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c


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. For all illnesses and present effects of "old" injuries:
a. If doctor talked to, ask:

What did the doctor say is was? ____
Did he give it a medical name? ____

b. If doctor not talked to, record original entry and ask (d-2) -(d-4) as required.
For all injuries which happened last week or the week before ask:

What part of the body was hurt? ________
What kind of injury was it? ________
Anything else? ________
(also, fill table A for all injuries)

d-2. Cause:
If the entry in Col. d-1 is : an impairment or a symptom or came from Question 11 or 13 ask:

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

d-3. Kind:
For any entry in Col (d-1) or Col (d-2) that includes the words:

Allergy
Asthma
Cyst
Growth
Stroke
Tumor
Condition
Disease
Trouble
Ask: What kind of ... is it? ________
For an allergy or stroke ask: How does the allergy (stroke) affect you? ________

d-4. Ask only for: Impairment, current injuries and present effects of old injuries
And for:

Abscesses
Aches
Bleeding
Blood clot
Boils
Cancer
Cyst
Growth
Hemorrhage
Infection
Inflammation
Neuralgia
Neuritis
Pains
Sores
Soreness
Tumor
Ulcers
Weak
Weakness
What part of the body is affected? ________
Show detail for:
Ear or eyes (one or both)
Head (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?
check one.

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

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

1[] No (go to col (k))
2[] Yes

g. How many days did you have to cut down during that two week period?

Days ____

h. During that two-week 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 yrs 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

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

k-1[] Before 3 months (go to col k-4)
k-2[] During 3 mos

k-3.Did it start (happen) 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

k-4. If col (k-1) is checked ask: Did you first notice it during the past 12 months or before that time?

[] 3-12 months
[] Before 12 months

To interviewer: continue if col (k-1) is checked or the condition is on card A or is an impairment; otherwise STOP

l. About how many days during the past 12 months has ... kept you in bed all or most of the day?

Days ____ or
[] None

m. If 1 or more days in col. l and col. h is blank or checked "None" ask: how many of these days were during last week or the week before?

Days ____ or
[] None

Ask after completing last condition for each person.
n. 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

o. If "1", "2" or "3" in col.n ask : is this because of any of the conditions you have told me about?

[] Yes
[] No

p. If "Yes" in col. o ask: Which? (enter X on line for each condition named) ____