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Condition approach

1a. What is the name of the head of this household?

First name ________
Last name ________

b. What are the names of all the persons who live here? List all.

First name ________
Last name ________

c. I have listed (Read names). Is there anyone else staying here now?

[] Yes (apply household membership rules)
[] No

d. Have I missed anyone who usually lives here but is now away from home?

[] Yes (apply household membership rules)
[] No

e. Do any of the people in this household have a home anywhere else?

[] Yes (apply household membership rules)
[] No

f. Are any of the persons in this household now on full-time active duty in the armed forces?
If "Yes" delete.

[] Yes (delete)
[] No

2. How is -- related to -- (head of household)?

Relationship ________
Head ________
Age ________

3. Person number. First column should have person 01, second column person 02 etc.

Per. No. ____

4a. How old was -- on his last birthday. Write in next to "relationship" and mark/

Age ____

b. Sec. Mark without asking unless sex is not obvious from name.

[] Male
[] Female

c. Race. Mark without asking.

[] White
[] Negro
[] Other

If 17 years old or over ask:
5. Is -- now married, widowed, divorced, separated or never married?

If 17 yeas old or over ask:
16. What was -- doing of the 12 months-
(for males) working or doing something else?
(for females) keeping house, working or doing something else?

[] WK
[] KH
[] SE
[] Under 17

If "SE" marked in Q.6 and person is 45 years old or over, ask:
7. Is -- retired?

[] Yes
[] No
[] V

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?)

[] Under 19
[] At home
[] Not home
[] V

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.

8a.Was -- sick at any time last week or the week before (the 2 weeks shown on that calender)?

[] Yes
[] No

b. What was the matter? ________

c. Did -- have anything else during that 2 week period?

[] Yes
[] No

9a. Last week or the week before, did -- take any medicine or treatment for any condition (besides ....which you told me about)?

[] Yes
[] No

b. For what condition? ________

c. Did -- take any medicine for any other condition?

[] Yes
[] No

10a. Last week or the week before, did -- have any accidents or injuries?

[] Yes
[] No

b. What were they? ________

c. Did -- have any other accidents or injuries during that 2 week period?

[] Yes
[] No

11a. Did -- ever have an (any other) accident or injury that still bothers him or affects him in any way?

[] Yes
[] No

b. In what way does it bother him? Record present effects. ________

12. Open your flashcard booklet to Card A and read both sides of Card A (A-1, A-2) condition by condition; record in his column any conditions mentioned for the person.

[] Yes
[] No

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 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?

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?

13.Turn to Card B and read both sides of card B (B-1, B-2), condition by condition; record in his column any conditions mentioned for the person.

[] Yes
[] No

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. Rheumatic 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?

14a. Does -- have any other ailments, conditions, or problems with his health?

[] Yes
[] No

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-entirely
[] Responded for self-partly
Person ____ was respondent


15a. Has -- been in a hospital at any time since-- a year ago?

[] Yes
[] No

If "yes" ask:
b. How many times was -- in a hospital during that period?

Times ________

16a. Has anyone in the family been in a nursing home, convalescent home, rest home, or similar place since -- a year ago?

[] Yes
[] No

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?

Times ________

Examine ages in question 1 for babies 1 year old or under. For each child 1 year old or under, ask 17a. When was --born?
If on or after the date stamped in 15a ask 17b.

Month ____
Day ____
Year ____

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.

[] Yes
[] No

c. Is this hospitalization included in the number you gave me for --?
If "No" correct entry for mother and baby.

[] Yes
[] No

These next questions are about recent visits to or from a medical doctor.

[] None

18. During the past 2 weeks (the 2 weeks outlined in red on that calendar) how many times has -- seen a doctor either at home or at a doctor's office or clinic?

Dr. Visits ________

19a. (Besides those visits) During that 2 week period has anyone in the family been to a doctor's office or clinic for shots, X-rays, test or examinations?

[] Yes
[] No

If "Yes" ask:
b. Who was this? ________ (mark "Yes" in person's column)

c. Anyone else? ( mark "Yes" in person's column)

[] Yes
[] No

For each "Yes" marked ask:
d. How many times did -- visit the doctor?
Exclude visits made on "mass" basis.

Visits ________

20a. During that period did anyone in the family get any medical advice from a doctor over the telephone?

[] Yes
[] No

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 --?

Telephone calls to Dr. ________

Visits reported in questions 18-20 for this person. Mark here

[] Visit rep'd in Q. 18-20 (go to 28b)

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]

[] During past 2 weeks/not previously reported
[] 2 weeks -6 months
[] 7-11 months
Years ________
[] DK
[] Never

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]

[] DK
[] Never
Times ____

Ask for all persons 17 years old or over:
24a. What is the highest grade (year) -- attended in school?

[] Under 17
Elementary: _______
High school: ________
College: ________

b. Did -- finish the - grade (year)?

[] Yes
[] No

Ask for all persons 17 years old or over:
25a. Did -work at any time last week or the week before? For females add: Not counting work around the house?

[] Yes (go to 26a)
[] No (ask both a and c)

b. Even though -- did not work during those 2 weeks, does he have a job or business?

[] Yes
[] No

c. Was he looking for work or on layoff from a job?

[] Yes-ask d
[] No-omit d

d. Which - looking for work or on layoff from a job?

[] Looking
[] Layoff
[] Both

If "Yes" in 25c only, questions 26a through 26d apply to this person's last full time civilian job.
Ask for all persons with a "Yes" in 25a, 25b and 25c.
26a. Who does (did) -- work first?

Employer ________

b. What kind of business or industry is this?

Industry ________

c. What kind of work is (was) - doing?

Occupation ________

Fill 26d from entries in 26a-26e; if not clear ask:
d. Class of worker

[] Pvt. paid
[] Gov't-Fed
[] Gov't- other
[] Own
[] Non-paid
[] Never worked

Ask for all males 17 years old or over:

27a. Did -- ever serve in the armed forces of the united states?

[] Yes
[] No- go to 28

b. Was any of his service during a war?

[] Yes- stop
[] No
[] DK

If "No" or "DK" in 27b ask:
c. Was any of his service between June 27 1950 and January 31 1955?

[] Yes-stop
[] No
[] DK

If "No" or "DK" in 27c ask:
d. Was any of his service after January 31, 1955?

[] Yes
[] No
[] DK

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.

[] A
[] B
[] C
[] D
[] E
[] F
[] G
[] H
[] I
[] J

Washington use:

Transcribe codes for item R (respondent)

0[] Self-entirely
1[] Self-partly
2[] Spouse
3[] Mother
4[] Father
5[] Other female family member
6[] Other male family member
7[] Other

Respondent ________

Age of respondent ________

Family relationship

[] PI
[] SI
[] FF
[] Head 1
[] Head 2
[] Wife
[] Child
[] Other relative

Education of head

[] Und 17
[] None


[] A
[] B
[] C
[] D
[] E
[] F
[] G
[] H
[] J
[] K
[] L
[] M


[] N
[] P
[] Q
[] R
[] S
[] T
[] U
[] V
[] W
[] X
[] Y
[] Z