[p. 65]
CONDITION 1
2. When did -- last see or talk to a doctor about his --?
1 [] Past 2 wks. (Item C)
2 [] 2 wks. - 6 mos. (Item C)
3 [] Over 6 - 12 mos. (Item C)
4 [] 1 yr.
5 [] 2 - 4 yrs.
6 [] 5+ yrs.
7 [] Never
A1
Examine "Name of condition" entry and mark
[] On Card C (4)
[] Neither (3a)
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:
Asthma
Attack
Condition
Cyst
Defect
Disease
Disorder
Growth
Measles
Rupture
Trouble
Tumor
Ulcer
Ask c:
c. What kind of -- is it? ____
For allergy or stroke, ask:
d. How does the allergy (stroke) affect him? ________
For an impairment or any of the following entries:
Ache (except for headache)
Bleeding
Blood clot
Boil
Cancer
Cramps (except menstrual)
Cyst
Damage
Growth
Hemorrhage
Infection
Inflammation
Neuralgia
Neuritis
Pain
Palsy
Paralysis
Rupture
Sore
Soreness
Tumor
Ulcer
Varicose veins
Weak
Weakness
Ask e:
e. What part of the body is affected? ____
Show the following detail:
Back/spine/vertebra...upper, middle, lower
Ear or eye...one or both
Arm...one or both; shoulder, upper, elbow, lower, wrist, hand
Leg...one or both; hip, upper, knee, lower, ankle, foot
4. During the past 2 weeks, did his -- cause him to cut down on the things he usually does?
2 [] N (9)
5. During that period, how many days did he cut down for as much as a day?
00 [] None (9)
6. During that 2--week period, how many days did his -- keep him in bed all or most of the day?
00 [] None
Ask if 17+ years:
7. How many days did his -- keep him from work during that 2-week period? (For females): not counting work around the house?
[] None (9)
Ask if 6-16 years:
8. How many days did his -- keep him from school during that 2-week period?
00 [] None
9. When did -- first notice his --?
2 [] Week before
3 [] Past 2 weeks - DK which
4 [] 2 weeks - 3 months
5 [] 3 - 12 months
6 [] More than 12 mos. ago
(Was it during the past 12 months or before that time?)
(Was it during the past 3 months or before that time?)
(Was it during the past 2 weeks or before that time?)
A2
[] First eye condition (under 6) (AA)
[] First eye cond. (6+ yrs.) (10)
[] Not first eye cond. (AA)
2 [] N
2 [] N
AA
Continue for conditions listed or reported in Probe question 38 or 39; otherwise, go to A3. For missing extremities or organs, go to A3.
[] Doctor not seen (11)
[End section AA]
11. During the past 12 months what did -- do or take for his --?
________ (18)
12. 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?)
2 ____ Days
3 ____ Weeks
4 ____ Months
5 ____ Years
13. BEFORE -- talked to a doctor about his --, did he do or take anything for it?
2 [] N
14a. Does -- NOW take any medicine or treatment for his --?
2 [] N
b. Was any of this medicine or treatment recommended by a doctor?
2 [] N
15. Has he ever had surgery for this condition?
2 [] N
16. Was he ever hospitalized for this condition?
2 [] N
[p. 66]
17. During the past 12 months, about how many times has -- seen or talked to a doctor about his --? (Do not count visits while a patient in a hospital)
000 [] None
18. About how many days during the past 12 months has this condition kept him in bed all or most of the day?
000 [] None
19a. How often does his -- bother him -- all of the time, often, once in a while, or never?
2 [] Often
3 [] Once in a while
0 [] Never (19c)
4 [] Other (Specify) ____
b. When it does bother him, is he bothered a great deal, some, or very little?
2 [] Some
3 [] Very little
4 [] Other (Specify) ____
[] All the time in 19a (A3)
c. Does -- still have this condition?
2 [] N
d. Is this condition completely cured or is it under control?
3 [] Under control (A3)
4 [] Other (Specify) ____
e. About how long did -- have this condition before it was cured?
Months ____
Years ____
f. Was this condition present at any time during the past 12 months?
2 [] N
A3
[] Other (NC)
[] Before 2 years (21a)
b. When did the accident happen?
[] Week before
[] 2 weeks - 3 months
[] Over 3-12 months
[] 1-2 years
21a. At the time of the accident what part of the body was hurt? What kind of injury was it? Anything else?
Kind of injury ____
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?
Present effects ____
22. Where did the accident happen?
2 [] At home (adjacent premises)
3 [] Street and highway (includes roadway and public sidewalk)
4 [] Farm
5 [] Industrial place (includes premises)
6 [] School (includes premises)
7 [] Place of recreation and sports, except at school
8 [] Other (Specify) ____
23. Was -- at work at his job or business when the accident happened?
2 [] N
3 [] While in Armed Services
4 [] Under 17 at time of accident
24a. Was a car, truck, bus, or any other motor vehicle involved in the accident in any way?
2 [] N (26)
b. Was more than one vehicle involved?
[] N
c. Was it (either one) moving at the time?
2 [] N
25a. Was -- outside the vehicle, getting in or out of it, a passenger or was -- the driver?
2 [] Getting in or out (c)
3 [] Passenger (c)
4 [] Driver (c)
b. What kind(s) of motor vehicle was involved?
2 [] Taxi (26)
3 [] Bus (26)
4 [] Truck (26)
5 [] Motorcycle (26)
6 [] Other (Specify) ____ (26)
c. What kind of motor vehicle was -- in (getting in or out of)?
2 [] Taxi
3 [] Bus
4 [] Truck
5 [] Motorcycle
6 [] Other (Specify) ____
26. How did the accident happen?
For motor vehicle accident, refer to Card Y and circle number for answer given.
Card Y
Motor Vehicle Accidents
How did this accident happen?
2. Accident between motor vehicle and person who was walking, running, or standing.
3. Other way (Specify how)
5. Motor vehicle came to sudden stop on roadway
6. Motor vehicle ran off roadway
7. Accident between motor vehicle and some other object on roadway (Specify object)
8. Other way (Specify how)
If "Outside" -
[] 2
[] 3* (Specify) ____
If "Inside" or "Getting in or out of" -
[] 5
[] 6
[] 7* (Specify object) ____
8 [] Accident on roadway (Specify how) ________
[] Accident not on roadway (Specify how) ________
For nonmotor vehicle accident, refer to Card Z and circle number for answer given.
Card Z
Nonmotor Vehicle Accidents
How did the accident happen?
12. Any injury involving discharge of a firearm
13. Any injury from an accident involving a nonmotor vehicle in motion (streetcar, railroad train, airplane, boat, bicycle, horse-drawn vehicle
14. Any injury inflicted by machinery (belt or motor driven) while in operation (Specify machinery)
15. Any injury inflicted by edge or point of knife, scissors, nail or other cutting or piercing implement
16. Any injury inflicted by foreign body in eye, windpipe, or other orifices
17. Any injury inflicted by animal or insect
18. Any injury inflicted by poisonous substance swallowed (Specify Substance)
19. Fell on stairs or steps from a height
20. All other falls
21. Bumped into object or person (covers all collisions between persons including striking, punching, kicking, etc.)
22. Struck by moving object (include objects held in own hand or hand of other person, also falling, flying or thrown objects)
23. Handling or stepping on sharp or rough object (include wounds from splinters, broken glass, etc.)
24. Caught in, pinched or crushed (i.e., between two moving objects or between a moving and a stationary object)
25. Came in contact with hot object or substance or open flame
26. Lifting or other exertion
27. Twisting or stumbling
28. Other (Specify how accident happened)
[] 12
[] 13
[] 14* ____
[] 15
[] 16
[] 17
[] 18* ____
[] 19
[] 20
[] 22
[] 23
[] 24
[] 25
[] 26
[] 27
[] 28* ____
*(Specify)