Data Cart

Your data extract

0 variables
0 samples
View Cart



c
[p.38]


Table I-Illness, impairments and injuries


[option for 5 entries with the same questions. Only one set is presented here].

1.
a. Col. No of person ____

b. Question No. ____

c. Did you ever at any time talk to a doctor about ...?

[] Yes
[] No

d-1: Ask for all illness and present effects of old injuries:
a. If doctor talked to:

What did the doctor say it was? ________
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 part of the body was hurt? ________
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.________

What was the cause of ...? ________ (if cause is an injury, also fill table A)

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?

[] Yes
[] No

d-4. Ask for any entry in Col.d-1 or Col d-2 that includes the words:

Allergy
Asthma
Cyst
Growth
Stroke
Tumor
"condition"
"disease"
"trouble"
What kind of ...is it? ________

For an allergy or stroke ask:
How does the allergy (stroke) affect you? ________

d-5. Ask only for: Impairment and injuries.
And for:

Abscesses
Aches
Bleeding
Blood clot
Boils
Cancer
Cyst
Growth
Infection
Inflammation
Neuralgia
Neuritis
Pains
Sores
Soreness
Tumor
Ulcers
Weakness
What part of the body is affected? ________
Show detail for:
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?

e.[] No (go to col. K)
f.[] Yes

f. Did you have to cut down for as much as a day?

1.[] No (go to col (K))
2.[] Yes

g. How many days during that two week period?

Days ____

h. During that two weeks period, how many days did ... keep you in bed all or most of the day?

Days ____ or
[] None

i. If 6-16 years old ask: How many days did ...keep you from school last week or the week before?

Days ____ or
[] 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?

Days ____ or
[] None

Did you first notice ... (did it happen) during the past 3 months or before that time?

k.[] Before 3 months (go to col n)
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?

[] Last week
[] 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?

Days ____ or
[] 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?

Days ____ or
[] None

p. Were you ever hospitalized for this condition?

[] Yes
[] 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

1. Not able to work at all
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

CARD E:
For: Housewife

1. Not able to keep house at all
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

1. Not able to go to school at all
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.

1. Not able to take part at all in ordinary play with other children
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?

[] Yes
[] No

s. If "Yes" in col. r: which? (enter X on line of each condition named) ________