Table I-Illness, impairments and injuries
[option for 5 entries with the same questions. Only one set is presented here].
c. Did you ever at any time talk to a doctor about ...?
[] No
d-1: Ask for all illness and present effects of old injuries:
a. If doctor talked to:
Did he give it a medical name? ________
b. If doctor not talked to: Record original entry and ask: (d-2)-(d-5) as required.
(also fill table A for all injuries)
Ask for all injuries during the past 2 weeks:
What kind of injury was it? ________
Anything else? ________
d-2. Ask if the entry in Col.d-1 is:
An impairment or a symptom or came from Question 11 or 13.________
d-3. Ask only if: 6 years old or over and blindness, poor vision, or eye trouble of any kind.
Can you see well enough to read ordinary newspaper print with glasses?
[] No
d-4. Ask for any entry in Col.d-1 or Col d-2 that includes the words:
Asthma
Cyst
Growth
Stroke
Tumor
"condition"
"disease"
"trouble"
For an allergy or stroke ask:
How does the allergy (stroke) affect you? ________
d-5. Ask only for: Impairment and injuries.
And for:
Aches
Bleeding
Blood clot
Boils
Cancer
Cyst
Growth
Infection
Inflammation
Neuralgia
Neuritis
Pains
Sores
Soreness
Tumor
Ulcers
Weakness
Ear or eye (one or both)
Had (skull, scalp, face)
Back (upper, middle, lower)
Arm (shoulder, upper, elbow, lower, wrist, hand; one or both)
Leg (hip, upper, knee, lower, ankle, foot, one or both)
Last week or the week before did ... cause you to cut down on the things you usually do?
f.[] Yes
f. Did you have to cut down for as much as a day?
2.[] Yes
g. How many days during that two week period?
h. During that two weeks period, how many days did ... keep you in bed all or most of the day?
[] None
i. If 6-16 years old ask: How many days did ...keep you from school last week or the week before?
[] None
j. If 17 years old or over ask: Last week or the week before how many days did ...keep you from work? (for females add) not counting work around the house?
[] None
Did you first notice ... (did it happen) during the past 3 months or before that time?
l.[] During 3 mos
m. Did... start during the past 2 weeks or before that time? (if during past 2 weeks, ask): which week, last week or the week before?
[] Week before
[] Before 2 wks.
aa. To interviewer:
Continue if col (k) is checked, or the condition is on card A or is an impairment; other wise STOP
n. About how many days during the past 12 months has .. kept you in bed all or most of the day?
[] None
o. If 1 or more days in col. n and col e is checked, ask: how many of these days were during last week or the week before?
[] None
p. Were you ever hospitalized for this condition?
[] No
Ask after completing last condition for each person:
q. Please look at each statement on this card. Then tell me which statement fits you best, in terms of health. (show cards D-G, as appropriate) ________
CARD D:
For: Workers and other persons except housewives and children
2. Able to work but limited in amount of work or kind of work
3. Able to work but limited in kind or amount of other activities
4. Not limited in any of these ways
2. Able to keep house but limited in amount or kind of housework
3. Able to keep house but limited in kind or amount of other activities
4. Not limited in any of these ways
CARD F:
For: Children from 6 through 16 years old
2. Able to go to school but limited to certain types of schools or in school attendance
3. Able to go to school but limited in other activities
4. Not limited in any of these ways
CARD G:
For: children under 6 years old.
2. Able to play with other children but limited in amount or kind of play
4. Not limited in any of these ways
r. If "1" , "2" or "3" in col.q: if is this because of any of the conditions you have told me about?
[] No
s. If "Yes" in col. r: which? (enter X on line of each condition named) ________