c

[p. 52]

CONDITION PAGE 1

Enter person number and "Name of condition."

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 or Arthritis

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? (Specify) ____

[p. 53]

FILL QUESTIONS 4-9 FOR ALL ACCIDENTS OR INJURIES

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

b. When did the accident happen?

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?

Ask for all accidents that happened during the past 2 weeks except those involving motor vehicles.

9. We are interested in the objects that caused this accident and injury. How did the accident happen? ________

Mark for all conditions

10.

10a. Can -- see well enough to read ordinary newspaper print with glasses?

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

12. During that period, how many days did he cut down for as much as a day?

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

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?

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

16 a. 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?

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

AA
Continue if reported in probe Q. 17, 28 or 36 or Card A, otherwise, go to next condition. Do not continue for missing extremities

INTERVIEWER CHECK ITEM

19. After -- first noticed something was wrong, about how long was it before he talked to a doctor about it? (Probe: Was it a matter of days, weeks, or months?)

20. Before -- talked to a doctor about his --, what did he do or take for his condition? Anything else? Write in ________

21a. Does -- NOW take any medicine or treatment for his --?

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

22. Has he ever had surgery for this condition?

23. Was he ever hospitalized for this condition?

24. During the past 12 months, about how many times has -- seen or talked to a doctor about his
--? (Do not count visits while a patient in a hospital.)

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

26 a. How often does his -- bother him -- all of the time, often, once in a while, or never?

b. When it does bother him, is he bothered a great deal, some, or very little?

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?