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[p. 48]

1 a. What is the name of the head of this household? Enter name in first column.

First Name ____
Last Name ____

b. What are the names of all other persons who live here? ________
List all persons who live here.

c. I have listed (Read names.) Is there anyone else staying here now, such as friends, relatives, or roomers?

[] Yes*
[] No

d. Have I missed anyone who USUALLY lives here but is now away from home?

[] Yes*
[] No

e. Do any of the people in this household have a home anywhere else?

[] Yes*
[] No

* Apply household membership rules.

If any adult males listed, ask:

f. Are any of the persons in this household now on full time active duty with the Armed Forces of the United States?

[] Yes
Col(s) ____ (Delete)
[] No


2. How is -- related to -- (Head of Household)?

Relationship ____

HEAD


3. How old was -- on his last birthday? (Enter Age and circle Race and Sex) ____

Race

[] 1 W
[] 2 N
[] 3 OT


Sex

[] 1 M
[] 2 F


Age ____

C
1. Record the number of Hospitalizations, and Doctor Visits.

Hosp. ____ (NP)
[] None (NP)

Dr. visits ____ (NP)
[] None (NP)

2. Record each condition in the person's column, with the question number(s) where it was reported.

Q. no. ____
Condition ____

[End of Section C]


If 17 years old or over, ask:

4. Is -- now married, widowed, divorced, separated, or never married? Mark one box for each
person

0 [] Under 17
1 [] Married
2 [] Widowed
3 [] Never married
4 [] Divorced
5 [] Separated

H

If related persons 19 years old or over are listed in addition to the respondent, say:

We would like to have all adults who are at home take part in the interview.

Is your --, your --, etc., at home now?

If other eligible respondents are at home, ask: Would you please ask --, --, etc., to join us?

0 [] Under 19
1 [] At home
2 [] Not at home

[End of Section H]



This survey is being conducted to collect information on the Nation's health. I will ask about visits to doctors and dentists, illness in the family, and other health related items. (HAND CALENDAR)

The first few questions refer to the past 2 weeks, that is, the 2 weeks in red on that calendar, beginning Monday, ____, and ending this past Sunday, ____.

5. a. During those 2 weeks, did -- stay in bed because of an illness or injury?

[] Yes (5b)
[] No


(If age: 17+ (5c), 6-16 (5d), Under 6 (5f))

b. During that 2-week period, how many days did -- stay in bed all or most of the day?
Days ____

(If age:17+ (5c), 6-16 (5d),Under 6 (5f))


c. During those 2 weeks, how many days did illness or injury keep -- from work? (For females): not counting work around the house.

WL days ____ (5e)
[] None (5f)


d. During those two weeks, how many days did illness keep -- from school?
SL days ____ (5e)
[] None (5f)


If BOTH bed days AND work or school days, ask:

e. On how many of these -- days lost from work/ school did -- stay in bed all or most of the day?
Days ____ (5f)
[] None (5f)


f. (NOT COUNTING the day(s) in bed
lost from work
lost from school: )

Were there any (other) days during the past 2 weeks that -- cut down on the things he usually does because of illness or injury?

[] Yes (5g)
[] No (6)


g. (Again, not counting day(s)
in bed
lost from work
lost from school)

During that period, how many days did he cut down for as much as a day?
Days ____ (6a)
[] None (6)

If 1+ days in Q. 5, ask 6; otherwise go to next person.

6 a. What condition caused -- to
stay in bed
miss work
miss school
cut down
during the past 2 weeks?

Enter condition in item C. ____ Ask 6b.

b. Did any other condition cause him to
stay in bed
miss work
miss school
cut down
during that period?

[] Yes (6c)
[] No (NP)

c. What condition? ____
Enter conditions in item C. Reask 6b.

[p. 49]


7 a. During the past 2 weeks, did anyone in the family, (that is you, your --, etc.) go to a dentist?

[] Yes (7b and c)
[] No (9)


b. Who was this? ____

Mark "Dental visit," box in person's column.
[] Dental visit


c. During the past 2 weeks, did anyone else in the family go to a dentist?
[] Yes (Reask 7b and c)
[] No

For each person with "Dental visit," ask:

d. During the past 2 weeks, how many times did -- go to dentist?

No. of dental visits ____ (NP)

If "Dental visit," ask:

8 a. For what (other) condition did -- see the dentist? ____ (8b)
Enter condition in 8a.

[] Exam. or cleaning (8b)

b. Did -- see the dentist for any other specific condition?

[] Yes (8a)
[] No other (8c)
[] No specific (NP)

For each condition in 8a, ask:

c. During the past 2 weeks was -- sick because of his --?

[] Yes (Enter condition in item C) (NP or 8c)
[] No (NP or 8c)


INTERVIEWER CHECK ITEM

1 [] 2 week dental visit (9b)
2 [] No dental visit (9a)


9 a. ABOUT how long has it been since -- went to a dentist?

Estimate is acceptable. If less than 1 year, mark appropriate box.
2 [] Past 2 weeks not reported (Q.'s 7 and 8)
3 [] 2 weeks - 6 months
4 [] Over 6 - 12 months
Years ____ (NP)
0 [] Never (NP)


b. During the past 12 months, about how many times did -- go to a dentist?
Number of visits ____ (NP)

10 a. Was anyone in the family a patient in a hospital during the past 2 weeks?

[] Yes (10b and c)
[] No (12)

b. Who was this? -Mark "In hospital" box in person's column.

[] In hospital (item C)

c. During the past 2 weeks, was anyone else a patient in a hospital?

[] Yes (Reask 10b and c)
[] No

If "In hospital," ask:

11 a. For what condition was -- in the hospital? ____

Enter condition in item C

b. While -- was in the hospital did he talk to a doctor about any other condition?

[] Yes
[] No (NP)

c. What condition? ____

Enter condition in item C. Reask 11b.


12. During the past 2 weeks (the 2 weeks outlined in red on that calendar) how many times did -- see a medical doctor? (Do not count the doctors he saw while in the hospital.)

[] None (NP)
Number of visits ____ (NP)


(Beside those visits)
13. a. During that 2-week period did anyone in the family go to a doctor's office or clinic for shots, X-rays, tests, or examinations?
[] Yes (13b and c)
[] No (14)


b. Who was this? -Mark "Doctor visit" box in person's column.
[] Doctor visit


c. Anyone else?
[] Yes (13b and c)
[] No (13d)


If "Doctor visit," ask:

d. How many times did -- visit the doctor during that period?
Number of visits ____ (NP)


14 a. During that period, did anyone in the family get any medical advice from a doctor over the telephone?
[] Yes (14b and c)
[] No (15)


b. Who was the phone call about? -Mark "Phone call" box in person's column.
[] Phone call


c. Any calls about anyone else?
[] Yes (14b and c)
[] No (14d)


d. How many telephone calls were made to get medical advice about --?
Number of calls ____ (NP)

[p. 50]

Fill item C, (Dr. visits), from Q.'s 12-14 for all persons.

Ask Q. 15a for each person with visits in Dr. visit box.

15 a. For what condition did -- see or talk to a doctor during the past 2 weeks?

[] Condition (item C THEN 15d)
[] Pregnancy (15e)
[] No condition

b. Did -- see or talk to a doctor about any specific condition?

[] Yes
[] No (NP)

c. What condition? ____

Enter condition in item C and ask 15d

d. During that period, did -- see or talk to a doctor about any other condition?

[] Yes (15c)
[] No (NP)

e. During the past 2 weeks was -- sick because of her pregnancy?

[] Yes
[] No (NP)

f. What was the matter? -Anything else?
Enter condition in item C (NP)


INTERVIEWER CHECK ITEM

1 [] Doctor visits in Q.'s 12-14 (16b)
2 [] 2-week hospital stay and no doctor visits (16b)
[] No visit reported (16a)


16 a. ABOUT how long has it been since -- saw or talked to a medical doctor?
3 [] Past 2 weeks not reported (Q.'s 12 and 15)
4 [] 2 weeks - 6 months
5 [] Over 6 - 12 months
Years ____ (NP)
0 [] Never (NP)

b. During the past 12 months, about how many times did -- see or talk to a medical doctor, not counting doctors seen while a patient in a hospital?

[] Only when in hospital
Number of visits ____ (NP)

17. INTERVIEWER: READ CARDS A and B
A1

17. Now I'm going to read a list of conditions. Does anyone in the family (you, your --, etc) HAVE any of these conditions...

Missing fingers, hand or arm- toes, foot or leg?
Permanent stiffness or any deformity of the foot, leg, fingers, arm or back?
Paralysis of any kind?

If "Yes" ask:
Who is this?

Does anyone else have [list conditions]?

A2
17. DURING THE PAST 12 MONTHS did anyone in the family have...

Arthritis of any kind or Rheumatism?
Gout?
Lumbago?
Osteomyelitis? [os-tee-oh-my-un-lite-iss]
A bone cyst or bone spur?
Any other disease of the bone or cartilage?
Trick knees?
A slipped or ruptured disc?
Curvature of the spine?
Repeated trouble with neck, back or spine?
Buxsitis or synovitis? (sin-uh-vite-iss)
Any disease of the muscles or tendons?

If "Yes," ask:
Who was this?

During the past 12 months, did anyone else have [list conditions]

A3
17. DURING THE PAST 12 MONTHS, did anyone in the family have...

A tumor, cyst or growth of the skin?
Eczema or psoriasis? (so-rye-uh-sis)
Trouble with dry or itching skin?
Trouble with acne?
A skin ulcer?
Any kind of skin allergy?
Dermititis or any other skin trouble?
Trouble with fallen arches, flatfeet or clubfoot?
Trouble with ingrown toenails or fingernails?
Trouble with bunions, corns or calluses?
A disease of the hair or scalp?
Any disease of the lymph or sweat glands?

If "Yes," ask:
Who was this?

During the past 12 months, did anyone else have [list conditions]



B
Exclude persons who have arthritis or other "arthritis" conditions.

17. (Besides --) During the past 12 months, did anyone (else) in the family have any of the following
AA. Any stiffness in the joints when first getting out of bed in the morning?
BB. Pain in the joints when they are moved?
CC. Swelling in any of the joints, except in the ankles or feet?
DD. Any pain or soreness in the joints when they are touched or pressed on?


If "Yes," ask: What was the cause of this?

Record letters and cause in item C-2.

Interviewer information

Other "arthritis" conditions
1. Lupus (atythematosus)
2. Scleroderma
3. Dermatomyositis
4. Polyarteritis
5. Periarteritis
6. psoriatic arthritis
7. Rheumatism
8. Gout

Enter name of condition and "17" in item C in appropriate person's column.


Ages 17+

18 a. What was -- doing most of the past 12 months --
(For males): working or doing something else?
(For females): keeping house, working or doing something else?

1 [] Working (NP-23)
2 [] Keeping house (NP-23)
3 [] Retired (NP-22)
4 [] Going to school (NP-25)
5 [] 17+ something else (NP-22)
6 [] 6-16 something else (NP-24)
0 [] 1-5 yrs. (NP-20)
0 [] Under 1 (NP-21)


If "something else," ask:

b. What was -- doing?
1 [] Working (NP-23)
2 [] Keeping house (NP-23)
3 [] Retired (NP-22)
4 [] Going to school (NP-25)
5 [] 17+ something else (NP-22)
6 [] 6-16 something else (NP-24)
0 [] 1-5 yrs. (NP-20)
0 [] Under 1 (NP-21)


If 45+ years and not "working," "keeping house," or "going to school, ask:

c. Is -- retired?

Ages 6-16

19 a. What was -- doing most of the past 12 months - going to school or doing something
else?
1 [] Working (NP-23)
2 [] Keeping house (NP-23)
3 [] Retired (NP-22)
4 [] Going to school (NP-25)
5 [] 17+ something else (NP-22)
6 [] 6-16 something else (NP-24)
0 [] 1-5 yrs. (NP-20)
0 [] Under 1 (NP-21)


If "something else," ask:

b. What was -- doing? ____
1 [] Working (NP-23)
2 [] Keeping house (NP-23)
3 [] Retired (NP-22)
4 [] Going to school (NP-25)
5 [] 17+ something else (NP-22)
6 [] 6-16 something else (NP-24)
0 [] 1-5 yrs. (NP-20)
0 [] Under 1 (NP-21)


Ages under 6

20 a. Is -- able to take part at all in ordinary play with other children?

[] Yes
1 [] No (27)


b. Is he limited in the kind of play he can do because of his health?
2 [] Yes (27)
[] No


c. Is he limited in the amount of play because of his health?
2 [] Yes (27)
[] No (26)


21 a. Is -- limited in any way because of his health?
[] Yes
5 [] No (NP)


b. In what way is he limited? ________ (27)

22 a. Does -- health keep him from working?
1 [] Yes (27)
[] No


b. Is he limited in the kind of work he could do because of his health?
2 [] Yes (27)
[] No


c. Is he limited in the amount of work he could do because of his health?
2 [] Yes (27)
[] No


d. Is he limited in the kind or amount of other activities because of his health?
3 [] Yes (27)
[] No (26)


23 a. In terms of health, is -- able to (work - keep house) at all?
[] Yes
1 [] No (27)


b. Is he limited in the kind of (work - housework) he can do because of his health?
2 [] Yes (27)
[] No


c. Is he limited in the amount of (work - housework) he can do because of his health?
2 [] Yes (27)
[] No


d. Is he limited in the kind or amount of other activities because of his health?
3 [] Yes (27)
[] No (26)


24. In terms of health would -- be able to go to school?
[] Yes
1 [] No (27)


25 a. Does (would) -- have to go to a certain type of school because of his health?
2 [] Yes (27)
[] No


b. Is he (would he be) limited in school attendance because of his health?
2 [] Yes (27)
[] No


c. Is he limited in the kind or amount of other activities because of his health?
3 [] Yes (27)
[] No (26)


26 a. Is -- limited in ANY WAY because of a disability or health?
4 [] Yes
5 [] No (NP)


b. In what way is he limited?
Record verbatim response ________

[p. 51]


27. About how long has he

been limited in ...
been unable to ...
had to go to a certain type of school?

[] Less than 1 month
Mos. ____
Yrs. ____

28 a. What (other) condition causes this limitation?

If "old age" only, ask: Is this limitation caused by any specific condition?

Enter condition in item C and ask b
[] Old age only (NP)

b. Is this limitation caused by any other condition?

[] Yes (Reask a and b)
[] No

If 2+ conditions reported in Q. 28a, ask:

c. Which of these conditions would you say is the MAIN cause of his limitation?

[] Only 1 condition (NP)
Enter main condition ____ (NP)

29 a. Was -- a patient in a hospital at any time since a year ago?

[] Yes (29b)
[] No (item C)

b. How many times was -- in a hospital since a year ago?

Times ____ (item C)

30 a. Was anyone in the family in a nursing home, convalescent home or similar place since
a year ago?

[] Yes
[] No (31)

b. Who was this? ____
Mark "Yes" in person column.

[] Yes

For each "yes" marked, ask:

c. During that period, how many times was -- in a nursing home or similar place?

Times ____ (item C)

For each child 1 year old or under, ask:

31a. When was -- born?
If on or after the date stamped on 29, ask 31b.

Month ____
Day _ _
Year _ _ _ _

b. Was -- born in a hospital?

[] Yes
[] No (NP)

If "Yes" and no hospitalizations entered in his and/or mother's column, enter "1" in 29 and item C.
If "Yes" and a hospitalization is entered for the mother and/or baby, ask 31c for each.

c. Is this hospitalization included in the number you gave me for --?

If "No," correct entries in Q. 29 and item C for mother and/or baby.

[] Yes
[] No

32a. Does anyone in the family (that is you, your --, etc.) stay in bed all or most of the time because of health?

[] Yes
[] No (33)

b. Who is this? ____

1 [] Stays in bed

c. Does anyone else in the family stay in bed?

[] Yes (Reask b)
[] No

33a. (Besides --) Does anyone stay in the house all or most of the time because of health?

[] Yes
[] No (34)

b. Who is this? ____

2 [] Stays in the house

c. Does anyone else stay in the house?

[] Yes (Reask b)
[] No

34a. (Besides --) Does anyone need help getting around inside or outside the house either from another person or from a special aid, such as a cane or wheelchair?

[] Yes
[] No (35)

b. Who is this? ____

3 [] Needs help getting around

c. Does anyone else need the help of another person or special aid?

[] Yes (Reask b)
[] No

35 a. (Besides --) Does anyone have trouble in getting around freely by himself?

[] Yes
[] No (36)

b. Who is this? ____

4 [] Has trouble getting around freely

c. Does anyone else have trouble in getting around feely by himself?

[] Yes (Reask b)
[] No

Ask for each person with a limitation reported in questions 32-35:

36a. About how long has --

had to remain in bed?
had to stay in the house?
needed help in getting around inside or outside the house?
had trouble in getting around freely by himself?
[] Less than 1 month
Months ____
Years ____

b. What (other) condition causes this?

Enter condition in item C and ask c
[] Old age only (NP)

If "old age" only, ask: Is this caused by any specific condition? ____

c. Is this caused by any other condition?

[] Yes (Reask b and c)
[] No

If 2+ conditions reported in Q. 36b, ask:

d. Which of these conditions would you say is the MAIN cause of his limitation?

[] Only 1 condition (NP)
Enter main condition ____ (NP)

[p. 52]

37 a. Does anyone in the family now use any of the following special aids-

1. An artificial arm?
[] Yes
[] No
2. An artificial leg?
[] Yes
[] No
3. A brace of any kind?
[] Yes
[] No
4. Crutches?
[] Yes
[] No
5. A cane or walking stick?
[] Yes
[] No
6. Special shoes?
[] Yes
[] No
7. A wheel chair?
[] Yes
[] No
8. A walker?
[] Yes
[] No
9. Any other kind of aid for getting around?
[] Yes
[] No

If "Yes," specify: ____

b. Who is this? Enter in Table SA

[Table SA shows blanks for 3 potential people. Only 1 space shown here.]

Table SA
a. Person No. ____
b. Type of aid ____
c. If 1-6 in (b), ASK: Does he use one or two ____ (at a time)?
[] 1
[] 2
Other ____
d. If 3-9 in (b), ASK: For what condition does he need this ____? (item C) ____

c. Anyone else?

R
Q.'s 5-37


For persons 19 years old or over, show who responded for (or was present during the asking of) Q.'s 5-37. If persons responded for self, show whether entirely or partly. For persons under 19 show who responded for them. If eligible respondent is "at home" but did not respond for self, enter the reason in a footnote.

1 [] Responded for self-entirely
2 [] Responded for self-partly
Person _ _ was resp.

[p. 56]


If 17 years old or over, ask:

38 a. What is the highest grad -- attended in school?

00 [] None (39a)
[] Und. 17 (NP)

Elem

[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8

High

[] 9
[] 10
[] 11
[] 12

College

[] 1
[] 2
[] 3
[] 4
[] 5+


b. Did -- finish the -- grade (year)?
[] Yes
[] No


Ask for all males 17 years or over:

39a. Did -- ever serve in the Armed Forces of the United States?

[] Yes
1 [] No (40)


b. Was any of his service during a war?
3 [] Yes (40)
[] No
[] DK


c. Was any of his service between June 27, 1950, and January 31, 1955?
[] Yes (40)
[] No
[] DK


d. Was any of his service after January 31 1955?
[] Yes
[] No (40)
[] DK


e. Was any of his service after August 4, 1964?
[] Yes
[] No
[] DK


Ask for all persons 17 years old or over:
40a. Did -- work at any time last week or the week before - (For females): not counting work around the house?

1 [] Yes (41a)
2 [] No

b. Even though -- did not work during these 2 weeks, does he have a job or business?

1 [] Yes
2 [] No

c. Was he looking for work or on layoff from a job?

[] Yes
[] No (Omit 40d)

d. Which -- looking for work or on layoff from a job?

1 [] Looking
2 [] Layoff
3 [] Both


If "Yes" in 40c only, questions 41a through 41d apply to this person's LAST full-time civilian job.

Ask for all persons with a "Yes" in 40a, b, or c.

41 a. Who does (did) -- work for?
Employer ____


b. What kind of business or industry is this?
Industry ____

c. What kind of work is (was) -- doing?
Occupation ____

Fill 41d from entries 41a-41c, if not clear, ask:

d. Class of worker

1 [] Pv't. pd.
2 [] Gov. Fed.
3 [] Gov. oth.
4 [] Own
5 [] Non-pd.
6 [] Nev. wkd.


Please look at this card-
I

Income

Under $1,000 (including loss) ... Group A
$1,000 - $1,999 ... Group B
$2,000 - $2,999 ... Group C
$3,000 - $3,999 ... Group D
$4,000 - $4,999 ... Group E
$5,000 - $5,999 ... Group F
$6,000 - $6,999 ... Group G
$7,000 - $9,999 ... Group H
$10,000 - $14,999 ... Group I
$15,000 and over ... Group J


42. Which of these income groups represents your total combined family income for the past 12 months -- that is yours, your --'s, etc.? Include income from all sources such as wages, salaries, social security, or retirement benefits, help from relatives, rent from property, and so forth.
Group
0 [] A* Under $1,000 (including loss)
1 [] B* $1,000 -- $1,999
2 [] C* $2,000 -- $2,999
3 [] D* $3,000 -- $3,999
4 [] E* $4,000 -- $4,999
5 [] F $5,000 -- $5,999
6 [] G $6,000 -- $6,999
7 [] H $7,000 -- $9,999
8 [] I $10,000 -- $14,999
9 [] J $15,000 and over


*For each family with A through E checked in question 42, ask:
43 a. During the past 12 months, has anyone in the family (you, your --, etc.) received any public assistance, relief, or welfare money from the State or local governments?

[] Yes (43b)
[] No (check item)


b. At present, are you or any member of your family receiving any of this aid?
[] Yes (43c)
[] No (check item)


43c. Which family members receive this aid? Anyone else?
[] Receives aid


d. What kind of aid does -- receive?
_____

SUPPLEMENT CHECK ITEM

Fill in Arthritis Supplement for each person for whom one or more of the following conditions has been reported:

1. Arthritis
2. Lupus erythematosus
3. Scleroderma
4. Dermatomyositis
5. Polyateritis
6. Periarteritis
7. Psoriatic arthritis
8. Rheumatism
9. Gout

Number of Arthritis Supplements required ____

[] None (Fill all required supplements)