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....?
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? ________
Do not ask for cancer.
3b. What was the cause of ....?
 Accident or injury - go to 4
If the entry in 3a or 3b includes the words:
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)
Cramps (except menstrual)
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
 Not an eye condition
 Not first eye condition
 Under 6
For person 6 years old or over
3f. Can -- see well enough to read ordinary newspaper print with glasses?
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
 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?
c. Was it (either one) moving at the time?
7. Where did the accident happen?
2 At home (adjacent premises)
3 Street and highway (includes roadway)
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?
3 While in Armed services
4 Under 17 at time of accident
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?
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?
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?
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
AA: continue if this condition started "Before 3 months" or is in this list:
Cirrhosis of the liver
Hernia, any kind
Rupture, any kind
Ulcer, any kind
STOP for all other conditions and for accidents, injuries, and pregnancies.
 "Doctor not seen" in question 2-Ask question 16
 "Doctor seen" in question 2-ask question 17
Ask if "doctor not seen" in question2.
16. During the past 12 months what did--do or take for his...? ________
Ask if "Doctor see" in question 2.
17. Before -- first talked to a doctor about his--what did he do or take for this condition?
18. Before --first talked to a doctor about this condition, what kind of symptoms did he have?
 None -go to 20
19. About how long did -- have any of these symptoms before he talked to a doctor about them?
20. Does --take any medicine or treatment which a doctor advised for his..?
21. Has -- ever had surgery for....?
22. Was --ever hospitalized for....?
23. During the past 12 months about how many times has -- seen or talked to a doctor for this condition?
Ask for all conditions past AA
24. About how many days during the past 12 months has his...kept him in bed all or most of the day?
25a. Does his ... bother him-- a great deal, some, very little, or not at all?
 Some - go to next condition
 Very little - go to next condition
 Not at all- ask b
 Other : For other answers: ________
If "not bothered at all" ask b, otherwise go to next condition.
b. Does -- still have this condition?
 No- ask c
c. Is this condition completely cured or is it under control?
2 Und control
d. About how long did -- have this condition?