[p.41]
CONDITION
Enter person number and name of condition from worksheet and ask question 2
1.Person number ________
Name of condition ________
Question number ________
Ask for all conditions
2. Did --ever at any time talk to a doctor about his --?
[] No
If the "name of condition" in item 1 is a condition on Card C or involves an accident or injury, mark here:
[] Condition on card C (go to 9)
For all other entries proceed as follows:
If "doctor talked to" Ask: 3a. If "doctor not talked to" record adequate description of condition or illness.
3a. What did the doctor say it was? Did he give it a medical name?
[] Accident or injury -go to 4
If the entry in 3a or 3b includes the words, ask 3c
Cyst
Growth
Measles
Tumor
Ailment
Condition
Disease
Disorder
Trouble
Ask:
3c. What kind of --is it?
For Allergy or stroke ask: How does the allergy (stroke) affect him? ________
For conditions on Card B-2 and for any entry that includes the words:
Ache (except headache)
Bleeding
Blood clot
Cancer
Cramps (except menstrual)
Cyst
Growth
Hemorrhage
Infection
Inflammation
Neuralgia
Neuritis
Pain
Palsy
Paralysis
Sore
Soreness
Tumor
Ulcer
Weak
Weakness
Ask: 3d.
3d. What part of the body is affected?
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)
CARD B-2:
Do you, your-- etc have any of these conditions?
2.Serious trouble seeing with one or both eyes even when wearing glasses?
3. Missing fingers, hand or arm--toes, foot or leg?
4. Missint lung or kidney (or breast)?
5. Club foot?
6. Permanent stiffness or any deformity of foot, leg, fingers, arm or back?
Cond.________
No of this condition ________
Mark one
[] Acute
Total conditions ________
Accidents-1st injury
[] No
Required hospitalization
[] No
Other Acc
[] O
IC or dum.code ________
Person days of disability
B.D
T.L
Fill questions 4-8 for all accidents or injuries
4a. Did the accident happen during the past 2 years or before that time?
[] Before 2 years- go to 5a
4b. When did the accident happen?
Enter month and year, mark one circle
[] Week before
[] 2 weeks - 3months
3-12 months
1-2 years
Month ________
Year ________
Ask for all accidents or injuries:
5a. At the time of the accident what part of the body was hurt?
What kind of injury was it? Anything else?
[option for 3 entries]
Kind of injury (injuries) ________
If accident happened before 3 months, ask:
5b. What part of the body is affected now?
How is his --effected?
[option for 3 entries]
Present effects ________
6a. Was a car, truck, bus or other motor vehicle involved in the accident in any way?
[] No (go to 7)
b. Was more than one vehicle involved?
[] No
c. Was it (either one) moving at the time?
[] No
7. Where did the accident happen?
[] At home (adjacent house)
[] Street and highway (includes roadway)
[] Farm
[] Industrial place (include premises)
[] School (includes premises)
[] Place of recreation and sports, except school
[] Other (specify the place where accident happened) Specify place ________
8. Was -- at work at his job or business when the accident happened?
[] No
[] Under 17 at time
[] While in Armed Forces
[p.42]
Refer respondent to two -week calendar for questions 9-14
Ask question 9a for all conditions
9a. Last week or the week before did his -- cause him to cut down on the things he usually does?
[] No (go to 14a)
b. Did he have to cut down for as much as a day?
[] No (go to 14a)
Ask questions 10 and 11 if "Yes" marked in 9b.
10. How many days did he have to cut down during that two week period?
Write in and mark
11. During that two week period, how many days did his -- keep him in bed all or most of the day?
Write in and mark
[] None
Ask question 12 if person is 6-16 years old.
12. How many days did his.. keep him from school during that two week period?
Write in and mark.
[] Und 6
[] None
Ask question 13 if person is 17 years old or over
13. How many days did his .. keep him from work during that two week period?
(for females add) not counting work around the house?
Write in and mark.
[] None
Ask question 14 for all conditions
14a. When did he first notice his --, during the past 3 months or before that time?
[] Before 3 mons (go to 15)
b. Did he first notice it during the past two weeks or before that time?
[] Before 2 wks (go to 16)
c. Which week, last week or the week before?
[] Week before (go to 16)
Ask question 15 only if condition was first, noticed before 3 months
15. Did -- first notice it during the past 12 months or before that time?
[] Before 12 mos
Ask for persons 6 years old or over for whom an eye condition or vision problem (including cataracts and glaucoma) has been reported.
[] Not first eye condition
[] Under 6
16a. Can -- see well enough to read ordinary newspaper print with glasses?
[] No (omit 16 b, c)
b. Can -- see well enough to recognize a friend walking on the other side of the street?
[] No (ask 16c)
c. How much trouble would you say that -- has in seeing: a great deal, some, or hardly any at all?
[] Some
[] Hardly any or none
AA: if this is a condition on Card A or B, or started "before 3 months". Ask 17 -18 otherwise go to item BB.
CARD A:
A-1
Now I'm going to read a list of conditions-please tell me if you, your--etc have had any of these conditions during the past 12 months?
1. Asthma
2. Chronic bronchitis?
3. Repeated attacks of sinus trouble?
4. Trouble with varicose veins?
5. Hemorrhoids or piles?
6.Hay fever?
7. Tumor, cyst or growth?
8. Chronic gallbladder or liver trouble?
9. Stomach ulcer?
10. Any other chronic stomach trouble?
11. Kidney stones or chronic kidney trouble?
A-2:
Have you, your-- etc had any of these conditions during the past 12 months?
13. Any allergy?
14. Chronic nervous trouble?
15. Chronic skin trouble?
16. Hernia or rupture?
17. Prostate trouble?
18. Palsy?
19. Paralysis of any kind?
20. Repeated trouble with back or spine?
21. Cleft palate?
22. Any speech defect?
CARD B:
B-1:
Have you, your--etc ever had any of these conditions?
2. Hardening of the arteries?
3. High blood pressure?
4. Cancer?
5. Heart trouble?
6. Stroke?
7. Rhematic fever?
8. Arthritis or rhematism?
9. Mental illness?
10. Diabetes?
11. Epilepsy?
Do you, your -- etc Have any of these conditions?
2. Serious trouble seeing with one or both eyes when wearing glasses?
3. Missing fingers, hand or arm- toes, foot or leg?
4. Missing lung or kidney (or breast)?
5. Club foot?
6. Permanent stiffness or any deformity of foot, leg, fingers, arm or back?
17a. About how many days during the past 12 months has his -- kept him in bed all or most of the day?
Write in and mark.
[] None (go to 18)
Ask question 17b if "1" or more days in question 17a and question 11 is blank or marked none.
b. Were any of these --days during last week or the week before?
[] No (go to 18)
c. How many? Write in and mark.
[] None
If "Yes" in question 2 ask 18 and if "No" in question 2 omit 18.
18. About how many times during the past 12 months has -- seen or talked to a doctor about his...?
Write in and mark.
[] None
BB: Is this the last condition for this person?
[] No -Go to next condition
Show card E, F, G or H as appropriate based on activity status or age
19. Please look at each statement on this card (card E, F, G , H). Then tell me which statement fits -- best in terms of health.
[] 2
[] 3
[] 4 (go to 21)
CARD E
For workers and other persons except housewives and children
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.
2. Able to keep hosue 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.
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
2. Able to play with other children but limited in amount or kind of play
4. Not limited in any of the above ways
If 1, 2, or 3 marked in 19 ask 20; if 4 marked in 19 go to 21.
20. Is this because of any of the conditions you have told me about?
[] No
21. Please look at the tan card, Card I. Which one of those statements fits --- best in terms of health?
[]2
[]3
[]4
[]5
[] 6 (stop)
For mobility:
2. Must stay in the house all or most of the time
3. Need the help of another person in getting around inside or outside the house
4. Need the help of some special aid, such as a cane or wheelchair, in getting around inside or outside the house
5. Does not need the help of another person or a special aid but has trouble in getting around freely
6. Not limited in any of the above ways
If 1, 2, 3, 4, or 5 marked in 21 ask 22; if 6 marked, omit 22 and go to next person.
22. Is this because of any of the conditions you have told me about?
[] No