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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 away from home?

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. 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? (Also, check race and sex for each person)

Race (check one box for each person)

Sex (check one box for each person)

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)

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?

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?

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

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

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

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?

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).

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

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)?

b. For what condition? ________

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

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

b. What were they? ________

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

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

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)

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)

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

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

c. Any other problems with your health?

13a. 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?
Includes stays in nursing homes, rest homes, or similar places?

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.

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:

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

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

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?

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

15a.

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)

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?

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?

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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.

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?

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?

e. How much did it cost?

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?

e. How much did it cost?

f. Where was it bought?

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?

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

19a. Do you smoke cigarettes now?

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?

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

(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?

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

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?

b. Do you smoke cigars now?

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

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

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

b. Do you smoke a pipe now?

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

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

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

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

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

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

[] 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")

Did you finish the -- grade (year)?

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.