First name ________
If 17 years old or over, ask:
4. Is -- now married, widowed, divorced, separated, or never married? (mark one box for each group)
If persons under 17 are or have been married mark the "Und 17" box and give marital status in a footnote.
 Never married
 Keeping house
 Something else
If related persons 19 years old or over are listedin addition to the respondent say:
We would like to have all adults who are at home take part in the interview. Is your --etc, at home now?
If other eligible respondents are at home, ask:
Would you please ask --, -- etc to join us?
 Under 19
 Not at home
This survey covers all kinds of illness. These first questions refer to last week and the week before, that is, the 2 week period outlined in red on this calender. (hand calendar)
6a. Was -- sick at any time last week or the week before? (the 2 weeks shown on that calendar)?
b. For what condition? ________
c. Did --take any medicine for any other condition?
b. What were they? ________
c. Did -- have any other accidents or injuries during that 2 week period?
b. In what way does it bother him? (Record present effects) ________
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?
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?
19. Paralysis of any kind?
20. Repeated trouble with back or spine?
21. Cleft palate?
22. Any speech defect?
Have you, your--etc ever had any of these conditions?
2. Hardening of the arteries?
3. High blood pressure?
5. Heart trouble?
7. Rhematic fever?
8. Arthritis or rhematism?
9. Mental illness?
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?
b. What is the condition?
(Record condition itself if still present; otherwise record present effects)________
c. Any other problems with his health?
For persons 19 years old or over, show who responded for (or was present during the asking of) Q6-14. 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 footnote.
Responded for self-partly
Person ____ was respondent
Transcription items to be marked for all persons after the interview
1a. Person no ________
b. Age ________
e. Marital status
 Under 17
f. Activity status
 Under 17
 None (go to 3a)
 No (ask both 3b and 3c)
 No (go to 3a)
 Gov't Fed
 Gov't other
 No (go to 6)
 No (ask 5d)
 DK (ask 5d)
 Other war
 DK -ask 5d
 Not last rel. person (go to next person)
6. 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 J. Include income from all sources such as wages, salaries, social security or retirement benefits, help from relatives, rents from property and so forth. (Mark income group on each person page for related members)
For: Total combined family income during past 12 months
$15,000 and over.... Group J
5-Other female family member
6-Other male family member
 Head 2+
Age of respondent ________
Education of head ________
Eyeglasses or contact lenses
 Und 3