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X-ray

[p.84]


X-RAY

A. PSU No. _____

B. Segment No _____

C. Serial No ____

D. Interview status

[] Interview (fill items E, F and G)
[] Non-interview (specify type)
[] Type A
[] Type B
[] Type C

E. 3 month reference period

From _____ to _____

F. Address of sample unit (item 2(b) or (a) of NHS-HIS-I)

_____________
City __________
State _________

G. Telephone No.

____ or
[] No telephone

Name Mr (MRS, Miss) ________

Relationship ________ , HEAD

Age ____

Race

[] White
[] Negro
[] Other

Sex

[] M
[] F
X-ray questions

1. (Exposure to all kinds of X-rays is a matter of particular interest to the public health services and I have a few final question about X-rays and fluoroscopes). Did you have your teeth X-rayed during the past 3 months (that is from ______ through last Sunday)?
(If "Yes" check the "Yes" box and enter "teeth")

[] Yes
[] No

2. During the past 3 months did you have a chest X-ray?
(if "Yes" check the "yes" box and enter "chest")

[] Yes
[] No

3. (a) Did you have any (other) kind of X-ray at all during the past 3 months?

[] Yes
[] No

If "Yes" ask:
b. What part of the body was X-rayed?

(enter part of body in person's column) ________

4. a. Did you have a fluoroscope during the past 3 months?

[] Yes
[] No

If "Yes" ask:
b. What part of the body was it for?

(Enter part of body in person's column) ________

If "X-rayed" in question 2 or 3 for the person, ask:
c. Was this included in the X-rays you told me about before?

[] Yes
[] No

5.a. Did anyone in the family, that is, you, your -- etc have any X rays for the treatment of a condition during the 3 month period from ____ through last Sunday night?

[] Yes
[] No

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

_________

c. What part of the body was treated?

(enter part of body in person's column) ________

If X rays in questions 2-4 for the person, ask:
d. Was this included in the X rays you told me about before?

[] Yes
[] No

6. What is your height and weight?

Height (feet) ____
Inches ____
Weight (pounds) ____

Table X-fill one line for each "part of body" entry from questions 1-5
[Upto three column entries]
a. Col. No. of person

Line number 1________
Line number 2. ________
Line number 3. ________

b.Question No.

Line number 1________
Line number 2. ________
Line number 3. ________

c. Part of body

Line number 1________
Line number 2. ________
Line number 3. ________

d. How many different times did you have your --X-rayed during the past 3 months?

Line number 1. ________ [times]
Line number 2. ________ [times]
Line number 3. ________ [times]

e. For dental X-rays, ask: where did you have the X-rays taken-at the dentist's office or some other place? For X-rays other than dental ask: where did you have the X-rays taken - at the doctor's office, a hospital, or some other place?
(if "some other place" determine place)
If more than one place given and more than one X-ray taken ask: How many X -rays were taken at the (hospital, doctor's office etc)

Line number 1:
[] Dentist's office ____ (times)
[] Doctor's office ____ (times)
[] Hospital ____ (times)
[] Other (specify) ____ (times)
Line number 2:
[] Dentist's office ____ (times)
[] Doctor's office ____ (times)
[] Hospital ____ (times)
[] Other (specify) ____ (times)
Line number 3:
[] Dentist's office ____ (times)
[] Doctor's office ____ (times)
[] Hospital ____ (times)
[] Other (specify) ____ (times)

f. What is the name and address of the (dentist, doctor, hospital etc) where the X-rays were taken?
Interviewer- For X rays taken at hospital, clinics etc. Also enter the name of the doctor. For X-rays taken at mobile units, enter: "Mobile unit" on name line; location of unit at time of X-ray on address line; an name and address of sponsoring organization and date of X-ray in footnote.
Verify name and address in telephone directory.
Enter the telephone number,
Check "verified" box. if unable to verify, given reason in a footnote.

Line number 1:
Name and title ________
Address ________
City________
State ________
Telephone No. ________
[] Verified
Line number 2:
Name and title ________
Address ________
City________
State ________
Telephone No. ________
[] Verified
Line number 3:
Name and title ________
Address ________
City________
State ________
Telephone No. ________
[] Verified

Interviewer- ask after completing Table X for all related persons with X -rays.
7. May we contact the (doctor, dentist, hospital etc) you have mentioned to obtain additional information about the X-rays? (present form for signature) will you please sign this form?

[] Signed
[] Not signed (enter reason)
[p.85]

g. What was this X-ray for- a checkup or an examination or for a treatment?

Line number 1:
[] Checkup/examination
[] Treatment (skip to column (I))
[] Both (ask column (h) and (I))
Line number 2:
[] Checkup/examination
[] Treatment (skip to column (I))
[] Both (ask column (h) and (I))
Line number 3:
[] Checkup/examination
[] Treatment (skip to column (I))
[] Both (ask column (h) and (I))

h. If "both" in column (g) ask: How many of these -- X-rays were for treatments?

Line number 1: Number ________
Line number 2: Number ________
Line number 3: Number ________

i. If "treatment" or "both" in column (g), ask: For what condition were you being treated? (enter condition)

Line number 1: ________
Line number 2: ________
Line number 3: ________

j. Interviewer- ask for each person with 2 or more lines in Table X after all X-rays have been recorded for a person. (Do not include dental X-rays in number of X-rays visits)
Altogether you had -- X-rays during the past 3 months. How many separate visits did you make to have these --X-rays?

Line number 1: ________ (number of visits)
Line number 2: ________ (number of visits)
Line number 3: ________ (number of visits)

8. Interviewer- After completing X-ray supplement, check appropriate box.

[] No X-rays reported
[] X-rays reported and
[] No problems (release, signed, no missing information etc)
[] Problems (release not signed, missing information etc) (enter problem in footnote)
Footnotes: ________