other place? 

1 

I I 0 Doctor’s office (private group practice or doctor’s clinic) 

a 1 

I t 0 Did not have health insurance 28 

I 2 q Hospital emergency room 

If hospital: Is this an outpatient clinic or an smwgsncy room? i 3 0 Hospital outpatient clinic 

4 0 Haahlf cantaior private neighborhood health clinic 

If cllnlc: Is this a public health clinic or some other kind of cllnlc? i s 0 Public health clinic 

I 6 0 Health clinic at work p (51 

I 

I 7 0 HMO/prepaid group practlce/“Group Haakh” 

I 8 0 Other iSpecify) 3 

.I 

I - I / 

1. Whom do you go when you are sick or need advice about I 

I 

t 0 Doctor’s office (private group practice or doctor’s clinic) 33 your 

I t 0 Hospital emergency room 30 

Mark all mentioned, do not probe. I I 0 

I 0 

Hospital outpatient clinic 

Health center or private neighborhood health clinic 

40 

41 

I t 0 Public health clinic 42 

I 

I I 0 Health clinic at work 43 

I t 0 HMO/prepaid group practice/“Group Heelth” 44 

I t 0 Haven’t needed a doctor 45 

I 0 Don’t go anywhere 46 

health? 

I t q Have two or more doctors or usual places depending on E 

I what is wrong 

I 1 0 Other Epecifyl 7 & 

I 

1ODK 1 

i 

5. Where do you get your most usiM lnformatlon about how to 1 

pnvent Illness and Improve your health? 

I I 0 Telephone Information-Public Service or Hotline 60 

I 1 q Family 61 

I 1 0 Friends 62 

Mhk all mentionad, do notproba. I 

I 1 0 Work 64 

i 

I 0 Television 

1 IJ Radio 

66 

66 

I 1 0 Books 67 

I 1 0 Newspaper 66 

I 

I 

1 0 Magazines 

1 0 Pamphlets in doctor’s office 

60 

60 

1 0 Other soume 61 

i 1 0 Nowhere/Don’t get information 82 

I 

1q DK 1 63 

1 0 Doctor 63 

I 

I 

I 

FORMHIS-,A,1SS7,,7-23 

73 
---- 

rNrr7 

Section Q - FOOD KNOWLEDGE 3-4 

l B. Have you erior mado any LASTING and MAJOR change8 in I 1q Yes I 

what you eat and drink for hralth naaona? I 20 No 12) 

----------------------------------------~---------------------------------------------

b.. in making these ohangsa, what fooda do you eat MORE of? 1 MORE 

I pix 

Enter responses verbatim, one food per line. Do not probe. I p=z 

I 

i pii 

I pi37 

I ooo 0 None 

q f 

I OBO DK 

______--------~-------~~~~~--~~~~~~- ----~-~-----------------------------------------~ 

C. What foods do you eat LESS of? I LESS 

I m 

Enter responses verbatim, one foodpsrlihe. Do not probe. 1 

I m 

I m 

t 

I E 

I 000 [7 None 

I BBB[7 DK -----------------------------------------~----------------------------------------

d. Have you made these changtia in what you eat and drink in I 10 Yes I 

the paat 6 years? . I 20No 

1 B 0 Dd ‘=I ______--------~~------~~~~~--~~~~~~~ -l--- ---------------c--------~-~~~~d~~~d~~ 

e. Did you make these changes in the paat year? 10 Yes I 

f 

I 20 No ) I=’ 

2. Pioaaa tall ma whether the following atatemanta an true for 1 

you. First -

I Yes (True) No (False) 

(a) It l aema that everything you eat ia bad for you so why f 

bother changing. (la that true for you?) I 

I 1Cl 20 1 

(b) I enjoy tha things I eat and I don’t want to change. I 10 20 I t 

(0) There are so many different racommandationa, I 

1‘0 20 I it’s hard for me to know which ones to follow. I 

(d) I eat out so much that maklng changer would be hard. I 10 20 I 

I 

(e) M&inn$angaa in the kind of food I eat would be I ru 20 I 

I 

I 

I (f) I would like to changa but the mat of my family I 

won’t change. I 10 20 1 

I 

(g) The thinga I eat and drink am healthy 80 there I 

is no mason for me to make changes. I 

10 20 cx 

I am going to read two (more) l tetementa. Please tail me which I one you agree with moat. 

1 

I 1q a 171 

(a) What people eat or drink has iittis effect on I whether they wlii develop major diseases. 

I 2c] b (4) 

OR i s 0 DK 151 

(b) By eating the right kinds of foods, people can reduce I 

their chances of devsioping major diseases. f 

1. Which majoi diseases do you think may be related to what 1q Cancer people eat and drink? I 0 Heart disease 

I I q Obesity/overweight 

Mark all mentioned, do notprobe. I I 0 Diabetes 

I 1 q Hypertension or High Blood Pressure 

I I 0 Other 

I

I $0 None 

10 DK 

I 

Ql Refer to 4 I t q Cancer in 4 16) 

8 0 Other 161 I 

~I%-lA~l007lIF26881 

74 
Section Q - FOOD KNOWLEDGE - Contlnued 

1 m 6. Do you thlnk car&may be related to what poop10 I 1 cl Yes 

l mtand drink? z 0 No (8) I 3 0 Probably/maybe/could balatc. 

I s 0 DK 181 

38. What food, do you think people should eat or drink MORE 1 MORE 

of to hip prevent cancer? 

110--1: 

Enter responses verbatim. one food per line. Do not probe. m 

Ise-sc 

I 

I m 

t 

I 0000 None 

I ssso DK -----------------------------------------~-------------------------------~-----------

b. What fooda should people eat or drink LESS of LESS 

to help pmvsnt cancar? I 

I & 

I 

Enter responses verbatim, one food per line. Do not probe. 

I 

Iss-s; 

i m 

I ~ i 

1 0000 None 

sssO DK 

~-----_~------------____________________~ r-----‘--------------~----------,------~~~~~~ I 

c. What kinds of cancer do you think may ba related to the I t 0 All kinds of cancar 74 things poop10 oat and &Ink? 

I 1 Cl Breast osncer 76 

1 0 Bladder csncer 76 

Mark all mentioned, do not +robe. 

1 1 0 Cancer of the mouth/throat/esophagus 77 

I 1 0 Cancer of the colon/bowel/intestine/rectum 78 

I 1 0 Stomach cancer 79 

I 

I t Cl Prostate cancer (81 80 

I 

10 Lung cancer 

1 Cl Liver cancer 

82 

83 

I i cl Other. 84 

I 10 DK ‘. Ia E 55 

ra. Hava you heard or read ANYTHING about how eating more of roma foods and less of otbar foods can help prevent 

1 

I 

1 Cl Yes 

20 No 

88 

I t 0 Csncer of the uterus 81 

l ome maJor direaws? 

I s 0 DK > ‘*I 

I --‘--------------------------------------~-------------------------------------------

b. Which maJor dlseasar have you heard may be ralated to I 1 cl Cancer 87 

what poop10 eat and drink? I q Heart disease 85 

w Mark all mentioned, do not probe. I 

I 1 q Obesity/overweight so 1 q Diabetes 

I 1 0 Hypertension or High Blood Pressure 01 

I I 0 Other 02 

I 1q None 93 

I 0 DK ‘,.I 04 

I 

1 30. Some foodr contain flbw. Have you heard of fiber? 10 Yes 86 

I 20 No 

I SO DK > “’ -----------------------------------------~------------------------~--------------

b. Overall, would you say your diet Is high, msdlum, I I 0 High 

T-se’ 

or low In fiber? 

I 2 0 Medium 

30 Low 

I so DK 

-----------------------------------------~------------------------------------------~ 

HAND CARD 0 1, read list if telephone htarview. I t 0 Bran flakes 97 

c. Hera is a Ilat of foods. Please tell ma which ones I t 0 Corn flakes 06 

you think an high in fiber. t 0 Hamburgers 9s 

I ,a Lettuce !W I Msrk all mentioned, do not probe. I t 0 Baked beans 101 

1 0 Carrots 102 I 

1, 1 IJ White rice 103 

I t 0 Raw apples 104 

,a None 106 

I I 0 DK 1 106 

I 
MU 

Section Q - FOOD KNOWLEDGE - Continued a-4 

1 Pa. Overall, would you say your diet Is hlgh, medium, I 0 High A 

oi low in fat? I

I 2 0 Medium 

i 30 Low 

I 9ClDK ------------________----------~-~-~~~~~~ ~-------------------------------’---’-”----~ 

HAND CARD 02, readlistif telephone interview. 1 10 F&d chicken b. Here Is [ahnothorl list of foods. Please tell me 1 0 White bread which ones you think are high In fat. I 1 0 Soda or soft drink8 

I 1 0 Peanut butter 

Mark all mentioned, do not probe. I 1 0 Broiled fish 

10 Bananas I 

1[3 Cold cuts or lunch meats 

I 1 q Doughnuts 

1 10 None 

I I q OK 

IO. thinking about what you aat and drink, which of the I 

following are IMPORTANT concerns for you? I 

I 

i 

i (a) Molding foods with too much salt or sodium. (Is that an Important concarn for you?) f 1 cl Yes 2 ONo I I 

(b) Avoiding foods with too inuch sugar. 1 

(c) Eating foods to,lower cholostsrol. I 1 cl Yes 2 ONo I 

I (d) Not having enough money to buy food. 1 cl Yes 2 ONo I I 

I (e) Being ovemalght. 1 Cl Yes bqction R) 2 ONo I 

I 

(f) Being too thln. I

I 1 Cl Yes 2 q NO 1 

dotes 

76 
-------- 

Sectian R -------- -- ----- ---- - GENERAL KN~~WLEDCZP ANt3 -

ATTITlll3F?C --_-- __ -..T- - . . - -7 

I 

Thssa next questions are about cancer risks. ’ INCREASE TWO MOST 

Hand Card Rl, read categories if telephone intervisw. ; CHANCES _ RESPONSIBLE 

f 0. Which of theta things do you think increases a person’s I IO I 0 Stress 

chances of getting cancer? I 

I. 10 I 0 Inherited make-up or heredity 

Mark all mentioned in first column, do not probe. I 

I 

ICI I q Exposure to x-r&e 

I 

! ICI I 0 Poor eating practices 

I 

I ICI I 0 Using chewing tobacco, snuff, pipes or cigars 

I IO I 0 Air pollution 

I. ‘1 IO r 0 Water pollution ’ 

3 

5 

I 

3 

I 

3 

3 

I ., 

---------------------------------------------------l 

If two or fewer responses in la, mark lb without 

asking and skip to 2 

b. In your oplnlon, of the things you just msntloned 

which TWO are responsible for the MOST cases of cancer In this country? 

Mark box in second column next iv me 2 items mentioned. 

Hand Card f?2 

!. Please tell me whether you strongly agree, agree, 

dlsagma, or strongly dlsagraa with this statement, or If 

you hava no oplnlon -

Tham Is vary llttle a person can do to reduce hls or har 

chancas of gattlng cancer. 

I IO I 0 Some cloth dves 

1 

, IO .’ I 0 Exposure to toxic waste dumps 

I 

1 IO I 0 Exposure to toxic substences on the job 

I 

I ICI t 0 Exposure to people with cancer ._ 

I 

I IO I 0 Excessive drinking of elcoholic beverages 

I 

’ ICI I 0 Exposure to the sun 

I 10 I 0 Cigarette smoking 

I 

f 10 I 0 Exposure to nuclear weste 

i IO I 0 Some strong soaps end detergents 

I 

1. ICI I Cl Viruses 

I 

, IO I 0 Some medicines 

I 

I ICI I 0 Medical procedures using radiation 

I 

I I q DK IODK I 

I 

I t .[7 Strongly agree

I z 0 Awee 

I 3 0 Disagree 

1 4 0 Strongly disagree 

. s 0 No opinion 

I 

3 

I 

3 

5 

r 

t 

I 

t 

i 

r 

!. 

I 

i 

1. ~haaCa:,w think arc the wamlng signs or symptoms I 

i 

Mark a// mentioned, do not probe. .j 

I 

I 0 Weight loss/loss of appetite 

t 0 Change in bowel or bladder habits 

I 0 Unusuel bleeding or discharge 

I 0 Lump in breast or elsewhere 

I 0 Indigestion 

I 0 Difficulty in swallowing 

I 0 Change in e wart or mole 

I 0 Nagging cough or hoerseness 

I q Chest pain 

I 0 Shortness of breath 

I 0 Sores that don’t heal 

I 0 Tired/fatigued 

I 

I 

I IODK 

I 
Section R - GENERAL KNOWLEDGE AND ATTITUDES - Continued 

I @a. If you were offered l fme 2 hour class on how to reduce 

your chances of getting cancer, would you be interested 

in going to it if it were convenient? 

-----------~~~~~~-----~~~~~~~~~~~~~~~---~---- +------------ --------------------~~~~~~~~~~~~ 

Hand Card R3, read categories if telephone interview. 

I 

I q Church 

Local school b. If you ware going to attend such a class, which of I 1’0 I 0 

these places would be convenient for you? Hospital

I 1 q Club meeting 

i q Workplace Mark all mentioned, do not probe. I I q Home 

I 1 Cl Senior center 

I 1 Cl Community center 

t 0 Other place 

i rnDK 

Notes 

78 
---------------- ---- ------ 

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

RT 88 

Section 8 - CANCER SCREENING KNOWLEDGE AND PRACTICE 3-4 

I 6. I 0 Male, under 40 141)

Sl Refer to age and sex I znMale,40+ 121) 

I 3 0 Female (I) 

ihxro next questions are about certain kinds of modlcal I 1OYes m 

tests xnd sxamlnxtlons. I 

18. Have you avoc heard of a Pap smear test? I ----__-------------------------~--------~--- ;------------ - - --7- .-= 

b. Have you ever had a Pap smear? lOYes 

---i v 

CO When dld you have your last Pap smear? 

If 3 years ago or less (21 If more than 3 years ago (41 

d. Was k wlthhi the past year or a year or more ago? I 0 Within past year fle) 

2 0 1 year or more (If! -----_----_----_--------------.--------------~--------------------------------------------- E 0. Was It less than three months, or 3 or more months ago? I t 0 Less then 3 months 

2 0 3 or more months 12) I sODK --------------------------------------------~---------------------------------------------

t . Was It 3 years ago or lesr, between three and S years, or I 

I 1q ,3 years or less 12) E 

6 or more yean ago? I 2 0 Between 3 end 5 

I 3 q 5 or more years (4) 

I saDK 

2. Whom was thls Pap smear done - In a doctor’s off Ice, a I 1q Doctor’s office k 

cllnlo, a hospital. or some other place? I 

I 

I 3 0 Hospital 

I 8 0 Other place Epscifyj 3 

I 

1 s0DK 

e 

20 Clinic 

30. Dld you go for your last Pap smear because of *health I 

I 1UYes 

problxml 

I 

----------------;----------------------------~---------------------------------------------

@. What was the problem7 I t 0 Follow-up tests/treatment I t 0 Bleeding 

i I Cl Pain 

Mark al/mentioned, do not probe. I t [7 Discharge 

I t 0 Itching 

I I 0 Burning 

I I 0 Infection 

I I 0 Unrelated medical problem 

---___~--------~--------~~~~~---~~~~~~~~~~~~ 

0. How were you told the results of the test - In person, over the talephone, through the mall, or some other 2 0 Telephone way7 

I 3 0 Through the mail 

40 Combination of methods 

f s 0 Never told; meaning results normal 

I 8 0 Never told; DK if problem 

1 8 0 Other 

I 

I 1q Yes(51 & 

s2 Refer to 3a. I 

I 

I 

I 1 40. Have you EVER had a Pap smear bscause of a health 1. lOYes 

problem? 

I 

-----_--------_-----------------------------~------------------------------------------------- b. Whxt was the problem7 I 

I i 0 Follow-up tests/treatment 

Mark all mentioned, do notprobe. I 

i q Pain 

10 Discharge 

I I 0 Itching 

10 Burning 

i 0 Infection 

I I 0 Bleeding 

t q Unrelated medical problem 

I 0 Other 

rnDK 

79 
Section S - CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued 

1 1 43 

5a. Have you ever had a Pap smear where the results I 1ElYes 

were NOT normal? 

i -------------_-----_--------- ---------------------------------------------~--------------- J--ii-­

b. Because of the abnormal resultx, did you have I 1OYes 

any additional tests? z0No 

I eODK 

------------------------------------------------T I ----_----__-----_-__~~~~--~~~~-~~~~~~~~~~~~~ -p--

0. Bacause of the abnormal results, did you have 1OYes 

any surgery or other treatment? I znNo 

I eODK __----__---___----__-------------- -----------t----------- - - -----d---__--___-...---~~----d~-- -pb-­ d. Did the [Pap rmearladdltlonal tsrtslrurgsry or other I 1clYes 

treatmentl Indicate that you had cancer? 20No 

I 00 DK “” 

__---___-_____----__------------------------- f--------- ------____________--------------­ e 8. When were you dlagnossd as havlng cancer? 

I i 0 Days ago 

OR - 2 0 Weeks ego 

s 0 Months ago 

4 q Years ego 

I we 0 DK 

1 

I t 0 More than 3 yeers in l-c or 1 f (61 s3 Refer to lc and If. I a 0 Other 171 I I Iss-sa ” 6. What Is the most important reason why you have [never had a / 000 Procrastinated/Put it off 

Pap amearlnot had a Pap smsar in the past fsw yearsl? 01 a Had a hysterectomy ISJ 

I 020 Didn’t know I should 

I 030 Not needed/not necessary 

040 Cost too much 

t 060 No insurance coverage 

I 060 Don’t go to doctors 

f 070 Don’t have e doctor 

080 Not recommended by doctor/Dr. naver said it was needad 

I oea Dr. said it wasn’t needed 

! toa Too embarrassing 

I t t 0 Haven’t had any problems 

120 Fear 

i seu Other 

f esO DK 

I 

I 1 7a. Do you have menstrual periods? 113 Yes IS! 

I 20 No 17b) 

I 3 0 Never had menstrual periods 17cl 

________---___-_____------------------------- f-------------------------------------------­

b. Dld they stop due to surgery? 1 OYes (~1 

E 

I 

I 20No 1 

---------------------------------------------~-------------------------------------------- E C. War this due to surgery? 1ClYes 

f 20No 1 

E 8a. Do you know how to examine your awn breasts for lumps? 1 lOYes 

I 20 No IS4) I ________---_________------------------------ T------------------ ----------------_-----~-~~ m b. About how often do you examine your brsasts for lumps? 1 tODaY 

2 0 Week 

I 3 17 Month 

I Times per 40 Year 

I ,{ 

I 0000 Never 

I ssso Other iSpecify) 3 

I 

I otwd DK I -------------------~-------------------------+-------------------------------------------------

c . Who taught you how to examine your breasts? 

I I 0 Doctor 64 

10 Nurse 06 

Mark all mentioned, do not probe. 

I 10 Other health professional 68 

67 I 10 Learned in a class/meeting so I 10 Read in a book, pamphlet, magazine, etc. 66 10 Television 

I 

! t 0 Other lSpscify~ 2 E 70 

80 
----- 

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

Section S - CANCER SCREENING KNOWLEDGE AND PRACTICE - ‘Cointimed 

I

I t 0 Under 40 1391 1 

s4 Refer to age. i 2 0 40 end over (91 

1 95. A bmast phyrlcal oxam Is when the breast Is felt for lumps i 1j-JYes 

by a doctoi or msdlcal asalrtant. Have you ever heard of a bnaat phyrlcal examlnatlon? i 

~~~~~--_~__~---___~----------------~----~~~~ ~~~----~~~-----.--.--~-----~------~~~~---~~ b. Hava you avar had a breast physIca exam? 1OYes m 

I 

,I 2 0 No (141 

gnDKf151 _____--_____-_______------------------- 1 _-------_------__-_----~~----~------~~~~~--~~ 

C. Whan did you have your last braaat physlcal axam? I .m 

r 

1 - -19. OR - If 3 yssrs ago or less 110) 

IllO. year If more then 3 years ago (121 

I 

f ----------------__---------------------- ---::---------------------------------------------‘~~2~’ ssso DK 19d) 

d. Was it wlthhn the past year or a year or more ago? 1 q Within past year 19ef Q 0 OK ff21 t 

I 2 0 1 year or more f9fl 

$--- ___---- ___- --------------------------w--m 0. War it leas than thma months, or 3 or more months ago? t q Less than 3 months 

2 0 3 or more months (101 

I sODK --------------------------------------------~-------------------------------------------~- E f. Was It 3 years ago or lass, between three and 5 years, or I 6 or mora yaars ago? 

I (121 

I 

I 

10. Whsra wao thlr exam done - in a doctor’s offica, a clinic, I 

I i 0 Doctor’s office a horpltal, or some othar place7 

I 2 Cl Clinic 

I 3 0 Hospital 

I 

I 8 q Other place K+~ecifvl~ 

I 

i snDK 

115. Did you go for your last bmast 

of a haalth problam7 

physlcal exam bscauas 

I lOYes ( 

I 

_____----___-______-------------------- I -----T---------------------------------------------

b. What warn the problem7 10 Follow-up tests/treatment 

; 1 Cl Soreness 

I i q Swelling Mart? a// mentioned, do not probe. I. 1 Cl Lumps 

1 q Pain 

I i 0 Discharge I 

t 0 Complications related to breast feedlng I t 0 Unrelated medical problem I 

t 0 Other 

I 1ODK --------------------------------------------+---------------------------------------------

c. How wera you told tha results of the test - In person, 1 Cl In person 

way7 I 3 0 Through the mail 

.I 4 0 Combination of methods 

I 

I 

6 0 Never told: meening results normal 

6 0 Never told: OK if problem 

I 

I 8 0 Other 

I lOYes 1131. b 

ovar the talaphons, through the mail, or some othar f 2 0 Telephone 

s5 Refer to 1 la. I 

I 

25. Hava you EVER had a braaat physlcal axam because 

of a health problem? 

--------------___---------------e-u----- I ___----___-----__------------~------------- b. What warn the problem7 ----1------

I r 0 Follow-up tests/treatment 

I 1 Cl Soreness 

Mark all mentioned, do not probe. I 1 q Swelling 

i Cl Lumps 

I 1 Cl Pain 

I t 0 Discharge 

I t 0 Complications related to breast feeding 

I I 0 Unrelated medlcel problem 

I 0 Other ,I rnDK 

i 

81 
--------------------------------------------- 

Section S - CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued 3-4 

I k ISa. Have you ever had a breast physical exam where the f 1clYea 

results were NOT normal? 

1 g ;o, IW > --------------,------------------------------~-------------~------------------------------- -__ 

b. Because of the abnormal results, did you have 1clYea L!!­

any additional tests? i 20No 

I snDK 

C. Because of the abnormal results, did you have I 1clYea 1 

any surgery or other treatment? I 20 No 

I so DK ---------------------------------------------~--------------------------------------------- d. Did the [breast physical examladdltional tests/surgery or 1OYes E 

other treatment] indicate that you had cancer? 1 20No 

I SO DK 1 ls6’ 

f------------------------------~~~~~~d~~~~~~d 

e. When were you diagnosed as having cancer? 

I 

I 1’19 

I mo. yea* 

I 

I 

I 

1 

I 10 S6 Refer to 9c and 9f. I 60 

I 

14. What is the most Important reason why you have [never had a ; 

breast physical exam/not had a breast physical exam in the 1 000 

past few years1 by a doctor or other health professional? I 010 

I 020 

030 

040 

060 

060 

070 

080 

os[7 

100 

110 

120 

aan 

es0 

Notes 

E 

I 0 Days ago 

OR- 2 0 Weeks ago 

3 0 Months ago 

4 cl Years ago 

sssn DK 

tzi=si 

b 

More than 3 years in SC or Sf (14) 

Other (161 

w Procrastinated/Put it off 

Didn’t know I should 

Not needed/not nacessarv 

Coat too much 

No insurance coverage 

Don’t go to doctors 

Don’t have a doctor 

Not recommended by doctor/Dr. never said it waa naadad 

Dr. said it wasn’t needed 

Too embarrassing 

Haven’t had any problems 

Fear 

Examine own breasts 

Other 

DK 
---- ------- 

--- 

--- 

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

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

Section S - CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued 

I & 

HAND CARD S 1 

I 

!?a. A mammogram is when an x-ray is taken only of the breasts 

by a machine that presses against the breast while the 1 1UYes 

picture 1s taken. Have you ever heard of a mammogram? I 

I 

_____--____-----------~~~--~~e----~----------. &-------------- _c____----_--------- ----_--­

b. Have you ever had a mammogram? lOYes F 

I 20 No f20) 

euDK 1211 ___________ -__-- ______________ - _____________ - E 

C. When dld you hava your last mammogram7 

If 3 years *go or less I1 6) 

If more than 3 yesrs ago (18) 

-----t--------------------------------------------­ d. ~~r~~~~~;inT~~~~~~~~~-~~~~~~~~-----

I --------------------------------------------~--------------------------------------------- C. Was It less than thrse months, or 3 or more months ego? 

I 

I --------------------------------------------~---------------------------------------------

f. Was It 3 years ago or less, between three and 5 years, or l 

6 or more years ago? I 

I 

I 

I 

16. Where was this test done - In a doctor’s office, a clinic, a 

hospital, or some other place? 

I 

I 

I 

I 

I 

I

I 

7a. Did you go for your last mammogram because of a I 

I health problem? 

I 

I 

I 0 Within past year f 15el 9 0 DK (181 

20 1 year or more I?5fl 

I 0 Less than 3 months lx?.­

2 0 3 or more months (161 

auDK 

1 Cl 3 years or less (16) Lz!L 

2 0 Between 3 and 5 

3 Cl 5 or more years fl8) 

anDK 

r 0 Doctor’s office 1 

2 Cl Clinic 

3 0 Hospital 

40 Imaging center/x-ray lab 

a q Other place (Specify) 2 

snDK 

1 

lOYes 

20No I1 7cl 

sODK 

T------------------------------------------------­ I

b, What was the problem? I 0 Thickening 

i 0 Soreness 

Mark all mentioned, do not probe. 1 Cl Stielling I 10 Lumps I 

I 1 Cl Pain 

I 0 Discharge 

I I 0 Unrelated medical problem I i 0 Othgr I 

I IODK 

+ _____ 

C. How were you told the results of the test - In person, I over the telephone, through the mall, or some other I 

way? I 

I 

I 

I 

I 

I 

I 

I

I 

I

s7 Refer to 17a. I 

I 

I 

I 

l&t. fi~i~;o;V~.Thad a mammogram because of a 1 

20 Telephone 

3 0 Through the mail 

40 Combination of methods 

50 Never told; meaning results normal 

e 0 Never told; DK if problem 

a0 Other 

lOYes (781 ) 

lOYes 1 

I 

I 

I --------------------------------------------~-------------------------------------------------

b. What was the problem? I I 0 Thickening I i Cl Soreness I Merk a// mentioned, do not probe. I 10 Swelling I i 0 Lumps I 

I 1q Pain 

I I 0 Discharge 

! I 0 Unrelated medical problem 

I I 0 Other 

I IODK 

I 

83 
Section S - CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued 

1 k 1%. Have you ever had a mammogram where the I 10Yes 

results were NOT normal? 1 20No 

1 SO DK I “‘) 

___------------------------------------------~--------------------------------------------- M-d. 

b. Because of the abnormal results, did you have I 

I lOYes Is-. 

any additional tests? I 20No 

I 8nDK 

---------------------------------------------T----- I ----------------------~----------~-~~~d~ 

c. Because of the abnormal results, did you have 1 Cl Y.es E 

any surgery or other treatment? i 20No 

I ---------------------------------------------+--------------------------------------------- snRK 

d. Did thB [mammogrem/addltlonaI tests/surgery or other rOYas E 

treatment] Indicate that you had cancer? t 

t lS8) 

____--------------~~~~------~~~~~~~~~~~~~~~-- t--------------‘-----------------------------­

e. When were you dlagnosed as having cancer? m 

’ I 1 0 Days ago 

1 -19 OR - 2 0 Weeks ago 

mo. year 3 0 Months ago 

I 

I. 4 0 Years ago I 

I 

I 58s 0 DK 

I /zzi 

k 

S8 Refer to 15~ and 15f. 

! I 0 More than 3 years in 15cor 1 Sf 1201 

! 8 0 Other (27) 

I 

1 b 20. Whet Is the most important reason why you leave [never had a ; 0017 Procrastinated/Put it off 

mammogram/not had a mammogram in the past few years]? 010 

I 

I 020 

030 

I 040 

f 060 

060 I 

I 070 

I 060 I 

I osn 

I ton 

I ito 

120 I 

I 130 

I 140 I 880 

I

I se0 

iotes 

Didn’t know I should 

Not needed/not necessary 

Cost too much 

No insurance coverage 

Don’t go to doctors 

Don’t have a doctor 

Not recommended by doctor/Dr. never seld It was needed 

Dr. said it wasn’t needed 

Too embarrassing 

Haven’t had any problems 

Fear 

Fear of radiation 

Painful procedure 

Unpredictable results 

Other 

DK 
Section S - CANCER SCREENING KNOWLEDGE AND PRACTICE - Contiliued 

I 

llhara next quertlons ara about cartaln ldnds of medlcal I 

tests and examinations.) 

18. Have you aver heard of a dlgltal rectal axem, that is 1UYes 

when a finger Is Inssrtad In the rectum to check for 

problems? I 

I --------------------------------------------~--------------------------------------------- b. Have you aver had a digital rectal exam? I ~OYes IE 

I * 0 No 1261 I 

I 90 DK (271 -,-__-----__----____--_____---____-------------------~--------------------------------------------- e C. When did you have your last dlgltal rectal exam? 

i 

1 ,?S -OR If 3 years ago or less (221 

I mo. VWM If more than 3 years ago 124) 

I 

I 

sssdDK (21dI 74-74 -----------------------~--------------------~--------------------------------------------- -~~. 

d. Was It wlthln the past year or a year or more ago? I 

I I 0 Within past year 121ej v 0 DK 1241 t 

2 0 1 veer or more f2 1fl ------------_------_------------------------~--------------------------------------------- --__ 

tt. Was It less than three months, or 3 or more months ago? I 

I I q Less than 3 months LE 

I 2 0 3 or more months 1221 

I s0DK ---------------------------~---------------- t-------------- -------------------------------m 

f. Was It 3 years ago or less, between three and 6 years, or 6 or more years ago? I 

I 

I

I 

2. Where was this ex;m done - In a doctor’s office, a clinic, I 

I 

a hospital, or some other place? I 

I 

I 

I 

I 

I 

I 

38. Dld you go for your last digltal rectal exam because of a health problem? .I

--------------------------------------------~---------------------------------------------

b. What was the problem? 

Mark a// mentioned, do notprobe. 

---------------------------~~---------------

t+ How were you told the results of the test - In person, over the telephone, through the mall, or some other 

way? 

ss Refer to 23a. 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I* 

I 

I 

I 

I 

! 

I 

1 

I 

I 

I 

I 

IO 3 years or less (22) 

2 0 Between 3 and 5 year 

3 Cl 5 or more years 124) 

a0DK 

t q Doctor’s office 1 

2 Cl Clinic 

3 0 Hospital 

a 0 Other place ISpecify 3 

sODK 

TOYes r 

i q Pain 

1 0 Constipation 

I q Bowel trouble 

I 0 Blood in stool 

1 0 Difficulty urinating 

10 Prostate enlargement 

I 0 Bleeding 

t q Hemorrhoids 

I 0 Diverticulitis 

I 0 Unrelated medical problem 

2 0 Telephone 

s.f-J Through the mail 

40 Combination of methods 

6 fJ Never told: meaning results normal 

en Never told; DK if problem 

a 0 Other 

I q Yes (251 m 

ILlYes. w 

i Cl Pain 

i Cl Constipation 

I 0 Bowel trouble 

t 0 Blood in stool 

I 0 Difficulty urinating 

t Cl Prostate enlargement 

I 0 Bleeding 

I 0 Hemorrhoids 

i •i Diverticulitis 

I 0 Unrelated medical problem 

I 0 Other 

1nDK , 

FORM HIS-IA nm7, ,7-2*-t 

85 

aa. Have you EVER had a dlgltal rectal exam because of a I health problem7 I --------------------------------------------~-------~-------------------------------------

b, What was the problem7 I 

1 

I Mark allmentioned, do not probe. I 

I 

I 

I 

I 

I 

I 

I 

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

fi 

Section S - CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued a-4 

258. Have you ever had a digital rectal exam where i 1clYe.s I 

the results ware NOT normal? z0No 

i BODK I “‘O’ 

_____________________________________----------------~--------------------------------------------- --__ 

D- Because of the abnormal results, did you have I 

I any additional tests? 

1 El Yes 

2[7No 

LAI SODK ~~~~~~~~~~~~-----~-~-~----------------------- +----- --------------------------------i---- _--_ 

c . Because of the abnormal results, did you have I 1clYes CAany surgery or other treatment7 I 20No 

I BODK ---------------------------------------------+--------------------------------------------- _-& 

t!. Did the [digital rectal exam/additional tests/surgery or 1clYes L!L 

other treatment] indicate that you had cancer? I 

I 20No 

anDK > ““’ 

I-----------------------~-------- - - ---“-m 

e. When were you diagnosed as having cancer? I 

I 1 0 Days ago 

I IL OR- 2 0 Weeks ago 

I mo. year 3 0 Months ago 

{ 4 Cl Years ago 

BBS 0 DK fi 

k I 

I I 0 More than 3 years in 21 c or 21f 1261 

SIO Referto21cand21f. 8 0 Other (27) 

I 

26. What is the most important reason why you have [never had a ; 000 Procrastinated/Put it off w 

digital rectal exam/not had a digital rectal exam in the past 1 010 Didn’t know I should years]? I 020 Not needed/not necessary I 030 Cost too much 

I 040 No insurance coverage I 

I 060 Don’t go to doctors 

060 Don’t have a doctor f 

1 070 Not recommended by doctor/Dr. never sald it was needed 

osn Doctor said it wasn’t needed I 090 Too embarrassing 

f 100 Fear 

I I I [7 Haven’t had any problems 

I 120 Painful procedure I 130 Unpredictable results 

I aan Other 

I BSO DK 

Votes 

AM HSIA 11987, V-28-88, 

86 
------------------ ------- --- ----- ------ 

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

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

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

Section S - CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued _- 27a. A btood stool ts8t is when tha at001 18examlnsd to I I 

datarmins whathsr it contahw blood. Have you avar I 

hoard of a blood stool tast? I lOYes 

b. H~~~~o~-~v~T~~~~~~-~-~~oi~~~~ 7-I ---A -------------------~ 

1clYes 

I ZUNO 1321 

! so DK 1331 

t----------------------------------------------- - C. When did you have your !ast blood stool test? G i 

I If 3 years Argoor loss 1281 i 1’9 

yeer 

OR .- If more then 3 years ego 1301 “lo. 

I 

-----------------------------------------~---~----. 

I ssso DK 127dl 

d. War It wIthIn the past year or a year or more ago? I 

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

0. Was It lass than thma months, or 3 or more months ago? I 

I

I 2 0 3 or more months 

s0DK 1 --------------------------------------------~---------------------------------------------

6 or mom yearn ergo? 2 0 Between 3 and 5 years 

3 q 5 or more years (301 

sODK 

!8. Old you do the blood stool test yourself 

doctor’or othar msdioal parson? or was it done by a I 10 Self-administered 

1 

f . Was It 3 yssrs ago or less, between three and 5 years, or I 1 cl 3 years or less I281 .E 

f 2 0 Doctor/medics1 person I 

I 

I 

190. Was your last blood stool test done because of a I 

lOYes 1 32 

hsslth problem? I 

I 

~--------------------------------------------------

b. What was the problek? 10 Hemorrhoids 

10 Bleeding 

Mark a// mentioned, do not probe. 10 Pain 

10 Constipation 

1 0 Bowel trouble 

1q Blood in stool 

1 El Ulcers 

10 Unrelated medical problem 

10 Other 

rnDK 

--------------------------------------------~--------------------------------------------- c. How wara you told the maults of the test --.ln person, 1 Cl In person over the tolsphone, through the mail, or soma other I 2 0 Telephone wuy? I s 0 Through the mail 

I 4 0 Combination of methods 

f 6 0 Never told; meaning rssulta normal 

a 0 Never told: DK if problem 

f s 0 Other 

I 

Sll Refer to 29a. I 

I 

I 

I 

00, Hava you EVER had a blood 

hsxlth problem? 

stool test because of a f lOYes 

lOYes (311 1 

I 

I --------------------------------------------~-------------------------------- b. What warn the problem? 4s 

I 10 Hemorrhoids 

10 Bleeding 47 

Mark all mentioned, do not probe. I 1 Cl Pain 48 

4s I 10 Constipation E 

I r 0 Bowel trouble 60 

10 Blood in stool 61 

I 1 Cl Ulcers 52 

53 I t q Unrelated medical problem 

I t 0 Other 64 

65

i 

I 

I 

toDK 

FORMHISlA,1ss7,,7.2*.*,

E31 

\ 

87 
Section S - CANCER SCREENING.KNOWLEDGE AND PRACTICE - Continued 

I k )I a. Have you ever had a blood stool test where the I 1clYes 

results were NOT normal? 

I g”, KS121 

I I 

_____-------------~~~~------~~~~~~~~~~~~~-~~~ +---------,6v,------------ _____----d -‘--“m 

b. Because of the abnormal results, djd you have I any additional tests? 2C1No 

I snDK 

---------------------------------------------T----- I ---i-----------------------------------

D. Because of the abnormal rasults, did you have 1OYes E 

any surgery or other treatment? f 20No 

I sODK _________-------------~--------------~~~~~~~~ t------------------~~--------------~-­

d. Did the [blood stool testladdttlonal tests/surgery or other lOYes E 

treatment] indicate that you had cancer? I ii;; 15121 > ________------------------------------------- I---------~~~~~~~~~~~~----------~----~--~-~­

8. When were you diagnosed as having cancer? I 

I 

’ !L 

i mo. year 

i 

I 

I 

I 

10 s12 Refer to 27c and 27f. : 8 0 

I 

32. What is the most important reason why you have [never had a i 000 

blood stool pt/not had a bloodstool test in the past few 0117 years]? I 020 

I 030 

I 040 I 

I 060 

060 f 

I 070 

050 I 

I 090 

1013 I II 0 

f 120 

130 

i sea 

I 990 

1 

uotes 

88 

e 

I 0 Days ago 

OR- 2 0 Weeks ago 

3 q Months ago 

{ 4 Cl Year5 ago 

SSSO DK 

More than 3 years in 27~ or 27f 1321 

Other 1331 

Isa-se Procrastinated/Put it off 

Didn’t know I should 

Not needed/not necessary 

Cost too much 

No insurance coverage 

Don’t go to doctors 

Don’t have a doctor 

Not recommended by doctor/Dr. never ssld it we5 needed 

Dr. said it wasn’t needed 

Too embarrassing 

Fear 

Haven’t had any problems 

Painful procedure 

Unpredictable results 

Other 

DK 
-------------------------------------------- 

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

--- 

1 

330. A prootorcoplc exam Is when a tubs Is bwerted In ! 1clYe0 

the rectum to check for problems. Have you ever I hmard of a proctoscopic exam? -------------,------------------------------~--------------------------------- --------~---~ b. Have you avar had a proctoscopic exam? i lOYes 

C. 

If 3 years ago or /Aa (34) If more than 3 yaws ago 136) 

~990 DK f33d) 

d. Was it within the past year or a year or mom ago? 

2 0 1 year or more f33fl ---------------------------------------_----~------------------------------------------ B. Was tt Isss than three months, or 3 or more months ago? I 

I 10 Less then 3 ---E 

2 0 3 or more months (341 

sODK 

t ~-----------~ f. Was It 3 yean ago or less, between three and 5 years, or I 1 cl 3 years or less (34) 6 or mom years ago? I 

I 2 0 Between 3 and 5 years (36) I 3 Cl 5 or more years 

r suDK 

I 14. Where was thls exam done - In a doctor’s office, a clinic, 10 Doctor’s office 1 

a hospital, or some other place? f 2 Cl Clinic 

I 3 Cl Hospital 

4 0 Other place &Specify/ J 

o0DK 

150. Dld you go for your last proctoscopic exam because lOYe 1 

of a health problem? I 

------------------------------------~------- 1----_____--______--____________________----------

b. What was the problem? I I 0 Bleeding 

I 10 Pain Mark all mentioned, do notprobe. ,. i 1 Cl Constipation 

I 1 0 Bowel trouble 

i 10 Blood in stool 

10 Unrelated medical problem I I 0 Other 

f tuDK 

--------------------------------------------~-----------------------------------------~--- c. How warn you told the results of the test - in parsoh, ovar the telephone; through the mall, or some other I 10 In person 

P!5. 

way? I 2 0 Telephone 

3 0 Through the mail 

4 0 Combination of methods 

s 0 Never told: meaning results normal 

6 0 Never told; DK if problem 

8 q Other 

1 El Yes 137) E 

s13 Refer to 35s. 

160. Have you EVER had a proctoscopic exam bacausa of a I lOYe 

& 

health prob!am? 

1 20 No 137) 

I a---------------------------------w--------- 7-------------------------------------------------

b. What was ths problem? I 

I 

I 1 0 Bleeding Mark all mentioned, do notprobe. I 1 Cl Pain 

I 1 Cl Conotipetion 

10 Bowel trouble 

I 0 Blood in stool 

10 Unrelated medical problem 

t q Other 

IODK 

89 
c Section S - CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued 

-7 

)7a. Have you aver had a proctoscopic axam where 

the rasults ware NOT normal? 

__----____---______----------------s-s -------~-------------------------------------------- W-D 

b. Because of the abnormal raaults, did you have I lOYfX3 w P 

any additional tastx? I 20 No 

auDK 

---------------------------------------------T----- I -------------_------------~~~~~--~--~-- m D. Because of the abnormal results did you have 1clYes 

any surgery or other treatment? I 

I ZCINO 

I anDK ---------------------------------------------~-------------------------------------------- m d. Did the [proctoscopic axamladditional tests/surgery or 1clYes 

I other treatment] jndicats that you had cancer? 

1 ---------------------------------------------~----------=-------

e. When ware you diagnosed as having cancer? I

I 

’ IL 

j mo. 

I 

I 

I 

I

s14 Refer to 33~ and 33f. i 

I 

38. What is tha most Important reason why you have [never had a / 000 

proctoscopic exam/not had a proctoscopic exam in the past 010 few yaarsl? I 020 

I 030 

040 I 050 

I oen 

f 070 

oan I oao 

ion : i I 0 

I 120 

f 130 

aso t 

I aan 

uotes 

__-----------_~_____~~~~~- E 

1 0 Days ago 

OR- 2 0 Weeks ago 

year 3 0 Months ago 

I 4 cl Years ago 

aaa 0 DK m 

b 

t 0 More than 3 years in 33c or 33f 1381 

an Other (515) 

Procrastinated/Put it off 

Didn’t know I should 

Not needed/not necessary 

Cost too much 

No insurance coverage 

Don’t go to doctors 

Don’t have a doctor 

Not recommended by doctor/Dr. 

Dr. said it wesn’t needed 

Too embarrassing 

Fear 

Haven’t had any problems 

Painful procedure 

Unpredictable results 

Other 

DK 

never said it ~35 needed ’ lsra 

/ 
Sectlon s - CANCER’SbiEENING KNOWLEDGE AND PRACTICE - Continued 

I 

39. A breast physical axam is whan the breast is felt for I 1OYe.s 

lumps by a doctor or madicai assistant. Have you ever 20No 

heard of a breast physical exam? I 90 DK I 

I 

Hand Card S I 1OYes 40. A mammogram is whsn an x-ray is taken only of the breasts by 1 20No a machine that presses against the breast while tha picture is f 

90 DK taken. Have you wear heard of a mammogram? I 

I 

(These next questions are about certain kinds of medical I 

tests and examinations.) I 1CiYes 

41. A digital rectal exam is when a finger is inserted in the rectum I 20No 

Fxzayck for problems. Have you aver heard of a digital rectal ( sUDK 

I 

I 

42. A blood stool test is when the stool is examined to determine 1 1OYes 

whether it contains blood. Have you over heard of a blood I 20No stool teat7 

I 

I BODK 

I 

4% A proctoscopic axam is when a tuba is inserted in the rectum to I 1OYes 

chack for problems. Have you evar heard of a proctoscopic I 20NO exam? I s0DK I 

I 

s15 Refer to sex. I 

I 8q Female (44) 

Mark box if “*No’Or ” DK” in le. I woo NolDK 

I 

$4. About how often do you think a woman should have a Pap i 0 Week(s) 

1 cl Male (471 

smear test? I Every 2 0 Month(s) 

I 

Number 3 q Year(s) 

{

I 7770 Never I SSS~ Other ISpecifyj 3 

I 

I 

I 6680 Only if problem/symptoms 

I sssn DK 

Mark box if l ‘No”or ‘PK” in 9a or 39. I ooo~ NolDK 

114-1’ 

&B. About how often do you think (I woman age SO and over I 

I 1 0 Week(s) 

should have a braaat physical examination 

hsaith profassionai? 

by a doctor or I 

I 

I 

Eiery Number 

2 0 Month(s) 

3 Cl YesrLsl 

{ 

I 7770 Never 

eseO Other (Specify) 3 

essn Only if problem/symptoms 

9e90 DK 

Mark box /f “No’or “‘DK” in 15s or 40. I oooo No/DK 

46. About how often do you think a woman age 50 and ovar I. 

I I 0 Week(s)

l houid have a mammograni? 1. Every um er 2 0 Month(s) 

I 3 Cl Year(s) 

I b { 

7770 Never 

I essn Other (Specify) J 

I 

I 

I eaeO Only if problem/symptoms I 9990 DK 

I 

Markboxif’No”‘or”DK”in21aor41. I 

Izo-2: 

I oocn NolDK 

47. About how oftan do you think a parson age 40 and over 

mhouid have digital rectal exam? I I 0 Week(s) 

Every 2 0 Month(s) 

I Number 3 Cl Yeerlsl I {’ I 7770 Never 

I 888n Other (Specify) 3 I 

I esan Only if problem/symptoms 

I sssn DK I 

_^_.. ...^ ._ ._^__. .- --

117-1 
Section S - CANCER SCREENING KNOWLEDGE AND PRACTICE - Continued 

Mark box if “No”or “‘DK” in 278 or 42. 

I 

I can NolDK 

121-21 

I 

B. About how often do you think a person age 40 and over I I 0 Week(r) should have a blood stool test? Every 2 0 Month(s) I Number 3 q Yesrb) I 1 777 0 Never 

888q Other lSpecify1 J 

ssao Only if problemlsymptomr 

80&i DK 

Mark box if “No”or “DK” in 33s oi 43. 

9. About how ofton do you thlnk a ponon ago 40 and ovar I 0 Week(s) 

should have a proctoscopic oxam? 1 EVEW 2 q Month(s) 

I 

Number 3 q Yesrlr) I { 

I 777 0 Never 

1 888q Otherf.SpeclfylJ 

I 

1 6660 Only if problem/symptoms 

I essu DK 

1 

D. Has a doctor or othar heslth prokulonal aver told you that 1 lOYeS 

you had any kind of cancar (including any cantor you hava 2 q No lsection T} l lraady mentioned)? 1 

I w l’ft. What kind of cancar was it? I

I 

1 799 0 DK 161bl 

---------------------m---------------------s’ i-- -----------------------------.--------------------­

b. What psrt of tha body was affected? I 

I 

I

I q IDK 

I e 2. How old wera you when this cancer was first diagnosad 

by a doctor? I Age ! esn DK 

3. Bealdos thlr cancer, has a doctor ever told you that you had ! I 

any other klnd of cancer? I I q Yes 

1 2 0 No (section T) 

@a. What kind of cancer was it? I 

I 

I Irr-)l 

i ib6, 

I 799 0 DK 154b) 

b. What part of the body was affected? I 

I 

1 

I q IDK 

5. How old wera you when THIS cancer was first diagnosed - 1 e 

by a doctor7 &le 

I oaCjDK 

1621 
Section T 

- SMOKING HABITS 

I 

Theaa next questions are about cigarette smoking. I .’ ICIYS~ 

1. Have you smoked at least 100 cigarettes In your entlre life? 1 ZONO 

If asked: approximately 5 packs I 

I 

snDK I 14’ 

, I 

2. How old were you when you first started smoking clgarettes 1 

fairly ragularly? I Age 

000 Never smoked regularly 14 

I 990 DK 

3. Do you smoke cigarettes now? I 1 El Yes (sectfon V) 

I 

I z 0 No lsection U) I 4. When you are Inslde public places that have nk rules 

I 

I I 0 Ask person not to smoke about smoking and someone lights up a cigarette, 

what ara jou most likely to do - ask the person not to I 2 0 Move eway 

amoke, move awdy from the person, Just do nothlng, 3 0 Do nothing 

or somsthlng elrs? B 0 Something else 

1 

142--4: 

1 

1 
--- 

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

Section U - FORMER SMOKER 

1 m 1. About how long has it bean since you last smoked I cigarettes 0000 Never smoked regularly (sectfort WI regularly? 

I 

10 Days 1 20 Weeks 

I 30 Months I 

1 4El Years I 

I ooo~ DK 

2. On the average, how many cigarettes did you usually I 000 Less than one cigarette per day 

b 

smoke a day? 

I Cigarettes per day 

! ooODK 

w 3. How many mlnutes or hours after awakening did you I Ooofl lmmedistely usually have your first cigarette? I 10 Minutes 

1 20 Hours 

! ooeu DK 

4. Before you quit (entry in II ego, did you make any other I lOYt3S k 

serious attempta to stop smoking? I 20 No (71 

w 5. Including the last time you quit smoking, how many f 

times did you make a serious attempt to atop smoking - Times 

cigarettes? I 

I ssn DK 

I m 6. Before you quit smoking (entry in 1) ago, what was the OooOLessthanoneday

longest period you stayed off cigarettes? I 

I 10 Days 

I 20 Weeks 

30 Months 

f { 413 Years 

I SSS~ DK I 

7. For how many years were you a regular smoker (do not f 000 Less than one year 

b 

include the times when you stayed off cigarettes)? I

I - Years 

I oso DK 

I’m going to read a Mat of methods which some people I 

I use to atop smoking cigarettes. I 

6a. When you quit did you ever/In any of your quit attempts did you ever] - f 

I 

I Yes No 

1) switch to lower tar or nicotine cigarettes? I 

I 117 20 +--------------------------------------------- IF --d 

2) use special filters or cigarette holders to regulate the I amount of smoke inhaled? 10 an 

L--------------------...~~~----------__-_---~~dd~~ 

3) ped;ra; decrease the number of cigarettes you smoked I 

I 10 +----------------------~-----------7~-~d--~.d~~ 20 F __-

I 

41 use prescription chewing gum called “nlcorette”? I 1U 20 ~----------------------------L--~-~~d~~~~ F __-

5) participate in the Great American Smoke-out? I 10 20 L------------------------------------,-------- 1 

6) stop l moklng along with friends or relatives who were I 

also trying to quit? 10 20 I---.--.----------------.--------~-~--~d~~~~ 1 _-- I 

7) atop by following instructions in a book or pamphlet? I________-__-------_-------------------------- L __- 1Cl 20 

8) atop “cold turkey”, that is, stopping all at once without I 

cutting down? 1 10 20 r--------------------------------------------- IF-___ 

B) use some other method7 I 

I 10 20 I I f------------------------------------------------~ 

If “No”in 4 or only 1 method in 88, mark box&) without I t 0 Switch to lower tar/nicotine cigarettes asking and skip to 9; otherwise ask: 

I t [3 Use special filters/cigarette holders 

b. Thinking of the methods you just mentioned, which ones 10 Gradually decrease number smoked 

did you use the last time you quit smoking? I 1 Cl Use “nicorette” 

I 10 Great American Smoke-out 

Mark all applicable boxes, do not probe. I 10 Stop with friends or relatives 

10 Follow instructions in pamphlet or book 

f 10 Stop “cold turkey” 

! t 0 Other 

I taDK 

I 

94 
10 desire 16 

Setting 

Dirty 17 

20 

1 

1 0 23 

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

Cough 33 

1 0 Sore 42 

I 

Section U - FORMER SMOKER - Continued 3-4 

I 

9. ThInkIng of the timeIs) you tried to quit smoking, 6 

ploaso tsll mo the masons you had for trying to quit. I 1 0 Health symptom/problem 

1 0 Present health 0

I 1 0 Future health 7 

Mark a// mentioned, do not probe. I 1 0 Both present end future health 8 

0 If for health reasons In general ask: I 1 Cl Cost of cigarettes 10 1 0 Pressure from family end friends 

Wms that concam for our health at the time or concern I 1 0 Advice from my doctor 11 

for your futun hm&h ‘I I 1 0 e for children 12 

I 1 0 Effect my good smoking example had on others 13 

I 1 Cl Pregnandy 14 

I 1 0 Lost habit ., - 18 

i 1ODK 10 Other 18 

I 10 160. Did yo,u l var try to qult smoking because of a health [ iClYes 

condltlon you had at the time? I znNo I1 11 

---------------------------------------------~--------------------------------------------------

b. What was the ha&h condltlon? I 1 0 Heart trouble/problem 20 

1 . 1 0 High blood pressure 21 

22 

Mark e/l mentioned, do not probe. I 1 Cl Cancer 

10 Emphysema 23 

I

I 10 Cough 24 

I 1 0 Shortnessof breath 25 

: 1 0 Other Cold/flu/virus respiratory problem -1 27 

I 1 0 Sore throat 26 

I 10Cl Other Pregnancy 30

I 10DK 31 

1. Dld l doctor ever advlss you to quit smoking? 

I

I i 0 Yes 32 

I z0No 

I sODK 

20. Do~~y~~~~llova your smoking affected your health In 

I

I 1Cl Yes 1 33 

20No 

I a0DK 1 “31 

b. ~~~;i17~~~i~~T~~~~~~ ------------------,- t- 7oHearttroub ---~4--

Mark all mentioned, do not probe. 

I 

I 

1 0 High blood pressure 

10 Cancer 

36 

36 

I 

lo Emphysema 37 

I 101 0 Shortness of breath 30 

f 

I 

1 0 Cold/flu/virus 

1 0 Other respiratory problem 

40 

41 

I 

I 

I 

1 0 Other throat 

1nDK 1 

43 

44 

46 13. Whan you an Inslde public places that have no rules I 1 0 Ask person not to smoke about smoking and someone Ilghts up a cigarette, 2 0 Move away whmt an you most (section W) likely to do - avk the person not I 3 0 Do nothing to smoke, move away from the person, Just do 

nothlng, or somsthlng eIse7 I 8 0 Something else I, 

Votes 
----------------------------- -- ---------- 

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

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

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

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

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

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

2 0 

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

Section V - CURRENT SMOKER 

If telephone interview, skip to lb. i 0 Yes U?acord UPC, THEN 31 Irs-n 

‘I 8. In order to get an accurate racord of the brand of cigarette f 

you smoke most often, I’d ilka to sea the cigarette package. Do you have the pack handy? f

I .DNo ” +----------------------------------dd---d-d---E 

b. What brand or type of clgaretta do you smoke most oftan? 

f 

I 

SrandKype name 

2. What type of clgarattes am the (brandin lblthat you smoke? 

I

! k 

Are they - i t 0 Filter tip ‘r 

a. filter tip or non-filter tip? f 2 0 Non-filter tip 

$---------------------~-----d--d~-~-~~~~~d~ 

I I 0 Hard pack ysz 

b. hard pack or soft pack? I 

I 2 O-Soft pack 

0. __-___-------_---__-------------------------- menthol or plain? +t ------- ~~~~~~~ -‘~

---------------------------------------------~---------------------------------------------

d. regular, king-size, 100, or 120 millimeter? f 1Cl Regular 

f 3 0 King-sire 100 millimeter 

t 4 •j 120 millimeter 

I snDK +---------------------------~-----------------~ 

8. regular, lights or ultra lights? I 1 El Regular 

I 20 Lights 

3 0 Ultre liahts 

t BODK -

3. On the average, how many cigarettes do youusually I 

000 Less than one cigarette per day Ise-sj 

smoke a day? I 

I Ciaarattes oer dev 

i 8anDK - - . I 

14. How many minutes or hours after awakening do you f ocon Immediately w 

have your first cigarette? 

t t q jMinutas 

2 OHours 

I 

I sss~DK 

5. What are the reasons you smoke cigaratMs? i I OAddictad 

Mark all mentioned, do notproba. t 1 ORalaxes or calms me/nervesktrasslhalps me cope 

I t q To keep my weight down 

I I q Wakas me up 

I 0 Gives me something to do with my hands I 

I I ‘aKeeps ma going/helps ma concentratalexctise to take a break 

I t aHabit 

I t 01 like tinjoY it 

t q Social reasons I 1 mother 

f 

I 1q DK 

6a. Have you avor made a serious 

cigarettes? 

attempt to stop smoking 

I

i 

I 

I 

lOYes 1 

t ---------------------------------------------~--- -Tsa’ 

b. Have you made more than one serious attempt? c 1OYas 

20No16dl - - $ ---- -----~~~---------_~--~~-~-- ----_ - ---____- rs?-iid 

0. How many times within the last year have you made a 010 Once l6dI serious attempt to stop smoking cigarettes? 000 Never 16aj 

+ ------ - sso DK 17al--------------------~ 

d. When did you make the serious attempt to quit smoking? 

I 

I izid ‘* - year . ---------_------____----------~~~------------~ T----- ---‘----‘-“--‘-‘-~ 

8. When did you last make a serious attempt to quit smoking? 

I 

I iizd lS - yeor /7b) 

I . 

1?a. When you tried to quit, how long did you stay off cigarettes? 1 lor-se 

0000 Less than a day 

f 

M 

96 
---- --- -- --- 

---- 

---- 

IiiG 

Sactian 

- V- - CURRENT --_- -_-- SMOKER -_----- - Cnntinuad --__-___--- 2-4 -

I 7b. When you tried to quit In (entry in 6e). for how long I oo~10 Lass than a day did 

I 20 Weeks 

I 30 Months 

I I 40 Years 

--------------------------------------------~---- ess~ DK - _ -~~-.a;;th-;.ia;----------------L------~-~~ 

you stay off clgarettaa? 10 Days 

C. Of all the times you have tried to quit smoking, what was I ths longest parlod you stayed off cigarettes? 10 Days I 20 Weeks 

30 Months 

I 40 Years 

SSS~ DK 

I’m going to read a list of methods which some paople use to atop rmoking clgaretter. 

8a. IWhen you tried to quit did you evadln any of your Yes No quit attempts dld you ever] - I 

I) awitch to lower tar or nlcotlne cigarettas? I IO 20 

2) use spaclal fllters or clgaratte holders to regulate the I_______________________________________------ !I!c 

amount of amoks Inhaled? I ICI 20 

+..------------------------------------- L_1_2_ 

3) pad;dl; decreasa the number of cigarettes you smoked 

1Cl 20 I-------------------------------~~~~.--&~~~ c 

4) usa prercrlption chewing gum called “nlcorette”? I IO 20 ;--------------------------------------------. Lx 

6) partlclpate in the Great Amarlcan Smoke-out? IO 20 i-------------------------------------------------- I 

8) stop smoking along with friends or relatlvss who were I also trying to quit? ICI 20 ~L--------------------------------.-~~-~~~.-~ L 

7) stop by following instructions In a book or pamphlat? IO 20 ~----------------------------------------~~~-~ IF--

8) atop “cold turkey”, that is, stopplng all at once without I 

cutting down? IO 20 ~------------------------------------.----.~~~ EC

81 use soma other method? 1 10 20 --------_--_---------------------------------~--------------------------------------------- L_?_a__ 

If “No”in 66, or only 1 method in 8a, mark boxlesl without I I 17 Switch to lower tarlnlcotina cigarettes 20 asking and skip to 9, otherwise ask: 

I I [II Use special filters/cigarette holdera 21 

I 0 Gradually decrease number smoked 22 

b. Thinking of the mathods y&t just mentlonsd, which ones I 1 El Use “nicoratta” 23 dld you uaa the last time you tried to quit smoking? I I 0 Great American Smoke-out 24 

I 

I I 0 Stop with friends or relatives 26 

I I u Follow instructions in pamphlet or book 23 

Mark all applicable boxes, do not probe. I I 0 Stop “cold turkey” 27 

I I 0 Other 23 

I IUDK. ‘_ 29 

I 

9. 

tell ma the reamonr you had for trying to quit. I 0 Present health 31 

I 0 Future health 32 

Mark a// mentioned, do not probe.. I 0 Both present and future health 33 

If for health’reasons in genera/ ask: 

1q Cost of cigarettes 

I 0 Pressure from family and friends 

34 

31 

I 0 Advice from my doctor 3 

Was that concern for your health at the time or I I q Setting a good example for children 97 

‘i i Cl Pregnancy ae 

I I 0 Lost desire 40 

Thlnklng of the tlmefs) you trlsd to quit smoking, please I I 0 Health symptom/problem 30 

concam for your future health? 10 Effect my smoking had on others 38 

I I q Dirty habit 41 

I q Other 42 

I 

I IODK 43 

1Ga. Did you aver try to quit smoking because of a health I 

I IUYes 44 

condition you had at tha time? I 20No ill! ---------------------------------------------+---------------------------------------------

b. 

Mark all mentioned, do not probe. I 

I 

I 0 High blood pressure 

i Cl Cancer 

I q .Emphysema 

43 

47 

43 

I 

I 

I 

I 0 Cough 

I 0 Shortness of breath 

49 

50 

I I 0 Cold/flu/vir(ls 61 

I r 0 Other respiratory problem 52 

I 0 Sore throat 53 

I 

What was the health condition? I I 0 Heart trouble/problem 45 

I 10 Pregnancy 64 

I 0 Other 55 ; 

I IODK ‘, ~ 56 

FORMHIS-IA1,887,,%2c*I 

97 
Section V - CURRENT SMOKER - Continued 

1 a. After your attempt(s) to quit, what were the reasons i con 

you started to smoke again? ! ot q I 020 

Mark all mentioned, dq notprobe. 030 

040 

060 

060 

07 0 

060 

090 

100 

t t 0 

IZ~ 

I 

I 130 

140 

f 880 

I ssn ---------------------------------------------~-----

If only one reason in 1 la, mark box without asking and skip 

to 12; otherwise ask: I 

b. Of the reasons you have told me,,whlch of these was f 000 

01 Cl 

Fear of gaining weight 

Actual weight gain 

Haadaches/irritability/difficuhy concentrating/drowsiness 

Borad/blua/daprassad 

Nervous/tense/angry/frustrated/stress 

Stressful life avant 

Pressure from others to smoke 

No support from others 

Habit/situation where used to smoke regularly 

Addiction/craving 

Pleasure of smoking/enjoy it 

Others smoking around me 

Not ready to quit/didn’t want to quit 

Didn’t try hard enough/no will power - 1 

Any mention of alcohol 8-l 

Other 87-W 

DK FE 89-91

MOST IMPORTANT “---EE 

0aCl 12 cl 070 13 0 the MOgl IMPORTANT to you as a reason for starting f 020 080 14 cl to smoke again. I 030 090 Cmcl 

f 040 100 99 Cl 

I 0617 1113 

2. Havs you aver switched to a lower tar and nicotine I lOYes I 

cigarette just to reduce your health risk? 

3a. Do you believe your smoking has affected your 

health in. any way? 

---___--------~~------~~~~~---~~~~----~~~~~~~ 

b. How has your smoking affected your health? 

Mark all mentioned, do notprobe. 

4. Has a doctor ever advised you to quit smoking? 

5. For how many years have you been a regular 

I 20No I 

I 1[7Yes k 

I 20No 

BODK 1 

(141 

I_____---____----____________,_,_,,,____----------

I 

I 

I 

I 

I 

f 

I 

I 

f 

I 

1 0 Haart trouble/problem 

1 0 High blood pressure 

10 Cancer 

10 Emphysema 

1q Cough 

1 0 Shortness of breath 

1 q Cold/flu/virus 

1 0 Other respiratory problem 

1 0 Other 

lODK 

1OYes m 

20No 

oo 0 Lass than one year m 

smoker (do not Include the times when you stayed off cigarettes)? 

i 

I 

I 

I sanDK 

Years 

6a. Could you quit smoking permanently if you wanted to? 

I 

rOYas e 

t 

I 20No 117) 

1 eODK ---------------------------------------------~--------------------------------------------- m b. How hard do you think it would ba to quit smoking I t q Very hard 

cigaretter entirely - very hard, somewhat hard, or I 20 Somewhat hard 

not hard at all? 

I 30 Not hard at all 

I sODK 

7. When you are inside public places that have no rules I I q Light up m 

about smoking, what are you most likely to do -

light up a cigarette if you wish, look around to see if i 20 Look around 

others are smoking and then light up, ask if others t 30 Ask others 

would mind, just not smoke, or something else? 4 [I1 Not smoke 

! a0 Something else 

lotes 

98 
------- ---- 

I RT 76 

Section W - OTHER TOBACCO USE 3-4 

I Those next questions are about the uss of other I ‘IAtobacco products. I 1OYes 

I ZUNO (13 18. Have you aver used chswlng tobacco, such as Rsdman, I 

I

I s 0 DK Chewing tobacco (61 Levi Qarrstt, or Beschnut? -----m.-------------------------~-------------’ 7----- ----, r5v,,---L - -------------r 

b: Have you used chewing tobacco at least 20 times? I 

I 

2. How old ware you when you first used chewing tobacco? 1 

I i Age 

I 99[7 DK 

1 I 3. Do you usa chewing tobacco now? I 

I lOYes 

zuNo I 

4. Altogether, about how long [did you use/have you used] I 0000 Less than one month 

@ 

chswlng tobacco? 

I. 

I i 0 Months 

2 0 Years { 

i ssso DK 

&I. On tha avsraga, how many days per month [did/do1 

you usa chewing tobacco? 

I 

I 

000 Less than one day a month 

970 Never used regularly (6) 

e 

I

I sam Everyday 

I -Days per month 

---------------------------------------------+--------------------------------------------- i 99[7 DK -

b. On the days that you usa chswhtg tobacco, how E 

many times [did/do1 you usa it? I -Times par day 

I sso DK 

60. Have you evar used snuff, such as Skoal, Skoal BandIts, I 

I ,UYes 1 

or Dopanhagsn? I 20 No (121 

90 DK Snuff (121 ---------------------------------------------~--------------------------------------------- b. Have you used snuff at least 20 times? I 1OYes r-irI 

I 

I , 

7. How old ware you when you first used snuff? Age i sso DK I 

8. Do you use snuff now? 1OYes 1 

i ZUNO 

9. Altogether, about how long tdld you use/have you used1 I 0000 Lass than one month (22--24 

snuff? 

I 

I xi90 DK I 

0~. On the 

[did/do1 

average, how many 

you use snuff? 

days per month I 

I 

000 

970 

Less than one day a month 

Never used regularly (121 

)26--28 

I sso Everyday 

-Days par month 

I 990 DK -~--~--~-----------------~~~~~~~~~~~~~~~~~~~~, $--------------~---------------------~-~~ 

b. On the days you use(d) snuff, how many times 

[dldldol you use it? I 

I 

-Times per day 

I aso DK I 

1 I. [Dld/Dol you use snuff by sniffing It or by placing I t 0 Sniffing 

It In your mouth? 20 Mouth 

I 

I 30 Both 

1 2ft. Have you ovsc smoked a plpe? I iUYes 

I 20No (17) 

I ---------------------------------------------~--------~------------------------------------

b. Have you smoked a pipa at Isott 60 times? I 10Yes 

E 

3. How old were you when you first smoked a QIQS? I 132--33 

-Age 

I 990 DK 

FORM HIS-,A,lSW ,7-28-S Sl 

99 
Section W - OTHER TOBACCO USE - Continued 

14. Do you smoke a plpo now? I lOY.55 1 34 

I 

I znNo 

1 13647 16. ~$~;.~tiar, about how long [did you smoke/have you smokodl 1 0000 Less than one month 

t 0 Months 

i 2 cl Years 

i soso DK 

168. On the averago, how many days par month 

you smoke a pipe? 

[didfdol I 000 Less than one day a month 

I 970 Never smoked a pipe reguJarly 1171 

b 

i ssn Everyday 

I - Days per month 

I 

I $90 DK ______--_-_-------~-____________________ -----~--------------------------------------------- m--w 

b. On the days you smokmId1 a pips, how many plpsfuls I 000 Less than one b 

of tobacco [did/do1 you smoke? ! 

i - Pipefuls per day 

I es0 DK 

I7a. Have you evqr smoked clgsrs? 1 

lOYe 1 

f 

I 20 No-(22) ---------------------------------------------~--------------------------------------------- b. Have you smoked at Ioast 60 cigars in your entire life? lOYe E 

I 

1 

I 

20. 

I 8. How old worn you when you first smoked cigars? I e 

I 

I ss[7DK 

Age 

1a. Do you smoke clgsrs now? I 

! rOYe5 

znNo 

E 

1 Altogathor, about how long [did you smoke/have you I 0000 Less than one month m 

amoked] cigars? (10 Months I

I

i ----I 2 ClYears 

I 

I SSB~ DK 

21 a. On the l verags, 

smokm cigars? 

how many days per month [did/do1 you 

I OOO Less’ than one day a month 

570 Never smoked cigars regularly 1221 

(10--1)1 

i 

550 Eberyday 

__ Days per month 

990 DK ---------------------------------------------~--------------------------------------------- __- b. On thm days you smokmld) cigars, how many [did/do] 000 Less than one w 

you qmokm? 1 

I

I __ Cigars per day 

i

I 990 DK 

Votes 
I 

Section W - OTHER TOBACCO USE - Continued 

I 

!2a. Do you believe ctgarette rmoklng Is related to - I HAND CARD W 

! ASK 22b for each “Yes” 

i ASK 

1 

2& for each 

in 228. 

“Yes” 

I in 228. I 

t D. Do you think there Is a ID. Do you believe that If a strong, moderate, or I person stopa smoklng 

slight relatfonrhlp I completely, his chancel 

i between clgaratte I of ga~ingJcondition)ara . . I smoking and Icondrty)?] reduced? 

1) emphysema? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

; 1 q Yes Py$j,;, /, ~;~;3(3j 88j ii;; ‘-

2) gallstones? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

31 lung cancer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

4) chronic bronchftls? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

6) diabetes? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

7) heart disease? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

I 

I 0 Sample 871 123) WI Mark appropriate box I 20 ‘Sample 872-074 IW21 I 

I 

I i 

Mark race. Refer to question 3, I I 0 White Isection XI w2 page 42 or 43 on HIS- 1. a 0 All others (231 

i 

!3a. Do you thlnk that using chewfng tobacco on a I ; HAND CARD W 

ragular barlr can increase a parson’s chances I Ask 236 for each “Yes” in 23a 

of getting mouth and throat cancer? 1 D. Do you thlnk there Is a strong, 

I I between mouth and throat 

I I 

I cancer and (YES in 23al I 

I 

I What about (YES in 23al7 

i I 

I 1 Cl strong 

moderate or slight connection 

i--------------------------

I i Cl Yes I z 0 Moderate 

I 2 0 No 1.3 I 3 0 Slight 

1) Udng chewing tobacco? . . . . . . . . . . . . . . . . . . . . . . . . I 90 DK > 1 77 I 

I 9nDK pr 

1 

.I 1 cl strong 

What about - I i 0 Yes I 2 0 Moderate 

1 .20No 13) I 3 0 Slight 

2) Using snuff by mouth? . . . . . . . . . . . . . . . . . . . . . . . . . J 

1 s 0 DK > 1 70 1 90DK piir 

.I 

I I i Cl Strong 

i Cl Yes I 2 0 Moderate I 2 0 No (41 I 3 0 Slight 

3) Smoklng a plpa? . . . . . . . . . . . . ..*............... i s 0 DK > 1 81 1 

I s0DK 

pEr 

I I i Cl Strong 

1 0 Yes z 0 Moderate I 2 0 No 12361 I 3 0 Slight 

4) Smoking cigars? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . s 0 DK I 9nDK > 1 83 ! I, 

FORMHISlA,lS87, IF2BI 

101 
----------------------- -------- 

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

Section W - OTHER TOBACCO USE - Continued 

HAND CARD R2 i I 

24. Now I’m golng to road a list of statements about 1 clStronQlysQree 

cigarette smoking. After I read oath one, pieare tell me f 2 aAgree 

whether you strongly agrae, agree, disagree, or strongly I 3 q Disagree 

disagree, or if you have no opinion. I 4 q Strongly disagree 

a. Everything causes cancer anyway so it doesn’t I 6 ONo opinion 

really matter if you smoke. I -----------~~-______---~~~~~~~~~~~----~------ T------------------------------------’--------

1q lStrongly m b. Smoking by a pregnant woman may harm the baby. I 2 q Agree agree 

I 3 aDisagree 

I 4 &Ztrongly disagree 

---------_-~~~~~~~~~~~~--~~~~~~~~~~~~~------- t

I 6 q NO opinion - ----‘-----‘-‘~ 

C- The smoke from someone alse’s cigarette is I 1 ElStrongly agree harmful to you. I 2nAgree 

I 3 q Disagree 

f 4 [7Strongly disagree 

I 6 q No ooinion ---------------------------------------------~-----~-----~--------------------------------- ___ d. Most deaths from lung cancer are caused by 1 q lStrongly agree b?!L 

cigarette smoking. I 2nAgree 

I 3 q Disagree I 

I 4 q 

- Strongly disagree

I 5UN0opinion --------~~~~~~~---~~~~~~~~~~~-~~~~~~~~~------ -~~ 

8. Peopio who smoke low tar and nicotine clgarettas are I t q lStrongly agree ,c-­ less iikeiy to get cancer than people who smoke high 2OAgree tar and nlcotlne cigarettes. I 

I 3 q Disagree 

i 4 Ekitrongly disagree 

I 6 q No opinion 

---------------------------------------------~----------- -----_-----------i---------------­

f. if people want to smoke, they should not do so inside I 1 q lStrongly agree public places where it mlght dfsturb otherr. 

I i OAgree 

I 3 aDisagree 

I 4 q Strongly disagree 

6 q No opinion I 

Notes 
--------------------------------------------- 

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

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

Section X - OCCUPATIONAL EXPOSURE 3-4 

I k 

Xl Refer to HIS-T, CI I 

I 

I 

1 0 VWWb box marked (II 

a 0 All others (6) 

I 

k 

I. On your currant Job, ara you exposed to any substances 

that would ba harmful if you braathsd them or got them I 1q Yes 

on your skin? I 

I 

Zg. Do you know how these substances could affect your health? I 10Yes L-zI 2 0 No 13s) +-------------------------------------------- b. Where did you learn how these substances could affect t 0 Employer 

your health? I 1 0 Union 

I t 0 Health clinic at work 

I 0 Magazines Mark a// mentioned, do notprobe. t 0 NewSpapers 

I 0 Notices posted at work 

I q Doctor 

I 0 Television I t 0 Read container label 

I I 0 Other 

I rnDK 

I 

3tt. Do you spend at least half your work day in an offlce 1 0 Inside 

bulldlng or some othar type of building or do you work I 2 0 Outside ,6, mostly outside? 

i 90DK 

i---------------------------------------------~-~~­

b. Are them at least five other people working In ths 1q Yes 

bulldlng? I 20No 

f SODK > @’

I 

4tt. Is smoking allowed where you work? I 

I i q Yes 1 21 

2 0 No 141.~) 1 enDK (61 

______---__----------------------------------~----- r-Tcb. Do you have smoking and non-smoking araas I 1q Yes 

whsra you work? I 20No 

I SODK ‘=’ I > 

__--_----------------------------------- -----i--------------------------------------------- pi-­ c. Does your amployar restrict smoking (to csrtaln araasl I t 0 Health/personal comfort 

for health reasons and parsonal comfort, or for some 2 0 Other reasons other reasons? 1 3 0 Both I 

I anDK 

1 If “No” in 4a, skip to 6; otherwise ask: I i Cl Very smoky 

5. Would you say your lmmadlate work area Is vary z 0 Somewhat smoky 

irz,t; from tobacco, somewhat smoky, or not smoky I 

I 3 0 Not smoky et all 

eODK 1 

8. In gansral, would you say the smoke from other people’s I 

I 1 Cl Very annoying 

L 

clgarattas is vary annoylng to you, somewhat annoying 2 0 Somewhat annoying to you, or not at all annoying to you7 i 3 0 Not at all annoying I 

Notes 
. . Section Y 

- HEIGHT AND WEIGHT 

I 

w I. About how tall are you wi&ut shoes? 

; 

- Feet I 

Inches 

2. About how much do you weigh without shoes? I )29--9 I

I 

- Pounds 

I 

3. When you weighed the most, how much did you I m 

weigh (do not lncl.ude pregnancy)? I 

I 

- Pounds 

Notes 
OMB NO. 0933-01Bl: Approval Explr5S March 31,198 

U.S. DEPARTh4EM OF COMMERCE S”REA”OFTHECB(SUS ACTIN5ASCW.ECTINGAGWTFORTHE U.S. PUBLIC HEALTH SERVICE 

NATIONAL HEALTH INTERVIEW 

SURVEY 

EPIDEMIOLOGY STUDY 

4 q Hisp. 

6 0 Hisp. 

8 0 Hisp. 

7 c] Hisp. 

8 0 Hisp. 

9 0 Hisp. 

Refer to the appropriate section of the sample person selection label and circle as applicable. THEN circle the “SPl” 

I Line No. in item 6s and mark “9” box on the H/S- 1 for the selected sample person. THEN go to Section AA. 

‘. FINAL STATUS 

o 0 No parson 18 + in this family (Household Page) Noninterview 

Interview 3 Cl Refusal (Explain in Notes) 

4 0 SP temporarily absent 1 

1 0 Complete interview (all appropriate sections completed) 6 q SP mentally or physically incapable 

s 0 Partial Interview (some but not ail appropriate aeotions 

completed) -Explain 3 

s 0 Other - Explain 2 

B. Ending time &Interview mode 10. Language of interview 1 44 11. Interviewer identification (46-4( 

38-411 42 ‘Name I Code 1 43 t 0 English 30 Both English and Spanish I 

1 a.m. i Cl Personal 20 Spanish so Other I 

I 2 p.m. z 0 Telephone 

, TRANSCRIPTION FROM COMPLETED HIS-1 

2. Sex of SP (Page 2 or 66, question 3) 13. Education of SP (Paga 42 or43, question 28) 14s-4s 14. Main race of SP (Paga 42 or 43, quastion 3a/bl 1 

oo 0 Never attended or kindergarten 

1 47 

Elem: 1 2 3 4 1nM 

2OF High: 9 10 11 12 

College: 1 2 3 4 

6. Marital status 19. Family income (Page 46, quest/on 861 

(Paga 46 or 47. question 71 OOOA 070n 1400 

I 0 Married - spouse in HH otcle OSOI 16OP 

20 Married - spouse not in HH ozoc OSOJ WCIQ 

3 0 Widowed 030D 1oCjK 17clR 

40 Divorced 040E IlCll. rfaa 

6 0 Separated 060 F 120 M 1SOT 

6 0 Never married 06OQ 130N 2ochJ 

(Transcribe from 8s if 8b blank) 

27 q $20,000 or more 

28 q Less than 820,000 

5 6 7 8 1 2 3 4 5 - Specify s 

5 6 + 

21ov 

220 w Person No. - Age230 x 2[xI Epidemiology study 

240 Y 

26cl z 

250 ZZ 
RT 78 

Simtion AA - ACCULTURATION 8-4 

I I 

I I q Available (AA21 

iA SP Status at initial interview 1. 2 0 Callback required flfouseholdpagel 

a 0 NoninteNiew /COVerpage) 

I

I 

I I 

I 

I I 17 Hispanic/English Supp. interview lla1 

Refer ro hispanic origin from family roster and I 2 q Hispanic/Spanish Supp. interview llbl 4A2 expected language for this supplement. a 0 Other fsection BB! i 

I 

Read to respondent: 

I’m going to be asking questions that are related to health concsms. such as smoking, eating practices, vitamin use and so 

forth. Before I ark these questions I would like to ask a few questions about the language you use most often. 

I 

I 

I I Cl Yes (2) 

1 a. Do you speak any Spanish? I z 0 No (41 

___________________------------------------------------------------ ---___--____-__-__-_-------- - ~ 

LE 

Read to respondent: 

I’m going to be asklng questions that are related to health concerns, such as smoking, eating practices, vitamin use and so 

forth. Before I ask these questions I would like to ask a few questions about the language you use most often. 

b. Do you speak any English? 1 i q Yes 

I 2 0 No 141 

1 

) 2. Would you say that you speak mostly Spanish, mostly English, 1 I 0 Mostly Spanish or do you speak Spanish and English about the same? I 

I 2 0 Mostly English 

3 0 Both about the same I 

( IO 

3. WRat language do you prefer: Spanish only, mostly Spanish, 1 I 0 Spanish only 

mostly English, English only, or Spanish and English about I 

I 2 q Mostly Spanish 

equally? 3 q Mostly English 

4 0 English only 

6 [7 Spanish and English equally 

4. Can you read Spanish? I 

I iUYes ) 

I 20No 1 

I fi 

5. Can you read English? I 1ClYes 

I 20No I 

I E If “Yes” to both 4 and 5 ask: I I q Spanish I 

I 2 0 English 

6. In which language do you read better? I 3 0 Both the same I 

I 1 7. Can you write in Spanish? I i q Yes 

I 20No I 

8. Can you write in English? I 

I i q Yes ) 

I 2[7No I 

if “Yes” to both 7 and 8 ask: I ‘I 0 Soanish 

) 

I 2 0 English 9. In which languege do you write better? I

I 3 0 Both the same 

I 

I m 

If self-reported on HIS-l, mark box wirhoor asking. I i 0 Puerto Rican 5 aChicano 

I 2 [7 Cuban 6 mother Latin Amencan I 

HAND CARD 0, read categories if telephone interview. I 3 [7 MexicanlMexicano 7 aOther Spanish 

I 4 0 Mexican American a mother Epecifyl 3 

IO. Which of these groups best describes your i 

ethnic identification? I 

1 w 11. Which of these groups best describes your I i Cl Puerto Rican 5 q Chicano 

mother’8 ethnic identification? I 

I 2 0 Cuban a nOther Latin American 

I 3 q Mexicenltvlexiceno 7 mother Spanish 

I 4 0 Mexican American 8 mother fspeclfyj 3 

I 

I

I 

12. Which of these groups best describes your I 

I 1q Puerto Rican 5 q Chicano 1 

father’s ethnic identification? 2 0 Cuban a mother Latin American 

1 3 cl MexicanlMexicano 7 DOther Spanish 

I 4 0 Mexican American a nOther (Specify) 3 

I 

106 
Section AA - ACCULTURATION - Continued 

I 

If self-reported on HIS-l. mark box without asking. I 

I 1 Cl U.S., except Puerto Rico 

I 3.. In what country or state were you born? I 

I 2 0 Puerto Rico 

s 0 Cuba 

4 17 Mexico 

a 0 Other (Specify) 3 

I 

14. In what country or state was your father born? I 

I 1 0 U.S., except Puerto Rico 

I 2 cl Puerto Rico 

3 0 Cuba 

4 0 Mexico 

8 0 Other (Specify) 3 

I 5. In whet country or state was your mother born? 10 U.S., except Puerto Rico 

2 0 Puerto Rico 

a 0 Cuba 

4 0 Mexico 

8 0 Other (Specify) 3 

Notes 

MH151811967)18.1.8'31 

1 

1 

1 

107 
1AT 7s 

Section ___--_---- BB - -FOOD __- ----__---_- FREQUENCY 1 3-4 I 

(I’m going to be asking questions that ara related to health concerns, such as smoking, eating practices, vitamin uao and so forth.) These next questions are ebout the foods you eat. Please tell me how often you eat each one, for 

Read to respondent: example, twice a week, three times a month and so forth. Also tell me whether you usually eat a small, medium or large portion of each food. Remember I’m only interested in the foods YOU eat. HAND FOOD FREQUENCY 

FLASHCARD BOOKLET. Please look at List 1 as I ask these first questions. 

I 

During the past year or so, how often did you usually [eat/drink] - / 1 III Day 1 6-8 Was It a *mall, mdlum or Iarfp portlcn? 

20 Weak I 

1 . Orange juice or grapefruit juice? I- Timesper 3 [7 Month 1 Cl Small 

1 4 Cl Year 3 0 Madlom (6 0z.J 

oooo 0 Less than 6 a year 3Cl Large or never 12) 

2. Other fruit juices or fortified fruit drinks? I 1[7 Day IO-13 1 

I 3 0 Week I 1 Cl Small 

/ Times per 3 q Month 3 0 Medium (6 oz.) 

I 1 4 Cl Year 3Cl Large I 0000 17 Less than 6 a year I 

1 or never (31 

3. Oranges? I 

I I[7 Day 116-18 

I 20 Week 1 Cl Small I- 3 0 Month 2 0 Medium (I med.) 

I Times per { 4 Cl Year 3 0 Large I 

I oooo 0 Less than 6 a year 

I or naver (4) 1 

4. Grapefruit? I 10 Day 120-23 1 

1 2q Week 1 0 Small 

;Timesper 3 0 Month 3 0 Medium (112 grapefruit) I 1 4 Cl Year I oooo 0 Less than 6 a year 

3Cl Large 

I 

I or never (5) 

I 5. Cantaloupe in season? I 10 Day 128-28 A medium servlng Is 

I 20 Week 114 cmltaloupl3 

;Timesper 3 0 Month 1 Cl Small 

I I 4 0 Year 3 0 Medium (114 med.) I oooa [7 Less than 6 a year 3 Cl Large I or never 161 

6. Apples or applesauce? 

I

I 

I 10 Day 130-33 k 

I 20 Week 1 Cl Small I 

1 Times per 3 q Month 2 q Medium (1 med, or l/2 cup) 

1 4 El Year 3 0 Large 

f 

I

I 

oooo 0 Lass than 6 a year or never (7) 

Now look at List 2. I 10 Day 36-38 Small, tnadium or Iargo? k 

During the past year or so, hpw often did you usually eat - I20 Week 

3 [7 Mdnth t Cl Small 

f Times per 1 4 0 Year 3 q Medium (314 cup) 

7. Beans, such as baked, pinto, kidney beans, I oooo 17 Less than 6 a year 3 El Large or in chili? Do not include green beans. I or never (81 

I 

8. Carrots, or mixed vegetables containing carrots? I 

I 

10 Day j46-43 1 

I 

I 20 Week 

1 Cl Small 

ITimesper 3 0 Month 

3 0 Medium (112 cup) 

t { 4 0 Year 

oooo 0 Less than 6 a year 

3El Large 

I or never 191 I 

10 Day hb-48 9. Tomatoes, I including In salad? 1 20 Week t Cl Small I­

, Times per 3 0 Month 2 0 Medium (1 tomato) 

I { 4 0 Year 

I oooo 0 Less than 6 a year 3 0 Large 

I or never (101 

IO. Green salad? I I[7 Day Iso-sa k 

I 2q Week 1 Cl Small I­/ Times per 3 0 Month 2 0 Medium (I med. bowl) 

I 1 4 q Year 3 Cl Large 

I ooco 0 Less than 6 a year 

I or never I1 1) I 

j 1. Salad dresrjng or mayonnaise, including on~sandwichar? I 10 Day 166-68 1 

2q Week 1 II Small I- 3 0 Month 3 17 Medium 12 tbs.1 I xmes per 4 0 Year I 3 q Large

I oow q Less than 6 a year 

I or never (121 
Section BB - FOOD FREQUENCY - Continued 

I ISO- 1 64 i 

12. Broccoli? I 0 Day Small, medium or large? I 20 Week’ 

I- 3 0 Month 1q Small I Times per 

I i 4 q Year 2 0 Medium (I 12 cup) 

I or never (131 

I 3. Spinach? I I 0 Day ]66-66 1 69 

I-

[ 

I 

2 0 Week 

Times per 3 0 Month 

I 4 Cl Year 

oaaa 0 Less than 6 a year 

1q Small 

2 0 Medium (112 cup)

3q Large 

I or never (141 , 170-73 1 74 

I noan 0 Less than 6 a year 3 Cl Large 

14. Mustard greens, turnip greens or collards? I 

I I 0 Day 

2 0 Weak 1 III Small 

I-I Timwper 3 0 Month 2 0 Medium I1 12 cup) 

I I 4 q Year 3 Cl Large 

I 

I oaaa 0 Less than 6 a year 

I or never 1751 

15. C?lerlaw, cabbage or sauerkraut? 1q Day 175-76 1 78 

2 0 Week 1 0 Small 3 0 Month Times per 

1 4q Year 2 0 Medium (112 cup1 

I 3 q Large 

I oaoa 0 Less than 6 a year I or never (161 , 

16. French fries or fried potatoes? I I 17 Day 160-63 

1 OSmall 

1 64 

I 2 0 Week 2 q Madium (3/4 cup) II Times per 3 0 Month sOLarge I 1 4 Cl Year 

I aoaa 0 Lass than 6 a year 

I or never (17) 

17. Potatoes, baked, boiled or mashed? I 

I 

10 Day 166-66 1 as 

I 2 [7 Week 1q Small 

L-- Times per 3 0 Month s q Medium (1 potato or 112 cup) 

i 4 q Year 3 q Large aaoo 0 Less than 6 a year or never (18) 

I 8. Sweet potatoes or yems? 1 I 0 Day /so-93 1 94 

I 2 0 Week 1 q Small 3 13 Month 2 q Medium (112 cup) I TimeS per i 4 q Year a Cl Large 

I - aaao 0 Lass than 6 a year 

I or never (191 

19. Rice? 

I 

I 0 Day ISS-96 1 as 

I 2 0 Week 1 0 Small 

I- Times per 3 0 Month 2 0 Medium (112 cup) 

1 4 q Year 3 0 Large 

oooo q Less than 6 a year or never 1201 

Now look at Li5t 3. I 

I I 0 Day boo-163 Small, medium or Isrge? 1 104 

During the past year or so, how often did you usually eat - 2 0 Week 

L- 3 0 Month t 0 Small 

20. Hamburgers, cheeseburgers or meatloaf? I limes per i 4 q Year 2 0 Medium 

I 

I asao 0 Less than 6 a year 3 0 Large 

I or never 1211 

h 1. Beef, such as steaks or roasts? 10 Day jlos-103 1 109 

I 2 0 Weak 1q Small 

L-----­

, Times per 3 0 Month 2 0 Medium (4 oz.) 

I 1 40 Year s Cl Large aaaa 0 Less than 6 a year I or never (221 I 

I 

22. Beef stew or potpie with vegetables? I I 0 Day ~10-113 

2 q Week 1 Cl Small 

I- Times per 3 0 Month 2 0 Medium (1 cup) 

I { 4 q Year 3 q Large 

aaao 0 Lass than 6 a year I or never (231 I 

23. Uver, Including chicken liver? I 

I 

t 0 Day ‘~15-116 * 

I 2 q Week 

1 Cl Small 

ITimesper 30 Month 

2 0 Medium (4 oz.) 

I 1 413Year 

aaaa 0 Less than 6 a year ‘313 Large 

I or never 1241 

I 

IRMHIS-181108711&1.801 
3 Month 

I 

3 Year 

USA 

I 

Section BB - FOOD FREQUENCY - Continued 8-4 

24. Pork, such as pork chops or roasts? 

I 

0 Day ) 6-8 A medium ssning is 2 pork k 

chops or 4 oz. of ro8st. i 0 Week 

Times per 1 3 0 Month 1q Small 

4 q Year 2 q Medium 

(2 pork chops or 402. Of roast1 oooo 0 Lass than 6 a year 3 0 Large or never 1251 

25. Fried chicken? I 110-13 A medium serving 1s 2. ) 

I small or 1 large piece. 

I 

I Times per 1q Small 

I 2 0 Medium (2 sm. or 1 lg. piece! 

I 

I 0000 0 Less than 6 a year 3 0 Large 

or never 126) 

4 medium serving is 2 1 26. Chicken or turkey, baked, stewed or broiled? I 

I i 0 Day 116--‘18 

imall or 1 large plecs. 

L----- 2 q Week 

( Times 3 0 Month 1q Small 

I 

per 

i 4 q Year 2 0 Medium (2 sm, or 1 tg. pfecej 

I oooo [7 Less than 6 a year 3 0 Large .I or never (27) 

120-23 27. Fried fish or firh sandwiches? I 

i 0 Day 

2 0 Week 1q Small I- 3 0 Month I Times per 2 0 Medium (4 oz.)

{ 4 q Year I 3 Cl Large I oooo 0 Less than 6 a year I 

I or never f28J 

I m . 1 28 28. Spaghetti, lasagna or pasta with tomato sauce? I I 0 Day I 2 0 Week 1q Small 

i- 3 0 Month 2 0 Medium (1 cup) , 

I 

Timespar 4 q Year 3 q Large 

I oooo 0 Less than 6 e year I or never 129) I 

Now look at List 4. I 1q Day 130--3: Small, medium, or 1~807 1 

During the past year or so, how often did you usually eat -

I 

I 2 q Week 

1 Times per 3 [7 Month 1q Small 

\ 4 Cl Year 2 0 Medium (I med. bowl) 

29. Cooked cereals like oatmeal? I 

a000 0 Less than 6 a year 3 0 Large 

I or never 1301 8 

136-31 ) 

30. High fiber cereals like bran, granola, or shredded wheat? 1 i [7 Day 

I----- 1 2 0 Week 1 0 Small 

20 Medium (1 med. bowll 

t Times per 4 0q Year 3 q Large 

f 0000 0 Less than 6 a year 

I or never 131) 

1 I 0 Day (40--4I 31. Highly fortified cereals like Product 19, Total, or Most? I 

I 2 0 Week 1 0 Small I

I Times per 3 0 Month 2 0 Medium (1 med. bowl) 

8 .4 q Year 3 Cl Large i 

I 0000 0 Less than 6 a year 

I or never 132) 

I 

32. Other cold cereals like Rice Krispies or corn flakes? I I q Day 145-41 ( 

I 2 0 Week 1q Small I 

i Times per 3 0 Month 2 0 Medium (1 med, bowl1 

.4 q Year 3 0 Large 

i oooo 0 Less than 6 a year I or never (331 , 

33. Eggs? I 

I q Day 160--6: How many rggr? 

las-ss 

0 Week 

II Times per [7 Month 

I Cl Year 

I 0000 0 Less than 6 a year Number I 

I or never 1341 

34. Bacon? I 

I )68-b How many sllcos? 

Iso-er 

I 

I- Times per 

I 

I 0000 0 Less than 6 a year Number 

I or never 1351 

I I 17 Day (82-6 How msny psttlos or links? Iss-n 

I- 2 0 Week 

I Times per 4 0q Month 

35. Sausage? I

I l 

I 0000 17 Less than 6 a year Number I i or never 136) 

110 
xmes 

1 

RT 81 

r Section BB - FOOD. FREQUENCY PAGE - Continued 3-4 

Now look at Ust 6. - Small, medium or large? 0 

I z 0 Week 

During the past year or so, how often did you usually eat - II Times per 3 0 Month 1q Small 

36. Vagatablesoup, vegatable baaf, mlnastrone or tomato I 4 0 Year 30Medium (1 med. bowl) 

soup? Do not Include 0th~ kinds of soup. 0000 0 Less than 6 a year 3ULarge 

or never 137) 

37. Hotdogs? 1q Day b How many hot dogs? b , 

2 0 Week 

It Times per 3 0 Month 

I 4 0 Year . I 

I 0000 0 Less than 6 a year 

i or never (381 

38. Ham or lunch meats? I 1 1 Cl Day e , 1 

2 q Week t 0 Small 

Times per 3 0 Month 3 17 Medium (2 slices) 

4 0 Year 3 17 Large 

oooo q Less than 6 a vaar 

I or never (39) . 

’ A mcdlum 8awing is 2 1 

39. White bread, rolls or crackers, lncludln~dwlches, 1q Day ” & 

!dlcsc or 4 crackers. 

bagela, and 80 forth? I’m going to esk a out dark bread 2 0 Week 

and corn bread next. +G$F 3 [7 Month 1 0 Small 

I 4 [7 Year 2 0 Medium (2 slices or 4 crackers) 

I 

I oecc 0 Less than 6 a year 3 Cl Large 

or never 140) 

40. Dark braada like whole wheat. rye or pumpernickel? 1[7 Day b ,, 

I- 2 0 Week 

I per3 0 Month 1q Small 

4 0 Year 2 0 Medium 12 slices) . I 

I oooo 0 Less than 6 a vear 3 •I Large I

I or never 141) 

1 

41. Corn bread, corn mufflnr, corn tortillas, or grits? I

I 10 Day 131--34 I 

I---- 2 0 Week 

I Times per 3 0 Month 1q Small 

I 4 0 Year 2 q Medium (1 piece or 112 CUPgrits) 

I 040 0 Less than 6 a year 

3q Large 

I or never (421 

I 10 Day m ?, 4 madiumaawingIs r 1 

42. gutter on bread, rolls or vegetables? I’ll ark about 

I 2 13 Week 2 pats. margarlne next. 

/Timesper 3 0 Month 1q Small 

I 4 0 Year 3 0 Medium (2 pats) 

I 0000 0 Less than 6 a year 3 0 Large I or never 1431 

I 

43. Margarine on bread, rolls or vegetables? I 10 Day b I# ;~a~ium *awing I8 1 

I 2 0 Week 

j Times per 3 0 Month 1q Small 

I 4 0 Year 2 0 Medium (2 pats) 

I ooco 0 Less than 6 a year 3q Large or never 1441 

e B 1 44. Cheere or cheese spreads, not Including cottage cheere? 1[7 Day 

2 0 Week 1 II1 Small 

3 q Month 2 0 Medium (2 slices or 2 oz.) 

I . 4 0 Year 3 q Large 

I 0000 17 Less than 6 a year I

I or never (451 

46. Peanuts or peanut butter? I I 0 Day e 4 1 

I z 0 Week 

1 Cl Small i

1 Times per 3 0 Month 

3 0 Medium (2 tbs.) I 4 0 Year . i 

I 0000 0 Less than 6 a year 3 Cl Large 

I or neverl461 

46. Salty snack8 like chlpr or popcorn? I

I 1q Day 168-6a 1 

I- 2 0 Week 1 0 Small 

I Times per 3 q Month 3 q Medium (1 handful) I 4 0 Year 3 I7 Large 

I 00~0 0 Less than 6 a year I or never 147) 

Now look at Ust 6. I 10 Day )81--( i4 A medium sening Is 1 k 

I 2 0 Week medium ccoop. 

During the past year or so, how often dld you urually [eat/drink1 - 1 Times 3 0 Month 1 0 Small 

47. Ice cream? 4 0 Year 2 0 Medium (1 med. scoop) 

0000 0 Less than 6 a year 3 q Large 

or nevar (481 . nw HI5lE 11087) ,&l.W, 

111 
----------------------------------------------- ------------------------------------------ 

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

Section BB - FOOD FREQUENCY - Continued 

I 

&8. pie? I I 0 Day Ise-ss Small, medium or large? ) 

I 2 0 Week 

I- 3 0 Month 1 Cl Small I Times per 

I 1 4 Cl Year 2 [7 Medium (1 med. slice) 

I oooo [7 Less than 6 a year 3 Cl Large I 

I or never 1491 

18. Doughmrts, cookies, cake or pastry? I 

I 1 c] Day 171-74 A medlum senlng is 1 h 

f 2 0 Week plsce or 3 cookiea 

;Timesper 3 0 Month 1 Cl Small 4 Cl Year I 1 2 0 Medium (1 piece or 3 cookies) 

I

I 

I oooo 0 La&than 6 a year 3 Cl Large or never (501 

50. Chocolate candy? I 

I 10 Day 178-79 k 

I 2 0 Week 

I - 3 0 Month i q Small 

i Times per 4 El Year 2 0 Medium (1 oz.) 

I i 3 Cl Large 

I oooo 0 Less than 6 a year I or nevei 151) 

il. Sugar in coffee or tea or on cereal? I 

I I 0 Day 181-84 1 

I 2 0 Week 

I 1 Cl Small 

ITimesper 3[7 Month 2 q Medium (2 tsp.) 4 Cl Year 

1 3 0 Large 

I 0000 0 Lass than 6 a year 

I or never (52) I 52. Whole milk or drinks made with whole milk, not Including on I I 0 Day 186-89 . ) 

cereal? I’m going to ask about 1 %, 2% and skim milk I 2 0 Week separately. I- 3 0 Month t 0 Small 

1 Times per 4 Cl Year 2 0 Medium (6 02, glass) 

I .{ 3 Cl Large 

I 

I oooo 0 Less than 6 a year 

I or never (531 

Is1 -s4 w 53. 2% milk or drinks made with 2% milk, not including on cereal? 1 I [7 Day 

, 2 0 Week i 0 Small 

Times per 3 q Month 2 q Medium (6 oar glass1 

1 4 Cl Year 3 q Large 

0000 q Less than 6 a year I

I or never (541 

54. Skim milk, 1% milk or buttermilk, not including on cereal? I 

I I q Day p-99 1 

2 0 Weak i •1 Small I- 3 0 Month i limes per 4 Cl Year z q Medium (8 oz, glass) 

I 1 3 0 Large 

0000 0 Less than 6 a year 

I or never 1551 

58. Milk or cream in coffee or tea? I I 0 Day ~101-104 1 

I 

I z [7 Week 

3 0 Month i Cl Small 

ITliiqz- 2 0 Medium (1 tbs.) I 1 4 Cl Year 3 Cl Large I oooo 17 Less than 6 a year I 

I or never 156) 

58. Soda or soft drinks with sugar? I 

I 

I 0 Day ~166-108 1 

I 2 0 Week t 0 Small 3 0 Month / Times per 4 0 Year 2 c] Medium (12 oz.1 

I i 3 0 Large I oooo 0 Less than 6 a year 

I 

57a. During the paat year or ao, how often 

drink beer? 

did you I 

I oat t 0 Everyday/daily 1111-11 

I 2 0 Week 

I 

I Times per 3 0 Month 

4 0 Year 

I 1 

I 

I 0000 0. Never (58) W-M 

I or never (571 

b. On the days you drank beer, how many tens, bottles T----- &v 

or glaues did you drink? I Number 

I ss[7DK f--------------------~~~~~~----------------~-. 

c. Were they small, medium, or large? I 1 0 Small E 

I 2 q Medium (12 oz.) 

I 3 0 Large (16 oz.) 

Uofes 

-. FORMHlClB 11087rlsl112 
Section BB - FOOD FREQUENCY - Continued 3-4 

I * 580. Dutlng the past year or so, how often did you drink wine? I ooi i 0 Everyday/daily I 

I 2 0 Week I 3 0 Month I Times per 4 0 Year I I 

I oooo 0 Never (591 

---_~-----__-----___-------~~~~~~--~~~-----~~~~ +-----------------~~~--~~~~~~-~~~~---------m b. On the days you drank wine, how many glasses did you drink? , 

I 

I Number 

I ssODK -----------------------------------------------~----------------------------------------------

C. Were they small, medium, or large? I 

I 1 0 Small m 

I 2 0 Medium (lmed. wine glass) 

I 3 cl Large 

I w 58a. Dutlng the past year or so, how often did you drink liquor? 1 001 I 0 Everyday/daily 

I 2 0 Week I 3 0 Month 

I Times per 4 Cl Year 

t I oooo 0 Never (601 -------------------------------------~---------~-----------------------------------------------

b. On the days you drank liquor, how meny drinks did you have? I E i 

I Number I 

ssODK ---_---------------------------__---------------~----------------------------------------------- - __ 

c. Were they small, medium, or large? 1 Cl Small E 

1 2 0 Medium (Ishot) I

I 3 0 Large 

SOa. Was there ever a petlod In your life when you drank five or mote dtlnks of any alcoholic beverage almost every 

day? 

I 

I 

I 

10YW k 

--__-------_------_-----1------------------------~--------------=-------------------------------- --__ b. For how long did that petlod last? I I 13 Days l;ro--23 r 

I 

I 2 [7 Weeks 

I 

Number 3 0 Months 

I 4 0 Years 

I 9999 0 DK 

61. When you eat chlcken or other poultry, how often do you eat it 1 10 Often or always 1 

wlth the skln on? Would you say often, sometlmes, rarely or [ 2 Cl Sometimes 

never7 I 3 0 Rarely 

4 0 Never 

I

I o 0 Don’t eat chicken or poultry 

32 n When you eat red meat, how often do you eat the fat? Would i 10 Often or always 1 

you say often, sometlmes, rarely or never? 

i 

I 

2 q Sometimes 

3 0 Rarely 

I 4 0 Never 

I 

I o 0 Don? eat red meat 

6%. On most weekdays, how many meals do you usually 

eat each day? 

o q Less than one a day 

- Meals 

1 

sODK -----------------------------------------------~----------------------------------------------- ---. b. On most weekdays, how many snacks do you usually I o 0 Less than one a day cz eat each day, lncludlng snacks after dinner? I 

‘Snacks 

I s0DK ------~----__---____--~~~~~~---~~~~~-----~~~--- T-----------------------------------------------

C. On most Saturdays or Sundays, how many meals do I o q Less than one a day r18’ 

you usually eat each day? I 

I Meals 

snDK ----_______-___---__---------------------------~--------------------------------------------------~ d. On most Saturdays or Sundays, how many snacks do you I o 0 Less than one a day 1 usually eat each day? 

I - Snacks 

I s[3DK 

34. In a typical week, how many meals do you usually get In I 

I oo 0 Less than one a week. e 

restaurants, cafetetlas, or fast food places? - Meals 

I soOdK 

otes 

113 
--- 

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

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

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

Section CC - VITAMIN AND MINERAL INTAKE 

I. During the past 12 months, that is, since (12 month dateLa I 

I 

1 Cl Yes ) a2 

year ago, did you take any vitamin or mineral supplements I z 0 No ~section DD! of any kind? 

I 

!a. During the past 12 months, that is, since 112 month date) I 1 cl Yes ( 

a year ago, did you take any MULTIPLE viteminr? I 

I z c] No 131 ----------------------------------------------~----- ------___________-----~~~~~~~~~~~~~~~~~~ 

b. What is the brand name of the multiple vitamins? I m 

If more than one brand, ask: 

What is the name of the brand you took most Brand Name 

often during the past 12 months? 

0 DKFIefused (Ask probe for type1 

If known, mark without asking, otherwise ask: I

r--------------------------------------­ m Is that a therapeutic type, a stress-tab type or I I 0 Therapeutic 8 0 None of these e am-a-day type? I 

I z?0 Stress-tabs snDK 

Mark first type listed I 3 0 One-a-day. ___________-________------------------------------------------------------------------------ I m c. For how many of the past 12 months did you I 000 Less than one 

teke [(name in 2bMmultiple vitaminsl? I tz[7 All of them 

I Number of months 

dm-Duti--ili ~-~----thowmanv f -&,~E;~--day----- -----__---d--- -___ m 

days per month did you take [. (name in 2bllmultiple vitamins]? I 

Number of days per month 

99 0 Other __------------------------------d-~~~d~~ -d-

& 

f. 

how many pills did you take per day? I Pills per day 

I 990 DK ---------------____-----------------------~~~~ i--------------------------------------------- k-d 

If less than 12 in 2c, ask: I 

I lOYes yss 

Did you take any multiple vitamins in the past month? I zmNo 

(The following questions are about vitamins not including the I 

I 

multiple vitamins you already told me about.) I lOYes 

)a. During the past 12 months, did you take any vitemin Al I z 0 No 141 

_____-----------------------------------------~--------------------------------------------- d-d 

b. For how many of the pest 12 months did you f 000 Less than one m 

take vitamin A? I 120 All of them 

I ~ Number of months ----------------------------------------------~--------------------------------------------­

~1).about how many I 99 0 Everyday E 

I

I Number of days per month 

I 99 0 Other 

b 

you usually take per day? I Pills per day 

----------,----,-------------------;-----

i ssODK ------I--------------------------------------------- - -

e. ,“,o5Tmany umts of vitamin A are in each of the pdls you I m 

___-----____________------------------------ “d, 

I - Units I 

I 99999 0 DK ----------------------------------------------+-------- ______----____-------~~~~~~----~-~~~- d-d 

If less than 12 in 3b, ask: I I 0 Yes L?!L 

I 

f . Did you take any vitamin A ln the pest month? I 

I 

20No 

0 

La. During the past 12 months, did you take any vitamin CT I 1 Cl Yes @ 

I 

I 2 q No151 ________________________________________---------------------------------------------------- b. For how many of the past 12 months did you I 

I 00 0 Less than one E 

take vitamin C? I 120 All of them 

I Number of months -----------------------------------------------~---------------------=----------------------- d-d c. During [the/those] (number m 4b) month(s), about how many ss 0 Everyday & 

days per month did you take vitamin C? I 

I Number of days per month 

I 

I 88 0 Other ----------------~---.--------.-----.--------------~---------------------------------------------

d. On the days you took wtamm C, how many pills did you I e 

usually take per day? I Pills per day 

990 DK ----1-------------------------------------------------

8. Flol;2many milligrams of vitamin C are in each of the pills you I (107-11 

I Mgs. I 99999 0 DK T--------------------------------------d- I

If less than 12 in 4b, ask: I 10Yes E 

f . Did you take any vitamin C In the past month? I 

I 20No 

kotes 

114 

1 
----------------------------------------------- 

---- 

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

Section CC - VITAMIN AND MINERAL INTAKE - Continued 3-4 

I 6 5a. During the past 12 months, did you take any vitamln E? I

I 1q Yes 2 q No16) __~__--____----_-------------------------------~~-----------------------~---------------------- __ w b. For how many of the past 12 months did you take vitamin E? 1 oo q Lass than one 

120 All of them 

I 

- Number of months 

C- During [the/those] mberm 5H month(s), about how many 

days per month did you take vitamin E? I 

Number of days per month 

88 0 Other d, 

you usually take per day? I Pills par day 

990 DK -----------------------------------------------~----------------------------------------------- ____ 

8. How many units of vitamin E are in each of the pigs you I e 

took? - Units 

99999 0 DK ------.------:------------------------------~----------~~~~s--------------------- ______- ----i--i;iIf less than 12 m 5b, ask. 

f . Did you take any vitamin E in the past month? I 

I 2 0 No 

68. During the past 12 months, did you take any calcium? I 1 q Yes 1 I 

I 2 q No kzsction DDJ -----------------------------------------------~~---------------------------------------------- ___- b. For how many of the past 12 months did you take calcium? , 000 Less than one w 

120 All of them 

- Number of months ~~~~---~------__-----~~~------~~~-----~~~-----~ +-- ~~~Everyday -= c. During [the/those] lnumber in 6b( month(s), about how many 

days per month did you take calcium? 

Number of days par month 

as 0 Other -------_------__------~~-------~~----~~~~---~~~~ ‘----------------~l~~~~d~~------------------------~ 

d. On the days you took calcium, how many pills did you usually l 

take par day? I 

I ssu DK -------‘--------------------------------------~~----------------------------------------------- g. ~o;w2meny mllllgrams of calcium are In each of the pills you B 

I Mgs. I 999&E&’ I ~~~~---~~~-------------~------~~~---~~~~~--~~~~ 1----- ---o;,-----------------------------L-E 

If less than 12 in Sb, ask: l 

f . Dld you take any calcium in the past month? I 

I 2 q No 

Notes 

115 
Section DD - FOOD KNOWLEDGE 

I 1 a1 I a. Have you ever made any LASTING and MAJOR f lOYes changes in what you eat and drink for health I 

I 2 0 No (2) reasons? 

___-----__----- --...--------_--------- -----~--------------------------------------------

b. ln;n;Ekb;Bese changes, what foods 

Enter response verbatim, one foodperline. 

----------______-------------------------

Ci What foods do you eat LESS of? 

Enter response verbatim, one foodperline. 

do *au eat I MORE 

I m I 

I 

Do notprobe. I 

I las-ar 

I oooq None I 

I 999 17 DK 

~--------------------------------------------

I LESS 

i 

I m 

Do notprobe. ; ,11’1--4( 

t 

I 

I _110--6; 

I 

I 000 c] None 

I 999 0 DK 

----.-------------------------------------~---------------------------------------

d. Have you made these changes in.what you eat I 

I 10 Yes E 

and drink in the past five years? I 20 No 

I 90 DK > ‘lf) 

-----------------------------------------T----- I ------__~---_____-------~d~~---d~- ­

8. Did you make these changes in the past year? I 1 cl Yes E 

I 

I 20 No 

I snDK 

-----------------------------------------~-------- I ------_-----___--------~-----~- - d 

f . Have there been any changes in the ways your I t cl Yes w 

food is cooked? I 20 No 

1 90 DK > ‘*’ -------------------------------------------~------- ------------------------------dd-ydb. 

g. What are these changes? I 

I MORE LESS 

Baking 

I IO Boiling 

Broiling 

Steaming 

Frying 

Stir-frying/wok 

Sauteeing 

Grillinglbarbecuir 1s 

Salting 

I Microwaving, 

I 10 20 Pressure-cooking 

I 10 20 Using non-stick pans 

I IO 20 Other 

I 

I 1nDK pT 

m 2. I am going to read two statements. Please tell me I 

which one you agree with most. I 

I Cl a (51 

(a) What people eat or drink has little effect on whether they will develop major diseases. 2 0 b (3) 

OR 9 0 DK 14) 

(b) By eating certain kinds of foods, people can raduce 

their chances of developing major diseases. 1 

I 3. Which maJor diseases do you think may be related I i 0 Cancer 74 

to what people eat and drink? I q Heartdisease 75 

1. I 0 Obesity/Overweight 70 

I I 0 Diabetes 77 

I 

I 1 0 Hypertension/ High Blood Pressure 78 

I i q Other 7s 

I I 0 None 80 

I I q DK 81 

116 
Section DD -l FOOD KNOWLEDGE 

DDI Refer to 3 I

I

I 

1 0 Cancer in 3 f61 

1 

8 0 Other 14) I 

L. Do you think cancar may be related to what psople 10 Yes 

1 

sat and drink7 20 No 

I 3 0 Probably/maybe/could be/&c. 

I aa OK 

ia. Some foods contain fibar. Have you heard of 

fiber7 

1 

I 

I 

I 1 cl Yes 

20 No 

1 

I so DK > (=) 

------------__---------------------------i-----------------------------------~--- ---_ 

b. Overall, would you say your diet is high, medium, I q .High t or low in fiber7 z q Medium 

acl Low 

s0DK 

i. Overall, would you ray your diet is high, medium, I q High 1 or low in fat7 z q Medium 

30 Low 

s0DK 

_~~ 

r. Have you gone on 8 dlet for weight loss or any 1 IJ Yes 1 

othsr medical rearon during the past 12 months7 i 20No I 

lotes 

117 
Section EE - SMOKING HABITS 

These next questions are about cigarette smoking. 

rclY= 1. Have you smoked at least 100 cigarettes in your entire life? I ',g; fsecdofl FFI 

If asked: approximately 5 packs I( > 

1 18940 2. How old were you when you first st+ed smoking cigarettes 1 

fairly regularly? I Age 

I 000 Never smoked regularly lsectlon FF) I 990 DK 

3. Do you smoke cigarettes now? I 1 Cl Yes f51 

I 

I ZUNO I 

4. How old were you when you stopped smoking cigarettes? 1 

I lo,-oa 

I 

I ss0DK 

Age 

I e 5. On the average, how many cigarettes [did/do1 you usually 000 Less than owcigarette per day sioka a day? 

Cigarettes per day 

i 

I ssn DK I 

I E 6. For how many years [have you been/were you] a regular I 0017 Less than one year smoker, do not include the times you may have stayed off I 

cigarettes? f - Years 

I ssnDK 

Notes 

FORM M-18 11987) W-14 

118 
---- ---- --- 

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

ST 84 

Section FF - OTHER TOBACCO USE 3-4 

These next questions are about the use of other 

I 

, 

lOYES 6, 

tobacco products. I 20No 16) 1 a. Have you avar used chewing tobacco, such as Rsdman, I s 0 DK Chewing tobacco 161 Levi Garratt, or Beechnut? ---------________-_--------__-______-------~----- ----, oy,,-------------------------~ 

b. Have you used chewing tobacco at least 20 times? 

I 

2. How old were you when you first used chewing tobecoo? 1 1 

I Age 

I 

I $90 DK 

I 3. Do you usa chewing tobacco now? I 1OYes 

k 

I 

I 20No I 

4. Altogather, about how long [did you use/have you used] I 0000 Less than one month m 

chewing tobacco? I 

I I 0 Months 

1 2 0 Years 

sssn DK 

5fJ. On ths average, how many days per month [did/do1 000 Less than one day a month 

you usa chewing tobacco? 970 Never used regularly 16) 

980 Everyday 

- Days per month 

se0DK -_~----~----_---_---____________________----- ‘-----------------------------------------E 

b. On the days that you use(d) chewing tobaoco, how 

many times [did/do] you use it? I 

I Times per day 

I sso DK 

6tt. Have you ever used snuff, such as Bkoal, Bkoal Bandits, I rlJYes 1 

or Copenhagen? I 20 No (721 

( 

I g 0 DK Snuff 172) b. -~~~~~o~-~s~~-~~~~~~~~~~~~~~~----- - c-- 1--------------------------_--------------------

lOYes t-2!% 

I 

I g;o, /la I 1 

7. How old wera you when you first used snuff? w 

Age 

ss0DK 

8. Do you use snuff now? lEtYes e 

I 20No 

9. Altogether, about how long [did you use/have you used] I 

I 0000 Less than one month w 

snuff? I 

I 0 Months 

2 0 Years 

I 

I ssso DK 

Oa. On the average, how many days per month 000 Less than one day a month 

[did/do1 you use snuff 7 970 Never used regularly 1721 

asa Everyday 

Days per month 

sso DK ---------------------------------------------~--------------------------------------------- b. On the days you use(d) snuff, how many times I E 

[did/do] you use it? I Times per day .I 

I 990 DK 

1. [Did/Do1 you use snuff by sniffing it or by placing . i 1 Cl Sniffing 1 

it In your mouth? I 2 0 Mouth 

I 

I 3 0 Both 

2a. Have you aver smoked a pipe? I 

I lOYes 1 

20 No 177) 

b.-~a~~~~~~~~~~i~~~~---------------~-- I --------,- eves r-sr 

I 

I 20No 

1 suDK 3 ‘17) 

3. How old were you when you first smoked a pipe? I 

I (32--3 

I Age I 

es0 DK 

I 

,MHIClS ~1$S7,,B-l-BB, 

119 
Section FF - OTHER TOBACCO USE - Continued 

I 1 a4 

1 -

i 2UNo 

115. Altogether, about how long [did you smoke/have you smokedl 

I 

1 0000 Less than one month w 

a pipe? 

I I q Months 

14. Do you smoke a pipe now? I 1clYes 

I 2 Cl Years 

I sssa DK 

e 1I6a. On the average, how many days per month [did/do1 I 

I 000 Lass than one day a month 

you smoke a pipe? I 970 Never smoked a pipe regularly (171 I 

I 980 Everyday 

- Days per month I 

I sso DK ---------------------------------------------~-------------~------------------------------- I b -de 

D. On the days you smoke(d) a pipe, how many pipefuls I 000 Less than one 

of tobacco [did/do] you smoke? I 

I - Pipefuls per day 

I 

I sso DK 

1/ 7a. Have you ever smoked cigars? 

1 

I 

I 

iUYes 

I 2 0 No (section GGI -----+---------------------------------------------

.( 

b.-~~~~~~~~~~~~ie~~~~~~~~~~~~~~~~~~~~~-- I 10Yes m 

I 20No I s ,-, DK bsction GGI I > 

w I 8. How old were you when you first smoked cigars? I 

I -Age 

I 990 DK I 

19. Do you smoke cigars now? I 

I 10Yes 1 

I 20No 

!O. Altogether, about how long [did you smoke/have you 

I ooon Less than one month 14’1--4( 

smokedl cigars? I 0 Months 

2 iJ Years 1 sssn DK 

i !I a. On the average, how many days 

smoke cigars? 

per month [did/do1 you 

I 

I 

I 

I 

000 Less than one day a month 

970 Never smoked cigars regularly fseotion GGj 

m 

I

I 990 Everyday 

I - Days per month I 

__--_-----_____------------------------------~---------~~~~~------------------- ------------M 

b. On the days you smoke(d) cigars, how many [did/do1 0017 Less than one 

you smoke? Cigars per day 

990 DK 

IJotes 

120 
---- 

---- 

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

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

Section GO - REPRODUCTION AND HORMONE USE 

GGI / Refer to sex 

Thaae next queatlons are about pregnancy and reproduction. [ 1 

1q Yes I 

f 8. Have you ever given bhth to a liveborn infant? I z 0 No (2) 

------------------------------------------------~---------------------------------------------- _---. 

b. How many live births have you had? I u 

I 

------------------------------------------------~---------------------------------------------- - Number m Cm How old were you when your (first) child was born? I 

Age 121 

I 

I ss 0 DK Ild) ------------------------------------------------~----------------------------------------------

d. Were you 20 or younger, or older than 20? I

I 1q 20 or younger 121 -EE 

I z 0 Older than 20 /lel 

-----------------------------------------------~~---------------------------------------------- I 9 0 DK (2) 

0. Were you 21 to 24,26 to 29,30 to 34, or 35 or older? I m I 1021-24 4035+ 

1 2q 25-29 sUDK: 

I 3 cl 30-34 

26. (Beslder [that pregnancy/those pregnancies& Have you 

I 

I 

I 

1 q Yes 1 

ever had any (other) pregnancies that lasted six months 

or more? I z 0 No 16621 

-------------------_---------------------------- ;--------- -------------------------_----------~---~ b. How many of those (other) pregnancies have you had? I 

I - Number ------------------------------------------------~--------------------------------~-------------

C. How old were you at the end of [that pregnancyl the first I Age 1662) m 

of those pregnancies]? I

I 99 0 DK G?dl -----------------------------------------------~ d. Were you 20 or younger, or older than 207 

i 2 q Older than 20 

I 

I s c] DK iGG21 

------------------------------------------------~---------------------------------------------- ----, 

8. Were you 21 to 24.26 to 29,30 to 34, or 35 or older? I I 021-24 4035+ -LA!c 

I 2 q 25-29 snDK 

I

I 3 q 30-34 I 

I e 

662 Refer to 1.9 I 

I I q “Yes” in 1a 131 

I a 0 Other (4) 

3. Did you breastfeed any of your children? I 

I 1 q lYes 

1 

I 20No I 

&a. How old were you when your menstrual cycles began? I

I Age 151 

171--7: 

i oo 0 Never menstruated f71 I 

I ss 17 DK 1461 

L----------------------------__-----------------­

b. ~~~ouyoungerthan10,10to12,13to15,or16or I I 0 Younger than 10 E 

2[710-12 I 3013-15 

I 4016+ 

I sODK 

i. Have your menstrual cycles stopped permanently? I l2c 

I 1q Yes 2 0 No 181 I 

I 

ia. How old were you when they completely stopped? I 

I Age (71 

~ 

---,-------------------------------------------~ b. Were you younger than 20,20 to 29,30 to 39.40 to 44, r------ E 

46 to 49,60 to 64, or 66 or older? I I 17 Younger than 20 

2 q 20-29 

3q 30-39 4 q 40-44 

6q 45-49 

60 50-54 

7055+ 

snDK 

r. [Dld they stop/Was this] due to surgery? I 1 q Yes 1 

I Z~NO 

I 

IM HIS-lb l1887i 18.l.BOl 
------ 

---- 

Section GG - RhPRODUCTlON AND HORMONE USE - Continued 

I 

8a. Have you aver had an operation to remove a lump from your i I q Yesf8bl 1 

breast that was found to be NONCANCEROUS? I 20No 

I s 0 Lumps removed 191 I were cancerous 

I s[7DK b. -~~~m~~~~~~~~~~~~~ -------c----------------------------------------------

YLXE I Number of operations

I s0DK -_----_____----------~~ -----T------------------~---------------------------------------------­

0. How old ware you when you had the (fust) I m 

ooaration? I Age at first operation

I ss(7DK 1 k We are interested in learning about the relationship I

between birth control pills and health. I 1 q Yes

zuNofGG31 

9. Have you aver used birth control pills? 

1Ua. How old wara you when you started using birth I (sr-el 

control pills? I Age (11) 

I $9 0 DK (lob1 I ______-_____________------------------- --------~----------------~~~----------~--~~~- ----emb. Ware you younger than 25, or 25 or older? I 

I I q Youngerthen 25 flOcl m 

I 2 0 25+ (IOdl I s 0 DK If 11 

___---_____________------------------------------ L..~~~------- __----____---_______------------- d-d_ 

c . Ware you 18 or younger, 19 to 21, or 22 to 247 I 

I I q 18 or younger 187 

2 q 19-21 (11) I 

I 3 c] 22-24 

I snDK 1 

----------------------------------------------~~---------------------------------------------- e-dd. Wara,you 25 to 29,30 to 34, or 35 or older? 10 25-29 1 

I 2 cl 30-34 

I 3035+ I 

I snDK 

115. Altogether, about how long did you take birth control I 

@l~lil~;~da any breaks m usage that lasted lass than I 

I . I Number fGG31 

I 

I 

I 0000 Less than one month (GG31 I 8880 Other Epecifyj 3 

I 

I 

I 1’3% 

I sssn DK (1 lb1 

___---___----_______------------------------------- ___---______________----------------------- 1 b. Was It lass than a year, or a year or more7 I I 0 Lass than one year (663) 192 

I 

I 2 q One year or more (1117) 

I snDKIGG31 I -----------------------------------------------i---------------------------------------------------

C. Was It 3 years or lass, more than 3 but lass than 5, or 1 El 3 years or less LE 

5 or more years7 2 0 More than 3, lass than 5 years 

3 q 5 or more years 

snDK 

I 

I I [7 Under 40 fsection H/-/j 663 Refer to age I 

I 2 q 40 and over (12) 

I I 

12. Estrogen Is a female hormone that may be taken after a I 

I 1q Yes 1 

hysterectomy or during menopause. Have you ever I 

taken estrogen pills for any reason7 I (section HHI 

I 

, I3a. How old ware you when you started using estrogen pills7 

Aae 1141 

I $9 0 DK /lib1 

-------_--------__________________------------------~---------------------------------------------- b. Ware you younger than 20,20 to 29,30 to 39,40 to 44, I E 

45 to 49,50 to 54, or 55 or older7 I t q Younger than 20 

I

I 2 q 20-29 

I 3 q 30-39 

I 4040-44 

5q 45-49 

8q 50-54 

, 7055+ 

snDK 

122 
------------- 

Section GO - qEPRODUCTlON AND HORMONE USE - Continued 1 

I b 4a. Altogether, about how long did you take estrogen pills? .I I 0 Days. 

. ln;nte any breaks in usage that lasted less than one 2 0 Months (15) . Number 3 0 Years 

I. I 

000 0 Less than one month 115) 

888 0 Other (Specify) 3 

(15) 

9990 DK (14bl b. -~~~iiie~*~~~n~~~~~~~~~~~~~~~~~~~ ---I L-------------------------~~~~~~~~~~~~--------- -___ 

7 I 0 Less than one year (151 

I 2 0 One year or more 114~9 I 9 0 DK (15) -----------------------------------------------~---------------------------------------------- ____ 

c . Was it 3 years or less, more than 3 but less than 5, or I 1 0 3 years or less 

1’103 

5 or more yeerr? I 2 0 More than 3, less than 5 years 

I 3 Cl 5 or more years 

I SnDK 

15. What was the brand name of the estrogen pills? I 

I 1104-11 

I 

I 

I Brand name I 

I q IDK I 

lotes 

123 
-- 

-- 

-- 

-- 

-- 

-- 

-- 

-- 

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

[ RT86 

Section HH - FAMILY HISTORY OF CANCER 8-4 

These next questions are about your natural or birth mother and father. Do not include 

step or ado&e parents. 

-

Ask I-2 for mother, then for father. 

1 a. In what year was your natural [mother/father] born? 

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

b. Is your Imotherlfetharl still living? 

C. At what age did your [mother/father] die? 

2S. Was your [mother/father] aver diagnosed by a doctor as 

having cancer? 

----------------------------------------~ b. What kind of cancer was it? 

C. Whet part of the body was affected? 

d. Did your [mother/father] have any other kind of cancer 

that wes diagnosed by a doctor? 

8. The FIRST time [she/he] was diagnosed with cancer, 

what kind of cancer was it? 

f. What part of the body was affected? 

g. How old was your [mother/father] when cancer was first diagnosed by a doctor? 

lotes 

la. 

b. 

C. 

-

la. 

b. 

C. 

d. 

.-- a. 

f. 

g. 

-

MOTHER FATHER 

1 6-8 22-26 

- Year - Year 

9999 0 DK ssss 0 DK 

.---lo,,,-------,-“-’ -__-_-_ r-23M2 0 No flcl 

9 q DK f21 

7 q Never knew natural mother 

11 for fathal) .----- ~~-AgB-------,Tc--,~~ 

ssDDK 

) 12 

1q Yes 20No (1 for father) anDK 1 .---------------___ lE=liii 

799 0 DK 1219 

0 DK .-------------_-___ 

1 cl Ye= -lzr 

20 No (2gl 

sC]DK 1 

.-----------------­

oooq Same as 2b/c f2gJ m 

799 [7 DK (2f) 

q DK . .-----------------­ pz-G 

Age 

ssnDK (1 for father) 

1 Cl Yes (2) 

2 0 No llc) 

s 0 DK 121 

7 0 Never knew natural father (31 

1q lYes 

799 0 DK I2f) 

17 DK --------4---d-------E 

Age 

ss 0 DK 

FORM HlblSll9(17l lb?4 

124 
---- 

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

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

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

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

Section HH - FAMILY HISTORY OF CANCER - Continued 

Read to respondent: Now I’m golng to ask about your sisters and brothers who have the same natural or birth 

mother AND father as you. Do not include step, half, or adoptive sisters and brothers. 

000 None h 

36. How many sisters do you have, including 3a. - Sisters any that may have died? 990 DK --------------------~~~~~~~~~~~~~~~~~~~~----~~~~~~-------~~~~~~~~~~~~~----------

b. How many brothen do you have, including b. 000 None E 

any that may have died? 

Brothers 

$90 DK 

1 If “None”in 3a and 3b, skip to 9: 1q lYas 

20No 4. Have any of your [brothers /(or) sisters] ever been 4. SDDK 1 (‘I diagnosed by a doctor as having cancer? 

1 44 1 

59 What are the first names of your fbrothers/(or) sistenl 5. 

who had cancer? 

Record each person in a separate &lumn Sex: I q Male sex: 1 0 Male 

Anyone alae? 2 q Famala 

9 q IDK 

2 0 Female 

saDK 

Ask 6-8 for the firstperson listedin 5 before asking 6-8 146-47 b 

far the nextperson. 16Cl m 

6g. What kind of cancer did (name in 6) have? 6a. 7ssnDK(6bJ 

~~~~~~~~~~~~~--------~~~~~~~~~~~~~-~~.--~---------------------~------‘----------~~~~~~ 

799 0 DK f6bl 

Name Name 

b. What part of the body was affected? b. 

0 DK --------------------____________________-~--------------- q DK 

---10yBs----------r88-

C. Did /name in 5) have any other kind of cancer that was C. 1 DYES 48 

dlagnosad by a doctor? 20N.3 20No 

s~DK (71 s~DK ‘7’ > > ------------------------------------~---.----------------- d. The FIRST tlme [he/she] was diagnosed with cancer, d. OooOSame as 6a/b (71 49-w 0000 Same as 6alb 171 FGi5 

what kind of cancer was it? 

(71 

7ss[7DK 164 799~ DK f6el 

______________-----------------------.---.-------------------~-- 6. What part of the body was affected7 e. 

q IDK q DK 

7. How old was (name in 5) when cancer was fint 7. p52--63 170-71 

diagnosed by a doctor7 Age Age 

ssuDK ssnDK 

8a. In what year was (name in 5) born7 6a. 164-67 172--76 

- Year - Year 

ssssnDK ssss 0 DK ----_---------------~~~~~~~~~~~~----~.--~-----------------

If known, mark without asking. 1ElYes lHH7) 68 1 OYes (HHl) yrsb. Is (name in 5) still llvlng7 b. 2 0 No (812) 2 0 No f8d 

snDK (l/HI) 9 0 DK lHH7) --------------------~~~~~~~~--------~.--~----------------- g n At what age did (name in 5) die7 C. m-so m 

Age Age 

$snDK SsuDK 

1 61 ) 

HHI Refer to entries in 5. HHI 1 0 Additional siblings (6) 1 0 Additional siblings (6) 

2 0 No more siblings (9) 2 0 No more siblings 191 

lotes 

___.. _ . _ . ___. ._ _ _ 
----------- ---- ----- ---------------------- ------- -- ----- ------- 

Section HH - FAMILY HISTORY OF CANCER - Continued 

?a&-/to respondent: These questions are about your natural or birth children. Do not include any children for whom you are an adoptive, 

step, or foster parent. 

000 None )23--24 

Da. How many daughters do you have, including 9a. Daughters any that may have died? 

99n DK oONone - -‘----‘--‘~ 

b. How many sons do you have, including any b. 

that may have died? 

- Sons 

990 DK 

1 If ‘None” in 9a and 96, skip to section II. 1q IYFJS 2 0 No 0. Have any of your children aver been diagnosed 10. 9nDK ‘15’ by a doctor as having cancer? > 

1. raha;e;e the first names of your children who had 11. (28-36 164-61 

Record each person in a separate coluinn Sex: Name sex: Name 

Anyone else? I 0 

2 0 

Male 

Female [ 36 

I q Male 2 0 Female p?r 

Ask 12- 14 for the firstperson listedin 11 before asking (37-3s )sa-se 

12- 14 for the next person. 

112c) 112a) 

29. What kind of cancer did (name in 11) have? 12s. 799 0 DK (126) 799 0 DK 112bl -----------__-_------~~~~~~~~~~~~~~-----_-~~~____-----------~~.~~-----~~~~--~~~~~~~~~~ 

b. What part of the body was affected? b. 

0 DK q IDK ----------_---------------------------------------------- ----._-----------i----- --_ 

C. ‘Did (name in 11) have any other kind of cancer that was C. lOYes 40 1clYes 1 Midiagnosed by a doctor? 20No 20No 

SnDK f’3’ s UDK (13) > > ----------_____-----~~~~~~~~~-----------~~~~-~----------- _---.------------_-----

d. The FIRST time [he/she] was diagnosed with cancer, d- ooo 0 Same as 1 Za/b I131 l4’-43 ooo 0 Same as 12s/b (131 1 ii?zdii 

what kind of cancer was it? 

(131 /I31 

79s 0 DK (72s) 799 q DK fl2e) ~~~~~~~~~~~~--------~~~~~~~----------~~~~~~--------~~~~~~___~~.~~-----~--~-~~-~_~_~~~_ 

8. What part of the body was affected? e. 

q DK q DK 

3. How old wasjname in 11) when cancer was first 13. (44-4s m 

diagnosed by a doctor? Age Age 

990 DK ssnDK 

14a. - Year - Year 

89. In what year was (name in 11) born? sssg 0 DK ssss 0 DK -----------~~~_____--~~-~~~~~~~~~---------~~~~~~--------- ----.------------------ --__ 

If this child in household, mark “Yes” box without , [7 Yes fHH2) 60 7 q Yes FLY21 7 

asking. b. 2 0 No (14~) 2 0 No /14cl 

b. Is (name in 11) still living? s q DKIHH2) g 0 DK fHH2/ ---------__----------~~~~~~~~-~-----------~~~~~---------------.~-~~~~~~~~----~~~- --i_ 

C n At what age did (name in 11) die? C. 61-62 J77--7e 

Age .- Age 

ssnDK 9sCl~K 

1 63 

HH2 Refer to entries in 11. HH2 1 0 Additional children 1121 

2 q No more children (15) 

1 0 Additional children (12) 

2 0 No more children (15) 

otes 

126 
------------------------------------- 

-- 

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

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

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

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

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

-- 

-- 

-- 

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

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

RT 88 

3-4 

r Section HH - FAMILY HISTORY OF CANCER - Continued -

15. Has the natural Cfathsr/mothsrl of [any of your (other) 

chlldranlyour ohlldl aver been dlagnossd by a doctor as having cancer? 

l&t. What Is the tfathsr’s/mothsr’sl name? 

b. Is-e in 16a) the [father/mother] of all your 

(other) childran? 

17a. What klnd of cancer did fname in 16~4have? 

-------------_-__-------------------- b. What part of the body was affected? 

C. Did (name in 16al have any other klnd of cancar that was dlagnossd by a doctor? 

d. Tha FIRST time Ihelshsl was diagnosed with cancer, 

what kind of cancer was It? 

C. What part of ths body was affected? 

I 8. How old was jname in 16aj when cancer was first 

dlagnossd by a doctor? 

1%L In what year wasJname in 16a) born? 

If person in household, mark “Yes” without asking. 

b. Is (name in l6a) still Ilvlng? 

C. At what age did (name m 16a) die? 

Z&t. How many chlldran dld you andjnaine in 164) have 

togathsr, lncludlng any that may have died? 

-_-_-------________-----------~-~~~~~ 

b. How many of these children ars sons and how many am daughters? 

C. What ara ths childran’s first names? 

HH3 1 Refer to 166. 

16. 

-

16s 

b 

-

17a 

b 

C 

_-

d 

_-

e 

-

19a 

_-

b 

C 

-

!Os 

_-, 

b 

_-

C 

1 q Yes 1 

2 0 No 9 q DK (sectionm > 

Name 

--,oy,---------------------------------~ 

20No 

m 

117cl 

799 q DK I1 761 .__-------_______-----~~~~~-----~~~~~~~-----

0 DK ‘-lov,--------------- -----E 

20No 

SnDK /‘*j 1 ‘,,os,,BslSelbnBI------- - m 

(181 

799 0 DK 1174 .~___-----------------~~~~~~~---------------

q IDK 

1’14--‘11 

Age 

ssnDK 

116--‘11 

- Year 

ssss 0 DK 

.------------------i~~~~~~~~~~~~~~~~~~-­ m 1 Cl Yea (20) 

2 0 No 1790) 

s 0 DK 1201 

.----------_--______-------------------- e 

Age 

ssnDK 

No. of children 

.-------------_-----------------------------

- No. of sons 126--2( 

No. of daughters m 

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

First “*me 

First name 

First name 

First name 

m 

First name 

169--7( 

First name 

e 

First name 

186--9: 

First name 

1 0 “No” in 16b 115) 

a 0 “Yes” in 16b (sectionID 

127 
I 

SectionII - CANCER SURVIVORSHIP a-4 

1. Has a doctor or other health profauional aver told you that you ; 

had cancer of any kind (Including any cancer you have already 1 lOYeS 

mentioned)? I 2 0 No fsectionJJI 

2a. What klnd of cancer was it; I

I w 

I 

I

I (3) 

i 

I 7% 0 DK 126) 

-------------------------------------------. l------ ___-_-----------------~~~~~~~~~~~~~~~~~~~~ 

b. What part of the body was affected? 

I 

1 

I q DK 

I 

3 - How old ware you when this cancer was first diagnosed I e 

by a doctor? I 

I Age 

I ssn DK 

6. Besides this cancer, has a doctor aver told you that you 1 1OYes 

) 

had any other kind of cancer? I 

I 2 0 No (section JJ) 

5a. What kind of cancer was it? b 

@I 799 0 DK 15bl -------------------------------------------~-----------------------------------------------

b. What part of the body was affected? I 

I 

h 

I 

I q IDK 

6. How old ware you when THIS cancer was first diagnosed I 1’11--1( 

by a doctor? I 

Age I 

I ssuDK 

8 

Notes 
Section JJ - OCCUPATIONAL EXPOSURE 

These next questions are about the kind of work you have I 

I 

I done the longest, not counting work around the house. 

I ooo 0 Never worked bsction KKI 

1. Thlnking of ail the jobs or businesses you have ever I 

had, what kind of work have you done the longest? I 

include work in the Armed Forces. For example, 

electrical engineer, stock clerk, typist, farmer. I Occupation/kind of work 

I 

2. When you were doing this kind of work, what were your most 1 

important activities or duties? For example, types, keeps account I 

books, files, sells cars, operates printing press, finishes concrete. I 

I 

I Duties 

I 

%t. How long did you do this kind of work? I 

I 

oo 0 Less than one year 

Izo--2: 

I 

I 

I Years 

I ssnDK -----------------------------------------~--------------------------------------- ---. 

b. How old were you when you started doing this kind of work? 1 * 

I Age I ssnDK I 

I. What kind of busfness or industry did you work in the I 

I 124--2( 

longest asjentrv MI I@ (For example, TVand radio I 

manufacturing, retail shoe store, State Labor I 

Department, farm.) I 

I 

I 

I Industry 

Complete from entries in 1,2, and 4. If not clear, ask: I 

I 

1 

I

5. Were you - 1 Class of worker 

An employee of a PRIVATE company, business or individual for wages, salary, or commission?. . . . . . . . . . P 1 1OP 

A member of the ARMED FORCES?. . . . . . . . . . . . . . . .AF 1 znAF A FEDERAL government employee?. . . . . . . . . . . . . . . . . F i 30F A STATE government employee?. . . . . . . . . . . . . . . . . . . S I 40s 

A LOCAL government employee?. . . . .’ . . . . . . . . . . . . . . L 1 SOL Self-employed in OWN business, professional I a01 practice, or farm? I 

I 7[7SE Ask: Is the busbwss incorporated? I OOWP Yes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

No . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . s: 1 

Working WITHOUT PAY in family business or farm? . . . WP / 

I 

Notes 

129 
-------------- ---------- ----------- 

Section KK - HEIGHT, WEIGHT, RELATIONSHIPS, AND SOCIAL ACTIVITIES 

t 

1. About how tall are you without shoe*? I - Feet I 

I 

I - Inches , 

2. About how much do you weigh without shoes? I 

I (31--33 

I - Pounds 

3. When you weighed the most, how much did you I 

I p4-a8 

weigh (not including pregnancy)? Pounds 1 - I 

There next questions are about social activities and I la748 

relationships. I 

I 

I - Friends 

&L (Not including your [husband/wife]) 

Of all your friends, how many are there that you can talk I 

I 000 None 

to about private matters or can call on for help? I ------------------------------------------------+----------------------------------------------- b. (Not Including your [husband/wife]) e 

How many relatives do you have that you can talk to I 

I - Relatives about private matters or can call on for help? 000 None ------------------------------------------------~----------------------------------------------- ____ 

If None in 4a and 4b, skip to 5. I & 

I Friends end relatives c . How many of these friends and relatives do you see or I talk to at least once a month? 000 None ._ 

5a. How often do you participate in or attend group I w 

meetings or activities, for example, social clubs, PTA, * 0 Week 

3 0 Month 

service groups? I 

I 

I ooon Never 

____----------------____________________~~~~~~~~~ f 2oweek __--__ rr’s7s 

b. How often do you go to church, temple, or other 

religious services? I 

I 3 0 Month 

sporting events, church groups or other community I -

Times par 4 Cl Year 

I Times par 4 q Year I 

I ooo[7 Never 

130 
Introduction: These next questions are to determine what people know about AIDS, also called 

Acquired lmmunodeficiency Syndrome. 

0010 Today la. When was the last time you saw, heard or 2 •J Days ago (1 

read something about AIDS? 3 0 Weeks ago (2) num6er 4 0 Months ago 

5 0 Years ago ( I 

000 0 Never 

999 0 DK when or DK (lb) 

disease 3 

1b. Have you ever heard of AIDS? 1OYei 

El 20No (SKIP l-0 ITEM 28, 9mDK I Page 9) 

1 q Alot 2. Compared to most people, how much 2 0 Some 

[I 

would you sayyou know about 3 0 A little AIDS...would you say a lot, some, a little, 4 ‘0 Nothing or nothing? 

HAND CARD A 

3. After I read each statement, tell me 

whether you think the statement is 

,definitel true, probably true, probably Def. Prob. Prob. Def. Don’t 

false, de Yinitely false or,you don’t know if True True False False Know 

it is true or false. 

a. AIDS is a disease caused by a virus. 10 20 30 4c.l 90 El ,....,,..,........,..,............,.............,...........................................................................,........................................................................ 

b. AIDS can cripple the body’s natural 

protection against disease. 10 20 30 40 90 pq 

........ ............... ............................................................................................................................................................................. 

C. AIDS is especially common in older 

people. 10 20 30 40 go El ........-........................................................................................................................................................................................ 

d. TheAlDSviruscandamagethebrain. 10 20 30 40 90 El 

I.*.................I...I............................................,...........,..........,.,...........................,.......,...,................................................. ........... . 

e. AIDS usually leads to heart disease. 10 20 30 40 go 1 ... ....._........................................................................................................................................................................................... 

f. AIDS leads to death. 10 20 30 40 go El 

131 
All Main 

4a. Where do you get most of your Sources Source 

information about AIDS? 

Any other sources? 10 1 0 Television ............................. ............................‘......~......‘............‘..‘.....~.................. 

(MARK ALL MENTIONED) 

10 1 q Newspapers 172 1921 

........................................~................‘...........~...~.............‘.~...................‘... 

10 1 IJ Brochures/Fliers/Pamphlets (73 193 

.. ..................................... .. .................... ..........‘..‘..‘.......‘I......................... 

10 1 0 Clergy/Church 174 1941 

......... ................. ............. ...~............~.......‘....~..~~.~..........~‘..‘~..........“.‘........ 

10 1 c] Doctor/HMO 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..‘......................................... 

t # 

10 1 0 Company or Industry Clinic 176.196 1 ............................................... ...................‘..~..~~...~1.‘*..tr...I~............I~...... 

If only one source or DK in 4a, 

mark box without asking and skip 

to 5a; otherwise ask.- 10 1 q Hospital/Emergency Room/OP Clinic 177 1971 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..~................‘.........‘..‘..*.....‘...........~.‘..........~ 

4b. Of the sources you just told me, 

from which ONE do you get the 10 1 0 Other Clinic ........................................ ............................~.......~~~~.~~.I.‘......~~~..~....~........ 

MOST information? 

10 1 0 Magazines 

. . . . . . . . . . . ..~....................~......................~.~.~.I..*.l~.~..~~~~~~~~~~~~.....,,,,,,,,~,,,‘.,,,,,, 

1U 1 0 Medical Journals ~~)1007 ...................................-................*...................................................,,,,,,. 

10 1 0 Library fsrG-jF-J .....-~..............~.........-......-...~...~....................~,,‘,.,.,,,,,.,,.,,*,,,..,,,,,,,‘,,‘.,,,,,,,, 

10 10 AIDS Hot Line 

. . . . . . . . . . . . . . ..~..-...-..........................................~.~..~.~~~....1...~~~1~.‘l...~..~‘~~~.‘....,~, 

I . 

10 10 Public Health Dept. (Local/State) 183 103 ................................*...-............................................................‘.‘....‘...,,,~ 

10 10 Red Cross/Blood Bank 

10 1 0 Radio 

1 

1 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..~........‘...~.....~...~.....*............1..‘.~ll..t.~......~..‘..‘....... 

10 1 0 Relatives . . . . ..-....-.....-..-.....-.................~........-.......~.......~...........~~~..~...,...,I~~~,~.,,,,‘,,,,, 

10 1 q Friends pqi-q 

........ .. ...........................................‘...........L.................~~~..........‘............... 

10 1 0 School (Class/Clinic) 

...............-..............~*...................~.~....~......“........~~r.~~~~~~~~~~~~~~~..~...~~.~...,,,,, 

10 1 0 Other Source - (SPECIFY) 

. . . . . . . . . . . . . . . . . . . . . . . . . . . ..-....~.......~........II............~~.L~.....~~..I......r.1~......~1~~...‘...‘.~.. 

10 10 Don’t Know pGiGi 

132 
5a. 

5b. 

If you wanted more specific 

information about AIDS, where 

would you get it? 

Any other sources? 

(MARK ALL MENTIONED) 

If only one place or DK in 5a, mark 

box without asking and skip to 6;’ 

otherwise ask: 

Which ONE source would you 

MOST likely use? 

All Main 

Sources Source 

10 1 c] Television p-jz-1 

.............................._..._.._.............................................................~.~.~.....~~~ 

1 q 1 aNewspapers 16 1261 ............................... .................................................... .. .................. ....... .. 

‘0 1 0 Brochures/Fliers/Pamphlets 17 127 ,..................................................................... ..........._................................ 

10 1 0 Clergy/Church f-5-j-q 

. . . . ..“......““...............~~.................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

10 1 0 Doctor/HMO 

................................................................................................................ 

10 1 0 Company or Industry Clinic ......... ....... ................................ ................~.....‘..........‘...‘.....‘.“.......,..”’...” 

10 1 0 Hospital/Emergency RoomlOP Clinic 

10 1 0 Other Clinic ._........,..,.................................,...,................................. .......... ................. 

10 1 0 Magazines 

1 

. 

.. 

I 

/

.. 

j

.. 

/

.. 

/ 

.. 

................................................................................................................. 

10 1 O-Medical Journals 114 1341 ,................................................................................................................ 

ICI 1 0 Library 

................................_................................................................._.............. 

10 1 fJ AIDS Hot Line pi-j-$ 

1El 1 0 Public Health Dept. (Local/State) 

............................. ........._.......................................................................... 

10 1 0 Red Cross/Blood Bank rii-j-q I 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

10 1 0 Radio 

‘1q 10 Relatives 120 1401 

.............. .. ................................................................................................. 

lIZI 1 0 Friends ................................._....................................... ........................................ 

10 1 0 School (Class/Clinic) 122 142 1 

............................... .................................................................................. 

1 0 Other Source - (SPECIFY) 10 

,..,................................................................ .............................................

10 1 q Don’t Know 1241 

133 

1 
HAND CARD A 

6. After 1read each statement, tell me 

whether you think the statement is Def. Prob. Prob. Def, Don’t 

definite1 true, probably true, probably True True False False Know 

false, de Yinitely false or you don’t know if 

it is true or false. 

a. A person can be infected with the 

AIDS virus and not have the disease 

AIDS. ,......_..._....__...-...................-......~.....~.........~...~...........~......... 

b. You can tell if people have the AIDS 

virus just by looking at them. 

,.._..........................~..........-.......~...-.........~...~...~.........~.-....~.. . . ..__.._.................~...........,..,.......,.,*~..~..~~,~..‘..,,‘.~,.,,*,,,,,,,.‘,.,,,,,.,,,.,,,,

C. ANY person with the AIDS virus can 

pass it on to someone else through 10 2cl 30 40 go L-l47 sexual intercourse. 

,..............................~....................~.......~............................. .......-.~...............~......................’......~..~‘.~~.L~tr..,rtrr,tr,‘,~.,,,,,,~,,,,,,,,,,,.,, 

d. A pregnant woman who has the I48 

AIDS virus can give AIDS to her baby. ......................................................................................... 

e. There is a vaccine available to the 

public that protects a person from, 10 20 30 40 go 0 49 

getting the AIDS virus. .........‘.........................“..........................................“.......... 

f. There is no cure for AIDS at present. 10 2cl 30 40 go I 50 

HAND CARD B 

7. After I read each statement, tell me if you 

think it is very likely, somewhat likely, 

somewhat unlikely, very unlikely, 

definitely not possible or if you don’t 

know how likely it is that a person will 

get AIDS or the AIDS virus infection that 

way. 

defy Somewhat Somewhat Very Not How likely do you think it is that a person Likely Likely Unlikely Unlikely Pox DK will get AIDS or the AIDS virus infection 

from.. . 

a. receiving a blood transfusion? 10 20 30 40 50 90 51 I ..........................-.............................................................. ...................................~....~.~~‘...............‘...~.....~..‘.‘..~......‘................,, 

What about.. . 

b. donating or giving blood? 10 20 30 40 50 go 152 1 ................~....~......~.~...~.....~.~........~...~~.~..__.____.._..__.._......._.__ -.........~...............-...~..~.........‘~,‘..,..‘..~I..~~..,~,,...,.,,...~I.,,,,,,~,,,..,,,,,,,,,,,. 

C. living near a hospital or home for ICI 20 30 40 50 90 I53 I AIDS patients? 

...............................................-............ ......._..______._..._.__._. 

d. working near someone with AIDS? 
. 

1 

How likely do you think it is that a person 

will get AIDS from.. . 

e. eatin in a.restaurant where the 

cook it as AIDS? ~....I.................................................................................... 

f. kissing -with exchange of saliva - a 

person who has AIDS? ,.....,...........,....................................................................... 

9. shaking hands with or touching 

someone who has AIDS? ...........I............................................................................. 

h. sharing plates, forks, or glasses with 

someone who has AIDS’ ............................................................... .......................... 

i. using public toilets? ......................................................................................... 

j- sharing needles for drug use with 

someone who has AIDS? 

.‘.........................................,............................................. 

k. kissing on the cheek a person who 

has AIDS? ......................................................................................... 

I. being coughed or sneezed on by 

someone who has AIDS? ......................................................................................... 

m. attending school with a child who 

has AIDS? .......L.................................................................................. 

n. mosquitoes or other insects? 

)........................................................................................, 

0. pets or animals? ...........~.................................................-........................... 

p. having sex with a person who has 

AIDS? 

8. Have you ever heard of a blood test for 

infection with the AIDS virus? 

9. Does this blood test tell whether a person 

has the disease AIDS? 

10. If someone has a positive blaod test for 

infection with the AIDS virus, does this 

mean that they can give someone else 

the AIDS virus through sexual 

intercourse? 

Very Somewhat Somewhat Very Not 

Likely Likely Unlikely Unlikely Poss. DK 

10 20 30 40 50 90 1 ...................... .......................................................................... ..... ..I. 

10 20 30 40 50 go l-56 I ....................................................................................................... 

10 2El 30 40 50 90 I 57 1 ................................................................_...................................... 

10 20 3.0 40 50 go I- 58 I ....................................................................... ............... .......... ....... 

10 20 30 40 50 go 1 1 ........................................................................................-.............. 

10 20 40 5cl go L-60 I 

10 20 30 40 50 90 I 61 I ,..............I...........................,........................................................... 

10 20 30 40 50 90 ( I . . . . . . ..“‘...“.....‘.“......‘..‘....‘..’..”....”.’”’.....‘..‘...”.................~............ 

10 20 30 40 50 90 L-63 I ...................................................................................................... 

10 20 30 40 50 90 I64 I . ..........................................................................~........................... 

10 20 30 40 50 90 I 65 1I ....................................................................................................... 

10 20 40 50 go I66 I

I 

1 OYes 

20No L-l67 I 

9 f”J Don’t Know > (15) 

lOYes ~ 

20No 

9 0 Don’t Know 

I 69 

1 OYes 

20No 

9 0 Don’t Know 

135 

I 
11. Have you had your blood tested for 

infection.with the AIDS virus? 

12a. Have you thought about having this 

blood test? 

12b. Do you plan to be tested in the next 12 

months? 

13. (If you were to be tested) Where would 

you go to have a blood test for the AIDS 

virus infection? 

(MARK FIRST PLACE MENTIO/JlED) 

14. Where would you go to find out where 

to have this blood test? 

Anywhere else? 

(MARKALL MENTIONED) 

1 q Yes 

2 0 Yes,in blood donation/transfusion 

30No > 

9 0 Don’t know (12) 

1q Yes 

2nNo(lS) 

1q Yes 

2f-JNo 

. 

00 fJ Nowhere/wouldn’t take test 

......-...--...-.....*.~.....................-...-....~..........,,,‘..,.,,.,,,,,. 

01 q AIDS Clinic 

....................................~_........................I...........‘...... 

02 fJ Company or Industry Clinic ..............................................................r.................. 

03 0 Doctor/HMO .............................................................‘.....‘...‘..r...‘.. 

04 0 Hospital/emergency room/OP Clinic ............................................................................ ..... 

05 0 Other clinic ...............*.....................................................‘........... 

06 0 Public Health Dept. .. ......-..........................................~...........r....,,,.,,,,*,,~. 

Of 0 Red Cross/blood bank ...................................._........................i.....I.........‘... 

88 0 Other (SPECIFY) 

....................... .................................. ...............‘......~ 

99 Don’t know ( 14) 

10 Nowhere 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..‘.......................‘.........U..... 

lo AIDS Hot Line 

. . . . . . . . . .._.__.............~.....~....................................,,.,,,,,,,,,,,. 

1 0 AIDS Clinic 

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

1 0 Clergy/Church ..~........_........~~.~.~~..........f...~I.....,........,.~....,..,.,,,,,.r.,,,,,.,,. 

10 Doctor/HMO .......~~..................................~...............~I~~....~‘.~...,,,...,,,,.. 

1 0 Friends 

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

1 f-J Hospital/emergency room/OP Clinic ..................................~...~..................‘....‘...............‘..‘I... 

1 0 Public Health Dept. 

. ..-...._............-..--....-....-...........,..,...,,.‘,,..,,.,.,,...‘,.,.,,,‘,,,,,.,..,,,,...,.,,,. 

10 Red Cross/blood bank 

. . . . . . ..~.~........I............................................,..,.‘.,,,,,,,rr.‘,r,‘ 

1 0 Relatives 

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

1 q Other (SPECIFY) 

10 Don’t know 

72 L-l 

[xi-] 1*,,,.*,

,‘<.‘.,.,,..,,I,. 

‘,‘,,.,,,,,,,,‘,. 

05) 

,,‘i,d,,,,,,#,,,. 

l,,,1,‘,,,#,,,,“ 

E-l 

l-z--l 

I 

E-i”‘­

78 L-J r.,.. 

79 cl I,,., 

80 I ,,a., 

I 81 ,,I,, 

r-l82 

I # 

L-l 83

El85 

86 L-l 

136 
virus, 

15. y;;av,you donated blood since January, 

16. Have you ever personally known anyone 

who had the blood test for the AIDS virus 

infection? 

17. What are the chances of someone ou 

know getting the AIDS ____ijrwoul you 

-high, medium, low or none? 

18. What are your chances of getting the 

AIDS virus, would you say high, medium, 

low or none? 

19. Here are methods some people use to 

prevent getting the AIDS virus through t sexual activity. 

After I read each one, tell me whether 

you think it is very effective, somewhat 

effective, not at all effective or if you 

don’t know how effective it is in 

preventing getting the AIDS virus 

through sexual activity. 

How effective is.. . 

a. Using a diaphragm? ,.,...I..,................................................................................., 

b. Using a condom? ,,,,O..,...I.I...,I...I.................................................................... 

C. Using a spermicidal jelly, foam, or 

cream? 

............................................................................................ 

d. El;inzcelibate, that is, not having sex 

.,~...,..,.................................................................................,...................................................................................................... 10 20 go 

e. Two people who do not have the 

AIDS virus having a completely 10 20 30 40 go 095 

monogamous relationship, that is, 

having sex &with each other? 

1 q Yes I 87 2nNo 

9 0 Don’t know 

1 (Z1Yes 

20No 

9 0 Don’t know 

i 0 High l-l 89 

2 0 Medium 

3OLow 

4 0 None 

7 0 Refused 

9 0 Don’t know 

1 0 High 

2 0 Medium 

3OLow 

4’0 None 

7 0 Refused 

9 0 Don’t know 

Don? 

Not know Don’t 

Very Somewhat At how know 

effective effective All effective method 

10 20 30 40 90 I 91 

....................................................................................................... , , 

92 l-l ....................................................................................................... 

10 20 3cl 40 go I 93 

......... ........................................................... ..... ..... .. ............ ........... 

I 94 

30 40 

137 
20. Have ou ever discussed AIDS with a 1 DYes 

frien J or relative? 2DNo El96 

9 0 Don’t know > (22) 

2 I. When was the last time you discussed 

AIDS with a friend or relative? 

22. Do you have any children aged 10 

through 17? 

23. How many do you have? 

24. Have you 

child/any 

25. [Has your 

instruction 

26. Have you 

with the 

27. Have you 

ever discussed AIDS with [your 

of these children]? 

child/Have your children] had 

at school about AIDS? 

ever personally known anyone 

AIDS virus? 

ever personally known anyone 

with AIDS? 

28. The U.S. Public Health Service has said 

that AIDS is one of the major health 

problems in the country but exactly how 

many people it affects is not known. The 

Sur eon General has proposed that a 

stu %y be conducted and blood samples 

be taken to help find out how 

widespread the problem is. 

If you were selected in this national 

sample of people to have their blood 

tested with assurances of privacy of test 

results, would you have the test? 

29. Would you want to know the results of 

the blood test? 

0010 Today 

2 0 days ago I 97-99 

3 0 weeks ago 

4 0 months ago 

number 5 0 years ago 

999 q don’t know 

1 q Yes 

2 0 No (26) El 100 

p6s-j 

1 q Yes 

103 2mNo I 

1 QYes 

2aNo 0 104 

9 0 Don’t know 

1 OYes 

I 105 

20No 

9 0 Don’t know if someone had/has AIDS virus . 

1 OYes 

20No I 106 

9 0 Don’t know if someone had/has AIDS 

1OYes 

2 f-J No (END INTERVIEW) El107 

8 q .Other response (SPECIFY) 

9 [3 Don’t know (END INTERVIEW 

1q Yes I 108 

213No 

9 0 Don’t know 

138 

I 
- - - 

--- 

CARD R 

RACE 

1. Abut, Eskimo, or American 

2. Asian or Pacific lslandw 

3. Black 

4. Whii 

CARD I 

INCOME 

u .. .. $20,000 - $24,999 

V . .. . $25,000 - $29,999 

w . .. ~30,060 - $34,999 

X . . .. $35.000 - $39,999 

Y .. .. *40,000 - *44,999 

2 .. .. (45,000 - $49,999 

ZZ... $50,000 and over 

CARD 0 

/ 

ORIGIN 

Indian 1. Puerto Rican 

2. Cuban 

3. MexicanlMexicano % 

wm r - _-. 

4. Mexican American 

5. Chicano 

6. Other Latin American 

7. Other Spanish 

--“eman 

I 

CARD J 

INCOME 

A .... . lass than *1,ooo fplhdhg IOU1 

B .*..... :1,ooo- *1,ms 

c ..-... *2,000- *2,999 

D . . . . . $3,000- $3,993 

E .m.... $4,000- *4,999 

F .-.I. *WOO- ~6,999 

6 - 16,OOO- $6.S9S UI 

-1 

‘H . . . .7,000- $7,999 r - - - - - - -

I - W,OOO- ~8,993 I 

J .- 83,000- 09,999 

K -. 11O@fJO- ~10,333 

L . ..-. *11.000- 011.s93 

a - *mow - tresaa I Y 

R . *17,000 - *17,999 

8 -. *18,wo - *1sass 

T - :19,ooo-:1%39s I

6 

M . . *12,Ooa - 112899 

N . *13,lWO-$13,399 .Y 

:I 

0 - *14.000-*14,SSs ;3 

P - *1s,OOO - *16~99 i! 
CARD M 

Has anyone in the family ever adopted 

any children? 

(‘II Yes 

(21 No 

CARDQ2 

Fried chicken 

White bread 

Soda or soft drinks 

Peanut butter 

Broiled fish 

Bananas 

Cold cuts or lunch meats 

Doughnuts 

CARD Ql 

Bran flakes 

Corn flakes 

Hamburgers 

Lettuce 

Bakedbeans 

Carrots 

White rice 

Raw apples 

CARD RI 

Stress 

Inherited make-up or heredity 

Exposure to X-Rays 

Poor eating practices 

Using chewing tobacco, snuff, pipes, 

or cigars 

Ak pollution 

Waterlpollution 

Some cloth dyes 

Exposure to toxic waste dumps 

Exposure to toxic substances on the job 

Exposure to people with cancer 

Exces%ive drinking of alcoholic beverages 

Exposure to the sun 

Cigarette smoking 

Exposure to nuclear waste 

Some strong soaps and detergents 

Viruses 

Some medicines 

Medical procedures using radiation 

140 
CARD R2 

1. Strongly agree 

2. Agree 

3. Disagree 

4. Strongly disagree 

5. No opinion 

CARD S 

CARD R3 

Church 

L&al school 

Hospital 

Club meeting 

Workplace 

Home 

Senior center 

Community center 

Other place 

CARD W 

1. Strong 

2. Moderate 

3. Slight 

1s-J u 

Sketch of woman on whom mammography is being performed 

using the most common type of X-ray equipment. Other types 

of X-ray equipment are also used. 

L 

L 
c 

LIST 1 

FRUITS AND JUICES 

HOW OFTEN DID YOU WHAT SIZE PORTION 

EAT OR DRINK - DID YOU USUALLY 

EAT OR DRINK? 

Orange juice or Small, medium, 

grapefruit juice? or large? 

Other fruit juices or fortified fruit drinks? 

Oranges? 

Grapefruit? 

Cantaloupe in season? Medium f%cant.) 

Apples or applesauce? 

LIST 3 

MEATS AND MIXED DISHES 

HOW OFTEN DID WHATSIZE PORTION 

YOU EAT - DID YOU USUALLY 

EAT? 

Hamburgers, Small, medium, or 

cheeseburgers, or large? 

meatloaf? 

Beef, such as steaks, 

or roasts? 

Beef stew or potpie 

containing vegetables? 

Liver, including 

chicken liver? 

Pork, such as chops, Medium (2 chops or 

or Toasts? 402. of roast) 

Fried chicken? Medium (2 small or 1 large piece) 

Chicken or turkey, baked, Medium (2 small or stewed or broiled? 1 large piece) 

Fried fish or fish 

sandwiches? 

Spaghetti, lasagna, or 

pasta with tomato sauce? 

LIST 2 

VEGETABLES Ll*tI 

u.t a 

HOW OFTEN DID WHAT SIZE PORTION ; 

YOU EAT - DID YOU USUALLY ; 

EAT? , 

Beans, such as baked Small, medium, or 1 

beans, pinto, kidney large? 

II beans, or in chili? I

Do not include green t t beans. ,

I 

Carrots, or mixed 

vegetables containing 

I

I 

carrots? I I Tomatoes, including / in salad? I

Green salad? : : Salad dressing or mayonnaise, including lo 

rs on sandwiches? ‘5 

Broccoli? :a 

18 *? Spinach? 1s9 

Collards, mustard greens, jd turnip greens, etc? I Coleslaw, cabbage, or sauerkraut? : I Frenchfries or fried 

potatoes? 

1

: I Potatoes, baked, boiled, , or mashed? I 

Sweet potatoes or yams? 

I

I 

Rice? 

II

I’ 

,LIST 4 

BREAKFAST FOODS 

HOW OFTEN DID WHAT SIZE PORTION 

YOU EAT - DID YOU USUALLY 

EAT? 

Cooked cereals like 

oatmeal? 

Small, medium, or 

large? 

-

u** 3 

List 4 r. .~ 

High fiber cereals like 

I

I’ 

bran, granola, or 

: shredded wheat? 

I’ 

Highly fortified cereals I 

like Product 19, Total, r 

or Most? I : Other cold cereals like 

Rice Krispies or corn I 

flakes? I 

Eggs? How many eggs? 

I

: 

Bacon? How many slices? I _ 

I .6 

Sausage? How many patties i i 

or links? 

ii 

1% 

I:: 

;P II

I ,IIII

I 

I :

I 

“!5501111981,,10.1186, 

142 
LIST 5 LIST 6 

BREADS, LUNCHES, AND SNACKS SWEETS AND BEVERAGES 

HOW OFTEN DID WHAT SIZE PORTION HOW OFTEN DID YOU WHAT SIZE PORTION 

YOU EAT - DID YOU USUALLY EAT OR DRINK - DID YOU USUALLY 

EAT?. EAT OR DRINK? 

Vegetable soup, vegetable 

beef, minestrone or tomato soup? 

Do not include other kinds 

of soup. 

Hot dogs? 

Ham or lunch meats? 

White bread, rolls, or 

crackers, including 

sandwiches, bagels, end so forth? 

Dark breads like whole 

wheat, rye, or pumpernickel? 

Corn bread. corn muffins, corn tortillas, or grits? 

Butter on bread, rolls or on vegetables? 

Margarine on bread, rolls, 

or on vegetab!es? 

Cheese or cheese spreads, 

not including cottage 

cheese? 

Peanuts or peanut butter? 

Salty snacks like chips or 

popcorn? 

Small, medium, or large? 

. How many hot dogs? 

Medium 

I2 slices or 4 orackers) 

Medium (2 slices) 

Medium (2 pats) 

Medium (2 pats.1 

Ice cream? Small, medium, or 

Pie? large? 

Doughnuts, cookies, 

cake, or pastry? 

Chocolate candy? us15 

Sugar in coffee or tea, Medium (2 tsp.1 US*6 or on cereal? r-‘-------

Whole milk or drinks made I

I 

with whole milk, NOT f

I

I including on cereal? 

2% milk or drinks made I 

with 2% milk, NOT I

I 

including on cereal? t 

I 

Skim milk or 1% milk or I

I 

buttermilk, NOT including 

I 

I

I on cereal? 

;ri:k,,o; cream in coffee 

Soda or soft drinks 

containing sugar? 

Beer? a. How often? 

Wine? b. On the days you drank it, how 

many cans, glasses, or drinks? 

liquor? c. Small, medium or large? 

143 
1988 

The 1988NHIS was conducted with a full sample. The 

sample consisted of 47,485 households, yielding 122,310 

personal interviews. As in prior NHIS survey instruments, 

the questions asked concerned acute and chronic conditions, episodes of persons injured, restriction in activity, 

limitation of activity due to chronic conditions, respondentassessedhealth status, and the use of medical servicesincluding physician contacts and short-stay hospitalization. 

Several health topics were included aspart of the 1988 

NHIS. The topics included medical device implants, occupational health, alcohol use, child health, and AIDS. 

The questions on medical device implants were designed to obtain information as to why the respondent 

needed the implant(s), problems associated with each 

implant, and the need for replacement or repair of each 

implant. 

The occupational health questions were concerned 

with gathering information on respondents’ work history, 

common work-related health problems, work injuries, and 

factors associated with cigarette smoking. 

Questions in the alcohol use section of the current 

health topic questionnaire asked about the amount 

and type of alcohol consumed, reasons for avoiding 

alcohol, family history of alcoholism, and alcoholrelated diseases. 

The child health section of the survey instrument 

included a series of questions designed to obtain data on 

child care, birth history, specific childhood illnesses, conditions and injuries, developmental milestones, use of 

health services, and behavior problems, 

The questions relating to AIDS were separate from 

the other 1988 current health topic questions. The questions were administered using computer-assisted personal 

interview (CAPI). The 1988 questions on AIDS were 

similar to those asked in 1987. The questions inquired 

about the person’s knowledge and attitude about AIDS, 

In 1988, a series of questions were asked to determine if 

the household received and read a special brochure containing information about AIDS. This brochure was mailed 

to each household by the Federal government. The questions asked about pamphlets, brochures, and announcements read or seen by the respondent, discussions held 

with children about AIDS, knowledge of AIDS, blood 

donation, a blood test for AIDS, the AIDS virus and 

sexual activity, the risk of getting the AIDS virus, whether 

‘person had known anyone with AIDS, and willingness to 

participate in sample of persons having their blood tested 

for AIDS. 

144 
----- ------ ------ --- 

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

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

‘-WT.613A OMB No. 0937-0021: Approval Expires 03/31/ 

~cml~,~S-1 A (1988) NOTICE - Information contained on this form which would permit identification of any individual or establishment has been collected with a guarantee that it will be held in strict confidence, will be used only for purposes stated for this study, and will not be disclosed or released to others without the consent of the individual or the U.S. DEPARTMENT OF COMMERCE establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242ml. eUREAUOFTHECENS”S ACTINGASCOLLECTING PlGENTFORTHE RT 67 U.S. PUQLIC HEALTH SERVICE 

1. 3-7 2.80. Number I g-1o 3.Sample 111--1 

9 NATIONAL HEALTH INTERVIEW Book -of- books SURVEY 4. Control number ;4-25 5i l33fclingi;g 2 

PSU I 1Gi Segment 111--23/Seriel 1 

SUPPLEMENT BOOKLET 1 a.n 

I I 2 p.n 

CHILD h$ND ADULT SAMPLE SELECTION 

6. Are there any nondeleted children O- 17 years old in this family? 1 31 7. Are there any nondeleted parsons 18 + years old in this family? 1 

10 Yes (List by age (oldest to youngestl in Table A, THEN 71 1 0 Yes (List by age (oldest to youngest) in Tab/e 6) 

20No (7) 20No 

6. TABLE A (O-1 7 year olds) TABLEB (18+) 

$a Percl Name Sax Line PWSOll Age No. No. Name SW Age 

33 34-x 36 37-39 40 41-42 43 44-4 

IOM I 0 Mos. tnM 

1

~~._----~~~_~~~~------~~~~~~~----------------------1_------_____-----------------__-______ 20F - 1 20Yrs. 1 20F 

luM 

2 

--._----_-__-_-_---------------------- 20F 4 

I 0 Mos. 

2 q Yrs. 2 --------------------____________________---------. 

t[7M 

2OF 

IOM I 0 Mos. IOM 

3 2’CiF --.----------------------------------- - c 2UYrs. 3 --------------_-----____________________---------. 20F 

IOM I 0 Mos. toM 

4 20F --._----_--_--__---------------------- 4 20 Yrs. 4 -----_-------_------____________________----~~~~~. 20F 

IOM I 0 Mos. 1OM 

6 -----_ _______ - -----------------------------~~~~~~. 

1OM I 0 Mos. IOM 

6 

--._----_____~--~~~~__________________ 2I3F - t- 20Yrs. 6 -----_--------------____________________-------~~. 20F. 

lOM I 0 Mos. TOM 7 

--.-------------- 20F - c 20Yrs. 7 -----_--------_---______________________---------. 20F 

IOM I 0 Mos. IOM 

~-._---_--___----- 20F 4 2q Yrs. 5 20F 

--.--- -----_ 8 20F - c 20Yrs. 8 _____ - _______--_______---_________________ 2[7F 

IOM I 0 Mos. ICIM 

9 ZCIF - c 2UYrs. 9 20F 

Refer to the appropriate sections of the sample person selection label and circle as applicable. THEN circle Person No. in TABLE A and/or TABLE Band mark ttie “SP” 

’ boxfesl on the HIS-l for the selected sample person(s). THEN go to Section M. 

9. FINAL STATUS OF SUPPLEMENT 

8. Section M (page 2) =j b. Section N (page 361 c.Section 0 (page 60) d. Section P ipage 76) 1 

(Medical Device Implant) (Occupational Health) 7 (Alcohol) 7 (Child Health) 

Interview I 

0 0 No Medical Device Implants I 

l 0 0 No person 16 + in this family l 

I 

0 0 No person 16+ in this family I 0 0 Nb child O-17 in this family 

I 

1 Cl Complete interview 1 Interview I Interview t InterView 

(all persons with MDls 

interviewedl l 1.0 Complete interview (all 

appropriate sections I 1 0 Complete interview (all 

appropriate sections and I 1 0 Complete interview (all 

appropriate sections 

2 q Partial interview (some but I 

I completed) I 

I HIS-2/HIS-3 completed) I 

I completed) 

not all persons with MDls I 2 17 Partial interview isome but l 2 0 Partial interview (some but not all l 2 0 Partial interview (some but interviewed) not all appropriate sections appropriate sections or HIS-2/HIS-3 i not all appropriate sections IExplain in notesl I completed1 (Explain in notes1 completed1 fExpla;n in notes) completed1 1Explein in notes) 

S q Partial Interview (Persons with I I 

;o;yot interviewed) (Explain in / Nonintemw Noninterview / Noninterview 

1 3 0 Refusal fExplain in notes) 3 q Refusal fExp/ain in notesj 1 3 0 Refusal fExp/ain in notes) 

Noninterview 1 40 SP temporary &sent 4 0 SP temporarily absent l 4 0 Eligible Resp. TA 

3 0 Refusal (Explain in notes) 1

I 5 0 SP mentally or physically incapable l 5 0 SP mentally or physically incapabje i 5 0 No eligible resp. in HHld. 

a 0 Other 1 8 0 Other IExplain in notes) 1 8 0 Other lExplain in not& l 8 0 Other (Explain in notes] 

0. Endlng time 11. Interviewer identification I 

160~631 54 Name 1 Code m I 1 a.m. 

I 2 p.m. I 

Jot.3 

145 
--------------------------------- 

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

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

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

Section Ml - MEDICAL DEVICE IMPLANT SCREENING 

CHECK Refer to HIS- 1. I 

I

I 1 

I

ITEM 1 Enterperson number of household respondent I Household respondent 

These next questions are about medical devices that are I 

SURGICALLY implanted in the body to help the body function or ( 

treat an illness or injury. I 1 IJYes I 

j G. Does anyone in the family NOW have a joint that has been I z0No 

replaced by an artificial one, such as an artificial hip, knee or I 9 q DK 1 12’ 

finger joint? 

p------------ ---------------------4. 

b. Who is this? I Record name and person number in table MDI. 

I Mark ‘Joint” box, I ---------------------------------~----------------------------------. 

0. Anyone else? I 

I 0 Yes fReask lb and cl 

I q No 

2G. Does anyone in the family NOW have a fixation device, such I IIVes 

as screws, pins, nails, wires or plates implanted to fix or hold ( 

bones in place, including skull plates? I

~----------------------------------* 

b. Who is this? I Record name and person number in table MD/. 

I Mark “Fix” box. 

---------------------------------t------------------------------------~ 

C . Anyone else? I 0 Yes (Reask 2b and c) 

I [7No 

sa. Does anyone in the family NOW have an artificial heart valve? i I tJYes 1 

I 

I 

I 

I 

p---------------------------“’ 

b. Who is this? I Record name and person number in table MDI. I Mark “HV” box. 

I 

c . Anyone else? I 0 Yes (Reask 3b and cl 

I 

I q lNo 

La. Sometimes the lenses of the eyes can be replaced with I 

I artificial ones called intraocular lenses, which are sewn 

I 

I 

into place during surgery. I q Yes

I Does anyone in the family NOW have an intraocular lens? I 

Do not count cornea/ transplants, if volunteered. 

-----------------------~---------~----------------------------------

b. Who is this? I 

I Record name and person number in table MD/, 

I Mark ‘IL” box. 

I __--------------------~---~~~~-~~’ )----------------------~~~---~~~-dd~ 

c . Anyone else? I 0 Yes iReask 4b and c) I 

I NO 

I 

ia. Silicone implants are used to reconstruct parts of the body, I ) 

such as breasts, ears, chin, or nose. I i q Yes 

Does anyone in the family NOW have a silicone implant? I 2[7No 

sODK > @’ 

Do not count injected silicone, if volunteered. I 

I ---------------------------------~-----------------------------------

b. Who is this? I 

I Record name and person number in table MD/. 

I Enter S/L/CONE IMPLANT in “Other” column. -------------‘-------------------~---------------------------------- I 

0. Anyone else? I i ;“6; lReask 56 and d 

I 

ia. A pacemaker is implanted in the chest to regulate the I 

I I q Yes. 1 

heartbeat. Does anyone in the family NOW have a I 

pacemaker? I 

I

I ---------------------------------~----------------------------------

b. Who is this? I Record name and person number in table MD/, I Mark “Pace” box. ~----------------------------------

0. Anyone else? I 0 Yes (Reask 6b and cl I q No 

dotes 

146 
--------------------------------- 

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

Se&ion Ml - MEDICAL DEVICE IMPLANT SCREENING - Continued 

7a. Ear vent tubes are often implanted in the eardrums of children 

I 

1 1 q Yes I 

and adults who get frequent ear infections. I 2nNo (8) Does anyone in the family NOW have ear vent tubas? I s0DK > --------------------------------_L-------------------------------------

D. Who is this? I 

I Record name and person number in table MDI. 

I Enter EAR VENT TUBES in “Other” column. 

y.---------------------------­ c. Anyone else? I 0 Yes (Reask 7b and c) 

8a. Infusion pumps are implants that pump medication such as 1 IAL 

insulin or cancer chemotherapy into the body. I i q Yes 

I 

Does anyone in the family NOW have an infusion pump? I 2ciNo (9) s0DK > -___-------___--~----------------~-----------------------------------

b. Who is this7 I Record name and person number in table MDI. 

Enter INFUSfON PUMP in “Other” column ---------------------------------L----------------------~------------­

c . Anyone else? 0 Yes (Ressk 8b and cl 

q No 

Da. Does anyone in the family NOW have a central nervous I 

I i q Yes fi 

system shunt that drains fluid away from the brain or 

I ZUNO splnel column? I 9 q DK 1 (‘01 

-----__-------__-----------------~---------------------------------~ 

b. Who is this? I 

I Record name and person number in tab/e MDI. 

I Enter CENTRAL NERVOUS SYSTEM SHUNT in “Other” column. 

I -----__-------------------------- r----------------------------------­

c. Anyone else? I 0 Yes lf?essk 9b and cl 

I 

I q No 

Ua. Does anyone in the family NOW have any type of shunt I 

I 1q Yes or catheter implanted in the body (besides the [infusion I 

pump/central nervous system shunt117 I 

Read if necessary: A shunt is a man-made tube through which blood or II 

body fluid is diverted from its natural path. I 

I Read if necessary: A catheter is a flexible tube implanted in the I 

body to remove or put in fluid. I 

b. Who is this? I 

I Record name and person number in table MDI. 

I --~---------__----_______________ r----------------------------------‘ 

Cm What kind of shunt or catheter does - - have? I 

I Enter kind of shunt or catheter in “Other” column. 

---------------------------------t-------------------------------------­

d. Does anyone else have any type of shunt or catheter I 0 Yes (Ressk 1Ob, c, and dl 

lmplented in the body? I q No 

1 q. Does anyone in the family NOW have any other kind of 1 q Yes 1 

medical device that has been implanted in the body 

during SURGERY? Some examples are artificial arteries z : !i (Check /tern 21 

and veins, ligaments and dental implants. > 

~-------------------------~~----~~-~ 

b. Who is this? 

I 

I Record name and person number in table MDI. 

c . What kind of implant a055 - - have? I 

I Enter type of imp/ant in “Other” column. 

d. Does anyone else in the family have any other kind of medical i q Yes (Reask 7 7b, c, and d) device implanted in the body? I 

I 0 No (Check /tern 21 

CHECK I 

I I [7 One or more MDl’s (Check /tern 2) 

ITEM 2 Mark appropriate box 

b I 

I z 0 No MDl’s (Section N, page 36) 

btes 
I 

I 

I 

I 

I 

I RTO 

Section Ml - MEDICAL DEVICE IMPLANT SCREENING - Continued 

TABLE MDI 

Complete the appropriate Medical Device Sections for each person and each device entered below. 

I 

Name 1 Person Joint Fix Others 

I (a) I lb) 

; 1 3-4 

(Cl 

1 5 IdI 16 

(4 

) 7 

(f) 

) 8 

(81 

1 9 

(h) 

) 10-11 

I

I 1. 

I 10 20 30 40 50 2. )12-13 

I number (pg. 6) (pg. 12) (pi!61 (pg!L221 (pE% (pg. 32) 

I 

A m 3. 

I 

; 1 16-17 I 18 1 19 1 20 ( 21 ) 22 1 23-24 

I 1. 

I 1 

I 10 20 30 40 50 2. I 

I 1 

I 3. I 

’ 124-30 1 31 1 32 1 33 1 34 1 36 ( 

I 1. 

I

I 1 

I 117 20 30 40 50 2. 

I 

I 

I 3. 

I 

I 

’ 142-43 ( 44 1 45 ) 46 1 47 1 40 & 1. I 

I 2. E 

I 10 20 30 40 50 

I ( I 

1 

w 

I 1. I 

I IO 20 30 40 50 2. m 

I 

I 3. E 

I 

/ 1 94-96 1 96 1 97 1 98 1 88 ) 100 1101-10: 

I 1. I 

I E 

I 10 20 30 40 50 2. I 

I 3. m 

I 

Notes 
Sectipn M2 - ARTIFICIAL JOINT PAGE 

I 1. Enter name and person number from Table MDI. I 

1 Name 

I 

2a. indicate type of respondent. I

1 i q iSelf personal 1313 Cl Proxy personal 1 

2 0 Self telephone 40 Proxy telephone -------------------------------------------~--------------------~ 

b. Relationship of proxy to the person 

I Relationship I 

These next questions are about your artificial joints. i 3. Joint 4. Number 

3. What kind of artificial joint(s) do you have? . j a. a. 

I 

I b. b. 

C. C. 

Ask for each entry in 3. I 

4. How many (entry in 3) do you have? I 

I d. d. 

i e. e. 

I f. f. 

5. Enter each joint in a separate column except for fingerjoints. Treat multiple fingerjoints i 1 

as a single joint and enter “fingerjoints”in 5. Also entername andperson number in I item 1 of each appropriate column. t 

Complete 6- 15 for the first artificial joint for this person before asking about the next. I I-E 

(These next questions refer to the FIRST finger joint thet was replaced) / t 0 Replaced 171 

6a. Wes the joint actually replaced with the lentrv in 51. or was something 1 8 q Something else 

else implanted, such as a pin or a plate? --------------------------------------------~------------------------

b. What was implanted? / Mark “Fixation” box of Table MDI, then 

I go to next column or next device. 

7. Is the artificial jentrv in 5) you have now. a replacement for a previous I lOYes 1 

artificial (entrvin 5)? ; 20Nollll 

8. How many times has this artificial joint been replaced? I 

I 1 

I Times 

I 

t m 9. When did you get the artificiel (entry in 51you had before the I 

I 119 current one? 

I 

I Month Go to 10 Year 

otes 

FORM HlSlA U988, MZ3.1 
-------------------------------------------- 

Section M2 - ARTIFICIAL JOINT PAGE - Continued 

I 

j Og. Why did you have that artificial fentrv in 5) replaced? I 010 Mechanical failure of the artificial joint - 20-21 

1 020 Loosening of the artificial joint 22-23 

Mark first three mentioned. Do not probe. I 03Cl infection 24-26 

1 040 Increased pain over time 

1 880 Some other reason - Specify 3 

I 

I 

I ----------------------------~---------------~-------------------- m Ask for each entry in 1Oa: I oooo 0 Lessthan1day I 

b. How long after that joint was implanted was this lentw in 7Oal first noticed? I 0 Days 5555 0 Lessthan30days 

2 [7 Weeks OR eeee a 30-90 days 

3 c] Months ,777 0 Morethan90 days 

4 q Years 9999 0 DK i---L- ----------dd-d’r 

Probe if DK: Was it lass than 30 days, 30 to 90 days, or more than 90 days? I oooo 0 Lessthan1 day 

asae q Lessthan30 days 

0 R eeee 0 30-90 days 

7777 0 Morethan90 days 

9999 0 DK -----------e-d oooo 0 Lessthan1day E 

I 

I 0 Days aeee0 Lessthan3Odays 

2 c] Weeks 0 R 8866q 30-90 days 

3 0 Months 7777 0 Morethan90 days 

4 q Years 9999 q DK 

m II. When did you get the artificial (entry in 5) (you have NOW)? I 

I 119 

I Month Year 

I 

Ask if finger joint; otherwise, skip to 13. I I 0 Siliconi? ) 

12. Is your artificial finger joint made out of silicone or some other material? I so Other 

I s[7DK 

j 3. Why did you need to get your (original) artificial (entry in 5)? 1 010 Osteoarthritis ) 

I 02n Rheumatoid arthritis 

Mark first three mentioned. Do notprobe. I 030 Arthritis, unspecified 

[ 040 Trauma/Injury 

, 050 Pain 

/ es0 Some other reason - Specify z 

I 

I 

CHECK 

ITEM 4 Refer to 7: 

1 I q Yes in 7 (14bl 

1 20Noin7(14al 

I 

j 4g. Since you received the artificial lentw in 51, would you say your mobility in that joint is I 10 Improved ) 

improved, about the same, or worse than it was before the implant? 1 20Same 1151 

-------------------------‘----------------------+--------------------

i 30 Worse 1 

b. Since you have had your current artificial (entry in 5). would you say your mobility i , [7 Improved E 

in that joint is improved, about the same, or worse than it was with the previous I 2USame artificial (entry in 517 1 30 Worse 

I ) 

Please tall ma if you have you had any of the following problems I or complications with your (current) artificial (entry in 5) - 1 lOYes 

1 20No 

I5a. Have you had any blood clots? 1 snDK > 115Cl 

--------------------------------------------~-------------------- m b. k~ loo: “,ttizio7had the artificial (entry in 5) when the blood clots I 

I oooo 0 Lessthan1 day ! 

I 0 Days 5555[7 Lessthan30 days 

2 0 Weeks 0 R eeeeu 30-90 days 

Probe if DK: Was it lass than 30 days, 30 to 90 days, or more than 90 days? I- 3 0 Months 77770 Morethan90 days 

I { 4 q Years ssss 0 DK 

G-------------------­

c. Have you had an infection? 1 lOYes m 

--------------------------------------------~--------------------

d. How long had you had the artificial (entry in 51 when the infection oooo 0 Lessthan1 day was first noticed? t 17 Days esse~Lesrthan30~ 

Probe if DK: Was it lass than 30 days, 30 to 90 days, or more than 90 days? 2 0 Weeks OR 6666 q 30-90 days 

3 0 Months 77770 Morethan90 days 

4 0 Years 9999 0 DK 

Go to 150 .-- FORMHIs.,A,,s*s, ,,(Fm 

150 
---- 

Section M2 - ARTIFICIAL JOINT PAGE - C ntinued I 

? 

I 

I

513. Has the artificial [entrv in 5) loosened? I 

I 

--------------i------__--__----------------------­

f . How long had you had the artificial Jentrvin 51 when it was first noticed 

I 

I 

I ‘---o;o;~c,,~a~~a~--------~ 

that the joint was getting loose? I 

I I 0 Days 55550 Lessthan30days 

I z 0 Weeks OR ased 30-90 days 

Probe if DK: Was it less than 30 days, 30 to 90 days, or more than 90 days? I 

I s 0 Monthi 7777 0 More than 90 days 

-{ 4 0 Years sssso DK 

--------,-----,----------------------------- I .--Tove~---------- Ts3’ 

g. Have you had Increased pam over time? I 

I 

I 

I .---_---_------------ h. How long had you had the artificial lentrvin 51 when the increased pain was I oooo q Less than 1 day first noticed? I 0 Days 55550 Lessthan 32 

2 0 Weeks OR 6666030-90 days 

Probe if DK: Was it less than 30 days, 30 to 90 days, or more than 90 days? 3 0 Months 77770 More than 90 days. 

-I 4 0 Years sssso DK ~_--__-___-----------~-~~~~~--~~--~~--~~--~-~ I .--------------------

1. Have, you had mechanicial problems with the artificial (eritry in 5) itself? I I 0 Yes T’ 

I 

I 

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

j. How long had you had the artificial {entrvin 5) when the mechanical problem oooo q Lessthan 1 day T69-7: 

was first noticed? I 

I I 0 Days 55550 Lessthan 30 days 

I 

I 2 0 Weeks 0 R cm30 30-90 days 

Probe if DK: Was it less than 30 days, 30 to 90 days, or more than 90 days? I 3 0 Months 77770 More than 90 days I 

-I 4 0 Years sssso DK 

----------------------me-..-------------------- t 

k. Have you had any other problems or complications with the artificial (entry in 5)? I 

I I q Yes l2E I 2 0 No (Next column or next device) I __---------__--_---_--~~~~~~~~~---~--~~--~-- t

I. What were they? 1 

Record first three mentioned. Do not probe. Be specific. (1) 76-T 

(3) 

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

Ask for each entry in 751. oooo 0 Less than 1 day 1 

m . How long had you had the artificial (entry in 5) when the (entry in 151) was I 0 Days 5555 0 Lessthan 30 days first noticed? iI)- I 2 IJ Weeks 0 R esss~ 30-90 days 

I 3 0 Months 7777 0 More than 90 days 

4 0 Years sssso DK 

Probe if DK: Was it less than 30 days, 30 to 90 days, or more then 90 days? ----o;o;y-~a;~a;-~-----~ 

I 0 Days 55550 Lessthan 30 days 

El- I 2 0 Weeks OR -9335030-90 days 

3 0 Months 7777 0 More than 90 days 

4 0 Years 99990 DK I 

I w I oooo 0 Less than 1 day I 

I I 0 Days 55550 Lessthan 30 days I (3)- 1 2 0 Weeks 0 R 66.560 30-90 days I 

I 3 I-J Months 77770 More than 90 days I 4 0 Years sssso DK I 

Go to next column or next device I 

Votes 
I 

Section M3 - FIXATION DEVICE PAT , 3-4 1 

1. Enter name and person number from Table MD/. Name 

I 

I 

I Person No. L 

i 2a. Indicate type of respondent. I 

I 

I Cl Self- personal 

1 (31 3 q Proxy- personalI-!­

2[7 Self -telephone 4 q Proxy- telephone I -------------------‘~ -r 

I b. Relationship of proxy to the parson I 

I 

I Relationship t 

These next questions ace about your skull or bone holding implant. 3s. IMPLANT 3b. NUMBER 

aa. What kind of implant do you have? 1. 1. 

Is it a bone screw, pin, nail, wire or plate? 2. 2. 

3. 3. 

Ask for each entry in 3a: 4. 4. 

b. How many (implants in 3a) do you have? 5. 5. _-__----___--_--_------~-~~--~~~-----~---~~~, -----------_------~-----

Ask for each entry in 3a: 1. 

c . In what part(s) of the body [is/are1 the (implant in 3al located? 2. 

3. 

4. 

I 5. 

___----_--__-__---_-------------------------. i- -___--__-__---------I_i_ 

d. Do you have any other bone holding implants? I 0 Yes (Reask 3a-dl I 

I t 

Refer to 3a-c. 

4. Enter implant and each SEPARATE body part and fill a column for each. Do I 

I 

~implant 

NOT duplicate body parts. (Enter name and person in each column.1 Body part I 

r 

I 01q Injury ) Complete 5- 10 for the FIRSTbone holding implant for this person before going to the next. I 020 Deformities I 

5. Why did you need to get a limplantin 4)? I 

I 

030 Infection 

040 Cancer I 

Mark first reason mentioned. eeO Other - Specify i7 

1 

6a. Is the (implantin 41 you have now a replacement for a previous (implant in 417 iI iLlYes 1 

I 20 No 19) -_--------~----____~ 

- b. How many times has the (implant in 4) been replaced? 

Times 

7. When did you get the (implant in 4) you had before the current one? 

119 Mnnth Ytaar 

Ba. Why did you have that (implant in 4) replaced? 010 Mechanical failure of the implant 

020 The implant did not work 

Mark first three mentioned. Do notprobe. 030 Infection 

Healing problem 

Pain or irritation 

Some other reason Specify 2 

.--------------A----- ___ 

Ask for each entry in 8a: ooooo Less than 1 day -4 27-30 

D. How long after that (implant in 41 was implanted was this (entry in 8al first noticed? (l)-

10 Days 5555 0 Lessthan30 days 

20 Weeks 0 R asas Morethan90days 

30 Months 7777 0 30-90 days 

---_____-____-___-______________________---- -iProbe if DK: Was it less than 30 days, 30 to SO days, or more than SO days? 40 Years 9999fJ DK __------_---~--~~-~_~~~--~-~-~ ooooo Lessthan 1 day m 

I 0 Days 5555 q Lessthan30 days 

20 Weeks OR seasO Morethan90 days 

30 Months 7777 0 30-90 days 

PI- { 40 Years sw99[7 DK __--_____--------------------- w ooooo Lessthan 1 day 

I 0 Days 5555 c] Lessthan30 days 

(3)- 30 Months 7777 0 30-90 days 

40 Years sssso DK I ciotos I . FORM HISfA ,198W ,,023-171 

20 Weeks OR aaeaO Morethan90days 

152 
------ ----- 

4 3q 0 Weeks Yar Days 6666 saaa TIT 0 So-90 DK Less than than 30 days 

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

r Section M3 - FIXATION DEVICE PAGE - Continued 

1 1. When did you get your (current) (implant in 4)? I19 

Month Year 

Please tell me if you have you had any of the following problems or 

complications with your (current)Jimolant in 4) -

Og. Have you had an infection? 

_______-__--__---------~---~--~~~~~~~~~~-~~~. 

b. How long had you had your (imolant in 4) when the infection was first 

noticed? 

1q Days assa 0 Less than 30 days I 2 0 Weeks OR 6666 0 30-9Odap 

Probe if DK: Was it less than 30 days, 30 to 90 days, or more than 90 days? I 

I s 0 Months 7777 0 More than 90 days 

__ t 4 El Years 9999 0 DK =~-H~v~~~u~e~y~~a~n~~r~~~m~~ - - --__ -__--_-. L -~~-e~--------------E 

I 

I 

I 

I 

I 

__________-______--_------------------------. 

d. How long had you had your (implant in 4) when the healing problem was f 

I oooo 0 Ldssthan 1 day 1 

first noticed? I 

I I 0 Days saaa 0 Less than 30 days 

I 

I z 0 Weeks OR rm6 0 30-90 days 

Probe if DK: Was it less than 30 days, 30 to 90 days, or more than 90 days? I 3 0 Months xw 0 More than 90 days I 4 0 Years sssg 17 DK 

__-_-__-__-___-__-__------------------------. L 

g. Have you had any problems with pain or irritation? I 

I I q lYes 1 

---------------------------T---.--.-~-----~------. 

f, How long had you had your (implant m 41 when the pam or urrtation was fust oooo 0 Less than 1 day 1 

noticed? 

4 2 0 Probe if DK: Was it less then 30 days, 30 to 90 days, or more than 90 days? .. I q Months OR 999s 0 More days90 days 

--_---_-------------------------------------. -,oy,,---------------~ 

9. Have you had any mechanical problems with your (implant in 41 that is, it has 

not worked correctly? 2 0 No 

g 0 DK (joi) > 

h. How long had you had your (implant in 41 when the mechanical problems oooo 0 Less than 1 day ) 

were first noticed? 

I 0 Days 5555 0 Lessthan 30 days 

0 z 0 Weeks OR 6~36 30-90 days __ Probe if DK: Was it less than 30 days, 30 to 90 days, or more than 90 days? 3 0 Months 7777 0 More than 90 days 

{ 4 0 Years 9999 0 DK 

--------------------------------------------. -1 i. Have you had any other problems or complications with the (implant in 4)? I q lYes 2 0 No g q DK (Next column or next device) 

_--_---~~-----_--_-----~-~~--~--~~-~~-~~~~~~. L __-__--__-__-------- . 

J. What were they? I e 

(1) E Record first three mentioned. Do not probe. Be specific. 

Ask for each entry in 1Oj: oooo 0 Lessthan 1 day 1 

k. How long had you had your (current) (implant in 4) when the (entry in 1Oj) I 0 Days sass 0 Less than 30 days 

was first noticed? (I) - 1 2 0 Weeks c5~~ 0 30-90 days 

3 0 Months OR 7777 0 More than 90 days 

Probe if DK: Was it less than 30 days, 30 to 90 days, or more than 90 days? 4 q Years 999s 0 DK 

----o;o;;;e;;a;;,-------~ 

I 0 Days 5555 0 Lessthan 30 days 

(2) - 2 0 Weeks OR 1x660 30-90 days 

3 0 Months 7777 0 More than 90 days 

4 Cl Years 999s q DK 

oooo 0 Less than 1 day 1 

5656 0 Lessthan 30 days 

(3) - 1333 0 30-90 days 

7777 0 More than 90 days 

9999 0 DK 

Go to next column or next device 

. . i 

153 
---- --- 

---- 

r Section M4 - HEART VALVE PAGE (H’ 

1. Enter name and person number from Tab/e MDI. 

Name 

Person No. i 

2a. Indicate type of respondent. I I USelf - personal (3, 3 0 Proxy- personal I 7 I 2 USelf - telephone 4 0 Proxy- telephone I 

----__-_____--_-----.--------~--------~~---- ---_ L- ___---------------4- -*A@­ I b. Relationship of proxy to the person 

Relationship 

t 

These next questions are about your artificial heart valve. 1 10 

3. At this time, do you have more than one artificial heart valve? i i q lYes 2 0 No (51 

4. How many artificial heart valves do you NOW have? 

L

I ( 11 

I 

I Number 

I 

5. There are four different heart valves - the mitral valve, the eortic r 

I I 0 Mitral ) 12 

valve, the tricuspid valve, and the pulmonic valve. I 2 0 Aortic I 

Which of these did you have replaced with (an) artificial valve(s)? I 3 0 Tricuspid I 

I 4 0 Pulmonic 

If “Yes” in 3, mark each one in a separate column. Also entername and person I anDK number in item 1 of each appropriate column. 

Comolete 6- 74 for the first heart valve for this person before t I q Yes 1 12 

ask&g about the next. 

6. Is the artificial [Itype in 5)/heartl vilve you have now a replacement for 

a previous artificial lltvoe in5)heartl valve? c 

7. How many times has this valve been replaced? I 

I 

Times 

t 

8. When did you get the artificial [(type in 5Mheartl valve you 

had before the current one? 119 

Month Year 

+ 20-21 9a. Why did you have that artificial [(type in 5) /heart1 valve replaced? or q Blood clots (Thrombus or thrombo embolism) 22-23

24-26 

Mark first three mentioned, do not probe. 02 !J Infection 

03 0 Bleeding 

04 0 Mechanical failure 

ss 0 Some other reason - Spacify 2 

I I 

--------_-------_------~-------~-------~ L _______d----_------+ 

Ask for each entry in 9a: -I26-29 

b. How long after that heart valve was implanted was this (entry in 9al I oooon Lessthan1 day 

first noticed? I 0 Days 55550 Lessthan30days I 20 Weeks OR seasO 30-90 days I 

I( l)- 3 0 Months 77770 Morethan90 days I { 4 0 Years ssss0 DK I 

I, ____---------

Probe if DK: Was it less than 30 days, 30 to.90 days, or more than 90 days? m 

oooon Lessthan1 day 

10 Days aaaao Lessthan30days 

:a- 2 0 Weeks OR seesO 30-90 days 

3 0 Months 7777 q Morethan90 days 

1 4 Cl Years gggsi=l DK 

-----------A-----

3iZi r 

ooooo Lessthan1 day 

I 0 Days 55550 Lessthan30 days I 

I( 3)- 2 0 Weeks OR saaan 30-90 days 

I 3 0 Months 77770 Morethan90 days I I 4 II Years ssssn DK 

c 

0. When did you get the artificial [(type in 5/lheartl valve (you have now)? I 

I 1 an-41 

I 119 I Month Year -I1. Some artificial heart valves are mechanical and made from I I 0 Mechanical/man made substance L/Esubstances such as metal or plastic and others are made from animal 2 0 Biological/animal tissue or human tissue. What is your artificial [(type in 5Mheartl valve made I 3 q Biological/human tissue (121 from? I 

I s0DK > , I 

L I FORM HIS-IA ,,818, Hom.a71 

154 
Section M4 - HEART VALVE PAGE (HVI - Continued 

( 

1%. Did you get a registration card for this heart valve from your doctor or 1 q YES 

from the hospital? z 0 No 

s0DK 

-------_----_------------------------------~-------------------- ___ 

b. What is the brand name of this artificial heart valve? -L% 

Probe if OK: Who is the manufacturer? 

Name 

1 

1%I. Anticoagulants are medications that help prevent blood clots. 

Do you take anticoagulants regularly? 1 q Yes

----m b. How often do you take them? 

114) 

I 

Notes 
Section M4 - HEART VALVE PAGE (HV) - Continued 

I 

Please tell me if you have had any of the following problems or complications I 

with your (current) artificiel fltvpe in 5heartlvalve - I i q Yes 

I ; ii; 174cl 

4a. Have you had blood clots? I > 

----_---___---- __---------------------------L---------------------

I x ; 

b. ~e~~~~ ~~~~~o~had the artificial valve when the blood clots I 

I oooo q Lessthan1day I 

I , 0 Days 555.50 Lesrthan3Odayr 

I 2 0 Weeks OR aassO 30-90days Probe if DK: Was it less than 30 days, 30 to 90 days, or more than 90 days? I -. sOMonths 7777 0 Morethan90 days 

I { 4 q Years 9999~ DK 

--------------------------------------------+--------------------

c. Have you had an infection or andocarditis? I m 

I rOYas 

I i 8;: f74el > I --------------------------------------------~-------------------- m i d. How long had you had the artificial valve when the infection or andocarditis I 

was I oooo 0 Lessthan1 day first notcad? I 

I I 0 Days 5555[7 Lessthan30dayr 

I 2 0 Weeks OR sseaEi 30-9Odays 

Probe if DK: Was it less than 30 days, 30 to 90 days, or more than 90 days? i - 3 0 Months 77770 Morethan90 days 

I { 4 q Years ggssn DK 

_---___-____----___-------------------------~--------------------

o. Have you had problems with bleeding? I 

I rClYes m 

20No i 

I snDK > (74g’ -----------------~----------------------- ----I--------------------~ 

f. How long had you had the artlflclal valve when the problem with blaadmg I oooo 0 Lessthan1 day c 

was first noticed? I 

I , 0 Days 55550 Lessthan30 days 

I 2 q Weeks OR eessn 30-90days 

I - 3 0 Months 77770 Morethan90 day!5 

Probe if DK: Was it less than 30 days, 30 to 90 days, or more than 90 days? I { 4 (-J Years sssau DK __--________________------------------------ +-----.-------------- - E 

g. Have you had any,mechanical problems with the artificial velve itself? I 1clYes 

; ;;“,; 174i) 

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

h. 

ware first noticed? 

Probe if DK: Was it less than 30 days, 30 to 90 days, or more than 90 days? 

I 

I 

I 

I -

I 0 

2 0 

3 0 

Days 

Weeks 

Months 

OR 

5555 q Lessthan30days 

eaaaO 30-9Odays 

77770 Morethan90 dayS 

I I 4 q Years asssn DK 

-..-.----------------------~~~-----.--~------ ----&-------------------. - m 

How long had you had the artificial valve when the mechanical problems I

I oooo 0 Lessthan1 day m r 

i. Have you had any other problems or complications? 1 i!JYas 

1 i i $ /Next column or next device) 

1 ---_----_____---___-------------------------~--------------------

j. What were they? I

I -p& rT 

/ (1) 

Record first three mentioned. Do notprobe. Be specific. 72-i 13 

I (2) 1 ‘6 I 

1 (3) 

--------------------------------------------+--------------------

Ask for each entry in 14j: I 

I oooo 0 Lessthan1 day 

m T 

k. How long had you had the artificial heart valve when the (entry in 14ji I I 0 Days 6555 0 less than30 days was first noticed? I(1) 2 0 Weeks OR Essex 30-9Odays 

/ - 3 0 Months 77770 Morethan90 dayI 

Probe if DK: Was it less than 30 days, 30 to 90 days, or more than 90 days? I t 4 q Years esssn DK 

;----------------d-w-w ,a I 

I oooo 0 Lessthan1 day 

I 1 0 Days 5555 q Lessthan30 dayr 

I (2)- 2 0 Weeks Ott saaan 30-9Odays 

I 3 0 Months 77770 Morethan90 day‘S 

I { 4 q Years ssssu DK 

; ---__-- ------d_dd-_-

I E ii 

I oooo 0 Lessthan1day , 

I I 0 Days 55550 Lessthan30days I 2 El Weeks OR asas 30-9Odavs 

I (3) - 3 0 Months 77770 Morethan90 day!5 

I I 4 q Years sassy DK 

Go to next column or next device I d 

FORM HIS-1A IlBaall1&23 .571

156 
I ill73 

Section M5 - INTRAOCULAR LENS PAGE (Ii) 

I 1. Enter name andperson number from Table MD/. 1 Name 

I 

[ Person No. 

I ( I %I. Indicate type of respondent. 1 i Cl Self -personal 3 0 Proxy -personal 

I z 0 Self - telephone (31 4 q Proxy -telephone ---------------------~----------------------~-------------------- I m

b. Relationship of proxy to the person I 

I 

I 

I Relationship 

1 There next questions are about your intraocular lens. I 10 Right eye 

3. Do you now have an intraocular lens in your right eye, left eye, or both eyes? 1 20Lefteye 

I 3 0 Both eyes - Fill this column for the “Right 

eye”, mark “Left eye”in next 

column and enter name and 

person number in item 1. 

4. is the intraocular lens you NOW have in your [right/left] eye a repiacemenhfopa I 

I 

iLlYes m 

previous intraocular lens in THAT eye? 1 20 No (71 

I 

5a. How many times has the intraocular lens in your [right/left] eye been replaced? I 1 

I Times 

--------------------------------------------~-------------------- m b. When did you get the intraocular lens you had before the current one? 

119 

Month Year 

6a. Why did you have the intraocular lens in your 

the current one? Cright/ieftl eye replaced with 

I 

I 01 Cl Injury/trauma 

1 ca 0 Mechanical failure 

13-11 

20-2: 

I 03 0 Glaucoma (after lens implant) 22-2: 

Mark first three mentioned, do notprobe. I 04 0 Irritation or inflammation 

i 06 q Trouble reading 

) 06 0 Infection 

I 07 0 Movement or displacement of the lens 

[ 06 0 Wrong lens power 

r 09 0 Cornea1 transplant 

i s6 0 Some other reason - Specify 5 

I 

I 

-------_------------------------------------ +------------------m 

Ask for each entry in 6a. I 

0006 0 Less than 1 day D. How long after that lens was implanted was this (entry in 6al first noticed? I 

I 1 0 Days ssasn Less than 30 days 

2 0 Weeks OR 666s~ 30-90 days 

Probe if DK: Was it less than 30 days, 30 to 90 days, or more than 90 days? I 

( (I)- 3 0 Months 7777 0 Mpre than 90 days I 

I I 4 Cl Years sssso DK 

I---__---__--__---__- __-

I k 

I 

I oooo 0 Less than 1 day 

I 1 17 Days ~666~ Less than 30 days 

I CL-.- 2 0 Weeks OR 66660 30-90 days 

I 3 0 Months 77770 More than 90 days 

I I 4 0 Years ssssn DK 

;-------------------m 

I 

I oooo [7 Less than 1 day I 1 0 Days 5.5550 Less than 30 days 

1 (3)- 2 0 Weak6 OR 66660 30-90 days 

I 3 0 Months 77770 More than 90 days 

{ 4 Cl Years gsggn DK 

7. When did you get the intraocular lens (that you NOW have) In your 1 

[rlghffleftl eye? 119 1 Month Year I 

I 

8. Why did you need to get an intraocular lens in your Cright/ieftl eye (in the first place)? I 01 0 Cataract m 

1 02 Cl Injury/Trauma 

1 68 0 Other - Specify 2 

I 

I 

1 aanDK 

9. Dld your doctor tell you that the (currant) lens in your fright/left1 eye 1 iLlYes 1 

Is an experimental or investigational lens? ’ 20No (lo)-

; anDK 

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

Section M5 - INTRAOCULAR LENS PAGE (IL) - Continued 

IO. Does this intraocular lens have a substance in it that absorbs some I 

I 1q Yes 1 

types of light? I 20 No I 

I anDK 

8 II. Because of the intraocular lens in your [right/left] eye, did your doctor advise you I 

I 1 q Yes k 

to wear sunglasses when you are in bright light or sunlight? I 20No 

I anDK I 

Please tell me if you have had any of the following problems or complications I 1 0 Yes k 

with the (current) intraocular lens in your [right/left] eye - I 20 No 

I2a. Have you had any infection? 

I 90 DK > “2c’ --------------------------------------------~--------------------

b. How long after your (current) lens was implanted was the infection first I 

I 

ooooo Less than 1 day E 

noticed? 

I 13 Days 65550 Lessthan30days 

Probe if DK: Was it less than 30 days, 30 to 90 days, or more than 90 days? 2 0 We&g OR 6666n 30-90 days I- 30 Months 77770 Morethan90 days 

I

j i 40Years esssn DK _____-----------------~~~~~----------------~ +---- ---------d----­

c. Have you had healing problems? I i Cl Yes E 

I 20 No I 

I 9 q DK I 1’2e’ --------------------------------------------~-------------------- E d. How long had you had the lens when the healing problem was first noticed? I ooooOLessthan1day 

I 0 Days 65550 Lessthan30days 

Probe if DK: Was it less than 30 days, 30 to 90 days, or more than 90 days? 20 Weeks OR 6666a30-90 days 

I-- 3 0 Months 77770 Morethan90 days 

j { 

---+L~EY ____ YEYL,_,_ 

8. Have you had pain, irritation, or inflammation of the inside of the eye? 

20 No I snDK > “2g’ -------_________----------------------------~-------------------- E f. How long had you had the lens when the pain, irritation, or inflammation I 

was first noticed? I ooooa Less than 1 day 

I 0 Days 55550 Lessthan30days 

Probe if DK: Was it less than 30 days, 30 to 90 days, or more than 90 days? 2[7 Weeks OR es660 30-90 days I- 3 0 Months 77770 Morethan90 days 

I t 40 Years 9999~ DK --------------------------------------------~-------------------- m g. Have you had glaucoma that started after the lens “8 implanted? I 17 Yes 

I 

I ; :: g( } 172il I 

__--------------____~~----------------------

h. How long had you had the lens when the glaucoma was first t--,,,,,,,$-------~ 

noticed? I 

I 0 Days 5555[7 Lessthan30 days 

20 Weeks 0 R masO30-90 days Probe if DK: Was it less than 30 days, 30 to SO days, or more than 90 days? 30 Months 77770 Morethan90 days 

i-t 40Years 9999[7 DK --------------------------------------------~--------------------

i. Have you had problems with clouding or blurred visions? I 

I I 0 Yes f-ss20 No I 9 0 DK 1 1’2k’ 

____------------------~~~~~----------------- .L----------~~~~d­ . 

1. How long had you had the lens when the clouding or blurred vision was I 

I pi%J 

first noticed? I oooon Less than 1 day 

I 0 Days 55550 Lessthan30 days 

ssesO30-90 days Probe if DK: Was it less than 30 days, 30 to 90 days, or more than 90 days? I- 2,8::i:ts OR 77770 Morethan90 days 

j

I t 40 Years QQQQUDK --------------------------------------------~-------------------- E k. Have you had trouble reading newspaper print? i 0 Yes 

I, 20No I 

I 9 0 DK 1 1’2m’ 

-------------------d-m---------------------- f---- ---------------m 

1. How long had you had the lens when this trouble was first 

noticed? ooooo Less than 1 day 

I 0 Days 55550 Lessthan30 days 

Probe if DK: Was it less than 30 days, 30 to 90 days, or more than SO days? 20 Weeks OR seea 30-90 days 

3 0 Months 77770 Morethan90 days 4 Cl Years 99990 DK 

Go to 12m 

Notes 

158 
Section M5 - INTRAOCULAR LENS PAGE (Il.1 - Continued 

am. Have you had problems with glare or light streaks? 1 q Yes 

(720) 

--------------------~----------------------- ~--------------------ts-re 

n. How long had you had the lens when the glare or light streaks 1. were first noticed? I oobo 0 Less than 1 day 

I q Days saas[7 Lessthan 30days 

Probe if DK: Was it less than 30 days, 30 to SO days, or more than SO days? z 0 Weeks 0~ aaee~ 30-90 days 

3 0 Months 77770 More than 90 days

4 q Years SSSSU DK --------------------------------------------~-------------------- -__ 

O. Have you had problems due to wrong lens power? I I q Yes f 

-----------__-___---------------------------

p. How long had you had the lens when the wrong lens power was 

fhst notlced? oooo 0 Less than 1 day 

Probe if DK: Was lt less than 30 days, 30 to SO days, or more than 99 days? 

---_-----~~~~-----_~~~~~~-~---~~~~~----~~~~~ C--------------------~ 

C. How long had you had the lens when this problem was first noticed? I 

I oooo 0 Less than 1 day 

2 0 Weeks OR 6666030-W days 

Probe if DK: Was it less than 30 days, 30 to 90 days, or more than 90 days? 3 0 Months 77770 More than 90 days 

4 q Years sgg9[7 DK 

-----------------------:----------------

I q Days 55550 Less than 30 days 

8. Have you had any other problems or complicatrons with the 

Intraocular lens in your [right/left] eye? 

I (Next column or next device) I 

--------------------------------------------~--~~----------------~ 

t. What were they? 

Record first three mentioned. Do not probe. Be specific. (2) 1 

(3) 

--------------------------------------------~-------------------- ___ 

Ask for each entry in 12t. h 0000 0 Less than 1 day

I q Days 55550 Lessthan 30 days 

u. How long had you had the lens when the (entry in 12tl was first noticed? 

l(l)- 2 0 Weeks OR 66660 30-90 days 

I a 0 Months 7777 0 More than 90 days 

I 4 q Years ssssn DK 

I-----_----__-------_ Probe if DK: Was it less than 30 days, 30 to SO days, or more than 90 days? I E 

I oooo q Less than 1 day 

5555 0 Less than 30 days 

77770 More than 90 days 

Go to next column or next device 

dotes 

%59 
-------------------------------------------- 

Section M6 - PACEMAKER PAGE 

1. Enter name andperson number from Table MDI. I 

I I a-r 

I Name 1 6-6 

!

l Parson No. 

7 2a. Indicate type of respondent.. I i Cl Self -personal (3, 3 Cl Proxy- personal’ 

1 2 0 Self -telephone1 4 q Proxy- telephons 

--------------------------------------------~--------------------

b. Relationship of proxy to the person 

I j--6=6-

I 

I 

I Relationship 

These next questions are about your pacemaker. I ( 10 

3a. Is the pacemaker you have now a replacement for a previous pacemaker? i 1OYes 

; 2 q No (71 

--------------------------------------------~--------------------

b. Altogether, how many times has your pacemaker been replaced? I 

I -p=rTI Times 

4. When did you get the pacemaker you had before the current one? I 

I w 

I 119 

Month Year I 

I 6a. Why 37-16 did you have that pacemaker replaced? r or 17 Battery failure 16-20 1 02 0 Lead failure (LCCed) 

Mark first three mentioned. Do not probe. l 03 q Mechanical failure, unspecified 21-22 

I 04 0 Infection 

l 05 0 Healing problem 

I 06 Cl Pain or irritation 

1 as 0 Some other reason - Specify 7 

I 

~------------------‘-~~=2~ 

Ask for each entry in 5a. I

I ooooq Lessthan1 day 

b. How long after that pacemaker was implanted was this (entry in 5a) first I i q Days 5555[7Less then30days 

noticed? 

I(l)- I 20Weeks OR seesO 30-90 days 

I 3 0 Months 77770: Morethan90 days 

I 4 q Years 9999U DK 

Probe if DK: Was it less than 30 days, 30 to 90 days, or more than 90 days? I

I_______----------------- 1 

I oooo 0 Lessthan1 day 

I 1 I 0 Days a5550 Lessthan30 days 

1cap 2OWeeks 3 Months OR aeeeCi 7777 30-90 days 

I 0 q Morethan90 days 

I 4 Cl Years ssss0 DK 

I

,__________-----_-------- 1 

I oooo 0 Lessthan1 day 

I 0 Days 55650 Lassthantodays 

2OWeeks OR aseaO30-90 days ; ,3)- 3 0 Months 77770 Morethan90 days I 

I { 4 q Years ssssO DK 

I 

6. How was the pacemaker you had before the current one monitored - 1 01 0 Not monitored ) 3646 

by telephone, at the doctor’s office. at the hospital, or in some other way? l 02 0 Telephone 

1 03 0 Doctor’s office 

1 04 0 Hospital 

Mark first applicable box l sa 0 Other - Specify z 

I 

I 

7. When did you get your (current) pacemaker? ; 1 

I 119 

.I Month Year 

6. How is this pacemaker monitored - by telephone, at the doctor’s office, 1 01 0 Not monitored 1 

at the hospital, or in some other way? l 02 q Teleohone 

1 03 [3 Doctor’s office 

Mark first applicable box l 04 0 Hospital 

1 86 q Other - specify 7 

I 

I 

I 

I 

9. Can your (current) pacemaker be programmed or adjusted I

I 

without surgery? 1 iElYes 

; 20No (101 

1 sODK > 

160 
--- 

Section M6 - PACEMAKER PAGE - Continued 

IOa. Hava you had any mechanical problems with your (current) pacemaker, w 

such as battery failure or lead lleedl failure? 

-----------_~---------~~~~~~~~~~~~----~----- T-------‘------------m 

b. What kind of mechanical problem did it have? 01 0 Battery fallure 

1 02 c] Lead failure 

Mark a// that apply. I aa 0 Other - Specify -J 

I 

I 

11. Please tell me if you have had any of the following problems or complications 1 

with your (current) pacemaker -

a. Have you had an Infection ? --------------------____________________---- ‘.--------------------z

b. 

first noticed? 55550 Lessthan30days 

OR seae~ 30-90 days 

Probe if DK: Was it less then 30 days, 30 to 90 deys, or more than 90 deys? 77770 More than 30 days 

----------------------------------------~~~~ +--------Bw---------tbz- sggg~ DK 

How long had you had your (current) pacemaker when the infection was I 

I oooo u Less than 1 day 

C. Have you had any healing problems? I iUYe.9 

--------------------------------------------~--------------------

d. How long had you had your (current) pacemaker when the healing problem l oooo 0 Less than 1 day t 

was first notlced? 5555 0 Less than 30 days 

Probe if DK: Was it less than 30 days, 30 to 90 days, or more than 90 days? 5585~ 30-90 days 

------------------------------.--------+-------------------- -__ 

f, ~l~~o;l~,hd”ld you had your (current) pacemaker when pant or urltatlon was I t oooo 0 Less than 1 day 

55550 Less than 30 days 

Probe if DK: Was it less than 30 days, 30 to 90 days, or more than 90 days? 6666[7 30-90 days 

55550 Less than 30 days 

66660 30-90 days 

Probe if DK: Was it less than 30 days, 30 to 90 days, or more then 90 days? 

(Next column or next device) 

--------------------------------------------~--------------------

J, What were they? I e 

1 (1) 1 70-71 

I 

Record first three mentioned. Be specific. Do notprobe. I (2) ) 72-73 

I 

; (3) 

--------------------------------------------+-------------------- ___ * 

. 

k. How long had you had your (current) pacemaker when the (entry in 7 7jj was I 

I oooo 0 Less than 1 day first noticed? 55550 Less than 30 days 

Probe if DK: Was it less than 30 days,.30 to 90 days, or more than 90 days? 

55550 Lessthan 30 days 

5555 0 Less than 30 days 

88860 30-90 days 

77770 More than 30 days 

I 

I Go to next column or next device 

FORM tics-IA 119ssl lm.23.a 

161 
I llT7B 

Section MT - OTHER DEVICE PAGE 

I 1. Enter name and person number from Table MDI. 1 NameI 3-4 

I

I Person No. .I 

I 7 2a. Indicate type of respondent. i i Cl Self- personal (9, 3 0 Proxy- personal’ 

r 2 0 Self- telephone 1 4 0 Proxy- telephone

_________________--------------------------~---------------------

b. Relationship of proxy to the person I j-s-oi Relationship 

3. Enter implanted device from “Other” column of table MDI. I ( 10-11 

I 

I 

I 

1 12 These next questions are about your (other) surgically implanted medical device(s). i 1 q iYes 

4a. Do you have more than one (implant in 31? 1 20No (4cl 

______------------------~~~~~~~--~~-~~~~-~-- I ---------d---d-- -i 

b. How many (implantin 3) do you now have? l----- T 13-C 

I 

I Number --------------T------------------------------------ I --------d-d---dC . In what part(s) of the body [rs/arel the (implant m 3) located? -l----- fiGiI 

If multiple parts, enter each different body part in a separate column. I 

Also enter name and person number in item 1. I 

I 

I

I I 0 Injected silicone (Next column or CHECK 1 2 0 Removable by person > next device) 

ITEM 5 Mark first appropriate box based on the entry in 3 and/or 4~. I a 0 Other (5) I 

I r--ii--

5a. Is the (implant in 3/4cl you have now a replacement for a previous (implant in 3/4c)? 1 1 q lYes 1 18 

2 0 No 181 

-------------------------------------------~---------------------

b. How many times has the (implant in 3/4c) been replaced? I 

I pzI Times 

I 

6. When did you get the (implant in 3/4c) you had before the current one7 I 

I 1 

I19 I Month Year I 

7a. Why did you hava the previous (implant in 3/4cl replaced? I 

I 01 0 Infection 

26-26 

27-22 

/ ci 0 Mechanical failure of the implant 2#-30 

Mark first three mentioned. Do not probe. 1 

I 

03 0 Implant did not work 

04 0 Healing problem 

I 0s •j Pain or irritation 

) 08 0 Blood clots 

1 07 c] Bleeding 

I cs 0 Trauma/Injury 

I as 0 Some other reason - Specify 5 

I 

I -------------------------------------------~---------------------

Ask for each entry in 7a. I 

I oooon Lessthan1 day m 

b. How long had you had your previous (implant in 3/4c) when the (entry in 7al I 

I I 0 Days ssss 0 Lessthan39 days 

was first noticed? 2 0 Weeks 66ee0 30-90 days [(l)- 3 0 Months OR 77770 Morethan90dayr 

I { 4 0 Years ssss 0 DK 

Probe if DK: Was it less than 30 days, 30 to 90 days, or more then 90 days? l___i_____----------_ 

I ooooo Lessthan1 day E 

I 

I I 0 Days ssss 0 Lessthan30 days 

2 q Weeks BBBB0 30-90 days l(2)- 3 17 Months OR 77770 Morethan90 days I 1 4 0 Years ssssCl DK 

I--------------______ 7 547 I oooon Lessthan1 day I 

I I 0 Days ssss 0 Lessthan30days I 20 Weeks aaaa0 30-90 days / (3)- 3 0 Months OR 7777q Morethan90 days I 

I 1 4 0 Years ssss 0 DK I 

I 

I 8. Why did you need to get the (implant in 3/4c) in the first place? I 01 El Infection 191 1 43-44 

I 02 0 Trauma/Injury > Mark first one mentioned. 1 as 0 Some other reason - Specify $ 

I 

I 191 

FORM "Is-14 l1Lv(l,,w-23~8 
--- 

--- 

--- 

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

----- 

30-90 

Section M7 - OTHER DEVICE PAGE -Continued 

9. When did you get your (currant) (implant in 3/4clT 1 

I19 

Month Year 

I 

IO. Please tell me if you have had any of the following.problems or complications I i q Yes - 1 

wlth your (current) (implant in 3/4c) - 1 20No> ,.n-, 

a. Have you had en infection? 1 g 0 DK) ’ ‘“w --------------------------------------------+--------------------

b. How long had you had your (implant in 3/4c) when the infection was first noticed 7 I oooonLess than 1 day 

T 

I lclDa~~ 5555 0 Lessthan 30 day6 

LWeeks OR sese[7 30-90 days Probe if DK: Was it less than 30 days, 30 to SO days, or more than SO days) I- 3OMonths 7777 0 More than 90 days 

I 

I 40Years 99990 DK --------------------------------------------~-------------------­

cm Have you had any healing problems? T--F 

---------------:---‘---------‘----------------~----~o~~L~~h~n~~y--------~ 

d. How long had you had your (Implant m 3/4cl when the heahng problem was 

first noticed? I 

I ,o Days 5555 0 Lessthan 30 days 

zl3’eeks OR asss~30-90 days 

Probe if DK: Was it less than 30 days, 30 to SO days, or more than SO days? .’ - 3OMonths 77770 More than 90 days 

4OYears 9999~ DK 

-------~~~--------~~~~~~~~---~~~~~~~~~~----- +--------------------

0. Have you had any problems with pain or irritation? t 

,109) 

-------------___------~~~~~~~~~~~~~~--------’ ----------~----- f. How long had you had your (implant in 3/4cl when the pain or irritation was first T---- E 

noticed? I ooooo Less than 1 day 

I , III Days 6555 0 LeSSthan 30 days 

I LlWeeks OR 6666[730-90 days Probe if DK: Was it less then 30 days, 30 to SO days, or more than SO days? 3ClMonths 77770 More than 90 days 

.I --I 40Years 999sn DK 

--------------_-----------------------------+-------------------- --_ g. Have you had any mechamcal problems with your (current) (implant in 3/4c) I I 0 Yes T Itself, that Is, it has not worked correctly? 

(lOi) 

------------------------------------------------+--------------------

h. How long had you had your (implant in 3/4cl when the mechanical problem T 

was first noticed? I oooon Lessthan 1 day 

,ODw 55660 LeSSthan 30 days 

Probe if DK: Was it less than 30 days, 30 to SO days, or more than SO days? I- LiWeeks OR 6666030-90 days 

3OMonths 7777 [7 More than 90 days 

i i,-~H~v~vo;?;~d~nr~~~m~~r~~~p~~~~o~~~------- --TTov,--- { 40Years _ ggss[7 DK 

TS6-

’ 2 0 No (Next column or next device) 

--------------------------------------------~-----------------------­

i- What were they? (1’ ( 

Record first three mentioned. Do notprobe. Be specific. (2) 1 

_____----________---------------------------~~~------------------~ 

Ask for each entry in 7Oj. I

I ooooi7 Lessthan 1 day 

T 

km $l~,Ioo:fsc~ha~ you had the (implant in 3/4c) when the (problem in IOjI was i I 0 Days 

2nWeeks OR 

66560 L6SSthan 30 days 

~33~ 30-90 days 

I

I (I)- 3 0 Months 77770 More than 90 days 

I 4 0 Years gsd DK 

---------------,80-~ 

Probe if DK: Was it less than 30 days, 30 to SO days, or more than SO days? I 

l oooon Less than 1 day 

I I 20Weeks 10 Days OR 666605550 Lessthan days 30 days

, (2) - 3 0 Months 77770 More than 90 days 

I 4 0 Years ssssn DK 

1 ----;o;o~;~s~;;d;-------l~~~ 

I 

I 1 0 Days 55550 Less than 30 days 

3nWeeks OR 6666~30-90 days 

I 13’- t 3 0 Months 77770 More than 90 days 

4 Cl Years cm& DK I 

I Go to next column or next device 
--------------------------------- 

I 11176 

- I e .A ) A A 

Section Nl - WORK HISTORY 

In this part of the sulvev I will ask about vour work exoerience. certain medical conditions and other health-related matters. 

1 a- First, I’ll ask about the KIND OF WORK you have done the 

LONGEST, not counting work around the house. Thinking of all 

the jobs or businesses you have ever had, what kind of work did 

YOU do the longest? Include work done while in the Armed Forces. 

b. When you were doing this kind of work, what were your Duties 

most important activities or duties? 

2% How long did you do this kind of work? cc q Less than 1 year 

Years 

+ b. How old were you when you started doing this kind of work? I 

I 

t 

I Age 

3a. In what kind of business or industry did you do this kind of I 

I industry ssz0Armed Forces - Civilian w 

work the LONGEST? For exampie, TVand radio manufacturing, I 94zuArmed Forces - Active duty 

retail shoe store, State Labor Department, farm. I 

-----------------------------.---- c -----~_~_-~~~~~_~----~-----~--- b. In the Industry where you worked the longest as a lentrym la) Class of worker Trr­ were VP” -

An employee of a PRIVATE company, business or 

individual for wages, salary, or commission? . . . _ _ _ _ . . . P 1OP 

A member of the Armed Forces? . . . . . . . . _ . . . . . . . . . . . AF znAF 

A FEDERAL government employee? . . . . . . . . . . . . . . . . . . F 3OF 

A STATE government employee? . . . . . . . . . . . . . . . . . . . . S 40s 

A LOCAL government employee? . . . . . . . . . . . . . . . . . . . . L 5OL 

Self-employed in OWN business, professional practice or 

farm? 

Ask: Is th’e business incorporated? 

Yes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..I 601 

No . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..SE 70SE 

Working WITHOUT PAY in family business or farm? . . . . . WP aclWP 

-i 

(CHECK 

IITEM 1 RefertoHiS-1, Cl: I q Wa/Wb box marked in Cl fCheck item 5A, page 381 

z 0 Neither Wa nor Wb box marked in Cl (41 

4-

&I- DURING THE PAST 12 MONTHS, that is, since172 month datela year I i q Yes 1 

ego, did you work at any time at a job or business not counting work 20No around the house? (Include unpaid work in the family business or farm.) ----____----___----

b. How long has it been since you last worked at a job or If less than 1 year I4cl 

E 

business? 

If 1 year or more 181 

iC. For whom did you work at your last job or business? Enter I 

name of company, business, organization, or other employer. 

---------------------------------i----------------------------------­

d. What kind of business or industry is this? For exampie, TVand 1 Industry 

radio manufacturing, retail shoe store, State Labor Department farm. I 

I ----:-----------r----------~-----~~~~~o~--------------------------~ 

8. What kmd of work were you domg? For example, eiectrrcai 

engineer, stock clerk, typist, farmer. 

--------------------------------~---------------------- _______~ f. What were your most important activities or duties at that job? 1 Dut’es 

For example, types, keeps account books, files, se/is cars, operates I 

printing press, finishes concrete. I ----------T-.---------------------L-----------------------------------

Complete from entrres m 4c-f. if not clear, ask: 1 Class of worker m 

9. Were you - I 

Ask: 

An employee of a PRIVATE company, business or 

individual for wages, salary, or commission? . . . . . . . . . . P 

I 

i 1OP 

AmemberoftheArmedForces? . . . . . . . . . _ . . . . . . . . . . AF I 2[7AF 

A FEDERAL government employee? . . . . . . . . . . . . . . . . . . F I 3OF 

A STATE government employee? . . . . . . . . . . . . . . . . . . , . S i 40s 

A LOCAL government employee? . . . . . . . . . . . . . . . . . . . . L ! 5ClL 

Self-employed in OWN business, professional practice or I 

farm? I 

I Is the business incorporated? I 

Yes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..I I 601 

No.........................................SE ; 7[7SE 

Working WITHOUT PAY in family business or farm? . . . . . WP ! 60wP 

164 
Section Nl - WORK HISTORY - Continued I 1 23-30 5. How long did you work as a (occuoation in 4el forlemoiover in 4clT 1 I 0 Weeks 

I z 0 Months 

I Number { 3 0 Years 

I 1 31 

CHECK Refer to 4e and la: I

I i q Occupation in 4e is same as in 1 a (81 

ITEM 2 I 

I 8 OAll others f6al 

6a. Considering ALL of your employers, for how many years i 000 Less than 1 year 

1 32-33 

altogether did you do this KIND of work? I 

I Years 

I -------------------------------------~-------------------------------

b. How old ware you when you started domg this kind of work? , -p--35 

I Age I 

7a. In what kind of business or industry did you do this kind of ; Industry 932 0 Armed Forces - Civilian 1 36-38 

work the LONGEST? For example, TV and radio manufacturing, 1 942 0 Armed Forces - Active duty retail shoe store, State Labor Department, farm. I 

I 

I ---------------------------------r----------------------------------­

b. Ware you - I Class of worker T-K I An employee of a PRIVATE company, business or I 

individual for wages, salary, 01 commission? . . . . . . . . . . P I 1UP 

A member of the Armed Forces? . . . . . . . . . . . . . . . . . . . . AF ) 2nAF 

A FEDERAL government employee? . . . . . . . . . . . _ . . . . . . F I 30F 

A STATE government employee? . . . . . . . . . . . . . . . . . . . . S / 40s 

A LOCAL government employee? . . . . . . . . . . . . . . . . . . . . L I SOL I Self-employed in OWN business, professional practice or I 

Ask: Is the business incorporated?. I 

Yes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..I 1 601 

No . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..SE I 70SE 

Working WITHOUT PAY in family business or farm? . . . . . WP I alIlWP 

Hand Card N I, read list if telephone interview. I [7 Stopped working because of own illness, injury, disability 1 4o 

8a. Which of these statements describe the reason or or other health problem that was JOB-RELATED. 

reaq;ons you stopped working ientry in 4bj ego? 2 0 Stopped working because of own illness, injury, disability 

or other health problem that was NOT JOB-RELATED 

Mark all that apply. I 3 0 Retired E 42 

4 0 Child/family care 

farm? I 

I 

5 0 On layoff from a job E 

I 

I s q Some other reason - Specify 3 46 

I 

I 

I 

I snDK pii- 1 47 CHECK 1 q Box 1 marked in Ba (8b) 

ITEM 3 Refer to 8a: s q All others (Check /tern 41 

I 

8b. Was a worker’s compensation claim filed for your illness, injury, i lOYes 1 

dlrabllity, or other health problem? I z 0 No (8dj 

-___---___---~-__-_______________L______------------------------- _-­

c. Have you received any money or other benefits from worker’s 1 lOYes T 

compensation alnce you stopped working (entrv in 4b) ago? I 20 No I _---------------____------------~--------------------------------

d. Was a claim filed for any other income or benefits because / 1q Yl3S~ m 

your health problem was job-related? I 2[7 No I 

I 

CHECK Refer to question 4. I I 0 “Armed Forces-Active Duty” in 4c (Section N7, page 56) !-.?!-

ITEM 4 Mark first appropriate box: I 

I 2 0 “Yes” in 4a (Check Item 7) 

I a q All others (Section N7, page 56) I 

Votes 

PM HIS-IA l1s36l110-23.67, 
--------------------------------- 

Section Nl - WORK HISTORY - Continued 

I ) CHECK 1 I [7 Self respondent for questions 6b-g (Check hem 5B) 

Refer to HIS- 1, pages 44 and 45: I 20 Proxy respondent for questions 6b-g 191 ITEM 5A 1 s 0 All others 191 

I 

9a. For whom were you employed during the 2 weeks outlined in ) Employer 932 0 Armed Forces - Civilian 

1 

red on that calendar? Enter name of company, business, 

I 

I 942 0 Armed Forces - Active duty > (90) 

organization, or other employer. 

I 

L--------------------------------+-.­

b. What kind of business or industry is this? For example, TVand 1 Industry 

radio manufacturing, retail shoe store, State Labor Department, I 

farm. I 

_______-------------------------- L------------------w-------w 

F 

If “Active duty” in 9a, mark “AF” box without asking. I 

I Occupation 942 0 AF (Section N8, page 59) 

I c . What kind of work were you doing? For example, electrical I 

engineer, stock clerk, typist, farmer. ______---------------------------~----------------------------------~ 

d. What ware your most important activities or duties at that job? 1 Duties 

For example, types, keeps account books, files, sells cars, I 

operates printing press, finishes concrete. I 

----_____________________________L______-------------------------

E 

Complete from entries in 9a-d. If not clear, ask: 1 Class of worker 

8. Were you -

An employee of a PRIVATE company, business or 

Individual for wages, salary, or commission? . . . . . . . . . . P 1OP 

A member of the Armed Forces? . . . . . . . . . . . . . . . . . . . . AF 1 20 AF (Section N8, page 59) 

A FEDERAL government employee? . . . . . . . . . . . . . . . . . . F \ 30F 

A STATE government employee? . . . . . . . . . . . . . . . . . . . . S I 4 0 S 

A LOCAL government employee? . . . . . . . . . . . _ . _ . _ . . . . L I 50 L 

Self-employed in OWN business, professional practice or farm? 1 

I Ask: I5 the business incorporated? I 

Yes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..I I 601 

No . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..SE ’ 70SE 

Working WITHOUT PAY in family business or farm? . . . . .WP i 8OWP 

1 Transcribe from questions 9a and c or from 86/c and e on HIS- 1. 

I 

CHECK Refer to questions 9a and c or to HIS- 1, 

I 

I 

I 

Employer @rn ITEM 5B pages 44-45: 

I 

I 

I Occupation 1. I 

Rf. (You told me that during the two weeks outlined in red on that j I 0 Weeks ( 

calendar you were employed as a (occupation in Check Item 5B) 

for (employer in Check hem 58.)) How long have you worked as a 1 2 0 Months 

(occupation in Check Item 5B) for (employer in Check Item 5B)? , Number 3 3 q Years 

! 

CHECK i I 0 Occupation in Check Item 5B is same as in 1 a (Check/tern 7) ) 

ITEM 6 Refer to Check Item 58 and question la: 1 s [7 All others (9gI 

I 

I 99. Considering ALL of your employers, for how many years I oo q Less than 1 year m 

altogether did you do this KIND of work? 

I 

I Years 

------------------_______________ +------------------------------

h. How old were you when you started doing this kind of work? I Tiiij-7ii 

I 

Age ---------------------------------c-------------------------------­

j. In what kind of business or industry did you do this kind of 1 Industry 932 q Armed Forces - Civilians 

work the LONGEST? For example, Nand radio manufacturing, I 942 0 Armed Forces - Active duty retail shoe store, State Labor Department, farm. I 

I 

---__-_--________________________ ~-------------------------------~ 

j. Were you - I Class of worker 

An employee of a PRIVATE company, business or I 

individual for wages, salary, or commission? . . . . . . . . . . P I 1 0 P 

AmemberoftheArmedForcer? . .._................ AF I 3flAF 

A FEDERAL government employee? . . . . . . . . . . . . . . . . . . F ; 30F 

A STATE government employee? . . . . . . . . . . . . . . . . . . . .S ’ 40s 

A LOCAL government employee? . . . . . . . . . . . . . . . . . . . . L I 5OL 

Self-employed in OWN business, professional practice or farm? 1 

I 

Ask: I5 the business incorporated? I 

Yes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..I I 1301 

No . . . . ..‘...................................SE 1 70SE 

Working WITHOUT PAY in family business or farm? . . . . .WP / B 0 WP 

1 

166 
--- 

--- 

Section Nl - WORK HIsTORY - Continued 

I II 1 72 

CHECK Refer to Check Item 58. 

ITEM 7 

I I 0 Entry in Check Item 58 

I (Transcribe entries) 

1 s 0 All others (Transcribe 

I entries from 4c and e) 

I 

Employer 

Occupation 

/IO) 

These next questions are about your job as a (occupation in 

Check Item 7) for (employer in Check Item 71. 

I 

I 

I 

73 

--I 

1UB. Did your job require you to do REPEATED STRENUOUS 

PHYSICAL ACTIVITIES such as lifting, pushing or pulling 

heavy objects? 

I 

I iUYes 

I 20No/77) 

--------------------------------7----------------------------------- 74-76 b. During a typical work day, how many minutes or hours I 

l 

I 0 Minutes altogether did you spend doing STRENUOUS PHYSICAL 

ACTIVITIES? I Number 2 0 Hours 

I > 

I 1 a. Did this job require you to do REPEATED bending, twisting ) , q Yes 1 77 

or reaching? 1 zuNo (72) 

___----------~---_-----~---- ----I-------------------------- i8~8~ I b. During a typical work dayi how many minutes or hours I I 0 Minutes altogether did you spend bending, twisting or reaching? I 

I Number 2 0 Hours > 

I 2a. Did this job require you to BEND or TWIST your hands rUYes 

1 81 

or wrists MANY TIMES AN HOUR? 20 No (73) 

--------------------------------+--------------------------~-------- I I 82-84 b. During a typlcal workday, how many minutes or hours I I 0 Minutes altogether did you spend bending or twisting your 

i Number 2 0 Hours hands or wrists? > -I 

I&t. On this job, did you work with hand-held or hand-operated I , q Yes 

vibrating tools or machinery? 1 20No(741 

--------------------------------$---------------------------------

b. During a typical work day, how many minutes or hours I I 0 Minutes altogether did you spend working with hand-held or I 

hand-operated vibrating machinery? I 

I Number > 2 0 Hours 

14. I am going to read a list of substances that some people get i 

on their skin AT WORK. Tell me if you got any of these 

things on your HANDS or ARMS at your job as a (occupation 

in Check /tern 7) for (emplover in Check Item 7) DURING THE 

PAST 12 MONTHS - 10 Yes 

20No a. Did you get solvents or degraasers on your hands or arms? 

_________--_______--___----_----1-------------------------------

I b. Petroleum products other than solvents? For example, I i q Yes 

grease, oil, or fuel? I 20No 

--------------------------------$---------------------------------

C. Soaps, detergents, or cleaning and disinfecting solutions I 1 q Yes used in performing your job? 1 20No 

--------------------------------f------------------------~---------- I 

d. Cuttlng oils, machine coolants, or metal working fluids? ) 1q Yes x 

znNo 

-------.--------------:----------i-;o;,--------------------------~ 

8. Paints, varmrhes, lacquers, or other coatmgs? 

20No 

--------------------------------J-------------------------------­

f. Glues, pastes, or other adhesives? 1 I q Yes m 

zuNo -------__-------__-------------- i------------------------------- --_ g. Acids or alkalies? I lOYes -L?!L 

: 20No --------------------------------+-------------------------------

h. Pesticides, insecticides, herbicides, fungicides, or 1 1q Yes fumigants? I 20No 

-----------___------------------i------------------------------­

j. Foods or food products handled as part of your job duties? I lOYes 

1 20No 

--------------------------------T----------------------------------­

j. Plants, trees or shrubs handled as part of your job duties? 1 1q Yes ; 20No 

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

k. Did you get any other chemicals or substances on your I 

I i Cl Yes - Specify 3 89 

hands or arms that could irritate the skin? I 

I -I 

I 

I 20No 100-101 

1 snDK cl 
1 3-4 Section N2 - BACK PAIN 

I 1 6 These next questions are about back pain. I 

I i q lYes 

1ft. At any time during the past 12 months, that is, since 112 month I 2 [7 No (Section N3, page 43) Etrzar ago, dad you have back pam every day for a week I 

I 

1 I

CHECK I I 0 SP is female under 50 (Ibl 

ITEM 8 Refer to sex and age: I 

I a 0 All others 121 

I I 1 

b. Did you have this back pain ONLY at the time of your monthly I 1 q Yes (Section fV3, page 431 

periods? z q No 

I 

I 3 c] Don’t menstruate 

!a. (The remaining questions are about back pain other than I sss aMenstrual pain only (Section N3, page 431 ) 

menstrual pain.) 3650 Every day During the past 12 months, on about how many days I 

altogether did you have back pain? I- Days 

___-_________-____---------- -----I-------------------------------

F 

D. During the past 12 months, how many full days did you 1 0000 None 

miss from work because of back pain? I 

I Days I 

I w I 

I i 0 Upper 

%a. When you had this back pain, what PART of your SACK I 2 [7 Middle 

bothered you the most - the upper back, the middle back or I 

I 3 0 Lower 

the lower back? ----_------------_------~------~~l I----------------------------------­

b. During the past 12 months, dld the back pain ever I 

spread to your: I Yes No DK I 

buttocks? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..I I 0 20 90 16 

thighs? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..I I 0 20 90 16 

lower leg or foot? . ..__........_._................_... 1 1.0 20 90 Is 17 

%a. Did any of the back pain you had in the past 12 months 

result from a SINGLE accident or injury? Some examples 

I 

I 

I I q lYes 

m 

are slipping, falling, twisting, lifting something, or being in I 2 ON0 (5) a cer accident. ___-___-____________------------- k-------------------------------­

b. When did the accident or injury happen? -@ 

! II 19- I Date Year ---------------------------------t--------------------------------- Month 

G. Were you at work at your job or business when the accident or I q Yes m 

injury happened? I 2 c]No (51 -------------y------------mmms--- L------------------------------- _-_ 

d. Was this at your job as a Joccuoation in Check Item 7) for I 

I I q lYesf51 .lL 

[emolover in Check Item 7)? I z[7No _---__--_________________________ +---------------------.~~~~--ddd~ AA 

8. For whom did you work when the accident or injury happened? I Employer 932 0 Armed Forces - Civilian ,4g, T 

Enter name of company, business, organization, or other employer. I 0

I 942 Armed Forces - Active duty 

I---- -__-----______-_____---------~ 

f . -~h~t~~~‘of~~~~~~~~~t~~~~s~Forexamp/e.TVan~-- I Industry 

radio manufacturing, retailshoe store, State Labor Department, farm. I

I -----------r--------------------- I ----_____________________i -__ 

g. What kind of work drd you do at that job? For example, TZGpX% w electrical engineer, stock clerk, typist, farmer. I

I

I -L-------------------------------~----------------------------------­

jy. What were your most important activities or duties at that ) Duties 

job? For example, types, keeps account books, files, sells cars, I operates printing press, finishes concrete. I 

-------------___---_______ -------i---.----------------------------

Complete from entries in 4e-h. If not clear, ask: 1 Class of worker pJ 

i. Were you -

An employee of a PRIVATE company, business or individual 

for wages, salary, or commission? . . . . . . . . . . . . . . . . . . . . P 

A member of the Armed Forces? . . . . . . . . . . . . . . . . . _ . . . AF 

A FEDERAL government employee? . . . . . . . . . . . . . . . . . . . F 

A STATE government employee? . _ . . . . . . . . . . . . . . . _ . . S 

I 

I 

I

I 

1020 

3040 

P 

AF 

F 

s 

A LOCAL government employee? . . . . . . . . . _ _ . . . _ _ _ . . . . L I so L 

Self-employed in OWN business, professional practice, or I 

farm? 

As;~! the business incorporated? 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 

I 

I 

I 601 

No . . . . . . . . . . . . .._........_... . . . . . . . . . . . . . . . . . . SE / 70SE 

Working WITHOUT PAY in family business or farm? . . . . .WP I 8clWP 

L 

168 
--------------------------------------------------------------------- 

Rn.-+inn Nu3 - RAPK DAIN - P....+:....sA WY"..".. ,mL - I-V.. . Pm... - Y" . . . ..I "W" 

ig. Was any of the back pain you had in the past 12 months 1 

brought on by REPEATED activities such as lifting, pushing, 1q lYes 

pulling, bending, twisting, or reaching? z q ]No 171 

* --------~-------____~~~---------~ I------.------------------------- ___ 

b. Where did you perform the activities that brought on your I I 0 At work (6) -Lx 

back pain? Mark only one box. I z 0 At home 

I 

I 3 Cl Recreational site (8) I s 0 Other - Specify J 

I 

I 

I 

I 

hl. Was this at your job as a occuoation in Check item 7)for I I IJYes (8) 1 

(employer in Check Item 717 I znNo 

--------------------------_______I______------------------------­

b. For whom did you work when the accident or injury I Employer ssz 0 Armed Forces - Civilian 

happened? 9.42 m Armed Forces - Active 

Enter name of company, business, organization, or other employer. 

I 

g. Whet kind of business or Industry is this? For example, TVend 1 Industry 

radio manufacturing, retail shoe store, State Labor Department, farm. 

I 

I 

I 

---_____-------___-_~~~~-----~~~~ I~~-----~~~~~~---~~~--------~~~ ___ 

d. What kind of work did you do at that job? For example, 1 Occupation b 

electrical engineer, stock clerk, typist, farmer. I 

I 

I 

I --------~~___----~~~~~~~~~------- ~~~_____----~__-_----~-~~ t--.-------­

g. What were your most important activities or duties at that I Duties 

Job? For example, types, keeps account books, files, sells cars, I 

operates printing press, finishes concrete. 

---------T-,---~-----------------~------------------------------- ___ 

Complete from entries m 6b-e. If not clear, ask: I Class of worker -IA!­ I f. Were you - I 

I 

An employee of a PRIVATE company, business or individual 

for wages,ralary, or commission? . . . . . . . . . . . . . . . . . . . . P 

A member of the Armed Forces? . . . . . . . . . . . . . . . . . . . . . AF 

A FEDERAL government employee? . . . . . . . . . . . . . . . . . . . F 

A STATE government employee? . . . . . . . . . . . . . . . . . . . . S 

A LOCAL government employee? . . . . . . . . . . . . . . . . . . . . . I. 

Self-employed in OWN business, professional practice, or 181 

farm? 

A&e! the business incorporated? 

e........................................... , 

No . . ..a........................................ SE 

Working WITHOUT PAY in family business or farm? . . . . .WP 

If “Yes” in 4a, go to 8. k 

7. Whet caused your back pain? I 

I 

I 

I 

I 

;a. Hos your back bothered you today? I 

I I q lYes f&l 1 

I 20No I 

~____~~~~~~~_____~~~_____________L______-~-~~~~~~~~--~~ _____ ___ 

c. For how many consecutive days, weeks or months [did your 1 T 

back bother you that time/has your back been bothering you]? , 

I 

I 

I Number 

I 

I 

Notes 

il HIS-IA 118331110.23.37l 
Section N2 - BACK PAIN - Continued I 

ga, In what year did you first have an episode of back pain that 

lasted for a weak or more? 

I 0 Earlier year - Specify 3 

I 

---:----.----------r--------------~------------------------------~ 

b. Countmg (year In 9a), in how many drffarant years have 

you had episodes of back pain lasting for a weak or more? Years 

I 

I 0 1 month, less than 3 months 

C. What was the longest period of time that you had back pain I z 0 3 months, less than 6 months 

every day? I 3 0 6 months, lass than 12 months, 

4 0 1 year, lass than 5 years 

I 6 0 5 or more wars 

Oa. Have you avar stopped working at a job or changed jobs I 

I 

1 0 Yes fSection N31 1 

because of back pain? 1 znNo 

--------------------_____________I______----------~--~~~~--~~~--- -_ 

7 b. Have you aver made a major change In your work activities 1 1 q lYas 

because of back pain? I ZUNO 

I 

Notes 

FORM HI-SlA f19991 HO-23.t 

170 
------ 

Section N3 - HAND DISCOMFORT I 

Now I will ask some questions about your hands 

I 

I I 0 Left, handed 

] 60 

and wrists. 

I. Are you left handed, right handed or able to use both I 

I z q Right handed 

hands equally well? I 3 0 Able to use both hands equally well 

2. Which hand do you use most et work? I 

I i q lLeft 

1 60 

I z 0 Right I 

I 3 0 Use both hands equally 

I 1 3. During the past 12 months {that is, since 112 month data) a I year ago}, have you had discomfort in your hands, wrists or I lOYes 

fingers? Discomfort can mean pain, burning, stiffness, I 2 0 No .(Section N4, page 46) 

numbness or tingling. I 

I 

4. Was this discomfort due entirely to an injury, such as a I- I 0 Yes (Section N4, page 46) 1 

cut, sprain or broken bone? I 20No I 

I snDK 

ig. During the past 12 months, on about how many 

I 

I (BB-Bb 

days altogether did you have discomfort in your ooo 0 Less than 5 days (Section N4, page 46) 

hands, wrists or fingers? 

Days 

365 0 Every day (6) 

----------------_----------~----~ +----------------------------- ___ 

b. During the past 12 months, did you have the discomfort I lOYes -LA!L 

every dey for a week or more? I 

I 20No I 

I 1 67 

CHECK Refer to 5a and 5b: i Cl20 or more in 5a 16, 

ITEM 9 Mark first appropriate box 2 0 “Yes” in 5b 1 

8 0 All others (Section N4, page 46) 

6. in which hand did you have this discomfort? I 

t 

i 0 Left ] 06 

I 

I 2 0 Right I 3 0 Both I 

7 - Was your discomfort worse when you were trying to .I lOYes 

] 69 

sleap or did it awaken you from sleep? I 20No I 

J 70 8. In the past 12 months, did your hands or fingers often 

feel clumsy, that is, did you often have difficulty picking lOYes 

up or holding things? 20No 

18. Has your hand(s) bothered you today? I i Cl Yes (3c) 1 71 I 20No 

----A--------------------------- L---------------------~~~~~~~~~ ___ 

b. :tv: rn;~~i~~~Lfyti;ks or months ago did you last I 1 0 Days ago 

J 72-71 

I 

I 2 0 Weeks ago 

I 

Number 1 3 0 Months ago 

---------_______----____________ ~~~~s-------- --7i6~7i -r--------­ o - For how many consecutive days, weeks, or months [did l 

your hand(s) bother you that time/he8 your hand(s) I 

been bothering you]? I Number 3 17 Months 

I 1 4 0 Years 

la. In what year did you first notice this hand discomfort? 1 

I 

8701987 

1 

I esn1988 1111 ) 

1 ssn1989 1 

I 0 Earlier year - Specify 7 

I 

-------------------_-------------~-----------~------------------- ___ 

b. Counting ( ear in 1Oa), in how many different years has I 

I ti 

your hand I) bothered you? I Years I 

I a. During the past 12 months, were you away from work lOYes 

1 

for more than one week for any reason7 

2 0 No 1721 

~~~~-~~~~~----__-------~~~~~~~~~~ ‘--o;~e~s~--------------------E 

b. When you were away from work for more than one I 

week, did your hand discomfort increase, decrease, or 

stay the same? 2 0 Decrease 

3 0 Stay the same 

I. During the past 12 months, did you miss at least a full 1 

day from work because of your hand discomfort? iClYes 

znNo 

171 
Section N3 - HAND DISCOMFORT - Continued 

I 1%. Have you EVER stopped working at a job or changed jobs I 

I I q lYes 114) because of your hand discomfort? I zaNo I 

I 

---------------------------------t--------------------------------­

b. Have you ever made a major change in your work activities I I q Yes l-Ybecause of your hand discomfort? I z[7No 

j4a. How long has it been since you last saw or talked to a I ( 

medical doctor, chiropractor, physical therapist or other I ooo 0 Never saw medical person (75) 

medical person about your hand discomfort? I 

I I 0 Days 

I z q Weeks 

I Number 3 0 Months 

I 4 q Years I 

I ---_----------------------------- L---------------------dvssd---.-­

b. What did the medical person call your hand discomfort? I 

I piI 

1 

j 5. Even if you have mentioned it before, please tell me if you I 

I 

have EVER had any of the following conditions - Yes No DK I 

I Sl a. Arthritis of the hand, wrist or fingers? . . . . . . . . . . . . . . . . . 1 10 20 90 

b. A broken bone in your hand, wrist, or fingers? . . . . . . . . . . . 1 I 0 z q 9 [7 E@2 

c. A condition affecting the wrist and hand called I carpal tunnel syndrome? . . . . . . . . . . . . . . . . . . . . . . . . . . . I 1Cl 20 90 I 

I 

. 

172 
---------- ----- 

Section N4 - WORK INJURIES 

Now I will ask about on-the-job injuries in the past 12 months. ’ 

I Hand Card N3 I 

By “on-the-job injury” we mean an injury at work that resulted In i 

at least one of the following: 

an injury that required you to get medical attention or treatment, , 

I 

other than first aid for MINOR INJURIES; OR to be unable to do I 

some of your work activities; OR to lose consciousness; OR to I 

transfer to another job. I 

I 

I 

1. DURING THE PAST 12 MONTHS, that is, since (12 month date) a 1 1OYes 

year ago, have you had any on- the- job injuries? I z 0 No (Section N5, page 521 ) 

2. How many times have you been injured on the job during I 

I 

1 

the past 12 months? I 

I Number of times I 

3. On what date did your [(moat recent) injurY/injury before 1 

that] happen? 

Enter each date in a separate column. -TGi+ -Tib lg- Year 

Complete questions 4-21 as appropriate for the first injury before completing them for the next, etc. 

I k 4. At the time of your injury on (date in 3) were you working as a 1 I q Yes (6) (occupation in Check Item 7) fmyer in Check Item 7) 1 I z0No I 

6B. For whom did you work when the injury happened? I Employer 932 0 Armed Forces - civilian 15cl 1 

I 

Enter name of company, business, organization, or other employer. 1 942 0 Armed Forces - active duty > 

I 

---------------------------------L______-----------------------------

D. What kind of business or industry is this? For example, TVand 1 Industry 

radio manufacturing, retail shoe store, State Labor Department, I farm. I 

I 

I 

~~~~~~~~_-------~_--------------- +)cccipTton - ---------~ 8. What kind of work did you do at that job? For example, electrical I 

engineer, stock clerk, typist, farm. I 

I 

I 

I 

I 

~-~------------_-_---~-------~~~~ ‘&----------- _______-----_____---____ d. What were your most important activities or duties at that job? I Duties 

For example, types, keeps account books, files, sells cars, operates 

printing press, finishes concrete. I 

I 

I 

I 

----------~~--------------L-------~-------------------------------

Complete from entries m 5a-d. If not clear, ask: I Class of worker E 

9. Were you - I 

I 

An employee of a PRIVATE company, business or individual 1 1 UP for wages, salary, or commission? . . . . . . . . . . . . . . . . . . . . .P 

AmemberoftheARMEDFORCES? . . . . . . . . . . . . . . . . . . . .AFI 2 OAF 

A FEDERAL government employee? . . . . . . . . . . . . . . . . . . . f 30F 

A STATE government employee? . . . . . . . . . . . . . . . . . . . . . . S 4cls 

A LOCAL government employee? . . . . . . . . . . . . . . . . . . . . . . L \ SOL 

Self-employed in OWN business, professional I 

practice, or farm? I 

ASK+F3sthe business incorporated? I 

I ,**...................................... 6 cl1 

No . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..E 1 7 USE 

Working WITHOUT PAY in family business or farm? . . . . . .WP 1 9 q IWP 

6. At the time of this injury: what part of your body was hurt? i Part(s) of body 1 24-26 1 Kind of Injury 1 

What kind of injury was It? Anything else? I 

I 

I 

I 

I 

I 

I 

I 1 29 7. Did you lose consciousness as a result of the injury? I 

I 1 q Yes 

I 

I 20No 

I 

B. What were you doing at the time of the injury? 1 29-30 

9 9 How did the injury happen? 1 

Go to 10 for this injury 

FORM HIS-,A ,1mJ*,110.23.t 
--------------------------------- 

Section N4 - WORK INJURIES - Continued 

0 b 

j 0. Was the activity you were doing at the time of I i q Yes (721 

the injury a NEW or unfamiliar job task? I znNo 

I 

j I. Was the activity you were doing at the time of the injury I 1q Yes I 

part of your usual job tasks? I 

I znNo 

( j 2. Did you see or talk to a medical doctor, nursa, chiropractor, I I OYes physician’s assistant, nurse practitioner or other medical I 

person as a result of this injury? I 2 0 No Kheck Item 101 

I 1 

j 3. Where did you FIRST see or talk to a medical person I 1 0 Work-site health unit 

about this injury? I 

I 2 0 Doctor’s office (group practice 

I or doctor’s clinic) 

I a q Emergency room I 

I 4 0 Walk-in clinic 

I 6 0 Hospital outpatient clinic 

I 8 0 Other - Specify 7 

I 

I 

CHECK 

ITEM 10 Refer to question 6: 

I 

I 

I 

I 

I 

I 0 “Eye” in 6 174) 

8 0 All others (751 

( 

I 

I4a. Were you wearing eye protection equipment over your I 

I I q lYes L2L 

eyes at the time of the injury? I 

I 2 [7 No (151 

I --------------------------------r----------------------------------­

b. What type of eye protection equipment were you wearing? I I 0 Welding goggles E 

2 q Other goggles 

3 [7 Glasses with side shields 

4 q Glasses without side shields 

I 5 0 Welding helmet 

I 

I 8 0 Face shield 

I a [7 Other I 

I I&. Did you miss more than half of the day from work on the I 1 q lYes 1 

day of the injury? I 

I 20No 

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

b. OTHER THAN THE DAY OF THE INJURY, how many FULL .I 

T?;I;; 

days of scheduled work did you miss as a result of the Injury? I Full days 

I ooonNone ------------------------i------------------------------------------

I E o. (Not counting the (number in 75bl full days), Did you I i q lYes 

miss any (other) scheduled time from work other than I 

I 2 [7 No (76) the day of the injury? I ----------_--__--________________ +------------ -----------___dd___ + . 

d. (Again, not counting the (number in 75b) full days), How meny ; -& 

days did you miss MORE THAN HALF THE DAY from work as a - Days 

result of the injury? I 000 ONone 

I6a. Were you temporarily transferred to another job because I 

I I q Yes 117) 

m 

of the injury? I 20No I

I ---------______~__----------~--~- +----------- -------------------d 

b. Were you temporarily assigned lighter work or excused from I 

I t q Yes D 

certain duties at work other than the day of the injury? I 20No 

I 7a. Did you report this injury to your employer? I 

I i q Yes 1 

I 20No I 

i------------------------------­

z b. Was a worker’s compensation claim filed as a result I I q Yes 

of this injury? t 20No 

I 

I I6a. Did you change employers as a result of the injury? I i q Yes 

1 20No 1791 

I ---------------------------------~------------------------------­

b- Was your salary lower, higher or the same after your change of , 1 Cl Lower T’;il’ 

employers? ! 2 0 Hiaher I 

i sOSame 

------------____----------------- +------ ______-------------------

C. Were you as satisified, less satisified or more satisfied with I 0 As satisified T-;;;’ 

your new employer as with your employer prior to the injury? I 

1 2 q Less satisfied I1 9 for this injury) 

I 3 0 More satisfied 

174 
------------------------ 

Section N4 -WORK INJURIES G Continued 

I 

I9t1. Did you change the kind of work you do as a result of the injury? ; 1 q lYes 

I z 0 No (Check /tern 7 II 

-~--~b;~o-a~k~ t--ooYeSmlB,ng,l------- ____--_______ T-seb. Was your salary lower, higher or the same after your job change? I I q Lower 

I z 0 Higher 

---------------------------------+-------------~----------~------ I 3 0 Same ___ 

with your new job as with your job prior to the injury? I 

I 

I 

I 0 As satisified 

2 0 Less satisfied 

I 3 0 More satisfied 

CHECK Refer to 18a and 19a: 

ITEM 11 1 

I 

I 

I

I 

I 

I 0 “Yes” in 18a OR 1 ga 127) 

s 0 All others 1201 

1 

!O. Did you make a permanent change in your work activities 

because of this injury? 

I 

I 

I I UYes 

.k 

I z0No 

!I. Did you change your off-the-job activities because of this injury? 1 

I 

I q Yes 

z0No 

1 

C- Were you as satisifed, less satisfied or more satisfied I T 

CHECK 1 

ITEM 12 Refer to question 2, section N4: I 0 Additional injury (4 for next injury) 

8 0 All others Eection N5/ 

Notes 

FORM H&1A,19881110.i3-8; 

175 
-- 

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

-

I RT78 

Section N5 - SKIN CONDITIONS 1 

Now I will ask about skin conditions. 

I ( 

a. During the past 12 months, that is, since I12 month date) a 

I

I 1q lYes 

year ago have you-had dermatitis, eczema, or any other red, I 

I 2 0 No (Section N6, page 541 

inflamed skin rash? ---------------------------------~-------------------------------

b. During the past 12 months, on about how many days i 385 0 Every day J& 

altogether did you have a skin condition? Include days I when you used treatment for the condition. 

I 

I Days 

. What parts of your body were affected by this skin condition? i I aHands a 

Mark all that apply I 

I 

I 

I 

s 0 Head, face or neck 

s 0 Other body area - Specify 3 

11 

E 12 

I 

I 9nDK 1 

. During the past 12 months, did you miss at least a full day I 

I 1q Yes m 

I z 0 Arms 10 

from work because of your skin condition? I 20No I 

6 g. Did any skin condition you had in the past 12 months result I 1 clYe.9 b 

from chemicals or other substances which got on your skin? I 20No I 

I 9nDK 1 f61 ---------------------------------+-------------------------------

b. What chemicals or other substances were these? I m I 

I 

I 

I 

-----_--------------------------- c-------------------------------~ 

c. Did you get these substances on your skin during the past I 

I 1 q Yes 

12 months? 20No 

---------------------------------~-------------------------------

d. Were you at work at your job or business when you got I 1q Yes 7-10‘ 

these substances on your skin? I 

I 20No 

I s[7DK 1 (” 

8. Was this at your job as a (occupation in Check Item 7lfor I 

I I OYes IS) ) 

(employer in Check Item 7R 20No 

L~~~~~------~~~~------~~ 

b. For whom did you work when you got these substances 1Employer s32uArmed Forces -,,ig-----T1;(­ on your skin? Enter name of company, business, I 9420Armed Forces - Active duty 1 organization, or other employer. I 

I 

I 

----T----,---T---7-,---------------~,~d~s~~-----------------------------~ 

C. What kmd of busrness or rndustry 15 thus? For example, TVand 

radio manufacturing, retail shoe store, State Labor Department, I 

farm. I 

---------------------------------~-------------------------------

d. What kind of work did you do at that job? For example, I Occupation m 

electrical engineer, stock clerk, typist, farmer. 

-----------1------TT~---~--------~D~~e~--------------------------------

0. What were your most rmportant actwmes or duties at 

that job? For exampie, types, keeps account books, files, I 

sells cars, operates printing press, finishes concrete. I 

I 

-_-----______-------_____________L______-------------------------

F. Were you - 1Class of worker E 

I 

An employee of a PRIVATE company, business 

individual for wages, salary, or commission? 

or 

. . . . . . . . . . . _ P 

I 1OP I 

A member of the ARMED FORCES? . . . . . . . . . . . . . . . . . _ . AF I 2nAF 

A FEDERAL government employee? . . . . . . . . . . . . . . . . . . . F I 30F 

A STATE government employee? . . . . . . . : . . . . . . . . . . _ _ . S i 40s 

A LOCAL government employee? . . . . . . . . . . . . . . . . . . . . . L , SOL 

Self-employed in OWN business, professional I 

practice, or farm? I 

I Ask: Is the business incorporated? 

Yes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..I [ 601 

No . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .._. SE I 70SE 

Working WITHOUT PAY in family business or farm? . . . . . WP ) 8[7wP 

a- During the past 12 months, did you use any prescription 1 OYes 1 

medications or other treatments prescribed by a doctor for 2[7No your skin condition? 

---_~_--~~------~~~-~~~~--~~~~~~~ ~-------------------------------~ 

3. Did you use any over-the-counter or non-prescription I 

medications or treatments for your skin condition? I 1 lJYe.9 

I 

I 20No 

I 

I 

FORM HIS-lA W80 ll&l%l 

176 
--- 

Section N5 - SKIN CONDITIONS - Continued 

7fl. How long has it been since you lest saw or talked to a coo 0 Never 

1 

dermatologist or skin specialist about your skin 

condition? I 0 Days 

z 0 Weeks I 

I Number 3 0 Months 

I 4 0 Years . ___--_~-~~---------_-~~~~~~~~~~~- f-------------------------------

D. How long has it been since you last saw or talked to I ooo 0 Never G 

any other type of medical person about your skin I 

condition? I 

I f I 0 Days 

I 

I 

I Number 

I \ 4 0 Years 

I 

8a. During the past 12 months, have you stopped working at a i I 0 Yes (Check Item 13) 36 

job or changed jobs because of your skin condition? I 

I 20No 

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

D. During the past 12 months, did you make a major change I 

I 1 OYas T-E 

in your work activities because of your skin condition? I 20No 

1 CHECK I 

I I 0 “Yes” in 4d (9) 

ITEM 13 Refer to question 4d: I 

I s 0 All others (Section N6) 

I I 

9. During the past 12 months, did you report your skin condition 1 i q lYes 39 

to your employer as a work-related illness or injury? I 

I 20No 

0. During the pest 12 months, was a worker’s compensation 1 

1q Yes 1 

claim filed for your skin condition? I 

I 20No 
Section ___.._ ~~~~~ N6 - EYE. ~~~.~~ NOSE. _ THROAT IRRITATION - Continued

I 1 9la. Did you have these symptoms while you ware at I

I i q Yes 

work? I 20No(lO) 

______-----_______--------------- k-------------------------------

T- b. When you were away from work, did these symptoms I 

I 

I Cl Increase 

increase, decrease or stay the same? I 2 0 Decrease 

I 3 0 Stay the same I 

I h 1 0. During the past 2 weeks when you had these symptoms, I 

I 1q Yes 

did you also have a fever? I 20No I 

Nlotes 

, 

178 
Section N7 - CONDITIONS 

I am going to read a list of medical conditions. Tell me if you 

have had any of these conditions even if you have mentioned I 

I them before. I 

I 

. DURING THE PAST 12 MONTHS, that is, since 172 month date) 1 

a year ego, have you had -, I Yes No I 

a. REPEATED trouble with neck, back or spine? . . . . . . , . . . . . . . . i 1 0 - Specify 3 20 1 

I 

I 

I 

b. A condition affecting the wrist end hand, called carpal tunnel I 

syndrome? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 10 20 1 

g. A condition affecting the fingers and/or toes, called Reynaud’s i 

(Rii’nEdes) phenomenon?. . . . _ . . . . . . . . . . . . . . . . . . . . . . . _ . . I I 0 20 1 

I 

d. A condition affecting the tendons called tendonitis?. . . . . . . . . . . / 1 0 20 1 

DURING THE PAST 12 MONTHS have you had -

G. Hepatitis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 10 2.0 i 

f. Skin cancer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..I 10 20 1 

g.l.ung cancer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..I IO 20 

h. Asthma? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ 10 20 E 

f. Chronic bronchitis? . . . . . . . . . . . . . . . . . . . . . . . <. . . . . . . . . . . 1 I 0 20 1 

j. Emphysema? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . / 1 IJ 20 1 

k. Any dust disease of the lungs, such as silicosis, asbestosis, 

brown lung, or black lung disease? . . . . . . . . . . . . . . . . . . . . . . . . i i 0 - Specify 7 20 1 

I 

I 

I 

I 

!. Do you NOW heve - Yes No 

a. Deafness in one or both ears? ICI 20 1 

I b. Any other trouble hearing in one or both ears? I 10 20 1 I 

I 1 83 CHECK Refer to questions 1 and 2: I 1 q “NO” or “DK” in ALL of 1 and 2 (Section AIS, page 59) 

ITEM 15 I 

I s 0 “Yes” in any part of 1 or 2 (Fill a column for each condition) 

I 

Jot& 

FORM HIS-IA ,ISSS) ,10-23-S,, 

179 
Section N7 - Continued 

L 

I CONDITION 1 

I Name of Condition

I3. Were you ever told by a doctor or other medical person that your I I q Yes LA­

(condition1 was related toany job you ever had? I :rnNo I 

i- 4. Was a worker’s compensation claim aver filed for your (condition)? I 

I 

I 

I 

5. Did you ever report to your employer or to other company personnel that your 

k 

I k 

(condition) was related to your job? 1 q Yes 

I 2uNo I 

t 1 6. Did you ever tell a doctor or other medical person that your (condition) was I 1 q Yes related to any job you ever had? I 

I 20No 

iI I 

CHECK I I 0 Entries in Check Item 7 (71 

ITEM 16 Refer to Check Item 7, page 39. I 

I s 0 All others (81 

L 

I I 7a. DURING THE PAST 12 MONTHS, were you told by your doctor or employer to I 

I 1 q Yes 

stay home from work temporarily because of your (condition)? I 2 q ,No 

---------------____-----------~~~-----------~ :-

I 

__&_------------d-dd E D. DURING THE PAST 12 MONTHS, did your employer transfer you to another I I q Yes (Check/tern 17) “ job, either temporarily or permanently, beceuse of your Icondition)? I 20No 

_______i______------------------------------- -;-s-----------Ls”­ tC. DURING THE PAST 12 MONTHS, did your employer give you lighter work or I 

excuse you from certain duties at work because of your (condition)? I 

1 20No 

-r 

6. Did you EVER stop working at a job or change jobs because of your I 

I 1 q Yes ( 

(condition)? I 20No 

t I CHECK 1 0 “Yes” in 3,4,5 OR 6 (91 

ITEM 17 Refe; to 3,4, 5, 6: I 

I s 0 All others (Ml 

- L 

I Occupation 1 

Ga. What kind of work did you do that was related to your (condition)? For I 

example, electrical engineer, stock clerk, typist, farmer. r 

I 

I 

----_--_____________------------------------- 1.. ----------#------d-d~d~. 

b. What were your most important activities or duties at that job? For example, types, I Duties 

keeps account books, files, sells cars, operates printing press, finishes concrete. I 

I 

I 

------------------_--------~~~~~---~~~~~~~~~~ 1- ----------------4~dd dd. 

C. In what kind of business or industry did you work the longest as a&t&&J? For I Industry T22-24 

example, Nand radio manufacturing, retail shoe store, State Labor Department, farm, I 

I 

I 

____-------__---------~---------------~------ --------------d-dddd 

-r­ d. In the industry where you worked the longest as a (entry in 9al were you - I Class of worker T321’ 

I - An employee of a PRIVATE company, business or individual for wages, salary, I or commission? ................................................ P I 10 P 

A member of the ARMED FORCES? ................................. AF I 20 AF I 

A FEDERAL government employee? ................................ F I 30 F 

A STATE government employee?. .................................. S I 40 s 

A LOCAL government employee? ................................... L I 60 L (NC) Self-employed in OWN business, professional practice, or farm? I 

I Ask: Is the business incorporated? I 

Yes ....................................................... I I so I I No.. ...................................................... SE 70 SE 

Working WITHOUT PAY in family business or farm? .................... WP I 

I so WP 

I 

L 

rlotes 

180 
--- 

Section N6 - EYE, NOSE, THROAT IRRITATION 

CHECK 

ITEM 14 Refer to HIS-l, Cl: 

I 0 Wa box marked (1) 

8 0 All others fSection II/~, page 661 

I 0 

Thasa questions are about aye, nose and throat irritation. I 

I & 

Hand calendar I 

a. During the past 2 weeks (outlined in red on that calendar), 10Yes 

beginning Monday Idatel. and ending this past Sunday 2 0 No 14) 

(H, have you had any episodes of itchy, irritated or 

watery ayes? ---------------------------------~------------------------------- ___ b. On how many days during the past 2 weeks did you have I 

I 

& i 

itchy, irritated or watery eyes? I 

I Days 

-----------------------~~--------~ --------------------------~ i------

C. Ware these symptoms due to a cold or flu, hay fever, other I q Cold or flu 14) 

aliargiss, or something else? I 2 0 Hay fever 

I 3 0 Other allergies I 

I 3 0 Something else - Specify -3 

I 

I 

I 

._ 

la. Did you have these symptoms while you ware at work? I 1 q Yes I I 2 0 No (3) 

---------------------------------t-------------------------------- -__ - b. When you wara?away from work, did these symptoms I 0 Increase -Lx 

increase, becrease, or stay the same? I

I 2 0 Decrease 

1

I 3 0 Stay the same 

3. 

did you also have a fever? I

I 20No 

%a. Do you wear contact lenses? I 

I 1 q Yes 43 

2 0 No 151 ---------------------------------L______------------------------- ___ 

During the past 2 weeks when you had these symptoms, I 

I 1 q Yes 48 

b. What type of contact lenses do you wear? I I 0 Hard Iens fin&de polyconl 60 

I 

Mark all that apply. I 

I 

I 

3 0 Soft Iens( extended 

4 0 Intraocular lens(es) 

wear 62 

53 

I 

I 8 0 Oiher - Specify 7 -E 64 

I 

I

I s0DK px 

I 2 0 Soft lens(es), daily wear 51 

ia. During the past 2 weeks, have you had any apksodes I 

I 1q lYes 1 

of stuffy, blocked, itchy, or runny nose? I 2 0 No (8) 

---------------------------------r------------------------------- I 

Da On how many days during the past 2 weeks did you I p& i 

have stuffy, blocked, itchy or runny nose? I Days 

---------------------------------~-------------------------------

0. Ware these symptoms due to a cold or flu, hay fever, I 1 17 Cold or flu (8) t 

other aliergias, or something else? I 2 0 Hay fever 

I 3 q Other allergies I 

I 8 q Something else - Specify 3 I 

I 

I 

6a. Did you have these symptoms while you ware at work? I 1q lYes m I 2 ON0 (7) ----------------_---------------- ~-------------------------------~ 

b. When you ware away from work, did these symptoms I i Cl Increase 

increase, decrease, or stay the same? I 

I 2 0 Decrease 

I 3 0 Stay the same 

7. Durlng the past 2 weeks when you had these I 

I I q Yes 1 

symptoms, did you also have a fever? I 20No 

I 1 3fJ. Durlng the past 2 weeks, have you had any episodes I 1 q lYes of sore or dry throat? 

I 

I 2 0 No (Section N7, page 561 

---------------------------------t----------------------------------- ___ b. On how many days during the past 2 weeks did you T i 

have sore or dry throat? I 

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

C. Were these symptoms due to a cold or flu, hay fever, other I I 0 Cold or flu (Section N7, page 561 T allargles, or something else? I 

I 2 q Hav fever I 3 0 Otker allergies I 

I 8 0 Something else - Specify 3 

I 

I 

FORM HIS-1A i18881110-23. 871 

181 
Section N8 - CIGARETTE SMOKING 1 

I k these questions are about smoking cigarettes. I 

I I q lYes 

I. Have you smoked at least 100 cigarettes in your entire life? 1 z 0 No (Section 0) 

2. About how old were you when you first started I oo 0 Never smoked regularly 

smoking cigarettes fairly regularly? I I Years 

I k 3 - Do you smoke cigarettes now? I 

I 1q iYes151 

i 2uNo 

I 

Mark w box or ask: 1 ooo[7 Never smoked regularly (Section 01 

4. About how long has it been since you last I 

smoked cigarettes fairly regularly? 10 Days 

20 Weeks 

Number 30 Months 

40 Years 

{ 

5. On the average, about how many cigarettes a oo 0 Less than one cigarette per day 

day [do/did] you smoke? 

Cigarettes per day 

Votes 

182 
--- 

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

Section 01 - ALCOHOL SC EENING AND ABSTAINER 1 

These next questions are about drinking alcoholic beverages. 

Included are liquor, such as whiskey, rum, gin, or vodka, beer, 

wine, or any other type of akxholio beverage. 

I a. In YOUR ENTIRE LIFE, have you had at least 12 lOYes 

drinks of any kind of alcoholic beverage7 2 c] No (2) 

___----_-----~----------~~~~ ‘--. 5 

b. In the PAST 12 MONTHS did you have at least 12 I 0 Yes /Section 03, page 67) E 6 

drinks of ANY kind of alcoholic beverage7 zuNo 

---------_-_____-----~-~~~------~ ___----------___---____________ T-l’ c. In ANY ONE YEAR of your entire life did you have at least i 0 Yes (Section 04, page 731 

12 drinks of ANY kind of alcoholic beverage7 z 0 No (Secrion 02, page 631 

Hand Card 01, read list if telephone interview. 01 0 Don’t socialize very much 6-S 

!a. (Please look at this list and tell me) What are your 

reasons for not drinking7 

02 q Don’t care for it or dislike it 

03 0 Am an alcoholic 

10-l' 

12-1: 

Anything else7 05 0 Had problems with my drinking w-1: 

Mark all mentioned. 06 0 Have a responsibility to my family 18-l! 

07 0 Family member an alcoholic or problem drinker 20-2 

08 0 Medical or health reasons 22-2: 

04 0 Thought I might become an alcoholic 14-11 

09q Religious or moral reasons 24-21 

26-2: IO q Brought up not to drink 23-2! 11 c] Makes me sick 30-3 12 0 Can’t control my drinking 

13 0 Costs too much or can’t afford it 32-3: 

\, 14 q Dieting or too fattening 34-31 

88 0 Other 36-3 

ssODK . E 33-3! c----------------T---_----------- C, -------------------------------~

If only one reason in Za, mark box wrrhour askmg; otherwise, ask: 01 0 Don’t socialize very much 

. Of the reasons you have just told me, which of these is 02 0 Don’t care for it or dislike it 

your MOST IMPORTANT reason for not drinking7 03 0 Am an alcoholic 

04 0 Thought I might become an alcoholic 

05 0 Had problems with my drinking 

06 q Have a responsibility to my family 

07 0 Family member an alcoholic or problem drinker 

08 0 Medical or health reasons 

09 Cl Religious or moral reasons 

IO 0 Brought up not to drink 

I I 0, Makes me sick 

12 q Can’t control my drinking 

13 0 Costs too much or can’t afford it 

14 0 Dieting or too fattening 

88 q Other 

ssODK 

c 6 People have different opinions about heavy, moderate and light I drinking. We would like to know how OFTEN and how MUCH I(1000 0 Everyday you think a person must drink in order to be considered a I 0 Week 

heavy, moderate or light drinker. I - Days per 2 0 Month 

3g. In your opinion, how OFTEN must a person drink in order to I!399s 0 DK 14) { 3 q Year 

be conridered a HEAVY drinker? I ------o~nk~----- E I b. On those days, how MANY DRINKS must a person have in order I 

to be considered a HEAVY drinker7 I 

seaDK c 

@fl- In your opinion, how OFTEN must a person drink in order to I(1000 0 Everyday I 0 Week 

( 

be considered a MODERATE drinker7 I 

1 -Days per 2 [7 Month 

I! cuss [7 DK (51 { 3 q Year 

----__--_________________________ I -------------------------------~ 

I b. On those days, how MANY DRINKS must a person have in order - Drinks 

to be considered a MODERATE drinker7 eeODK I 

5a. In your opinion, how OFTEN must a person drink in order to I’1000 q Everyday 

I 0 Week 

1 

be consldered a LIGHT drinker7 Days per 2 [7 Month 

I 

I! ssss 0 DK (61 3 q Year 

-----------_____--------~-~------ I -----------------------------------.-E i I b. On those days, how MANY DRINKS must a person have in order I - Drinks 

to be considered a LIGHT drinker? I 

esnDK 
Grandmother(s) 

Section 01 - ALCOHOL SCREENING AND ABSTAINER - Continued I 

I 6a. When you were growing up. that is, during your first 18 1 i q Yes I 

years, did you live with anyone who was a problem drinker i 2 q No or alcoholic? ’ snDK > 171 ---------------------------------~----------------------------------

b. Who was this? I 

I 

I Anyone else? I 

I 

If parent, ask: Was this your biological (natural), adoptive, I 

step, or foster [mother/father]? I 

P 

If brother/sister, ask: Was this your full, half, adoptive, step, or foster [brother/sister]? 

Record up to first 5 mentioned. 

I 

I 

I 

I 

I 

; 

I 

I 

I 

I 

I 

’ 

7a. Have any of your (other) blood ralatives EVER been a I 

problem drinker or alcoholic? I 

---------------------------------t-----j-~~~~~~~-­

b. Who was this? i Anyone else? , 

Mark all mentioned. 1 

1 If necessary, probe as indicated in 6b. ! 

; 

1 

I ’

I 

I 

I 

I 

I 

1

I

I 

’ 

I 

I 

6. Have you ever been married to, or lived with someone as if 1 

you were married, who was a problem drinker or alcoholic? [ 

I 

IM IilSlA 1199811102387, 

184 

I Ask 6c for each person in 6b, 

I 0. For how long did you lfrv;;th I boerson in 6b) while lee s 6bL 

1 was a problem drinker or alcoholic? 

I 

I aDays 1 

2 q lWeeks 

3 q Months 

I 4 q lYears 

1 71-72 ’ I q Days 1 73-76 

2 q Weeks 

I 3 q Months 

I 4 ElYeers , 

) 76-77 I 1q Days 1 73-60 

I- 2 q Weeks 

3 q Months 

I 

II 4) I I 4 OYears 

) 81-62 I 1q Day.s 1 83-W 

I 

I z q Weeks I 3 q Months 

5) I 

I 4 q Years 

1 al6 i 

1 ElYes 

‘\ 

I 

-------------------------t-l 

1 0 Biological mother 

2 0 Biological father 

I 0 Biologidal brother(s) 

2 0 Biological sister(s) 

I 0 Half brother(s) 

2 0 Half sister(s) 

I 0 Biological son(s) 

2 0 Biological daughter(s) 

1 0 

2 0 Grandfather(s) 

1 q Aunt(s) 2 0 Uncle(s) 

1 0 Niece(s) 

2 17 Nephew(s) 

i q Cousinls) 

2 [7 Other blood relative(s) 

IODK 

( i IJYes 

20No 

J 
-- 

-- 

--- 

-- 

-- 

-- 

--- 

r Section 01 - ALCOHOL SCREENING 

Refer to Table B on the Cover Page and ask for each person listed 

except the sample person. 

If personal interview - hand Card 02 and read first alternative 

wordirig. 

If telephone interview - read second alternative wording and the 

list of answer categories. 

Please look at this card and tell me which number best 

describes drinking during the past year. ----------_---_-----_______ 

I am going to read a list of different drinking categories, 

please tell me which one best describes drinking in 

the past year. --------------__------------~ 

What about - - drinking? 

-------_--------~________________ 

C. What about - - drlnklng? 

----------------------___________ 

d. What about drlnklng? 

\ 

i 

t -_______---------_-_--~~--------­

i’g. What about drinking? 

i 

I f. What about drinking? 

IO. Tell me whether or not you have EVER had any of 

the following conditions even if you have 

mentloned them before -

g . Hypertension or high blood pressure (excluding 

durlng pregnancy)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

b. Hardening of the arteries?. . . . . . . . . . . . . . . . . . . . . . . . . . . 

C. Any heart disease? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

d. Arthritis or rheumatism? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

I 

I 

I 

I 

I 

.L 

I 

I 

I 

I 

I 

I 

I 

I 

-lI 

I 

I 

I 

I 

I 

‘iI 

I 

I 

.$ 

I 

I 

I 

I 

II 

I 

c 

I 

I 

I 

I 

I 

I 

I 

8. An ulcer, not including skin ulcers? . . . . . . . . . . . . . . . . . . . . . 

f. Diabetes? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

g. Any disease of the liver, such as yellow jaundice, 

hepatitls or cirrhosis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

h. Cancer, other than skin cancer? . . . . . . . . . . . . . . . . . . . . . . . 

i.Alcohollsm? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 

I 

r 

CHECK 

ITEM 1 Mark one box, then go to HIS-lS(AIOSI. 

L 

AND ABSTAINER - Continued 1 3-4 

I 3-s 

Person No. -

I 0 Heavy 50 Quit drinking 

2 0 Moderate a 0 Never drank a 0 Light snDK 

4 0 Very light or occasional 

7 ------__----~~~~~~~~~~~~~~~~---

t 9-9 

Person No. -

I 0 Heavy 60 Quit drinking 

2 0 Moderate 6 c] Never drank 

30 Light s0DK 4 0 Very light or occasional 

Person No. -

I 0 Heavy 60 Quit drinking 

2 0 Moderate a 0 Never drank s 0 Light s0DK 4 17 Very light or occasional 

13 ------_-----___--------~~~~~~~-

t 14-16 

Person No. -

I Cl Heavy- 60 Quit drinking 

s 0 Moderate 60 Never drank 

30 Light snDK 4 0 Very light or occasional 

16 ------------_-___---_______i___ ___ 

-El-17-18 

Person No. ,-

I 0 Heavy 60 Quit drinking 

2 0 Moderate 60 Never drank s 0 Light snDK 

40 Very light or occasional 

19 ~~~~~____--------~~____________ ___ 

f 20-21 

Person No. -

I q Heavy 6 0 Quit drinking 

z 0 Moderate 60 Never drank 30 Light snDK 

40 Very light or occasional 

Yes No 

10 20 ITT 

117 20 1 

'El 20 

ICI 20 p 

10 20 1 

1U zlzi 1 

1U 20 E 

10 20 

31 10 20 FL 

) 32 

I 0 SP alone during interview 

2 0 Child(ren) present during interview 

3 0 Other adult(s) present during interview 

4 0 Child(ren) and other adult(s) present during interview 

6 0 Telephone interview 

FORM HIS-IA ll9S6,lo-23-8
-------- ------ 

Section 02 - LIFETIME INFREQUENT DRINKER 

1. Not counting small tastes, how old ware you when you started 1 

, -Years drinking alcoholic beverages? 

1 SSODK 

2. In the PAST 12 MONTHS about how many drinks of ANY kind i o. q None 1 36-a0 

of alcoholic beverage did you have? I 

1 ~ Drinks 

1 ssnDK 

3. When did you have your last drink of any kind of alcoholic I 1 

beverage? I 

I 19-

I Month Year 

(9999ODK 

g. What type of alcoholic beverage [do/did3 you PREFER I I [7 Beer to drink - beer, wine, or liquor? r 2 0 Wine 

Mark only one box. r 3 0 Liquor 

I 4 0 No preference 

’ sODK 

5. When you [drink/drank] who [do/did] you USUALLY I 

I 

I 0 Friends drink with - friends, relatives, people from work, other 1 2 Cl Relatives people, or by yourself? I 3 0 People from work 

Mark only one box. i 4 0 Other people 

I 5 Cl Self 

1 sODI< 

I 

I 

Hand Card 01, read listif telephone interview. I r 

! 01 0 Don’t socialize very much 43-44 

5g. (Please look at this list and tell me) What are your reasons i 02 0 Don’t care for it or dislike it 46-46 for 

-llymlng else? , 04 0 Thought I might become an alcoholic rsso -

Mark all mentioned. I 05 0 Had problems with my drinking 61..62 

1 06 0 Have a responsibility to my family 6ais4 

; o: 0 Family member an alcoholic or problem t&,36 

08 0 Medical or health reasons 67-h 

I 09 Cl Religious or moral reasons ss-641 

not drinking very much? 

1 03 q Am an alcoholic 47:4a t 

10 q Brought up not to drink El-621 

II 0 Makes me sick 63-64 

12 0 Can’t control mv drinkina OS-II 

i 13 [7 Costs too much’or can’t afford it 

b. 

1 14 [7 Dieting or too fattening 

88 0 Other I 

, ssnDK 

______--------------_____________I r-------- - --------~ 

If only one reason in 6a, mark box without asking; otherwise, ask: I 

Of the reasons you have told me, which of these is your MOST 1 01 q Don’t socialize very much 

IMPORTANT reason for not drinking very much? 02 0 Don’t care for it or dislike it 

I 03 0 Am an alcoholic 

1 04 0 Thought I might become an alcoholic 

r 05 0 Had problems with my drinking 

I 0s 0 Have a responsibility to my family 

I 07 0 Family member an alcoholic or problem drinker 

i cs 0 Medical or health reasons 

I 0s 0 Religious or moral reasons 

1 10 [7 Brought up not to drink 

r 11 q Makes ma sick 

r 12 q Can’t control my drinking 

1 13 0 Costs too much or can’t afford it 

1 14 0 Dieting or too fattening 

r asOOther 

1 ssnDK 

I 

Notes 

186 
I 

-- 

--- 

Section 02 - LIFETIME INFREQUENT DRINKER - Continued 

People have different opinions about heavy, moderate and light i 1 p 

drinking. We would like to know how OFTEN and how MUCH 

you thinka parson must drink in order to be considered a i 

I 

oooo q Everyday I 0 Week heavy, moderate or light drinker. 1 -Days per 3 q Month 

7o. In your opinion, how OFTEN must a parson drink in order to I sOYear 

be considered a HEAVY drinker? 1ssss 0 DK (8) 

I 

---------------------------------t---------------------------------~ 1

b. On those days, how MANY DRINKS must a parson have in order ; 

to be considered a HEAVY drinker? , Drinks 

1 ssnDK 

I 

80. In your opinion, how OFTEN must a person drink in order to i 

, oooo 0 Everyday 

1 6 

be considered a MODERATE drinker? 

I I 0 Week 

I -Days per 2 0 Month I 3 q Year 

i 9999 0. DK (91 

I 

I 

--_-__----_--------______________ r----------------------------

b. On those days, how MANY DRINKS must a person have in order I -p@ ito be considered a MODERATE drinker? I- Drinks 

1 ssnDK 

, 

I 

Ga. In your opinion, 

be considered 

how OFTEN must 

a LIGHT drinker? 

a person drink in order to 1 

, oooo 0 Everyday 

1 2 

I 0 Week 

I 

I -Days per 2 q Month 

\ / 999s 0 DK (101 3 q Year 

i ______--___------_-----__--- _____r-------------------------------~ 1 4 

h?. On those days, how MANY DRINKS must a person have in order I 

, to be considered a LIGHT drinker? I 

, Drinks 

I 

I s3ODK 

I 

- :&e; i When you were growing up, that is, during your first 1 

I 

iUYes 

1 

{ 18 years, did you live with anyone who was a 

problem drinker or alcoholic? , z.uNo I1 1) ’ 3nDK > 

______----_----_-_-______________ $-------------

b. Who was this? I

I 

Anyone else? i 

I 

I If parent, ask: Was this your biological (natural), I adoptive, step, or foster [mother/father]? I 

I 

If brother/sister, ask: Was this your full, half, adoptive, step, I 

I 

-r------- _-----------_ -

1 Ask IOc for each person in 1Ob. 

1 C . For how long did you live with , (person in 7Ob) while (person in 1Obl I was a problem drinker or alcoholic? I 

I 

S-67 I I q Days (98-1( IO 

or foster [brother/sister]? I q 2 0 Weeks I 

Record up to first 5 mentioned. I I 

I 

3 0 Months 

; 1) I 4 q Years 

i 

I I 

I ~101-102' 1103-1 05 

I I I 0 Days 

I 

I 

I 2 0 Weeks 

3 0 Months 

2) I 

I 4 0 Years 

I 

1106-107' Iros-1 10 

I I 0 Days 

I 

I 2 0 Weeks 

I 3 0 Months 

I 3) I 

I 4 q Years 

I 

1111-112' 1113-1 15 

I I q Days I 2 0 Weeks 

:--- 3 0 Months 

i 4) I 

I 4 q Years 

1 I 

1116-117' 1118-1 20 

I I 0 Days 

I 2 0 Weeks I 

I I I 3 0 Months 

’ 5) I 4 I 4 0 Years

I I L 

- FORM HIS-IA 11988, ,10.23-37, 
-- 

-- 

-- 

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

-- 

-- 

-- 

1 

( 

Section 02 - LIFETIME INFREQUENT DRINKER - Continued ( 1 m 118. Have any of your (other) blood relatives EVER been 

problem drinkers or alcoholics? I illYes 

’ zuNo 

1 snDK lIzI I > 

--------------.-------------------c--------------------------------------­

b. Who was this? 1 I [7 Biological mother 

Anyone else? I z q Biological father 

1 I 0 Biological brother(s) 

Mark all mentioned. I z 0 Biological sister(s) 

If necessary, probe as indicated in 1Ob. I I 0 Half brother(s) 

I 20 Half sister(s) 

1 I 0 Biological son(s) 

I 20 Biological daughter(s) 

I q Grandmother(s) 

20 Grandfather(s) 

I 0 Aunt(s) 

20 Uncle(s) 

, I q Niece(s) 

I 2 0 Nephew(s) 

I I q Cousin(s) 

I 2[7 Other blood relative(s) 

I rnDK 

12. Have you ever been married to, or lived with someone as if lOYes you were married, who was a problem drinker or alcoholic? 20 No r,

! 

Refer to Table B on the Cover Page and ask for each person listed i 

except the sample person. I 

I If personal interview - hand Card 02 and read first I alternative wordina. I 

If telephone interview - readsecond alternative wording and the list I Person No. 

of answer categories. ’ tOHeavy 5 0 Quit drinking \ ISa. Please look at this card and tell me which number best 20 Moderate em Never drank 

describes drinking during the past year. 30 Light snDK ------------__-------------

I am going to read a list of different drinking categories, 40 Very light or occasional 

please tell me which one best describes drinking in 

the past year. 1I 

I 

________-___----__------------- I 

b. What about drinking? I 

I Person No. - I 

1 l(7Heavy 5 0 Quit drinking 

I 2 0 Moderate 80 Never drank 

1 3iJLight snDK 

I 

I 40 Very light or occasional 

---------------------------------~----------------------------- I 2D 

C . What about - - drinking? t 3031 

: Person No. - / 

1 toHeavy 5 0 Quit drinking 

I 2 q Moderate s 0 Never drank 

I 30 Light snDK 

r 40 Very light or occasional 

I 

L------------------------------­

d. What about drinking? ) Person No. 

I I q Heavy 5 q Quit drinking I 2 0 Moderate so Never drank 

I 30Light anDK 

! 40 Very light or occasional 

---------------------------------t----------------------------------- i 

e. What about drinking? I 

I Person No. -

1 tOHeavy 5 0 Quit drinking 

r 2 0 Moderate 6 0 Never drank 

’ 30Light s[7DK 

I 4 0 Very light or occasional 

- I --------_____---____~~----------- I 36 r-----------------------------‘- ___ 

f = What about drinking? 

I 

I Person No. - f an-40 _ I 

d 

1 tOHeavy 5 0 Quit drinking 

1 20 Moderate an Never drank 

1 30Light sODK 

417 Very light or occasional 

L I ) FOFIMHISIA 11989,,loz3-87, 

188 
r Section 02 - LIFETIME INFRI X 

-r 14. Tell me whether or not you have EVER had any of the following I 

conditions even if you have mentioned them before -

a. Hypertension or high blood pressure (excluding 

durlng pregnancy)? . . . . . . ., . . . . . . . . . . . . . . . . . . . . . . . . . . 

b. Hardening of the arteries?. . . . . . . . . . . . . . . . . . . . . . . . . . . 

C.Any heart disease? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

d. Arthritis or rheumatism? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

e. An ulcer, not including skin ulcers? . . . . . . . . . . . . . . . . . . . . . 

f.Dlabetes? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

g. Any disease of the liver, such as yellow jaundice, 

hepatitis or cirrhosis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

I h. Cancer, other than skin cancer? . . . . . . . . . . . . . . . . . . . . . . . 

I 

I i. Alcoholism? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 

I 

L 

I 

CHECK Mark one box, then go to HIS-1 EVAIDS). 

llTEM 2. 

I 

-

WENT DRINKER - Continued 

-Yes No 

10 20 1 

10 20 1 

10 20 1 

10 20 1 

10 20 1 

10 2. 0 1 

10 20 1 

10 20 1 

10 20 1 

1 

I 0 SP alone during interview 

z 0 Child(m) present during interview 

s 0 Other adult(s) present during interview 

40 Childlren) and other adult(s) present during interview 

so Telephone interview 
--------------------------------- 

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

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

Section 03 - CURRENT DRINKER 

I 1. Not counting small tastes, how old were you when you 1 -Years started drinking alcoholic beverages? 

1 ssODK 

2a. On the average, how often do you drink any alcoholic ) oooo 0 Everyday beverages? I I 0 Week 

I -Days per 20 Month 

30Year 1 ssssnDK { 

f----- ---------------------~~-~-d~ 

b. On the average, on the days that you drink alcohol, how 1 - Drinks per day many drinks do you have a day? 

I ssnDK 

Hand calendar. I 

SC. Did you have a drink during the l-week period [outlined on that I I q Yes 

calendar/beginning Monday,aand ending Sundav? I 

I 2 0 No (3~) 

I -------------------------------+------------------------------

b. During that period, when did you last have a drink? I 

I ~- IS- 141 

1 Month Date Year 

_----_--------------------------- Lee-------- ------------------_~_ C. When was your last drink prior to that l-week period? I 

I --IS- (101 

! Month Date Year 1 

aa. During that 2-week period, on how many days did you I 

I oo 0 None or never (5) drink any beer? I 

II 

t-----------­ b. On the day (8) when you drank beer, about how many beers 1 

did you drink a day? I I6eers 

1 ssuDK 

t------------ -------------H----F 

C . About how many ounces were in a typical can or bottle or I 

glass of beer that you drank during that period? I Ounces 

I 

5a. During that l-week period, on how many days 

drink any wine? 

did you 

I 

1 

Ioo ONone or never 16) 

I -Days 

---------------------------------t---------------------------------~ 

b* On the day(s) when you drank wine, about.how many 

glasses of wine did you drink a day? I IGlasses 

! ss.ssODK 

/ ssnDK 

I ---------------------------------~-------------------------------

C. About how many ounces of wine were in a typical glass I 

that you drank during that period? I -Ounces 

; ss.ssnDK 

6D. During that 2-week period, on how many days did you I 

drink any liquor, such as whiskey, rum, gin, or vodka? 1 oo ONone or never lChack /tam 3) 

1 IDays 

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

D. On the day(s) when you drank liquor, about how many I 

k 

1 

( 

m 

T67-71 

1 

w 

-I 

7 3i 

4-

1 #l-S2 

TiGi 

drinks did you have a day? I 0 Drinks 

1 ssnDK 

---------------------------------~-------------------------------

c. About how many ounces of liquor were in a typical drink I 

I that you had during that period? I -Ounces 

j ss.ssnDK 

I 

1 I 0 One day and one beverage type (9) CHECK Refer to 4a, 5a, and 6a I 2 [7 Only one beverage type (8) (Do not read Intro above 9,8l 

ITEM 3 Mark first appropriate box. I 3 0 14 days in 4a. 5a, or 6a flntro above 9,8) 

I s 0 Other (71 

I 

I have asked you about beer, wine, and liquor separately. I 

I Now I want you to think about them combined. I 

7. During the 2-week period [outlined on that calendar/beginning L---- Days (8) Monday, (dateland ending Sundaym, on how many days ; 

altogether did you drink alcoholic beverages, that is, beer, or I 01 0 One day only 19) wine, or liquor? I 

I 

I 

L 
--------------------------------- 

Section 03 - CURRENT DRINKER - Continued 

I have asked you about beer, wine, and liquor separately. 

Now I want you to think about them combined. 

Refer to questions 4b, 56, and 6b 

8a . During that P-week period, did you have more than 

I 

1 i0Yes 

D 

(largest number in 4b, 5b. or 66) drink(s) on a single day? ; znNo (91 --I ------------------------_--------L----~----------------------------------- I 1 

I 

b. On how many days did you have more than &west 

I 

I 

Days number in 46. 5b. or 661 drink(s) of beer, or wine, I or liquor? 010 One day only 18el ---------------------------------~-------------------------------

C. What was the largest number of drinks you had on any one I E 

of those days? 1 ~ Drinks ---------------------------------r-----------------------------------

d. On how many days during that l-weak period did you have I E 

lnumber in BcLdrinks? I Days 19) 

-------------------------------L-------------------------------

e. How many drinks did you have on that day? I 

I 

E 

I ____ Drinks 

3a. Wes the amount of your drinking during that 2-week period 

typical of your drinking during the past 12 months? 

b. Was the amount of your drinking during that 2-weak period ( 

MORE OR LESS than your drinking during the past 12 months? I $rss,” 176) 

I > 

I C. For how many years has this bean typical of your drinking? 1 -Years 

I oo 0 Less than one 116) 

Let’s talk about the 2-week period ending the day you had 

your last drink. Please include that last day. 

Days 

1. During that 2-week period, on how many days did you 

drink any beer? ) oo 0 None or never (7 II 

‘---------------------------------t---------------------------------

On the day(s) when you drank beer, about how many beers 

did you drink a day? I IBeers 

1 ssnDK 

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

C. About how many ounces ware in a typical can or bottle or I 22-26 

glass of bear that you drank during that period? I

1 - Ounces -I 

11 a. During that 2-week period, on how many days did you 

drink any wlne? 

( IDays 

I oo 0 None or never (721 

;-----------------------------

b. On the day(s) when you drank wine, about how many I 

glasses of wine did you drink a day? I 

I I/Glasses I 

I ssuDK 

---------------------------------t----------------------------- ---_ 

C. About how many ounces of wine were in a typical glass that I pi-35 

you drank during that period? 1 -Ounces 

I 1 99.990 DK 

I 1 

%I. Durlng that l-weak period, on how many days did you drink ; 

any liquor, such as whiskey, rum, gin, or vodka? 

1 DDays 

1 oo ONone or never Kheck /tern 41 

-----------_----_-_______________ I

r-------------------------------

b. On the day(s) when you drank.liquor, about how many I 

drlnks did you have a day? I 

I IDrinks 

I ssnDK 

---------------------------------L-------------------------------

C. About how many ounces of liquor were in a typical I 

drink that you had during that period? 1 -Ounces 

f scw[7 DK 

I 

CHECK Refer to IOa, 1 la, and 12a. I I q Only one beverage type 1741 

z~14daysinlOa,Ila,or12af741 ITEM 4 Mark first appropriate box. 

i 

I 

8 0 Other (73) 

191 
--------------------------------- 

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

Section 03 - CURRENl 

I have asked you about beer, wine and liquor separately. 

Now I want you to think about them combined. 

13. Still thinking about the same l-week period, on how 

many days altogether did you drink alcoholic 

beverages, that is, beer, wine, or liquor? 

I4a. Was the amount of your-drinking during that 2;week 

~;~t~~ptcal of your drmkmg during the prewous 12 

_---_____________________________ 

b. During that 2-week period, did you drink MORE 

OR LESS than usual? 

--------____----__---------------

C. For how many years has this been typical of your drinking? 

Hand Card 0 1, read list if telephone interview. 

ISa. (Please look at this list and tell me) What are 

your reasons for not drinking since (date in 3cl? 

Anything else? 

Mark all mentioned 

If only one reason in 15a, mark box without asking ; 

otherwise ask: 

b. Of the reasons you have told me, which of these is your 

MOST IMPORTANT reason for not drinking since 

(date in 3cl? 

C. Do you think you will probably drink again or have you 

stopped drinking permanently? 

I Ga.‘(Thinking about the 12 months before your last drink) Did 

you have at least one drink in every month [last year/of that 

year]? 

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

b. In how many months did you have at least one drink? 

ri iI 

L 

I

I

I

I

I

t 

i 

I 

I 

I 

4-

DRINKER - Continued 

010 One day only 

Days 

lOYes (14cl 

ZUNO 

____------_-----___--~-~-------

I 0 More 

2q Less > (75) 

_____-----------____-d--------­

oo q Less than one year 

-Years 

or 0 Don’t socialize very much 

020 Don’t care for it/dislike it 

03 0 Am an alcoholic 

04 [7 Thought I might become an alcoholic 

os 17 Had problems with my drinking 

os [7 Have a responsibility to my family 

07 0 Family member an alcoholic or problem 

08 0 Medical or health reasons 

09q Religious or moral reasons 

IO 0 Brought up not to drink 

I I 0 Makes me sick 

12 0 Can’t control my drinking 

13 0 Costs too much or can’t afford it 

14 0 Dieting or too fattening 

as 0 Other 

l-5 

E 

T 

drinker 

-f& 

drinker 

I

. 

+-------------------------------

I 

\ 

I 

I 

I 

1 

I 

i 

I 

1 

I 

1 

I 

I 

I 

I 

1 

I 

010 Don’t socialize very much 

oz 0 Don’t care for it/dislike it 

03 0 Am an alcoholic 

04 0 Thought I might become an alcoholic 

os 0 Had problems with my drinking 

06 [7 Have a responsibility to my family 

07 q Family member an alcoholic or problem 

08 0 Medical or health reasons 

09 0 Religious or moral reasons 

IO 0 Brought up not to drink 

II 0 Makes me sick 

12 0 Can’t control my drinking 

1s 0 Costs too much or can’t afford it 

14 0 Dieting or too fattening 

ssnOther 

ssnDK 

;--------- -------------.dd------E 

I 

I I 0 Will probably drink again 

I z 0 Stopped permanently 

I another 

; anDK F I 

I 

f lOYes 1171 

I 20No 

I 

I 

I 

I -Months 

! oo 0 None 1781 

Days 

ooon None 

I7a. During [that month/those 

you have 9 or more drinks 

b. During [that month/those 

you have 5 or more drinks 

(Include the (number in 17al 

months], on how many DAYS did 

of ANY alcoholic beverage? 

1 ) 17 

- - p.79 

1 90-92 

pG­

---+-------------------------------

months], on how many DAYS did I 

of ANY alcoholic beverage? I -Days days you had 9 or more drinks.) 1 ooonNone 

IRM HISlA ,1988,11023-87, 

192 

I 
1 RT86 

r Section 03 

- CUfkENT DRINKER 

- Continued 1 3-4 

1 18. Do you NOW conaider yourself to be a heavy, moderate, I

I 1q Heavy 

1 6 

light, very light or occasional drinker? r 3 0 Moderate 

I 3[7Light 

I 4 0 Very light or occasional 

I 5 q Quit drinking I 

1%. In your ENTIRE LIFE, when you drank the MOST, about 

t 

I 1 

how often did you drink? I 

I oooo 0 Everyday 

I I 0 Week 

I -Days per 20 Month 

I 30Year 

; ssssnDK 

1 I b. On these days, about how many drinks did you 

have a day? .’ 

- Drinks 

ssnDK 

-______---------_----------------~-----------------~----------~~~ 

C. For how long of a period did you drink this amount? I E , 

I 

I 

I I 0 Days 

I - 20 Weeks 

I Number 30 Months I 4ClYears 

; ssssnDK 

I 

20. (Before you stopped drinking) What type of alcoholic I 1 

beverage [do/did] you PREFER to drink - beer, wine, or 1 I q Beer 

liquor? I 20Wine 

I aLlLiquor + Mark only one box. I 4 0 No preference 

I 

:I I (Before you stopped drinking ) When you drink who 17 --I[did/do1 you USUALLY drink with - friends, relatives, I aFriends 

people from work, other people, or by yourself? 2 0 Relatives 

3 0 People from work 

Mark only one box. 4 0 Other people 

I 5 OSelf 

; snDK 

People have different opinions about heavy, moderate and light i 1 

drinking. We would like to know how OFTEN and how MUCH ’ ooooCIEverydav 

you think a person must drink in order to be considered a heavy, f I 0 Week 

moderate or light drinker. z 0 Month 

22B. In your opinion, how OFTEN must a person drink in order to I 30Year 

be considered a HEAVY drinker? 

___________-----------~~~~~~~~~~~~~~~----~~--------------~~--~~~~ 

m b. On those days, how MANY DRINKS must a person have in 1 

order to be considered a HEAVY drinker? I -Drinks 

/ ssnDK 

I 

, 23B. In your opinion, how OFTEN must a person drink in order I 1 

I [I1 Week 

~ Days per 20 Month 

to be considered a MODERATE drinker? oooo 0 Everyday 

30Year 

I gssgq DK (24) 

---------------__~~~--~~~--------~~~~~~~~~~-------------------~~~ E 

D. On those days, how MANY DRINKS must a person have in 

order to be considered a MODERATE drinker? 

1 

I - Drinks 

; ssnDK 

I 

1 , 24B. In your opinion, how OFTEN must a person drink in order 1 oooo q Everyday 

I I 0 Week 

r -Days per 2 [7 Month 

I 3OYear 

to be considered a LIGHT drinker? I 

1 ssss 0 DK (25) 

-----------------------------;---I---------------------------------~ 

b. On those days, how MANY DRINKS must a person have m 

order to be considered a LIGHT drinker? Drinks I 

I ss[7DK 
------------------------------- 

Section 03 - CURREN’ 

!5C. When you were growing up, that is, during your first 18 

years, did you live with anyone who was a problem drinker 

or alcoholic? 

____-------------------------------------

b. Who was this? 

Anyone else? 

If parents, ask: Was this your biological (natural), adoptive, 

step, or foster Imothedfatherl? 

If brother/sister, ask: Was this your full, half, adoptive, step, 

or foster fbrother/sisterl? 

Record up to first 5 mentioned. 

!6a. Have any of your (other) blood relatives EVER been a 

problem drinker or alcoholic? 

b. Who was this? 

Anyone else? 

Mark all mentioned. 

If necessary, probe as indicated in 25b. 

7. Have you ever been married to, or lived with someone as if 

you were married, who was a problem drinker or alcoholic? 

otes 

rclI 

I 

I 

;-

I 

llI 

I 

I 

L 

I 

l 

I 

I 

I 

I 

I 

I 

I 

I 

I 

+ 

I 

I 

I 

-

BRINKER - Continued 1 

I q Yes & 

ZUNO 

9 q DK > ‘g6’ 

-------------------r----------‘---------------

I Ask 25c for each person in 25b, 

I C. For how long did you live with 

I @erson in 2561 while (person In 26bl 

I was a problem drinker or alcoholic1 f 

537-36 I 

I 

I 1) I 

1 42-43 ’ 

I---­

l 

a I 

I 

1 47-43 1 

i31 I 

I 

1 62-63 I 

I 

I 

iI 

4) I 

67-66 I 

I 5) I 

1 q Yes 

I 0 Biological mother 

z [7 Biological father 

I c] Biological brother(s) 

6 0 Biological sister(s) 

I 0 Half brother(s) 

2 q Half sister(s) 

I 0 Biological sonLs) 

2 0 Biological daughter(s) 

I 0 Grandmother(s) 

2 0 Grandfather(s) 

I q Auntfsl 

2 I3 Uncle(s) 

I 0 Niece(s)

2q Nephew(s) 

I Cl Cousin(s) 

6 0 Other blood relative(s)

I q IDK 

i q Yes 2nNo 

I aDays ) 

z (7Weeks 

a q Months 

4 q Years 

1q Davs b 

2 q Weeks 

s q Months 

4 q Years 

1q Days 1 

2 q Weeks 

3 q Months 

4 q Years 

I aDay. 1 

2 q Weeks 

3 q Months 

4 q lYears 

1q Days b 

2 q Weeks 

3 q Months 

4 q lYears i 

) 60 
-- 

-- 

-- 

-- 

-- 

-- 

-- 

-- 

-- 

-- 

-- 

i Section 03 - CURREI DRINKER - Continued 

Refer to Table B on the Cover Page and ask for each person listed 

except the sample person. 

If personal interview - hand Card 02 and read’first alternative 

wording. 

If telephone interview - read second alternative wording and the Person No. -

list of answer categories. I 0 Heavy 5 0 Quit drinking . 

28a. Please look at this card and tell me which number best 2 0 Moderate 6 0 Never drank describes drinking during the past year. 

- i -------_---------------------- 30 Light snDK

l am going to read a list of different drinking categories, please 40 Very light or occasional 

I tell me which best describes drinking in the past year. __I- E ----_~-----____----------------- 83

drinking? 

1: 

84-a .--------________-~~____________ 

b. What about Person No. -

I 0 Heavy s 0 Quit drinking 

2 0 Moderate 60 Never drank I 

I 30 Light snDK I 4[7 Very light or occasional E -----___---~~_______-~~~~------- I .__--___---_______-------------- 96 --I- 87-8 C. What about drinking? I 

I Person No. -

I 

I I 0 Heavy 5 0 Quit drinking 

20 Moderate 6 0 Never drank 

3 0 Light snDK 

40 Very light or occasional 99 ---------_--_----_______________ .-- .----___-~~__-----_-------~~~--- 90-9 d. What about drinking? E 

Person No. -

I 0 Heavy 5 0 Quit drinking 

z 0 Moderate 60 Never drank 

3 0 Light snDK 

40 Very light or occasional ----__-_--------_--------

92 .-II ._-_--~~___-~___----________

97-< 8. What about drinking7 I E I Person No. ___ I 

I I 0 Heavy 5 0 Quit drinking I 20 Moderate I 6 q Never drank

3 0 Light s0DK 

40 Very light or occasional 96 --------~~_-----____------------ .-I- I .----____~~.~__----_________

36-9 f. What about drinking? Person No. - E 

I Cl Heavy s 0 Quit drinking 

2 0 Moderate 6 0 Never drank 

3 0 Light snDK 

4 0 Very light or occasional 1 A- 29. Tell me whether or not you have EVER had any of l 

the following conditions even if you have I 

mentioned them before - I 

Yes a. Hypertension or high blood pressure (excluding I 

during pregnancy)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 10 

b. Hardening of the arteries? . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 

g. Anyheartdlsease? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . '0 

d. Arthritis or rheumatism? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 * I 

8. An ulcer, not Including skin ulcers? . . . . . . . . . . . . . . . . . . . . . I 10 

I f. Diabetes? ,...................................... . I rcl 

I g. Any disease of the liver, such as yellow jaundice, I 

hepatitis or cirrhosis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 10 20 

h. Cancer, other than skin cancer? . . . . . . . . . . . . . . . . . . . . . . . I 

I 10 20 

I i. Alcoholism? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 10 20 

I -1 

I 0 SP alone during interview 

CHECK Mark one box, then read “Intro” for HIS-Z, I 

I 2 0 ChildLren) present during interview 

ITEM 5 Alcohol Questionnaire. I 3 0 Other adult(s) present during interview 

I 4 0 Child(ren) and other adult(s) present during interview I 

I 5 0 Telephone interview -

INTRO: (Hand questionnaire and read to respondent) These next questions are about things that happen to people when they are drinking or 

after they have been drinking. We would like to know if any of these things have ever happened to you. (I can read the questions 

to you or you can fill out the form yourself. Which would you prefer?) 

METHOD OF INTERVIEW ( 109 1 

1 0 Read to SP (HIS-Z) 1 INSTRUCTIONS - In COLUMN 1, please circle the answer that best describes the number of 

times each of these things has happened to you IN THE PAST 12 MONTHS. Complete column 1 for 2 0 Self-administered (Instructions) each question first. Then go back and in COLUMN 2, circle “Yes” or “No” if any of these things 3 UT&phone interview (HIS-21 have or have not ever happened to you IN YOUR ENTIRE LIFE. If you need any help ask me for 

40Refused HIS-2.(H/S-IS) assistance. 
Section 04 - FORMER DRINKER ) 2-4 

I. Not counting small tastes, how old were you when you started 

drinking alcoholic beverages? 

!. In the PAST 12 MONTHS about how meny drinks of ANY kind 

of alcoholic beverage did you have? 

1. When did you have your last drink of any kind of alcoholic 

beverage? 

La. In your ENTIRE LIFE, when you drank the MOST, about 

how often did you drink? 

______---------------------------i------------------------------­

b.. On those days, about how many drinks did you have a day? 

---------------------------------~-------------------------------

C . For how long of a period did you drink this amount? 

i. What type of alcoholic beverage [do/did1 you PREFER 

to drink - beer, wine, or liquor? 

Mark only one box 

3. When you [drinwdrankl who [do/did] you USUALLY 

drink with - friends, relatives, people from work, other 

people, or by yourself? 

Mark only one box. 

Hand Card 01, read list if telephone interview. 

ra. (Please look atthis list and tell me) What are your reasons 

for drinking less than 12 drinks in the past year? 

Anything else? 

Mark all mentioned. 

If only one reason in 7a, mark box without asking; otherwise, ask: 

b. Of the reasons you have told ma, which of these is your MOST 

IMPORTANT reason for drinking less than 12 drinks in the 

past year? 

f 

, -Years 

f ssnDK 

I o. 0 Rone 

I 

I -Drinks 

1 ssnDK 

I 

’ -lSI Month Year 

;ssssnDK 

I 

1oooo 0 Everyday I q Week 

1 -Days per z q Month 

I 3 q iYear 

IssssnDK 

1 oonNone 

I 

I -Drinks 

I ssnDK 

I 

I I 0 Days 

I- 2 q Weeks 

3 q Months 

jssssaDK 4q Years 

I 

I i q Beer 

r 20 Wine 

r 3 q Liquor 

1 4 0 No preference 

I snDK 

1 I 0 Friends 

2 El Relatives 

3 0 People from work 

4 c] Other people 

, 5 q Self 

! s0DK 

01 0 Don’t socialize very much 

02 0 Don’t care for it or dislike it 

03 [7 Am an alcoholic 

04 0 Thought I might become an alcoholic 

os 0 Had problems with my drinking 

06 0 Have a responsibility to my family 

07 c] Family member an aIcoholic or problem 

0s q Medical or health reasons 

0s 0 Religious or moral reasons 

10 0 Brought up not to drink 

11 0 Makes me sick 

12 q Can’t control my drinking 

13 0 Costs too much or can’t afford it 

i 14 0 Dieting or too fattening 

, ssc] Other 

I 99nDK 

.~-----------------------------------

I 01 0 Don’t socialize very much 

1 02 0 Don’t care for it or dislike it 

I 03 0 Am an alcoholic 

r1 04 0 Thought I might become an alcoholic 

os 0 Had problems with my drinking 

1 0s 0 Have a responsibility to my family 

I 07 0 Family member an alcoholic or problem 

( 08 0 Medical or health reasons 

I 09 0 Religious or moral reasons 

i 10 13 Brought up not to drink 

1 b-6 

( 7-8 

) 

) 

23 

1 

drinker 

I. 

( 

drinker 

I 11 [7 Makes me sick 

1 12 0 Can’t control my drinking 

I 1s 0 Costs too much or can’t afford it 

f ’ 14 0 Dieting or too fattening 

ssm Other 

; ssODK 

196 
Section 04 - FC RMER DRINKER 

People have different opinions about heavy, moderate and light 

drinking. We would like to know how OFTEN and how MUCH 

you think a person must drink in order to be considered a 

heavy, moderate or iiaht drinker. 

8fL In your opinion, how UFTEN must a person drink in order to 

be considered a HEAVY drinker? 

~~~-----~~__----~~_______________ 

b. On those days, how MANY DRINKS must a person have in order 

to be considered a HEAVY drinker? 

&t. in your opinion, how OFTEN must a person drink in order to 

be considered a MODERATE drinker? 

--------~~~__---_________________ 

b. On those days, how MANY DRINKS must a person have in order 

to be considered a MODERATE drinker? 

Oa. in your opinion, how OFTEN must a person drink in order to 

be considered a LIGHT drinker? 

~~~~~__-------__----_____________ 

b. On those days, how MANY DRINKS must a person have in order 

to be considered a LIGHT drinker? 

8. When you were growing up, that is, during your first 

18 years, did you live with anyone who was a 

problem drinker or alcoholic? 

~~~-----~_-------_--------~-~~~~~ 

b. Who was this? 

Anyone else? 

If parent, ask: Was this your biological (natural), 

adoptive, step, or foster (mother/father)? 

If brother/sister, ask: Was this your full, half, adoptive, step, 

or foster (brother/sister)? 

Record up to first 5 mentioned. 

1 

oooo 0 Everyday I 0 Week 

- Days per z 0 Month 

3 Cl Year 9999 0 DK (9) 

___--_-----_----________________ m 

Drinks 

I s3[7DK 

I 

1 I oooo 17 Everyday I I 0 Week 

- Days per z 0 Month 

3 Cl Year 

9999 0 DK (70) 

-c 

I

I - Drinks 

I 

I wC]DK I 

+ 

oooo 0 Everyday 

I c] Week 

I - Days per z [7 Month I 

I (30Year 

I! 9999 17 DK (7 7) 

I 

‘r 

I 

I 

I - Drinks 

I 

I 33nDK 

I .----___-____---________________ m 

I 

t 

I I q Yes 

‘r .------____ p,,~-----------------~ 

I 

I 

I 

I 

1) I 

I 

I 

II 

I 

I 

I 

I 

I 

1-

4) 

Ii 

I 

I 

I 

I 

I 5) L 

Ask 11 c for each parson in 11 b. 

i Cm For how long did you live with 

(person in 1 lb) while (person in 11 bJ 

was a problem drinker or alcoholic? 

I I q Days I z 0 Weeks I 

I 3 0 Months I 4 0 Years - I 

I 

133-04 1 

I 

I z 0 Weeks 

I 3 0 Months I

I 4 0 Years 

I 

139-99 : 1 

I I 0 Days I 

I z 0 Weeks 

I 3 0 Months I

I 4 0 Years 

I 

1 

I 0 Days 

z q Weeks 

I- 3 0 Months I

I 4 0 Years 

I 

98-99 1 

I 1 0 Days 

I

I 2 0 Weeks 

I 3 0 Months I

I 4 0 Years 

.I 

FORM HIS-IA 11988,110-23.8 

197 

.I 
-- --- 

-- 

-- 

-- 

-- 

-- 

-- 

-- 

-- 

--- 

--- 

--- 

Section 04 - FORMEF 

Pa. Have any of your (other) blood relatives EVER been 

problem drinkers or alcoholics? 

b. Who was this? 

Anyone else? 

Mark all mentioned. 

If necessary, probe as indicated in 1 lb. 

3. Have you ever been married to, or lived with someone as if 

you were married, who was a problem drinker or alcoholic? 

Refer to Table B on the Cover Page and ask for each person listed 

except the sample person. 

If personal interview - hand Card 02 and read first alternative 

wording. 

1 6766 1 

BRINKER - Continued 1 3-4 

L 6 

lOYes 

zuNo 

s0DK > (‘3) 

.--~---___-~------__~~~~~~~~~-~~~~~-

I 0 Biological mother 

2 0 Biological father 

r 0 Biological brother(i) 

20 Biological sister(s) 

I 0 Half brother(s) 

2 0 Half sister(s) 

I 0 Biological son(s) 

2 0 Biological daughter(s) 

? 0 Grandmother(s) 

20 Grandfather(s) 

10 Aunt(s) 

2 0 Uncle(s) 

I 0 Niece(s) 

2 0 Nephew(s) 

I 0 Cousin(s) 

20 Other blood relative(s) 

10DK 

I 

-II 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

L 

II lOYes 

20 No 

-II 

I 

I 

I - I Person No. 

If telephone interview - read second alternative wording and the I list of answer categories. 10 Heavy 5 0 Quit drinking I 

4g. Please look at this card and tell me which number best I 2 0 Moderate s 0 Never drank 

describes drinking during the past year. I s 0 Light snDK 

_---_----__-____c___________ 

I am going to read a list of different drinking categories, please I 

I 

4 0 Very light or occasional 

tell me which one best describes drinking in the past year. 1 I 26

l- ____-___________-------------- -I- ___-----__--------_-----~--ddd~~ 2%T b. What about drinking? I t 

Person No. -

I 

I I 0 Heavy s 17 Quit drinking 

I 20 Moderate so Never drank I 

I 30 Light snDK 

I 40 Very light or occasional 

26 _____-_-----_-____------~~~~- ---. 1 ___------_-____------------4~~dd 

E ao-at I 

C. What about drinking? I Person No. -

I Cl Heavy 5 0 Quit drinking 

20 Moderate so Never drank 

I 30 Light saDK 

I 40 Very light or occasional I 32 ---_________-_____-______________ ___--_-________---__------------

l t 33-34 

d. What about drinking? I 

I Person No. -

I 

I 

I 

I 

I I 0 Heavy 5 0 Quit drinking 

2 0 Moderate 60 Never drank 

I 4 0 Very light or occasional 

so Light soDK 

I 36 -I- ___------______---~________i____ 

t 36-a7 

g. What about drinking? 

Person No. ~ 

I •I Heavy so Quit drinking 

20 Moderate 8 0 Never drank 

3 0 Light snDK 

40 V&y light or occasional 

I 36 _--__----______---__~~-----~~~~~ --. I t as-46 

f . What about - - drinking? I 

Person No. -

I 0 Heavy 5 0 Quit drinking 

20 Moderate s 0 Never drank 

30 Light snDK 

40 Very light or occasional 

-L I 
Section 04 - FORMER DRINKER - Continued 

I 

5. Tell me whether or not you have EVER had any of the following 

conditions even if you have mentioned them before -

a. Hypertension or high’ blood pressure (excluding 

during pregnancy)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

b. Hardening of the arteries?. . . . . . . . . . . . . . . . . . . . . . . . . . . 

t&Any heart disease?................................ 

d. Arthritis or rheumatism? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

8. An ulcer, not Including akin ulcers? . . . . . . . . . . . . . . . . . . . . . 

f.Diabetes? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

g. Any disease of the liver, such as yellow jaundice, 

hepatitis or cirrhosis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

h. Cancer, other than skin cancer? . . . . . . . . . . . . . . . . . . . . . . . 

i. Alcoholism? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

I 

L 

I 

I 

I

CHECK Mark one box, then read “Intro” for HIS-3, 

ITEM 6 Alcohol Questionnaire. 

INTRO: (Hand questionnaire and read to respondent) These next questions 

after they have been drinking. We would like to know if any of 

to you or you can fill out the form yourself. Which would you 

METHOD OF INTERVIEW ] 62 

I 0 Read to SP (HIS-3) INSTRUCTIONS 

Yes 

10 

10 

10 

10 

10 

10 

10 

I 0 SP alone during interview 

2 0 Childfren) present during interview 

30 Other adult(s) present during interview 

40 Childfren) and other adult(s) present during interview 

5 0 Telephone interview 

are about things that happen to people when they are drinking or 

these things have ever happened to you. (I can read the questions 

prefer?) 

- Please circle “Yes” or “No” if any of these things have or 

‘1 

z q Self-administered (Instructionsl have not ever happened to you IN YOUR ENTIRE LIFE. If You need any help ask me 

3 q Telephone interview (HIS-31 for assistance. 

40 Refused HIS-3 (HIS-IS) 

Notes 

1 

I 
-- 

Section PI - INTRODUCTION 

t 2-4 The next questions will be used to study the health of the Nation’s children. 

(It would be beat if I could ask these questions in private.) 

Arrange to conduct supplement in private if possible. 

If more than one child in family read: The only child I will ask the rest of my questions about is-- . 

I Ask or verify for each HH member. , Pynrw-yber Relationship to sample child . How is (Name on HIS-l) related to --? I 

I 

I 1 S-6 [ 

If parent, ask: Is (Name of parent) - - biological I 1 

(natural), adoptive, step, or foster [mother/father]? I 

I J 7-a 

I 2 

If brother/sister, ask: Is [Name of sib/ins1 full, I 

I 1 s-10 

half, adoptive, step or foster fbrother/sisterl? I 3 

I 

I Ill-12 

Enter “sample child” on appropriate line. I 4 

I 

I La-14 

Enter “unrelated” forpersons not related to the sample child. I 5 

I 

I 1 16-10 

I 6 

I 

I ~17-18 

I 7 

I 

I 121-22 

I 9 I I , 

I 1 22-24 

I 10 

I 

I [ 2s , 

I I 0 Biological or adoptive mother in hhld (Check /tern 2) I 

I CHECK 2 0 Biological father or step or foster mother in hhld, (Check /tern 21

ITEM I Mark first appropriate box. 

!a. Which family member knows the most about 

the health related matters of --? 

----__---_________---------------

b. Is (person named in 2a) available? 

CHECK Mark first appropriate box. ITEM 2 

Votes 

200 

I 3 0 One adult relative in hhld. (Check /tern 21 I 4 0 2 + adult relatives in hhld. (2) 

I 

I 5 q No eligible respondent in household lCover Page) 

I 

I 

I 

i_______---------______,,__,__,_ 

I 

I I Cl Yes (Section P2) 

I 2 [7 No (Arrange callback, THEN Cover Page) I 

I 

I I 0 Person in Check Item 1 available (Section P2) I 

I 2 0 Person in Check Item 1 not available (Arrange I callback, THEN Cover Page) 

m 

1 
-- 

-- 

-- 

-- 

-- 

-- 

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

-- 

Section P2 - CHILD CARE 

I 0 Same as respondent in HIS-1 CHECK Person number (Check Item 41 

ITEM 3 Mark box and enterperson number of respondent. 

2 0 New respondent 

I - Person number 

These questions will be used to study the health of the Nation’s children. (It would be best if I could ask these questions in private.) 

I will be asking questions about - -. 

Arrange to conduct supplement in private if possible. 

I I 

CHECK I I q Under 2 years old (Check Item 5) 

z 0 2 or 3 years old 121 

ITEM 4 Refer to age of sample child 3 q 4 or 5 years old (7) 

4 0 6 + Years old (Section P3, page 831 

18. Is currently attending either kindergarten or first grade? I 

I I 0 Yes, kindergarten 1 

I 2 0 Yes, first grade I 3 0 No 12) I ---------------------------------c----------------------------------­

b. At what time of day does the [kindergarten/first gredej start? 1 : I 0 A.M. 3 0 Noon m 

1 znPM snDK _---------___--------------------~----------~~-------------------

0. At what tlme does the [kindergarten/first grade] end? I 

I I 0 A.M. 3 [7 Noon E 

I { 2 0 P.M. s0DK ---------------------------------c----------------------------------- --. 

If in first grade, go to 3 I 

I 

7 Cl Yes Ixd. Does the kindergarten have a day care or extended I 

day program thet - - also takes part in? I f, i :“, (Check /tern 5) I 

I > 

---------------------------------~------------------------------- e. How many hours per week does spend in this I r48-49 

program? I Hours (Check /tern 5) 

\ ) ssODK > 

I . During the past four weeks has attended I I 0 Yes, Nursery 1 

f nursery or preschool? I 

I 2 0 Yes, Preschool 

---------------------------------L----------------------------------- I 3 0 No (Check /tern 5) --. 

b. Dld the [nursery school/preschool] have a day care or I -lhL 

extended day program that also took part in? I 

I I Cl Yes 

I 20 No 

---------------------------------c-----------~----------------------- --. 

c. How many hours per week did spend in the [nursery I r52-53 

school/preschool (with day care)]? I 

I Hours per week 

I ssnDK 

I 

CHECK Refer to Check Item 1. I I 0 Biological mother respondent (3al 

I 

I

I 

s 0 Other 13a) 

jg. Have you worked at a job or business 

last four weeks? 

for pay in the I 

I 

I 

I I 0 Yes 

2 q No (41 

1 

---------------------------------c----------------------------------- --. I + 

ITEM 5 

Mark first appropriate box. I 

I 2 0 Biological/adoptive/step or foster mother in hhld., NOT respondent (3dl 

b. 

I 

, sss 0 DK 

---------------------------------t----------------------------------

Mark box or ask: I o q Child under 2 or “No” in 1 a AND 2a (5bj E 

I 

How many hours a week do you usually work? I Hours per week 

C . Do you only work while - - is in Ischooi level in la or 2al I 

or do you work during other hours? I I 0 Only while child is in school (4) I a 13 Other hours (561 I 

I __-----------_______~~~~~--------’ r-------------------------------~ 

d. Has (mother) worked at a job or business for pay in the I 

last 4 weeks) I 

I 

1 Cl Yes 

I 2 0 No 141 

;----- Hourspee~wee~~ ~ 

8. How many hours a week did she work? I 

I 

I SSSODK 

I ---------------------------------~------------------------------- --. 

Mark box or ask: o 0 “No” or blank in la AND “No” in 2a (5b) -P!L 

f . Does she work only while is in (school/eve/ in la or 2a) I 0 Only while child is in school (41 or does she work other hours? 

8 0 Other hours (Sb) 

I 

1M”,S.,Al,988,l10.23.87, 

201 
-- 

-- 

-- 

-- 

-- 

---- 

-- 

----- 

-- 

-- 

----- 

-------- 

--- 

Section P2 - CHILD CARE - Continued 

1 I 66 

4 . (Other than the [nursery school/praschooil), In the past four i Cl Yes weeks, has - - bean cared for in ANY kind of regular child 

care arrangement such as a day care canter, playgroup, by a 2 0 No (Check /tern 6) 

babysitter, relative, or some other regular arrangement? t 

Hand Card PI, raadliat if telephone interview. or c] Day care center 

6a. HOW was USUALLY cared for during the hours 02 c] Babysitter in child’s home 

that child care was used? i 

I 03 0 In babysitter’s home 

Mark only one box. I 04 0 Father cares for child 

I oa 0 Mother cares for child while Eel 

I working at home I 

I oa 0 Mother cares for child while 

I 

I working outside of home I I 07 0 Child cares for self I I 

I oa 0 Other relative cares for child 15cl 

oQ 0 Day camp Eel I 

I Qa 0 Other - Specify p 

I 15el 

____-----__--__-____~~--~----~--~ _____-___--_----~_-~~~~~~-~~-~~ -d -t- r Hand Card PI, read list if telephone interview. 010 Day care center 

b. (Other than (kindergarten/first grade/nursery I 

I 02 0 Babysitter in child’s home 

school/preschool]) How was usually I 030 In babysitter’s home 

cared for while you worked? I 

I 04 q Father cares for child 15el I 05 0 Mother cares for child while Mark only one box. I 

I oa 0 Mother cares for child while 

i 

I 

working outside of home 

07 17 Child cares for self I ld 

08 q Other relative cares for child (512) 

oQ 0 Day camp 15eI 

working at home 

ss 0 Other - Specify r I 

I 

I 

____-----__--__-_________________ -+ 

I __-__--__-__--------_‘5”‘_,,_------­

c. How is this parson related to ---1 I I q Sibling a [7 Other relative 4 -1 

I 2 0 Grandparent QnDK 

____-------__--_-_----~--~~~~~~~- + _____ -___-__----_------ -w-----d m 

d. Where does this parson usually care for --, I q At home 

in (sample child) home or somewhere else? 2 0 Somewhere else 

-t _____-___-__--_------------~~--

g. About how many hours par weak was usually I 

Hours per week 

T 72-7; 

cared for [by/at1 (arrangement)? 99 q DK 

-i J 

6a. Besides (nursery or preschool (andVfchi/d care arrangements in I 1 q lYes I 

5a/bfl, during the part four weeks, has 

any other regular child care arrangement? 

bean cared for in I 

I 2 0 No fCheck item 61 

________--_----___----------- A- ,---------------d--_----~---~--~ 

m Hand Card PI, read list if telephone interview. 010 Dav~care center \ ! b. Other than (nursery or preschool (and) (child care arrangement in 02 q Babysitter in child’s home 

5a/bn, how was usually cared for during most of the other I 03 q In babysitter’s home 

hours that child care was used? I 

I 04 [7 Father cares for child (6s) I 05 0 Mother cares for child while 

Mark only one box. I 

I working at home 

I 06 0 Mother cares for child while I working outside of home I 07 0 Child cares for self I 

I 08 0 Other relative cares for child (6cl 1 

I 09 0 Day camp (Se) 

I 88 0 Other - I Specify g 

I 

I /6al 

_--_---_-__---_--_---------- -L .------------- _#--- d-dd-- --m 

c . How is this parson related to - -7 1 I 0 Sibling a 0 Other relative 

I 2 0 Grandparent QODK 

_____------------_--------------~ I .-loAthorne- ------------‘dm -r 

d. Where does this parson usually care for --, 

in (sample child) home or somewhere else? I 2 0 Somewhere else 

_-___---------------------------- -I .--_-__--_-___--______________3_ 

e. About how many hours per week was usually I 

I 

Hours oer week 

T;;,-,; 

cared for (by/at1 (arrangement)? I 

I ssC]DK + 

7a. Ware any other child care arrangements used i q Yes u 

on a regular basis? I 

I 2 q No (Check /tern 6) --~------------------------------ -c _-_----------------------d-+----

I T b. How many additional hours a week was child 

I 

I Hours per week care used? I QQODK I 

71 

202 
-- 

-- 

-- 

-- 

-- 

-- 

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

Section P2 - CHILD CARE - Continued 1 

T 

I I 0 No or blank in 1 d AND No in 2a AND blank in 5a/5b/77! 1 

CHECK I 

I (No nursery school or child care) 

ITEM 6 Refer to Id, 2a, 5a/5b, 6b. I 

I z 0 Box 4,5,6, or 7 in 5a15b AND blank or box 4,5,6, or 7 in 6b (731 

I (Mother, Father, self care ONLY) 

I 

I s 0 Other (8) I + 8. Now I would like to ask you about J”Main” child care 1 

arrangementl. 

including --, how many children are usually cared Children 

for together, in the same group, at the same time? Do I ssnDK 

not include children in the entire school or program. 

I 

9. How many adults usually supervise the children in I 

I Adults the seme group as ---I I ssnDK 

I 

I’0. Has the main person responsible for caring for received 

education or training specifically related to young children, I 

I I 0 Yes I 

such as early childhood or elementary education, or child 20 No (131 psychology? so DK 

i 

1 1. Was ever cared for in any regular child care arrangement? I 

I 1q Yes I-K I 

I 2 0 No (Section P3, page 831 

1 2. Whendid - - last receive care in a regular child care -I- 1 

arrangement? I 0 Within last 12 months 

2 q Prior to last 12 months (75) 

i- 1 3. How many times has main child care arrangement ooo 0 None (75) 

92-9~ 

been changed in the past year? 

I Times 

I- I Hand Card P2, read list if telephone interview. + 

010 Nursery school or preschool \ 1 

I 8. What was the last type of care used before changed to 02 0 Nursery school or preschool with day care T the type of care is using now? 03 0 Day care center 

Mark only one box. 04 0 Babysitter in child’s home I 05 0 In babysitter’s home 

06 0 Father cares for child ! 114dl 07 13 Mother cares for child while 

working at home 

I 

08 0 Mother cares for child while 

I working outside of home 

I 

I OS 0 Summer day camp 

I IO 0 Child cares for self I 

I I 0 Other relative cares for child (746) I 

I ss 0 Other - Specify. 

I 17 

I 

I U4d) I ss c] DK 1751 I 

I ----------------~___------------- .t 

b. How is this person related to --? I 

I I 0 Sibling s 0 Other relative IAL 

I 2 0 Grandparent sODK I -------------___-----------~~~~~~ c 

C. Where did this person usually care for --, in I 

I I 0 At home 

Ts8’ 

(sample child) home or somewhere else? I 

I 2 0 Somewhere else 

L ----------___------------------

d. About how many hours per week was usually I 

I E 

cared for [by/at1 (arrangement)? I Hours per week 

I ssnDK I -

Jotes 

203 
-- 

-- 

Section P2 - CHILD CARE - Continued 

I 

15. How old was when reg&ar child care was begun? 1 000 [7 Less than 1 month 1101-10~ 

I 

I 

I 

I 

+ 

Hand Card P2, read list if telephone interview I 

I6a. What type of child care arrangement was first used for ---7 I 

I 

1 0 Months 

Age 2 Cl Years 

Mark only one box. 

b. How is this person related to --? 

____------_-----_________________ 

c. Where did this person usually care for --, 

in (sample child) home or somewhere else? 

-_-_____-----____----------------

d. About how many hours per week was usually 

cared for my/at1 (arrangement)? 

dotes 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

L 

I 

I 

I 

I 

i 

lI 

I 

I 

I 

C 

999 0 

010 

02 0 

03 0 

04 0 

05 0 

06 0 

or 0 

o* 0 

os 0 

IO 0 

II 0 

sa 0 

9s q 

DK 

\ )104-10! I 

Nursery school or preschool 

Nursery school or preschool with day care 

Day care center 

Babysitter in child’s home 

In babysitter’s home 

Father cares for child ll6dl 

Mother cares for child while 

working at home 

Mother cares for child while 

working outside of home 

Summer day camp 

Child cares for self I 

Other relative cares for child /16bl 

Other - Specify z 

(16dl 

DK (Section P3) ___------------__----~----~~--- T?wI 0 Sibling 

2 0 Grandparent 

s 0 Other relative 

euDK ___-------_-----_---------~~--~ 

I c] At home 

2 0 Somewhere else 

Hours per week 

ssoDK 

204 
-- 

-- 

-- 

-- 

I 

I FIT92 

Section P3 - RELATIONSHIPS AND MOBILITY 1 

1 These next few questions are about - - (biological mother). Age 

8s q I. How old was - - (biological mother) when - - was born? I ssODK 

Respondent knows nothing about biological mother (Check /tern 7) 

I 

l 1 

2. Including , how many children has she ever had? I 

Do not count miscarriagesor stillbirths. I or 0 One/sample child only (Check item 71 

I Number 

; ssC]DK 

I 1 3. Was the first born (or) second born (or’third, etc.)? I 

I I q First (Check /tern 7) 

I z 0 Second 

I s 0 Third 

4 0 Fourth 

s 0 Fifth 

6 0 Sixth or Later 

9 0 DK (Check /tern 7) 

4. How old was - - (biological mother) when the first child ) 

wes born? I * Age 

/ ssnDK 

I k 

CHECK I

I I 0 Biological mother in hhld. (8) 

ITEM 7 Refer to 0. 1, page 78 I s 0 Other (5) 

I 

1

5a.. Has ever lived with - - biological mother for i Cl Yes 

at least 4 consecutive months? 7.0 No 

snDK 1 (6) 

--------------------------------~------------------------------- \ - 4. In what month and year did last live with her? 1 oooo 0 Lived here since birth 

r14-lj 

t I 

I 

I 

I 7GiiYg Year 

I 1; ,’ 1 ssssn 

i. Is she now living or deceased? I 0 

2 0 

s 0 

7. How often does - - see her? I 01 0 

! 02 0 

1 0s 0 

r 04 0 

I 05 0 

I 06 0 

I 07 0 

I 08 0 

I 00 0 

DK 

) 19 

Living 

Deceased (Check item 11) 

DK Kheck /tern 7 71 

Everyday 1 19-20 

Almost every day 

Several times a week 

About once a week 

Two or three times a month 

About once a month 

Several times a year 

Once a year or less 

Never 

! ssODK 

EI. I s - - (biological mother) now married, 

divorced, separated, or has she never 

widowed, 

been married? I 

I 

I 

1 0 Married 

2 0 Widowed 

I 

I 3 0 Divorced 

I 

I 

I 

I 

4 0 Separated 

0 q Never married (Check 

9 0 DK (Check /tern 7 II 

Item 1 II 

91. How’many times altogether has she been married? 1 

irimes 

snDK 

hlotes 

FOI 

205 

.i 
-- -- 

-- 

-- 

b. In what month and year did - - (biological mother) stop 

living with -- fbiological father)? 

Year 

9999[7 DK --------------------------------- If biological mother now separated, go to Check item 11. 

c. In what month and year did the marriage to -- (biological 

father) (legally) end? 

CHECK 

,TEM ,0 Referto8. 

I9 

99990 DK 

Year 

I [7 Biological mother now widowed, divorced, separated, 

1 

never married, or don’t know (Check /tern 17) 

z q Biological mother now married to someone other 

than biological father (12) 

-- 

Section P3 - RELATIONSHIPS AND MOBILITY - Continued 

I 

CHECK I q Biological mother and biological father in household, and now married to each other (lob) ITEM 8 Refer to 0.1, page 78 and 0.8. 

8 q Other (7Da) 

1Oa. Was (biologicalmother) ever married to (biological I 0 Yes f7Ob) 

1 

father)? z 0 No, (Check /tern 70) 

I 9 [7 DK (Check /tern 7 1) 

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

b. In what month and year was (biologicalmother) married to 1 E 

- - (biological father)? I 

I 

I -xiii+ I9 Year 

I

I 98990 DK 

I

I 

I I 0 Married only once and now married fCheck Item 7 7) 

1 

I z 0 Married only once and now separated or divorced (7 lb) CHECK Refer to 8 and 9. I 

I s 0 Married only once and now widowed (7 lcl 

ITEM 9 I 4 0 Married more than once and marriage to child’s father is 

I current marriage (Check Item 7 1) I 8 0 Other (11) 

I 

, a. Was (biologicalmother) marriage to ibiological father) I 

I I Cl Separation ( 

ended by death, divorce, separation, or annulment? I 2 0 Divorce I 

I a 17 Death I7 7~) 

I 4 0 Annulment 

9 q DK (Check /tern 17) 

---------------------------------c----------------------------------- _- ! ---------------------------------L 

I 

.----------------___--~~~~~--~~~ TaG-3 b. In what month and year did - - (biological mother) stop I 4

at-a4 

living with fbiological father)? I 

I -xiii+xiii+ I99Year I i 

1 9999[7 DK ‘-----------------------------T3s-31r 1 

If biological mother now separated, go to Check item 11. I 

I 

c. In what month and year did the marriage to (biological I 

I father) (legally) end? + I9 Year

j 9999 0 DK 3 

1 

CHECK 

I [7 Biological mother now widowed, divorced, separated, never married, or don’t know (Check /tern 17) 

,TEM ,0 Referto8. I 

I z q Biological mother now married to someone other 

I than biological father (12) 

I I 

12. In what month and year did (biologicalmother) I 

I Ira-43 

current marriage begin? I 

I 

I Year I 

1 aassnDK 

Uotes 

206 

II 
-- -- 

-- 

-- 

-- 

-- 

Section P3 - RELATIONSHIPS AND MOBILITY - Continued 

CHECK 

ITEM II Refer to 0. 1, page 78. 

I 0 Biological father in household 1761 

s 0 Other (73) 

1 

I I 

These next few questions are about - - fbiological father). o 0 Respondent knows nothing about father (76) ( 

i q Yes 

ISa. Has ever lived with biological father z 0 No 

for at leaat 4 consecutive months? snDK > f’6) 

___--_--___------________________I r---------~-~-------------------T,, 

b. In what month and year did last live with him? I oooo 0 Lived here srn’ce brrth I 

I 

‘-/ISI Month Year 

’ 99990 DK 

14. Is he now living or deceased? i 1 0 Living 

r 2 0 Deceased 

/ s~DK (76) 

15. How often does - - see him? rI or 0 Everyday 

) 02 0 Almost every day 

I 03 0 Several times a week 

04 17 About once a week 

05 0 Two or three times a month 

06 0 About once a month 

07 0 Several times a Year 

08 0 Once a Year or less 

00 0 Never 

I 6. In what month and year did fsamole child) move to this 1 oooo 0 Lived here since birth (Check /tam 72) address or has - - lived here since birth? I 

I -/ISI Month Year 

I 999euDK 

7. tif;;how far from here is the home (sample child) lived in 1 t 0 Less than 1 mile moved to this home - less than a mile, 1 to 50 

miles, or more than 50 miles? r 201--5Omiles 

1 3050+ miles 

’ snDK 

6. Altogether, how many times has ever moved? I 

I 

I Times I 

’ 9sODK 

1 

( 

1 

1 

1 

CHECK I 0 Respondent is biological mother or biological father (Section P41 

ITEM 12 s 0 Other 1191 

I I 

9. In what month and year did begin living with you? ) oooo 0 Since birth ( 

; -IISI Month Year 

I 

r 8888 0 Does not live with respondent 

1 sssslJDK 

1 

Notes 

207 

60 
-- 

-- 

-- 

-- 

-- 

-- 

-- 

-- 

-- 

r Section P4 - BIRTH 

la. Was born in a hospital or some other place? I 

I k 

j 

I 

r 4 0 In transit to hospital l7bl 

I s 0 Other - Specify 12) 

’ snDK ------‘---------------‘--------------

b. How many mghts was - - lbrologrcal mother) m the 

[hospital/birthing center1 during this stay? Nights 

1 ssnDK 

---------------------------------L-----------------------------------

C. How many nights was in the [hospital/birthing center] I 

I 

000 None G 

during this stay? 

I Nights 

’ ssODK 

!a. How much did weigh et birth? 

I ( 

I 

I Lbs. Or- (31 

Probe for ounces if not.reported. 1 ssssnDK 

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

I Tlr’ b. Did --weigh more than 5 II2 pounds or less? I 0 More than 5 l/2 Ibs. I 

i I ~0 Less than 5 112 131 I 7nDK 

---------------------------------t------------------------------------~ 

C. Did weigh more than 9 pounds or less? I z 0 More than 9 Ibs. 

1 s 17 Less than 9 Ibs. 

I snDK I 

I ( lg. How many months pregnant was (biologicalmother) I 

I Months when - - was born? 

I SSODK 

---------------------------------t---------------------------------- - . b. Was born about when expected, or was it earlier or later? I I 0 Earlier than expected E 

r z 0 When expected (Check item 131 

r 3 0 Later than expected 

1 s 0 DK (Checkitem 731 ---------------------------------r----------------------------------­

o. About how many weeks learlier/laterl than expected E 

was born? oo 0 Less than one week 

Weeks 

, ssn DK 

b

CHECK I 

I 

I 0 Under 6 years old AND biological mother respondent (4J 

ITEM 13 1 s 0 Other ASection P5, page 881 

I 

. . How many weeks 

you were pregnant 

pregnant were you when you first 

with --7 

thought I 

I 

I Weeks 

1 

1 ssnDK 

I 

ia. Did you see or talk to a doctor to find out if you were pregnant? ) lOYes m 

1 

---------------------------------L______---------------------~---­

b. About how many weeks pregnant were you when you first 

found out from a doctor that you were pregnant? 

------___--______________________ 

c. Did you see or talk to a doctor about your pregnancy at 

any (other) time during that pregnancy? 

------____--_____________________ 

If “Yes”in 5a, go to 6 

d. How many weeks or months pregnant were you when you 

first sew a doctor about your pregnancy? 

i. Altogether, how many pounds did you either gain or 

lose during that pregnancy? 

‘a. Did receive any newborn care in an intensive care unit, 

premature nursery, or any other type of special care unit? 

------__---________---~~~~~~~-~~~ 

b. How many nights did stay in the special care unit? 

2 0 No (5~) 

m 1 1q 4weeksorless 4 0 28 weeks or more 

I 2 0 5-13 weeks sUDK 

I 3 0 14-27 weeks 

~-------------------------------

I T46’ I 1q lYes 

1 2 0 No f6j 

; 

I 

I 1 0 4 weeks or less 

I 2 0 5-13 weeks s0DK 

i 3 0 14-27 weeks 

187-) 1 0 Gained 

Pounds 20 Lost 

)

1q lYes 2 0 No (8) 

~------------------------------- -

i ooq None & 

I 

I 

I Nights 

I 

cne,, “IC .1 ,.nm.,I.6 -9 

208 
---- 

-- 

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

-- 

Section P4 - BIRTH - Continued 

. Do you NOW have diabetes or sugar diabetes? I 

I 1 93 

’ tOYes 

1 znNo 

, 9nDK 

la. At any time during your pregnancy with --, did you have - Sugar in the urine? High 

in the 

sugar 

blood? Diabetes? 

(1) (21 (3) 

1 94 187 100 

1 10 Yes (96 and cl I 0 Yes (9b and cl I 0 Yes (9b and cl 

’ z 0 No (Next column) 2 0 No (Next column) ----------------------------------------~---------- -~------------ ----e----­

b. When did you FIRST notice it - was it during your 1 I 0 During I 0 During I 17 During 

T 101 

pregnancy with or before? 

I 20Before 2 0 Before 2nBefore 

__________--------------------------L--- -l----------

Mark box or ask: l 98 88 T 102 

C. Did you have the (condition) for at least 3 months ’ o 0 Child und. 3 mos. o 0 Child und. 3 mos. o 0 Child und. 3 mos. 

after was born? 

/ 10Yes 1q lYes I q lYes 

, 20No @al znNo 19d znNo 

I 

lotes 

M HIS-IA n9sw 110-23-87, 
-- 

-- 

-- 

-- 

mn 

Section P5 - CHILDHOOD CONDITIONS 3-4 

1a. During the past 12 months, did have an accident, injury, or poisoning 1s. & 

that required medical attention? 1UYes 

Z~NO 

snDK > 12’ 

------_____-----------------------~~-----------~-----~-~~~~~~~~~~ ___ b b. How many accidents, injuries, or poisonings did - - have in the last 12 b. 

months that required medical attention? -Number 

_-------------------------_-_________--------­ cr~“~AB~-----~ c. (Beginning with the most recent,) what caused the accident, injury, or poisoning? C. 

For example, was hit by a car while riding a bike, or burned by hot liquid or 

did swallow an object or pills? (1) 

Enter each in a separate column. 

----------------------------------~~~~~~~~~~---~~--------~-----------~ 

Hand Card P3, read list if telephone interview. 01 q Broken or dislocated bones 16-1(

d. Which of the conditions on this list OR ANY OTHER CONDITIONS resulted d’ 020 Sprain, strain, or pulled muscle 17-11 

from the (entryin Ic)? 03 0 Cuts, scrapes, or puncture wounds 16-20 

Mark all that apply and ask 1e. 04 0 Head injury, concussion 21-22 

os 0 Bruise, contusion, or internal 

bleeding 23-24 

26-26 060 Burn, scald E 

07 0 Poisoning from chemicals, 

medicines, drugs m 

08 q Respiratory problem such as breathing, cough, pneumonia 28-30 

as 0 Other 31-32 

ss 0 Don’t know type of condition lffl ii-:: 

ooq None 1 E 

-----------------------------------------------~~---------~-----~-~-~ 

8. Were there ANY other conditions that resulted from this accident, injury or a. 

poisoning? 0 Yes (Reask id, THEN Ifj 

Mark any additional conditions ONo 

-------------------------~--~~~~---------------~--------~~-~~~~~~ 

f. Where did this eccident or injury or poisoning happen? T3r’ 

I 0 Home (not necessarily ohild’sl 

DO NOT READ CATEGORIES 1. 20 Day care location (preschool/nurseryj 

Mark only one box. 30 School (including grounds and 

athletic areas) 

4 0 Street or highway 

5 0 Public building or space (other than 

street or school) 

en Farm or agricultural area, except farm home 

7 Cl Place of recreation or sports, except 

at school 

List each accident, injury, or poisoning which resulted in at least one condition (Codes 01-88) on a 0 Other a condition page as group A and a short name for the accident, injury, orpoisoning from lc. Then 

go to 7c in next column or question 2. s 0 Don’t know 

ma4 

. Does now have - 2. a-4 

1 0 Yes (Ask probe questions) s a. a missing finger, hand, arm, toe, foot, or leg? . . 20No 

If “Yes, ” ask: Which is it? auDK 

Is - - missing [I or both/more than one] (body part)? 

(Enter on a Condition page, Group J) 

--------________________________________-------~----------------- _-

b. permanent impairment, stiffness or any deformity of the back, foot, or leg? b. L!­

I 0 Yes (Ask probe qoestionsl If “Yes, “ ask: Which is it? 20No 

Is [I or both/more than one] (body part) affected? saDK 

(Enter on a Condition page, Group J) 

-----------------------------------------------~----~--~~~~~~~~~~~ _ 

c. permanent impairment, stiffness or any deformity of the fingers, hand, or arm? C. lx 

I q Yes (Ask probe questions) If “Yes,“ask: Which is it? 20No 

Is [I or both/more than one] (bodypati) affected? smDK 

(Enter on a Condition page, Group J) 

FORM HIS.lA IlDSll ,fWW 

210 
-- 

-- 

-- 

Section P5 - CHILDHOOD CONDITIONS - Continued 

I I I The next questions are about other health I 

I 

ASK if Yes in 3. I [ Mark without asking conditions mav have EVER had. I 

3. Did - - ever have - I 4B. Did--have 1 4b. Has had 1 40. Is it an obviously 

[condition) in the I fcondition) for at permanent 

GROUP B last 12 months? 1 least 3 months in / condition that 

I lifetime? began less than 3 

I months ago? 

Repeated tonsfiitfs or enlargement of the ~1OYesI * 0 Yes (Enteron Cond.Page) i 

tonsils or adenoids? . . . . . . . . . . . . . . . . . . . I z 0 NolDK 0 NolDK /Next Yes) I 

I b 

IrOYesI 9 0 Yes (Enteron Cond.Page) 1 I 

Frequent or repeated ear infections? . . . . . . I 2 [7No/DK 0 NolDK (Next Yes) , I

I 

I 

IlnYes ‘0 q Yes 14bl i 0 Yes (Enteron Cond. Page) i 

Any kind of food or digestive allergy? . . . . . 1 z q NolDK 0 NolDK (Next Yes) l 0 NolDK INexf Yes) I 

I FREQUENT or REPEATED diarrhea or [InYes ‘1 0 Yes (Enteron Cond. Page) 1 I 

colitis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ! 2 0 No/DK 0 NolDK /Next Yes) l I I I , 

Any other persistent bowel trouble ? . . . . . . I 1 0 Yes 1 ” [7 Yes (4b) i q Yes (Enteron Cond. Page] i 

Specify T 1 2 17 NolDK 0 NolDK /Next Yes) 1 0 NolDK (Next Yes) I 

I 

1 1 q lYesI ‘3 0 Yes (4bl i 0 Yes (Enteron Cond. Page) I 0 Yes (Enteron Cond. Page) 

Dlabetes? . . . . . . . . . . . . . . . . . . . . . . . . . . . I z 0 NolDK 0 NolDK /Next Yes) 1 0 NolDK 14~) 1 0 NolDK /Next Yes\ 

I

I i q Yes1 14 0 Yes (Enteron Cond. Page) i I 

Sickle cell anemia? . . . . . . . . . . . . . . . . . . . ] 2 [7No/DK q NolDK (Next Yes) , 

[ I q lYesI 15 0 Yes (Enteron Cond. Page) j 

Anemia? . . . . . . . . . . . . . . . . . . . . . . . . . . . . I z [7No/DK 0 NolDK /Next Yes1 l 

I i q lYesI 15 0 Yes (Enteron Cond. Page) 1 

Asthma? . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 z q No/DK 0 NolDK INext Yes\ I

I ‘II 

I 17 I 

I GROUP C 1 i q lYes 0 Yes (Enteron Cond.Page)1 

Mononucleosis? . . . . . . . . . . . . . . . . . . . . . ! z 0 NolDK 0 NolDK /Next Yes) l 

i i q Yes1 ‘* 0 Yes /Enter on Cond. Page)i I 

I 

Hepatitis? . . . . . . . . . . . . . . . . . . . . . . . . . . 1 z q NolDK 0 NolDK fNext Yes) I I 

I ;lOYesl ‘9 0 Yes (Enteron Cond. Page)i I 

Meningitis or spinal meningitis? . . . . . . . . . / z q NolDK 0 NolDK (Next YesI ] I

I 

q Yes [Enteron Cond. Page)I 

‘Bladder infection or urinary tract infection? 1 2 0 NolDK 0 No/DK 1Next Yes) I 

i i q lYes 21 0 Yes (Enteron Cond. Page) i I 

Rheumatic fever? . . . . . . . . . . . . . . . . . . . . _ I z 0 NolDK-I 0 NolDK /Next YesI I I 

I 

IrClYesI 22 0 Yes /Enter on Cond. Page) [ I 

I 

Pneumonia? . . . . . . . . . . . . . . . . . . . . . . . . . I z q NolDK q NolDK (Next YesI I I 

, 

1 23 I 

I 

GROUP D I 

i q Yes 0 Yes (Enteron Cond. Page) / 

Hay fever? . . . . . . . . . . . . . . . . . . . _ . . . . . . 1 2 0 NolDK 0 NolDK /Next Yes1 ! L I / 

I 1 24 I I 

I i q lYes 0 Yes (Enteron Cond. Page) 1 I 

I Any (other) kind of respiratory allergy? . . . . i 2 0 ko,p~ 0 NolDK /Next YesJ I I 

1 26 I 

GROUP E I 

I 

Deafness or trouble hearing I 

with one or both ears? I 

I 

I If “Yes,“ask: Is it one or both ears? . . . . . i 1 13 Yes, Oneear 

l 2 0 Yes, both ears 0 Yes (4hl 1 0 Yes /Enter on Cond. Pagel 1 0 Yes (Enter on Cond. Page) 

; 9 0 NolDK 0 NolDK (Next YesI 1 0 No/DK (4~) I 0 No/DK /Next Yes) 

I I I 

Blindness in one or both eyes? I 

I 1 26 I 

I 

I If “Yes,“ask: is it one or both eyes? . . . . . 1 I Dyes, oneeye I 

1 2 0 Yes, both eyes 0 Yes (Enteron Cond. Page) ( I. I 9 q NolDK 0 NolDK (Next Yes) , I 

I I 27 I I I -. I I 

1 1q Yes 0 Yes (Enteron Cond. Page) I I 

I Crossed eyes? . . . . . . . . . . . . . . . . . . . . . . . 1 2 [7No/DK 0 NolDK (Next Yes) I I 

I 

I 1 23 I I 

Any other trouble seeing with one or both I I I 

eyes, even when wearing glasses? . . . . . . . . 1 , q Yes 

0 Yes(4bl Specify i 0 Yes(EnteronCond.Page/ 1 0 Yes(EnteronCond.Page] 7 /anNo/DK 0 No/DK (Next Yes) 1 0 NolDK f4cl 1 q NolDK (Next Yes) 

211 
--- 

r Section P5 - CHILDHOOD CONDITIONS - Continued 

I 

I 

I 

I 

i 

I 

I 

I 

II 

ASK if Yes in 3. 1 Mark without asking 

4a. Did --have i 4b. Has --had i 4~. Is it an obviously 

lconditionlin the Jcondition) for at permanent 

last 12 months? ; least 3 months in 1 condition that 

began less than 3 I - - lifetime? I I months ago7

[ 29 I I 

I q Yes II] Yes 14bl 1 0 Yes (Enteron Cond. Pagel 1 

2 0 NolDK 0 No/DK(Next Yes1 ; 0 No/DK(Next Yes1 : 1 30 I I 

1q Yes [7 Yes (Enteron Cond. Page) 1 1 2 0 NolDK 0 NolDK(NextYes) I 

I I 

I 1 31 I q Yes [7 Yes (Enteron Cond. Page) ! I 

z 0 NolDK 0 NolDK[Next Yes] ) 

I ! 

32 I 1 q Yes 0 Yes f4bl i [3 Yes (Enteron Cond. Page) 1 

z 0 NolDK 0 NolDK(NextYes) I q NolDK(Next Yes! 1 

I 

1 q Yes 0 Yes (Enteron Cond.Page1 I

I i 

2 0 NolDK 0 NolDK(NextYesl I 

I I -l I

I I 

0 NolDK(Next Yes) 1 0 NolDK14cl ; q NolDK(NextYesl 

I I I I 

) 35 I 

I I 

I 

I I 

0 Yes (4b) 1 q Yes /Enteron Cond. Page) [ q Yes {Enteron Cond Page! 

1 q Yes q Yes (Enteron Cond. Page) 1 I 

I 2 111NolDK 13 NolDK(Next Yes) I I 

I 1 36 I I I 

I I I I 

I q Yes 0 Yes 14bl I 0 Yes (Enteron Cond. Pagel ; 0 Yes /Enter on Cond.Page! 

z 0 NolDK 0 NolDK(Next Yes\ 1 0 NolDKWcl I q No/DK/Next Yes! 

I I I 

1 37 I I I q Yes [7 Yes 14bl i 0 Yes /Enter onCond. Page\ i 0 Yes (Enteron Cond. Page/ 

2 0 NolDK 0 NolDK(Next Yes) 1 0 No/DK(4~) 1 0 NolDK(Nexf Yes) 

I I 

I I I I 30 I 

I q Yes [7 Yes (Enteron Cond. Page) I I’ 2 0 NolDK [7 NolDK(Next Yes1 I I 

I i 

1 39 I , 

I 

I q Yes 2 q NolDK 0 Yes (Enteron Cond. Page1 [ 

0 NolDK(Next Yes/ I 

I 

I 

I 

I 

I 

I 

I I I 40 I I 

2 0 NolDK [7 NolDK(Next Yes) I 

I I 

I f 

1 41 I 

I I 

I I I 

0 Yes {Enteron Cond. Page1 I 

I q Yes 0 Yes (Enteron Cond. Pagel I 

0 NolDK I 

I 

i 

q Yes 

0 NolDK I 

1 42 I 0 Yes (Enreron Cond. Page) i 

S. 0 NolDK(Next Yes1 1 

3. Did - - ever have -

GROUP F 

Eczema? . . . . . . . . . . _ _ . . . . . . . . _ . . . . . . . 

GROUP G 

Epilepsy or repeated convulsions or seizures 

not associated with fever? _ _ . . . . . . . . . . . . . 

Seizures associated with fever? . . . . . . . . . . 

Frequent or severe headaches, including 

migraines? . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Child under 3, go toI 

GROUP H 

Stammering or stuttering? . . . _ _ _ _ _ . . . . . . . 

Any other speech defect? . . . . . . . . . . . . . . . 

Specify 3 

Child under 6, go toI 

Enuresis or bedwetting prpblem? _ _ _ . _ _ . . . 

GROUP I 

Arthritis or any other joint disease or joint 

problem? . . . . . . . . . . . . . . . . . . . . . _ . . . . 

Specify 3 

Any other condition affecting the bone, 

cartilege, muscle, or tendon? . . . . . . . . . . _ . 

Specify 7 

Cerebral palsy? . . . . . . . . . . . . . . . . . : . . . . . 

Congenital heart disease? . . . . . . . . . . . . . . . 

Any other heart disease or condition? -

Specify 3 

Any other conditions that required surgery in 

past 12 months? . . . . . . . . . . . . . . . . _ . . _ . . 

Specify z 

Any other condition that lasted three months 

or more? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

List below and reask. 

b. 

I 

I 

I 

I 

: 

I 

I 

L 

I 

I 

I 

I 

: 

I 

I 

I 

I 

II 

I 

I 

I 

I 

I 

: 

I 

IL 

I 

I 

r 

lt 

t 

i 

t 

I 

I 

I 

I 

I 

I 

___ _---------------- 43 

0 Yes (Enteron Cond. Page/1 

I b. 0 NolDK(NextYes) I 

------_------- -104 0 Yes (Enteron Cond. Page1( 

C. 0 NolDK(Next Yes) ; I 

212 
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-- 

-- 

-- 

-- 

-- 

-- 

-- 

-- 

RTBS 

Section P6 - SUPPLEMENTAL CONDITION PAGE 3-1 6-8 I 7-8 1 Condition 1 

CHECK 0 No conditions reported (Section P7, page 961 I 

I Condition/AR ITEM 14 Enter condition/A/P name and group letter: I 

I 

I Group letter 

The next questions are about (condition/AIP). 1 ooo q Les.s than 1 month 

s 0 Months 

How old was - - when (condition/A/PI [happened/was Age 4 0 Years 

first noticed]? sssq DK 

I 

CHECK 1 I q Group E (4) 

I 2 0 Group F or H (51 ITEM 15 Refer to Check Item 14 ! s 0 All others 121 

If not known, ask: I 

8. (Including nursery or preschool) Did attend 

school at all during tbe past 12 months? 

D. During the past 12 months, 

cause to miss any time 

did --(condition/A/P) 

from school? 

I

1 i q lYe.8 Lx-

_--_----------------------------- c-----------------------------------

C, How many days in the past 12 months did miss I 118-18 

all or part of the day? I Days I

I 999 q DK 

8. During the past 12 months, did @condition/A/P) 18 

cause - - to stay in bed more than half of the day? 

_---------------------~~--~~--~~~~ -----------------------------~ 

b. How many days in the past 12 months did - - stay r--­

in bed more than half of the day? I 

I Days

! 999 q DK ---------------------------------c------------------------------------~-­

c. During the past 12 months, did - - (condition/A/PI limit or 1 i q Yes IAL. 

prevent - - from doing usual childhood activities, such as 

playing with other children or participating in games or sports? 1 z0No 

, snDK 

,. During the past 12 months, about how many nights [ ooonNone 1 

did spend in the hospital because of I (condition/AIP)? I Number of nights

f 999 q IDK 

i. During the past 12 months, about how many times did 

I 

I 1 

[--/anyone] see or talk to a medical doctor or assistant about ; 000 q None 

this (condition/A/P)? (Do not count doctors seen while an I overnight patient in a hospital.) I Number of doctor visits 

i 999 q IDK 

I . During the past 12 months, did this (condition/AIP) make it 1 1 q Yes 1 

necessary for to use any medicine, other than vitamins, 

; z0No that a doctor prescribed OR told to take? 

! s0DK I 

I ,k I

CHECK I I 0 Group D or F or H (8) 

ITEM 16 Refer to Check Item 14 I 8 0 All others (7) 

I 

. During the past 12 months did have any surgery 1. 1UYes 

-1 

performed, including bone settings and stitches for 

this (condition/AIP)? ’ Z~NO

; snDK 

tt. In the last 12 months, how often [did this condition/the [ I 0 All of the time 1 

conditions resulting from thew cause pain or I 2 q Often discomfort or upset - all of the time, often, once in a I 

, s q Once in a while while, or never? 

I o 0 Never (Check /tern 771 

_---------_--------_---------~--- L--------.------------~~-~~~~---- --_ 

b. When this condition did bother --, was bothered I 

I I 0 Great deal T a great deal, some, or very little? 

! 20Some 1 

I 3 0 Very little I 

I 36 I 

CHECK Refer to Check Item 14 i I 0 Group A or I3 or D or F (NC) 

ITEM 17 I s 0 Other (91 

I 

213 
--- 

Section P6 - SUPPLEMENTAL 

6a. Did the (condition) result from an accident, injury or poisoning? 

b. Did this occur within the last 12 months? 

--_----_____-___----_____________ 

C. Did You already tell me about this accident, injury or poisoning? 

_----____-________--__________ d. Which accident, injury, or poisoning was it? 

------------+------------m&--mm---­

g. What kind of accident or injury or poisoning was It? 

Hand Card P3, readlist if telephone interview. 

f. Which of the conditions on this list OR ANY OTHER 

CONDITIONS resulted from the (entry in Se). 

Mark all that apply in chart and ask Sg. 

__----___--______-----~~~-------- g. Were there ANY other conditions that resulted from this 

accident, injury or poisoning? 

Mark any additional conditions. __----__---______-----~-....~~~------

h. Where did this accident or injury or poisoning happen? 

DO NOT READ CATEGORIES 

Mark only one box. 

Notes 

I 

+. 

I 

I 

I 

r’ 

I 

I 

I 

t. 

I 

I 

I 

I 

I 

I’ 

I 

I 

I 

I 

I 

I 

I 

I 

I 

.II 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

-L 

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I 

I 

I 

I 

-II 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

I 

c 

DNDITION PAGE - Continued 

I q lYes ) 36 

--------__------___------------

I q lYes m 

z0No _______-______--____----------- m I q Yes 

2 0 No (Se) 

------------..-------------------E 

Condition No. (NC) 

--------------------------.--.--E 

Brief description 

-----------__----------~-----~d---

01 q Broken or dislocated bones 46-d 

40-r 02 0 Sprain, strain, or pulled muscle E aa 0 Cuts, 

wounds 

scrapes, or puncture 60-

62-1 04 0 Head injury, concussion E 

05 0 Bruise, contusion, or internal 

bleeding 64-1 

66-I oe [7 Burn, scald E 07 0 Poisoning from chemicals, )68-l medicines, drugs 

08 0 Respiratory problem, such as E breathing, cough, pneumonia 60-I 88 0 Other 62-r 

aa 0 Don’t know type 

of condition Wd 64-l 

66-r oo 17 None E 

__----____________--__________i___ 

0 Yes (Reask Sf, THEN Shl 

1 [7 Home (not necessarily child’s) 

2 0 Day care location (preschool/nursery) 

3 0 School (including grounds and 

athletic areas) 

4 q Street or highway 

a 0 Public building or space (other 

than street or school) 

a [7 Farm or agricultural area, except 

farm home 

7 •i Place of recreation or sports, except 

at school 

8 0 Other 

s 17 Don’t know 

214 
-- 

-- 

-- 

--- 

-- 

Section P7 - GENERAL HEALTH STATUS ( 

u CHECK I

I 

ITEM 18 Refer to age of sample child. I

I I 0 3 + years old (7) 

I z 0 Under 3 years old (3) 

1. Does - - wear glasses or contact lenses? I 1 

I q Yes 20No 

2. About how long has it been since LAST saw I I 0 6 months ago or less 1 

someone for dental care? I 

I 2 0 Over 6 months to 12 months 

I 5 0 Over 12 months to 2 Years I 

I 4 0 Over 2 year5 to 5 years 

I 

I 5 0 More than 5 years 

I o 0 Never I 5mDK 

3. When riding in a cer, does wear a seat belt or I 0 AH /most of time 

1 

restraint ell or most of the time, some of the time, 

once in a while, or never? 2 0 Some of the time 

3 0 Once in a while 

o 0 Never 

I 5nDK I

1 

I 1 ZHECK I I 0 Under 6 years old and biological mother is respondent (4) 

ITEM 19 Refer to age of sample child. 5 mother (6) 

10 

4a. Dld you smoke cigarettes at all during the year I q lYe5 before was born? 2 0 No (4e) 

I 

--------------------------------~-------------------------------

m b. Did you continue to smoke during the entire pregnancy? I 

I 

I I q Yes 14dl 

I 

I 20No 

I --------------__----____________ I------------------------------­

c. Dld you stop during the first three months of the r 0 Before pregnancy n 

pregnancy or later? 

2 0 1 st three months 

5 0 Later 

90DK 

--------~_------________________ ‘-------------------------------~ig=~ 

d. About how meny cigarettes e day did you usually smoke? 

Number 

55nDK 

-----------_____---------------- +----------------T-----------em,-T5F 

8. Do you now smoke? I 

I i q lYes(5) 

I 20No 

--------------------------------~-------------------------------

f. How long ago drd you stop? 1 16-18 

I [7 Days 

2 0 Months 

Number 1 3 0 Years 

5. During most of your pregnancy, would you say you I 

I I 0 Occasionally 1 19 

were In contact with persons who smoked cigarettes 2 0 Often 

such as friends, co-workers or family members - 3 q Always occasionally, often, always or never? o 0 Never 

5nDK 

6a. Her anyone In your household smoked regularly 1 q Yes 1 

since - - was born? 20No 

50DK 1 (7) 

--------------------------------~--------~----------------------

b. Is anyone in the household currently smoking cigarettes? i 7q lYes 171 x 

I 

I 2 0 No 16~) 

9 0 DK (7) 

I ____------------____------------ +--------------------------~--------

c. How long has it been since anyone in the household I 

I 

I 0 During the last 12 months L-E 

rmoked cigarettes? 

I 

I 2 0 More than 12 months ago 

I 

215 
-- 

-- 

-- 

-- 

-- 

-- 

-- -- 

-- 

-- -- 

-- 

-- 

-- 

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

Section P7 - GENERAL HEALTH STATUS - Continued 

7. Please tell me whether each of the following statements about health is mostly true or mostly false. 

The first statement is: “(sample chi/dj health is excellent.” Has this been mostly true or mostly false? 

(Record response and continue with statement b.) 

Mostly Mostly 

true false 

Ill I (21 I 

a. health is excellent ..................................... 10 20 

( 24 

b. --seems to resist illness very well ........................... 10 20 

1 25 

C. seems less healthy than other children I know ............... 10 20 

1 26 

d. When there is something going around, usually catches it . . _ _ . . . 10 20 

1 27 

8. Issomewhatclumsy .___. __._. _._.. . . . . . . . . . . .__ __._... 10 20 

) 26 

f. seems accident-prone ................................. rcl 20 

1 29 

D. When is sick or injured, usually recovers quickly ......... 10 20 

8a. Has EVER been seriously ill? I iUYes 

; 2[7No 

f suDK > (Check Item 201 

------------------------------------r-------------------------------­

b. Was EVER so sick that you thought might die? I iUYes L-z 

’ 20No 

; enDK 

I k 

ZHECK I

1 1 [7 Under 1 year 1701 

TEM 20 Refer to age of sample child. i 2 q 1 + years old 191 

I 

1 ( 

DC. On weeknights (If 4+: during the school year), does usually go 1 , q Ras usua, bedtime 

to bed at about the same time each night, or does bedtime vary / 2 [7 Bedtime varies (9cl a lot from night to night? 

________------------------------ ----I--- ---------,o,,------dd--~~ 

b. About what time does usually go to bed? I 

I 

I 2Up~m~~‘70) 

Round time to nearest quarter hour. 1 99999u DK --------+----------------------------

C . What is the latest time that - - goes to bed on weekdays? I i q a.m. 

-Ja& 

I 

I 2 q p.m. 

Round time to nearest quarter hour. ( 99mu DK 

Oa. Does-- usually sleep in one room or in different rooms? I b!­ I I q One room 

I 2 0 Different rooms 

___--_________-__-------------------~----------------------------

b. Does - - usually sleep alone in a room or share a room? I E 

1 I 0 Alone (Section P8) 

1 20 Shares 

------------------_----------------- i 

c. Who usually sleeps in the room with ---7 I 

I 17 Brother(s) 

2 0 Sister(s) 

Mark all that apply. 3 0 Other childben) 

4 q Father 

5 0 Mother 

Anyone else? 8 0 Other adult(s) 

6nDK 

I 
-- 

-- 

-- 

-- 

-- 

-- 

-- 

-- 

-- 

-- 

Section P8 - SCHOOL 

CHECK c 0 Under 5 years cld (Section P9) 

1 63 

ITEM 21 Refer to age of sample child. 

I 0 5 -I- years old 

1. Has ever attended school? I 1 q Yes I 64 

I 

I 2 0 No (Section P9) I 

2. Is NOW either going to school or on vacation I 

I I q Going to school 1 66 

from school? I 

I z q On vacation from school 

I o 0 Neither (5) 

I is - - in now? I 21 0 Nursery school or preschool I 3. What grade will be in? 1 / 22 0 Kindergarten > (Section P9) 

If child is between grades, enter grade promoted to. I 

/ I 

I Grade 

4. Overall what kind of student would you say - - is now? I I 0 One of the best 1 

Is one of the best in the class, above the middle, in the I 

I 2 0 Above the middle 

I middle, below the middle, or near the bottom of the class? I s 0 In the middle 161 I 

I 4 0 Below the middle 

I 5 0 Near the bottom 

5a. Whydid stop going to school? I o q Never went - health reasons. lSection pg, 1 

I 0 Never went - other reasons > 2 0 Graduated 

3 0 Health problem 

4 0 Dropped out 

I 8 q Other - Specify z 

I 

I 

I 

I 

I I I 

I --------------------------------f----------------------------------- I I 

b. How long ago did stop going to school? I I 0 Less than 12 months I 

I 2 0 12 months - less than 2 years (7) 

I 3 0 2 + vears (71 

61-62 6. During the past 12 months, that is, since (12 month date) 1 ooONone 

a year ago, about how many days was absent from 

school because of illness? I Davs -I 

I 7a. Hos T - repeated any grades for any reasons? I i q Yes 2 0No (81 _--___--------_------------------ /-------------------------------

b. Whet grade or grades did repeat? I 

I 

I Grade(s) --------------------------------f---------------------------------------

C . Why did - - repeat the (grades in 7bl grade(s)? I I 0 Academic failure I 

I 2 0 Immature/acted too young I 3 0 Frequently absent I 

I 4 0 Moved into more difficult school 

Mark all that apply. I 

I s 0 Other - Specify 7 

I 

I 

-----~-------------------------- s0DK L-----------------------------~~--

1 

d . Any other reasons? I q Yes IReask 7c and d) 

I ONo , 

- - ever been suspended, excluded, or expelled I

I 1q lYes 1 

8ag k school? _____-____-____---_-------------~------------------------------- 2 0 No (91 

m b. How merry times has this happened? I 

I 

Number -____-,___--___-___-------------~-------------------------------

C. How long ego was the last time? I 

I 10 Days 1 77-79 

I 2 0 Weeks I 3 0 Months I 

&------------ ------------------1-~- 4 0 Years 

d. -Wesitto~~a~horT;B?;aviorreasons)------------- , I 0 Health I 

I 2 0 Behavior 

8 0 Other I 

I sUDK 

3a. Not counting routine conferences, has anyone from I 

I 1q lYes 1 61 

school ever asked someone to come in to talk about I 

I 2 0 No /Section P9! problems - - was having? -----‘-----------------------------.---------------------- I -----_

b. How long ago was the last time? I I 0 Days 1 

I 2 0 Weeks I 

I Number 3 0 Months 

I 4 0 Years 

FORMHIS-,l\,1988,,10-23.8 

217 
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-- 

-- 

-- 

I 

1 Section P9 - DEVELOPMENT, LEARNING, BEHAVIOR 

I. Has EVER had - I I El Yes 

k 

I 

I znNo 

a. a delay in growth or development? I 

I 

--------------------------------t----------------------------------- d-k 

Mark box or ask: 1 o [7 Child under 3 (Check /tern 22) -LL 

b. a learning disability? I 

1 lOYes 

1 20No -----------------~--------------r-----------------------------------

E C. an emotional or behavioral problem that lasted 3 I

I lOYes months or more? ’ 2C1No 

I k

CHECK I I 0 1 or more “Yes” in 1 a-c 121 

ITEM 22 Refer to 1 i s c] All other (Check /tern 231 

I 

I 

I Delay in Learning Emot~io~geavior 

Development Disability 

Ask 2a-h for each “Yes”in la-c. (I) (2) (3) 

I h 1 23-26 1 

I 

I ooo 0 Since birth oooq Since birth ooo q Since birth 

I q Months I q Months 

2a. How old was when the (condition) was first noticed? 2 q lYears 

Age 2 q Years 

-----------------------------v----------­

b. Has ever received treatment or counseling for the I lOYes I 1 q Yes I-A 

(condition17 2 0 No L?e) 

d----_­

m C. Has-- received any such treatment or counseling 

during the past 12 months? 1 q Yes 2 q No (2el 

d. 

_-------------------------------L-----------

During the past 12 months, about how many times did u

___ ,_-__--- I 

anyone see or talk to a doctor, psychologist, or counselor I 

about this problem? I Times 

; SSSODK 

---------------------m----------+-------7-z- ,------- I Mark L!L- box or ask: I o q Not in school 12h ) e. During the past 12 months, did the (condition) cause 1 I q Yes to miss any time from school? 1’ zONof2gl ____------------------------ ----t----m .-------

f . On how many days in the past 12 months did miss part 

or all of the school day because of this problem? 

Days 

I

, sss[7DK ssso DK --------------------------------r-----------

9. During the past 12 months, did the (condition) make it I I 

necessary for - - to attend special classes, or a special 1 1CiYes 

school, or get special help at school? I znNo 

--------------------------------’ _------­ i-------- h. During the past 12 months, has - - been taking any E l 

medicine for the (condition)? I iClYes 

1 20No 

I 

; (Cot. (2) or Section PI 0, (Cal. 131 or Section PlO) (Saotion PlOl 

I 

I 

I 

I 

CHECK 

ITEM 23 Refer to age of sample child. 1 o 0 Under 3 years old (Section PlOl 

I I 0 3+ years old (3) 

I 1 E 3a. Has ever seen a psychiatrist, psychologist, I 

doctor, or counselor about any emotional, mental, I i q Yes 

‘or behavior problem? 1 20No(L?d 

--------------------------------L_______-------------------

D. When was the last time saw this person? I 0 More than 12 months ago ------lx 

2 0 Within past 12 months (Section PlOl 

--------------------------------r----------~-------------------­

c. During the past 12 months, have you felt, or has anyone I -&-

suggested, that needed help for any emotional, I 

mental, or behavioral problem? I 

/ i q lYes I 2C7No I 

’ i 

I 

I 

218 
-- 

-- 

-- 

-- 

-- 

Section PI 0 - HEALTH SERVICES 

I 

I I 0 Less than 6 months 1 

Now I will ask about ROUTINE care, including routine I z 0 6 months, less than 1 year checkups and immunizations when nothing is wrong. I 

I s 0 1 year, less than 2 years 

1. How long has it been since - - last visit to a clinic, I 4 q 2 years, less than 5 years 

health center, hospital, doctor’s office or other place I 5 q 5 or more years 

for routine health care? I sODK 

I o 0 Never 14) I 

I E 2. is there a particular clinic, heeith center, hospital, I 

I 1q Yes 

doctor’s office or other place that - - usually goes I z 0 No (41 to for routine health care? I 

I 

1 3. What kind of place is it - a clinic, a health center, a 010 Home 

hospital, a doctor’s office, or some other place? 02 0 Doctor’s office or private clinic 

PROBEIF CLINIC: b3 0 Company or school clinic 

04 0 Hosbital outpatient clinic Is this a private clinic, a hospital outpatient clinic, os 0 Migrant clinic a company or school clinic, a migrant clinic, or 

some othar kind of clinic? 1 os 0 Other clinic - Specify 

I or q Hospital emergency room PROBE IF HEALTH CENTER: ’ OS 0 Community, neighborhood, or family health center is thls a community health center, neighborhood 

health center, a family health center, a rural health 1 OS 0 Walk-in/emergency care center 

center, or some other kind of health center? IO 17 Rural health center 

PROBE IF HOSPITAL: I I 0 HMO/prepaid group 

is this an outpatient clinic or emergency room? 8s 0 Other place - Specify 

Now I will ask about - - visits for health care when I ( 

I is sick or injured. I 

4. is there a particular clinic, health center, hospital; i q Yes 

doctor’s office or other place that - - usually goes 2 0 No (8) 

to when - - is sick or injured? 

5. is this the same (place in 31 or is it somewhere else? I 

I 1 Cl Same place ( 

I 2 0 Somewhere else I 

IF”SAMEPLACE”IN5, REFERTO3ANDMARK I 

I ) 

WITHOUTASKING, OTHERWISEASK: I 

I 

6. What kind of place is it - a clinic, a health center, a 1 01q Home 

hospital, a doctor’s office, or some other place? 1 02 0 Doctor’s office or private clinic (91 

PROBEIF CLINIC: I 03 0 Company or school clinic 

Is this a private clinic, e hospital outpatient clinic, a ’ 04 0 Hospital outpatient clinic 

company or school clinic, a migrant clinic, or some I 05 0 Migrant clinic 

other kind of clinic? 1 06 0 Other clinic - Specify 

PROBE IF HEALTH CENTER: I 07 0 Hospital emergency room 

is this a community health center, neighborhood OS 0 Community, neighborhood, or family health center 

health center, a family health center, a rural health OS 0 Walk-in/Emergency clinic 

center, or some other kind of health center? IO 0 Rural health center 

PROBE IF HOSPITAL: I I 0 HMO/prepaid group 

is this an outpatient clinic or emergency room? r ss 0 Other place - Specify I 

1 7a. is there a particular medical person usually sees at the 1 I q Yes (place in 6) when is sick? I 2 0 No (91 

-------------------------------J-------------------------------­

b. Is there someone at the {place in 61, that knows about 1 i q Yes E 

hoaith history who will give you advice over the telephone? I 2[7No (91 I snDK I 1 I 

Hand Card P4. Read categories if telephone interview. I 

I ) 

I 

8. Many people do not have a particular place they usually go ; 

when they are sick. (Could you please give me the number 

of the statement) which is the MAIN reason does not I 

I 

have a particular place - - usually goes? 

I 

I 1 2 3 4 5 I *z I 1. Has two or more usual doctors or places depending I 

on what is wrong. I 

2. Has not needed a doctor. I 

I 3. Previous doctor no longer available. I Specify 

4. Have not been able to find the right doctor. I 6. Recently moved to area. I 

8. Other reason (Specify). I 

I’ 

I 

I 

I 

, 
-- 

-- 

-- 

-- 

-- 

-- 

Section PI 0 - HEALTH SERVICES 

- Continued 

I 1 66 9u. During the past 12 months, that is since /12 month date1 a I 

I I •1 Yes 19c) 

year ago, did receive any health care which has been I 20 No or will be paid for by Medicaid? I s0DK 

-----___________________________ +-----------~-------------------~~ 

b. During the past 12 months, was covered at any I 1 Cl Yes I 

time by Medicaid? I 20No I 

I snDK 

C . During the past 12 months, did receive assistance I 

I 

1q lYes f--ii-­

through the “Aid to Families with Dependent Children” I znNo 

program, sometimes called AFDC or ADC? I 

I snDK 

I 

IO. Is now covered by a health insurance plan which I 

I 

1 0 Yes 1 66 

pays any part of a hospital, doctor’s or surgeons bill? I 

I 20 No I s[7DK I 

1lg. Has EVER been enrolled in the “Head Start” 1 70 

program? 10 Yes 

20 No 

90 DK ““’ 

__-------_____-----_--~-~~~~ ----~----------------~-~~-~~d----~~d4-~w. 

D. In which “Head Start” program was enrolled, the I L-z- Center based or the Home based program? I I c] Center based I 

I 2 0 Home based 

I snDK I 

totes 
-- 

-- 

I 

I 

-- 

I 

Section PI 1 - BEHAVIOR PROBLEMS INDEX I ( ZHECK I I 0 Under 5 years old (Cover Pagel 

TEM 24 Refer to age of sample child. I 

I 2 0 5 + years old Ilntrol 

I - Now I am going to read some statements that describe the I 

behavior of many children. Please tell me whether each I 

statement has been OFTEN true, SOMETIMES true, or NOT true I 

of during the past 3 months? I 

I 

The first statement is: “Has sudden changes in mood or I 

feelings.” Has that been OFTEN true, SOMETIMES true, OR I 

I NOT true of in the past 3 months. I 

I Record response and continue with statement 2. I 

Read list repeating categories and/or time reference as needed. I 

I 

I 

I Often true Sometimes Not true I true 

I (al (bl (c) 

I 

1. Has sudden changes in mood or feelings. t 

I 10 20 30 l-zI 74 

2. Feels or complains that no one loves --. I 10 20 30 

I 1 

3. Is rather high strung, tense, or nervous. I 10 20 30 

I 1 

4. Cheats or tells lies. I 10 20 30 

I 1 

5. Is too fearful or anxious. I

I 10 an 30 

I 10 ( 

6. Argues too much. I

I 20 30 

I 1 

7. Has difficulty concentrating, cannot pay attention for long. I 10 20 30 

8. Is easily confused, seems to be in a fog. I 10 20 30 1 

I 

I 

9. Bullies, or I5 cruel or mean to others. I 10 20 SO IAL 

I 1 

10. Is disobedient at home. I 10 20 30 

I 

11. I5 disobedient at school. I

I 10 20 

I 10 20 30 1 

12. Doer iot seem to feel sorry after misbehaves. 

I 1 

13. Hos trouble getting ,along with other children. I 10 20 30 

1 I 

14. Has trouble getting along with teachers. I 10 20 30 

16. Is Impulsive, or acts without thinking. I

I 10 20 30 ) 

I 

I e 

16. Feels worthless or inferior. I

I 10 20 30 

I 

17. Is not liked by other children. 

thoughts, has obsessions. w I 19. I5 restleas or overly active, cannot sit still. ’ I 10 20 30 

I 1 I 10. Is stubborn, sullen,br irritable. I 10 20 30 

I 1 

!I. Ho5 a very strong temper and loses it easily. I

I 10 20 30 

I 94 

22. Is unhappy, sod or depressed. , 

I 10 20 30 

I I 1 

23. Is withdrawn, does not get involved with others. I 10 20 30 

If child is 12 + years old, go to 29. I ( 

24. Breaks things on purpose, deliberately I 

I 

10 20 30 

doatroys - - own or others’ things. I , 

I E 

35. Clings t0 0duits. I 10 20 30 

I b 

26. Cries too much. I 10 20 30 

I

I m 

27. Domands a lot of attention. I 10 20 SEI 

I I 100 I 

28. Is too dependent on others. I 10 20 au -

If child is under 12 years, go to Coqer Page 

I 

I 

I 10 20 30 

1 101 

29. Feels others are out to get --. I FORM HIS-1A I19891 110-23-87) 

221 
r Section PI 1 - BEHAVIOR PROBLEMS INDEX - Continued 

I

I 

I Often true I 

Sometimes Not true true 

I (4 (b) kd I 

30. Hangs around with kids who get into trouble. I IO 20 3u Llw- I 

31. Is secretive, keeps things to thimselflherselfl. 

32. Worries too much. 

Notes 
-- 

OMS No. 0937-0021: Approval Expires 03/31/89 

~99:“~4,~HlS-3 U.S. DEPARTMENT OF COMMERCE NOTICE - Information contained on this form which would permit identification of B”REA”OFTHECENS”S any individual or establishment has been collected with a 9uarantee that it will be held in strict confidence, will be used only for purposes stated for this study, and will not be disclosed or released to others without the consent of the individual or the I ALCOHOL QUESTIONNAIRE establishment in accordance with section 30Sldl of the Public Health Service Act 

1. RO 2. Sample 3. Control number 

PSU i Segment 

I 

I

1 

INSTRUCTIONS -

ever happened to you 

IN YOUR ENTIRE LIFE HAVE you ever.. . 

1. Had a strong desire or urge to drink? 

‘2. Started drinking even though you hadn’t 

142 USC 242ml. 

4. Person 5. interviewer’s name I Code 1 

1 Serial number 

I 

I

I 

Please circle “Yes” or “No” if any of these things have 

IN YOUR ENTIRE LIFE. If you need any help ask ma for 

Intended to? 

3. Ended up drlnklng much more than you Intended to?’ 

4. Found it difficult to stop drinking once you had started? 

5. Driven a car after having had too much to drink? 

6. Bean sick or vomited after drinking, or the morning after? 

7. Done things when drinking that could have caused you to be hurt? 

8. Felt the effects of alcohol sooner than you used to? 

9. Kept on drinking for e longer period of time than you intended to? 

10. Found that the same amount of alcohol had less effect than before? 

11. Felt depressed, irritable, or nervous after drinking, or the morning after? 

I” 

12. Felt powerless over your drinking? 

13. Sought help from family, frienda, profassionals or self-help groups about your drinking? 

14. Had a spouse or someone you lived with threaten to leave you because of your drinking? 

15. Gone on banders or bingea that lasted two or more days? 

16. Tried to cut down or stop drlnking and found you couldn’t do it? 

17. Found yourself sweating heavily or shaking after drinking, or the morning after? 

IS. Given up or cut down on activities or interests like sports or essociations with frlends, In 

order to drink? 

19. Boon unable to remember some of the things you did while drinking? 

20. Needed l drink so badly you couldn’t thlnk of anything else? 

21. Found thst you hsd to drink more than you once did to get the ssma l ffoct? 

or have not 

assistance. 

I 

I 

I 

I iYes 2No IIiI I 

, 

I 

I tYes 2No I I

I 

I 

I 

I iYes 2No 1 

I 

I 

I 

I 1Yes 2No I 

I 

I tYes 2No 

I 

I 

I tYes 2No I 

I 

I 

I tYes 2No I 

I 

I 

I iYes 2No t 

i 

I 

I 

I tYes 2No I 

I 

I 

I tYes 2No 16 

I 

I 

I 

I IYes 2No I 

, 

I 

I tYes 2No 17 

I 

I 

I 

I 1Yes 2No 18 

I 

1 

I 

I 

1 Yes 2No 1B 

I 

I 

I iYes 2No I 

I 

I 

I 

I tYes 2No 21 

I 

1 

I 

I iYes 2No 22 I

8 

I 

I 

I IYes 2No 1 23 

I 

I 

’ I I iYes 2No 24 

I 

223 
ALCOHOL QUESTIONNAIRE - Continued 

I 

INSTRUCTIONS - Please circle “Yes” or “No” if any of these things have or have not ever happened to you IN YOUR ENTIRE LIFE. If you need any help ask me for assistance. _ 

I 

I IN YOUR ENTIRE LIFE have you ever.. . I 

I 

22. Stayed away from work or gone to work late because of drinking oc a hangover? I 

I iYes 2No 1 

I 

23. Spent money on drinks that was needed for essentials like food, or bills? I iYes zNo 1 

; 

24. Lost ties with or drifted apart from a family member or friend because of your drinking? ; iYes 2No I 

! 

I 

I 

25. Gotten drunk instead of doing the things you were supposed to do? I 1Yes 2No E 

I 

26. Had a doctor suggest that you cut down or stop drinking alcohol? I iYes 2No 1 

, 

I 

27. Continued to drink alcohol even though it was a threat to your health? I iYes 2No CE 

t 

8 

26. Lost a job, or nearly lost one, because of drinking? I 

! tYes 2No Ez 

, 

! 

29. Had family, friends or co-workers suggest that you itop 01 cut down on your drinking? I iYes 2No E 

I 

I 

30. Done things when drinking that could have caused someone else to be hurt? I 

I iYes 2No E 

I 

I 

I 

31. Felt uneasy if alcohol was not around in case you wanted a drink? I

I 

iYes 2No I 

i 

32. Spent a lot of time drinking, or getting over the effects of drinking? I tYes 2No I 

I 

I 33. Been so hung&or that it interfered with doing things you were supposed to do? I iYes 2No 1 

I 

34. Kept drinking even though it caused you emotional problems? I

I iYes 2No 1 

I 

I 39. Had your chances for promotion, raises, or bener jobs hurt by your drinking? I

I *Yes 2No 1 

36. Heard 01 seen things that weren’t really there after drinking, or the morning after? I 

I IYes 2No I 

37. Taken e drink to keep yourself from shaking or feeling sick either after drinking, or the I 

I 1Yes 2No I3 morning after? I 

I 

I I 

36. Kept drinking even though it caused you problems at home, work, or school? I iYes 2No , .a 

I 

I 

I 39. Attended e meeting of Alcoholics Anonymous (AA) because of your drinking? I iYes 2No 43 

I 

I 

I 

40. Been aneated ot had trouble with the police because of your drlnklng? I 

I iYes 2No 

I 

I 41. Wanted to cut down or stop your drinking and found you couldn’t do It? I iYes 2No 

224 
1 

ALCOHOL QLtESTIONNAjRE 

1. RO 2. Sample 3. Control number 4. Person 5. interviewer’s name i Code 

I PSU i Segment ! Serial number I 

[ 3-4 INSTRUCTIONS - In COLUMN 1, please circle the answer that best describes the 

number of times each of these things has happened to you INTHE PAST 12 ‘COLUMN 1 COLUMN 2 

MONTHS. Complete column 1 for each question first. Then go back and in COLUMN 

2, circle “Yes” or “No” if any of these things have or have not ever happened to YOU IN THE PAST 12 MONTHS how In your ENTIRE LIFE 

IN YOUR ENTIRE LIFE. If you need any help ask me for assistance. msny times have you.. . have you ever.. . 

0 1 2-3 4 or more 6 iYes 2No 6 

1. Had a strong desire or urge to drink? 

0 1 2-3 4or more I 7 1Yes 2No is 

2. Started drinking even though you hadn’t intended to? 

0 1 2-3 4 or more 9 lYes 2No 2 

3. Ended up drinking much more than you intended to? 

0’ 1 2-3 4ormore ‘I’ tYes 2No 12 

4. Found It difficult to stop drinking once you had started? 

0 i 2-3 4 or more ‘13 lYes 2No 5. Driven a car after having had too much to drink? 

6. Been sick or vomited after drinking, or the morning after? 0 1 2-3 40r more 1. 15 -Yes 2No ‘16 

I 0 1 2-3 4ormore i ‘17 lYes 2No ! ‘* 

7.. Done things when drinking that could have caused YOU to ba hurt? 

0 1 2-3 4 or more 19 - 1Yes 2No ] 20 

8. Felt the affects of alcohol soonar than you used to? 

Kept on drinking for a longer period of time than you intended to? 0 1 2-3 4ormore I 21 . ryes 2No 

Found that the same amount of alcohol had less effect than before? 0 1 2-3 4ormore 23 ryes 2No 1 24 

Falt depressed, irritable, or nervous after drinking, or the morning after? 0 1 2-3 iYes zNo 1 26 

Felt powerless over your drinking? 0 1 2-3 4 or more iYes 

13. Sought help from family, friends, professionals or satf-help 0 1 2-3 4 or more 29 IYes 2No 30 

groups about your drinking? 

14. Had a spouse or someone you lived with threaten to leave you bacausa of j 0 1 2-3 4ormore I 31 iYes 2No 1 32

your drinking? 

0 1 2-3 4 ormore I 33 iYes 2No 34 

15. Gone on banders or binges that lasted two or more days? j 

T 8. Tried to cut down or stop drinking and found you couldn’t do it? P 1 2-3 4ormore ” IYes 2No 136, 

17. Found yourself sweating heavily or shaking after drinking, or the 0 1 2-3 iYes 2No 

morning after? I 

18. Given up or cut down on activities or interests like sports or 0 1 2-3 4 or more 39 iYes 2No 40 associations with friends, in order to drink? 

1% Bean unabla to remember some qf the things youdid 0 1 2-3 iYes 2No while drinking? 

0 1 2-3 iYes 2No 20. Needed a drink so badly you couldn’t think of anything else7 

I

21. Found that you had to drink more than you once did to gat the 

I 0 1 2-3 ’ 4ormore iYes 2No -me sffaa? 

225 
Had 

ALCOHOL QUESTIONNAIRE - Continued 

COLUMN 1 COLUMN 2 

IN THE PAST 12 MONTHS how In your ENTlRE LIFE 

I many times have you.. . have you ever,. , 

22. St&d away from work or gone to work late because of 0 1 2-3 4 or more 47 iYes zNo E 

drinking or a hangover? I 

23. Spent money on drinks that was needed for essentials like food, 0 1 2-3 4ormore 4g iYes zNo E or bills? 

I 

24. Lost ties with or drifted because of drinking?apart from a family member or friend 0 1 2-3 4 ormore 1 ” iYes 2No 1 

your 

25. Gotten drunk instead of doing ths things you wera 0 1 2-3 4ormore 1 63 tYes zNo E 

supposed to do7 

I 

26. alcohol? Had a doctor suggest that you cut down or stop drinking 0 1 2-3 4or more iYes zNo E

I 

27. Continued to drink alcohol even though it was a threat to your 0 1 2-3 4 or more IYes 2No 1 

health? I 

I 

0 1 2-3 1Yes 2No k%L 

28. Lost a job, or nearly lost one, because of drinking? 

29. Had family, friends or co-workers suggest that YOU stop or cut down on 0 1 2-3 4 ormore 61 iYes 2No 1

your drinking? 

30. Done things when drinking that could havecaused someone else to be hurt? I 0 1 2-3 4ormore 63 IYes 2No E

31. Felt uneasy if aIcoho1 was not around in case you,wanted a 0 1 2-3 4 or more 65 drink? IYes

I 

32. Spent a lot of time drinking, or gening over the effects of j 0 1 2-3 iYes zNo ‘-I g* drinking? 

I 

33. Been so hungover that it interfered with doing things YOU we10 supposed to do? I 0 1 2-3 40r more I 69 iYes 2No &

I 

34. Kept drinking even though it caused you emotional problems? 0 1 2-3 4ormore ” iYes 2No 1 

35. Your your drinking? chances for promotion, raises, or better jobs hurt by 0 1 2-3 4 or more IYes 2No m

36. Heard or seen things that weren’t really them after drinking, or the morning I 0 1 2-3 4 ormore I ” IYes 2No E after? 

37. Taken a drink to keep yourself from shaking or feeling sick 0 1 2-3 .4 or more I ” iYes 2No E either after drinking, or the morning after? I 

38. Kept drinking even though it caused you problems at home, 0 1 2-3 4ormors 7s iYes 2No E work, or rchool? I 

3% your Attended drinking? a meeting of AIcohoIict Anonymous IAAi bscauea of 0 1 2-3 4ormore 1 *’ IYes 2No =

46. Been arrested or had trouble with the police because of your 0 1 2-3 4 or more 1Yes 2No E drinking7 . 

41. Wanted to cut down or stop your drinking and,found You I 0 1 2-3 iYes 2No E couldn’t do it? 

226 
OMB# 0920 0214 Apbroval Expires 3.31-8 

FOPMHIS-4A (1988) 

NATIONAL HEALTH INTERVIEW 

SURVEY 

AIDS KNOWLEDGE AND ATTITUDES 

NOTICE - Information contained on this form which would permil ~dentilicebon dl any individual or eotablirh. ment has been collected with a guarantee that it will be held in stric:,confidencs. will be used only for purposes stated far this study. and will not be disclosed or released to others without the consent of the-individual or the establishment in accordance with secdon 3oeldl of the Public Health Service Act 142 USC 242ml. 

1. 19--10 3. Sample w 

Book -of __ books 

4. Control number 5. Beginning time 

PSU TSwyt jxizxI a.m. 

6. NUMBER OF FAMILY MEMBERS lB+ YEARS OLD 

(Record number of nondeleted family members 18 + years old.) 

Space 133-361 

0 0 No person 18 + in this fa’mily (Household Page) 

I~WIOW{Complete’Item 63, Page 18) 

1 0 Complete Interview fall appropriate questions completed) 

2 0 Panial interview [some but not all appropriate questions 

completed1 -Explain z 

I. Ending time E.lnterview mode 

38-411 42 

I a.nl. 10 Personal 

2 p.m. 2 0 Telephone 

TRANSCRIPTION FROM COMPLETED HIS-l 

Noninterview (Complete I tern 63, Page 18) 3 0 Refusal l.Explain in Noted 

4 0 SP temporarily absent 

5 0 SP mentally or physically incapable 1 

8 0 Other - Explain z 

11. Interviewer identification 

Name 

2. sex of SP /page 2 or 51, 

1UM 

20F 

5. Marital status 1 

Page 46 014 7, question 71 

I 0 Matried - spouse In HH 

2 tf Mauled -spouse not I” HH 

3 0 Widowed 

4 0 Divorced 

5 0 Separated 

6q Nevermarried 

13. Education of SP (Page 42 ~43, 

oo 0 Never attended or kindergarten 

I 

I 

Elem: 1 2 3 4 5 6 ‘7 S 1 2 3 4 5 - Specify z 

High: 9 10 11 12 

College: 1 2 3 4 5 6 + 

_--_________________----

Finish grade/year IOuestion 261 K 

I Dyes 

20No 

I& Famdy income (Page 46. question 861 w 17. 155--56 18. 157-58 19. Booklet type 1 

oo[7A 07[7H 14ClO 210 v 

OllJS 06UI 15UP 

02nc 090J l6tlQ 

22u w 2317x Sample 

Person 

Sample 

Person 1 x AIDS Knowledge 

OJ~D 10nK 17UR 

04ClE IllIlL WCIS 

24u Y 

25clz 

Number Age and Attitudes 

Version 1 

osnF 12OM 19171 260 22 

0600 13UN 2oou 

(Transcribe from 8a if 8b blank) 

270520.0000rm0re - 29 q Less than 520.000 

227 

1 
Introduction: These nextquestions are to determine what people know about AIDS, 

also called Acquired Immunodeficiency Syndrome. 

1. In the PAST MONTH, have you . . . 

a. seen any Public Service 

Announcements about AIDS on 

television? 

b. heard any Public Service 

Announcements about AIDS on 

the radio? 

CHECK 

ITEM 1 Refer to Q. la,b 

2. Were any of those Public Service 

Announcements called "America 

Responds to AIDS"? 

3. In the PAST MONTH, have you read any 

brochures or pamphlets about AIDS? 

Do not include articles in magazines 

or newpapers. 

4. Have you EVER read any brochures or 

pamphlets about AIDS? Again, do not 

include articles in magazines or 

newpapers. 

1 II Yes 2 Cl No 9 II DK 1 

10 Yes 2 Cl No 9 II DK I 611 

Cl "Yes" in la and/or lb (2) 

0 Other (3) 

1 Cl Yes 0 62 

2 Cl No 

9 Cl DK 

1 Cl Yes (5) 

2 Cl No 

9 Cl DK 

Item 2) 

228 
5. Where did you get the pamphlets or 1 II Clinic, other than work clinic 65 

brochures? Anywhere else? 1 II Doctor's office/HMO 66 

(MARK ALL THAT APPLY) 1 0 Drug store 67 

1 II Public Health Department I 68 

1 0 Received it in the mail without 

asking for it 1 

1 Cl Red Cross/with Red Cross blood 

donation 

1 II With other blood donation 

1 II School 

1 II Sent/phoned for it myself, 

requested it 

1 0 "The 

state 

1 Cl Work, 

nurse 

1 0 Work, 

1 Cl Other 

LHECK 

ITEM * Refer to assignment 

6. The Government is mailing a brochure 

with basic information about AIDS 

to each household in the country. 

, HOLD COPY UP 

The brochure'looked like this. / 

The brochure is 8$'by 11 inches, white 

with blue and black printing, and has 

a picture of Dr. C. Everett Koop, the 

Surgeon General of. the United States 

on the cover, with the title, 

"Understanding AIDS" printed at the 

top.. 

Was this brochure received at this 

household? 

7. How much of the brochure did you read; 

would you say all or almost all of it, 

about half, less than half, or none of 

it? 

Government" - Federal, 

or local 

other than clinic or 

nurse or clinic 

(SPECIFY.) 

%?cF 

II May, June, July4 (6) 

II Other (17) 

1 0. Yes (7) 

2 Cl No 

9 Cl Don't Know I (17) 

1 ll All/Almost all 

2 II About half 

3 0 Less than half 

4 Cl None 

9 Cl DK 

70 

71 

Ed 

1 

1 

q

75 

76 

ml 

1 

vl 

229 
). When you read it, did you read it 1 II Read carefully 1 

carefully or did you just skim through it? 2 II Skimmed through 

8 0 Other (SPECIFY) 

9 Cl DK 

3. Did the brochure give you any new 1 II Yes 183. 

information or answer any questions 2 II No 

you had about AIDS? 

(IF ONE-PERSONHOUSEHOLD,MARK BOX 3 

AND SKIP TO Q. 11) 

10. Did you discuss the brochure with anyone 1 Cl Yes ml 

else in the family? 2 II No 

3 Cl One-person 

11. Do you have any children aged 1 Cl Yes 1 

10 through 17? 2 Cl No (21) 

12. How many do you have? 1 

13.,Did bhis child/any of your children 1 II Yes 1 

aged 10 through 17) read the 2 0 No 

brochure? 9 Cl DK 

14. Was the brochure discussed with &his ; i ;;s (16) 1871 

child/any of our children aged 

10 through 17r ? 9 II DK 

15. Have you ever discussed AIDS with &his 1 0 Yes IzE child/any of your children aged 10 2 II No 

through 17]? 

16. [Has this child/Have any or all of your 1 Cl Yes 1 

children aged 10 through 171 had 2 Cl No (21)

instruction at school about AIDS? 9 0 DK 1 

17. Do you have any children aged 1 Cl Yes 

10 through 17? 2 II No (21) 

I go 

18. How many do you have? [91-92 
--- 

19. Have you ever discussed AIDS with phis 1 II Yes 1 

child/any of our children aged 2 0 No 

10 through 17i ? 

20. Bas this child/Have any or all of your 1 0 Yes 1 

children aged 10 through 177 had 2 Cl No 

instruction at school about AIDS? 9 Cl DK 

21. How much would you say you know about 1 II A lot 1 

AIDS a lot, some, a little, or 2 0 Some 

nothing? 3 II A little 

4 Cl Nothing 

22. To the best of your knowledge, is 1 0 Yes 1 

there a difference between having 2 Cl No 

the AIDS virus and having the 8 Cl Other (SPECIFY) 

disease AIDS? 

9 II DK 

HAND CARD A 

?3. After I read each statement, 

tell me whether you think the 

statement is definitely true, 

probably true, probably false, 

definitely false, *or you don't Def. Prob. Prob. Def. 

know if it is true or false. True True False False DK 

a. AIDS can reduce the body’s 

natural protection against 

disease. 10 2u 30 40 90 1-37-j 

b. AIDS is especially common in 

older people. 10 20 30 40 90 r-%-] 

c. AIDS can damage the brain. 10 20 3u 40 9cl f-3q 

d. AIDS usually leads to heart 

disease. 10 20 30 40 90 /Tmq 

e. AIDS is an infectious disease 

caused by a virus. 10 20 30 40 90 jlol1 

f. Teenagers cannot get AIDS. 10 20 30 40 90 1--mq 

g. AIDS leads to death. 10 20 30 40 90 piq 

231 
3. (Continued) 

Tell me whether you think each of 

these statements is definitely true, 

probably true, probably false, 

definitely false, or you don't 

know if it is true or false. 

h. A person can be infected with 

the AIDS virus and not have the 

disease AIDS. 

i. Looking at a person is enough to 

tell if he or she has the AIDS 

virus. 

j. ANY person‘with the AIDS virus 

can pass it on to someone else 

through sexual intercourse. 

k. A person who has the AIDS virus 

can look and feel well and 

healthy. 

1. A pregnant woman who has the 

AIDS virus can give the AIDS 

virus to her baby. 

m. There is a vaccine available to 

the public that protects a person 

from getting the AIDS virus. 

n. There is no cure for AIDS at 

present.' 

Def. Prob. Prob. Def. 

True True False False 

10 20 313 40 

10 2cl 30 40 

10 20 30 40 

10 20 30 40 

10 20 30 40 

10 20 30 40 

10 20 30 40 

I -

. 

I 

, 

232 
--- 

HAND CARD B 

14. After I read each statement, tell 

me if you think it is very likely, 

somewhat likely, somewhat unlikely, 

very unlikely, definitely not 

possible, or if you don't know how 

likely it is that a person will get 

AIDS or the AIDS virus infection 

that way. 

How likely do you think it is that 

al 

ii*I­v) 

a person will get AIDS or the AIDS F is E 2 z 

virus infection from 2 :: :: 2 E 25 

a. living near a home or hospital 

for AIDS patients. 10 20 30 40 50 9oriiiJ 

b. working near someone with the 

AIDS virus. 10 20 30 40 50 9oFJ 

c. eating in a restaurant where the 

cook has the AIDS virus. 10 20, 3ll 40 50 9011131 

d. kissing - with exchange of saliva - ' a person who has the AIDS virus. 10 20 30 40 50 90(-1141 

e. shaking hands, touching, or.kissing 

on the cheek someone who has the 

AIDS virus. 10 20 30 40 50 9opE-~ 

f. sharing plates, forks, or glasses 

with someone who has the AIDS 

virus. 10 20 30 40 50 90~~1 

g. using public toilets. 10 20 3u 40 50 90~1 

h. sharing needles for drug use with 

someone who.has the AIDS virus. 10 20 30 40'50 9011181 

i. being coughed on or sneezed on 

by someone who has the AIDS virus. 10 2Cl:.30 40 50 SO/m1 

j. attending school with a child who 

has the AIDS virus. : 10 2 cl-’ 3 II 4.0 50 9iq-mq .. 

k. mosquitoes or other insects. 10 20 ,30 40 50 9clri7iJ 

233 
--- 

--- 

1 -

25. Have you ever donated ,blood? 

216. Have you donated blood 

a. since March, 1985? 

b. in the past 12 months? 

217. Have you ever heard of a blood test 

that can detect the AIDS virus 

infection? 

'he next questions are about the blood test 

'or the AIDS virus infection. No question 

rill ask what the results are of any tests 

rou may have had. 

!8. To the best of your knowledge, 

are blood donations routinely tested 

now for the AIDS virus infection? 

i !9a. Have you ever received counseling 

or had a talk with a health 

professi&al about taking the 

AIDS virus test? 

i!9b. Was the discussion 

1. with a private doctor? 

2. at a family planning clinic? 

3. on an AIDS hotline? 

4. at a prenatal clinic? 

5. at an STD or sexually transmitted 

disease clinic? 

6. at an AIDS/HIV counseling and 

testing site? 

7. with some other health professional? 

8. with some other counselor? 

~_ 

1 0 Yes (26) I 122 1 

;-"0 "D; (27) t 

Yes No DK 

10 2 0 (27) 9 II (27) I=1 

10 20 90 m 

1 II Yes m 

2 Cl No 

9 Cl DK 

1 Cl Yes (29b) 

Yes No DK 

10 2 II 9 u 1Tq 

10 2 II 901129 

1 0 2 cl 9 II jmq 

10 20 9 II [-iq 

10 2 cl 9 II pz-1 

1 0 2 II 9 cl p-j 

10 20 =Jm 

1 Cl 2 cl -uzEl 

234 
-- 

-- 

.-

30. During that discussion, did you receive 1 II Yes f-izq 

information about .how to avoid getting 2 0 No 

or passing on the AIDS virus? 9 Cl DK 

31. Have you ever been advised by a health 1 0 Yes ITJ 

professional NOT to have the blood test 2 0 No 

for the AIDS virus infection? 9 II DK 

32. Have you ever been advised by friends 1 II Yes pq 

or relatives NOT to have the blood test 2 0 No 

for the AIDS virus infection? 9 II DK 

33. Have you had your blood tested 1 Cl Yes (34a) pi%-1 

for the AIDS virus infection? 

; ; ;; (41) i 

34a. Have you had your blood tested : E: yN;s (35a) [pm-~ 

for the AIDS virus infection more 

than once? 9 0 DK 

34b. Was your blood tested in the past 1 II Yes 1141/

twelve months? 2 0 No (36) 

9 0 DK I 

35a. How many times have you had your Total Number times in 

blood tested for the AIDS virus times past 12 Months m{ 

infection? (35a.) (35b.) 

xxxx 00 Cl None in past 

35b. How many times in the past 12 months twelve months 

have you had your blood tested for xxxx 01 Cl One time 

the AIDS virus infection? 02 II 02 Cl Two times 

03 II 03 0 Three times 

04 cl 04 Cl Four times 

05 0 05 II Five times 

06 0 06 II Six times 

07 0 07 II Seven times 

08 0 08 II Eight times 

09 0 09 Cl Nine times 

10 II 10 II Ten times 

11 Cl 11 .ll Eleven times 

12 Cl 12 II Twelve times 

13 II 13 Cl More than 

twelve times 

99 0 99 0 DK 
36. ,Was the test --- / Were any of the 

blood tests, including those you 

had before the past twelve 

months ---. 

a. part of a blood donation? 1 II Yes 2 Cl No 1pitq 

b. part of a blood transfusion? 1 Cl Yes 2 II No m 

c. voluntarily sought from a 

source such as your doctor, 

clinic, or HMO? 1 II Yes . 2 0 No m 

d. part of some other activity 

that requires a blood sample 

and includes automatic AIDS 

testing, such as testing for the 

military or immigration? 10 Yes 2 II No m 

CHECK 0 "Yes" in Q. 36d (37) 

ITEM 3 Refer to Q. 36d 0 Other (38) 

37. Where did you have your blood tested 1 II STD clinic 150 

for AIDS virus infection? 1 Cl Family planning clinic 151 

Anywhere else? (MARK ALL THAT APPLY). 1 Cl Prenatal clinic 152 

1 Cl Drug treatment facility 153 

1 II Tuberculosis clinic El154 

1 II Work clinic/health 

station 1 

1 II AIDS counseling/testing 

site 156 

1 0 Military induction 157 

1 II Immigration site 158 

1 Cl Other (SPECIFY) P 159 

1 0 DK I 160 

38. Did you get the results of ,your test?/ 1 Cl Yes (39) r 161 

any of your tests?. 

; ; ;; > (40) 

39. When you received your test results, 1 II Yes (41) pzq 

did you receive counseling or talk 2 0 No 

with a health professional about 9 Cl DK 

how to lower your chances of becoming 

infected with the AIDS virus or how 

to avoid passing it to another person? 

236 

I 
--- 

10. Were you referred to a health 1 II Yes 

professional to get counseling about 2 ClNo 

the AIDS.virus infection? 9 0 DK 

11. Do you expect to have a blood test 1 Cl Yes (42) 

for the AIDS virus infection in the next 

12 months? 

12. Will you have the blood test 

a. as part of a blood donation? 

b. voluntarily from a source 

such as your doctor, clinic, 

or HMO? 

c, as part of some other activity. 

that requires a blood sample 

and includes automatic AIDS 

testing, such as testing for the 

military or immigration? 

:HECK 

:TEM 4 Refer to Q. 42b 

13. Where would you go to have a blood 

test for the AIDSvirus infection? 

(MARK FIRSTMENTION) 

; : ;: > (44) 

1 Cl Yes 2 ClNo 9 II DK j-iJ 

10 Yes 2 ClNo 9 II DK m 

1 0 Yes 2 ClNo 9 Cl DK 1 

II "Yes" In question 42b (43) 

II Other (44) 

/--%zim 

00 Cl Nowhere, wouldn't take the test 

01 0 AIDS clinic 

02 II Company or industry clinic 

03 Cl Doctor/HMO 

04 II Hospital/emergency room/OP clini 

05 II Other clinic 

06 Cl Public Health Department 

07 Cl Red Cross/blood bank 

88 Cl Other (SPECIFY) 

99 0 DK 

EJ 

ic 

-

237 
--- 

94a. Did you have a blood transfusion 1 0 Yes m 

at any time between 1977 and 1985? 2 II No 

9 0 DK 

44b. Do you think the present supply of 1 Cl Yes p7iblood is safe for transfusions? 2 II No 

9 II DK 

HAND CARD C 

$5. Here are some methods people use al

to keep from getting the AIDS virus >

.F

through sexual activity. 2

-I- z 

+ aJ z

*I­ F z % After c, I read each one, tell me -7 

whether you think it is very c, z 

a, P ; 

effective, somewhat effective, not z +J -

Ia z a, 2i 

at all effective, or if you don't know z

Q) f 

rb 

2 z 5 how effective it is in preventing 

getting the AIDS virus through sexual 2 !s c, ;c E" 

activity. How effective is s 5: 8 2z zi 

a. Using a diaphragm? 10 20 30 40 90 pzT 

b. Using a condom? 10 20 30 40 90 p7r 

c. Using a spermicidal jelly, foam 

or cream? 10 20 30 40 90 pq 

d. Having a vasectomy? 10 20 30 40 90 p73-j 

e. Two people who do not have the 

AIDS virus having sex only with 10 20 30 40 90 j-m-1 each other? 

16. What are your chances of having the 1 Cl High (Check Item 6) AIDS virus; would you say high, 2 Cl Medium 

medium, low, or none? 3 II Low 

4 Cl None 

7 Cl Refused 

9 II DK 

233 
--- 

17. What are your chances of getting 1 II High I 178 I 

the AIDS virus; would you say 2 0 Medium 

high, medium, low, or none? 3 rl Low 

4 II None 

7 II Refused (Check Item 6) 

9 Cl DK 

18. People have different meanings when p7iTiE~ 

they say a "high", "medium", or "low" 

chance. 000 Cl Less than 1 out of a 100 

If "no chance" is zero-out-of-one out of a 100 

hundred, what would you.say 

,High/Medium/Low. is? What number of 999 Cl DK 

times-out-of-one hundred? 

:HECK 

ITEM 6 Refer to Q. 47 

49. Do you say your chance of getting 

AIDS is ihigh/medium) because 

you 

a. Have had a blood transfusion? 

b. Have had sexual contact with 

someone who might have the virus? 

c. Some other reason? (SPECIFY) 

II "High" OR "Medium" IN Q. 47 (49) 

Cl Other (Check Item 6) 

1 Cl Yes 2 II No [-XT1 

1 Cl Yes 2 II No I 183 

1 Cl Yes 2 Cl No 1184 

239 
--- 

--- 

:HECK 

ITEM 6 Refer to age and -sex of S.P. 

50. In the past twelve months, have you 

received services or care at 

a. a prenatal health clinic? 

b. a maternal and infant health clinic? 

c. a family planning clinic? 

d. a hospital, as an inpatient? 

e. a hospital emergency room? 

f. a tuberculosis clinic? 

g. a drug treatment facility 

or clinic? 

h. an STD (sexually transmitted '* 

disease) clinic? 

i. an alcohol treatment facility 

or clinic? 

j. an AIDS counseling and testing 

clinic? 

k. a correnunity health clinic? 

1. a public health clinic? _ '. 

il. In the past twelve months, have you 

a. been in the Job Corps? 

b. had a physical examination to join 

the military? 

c. been in prison? 

;2. Have you ever discussed AIDS with 

a friend or relative? 

0 Female 18-45 (50 Intro, then 50a) 

Cl Other (50 Intro, then 50~) 

Yes No DK 

10 20 90 

10 20 90 

10 20 90 

10 20 90 

10 20 90 

10 20 90 

10 20 90 

10 20 90 

10 20 90 

10 20 90 

10 20 90 

10 20 90 

Yes No DK 

10 2ll 90 

10 20 90 

10 20 90 

1 II Yes (53) 

; : I$ }(54) 

p7-1 

m 

I1871 

lrssl 

1 

[im-) 

pE-1 

mzi-l 

pi75-1 

9 11-61 

t2zl 

m 

II 99 

240 
--- 

53. When was the last time you 1 Cl Today '201-203) 

discussed AIDS with a friend * 

or relative? 2 Cl Days ago 

3 II Weeks ago 

Number 4 II Months ago 

5 II Years,ago 

9 II DK 

54. Have you ever personally known 1 Cl Yes (55) /--nq 

anyone with AIDS or the AIDS virus? 2 II No 

9 II DK if someone (57) 

has/had AIDS 

AIDS virus I 

(IF MORE THAN ONE PERSON VOLUNTEERED IN Q. 54, ASK Q. 55 and Q. 56 ABOUT 

THE PERSON KNOWNBEST) 

35. How long has it been since you 

saw this person? 

56. How well do you know this person? 

Would you say 

1 Cl Wi'thin the past two-weeks 11 

2 Cl Two weeks to less than one month 

3 II One month to less than 3 months 

4 0 3 months to less than 6 months 

5 II 6 months or more 

9 II DK 

1 Cl Very well, it is a close 1p-q 

relationship? 

2 0 Fairly well, but it is not 

a close relationship ? 

3 Cl Not very well, 

acquaintance 

relationship? 

or 

4 Cl You don't really 

personally, 

of a friend? 

8 0 Other (SPECIFY) 

it is only an 

or casual 

know them 

such as a friend 

241 
I -

’ tiAND CARD D 

.

I

57. (I 

After 

am going 

I have 

to 

read 

read 

them 

a list 

all,) 

of statements. 

Please tell m

me any of these statements is true for 

you. 

Do not tell me which statement or -w 

statements are true for you, just if anx 

of them are. 

a. You have hemophilia and have received 1 Cl Yes to at least one 

clotting factor concentrates since statement 

1977. 

2 II No to all statements 

b. You are a native of Haiti, Central or 

East Africa who has entered the United 

States since 1977. 

c. You are a man who has had sex with 

another man at some time since 1977, 

even one time. 

d. You have taken illegal drugs by needle 

at any time since 1977. 

e. Since 1977, you are or have been the 

sex partner of any person who would 

answer "yes" to any of the items 

(I have read./above on this card.) 

f. You have had sex for money or drugs 

at any time since 1977. 

5;8. The U.S.Public Health Service has 

said that AIDS is one of the major 

1 II Yes (60a) 

2 Cl No 

pq 

health problems in the country but 8 0 Other response (SPECIFY) 

exactly how many people it affects 

is not known. The Surgeon General 

has proposed that a study be 

conducted and blood samples be.taken 

to help find out how widespread the 

problem is. 

If you were selected in this national 

sample of people to have their blood 

tested with assurances of privacy of 9 Cl DK 

test results, would you have the test? 

242 
59. Why wouldn't you take part in 1 II Don't want to know 

the test? Any other reason? if I have AIDS pm-l 

(MARK ALL THAT APPLY) 1 II Don't want any bob) counseling about AIDS 

1 0 Fear I'll get ,AIDS \ 

1 Cl Don't like to give 

blood 

1 Cl Don't trust Government 

programs 

1 0 It is a waste of money 

1 Cl Don't believe AIDS can 

really be cured anyway 

1 II Other (SPECIFY) 

1 tiTK-j 

5Oa. If it were not possible to provide 1 Cl Yes 

YOU with theresults of the test. 

would you still take part in the' 

2 0 No 

9 II DK (61) 

study? 

5Ob. If the results of the test were not 1 II Yes 

provided to you, then would you -

take part in the study? 

51. When Federal Public Health officials 

give information about AIDS, do you 

believe what they say or are you 

doubtful about the information they 

give? 

52. When they give advice about how to 

help keep from getting AIDS, do you 

believe their advice or are you 

doubtful about what they say? 

2 II No 

9 II DK 

1 II Believe them 

2 II Doubtful 

9 0 DK 

1 0 Believe their advice 

2 Cl Doubtful 

9 II DK 

(61) 213' 

e 214 

El 

I‘ 

0 221 
-- 

--- 

63. Date AIDS Supplement .Final Status / 

INTERVIEWERTRANSCRIPTIONFROMHIS-l 

64. Hispanic Origin (Item 4a/b, Page 41, HIS-l) 

HIS-l Item 4a 

HIS 1 Item 4b -_-

65. Questionnaire Version 

66. Exact Address (Item 6a, Cover Page, HIS-l) 

State County 

67. Mailing Address (Item 6b, Cover Page, HIS-l) 

City State County 

68. Telephone Number (Item 11, Cover Page, HIS-l) 

/ 19 lz!zzE3 

2 Cl No 

1 Cl Puerto Rican 

2 Cl Cuban 

3 Cl Mexican/Mexican0 

4 0 Mexican American 

5 II Chicano 

6 II Other Latin Americari 

7 II Other Spanish 

--._-ZIP Code 

Cl Same as 6a 

ZIP Code 

1 Cl Yes, telephone (RECORD NUMBERBELOW) 

2 II No telephone 3 II Phone, but no number listed or number refused 

9 II DK or Refused 

/ / -e--p A.C. Exch. Number 

244 
CARD R CARD 0 

RACE ORIGIN 

1. Aleut, Eskimo, or American Indian 1. Puerto Rican 

2. Asian or Pacific Islander 2. Cuban 

Cd 

3. Black 3. MexicanlMexicano iz 

:---

4. White 4. Mexican American 

5. Chicano 

6. Other Latin American 

7. Other Spanish 

CARD I CARD J 

INCOME INCOME 

U . . . . $20,000 - $24,999 A . . . . . . . Less than $1,000 (including loss) 

G . . . . . . . $l,OOO- $1,999 

V ..A 825,000 - $29,999 c . ..I... 82,000- $2,999 

D . . . . . . . 83,000- $3,999 

w . . . $30,000 - $34,999 E . . . . . . . $4,000 - $4,999 

X . . . . 535.000 - 539.999 F . . . . . . . $5,000 - $6,999 

G ....... $6,000- 66,999 MI 

MJ 

Y . . . . 540,000 - $44,999 H . . . . . . . b7,000- $7,999 :-------’ 

I . . . . . . . . $8,000- $8,899-

2 . . . . 845,000 - $49,999 J . . . . . . . $9,000 - $9,999 

ZZ... $50,000 and over K . . . . . . . $10,000 - $10,999 

I L . . . . . . . . $11,000 - $11,999 I 

I

I M . . . . . . $12,000- $12,999 I

I N . . . . .:. $13,000 - $13,999 ;a 

I E D . . . . . . . $14,000 - $14,999 rii 

P . . . . . . . $15,000 - $16,999 I{ 

Q . . . . . . . $16,000 - $i6,999 ; Y 

I

I R . . . . . . . $17,000 - $17,999 I

I

t

I s . . . . . . . 818,000 - $18,999 I 

T . . . . . . . $19,000 - 819,999 

245 
1 

CARD N2 

CARDNI 

t Stopped working because of own illness, injury, 

disability or health problem that was JOB-RELATED 

2 Stopped working because of own illness, injury, disability or 

other health problem that was NOT JOB-RELATED 

3 Retired 

4 Child/family care 

5 On layoff from a job 

8 Some other mason ISpecifyl 

CARD N3 

TO GET MEDICAL ATTENTION OR TREATMENT 

OTHER THAN FIRST AID FOR MINOR INJURIES 

OR 

TO BE UNABLE TO DO SOME WORK ACTIVITIES 

OR 

TO LOSE CONSCIOUSNESS 

OR 

TO TRANSFER TO AhOTHER JOB 

0 Less than one month 

1 1 month, less than 3 months 

2 3 months, less than 6 months 

3 6 months, less than 12 months 

4 1 year, less than 5 years 

6 5 or more years 

CARD 01 

01 Don’t socialize very much 

02 Don’t care for it or dislike it 

03 Am an alcoholic 

04 Thought I might become an alcoholic 

05 Had problems with my drinking 

06 Have a responsibility to my family 

07 Family member an alcoholic or problem drinker 

08 Medical or health reasons 

09 Religious or moral reasons 

10 Brought up not to drink 

11 Makes me sick 

12 Can’t control my drinking 

13 Costs too much or can’t afford it 

14 Dieting or too fattening 

88 Other 

246 
CARD 02 

1 Heavy 

2 Moderate 

3 Light 

4 Very light or occasional 

5 Quit drinking 

6 Never drank 

CARD P2 

01 Nursery school or preschool 

02 Nursery school or preschool with day care 

03 Day care center 

04 Babysitter in child’s home 

05 In bebysitter’s home 

06 Father cares for child 

07 Mother cares for child while working at home 

08 Mother cares for child while working 

outside of home 

09 Summer day camp 

10 Child cares for self 

11 Other relative cares for child 

88 Other (Specify) 

CARD PI 

01 Day care center 

02 Babysitter in child’s home 

03 In babysitter’s home 

04 Father cares for child 

05 Mother cares for child while 

working at home 

06 Mother cares for child while 

working outside of home 

07 Child cares for self 

08 Other relative cares for child 

09 Day camp 

88 Other (Specify) 

CARD P3 

01 Broken or dislocated bones 

02 Sprain, strain or pulled muscle 

03 Cuts, scrapes, or puncture wounds 

04 Head injury, concussion 

05 Bruise, contusion, or internal bleeding 

06 Burn, scald 

07 Poisoning from chemicals, medicines, drugs 

08 Respiratory problem, such as breathing, 

cough, pneumonia 

88 Other 

99 Don’t know type of condition 

00 None 

247 
CARD P4 

1 Has two or more usual doctors or places 

depending on what is wrong 

2 Has not needed a doctor 

3 Previous doctor no longer available 

4 Have not been able to find the right doctor 

5 Recently moved to area 

8 Other reason ISpecifyl 

248 
1989 

The 1989NHIS was conducted with a full sample. The 

interviewed sample included 116,929 household members 

in 45,711 sample households. In addition to the basic 

health and demographic questionnaire, the 1989 survey 

included questions on the following special health topics: 

health insurance-which also included a special survey of 

California residents, adult immunization, mental health, 

dental health, orofacial pain, diabetes and diabetes risk 

factors, digestive disorders, and AIDS. 

The health insurance questions asked about Medicare, Medicaid, public assistanceprograms, types of health 

insurance plans, plan coverage, who pays for the insurance, reasons for not having health insurance, and health 

care benefits from the Armed Forces or Veterans’ Administration such as CHAMPUS or CHAMP-VA. The questions also asked about service-related disability, lay off or 

loss of job and subsequent loss of health insurance coverage, and health insurance coverage during job loss. 

A special health insurance survey of California residents was conducted in conjunction with the 1989 NHIS. 

This survey was in collaboration with the State of California and the University of California, Los Angeles. In 

addition to the health insurance questions included in the 

NHIS Current Health Topics Questionnaire, questions 

were asked about usual source of care, barriers to needed 

care, income and employment status, characteristics of the 

place of employment, and opinions about various proposals for reducing the size of the uninsured population. The 

survey was in the field for three quarters of the year and 

included about 4,200 out of the 5,600 households in the 

California sample. NCHS produced special weights for the 

California population that will take into account the 

18 percent of the population not covered by the sample. 

The survey was also conducted in Spanish. A Spanish 

translation of the questionnaire was prepared and used in 

the field; however, it is not included in this report. The 

health insurance data collected in the special California 

survey has not been released on a public-use data tape. 

Immunization questions were asked of family members 18 years of age and over. The questions inquired 

about vaccinations to prevent influenza, pneumonia, and 

tetanus. 

The questions on mental health inquired about mental and emotional disorders such as schizophrenia, paranoid disorder, manic depression, major depression, senility, 

alcohol abuse disorder, drug abuse disorder, and mental 

retardation. For each disorder reported, questions were 

asked about whether the disorder(s) prevented or limited 

the person’s work, job, or school attendance. 

Dental health questions obtained information about 

the number of visits in the past 2 weeks, reasons for not 

visiting the dentist in last 12 months, loss of natural teeth, 

dentures, dental sealants, use of mouthwash, use of fluoride, and missed work or school because of someone’s 

dental problem. 

The diabetes questionnaire asked adult diabetics for 

information about diagnosis, use of insulin and .diabetes 

pills, diet, doctor visits, and sources of information. The 

questionnaire also asked an adult in the family who was 

nondiabetic about diabetes risk factors; urinary, foot, and 

eye problems; smoking; and family history of diabetes. 

The current health topic questionnaire on orofacial 

pain included questions about toothaches, mouth sores, or 

burning sensations in the mouth in the past 6 months; pain 

in jaw joint or face in the past 6 months; visits to the 

dentist, doctor, or health professional for the pain in the 

past 6 months; and what was done for the pain during the 

past 6 months. 

The questionnaire on digestive disorders asked about 

gallbladder trouble, ulcers, diverticulitis, and irritable bowel 

syndrome. In addition, questions asked about onset of 

condition, diagnosis abdominal pain, cause of pain, doctor 

visits, diagnostic tests, and questions on normative bowel 

functions. 

The questions relating to AIDS were separate from 

the other 1989 current health topic questions. The interview was conducted using CAPI. The 1989 questions on 

AIDS were similar to those in 1987 and 1988. The series 

of questions asked in 1988 about the special brochure that 

was mailed to each household was excluded. As in the 

previous 2 years, the questions about AIDS pertained to 

AIDS knowledge and attitudes and were asked of persons 

in the family 18 years of age and over. Included were 

questions about pamphlets or brochures read or seen 

about AIDS, discussion of AIDS with their children, 

knowledge ,of AIDS, blood donation, blood testing for 

AIDS, the AIDS virus and sexual activity, the risk of 

getting the AIDS virus, whether person knew anyone with 

AIDS, and willingness to participate in sample of persons 

having blood tested for AIDS. 

249 
----- ----- 

----- 

----------- 

---- ------- 

. 

Oh48 No. 0920.0214~ Aouovsl Exdm 3dtlt@ 

NOTICE - lnfcmutkn cmt&c~I on this farm which wwkfpmnit idmtificstica of my fad!vMcsl M RT 66 

emMirhmamhw~cW~~~~~~~W~beheldinrtrictMnfl,Willk~ 3-7 

nmdfa~mdy,ndwillnotbedirloledorr~toothmwhhoultke +qgg?-. . ttvhdud w the aublishmnt in accon%nca with sectkn 308ld) o! tf~kzc~lt$ S 

U.S. DEPARTMENTOFCOMMERCE E Act I42 USC 242m). public nponicg burden for this cdkctiaa of icfcmrstma ncREA”oFlHEcENsuS ACTWSASC-W*OGaCTMRTHE vary from 20 to 75 minute pn r-, with * awmgs of 41 minutas par respoma. 3WId Ecm- , &6#t -d U.S. FUBLIC HEALTH SERVICE IlMmts rsqsrdicg thii bwdbn bstimbtb w bny olhbr aspact of this cdlsctioa of iaformatlca, iccfcdii ’ 

wgestims for mdccfa6 thfs tnadsn,.tc f’HS Rapcru Qaarsnca Dffkar; Room 721-H. Hcmphrsy 6$ding; 200 Indrpadmce Avmua, 5W; Washington, DC 20201; Al-W: PRA, and to thb Offk. of -book8 omutim d fisaubt~ Affbim. Offics of Mamgemmt and SK!@. Washirqton, DC 20603. NATIONAL HEALTH INTERVIEW 2. R.O. Number I s-1o 3.Samplo [W-l3 

SURVEY 

1989 CURRENT HEALTH TOPICS 4. Control number 8. &ginning time I 26-29 1 3o 

PSU F/ “?* ] 24-26 10 &Ill, 

20 pm, I I 

ADULT FAMILY ROSTER 

EI. Amtbbm8nyttcdddd p~~18+~mn~~~fomiM i i~Yeb~Listbyaga,oldejtto~o~ngertl 1 31 . 

1 z~NoI~donM~ 

I 

Name 

I I 

1 1OM 20F 

2 1Clh-l ZCIF 

3 1ClM ZCIF 

4 I I rclrkl 20F 

I 

5 I I 1OtVl 20F 

I 

6 1 I rclhn 2mF 

I 

7 I I 1lJM 2c3F I I 

8 I I 

9 I I 

Refer to the sample person selection label and circle as applicab& TH~N’circle ye&on vumbe; in item 6 and m(lrk the “SP” box on the HIS- 1 for the 

selected sample person. THEN go to Section M. 

7 . FINAL STATUS 

a. Household respondent 

I 

Merk as appropriate 

I 

Complete interview 

I Partial interview Nonkmsrview 

l&plain in nore.91. Refusal (Explein in notesJ Qther IExplain iii notes) (1) (21 131 14) 16) , 1 

s [7 Not required in 217 3n 6[7 ’ 38 ----------_ ---------------.--‘------ ----.----,------.-----,,, 4-e 

N. Immunization o 0 No person 18+ in this family .’ lcl 20 3cl 60 

T 3a 

---------__ -------___-------__------ ye.- --L----i-------.-------- dd’ 

0.. Mental Health la 2Q.’ 30 60 ’ 40 

-T---- ---_-----_____-_--_; i .a-- ~-----,,--,--,----.-,,,,,,, -4-

P. Dental - ---------__ --------------------e-e-- ICI .---- tcl __--___-- 30 ---.- .--._’ BO l-11 -.dQl. Diabetes Screenina o 0 No person 18+ in this family a. ICI 3.0 60 42’ 

b. Household diabetic(s) 4c. Sample person 

Section 02 (page 32) 1 -I,I. Section R (page 48) 171.3. Section T (page 581 1 (Diabetes Followup) (Orofacial Pain) I (Diabetes Wsk Factors) 

I 

o 17 No diabetics 1 s 0 Not required o q No person 18 + in this family i 00 No percon 18 + in this family f o [7 No parson 18 + In this family 7 q 01 Noninterview Interview I Interview 

I I 7 q Ql ~Nonfntervisw 

lnteryisw 10 Complete interview fall I 117 Complete interview fall I Interview appropriate questions appropriate sections 

IO Complete interview fall persons completed) I 

I completed) 1 i Cl Complete intervlew (all 

iith diebetes interviewed) appropriate questions completed) 20 Partial interview (some but not I 2 0 Partial interview (some but not i 2 q Partial interview (some but not all 2 0 Partial interview (some but not all appropriate questions 1 all appropriate sections 

all parsons with diabetes completed) (Explain in notes) , completed) IExplaiti in notes! , appropriate questions completed) 

interviewed) (Ewplein in notes) (Explain in notes) 

Noninterview ;

I Noninterview I N.&ilntarview - 3 U Refusal (Explainin notas) i 3 [7 Refusal (Expreinin notes) ; 3 n Refusal IExpklln in notasl 

3 iIl Refusal 40 SP temporarily absent 1 40 SP temporarily absent f 40 SP ta’niporarily absent 

a [7 Other (Explain in notes) s 0 SP mentally or physically incapable I s [7 SP mentally or physically incapable 1 s 0 SP mentally or physically hcapabla 

8 0 Other Kxp/ain in notes) / a Cl Other LExplain in notes) 1 B 0 Other IE;plain in noteej 

8 . Ending time 9. Interviewer identification ; Codb 

[V Name /ii& 

i 

i 

Nlotes 

250 
-- 

-- 

-- 

-- 

---------- _. I 

-- 

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

PERSON 1 1 

)

CHECK 

ITEM 1 Refer to letter indicated on Sample Selection label. 1 0 Letter M (1) 

2 0 Letter T fsecf;on N) 

Medicare is a Social Security health insurance program for disabled persons and for parsons 65 

years old and over. People covered by Medicare have a card that looks like this. Show Medicare Card. 

1il. Is anyone In this family, that is Ireadnamesj, now covered by Medicare? q Yes 

0 No 141 0 DK (41 ____---~___---_----_____________________~-~~~~~-. - b. IS- - now covered? lb, I 0 Covered s 0 DK / 

2 0 Not covered 

Ask for each person with “Covered”or “LJK’% lb. H. 1. C. Number 

2. May I please sea the Social Security Medicare card(s) for (and --I to determine the type of coverage and 2. to record the Health Insurance Claim Number. Providing the Health Insurance Claim Number is voluntary and 

collected under the authority of the Public Health Service Act. There will be no effect on benefits and no 

Information will be given to any other government or nongovernment agency. I 0 Hospital ” 1 

z 0 Medical 

Read if necessary: The Public Health Service Act is Title 42, United States Coda, Section 242k. 3 0 Card N. A. 

Transcribe the number, then mark the appropriate boxfes). 

- Ask for each person with “Card NA” in 2. 1 

35 Is now covered by the part of Social Security Medicare which pays for hospital bills? 3a. 10 Yes s q DK 

2uNo _-_ b. IS-- now covered by that part of Medicare which pays for doctor’s bills? This is the Medicare plan b. sODKrEfor which or some agency must pay a certain amount each month. 10 Yes 

20No -

&I. (Not counting Medicare) is anyone in the family now covered by a health insurance plan which pays any 

part of hospital, doctor, or dental bills? Do NOT include plans that pay for ONLY ONE type of service, 

such as nursing home care or accidents. 

0 Yes 0 No (81 0 DK (81 ------__----~____-_-----~~~-------~~-----~~~~~~~ --. b. It’s important that wa have the complete and accurate name of your health insurance plan. What is 

the COMPLETE name of the plan? 

Recordin Table H.I. If ‘PK”, probe: Do you have something with the plan name on it? 

------------------------------------T----------- --. 

C. Is enyone In the family now covered by any OTHER health insurance plan? Again, do NOT include 

plans that pay for ONLY ONE service. 

0 Yes (&ask 46 and cl 0 No 0 DK 

TABLE H.I. 

(Now I am going to ask some questions about the plan(s) you just told me about.} 

Read if necessary: Health Maintenance Organizations, or HMO’s, sometimes called Individual Practice 

Associations, or IPA’s, are plans whose members am required to use only those health care providers who work for the HMO or IPA. Also, members do not have to submit 

claims for costs of medical care services. - /21 

-

6a. Is 7. I 17 Covered . . covered 2 0 Not covered V.‘Pl under b. this doctor’s or surgeon’s bills for (name) 

s0DK . . . . . . > 

operations? plan? 

b. Was this plan 

obtained through an employer or union? 

drugs other than those administered during a hospital stay? 

C, Is it now carried 

through an employer e. 

health, alcoholism, or drug or union? abuse services? -

Yes No DK Yes No DK 

Ea. y;;qfg.;~ba~;5 1 .2 9 134 6a. Doss this lnamelplan pay any ’ ’ 37 7. Is-- 1 0 Covered . . part of hospital expenses? covered Or~o~5ation or - ______ -------_-._- 1 * 

.-m 

7. 

2 0 Not covered 

> 

iNPl under b. Does this plan pay any part of i 38 this. snDK . . . . . . doctor’s or surgeon’s bills for - - 1 216al 916al L--------.-.--- ouerations? plan? 

b. Was this plan d36 C. Does it pay for any DENTAL l-- 2- s 39 

obtained through an employer or union? d. 

services other than oral surgery? tt _. F 40 drugs other than those edministered during a hospital stay? 

C. 

through 

Is It now an carried 

employer 36 B. _--.....--A---

Does it pay for any mental _____ 

I- __ 2-

__s 41 

or union? 4health, alcoholism, or drug

abuse services? I 

251 
------------- -------- 

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

---------- 

-- 

-- 

Section M - HEALTH‘INSURANCE - Continued PERSON 1 

Yes No DK Yes No DK 

5a. Ist;~i~fggp;h;~~ ’ 2 g ) 66. Doesthis f’lplanpayany 

part of hospital expenses? 

’ * g 1 46 7. Is-- 7. I 0 Covered r s covered $ao;zation or 2 0 Not covered lNPl b. Doasthisplanpayanypartof 1 2 9 1 under euDK ,,,,,, doctor’s or surgeon’s bills for this 1

--------i- 2T&91?zw operations? _---- b?imzQJ ____ 

b. Was this plan r 46 C. DoesitpayforanyDENTAL 1 2 9 & plan? 

obtained through an services other than oral surgery? ______ ----------.---- employer or union? d. Doeritpayforanyprsscription ’ 2 9 - - 1 2- s drugs other than those administered during a hospital 

C. Is it now carried ______ --------_-_--__stay? 

through an employer r 47 6. Does itpayforanymental or drug 

1 2 9 1 

or union? health, alcoholism, 

abuse services? 

Yes No DK Yes No DK 

5,a. p;thfhhnme ’ 2 9 156 6a. Does this (-plan pay any ’ 2 g 17. Is-- 7. i d Covered , , part of hospital expenres? covered 2 ci Not covered INPI ----------------_--­ $ao;kation o* b. Doasthisplanpayany partof 1 2 9 E under 

doctor’s or surgeon’s bills for this eC]DK ,,r<rr > --------i- Z76d ma, operations? (namel -------------_------

b. Was this plan 157 C. DoeritpayforanyDENTAL 1 2 9 ) plan? 

obtained through an services other then oral surgery? 

employer or union? d. ~o~Zt-~~~Gr~n&i&$iiiiii ‘- 2- 9 

--------i- 2- 9 drugs other than those administered during a hospital stay? 

C . Is it now carried -------------_-.----

or union? health, alcoholism, 

abu?e sarvicss? 

. a, ,.I ~66-66 I-x 

Yes No DK Yes No DK 

.5a. ht;~h~t~~n~e ’ ’ ’ 1 6a. Doesthisfname)planpeyany 

part of hospital expenses? 

1 2 9 E 70 7. Is-- 7. I 0 Covered , , 

through an employer ) e. Doesitpayforanymental or drug 

1 2 9 ) 

----------------.---- covered 2 0 Not covered $$etion or b. Doesthis plan payanypartof 1 2 9 1 under snDK .<.,*, > 

Wl 

doctor’s or surgeon’s bills for this 

--------i- 2xaJ fl6aJ operations? I@& ----------------_---

b. Was this plan ( C. Doeritpayfor any DENTAL 1 2 9 1 plan? 

obtained through an services other then oral surgery? 

employsr 01 union? d. Eo~%&ifGr%ii~&i&n ‘- 2- 9 1 

--------i- 2- s drugs other than those edmiw 

istered during a hospital stay? C. Is it now carried ----------------_---

through an employer 

1 6. Doesitpayforanymental 1 2 9 1 

or union? health, alcoholism, or drug 

abuse services? 

8a. [In addition to the plan(s) you just mentionedl Is anyone in the family now covered by an insurance plan that pays for ONLY ONE type of health care service, such as nursing 

home cara, eye cara, or prescriptions? 

0 Yes 0 No (Check /tern 21 [7 DK (Check Item 21 

--------------------____________________--------------------------~~~~----~---~~ d-d. 

b. Is covered by this type of plan? 

6b. 1 0 Covered dlDK--

2 q Not covered 

Ask for each’person ‘%overed” in 8b: C. i 0 Prescriptions 77 

C. What type of service does plan pay for? 2 0 Eyecare 76 

3 Cl Cancer treatment 79 

4 q .Catastrophic 60 

5 0 Nursing home care 6% 

6 0 Accidents 62 

7 0 Dental care 63 

8 0 Other - Specify 7 E 64 

_______---------------------~------~----------~~~~~~~~---~~~~-~~~~~~~~----~-~~---~-~ 

d. !a,,,,:,~ covered by any OTHER insurance plan that pays for ONLY ONE d. 0 Yes lffeask Bc-d) 

0 No (NP with “Covered”/n 8b 

252 
-- 

-- 

-- 

-- 

-- 

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

-- 

-- 

-- 

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

-- 

Section M - HEALTH INSURANCE - Continued ,I I PERSON 1 

CHECK Review lb and 7 for each person and determine if “Covered” by either Medicare 

ITEM 2 insurance ’ or “Not covered ; ” 

and/or 

CK 

2 

1 0 Covered . . . . . .‘. . . . 

2 0 Not covered under 65 

3 0 Not covered 65 and over (NF 

s[7Dk . . . . . . . . . . . . . . I 

.,.I. j. .’ * : ‘,I’ :\ : _, 

Ask for each person “Not covered”in Check Item 2. m 

If “Not covered 65and over,“in Check Item 2, in&da “or Medicare.” 

9it. 123456783 

;, .‘-‘..‘ 

983. (Many people do not carry health insurance for various reasons.} Hand Card M. ’ . Which of those statements describes why is not covered by any health insurance (or Medicare)? 

Any other reason? Circle a// reasons given. (Specify) 

88-8 

----T------------------------------------~---------- -----_------ s--9 

Mark box If only one reason. 

If “Not covered 66 and ovar, “in Check Item 2, include “or Medicare. ” 

. . ’ b. 00 III Only one reason E 92-s 

b. What is the MAIN reason is not covered by any health insurance (or Medicare)? 12345678 

3 

. lSpecifi4 

Ask on/y if persons under age 20 in femily; otherwise skip to 11. 

1OS. Does anyone in the family now receive assistance through the “Aid to Families with Dependent Children” program, 

sometimes called “AFDC” or “ADC”? ____-__--------------------------~---~~---------~---~---~--~~~~~ q Yes q Noflll ODKUII 

b. Does now receive AFDC or ADC? l.Ob. 1El Yes e0DKE 

2I3No 

11 a. Does anyone In the family now receive the “Supplemental Security Income” or “SSI” check? 

--__--_------------------~~~--~~-~~--~~--~~~~~--~~~~~~~~~~~-~~~~ [7Yes q No (121 0 DK (721 

b. Does now receive this check? Ilb. 1q Yes &JDK-GE 

20No 

1*a. There is a program called Medicaid that pays for health care for 

persons In need. (In this State It Is also celled(namel.) 

During the past 12 months, has anyone in this family 

received health care which has been or will be paid for by 

Medlcald (or (-17 0 Yes c] No (131 0 DK 173) -------------------------~-----------------------------­ -,o~e~---gooK~ b. Has received thls care in the past 12 months7 12b. 

20No 

1% Does anyone in the family now have a Medicaid (or ml) card7 

17 Yes 0 No f741 0 DK (741 -----------------------------------------------~---- -IcIyes---soDK~ b. Does - - now have this card7 13b. 

20No -

Ask for each person with “Yes” in 136. 

C. --;;edi,,-cyr;e;e;--

C. May I please s8e (and --I card(s)7 1 0 Current 3 

Mark appropriate boxlesl in person’s column. 2 0 Expired 

3 0 No card seen 

e 0 Other card seen 3 

(Specify) 

1&I. Is anyone in the family now covered by any other public 

assistance program that pays fpr health care? 0 Yes 0 No (751 q QK (751 --__-----------------~-----~-------~~~~~~~-~~~--~---- ~toves~~~sooK~

b. Is now covered7 14b. 

20No 

15. Is anyone In this family now covered by health care 

benefits from the Armed Forces or Veterans’ 

Adminlrtraticn? 0 Yes 0 No (Check /tern 3! q DK (Check Item 31 

I6a. Does anyone In the family now receive military 

retirement payments from any branch of the Armed 

Forces or a pension from the Veterans’ Administration) DC not include VA dlsebility compensation. 

0 Yes 0 No (17) 0 DK (171 ____-___--_---_--------~~~~~--~~--~~~--------------- -Ioyes---soDK~

b: Does now receive military retirement or a VA pension7 16b. 

20No --__-----------~-------~~~-~~~~---~~~-~~~-------~-~~ 

Ask for each person with “Yes”in 76b. . C. I 0 Armed Forces m 

C. Which does receive - the Armed Forces retirement, the VA 20VA 

pcnslcn, or both? 3 q Both 

FORM“IS.1*,19*91m-11.1 

253 
-- 

--- 

--- 

-- 

---- --- 

-- -- 

-- 

-- 

---- 

------ 

-- 

-- -- 

----- -- 

-- 

-- 

-- 

-- 

-- 

-- 

-- 

-- 

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

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

I RT 67 

Section M - HEALTH INSURANCE - Continued ! l- PERSON 1 1 g-’ t 

1I7g. Is anyone in the family now covered by CHAMPUS, which is a 

program of medical care for dependents of military personnel? Cl Yes q No (7 7~) 0 DK 177~1 .--- ----------dd 

b. Is now c&red by CHAMPUS? 17b. 10 Yes sUDK Ts20NO -----_________-----_------------------~~~~~~~~-- _--_--------dd--

C. Is anyone in the family now covered by CHAMP-VA, which is medical 

insurance for dependents or survivors of disabled veterans? 13 Yes 0 No 1781 0 DK (781 -----____-______---_____________________~~~~~~~~ --------d-Ad ddd. Is now covered by CHAMP-VA? d. 1q Yes s0DK l- ’ 

20No 

1I8a. Is anyona in the family now covered by any other program 

that provides health cere for military dependents or 

survivors of military persons?. q Yes 0 No [Check /tern 3) 0 DK /Check /tam 31 

_------_-------_________________________~~~- -------kdd-d -km 

b. IS-- now covered? 

I 18b, lOYES s0DK 7 

20No 

+ 

CHECK CK I 0 AF box marked 1191 

1 8 

ITEM 3 Refer to “AF” box above person’s column in HIS- 1. 3 

11%. Does have a disability related to service in the Armed Forces of the United States? lge. 

___-~--_____------------------------------------ ___ b. Does now receive compensation for this disability from the Veterans’ Administration? 1 b. ----------__--------~~-------~~~~-----~~~~~~~~~~ -2. 

C. Has ever applied for a service-connected disability rating from the Veterans’ Administration? C. 

-----_----___------_~~-------~~~~-----~~~~--.~~~~~ d. Was it approved or denied? d. I 0 Approved 3 0 Pending 

2 0 Denied snDK 

2!OS. During the past 12 months, that is since (78month date) a year ago, have (read names of related HH members 18 or over) been laid off from a job or lost a job? ___________-____________________________--------- Cl Yes 0 No lSecdon NI 0 DK /Section N1 

b. Whd was this? 

20b I q Laid off/lost job Mark ‘Zaid off/lost job” box in person’s column. ____-------__------------------------~~~~~~~~ ----------d--d3

C. Anyone else? 0 Yes (Reask 2Ob and cl ‘0 No ------------_------------------------------

Ask ZOd, e, and f for each person with “Laid off/lost job”in 2Ob. 

d. How many times has been laid off or lost a job during the past 12 months? d. 

g. In what month and year was laid off or did lose a job ([the last time/the time before that])? 0, 

____--------------_-----------~~~~~~~~~~~~~ f. For ANYTIME during [that/those] job layoff(s) or job loss(es), did receive unemployment f. insurance benefits? I 

i !I a. Because of (names of persons in 2Ob)job layoff Is) or job 

loss(es), did anyone in the family lose any health insurance 

coverage that had been carried through [that/those1 job(s)? q yes q No (Section N) 0 DK fsecdon NJ --. -____

-5s b. Who wes this? 21b I •i Lost coverage Mark “Lost coverage” box in person’s column. --------__------__-------------------~~~~~-~~-~~- .--. ------d-----idC. Anyone else? 0 Yes (Reask 2 Ib and cl 0 No 

t 

4

CHECK Refer to 2 1b and mark appropriate box. CK 

ITEM 4 4 

i !2a. Was covered by soma OTHER health insurance plan at anytime during [that/those] job 22a layoffs(s) or job loss(es)? Do not count military insurance or health programs such as 

Medicaid or AFDC. __________---___________________________----------- ____--------

b. Was covered by another plan for the entire time (names ofpersons in 2061 [was/were1 off work? b, I q Yes (23j s q DK (231 

20No ------------________~~~~~~~~~~~~~~~~~~~--------- .- -----------_ 

C. For how long was not covered by any kind of health insurance plan? CO oo q Less than 1 month 

34 : 13B. At ANYTIME during [that/those] job layoff(s) .or job IosslesL was covered by a military 23a , 10 Yes s 17 DK (NP) program or by a health program such as Medicaid or AFDC? 2 0 No lNPl -I ---------a-­

b. For how long was covered by this kind of program? b, oo 0 Less than 1 month 

I 

254 
--- 

PERSON 1 

1

CHECK 1 0 Persons 18 and over in family IfI 

ITEM 1 Refer to ages of all family members. 2 0 No person 18 and over fSecti0” 0) 

1 

Tho following questions are about immunizations to prevent influenza, 

pneumonia, and tetanus. In this family, they refer to (read namee of a// 

persons 18 + 1. 

lg. During the past 12 months, that is, since (7%month date) e year 

ago, have any adults in the family received a flu shot? 

Read if necessary: This vacolnation is usually given in the fall and 13 Yee 0 No (2) 0 DK 121 protects against influenza for about one year. --_ ------------Ts’ 

b. Who was thls? 

Mark ‘influenza immunization” box in person’s column. lb. 1 Cl Influenza immunization 

_-_ 

C. Anyone else? 

0 Yes f&ask Ib and cl 0 No 

20. Have any adults In the family evar received a pneumonia 

vaccination? 

Read if necessary: This shot first became available in 1979, and Cl Yes 0 No (31 0 DK (3) 

is glvsn only onca In a person’s lifetime. _---_---__-----------~-------------------------- --_ ---L------E

b. Who was thls? 

2b. 1 0 Pneumonia vaccination Mark “Pneumonia vaccination” box in person’s column. ~--__----_----~__-~~~~~~-------~~--~~---~---~--- --_ ---------------. 

C. Anyone also? 17 Yes (Reask 2b and cl 0 No 

-------------------------~~---------------------

Ask for each person with “Pneumonia vaccination” in 2b. 

d. Old - - recsivs the pneumonia shot within the past 12 months? d. 20No 

sUDK 

%I. During the past 6 yams, have any adults in the 

family had a tetanus shot? 

Read if necessary: :d)c;au; Is sometimes called 

0 Yes 0 No l.Section 01 0 DK (Section 01 

_---_-------------__--~~~~~---~---~----~-------- ------------~

b. Who was this? 

Mark “Tetanus immunization” box in person’s column. 3b. i 0 Tetanus immunization 

--_ 

C. Anyone slse? q Yes IReask 36 and cl q No _--__---_---------------------------------------

Ask for each person with “Tetanus immunization”in 3b. 

1 q Less than 1 year 

I d. About how long ago dld - - have the LAST tetanus shot? d. 2 IJ 1 year, but less than 3 years 

3 0 3 or more years ago 

snDK 

Notes 
---------------------------------------------- 

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

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

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

-- 

-- 

-- 

-- 

-- 

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

I Itrag 

1 Enter person number(s) of respondent(s). 

These questions are about mental and emotional disorders. 

1a. DURING THE PAST 12 MONTHS,did anyone in the family have -

If “Yes I “ask lb and c. 

b. Who is this? 

Mark box in appropriate person’s column. 

C. DURING THE PAST 12 MONTHS, did anyone else have -

A. Schizophrenia (skit-suh-free’-nee-uh)? q Yes 0 No 

_______________-------------------------------

B. Paranoid or delusional disorder, other than schizophrenia? Cl Yes [7 No 

C . Manic episodes or manic depression, also called bipolar disorder? [7 Yes /Specify) 0 No 

D. Major depression? 

Read if necessary: A depressed mood and loss of interest in almost 

all activities FOR AT LEAST TWO WEEKS. 

E . Anti-social personality, obsessive-compulsive personaiiti, 

or any other SEVERE personality disorder? Cl Yes 0 No 

__--------------------------------------------

F. Alzhaimer’s (alit& hTmarz) disease or anothertype of senile disorder? 0 Yes 0 No 

G. Alcohol abuse disorder? Cl Yes c] No 

H. Drug abuse disorder? Cl Yes 0 No 

_________-------------------------------------

I. Does anyone in the family NOW have mental retardation? 0 Yes 0 No 

2g. DURING THE PAST 12 MONTHS, did anyone in the family have any OTHER mental or emotional disorders? include ONLY those disorders 

which SERIOUSLY interfere with a parson’s ability to work or attend 

school, or to manage their day-to-day activities. 0 Yes 0 No (Check /tern 7, 

b. Who is this? Anyone else? Mark box in appropriate person’s column. 

Ask for each person with “0ther”in 2b: 

C. What would you call the disorder - - has? 

CHECK Refer to lA-Fand 2b/c.

ITEM 1 

Enterdisorderlsl from IA-FandZc. DO NOTRECORD G, H, ORI. 

CHECK 

ITEM 2 

L 

Jotes 

A. 

B. 

C. 

_-

D. 

E. 

AF. 

G. 

H. 

l. 

ii. 

C. 

CK 

1 

CK 

2 

PERSON 1 1 a-’ 

Person number(sl of respondent(sf 

--. 

1 0 Manic episodes ‘If 

I 0 Manic depretisfon Ii 12 

_---- _----kd m 

I 0 Major depressfon 

l-x 1 0 Personality dfsorder 

I I 0 Alcohol abuse 

I 

1 0 Drug abuse 

1 1 0 Mental retardation 

1 0 One or more entrie 

in IA-F or 2blc 

(Check hem 2) 

s 0 All others INPor 

Section Pl 

256 
---------------------------------------------------------------- 

Section 0 - MENTAL HEALTH - Continued PERSdN 1 

1 

CHECK 

ITEM 3 Refer to Age. CK 

3 

i 0 Under 5 (8) 

20 5-17 141 

3 0 70 or over (51 

s 0 All others 131 

Ask questions 3-8 about ALL disorders reported in 1 and 2. 3a. I 0 Yes 13dl 

1 

3a. Does - - (disorder(sj in questions 1 and 21 NOW entirely prevent - - from working at a paid job or business? z0No 

3 0 Doesn’t work - Other reasons 

e0DK ----_-----------------------------------------------. -lovesG.------~ 

b. Because of Ithls dlsorderfany of these disorders], is - - limited in the kind 01 amount of work - - can do? b. 

Z~NO 

90 DK -----~~~~---_-----------~~~~~~--~~~~~~~-------~~~--~ -,ov,,------ym 

Mark “Doesn’t work” if marked in 3a: otherwise ask: C. 

C. Because of [this disorder/any of these disordersl, does - - have trouble finding or keeping a job or doing job tesks? 20No . . . . . . . 

; i &esn’t work !EE>; 

~----~~_----------__~~--~~~-~~~~~~--~~-------~~~-~~~. . . . . . . . . > 

d. For how long has - - [been unable to work/ been limited in work/ had trouble with work1 because of [this d. -,oGs;tie;;,,th,-f 

dlsorderlany of these dlsordsrsl? 2 0 3 months, less than 1 year 

3 0 I year, less than 5 years 

417 5 years or more 

9nDK 

CHECK Refer to Age AND HIS-l, Cl. ITEM 4 

CK 

4 

I 0 18-24 AND neither 

WalWb box marked (4) 

e 0 All others (Check /tern 5) 

Pa. Does - - /disorder(s) in questions 1 and 21 NOW entirely 

school (or college17 

prevent - - from attending regular 4a. 1q Yes 14c) 1 

20 No 

3 0 Not in school - Other rewsons (Ck. Item 51 

s0DK ~-----~~----_-----_----------~----~~-----~~---~~----~~~--~~~~--~ 

b. Because of [this disorder/any of these disorders], does - - have trouble with school attendance or school work7 b. 1q Yes E 

20No . . . . . . . . . . . . 

3 c] Not in school - (Check Other reasons . . . . Item 5; 

sUDK . . . . . . . . . . . . 1 ----------------__---~-~----~~---~~~---~~~~-~~~,~~-~~ 

C. For how long has - - fbeen unable to attend school/had trouble with school] becsuse C. --T~less~W;;G~L-~ 

of [this disorder/any of these disorders]? 2 0 3 months, less than 1 year 

3 0 I year, less than 5 years 

4 q 5 years or more 

e0DK 

1 

CHECK CK I 0 Under age 10 17) 

ITEM 5 

Refer to age, then questions 3d and 4c and mark first appropriate box. 

5 2 0 Entry in 3d or 4c (51 

aa All others 18) 

Sa. ON - - OWN AND WITHOUT HELP, does - - appropriately take care of - - own 5a. I 0 Yes (61 k 

personal cere needs, such as eating, dressing, bathing, and going to the toilet? 20No 

so DK (61 

b. Is thls because of I - - Idisorderpany of these mental disorders]? b. lOYes m 

2[7No (61 s0DK 1 _________________----------------------------------~------------ A..

C. For how long has - - had trouble taking care of any of these needs? C. I 0 less than 3 months 

203months.lessthenl~ 

3 [7 I year, less than 5 years 

4 q 5 years or more 

e0DK 

Dtes 

257 

29 
Section 0 - MENTAL HEALTH - Continued PERSON 1 

6a. ON - - OWN AND WITHOUT HELP, does - - adequately handle routine mattan such as - 6a. 1q Yes c?l 

I a7 

zuNo 

(I). Managing money? (11 3 0 Doesn’t do ____----______--_---------~~~~~~-------~------~~-------~--------

b. Is this because of [ - - IdisorderMany of these mentsl dIsordersI? -pii-­

b. ruYes z[7No 90DK 

---------------------------------------------------~-----~~-y~~3~-----T-~~­

(ON-- OWN AND WITHOUT HELP, doas - - adaquatsly handle) (2) 20No 

(2) Doing waryday houuhold chores? 3 0 Doesn’t do 

____----_______-____-------------------------------------------­ -j---z b. Isthisbacausaofc- - IdisorderMany of thasa msntal disordarsl? 

b. rnYes 20No PUDK 

_--------___________--------~~~~~~----------~~~~~--~ -loYBs;l--d--rd4T­

(ON-- OWN AND WITHOUT HELP, doas - - adaquataly handle) 131 

2I3No 

(3) Shopping? 3 q Doesn’t do 

____-----_______________________________----------- -------------+-4Tb. Isthisbeoausaof[- - ldisorderllany of thesa’msntal dlsordaml? 

b. ruYes 20No 90DK 

______--______--____-------------------------------------------- 7---z-

(ON -‘- OWN AND WITHOUT HELP, doss - - adequately handle) (41 i Cl Yes (617) 

20No 

(4) Getting around outslde the home? 3 q Doesn’t do 

--------------~----------------------------------------,--------- m b. IsthisbacausaofI - - Jdisorderj/any of thesa m6ntal disordarsl? 

b. lOYes 20No onDK 

______--________________________________------------------------

If “Yes”in ALL of /l)-(4), go to 7; if “Yed’in any.66, ask: C. 10 Less than 3 manths . 20 3months , Iessthan,? 

6~. For how long has - - had trouble taking cam of any of these things? j 0 1 year, lass than 5 years 

4 0 5 yeers or more 

oU.DK 

votes 

258 
------- ------- ----------- --------- -------- 

Section 0 - MENTAL HEALTH - Continued PERSON 1 

Hand Card 0 1. Read answer categories if telephone interview. 7a. I 0 No difficulty 1 46 

7. Because of - - (disorder(s) in questions 7 and 21, how much difficulty does - - NOW have - 2 0 Some difficulty 

8. Forming friandships? 3 [7 A lot of.difficulty 

4 Cl Completely unable 

s0DK ~------------~~_~__------~~~~~~~~~~~~---~~~~-------

b. Keeplng friendships? b. --~yd;&-;;---i-fi2 0 Some difficulty 

3 0 A lot of difficulty 

4 q Completely unable +” 

s~DK _---------~~~__------~~~~~~--~~~~~~-----~------~~~~~~------~~~ T-iiC. Concentrating long enough to complete tasks? C. I q No difficulty 

2 0 Some difficulty 

3 0 A lot of difficulty 

4 0 Completely unable 

smDK 

---------,-~-N~d~~~~~t~---~-4~­

d. Coping with day-to-day stresses? d. 2 0 Some difficilty 

3 0 A lot of difficulty 

I 4 0 Completely unable 

sUDK -__________-----------~~~~~~-----------~~~~~ __-----

If a// “No difficulty”end/or ‘DK”in 7a-d, skip to 8; otherwise ask: 0. Y ocessthan3months -txE 

a. For how long has - - had any of these difficulties? 2 0 3 months, less than 1 year 

3 0 1 year, less than 5 years 

4 0 5 years or more 

snDK 

8a. Whon did - - LAST 5cw or talk to a MENTAL HEALTH PROFE&ONAL about - - Idisorder in questions 8a. 

1 61 

i 0 Less than 2 weeks ’ 

7m? Include psychiatrists, psychologists, 

mental health professional. 

social workers, psychiatric nurses, and any other type of 2 0 2 weeks, less than 1 month 

3 q 1 month, less than 3 months 

4 0 3 months, less than 1 year 

s 0 1 year, less than 5 years 

6 Cl 5 years or more 

7 0 Never f&l 

snDK --------__-------_-_____________________------------------------ ___ 

b. What type of mental health professional was last seen? 62-63 

b. 

Mental health professional -----------~_~_--------~~~~~~--------------~~---~-------------~~ ___ r 54 C. (Besides mental health professionals) When did - - LAST see or talk to a doctor or other health professional C. I 0 Less than 2 weeks 

about - - (disorder(s) in questions 1 and217 2 0 2 weeks, less than 1 month 

3 0 1 month, less than 3 months 

4 0 3 months, less than 1 year 

5 0 1 year, less than 5 years 

6 0 5 years or more 

7 0 Never 

s0DK 

1 56 

ITEM 7 Refer to 8a and c. CK 

7 

I 0 Never in 8a AND c (72) 

8 0 Other (9) 

CHECK 

Notes 

FORMHIS-IA“989, WI 6.881 

259 
-------- 

Section 0 - MENTAL HEALTH - Continued PERSON 1 

Ask 9 for the first 4 disorders recorded in Check /tern 2. 68 

17 

b FIRST DISORDER IN CHECK ITEM 2: 9a. 1 0 Less than 1 year 

z 0 1 yr., less than 5 yrs, 1961 

9g. When did a doctor or other health professional FIRST give a diagnosis 3 0 5 years or mom of (first disorder in Check Item 21 for - - 7 I=

4 0 Never 19dl 

s~DK 

_______--___-----_______________________------------ -li;e;----dm 

b. Did the doctor call the (first disorder in Check Item 2) by a mom technical or specific name? b. 

20No 

sUDK 1 (Next disorder or 101 

------___--------___~~~-----~~~~~~--------------~~~~ ----= 

C ,. What did he or she call it? C. 

’ (Next 

C% 

_____----_______________________________------------ -TOYIIe;-------E 

d. Has a DOCTOR OR OTHER HEALTH PROFESSIONALever given this disorder a technical or specific name? d. 20No 

s0DK 1 

(Next disorder or lOj 

________________________________________------------ -----------dm 

B. What did ha or she call it? e. 

__-------___-----___~----------~-~-------------~~~~- ---------‘--m 

f. When did a doctor first call this disorder fentry in gel? 

I f. I q Less than 1 year 

2 0 1 yr., less than 5 yrs, $Ts>t 

3 0 5 years or more OfIO/

9[7DK 1 

b SECOND DISORDER IN CHECK ITEM 2: 

9g. When did a doctor or other health professional 

of (second disorder in Check hem 21 for - - 1 

FIRST give a diagnosis 9a. 1 q Less than 1 year 

2 0 1 yr., less than 5 yrs, 

3 q 5 years or more > 

(9bj 

4 0 Never (9dl 

sUDK 

b. Did the doctor call the (second disorderin Check /tern 21 by a more technical or specific name? 

b. 1q Yes w 

20No 

saDK 1 (Next disorder or 10) 

----------_-----________________________--------~~~~~--~--------

C. What did ha or she call it? C. m 

lt+Xf 

I %F 

_______--___________--------------------------------------------

Tra’ d. Has a DOCTOR OR OTHER HEALTH PROFESSIONAL aver given this disorder a technical or specific name? if. 10 Yes 

z0No INext disorder or 101 s0DK I 

--------_--------_______________________--------~~~- ------4d----w 

g. What did he or she call it? e. 

____---_____________------------------------ -----------__---_ddf, When did a doctor first call this disorder (entry in 9e)? E 

f. I 0 Less than 1 year (Next 2 0 1 yr., less than 5 yrs. d,sords 

3 Cl 5 years or more or 101 

snDK I 

FORMHIS-IA,,mw 11,154 

260 
--- 

--- 

--- 

--- 

--- 

--- 

Section 0 - MENTAL HEALTH - Continued PERSON 1 

78 

79 

b THIRD DISORDER IN CHECK ITEM 2: 9a. I 0 Less than 1 year 

2 0 1 yr., less than 5 yrs. 1961 

%I. When did a doctor or other health professional FIRST give a diagnosis 3 0 5 years 0, more of {third disorder 1! in Check Item 21 for - - 7 4 0 Never (9dl 

--------__-------__---------------------------------------------

b. Dld the doctor call the (third disorder in Check Item 21 by a more technical or specific name? b. 10 Yes .t 80 

?.[7No 

Qjo DK 1 (Next disorder or 70) 

-----~~~~-~~~_-----_----------~~~~~~---~~--------~~~~~~---~~~---

C. What dld he or she call it7 C. El-83 

(Next 

‘disorder 

or 101 

---------------____---------------------------------------~----- -__ r 84 d. Has a DOCTOR OR OTHER HEALTH PROFESSIONAL ever given this disorder a 

d. 10 Yes technlcal or spscitic name? 20Nd 

s0DK 1 (Next disorder or 10) 

---_-------------__---------------------------------------------

g. What dld he or she cell It? 8. j%S-87 

~__~_-----~--------~____________________--------~-----~---~~~~~-

f. When did a doctor Rrst call this disorder fentryin Se)? j- 88 

f. I q Less than 1 year 

2 0 1 yr., less than 5 yrs. $T;;sr 

3 cl 5 years or more or 101 

QnDK 1 

89 

b FOURTH DISORDER IN CHECK ITEM 2: so 

9a. 1 0 Less than 1 year 

%I. When did a doctor or other health professional 

of (fourth disorder in Check /tern 21 for - - ? 

FIRST give a diagnosis z 0 1 yr., less than 5 yrs. 

3 q 5 years or more 1 

(961 

4 q Never i9dl 

QnDK 

---__-----~~~~~___-~~~~------~~~~~~~~~~---~~~~~~~---~~~~~~---~~~ 

b. Did the doctor cell the (fourth disorderin Check Item 21 by a more technical or specitic name? 

b. 1Cl Yes 

j- 91 

20No 

s0DK 1 

(Next disorder or 10) 

---------------------------~------------------------------------ : 

C. What did he or she cell it? c. j32-94 

(Next 

disorder 

or 101 

---__~_---~___-_---~~~~~~~~~-~~~~~~~~~~--~~~~~~~~-----~~--~~~--- --_ r 95 d. Has e DOCTOR OR OTHER HEALTH PROFESSIONAL ever given this disoider a technlcal or specific name? d. 10 Yes 

20No 

s~DK > (Next disorder or 10) 

-----_----~____----_____________________------------------~~~--- -__ r96-98 8. What did he or she call it? e. 

-------------------------------------------------------~-------- ---’ 

f. When did e doctor first call this disorder fentry in 9ej? r 99 

f. I 0 Less than 1 year 

2 0 1 yr., less than 5 yrs. (Next

disorder 3 0 5 years or more or 10) 

QnDK 1’ 

261 
Section 0 - MENTAL HEALTH - Continued - PERSON 1 

1 100 

1Og. Does - - NOW take any prescription medication for - - Idisorder( IOa. 1 cl Yes f1Od 

ZONO 

9mDK 

-----_______------------------------------------ --_ -TO;e;----dr?b?-

b. DURING THE PAST 12 MONTHS,did - -take any prescription medication for 

[this disorder/any of there disorders]? 

b. 

2UNo 1121 

sUDK I 

--_ -_d--d-- ___- T;io?-

C. How many DIFFERENT medications [does - -take/did - -take during the past 12 months1 

for Ithis disorder/any of these disorders]? C. Medication(s) Number 

smDK 

11 a. [May I see/Would you please bring to the telephone] the container(s) for the medication(s) 

you just told me about? lla. I 0 Container available 

2 q No container available 

_-____------_______------------------~~~~~~~~~~~ --_ ------------= 

Record from container label. If no container available and for telephone, ask 1 lb-d as appropriate. 

If OK, show Card 02, asking ‘ls it any of these?” before marking “DK”. b. 

b FIRST MEDICATION 

b. What is the name of the first medication? 

sss 17 DK 

--. 

b SECOND MEDICATION 

C. What is the name of the second medication? C. 

sss 0 DK 

--. ------------= 

b THIRD MEDICATION d. 

d. What is the name of the third medication? 

sss 0 DK 

2a. Does - - NOW receive a disability payment through any government program because of - - (disorder(s) in Check Item 2)? ~2a. 

1 

1 0 Yes 

20 No (Check /tern 1for NP 

9 0 DK or SectIon Pl 

________________________________________-------- ---

b. Is this payment through Social Security Disability Insurance, called “SSDI”; through Supplemental Security Income, celled SSI” ; through the Veteran’s Administration; or through some other program? b. I 0 SSDI 

2USSI 

Mark all that apply. 30VA 

4 0 Other 

- lotes 

262 
-- 

-- 

-- 

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

-- --------- 

-- 

-- 

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

1 FIT 70 -

Hand calendar. 

These next questions ara about dental care received during the 

2 weeks [outlined in red on that calendar/beginning Monday 

wand ending this past Sunday-. 

1a. DURING THOSE 2 WEEKS did anyone in the family go to a dentist? Include all types of dentists, such as orthodontists, 

oral surgeons, and all other dental specialists, a5 well as 

dental hygienists. 0 Yes 0 No PI 0 DK (21 

b. Who was this? 

Mark “Dental visits” box in person’s column. 

------------------------------------------------. C. During those 2 weeks, did anyone else in the family go 

to a dentist? 0 Yes h%ask Ib and cl [7 No 

I 

Ask for each person with “Dental visit”in lb. 

d. During those 2 weeks, how many times did - - go to a dentist? 

Mark box if under 2. 

28. During the part 12 months (that is, since (12-month date) a year ago}, about how 

many visits did - - make to a dentist? (Include the (number in Id I visits) you 

already told me about.) 

Mark “2-week dental visit” box in person’s column if visitlsl reported in 7d. 

b. ABOUT how long has it been since - - LAST went to a dentist? 

3. What ere the reasons - - has [not visited the dentist in over 12 months/never gone to the dentist]? 

Do not read categories. Circle a// that apply. 

01 Afraid 07 Can’t get there 99 Don’t know 

02 Nervous 08 No problems 

03 Needles OS No teeth 

04 cost 10 Not important 

05 Don’t know dentist 1 1 Didn’t think of it 

06 Dentist too far 88 Other (Specify) 

4g. Is there anyone in the family who has lost ALL of his or her 

upper (permanent) natural teeth? 0 Yes 0 No 14e) 

___________-__------------------------~~~~~~~~~--

b. Who is this? 

Mark “No uppers” box.in person’s column. 

C. Anyone else? 

0 Yes fReask 4b and cl 0 No 

Ask for each person with “No uppers”in 4b. 

d. Does - - have an upper denture or plate? 

t3. Is there anyone in the family who has lost ALL of his or her 0 Yes 0 No (5) lower (permanent) natural teeth? 

______~-___-______------------------------------~ 

f, Who is this? 

Mark “‘No lowers” box in person’s column. _______-___-____________________________---------

9. Anyone else? 

0 Yes Beask 4f and gl 0 No 

________________________________________--------. 

Ask for each person with “No /owers”in 4f. 

h. Doe5 - - have a lower denture or plate? 

PERSON 1 1 -

lb, 

-----------= 

d. 2-week dental visits 

Is-lo 

2a. 9% 0 Under 2 INPI 

__ 1 P-month dental visits 

300 0 None 

---= 

b. I 0 Past 2 weeks no3 reported 

(Mark lb, ask lcl 

z 0 2-week dental visit 

s 0 Over 2 weeks, less 

than 6 months lNPl 

4 0 6 months, less 

than 1 year 1 

5 0 1 year, l&s than 2 years 

6 q 2 years, less than 5 

7 •l 5 years or more 

o 0 Never 

01 07 99 -14-15 

16-17 

02 08 18-19 

20-21 

03 09 22-23 

04 10 24-25 

26-27 

05 11 28-29 

06 88 30--31 

13i 

3 32~33 

H (Specify1 

x 

I 0 No uppers 

_-

_- _-----------

d> 1 q lYes z0No = 

-

_--------___ Toi I 0 No lowers 

_-, .-------L--A---­

hm 

-

34-35 
Section P - DENTAL - Continued PERSON 1 

1 I 0 All family members have lost all CHECK Refer to 4b AND 4f. teeth: upper end lower ICheck Item 2) 

ITEM 1 8 0 Other 151 

5S. Dental SEALANTS are special plastic coatings 

that ara painted on the tops of the back teeth to 

prevent tooth decay. They are DIFFERENT from 

fillings, caps, crowns, and fluoride treatments. 

Has anyone in the family EVER had dental 

SEALANTS painted on their teeth? 

q Yes 0 No (61 0 DK 161 

_______--_--__--__-_~--~~---~~-~~~~~~~-~~--~~-~~~--

b. Who is this? - ---~t--~~a~t~--EI 

Mark “Dental sealants” box in person’s column. 5b. 

-__--__--_--__--__-_~-------~~~-~~--------~--~~~~~--~~~~~-~-~--~-~~. 

C. Anyone else? 

0 Yes IReask 5b and c) UN0 

6a. In the past two weeks has anyone in the family used a 

mouthwash or mouthrinse at home? 

0 Yes 0 No fCbeck /tern 21 q DK (Check /tern 2) 

________________________________________------------ ----------r44’ 

b. Who is this? 

6b. I 0 Mouthrinse 

Mark “Mouthrinse” box in person’s column. 

--_-----------_---_--~~--~---~--~~-----~---------~~~~~~~~------~---. 

C. Anyone else? 

0 Yes (&ask 6b and cl q No 

---------------------------------------------------------~---~-- m Ask for each person with “Mouthrinse”in 6b. 

d. What brand did - - use most often during the past 2 weeks? 

Do not read answer categories. Circle ONE brand. d. 1 2 3 4 87 9 

ACT 

Fluorigard 2. Prescription fluoride rinse 

1. Kolynos 3. PLAX 

Listermint 4. Scope, Listerine, Lavoris ~Speolfyl Reach 8. Other (SpecifyJ 

i 

StanCare 9. Don’t know 

---------------------------------~------------------------------ m 

Ask or verify. e. 1 q Yes 2 0 No 

9. Does this mouthrinse contain fluoride? saDK 

1

CHECK CK 1 q Under 2 (8) 

ITEM 2 Refer to age. 2 2 0 2-17 (71 

3 0 18 and over (NPI 

e 7. {Some schools have fluoride MOUTHRINSE programs.} 7. 10 Yes 

Does - - now take part in a fluoride MOUTHRINSE program at school? 20No 

s0DK 

1 

{Doctors or dentists may prescribe or provide tablets, drops, or supplements 

with fluoride in them. (Sometimes these are given at school.)} 6. 1q Yes 20No 8. Does - - now take vitamins with FLUORIDE in them or any other kind of s0DK FLUORIDE tablets, drops, or supplements? 

Notes 

FORM“LWA ,,989,,1.16-* 

264 
------------ 

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

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

Section P - DENTAL - Continued PERSON 1 

These next quertions refer to the 2 weeks [outlined on that 

calandar/beglnnIng Monday (date) and ending Sunday (date& 

%I. During that 2 week period, did anyone in the family miss any time 

from work or school because of a dental problem or dental visit? q Yes 0 No 00) 0 DK (701 

----------------------------------------------------.------------r-5ib. Who was this? 

Mark ‘Missed time”box in person’s column. Sb. I q Mlssed time 

__________---_______--------------------------------.----------------

C. Anyone else? 0 Yes lReask9bandcl 0 No 0 DK 

_-_-------~~-___---_~-----~----~~-----~-------------. --~------;~~--~zi~ Ask for each person with “Missed time” in 96. d. 

d. How much time did - - miss because of a dental problem or dental visit? 52 0 1 hour, less than 3 hours 

aa 0 3 hours, less than 5 hours 

54 0 5 hours, less than 7 hours 

55 0 7 or more hours 

OR 

-Days 

1OS. During that two week period did anyone in the family miss any time 

from work or school to assist a relative or friend with a dental 

problem or dental visit? Cl Yes q Nol77) q DK(ll) 

__________--________--------------------------------. 

b. Who was this? T-54-

Mark “‘Missed time” box in person’s column. lob. I 0 Mlssed time 

____---___---___-__-~----~~--~~~~---~~----~~--~~~~- -

C. Anyone else? 0 Yes f&ask IObandcl 0 No 0 DK 

-___------_--___---------~~---~~~----~-----~-------~ ,o-----;;;--~ Ask for each person with “Missed time”markedin 7Ob. d. d. How much time did - - miss because - - was assisting a relative or friend 52 0 1 hour, less than 3 hours with a dental problem or visit? as q 3 hours, less than 5 hours 

‘54 0 5 hours, less than 7 hours 

ss 0 7 or more hours 

OR 

Days 

118. (Not counting the time missed from work or school) Was there 

any (other) time during those 2 weeks that anyone in the 

family cut down on normal activities for MORE THAN HALF 

OF THE DAY because of a dental problem or dental visit? 0 Yes 0 No (Check /tern 31 0 DK (Check /rem 31 

_--__-----__-___---_____________________-~~~-------~~~~~----~--- -1 b. Who was this? 

Mark “Cut down” box in person’s column. llb. I 0 Cut down 

_____--___---___-_______________________----------------------------

C. Anyone else? 

0 Yes (Reask Ilbandc) 0 No q DK 

------------~----------~~~~----~--.------~~~-- G 

Ask foreachperson with “Cotdown”in 7 7b. d. oo 0 None 

d. During that period, how many (other) days did - - cut down for MORE 

THAN HALF OF THE DAY because of a dental problem or dental visit? - Days 

1 a. Mark first appropriate box. CK o q Under 17 

3a. I 0 Present for all questions 

2 0 Present for some questions 

CHECK 3 c] Not present

---------------------------~------------------------------ ITEM 3 b. Enter person numberfsl of respondent(s) to “Denta/“section. b. wj 

Person numbirk) of respondent(s) 

Notes 

265 
------------------------------------------------ 

-- 

-- 

-- 

-- 

-- 

-- 

I 

PERSON 1 1 

Section Ql - DIABETES SCREENING 

I 0 Persons aged 18 and over in family 171 Refer to ages of all family members. z 0 No persons aged 18 and over in family ISectIon R1 

1a. Has any adult in this family, that is (read names of persons 18 and over) 

EVER bean told by a doctor that they had diabetes? Do not include 0 Yes 0 No (Section RI pre, potential, or borderline diabetes. 

------------------------~~~-----~~~~~~----~---~~ 

b. Who is this? 

Mark “Diabetes” box in appropriate person’s column. 

------------------------~~~-------~------~~~~~~-

C. Has any other adult in this household bean to&l they have diabetes? 

Do not include pra, potential, or borderline diabetes. 0 Yes (Reask lb and c) 0 No 

Section Q2 - DIABETES FOLLOWUP QUESTIONS 

CHECK Refer to lb above. ITEM 2 

CHECK Status of diabetic. ITEM 3 

(Earlier I was told you had diabetes.) 

1. How old ware you when you got diabetes? Do not include pre, potential, or borderline diabetes. 

2. Are you NOW a diabetic? 

38. When you first learned that you might have diabetes, were you sick or feeling diabetic symptoms, 

OR was the diabetes discovered by chance? 

b. Were you at your doctor’s office, a patient in the hospital, or somewhere else? 

C. Was the diabetes discovered while getting a routine physical, a screening test for diabetes, or while being treated for something else? 

48. When your diabetes was first diagnosed, did you have a blood test, a urine test, or both? 

b. Was the blood test an oral glucose tolerance test? 

Ask if female; otherwise, go to 6. 

5g. Were you pregnant when you were first told that you had diabetes? 

----------------------~-~--~----------------~~~- b. Other than during pregnancy, did a dootor EVER tell you that you had diabetes? 

dotes 

266 

lb. 

CK 

2 

-

CK 

3 

1. 

2. 

b. 

C. 

4a. 

b. 

5a. 

b. 

i 0, Diabetes 

o 13 Under 18 INPI 

I q “Diabetes” box marked 

in 1b (Check item 31 

s 0 All others INP\ 

) 

I 0 Available 11) 

2 E Callback required lHh/dpage 

of HIS- 1, THEN NPI 

3 E Noninterview fcoverpage of 

H/S- 1A, THEN NP) 

w 

oo E Don’t have diabetes fNPl 

ss q Have pre, potential, or borderline diaberes iNPl 

Years old 

ssnDK 

i 0 Yes 

2 E No (NPI 

1 

1 0 Sick/symptoms 

2 E 6y chance (3~1 

9 0 DK 

3 q Somewhere else 

-,o ;o;t;e-p;y;;lcar­ -Tir’ 2 0 Screening test for diabetes 

3 0 Treated for something elsr 

s 0 Other 

9 0 DK 

1 

, 0 Blood 

2 n Urine (51 

3 0 Both 

9 q DK (51 

-To;a;-------T 

2 0 No 

9 EDK 

1 

I Eyes 

2 0 No (6) 

-o;ey-------r 

2 q No lNPl 

‘1 
Section 42 - DIABETES FOLLOWUP QUESTIONS - Continued PERSON 1 

1 is’ 

6a. Am you NOW taking insulin? 6a. I q Yes 

2 0 No16eJ 

__---_---__T___--__---~~----~~--~~~~-----~----~~----. 

b. For how long have you been taking insulin? b. ,,~;e~s~h~“~--,- laz 

, 0 Months 

99s 0 DK { 2 q Years 

_--__----_-------_______________-------------~-----------------: --------.----b3--2i 

C. Currently, about how often do you use insulin? 

C. .I q Day 

Times per t 2 [7Weak 

999 0 Use insulin pump 

sssq DK 

------~~-_----_--__------~--~~~~~----~~--~---,-------. 

d. On an average day. about how many units of insulin do you take7 --------u~i~----~~c--” 

d. 

,999 0 DK 

---------__-___--__--------------------------------- -Oye;---m---rlsMark without asking if known. 

g. Have you EVER used an insulin pump? 0. 2 q No 

smDK 

__---__--__-___--__---~~----------~~~---~--~~~--~~-~ -,iei--m----raof. Are you NOW taking diabetes pills to lower your blood sugar? f. 

Read if necessary: These are sometimes ceiled oral agents or oral hypoglycemic agents. z0No 171 

s0DK I­

__-------__-___--__---~~----~~--~~-~-----~----~-~~---~ __--__------

g. For how long have you been taking them? ooo 0 Less than 1 monih j?iizi 

g. 

I q Months 

1 2 0 Years 

999 [7 DK 

-_----~_-__------___~~~~--~~------~~~-~~~-~~~~-~-~-~ ------------’ 

h. About how often do you take them? , q Daye 

It. Times per -t 2 0 Week 

95s 0 DK 

78, Has a doctor or other health professional 

you should eat es e diabetic? ever given you e diet or instructions on whet foods 

7a. I q Yes 

z i?t No 

1 37 

s [7 DK > “’ 

--------------------------------------------------~- -,nY,-------m 

b. In the past 12 months, have you tried to follow the diet or instructions? b. 

2 0 No (91 

___------__-___--_______________________~~--~~-----~ ------------r39-

Hand Card 0 7. Read categories if telephone interview. c. I 0 Always 191 

C. In the past 12 months, about how often have you been able to follow the diet or instructions? 2 0 Most of the time 

s 0 Some of the time 

4 0 Rarely 

(&?hJ 

> 

Notes 

.._ 
--- 

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

Section Q2 - DIABETES FDLLOWUP QUESTIONS - Continued PERSON 1 

8a. Is it difficult for you to stay on your diet - 8a. o 0 Not applicable 

(1) 1OYes 

z 0 No 

(1) When you eat in restaurants? e0DK 

_--------------------~~~~~~~~~~-------~~~~~------~~~~~~~~~~~~ 

(2) When you go to parties or social events? (21 o 0 Not applicable 

i Cl Yes 

z 0 No 

9 0 DK 

y;;;yp;,Ya;,--= (3) When you ara busy with other activities? (31 1 cl Yes 

20No 

s 0 DK 

(4) When you go on a trip? (4) o 0 Not applicable 

1 0 Yes 

20No 

s q DK 

-------------------------------~~~~~~~~~~~~~~~~---~----------

(5) When you are feeling upset or angry? (51 o q Not applicable 

1 Cl Yes 

2 q No 

9 0 DK 

(6) When you ara feeling sad, depressed, or blue? (61 o 0 Not applicable 

i Cl Yes 

2 q No 

9 0 DK 

,oN,--p-,;e;,--= (7) When you are feeling bored? (71 1clYes 

2 q No s 0 DK 

________________________________________------------------------

b. Do you (also) find it difficult to stay on your diet -

(1) Because foods you should eat do not taste good? 

----!Y!!~:~:~d~ 

(2) Because you crave foods not on your diet? (21 o 0 Not applicable

1 q lYes 20No 

9 q DK 

(3) Because you have to prepare food separately for yourself? (31 o 0 Not applicable 

1q lYes 2 q NO s 0 DK 

,;;,;p;i,,;a---= (4) Because of lack of help or support from your family or friends? (41 1OYes 

20No 

s 0 DK 

(5) Because you are unsure about what foods you should eat? (51 o 0 Not applicable 

1 0 Yes 

20No 

s 0 DK 

9. How important do you think what you eat or drink is in controlling your diabetes? Is it very 

important, somewhat impofiant, or not important? 9. 1 Cl Very important 

I 40 

m 

-psam 

m 

48 

piT--G1 

2 0 Somewhat important 

3 cl Not important 

s 0 DK 

268 
Section Q2 - DIABETES FOLLOWUP-QUESTIONS - Continued PERSON 1 

1&I. Is there ONE doctor you usueiiy see for your diabetes? - IOa. 1 cl Yes 1 63 

2 0 No i7Ocl --------_____-------------~~~~------------~~~~----~- ---;--,----~.&x” 

b. How many times have you seen this doctor in the past 12 months? b. -

990 DK --_________---__----____________________----~~~~~~~~--~~~~~----~ 

C. Which of the following did ycu see in the past 12 months for any reason - C. 10 Yes -pz 

(1) A cardioioglst or heart doctor? Ill 20NC 

sDDK 

_-_--------______---____________________~~~---~~~~~~--~~~~---~~~ 

(2) An ophthaimologist, that is, a medical doctor who specializes in Jye care? (2) 1 cl Yes 

2CiNC 

j-57-

----------------__----------------------------------

Ask if female; otherwise go to (4). 

(3) An obstetrician or gynecologist? 

~~~__~_~-----_-----------~~~~~~~~~~~~~~----~~~~~~~~~ 

(4) A podiatrist or foot doctor7 

~-_-------_-------_-____________________---~~~-~----~~~~~~~~~~~~ 

(6) A prychologirt or psychiatrist? 

--------_____------------~~~~~~~~-~~---------~~~~~~~ 

(6) A dietitian or nutritionist? 

~~~-__-------___________________________-------~~~~-

(7) Any other medical doctor7 - Specify 

9nDK 

--;ez-------r58-

(3) 

20NC 

9nDK 

-lo~~~-------r”‘­

(4) 

20NO 

9nDK 

(5) 10 Yes po2tlNO 

9nDK --;e;-------T”‘­

(6) 

ZCINO 

9nDK 

--y~v,-s,,irv,-r%-~­ (7) 

z.uNo 

9nDK 

The next few questions are about glucose or sugar in your urine and blood. lla. 00 0 None 

1 18. About how many times in the past 6 months has a health professional checked 

glucose or sugar? Do not count times when an overnight patient in the hospital. 

your URINE for -Times 

990 DK -----------__-_------~~~~~~~~~-------------~---~--------------~~ 

b. On your own, about HOW OFTEN do you check your urine for glucose or sugar? p--67 

Include times when checked by a family member or friend. b. ooo 0 Never I 0 Day 

-Times per 

2 q Week 

3 q Month 

999 0 DK 

{ 4 0 Year 

---------____-_-----____________________~~~----------~~~~~~~~~~~ 

If “None”in 1 la and “Never”in 1 lb, skip to 1 Id. c. I 0 Always rssHand Card Cl7. Read list if telephone interview. 2 0 Most of the time 

C. Based on ALL your urine tests during the past 6 months, how often would you say 3 0 Some of the time 

you have had glucose or sugar in your urine? 4 0 Rarely 

5 0 Never 

3nDK ---------------------------------------~------------------------

d. Have you been tested for ketones in the past 6 months? d. 10 Yes rss20No 

9uDK I (1.21 

----------_---_-_-______________________~~-~~~~~~~~~~~~---------

6. Were any of these tests positive? e. 10 Yes TX20No 

90DK : 

12B. About how many times in the past 6 months has a health professional checked 12a. oo 0 None 171-72 

your BLOOD for glucose or sugar? Do not count times when an overnight patient in a hospital. -Times

ssn DK ---------__----------~~~~~~~---------------~~~~~~~~~~~~---~~~---

b. On your own, about HOW OFTEN do you check your blood for glucose or sugar? p3--75 

include times when checked by a family member or friend. b. ooo 0 Never I q Day 

2 0 Week -Times per 3 0 Month 

99s 0 DK { 4 0 Year _-_________---------____________________~--~~~---~----~~~~~~~~~-

If “None”in 12a and “Never”in 126, skip to 13.. C. I 0 Always rxHand Card (11. Readlist if telephone interview. 2 0 Most of the time 

C. Based on ALL your blood sugar tests during the past 6 months, how often would 3 0 Some of the time 

you say your blood sugar level has been too high? 4 0 Rarely 

5 0 Never 

9nDK 

163-64 
-------- ---- 

SectionQ2 - DIABETES FOLCOWUP QUESTIONS - Continued I PERSON 1 

136. Have you ever heard of glycosylded hemoglobin (glFko’sil-Gtted he”mo-glo’binl 13a. 1OYes 

) 77 

or hemoglobin “A one C”? 

20No f14sl 

____________________-------------------------------- r7id.-9 

b. About how many times in the past 6 months has a doctor, oursa, or other health 

professional checked you for glycosylated hemoglobin or hemoglobin “A one C”? b. 000 None 

-limes 

ssODK 

1Ida. About how many times in the past 6 months has a health professional checked 180-81 

your feet for eny sores or irritations? 14a. 000 None 

- Times 

990 DK 

----___---_____------~---~~~~~--~~~~~~~~----~--~~---. -------.---~ 

b. About,how often do you check your feet for sores or irritations? 

b. ooo0 Never 10 Day 

__ Times per 2 0 Week 

3 q fvlontt aa9q DK 1, 40Ysar 

115. During the past 6 months have you had any sores or irritations on your feet or 

ankles that did not heal normally? 15. lOYeS 

86 

20No 

s0DK 

116. When wes the last time you had an eye exam in which the pupils were dilated? 

This would have made you temporarily sensitive to bright light. 16. 

m 

I 0 Less than 1 month IIW zultol2months > 

3 0 13 to 24 months 11761 

4 q More than 2 years 

5 u Never 

saDK 

176. Have you had ANY klnd of eye axam by a doctor within the past two years? 17a. I 0 Yes 

1 

k2mNo 

sODK 1 

(181 

____---------__--_______________________--~------~~- -lII1;e;-----m 

b. Have you had &NY kind of eye exam by a doctor within the past 12 months? b. 

20No 

s0DK 

118a. Have you EVER been told that diabetes has affected the back of your ayes, that is, 18a. 10 Yes 

1 

the retina? 

2[3No 1201 s0DK I 

-___------__-__-------------~~~~-----~-----------~-- -----------m 

b. How old ware you when the doctor first told you this? 

b. __ Years old 

990 DK 

11%. Have you aver had laser or photocoagulation treatment 

Do not include treatments for cataracts. 

for this problem? 19a. 1 Cl Yes 

k 

z0No 

s0DK > 1201 

----------_-___--------~~~--~~~~---------~~~~~~~~~~~~~~~~~~~--~~ 

b. Did you receive this treatment within the past 12 months? b. 10 Yes E 

20No (201 snDK > --_--------____----_____________________~~~~~~~~~~~~~~~~~~~~~~~~ 

C. Was this the first time you had this treatment? C. 1CJYes m 

z[3No 

suDK 

2!O. Have you ever had photographs taken of the retina or inside of your eyes? 20. 1ClYes 

k 

z0No 

s0DK 

2!I. Do you have serious trouble seeing with one or both eyes eien when 21. lOYes 

) 

wearing glasses? z0No 

saDK 

FORM HIWA 11s19, ,&I51 

270 
------- 

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

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

I 

, RT 72 

Section Q2 - DIABETES FDLLDWUP QUESTIONS - Continued PERSON 1 1 

t&l. About how many times in the past 12 months has a doctor or other health professional 1 

checked your blood prassura? Do not count timea when an overnight patient in a hospital. 22a. ooo 0 None 

- Times 

999 0 DK -------------------------------------------.---------. -.;-------m 

b. Haa a doctor EVER told you that you had high blood pressure or hypertension? b. 

sUDK ----------------------------------------------------. -Tb-v,,-----T-Ts’ 

g. Are you doing any of the following [for your/to prevent] high blood pressure -

(I) Taking prescribed medication? (1;’ 20No 

s~DK --------------------____________________~~-------~ -TDv,-- -_--- m 

(?I Lonlng weight or controlling weight? (21 

ZEN0 

9uDK --------------__________________________~~~~~~~~-----~~~~~~~~~ 

(3) Cutting down on salt or sodium? (31 1 cl Yes m 

20No 

------------____________________________-~~~~~~~~- snDK -To76,-------m 

(4) Getting physical activity or exercise? (4) 20No 

snDK ---------__-_______-____________________------~~~~~-. -IoHigh m 

d. The last tlms you had your blood pressure checked, were you told it was high, d. 

borderline, low, normal, or ware you not told? 2 0 Borderline 

3OLow 

4 q Normal 

6 0 Not told 

6 q Never checked 

90DK 

13. Has a doctor EVER told you that you had - 23a. 1q Yes 1 

ft. Glaucoma? 20No 1234 9nDK I --------------------------------~~~~----------~~~~~~~~~~~~~~~~~~ 

b. Are you NOW taking any medication for It? b. 1q Yes E 

20No --_-----------------------------~~~~~~~~~-----------------------

C. Angina? C. 1q Yes m 

20No (2361 9 0 DK 1 ---------------------------~~~~~------------------~-.~-~~~~~-~~~~ 

d. Are you NOW taking any medication for it? d. 10 Yes Trl‘ 

20No 

sUDK ~-_-----------------------------~~~~--~------------------------- -

g. Any other heart trouble? e. 10 Yes E 

20No ew 9nDK 1 ------____-_----________________________---------------~-~~~~~~~ 

f. Are you NOW taking any medication for it? f, 1q Yes Tls’ 

------------------------~---------------------------------------

B. A stroke? 

---------------------~~~~~~~~~~~----~~~~---------~~~~~~~~~~~~~~~ 

h. Cataracts? 

i. Protein or albumin in your urine? 

j. Periodontal or gum disease? 

20No 

9nDK 

5 1q Yes Tlo’ 

20No 

snDK 

h. 1q Yes E 

20No 

9uDK 

i. 1CYes E 

20No 

9nDK -

j. 1q Yes E 

2C1No 

snDK 

!4. Has a doctor EVER told you that you had - 24a. 1q Yes 1 

20No ft. Kidney disaara? Do not include kidney stones or bladder infection. (251 snDK I --------------_-______________________i_-----------------------­

b. Polycystic kidney disease? b. 1q Yes e 

2 0 No 

9nDK 

!5. About how many different times in the past 12 months have you had a bladder or urinary tract infection? 25. oo 0 None r 

- Times 

9sc DK 

,6. Have you ever had symptoms of a bladder infection that lasted more than 3 months, such aa frequent 26. 1q Yes 1 

urination and pain in your bladder? 20No 

9nDK 

271 
Section 42 - DIABETES FDLLDWUP QUESTIONS - Continued PERSON 1 

!7. When you had these symptoms, ware you told that you had painful bladder 

syndrome or Interstltfal cystitis (in’ter-stish’al sis-ti’tis)? 

27. 10 Yes 

ZCINO 

b 

BODK > 1291 

!8. How old wera you when you wars first told that you had painful bladder 

syndrome or intantltial cystitis? (In’ter-stish’al sis-ti’tis) 

28. 

-Years old 

loo-al 

SD0 DK 

!S. When you urinate - 29a. o 0 NA/Dialysis (311 

1 

a. Do you USUALLY have trouble starting? 1q Yes 20Na 

B~DK 

--------------------------------------------~----~~~~~~--------~ 

b. Do you USUALLY feel like you have not completely emptied your bladder? b. 1q Yes 

m 

20No 

9uDK 

1 IOR. Do you USUALLY have to get up at night to go to the bathroom to urinate? Exclude 30a. 1q Yes .nights when you drink a lot of liquids. 2 0 No 

1311 snDK > -----------------__--~~--~~~-~~--~---~~~--~--~--~~~~~ -----------dm 

b. About how many times each night do you have to get up? b. - Times 

oo 0 Lass than once a night 

II. Have you aver had an amputation of your toe, foot, lag, or part of a leg? 31. 10 Yes, toe 

If “Yes , ” ask . Which? 2 q Yes, foot 

3q Yes, leg or part of leg 

Mark a// that apply. 40No 

12. During the past THREE months have you had - 32a. 1q Yes I 

a. Numbness or loss of feeling in your hands or feat other than from your hands or feet falling asleep? 20No 

SODK 

-----------------------------------------------~-----~--~~~~~~--~ 

b. A painful sensation or tingling in your hands or feet? Do not include 1 Cl Yes m 

normal foot aches from standing or walking for long periods. b. 10 No 

snDK _----------------~------~---~~---~--~~--~--~~--~~--~ -lo-e;--d-E 

0. Decreased ability to feel hot or cold in things you touch? C. 

2 0 No 

s~DK 

13fl. Do you NOW smoke cigarettes? 33a. 1q Yes 

1 

2 0 No 1341 

_---_-----------------------------------------------------------

b. About how many cigarettes do you smoke par day? b. 000 LassthanonaperdayE 

___ Per day 

ss 0 Don’t smoke regularly 

1&t. Have you triad to lose weight in the past year? 

20No 

----_-----------------------~~--~~--------~-----~ 

‘b. Is your weight now more, less, or about the same as,a year ago? b. I 0 More 

__--------------------~~--~-------~~--~---~---~~~~~~~~~-~---~--~ 

C. In the past year, about how much weight have you [gained/lost]? C. m 

-Pounds 

sss 0 DK 

Ask if 26 or older; otherwise go to 36. 150--6: 

#Ea. About how much did you weigh when you were 25 years old? 35a. 

Read if female: If you wars pregnant when you were 25, tell me your weight just before -Pounds 

you became pregnant. SDS0 DK 

-_---------------------~---------~~-----------~---~~ -_------__--

D. What is the most you have EVER weighed? b. w 

Readif female: Except when you ware pregnant. -Pounds 

sss 0 DK 

_--__---_-___--_--__--------------------------------------------

C. About how old ware you when you FIRST weighed that much? C. 00 [7 Now m 

-Years old 

Ki.11.1 

272 

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

Section Q2 .- DIABETES FOLLOWUP QUESTIONS - Continued PERSON 1 

160. 

Hand card Q2. Read categories if relephona interview. 

Where have you obtained information about diabetes? 

36a. oc 0 

01 0 

Nowhere 1391 

Doctor’s office - doctor 

b 

L 

Mark a// mentioned. Do not probe. 02 0 Doctor’s office - ““*Se 162--6: 

03 0 Dietitian or’nutritionist E 

04 0 Doctor or nurse in a hospital E 

05 0 Relative or friend 66-65 

08 0 Another diabetic 70-71 

07 0 Health department 72-7: 

08 0 Diabetes organization E74--7t 

09 0 National Diabetes 

inztion Clearing E 

10q rA&tes support & 

II 0 Library 60-61 

12 0 Newspapers E 82-8:

13 -0 Diabetes education 

class 

aa q Other - Specify 3 E86 8, 

___-______________-----------------------------~---_.________--------

If three sources or less in 36a, mark boxes without asking andskip to 37. b. 01 0 Doctor’s office - )88--8! 

doctor 

b. Which three of these sources have provided you with the MOST 02 0 Doctor’s office - USEFUL information about diabetes? E nurse 

Mark up to 3. 03 0 Dietitian or nutritionist I 92-S’ 

04 0 Doctor or nurse in a hospital 

05 q@slative or friend 

06 0 Another diabetic 

07 0 Health department 

oa 0 Diabetes organization 

09 0 National Diabetes information 

Clearing House 

IO 0 Diabetes support group 

II 0 Library 

12 fl Newspapers 

13 0 Diabetes education class 

aa [7 Other - Specify 3 

)76. Have you ever taken a course or class in how to manage your diabetes yourself? 37a. 10 Yes 1 

zuNo 

(381 a0DK 1 -------__-----_____----------~~~~m-...-.--------­

b. About how many hours of instructions did you receive on how to manage your diabetes7 b. Hours 

jig 

‘999 0 DK _________________----------------------------------------------- E 

C. Did this course include any of the following subjects - C. 1q Yes 

zuNo (1) How to inject insulin? (II -----_------__---------~~~~~~~----~~~~-------~-----------~~~~~ 

(2) How to change the insulin dose? (2) 1’0 Yes E 

znNo ------___---__-_--------~~~~~------~~-~~~~~~~~---

(3) How to manage your diabetes when you ara sick? ‘“‘-:&j-------E 

_____-____________-------------------------------- -ToveT-------m 

(4) How to test your blood or urine for sugar? (4) 

znNo ___---______________------------------------------ -,ove;-------E 

(5) How to plan meals? (5) 

znNo ____________-------------------------------------

(6) How to take care of your feet? @37&j-----.--m 

38. Hava you aver attended any (other) education program or class about your diabetes? 38. 1q Yes ) 

zuNo 

snDK 

3% Wore either of your parents EVER told that they had diabetes? Do not include 

borderline diabetes. 

pm, potential, or 39. 1q Yes, father 1 

2 Cl Yes, moth& 

If “Yes , “ask: Which? s q Yes, both 

40No 

smDK 

IQ. How many children have you had, including any that may have died? 40. oo 0 None (106-10: 

Read if female: Do not include stillbirths or miscarriages. -.-,.,-Total number of children 

ss [7 DK 

FORMHIS-1A 11989,WI s-1 

273 
-------------------------------- 

c ’ o [7 No person 18 + in family (Cover page of HIS-IA) CHECK status of sample person. I I 0 Available fhrrol 

ITEM 1 I 2 0 Callback required (Hhldpaga of HIS-11 

I s 0 Noninterview lSecrion T! 

INTRO I 

There next questions concern conditions of the teeth, mouth, or face. 1 

Tall me if you experienced any of these conditions MORE THAN ONCE , 

in the past 6 months. I 

I h

CHECK Refer to 46 and4f, ‘Pental”page 26, forsampleperson. ; ’ 1 0 Sample person has no teeth 121 

ITEM 2 I 8 0 Other (1) 

I 1 

16. During the past 6 months, did you have a toothachs more than onca, i ’ [7 Yas 

when biting or chewing? 2 [7 No (21 -----------------_______________ ;----- -----------------------~--~ 

b. Did you first have this pain more than 6 months ago? I 1OYes 

; 20No 

I h 26. (During the past 6 months) Did you have painful sores or irritations I 1 q Yes 

around the lips or on the tongue, cheeks, or gums more than once? ’ 2 0 No (3)

;----- --------.-----d-----------E 

b. Did you first have the sores or irritations more than 6 months ago? lOYes 

; 20No 

36. (During the past 6 months) Did you have a prolonged, unexplained burning 1 1 q yes ) 

sensation in your tongue or any other part of your mouth mora than once? 1 20No (41 I s0DK 

--------------------------------L----i__-----------------------­

b. When you have this sensation, does it coma and go or is it I 0 Come and go T?z’ 

continuous and uninterrupted? 2 [7 Continuous/uninterrupted 

s [7 Other 

I snDK --------------------------------c---------------,-------------------­

0. During how many DIFFERENT MONTHS in the past 6 months did m 

you have this sensation? I 0 Months --------------------------------~-------------------------------

d. How many total days in the past 6 months did you have this sensation7 , 1 0 1-3 days 4 0 16-30 days 7 0 “Everyday” m 

I 2 0 4-l 0 days 50 31-45days s0DK 

I 30 ll-15days 6[746+days --------------------------------L--_____------------------------

0. Did you first have this sensation more than 6 months ago? 1 1 q Yes m 

1 20No 

46. (During the past 6 months1 Did you have pain in the jaw joint or in 

front of the ear more than once? 

--------------------------------!--------------------------------+--= 

b. When you have this pain, does it coma end go or is it continuous and ; I 0 Come and go I 

uninterrupted? I 2 0 Continuous/uninterrupted 

I soother 

--------_-------____------~~~~~~ : s0DK ---____------------------- C. During how many DIFFERENT MONTHS in the past 6 months did r----- E 

you have this pain? i 0 Months --------------------------------L----___-----------------------­

d. How many total days in the past 6 months did you have this pain? 1 10 l-3days 4 q 16-30 days 7 0 “Everyday” m 

I 2 0 4-10 days 5q 31-45 days snDK 

I 30 ll-15days sO46+days ----____------------------------ r------------------------------- --_ 

6. Did you first have this pain more than 6 months ago? 1 i q Yes j- 20 

; 20No ___-----~____---~~~~~~~~~~------ r------------------------------- ___ 

f . On a scale of l-10, where 1 is mild and IO is severe, how would ) 1 2 3 4 5 6 7 8 9 10 21-22 

you rata this pain at its worst? Circle onbone. 

5a. (During the past 6 months) Did you have a dull, aching pain across 1 i Cl Yes 1 23 

your face or cheek more than once? Do not count sinus pain. I 2 0 No (Check Item 31 -------_--------_-----------~~~~ c------------------------------- 3--E_-

b. When you have this pain, does it coma and go or is it continuous and 1, 1 0 Come and go 24 

uninterrupted? I 2 [3 Continuousluninterruoted -I 

! so Other 

sUDK --------------------------------~-------------------------------

C. During how many DIFFERENT MONTHS in the past 6 months did I I I 

you h&v this pain? 1 U Months d. _-----_-~~___-_-~~~~~~~~-------- How total in the 6 months did have this r------------------------------­

many days past you pain? 1 10 l-3days 4 0 16-30 days 7 q “Everyday” 

! 204-lOdays 5 0 31-45 days s~DK I

I 30 ll-15days 6046+days -----------------------------------------------------~----------+--=-

6. Did you first have this pein more than 6 months ago? I 1 UYes , ZI I 

I 20No ---~--------------------------- ~--------------------------------~8--~gf. On a scale of l-10, where 1 is mild and 10 is severa, how would 

you rate this pain at its worst? Circle only one. I 1 2 3 4 5 6 7 8 9 10 

I FORMHIS-IA,,sm, ,&,C81, 

274 
--- 

Section R - OROFACIAI. PAIN - Continued 

I 1 I 

CHECK Refer to9c, 412,and 5c. l

I I 0 Two or more months in any one of 3c. 4c. or 5c (6) 

ITEM 3 ’ s 0 Other LSection SI 

I 

I 1 

6s. In the past 6 months, did you saa or talk to a DENTIST for ' lOYES 

the paln we just dlscussed? 1 z q NoEC) ---------------_--__------- -_-1------------------------------- ~ b. How many tlmas during the last 6 months did you see or talk to a 1 

dentist about the pain? I - Times I 

’ 9990 DK 

____--_-_______-___------------- I----- -------------_____________ m 

C. Iln the past 6 months) Did you sac or talk to a MEDICAL DOCTOR ’ 1 q Yes 

about the paln? I 20No(fW 

------------------------------i---------------------------,~------- I \ E d. HOWmany times? I 

I - Times 

I 

I 999n DK 

--------------------------------r----------------------------------- E 13, (In the pant 6 months) Did you set) or talk to any other ' 1OYes 

type of health profesoional about the pain? I 2 0 No (6hl 

--------------------,---------I-----------------------------------­

f. What klnd of health professional? I Health professional b 

------------------------------+-------------------------------

g. How many times during the past 6 months did you SBB or I 

I 

G 

talk to the (person in 6f)? I - Times 

I 999q DK 

--------------------------------L____T__------------------------ --_ 

h. (In the past 6 months) Did you worry about the health of I 

1 1q Yes 

L!!L 

your teeth and gums because of the pain? 

I 20No 

--------------------------------r----------------------------------- r46‘ i. (In the paat 6 months) Did you worry about the health of ’ 1 0 Yqs 

your body because of the pain? 1 20No 

I 

I 

HAND CARD Rl . Readlist if telephone intarviaw. I 

I 

7. Here Is a list of thlngs people do when they have teeth, mouth, or 1 

face pain. Please tell me the things you did for the pain during the I 

part 6 months. I 

I Circle all that apply. I 

I 

1 - Use a hot or cold compress ’ 1 1‘1 

2 - Take a prescription drug I 2 21 

I 

3 - Take an over-the-counter drug I 3 31 

4 - Drink some liquor or wine because of the pain I 4 41 

I 

6 - Take time off work I 5 51 

I 

6 - Stay home more than usual I 6 6( 

7 - Avoid family and friends I 7 71 

I 

S - Anything else? (Specify1 I 8 (Specifyj 81 

0 - None of the above I 0 01 

I 

9 - Don’t know I 9 91 

Notes 

I 

5 

i 

-

275 
-------------------------------- 

Section Sl - SPECIFIC CONDITIONS 

0 

3. DURING THE PAST 12 MONTHS, did you have gallstones? i i 0 Yes 151 

I znNo 

1 sC]DK 

2. DURING THE PAST 12 MONTHS, did you have any other ’ 1 I7 Yes 15) gallbladder trouble? i 2nNo 

3. Have you aver had gallstonss? , 

I 1 0 Yes Ed 

’ 20No 

1 snDK , 

I 4. Have you ever had any other gallbladder trouble? I 1 q lYes 

I 

5. When did a doctor tell you that you had I Cgallstoneslgallbladder l I fl Less than 3 months ago first trouble]? 

1 2 17 3 months, less than 1 

1 s [7 1 year, less than 2 yearsyear 

1 4 0 2 years, less than 5 years 

6a. Have you ever had gallbladder surgery? I

1 1 q lYes 

--------------------____________I 

b. When did you last have gallbladder surgery? l 1 0 Less than 3 months ago 

I 2 0 3 months, less than 1 year 

I 3 0 1 year, less than 2 years 

l 4 0 2 years, less than 5 years 

I 

I 

7. Have you ever had any of the following tests to help diagnose I 

your Lgallstones/gallbladder condition] - I 

I 

8. An X-ray of your gallbladder or abdomen? I 

I 

’ i 0 Yes Read if nec&sary: For thls X-ray you would have been given either pills 1 2 q No 

the night before or an iqtravenous injection just before the X-rays were taken. ; s[7DK 

I------- ----------------------vwwm 

b. A sonogram or ultrasound of your gallbladder? I 

1 i Cl Yes Read if necessary: For this test, a gel is rubbed on your upper right side , and an instrument is moved around the area while 2 q No an examiner watches on a television screen. j s[7DK 

--------------------------------~-------------------------------

C. An upper GI series? I

I 

Read if necessary: For an upper GI series, you drink a chalky white ’ 1 q lYes 

liquid called barium, and then X-rays are taken. , 20No 

’ suDK 

8. DURING THE PAST 12 MONT&, did you have an ulcer? 1 i q Yesi701 I 20No 

1 snDK 

9. Have you ever had an ulcer? 

10. When did a doctor first tell you that you had an ulcer? 1 I q Less than 3 months ago 

I 2 0 3 months, less than 1 year 

I 3 0 1 year, less than 2 years 

1 4 0 2 years, less than 5 years 

I 

11. Did the doctor say you had a gastric, duodenal, or peptic ulcer, some 1 o [7 Skin (731 other type, or were you not told? I I 0 Gastric 

Mark a// that apply ’ 2 0 Duodenal 

I 3 0 Peptic 

’ 40 Stomach 

I 7 [7 Nottold 

1 8 [7 Other - Specify 3 

h 

h 

L-L 5 0 5 years, less than 10 years 

6 Cl 10 or more 

7 0 Doctor yearsnever seen I61 

9 0 DK when 

1 

6 Cl 10 years or more 

s 0 DK when 

E 

a 

I 

I 

1 s 0 5 years, less than 10 years 

6 Cl 10 or more 

7 0 Doctor yearsnever seen 1131 

s 0 DK when 

276 
------------------------------- -- 

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

Section Sl - SPECIFIC CONDITIONS - Continued 

I 

2. Hove you ever had any of the following tests to help diagnose I 

I 

1 

your ulcer - I a. An upper 01 series? I 1 0 Yes 

Read if necessary: For an upper 01 series, you drink a chalky white ; znNo 

liquid called barium, and then X-rays are taken. I snDK 

.-L-------------------~~~~-~~-~~--­

b. An upper endorcopy or gastroscopy? l LE I 

Reedif necessary: For this test, a long flexible tube with a light on the I 1 0 Yes 

end Is inserted down the throat so that the lining of 

the stomach and the upper intestine can be 

examined. 

3. DURING THE PAST 12 MONTHS, did you have diverticulitis? i 1 clYes~751 1 

2 0 No 

s 0 DK 

4. Have 

you ever had diverticulitis? I 1 

0 Yes 

1 

5. When did a doctor first tell that had diverticulitis? 1 

you you 1 0 Less than 3 months ago 5 0 5 years, less than 10 years 

2 0 3 months, less than 1 year 6 0 10 years or more 

3 0 1 year, less than 2 years 7 0 Doctor never seen (18) 

I 4 0 2 years, less than 5 years s 0 DK when 

6a. Have you aver been In the hospital overnight for diverticulitis? I 

I 1 0 Yes 1 

) znNo 

--------------------------------~------------------------------- sUDK 1 ‘17’ __ 

b. When wera you last in the hospital overnight for diverticulitis? I 1 0 Less than 3 months ago 5 0 5 years, less than 10 years tz 

I 2 0 3 months, less than 1 year 6 0 10 years or more 

I 3 q 1 year, less than 2 years s 0 DK when 

I 4 0 2 years, less than 5 years 

7. Have you evar had a barium enema to help diagnose I 

I 1 

your dlvertlculltlr? I 

Readif necessary: For this X-ray, you would have been given an enema 1 : i ir 

containing barium and X-rays of your abdomen 

would be taken. 1 s[7DK 

I 80. DURING THE PAST 12 MONTHS, have YOU had a spastic colon, 1 1 0 Yes 1 

functional bowal, Irritable colon or Irritable bowel syndrome? 

--------------------------------t------------------------------------­

b. Which - spastic colon, functional bowel, Irritable colon, or irritable 1 q Spastic colon 

bowel syndrome? 1 2 0 Functional bowel 

Merkallreported, do notprobe. I 3 q Irritable colon 

I 4 0 Irritable bowel syndrome 

I 8 0 Other similar condition mentioned - Speciv 

9g. Have YOU evsr had a spastlc colon, functional bowel, irritable colon, or 1 1 0 yes 

irritable bowel syndrome? I znNo 

) s~DK > i20’ 

--------------------------------~----------------------------------

b. Which - Spastic colon, functional bowel, irritable colon, 01 Irritable 1 I 0 Spastic colon 

bowel syndrome? 2 0 Functional bowel 

Mark allreported, do notprobe. 3 0 Irritable colon 

4 0 Irritable bowel syndrome 

8 13 Other similar condition mentioved - Spa&y -

C. When did a doctor first tall you you had lentrym 786 or 19blT 

z 0 3 months, less than 1 year 6 0 10 years or more 

I 3 0 1 year, less than 2 years ? 0 Doctor never seen 

I 4 17 2 years, less than 5 years s 17 DK when 

). Have you had hemorrhoids In ths past 12 months? I

I 1 q Yes (27bl 

1 

! 20No 

1 9[7DK 

1 18. Has a doctor evar told you that you had hemorrholds? .I( 1 0 Yes 

. --_---_-----_------_____________I 

b. When did you last talk to a doctor about your hemorrhoids? 

2. Have YOU ever had surgery in a doctor’s office, clinic, or hospital for hemorrhoids? 1 20No 

I 2 0 3 months, less than 1 year 6 ITI 10 years or more 

I 3 0 1 year, less than 2 years 7 0 Doctor never seen 

1 4 0 2 years, less than 5 years s 0 DK when 

1

I i 0 Yes 1 

277 
I Section S2 - ABDOMINAL PAIN 

I Hand CardSI. . I 

The next questions ara about pain and discomfort in the abdomen. By I 

abdomen, we mean [the shaded area on this diagram/the area between the ’ 

lower ribs and the hips]. Do not include pain related to kidneys, bladder, or 1 

arthritis (menstruation or pregnancy). 1 cl Yes 

1. DURING THE PAST 12 MONTHS, have you had any type of pain or go

I 

I znNo DK lSecdon s31 savere discomfort in your abdomen three or more times? I > I 

2. Have you aver made a visit to a doctor for your abdominal pain? 1ElYes 

If asked: or the condition that caused the pain. 20NO 

90 DK 1 14) 

1 

36. What condition did the doctor say was the cause of the pain? ( 980 Doctor didn’t say 

Enter first 5 code numbers and the conditions in the order mentioned. I ssnDK 1 

Do not probe. I 

I Code I 

II 

II 

I 

I 

I 

I 

I 

I 

I­

----------------------------------------l~-------------------------------------------. 

If only one response to 3~9,enter in 3b without asking. I 

b. ~l~i;~ts~ cdnditioris caused the MOST pain during the past I 

I 

I 

Enter code number and condition. 1 ssn DK (Checkitem 7) 

I 

49. What condition do you think was the cause of the pain? 

Enter first 5 coda numbers and the conditions in the ordermentioned. ssn DK (5~ 

Do not probe. Code 

I 

I 

III 

I 

II 

I 

I­ ----------------------------------------~-------------------------------------------, 

If only one response to 4a. enter in 4b without asking. I 

I b. ~I~inqfhts:85a conditions caused the MOST pain during the past 1 

I 

Enter code number and condition. I 990 DK (Check item 71 , 

0 I Spastic colon 22 Gallstones 

02 Functional bowel 23 Gastritis 

03 Irritable colon 24 Gastrdenteritis 

04 Irritable bowel syndrome 25 Growth 

05 Allergies 26 Heartburn 

06 Anxiety 27 Hepatitis 

07 Appendicitis 28 Hernia, other than hiatal 

08 Cancer 29 Hiatal hernia 

09 Cirrhosis 30 Impacted bowels 

IO Colitis 3 1 Indigestion 

11 Constipation 32 Infection 

1 2 Crohn’s disease 33 Influenza 

13 Depression 34 Lactose Intolerance 

14 Diarrhea 35 Medication side effects 

1 5 Diverticulitis 36 Nerves 

1 6 Diverticulosis 37 Obstructed bowels 

1 7 Enteritis 38 Other bowel trouble 

18 Esophagitis 39 Other liver trouble 

19 Flu 40 Other stomach trouble 

20 Food poisoning 41 Peritonitis 

21 Gallbladder problem 42 Stress 

u 

& 

141 

Condition 

I pir 

~-TX 

piz 

pxi 

pizi 

(Check item II pGil 

Condition 

pizil 

pcz 

rszz4 

Jzzi 

Jzzi 

(Check itam 11 lzg-3p 

43 Tension 

44 Trouble swallowing 

45 Tumor 

46 Ulcer 

47 Ulcerative colitis 

48 Virus 

* 55 Arthritis 

* 56 Back problems 

* 67 Bladder 

* 58 Kidneys 

* 59 Menstruation 

* 60 Other female trouble 

l 61 Pregnancy 

l 62 Prostate 

63 Other - Specifyabove 

64 Other - Specify above 

65 Other - Specifyabove 

66 Other - Specifyabove 

67 Other 2 Specifyabove 

* Do not ask questions 5-27 about these conditions 

n-llll H14.46119141,*.,r., 

278 
Did 

-- 

Section S2 - ABDOMINAL PAIN - Continued. 

) Ask questions 5-27 about the first condition coded 01-04 in 3a or 4a. If none, ask about condition in 3b or 4b. If this is an asterisked condition, ask 

about next condition mentioned. If no other condition, go to Section 53. 

I 

I 131-32 .

IO. Was the pain on the right side, the left \ , 0 Right 

CHECK Enter code and I 

I Code side, or down the middle? I 2OLeft 

ITEM 1 condition. I Mark a// that apply. ! 3 0 Middle 

I 

I 

I Condition II. When you get this pain, how long I I 

1 33 does it USUALLY last? I 

(These next questions are about pain i 

related to your/condition in Check /tern 71.1 iAsk if “Yes” in 2; otherwise go to 8. o 0 None (81 I 

1q One [xw 0 Constant, all the time 5. How many DIFFERENT doctors have znTwo 1ass8 0 Varies too much for a you visited for this pain? 3 0 Three or more usual duration 

6. DURING THE PAST 12 MONTHS. ’ ooo 0 None ( 34-36 1 I

12. During how many days in the past j 001 Cl One (751 

how meny doctor visits did you have I 001q One vear did YOU have this oain? 

because of this pain? I I -Days 

I 

I Number of visits I 3650 Everyday 

lfmorethan 14daysin 12,goto 14 I 1 65 

week period? I 1 0 Yes (151

/ 37 13. two all of this pain occur during one 1 2 q No 

7. Were any of the following tests done (to! I 

diagnose your (condition in check item l)l? I 14. During how many DIFFERENT months / 1 66-67 

8. Upper 01 series? 

I in the past year did you have this pain? I __ Months 

1 15. On II scale from 1 to IO. where 1 is I 1 68-69 Read if necessary: You drink e chalky 1q Yes white liquid called znNo mild and 10 is severe, how would you I 01 02 03 04 05 barium and then rate this pain at its worst? X-rays em taken. snDK Circle one 1 0607080910 

---------__----- -+--------------

1 16. Have you ever taken any medication , 

I 10 Yes ) 70 

b. ttorium enema? I 

I for the pain? , zC]No 1781 Readif necessary: YOU are given an 

enema containing 71 1q Yes barium and X-rays of 17. Was any of the medication you took 1 I 0 Yes z0No prescribed for you by a doctor? your abdomen are I z.[3No --I

taken. snDK 

-----------------+---------- 18. When this pain starts, do you have to i , 0 Yes 

C. Upper endoscopy or gastroscopy? ; rx- s$:5;hat you are doing because tit ’ znNo 

Resd if necessary: A long flexible tube 

with a light on the 19. When you have this pain, do you I 73 

end is Inserted down usually have bowel movements? 1 I q lYes 

tho throat so that the 1q lYes ! 20No ---I 

lining of the stomach I

and the upper 20No 20. When you have this pain, are your I L 74 

intestine can be snDK po;;;ovements usually looser than 1 1 Cl Yes 

examined. I 20No -----------------T------ I d. dower endoscopy or co1ono5copy? I

I ----r,: 21. When you have this pain, are your bowel 1 , q Yes ( 76 

Read if necessary: A long flexible tube royn;nts usually more frequent than I 20 No with .a light on the 

end is inserted in the 1q lYes 22. Is the pain usually relieved or 10 Yes 

1 78 

rectum so that the 

lining of the large 20No lessened by having a bowel 2CjNo intestine can be snDK movement? 

examined. 1 77 

-----------------f-------------. - 23. Is the pain relieved by passing gas? 1OYes 

6. Sonogrem or ultrasound? I I-c ] 20No 

Read if necessary: A gel is rubbed on your upper right side 24. When you have this pain, is your I 10 Yes 

78 

and an instrument is abdomen usually swollen or bloated? 1 20No -I 

moved around the I I 

area while an 1 10Yes I 1 79 

examiner watches 1 20No 25. When you have this pain, are you ever 1 lOYes 

on a television 1 snDK awakened from sleep? , znNo screen. I 

I 26. In the past 30 days, has this pain I 8” 

I ( caused you to cut down on the things I 1q Yes j Mark box or ask. 1 o q Telephone you usually do? ! 2 0 No (Section S31 --I HandCardSl. interview (91 

8. Looking at this card, tell me the 

number5 

(from the (condition 

located? 

in Check /tern 11)was; 2 q 44 you cut down for more than half the day?; -Days 

Notes 

Mark all that apply. 

Do not probe. 

that show where the pain i 10 E43 27. In the past 30 days, how many days did I 00 q None ( 81-62 

9, Was the pain above the waistline, ; , q Above 

below the waist, or around the 

waistline? 1 2 0 Below 

Mark a// that apply. 1 3 mAround 

279 

7 
--------------------------------- 

I RT7ll 

Section S3 - NORMATIVE BOWEL FUNCTIONS 1 3-4 

These next queetionr are about bowel habits during the part 12 months. I [ 6-6 

(Because these questions are peraonel, I can reed the questions to you or if I Times per day 

you prefer, you can fill them out yourself.) I 

I OR 

I 

l ____ Times per week 1. How often do you usually have bowel movamants? r--zF L 000 Less than one time per week 

Hand Card Q 1. Read answer categories if telephone b&view. I 

I Most of Some of 2. During the past 12 months, how often have your bowel movements been- ; Always Rarely Never DK the time the time 

a. Hard? . . . . . . .._..__...._...._._.__.._..................._ I 1n 20 30 40 50 90 I 

I 

I b. Accompanied by mucus? . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I I 0 20 30 40 50 90 1 

I 

C. Accompaniadbypain?......................................I 10 2u 30 40 50 90 I 

I 

d. Accompanied by swelling or bloating? . . . . . . . . . . . . . . . _ . _ . _ _ . . . _ .I I 0 20 30 40 50 SO 1 

I 

B. Accompanied by straining to move bowels? . . . . . _ _ _ . . _ _ . . . . . . . . . .I I 0 20 acl 40 50 90 1 

f. Followed by a feeling of not being finished after moving bowels? . _ . . . I I 0 2 0 3 0 40 5 0 Q [7 E 

I 

1 16 3. During the pest 12 months, how often have you been constipated? 1 10 Always 

I zOMostofthetime 

I 30 Someofthetime 

I 40 Rarely 

1 50 Never 

1 16 4. How often have you had diarrhea? ; I 0 Always 

I 20 Mostofthetime 

( 3 0 Some of the time 

I 40 Rarely 

I 50 Never 1 

(81 

1 17 

5. DURING THE PAST 12 MONTHS, have you seen e doctor about I. 1OYes 

your diarrhea? I 20No(81 

I 1 18-19 

6. How many times in the past 12 months have you seen a doctor about your I 

diarrhea? I -Times 

I 

7. What did the doctor say caused the diarrhea? f 010 Enteritis 09 Cl Lactose Intolerance 20-21 

l 020 Diverticulitis to 0 Travelers diarrhea 22-23 

Mark first 4 mentioned. Do not probe. I 030 Crohn’s disease 1I 0 “Something I ate” 24-28 

1 040 Intestinal flu or virus 12 0 Dysentery 26-27 

1 0517 Spastic colon, functional bowel, 13 0 Medication 

I

I Irritable bowel syndrome, 14 q Nervesorstress irritable colon 

l 060 Colitis 88 0 Something else 

1 070 Ulcerative colitis 98 q Doctor didn’t say 

I 080 Infection ssmDK 

8a. IN THE PAST 30 DAYS, did you take any laxatives or stool softeners, such 1 1 q Yes 1 28 

as Ex-Lax, Metamucil or Fiberall, to help move your bowels? 

’ znNo 

1 s0DK (91 

> 

~-----------------------~~~~~~~~ 

b. How many times have you taken laxatives or stool softeners in I -f i!La0 

the past 30 days? I 

-Times 

9. How often do you think a person should have bowel movements? ) 31-32 

~ Times per day 

I OR I 

I Times per week r?zizcl 

I 

1 000 Less than 1 time per week 

lotes 

FORM HIS-1A 11969, I&t&8 

280 
, 

Section 53 - NORMATIVE BOWEL FUNCTIONS - Continued I 

IO. I am golng to read a llrt of health problems that may have been a lot of 

trouble for you in the past year. By “a lot of trouble” wa mean that in 

the paat year, you saw or talked to a doctor or other health 

profarrlonal, you took medication more than once, or the problem ,i’ 

interfered with your life or usual activities. 

Hand Card 52. 

In the past 12 months, heve you had a lot of trouble with - Y!SS NO 

a. Diulness? . . . . . . . . . . . . . . . . . . .._..........................I ICI 20 1 

b. Nsusoa? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .._..........._.. i 10 20 1 

C. Diarrhea? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 10 20 1 

I d. Feeling sickly? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..I 10 20 1 I 

8. Abdominal pain? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..I I 10 20 1 

--___-------_____________________c______----------------~~~~~~~~~~~~~ 

I In the paat 12 months, have you had a lot of trouble with - I 

I 

f. Abdomlnalgas?...........................................I 10 20 1 

I 

g. Chestorheartpain? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..I 10 20 1 

h. Fainting spells? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1O 20 EC I 

i. Palninthejoints? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ._.. . . . . . .) I 13 20 1 

j. Paininyourarmsendlegs,otherthaninthejointsl. . . . . . . . . . . . . . . . 1 I 0 z.0 1. --_-________--------____________________--------------------~~~~~~~~~ 

In the past 12 months, have you had a lot of trouble with - I 

I 

k. Vomiting? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 10 20 1 I 

1. Weakness? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..I 10 20 1 

ttl. gackechss? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 10 20 1 

I Il. Headaches? . . . . . . . . . . . . . . . . .._..._._._..............._...I 10 20 1 I 

I 0. Nervousness or anxiety? . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . I I 0 20 .pic 

-----------___---------~~~-------l------------------------------~~~~~~ 

In tho past 12 months, have you had a lot of trouble with - I 

p. Faellngtenreorkeyedup? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ 10 20 1 

q. Feeling sad, blue or depressed? . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . I 10 20 1 

f’. Pain when you urinate or pass your water? . . . . . . . . . . . . . . . . . . . . . .I 10 20 1 I 

I 

1 63 kHECK , 

I I 0 Completed by interviewer 

ITEM 2 Mark appropriate box. I 

I 2 q Completed by respondent 

I 

lotes 

281 
I CHECK Refer to lener indicator on sample selection label. I I 0 Letter M (Coverpage of HIS-1AI 

ITEM I 1 z 17 LetterT (Check /tern 21 

1 

CHECK Refer to Section 0 1, item lb on page 32. I : i ~~~~~~~n~~~e~.~~ 

> (Cover page of H/S- 1Al 

ITEM 2 . I 2 0 All others (1) 

I eI -# 

1. Has a doctor EVER told you that you had - 1 1 q Yes 

I znNo 

a. Protein or albumin in your urine? ; s[7DK 

~~~~~__-_----~----_______-~~---~~~~ -I--------------------------------

E b. Kidney disease? Do not include kidney stonss or bladder infection. 1 : 51 i”,’ 

I lid) ’ s[7DK > ___---------______------------~-------------------------------- m 

C. Polycystic kidney disease? 1 1 q lYes 

I 20No 

’ s0DK 

--------_______-------~~~~~~~~ ~___________-------____,,,,,,,_,, E d. Periodontal or gum disease? 1 1 q lYes 

2 0 No 

1 

, sODK 

m 

2. About how many times in the past 12 months has a doctor or I 000 None 

other health professional - I 

I -Times 

3. Checked you for diabetes? ( SSODK 

-------------------------------~-o~o~N~~--------------------------~ 

b. Checked your blood pressure? 

i -Times 

1 SSSODK 

I m 3. About how many different times in the past 12 months have 1

I ooq None 

you had a bladder or urinary tract infection? I 

I -Times 

1 ssnDK 

4. Have you ever had symptoms of a bladder infection that 1

I 1q Yes I 

lasted mom than 3 months, such as frequent urination and ’ 20No paln In your bladder? , sUDK (6) 

I LJ!L 

5g. When you had these symptoms, were you told that you had painful I 1 0 Yes 

bladder syndrome or interstltisi cystitis? lin’ter-stish’alsis-ti’tisl 1 2[7No 

I snDK (61 

------------------------------~-----~-------------------------- Giis -“-m 

b. How old were you when you wwe first told that you had painful I -Years old bladder syndrome or interstitial cystitis? fin’terstish’al sis-ti’tis) I 

, ssODK 

I 

6. When you urinate - I o q NAlDialysis 181 1 

1 1 Cl Yes 

I 20No 

3. Do you USUALLY have trouble starting? ’ s0DK 

___--------------------------- A----- _________ ------, ----------dE 

b. Do you USUALLY feel like you have not completely emptied I 1 q lYes 

your bladder? 1 20No 

I sC]DK 

I 1 73. Do you USUALLY have to get up at night to go to the 

bathroom to urinate? Exclude nights when you drink a lot I 1q lYes 

of liquids. I 20No 

‘I s 0 DK 1 18’ 

-------------------------------,----------------.---------------- I 

b. About how many times each night do you have to get up? I E 

1 -Times 

l oo 0 Less than once a night 

8. During the past 6 months have you had any sores or irritations on your ) I 0 Yes ,( 

feet or ankles that did not heal normally? I 20No 

’ sUDK 

282 
Section T - DIABETES RISK FACTOR QUESTIONS fSP) _ _ - Continued -~~ ~~~~~~~ 

I 

,

9. Have you ever had an amputation of your toe, foot, leg, or part of leg? 1 1 cl Yes, toe 

If “Yes , “ask: Which? 2 0 Yes, foot 

3 Cl Yes, leg or part of leg Mark all that apply. 4 0 No 

10. During the past 3 months have you had - 1 q Yes 

g. Numbns#s or loss of feeling in your handa or feet other then 

! 2 0 No 

from your hands or feat falling aslssp? snDK 

------------------------------J_;oy.;--------------------------~ 

b. A palnfull swwatlon or tingling in your hands or feet? Do not include1 

normal foot ache8 from standing or walking for long perlods. ’ 20No 

9 17 DK 

------------------------------t;,;----------------------------~ 

C. Dacreasad ability to feel hot or cold in things you touch? 

2 0 No 

snDK 

118. Do you NOW smoke clgamttes? 1 q Yes 

2 0 No (721 

----~~~--~~----------~---~----- -L----------------------~~~~~~~ 

b. About how many cigarettes do you smoke per day? ’ 

: 

1 

I

I 

I 

1I&l. Hava you tried to lose waight In the past year? I 

, 

1 

--------------------------------,-------------------------------- I 

b. Is your welght now more, less, or about the same as a year ago? I 

1 

I 

-------------------------------~--------------------------------

I C. In the past yaar, about how much weight have you [gained/lost]? I 

1 

00 0 Less than 1 per day 

-Perday 

aa 0 Don’t smoke regularly 

1 q Yes 

20No 

I 0 More 

2 q Less 

3 0 About the same (131 

-Pounds 

; 9990 DK 

Ask if 26 or oldar; otharwisa, go to 14. I 

1%. About how much dld you weigh when you were 25 years old? 1 -Pounds 

For fernalas: If you were pregnant when you were 25, tell me your 

weightjust before you became pregnant. 1 sssnDK 

-------------------_----------- A--------------------------------

I 

b. What Is the most you have war weighed? 1 -Pounds 

For females: Except when you were pregnant? 1 9ssuDK 

---_------__---~~----~--------- A,------------------------------

C. About how old were you when you FIRST weighed that much? , oonNow 

I 

1 -Years old 

114. Do you have l wious trouble seeing with one or both eyes even when I 1 q Yes 

wearing glassaa? .I 2 c] No 

I 

I 

15. Ware either of your parents ever told that they had diabetes? I I 0 Yes, father 

Do not Include pra, potential, or borderline diabetes. ’ 2 q Yes, mother 

If “Yes , ” ask . Which? 3 q Yes, both 

4 0 No 

9 0 DK 

I 

16. How many chlldren have you had, including any that may have died? I 0017 None 

for females: Do not Include stillbirths or miscarriages. I 

) -Total number of children 

1 ssnDK 

Notes 

1 

1 

_-. b i 

1 

E 

m ) 

w I 

_-. r44--4( i 

--. m I 

1 

1 

151--5: 2 

283 
, 

CARD R CARD 0 

RACE ORIGIN 

1. Aleut, Eskimo, or American Indian 1. Puerto Rian 

2. Ash or Pacific Islander 2. Cub8n 

3. Black 3. MsxicanlMexiuno 

&White 4. Maxican American 

5. Chicano 

6. Other Latin Amwiun 

i 7. Other Spanish 

il 

i! 

Ii 

;” 

I 

I 

t 

: 

, 

,

I 

I 

I -me 

CARD I 

lNCOh+E 

U . . . . $20,600 - $24,999 

V ..A $25,066 - $29,999 

w . . . $3O,ooo - $34,999 

X . . . . $35,000 - $39,999 

Y . . . . *40,000 - $44,999 

2 . . . . *45,000 - $49~99 

ZZ... $50,606 and over 

I 

, 

CARD J 

INCOME 

A -Luthnt1,ooolindudingIoul 

6 - *1,ooo- *1,sss 

c -... $2,ooo- $2,999 

D - *3,ooo- *3,sss 

E .- $4.000- :4,9OS 

F -. LS,OOO- W5.999 

0 - 16,ooo- *wB9 S-4, 

H - *7,ooo- $PSSS c -22 - sI - $8,000- $8,990 t

, 

, J - 49,000- $9,999 I 

I 

K - ~10,000 - 310,lNB I

I 

I) 

L - *11,ooo-*11,999 E 

M . H2,000-tl2.999 

111 - :13,ooo-813#999 :i 

0 - 314,ooo - M4,SSS 

ii ? - *16,ooo-*15~99 

a - 316mo - 316Jlss p 

, . t17noo-*17#sss I 

I 

S - 318,000 - *18,SN I 

1 - *19,orJo - *1s@3a@ ,

8

t 
MEDICARE 

I.. 

2. 

SOCIAL s~cu,Rlsv ACT 3. 

HERE 

NAME Of BENEFICIARY 

John Q. Public CLAIM NUMBER g* sex 4. 

000-00-0000-A 5 P MALE 

IS ENTITLED TO EFFECTIVE DATE 5. 

Hospital Insurance 7-l-66 6. 

Medical Insurance 7-l-66 

SIQN , &L4@& 7. 

8. 

STATE NAMES FOR MEDICAID 

MEDI - CAL 

California 1. 

MEDI- RAN 2. 

KWISSS 3. 

HEALTH CARE COST CONTAINMENT 4. 

SYSTEM (HCCCS) 

AdZOlla 

MEDICAID AND/OR MEDICAL ASSISTANCE 

All other States 

CARD M 

REASONS FOR NOT HAVING 

HEALTH INSURANCE 

Job l.ayoff, job loss, or any reasons related to unemployment 

Can’t obtain insurance because of 

poor health, illness, or age 

Too expensive, can’t afford health 

insurance 

Dissatisfied with previous 

insurance 

Don‘t believe in insurance AlHave been healthy, not much C-d* 

sickness in the family, haven’t -----. needed health insurance j

I 

Covered by some other health I 

plan 

I 

Some other reason .I 

CARD 0% 

No difficulty 

Some difficulty 

A lot of difficulty 

Completely unable to do because of 

disorder 

285 

6 
CARD 02 

Adapin Nardil 

Amitid Navane 

Amitril Norpramin 

Asendin Pam&r 

Ativan Parnate 

AWlltyl Paxipam 

Azene Permitil 

Centrax Perrofrane 

Cibalhh-S Presamine 

Comparina 

Daxolin Prolixin 

Dssvrsl Guide 

Dexedrine Repoise 

Elavil Ritalin 

Endep Serax 

Eskalii Sarentil 

Haldol Sinequan 

lmavats Stslazine 

Janimine Taractan 

Librax Tagretol 

Libritabs Thorazine 

Librium Tindal 

tidons Tofranil 

Lkhans TG3lWene 

Lithobid Mlafon 

Loxitane Valium 

Ludiomil Vesprin 

Marplan Vestran 

Msllaril Vivactil 

Moban Xanax 

CARD 02 

00. Nawl@rs 

01. Doctor’s office - doctor 

02. Doctor’s offlcs - nyss 

03. Dletiti’an or nutritionist 

w. Doctor or nurse in a hospital 

05. Rslatlvs or friend 

06. Anothsr diabetic 

07. Health drpartmsnt 

08. Diabatss organization 

09. National Dkbetsr Information Clearing House 

10. Diabetas support group 

11. library 

12. Newspapers 

13. Diabetes education class 

88. Other 

CARD Ql 

1. Always 

2. Most of the time 

3. Some of the time 

4. Rarely 

5. Never 

CARD Rl 

1. Use a hot or cold comprssa 

2.. Take a prescription drug 

3. Take an over-the-counter drug 

4. Drink some liquor or wine because of the pain 

5. Take time off work 

5. Stay home more than usual 

.7. Avoid family and friends 

8. Something else 

266 
CARD Sl 

Left 

side 

CARD 52 

In the past year. . . 

.Saw or talked to a doctor or other, health professional 

or 

Took medication more than once 

or 

Problem interfered with your life or usual activities 

287 
CARD A 

1. Definitely true 

2. Probably true 

3. Probably false 

4. Definitely false 

9. Don’t .kn’ow if true or false 

CARD B 

1. Very likely 

2. Somewhat likely 

3. Somewhat unlikely 

4. Very unlikely 

5. Definitely. not possible 

9. .Don’t know how likely 

L 

CARD C 

1. Very effective 

2. Somewhat effective 

3. Not at all effective 

4. Don‘t know how effective 

9. Don’t know method 

CARD D 

You have hemophllla and have reoelved clotting 

factor concentrates alnce 1977, 

You are a natlve of Halt1 or Central or East Afrfca 

who has entered the United States .slnce 1977, 

You are a man who has had hex wlth another man 

at Some tlme since 1977, even one time. 

You have taken Illegal drugs by needle since 1977, 

Since 1977, You are or have been the dex partner 

of any person who would anewer ‘yea* to any 

of thi items above on this card. 

You have had sex for money or drugs at any 

tlme sfnce 1977. 

!88 
References 

1. Moss AJ, Parsons VL. Current estimates from the National 

Health Interview Survey, United States, 1985. National 

Center for Health Statistics. Vital Health Stat lO(160). 1986. 

2. Massey JT, Moore TF, Parsons VL, Tadros W. Design and 

estimation for the National Health Interview Survey, 1985 

94. National Center for Health Statistics. Vital Health Stat 

2(110). 1989. 

3. Durbin J. Design of multi-stage surveys for the estimation of 

sampling errors. Appl Stat 16~152-64.1967. 

4. Wolter KM. Introduction to Variance Estimation. New 

York: Springer-Verlag. 1985. 

5. Parsons VL, Casady RJ. Variance estimation and the redesigned Health Interview Survey. In American Statistical 

Association, Proceedingsof the Social Statistics Section. 

1987. 

6. Parsons VL, Chan JY, Curtin LR. Analytic limitations to 

current national health surveys. In American Statistical 

Association, Proceedings of the Section on Survey Research 

Methods. 1990. 

7. SUDAAN. Professional software for survey data analysis. 

Research Triangle Park, North Carolina: Research Triangle 

Institute. 1989. 

8. PC-CARP. Program for the analysis of survey data. Iowa: 

Statistical Laboratory, Iowa State University. 1989. 

9. OSIRIS IV. Statistical analysis and data management software system. Survey Research Center. Michigan: Institute 

for Social Research, University of Michigan. 1982. 

10. Fay R. VPLX: Variance estimates for complex samples. In 

American Statistical Association, Proceedings of,the Section 

on SurveyResearchM&hods. Alexandria, Virginia. 1990. 

11. WESVAR. Software for survey data analysis. WESTAT. 

Rockville, Maryland. 

289 

1 
Appendixes 

Contents 

I. Data collection procedures ........................................................................ 291 

II. NIBS design and estimation structures .............................................................. 292 

A conceptual model of the NHIS ................................................................. 292 

Simplified NHIS design structures and variance estimation methodology............................... 293 

Variance estimation for person data using SUDAAN and the NHIS public use person 

data tapes, 1987-92............................................................................. 293 

III. Responserates................................................................................... 295 

IV. Topical index to questionnaire items, by year ........................................................ 296 

, 

290 
Appendix I 

Dbta col,lectiqn procedures 

Data are collected through a personal household 

interview conducted by interviewers employed and trained 

by the U.S. Bureau of the Census according to procedures 

specified by the National Center for Health Statistics. 

All adult members of the household 18 years of age 

and over who are at home at the time of the interview are 

invited to participate and to respond for themselves. 

Information for children and for adults not at home 

during the interview is provided by a responsible adult 

family member (19 years of age and over) residing in the 

household. Between 65 and 70 percent of the adults 18 

years of age and over are self-respondents. Generally, a 

random subsample of adult household members is selected to respond for themselves to questions on current 

health topics. 

Nationally, there are approximately 250 interviewers 

trained and directed by health survey supervisors in each 

of the 12 U.S. Bureau of the Census regional offices. The 

supervisors are career civil service employees whose primary responsibility is the National ,Health Interview Survey. The interviewers are part-time employees selected 

through an examination and testing process. Interviewers 

receive thorough training in basic interviewing procedures 

and in the concepts and procedures unique to the National Health Interview Survey. 

Depending on the family size and the nature and 

extent of health conditions of family members, the length 

of interview ranges from 30 to 90 minutes. On average, the 

interviews require about 50 minutes in the household. 

291 
Appendix II 

NHIS design tind estimation 

structures 

The NHIS is designed to provide statistics on the 

civilian noninstitutionalized popuIation. To produce these 

statistics and to produce standard errors for these statistics, one has to take into account the survey’s complex 

statistical design. In this section the NHIS sample design 

is described and a methodology for producing NHIS 

estimates and their standard errors is provided. 

A conceptual model of the NHIS 

A detailed description of the NHIS design is given in 

Series 2, No. 110, in the Vital and Health Statistics series 

(2). The annual NHIS itself consists of two surveys, a core 

survey of general health characteristics and supplemental 

survey(s) on current health topics of interest. For practical 

purposes, the sample design for the NHIS can be conceptualized in a classical hierarchical framework. 

NHIS sample design 

The target population for the NHIS is the civilian 

noninstitutionalized population of the United States. The 

NHIS is a stratified, multistage sample. Primary sampling 

units (PSU’s) for the NHIS are usually counties or groups 

of counties. The strata and sampling units of the NHIS 

core and/or supplement samples have the following hierarchical levels: 

1. Stratum: 52 self-representing (SR) and 73 non-selfrepresenting (NSR) strata. 

2. Primary sampling unit (PSU): Self-representing strata 

are defined as containing a single PSU, each SR PSU 

is in the sample with certainty. For the NSR strata, a 

sample of the population PSU’s is selected from each 

stratum. For the current NIBS design (1985-94), two 

PSU’s are selected from each NSR stratum. The PSU’s 

are selected with probability proportional to PSU 

population size using Durbin’s (3) method. 

3. Substratum: Once selected into the sampIe, each PSU 

is (or may be) partitioned into at most three parts. This 

allows for differential sampling rates to ensure target 

sample sizes for specific subdomains of the population, 

such as blacks. The differential sampling is not used in 

every PSU. 

4. Secondary sampling unit (SSU): Within each substratum, a cluster of dispersed housing units is selected. 

This cluster is called a secondary sampling unit. 

292 

5. Sample household: Within each SSU, a sample of 

households (usually all) is designated for interview, 

6. Sample person: For the NHIS core sample, all eligible 

persons within each household are selected for interview. For the supplement(s) sample, typically one 

sample adult is selected from each family in the 

household for interview; under special circumstances, 

that are specific to a supplement, sometimes more than 

one person in a family is selected for interview, 

Subdesigns 

To allow for flexibility due to budget constraints, the 

NHIS was further partitioned into four subdesigns called 

panels. Each panel is formed by the appropriate grouping 

of PSU’s. The subdesigns are generated so that each 

panel, and any combination of panels, is representative of 

the target population. 

For most years, all four panels are used in the NHIS, 

However, in 1985,budgetary restrictions resulted in NCHS 

fielding a three-panel design. Similarly, in 1986the NHIS 

was limited to a two-panel design. 

Sampling weights 

In order to produce a national estimate, a sampling 

weight must be associated with each interviewed sample 

person. At each stage of the sample design, there is a 

known probability of selection into the sample. The basic 

(or inflation) sampling weight is the product of the recip 

rocal of the hierarchical probabilities of selection at each 

stage of the sample design. Unfortunately, all household 

sample surveys experience nonresponse and incomplete 

population coverage. To produce a final survey weight for 

each individual respondent, the basic sampling weight, for 

example, is adjusted for nonresponse and then ratio adjusted to population control totals. This last ratio adjustment is called poststratification. 

Estimation 

If xi represents, a characteristic of interest for respondent i, and Wi is the NHIS (annual) final sampling 

weight for respondent i, then the aggregate estimator 

X =Xi Wi Xi 

is assumed to be an unbiased estimator for the population 

total for the characteristic of interest. NHIS descriptive 
statistics that are published by NCHS, such as totals, 

means,percentages, and ratios, are based upon this method 

of estimation. 

Variability due to sampling 

Whenever a descriptive statistic is published, it is 

considered a sound statistical practice to publish its estimated standard error. NCHS has developed variance 

estimation methodologies for the N-HIS .that exploit the 

detailed level of design information as outlined above. 

This information is used for NCHS analyses and in the 

production of generalized variance functions. In almost all 

NCHS series reports for statistical surveys, generalized 

variance functions are used to present standard errors 

because space limitations prevent including individual 

standard errors for each published statistic. If a sampling 

error was presented for each estimate in a report, the 

report would be too lengthy and too costly for consumers. 

Nonetheless, while these generalized variance functions serve a useful purpose, they are subject to a number 

of limitations (see, for example, Wolter (4)). For the 

NHIS, the reader is referred to Massey et al. (2) and 

Parsons and Casady (5) for additional technical discussion. 

An additional complication for variance estimation 

results from NCHS confidentiality constraints. Presently, 

NCHS confidentiality constraints limit the amount of 

design information that can be placed on public-use data 

tapes. By law, NCHS cannot release information that 

might lead to the identification of a surveyrespondent. In 

order to maximize the amount of analytic variables releasedto the public, somedetailed sampledesigninformation is suppressed.This limits the public-use data tape 

user to a simpler conceptual designstructure when analyzing the NHIS. 

A simplified NHIS design has been developed for the 

users of NHIS public-use data tapes. The effect of using 

this simpler design structure has been reported by Parsons, Chan, and Curtin (6). 

Simplified NHIS design structures and 

variance estimation methodology 

Variance estimation software 

The analysis of survey data usually requires computer 

software that can take into account the survey’s complex 

design. Available software for the analysis of complexsurvey data differs by features, including methodology, 

admissible class of survey designs, user support, ease of 

use, and operational costs. Some available software packages are SUDAAN (7), PC-CARP (8), OSIRIS IV (9), 

VPLX (lo), and WSVAR (11). The first three are 

commercially available, while the latter two have been 

used with large-scale Government surveysand are available from the authors. Additional software is identified in 

Wolter (4). The SUDAAN package (partially funded by 

several U.S. Public Health Service agencies with such 

support coordinated by NCHSKDC) uses Taylor linearization methodology and has been used extensively by 

NCHSKDC in analyzingthe NHIS. 

Variance estimation for person data using 

SUDAAN and the NHIS public-use person 

data tapes, 1987-92 

.Design information is available on the NHIS publicuse basic health and demographic and current health topic 

data tapes. 

All of the following variables are not used for some 

methods of variance approximation. Field locations 

may change on some tapes; the user should check file 

documentation. 

Variable 

name Location Field label Values 

Stratum 179-81 Full sample stratum identifier 

CSTRATUM i 87-a “Pseudo PSU codes,” first two 1, 2, . . ., ‘62 

columns 

CPSU la9 “Pseudo PSU codes,” last 1,2,3,4 

column 

SUB 178 Type of substratum 0,1,2 

ssu 5-12 Concatenation of “processing 

quarter, ” “random recode of 

PSU number ” and 

“week-censuk code,” and 

“segment number” 

TYPE-PSU 185 “Type of PSU,” 

self-representing of PSU, and 1, 4 

non-self-representing PSU 3, 6 

WI-F 207-I 2 “Final basic weight” 

Method 1 -Single-stage PSU’s sampled with 

replacement within strata design for 1985-94 NHIS 

This method is statistically less efficient than the 

method described below but is more flexible. This method 

requires no recoding of design variables, may be applicable to many complex survey sample design computer 

programs, and covers the 1985-94 NHIS survey years. 

Using the variables CSTRATUM, CPSU, and WTF, the 

PSU unit CPSU is treated asbeing sampledwith replacement within stratum unit CSTRATUM. The data file 

needs to be sorted only by CSTRATUM and PSU prior to 

SUDAAN. 

For the above simplification of the NHIS sample 

designstructure, usethe following SUDAAN designstatements: 

PROC . . . DESIGN = JKR; 

NEST CSTRATUM CPSU; 

Method 2 -Multistage stratified sampling design 

for the 1987-94 NHIS 

This design provides for more statistically efficient 

variance estimation than Method 1, since it makes fewer 

simplifications of the NHIS sample design structure but is 

only applicable to SUDAAN. This method also requires 

recodes of the design variables and is only applicable to 

surveyyears 1987-94 NHIS person data. 

293 
Prior to use of this method, the following recoding 

must be done on the HIS file. This exampleis in SAS but 

other programming languagesmay be used. 

If (TYPEJSU = 1 or TYPELE’SU = 4) then do: 

PSU = 1; 

POPPSU = 0; 

END. 

If (TYPE_PSU = 3 or TYPESSU = 6) then do: 

PSU = CPSU, 

POPPSU = -1; 

END. 

On the record for eachperson, this recode createstwo 

new variables PSU and POPPSU for use by SUDAAN’s 

NEST and TOTCNT statements. For more information 

on the purpose of these statements refer to SUDAAN 

documentation. With these additional variables, the fol­

,lowing describes SUDAAN code for NHIS data sets 

assuminga multistage stratified sampling design. 

Before running SUDAAN against the data file, however, sort. the input file by the NEST variables (STRATUM, PSU, SUB, and SSU). 

For SUDAAN describe the NHIS sampling plan as 

follows: 

PROC... DESIGN = WOR; 

NEST STRATUM PSU SUB SSU /MISSUNIT; 

TOTCNT POPPSU ZERO- 2IINUSL ZERO-. 

Caution. This method assumesthat all records on the 

basic health and demographic (BHD) or current health 

topic (CHT) tape are being used. If, however, you keep 

only selectrecords on a file, for example,persons aged 65 

yearsand older (which may delete all records from one or 

more SSU’s), care must be taken to preservethe integrity 

of the sampling design.A methodology for preservingthe 

NHIS sample design integrity on subsetted ties, which 

exploits a feature in SUDAAN 6.xX or later, follows. 

All SR SSU’s(TYPE_PSU = 1 or 4) listed on the full 

NHIS tape (BHD or CHT) must have at least one representative on the data file used for input to SUDAAN. 

Moreover, all NSR PSU’s must have at least one record 

for a person on this data file. The NEST variables (STRATUM, PSU, SUB, and SSU) along with the weight variable must be on each record of the analysisfile, All data 

fields other than the designvariablesand the weight must 

be defined asmissing“.“. This can be achievedby creating 

a “design” file as follows using SAS or some other programming language: 

Sort the full file by the NEST variables (after making 

the aboverecodes). 

Arbitrarily select and savein a separate file (call this 

the designfile), one record from eachSR SSUor NSR 

PSU (either, for example,the first or last record will 

do). Each record in this file must contain the design 

variables (STRATUM, PSU, SUB, and SSU) but the 

remainder of the fields on the design file (except the 

weight variable) must be set to missing in SAS or “,” 

in text file. 

Set the weight variable(s) in the design file to a very 

small value, say 10-r’. 

To preserve the design integrity, append the “design 

file” created aboveto the subsetted analytic file. This 

is the new analysisfile that consistsof the subsetted 

analysisfile plus the newly created “design file,” 

On the new analysis file, define a new variable, say 

“DUMMY” ‘that takes the value 1 if the corresponding record correspondsto data from a respondent and 

takes the value 0 for other records. With this approach, in SUDAAN 6.XX or later, it is important to 

add the following SUBPOPN statement to the 

SUDAAN code: “SUBPOPN DUMMY = 1;” 

Finally, prior to running SUDAAN against the new 

analysisfile, sort this file by the new analysisfile by the 

NEST variables (STRATUM, PSU, SUB, and SSU), 

SUDAAN assumesits input file is sorted by the NEST 

variables. 

Run SUDAAN againstthe new analysisfile created by 

the preceding steps. 

If subsetted data sets are used without a “design 

fix-up” like the above,the self-representingcomponent of 

variance may be biased. 

294 
Appendix III 

Response rates 

‘l3vo components comprise the response rates shown 

in the table that summarizes the characteristics of the 

current health topic questionnaires: the completion rate 

for the current heaIth topic questionnaire and the completion rate for the basic health and demographic questionnaire. Multiplying the two rates together yielded the 

response rate presented for each current health. topic in 

the table..For example,the completion rate for the 1985 

child safety and infant feeding questionnaire was 92.7 and 

the completion rate for the 1985 NHIS basic health and 

demographic questionnaire was 95.1. The overall response 

rate for the questionnaire (0.927) x (0.951) was 88.7. 

Completion rates were calculated using either numbers compiled by the Bureau of the Census or numbers 

available on in-house data tapes prepared by the Division 

of Health Interview Statistics (DHIS), NCHS. Counts 

were obtained from DAIS tapes if the counts were not 

availablefrom the CensusBureau or if the CensusBureau 

did not compile separately the count of respondents and 

nonrespondents needed to calculate the completion rate 

for a particular current health topic. 

The completion rate for the NHIS basic health and 

demographic questionnaire was based either on data from 

the NHIS found in the Current Estimate series report for 

the particular interview year or on numbers provided by 

the Census Bureau. A completion rate for the NHIS basic 

health and demographic questionnaire was based on counts 

obtained from the Census Bureau if the completion rate 

for the current health topic was based on Census data. To 

this extent the response rates are limited and should be 

used as a gauge. 

The completion rate for eachcurrent health topic was 

calculated in one of two ways, either by dividing the 

number of completed and/or partial interviews by the 

number of persons eligible for the questionnaire or by 

dividing the number of dummy records created by the 

number of persons eligible for the questions. The latter 

method was sometimes used because not all current health 

topic questionnaires included information that identified 

interviews as complete, partial, or noninterviews. Usually, 

this information was missing when the current health topic 

was printed and administered as part of the basic health 

and demographic questionnaire. A dummy record was 

created when a person responded to questions in the basic 

health and demographic questionnaire and was eligible for 

the current health. topic questionnaire but for one reason 

or another he or she did not respond to the current health 

topic questions. 

295 
Appendix IV 

Topical index to 

questionnaire items, by year 

Topic Questionnaire item 

Abdominal Pain (see also Digestive Disorders) 

During the past 12 months, have you had any type of pain or severe 

discomfort in your abdomen three or more times 

Have you ever made a visit to a doctor for your 

abdominal pain 

What condition did the doctor say was the cause of the pain 

Which of these conditions caused the most pain 

during the past 12 months 

What condition do you think was the cause of the pain 

during the past 12 months: 

spastic colon 

functional bowel 

irritable colon 

irritable bowel syndrome 

allergies 

anxiety 

appendicitis 

cancer 

cirrhosis 

colitis 

constipation 

Crohn’s disease 

depression 

diarrhea 

diverticulitis 

diverticulosis 

enteritis 

esophagitis 

ffll 

food poisoning 

gallbladder problem 

gallstones 

gastritis 

gastroenteritis 

growth 

heartburn 

hepatitis 

hernia, other than hiatal 

hiatal hernia 

impacted bowels 

indigestion 

infection 

Year 

1989 

1989 

1989 

1989 

1989 

296 
Topic 

Abdominal Pain (continued) 

influenza 

lactoseintolerance 

medication side effects 

nerves 

obstructed bowels 

other bowel trouble 

other liver trouble 

other stomachtrouble 

peritonitis 

stress 

tension 

trouble swallowing 

tumor 

ulcer 

ulcerative colitis 

virus 

arthritis 

back problems 

bladder 

kidneys 

menstruation 

other female trouble 

pregnancy 

prostate 

other (specify) 

Questionnaire item 

How many different doctors haveyou visited for 

this pain: 

none 

one 

tW0 

three or more 

During the past 12 months, how many doctor visits 

did you have because of this pain 

Were any of the following tests done (to diagnose) 

your (condition): 

upper GI series 

barium enema 

upper endoscopyor gastroscopy 

lower endoscopyor colonoscopy 

sonogramor ultrasound 

Show where the pain from the (condition) was located 

Was the pain above the waistline, below the 

waist, or around the waistline 

Was the pain on the right side, the left side, 

or down the middle 

When you get this pain, how long does it usually last: 

number of minutes 

number of hours 

number of days 

constant, all the time 

varies too much for a usual duration 

During how many days in the past year did you have this pain 

Did all of this pain occur during one 2-week period 

Year 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

297 
Topic Questionnaire item 

Abdominal Pain (continued) 

During how many different months in the past 

year did you have this pain 

On a scalefrom 1 to 10, where 1 is mild and 10 is 

severe, how would you rate this pain at its worst 

Have you ever taken any medication for the pain 

Was any of the medication you took prescribed 

for you by a doctor 

When this pain starts, do you have to stop what 

you are doing because it hurts 

When you have this pain do you usually have bowel movements 

When you have this .pain, are your bowel movements 

usually looser than normal 

When you have this pain; are your bowel movements 

usually more frequent than normal 

Is the pain usually relieved or lessened by having 

a bowel movement 

Is the pain relieved by passing gas 

When you have this pain, is your abdomen usually 

swollen or bloated 

When you have this pain, are you ever awakened from sleep 

In the past 30 days, has this pain caused you to 

cut down on the things you usually do 

In the past 30 days, how many days did you cut 

down for more than half the day 

How often do you usually have bowel movements 

During the past 12 months, how often (always, most 

of the time, some of the time, rarely, never, don’t know) 

have your bowel movements been: 

hard 

accompanied by mucus 

accompaxiied by pain 

accompanied by swelling or bloating 

accompanied by straining to move bowels 

followed by a feeling of not being finished 

after moving bowels 

During the past 12 months, how often have you been constipated: 

always 

most of the time 

some of the time 

rarely 

never 

How often have you had diarrhea: 

always 

most of the time 

‘some of the time 

rarely 

never 

During the past 12 months, have you seen a doctor 

about your diarrhea 

How many times in the past 12 months have you seen 

a doctor about your diarrhea 

Year 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 
Topic Questionnaire item Year 

I Abdominal Pain (continued) 

What did .the doctor say caused the diarrhea: 

enteritis 

diverticulitis 

Crohn’s disease ’ 

intestinal flu or virus 

spastic colon, functional bowel, irritable 

bowel syndrome, irritable colon 

colitis 

ulcerative colitis 

infection 

lactose intolerance 

travelers diarrhea 

“something I ate” 

dysentery 

medication 

nervesor stress 

something else 

doctor didn’t say 

don’t know 1989 

In the past 30 days, did you take any laxatives or 

stool softeners such as Ex-lax, Metamucil, or 

Fiberall to help move your bowels 1989 

How many times have you taken laxatives or stool 

softeners in the past 30 days 1989 

How often do you think a person should 

have bowel movements 1989 

In the past 12 months, have you had a lot of 

trouble with: 

dizziness 

nausea 

diarrhea 

feeling sickly 

abdominal pain 

abdominal gas 

chest or heart pain 

fainting spells 

pain in the joints 

pain in your arms and legs, other than in the joints 

vomiting 

weakness 

backaches 

headaches 

nervousness or an&ety 

feeling tense or keyed up 

feeling sad, blue or depressed 

pain when you urinate or pass your water 1989 

Access to Care (see Health Insurance and Usual Source of Cake) 

Adoption 

Anyone in family ever adopted children 1987 

Who in family adopted children 1987 

299 
Topic. Questionnaire item 

Adoption (continued) 

Number of children adopted 

Number of adopted children living in household 

Name of adopted children living in household 

Relationship of adopted child to adoptive mother 

Adoptive child born in the United States or a foreign country 

When was adoptive child born 

Mdnth and year adoptive child began living with adoptive mother 

Adoption arranged through: 

public agency 

private agency 

some other way 

don’t know 

AIDS 

When was the last time you saw, heard or 

read something about AIDS: 

today 

number of days ago 

number of weeks ago 

number of months ago 

number of years ago 

never 

don’t know 

Have you ever heard of AIDS 

Compared to most people, how much would 

you say you know about AIDS . . . would you say: 

a lot 

some 

a little 

nothing 

Tell me (interviewer) whether you think the statement is definitely true, 

probably true, probably false, or definitely false or 

you don’t know if it’s true or false: 

AIDS is a disease caused by a virus 

AIDS can cripple the body’s natura1 protection against disease 

AIDS is especially common in older people 

the AIDS virus can damage the brain 

AIDS usually leads to heart disease 

AIDS leads to death 

Where do you get most of your information 

about AIDS: 

television 

newspapers 

brochures/fliers/pamphlets 

clergy/church 

doctor/HMO 

company or industry cliic 

hospitallemergency room/outpatient clinic 

other clinic 

magazines 

medical journals 

library 

Year 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

300 
Topic Questionnaire item 

AIDS (continued) . 

AIDS hot line 

public health department (local/State) 

Red Cross/blood bank 

radio 

relatives 

friends 

school (class/clinic) 

other source (specify) 

don’t know 

If you wanted more specific information about AIDS, 

where would you get it: 

television 

newspapers 

brochures/fliers/pamphlets 

clergy/church 

doctor/HMO 

company or industry clinic 

hospital/emergency room/outpatient clinic 

other clinic 

magazines 

medical journals 

library 

AIDS hot line 

public health department (local/State) 

Red Cross/blood bank 

radio 

relatives 

friends 

school (class/clinic) 

other source (specify) 

don’t know 

Tell me (interviewer) whether you think the 

statement is definitely true, probably true, 

probably false, definitely false or you don’t 

know if it is true or false: 

a person can be infected with the AIDS virus and 

not have.the disease AIDS 

you can tell if people have the AIDS 

virus just by looking at them 

any person with the AIDS virus can pass 

it on to someone else through sexual intercourse 

a pregnant woman who has the AIDS virus 

can give AIDS to her baby 

there is a vaccine available to the public that protects 

a person from getting the AIDS virus 

there is no cure for AIDS at present 

Tell me (interviewer) if you think 

it is very likely, somewhat likely, somewhat 

unlikely, very unlikely, definitely not possible 

or if you don’t know how likely it is that a 

person will get AIDS or the AIDS virus infection from: 

receiving a blood transfusion 

donating or giving blood 

living near a hospital or home for AIDS patients 

Year 

1987 

1987 

1987 

301 
Todc Questionnaire item 

AIDS (continued) 

working near someone with AIDS 

eating in a restaurant where the cook has AIDS 

kissing, with exchange of saliva, a person who has AIDS 

shaking hands with or touching someone who has AIDS 

sharing plates, forks, or glasseswith someone who has AIDS 

using public toilets 

sharing needles for drug use with someone who has AIDS 

kissing on the cheek a person who has AIDS 

being coughed or sneezed on by someone who has AIDS 

attending school with a child who has AIDS 

mosquitoes or other insects 

pets or animals 

having sex with a person who has AIDS 

Have you ever had a blood test for 

infection with the AIDS virus 

Does this blood test tell whether a person 

has the disease AIDS 

If someone has a positive blood test for infection 

with the AIDS virus, does this mean that they can 

give someone else the AIDS virus through sexual intercourse 

Have you had your blood tested for infection with 

the AIDS virus 

Have you thought about having this blood test 

Do you plan to be tested in the next 12 months 

(If you were to be tested) Where would you go to 

have a blood test for the AIDS virus infection: 

nowhere/wouldn’t take test 

AIDS clinic 

company or industry clinic 

doctor/HMO 

hospital/emergency room/outpatient clinic 

other clinic 

public health department 

Red Cross/blood bank 

other (specify) 

don’t know 

Where would you go to find out where to have this 

blood test: 

nowhere 

AIDS hot line 

AIDS clinic 

clergy/church 

doctor/HMO 

friends 

hospital/emergency room/outpatient clinic 

public health department 

Red Cross/blood bank 

relatives 

other (specify) 

don’t know 

Have you donated blood since january 1985 

Have you ever personally known anyone 

who had the blood test for the AIDS virus infection 

Year 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

‘1987 

1987 

1987 

302 
Topic Questionnaire 

AIDS (continued) 

What are the chances of someone you know 

getting the AIDS virus, would you say: 

high 

medium 

low 

none 

refused to respond 

don’t know 

What are your chances of getting the AIDS 

virus, would you say: 

high 

medium 

low ,’ 

none 

refused to respond 

don’t know 

Here are methods some people use to prevent 

getting the AIDS virus through sexualactivity; 

tell me (interviewer) whether you think it is 

very effective,somewhateffective,not at all 

effectiveor if you don’t know how 

effectiveit is in preventing getting the AIDS 

virus through sexualactivity: 

using a diaphragm 

using a condom 

using a spermicidaljelly, foam, or cream 

being celibate, that is, not having sexat all 

two people who do not have the AIDS 

virus having a completely monogamous 

item Year 

1987 

1987, 1988, 1989 

relationship, that is, having sexonly with each other 1987 

Have you ever discussed AIDS with a friend or relative 1987,1988 

When was the last time you discussed AIDS with a 

friend or relative: 

today 

number of daysago 

number of weeks ago 

number of months ago 

number of years ago 

don’t know 1987, 1988, 1989 

Do you have any children aged 10 through 17 1987, 1988, 1989 

How many do you have 1987,1988,1989 

Have you ever discussed AIDS with (your child/ 

any of these children) 1987 

(Has your child/haveyour children) had instruction 

at school about AIDS 1987 

Have you ever personally known anyone with the AIDS virus 1987,1988,1989 

Have you ever personally known anyone with AIDS 1987 

Would you want to know the results of the blood test 1987 

In the past month, have you seen any public service 

announcements about AIDS on television 1988, 1989 

In the past month, have you heard any public service 

announcementsabout AIDS on the radio 1988,1989 

303 
Topic Questionnaire item Year 

AIDS (continued) 

Were any of those public service announcements 

called “‘America Responds to AIDS” 1988, 1989 

In the past month, have you read any brochures or pamphlets about 

AIDS (do not include articIes in magazines or newspapers) 1988,1989 

Have you ever read any brochures or pamphlets about AIDS 

(do not include articles in magazines or newspapers) 1988, 1989 

Where did you get the pamphlets or brochures: 

chnid, other than work clinic 

doctor’s office/HMO 

drug store 

public health department 

received it in the mail without asking for it 

Red Cross/with Red Cross blood donation 

with other blood donation 

school 

sent/phoned for it myself, requested it 

the Government-Federal, State or local 

work, other than clinic or nurse 

work, nurse or clinic 

other (specify) 1988,1989 

The Government is mailing a brochure with basic 

information about AIDS to each household in the 

country, the brochure is 8 112by 11 inches, 

white with blue and black printing, and has a 

picture of Dr. C. Everett Koop, the Surgeon 

General of the United States, on the cover, with 

the title, “Understanding AIDS” printed at the 

top: Was this brochure received at this household 1988 

How much of the brochure did you read; 

would you say: 

all or almost all 

about half 

less than half 

none of it 

don’t know 1988 

When you read it, did you read it carefully or 

did you just skim through it 1988 

Did the brochure give you any new information or 

answer any questions you had about AIDS 1988 

Did you discuss the brochure with anyone else 

in the family 1988 

Did this child/any of your children aged 10 

through 17 read the brochure 1987, 1988, 1989 

Was the brochure discussed with this child/ 

any of your children aged 10 through 17 1987,1988,1989 

Have you ever discussed ADX with this child/ 

any of your children aged 10 through 17 1987, 1988, 1989 

Has this child/have any,or alI of your 

children aged 10 through 17 had 

instruction at school about AIDS 1987, 1988,1989 

How much would you say you know about AIDS: 

a lot 

304 
Topic Questionnaire item 

AIDS (continued) 

somP. 

a little 

nothing 

To the best of your knowledge, is there a 

difference between having the AIDS virus 

and having the disease AIDS 

Tell me (interviewer) whether you think the 

statement is definitely true, probably true, 

probably false, definitely false, or you don’t 

know if it is true or false: 

AIDS can reduce the body’s natural protection against disease 

AIDS is especially common in older people 

AIDS can damage the brain 

AIDS usually leads to heart disease 

AIDS is an infectious disease caused by a virus 

teenagers cannot get AIDS 

AIDS leads to death 

a person can be infected with the AIDS virus and not have the 

disease AIDS 

looking at a person is enough to tell if he or she has the AIDS virus 

any person with the AIDS virus can pass it on to someone else through 

sexual intercourse 

a person who has the AIDS virus 

can look and feel well and healthy 

a pregnant woman who has the AIDS virus can give the AIDS 

virus to her baby 

there is a vaccine available to the public that protects a person 

from getting the AIDS virus 

there is no cure for AIDS at present 

After I read each statement, tell me if you think 

it is very likely, somewhat likely, somewhat 

unlikely, very unlikely, definitely not possible, 

or if you don’t know how likely it is that a person 

will get AIDS or the AIDS virus infection that way, 

how likely do you think it is that a person 

wiIl get AIDS or the AIDS virus infection from: 

living near a home or hospital for AIDS patients 

working near someonewith the AIDS virus 

eating in a restaurant where the cook has the AIDS virus 

kissing, with exchange of saliva, a person who has the AIDS virus’ 

shaking hands, touching, or kissing on the cheek someone who 

has the AIDS virus 

sharing plates, forks, or glasseswith someone who has the AIDS virus 

using public toilets 

sharing needles for drug use with someone who has the AIDS virus 

being coughed on or sneezed on by someone who has the AIDS virus 

attending school with a child who has the AIDS virus 

mosquitoesor other insects 

Have you ever donated blood 

Have you donated blood: 

since March 1985 

in the past 12 months 

Have you ever heard of a blood test that can 

detect the AIDS virus infection 

Year 

1988, 1989 

1988, 1989 

1988,1989 

1988, 1989 

1988, 1989 

1988,1989 

1988, 1989 
Topic Questionnaire item Year 

AIDS (continued) 

To the best of your knowledge, are blood donations 

routinely tested now for the AIDS virus infection 

Have you ever received counseling or had a talk with 

a health professional about taking the AIDS virus test 

Was the discussion: 

with a private doctor 

at.a family planning clinic 

on an AIDS hotline 

at a prenatal clinic 

at an STD or sexualIy’transmitted disease clinic 

at an AIDS/HIV counseling and testing site 

with some other health professional 

with some other counselor 

During that discussion, did you receive information 

about how to avoid getting or passing on the AIDS virus 

Have you ever been advised by a health professional 

not to have the blood test for the AIDS virus infection 

Have you ever been advised by friends or relatives 

not to have the blood test for the AIDS virus infection 

Have you had your blood tested for AIDS virus infection 

Have you had your blood tested for the AIDS virus. 

infection more than once 

Was your blood tested in the past 12 months 

How many times haveyou had your blood tested for 

the AIDS v@~sinfection 

How many times in the past 12 months have you had 

your blood tested for the AIDS virus infection 

Was the test/were any of the blood tests, 

including those you had before the past 12 months: 

part of a blood donation 

part of a blood transfusion 

voluntarily sought from a source such as 

your doctor, clinic, or HMO 

part of some other activity that requires a 

blood sample and includes automatic AIDS 

testing such as testing for the military or immigration 

Where did you have your blood tested for AIDS virus 

infection: 

STD clinic 

family planning clinic 

prenatal clinic 

drug treatment facility 

tuberculosis clinic 

work clinic/health station 

AIDS counseling/testing site 

military induction 

immigration site 

other (specify) 

don’t know 

Did you get the results of your test/any of your tests 

1988,1989 

1988, 1989 

1988,1989 

1988,1989 

1988,1989 

1988, 1989 

1988,1989 

1988,1989 

1988,1989 

1988,1989 

1988,1989 

1988, 1989 

1988,1989 

1988,1989 

306 
Topic Questionnaire item 

AIDS (continued) 

When you received your test results, did you 

receive counseling or talk with a health 

professional about how to lower your chances 

of becoming infected with the AIDS virus or how 

to avoid passingit to another person 

Were you referred to a health professional to get 

counseling about the AIDS virus infection 

Do you expect to have a blood test for the AIDS 

virus infection in the next 12 months 

Will you have the blood test: 

aspart of a blood donation 

voluntarily from a source such as your doctor, clinic, or HMO 

aspart of someother activity that requires a blood sample 

and includes automatic AIDS testing, such as testing for 

the military or immigration 

Where would you go to have a blood test for the AIDS 

virus infection: 

nowhere, wouldn’t take the test 

AIDS clinic 

companyor industry clinic 

doctor/HMO ’ 

hospital/emergencyroom/outpatient clinic 

other clinic 

public health department 

Red Cross/bloodbank 

other (specify) 

don’t know 

Did you have a blood transfusion at any time 

between 1977 and 1985 

Do you think the present supply of blood is safe 

for transfusions 

Here are somemethods people use to keep from 

getting the AIDS virus through sexualactivity. 

After I read each one, tell me whether you think 

it is very effective,somewhateffective,not at 

all effective,or if you don’t know how effective 

it is in preventing getting the AIDS virus through 

sexualactivity. How effective is: 

using a diaphragm 

using a condom 

using a spermicidaljelly, foam or cream 

having a vasectomy 

two people who do not havethe AIDS virus 

having sexonly with each other 

What are your chances of having the AIDS virus; 

would you say: 

high 

medium 

low 

none 

refused to respond 

don’t know 

Year 

1988,1989 

1988,1989 

1988, 1989 

1988, 1989 

1988,1989 

1988,1989 

1988,1989 

1988,1989 

1988,1989 

307 
Topic Questionnaire item Year 

AIDS (cgntinued) 

People have different meanings when they say a 

“high, ” “medium,” or “low” chance, if “no chance” 

is zero-out-of-one hundred, what would you say 

high/medium/low is, what number of times-out-of-one hundred 1988, 1989 

Do you say your chance of getting AIDS is high/medium because you: 

have had a blood transfusion 

have had sexual contact with someone who might have the virus 

some other. reason (specify) 1988,1989 

In the past 12 months, have you received services or care at: 

a prenatal health clinic 

a maternal and infant health clinic 

a family planning clinic 

a hospital, as an inpatient 

B hospital emergency room 

a tuberculosis clinic 

a:drug treatment facility or clinic 

an STD, sexually tr&smitted disease, clinic 

an alcohol treatment facility or clinic 

an AIDS counseling and testing clinic 

a community health clinic 

a public health clinic 1988,1989 

In the past 12 months, have you: 

been in the job corps 

had a physical examination to join the military 

been in prison 1988,1989 

Have you ever personally known anyone with 

AIDS or the AIDS virus 1988 

How long has it been since you saw this person: 

within the past 2 weeks 

2 weeks to less than 1 month 

1 month to less than 3 months 

3 ‘months to less than 6 months 

6 months or more 

don’t know 1988,1989 

How well do you know this person, would you say: 

very well, it is a close relationship 

fairly well, but it is not a close relationship 

not very well, it is only an acquaintance or casual relationship 

you don’t really know them personally, such as a friend of a friend 

other (specify) 1988,1989 

Please tell me (interviewer) if any of these statements 

is true for you, do not tell me which statement or 

statements are true for you, just if any of them are: 

you have hemophilia and have received 

clotting factor concentrates since 1977 

you are a native of Haiti, Central or East Africa 

who has entered the United States since 1977 

you are a man who has had sex with another man at some 

time since 1977, even one time 

you have taken illegal drugs by needle at any time since 1977 

since 1977, you are or have been the sex partner of any person who 

would answer “yes” to any of the items listed above 

you have had sex for money or drugs at any time since 1977 1988, 1989 
Topic Questionnaire item 

AIDS (continued) 

The US. Public Health Servicehas said that AIDS 

is one of the major health problems in the country 

but exactlyhow many people it affectsis not known. 

The Surgeon General has proposed that a study be 

conducted and blood samplesbe taken to help find 

out how widespread the problem is. If you were 

selected in this national sample of people to have 

their blood tested with assurances of privacy of 

tests results, would you have the test 

Why wouldn’t you take part in the test: 

don’t want to know if I have AIDS 

don’t want any counseling about AIDS 

fear 1’11get AIDS 

don’t like to giveblood 

don’t trust Government programs 

it is a waste of money . 

don’t believe AIDS can really be cured anyway 

other (specify) 

don’t know 

If it were not possible to provide you with the results of the test, 

would you still take part in the study 

If the results of the test were not provided to you, 

then would you take part in the study 

When Federal Public Health officials give information 

about AIDS, do you believe what they say or are 

you doubtful about the information they give 

When they give advice about how to help keep from 

getting AIDS, do you believe their advice or are 

you doubtful about what they say 

Alcohol (see also Drinking) 

In your entire life, haveyou had at least 12 drinks 

of any kind of alcoholic beverage 

In the past 12 months did you have at least 12 drinks 

of any kind of alcoholic beverage 

In any one year of your entire life did you have at 

least 12 drinks of any kind of alcoholic beverage 

Have you had at least 1 drink of beer, wine, or liquor 

during the past year 

What are your (main) reasons for not drinking: 

no need/not necessary 

infrequent drinker 

don’t socializevery much 

don’t care for it or dislike it 

am an alcoholic 

thought I might become an alcoholic 

had problems with my drinking 

have a responsibility to my family 

family member an alcoholic or problem drinker 

medical or health reasons 

religious or moral reasons 

brought up not to drink 

Year 

1987,1988,1989 

1988,1989 

1988,1989 

1988, 1989 

1988,1989 

1988,1989 

1985,1988 

1988 

1985,1988 

1985 

309 
Topic Questionnaire item Year 

Alcohol (continued) 

makes me sick 

can’t control my drinking 

costs too much or can’t afford it 

dieting or too fattening 

other 

don’t know 

Of the reasons you have told me (interviewer), which 

of these is your most important reason for not drinking: 

don’t socialize very much 

don’t care for it or dislike it 

am an alcoholic 

thought I might become an alcoholic 

had problems with my drinking 

have a responsibility to my family 

family’ member an alcoholic or problem drinker 

medical or health reasons 

religious or moral reasons 

brought up not to drink 

makes me sick 

can’t control my drinking 

costs too much or can’t afford. it 

dieting or too fattening 

other 

don’t know 

In your opinion, how often must a person drink in 

order to be considered a heavy drinker: 

every day 

days per week 

days per inonth 

days per year 

don’t know 

On those days, how many drinks must a person have 

in ordei to be considered a heavy drinker 

In your opinion, how often must a person drink in 

order to be considered a moderate drinker: 

every day 

days per week 

days per month 

days per year 

don’t know 

On those days, how many drinks must a person have 

in order to be considered a moderate drinker 

In your opinion, how often must a person drink in 

order to be considered a light drinker: 

every day 

days per week 

days per month 

days per year 

don’t know 

On those days, how many drinks’ must a person have 

in order to be considered a light drinker 

1985,1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

310 
Topic Questionnaire item 

Alcohol (continued) 

When you were growing up, that is, during your 

first 18 years, did you live with anyone 

who was a problem drinker or alcoholic 

Was this your biologica (natural), adoptive, step, 

or foster (mother/father) 

Was this your full, half, adoptive, step, or 

foster (brother/sister) 

For how long did you live with (person) while 

(person) was a problem drinker or alcoholic: 

days 

weeks 

months 

years 

Have any of your other blood relatives ever been 

a problem drinker or. alcoholic 

Who was this: 

biological mother 

biological father 

biological brother(s) 

biological sister(s) 

half brother(s) 

half sister(s) 

biological son(s) 

biological daughter(s) 

grandmother(s) 

grandfather(s) 

aunt(s) 

uncle(s) 

niece(s) 

nephew(s) 

cousin(s) 

other blood relative(s) 

don’t know 

Have you ever been married to, or lived with someoneas if 

you were married, who was a problem drinker or alcoholic 

Pleasetell me (interviewer) which category best 

describes (each adult family member’s) drinking 

during the past year: 

heavy 

moderate 

light 

very light or occasional 

quit drinking 

never drank 

don’t know 

Tell me (interviewer) whether or not you have had any 

of the following conditions even if you have 

mentioned them before: 

hypertension or high blood pressure (excluding during pregnancy) 

hardening of the arteries 

any heart disease 

arthritis or rheumatism 

an ulcer, not including skin ulcers 

Year 

1988 

1988 

1988 

1988 

1988 

1988 

19fiS 

1988 

311 
Topic Questionnaire item Year 

Alcohol (continued) 

diabetes 

any disease of the liver, such as yellow jaundice, hepatitis or cirrhosis 

cancer, other than skin cancer 

alcoholism 

Not counting small tastes, how old were you when you 

started drinking alcoholic beverages 

In the past 12 months about how many drinks of any 

kind’of alcoholic beverages did you have 

When did you have your last drink of any kind 

of alcoholic beverage 

What type of alcoholic beverage (do/did) you 

prefer to drink: 

beer 

wine 

liquor 

no preference 

don’t know 

iNhen you (drink/drank) who (do/did) you usually 

drink with: 

friends 

relatives 

people from work 

other people 

self 

don’t know 

What are your reasons for not drinking very much: 

don’t socialize very much 

don’t care for it or dislike it 

am an alcoholic 

thought I might become an alcoholic 

had problems with my drinking 

have responsibility to my family 

famiIy member an alcoholic or problem drinker 

medical or health reasons 

religious or moral reasons 

brought up not to drink 

makes me sick 

can’t control my drinking 

costs too much or can’t afford it 

dieting or too fattening 

other 

don’t know 

Of the reasons you have told me (interviewer), which 

of these is your most important reason for not 

drinking very much: 

don’t socialize very much 

don’t care for it or dislike it 

am an alcoholic 

thought I might become an alcoholic 

had problems with my drinking 

have responsibility to my family 

family member an alcoholic or problem drinker 

medical or health reasons 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

312 
Topic 

Alcohol (continued) 

religious or moral reasons 

brought up not to drink 

makes me sick 

can’t control my drinking 

costs too much or can’t afford it 

dieting or too fattening 

other 

don’t know 

Questionnaire’ item 

On the average, how often do you drink any alcoholic 

beverage: 

every day 

days per week 

days per month 

days per year 

don’t know 

On the average, on the days that you drink alcohol, 

how many drinks do you have a day 

Did you have a drink during the 2-week period 

(outlined on the calendar) beginning Monday and ending Sunday 

During that period, when did you last have a drink 

When was your last drink prior to that 2-week period 

During that 2-week period, on how many days did 

you drink any beer 

On the day(s) when you drank beer, about how many 

beers did you drink a day 

About how many ounces were in a typical can or bottle or 

glass of beer that you drank during that period 

During that 2-week period, on how many days did you 

drink any wine 

On the day(s) when you drank wine, about how 

many glasses of wine did you drink a day 

About how many ounces of wine were in a typical 

glass that you drank during that period 

During that 2-week period, on how many days did you drink 

any liquor, such as whiskey, rum, gin, or vodka 

On the day(s) when you drank liquor, about how 

many drinks did you have a day 

About how many ounces of liquor were in a typical 

drink that you had during that period 

During the 2-week period (outlined on the calendar/ 

beginning Monday and ending Sunday), on how 

many days altogether did you drink alcoholic 

beverages, that is, beer, or wine, or liquor 

During that 2-week period, did you have more 

than largest number reported 

On how many days did you have more than (largest 

number) drink(s) of beer, or wine, or liquor 

What was the largest number of drinks you had on 

any one of those days 

On how many days during that 2-week period did you 

have (number of) drinks 

Year 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

313 
Todc Questionnaire item 

Alcohol (continued) 

How many drinks did you have on that day 

Was the amount of your drinking during that 2-week 

pbriod typical of your drinking during the past 12 months 

Was the amount of your drinking during that 2-week 

period more or less than your drinking during 

the past 12 months 

For how many years has this been typical of y&r drinking 

During that 2-week period (ending the day of last 

drink), on how many days did you drink any beer 

During that 2-week period (ending the day of last 

drink), on how many days did you drink any wine 

During that 2-week period (ending the day of last 

drink), on how many days did you drink any liquor 

During that 2-week period, did you drink more or 

less than usual 

Do you think you will probably drink again or have 

you stopped drinking permanently: 

will probably drink again 

stopped permanently 

other 

don’t know 

Did you have at least one drink in every month (in the 12 months 

before last drink/last year/of that year) 

In how many months did you have at least one drink 

During (that month/those months), on how many days did you 

have 9 or more drinks of any alcoholic beverage 

During (that month/those months), on how many days 

did you have 5 or more drinks of any alcoholic beverage 

Do you now consider yourself to be a heavy, moderate, 

light, very light, or occasional drinker 

In your entire life, when you drank the most, about 

how often did you drink: 

every day 

days per week 

days.per month 

days per year 

don’t know 

On these days, about how many drinks did you have a day 

For how long a period did you drink this amount: 

number of days 

number of weeks 

number of months 

number of years 

don’t know 

Before you stopped drinking, what type of 

alcoholic beverage (do/did) you prefer to drink: 

beer 

wine 

liquor 

no preference 

don’t know 

Year 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

314 
Topic Questionnaire item Year 

Alcohol (continued) 

In the past 12 months about how many drinks of any 

kind of alcoholic beverage did you have 

When did your have you last drink of any kind of 

alcoholic beverage 

In your entire life, when you drank the most, about 

how often did you drink 

On those days, about how many drinks did you have a day 

For how long a period did you drink this amount: 

number of days 

number of weeks 

number of months 

number of years 

don’t know 

What are your reasons for drinking less’than 12 

drinks in the past year: 

don’t socializevery much 

don’t care for it or dislike it 

am an alcoholic 

thought I might become an alcoholic 

had problems with my drinking 

haveresponsibility to my family 

family member an alcoholic or problem drinker 

medical or health reasons 

religious or moral reasons 

brought up not to drink 

makes me sick 

can’t control my drinking 

costs too much or can’t afford it 

dieting or too fattening 

other 

don’t know 

Of the reasonsyou have told me (interviewer), which 

of these is your most important reason for 

drinking less than 12 drinks in the past year: 

don’t socializevery much 

don’t care for it or dislike it 

am an alcoholic 

thought I might become an alcoholic 

had problems with my drinking 

have responsibility to my family 

family member an alcoholic or problem drinker 

medical or health reasons 

religious or moral reasons 

brought up not to drink 

makes me sick 

can’t control my drinking 

coststoo much or can’t afford it 

dieting or too fattening 

other 

don’t know 

In your entire life, have you ever: 

had a strong desire or urge to drink 

started drinking even though you hadn’t intended to 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

315 
Topid Questionnaire item Year 

Alcohol (continued) 

ended up drinking much more than you intended to 

found it difficult to Stop drinking once you had started 

driven a car after having had too much to drink 

been sick or vomited after drinking, or the morning after 

done things when drinking that could have caused you to be hurt 

felt the effectsof alcohol sooner than you used to 

kept on drinking for a’longer period of time than you intended to 

found that the same amount of alcohol had less effect than before 

felt depressed,irritable, or nervous after drinking, or the morning after 

felt powerlessover your drinking 

sought help from family, friends, professionaIs, 

or self-help groups about your drinking 

had a spouseor someoneyou lived with threaten 

to leave you because of your drinking 

gone on benders or binges that lasted two or more days> 

tried to cut down or stop drinking and found you couldn’t do it 

found yourself sweating heavily or shaking after drinking, 

or the morning after 

givenup or cut down on activities or interests like sports 

or associations with friends, in order to drink 

been unable to remember some of the things you did while drinking 

needed a drink so badly you couldn’t think of anything else 

found that you had to drink more than you once 

did to get the same effect 

stayed away from work or gone to work late becauseof 

drinking or a hangover 

spent money on drinks that was needed for essentialslike food, or bills 

lost ties with or drifted apart from a family member or 

friend because of your drinking 

gotten drunk instead of doing the things you were supposed to do 

had.a doctor suggestthat you cut down or stop drinking alcohol 

continued to drink alcohol even though it was a threat to your health 

lost a job, or nearly lost one, because of drinking 

had family, friends or co-workers suggest that you stop or 

cut down on your drinking 

done things when drinking that could have causedsomeoneelse to be hurt 

felt uneasy if alcohol was not around in case you wanted a drink 

spent a lot of time drinking, or getting over the effects of drinking 

been so hungover that it interfered with doing 

things you were supposed to do 

kept drinking even though it caused you emotional problems 

had your chances for promotion, raises, or better 

jobs hurt by your drinking 

heard or seen things that weren’t really there after drinking, or the morning after 

taken a drink to keep yourself from shaking or feeling sick either 

after drinking, or the morning after 

kept drinking eventhough it causedyou problems 

at home, work, or school 

attended a meeting of Alcoholics Anonymous (AA) 

becauseof your drinking 

been arrested or had trouble with the police because of your drinking 

wanted to cut down or stop your drinking and 

found you couldn’t do it 1988 

316 
Topic Questionnaire item 

Alcohol (continued) 

In the last 12 months, how many times have you: 

(See previous list) 

Birth (see also Child Health) 

‘Have given birth to live infant in the past 5 years 

In what month and year was your last child born 

Birth Control Pills (see also Cancer) 

If a woman takes birth control pills is she more likely to have 

a stroke if she smokes than if she does not smoke 

If a woman takes birth control pills is she much more 

likely or somewhat more likely to have a stroke 

Blood Pressure/Hypertension (see also Stress/Stroke) 

Which of the following definitely increases, probably increases, 

probably does not, or definitely doesnot increase 

a person’s chance of getting heart diseasei 

cigarette smoking 

worry or anxiety 

high blood pressure 

diabetes 

being very overweight 

overworked 

drinking coffee with caffeine 

eating a diet high in animal fat 

family history of heart disease 

high cholesterol 

Which one of the following substances in food is most 

often associated with high blood pressure: 

sodium 

cholesterol 

sugar 

other (specify) 

don’t know 

Have you ever been told by a doctor or other health 

professional that you had hypertension, sometimes 

called high blood pressure 

About how long has it been since you last had your 

blood pressure taken by doctor or other health professional: 

number of days 

number of weeks 

number of months 

number of years 

don’t know 

never 

Blood pressure is usually given as one number over 

another. Were you told what your blood pressure 

was, in numbers 

What was your blood pressure, in numbers 

At that time, was your blood pressure: 

high 

Year 

1988 

1985 

1985 

1985 

1985 

1985 

1985 

1985 

1985 

1985 

1985 

317 
Topic Questionnaire item Year 

Blood Pressure/Hypertension (continued) 

low 

normal 

other 

don’t know 1985 

Is this condition (high blood pressure/hypertension) 

completely cured or under control 1985 

Do you still have high dlood pressure or hypertension 1985 

Were you told two or more different times that you 

had hypertension or high blood pressure 1985 

Are you now taking any medicine prescribed by a 

doctor for your hypertension or high blood pressure 1985 

Was any medicine ever prescribed by a doctor for your 

hypertension or high blood pressure 1985 

Did doctor advise you to stop taking medicine 1985 

Because of your hypertension or high blood pressure, 

has a doctor or other health professional ever 

advised you to: 

diet to lose weight’ 

cut down on salt or sodium in your diet 

exercise 1985 

Have you ever followed this advice to: 

diet to lose weight 

cut down on salt or sodium in your diet 

exercise 1985 

Are you now following this advice to: 

diet to lose weight 

cut down on salt or sodium in your diet 

exercise 1985 

Breastfeeding (see Child Health) 

Cancer (see also Smoking) 

Cancer Control 

Acculturation 

Respondent speaks Spanish 1987 

Respondent speaks English 1987 

Respondent speaks mostly Spanish, mostly English 

or both Spanish and English about the same 1987 

Language respondent prefers 1987 

Can respondent read Spanish 1987 

Can respondent read English 1987 

Respondent reads better in Spanish or English 1987 

Can respondent write in Spanish 1987 

Can respondent write in English 1987 

Respondent writes better in Spanish or English 1987 

What is your ethnic identification: (see list below) 1987 

318 
Topic Questionnaire item 

Cancer Control (continued) 

Acculturation (continued) 

What is respondent mother’s ethnic identification: (see list below) 

What is respondent father’s ethnic identification: 

Puerto Rican 

Cuban 

Mexican/Mexican0 

Mexican American 

Chicano 

other Latin American 

other Spanish 

other (specify) 

What country or State respondent born in 

What country or State respondent’s mother born in 

What country or State respondent’s father born in 

Medical Care 

Needed medical care or advice in past 12 months 

During past 12 months, did not get needed medical care or advice 

Why didn’t you get the care that you needed: 

procrastinated/put it off 

did not have health insurance 

care was not available when needed 

cost too much 

didn’t know where to go 

didn’t know what kind of doctor to see 

didn’t have a way to get there 

hours not convenient 

fear of being treated rudely or unkindly 

other reason (specify) 

don’t know 

Is there a particular doctor’s office, clinic, health center, or place 

you usually go to for medical care or advice 

What kind of place is it: 

doctor’s office 

hospital emergency room 

hospital outpatient clinic 

health center or private neighborhood health clinic 

‘public health clinic 

health clinic at work 

HMO/prepaid group practice/“Group Health” 

other (specify) 

don’t know 

Where do you go when you are sick or need advice 

about your health: 

doctor’s office 

hospital emergency room 

hospital outpatient clinic 

health center or private neighborhood health clinic 

public health clinic 

health clinic at work 

HMO/prepaid group practice/“Group Health” 

Year 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

319 
Topic Questionnaire item 

Cancer Control (continued) 

Medical Care (continued) 

haven’t needed a doctor 

don’t go anywhere 

have two or more doctors or usual places depending on what is wrong 

other (specify) 

don’t know 

Where do you get most useful information about 

how to prevent illness and improve your health: 

telephone information-public service or hotline 

family 

friends 

doctor 

work 

television 

radio 

books 

newspaper 

magazines 

pamphlets in doctor’s office 

other source 

nowhere/don’t get information 

don’t know 

Food Knowledge 

Ever made any lasting and major changes in what you 

eat and drink for health reasons 

If foods changed, what foods you eat less of 

If foods changed, what foods you eat more of 

Have you made changes in what you eat or drink in past 5 years 

Have you made changes in what you eat or drink in the past year 

Are following statements true or false for respondent: 

everything you eat is bad for you so why bother changing 

respondent enjoys the things eaten and don’t want to change 

there are so many different recotiendations, it’s hard for respondent 

to know which ones to follow 

respondent eats out so much that making changes would be hard 

making changes in the kind of food respondent 

eats would be expensive 

respondent would like to change but rest of family won’t change 

the things respondent eats are healthy so there is no 

reason to make changes 

Respondent agrees most with one of the following two statements: 

what people eat or drink has little effect on whether they will 

develop major diseases 

by eating the right kinds of food, people can reduce their chances 

of developing major diseases 

Which major diseasesyou think may be related to 

what people eat and drink: 

cancer 

heart disease 

obesity/overweight 

diabetes 

Year 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 
Topic Questionnaire item Year 

Cancer Control (continued) 

Food Knowledge (continued) 

hypertension or high blood pressure 

other 

none 

Do you think cancer may be related to what people 

eat and drink 

What foods should people eat or drink MORE of to 

help prevent cancer 

What foods should people eat or drink LESS of to 

help prevent cancer 

What, kinds of cancer do you think may be related 

to things people eat and drink: 

all kinds of cancer 

breast cancer 

bladder cancer 

cancer of the mouth/throat/esophagus 

cancer of the colon/bowel/intestines/rectum 

stomach cancer 

prostate cancer 

cancer of the uterus 

lung cancer 

liver cancer 

other 

don’t know 

Have you heard or read ANYTHING about how eating 

more of some foods and less of other foods can 

help prevent some major diseases 

Which major diseases have you heard may be related 

to what people eat and drink: 

cancer 

heart disease 

obesity/overweight 

diabetes 

hypertension or high blood pressure 

other 

none 

don’t know 

Have you heard of foods containing fiber 

Diet high, medium, or low in fiber 

Tell me (interviewer) which of the foods listed 

is high in fiber: 

bran flakes 

corn flakes 

hamburgers 

lettuce 

baked beans 

carrots 

white rice 

raw apples 

none 

don’t know 

Diet high, medium, or low in fat 

I 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

321 
Topic Questionnaire item Year 

Cancer Control (continued) 

Food Knowledge (continued) 

Tell me (interviewer) which of the foods listed 

is high in fat: 

fried chicken 

white bread 

soda or soft drinks 

peanut butter 

broiled fish 

bananas 

cold cuts or lunch meats 

doughnuts 

none 

don’t know 

Thinking about what you eat and drink, which of 

the following are important concerns for you: 

avoiding foods with too much salt or sodium 

avoiding foods with too much sugar 

eating foods to lower cholesterol 

not having enough money to buy food 

being overweight 

being too thin 

General tiowledge and Attitudes 

Which do you think increases a person’s chances 

of getting cancer: 

stress 

inherited make-up or heredity 

exposure to x-rays 

poor eating practices 

using chewing tobacco, snuff, pipes or cigars 

air pollution 

water pollution 

some cloth dyes 

exposure to toxic waste dumps 

exposure to toxic substances on the job 

exposure to people with cancer 

excessivedrinking of alcoholic beverages 

exposure to the sun 

cigarette smoking 

exposure to nuclear waste 

some strong soaps and detergents 

viruses 

some medicines 

medical procedures using radiation 

don’t know 

In your opinion, of the things you just mentioned 

(see list above), which two are responsible 

for the most cases of cancer in this country 

Do you strongly agree, agree, disagree, or strongly 

disagreewith this statement,or if you have no opinion: 

there is very little a person can do to reduce 

his or her chances of getting cancer 

1987 

1987 

1987 

1987 

1987 

1987 

322 
Topic Questionnaire item 

Cancer Control (continued) 

General Knowledge and Attitudes (continued) 

What do you think are warning signs or symptoms of cancer: 

weight loss/lossof appetite 

changein bowel or bladder habits 

unusual bleeding or discharge , 

lump in breast or elsewhere 

indigestion 

difficulty in swallowing 

changein a wart or mole 

naggingcough or hoarseness 

chest pain 

shortnessof breath 

soresthat don’t heal 

tired/fatigued 

changeson skin/rash/blemish/sunspots/blotches 

other 

don’t know 

Would you attend, if convenient, a free 2 hour class 

on how to reduce your chances of getting cancer 

Which of these places would be most convenient for you to attend class: 

church 

local school 

hospital 

club meeting 

workplace 

home 

senior center 

community center 

other place 

don’t know 

ScreeningKnowledge and Practice 

Ever heard of Pap smear test 

Ever had a Pap smear 

When had last Pap smear 

Was Pap smear done: 

within past year 

a year or more ago 

Was Pap smear: 

lessthan 3 months 

3 or more months ago 

Was Pap smear: 

3 years ago or less 

between 3 and 5 years 

5 or more years ago 

Where was Pap smear done: 

in a doctor’s office 

a clinic 

a hospital 

someother place 

Did you have Pap smear because of health problem 

Year 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

323 
Topic Questionnaire item Year 

Cancer Control (continued) 

Screening Knowledge and Practice (continued) 

What was problem for Pap smear: 

follow-up tests/treatment 

bleeding 

pain , 

discharge 

itching 

burning 

infection 

unrelated medical problem 

other 

don’t know 

How were you told results of Pap smear: 

in person 

telephone 

through the mail 

combination of methods 

never told; meaning results normal 

never told; don’t know if there is a problem 

other 

What was health problem for Pap smear: 

follow-up tests/treatment 

bleeding 

pain 

discharge 

itching 

burning 

infection 

unrelated medical problem 

other 

don’t know 

Have you ever had Pap smear and results not normal 

Because of abnormal results, did you have additional tests 

Because of abnormal results, did you have any 

surgery or other treatment 

Did Pap smear/additional tests/surgery or other 

treatment indicate cancer 

When were you diagnosed as having cancer 

What is most important reason (why you have never 

had/not had a Pap smear in the past few years): 

procrastinated/put it off 

had a hysterectomy 

didn’t know I should 

not needed/not necessary 

cost too much 

no insurance coverage 

don’t go to doctors 

don’t have a doctor 

not recommended by doctor/Dr. never said it was needed 

doctor said it wasn’t needed 

too embarrassing 

haven’t had any problems 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

324 
Topic Questionnaire item Year 

Cancer Control (continued) 

Screening Knowledge and Practice (continued) 

fear 

other 

don’t know 

Do you have menstrual periods 

Menstrual periods stopped due to surgery 

Know how to examine breasts for lumps 

How often you examine breasts for lumps: 

day 

week 

month 

year 

never 

other (specify) 

don’t know 

Who taught you how to examine breasts: 

doctor 

nurse 

other health professional 

learned in a class/meeting 

read in a book, pamphlet, magazine, etc. 

television 

other (specify) 

don’t know 

Ever heard of a breast physical examination 

Have you ever had breast physical exam 

When did you have last breast physical exam: 

days ago 

weeks ago 

months ago 

years ago 

don’t know 

Was breast exam: 

within the past year 

1 year or more ago 

Was breast exam: 

less than 3 months 

3 or more months ago 

Was breast exam: 

3 years ago or less 

between 3 and 5 years 

5 or more years ago 

Where was breast exam done: 

doctor’s office 

clinic 

hospital 

other place (specify) 

don’t know 

Did you go for last breast exam because of health problem 

What was health problem: 

follow-up tests/treatment 

soreness 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

325 
Topic Questionnaire item Year 

Cancer Control (continued) 

Screening Knowledge and Practice (continued) 

swelling 

luaps 

pain 

discharge 

complications related to breast feeding 

unrelated medica problem 

other 

don’t know 1987 

How were you told results of breast exam: 

in person 

telephone 

through the mail combination of methods 

never told; meaning results normal 

never told; don’t know if probiem 

other 1987 

Ever had a breast physical exam because of health problem 1987 

What was health problem: 

follow-up tests/treatment 

soreness 

swelling 

lumps 

pain 

discharge 

complications related to breast feeding 

unrelated medical problem 

other 

don’t know 1987 

Ever had a breast physical exam where the results were not normal 1987 

Because of abnormal results, did you have additional tests 1987 

Because of abnormal results, did you have surgery or other treatment 1987 

Did breast physical exam/additional tests/surgery or other treatment indicate cancer 1987 

When were you diagnosed as having cancer: 

days ago 

weeks ago 

months ago 

years ago 

don’t know 1987 

Most important reason you have not/never had a breast physical exam 

in the past few years by a doctor or other heahh professional: 

procrastinated/put it off 

didn’t know I should 

not needed/not necessary 

cost too much 

no insurance coverage 

don’t go to doctors 

don’t have a doctor 

not recommended by doctorllk. 

doctor said it wasn’t needed 

too embarrassing 

haven’t had any problems 

fear 

examined own breast 

never said it was needed 
Topic Questionnaire item 

Cancer Control (continued) 

ScreeningKnowledge and Practice (continued) 

other 

don’t know 

Ever heard of a mammogram 

Ever had a mammogram 

When was last mammogram: 

daysago 

weeks ago 

months ago 

years ago 

don’t know 

Was last mammogram: 

within past year 

1 year or more ago 

Was last mammogram: 

lessthan 3 months 

3 or more months ago 

Was last mammogram: 

3 years ago or less 

between 3 and 5 years 

5 or more years ago 

Where was mammogram test done: 

doctor’s office 

clinic 

hospital 

imaging center/x-raylab 

other place (specify) 

don’t know 

Did you go for last mammogram because of health problem 

What was health problem: 

thickening 

soreness 

swelling 

lumps 

pain 

discharge 

unrelated medical problem 

other 

don’t know 

How were you told results of mammogram: 

in person 

telephone 

through the mail 

combination of methods 

never told; meaning results normal 

never told; don’t know if problem 

other 

Ever had mammogram because of health problem 

What was health problem: 

thickening 

soreness 

swelling 

lumps 

Year 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

327 
Topic Questionnaire item Year 

Cancer Control (continued) 

Screening Knowledge and Practice (continued) 

pain 

discharge 

unrelated medical problem 

other 

don’t know 1987 

Ever had mammogram where the results were not normal 1987 

Because of abnormal results, did you have additional tests 1987 

Because of abnormal results, did you have any surgery or other treatment 1987 

Did mammogram/additional tests/surgery or other treatment indicate cancer 1987 

When were you diagnosed as having cancer: 

days ago 

weeks ago 

months ago 

years ago 

don’t know 

What is most important reason why you have not had/ 

never had a mammogram in the past few years: 

procrastinated/put it off 

didn’t know I should 

not needed/not necessary 

cost too much 

no insurance coverage 

don’t go to doctors 

don’t have a doctor 

1987 

not recommended by doctor/Dr. never said it was needed 

doctor said it wasn’t needed 

too embarrassing 

,haven’t had any problems 

fear 

fear of radiation 

painful procedure 

unpredictable results 

other 

don’t know 

Ever heard of digital rectal exam 

Ever had a digital rectal exam 

When did you have your last digital 

daysago 

weeks ago 

months ago 

years ago 

don’t know 

Was rectal exam: 

within the past year 

1 year or more ago 

Was rectal exam: 

less than 3 months 

3 or more months ago 

Was rectal exam: 

3 years ago or less 

between 3 and 5 years 

5 or more years ago 

1987 

1987 

1987 

rectal exam: 

1987 

1987 

1987 

1987 

328 
Topic Questionnaire item 

Cancer Control (continued) 

Screening Knowledge and Practice (continued) 

Where was rectal exam done: 

doctor’s office 

clinic 

hospital 

other place (specify) 

Did, you go for your last digital rectal exam because of a health problem 

What was health problem: 

pain 

constipation 

bowel trouble 

blood in stool 

difficulty urinating 

prostate enlargement 

bleeding 

hemorrhoids 

diverticulitis 

unrelated medical problem 

other 

don’t know 

How were you told the results of the test: 

in person 

telephone 

through the mail 

combination of methods 

never told; meaning results normal 

never told; don’t know if problem 

other 

Ever had digital rectal exam because of health problem 

What was health problem: 

pain 

constipation 

bowel trouble 

blood in stool 

difficulty urinating 

prostate enlargement 

bleeding 

hemorrhoids 

diverticulitis 

unrelated medical problem 

other 

don’t know 

Ever had digital rectal exam where results were not normal 

Because of abnormal results, did you have additional tests 

Because of abnormal results, did you have surgery or other treatment 

Did digital rectal exam/additional tests/surgery 

or other treatment indicate you had cancer 

When were you diagnosed as having cancer: 

days ago 

weeks ago 

months ago 

years ago 

don’t know 

Year 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

329 
Topic Questionnaire item 

Cancer Control (continued) 

ScreeningKnowledge and Practice (continued) 

What is most important reason why you have 

(never had/not had a digital rectal exam in the past years): 

procrastinated/put it off 

didn’t know I should 

not needed/not necessary 

cost too much 

no insurance coverage 

don’t go to doctors 

don’t have a doctor 

not recommended by doctor/Dr. 

Dr. said it wasn’t needed 

too embarrassing 

haven’t had any problems 

fear 

painful procedure 

unpredictable results 

other 

don’t know 

Ever heard of blood stool test 

Ever had a blood stool test 

When had last blood stool test: 

month/year 

days ago 

weeks ago 

months ago 

years ago 

Was blood stool test: 

within the past year 

1 year or more ago 

Was blood stool test: 

less than 3 months 

3 or more months ago 

Was blood stool test: 

3 years ago or less 

between 3 and 5 years 

5 or more years ago 

never said it was needed 

Blood stool test done by self, done by doctor or other medical person 

Last blood stool test done because of health problem 

What was problem: 

hemorrhoids 

bleeding 

pain 

constipation 

bowel trouble 

blood in stool 

ulcers 

unrelated medical problem 

other 

don’t know 

How were you told results of test: 

in person 

telephone 

Year 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

330 
Topic Questionnaire item, 

Cancer Control (continued) 

ScreeningKnowledge and Practice (continued) 

through the mail 

combination of methods 

never told; meaning results normal 

never told; don’t know if problem 

other 

Ever had a blood stool test because of health problem 

What was problem: 

hemorrhoids 

bleeding 

pain 

constipation 

bowel trouble 

blood in stool 

ulcers 

unrelated medical problem 

other 

don’t know 

Ever had blood stool test where results not normal 

Because of abnormal results, did you have additional tests 

Because of abnormal results, did you have surgery or treatment 

Did blood stool test/additional tests/surgery 

or other treatment indicate you had cancer 

When was cancer diagnosed: 

daysago 

weeks ago 

months ago 

years ago 

don’t know 

What is most important reason why you have (never had/not had a blood 

stool test in the past few years): 

procrastinated/put if off 

didn’t know I should 

not needed/not necessary 

cost too much 

no insurance coverage 

don’t go to doctors 

don’t have a doctor 

not recommendedby doctor/Dr. never said it ‘wasneeded 

Dr. said it wasn’t needed 

too embarrassing 

fear 

haven’t had any problems 

painful procedures 

unpredictable results 

other 

don’t know 

Ever heard of a proctoscopic exam 

Ever had a proctoscopic exam 

When was last proctoscopic exam: 

daysago 

weeks ago 

months ago 

years ago 

Year 

1987 

1987 

1987 

1987 

1987.’ 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

331 
Topic Questionnaire item 

Cancer Control (continued) 

Screen&g Knowledge and Practice (continued) 

Was the proctoscopic exam: 

within past year 

1 year or more ago 

Was the proctoscopic exam: 

less than 3 months 

3 or more months ago 

Was the proctoscopic exam: 

3 years ago or less 

between 3 and 5 years 

5 or more years 

Where was proctoscopic exam done: 

in a doctor’s office 

a clinic 

a hospital 

other place (specify) 

don’t know 

Did you go for last proctoscopic exam because of health problem 

What was problem: 

bleeding 

pain 

constipation . 

bowel trouble 

blood in stool 

unrelated medical problem 

other 

don’t know 

How were you told results of proctoscopic exam: 

in person 

telephone 

through the mail 

combination of methods 

never told, meaning results normal 

never told; don’t know if problem 

other 

Ever had proctoscopic exam because of health problem 

What was problem: 

bleeding 

pain 

constipation 

bowel trouble 

blood in stool 

unrelated medical problem 

other 

‘don’t know 

Ever had proctoscopic examwhere results not normal 

Because of abnormal results, did you have 

additional tests 

Becauseof abnormal results, did you have surgery or treatment 

Did proctoscopic exam/additional tests/surgery 

or other treatment indicate you had cancer 

Year 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

332 
Topic Questionnaire item 

Cancer Control (continued) 

Screening Knowledge and Practice (continued) 

When was cancer diagnosed: 

days ago 

weeks ago 

months ago 

years ago 

don’t know 

What is most important reason why you have (never had/not 

had proctoscopic exam in the past few years): 

procrastinated/put if off 

didn’t know I should 

not needed/not necessary 

cost too much 

no insurance coverage 

don’t go to doctors 

don’t have a doctor 

not recommended by doctor/Dr. never said it was needed 

Dr. said it wasn’t needed 

too embarrassing 

fear 

haven’t had any problems 

painful procedures 

unpredictable results 

other 

don’t know 

Ever heard of: 

a breast physical exam 

a mammogram 

a digital rectal exam 

a blood stool test 

a proctoscopic exam 

How often you think women should have a Pap smear: 

number of week(s) 

number of month(s) 

number of year(s) 

never 

other (specify) 

only if problem/symptoms 

don’t know 

How often women age 50 and over should have breast physical exam 

by a doctor or health professional: 

number of week(s) 

number of month(s) 

number of year(s) 

never 

other (specify) 

only if problem/symptoms 

don’t know 

How often women age 50 and over should have 

a mammogram: 

numberof week(s) 

number of month(s) 

number of year(s) 

Year 

1987 

1987 

1987 

1987 

1987 

333 
Topic Questionnaire item 

Cancer Control (continued) 

Screening Knowledge and Practice (continued) 

never 

other (specify) 

only if problem/symptoms 

don’t know 

How often person age 40 and over should have digital rectal exam: 

number of week(s) 

number of month(s) 

number of year(s) 

never 

other (specify) 

only if problem/symptoms 

don’t know 

How often person age 40 and over should have blood stool test: 

number of week(s) 

number of month(s) 

number of year(s) 

never 

other (specify) 

only if problem/symptoms 

don’t know 

How often person age 40 and over should have a 

proctoscopic exam: 

number of week(s) 

number of month(s) 

number of year(s) 

never 

other (specify) 

onIy if problem/symptoms 

don’t know 

Ever told by doctor or other health professional 

that you have cancer 

Kind of cancer 

Part of body affected by cancer 

Age when cancer first diagnosed 

Doctor told you about other cancer 

Kind of other cancer 

Part of body affected by other kind of cancer 

Age when other kind of cancer first diagnosed by doctor 

Smoking Habits and Tobacco Use 

Ever smoked 100 cigarettes in entire life 

Age when first started smoking cigarettes fairly regularly 

Do you smoke now 

When you are inside public places that have no 

rules about smoking and someone lights up a 

cigarette, what are you most likely to do: 

ask the person not to smoke 

move away from the person 

do nothing 

something else 

Year 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

334 
Toxic Questionnaire item 

Cancer Control (continued) 

Smoking Habits and Tobacco Use (continued) 

About how long has it been since you last 

smoked cigarettes regularly 

On the average, how many cigarettes did you usually smoke a day 

How many minutes or hours after awakening did 

you usually have your first cigarette 

Before you quit, did you make any other 

serious attempts to stop smoking 

Including the last time you quit smoking, how many times 

did you make a serious attempt to stop smoking cigarettes 

Before you quit smoking, what was the 

longest period you stayed off cigarettes 

For how many years were you a regular smoker 

(do not include the times when you stayed off cigarettes) 

(When you quit smoking, did you ever/In any of your 

quit attempts, did you ever): 

switch to lower tar or nicotine cigarettes 

use special filters or cigarette holders to 

regulate the amount of smoke inhaled 

gradually decrease the number of cigarettes 

you smoked in a day 

use prescription chewing gum called “nicorette” 

participate in the Great American Smoke-out 

stop smoking along with friends or relatives 

who were also trying to quit 

stop by following instructions in a book or pamphlet 

stop “cold turkey,” that is, stopping all at 

once without cutting down 

use some other method 

Thinking of the methods you just mentioned (see 

previous list), which ones did you use the 

last time you quit smoking 

Thinking of the time(s) you tried to quit smoking, 

please tell me the reasons you had for trying to quit: 

health symptom/problem 

present health 

future health 

both present and future health 

cost of cigarettes 

pressure from family and friends 

advice from my doctor 

setting a good example for children 

effect my smoking had on others 

pregnancy 

lost desire 

dirty habit 

other 

don’t know 

Was that concern for your health at the time or 

concern for your future health 

Did you ever try to quit smoking because of a 

health condition you had at the time 

Year 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

335 
Topic Questionnaire item 

Cancer Control (continued) . 

Smoking Habits and Tobacco Use (continued) 

What was the health condition: 

heart trouble/problem 

high blood pressure 

cancer 

emphysema 

cough 

shortness of breath 

cold/flu/virus 

other respiratory problem 

sore throat 

pregnancy 

other 

don’t know 

Did a doctor ever advise you to quit smoking 

Do you believe your smoking affected your health in any way 

How did smoking affect your health: 

heart trouble/problem 

high blood pressure 

cancer 

emphysema 

cough 

shortness of breath 

cold/flu/virus 

other respiratory problem 

sore throat 

other 

don’t know 

In order to get an accurate record of the brand 

of cigarette you smoke most often, I’d like 

to see the cigarette package (do you have the pack handy) 

What brand or type of cigarette do you smoke most often 

What type of cigarettes are the (brand) that you smoke, are they: 

filter tip 

non-filter tip 

hard pack 

soft pack 

menthol 

plain 

regular 

king-size 

100 millimeter 

120 millimeter 

lights 

ultra lights 

don’t know 

What are the reasons you smoke cigarettes: 

addicted 

relaxes or calms me/nerves/stress/helps me cope 

to keep my weight down 

wakes me up 

gives me something to do with my hands 

Year 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

336 
Topic Questionnaire item 

Cancer Control (continued) 

SmokingHabits and Tobacco Use (continued) 

keepsme going/helpsme concentrate/excuseto take a break 

habit 

I like it/enjoy it 

social reasons 

other 

don’t know 

Have you ever made a serious attempt to stop 

smoking cigarettes 

Have you made more than one serious attempt 

How many times within the last year haveyou 

made a serious attempt to stop smoking cigarettes 

When did you make the serious attempt to quit smoking 

When did you last make a serious attempt to quit smoking 

When you tried to quit, for how long did you 

stay off cigarettes: 

lessthan a day 

days 

weeks 

months 

years 

don’t know 

Of all the times you have tried to quit smoking, 

what was the longest period you stayed off cigarettes: 

lessthan a day 

days 

weeks 

months 

years 

don’t know 

After your attempt(s) to quit, what were the 

reasons you started to smoke again: 

fear of gaining weight 

actual weight gain 

headacheslirritabilityldifliculty concentrating/drowsiness 

bored/blue/depressed 

nervous/tense/angry/frustrated/stress 

stressfullife event 

pressurefrom others to smoke 

no support from others 

habit/situation where used to smoke regularly 

addiction/craving 

pleasure of smoking/enjoyit 

others smoking around me 

not ready to quit/didn’t want to quit 

didn’t try hard enough/no will power 

any mention of alcohol 

Year 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

. other 

don’t know 1987 

Of the reasonsyou have told me (seeprevious 

list), which of these was the most important 

to you as a reason for starting to smoke again 1987 

337 
Topic Questionnaire item Year 

Cancer Control (continued) 

Smoking Habits and Tobacco Use (continued) 

Have you ever switched to a lower tar and nicotine 

cigarette just to reduce your health risk 1987 

Do you believe your smoking has affected your 

health in any way 1987 

How has your smoking affected your health: 

heart trouble/problem 

high blood pressure 

cancer 

emphysema 

cough 

shortness of breath 

cold/flu/virus 

other respiratory problem 

other 

don’t know 1987 

Has a doctor ever advised you to quit smoking 19851987 

For how many years have you been a regular smoker 

(do not include the times when you stayed off cigarettes) 1987 

Could you quit smoking permanently if you wanted to 1987 

How hard do you think it would be to quit smoking 

cigarettes entirely: 

very hard 

somewhat hard 

not hard at all 1987 

Have you ever used chewing tobacco, such as Redman, 

Levi Garrett, or Beechnut 1987 

Have you used chewing tobacco at least 20 times 1987 

How old were you when you first used chewing tobacco 1987 

Do you use chewing tobacco now 1987 

Altogether, about how long (did you use/have you 

used) chewing tobacco 1987 

On the average, how many days per month (did/do) 

you use chewing tobacco 1987 

On the days that you use(d) chewing tobacco, how 

many times (did/do) you use it 1987 

Have you ever used snufF, such as Skoal, Skoal 

Bandits, or Copenhagen 1987 

Have you used snuff at least 20 times 1987 

How old were you when you f?rst used snuff 1987 

Do you use snuff now ,l987 

Altogether, about how long (did you use/have you used) snuff 1987 

On the average, how many days per month (did/do) you use snuff 1987 

On the days you use(d) snuff, how many times 

(did/do) you use it 1987 

(Did/Do) you use snuff by sniffing it or by placing 

it in your mouth 1987 

Have you ever smoked a pipe 1987 

Have you smoked a pipe at least 50 times 1987 

How old were you when you first smoked a pipe 1987 

338 
Topic Questionnaire item 

Cancer Control (continued) 

SmokingHabits and Tobacco Use (continued) 

Do you smoke a pipe now 

Altogether, about how long (did you smoke/haveyou 

smoked) a pipe 

On the average,how many days per month (did/do) 

you smoke a pipe 

On the daysyou smoke(d) a pipe, how many pipefuls 

of tobacco (did/do) you smoke 

Have you ever smoked cigars 

Have you smoked at least 50 cigars in your entire life 

How old were you when you first smoked cigars 

Do you smoke cigars now 

Altogether, about how long (did you smoke/haveyou 

smoked) cigars 

On the average,how many days per month (did/do) 

you smoke cigars 

On the daysyou smoke(d) cigars,how many (did/do) 

you smoke 

Do you believe cigarette smoking is related to: 

emphysema 

gallstones 

lung cancer 

chronic bronchitis 

diabetes 

cancer of the mouth and throat 

heart disease 

Do you think that using chewing tobacco on a 

regular basiscan increase a person’s chances 

of getting mouth and throat cancer 

What about using snuff by mouth 

What about smoking a pipe 

What about smoking cigars 

Do you think there is a strong, moderate, slight 

connection between mouth and throat cancer and: 

using chewing tobacco 

using snuff by mouth 

smoking a pipe 

smoking cigars 

Pleasetell me (interviewer) whether you strongly 

agree, agree,disagree,or strongly disagree,or 

if you have no opinion on each of the following 

statements about cigarette smoking: 

everythingcausescancer anywayso it 

really doesn’t matter if you smoke 

smokingby a pregnant woman may harm the baby 

Year 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

the smokefrom someoneelse’scigarette is harmful to you 

most deaths from lung cancer are causedby 

cigarette smoking 

people who smoke low tar and nicotine cigarettes 

are lesslikely to get cancer than people who 

smoke high tar and nicotine cigarettes 

339 

1 
Topic Questionnaire item 

Cancer Control (continued) 

Smoking Habits and Tobacco Use (continued) 

if people want to smoke, they should not do so 

inside public places where it might disturb others 

How long since last smoked 

Occupational Exposure 

Exposed to any substances that would be harmful 

if you breathed them or got them on your skin 

on current job 

Knowledge of how substances affect your health 

Where did you learn that substances could affect 

your health: 

employer 

union 

health clinic at work 

magazines 

newspapers 

notices posted at work 

doctor 

television 

read container label 

other 

don’t know 

Work at least half day in office building or work mostly outside 

Are there at least five other people working in building 

Smoking allowed at work 

Smoking and non-smoking areas at work 

Employer restricts smoking to certain areas for health reasons 

Work area: 

very smoky 

somewhat smoky 

not smoky at all 

don’t know 

Smoke from other people’s cigarettes: 

very annoying 

somewhat annoying 

not at all annoying 

Height and Weight 

Height without shoes 

Weight without shoes 

When you weighed the most, how much did you weigh 

Cancer Epidemiology 

Acculturation (see Cancer Control) 

Year 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1985, 1987 

1985,1987 

1987 

Foqd Frequency 

How often usually ate/drank during past year or so: 

orange juice or grapefruit juice 

340 
Topic Questionnaire item 

Cancer Epidemiology (continued) 

Food Frequency (continued) 

other fruit juices or fortified fruit drinks 

oranges 

grapefruit 

cantaloupe in season 

apples or applesauce 

How often usually ate during the past year or so: 

beans 

carrots 

tomatoes 

green salad 

salad dressing or mayonnaise 

broccoli 

spinach 

mustard greens, turnip greens, or collards 

coleslaw, cabbage, or sauerkraut 

french fries or fried potatoes 

potatoes, baked, boiled, or mashed 

sweet potatoes or yams 

rice 

How often usually ate during the past year or so: 

hamburgers, cheeseburgers or meatloaf 

beef, such as steaks or roast 

beef stew or potpie with vegetables 

liver, including chicken liver 

pork, such as pork chops or roasts 

fried chicken 

chicken or turkey, baked, stewed or broiled 

fried fish or fish sandbiches 

spaghetti, lasagna or pasta with tomato sauce 

How often usually ate during past year or so: 

cooked cereals like oatmeal 

high fiber cereals like bran, granola, or shredded wheat 

highly fortified cereals like Product 19, Total, or Most 

other cold cereals like Rice Krispies or corn flakes 

eggs

bacon 

sausage 

How often usually ate during past year or so: 

vegetable soup, vegetable beef, minestrone or tomato soIuP 

hot dogs 

ham or lunch meats 

white breads, rolls or crackers 

dark breads 

corn bread, corn muffins, corn tortillas, or grits 

butter on bread, rolls or vegetables 

margarine on bread, rolls or vegetables 

cheese or cheese spreads, not including cottage cheese 

peanuts or peanut butter 

salty snacks like chips or popcorn 

How often usually ate during past year or so: 

ice cream 

pie 

doughnuts, cookies, cake or pastry 

Year 

1987 

1987 

1987 

1987 

1987 

341 
Topic Questionnaire item 

Cancer Epidemiology (continued) 

Food Frequency (continued) 

chocolate candy 

sugar in coffee or tea or on cereal 

whole milk or drinks made with whole milk 

2% milk or drinks made with 2% milk 

skim milk or 1% milk or buttermilk 

milk or cream in coffee or tea 

soda or soft drinks with sugar 

How often drank beer during past year or so: 

every day/daily 

number of weeks 

number of months 

number of years 

never 

Days you drank beer, how many cans, bottles or glasses dranked 

Cans, bottles, or glasses of beer small, medium, or large 

How often drank wine during past year or so: 

every day/daily 

number of weeks 

number of months 

number of years 

never 

Days you drank wine, how many glasses dranked 

Giasses of wine small, medium, or large 

How often you drank liquor during the past year or so: 

every day/daily 

number of weeks 

number of months 

number of years 

never 

Days drank liquor, how many drinks did you have 

Liquor drinks small, medium, or large 

Any period in life when you drank five or more 

drinks of any alcoholic beverage almost every day 

How long did period last: 

number of days 

number of weeks 

number of months 

number of years 

don’t know 

How often eat chicken or other poultry with skin on: 

often or always 

sometimes 

rarely 

never 

don’t eat chicken or poultry 

When eating red meat, how often eat the fat: 

often or always 

sometimes 

rarely 

never 

don’t eat red meat 

On most weekdays, how many meals eaten each day 

Year 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

342 
Topic Questionnaire item Year 

Cancer Epidemiology (continued) 

Food Frequency (continued) 

On most weekdays, how many snacks eaten each day 

On most Saturdays or Sundays, number of meals 

eaten each day 

On most Saturdays or Sundays, number of snacks 

eaten each day 

In a typical week, number of meals eaten in 

restaurants, cafeterias, or fast food places 

Vitamin and Mineral Intake 

Took vitamin or mineral supplements during past 

12 months 

Multiple vitamins taken during past 12 months 

Brand name of multiple vitamin 

Brand name taken most often during past 12 months 

Vitamin therapeutic type, stress-tab type or one-a-day type 

How many of the past 12 months did you take 

multiple vitamins 

Days per month took multiple vitamins 

Day you took multiple vitamins, how many pills 

taken per day 

Multiple vitamins taken during past month 

Took vitamin A during past 12 months 

How many of the past 12 months did you take vitamin A 

How many days per month took vitamin A 

How many vitamin A pills you usually take per day 

Units of vitamin A in each pill taken 

Vitamin A taken during past month 

Took vitamin C during past 12 months 

How many of the past 12 months did you take vitamin C 

How many days per month took vitamin C 

On the days you took vitamin C, how many pills 

did you usually take per day 

Milligrams of vitamin C in each pill taken 

Vitamin C taken during past month 

Took vitamin E during past 12 months 

How many of the past 12 months did you take vitamin E 

How many days per month took vitamin E 

How many vitamin E pills did you take per day 

Units of vitamin E in each pill taken 

Vitamin B taken during past month 

Took calcium during past 12 months 

How many days per month took calcium 

On the days you took calcium, how many pills did 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

you usually take per day 1987 

Milligrams of calcium in each pill taken 1987 

Calcium taken during past month 1987 

343 
Topic Questionnaire item Year 

Cancer Epidemiology (continued) 

Food Knowledge 

Made lasting and major changes in eating and 

drinking for health reasons 1987 

In making changes, what foods eat more of 1987 

In making changes, what foods eat less of 1987 

Changes in eating and drinking made in the past 5 years 1987 

Did you make these changes in the past year 1987 

What were changes (in way food is cooked) more or less: 

baking 

boiling 

broiling 

steaming 

fIying

stir-frying/wok 

sauteing 

grilling/barbecuing 

salting 

microwaving 

pressure-cooking 

using non-stick pans 

other 

don’t know 1987 

Agree most with what people eat or drink has 

little effect on whether they will develop 

major diseases or by eating certain kinds of 

foods, people can reduce their chances of 

developing major diseases 1987 

which major diseasesyou think are related to 

what people eat and drink 

cancer 

heart disease 

obesity/overweight 

diabetes 

hypertension/high blood pressure 

other 

none 

don’t know 1987 

Cancer related to what people eat and drink 1987 

Ever heard of foods containing fiber 1987 

Diet high, medium, or low in fiber 1987 

Diet high, medium, or low in fat 1987 

Gone on diet for weight loss or any other 

medical reason during past 12 months 1987 

Smoking Habits and Other Tobacco Use (see Smoking Habits and 

Tobacco Use in Cancer Control) 

How old were you when you stopped smoking cigarettes 1987 

For how many years (have you been/were you) a 

regular smoker (do not include the times you 

may have stayed off cigarettes) 1987 

344 
Topic Questionnaire item 

Cancer Epidemiology (continued) 

Reproduction and Hormone Use 

Given birth to a live born infant 

How many live births 

Age when first child was born: 

20 years or younger 

older than 20 years 

21 to 24 

25 to 29 

30 to 34 

35 or older 

don’t know 

Had other pregnancies lasting 6 months or more 

How many other pregnancies lasting 6 months or more 

How old were you at end of pregnancies lasting 6 months or more: 

20 years or younger 

older than 20 years 

21 to 24 

25 to 29 

30 to 34 

35 or older 

Breast-fed any children 

Age menstrual cycle began: 

younger than 10 

10 

10 to 12 

13 to 15 

16 or older 

don’t know 

Menstrual cycles stopped permanently 

Age when menstrual cycle stopped permanently: 

younger than 20 

20 to 29 

30 to 39 

40 to 44 

45 to 49 

50 to 54 

55 or older 

don’t know 

Menstrual periods stopped due to surgery 

Ever had operation to remove NONCANCEROUS lump from breast 

How many operations to remove NONCANCEROUS lump from breast 

Age when you had first operation to remove 

NONCANCEROUS lump from breast 

Ever use birth control pills 

Age when started using birth control pills 

younger than 25 

25 or older 

18 or younger 

19 to 21 

22 to 24 

25 to 29 

Year 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

345 
Topic Questionnaire item Year 

Cancer Epidemiology (continued) 

Reproduction and Hormone Use (continued) 

30 to 34 

35 or older 

don’t know 

How lqng respondent took birth 

number of days 

number of months 

number of years 

less than 1 month 

less than 1 year 

1 year or more 

3 years or less 

control pills: 

more than 3 but less than 5 years 

5 or more years 

don’t know 

Ever taken estrogen pills 

Age when started taking estrogen pills: 

younger than 2020 to 29 

30 to 39 

40 to 44 

45 to 49 

50 to 54 

55 or older 

don’t know 

How long respondent took estrogen pills: 

number of days 

number of months 

number of years 

less than 1 month 

less than 1 year 

1 year or more 

3 years or less 

more than 3 but less than 5 years 

5 or more years 

don’t know 

Brand name of estrogen pills 

Family History of Cancer 

Year of natural mother’s/father’s birth 

Mother/father still living 

Age when mother/father died 

Mother/father diagnosed by doctor as having cancer 

Kind of cancer mother/father had 

Part of mother’s/father’s body affected by cancer 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

Other type of cancer mother/father had diagnosed by doctor 1987 

Qpe of cancer first diagnosed for mother/father 1987 

Part of mother’s/father’s body affected when first diagnosed with cancer 1987 

MotherWfather’s age when cancer first diagnosed by doctor 1987 

Number of sisters respondent have (dead or alive) 1987 

Number of brothers respondent have (dead or alive) 1987 

Any sisters/brothers diagnosed by doctor as having cancer 1987 

346 
Topic Questionnaire item 

Cancer Epidemiology (continued) 

Family History of Cancer (continued) 

Kind of cancer sisters/brothers have 

Part of sisters’/brothersl body affected by cancer 

Did sister/brother have any other kind of cancer 

that was diagnosed by a doctor 

The first time sister/brother was diagnosed with 

cancer, what kind of cancer was it 

What part of the body was affected 

Age of sisters/brothers when cancer first diagnosed by doctor 

Year sisters/brothers born 

Sisters/brothers alive 

Age sisters/brothers died 

How many natural daughters respondent has (dead or alive) 

How many natural sons respondent has (dead or alive) 

Any of respondent’s natural children diagnosed 

by doctor as having cancer 

Kind of cancer natural children have 

Part of children’s body affected by cancer 

Children have any other type of cancer 

diagnosed by doctor 

Type of cancer when first diagnosed by doctor 

Part of children’s body affected when first diagnosed with cancer 

Age of children when tirst diagnosed by doctor 

Year of birth for children diagnosed with cancer 

Children still living 

At what age did child die 

Natural father/mother of children ever been 

diagnosed by a doctor as having cancer 

Is father/mother natural parent of all children 

Kind of cancer natural father/mother have 

Part of natural father’s/mother’s body affected by cancer 

Natural father/mother have any other cancer 

diagnosed by doctor 

Type of cancer natural father/mother have when 

first diagnosed by doctor 

Part of natural father’s/mother’s body affected 

when first diagnosed by doctor as having cancer 

Age of natural father/mother when cancer first 

diagnosed by doctor 

How many children are sons and how many are 

daughters (of natural father/mother) 

Cancer Survivorship 

Ever told by doctor or other health professional 

you had cancer 

Kind of cancer 

Part of body affected by cancer 

Age when cancer first diagnosed by a doctoi 

Year 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

347 
Topic Questionnaire item 

Cancer Epidemiology (continued) 

Cancer Survivorship (continued) 

Respondent ever told by doctor had any other kind of cancer 

Kind of other cancer 

Part of body affected by other cancer 

Age when other cancer was first diagnosed by doctor 

Occupational Exposure 

Kind of work done the longest (including Armed Forces) 

Most important activities or duties when doing longest kind of work 

How long respondent did work 

How old was respondent when respondent started 

doing this kind of work 

Kind of business or industry respondent did longest work in: 

an employee of a private company, business 

or individual for wages, salary, or commission 

a member of the Armed Forces 

a Federal govermnent employee 

a State government employee 

a local government employee 

self-employed in own business, professional 

practice, or farm 

is business incorporated 

working without pay in family business or farm 

Height and Weight (see Height and Weight in Cancer Control) 

Relationships and Social Activities 

Excluding spouse, how many friends can you talk 

to about private matters or can call on for help 

Excluding spouse, how many relatives can you talk 

to about private matters or can call on for help 

How many friends/relatives does respondent talk 

to at least once a month 

How often attend or participate in group meetings 

or activities, such as social clubs, PTA, sporting 

events, church groups or other community service groups 

How often respondent goes to church, temple, or 

other religious services 

Car Safety Seats 

Have you heard about child safety seats, sometimes 

called car safety carriers, which are designed to 

carry children while they are riding in a car 

Did a doctor or other health professional ever tell 

you about the importance of using car safety 

seats for your children 

When child was brought home from the hospital 

following birth, was child buckled in a car safety seat 

Does child now have a car safety seat 

Year 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1987 

1985 

1985 

1985 

1985 

348 
Topic Questionnaire item 

Car Safety Seats (continued) 

When riding in a car, is child buckled in a car safety seat: 

all or most of the time 

someof the time 

once in a whiie 

never 

When riding in a car, is seat belt worn: 

all or most of the time 

someof the time 

once in a while 

never 

Child Health (see also Car Safety Seats and Poisoning) 

Month and year your last child born 

Was child ever breastfed 

How old was child when breastfeeding completely stopped: 

still breastfed 

age in days 

age in weeks 

age in months 

age in years 

Was (child) born in a hospital or someother place 

How many nights was (.child’sbiological mother) in 

the (hospital/birthing center) during this stay 

How many nights was (child) in the (hospital/ 

birthing center) during this stay 

How much did (child) weigh at birth 

Did (child) weigh more than 5 112pounds or less 

Did (child) weigh more than 9 pounds or less 

How many months pregnant was (child’s biological 

mother) when (child) was born 

Was (child) born about when expected, or was it 

earlier or later 

About how many weeks (earlier/later) than, expected 

was (child) born 

How many weeks pregnant were you when you first 

thought you were pregnant with (child) 

Did you see or talk to a doctor to find out if 

you were pregnant 

About how many weeks pregnant were you when you 

first found out from a doctor that you were pregnant: 

4 weeks or less 

5-13 weeks 

14-27 weeks 

28 weeks or more 

don’t know 

Did you see or talk to a doctor about your pregnancy 

at any other time during that pregnancy 

How many weeks or months pregnant were you when 

you first saw a doctor about your pregnancy 

Altogether, how many pounds did you either gain 

or lose during that pregnancy 

Year 

1985 

1985 

1985 

1985 

1985 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

349 
Topic Questionnaire item Year 

Child Health (continued) 

Did (child) receive any newborn care in an 

intensive care unit, premature nursery, or any 

other type of special care unit 

How many nights did (child) stay in the special care unit 

Do you now have diabetes or sugar diabetes 

At any time during your pregnancy with (child), 

did you have: 

sugar in the urine 

high sugar in the blood 

diabetes 

When did you first notice it-was it during your 

pregnancy with (child) or before 

Did you, have the (condition) for at least 3 months 

after (child) was born 

Is child currently attending either kindergarten 

or first grade 

At what time of day does the (kindergarten/first 

grade) start 

At what time does the (kindergarten/first grade) end 

Does the kindergarten have a day care or extended 

day program that child also takes part in 

How many hours per week does child spend in 

this program 

During the past 4 weeks has child attended 

nursery or preschool 

Did the (nursery school/preschool) have a day care 

or extended day program that child also took part in 

How many hours per week did child spend in the 

nursery school/preschool (with day care) 

Have you/she worked at a job or business for 

pay in the last 4 weeks 

How many hours a week do you usually work 

Does she/do you work only while child is in 

school or does she/do you work other hours 

Other than the (nursery school/preschool), in the 

past 4 weeks, has child been cared for in any 

kind of regular child care arrangement such 

as a day care center, playgroup, by a babysitter, 

relative, or some other regular arrangement 

How was child usually cared for during the 

hours that chid care was used: 

day care center 

babysitter in child’s home 

babysitter’s home 

father cares for child 

mother cares for child while working at home 

mother cares for child while working outside of home 

child cares for self 

other relative cares for child 

day camp 

other (specify) 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

350 
,Topic Questionnaire item 

Child Health (continued) 

Other than (kindergarten/first grade/nursery 

school/preschool), how was child usually cared 

for while you worked: 

day care center 

babysitter in child’s home 

babysitter’s home 

father cares for child 

mother cares for child while working 

at home 

mother cares for child while working 

outside of home 

child cares for self 

other relative cares for child 

day camp 

other (specify) 

How is this person related to child: 

sibling 

grandparent 

other relative 

don’t know 

Where does this person usually care for 

child, in child’s home or somewhere else 

About how many hours per week was child 

usually cared for by/at (arrangements) 

Besides nursery or preschool and during the 

past 4 weeks, has child been cared for in 

any other regular child care arrangement 

Other than nursery or preschool during the past 

4 weeks, has child been cared for in any other 

regular child care arrangement: 

day care center 

babysitter in child’s home 

babysitter’s home 

father cares for child 

mother cares for child while working 

at home 

mother cares for child while working 

outside of home 

child cares for self 

other relative cares for child 

day camp 

other (specify) 

Were any other child care arrangements used 

on a regular basis 

How many additional hours a week was child care used 

Now I would like to ask you about main child care 

arrangement. Including (child), how many children 

are usually cared for together,‘in the same 

group, at the same time (Do not include children 

in entire school or program.) 

How many adults usually supervise the children 

in the same group as (child) 

Year 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

351 
Topic Questionnaire item 

Child Health (continued) 

Has the main person responsible for caring for 

(child) received education or training specifically 

related to young children, such as early childhood 

or elementary education, or child psychology 

Was (child) ever cared for in any regular child 

care arrangement 

When did (child) last receive care in a regular 

child care arrangement 

How many times has main child care arrangement 

been changed in the past year 

What was the last type of care used before (child) 

changed to the type of care is using now: 

nursery school or preschool 

nursery school or preschool with day care 

day care center 

babysitter in child’s home 

in babysitter’s home 

father cares for child 

mother cares for child while working at home 

mother cares for child while working outside of home 

summer day camp 

child cares for self 

other relative cares for child 

other (specify) 

How is this person related to (child): 

sibling 

grandparent 

other relative 

don’t know 

How old was (child) when regular child care was begun 

What type of child care arrangement was first 

used for (child): 

nursery school or preschool 

nursery school or preschool with day care 

day care center 

babysitter in child’s home 

in babysitter’s home 

father cares for child 

mother cares for child while working at home 

mother cares for child while working outside of home 

summer day camp 

child cares for self 

&her relative cares for child 

other (specify) 

How old was child’s biological mother when (child) was born 

Including (child), how many children has 

(child’s biological mother) ever had, 

do not count miscarriages or stillbirths 

Was (child) the tist born (or) second born (or third, etc.) 

How old was (child’s biological mother) when 

the first child was born 

Has (child) ever lived with (child’s) biological 

mother for at least 4 consecutive months 

Year 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

352 
Topic Questionnaire item Year 

Child Health (continued) 

In what month and year did (child) last live with her 1988 

Is she now living or deceased 1988 

How often does (child) see her: 

every day 

almost every day 

severaltimes a week ’ 

about once a week 

two or three times a month 

about once a month 

severaltimes a year 

once a year or less 

never 

don’t know 1988 

Is (child’s biological mother) now married, 

widowed, divorced, separated,or has (child’s 

biological mother) never been married 1988 

How many times altogether has (child’s 

biological mother) been married 1988 

Was (child’s biological mother) ever married 

to (child’s biological father) 1988 

In what month and year was (child’s 

biological mother) married to (child’s 

biological father) 1988 

Was (child’s biological mother’s) marriage 

to (biological father) ended by: 

death 

divorce 

separation 

annulment 

don’t know 1988 

In what month and year did (child’s biological) 

mother) stop living with (biological father) 1988 

In what month and year did the marriage to 

(child’s biological father) legally end 1988 

In what month and year did (child’s biological 

mother’s) current marriage begin 1988 

Has (child) ever lived with (child’s biological 

father) for at least 4 consecutivemonths 1988 

In what month and year did (child) last 

live with him 1988 

Is he now living or deceased 1988 

How often does (child) see him: 

everyday 

almost every day 

severaltimes a week 

about once a week 

two or three times a month 

about once a month 

severaltimes a year 

once a year or less 

never 

don’t know 1988 

353 
Topic Questionnaire item Year 

Child Health (continued) 

In what month and year did (child) move to 

this address or has (child) lived here since birth 

About how far from here is the home (child) 

lived in before (child) moved to this home: 

less than 1 mile 

1 to 50 miles 

more than 50 miles 

don’t know 

Altogether, how many times has (child) ever moved 

In what month and year did (child) begin 

living with you 

During the past 12 months, did (child) have 

an accident, injury, or poisoning that 

required medical attention 

How many accidents, injuries, or poisonings 

did (child) have in the last 12 months that 

required medical attention 

(Beginning with the most recent,) what caused 

the accident, injury, or poisoning; for example, 

was (child) hit by a car while riding a bike, 

or burned by hot liquid or did (child) swallow 

an object or pills 

Which of the conditions on this list or any 

other conditions resulted from the (cause 

of accident): 

broken or dislocated bones 

sprain, strain, or pulled muscle 

cuts, scrapes, or puncture wounds 

head injury, concussion 

bruise, contusion, or internal bleeding 

burn, scald 

poisoning from chemicals, medicines, drugs 

respiratory problem such as breathing, 

cough, pneumonia 

other 

don’t know type of condition 

none 

Were there any other conditions that resulted 

from this accident, injury or poisoning 

Where did this accident or injury or poisoning happen: 

home (not necessarily child’s) 

day care location (preschool/nursery) 

school (including grounds and athletic areas) 

street or highway 

public building or space (other than street or school) 

farm or agricultural area, except farm home 

place of recreation or sports, except at school 

other 

don’t know 

In what month and year did the accident, 

injury, or poisoning occur 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

354 
Topic Questionnaire item 

Child Health (continued) 

Does (child) now have: 

a missing finger, hand, arm, toes, foot, or leg (which is it) 

is (child) missing one or both/more than one body part 

permanent impairment, stiffness or any deformity of the back, 

foot, or leg (which is it) 

is one both/more than one body part affected 

permanent impairment, stiffness or any deformity of the fingers, 

hand, or arm (which is it) 

is one or both/more than one body part affected 

Did (child) ever have: 

repeated tonsillitis or enlargement of the 

the tonsils or adenoids 

frequent or repeated ear infections 

any kind of food or digestive allergy 

frequent or repeated diarrhea or colitis 

any other persistent bowel trouble (specify) 

diabetes 

sickle cell anemia 

anemia 

asthma 

mononucleosis 

hepatitis 

meningitis or spinal meningitis 

bladder infection or urinary tract infection 

rheumatic fever 

pneumonia 

hay fever 

any (other) kind of respiratory allergy 

deafness or trouble hearing with one or both 

ears; is it one or both ears 

blindness in one or both eyes; is it one or both eyes 

crossed eyes 

any other trouble seeing with one or both eyes, 

even when wearing glasses 

eczema or any kind of skin allergy 

epilepsy or repeated convulsions or seizures 

not associated with fever 

seizures associated with fever 

frequent or severe headaches, including migraines 

stammering or stuttering 

any other speech defect (specify) 

enuresis or bedwetting problem 

arthritis or any other joint disease or joint problem (specify) 

any other condition affecting the bone, cartilage, 

muscle, or tendon (specify) 

cerebral palsy 

congenital heart disease 

any other heart disease or condition 

any other condition that required surgery in past 

12 months (specify) 

any other condition that lasted 3 months or more (specify) 

Did (child) have condition in the last 12 months 

Has (child) had condition for at least 3 months in lifetime 

Year 

1988 

1988 

1988 

1988 

355 
Topic Questionnaire item 

Child Health (continued) 

Is it an obviously permanent condition that began 

less than 3 months ago 

How old was (child) when condition or AIP 

accident, injury and poisoning (happened/was first noticed) 

Including nursery or preschool did (child) attend 

school at all during the past 12 months 

During the past 12 months, did (conditionNIP) 

cause (child) to miss any time from school 

How many days in the past 12 months did (child) 

miss all or part of the day 

During the past 12 months, did (condition/AJP)cause 

child to stay in bed more than half of the day 

How many days in past 12 months did (child) stay 

in bed more than half of the day 

During the past 12 months, did (condition/AIP) 

limit or prevent (child) from doing usual 

childhood activities, such as playing with 

other children or participating in games or sports 

During the past 12 months, about how many nights did (child) 

spend in the hospital because of (condition/AIP) 

During the past 12 months, about how many times 

did (child/anyone) see or talk to a medical 

doctor or assistant about this (condition/AIP) 

(do not count doctors seen while an overnight 

patient in a hospital) 

During the past 12 months, did this (condition/ 

AIP) make it necessary for (child) to use any 

medicine, other than vitamins, that a doctor 

prescribed or told (child) to take 

During the past 12 months did (child) have any 

surgery performed, including bone settings and 

stitches for this (condition/AIP) 

In the last 12 months, how often did (this 

condition/the conditions) resulting from the 

(AIP) cause (child) pain or discomfort or upset: 

all of the time 

often 

once in a while 

never 

When this condition did bother (child), was (child) 

bothered: 

a great deal 

some 

very little 

Did the (condition) result from an accident, 

injury, or poisoning 

Did this occur within the last 12 months 

Which accident, injury, or poisoning was it 

What kind of accident or injury or poisoning was it 

Does (child) wear glasses or contact lenses 

Year 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 
Topic Questionnaire item Year 

Child Health (continued) 

About how long has it been s@e (child) 

last saw someone for dental care: 

6 months ago or less 

over 6 months to 12 months 

over 12 months to 2 years 

over 2 years to 5 years 

more than 5 years 

never 

don’t know 

When riding in a car, does (child) wear a 

seat belt or restraint: 

all or most of the time 

some of the time 

once in a while 

never 

don’t know 

Did you smoke cigarettes at all during the 

year before (child) was born 

Did you continue to smoke during the entire pregnancy 

Did you stop during the first 3 months of 

the pregnancy or later 

About how many cigarettes a day did you usually smoke 

Do you now smoke 

How long ago did you stop: 

number of days 

number of months 

number of years 

never smoked 

During most of your pregnancy, would you say you were 

in contact with persons who smoked cigarettes 

such as friends, co-workers or family members: 

occasionally 

often 

always 

never 

Has anyone in your household smoked regularly 

since (child) was born 

Is anyone in the household currently smoking cigarettes 

How long has it been since anyone in the 

household smoked cigarettes 

Please tell me (interviewer) whether each of the 

following statements about (child’s) health 

is mostly true or mostly false: 

health is excellent 

seems to resist illness very well 

seems less healthy than other children I know 

when there is something going around (child) 

usually catches it 

is somewhat clumsy 

seems accident-prone 

when (child) is sick or injured, (child) 

usually recovers quickly 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

357 
Topic Questionnaire item 

Child Health (continued) 

Has (child) ever been seriously ill 

Was (child) ever so sick that you thought (child) might die 

On weeknights, (if over 4, during the school year), 

does (child) usually go to bed at about the 

same time each night, or does (child’s) 

bedtime vary a lot from night to night 

About what time does (child) usually go to bed 

What is the latest time that (child) goes to bed on weekdays 

Does (child) usually sleep in one room or in different rooms 

Does (child) usually sleep alone in a room or share a room 

Who usually sleeps in the room with (child): 

brother(s) 

sister(s) 

other child(ren) 

father 

mother 

other adult(s) 

anyone else 

don’t know 

Has (child) ever attended school 

Is (child) now either going to school or on 

vacation from school 

What grade (is child in now/will child be in) 

Overall what kind of student would you say 

(child) is now, is (child): 

one of the best 

above the middle 

in the middle 

below the middle’ 

near the bottom 

Why did (child) stop going to school: 

never went-health reasons 

never went-other reasons 

graduated 

health problem 

dropped out 

other (specify) 

How long ago did (child) stop going to school: 

less than 12 months 

12 months-less than 2 years 

2 or more years 

During the past 12 months, that is, since (date) 

a year ago, about how many days was (child) 

absent from school because of illness 

Has (child) repeated any grades for any reason 

What grade or grades did (child) repeat 

Why did (child) repeat the grade(s): 

academicfailure 

immature/acted too young 

frequent absence 

moved into more difficult school 

other (specify) 

Year 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 
Topic Questionnaire item 

Child Health (continued) 

any’other reasons 

don’t know 

Has (child) ever been suspended, excluded, or 

expelled from school 

How many times has this happened 

Was it for health or behavior reasons 

Not counting routine conferences, has anyone from (child’s) 

school ever asked someone to come in to 

talk about problems (child) was having 

How long ago was the last time: 

number of days 

number of weeks 

number of months 

number of years 

Has (child) ever had: 

a delay in growth or development 

a learning disability 

an emotional or behavioral problem that 

lasted 3 months or more 

How old was (child) when the (condition) was 

first noticed 

Has (child) ever received treatment or counseling 

for the (condition) 

Has (child) received any such treatment or counseling 

during the past 12 months 

During the past 12 months, about how many times did 

anyone see or talk to a doctor, psychologist, or 

counselor about this problem 

During the past 12 months, did the (condition) 

cause (child to miss any time from school) 

On how many days in the past 12 months, did (child) miss part or 

all of the school day because of this problem 

During the past 12 months, did the (condition) 

make it necessary for (child) to attend special classes, 

or a special school, or get special help at school 

During the past 12 months, has (child) been taking 

any medicine for the (condition) 

Has (child) ever seen a psychiatrist, psychologist, doctor, 

or counselor about any emotional, mental, or behavior problem 

When was the last time (child) saw this person 

During the past 12 months, have you felt, or has 

anyone suggested, that (child) needed help for 

any emotional, mental, or behavorial problem 

How long has it been since (child’s) last visit to 

a clinic, health center, hospital, d@or’s office 

or other place for routine health care: 

lessthan 6 months 

6 months, less than 1 year 

1 year, less than 2 years 

2 years, less than 5 years 

5 or more years 

Year 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

359 
Topic Questionnaire item 

Child Health (continued) 

don’t know 

never 

Is there a particular clinic, health center, 

hospital, doctor’s office or other place that 

(child) usually goes to for routine health care 

What kind of place is it: 

clinic: 

private 

hospital 

outpatient 

company or school 

migrant 

some other kind of health clinic 

health center: 

community health center 

neighborhood health center 

family health center 

walk-in/emergency clinic 

rural health center 

HMO/prepaid group 

some other kind of health center 

hospital: 

outpatient clinic 

emergency room 

doctor’s office or private clinic 

other place (specify) 

Is there a particular clinic, health center, hospital, 

doctor’s office or other place that (child) usually 

goes to when (child) is sick or injured 

Is this the same kind of place (see above list) 

or is it somewhere else 

Is there a particular medical person (child) 

usually seesat the (place) when (child) is sick 

Is there someone at the (place), that knows about (child’s) 

health history who will give you advice over the telephone 

Many people do not have a particular place they 

usually go to when they are sick. (Could you please 

give me (interviewer) the number of the statement) 

which is the main reason (child) does not have a 

particular place (child) usually goes: 

has two or more usual doctors or places 

depending on what is wrong 

has not needed a doctor 

previous doctor no longer available 

have not been able to find the right doctor 

recently moved to area 

other reason 

During the past 12 months, that is since (12-month 

date) a year ago, did (child) receive any health 

care which has been or will be paid for by Medicaid 

During the past I2 months, was (child) covered 

at any time by Medicaid 

Year 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

360 
Topic Questionnaire item Year . 

Child Health (continued) 

During the past 12 months, did (child) receive 

assistance through “Aid to Families with Dependent 

Children” program, sometimes called AFDC or ADC 

Is (child) now covered by a health insurance 

plan which pays any part of a hospital, doctor’s 

or surgeon’s bill 

Has (child) ever been enrolled in the “Head Start” program 

In which “Head Start” program was (child) enrolled, 

the Center based or the Home based program 

Please tell me (interviewer) whether each of the 

following statements are often true, sometime 

true, or not true of (child) during the past 3 months: 

has sudden changes in mood or feelings 

feels or complains that no one loves (child) 

is rather high strung, tense, or nervous 

cheats or tells lies 

is too fearful or anxious 

argues too much 

has difficulty concentrating, cannot pay 

attention for too long 

is easily confused, seems to be in a fog 

bullies, or is cruel or mean to others 

is disobedient at home 

is disobedient at school 

does not seem to feel sorry after (child) misbehaves 

has trouble getting along with other children 

has trouble getting along with teachers 

is impulsive, or acts without thinking 

feels worthless or inferior 

is not liked by other children 

has a lot of difficulty getting (child’s) 

mind off certain thoughts, has obsessions 

is restless or overly active, cannot sit still 

is stubborn, sullen, or irritable 

has a very strong temper and loses it easily 

is unhappy, sad or depressed 

is withdrawn, does not get involved with others 

breaks things on purpose, deliberately destroys 

(child’s) own or others’ things 

clings to adults 

cries too much 

demands a lot of attention 

is too dependent on others 

feels others are out to get (child) 

hangs around with kids who get into trouble 

is secretive, keeps things to (himself/herself) 

worries too much 

How is (name of person) related to (child) 

Is (name of sibling) -full, half, adoptive, 

step or foster (brother/sister) 

Which family member know the most about the 

health related matters of (child) 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

361 
Topic Questionnaire item Year 

Cholesterol 

Have you ever been told by a doctor or other 

health professional that you had high cholesterol 

DeMal Care 

Have you ever heard of dental sealants 

Which of the following best describes the purpose 

of dental sealants: 

to prevent gum disease 

to prevent tooth decay 

to hold dentures in place 

Tell me (interviewer) if you think it is definitely 

important, probably important, probably not, or 

definitely not important in preventing tooth decay: 

seeing dentist regularly 

drinking water with fluoride from early childhood 

regular brushing and flossing of the teeth 

using fluoride toothpaste or fluoride mouth rinse 

avoiding between-meal sweets 

In your opinion, how important or not important is 

each of the following in preventing gum disease: 

seeing dentist regularly 

drinking water with fluoride from early childhood 

regular brushing and flossing of the teeth 

using fluoride toothpaste or fluoride mouth rinse 

avoiding between-meal sweets 

In your opinion which of the following is the 

main cause of tooth loss in children: 

tooth decay 

gum disease 

injury to the teeth 

In your opinion which of the following is the main 

cause of tooth loss in adults: 

tooth decay 

gum disease 

injury to the teeth 

What is the purpose of adding fluoride to the 

public drinking water 

Does the water that you drink at home come from a 

public water system or another source, such as a well 

Does this drinking water have fluoride in it 

During the 2 weeks (outlined on calendar) did anyone 

in the family go to a dentist (include all types) 

During those 2 weeks, how many times did person 

go to a dentist 

During the past 12 months, how many visits did 

person make to a dentist 

How long since last went to a dentist: 

over 2 weeks, less than 6 months 

6 months, less than 1 year 

1 year, less than 2 years 

2 years, less than 5 years 

1985 

1985 

1985 

1985 

1985 

1985 

1985 

1986 

1986 

1986 

1986 

1986 

1986 

362 
Topic Questionnaire item 

Dental Care (continued) 

5 years or more 

never 

What was the main reason person last went to the dentist: 

went in on own for check-up, examination, or cleaning 

was called in by the dentist for check-up, 

examination,or cleaning 

something was wrong, bothering, or hurting 

went for treatment of a condition that dentist 

discovered at earlier check-up or examination 

other (specify) 

don’t know 

Anyone in family lost all of his or her natural teeth 

What does person use when brushing teeth, 

toothpaste, tooth powder, or something else 

What brand did persons use most often during the past 2 weeks 

Anyone in family now use a fluoride mouthrinse at home 

What brand did person use most often in the past 2 weeks 

Does person now take part in a fluoride mouthrinse program at school 

Does anyone in the family now take vitamins with fluoride 

in them or any other kind of fluoride drops, 

pills, or tablets at home or school 

Anyone in family had dental sealants placed on their teeth 

During those 2 weeks did anyone in the family 

go to a dentist (include all types of dentists, 

such as orthodontists, oral surgeons, and all other 

dental specialists, as well as dental hygienists) 

Who was this 

During those 2 weeks, did anyone else in the 

family go to a dentist 

During those 2 weeks, how many times did (name) 

go to a dentist 

During the past 12 months (that is, since (12-month 

date) a year ago), about how many visits did 

(name) make to a dentist (include the number 

of visits you already told me about) 

About how long has it been since (name) last 

went to a dentist: 

2 weeks 

over 2 weeks, less than 6 months 

6 months, less than 1 year 

1 year, less than 2 years 

2 years, lessthan 5 years 

5 years or more 

never 

What are the reasons (name) has (not visited the 

dentist in over 12 months/never gone to the dentist): 

afraid 

nervous 

needles 

cost 

don’t know dentist 

dentist too far 

Year 

1986 

1986 

1986 

1986 

1986 

1986 

1986 

1986,1989 

1986 

1986 

1989 

1989 

1989 

1989 

1989 

1989 

363 
Topic Questionnaire 

Dental Care (continued) 

can’t get there 

no problems 

no teeth 

not important 

didn’t think of it 

other (specify) 

don’t know 

Is there anyone in the family who has lost all 

of upper (permanent) natural teeth 

Who is this 

Does (name) have an upper denture or plate 

Is there anyone in the family who has lost all 

of his or her lower (permanent) natural teeth 

Who is this 

Does (name) have a lower denture or plate 

Dental sealants are special plastic coatings that 

are painted on the tops of the back teeth to 

prevent tooth decay, they are different from 

fillings, caps, crowns, and fluoride treatments, 

has anyone in the family ever had dental 

sealants painted on their teeth 

Who is this 

In the past 2 weeks has anyone in the family 

used a mouthwash or mouthrinse at home 

Who is this 

What brand did (name) use most often during 

the past 2 weeks: 

Act 

Flurigard 

Kdynos 

Listermint 

Reach 

StanCare 

Prescription fluoride rinse 

PLAX 

Scope, Listerine, Lavoris 

other (specify) 

don’t know 

Does this mouthrinse contain fluoride 

‘Does (name) now take vitamins with fluoride 

in them or any other kind of fluoride tablets, 

drops, or supplements 

During the 2-week period, did anyone in the family 

miss any time from work or school because of 

a dental problem or dental visit 

Who was this 

How much time did (name) miss because of a 

dental problem or dental visit: 

less than 1 hour 

1 hour, less than 3 hours 

3 hours, less than 5 hours 

item Year 

1989 

. 1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

364 
Topic Questionnaire item Year 

Dental Care (continued) 

5 hours, less than 7 hours 

7 hours or more 

During that 2-week period, did anyone in the 

family miss any time from work or school 

to assist a relative or friend with a dental 

problem or dental visit 

Who was this 

How much time did (name) miss because (name) 

was assisting a relative or friend with a dental 

problem or visit: 

less than 1 hour 

1 hour, less than 3 hours 

3 hours, less than 5 hours 

5 hours, less than 7 hours 

7 hours or more 

Was there any (other) time during those 2 weeks 

Did anyone in the family cut down on normal 

activities for more than half of the day 

because of a dental problem or dental visit 

Who was this 

During that period, how many (other) days did 

(name) cut down for more than half of the 

day because of a dental problem or dental visit 

Diabetes 

Do you now have diabetes or sugar diabetes 

Has any adult in this family ever been told by 

a doctor that they had diabetes (do not include 

pre, potential, or borderline diabetes) 

Who is this 

Has any other adult in this family been told 

they have diabetes (do not include pre, 

potential, or borderline diabetes) 

How old were you when you got diabetes (do not 

include pre, potential, or borderline diabetes) 

Are you now diabetic 

When you first learned that you might have diabetes, 

were you sick or feeling diabetic symptoms, 

or was the diabetes discovered by chance 

Were you at: 

doctor’s office 

patient in hospital 

somewhere else 

don’t know 

Was the diabetes discovered while getting: 

routine physical 

screening test for diabetes 

treated for something else 

other 

don’t know 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

198.5 

1989 

1989. 

1989 

1989 

1989 

1989 

1989 

1989 

. 

365 
Topic Questionnaire item Year 

Diabetes (continued) 

When your diabetes was first diagnosed, did you have: 

blood test 

urine test 

both 

don’t know 1989 

Was the blood test an oral glucose tolerance test 1989 

Were you pregnant when you were first told 

that you had diabetes 1989 

Other than during pregnancy, did a doctor 

ever tell you that you had diabetes 1989 

Are you now taking insulin 1989 

For how long have you been taking insulin: 

less than 1 month 

number of months 

number of years 

don’t know 1989 

Currently, about how often do you use insulin: 

times per day 

times per week 

use insulin pump 

don’t know 1989 

On an average day, about how many units of 

insulin do you take 1989 

Have you ever used an insulin pump 1989 

Are you now taking diabetes pills to lower your blood sugar 1989 

For how long have you been taking them: 

less than 1 month 

number of months 

number of years 

don’t know 1989 

About how often do you take them: 

times per day 

times per week 

don’t know 1989 

Has a doctor or other health professional ever 

given you a diet or instructions on what foods 

you should eat as a diabetic 1989 

In the past 12 months, have you tried to follow 

the diet or instructions 1989 

In the past 12 months, about how often have you 

been able to follow the diet or instructions: 

always 

most of the time 

some of the time 

rarely 

never 

don’t know 1989 

Is it difficult for you to stay on your diet: 

when you eat in restaurants 

when you go to parties or social events 

when you are busy with other activities 

when you go on a trip 
Topic Questionnaire item 

Diabetes (continued) 

when you are feeling upset or angry 

when you are feeling sad, depressed,or blue 

when you are feeling bored 

Do you (also) find it difficult to stay on your diet: 

becausefoods you should eat do not taste good 

becauseyou cravefoods not on your diet 

becauseyou have to prepare food separatelyfor yourself 

becauseof lack of help or support from your family or friends 

becauseyou are unsure about what foods you should eat 

How important do you think what you eat or drink 

is in controlling your diabetes: 

very important 

somewhatimportant 

not important 

don’t know 

Is there one doctor you usually seefor your diabetes 

How many times haveyou seen this doctor in the 

past 12 months 

Which of the following did you seein the past 

12 months for any reason: 

a cardiologist or heart doctor 

an opthalmologist, that is, a medical doctor 

who specializesin eye care 

an obstetrician or gynecologist 

a podiatrist or foot doctor 

a psychologistor psychiatrist 

a dietitian or nutritionist 

any other medical doctor (specify) 

About how many times in the past 6 months has 

a health professional checked your urine for 

glucose or sugar (do not count times when an 

overnight patient in the hospital) 

On your own, about how often do you check your 

urine for glucose or sugar (include times 

when checked by a family member or friend): 

never 

number of times per day 

number of times per week 

number of times per month 

number of times per year 

don’t know 

Based on all your urine tests during the past 6 

months, how often would you sayyou have had 

glucose or sugar in your urine: 

always 

most of the time 

someof the time 

rarely 

never 

don’t know 

Have you been tested for ketones in the past 6 months 

Were any of these tests.positive 

Year 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

367 
Topic Questionnaire item Year 

Diabetes (continued) 

About how many times in the past 6 months has a 

health professional checked your blood for 

glucose or sugar (do not count times when an 

overnight patient in a hospital) 

On your own, about how often do you check your 

blood for glucose or sugar (include times when 

checked by a family member or friend): 

never 

number of times per day 

number of times per week 

number of times per month 

number of times per year 

don’t know 

Based on all your blood sugar tests during the past 

6 months, how often would you say your blood 

sugar level has been too high: 

always 

most of the time 

some of the time 

rarely 

never 

don’t know 

Have you ever heard of glycosylated hemoglobin 

or hemoglobin ‘A one C” 

About how many times in the past 6 months has a 

doctor, nurse, or other health professional checked 

you for glycosylated hemoglobin “A one C” 

About how many times in the past 6 months has a 

health professional checked your feet for any 

sores or irritations 

About how often do you check your feet for sores 

or irritations: 

never 

number of times per day 

number of times per week 

number of times per month 

don’t know 

During the past 6 months have you had any sores or 

irritations on your feet or ankles that did 

not heal normally 

When was the last time you had an eye exam in.which 

the pupils were dilated (this would have made 

you temporarily sensitive to bright light): 

less than 1 month 

1 to 12 months 

13 to 24 months 

more than 2 years 

never 

don’t know 

Have you had any kind of eyeexamby a doctor 

within the past 2 years 

Have you had any kind of eye exam by a doctor 

within the past 12 months 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

368 
Topic Questionnaire item 

Diabetes (continued) 

Have you ever been told that diabetes has affected 

the back of your eyes,,that is, the retina 

How old were you when the doctor first told you this 

Have you ever had laser or photocoagulation treatment 

for this problem (do not include treatment for cataracts) 

Did you receive this treatment within the 

past 12 months 

Was this the first time you had this treatment 

Have you ever had photographs taken of the 

retina or inside of your eyes 

Do you have serious trouble seeing with one 

or both eyes even when wearing glasses 

About how many times in the past 12 months 

has a doctor or other health professional 

checked your blood pressure (do not count 

times when an overnight patient in a hospital) 

Has a doctor ever told you that you had high 

blood pressure or hypertension 

Are you doing any of the following (for your/to 

prevent) high blood pressure: 

taking prescribed medication 

losing weight or controlling weight 

cutting down on salt or sodium 

getting physical activity or exercise 

The last time you had your blood pressure 

checked, were you told it was: 

high 

borderline 

low 

normal 

were you not told 

Has a doctor ever told you that you had: 

glaucoma 

angina 

any other heart trouble 

a stroke 

cataracts 

protein or albumin in your urine 

periodontal or gum disease . 

Are you now taking any medication for any of 

these (glaucoma, angina, other heart trouble) 

Has a doctor ever told you that you had: 

protein or albumin in your urine 

kidney disease (do not include kidney 

stone or bladder infection) 

polycystic kidney disease 

periodontal or gum disease 

Not counting times while an overnight patient in a hospital, 

about how many times in the past 12 months 

has a doctor or other health professional: 

checked you for diabetes 

checked your blood pressure 

Year 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

: 

1989 

1989 

1988 

1989 

1989 

1989 

1989 

1989 

369 
Topic Questionnaire item 

Diabetes (continued) 

About how many different times in the past 12 months 

have you had a bladder or urinary tract infection 

Have you ever had symptoms of a bladder infection 

that lasted more than 3 months, such as 

frequent urination and pain in your bladder 

When you had these symptoms, were you told that 

you had painful bladder syndrome or interstitial cystitis 

How old were you when you first told that you 

had painful bladder syndrome or interstitial cystitis 

When you urinate: 

do you usually have trouble starting 

.do you usually feel like you have not completely 

emptied your bladder 

Do you usually have to get up at night to go to 

the bathroom to urinate (exclude nights when 

you drink a lot of liquids) 

About how many times each night do you have to get up 

During the past 3 months have you had: 

numbness or loss of feeling in your hands or 

feet other than from your hands or feet falling asleep 

a painful sensation or tingiing in your hands or feet (do not include 

normal foot achesfrom standing or walking for long periods) 

decreased ability to feel hot or coId in things you touch 

Have you tried to lose weight in the past year 

Is your weight now more, less, or about the 

sameas a year ago 

In the past year, about how much weight haveyou 

(gained/lost) 

About how much did you weigh when you were 25 years old 

(if pregnant, weight just before becoming pregnant) 

What is the most you have ever weighed (except 

when you were pregnant) 

About how old were you when you first weighed that much 

Do you have serious trouble seeing with one or both 

eyes even when wearing glasses 

Where have you obtained information about diabetes: 

nowhere 

doctor’s office -doctor 

doctor’s office-nurse 

dietitian or nutritionist 

doctor or nurse in a hospital 

relative or friend 

another diabetic 

health department 

diabetes organization 

National Diabetes Information Clearinghouse 

diabetessupport group 

library 

newspapers 

diabetes education class 

other (speci@) 

Year 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

370 
Topic Questionnaire item Year 

Diabetes (continued) 

Which three of these sources have provided you with 

the most useful information about diabetes: 

doctor’s office -doctor 

doctor’s office-nurse 

dietitian or nutritionist 

doctor or nurse in a hospital 

relative or friend 

another diabetic 

health department 

diabetes organization 

National Diabetes Information Clearinghouse 

diabetes support group 

library 

newspapers 

diabetes education class 

other (specify) 

Have you ever taken a course or class in how to 

manageyour diabetesyourself 

About how many hours of instruction did you 

receive on how to manage your diabetes 

Did this course include any of the following subjects: 

how to inject insulin 

how to change the insulin dose 

how to manage your diabetes when you are sick 

how to test your blood or urine for sugar 

how to plan meals 

how to take care of your feet 

Have you ever attended any (other) education 

program or class about your diabetes 

Were either of your parents ever told that they had 

diabetes (do not include pre, potential, or 

borderline diabetes or step, adoptive, or foster 

parents) Which one 

How many children have you had, including any that 

may have died (do not include step, adoptive, or 

foster children/stillbirths or miscarriages) 

Digestive Disorders (see also Abdominal Pain) 

During the past 12 months, did you have gallstones 

During the past 12 months, did you have any other 

gallbladder trouble 

Have you ever had gallstones 

Have you ever had any other gallbladder trouble 

When did a doctor first tell you that you had 

(gallstones/gallbladder trouble): 

less than 3 months ago 

3 months, less than 1 year 

1 year, less than 2 years 

2 years, less than 5 years 

5 years, less than 10 years 

10 years or more 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

371 
ToDic Questionnaire 

Digestive Disorders (continued) 

doctor never seen 

don’t know when 

Have you ever had gallbladder surgery 

When did you last have gallbladder surgery: 

less than 3 months ago 

3 months, less than 1 year 

1 year, less than 2 years 

2 years, less than 5 years 

5 years, less than 10 years 

10 years or more 

don’t know when 

Have you ever had any of the following tests to help 

diagnose your (gallstones/gallbladder) condition: 

an X-ray of your gallbladder or abdomen 

a sonogram or ultrasound of your gallbladder 

an upper GI series 

During the past 12 months, did you have an ulcer 

Have you ever had an ulcer 

When did a doctor first tell you that you had an ulcer: 

less than 3 months ago 

3 months, less than 1 year 

1 year, less than 2 years 

2 years, less than 5 years 

5 years, less than 10 years 

10 years or more 

doctor never seen 

don’t know when 

Did the doctor say you had a gastric, duodenal, or 

peptic ulcer, some other type, or were you not told: 

skin 

gastric 

duodenal 

peptic 

stomach 

not told 

other (specify) 

don’t know 

Have you ever had any of the following tests to 

help diagnose your ulcer: 

an upper GI series 

an upper endoscopy or gastroscopy 

During the past 12 months, did you have diverticulitis 

Have you ever had divekiculitis 

When did a doctor first tell you that you had 

diverticulitis: 

less than 3 months ago 

3 months, less than 1 year 

1 year, less than 2 years 

2 years, less than 5 years 

5 years, less than 10 years 

10 years or more 

doctor never seen 

don’t know when 

item Year 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

372 
Topic Questionnaire item 

Digestive Disorders (continued) 

Have you ever been in the hospital overnight 

for diverticulitis 

When were you last in the hospital overnight 

for diverticulitis: 

lessthan 3 months ago 

3 months, lessthan 1 year 

1 year, lessthan 2 years 

2 years, lessthan 5 years 

5 years,lessthan 10 years 

10 years or more 

don’t know when 

Have you ever had a barium enema to help diagnose 

your diverticulitis 

During the past 12 months, have you had a spastic 

colon, functional bowel, irritable colon or 

irritable bowel syndrome 

Which one: 

spasticcolon 

functional bowel 

irritable colon 

irritable bowel syndrome 

other similar condition mentioned (specify) 

Have you ever had: 

spasticcolon 

functional bowel 

irritable colon 

irritable bowel syndrome 

other similar condition mentioned (specify) 

Which one: 

spasticcolon 

functional bowel 

irritable colon 

irritable bowel syndrome 

other similar condition mentioned (specify) 

When did a doctor first tell you that you had 

(condition): 

lessthan 3 months ago 

3 months, lessthan 1 year 

1 year, lessthan 2 years 

2 years, lessthan 5 years 

5 years,lessthan 10 years 

10 years or more 

doctor never seen 

don’t know when 

Have you had hemorrhoids in the past 12 months 

Has a doctor ever told you that you had hemorrhoids 

When did you last talk to a doctor about your 

hemorrhoids: 

lessthan 3 months ago 

3 months, lessthan 1 year 

1 year, lessthan 2 years 

2 years,lessthan 5 years 

5 years,lessthan 10 years 

Year 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

373 
Topic Questionnaire item 

Digestive Disorders (continued) 

10 years or more 

doctor never seen 

don’t know when 

. Have you ever had surgery in a doctor’s office, 

clinic, or hospital for hemorrhoids 

Doctor Visit (see Usual Source of Care) 

Is there one particular doctor you usually see 

When visiting a doctor or other health professional for 

routine care, are proper foods discussed: 

often 

sometimes 

rarely 

never 

Drinking (see also Alcohol) 

Tell me (interviewer) if you think heavy alcohol 

drinking definitely increases, probably increases, 

probably does not, or definitely does not increase 

a person’s chances of getting the following problems: 

throat cancer 

cirrhosis of the liver 

bladder cancer 

cancer of the mouth 

arthritis 

blood clots 

Have you had at least one drink of beer, wine, or 

liquor during the past year 

What is your main reason for not drinking 

(in the past year): 

no need/not necessary 

don’t care for/dislike it 

medical/health reasons 

religious/moral reasons 

brought up not to drink 

costs too much 

family member an alcoholic or problem drinker 

infrequent drinker 

other (specify) 

In the past 2 weeks beginning Monday and ending 

this past Sunday, on how many days did you 

drink any alcoholic beverages, such as beer, wine, or liquor 

On the days that you drank alcoholic beverages, 

how many drinks did you have per day, on the average 

Was the amount of your drinking during that 

2-week period typical of your drinking during 

the past 12 months 

Was the amount of your drinking during that 2-week 

period more or less than your drinking during 

the past 12 months 

Year 

1989 

1989 

1985 

1985 

1985 

1985 

1985 

1985 

1985 

1985 

1985 

374 
Topic Questionnaire item Year 

Drinking (continued) 

During the past 12 months, in how many months did you 

have at least one drink of any alcoholic beverage 1985 

During (that month/those months) on how many days 

did you have 9 or more drinks of any alcoholic beverage 1985 

During (that month/those months) on how many days 

did you have 5 or more drinks of any alcoholic beverage 1985 

During the past year, how many times did you drive 

when you had perhaps too much to drink 1985 

Do you think heavy alcohol drinking definitely 

increases, probably increases, probably does not, 

or definitely does not increase a person’s chances 

of getting the following problems: 

throat cancer 

cirrhosis of the liver 

bladder cancer 

cancer of the mouth 

arthritis 

blood clots 1985 

Does heavy drinking during pregnancy definitely 

increase, probably increase, probably not, or 

definitely not increase the chances OE 

miscarriage 

mental retardation of the newborn 

low birth weight of the newborn 

birth defects 1985 

Have you ever heard of Fetal Alcohol Syndrome 1985 

In your opinion, which one of the following best 

describes Fetal Alcohol Syndrome: 

a baby is born drunk 

born addicted to alcohol 

born with certain birth defects 1985 

Eating Habits (see also Cancer) 

How often do you eat breakfast: 

almost every day 

sometimes 

rarely 

never 1985 

How often do you eat between meals: 

almost every day 

sometimes 

rarely 

never 1985 

When you visit a doctor or other health professional 

is eating proper foods discussed: 

often 

sometimes 

rarely or never 

don’t visit for routine care 1985 

375 
Topic Questionnaire item 

Emotional/Personal Problems (see also Cancer and Mental Health) 

In the past year, did you think about seeking help 

for any personal or emotional problems from 

family or friends 

In the past year, did you think about seekinghelp for 

any personal or emotional problems from a 

helping professional or a self-help group 

Did you actually seek any help (for emotional 

problems) 

From whom did you seek help (for emotional 

problems): 

family member or relative 

friend 

psychologist 

psychiatrist 

psychiatric social worker 

other mental health professional 

medical doctor 

religious counselor 

Alcoholics Anonymous 

Gamblers Anonymous 

Weight Watchers 

counselor at work 

counselor at school 

probation officer 

other (specify) 

Employment (see also Work Injuries and Work Risk) 

The kind of work you have done the longest, not 

counting work around the house. What kind of work 

did you do the longest (include work done while 

in the Armed Forces) 

When you were doing this kind of work, what were 

your most important activities or duties 

How long did you do this kind of work 

How old were you when you started doing this kind of work 

In what kind of business or industry did you do this 

kind of work the longest, were you: 

an employee of a private company, business or 

individual for wages, salary, or commission 

a member of the Armed Forces 

a Federal government employee 

a State government employee 

a local government employee 

self-employed in own business, professional 

practice or farm 

working without pay in family business or farm 

Was the worker’s compensation claim for your injury 

awarded, denied, or is it still in process 

Was the worker’s compensation claim for your skin 

condition awarded, denied, or is it still in process 

Year 

1985 

1985 

1985 

1985 

1986,1988 

1988 

1986, 1988 

1988 

1986,1988 

1988 

1988 

376 
Topic Questionnaire item 

Employment (continued) 

Was the worker’s compensation claim for your 

condition awarded, denied, or is it still in process 

In the industry where you worked the longest as a 

(name of occupation) were you: 

an employee of a private company, business or individual 

for wages, salary, or commission 

a member of the Armed Forces 

a Federal government employee 

a State government employee 

a local government employee 

self-employed in own business, professional 

practice or farm 

is the business incorporated 

working without pay in family business or farm 

During the past 12 months, that is, since (12-month 

date) a year ago, did you work at any time at a 

job or business, not counting work around the house 

(include unpaid work in the family business or farm) 

How’long has it been since you last worked at a job or 

business: 

number of weeks 

number of months 

number of years 

For whom did you work at your last job or business 

What kind of business or industry is this 

What kind of work were you doing 

What were your most important activities or duties at that job 

Were you: 

an employee of a private company, business or individual 

for wages, salary, or commission 

a member of the Armed Forces 

a Federal government employee 

a State government employee 

a local government employee 

self-employed in own business, professional 

practice or farm 

is business incorporated 

working without pay in family business or farm 

How long did you work as a (name of occupation) for 

(name of employer): 

number of weeks 

number of months 

number of years 

Considering all of your employers, for how many years 

altogether did you do this kind of work 

Which of these statements describe the reason or 

reasons you stopped working: 

stopped working because of own illness, injury, disability or 

other health problem that was job-related 

stopped working becauseof own illness, injury, disability or 

other health problem that was not job-related 

retired 

child/family care 

Year 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

377 
Topic Questionnaire item 

Employment (continued) 

on layoff from job 

some other reason (specify) 

don’t know 

Was a worker’s compensation claim filed for your 

illness, injury, disability, or other health problem 

Have you received any money or other benefits from 

worker’s compensation since you stopped working 

(number of weeks, months, years) ago 

Was a claim filed for any other income or benefits 

because your health problem was job-related 

Earlier I was told that you had a job during the 2 

weeks (outlined on the calendar/beginning Monday (date) 

and ending Sunday (date)). For whom did you work 

Exercise 

In the past 2 weeks begnming Monday (date) and ending 

this past Sunday (date), have you done any (of the 

following exercises, sports, or physically active hobbies): 

walking for exercise 

jogging or running 

hiking 

gardening or yard work 

aerobics or aerobic dancing 

other dancing 

calisthenics or general exercise 

golf 

tennis 

bowling 

biking 

swimming or water exercises 

yoga

weight lifting or training 

basketball 

baseball or softball 

football 

soccer 

volleyball 

handball, racquetball, or squash 

skating 

skiing 

Have you done any other exercises, sports, or 

physically active hobbies in the past 2 weeks 

In the past 2 weeks beginning Monday (date) and 

ending this past Sunday (date), have you done any 

exercises, sports, or physically active hobbies 

What were the (exercises, sports, or physically active hobbies) 

Knowledge of strengthening heart and lungs through exercise 

How many days a week do you think a person should 

exercise to strengthen the heart and lungs 

For how many minutes do you think a person should exercise on each 

occasion so that the heart and lungs are strengthened 

Year 

1988 

1988 

1988 

1988 

1988 

1985 

1985 

1985 

1985 

1985 

1985 

1985 

378 
Topic Questionnaire item Year 

Exercise (continued) 

During those minutes (of exercise),how fast do you 

think a person’s heart rate and breathing should 

be to strengthen the heart and lungs 

Do you think that the heart and breathing rate 

(for exercise)should be: 

no faster than usual 

a little faster than usual 

a lot faster but talking is possible 

so fast that talking is not possible 

don’t know 

Do you exerciseor play sports regularly 

For how long haveyou exercisedor played sports 

regularly: 

number of days 

number of weeks 

number of months 

number of years 

How much hard physical work is required on 

your job: 

a great deal 

a moderate amount 

a little 

none 

About how many hours per day do you perform 

hard physical work on your job 

How much hard physical work is required in your main 

daily activity: 

a great deal 

a moderate amount 

a little 

none 

Functional Limitations 

Because of a health or physical problem, do you have 

any difficulty (by yourself and without using 

special equipment): 

bathing or showering 

dressing 

eating 

getting in and out of bed or chairs 

walking 

getting outside 

using the toilet, including getting to the toilet 

If doesn’t do activity listed above,is it because 

of a health or physical problem 

By yourself and without using special equipment, how 

much difficulty do you have (in activity): 

some 

a lot 

unable 

Do you receivehelp from anyone in (activity) 

Who givesthis help: 

1985 

1985 

1985 

1985 

1985 

1985 

1985 

1986 

1986 

1986 

1986 

379 
Topic Questionnaire item Year 

Functional Limitations (continued) 

household member 

relative 

nonrelative 

non-household member 

relative 

nonrelative 1986 

Is this help paid for 1986 

Which helpers are paid 1986 

Do you use any special equipment or aids in (activity) 1986 

What special equipment or aids do you use 1986 

Do you have difficulty controlling your bowels 1986 

How frequently do you have this difficulty: 

daily 

several times a week 

once a week 

less than once a week 

don’t know 1986 

Do you have a colostomy or a device to help control 

bowel movements 1986 

Do you need help from anyone in taking care of this device 1986 

Do you have difficulty controlling urination 1986 

How frequently do you have this difficulty: 

daily 

several times a week 

once a week 

less than once a week 

don’t know 1986 

Do you have a urinary catheter or a device to 

help control urination 1986 

Do you need help from anyone in taking care of this device 1986 

Becauseof a health or physical problem, do you usually: 

stay in bed all or most of the time 

stay in a chair all or most of the time 1986 

Because of a health or physical problem, do you 

have any difficulty: 

preparing your own meals 

shopping for personal items (such as 

toilet items or medicines) 

managing your money (such as keeping 

track of expenses or paying bills) 

using the telephone 

doing heavy housework (such as scrubbing 

floors or washing windows) 

doing light housework (such as doing dishes, 

straightening up, or light cleaning) 1986 

If doesn’t do activity listed above, is this because 

of a health or physical problem 1986 

By yourself and without using special equipment, 

how much difficulty do you have (in activity): 

some 

a lot 

unable 1986 
Topic Questionnaire item 

Functional Limitations (continued) 

Do you receive help from anyone in (activity) 

Who gives this help: 

household member 

relative 

nonrelative 

non-household member 

relative 

nonrelative 

Is this help paid for 

Which helpers are paid 

Is it necessary to go up or down a step to get into 

this (house/apartment) from the outside: 

1 step 

more than 1 step 

Counting basements and stepdown living areas as 

separate levels, does this (house/apartment) 

have more than one floor or level 

Does this (house/apartment) have a bathroom, bedroom, 

and kitchen all on the same floor or level 

Does this (house/apartment) have a walk-in shower, 

that is, where you don’t step over 

the side of the tub to get into the shower 

Because of a health or physical problem do you need 

a bathroom, bedroom, and kitchen all on the 

same floor or level 

Because of a health or physical problem do you need 

a walk-in shower 

Health Insurance/Health Care Coverage 

Now covered by the part of Social Security Medicare 

which pays for hospital bills 

Now covered by that part of Medicare which pays for 

doctor bills 

Social Security Medicare card (s) seen to determine 

type of coverage 

Now covered by health insurance plan which pays for 

any part of a hospital, doctor’s, surgeon’s, or dentist’s bill 

Is plan a Health Maintenance Organization (HMO) 

Was plan (HMO) obtained through an employer or union 

Is (HMO) plan now carried through an employer or union 

Does plan (HMO) pay any part of a hospital expense 

Does this plan (HMO) pay any part of doctor’s 

or surgeon’s bills for operations 

Does plan (HMO) pay for any dental services other 

than oral surgery 

Who is covered under this plan (HMO) 

Main reason not covered by health insurance (or Medicare) 

Is anyone in this family, that is (read names), 

now covered by Medicare 

Year 

1986 

1986 

1986 

1986 

1986 

1986 

1986 

1986 

1986 

1986 

1986, 1989 

1986,1989 

1986 

1986, 1989 

1986,1989 

1986, 1989 

1986,1989 

1986, 1989 

1986, 1989 

1986, 1989 

1986, 1989 

1986 

1986, 1989 

381 
Topic Questionnaire item 

Health Insurance/Health Care Coverage (continued) 

Is (names) now covered 

May I please see the Social Security Medicare card(s) 

for (names) to determine the type of coverage and 

to record the health insurance claim number 

It’s important that we have the complete and accurate 

name of your health insurance plan. What is the 

complete name of the plan 

Is anyone in the family now covered by any other 

health insurance plan (again, do not include 

plans that pay for only one service) 

Does it pay for any prescription drugs other 

than those administered during a hospital stay 

Does it pay for any mental health, alcoholism, 

or drug abuse services 

Is anyone in the family now covered by an 

insurance plan that pays for oniy one type of 

health care service, such as nursing, home care, 

eye care, or prescriptions 

Is (name) covered by this type of plan 

What type of service does (name) plan pay for: 

prescriptions 

eyecare 

cancer treatment 

catastrophic 

nursing home care 

accidents 

dental care 

other (specify) 

Is (name) now covered by any other insurance 

plan that paysfor only one service 

Which of these statements describes why (name) is not 

covered by any health insurance (or Medicare): 

job layoff, job loss, or any reasons related to 

unemployment 

can’t obtain insurance because of poor health, illness, 

or age 

too expensive, can’t afford health insurance 

dissatisfiedwith previous insurance 

don’t believe in insurance 

havebeen healthy, not much sicknessin the 

family, haven’t needed health insurance 

coveredby some other health plan 

some other reason 

What is the main reason (name) is not covered by 

any health insurance (or Medicare) 

Does anyone in the family now receive assistance 

through the “Aid to Families with Dependent 

Children” program, sometimes called ‘cAF’DC” or “ADC” 

Does (name) now receive AF’DC or ADC 

Does anyone in the family now receive the 

“Supplemental Security Income” or “SSI” check 

Does (name) now receive this check 

Year 

1986,1989 

1989 

1986, 1989 

1986, 1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1986,1989 

1989 

1986,1989 

1989 

382 
. Topic Qllestionnaire item 

Health Insurance/Health Care Coverage (continued) 

During the past 12 months, has anyone in this 

family received health care which has been or 

will be paid for by Medicaid 

Has (name) received this care in the past 12 months 

Does anyone in the family now have a Medicaid card 

Does (name) now have this card 

May I please see (name(s)) card(s) 

Is anyone in the family now covered by any other 

public assistance program that pays for health care 

Is (name) now covered 

Is anyone in this family now covered by health 

care benefits from the Armed Forces or Veterans’ Administration 

Does anyone in the family now receive military 

retirement payments from any branch of the Armed Forces 

or a pension from the Veterans’ Administration 

(do not include VA disability compensation) 

Does (name) now receive military retirement or a VA pension 

Which does (name) receive: The Armed Forces 

retirement, the VA pension, or both 

Is anyone in the family now covered by CHAMPUS, 

which is a program of medical care for 

dependents of military personnel 

Is (name) now covered by CHAMPUS 

1s anyone in the family now covered by CHAMP-VA, 

which is medical insurance for dependents or 

survivors of disabled veterans 

Is (name) now covered by CHAMP-VA 

Is anyone in the family now covered by any other 

program that provides health care for military 

dependents or survivors of military persons 

Is (name) now covered 

Does (name) have a disability related to (name’s) 

service in the Armed Forces of the United States 

Does (name) now receive compensation for this 

disability from the Veterans’ Administration 

Has (name) ever applied for a service-connected 

disability rating from the Veterans’ Administration 

Was it approved or denied 

During the past 12 months, that is since (12-month 

date) a year ago, have (names) 

been laid off from a job or lost a job 

Who was this 

How many times has (name) been laid off or lost 

a job during the past 12 months 

In what month and year was (name) laid off or 

did (name) lose a job (the last time/the time before that) 

For any time during that/those job layoff(s) or 

job loss(es), did (name) receive unemployment 

insurance benefits 

Year . 

1989 

1989 

1989 

1989 

1989 

1986, 1989 

1989 

i 

1989 

1986,1989 

1989 1 

1989 

1986, 1989 

1986, 1989 

1986,1989 

1986, 1989 

1986, 1989 

1986, 1989 

1986, 1989 

1986,1989 

1986, 1989 

1986, 1989 

1986, 1989 

1986, 1989 

1986, 1989 

1986,1989 

1986,1989 

. 

383 
Topic Questionnaire item Year 

Health Insurance/Health Care Coverage (continued) 

Because of (name(s)) job layoff(s) or job 

loss(es), did anyone in the family lose any 

health insurance coverage that had been 

carried through that/those job(s) 1986, 1989 

Who was this 1986,1989 

Was (name) covered by some other health insurance 

plan at any time during that/those job 

layoff(s) or job loss(es) (do not count military 

insurance or health programs such as Medicaid 

or AFDC) 1989 

Was (name) covered by another plan for the entire 

time (name(s)) was/were off work 1989 

For how long was (name) not covered by any kind 

of health insurance plan 1986, 1989 

At any time during that/those job layoff(s) or 

job loss(es), was (name) covered by a military 

program or by a health program such as Medicaid or AFDC 1986,1989 

For how long was (name) covered by this kind of program 1986,1989 

Does the employer or union pay any part of the cost 

for this (name) plan 1989 

Does the employer or union pay for all or just part 

of the cost 1989 

In whose name is the (name) plan 1989 

Health Insurance (Conducted only in California) 

Female respondents (15-45 years of age) have health 

care coverage for prenatal care 1989 

Children respondents (under 15 years of age) have 

health care coverage for check-ups, that is visits 

when not sick 1989 

Place respondent goes to when in need of professional 

medical care 1989 

Kind of place respondent goes to for professional 

medical care: 

doctor’s office or private clinic 

company or school clinic 

community/neighborhood, or migrant/rural clinic 

county clinic 

private hospital clinic or emergency room 

county hospital clinic or emergency room 

other hospital clinic or emergency room 

HMO/prepaid group 

some other place (Specify) 1989 

Particular person respondent usually seeswhen 

respondent goes there 1989 

During past 12 months, did respondent need or thought 

he/she needed medical care or surgery but did 

not get it 1989 

The last time this happened, what was the 

main reason respondent didn’t get medical care: 

could not afford it 
Topic Questionnaire item 

Health Insurance (Conducted only in California) (continued) 

no insurance 

not serious enough 

wait too long in clinic/o&e 

difficulty getting an appointment 

don’t like/trust/believe in doctors 

didn’t know where to go 

no way to get there 

hours not convenient 

other reason (specify) 

Was lack of insurance or lack of money a reason why 

respondent didn’t get medical care respondent needed 

Was respondent self-employed at job worked at during 

past 2 weeks 

How many hours per week respondent worked at job 

during past 2 weeks 

How long respondent worked at current job: 

number of weeks 

number of months 

number of years 

don’t know 

Is respondent paid by the hour at current job 

How much respondent earns per hour 

How much does respondent usually earn per week 

at this job before deductions 

At respondent’s work place, are there: 

fewer than 25 full and part-time employees 

less than 10 or 10 to 24 full and part-time empIoyees 

less than 50, 50 to 99, or 100 or more full 

and part-time employees 

Respondent employer has additional employees 

working in other locations 

(Asked only of sample persons) 

. Has sample person heard or read about large number 

of people without health insurance 

Has sample person heard or read about proposals 

to deal with issue of people who don’t have 

health insurance 

Does sample person believe government should give 

tax breaks to encourage employers to provide 

health insurance to their employees: 

strongly favor 

somewhat favor 

somewhat oppose 

strongly oppose 

no opinion/don’t know 

Does sample person believe government should require 

employer to provide health insurance to all 

employees who work full or part-time: 

strongly favor 

somewhat favor 

somewhat oppose 

Year 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 
Topic Questionnaire item 

Health Insurance (Conducted only in California) (continued) . ‘ 

strongly oppose 

no opinion/don’t know 

Does sample person believe that government should 

develop some form of national health insurance 

that would cover everyone: 

strongly favor 

somewhat favor 

somewhat.oppose 

strongly oppose 

no opinion/don’t know 

Does sample person believe that government should 

develop health insurance for people who are uninsured: 

strongly favor 

somewhat favor 

somewhat oppose 

strongly oppose 

no opinion/don’t know 

Heart Disease 

Do you have any hind of heart condition or heart trouble 

List of things which may or may not affect a person’s 

chances of getting heart disease. Tell me (interviewer) 

if you think it definitely increases, probably increases, 

probably does not or definitely does not increase a 

person’s chances of getting heart disease: 

cigarette smoking 

worry or anxiety 

high blood pressure 

diabetes 

being very overweight 

overworked 

drinking coffee with caffeine 

eating a diet high in animal fat 

family history of heart disease 

Height and Weight (see also Cancer) 

About how much do you weigh without shoes 

In your opinion which of these are the two 

best ways to lose weight: 

don’t eat at bedtime 

eat fewer calories 

take diet pills 

increase physical activity 

eat no fat 

eat grapefruit with each meal 

Are you now trying to lose weight 

Are you eating fewer calories to lose weight 

Have you increased your physical activity 

to lose weight 

PO you consider yourself overweight, underweight, 

: or just about right 

Year 

1989 

1989 

1989 

1985 

1985 

1985 

1985 

1985 

1985 

1985 

1985 
Topic Questionnaire item Year 

Heiqht/Weight (continued) 

Could you say you are very overweight, somewhat 

overweight, or only a little overweight .1985 

Hot Water Temnerature 

Do you know about what the hot water temperature 

is in this home 1985 

About what temperature is the hot water 1985 

How did you estimate the hot water temperature: 

the setting on the hot water heater 

tested with thermometer 

guessed 

other (specify) 1985 

In the past 12 months, have you (or has anyone 

in your household) used a thermometer to test 

the temperature of the hot water here 1985 

About what temperature will hot water cause 

scald injuries 1985, 

Immunization 

During the past 12 months, that is, since 

(la-month date) a year ago, have any adults 

in this family received a flu shot 1989 

Who was this 1989 

Have any adults in the family ever received a 

pneumonia vaccination 1989 

Who was this 1989 

Did (name) receivethe pneumonia shot within the past 

12 months 1989 

During the past 5 years, have any adults in the 

family had a tetanus shot 1989 

Who was this 1989 

About how long ago did (name(s)) have the last 

tetanus shot 1989 

Injuries (see Child Health, Poisoning, Work Injuries, and Work Risks) 

Medical Device Implant 

Does anyone in the fam’ily now have an artificial 

joint, such as an artificial hip, knee or 

finger joint 

Who is this 

Does anyone in the family now have any implants, 

such as pins, screws, nails, wires, rods 

or plates that have been surgically 

inserted in the body 

Who is this 

Does anyone in the family now have an artificial 

heart valve 

1988 

1988 

1988 

1988 

387 
Topic Questionnaire item Year 

Medical Device Implant (continued) 

Who is this 

Does anyone in the family now have a lens implant 

(do not include comeal transplants) 

Who is this 

Does anyone in the family now have a silicone 

implant (do not include silicone injections) 

Who is this 

Does anyone in the family now have a pacemaker 

Who is this 

Does anyone in the family now have ear vent tubes 

Who is this 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

Does anyone in the family now have an infusion pump 1988 

Who is this 

Does anyone in the family now have a shunt that 

drains fluid away from the brain or spinal column 

Who is this 

Does anyone in the family now have any other type 

of shunt or catheter implanted in the body 

Who is this 

Does anyone in the family now have any other kind 

of medical device that has been implanted 

in the body during surgery 

Who is this 

What kind of implant does (family member) have 

What kind of artificial joint(s) do you have 

How many artificial joints do you have 

Do you have any other artificial joints 

Was the joint actually replaced with an artificial 

(joint), or was something else implanted, 

such as a pin or plate 

Is the artificial finger joint you have now made 

out of silicone or some other material 

Is the artificial (joint) you have now a 

replacement for a previous artificial (joint) 

How many times has this artificial (joint) 

been replaced 

Why did you have the artificial (‘joint) replaced 

(the last time): 

normal growth 

defect or malfunction 

loosening 

infection 

pain 

some other reason (specify) 

How long after that joint was implanted was this 

(reason for replacement.) first noticed: 

less than 30 days 

30 to 90 days 

more than 90 days 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

388 
Topic Questionnaire item Year 

Medical Device Implant (continued) 

How long did you have the artificial (joint) before 

it was replaced with the one you have now: 

less than 6 months 

6-11 months 

number of years 

In what month and year did you get it 

How long have you had the artificial (joint) you have now 

In what month and year did you get this one 

Since you received the artificial (joint) you 

have now, would you say your mobility in 

that joint is improved, about the same, or 

worse than it was before this (last) implant 

Have you had any of the following problems or 

complications with or as a result of the 

artificial (joint) you have now: 

any blood clots 

an infection 

loosening 

increased pain over time 

any defects or failure to operate properly 

any other problems or complications (specify) 

(For each problem or complication) How long had 

you had the artificial (joint) when the 

(problem or complication) was first noticed: 

less than 30 days 

30 to 90 days 

more than 90 days 

Why did you need to get an artificial (joint) 

in the first place: 

osteoarthritis 

rheumatoid arthritis 

arthritis, unspecified 

injury 

pain 

some other reason (specify) 

In what part of the body is your implant (such as 

pins, screws, nails, wires, rods or plates) located 

Do you have any implants anywhere else 

Have you ever had surgery to replace or repair 

the implant in your (body part) 

How many times haveyou had surgery to replace 

or repair the implant in your (body part) 

Why did you have to have surgery to replace or 

repair the implant in your (body part) 

(the last time): 

normal growth 

breakage or defect 

healing problem 

infection 

pain or irritation 

loosening 

some other reason (specify) 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

389 
Topic Questionnaire item Year 

Medical Device Implant (continued) 

How long did you have the implant before the 

(problem) was first noticed: 

less than 30 days 

30.to 90 days 

more than 90 days 1988 

How long has it been since the (surgery for/ 

last surgery on) the implant in your (body part): 

less than 6 months 

6-11 months 

number of years 1988 

In what month and year did you have the (last) surgery 1988 

Since the (surgery for/last surgery on) the implant 

in your (body part) have you had any of the 

following problems or complications: 

infection 

healing problems 

pain (other than discomfort generally 

associated with surgery and healing) 

loosening 

a part breaking or wearing out 

any other problems or complications (specify) 1988 

How long after the (last) surgery was the (problem 

or complication) first noticed: 

less than 30 days 

30 to 90 days 

more than 90 days 

Why did you need to get the implant 

part) in the first place: 

injury 

deformity 

infection 

cancer 

other (specify) 

1988 

in your (body 

1988 

How long ago did you get the first implant in 

your (body part): 

less than 6 months 

6-11 months 

number of years 1988 

In what month and year did you get it 1988 

How many artihcial heart valves do you now have 1988’ 

There are four different heart valves-the mitral 

valve, the aortic valve, the tricuspid valve, 

and the pulmonic valve. Which of these did 

you have replaced with (an) artificial valve(s) 1988 

Is the artificial heart valve (name) you have now a 

replacement for a previous artificial valve 1988 

How many times has this artificial valve been replaced 1988 

Why did you have the artificial heart valve (name) 

replaced (the last time): 

normal growth 

blood clots 

infection 

bleeding 
Topic Questionnaire item 

Medical Device Implant (continued) 

defect or malfunction 

someother reason (specify) 

How long after the heart valve was implanted was this 

(reason for replacement) first noticed: 

less than 30 days 

30 to 90 days 

more than 90 days 

How long did you have the artificial heart valve (name) 

before it was replaced with the one you have now: 

less than 6 months 

6-11 months 

number of years 

In what month and year did you get it 

How long have you had the artificial heart valve (name) 

you have now: 

lessthan 6 months 

6-11 months 

number of years 

In what month and year did you get this one 

What is your artificial heart valve made from: 

manmade substance 

animal tissue 

human tissue 

don’t know 

Did you get a registration card for this artificial 

heart valve 

Do you know the name of the manufacturer 

Who is the manufacturer 

Have you had any of the following problems or 

complications with or as a result of the 

artificial heart valve (name) you have now: 

blood clots 

an infection or endocarditis 

bleeding problems related to surgery 

any defects or reason to believe it is not working properly 

any other problems or complications (specify) 

(For each problem or complication) How long had 

you had the artificial valvewhen the 

(problem or complication) was first noticed: 

less than 30 days 

30 to 90 days 

more than 90 days 

ATlticoagulants are medications that help prevent 

blood clots. Do you take anticoagulants 

Do you take aspirin or any other medication to help 

prevent blood clots 

How many days a week do you take them 

Why did you need to get an artificial 

heart valve (name) in the first place: 

congenital defect 

rheumatic heart disease 

heart attack or myocardial infarction 

Year 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

391 
Topic Questionnaire item Year 

Medical Device Implant (continued) 

calcification 

endocarditis 

other (specify) 

Do you now have a lens implant in your right eye, 

left eye, or both eyes 

Is the lens implant you now have in your (right/left) 

eye a replacement for a previous lens implant 

in that eye 

How many times has the lens implant in your (right/ 

left) eye been replaced 

Why did you have the lens implant in your (right/left) 

eye replaced (the last time): 

normal growth 

injury 

glaucoma after implant 

irritation or inflammation 

trouble reading 

infection 

movement or displacement of the lens 

wrong lens power 

problem due to cornea1 transplant 

some other reason (specify) 

How long after that lens was implanted was this 

(reason for replacement) first noticed: 

less than 30 days 

30 to 90 days 

more than 90 days 

How long did you have the lens implant in your 

(right/left) eye before it was replaced with 

the one you have now: 

less than 6 months 

6-11 months 

number of years 

In what month and year did you get it 

How long have you had the lens you now have 

in your (right/left) eye: 

less than 6 months 

6-11 months 

number of years 

In what month and year did you get this one 

Did your doctor tell you that the lens you now 

have in your (right/left) eye is an 

experimental lens 

Does this lens have a substance in it that absorbs 

some types of light 

Because of the lens implant in your (right/left) 

eye, did your doctor advise you to wear 

sunglasses when you are in bright light 

or sunlight 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

392 
Topic Questionnaire item Year 

Medical Device Implant (continued) 

Have you had any of the following problems or complications with or 

as a result of the lens you now have in your (right/left) eye: 

infection 

any healing problems 

pain, irritation, or inflammation of the inner eye 

glaucoma that started since lens was implanted 

clouding or blurred vision 

trouble reading newspaper print 

problems with glare or light streaks 

problems due to wrong lens power 

any other problems or complications (specify) 

(For each problem or complication) How long had you had 

the lens when the (problem or complication) 

was first noticed: 

less than 30 days 

30 to 90 days 

more than 90 days 

Have you had problems with your eyesfeeling tired 

when you wake up 

Did this problem start after the lens was implanted 

How long had you had the lens when this trouble 

was first noticed: 

less than 30 days 

30 to 90 days 

more than 90 days 

Why did you need to get a lens implant in your (right/ 

left) eye in the first place: 

cataract 

injury 

other (specify) 

Is the pacemaker you have now a replacement for 

a previous pacemaker 

How many times has your pacemaker been replaced 

(the last time): 

normal growth 

battery failure 

lead failure 

other mechanical failure 

infection 

healing problem 

pain 

some other reason (specify) 

How long after that pacemaker was implanted was this 

(reason for replacement) first noticed: 

less than 30 days 

30 to 90 days 

more than 90 days 

How was that pacemaker monitored: 

not monitored 

by telephone 

at a doctor’s office 

at the hospital 

in some other way (specify) 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

393 
Topic Questionnaire item 

Medical Device Implant (continued) 

How long did you have that pacemaker before it was 

replaced with the one you-have now: 

less than 6 months 

6-11 months 

number of years 

In what month and year did you get it 

How long have you had the pacemaker you have now: 

less than 6 months 

6-11 months 

number of years 

In what month and year did you get this one 

How is this pacemaker monitored: 

not monitored 

by telephone 

at a doctor’s office 

at the hospital 

in some other way (speci@) 

Can the pacemaker you have now be programmed 

or adjusted without surgery 

Please tell me if you have had any of the following 

problems or complications with or as a result 

of the pacemaker you have now: 

an infection 

any healing problems 

pain, other than discomfort 

generally associated with surgery and healing 

any irregular heart beat 

any mechanical problems (with the pacemaker you have now), 

such as battery failure or lead failure 

What kind of mechanical problem did it have: 

battery failure 

lead failure 

other mechanical problem (specify) 

Have you had any other problems or complications 

(with or as a result of the pacemaker you have now) 

What were they 

How long had you had your pacemaker when the (type 

of problem or complication) was first noticed: 

less than 30 days 

30 to 90 days 

more than 90 days 

Is the infusion pump for chemotherapy, insulin 

treatment, or something else 

Is the pump itself implanted inside your body, 

or is the pump worn on the outside 

In what part of the body is the (other) device located 

Do you have any other device 

Is the (device) in your (body part) a replacement 

for a previous one 

How many times has the (device) in your (body part) 

been replaced 

Year 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

394 
Topic Questionnaire item Year 

Medical Device Implant (continued) 

Why did you have the (devicej replaced 

(the last time): 

normal growth 

infection 

defect or malfunction 

healing problem 

pain 

blood clots 

bleeding 

injury 

someother reason (specify) 

How long had you had that (device) when the (name of 

problem) was first noticed: 

lessthan 30 days 

30 to 90 days 

more than 90 days 

How long did you have the (device) before it was 

replaced with the one you have now: 

lessthan 6 months 

6-11 months 

number of years 

In what month and year did you get it 

How long have you had the (device) you have now: 

lessthan 6 months 

6-11 months 

number of years 

In what month and year did you get this one 

Pleasetell me if you have had any of the following 

problems or complicationswith or as a result 

of the (device) you now have in your (body part): 

an infection 

any healing problems 

pain, other than discomfort 

generally associatedwith surgery and healing 

any defects or has it failed to operate properly 

any other problems or complicationswith the device 

what were they 

How long had you had your (device) when this problem 

was first noticed: 

lessthan 30 days 

30 to 90 days 

more than 90 days 

Why did you need to get the (device) in the first place: 

infection 

injury 

someother reason (specify) 

Mental Health 

During the past 12 months, did anyone in the 

family have: 

schizophrenia 

paranoid or delusional disorder, other than schizophrenia 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

395 
Topic Questionnaire item 

Mental Health (continued) 

manic episodes or manic depression, also called 

bipolar disorder 

major depression 

anti-social personality, obsessive compulsive 

personality, or any other severe personality disorder 

Alzheimer’s disease or another type of senile disorder 

alcohol abuse disorder 

drug abuse disorder 

mental retardation 

During the past 12 months, did anyone else have: 

(see previous list) 

During the past 12 months, did anyone in the 

famiIy have any other mental or emotional 

disorders (Include only those disorders 

which seriously interfere with a person’s 

ability to work or attend school, or to manage 

their day-to-day activities.) 

Who is this 

What would you call the disorder (person). has 

Does (disorder(s)) now entirely prevent (person) 

from working at a paid job or business 

Because of (this disorder/any of these disorders), 

is (person) limited in the kind or amount of 

work (person) can do 

Because of this disorder/any of these disorders, does 

(person) have trouble finding or keeping a job or 

doing job tasks 

For how long has person (been unable to work/been limited 

in work/had trouble with work) because of this 

disorder/any of these disorders: 

less than 3 months 

3 months, less than 1 year 

1 year, less than 5 years 

5 years or more 

don’t know 

Does (disorder) now entirely prevent person from attending 

reg,uIar school or college 

Because of (this disorder/any of these disorders), does 

person have trouble with school attendance or school work 

For how long has person been unable to attend school/had tra 

with school because of this disorder/ any of these disorders 

On own and without help, does person appropriately take 

care of own personal care needs, such as 

eating, dressing, bathing, and going to the toilet 

Is this because of disorder/any of these mental disorders 

For how long has (person) had trouble taking care of any 

of these needs: 

less than 3 months 

3 months, less than 1 year 

1 year, less than 5 years 

5 years or more 

don’t know 

Year 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

396 
Topic Questionnaire item Year 

Mental Health (continued) 

On (person’s) own and without help, does (person) 

adequatelyhandle routine matters such as: 

managing money 

doing every day household chores 

shopping 

getting around outside the home 

Are these because of (person’s) (disorder)/any of 

these mental disorders) 

For how long has (person) had trouble taking 

care of any of these things: 

less than 3 months 

3 months, less than 1 year 

1 year, less than 5 years 

5 years or more 

don’t know 

Because of (person’s) (mental and emotional disorders), 

how much difficulty (no difficulty, some difficulty, 

a lot of difficulty, completely unable, don’t know) 

does (person) now have: 

forming friendships 

keeping friendships 

concentrating long enough to complete tasks 

coping with day-to-day stresses 

For how long has (person) had any of these 

difficulties: 

less than 3 months 

3 months, less than 1 year 

1 year, less than 5 years 

5 years or more 

don’t know 

When did (person) last see or talk to a mental 

health professional about (person’s) (mental and 

emotional disorders) (Include psychiatrists, 

psychologists, social workers, psychiatric nurses, 

and any other type of mental health professional.): 

less than 2 weeks 

2 weeks, less than 1 month 

1 month, less than 3 months 

3 months, less than 1 year 

1 year, less than 5 years 

5 years or more 

never 

don’t know 

What type of mental health professional was last seen 

When did (person) last see or talk to a doctor or other 

health professional about (mental and emotional disorders): 

less than 2 weeks 

2 weeks, less than 1 month 

1 month, less than 3 months 

3 months, less than 1 year 

1 year, less than 5 years 

5 years or more 

never 

: i*i a.. 

1989 

1989 

1989 

: -

1989 

1989 

1989 , 

1989 

i 

i 
Topic Questionnaire item Year 

Mental Health (continued) 

don’t know 1989 

When did a doctor or other health professional 

first give a diagnosis of (mental and emotional 

disorders) for (person): 

less than 1 year 

1 year, less than 5 years 

5 years or more 

_ never 

don’t know 

Did the doctor call the (mental and emotional 

disorders) by a more technical or specific name 

What did he or she call it 

Has a doctor or other health professional ever 

given this disorder a technical or specific name 

What did he or she call it 

When did a doctor first call this disorder (name of 

disorder): 

less than 1 year 

1 year, less than 5 years 

5 years or more 

never 

don’t know 

Does (person) now take any prescription medication 

for (mental and emotional disorders) 

During the past 12 months, did (person) take any 

prescription medication for (this disorder/any 

of these disorders) 

How many different medications (does (person) take/ 

did (person) take) during the past 12 months for 

(this disorder/any of these disorders) 

(May I (interviewer) see/Would you please bring to the 

telephone) the container(s) for the medication(s) 

you just told me about 

What (is/are) the name(s) of the medication(s) 

Does (person) now receive a disability payment 

through any governmentprogram becauseof 

(mental and emotional disorders) 

Is this payment through Social Security Disability 

Insurance, called “SSDI”; through Supplemental 

Security Income, called “SW; through the 

Veteran’s Administration; or through some 

other program 

Orofacial Pain 

During the past 6 months, did you have a toothache 

more than once, when biting or chewing 

Did you first have this pain more than 6 months ago 

During the past 6 months, did you have painful 

soresor irritations around the lips or on the 

tongue, cheeks, or gums more than once 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

. 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

398 
Topic .Questionnaire item Year 

Orofacial Pain (continued) 

Did you first have the sores or irritations more 

than 6 months ago 

During the past 6 months, did you have prolonged, 

unexplained burning sensation in your tongue or 

any other part. of .your mouth more than once 

When you have this sensation, does it come and go 

or is it continuous and uninterrupted 

During how many different months in the past 6 

months did you have this sensation 

How many total days in the past 6 months did you 

have’this sensation: 

l-3 days 

4-10 days 

11-15 days 

16-30 days 

31-45 days 

46 or more days 

every day 

don’t know 

Did you first have this sensation more than 6 months ago 

During the past 6 months, did you have pain in the 

jaw joint or in front of the ear more than once 

When you have this pain, does it come and go or is 

it continuous and uninterrupted 

During how many different months in the past 6 months, 

did you have this pain 

How many total days in the past. 6 months did 

you have this pain: 

1-3 days 

4-10 days 

11-15 days 

16-30 days 

31-45 days 

46 or more days 

every day 

don ‘t know 

Did you first have this pain more than 6 months ago 

During the past 6 months, did you have a dull, 

aching’pain across your face or cheek more than 

once (do not count sinus pain) 

On a scale of l-10, where 1 is mild and 10 is 

severe, how would you rate this pain at its worst 

In the past 6 months, did you see or talk to a 

dentist for the pain we just discussed 

How many times during the last 6 months did you see 

or talk to a dentist about the p,ain 

In the past 6 months, did you see or talk to a 

medical doctor about the pain 

How many times (in the past 6 months) did you 

see or. talk to any other type of health professional 

about the pain 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

1989 

399 
Topic Questionnaire item 

Orofacial Pain (continued) 

In the past 6 months, did you see or talk to any 

other type of health professional about the pain 

What hind of health professional 

How many times during the past 6 months did you 

see or talk to the (health professional) 

In the past 6 months, did you worry about the 

health of your teeth and gums because 

of the pain 

In the past 6 months, did you worry about the 

health of your body because of the pain 

Here is a list of things people do when they have 

teeth, mouth, or face pain. Please tell me 

(interviewer) the things you did for the pain 

during the past 6 months: 

use a hot or cold compress 

take a prescription drug 

take an over-the-counter drug 

drink some liquor or wine 

because of the pain 

take time off work 

stay home more than usual 

avoid family and friends 

anything else (specify) 

none of the above 

don’t know 

Pain (see Orofacial Pain, Abdominal Pain, and Work Injuries) 

Physical Activity (see also Exercise) 

How many times in past 2 weeks did you (play/go/do) 

particular activity 

On the average about how many minutes did you 

actually spend doing particular activity 

What usually happened to your heart rate or 

breathing when you did (particular activity) 

Did you have a small, moderate, or large increase, 

or no increase at all in your heart rate or breathing 

Would ydu say that you are physically more active, 

less active or about as active as other 

persons your age 

Is that (a lot more or a little more/a lot less 

or a little less) active 

Poisoning 

Have you everheard about Poison Control Centers 

Do you have the telephone number for a Poison Control 

Center in your area 

Do you now have any Ipecac Syrup in this household 

Year 

1989 

1989 

1989 

1989 

1989 

1989 

1985 

1985 

1985 

1985 

1985 

1985 

1985 

1985 

1985 
Topic Questionnaire 

Poliomyelitis 

Ever told by doctor or health care professional 

that you had poliomyelitis or polio 

Ever have paralysis caused by polio 

Do you now have paralysis or any health impairment 

or health problem caused by polio 

Pregnancy (see also Birth, Smoking, Vitamin and 

Mineral Intake, and Cancer) 

Any women M-44 years old now pregnant 

Does cigarette smoking during pregnancy definitely 

increase, probably increase, probably not or 

definitely not increase the chances of: 

miscarriage 

stillbirth 

premature birth 

low .birth weight of the newborn 

Smoke during this pregnancy 

On average how many cigarettes a day did you smoke 

before you found out you were pregnant/this time 

On average how many cigarettes a day did you smoke 

after you found out you were pregnant/this time 

Would you say you smoked cigarettes during most 

of that pregnancy 

Sleep 

Sleep,number of hours nightly 

On the average, how many hours of sleep do you get 

in a 24-hour period 

Smoke Detectors 

How many smoke detectors are installed in this home 

How many of them (smoke detectors) are now working 

Is it (smoking detector) now working 

How do you know (it is/they are) working 

(smokedetectors): 

tested it/them 

it/they went off because of smoke 

it/they went off while cooking 

changed the batteries 

the light is on 

beeps when battery is low 

other (specify) 

Is/Are any of smoke detectors next to a sleeping area 

Smoking (see also Cancer and Diabetes) 

Have you smoked at least 100 cigarettes in 

your entire life 

item Year 

1987 

1987 

1987 

1985 

1985 

1985 

1985 

1985 

1985 

1985 

1985 

1985 , 

1985 

1985 

1985 

1985 

1985,1987,1988 

About how old were you when you first started 

401 
Topic Questionnaire item 

Smoking (continued) 

smoking cigarettesfairly regularly: 

number of days 

number of weeks 

number of months 

number of years 

never smoked regularly 

Do you stioke cigarettes now 

About how many cigarettes do you smokeper day 

About how long has it been since you last smoked 

cigarettes fairly regularly: 

never smoked regularly 

number of days 

number of weeks 

number of months 

number of years 

Did you smoke cigarettes at all during the 12 months 

before your last child was born 

On the average, about how many cigarettes a 

day do/did you smoke 

Do you think cigarette smoking definitely increases, 

probably increases, probably does not or definitely 

doesnot increase a person’s chancesof getting 

the following problems: 

emphysema 

bladder cancer 

cancer of larynx or voice box 

cataracts 

cancer of the esophagus 

chronic bronchitis 

gallstones 

lung cancer 

Did a dqctor ever advise you to quit or cut down on smokitig 

Do you live with anyonewho smokescigarettes 

Do they regularly smoke in the home 

Is smoking ailowed in your place of work 

other than in designated areas 

Do you find that cigarette smoke in the work place 

causesyou: 

no discomfort 

some discomfort 

moderate discomfort 

great discomfort 

Social Relationships (see Personal/Emotional Problems) 

Stress/Stroke 

During the past 2 weeks, would you say that you 

experienced stress: 

a lot 

moderate 

relatively little 

Year 

1985, 1988 

1985,1988,1989 

1989 

1985,1988 

1985 

1985,1988 

1985 

1985 

1988 

1988 

1988 

1988 
Topic Questionnaire 

Stress/Stroke (continued) 

almost none 

don’t know what stress is 

In the past year, how much effect has stress had on 

your health: 

a lot 

some 

hardly any 

none 

Have you ever had a stroke 

The following conditions are related to having a 

stroke; in your opinion, which of these 

conditions most increases a person’s chances of 

having a stroke: 

diabetes 

high blood pressure 

high cholesterol 

don’t know 

Tobacco Use (see Smokinq and Cancer) 

item Year 

1985 

1985 

1985 

1985 

Usual Source of Care/Place of Care (see also Cancer Control and Doctor Visit) 

Is there a particular clinic, health center, doctor’s 

office, or other place that you usually go to if 

you are sick or need advice about your health 

What kind of place is it: 

a doctor’s office 

hospital outpatient clinic 

sample person’s home 

hospital emergency room 

company or industry clinic 

health center 

other (specify) 

Which of these is the main reason you don’t have a 

particular place you usually go: 

have two or more usual doctors or places 

depending on what is wrong 

‘haven’t needed a doctor 

previous doctor no longer available 

haven’t been able to find the right doctor 

recently moved to area 

can’t afford medical care 

other reason 

Vitamin and Mineral Intake 

During the past 2 weeks (outlined on calendar), did 

(child/adult) take any vitamin, mineral, 

or fluoride products 

How many different vitamin, mineral, or fluoride 

products did (child/adult) take during the past 

2 weeks 

What is the product name 

1985 

1985 

1985 

1986 

1986 

1986 

403 
Topic Questionnaire item Year 

Vitamin and Mineral Intake (continued) 

What is the manufacturer’s or distributor’s name 1986 

In what form did (child/adult) take this product: 

capsules, tablets, or pills 

wafers 

teaspoon(s) 

tablespoon(s) 

drops/droppers 

some other form (specify) 

don’t know 1986 

How many (see list above) must (child/adult) take 

to obtain the amount of nutrients listed on the label 1986 

During the past 2 weeks, on how many days did (child/ 

adult) take the vitamin or mineral 1986 

On the days when (child/adult) took the vitamin or 

mineral, how many did (child/adult) take per day 1986 

For how long has (child/adult) been taking this 

type of product: 

number of days 

number of weeks 

number of months 

number of years 1986 

Did (child/adult) have a doctor’s prescription to 

obtain this product 1986 

Were you pregnant during the past 2 weeks 1986 

Were you breastfeeding a baby during the past 2 weeks 1986 

Work Injuries (see also Employment and Work Risks) 

During the past 12 months, that is, since 

a year ago, have you had: 

repeated trouble with neck, back or spine 

a condition affecting the wrist and hand, 

called carpal tunnel syndrome 

a condition affecting the fingers and/or toes, 

called Raynaud’s phenomenon 

a condition affecting the tendons called tendonitis 

hepatitis 

skin cancer 

lung cancer 

.asthma 

chronic bronchitis 

emphysema 

any dust disease of the lungs, such as silicosis, asbestosis, 

brown lung, or black lung disease 1988 

Do you now have: 

deafness in one or both ears 

any other trouble hearing in one or both ears 1988 

Were you ever.told by a doctor or other medical person 

that your condition was related to any job you 

ever had 1988 

Was a worker’s compensation claim ever filed for your 

condition 1988 

. 

404 
Topic Questionnaire item 

Work Injuries (continued) 

Did you ever report to your employer or to other 

company personnel that your condition was related 

to your job 

Did you’ever tell a doctor or other medical person that 

your condition was related to any job you ever had 

During the past 12 months, were you told by your 

doctor or employer to stay home from work 

temporarily because of your condition 

During the past 12 months, did your employer transfer 

you to another job, either temporarily or 

permanently, because of your condition 

During the past 12 months, did your employer give you 

lighter work or excuse you from certain duties at 

work because of your condition 

Did you ever stop working at a job or change jobs 

because of your condition 

What kind of work did you do that was related to 

your condition 

What were your most important activities or duties 

at this job 

In what kind of business or industry did you work 

the longest as: 

an employee of a private company, business or 

individual for wages, salary or commission 

a member of the Armed Forces 

a Federal government employee 

a State government employee 

a local government employee 

self-employed in own business 

professional practice, or farm 

is the business incorporated 

working without pay in family 

business or farm 

During the past 12 months, have you had any on-the-job injuries 

How many times have you been injured on the job 

during the past 12 months 

On what date your (most recent injury/injury before 

that) happened 

At the time of your injury (date) were you working as a 

(name of occupation) for (name of employer) 

For whom did you work when the injury happened 

What kind of business or industry is this 

What kind of work did you do at that job 

What were your most important activities or duties at that job 

Were you: 

an employee of a private company, business or 

individual for wages, salary, or commission 

a member of the Armed Forces 

a Federal government employee 

a State government employee 

a local government employee 

Year 

1988 

1988 

1988 ’ 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

405 
Topic Questionnaire item Year 

Work Injuries (continued) 

self-employed in own business, professional practice or farm 

is the business incorporated 

working without pay in family business or farm 1988 

At the time of this injury, what part of your body 

was hurt, what kind of injury was it 1988 

Did you lose consciousness as a result of the injury 1988 

What were you doing at the time of the injury 1988 

How did the injury happen 1988 

Was the activity you were doing at the time of the 

injury a new or unfamiliar job task 1988 

Was the activity you were doing at the time of the 

injury part of your usual job tasks 1988 

Did you see or talk to a medical doctor, nurse, 

chiropractor, physician’s assistant, nurse 

practitioner or other medical person as a 

result of this injury 1988 

Where did you first see or talk to a medical person 

about this injury: 

work-site health unit 

doctor’s office (group practice or doctor’s clinic) 

emergency room 

walk-in clinic 

hospital outpatient clinic 

other (specify) 1988 

Were you wearing eye protection equipment over your 

eyes at the time of the injury 1988 

What type of eye protection equipment were you wearing: 

welding goggles 

other goggles 

glasseswith side shields 

glasseswithout side shields 

welding helmet 

face shield 

other 1988 

Did you miss more than half of the day from work on 

the day of the injury 1988 

Other than the day of the injury, how many full days 

of scheduled work did you miss as a result of the injury 1988 

Did you miss any other scheduled time from work 

(other) than the day of the injury 1988 

How many days did you miss more than half of the day 

from work as a result of the injury 1988 

Were you temporarily transferred to another job 

because of the injury 1988 

Were you temporarily assigned lighter work or excused 

from certain duties at work other than the day 

of the injury 1988 

Did you report this injury to your employer 1988 

Was a worker’s compensation claim filed as a result 

of this injury 1988 

Did you change employers as a result of this injury 1988 
Topic Questionnaire item 

Work Injuries (continued) 

Was your salary lower, higher or the sameafter your 

change of employers 

Were you as satisfied, lesssatisfiedor more 

satisfiedwith your new employer as with your 

employer prior to the injury 

Did you change the kind of work you do as a result 

of the injury 

Was your salary lower, higher or the sameafter your 

job change 

Were you as satisfied, lesssatisfiedor more 

satisfiedwith your new job aswith your 

job prior to the injury 

Did you make a permanent change in your work 

activities becauseof this injury 

Did you permanently change your off-the-job 

activities because of this injury 

During the past 12 months haveyou had dermatitis, 

eczema,or any other red, inflamed skin rash 

During the past 12 months, on about how many days 

altogether did you have a skin condition 

(include dayswhen you used treatment for the condition) 

What parts of your body were affected by this skin 

condition: 

hands 

arms 

head, face or neck 

other body area (specify) 

don’t know 

During the past 12 months, did you miss at least a 

full day from work because of your skin condition 

Did any skin condition you had in the past 12 

months result from chemicalsor other 

substances which you got on your skin 

What chemicals or other substances were these 

Did you get these substances on your skin during 

the past 12 months 

Was this at your job 

Were you at work at your job or businesswhen you 

got these substances on your skin 

During the past 12 months, did you use any prescription 

medications or other treatments prescribed by 

a doctor for your skin condition 

Did you use any over-the-counter or non-prescription 

medications or treatments for your skin condition 

How long has it been since you last saw or talked 

to a dermatologist or skin specialist about your 

skin condition: 

number of days 

number of weeks 

number of months 

number of years 

never 

Year 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

407 
Topic Questionnaire item Year 

Work Injuries (continued) 

How long has it been since you last saw or talked to 

any other type of medical person about your 

skin condition: 

number of days 

number of weeks 

number of months 

number of years 

never 

During the past 12 months, have you stopped working 

at a job or changed jobs because of your skin condition 

During the past 12 months did you make a major change 

in your work activities because of your skin condition 

During the past 12 months, did you report your skin 

condition to your employer as a work-related 

illness or injury 

During the past 12 months, was a worker’s compensation 

claim filed for your skin condition 

During the past 2 weeks, have you had any episodes 

of itchy, irritated or watery eyes 

On how many days during the past 2 weeks did you have 

itchy, irritated or watery eyes 

Do you wear contact lenses 

What type of contact lenses do you wear: 

hard lens(es) (include polycon) 

soft lens(es), daily wear 

soft lens(es), extended wear 

intraocular lens(es) 

other (specify) 

don’t know 

During the past 2 weeks, have you had any episodes 

of stuffy, blocked, itchy, or runny nose 

On how many days during the past 2 weeks did you have 

stuffy, blocked, itchy, or runny nose 

During the past 2 ,weeks,have you had any episodes 

of sore or dry throat 

On how many days during the past 2 weeks, did you 

have sore or dry throat 

Were these symptoms due to: 

cold or flu 

hay fever 

allergies (other allergies) 

something else (specify) 

Did you have these symptoms while you were at work 

When you were away from work, did these symptoms: 

increase 

decrease 

stay the same 

During the past 2 weeks when you had these symptoms, 

did you also have a fever 

At any time during the past 12 months, that is since 

(12-month date) a year ago, did you have back 

pain every day for a week or more 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

408 
Topic Questionnaire item Year 

Work Iujuries (continued) 

Did you have back pain only at the time of your 

monthly period 

During the past 12 months, on about how many days 

altogether did you have back pain 

During the past 12 months, how many full days did 

you miss from work becauseof back pain 

When you had this back pain, what part of your back 

bothered you the most-the upper back, the 

middle back or the lower back 

During the past 12 months, did the back pain ever 

spread to your: 

buttocks 

thighs 

lower leg or foot 

Did any of the back pain you had in the past 12 months 

result from a single accident or injury (some 

examplesare slipping, falling, twisting, lifting 

something,or being in a car accident) 

When did the accident or injury happen 

Were you at work at your job or businesswhen the 

accident or injury happened 

Was this at your job as a (name of occupation) for 

(name of employer) 

For whom did you work when the accident or injury 

happened 

Was any of the back pain you had in the past 12 months 

brought on by repeated activities such as lifting, 

pushing, pulling, bending, twisting, or reaching 

Where did you perform the activities that brought on 

your back pain: 

at work 

at home 

recreational site 

other (specify) 

Was this at your job as a (name of occupation) for 

(name of employer) 

What caused your back pain 

Has your back bothered you today 

How many days, weeks, or months ago did you last 

have back pain 

For how many consecutive days, weeks, or months 

(did your back bother you that time/hasyour 

back been bothering you) 

In what year did you first have an episode of back 

pain that lasted for a week or more: 

1987 

1988 

1989 

earlier year (specify) 

Counting (reported year), in how many different years 

haveyou had episodesof back pain lasting for 

iaweek or more 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 / 

1988 

1988 

1988 

1988 

1988 

409 
Topic Questionnaire item Year 

Work Iniuries (continued) 

What was the longest period of time that you had 

back pain every day: 

less than 1 month 

1 month, less than 3 months 

3 months, less than 6 months 

6 months, less than 12 months 

1 year, less than 5 years 

5 or more years 1988 

Have you ever stopped working at a job or changed 

jobs because of back pain 1988 

Have you ever made a major change in your work 

activities because of back pain 1988 

Are you left handed, right handed or able to use 

both hands equally well 1988 

Which hand do you use the most at work: 

left 

right 

use both hands equally 1988 

During the past 12 months, that is, since (12 month 

date) a year ago, have you had discomfort in 

your hands, wrists, or fingers (discomfort 

can mean pain, burning, stiffness, numbness 

or tingling) 1988 

Was this discomfort due entirely to an injury, such 

as a cut, sprain or broken bone 1988 

During the past 12 months, on about how many days 

altogether did you have discomfort in your 

hands, wrists, or fingers 1988 

During the past 12 months, did you have the 

discomfort every day for a week or more 1988 

In,which hand did you have this discotifortz 

left 

right 

both 1988 

Was your discomfort worse when you were trying to 

sleep or did it awaken you from sleep 1988 

In the past 12 months, did your hands or fingers 

often feel clumsy, that is, did you often have 

difiiculty picking up or holding things 1988 

Has your hand(s) bothered you today 1988 

How many days, weeks, or months ago did you last have 

this discomfort 1988 

For how many consecutive days, weeks, or months 

(did your hand(s) bother you that time/has 

your hand(s) been bothering you) 1988 

In what year did you first notice this hand 

discomfort: 

1987 

1988 

1989 

earlier year (specify) 1988 

410 
Topic Questionnaire item 

Work Injuries (continued) 

Counting (reported year), in how many different years 

hasyour hand(s) bothered you 

During the past 12 months, were you away from work 

for more than 1 week for any reason 

When you were away from work for more than 1 week, 

did your hand discomfort: 

increase 

decrease 

stay the same 

During the past 12 months, did you miss at least a 

full day from work because of your hand 

discomfort 

Have you ever stopped working at a job or changed 

jobs because of your hand discomfort 

Have you ever made a major change in your work 

activities because of your hand discomfort 

How long has it been since you last saw or talked to 

a medical doctor, chiropractor, physical 

therapist or other medical person about your 

hand discomfort: 

never saw a medical person 

number of days 

number of weeks 

number of months 

number of years 

What did the medical person call your hand discomfort 

Even if you have mentioned it before, please tell me 

(interviewer) if you ever had any of the 

following conditions: 

arthritis of the hand, wrist, or fingers 

a broken bone in your hand, wrist, or fingers 

a condition affecting the wrist and hand 

called carpal tunnel syndrome 

Work Risks (see also Employment, Smoking, and Work Injuries) 

In your present job, are you exposed to any 

work conditions that could endanger your 

health, such as loud noise, extreme heat or cold, 

physicalor mental stress,or radiation 

What work conditions are you exposed to that could 

endanger your health 

How can (work condition) endanger your health 

In your present job are you exposed to any risks of 

accidents or injuries 

What risks of accidents or injuries are you exposed to 

In your present job are you exposed to any 

substances that could endanger your health, such 

as chemicals,dusts, fumes or gases 

What substances are you exposed’to that could 

endangeryour health 

How can (substance) endanger your health 

Year 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1985 

1985 

1985 

1985 

1985 

1985 

1985 

1985 

411 
Topic Questionnaire item 

Work Risks (continued) 

Did your job require you to do repeated strenuous 

physical activity such as lifting, pushing, or 

pulling heavy objects 

During a typical work day, how many minutes or hours 

altogether did you spend doing strenuous physical activities 

Did this job require you to do repeated bending, 

twisting or reaching 

During a typical work day, how many minutes or hours 

altogether did you spend bending, twisting or reaching 

Did this job require you to bend or twist your hands 

or wrists many times an hour 

During a typical work day, how many minutes or hours 

altogether did you spend bending or twisting 

your hands or wrists 

On this job, did you work with hand-held or handoperated vibrating machinery 

During a typical work day, how many minutes or hours 

did you sljend working hand-held or hand-operated 

vibrating machinery 

I (interviewer) am going to read a list of substances 

that people.get on their skin at work. Tell me 

if you got any of these things on your hands or 

arms at your job as a (name of occupation) for 

(name of employer) during the past 12 months: 

did you get solvents or degreasers on your hands or arms 

petroleum products other than solvents,for example 

grease,oil, or fuel 

soaps, detergents, or cleaning and disinfecting solutions used in 

performing your job 

cutting oils, machine coolants, or metal working fluids 

paints, varnishes, lacquers, or other coatings 

glues, pastes, or other adhesives 

acids or alkalines 

pesticides,insecticides,herbicides, fungicides, or fumigants 

foods or food products handled as part of your job duties 

plants, trees or shrubs handled as part of your job duties 

did you get any other chemicals or substances on your hands or 

arms that could irritate the skin 

Year 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

1988 

412 ‘U.S. Government Printing Office: 1993- 342.327/80014 
I Vital and Health Statistics 

series descriptions 

SERIES 1, Programs and Collection Procedures-These reports 

describe the data collection programs of the National Center 

for Health Statistics. They include descriptions of the 

methods used to collect and process the data, definitions, 

and other material necessary for understanding the data. 

SERIES 2. Data Evaluation and Methods Research-These reports 

are studies of new statistical methods and include analytical 

techniques, objective evaluations of reliability of collected 

data, and contributions to statistical theory. These studies 

also include experimental tests of new survey methods and 

comparisons of U.S. methodology with those of other 

countries. 

SERIES 3. Analytical and Epidemiological Studies-These reports 

present analytical or interpretive studies based on vital and 

health statistics. These reports carry the analyses further than 

the expository types of reports in the other series. 

SERIES 4. Documents and Committee Reports-These are 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 5. internatlonai Vital and Health Statistics Reports-These 

reports are analytical or descriptive reports that compare US. 

vital and health statistics with those of other countries or 

present other international data of relevance to the health 

statistics system of the United States. 

SERIES 6. Cognition and Survey Measurement-These reports are 

from the National Laboratory for Collaborative Research in 

Cognition and Survey Measurement. They use methods of 

cognitive science to design, evaluate, and test survey 

instruments. 

SERIES IO. Data From the National Health interview Survey-These 

reports contain statistics on illness: unintentional injuries; 

disability; use of hospital, medical, and other health services; 

and a wide range of special current health topics covering 

many aspects of health behaviors, health status, and health 

care utilization. They are based on data collected in a 

continuing national household interview survey. 

SERIES 11. Data From the National Health Examination Survey, the 

National Health and Nutrition Examination Surveys, and 

the Hlspanic Health and Nutrition Examination SurveyData from direct examination, testing, and measurement on 

representative samples of the civilian noninstitutionalized 

population provide the basis for (1) medically defined total 

prevalence of specific diseases or conditions in the United 

States and the distributions of the population with respect to 

physical, physiological, and psychological characteristics, 

and (2) analyses of trends and relationships among various 

measurements and between survey periods. 

SERIES 12. Data From the Institutionalized Population SurveysDiscontinued in 1975. Reports from these surveys are 

included in Series 13. 

SERIES 13. Data From the National Health Care Survey-These 

reports contain statistics on health resources and the public’s 

use of health care resources including ambulatory, hospital, 

and long-term care services based on data collected directly 

from health care providers and provider records. 

SERIES 14. 

SERIES 15. 

SERIES 16. 

SERIES 20. 

SERIES 21. 

SERIES 22. 

SERIES 23. 

SERIES 24. 

Data on Health Resources: Manpower and FacilitiesDiscontinued in 1990. Reports on the numbers, geographic 

distribution, and characteristics of health resources are now 

included in Series 13. 

Data From Special Surveys-These reports contain 

statistics on health and health-related topics collected in 

special surveys that are not part of the continuing data 

systems of the National Center for Health Statistics. 

Compilations of Advance Data From Vital and Health 

Statistics-Advance Data Reports provide early release of 

information from the National Center for Health Statistics’ 

health and demographic surveys. They are compiled in the 

order in which they are published. Some of these releases 

may be followed by detailed reports in Series 10-13. 

Data on Mortality-These reports contain statistics on 

mortality that are not included in regular, annual, or monthly 

reports. Special analyses by cause of death, age, other 

demographic variables, and geographic and trend analyses 

are included. 

Data on Nataiity, Marriage, and Divorce-These reports 

contain statistics on natal@, marriage, and divorce that are 

not included in regular, annual, or monthly reports. Special 

analyses by health and demographic variables and 

geographic and trend analyses are included. 

Data From the National Mortality and Natality SurveysDiscontinued in 1975. Reports from these sample surveys, 

based on vital records, are now published in Series 20 or 21. 

Data From the National Survey of Family Growth-These 

reports contain statistics on factors that affect birth rates, 

including contraception, infertility, cohabitation, marriage, 

divorce, and remarriage; adoption: use of medical care for 

family planning and infertility; and related maternal and infant 

health topics. These statistics are based on national surveys 

of childbearing age. 

Compilations of Data on Natality, Mortality, Marriage, 

Divorce, and induced Terminations of PregnancyThese include advance reports of births, deaths, marriages, 

and divorces based on final data from the National Vital 

Statistics System that were published as supplements to the 

Month/y vital Sfafisfics Report (MVSR). These reports provide 

highlights and summaries of detailed data subsequently 

published in Vital Statistics of the United States. Other 

supplements to the MVSR published here provide selected 

findings based on final data from the National Vital Statistics 

System and may be followed by detailed reports in Series 20 

or 21. 

For answers to questions about this report or for a list of reports published 

in these series, contact: 

Data Dissemination Branch 

National Center for Health Statistics 

Centers for Disease Control and Prevention 

Public Health Service 

6525 Belcrest Road, Room 1064 

Hyattsville, MD 20782 

(301) 436-8500 
DEPARTlMENTOF 

HEAJiTH&l!!lmmN SERVICES 

Public Health Service 

Centers for Disease Control and Prevention 

National Center for Health Statistics 

6525 Belcrest Road 

Hyattsville, Maryland 20782 

OFFICIAL BUSINESS 

PENALTY FOR PRIVATE USE, $300 

, 

. 

;. 

DHHS Publication No. (PHS) 93-1307, Series 1, No. 31 

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