The items below show the exact content and wording of the basic questionnaire used in the nationwide household survey of the US national Health Survey. The actual questionnaire is designed for a household as a unit and includes additional spaces for reports on more than one person, condition, accident, or hospitalization. Such spaces are omitted in this illustration.
Notice: All information which would permit identification of the individual will be held in strict confidence, will be used only by persons engaged in and for the purposes of the survey, and will not be disclosed or released to others for any purposes.
BUREAU OF THE CENSUS
ACTING AS COLLECTING AGENT FOR THE
US PUBLIC HEALTH SERVICE
US HEALTH INTERVIEW SURVEY
ZIP code ________
For area segments enter:
Line No. ________
b. Mailing address: if different from 2a
Zip Code ________
2c. Special dwelling plan-Name and Sample number
Sample no. ____
 After 4-1-60 -go to Q10c, ask if required and end interview
b. SEG type (circle)
 Usual residence elsewhere
 Armed Forces
 Other -specify ________
 After 4-1-60
 Oth ________
 Other unit
b.  Ask
Are there any occupied or vacant living quarters besides your own on this floor?
c.  Ask
Is there any other building on this property for people to live in- either occupied or vacant?
1 All other - go to 13
 Rent- Ask 12b
 Rent free-Ask 12a
 No-ask d
 No-ask 12d
 No (4)
 No (5)
 No-leave thank you letter and depart
b. Was this interview observed?
b. Interviewer number ________
Total number of conditions in this HH ________
Total number of hospitalizations in this HH ________
Total number of Doctor visits in this HH ________
Total number of persons in this HH ________
Total persons requiring home care in this household ________