c

[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 --?

Examine "Name of condition" entry in item 1 and mark

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:

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:

Ask:
e. What part of the body is affected?

WASHINGTON USE

FILL QUESTIONS 4-8 FOR ALL ACCIDENTS OR INJURIES

4a. Did the accident happen during the past 2 years or before that time?

b. When did the accident happen?
Enter month and year: Mark box.

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?

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?

6a. Was a car, truck, bus, or any other motor vehicle involved in the accident in any way?

b. Was more than one vehicle involved?

c. Was it (either one) moving at the time?

7. Where did the accident happen?

8. Was -- at work at his job or business when the accident happened?

[p. 53]

Mark for all conditions
9.

9a. Can -- see well enough to read ordinary newspaper print with glasses?

10. During the past two weeks, did his ... cause him to cut down on things he usually does?

b. Did he have to cut down for as much as a day?

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?

13. Ask if 6-16 years: How many days did his ... keep him from school during that 2-week period?

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?

15a. When did he first notice his ...? -- Was it during the past 3 months or before that time?

b. Did he first notice it during the past two weeks or before that time?

c. Which week, last week or the week before?

16. Did -- first notice it during the past 12 months or before that time?

AA
Continue if
[reported in probe Q. 16
reported in probe Q.25
on Card D]
Otherwise, go to next condition.

INTERVIEWER CHECK ITEM

18. After -- first noticed something was wrong, about how long was it before he talked to a doctor about it? (Estimate is acceptable)

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 ...?

b. Was any of this medicine or treatment recommended by a doctor?

21. Has he ever had surgery for this condition?

22. Has he ever hospitalized for this condition?

23. During the past 12 months, about how many times has -- seen or talked to a doctor about his ...?

24. About how many days during the past 12 months has this condition kept him in bed all or most of the day?

25a. How often does his ... bother him -- all of the time, some of the time, or never? (Mark one box)

b. When it does bother him, is he bothered a great deal, some, or very little? (Mark one box)

c. Does -- still have his ...?

d. Is this condition completely cured or is it under control?

e. About how long did -- have this condition before it was cured?