p

[p. 50]

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

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?

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

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

* 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?

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

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

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

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

[MK Note: End 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

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 next few questions refer to the past 2 weeks, the 2 weeks outlined in red on that calendar, beginning Monday, (date), and ending this past Sunday, (date).

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

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?


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.


d. During those 2 weeks, how many days did illness or injury keep -- from school?


IF BOTH bed days AND work or school loss days, ask:
e. On how many of these -- days lost from
[work
school]
did -- stay in bed all or most of the day?


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?


g. (Again, not counting the 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?


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

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

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

c. What condition?

[p. 51]

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

b. Who was this? ____
Mark "Dental visit," box in person's column.


c. During the past 2 weeks, did anyone else in the family go to a dentist?


For each person with "Dental visit," ask:
During the past 2 weeks, how many times did -- go to dentist?


If "Dental visit," ask:
8 a. For what (other) condition did -- see the dentist? ____ (8b)
Enter condition in 8a.


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


For each condition in 8a, ask:
c. During the past 2 weeks was -- sick because of his [condition]?

Do not ask for children 1 yr. old and under.
9 a. During the past 12 months, (that is, since (date) a year ago,) about how many visits did -- make to a dentist? (Include the -- visits you already told me about.)

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

[p. 52]

10. During the past 2 weeks (the 2 weeks outlined in red on that calendar) how many times did -- see a medical doctor?

(Besides those visits)
11 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?


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


c. Anyone else?


If "Doctor visit," ask:
d. How many times did -- visit the doctor during that period?


12 a. During that period, did anyone in the family get any medical advice from a doctor over the telephone?


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


c. Any calls about anyone else?


If "Phone call," ask:
d. How many telephone calls were made to get medical advice about --?


Fill item C, (DR. VISITS), from Q.'s 10-12 for all persons. Ask Q. 13a for each person with visits in DR. VISIT box.
13 a. For what condition did -- see or talk to a doctor during the past 2 weeks?


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


c. What condition? ____

Enter condition in item C and ask 13d.
d. During that period, did -- see or talk to a doctor about any other condition?


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


f. What was the matter? ____
Anything else? ____

14 a. During the past 2 weeks did anyone in the family have any (other) accidents or injuries?

b. Who was this? ____
Mark "Accident or injury" box in person's column.

c. Did anyone else have any accidents or injuries during that period?

If "Accident or injury," ask:
d. As a result of the accident, did -- see a doctor or did he cut down on the things he usually does?

e. What was the injury? ____

15 a. During the past 12 months, (that is, since (date) a year ago,) about how many times did -- see or talk to a medical doctor? (Do not count doctors seen while a patient in a hospital.) (Include the -- visits you already told me about.)

b. ABOUT how long has it been since -- last saw or talked to a medical doctor?

[p. 53]

16 a. Now I'm going to read a list of conditions;

During the past 12 months, did anyone in the family (you, your --, etc.) have any of these conditions:

If "Yes," ask b and c
b. Who was this? ____
Enter name of condition and letter of line where reported in appropriate column(s) in item C.

c. During the past 12 months did anyone else have [conditions a-e above]?

Do not circle "Y" and make no entry in item C for cold; flu; red, sore, or strep throat; or "virus" reported in answer to question 16.

During the past 12 months did anyone in the family have ... ? If "Yes," ask b and c

*If reported in question 16 only, ask:
1. How many times did -- have [condition] in the past 12 months? ____
If 2+, enter in item C.

If only 1 time, ask:
2. How long did it last? -- If 1 month or longer, enter in item C. If less than 1 month, do not record.

If tonsils or adenoids removed during the past 12 months, enter in item C.

Do not circle "Y" and make no entry in item C for cold; flu; red, sore, or strep throat; or "virus" reported in answer to question 16.

[p. 54]

Ages 17+
17 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?

If "something else," ask:
b. What was -- doing? ____

If 45+ years and not "working," "keeping house," or "going to school," ask:
c. Is -- retired? ____

d. If "Retired," ask: Did he retire because of his health?

Ages 6-16
18a. What was -- doing most of the past 12 months - going to school or doing something else?

If "something else," ask:
b. What was -- doing? ____

Ages under 6


19a. Is -- able to take part at all in ordinary play with other children?


b. Is he limited in the kind of play he can do because of his health?


c. Is he limited in the amount of play because of his health?


20a. Is -- limited in any way because of his health?


b. In what way is he limited? ____ (26)

21a. Does -- health now keep him from working?


b. Is he limited in the kind of work he could do because of his health?


c. Is he limited in the amount of work he could do because of his health?


d. Is he limited in the kind or amount of other activities because of his health?


22 a. Does -- now have a job?


b. In terms of health, is -- able to (work -- keep house) at all?


c. Is he limited in the kind of (work -- housework) he can do because of his health?


d. Is he limited in the amount of (work -- housework) he can do because of his health?


e. Is he limited in the kind or amount of other activities because of his health?


23. In terms of health would -- be able to go to school?


24 a. Does (would) -- have to go to a certain type of school because of his health?


b. Is he (would he be) limited in school attendance because of his health?


c. Is he limited in the kind or amount of other activities because of his health?


25 a. Is -- limited in ANY WAY because of a disability or health?


b. In what way is he limited? Record limitation, not condition ____

26. About how long has he
been limited in --
been unable to --
had to go to a certain type of school?

27a. 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

b. Is this limitation caused by any other condition?

If 2+ conditions reported in Q. 27a, ask:

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

[p. 55]

28 a. Was -- a patient in a hospital at any time since (date) a year ago?

b. How many times was -- in a hospital since (date) a year ago?
Times ____ (Item C)

29 a. Was anyone in the family in a nursing home, convalescent home or similar place since (date) a year ago?

b. Who was this? ____
Circle "Y" in person's column.

For each "Y" circled, ask:

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

For each child 1 year old or under, ask:

30a. When was -- born? If on or after the hospital reference date, ask 30b.

b. Was -- born in a hospital?

If "Yes" and no hospitalizations entered in his and/or mother's column, enter "1" in 28 and item C.

If "Yes" and a hospitalization is entered for the mother and/or baby, ask 30c for each.

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

If "No," correct entries in Q. 28 and item C for mother and/or baby.

R

Q.'s 5-30

For persons 19 years old or over, show who responded for (or was present during the asking of) Q.'s 5-30. If persons responded for self, show whether entirely or partly. For persons under 19 show who responded for them.

[p. 60]

These next questions are about health insurance.

IF 65 OR OVER, ASK:
31a. Is -- covered by that part of Social Security Medicare which pays for hospital bills?

b. Is -- covered by that part of Medicare which pays for doctor's bills, that is, the Medicare plan for which he or some agency must pay $4.00 a month?

For each person with "DK" in Q. 31a or b, ask:

32. May I please see -- (and --) Social Security Medicare card(s) to determine type of coverage?

(Transcribe the information from the card or mark the "Card not seen" box.)

We are interested in all kinds of health insurance plans except those which pay only for accidents.

(Not counting Medicare)

33a. Is anyone in the family covered by hospital insurance, that is, a health insurance plan which pays any part of a hospital bill?

b. What is the name of the plan? (Record in Table H.I.) ____

c. Is anyone in the family covered by any other hospital insurance plan?

d. Is anyone in the family covered by a health insurance plan which pays any part of a doctor's or surgeon's bill?

e. What is the name of the plan? (Record in Table H.I.; complete Table H.I. for each plan.) ____

If 17 years old or over, ask:

34 a. What is the highest grade or year -- attended in school?

b. Did -- finish the -- grade (year)?

Ask for all males 17 years or over:

35a. Did -- ever serve in the Armed Forces of the United States?

b. When did he serve? Circle code in descending order of priority. Thus if person served in Vietnam and in Korea, circle VN.

[p. 61]

[Page 61 appears to be a response sheet for the questions asked on page 60]

31a.

b.

32.

TABLE H.I.

Name of Plan (1)

[Rows] A-E

Which members of the family are covered by (name of plan)? Circle column numbers.

Is anyone else in the family covered under this policy? (2)

Was this insurance plan obtained through an employer, union, or place of work? (3)

Does [plan] pay any part of a hospital bill? (4)

Does [plan] pay any part of a surgeon's bill? (5)

Does this plan pay any part of a doctor's bill for office visits or home calls? (6)

Does this plan pay any part of a doctor's bill for office visits or home calls after a certain amount has been paid by the family? (7)

[Column 2-6]
34 a.

b.

35 a.

b.

[p. 62]

Ask for all persons 17 years old or over

36 a. Did -- work at any time last week or the week before - (For females): not counting work around the house?

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


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


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

If "Yes" in 36c only, questions 37a through 37d apply to this person's LAST full-time civilian job.

Ask for all persons with a "Yes" in 36a, b, or c.


37a. Who does (did) -- work for?

b. What kind of business or industry is this?

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

Fill 37d from entries in 37a-37c; if not clear, ask:

d. Class of worker

Please look at this card - (Show Card I)
I

Income

38. 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.

[p. 63]

SMOKING PAGE

Complete Smoking Page for each person 17+ years of age.

Person No. ____

Now, I have a few questions about smoking:

1. Has -- smoked at least 100 cigarettes during his life?

2. Does -- smoke cigarettes now?

3. How long has it been since -- smoked cigarettes fairly regularly?

4. For years 1-10 ask: Which of these statements (Hand Card S) were reasons -- decided to stop smoking cigarettes? Please give me the number of statements that applies. Circle number.

CARD S
Which of the following were reasons you decided to stop smoking cigarettes?

Any other reason? ____

If more than one circled, ask: What was the main reason -- decided to stop smoking cigarettes?

Enter number of the main reason _ _ (9)

5. On the average, about how many cigarettes a day does -- smoke?

6. What size cigarette does -- usually smoke: regular size, king size, or extra long?

7. Does -- usually smoke filter or nonfilter cigarettes?

8. On the average, about how many cigarettes a day was -- smoking 12 months ago?

9. During the period when -- was smoking the most, about how many cigarettes a day did he usually smoke?

10. About how old was -- when he first started smoking cigarettes

11. Has -- smoked at least 50 cigars during his entire life?

12. Does -- smoke cigars now?

13. About how many cigars a day does -- usually smoke?

If less than 1 per day:

14. About how long has it been since -- smoked 3 or more cigars a week?
No. of completed years ____ (17)

15. What size cigars does -- usually smoke: full-sized, the small cigars sometimes called cigarillos, or the very small cigars about the size of a cigarette?

16. Twelve months ago, about how many cigars a day did -- usually smoke?

If less than 1 per day:

17. Has -- smoked at least 3 packages of pipe tobacco during his entire life?

18. Does -- smoke a pipe now?

19. About how many pipefuls of tobacco a day does -- usually smoke?

If less than 1 per day:

20. About how long has it been since -- smoked 3 or more pipefuls a week?
No. of completed years ____ (22)

21. Twelve months ago, about how many pipefuls a day did -- usually smoke?

22. Does -- presently use any other form of tobacco, such as snuff or chewing tobacco?

Fill Interviewer Check Item

INTERVIEWER CHECK ITEM

Respondent for Q's. 1-22

[p. 64]

Exposure to all kinds of X-rays is a matter of particular interest to the Public Health Service, and I have some questions about X-rays and fluoroscopes.

39a. Did anyone in the family have his teeth X-rayed during the past 3 months, that is from (date) through last Sunday?

b. Who was this? ____

Mark "Dental" in person's column.

c. Anyone else? ____

40a. During the past 3 months did anyone in the family have a chest X-ray?

b. Who was this? ____

Mark "Chest" in person's column

c. Anyone else? ____

41a. Did -- have any (other) kind of X-ray at all during the past 3 months?

If "Yes," ask:

b. What part of the body was X-rayed? Enter part of body in person's column.

c. Did -- have any other X-ray during the past 3 months?

42a. Did -- have a fluoroscope during the past 3 months?

b. What part of the body was it for? Enter part of body in person's column

c. Did -- have any other fluoroscope during the past 3 months?

43a. During those 3 months, did anyone in the family have any X-rays for the TREATMENT of a condition?

b. Who was this? Mark "Treatment" in person's column

c. Anyone else? ____

d. What part of the body was treated? Enter part of body in person's column

For each person with X-rays, fluoroscopes, or treatment in 39-43, ask:

44. What is --'s height and weight?

Weight (Lbs.) ____

Table R
Fill one line for each "PART OF BODY" entry from Questions 39--43

Line number
[3 identical lines given for respondents. Only 1 line shown here]

a. Col. No. of person ____

b. Question No. ____

c. Part of body ____

d. How many different times did -- have his . . . X-rayed during the past 3 months?

e. For dental X-rays, ask: Where did he have the X-rays taken - at a dentist's office or some other place?

For X-rays other than dental, ask: Where did he have the X-rays taken - at a doctor's office, a hospital, or some other place?

(If "Some other place," determine place.)

If more than one place given, ask for each place: How many X-rays were taken at the (hospital, doctor's office, etc.)?

f. If more than one time at any one place, ask: Were all these X-rays taken at the same (dentist's office, doctor's office, etc.)? (f)

g1. What is the name and address of the (dentist, doctor, hospital, etc.) where the X-rays were taken?

For X-rays taken at hospitals, clinics, or similar places, ALSO enter the name of the doctor who took the X-rays.

For X-rays taken at mobile units, enter:

"Mobile unit" on name line; location of unit at time of X-ray on address line; and name and address of sponsoring organization and date of X-ray in footnote.

Verify name and address in telephone directory.

Check "Verified" box. If unable to verify, give reason in a footnote.
Enter telephone number if available

Ask after completing Table R for all related persons with X-rays.

45. May we contact the (doctor, dentist, hospital, etc.) you have mentioned to obtain additional information about the X-rays?

(Present form for signature)

Will you please sign this form?

[p. 65]

[MK Note: Page 65 appears to be a response sheet for questions from page 64]

39b.

40b.

41 a, c.

b. Part of body ____

42 a, c.

b. Part of body ____

43b.

d. Part of body ____

44.

Weight (Lbs.) ____

Table R - Continued

Use for additional name and address (g2)

DO NOT ASK FOR DENTAL X-RAYS

What was this X-ray for - a checkup, an examination, or for a treatment? (h)

How many of these -- X-rays were for treatment? (i)

Ask for each person with 2 or more lines in Table R after all X-rays have been recorded for a person. DO NOT include dental X-rays in number of visits.

(Not counting his dental X-rays) Altogether he had -- X-rays during the past 3 months. How many separate visits did he make to have these -- X-rays? (k)