Data Cart

Your data extract

0 variables
0 samples
View Cart



c

[p.42]


Table I- illness, impairments and injuries


[option for 3 entries with the same questions. only one set is presented here]

Line number 6

a. Col. No of person ____

b. Question No. ____

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

[] Yes
[] No

If condition is on Card C, enter condition without asking columns (d-1) through (d-4) and go to columns e-f.

d-1.For all other illness and present effects of "old" injuries
a. If doctor talked to, ask:

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-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? ____
(for injuries or accidents which happened before the past 2 weeks, enter the present effects)

d-2.Cause:
If the entry in col. (d-1) is: an impairment or a symptom or came from question 9 or 11 ask:

What was the cause of ...? ____
(if "cause" is an injury enter "accident" or"injury" and 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. Part of body.
Ask only for: Impairments, "current" injuries and present effects of "old" injuries.
And for:

Abscess
Ache (except headache)
Bleeding
Blood clot
Boil
Cancer
Cyst
Growth
Hemorrhage
Infection
Inflammation
Neuralgia
Neuritis
Pain
Sore
Soreness
Tumor
Ulcer
Weak
Weakness
What part of the body is affected? ________
Show detail for:
Ear or eye (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 your ...cause you to cut down on the things you usually do?
Check one.

e[] No (go to col m)
f[] Yes

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

g[] No (go to col m)
h[] Yes

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

Days ____

j. During that two week period how many days did your ... keep you in bed all or most of the day?

Days ____ or
[] None

k. If 6-16 years old, ask: how many days did your ... keep you from school during that two week period?

Days ____ or
[] None

l. If "Yes" in Q.5a or Q.5b, ask: how many days did your ... keep you from work during that two week period?

Days ____ or
[] None

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

m[] Before 3 months (go to col p)
n[] During 3 mos

o. Did you first notice it (did it 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

p. If col (m) is checked, ask: Did you first notice it during the past 12 months or before that time?

[] 3-12 mos
[] Before 12 mos

To interviewer: continue if col (m) is checked, or condition is on card a or is an impairment otherwise stop.

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

Days ____ or
[] None

r. If 1 or more days in col (q) and col (j) is blank or checked "None" ask: were any of these --days during last week or the week before?
If "Yes" ask: how many? ____

Days ____ or
[] None

s. If "Yes" to col (c) ask: about how many times during the past 12 months have you seen or talked to a doctor about your ...?

Times ____ or
[] None

Ask after completing last condition for each person.
t. Please look at each statement on this card, card -- (show card E, F, G or H as appropriate). Then tell me which statement fits you best, in terms of health. (if "4" go to col (v)). ________

Card E
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 the above ways
Card F
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 the above ways
Card G:
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 the above ways
Card H
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 the above ways

u. If "1", "2" or "3" in col (t) ask: is this because of any of the conditions you have told me about? If "Yes", ask: which? (enter X on line for each condition named)

[] Yes
[] No

v. Please look at the tan card, Card I. which one of those statements fits you best, in terms of health. ________

w. If "1" -"4" in col (v) ask: is this because of any of the conditions you told me about? If "Yes" ask: which? (enter X on line for each condition named) ________

[] Yes
[] No

T
Interviewer:
Enter total number of hospitalizations recorded in question 12.

Number ________

Fill one line of Table II for each hospital stay reported. If no hospitalization reported, check the "none" box.

[] None