[p. 56]
CONDITION PAGE
CONDITION 1
2. When did -- last see or talk to a doctor about his ... ?
1 [] Past 2 wks. (Item C)
2 [] 2 wks. - 6 mos.
3 [] Over 6 - 12 mos.
4 [] 1 yr.
5 [] 2 - 4 yrs.
6 [] 5+ yrs.
7 [] Never
Examine "Name of condition" entry and mark
[] On Card C (Check item)
[] Neither (3a)
3a. What did the doctor say it was? -- Did he give it a medical name? ____
Do not ask for Cancer
b. What was the cause of -- ? ____
If entry in 3a or 3b includes the words:
Asthma
Attack
Condition
Cyst
Defect
Disease
Disorder
Growth
Measles
Rupture
Trouble
Tumor
Ulcer
Ask c:
c. What kind of -- is it? ____
For allergy or stroke, ask:
d. How does the allergy (stroke) affect him? ____
e. What part of the body is affected? ____
Show the following detail:
Back/spine/vertebra...upper, middle, lower
Ear or eye...one or both
Arm...one or both; shoulder, upper, elbow, lower, wrist, hand
Leg...one or both; hip, upper, knee, lower, ankle, foot
FILL QUESTIONS 4-9 FOR ALL ACCIDENTS OR INJURIES
4a. Did the accident happen during the past 2 years or before that time?
[] Before 2 years (5a)
b. When did the accident happen?
[] 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?
Kind of injury ____
If accident happened more than 3 months ago, ask:
b. What part of the body is affected now? How is his -- affected? Is he affected in any other way?
Present effects ________
6a. Was a car, truck, bus, or any other motor vehicle involved in the accident in any way?
2 [] N (7)
b. Was more than one vehicle involved?
[] N
c. Was it (either one) moving at the time?
2 [] N
7. Where did the accident happen?
2 [] At home (adjacent premises)
3 [] Street and highway (includes roadway and public sidewalk)
4 [] Farm
5 [] Industrial place (includes premises)
6 [] School (includes premises)
7 [] Place of recreation and sports, except at school
8 [] Other (Specify) ____
8. Was -- at work at his job or business when the accident happened?
2 [] N
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 both the accident and the injury. How did the accident happen?
Cause of injury ________
[p. 57]
INTERVIEWER CHECK ITEM
[] Under 6 (11)
[] First eye cond. (10)
[] Not first eye cond. (11)
2 [] N
2 [] N
11. During the past 2 weeks, did his -- cause him to cut down on the things he usually does?
2 [] N (16a)
12. During that period, how many days did he cut down for as much as a day?
Days ____
13. During that 2 week period, how many days did his -- keep him in bed all or most of the day?
Days ____
Ask if 17+ years:
14. How many days did his -- keep him form work during that 2-week period? (For females): not counting work around the house?
00 [] None (16a)
Ask if 6-16 years:
15. How many days did his -- keep him from school during that 2--week period?
00 [] None
16a. When did -- first notice his --? (Was it during the past 3 months or before that time?)
[] More than 3 mos. ago (17)
b. Did he first notice it during the past 2 weeks or before that time?
4 [] More than 2 wks. ago (AA)
c. Which week, last week or the week before?
2 [] Week before (AA)
17. Did -- first notice it during the past 12 months or before that time?
6 [] More than 12 mos. ago
AA
Continue if condition listed or reported in probe Q. 16. Otherwise, go to next condition. Do not continue for missing extremities or organs.
INTERVIEWER CHECK ITEM
[] Doctor not seen (18)
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?)
2 [] Days
3 [] Weeks
4 [] Months
5 [] Years
20. BEFORE -- talked to a doctor about his --, did he do or take anything for it?
2 [] N
21a. Does -- NOW take any medicine or treatment for his --?
2 [] N (22)
b. Was any of this medicine or treatment recommended by a doctor?
2 [] N
22. Has he ever had surgery for this condition?
2 [] N
23. Was he ever hospitalized for this condition?
2 [] N
24. During the past 12 months, about how many time has -- seen or talked to a doctor about his --? (Do not count visits while a patient in a hospital.)
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?
000 [] None
26a. How often does his -- bother him -- all of the time, often, once in a while, or never?
2 [] Often
3 [] Very little
0 [] Never (26c)
4 [] Other (Specify) ____
b. When it does bother him, is he bothered a great deal, some, or very little?
2 [] Some
3 [] Very little
4 [] Other (Specify) ____
[] All the time in 26a (NC)
c. Does -- still have his --?
[] N
d. Is this condition completely cured or is it under control?
3 [] Und. cont. (NC)
4 [] Other (Specify) ____ (NC)
e. About how long did -- have this condition before it was cured?
Months ____
Years ____