[p.53]
CONDITION
Condition approach
Enter person number and "name of condition" and ask question 2
1. Person number ________
Name of condition _______
Ask of all conditions
2. Did -- ever at any time talk to a doctor about his....?
2[] No
Examine "name of conditions" entry in item 1 and mark
[] 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:
Cyst
Growth
Hernia
Measles
Rupture
Tumor
Ulcer
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 any entry that includes the words:
Ache (except headache)
Bleeding
Blood clot
Boil
Cancer
Cramps (except menstrual)
Cyst
Damage
Growth
Hemorrhage
Infection
Inflammation
Neuralgia
Neuritis
Pain
Palsy
Paralysis
Rupture
Sore
Soreness
Tumor
Ulcer
Weak
Weakness
Ask:
3e. 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
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
b. When did the accident happen?
Enter month and year: mark one box
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]
Kind of injury ________
If accident happened before 3 months, ask:
b. What part of the body is affected now? How is his -- affected?
[option for 3 entires]
Present effects ________
6a.Was a car, truck, bus, or other motor vehicle involved in the accident in any way?
2[] No -go to 7
b. Was more than one vehicle involved?
[] No
c. Was it (either one) moving at the time?
2[] No
7. Where did the accident happen?
2[] At home (adjacent premises)
3[] Street and highway (includes roadway)
4[] Farm
5[] Industrial place (includes premises)
6[] School (includes premises)
7[] Place of recreation and sports, except at school
8[] Other -specify the place where accident happened
8. Was -- at work or at his job or business when the accident happened?
2[] No
3[] Under 17 at time of accident
4[] While in Armed services
Washington use:
Question number:
[] 9
[] 10
[] 11
[] 12
[] 13
[] 14
[] H
[] C
[] DV
[] HC
[] OT
Cond:
[] 0
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 9
No of this condition
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 9
Mark one:
[] Acute
Total conditions:
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 9
[] No
Required hospitalization
[] No
Other Acc.
[] Oth
IC or Dum code
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 9
Person days of disability:
B.D
T.L
[p.54]
Refer respondent to two-week calendar for questions 9-14.
Ask question 9a for all conditions.
9a. During the past two weeks, 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 question 9b.
10. How many days did he have to cut down during that two-week period?
11. During that two-week period, how many days did his ... keep him in bed all or most of the day?
[] 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?
[] 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?
[] 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?
6[] Before 3 months- go to 15
b. Did he first notice it during the past two weeks or before that time?
3[] Before 2 weeks- go to AA
c. Which week , last week or the week before?
1[] Week before (go to AA)
Ask questions 15 only of condition was first noticed "Before 3 months"
15.Did -- first notice it during the past 12 months or before that time?
5[] Before 12 months
Ask for person 6 years old or over for who 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 16b, 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 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?
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. 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?
2. Emphysema?
3. Hardening of the arteries?
4. High blood pressure?
5. Cancer?
6. Heart trouble?
7. Stroke?
8. Rheumatic fever?
9. Arthritis or rheumatism?
10. Mental illness?
11. Diabetes?
12. Epilepsy?
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. 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 is blank 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?
b. Were any of these --days during last week or the week before?
[] No - go to BB
c. How many?
BB: Is this the last condition for this person?
[] 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.
[] 2
[] 3
[] 4- go to 29
If 1, 2, or 3 marked in 18 ask; If 4 marked in 18 go to 20.
19. Is this because of any of the conditions you have told me about?
20. Please look at the blue card, card H. Which one of those statements fits -- best in terms of health?
[] 2
[] 3
[] 4
[] 5
[] 6-stop
If 1, 2, 3, 4, or 5 marked in 20, ask; if 6 marked, omit 21 and go to next person.
21. Is this because of any of the conditions you have told me about?