c
[p. 56]

CONDITION PAGE

CONDITION 1

1. Person number ____

2. When did -- last see or talk to a doctor about his ... ?

Examine "Name of condition" entry and mark

If "Doctor not talked to," record adequate description of condition. If "Doctor talked to," ask:

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:

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:

FILL QUESTIONS 4-9 FOR ALL ACCIDENTS OR INJURIES

4a. 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 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?

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 both the accident and the injury. How did the accident happen?

[p. 57]

INTERVIEWER CHECK ITEM

10. Can -- see well enough to read ordinary newspaper print with glasses in his

11. During the past 2 weeks, did his -- cause him to cut down on the 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?

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?

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

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

b. Did he first notice it during the past 2 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 condition listed or reported in probe Q. 16. Otherwise, go to next condition. Do not continue for missing extremities or organs.

INTERVIEWER CHECK ITEM

18. During the past 12 months what did -- do or take for his -- ? (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?)

20. BEFORE -- talked to a doctor about his --, did he do or take anything for it?

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 time 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?

26a. 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?