[p. 52]
CONDITION PAGE 1
Enter person number and "name of condition" and ask question 2.
1. Person number _____
Name of condition ____
Ask for all conditions
2. Did -- ever at any time talk to a doctor about his --?
2 [] No
Examine "Name of condition" entry in item 1 and mark
[] On Card C (9)
[] Neither (3a)
If "Doctor talked to," ask:
3a. What did the doctor say it was? Did he give it a medical name?
If "Doctor not talked to," record adequate description of condition or illness.
Do not ask for Cancer.
b. What was the cause of ...?
If the entry in 3a or 3b includes the words:
Cyst
Growth
Measles
Rupture
Tumor
Ulcer
"Ailment"
"Attack"
"Condition"
"Defect"
"Disease"
"Disorder"
"Trouble"
Ask:
c. What kind of ... is it?
For allergy or stroke, ask:
d. How does the allergy (stroke) affect him?
For any injury 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
Varicose veins
Weak
Weakness
Ask:
e. What part of the body is affected?
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
WASHINGTON USE
Condition diag. code
Number of this condition
2[] Acute
Total conditions
Accident - 1st injury
2[] No
Req hospital
2[] No
Other accident
2[] Other
Cause of limitation
1[] Yes (MC)
2[] Yes (Not MC)
3[] No
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 (5a)
b. When did the accident happen?
Enter month and year: Mark 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?
Kind of injury ____
If accident happened BEFORE 3 months, ask:
b. What part of the body is affected now? How is his -- affected? Is he affected in any other way?
Present effects _____
6a. Was a car, truck, bus, or any other motor vehicle involved in the accident in any way?
2 [] No (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 school
8 [] Other (Specify the place where accident happened) ____
8. Was -- at work at his job or business when the accident happened?
2 [] No
3 [] While in Armed Services
4 [] Under 17 at time of accident
[p. 53]
[] First eye cond. (9a)
[] Under 6 (10a)
[] Not first eye cond. (10a)
9a. Can -- see well enough to read ordinary newspaper print with glasses?
[] No
10. During the past two weeks, did his ... cause him to cut down on things he usually does?
[] No (15a)
b. Did he have to cut down for as much as a day?
[] No (15a)
11. How many days did he have to cut down during that 2-week period?
12. During that 2-week period, how many days did his ... keep in bed all or most of the day?
00 [] None
13. Ask if 6-16 years: How many days did his ... keep him from school during that 2-week period?
00 [] None (15a)
14. Ask if 17+ years: How many days did ... keep him from work during that 2-week period?
(For females): not counting work around the house?
00 [] None
15a. When did he first notice his ...? -- Was it during the past 3 months or before that time?
[] More than 3 mos. ago (16)
b. Did he first notice it during the past two weeks or before that time?
4[] More than 2 wks. ago (AA)
c. Which week, last week or the week before?
2[] Wk before (AA)
16. Did -- first notice it during the past 12 months or before that time?
6[] More than 12 mos. ago
AA
Continue if
[reported in probe Q. 16
reported in probe Q.25
on Card D]
Otherwise, go to next condition.
INTERVIEWER CHECK ITEM
[] "No" in question 2 (17)
18. After -- first noticed something was wrong, about how long was it before he talked to a doctor about it? (Estimate is acceptable)
2__ Days
3__ Weeks
4__ Months
5__ Years
19. Before -- talked to a doctor about his .., what did he do or take for his condition? Anything else? Write in
20a. Does -- NOW take any medicine or treatment for his ...?
2[] No (21)
b. Was any of this medicine or treatment recommended by a doctor?
2[] No
21. Has he ever had surgery for this condition?
2[] No
22. Has he ever hospitalized for this condition?
2[] No
23. During the past 12 months, about how many times has -- seen or talked to a doctor about his ...?
000[] None
24. About how many days during the past 12 months has this condition kept him in bed all or most of the day?
000[] None
25a. How often does his ... bother him -- all of the time, some of the time, or never? (Mark one box)
2[] Some time (25b)
0[] Never (25c)
3[] Other (Specify) ____ (26b)
b. When it does bother him, is he bothered a great deal, some, or very little? (Mark one box)
2 [] Some (NC)
3 [] Very little (NC)
4 [] Other (Specify) ____ (NC)
c. Does -- still have his ...?
[] No (25d)
d. Is this condition completely cured or is it under control?
3[] Und. cont. (Next cond)
4[] Other (Specify) ____ (Next cond)
e. About how long did -- have this condition before it was cured?
____ Months
____ Years