Last name ________
b. What are the names of all the persons who live here? List all.
Last name ________
c. I have listed (Read names). Is there anyone else staying here now?
d. Have I missed anyone who usually lives here but is now away from home?
e. Do any of the people in this household have a home anywhere else?
f. Are any of the persons in this household now on full-time active duty in the armed forces?
If "Yes" delete.
b. Sec. Mark without asking unless sex is not obvious from name.
c. Race. Mark without asking.
 Under 17
If related person 19 years old or over are listed in addition to the resp, say:
We would like to have all adults who are at home take part in the interview, is your-- etc, at home now? (would you please ask--etc to join us?)
 At home
 Not home
This survey covers all kinds of illnesses, these first questions refer to last week and the week before, that is, the 2 week period outlined in red on this calendar. Hand calendar to respondent and ask 8a.
b. What was the matter? ________
c. Did -- have anything else during that 2 week period?
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. ________
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?
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?
3. Hardening of the arteries?
4. High blood pressure?
6. Heart trouble?
8. Rheumatic fever?
9. Arthritis or rheumatism?
10. Mental illness?
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?
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 Q.8-11. 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
If "yes" ask:
b. How many times was -- in a hospital during that period?
If "Yes" ask:
b. Who? ________
For each person reported in 16b ask:
c. How many times was -- in a nursing home or similar place during that period?
b. Was -- born in a hospital? If "Yes" and no hospitalizations entered in his column, enter "1" in 15. If "Yes" and a hospitalization is reported for the mother and baby ask 17c.
c. Is this hospitalization included in the number you gave me for --?
If "No" correct entry for mother and baby.
These next questions are about recent visits to or from a medical doctor.
If "Yes" ask:
b. Who was this? ________ (mark "Yes" in person's column)
c. Anyone else? ( mark "Yes" in person's column)
For each "Yes" marked ask:
d. How many times did -- visit the doctor?
Exclude visits made on "mass" basis.
If "Yes" ask:
b. Who was the phone call about? (mark "Yes" in person's column) ________
c. Any calls about anyone else? (Mark "Yes" in person's column) ________
For each "Yes" marked, ask:
d. How many telephone calls were made to get medical advice about --?
If no visits reported in questions 18-20 ask:
21a. About how long has it been since -- saw or talked to a doctor?
Estimate is acceptable. If less than 1 year, mark appropriate circle; if more than 1 year, mark number of whole years.
[Years choices were not clear in the survey]
 2 weeks -6 months
 7-11 months
If the last visit was within the past 12 months, ask:
b. In total, about how many times has --seen or talked to a doctor during the past 12 months?
[times choices were not clear in the survey]
High school: ________
b. Did -- finish the - grade (year)?
 No (ask both a and c)
b. Even though -- did not work during those 2 weeks, does he have a job or business?
c. Was he looking for work or on layoff from a job?
 No-omit d
d. Which - looking for work or on layoff from a job?
 Gov't- other
 Never worked
 No- go to 28
28. Which of these income groups represents your total combined family income for the past 12 months-that is, yours, your--'s etc? Show card I. 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 in each related person's column.
5 Other female family member
6 Other male family member
Age of respondent ________
 Head 1
 Head 2
 Other relative