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[p. 52]


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 --?

1 [] Yes
2 [] No

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

[] Accident or injury (4)
[] 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 ...?

[] Accident or injury (4)

If the entry in 3a or 3b includes the words:


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)
Blood clot
Cramps (except menstrual)
Varicose veins

e. What part of the body is affected?

Ear or eye ... one or both
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


Question No.

Condition diag. code

Number of this condition
1[] Chronic
2[] Acute

Total conditions

Accident - 1st injury
1[] Yes
2[] No

Req hospital
1[] Yes
2[] No

Other accident
1[] Adv. Reac.
2[] Other

Cause of limitation
0[] NA
1[] Yes (MC)
2[] Yes (Not MC)
3[] No


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

[] During past 2 years (4b)
[] 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?

Part(s) of body ____
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?

Part(s) of body ____
Present effects _____

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

1 [] Yes (6b)
2 [] No (7)

b. Was more than one vehicle involved?

[] Yes
[] No

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

1 [] Yes
2 [] No

7. Where did the accident happen?

1 [] At home (inside house)
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?

1 [] Yes
2 [] No
3 [] While in Armed Services
4 [] Under 17 at time of accident

[p. 53]

Mark for all conditions

[] Not an eye cond. (10a)
[] First eye cond. (9a)
[] Under 6 (10a)
[] Not first eye cond. (10a)

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

[] Yes
[] No

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

[] Yes
[] No (15a)

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

[] Yes
[] No (15a)

11. How many days did he have to cut down during that 2-week period?

___ Days

12. During that 2-week period, how many days did his ... keep in bed all or most of the day?

Days ____
00 [] None

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

Days ____ (15a)
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?

Days ____
00 [] None

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

[] During 3 mos. (15b)
[] More than 3 mos. ago (16)

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

[] Past 2 weeks (15c)
4[] More than 2 wks. ago (AA)

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

1[] Last week (AA)
2[] Wk before (AA)

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

5[] 3-12 months
6[] More than 12 mos. ago

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


[] "Yes" in question 2 (18)
[] "No" in question 2 (17)
17. During the past 12 months what did -- do or take for his ...? Anything else? Write in

________ (25)

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

0[] Discovered by doctor (20)
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 ...?

1[] Yes
2[] No (21)

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

1[] Yes
2[] No

21. Has he ever had surgery for this condition?

1[] Yes
2[] No

22. Has he ever hospitalized for this condition?

1[] Yes
2[] No

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

Times ____
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?

Days ____
000[] None

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

1[] All the time (25b)
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)

1 [] Great deal (NC)
2 [] Some (NC)
3 [] Very little (NC)
4 [] Other (Specify) ____ (NC)

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

1[] Yes (Next condition)
[] No (25d)

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

2[] Cured (25e)
3[] Und. cont. (Next cond)
4[] Other (Specify) ____ (Next cond)

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

[] 0 Less than one month
____ Months
____ Years