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[p.45]


CONDITION

1. Person number ________

Enter person number and "name of condition" and ask question 2

Name of condition ________

Ask for all conditions
2. Did --ever at any time talk to a doctor about his...?

[] Yes
[] No

Examine "name of condition" entry in item 1 and mark one box.

[] Accident or injury -go to 4
[] Condition on Card C - go to 9
[] Neither - go to 3a

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? ________

3b. What was the cause of ..?

________
[] Accident or injury -go to 4

If the entry in 3a or 3b includes the words:

Asthma
Cyst
Growth
Measles
Tumor
Ailment
Attack
Condition
Defect
Disease
Disorder
Trouble

Ask:
3c. What kind of --is it? ________

For allergy or stroke, ask:
3d. How does the allergy (stroke) affect him? ________

For conditions on Card B-2 and for any entry that includes the words:

Abscess
Ache (except headache)
Bleeding
Blood clot
Boil
Cancer
Cramps (except menstrual)
Cyst
Growth
Hemorrhage
Infection
Inflammation
Neuralgia
Neuritis
Pain
Palsy
Paralysis
Sore
Soreness
Tumor
Ulcer
Weak
Weakness

Ask:
3e. What part of the body is affected? ________

Show the following detail:
Ear or eye.... one or both
Head .... skull, scalp, face
Back.... Upper, middle or 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?

1. Deafness or serious trouble hearing with one or both ears?
2. Serious trouble seeing with one or both eyes even 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?

Fill Questions 4-8 for all accidents or injuries
4a. Did the accident happen during the past 2 years or before that time?

[] During past 2 years -ask 4b
[] Before 2 years - go to 5a

4b. When did the accident happen?
Enter month and year; mark one box

Month ________
Year ________
[] Last week
[] Week before
[] 2 weeks-3 months
[] 3-12 months
[] 1-2 years

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]

Part(s) of body ________
Kind of injury (injuries) ________

If accident happened before 3 months, ask:
5b. What part of the body is affected now? How is his -- affected?

[option for 3 entries]

Part(s) of body ________
Present effects ________

6a. Was a car, truck, bus or other motor vehicle involved in the accident in any way?

[] Yes
[] No- go to 7

b. Was more than one vehicle involved?

[] Yes
[] No

c. Was it (either one) moving at the time?

[] Yes
[] No

7. Where did the accident happen?

[] At home (inside house)
[] At home (adjacent house)
[] Street and highway (includes roadway)
[] Farm
[] Industrial place (includes premises)
[] School (includes school premises)
[] Place of recreation and sports (not school)
[] Other (specify place where accident happened) Specify Place ________

8. Was -- at work at his job or business when the accident happened?

[] Yes
[] No
[] Under 17 at time
[] While in Armed Forces

WASHINGTON USE

Question Number

[] 8
[]9
[]10
[]11
[]12
[]13
[]14
[] H
[] C
[]DV
[] HC
[]OT

Cond: ________

No of this condition ________

Mark one

[] Chronic
[] Acute

Total conditions ________

Accident -first injury code

[] Yes
[] No

Required hospitalization

[] Yes
[] No

Other Acc

[] T. Mrs
[] Oth

IC or dum code ________

Person days of disability

2 wks
[] R.A
[] B.D
[] T.L
[] Under 6
12 months
[] B.D

[p.46]

Refer respondent to two-week calender for question 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?

[]Yes
[] No -go to 14a

b. Did he have to cut down for as much as a day?

[] Yes
[] No- go to 14a

Ask questions 10 and 11 if "Yes" marked in question 9b.
10. How many days did he have to cut down during that two week period?

Days _______

11. During that two week period, how any days did his ... keep him in bed all or most of the day?

Days ________
[] 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?

Days ________
[] Under 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?

Days ________
[] None

Ask question 14 for all conditions
14a. When did he first notice his ....? Was it during the past 3 months or before that time?

[] During 3 mos
[] Before 3 mos -go to 15

b. Did he first notice it during the past two weeks or before that time?

[] Past 2 wks
[] Before 2 wks - go to 16

c. Which week, last week or the week before?

[] Last week -go to 16
[] 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?

[] 3-12 mos
[] Before 12 mos

Ask for person 6 years old or over for whom an eye condition or vision problem (including cataracts and glaucoma) has been reported.

[] Not an eye condition
[] Not first eye condition
[] Under 6

16a. Can -- see well enough to read ordinary newspaper print with glasses?

[] Yes (ask 16b)
[] No -omit 16b, c

b. Can -- see well, enough to recognize a period walking on the other side of the street?

[] Yes -omit 16c
[] No-ask 16c

c. How much trouble would you say that --has in seeing; a great deal, some, or hardly any at all?

[] Great deal
[] Some
[] Hardly any at all

AA: if this is a condition on card A or B, or started "before 3 months" ; Ask Q. 17; 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 or 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?

12. Thyroid trouble or goiter?
13. Any allergy?
14. Chronic nervous trouble?
15. Chronic skin trouble?
16. Palsy?
17. Paralysis of any kind?
18. Repeated trouble with back or spine?
19. Cleft palate?
20. Any speech defect?
21. Hernia or rupture?
22. Prostate trouble?

CARD B.
B-1:
Have you, your-- etc ever had any of these conditions?

1. Tuberculosis?
2. Emphysema?
3. Hardening of the arteries?
4. High blood pressure?
5. Cancer?
6. Heart trouble?
7. Stroke?
8. Rhematic fever?
9. Arthritis or rheumatism?
10. Mental illness?
11. Diabetes?
12. Epilepsy?
B-2:
Do you, your--etc have any of these conditions?

1. Deafness or serious trouble hearing with one or both ears?
2. Serious trouble seeing with one or both eyes even 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?

Ask question 17b if "1" or more days in question 17a and question 11 islank or marked "None"
17a. About how many days during the past 12 months has his -- kept him in bed all or most of the day?

Days ________
[] None - go to BB

b. Were any of these--days during last week or the week before?

[] Yes
[] No -go to BB

c. How many?

Days ________

BB: Is this the last condition for this person?

[] Yes- ask 18-21 if person has "1" or more conditions past AA
[] No- go to next condition

Show card D, E, F, or G as appropriate based on activity status or age.
18. Please look at each statement on this card (card D, E, F, G). then tell me which statement fits --best in terms of health.
Mark statement number

[] 1
[] 2
[] 3
[] 4-go to 20

CARD D:
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.

CARD E:
For: housewife

1. Not able to keep house at all
2. Able to keep house 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 F:
For: children from 6 through 16 years old

1. Not able to go to school at all
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 G:
For: children under 6 years old

1. Not able to take part at all in ordinary play with other children
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 18 ask:
19. Is this because of any of the conditions you have told me about?

[] Yes?
Which? Enter condition numbers ________
[] No
What does cause this limitation? Enter cause ________

20. Please look at the blue card, card H. which one of those statements fits-- best in terms of health?
Mark statement number.

[] 1
[] 2
[] 3
[] 4
[] 5
[] 6-stop

If 1,2, 3, 4, and 5 marked in 20, ask 21; if 6 marked, omit 21 and go to next person.
21. Is this because of any of the conditions you have told me about?

[] Yes
Which? enter condition numbers ________
[] No
What does cause this limitation? Enter cause ________