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[p.58]

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

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 person
s in this household now on full-- time active duty with the Armed
Forces of the United States?

[] Y
Col(s). ____ (Delete)
[] N


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 Doctor Visits and Hospitalizations.

Doctor ____ (NP)
Hosp. ____ (NP)

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

Reference dates
2--week period ____, ____.
Dentist and Doctor visit probe ____
Hospital probe ____
Q. no. ____
Condition ____


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 [] Nev. married
4 [] Divorced
5 [] Separated


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 any illness or injury?

[] Y (5b)
[] 00 N (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)
00 [] None (5f)


d. During those 2 weeks, how many days did illness or injury keep -- from school?
SL days ____ (5e)
00 [] None (5f)


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?
Days ____ (5f)
00 [] 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?
1 [] Y (5g)
2 [] N (6)


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?
Days ____ (6a)
00 [] None (6)

[p. 59]

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? ____

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?

[] Y (6c)
[] N (NP)

c. What condition? ____

Enter conditions in item C. Reask 6b.

7a. During the past 2 weeks, did anyone in the family, that is you, your --, etc. have any (other) accidents or injuries?

[] Y (7b and c)
[] N (8)

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

[] Accident or injury

c. What was the injury?

Injury ____

d. Did anyone have any other accidents or injuries during that period?

[] Y (7b and c)
[] N

For each person with "Accident or injury," ask:

e. As a result of the accident, did -- see a doctor or did he cut down on the things he usually does?

[] Y (Enter injury in item C)
[] N


8a. During the past 2 weeks, did anyone in the family, (that is you, your --, etc.) go to a dentist?

[] Y (8b and c)
[] N (10)


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?
[] Y (Reask 8b and c)
[] N


If "Dental visit," ask:

d. During the past 2 weeks, how many times did -- go to dentist?
No. of dental visits ____ (NP)


For each dental visit, ask:

9a. What did -- have done (the last time, the time before, etc.)? (Mark all that apply for each visit)


[Columns 1-3 for different people omitted here]


[] Cleaning teeth
[] Exam. (X-ray)
[] Fillings
[] Extractions or other surgery
[] Straightening (Orthodontia)
[] Treatment for gums
[] Denture work
[] Other (Describe) ________


b. Anything else?
[] Cleaning teeth
[] Exam. (X-ray)
[] Fillings
[] Extractions or other surgery
[] Straightening (Orthodontia)
[] Treatment for gums
[] Denture work
[] Other (Describe) ________


Do not ask for children 1 yr. old and under.

10a. 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.)

Number of visits ____


b. ABOUT how long has it been since -- LAST went to a dentist?
1 [] 2-week dental visit
2 [] Past 2 weeks not reported (Q.'s 8 and 9)
3 [] 2 weeks - 6 mos.
4 [] Over 6 - 12 mos.
5 [] 1 year
6 [] 2 - 4 years
7 [] 5+ years
8 [] Never


11a. Is there anyone in the family who has lost ALL of his teeth?

[] Y
[] N (12)


b. Who is this? Anyone else? ____
[] No teeth


For each person with "No teeth," ask:

c. Does -- have false teeth?

[] Y
[] N (NP)


d. Does -- have an upper plate, a lower plate, or both?

[] Upper
[] Lower
[] Both


e. Does -- usually wear

[the upper
the lower
both]

plate(s) while eating?
[] Y
[] N


f. Does -- usually wear

[the upper
the lower
both plate(s)]

when not eating?
[] Y
[] N


g. Does -- need new false teeth?

[] Y (NP)
[] N


h. Do the ones he has need refitting?

[] Y
[] N

[p. 60]


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

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


(Besides those visits)
13a. 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?
[] Y (13b and c)
[] N (14)


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


c. Anyone else?
[] Y (13b and c)
[] N


If "Doctor visit," ask:
d. How many times did -- visit the doctor during that period?
Number of visits ____ (NP)


14a. During that period, did anyone in the family get any medical advice from a doctor over the telephone?
[] Y (14b and c)
[] N (15)


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


c. Any calls about anyone else?
[] Y (14b and c)
[] N


If "Phone call," ask:
d. How many telephone calls were made to get medical advice about --?
Number of calls ____ (NP)


Fill item C, (DOCTOR), from Q.'s 12-14 for all persons. Ask Q. 15a for each person with visits in DOCTOR box.

15a. 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?
[] Y
[] N (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?
[] Y (15c)
[] N (NP)


e. During the past 2 weeks was -- sick because of her pregnancy?
[] Y
[] N (NP)


f. What was the matter? ____
Anything else?

Enter condition in item C (NP)

16a. 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.)

000 [] Only when in hospital
Number of visits ____


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

1 [] 2 week doctor visit
2 [] Past 2 weeks not reported (Q.'s 12 and 15)
3 [] 2 weeks - 6 months
4 [] Over 6 - 12 months
5 [] 1 year
6 [] 2 - 4 years
7 [] 5+ years
8 [] Never

17a. Does anyone in the family (that is you, your --, etc.) stay IN BED all or most of the time because of health?

[] Y
[] N (18)

b. Who is this? ____

1 [] Stays in bed

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

[] Y (Reask b and c)
[] N

18 a. (Besides --) Does anyone stay IN THE HOUSE all or most of the time because of health?

[] Y
[] N (19)

b. Who is this? ____

2 [] Stay in the house

c. Does anyone else stay in the house?

[] Y (Reask b and c)
[] N

19a. (Besides --) Does anyone need the help of ANOTHER PERSON in getting around inside or outside the house?

[] Y
[] N (20)

b. Who is this? ____

3 [] Need help getting around

c. Does anyone else need the help of another person in getting around?

[] Y (Reask b and c)
[] N

20a. (Besides --) Does anyone in the family need the help of a SPECIAL AID, such as a cane or wheelchair in getting around inside or outside the house.

[] Y
[] N (21)

b. Who is this? ____

4 [] Needs help getting around

c. Does anyone else need the help of a special aid in getting around?

[] Y (Reask b and c)
[] N

[p. 61]

21a. (Besides --) Does anyone have trouble getting around freely by himself?

[] Y
[] N (22)

b. Who is this? ____

5 [] Has trouble getting around freely

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

[] Y (Reask b and c)
[] N

Ask for each person with a limitation reported in questions 17-21.
22a. About how long has --

[had to stay in bed because of his health?
had to stay in the house because of his health?
needed help getting around inside or outside the house?
had trouble getting around freely by himself?]
000 [] Less than 1 month
1 ____ Mos.
2 ____ Yrs.

b. What (other) condition causes this? ____

If "old age" only, ask: Is this caused by any specific conditon?
Enter condition in item C and ask c

[] Old age only (NP)

c. Is this caused by any other condition?

[] Y (Reask b and c)
[] N

Mark box or ask:
d. Which of these conditions would you say is the MAIN cause of his limitation?

[] Only 1 condition
Enter main condition ____


Ages 17+
23a. 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 (28a)
2 [] Keeping house (28b)
3 [] Retired, health (27)
4 [] Retired, other (27)
5 [] Going to school (30)
6 [] 17+ something else (27)


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
24a. What was -- doing most of the past 12 months - going to school or doing something else?
5 [] Going to school (30
7 [] 6-16 something else (29)


If "something else," ask:

b. What was -- doing?
1 [] Working (28a)
2 [] Keeping house (28b)
3 [] Retired, health (27)
4 [] Retired, other (27)
5 [] Going to school (30)
6 [] 17+ something else (27)
7 [] 6-16 something else (29)


Ages under 6
0 [] 1-5 yrs. (25)
0 [] Under 1 (26)

25a. Is -- able to take part at all in ordinary play with other children?

[] Y
1 [] N (32)


b. Is he limited in the kind of play he can do because of his health?
2 [] Y (32)
[] N


c. Is he limited in the amount of play because of his health?
2 [] Y (32)
[] N (31)


26a. Is -- limited in any way because of his health?
[] Y
3 [] N (NP)


b. In what way is he limited? ________ (32)

27a. Does -- health now keep him from working?
1 [] Y (32)
[] N


b. Is he limited in the kind of work he could do because of his health?
2 [] Y (32)
[] N


c. Is he limited in the amount of work he could do because of his health?
2 [] Y (32)
[] N


d. Is he limited in the kind or amount of other activities because of his health?
3 [] Y (32)
[] N (31)


28a. Does -- NOW have a job?
[] Y (28c)
[] N


b. In terms of health, is -- NOW able to (work - keep house) at all?
[] Y
1 [] N (32)


c. Is he limited in the kind of (work - housework) he can do because of his health?
2 [] Y (32)
[] N


d. Is he limited in the amount of (work - housework) he can do because of his health?
2 [] Y (32)
[] N


e. Is he limited in the kind or amount of other activities because of his health?
3 [] Y (32)
[] N (31)


29. In terms of health would -- be able to go to school?
[] Y
1 [] N (32)


30a. Does (would) -- have to go to a certain type of school because of his health?
2 [] Y (32)
[] N


b. Is he (would he be) limited in school attendance because of his health?
2 [] Y (32)
[] N


c. Is he limited in the kind or amount of other activities because of his health?
3 [] Y (32)
[] N (31)


31a. Is -- limited in ANY WAY because of a disability or health?
4 [] Y
5 [] N (NP)


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


32a. About how long has he

[been limited in --
been unable to --
had to go to a certain type of school?]

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

b. 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 c

[] Old age only (NP)

c. Is this limitation caused by any other condition?

[] Y (Reask b and c)
[] N

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

[] Only 1 condition
Enter main condition ____

[p. 62]

33a. Was -- a patient in a hospital at any time since (date) a year ago?

[] Y
[] N (Item C)

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

Times ____ (Item C)

34a. Was anyone in the family in a nursing home, convalescent home or similar place since (date) a year ago?

[] Y
[] N (35)

b. Who was this? ____

Circle "Y" in person's column.

[] Y

For each "Y" circled, 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:

35a. When was -- born? If on or after the hospital reference date, ask 35b.

Month ____
Day ____
Year _ _ _ _

b. Was -- born in a hospital?

If "Yes" and no hospitalizations entered in his and/or mother's column, enter "1" in 33b and item C.

If "Yes" and a hospitalization is entered for the mother and/or baby, ask 35c for each.

[] Y
[] N (NP)

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

If "No," correct entries in Q. 33 and item C for mother and/or baby.

[] Y
[] N

36a. Does anyone in the family (you, your --, etc.) NOW have -
If "Yes," ask b and c

A. Deafness in one or both ears?
[] Y
[] N
B. Any other trouble hearing with one or both ears?
[] Y
[] N
C. Tinnitus or ringing in the ears?
[] Y
[] N
D. Blindness in one or both eyes?
[] Y
[] N
E. Cataracts?
[] Y
[] N
F. Glaucoma?
[] Y
[] N

b. Who is this? ____

Enter name of condition and letter of line where reported in appropriate person's column(s) in item C.

c. Does anyone else have --?

Does anyone in the family NOW have . . . ?

If "Yes," ask b and c

G. Color blindness
[] Y
[] N
H. A detached retina or any other condition of the retina?
[] Y
[] N
I. Any other trouble seeing with one or both eyes even when wearing glasses?
[] Y
[] N
J. A cleft palate or harelip?
[] Y
[] N
K. Stammering or stuttering?
[] Y
[] N
L. Any other speech defect?
[] Y
[] N
M. A missing finger, hand, or arm, toe, foot, or leg?
[] Y
[] N
N. A missing (breast), kidney, or lung?
[] Y
[] N
O. Palsy or cerebral palsy?
[] Y
[] N
P. Paralysis of any kind?
[] Y
[] N
Q. Curvature of the spine?
[] Y
[] N
R. REPEATED trouble with back or spine?
[] Y
[] N
S. Any TROUBLE with fallen arches or flatfeet?
[] Y
[] N
T. A clubfoot?
[] Y
[] N
U. Permanent stiffness or any deformity of the back, foot, or leg?
[] Y
[] N
V. Permanent stiffness or any deformity of the fingers, hand, or arm?
[] Y
[] N
W. Mental retardation?
[] Y
[] N
X. Any condition caused by an old accident or injury? If "Yes," ask: What is the condition?
[] Y
[] N


37a. Does anyone in the family use-

1. Contact lenses?

[] Y
[] N


If "Yes," ask b and c

b. Who is this? Circle person's number
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 9
[] 10


c. Anyone else?
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 9
[] 10


2. Eyeglasses?

[] Y
[] N

[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 9
[] 10


3. A hearing aid?

[] Y
[] N

[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 9
[] 10

For "hearing aid," with no hearing problem reported, ask:

For what condition does he need this? ____
Enter condition in item C

[p. 67]


If 17 years old or over, ask:
42 a. What is the highest grade or year -- attended in school?

[] Und. 17 (NP)
00 [] None (43)


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)?
1 [] Y
2 [] N


Ask for all males 17 years or over:

43a. Did -- ever serve in the Armed Forces of the United States?

2 [] Y
1 [] N (44)


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

Vietnam Era (Aug. '64 to present) . . . VN
Korean War (June '50 - Jan. '55) . . . KW
World War II (Sept. '40 - July '47) . . . WWII
World War I (April '17 - Nov. '18) . . . WWI
Other Service (All other periods) . . . OS

1 [] VN
2 [] KW
3 [] WWII
4 [] WWI
5 [] OS
6 [] DK


44a. Did -- work at any time last week or the week before - (For females): not counting work around the house?

1 [] Y (45a)
2 [] N


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


c. Was he looking for work or on layoff from a job?
1 [] Y
2 [] N (Omit 44d)


d. Which - looking for work or on layoff from a job?
1 [] Looking
2 [] Layoff
3 [] Both


Ask for all persons with a "Yes" in 44a, b, or c.

If "Yes" in 44c only, questions 45a through 45d apply to this person's LAST full-time civilian job.

45a. 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 45d from entries in 45a-45c; if not clear, ask:

d. Class of worker
1 [] Pv't. pd.
2 [] Gov. Fed.
3 [] Gov. oth.
4 [] Own - If not a farm, ask:

Is the business incorporated?

[] Y
[] N

5 [] Non-pd.
6 [] Nev. wkd.


Please look at this card - (Show Card I)

I -- INCOME
Card I

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 - $24,999 ... Group J
$25,000 and over ... Group K


46. 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.
00 [] A
01 [] B
02 [] C
03 [] D
04 [] E
05 [] F
06 [] G
07 [] H
08 [] I
09 [] J
10 [] K