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xray
[p.86]

X-RAY

Exposure to all kinds of X-rays is a matter of particular interest to the public health services 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?

[]Y
[] N(40)

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

[] Dental
[] Other (specify) Part of body ________

c. Anyone else? _______

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

[] Y
[] N (41)

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

[] Chest
[] Other (specify) Part of body ________

c. Anyone else? ________

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

[] Y
[] N (NP)

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

Part of body ________

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

[] Y
[] N (NP)

42a. Did -- have a fluoroscope during the past 3 months? If "Yes" ask:

[] Y
[] N (NP)

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

Part of body ________

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

[] Y
[] N (NP)

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

[] Y
[] N (43d, 44)

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

[] Treatment

c. Anyone else? ________

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

Part of body ________

For each person with X-rays, Fluoroscopes, or treatment in 39-43,ask:
44. What is --'s height and weight?

Height
Feet____
Inches ____
Weight (Lba) _____

Table R
Fill one line for each "part of body" entry from Questions 39-43

[upto three entries for each set : a-k]

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?

Times ____

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)?

[] Dentist's office. Times ____
[] Doctor's office. Times ____
[] Hospital. Times ____
[] Other (specify)____. Times ____

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)

[] Y
[] N (g1, g2)

g. What is the name and address of the (dentist, doctor, hospital, etc) where the X-rays were taken?
For X-rays taken at hospital, 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-rays 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 the telephone number if available.

Name and title ________
Address ________
City ________
State ________
Zip code ________
[] Verified
[] Telephone no

Ask after completing Table R for all related persons with X-rays.
g2. Use for additional name and address.

Name and title ________
Address ________
City ________
State ________
Zip code ________
[] Verified
[] Telephone no. ________
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?

[] Signed
[] Not signed (enter reason)

Table R - continued.
DO NOT ASK FOR DENTAL X-RAYS
h. What was this X-ray for -a checkup, an examination, or for a treatment?

[] Checkup/examination (k)
[] Treatment (k)
[] Both (i)

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

Number ________

k. 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?

Number of visits ________