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[p.44]

1. a What is the name of the head of this household? (enter name in first column)

b. What are the names of all other persons who live here?

c. I have listed (read names). Is there anyone else staying here now such as friends, relatives or roomers?

d. Have I missed anyone who usually lives here but is now-

e. Do any of the people in this household have a home anywhere else?

If any adult males listed, ask:
f. Are any of the persons in this household now on full-time active duty with the Armed Forces of the United States.

2. How are you related to the head of household? (enter relationship to head, for example: wife, daughter, grandson, mother-in-law, partner, roomer, roomer's wife etc)

3. How old were you on your last birthday?

4. Race (check one box for each person)

5. Sex (check one box for each person)

If 17 years old or over, ask:
6. Are you now married, widowed, divorced, separated or never married?
(check one box for each person)
(if you learn that persons under 17 are or have been married (other than annulled) check the "Und 17 yrs" box but give marital status in a footnote)

If 17 year old or over, ask:
7a. What were you doing most of the past 12 months-
(for males): working, or doing something else?
(for females): keeping house, working or doing something else?

If "something else" checked, and person is 45 years old or over, aks:
b. Are you retired?

H
Determine which adults are at home and record this information. Beginning with question B you are to interview for himself or herself, each adult person who is at home (if person under 19 is the respondent, check the "at home" box)

8. Were you sick at any time last week or the week before? (That is, the 2 week period which ended this past Sunday night).

9. Last week or the week before did you take any medicine or treatment for any condition (besides... which you told me about)?

10. Last week or the week before did you have any accidents or injuries?

11. Did you ever have an (any other) accident or injury that still bothers you or affects you in any way?

12. Has anyone in the family- you, your, --- etc had any of these conditions during the past 12 months?
(Read Card A, condition by condition; record in his column any conditions mentioned for the person)

CARD A
Check list of chronic conditions
Has anyone in the family had any of these conditions during the past 12 months?

13. Does anyone in the family have any of these conditions?
(Read card B, condition by condition, record in his column any conditions mentioned for the person)

CARD B:
Check list of selected impairments:
Does anyone in the family have any of these conditions?

14. Do you have any other ailments, conditions, or problems with your health?

15. a. Have you been in a hospital at any time since ____, a year ago?

If, "yes" ask:
b. How many times were you in the hospital during that period?

16. a. Has anyone in the family been a patient in a nursing home, rest home, or any similar place since ____, a year ago?

If "Yes", ask:
b. Who was this? ________

c. How many times were you in a nursing home or rest home during that period?

R
(for Q. 8-16)
For persons 19 years old or over, show who responded for (or was present during the asking of ) Q 8-16. If persons responded for self, show whether entirely or partly. For persons under 19 show who responded for them.

Interviewer: Examine ages and relationships in Questions 2 and 3 for children one year old or under, then check the appropriate box in Question 17(a).

17a.

b. Are birth(s) for baby (babies) and delivery for mother shown in table II?

c. Was -- born in the hospital?

d. When was --born? (enter month, day and year)

Interviewer: After completing table II for all persons, carry each condition in col (h) or col (i) back to table I if it does no already appear there; and either ["1" or more nights in column (f); or an impairment or a condition on Card A]

CARD A
Check list of chronic conditions:
Has anyone in the family had any of the these conditions during the past 12 months:

[p.45]

18. Last week or the week before did anyone in the family go to a dentist?

If "Yes" ask:
a. Who was this? ________

b. Anyone else? ________

For each person with "yes" checked, ask:
c. How many times did you visit the dentist last week or the week before?

d. What did you have done (the last time, the time before etc)?

If "No" to question 18, ask:
19. About how long has it been since you went to a dentist?

20. Last week or the week before did anyone in the family talk to a doctor or go to a doctor's office or clinic?
Interviewer: do no count doctors seen while an inpatient in a hospital.

If "Yes" ask:
a. Who was this? ________

b. Anyone else? ________

For each person with "yes" box checked, ask Questions 20c through f:
c. How many times did you see or talk to a doctor last week?

d. How many times did you see or talk to a doctor the week before last?

Ask for each visit to a doctor in last 2 weeks:
e. Where did you talk to the doctor (the last time, the time before, etc)?

[option for 6 different places and purposes]

Place:Purpose

f. Why did you go to (call) the doctor (that time)? ________

If "No" to question 20, ask:
21. About how long has it been since you have seen or talked to a doctor?

If any children under 17 years in household, ask:
22. During the past 12 months was (were--etc) taken to a doctor for a routine physical examination, that is, not for a particular illness but for a general check-up?

23. During the past 12 months has anyone in the family-that is, you, your etc- received any services from any of the persons listed on this card? Please check "Yes" or "No" for each one listed.
Hand respondent pencil and card (NHS-HIS-1a)

For each "Yes" box checked on the card, ask:
a. Who saw the (specialist)? (Mark X for each specialist in person's column)

b. About how many times did you see a (specialist) during the past 12 months (not counting any visits while you were in the hospital)?

c. Did anyone else see a (specialist) during the past 12 months?

If "Yes" ask:
d. Who was this? ________

e. About how many times did you see a (specialist) during the past 12 months (not counting any visits while you were in the hospital)?

Check the "none" box for each person who did not see a specialist

If male and 17 years old or never, ask:
24.a. Did you ever serve in the Armed Forces of the United States?

If "Yes" ask:
b. Was any of your services during a war or was it peace-time only?

If "war", ask:
c. During which war did you serve?

If "peace-time only" ask:
d. Was any of your service between June 27, 1950 and January 31, 1955?

If 17 years old or over, ask:
25.a. What is the highest grade you attended in school?
(circle highest grade attended or check "None")

b. Did you finish the -- grade (years)?

Ask for all persons 17 years old or over:
26. a. Did you work at any time last week or the week before?

If "No" ask both 26b and 26c:
b. Even though you did not work last week or the week before do you have a job or business?

c. Were you looking for, work or on layoff from a job?

27. Which of these income groups represents your total combined family income for the past 12 months, that is, yours, your--'s etc.? (show card H). include income from all sources, such as wages, salaries, rents from property, social security or retirement benefits, help from relatives etc.

CARD H:
Family income during past 12 months:
Group A: Under $500 (including loss)
Group B: $500-$999
Group C: $1,000-$1,999
Group D: $2,000-$2,999
Group E: $3,000-$3,999
Group F: $4,000-$4,999
Group G: $5,000-$$6,999
Group H: $7,000-$9,999
Group I: $10,000 and over

T
Interviewer: Enter the total number of hospitalizations for each person from Questions 15 and 16, or checks the "None" box. Fill one line of table II for each separate stay in the hospital.

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Table B

a. Col number of person(s) with eye condition(s) reported in table I ____

b. (Read to respondent) Earlier in the interviewer you told me about your eye condition. This is a matter of special interest to the public health services this yaar and I have some additional questions about it. ________

c. Can you see well enough to read ordinary newspaper print with glasses?

d. Can you see well enough to recognize the features of people you know if they are close enough?

e. Can you see objects that move such as cars moving or people walking?

Interviewer:
All "Yes"-ask cols. g and h.
All "No" -fill sect B supp.
Both "Yes" and "No"-fill sect A supp

"Yes" to cols. c, d, e
g. Can you see well enough to step down?

h. Can you see well enough to recognize a friend walking on the other side of the street?

Interviewer:
"Yes" to both Cols. g and h- STOP
"No" to either- Ask col (l)

"No" to either Cols g or h
How much trouble would you say that you have in seeing- a great deal, some or hardly any at all?