Family Health History – Male Version 

Question Number 

Verbatim Question Response categories and comments 

1 What is your birth

date? 

Month ____ 

Year______

1b What state were you born in? 

State __________ 

enter two letter state code DC=District of Columbia 

I was born outside the U.S. 1 = box checked 

2 What is your sex? 1=male 

2=female 

3a What is your race? 1=asian 

2=black 3=white 4=american indian 5=other 9=multiple boxes checked 

3b Are you of Mexican, Latino, or 

Hispanic origin? 

1=yes 2=no 

4 Please check how far you’ve gone 

in school.... (Choose one) 

1=Didn’t go to high school 2=Some high school 3=High school graduate or GED 4=Some college or technical school 5= 4 year college graduate 9=Multiple boxes checked 

5 What is your current marital status? 

Are you now... 

1=married 2=not married, but living together

 with a partner 3=widowed 4=separated 5=divorced 6=never married 9=multiple answers checked 

6a How many times have you been 

married? 

1=1 2=2 3=3 4=4 or more 5=never married 9=multiple boxes checked 

FHH Male 
Question 

Number 

Verbatim Question Response categories and comments 

6b During what month and year were 

you first married? 

 Month___ 

Range: 1-12 

 Year___ Range: 10-96  Never married 1=never married 

7a Which of the following best 

describes your employment status? 

1=full time (35 hours or more) 2=part-time (1-34 hours) 3=Not employed outside the home 9=multiple items checked 

7b If you are employed full time (35 

hours per week or more): 

Range: 0-30 

7c Range: 0-30 8 

How many days of work did you miss in the past 30 days due to stress or feeling depressed? 

How many days of work did you 

miss in the past 30 days due to poor physical health? 

For most of your childhood, did your family own their home? 

1=yes 2=no 

9a During your childhood, how many 

times did you move residences, even in the same town? 

# of times ________ 

Range: 0-999 

9b How long have you lived at your 

current residence? 

1=Less than 6 months 2=Less than 1 year 3=Less than 2 years 4=2 or more years 9=Multiple boxes checked 

10 How was your mother when you 

were born? Age________ 

Range:0-99 

FHH Male 
Question 

Number 

Verbatim Question Response categories and comments 

11a How much education does/did your 

mother have? (Choose one) 

1=Didn’t go to high school 2=Some high school 3=High school graduate or GED 4=Some college or technical school 5=4 year college degree graduate or higher 9=Multiple boxes checked 

11b How much education does/did your 

father have? (Choose one) 

1=Didn’t go to high school 2=Some high school 3=High school graduate or GED 4=Some college or technical school 5= 4 year college graduate or higher 9=Multiple boxes checked 

12a Have you smoked at least 100 

cigarettes in your entire life? 

1=yes 2=no 

12b How old were you when you began 

to smoke cigarettes fairly regularly? Age______ 

Range: 0-99 

12c Do you smoke cigarettes now? 1=yes 

2=no 

12d If yes, on average, about how many 

cigarettes a day do you smoke? Number of cigarettes___ 

Range: 0-99 

13a If you used to smoke cigarettes but 

don’t smoke now, about how many cigarettes a day did you smoke? 

Range:00-99 

13b How old were you when you quit? 

Age ________ 

Range:00-99 

14a During your first 18 years of life did 

your father smoke? 

1=yes 2=no 

14b During your first 18 years of life did 

your mother smoke? 

1=yes 2=no 

15a During the past month, about how 

many days per week did you exercise for recreation or to keep in shape?  ______ days per week 

Range: 0 - 7 

FHH Male 
Question 

Number 

Verbatim Question Response categories and comments 

15b During the past month, when you 

exercised for recreation or to keep in shape, how long did you usually exercise (minutes)?  ______minutes 

0=0 1=1-19 2=20-29 3=30-39 4=40-49 5=50-59 6=60 or more 

16a How old were you when you had 

your first drink of alcohol other than a few sips? Age_______ 

Range:00-99 

Never drank alcohol 1=Box Checked 

During each of the following age intervals, what was your usual number of drinks of alcohol per week? 

16b1 Age 19-29 1=None

2=Less than 6 per wk 3=7-13 per wk 4=14 or more per wk 9=multiple responses 

16b2 Age 30-39 1=None

2=Less than 6 per wk 3=7-13 per wk 4=14 or more per wk 9=multiple responses 

16b3 Age 40-49 1=None

2=Less than 6 per wk 3=7-13 per wk 4=14 or more per wk 9=multiple responses 

16b4 Age 50 and older 1=None 

2=Less than 6 per wk 3=7-13 per wk 4=14 or more per wk 9=multiple responses 

16c During the past month, have you 

had any beer, wine, wine coolers, cocktails or liquor? 

1=yes 2=no 

FHH Male 
Question 

Number 

Verbatim Question Response categories and comments 

16d During the past month, how many 

days per week did you drink any alcoholic beverages on average? 

Range: 0 - 7 

16e On the days when you drank, about 

how many drinks per day did you have on average? 

1=1 2=2 3=3 4=4 or more 5=didn’t drink in past month 

16f Considering all types of alcoholic 

beverages, how many times during the past month did you have 5 or more drinks on an occasion? Number of times_______ 

Range:0-999 

16g During the past month, how many 

times have you driven when you’ve had perhaps too much to drink? Number of times_______ 

Range:0-999 

16h During the past 30 days, how many 

times did you ride in a car or other vehicle driven by someone who had been drinking alcohol? Number of times______ 

Range:0-999 

17 Have you ever had a problem with 

your use of alcohol? 

1=yes 2=no 

18 Have you ever considered yourself 

to be an alcoholic? 

1=yes 2=no 

19a During your first 18 years of life did 

you live with anyone who was a problem drinker or alcoholic? 

1=yes 2=no 

19b If “yes” check all who were: 

father 1=if boxed checked 

mother 1=if boxed checked 

brothers 1=if boxed checked 

other relative 1=if boxed checked other non-relative 1=if boxed checked 

FHH Male 
Question 

Number 

Verbatim Question Response categories and comments 

sisters 1=if boxed checked 

20 Have you ever been married to 

someone (or lived with someone as if you were married) who was a problem drinker or alcoholic? 

1=yes 2=no 

21a Have you ever used street drugs? 1=yes 

2=no 

21b If “yes” how old were you the first 

time you used them? Age___________ 

Range:0-99 

21c About how many times have you 

used street drugs? 

0=0 1=1-2 2=3-10 3=11-25 4=26-99 5=100+ 9=multiple responses 

21d Have you ever had a problem with 

street drugs? 

1=yes 2=no 

21e Have you ever considered yourself 

to be addicted to street drugs? 

1=yes 2=no 

21f Have you ever injected street 

drugs? 

1=yes 2=no 

22 Have you ever been under the care 

of a psychologist, psychiatrist, or therapist? 

1=yes 2=no 

23a Has a doctor, nurse, or health 

professional ever asked you about family or household problems during your childhood? 

1=yes 2=no 

23b How many close friends or relatives 

would help you with your emotional problems or feelings if you needed it? 

1=none 2=one 3=two 4=3 or more 9=multiple responses 

During your first 18 years of life, was anyone in your household... 

24 Did you live with anyone who used 

street drugs? 

1=yes 2=no 

25a Were your parents ever separated 

or divorced? 

1=yes 2=no 

FHH Male 
Question 

Number 

Verbatim Question Response categories and comments 

25b Did you ever live with a 

stepfather? 

1=yes 2=no 

25c Did you ever live with a 

stepmother? 

1=yes 2=no 

26 Were you a foster child? 1=yes 

2=no 

27a Did you ever run away from home 

for more than one day? 

1=yes 2=no 

27b Did your brothers or sisters run 

away from home for more than one day? 

1=yes 2=no 

28 Was anyone in your household 

depressed or mentally ill? 

1=yes 2=no 

29 Did anyone in your household 

attempt to commit suicide? 

1=yes 2=no 

30a Did anyone in your household go to 

prison? 

1=yes 2=no 

30b Did anyone in your household ever 

commit a serious crime? 

1=yes 2=no 

31a What is the most you have ever 

weighed? Weight in pounds______ 

Range: 000-999 

31b How old were you then? 

age:_______ 

Range:18-99 

32a Have you ever attempted to commit 

suicide? 

1=yes 2=no 

32b If “yes”, how old were you the first 

time you attempted suicide? Age______ 

Range:1-99 

32c If “yes”, how old were you the last 

time you attempted suicide? Age______ 

Range:1-99 

32d How many times have you 

attempted suicide? # of times_________ 

Range:01-99, 

32e Did any suicide attempt ever result 

in an injury, poisoning, or overdose that had to be treated by a doctor or nurse?

1=yes 2=no 

FHH Male 
Question 

Number 

Verbatim Question Response categories and comments 

In order to get a more complete picture of the health of our patients, the next three questions are about 

voluntary sexual experiences. 

33a How old were you the first time you 

had sexual intercourse?  Years______ 

 Never had intercourse 1=box checked 

33b With how many different partners 

have you ever had sexual intercourse?  Number of partners_____ 

number of intercourse partners, lifetime Range: 0-999 . 

33c During the past year, with how 

many different partners have you ever had sexual intercourse? # of partners_______ 

number of intercourse partners, past year Range: 0-999 

34a Have you ever gotten someone 

pregnant? 

If “Yes”:

1=yes 2=no 

34b How old were you the first time you 

got someone pregnant? age:______ 

Range:00-99 

Never got someone pregnant 1=box checked 

. 

34c What was the age of the youngest 

woman you ever got pregnant? 

Range:00-99 

Never got someone pregnant 1=box checked 

34d How old were you then? Range:00-99 

Sometimes physical blows occur between parents. While you were growing up in your first 18 years of life, how often did our father (or stepfather) or mother’s boyfriend do any to these things to your mother (or stepmother)?

FHH Male 
Question 

Number 

Verbatim Question Response categories and comments 

35a Push, grab, slap or throw something 

at her? 

1=never 2=once, twice 3=sometimes 4=often 5=very often 9=multiple responses 

35b Kick, bite, hit her with a fist, or hit 

her with something hard? 

1=never 2=once, twice 3=sometimes 4=often 5=very often 9=multiple responses 

35c Repeatedly hit her over at least a 

few minutes? 

1=never 2=once, twice 3=sometimes 4=often 5=very often 9=multiple responses 

35d Threaten her with a knife or gun, or 

use a knife or gun to hurt her? 

1=never 2=once, twice 3=sometimes 4=often 5=very often 9=multiple responses 

Sometimes parents spank their children as a form of discipline. While you were growing up during your first 18 years of life: 

36a How often were you spanked? 1=never 

2=once or twice 3=a few times a year 4=many times a year 5=weekly or more 9=multiple responses 

36b How severely were you spanked? 1=not hard 

2=a little hard 3=medium 4=quite hard 5=very hard 9=multiple responses 

36c How old were you the last time you 

remember being spanked? age:______ 

Range:18-99 

FHH Male 
Question 

Number 

Verbatim Question Response categories and comments 

While you were growing up, during your first 18 years of life, how true were each of the following statements: 

37 You didn’t have enough to eat? 1=never true 

2=rarely true 3=sometimes true 4=often true 5=very often true 9=multiple responses 

38 You knew there was someone to 

take care of you and protect you? 

1=never true 2=rarely true 3=sometimes true 4=often true 5=very often true 9=multiple responses 

39 People in your family called you 

things like “lazy” or “ugly”? 

1=never true 2=rarely true 3=sometimes true 4=often true 5=very often true 9=multiple responses 

40 Your parents were too drunk or high 

to take care of the family? 

1=never true 2=rarely true 3=sometimes true 4=often true 5=very often true 9=multiple responses 

41 There was someone in your family 

who helped you feel important or special? 

1=never true 2=rarely true 3=sometimes true 4=often true 5=very often true 9=multiple responses 

42 You had to wear dirty clothes? 1=never true 

2=rarely true 3=sometimes true 4=often true 5=very often true 9=multiple responses 

FHH Male 
Question 

Number 

Verbatim Question Response categories and comments 

43 You felt loved? 1=never true 

2=rarely true 3=sometimes true 4=often true 5=very often true 9=multiple responses 

44 You thought your parents wished 

you had never been born? 

1=never true 2=rarely true 3=sometimes true 4=often true 5=very often true 9=multiple responses 

45 People in your family looked out for 

each other? 

1=never true 2=rarely true 3=sometimes true 4=often true 5=very often true 9=multiple responses 

46 You felt that someone in your family 

hated you? 

1=never true 2=rarely true 3=sometimes true 4=often true 5=very often true 9=multiple responses 

47 People in your family said hurtful or 

insulting things to you? 

1=never true 2=rarely true 3=sometimes true 4=often true 5=very often true 9=multiple responses 

48 People in your family felt close to 

each other? 

1=never true 2=rarely true 3=sometimes true 4=often true 5=very often true 9=multiple responses 

49 You believe that you were 

emotionally abused? 

1=never true 2=rarely true 3=sometimes true 4=often true 5=very often true 9=multiple responses 

FHH Male 
Question 

Number 

Verbatim Question Response categories and comments 

50 There was someone to take you to 

the doctor if you needed it? 

1=never true 2=rarely true 3=sometimes true 4=often true 5=very often true 9=multiple responses 

51 Your family was a source of 

strength and support? 

1=never true 2=rarely true 3=sometimes true 4=often true 5=very often true 9=multiple responses 

Sometimes parents or other adults hurt children. While you were growing up, that is, during your first 18 years of life, how often did a parent, step-parent, or adult living in your home:

52a Swear at you, insult you, or put you 

down? 

1=never 2=once, twice 3=sometimes 4=often 5=very often 9=multiple responses 

52b Threaten to hit you or throw 

something at you, but didn’t do it? 

1=never 2=once, twice 3=sometimes 4=often 5=very often 9=multiple responses 

52c Actually push, grab, shove, slap 

you, or throw something at you? 

1=never 2=once, twice 3=sometimes 4=often 5=very often 9=multiple responses 

52d Hit you so hard that you had marks 

or were injured? 

1=never 2=once, twice 3=sometimes 4=often 5=very often 9=multiple responses 

FHH Male 
Question 

Number 

Verbatim Question Response categories and comments 

52e Act in a way that made you afraid 

that you might be physically hurt? 

1=never 2=once, twice 3=sometimes 4=often 5=very often 9=multiple responses 

Some people, while growing up in their first 18 years of life, had a sexual experience with an adult or 

someone at least five years older than themselves. These 

experiences may have involved a relative family friend or stranger. During the first 18 years of life, did an adult or older relative, family friend or stranger ever: 

53a Touch or fondle your body in a 

sexual way?  If “Yes”:

1=yes 2=no 

 The first time this happened, how 

old were you?  age:_____ 

Range:00-99 

The first time, did this happen 

against your wishes? 

1=yes 2=no 

The last time this happened, how 

old were you?  age:_____ 

Range:00-99 

About how many times did this 

happen to you?  # times:_____ 

Range:00-99 

How many different people did this 

to you?  # people______ 

Range:00-99 

What was the sex of the person(s) 

who did this? 

1=male 2=female 3=both 9=multiple responses 

54a Have you touch their body in a 

sexual way?  If “Yes”:

1=yes 2=no 

FHH Male 
Question 

Number 

Verbatim Question Response categories and comments 

 The first time this happened, how 

old were you?  age:_____ 

Range:00-99 

The first time, did this happen 

against your wishes? 

1=yes 2=no 

The last time this happened, how 

old were you?  age:______ 

Range:00-99 

About how many times did this 

happen to you?  # times:_____ 

Range:00-99 

How many different people did this 

to you?  # people:______ 

Range:00-99 

What was the sex of the person(s) 

who did this? 

1=male 2=female 3=both 9=multiple responses 

55a Attempt to have any type of sexual 

intercourse (oral, anal, or vaginal) with you?  If “Yes”:

1=yes 2=no 

 The first time this happened, how 

old were you?  age:______ 

Range:00-99 

The first time, did this happen 

against your wishes? 

1=yes 2=no 

The last time this happened, how 

old were you?  age:______ 

Range:00-99 

About how many times did this 

happen to you?  # times:______ 

Range:00-99 

How many different people did this 

to you?  # people:_____ 

Range:00-99 

What was the sex of the person(s) 

who did this? 

1=male 2=female 3=both 9=multiple responses 

FHH Male 
Question 

Number 

Verbatim Question Response categories and comments 

56a Actually have any type of sexual 

intercourse with you (oral, anal, or vaginal) with you?  If “Yes”:

1=yes 2=no 

 The first time this happened, how 

old were you?  age:______ 

Range:00-99 

The first time, did this happen 

against your wishes? 

1=yes 2=no 

The last time this happened, how 

old were you?  age:______ 

Range:00-99 

About how many times did this 

happen to you?  # times:______ 

Range:00-99 

How many different people did this 

to you?  # people:_______ 

Range:00-99 

What was the sex of the person(s) 

who did this? 

1=male 2=female 3=both 9=multiple responses 

If you answered “No” to each of the last 4 questions (54a-57a) about sexual experiences with older people, please skip to question 62a. Did any of these sexual experiences with an adult or person at least 5 years older than you involve:

57a A relative who lived in your home? 1=yes 

2=no 

57b A non-relative who lived in your 

home? 

1=yes 2=no 

57c A relative who didn’t live in your 

home? 

1=yes 2=no 

57d A family friend or person who you 

knew, and who didn’t live in your home? 

1=yes 2=no 

57e A stranger? 1=yes

2=no 

FHH Male 
Question 

Number 

Verbatim Question Response categories and comments 

57f Someone who was supposed to be 

taking care of you? 

1=yes 2=no 

57g Someone you trusted? 1=yes 

2=no 

Did any of these sexual experiences involve:

58a Trickery, verbal persuasion, or 

pressure to get you to participate? 

1=yes 2=no 

58b Being given alcohol or drugs? 1=yes 

2=no 

58c Threats to harm you if you didn’t 

participate? 

1=yes 2=no 

58d Being physically forced or 

overpowered to make you participate? 

1=yes 2=no 

59a Have you ever told a doctor, nurse, 

or other health professional about these sexual experiences?

1=yes 2=no 

59b Has a therapist of counselor ever 

suggested to you that you were sexually abused as a child? 

1=yes 2=no 

60 Do you think that you were sexually 

abused as a child? 

1=yes 2=no 

Apart from the other experiences you have already told us about, while you were growing up during 

your first 18 years of life: 

61a Did a boy or group of boys about 

your own age, ever force or threaten you with harm in order have sexual contact? 

1=yes 2=no 

61b If yes did the contact involve 

someone touching your sexual parts or trying to have intercourse with you (oral or anal)? 

1=yes 2=no 

FHH Male 
Question 

Number 

Verbatim Question Response categories and comments 

61c If yes how many times did someone 

do this to you? 

1=once 2=twice 3=3-5 times 4=6-10 times 5=more than 10 times 9=multiple responses 

61d Did the contact involve a person 

actually having intercourse with you (vaginal, oral or anal)? 

1=yes 2=no 

61e If yes how many times did someone 

do this to you?

1=once 2=twice 3=3-5 times 4=6-10 times 5=more than 10 times 9=multiple responses 

62a As an adult, (age 19 or older) has 

anyone ever physically forced or threaten you to have sexual contact? 

1=yes 2=no 

62b If yes did the contact involve 

someone touching your sexual parts or trying to have intercourse with you (vaginal, oral or anal)? 

1=yes 2=no 

62c If yes how many times has 

someone done this to you? 

1=once 2=twice 3=3-5 times 4=6-10 times 5=more than 10 times 9=multiple responses 

62d Did the contact involve a person 

actually having intercourse with you (vaginal, oral or anal)? 

1=yes 2=no 

62e If yes how many times did someone 

do this to you?

1=once 2=twice 3=3-5 times 4=6-10 times 5=more than 10 times 9=multiple responses 

FHH Male