Vitaland


HealthStatistics


Questionnaires From 

the National Health 

Interview Survey, 

1980-84


Series 1: 

Programs and Collection Procedures 

No, 24 

This series report includes the questions used in the National Health


Interview Survey from 1980 to 1984. The report contains the basic health


and demographic questionnaires and current health topic queWonnaires.


US. DEPARTMENTOF HEALTHANDHUMANSERVICES


PublicHealthService


Centersfor Disease Control


NationalCenterfor HealthStatistics


Hyattsville, Maryland


March 1990


DHHS Publication No. (PHS) 90-1302

Copyright information


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, 1980-84. National Center for Health Statistics.


Vital Health Stat 1 (24). 1990.


Library of Congress Cataloging-in-Publication Data


Chyba, Michele M. 

Questionnaires from the National Health Interview Survey, 1980-

84. 

P. cm. — (Vital and health statistics. Series 1. Programs 

and collection procedures ; no. 24) (DHHS publication ; no. (PHS) 

90–1	 302) 

8y Michele M. Chyba and Linda R. Washington. 

Includes bibliographical references. 

ISBN 0-8406 -0423-8 

1. National Health Interview Survey (U. S.) 2. Questionnairas. 

3. Public health—United States. 4. Health surveys-United States. 

1. Washington, Linda R. Il. Title. Ill. Series. IV. Series: DHHS 

publication; no. (PHS) 90–1302. 

[DNLM: 1. Health Surveys–United States. 2. National Health 

Interview Survey (U.S.) 3. Questionnaires.4. United States. W2 

N148va no. 24] 

RA409. U44 no. 24 

[RA 407.3] 

362.1’0723 s—dc20 

[61 4.4’2’028] 

DNLM/DLC 

for Library of Congress 89–600285 

CIP 
National Center for Health Statistics 

Manning Feinleib, M.D., Dr. P.H., Director 

Robert A. Israel, Deputy Director 

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

and Epidemiology 

Gail F. Fisher, Ph. D., Associate Director for Planning and 

Extramural Programs 

Peter L. Hurley, Associate Director for Vital and Health 

Statistics Systems 

Stephen E. Nieberding, Associate Director for Management 

Charles J. Rothwell, Associate Director for Data 

Processing and Services 

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

and Methodology 

Division of Health Interview Statistics 

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

Deborah M. Winn, Ph. D., Deputy Director 

Gerry E. Hendershot, Ph.D., ChieJ Illness and Disability 

Statistics Branch 

Nehna B. Keen, Chie~ Systems and Programming Branch 

Stewart C. Rice, Jr., ChieA Survey Planning and 

Development Branch 

Robert A. Wright, Chiex Utilization and Expenditure 

Statistics Branch 

Acknowledgments 

The authors are grateful for the assistance and support received in preparing this report. 

Support was received from Linda Purvin and staff in the Utilization and Expenditure 

Statistics Branch and from Lidia Velasques of the Scientific and Technical Information 

Branch. We would also like to acknowledge the technical assistance provided by 

Susan S. Jack. 
This series report includes the questions used in the 

National Health Interview Survey (NHIS) from 1980 to 

1984, It is the first in a series of reports that describes the 

questionnaires used in NHIS. The report contains the basic 

health and demographic questionnaires for the 1980 and 

1982 data collection years and the current health topic 

questionnaires used from 1980 through 1984. The 1980 

basic health and demographic questionnaire was revised in 

1982, This revised questionnaire has been used each year 

since 1982. 

It should be noted that not every question included in a 

survey instrument appears on an NHIS public use data tape. 

The information may be excluded because of National 

Center for Health Statistics confidentiality provisions, 

combining of variables 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. These generated variables are a result of 

combining data items in the questionnaire. 

Three appendixes provide detailed discussions of the 

survey and estimation procedures and the 1982 redesigns. 

These features were added to provide the user with a more 

indepth knowledge of the procedures and redesign of NHIS 

from 1980 through 1984. For additional information, a 

topical index (appendix IV) and a list of references are 

included. 

Current health topic questionnaires are organized 

according to year, beginning with 1980. A brief introduction 

precedes each year. Each introduction summarizes the data 

collection activity in that year and highlights the main 

differences from the previous years. 

This report excludes information on the Targeted 

Population Study program, initiated by the Division of 

Health Interview Statistics in 1984. A Targeted Population 

Study is a survey of persons selected from the sample 

population of NHIS who are recontacted for the purpose of 

obtaining addhional health-related information. 

This report serves as a reference tool and as a 

mechanism that enables researchers to grasp the focus of 

NHIS during the period 1980–84. This publication is the 

first in a series of reports about the questions asked in 

NHIS. The second report planned in this series will 

encompass the questionnaires used in the years 1985–89. 

Ill 
Overview of National Health Interview Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Back#ound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Purpose and scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


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


Basic health and demographic questionnaire (formerly core) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Cumenthedth topics (formerly supplements) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Sumey instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Basic health anddemographic questiomaires (formerly core): 1980, 1982... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


1982 ,, ..,,,... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Changes in’the NHIS basic health and demographic (or core) questiomaire, 980-84.. . . . . . . . . . . . . . . . . . . . . . . . . . . .


1981 and1980 changes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


1982 changes,, ..,,,... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


1983 changes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Current health topics (formerly supplements): 1980.84 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


1981 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


1982 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . .


1983 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


1984 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


References . ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Appendixes 

I. Data collection procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


II. 1982 survey revisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


III. Estimation procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


IV. Topical index to questionnaire items, by year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Table 

Current healthtopics ofthe NationalHealth Interview Survey,19 80-84 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


1 

1 

1 

1 

1 

2 

4 

4 

4 

33 

59 

59 

59 

60 

60 

60 

72 

104 

110 

129 

154 

157 

158 

171 

176 

3 
---

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, 1980-84 

by Michele M. Chyba, Division of Health Intetview 

Statistics, and Linda R. Washington, Division of Data 

Services 

Overview of National Health 

Interview Survey 

Background 

The National Health Interview Survey (NHIS) is the principalsource 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 the 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 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. 

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 coun&es. Appendix III describes the 

estimation procedures for the survey. 

The questionnaire consists of two parts: (1) a set of basic 

health and demographic items and (2) 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 heelth and demographic questionnaire 

(formerly core) 

The questionnaire includes the following types of basic 

health and demographic questions including those revisions 

made during a redesign in 1982. (Complete details of the 

changes made in 1982 are in appendix II.) 

� 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 2-week period, 

interval since the last physician visit, and number of visits 

in the last 12 months 

1 
�	 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 

.	 Shofi-stay hospitalization data, including the number of 

hospital episodes during the past year and the number of 

days for each stay 

Data tapes, with findings from the National Health Interview Survey basic health and demographic questiomaire, can 

be purchased from the National Technical Information Service 

(703) 487-4650. These files include household, person, condition, hospital episode, and doctor visit records. 

Current heekh topics (formerly supplements) 

The current health topics facilitate a response to the need 

for population-based data on current or emerging health issues 

2 

and coverage of a wide variety of topics. Questions on special 

health topics, shown in the table, change in response to current 

interest and need for data. In 1980, the current health topics 

included smoking, special aids, and home care. The topic in 

1981 was child health. The 1982 topics were health insurance 

and preventive care. The 1983 questionnaire contained questions on alcohol, dental care, doctor services, ”and health insurance. The 1984 current health topic questiomaire was 

devoted entirely to issues of aging. Current health topics for all 

4 years are listed by subject in appendix IV. 

Data tapes with tindings from the current health topics can 

be purchased directly from the Division of Health Interview 

Statistics (301) 436-7087. 
Current heelth topics of the National Health Interview Survay, 1980-84 

Data collection 

Number of persons Period 

Persons eligible for in sample on Respondent 

Year and topic sample public use tape rule Weeks Other Sourcel 

1980 

Health insurance 

Home care 

Disability 

Speciel aids 

Corrective lenses 

Heering sids 

Residential mobility 

All household members 

All housahold members 

All household members 

All household members 

All household members 

All household members 

Selected household members 17 years 

102,629 

102,629 

102,629 

102,629 

102,629 

102,629 

24.104 

(2)

(*)

(2)

(2)

(2)

(2)

(2) 

348 

348 

348 

2.48 

348 

348 

348 

c 

c 

c 

c 

c 

c 

c 

and over 

Medicaid 

Aid to Families With Dependent 

All household members 

All household members 

102,629 

102,629 

(2)

(2) 

348 

348 

c 

c 

Children 

Retirement income All household members 102,629 (2) 348 c 

Smoking Selected household members 11,333 (4) Quartera 3 s 

17 years and over and 4 

1981 

Child health Selected child in household under 15,416 (5) 52 s 

18 years 

1982 

Health insursnca All household members 103,923 (2) 350 c 

Preventive care All household members 103,923 (2.6) 350 c 

1983 

Doctor sewices All household membara with doctor 20,579 (2) 52 s 

visit in last 2 weeks7 

Dental care All household members 105,621 (2.8) 52 s 

Health insurance All household members 52,743 (2) Quartera 3 s 

and 4 

Alcohol and health practices Selected household member 22,418 (9) 52 s 

18 years and ovar 

1984 

Heelth 

Supplement on aging Household members 65 years and 16,148 ,10, 52 s 

over and one-half of persons 55-64 

yaars and over 

lSource: c meana core/basic health and demographic questionnaire; S means supplement/current heskh toPics. 

insuranca Ail household members 105,290 (2) 52 c 

2Any “responsible,, sdult household member I g yeara of sge and over or any person who waa married may have answered the questions for all related household 

members. Single persons 17 or 18 yeers of age msy heve raaponded for themselves. 

3Number of weeks in NHIS aemple reduced because of budget COnstrainta. 

4The question hed to be completed by the ssmple person. A household resrzondent was accepted as proxy if the sample person were unable to reepond because of 

health, 

aTh.a prsferred respondent wes the biological mother if in the household, regardless of the chiltis ege, or the biological father if in the household snd the child was 

e yesrs or over. The biological father wes the respondent if in the household end the mother wes not e household member. If neither evsileble initislly or efter 2 

cellbacks, the respondent order was aa follows adoptive, step, or foster parent; legal guardian; primary caretaken end other Health Interview Survey eligible 

respondent. 

‘A proxy respondent wes not eccepted if the sample person wes not et home st tha time of the initial visit. At least 3 additional callbecks were made before e proxy 

respondent wes accerzted. 

71nCludesonly thoee ‘household members who stayed in bed more thsn half a dey because of iihess or injury. 

aQuestion 2 (Dentel cere) wes a self-response question for all persons 17 years of age and over. A proxy was eccepted if the person waa under 17 years if the 

person wea over 17 years, but physically or mentally incapable of responding; or if the person was over 17 years but temporarily absent and not returning during the 

Interview period. 

‘The questions hed to be complated by self-response. Proxies were not eccepted. Callbscka were made by telephone unless there was no phone or the respondent 

requested e return visit. 

10The semple persons responded for themselves. Proxiss wera sccspted when sample persons were physically or mentally incapeble of responding, whether or not 

temporarily abaent. 

NOTE All Interviews on these topics were conducted in person. 

3 
Survey instruments


Basic health and demographic 

questionnaires (formerly core): 1980, 

1982 

The 1980 National Health Interview Survey (NHIS) sample consisted of approximately 42,000 eligible households, 

which yielded a probability sample of about 111,000 persons. 

The fourth quarter of 1980, however, had a sample reduction 

of 4 weeks of interviewing because of budgetary constraints. 

During the 4/3 weeks of interviewing in 1980, the sample was 

composed of approximately 39,000 households containing about 

103,000 persons. Comparability with previous annual estimates 

is not affected by the reduced sample because the weighting 

procedure employed by NHIS adjusts for the missing weeks. 

Data collected in 1980 include information on acute illnesses 

and hjuries, disability days, limitations of activity due to 

chronic conditions, prevalence of selected chronic conditions, 

respondent-assessed health status, and measures of health care 

utilization. 

In 1980, a large number of the questions relating to the 

special health topics were included in the core questionnaire. 

4 

1980 
1980 Questionnaire 

O.M.0. . . NO.68-RI 6CO: Acmroval . Excdres March 31. !98’

5 
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--

--

--

--

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--

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

SP H 

u u 

la. What is the name of the head of this household? - Enter name in first column 1a. First name AGE 

b. Whet arc the nom-s of all other persons who live here? - List all persons who live here. Yes * No 

c. I have Iistad (Read names). Is th~e onyonc �lse staying here now, such as friends, relatives, or roomers? a � o1 — 

d. Hove I missed anyone who USUALLY lives htre but is now away from horn.?. . . . . . . . . . . . . . . . . . . . . . � � RACE 

�.Doanyaf thcpeoploin this hcwseholdhavea horny anywhcrs else? . . . . . . . . . . . . . . . . . . . . . . . . . . . . � n Last name IW 

‘Apply household memt,e,sh, p ,“les. 2s 

f.	 Arecnyof the persons inthishouschold nowon full-time 3 OT active duty with the Arrrred Forces of the United States?. . . . .. . . . . . I Y CoI(s). (Delete) 2 N 

2.	 How is related to (Head of household)? 2. Relationship SEX 

IM 

HEAD 2F 

3. Monti Oate Year 

3. What is--’sdote of birth? (Enter date and Age, andcircle Race and Sex) 

BED DAYS DV HOSP. 

L Ask Condition list_. Use Flashcard todetermine%mple persons; mark SP boxes. � ~;; o t#; � fro; 

l. Record the number of Bed Days, Doctor Visits, and Hospitalizations 

r 

L c —(N’) –(N”
–’Np) 2.	 Record each condition in the person’s column, with the question number(s) where it was reported. Q. No. Ccmditlon 

1 

Reference dates 1


1
 2-week period 1


I 12-month Bed Days 

and Doctor visit	 I 

1 probe 

Hospital probe I 

1 d 

If 17+, ask: 0 � Under 17 

4. Is now married, widowed, divorced, separated, or never married? 4. I � Married - spouse present 

S � Married - spouse absent 

2 (g Wtdowed 

4 � Oivorced 

5 � Separated 

3 H Never married 

,. 

If related persons 17 years old or over are listed in addition to the respondent, say: 0 � Under 17 

� would like to have all adults who are at home take part in the interview. H 1 � At home 

H : your --, your --, etc., at home now? If “Yes, ” ask: Please ask them to ioin us. 

2 n Not at home 

This survey is being conducted to collect information on the Notion’s, h&alth. f will ask about visits to’


doctors and dentists, illness in the family, ond other health related items. (Hand calendar)


The next few questions refer to the past 2 weeks, the 2 weeks outlinrd in red on that colendar,


beginning Monday, (date) , and �riding this past Sunday, (d ate) Y (5b) 

50. During those 2 weeks, did stay in bed because of ony illness or Iniury? 50. 00 N N age: 

.	 . .._ ______________________________ :________ 17+ (61 

6- I 6 (7) 

b. During that 2.week period, how many days did stay in bed all or most of the day? b._ Oays } Under 6 (9) 

6.	 During those 2 weeks, how many days did illness or iniury keep from work? 6. _ WL days (8) (For females): not counting work around the house? 00 � None (9) 

7.	 During those 2 weeks, how many days did illness or iniury keep from school? 7. SL days 

OO� None (9) 

If one or more days in 5b, ask 8; otherwise go to 9 

Days 8.	 On how many of these days lost from stay in bed all or most of the day? 8. —00 � None 

{ ~~~~o’} ‘id-- ~ 

in bed 

90. (NOT COUNTING the day(s) lost from work ) 9. .IY 

{ lost from school } 

Were there any (other) days during the past 2 week5 that cut &wn on the things 2 N (10) 

he usually does because of illness or iniury? 

..--. _ - _ - _ _ — 

in bed 

b.	 (Again, not counting the day(s) lost from work ) b.— Days 

{ lost from school } 00 � None 

During that pariod, how many (other) days did he cut down for os much as a day? 

If one or more days in S–9, ask i O; otherwise go to next person. 

Enter condiflon in Item C 

100. What cmdition caused to during the past 2 weeks? 100. Ask 10b 

{%!:’} 

Y 

b. Did any other condition cause him to b. 

N (NP) 

{!!%!’ }d”’:th”tperi”d’ 

C.	 What condition? c. Enter cotillion in Item C (iOb) 

I $ 

Fill item C, (BED DAYS), from Sb for all perscms. 

6 
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la, During the past 2 weeks, did anyone in the family, that is you, 

your , �tc., hove any (other) accidents or iniuries? 

..-I.---..-.---__-_.-_________-__--_"_-___-______-_______-?__-__-___-_____!-Y!!_ 

b.	 Who wos this? - Mark “Accident or injury” box in person’s column. � Acc!dent or iniury 

Injury 

c. What was the iniury? 

d. Did anyorm have any other accidents or iniuries during that period? Y (Reask I lb and c) N 

If “Accidento rinjurfi” ask 

� . As o result of the accident, did - - see a doctor or did he cut down on the things he usually does? 

., 

2a.	 During the past 2 weeks, did anyone in the family 

go to the dentist? Y N (13) 

b, Who WaS this? -Mark “Dental visit” box inperson’s column. 

c.	 During tho past 2 weeks, did anyone else in the family go to o dentist? Y(Reosk 12bandc) N 

If “Dental visit,’’ ask: 

d. During thcp.ast 2wecks, howmany times did --go to a dentist? 

Donotask for children I yr. old and under.


Mark box or ask:


ABOUT howlonghos it beerrsince LAST went too dentist?


‘OOTNOTES 

Y (Enter hrjury In item C) 

N 

1 � 2.weak dental visit 

2 �	 Past 2 weeks not 

reported (12) 

3 � 2 weeks-dmonths 

4 l_J Over 6-12 months 

5 � I year 

6 � 2-4 years 

70 5+ Years 

e I_J Never/a;e I or under 

7 

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L During the past 2 weeks (the 2 weeks outlinod in rcd on that calendar) how many times did sec a medieal doctor? 

_ Number of voslts 

(B-sides those visits) 

k,	 During that 2.week period did anyone in the family go to a doctor’s office or Y 

clinic for shots, X.rays, tests, or �xaminations? N (16) 

b. Who was this? - Mark “Doctor visit” box in person’s column. 15b. 

c.	 Anyone cl se? Y (Reask 15b and c) 

N 

If “Doctor vistt, ” ask: 

d. Hew many times did visit the doctor during that period? 

h. During that period, did anyone in the family gtt any medical advice from Y 

o doctor over the telephone? N (17) 

b. Who was the phone call about? - Mark “Phone call” box in person’s column. 16b. 

c.	 Any calls about anyorw �lse? Y (Reask 16b and c) 

N 

If “Phone call,” ask: 

d. How many telephone calls were made to get medical advice about ? d. _Number of calls (NP) 

}	 Fill item C, (DV), from 14-16 for all persons. 

Ask 17a for each person with visits In DV box. � Presnan.y (77e) 

7a.	 For what condition did see or talk to o doctor during the past 2 weeks? 17a. � No condition . . . . . . . . . 

b. Did see or talk to o doctor about any specific condition? b. Y N (NP) 

Enter condition In Item C c.	 What condition? c. Ask 17d _________ --_-- _-_--------- _ --, 

d. During that period, did see or talk to a doctor about any other condition? d. Y (17c) N (NP) 

c. During the post 2 weeks wcs sick because of her pregnancy? e. Y N (l?d) 

f. What was the matter? ‘ f. Enfer condition In item C (Vd) 

-

Ea.	 During the past 12 months, (that is since (date) a year ago), about how many times did see or 180. 000 � Only when in hospital 

talk to a medical doctor? (Do not count doctors seen while a patiant in a hospital.) 000 � None 

(Include the visits you olreody told me about.) _ Number of visits 

b. ABOUT how long has it been since LAST sow or talked to a medical doctor? b. 1 � 2-week DV 

Include doctors seen while a patient in a hospital. 

z �	 Past 2 weeks 

not reported 

(14 and 17) 

3 � 2 wks.-6 mos. 

4 � Over 6-12 mos. 

5 � I year 

6 � 2-4 years 

7 � 5+ yesrs 

s 0 Never 

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19.. What was doing MOST OF THE PAST 12 MONTHS - (For males): woklng or doing something else? 19. t � Working (24.@ 

If ‘“something else,” ask: (For females): kaaping hwse, working, or dehrg J 2 � Keeping house (24b) 

Ages b. What was doing? something else? 

17+ If 45+ years and was not “’working, ” “keeping house,” or “going to school, ” ask: 3 I_J Retired. health (23) 

c. Is retired? 4 � Retired, other (23) 

d, If “retired,” ask: Did he retire because of his health? 3 a Going to school (26) 

20.. What was doing MOST OF THE PAST 12 MONTHS - geing to school or doing something �lse? 6 � 17+ something else (23) 

Ages


6-16 If “something else,” ask: 7 � 6-”16 somsthing else (25


b.	 What WOS doing? ________________________________________________________________________ ___ ___________________ 

Ages 0 � I -5 years (27) 

under 6 0 � U rider I (22) 

!10.	 Is ctblc to take part at all in ordinary ploy with other children? ----. ----_ -____ ----------------_ -.--_ -----:____________________________________ ?;?- ___?-_ -.--____l_!_&z 

b, lshelimited inthektnd ofplayhe candobecaus@ of his health? b. z Y (28] N _______________________________________________________________________________ __ ___________________ 

c. Is ho limited in the amount ofplay because of his health? c. 2 Y (28) N (27) 

!2a, ls limited in any way because of his hcelth? 220. }Y 5 N (NP) __ ___________________ 

b. In what way ishe limited? Retard Iimitatian, notcanditian. b. (28) 

3a. Does health now keep him from warkirrg? 230. I Y (28) N __ ___________________ 

b.	 Is he limited in the kind of work he could do because of his heolth? b. 2 Y (28) N _______________________________________________________________________________ __ ___________________ 

c.	 Is h~ limited in the omourn af wark he could do because of his hwrltb? _~ _ _2_~_(_2:)_____________ _______________________________________________________________________________ 

d. Is h- limited in the kind ar amount of other activities bccatrse of his health? d. 3 Y (26) N (27) 

4a,	 Does NOW have a iob? 240. Y (24c) N _______________________________________________________________________________ ___ __________________ -

b, hr terms af haalth, is NOW able @ (work _ keephou@ atall? b. Y I N (28) _____________________________________________________ ___ __________________ -

c.	 Is he limit-d in the kind of (work - housework) he con do because of his health? _______________________________________________________________________________ ___ c. __________________ 2 Y (2a) N ~ 

d.	 Is he limited in the amount of (work - housewark) he con do because af his hatzlth? d. 2 Y (28) ___ _____________ ~_____ 

c. Is he limited in the kind or amount of ather activities becaus. of his health? e. 3 Y (28) N (27) 

5. In terms of health would be ablo to ga ta schoal? 25. Y 1 N (28) 

$a, Does (would) have to go to a certain type of schoal because af his health? ---------_ ----_ --_---_ -------_ --------_ -----_ --_--_ ----_ -__---__ -_------__ --_--..3 ?-- :-Y!! ?___ -___! ____, 

b, Is ho (would he be) limited in school attendance because of his health? b, 2 Y (28) N _______________________________________________________________________ _ __ __________________ 

c. Is hc Iimitcd in the kind or amaunt of other activities because of his health? c. 3 ‘r (26) N 

70. Is Iimitsd in ANY WAY bacause af a disability or health? 27 0. 4Y s N (NP) ________________________________________________________________________________ _ __ __________________ . 

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

been limited in 000 � Less than I month 

8tt. About how long has he been unable to a 0. 

{ had to go to o c~rtain type of school? } 1 — Mos. 2 — Yrs . ___________________________________________ _ __ ________________ 

b, What (other) condition causes this Iimitetion? b. Enter Condltfon h Item c 

Ask 28c 

If “old age” only, ask: Is this limitation caused by any specific condition? u Old a8e only (NP) 

_______________________________________________________________________________ _ __ __________________ -

Y (Reask N c.	 Is this limitation caused by any other condition? C. 26b and c) _ -_ ___________________ 

� Only I condition Mark box or ask: 

d. Which of these condition3 would you say is the MAIN cause of his limitation? d. Enter main condi ti.an 

9 
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9a. p_s-:z----"--_-------'--__---:-__:-___-_-:~:y_aj:~______________________________ o ~tlent m a hospital at any 390, tlmo slncc~ate) 

b, How many timss was in a hospital sine. _ (date) a Year WZo? T,mes(Item C) 

Da. Was anyone in the fomily in o nursing horn-. convalescutt home, or 

- similar place since ~date) 0 year ago? Y N (3/) 

----*-

b.	 Who was this? - Circle “Y” in person’s column, 3ob. Y. 

--,r ___________________________________________________________________________ .----------------

If Y,” ask: 

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

Ask for each child I year old or under if date of birth is on or after reference date. 

la. was born in a“hospital? 310. 

If “Yes,” and no hospitalizations entered in his and/or mother’s column, enter “I” in 29b and item C. Y N (NP) 

If “Yes,” and a hospitalization is entered for the mother and/or baby, ask 31 b for each. 

____________ b.	 Is this hospitalization included in the numb-r you gave me for --? b. If “No,”’ correct entries in 29 and item C for mother and/or baby. 1 Y N 

Oomo’mss 

10 
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32a. DURING THE PAST 12 MONTHS, did anyone in the A. Gallstones? 1, Any disease of the pancreas? 

family (you, your --, �tc.) have -

B. Any other gallbladder trouble? J. Ulcer? . .__. ________________________ __ If “Yes, ” ask 32b and c. 

C. Cirrhosis of the liver? K. Hernia or rupture? 

___ ____________________ b, Who was this? Enter name of condition and letter of fine 

1 where reported in appropriate person’s column in item C. D. Fotty liver? L. A disease of the. esophagus? . ____ ________________________ 

c. During the post 12 months, did anyone else have . . .? E. Hepatitis? M. Gastritis? ___ ________________________ -_ 

Conditions affecting the digestive system. F. Yellow ioundice? N, FREQUENT indigestion? ___ ________________________ __ 

Make no entry in item C for cold, flu, or grippe even G. Any other liver trouble? 0. Any other stonroch trouble? 

if reported in question 32. - -_ ___ 

H. Diabetes? P. Enteritis? 

32a. Dots anyorm in the family (you, your --, etc.) NOW have -

If “Yes,” ask 32b and c. A. Permanent stiffness or any deformity of tfw foot, leg, firrgcrs, mm or back? 

(Permanent stiffness - joints will not move at all) 

b. Who is this? Enter name of condition and letter of line __ where reported in appropriate person’s column in item C. 

c. Do-s anyone �lse have . . .? B. Paralysis of any kind? 

C. Arthritis of any kind 

}32d. DURING THE PAST 12 MONTHS, did anyone in the family 4 or Rheumatism? 1. Trick knee? 

. (you, your --, �tc.) have - If “Yes, ” ask 32e and f. 2 D. Gout? J. A slipped or ruptured disc? 

. ___ � . Who was this? Enter name of condition and letter of line 

where reported in appropriate person’s column in item C. E. Lumbogo? K. Curvature of the spine? . __ 

f. During th* past 12 months, did anyone else hove . . .? F. Osteomyelitis? L. REPEATED troubla with 

(os.tee.oh-my-uh.l	 ite-iss) neck, back, or spine? . 

Conditions C-N and V are conditions affecting the bone M. Bursitis or Synovitis? 

and muscle. G. A bone cyst or bone spur? (sin-uh.vit~.iss) . .___.. .__, 

H. Any other disease of the N. Any disease of the muscles 

bone or carti Iage? or tendons? ,:. . ,,. 

A. Geiter or other 

320. DURING THE PAST 12 MONTHS, did anyone in the thyroid troub la? . family (you, your --, etc.) have - Glandular 

B. Diabetes? disorders . ,-- If “Yes, ” ask 32b and c. 

3 b. Who was this? E“terrsame of comdition and letter Qf line 

C. Cystic fibr.asi5? 

. j 1 

where reported in appropriate person’s column in item C. D. Anemia? Blood disorder 

c.	 During the past 12 months, did onyone �lse hove . . .? E. Epilepsy? 

.-. Conditions affecting 

the nervous system F. Multiple sclerosis? 

G. Migrairm? : 1 

11

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----

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

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

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

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

----

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

----- ----

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----

----

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W. Cancer of the stomach, 

32a. DURING THE PAST 12 MONTHS, did anyone Q. Diverticulitis? colon or rectum? ________________________ in tho family htrvc -

If “Yes,” ask 32b and c, R, Colitis? X. During the past 12 months, 

. did anyone in the family 

b. Who was this’? Enter in item C. have any other condition of 

1 the digestive system? c. During tho post 12 months, did anyone S. Spastic colon? If “Yes, ” ask: Who was �lsthava . . . ? this? - Whet wos the 

condition? (Enter In item C) 

“Conditions affecting the digestive system. T. FREQUENT constipation? ____ -__- _---- _____ —_____ 

Make no entry in item C for cold, flu, or grippe even 

if reported in question 32. U. Any other bowel trouble? 

________________________ 

V. Any etirar intestinal trouble? 

32d. DURING THE PAST 12 MONTHS, did anyono O. A tumor, cyst or growth U. Dermatitis or wry other 

of the skin? skin trouble? in thm family havo - -

If “Yes,” ask 32e and f. P. Eczemo o! soriasis? V. TROUBLE with fallen arches, 

1’so.rye.uh.sis) flatfeet or clubfoot? 

� . Who was this? Enter in item C. _______________________ -. --, 

f. ~;~ ~~?post 12 months, did anyone �lse Q.	 TROUBLE with dry or W. TROUBLE with ingrown toenail s 

itching skin? or fingernails? 2 Conditions O-U and W-Z are conditions

affecting the skin. X. TROUBLE with bunions, corns, 

R. TROUBLE with acne? or callu5as? 

--__ -_-----_--------—--

S. A skin ulcer? Y. A disease of the hair or scolp? 

-_ A ---------------------

Z. Any disease of the lymph or 

T. A’ny kind of skin allergy? sweet glands ? 

H. Neuralgia or neuritis? 320. DURING THE PAST 12 MONTHS, did anyone -—_—--___-___-----—--—- - Conditions affecting the 

nervous system in the fami Iy hove -. l.. Sciatica? 

:_- - \ If “Yes,” ask 32b and c. J. Nephritis? —---------------- -

b. Who was this? Enter’ in item C. K. Kidney stones? 

3 c.During the past 12 months, did anyone L. Any other kidney trouble? 

�lse have . . . ? _-_--- __-__ — -

M. Blodder trouble? Genito-urinary 

—-- —- —------------— ___ - b conditions 

N. Prostote trouble? __-_ --_-. --___ -__ -—___ -

0.	 Disaos* of the uterus or ovwY? -

* P. Any other female trouble? 

12 

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32a. Does anyone in the fami Iy (you, 

your --, �tc.) NOW have -

If “Yes, ” ask 32b and c, 

b. Who is this? - Enter name of condition 

and letter of line where reported in 

appropriate person’s column in item C, 

c. Does anyone else have . . .? 

hearing 

A-L are conditions affecting vision 

{} speech 

2a. Has anyone in the family (you, 

your --, etc.) EVER had -

If “Yes, ” ask 32b and c. 

b,	 Who was this? - Enter name of condition and letter of line where reported in 

appropriate person’s column in item C. 

c. Hat anyone else � ver had. . .? 

Conditions affecting the heart 

and circulatory system. 

2a.	 DURING THE PAST 12 MONTHS, did 

srnyonc in the family (you, your --, 

�tc. ) have -

If “Yes, ” ask 32b and c. 

b. Who was this? - Enter name of condition 

and letter of line where reported in 

appropriate person’s column in item C. 

c,	 During the past 12 months did anyone 

�lse have , . .? 

Conditions affecting the 

respirator y system. 

A. Deofness in one or both ears? 

—--- —-- —----- .-. —-

B. Any other trouble hearing with one or 

both ears? ----. _— --— __ —___ .. ___ ___ I 

C. Tinnitus or ringing in the ears? 

. . —------- --—— . 

D. Blindness in one or both eyes? 

E. Cataracts? 

==4 

F. Glaucoma? . --—-----------------—-----—-- -. 1

A. Rheumatic fever? —-------- — -. I 

B. Rheumatic heort disease? 

C. Hordening of the arteries or 

arteriosclerosis? 

——--- —-------- —--- —--------- t 

D. Congenital heart disease? —--------------- —-------- L -. 

3.	 Bronchiectasis? (brong ke-ek tah-sis) .-- ——- —------- —-------— L -. 

= 

*lf reported in question 32 only, ask: 

H. A detachad retina or any other condition 

of the retina? 

______________________________ 

1. Any other trouble seeing with one or both 

eyes	 even when wearing glasses? _________________________ 

J. A cleft palate or harelip? 

K. Stammering or stuttering? ---— —--------------

L. Any ether speech defect? 

M, A missing finger, hand, or arm, toe, foot, 

or leg? . —----------------------

G. Stroke or o cerebrovascular accident? 

H. Hemorrhage of the brain? —-----------------

1. Angino pectoris? 

J. Myocardial infarction? 

K. Any other heart attack? 

F. Sinus trauble? 

G. Deflected or deviated nasa I septum? :--

H. *Tonsillitis or enlargement Of the 

tansils or adenoids? 

-—— 

1. *Laryngitis? 

-. 

-. 

.. 

.-

.-

.-

?& 

-. 

~ 

.-

1.	 How many times did hove . . . in the post 12 months? - If 2+ enter in item C. 

If only I time, ask: 

2.	 How Iang did it lost? - If I month or longer, enter in item C. 

If less than I month. do not record. 

If tansils or adenaids removed during the past 12 months, enter condition causing removal in item C. 

Make no entry in item C for cold; flu; red, sore, ar strep throat; or ‘“virus” reported 

in answer to question 32. 

13 
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U. PERMANENT stiffness or any deformity 

32a. Doss anyone in tho family NOW have - of the back, foot, or ieg? (Permanent 

0. Palsy or carcbral palsy? stiffness - joints WIII not move at all) 

______________________________ - If ‘“Yes,” ask 32b and C, 

V. PERMANENT stiffness or any deformity 

b, Who is this? Enter in item C. P. Paralysis of any kind? of the fingers, hand, or arm? —-- —---- ——— ______________________________ --- —------- —---

4 c.Ooes anyone �lse have . . . ? Q. Curvature of the spine? W. Menta I retardation? 

-

Conditions O-W are impairments. X. Any condition caused by an old accident 

Conditions.Y and Z affect the R. REPEATED trouble with back or spine? 

or iniury? If ‘“Yes, ” 

condition? 

ask: What is th. 

nervous —-- — system. 

S. Any TROUBLE with fallen arches or 

flatfcot? Y. Epilepsy? 

—- —- ——--— — - ----------------

Z. REPEATED convulsions, seizures, or 

T. A clubfoot? blackwts? 

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

32a. DURING THE PAST 12 MONTHS, did L. Damaged h-art valves? R. Gangrene? 

anyons in the family (yau, ywr --, —----------—-- —-------- - -etc. ) have - M. Tochycardia or ropid heart? S. Varicose veins? 

—-------- ——-------------- . If “Yes,” ask 32b and c. 

N. Heart murmur? T. Hemorrhoids or piles? 5 b. Who was this? Enter in item C. —- —-------- —----- —- ———-

c.	 During the past 12 manths did onyono O. Any other heart trouble? U. Phlebitis or thrombophlebitis? 

—--------- ————--------—-- — �lse havo . . .? 

P. Aneurysm? V. Any other condition affecting 

Conditions affecting the heart ______________________________ ___ blood circulation? 

and circulatory system. Q. Any blood clots? 

J. Tumar, c st, or growth of the 0. Tumor, cyst, or growth of the 32a. DURING THE PAST 12 MNTHS, did bronchio r tuba or lung? throat, larynx, or trachea? anyone in tho fomily have - ______________________________ . __ _ - _ - —------------------------- . ___ 

If ““Yes,” ask 32b and c. K. Emphysema? 

- = ______________ . __ P. Any work. related respiratory condition 

b. Who was this? Enter in itam C. such as dust on the lungs, 

L. Pleurisy? silicosis or pneu.mo.co-n i-o.s is? 

c. During the post 12 rno”ths, did onyo~ _______________________________ - . 

�lse have . . . ? Q. During the past 12 months did anyone in 

M. Tu’barcldosis? the family have any other respiratory, 

Make no entry in item C for cald; flu; ______ :______________ ___ ~f~y+~~ ptr Imonar cod tion? 

red, sare, or strep throat; or ‘“virus” 6 , ask: #ho was this? - What

reported in answer to question 32. N. Abscess of the lung? was the condition? (Enter in item C) 

Conditions affecting the 

respi ratary system. 

14

--

33. Compared to othsr pwsons --’s age, would you soy that his health is excellent, good, fair, or poor? 33. IE2G3F4P 

. . 

1 � I + Bed Days 

Mark box(es) from item C, 

BD ‘n 

1+ Hospital .%ys

BD 3 � No Bed Days 

14. During the past 12 months (that is since (date) a year ago), ABOUT how many days did 34. 0 � None 

illness or iniury keep in bed all or most of the day? 101-7 

(Include the days in the past 2 weeks.) (Include the days while o potient in o hospital.) 2 � 8-30 

(Was it more than 7 days or I*.s then 7 cloys?) 3a31-180(l -61n0nrhs) 

(Was it more than 30 days w less than 30 days?) 4 � 181+ (6 months +) 

(Was it more than half the year or less than half the year?) 

R 

For persons 17 years or over, show who responded for (or was present during the 

R 

1n ResPMded for self-snci rely asking of) Questians 4-34. 

2 � Responded for se! f.pzdy If persons respanded for self, show whether entirely or partly. For persons under 

Q’s 4-34 l? show wha respanded far them. Perscm_was respa”dent 

=OOTNO-KS 

w 

15 
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CONDITION 1 

1. Person number Name of condition 

1 

2. When did lost see or tolk to o doctor about his . . .? 

lo In Interview ID Past 2 wks. (Irem C] SD 2–4 yrs. 

week 213 2 wks. -6 mos. 6D5. yrS. 

(f?eosk 2) sOOver 6-12 mos. 7 � Never 

40 I yr. SD DK If Dr. seen 

9D DK when Dr. seen 

Examine ‘a Name of condition” entry and mark 

AJ	 Cl Color bl,nd”ess (NC) ~ On Card c (,42) 

� Accident or injury (A2) � Neither (3a) 

If “Doctor not talked to,” transcribe entry from Item 1. 

If “Doctor talked to, ” ask: 

30. What did the doctor say it was? - Did he give it o medical name? 

Do not ask for Cancer U On Card C (A2) 

b. What was the cause of , . .? 

U Accident or injury (A2) 

If the entry in 3a or 3b includes the words: 

Ailm.nt Condition Disorder Rupture 

Anemia cyst Growth Trouble 

Asthma Defect Measles Tumor Ask C: 

Attack Disease Problem ulcer } 

c. What kind of . . . is it? 

_________________________________________________ 

For allergy or stroke, ask: 

d, How does the allergy (stroke) affect him? 

_________________________________________________ 

If in 3a-d there is an impairment or any of the following entries: 

Absc*ss Damage Poralysis 

Acht (excapt hood o, �m,) t?rowth Rupture 

Ble*ding Hemordmgc Sore(ne. s) 

Blood clot lnf*ction Stlff(ness) 

Boil Inflammation Tumor Ask e 

Canc*r Neuralgio ulcer 

cramps (*xc*pt Neuritis Varicose vbins 

mrnswuol) Pain Weok(ness) 

cyst Polsy 1 

� . What part of the body is affected? 

Specify Show the following detail: 

Heed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..kul\. &alp. face 

Back/spine/ve,tabrae . . . . . . . . . . . . . . . . . . . . . . . . .Upper, ~fdd[e, lower 

Side . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . ..left ~rrig~t 

Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . inner or outer; left, right, or both 

Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..lef.. r.ght. or both 

Awn . . . . . . . . . . . . shoulder, upper, elbow, lower or wrixt; left, right, or both 

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

Leg . . . . . . . . . . . . . . . .hip, upper, knee, Iowet, oronkle; Ieft, right, or both 

Foot . . . . . . . . . . . . . . . . . . entire foot, arch, or toes only; loft, right, or both 

Except foreyes, ears, or internal organs, ask if there are any of 

the following entries in 3a-d: 

Infection s ore SOren*ss 

f.	 What pert of the(part of body in3e)is affected bytht (infection/ 

sOre/sOreness) - theskin, muscle, bone, orsomcotherpcrrt? .SPecify~ 

_________________________________________________ 

Ask if there are any of the fol[owingenrries in 3a-d: 

Tumor cyst Growth 

g. Is this (tumor/cyst/growth) malignant or benign? 

I � Malignant 2 u Benign 9DDK 

)42 “k::~;~lq”estion’a::;:~~ ‘orheygi: ;tered in: . 21_JQ.3a 4DQ.3c .sOQ.3e 

L During thepost2wo~ks, did his . . . couschirn 

to cut down on the things he usuolly does? IY 2 N (9) 

5. During that period, howmany doysdid he cut 

down	 foros much as a day? _ Days 

oom None (9) 

5. 2&ringth at2-wcekpariod, howmanydoys did I _Days .	 . . . kccp him in badallor most of the day? oom None 

Asklf 17+ years: _Days (9) 7.	 Howmanydays did hi. . ..keephim from work 

during thot2.weck period? (For females): not 

countina work around the house? 000 None (91 

Ask if 6-16 years: 

L	 Howmony days didhis. ..keep him from _ Days 

school during that 2-week period? 00U None 

?. Whmndid first noticc his...? 

10 Last week 4D 2 weeks-3 months 

ZD Week before so Over 3-12 months 

3D Past 2 weeks-DK which GO More than 12 months ago 

(Was itduring thcpost 12months or baforathot time?) 

(Was it during the post 3 months or before that time?) 

(Was it during the past 2 weeks or bcfert thot time?) 

I � Notaneyecond. (AA) 30 First eye cond. (6+ yrs.) 

2D	 First eye cond. (10) /43 (under6) (AA) 411 Nut first eyecond. (AA)

O. C.n see well �nough to read ordinary ncwspcrper print 

WITH GLASSES with his Iefi eye?, ..l Y 2N 

right ye?. ..t Y 2N {1 � 

FOOTNOTES 

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I � t-lissing extremity (A4) IA41 � Accident or injury � Other (NC) 

AA	 2(_J Contliticm in C2 does not have a letter as source (A4) 

s a Condition in C2 hasa Ietteras source, Doctor seen(n) 17a. Did the occid.nt happen during the post 2 years or before that time? 

QUCOndition in C2 hasa Ietteras source, Doctor not seei (15) (_J During the past 2 years � Before 2 years (18cI) _________________________________________________ 

11o.
Does NOW tako any madicine or troatmont lY. b. When did the accident happen? 

for his . . .? z N(12) � Last week a Over 3=i 2 months . 

b. Was any of this mcdicirw or treotmcnt rccommcndod I Y � Week before D 1-2 years 

by a doctor? 2N � 2 weeks-3 months 

12. Hos h~ cv~r had surgary for this condition? lY 180, At the time of the accident what port of the body was hurt? 

2N What kind of in@y was it? Anything else? 

Part(s) of body Kmd of ,njury 13, Was ho cvor hospitolizcd for this condition? lY 

2N 

__________________________________ 14. During the post 12 months, abaut how many times has 

sacn or talked to a doctor about his . . .? _ Times [ i 1 i 

(Do not count visits whil* a patient in o hospital.) 000 � None If accident happened more than 3 months ago, ask: 

15a. About how many days during tho post 12 months has b. What port of the body is effected now? 

this condition kept him in bcd all or most of the day? _ Days How is his affected? Is he affected in any other way? 

ooa � None Part(s) of body Present effects 

Ask if 17+ years: 

b.	 About 

this condition 

how many 

kept 

days 

him 

during 

from work? 

the past 12 months has _ Days ______

Far females: Not counting work around the house? 000 � None t 

1 11 

Ida. HOW offan dots his . . . both-r him - all of tha time, often, 19. Where did the accident happen? 

onto in o while, or never? 1 � At home (inside house) 

I u All the time 2 n Often 3 D Once in a while 2 � At hame (adjacent premises) 

s � Street and highway (includes roadway and public sidewalk) 

o � Never (16c) a (_J Other - Specify 4 � Farm 

________________________________________________ . S � industrial place (includes premises) b.	 Whwr it daas bother him, is he bothered a great deal, some, or very little? 

G � Schooi (includes premises) t � Great deal 2 � Some 3 n Very little 7 � place of recreation and sports, except at school 

4 � Other - Specify a � Other - Specify # 

& ---------------------------- , 

n Ail the time in 16a OR condition list 4 asked (A4) 20. Wos at work at his iob or business when tho accidwrt hoppened? 

c. Does still have this condition? lY 3.CI while in Armed Services 

I Y (A4) N 2N 4 � Under 17 at time of accident :________ 

d. Is this condition complatcly cur~d er is it under control? 21r2. Was a car, truck, bus, or other motor vehicle 

2 � Cured 3 D Under control (A4) involved in the accident in any way? lY 2 N (NC) 

40 Other - Specify (A4) b. Was more then one vehicle involved? Y N . _________________________________________________ 

c. About how long did havr this condition before it was cured? 

o D Less than one month — Months — Years c. Was it (either one) moving at the time? lY 2N 

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2-WEEKS DOCTOR VISITS PAGE 1. Parson number 

Earlier, you told ~. that had seen or talked to a doctor during tho past 2 wcoks. 20. 7777 � Last week 

OR 

!o. on what (other) dates during that Z.weak period did visit or talk to o dotter? _- —. Date 

{ Ease � Week before 

Month . .__ ,,, ____ ________ 

Y (Reask 2a md b) N (Ask 3-6 for b. Were there any othrr doctor visits for him during that period? b. each vlslt) 

1. where did he sre the doctor on the (date),h ata 3. 0 � while ,nPatlent ,n hospi;al (NOXI DV) 

clinic,	 hospital, doctor’s office, or soma ot cr placa? 1 � ~clOr’s office (croup pracuce ~ doctor, s clinic) 

If Hospital: Was it the outpatiwrt clinic 2 � Telephone or thr �mcrgancy room? 3 D Hospital Outpatient Clinic 

If Clinic: Was it o hospital otttpatiwtt 4 � Home 

clinic, a company clinic, or some othar 5 � Hospital Emergency Room 

kind of clinic? 6 � Company or Industry Clinic 

7 � Other (Sp80//y) ~ 

1. Was th. doctor a g-oral practitioner or a specialist? 4. 01 n General practitioner � ~eCiaII~t -

What kind of specialist is ha? 

7 

. During this visit (call) did actually s~e (talk to) the dactar? 5. IY 2N 

a. Why did he visit (call) tha doctor on (date) ? 6a. 

Write in reason 

1 n Disc. or tr.zatmsnt (6c) 

Mark appropriate box(es) 3 � General checkup (6b) 

2 (_J Pre or Postnatal care 

4 I_J Eye exam. (glasses) (&v;l 

5 � Immunization 

6 � , Other } __________________ _______________________________ 

b.	 Was this for any specific candition? b. Y (En tar cwrttit/on in 6a N (Next DV) 

snd cfmrrge to ““D/ag. or treafmsnt””) —----- Mark box or ask: � Condition raported in 6a 

C. For what cettdition did visit (call) tha doctor en (date) ? e. 

‘OOTNOTES 

PI A Candition page is required for the conditian in questian 6. If then? is no Condition page, enter condition in item C and 

fi II a page for it after completing columns for all required dactor visits. 

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1 

HOSPITAL PAGE 1. P*rson number 

YOU said that was in tho hospitol (nursing horn.) during fhc past year. USE YOUR CALENOAR Month Date Year 

. M*II did �ntar tiw hospitol (nursing home) (th. last time)? Make sure he YEAR is correct 2. 19_ 

Name 

Street . Whet is the rromo and oddrcss of this hospital (nursing home)? 3. 

City (or county) State 

How many nights was in the hospitol (nursing honm)? 4. Ni;hts 

Complete 5 from entries in 2 and 4 if not clear, ask the questions. 

a, How merry of those nights wore during ths past 12 months? 50. __-_--__N::h:____________________ 

b, How many of those nights were during tlw past 2 weeks? b. --_-_-__N_i:h:____________________ 

c. Was --still inthchospitol (rrursinghomo) lost Sundoynight for this hospitalization (stay)? c. Y N 

Far what canditian did �nter the hospi~l (nursing horn.) - do you know tfm mdical trams? 6. � Normaldelivery a Normal at birth 

If medical name unknown, enter inadequate description, Condition 

_______________________________ For delivery ask: 1

1 Show CAUSE, KIND, and Cause (J On Card C � Ac.. or l“j. 

Was this a normal delivery? If “NO,” ask: 1 PARTOF BODY in same _______________________________ 

For newborn, ask: Whet wos the matter? 1 detail as required for the Kind 

Was the baby nonnol ot birth? 1 : 

I 

I Condition page. 

Part of body 

0, Wcreonyopemtiarrs perfarmedon during this sfeyotthc hospitel (nursing home)? ~: __-y--_--___-iN-(~_x:_HyP]____,__, 

b. What was the name of the operotion? b, 

If name of operation is not known, describe what was done. - -

Y [Oescribe) 7N 

c. c. Anyothoropemtians during this stay? 

00TNOTES 

A Condition page is required if there is an entry of “I’’orm orenights in 5b. If there isno Condition page, enter P2I condition in item C and fill a page for it after completing columns for all required hospitalizations. 

19 
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HEALTH INSURANCE PAGE 

M*dicaro is a Social Security health insurance program for disabled persans andjpr ptrsans 65 ytars old and 

over. Poaple cavcr~d by Medicare have a card that Iaaks like this. Shoiv card 

la. lsanyane inthisfomily covercdby Medicare? Y N(4) DK 

b. IS cev=red? Mark box in prysant~Ca[umn. 1b.	 1 fgcov. 9UDK 

zm Not COV. 

Ask fareach persanwith’”Cavered” in lb. 1 � C6V. HO$P. sDDK 

20.	 IS _- Cover.tf bY that part of Social S.curity Modicrzre which pays for hospital bills? Mark bax in person”a calumn. 2a. 2DN0 . 

b. IS cav.r.d bv that Dart of Medicare which nays for doctor’s bills, that is, the Medicare tslan far which 4 h. 1 � COV. Med. 90DK 

Ask for each person with “DK” in 2 and far each person under 65 with “Covered” in I b. 1 � Cov, HOSP. 3 � ~d 

3. Maw I nksa see ths Sacial Sectrritv Mrdicarc card(s) far --(and --) to determine the (tveddates) of caverage? 3. —. 

I We are interested in all kinds of health insurance plans �xc*pt those which pay only far accidents. m 

I c.	 Is anyane in the family cavered by any ather haspital insuranco plan? Y (Reask 4b and c) N -______---___-____---—_ 

d. Is anyane in th~ family cavered by any (other) hwzlth insurance plan which 1 

5C. Daes this plan pay any port &. IS-- Cover.d under ?fri -— of hospital �xpenses? (name) plan? 2 m Not COV. (NP) __-___ I~___2_N 9 DK-­ , . 

d. Does this plan pay any port b. During the past 12 manths b, 

of doctar’s or surgoan’s bills did receive medical care lY 2N s DK 

far operati~~s? ~ N which has bees or will be 

.9DK paid far by this pftrn? 

Daos this plan pay any part ~. is Cov.r.d und. r this 1 � Cov. 

2 I of hospital �xp.nscs? 

__-___I~- 2 N 9~&_. ~ plan? 

—-----

2 � Not COV. (Npj 

50.	 Was this _@EL plan abtained thraugh 

an �mployor @ unian? d. Daes this plan pay any part b. During the past 12 mantbs 

1Y(5c) ZN 9DK af doctar’s or surgean’s bil Is did recc{ve medical care iY 2N s OK 

b.	 Was it obtained through ~a~ ath~r~ro~pJK far operati~ys? which has been or will be 

2N sDK. paid far by this plan? 

P LAN 5c. Do.s this plan pay any part 6a. [s =evered under this. -z 1 n Cov. 

3 of hospital �xpanses? (narns) plan?. 2 � Not COV. (NP) __-___~~___2-N___~Q~-- ____________________ , __________________ 5a. Was this (name) plan abtairmd thraugh d. Daes this plan py any part b, During the past 12 months b, 

an �mplayer or unian? 1Y(5c) 2N 9DK af dactar’s ar surgeon’s bills did receive medical care IY 2N s OK which has bewr or will tie 

-“:4 L. l.” �t.:. “1”..9 

I For each person review 1,2,3, and 6 for each plan and determine if “Covered” by either Medicare or irraorance, or “Not covered.” I tn CW.(NP) 2 � Nucw.(NPJ 

Ask far each person “Not covered,” Ciroleall reescxrs given ~ 123456789 

Many peaple do nat carry health insurance far variaus reasons. Hand Card N P 

7a. Which _________ of thosa statements describes _____________ why is not eovared by _- any ________________ hcolth insurance plan? Any other reason? ___________ -7:_ ____ -__pp:~f[)--------

Mark bax ar ask: 00 I_J Only one reason 

b. What is the MAIN roasan i9 nat covered by any health insuranco plan? b. 123456789 F 

l.clnw if wI 

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HOME CARE PAGE 

Somtpooplcar* limitad inwhatthey condo bacausa ofaphysical orwntal condition; that is, 

they cttnnotda soma of the drtilyactivitios that other pooplc do. 

la, Bccauso of a disability or health problem, d-s Ii “doesn’t do,,, Dc.es r.ceive D-s __ need help from anether person in 

(a~ most of the time, somo of th@ anyano in the family, (that is yau, yaur --, �tc.), i%; ::;:%, ~ ~i%%Epip time, or once in o whila? 

receive ar nood help fram anather pwsan, ar US* pers~ Activity Doesn’t do SPECIAL PERSON in 

special cqulpm*nt in - number EQUIPMENT in (a-? 

Y or (-)? 

If “Yes, ” ask lb and c “doesn’t do” N ... (a) (b) ‘ 1 (cJ‘ I (d) I (e) I (?J 

(1) Walking, �xe+ for using stairs? n D.cesn’t , m Al l/m.., A .W n . ..-.-, . . . . Mark (2) Gaing outsid*?. . . . . . . . . . . . . I -do... I ,Y *N I I-Y 2t4,rJext12H=:”--- s n Other - f:n,acif”1 “ 

(3) Using tht toilet in the bothroom, . . . I I 

including getting ta the brithraam? � :O-sn’t — —.. x 

1 U All/most 4 U Never Mark (4) Bathing, including spongo both.? 

(Mark H box, “zN 

., !Y 2 N (Next 2 � so~ 8 D Other - Specify H 

(5) Dressing ? . . . . . . . . . . . . . . . 7“=., .-, Ilne) 3 � Once box 

1 I ,,, -,. ,., I ) (6) Eating? . . . . . . . . . . . . . . . . . m r. ---,. u ;O==n 1 1 � Al I/most 4 � Never (7) G*tting in and aut af bod or choirs? II - . “ - ., ,., . ... . n c.- - ~ Other - SpecNy1 ‘tik (Mark H box, ~y 2N 1’ Z N [NWXF . u --ss= -L 

:HEN Ic) line) 3 � Once 

b. Who is this? — :’”’ c. Dacs anyana �lso rocaivt ar need help ar usc � :Oyn”t I � All/most Mark 

spacisl	 �quipmont in - ? [Mark H box. tY 2N lY 2 N (Next 2 � some J ucner - Spec/fy \ H —-

YHEN w - Ilne) 3 U unce Jbox 

2a. BECAUSE OF A DISABILITY OR HEALTH 

PROBLEM, daos anyone in tho family roceivo (1) Preparing their awn meals?. . . . . . . . . . . . . . 

or nood help from an”othar persan in - (2) Shopping for pcrsornl it 

If “Yes, ” ask 2b and c. tailet items, ar medicine ‘- ‘::;:::~ 

‘ 

2b g~:ey ~ 

(3) Doing routirm ‘nousenold‘ ‘ choras, not 

b, Wha is this? including yard Iwa,k$-. . . . . . . . . . . . . . . . . . ..-. 

c.	 Daes anyenc �ls~ receive or need heip in - ? (4) Handling their own mon~ — 

3a. Bocaus. af a disability or h.aith probl.m do.s anyon. in th. family usually .,.2 

stoy in bad all ar most of the tima? Y N (4) 1? 

f-- 4’ -—

b. Who is this? Mark box in person’s column. � Stays in bed (HbGx THEN SO) 

c. Anyone �Is*? Y (Reask 3b and c) N 

Mark box or ask: H No H box (NP) 

&. What (othor) condition cousos --_______ —________________ 

b. DO*S any othor canditian cause to (need help in wt ivities in I and~ /(or) stay in bed)? b.	 t y (Reask 4a and b) z N _______________________________________________________________________________ —————------ —-------

Mark box or aslc � Old age only (NP) 

c. Which of thasc conditions would yau say is tho MAIN condition that cousos to (need help in c. n Only one condition 

activities in I and 2/(ar) stay in b*d)? Main cond it ion 

Refer to item C2 ta determine if a condition page was (NP 

HCl completed for the main canditian in 4. HC1 Cond. number 

Enter condition number, or mark box. � No condltian pa;. 

5.	 When did first natico his (main condition in 4)? 5. 1 � Last week 

2 � Week bef txe 

3 � Past 2 weeks, OK which 

�U2w=e~ -3 m~ths 

s � Over 3-12 months 

6 � Mare than 12 months �go 

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60.	 Doos anyorw in tho family hove a colostomy, a urinary cathator, or any other device to help 

control bowol movaments or urination? Y N (7) 

b.	 Who is this? Mark “Device’” box in person’s column. 

---_ -------------______---------------___2____________________________________ 

c. Anyone �tse? Y (Reask 6b and c) t.1 

If “Device,” ask6d and e t I_J Colostomy 

d. Which doos hove - a colostomy, o catheter, or anothor typo of dovicc? d. z Q Catheter 

o � Otlmr - Specify P 

----, 

. . Doss racoive or nocd help from anothor person in taking cam of his (device in 6d)? � . 

‘ y $!.%%w 2 N 

7CI. (Besides --) Does arryono (else) in the family have any accidants or any 

troublo controlling their bowel movomtnts or urination? Y N (8) 

b.	 Who is this? Mark “Trouble controlling” box in parson’s column. 7b. I � Trouble cantrolllnc 

______________________________________________________________________________ 

c. Anyorm �lsa? Y (Reaak ?b and c) N 

80. Does onyorm in th~ family (that is yau, your, -- �tc,) now use (ony of the following spaclal aids) - 8b. t � Artificial arm 

if “Yes,” ask 8b and c YN 2 � Artificial Ies 

(l) An artificial arm? . . . . . . . . . . . . . . . . . . . . . . . .. OO. .$ . . . .. O.. OO. . ..+ 00 .(l) 3 � Brace - fart of bodyP (2) An artificial lag? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (2) 

(3) A braco of any kind? (If “Yes,” ask On what part of tho body is tfm brace worn?) . . . . . (3) 

(4) Crutches? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (4) 4 � Crutches 

(5) Acanoor walking stick? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..(5) 5 � Cane or walking stick 

(6) SP~CiOl sho~s? . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (6) e � Special shrns 

(7) A wheal chair? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . 

(8) Awalkcr? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 . . . . . . . . . . . . [; 71_JWhecd chair 

(9) A guide dag?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .: .,. (9) s � Walker 

(lO)Any other kind ofaidfor gatthrg around? . . . . . . . . . . . . . . . . . . . . .. . . . .,4. . . . . ..(10). 9 � Guide dog 

b. Who is this?Mark box in person’s column. 10 � Other - SpeolfyP 

c. Anyane �lse? 

la. Dacs anyane in tfro family us”e- YN gb. lnEyaglasses 

If “Yes.” ask9bandc 

(1) Eyeglasses? . . . . . . . . . . . . . ...”.. . . . . . . . (1) 2 � Contsct lenses 

b. Who is this? Mark box in 

person’s column (2) Cantact lenses? , . . . . . . . . . . . . . . ...”.....(2) 3D Hearln; aid 

c. Anyono �Is.? (3) A hearing aid? . . . . . . . . . . . . . . . . . . . . . . . (3) m 

Da.	 Doss anyane in the family racaive help here at home with - YN 10b. 1 � Injections 

lf’’Yes: ask 10bandc (l) Rocoiving in@tionsor shots? . . . . . . . . . . ...(1) 2D Physical therapy 

b.	 Who is this? Mark baxin (2) Physical thempy? . . . . . . . . . . . . . . . . . . ...(2) 3D Sandages 

person’s coiumn (3) Changing bandages? . . . . . . . . . . . . . . . . . ...(3) 

e. Anyorw �lse? (8) Anyothor nursing orm*dical troatmmrts? . . . ...(8) � s � Other - SPo//y P 

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Ila. During tho post 12 months, (that is since (d&e) o year age) 

hos anyanc in the family reccivcd MEALS that were prepared 

outside tha homo and brought in on a fairly regular bosis? Y N (12) 

,. 

b. Who rocaivad the meals? Mark “’Meals” box in person’s column.. IIILI.I ! nMaals 

c.	 Anyorw �lsc? Y (Reask 1lb end c) N 

_______________________________________________________________________ 

If ‘t~als)t in I lb,ask I Id-e 

d, Does NOW regularly roccive meals that arc prepared outside the horn. and brought in? d. tY 2 N (NP) 

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11’ 

� . What agarrcy, organization or program providos these mesrls for --? 

12a.	 During the past 12 months, has anyorm in the family rmceivcd any car. 

at horn. from a nurse? Exclude related HH members. Y N (//fCP) 

b. Who rcceivcd the car-? t-lark “Nurse” box in person’s column. I 124 I � Nurse 

c. Anyorm �lsa? Y (Reask 12b and c) N 

‘OOTNOTES 

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Complete for each person with H box INDIVIDUAL HOME CARE PAGE 1. Person number 

20. Earli*r yousaidthot racaivcs ornecdsthehclpof another person. Who helps --? 2a. 1 � Related HH members 

2D Nurse (Is halpcd by anyerm who Iivcs hors, by �ny othor friends or rclativas, a nurse, or any ~ •~o~k~rhealth other harlth care professionals who come into tha home, or is helped by someone else?) - Specify 

4n Other relatives or friends 

8 nOther - Spec/fy . —- —_________________________ 

b. Does anyone els. help --? b. Y (Reazk 2a and b) N 

If “Nurse” in 2a, ask: 

3a. On the average,_----how many doYs Per week does the nurse visit -~ ———__ - _____________________________________________ -K ._-!’YY_V!!!_______________

b.	 When the nurse visits, how many hours per day does he or she usually spend helping --? b. 00 � Less than 1 h~r Hours —_____________________________ 

c.	 Does onyonc in the family, that is you, your --, etc. pay any part of the cost for the nurse? lY 2N __=: -_ ————________________ 

d.	 ——Does — any government agency or program help pay for the nurse? d. lY 2 N (3f) ______________________________________ _ __ ___________ 

� . What agency or program helps pay? e,	 1 � Medicaid H Other - SpmNyF 

z � Medicare 

3 � Health insurance -—- ---___ —_ ——______________________ 

f. During the post 2 weeks, how many times was visited by he nurse? f. Number of times 

If “Other health worker” i“ Za, ask: 

4a. On th~ avera~o, how many days per week does the (other health worker) visit --? 4a. . Days per week ----———- ___________ ___ —-- —--- —----- ——------- —------ -—- —_________________________ 

b.	 Wlrur —______________________________ thr (gjher health worker) visits, how rsasy hours per day dees _____ he or she usually spend helping --? ______ __ b. 00 

__ � Less than I hour — Hours

c.	 Decs —enyorm 

_______________________________ in the fami Iy, thet IS you, ywr --, etc. pay any part of the cost for the (other health worker)? ___ __ c! ry ZN

d.	 Does any government agency or program help pay for the (other health worker)? d. lY 2 N (4!) --_---- ——___— —__________________ 

c.	 What ag.ncy or program helps pay? e. I � Medicaid � Other - Sp.0Ny7 

2 � Medicare 

__ 3 � ‘ea’th ‘“suranc= _________ 

f. During the past 2 weeks, how many times was visited by the (other health worker)? f. . Number of times 

HC2 I HC2 1 � Under 17 (NP) 2017+ 

50. Does receive or need help from others in using public transportation, 50. 

such buses 1 Y 2N 4 � Doesn’t use (5c) —- _-- as —-—-J____trainsl subway sz~~planes? ___ __ -_---- (6) 

———-—_ —___________________ 

b.	 Does use public transportation? b. 1 Y (6) 2N ---__ —- ——_ —__________________________ ____ __ _______ 

c. If hod to USQ public transportation, would need the help of other persons? lY 

6a. Does 

_-__:: !Ii:::5:Y--_-_________ --_____ -.______________ ;________________ ::; -:;;::G----------:A--;6-;;:---­

b. Does not drive a cor because of a disability or health prablem or because of same ather reasan? b. 2 I_J Disability 

70.	 Doos usc the telephane without the help of another person? -_ _ y: 1 Y(8) 2N _ 

b. Warsld be able to use the telephorm in an emergency? b. lY 2N 

8a. During the 2 wacks outlined in red on tha calendar, did hava any visits from a friend, relative or neighber? ea. 

___ - ‘y ZN @:)__--

b.	 How many times during that period was visited by friends, relatives or neighbors? b. 1 � I-3 times 3n13+tirn2s 

(Was it 3 or more times or less than 3 times?) z � 4-12 times (Was it 12 or more times or 1-ss than 12 times?) -——- L ___________________________ 

c.	 During theso 2 weeks, did go out ta visit a friend, relative or neighbor? c, ___ - ‘ y _____ ‘N (9) 

d.	 How many times during that period did ga out to visit friends, relatives or neighbors? d. 1 � I-3 times 3D13+tlms 

(Was it 3 or more times or less than 3 times?) 2D 4-12 times 

(Was it 12 or mar= times or less than 12 times?) 

9. During the past 12 months, did go on a vacation? 9, lY 2N 

10. Because of a disability or h~lth problem, how often must someone be here with --, 10. ! � Most/All 4 � Never 

most	 of tha time, $ome af the time, once in a while or never? 2 � Some s � other - sP*c/fY~ 

3 � Once 

24 
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-- --

--

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--

--

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--

RESIDENTIAL MOBILITY PAGE 

1 I_J H box, 17+ (1) 

RM1 RM1 2USP, 17 + (1) 

3 � Other (NP) 

Complete la and b from household composition items, if not clear, ask: 

la, 1s rclatod to any persons now living in this housohold? 10. lY 2 N (2) _______________________________________________________________________________ .__. ___________________ 

b. Is naw living with --’s: b. 1 m Brothtr/sister 

(1) Brothor or sister? 3 � Parent 

(3) Father or mothar? MARK ALL THAT APPLY 5 � Spouse 

(5) (Husbond/wife)? 7 � Son/daughter 

(7) Son or doughttr? o � None of the above 

2. How long has Iivcd at this addrass? Enter number, then mark box 2. t n Days 

2 � Weeks If “3” years, ask: 

Number 3 � Months Was it Icss than 3 years or more than 3 years? 

4 � Years { 

1 � 3+ years in 2 (RM2) 

RM2 RM2 z � Less than 3 years in 2 

L Including tht time movad her~, how many times has movod in the past 3 years, 3. 

that Is, sinco (12-month date), 1977? — N umber 

10, What was --’s address, including county on ( 12-month date), 1977? 4a. c~”ty 

Enter only county and State State _______________________________________________________________________________ ,. __. ___________________ 

b. About how many miles is thot address fram here? b. � Initial OK - PROBE 

—Miles 

,+ __. . ___________________ _______________________________________________________________________________ 

C. Howmonypooplc was living with at thot time, not counting --? c. oon Lived almw (6) 

__.. ______!?’!_!-? __, _________________________________________________________________________________ 

d. War@ any of these pooplo related to --? d. ,y 2 N (5) ---------—--— . 

c. Was Iiving with --’s: e. 1 � Brother/sister 

(1) Brothor or sister? S � Parent 

(3) Fatherormother? MARKALLTHAT APPLY 5 � Spouse 

(5) (Husband/wife)? 7 � Sm~dau;hter 

(7) Son or daughter? 0 � None of the above 

h. What isthe(other) resrson --moved HERE? Wasitbccause --changodiobs, 50. 1 � Job-self 

because	 retired, because of --’~ health, or was it for some other reosoa? 20 Retired-self 

3 � Health-self 

c � Job-other person 

5 � Retired-other person 

6D Health-other person 

en Other -Spec/fy 

7 

. __.. ___________________ - ______________________________________________________________________________ 

b.	 Any othar rtoson? b. Y (Re.mk5aandb) N 

L -—------------------------——--------- . --------------—---- . 

Mark box or ask: � On Iy one reason 

c. What is the MAIN reason moved? c. 

For persons 17 years or over, show whoresponded for(orwas present during the 1 � Responded for self-entirely 

RM3 asking of) Questions 1-5. RM3 2 � R=sp~ded for self-partly 

Q’s 1-5 Ifpersons responded for self, show whether entirely or partly. Person _was respondent 

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

-- --

--

--

--

--

--

--

--

--

--

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

--

� Under 17 (f#P) 

I 0. —F-t — Inch­ ---------------_..-

b. Pounds 

~ 

_______________ 

b. Did finish the grade (year)? 

b.	 Did EVER serve onactivedrrty in the Armed Forces of tbe United States? _______________________________________________________________________________ 

b. When did serve? VietnamEra(Aug. ‘64-April ’75) . . . . . . VN 

Korean War(June”50-Jan. ‘55). . . . . . . . KW Circle code indescending order of priority. Thus, if World Warll(Sept. ”40-July ’47) . . . . . . .wll person sewed in Vietnam and in Korea, circle VN. World War l(Apri1’17-Nov. ,18) . . . . . ..WWI 

Post Vietnam (May ’75 to present) . . . . . . PVN 

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

_______________________________________________________________________________ 

c.	 was-- EVER an active member of a National Guard or military reserve unit? 

_______________________________________________________________________________ 

d. Was ALL of --’s active duty service related to National Guard or military reserve training? 

Hand Card R - Mark box or ask: 

a. Pleose give me the number of the group or groups which describes --’s racial background. 

Circle all that apply. 

I - Aleut, Eskimo or American Indian 

2- Asian or Pacific Islander 

3- Black 

4- White 

5- Another group not I is ted - Please specify 

_______________________________________________________________________________ 

If multiple entries ask: 

b. Which of those groups, that is, (entries in 4a) would you say BEST describes --’s racial background? 

Hand Card O - Mark box or ask 

ia. Are any of those groups --’s national origin or ancestry? 

(Where did --’s ancestors come from?) . 

& 

2.. 

b. 

. 

30. 

b. 

c. 

i 

40. 

; 

5.. 

� Under 17 (NP) 

10 D None (3) 

Elem: 12345678 

High: 9 10 II 12 

College: I 2 3 4 5 6+ 

lY 2N 

lY 2 N (NPJ 9 OK (NP) ___________________ 

1 VN s PVN 

2 KW 6 0s 

3 Wwll 9 OK 

4 WI 

___________________ 

lY 2 N (NP) 9 D K (NP, ___________________ 

IY 2N 9 DK 

� Under 17 (NP) 

I 2 3 4 s - Spdfyz 

___________________ 

1234S - Spoclfyp 

F ‘“ ,,. 

� Under 17 (NPj 

lY 2 N (NP) 

_ -- —_____________ 

12345678 

______________________________________________________________________________ 

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

Circle all that apply. 

1 - Puerto Rican 4- MexicanO 7- Other Latin American 

2- Cuban 5- Mex lean-American B - Other Spanish 

3 - Mexican 6- Chicano 

— 

26 
--

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-- --

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

--

-----

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

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

--

--

--

--

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

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

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

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

--- -- --- --

--

--

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

Mark box or ask: � Under 17 (NP) 

60.	 Did work ot ony timo last week or the week before - not counting work around the house? 6a. 1 Y (7) 2N .——. . ------—--------—--—-

b.	 Even though did not work during these 2 week=, does have a iob or busines5? b. ,Y 2N . -------- — —-----

c, Wos looking for work or on Ioyoff from o iob? c. J: 2r4 (7) - .— -

d, Which - looking for work or on Ioyoff from a iob? d. 1 � Looking 3 � Both 

2 � Layoff 

70. For whom did (last) work? Name of company, business, organization, or other employer 70. a Never worked (NP) 

Mark for all Employer 

persons. 

_______________________________________________________________ —-- ———-___________ —____ 

If “N” in 6a and b, What kind of busirmss or industry is this? For example, TV and radio manufacturing, b. Industry 

in 6b, then 

question 7 applies retail shoe store, State Labor Dept., farm 

to person’s LAST C. What kind of work was doing? Forexample, electrical engineer, stock,clerk, typwt, farmer –:: -O;X;X------––––––’ 

job either fulltime or part-time. ___________________________________________________________________ —-— -— ——--------- —------

include miiitary d. What were --’ s most important activities or duties? For exampie, types, keeps account books, d. Duties 

jobs. files, sells cars, oparates printing press, finishes concrete 

..-— —----------------

Complete from entries in 7a-d; if not clear ask: e. Class of worker 

� , Was -_	 m employ.e of PRIVATE ..3m P0”y, self-employed in OWN business, pro fassl onal lUP business, or sol individual for wages, practice, or farm? 

salary, or commission? . . . . . . P If not farm, ask: Is the business incorporated? z13F 6 USE 

a FEDERAL government employee? F Yes . . . . . . . . . . . . . . . . ..l 3US 7UWP a STATE government employee?. S No(orfarm) . . . . . . . . . . ..SE 

--0 LOCAL government employee? . . L working WITHOUT PAY in family business 40L or farm? . . . . . . . . . . . . . . . . . . . . . . . . . . . WP 

WI Mark appropriate box. I� Under 17 or Nev. w. (NP) 

WI 2 � Cal I back required (NP) 

3n Person is svsilable 

(Earlier i was told that you (last) worked � s a (occupation in 7c) for (employer in 7a).) 2 � Weeks 

8a. How long (did/hove) you ever work(ed) as a (occupation in 7c) for (employer in 7a)? a ~. 3 � Months Number { 4 � Years 

-. .---- —- —- —---- ——-----

b. Hove you �ver had a @b, that is, a specific kind of work for one empioyer, ot which b. ,Y 2 N (NP) you workad for more than (time in 8a)? inciude military iobs. 

Of ail th~ \obs you have � ver had, inciuding military iobs, I’d like to know about tha one � t which you worked iongesi. Employer 

9a. For whom did you work? Name of company, business, organization, or other employer 90. 

----——-----------—— -

b. Whet kind of business or industry was this? For example, TV and radiO manufacturing. b. Industry 

retell shoe store, State Labor Dept., farm 

—--- —------------- -

c. What kind of work wwt you doing? For example, electrical engineer, stock clerk, typist, farmer =. Occupati.a” 

_______________________________________________________________________________ --— -

d. Whet were your most important activities or duties? For example, types, keeps account books, d. Duties 

fiias, selis cars, operetes printing press, finishes concrete 

--------------------------------------------------------------------------,---- — —- —- — —-------

Complete from entries in 9a-d; if not clear, ask: Class of worker 

� . Were You an �mploys* of PRIVATE company, business, or -— self-employed in OWN business, professional � . rlgp 501 individual for wogcs, salary, or commission?. . . . P practice, or form? 

--0 FEDERAL govommont employee?. . . . . . . . . . . . . F If not farm, ask: Is the business incorporotod? 213F 60SE 

a STATE govarnmcnt employe*?. . . . . . . . S Yes . . . . . . . . . . . . . . . . . ..l 

--0 LOCAL govamment employee? . . . . . . . L No(orfarm) . . . . . . . . . . . . ..SE Sns 7nwi= 

n.mking WITHOUT PAY in family business 4nL Or farm? . . . . . . . . . . . . . . . . . . . . . . . . . . ..WP ---_ -____ —_________ -

f. How long (did/hava) you ever werk(cd) as a (occupation in 9c) for (employer in 9a)? f. � Less than I year 

—Years 

27 
I 

28 
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--

-- --

a.	 Doss anyorw in the family racoive the ‘“Supplam*ntel Security Incom*” Y 

or “SS1” gold.colorod chock? N (17) 

b. Who racaivcs this check? Mark “SSi” box in person’s column. 16b 

c. Anyorsc Qlso? Y (Reask 16b and c) 

‘o. Dots onyorw in the family receive any (othor) incomo from Sociol Sccurify?	 Y 

N [19) 

17b b. WhO is this? Mark “Saciai Security”’ box in person’s column. I � social SecurW 

—.. 

c, Anyono .1 sa? Y (Reask 17b and c) ~’ ~ 

N 

Pcoplo may r~caivc Social Security bormfits bacausa of their own work �xperience or becauso they ore 

dcpcndonts or wrvivors of somoorw who qualified, based on work �xperience. 

Ask for each person with “’Social Security’” marked in 17b: I � work experience 

!.	 Doss (person in 17b) receive Social Security payments bacmtse of --’s own work 18. * � Dep=nde”~ or survivor 

�xperience or bccausc is a depondont or survivor of somoone who worked? 

la, Including retirement payments recaiv~d bccau ss of di sabi I it y, does arryorw 

in the family, (that is you, your --, �tc.) racaive any income from -

If “Yes,’’ask 19b and c (1) Railrood retirement? . . . . . . . . . . . . ...6 & 19b. I � Raiirosd 

(2) P-nsion as a military retiree?. . . . . . . . . � n 2nMilicsry 

(3) Gevarnmwtt employee pension? 3 � Government employee 

(Federal, State, or local government) . . . . � � 4 � Private or unian 

(4) Private amployer or union pension? . . . . . � O 

b. Wha is this? Mark box in parson’s column. 

c. Anyorw �1se? 

Far each income reported in 19b, ash OWN SURV 

}. Does receive tha (entry jn 19b) bocousa of --’ s own work �xparicnca or bacauso 20. 

is a dopendcnt or survivor of somcorm who worksd? RR. . . . . . . . 

Military . . . . 

Gov’t . . . . . . 

Private. . . . . 

OOTNOTES 

29 
6.I 

o


E If this questionnaire is for an If in AREA SEGMENT, LISTING SHEET 

EXTRA unit, enter Control Number OISO enter for FIRST unit Sheet number Line nut 

of originol sample unit ._} listed on pfoperty ~ 

TABLE X - LIVING QUARTERS DETERMINATIONS AT LISTED ADDRESS 

LOCATION OF UNIT � If Iistod, triter If outside Area segment Art thes. USE OR CHARACTERISTICS CLASSiFICAWh.r. or. th.s. quart.,s Iocot.d?	 sham and line. boundary, mark box below. (Spec/fy location) 

En numbw STOP STOP and - quartmrs for more OCCUPIED ALL QUARTERS N - Not 0 s*pa,at. , te, exact descdptkn or Iocaticm, e.g., basement; Table k, cod than one
 Z“d floor, raw cOntinu* intmr- � Go to next line of Table X, of pcoplo ! 

roup Oo theso quarters in Add OCG”ParItSI


After entering description or location: view for determined.


if additional quarters Do the occupants (Specl& location) havw this quostion”al 

ine . in Area Sezment, xc, to (3) original sample If “Yes, “ fill of thass (Specify (Complete 0 se 

No. � In other type of Se;ments. unit. OR one line for location] quart8rs Di,.cv acc.ss Compl.to Ititchcm	 questionnaj re 1 

each u“relc.ted p - If livin; quarters are not within the s8me � If unlist~d, � Go to Household pa;e, each group. Iivc and cat with from tht outsi d. facilities for this or family group. specific sample address (and structure, if - And Area item 9, or Probe page, any other group or throu~h a unit only? ______________ Permit Se~nwnt) - STOP TABLE X S9 m*nt, go question I (as applicable). of paopl.? commen hall? hparatm unit - - Otherwise, COto (3) to 74). 

- And snothmr HIS ~“t.,”i.w ~~ ~ 

tvpe of s*gme”t, go to (5) 

OT} soporata Qu.sti( 

:1) (2) (3) (4) (5) (6) (7) (8) (9) 

Yes - Go to (9) No 

1 s_ L— Q Outside segment boundary Yes No ond circle N Yes No Yes No N HU 

Yes - Go to (9) No 

2 s— L— � Outside segment boundary Yes No and circle N Yes No Yes No N HU 

Yes - Go CO (9) NO 

3 s— L— I_J Outside segment boundary Yes No and circle N Yes Na Yes No N HIJ 

NOTE: Be sure to continue interview for ariginal sample unit. 

FOOTNOTES 
CARD C 

Canditia+m rapwtad for which questions 2a-2s noad not bs asktd:


Ausa Hamcmhoids or piles (sny kind)


Appartdicitis Hernia (my type)


Arterloaclwosis Kidney stones


Artlwltls (any kind) Laryngitis


Athlete’s foot Migraine (any kind)


Bmndsltls (any kind) t%mps


PMiom Normal delivsry


Bura;tls Phlebitis (Thromb-aphlebkis)


Gllusta Pneumonia


Chickanp-m( Pregnancy


Cold sciatica


Coma Sinus (any kind)


Croup Strep (Streptococcus) throat


Dlabstsa (arty type) Tonaillitia 

Epilt~y (any kind) Ulcer (duodenal, stomach, psptic 

w gastric wtly) 

Gallatmas 

Vasectomy 

Goiter 

W%ts 

Hsrdanln; of the srtariea Whooping ccugh 

Hay fever 

CARD E2 

Show datall in ussNm 2e, CmdiNon poga and/or quastion 6, Hospital pea.for 

thast IMPAIR & NTS. 

Daafnsss 

Troubl@ haaring 

Other ear condition 

Ellndnaaa 

Tmublt aaaln~ 

Ott& aye cmditlon 

Mlsaint hand - all or part 

Mlaalnz arm - all w put 

Mi*aing fcot - all or part 

Mlaalnt la; - all or part 

Trouble, atiffnaaa or MY deformity of - foot, leg, finssm. W% w bs~ 

CARD I 

Under S1,OOO(including loss) . . . . . . . . . . . . . . . . . . . . . . ..&wp A 

s 1,000 -$ 1,999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. GrouPB 

S2,W0-S 2,999.. . . . . . . . . . . . . . . . . . . . . . . . . . . .. Group C 

s3,000- $3,s99 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. GwPD 

s 4,000 -$ 4,959 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Group E 

$ 5,000 -$ 5,999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Group F 

S6,000- S&9?9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..&mpG 

S7,000- S 9,999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. GrouPH 

SIO,OOO- S14,9S9 . . . . . . . . . . . . . . . . . . . . . . . . ..~ . . .. Grcup I 

S15,000- S24,595’ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..&o”p J 

S25,000 and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Group K 

CARD N 

1. Care received thrcugh Medicaid or Welfare. 

2. Unemployed, w reascms related to unemployment. 

3. Can’t obtain insurance because of poor healti, i Ilness, or age. 

4. Too expensive, can’t afford health insurance. 

5. Dissatisfied with !xevi ws insurance. 

6. Don’t believe in insurance. 

7.	 Have pen healthy, not rraxh sickness in the fami IY, 

haven t needed health instmmce. 

8. Mi Iitary dependent, (CHAMPUS), veterans’ tmefita. 

9. % other reascm - 5+ecify 
CARD O CARD R 

1. Puerto Ricm 5. Mexican-Amrican 1, Aleut, Eskim w American Indian 

2. Cuban 6. Chicano 2. Asian or Pacific Islander 

3. Mexicm 7. Other Latin American 3. Black 

4. Mexiccmo 8. Other Spanish 4. white 

5. Anotlw group not listed - Specify 

32 
1982 

The questionnaire and data preparation procedures of the 

survey were revised extensively in 1982. In some cases the 

revisions have changed the basic concepts. In other cases the 

concepts are measured in a different way. The primary goals of 

the revision were to solve problems that had been noted over 

the years in administering the earlier version of the questionnaire and to take into account areas ofnew interest related to 

the health and health care delivery system of the Nation. 

Changing the core questionnaire required a change in interviewing procedures as well as revisions of the coding and 

editing procedures associated with the earlier version of the 

questionnaire, 

In some cases concepts were redefined, and in others the 

same definition of a concept was retained, but the nature of the 

questions asked or the procedure followed to measure that concept was changed. Both differences can involve substantial 

changes in the estimates associated with the concepts. It was 

decided that potential improvement in the quality of the information outweighed the disadvantage of a loss of continuity that 

would, in some cases, make 1982 and future estimates incompatible with estimates derived from the earlier version of the 

questionnaire, The following paragraphs contain examples of 

some of the revisions. Appendix II includes a more detailed 

examination of the implications of the changes summarized in 

this section. Appendix II also includes a discussion of the 

steps taken to evaluate the differences between estimates derived 

from the earlier and the present forms of the questionnaire. 

The 1982 version includes many more questions concerning each of the doctor visits, and some questions were 

expanded to include more detail or to make explicit what was 

only implicit in the 1981 version. For instance, visits to psychiatrists and other medical specialists were meant to be 

reported by the respondent in the 1981 version, but this was 

not made explicit, as it is in the 1982 version. The most extensive change involved adding a section to gather information on 

minor surgery performed without an overnight hospital stay 

and incorporating this topic into the doctor visit section of 

the questionnaire. 

The questions relating to restriction of activity were structured in an entirely new manner and were asked later in the 

interview. The question wording was not extensively changed, 

except that “more than half a day” of restriction is specitled as 

the minimum amount of time constituting a day of activity 

restriction. 

The questions relating to hospitalization underwent only 

slight changes. The condition for which, a person was admitted 

to the hospital, however, is no longer included in the final 

data tile. 

A relatively extensive set of questions is asked about each 

condition reported in the survey, primarily to facilitate medical 

coding. The main changes involved expanding the amount of 

detail obtained for each condition and the addition and deletion 

of a few questions. In addition, the procedure for obtaining the 

number of restricted-activity days associated with each condition was signitlcantly modified. 

Although an instruction to respondents was added at the 

beginning of the chronic conditions section in 1982, there were 

no substantial changes in the lists of chronic conditions read to 

the respondent. The instruction was included to determine 

whether any family member had any of the conditions contained on the list. 

This summary of major changes focuses on differences 

that are readily apparent when comparing the 1982 and 1981 

versions of the questionnaire. However, it should be noted that 

changing a single word in a question or merely adding an 

emphasis where none existed before may have a dramatic 

effect on the estimate. 

Differences in estimates can result from some apparently 

minor change not even mentioned here. Therefore, the data 

user wishing to compare the 1982 estimates with estimates for 

earlier years should consider all changes in any way related to 

the measure being considered. The Division of Health Interview Statistics should be contacted regarding changes in the 

interview, coding, and editing procedures. 

In 1982, 2 weeks of data collection were omitted because 

of budget restrictions. The results from the 50 weeks of data 

collection were weighted to compensate for the missing weeks 

of data. The sample was composed of approximately 40,000 

households including about 104,000 people living at the time 

of the interview. 

33 
.. .. ----

, 

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

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

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

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

-------

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

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

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

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

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

1982 Questionnaire 

n“ . .. ->,m,...... ..... .. ,,,-.,“ l“. “.-l. . . ““. .7. , . . . . . . . . -“.,. . . . . . .. . . . . ,., 

TTICS - lnfamflon cenfJ1d c+ IIIls lwn MIMI wvld Wrmlt Itit,flctiim of w tndiwtil of 1. 2. R.O. number 3. sample€

@ldwaIt h“ MM cotl,ctd “Isa , 8J”BIIOC ~~ it will b, IwM d. ,Ulct ccalldmm. will ti “W Book _Of
 If fw S.RVES8S
 *uwd fm this NIIdI. M .111rat b+*I=I08M w t*l*n.d m 0-s wlttd W cmnm 

dm mdvikIal w tfa es!tillstil in BX816mc9 wi61 soct!+n $X{d) .1 w public lddth SUViCe —b.k. t (42 WC Z4a). 

!.” km-l (1912) 4. Segment type 5. Control number ,...,, I-J AI., Psu I

, S.vmlt / *1.1 “.5. DEPARTMENT OF COMMERCE � P“fnnc 1 ..”.. ” or 7“. ,,.s”s AC,,.. ., .0,.,. m“. ..’”, ,0” 7.. � Add,=,. 

1 : 

U.S. �U.LIC HEALTH SERVICE � C.n-slp I

1 1

NATIONAL HEALTH INTERVIEW SURVEY I •150..!.!Place 1 

6..Wh.tISyour .x*c1 ddr.ss? (Include House No.. APL No.. or other ident,ficalfm ~ LISTING 14. No.interview reason 

county and ZIP cede) ~ SHEET TYPE A 

J of fg R.fusd - Mwlbc in IMLWWS ;gl~ 

:= oz O h .“. m:honn - r.mamd calls *a*’ ‘ 

8s � TemD-”ilY .b.wmt - Fc0fnc48 yyi:. 

tiiw---------------------[G---------@i-ntY ----------@P-c-d-i--- i

, _ e, � OUw (SPUIIYJ } 

1 1 ~ \ Lin. No. J 

b.	 1. this y... “ilio, ,44,.ss? (Mark k-x or specffy II different. Mlude m SarM .s 6a 

CWIIY and ZIP code.) TYPE B 

01 � v-ml - Ilccls. **onal 

. . � v=.., - ..a.on.l 

m � CXc!ml.d ..[ir.ly by 

?.rs.n* wid! URE E;v-------------------------~E;a;e----------~?-w-n-w-----------~ilF-c-~;-- ~, � *cup,d �“,,,*IY ~ ~& 

I # 1

! Fe,.., momb,,s Fill MM 

os � Unfit w t. b. d.rmllsh.d 1+4, 7, 8, 

c. Special place name o �s

I 

; SafnPle unit number 

I 

/ Type code 1.0 Und.r .on%uuctlc% not r..dy 4#:/&g. 

t ! O C.nv.r;.d t. t.mpw.w b.srn..s e Cf SIor.zo AREA SEGMENTS ONLY ,2 Ig U&@ed mm sit. w 1,.11., 

7.	 YEAR BUILT 

� Ask ,, I-J :::::, feytd, CO”strlxtlc.n 

� 00”0! ssk ‘ t 4 � Oth.r (SphWyJ I Wh.n w.. this strucwr. wi,in.lly built? J 

~ Bwfwc 41.70 (CmNnu9 /“t.rv/*w) 

� Aft., +1.70 (CqDht. lt.m .% who” ,cq”l,.d: �nd i“lwwl.w) 

TYPE C 

8.	 COVERAGE QUESTIONS Is � Unus.d 11.. of I[stinz lh.m 

� A,k 1,.- ,h.t .,. muk.d t so !Anmllsh.d 

� O. nci .,k I ?O HmJs. or trailer m.av.d 

a.	 � At. dwr. �.Y occupied w v.cmnt living qumfacs bsid.s ~ � Y., (Fill Tabl, X) I on Out* Id. ..:mant :qll,@m 

Y.., OWII i. fhis b.ildiw? : ON. I $0 $wv;$ to pwnun.nt b.sin.as If Il&vd, 

W-J6, born 

__---- _-------------------------------:--------------------- ,0 ~ ~cc.~ hlf,,-cmmn 

b. O Aro fh... �y �..upt.d or vacanf Nvlng QWI1.IS botid.s , � Y.. (Fill Tebh X) 2, � Cmd~t=d yew own �n this floor? ! � N, 21 � mill �rm, Awl! 1. Iwo 

— +------------------_-- *, � ~w ,m,v, 1 

c.	 � Is fhcI* �#y �khor buildinf �n this propmty fw POPI* : � Y., (Fill Table X] i 

to Iiv. in .ithw �ccupiedw vscm.t? ~ � N’. 

15. Record of calls 

9-. LANO USE ~ EJd.?t COm91.t( t ~ UR8AN (fO) Month : D.,. mk (x 

2 ~ RURAL I 

- Reg. tmtfs �d SP. PL. units cod.d 8S-86 in 6.- A8k item 9b 1 ; .,m. *m. 

- 5P. PL. ..11. WI ccd.d S5-s6 1.6. - 6kfk We.. /. /fcm * wlfhout ?$klc9 P.m. p.m. 

,. 

b.	 During the F@ 12 � onth did ..1.. .f c-p. Iiv..hek, �nd .ffmc 2 1 .Im ..m. 

k,” pOductl fmm fhis ph.. �-f !0 $l,o& u alOf*? p.m. P.m. 

I Iq Y.* (lo) 1 ..m, &m. 3 ~ ZDNO } P.m. P.m. 

1 

0, CLASSIFICATION OF LIVING QUARTERS - #ark b+’obkewcdlon .m. .m. 4 I 

(M.zk one. THEN pace 2] P-n. *.- �. LOCATION of unit ~ d. HOUSING unit ~ Un[c 8s: 01 � HaJs.. q-IMMt. fist t a.m. M. � 1.. SWI.1 Plmu - R,hf to Ttil# D in : 02 � HU 1. MtrM*i9nt hot.!. mod, �=. s : mm. ?.~ P@rf c 0! -1; thal CM@d8 lW m � , 0>0 NU.smnmmnt 1. LWSIM1 howl. mOml. .Ic. ! � NOT I“ � SPOC1.I P18c. (lIX) /

1 04 � HU In meml.s ho... a.m. ..M. 4 , 

b. Access I 0s � tllkdh~ or uall.r with ma P.fmmom p.m. P.m. 

fg Olmct (PM) I 16, List column numbws of persons wulrln; 

� Thrmuh .nothw wlt (P&) / .X Ol?mbllo h.rra or !rmI!+r with m. = 

w. csllbscks for “’PIavenciv. Care’. q!nstlom. VOrlran.in .- tid.d 

: 07 � l#J&ti&~ ill-d +“. - OMcrlw o NOM 

c. Cwnplese kitchen facilities ~ -

� 

� &:nv:: Oa � Qusrt.r. .s MU 1. .OC.MI.Z w bmdkw hous. column 

numbw + 

hcua.hc.ld Wl;~mff;U#ylm [ os � LhI&;m~nmm! In tm.sl.mt h.m.l. 

� Nwa 

} %&&%’’f%{ 

s- W.* II* M a8Fua M*.) 

~ 

: 

10 � Uticu91.d t.”t sit. m u.IIu S11. 

, t � OTHER .ntt “S s~. ifl.d abov. - C9$CNIV 

!. 10afnOm* 

17. Record of .ddixirnal contacts 

Month 

I 

/ Oat* B.~/I#ln~ Endin’ 

Mum 

C.mplu 

Cd. N, 

1 

\ p ,.m. *m 

t , T p.m. p,m. 

Fw thl. WIII c.Ily (f@) / . . OTHER unit (Mark me) 

GO 10 HOUSEHOLO COMPOSITION PAGE 1 P mm. o.m. 2 ~ 

11. Wlwf is th. t.1.ph.no n.mb.r h.,.? ~ Are. ced.h.mbm 12. Was this interview observed? 1 T ‘.m. ‘.m. 

P � Mm. 1 1 ~ .,rm .m. 

T P.m. *.m13.	 Interviewer% name ~ Code : P 

! 4 , a.m. a.m. 

1 , T P.m. p.m. 
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A. HOUSEHOLD COMPOSITION PAGE 

e, Whet .,. !h. nom., of OH persons living ., slaying hr.? Stori with *h. n.m. .1 *h. p.m.. w on. .f 

th. p.r.on. -he w.. m t..ts thi. hwn.. Enter name m REFERENCE PERSON column. 1 

Laxt .amc sex 

,g. 

b. W3101.!. th. names of .11 .th.r p.m... living ., staying hr.? Enter names ,. columns. zrJF 

Iz==l 2. Rela,lon,hlP 

c. I h... Iist.d (read nomes). Hove I mits.d Ye. No REFERENCE PERSON 

3. 0.1. .1 b,rth 

-.. yb. bI.*erimo 11. hildr. n. . . . . . . . . . . . . . . . . . . . . . . . ...0 c: Mmth Date Year 

- ..y lod~. rs, b.. rd. r., or p.m... y.. .mpl. y who Ii,. hr.? . . . . . . . . . . . . . . . . � c1 HOSP. wORK RO l.w K. DV 

- any... who USUALLY Iiv. s h.,. b.? is ..- .WOY frm h- tiding or i.. hospitol?. . G Ill Cl o. 13NCM. , •~. � Y., ‘W GN..e ~ -ony . . ..lse tt. yinqh. r. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..c.I m N..M, z � wb ~N” ~ 

d. De all of th. P+tsc.ns ye. hav. nan.d .S.ONY Ii.. hr.? � Yes (2) 

� NO (APPLY HOUSEHOLD MEMBERSHIP 

Probe ,1 necessary RULES. Delete n.anhousehold members C2 

08.s usually Ii”. sem.wh.r. �IS.? by on ‘“X.. from I-C2 o“d enter reason.) 

,, 

I.	 Who! 

Ask for 

IS 

all persons 

r.lofl.nship 

bezmnmg 

to (reference 

wth column 

person)? 

2: +=3 ,.,!

“. .“ !“, ,<, ,7” 

.“, ,<0”, 

1. What IS dot. of birth? (Enter dote and age and mork sex.] ,’,~,’ 

REFERENCE PERIODS ---, ”_ ,- ;,; :,”- ;$ ,:O.”, B ,. .“A 0“

iin 2.WEEK PERIOD .. ---- . . . . . . . . . . . 

Al ;,--- .-, i A-_ ,.o F ~; ;,”-,.”~ .-,7 0 -,0

12. MONTN DATE ,,, ‘mJ, ) , - _________________________________________________________ ,!11 

13-MONTN NOSPITAL DATE 

--.----- _______ ,------

LA “. 0“ 8“. ,,, my, Ico”o A2 I ASK CONOITION LIST	 M,, :.,, 

I t 

A3 � Alt c-mom 65 and ova (5) 

~3 Refer to .*u O( .1) reloted HH members. U Other (4) 

la. AI. any of *h. p.rs.ns i. !hls Iomil now . . f.11-?im. ..*i.. 

duty with th. Armed Fat... of *h. d not.d Stst.s? 

m Yes � No {5) 

b. Who is this? 

Delete column number(s) by on .*X. from I - C2. -.. .. . . . . . 

.. Anyone .1s.? CI Yes 

-----, IReosk 4b and c) � No 

- —_-—_ --—_____ Ask for eoch pus.” ,. Armed Force.: 4d. � Lwmt m hc.w 

d.	 Whw. d..s .su.IIv 11.. end sloop, h.,. . . ..m.wh.r. .1s.? t m Not Iwml S, h- { 

Mwk box in person’s column. 

1( related persons 1? and over ore 1!sled m odd, t,o” to the rcspo”dent .“d are ..1 pmsenc. soy: 

5.	 W. would lib. t. h.v. .11 adult f.mily rn.mb.rs who or. at hem. tab. p.tt i. fh. i.1.tyi.w. 

Am (names of persons 17 and over) et h.m. new? lf .<YeS,., osk: Could thy i.in .s? (Allow t,me) 

Read to respondent(.): 

This Iurv.y i. b.i.g c..d..d.d to c.11..t i. fommti.. . . th. nation’. h..lfh. I will .sb about 

h.spit.li.oti..s, disobl lily, visits t. doctors, 111..ss i. th. family, and oh., h..lth r.1.t.d i*.ms. 

HOSPITAL PROBE 60. , ~ ,., 

6.. Sin.. ( 13-month hospitol dote) a y.., ago, was a pati..t in e hospital OVERNIGHT? I � NC.~arNkp.;HCSP. )) box, 

.-

b.	 HOW many diff.t.nt tim.s did SIOY 1. O.Y h.vi~.l .,*@h* O* IOW*I ~inc* (f&k* *“1,” In 

( I?-month hosD8tol date) a y... ago? b. ;;yKSPh’,y, 

Number of ,Im.% } 

Ask for each chti!d under one: 7m. , ~ Y., 

‘m. Was born in o hospitol? 2 rl N. (NPJ 

--. b .. . .. . . 

Ask for mother and chtld: u Ye, (NP) 

b. Hm+. y.. i.el.d.d thts h., pit.lixoti.n in th. .umbcr y.. go.. m. for --? [~ NO;cotrect.3 and ‘<HOSP. ““ 

OOTNOTES 

.“M .!s.!!,O., ! ,4...**) 

35 
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B. LIMITATION OF ACTIVITIES PAGE b 

B1 I B1 Refer to age. 

1.	 Wh.t W.S JOIIIS MOST OF THE PAST 12 MOfkTH5; w.tkinz S? c i.b �r busln*ss, 1. t o Wwki”, (2) 

k.*#in, hws., g.alnq to school, or somethlns .1s.? 2 � KOOPI.C how,. (3) 

Priority if 2 or mwe activities repcaed: (1) SPent the mo$t time dome; (2J Considers tie most imlwmnt. 10 G.I”c t. school (5J 

4 Osormthlmt �IS. (5) 1 

b. O-i SIIY lmyairmon! w health PI*bl*m NOW hoop from w~kins .? . lab # busirnss? ::- 1 � Y.* f7) � n. 

b. Is Ilmlhd i. h kid OR .MOUIIY .1 work can 4. k..... of .ny Impobu.nt w hnlth pmbl.m? b. 2 � Y.* (7) la No(6) 

3m. Oo.s 0.V imFltMM u II-M problem NOW k-p from d.lng #ilY hwacwork .t �ll? 4 Ig Y.* (4) n N. 2 .---------------------­

k. 18-- Iimhad in tlw kind OR � MOW .f kous.werk can do bu.ose of �y impim.nt w hlfh pmbl.m? k. s (-J Y., (4) 6 n N. (5/ 

k.	 What (Ad ecndiiioocouw this? 

Ask if injury or c$eraion: WIWII 414 ~ (t. #y) accw?l--hv. k .PomficaYI 49. (E.tw Cmo!tlm In C2, THEN 4b)

Ask if cperaion over 3 m.xths .J80: FW w t condition did fro.. the epomthm? ! � yld.r.$mrk -old @gD,.box, If Pre#.mcr/deiivew or O-3 months inpw w operaion -

Reosk question 3 where flmit.t ion repwted. savint: Exe@ fw (~), . ..? 

OR rcask 4b/c. 

b. hsidot (CAM) is tbww .IIY ellwr COndllim that C-US*S this Iimlwim? Ib. � Y*s (Rn2k 4S 2nd b) 

� N. (4d) 

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

c.	 Is this limitation c..s.d by �y (Ad spdfic condition? . . � Y., (fis,,k 44 �nd b)

1 � N. 

hbrk box if only one condition. d. n Onlr 1 Calldl,lon 

d. Which dNmse
cmdlliona would YOMt-y h the MAIN C-USC of this Iimi*tirn? 

1 !.!41” cm,. 

fa. Oaca �ny imyatrnmnf w heclth v.blm kcop from waking �t � Iob ., bmdmm? %. 1 � Y., f7J � no 

b. Is Iimlt.d in I!+. kind OR nmount of work could d. boc.us. ok �ty i!wirmmt etkalzk
 PAlem? b. 2 � Y*S fY) 3DN0 

B2 ! @ ,, Y. SCOI.2. e 3b fP4P) B2 Refer t. wtesticms 3. ad 3b. 2no!hu@) 

k f. Ilmitcd i. ANY WAY 1. any activitl.s kuauac �f.. impirmcnt w hoaltk problem? ! � Y*. 2a No (NPI 

?: 

b. In what war IS Iimhd? Record limitation. not condttion. b. + LlmiI=tImI 

r.. -t (c&,) condition causes this? 

Ask if injury w qemtion: Wha did fib (in’. ) occ.r?/--haw tfw eporwl.nfl 7.. (Enmr cmdltlm in C2, THEN 7bJ 

Ask if operat;on aver 3 months OZO: FW w? .t c.ndltl.n did k,. NM ~m~ien? 

If Pe;nancy/dehvev w O-3 months injw or opwation -

Reask question 2,5, cf b where limitation repimed, saying: Except for -- (gW.MO), . . .? 

1 D Wah,:jlzrk ‘corn *- k, 

OR reask 7b/c. 

b. Bosl&s (-.) is tko �ny �tkw cmditim Ntat C.US.S zhi~ Iintizatien? b. [~Y., (flWk Y. .IW’ b) 

i DN. fYdJ ,-: 

c.	 h this Iimihlion cwmd by �ny (othcd spciflc emdifh? � Y,, (Ruzk Y. �& b) 

D No 

we condition. Mk & nmly 1 .Ordltlnn box II only d. fffkk �f 2k0,C .diii-, WOU!d y- S.Y iS tk. MAIN C. MS. Of thi. Ii.hlh? 1 *I” a“.. 

>“.4 “Is., ,,,,,, ,4.,.,1) 

36 

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B. LIMITATION OF ACTIVITIES PAGE, Continual 

B3 0 � Und*r 5 (10) 3 � 6.3-71 (14 

! � 5-17(71) 4D71 Md B3 Refer to q,. 2 I-J I S-59,(84 ..*, (u 

, 8. Wh.t w.. din. MOST OF THE PAST 12 k!ONTHS; w.tking .1. [.b .C bu.in.ss, k..pl.~ he..., 8. I o Wo,kini 

pins t. �chod, � .anuthing .1s.? 1 � K..c.I”s has. 

1 � Coin’ to schml Priority if 2 or mwe activities rewrsed: (1) Spent the most time doint; (2) Considers the most important. 4 � SOm.(lllns .1,. 

9a. B.c.us. .f .ny lmp.lrm.nt w h.olth Fr.bl.m, d... . ..d.th. h.lp .f .th.r p.rs..s with p.tsond 9.. ! � Y** (13) � No 

cm nccis, such� ootlny bathin~ drosslrq, or @fim �mu.d this km.? 

$.	 6i;:.;;;i;i~~X;;:;nt-~,-~.;i~ Fr.bl.m, do.. a..d th. h.tF ml AI., p.r..ns III handling rwtln. b. 2 D Y., (13) s � No (12) 

rued,, much ,, .v.ryd,y he...ldld ch.,.,, deing ,,..,,.v b,, ia., s, shoppl.,, ., @ti.g wound for 

�F!+” pwp.s.,? IOC. Is ablo 9. fck. patf AT ALL h! th. .s..1 kinds OFF.!.Y ..ti”hb don. by � .,f children .s.? Ih. Q Y.* o @NO (w) 

. 

b! I* Iimlwd in th. kind OR amo.nt .f FI.Y sc8iviw.s d. k.... of �y finIF.trm..+ . . h.olth pc.bl.m? b. I Q Y.. (f3) 2D N. (13) 

11. .0,,, ..” lmpai,mmnt .,
h.elth p,.bl.m NOW FIMF Pr.m .tt.. din. schd? 11.. ! Q Yc, ff3J I-J N* 

b. b~.-.-= ~ ~&-d--- ~p-.z i.i ~ ~h-~zi &-.-pz ~i~ i ~1~~.-.l ‘b~z.-.~~ ~ r ~.-y-i-m~ ~i~~.-.;; ~ ~.-.h~ ‘Fie-bi.-m-?--------- ‘-i. 2 Q Y*S (13) c No . 

-

e. 0... “A 1. .ft.nd s ,p,Cid! sehe.1 o, SP..id cl.,,,, k..,. of any impairrm.nt o, h,olfh p,.bl.m? c. 3 n Y.* (r3) a No 

____ 

d. Is Iimittd {n SCM att..da.cc bwauso of h..lth? d. �O Y., (13) sum 

120. I* Iimifi.d i. ANY WAY In .ny q.tivitl.s bo...s. ef en impainn..t . . h.olfh pr.bl.m? 12.. I o Y., 2 (-J No (NP) 

b.i;;K~;l;i:::--------------~-'---------"----------------------------------­ limited? Record lim#tat# on, not condot, on. ‘--

b. L!ml,,,bn 

13..	 Wht (Othw) Cmdltiofl Ctnsos *IS? 

Ask if Injury or operation: Whom did [d+o (I*) ec..r?/--h.v. th. opomti..fl 1b. (EntcI oawlllm In C2, THEN 13b) 

Ask if.aperatlon over 3 monfhs OZO: For wha~ .emditi.. did k. fh .por.ti.n? , n Old . . (&,k+<0fd%19.. ba, 

1( Pre#nancv/delivev w O-3 monLks injury or opmtion - THEff130) 

Reask question where Nmifation reported, sayinr: Ex.wt for (~i, . . .? 

OR mask 13WC. ________________________ 

b.hiiiit-ii=nji;ihii.-i”j-oii.; ~;;d~~;n-i;;~.;;;s-~ ~s-fi;~~;.~? ‘ --i � Y., (R,ask 939 �M b) 

Q N. FM) & ------------ -

c.	 18 this Iimikiti.m e.wscd & any (Ac,) specific .ondltion? c. ~ Yes (fl#ask f3# �nd b) 

Q No 

Mark box If mly one cmdit(m. d. o Only I CO”dltion 

d, Which of the%. conditions would ye. soy is th. tkAIN ..”S. of this ihaimtien? 

mill calm. 

M O ;.-? .nd ..Old ace.” box nurk.d 

B4 R.tuto ““A*, ““ “’Old age,’” .md ‘“LA’” boxes. &ark first op$wwio:e box. O 3-S9 �nd .“- 1“,.LA’. tax (14) 

o Other (NPJ 

14..	 B.c.v,. .f .ny impoi,mc.t ., h..lth F,.bt.m, d.., n..d th. h.lp ef .lh., p.,..., with p.rs.maf 14. 

emro M+ such .s ufl.~ Mhin., dressing, ., qef+ln. at..nd fhi. hem.? __’_:_?::_:_ -_--n: 

Ask if .aB 18 (md O“,r. b. z I-J Y.. ,0!4. 

b. Bwwm d �y Iqalrmmt.hoalfh Polk, dms mod lh f+ of otfmr Psens inhandfins --h reads, 

sub os �V.@y wmh.ld chins, dofng IWC.SSOW buslnoss, shopping, of @tiIw around br otfmr PWPOSOS? 

,m~ MM 0..2, ,.....m 

37 
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boid-y”?’md’’im’ov’”-

D. RESTRICTED 

Had calendcw.


{Th. “.x9 ,“,,tle”8 ml..


bqhni.s MEAY, (4QE4 

I Refer to ate. 

D1 “’ - CJUnder 5 (4) 

ACTIVITY PAGE PERSON 1 D2 Refer to 2b and 3b. 

0 No dsys ,. 2b w 3b (6J 

n 

— I or more days in 2b w 3b (5)

I 

5.	 On hew many of tbe (number in 2b or 3b) days missed from 

[wWk/s$kW~ did stay in H ~m ham ball .f th. &y 

ta A. 2 w..ks eutlh.d I. 

..d dims ihi* P.W *.d~ 

a 5-17 [3) O 

A . . that c.lend.,, 

fd@) 

!8 �nd o;er (1) 

at a ieb w kd-%s, 

wotk in ISI. fomily 

No 

did 

beecus* .f illmo*s u i.i.q? 

00 CJ None 

f?efIY m ~, 3b, md 4b. 

miss-d 

do. (NDY COIJ.ii~ fkc day(s) mlsscd 

[ (d) i. 

Was thwc My (OTHER) ti:. dwi~ 

on th. tbinss usually 4s.. b...0* 

~ Yes 

Y40. of d.ys 

from work 

h sckool h 

b.d 1 

k,. 2 w..ks-yfwt CMt &Wn 

of ilhmas of injury? 

w � No (D3) 

1s.	 OURINO THOSE 2 WEEKS, did work O* .“V limo 

not counting work amwnd iho hous.? (Inel.dc .npoid 

[fer!+asitwss].) 

I o YCS (Afmk “WO” lxIx, THEN 2) I C] 

b. Ev.n th.ush did not wack duri~ thos. 2 waks, 

have. [.b or b.sl-ss? 

t O Yes (Afork “W6”’ box, THEN 2) 

20.	 Du,iW ~e,. 2 ~e.k,, did mls, ~ny jim. frw 

or kusl..ss hews. .f ill.*ss �. iniwry? 

I-J Yes 00 ~] tk.a(41 

b. OWIIIE thct 2.w~k p,,ie.d, h.W -“y &y, dld 

tlm


z	 C7 No (4) 

a lob 

miss
 mom


�iss.d from work 

b. (Main, MPcowPins
 tkoday(s) misaod from $chool ), 

[ (end) in bcd 1 

Duriq ykd Ywid, how �.ny (OT~ER) dmys did .wt-&wn for 

� om then half of bfw &Y b.c.u.* .f Illness .t fi.i.ty? 

) N.. d .wl-do-” days I I 000 Now I 1 

Refer to 2-6. 

No dv$ i. 2-6 (Krk ““No” in RL THEN NPJ 

0 I or mwe days i. 2-6 (~k “’yes” in RD. THEN 7J D3 O 

I

‘efer’0’b’3b’4b’”

half .f lb. &y from lob w busin.ss bccwsc of 

illn*ss at in@ry? 

00U None (4J B (4i 

7a. mm (**.,) condition Cwscd 

A. Du,in, the 2 w-k,, did d,, my iim. fromAnd kuau,. 

�f 11111*.SOf ini”fy? --b[f$i::::dl::::?h”2 (Enter ccadition in Cl, THEN 7b) 

� Yes 00 u No (4) 

b.	 During that 2.wmk Pwiod, how many d~ys dld miss M.-

than half of th. &y from sckrnl boc.us. of th0S9 w injwy? 

t � Yes (Re.a$k 70 and b) 

ii:i?dl=,k’ 213N0 

FOOTNOTES 

00 u None LEzEEzl da. OM,II13 th.s. 2 w..bs, did stay i. bcd b.c.ws. �f illness a iniury? 

i-J Yes 000 NO (6J 

b. During lkol 2.w,ck poricd, how �any + did spay h kcd more 

k k.lf of bk. &y kwaus. .f illn.m � i.Iwy? I

I 

I 

38 
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E. 2.WEEKDOCTORVIS{TSPROBEPAGE 

Read to respondent: 

Th... ..M . ..stlons .,. about h.alth car. r...id.d during th. 2 w..ks ..dl..d in v.d . . lfmt c.1..d.r. I I 

El � Undw 14 (fb) 

El I Refer to .w.e. a 14 and c+., (W 

, I 

h.	 Durlnoik.m 2 w..k., how mmy NIII.S did or talk i.. wmdical doctor? (1.clud. .I1 VP.. .f dectws, ~cJNsuch � s darnmt.laplst% psy.hlahlsts, and .phthalmolosists,. .s w*II as g.n.r.l pmctiti...r. end .a?..pdh..} + 

(D. ..P count Nm.s whit. an .v.rnisht pati.nt in. h..~ital.) 1 J IMP) L 

b, During thaw 2 w.eks, how many Nm.s did ..vo.. s.. . . talk t.. modi..l doctor b-t --? (D. ..+ count ~JNumb.. of Was 

NW. whll. a. .v.mioht sd.nt I. . h.spltd.) 

2..	 (B.sld.s th. Nm.(s) you lust told w about) Duritw those 2 w..k., did any... in th. Pmmily /...1.. htilth 

car. .t hem. . . S. t. . dome.’. .Hi.., .11.8., h.spital . . ..m. .th.r PI...? lmclud. car. from . n.,.. w 

.nyans worklfiq with or for . rtwdlcol doctor. Do not count tlm.a whil. an .v.might poN..v in . he.plt.l. 

� Y., � No (30) 

--, b.	 Wk. m..lv.d this ..r.? M-k “DR Visit”’ box m Person’s column. � DR Vl,it 

.:?. 

c. Anyan. �Is.? I_J Yes (Reask 2b ond c) � No 

L How m.ny Nm.. did v...iv. this c.m during that pried? d. 1 

I I 

Numbu of tlnns 

3.. (hold.. AI. llmofs) y.” .Ic.ady told m. about) D.rim h.. 2 w..ks, iid amyon. in ho fmmily @ .Ity 

mcdlcal .dvl.., pr.sctlpti.ns w ?.s? ..s.IM m.., *. PNONE ft.m. d..%., ..,s., or ..Y... w.rki.. wttk 

w f?? a modlcol dc.ctw? 

O Yes � No (E2) 

Ask for each person with ‘*DR Visit-” in 2b: 1 

b. Wk. w.. th. phon. c-N eb..t? Mark “Phone COII.’ b-x i“ persons column. :!, I--J Phun ..11 

c, W-m thcm any calls about anpno �II.? � Yes (Re.$k 3b d cj � No 

Ask for each person with ‘“Phcoe call’” in 3b: 

d. ffOW many tol.phon. ..11, w.,. mad. obout --? d. n 1 i 

E2	 I Add numbers i. 1, 2d, .nd3d foreach $mrsom Record tad n.mberof visits .a.d CONS in “2-WK. DY box i“ item cl. , ‘OOTNOTES 

,“” “!1.! ,,,.,, ,...,,, 

39 
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F. 2-WEEK DOCTOR VISITS PAGE DR VISIT I 

Refer m Cl. “’Z-WK. DI#. box. P.,,.. .umb., _ 

FI RefercoWC. R 

— L 

~] 

under 14 (lb) 

14 and ow (la) 

, Qn.*-(.** r)+-*J~)-&-r~.g _@.~ w+! ~1~::::...: h!k p-. mdi.ml &dOr, ..rs...* &.*f’s .ssi*Wnt? 1.. 

0. what (.th.r) da.(s) dwi.g the’. 2 w..ks did my... s.. ., tolk m . rn.dicol doctor, ..,s., ,:: 

., doctor’s .ssistnnt about --? . . . . . . ..- . . . . . . . . . . . . . . . . . . . . . ..—. .- .-. . . . . . . . . . . . . . 

Ask after lost DR v,s, t col.nm f., th, s person: . . 

%. i%. my etfmr visits or AI* fgr--dwi.w !fmi pwid?hbke n&S!OIY <art<t,cM 10 2-Wk. DV k r. Cl. 

Wh. m did r.c. iv. h.o!th ..r. . . (~11. at . d.. t.r”z .ffi.., clinic, h.spitol, z.m. .Ih. r r-
 do... or was this . d.phc.n. ..11? iii ,.ho. pi,.l. H..!d,ml

if doc~or-s offtce: Wes ~is offi.. In . h.,piml? 02 !-J Hnmm 0.[: O.P. <1,., <

0, u 00.,.?.. .If,c. 0, 1~ Emw,ncY mom If hosp,tol: W.. it ih. ..tp.ti.nt .11.1. or !h. .m.,g.,c~ room? 04 ~] co. ., M. .,,”,. ,. !-J O.,,.,., .,,,ce 

If clime. Was it . hospital ..tpotl.nt clinic, o .omp..y clinic, a public h..lth .t,.ic, et sm. 0s o Oumr .1, ”,< t I ~~ L.b .ih.r Md of .11.1.? 0’ g Lab 12 ~ Ovwwh, m,,..,

If lob: Was fhls lab in . h.spiml? 07 a O,hm &08c,l”) (N,xI OR v,,,,) 

Whet w.. d+.. d.ri.g this visit? (Footnote) J �* ~ Otis, fs~ll”, 

# 

Ask 3b tf under 14. r , ~~d_==,o~@Sly talk to . m.dic.l doctor? ,gd 

Did O.YWIO octiail~-Sli7ii -mziiciii~.i:,-.-~"i-----?--------------”- a ‘------------” -. 

WM typ. el m.dlcol Pam.. m assistantw.. mlk.d to? . . 

-. .-. --... -. JIB:----------- :-9-: 

Era~~ti.n.r 

0..s lh. fe~c) work with w f.. ONE L&t., or MORE than . . . doctor? d. I (-J 0“. fll) 1 ~ None (4) 

2 n more 9mDK ,-. . . . . . . . . . 

For this Gislt/calflwh.t bind of decto, w.. fh. (entry in 3c) working with or for -. g...ml . . 1 u GP (4) z rJ %ec,all, t (W , D OK (, or o sp..i.list? ,:d 

Is *Ot-&Z~jZ-g;;;t;i~tiS~ fi;~r-Jrl-s~;;i; fi*?--------------------­ “------”-


What kind of Sp.Cillli’l? 

9. 

K,”d of ,P,cmll, t 

Ask 4b If under 14. r I u Co.ostawl {Iwll C2, THEN 49) 

, For +mI .andrticm did — se. or folk to $lm [&ddfea.] m fti~l)? Mwk fmt omim to.. ~: * ~ P,.g.lan ., (4,) 

3 � T,.,(s) m ,Xam,”a, !o” (4.) 

F.. what c..dlti.. did a.yon. s.. . . talk t. A. @tor/(entV in 3c] abvvt on (d~]? i � Oth*r &XC//y)d 

hfork first appmpriote box. 

-. (49) 

‘&-i ;;.~;i~.;-f;;.j-.;-.-r;;;l; ;;~;-fi;;~;)~~x~;;.;fi~ ~-?--------- ‘---------------” .. n Yes (4h) � No . 

Was *is~&~t@-..pL.Sti. d-~sx.:?pfs *e:-------------------------------------- ific ..nditl.. bed? i. “--O-F.; i&j--------~:~~ @~):::::: 

b;fi;~%. past ~w-ks WCS sick beaus. of Pr*gIo-nsy~.---.-_- .---- _-__ -__-.-, .-. � Ye, n No (4#) , -. .---------

Wha9 w., th. melt.,? f. (Ifm C3, 

~--	- --.---------_- ____ -. Cmdl,, o” THEN 4@ -

During this &,slt/&lnwas th. Tddo,/fentw m 3cfl ‘til~~~~”e-~;f-.j~l~i;ri ;;{d~t;._n;----- -‘ %. “--~-&----------- ~-K;i57--- , .-. —-------- .-- . . .

Wh@ w., th. condition? h. � Pr.’”.”cy (4”) 

(lm,n C2. 

— C.a”d,t,c.n THEN 4$.)

de$crih 

hfmk lmx if ““Telephone,’ m 2. e. o � T.l=#me m 2 (N,xf m VISJII 

Did hav. any kind .f s.rg.ry ., .p.r.ti.. dvrins this visit, i.cl.di.g be.. s.tti.g. I � Y., 

and stitch.,? z � 8. (Next DR “1,1(J -. 

What was tfn nom. .1 the $wgory w ep8r.tie”? If nome of o~ration not known, b. O) 

whal was done. (2) 

,: :& (R,d.k .5b,,?d G, 

40 
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- ... .. . .. .--------- II U. flCAL I H INUILA I Uff PAGE 

a,	 Du,lng tho 2.w”k pml.d .utlln.d in ,.4 � fh.t c.lgnd.,, h., .n~.n. {n A. f,mlly h.d a. ln@V 

frwn �n ..cid.mt.. .fh.r e.us. fh.t y.u h... ..t y.t !oId m. .kwt? 

n Y.. 0 No (2) ,---

b. Wh. w.. Ais? Mark ,VnjurySa box m persons column. I b. G 1“,.,” 

!2, Wh.i w., l“@y? 

Enter injuty(ies) i“ person’s column. . . 

In,w, 

~ ----------------------------------- ,___

d. Did ..y.no h... any oh., I. IWI.S d.,ing tha* p.,ied? 

U Yes [Re.sk lb, c. and d) � N. 

— 

Ask fa, each Injwy in lc: 

�. A. e I..UI, �f th. (,n,urp ~ 1.) did [- - / .ny...~ s.. ., “Ik !s . modl..l d.. wr ., .,sl,lont . . � Yes 

1.,

(En,., ,n,”,y 1“ C2, 714EN 

1* n.”, In,”,y, 

(about --) � , Jld .“, �wn en USWI .ctivili.s F., m.,. the. half of . da”? ON. (?. for ,m., ,.,.,Y, 

Durln. fh. pc.t 12 mmtfh., (ffmt i., sin.. (lZ-month date) . ytir qs) ABWT how mmy day. did illm..s 2. 0,0 � Nw. 

� r ln@y ko.p --1. b.d m.r. Am. fmlf �f th. day? (Mud. days whit. . . .v.r.i@ht patl-t I. . h..piml.) 

—No. .f d.r. 

I. During !h. past 12 m.fk. ABOUT how meny iim.. did [--/..Yam] .“ er folk to . m.di..l &ctot 3.. 0.. � Nc.m (30, 

� r astlsrnnt (abcut --)? {D. ..1 countdocfors s-n whit. on .v.mi+t tint i.. h..pltol.) sw o WY whm ..,,”12!),

(Mud. fh. (number in 2.WK OV to.) visit(.) y- .Ir.ady fold m. cbout.r Patient 1“ h.asoltd 

[HP 

No. of .8s1,s } . _ -.. . 

I.	 About how Imo has it b.. sin<. [--l.ny...] last saw . . MM fa . m.dicol &ctor., assispanq b. I •1 l.,*~lew **k (RwSk 3b) 

(-bout --)? Inclvd. doctor. 10.. whil. a pa!i.m i.. h.spi$ol, , 0 L.., ,h>” I ,,. N70ash 3@ 

J � I y,.. 1“s *.O 2 y,,. 

. � 2 y,,., 1.,s than 5 y,.. 

, I-J 5 y,,. 0, MO,. 

o H N.=r 

W.uld � s.y ho.hh 1. g.n.rd is . ..AI..*. v.q Qaad, 4. 10 E.-II ... 4 � Fair s04, f% b, w pot? ~ � VW !Od , � Poor 

s o Good 

Mark bax if under 18. 5.. D U“d.r 18 /NP) 

, About h,w M is Wifh.”i ,h~s? 

—F*.C —Inches 

,iL-uiiii;iiiiiai-~--ii f~t;i&i.i-s<L-s7 -------------------------------------------" - ‘-’” ‘----------------------

b. _ P.nd, 

OOTNOTES 

.“ . .. .. ,. . . . . . . . . . 

41 , 
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u ea.,m,’r,,lu i ,.7. , A .,m . “. u“””, , ,“” G,. ,+ , m“” 4 

Read to respondent(s) and ask lost sp+c, fred in A2: 

Now 1.m wing w mod a list of m.dlcml conditions. Toll m. if any... in th. family h.. ..Y ef $b.s. conditions, .VWI if 

w h... mentienrd them fmfor.. 

1..	 D... .npm. i. t!+. family (read names) NOW h... - 28. Des anyen. in fho fwnlly {read names) NOW have -

If ““Yes,”” ask lb and c. 

b. Wh. iS this? If “Yes,”’ ask 2b and c. 

c, De., MY.., .1s. NOW ha., - b. Who is lhis? 

Enter c.mdidori amd letter m appropfi.te Person’s column. e. tkoosany... .1s. NOW ha.. -

1 A. PERMANENT s+iffn.ss et my d. formi~ of AI. foot, I.,, 

fin,..., mm, . . back? (Permanent strffness - i.i.ts will Enter conditmn and letter in appropriate person’s column. 

net .uOv* at .11.) 

A-L we conditions offectmr 

B. Paralysis of .“y kind? 

Id. DURING THE PAST 12 MONTHS, did any... i. th. family Conditions O-W me iqxirti.ts. 

h... - 1/ .. Yes... ask /e and f. Conditions Y and Z affect the newt.us svstm-n. 

c. Who w.. this? Reosk 2a 

f. OURING THE PAST 12 MONTHS, did 0.y080 .Iso have - A. O.. fn.ss III on. . . beih O. f%ky e? C.r.bral p’Jky? 

(scr’a.brml) 

En[e, condtti.ao and letter in apgxo!xiote person’s column. _--.-----_----_--- . -. 

Conditions C-N and V are cond mans offeccing the bone P. PmIIlySIS of any bind? 

and muscle. . -. 

Conditions O-U .“d W-Z ore c.a”dttiom .aff.xtinz the skin. Q. Cwutw. et tho ,piR.? . . 

C. T!n. ifus . . ringing i. C.	 Arthritis of �ay kind ., Reosk Id the .8,s? R. REPEATEO trouble with 

Rh..mw*ism? P. Ecz.me o, P,ori,, i.? - ------------------. . -. 

0. O@? (,o.ry,.uh.s is) . S. Amy TROUBLE wiih ..---------

Q. TROUBLE With dry., fallen arches m Flotfeet? . -, 

E. L.mkaP? itching ski.? 

. . , T. A etubf,et? 

F, -. k)st..,nyditi,? R. TROUSLE with . ...? F. G1.mxema? (.s.tc.-oh.my-uh.ly .’tia) .- . 

U, PERMANENT stiffs... G. A b. cyst., bon. G. Color blindness? ., E“y dofmllfy Of tho spur? S. A skfn IA,? fd, lq, w kacb? 

H. A dotaehed ,otina or tmy (Pe,manent stiffness - H. Any eth.r di,oa,e of IFI. .*., c.”diti.n .f *. *.)will “et me”. ho”. ., CO,tilmg.? T. Any kind of skin dh,~y? r.ti”.? --------.--------- . -

U, D.rmatitia et .my .th.r 1. A t,icb km”? skin trouble? L Any otfmr hnubf. awing 

wit+aworbhqos EVEN V, PERMANENT Stiff”.SS ___ w any d. formity of fh. J. Ad\pp,d w ruptw,d whrn waring @ss**? fingers, hand, ., orm? 

. - V. TROUBLE with Fsll,n = .­

m,.h. s, fl.mf.et, ., J. A .I.ft pel.q. et fk.r.lip. * W, Mwtml rom,datlom? K. CtvWIUr. of th. spitw? .Iubf.o!? .-- .- . 

L, REPEATED troubl. wlih W, TROUBLE with ingruvm K. .%mm. ring or StIJpt.ring ? X. Any coridition ..ps*d by 

twcb, ba.b, . . spi.e? tO*..ils or fing.nmils? ~:~k$~%!%%ha. ---------.--------- .- . L. A.Y othor sp”ch ief..t?


M. ffursif ii or Synoviiia? X. TRWBLE with k+mien., ..---------.- I ~Yn’$%~: Whet i,


(sin.o.vy.’tic) cems, or .all. s*s? t . cc.n~ilion? M. A missing Fing.r, hind, __________________ . . 

N. Any dis~so of IFI. Y. Any dl,eso of th. hair 0, am; +0., foot, Y. Epil.p,y? RWS+S ., vend...? or s.+? ., I*S? .-. . 

0. A timer, ~@, ., growth Z. Any disco,. of tho lymph N. A mis~ing (br..st), Z. REPEATED Cc””.ki.”, , 

of th. skin? or sW.dt glands? kid..y, . . I.ng? s.iz. rcs, or bl.cke.ts? 

. . . . . . . . . . . . . ,0.-.,..,.,..’, ,......, 

42 
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... . . ... .... .. -.. .---,.- - Rcnd to respondent(s) and ask list specified in AZ: 

New I am SOIRO w rad � Ild �f �dlc.1 cendltl.ns. T.11 � . if any.n. in th. fsmily has hod any qf the.. conditions, .v.. if 

hOVO montionod lkcm bofwo. 

*, DURINGNfE PAST 12 MONTffS, did .ny~. in *. 40. OURING TNE PAST 12 MONTNS, dld ..7...1. tk. f.mily 

kmllr (read names) h.v. - \;*jy:o;d ~, If “’Yas.”’ osk 3b and c. 

b. Who w., this? b. wk. w.. *I*? 

3 c.DURING TNE PAST 12 MONTNS, did 9.yOnO .1s. havw - ,4 . . OURING THE PAST 12 MONTHS, did any... d.. h... -

Enter condition and letter in opw.apriate person’s column. Emer condition and letter in opr@r,.ze perxm”s colunm. 

&ke no entw in Item C2 for cold: flu; red, sore, or streP 4 A. ~I~~M; e. db.r thyrnid thro.ati or %i,us., even if resafied i“ this list. ___________________ __ Conditims offectlnr the dllestive system. 

B. Oi.bws? Gl,ndu la, dlsotders 

A, GII,*”O*? c. cystic fibro, i.? # 

D. Anemia? S1.aod d,t.rder -_,--- ,_----_-.-----_-___ __ 

E. Epil.psy? ,---------__--_-_-- _-

1 ,. 

10. Fwtyliv.r? I lrs.cdhh?
 f-. .-----------_.~-_f ----_-,__, II Condition .tf.scti.g the
 G. M1.rdn.? ne,vous system __ H H. N.umlgi. w Neuritis? 

__ 

p--

K. Kidn,y ste.a.s? 1 ___________________ __

-

II ] F. Ydlow-.-----------,__,-- Iowtdlc.? I IS. FREQUENTWISIIP.11..4 -_-__-+-, I 

IG.h, d!., ti”.,ti”bb? ! I 1. k, d!., bSW.1 tmubl.? I I J. N.pkritis? 

H. A>:cdyd:so �f tbo U. A;[;l~r intestinal II 

11 .“-–– .,.,. 

~_+_ 

L. An~;:r kid”oy 

Ill ~_:,:- -_-_--_,__ *st 12 J. A Iwmia ., ruptwc? II w.ourl”~ K. A@h:;; , ., m. t--l 

I I ?FH!W;Y) T- N. Prostat. tr.ubl.? _ -’ “ ! dlp,,iv.sy.toln? I 0. Any disu,. �f tk. ___________________ “t.ills ., .Vmy? 

I F--J ,, Wa.-osk wk. _-

was *IS? - Wbal was 1 

L. ti.tiitts? A1 . . . . ..dlti.m? . . . .. Enter . .

in item C2. THEN 1-L ____ --y_, ,

IM. FREGUENT Indlmtirn? 11’ 

reask W. 

II 

, “,s., ,,.”, ,4..4,, 

43 
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H. CONDITION . . LISTS. .. . AND. 6. Read to respondent(s) and ask list Spcc!fmd i. A2. 

Pbw I .m wing t.rod.list.f mdlc.1 <Atei.ms. Toll m. If o.y.n. i. tb. f.mily h.. h.d -y .f th... c.odili..., .V.H if 

YOU h.wo �.ntl. nod Awm khm. 

Em H.s .ny.n. in tlw kmily (reed ndnws) EVER bd - da. DURING THE PAST 12 MONTHS, did .ny.n. 1. th. Iomlly 

If ‘“Yc$ ,”” ask 5b and c. @2L@!@ ~v* -

b. Who w., W? 

1[ ‘“YeS,”. ask 6b and c. 

b. Who was this? 

5 . . fh, .“y.~ .1,. EVER had - 6 c. OURING THE PAST 12 MONTHS, did any... �Is. hcve -

Enter condition and fetter in @LWMttme persot”s COIUIM. Enter condu:on o“d letter 8. Gwropt!.te person.. column. 

Pk.

Conditions affecting lhe heart and circulot.xy system. Make no enlry I. teem CZ for co{d, flu. red. sore, or strep 

threat; or “virus,, eve” ,/ repmced m th, s 1,s1. 

A, Rhomnctlc ---------------.--- fcwr? G. A sl,.b. � . 

Condnmns o(fecttne the resp8rotory system. 

Reosk 6.2. C.,. br.vm,cul,, eccld..l? A. Bronchitis? K. t%Physomm? Rfwumattc h,mf dls”s.? (..r’..bro ..s k..l.t) 

c. Hudollills�f *. crfwi*s H. ::.:T**q. �f AI* B. Bmnchi..tm. is? L. P1.”<isy? . . . . . 

w	 Arfui.sclomsis? (bmns ko..k tsk.siz) 

- N. Tub.rc.l.sis? 

i. A Irm PCtMiS? C. As fhm.? -. 

D. t~nitcl fwrf diswso? (P%..rh) . - N. An .bsc.ss of th. lung? .-

& ComnmP houf dlsna.? J. A �ye.mtdiol D. Hey f...?? 

inhtceicn? O. A l.mer, Cyst, et gtowth 

E. A 110.dl polyp? of th. *r..f, Iwynx, et 

F. Hy wfcasfrn, *mOfimOS t,. chea? cc { 1A ffi~b blood K. Any �ffwr heart F. Sinus *r.ubl.? .-. 

plesmlle? -ck? 

Sal. gfJJW~:E PAST 12 NoNlffS, dld �IIY_ i. AM :.“ G. A d. fl.ct.d or d..i.at.d 

P. Any work. r.l.f.d I. SPII..

Iery eondi+i.n such .s 

~ “.s.1 ..pfnm? d.st mfulwqx, .118..s1s 

If ““Yes,”” ask 5e and f. w p...-m . . . ..ni... sis? .-, 

,. Who w., tkis? 3 H. “Tensillifis w .nl.rg.-

m.nt ,f th, fo. sifs a Q. During fh. patt 12 RIOA 

f.	 DURING THE PAST 12 NGNTH5, Jld �nyrno �fso kW8 - .dwmids? did emyo.. (.1s.) I“ th. 

. femily h... ony elk.. 

Enter cmditirn and letter in apknuwhxe Pcrs.ds column. 3 1. �Laryngitis? :?%x,i’:%w?. C.xditicns af(eccinz fhe hecct and clrculowf system. ask, Yfne was th; s? 

J.	 A fumar, .yst, . . growth whet W.S th. . ..diti..? 

.f Ih. br.nchi.l tub. Enter ,“ ttem C2, THEN 

L. DmIwE,d hWIP “d”.,? R. GM#wwe? er lung? r.sosk Q. 

: ‘If reported in this fist only, ask: 

M. h:cwdia .r Rcpid s. V.ric.,. “*i”.? . --- . -- 1. HOW 1110.Y times did hov. (_.) in th. P.St U m..th.? 

- T. Hom.nh.ids ., 

ff. A fwwf mwmu,? PII.*? If 2 .xmore times. �nter cond,tmn in nem C2. 

. If only I lime. ask 

O. hy ~,, hwrf hwblc? U.	 Phlebitis w 

Thr.mbcphl. bitis? 2. How I.IIS did it low? If 1 month or fcmger, enter m ttem C2. 

P. An wwnlys.? lf less ch.an 1 momh, do not racord. 

(M Yu-,iam) - V. &Iy .fhor condition If tonsils or .denoids were removed during pal 12 months, 

dfseilng bl”d enter the condition causing rcnwvol m item C2. 

0. k? blood .1.1s? .ir..f.tisn? 

!“M “,,., ,!,,,, ,44.,,, 

44 
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J. HOSPITAL PAGE 

1, Refer to C 1, “HOSP.” box, 

!.	 Ye. s.14 Ala lfnt w.* a pati.m in th. h.spl~l inc. ( 12-nwnth hosoitol date) � yaw 

.s., On wh.t At. did .nwr th. h.spital [[*h. I.si limAh. Nm. k.f.r. that])? 

Record each enuy date m o separate Hospital Stay column. 

L HOW M“y nights w., in th. h.sptit.l? 

1. h, what c.nditi.n diJ .ns.r th. h.spiml? 

.	 For delivery ask: . For newborn ask: . Fcf initial “NO condition” ask:


W-. this � nmd Alivory? Wa$ *h. kchy namd at birth? Why did �nt.r A. h.spi!.l?


lf “No,”” ask: If ““No,., ask: . For tests, ask:


who? W-1 fho manor? Wh9t was fh* maff*r? whatw.” fk,,.s”hs of th. I.,*S?


If no results. ask:


WhY WCf@ the *ltS mfcfmod?


J1 Refer m questions 2, 3. and 2-week reference period. I � .	 Did how any kind of wrsory or opomilon during this sfay i. tho hospitaf, 

tn.1.din, k. S*Win,. �d stifcfws? 

b,	 Wfmt W#S the MM �f *k* SU?SWY � q.cmliam? 

If name of op+rati.m not known, describe !+fIot was done. 

.. Was 41.N.w dfmrs.rwry .r.p.mtl.nd.riw this �WY? 

Whet i. ih. Mm. �nd sddr.ss �f this h.spissl? 

30TNOTES 

,“”,s., ,,,,,, ,+4.,,) 

1. 

— 

z. 

3. 

zX 

%. 

b, 

. . 

— 

L 

HOS?!TAL STAY 1 

Pe.s.n numb 

.“NI 0.- Y.-

19_ 

IM @ N... (Net ~s) 

—N ,dI � N-MI d*l,v*~y 

z13~c-Ml -bl,th 15) 

3 � N. Cond(t,.n } 

o	 Cmd,,,ca 

2 

! •1 Y*S 2 � No (6J 

(1) 

(2) 

(3) 

� Y“ (mask * tic) � N. 

Iky e8c0u”ty S18U 

45 
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CONDITIW 1 I P*,’.*If.._ Ask 3* if thwe is an tmpai,mem (refer m Ccrd CP2) w my of the 

1. N.m.cfcdlwon Iollowmz emries in 3b-f: 

Ah..,, o*m93c P.t,y 

kbk ““2.wk. r?i. pd. -sbx wIhut Osktngif ,,DV,S Or ,<ff~- Adn (.*..,, F!4.d “ ..,) G,”lh �udr.i. 

i“ c2ass0urce. 8t.Odin, (..CO,I m.”s”d) n..”+,.,. RM,tw, 

stood .1., I“f.elign 2U9(M,*) 2.	 ~~did[--/.~~*J l,s!s~o, talk w,{~bro, as,is~mt Ml M.mm.,ign S,w(no,,] cb**-- (c-n)? c.”.., N..,.tmh T.I.w 

S � ln,~r~fi~ W* (Rusk 2) sD2yr*., 1.,, ltlti 5 y,,. Cro”l,. (....s, I.*.*,,WI) N..,l,i. Ill.., 

I � 2.wI. r.f. pd. Sos Yr*. c+ m.,. %, Pmh v.,!..,. “01”, 

W..k( . ...) la 0“., 2 Wok,. 1,,, than 6 me,. >0 D,. ,..”, OK wh.n 

ao6 ~.,.. I*SS lhmn t Y,. sODK II ~. ,,,. 

4D I yr.,1.ssdlmlyrs. s Ig Dr. “*VW S*M } 

(.!b) 

h.	 (Ed., you told � . .bg”* (cwuUieo)) Did tfw docto r., ..sistint 

41 Ik. (~) by . � .,. t.chmhl . . *p8cifl. Mm.? 

I � Y., Zntlo BOOK 

------7.---.7: .-------, : Ask 3b if Yes #n 30. othe,wrse b-ansutbe amdlt,m nom from

i19m I without akin;: 

b. WW did h. w A, call it? 

S#ecify 

$ � Celor Sl!ndr,cs, [NC] 2 I-J Cmco, (s.) 

3 � Ncamal w.c.m,ye � I-J 0 M a. VW “Wfml d.liw,y, @l 9 I-J CttW (3.) v.ssc,.my } 

-

c, Rek was fkc c?mst �f (Wndi!lm in 3b)? (Specify) 

2 

Mark box lf occident or i@-y. o � AccidemViniury (5) 

d. D14 tk~ (condltlon in 3b) r.s.lt fwu aR .c.ld.nt or im@rY? 

I I-J Y.. (5) 2DN0 ,-: 

Ask 3e if the condttmn name in 3b includes any of the I.allc.win# wwds: 

Ail-., Gnu, 01s.0,. P,obl*m 

A..mI. Culdi,loll Dlsud., R.plwe 

A,thma G,, Gle.* T,.”bl. 

Alhsk o.k., M,., 1., rum., 

394 lx.., 

. . Wh kind 4 (Condition i“ 3b) i. it? 

Spec,fy 

Ask 3f only if ollerty or stroke in 3b-e: 

f.	 HOW do.. Am G1l.rgy/stmk.] NOW .W.t --? (Specify) 

J 

Far’Stmke, /111 re,noi”der of this <onditlo” palefor the first ~esen~ 

�ffCCL Enter in item C2 and complete a separate condltio” &age for 

each additional mse”t ~ffect 

w “,s., ,,”,, 14.4.0,, 

B. What wti of lb My 18 aff.chd? 

Sp&ci fy 

Shon the followinc detail: 

Nod . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..ku[I. .,. t,. fg.. 

~-~*Pi-/-,*km. . . . . . . . . . . . . . . . . . . . . ..ppor. Iniddl., low,,

Sly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .*..”..+. 

E.,. . . . . . . . . . . . . . . . . . . . . . ..,nw, wwh,; ,ef,, ,,~, wbh 

h . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . w+, ,123W,., hlk 

A- . . . . . . . . Add.,, .,pw, .Ikmv, 1-., - .,I, I; hh, r12ht, ., hh 

. . . . . . . . . . . . . . . . . ..m. imbr.dwf.. pm AY:W,,, 1+,,0, W 

L=, . . . . . . . . . . . . hi,, .p~r, k,m.. tm..r, � �AI.; 1.1,, ,1+,, w 6.* 

~m* . . . . . . . . . . . . ..18” 1“% �rch, w v.., d,, l.h. .I+t. ., kuh 

. Except for eyes, ears, or mlemal organs, ask 3h if &we w OnY of the 

Iollowi”t entries i. 3b-f: 

l.(..,lon S.ra Somn,.. 

h.	 WT+a part ef A. ( on o bod !. 3b- ) i. .ff..# by & On foctid 

****/*Q,*.*.~1 -HiF&lz&, Wsom.dw,p.., 

Ask if there we my of the following �ntries in 3b-f: 

T.** C,** CmWllk 

fs this Gumev/cyst/*rmw~ mali2nm.t *. hfii~? 

I I-J M.11,.a!w zig Bmitn 90DK 

0. ~~ was (<onditi~n in j’b/ I u 2-wk. r-f. ed. 

fi,se no,k.d? 2 u O“,r 2 M.eks ,.3 mmth, 

s I-J 0“., 3 .nomk, to 1 y,,, 

b. W2wn did (name of inl.ty t. 40 Ow t Y..r to 5 V.*S 

[ w “1 s � 0“.. 5 “.,,s 

Ask probes as necesmry: 

(W.. it en w sin.. (/irst date of 2.wek ref. Deriod) 

0, W~S i? bob,. N@ dot.?) 

(W’s it 1.ss than 3 months s. � e.. tkam 3 memths ago?) 

(Was it 1..s then 1 y.a et � ar. thm 1 Y*W a-?) 

(Wins it 1.ss thaa 5 ~wrs o, mot. then 5 y.ars .P?) 

46 
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R*IW 1.3RD�M C2. 

K1 p%:.;.h-no- &C.xAN, ma,. *U,, mnd,t,wl (“Q,,, 

6-.	 Durfno (kz 2 wnks -dinedin
d onk!calcndnr, dld .- (~ 

cwso to cwt Auh .“ tk, zkl.s, W*U+ d“.? 

� Y*S u No (K2) 

b.	 Durlmm tit nrlod. kOW M., dam did cut down kr � ar. zknn half 

d AI*-*? “ 

m I-J 21W,. (/(2) —OW* 

7.	 D#rln tkas. 2 W-k., h.w monr &YS did SW in bod fat m-m fbe( 

kalf �1 tfw dq bocous. of tkis condiNm? 

w � Nm. — O** 

Ask If “~e/Wb”” baz mdad in Cf: 

& ~R#kO 2 WZOh. h Hny + did -- �l,, x k fldf d 

lob Or buslmss k999. �f *i*CMdlfzm?


00 I-1 N0n6 _OaYs 

Ask if aae 5-l?: 

9,	 Dwlw zbw 2 .+s, k. many dcys did �!9S mom tkN half �f zk 

dzy k Scbml ka,. �f All emaditlw? 

w o Nom —%, 

Il. If.. .W k.@dIsd k (cadicion in -W]? 

I � Y*S xf_JNo 

� M18M’ .xlmndly m w,an (K4) K3 � olhr (12) 1 

I*. ko Will bow *i* condiNOa? 

t n Y** (/(4) o No 

1 u Y.. Z=NO 

0 � Net m accldw,tilnjw (NC)

K4 tmF,,’,#ccidmVl”lurytor 0!,s wcen (14) 

o � O*W (r3J 

1“ “,s., ,,,U, [M*,, 

12. fll~,cf#gm?3,2k..s”hof *. ,Onl.a..idwltyc udmdy 

!2 Y.* (R- C4n41flmqss Ilunltw Wnelv #cc/dMf qlmslk.m / “f LnnJ)wej.) 4 — (NC) P.’. NO. a Me 

14. W%”. did !2+. .A6.nf h.ppm? 

, � At h. (Inlidc fws9) 

z � At he+). (dIacom B,tilss,) 

3 n 2t~*.1 -d hkhww (incl. d.. r..dw.r -d wbh.Sldw.lk) ,D!=um 

s = 1“4,,,1s1 @l... [[”CM.* Wmm,, ) 

� � .2dm01 {I”r.hd.s Prcml* **) 

7 I-J PI*C. .1 ,*c,**ttor, md spat,,. .X.,f,t ., SClbaal 

. ig oh” Ismlfy) d 

Mark k.m if under 18. ~ Undw 18 (16) 

162. W*S -- On&l 1s wban � acclkt happwwd? 

I ~ Y-s ff@J o No 

b.	 W*S .1. !k. Arm.d Fore.. whoa fk. a..id.rn k-mod? 

> � Yes (18) � NO 

e.	 Was ct w.rb e icb w bm,l”,s ~on tb. aceidc~” h~!.. J o Y.$ *‘a No 

16-. Wa , car, twck, b2S, u oh mdw vobidz Invzlvtd h tfw ozddcm 

fn Znf W2y? 

t D Y., 2 � No (f?) 

b. WasW“ Am o.* mkich iWOhd? 

t � Y** *UN. 

c. w., ~t/.i!bef .Ilc] Illovilly * Zba limo? 

I n v-s XI-IN* 

L----------_ -_-__ ------_L 

Ask if box 3, 4, or S morkedin Q.5: 

b.What pt of tke body i, �fkctcd now? 

H- is fpmt of 2+) dfec2A? 

Is sffcchd in �ny @k my? 

P.M.) 4 u, � I �-,..* .NC.M -

� Enter F.arz of body in same &uil as for 3z. 

�. If ~ulfjpl. pres.nt effzcq, ahur in C2 �d om tblt it M! ffM 

S2m2 � S 3b of C2 �!6 r.on@tM � SSPWZM CdiffM PZ;t fcf it. 

47 
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L. DEMOGRAPHIC BACKGROUND PAGE 

I I- ~ Under 5 (t/P) 

L1 Rcterto ace.	 c S-17 (2/ 

c; 18 �d over (IJ 

10. Did EVER s.rv. m s.!iv. duty III th. Amwd Fwccs O! tfI. Umitcd St.t.s? ‘.. I (_! Ye! (Mark ..AF,. Mx, TH.5,N II 

2 El No(2) 

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

b. WfI,” &f s,,..? 

viemmn Era (Aug. ’64 so April ’75) . . . . VN b. 1 L; VN s ~ PvN 

Mark	 b.a.xm de%cendi.nt order of Drionty. Korean WaI (J.ne .S0 to JarI. “55) . . . . . . . . KW 2 L1 KW , L-J 0s 

7hus. 81 person sewed in Viernom .md I. Korea. World War II (Sept. .* to July .47). . . . . . . . WWll , I--J Wwl ,~OK 

POSCVietnam (hbY ’75 to present) . . . . . . . . PVN 

. . . . . . . . . . . . . { Other Service (811 ocher ~rtod%) . . . . . . . . . . OS .. ---- . c, W.. EVER on eeNv. msmb.t of . Ngtien.1 Guard w militwy WS.N. unit? 

. . ~Yes 2C[NC. (2) 7[j OK(2 

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

mcvk VN. V@rld War I (ADr,l ,17 to Nov. .18) . . . . . . . . WWl .~ww 

d. Was ALL et OCtiV. do!y S01VtC9 rolatod I- NmNmol Guard et military t,sorvo tminime? d, lcl Ya* lUN. s ~1 OK 

SO. what i, tfw highest grad. .r Y.OC of t.gulor school has �ver .ti*nd*d? �. 00 p N..., ,ttmd.d or 

k,”dq,rt,” (NPJ 

El,w 12345678 

H,zh: 9 10 11 12 

GM.*.: 1 2 3 4 5 6 � 

-. , . 

b. Old flnith *h. (number m 20) f_ywde/yur]? 

. 

h. !UY.S *UN. 

Hand Card R. Ask first alternative for first person; ask second altemmi.e for ulher pers&s. 

k.~/:~~;;~~of*. oroopo,g,oupswhlch m,,...”,. --race?j 

).. 17.34 ‘d Circle all that apply 

I - Alew, Eskhno, or American Indmn 4- White 

1- Asian or Pactf@c Islander 5- AwXher Lroup not ltsted - Spacify 

3- Black sp+my -. 

Ask tf multiple entrtes: b. 1234 

b. Whfch of th.s. SW.ps; the? is, ($.w,es i. 30) would YWJ S*Y BEST W91CS*IWS mcu? ‘J 

.. . ...- .. .. .. ... . . .. . .. ... .. . . . -. sjncily ., . 

c. Mark observed race 0/ respwden!(sl onlv. c. Inw 2C]B 3U0 

Hand Card O. 

h. Are any of th.s. gre.ps mdi.nal .rigln .r ancwswy? (Wfm. did anc.st?ts c-e frem?) l.. t u Ye, 2 n No (NP) 

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

b.	 PleoIe give me tfm number of tfw group. 

Circle all that OMIIY 

I - Puma Rican S - Chtcan-a b. 123,56, 2- Cuban 6- Other Latin Aowticsn 

3- Mexican/t4exican0 7- Other Spantsh 

4- Mexican American — ,“M “,s., ,,,,,, l,.,.,,, 
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L DEklOGRAPfffC BACKGROUND PAGE, Ceniinued 

L2 .anu- lE(IJPJ 

, � w. bx hurk*d (6,) L2 Wkrto ““AI.” atd ‘“WO/Wtf”kaxes in Cl. 2 ~ Wb 00” marked (54) 

3 � N,lth., be, mafk.d (5LI) 

k, edkw yau W* w bAs� job W bmsirnssbat dii me wub h w-k w h w-k bcfom. 

was -- Iwbln$ PmWmk u on kydf @a � w dwl~ eho 2 WNks? h. t n Y- (=) 2 I-3 N. (s4 

e. 

b. 

Wklch, 

ths	

hliw 

” 

hbin, 

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

vw 

l“kl~ 

s,14 

fu 

f“ 

&t 

WA 

wwk 

w

dl#a”t 

w 

M 

~ 

kyoff 

hycff 

hvc 

hm 

� 

from

@or 

� 

� 

1A? 

@b 

bu$lmts 

4U,IIII efwsa 

lam wtik 

2 w“ks? 

or vfm w-k hforc. 

. F h.	 hklw you Scld *M worbd last wook� r th w-k bhm. A$k 6b. 

. ­ b. P., Am w wA? Enttr nameof c-my. busimss, ~izatlrn, w othu �@ow. IL Employ.. 

,mk 

. . 

c. F*!Wksa dfd Wwb �? -- lost full-he ciWik lob “ bmslnom hlIIS ~ MSSdfVC w~ks � r -? 1 Ent*r nanw of compaw kwifnss. wsanizatiOn, or OIhw amPlOvw. 

. . d. YVkst kld d buBlmDssu idwcy h lbls? Far �UQIO, TV and rddio monufacturinr, MM shoe store. 4. Indu$lIf 

Stat LabwDkpmment,/aml. 1 

0. Wh kind d wuk was Aims? Far .XOIIVIC. *lectric@l cnsincer, $Iack cl-k. twist, (crmcr. 

. .Oecu$-lwl 

. . I . f. WV wcm most l~nV �ctfvltics u &tlos � t AMI lob? For wmmple, types. kmps account kooks, 1. O“tk. 

fllcs, salts cws, ofwaes guintns press, finiafms concfwc. 

. e -

I

Comphto /mm Muics in 6k-f, If m dew, osk: . 

,. was * ,mP 

Am yl~ d . ~WAW .-w.,, bmsm.csw Sdv-ampl.pd 1“ OWNbw.lw.s. CmfOsslmd 20F Ml” - 10?-., .alwv, “ .mlm.ion? . . . . . . . � Pmcll.o. - *-? 

A �UORR4L �— .=Plom=? ... . . . . . . . . ..P Ifmkm, ”k:l. tib.i-. .u-ti?i? 30s 

ASTATCgew+nm-* -vkIN? . . . . . . . . . . . . . ..S Y. . . . . . . . . . . . . . . . . . . . t 4nL 

ALOCAL,UW-l *VIOTU? . . . . . . . . . . . . . ..L No(afofm) . . . . . . . . . . . . .5E 

Wq”lww *A, ,“A4, b.h,.


“km . . . . . . . . . . . . . . . . . . . . . . . . . ..WP


.	 Mf!VCR wMKCO �, mm, wakd d c 1.114-, 

c[. {lk. 1A I.. *IW z “A �? mwo. . . . . . . . NSV 

SOTNOTES 

w “,s., ,1,,1, ,4+..1 

49. 
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Mark bax lf under 14. V %4.rried’” refer to household comps.im. and mark occordinclv. 1. 

7. Is MW �ard.d,wid.w.d, div.r..d, sapmrtid,et h-a ..VW boo. �wtld? 

8..€ W.s fho WWI cemblrnd FAMILY inc-e during th. past 12 me.ths - that is, yews, (reed nomes, includin’ K Anneal Forces members [ivinz .1 home) m... et 1.ss &.. $20,000? Mud. m~.y from iobs, ..cids.c.rity, 

mttmmem! III.*IIW, ..mpl. ym.nt P.YM-*S, public .ssist . . . . . ..d s. Porfh. AI.. Imcl.d. in.om. hem 

I.t.r.st. dividds. n.t 4..-. from bvsln.ss. f.nn. or c..*, and any .Ih.r mow in..- IU.lVA 

Read ifnecessaw: km. i. imp.rt..t 1. . .. IYxI.s lh. health i.fsrmd.m w. cdl.ct. For .x.mpl., this 

Ir!f.rmation h.lps.s t. 1-.. wh.kt P.t..n. In . . . i.conw smw us. c.tiln v?.% .f �edical ..ra SW!.*. 

or hav. c.rwin co.dlti.ns III... or 1.ss .Pfm than thes. i. �oth.r group. 

, . .. Read Darentheticol Dhrase if Armed Forces memtwr ltvint at home or if necessarv. k. 

b.of this. iw.m. ro.ps,whl.hl.tmr b.st r.pms.nts th. t.t.l cc-mbhmd FAMILY in.om. 

d.rtms th. P.S* 1! m..th. (thsl is, Y..rs,(rend nomes, includi.z Armed Forces member. 

Iivinn at home))? I.cl.d. wags, s.1.rl.% �nd Pk. eth., [1.m. W. @lt talbd ,bSUt. 

Rend if necessary: Iac-. is Impshnf I. a.dyzl.sth.healthinformationw. e.11..t.Far .xampl*, fhis 

in fwmati.fi helps us ta loom Adher pusans In en. incomeWP us. eutdn typesof medical care SWVIGWS 

�r hcvc c~faln conditions mow or 1sss Am than ha- in anoflmr group. 

‘* 

m. Mark flrsl appupriate fwx. 

R . . 

b, Enter person “umber of mspmdem b 

FOOTNOTES 

,0”” “,s., ,x, ,,,”, (,4.,,, 

Oou.dw 14 

, � Ii,,ri.d - SW,. I. NH 

2 � M”rlcd - w,, net In HH 

1 I_J Wld.w.d 

a � Dlvorud 

s � %--d 

6 � !k.v.r K4.tti.d 

I I-J $2&a . w. (Hand 

z � * ~j Szo,coo of-w 

.-.,----.-

Zonu 

21OV 

Zznw 

Zaox 

240Y 

Ztnz 

Z6 � 22 

0 � UAW 1? 

t n

—�msmtPot.11w.818M8 

2 � Fmauit for SMIUWS,hn, 

s � N,%pros-l 

P.Sal “Umbaf,) .f ,.op.dUq.) 

50 

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

----

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

--

M. 

,, ,,-. 

litALl , -.. II ,.,.IKIUKANLC 

,.,...,-- rAbl= ,----- 11 Rcod to reSDondc”t(S):


M*dlcar. II a Social Security h..lth i.sur.n.. p,oqr.m l.r di..bl.d p.rs.a.s o.d IOF p.rs.ns 65 y.ors old and


eve.. P.oPI* c.v.r.d by M.dicm. h... o ..rd th.! looks like this. sh.w cord.


a, Is .nyon. 1. this hnily, that is (reed nomes), waw coved by \l@&.~ _--~j~es _-_-__El!!J4__I:l.EK___ -

b. ~-~~ ;;; ;;~.;<d? ‘fi~,~%;~ ;~~~~{n’~ ;~;~< ‘--- ;b: IIJcw. z1.]N~cw. 9mol 

Ask for each person w,lh ‘“Coverefl’ m lb 

2..11 .OW .ov.r.d by +e port .1 Soci.1 $.cx.rity M.di..r. ,,h~ch pays hor ho.piml bill.? 

‘z.. I ny- 9m0K 

ZmNO tirk box m person.s column. . . . . 

b.	 Is now cov.r.d by that wrl .1 M.di.mr. which pay. for doctor’s bil l,? This is the M.dicm. plan fer b. , Dye, 9~DK 

which or some og.ncy must pQy o c.rtoln amount ..a. h rno”th. Atork box in pcrsoo’s column. 2UN0 

Ask for each person with ‘“DKr’ ,.20 .nd!or k 3. t n HO. PI,. I 

3.	 Nq I plms. s.. the Social Sec.dty M.dic.r. card(,) lot (and --) I. d.tennin. th. Iyp. of cc.v.tq.? z(_JMedlc.1 

Transcribe lhe mformat,on (mm the card or mark the ‘“Cord N.A. ”’ box. 3~ C.td N.A. 

W. am Int.r..md tin .11 kind. of h.olth i...mnc. plo.s .x..pt th... which pay .a.ly (.. occid.nts. 

da. (Not counting Mufic. r.) Is my... i.th. family now c.v.r.d by. h.ohh ins., . . . . 

plan which pay. any pod .1 Q hosplt.1, doctor’s M ..rg..n’s bill? ~ Yes ~ No (Ml) ~ ------------------------------------------------

b. ~~q~~~~.-=ng::~ ~~.~j~.:-~~:gl m T.ble HJ. _______________________________________ - e.	 h .nyow In th. I.mily now ..vet.d by any .th.c h.elth Insurance plan 

which pays my jmrt .1 a hospital, doe)..’. or s.rg..n’s biil? r] Yes (Re.$k +b and C) � No (5) 

TABL E H.L 

PLAN 1 ho. D=.. this o!mnmy?

. . . F., .6 7. 1. c...md h.spi,. i .X f.n,., ““;:; *hc. (Zm) 7. I m c.v=,.d fNJ’) 

. Was lhl, (urn) PI.. oht.1..d l~9h , ~ Ye. 2(-f N. 9r10K 2 D NOI covered (NP) .“ �R@.”., w .“IC.17 ..------ .. — LWk bm In ! (--J Y.,
 ----------------------. 2m No(6) 9mDK (6) h. Do.. ,h,. l.. p., O.V w,, .1 do.,.,,, ., pmlm % COl”m.


b, : i,nm~, <.,,led ,hrounh . . .mploy.. SUr$!...,. Kills 1., c.p.,ot k..,? 

,6,., 2[-]N0 91 lDK , ~ Yes 2(-IN. 9(IDK 

PLAN 2 6..	 Doos this F&n WY .ny W, I .1 7. 1, ..a..r.d I,.. @!,ml.Xp. n..,? .nd., thl. (nLm) 7. I nc.-fNpJ S. W., Ihl, 1~) plan ebmi..d Ihr..gh I r] Y=$ 2mN. ,f:]l)K *I.”? 2 n Not covered (NP) .“ .mplor., m ““l-? 

I m Yes Mark b.. In 

2-r~l-N_”-’g)-_ :-~..%f:! b. Oat. th,s ~!m m, . . . pnrr .1 d=mr<. ., ,?wscws COl”ml. b. 1: :n;nwt mrrl.d lhr..+ a. .mpl.y.r ,.,9 . . . .. ,11sf., op,”,l... ? 

I ~ Y., 2 r] N. smDK , ~] y=, 2~No 9~]OK 

PLAN 3 6..	 Doe. lh,s PI.. p.y any pm, .1 7. IS c..,,.d 

h..pl,cd .. F.,.,.,? .nd., this (&mJ 7. t D Cove,ed (NP) 

S+.	 W.. this imuw) pb. .hl..d thr.wjh , ~ Yes 2~JNo 9~]DK 010.? 2 D Not ..v.rod fNP) .“ .mploy., ., ““l.”? Mark box i“ 1 n Y., 2 ~ No (6) 9 m DK (6) . b. Do.. ,hl, PI.. m, .“, w., of d.. tor,, . . wrs w.. ..j.m.. b. & lm~, .wtl.d lhr.vgh . . .ml.y.r s,>,,. . . .. bill, 10! OWm!,.a. s? 

tr Y., 2 ~ No 9 [-] DK t rd Ye% 2( ]No 9mDK 

MI :ev:vt J&f7J eoch person ond d.termme tf Cover.& by mthertdedrcm.! mdlor Insurance. Ml	 , � Covm=d (NP) 

z 13 ‘Ot covered~der 65 fNpJ 3 I_J Not .ov.r.d 65 ..d over [NP) 

Ask f.a, each person .. Not Covere# 8 m Ml. 1/ Nor .ov.,ed 65 .nd over.,, mciude “,or Med#cmt. ”’ b. s134567: IAany p..plw d. ..9 catty h..lth i..., . . . . for various r-sons. Hand Cord N. 

h. Which of th.s. st.t.m.nts d.s.tib.s wby i. not ..v.r.d by any h..lth i.s.mne. (., M.dic. r.)? 

Circle .!1 reosons gove.. ----------------------- Any .th.r was..? smlfY ;,--------- ;,- . ---------,: - . . .,7 

Murk box I/ only one reason, If Not covered 65 and over, m M!, mcl.de or Mcdt@JrE. l,. cm� Only M r..... 

b. What is the MAIN t..son is n.t .ov.md by .-y heolth i.s.,.nce (or M.dic.r.)? 11345678. 

sp6cl!y 

0.” .,,., ,,,,,, {4 . . . . . . 

51

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

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

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

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

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

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

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

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

--

---------

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

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

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

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

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

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

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

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

M. HEALTH INSURANCEPAGE, Cmtinwd 

?.,	 Dws 811yon. h thit fsmily now ts..lw .S.i.tmc. ~tw+ ~ a-Ai~ f. Faml[[., 

with DqA@ Chil&.n” P,e.mm, SHetim., .xlled 4CAPDC’, w ‘OADC, S? 

rl Yes CNO(IO} cDK [10, .------------------------

b.	 Which (ok?) f.mlly mmbom arc Ineluicd in AI. AFDC cssi.font. pqMMIt? s$. , m AFOC Mark “’AFDC,, box in Mrson-s column. 

c. Are �ny .Ifwr family mcmborz in.lud.d in this p-m? 1 m Yes (Reosk 9b ond c) m No 

00.	 DOas .myon* in this femily 6CW r.c.lv. & “Suppl.me.mi S.eWity 

Incoao’” w “’ss1”’ gsld.cdewd cheek? 

n Ye. ~NO(IIJ ~DKfl II 

b. Wbe (.lse) t.c.i.es this clwcb? Murk “’SS1”’ h. in personas c~lumn. I ok. I ~ssl 

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

e.	 A,yu. ds.? 

El Yes (Reask 10b ond c} O No f 

10.	 Thcm is a naNwwl pfqmm coibd Mdcoid which ~y~ h hcdth ccm 

forpwsonsinmd. (1. ihis~c~it iaals. c.lld(~~)). 

Dudng Am P@St 12 moa+ha, ha, .nyan. in this f.mily “Cd”d hcdth 

..- which has b..n w will k pid for by lddiedd (u (n-e))? 

n Y*S ~N0(12J nDK(121 

Medtcad .-:---------- b. Wh. wos this? Mark :,----- boxm persons : column. ------------, 

1lk. I ~ Wd,caid 

..-- + .-------- . 

c.	 Anyone dse? 

17 Ycs(Re.skllb.nd.) nNo 1 !s,	0-s ony.nr in tho family IWW havo a Mcdlemid (w (me)) card which 

Iaakcllk. shis? Show Akd,coidc,xd. 

------------------------.----------------------o-u-s-----,.~:::::3!---Q-:~:l:! .­ . b.wlnistbis? mrk’”Cor<” hsinpwson.scorumn. 

12k. t ~ Cud 

+ . 

e. Anyem .1s.? 

[~ Yes(Reask12bwdc) aNa --1----------------------- Ask foreach person wilh,,Co&m 12b: ~ FwI,.,d <“d **,” 

d. ~y i +s8 s.? (.nd --) cd(s)? I n cwr*m J Morkappro9fig1c	 box[e$) tnpersm+scolumn. z17ERW.4 

sn N. Cti s“. 

, ~ Other card s... 2 

. . Is.nyes. i. th. family 11.w c.v.rdby .nyaih.rpblic 

as.istqncc pqrcm that pays fw hadth COIC? u Yes u NO (NQXI I_J OK(tdwa 

-_------------_ ------------_ .------.--------*! ------p-~~-, 

b. Nh. is this? Uark ,. Other PNC box in person% alum.. 

e.	 Anyw d,.? 17 Yes O?eosk 13b ond.) m No 

,“14 .,,., ,,,,,, ,4.,.,*, 

52 
------------------------------------------------------------------------

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

---

---

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

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

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

----

-- --

----

--

1A. Dns �npw in tfw hmlly IWW mcdvc military mtlmmcni poymmts 

fwm any bmnch �f the &d Fucct w a pmsion from tlm Vatcrans 

A6mlni.tr.tl..? D. ..* i..lw& VA ~i..billty comFo.s.ha. m Yes O No (IS) O DK (15] .-. b, K:rs-ir*l---------------------------------------------"------------------" 

Mork ‘“MM ret./VA pen.” tix in p“son,s column. 14b. ! � Ml. m./VA m.. 

. 

c. Ally- �IS.? 

n Yes (f4w$k 14b d c) � No :--------------------------------------------------- . ,-------------—---- -. Ask for eoch PCVSmwith ..Mil. ret./VA f)e”.e. in 14b: A 1nArmD4Fa=” 

40 hi.h &S .- WC-IV. - tbc AImd kc., ratl,mont, Am VA penslen w Mb? 2nVA 

lDElah 

Mc. f, cnyoao i. fk. fm.mily now cwcd by CH6AWLVA, wkkh i, did 

imsumncok 6+m6mlts 41 Suwlws �f dlsdfd -9? 

Ig Yes n No (16) � OK (f6) 

b. WbOisIbis? &k ‘“CHAMP-VA., kw in pgrso.-s column. !s. I o CW-VA 

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

c. h“- f..? 

� Yes (Re.sk 1S4d b) m No 

1 k. fs � w h Ifm fcaily MW COVWC6 by -Y clk 

w% cam 1“ military 64pm6cnm “ S“rdv”s J’m’w’%a’by= � No(k4Zf � OK(MZI ----------------------------------------------:--------------------------- .—-------------------

b. Wfmis *is? 

Wk “’Hedlh Cae.. box {n pwmn% dumn. 14L tnHdtt.cam 

c. -------------------------------------------------------------------------+---t--------------------­ Aw4n* �f**? 

~ Yes (Rrnsk 160 ad b) n No 

W? 11_JAFbanutlu4(17) M2 Refer to ““AF”’ be. dove pemon”s column. 2 n Cl* (NPJ 

17a. 0“s fnv. . ils.bility rd,td t. -1.. i“ * ~ p-e.. 4 * ff”itsd *.? 17.. loY2 l-g N. (UP) -:----------------------------------------------------------------------- . .---------------------

b. D- w rod,. c-.srnion {or Al. Ability 6- & V-n. AdmInistrMIM? b. , i--JY.’ 

2UN. 

FOOTNOTES 

0.14 “,s.,,,,.,,,.4.,,, 

53 
-------------------------------------------------------------------------

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

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

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

----

N. PREVENTIVE CARE PAGE 

IUl Refer m age. 

1. Abeufi how long kas it ban slnem you kad mn .Iectmcwdlegvam, w EKG, which im.elvas placing wit.. en 

tko chestend�m,? 

3. About how ton, b, it bum SilK. y.” had. Ch.St x-my? 

4, AbouI kow 10n9 Iw It boon since you hod yew blood prcisurc takm? 

Ss. ffava P. EVER b. told by . doc~r tknt YOU had high blood prs.sw.? 

b. 16nvs you EVER km told by a doctor llmt yW kod hy~It,”SiM? 

6. At. YOMNOWt.kln9 ony mdiciM pr.sctibod by a hctat {w y.w Kish blood pr..s.,.,%ypstttosi~? 

7.. D. ye. still Imv.Chi@h blood W.ss.r4Yperh.si..~ 

b. h this .odti.. ..mpl.dycurd m is itu.d.r .cut.el? 

N2 I Refer tosex, 

8. About how long has it b... sin.. y.. kad . Pap SW., t.si? 

9, AbOIII k4W IOIIS ho. i] b-n sine. yOU kad a bmait �xaminati.n by a m.dhl deetoz a assistant? 

Ih. D. y.. fmv. .y.gh.s.s et c.nh.a 1. . ..s? 

b.	Abeui how Ions has it bon sine. you had your .y.s .xemin.d t. s“ if y..’.dd.d sIQ.s.. (w IWW glass..)? 

Red if ace t7: In.1.do any �ye �xams givm in school. 

Rsl 

..”” .,*, ,,,,, ! 14.0.,,, 

2.	 00 199HR’I-.,Y*= 

— Y“. 

k 1 

-N: 

b“ $&i?, 

: K&son) 

. t V.* (Nz) 

~.. 

Ig OK ,-------------__-_-------

b“ ~H~::...l,., 

‘2 :’%=?’ 

8.	 00 

,a13~:*.fI ,Y**, 

54 

I 
--

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

--

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

--

-- --

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

N. PREVENTIVE CARE PAGE, Continwd 

N3 Ref., to .,,. 

I la. D.,% ha,. .Y.s[..s.. w ec+t.ct l....,? 

.---------- : b.	 About how IORE has It b... Ii... h.d .Y.s .xami..d to sw If ..cdod gl.ss.s (et new gl.ts.s)? 

Read d age S-1b: I.ctud. tiny .“. . ..ms glv.. III school. 

Ss. Durln fh. post E? month., that is, since{ f 2 month datf) a per ego} was tob.n te. doctor fw Q 

ROUT%W physical .xemln/tl.n, *hot is, net fer a pO,tiC”[W illn.ss but Pu a .enoral ch.ckup? 

Read if aae 5-M: I.clud. routin. physical ..emin.lions sivrn in school. 

b. ;t~;~;~w long has it b..” sin<. w., t.k.. t. a dotter for. ,wti.. +Y’kd �zaminahn o, g.moml 

Rnod i( ate 5-16: Include t.uti.. physical . ..min.tiomn given III schcal. 

1. AbcuI how .14 was wh.. FIRST w.mt to a dentist? 

{s2 

30TNOTES 

+ 

T== 

b. ce � N.-r 

1


+=-

1s2 _ P“,. No. d Rasp. 

55 
m 

U) 

LISTING SHEET 

E EXTRA un,t, enter C.”uvl Number alw entet for FIRST .ntt Sheet n.mbet Line number 

of onmnot sample unit ~ listed on Prolwty ~ 

TABLE X - LIVING QUARTERS DETERMINATIONS AT LISTEO ADDRESS 

AD- CE s P 

ADDRESS OF ADDITIONAL LIVING QuARTERS LOCATION OF UNIT SEPARATENESS ANO FACILITIES CLASSIFICATION AREA SEGMENTS ANO SPECiAL !LiCE PERMIT SEGMENTS SEGMENTS 

Enter baste ad&ess md unit address. if my Is Nds . unit i. D*** �e.”wntl (., Dec. (addressm Does f~ N - N? . s.pmb Is tkis..it - I. Iki. vniP - Is this nil -

+ 

If th#sq.estmnncwreIS for on If in AREA SEIWENT. 

. s,eci.1 pk.? inmlded .cCllpmlts) @J)) h“. Col. 1 ) h.”. “;” -:’’”d’ . ..N# . ““list.d . ..li*t.d OR d (odd=essin cd. (1)) ilmct .Ccns k c- �t. klt.h.. on thm ques. AND AND Ii”. . ..t ,, - description of locati.a” .mt.[?kw.lr &’#!’::*” $%: :2:!$,? 1’””””’” unit - . within tk. � wilki. Ik* � witki. th. .p.. ifi. 

.fk.r p,,,.”, .“ S*pw.* s .Cific .UM.* (bssie .4A.,* (h,;. plus 

**	 ,Wp.rly? Do not include ;%:;..? pfus wait, N �ny) �F u.it, if ..y) .! 

HU , ;&#&~ Ill. Wi,inat SWlnpl.““I*? $m:,-ici-l s-d. 

DT ~ f~;;~$w AND 

~ntewieyi”~ . wlthi. th. ..m. 

{ mstructmns. Stmclut. ., Ill. 

.risin.l s~90# .ni* ? (1) cl) (3) (4] (5) (6) (7) (0) 

� Yes - SkiP to U Yes n Yes - Skip to ~ Yes - Mark Cl N - Stop Table X � Yes - Interview [~ Yes - Interview � Yes - lntcrview <cd. (6) and Cd. (6) md ‘u ‘n ‘O1. (b) U HU - FIN CO!. fTf, os an EXTRA as m EXTRA m m EXTRA 

10 Table O i“ 

Part C of monual mmk N o No N i“ COI.(6) �%:;:.01.(7), c’ %.2”’” mNo-OonoI i.temi.w � NO- L4N1 

intewiew 

� No (8). or (9), as 

appropriate 

� Ye. - Skip to CO/. (6J ad 

mark occotiint 

u Table D in 

O 

0 

Yes 

No - SkiP 10 oaf. (6) md 

m Yes - Skip to c.al. (6) md. 

mtxhHU 

m Ye%-Mo,k 

HU i. COL(6) 

E] No - Mark 

� N - Stop Table X 

•l HU - FiN COI.(7), 

(8), or (9). .s 

� Yes - Interview as on EXTRA 

unit 

n Yes - Interview 

os m EXTRA 

unit 

� Yes - Intewicw 

os on ExTRA 

unit 

~a,k ~ccwdinz ig	 No - Skip t. mmk HU F3 IA. - Mmk (8). or f9), 0s UQ,c unit ..,1 COI. (6) md 

0 OT - Fill ..1. (7), � Kc;?.n”’ interview inlewiew 

� No (8]. or (9). os 

appropriate 

� Ye, - ‘Skip m m Yes � Yes - Skip to ~ Yes - t+xk U N - Slop Table X Ej Yes - Interview D Yes - Interview m Yes - Interview 

Pwt C of mm.ol mcrkN � No N m cot. f6) appropriate aNo-Donol � No- Oonot 

COL(6) and COI. (6) and Hu in col. (6) � HU - Fill .oL (71, as m EXTRA as m EXTRA as an EXTRA 

mmk according � No - Skip 10 mwk HU m No - Mark (.9). or (p), as unit unit unit 

to Table O h COI. (6) and 

Pat C of manwl ma,k N � No N in COI.f6J fgNo-Conoc 

C3~~:$(7), “ %&? n !%%:’ interview 

D No &mpriOce 

IOTE: Be sureto continue interview fw original unit �ftw cc+npletin; Table X for �ll Ii”es. 

‘OOTNOTES 
CARD R CARD O 

1. Aleut, Eskimo, or American Indian 

2. Asian or Pacific Islander 

3. Black 

4, white 

CARD 1 

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 

~ 

1. Puerto Rican 

2. Cuban 

3. Mexican/Mexicano 

4. Mexican American 

5. Chicano 

6. Other Latin American 

7. Other Spanish 

CARD J 

A ......... Less than 1.000 (including loss) 

B ......... 1,000 – 1,999 

c ......... 2,000 – 2,999. 

D ......... 3,000- 3,999 

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 ......... 9,000- 9,999 

K .........10.000 – 10,999 

L .........11.000 – 11,999 

M ........12.000 – 12,999 

N .......... 13,000 – 13,999 

0 .........14.000-14.999 

P .........15.000 – 15,999 

Q .........16.000-16.999 

R ......... 17,000 – 17,999 

s .........18.000 – 18,999 

T .........19.000 – 19,999 

57 
---------------------------------

MEDICARE CARD N 

80ela Lsm0vmlvv ac’r 

MA.c 0, W!MI!,,C,A”V 

“’’’” ‘“p’’’’” #x 

:=@$ .,14AL:,VC0,,= 

HOSPITAL INSUR4NCE 7-1-66 

*OICAL INSURANCE 

=0 +42 ph 7-’-

1. Unemployed, or reasons relsted to unemployment 

2. Can’t obtain insurance because of poor health, !Ilneas, or age 

3. Too expensive, can’t afford health insurance 

4. Dissatisfied with previous insurance 

5. Don’t believe in insurance 

6.	 Have been healthly, not much sickness in the family, 

haven’t needed health insurance 

7. Covered by some other health plan 

8. Some other reason – Specify 

’58 
Changes in the NH IS basic health and 

demographic (or core) questionnaire, 

1980-84 

Except for the 1982 redesign, the basic health and dem~ 

graphic questionnaire (formerly the core questiomaire) has not 

changed drastically from year to year. The questionnaire has, 

for the most part, remained the same during the periods 1980-

81 and 1982–84. This section describes the changes in the core 

or basic health and demographic questionnaire from 1980 

through 1984. 

It should be mentioned that each year a public use data 

tape is produced following the completion of data collection. 

Changes in variables can occur from year to year on the public 

use data tape as a result of computer editing and processing 

that are not a result of changes in the questionnaire. For 

example, the 1984 and 1983 questionnaires did not change 

with respect to the question on reason for hospital stay. However, 

the coding for the question on the public use data tape did 

change from 1983 to 1984, The coding change involved combining responses on reasons for entering the hospital and surgical procedures. This change enables the user to identify hospitalizations for deliveries. For additional changes, the reader 

should consult the public use tape documentation for the particular year of interest. 

1981 and 1980 changas 

.	 An individual’s race was determined by asking the respondent to select a category listed on a card. In previous 

years race was determined by interviewer observation. 

1982 changes 

In 1982 the questionnaire was redesigned major changes 

were initiated, 

Person questions 

�	 Instead of having relationships and demographic variables 

such as education and age defined for a “head of household,” 

beginning in 1982 they are defined for a “reference person,” 

who is usually the person who owns or rents the home. 

� The age group of children assumed to be attending school 

has been increased to include those 5–17 years of age. 

� Years of education is now included for all persons 5 years 

of age and over. 

� Family income is available in much greater detail, but 

individual income is no longer obtained. 

� Self-assessed health status has an additional category, 

“very good.” 

Limitation of activity questions 

�	 The limitation of activity variable was changed to classify 

all individuals based on the ability to perform activities 

that are usual for their age group. 

�	 An additional limitation of activity classification based on 

ability to work was included for all persons of working age 

(18-70 years of age). 

�	 The specific age ranges for the limitation groups were 

changed. The age categories more closely correspond to 

those commonly associated with the preschool, schoolj 

age, working, and retired populations. 

� The phrases used in the limitation of activity questions— 

“because of health” and “because of disability or health”— 

were changed to “because of any impairment or health 

problems.” 

�	 Because of increased availability of specialized instructions and special classes for some children with learning or 

other disability, the activity limitation questions for the 

school-age population now include specific reference to 

the use of and need for these programs. 

�	 The limitation of activity question set now appears near 

the beginning of the interview. 

�	 The previous variable “usual activity” has become “major 

activity” and is coded only for those 18 years and over. 

“Retired” has been eliminated as a category, and “keeping 

house” is no longer restricted to females. 

�	 A new variable of limitation status measured by “ability to 

work” has been added. “Duration of limitation” of activity 

has been eliminated. 

Days of disability questions 

�	 Each person initially was asked about disability days and 

the condition(s) that caused them. Persons who reported 

no disability days in the 2-week period or who reported 1 

day or more of disability but only one condition were not 

asked the disability day questions again. The 2-week disability day questions, however, were asked again later in 

the interview for every reported condition for perscms who 

initially reported 1 day or more and also reported two conditions or more during the interview. 

�	 The questions about work-loss days were asked only for 

currently employed persons. 

�	 The description of the period of time constituting a workIoss or school-loss day, a bed day, or a cut-down day was 

clarified and made consistent for all types of disability 

days. 

�	 The age groups used for the questions about work-loss and 

school-loss days were changed to 18 years and over and 

5–17 years, respectively. 

� The placement, format, and order of the disability day 

questions also were changed. 

Condition questions 

�	 Codes are no longer restricted to acute injuries and certain 

impairments caused by injury. Any disease that the respondent felt was caused by an injury (arthritis, for example) 

now has a code. 

.	 No conditions voluntarily reported during the interview 

were recorded. 

.	 Several chronic condition variables originating on the checklists were deleted. They concerned 12-month work-loss 

days: medicine, surgery, or treatment, and a count of 12-

month doctor visits. Also deleted was information concerning how the chronic condition bothered the respondent. Added to the list was “cancer of any kind. ” 

Physician contact questions 

�	 The category of medical practitioners providing care has 

been expanded to include the doctor responsible for providing care, whether he or she was actually seem the 

59 
medical assistant seen when no doctor was see% and, for 

all types of practitioners, the medical provider actually 

seen, with preference given to the physician rather than an 

assistant if both were seen. 

� Emphasis was added to site of visit (for example, home, 

doctor’s ofllce, or clinic). 

�	 Probe questions about telephone calls to doctors for advice 

were expanded to include calls to nurses and others for 

prescriptions or test results. 

Hospitalization questions 

�	 The operation variable is different from the former “surgically treated” variable. Except for hospitalizations in the 

past 2 weeks, a detailed description of the condition for 

which the person entered the hospital was not recorded. 

The item is used to identify deliveries. 

� Probe questions about stays in nursing or convalescent 

homes were dropped. 

� The hospital probe question was moved to the beginning of 

the interview. 

� The term “overnight” was added to keep respondents from 

reporting outpatient hospital visits. 

Information about the effects of questionnaire changes and 

data processing changes in 1982 can be found in the Vital and 

Health Statistics report, Series 10, No. 150 (1). Data processing changes for each year also are discussed in the NHIS 

public use data tape documentation for the survey year of 

interest. Additional discussion of the 1982 questionnaire revision is available in Series 1, No. 18, in the Vital and Health 

Statistics series (2). 

1983 changes 

�	 The age range for limitation in ability to work was changed 

from 18–70 years to 19–69 years. 

Current health topics (formerly 

supplements): 1980–84 

1980 

In 1980, a large number of the questions relating to the 

special health topics were included in the core questionnaire. 

These special topics are not labeled “supplements” and, consequently, are not separate booklets administered after the core 

questionnaire, as was the case in later years. An exception to 

this is the smoking supplement, added during the third and 

fourth quarters of 1980. The 1980 topics are included in a section of the core questionnaire in which the core question bears 

some similarity to the subject of the special health topic. In 

several instances, questions on the special health topics are 

found in other health topic sections. 

The special health topics listed as individual sections within 

the core questionnaire are health insurance, home care, individual home care, and residential mobility. Only those persons 

17 years of age or over who were at home and took part in the 

interview as indicated in the H box at the beginning of the core 

questionnaire were asked questions from the section on individual 

home care. 

Questions on special aids are located in the home care section. Question 8A is: “Does anyone in the family (that is you, 

your ——— etc.) now use (any of the following special aids)?” 

Some of the aids listed are an artificial armor leg, crutches, or 

a cane or walking stick. Directly following this set of questions 

are questions covering health topics on corrective lenses, eyeglasses, and hearing aids. 

The questions on sources of retirement income are included 

in the special topic section on residential mobility. The residentialmobility section also includes questions about longestjob worked, 

Medicaid, and Aid to Families With Dependent Children, 

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: ~.” .j WC arc interested in all kinds of heelth insurance plans �xcept those which pay only for accidwrts. Y*.’:; 40.	 (Not counting Medicare) Is mryone in the family covwcd by hospital inmcmrrcc, 

that _---L----__----__-______-_____________-_-_-__:_--_______y__________-_____y_@g~ is a hwzlth insuranco plan which pays any part of o hospital bil17 +g:t 

b. What IS the narrra of the plan? (Record In Table H. I.) I ---:_-_-_________________:_____________________-______________________________`~:'~''`'`~`';~``'* ~~ c.	 Is anyorm in tho family covar~d by any othar hospital insurance plan? Y (Reask 4b and c) N 

6:.34 d. Is anyon~ in tht family cevarcd by any (othor) haalth irrsurarrcc plan which 4 

pays any @ of a DOCTOR’S or SURGEON’S bill? Y N (5) ““’ 

�.What is thcnamoof thoplon? (Record in Table H.l., reask4d) F 

TABLE H.1. 

PLIAN 5c. Dcros this plan pey any pert 60. IS --covered under this 6a. 1 i-JcOv. 

of hospital �xpenses? (name) plan? 2 � Not COV. [NP) _____ t Y 2 N ~_D~__ —-------- —-- —-. 5a.	 Was this (name) plan obtained through d. Doss this plon pey any port b. During the past 12 months b. an �mployer or unian? IY(5c) 2N sDK of doctor’s or surgeon’s bills did ,.c. iv. medical car. lY 2N s OK 

b.	 ~;;fi~~~~n~~;~r;;g~-s;~; %;h=;-fi;~?_- far Op*rcrti~~s? ~N which has boar or will bs 

2t? ,DK1 9 DK rxrid far by this plan? 

PL/N 5c.	 Does this plan pay any part 60. IS Cov.red und.r this 6a. 1 � cov. 

af hospital �xpansos? (nama) plan? 2 � Not COV. (NP) ______ lI___?_N_-2_DK__ —------- —--- .- 5a. Was this (n~m=) plan obtoirwd through d. Doss this PI.. pay any part b. ~,~ing tho past 12 months b. an .mployor or unian? tY(5c) ZN 9 OK of doctor’s or surgeon’s bills . racoivc medical cora ~ IY 2N 9 DK

b.	 Wrrs it obtained through ;o+ra oth;rNgro~pJK for opemtions? which has been or will bc 

IY2N 9 OK paid for by this plon? 

PL$N 5c.	 Dots this plan pay any port 60. Is cavored under this 60. 1 D Cov. 

of hospitel �xpenses? ~ plan? 2 � Not COV. (NP) ______ I~___2_N___~~E__ —- —- ——--—--—--- ———--—----------—--—-—- 50. Was this (name) d. Dots this plan pey any pert b. ~,~ing the past 12 maths b. 

an	 Qmplay*r or union? IY(5c) 2N 9DK of doctor’s or surgeon’s bills . rccaivo medical cara IY 2N 9 OK 

which hsrs been w will b. b.	 ~~< ~>~;~;~ ;fir~~g%-~$<>T~;;N~6~~~- !Y 2N 9 DK ““;.4 #“r h“ A;* “1,3s? 

For each person review 1,2, 3, and 6 for each plan and determine if “Covered” by either Medicare or insurance, or “Not covered.” I t� Cw. (NP) 2 � Nc5cw.(NPJ 

Ask for each person “’Not covered,” Circle all re8sms given ~ 123456789 P Many paoplo do not carry hoolth insuroncc for various roaseos. Hand Card N 

7a. Which of thase statcmmts dcscribos why is nat cavered by any health insurance plan? Any othw rwzson? 70. (spec/fy) _______________________________________________________________________________ 

Mark box or ask: 00 � Only one reason 

b. What is tho MAIN raoson is not covored by any heelth insurance plan? b. 123456789 F 

tsn?cif” 1 

61 

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Soma peopl. ar. Iimit.d inwhatthay candobecausoof a physical ormsntol condition; thot is, 

they cannot do some of the daily activities thotathar peoplo do. 

10. Bocauso of o disability or haalth problem, does 1/ “’doesn*t do,,, Do.s r... iv. D.ms m-d hdpframa notharpwson in 

anymw in the family, (that is you, your --, �tc.), ~~ ::;h;n, ;Ep::$k’p	 (a~ mast sf Ih. iim., somo of tha 

tires, o, MC. in s ~h{l.? 

special �quipment in - number EQUIPMENT in (a=? 

Y or (=)? 

If ‘“Yes, ” ask lb and c ‘“doesn’t do’” N (8) (b) (c) (d) (e) (f) 

(1) Walking, �xcept for using stoim? � l&6n’c I n All/most 4 � Never Mwk 

rccoivo or need help from arrothor person, or US* pcrsm Activity Doesn’t do SPECIAL 

(2) Going autsido? . . . . . . . . . . . . . 

(Mark H box, IY 2N IY z N (Next 2ns- 8 � Other - Sp*cNy H 

(3) Using tha toilet in tha bothreonr, THEN lc) IIne) 3 a Once } box 

including gatting to th~ bothroom? � D&t ! � A 11/mc.st 4 � Never (4) Bathing, including spongo boths? Mark

(Mark H box, !Y 2N lY 2 N (Next 2 � =~ a � Other - Spcclfy H 

(5) Dressing? . . . . . . . . . . . . . . . . THEN iC) line) 3 � Once box 

(6) Eating? . . . . . . . . . . . . . . . . . }. 

� $o*sn”t 1 n All/most 4 a Never (7) Getting in and out of b.d or chirs? Mark I (Mark H box, lY 2N lY 2 N (Next 2 fg sow a � Other - SpCC/fy H 

b. Who is this? THEN IC) //03) 3 � Once 

} 

box 

c.	 Doss anyorm �lso rwctivc or need help or use � :o*sn”t t � Al I/most 4 � Naver 

spatial �quipmmt in - ? (Mark H box, !Y 2N 

THEN Ic) 

a. BECAUSE OF A DISABILITY OR HEALTH 2N~l “: ;:~”; PROBLEM, does anyone in tha fomily reecivo (1) Prsparirrg their own moats?. . . . . . . . .

‘y. . . . . 

or need hoip from another parson in - (2) Shopping for personol items, such as magazines, 

If “Yes,” ask 2b and c. toilot items, or modicinas? . . . . . . . . . . . . . . 

(3) Doing routina housohold .hcwos, mat b. Who is this? including yard work? . . . . . . . . . . . . . . . . . . 

c. Doss anyono �lso rscaivo or mad help in - ? (4)tfandling th*ir own money? . . . . . . . . . . . . . . 

0. Bocauso of a disability or h~lth problem doos enyona in the family usually 

stoy in bad all or most of tlw time? Y N (4] 

_______________________________________________________________________________ 

b. Who isthis? Mark box in person’s column. _______________________________________________________________________________ 

c. Anyone dsa? Y (Reask Sb and c) tk 

Mark box or ask: 

a.	 What (othtr) condition couscs to (naod help in ~t ivities in I and 2 /(or) sfoy in bed)? &. _______________________________________________________________________________ .__. ___________________ 

b. to (need stay _Do-s any other condition causo -------------3~~__- halp in ivities i n I and 2/ (or)________in bsd)? _______ ~_ 1 Y (Reask 4a �nd b) z N -----------.-------

Mark box or ask � Old ,z. 0171Y(NP) 

c. Which of theso conditions would ou soy is the MAIN csmdition thot cousos to (tmsd heip in =. � Only one condition 

activities in I and 2/(ar) atoy in ~d)? 

Win condition 

Refer to item C2 to determine if a condition page was (NP) 

HC1 completad for dre main condition in 4. HC1 Cd. numbr 

Enter condition number, or mark box. � No conditica p;-

. Whan did first notice his (main condition in 4)? s. t � Last week 

2 n Week befc+a


3 � Past 2 weeks, DK which


4D2wcsk3 -3 moiwhs


s � Over 3-12 months


6 � tie than 12 monrhs a60


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60.	 DOQSonyorw in tho fomily hova a colostomy, o urinory cathctar, or any other device to help 

eontml bowel movamcnts or urination? Y N (7) 

b. who is this? Mark *’Device’” box in pers~’s column. 6b. 

c. Anyona .1 se? 

If “Device,” eskijd and e 1 � Colos\omy 

d. Which doos havo - a colostomy, a catheter, or an,othar typo of dovico? d. 2 � Carheter 

a	 I_J Ochar - Spec/ly 

P 

� . Deos roctivo or rrood help from another parson in taking cam of Iris (device in 6d)? � . 

7a.	 (Besides --) Do-s arryorr. (ds.) in tho family havo any aecidwrts or any 

trouble controlling thair bowal movamenta or urination? Y H (8) 

b. Who is ibis? Mark “Trouble controlling’” box in parson’s column. ?b. I � Trouble controlling 

c. Anyone �lse? Y (Reaak ?b and c) N 

8a. Does onyano in tho femlly (that is you, yaur, -- �tc.) now use (any of tho following special aids) - ab. ! � Artificial arm 

If “Yes,” �sk 8b and c YN 2 � Artifiei81 18s 

(1) An ortificiol orm? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . ...(1) 3 � Brcce - Perf of body 

P 

(2) Anofiiflcial lag? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...-..........(2) 

(3) A braco af onY kind? (If “Yes,” asic on what port of the body ia the bmco worn?) . . ...(3) 

(4) Crutches? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(4) 4 � Crutches 

(5) Acanaor walkirrg stack? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...(5) s � Cana or walkins stick 

(6) Spaciol ahoas? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...(6) 6 � Special ahoas 

(7) A whoal choir? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...(7) 7 � Wheel chair 

(8) A walker? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . (8) 

e � Walker (9) Aguida dog?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..(O 

.1 (lO)Any othorkhrd ofaidforgcttiag araund? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,. 410) 9 � Guide dq 

b. Who is thia?Mark box in person’s column. 10 � Ocher - Specifyp 

a. Anyone �lse? 

la. Daas anyona in tfm family us- - YN 9b. I f_J Eyeslas*es 

If “Yea,” �sk 9b and c (l) Eyagh3s6as? . . . . . . . . . . . . . . . . . . . . . . ...(1) 2 � C0n2ect Iensea 

b. who iS thi6? ‘ark ‘X ‘n (2) Contact lanscs? . . . . . . . . . . . . . . . . . . . . ...(2) 

c. Anyone �l aa?

person’s column (3) A haoring oid? . . . . . . . . . . . . . . . . . . . . . . . (3) � ,’ 

3 � Hearins aid 

De. Dees anyone in tho family rocoivo help hero at ham- with - YN 10b. r � Injections 

If ‘“Yeafl �sk iOb and c (1) Rocoiving inlectiarrs or shats? . . . . . . . . . . . . . (1) z � Physical rhar=py 

b. Who is this? Mark box in (2) Phyaicai thampy? . . . . . . . . . . . . . . . . . . ...(2) 3 � B2mJases 

person’s column (3) Changing berrdages? . . . . . . . . . . . . . . . . . ...(3) 6 � Ocher - Spdclfyp 

c. Anyana d SC? (8) Aay athar nursing or madicai fmatmants? . . . ...(8) m 

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Ila. During the past 12 months, (that is sine- (d~e) a year ago) 

has anyenc in tha family received MEALS that wore prepared 

outside tho homo and brought in on a fairly ragular basis? Y 

______________________________________________________________________________ 

b. Who roceivcd tho m.a[s? Mark ‘“Meals” box in person’s column. Illil.11 13wals I 

c.	 Anyon. cIs*? Y (Reask 1lb and o) N 

~ 

If “Meals” in I Ib,ask I Id-e 

d.	 Does NOW regularly receive mods that arc prepared outside tho horn- and brought in? d. lY 2 N (NP) 

______________________________________________________________________________ _____________ -

1[’ 

r. What agency, organization or program provides those mcal~ for --? 

12a.	 During the post 12 months, has onyona in tho family r~ceived any care 

at ho ma from a nursa? Exclude related HH members. Y N (IHCP) 

b. Who rsccivad the cara? Mark “Nurse” box in person’s column. I 12LI 1 � thrse 

c. Anyon. �lse? Y (Reask 12b and c) N 

‘OOTNOTES 

, 

64 

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Complete for each person with H box INDIVIDUAL HOME CARE PAGE 1. Person number _ 

2a. Earlier youzaid that-- rtcaiv~s or rinds the help of enothcrpcmon. Who helps --? 20. ! � Related HH mambers 

2 � Nurse (Is halpod byrsnyerm wholivcs hcra, byanyoflmr friends ormlativ~s, a mm=, or any s � Other health othar health cam professionals who come into ths homo, or is holpod by somaano �is=?) warker - Specify 

400ther relatives wfricnds 

8 � Other - Spec//y .___ - _ —-------------- —-----

b. Doos anyone �ISC help --? b. ‘f (Reaak 2a and b) N 

If “Nurse” in 2a, ask: 

3a. On the avomgc, how many days par wok do.s tho mrrsc visit --? 30. ._-_ -_-- Days per week _ -------------------------—----- -— _-__ __ —-------

b. ~~;n-~;;;~;;~s;~~~o;~any hours por doy do-s h~ or shc usually spend htlping --? 6. 00 � LeSS than I hmr — Hours — -—-—- -— —- —----- —-----— 

c. DO*S onyone in the family, that is you, your --, �tc. pay any part of tho cost for the nurse? _c: ~:_______________2 AN_____________ 

d.	 Deos any govornmwrt agwscy or program help poy for tha nurse? d. lY 2 N (31) - —- —----- —----------------------

� . What agmscy ar progmm helps pay? �.	 ! o Medicaid � Othsr - .$peclty~ 

2 � Madicare 

3 � Health insurance —------------- ——---

f. During th~ past 2 wocks, how many times was visittd by the nurse? f. . Numbsr of rims 

If “Other health warker” in 2a, asic 

4a. On tha avQm~a, how many days par w-ok does tht (other health 

---______ --— —------ —------------------- worker) visit --? —_-___ ----—--- 40. . Days per week 

b. -&s-&-(~ health wcv@_::_ ) vrstts, how rnarsy hours _____________ per day de.. ho or she usually_________ sp.nd halping —? b. 00 � Less than I how — Hours . —------------------

C.	 Daes ersyarm in the family, that is you, your --, tic. pay any part of tiw cost far the (@er health wafkcr)? e. lY 2N —----------------

d. DO*S any govornmont agency or program hdp pay for the (ather health worker)? d. lY 2 N. (4t) 

. . --------’---’------ ! � Mcdica!d fi-6tKs;Yszci&j­ c. What rsgwrcy or pragram halps pay? 2 � Medicare 

3 � Health insurance 

--— 

f. During tho past 2 waoks, how many times was visited by the (other health worker)? f. _ Number of tinms 

HC2 I HC2 1 � Under 17 (NP] 2U 17+ 

5a.	 Da*s recoivc or rsaad help from othars in using public transportation, 50. t Y (6) 2N 4 � Dassn’t use (5c) such as busasJj~ajn_sL -s_u~ya~sL S~~lgEqs?______________________________________ - ——---- —---------------- —-----

b.	 Dacs use public transpartatiars? b. 1 Y [6) 2N ------------------2-N 

c. If had to use public tmnsportation, wauld need the hoip of other persons? c. lY 

69.	 Does drive a car? 60. t Y (7) 2N -—-

b. DO*S not drive a car because of a disability or health problem or because of somo athcr mason? : b. t � Aze z � Disability e n Dchsr 

Ta. Daes US. th. tclephano withaut the help of anathw person? ?a. 1 Y (8) 2N 

——---- —- —-----------------

b. Would b. able to US* tho tclephorm in an �mcrgwscy? b. lY 2N 

80.	 Ourfng tfm 2 wacks wtlinad in den tfrc cal.mbr, did how any visits from a friend, rdativc ar rsoi$bar? am lY 2 N (.2c) 

-—- ------------------------.-—-----— 

b. How many times during that period was visit.d by friends, r.latives or rmighhom? b. t � I-3 timas 3U13+CIMCS 

(Was it 3 or more times ar Icsa than 3 times?) 2n4-12tiInas 

(Was it 12 or mom timas ar loss than 12 times?) -___ —---------

c.	 During thase 2 weeks, did go out to visit o friend, mlativc or neighbor? c. lY 2 N (9) 

__--------------------------------———--- —- ——---- —------ —---------

d. Haw many times during that period did go out to visit friends, mlativos or ncighbom? d. t � I-3 times 3n13+ times 

(Was it 3 or mom tim*s or Its. than 3 times?) Za 4-12 timss 

(Was it 12 or mam timca ar less than 12 times?) 

9. During the past 12 months, did go on a vacatian? 9. IY 2N 

10. Bocausa of a disability ar hoaith prablam, how ohwr must somean. bc here with --, 10. I � Most/All 4 � Never 

most af the time, somo of th. time, once in a while or ncv.r?	 2n Some a Q other - spsclry F 3 � once 

65 
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RESIDENTIAL MOBILITY PAGE 

I n H box, 17+ (1) 

RM1 RM1 20SP, 17 + (1) 

3 n Other (NP) 

Complete la and b from household composition items, if not clear, ask: 

10.	 Is r.iat.d to any persons now living in this household? 10. lY 2 N (2J . - —-------------- ~-------------------------------------------------------------

b. IS now living with --’5: b. f a Bro&/sister 

(1) Brothor or sister? 3 n Parent 

(3) Fetbor or mothor? MARK ALL THAT APPLY 5 � spouse 

(5) (Husband/wife)? 70 Sm/dau;hter 

(7) Son or daughter? o I_J None of the above 

2. How long has lived at this addrass? Enter number, then mark box 2. t � Days 

2 � Waeks If “3” years, ask: 

Number 3 a Months Wrrs it less than 3 yoors or more than 3 yaars? 

4 � Years { 

1 � 3+ yews h 2 (RAk7) 

RM2 I RM2 ~ ~ LaSS than 3 Ye8rs ‘n 2 

— 1 I 

3.	 Including the time movod ham, how marry times hos moved in the post 3 ycers, 3. 

that ig, since (12-month date), 1977? _Number 

.fa. What WOS ‘s oddrass, including county on (12-nronth date), 1977? 40. Cw”ty 

Enter only county and State State —--------------------------

b. About how mony miles is that address from horc? b. � Initial OK - PROBE 

—MI!= ______________________________________________________________________________ 

c. How many poopla wos living with at that time, not counting --? c. 00 � Lived alone (5)

—---—--- _______________________________________________ _________________ I—Number ,--_----------_-------

d.	 War* any of thoso POOPI. rolatod to --? d. ,Y 2 N (5] ______________________________________________________________________________ ,---------------------

� . was living with --’s: �. 1 � Brother/sister 

(1) Brothor or sister? 3 � Psrent 

(3) Fatfmr or moth-r? MARK ALL THAT APPLY 5 � spouse 

(5) (Husband/wife)? 7 � Scm/dau;htsr 

o � None of the above

50. What is tho (oth*r) reason movad 

(7) 

HERE? 

Son or 

Was 

daughter? 

it bccrruso chrrngcd lobs, 

L

50. I � Job-sdf 

becauso	 retired, bccauso of --’s hcrrlth, or wos it for some othor raasotr? 2 � Retired-self 

3 � Health-self 

4 � Job-odmr parson 

s � Retired-other per30w 

6 � Health-other parsatr 

e � Other - SpccNy 

7 

.-- — b.	 Atry ether rcasan? b. Y (Ramsk 5a and b) N , 

Mark box or ask: � Cnly an. reason 

c. What is tlm MAIN mason movad? e. 

For persons 17 years or over, show who responded for (or was present during the t � Respmdad for salf-strtircly 

RM3 asking of) Questions I-5. RM3 2 � Rasp~ded far se] f-parrty 

Q’s 1-5 If persons responded for self, show whether entirely or partl y. Persrn-was rezc.andmnt 

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Mark box or ask: i_J Under 17 (NP) 

6a. Did work at any tima last week or tho week b-fore - not counting work around the houst? 6a. ! Y (7) 2N 

b, Evorr though did not work during these 2 weeks, doos havo o ieb or busin~ss? b. ,Y 2N 

c. Was looking for work or on layoff from a iob? c. lY 2 N (7) . -

d.	 Which - looking far work or on layoff from a lob? d. 1 � Lookinc 3 a Both 

2 a Layoff 

7a. For whom did (last) work? Name of company, business, organization, or other employer 7a. � Never worked (NP) 

Mark for all Employer 

persons. 

—-----

If “’N” in 6a and b. What kind of business or industry is this? For example, TV and radio manufacturing, b. Industry in 6b, then 

question 7 applies retsi I shoe store, State Labor Dept., farm --— —-- —---------- —----

to pers on’s LAST ---------------------------------------'-----~-------------:-------- c. What kind of work was doing? For example, electrical engineer, stock clerk, typist, farmer c. Occupation 

job either fulltime ar pert-time. 

Include miiitary d. What wsre --’ s most important activities or duties? For example, types, keeps account books, d. Oucies lobs. files, sells cars, operates printing press, finishes concrete 

_______________________ _____________ —__________ -— _ —---------- ..-— —------------------

Complete from entries in 7a-d; if not clear ask: �. Class of worker 

c. Was m .mploy.. ef PRIVATE compnny, self -amploysd in OWN business, pmfsssionol !f-JP sol businasi, or individual for wag-s, pracficq or farm?


salary, or commission? . . . . . . . P If not farm, ask Is tho businmss ineotporatad? zUF 60SE


0 FEDERAL gov.mm..t �mploy.-? . F Yes . . . . . . . . . . . . . . . . ..l 7UWP
 a STATE govamm-nf cmployao?, . . . S No(orfsrm) . . . . . . . . . . ..SE 3C-JS 

a LOCAL govomment .mployeo? . . L working WITHOUT PAY in family business 40L or form? . . . . . . . . . . . . . . . . . . . . . . . . . . . WP 

,.. . . . . . . . ,..’” 

I � Under 17 w Nev. W. (NP) Mark appropriate box. 

WI z � Cal Iback requirad (NP) 

3~ Pers.x is available WI 

(Earlier I was told that you (last) worked as a (occupation in 7c) for (employer in 7.3).) 2 � Weeks 

3 � Months So. How long (did/have) you � ver work(ed) as a (occupation in 7c) for (employer in 7a)? 8a. Numbsr { 4 � Years 

b.	 Havo you �var had a iob, that is, a specific kind of work for orso �mployar, at which b. ,Y 2 N (NPJ you workod for morn than (time in 8a)? Include military lobs. 

Of all the jobs you hssvo� ver had, including military iabs, I’d Iiko to know about the errc at which you warked Iongcst. Employsr 

90.	 For whom did you work? Name of company, business, organization, ar other employer 9Q. _--__ — -

b. What kind of business or industry WaS this? For example. TV and radio manufacturing. b. Industry 

retail shoe store, Stste Labar Dept., farm 

. -

c. What kind of work w-rc you doing? For example, electrical engineer, stock clerk, typist, farmer =. occupation 

--— —--------------------

d.	 ~~a;;;;;~~u;;;;t-i;~ ;;a;;;;t;~~;s-;r-duties? For example. types, keeps account baoks, ‘ d. Duties 

files, sells cars, operates printing press, finishes concrete 

Complete from entries in 9a-d; if not clear, ask: Class of worker 

� . Were YOUan �mployct of PRi VATE company, businasa, or self-amploycd in OWN busirmss, professional � . IDP 6DI individuoi for wages, salorj, or commission?. . . . . . . P pmctic*, or form? 

mployoc?. . . . . . . . . . . . . F a FEOERAL govemmant � If not farm. asiG Is fho Ixminsss incorpamrsd? 2DF 6 USE

--0 STATE govmmmwit �mploy**?. . . . . . . . . . . . . . . S Yes . . . . . . . . . . . . . . . . . ..l 

a LOCAL govommcnt �mployo*? . . . . . . . . . . . . . . L No(orfsmO . . . . . . . . . . . . ..SE 30s 71-JWP 

~,o~rk~ WITHOUT PAY in family busintss sOL ..WP ~-----——— __::2L.-.-.-.—.: =:LL.-.-.-.-”: :J::L L-----­

f. How Iang (did/hov4 you � ver work(ed) as a (occupation In 9c) far (employer in 9a)? f. � Less than I year 

—Years 

67 
-------------------------------------------

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

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

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

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

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

--

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

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

Oa. Thor. is a national program called Madicaid which pays for health cnra Y 

for persons in n..d. (In this State it is also cal led_. ) 

During tha past 12 months, has crny.aw in this family rccaivad N (11) ,.. . ..-, * 

health cart which has b-an or will b. paid for by Madicaid (or_ )? 

-.__ - —_____________________________ 

b. Who was this? Mark “Medicaid” box in Person’s column. 10b. 

c. Anyono �is.? 

.. N 

la. Deos anyono in the family now have � Madicaid (or _) card which looks Y 

Iikc this? Show Medicaid card. N (12) 

—---------

b. Who is this? Mark ““card”” bax in person’s calumn. 

c.	 Anyorm �1so? Y (Reask llb and c) 

N 

If “Card,’” ask: � Medicaid card seen~ 

d. May I plaasc sac --’s (and --) card(s)? d. 1 � Current 

Mark appropriate bax(es) in person’s column. 2 � Expired 

3 � No ca!d seen 

s � Other card saen P 

(Spaclly) 

Hand Card I. OOOA u60G 

L Which of those incoma groups rapressnts your total combinod family income for tha past 12 months - 12. 0!06 070H 

that is, yours, your --’s, �tc.? Include income from all sources such as wagss, salaries, social Ozoc Oeol security or rotir~msnt bordits, hdp from ralativts, rant from propwty, and so forth. 

0300 OSDJ 

04DE !oOK 

OSOF 

10. Which (othor) family mambors racoiv.d ~om~ incom. during th- past 12 mQn*s? 130. 

Mark “lncame” box in person’s column. 

� Income 

b.	 Did aay other family mombws rocoive any incemo during tho past 12 months? Y (Reaak 13a and b) 

N. 

If only one person with “income” box marked. go to 15. 00DA OSOG 

If 2 or mare persons with “Income’” box marked, ask 14 far each. Olatf 070H 

L Which of those incomo groups rapreswrts ‘s incomo for thm past 12 months? 14. Ozlgc 0s01 

.. , 030D OSOJ 

041_JE 10UK 

OSDF 

So.	 Do-s anyonm in this family rccaive assistonco through tho “Aid to Y 

Families with Dcpmrdont Childran” Program, sometimas called N (16) “’AFDC” or “ADC”? 

-= 

b.	 Which (other) family mcmbars are includsd in tho AFDC assistance payment? lsb. 

Mark ‘“AFDC’” box in person’s column. 

c.	 Arc any othor family membars inclvdcd in this program? Y (Reask 15b and c) 

N 

68 
---------------------------------------------------------------------- -----

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

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

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

--

-- --

16a. Do-s anyono in the family roccive tho “Suppi*mon~i socuri~ lncm*” Y 

or “SS1” gold.colored check? N (17) 

—--

b. Who roceiv*s this check? Mark “SS1” box in person’s column. 16b 

..+:-~.-v$~ c. Anyone �lso? Y (Raash 16b and o) 

17a. Da*s anyona in the family rocoivo any (athor) incomo fram Social Security? Y 

N (19) ____ -__________ —__________________________ 

b. Who is this? Mark ‘“Social sec~iw” box in 1=~’s Calumn. 17b 

1 � social ~Curiv 

.> c.	 Anyam �ISO? Y (R8a8k 17b and c) 

N 

P*OPIO may rocoiv~ Social Security bon-fits because of their own work cxporiance or bacausc they am 

dapondmsts or survivors of somaonc who qualified, based on work �xparionco. 

Ask for each person with “Social Security’” marked in 17b: I � Work experience 

18.	 Dots (persnn in 17b) receive Social Security paymmts because af --’s awn work 18. z � Dependent or survivor 

cxpcri~ncm or bocausc is a dependwit or survivor of somaono who worked? 

19a. Including rctiromant paym.nts raceivod bacauso of disability, doos anyone 

in thm family, (that is you, your --, �tc.) racoivo any incame from - YN 

If “Yes,’’ask 19b and c (l) Railread r.tiremont? . . . . . . . . . . . . . ..Cl � 19b. I � Railroad 

(2) Pension as a military ratirc-? . . . . . . . . . � � Zatlilisary 

(3) Government �mployae pension? 3 H Government employee 

(Federal, State, or local government) . . . . a 

(4) Private amplayer 03 union pension? . . . . . � 

n 

� # � private - unl~ 

b. Who is this? Mark bax in person’s column. 

c. Anyone �1so? 

Far each income reported in 19b, aslc DWN SURV 0.	 DO.S receiv. the (em . ryf in 19b )beca uso of --’s own work �xperience w because 20. 

is a dapondont or survwor o Somoonc who worked? RR. . . . . . . . 

Military . . . . 

Gov’t . . . . . . 

Private . . . . . El 

‘OOTNOTES 

69 
O.M.B. No. 68. fU6rn APP+ovd Expires March 31, 19S1 

,e.w IK-l{SI (19$0) HoTICE - All Infornullw! which would mlmll Identlllcallon of lb Indlvldual L 

,s.,,.,0, wIII td hold In strlcl confrdance, wIII lx used only by prsons enm d In ati 

for lb wp.x.s al I* zumv, �d will ..! b dkclosed w release f 10 mm Oook _ of_ Books U.S. DEPARTMENT OF COMMCRCC [c+ my PWm,l. .“”*A” 0. . . . cm.,”. 

AC T,.. .S .OLLCCVU. O . ..”’7 .0. ?“S 2. R.O. n“u&l & 3. SIWI* & 4. Cc$lwot Ilulrbl 

U.S. PUDLIC HEALTH SCRVICI! Psu 

U.S. HEALTH INTERVIEW SURVEY s. lolalvlew$r’s II*W 17,10 c. T#l@0119 (0 is) ~ 

SMOKING SUPPLEMENT IY ~ aN. 

INTERVIEWER - Fcf this supplement, interview sample persons ONLY. However. if SP IS unable to respond because of health, Cod, Blank ~ 

accept household resp.wdent �s proxy. Footnote reason and column number of respondent. 

FOOTNOTES 

70 
~ For eoch sample person enter nome, 

person number, age, and sex from HIS-I. Fbst narm 

~ 

Person No. 

~ 

First nm!z Person No. 

lz~ 

First nlma Person Ne. 

La,l nanm LA nams Last narm 

Age 26,27 sea 2! C’ad,r%us. 29 

IM2F 

2 20 uLlrdef17 (NP) 

z U 17+ callbick req. (NP) 2 � 17+ callback 16% f Np) U17+callback req. (NP) 

1 � 17+ svall,ble 2 � 17+ svallab!e u 17+ avdlable 

In your .ntlr. III*? 

2.. About how old were YOU wh.n ye. first 2Q. ~ 2.. @ 2E. =l!l 32 33

mtott.d srrmklng clgat.ttes faitly regularly? _Y81r$ (3J _Yems 13) _Yeats (3) I 

00 C] Never smoked regularly w U Never smoked regularly UNever smoked twJlallY 

b, De you mnek. .Igor.!t.s 00 VII b. ,y * N (NP) !2! b. ,“ 2 N (t/P) & b. Y z N (NP) 34 

1, Hove V.U wnok.d at I.ost 100 clgnwtt.s 1. ,Y z N (NP) 

h 1. 

IY a N (NP) 

L2J 1. 

Y 7, N (NP) 

31 

Clilat*ll*s . . ~ . . -. c. ~ e. 3s, 34 c, O. th. .v. reg., obe. t hew many .“ _Numbe, a doy d. you smoke? 

sm. klnst 3, 

_NuIok, (NP) 

~ 3. 

— _tl”mbe, (NP) 5 (NPI 

S7 SI 3.	 During $he �clod whan you wera I 

Ih. most, aKout fww many clgor.t! t., o doy — N.mter — Nvmbw —Nmkr did y.” USldy amok.? I 

4s, De yeu smoke clgatattes now? 4.. IY (6) *N E 4a. ,Y (5) 2N @ 4.. Y(5J 2N 3! 

b. About how long ho. I* b... sine. . . lost b. , f-J D*YS ~ b. 2 � Days b b. * f-J Days 44-42 

smokod C@,*tt99 !Oifiy wW1.dy { 3 fgWeeks S3 3 fgweeks _ sCIWeeks .s3 

s 4 U MOnlhl -m&r 4 � Monlhs Vumter 4~1 Mcmlhs ‘3 

s U Years }. s D Years } s L-j Years } 

5.	 0. th. ovwag., about how m.ny clg.:.tl.n ‘- I.qs. I _ ~ 5. 43,44 

0 day d. YOU now smok.? * 1’ I —–. N.m~r —Num&r —N.mLur 

3 53 I c],%’,’ In 4. 18) i 53 t m w, In 4a w S3 U-Y-1.4, (6) 

z H Less Iban 1 year In 4b (6) 2 f_J Less man 1 year In 4b (.3) [;] Lessthanlyearln4b (8) 

3 fg 1 t years 1. 4b fNP) 3 U 1+ yews In 4b (NP) Ul*yearsln4b (NPI 

60, What brand of cigar.tt.s d. (dId) you & 6a. grad “arm(,) ~ 6e rwd lunw) =445

usually amok.? 

7.	

‘“ 1 ~ 

II more than one brand ask: B,,nd “,me Bcm,dmm ~ I,,nd “am+ 44-41 

b, Which hmd do (did) y.” sm.k. the mOSf? 

b ~“ — b ~ b 

~ ~ Who! typ. of clgot.tt.s am th. (iw?n.d) 

that vow sm. k. (sm.ak. d)? Are th.fi 

a. FIII.I tip OR Non.filter tip? 70. IOFT 20NFT 7.. IUFT zONFT 70. 

=! 

U FT z rlNFT I 

b. Plaln OR M.nthol? b. IUP ~E.lM k b. IDP znM M b. f-JP 2UM so 

c. Nordpack O R Softpa.k? c. !DHP lf-JsP m e. ,DHP 2DSP @ . . UHP zC]SP $1 

d, R..JIlar OR King SIX. OR 100 Mlllim.t.r? d. ,~R 10N ,Dloow d. IDR ,OK SU1OOU2 d OR z~K Slglzo 52 

,4 54 , (_JoV4c.In4. (NP) ~ $4 , U ‘, N”, In 4, (NPI ~ Sc =, W,, I”4. (NPI 53 

2 � ‘Y’ In 4* 2f-J,:Y- In 4, ! fg -Y,’ In ti 

8s, How you � v.: m.d. o WIOU* at!.mpt fO 

stop smoking cfgar*tt*s? 

80. 

lY z N (NP) 

~ 80 . 

IY z N WJP) 

~ 8., 

IY 2 N (NP) ==”54 

b.	 Ab-avthew many tlm.sweuld you WJy you b. o(_JNevar (NPJ ~ b. oDN,w, (NPJ ~ 5 b )f_JNavcr (NPI 5s 

mad. a faltly settousawmnpt t. stop 1234s+ 1’2 345+ srnoktnq .Iqar.ttm.ntltely? 

c, burinq the past 12 maths, thot IS *I..* $3 = , 5Sc 

(M) E Y*OI w, _bou* hOw many ltm*~ would c. 

yavsayyou mad. afohly serleusatt.rnptte 012345+ 012345+ 

ttop tmoklng cfgatetles entlrefy? 

9. H.wlong ag. was*h. START .ffh. f-AST 

time youtrl.dto ,top.nwt.ly? 

9. 

srlwmks 

2 u D*Y, 

, (-J week, 

u-s? 

Number	 4 ~MonNII — 4nManlhs Numb+I � l-] Months Numter 

10. Elem: 12345678 la. Elem ,12345678 la Elcnt 12345678 

10. fllghest erade atte.ded in school 

(0. 2a, D. 48) HIch! 9 10 11 12 Hlgk 9 10 11 12 Hltk 9 10 11 12 

COII,W 1 2 3 4 5 6+ college: 1 2 3 4 S 6+ Col!ws 1 2 3 4 s 6+ 

b.	 Flnlshed clad!le(Q2b, P. 48) b. ,YZN k b. ,y IN ~ I *Y ZFI 6s 

, u Years s � Ye*f, s c 1Yem 

O. Hew fengdld yeunctunlly stoy. ffcigorottea 10. Z C] D*Y8 ~ lQ. 2 ~] nays ~ 10 = 2 c] Days 6c<2 

th. lost Wm.7 s m !4keks I i_JWeeks 

Number � C] Month% Numlw , m Mo”lhs 

s ~] Years s L1 Years 

. . . ~] Did not stay Off 000 U D!d not stay off 

,5. Tronscrlbe loreach sample person 17+af1er Ss ~DNoM ~ s~ m f_JNom 

~ 55 

kW’ill# household. 

=466 2 Racial background (Q	 440, b, p. 48) 2. 1 2 3 4 5-sPcw~ & 2. 1 2 3 4 5-sF+clfYg @ 2. 1 2 3 4 5-smJfY 

transcribe that entrv. ti ‘ [lrslnKle en1rfln40, t 

lfmultipleentrt ln40, transcribe entrv I. 4b.) 

— 

3. Famllyincome[Q 12. P. 521 3. ,,,* S6 !l*tc-P07*0n11 VIM 9 f_J Ccmpleh-Pemonal vldt 56, Final Status Js tacow!ete-personal vlslt S6 , u COmpl lx 2 � C.mplete-telwhm

. 2 � Cow!ete-lelaQhorn z � Complet.-te!eph.m


s ~ Refused , U Refu,ed a � Refused


� O Not at lwn,-77ewted .,11s , U Not .1 homa-RePs.l@d ClllS � U Not ,1 lwm@-RwmatOd C.ltl T-” s Ig TenwuNY abnnt s � T. ITWWNY .bs.nt I � Temporarily absent

a � O1hr - SFWI % 

* � Othu - Spcwy

i 9 � Othsr - Spclfy 

d 

,“M”!S.,, S,t.,,.,.) II P*1* 2 

II I 

7 

I 

71 
1981 

In 1981, 111,000 persons participated in NHIS, which 

was conducted for the full 52 weeks. Data on the incidence of 

acute conditions, limitations of activity, persons injured, hospitalization, disability days, dental visits, physician visits, and 

the prevalence of-selected chronic conditions were collected. 

The 1981 NHIS core questionnaire also contains questions on 

supplemental income, including Supplemental Security Income 

and other income from Social Security. 

During 1981 a supplement on child health was also administered. A total of 15,416 children under 18 years of age wert 

included in the sample. The supplement included questions or 

child care, relationships, residential mobility, breastfeeding, 

motor and social development, birth, prenatal care, hospitalizations and surgery, conditions, weight, eyes, teeth, medicine use, school, behavior, social effects of ill health, sleep, and 

seat belt use. 

72 
O.M .B. No. 6B-R1800: Approval Expires March 31, WE 

ORM HIS-1(CH) (1981) NOTICE: Information contained ,on this form which would permit identification of I1.03.801 any individual or eatabliahment haa 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 

U.S. DEPARTMENT OF COMMERCE be disclosad or released to others without the consent of the individual or the 

BuREAU OF THE CENSUS establishment in accordance with section X8(d) of the Public Health Service Act (42 ACTING AS COLLECTING AGENT FOR THE USC242m). U.S. PUBLIC HEALTH SERVICE 

1. 2. R.O. Number 3. Sample 

1981 CHILD HEALTH SUPPLEMENT Book —of—books 

NATIONAL HEALTH INTERVIEW SURVEY 4. ~yJrol number 

I Segment I Serial 

I 

I I 

i 

t I 

5. Interviewer’s 6. Sample child / Age I Person 

code First name 1 number I Yrs. ~ 1 

I _ Mos. : 

~.Final status of interview 

I � Supplement completed 

21J Refused . . . . . . . . . . . . . . . . . . . . . . . . . ) 

3 � Eligible respondent not available . . . . 

4 � No eligible respondent in HH . . . . . . . } Explain in footnotes 

� Other noninterview reason. . . . . . . . . J 

COMPLETE REMAINING ITEMS ON HH PAGE OF HIS-1, 

b BEGIN CALLBACK INTERVIEW WITH CHECK ITEM B1 ON PAGE 4. 

‘OOTNOTES 

-,, /.3 
--------

---

S.-tin. A lNTRfilll l~llo~ n. m.. .w. wkwk .. —._ 

The next questions will be used to study the health of the Nation’s childran. 

/frnore than one chi/d in fwni/y read; The only child I will ask the rest of m y questions about is 

(These questions will go much more quickly if we can do them alone.) 

Arrange to conduct supplement in private if possible. 

Ask or verify for each HH member. ~Personnumber Relationship to ssmple child on HIS-1 I 

1. How is (Name on HIS-1) releted to - –? I 

/fparent ask; Is fNarne Of Parent) - – biological ~ 1 

(neturel), adoptive, step, or foster parent? I 

I 2 

If brother/sisterask: IS (Name of sib/inQ) - – I 

full, half, step, adoptive, or foster I 3 

(brother/sister)? I 

I 

I 4 Enter “sample chil#’ on appropriate line. I 

I Enter “unrelated” for persons not related to the I 5 

sample child. I 

I 6


I


I


I 7


I


I 8
 I


I 

,. 9 I


1’


I 10


I I•! Biolog” al mother in HH and available &ction B, 

1“ pagedy 

I 2 � Sample child 6+years old AND biological father 

I in HH and available (Section B, page 4) CHECK 

Al � Mark first appropriate box. I 

I 3 � Biological mother not in HH, only one adult relative 

ITEM 

I in HH (Section B, page 4) 

I 4 IJ Biological mother in HH not available (2)


I 5 � Biological mother not in HH, 2+


I adult relatives in HH (2)
 I


2.	 (Besides (Bio/ogica/ mother)) which family I 

membar knows tha most about the health-related ~ 

matters of -—? I Person number(s) 

I 2 � Biological mother in HH not available (arrange
 I


I callback and complete remaining items on


I HIS-I, HH page)


CHECK I 3 � Biological father or person in 2 available ITEM A2 ~ M.rkfirstappropriatebox. I (Section B, page 4) 

I 

I 4 � Biological father or person in 2 not available 

I (arrange callback and complete remaining 

I items on HIS-1, HH page) 

:OOTNOTES 

74 
---- ---- ---- ---- ---- ------ --

--

--

--

Section B. CHILD CARE I t 

I I U Same respondent as HIS-1 z 

CHECK Mark box and enter person number 

I Person number (82) 

ITEM B1 F of respondent. I 

/ 2 •l New respondent k? 

/ Person number (INTRO) 

INTRO - I will be esking questions ebout --, These questions will be used to study the health of tha 

Nation’s children. 

(These questions will go much more quickly if we can do them alone.) 

Arrange to conduct supplement in private if possible. 

I 

CHECK ,TE M B~ � Refer to age of sample child. 

I IJ Under 15 years old (63) 

i z H 15+ years old (3/ 

ITEM B~ � Refer to HH CO/?7pOShiOt2 On HIS-1. / CHECK I El Only 1 related HH member 12+ years old /2)

2 •l 2 + related HH members 12+ years old f 1) I 

1. Which family member, that is, (E?e/aredHH I 

I members 12+), spends the most time taking I Person number care of - -? I 

, !a. Not counting OCCASIONAL sitters, who (else) I I •l Related HH member(s) takes care of - – 7 Include day care centers, 

nurseries, sitters, or anyone else who takes care I 6 � Child cares for self - of --, 

Do not include regular school. .1 

i 2 � Unrelated HH member(s) b? 

Indicate 

I each person 

If non HH member, ask: Is this person related I Person number(s) . or place on d 

separate Iirx or unrelated to ? 1’ 3Cl Related non H H member(s) . . . . . . . in column 4 

; 4 •l Unrelated non HH member(s) . . . . . of the Child 

~ sODay Care/Nursery . . . . . . . . . . . . . . . Care Table, 

1 .} then ask 2b. 

b. Again, not counting OCCASIONAL sitters, does ~ 

anyone else take care of either in this home I


or some other place? I 

Y (Reask 2a and b) N


Who 1 usually takes to the doctor for I � HH member 

“ chackups or other nonemergency visits? I z 

I Person number 

I 

310 Non HH member - Specify I J7 

i


I


i 33 � Child takes self
 I


I 44a Never went to doctor


I


75 
Section B. CHILD CARE – Continued 

CHILD CARE TABLE 

Ask questions 5 through 7 for first caretaker before proceeding to next caretaker 

. CARETAKER 5. Does (Caretaker in 4) 6. Is this (other place) in 7. On the average, about 

take care of – – “in someone’s home or how many hours per 

this home or some some other place? week does (Caretaker in 4) 

other place7 take care of - – (in this 

home/outside this home)i 

I � Sitter (Unrelated) I � This home only (7) 1 � Someone’s home 

z � Sitter (Related) – 8 � Some other plaCe Only 8 IJ Some other place -

Specify ~ 3 � Both Specify ~ Hours/week m 

this home 

3 IJ Day care center(7J Hours/week 

4 � Nursery (7) outs!de this home 

1 D Sitter (Unrelated) I � IThis home only (7) 1 � Someone’s home 

2 � Sitter (Related) – 8 � Some other place only E� Some other place – 

Specify ~ So Both Specify ~ Hours/week in 

this home 

3 � Day care center(7) Hours/week 

outside thts home 4 •l Nursery (7) 

1 � Sitter (Unrelated) I � This home only (7) I IJ Someone’s home 

2 D Sitter (Related) - 8 � Some other plaCe Only 8 � Some other place – 

Specify ~ So Both Specify ~ Hours/week m 

this home 

3 � Day care center(7) Hours/week 

outside this home 4 � Nursery (7) 

t •l Sitter (Unrelated) 1 � .lThis home only (7) I � Someone’s home 

z � Sitter (Related) - 8 � Some other place only 8 IJ Some other place – 

Specify ~ 3 IJ Both Specify ~ Hours/week m 

this home 

3 � Day care center(7) Hours/week 

4 � Nursery (7) outside this home 

76 
-- --

--

--

Section C. RELATIONSHIPS AND RESIDENTIAL MOBILITY 

CHECK I€

lTENl Cl � Refer to question 1,page 3 of CHS. /


I


la.	 Has ever lived with biological mother I


for at least 3 months?


/

I
 b. How long has it been since -- last lived 

with her for at least 3 months? ; 

I 

/ 

I


I


I
 2.	 Is -- biological mother now living or I


deceased?


I


I


—


3. HOW often does see her? I

I 

I


I


I


I


I


I


1. 

: 

I

I


1“ 

CHECK


ITEM C2P Refer to question 1,page 3 of CHS. ~


I


la.	 Has ever lived with — - biological father ~ 

for at least 3 months? I 

I


1


b, HOW long has it been since – – last lived I


with him for at least 3 months? I 

I


I


I


I 

I


i. Is – –biological father now living or I 

I
 deceased? I


I


i


I


1


i, How often does – – see him? I


I


I


I


I 

I


I


I


I


1


I


I


I


I


I D Biological mother in HH (C2) 

EI_JOther (1) 

IY 2 N (2) 9DK (2) 

I IJ Days 

2 � Weeks 

3 � Months Number 

{ 4 � Years 

I � Living 

2 •l Deceased 

90 DO....... 1 (C2) 

I •l Every day, 

z � Almost every day 

3 IJ several times a week 

4 � About once a week 

5 � 2 or 3 timesa month 

6 � About once a month 

7 � Less than once a month 

0 � Never 

I � Biological father in HH (7) 

o� Other (4) 

lY 2 N (5) 9DK (5) 

I � Days 

2 � Weeks 

Number s � Months 

{ 4 I_J Years 

I � Living 

2 � Deceased 

9DD K....... } (7) 

1� Every day 

2 a Almost every day 

3 � several times a week 

4 � About once a week 

5 � 2 or 3 tirn& a month 

6 � About once a month 

1 � Less than once a month 

0 � Never 

77 
--

Section C. RELATIONSHIPS AND RESIDENTIAL MOBILITY – Continued


I


7a.	 How many children has (Biologicalmother) I 1 •l Only one (C3)


EVER had? Do not count miscarriages or I
 stillbirths. I Number


I


b , Of those (Number in 7a) children, was – - born ~ I U First 

first (or) second (or third, etc.)? 2 •l Second
 i


3 � Third


I
 4 •l Fourth 

5 •l Fifth 

•l Other - Specity 

I z’ 

/

I 

I


I I � Biological mother in HH (9)


CHECK Refer to question 1,page 3 of CHS or ~ 2 � Biological mother deceased or DK (12)
 ITEM C3 ~ roquestion 2 on page 6 of CHS. I 3 � Biological mother not in HH (8)
 I


r


8. k – - biological mother now married, I 

I Q Married widowed, divorced, separated or never I


married? I 2 a Widowed


!

I 4 � Divorced 

I 5 � Separated ,i

1 3 � Never married 

I (12) 

1. 9cl DO . . . . . . . . . ) 

9. How many times altogether has – – I


(Biological mother) been married? 0 � Never married (72) 

:“ 

.1 Number 

1. 

Ask 10a– c about each marriage before I

[ MARRIAGE


proceeding to next marriage. I 1St 2nd 3rd


10a. In what year was – – (Biological mother) “ I


married (the (first/second/third) time)? ~ 19 19 19


I Yr. began Yr. began Yr. began I 

If nowmarriedandthisislastor onlymarrhge,go to question12, ~ 

If now separatedand this is last or only marriage,go to I


quastion 11. ;19’ 19 19


b. In what year did this marriage end? 

I Yr. ended Yr. ended Yr. ended 

For divorce and annulment, record legal end. 1


{f now widowed or divorced and this is last or only I


marriage, go to question 12. I I � Death I � Death I � Death


c. Was this marriaga ended by death, divorce, or I 4 � Divorce 4 � Divorce 4 � Divorce 

annulment?	 I 5 � Annulment 5 � Annulment 5 fi Annulment
 I


\


11, How long has she been separated? I


I I � Days


I


I 2 a Weeks


I


I Number 3 ~ Months


I { 4 Cl Years
 I


I


12. In what month and year did – – move 

to	 this home? f 0000 Cl Lived here since birth (C4)


I


I 19 I / .— 1 Month Year 1 

78 
--

Section C. RELATIONSHIPS AND RESIDENTIAL MOBILITY – Continued


I
 13. About how many miles from here is the


home -- lived in before moved to 

I ooo� Lessthan 1 mile


this home? I


I


Range acceptable	 i Miles
 1


14. How many times has - -ever moved? I

I


I


I


I ‘ Number
 I


I


I I � Respondent is biological mother or


CHECK 

I 

I biological father (Section 0, page 9) 

ITEM C4 b	 I 8 � Other (15)
 I


15.	 How long has -- lived with you? I


(I � Days


I 2 � Weeks 

/ Number 3 � Months
 I
 4 •l Years I [ 

FOOTNOTES 

79 
--

Section D. BREASTFEEDING 

1

CHECK 5 � Under 6 months old (1) 

ITEM D1 � Refer to age of sample child, I 6 a 6+ months old (2) 

1. Is - – being breastfed at the present time?” 

/ 

1 Y (02) 2N 

I 

. Was — – ever breastfed? I 

I 

I lY 2 N (D4) 

I 

3.	 How old was – - when– - completely stopped I 000� Still breastfsading breastfeeding? I

1 � Days 

i 

I 2 � Weeks 

I 

Number { 3 � Months 

I 6•l 6+ years old (Section F, page 14) 

CHECK 

ITEM D2 � Mark first appropriate box. / 2 � Respondent not biological mother (03) 

I � Respondent is biological mother (4) I 

, 4.	 Whila breastfeeding – –, did you ever take I 

any birth control pills? I lY 2N 

I I � 3+ years old (Section E, page W 

CHECK 

ITEM D3 � Refer to age of sample child. 2 � Under 6 months old (5a) 

8 u Other (5b) 1. 

5a, Has –– ever baen given any formula or regular milk7 ~ 

I ~Y 2 N (D4) 1, 

I 

b.	 HOW old was – - when - – was first fed 

formula or regular milk on a daily baais? .! coo� Never on a daily basiS 

I I U Days 

I 2 � Weeks 

/ Number 

{ 3� Months 

I 

CHECK 1� 3+ years old (Section E, page 10) 

ITEM D4 b Refer to age of samp/e chi/d,	 / 2 � Under 6 months old (6aJ 

I a � Other ($b) 

6a.	 Has – – ever been given any solid food, such as ; 

commercially preparad strained and junior foods, 1,y 2 N (Section E, page 10) “tabla foods,” or any other non-liquid foods? / 

I
 b.	 HOW old was when – – started eating 

solid food (such as strained foods or any other ! wo � Never on a daily basis 

non-liquid foods) on a daily basis7 I ( 1 � Days 

i 2 � Weeks 

: Number { 3 � Months I 

‘OOTNOTES 
Section E. MOTOR AND SOCIAL DEVELOPMENT 

CHECK I 

I I � Under 2 years old (INTRO)
 ,~~M ~, p f?efer to age ofsamp/e chi/d. 2 •l 2-4 yearsold I
 I


3 � 5+ years old (Section F, page 14) I


INTRO - Now I would like to ask a few questions about various things children do at different ages. 

I


I Sequences


CHECK 1 2
 ~2 � Refer to age of semp/e child. I Age Dssmnding Ascending
 ITEM order 

I (Mark only one) order beginning beginning with 

w::it~tion question 

After marking the appropriate box, go J numberto the list of questions and circle the 

corresponding question numbers. I


t•lUnder 4 months 6 7
 I


t 

Ask first sequence of questions until


five consecutive “Yes” responses are ,

i 2 •l 4 months 8 9


given, then ask second sequence of ,


questions until five consecutive “No” I


responses are given. One or more of


the five consecutive ‘*No” responses / 3 •l 5 months 10 11


may have been given at the beginning 1


of the first sequence, thus requiring I


less than five consecutive “No”
 4 •! 6 months 12 13
 responses in the second sequence. .}


I


After completing second sequence, go ~ s •l 7 months 14 15


to Check Item E3. If 10consecutive


“No’* responses are given in the first J


sequence, go to Check Item E3 without /


asking any further questions in the list. I e •l 8 months 16 17


I


I


I 7 D 9 months 18 19


I


I


s •l 10 months 20 21


I


1


I
 9 •l 11 months 22 23


I


i


1 lo U12-14 months 24 25
 I


I


I
 llC115-?7 months 28 29


I


1


tzlJ18-23 months 33 34


I


13 fJ2 years 36 37


I


{


: 14 � 3 years 41 42
 I


I


I


t5C14 years 44 45


I


81 
Section E. MOTOR AND SOCIAL DEVELOPMENT – Continued 

1.	 When lying on - – stomach, has – – ever / , ~ 2N 9 DK turned – –head from side to side? I


2. Have –– eyes ever followed a moving object at all? ~ I Y 2N 9 DK 

1


3. V$en lying on – – stomach on a flat surface I
 ——
 ever lift — — head off the surface for a ; I Y 2N 9 DK


moment? I


4.	 Heve –– eyes ever followed a moving object ~ , y 2N 9 DK
 all the way from one side to another? I


1


5a. Has-– ever smiled at someone when they talked I , y 2N 9 DK
 to or smiled at – - without being touched? ! 

I
 b.	 If “Yes, “ask: How old was – – when – – 

first smiled at someone when they talked to I 2 � Weeks 

or smiled at — —? I Number ( 3 � Months 

6.	 When lying on - – stomach, has – – ever \ 

raised — — head AND chest from the surface 

while resting — - weight on — — lower arms 1 lY 2N 9 DK 

or hands? I


7.	 While lying on – – back and being pulled up ~ 

to a sitting position, did –– ever hold - – 

head stiffly so that it DID NOT hang back as ~ I y 2N 9 DK 

–– was pulled up? I


I


8. Has –– ever laughed out loud without being ] . 

tickled	 or touched? I lY 2N 9 DK


1


9.	 Has - – ever turned - – HEAD around to I


look at something? I 1“Y 2N 9 DK


O. Has – – ever held in one hand a moderate size I


lY 2N 9 DK
 object such as a block or a rattle? I


1.	 Has - – ever looked around with — — eyes for i lY 2N 9 DK a toy which was lost or not nearby? 

I
 12a, Has –– ever rolled over on — — own ON


PURPOSE7 I lY 2N 9 DK


b.	 If “Yes, “ask: How old was – – when – – first / 2 •l .Weeks
 rolled over? I


3 IJ Months
 I Number {


I
 13.	 Has - — ever been pulled from a sitting to a I


standing position and supported — — own


weight with legs stretched out? I lY 2N !9DK


I


I


I
 14, Has –– ever sat alone with no help except for I


leaning forward on – – hands or with just a :


little help from someone else? lY 2N 9 DK


I


15. Has –– ever seemed to enjoy looking in the ~ 

mirror	 at (himself/herself)? I lY 2N 9 DK


I


16a.	 Has — — ever said any recognizable words, I

I


such as “mama” or “dada”7 lY 2N 9 DK
 ! 

b. M “Yes, “ask: How old was – – when – – first ~ 2 � Weeks
 said any recognizable words? I


Number { 3 •l Months


I


82 
--

--

--

--

--

--

Section E. MOTOR AND SOCIAL DEVELOPMENT – Continued I


I 4


17a. Has ever crawled when left lying on I


— - stomach? I lY ZN 9 DK


I


b. /f “Yes, “ask: How old was – – when – – first ~ 2 � Weeks 

crawled? I Number { 3 •l Months 

18.	 Did –– ever sit for 10 minutes without any I


support at all? I

I lY ZN 9 DK


19. Has -– ever pulled (himself/herself) to a standing I


position without help from another person? lY ZN 9 DK
 I


I


20.	 Has ever recognized – – own name when I


someone said it? I lY ZN 9 DK


I
 21, Has ever picked up small objects, such as I
 raisins or cookie crumbs, using only — — thumb I


and first finger? I lY ZN 9 DK ,1 

I
 22a. Has — - aver waved good-bye without help I


from another person?	 I lY ZN 9 DK


I


b. If “Yes, “ask: How old was – – when – – first [ 2 � Weeks 

waved good-bye? I Number { 3 � Months
 I 

23a.	 Has ever stood alone on — — feet for 10 I


seconds or more without holding on to I 

I


anything or another person? I lY ZN 9 DK 

I


b.	 If “Yes, “ask: How old was – – when – – first ~ 2 � Weeks 

stood alone? I Number { 3 •l Months T 

24. Has -– said 2 recognizable words besides I


“mama” and “dada”?	 I lY 2N 9 DK
 I


1
 25.	 Has — — ever walked at least 2 steps with I
 one hand held or holding on to something? I lY 2N 9 DK


16. Has –- ever shown by –– behavior that –– knows ~ 

the names of some common objects when somebody I , ~ 2N 9 DK else names them out loud?	 1


)


!7, Has - — ever crawled up at least 2 stairs or steps? ~ , y ZN 9 DK 

?8,	 Has ever said the name of a familiar object, I


such as a bail? I lY ZN 9 DK


?9a. Has ever walked at least 2 steps without t 

holding onto anything or another person? I lY .ZN 9 DK 

I
 b. If “Yes, “ask: How old was – – when – - 1. 2 � Weeks 

first walked at least 2 steps?	 I Number { 3 � Months
 I


IO,	 Has –– ever shown that – – wanted something I


without crying or whining? It may have been by I 

lY ZN 9 DK


pointing, pulling, or making pleasant sounds. I


I


11. Has - – ever made a line with a crayon or pencil? { , y 2N 9 DK 

12.	 Has — — ever run? I


I lY 2N 9 DK I


13. Did - – ever walk up at least 2 stairs with one hand ~


held or holding the railing?	 I lY ZN 9 DK I
 1


14.	 Has T — ever let someone know, without crying, I


that - – was bothered by – – pants or diapers ~ 1y ZN 9 DK


being wet or soiled? I


3!3,	 Has –– ever fed (himself/herself) with a spoon or I 

I ~Y ZN 9 DK fork without spilling much? , 

83 
Section E, MOTOR AND SOCIAL DEVELOPMENT – Continued 

I 36. Has –– ever walked upstairs by (himself/herself) I , ~ 

without holding onto a rail? I 2N 9DK 

37.	 Has – – ever spoken in a partial sentence of 3 I 

words or more? I lY 2N 9DK 

38. Has – – ever said – – first and last names 1“ 

together without someone’s help? I lY 2N 9DK 

Nickname may be used for first name.€ I 

39. Has –– ever walked up stairs by (himself/herself) with ~ 

no help, stepping on each step with only one foot? I lY 2N 9DK 

40. Has – – ever counted 3 objects correctly? I lY 2N 9DK 

41. Has–- ever pedalad a tricycle at least 10 feet? ~ I Y 2N 9DK 

I 

42.	 Doas ––know–– own age AND sex? I lY 2N 9DK 

I

43.	 Has – – ever washed and dried – - hands without I 

any help except for turning the water on and off? ; l.y 2N 9DK 

44.	 Has – – ever done a somersault without help \ , y 2N 9DK from anybody? I 

45. Has –– ever drawn a picture of a man or woman [ 

with at least 2 parts of the body besides a head?	 , ‘ y 2N 9DK 

, 

46. Has –– ever gone to the toilet alone? I

I lY 2N 9DK 

47. Has – – ever played with several children at the ~ 

same time? I 

lY 2N 9DK 

1 

48. Has – – ever said the names of at least 4 colors? I I Y 2N 9DK 

49. Has – – ever dressed (himself/herself) without [ 

any help axcept for tying shoes (and buttoning lY 2N 9DK 

the back of dresses)? “/

1 

50. Has – – ever counted out loud up to 10? I lY 2N 9DK 

I 

1D Under 2 years old (51a) 

CHECK~3 ~ Refer to age of sample child. 

I 2 IJ 2 years old f51b) l~E~€

I 3 •l 3+ years old (E4) 

I 

51a. Are any of – – teeth in yet, that is, have any I

teeth broken through the gums? lY z N (E4), 

I 

I b.	 How old was –– when the first tooth came I 

in (that is, broke through the gums)? I 2 Cl Weeks I Number I 3 •l Months 

I 

1 � Under 1 year old (Section F, page 14)

CHECK

E4 b Refer to age of sample child. I

I z � 1– 3 years old (52al ITEM 

I 3 � 4 years old (52b) 

I 

52a.	 Except for occasional accidents, is –– completely I 

toilet trained? (That is, does – – go to the bathroom I t y 2 N (Section F, page 14) by (himself /herself) when –– needs to?) . I 

b. How old.was – – when – - was completely 1

! toilet trained? 000� Not completely toilet trained

I 3 � Months
 I€

I Number d � Yaars


I (€

84 
--

--

--

--

Section F. BIRTH 

In studying the health of children, it is important to have information about their birth, 

, 

CHECK I 1 � Biological mother in HH {F2) 

ITEM FI b Refer to question 1,page 3 of CHS. 

I

I z � Biologicalmother not in HH (1) 

1. How old was biological mother when I -— was born? I Years 

1 

CHECK I 

I 1 � Biological father in H H (F3) 

ITEM F2 b Refer to question 1,page.3 of CHS.	 I 2 � Biological father not in HH (2) 1 

I 2.	 How old was biological father when I 

was born? I Years 

I 

I I •1 RespondentiSbiologicalmothw CHECK I or biological father (3) 

ITEM F3 b I * � Other (9) I 

3a. Was –– born in a hospital or some other place? t I � Hospital (3b) I 

I � Other – Specify (4)7K. I 

I 

I 

b, How many nights was – – (Biological mother) in the ~ 

hospital during this stay? I on None 

I 

I Nights I 

c.	 How many nights was – — in the hospital during 

this stay~ ;

I o ~ None 

I


I Nights


4a. How much did weigh at birth? 

I 

I 

9999 ~ DK 

Probe for ounces if not reported. I 

1 . Lbs.. oz. (5) I — 1 

b.	 Did – - weigh more than 5 1/2 pounds or less? I � More than 5 1/2 Ibs. a 

, 2 n Less than 5 1/2 Ibs. 

1 7@DK . . . . . . . . . . . . . ) 

(5) 

I 

c, Did - -weigh more than 9 pounds or less? I

I 3 � More than 9 Ibs. 

I 4 ~ Less than 9 Ibs. 1 

I 9CIDK , 

5a, Was – - born about 

it earlier or later? 

when expected, or was I 

a I U Earlier than expected 

2 � When expected @ 

3 � Later than expected 

9 C DK (6) 

b. About how much (earlier/later) than expected -

was — — born? 1 I ~ Days 

I 2 ~ Weeks Range acceptable I Number - { 3 � Months 

6.	 How many hours was – - {Biological mother) in labor? \ —. 00~ None (8a)

. Hours I 

CHECK I I [~ Under 6 years old (7a) 

ITEM F4 b Refer to age of sample child. I 

2‘~ 6+ years old (11) 

85 
Section F. BIRTH - Continued 

I
 7a: Now I’m going to ask about medicina, shots, and


gas given during labor AND delivery. First I’ll ask I


about LABOR, While (Bio/ogica/ mother) was in


LABOR, was she given any medicine, shots, or gas?. ~


I
 Read if necessary.’ Labor begins with tha onset of I lY 2 N (8a)


contractions that lead to delivery, Do not include false I


labor but do include medication to induce labor. I


b. How was it given to (~iolo.qical mother) during labor? ; 1El Spinal 

Was it a spinal shot, some other type of shot, gas, or , 2 � Other shot/1.V. some other method?	 I


I 3 � Gas


I


I 8 � Some othar method - Specify ~ 

I


I


c. Was (Bio/ogica/ mother) —.. given anything else during labor? ;

1’ Y (Reask 7b and c) N 

8a. While (Biologicalmother) was in DELlVERY, was she ~ 

given any medicine, shots, or gas? I


I


Read if necessary: Delivery begins when the baby I lY z N (9)


starts to show, or the doctor starts to use forceps I


or to operate in the case of a caesarean saction. I

I


I


I
 b, How was it given to (Biological mother) during I � Spinal
 delivery? Was it a spinal shot, some other type of ~ 2 � Other shot/1.V. shot, gas, or some other method?
 I


I 3 � Gas 

8 � Some other method – Specify ~ 

./ 

I


c.	 Was (Biological mother) given anything else during I


delivery? 8“

I Y (Reask 8b and c) N


I
 9a. Was –– delivered by caesarean section? 1


!


I 1 Y’ 2 N (10)


——... _ I


b.	 Why was the caesarean performed? I


I


I (1lC)
 I


I } 

10. Was –– born head first or feetfirst? I I � Head first 

I
 2 ~ Feet first


I


1 8 ~ Other way – Specify~


I


I


Ila. Was it a normal delivery or were there any I

I
 complications or problems? I I ~ Normal delivery (72)


I 

, 2 ~ Complications/problems — b. What was the matter? ‘– ,


I


1


I

1 

-—_____ I ———
 1
 c. (Besides the caesarean section ) Were there any ! 

other problems during delivery? I 

t ‘f (Reask 1lb and c) k 

86 
-- --

--

--

Section F. BIRTH–Continued


1


12a.Including any condition not known about immediately I


after dalivery but found out about later, was there lY 2 N (13) 

anything (else) wrong with when was born? ~ 

I
 b. What (else)was wrong with - -? I


i


c. Was there anything else wrong with”- – ? I


I Y (Reask 12b and c) N


I


I
 3a. Did receiveany newborn carein an intensive I


careunit, prematurenursery,oranyothertypeof 

; lY 2 N {/%) specialcarefacility? 

I


b. How many nights did -- stayin the 00� None


specialcarefacility? I

I


i Nights 

1


CHECK I � Ma!e (14)


ITEM F5 b Refer to sex of sample child. 

I � Female(Section G, page 17)


4, Was ever circumcised? I


I lY 2N 9 DK 

I


‘OOTNOTES 

87 
-------------

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

Section G. PRENATAL CARE 

I


CHECK I I l_J Under 6 years old AND biological mother 

ITEM GI - I respondent (1) 

8•l Other (Section H, page 21) 

1.	 The next set of questions is about the health”ca~e you ;


may have recaived during your pregnancy with ——. I


How many weeks pregnant were you when you first ~ Weeks 

thought you ware pregnant with – –? 1


,
 2a. Did you see or talk to a doctor to find out if you I
 were pregnant? lY 2 N (2c)


1


b.	 How many weeks or months pregnant were you I


when you first saw or talked to a doctor to find out if I 2 El Weeks


you were pregnant? I Number 

{ 3 � Months


, c.	 Including routine checkups, did you see or talk to I
 a doctor about your pregnancy at any (other) time


during that pregnancy? I lY 2 N (3)


If “Yes” in 2a, go to 3.	 I


I 2 � Weeks


d.	 How many weeks or months pregnant were you Number s � Months 

when you first saw a doctor about your pregnancy? I { 

la,	 How much did you weigh just before you became I


pragnant with – – ? I Pounds


b.	 Altogether, how many pounds did you either gain I


or lose during that pregnancy? / I �“ Gained


I Pounds { 2 � Lost 

C.	 How many months pregnant were you when ~ 

— — was born? 1 Months 

� NOTE – 4a-h are conditions that may occur during pregnancy.. ~ 

1.	 At anytime during your pregnancy with – –, did 

you have: 

a.	 A urinary tract infection? lY 2N


I


b. Measles? I 

lY 2 N (4c) 

l _________________ /f “Yes, “ask: Was it German measles, sometimes 

known as Rubella or 3-day measles, OR was it Red I 1 � German/Rubella/3-day 

measles, sometimes known as 8-day measles? I 2 � Red18-day 

I 3 � Both 

I
 At anytime during your pregnancy with ––, did i


you have: I


c. Hypertension or high blood pressure? I lY 2N 

1
 d, Preeclampsia, eclampsia (eek-lamp-see-ah), I lY 2 N (4e)
 or convulsions?	 I


l–----––––––-–-––


if “Yes, “ask.’ Which was it, preeclampsia, eclampsia, ~ 1 � Preeclampsia


or convulsions? I 2 � Eclampsia
 I
 3 •l Convulsions


I
 At any time during your pregnancy with – –, did I


you have: I


e. An embolism or blood clot? I lY 2N 

f.	 Abnormal position of the placenta? I lY 2N


1


g. Abnormal position of tha cord? I

I lY 2N 

h, Vaginal bleeding? I lY 2N 

88 
Section G. PRENATAL CARE – Continued I


5a, At any time during your pregnancy with --, j High sugar
 did you have - , Sugar in the urine? in the blood? I Diabetes?


I


I (Ik (2) I (3)


I I Y (5b and c) 1 Y (5b and c) I Y (5b and c)
 I


I 2 N (Next column) 2 N (Next column) 2 N (6)
 I


b. When did you FIRST notice it - was it during ~ I •l During I •l During 1 •l During 

your pregnancy with -- or befora? I 2 � Before 2 � Before 2 •l Before 

c. Did you have the (Condition) for at least 3 months ~ , ~ lY lY after -- was born? I 2N } (5a) 2N I (5a) 

[ 2N I 

(6) 

I

6. Do you NOW have diabetes or sugar diabetes? ~ 

I lY 2N


I


7a.	 At any time during your pragnancy with – –, I


did you stay in a hospital overnight? Do not


count the hospitalization for — – birth. I Y O N (8)
 1


I


b.	 How many times? I
 .


c. 

d.


e. 

la. 

b,


c.


d.


9. 

I Number
 I


I


For what (other) conditions did you stay in a t


hospital overnight? I


I


I


I


Any other conditions?	 I


I


I Y (Reask 7Cand d) ‘N


I

Altogether, how many NIGHTS did you stay in ~


a hospital for (Conditions in 7c) ? I


I Nights
 I


(Not including the times you stayed overnight in ~


the hospital, ) Did a doctor ever tell you to remain ~


in bed for one or more weeks during your I 

lY 2 N (9)


pregnancy? I


For what (other) conditions did the doctor tell i 

you to remain in bed for one or more weeks?	 I


I


I


I


I


I


I


, Any other conditions? I 

Y (Reask 8b and c) N
 I


Altogether, how long did you stay in bed I 

for (Conditions in 8b)during your pregnancy I 1‘~ Days 

with – -7 {Do not include time spent in ,

I 2 D Weeks 

the hospital.)	 I Number { 3 D Months
 I


DURING your pregnancy with -–, about how I 00 n None 

many cigarettesa day did you usuallysmoke? I “ 

I


I


I Number


I


89 
Section G. PRENATAL CARE - Continued 

I
 Oa. At any time during your pregnancy with 

––, did you take tranquilizers? I lY 2N(11) 

1


Hand card T I I n Everyday 

b. Which number on that card best describes how ; 2 � Nearly everyday 

often you took tranquilizers DURING your I 3 IJ Once or twice a week 

pregnancy? 

I 4 D 2 or 3 times a month 

I 5 � About once a month


1


I 6 iJ Less than once a month


I


la. Had you ever had a miscarriage before you I


t
 became pregnant with – –7 I lY 2 N (Section H, page 27)


—— I


b.	 How many? I


I


I
 Number
 i


c. How long before – – was born did you have the \ 

(most recent of those) miscarriage(s)? I 3 C Months 

Number 4 � Years 1 { 

I


‘OOTNOTES 
--

Section H. HOSPITALIZATIONS AND SURGERY


1
 la. Since –- was born, how many different times I 00IJ None (3) has stayed in the hospital ovarnight? Do I


not include the hospitalization when — — was 1


born.	 I

I 

Number of times


I


b. During any of these hospitalizations was – – I

I
 treated	 for diabetes or sugar diabetes? lY 2 N (2)
 I


c. Does – - take insulin shots? I


I


I lY 2N


I


2a.	 Was surgery of any kind or were any operations ~


performed on – - during any stays in the I lY 2 N (3)
 hospital? Include bone sattings and stitches. I


b.	 What are the names of these surgeries or I


operations? 1.


If name is not known, describe what was done.	 I


I


I


I


c, Any others7	 I


I


I Y (Reask 2b and c) N


I


3a.	 (Excluding the operations performed on – –while ~


– - was an overnight patient in the hospital) I


Has - – EVER had any (other) surgery or I lY 2 N (Section 1, page 22)


operations? Include bone settings and stitches. ~


b.	 What are the names of these surgeries or I

I
 operations? I


If name is not known, describe what was done. I


I


I


I


I


c.	 Any others7 I


I


I Y (Reask 3b and c) N


I

I


‘OOTNOTES 

91

--

---

--- ---

---

--- --

-- ------ ---

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

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

--- -- --

-- ----

--- ----

---- --

----

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

---- -- -----

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

----

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

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

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

-----

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

Section I . SUPPLEMENTAL CONDITION LIST 

Some of the following conditions were asked about earlier, but tell me whether or not – – EVER had any 

of these conditions even if they have been mentioned before. 

If “Yes,” enter conditon and number in Item 1 of Section J. 

Did – – EVER have – Did – – EVER have – 

1. Hepatitis? 33. Palsy or cerebral palsy? --—- _____ ____ ____ ____ ____ _____ ___ —-- ———- ____ ____ ____ ____ ____ ____ __ 

2.	 Yellow jaundice? 34. Paralysis of any kind? ---— ____ ____ ____ ____ ____ ____ __ __ --—— —--- ____ ____ ____ ____ ____ __ __ 

3. Any other liver trouble? * * 35. Mental retardation? -— -——- ____ ____ ____ ____ ____ ,___ _ -- _ --— ——— ___ ___ ___ ___ ___ ___ ___ __ 

4.	 Colitis? - -. ____ _ 36. Epilepsy? --—— ____ ____ ____ ____ ____ ____ __ ____ __ —-— ——- ——- -—- ___ ___ 

—-— 5.	 Any other bowel trouble? *” _ 37. REPEATED convulsions, seizures, or ___ ___ ___ ___ ___ ___ ___ ___ —-

6. An ulcer? blackouts? ——-—— __ ____ ____ ____ __, _ ____ ____ - - —--— ——-.— -- ..-— ___ __— ___ ___ __ 

38. Migraine? 7. A hernia or rupture? -.-—— —--- ____ ____ ____ ____ ____ __ __ -— ____ ____ ____ ____ ___ —-— 39. FREQUENT or SEVERE headaches? 8. Any other condition of the digestive ——- --— -—- -—- --— ___ __ 

system ? * * 40.Meningitis? --—— ____ ____ ____ ____ ____ __ --— - — -. .. —- —-— —-- ___ ___ ___ _-

9. Asthma? ---— —____ ____ ____ ____ ____ _., ___ —- _ 41. Chores (ko-ree-uh) or St. Vitus’ dance? ——---- ———- —— ____ ____ ____ ____ 10. Hay fever or allergies? --—-	 ____ ____ ____ ____ ____ -. _.> 42. Nephritis? —— —--— ——__ __. . __ 

11. Tonsillitis or enlargement of the tonsiis ““- - – ‘43.-U-rinar~;rXt;;f=c%&i~ -

or adenoids? * ——-—— -. —-- ____ ____ ____ ____ _. __ 

---— ____ _____ ____ ___ _-. _. ___ - ,- -. ---- 44. Any other kidney trouble? � � 

12. Tuberculosis? -——— -,--- ____ ____ ____ ____ _____ __ __ 

—--- ..-__ ____ ____ ____ ,----- -_, _ -. .-. 45. Diabetes? 

13. Pneumonia? —-.. ——-—— —-—— . . __ 

--— --— ___ ___ ___ ___ ___ ___ ___ ___ ‘46.-Go~t;r-o-r~ther thyroid trouble? 

14. Any other respiratory, lung, or pulmonary — -—-. .-— ——--. —---— —--- -.. 

condition? * * 4~.-Cy~t~c-f~brosis ? ————____ ____ ____ ____ ____ __. . _ ,. -—— ___ ___ ___ - - .. . .­

- ‘l~O”-Arthritis of any kind or rheurnatis~;? ‘“ 48. Anemia or sickle cell anemia? 

—--— ____ ____ . . . . -. -— —--- -—— ——- ___ ___ ___ ___ _.. -_ 

- ‘l~.-C;rvature of the spine? 49. A heart murmur? —--- —-. --. .— _____ ____ ____ -,-

17, Clubfoot? - -’50. ‘C-aXe; ;f-a;~ ~i;;?- —-—- ____ ____ _ 

18. Any other cond~t~o~ affecting the bone, “ “-

—--— cartilage, muscle or tendon? * * ____ ____ ____ -,- - ‘“ - ‘- 19. Eczema or psoriasis (so-rye-ui-s”i~)? - ‘5i.-Hig~Gi;od-pie&u-re?” . . . .. . . . .. . _. -. . ..- —___ ____ ____ _.. - -h.. 52. Rheumatic fever? 20. TROUBLE with acne? -..—— ———- ____ ____ ____ ____ ____ . . . ._ — 53. Rheumatic heart disease? ‘2~ .-~-n~ ~~~ ~f-s~~n~~ergy?” - ““- ‘- – ____________________ .. . . . . .. . . . . . _ -.. .— ____ ____ ____ . .._ 54. Congenital heart disease?

22..- Any other kind of skin..-trouble~; ~ ‘- - ‘ - ““ -_ ______________________ ____. .. ___...,. __ —- _____ ____ __ . .. . . . -

23. REPEATED ear infections? 55. Any other heart trouble? � � 

—--- ____ ____ ____ _. 

24. Deafness in one or both ia&? - —-—-	 ____ ____ ____ ___ —— 25.	 Any other trouble hearing Wth one or - 56. “D-OZS:-–-N6W h&;--– a miXi;g f~n~ir~ - ‘- both ears? � * ____	 ____ ____ -h- - and, or arm, toe, foot, or leg? -——— —-.—— —--- ., .,--- ___ 26. Blindness in one or both eyes? -. ----- ,____ ____ ____ --, - -.. - 57. PERMANENT stiffness or any deformity 27. Cataracts? of the back, foot, or leg? (Permanent 

- ~~.-A~~ ~~~r-t~o~~l~ ~~e~ng “With one” or b~t~ - “-_ stiffness – joints will not move at all) .,.. _. 

—___ eyes even when wearing glasses? “ � 58. PERMANENT stiffness or any deformity . .._ ___ ___ ___ ___ 

-— .

29” A cleft ____ ____ - of the fingers, - . . _____ palate or hareliP? - - - - - --—— ———————— hand, or arm?____ -.. . . 

30. Stammering or stuttering? 59. Did –– EVER have any other health —---- -——— -— __ ____ -—. . . - problem which lasted for at least 3 

-—- -.. . ___ ___ ___ -. _.. .- 31. Any other speech defect? � � months which you have not mentioned? 

32. Autism or has — — ever been autistic? - ‘“ If “Yes, “ask: What was the condition? 

� Makeno entwin SectionJ forco,d; fh); gnvpe; red, sore, orwc,. throat; or I’WUS”. 

* 1.How many times did – – have . . .? /f2+ , enterm Section J. 

If only 1 time, ask: 

2.	 HOW long did it last? – /f I month or /onger, enter in Section J. If less than 1month, do not record. ..__ ___ ___ ___ __ ** Did this condition last for at least 3 months? “if“Y~5,’’’-e~ti~~e~~o~~~~~~ -

If “No, “ do not record unless it is an obvious permanent condition which began less than 3 months ago. 

92 
--

--

--

--

Section J. SUPPLEMENTAL CONDITIONS 

CONDITION 1 CONDITION 2 

1. Itsrm number I’dama of condition 1. Item number Namtr of condition 

For allergy ask: For allergy ask: 

2. How doaa tfra allergy affect -– 7 2. How does the allargy affect –– ? 

For m Impamrront or ulcer, ask: For an impairment or ulcer, ask: 

3. What part of the body is affrsctad lry(Condition/? 3. What part of tha body is affactad by(Conditian)? 

!.ihow the following detail: Show the following detail: 

I+cmd [skull, scalp, face) Head (skull, scalp, face) 

Back/spine/vertebrae (upper, middle, lower) Back/spine/vertebrae [upper, rmddle, lower) 

Side (left or right) Side (left or right) 

Eisr hnnar or outer; left, right, or both) Ear (inner or outer; left, right, or both) 

Eye (Iaft, right, or both) Eye [left, right, or both) 

Arm (shoulder, upper, elbow, lower or wrist; left, right or both) Arm (shoulder, upper, elbow, lower or wrist; left, right or both) 

Hand [entire hand or fingers only; left, right, or both) Hand (entire hand or fingers only; left, right, or both) 

LtWI [hip, upper, knee, lower, or ankle; left, right, or both) Leg (hip, upper, knee, lower, or ankle; left, right, or both) 

f%mt (entire foot, arch, or toes only; left, right, or both) Foot (ent!re foot, arch, or toes only; left, right, or both) 

I I =hen waa (Condit!on)first noticed? I 4 � 3 m~n~h~or jes~ (6/ 4a. When was (Conditton)firat noticed? I 4 � 3 m~nth~ or Ies$j (6) 

(Was it durirr~ tha past 12 months I (Was it during the psrst 12 months 1 

or bafore that time?) , 5 � over 3-12 rrlonths(6) or before that time?) , 5 � Over 3-12 months {6) 

[Was it during tha past 3 months ! 6 � More than 12 months ago {Was it during the past 3 months I 6 n More than 12 months ago or bafore that time?) I or bafore that time?) I 

b.	 How old was –- whan 0 I_J Condioon from 56,57, or b. How old was –– when 0 � Condition from 56,57, or 

this was first noticad? 58 (NC) this was first noticed? 58 (NC) 

QU L~ss than 1 month 5. Did have this condition 0 � Less than 1 month 5. Did –– have this condition 

at any time during the past 12 3 � Months 

et:::h:~e during tha past 12 

~ � Months months? 

Number ( 4 � Years lY 2 N (6b) Number ( 4 � Years lY 2 N (6bl 

O � Condttion from 56, 57, b. Is this condition completely O U Condmon from 56, 57, , b. Is this condition completely 

or 58 (NC) I cured or is it under controi? or 58 (NC) cured or is it undar control? 

6a. Does still have this 2 � Cured ~a. Does –– still have this ~ 2 a Cured 

ctrndition? I 3 � Under control condition? 3 � Under control I 1 Y (NC) N I 4 � Other - Specify 1 Y (NC) N I 4 � Other – Specify 

CONDITION 3 CONDITION 4 

1. Item number Name of oondition 1. ltam number Name of condition 

For allergy ask: For allergy ask: 

Z. How doas tha allergy affect ? 2. How does tha allargy affect --7 

For an mt~a,rmorrt or ulcer, ask: For an imparment or ulcer, ask: 

L What part of the body is affected by(Condit\on)7 3. What part of tha body is affectad by(Condit!on)? _ 

Shcrw the following detad: Show the following detail: 

Head [skull, scalp, face) Head (skull, scalp, face) 

Et~ck/spme/vertabrae [upper, middle, lowed Back/spine/vertabrae (upper, middla, lower) 

Side [left or right) Side (left or right) 

Ear (u-mar or outer; left, right, or boti?) Ear [inner or outer; left, right, or both) 

Eve (left, right, or both) Eye (left, right, or both) 

Arm (shoulder, u~par, elbow, lower or wrist: left, right or both) Arm [shoulder, u&per, albow, lower or wrist; Iaft. right or both) 

Hand [enttr~ hand w fingers only; left. right, or both) Hand {entire hand or fingars only; left, right, or both) 

Leg [hip. upper, kr%w, lower, or ankla; left, right, or both) Leg (hip, upper, knee, Iowar, or ankle; left. right, or both) 

Foot (enure foot, arch, or teas only; left, right, or both) Foot [entire foot, arch, or teas only: left, right, or both) 

i 

la. When was /Condit/on/first noticad? 

I

‘ 4 D 3 monthsorless [61 

4a. When was {Condition) first noticed? 

i

‘ 4 � 3 monthsor less (6) (Wae it during the past3 months (Was it during the past 3 months 

or bafore that time?) I 5 ~ 0Ver3- 12 months /6] or before that time?) ~ 5 � Over3-12 months (6) 

(Was it during tha past 12 months I 6 � More than 12 mofltbSago (Was it during tha past 12 months I 6 � More than 12 months ago or before that time?) or bafore that time?) 

b kSOW old waa – – when 0 U Condition from 56,57, or b. How old was whan 0 � Condttion from 58,57, or 

this was first noticed? 5B (NC] this was first noticed? 58 (NC) 

@~ Lw:?i than 1 month 5. Did -– have this condition O � Lass than 1 month 5. Did –- have this condition 

J @ Months at any tima during the past 12 

months? 3 � Months at anytima during the past 12 

months? ——. 

Numttir { 4 LI Years lY 2 N (6b) Number { 4 � Yaars lY 2 N (6b) 

0 D Conditmn from 58.57, ~b. Is this condition completely 0 G Condition from 58,57, ~b. Is this condition completely 

or 58 (NC) I cured or is it under control? Or 58 (NC) I cured or is it under control? 

ia.	 Does — - still f’ravo this , 2 ~ Cured 6 a. Does -– still have this , 2 a Cured 

condition? I 3 � Under control condition? I s g under control 

1 Y (NC) N I 4 G Other - Spec/fy 1 Y IN(3 N I 40 Other - Specify 

93 
--

Section K. WEIGHT, EYES, AND TEETH 

la.	 For —— height, would you say - – is i � Underweight (lc)
 underweight, about the right weight, or I
 overweight? I ‘ � About the right weight (Kl)


I Q Overweight
 I


b. Would you say is extremely overweight, 

I 

I 2 •l Extremely overweight somewhat overweight, or only a little


overweight? I

I 3 Cl Somewhat overweight (Kl)


I 4 •l Only a little overweight }


—— I
 .
 I
 c.	 Would you say — — is extremely underweight, I 50 Extremely underweight
 somewhat underweight, ar only a little I


underweight? I 

6 ~ Somewhat underweight


1 7 U Only a little underweight


I


I


,TE~ K, > Refertoageofsanp/echi/d. I CHECK o � Under 3 years old (Section L, page 26)

I I � 3+ years old (2) 

I
 2a. Does – - wear glasses or contact lenses?


I lY 2 N (3)


I


b. which does - – weer? I I � Both glasses and contacts 

[

I

I 

2 � Glasses only 

3 El Contacts only 

3a. Has – – ever had – – teeth straightened or had ;


braces or bands on the teeth? 1 Y (4) 2N


I


! 

b.	 Would you say – – teeth need to be straightened? I


lY 2N


—- I
 - —-
 1


C. Has a doctor or dentist ever said that — — teeth , 

need to be straightened? 1 lY 2N 

I


la. Does –– have any fillings in – – teeth? 

I 

I Y o N (Section L, page 26) 

..—— I


b. How many teeth NOW hava fillings? 

Range acceptable – Exc/ude baby or other teeth ‘ Number


child no longer has. I


00 TNOTES 

94 
----- -----

--

--

-- -- --

Section L. MEDICINE USE 

NOTE - Ask la- k before asking 2-5. NOTE - Ask 2-5, only for those questions in la-k wh!ch were answered “Yes.” 

_____ _____ ___ -.—— ---— - ——-— — .——- -— ._— _ ____ ---— 

Hand calendar !. What is the 3. Did anyone i. Did a doctor Hand card T 

The next few questions refer to the use main health get a recommend 5.ljlJhich number on 

of medicines, pills, or ointments. problem for prescription that - – take that card best which took from a dot. or use the describes how 1.	 During the 2 weeks outlined in red on or used the tor for –– (Medication)? often — - took or that calendar, did – - take or use any: (Medication)7 to take or used the 

1 use the (Medication) during 

I (Medication) the past 3 months?
 I


a. Pain relievers such as I


aspirin (or Tylerrol and ; Y N I’i(5) 2 N Iy 2N 123456


the like)? I


b. Cough medicines (such ~


as Vicks, Robitussin, or , y


Phenergan Expectorant I N IY(5) 2 N ly 2N 123456


and the like)? I


1


c.	 Any other medicines or I


remedies for colds? ~YN 1Yf5) 2 N ly 2N 123456


d .Asthma or allergy pills ;


or medicines (such as IY N I’f (5) 2 N ly 2N 123456
 Benadryl, Dimetapp. or ,


Sudafed and the like)? I


c e, Topical Steroids (such as , 

hydrocortisone cream or I y N 1Y(5) 2 N Iy 2N 123456


valisone and the like)? ~


f.	 Other skin ointments or ~


salves (such as Desitin,


Calomine Lotion, Vaseline,] ‘YN 1Y(5) 2 N ly 2N 123456


or Clearasil and the Iika)? ~


g, Laxatives or any other ~ 

mediciwr or remedies for I


the stomach (such as Ex- I y N 1Y(5) 2 N ly 2N 123456


Lax, Roiaids, Colace, or ~


Donnatal and the like)? ,


h, Vitamins or minerals? ~ y N


IY(5) 2 N ly 2N 123456


I


I


i.	 Tranquilizers or I


sedatives (such as ‘YN 1Y(5) 2 N IY 2N 123456
 Valium, Chloral Hydrate, 1


or Seconal and the like)? ~


I


i$ Antibiotics (such as ~ 

Penicillin, Tetracycline, , Y N 1Y(5) 2 N IY 2N 123456


Ampicillin and the like)?	 I I


I


k.	 Are there any other pills, ~ 

ointments, or other ~ 

types of medicines that ; y N 

has taken or used ,


during that 2-week I
 period? - Specify I


Any others?	 I


I


I


K1 I I IY(5) 2N , IY zN 1123456


1


K2	 I IIY(5)2NIIY2N1123456
 I


I


K3 I

I 

1Y(5) 2 N Iy 2N 123455


95 
.

Section M. SCHOOL 

I 

I o � Under 5 years old (Section N, page 31) 

CHECK F.. I 

ITEM Ml p 

Refer to age of sample child, I I •l 5 years old (1) 

I 2 •l 6 t years old (M2) 

1. What was – – doing most of the past 12 months – ; 

going to school or doing something else? I •l Going to school (3) , 

I 2 •l Something else 

I 

2.	 In terms of health would – – be able to go to school? ~ 

I lY 2 N (6) 

3a. Does (Would) – – have to go to a certain type I 

of school because of — — health7 I I Y (6) 2N 

I 

b. Is (Would) – – (be) limited in school attendance ; 

because of – – health? 1 1 Y (6) 2 N (M3/ 

1 

oG Under 17 years old (M3)

CHECK Refer to age of sample child and/or to 1 J 17 years old and SCHOOL box marked (M3) ITEM M2 b SCHOOL box 0(7 HIS- 1. 

2 I_’J 17 years old and SCHOOL box not marked (4J 

4. In terms of health would – – be able to go to school? j 

IY 2 N (6) 

5a. Would – – have to go to a certain type of ! 

school because of — — haaith? I 1 Y (6) 2N 

—.— . .. . .- ..— 

b. Would – – be limited in school attendance because–~ 

of–– health? IY 2 N (M3) 

6a. What is the MAIN condition which causes – – to j 

( not be able to go to school? \ 

have to go to a certain type of school? ———— . ..— 

{ be limited in school attendance? } 

-—.—.-———. -..——. .. .. . —— 

b. When was this condition first noticed? — 

[j During !he past 3 months 

(Was itduring the past 3 months or before that time?) i [~ over 3 moptp,s 

CHECK Refer to SCHOOL box on HIS- 1andior to ‘ I ‘;.: SCHOOL box marked (8) 

ITEM M3 b question 1, above. :- ‘-; Going to school m Q1 (8) 

1 

, 8 [:) Other {7) 

7. Has – – ever attended school? 

lY 2 N (Section N, page 31) ——. 

8.	 Is – – NOW either going to school or on 

vacation from school? I :: GoIq tO SChOOi 

2 L“; (ln vacatwn from school 

c , INelther {11) 

. 

is—— in now? 

9.	 What grade { will — — be in? } 21~; lNursery school 

[Section N, page 31~ , 22 ~j Kindergarten I 

If child is between grades, enter grade promoted to. 

..—-. . ... --- Gr8de 

10a. Does – – go to a special class or get special help in I 

school because of a disability or health problem? f v [11) 2N 

—-.— .. . .... . . ... .— -——— 

b.60 you think that –– needs to attend a special class 

or get special help in school because of a disability or : ‘{ ( 12) 2 N (12) 

health problem? 

96 
--

--

--

--

Section M. SCHOOL - Continued I


Ila. Why did stop going to school? I o H Never went - health reasons (Section IV,
 I


I I � Never went - other reasons page 31)


)


I 2 � Graduated
 i


I 3 � Health problem
 I


I 4 � Dropped out


I


I E� Other - Specify ~


I


I


I


I


I


I


I
 b.	 How long ago did – – stop going to school?
 I


I


I I •! Lessthan 12 months


[ 

I 2 •l 12 months - less than 2 years (13) 

I 3 � 2+ years (13)


I


I


12. During the past 12 months, that is, since (12month date) [ 

a year ago, about how many days was – - absent I 

00 � None 

from school because of illness? 

Range acceptable I 

I Days


I


13a. Has repeated any grades for any reasons? I


I lY 2 N (14)
 I


I
 b, What grade or grades did repeat? I


I Grade(s)
 I


C. Why did - – repeat the (Grades in 13b) grade(s)? I

I I � Academic failure 

I z � Immature/acted too young
 I


I 3 � Frequently absent


I

1. 4 � Moved into more difficult school 

I E� Other – Specify ~
 I


I


1


d.	 Any other reasons? I


I Y (Reask 13c and d) N


I


14a.	 Has - – ever been suspended, excluded, or expeiied \ 

from school? I 1 .Y 2 N (14d) 

b. How many times has this happened? I


I Number
 I


I


c. How long ago was the last time? I

I I � Days 

I 2 @ Weeks 

I

I Number 3 � Months 

I

I { 4 •l Years 

d. Not counting routine conferences, has anyone 

from school ever asked someone to come in 

I

I lY 2 N (M4)
 to talk about problems – — was having7 I


e. How long ago was the last time? I


1. 1 � Days I


I 2 � Weeks


I


I Number 3 g Months


I { 4 •l Years


I


97 
Section M. SCHOOL – Continued 

CHECK I I � In school or on vacation (15) 

Item M4 b Refer to question 8, page 27 of CHS. I

o � Neither (Section N, page 31) 

I 

5. prall what kind of student would you say – - is now?\ 1 � One of the best -— one of the best in the class, above the middle, in 

the middle, below the middle, or near the bottom of the ~ 2 � Above the middle 

class?	 I 3 � In the middle 

I 

I 4 � Below the middle


I


I 5 � Near the bottom


I 

6.	 How do you feel – – is doing in school? 1s – - doing ~ 

really well, doing about as well as – — can, or could I 1 � Doing really well 

- – be doing better? I 2 � Doing about as well as helshe can 

I 3 � Could be doing better I 

‘OOTNOTES 

9a 
--

--

-- --

--

--

--

--

--

Section N. BEHAVIOR


I


I
 CHECK I •l Under 3 years old (Section P, page 34


ITEM N1 b 

Refer to age of sample child. I 8 � 3+ years old (1)


la.	 During the past twelve months has ever I


wet the bed? I lY 2 N (2)


b. About how many times has this happened? / 

/


Range acceptable Number
 I


z.	 Does – - now suck thumb or fingerseither j 

during the day or at night? 1 lY 2N 

I


3a. Has - — ever run away from home? (Disappeared I


at a time when you thought this is what — - might [


be doing, and stayed away so long that you had to , 1 Y 2 N (4)


start searching or looking for - -.) I


b. How many times has – – run away? I


I
 Number


I


C. How old was tha (last) time ran away? ~ 

I Years
 I


4,	 Does take any medicines or drugs to help ~ 

control activity or behavior? I lY 2N 

1
 6a. Has ever seen a psychiatrist, psychologist,


or psychoanalyst about any emotional, mental, or ~ , y 2 N (5d)
 behavior problem? I


b. Is still seeing this person? I


I Y (Section O, 2N 

/ page 32) 

I
 c.	 When was the last time saw this person? I
 1 •l More than 12 months ago


i a •l Within past 12 months (Section O, page 32) 

d,	 During the past 12 months, have you felt, or has I


anyone suggested that needed heip for any I , y 2N


emotional, mental, or behavior problem? I


OOTNOTES 

c 

99 
1 

Section 0. BEHAVIOR PROBLEMS INDEX
 1
 I


CHECK 

~1 ➤Refer to age of sample child. 

I 

I 

I D Under 4 years old (Section P, page 34)


l~E~ 

I 2 ❑ 4 + years old (INTRO) 

Hand card B I


INTRO - Now I am going to read some statements ~


that describe behavior problems many children have. I


Please tell me whether each statement has been I


OFTEN true, SOMETIMES true, or NOT true of - – \


during the past 3 months. I


The first statement is: “Has sudden changes in mood ~ 

or feelings.” Has that been OFTEN true, SOMETIMES , 

true, or NOT true of – – in the past 3 months? t 

I Sometimes Record Not true response and continue with statement 2. I Often true true 

Read list repeating categories andlor time reference ~ (A) I (B] (cl


as needed. I


1


I


1. Has sudden changes in mood or feelings. I 10 20 3CI


1


2. Feels or complains that no one loves – –. 1


I 10 2CI 30
 I


I


3. Is rather. high strung, tense, or nervous, I


I 10 2EI 30
 1


I


4. Cheats or tells lies. I


I 10 2EI 30
 I


1


5. 1s too fearful or anxious. I


I 10 20 30


[


6. Argues too much, 1


1’


1 In 2“EI 30


I i I


1
 7.	 Has difficulty concentrating, cannot pay I
 attention for long. I 10 20 3D


I


8. Is easily confused, seems to be in a fog. I


I	 10 20 30
 I 1


, 9. Bullies, or is cruel or mean to others. I I I
 I


la 20 30


10. Is disobedient at home. I


I


I In 20 3U


11. Is disobedient at schoo!. I


I


I 10 20 30
 I


12. Does not seem to feel sorry after – – I


misbehaves.	 I


I la 20 3E’J


I


13. Has trouble getting aiong with other children. J 

I 10 2CI 30


14.Has trouble getting along with teachers.	 ,


I


I la 2EI 30


1


15. 1s impulsive, or acts without thinking. I


I 10 2C 3EI
 I


16. Feels worthless or inferior, I


I


I


[ 10 I 2D I

Section O. BEHAVIOR PROBLEMS INDEX – Continued 1


I Often true Sometimes Not true I true 

I IA) (e) (c) 

I


I


17, Is not liked by other children.	 I 10 20 30


I


I


18.	 Has a lot of difficulty getting – - mind off I


certain thoughts, has obsessions. I In 20 30


I


19. Is restless or overly active, cannot sit still. \ 

I 10 20 30


i


I
 20. Is stubborn, sullen, or irritable. I


I In 20 30
 I


, 

21. Has a very strong temper and loses it easily. \ 

I 10 20 30


I


Z?. IS unhappy, sad or depressed, I

I


I In 20 3CI
 I


I


23. Is withdrawn, does not get involved with others. ~ 

I 10 Zn 30


I


1
 If child is 12+ years old, go to 29. I


24,	 Breaks things on purpose, deliberately I in Zn 30


destroys – – own or others’ things. {

1


25.	 Clings to adults. I


I


I 10 Zn 30


I


26.	 Cries too much. I€

I€

I In 2E 30


I


27.	 Demands a lot of attention. I


I


I In Zn 3CI


I


28, Is too dependent on others. I

I


I


I 10 a an


If child is under 12 years old, go to Section P, page 34. ~ 

Z9. Feels others are out to get – –.	 I In m 30


I


10, Hangs around with kids who get into trouble. j 

I 10 3!J


I
 I


11. Is secretive, keeps things to (himself/herself). ; 

I in Zn 30


I


I
 12, Worries too much. I
 in Zn 30
 I


I I I


‘OOTNOTES 

101 
---

--

Section P. SOCIAL EFFECTS OF ILL HEALTH


I
 .	 A child’s illness or disability may causo problams I


for other members of the family, Tell me if any of I


tho following things have EVER happened I


because of a heeith probiem of I


Because of a health problem of -–: I

[ 

a. Has the family moved to a differant home? I 

lY 2N 

b.	 Has a famiiy member not been abie to take a job? I


I


I lY 2N
 I


I
 c.	 Has a family member quit or changed jobs? I


I


I lY 2N


I


d.	 Has a family member been forced to take a job I
 when he or she otherwise would not have? I


I lY 2N


I


e.	 Has a family member ieft home? I


“1


I lY 2N
 I


f,	 Has a famiiy member gotten a divorce I 

I
 or legal separation? 1


I lY 2N 

Because of a health problem of -–: I


g. Has the famiiy been under severe probiems I

I 

lY 2N making	 ends meet? I


I
 h.	 Has the family or any family member made some I


{other) major change in regular ways of iife? 

I

I 

lY 2 N (PI)


1


i. What (other) changes were made?	 I


1


I


I


I


1


I


j.	 Were any other changes made? I


I


I Y (Reask Ii andj) N


I


t


CHECK 1 

i 1 � “N” in 1a above (Section Q, page 35)


ITEM PI b Refer to question la above. I 8 � Other (2)
 I


,. When the family moved because of health I


1 probiem, was I � Near services
 it to be nearer to certain special I
 services that were needed, was it because the I 2 � Could not afford


family could not afford to stay where it was, or I 

I 8 � Other - Specify~
 was it for some other reason?
 I


h-lark the most appropriate box. I


‘OOTNOTES 

102


I 
--

Section Q. SLEEP AND SEAT BELTS I


I


CHECK I I � Under 1 year old (Id)


ITEMQ1 F 

Refer to age of sample child. 1 2 � 1 + years old (la)
 I 

If respondent asks, question 1refers to sleeping I o � No usual time 

patterns on school CYaysand nights.	 [ 

1 I“ � Before 8p. m. 

la, About What time d~e~ _ _ u~ually go to bed 

I 

I 2 n8–8:59p. m. ( /f5+.’ on school nights)? I 3 lJ9-9:59p. m. I


4 � 110-10:59p. m. : 

I 5 � 11-12 midnight 

I


I 6 � After midnight


b. About how many hours does – – usually SLEEP ~ I � Less than 5 hours 

each night?


I z � 5–6 hours


I


I 3 � 7-8 hours


I 4 � 9– 10 hours
 I


I 5 � 11+ hours


I


c.	 Does —— usually take naps during the day? I


I


I lY 2 N (2)
 I


d. Counting daily naps and night-time sleep, about I I � Less than 8 hours how many hours in all does - – usually sleep I each day? 2 l_J8-9 hours ! 

I 3 � 10-11 hours


I


I 4 � 12-14 hours


I 5 � 15+ hours
 I


I
 2a. During the past 12 months has – – walked in I 4 � Child does not walk (3)


sleep?	 I


I


I lY 2 N (3)


b. About how many times has – – walked in – - I 

sleep during the past 12 months?
 I Times


Range acceptable I


I


la, Does – – usually sleep in one room or in I 

! 1 � One room different rooms?
 I 2 � Different rooms
 I


I


b.	 Does–– usually sleep in a room alone or I

I I � Alone (4)
 share a room? I


I 2 � Shares
 I


I


I 1 •l 8rother(s) C. Who (else) usually sleeps in the room with — -? I 2 � Sister(s) 

I

I 3 � Father 

I 4 � Mother
 I


I e � Other(s)
 I


I


d.	 Anyone else? I

I Y (Reask 3C and d) N


1


4. When riding in a car, does – – wear a seat belt or \ I � All/most of time restraint all or most of the time, some of the I
 time, once in a while, or neveri’ 2 •l Some of the time 

I 3 •l Once in a while
 I


I o � Never


I


b COMPLETE ITEM 70N PAGE 1 (3FCHS. 

103 
1982 

The 1982 survey also included special health topics: health 

insurance and preventive care. The questions on these two 

topics were not in separate booklets but were included as 

individual sections within the core questiomaire. The health 

insurance questions were asked of all household members; “the 

preventive care questions were asked of household members 

who were 17 years of age and over. 
--

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

--

--

--

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

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

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

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

--

--

--

--

--

---

--

--

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

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

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

— 

M.dic.r. I. a S.. ml S.c.rity h..lth ,. mm... program la di..bl.d p.m... and I.r p.r...s 65 y..r. old .nd 

P..pl. .ov.,.d by M.di.ot. h.v,, . ..rd th.t looks I ik. this. >how cord. 

o, s .nyon. i. I i. family, thot 1$ lr~~sJ, now ..YGA by hkdic.r.? k=E=HEALTH’N’”

b. L-ZIG~; Z~v;;.JT-iZr%-G; 7n-~GZ<.`LTS~;Z ----" ------------" ----------------=----- ~ --N04}-loK — Ask for each Derso. w!h , ‘Covered-. ,,, lb 1“2,. 1, new .o. ”.d by ~. ~.” .{ S.C,. I S.<.,, W M,dic .,. Ai. h w,, 10, ho,,,,.1 b,ll, ? 1. I ny,. 9m0K 2nN. Mwk b.. m person.. .il.rin.
 -------.-- . .
 b. I. new ..v. t.d by that part .{ M.dic. m which p+y. {m doctor.. bills? This IS th. kdi. dr. III.. (et b , f-J Y.* snOK 

which	 w sore. .q... y SW, ! pay . ..rloi. om.unt ..ch month. Mark box m pcfson’s col.mn. 2n No — 

Ask for each person wtth a.DK.a m 2. end/or b 3. 

3.	 M.y 1 PIWS. . . . th. S.ei.l S...tity M,tdic.t. card(,) lot (and --) t. d.t.smi.. tb. typo of c.varaca? 

Transcribe the m/cmQt80” from the cmd or mork the ..Cmd N.A.,. b... 

W. .m lmt.ra.td {. .11 k,.J, �f h..lth ins.ro... PI.., . . ..pI th.s. .hi.h P.Y ..1, I.. . ..id..ts. 

~. (Net . ..n!imd NAi.. r.) IS any... in *h. family new c.v.r.d by e h.ohh i...ran.. 

plan whir.h pays my P@ .10 h.spitel, d.ci.r’$ or s.qe..’s bill? mYe:__-------_!:l~-~-!:l .-. .-------------------_- . b. Wk.t I* Ih. nam. of th.~l ..? Record m T’.bf. H.I. .-. . . 1. ..yorw 1. A. fcnmly new ..v.r.d by ..y .AI.r h..lth i.s.m.c. plan 

which pays ony pat of . h.spit.1, doctor’, ., s.w...,. bill? V Yes [Reask 4b and c) (_J No (S) 

/ . . ..... “.L I., .,, ! i h.. De-.. ,hs. .1. 7	 1. . . . ...4 ““d.. *I. (mm) 7. ,~ Cw.r.d lNP1 

plan? 2 n No<. . ..ted lNPJ


Ua,k baa m
 @“c#s COt”,ln.


D-.thl. Pt.” m, .“” pm.. .1 7. IS ,...d.d h.. bl,.l *SW . ...? ..d., rhi, (“L-J 7. 

SO. W*, thy . !Iy@l P$n..bmi”., d ,h,ou*h I ~ Y.* ZnNO 9(’_JOK s!.. ? .- .-. . . .-,,.,., “ ..,.”, 

PLAN 2 =1t+. I n Y,,
 . Mark bo. m -:--------~-Q-y_f:y - :-g..yc-(s~ b. O-, ,h,, ,1.. W, any ~,, .6 doc,o.e. c. Fntx.1% Co(”m.
 b.	 1, i, n-- a,,l.d ,bt..* . . .mplq., ,.q...h hill, {m .PW.,,..,? “ ..mn, , n Y.. tn~o 9~DK t ~ Yes l~No $nOK — 

�LAN 3 6.. Da.. A,, pk. PY ..y m,, .{ 7. 1, . . . . ..d 

h.. p,,.l ..pm...7 MA; !hl. (km] 7. 

>. w.. !klo ,@auJ ph. .*,.,.,4 ,h?..,h , ~ Ye, 2nt4. SCOK .“ .m,l.yw “ ““la!? . U,,h W v“ I L~ Y.* 

----------lfl!l!% - ST+! !:J b. Da, ,h,s d.. P.y -q pa,, d 40C,W!. w PWsm 3 Gol”nm. b. 1, ,, .4” ..” IA ,h,ov,h . . .,”,lq., ..,9 . . . .. b!ll. Ici 0F9m,a”.? 

Rewm I and 7 for each person md dcce,mme ,/ .-Co.ere& by e,thef Mtd#cme .nd/or Insurance, E I � c--~ ccv.,d IMII or ‘. Not Cov<,ed... Not (NPJ .nde, 65 lNP) 

:8 No, .ov.,.d 6S .nd o“” IMP] 

Ask fW each person ..NLTCCovere.#- ,r, Ml. lf .. Not covered 45 and over... mcl.de % Medmm... s=. 1134 S67S tiny p..pl. de net carq Iwollh i.s.ra.c. f., various ,“s.,s. Hmd Card N. , 

b. which .{ th... t199.m..Is d.s.tib why is ml ..v.md by .SY h.elth i.s.m.c. (or fkdfcnm)? 

Amy -------------___ .th., t-sat? .---- . ..----- __---- ____ ---__ -__-- __-_ --gf~lf_ql-r.g~: $gy:~----- (1Y . 

MUk tax If only one reason. 1/ “No; covered 6S and over, ,! in Ml, ,nc.lude ... . AWd!care... b. 00only ~ =-* b. Wfut i. th. klA!N . . . . . i. ..I c.v.t.d by any h..ah$ in..rmc. (.r M.dicm.)? 12345678 

I — *lly 

,.”.( .,*., ,,.,, ! ,4...0,, 

105 
---- ------------------------

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

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

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

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

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

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

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

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

--

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

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

M. HEALTH INSURANCE PAGE. Ccmfi..4 II 9.. D-s ..PW In Ibis haily n- *...,.. .ss,sto... &rou& th. “’Aid ID F.mili.s 

With D.p+mII Chil&.m’” Pqmm, s-tiIm.. ..11A “AFDC’” * “AOCe~ 

.------.. ----------------------. ---. -----. ----FJ-E:------E:Y-!!! --r::-ggL 

b.	 WIi.h (.dwr) f.milr m-bus .,. i.cl.i.d i. *. A6DC .s.islsmc. tqmontt *. I ~ AFOC mark ‘, AFDC’. bo. m Person’s column. 

c. & �y oth.r Immily membts inchded i. Ikis ~mm? 

m Y.. (Reask 9b and C) ~ No 

00. 0.4s ..pn. i. this kmilr - m..i.. *. “’S4***I k.rily 

III.*-” or “SS1” go:i.colued b-k? 

n Yes mNo(lll � DK(IIJ ------------------.-----

b. * [.1..) rod..s Ibis .Imck? MWk “SS1’” t-ax m person”s cofumn. lob. * (--JSsl 

c.	 Ally-. .1s0? 

~ Yes (Rcask 10b end c) O No 

la.	 Thor. i. . nati.nd F.qmm e.lled M.di..id whi.h PY. f- hnlth cam 

f“ ,-.~. in a. (I. this St@o ii is 01*0 coll~ (Ue}). 

Owl.. *. P.V 12 rmath., h.. �ny... i. Ibis (amity ..c.wcd h.slth 

.-I. which has b-. w will b ynid fw by M.dic.id (.I (nge))? 

m Yes ~No (121 ~OK (12) 

b.	 ‘ah. -s tbi.? AWk “ Afedwkwd’” LVX m Wson”s column. trb. I (--J I’tmd!cald 

c.	 Any-. �Is.? 

I_J Yes ,Reosk I lb and c) n N. 

!e. D-. �nyone i. he f.mlly now Its... Mdicsid (u (gt)) ..rd which 

Iwks Iik. thit? Show MMcmd C.nd. 

m Yes fiN0(13) ~DKf13) 

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

b.	 WI. i. AIis? Mork “’COW” box m ocrmn’s column. 12L I m Cud 

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

c. AIIy*w .1s.? 

~ Yes (17eosk 12b tid.1 D No -

Ask M each Persw w,th “’Cord’” III 12b: lad. c Wdt.atd cxd s“” 

A bky I ,109*. s.. (.”J --) CA(s)? , n CW..1 J 

.+drk apixowate k.az(esl m pefsds cok+in. z m Exc...d 

1 I--J M. cud s“” 

.mti,+zI 

splat” 

h.	 IS ..7... i. III. family n- c.v.nd by ..Y tibac p.bli. 

cssismaco pcqmm tkt psys f“ k-itk .-.? u fka (Mrt � DK{Neai 

----------------------. --.-. -------------------y::;_.-------*j------y----­

b. Silm is this? Mark ‘“Othe( PA”” box m pemon”s column. 13k. I m Otb.f PA 

-

e.	 Amy-. .1s9? 

~ Yes (Ife.?k 13b ..4.) n No 

,.,” .,,., ,,..,, ,H.. a 

106 
--------------------------------------- ----------------------------------- ---- -----------------------

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

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

--

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

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

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

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

-- --

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

--

1, “.. ., . . . ,.,., ,.. ..,-- c. . . . . . . . . , II a. nCAL I n Imwnamx rmx, t..nwww 

Ik.	 0-s �mv.na im th. hmily �ew rm.iv. -ilik-y rotimmti WY-M 

from an” b.dl d *JI. And Fare., “ . @n*i.” (m- lb. Vclwc”s 

Addaislrdim? De w idM& VA diambiliv eo-~*.don. ~ Yas � N, (IS) O DK (15) 

-

b.	 Wk. is Atis? 

~rk .“Mil. ret./VA pen.,. bx ,. puson. s column. 1A. , 0 ?411.ml.nA P“. 

c. Aay.m d,.? 

nYes(Re0$b14bdc)	 ONO .---.---—----—--------

Ask fcf each pc?son wlh Wil. rW./VA pen... in Mb: d. in-F9m. 

4. Wick k, “c.ivg - & Arm6 Farcas “li,~, h. VA ~SiNl w ti? 20VA 

Sauoth 

k.	 Is WY- i-h Ismily w .mvmd by CJW6W.VA, whit; is mdi.d 

199”m9c. k &@n60us - SU9viws 04 dl.abti — 

Ig	 Y. a No (16) � OK (16) . -----------------------

b.	h i* (41s? 

w “CHW-VA”. h. in WS#$ d.- 1s I a CW-VA 

. -------—--------------, 

c.	 klyoac �IS*? 

~ Y.. (Rtosb lSd and b) (_J No 

6a. lsa -imlbofuil, wwcowcdbymy.k _&_i&s 

h-l% c.mf-.ilitW7&pMdcml. -.9rdv0rs J“Jll*t7?a9”.? “ya 0No(M7J � 0K(AW z------------------------------:---------------------------- ----------_--------_-. 

b. VfkO i. hi.? 

Mak .“Hwlth Cme”” lw in won.s column. Mb. ii-g HO1dlc=M 

-------—-------------. 

c. AWsm* �I..? 

~ Y= (t7wSk 160 ad b) � No 

M2 ,n&Fbal-(f7) M2 WWt. .“AF”’ box+ave xrsds cohnm. 2 u a- (NPJ 

k D-$ )W9 � diltiti~ ddd t. nwic. h lb Ard F-c.* d lb Unid -s? 17.. !cJy2 a N. (NPJ -, . . . . . . . . . . . . . . 

b. Dms _ red.. .-p+.. atl.a f., this diaabiliq k t~e Wtims A&imi$tmtkd L 1 � Y.* 

Znllo 

DOTHOTES 

. . . . 

107 
------------------------------------------------------------------------- ---- --

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

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

1C9.

N1 O!; 17-39. SV.,hbl. (31 

t ~ 40 ati .“-, ,v,,l.bl. If) 

N1 Refer w age. ZG ‘7 -d O-I. ..llb..~ 

rmuwed oipI 

3 ~ Ci!I.r (HP) 

1.	 Ab.w ha I.ay Ins il h. sm.. yea hsd �. .I..tmc.rdicqt.m, .r EKG, which i...ls.s pi..iq wit.. . . 1. w ~ NW= 

tk .Im$f .!!4 �m.? w IZ LCSSl~n I Y*U 

— Y*-% 

4.	 About how INIS fm. if bun sine. w had 7W blood F.I.SW. tak..? 

4“ :Qh:m= ! ,.” 

— .-,s 

Ee, N,.* y.W EVER kcm told by � 40CW, thot you M high blood ymss.r.? 

. : %rn.?_____ 

b. thvw you EVER bnri *old by. 60.w dmt YOUhad h,pti,.,si.n? N. (N2) 

6.	 &. YU NOYf t.kiq ..y mdf.ina prsscrtkcd by e 40CW f- y.ur [I@h blood pr.ssw.,%rpwt.. siem]? 6. , ,: Y** (.+7) 

2 Ig N. 

7..0. YW still fwv~[hi~h blood pmss.t.fiyp.asiml? 7.. I n Y*S (f/2) 

� No 

� ox 

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

b.	 1. this caditian camrl.~ly ..md w is I* .nd.r control? b. 2 e CW*6 , ~q Und” . ...,.1 

N2 2 Fenmk (8J

NZ I Re/tr ,. sex. , Y L *k (1OJ

8.	 About % I.ny b. it b. sine. you kd o Pap S-C t.st? 

8“ ~8~~~~*.,y..r 

ma.D. pu k“. .y*Q1.Is*s Of Cwt.ct I.na..? II-:__f:---------

b. m 

‘lEl’=’ b. About hw l.IW h.. it bN. sine. you hod your .y.s .xsmirmd *Oa- if y.. .ndd gl.ss.t (“ new s1.ss.s)? 

Red if oze 17: l.clmda ..y .Y. .x.m. gi..a i. s.lmd. **B:=*. , ,*-

— Y*-

I n %11R,,P. 

RS1 RS1 —

P.”. No. 2 � Proxy m,.sw 

8 d R.so. { 

,0”” “,., ,,.rx {*4,, 

108 
--

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

-- --

— y-. 

W.	 Lkriw * p.! 12 RNA., that is, sin.. ( 12 nw!h date) Q y-r .s.} -s *kn m. doctu f-. 12.. Y.* (13) 

RWTIMSJ phyticcl .IC.I-!I.., M Ii, nti k. sateulot illrnss k (u. ~-l chocksp? :% 

Red II am S- lb: l.dd. CWNM physk.1 . ..-4-*4Ms si.- i. school. ,. -5i:-._i:_-G..iiitii ;7"i:1:-i;,-Gi:"-;-a-i2-Gj&-m-;&iL-&i;G;iiii7Gzi­ ;-___:i t. moYkRcod ii wc S-16: lmcl.d. r.utk phvsic.1 ...mhdoa. siuni. s.hul. I	 I —’- , 13. Abx how .Id w.. whan FIRST wont t. . d..tist? 13. = o~*-

1 I — ~-.l~ 

I 

RS2 RS2 _ P“,. NO.4 Rue. 

I i [ 

FOOTNOTES 

.0.” .,,., ,,.,,, ,44..., 

109 
1983 

The sample for the 1983 NHIS was composed of approximately 41,000 households containing about 106,000 persons 

living at the time of the interview. In 1983, data on acute 

illnesses and injuries, disability days, limitations of activity due 

110 

to chronic conditions, prevalence of selected reported chronic 

conditions, respondent-assessed health status, and measures Ot 

health care utilization were collected. The special health topics 

covered in 1983 include doctor services, dental care, health 

insurance, and alcohol and health practices. All of these topics 

are contained in a separate booklet. 
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

O.M.B. No. 09370021 ADProval Exp,res June 30.1984 

NOTICE Inlmmatzon contatned on this form which would permit identification q. I R?So 2. R.O. “umber I 3-4 3. Sample 1.-5.:7 . of any mdtwdual or eslabbshment has been collected with a guarantee that it WIII 

be held m Wet conhdence, will be used only for purposes stated for this study. Book _ of 

and WIII not be dmclosed or released to others without the consent of the 

mdwdual or the eatabhshment m accordance wnh section W@(d) of the Public — books Health Serwce Act [42 USC 242ml. 

:m:BglS-l (SS} (1983) 4. Control number 5. Interviewer’s name 

U. S. DEPARTMENT OF COMMERCE PSU ~~ Segment ~ Serial I Is–fe UUREAUOF WE CENSUS I 1 

ACTING AS COLLECTINGAGENT FO.$1THE I I 

U S PUBLIC HEALTH SERVICE I I 

, t


NATIONAL HEALTH INTERVIEW SURVEY I I 

I I 

SUPPLEMENT BOOKLET I I 

I I 

I t 

I I Code -17-18€

6. Status of supplements I 19 FOOTNOTES 

1 "; Complete interview [allappropriate pages completed~ . 2 ‘ Psrtiel interview (some but not all appropriate pages completed) Explain in footnotes s . Noninterview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . } 

7, Use Flashcard X, Y, or Z as indicated on-HIS-l Household Composition Page. 

Circle thatletter befow. Also, circle thetota/number of persons. ‘, & 

CARO X CARD V CARD Z 

Ifthenumber the following person(s) If the number the following person(s) If the number the following person(s) 

of persons will be the sample of persons will be the sample of persons will be the sample 

Is – person(s): is — person(s): is — 

1 — 1 

1 2 2 2 

3 3 1 3 

2 4 3 4 

1 and 4 6 2 snd 5 s 

3 and 6 6 1 and4 6 

— 2 and 5 7 3 and 6 7

1,4, and7 a 2,5, and 8 8 . 

— 3,6,and9 D 1.4,and7 9

2,5, and8 10 3,6, and 9 10 

1,4,7, and10 11 2, 5,8, and 11 11 

3,6,9, and 12 12 1,4, 7, and 10 12 —— 

2, 5,8, and 11 13 3,6,9, and 12 13. 

1,4. 7,10, and13 14 2.5, 8,11, and14 14 

person(s): 

1 

— 

2 

1 and 4 

3 

2 and 5 

1,4, and7 

3 and 6 

2,5.and8 

1,4. 7.and10 

3, 6, and 9 

2, 5,8, and 11 .. ——— — . . . . . . . 

1,4,7,10, and13 ..— — 

—-3.6,9, ——- and 12 ___ - ._. . . .—

3,6,9, 12, and15 15 1,4,7,10, and13 15 2,5, 13,11, and14 

If more than 16 persona, call your regional office for sample person selection instructions. 

a 

111

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--

M. DOCTOR SERVICE PAGE 

Refer to “2. Week Doctor Visits Page, ” and complete for � No 2-week doctor visits for 

each vls;t, or mark box. famdy (IW2J 

Ml I Refer to question 2 on.2- Week Doctor Visits Page end mark appropriate box. 

I 

Hand calendar. 

Refer to questians 1 end 2 on “2-Week Doctor Visits Page” for date and t ype of health care tacility. 

la.Eadloryout# mothatduting thotwowacks wtlindh ti~WstcaWw, Waiw~ 

tsdth cam loss(@#)/lsst wooklthe wook bofom I=stl. In what C~, county, �rd State is the 

fpface in 2) Ioatod? 

b. How long dti it tako for -– to-t to this Q&) this t3m8? 

Hand Card M. 

C. Which Mt.rs �Xf4!*in why went to this (=) this time? 

Mark all that apply. 

d. Any otfr.r raason? 

00TNOTES 

,M”#5 , .x,., 98,,,3 ,4s3, 

— 

i 

— 

Ia. 

b. 

o. 

d. 

DR VISIT 1 

1 3-4 &. _ 

P*rsOrs numbw __ LL6 

I 1 r: Telephone Cal! (Next DR vIsIr/ ‘– ‘-’- 2 r] Home visn 

8 ~ Other(l) 

:!tv -—.

I 8-11.— 

———— — ——­ :ounty ..——_— p2.Ti 

Mata I-!?:2! 

~17-ls 

—. Minutes 

I D A. Place used for neadv %11medtcal care I A 

I n B. Especially good for freming thla ~:z{. 

condition . —— 

L_ 22 I ~ C. Convenient to home 

I ~ D. Convenient to $wmk,khoppmg [-23 

fl E. Referred bv a doctw	 [ 74 

, –25 

D F. Raferred by friend/relative 1 —.. 

~ -:~6-” O G. Only place ava!lable .—— 

~ H. Health insurance plan requires I- 2-L-

~ 1. Emergency [:= 

~ J. Other (Sgecifyl > [::m”— 

) 

I 

s 

112

M. DOCTOR SERVICE PAGE, Continued I PERSON 1 I-Al 

M2 M2 I n ED box marked (2) & 

Refer to “ED” box abova parson’s column. � No 2-week bed days for 8 m Other (fVP) family (Next page) 

1 

Hand calendar. 2. 1 � Yes ~6 — 

2.	 Earllsr you told m. thst durlrrg the 2 weeks outlirsuk in rad on thatcalondar, –– stayed in kr.d more them 2~N0 

hslf � da~ bacmrsa of illrwss or inJsrry. Did � doctor �dvis- –– to stay in bed durlsrg that tire.? 9~OK 

FOOTNOTES 

ranMM,st,sB,t1983,,3 1483, 

113 
-- --

RT 83 

N. DENTAL CARE PAGE 

Handcalendar. Thes*next question; areatitidantaf cam*ti*tiwtk 2w*stiHtiindmtht c~. 

la. DURINGTHOSE 2WEEKS, didsnyoncinttifamily ~to~tist?lwltiaW 

tYPW Of dentists, such �s orthodontists, oral susgaons, �nd all othw dental 

specialists, �s well ss dental hygienists. •l Yes � No 131 

b. Whowasthis? Mark’’Dentaf vmf’’boxmpersoscocumnmn. 

c. Ouringthose 2wcaks, tidanyona@lse inth#ftmily gotoadcntist? ‘tl Yes fReasklbandc) � No 

d. Ask/oreachperson wlth’’Dent81v6,t’’m lb: Oufingtbsa 2wc6ks, howwnyti~sfi --~toa&tlti? 

NI Refer to “Dental visit” m lb. 

N2 Refer to age. 

Complete a separate column for each 2. week dentd v;aft. 

2a. lEarlierlwastold --wenttothekntistdu~ tti2w*wridwnning Motiy;(@e) ti~tiy, (@e).l 

{Now I �m going to read � fist of danld smvicw. } 

When went to the dwrtist [[tho last timeNfw time bafora that]), did Isavti 

A, h x.ray taken? 

B. A tooth filled? 

C.A teeth pulled?€

O. Any other oral surgary?€

E. A fluotida traatmamt?€

F. Teeth cleaned?€

G. Teeth atraightaned, that is, osthoslontia?€

H. Treatment for gums?€

1.Work done on a complsde denture? 

J. Wmk dons on a pastial dantum? 

K. Wsak dons on 8 briiga? 

L. Wosk dmw on 8 crown or cap? 

M. Work done on � root canal? 

N. An examination? 

O. Something ala. dcasa? ISpecdy for appropriate visit, THEN reask 0) 

b. Owingthatviait,d d--saearagulardantiatoradantalspccicliat? 

Ask only d Wental specialist” m 2b: 

c. Whatkitsdofdantal qaecialistdi d--aaa? 

d. Howlongddittaka for-- togcttothisdantiatthiitima? 

N3 Rewew ldforadd{t(onal vJs!tsfor th;sperson. lfaddft;ona/ visits, reask2a- dforeachvis;t. 

ImMMIS],sal119a3C83 ].a3, 

PERSON 1 I 3-4 

— 

b. lfl Oentalvmt 5 

-1 

d. 91 ~ “Dental v!slf ’’marked m lb IN21

12	 on Under 17 (2/ ~s 

I L317 and over, available 121 

2� 17 and over. callback remmd INPI -i J 

123 

A. X ray 10 

B. Fdled 11-12 

c. Pulled 13 

D. Oral surgery 14 

E. Fluoride 15 

F. Cleaned 16 

G. Swa!ghtened 17-11 

H. Gums 18-20 

L Complele denlufe E 

J. Pamal denwre 23-24 

K. B,idge 35-’2s 

L Crown 01 cap 27 

m. Rmd canal 2s-29 

N. Exammauon 30— 

0. i LSpecdy. THEN : 31 : 

r visit 1 

Visit 2 —— 

Vlsll 3 

teask 0) Y 

123 

b. 

EEEID::S!-E 

LlK!!5 

c. Visit 1 

VISI12 

vow 3 

d. visit 1 — Minutes I-!!!@! 

Vlsll 2 Minutes 

Vtslt 3 —_ Mmules 

I [] Self ResD. & 

z [~ P,oxY (Footnore reman tf f 7 and W’erJ — 

114 
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7 

N. DENTAL CARE PAGE. Continued PERSON 1 

Mark box if .’One year old or under 1.” 38. 998~ One year old or p7.7s 9 

!Sm. Duringtha past12months (that Is,shrco (l Z-month date)a Yom�go} �bout how msny visitsdid -– under 1 (W) 

makato � dentist?(Isscludotho(numberin 1~) visit(s)YOU �1--fv told mm •~~.) ___ Visits 

Ooor]None 

Mark “’2.week dental visit” box in person’s column if visit(s) reported in Id. b. I ‘;-] Past 2 weeks not 1.-Mb.	 ABOUT how long ha$it Itaensir=. LAST wont to 8 dentist? reported (Reask 7) 

2 ~ ] 2.week dental visit 

3 [1	 Over 2 weeks, less than 

6 months 

4 r ] 6 months, less than 1 year 

s [–J 1 year. less than 2 years 

6 [ 12 years, less than 5 years 

7 m 5 years or more 

o [ ] Never 

4W. Doss �ryorw Inthafamily usatoothpastewithfluoride? u Yes � No (5) � DK (5) 

b. Who h this? Mark “’Toothpaste” box in person’s column. 4b. I n Toothpaste L 

U. Anvorso �tS*? n Yes (Reask 4b and c) � No 

mh.	 D-o �nvone Inthofamily usofluorfdadrops, tablats,or �ny � Yes � No(6) � DK (6J othor fluoridosupplomontswhich �reswallowad? 

b. Who Isthis? Mark “Fluoride supplements” box in person’s column. 5b. I ~1Fhmide s.ppkmwma L+ 

c. Anyorw �lsa? � Yes (Reaak 5b and c) � No 

aDa.	 Doss �syorraInthaf-milv uso � fluoskdomouth rins=which is � Yes � No (7) � DK (7) NOT 9Wd10WOd? 

b. Who 18this? Mark ‘“Fltmride mouth rinse” box in person’s column. 6b. I [ ] Fluoride mouth rinse I

& 

c. Anyom �lsa? � Yes (Reask 6b and c) � No 

17a. Is thata�nyonaInthofamily who haslostALL of hisor hor toath? � Yes � No(NEXT PAGE) 

b. Who isthis? Mark “Lost all teeth” box in person’s column. 7b. 1n Lost all teeth L -v_. 

e. Anvona �Is-? � Yes ;Reask 7b and c) ~ No 

Ask 8a-f as appropriate for each person with “Lost all teeth” in 7b. 88. I ~ Yes 2[]N0W)i — !!.5— 

I 89. Ltoaa haw falaotosth?

b.	 Ooaa hwa an upp.r plats, � 10-r pfata,or both? b. I [3 Upper 3 ~ Both l--~~. — 

2 m Lower 

a. Doaa usuallywaar -- -plate(a)whllo �atirrg? C. I r:]Yea 21JN0 

l.__!!!­

d. oma usuallywom -- plate(s)wts.rsnot �athwt? [~ 

d. Irlyes 2i”]N0 

~ . . Doaa -- naadrwwfalsotaath? � . 1nyeafNP)2~lN0 

f. Ooths on-s haa mad rafitthsg? f. I [3 Yes 2~N0 I_.?!!_ 

M3nwlw IIsm ,1803113 14031 

115 
— 

Lx 

q 

P. HEALTH INSURANCE PAGE 

Read to respondent(s): 

Mxdicara is � Social Security health insurapca program for disabiad persons �id for psrsorw 65 yoms ofd 

8nd ovor. Poopk covarcd by Mxdicme havo � card that locks like this. Show card. 

1 � . Is �nycns in this family, thst is (read names), now covomd by McdiGara? � Yes D No (4J D DK 

b. k –– now covorui? Mark box m person’s column. 

Ask for each person with “Covered” in 7b: 

2a. k –– now coverod by tha pmt of SCCkl Sacurity Msdicaro which psys for hospital bills? 

Mark box in person’s column. 

b.	 Is –– now covor.d by thst part of M.dicmo 

which —— or soma qfoncy must pay � cwtain 

Ask for each person with “DK” in 2a and/orb: 

3.	 May 1 PIOSSO sea tho Social Security Medicaro 

Transcribe the information from the card or mark 

which pays for doctor’s bilk? This is tha Madicara plan for 

�mount �ach month. Mark box in person’s column. 

cwri(s) for –– (and –-) to datwmirvo tha typa of covorage? 

the “Card N. A.” box. 

W* �o intwost.d in �ll kinds of hoaith insuranco plans �xcept tho80 which pay oniy for cccidxnts. 

48.	 (Not counting Modicwx) k �nyono in tha family now covored by �health insuranco 

plan which pays �ny part of 8 hospitsl, doctor’s or surgson’s Lriil? � Yes D NO (P1 

b. what is tho namo of tho pl~n? Recofd in “table H./L If MO; ~hafl ~h~ee~@n~, ~O~t~P& {2.. . -

G. IS Snwcno in tho famiiy now covwed by any othor hadth insuranco plan 

which pays �ny pwt of � hospital, doctor’s or surgwm’s bill? � Yes (Reask 4b and c) � No (5) 

TASLE H.L 

PUN 1 10 6a. DOcs this plan pay �y part of hospitxl 7. IS--COWXW 

50. Was this fn&m~)pkn obtairmd through �xpansa*? under this 

� [name)@an? n �mpkryw or union? 1 � Yes 2DN0 eDDK \ 13 —— 

1 � Yes 2 � No (6J aDDK(6)[ 11 b. &?&&ii ~m pa~a;y “+ ~ &–t&’; & - - Mark box in 

Pwm:’: b.	 Is it now cxnfad through an �mplayar or unioi?- mrrf#Hm’s bins for Opar*trena? 

1 � Yes 2DN0 90DK 12 1 •l Yes 2DN0 9EIDK I 14 

PLAN 2 16 6*. Does thk plan pxy �ny pa3tof hospital 7.k--c0ve# 

Sw	 Was this (=I plan abtdnad throqh �xpansos? Undxr this 

�n �mpkyxr w union? 1 � Yes 2DN0 9nDK 1 19 @~) @an7 

1 � Yes 2 ~ No (6J aGDKf6)l 17 Mark box in b. L&& this plti Wy”X;y PX; of &’toc’s or “ - person’s b. Is it new cxwied through �n �mpk.yxr or union? surgeon’s bilk for epxrxtkn*? column. 

1 U Yes 20N0 9nDK 18 1 � Yes 2DN0 9,D DK 1“ 20 

PLAN 3 22 6a. Does this pkn pay �ny part of hoapftxl 7.19 --c0varad 

6-. Was this l-) pkn obtxkwd through 

�n �mployw or union? 

�xpansas? 

1 � Yes 2DN0 9CIDK L 25 

Undxr thk 

(name)pfan? — 

1 •l Yes 2 � No (6) 9DDK(6J[ 23 b. Does this plan pay �ny pwt of &t&% w ““ Mark bLx in 

~mn: b. kit now cwrixd through WI �mployxr or unien7 Surgeon% bills for Oparatkns? 

1 n Yes 2DN0 911DK [ 24 1 � Yes 2DN0 9ci DK [ 26 

I 

~1 Review 1 and 7 for each person and determine if “Covered” by either Medicare andlor insurance, or “Not covered. ” 

Ask for each person “Not covered” in PI. If “Not covered 65 and over, ” include “or Medicare. ” 

Ss.{	 Many fteopfs do not carry hoaith insuranco for various rcssosts. Hand Card N. 

Which of thoso stakmonts describes why –– is not covcrcd b I �ny frcaith ineumnco (CWMxdicwc)? 

Any othor reason? Circle all reasona given. 

Mark box if only one reason. If “Not covared 65 and over, ” in PI, include “or Medicare. ” 

b. What is tho MAiN reason –– is not covorcd by wry health insuranco (or M.dkmci7 

8HIS1,S0,$1983,,31483, 

116 

,~y-iy. 

PERSON 1 ~3-4— 

lb 1 a Cov. a~DK l-l 

2 D Not COV. 

6 t EI Yes 9 ~] DK ~— . 2a 2L..INo 

b 

— 

3. 

I-2.3 I � Covered (NP) 

z � Not covered (NP) 

7.	 m 1 � Covered (NPI 

2 a Not covered (NP) 

I u Covered (NP) 

2 � Not covered (NP) 

i=l ! D Covered fNP) & 

2 U Not covered under 65 (NP) 

3 � Not coverad 65 and over INPJ 

Ea. 

10El Only one reason k 

12345678+ b. 

Specify – — 
P. HEALTH INSURANCE PAGE, Continued PERSON 1 

TABLE H. I., Continued 

PLAN 4 28 6a. Does this plan pay any pert of hospital 7. IS –– covered 7. L 33 

—. expenses? under this I L~ Covered (NP) 

5m.	 Was this (name) plan obtained through (name) plan? 20 Not covered (NP) 

an smplo~r union? 1 � Yes 2DN0 9CIDK 31 Mark box in 

person’s 

1 [ “1Yes 2 [~ No 16) 9 n DK (6I 29 column. 

b. Does this plan pay any part of doctor’s or 

b. Is it now carriad through an employer or union? surgeon’s bills for operations? 

l(IYOS 2 LINO 9C!DK I 30 1 ~ Yes 2~N0 9~DK [ 32 

PLAN 5 34 6a. Does this plan pay any part of hospital 7. Is –– covered 7. ~9 — expenses? under this I fl Covered (NP) 

5a. Was this =Jplfm obtained through 

an �mplOvrnror union? 1 cJ Yes. 2fl No 9CIDK [ 37 

(name) plan? 

Mark box m 

2 ~ Not covered (NP) 

person’s 

11 iYes 2; 1No (6I 9 ~ DK 16) 35 column 

b. Does this plan pav anv parz of doctor’s or 

b. Is it now carried through an employer or union? surgeon’s bills for operations? 

\ Yes z [-; NG !3fl DK 36 1 � Yes 2DN0 90DK 38 

PLAN 6 40 6a.	 Does this plan pav anv part of hospital 7. is -– covered 7. ~5 — 

expen*Os? under this I � Covered (NPJ 

% Was this -I plan obtahwd through (name) plan? z D Not covered (NP) 

at<�mplovmr or union? 1 � Y9S 2DN0 90DK I 43 Mark box m 

person’s 

1!-’ }!3s 2 ,–: No (6) 9 n DK 16) 41 column. 

b. Does this plan pav anv part of doctor’s or 

b. Is it now carried through � n emplover or union? surgoon”s bills for opm~tions? 

1 –“’ Yes 2 i~ No 9L-JDK 42 1 � Yes 2DN0 9nDK 44 

32 Go to Item P1 on page 10 

30 TNCiTES 

MI+(Z, %,.,11, ’I,lR1,II !4 H-l

117 
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P. HEALTH INSURANCE PAGE, Continusd PERSON 1 

9a.	 Does anyone in this family now receivo �ssistance through tha “Aid to Familiss 

with Dependent Children” Program, somotimos caliad ‘“AFDC” or ‘“ADS’”? 

� Yes � No (10) � DK (10/ ———— 

b. Which (othar) family membars � ra included in tho AFDC �ssistance paymmt? E 9b. I ~ AFDC Mark “AFDC” box m person’s column. 

.—-— — .——---—-— — .— -.-—- _______ __________ . .._. ._ ___ ____

c. Are any-other family members included in this program? 

� Yes (Reask 9b and c) •1 No 

Oa. Doss arryonn in this family now racaive the “Supplamontal S@curity 

Income” or 4’SS1” gold-colorad chack? 

� Yes � No (11) —-- .-. � DK (11) 

b. Who (eIsa) receives this chack? - k 10b. 1 0ss1 Mark “SS1” box in person’s column. -— -—. - - . . 

c. Anyone elsa? 

� Yes (Reask 10b and c) � No 

1a.	 There is a national program called Medicaid which pays for haalth cara 

for parsons in need. (In this State it is also called (-}). 

During the past 12 months, has �nyone in this family r~aiv.d ~alth 

care which has baan or will ba paid for by Madicaid (or (nameh? 

� Yes � No (12~ .O D~..f72) .-— —. ——-— _____ ____ --—- .__. __

b. Who was this? L 57 

llb. I ~ Medicaid 

&fa~k “Medicaid” box ~nperson’s column. —.. -—-. ——.—_ —___ ___ 

c. Anyona alsa? 

� Yes (Reaak 7 lb and C) ii No 

2a.	 Does anyone in the family now hava a Medicaid (or -h card which 

looks iika this? Show Medlcajd card. 

� Yes � No (13) � DK (13) 

b. Who is this? “- r-z 12b. I � Card Mark	 “Card” box m person’s column. ———-—— .— 

c. Anyone alse? 

U Yea (Reask 72b aqd c) � No 

Ask for each person with “Card” in 12b: d. ~ Medicaid card seen 1.!!!!­

d. May 1please see –– (and –-) card(s)? 1 El Current A ‘ 

Mark appropriate box(es) in person’s column. 2 ~] Expired 

3 ~ No card seen 

a fl Other card seen 

k 

Specffy 

3a. Is anyone in the family now covarad by any othar pubkic 

assistance program that pays for haalth cars? •l Yes •1 M#M •1 :}g[y 

b. Who is this? Lx 13b. I n Other PA 

Mark “Other PA” box in person’s column: 

c. Anyone alse? 

� Yea (Reask 13b and c) � No 

,RM Ells11s8, !983, t3 14,3, 

118 
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-- --- ----

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P. HEALTH INSURANCE PAGE, Continued PERSON 1 

4a. Doos �nyorra in tho family now receive military ratlromwrt paymonta 

from �ny branch of the Arrnad Forces or a pansion from tha Vatarmrs 

Administration? Do not include VA disability compensation. 

� Yes � No (15) � OK (15) -. -. — 

161_ b. Who is this? 14b. I � MII. ret./VA pen. 

Mark	 ‘ ‘MII, n.t./VA pen. ” box in person’s column. . . -. . . 

c.	 Anyorm �Iso? 

•l Yes (Reask 14b and c) � No 

Ask for each person wth “WI. ret./VA pen. ” in 14b: I � Armed Forces “L.!E_ 

d.	 Which dots -– recaiva - the Armed Forces retirsnmttt, tho VA pension or both? d. zOVA 

3 � Both 

SW	 Is �nyorm in th- family now covered by CHAMP-VA, which is medical 

insurance for dcpondamts or survivors of disabled veterans.? 

� Yes � No (16} � DK (16) 

.-- —- --—- -.. ..— -— ——. —- -_—- ..-. . .— 

b. Who h this? 15b. I � CHAMP-VA M 

Mark	 “CHAMP VA” box in person’s column. -_—- ----——- ——.--—- —--- —-—- -— -—. — ---- .-. —---

c.	 Anyontr else? 

� Yes (17eask 15b and c) � No 

60.	 la myorro in the family now covered by any other program that providas 

hahlth cara for military dependams or survivors of military psraons? � yes � No (P3) � DK fP3) -—-—- ————————-—-——- —----- - .— ——-—-—- --—— —----

b. Who is this? %6b. I � Health Care E 

Mark	 ‘W?alth Care” box in person’s column. _- —— - —-- —-. —-— —— —--- ----— —-—-

c.	 Anyona else? 

� Yes (Reask 76b and c) � No 

I � AF box marked (17) P3 2 � Other (NP) 

?a. Dogs hava a disability ralatad to –– aarvica in the Armad Foroea of ttw Unitad Stataa? 1 7a. I •l Yes & 

2 � No (NP) 

--——- ——— ——— —- —- —— -- -— —- —- ——— —-— —--

b.	 Doaa now roceiva compensation for this disability from tha Vaterana Adrnirriatratiom? b. ; n-ye; L!z_ 

ZDNO 

OOTNOTES 

,,?4, ,,981,,.1 14 IN, 

119 
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P. HEALTH INSURANCE PAGE, Continued PERSON 1 

188.During thopast 12 months, thm h sinco[12-monthdate) � year �go, hmro (read names of 

related W+ members 18or over) ken laidoff from � job or Ioat� job? 

•l Yes n M#eSt 

.— .-.. -..
 .-. —-
 68 b. Who W*Sthis? 8b, I fl Laid off/lost job .——.

/ 

Mark “Laid off/lost job” box in person’s column. —--- . 

c. AnWXW �lsa? 

� Yes	 (Reask 18b and c) � No .- -

Ask 18d and e for each person with “Laid o{f/~st job’; i; 78~.- ~69_ 

d. How manytimeshas -– bawtIdd off or lostojob during thepast12 months? d. — Times ‘ 

--e- .— -- -.. 

e. In whst month was -– laidoff or did –- lose � job ([thoIssttimo/ths a 

timobsforo that])? 

— 9s. B.osuso of hrames of persons in 18b)job layoff(a) or job fossi*s). d~ �nYon* in 

the family IOSQ�ny healthinsurancecovoragothat had booncomfadthrough 

[th~ffthosoljobls)? 

•l Yes c1 goJaxt � Cl:g:iex 

—---- —---- -— ..-. . . . . 

b. Who WaSthis? 

9b. I D Lost coverage L’s Mark	 “Lost covarage” box ;n person’s column. . . ..- ___ ._-. . 

c. Anyono .1s.? 

� Yas (Raaak 19b and c) � No 

i __77 I ~ Lost coverage (20) P4 I Refer to 79bandmark appropriate box. 

2 � Did not lose coverage (NPJ 

!Oa. FIXANYTIME during [thathhosoljo layoff(s)or job Ioes(osl,was -- without sssy Oa 1 Cl Yes typeof healthinsurmtcocovwago? 1 Do not includshoolthcsroprograms,such �s

M.dirxid, AFDC, or militarybenefitpsograms,�s kwsfth 2 � No (NP) insur=ncscovorage.} 

.- .-—. -. -—-- -..-——- —- ..,. . . 

b. For how long was -– without $o-m”otyps of hdth insurmisecovorsga? b, 00 U Less than 1 month l?!?Z?? 

(How mwrymonths is thst?) — Montha I 

— 

!1w For ANYTIME during [thatithosaljob layoff(s)or job Ioss(os),w-o covsrcdby la 1 Cl Yes 1 81 

any hsalthcam program, such �s M.dicaid, AFDC, or � militwy b.nafft Progrsm? —----——- —-- . ..- . 2 n No (NP) 

b. Frx tiw” long wiis “covo&f by-ioms Itdth carspr~fsm? LI=13_’ 

b, 00 ~ Less than 1 month 

(How many months is that?) —— Months — / ‘OOTNOTES 

120 
121 

I UT 64 

0. ALCOHOL/HEALTH PRACTICES PAGE 

Sample Person Number _ 

Refer to household composition and age. 

I r: Deleted (Next SP) 

2[; Under 18 fNext SP)

01 Jn l~and~ver, callback required (Next SP) 

a [ I 18 and over, nonmtervlew (Specify, THEN next SP) 

5 r] 18 and over, available (1) 

~L!Id to respondent: 

ltdtvm!of SP), the following questions concern your health practices, 

smoking, and alcohol use. (It is not necassary for anyone alse to be 

prasant.) 

1. How many hours do you usually sleep at night? 

Hours 

2.	 How often do you eat breakfast - almost every day, sometimes, 

rarely, or nevar? 

I ~] Every day 

2 [-1 Sometimes 

3 ~ Rarely or never 

H ~ Other (Specify) 

3.• Including evening snacks, how often do you eat between meals – 

alrqost �vary dsy, sometimes, rarely, or naver? 

I [“] Every day 

2 i“ I Sometimes 

3 ‘-’ Rarely or never 

H [ = Other LSpemfy) 

4.	 Would you say that YOUare physically more active, lass active, or 

shout ss �ctive as other persons your age? 

I 1-] More ectwe 

2 r.]Less active 

3 [ 1 Same 

8 r] Other (Specify) 

5a. Have you smoked at Iasst 100 cigarettes in your life? 

1[1 Yes 2 � No (8) 

b.	 Do you smoke cigtrettos now? 

I n Yes 2DN0 

c. On tha averaga, about how many cigarettes a day [do/did] YOU smoke? 

—- _ Number 98 � Never smoked regularly (8) 

Refer to 5b. 

“Yea’” m 5b(7) 

2 m “No” in 5b (6J 

02 I n 

6.• About how long has it been since you last smoked cigttretfes fairly 

ragularly? 

20 Oays 

3D Weeka 

Number 4D Moritha 

{ 50 Years 

000 � Never smoked regularly f8) 

?MMISI[bll,,1903,1314831 

L19 

Refer to 6. 

p 03 I n Less than 5 years (7bJ 

2~ 5years0rm0re (8) 

5 20 7a. lnthepast 5years, have you EVER tried tostopsmoting cigarettes? . 

1 ~ Yes 2 ‘: No (8) 

b. Now I am going to read a list of methods which some people use to 

stop smoking cigarettes. Tell me which of these methods you used in 

the past 5 years to stop or try to stop smoking. 

(1) Oid you attend a formal program SUCH 

AS SmokErrders, the American Cancer 

Society program or American Lung 

Association program? ......................... I “ ~yes No z [- —zl_ 

6-7 

(2) Did You go to a health professional for 

help, SUCH AS a physician, 

psychologist, or psychiatrist? ............... I ‘ ~ Yes 2 No 

_.— 

L..22-. 

I 8 (3) Oid You use special filters or cigarette 

holders to regulate the amount of 

smoke inhaled in an attempt to stop ~ 

smoking? ........................................... I I ~ yes 2:IN0 ~ 

(4) Oid YOU switch to lower tar and 

nicotine cigarettes in an attempt to 

stop smoking? ..................................... I n Yes z~~No ~ 

la 

(5) Oid you stop or try to stop smoking ~=.. with a few friends, relatives, or 

acquaintances? ................................... I m Yes ~!;NO 

(6)	 Did you stop or try to stop entirely on 

your own? .......................................... 1 n Yes 2 [-; No E 

10 (7) Did Yau use some other method to stop 

or try to stop smoking? ........................ 1 [1 yes z ‘“: No = 

(SpecrfYQ 

Read to respondent: 

These next questions are about drinking alcoholic beverages. Included 

are liquor such as whiskey, rum, gin, or vodka, and beer, and wine, and 

I 11 any other type of alcoholic beverage. 

8a.	 In YOUR ENTIRE LIFE hava you had at least 12 drinks of ANY kind of 

alcoholic beverage? 

1 12 I � Yes 2 tl No (8cJ m 

I 29 

.b. In ANY ONE YEAR have you had at least 12 drinks of ANY kind of I-——— 13-14 alcoholic beveraga? 

07 � Infrequent drinker€

I •l Yes (9) 2DN0 

I 15 c. What is your MAIN reason for not drinking? e 

00 � No needlnot necessary 

01 � Don’t care forldislike it 

I 16-18 02 n Medical/health reaaons 

03 •l Religious/moral reasons 

04 � Brought up not to drink 136) 

05 � Costs too much 

os � Family member an alcoholic or problem drinker 

88 � Other (Specify) 1

9. Not counting sin-M tastas, how old wsro you whm you started 132-33 13.. ~urjng that 2.wask period, on how many days did you drink any p6.67 

d?kafdi sloofwsc bavaragas? Iiqaaor,such as whisk-y, rum, gin, w vodka? 

Years old ODW. I 

Hand calendar. 00H Nnrw or never (05/ 

Oa. Dd you have � drink during tfaa 2-w.ak period [outfined on that b. During that 2-week pariod, on the day[s) when you dmnk hquor, - cafandad faagimairag Monday, (me) �nd �ndhtg Sunday (d&e)]? �bout how many drinks did you ham a dnY7 

I � Yes ztl No(1OC) 

mD,$n~: b. Duting W patiod, whan dfd yw’fast ha;e � drink~ ““& “-’-’ c. During thxt 2-warok period, svhnt 7WRSthe total number of drinks of L!E?L 

liquor YOU had? 

19— (11) 

Month Date Year 

c. Whara was your ksst dkfr &fortO-t&t-2–wA- &rW? ‘- ”--- -Drink’ - - -“EEX d. About Iww many mmcaa of liquor were in � typical drink that LEIV_ 

w.u had dwing that patiod? 

19_ 

04 

Month Date Year / ~ut,:’,~ 

~ Refer to IOC. Etif2r to 1 id, 12a. ,md 13a. 

I D Over 2 weeks, leas than 1 year f 17) T u One rla,f and one bew?rage type (16J 

2 � 1 year or more (26) ~~ 2 fl Only one beverage type (15) 

118.Qti2-W~, mtiwmany&ys dMyw Wany~? = 3 D 14 days in 1 la, 12a, or i 3a (Intro) 

en Other (14} 

ODws Read to respondent: 

eon None or never (12)	 I have �sksd you �bout bear, wine, and liquor scparalaly. Now 1 

want you to think �bout thsm combined. 

b. Dttriqf tttzt 2-wask ftariod, 0SStha d37(s) wftaatYOUdrank bow, a 14. During tft. 2-wsak pwiod [ouflhwd on that calandar/bsghrning fWcmday, about fmwmanybaatadid youdrinkaday?	 (We) �sadwrding SussdsY (@)], on how many days �kogathw did YOU 

drink afcoholk Lwvsragos, that is, bsar, or win., or liquor? 

_ —--—- U~eers —— . . . . ..—. Days f 15) E&z 

c.	 DusinzI that 2-wsak pariod, what was the total numbar of baers 1-52-54 

you drank? OT ~ One day only (16) 

I hmm �sksd you �bout boar, wins, �nd liquor saparatoly. Now I 

Beers want you to think �bout thorn combinsd. 

d. Aboaat how mway ounas WC;* in � &it& can; && ~ glass of Refer to questions 1 lb, 72b, and 13b. 

Iraw thst YOUdrank during that parkd? 1 S*. During that 2-waak pariod, did you haw mora than (largest, mrnber 

in 1lb, 12b, or 13b)drkak(s] on � singls day? 

Ounces I Cl Yes 2HNo(T6J [ .?L 

12*. During that 2-waak pwiod, on how many days did you drink �ny wiraa? ~ 

b. During that 2-wsak paried, on how many days did you hsva mom than I_zE!!l 

(largest number m 1 lb, 12b. or 73b) drink(s) of bsar, or wine, or fiquor? 

=Days 

oofl None or never (13) Oays 

b. During that 2-weak pariod, on ths day(a) when You drank wkm [69-60 01 D One day only (15e) 

�bout how many glasaas of wiam dti you drink �day? a. What was ths fargost numbsr of drinks you had am �ny on, of l~i 

those dsya? 

_~_G!s:s:s 

c. During that 2-w@ak fmiod, what was tho total numbsr of gfaasos of ] si -83 Drinks 

wine	 you drank? d. On how many dsYs during that 2-waek p&iod did you havo L!!E!K. 

(number in 15c) drinks? 

Glasses 

d. About how many ounces of wino war. in � typical glaas that you [6i-6s Days (76) 

drank during that pariod? � . How many drinks did you hatm un that day? L!E!zE 

Ounces Drinks 

RM HIS.llSB, {19831 1314.831 

122 
--

———

r~. ..s . . 

1 %a.	 During that 2-week period, on how many days did you drink any E 

UTJcr, such as wtdahey, rum, gin, or vodka? 

lCl Yes(76cJ m DDa~a 

00D None or never (06) 

b.	 U!$7irIgthat 2-wes!t period, on the day(s) when you drank liquor, e 

C!:SQI how mmry trin!m dd you have a day? 

c. For how many yaara hsa this boon tv~kx?l of vmw drinking? ~ ,-o”~ _ _ Drinks 

Years (23) 00 � Less than one (23) c.	 During that 2-wee!t pwiod, what wtrs tha totrd number of drinks @ 

of WWW vcw h:d? 

Wad to rPSDOfldeflt: 

Lat’s talk �but tht 2-waek fmrlod ENDING t$JITN ALID Drinks INCLUDING tho day YOU had yOIU test ME>. 

17a. During thst 2-wask psdrrd, on how many dsyo M vcs <XC!I znjj km? c1. Abut !mw many ounces of Iiqimr were in a typical drink that M

I YOU ‘------- had duriirjj timt period? ‘--- ‘- D3.Y. m 

WJn Nom or never (18) f Ounces 

—— —..———- b.	 During that 2-wssk paric.% on t~~at!ay{t) t--km WXI d?zri:! beer, m Refer to 17a, 18a, and 19a. US_ 

�bout how many beers did ymI c!rlnk o dw+? I � Only one beverage type(21 J 

06 :: ::;;17a, I%,or 19.(21) 

Elem 

. — ——-————. . c. During that 2-ws@k parlod, what wm Wa total INN&W of IxMm w Read to respondent: 

you drank?	 I ham CC!A ycm cbmtbeer, wins, and liquor separately. Now I 

wcri2 ya~ tg t~!nh c.%i tbxncombined. 

Beers 20. EtLL7k23tr’m 2-ccc!{ Gc7hJ EHDING WITH AND INCLUDING tha day 

—_——_ —.. — ycm hcsl vow !cst Mizk, on l:aw many days shognthsr did you drink ..— ————— d.	 About how many ounces ware In a typical caq 127Ix@e OFr.T!:ss e C!CC!WKS bcvz7c~:a, t!wt io, beer, or wine, or liquor? 

of&r that you drank during that pariti? 

Days E 

Oullms 21a. Wcs ths cmomt o? your d%hing during that 2-waak period typica! @ 

of ‘@n sXnkiny c!wizg tha 12 months bafora your last drink? 

lEm ~ During that 2-wsak pmiod, on h~.u many daya IM vcu dr:z!i 

�ny wins?	 10 —Yes (21c) — 2tl N0

-_E 

b.	 LYm th cmmmt of ya7 d7Min9 r!tving that 2-waak period moro 

m !::s th:n you? d7h!tin3 Cu?kyj tim 12 months bafore your last I drink?

‘- ‘- -‘-------””----” 

GIwxms 

— — — — — — 

d. About how msury mmcr!s of wdmrwere in–~ typl~zl cLts~ Cm? y~u~---@@. -1 

rfrmrk during $?urtpwled? 

I 

Crumms 1 .. . . . . . .. . . . . . . . mm “,. ,,,.! ,,,”., , ,.,.. ”.,, 

123 
~ 22a. What is your MAIN reason for not drinking since [date in IOC)? 

00 � No needhmt necessary


01 � Don’t care for/dislike it


02 � Medical/health reasons


030 Religious/moral reasons


04 Q Alcoholic/problem drinka r-self


05a Costs too much


060 Family member an alcoholic or problem drinker


07 n Quit drinking (23b)


os a Infrequent drinker (23a)


88 � Other (.SpeCify) _


b. Have you compktely stoppad drinking �lcoholic beverages? ‘--l..xC 

I � Yes (23bJ 2DN0 

238.	 During tho past year, in how many MONTHS did you have at least e 

ona drink of ANY �lcoholic beveraga? 

Months (24) 

b.	 During tho year bafora’ your l~std%k,inhow”rn&~ MON;HS-d~ ‘ ~ 

you have �t Iaast orw drink of ANY �koholic bavsmge? 

Months 00 � None (25) 

24a.	 During [that month/those months], on how many DAYS did you U 

hav? S or more drinks of ANY �lcoholic baverage? 

Days 000 a None 

b. During [that month/thoaa months], on how many DAYS did you---lEE

havo 5 or mora drinks of ANY alcoholic baverage? (ktckrda tha 

(number in 24a) days you h~ 9 or more drinks.) 

Dava 000 � None 

Read to respondent: 

Thaaa nast quaations �rm�bout drinking during your Iifatime 

bagkarairrgwfth tha �ge you statiad drinking. I will ask you 

about haavy, modsmte, and light drinking. 

25*.	 Was thara war � pariod in your Iik whan you considtrrad 

Yowadf to be � heavy drlnkar? 

1Cl Yes 2 H No (25d) E 

b. For how many y.ara were you a hamry drinker? -’-IEEE 

Yeara 00 H Less than one 

c.	 Wfwn you war. � h~~vy rkink’er~ how ma; y-d%ksof �l;oholic- – – ‘w 

bawaraws did yOSlhavo in � waak? 

Drinks ooo � Less than one 

d.	 Was thara �ver � pariod in your life when you corwkfamd ‘-K 

yoswsalf to ba � modarafo drinkar? 

t � Yes 2 � No (25g) 

.—. — 

e. For how many yams wwo you � modarato drinkar? l_E!!z 

Years 00 � Less than one 

25f.	 When you wam 8 modarate drinker, how many drinks of I 66-66 

� lcoholic bavww6a8 &d you have in � warak? 

Drinks 00 � Leaa than one 

g.	 Was there aver � pwiod in your life when you considered L!z_ 

yourself to be � Iiiht drinker? 

1 � Yes 20 No (07) 

h. For how many yews were you a light drinker? e 

Years 00 � Less than one 

i.	 When you war-• light drinker, how many drinks of alcoholic & 

bavmages dti you have in a weak? 

Drinks 00 � Less than one 

Refer to 25a, 25d, and 25g. 1.-.z3-

07 I � 25a, 25d, and 25g ara all “No” (25j) 

8 � Other (25n) 

25j.	 Was thwa avar a pwiod in your Iifa when you considered yourself L.Z!_. 

to 2s6� WWYIiiht, occasional, or infrequent drinkw? 

1� Yea 2 ~ No (25m) 

k.	 For how many yeara wara you a vary light, occasional, or m 

infraquant drinkar? 

Yeara 00 � Less than one 

1.	 When you wore � very light. occasional, or infrequent drinkar, @ 

how many drinks of �lcoholic baverages did you have in � 

waak? 

Drinka 00 � Less than one 

m.	 00 yw now considar yoursalf to ba wr sbstairmr or � VWY fiiht, l-z occasional, or infraquant drinkar? 

1� Light 

2 � Moderate 

3 � Heavy 

4 � Abstainer 

5 � Very light, occasional, infrequent 131) 

s � Other I.Specify) 

J } 

m	 Oo YW now coras:tir yoursaff to ba an �bstainar or � light, L_E 

modarata, or Iaaavy drinkar? 

I � Light 

2 � Moderate 

3 � Heavy 

4 � Abstainer (31) 

5 � Very light, occasional, infrequent 

a U Other (Specify) 

a)	 }

J I 

IW H15.l[SB1 119831 13.14.S3)

124 
Read to respondent: 29f. Whwr you were a moderate drinker, how many drinks of I103-104 

I would Iiko you to think ●bout your drinking of ●lcohotic bsvemgos, alcohofic beveragea did you have in a week? 

that is, baar, or wine, or liquor, around (date in 10c.) 

Z6a. In ● typical week, on how many days did you drink alcoholic Drinks Oofl Less than one 

bavaragas? g. Waa there ever a period in your life when you considered 105 

yourself to be a light drinker? 

Days ootl None (27) .IzEz t Cl Yes 2:: No (08) 

b.	 On tha day(s) when you drank, about how many drinks did you M loa-lo7 have ● day? h. For how many yeara were you a light drinker? 

J 

Drinks Years 00 [] Less than one I 

c. For how many yoms was this typical of your drinking? I-EH i. When you were a tight drinker, how many drinks of alcohofic ~lo8-lo9 

13cvwages did you have in a weak? 

--l 

Years 000 Less than one Drinks oo~ Less than one as ❑ Not typical 

110 Refer to 29a, 29d, and 29g. 27. During the year before your last drink, in how marry MONTHS I❑ 29a, 29d, and 29g are all “No” (29jJ did you have ●t least on. drink of ANY alcoholic bavarafm? 08 SD Other (30) 

Months 00 D None (29) E 29j. Was there aver a pariad in your I“?nwhan YOUconsidered yoursolf I.__U 

W. During [that month/those months], on how many DAYS did you & to be a very fight, occasional, or infrequent drinker? 

hmm 9 or more drinks of ANY ●lcoholic bavwaga? 1•l Yes 2tl N0 (30) i 

—	 112-113 .— Days 0000 None k. Forhowmany years wareyou avaryiight, occasional, or 

infraquont drinkar? 

b. During [that month/those months], on how many D \YS did YOU“E.@ -i 

havo 5 or more drinks of ANY alcoholic bavorago? (includa tho Yeera 00 D Less than one I (number m 28aJ days You had 9 or more drinks.) 114-t15 1. Whenyou weraaveWfight, occasional, orinfraquent drinkar, how 

many drinka of alcoholic bevaragm did you have in a week? 

Days 0000 None + 

Read to respondent: Drinks 00 ❑ Leaa than one 

~ Thaso rmxt quastiorrs ●r~ ●bout drinking during your Iifotima baginning 30a. What is your MAIN mason for not drinking since (date in 10c)? 

with the ●gb you stmtod drinking. 1will ●sk you about heavy, modorato, 00D No needlnot necessary ●nd light drinking. OID Don’t care for/dislike it 

!9a. Was 

yourstlf to ba ● heavy drhrkor? 030 Religious/moral reasons 

1•l Yea 2 ❑ No (29d) E 04Q Alcoholic/problem drinker-self 

OSD Costa too much 

thwc ●ver ● pwiod in your Iifa whmr you considarad ozn Medical/health reasons 

b.	 For how marry yoms ware you ● hwwy drinkar? - - “w 

Oan Family member an alcohohc or problem drinker 

—.— Years 00D Less than one 070 Quit drinking (311 oan infrequent drinker } 

c, Whan you wart ● heavy drinkar, how many drinks of alcoholic ““”@ 880 Other (Specify) _ bovwagas did you hava in ● w-k? 

33. Havaycu completely stopped drinMng alcoholic bavercges? I_l!E 

Drinks 000 ❑ Less than one I ❑ Yes 2fl N0 

d.	 Was thwa ●v@r a period in your life when you considered L?!!?_ 

yoursalf to b. a modsrata drinkar? ‘OOTNOTES 

1 •l Yes 2 ❑ No (29g) 

● . For how many yams wart you ● morkrato drinker? l!!!!+ 

—_ Years 00 D Leaa than one 

H!. ,,..! ,,..l, ,. ,. *-I, 

125 
lii7G 

~ 31sI. Somepeople havaproblems ralatedtodrinting. Havayou EVER 

had a family or marital problem related to YOUR drinking? 

I C Yes 2DN0 (32} P 

b. Whatproblem didyou have? ‘I&l! 

c. Anything elle? ‘L.l!!x 

nYes(Reask37bandcJ � No 

Mark box or ask. � ”1 year or more” in 04 (32) LE.. 

d.	 Did [this problem/any of these problems] occur in the past 

12 months? 

I ~ Ye3 2~N0 

32a.	 Have you EVER had a job or work pr&!em related to e 

YOUR drinking? 

t fl Yes 2 H No (33) 

b. What problem did you have? “k 

c.	 Anything else? L!@ D Yes (Reask 32b and.) n No 

Mark box or ask. Cl”1 year or more” in 04 f33) “LX 

d.	 Did [this problem/any of these problems] occur in the past 

12 months? 

1CYes 2DN0 

33a. Have	 you EVER had an injury related to YOUR drinking? -M 

lCi Yes 2 � No (34) 

b. What was the injury? L%?? 

c.	 Anything else? --M 17 Yes (Reask 33b and.) � No 

Mark box or ask. U ‘“1 year or more” m 04 (34) m 

d. Did [this injury/any of these injuries] occur in the past 12 months? 

1nYes 2fl No 

RMHIS11SS!+1983!,3.1483, 

34a.	 Oid you EVER have any (other) health problem related to /__2~ -

YOUR drinking? 

1 U Yes 2 .~ No (35) 

~3~:3> b. What was tho health problem? 

c. Anything eke? ]__NCN 

� Yes (Reask 34b and c) ~ No 

Mark box or ask. U”1 year or more” in 04 (35) I–E 

d.	 Oid [this problemlany of these problems] occur in the past 

12 months? 

1•1 Y&s 2~No 

35a.	 While YOU wera driving, did you EVER have a motor vehicle ~_~~­

�ccident or traffic violation ralated to YOUR drinking? 

1•l Yes 2 n No (36) 

b. Wh}ch, a motor vehicle accidant or traffic violation? ~>8– 

1 � Accident 

2 � violation 

3DEloth 

Mark box &ask. m”1 year or more” in 04 136) E. 

c.	 Oid you have a [motor vehicla accident/ traffic violation] related 

to YOUR drinking in the past 12 months? 

1 ClYes 2QN0 

‘OOTNOTES 

126 
36.	 Tell m- whothar or not you hava EVER had �ny of tho following FOOTNOTES 

conditions �m if you havo mmttloned tham before. 

�. lf~psrtwwion or high blood PWCSWO?........... t � Yes 

b. Hardening of tha �twles? ............................ I � Yes 

c. Tachycardia, �rtrythmia, or rapid howt? ....... I D Yes 

d.	 Arthrttis or rheumatism? ............................... 1@ Yes 

�. Convulsions or sclzur-? .............................. 1� yes 

f. Blackouts? .................................................. 1� Yes 

g. Shortnoss of breath? .............................. I •l Yes 

h.	 Insomnia or slscplaswtsss? .......................... 1� yes 

L Hopdtls? ..m...........o....m............................... 1•l Yes 

j. Any dimcm of tho pancraas? ........................ I � Yes 

k.	 An rdcw, othar than a skin ulcw? .................. I � Yes 

L Any gaatrohrtestirml Mowfing? ...................... I � Yes 

m. Dicbotas? ...................m............................... lCIYes 

n. Hsartattack orhoa@fallum? ........................ In Yes 

o. Coronaw hoatidis-so? ............................... In Yes 

p. Strolm or homorrtmga of tho brain? ............... I H Yes 

q, Anoiru P+ctoris? ......................................... 1•i Yes 

r. C8ncw7 ...................................................... I •l Yes 

s.	 Ydkwjautiica? .....m.................................... laye~ 

t, Fatty lhrss?.,..............0................!. ............... 1•l Yes 

u.	 Enlxtgwl Iivar? ............................................ 1•l Yes 

v, Clfiosis ofthaiivor? .................................... 1� Yes 

w. Any otlwr Ilvsr tmubfc? ................................. 1•l Yes 

x. DT’s or d.iirium tmrrwrm? ............................. I � Yes 

y. Alcofwhm? ................................................ I •l Yes 

Mark by observation. Mark all that apply. 

Who wss present during the interview? 

1� Telephone Interview 

I ~ No one else present 

09 1 � Husband/wife

1 � Child/children under 18 years old 

t � Parent(s) 

1� Other adult(s) 

OllMHIS.I(SB IWrll13.14.831 

20N0 40 

2DN0 43 

20N0 42. 

43 2DN0 

2DN0 44 

2DN0 46 

2DN0 46 

2DN0 47 

2DN0 48 

2DN0 49 

so 20N0 [ 

2DN0 

2DN0 

2DN0 

2DN0 

20N0 

2DN0 

20N0 

2DN0 

20N0 

20N0 

2DN0 

2DN0 

2DN0 

2DN0 

~ 

~ 

68 

~ 

127 
---------------------------------

Card M CARD N 

A. Place used for nearly all madical care 

B. Especially good for treating this condition 

C. Convenient to home 

D. Convenient to work or shopping 

cd d 

cd M 

E. Raferrad by a doctor ,. . ..-

F. Referred by friand or relative 

G. only placa available 

H. Haalth insurance plan raquiraa ,

! 

1. 

1.	 Emergency :3 

,: 

;1 

$ J. Some other raason – Specify ,;

{g 

I 

‘*.!s %0!!,,,,,,,.,, 

MEDICARE 

1. Job layoff, job loss, or any reasons related to unemployment 

2. Can’t obtain insurance becauee of poor health, illness, or age 

3. Too expensive, can’t afford health insurance 

4. Dissatisfied with previous ineurance 

S. Don’t believe in insurance 

6.	 Have been healthy, not much sickness in the family, 

haven’t needed health insurance 

7. Covered by soma other haalth plan 

8. Some other reason - Specify 

,mmin, (,n3,,<z.m) 

1 Health ,@ Insurance 

.m. ,.t . ..””!.” SC, 1 

,-., U, I(0”3, !.1..3! 

128 
� 

� 

� 

� 

� 

1984 

The 1984 NHIS was composed of approximately 41,000 

households containing about 105,000 persons. As in previous 

years, information was collected on acute conditions, episodes 

of injury, restriction in activity, limitation of activity due, to 

chronic conditions, prevalence of chronic conditions, respondentassessed health status, and the use of medical services— including physician contacts and short-stay hospitalization. 

A special supplement on aging was added to the 1984 

NHIS. This supplement was added to obtain information about 

okler people who were living in the community at the time of 

the interview, The supplement on aging was designed to collect 

information on the following issues: 

�	 Family structure, relationships, SUppOr-t, and living 

arrangements 

e 

e 

e 

e 

Community and social support


Occupation and retirement


Conditions and impairments


Activities of daily living


Instrumental activities of daily living


Nursing home stays


Help with care


Familiarity with hospice


Health opinions


Additional information about the Supplement on Aging can be 

found in Vital and Health Statistics report, Series 1, 

No. 21 (3). 

129 
--

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

--

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

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

h ---- ---- ------- ---- --

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

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

----- --

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

--

-------

--

----

il. HEALTH INSURANCE PAGE 

Read to respondent(s): 

M.dicarm is � Social Sacurity hodth Insuranca program fw di?ablod pmrsc.ns�nd for prsons 66 vaarw old 

�dovw. P-Di*covard bvM*dlcam hsva8card 1h#tlo&811k9tihlB. 

I Showcard. 

I 

~a. ls.nyon. inthlsfamlly, thatls [,eadnamesL nowcovarti by Mtilcar9? � IY.S � N. (4I � DK . . . _- ._. . . . . -—. . .-. . . 

b.	 ls-–n0WC0Vm,9d? i b. I E Covered 9DDK 

z tl No?covered 

Ask for each person with “Covared’< in 1b: lcl Y22 900K 

2*.	 Is tlOW covs~ by tlM P*tt of SOCM 89curktv Modicam which P8YS for b08Pitsl LMfc? 2a 

M<rkhcxyeep%n!Eofgqn.._.-- ____ ____________ -. 

b.	 ls--mwceva4 bythnt Wnof M&lc8mwblch pays ford=tw"s Wlls? Thislstfn MwNcamplanfw b. 

which wsoma~ncv mustpav .cti~ln smwntaach month. +farkbox inperson’s column. 

Ask for each person with ‘WV in 2a andlor fx I U Hospital 

3.	 May I P2eaza no tfn SoclaI 6UUdtJ Modkwa CSt2f[S)fO? -- (and --) 10 dU9mtlna tfm tyP9 of C0V9tw? 3. z � Medical 

Transcribe the information from the card or mark the ‘,Card N.A. ,’ box. 3 � Card N.A. 

W* �rc Intrnstad in 4 kinds ef hdth ItUuranca plans �XCWP1thou which pay only for �cctd.nfs. 

4m (Not counting Muficu@ Is .nyona in tfn f.milv now COVW9CIby � fnsffh Insuranca 

@an wblch vw MY put Of � h0@9f, docfo?’s M *ur9bofI’s Wli? � Yes � No (Ml) � DK (Ml) ----— . . . . . .. —-. b. _Wf@ Igt_ti-~m_o~fJ& @@ @:o[d@Ia&lCHfl~ ____ ___ ______ - _- ______ _ - ..-. . . . . --- c.	 IS .nyotw In NW family now covwsd by �ny ofhcr haalth Inuwanco pbn 

which p~yt W’ly pWf Of ~ h2+2flhd, 2f02t0f% W WtU60tlS9 biit? � Yes ffkwsk 4b and.) � No (5) 

L.. - TASLE H.1. 

m.. “., ,.,111.fnsmd C&II ** — 

�. umpliw&&t- ““-– 2DN0 9DDK @@ pbn7 

I � Covered lNPI 

2 � Not covered lNP) 

1 � Y,. 2 � No (2N 9 � DK 16) b. 0oufb4s plmpy.ny pw2c.fdmw.r’sm 

9uqum% kms * opamfhlut 

sm.W.*w. @!EIP1. 0b2=kmd 2hrw9h .0mp10yuwun10n7 

S*. riJul&N~M#8n pay my pm of bMPw 

1 � Yes 2DN0 9f3DK 

7. ~-&-

@Q@911? 

7. 

T � Covered (NP) 

2 � Not covered lNP) 

6.. 00u10uli911n pw .“ Pm2d ~ 7. ~.--~ 7. 

I b. l,12nowm-dod21wo@IoII,m@aywwunlm7 I 1 � Ye, 

1 1 � Ye, 2DN0 9DDK 1 � Ves 2DN0 9DDK 

1 � Ye, 2 � No f6J e � OK 18) b. Dan Nlh F4m WY m“ pm of doczar%W 

b. 1oknowcuT1062hrc+sh .mPIo”worunlm? 9nluwrl% w for Opuaflon.? 

1 cl Yes 2DN0 9DDK 1 •1 YC1 2DN0 9CIDK 

6*. omwt~lan.,.nvwo fhownd 7. &-e.:md 7. 

6*. Wm. Zhh -plan 0b2An8d2hr0uqb I � Covered (NPJ 

WI .Inptw. . tmront 1 � Y*, 20N0 9DDK @@plm7 2 � Not covered (NP) _ — ---------- 1 � Y.* 2 � No 16) 9 � DK 16) b. Dmo2bb PIMw”an” PMofdoctc.f,Ix 

b. I,iznowcmdod tlwc+whrnwn+lovworunlen? S-”* bwo fol 0Pwa2!ons? 

1 � Yes 20N0 9DDK 1 � Ya* 20N0 .9DDK i 

Ml R6WILWV1 md 7fo,eachpe,sonandde fe,mf”eif `>Cove,ed'`byeltherMedicarea"d/orl"s.ra".e,or`,Notcova,ad.'' M’ I � Covered lNP) 

2 � Not covared under 65 (NPJ 

3 � Not covered 65 and over (NPi 

Ask for each person “Not covered” in M 1. If “Not covered 65 and over, ” include “or Medicare.,, 

sa.{MMw POO@* do not C*ITV h.dth Insurmc@ foc vsrfaus mscc.tw. ) Wand Card hf. s- 12345676 

Which of them stat~mrnts &Boribos why I* not oovwwf by anv hodfh Insurance (or Mcdlcam)? d 

Any offmr N~SOn? - . . __________________ --_-- __-____ -_C~cJegll~egsg”~ QvgnL - Spegfy

Mark box if only one reason. If ‘*No: covered 66 and over,,, h Ml, ;ncluda ,’or Med[caro.,. ]0 � Only one reason 

b. What h tfn MAIN mawon h not covcmd by � ny tmafzh Insuran.a (or M.dkaro)? b 12345678d 

Specdv 

FOFIMHIS!,1S84,{8.9.83) 

130 
-------------

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

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

-----

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

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

-- -----

b. ~.--~ 

18,	 Thbr91t mnmMulp?0sFml odkdMduidnliohvysfarhdIhura 

fuFuSOlnblmad. ontllksmmltlOabO dlGde). 

lllOnnN, hnanyOmhtfthfamNy luwhvdhwcnfl 

=Wwht%ii Orwnl b, Paidfork? Mdodd (- -n7 

--__-------_---!-I?L-----:?-!’?L--!-D!---­ b. nm-- meakv9dAAacamhth8pUt12month87 

Ask fof ouh wrwn with “YcI” h 12b: 

a, Msvlpkuw sa. -hnd--)card(cl? 

Mark appropriate baxlas) in PWSnn’s column. 

am ls9nwNlntkntunihn0wa0vuuJby911v0uwp4bklE 

~--na=twP*kD=M-? 

� Yos i3N.IN.xt � IOK 

psga) 

b. (, ---~? 

M. HEALTH INSURANCE PAGE, Continusd — Ask only N parsons under 20 in Iamlly: 

�m. - NIVOM k! tlk f8mUynowIWOIVCDUktMCO tkwoushtha‘“AH In FuwII188 

with Oafmdmt Chlldrm””�mvmn, ,omuImea CDIM a,AFDc,nw a,AOC,v? 

_-.-..---.---.---_----------------__P-~::--_-_Q?-!?!_.!_D?____ 

b.	 Don--Iuwr8eolvaAFOCwAOC? S1 

— 

Oeo mumwh&lamw,lha’”suk#mlmt81suurltv 

ImomD’, or -ssl­

--.--------__.----__------___-----__u_!':_____g!lL~2L __o.w___ WChmk? 01 

— 

11


—


21 

1 

— 

31 

— 

_— —_-..... . . . . . 

I tlYes 

20No 

sODK 

1 KIYes 

ZONO 

90DK —— —--------

� Medicaid card seen1 •l Current 

2 � Expired 

3 � N. card seen 

a O Other cud seen 

d 

Specify


I � Yes 

ZONO 

sDOK 

131 
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--

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

-- --

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

------

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

M. HEALTH INSURANCE PAGE, Continued — k	 Doo. .nyon. in th. f.mlly now mod,. mlllt.ry mtlmnmnt p.ymants 

from �ny branch of the Armad Forcms or � P8nsion from tfn Votwans 

Administration? Donottncluda VAd18aMllW comwnsaUw. 

12Ye. � N. (15) D DK 

b. Doss --now rmcalvemititaq rmtlr9mantora VApanslon? 

. . ... . Ask forench pe,$onwith <,Yes, <{n 14b: 

c.	 Whlchdrns --rbcaiva -tha Amti Fovcasratlramti, th*VApnslmorkth? 

Mark box in person’s column. 

Sm. lsanyorn Inth. famllynowcowrti by CHAMP-VA, whlchistikal 

Insur.n.x f., -pmd.nfs or suwlvors of dkabkd .. fomns? 

� Yes � No (16) � OK 

b. Is now covtmd by CHAMP-VA? 

5-.	 k �nvoiw In the family now covamd by �ny ofhu Program that pmvlhs 

health .wn for mllkaw dap.ndwits or survlvo?a of milkaw PUWIM? 

� Yes � No f&f2J � DK 

b. IS -- now co.m.tf? 

7a. Does hmve � dlsabllky mktod to sarvia In tha Armti ForGQaof tfn Unftcd StatiI? 

. b. Doss now mcekw compmwation for thiwdlsabllky from ttw Vatwm’m Adminlmrmion? 

20TNOTES 

$b 

o 

— 

6b 

6; 

— 

n: 

— 

7, 

. 

h 

! � Yes 

2~No 

sDDK 

I � Armed Forces


2~VA


3 � Both


t � Yes 

2DN0 

9DDK 

. . . . . . 

1 � Yes
 20N0


9DDK


t � AF box marked f 17)


2 � Other (NP)


1 � Yes 2 � No (NP) . . 

1 •1 Yes 

2DN0 

132 
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--

--- -------

--

---

--

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

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

--

--

--

M. HEALTH KWXUIANCE PAGE, Ccmt:nued 

18a. Wti Wt12mmtlts, thtis$lnco(12.m .fhdate �y~aua, h?sfrer:dnamasof 

r8!ntad HHmembcrs 180rovorJbnlddak+ =i+166&.lcb? mma 

il Yes Cl No [M41 � DK (M4) . . . . --—. b. Whawco2hls?’ 1l!b. { t � La,d of fllost job 

Mark	 “Ldd of f/fost job” box m persons ccl-mm . . . 

c. AnvoM &m? 

� Yes(Reask18bmIdd EN. -. ~a~ 18d~~ir;difo;e>;h~ ;r;o; ;~l;';;i;;f;l;8;];~ '~n-l>6-------------- ‘-- ‘,” ‘-i=-”‘­

d. flow mm’wtlmss ha br+mlafd off or foztolobduvbw tfm pasf 12 rrwwks? d. — T,rnes 

. .. ---— —. .-. . — —---

�. III what monfk W*M -,- laid Gff crdld h aIcA lithe Imzt tfm-a;ti 

vf1222bufR* tfmfl)? -“-t ““ C3imel 

I nTmle2 

.——_ —_- .- —---.--... -.------- ——----. —------ ——— — ___ fi~,e, f.	 Fur ANYTIME {tir w [thaLRhoz=J JCLIf6?rnfNDl WMJ 10Z3:OCI, *-- -I= ~------ ,a Yes 

vmmf9f6v2w2t ln9a132.nca L~fim? ~oNo

� Vas � NO fhf4 J � DK {M4 J _ —.. _ —--------- . ---

b. Whd W~C this? lsfa.,~ Lost CtY#W~~O 

Mark	 “Lost covarage” box in person% column. .- —- --——— .--—. —.-

0. A22pn2 dad 

� Yss Ksssk fSLI and c) � No 

M3 fl.ferta 19ba”dmarkappro2,ta:ahx. ?A3€ I � Lost COVWW3 (20) 

z � Dtd not lose coverage 0L9J 

20a.	 For ANYYIME dwfnn [ffmfffhemlhzb f*YOff(S) or lob V0221-1, W- ‘- ~ MY 20*. 1 13 Yes w of haaffh fkwtwanea cow?nifa? {Da M fnofudz fmzffh UN8 m~nzs, such s= 

Mz&zfd, 2 � No iNP) AFOC, m ntffftzty fzcn41 PZUWZmS, M ftmftft fnzw- aumffz.} 

-. --—-. . . . . 

b. Foffu.w kms wu wfffmutsowntvwof huWI fmunnm COVWZW h w n Less than 1 month 

(flow msrw monzfu Is vhf?) 

— Month3 

21a. Fot ANYYIME dudno Ifhzv/OIOuIjob favc?f(ol 0rlobfw2[22L W= COV=+ bY 21 e. 1 � Y.m 

MV fmafth crn p?cwam, such 82 IVM!.%+A AFaDC, of � mfffuq benofff pcqiram? 2 � No (,’4P) ___ ---.. —-------- . . . . 

b. Fw how f.znff was covzwud by mmms fzwMfh c81% fvwifzf?n? b. 00 � Less than 1 month 

(Hrnw mwty monffm Is 2!IM?I 

— Months 

M~ f?efortoag,,,). mdrnmk .qwwprkfebox. 

M4€ 1 � No wrson 55s ,. famw lHHc.f 

s � Other lSupDlemen: on 4wc31 

133 
0!40 No 0937.0021: ALIP<.w,l Eztiras M,,ch 31, 1086 

,O,M HIS-1 (SS) {1S84) MOTICE I“fo,m,ldo” e.an,,,.ed o“ th,, fo,m wh,ch would r,.!m,t ,de”t,f,c,t,,” d ,“, ,“dwd”,f or e,t,bl,,bm,”t ,,.,, ,4, h,, been collected w,th a gua<,”t,, that ,! w,II be h,ld ,“ ,tr,ct c.mfnde”ce, w$I1be wed 0.1” f., W190S.1 staled f.< 

th<sstud”, *.6 wtl .01 h dmclo,,d or r,h,’ed to others w,,ho”t ttw cc+sent .1 the ,“d,,,du,l m the ,Stabh,fmw”t 

u.S. DEJ~~JuM&N;H~~E;~~~ME8CE ,“ ,ccord,”ce w,h nct,on 308[d) of the PubNcHealth Sa,v,ce Act 142 USC 242m) 

Ac,lNa ASCG+,,C7M3.GEW FCnWf 1. u S. PU21rCHEALTHSERVICE 

�ook _ of _ books 

number 8-t O ‘Segmeo! 33-74 Sena[ NATIONAL 1s-1s ~l~;T#ylNTERVIEW 4. ;yutml

t 

SUPPLEMENT BOOKLET number r 1 � Male I I 1 z � Female ~ 1 

S. Find status of supplement ~ 9. Datt supplement 67-00 10. In,e,v,awer ,dmt,f, cation !Code 

�I -92 

o � No SP salected completed Name lnWvl*w 

I � Comphte intewiew (allappropriatepagescomoletedl 

2 � Pmti81intcfview (some but not all approprmte m ,

( 

pagesccmplmtedl(Explain in natasl NOTES Nonint@rv18w 

3 � Refund (Explain in IWtes} 

4 � SP temporarily absent. no proxy available 

I 

5 � SP mentdlv or ohvaioallv Incaoabla, no Droxy avsileble 

0 � Otlwr f.%pisinin tires)” I 

CONTACT PERSON INFORMATION 

b

� Contact informationfor this famllq unit already obtained, transcribe when Kfitmg. Fill item 15 b.slow, THEN go to HIS. 1 Household Page or next SOA. ResL+ toSOArespondanr8tendof Interview - Tba N8Nond Ca.tu for H*alth Svatistlcsmmywishto oontsctyouwat. to obtainmfdltlotmlhdth mlat~ 

kifwmatbft. -~ ma@mMm., addmw, �nd tel~on. numbarof 8cI08*mlatIv8w frbnd who woukfknowwfmr. VW cotdd ba mschwt In “r 62 

CMZ W- ham smub66 tsaehtmg vw. (PloasaOIVCnwtfmnamaof somsonowho Isnotcurwntiylivingintha bousshokl,)Pleasopdnf irerns 11, 12, 14. d,-A 

11. Contact Personnwnv 1ml � I 3-4 I S-24 I 26-3s1 

Last	 ~First , Middle 

# 1 ninittal z ‘pm-~ 2 � Refused 

Gr ! I 

12m Address (Number and $treetl & 14. Relat,rmship to Sample Pe,so” 10-$7 

18-21 

b. City ~ state SE-87’ Z,p ~8_*6 S. Supplement ending time 

1 , Code 

1 L ‘ w] {%%} !%%&&> 1 ! 

TRANSCRIPTION FROM HIS-1 a-e 

1.. Area codelmlephone number from HIS.1, item 11 ~ 17b. Malli”g address from HIS-1, item 6b 1 � Same as 6a on HIS.1 6 

Number and street e-30 

Q1 EIIJ-um 

F 

~ 17*. Exsct �ddreasfrom HIS-1, itam 6a (Ff@aaeprint it#ma 17a -cl ~ city 31-60( state 

Number �nd streatfdescriptlon 1 

# I 1 1 

I city pplicable) 

1 N Code 

1 

SUPPLEMENT ON AGING SAMPLE SELECTION 

M, Zlp c. SpecmlPlacename (FJIIif �

Use Table A or S � indicated on HIS-1 Hounhold CompositionPage, Circlethat letter and enternumber below to mdkate the order of intewi.w (1 = down 

from the top of the thting, 2 = up from the bovtom). Followth16orderwhenever two or more samplepersonsare at home at the snmetime. 

1 ppmfxiara fabl,% 

or olde, In the fsmlly? { 

I 

mark “W” box on HIS- 1 for each, THEN 19J 

2 � No (19) 

1 S. Are there Onvn0ndeNt6d persons5@!34 old in the famllv? years ~ 1 � Yes (Listbv age (oldest to youngast) in 10wer portion of appropriate table, mark “SP” box on 

HIS. 1 for each ‘,X” pamon, and begin supplement using the approprlare “order of intarviaw”) 

6 

I 2 � No (Se#n mtmvlew(sj using the aptvooriata %rder of mtervtew<al -i 

S. Are thwa anv nondeletedpersons65 ve8rs old ~ I � y.. (List by aga fc.ldast to you”gestl h upper porfirm of �

134 
01

02

03

04

05

06

07

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

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

SUPPLEMENT ON AGgR9G 

Section N. FAMILY STRUCTURE, RELATIONSMPS, SUPPORT, AND L$V#NG ARRANGEMENTS 

I � Avakble @dlb) �. Initial status of sample person I 2 � Callback required (Mxt SPJ 

NI b.	 Supplement bagmning time 

i m{ :~~: 

} Read to respondent -We �m Intomstwl In obtzi88kts ft!ttba? Infomwtknn �bom *BZOfsdth of pzopfa 55 yaars of �W �nd oldar hs 

tha Unitad Statom I wIN atso tmkyou m.mo quzstk)sm about your famliy �nd odd activitiaa. 

Ask or verify for each HH membw PersonNo. Age on Relationshipto Sample Person on HIS-1 HIS.1 

1. How la (name on HIS-1) mlalcd to VW? 11-12 [13-14 

Enter “Sample Person” on appropriate line. 

[17-1S 11s-20 

Emer ‘“Unrelated” for persons not related to the samp!o psxon. 

Enter “’fJeleted” for any deleted persons, except AF membars 123-24 

kving at home and bab;es born during interview week. 

Enter agm from HIS. 1. [2s-30 

137-38 

L47-43 149-60 

63-S4 165-ss 

,. 0s .—— . “.~i— 1— g, -“~ I 

w I 

p.5-ea I 1s7-6s1 

1


1 I � Sam.n!o fmrson is now married (N3J


N2 Refer to marital status (psgo 46 or 47) on HIS- 1	 , 2 � S.srnp!s parson is now widowed, divorced, separated f2b) 1 3 � Ssrnpb fmrson has never been marri~d f6J 

I 

N3 Spouse of Sample Person previously ;nferviewcd on SOA ~ 1 � Yes (6) 

2 u No /2) 1 

h.	 How long bavo you baan mwriwt (to (name cIfspouw))? 1 w � Less then one yea, 1 

1 (3) ! 

! Number of yews } 

. . . . —..—- . ----l- ____— —---- -— ___ __ —_-

b, Swfias [you told mall W~, tdtll that vow ON mow I 02 � Loss thm W13year 

[wldowod/divcwzadfaafszrz30cU. How fsmo tsavo 1 

you bam [widowad/divorcd/aopzrztwll? 

b,	 How many d your children ma GS.YJ:-%1kv 

many �a d@ughWa? 

WA . . . . ,,,! ,,,04, ,, ,, rJ., 

1 

1 

I 

-L--–––––––-–– 

, 

I 

I 

1 

+ 

I 

1 

Number of years 

Number 

Numbsr of sons 

Number of daughters 

/	 l_lTotal”.m&rof ctild,e” 

Cmn?:m with 3a, reconcile differences 

135 
---- ---- ---- ---- ---- ---- ---- --- ---- ----

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

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

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

----

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

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

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

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

— Soctlon N. FAMILY STRUCTURE, RELATIONSHIPS, SUPPORT, AND LIVING ARRANGEMENTS, Continsmd 

6s. How quickly cm [my OM of your childrmlyow son/Your L!&! 

daqihtwl tIOthww? , D Minutes 

, 2n Hours 

, Number { 3 m Days 

, 

-_ ;__ —--- —--- . . 

b.	 How often do you �m [WV ozw of your childmniyour ; 000 n Less than once a vea?hzever & 

swzlyaur daughtwl? ! I � Day 

, 2D Week I 

1 Times per 3 � Month 

! { 40 Year 

- &______ . ..— . . 

c.	 kfowoftmdo yout81kcmtho @ofzhom with [any ozw of I 000� Less than once a year[never I@ 

yaur ehlldmn/yznw sonfvwr daushtarl? 1 1 � Day 1 2� Week I 

1 3D Month 

----1 ~ { . . . . 

d.tfowofMm doyou@fznaik from[anyorwofyow I coo � Less than once a yearlnever M 

chkldmzzfyour @our dm!ghtw]? t I � Day 

1 2 D Week 

1 Times per 4 a Year 

I Times per 3 � Month 

1 { 40 Year I 

, @ 6.	 [Do vow cbUdzwn/Doos your son/Doos vow dau@htw1 I 

1 I U Yes 2outkAy gkva you -v to fwlp Wftf2y022rlh.fng 

�W-O 0? Psv your bilk? ! zll No 1 

69. ~~timWW)dWZX+WZI bmthws, how mw2v LIVING / can Nme @ 

1 

1 Number of brothers 

1--------------- ) —- _ .. 

b. lnolzKWZW~ md adc@ad dstars, f20W many LIVING I 

1 m � None I.!.W 

siakws do vou hava? 1 

1 

1 

I Number of sisters 

103-1 7. How kmg ha yw bn22 NV* hww, 122Zf2h Ih2J2u0fak2wt21w12tl? : m � Less than 1 year 

I


f Number of years


I


N5 Other fsmily member previously inrawkwed WI SOA ; I El Yes (12) 

2 •! No (8) 

Mark if known I @ 

8, Is this ~qmtmwit] iw � RETIREMENT 1 

I 1 � Yes 

[c--~ 02 Zmmf2kd? 1 ZD No (10) 

1 @


~ s. wfwtfwry02s2w9shwn 022mf, aradwf~s42ukw2 

�vallabb bzTHIS ~mont [conwudty fbdMk2g w ew22p10xl? ; I � Yes I 20N0 � . %XP.vh fw. 2d2kw2q? _. __ . . . . . . . . . . . . . . \ _. . .. . . . . . . . 

b. Hmmafzooping or mski suvlce? 1 

I 1 •1 Yes l-u 

1 z~No l---- .—. . . . ! e. Mwmwl W2Vic#s? t t � Yea I_l.u 

zCJNO ~ 1..-. .-— _ _—-. .—.

1 d.	 Tol@soswzwSswvlceto chcckonyourwaUbokw? r 1•1 Yes lx 

i 213N0 1 . .. –... 

c. nOwOaWmd 242vfc*8? 1 1 � Yes l-?..u 

1 

! 213N0 

;10@.lsk NECESSARVWWq W~maqW~~~ ~ ICINO ~ 

~~-~~? 1 

1 Yes – If not mentioned, ask: Is it ozu or nzora thuz otw>

1 2 � 1 step 

_______ 

u 

1 3 � More than 1 step 

!-------------- _ – _____________ _____ 

b. Czumtkwsbassmant8 assdstopdwm~amasu I m 

9oPu* kswls, &s tflh [htwsd Wwtm@@bw- ; I •l Yes 

tf2w2wwf100rorlw9k? 1 20 No (Ilbl 

1 

.—. 

136 
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------------- ------------- --- ---------- ------------- ---------

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

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

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

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

11 

1 

~ 

:$ 

137 

“–tll-ii : 

Section N. FAMILY STRUCTURE, RELATIONSHIPS, SUPPORT, AND LIVING ARRARJGEMEk’JTS,Continued 3-4. 

11 �. Does this [house/apartment] have � bathroom, bedroom, ,“’ Yes 5 

�nd kitchen ALL on the SAME floor or Iw+al? >“-. No 

b. Docc this [hous@/apartmantl hava � walk-in shower, that ~:1 Yes 6 

16, whore You don’t step over the side of the tub to get into 

tha shower? >“, No 

12a. Bacause of a health or physical problem, do YOU NEEO ,: Yes .

7 

a bathroom, bedroom, and kitchen �ll on the same floor z’: No or Iavel? 8 b.•Because of a health or physical problem, do YOU NEED ,rl Yes � walk-in shower? 2’-; No I 3n sww3h parson hves alone f 14) .L 

N6 2n Sampla parson fwes with spouse only 

Mark ftrst appropriate box 3~ Sample !xrsm hves only woth persons lN 71 

under 18 years old [and spouse) } a n All othar ( 13aJ 

-. 

,“

13a. Oo you �nd @a$~ames of all other household members) live 1El Yes togathor NOW bscm!se YOU need to shara living �xpenaes? ; ZU No --l . - 4 . . . . . . . . . . . . . . . . . . 

b. Oo you and [read names of all other household members) Ilva together ~ I � Yes NOW kwcauscof � hmlth or physical problom YOU have? ! zm No + 

I 

N7 Spouse of SP previously interviewed on SOA , 

1 

t � Yes (Section 0) 

2D No (14) 

148. Is this [houso/ap8rtmentl now - 1 

(1) Owned or bdng bought by you (ORsomcontt in the Iuxmeholdl? . ~ Ii3 Yes f14b) � No m 

(21 Rmttadf ormonay? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ID Yes (14h) � No E 

(31Occuplmdwithout pavmant of monay rant? .1 I 11 Yes (SectionO) E 

:--- ---— b. Who owns or is buying k? , I � Sample person 1* 

1 Anyorm �lsa? I

, 2 •! Spouse 114CJ 17 

I 3 � Child ‘la 

I* Follow skip instructions for 10west numbered box marked. I 4 � Grandchild 1 5 � Other relative {Section 0) 20 I 

1 6 � Nonrelative 1 E a -&. 

c. Is this plnc@ fully paid for or Is three 4 mortgaga bohtg paid? ~ I � Fully paid for f14fJ 

1 2 � Mortgage being paid 

: 90 DK (14f) 

-1-------------

d. Do you know �bout how much prlnclpd h still owed on the / I � Yes -= 

s, How much pri;~l~~;i;~;ili;w;~7- --- l--- ,“ 12H! ! 

, $ I Amount +-----— -----—— —----

mortgage? 1 2D No/OK (14f) 1 ---

f.• Oo you know tha proswtt value of this pfmco,that is, about how : r E Yes 

much it would bring if YOUsold it on today’s market? , 2 � No/DK (Section 0) 

. . -. - ; ___-_______-,-- . . . 

g. What is tha proswtt value? @ 

, R%ctiOn 0) 

—_—— Amount ____ ____ {------- h. Who Is paying rent for it? I I � Sample person 37 

1

1 2 � Spouse 38 

Anyona �lma? 1 3 � Child 39 

1


I 4 � Grandchild 40


1 5 � Other refative 41


1

I 0 � Nonrelative E 42

--

$.ctlon O. COMMUNITY At%iY WXWkf. StJfVORT 

I ~ I L Sample person is 55-59 (3)

01 I Refer to age > ? Sample parson is 60 or older 11) 

I NOTE - Ask 2 immediately after recewmg a ‘,Yes” m 1. 2. tfOW oft,n did YOU UZ4 if - hqucntiy, Read to responden$ - Tha Mxf qoastions am �bout sozn.tinws, or rm81y? cammutzhy sorukas.€

i ~ & 1. In th.past12 months, dJd YOU - I	 t Cl Yes , ~ Frequently 

2!zl N0 2 G Sometimes Reask 1and resume list 

C,rttw? 1

1 ~� ~~ 

} 

(Next SWVICL7) 30 Rarely } � . u- 8 Sarlvor

~ b. Usa s+wekl tfmfwortaticm for tha : I n Yes I D Frequently @ 

�ldofiy? 20N0 2 � Sometimes Reask 1 and resume list 

: ~ D 0 K (Next sew;cel 3 D Rarely } I }€

~€ ~ c. H-n m-k ddivwod to your horn- I ~@ Yes t a Frequently 

by �n Woncv or 0ruU2fzatkn Iko ; 2UN0 2 � Sometimes Reask 1 and resume list 

M*8Is on Whaak? I ~ ~ ~ ~ } 

(Next service) 30 Rarely } I 

~ ~€ d. Est mods In � 8MJW cmfcr c+Jn : 1n Yes I � Frequently 

Sozna PI=* with � sp@cM Zf2aalpro. I 2DN0 2Cl Sometimes Reask 1 and resume list 

gram for tha ddwlv? 1 ~ � o ~ fNext service) 3 B Rarely 1 } }€

~ � . Un � h-makw MNIC. fof tha 1 1� Yes l_s~ t � Frequently 

ddwfv that provtdos 8wvk9s Mm ZONO 2 Cl Sometimes Reask 1 and resume list ckmittk! �ndcoofdnff in
the hozno? ; ~ � D ~ } (Next serv;ce) 3 n Rarely } 

,€ f. U-• aewka whkh makes routirn t D Yes L 54 I � Frequently -TIC 

td@f2h0t’W Cdk to chock 021the ! ZDNO 2 Cl Sometimes Reask 1 and resume list 

Imhh of �lzhffv pmpk? I ~ G D K} fp~extser~lc@~ 30 Rarelv } —— — 

g. U* � Vkltlnfjm2f8*nz’vko? 1

1 8U Yes ~ I D Frequently ~ 

ZUNO 2 ~ Sometimes Reask 1 and resume list t 9,u o ~ 

} (Next service) 3 D Rarelv } 

~ h. Usa � hadfft Afa who comes into ! I Cl Yes L 68 t O Frequently 

the	 homa? 1 2~No 2El Sometimes Reask 1 and resume Ii?t I ~ D o ~ (Next service) 1 } 3D RareIV } 1 

~€ ~ i. U- wftdt day C-N or day C#M fw the I , D Yes I D Frequently 

�1CJWJV7 1 20N0 2 Cl Sometimes 

1 ,DDK } ‘3) 3 n Rarely 

I & 

la. Inth,p*t1212’20ntf29, dJdyou do �2IVVokmtcw work for �ny , 10 Yes 

Orgmixod Jfr022p? $ :~No ,4) 

, 9UDK } .— ; . . . . . . . . . . . . _____ ____ 

m b. kfow oftm did y022do W2fUIVtQ0f€ WWk - fwucntfyr sonmtitnec, of rarefy? ; I ~ Frequently 

2 U Sometimes 

I ~ Rarely 

Hand Calendar 

} Read 2. respondent –	 The ZWXftfzmsfkns r-far to the Z WMAIS(Outlind in md w that =Jmcfar), b@nnkw Mc4wfav@z.@ �nd �tzdingthis WSt 82212deY(UL€

, @-€

1. During fhosc 2 wdts dJdvw -€

s. Gcf t~ethw 80cidtV with friends or ttci@zbom? I ~ Yes 217FJ0€

..-.. —. . . . . . . . 1€

(€ b. Talk With ffknfk or tmbhbora on the td@mtze? I I-W€

I n ‘/(3s 2[1N0€

.,.€

e. Gat togc;hor with ANY-roiat;os (not-includinkthousaftoJdnwmbw;l? 1r2ye5 2rl PJo L_!?l 

, d. Talk with ANY fOkiiVOS on *ho fokphc.rw (not including l:lYes 2L1fiJ0 [.X_ .. houaahold nwmbcrs)? 

� . Go to church or tempk for sowices or othw �ctlvltios? t k 

I rl Ye5 2.1 No ( 

f. Go to � chow or movio, spofts �wrnt, club nmofizttt,CICSSOSw 1 !!-

ofV2*rgroup �v*nt? I [“: Yes 2!”:N0 

I ~;Self (5) 1 K. 

02 Respondent 2 ;-; Proxy fSectlOnP) 

~ 71 i. fkgsrding Vour present social �ctivitks, do vw fsol that I ‘ ~About enough 

you W* doing �bout wfough, too much, of would YOUIlk* z Too much to h doing mora? 3, “~Would I!kem do more€

. . .. .. ... . . . .€

138€
--- ---- --- --- ----- ----- ------ ----- ----- ---

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

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

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

,11 

~ Section P. OCCUPATION AND RETII?EIWENT 

& Refer to WalWb boxes /or SP in C 1 on the ,~ Wa or Wb marked (Id) PI HIS. 1, Household Composition Page s C: Other (18) 

� . Have vou EVER worked �t � job or buslncxs?	 , m Yes ~ 

2 fl No (2) 

b. HmImvou work-d it � job or bushtas;, k �nv time slnco vou ; 1 ~ Yes L_.z.­

wara	 45 vcars old7 2DN0 

9170K_}_ 

12) 

c. Old vou work �t all �t � job or busitmaa in the p=st 12 “V ,~Yes -L.& 

months,	 that 1%dnco 112month date) � year �go? 1 2 tl No (2) -. . . 

d.	 SInc;; 12 month d~tel a par ago, In how M;IIV wocks did VW- I 52 � All year – 52 WeGkS -b 

work, �lthar full or part limo, not counting wark �round tha , house? Includa paid wacatlona�nd paid sick Ioav*. , 

, Weeks . . . . . —---- -..-—- -— L— 

� . In tho weeks that vou worftad, how manv hourss 

vou USUALLY work m ALLJobs? 

w-ok did I 

, 

w 

Hours , 

!h. At this lima, do vou consldw yourself comphtslv 

partlv retlrod, or not ratlrad �t �ll? 

rsthed. i 

1 

I � Comptotely retired 

2 n Partly retired 

3 U Not re!ired at all 

~ 

131 

! 4 n Never worked } 

1 ~ 1 I fl “No’”in Iaor lb (3/ P2 Refer to SP’S work status in la and lb 1 

1 8 � All other (2b) 

&

!b. Hw+ovou retired mom thmt once? 1 , n YeS 

1 

.---— —-. —-- : afl No “. 

c. How Io”g hag It fmgn slnco you retired (the I@sttimal? 1 w � Less than 1 year m 

, 

,

, Number of years I 

k-- -,i -

d, ilik-hiitimi ~oi Xlr-d-) hi io;hilrnrnilit~ ftwauao of � : I � Yes (3) health or phydcal problcm you had7 20N0 ---’ ~ -

c. {That tired Did you rotlro mainly becausm vou thought your 1 -ti-
 work would cauw # haslth problcm? 1 1 � YeS a -—.No. 

Hand card SOA 1 or read sources for a talephona interview ~ $ la.	 (Evan though vou do not .xxmldor vouraclf ratircdl Am 1 t � Yes you NOW reccl~ing RETIREMENT Incomo from wtv of 1 

thcso sourcas? Do NOT btcludo �ny disability incoma. 1 2 � No (6I 

, 

b. Which onca? Mark all sources given Note - Ask 4 and 5 for each source marked in 3b 

Anv othar source7 . HOW tong hava vOU been Mceftffq 5. Dovou NOWme@feelt bc8unaf Vmn 

(source in 3b)? OWN WOtk �XXO OCb9C@MS4 V- ON 

•tkfnndmltw~of~w? 

1 

t n Social Security W w � Less than 1 year t � Own ~ 

I 2 � Someone dse 

Number of years I 3 � Both 

2 n Railroad retirement ~ m � Less than 1 vear I •l Own ~ 

Number of years I 2 � someone else 

3 � Both 

s 11 A private emplover or m m � Less than 1 year t � Own & 

umon oension 2 •l Someone else 

Number of vears a � Eolh 

~ ~ 4 E A government employee pension l--.zl 00 fl Less th3n 1 year t � Own 

(Federal, State. or local) 2 � Someone else 

Number of years 3 � Both — 

~ 1-] Whtary retirame”t ~ 00 n Less than 1 year & I n Own ~ 

2 n Someone else 

Number of years I 3 � Both 

6‘ SOM.9 other source - Specify L-?.!_ 30TNOTES 

d 

42-4 

?Mw , !,,!, ,,,4,!, ,,,4 

139 
Section P. OCCUPATION AND RETIREMENT, Contlnud 

6. Am You now -.ivinti dlubllfty ssymwttc frcm �ny SOW.*? : 

7.	 Am ,fou NC.IVIC3Udlssbllfty payrnent8 Iwrxusc of � dlcabl{lty ; Lx 

You f3wo*f.2’”2’aB you �r* � ~nt or S.WVIV07 of TZI Own 

�— , 2 Cl %mwone else (9) 

( 3 El Both€ )€

If more than one, record the Ioflgest one. 1

, I I NJriaW of years I 

) Nofa - Ask 10a-j befora asking 11 and 12. $ Eof*-Ask lfcnd12foreach,y~sj” ICIa_J. I 

Raad to renpondem - . How much diffkuitv do YOU ‘12. For how infig have YOU[h*d 

havo (acfiiitv in fO), 80MQ, � some dffficuityllmd � fotof

~ M 333sff YOU 33w0 ANY #JffficuhY wfmn YOU do tho lot, or �, you unabla to do it? Wfb@fboon utmld. to] loffowhw Udvftfm - facd;ity in 10)? 

, ~ ~ I o. By yowdf arbd not using dds, do you f , ~ ,te,7E 

I El S0m8 mu Less than 1 Year f30v0mydfwwfty-€ ! 2U Alot€

a. W** fOraqumfuofamlh {tfmls j zC!NO 3 R Uneble ab0ut2w3bf00ks)?	 # 9 ~ NA, DK Nu,mbar of years 

— ~ ~ @€ b. WAdnfftIP1O ~wfthoutr8stinS? ; 1 cl Yes I � Some oo~ Ltws thm 1 year 1 zo Alot I z~Na 3 Cl Unable€ t s � NWLYK PJumberof years€

~ ~€

c. ~yybng 033 your foot for 1 1� V8S LS_ I •l Some COD Less than 1 year I

I

1 2 ClNo

1 s � NAIDK I

t Number of years€

1 E ~ ~ d. ~fcxdmuf2fmum? 

!

1 I � Yes I •l Some c*D Lass than 1 year 

2nAIot€

I z~No s � Unsble€ 1 a O NA/DK Number of years€

~ �7-

t R S0m9 NO Less tbsn 1 year 

z~Alot 

s ~ Unable Number of yams 

~€ ~€

t Cl Some con Less than 1 /ear€

2DAI(X€

3 D LWrble Number of years 

~ 76-

I n Some ciao Le6s than 1 yew 

2tl A10t 

~ ~ Unable 

I Number of years

7sI •l Same m~ Less tt:an 1 year 

I Number @fveers€

3 a lJnabIe I Numbnr of years€

140 

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

$sction P. OCCUPATION AND RETIREMENT, Continued 

~ 

Refer to Wa/Wb boxes for SP in C 1 on the 1 

, I ❑ Wa or Wb box marked (Section 0) P3 I HIS- 1 Household Comwxition Page s ❑ Other (P4J 

1 & 

1 tiJSPis 75+ (Section Q)

P4 Mark first appropriate box 1 2 ❑ Proxy } , 

1 3 ❑ Self response (13) I 

1 ~ lJm Do VOU think lhwo ●m SOWN kindsofWOfk t ~ ❑ Yes you codd do nowIf Jobs WON WallGbf@? 1 20N0 , 

1 9 ❑ OK/maybe } 

(Section 0) 

-. p . . . .. . . . .. . . . . . .. . . . . . . . . 

to Wdl at ● job or busincu? 1 b. Do WI WANT 1 I 13Yes “bi.- 1 aoNo 1 

I FOOTNOTES 

141 
S..*i.. 0 rnhlnlmtmtc aun luDalD~ENTs
 ““.-.. ”,. -. -.. ,.-, , .-,. ”n,. ” ,,., r at,”,,._. ._ 3.


Read m re.spcmdent – Now tell me if you have �ny of these eye conditions, even if you have mentioned them before. 

1. Do you NOW have – s 

� . cataracts? I Yes 2 No 9 DK 

b. G18ucoma? 6 

, I Yes 2 .No 9 DK 

c. Color blindness? !—7— 

1[ lYes 21 .No 9 .DK 

d. A datachuf retina or �ny other condition of th~ ratin8? ~__,_ 

Circle appropriate co”ditio” I TJ Yes Zr”! No 9LDK 

7 

� . Blindttosa in otm or both �yes? L1 

Yes If ““Yes,“ ask: Which - on-o, both? , 00 One 2UN0 9[J DK 

, : ~ Both (Qlj , 

f. Any othor troubla scdng with ottc of both �yes EVEN wftan ~ LIP. 

w9arlnff glassas? , I D Yes zDNo 9[]DK 1 

1 ~ I :n All 4,N0,. or ,;OK,, in la-f (2) 

Q1 Refer to answers in la- f 1 8 � Other - Enter ‘<Yes,, responses in EYE LTR box on 

I Condit#on Summary Chart. THEN Q2 

! ~ 1 I D Yes (4a THEN 9} Q2 Blindness in BOTH eyes repxted in 1e ,

! 2n No (2) , 

& k. Do you usa �yaglasses? Incluch �v@ass.s that just magnify. ~ , n Yes 

!

( z � No (3J 

1 

b. Wom thaso Qy@a;sos pNICifbd for ;w7 ( lJ5- r I IZ Yes , 20 No 

1. Do vw uu contact luwas? 1U Yes @ 

,

k 2rd No 

4u. Havmyou �WWhad �n op.rmion for catwscts? [

I I n Yes ~ 

1 z � No (5) 

;-

b. io~ou havg � Ions Impfant? 1 I � Yes Lz 

, z~ No I 

( ~ 5. L% you uso � magnifying glass to road or to do othar CIOU work? , t @ Yes 

I Zn No 

I Read to respondent - Tho twxf faw qtmstlom �m �bout how w*II vou cm - (w*arirtg vow [glasus/(orI contact 1..s-s] ff 

that’s how vOU ,.0 boot). 

~ Oa. Can you �a wall �tottgh to racagnizc tktofmfur.s of paopfo I I � Yes 

ff they �m within two or thrw faot? 20 No 

, 

b. Cm ~ou saa wall � noueh tow~tch T.V. 8 to 12 foot �way? I I U Yes w 

I ZD No 1 

c. Cm ~ou 8- WOII � 1 nouah-toroad ns-wspapai print? 1 1� Yes k 

! 

I 2D No 

~ 7a. Can vou sowWOII�nough to stap off � curb or down � stop? I 1� Yes 

c 20 No 

other side of tha sent? 1 1� Yes L_z 

I IDNO I 

B. Whkh statomant b.st chscrlhs vow vision iwoarh-tg[glasaod I t � No trouble & 

(or) contact Ianna]) - no trouble swing, � Ml= troubf., or � t 2 � Little trouble 

{------- b. C-a; Vti ;oa Wd! ono;;h ‘&-&”~”nizo � frhid walking &-tio , 

lot of trdubfa? z 3 � Lot of trouble 

w .,. , ,<.,r,..., ,. !. . . . 

142 
---- --- ---

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

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

---

--- ---- ----

--- ---- --

-- --

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

---- -- -----

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

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

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

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

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

Section Q. CONDITIONS AND IMPAIRMENTS, Continued 

Read to respondent – Thosa ntxt quastlona �re �bout hearing. : ~ 

9, Do you NOW haw -

� . Tlnnltus or dnglng in tha cars? Circle appropriate condition. I U Yes 2i. NO 9GDK 

b. Daafntas in on; &-h-th &a? Yes I..-zL 

If “Yes,” ask: Which - c.noor both? t 0 •l One ZUNO 9[~OK 

, � Both (03) 

, c. in~ &h#; iro-u~l; ha;riti with cm- or both �ars? , k 1 1 � Yes 20N0 9fl DK , 

1 @ 1 I � All “No” or “DK” in 9a–c 1101

Q3 Refer to answers in 9a – c	 , 8 D Other – Enter ‘“Yes” responses in EAR LTR box , 

, on Condition Summary Chan, THEN 10 

~ h.	 Do you uu � hearing �id? !

I * � Yes 

1 2DN0 

+ b, (With y~& h~ming �id) C~;y~~ hear M“OkT of &o things I

I 1 n Yes (11) k pOopl* Say? 1 2CIN0 t 

c. (Wit~y-M-r~:a;n-g ;ti)-C;;y:; ~~r ‘ONLV A FEW “WORDS : I El Ves l-x--­ paaplo smyor LOUD nolaas? 

I :ONO 

I ~ 1. Which statammtt bast dtscrilws your h~ming (with your I I � No trouble 

hcarlng dd) - no troublo haating, � Iittla troubfe, or � lot of 1 z � Lettle trouble troubla?	 I 

1 3 � Lot of trouble 

1 

Read to respondent - Plaasa tall ma if vou havo EVEfI had �y of tttafollowing conditions, OVWIIf you hava mantiomd thorn b.fora. 

L Havs YOUEVER had - ~ , 

� . Oat.oporoals, �omatimes callad fmgih or soft bon.s? 1 

, 

I •l Yes 2@N0 900K [0s tee0 po ro’ sis) I 

. .; . . . . b. Abrokonhip7 - ‘----”” ‘-”------”” I “-w I 0 Yes 20N0 900K , . . . . . . . .. . . . 

c. Hardmln@ of tha �ttorlos or �rtwkmclmroals? 1 -l-xCircleappropriate condition 1 I � Yes 20N0 sOOK 

;. . . . . . 

d. Hypwt-m-si~, somctlmas cell;dhl~h ~l;~ prna;u-m? - , k 

1 1 � Yes ZDNO !IDDK 

I -. _- .- . . . . —.. . .-. -., . . . . . . . . 

� . Rhwtmatk fewr?	 1 k I I � Ves 20N0 9nOK 

- j . . . . . . . . . . . . . . . . . 

f.€R~m-atlc-h;ati”di8usa? - - - - - - - - , E 

I , n Yes 2DN0 900K 

;---- . . . ---—-

e, CoronarV heart dissase?	 , -l..zI­ , I � Yes 2DN0 9UOK 

. . -. -.. . . . ; . . . . .. . .. . . . . . . . . . ..-

h. Angin8 pacto?im? 1 l-&­

{pek’ to ris) 1 ~ Q Yes 2DN0 9DIJK 

.. --—-. . . . . ;.. – . -–-.-.... _. _. ___ 

i, A myocmtfial Infmotion?	 1 -l_x- 1 I � Yes 2DN0 9DDK 

—--- -.. —. - ; 

j.	 Any othm fmwt �ttsck? , u 

I I � Yes ZONO 90DK 

1 ———- —--- * __ -.. 

k, A stroka or � CSr~OV~SCUhf �CCid411t? I w I lser’ a-bro vas ku Iar) I •l Yes 20N0 9CIDK I Circle approprlnte condition 

.- _ ; 

I. Alxhalmm% dlscase? I E 

(al’2i mars) 1 t � Yes 20N0 9DDK 

_ +------- . -_. E 

! m, Cancer of �ny kind? I 1 � Yes ZDNO sODK 1 

1 

& ! I� All “’No”’ or “DK” in 12a-m (T3)

Q4 Refer to answers in 12a-m 1 

1 e � Other – Enter “Yes” responses in EVER LTR box on Condition 

Summary Chart, THEN 13 

,M“(a,,$B),,OW,3,304, 

143 
-----

---

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

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

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

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

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

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

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

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

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

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

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

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

-h cl Pnuns’flnua awn au.. mmu=u.. . . ..*x­ s. ““..”. . .“,. - --” ,nlrn, mmlcm ,-, w9nxln---

~ I.	 ~ ~ ~As7 13.MONTHS, * VWJfww - 1 

1 8. 

cirCb �ppropriate condition [

1 . . . . . . 

b.ti;;?------ ‘ “”-----’-----’-- - “;- k 1 1 � Yes 2DN0 9DDK t 

Artftdtle ofrnykimdor dwumdmt? I I � Yes 2UN0 90DK 

____ _ ~ . . . . . . . . . 

e. ~ ~? 1 k 

(M’	 voo rizm) 1 1 � Yes 213N0 sODK 1 

4 

4.	 Amy bfwod cfot87 1 G 

1 1 � Y*S 2UN0 eoDK 

_____ 

�. ix&l&-&i&>--------- ----------------q w 1 1 � Yes 213N0 sDDK 

1 

8 ~ 1 I � All “No” or “OK” in 130-0 (14) 

R5 Refer to �nswers in 138-. : 8 � Other - Enter “Yes” respoows in 12-MO LTR 

box on Condition Summary Chart, THEN !4 

~ la. OwbWtfNp.et 12 nwnlfw, dutb, sfneof12-month dsre) 1 1 � Yes 

�W+. hmmfti? I z � No (74d) 

b.%wmamy~?----------- ‘------------ ;--; ~o;e- ‘ ‘ ---~ 

I z � Mom thm ona 

o.[Mysf~~~”**f*]~y~*~? --~-_ , 1� Ym (f4~) 

-

m 

1 I~NQ 

d.be-a-~--=iirfih-~? ‘“”------”~-

r 

‘“- ‘“-- 1 � Yes ‘ ~ 

I 2 � No (IS) ____ . . : . - . . . . . . . . . . . . . -

� . -~ fJvemtYOuimamvwWfrom 0tfwldnc0wldd07 i+3bWtftJngsy0tl , 

1 1 � Yes E 

ZONO 

~ 5. 00vwhau9trw#bh bftkgO?~mvihdsOff trod, 1 1 � Yes wwhasfkmmamw~s? r 20N0 If �sked - includes wearhtg false tecthfdentures. 1 

Read to mspordent -$ =: detwmbw hOufwAtflpmctkwewIdcOn4t&mg ammlmwJtOhow lw$gpwtp14 fin, w,wtifk0 

sMetIedmrmrdDnUbttbbwd bVtfw Nmiowof CwttwfWH&SigtIMICs. 

m.	 ~ I hava vow data of bkth u Mthckte from item 3 on HIS- 1 Household I 

Compasit{on page). I* that c0tr8et7 Date of birth 

i~ ____ ____ ____ _ . . . 

b. lnwhm8twtoorce+mfry wwsyowttme? M � OK w 

I Write in the fulf name of the Stma or mark the �pproprkte box if the I State ~m’wk Pomon was not Lmm in the United States. 1, 

01� Pwrto I Rico 050 Cuba 

1 02� Virgin Islands oeO Mexico 

1 oaO Guam mm All other countries 

MO Canada ____ .._. . . . . .J_. ____ ____ ---, 

e.~hv@J&_tikmhdf-,~ / Last w 

1 

I Firm ~ 

I 

I 

I Middla initial & 

1 --, ____ ____ ,___ . . . . -J __ ,-.. .._- _-., --~ 

VwIfy for malu: .wk for fmnafes. 1 -E+! 

d. What was vow fsthw’s LAST rNtn97 1 

Vwify spelling. DO NOT write “Swns.” Father’s LAST name ..--. — _____ -_ I ---------- . . -

Read to respondent -We 81ao rmwl your 2wJal 2uwrNv Numbot. 

Thf9k&wmawmbv0kmtmy amdc0t&t0d 

\ wasssoas� D K m 

LmdsdwwtfldtyOf tfwPub4kffo2u -

vkm Act. TfUMWwbOfW OffOCEWIvUW 

kunfitew—4rmblf0muti0n WHfkwgiwmta 

-v-~w—w---

; 

; 

1, m-m-inn -v. social Security Number 

Read if necessary -lJu&~&~&wmka Au la titla 42, ! 

� . WSutbvour Socfml 2uwttv NutnbDr7 

, s8ctiaI 242k. I 

1 Mark if number obtained from— I � Memory 

2 � Records E 

1 

. . . . . . . .. . . . . . .“ m. ,, H,,, H., ,, ,,..,, 

144 
--------

~ti,t,m, 

riiii( 

SootIon RI. ACTIVITIES OF OAILY LIVING (ADL’S) I a-e 

F?c#d to respondent - Tho Msf qtmstlons �m dzout how wall YOU�ro dzk to do ctttzin �ctkitks -

by yofzrsclf and wlthwf uslns spzckl oqulpmont. 

~ ~ ~ 1. sazaucaof � h8#th or Physkzl (11 (2) (3) SW#WII&& youham ANV hthlns or �howwlw? Omsdno? E-tins? 

Ask if “Da#sn’t do,,: 1Q Yes 1� Yes 1� Yes kthk boawza of � ffEALTff w 

�S4VSICALPIOM2M7 20N0 2DN0 20No N ,,Yas,’<mwkbox 1; if ,<No,,< s � Doesn’tdo for othar. aason 3 � Doom-t doforolherreas.m 3 � Ooesn’tdo for othw mason mark Lmx 3 

Ak 2-6 farmch AOL marked ~ ~ & 

“;ca” In 1. 

2. �vyMWffm2dwithwfuo InS t � Some ! •1 some T � Some 

~W+=&~*=~h 2a Alot 2D Alot 20 A10t 

-,afet, wzmyc.uuiubs, 3 � Unable 3 � Unable 3 � Unable 

t0d01t7 

~ ~ ~ s.	 06v0ur2dciv2h0ff2 fr0m 

Hmlfn?Pu2Qnkl @&)? 1 � Yes I � Yes 1 13 Yes 

2 � No (5) 2 � No (5J 2 � No (5J 

08. WhOsfwcthb hbtp? 4z. Sourceof help I 4b. Paid 42. Sourceof help I 4b. Paid 4z. Source of help \ 5b. Paid 

8-111 12-35 26-2s1 29-32 42-461 4a-4 

Anv0n92S2a7 HH member I 0 � s/c/P (6) HH member I 0 � s/c/P (5) HH member I 0 � s/c/P (5) 

~aiki~ ~l~P-box without lDRddvO. .,, ~ IDYes 2DN0 t � Relative. j IDYes 20N0 lmflelative . . ..~ I � Y,S 20N0 

�sking if ONLY help k from 2 � Nonrelative . j I n ‘es 2 � No 2 •l Nonrelative [ I � Yes 2 � No 2 il Nonrelative ~ I � Yas 2 � No 

#pause/chNdr#n/par@nM. Non-HH member ~ Non.HH member ~ NomHH member ~ b. kthfohdppaldfor? 3nRelntive . . ..l IDY08 2DN0 3nRektive . . ..l In Yes ZDNO 3DRektive . . ..l I DYes znNn Ask N nemasmy: 4 � Nonrelative ~ t � Y.S 20N0 ~ � Nonrelative ~ I � Yes 2 � No 4 � No”relative ~ I � Yes 2 � No Whbh h21P2Mam P&L? 

~ & ~ ma. 00 VOuUn my SP8clal 9qlAP. 1 � Yes 1 � Yes t � Yes ttwnt or Ms fn —fAOL)? 2 � No 12for next ADL 2 � No 12for next ADL 2 � No (2 for n-xi ADL with ,>Yes,, in 1) with ‘>Yes<<;n 1) with ‘+Yes<<in 1) 

b. whm&ywlO”dPlnMt m SP8cid equipmentor aids Specialequipmentor aids Specialequipmentor aids 

ARyfftbfg Sk,? ~ V E 

3s-20 E E 

Ask 6if myADL marked ,,Yes”in 1. � Old ago f6c) Im	 Whzt (otflwl Candltbn Causes ttw troubk tn (rind ADLkJl? 

Ask if in)ury or operation: 

%XWW%&%w7’ 

Enfw in/urv if ovw 3 months �go. 

Ask w mssk 6b, ifO–3 months 

Injxy or 0p8rmion. 

Ask If opmtion over 3 months 

#uo: Fat whatcondltlat dld 

vou ham tha ofwztbn? Ent.zr 

condition. 

b.	 BUbJOZ on M n , k tfwm MV Mftw#i&i%hkhc5fthtroubfaIn Im#d ACILM? � Y.. lRemk 6a nnd’b) 

� No f6dJ 

o, k thk lroubk In re#d AOL 3 (mttoed byMY (J=l+#. � Yes (Reask60 and b) 

� No 

~ If mult{pb conditions, including old (1 I & (7.) ~ (3) 

8LW, �re Iktcd in 6a, ask 6d for 1 � O-3 month lnj/Op ONLY I � O-3 month lnj/Op ONLY ! � O-3 month lnj/Op ONLY
 �ach AOL with � “Yes” h f.


Othcrwbc, mark appropriate box 2 � Old age } J 2 � Dld age } J 2 � Dld age } J
 or trmwcrlbz the only Iistad Ask 6d fw nuxt AOL with ‘,Yes,, i“ 1 Ask 6d for “-M ADL with ‘,Yes,, in 1 Ask 6d fo, next ADL with Was,” in 1
 condhion for �#ch AOL.


d. Whkh of thozz oondlfbnc, 30 30 3CI tit k (r#sd conditions in 6a) 

Would vouwvhzlm Mm Condition - En:er in ADL box on Condition – Enter in ADL box on Co”dirIon - Enter in AOL box on 

aDWa of tftztreub!z ItIfAOL)? Condit;onSummar~ Charf, THEN ask Condition Summary Char2, THEN ask Condifion Summary Chart, THEN �sk — 6d fornaxt AOL with “Yes”In 1. 6d for next ADL with “’Yes” in 1. 6d for next AOL with “Y#s” in 1. 

FOOTNOTES 

145 
OAILY -----

----

m 

LIVING fAISLOS1.CCNZSi2tUad & Sadon RI. ACTIVITIES OF —...—.—. ._____.. ___...... . . 

Rzzzk 1 (4) & 

adtflwln+8u20fm wcfNira? 

1 a Ycs 

2UN0


3 � 0022n”tdo fcwofhzfrcszon


~ 

!Clsonw 

zDAfot 

2 � Un2bi2 

~ 

1 •1 Y*8 

2 a No (6) 

14iM2n2b2r 

IO RzIativo . . . . . 1aYe8 2DN0 

2DNonrd#tlvz .1 lD Y., 2DN0 

la?-HH mzti ; 

3 •1 R2Miw . . ..11 DYas2DN0 

4DHonrWvc.j IaYea 20N0 

~ 

1 � Y*S 

2oN0(2f0rn2xf ADL 

wfth “W” in 1) 

Sp92ial mfuipnwnt or �ids 

~ 

G 

~ 14) 

I � O-3 month lnjlOp ONLY 

Zcloldzga } J 

A9k 66 for nzxl ADL with ,4Yes,, h ? 

soC0d2im - EntzrlnADLLwxon

Condition SummwV Chart, THEN �sk 

6d WMMAOL with “Yes” in 1. 

FOOTNOTES 

--, .— ..- . . . -,,..., ,..J..., 

~ 16) 

Wdklns? 

1 � IY*S 

20N0


3� D02an’t dafor Ofhzr ,,asml


74 

1 � Some 

2nAhf 

3 •l Un2h10 

~ 

1 � Y*8 

2 � No (5) 

lDRelstivc . . ..~ IOYCS 2DN0 

2 � Nonmlstiva . ~ I L 1V*S 2 � NO 

Non-HH m+niwr ~ 

3a Relative . . ..l tmYas 2DN0 

4 � Nonmlatlvo ; 1 � Yc8 2 � No 

& f � Yes 

2 � No (2 fornatAL2L 

wkh “Ycs” in f) 

Sp2cial 2quiprnant or �ids 

G 

G 

(s1 & 

1 � O–3 nwinh Injlop 0NL% 

2001dqia } J 

Ask Sd fc+MM AOL with ,<Ycs,,in 1 

30 

Condithm - Emzr in AOL bOXon 

Conditbn .Summuy Cfwf, THENuk 

6dfornzx2ADL with “Ye#”in 1. 

m ~ ~ (7) 

Gmtkw 8u2S2&7	 Wk$s*8alf2t.~s=nhs 

2027m20sm7 

1 � Y*s 1 � Y*S 

2DN0 2DfJ0 

do

~ & 

3� D02dt for Ofh+f,,,wn 3DD0s2n’td0 f0r0ffWm22al 

1 � Some 1 � Sonw 

2a Alot 2 mAlot 

3 � Un2tAo 3 Cl Und2i2 

~ ~ 

1IJ Y*3 1•1Y*S 

2 � No (6) 2 � No (S) 

42. Sourceof hzfp I 4b. PM 

lnlfd2tive . . . . . lDYcs 2DN0 10 IWVO.. . . . IaYe, zDNc. 

2 d Nonrohtivc . ; 1 � Yes 2 � N,o 2nN0d2W2.: IDY*s 2DN0 

Non-HH mzmbzr ~ Ncm-HH mzmbw : 

20 FW2five . . . . I lD Yes 2DN0 3 � Rdztivz . . .. I tDYa 2DND 

4 � Nonrelative . ~ I � Yes 2 � No 4 � NOIWOMVO .: I � Yos z � No 

~ ~ 1 •l Ym. 1 � Y*S 

2 � No (2 fcwnzxf AL2L 2 � No (6) 

with “Yes” h f) 

Sp2cial aquipnwnt or �ids Spdd c.qulpnmntw 2id8 

G E 

tw-lw B 

~ (6) 

1 D O– 3 rwxth lnjlOp ONLY ,I+##;” ,Mx,,w: 

Zo wage } J ZOOM* } Ask 6d farrnxtADL wifh #sYespsin1 

30 30
 Condition – Enfzf in A27Lbox on Condhim – EntwbIAOL bOXM


CowWun Swmnzry Cfurt, THEN uk Condlt&n SunmwW Chzrt. THEN


6d fornzxt ADL With #aYos,s
in 1. mxt p2g2. 

146 
---- ---- ---- ---- ---- ---- --------- ------------------ --------

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

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

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

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

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

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

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

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

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

Section RI. ACTIVITIES OF DAILY LIVING {ADL’S), Continwd 

~ 

7~.~ VWhwadkffkll~ CClltMki~ VOW bowds? 1 I � Yes I 

20 No f7c) 

_ }-------- >i - b.	 Htib@*vakvo *is*kuti-tiUv, -al , I � Daily -ad, m9md, ffk8s*anmamwti? r

1 ZD Sword times a week 

I 30 Once a week€ 1€

1 ~a Less than once a week


1 LID OK


_____ _____ - _&- ; ------’ ___________ 24 0.00 you hwa � cdodomv or � dwica to hdp CW2td , I � Yes 

bowd naovcnwnt87 $ 

1 20 No (8I 

-_ t--- ­

d. ~vC#F#WfQfNWMtl 1 MhW~lnteb~CWCOf I � Yes I 26 

1 20 No J 

2D No (8c) 

hwathk diffkukty- ddky,sward 

finwI� wok, onca� wwk, w lass thwt watn � week? 

, I•l Daily 1 ZU Saveral times a week 

-E 

t 30 Once a week I 

1 d Less than once a week 

1 SD OK 

-----_-_------:- _______________ 

O.=twwwvcmhctwormde vkmtokwfp 1 •1 Yes lxx 

: ZU No (/31) _____ _______ .. ___ ____ + -----: ___ 

; ________________ _______________ -—-

b. Ihw ~UW2tfv dcVOU

d. &v&~ hakPfmm WICUIW PWCCn in tik~ cwc of 1 I •l Yes L2E 

1 20 No 

I


1 t � Respondent is a prwq c


I 20 Sample person hw only been [9) RI Mark first appropriate box 1 wcn in a LA or chair 

30 TeleDhOrm interview } 

I 1 enAll oief (Nextpage) # 

~ Mark If known 1 

0. MWofa*w@v*l~, *vmuaW*- ~ ICI Yaa (10) 

�.stcvinbcd dkwnwctoftlwtfnw? i 2D No --—- - _ --------.; _______ 

b. 8tCVbladWk~Wl1109t0f tfWtk!W? i 10 Yes Ho) E 

1 ZU No(Nextpage)€

‘ti. Wfwt (other) ccnditkw ccuccs vou tc �tav MI[bwfh chab]? ~ � Old age flDc) 

I 

Ask If injury w opcrat{on: I 

Wfwndldma (hlJ2JrJoccur?/ VWflawtfwOpwdwl?i 1. 

# Entw Injury If over 3 months ago. 1 

.1 

1 Ask or re~sk 1(M, if O-3 months injury or operation. 1 

t€

1€ Aak if operatkm over 3 months ago: 1€

1
 Fw WkwtCcndktkn did Vou hwo tfw opwdwl? I 

1 Entar condition. t _____ ___4------..---–.–– _- ___ 

b. Beckfu condition b tfwm wav othw candWkn whkh ,

1 —*W	

I 

1 � Yes [Reask 108 and bl 

1 � No (1(M) 

_____ ___ }------ ______ ____ ____ 

e. la WC awed bv �V htfiw) �pcolfk wmdticn? 1 

I � YES (Reask 10a and b) 

1 � No 

1€

1€ _ :€

E Ask if multiple conditioq including old age. are listed in 10a. 

Otherwlae, mark appropriate box or transcribe the only listed ~ I� 0- 3,month lnj/Op ONLY


condition. 1 no Old age } (Next page)


! d.	 Whkh of tfwec cwdktiww, that la (read conditions in 10dy# 

vCU CCvk the MAIN C~U90Of vCW CtCvi~ in [badh CfWk ; 3U 

w rncnt of tha tfma? 1 

1 Condition – Enter “9” in ADL box on Condition %mrna,y Chart, THEN 1 next page.€ I€

147 
----

Socskm R2. INCIDENTAL ACTIVITIES OF DAILY LIVING CIADL”S) 

Rezdtorespondent- NOWl WMmbabOUSSOIW OSVWUSMUN. Tdfmodmuszfobwsfm byprggu. 

1. ~vd&ww~~#&m (1) a4 12) ~ 

?Npmkls your awn muwf •~ f- Wmmat Itmw, 1202EI m 20Lh2*m. w mdEEbw@? 

Askif ,Wunl&W 1❑ w, 1 ❑ Yes 

h Ath bwnua W ● HEALTH at ●EWStCAL ytzbtun? 

20N0 20N0 N “Yw,e,mwk box 1; If Wo,$,m3, k LZ)x 3.

3 ❑ Omsn’t do for othzr reason 3 ❑ Doasn’t do fcf otiw mason 

A3k 12-14 forwhfADL nulkl %’d,kl 11. & ~ 

2.	 ●yyalmEf, t9w2mt20h~tEDyau fu3vm@QQ, : ❑ some 1 ❑ some 

-,a EoGumy02tlmdE0 tDd0EE? 2DAM 2DAIot 

3 ❑ Un3bb 3 ❑ lhbb 

[. tiv0M190dw f12@fMIDImMfIu~ fnfTAOLJ? & ~ — 

1 ❑ YGS 1 ❑ Yes 

2 ❑ No	 f12fornaxt24fJL with 2 ❑ No (12 forrwxtIADL with 

‘“Y*s-’ In 17) “Y**” in 11) 

1 

t9. wEt0,iv32tElf2*? 30urc* of hdp 1 Pdd 

lh. - -P 

1 HH m+mber ~ o ❑ WCIP HH memb+r I o •1 s/c/P 

_________________________________ to Ra!mive . . . . ‘. 1 ❑ Yes 2BN0 I ❑ Rdstlve ....~IDYos 2DN0 

Afs?kthz WC/P&X without zzk~ NONLYf#p /3 ffom 2/WU1bICh//dWI/ 2 ❑ Nonrdativo ~ I ❑ Yes 2 ❑ No 2 ❑ Nonrdatiw ~ I D Yas 2 ❑ No _m. THEN 12 f0rn3xtlAOL wfth ‘, Yin.,, In 11. 

Nc+I-HH nurdw ; Non.HH member ~ 

b.	 l**h3t@xf&r? 3DRdztiva . . ..l1OYos 20N0 

Asklfnzcnsay: Wttkkk+msrnpm147 40 Ncindativs	 ~ 1 ❑ Yes 2 ❑ NO 

, 

A341 16 If myIAOL nwkod “Ye8”in 11. ❑ old agz flscl 

S& Wk24 WI@ 00#ftlM —tAz~bI(mzdUOL(sJJ? 

A2k If /@y w opsrmbn: 

WkatzdUIAn@gJ_? lyoIIEIM.ZAIOoyZWMTI 

Entw l@tnylf ovw 3 m+mths ago. 

Azkwmztk lVb, if 0-3munfuJ@wytwof mmti.n. 

Ask If ~sfbn owr 3 months ago: 

VWwEutWndltkuti y0uh2v2tft40y2t2tta17 

Ent#r condlt.bn. 

b. Bddza b.mdltbnktc duroz!tyethu~whhft 

—	 ~ h lmsdlADLblJ7 ❑ Y*. (Rsa8k 15a w)db) 

❑ No (t5d) 

c.	 l*shO~ h /mzdrAoL(#)) 2a12,d by any [Ottld 

2?241S9 Wdn2iiiiii ❑ Y*s (Ressk 15a ●ndb) 

❑ No 

~ If nwffb& cmdkbns, Including dd 3STS,m f& fed/n 15A ●sk 1id 11) 

for #sch2ADL with ● ,,Yc# in 11. Oflmn+[u, mark WWOIJIM. T ❑ O– 3 matth Injl Op ONLY 

hx G+tranzcrhs tfm only fiztcd cc+difjm. 2uOlda.#z } J d.	 whhEtoft4n92wm4isbm, ttwl h (mad cundltiom III 158) 

m&voucsvWJIWMAl Mo8uoa~ Ask 15d fornextIADL with ,,YCIS,8h 11 

3CI


Cmditk.n - Entw W.40L Lwx on Conditim


3UMMSIY Chwt. THENs$k 15d fof MxtTADL
 wifh ‘, Yes,$in 11.


‘OOTNOTES 

. . . . . . . . . . . 

3 ❑ Rd*tivO . . . . IIDYW 2DN0 

4 ❑ Nonmlatlw . I ! ❑ Yas 2 ❑ No 

{2) & 

1 ❑ O–3 month 1“]/ Op ONLY 

2 ❑ Old aga } J 

Ask 15d fornextZ40L with 7JY##,, /n ? I 

3U 

Conditti - Enter rnlADL box m COWJW.I 

Swnmmy Chwt, THEN ask 16d to, Iwa’t2A0, 

w;th ‘. VeS,Sh 11. 

I4a 
Sactinn R2. incidental ACTIVITIES OF DAILY LIVING fIADL’SL .— .. Continued

~ ~ ~ ~ 13) (4I (s1 (6) 

-v, Nuclf �s kow- Raask 11 Ooing fmavy h0US9W01k, (fikmSC1’tb DoknLIlight hOUS*WOIk, IIika daHsx’&I- pzyimsMa)? kkslag NW W@lOM? bhlE t!-, 07 wmshi~ WhdOWS)? ing dlshas, swalghtaning UP, or light ckankng)? 

t � Yes 1 � Yes 1 � Yes 1 � Yes 

2DN0 2aN0 2nNo zn~o 

3 n Om:n”l da hi 00IN mum 3 m Wsn’t do for olher *eascm 3 � Dc.esnl da for other mason 3 ~ Doesn.t do for .Xher 1.3.s.. 

~ ~ ~ ~ss— 

s � Soma s � Some ~ � Some I � some 

zBAIo: 2u Alot 2~A101 20 AIoI 

3 � UnAA* 3 � Unable 3 u Lhmble 3 n Unable 

~ ~ ~ ~ 

1 •1 V,* I � Yea 1 a Yes 1 Cl - Yes 

2 � No f !2 for rwxtJXDL wirh 2 � No 112 for ncxt2ADL with 2 � No (J2 for next lADL with 20 No(15J 

-Ya#”kl 11) -Yes” * 11) Wes,.in 11) 

1 , 

Swrco 01 help ; 

34*. t 

Paid 

t4b. 

Source of help [ 

14*. I 

Paid 

t4b. 

Source of help I 

14,. 1 

Paid 

14b. 

Source of he!D 

14,. 

I 

; 

Paid 

t4b. 

~ 7S-7*1 ~ 86-881 ~ s7-300 * -Ot-lo 

1 

IH nwmbw / o � SICIP Hfi m+mbar ! 0 Q s/c/P HH membef t 0 � SICIP HH member , 0 � SIC/P 

lnfld~tiv- . ...1 1 1 � Yas 2DN0 !nRolmivt . . . . . 1 L] {e. 2UN. tClfwhtivO . ...1 I � yes 2GN0 I � Relative . . . ‘ I � Y.s 2CN0 

2 � Nonralatlvc .: 1 � Y09 2 u No 2 u Nonrelative I I ~ Yes 2 � No 2 D Nonrelative [ I � Yes 2 � No 2 n Nonrelative I I � Yes 2 � No 

l.m.HH nwmbw : Non.HH member [ Non.HH member 1 Non.HH member ~ 

3DtIMv#,,..l!RYos 2UN0 3DReletlve. . 1 In Yea 2UN0 3fl R@.lstive .,. .~l OY.9s 2DN0 3 � Relative I ~ Yes 2 ~ No 

4 ~ Nwirdatlve. ~ 1 � Yas z rj No 4 � Nonrelative ~ I � YES 2 � NO 4 � Nonrelative ~ I � Yes 2 � No 4 u No”,elatlvn ; 1 !3 Yes 2 n No 

m ~ 14) ~ 15) ~ (6 I	 —-

I 106

I ~ 0-3 month tnjl Op ONLY 1 D O-3 month I“jl Op ONLY T n O- 3 rmmth 1.!/ Op ONLY tUO–3 month


2 n Old em } J

2 � Old age } J 2 fl Old age } J 

Inj/ Op ONLY Next page


Ask 15d Ior naxt2AL7L with W’es”’in 11 Ask 15d for next2AOL wirh ., Yes., in 11 Ask 15d b, “ext SAOL wizh +’es,. m 17 2 ~] Old age }


~~ an 3D 3n — 

hIditiOtI - Enter in140L box on Codtkm CGfKhtkXI - Enter inIADL box on Cdirion Cocdbmn - Emef hlAOL box m Cmdmon Condillo. Enter mlADL Lmx on Condmo” 

%mmwv Ctw?. THEN uk Isd fw rnxtIAOL SUmmaw Chart THEN zzk 15d Icf nextJAOl Summary Ch.wz. THEN �sk 15d fat nextIAOL Summary Chart THENnext page. 

with .Ws.. m 1$. wnh W’es,. m 11. with W’es., i. 11. 

FOOTNOTES 

149 
------- ------------------------

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

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

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

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

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

� 

E 

~ SwotlonS. NURSING HOME STAY, HELP WITH CARE, AND HOSPICE 

89. HmvOuwukmna mkfmttwpat14ntknalntnknsfwtt*? / I � Yes 

. — : _________________________________ b.	 How many DIFFERENT TIMES Vuw you boon � rdcknt M 1 E 

pdvntk18mn8ktsflaim9? — Number of times 

c. Wlmn wws yau tin#ttad (tha FIRST ffmd? ;--------------------------------= 

— — 1 Month Year 1 

d, Whm - you dkscfuqfod (UN LAslurn.)? ;--;:---- ;mir-----------------------mi 

IA — � . H0wf01t5-ywtlnth0 ntwakfJhOmO (lfw LAsTtkltw)7 f-;-&.;;; n-l;;;;-------------------H 

I 

1 Number of months 

S1 [ I � Date discharged is since the 12-month reference date (7 f) ~ Refer to Id 1 a tl All other (S2) 

~ lf. ffOwmunywufu knfItakn8t 12m0twh8, th8tk,8inca I w � Leas than 1 week 

(12Mthd#te)a~W,_ymhm_h~? 1 

1 

Number of weeks ~ & 

Refer to �ge t I� Sample person k 55-64 (2) 

I S2 2 � Sample person is 65 or older (Ig)

1 & 

lg. tiywmwMaws* lMtigOinmamlqh? 1 � Yes i 2DN0 

1 SDOK 

2s. k thwa � W, rOldW, 0? ~hbw who WWtfd tako 

m of VW for � fow DAYS, kfMwuwy? (Inclutk tfto 

I 

I Yes -

2DN0 

Who k this puwn? ~ 

- Yw I* W*.) I HH member \ Non-HH member 

Mark one box only, 1 3 •l Relative OR s � Relative 

1 4 � Nonrelative an Nonrelative 

— b. k thwa � frimd, ralatke, or wbhbor who WOdd tako :--;;.:-wh;;mi;.-~U C---------------UC 

H of YWUfor � faw WEEKS, ff mwwaty? {Indttda 2DN0 * flWflk you liw with.) 1, HH member \ Non-HH membw 

Mark OIM box only. 1 3•l Relative OR s � Relative 

1 4•l Nonrelative 6 � Nonrelative 

Skip to Section T If @proxy I & 

Zk.	 Am YOU fwtkklsr with tfm twm ‘“HOSPICE,” that k, � satvlca ~ 1 � Yes 

fw tfw fumlndly ill? 1 2 � No/DK (Section T) 

}-------

I w b. kth0f9*fIWPko WmitFflOMC hWPkW90tVks IItti $ * � Yes [nnwwdlta. �ufcowwl that Vou Cwfd u- H VW 1 2DN0 ttad9d	 Wm? BODK 1 

‘OOTNOTES 

150 
------------------------ ------ ---------------------------- ---- ---

-------

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

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

SootIon T. HEALTH OPINIONS 

~ 1 I � Self response (1) T1 Respondent I 

1 2 � proxy (12) 

~ 

} Read to rwpondmt - N&l’~tooakkour~url oplnbta / t � Excellent d � Fair 1 2 � Very good s � Poor 1. How~aWtivW WVNm~b TAKING CAREti YW i 1 � Good tnaith? Wwkl V0a2aav�xmfbnt w 2004 E-L f~h - m? ! 

2.	 c~hlyaarw,-ywmvtimvmr-ls I I � Better & 

2WW bamf. WWW, Of �bwt tfw awtaa �s it Waa thwt7 I 2 •l Worse I 

1 3 •l Same 

~ 3, Oufin@ tfw �AST YEAR, has v- OVOWU fwa~ W* YOU � [ I � A great deal of worry 3 � Hardlv any worry ~*tildww, -win. wmvm, wwwm , 

1 2 � Some worry � � No worry at all 

& 4m c ra2tt00dtar faaaQf9va41fafRwmf4WtJaWv-2- ; I � More active 

fl%’=UvntolOactl vaJ4aa=tfv9,w*as*m7	 , z � Less active I 

I s � About as active (5) 

---------------------------------:--,-;L:t-m;:-------;;;;t;a:,-----------E b.	 ~sttak,mw40?dttf 9=w4-f-fa-swati 

1 

! 2 •l Little mom 4 � Liftle !ess 

& 8a.colaf(f4f4dto yowOwmlavalofPf2vaawfaotMtvl Wa?aoo, / I n Mom �ctive

w02tmv0ua4vva!u8fwwnam 4cNtmo14--, ~- I z � Laaa active tha-uvo22w4muwat? 1 3 � About the same (6) 

..-. L 34 b, tr&atathW#nOW@Wla-aathfa fdOthaaLWdW :

1 I � Lot mora 3 � Lot leas 

2 � Little ntora 4 II Little less 

1 d 

& 0. HowrmzmIaawztwt 40vozttfaHIVOU fWV4mVoaWfzttLW ~ I � A great deal of control 3 n Vary little control hadtlf?wouldvwsavv wfwwcw--~~? I 2 � Some convd � � None at �ll aot2w, Y4qlNda, aNnwwmaN? 1 & 7.	 p“rououtiwmdllt m n anawh SXwoiaam Voata20ad# or I I � As mush �s nti

I 2 � bss thannaadad 

~ 8. 00 vou fONOW s REOULAR warfkta of IMIvahd �Xatd20? 1

t I � Yes 

20N0 t 

~ B. uowotfwdravwwa kamkw-tia-.~-? i I � EVWVday � � 1 day a week 

fNota: Ona mlla aquala 8-12 bfoaka.) I 2 � 4-6 dava a week 6 � Less than 1 day a weak 

Profza If namamy: Aboa2af20u2mwwafaY88 wuk Ia that? 1 3 � 2–3davs a week o � Naver 

lea. Paoplaf12Mathattftavaamuhtu fzawrnacotmtzbla 

mmaAwhwttalm2au*@*. 1.tkpA51vEAR, 

1“ 

1 

I � Frequently 

2 � Sometimes 

& 

afa.wnft4auaaftan dldv01ahawtmbriA4 ~-- } 3 •l Rarely 

M*O a0m@m4a, rarely. or nawr? I o � Naveril 1) _________________________________ :------------------------- ~o__
 b.	 cW2tfWld Udtt2=VaWw, d0Wtf2h110Ww - 1 I � More often 

0ft022#iaaa 0fta2a,0r8fa021t tfmawnat 1 2 � Leaa often 1 3 � About tha wme 

~ P4qala112a4thaldt4v wnwth4a2at owlt2wd&8thaygaa I 

I 119. I � Frequently

*&~Z=2wd&l#JaJpfaa I 2 � Sometimes 

1 3 � Rarely


1 0 � Naver (T2J
 : ____________________-----------------
 b. C~wfthcvoarcem,4wa tf4azaowfaawatt tnora I I � Mom dam C.zc 0fa4n,lawofwa, or-dw-? 1 2 � Less often 

3 � About tha same 

~ 1 

I I � Salf-paraonal 

T2 Tvpaof intawiaw 1 z � Self-telephone Go to Condition Summary Chart 

1 3 •1 proxy pzmatld IT3J
 ! 4 •1 Proxy Wktphone 1
 , 4
 I ~ I � Sam@ Wraon temporarily absent 

I 2 � Sampb parscm mantallv/phvsicallv incapable of responding (Explain) 

�. Proxy Reman I s � Other fExp/aln)J J 

~3 1

:, -----------------------­

cm� Non-HH member m 

b. Enter paraon numbarof proxy respondent, or mark box. ; Go to Condition Summary Chart 

I Proxv Parson No. } 

151 
----

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

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

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

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

------

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

--

--

..............9amusdu. ....................... ................... ....................

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

~ 

~ 

!111 

152 

t m 

SsactionU. SUPPLEMENT CONDITION PAGES 

CONDITION A• Except for eyes, ears, or internal organs, ask 3h if there are any of 

the following entries in 3b - f; 

1. Name of condition In fmctlon SO?* S0r*n9ss 

3h. What IMtt of tha (pan of body h 3b - ) k �ffcctcd by 

2. Wlwn dld you last S- or talk to� doctor or �sslctwtt �bout ~ the [infmctlonlsorolsoranasal - thes in, muscle, 

your (condition)? bone, or soma othor pstt? (Specify) s 

o a Interview week (Ffeask 2) 5 � 2 yrs., lessthan 5 yrs. 

I � 2-wk. ref. pd. 6 !3 5 yrs. or more 

z � Over 2 weeks, less than 6 mos. -7 � O-r._s~e~,QE wh~~ 

o � 6 mos., less than 1 yr. 8UDK If Dr. seen Ask if there are any of the following ent,;es i“ 3b - /: w 

4 El 1 yr., less than 2 yrs. o •l Dr. never see”1 f3b) Tumor cyst Growth . SW Dldh dostoror�ssistant call tfm (condition) by t mom ~ 4. k this [tumorlcvstfgrowthl mallgnwtt or benign? 

t.shnf.d w SPOONICnsmo? I � Malignant 2 ~ Benign s@DK 

1 � Yes 2DN0 90DK 

6. ~. Whttt WaS vOUr (!iLI@(& I ~ 2-week ref. pd. & 

Ask 3b If “Yes” in 3a, otherwise transcribe condition b Mf) first notlcad? 2 � Over 2 weeks to 3 months ttanw from itam 1 without esklng: .

1 3� Over 3 months to 1 year b. Whti dfd It@w sho CM If? (specify) 4 � Over 1 year to 5 years J b. When did YOU(= 1of injury in 3bJ? 1 50 Over 5 years 

Ask probes as necessary: 

I � Color Blindness (NC) 3 •l Vasectomy (5) t$ (was Non w slnco (first date of 2-week ref. period) or I 2 •l Cancer (3.9) 80 Other (3c) + WS8 If bfora tfmt date?) 

iwas if 10ssthan 3 motttfm or mom than 3 months �go?) a, WhAS was tha cams ofyour(condhion In 3bJ7 (Specify).B (Was k loss than 1 Y*ar w mom than 1 v-? �so?) 

iWss is IO*S than 5 y.- or mom than 5 yams �go?) 

______________________________ UI T� Missing extremity or organ in 3t/3f (u2) ~ 

Mark box if accldant or injury o � Accident finiury (5) x (KS) 8� Other (12) 

d.Diddto(cond/t/on h 3b) mgulf from �t �ccfdant or Injtwy? 2t.00 yOU still hava this condltkott? 

:~~e5(6~_ -___2_a_N3____________________ I � Yes (U2J � No 

Ask 30 if the condltlon name/n 3b includes any of the following words: -------------------------E


AsmDnt Cuw” Di..a,. Pmhlom b,ls thk condttiott complataly curd or h if umfor control?€

Ammh GmdmOn Dh0Fd8r Rum”,.€

Asthma Cw a,owb -lroubla 2D Cured s � Othar [Spocify~


mtaok Mu.in Tumor an Under control (U2) (U2 ha Uk., ‘ ‘ c .:~:,w?long dld you have thk condftlon bofom it -!7s=;1 

�. Wht kftsd of (conditkm /n 3b) Is It? (Specify! 

oo~ Less than 1 month OR I n hfDnths 

Numb,, { 2 Cl Years ---------- ----------------- --- ~ Aak 3f onfy if allergy or stroke in 3b-@: d. Was this condlficn ptosettt �t �ny Uma durtng tfm 

f. ffGW* SW[sllwfjy/m70kol NOW�ffwt Vxt? (Specify~ paat12months? 

I ~ Yes 2i3N0 

, � Not an accidem/injUry (MC) 

FwStcoke, fkSr8mdnderOfthk COlddOJIP8W fofthe firstfxesenteffect. If addidmta f4~ 2 t3 First accidentlinjuty for this par8Dn (17b)


padnt effesfs, cww In Cmdithm Sumntmy Chart .moh me that is not almdy h the 8 � Other (17bJ
 Ccdffon Summmy Chsff. (If in C2 in HIS-1, enterccmltim numberandfranscribs


whm 

__________________________________
 dtlng; if not, flUadditlmwls@mtent Pa@) dwing~rnw.) Ask if box 3,4, or 5 marked in item 5


Ask 3g Jf them /$ en Impshment (refer to Card CP2) or any of tho 7b.Whtt PFS Of SiWbOtfYh �ff=td ttOW? 

followlng emrks ht 3b-f: !fow is yGUFffhwtof bod~) �ffoctd? Same ace. as Cond. _ 

cam- I“fMNm Mupfu,. Am YOU�ffcotod in wty othor way? 

A@lnw:x y~y• Inft,mnuwan Swetnn.1 

Nun@ Sttttiwl 

I 

t 

I I 

“ Enter part of body In same detail sc for 3g. 

II m4t@le~ment dfwta, mt~ in Ccw!itkm Summuy ChM o$chGW thW ISM tfw 31MC81 a 

g.what put oftlta body h affccfad? (Spacify#	 aboveu ismtakady in II’MCadtkn SummW Chan. Ilf h C2inHIS.1,mwf CCIXStica­

@ trmwkw when@itiW ifnot,WIsdditkmisuppfmwtp@s) dwnginttwkwl 

E 

Show the folowing detslk �. Indicate status of thk I DTranscribed from HIS.1 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..9kllll. *.faw condition page, ~ z � Obtained in SOA Intarvlcw 

~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Iw@w. mldd9.1mv” 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19ftwri#lt 

Raw .... ........................................ WW. WW 1= . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..klr19r arOutWhft.lf.ht. wb0vl U3 b.•When editing, transcribe source date for this condit!on ..
 from the appropriate Nne in the Condition Summary Chart.

h . . Uw9r, dbOw, hwwOrtilOft,
 dQbt,
 wk4fI


w . .aNlmhmdwfanwn
 *htt, ra#!t.
 OrkOIh
 Zc I 27 I 28 I 2s 1s0- 17 * ...
W.-.-WWM. W.. M.-M
 M ...-titi.w*w. w*. wm Ill 1 1 

-W&lGm11H411.7.IM41 
Cord M 

1.J&kwLl# or my rnwlu r9m0rl 

2. can’tdw181mrIr8mmlrRCarmafpcmr 

hdth, Iamu, or W 

3. t00arpudv9, Can’taffardfrnfdrimurbma 

— 

Um 

4. Dksuwkfwftir pr0nku9fmurarrC9 

6. Dadt Imkiw# III kuuraneo 

?.Cowrmfby-offnrlmflfiphn 

CARD SOA 1 

1.SoohlSeourlty 

2. Railroad Retimmont 

3. A private employer or union pension 

4. A government ●mployee penelon -

Federal, Stete, or Iocel es 

WWa5. Miikery mtimment 

6. Some oknr source - Specify 

-!O!,, ”.4.,, ”. 

153 
1.	 National Center for Health Statistics. Current estimates from the 

National Health Interview Survey United States, 1982. National 

Center for Health Statistics. Vital Health Stat 10(150). 1985. 

2.	 Kovar MG, Poe GS. The National Health Interview Survey 

design, 1978–84, and procedures, 1975-83. National Center for 

Health Statistics. Vital Health Stat 1(18). 1985. 

3.	 Fitti JE, Kovar MG, The supplement on aging to the 1984 

National Health Interview Survey. National Center for Health 

Statistics. Vital Health Stat 1(21). 1987. 

4.	 Gleeson GA. Interviewing methods in the Health Interview Survey. 

National Center for Health Statistics. Vital Health Stat (2)48. 

1972. 

5.	 Givens J, Moss A. Redesigning the National Health Interview 

Survey’s data collection instrument. In Silver anniversary of the 

National Health Survey Act. Hyattsville, Maryland National 

Center for Health Statistics. 1981. 

6.	 Sirken M, Royston P, Bercini B, et al. Completeness of enumeration of cancer cases in health surveys. In American Statistical Association, Proceedings of the Social Statistics Section. 

Washington American Statistical Association. 1981. 

7. National Center for Health Statistics. The statistical design of the 

health household-interview survey by staff of the U.S. National 

Health Survey and the Bureau of the Census. In Health Statistics. Washington Public Herdth Service. 1958. 

8.	 Keyfitz N. Estimates of sampling variance where two units are 

selected from each stratum. JASA 52(280):503–10. 1957. 

9.	 McCarthy PJ. Replication, an approach to the analysis of data 

from complex surveys. National Center for Health Statistics. 

Vital Health Stat (2)14. 1966. 

10.	 McCarthy PJ. Pseudoreplication, further evaluation and application of the balanced half-sample technique. National Center for 

Health Statistics. Vital Health Stat (2)3 1.1969. 

11.	 Schnack G. Memorandum to Madigan on HIS variance— 1973. 

National Center for Health Statistics. April 3, 1974. 

12.	 Jones G. HES variance and cross tabulation program, version 2. 

National Center for Health Statistics. Unpublished. March 10, 

1977. 

13.	 Bean JA. Estimate and sampling variance in the Health Interview Survey. National Center for Health Statistics. Vital Health 

Stat (2)38. 1974. 

14. Hansen MH, Hurwhz WN; Madow WG. Srunple survey methods 

and theory, vol I, methods and applications, vol II, theory. New 

York John Wiley and Sons, Inc. 1953. 

15.	 Givens J. Memorandum to Sirken on NHIS variance comparisons 1973, 1979, 1980. National Center for Health Statistics. April 12, 1982. 

16. Shah BV. SE SUDAAN, Standard errors program for computing 

of standardized rates from sample survey data. Research Triangle 

Park, North CaroIina Research Triangle Institute. 1981. 

17.	 Survey Research Center Computer Support Group. OSIRIS IV 

user’s manual. Arm Arbor, Michige.m Institute for Social Research, 

University of Michigan. 1979. 

18. Holt MM. SURREGR. Standard errors of regression coefficients 

from	 sample survey data. Research Triangle Park, North 

Carolimx Research Triangle Institute. 1977. (Revised 1982 by 

Shah BV.) 

19. Hidiroglou MA, Fuller WA, Hickman RD. SUPER CARP, 6th 

ed.	 Ames, Iowa Survey Section, Statistical Laboratory, Iowa 

State University. 1980. 

154 
Appendixes


Contents 

I. Data collection procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 

II.	 1982 survey revisions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 

Background . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 

1982 NHISchanges and comparison of 1981 and 1982 estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 

III.	 Estimation procedures . . , , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 

Point estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 

Variances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 

Weights on public use data tapes . . . . . ., . . . . . . . . . . . . . . . . . . . . . . . . !. . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . 174 

IV. Topical index to questionnaire items, by year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 

List ofappandix figures 

I. Summa~ofNational Health Interview Survey changes regarding physician contacts: Before and since 1982... . . . . 160 

II. Summary ofNational Health Interview Survey changes regarding hospitalizations: Before and since 1982 . . . . . . . . . 161 

111, Summary ofNational HealthInterview Survey changes regardinglimitationof activity Before and since 1982..... 162 

IV. Summ~of National Health Intemiew Sumeychanges regmding days ofdisability Before adsince 1982 . . . . . . . . 164 

v. Summary ofNational Health Interview Survey changes regarding acute conditions: Before andsince 1982 . . . . . . . . 168 

VI. Adjustment for noninterviews. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 

VII. The 60 age-sex-race cells inthe National HealthInterview Survey . . . . . . . . . . . . ! . . . . . . . ,. . . . . . . . . . . . . . . . . . . . . . 172 

List of appendix tables 

L	 Number ofphysician contacts per 100 persons per year, byplace of visit andtype ofdoctor seen: United States, 

1980-83 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 

II.	 Percent ofpersonswithl hospital episode ormore, byageand sex: United States, l98O-83 . . . . . . . . . . . . . . . . . . . . 162 

111, Days of disability per person per year, by type of disability, age, and sex: United States, 1980-83 . . . . . . . . . . . . . . . 165 

IV.	 Number ofrestricted-activity days perperson perquatier, stadmdemors, andratioofl982to 1981 estimates, by 

quartec United States, 1981-82 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 

v.	 Number of days of disability per 100 persons per quarter for old and new data processing edits, standard errors, 

and ratio ofnewto old estimates, by type ofdisability Quarterl, 1982 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 

VI.	 Number of restricted-activity days, standard errors, and ratio of 1982 to 1981 estimates, by condition group 

United States, 1981–82 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 

VII.	 Number ofdisability days associated with acute conditions per 100 persons peryear and disability days per person 

per year, standard errors, andratio of1982to 1981 estimates, by type ofdisabilitjc United States, 1981–82 . . . . . . 167 

VIII,	 Days of disability associated with acute conditions per 100 persons per year, by type of disability, age, and sex 

United States, 1980-83 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 

IX. Number ofacute conditions per 100 persons per year, by condition group, age, andsex: United States, 1980–83. . . 169 

x.	 Number of acute conditions per 100 persons per year, standard errors, and ratio of 1982 to 1981 estimates, by 

whether medically attended and condition group: United States, 1981–82 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 

155 
XI.	 Number of acute conditions per 100 persons per quarter, standard errors, and ratio of 982 to 1981 estimates, by


medical attention status and condition group United States, 1981-82 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170


XII.	 Number, proportion of children who received care within an adequate interval, estimates of standard errors, and


design effects, by selected characteristics of children and youths under 18 years of age: National Health Interview


Survey, 1975–76 amual average. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174


156

Appendix I 

Data collection 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 17 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 prcvided by a responsible adult family member (19 years of age 

and over) residing in the household. Between 65 and 70 percent of the adults 17 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 150 interviewerstrained 

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 20 to 90 minutes. On average, the interviews 

require about 50 minutes in the household. 

157 
Appendix II 

1982 survey revisions 

Introduction 

In 1982, the Division of Health Interview Statistics (DHIS) 

implemented a number of major changes in the National Health 

Interview Survey (NHIS). Changes involved the questionnaire, definitions of some of the health variables measured, and 

data processing specifications. As a result of these modifications, many of the estimates routinely produced by this 

survey, which had remained relatively stable over time, changed 

significantly. This appendix includes a description of and rationale for the majo~changes that were made. Selected key estimates 

collected before and after the changeover are compared, and 

some explanation of the differences is presented. Background 

information about the survey’s program for periodic appraisals 

is included, along with a description of the sequence of events 

that led to its most recent redesign effort. 

Not all of the changes in the 1982 estimates were anticipated 

or can be explained fully, but the following description will aid 

data users in better understanding the 1982 and subsequent 

NHIS data sets. Figures I–V contain brief synopses of the 

changes and selected key statistics produced from both versions. 

Background 

NHIS officially began data collection in 1957 and has 

remained in continuous operation since that time. In its early 

years, the NHIS procedures were steadily undergoing change 

because the survey mechanism was somewhat experimental. In 

later years, however, changes were restricted and, for the most 

part, made only at regular intervals. This approach reflects a 

long-range plan developed shortly after the survey was undertaken that provided for an evaluation of the design and format 

of NHIS approximately every 10 years. 

The rationale for regularly scheduled major redesign efforts 

has several bases. It recognizes the need to be responsive to 

different data requirements and new methodologies, and it provides an orderly process for implementing such modifications. 

It also ensures some degree of continuity in survey concepts 

over an extended time period to facilitate trend analysis. 

The first major revision of NHIS procedures was implemented in July 1967, after the survey had completed its first 

10-year cycle of data collection. A description of this first 

evaluation effort, including the rationale for the changes, the 

modifications made, and the subsequent data results, are documented in Series 2, Number 48, in the Vital and Health 

Statistics series (4). 

Plans for a second major revision of NHIS began in 1978 

following another 10-year period when changes to the survey 

were restricted. The primary objectives identified for this second 

redesign effort were as follows: 

1.	 Modify survey concepts, as required, to reflect current and 

known future data requirements 

2.	 Reduce nonsampling errors caused by interviewers and respondents by simplifying the format and administration of 

the questionnaire and improving the techniques used to 

convey to respondents the specific nature of the information being requested 

3.	 Improve the flow of the interview by eliminating repetitive 

or inapplicable questions 

4.	 Reduce the core component of the questionnaire to allow 

more interview time for rotating supplemental topics 

During the planning stage of the second major NHIS 

redesign effort, input was received from a number of different 

sources. On the recommendation of the National Committee 

on Vital and Health Statistics, suggested changes were obtained 

from a panel of experts outside the National Center for Health 

Statistics (NCHS). This peer review group, or technical consultant panel on NHIS, was spectically charged with evaluating 

how well the survey was meeting its legislative mandate. Recommendations for changes also were sought from NCHS personnel who had knowledge of the survey. 

Several pilot studies were undertaken during 1978 and 

1979 to test a revised NHIS questionnaire instrument and 

related documents. The studies were conducted under contract 

by a private research firm and by the U.S. Bureau of the 

Census. 

The first of these studies, conducted in the Washington, 

DC, area, provided the DHIS staff an opportunity to make a 

subjective assessment of the revised questionnaire’s concepts, 

procedures, and overall feasibility. However, before major 

changes in the ongoing NHIS could be implemented, a quantitative assessment of the revised document and related materials 

also was needed. Therefore, the National Pilot Study, specifically designed to provide a data base for a comparative analysis 

of selected estimates produced from the current and revised 

NHIS questionnaires, was conducted in the final three months 

of 1979. 

Selected results from the National Pilot Study appear in a 

paper presented at the 1981 annual meeting of the American 

Public Health Association (5). The paper focused on a com158 
parison of three health variables: limitation of activity, physician visits, and days of disability. 

Results from the National Pilot Study, along with observations made from earlier field tests, provided sufficient evidence to conclude that, for many of the health measures, the revised questionnaire represented an improved data collection 

instrument, 

However, the revised NHIS questionnaire that was finally 

fielded in January 1982 differed somewhat from the National 

Pilot Study questionnaire, as some modifications were made to 

those questions where problems were found. The disability day 

questions underwent the greatest change. For this reason, several 

estimates from the National Pilot Study differ from estimates 

later produced from the 1982 NHIS questionnaire. 

For persons interested in a more indepth description of 

this second evaluation effort, specific details are presented in 

Series 1, No. 18, in the Vital and Health Statistics series (2). 

1982 NHIS changes and comparison of 

1981 and 1982 estimates 

This section contains a summary, by topic area, of questionnaire and other changes that may have contributed to the 

differences found between the 1981 and 1982 NHIS estimates. 

The rationale for the changes that were adopted is also given, 

Five major NHIS health variables for which statistics are 

routinely produced are addressed. They are physician contacts, hospitalizations, limitation of activity, days of disability, 

and acute and chronic conditions. For a description of all of the 

changes made to the 1982 NHIS questionnaire, see Series 1, 

No, 18 (2). 

The computer editing cha~ges most likely to have had an 

effect on the 1982 estimates shown in this report also are described, Although the 1982 computer edit specifications used 

many of the same kinds of edits employed previously, the differences between the questionnaires themselves necessitated a 

complete redesign of the data processing specifications. Some 

of the modifications made to the computer edit specifications 

also reflected current opinion about how to edit certain items. 

A comparison of selected key statistics for the 1981 and 

1982 periods is included for each major health variable. Where 

differences were found, an attempt has been made to explain 

these findings. In addition, selected estimates for these health 

variables are presented in more detail in tables I-III, VIII, and 

IX, Most of these estimates, which cover the period 1980-83, 

are by sex and selected age groups. The 1980 estimates provide some indication of the stability of the specific 1981 and 

1982 estimates being compared. Most NHIS estimates remain 

relatively stable over time, but some rates, particularly rates of 

acute conditions, fluctuate seasonally as welI as from year to 

year, The 1983 estimates, although provisional, provide additional evidence as to whether any differences found between 

the 1981 and 1982 figures actually represent differences that 

can be expected to continue in future years. 

Physician contacts 

Questionnaire changes 

The changes in the physician contact probe questions 

itemized here reflect the basic philosophy that influenced many 

of the 1982 revisions— that respondents need to be fully aware 

of any specific inclusions or exclusions that relate to the health 

variables about which they are asked to report. 

The conceptual definition of what constitutes a physician 

contact did not change in 1982 (figure I). However, the probe 

questions, which elicit reporting of physician contacts in the 2-

week period and provide the framework on which the estimated 

volume and number of contacts per person per year are based, 

were changed to describe more explicitly the kinds of contacts 

respondents should report. Some examples follow 

1. In 1982 the term “medical doctor” was further defined for 

respondents with the addition of the following statement 

“Include all types of doctors, such as dermatologists, psychiatrists, and ophthalmologists, as well as general practitioners and osteopaths.” 

2.	 Previously, specific types of services performed ‘during 

physician contacts were mentioned to aid respondents’ 

recall (“. . . go to a doctor’s office or clinic for shots, 

x rays, tests, or examinations”). In 1982 more emphasis 

was placed on where the visit took place (“. . . receive 

health care at home or go to a doctor’s office, clinic, hospital, or some other place”). 

3. Contact with nurses or other medical persons working 

under the dhection of a medical doctor was always included 

in the DHIS definition of a doctor contact. However, 

1982 was the first time that contacts of this type were 

specifically referred to in the probe questions. 

4. The probe question about telephone calls to doctors to 

receive medical advice was expanded to inquire also about 

calls to nurses and others for prescriptions or test results. 

These changes were implemented with the intention of increasing the reporting of those kinds of physician contacts that 

respondents are most likely to forget, be reluctant to mention, 

or not think to report. 

Data processing changes 

The editing procedure used in 1982 differed for physician 

contact records for which the date of the doctor contact could 

not be determined. Previously, records with unknown dates 

and records with dates identified as outside the 2-week reference period were treated in the same way. They were assigned 

a code of “week unknown” and were left on the final doctor 

contact record file, but they were not subsequently used in any 

tabulations run to generate doctor contact estimates. In 1982, 

in contrast, doctor contact records with unknown dates were 

assigned to the code category “in past 2 weeks, don’t know 

when” an-dwere used to calculate the doctor contact estimates. 

Records with dates outside the reference period were deleted 

from the file altogether. 

Results 

The average number of physician contacts per person 

per year increased from 4.6 to 5.2 visits from 1981 to 1982 

(table I). This difference of about 13 percent is similar to the 

difference found between the estimates obtained from the National Pilot Study and substantiates the concern that DHIS has 

underestimated certain types of contacts in the past. As expected, 

159 
Definition: 

Questionnaire: 

Data processing: 

Estimates: 

Before 1982 

Consultation with a physician inperson or by telephone for 

examination, diagnosis, treatment, or advice. Service can be 

provided by the physician or by a nurse or other person 

acting undera physic ian’ssupervision. ’’Phy6iciainc ludesdea 

doctors of medicine and osteopathic physicians. 

3 probe questions aakedabout— 

1. Number of times amadical doctor was seen. 

2.	 Visits to a doctor’s office or clinic for shots, x rays, 

tests, or examinationa. 

3. Medical advice from a doctor over the telephone. 

Doctor contact records with unknown date of contact were 

left on the final data tepe but not used to produce doctor 

contact estimates. 

Type of contact 

All physician contacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Home visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Telephone calls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . 

Dermatologist, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Psychiatrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Ophthalmologist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Ostaopath . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . 

Since 1982 

No change. 

The probaquestions were changed to include— 

1. An additional statement dafining “medical doctors” as 

including “all types of doctors such as dermatologista, 

psychiatrists, and ophthalmologists as well as general 

practitioners and osteopaths.” 

2. Refarenceto wherathe visit took place instead of to 

tha type of services received, i.a., “.. . receive health 

care athomeor gotoadoctor’s office, clinic, hospital, 

or some other place?” 

3.	 An additional statement about contacts with nurses or 

other madical persons working under the direction of a 

medical doctor. 

4.	 An additional statement about telephone calls to nursas 

(and others) to obtain prescriptions or tast results, 

Doctor contact records with unknown date of contact are 

assigned to tha category “in past 2 weeks, don’t know 

when” and are included when processing doctor contact 

1981 1982 

Standard Standard Percent chenge 

Rate error Rate error 1982-81 

Number per person per year 

4.6 0.1 5.2 0.1 i-l 3 

Number per 100 persons per year 

2.9 0.1 10.0 0.8 +345 

53.3 1.7 74.1 2.1 i-39 

8.9 0.7 10.5 0.8 +18 

5.5 0.5 8.9 0.7 +62 

11.7 0.8 18.2 1.1 +56 

1.9 0.3 3.3 0.5 +74 

Figure 1. Summary of National Health Interview Survey changes 

overall reporting was increased by changing the questions to 

more completely describe the kinds of physician contacts respondents were to report. 

In 1982 the rate of telephone doctor contacts was 74.1 per 

100 persons, up from 53.3 per 100 persons reported in 1981. 

This difference clearly reflects the effect of the more definitive 

probe question used in 1982, which queried specifically about 

getting “any medical advice, prescriptions, or test results over 

the phone from a medical doctor, nurse, or anyone working 

with or for a medical doctor. ” The proportion of visits at home 

that were specifically asked about in the 1982 doctor contact 

probes also showed an increase in reporting from a rate of 2.9 

home visits per 100 persons to 10.0 visits per 100 persons. The 

increase in the rate of visits to other places mainly reflects a 

change in the interviewer instructions. Interviewers were told 

to class@ grouppractice clinics and health maintenance organizations in this category instead of in the doctor’s office category, 

as was done previously. The rate of doctor contacts for some 

kinds of medical specialists previously thought to be underreported (dermatologists, psychiatrists, ophthalmologists, and 

regarding physician contacts: Before and since 1982 

osteopaths) also increased in 1982 as a result of changes to the 

doctor contact probe questions. 

Hospitalizations 

Questionnaire changes 

The following changes were made to the hospitalization 

probe questions in 1982 (figure II): 

1.	 The term “overnight” was added to keep respondents 

from reporting outpatient hospital visits, 

2. The probe question about stays in nursing or convalescent 

homes, previously used as an extra screener to pick up 

missed short-stay hospitalizations, was dropped. Few additional hospitalizations had been detected through this 

question. 

3. The hospital probe question was moved to the beginning of 

the interview. It was viewed as a good introductory healthrelated question to begin a health interview, and it also 

provided the interviewer with useful information that could 

160 
Table 1. Number of physician contacts per 100 persons per yaar, 

by place of visit and type of doctor seen: United States, 1980-83 

Place of vkit and type of doctor 1980 1981 1982 19831 

Number of physicisn visits per 100 

persons per year 

All visits . . . . . . . . . . . . . . . . . . . . 475.4 461.5 516.3 507.6 

Place of visit 

Doctor’s office . . . . . . . . . . . . . . . 322.8 320.1 296.1 285.4 

Telephone . . . . . . . . . . . . . . . . . . 57.8 53.3 74.1 74.7 

Home, . . . . . . . . . . . . . . . . . . . . 3.1 2.9 10.0 10.2 

Hospital (emergency room, 

outpatient clinic). . . . . . . . . . . . 61.5 60.9 60.7 62.9 

Company clinic . . . . . . . . . . . . . . 3.1 2.4 5.8 5.3 

Other . . . . . . . . . . . . . . . . . . . . . . 25.1 20.2 53.2 54.4 

Type of doctor 

Dermatologist . . . . . . . . . . . . . . . 8.3 8.9 10.5 9.8 

Psychiatrist . . . . . . . . . . . . . . . . . 4.9 5.5 8.9 8.7 

Ophthalmologist. . . . . . . . . . . . . 11.3 11.7 18.2 17.5 

Osteopath . . . . . . . . . . . . . . . . . . 2.1 1.9 3.3 z.9 

Pediatrician . . . . . . . . . . . . . . . . . 46.3 44.5 45.4 46.0 

Obstetrician-gynecologist . . . . . 34.3 32.3 36.3 34.8 

Internist . . . . . . . . . . . . . . . . . . . . 52.2 50.8 61.1 55.6 

Generel practitioner ., . . . . . . . . 226.6 217.9 204.5 206.9 

Other and unknown . . . . . . . . . . 90!5 87.9 128.2 125.5 

1Provisional. 

be used later when asking respondents questions about 

physician contacts in the past year. 

There also were several differences in the detailed hospital 

page questions. Previously, information was obtained about 

the reason for each hospitalization. However, it is generally 

recognized that more complete and accurate hospital diagnosis 

information is obtained through the NCHS National Hospital 

Discharge Survey. This item, therefore, was modified for 1982. 

To continue to have the capability to produce NHIS discharge 

estimates for all hospitalizations excluding deliveries, the question “For what condition did —— enter the hospital?” was 

left on the questionnaire. However, except for hospitalizations 

8efore 1982 

occurring in the previous 2 weeks, intewiewers no longer record 

a detailed description of the condition for which the person 

entered the hospital, and coders use this item only to identify 

whether the hospitalization was for a delivery. 

Data processing changes 

Beginning in 1982, NHIS discontinued coding the specific 

condhion for which a person entered the hospital. These codes 

had been one of the items used to identify hospitalizations for 

deliveries, a category for which DHIS routinely produces estimates. Instead, a separate delivery recode was created for this 

purpose using coded information from the questiomaire. This 

recode was inadvertently omitted from the final 1982 Hospital 

Record, however. For this reason, hospital-specific data, such 

as average length of stay for hospitalizations with and without 

deliveries, are not included in the 1982 Current Estimates 

report; 

The delivery recode was used to produce the following 

categories on the final 1982 Person Record, providing person 

hospitalization data using these four groups: (1) number of 

short-stay hospital episodes in the past 12 months, excluding 

episodes for deliveries; (2) short-stay hospital episode days in 

the paat 12 months, excluding episodes for deliveries; (3) 

number of short-stay hospital discharges in the past 12 months, 

excluding discharges for deliveries; (4) days in the past 12 

,months in short-stay hospitals, excluding discharges for deliveries. Information on hospital discharges and days in (3) and 

(4) are based on experiences in the 6 months prior to interview. 

Results 

The hospitalization estimates for 1981 and 1982 remained 

essentially the same— 10.2 and 10.3 percent of persons with 

one hospital episode or more (table II). Slightly changing the 

wording of the hospital probe question and its location to the 

beginning of the interview and dropping the additional nursing 

home screener question did not appear to affect reporting. 

Since 1982 

Definitiorx Any continuous period of stsy of 1 night or more in a hos- No change. 

pital as an inpatient except the period of stay of a well newborn infant. 

Questionnaire: 3 probe questions asked about whether— Changes included— 

1. Anyone was a patient in s hospital. 1. Relocating the hospital probe question to the begin2.	 Anyone was in a nursing home, convalescent home, or ning of the questionnaire document. 

similar place. 2. Adding “overnight” to the phrase “was ——— a patient 

3. Any child 1 year or under was born in a hospital. in a hospital (overnight) . . . ?“ 

3. Deleting the nursing home stay probe question. 

Data processing:	 The specific condition causing the hospitalization was The condition causing hospitalization is used only to detercoded. mine whether the hospitalization waa for a delivery. 

Estimatea: 1981 1982 

Percent of Standard percent of Standard Percent change 

Item persons error persons error 1982-81 

Persons with 1 hospitalization or more . . . . . . . . . 10.2 0.1 10.3 0.1 +1 

Figure Il. Summary of National Health Interview Survey changes regarding hospitalizations: Before and since 1982 

161

Table Il. Percent of persons with 1 hospital episode or more, by Limitation of activity 

age and sex Unitad States, 1980-83 

Age and sex 1980 1981 1982 1983’ Questionnaire changes 

This health variable received fairly extensive revisions in 

Percent	 ofpersonswithl hospital 1982 (figure III). The changes having the greatest impact are 

episode or more as follows: All persons . . . . . . . . . . . . . . . . . . . 10.4 10.2 10.3 10.1 

1. The limitation of activity variable was changed to clasAge sify all individuals based on the ability to perform activities 

Under 17 years . . . . . . . . . . . . . . . 5.2 5.1 4.7 4.7


17-24 years . . . . . . . . . . . . . . . . . . 11.0 10.6 9.8 9.7 that areusual for their age group. The criteria for deter-


25-34 years . . . . . . . . . . . . . . . . . . 12.2 11.7 11.5 11.0 rnining activity limitation changed most significantly for


35-44 years . . . . . . . . . . . . . . . . . . 9.6 8.9 9.2 8.8 the elderly. Previously, persons 65 years of age and over


45-64 yaars . . . . . . . . . . . . . . . . . . 11.6 11.9 12.0 11.8


65 years and over . . . . . . . . . . . . . 18.3 18.0 19.9 19.9 who did not report their major activity as keeping house


were classified according to their ability to work. The


Sax revised version bases major activity limitation for all per-


Male . . . . . . . . . . . . . . . . . . . . . . . . 8.6 8.2 8.4 8.2 sons 71 years of age and over on (a) the ability to manage


Female . . . . . . . . . . . . . . . . . . . . . . 12.1 12.1 12.0 11.9 personal care needs, such as eating, bathing, dressing, and


1Provisional. getting around one’s own home, and (b) the ability to


Before 1982 Since 1982 

Definition: The extent to which a person’s usual activities (for example, All parsons are now classified according to their ability to 

playing, working, keaping house, going to school) are limited perform activities normal for their age group. For older perat presant because of a chronic condition or disability. The 4 sons, the concept chsnged from ability to work or keep 

dagrees of activity limitation are— house to ability to take care of ona’s personal care needs. 

1. Unable to carry on major activity. 

2. Limited in amcrunt or kind of major activity. 

3. Not limited in major activity but otherwise limited. 

4. Not limited in activities. 

Questionnaire: Different questions. were used for preschool and school-age In the previous version, persons 65 years and over whose 

children, housewives, workars, and persons whose usual usual activity was “something else” were asked about their 

activities were “something else.” For example, housewives ability to work. Major activity limitation for persona ovar 70 

were asked whether they could keep house at all, were years of age is now based on— 

Iimitad in tha amount or kind of housework they could do, or 

were limited in the kind or amount of other activities becausa 

, Ability to manage one’s own parsonal care needs, such 

“ as eating, bathing, dressing, or gatting around home. 

of health. 2. Ability to handle other routine needs, including everyday 

The phrases used to describe the types of health problems to household chores, doing nacessaty business, shopping, 

include as causing a limitation were “becausa of (his) health” or getting around for other purposes. 

and “bacause of a disability or health,” The phrase used to describe the types of health problems 

causing a limitation reads: “bacausa of any impairment or 

health problem.” A limitation of activity question about the 

ability to work is asked for all persone of working aga (1 8-70 

years). Limitation of activity questions are now located near 

the beginning of interview. 

Estimates: 1987 19831 

Percent of Standard Percent of Standard Percant changa 

Age and activity limitation persons error parsons error 1983-81 

Activity limitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.4 0.1 14.3 0.1 -1 

Under 17 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.8 0.1 5.0 0.2 +32 

17-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.4 0.2 8.7 0.2 +4 

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23.9 0.4 24.3 0.4 +2 

65 years and over . . . . . . . . . . . . . . . . . . . . . . . . . . 45.7 0.8 40.2 0.7 -12 

Major activity limitation . . . . . . . . . . . . . . . . . . . . . . . . 10.9 0.1 9.9 0.1 -9 

Under 17 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.0 0.1 . 3.6 0.2 +80 

17-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.4 0.1 5.9 0.1 +9 

45-64 yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.1 0.4 18.4 -4 

65 years and over . . . . . . . . . . . . . . . . . . . . . . . . . . 39.2 0.8 25.4 ::; -35. 

lNo activity-limitation estimates available for 1982. 1 

Figure ill. Summary of National Health Interview Survey changes regarding limitation of activity: Befora and sinca 1982 

162 
2, 

3. 

4. 

5. 

6. 

handle other routine needs, including everyday household


chores, doing necessary business, shopping, and getting


around for other purposes, This revised concept, which


replaces’’work” with activity more commonly associated


with older persons, was introduced to provide more realistic


classification criteria for this age group.


An additional limitation of activity classification based on


the ability to work was included for all persons of working


age (18-70 years of age), reflecting the considerable change


that the usual activity roles of men and women have


undergone since the survey’s onset. This added item enables


the data user to classify all persons of working age by a


single measure (the ability to work). It also resolves a con­


cern with the earlier version Women who did not work


because of a health problem but who could keep house


were not classified as limited in their major activity, whereas


men with this same set of circumstances were, by defin­


ition, limited in their major activity.


The specific age ranges for the limitation groups were


changed. (For instance, the school-age population, for


which major activity limitation is defined in terms of school


activities, was changed from 6–16 to 5–17 years of age.)


Now age categories more closely correspond to commonly


accepted age groups associated with the preschool, school-


age, working, and retired populations.


The phrases used in the limitation of activity questions—


“because of. . . health” and “because of a disability or


health” —were changed to “because of any impairment or


health problem,” This more clearly informs respondents


that they should report activity limitations resulting from


all kinds of handicaps as well as health condhions.


Because of increased availability of specialized instruction


and special classes for some children with learning or


other disabilities, the activity limitation questions for the


school-age population now include specific reference to


the use of and need for these programs.


The limitation of activity question set now appears near


the beginning of the interview. This change was made so


that questions with similar reference periods would be


asked in sequence.


Results 

Unfortunately, no activity limitation estimates are available for 1982 because of an oversight that occurred when 

finalizing some of the revised activity limitation questions for 

the 1982 questionnaire. Specifically, the DHIS activity limitation definition states that only limhations resulting from chronic 

conditions or impairments are included. However, no question 

was included for determining the condition(s) causing the limitations of some persons 60–70 years of age. Because the specific 

condition information for these persons was not available, it 

was not possible to edit out any limitations caused only by an 

acute illness episode. It was decided not to publish any activity 

limitation estimates for 1982 because they would not be comparable with estimates produced in subsequent years. This 

error was corrected in 1983. 

A comparison of the 1981 estimates and 1983 provisional 

estimates shows the same percent of persons with an activity 

limitation for both years-about 14 percent (figure III). However, there are noticeable differences between 1981 and 1983 

in the percents with an activity limitation for children (from 4 

to 5 percent) and older persons (from 46 to 40 percent). 

Similarly, the differences in the percents of persons in these 

age groups who are limited in their major activity are substantial. For example, the percent of children limited in their major 

activity increased from 2 percent in 1981 to 3.6 percent in 

1983. Proportionately, about one-third fewer persons 65 years 

and over were classit3ed as limited in their major activity in 

1983 as in 1981 (25 versus 39 percent). The differences between these estimates reflect a pattern consistent with the kinds 

of changes made to the limitation of activity questions. 

Days of disability 

Questionnaire changas 

The final version of the disability day questions introduced 

in 1982 represents a compromise between the version tested in 

the National Pilot Study and the disability day questions used 

prior to 1982. Before 1982, the disability day questions initially 

were asked about every persom For those persons with days 

reported, the condition(s) causing these days was obtained. 

These same questions then were repeated laterin the interview 

for all reported conditions. This procedure was necessary to 

link specific days of disability with each condition. In the version tested in the 1979 National Pilot Study, repetition of these 

questions was eliminated by designing the initial questions so 

that speciticdays of disabilitycould be determined on a conditionby-condition basis. 

Following the Pilot Study, however, several concerns were 

expressed about the impact these questiomaire changes would 

have on the subsequent disability day estimates. It was thought 

that some respondents mi&ht forget to report all conditions 

associated with their”disability days. Also, the format of the 

questions designed to identify which days of disability were 

associated with each condition (when multiple conditions were 

reported) was somewhat complicated. Nevertheless, there was 

a consensus that the flow of the interview using the revised 

questionnaire was greatly improved by not having to repeat 

these questions for every reported condition. 

Given these considerations, a modified approach was 

adopted in 1982 to obtain disability day estimates associated 

with specific conditions (figure IV). As with the pre-1982 version, each person initially was asked the disability day questions and the condition(s) that caused disability days. Persons 

who reported no disability days in the 2-week period or who 

reported one day or more of disability but only one condition 

were not asked the disability day questions again. The 2-week 

disability day questions, however, were asked again later in the 

interview for every reported condition for persons who initially 

reported one day or more and also reported two conditions or 

more during the interview. 

This modified procedure reduced repetitive questioning, 

simplified the approach to determine which days of disability 

were associated with multiple conditions, and provided respondents who had multiple conditions and days of disability 

an opportunity to report days previously forgotten. 

163 
Definition: 

Questionnaire 

Data processing: 

Estimates 

Before 1982 

Disability is a term used to describe any temporary or longterm reduction of a person’s activity aa a result of an acute 

or chronic condition. Four types of disability (or restrictedactivity) days are identified in the National Health Interview 

Survey 

1.	 Cut-dowrI day: A day on which a person cuts down on 

usual activities for the whole day because of an illness 

or injury. 

2.	 Bed day: A day on which a person stays in bed for all or 

moat of the day becauae of illness or injury. 

3.	 Work-/oss day: A day on which a currently employed 

person doea not work at a job or business for at leaat 

half of the normal workday because of a specific illness 

or injwy. 

4.	 Schoo/-/oss day: A day on which a child does not 

attend school because of an illness or injury. 

The disability day questions firat were asked for all peraona 

on an individual basis and answera were recorded in the 

appropriate Person’s columns. The questions also appeared 

on the detailed condition pages and were asked for all conditions reported in the interview to determine which condition(s) caused which type of disability day(s). The workIoss day questions were asked of all adulta 17 years of age 

or over. The questions on work-loss and school-loss days 

did not contain a description of the time period Usedto 

define these days. 

The number of disability days reported to questions on the 

detailed condition pages waa used to override reap~naea to 

the person disability day questions reported earlier in the 

interview. Work-loss daya reported for persona not currently 

employed were used to derive a person’s total number of 

Since 1982 I 

The time period used to define a cut-down day, bed day, 

work-loss day, and school-loss day has changed to “more 

than half of the day.” 

A separate page containing the disability day questiona is 

completed for every peraon. These questions also appear on 

the detailed condition pages, but, unlike the previous version, they are used only when the person with the condition 

has initially reported 1 disability day or more and 2 conditions or more. The work-loss questiona are asked only of 

currently employed persona 18 yeara of age or over. Unlike 

the previous version, the time period describing what constitutes a cut-down, bed, work-loss, or school-leas day ie 

the same for each type of disability day and is specified in 

the questions. 

In contrast to the earlier procedure, days of disability reported 

for a specific condition now cannot exceed the totel number 

of person days initially reported for that person. Because 

work-loss day queationa are asked only of the currently 

employed, days for persons not currently employed are not 

available to use in calculating a person’s overall number of 

restricted-activity days, as was done previously. 

1981 1982 

Standard Standard Percent change 

Rate error Rate error 1982-81 

Days per person per year 

restricted-activity days. 

Type of disability day 

Disability days 

Restricted-activity dada . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Bed days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Work-loaa daysl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Disability days associated with acute conditions 

Restricted-activity days, . . . . . . . . . . . . . . . . . . . . . . . . . . 

8ed days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Work-loss daysl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

1For currently employad persons, 

19.1 0.4 14.3 0.3 -25 

6.9 0.2 6.4 0.2 -7 

4.9 0.1 4.6 0.1 -6 

Days per 100 persons per year 

959.1 24.7 644.0 17.7 –33 

419.0 13.2 295.5 10.1 –29 

337.4 11.5 274.9 10.0 -19 

deys of diaabili~ Before and since 1982 

days. Specifically, in 1982 “days of disability” were described for respondents as days in which they stayed in 

bed, missed work or school, or otherwise cut down on their 

other activities for more than half the day. This differed 

from the earlier version, in which no qualifications were 

given in the work-loss or school-loss questions. Further, 

the bed day question used prior to 1982 contained the 

phrase “all or most of the day,” but other cut-down days 

were defined for respondents as days in which they “cut 

down for as much as a day.” Using the same time period 

(more than half the day) to define each type of disability 

Figure IV. Summary of National Health Interview Survey chenges regarding 

Other changes to the disability day question set included 

the following 

1.	 The work-loss day questions were asked only for currently 

employed persons. This rnodiiication has the obvious benefit of eliminating unnecessary questions that, in the past, 

had caused some problems when asked of persons who did 

not work. 

2.	 The description of the period of time constituting a workioss or school-loss day, a bed day, or a cut-down day was 

clarified and made consistent for all types of disability 

164 
day and incorporating it into the questions was done to 

improve the disability day estimates produced. 

3.	 The age groups used for the questions on work-loss and 

school-loss days were changed to 18 years and over and 

5-17 years, respectively, to more closely correspond to 

the usual ages of persons engaged in those activities. 

4,	 The placement, format, and order of the disability day 

questions also changed. In 1982 these questions preceded 

the questions on 2-week physician contacts, and information was recorded on a separate page for each family 

member instead of in columns. The relocation of the dkability day probe questions was done to group together 

sets of questions with similar reference periods and was 

not expected to affect reporting. The new page format for 

recording responses was expected to reduce recording and 

coding errors and to improve the overall quality of reporting. 

Interviewers were more likely to ask all the questions as 

worded for each family member instead of modifying them 

into “family-style” questions, as was sometimes done with 

the column format. The reordering of the disability day 

questions, work-loss first instead of bed days, was done to 

more easily integrate the current employment questions 

added to this page in 1982. 

Data processing changes 

Before 1982, discrepancies between the total number of 

person days and the condition days of disability that were 

reported were resolved as follows 

1,	 If any condition had a greater number of restrictedactivity days than was calculated for that person’s total 

number of restricted-activity days, the person’s restrictedactivity, bed, and work-loss or school-loss days were replaced with the number of days from the condition record 

listing the largest number of restricted-activity days. 

2,	 If a person who initially reported 1 day or more of disability had no condition records with days, the person’s 

days were changed to zero. 

3.	 If the sum of ,restricted-activity days from all condition 

records for a person was less than the person’s restrictedactivity days, the person’s restricted-activity days were 

changed to agree with the summed number of days. 

In contrast, in 1982, if a greater number of restrictedactivity days was reported for any condition than the person 

had for total number of restricted-activity days, the condition 

restricted-activity days were decreased to agree with the person’s originally reported number. Similarly, if a greater number 

of bed, work-loss, or school-loss days were reported for a condition than the person had originally reported, the condition 

days were changed accordingly. This procedure was adopted 

so that condition days of disability were derived in a way consistent with the approach used for persons not reporting two 

conditions or more, Specifically, persons originally reporting 

no days of disability or only one condition were not given 

another opportunity to report any days previously forgotten. 

Another difference between the disability day edits for the 

two periods involved the work-loss day question. In the prior 

period, work-loss days reported for persons who were not 

currently employed were used to derive the person’s total 

number of restricted-activity days. Because the revised questionnaire limits work-loss day questions to the currently employed population, these days, unless reported as cut-down 

days, do not exist in 1982. 

A final change to the disability day edits involved the 

specifications for editing out-of-range numbers of days (days in 

excess of 2 weeks). Codes of 15 days or more previously were 

edited to 14 days; in 1982 these codes were edited to O days. 

This change was made after looking at a number of individual 

records and determining that these out-of-range codes were, for 

the most part, the result of off-line keying or other errors and 

not actually reported days. 

Results 

Person days of disabili~—l%e averagenumber of restricted- , 

activity days per person per year fell from 19.1 to 14.3 days 

from 1981 to 1982 (table III). The differences between the 

average number of bed days per person (6.9 compared with 6.4 

days) and the number of work-loss days per person (4.9 compared with 4.6 days) were not as great. 

Table Ill. Daya of disability per person per year, by type of 

disability, age, and sex United States, 1980-83 

Typeof disability.age,’ and sex 1980 1981 1982 19832 

Days of disability per person 

Restricted activity per year 

All persons . . . . . . . . . . . . . . . . . . 19.1 19.1 14.3 14.5 

Age: 

Under 17(18 )ysars . . . . . . . . . 11.6 10.5 8.7 9.6 

17(18 )-24 years . . . . . . . . . . . 12.5 12.0 8.6 8.5 

25-44 years . . . . . . . . . . . . . . . 16.5 16.7 11.6 11.6 

45-64 years . . . . . . . . . . . . . . . 26.5 27.6 20.2 19.3 

65 years And over . . . . . . . . . . . 39.2 39.9 31.6 32.1 

Sex: 

Male . . . . . . . . . . . . . . . . . . . . . . 17.1 17.3 12.5 12.3 

Female . . . . . . . . . . . . . . . . . . . . 21.0 20.7 16.0 16.5 

8ad disability 

All persons . . . . . . . . . . . . . . . . . . 7.0 6.9 6.4 6.7 

Age: 

Under 17(18 ) years . . . . . . . . . 5.2 4.8 4.0 4.5 

17(18 )-24 years . . . . . . . . . . . 4.7 4.9 3.6 3.7 

25-44 years . . . . . . . . . . . . . . . 6.1 5.6 5.1 4.9 

45-64 years . . . . . . . . . . . . . . . 8.4 9.0 8.4 8.5 

65 years and over . . . . . . . . . . . 13.8 14.0 14.7 16.7 

Sex: 

Male . . . . . . . . . . . . . . . . . . . . . . 5.9 5.8 5.4 5.7 

Female . . . . . . . . . . . . . . . . . . . . 8.0 7.9 7.3 7.6 

Work IOSS3 

All persons 17 (18) years 

and over . . . . . . . . . . . . . . . . . . . 5.0 4.9 4.6 4.2 

Age: 

17(18 )-24 yeara . . . . . . . . . . . 4.6 4.1 3.9 3.5 

25-44 years . . . . . . . . . . . . . . . 4.9 4.8 4.3 4.1 

45-64 years . . . . . . . . . . . . . . . 5.4 5.7 5.6 4.8 

65 years and over . . . . . . . . . . . 3.9 4.2 5.3 5.2 

Sex 

Male . . . . . . . . . . . . . . . . . . . . . . 4.9 4.6 4.1 3.7 

Female . . . . . . . . . . . . . . . . . . . . 5.1 5.3 5.2 4.9 

lAges in parentheses were implsmentsd beginning in 1982.


2Fr0visi0nal.


3For currently employed persons.


165 
The decline of about 25 percent in the estimate of restnctedactivity days was not anticipated. Therefore, investigations 

were undertaken in an attempt to explain the drop. It was con­

, eluded that the difference resulted from a number of contributing factors rather than from a single cause. The following 

possible explanations for the differences were examined. 

With the newly designed questions, interviewers and coders 

made errors in administering the questionnaire, recording answers, and coding data entries. This temporary decline would 

reverse itself after interviewers and coders became more familiar 

with the new questionnaire. 

To investigate this explanation, the 1981 and 1982 quarterly estimates were compared for person days of restricted 

activity (table IV). Analysis of these data is based on comparability ratios. For instance, the ratio of 0.71 for quarter 1 

indicates that the 1982 NHIS sample yielded 29 percent fewer 

restricted-activity days per person than did the 1981 quarter 

1 sample. 

This comparison revealed a greater difference between the 

quarter 1 estimates for 1982 and 1981 than between the 1982 

and 1981 estimates for quarters 2 and 4. However, differences 

in quarter 3 resembled those in quarter 1, so the findings seem 

to refute the hypothesis that the differences were the result of 

interviewer unfamiliarity with the new design. Furthermore, 

the 1983 rate remained at about the same level as the 1982 

rate (14.5 restricted-activity days per person in 1983 compared with 14.3 days in 1982). 

A second explanation is that repositioning the disability 

day questions after the hospitalization and activity limitation 

questions and changing the order and wording of the questions 

influenced respondents to report only the more severe kinds of 

illnesses and injuries that caused days of disability. 

To evaluate whether respondents were less likely to report 

less serious acute illnesses or injuries in 1982 than in 1981, 

and therefore have fewer days of disability, a comparison was 

made between the proportion of acute conditions reported with 

and without medical attention and with less than 3 or 3 days or 

more of restricted activity. This analysis revealed that, for 

whatever reason— questionnaire placement, wording, or othera higher proportion of acute conditions reported in 1982 thart 

in 1981 had medical attention (60 percent compared with 54 

percent). This finding probably also reflects improved reportini; 

of physician contacts in 1982 because of changes in that per. 

tion of the questionnaire. 

However, of acute conditions not medically attended, therx 

was a hQher proportion with only 1 or 2 days of restricted 

activity in 1982 (74 percent) than in 1981 (70 percent). Further, 

the proportion of acute conditions that had medical attentiorl 

and restricted activity was higher in 1981 than in 1982 (37 percent compared with 32 percent of all acute conditions). These 

somewhat contradictory results make it diftlcult to conclude 

that the less serious acute conditions tended to be underreported 

in 1982. 

A third explanation is that a change in the computer edifi; 

that disallowed changing the reported person days of disability 

to agree with subsequent reporting of condition dlsabilit y day~~ 

resulted in an overall decrease in days. 

To determine whether the 1982 decision to accept the initial reporting of person days of disability and not edit that ent~ 

based on later reporting of condition days of disability affected 

the overall estimates, the 1982 quarter 1 data file was run usin~, 

both methods. The results are shown in table V. The new edit 

which did not “back-edit,” did not significantly affect tht 

“estimate produced for person days of disability and does no{ 

explain the difference between 1981 and 1982. 

A fourth possible explanation examined is that other factors, including a milder flu season in 1982 than in 1981, 

resulted in the lower reporting. Restricted-activity day estimates 

associated with all acute conditions and acute conditions except 

flu were compared for the tio years (table VI). The ratio was 

not affected by excluding flu in the restricted-activity day 

estimates for the two years. 

Table IV. Number of restricted-activity days per person per quarter, standard errors, and ratio of 1982 to 1981 estimates, by quarter: 

United States, 1981-82 

1981 1982 

Days per Standard Days per Standard 1982-81 

Quarter Person error Derson error ratio 

Quarter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.5 0.16 3.9 0.12 0.71 

Quarter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.5 0.14 3.6 0.12 0,80 

Quarter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.5 0.14 3.1 0.10 0.69 

Quarter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.6 0.14 3.7 0.12 0.80 

Table, V. Number of days of disability per 100 parsons per quarter for old and new data processing edits, standard errors, and ratio of naw to 

old estimates, by type of disability Quarter 1, 1982 

Old edit New edit 

Days Days 

per per New-old 

100 Standard 100 Standard edit 

Type of disability persons error persons error ratio 

Restricted activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384.0 12.1 394.7 12.4 1.03 

Bed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182.4 7.4 176.7 7.3 0.97 

Work loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130.6 6.9 131.1 6.9 1.00 

166 
TableVI. Number of restricted-activity days, standard errors, and ratio of 1982	 to 1981 estimates, by condition group United States, 1981-82 

1981 1982 

Days in Standard Days in Standard 1982-81 

Condition group thousands error thousands error ratio 

All acute conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,158,450 55,640 1,462,670 40,177. 0.68 

Allacute conditions except influenza . . . . . . . . . . . . . . . . . . . . . . . 1,730,198 46,700 1,210,044 34,836 0.70 

Table VI 1. Number of disability days associated with acute conditions per 100 parsons per year and disability days per person per year, 

atanderd errors, and ratio of 1982 to 1981 estimates, by type of disabili~ United States, 1981-82 

1981 1982 

Standard Standard 1982-81 

Type of disability Days error Days error ratio 

Per 100 persons per year 

Restricted activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 959.1 24.7 644.0 17.7 0.67 

Bed, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419.0 13.2 295.5 10.1 0.71 

Work loss, ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., 337.4 11.5 274.9 10.0 0.81 

Per person per year 

Restricted activity . ., .,, .,....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.1 0.4 14.3 0.3 0.75 

Bed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.9 0.2 6.4 0.2 0.93 

Work loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.9 0.1 4.6 0.1 0.94 

Other explanations for the difference between the restrictedactivity day estimates also were considered. For instance, 

work-loss days reported by persons not currently employed 

were used in 1981 to calculate restricted-activity days. In 1982 

people who were not currently employed were not asked about 

work loss, so these “days” were not obtained and, therefore, 

were not part of the 1982 restricted-activity day estimate. To 

measure the effect of this difference, a rough approximation 

was determined of the proportion of 1981 restricted-activity 

days derived only from work-loss days reported by persons not 

currently employed who reported no other type of disability 

day. (This second qualification was important to derive a conservative approximation of the impact of this estimate because 

work-loss days that were also bed days would, by definition, 

contribute to the overall restricted-activity estimate in both 

years,) Approximately 73 million of such work-loss days were 

reported. They represented less than 2 percent of the total 

number of restricted-activity days reported in 1981. Had these 

days not been included in the 1981 restricted-activity day 

estimate, the rate would have changed from 19.1 to 18.8 days 

per person per year. 

Disabili{v days associated with acute conditions—A 

comparison of the disability day estimates associated with 

acute conditions for 1981 and 1982 revealed even greater 

differences than were found between the person disability 

day estimates for this period (tables VII and VIII). These 

results suggest that underreporting occurred with proportionately greater frequency for restricted-activity, bed, and 

work-loss days associated with acute conditions than for 

days of disability associated with chronic conditions. In 

1981, 50 percent of all reported restricted-activity days were 

caused by acute conditions. In 1982, the proportion of days 

attributed to acute conditions dropped to 45 percent. 

The types of comparisons made to investigate the 

reasons for the difference between the 1981 and 1982 

Table Vlll. Days of disability associated with acute conditions 

per 100 persons per year, by type of disability, age, and sex 

United States, 1980–83 

Type of disability. age, ~ 

and sex 

Restricted activity 

All persons . . . . . . . . . . . . . . 

Age: 

Under 6 (5) years . . . . . . . 

6 (5)–16 (17) years. . . . . . 

17(18 )-44 years . . . . . . . 

45 years and over. . . . . . . 

Sex: 

Male . . . . . . . . . . . . . . . . . . 

Female . . . . . . . . . . . . . . . . 

Bed disability 

All persons . . . . . . . . . . . . . . 

Age: 

Under 6 (5) years . . . . . . . 

6 (5)-16 (17) years. . . . . . 

17(18 )-44 years . . . . . . . 

45 years and over. . . . . . . 

Sex: 

Male . . . . . . . . . . . . . . . . . . 

Female . . . . . . . . . . . . . . . . 

Work IOSS3 

All persons 17 (18) years 

and over . . . . . . . . . . . . . . . . 

Age: 

17(18 )-44 years . . . . . . . 

45 years and over. . . . . . . 

Sex: 

Male . . . . . . . . . . . . . . . . . . 

Female . . . . . . . . . . . . . . . . 

1980 1981 1982 19832 

Days of disability per 100 persons 

per year 

986.9 959.1 644.0 721.9 

1,195.5 1,060.7 723.5 948.1 

979.6 828.7 645.1 761.5 

980.6 985.0 629.4 648.9 

940.7 966.3 643.5 739.6 

869.9 834.1 580.8 611.4 

1,095.9 1,075.6 702.9 825.0 

426.6 419.0 295.5 334.9 

581.6 527.1 368.1 466.7 

462.8 418.6 299.0 357.9 

413.5 410.5 290.6 292.6 

380.1 399.6 281.9 345.0 

353.6 346.3 259.7 273.0 

494.6 488.7 329.0 392.7 

347.7 337.4 274.9 272.4 

367.6 355.5 281.2 205.8 

305.0 296.4 261.1 103.6 

327.4 298.7 233.2 227.9 

374.7 388.9 329.7 330.3 

‘Ages in parentheses were implemented beginning in 1982.


2Pr0visi0nal.


3For currently employed Persons.


167 
estimates of person days of disability also were made for the 

estimates of disability days associated with acute conditions. 

The conclusions reached were similar. Changes in the data 

processing specifications between 1981 and 1982,, a milder 

flu season, and interviewers’ unfamiliarity with the questionnaire document did not appreciably affect reporting. The 

primary explanation for the difference appears to be found in 

changes to the questionnaire format and question wording. 

Acute and chronic conditions 

Questionnaire changes 

During both periods, acute conditions were elicited by 

reporting doctor contacts and disability days occurring in the 

2-week period preceding the interview (figure V). However, as 

described earlier, the sets of questions used to obtain information on doctor contacts and disability days were different in 

1981 and 1982. 

The different levels of reporting of doctor contacts and 

days of disability for the two periods had an indirect impact on 

the estimated number of acute conditions even though, technically, the concept of an acute condition did not change. 

Before 1982, interviewers recorded all reported “volunteered” conditions, that is, conditions reported on questions 

not designed to pick up conditions. In the revised version, no 

volunteered conditions reported during the interview are recorded by interviewers. 

The six lists of conditions from which the NHIS chronic 

condition prevalence estimates are derived were similar for 

both periods, except for “cancer of any kind,” which was 

added in the 1982 version. 

There have been numerous requests for cancer prevalence 

Before 1982 

estimates. Although several of the chronic condition checklists 

included specific kinds of cancers, the NHIS questionnaire did 

not have the capability to produce an overall prevalence estimate 

for this condition. Recent research has shown that this statistic! 

can be reliably produced fkoma household interview survey (6). 

Changes were made to the NHIS detailed condition page 

questions in which more detailed information is obtained about 

chronic and acute conditions reported in the interview. Most of 

the changes involved either dropping selected questions for the 

purpose of shortening the length of the interview or modifying 

the instrument to simplify its administration. The following 

types of condition-specific information are no longer obtained 

use of medicine or treatment, surgery ever undergone, number 

of work-loss days in past 12 months, number of contacts with 

physicians in past 12 months, and frequency and degree of’ 

bother caused by condition. (For a complete description of the 

specific changes made, see Series 1, No. 18 (2).) 

Data processing changes 

The International Classification of Diseases code assigned to every reported condition was edited for the first time 

in 1982. Most impossible codes that were detected were corrected, but this new procedure created some additional rejected condition records when a feasible code could not be 

determined. 

The computerized list of conditions considered always 

‘chronic or always acute, regardless of onset, was expanded and 

revised. 

Results 

Another difference that was not anticipated based on the 

1979 National Pilot Study findings involved incidence rates of 

Since 1982 

Definition: An acute condition is defined as a condition that has lasted No chsnge. 

less than 3 months and involved either medical attention or 

restricted activity. For purposes of producing incidence 

estimates, acute conditions are limited to those whose 

onset occurred during the 2 weeks prior to the interview 

week. 

Questionnaire: Acute conditions were elicited from the reporting of doctor ‘There are changes to the physician contact and disability 

visits and disability dsys occurring in the 2-week period pre- day question sets from which acute conditions are derived. 

ceding the intetview. (See Physician contact and Disability day sections.) 

Data processing: International Classification of Diseases codes assigned to 

conditions are now edited. There is now an updated computerized list of conditions considered always acute, regardless of onset. The NHIS acute condition recode is also 

revised. Most changes involve adding more categories for 

conditions of sufficient size and interest to warrant showing 

them apart from the “other” categories to which they previously were assigned. 

Estimates: 1981 7982 

Number per Number per 

100 persons Standard 700 persons Standard Percent change 

Item per year error per year error 1982-81 

Acute conditions . . . . . . . . . . . . . . . . . . . . . . . . 212.4 6.3 167.1 3.9 –21 

Figure V, Summary of National Health Interview Survey changes regarding acute conditions: Before and since 1982 

168

acute conditions. In 1982 there were 167 reported acute conditions per person per year, compared with 212 conditions in 

1981; this represented about a 21-percent difference (table 

IX). A similar comparison between the rates excluding flu produced about a 17-percent difference. Substantial differences 

occurred among all age groups, although the greatest difference 

between the rates, 28 percent, was for persons aged 17–44 

years. Rates of acute digestive conditions, like those for flu, differed the most. About one-third fewer acute digestive conditions were reported in 1982 than in 1981, but because they 

represent less than 4 percent of all acute conditions, the decrease did not greatly affect the total rate. 

Because acute condition information is derived from reported days of disability, as well as from physician contacts, 

and because the 1982 disability day rates were well below the 

1981 estimates, it is not surprising that the 1982 acute condition rates differed as much as they did. In the previous discussion focusing on factors affecting the 1982 disability day estimates, it was pointed out that a higher proportion of reported 

acute conditions that year had medical attention. Thk finding 

is consistent with the overall increase in reporting of doctor 

contacts for that year. Further, the estimated number of medically attended acute conditions that had no associated restricted activity increased in 1982—from about 86.5 million 

conditions (38 per 100 persons) in 1981 to 107.5 million (47 

per 100 persons), an increase of about 25 percent. However, 

other findings do not support the idea that the less severe kinds 

of acute conditions as measured by total days of associated disability (1 or 2 days versus 3 days or more) were those most 

underreported. 

Table X shows the 1981 and 1982 rates of acute conditions per 100 persons by whether medical attention was 

received. The 1982 rates are significantly below the rates for 

1981 regardless of whether a physician was seen, but the 

greatest difference is clearly among acute conditions that were 

not medically attended. 

Furthermore, differences in the reporting of acute conditions do not appear to be caused by the interviewers’ and 

coders’ unfamiliarity with the questionnaire document. A comparison of these rates by quarter found no consistent pattern of 

improved reporting over time (see table XI). Additionally, the 

provisional 1983 acute condition rate of 175 conditions per 

100 persons is still 18 percent below the rate obtained in 

1981:. 

Changes in the 1982 computer edit specifications for acute 

conditions also were examined to determine what impact they 

might have had on the estimates. As described earlier, under 

certain circumstances some condition records are changed 

from acute to chronic and vice versa. Further, less serious 

acute condMons (those having neither medical attention nor 

days of disability) are deleted from the tiles. 

For quarter 1 of 1980 and 1982, a count was made of condition records for which either the acute-chrotic code was 

changed or a less serious acute condition record was deleted 

Table IX, Number of acuta conditions par 100 persona par year, by condition group, age, snd sex United States, 1980-83 

Condition group, age, and sex 

All scute conditions 

All parsons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . 

Age: 

Under 6 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .,, . ., . . . . . . . . . . 

6-16 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

17-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

45 years and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Sex: 

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

All acute conditions except influenza 

All persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Age: 

Under 6 years ., ., ., ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

6-16 years.................,,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

17-44 years, e. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

45years andover . . . . . . . . . . ..~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Sex: 

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Acute condition group 

Infective snd parasitic diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Respiratory conditions...,....,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Upper respirato~ conditions, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Influenza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Other respiratory conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Digestive system conditiona . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

injuries . . . . .. l . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Another acute conditions .,....., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

‘ Provisional. 

1980 7981 1982 19831 

Number of acute conditions per 100 

parsons per year 

222.2 212.4 167.1 174.7 

399.6 380.0 320.7 348.1 

293.0 275.9 229.1 242.8 

222.6 217.6 157.6 160.5 

130.6 120.6 101.4 106.1 

204.1 202.2 155.9 162.7 

239.0 221.9 177.6 185.9 

170.0 162.7 134.2 136.6 

345.7 323.0 277.9 293.0 

219.5 212.8 182.5 186.3 

167.5 163.5 122.5 121.7 

95.2 86.8 81.6 83.0 

158.0 154.4 125.3 126.7 

181.1 170.5 142.5 145.9 

24.6 23.6 18.8 20.3 

116.2 111.9 79.7 85.0 

57.0 55.7 41.0 40.5 

52.2 49.7 33.0 38.1 

7.0 6.5 5.7 6.3 

11.4 9.7 6.5 7.6 

33.4 33.2 27.2 27.5 

36.6 34.1 34.9 34.4 

169 
Table X. Number of acute conditions per 100 persons per year, standard errors, and ratio of 1982 to 1981 estimates, by whether medically 

attended and condition group: United States, 1981-82 

Medical attention status and condition group 

Medically attended 

All acute conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

All acute conditions except influenza . . . . . . . . . . . . . . . . . . . . . . . 

Not medically attended 

All acute conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Allacute conditions except influenza . . . . . . . . . . . . . . . . . . . . . . . 

1981 1982 

Conditions Conditions 

per 100 per 100 

persons Standard persons Standard 1982-81 

per year error per year error ratio 

115.8 3.7 100.0 2.6 0.86 

100.8 3.3 89.3 2.4 0.89 

96.7 3.1 67.2 1.9 0.69 

61.9 2.2 44.8 1.4 0.72 

Table Xl. Number ofecute conditions perl OOpersons perquaRer, standard errors, endratio ofl982tol98l estimates, by medical attention 

status and condition group: United States, 1981-82 

1981” 1982 

Conditions Conditions 

per 100 per 100 

persons per Standard persons per Standard 1982-81 

Medical attention status, condition group, andquafler quarter error quarter error ratio 

Medically sttended 

All acute conditions: 

Quarter 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Quarter 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Quarter 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Quarter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

All acute conditions except influenza: 

Quarterl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Quarter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Quarter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Quarter 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Not medically attended 

All acute conditions: 

Quarterl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Quarter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Quarter 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Quarter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

All acute conditions except influenza: 

Quarter 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Quarter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Quarter 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Quarter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

during the editing process. After adjusting the 1982 figures for 

one missing week of data, about 80 fewer acute condition 

records were found to have been created by these edit procedures in quarter 1, 1982, than in quarter 1, 1980. (Quarter 1, 

1980, was used in this comparison rather than quarter 1, 1981, 

because the former period had similar levels of flu.) Had these 

36.6 1.1 28.9 1.2 0.79 

26.2 1.1 24.1 1.1 0.92 

24.7 1.1 20.9 1.0 0:85 

28.3 1.2 26.0 1.1 0.92 

27.9 1.2 24.1 1.1 0.86 

24.7 1.1 22.1 1.0 0.90 

23.3 1.1 19.6, 0.9 0.84 

24.9 1.1 23.7 1.1 0.94 

33.6 1.4 21.2 1.0 0.63 

16.6 0.8 12.6 0.7 0.76 

17.1 0.9 12.0 0.7 0.70 

29.5 1.2 21.3 1.0 0.72 

17.4 0.9 12.9 0.7 0.74 

12.8 0.7 9.1 0.6 0.70 

12.1 0.7 9.1 0.6 0.75 

19.7 0.9 13.8 0.7 0.70 

records been included, the ratio for the 1980 and 1982 quarterly acute condition incidence estimates would have changed 

from 0.72 to 0.74, not enough to provide an adequate explanation for the differences found. It appears that respondents are 

simply reporting fewer acute conditions as a result of changes 

in the 1982 probe questions designed to elicit this information, 

170

Appendix III 

Estimation procedures 

Point estimates 

The National Health Interview Survey (NHIS) is designed 

to make inferences about the civilian noninstitutionalized pop 

ulation of the United States. To do so it is necessary to inflate 

the sample counts to national estimates. 

Four basic operations were involved for the data for each 

elementary unit (household, person, condition, hospitalization, 

and doctor visit) collected from 1973 through 1984: 

�	 Probability of selection injlation-The data for each elementary unit were multiplied by the reciprocals of the prob 

abilities of selection at each step in the desigrx primary 

sampling unit (PSU), segment, and household. 

�	 Nonresponse adjustment—The data for each elementary 

unit were inflated by a multiplication factor to adjust for 

units where an interview was not obtained. 

�	 First-stage ratio adjustment—The data for each elementary unit were ratio adjusted to the 1970 population within 

12 race-residence classes within each geographic region. 

� Poststrat#ication by ag&sex-race—The data for each 

elementary unit were ratio adjusted within each of 60 agesex-race cells to an independent estimate of the population 

of each cell by a multiplication factor applied to the weight 

of each elementary unit (household, person, condition, 

hospitalization, and doctor visit). These independent 

estimates are prepared by the U.S. Bureau of the 

Census. 

The probability of selection inflation is carried out each 

week. After the incoming reports are passed through controls 

to ensure that the data input to the computers are consistent 

with sample design, properly coded, and capable of being 

tabulated, a series of mechanical edits is carried out on the 

computers. These edits make the questionnaire internally 

consistent, and adjust or account-for item nonresponse. 

Into each record of an elementary unit (person, household, 

condition, and hospitalization) basic sampling inflation factors 

are inserted, This step takes account of all stages of sampling. 

The factor is the reciprocal of the combined sampling fraction, 

which varies among tabulation areas. 

These steps are carried out weekly and provide a tape of 

edited and adjusted sample data for each week of the 13 weeks 

of the quarter. Therefore, the “scale” of data at this point is 1/ 

13th of universe totals. Weekly data then are merged into quarterly totals. The nonresponse adjustment first-stage ratio adjustment, and poststratification are performed for each quarter 

(13 weeks). 

Despite intensive followup efforts, reports on some households in the sample had not been received at the tabulation 

cutoff. The noninterview rate usually was very low. Less 

than 5 percent of the households did not respond— 1 percent 

refusal and the rest for all other reasons, such as no one at 

home after repeated callbacks. Nevertheless, any estimating 

procedure must necessarily impute values for statistics for 

which measurement had been intended for a sample 

household for which no interview is obtained. 

Adjustment for noninterviews was accomplished by a calculation that assumes respondents within a particular segment 

for a quarter represent the nonrespondents in that segment. In 

the rare instance in which less than half a segment is interviewed, the noninterview adjustment is modified by evidence 

from reports over the entire tabulation area. An illustration of 

the process is given for a hypothetical tabulation area in figure 

VI. Data for the five households in segment 2 are multiplied by 

the factor 1.2000 so that the five representthesixhouseholds


intended for interview in the segment. Segment 4 ‘inthe example 

is of the unusual type in which less than half the households in 

the segment were interviewed, which leads to a further adjustment at the tabulation area level after a preliminary one has 

been made at the segment level. The tabulation area adjustment factor is the ratio of total households scheduled for interview to total households scheduled for interview minus the 

“excess” noninterviews; that is, the factor in the example is 

220/21 8, or 1.0092. Data for all reporting households in the 

hypothetical tabulation area are multiplied by this factor to 

account for the two-household “excess” of noninterviews. 

Statistical theory demonstrates that a ratio estimate for a 

statistic generally is superior to an ordimyy inflation estimate if 

there is correlation between the numerator and the denominator 

of the ratio. Also, if Y’ and X are ordinary inflation estimates 

of two characteristics of a population, Y and X, respectively, 

and if the “true” total X is known independently, then the ratio 

estimate Y“ = ( Y’/X’)X is a better estimate of Ythan is Y’, if 

there is correlation between Y’and X. In this form of estimate, 

the quantity (wX’) becomes a calibration factor for the survey. 

This principle is utilized at two stages in NHIS. In the 

first-stage ratio adjustment it was used to reduce sampling 

variance among PSU’S. Estimates of the 1970 population that 

Households 

scheduled Households Segment Excess 

Segment for not adjustment nonnumber interview intewie wed factor interviews 

1 6 0 1.0000 0 

2 6 1 1.2000 0 

3 8 0 1.0000 0 

4 4 3 2.0000 2 

. . . . . . . . . . . . . . . 

. . . . . . . . . . . . ,.. 

. . . . . . . . . . . . . 

Tabulation 

area 

total 220 10 . . . 2 

Figure W. Adjustment for noninterviews 

171

would have been obtained from a complete enumeration of 

only the 376 sample PSU’S were compared with oftlcial 1970 

population counts for each of 12 race-residence classes within 

each of the four geographic regions. A multiplication factor 

was applied to the weight of each elementary unit. This brought 

the sample data into closer conformity with population controls for 

the univers~ introduced only trivial, if any, bias into the estimate; and reduced sampling variance. 

Advantages of the ratio-estimating process were exploited 

further by the introduction of a second calibrating or ratio 

factor, the poststratification, which brought the estimates of the 

U.S. population derived from NHIS into agreement with independently determined controls for 60 age-sex-race classes of 

the civilian noninstitutionalized population of the United States. 

The last poststratification factor is probably the one most 

important to users because the independent estimates are the 

same as those used for the Current Population Survey (CPS). 

Thus the national population estimates for these characteristics from the two surveys are the same, which greatly 

enhances comparability for users of data from both surveys. 

The CPS is conducted the first week of every month, and 

independent national estimates of the civilian noninstitutionalized population are produced for each month. NHIS 

is conducted weekly and is designed to produce quarterly 

estimates as well as annual ones. In practice, the estimate for 

the CPS conducted in the middle month of the quarter was 

used for the NHIS quarterly estimate. The NHIS quarters and 

the dates of the estimates are 

NHIS quarter Population estimates 

January-March . . . . . . . . . . . . . . . . February 1 

April–June . . . . . . . . . . . . . . . . . . . . May 1 

July-September . . . . . . . . . . . . . . . . August 1 

October-December . . . . . . . . . . . . . November 1 

The 60 age-sex-race cells are shown in figure VII. Note that 

the race categories were changed from white and other to black 

and other beginning in 1980. The change was made to improve 

the precision of the estimates for the smaller black population. 

Variances 

One of the advantages of a probability sample is that an 

estimate of the reliability of the results can be made from the 

sample itself. The form of the variance estimator depends on . 

the sample design and the estimation procedures. It is desirable 

that the variance estimator be unbiased (and it should be consistent if not unbiased) and that it have a small sampling error. 

It is also desirable for computation to be simple. 

At the time NHIS was designed, there had been relatively 

little work on methods of estimating variances for surveys with 

complex sample designs. Computers were slow, awkward, and 

had little memory. Computer software was virtually nonexistent. Nevertheless, the decision was made to present sampling 

errors in all reports based on NHIS data, Calculating and 

presenting sampling errors for the national estimates from 

NHIS in all reports was a great advance in the presentation 

and interpretation of data. 

Race 

1979 and earlier 

White Other 

1980 and.later 

Other Black 

Male Female Male Female 

Under l year . . . . . . . . . . . . . 

l-4 years . . . . . . . . . . . . . . . 

5-9 years . . . . . . . . . . . . . . . 

10-14 years . . . . . . . . . . . . . 

15-16 years . . . . . . . . . . . . . 

17-19 years . . . . . . . . . . . . . 

20-24 yeara . . . . . . . . . . . . . 

25-29 years . . . . . . . . . . . . . 

30-34 years . . . . . . . . . . . . . 

35-44 yeara . . . . . . . . . . . . . 

45-49 years . . . . . . . . . . . . . 

50-54 years . . . . . . . . . . . . . 

55-64 years . . . . . . . . . . . . . 

65-74 years . . . . . . . . . . . . . 

75 years and over . . . . . . . . 

Figure VI 1. The 60 age-sex-race cells in the National Health 

Interview Survey 

The presentation of sampling errors in statistical reports is 

not a simple matter. Two major decisions must be made. The 

first is how to calculate the variances. The second is how to 

present them. The method used for estimating the variances for 

the statistics presented in the .Series 10 reports has changed 

over time. The method of presenting them, charts of relativ: 

standard errors for classes of variables, has remained relatively 

constant. 

Initially variances for NHIS were calculated by 

technique called the random group method (7). The method 

was used first for data collected in 1957. The variance 

charts constructed in 1961 based on the random grou:~ 

method of variance estimation were used until the late 

1960’s, when some of them were replaced by charts based 

on the Keyfitz estimation procedure (8). For data collected 

in 1972, the Keyfitz estimation procedure was used t,> 

calculate new variance curves. 

When the redesigned sample for the survey was 

implemented in 1973, new estimates of variances wer: 

needed. Balanced half-sample replication had been considered before, and early work on the method had been supported by the National Center for Health Statistics 

(NCHS) (9). In the meantime there had been further work 

(10) and a computer program had been written to apply thl? 

technique to the data from the National Health Examination 

Survey (NHES, now NHANES). However, at that time no 

one knew how to form orthogonal patterns when there were 

as many PSU’S as there were in NHIS. That problem wa; 

solved when George Schnack formed the orthogonal patterns 

for more than 100 strata (11 ). The computer program wa:; 

extended so that it could be applied to NHIS (12). Usin~ 

172 

I 
this program, variances were calculated for data collected in 

1973 (12). Those calculations are the basis for the relative 

standard error charts published in Series 10 reports for data 

from 1973 through 1984. 

The problem of presenting variances for a great number of 

statistics in limited. space was solved by publishing charts of 

relative standard errors for classes of statistics. 

A report on the research on the Keyfitz procedure (8) 

also gave the argument for presenting curves for classes of 

estimates: 

Instead of presenting variances for each statistic, the data 

can be grouped and “average variances” given. . . . Grouping 

the statistics is not easy, but two points to consider are that 

the survey characteristics such as prevalence of any diseases 

represented in a group should have similar design effects and 

that the groups should cover the possible range of variation in the data. ( 13) 

Instead of presenting the individual estimates for each cell in 

the tables, a set of relative variance curves was drawn using the 

empirical relationship between the size of the estimate and the 

relative variance of the estimate. The formulas and the procedures for estimating the parameters are given in Hansen, 

Hurwitz, and Madow (14), The procedures, using a fimction of 

the form, v;, = a + b/x’, are illustrated in the case study on 

the CPS. 

The curves of relative standard errors (the square root of 

the relative variances) are published in Series 10 reports from 

NHIS for 1980 through 1984. There are curves for widerange, medium-range, and narrow-range response variables to 

allow for the differing distributions of the variables and their 

design effects. The curves were calculated for each of the recall 

periods used on the questionnaire and for each period of data 

collection from one quarter through 2 years. 

A narrow-range statistic is defined for this purpose as (a) 

an estimate of the number of people in the population with a 

characteristic, such as the number of high school graduates or 

the number in excellent health, and (b) an estimate for which 

the response is usually O or 1 but may take on the value of 2 or 

very rarely 3, such as the number of hospital episodes in a 

year. 

A medium-range statistic is defined for this purpose as an 

estimate that will rarely lie outside the range O–5, such as the 

number of doctor visits in 2 weeks. 

A wide-range statistic is defined for this purpose as an 

estimate that often will lie outside the range O–5, such as the 

number of days of restricted activity in 2 weeks or the numberof contacts with a physician in a year. 

The total number of persons in the U.S. civilian noninstitutionalized population or in an age-sex-race class or combination of classes used for poststratification is not subject to 

sampling error because these numbers are adjusted to demographically adjusted decennial census figures supplied by the 

U.S. Bureau of the Census (12). Also, when the number of 

people in one of those classes is the denominator for a rate, the 

denominator has no sampling error. 

The curves of relative standard errors serve a usefid purpose by allowing the reader to obtain an estimate of the variability of the statistic of interest quicklfi however, they may not 

be sufficient for relational ‘malysis for several reasons. One is .,, 

that a number of approximations and assumptions were required 

to derive relative standard errors that (a) would be applicable 

for the large number of data items obtained from NHIS, (b) 

could be prepared at reasonable cost, and (c) could be presented hi relatively little space. As a result, the charts provide 

estimates of the approximate relative st~dard errors rather 

than an estimate for each specific estimate. Second, although 

they take the size of the denominator into accoun4 they do not 

take the differential effects of the clustered design into accoun~ 

that is, two population groups of the same size may have different design effects. A limitation in using the curves is that the 

analysts cannot incorporate covariances in the analysis where 

it is appropriate. 

An example of the differences in design effects for pop 

ulations of similar size is shown in table XII for the proportion 

of children with medical care within an interval. There are 

approximately 22 million children in families with six members 

or more in the household and there are approximately the same 

number in families in which the head has 13 years of education 

or more. Nevertheless, as can be seen in table XII, the design 

effect for children in the first category is 3.41, and for the 

second it is 1.62. The standard error of the proportion of ~ 

children with medical care for the first group is twice that for 

the latter. 

Each time the curves have been recalculated, they have 

been used without moditlcation in succeeding years until we 

sample is redesigned as if there had been no change in the dis- ‘ 

tribution of the population or the dependent variables over an 

extended time period. The effect of the changes over time may 

not be trivial. In evaluating the change from 1973 through 

1979, Givens found that the weighted relative standard errors 

for each of the eight curves he evaluated showed consistent 

increases over time “because of the attrition in sample size (15). 

Moreover, the values predicted from the curves differed from 

the computed values. In 1980, which was a special case because 

4 weeks were eliminated from the sample, one-third of the 

variance estimates were in error by more than 20 percent. 

Also, it is important to note that NHIS was designed with 

one sample PSU selected from each stratum (there is more 

than one if the stratum is a non-self-representing stratum and 

the PSU is a rotation cluster containing more than one PSU, 

although it is still treated as one and there is only one in any 

given year). The methods usually used for estimating the variances assume two PSU’S in each stratum. Therefore, pseude 

strata, each containing two PSU’S, had to be created to calcu~ 

late the variances. This was done in the self-representing strata 

by dividing each stratum into two PSU’S so that it was a 

stratum with two PSU’S. The non-self-representing strata were 

paired with one another and a pseudoPSU number was assigned 

to one member of the pair, and that number plus 1 to the 

other(n). 

The pseud@PSU’s are on all public use data tapes for data 

collected in 1980 or later. They enable the interested tape user 

to estimate variances and standard errors for a variety of statistics using one of several commercially available computer 

programs ( 16– 19). They do not enable the user to replicate 

173 
Table X11. Number, proportion of children who received care within an adequate intervel, eatimatea of standard errors, and design effects, by 

selected characteristics of children and youths under 18 years of age: National Health Interview Survey, 1975–76 annual avaraga 

Standard error 

Proportion 

Number with Simple Design effect 

in adequate random 

Characteristic thousands interval sample Complex SE Variance 

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73,234 0.8566 0.001295 0.002152 1.66 2.76 

,, Family size 

l-3 persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12,789 0.9090 0.002543 0.002693 1.06 1.12 

4 persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21,063 0.8963 0.002101 0.002687 1.28 1.64 

5 persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17,081 0.8598 0.002656 0.003170 1.19 1.42 

6persons or more . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22,301 0.7864 0.002744 0.005067 1.85 3.41 

Education of head of family 

O-n years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24,771 0.7953 0.002563 0.004240 1.65 2.74 

12 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25,888 0.8678 0.002105 0.002960 1.41 1.98 

13years ormore . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.874 0.9161 0.001875 0.002383 1.27 1.62 

Family income 

$0-$4,999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8,418 0.8186 0.004200 0.005437 1.29 1.68 

$5,000-$ 9,999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15,171 0.8231 0.003098 0.004678 1.51 2.28 

$10,000-$ 14,999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17,558 0.8543 0.002663 0.003760 1.41 1.99 

$15,0000 r more . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26,697 0.8932 0.001891 0.002822 1.49 2.23 

Age of child 

O-5 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21,130 0.8789 0.002244 0.002796 1.25 1.55 

6-n years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24,298 0.8693 0.002157 0.003257 1.51 2.27 

12-17 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27,806 0.8287 0.002265 0.003284 1.45 2.11 

Standard metropolitan statistical area 

Yes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53,324 0.8701 0.001456 0.002415 1.66 2.75 

No . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19,910 0.8204 0.002720 0.004562 1.68 2.81 

NOTE SE = standard error. 

SOURCE Kovar MG. Amethodological study of fsctors associated with whether children receive adequate medical care. institute of Statistics Mimeo Series No. l428. 

Chapel Hill, North Carolina: University of North Carolina. 1982. 

the variance estimation procedure used by NCHS for the 

Series 10 reports. The NCHS balanced half-8ample replication program takes poststratification into account. To do 

so, the balanced half-sample replicates must be used and those 

replicates, which take up agreat deal of space, are not on the 

‘public use tapes. 

Tape users should also note that the variance estimation 

methods based on a Taylor-series approximation ( 16,18, 19) 

cannot be used directly for estimating the variances of medians. 

The balanced half-sample methods can be used. 

For data collected prior to 1980, the published curves of 

relative standard errors must be used. These are adequate for 

many analyses, and many users of the data will prefer using 

them regardless of when the data were collected. Instructions 

for using the charts are given in NCHS Series 10 publications. 

To familiarize themselves with the estimation procedures for a 

given data year, the data user should consult the technical 

appendix in the Series 10 report for the data year of interest. 

Weights on public use data tapes 

Core questions 

For estimates of the population of persons with attributes 

(such as persons limited in activity, in poor health, or with one 

bed day or more during the year), the four quarterly weights are 

averaged to produce the annual weight. This is labeled “basic 

weight” on the public use data tapes. Weights for one quarter, 

6 months, 1 year, and 2 years of data collection are on the 

public use data tapes. Weights for longer periods of time can be 

constructed by averaging the annual weights over the desired 

time period. 

For estimates of events with 2-week recall periods (such 

as the “number of disability days, doctor visits, or acute conditions), events are added to produce the annual estimate. This 

is labeled “6,5 weight”on the public use data tapes. The 

weight is 6.5 because 13 weeks in the quarter divided by 2 

weeks of recall equals 6.5. 

Example—A user wanting to estimate the number of 

people limited in activity should use the basic weight if using 

data from a full year of data collection. 

Example—A user wanting to estimate the number of bed 

days (2-week recall) should use the 6.5 weight. 

Example—A user wanting to estimate the number of bed 

days per person limited in activity should use the 6.5 weight for 

the numerator and the basic weight for the denominator. 

Special core questions 

Because six different lists of chronic conditions were used 

beginning in 1978, with respondents in one-sixth of the house174 
holds being asked each list, special weights had to be developed 

to provide national estimates of the prevalence of chronic conditions. A factor, which is also on the public use tapes, is multiplied by the basic person weights to produce weights approximately six times as large. 

Similarly, the recall period used for the number of hospital 

discharges and days in shofi-stay hospitals published in Series 

10 reports is 6 months. Therefore, the weight is double the 

basic person weight (that is, the semiannual weight), if the user 

wants to duplicate the published estimate. That can be done 

from the information on the hospital tape. 

However, the user of the public use data tapes should be 

careful to note that the published number of hospital episodes 

during the year is based on a 12-month recall question, so the 

appropriate weight for episodes and the associated days is the 

basic person weight. 

Supplements 

The questions on many supplements were asked about all 

household members at the time of the interview. The weights 

for questions on those supplements are the same as the ones for 

equivalent core questions. 

In other cases, there was subsampling for the supplement 

or response rates were different (as when supplements were left 

to be mailed in or only a fraction of the people in the household 

were asked the question). The weights for questions on those 

supplements are different ffom those for core questions. 

For example, questions about smoking were asked of 

one-third of the adults in the last 6 months of 1980. The 

weights reflect the subsampling. The Child Health Supplement 

questions were asked about only one child in each family in 

1981. The weights for that supplement also reflect the subsampling and differ from the basic weights by a factor 

approximately equal to the inverse of the number of children 

under age 18 in the household. 

Thus, each supplement is given appropriate weights, and 

the public use data tapes are released separately from the core 

questionnaire tapes. 

175 
Appendix IV 

Topical index to questionnaire items, by year 

WC @f2s15cmd3x3 item Yfx3r

ACtiYitvM


Would you say that ym are @ysically mm active, 1983


less active, or about as active as ot&r persons


P-


AJmc


Receive ass”
~ t.hrcK@ Aid TO Families wi~ 1980, 1982, 1984


Dqendmt Ulildren (Almc)


2!9&23


Z4@gmqm3ent staysin bedallormst of the 1984


time becauseof =ti or @ysical pr&lem


Agiq respmkmk staysin * all or mst of 1984


the time becauseof hezilth
or physical prcbl-


Health or physical comlitkms that cause aghg 1984


mspm%nt tostayinbd or chair


was =@IB3 ~ fij-d 1984


When did injuryfor k@g ~ cccur 1984


Did * ~ have = -ti~ 1984


-~hasdiffi~~~ --s 1984


I!giq ~ has difficultyshqpimg for pemanal 1984


items (such as toiletitemsor medicine)


~
 receivesMlp fromanotherperson 1984


pmvldes help toagbqmspcmmt 1984


Is help for agirg~ @ for 1984


Healthor physicalcamlitionthat causesagbg 1984


respondentto have difficulty prqarirg own reals


ltqkqmspmk nthasdifficu l~mamgiq wnmmy 1984


(such as keepingtrackof expemes or payingbills)


Ag@ mqomknt has difficulty usirq W telephom 1984


Agimj resporikmt has difficulty doing heavy hcmsemrk 1984


(like scrubbing floorsor Wash@ windows)


Agiq mspo@mt has difficultydoirqlighthmsework 1984


(likedoingdishes,straightening
up, or light


cleaning)


%qimj mspmknt has everbeen a residentor patient 1984


inanumirghum2


Numberoftimesa@lgreS@mem has ken residentor 1984


patient in nmd.ng halE 

How does agingmspcdmt’s healthtcdayccqare with 1984


her or his health1 year ago


Tmlchworr yhasagillgmspmklt ‘s overallhealth 1984


causedherorhim duringthe past year


acti. isa@qmqm3ent Cxqared with 0-Wersof 1984


the same age


q—W=P—— ‘s levelof @ysica.1activity 1984


~ord~frcnnl year ago.


mchccmtml doesagingmspmknt have over 1984


his or her futurehealti


176 
-c Questicmnaim2 item 

mesaor ging ~=~
 get as much exercisers needed,


Does*~foll~a@ar~ of


physicalexercise


Howoftendoesagirq Rspmikt walk amileor moreat


atimewi~mstiq


Inthepast year,ti oftendid agiq~have


bmible ~-
 Inthepast year,hmofbm did- mspmkmt get


Lasttime agingmspmdmt sawortalked toadocbr


or assistantabaxt (comiiticm)


causeof aging~’s (-ti~)


Did W@ ~’s (Cmdition)reSultfroman


aocickntor injury


What did doctoror assistantcall agiq mspiknt’s


(Cmditicm)


HcW cbes alleq@tr&e nuw affectaging~
 Whenwas agingmspmdmt’s (Condition)
firstWticeii


Dmagingmspmdmt stillhave this czrditim


IS=Lz’s (cmdkion) cmpletely ~ or


Hcxlcqdid agingmspmdmt have this (ccmlition)


beforeit was cured


WaS agiq mqmdent’s (cmdition)presentat any tim


duringpast12nKmldls


Whatpart of agingmspcdmt’s body is affeckd now


and how


men was agingmspmkmt admittedfor the fti time


at mming hcm


Whenwas thelast*agirq~ wasdis&3m@


fromnm&ng hcme


Howlong wasaging Rspmdmt in nursingb the last


tim


Hmmanyweeks jnthepastl.2nmnths wasagiq


mqcdent inmrsing home


= @W;= nowonawakhql isttogo into


lXRS ZlgiXXJ
 reqmknt have frieml,relative,or


neighborvhowwldtakecare ofagiqmspmdmt


for a few weeks if mcessaq


IS agiq mqmikmt familiarwith the tem %ospice,u


a servicefor the terminallyill


Is therea hospiceor an in-hme hospiceservice


in the metropolitanarea or county*t agiq


reqxmkk -duse if needed


Hmgoodaj&does~~ feel she or he


isdoing intaldqcamof hisorherhealti


Maribl.smusofagingmspmdem


Childn?nofagingmspmdmt


YeHr 

1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


177 
-C Questicxmaim item 

A!3&2!J
 (~)


sexof CMMrenofa
gingRsp Cdmt


HmqlicKly chmrenofa
gingRsp&kmt can get to


Howofbm agingmqmdent ~ children


Howofkl aghlgmspmdmt tzilks
to childrenon


telephone


Howof&!n aCJingmSpmdmt receivesmail from


children


W@ ==P=@=t routfiY Keceives IrKxEy frcan


cMldren to help with living@qenses or pay bills


Numberof li~~ (including
adopted)agiq


~h=


~mo: li=~~sters (including
adopted)agirrj


IengHlof timeagingmspmdmt livedh present-


Agiqmspo@mt lmstogo upor downa stepto


getimto hm2frmmtside


~rr ‘slxm2has mmthancm floor


W@3 ~’s ba~l ~r a?xikitchen


all on the sanE flooror level


~s~~a~-ti~
 *~


@W~ liveswith * how&old meWers


becausemspo@mtm2eds to sham livingewpmses


-~
 liveswith otherhouseholdmenibem


becausemqmxkmt has healthor physicalprcblem


%@W ~’s --:


mned or beingbmxjht


rentedfor money


occupiedwithoutpaymentof rentmoney


WhouWnSagimJ ~’s -
 Is ~ ~’S hclte f@ly paid for


Mmipal stillUGA on ag~ reqm%mt’s mrtgage


Ammt of *@al stillowed on agingneqcdmt’s


PresentvalU20f agimJmqmdenVs hmle


Who pays rents for agimjmspmkmt’s hcm2


-l=’s - of ~ w Servicesin past
 .


use a seniorcenter


use special. transportation for the elderly


have AS deliveredto hme by an agency 

eat meals in a specialplace for seniorcitizens 

use a hmemaker’s services 

use a servicethatm.kesroutinetelephonecallsto 

checkon healthof elderlypeople


use a visitingnursesemice


use a healthaidewho cornsintothe hme


use adultday care or day care for the elderly


*~ doesvolumker work


Year 

1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


178 
WC Qwsticmnaire ilxm 

Howoftenaghg ~ d- ~1~ ~rk


lilpast2wee@, agingmspm3mt:


got togethersociallywith frieIx3s
or neighkms


tal.kxi
with frid or mighbors on telqhone


9~ ~ with relativeotherthan those in


household


talkedwith xelatim otherthan those in household


went to ~ or templefor servicesor other


activities


* b shm or mvie, sportsevents,clubmeting,


classesor othergrmp activities


l@hqmspodmt~mr3md atajob or business


~mspm@mt~m13Kx3 atajoborkusiness


Silmeage 45


Agirqmqmdentmrkdat jobor MdnessinW


past 12mCmms


NlmWrof W?eksa@lg mspadmt workedat job or


businessin the past 12 months


Ntnd3er
ofhmrsa weekagiqmspmknt workedat all


jobsworkedduringpast 12 mnths


w-~ C=l?letelY~ , partlyretired,


or not retiredat all


x$@3==P-ent~ Imretha nome


Hmloqhas it beens*a@q mspcdmt’shst


At last retiremen
t,=JiW~~-=


of a healW or physicalproblem


-~-=~
 -mmm


SocialSecurity


railroadretirement


privateemployeror unionpension


governmentemployeepension


militaryretiremnt


othersources


HmlCmg aging=---*


-~-=~
 becauseof mrk


isa~


Agirqmspmkmt receivesdisabilitypaymnt


M#—Wr=PQ@=t receivesdk3bility paymentsbecause


of respondentdisabilityor -use respondentis


dependentor survivorof someoneelse


How long aging~has--­


disabilitypayments


A9*-=& C3RX -veil any disabilitypayment


S==-iW


Agiq mspmkmt has difficultywith folluwing


activities(byoneselfand not US* aids):


~fora~of atile


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


179 
. . . . . . 

-c QM3stl.orlname lwm Yeir 

- q?? 10 stepswithout resting 

S* for 2 hours 

sittirqfor 2 hours 

-b, ~CM.ng, or kneeling


machirq up overhead


readl.ing
out


using fingersto graspor handle


liftingor carrying25 pom3s


liftingor carrying10 pouMs


I@13sofworkagiIKJ
.? cm.lddoncx?if


jobs were avmlab


-==
 has follcmingeye cxrxtitims:


glaucoma


colorblindness


detachedretinaor otherconditionsof the retina


blininessin one or both eyes


troubleseeingwith one or both eyes evenwhen


wearingglasses


*—W---%=+==


-~-==~ eYe9—===


m~==~l==


Aging mspn&?m everhad Cperatims for cataracts


*=P-t-l== *l*


-~==a~ glassto md or do


otherclosework


Aging msqmdem seeswel.lenoughto recognizefeatxms


ofpeople iftheyarewithin2 or3 feet


Zqirqmspmdmt seeswell Gmou9hto watch!1578tx)


12 feet away


Jk@3m-=x&@= Sees well enough toreadmwqaper


kjirgreqmdak sees well enoughtostepoff acurb


0r&xt7nas@p


Z!giqmspmknt sees well enough tommgnizea


friendwalkingon the otherside of the street


statusof aging==Po@=@s *i­


no troubleseeing


a littletroubleseeiq


a lot of troubleseeing


@—W~~~-=~ in tieam


-~-d=@== inoneor both ears


Agixqmspm&mt hastrmbleheariq with one or both


?qisq mqcdent uses a hearingaid


With hearbq aid, agiq rqxmknt hearsmst of the


- peoplesay


statusof aging~’S hearirq with heariq aid:


no troublehearing


a littletroublehearing


a lot of troublehearing


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


1984


180

mpa Questionmim item 

E@29 (~) 

- &== SEC ha: 

a brokenhip


hanknhj of the arteriesor arteriosclerosis


hypatension or high blocdpre=sure


rheumaticfever


rheumaticheartdisease


cormary heartdisease


angimapectoris


a wocardial hfarction


any otherheartattack


a strok or cerebmvascular accident


Alzheimer’sdisease


Cancerof any kind


Z!qiq mspmdmt had followhg @tions duringthe


past 121mnkhs:


diabetes


R3?%ots


varicoseveins


MJing~has fallendurirKJ
past u?mmths


IWmanytimes hasagingmspmdmt fallenduringpast


A9in9:-ti%ll=e” ~m -1-2 ~


m~ has trmble with dizz-


I@q mqxmimt has trmble bitingor ciEw@ food


m~ ableto do certainactivitiesof


daily li* ~ sdLfand withoutusing


-id eq@m=t:


bathimjor shuwering


dressing


Axi3-lg


gettirqMm and out of bed or chair


-

gettirqoutside


US* the toilet


m~ reoeims help fKlmlanotherpemon in


activitiesof dailyliving


WhohE@6a gingmspc@mt in actixrities
 of daily


livirq


@W=W-===m=iale@JP- or aids


Z!@q mspmknt has difficultycontmllirgknwels


2@rqmspm@mt hasmlo6tany oradevice to help


CmntmlbCxRS1.
lKwemnt


A@rKJmqCdent needsMlpfrm anotherpemmin


- ~ of mlosbuy or otherdevice


Igirq mqomknt has difficultycontrollhqurination


Year 

1984


1984


1984


1984


1984


1984


.1984


1984


1984


1984


1984


1984


1984


1984


1984


181

?JJs4 guestionnaimitem 

-~Y-w@J mspcdmt have difficulty 

cmtmlling Urinaticn


catkter or a deviceto


Agi.qmspommt IE?edsklpfmll amthapersmin


takingcamof * =~


Alcchol (seealso Winkinq)


Not COUtlthCJ Slldl taStf2S, b Old Were YOU k?h211YOU 

~ drinkiq alcdmlic bewrqes


!kllmwhether youhaveemckd anyof­


followingcmlitims even if you have mentioned


them before:


hyperkmion or high bloodpressure


&udening of the arteries


tachycardia,arrhythmia,or rapidheartbeat


arthritisand rheumatism


convulsionsor seizures


blackouts


ShOrtlleSS of bxwdh 

insomniaor sleeplessness


hepatitis


anydisease of thepancmas


anulcer, otheri5mn askin ulcer


any CJ-=i.nt=tti bkediq


diabetes


heart attackor heart failure


coronaryheartdisease


strokeor hemorrhageof the brain


arqinapectoris


yelluwjaundice


fattylivex


cirrhosisof the liver


any otherlivertrouble


IYl?sor deliriumtremems


alcoholism


Armd Fb!mes (see also Disability) 

Have disabilityrelatsdto semice in Amed


Forcesof UnitedStates


~w= —w==ti~ for @fii@ f-


VeteransAdministration


mood ~ (see also Hiclh-Blood Pmsslue ) 

Ever told by dcctorhave high bloodpressure


Howlcmg sinceblodpressumtahn


Year 

1984


1984


1984


1983


1983


1982


1982


1982


1982


182 
W2P& guesticmnaimitm


Breast caKxi?r Prevenb “on 

Howlqsime breast exam by dockor orotherhealt.h


professional


Child Health


Child li= with biological fat3er for at least


3 months


CMld lived with biological mther for at least


3 months


Child’s klaticmship to hmselr)ld menber


A~hmmperweek*d iswifi~


Howloqhas child lived with~


How often child sees biological fatkr


Fk%#oftm -d sees biological mth=


Iast the d.ild li- with biological fa- for at


least 3 months


Iast time child lived with biological mther for at


least 3 months


Month zuxlyea rchildmv edto
thishcms


Nmberof times child rimed


(Memtakiny czm of child


Place whemchild islmken care of


Was child first, secml, or * born


- in hmsehold ~ for child


hlx)takes child to doctor


Child’s biological father nm liscbg or deceased


Child’s biological mthe.r nm lischq or deceased


Urild’s biological ~’s current address


How loq has child’s biological nmther


been Separatx?d


Nunberofch.ildrenchild’sbiological~


has ever had


M.mi)Erof miles between tid’s current hame


andpEviowhmE?


Nmberof - &LLd’s biological mther married


Year each time child’s biological ~’s mrriage


Reasms and year each the child’s biological


lldmer’smarriage elxkd


Year =ch the child’s biological ~married


Whattime dcesdil.d usuallygo tilxxl onschool


nights


lkxvmaIW hums does child UsLldly skq each ni@t


Ibeschil dusuall ytakenapsduri.mj the day


HcW many hums h all (Countirqnaps and night-time


sleep)does child usually sleep each C@?


tming past 12 mnths has dhild walked in slesp


Howmq*hastid walked insleepduri.ng the


past 12 months


Year 

1982


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


183 
Does childusuallysleepin me rum or in different 1981


Ibeschild usuallysleepha roan alme or sham 1981


Who A--ly sleepsin the roanwiti child 1981


Whenridimj inamr, does child~seat belter 1981


restraintall or most of me time,same of the


time,once in a while,or never


Childbehaviorpmbl- index (oftentrue, 1981


scawtimestrue,not true):


13assudde nchaqesi nmmdorfeeliqs


feelsor conplainsthat no one luveschild


is rathexhigh strung,tense,or nemous


cheatsor tellslies


is too fearfulor anxious


arguestoolnuch


has &ifficul@ concentra
 ting,cannotpay


attentionfor long


iseasily confused,seemsto bein afog


bullies,or is cruelor mean to others


is disobedientat home


does not seemto feelsorryaftermkkehaves


has troublegettingalongwith otherchildren


has troublegettingalongwith teachers


is impulsive,or sotswithoutthhking


feelsworthlessor inferior


isnotlikd by otherchildren


has a lot of difficultygettingmind off certain


thoughts,has obsessions


is restlessor merly active,cannotsit still


is stubborn,sullen,or imitable


hasavery strongtemperandlcses it easily


is unhappy,sad, or dep~


is withdrawn,does not get involvedwith others


bti thingson puqose, deliberatelydestroys


mm or others’things


clingsto adults


oriestoo much


demandsa lot of attention


is toodependent
on others


feelsothersareoutto get him or her


hangs~ with kids who get intotrouble


is secretive,keepsthingsto himselfor herself


worriestoo much


Childbeingbmastfed at presenttim 1981


Was childever breastfed 1981


I-kwoldwaschildwhenbmastf eed@J completely 1981


- bkth ~1 pillstie ~ti -d 1981


U&ldgiven fcmmlaor regularmil.k 1981


184 
Ebv old was child h fimt fed foznmla or regular


mi3Jcon a dailybasis


Child given any solid food, MmlM31mially pmpamd


strained ad juniortable focal,
or the non


liqqidfoa3s


HOW old was childwh?n firstate solklfood


Childturnshead from sideto sidewhen lyingm


Child’s eyes folluw moving cbject at all


Childliftshead off flatsurfacewhm lyingcm


Child’seyes follownmviq cbjectall the way from


one side to another


Childsmiledat scmeonewhen smeonetalked toor


smiledat childwithouttouchingchild


Howoldwas dhildwhenchild firstsmiledat~ne


when scmone talkedor smiledat child


l-hschild~~headand chest frm surface


wkn lyingcm stma* and restingweighton


lowerarms or hands


While lyiqonback aIxlbeirKJ@.lEii
 up toa


sittingposition,did childeverhold head


stifflyso that it did not hang back


Childlaqhs out loudwithoutbeingtickledor


toucihed


Child=headarourdtolmkat smet.lrhg


ChildHd mderate-size&ject such as blockor


rattlein one hand


Childlookedaruniifor a toy thatwas lastor not


Childever mlkii overon ppse


Ikw old was childwhen firstrolledover


lhschild ~pilledfranasitkbg tosbndiq


positim and -r-ted mm weightwith legs


stretchedout


Has childever sat alonewiti no help except for


leaningforwardon hank or with just a little


help from SmEone else


C!hildseem toenjql_fi mirror


Child ever said mmgizab le wrds such as Wan@’


or Ilmdall


How old was child when f.imt said any recognizable


Givendild’s height,is child~ “ght,right


w2.igbt,
or C%JelWight


Dxs dild wear glassesor contactlenses


Has child ever had teeth stm.ightx?md, bracesor


bardson teeth


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


185 
‘J&aC Questionnaire iti 

childHealth (mnthued)


(Mid’sð needtobestraighbed


Hasdoctor or dentistever saidthat child’steeth


Eedtobestmightened


Ibeschil dhweanyfilliqs


Hcw many of &ildls teethhave fillirrjs


Child’s- of mdicines, pills, — or Ointmenb:


“ pain relievers 

coughmdicines


coldllEiiiCilleS


asthm or alleqy pills


topical.
steroids


skin Ointmmts


laxativesor medicinesfor the stomach


vitaminsor mineral


tranquilizers
 or se&ives


antibiotics


otherpills,ointments,or medicines


If ad used lU2diCiIE2 what was the mainhealfi


pmblaa


Was*apresc@b “onfrma doctorfor child


Did doctor recmmml Wt childtake the fiche


Hwoften didchildtake or use nEdick? during


past 3 months


What &s childdoing in past 12-monthsgoingto


schoolor somethingeke


Intxzmof health,would drildkableti goto


school


Wmldchildh avetoattemlacerbm “ qpeofschCOl


becauseof kallm


W6u.ldcMJ.dbelimit@insdmol atkxlamekecause


of health


What	is the main comlitionthat causesc!hild
notto


keableto gotoschcol, haveto goto acertain


type of schcol,or be limitedin sdhool


a~


Was ctxild’s c(xrlition
 fimt noticeddurimjpast


3 monthsor uver 3 monthsago


Hasdril deveratbxklsdwol


tidmwin sclmolaronvacaticm


Qadediild isin


IXXS -d go b a specialclassor get specialhelp


in schoolbecauseof a disabilityor


kal.. p?mblem


Childmedstmattxml aspecialdass or get


specialhelp in schoolbecauseof a


disabilityor H& problem


V3ydidclrUd stqgoingtos(3mol


~ lcq ago did tid step school


Year 

1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


186

Childmxilth (amtimed)


Euringpast 12xrmthshuwq dayswaschild~


from schoolbecauseof illness


Has tid qt@ CJEidE?(S)


What P(S) did childzqeat


g ti&y~=P& -(s)


sqxaxkl, excludedor expelled


“froms C3Mlol


Howmany timeshas@ild been SWpe@Sd, excluded,


or expelledfkxxusdmol


mlcrqago wasthe lasttime childwas~,


excluded,or expelledfmu SC3MOl 

Hasanyme franschoolaskd Solneonetocmein 

to talk abmt child’spzrbkm(s) 

Hmlcqago wasthe lasttim anyum-scimol 

asksdsmneoneto talk abmt tid’s ~lem 

overallwhat kimi of Stlxkmtis childnow: One 

of best,abovethe middle,in the middle,below 

the middle,near the bottom 

Hmdoesmqomkmt feelchildis bhqinschool


doingreallywell,doingabut as well as other


children,couldbe doingbetter


lMringpst 12nmnthshas Wd everw?t the bed


Abouthurmany timshascidld=t tbe bed


inthepast12~


meschild smk -or fingertiingtheday


or night


Haschild everrunawayfrcm hcnne


Hmmanytims haschildnm away frmhm=


Hmoldwas tidthelasttime ran away


Dxs childtake any mdicirm?sor drugsto help


cmtml activityor behavior


w childever seena psychiatrist,
psydholcgist,


or psychoanalyst abmt any emotional,mental.,
or


bdHSTiorprcblem


Is childstillsee.irq psychiatrist, psychologist,
or


psychoanalyst


Whenwas lasttime childsaw--,


psychologist, or psychoanalyst:
 morethan12


monthsago or withinthe past 12 months


mr@past HmnHEbs anyme sqgeskd-d


neededhelp foran emtional,nmtal, or


behaviorproblem


social effectscm familymemberscaused~ dKld’s


ill healti:


familymovedto a differenthome


familymenbe.r
not been ableto take a job


familymxber quit or changedjobs


familymmber forcedto take a job when


otherwisewouldnot have


Year 

1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


187 
-C Questionnaire item 

familymember left home


familymmber gottena divorceor legal


separation


familybeen U1’KkrSevereproblemsmakingel13snk=et


familyor familymmber made some (other)major


-e in regularways of life


what (other)changeswere made


Did family mwe to be rearer b servioes for child,


because the familycouldnot affordto staywhere


it was, or othermason


Child ever dmsd himselfor herselfWWCW help,


-=@ for tyingshoesZ@ buttonimj


back of *


Has child ever cOunted Outloud up tolo


Have child’s ~ bmlmn thmqh the gmw


i!gewhe nchild’ sfimttoolhczune in


Is child completelylmilettmimd


Age wkn child was completelytiilettmiTxx3


Age of child’s biological mdhe.r at child’sbirth


Age of child’s biological fath.r at child’sbir&


WasdxLld born inabcspital. orsame otherplace


Hm mmy nightswas child’s biological mther in the


hospital duri.mjchild’sbirth


Hm many nightswas child in the hospital (at birth)


Wkightof child at bti


Child weighed mm than 5$ pcam3s (orless)


Child weighed more than 9 pamds (orless)


Child born at time cxpdxxl or earlieror later


EImnudh earlier or later than expcted was


child born


Ikw many lmms was child’s biological ILKMMX


in labor


C2Ud’s biological mkhx @. any IEdiCiIE?,


shats, or gas while in lal.mr


Hm was mdicim givento child’s biological


IIK&erdllringlabor


-d’s biological mtkr given any medich,


shots, or gas duriq deliq


I@w was medicim given to child’s biological


~ - Hiwzy


Was child’s biological mther given anythhg


else durirq delivery


Was child iklive.redby cesaman section


Reasm for deliveringchild by cesaman section


Child born head fimt or feet first


Was child’s deliwxy mrml or were thereany


complications
or problems


What type of pr&l- or complications
came about


as result of child’s deliq


Year 

1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


188 
‘m& guestionnaimitem 

Clmd Health tcomnusd ) 

Did childmoeive any *rn cam in an intensive


careunit,prematurenursery,or in any


othertyp of specialcam facility


Howmnynights didc+hildstayin thespscialcme


facility


Was ctdldever CilWIXEiSd


NuWer of weeks child’sbiological~ was


pm?gnmt when firstSmpeCtd pregnamy


ClrLldts
biologicalmUEW saw or talkedto doclmr


‘to&temiTE ifpmgnant


Nmber of weeE child’ sbiological
 ~was


p-twhmsawor~ti~ to


Ckkrmmeifpzqnant


Weightof child’sbiologicalmotherjustbefore


Amountof pmmk @iId’s biologicalmtherga.ind


or lostduriq pmgnanq


tid ever crawledwhen left lyil_KJ
 cm **


Aye when childfirstcrawled


Childever sits for 10 minuteswit3xxtsqymt


Childeverplls b stamlhq positionwbmt help


frcmanotherperson


Childeverrem@zesmn xmmwhen somone saysit


Childeverpicksup smalltijectsus% onlytlmb


and firstfinger


childever~ ~ ~- help froman&her


Age ~=&d firstwavedgoodbye


Childever stoodalm on feet for 10 ssccxdswithout


hol~ on to anyth@ or anotherperson


~whenchild fimtsbxialcme


CWldsaid2 recognizable
wordskesides‘-”
 ~ !l~dal!


Cbildsver walkedatleast2step6 with one had


held or holdirgm Im ~


Child’sbehaviorshowskmwledge of - of ccmmon


cbjectswhensm2body elsemm2s them out loud


Childsver crawledup at Last 2 stxxb or ste~


Childever said name of familiarcbject


Childsverwalluxiatleast2skp wi~


holdimjon to anythingor anotherperson


Age when childfirstw&lksd2step6


Childeverwithoutcryingpointed,@led, or


made soundsto in-licate
 wantixgsamAhhq


Childevermxle linewith craym or pencil


Hascbild ever run


CMldever walkx3upatleast2 S&irswit hone


hand or hoi@ the rail-


CMld ever let somone IUXXJ,
withoutcrying,that


~ w213e& or soiled


Year 

1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


189 
kc guesti.onnaimitem 

childever fed himselfwitlmxtspillimjnnch


ChDdever mlEl~with.xt M.diqcn


to a rail


ChildeverqmWinapartial~ of3


words or mm


Childever said firstZUX3lastmm Ixgeh


WmKalt help


Hascbild everwalklupstaim With IK)hdp,


-b on each stepwith only one foot


Childeverp&kled a tric@Le at least10 feet


Childlumsumage ad sex


C!hildeverwshedad driedbardsWittKXXtbdp


-for ~tiemkmti Off


Childever done a SomersaultWitlmlthelp fran


anybody


Childwerdrawn pictureof aman orwmen with


at least2 parts of Imdy besidesa head


child W= g- to Ixx@t alm


Childwer playd witi severaldrLMren at the


Same time


Wd ever saidname of at least4 mlors


Child’sbiologicalmlhr stayedin ~iW 1


nightatanytim duriqpzegmmy Otherthan


duringbirth


Nuuberof tireschild’sbiologiti ~ stayedin


M&&al& n&gh&~*7&IE duringp.mgmmy


Reasonchild’sbiological~ stayedin


hospitalOvernightatqtimdurirg pregmuq


otherthan duriigbirth


Ihctorwer tild child’sbiologicalmtber ti


mmininbed lweekornnre durixgpregmmy


Reasm ~ told child’sbiologicalmther to


remainin bedlweekormre durhgprqmncy


-tio~h_~d’s biologicalmher stayed


Child’sbiologicalndAer everhad mkamiqe


&fore prqnant with child


Nun&m of previous~ of -d’s


biologicalmlher


Time of nmst ~ mkanhge priorto c3Kld’s


b~ 

Child’sbiological~ stayedin hospital


overnicjkSitXX! bti of child


Child’sbiologicalnutherstayedin ~ital


mxnicjht SiM3 birthof childfar diabtes


or sugardiabetes


Child’sbiologicalmther takes insulinshuts


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


1981


i981


1981


1981


1981


1981


1981


1981


1981


1981


1981


190 
Es& fuestionnain iixm Year 

.
 Child Health (~ )


Child’s biological mther ever had suqety 1981


Type Ofsuqexy performed on child’s biological 1981


Nunher of nYX@ISchild’s biological mther 1981


pmgnaxk at &dld’s bir&


Did child everhan (ccmiitim): 1981


hepatitis


yellcwjaundice


any otherlivertrouble


colitis


any otherbuweltrouble


an ulcer


a herniaor rupture


any othercotition of the digestivesystem


asthlna


hay feveror allergies


tonsillitisor enlargementof the tonsils


or adenoids


tubemilosis


pneumonia


any otherrespiratmy,lung,or pulmonarycondition


arthritisof any kind or rheumatism


oumature of the spine


clubfoot


any otherconditionaffectingthe kone,cartilage,


muscle,or tendon


eczemaor psoriasis


troublewith acne


any kind of skinallergy


any otherkind of skintrouble


repeatedear infections


d=fness in one or both ears


any othertroublehearingwith one or Imth ears


blWlness in one or Imth eyes


cataracts


any othertroubleseeingwith one or both eyes


evenwhen wearingglasses


a cleftpalateor harelip


stammeringor stuttering


any otherspeechclef­


autismor has ever been autistic


palsyor oerebralpalsy


paralysisof any kind


mentalretardation


epilepsy


repeatedconvulsions,seizures,or


migraine


fqent or severeheadaches


meningitis


choresor St. Vitus’dance


blackouts


191

LE?I@ $luesticmnixin itm Year 

nephritis


urinarytract infection


any otherkidneytrouble


diaktes


goiteror otherthyroidtrouble


cysticfibrcsis


anemiaor sicklecell anemia


aheartmurnm


CanceJCofanyki.m


hicjhbloodp~


rheumaticfever


rheumaticheartdi~


congenitalheartdisease


any otherhearttrouble


HOW mny timesdid childhave (condition) 1981


m 1- did child’s(cmlitim) last 1981


Ikeschild now have: 1981


a missingfinger,hand,arm, toe, foot,or leg,


permnent stiffnessor any deformityof the


back, foot,or leg


permnent stifk or any defomity of the


fiqer, hard,or ann


mntactwit211%milv aI13m-ierds 

~ of tireswent out to visit friends,


relatives,or neighborsduriq a 2-week


period


Mmber of visitsfrom frie.rkls,
 relatives,


or neighbom duriq a 2-wEk period


DeIbl cam 

1980


1980


Anyonein familywhohaskstallof his or her- 1983


For -c5 personwith ‘Wst all teeth”: 1983


have falseteeth


have - plate,lmmr plate,or both


usuallywear plate(s)while eating


usuallywear plate(s)when not eating


need new falseteeth


falseteethneed refitting


Anycm in familyuses fluoridedrops,tablets,or any 1983


otherfluoriCkSll@ementsthat are Swallc%ed


that is 1983


~*h&y&~ ‘1~ ~ -


Myme in familyuses tmthpaste witi fluoride 1983


Hmoldwhen firs-t
wrrt to dentist 1982


Duringthosem2~ did anycmein familyq 1983


to ~ (tilude all typesof dentists,


ortlmlontists,
oral surgeons,dentalhygienists)


192 
232F& pestionnaim item Year 

Dental Cax2 (Cmtimed) 

Euringthose2weeks,hYwmaIIY~ didsanple 1983


~wto~


l$hensampl epersonw=ntb~ (the last time/ 1983


the ths beforethat)didsamplepemm have:


Xray taken


Ix&h filled


toothpulled


otheroralSuryery


fluoride
treatmmt


teethcleaned


teethstraightened-orthodontia


treatment
forgums


workdoneon a cmpletedenture


workdoneon a partialdenture


workdoneon a bridge


workdoneon a crmn or cap


workdoneon a rootcanal


an examhation


some- else


IMrirg visitdid saqle pezsonseea regular 1983
 .
 ikmhst or dentalspecialist


whatIdlYa
of dentalspecialist 1983


IImlcqdid ittaketo getto dentistthistime 1983


Duringpast12~hm7 manyvisitstockmtkt 1983


HCW lCHKJsti lastwentto dentist 1983


Diabetes


Diabetes or sugar diabetes 1981 

Disability


Disabilityrelated to service in the Armed Forces 1984 

usuallystaysin beddueto IEEimlpmbl(alls 1980 

Doesmt drivecarbecauseof disability 1980 

or lxxil.th
 ptilm or - otherreason


Ihdor Visit


Rmtim @ysical examinationbydocbr in past 1982


3.21mIms


Didibctor advkesar@e~ Imstayinbed(mre 1983


thanhalfdaybE!caLEeofmneSs or injury)during


thatthe


Wasdoctorservicea telqhonecall,hcane
visit, 1983


or C@E?r


193 
———
-
 =C Questionnaire item 

E&2?@9 (see also Alcohol) 

Inymremtire lifehaveyoulnd atleast32 drinks


of my kind of alooholicbsvemge


Inanyone year have you hadat least12 drinksof


any kind of alodmlic bwerage


Did you have a drinkduringthe 2+E?elc
~~


IkuAngthat period,when did ym lasthave a drink


When was your last drinkpriorto that 2-weekpericd


Wing Ut 2-weekpericil,
on how my days did you


drimcanybeer


Wing that 2-weekperiod,on the day(s)when


Youdrank beer,abut how many= did


youdrink aday


Duringtbt2-week periodwhat was the total


Imm&rof beem you drank


Abouthowmanyamces wereina tyyimlean or bottle


or glassof beer that you drankduringthatperid


IWri.ng
that 2-weekpericd,on huw my days did you


drinkqwine


Ihringthat 2-weekperiod,on the days you


dmnkwine, abouthow many glassesofwine did you


drinkaday


Ihringthat 2-weekperiod,what was the M number


of glassesOfwimyoudlanlc


Abouthowmanyoumes of wim - in a typicalglass


that you Ch3Mkduringthat pericd


Dmi.ngthat 2-weekperirxl,
cm how many days did


youdrink anyliquar suchasvhkkey,


~, gin, or vdka


Duriq that 2-weekperiod,on the day(s)when


youdmnk liqmr, akcuthow many drinksdid you


have a day


Wing that 2-weekperiodwhat was the Imtalnumber


of drinksof liquoryOU had


Akouthowmany alnoesof liquorwere in a typi=l


drirkycm had duringthat period


Durimjthe 2-weekpericd,on W many days altqether


did you drinkalccholicbsverages,that is,


beer,wine, or liquor


IMrhg that 2-weekperiod,did you have mom than


(~ ~ of beer,*, or liquar)drink


m a sirqleday


IWringthat 2-weekperiml,on how many days did you


have more than (laqsst numberof beer,


wine, or li~or) drink(s)of beer,or wine,


or liquor


What wasthelargest mmbr of drink ym had


cm~cmeof thosedays


On hw many days duringthat 2-weekperioddid you


have (laqest~of drinkson anycme day)


drinks


..


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


194 
. 

195 

-c questionnaireitem 

mziIikh (~) 

13xmary drinksdidyou haveon that day 

Was the amount of d&inkiq dur~ that 2-weekperiod 

typicalofyour~-w~ 12~ 

was ‘thealIWntof yourdriTMng duringthat 2-we@lC 

periodm3mmless_yourdrWc@ during 

thepaSt121mIms 

Fbrlmwq yeamhastis been @pical of your 

~ Wing the 2-weekperiod (eMing with W including 

thedayyou hadyour last drink),onhm many

dapdidyou drinkanykx?er 

Duringthe 2-weekperiod (mling with and including

the day you had your last drink),on the day when 

youdrank beer abouthownmy beem did you drink 

a day

Euri.ngthat 2-weekpried (endingwith and imluding 

the day you had your last drink),what was tie 

totzd.numberof beersyoudmnk

Abouthmmary cumeswereinatypiml caner 

battleor glassof beer that you dmnk during 

that period 

Duringthat 2-weekpericd (endingwith and including

the day you had your last drink), on hcxvmany 

da. didyoudrink any wine 

Dining that 2-weekperiod (endingwith mi including

the day you had your last drink)aboutb many 

glasses ofwimdidycu drinka cby 

Duriq that 2-week pied (endingwith aml including 

the day you had your last drink),what was the 

*nul&rof CJlassesof wine you drank 

Abcuthmmanyounoes of * were in a typicalglass 

thatyou drankduringthat pericd 

Duringthat 2-weekpericd (endingwith and imluding 

the day you had your last drink),on how many 

daysdid you drinkany liquor,such as whiskey, 

~J gin, or vodka 

Iku5.ng that 2-weekperiod (erdi.ngwith and including

thedayym hadyourlastdrfi) ,WheIlyOUdHWlk 

liquoraboutIxxwmany drinksdid you have a day 

IMringthat 2-weekperiod (endingwith ZUX3inoluding

the day you had your last drink)what was the 

tubl of drinksof liquoryou had 

Nmutlmwmanyounces of liquor were in a typical 

drink that you had duringthat ~iod 

Wing that 2-weekperiod,on how many da. altogether 

did ym drink a.bimlic Mmrqes 

Was the amount of your drinkiq duringthat 2-week 

periodtypicalof your drirkiq duringthe 

12months befamycur lastdzYink 

Year 

1983 

1983 

1983 

1983 

1983 

1983 

1983 

1983 

1983 

1983 

1983 

1983 

1983 

1983 

1983 

1983 

1983 

1983 
-C guesticmnaimitm 

Ei@iQ9 (-” 4


Wastheamount ofyourdrinkiq duringthat 2-week


periodmmorless Wanywr~ during


the12monlk hfareywr lastdrink


Forhmqyears was this typicalofyourdrinl@


Imriq that pasty-, inlmmarymdkdidycu


hveatleast ldrinkof anyal~~
 Duringtheyear befomyour lastdrink,inhmmaq


nrnthsdid ymhaveat leastldrink of any


alcoblic lxwemge


Duringthat montQ/thosemnths, on hm q


daysdidyouhave9drinksormre of any


alcholic bevemge


Duringthat month/thosemonths,on how many days


didyoukve 5drinksormmof any


alcoholicIJEmmge


Wasthere ever aperiod in your lifewhe.nyou


cmsidered ymrselftobe aheavy drinker


Forhmmany yearswere ya heavydrirker


When youwere ahsmyd.rmkex hcwmany drinksof


alcoholicbewxqes did&uhaveina -
 Wasthere everaperiod in your lifewhenym


~idered yumselftc bea m&mte drinker


Forhm~yeam wereyouanmdemte drinker


Whenyou wereamdemte drinker lxw many drinks


of alcmtmlicbewmges did~ouhavein aweek


Wasthere ever aperiod in your lifewhenym


CuAi&edy cmselftobealicjtkt drinker


Forhmqm were you alight drinkr


Whmyouwere alight drhiker hmmany drinksof


alccholicbewrqes did~ouhavein aweek


Wasthem everaperiod in your lifewhen you


cmshkred yun2+Lf to be a very light,


omasioma.1,or infrequentdrinker


For b many yearswere you a very light,CC!CaSid,


or infrequent&hiker


When you were a light,occasimal, or infreqgmt


lxx many drinksof alccholicbewxqes


did you’havein a wek€

Doyouncw cmsidarymme3.fto bean abstmkxar


a very light,cccasicmal.,
 or infrequentdrinker


Doycumw cmsiderycuzSelfto beanaMA-TEr,


or a light,nmdemte, or heavydrinker


In a typicalweek (priorto lastdrink), on b


IIEU!Y
 @YS did YOUdrink alcoholicbemxges


On the day(s)when you drank,abouthow many drinks


didyouhave aday


Forhowmany yemswas this typicalofyourdrhkhg


What is your main mason fornotdrmingsince


(dateof lastdrinkpriorto 2-weekperiod):


noneeqhctneessay


don’tcare for/dislik it


Year


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


196 
WC westicmnaim item 

Drinking (cart “ y 

( 

I


I


I


~ 

mEdical/health reasons 

religious/mmd.~ns


bmughtupnot to drink


Coststoo much


familymmber an alcoholicor problemdrinker


infrequentdrhk?r


other (specify)


Have w =@-Y =-m- ~ al-lie 

some peoplehave prcblem relatedto drinkhq


Have youever hadafamily ormarital problem


rela@d b ycmr drink@


What pmblm did you have (rela~ to your drhkirq)


Did this prcbleqhny of theseproblem relatedto


m~~h-~n~


Have ymeverhadajcbormrk pmblem~tedto


w~


What problem did you have (rel- to ymr drinkhq)


Did this pmbleq!any of tieseprcbl- nilalxdto


your drinkingoccurhlthepast12nmHls


Haveyou ~hadaninjury relat@itiyourdrinkhg


What was the injury (n21a&d to your drinkiq)


Did this injury’anyof these injuriesrela= lm


w~ occurinwlepast12nmths


Did you ever have any (other)heal- pxblem related


tiyourdrinkiq


What was the kal.thpmbkm (relatedto your drinkiq)


Did this prcblqhny of tkse pcblesm relatedb


-~
 occurinthepast12mcmu3s


Whileycm wem driving,did you ever have a mbr


whicle acdknt or trafficviolationrela= to


-~
 Which cm (motorvehicleaccidentor traffic


violationrelatedb your drinkiq)


Did ym have a rotorwhicle accidentor traffic


violationrelatedto your dr- in & past


321mnmS


Eat53xx Habits 

Includingeveningsnacksb Ofhl do yOU eat betWE!n


IIEalS(almostevelyday, sometimes,rarely,never)


HCW 0- do yOU eat breakfast(ahmt everyday,


scmstims, rarely,or never)


lmmm?nt (seealsomalti~.work l—wards)


. Esmaptic4-Iof work activities


KiId of work, business or industry


m for wrk or on layofffrm job


Wark at Zqtimeinmelastwek


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983


1983 —


1983


1983


1983


1983


1983


1980


1980


1980


1980


197


I 
Vbrk for whau


Ikwlcxq workedfor currenterlployer


~ job everWCXWX3:


kind of work


lCiIlaof
kusinessamb311stq


imgmtant work activities


Forarytim -layoff orjti lossdidreqmdmt


receiveumqloymnt imuranm &mfi&


lmringpast 12nKxmshas Espm&nt been laid off


or lost a job


HowlKGq tinE?shasmqxx&nt keen laid off or lost


ajobinthe past12 months


Whatnunldlwas mspmkmt laidoffarlo+jd


Eecauseof jcb layoffor jcb lossdid anyonein


familylosehealthimumme coverage


Foranytime durhqlayoff or Jab losswasmqxdent


withmt any @pa of kal.tiinsumnm cuverage


Forluwlcng was mspmdmt withmltsomtype of


IEaml hlsmame coverage(layoffor job loss)


For aq time duringlayoffor j& losswas mspdent


~b?w-fi=-~aa as


Medicaid,AFDC, or a militarybenefitprogram


Forhmlcaq wasmspmknt awered bysomeheaml


care programduringlayoffor job loss


mmticmal Limitations(- ZiL50Aui@


Rmeives help frm anotherpersonfor


fllmticml limitatims:


PrePar@l m meals


-m


routinehouseholdChORS 

handling Cwn money 

Heal121c3recmTeram 

I-EsvelJ&dicam card 

I-melsedicaidcazd 

Receive healthcare pi-d for by lfed.icaid 

MedicareCmerage


Medicare,PartA (lmapitals)


Wdiczm, Part B (doctors)


~manY*~ providiq healthmm


for mili~ depmdents or survivorsof military


Coveredbyanyotherpblicassisbme program


Health msurmEe (see also Immwmnt) 

Medical.
careservicespaid by Wal~ insmame 

Healthinsumme ~ enployeror union 

1980


1980


1980


1984


1983,1984


1983,1984


1983,1984


1983,1984


1983,1984


1983,1984


1983,1984


1983


1980


1980,1982,1984


1980,1982,1984


1980,1982,1984


1980,1982,1984


1980,1982,1984


1980,1982,1984


1982,1984


1982,1984


1980


1980,1982,1984


198 
ml?k Questicmx3ire item 

Health Imumna2 (see also mmwlEmq (Cmtimsd) 

Heal-m insmameCbtainedl almughsmewgmup


malth insumme 0cm7ers CkIctor’sor SUH&CX1’S bills


Healthkamume (~ ‘ coverage)


Healm insumme (hospitalcaverage)


H?EiLth
insumme plan nallE


Waslmsmt covemdbyheamlinsmmce


Hicih Inoal Pmssurd GcxY3itim 

- ~~ ~i~


cumdorumier~l


Nuwtaking anymedicinepmsdbed by doctor


for high blouipressure


Stillhave high blood~ion


Ever beentold byaikxkm or otherhealth


professional*t you had hyper&mim,


smetks calledhigh bloodpressure


HtmEc!aze 

lWceivsdcareathanefmma nurse


HM# oftenmust smeonebe hmewith personwho is


disabledor has otherhealthproblems:


most of the time


scam of the time


once in a while


never


-i= ~ PD=@ *


mc!ehed meals prepmed mtside - bane regularly


C3xK1.itim(s) causing. personsto l’Eed
help in


activities


Date firstmticed cxxxlitim(s)
causingperson


to needhelp in ackkities


ReueivesElp at km with


receivinginjectionsor shots


physicaltherapy


mm bandages


any othernursirqor medicaltreatment


Reu2ivesMlp frunanotherpemon in cariq for:


colostomy


urinarycatheter


otherdevice


Recei, klp fmm mme or otherhealthworker


Receivesarmds help at- frananotherpersm


Receiveshelp frm aUxnxsin usirqpublic


transportation


Uses tekghme witi klp of anotherperson


Rxscm’s z@latimSh.ip
b otherhmsehold ~


Averagemmber of daysper week personvisits


l?amily
pays co6tsof person


Year 

1982


1982


1980,1982,.1984


1980,1982,1984


1982


1980,1982,1984


1982


1982


1982


1982


1980


1980


1980


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1980


1980


1980


1980


1980


1980


1980


1980


1980


1980


1980


199 
--

m2$G Questiamim item Year


Hanecare(omtinwd )


,- Gbvernment agencyor program&lps pay for person’s 1980


Howmany timsperscm visitedin past 2 weeks


Name of guverTmEn
t agmcy or ~ PaYiw


for pemcm’s costs


N.mberof lmrsper daype.rsmhelw


ITEcme 

Receism disability . .—P-- ­ veterans Mmmstxa ticm 

Ammee&Jamily (W) ~ f=


~~
 ReasmE receiveSocialsecuritypayments


ExVesocial ~@~-


Recei- Su@emental securityImxme (SS1)


CmMnE?d familyimcm3 forpast12mnths


ReceivesimcmE becauseof work experience


or~or~= of====


who mrked


Receives-frum


railroadretirement


military


governmentexployeepension


privateemployeror unionpension


M2dical I&vices 

tics tm controlurinaticmor bmel movement


colostomy “


urinarycatheter


otherdevice


Place of Residema 

Nmherof timesnuVedinpast3 years


Distanoein miles~-~~
 address3 yearsago


Aadress3yarS ago


Nuubrof personsataMress 3yE?arsago


masons mv@topresent acmmsS:


~& @


health


Yearsat presentaddress


Atqtime duriqyourpmymncy didyullhave:


1980


1980


1980


1984


1980,1984


1980


1980,1982


1980,1982


1980


1980


1980


1980


1980


1980


1980


1980


1980


1981


urinarytract infection


200 
@esticmmire item 

EE29Qmx (==--) 

measles


hyperbmsion or high bloodpressure


p~lampsia, eclaqsia, or convulsions


embolismor bloodclot


abnormalpositionof the placenta


abnmmd positionof the cozd


vaginalbleeding


=.lgarinthe urine


high sugarin the blood


diabetes


-


Ixanq@lizew-s


E!mEntive m 

Htxr lcmg Silwe 

Hul# lmg Sime 

Hf%w lmg since 

I-kx# lcmg since 

R2ceiw2 military~Pa-“ from bra.nch 

of Axmd Forces or pension from Veterans 

Administration 

Semia2sof ~ “ --n@:


- -s


housekeeping or maid service


mdical services


telephom call services to check on your 

well-being 

recreational sezvia3s


S!@&!9 

Nuniberof cigamtkes smoked


I!KJefimtsmkd


13raml
of cigarettessmkd


Hnwlong sincelastslmked


Type of cigarettessmked


Doyousmke ciqwettesm


Everattemptedtostcp -


Iasttime triedtostopsnd&g


J.E=Jth
oftims toppedsmoking


Nud3erof timsattemptedto s&p smdchq


Have you smked at least100 cigaretks in your life


Doyousmke cigamttesm


Year 

1982


1982


1982


1982


1982, 1984


1984


1980


1980


1980


1980


1980


1980


1980


1980


1980


1980


1983


1983


201 
mQ& guesticmaire iixm 

Sm?uQ!3 ~~)


On the average,abouthm many &jam&es aday


do/didym smke


Abmthxlmq hasitbeensh you lastsndaxi
 .
 mgamtts fairlyregularly


Inthepast 5years, have you evertriedtostmp


- @3===’=


IMhodssome peopleused tmstcp *@amttes


Whichmethodhaveyouusedin ime past5 years: 

atterdaformi lpmgramsuchas~, 

- American-C%cer Kie@ progmm, or”


AnericanImg Associationprogram


go to a healtiprofessioml for help,


such as a physician,psychologist,


or psychiatrist


use specialfiltersor cigaretteholdersto


regulatethe amountof smokeinhaled


Swi= to linertar and nicotinecigarettes


stop or try to stopwith a few friends,


relatives,or accpaintances


stop or try to stop entirelyon own


use SonE!Uthermethod


. sueclal Aids 

-*==: 

artificialarm


artificialleg


braceof any kind


Crutches ­


cane or walkingstick


specialshoes


wheelchair


guidedog


otheraid for gettingaround


-~=


SeEdiL 

special equipmt or receiveshelp frcmanother 

personwitiactivitiesof dailyliwbg:


walking


goingoutside


usingtoilet


batming


dressing


eating


gettingintoaml out of bed and chair


~a


1983


1983


1983


1983


1980


1980


1980


202

!&P& Shx#zicxmaire item Year 

usual Sulrc#20f Qm/Health Gwe Place€

Ci@, county, zud state location of heal.ticaze 1983€

Hcwlcqdid it bketo getto healticareplaoe 1983€

Wydidmqxden tgotohealthcamplace this time: 1983€

placeused for nearlyall msdical.€care€

-pecially good for treatingthis oofition€

ccmenient to home€

convenientto work/shopping€

referredby a doctor€

referredby frie.@/mlative€

onlyplace available€

heath imumnce plan requires€

-m


other (specify)€

Vacation€

vacation taken during past 12montbs 1980 

Vkicm€

USecontactkmses 1980 

Eyeglasses use 1980 

Have eyeglasses or contactlenses 1982 

Visicm Gre€

- lq sime test for glaucuua 1982€

Wrkmzards€

Inyourp resentjob are youexposdtoaq 1983€

risksof accidentsor injuries€

203 
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Vital and Health Statistics 

series descriptions 

SERIES 1.	 Programs and Collection Procedures—Reports describing 

the general programa of the National Center for Health 

Statistics and its offices and divisions and the data collection methods used. They also include definitions and 

other material necessary for understanding the data. 

SERIES 2.	 Deta Evaluation and Methods Research—Studies of new 

statistical methodology including experimental tests of 

new survey methods, studies of vital statistics collection 

methods, new analytical techniques, objective evaluations 

of reliability of collected data, and contributions to 

statistical theory. Studies also include comparison of 

U.S. methodology with those of other countries. 

SERIES 3.	 Analytical and Epidemiological Studias— Reports presenting analytical or interpretive studies based on vita! 

and health statistics, carrying the analysis further than 

the expository types of reports in the other series. 

SERIES 4.	 Documents and Committee Reports-Final reports of 

major committees concerned with vital and health statistics and documents such as recommended model vital 

registration laws and revised birth and death certificate. 

SERIES 5.	 Comparative International Vital and Health Statistics 

Reports-Analytical and descriptive reports comparing 

U.S. vital and health statistics with those of other countries. 

SERIES 6.	 Cognition and Survey Meaeurament— Reports from the 

National Laboratory for Collaborative Research in Cognition and Survey Measurement using methods of cognitive 

science to design, evaluate, and test survey instruments. 

SERIES 10.	 Data From the National Health Interview Survay-Statistics on illness, accidental injuries, disability, use of hospital, medical, dental, and other services, and other 

health-related topics, all based on data collected in the 

continuing national household interview survey. 

SERIES 11.	 Data From tha National Health Examination Survay and 

the National Health and Nutrition Examination Survey— 

Data from direct examination, testing, and measurement 

of national samples of tha civilian noninstitutional ized 

population provide the basis for (1 ) estimates of the 

medically dafined prevalence of specific diseases in the 

United States and the distributions of the population 

with respect to physical, physiological, and psychological characteristics and (2) analysis of relationships 

among the various measurements without reference to 

an explicit finite universe of persons. 

SERIES 12.	 Data From the Institutionalized Population Surveys- Discontinuad in 1975. Reports from these surveys are included in Series 13. 

SERIES 13.	 Data on Health Resources Utilization—Statistics on the 

utilization of health manpower and facilities providing 

long-term care, arnbulatoty cere, hospital care, and family 

planning services. 

SERIES 14. Data on Health Rasourcas: Manpower and Facilities— 

Statistics on the numbers, geographic distribution, and 

characteristics of health resources including physicians, 

dentists, nurses, other health occupations, hospitals, 

nursing homes, and outpatient facilities. 

SERIES 15.	 Data From Special Survays-Statistics on health and 

health-related topics collected in special surveys that 

are not a part of the continuing data systems of the 

National Center for Health Statistics. 

SERIES 16.	 Compilations of Advance Data From Vital and Health 

Statistice—These reports provide early release of data 

from the National Center for Health Statistics’ health and 

demographic surveys. Many of these releases are followed 

by detailed reports in the Vital and Health Statistics 

Series. 

SERIES 20.	 Data on Mortality-Various statistics on mortality other 

than as included in regular annual or monthly reports. 

Special analyses by cause of death, age, and other demographic variables; geographic and time series analyses; 

and statistics on characteristics of deaths not available 

from the vital records based on sample surveys of those 

records. 

SERIES 21.	 Data on Natality, Marriage, and Divorce—Various statistics on natality, marriage, and divorce other than as 

included in regular annual or monthly reports. Special 

analyses by demographic variables; geographic and time 

series analyses; studies of fertility; and statistics on 

characteristics of births not available from the vital 

records based on sample surveys of those records. 

SERIES 22.	 Data From tha National Mortality and Natality Survays— 

Discontinued in 1975. Reports from these sample surveys 

based on vital records are included in Series 20 and 21, 

respectively. 

SERIES 23.	 Data From the National Survey of Family Growth— 

Statistics on fertility, family formation and dissolution, 

family planning, and related maternal and infant health 

topics derived from a periodic survey of a nationwide 

probability sample of women 15–44 years of age. 

SERIES 24.	 Compilations of Data on Natality, Mortality, Marriage, 

Divorce, and Induced Terminations of Pregnancy— 

Advance reports of births, deaths, marriagea, and divorces 

are based on final data from the National Vital Statistics 

System and are published annually as supplements to the 

Monthly Vital Statistics Report (MVSR). These reports are 

followed by the publication of detailed data in Vital Statistics of the United States annual volumes. Other reports 

including induced terminations of pregnancy issued periodically as supplements to the MVSR provide selected 

findings based on data from the National Vital Statistics 

System and may be followed by detailed reports in Vital 

and Health Statistics Series. 

For answers to questions about this report or for a list of titles of 

reports published in these series, contact 

Scientific and Technicsl Information Branch 

National Center for Health Statistics 

Centers for Disease Control 

Public Health Service 

Hyattsville, Md. 20782 

301 –436–8500