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. For all illnesses and present effects of "old" injuries:
a. If doctor talked to, ask:
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 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:
(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:
Asthma
Cyst
Growth
Stroke
Tumor
Condition
Disease
Trouble
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:
Aches
Bleeding
Blood clot
Boils
Cancer
Cyst
Growth
Hemorrhage
Infection
Inflammation
Neuralgia
Neuritis
Pains
Sores
Soreness
Tumor
Ulcers
Weak
Weakness
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.
f.[] Yes
f. Did you have to cut down for as much as a day?
Check one.
2[] Yes
g. How many days did you have to cut down during that two week period?
h. During that two-week 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 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?
[] None
k. Did you notice .. (did it happen) during the past 3 months or before that time?
check one.
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?
[] 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?
[] 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?
[] 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?
[] 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
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
o. If "1", "2" or "3" in col.n ask : is this because of any of the conditions you have told me about?
[] No
p. If "Yes" in col. o ask: Which? (enter X on line for each condition named) ____