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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 --?

1 [] Yes
2 [] No

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

[] Accident or injury (4)
[] On Card C (10)
[] 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 or Arthritis

b. What was the cause of --? ____

[] Accident or injury (4)

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

Arthritis
Asthma
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:

Abscess
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? (Specify) ____

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

[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?

[] During the past 2 years (4b)
[] Before 2 years (5a)

b. When did the accident happen?

[] 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
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

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.

[] Not an eye cond. (11)
[] First eye cond. (10a)
[] Under 6 (11)
[] Not first eye cond. (11)

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

[] Yes
[] No

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

[] Yes
[] No (16a)

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

Days ____
00 [] None (16a)

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

Days ____
00 [] None

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 ____ (16a)
00 [] None (16a)

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

Days ____
00 [] None

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

[] During 3 mos.
[] More than 3 mos. ago (17)

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

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

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

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

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

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

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

[] Doctor seen (19)
[] Doctor not seen (18)
18. During the past 12 months what did -- do or take for his --? Anything else? Write in ________ (25)

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?)

0 [] Discovered by doctor (21)
2 [] Days
3 [] Weeks
4 [] Months
5 [] Years

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

0 [] Nothing

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

1 [] Yes
2 [] No (22)

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

1 [] Yes
2 [] No

22. Has he ever had surgery for this condition?

1 [] Yes
2 [] No

23. Was he ever hospitalized for this condition?

1 [] Yes
2 [] No

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.)

Times ____
000 [] None

25. 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

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

1 [] All the time
2 [] Often
3 [] Once in a while
0 [] Never (26c)
4 [] Other (Specify) ____ (26b)

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

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 (26d)

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

2 [] Cured (26e)
3 [] Und. cont. (NC)
4 [] Other (Specify) ____ (NC)

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

[] 0 Less than one month
Months ____
Years ____