p

[p.58]

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

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 person
s 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

Age ____

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.

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 any illness or injury?

b. During that 2-week period, how many days did -- stay in bed all or most of the day?

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)

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)

During that period, how many days did he cut down for as much as a day?

[p. 59]

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

6a. What condition caused -- to

during the past 2 weeks? ____

Enter condition in item C. Ask 6b.

b. Did any other condition cause him to

during that period?

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?

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

c. What was the injury?

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

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?

8a. 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?


If "Dental visit," ask:

d. During the past 2 weeks, how many times did -- go to dentist?

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]

b. Anything else?

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.)

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

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

b. Who is this? Anyone else? ____

For each person with "No teeth," ask:

c. Does -- have false teeth?

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

e. Does -- usually wear

plate(s) while eating?

f. Does -- usually wear

when not eating?

g. Does -- need new false teeth?

h. Do the ones he has need refitting?

[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?

(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?


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?


14a. 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, (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?


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


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?


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


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.)

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

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

b. Who is this? ____

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

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

b. Who is this? ____

c. Does anyone else stay in the house?

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

b. Who is this? ____

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

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.

b. Who is this? ____

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

[p. 61]

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

b. Who is this? ____

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

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

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

c. Is this caused by any other condition?

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

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?

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?


If "something else," ask:

b. What was -- doing?

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?

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?


26a. Is -- limited in any way because of his health?


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

27a. 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?


28a. Does -- NOW have a job?


b. In terms of health, is -- NOW 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?


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


30a. 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?


31a. Is -- limited in ANY WAY because of a disability or health?


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

32a. About how long has he

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

c. Is this limitation caused by any other condition?

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

[p. 62]

33a. 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?

34a. 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:

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

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.

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.

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

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

37a. Does anyone in the family use-

If "Yes," ask b and c

b. Who is this? Circle person's number


c. Anyone else?

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?

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

Ask for all males 17 years or over:

43a. 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.

44a. 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?

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?

b. What kind of business or industry is this?

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

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

d. Class of worker

Please look at this card - (Show Card I)

I -- INCOME
Card I

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.