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PERSON

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

Last name ________
First name ________

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

(List all persons who live here) ________

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

[] Yes (list)
[] No

d. Have I missed anyone who usually lives here but is now away from home?

[] Yes
[] No

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

[] Yes (apply household membership rules)
[] No (leave on questionnaire)

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.

[] Yes (delete)
[] No

2. Enter relationship to head, for example: wife, daughter, grandson, mother-in-law, partner, roomer, roomer's wife etc)

Relationship ________
Head ________

3. How old were you on your last birthday? (Also, check race and sex for each person)

Age ____

Race (check one box for each person)

[] White
[] Negro
[] Other

Sex (check one box for each person)

[] Male
[] Female

If 17 years old or over, ask:
4. 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)

[] Und 17 yrs
[] Married
[] Widowed
[] Never married
[] Divorced
[] Separated

For all persons 17 year old or over, ask:
5a.Did you work at any time last week or the week before? (for females add)-not counting work around the house?

[] Und 17 yrs
[] Yes
[] No

If "No" ask both Q 5b and 5c:
b. Even though you did not work during the past 2 weeks, do you have a job or business?

[] Yes
[] No

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

[] Yes
[] No

If "Yes" to Q 5c, ask:
d. Which -- looking for work or on layoff from a job?

[] Looking
[] Layoff
[] Both

If male 45 years old or over and all "No's" ask:
e. Are you retired?

[] Yes
[] No

H
If related persons 19 years old or over are listed in addition to the respondent say:
we would like to have all adults who are at home take part in the interview. Is your --, your -- etc at home now?

[] At home (interview for self)
[] Under 19 years
[] Not at home

This survey covers all kinds of illness. These first questions refer to last week and the week before, that is, the period outlined in red on this calendar (hand calendar).

[] Yes
[] No

6a. Were you sick at any time last week or the week before (the 2 weeks shown on that calendar)?

[] Yes
[] No

b. What was the matter? ______

c. Did you have anything else during that period? ________

7a. Last week or the week before, did you take any medicine or treatment for any condition (besides... which you told me about)?

[] Yes
[] No

b. For what condition? ________

c. Did you take any medication for any other condition?

[] Yes
[] No

8a. Last week or the week before, did you have any accidents or injuries?

[] Yes
[] No

b. What were they? ________

c. Did you have any other accidents or injuries during the 2 week period?

[] Yes
[] No

9a. Did you ever have an (any other) accident or injury that still bothers you or affects you in any way?

[] Yes
[] No

b. In what way does it bother you? (record present effects) ________

Now I am going to read a list of conditions.
10. Please tell me if you, your -- etc, have 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)

[] Yes
[] No
Card A
Check list of chronic conditions:

1. Asthma
2. Tuberculosis
3. Chronic bronchitis
4. Repeated attacks of sinus trouble
5. Rheumatic fever
6. Hardening of the arteries
7. High blood pressure
8. Heart trouble
9. Stroke
10. Trouble with varicose veins
11. Hemorrhoids or piles
12. Hay fever
13. Tumor, cyst or growth
14. Chronic gallbladder or liver trouble
15. Stomach ulcer
16. Any other chronic stomach trouble
17. Kidney stones or chronic kidney trouble
18. Mental illness
19. Arthritis or rheumatism
20. Diabetes
21. Thyroid trouble or goiter
22. Any allergy
23. Epilepsy
24. Chronic nervous trouble
25. Cancer
26. Chronic skin trouble
27. Hernia or rupture
28. Prostate trouble

11. Do you, your -- etc have any of these conditions?
(read card B, condition by condition; record in his column any conditions mentioned for the person)

[] Yes
[] No
Card B
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

12a. Do you have any other ailments, conditions, or problems with your health?

[] Yes
[] No

b. What is the condition? ________
(record condition itself if still present; otherwise record present effects)

c. Any other problems with your health?

[] Yes ________
[] No

13a. Have you been in a hospital at any time since -- a year ago?

[] Yes
[] No

If "yes" ask:
b. How many times were you in the hospital during that period?
Includes stays in nursing homes, rest homes, or similar places?

________ No of times

R
(for Q 6-13)
For persons 19 years old or over, show who responded for (or was persent during the asking of) Q 6-13. if persons responded for self, show whether entirely or partly. For persons under 19 show who responded for them. If eligible respondent is "at home" but did not respond for self, enter the reason in a footnot.

[] Responded for self-entirely
[] Responded for self-partly
Col. ____ was respondent

Interviewer: Check table I for eye conditions or vision problems (including cataracts and glaucoma) affecting persons 6 years old or over. For each such person ask:

[] No eye condition or under 6 years

14a. Can you see well enough to read ordinary newspaper print with glasses?

[] Yes (ask b)
[] No (stop)

If "Yes" to a, ask:
b. Can you see well enough to recognize a friend walking on the other side of the street?

[] Yes (stop)
[] No (ask c)

If "No" to b, ask:
c. How much trouble would you say that you have in seeing-- a great deal, some, or hardly any at all?

[] Great deal
[] Hardly any or none
[] Some

Interviewer: Examine ages in question 3 for children one year old or under, then check the appropriate box in question 15a.

15a.

[] Baby (babies) one year or under listed (go to Q 15b)
[] No baby (babies) one year or under listed (go to Q 16)

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

[] Yes (go to Q 16)
[] No (go to Q 15c)

c. Was -- born in the hospital?

[] Yes (go to Q 15 d)
[] No (go to Q 16)

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

Month ____
Day ____
Year ____
(if birthdate is on or after date shown in question 13, fill one line of table II for mother and one line for child)

Now I have some questions about purchases of medicine. First, I want to ask you about medicines prescribed by a doctor:
16a. Last week or the week before, did anyone in the family buy or obtain any kind of medicine prescribed by a doctor?

[] Yes
[] No (go to Q 17)

If "Yes" ask:
b. What is the name of the medicine? (enter name of medicine in column (a) of table P. If name is unknown, enter DK in column (a) and ask: what condition is it for? Then enter the condition in column (b)) ________

c. Last week or the week before, did anyone buy or obtain any other medicine prescribed by a doctor?

[] Yes (re-ask Q 16b)
[] No (fill remaining columns of table P for each medicine reported)

[p.41]

Turn to Card J and ask:
17a. Last week or the week before, did anyone in the family buy or obtain any medicine not prescribed by a doctor? This (show card J) is a list of some of the items in which we are interested.

[] Yes
[] No (go to Q 18)

If "Yes" ask:
b. What is the name of the medicine? ________
(enter name or kind of medicine in column (a) of table NP)

c. Last week or the week before, did anyone buy or obtain any other medicine not prescribed by a doctor?

[] Yes (re-ask Q 17b)
[] No (Fill remaining columns of table NP for each medicine reported)

Interviewer: "Impairments" or "conditions" on Card A reported in question 16 or 17, should be carried back to table I if they do not already appear there.

Table P- Prescribed medicines

Line number 1
a. Name of medicine (if name is unknown enter "DK" in col. a and ask col. b) ________

b. What conditions is the -- for? ________

c. Who was it prescribed for? (enter column number of person) ________

d. Which week was the -- bought, last week ___ or the week before last?

[] Last week
[] Week before
[] Before 2 weeks (STOP)

e. How much did it cost?

Dollars $________
Cents ________

Table NP- Nonprescribed medicines

Line no.1
a. Name of medicine (if name is unknown, enter the kind of medicine) ________

b. What is the -- generally used for by this family? ________

c. Which members of the family use the --? (enter col. nos of persons) ________

d. Which week was the -- bought, last week ____ or the week before last?

[] Last week
[] Week before
[] Before 2 weeks (STOP)

e. How much did it cost?

Dollars $ ________
Cents ________

f. Where was it bought?

[] Drug store
[] Grocery store
[] Mail order house
[] Other (specify)

Now I have a few questions about smoking-
For each person 17 years old or over, ask:
18a. Have you smoked at least one hunded cigarettes during your entire life?

[] Under 17 years
[] Yes
[] No (go to 21)

If "Yes" ask:
b. During the period when you were smoking the most, how many cigarettes a day did you usually smoke?

Per day ________ or
Per week ________

19a. Do you smoke cigarettes now?

[] Yes
[] No (go to 20)

If "Yes" ask questions 19b and 19c. If "No" go to question 20:
b. On the average, about how many cigarettes a day do you smoke?

Per day ________ or
Per week ________

c. Twelve months ago, how many cigarettes a day were you smoking?

Per day ________ or
Per week ________

(Go to question 21)

If "No" to question 19a, ask both questions 20a and 20b:
20a. On the average, about how many cigarettes a day were you smoking 12 months ago?

[] None
Per day ________
Per week ________

b. How long has it been since you smoked cigarettes fairly regularly?

Months ________ or
Years ________

For each male 17 years old or over ask questions 21 and 22:
21a. Have you smoked at least 10 cigars during your entire life?

[] Fem. or under 17
[] Yes
[] No (go to 22)

b. Do you smoke cigars now?

[] Yes (ask c)
[] No (ask d)

If "Yes" to 21b ask:
c. About how many cigars a day do you usually smoke?

Per day ____ or
Per week ____

If "No" to 21b, ask;
d. About how long has it been since you smoked 3 or more cigars a week?

Months ____ or
Years ____
[] Never smoked 3 or more a week

22a. Have you smoked at least 3 packages of pipe tobacco during your entire life?

[] Yes
[] No (stop)

b. Do you smoke a pipe now?

[] Yes (ask c)
[] No (ask d)

If "Yes" to 22b, ask:
c. About how many pipefuls of tobacco a day do you usually smoke?

Per day ____ or
Per week ____

If "No" to 22b, ask:
d. About how long has it been since you smoked 3 or more pipefuls a week?

Months ____ or
Years ____
[] Never smoked 3 or more a week

For each make 17 years old or over, ask:
23a. Did you ever serve in the Armed Forces of the Unites States?

[] Fem or under 17
[] Yes
[] No

If "Yes" ask:
b. Was any of your service during a war?

[] Yes (ask c)
[] No (ask d)

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

[] WWII
[] Korean
[] Other

If "No" to 23b ask:
d. Was any of your service between June 27, 1950 and January 31, 1955?

[] Yes
[] No

[] Under 17
If 17 years old or over, ask:
24a. What is the highest grade you attended in school? (circle highest grade attended or check "None")

[] Elem
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] High:
[] 1
[] 2
[] 3
[] 4
[] College:
[] 1
[] 2
[] 3
[] 4
[] 5+
[] None

Did you finish the -- grade (year)?

[] Yes
[] No

Turn to Card K and ask:
25. Which of these income groups represents your total combined family income for the past 12 months, that is, your's, your--'s etc? (show card K). Include income from all sources, such as wages, salaries, social security or retirement benefits, help from relatives, rents from property and so forth.

Group ________
Card K:
For: Total combined 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