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c

[p. 65]

CONDITION 1

1. Person number ____

Name of condition ____

2. When did -- last see or talk to a doctor about his --?

1 [] In interview week (Reask 2)
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

[] Accident or injury (4)
[] 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 --? ____

[] Accident or injury (4)

If entry in 3a or 3b includes the words:

Ailment
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:

Abscess
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:

Head...skull, scalp, face
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?

1 [] Y
2 [] N (9)

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

Days ____
00 [] None (9)

6. During that 2--week period, how many days did his -- keep him in bed all or most of the day?

Days ____
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?

Days ____ (9)
[] None (9)

Ask if 6-16 years:
8. How many days did his -- keep him from school during that 2-week period?

Days ____
00 [] None

9. When did -- first notice his --?

1 [] Last week
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

[] Not an eye cond. (AA)
[] First eye condition (under 6) (AA)
[] First eye cond. (6+ yrs.) (10)
[] Not first eye cond. (AA)
10. Can -- see well enough to read ordinary newspaper print with glasses with his

left eye?
1 [] Y
2 [] N
right eye?
1 [] Y
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 seen (12)
[] Doctor not seen (11)

[End section AA]

11. During the past 12 months what did -- do or take for his --?
________ (18)

Anything else? ____

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?)

0 [] Discovered by doctor (14a)
2 ____ Days
3 ____ Weeks
4 ____ Months
5 ____ Years

13. BEFORE -- talked to a doctor about his --, did he do or take anything for it?

1 [] Y
2 [] N

14a. Does -- NOW take any medicine or treatment for his --?

1 [] Y
2 [] N

b. Was any of this medicine or treatment recommended by a doctor?

1 [] Y
2 [] N

15. Has he ever had surgery for this condition?

1 [] Y
2 [] N

16. Was he ever hospitalized for this condition?

1 [] Y
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)

Times ____
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?

Days ____
000 [] None

19a. How often does his -- bother him -- all of the time, often, once in a while, or never?

1 [] All the time
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?

1 [] Great deal
2 [] Some
3 [] Very little
4 [] Other (Specify) ____
[] All the time in 19a (A3)

c. Does -- still have this condition?

1 [] Y (A3)
2 [] N

d. Is this condition completely cured or is it under control?

2 [] Cured
3 [] Under control (A3)
4 [] Other (Specify) ____

e. About how long did -- have this condition before it was cured?

0 [] Less than one month
Months ____
Years ____

f. Was this condition present at any time during the past 12 months?

1 [] Y
2 [] N

A3

[] Accident or injury
[] Other (NC)
20a. Did the accident happen during the past 2 years or before that time?

[] During the past 2 years (20b)
[] Before 2 years (21a)

b. When did the accident happen?

[] Last week
[] 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?

Part(s) of body ____
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?

Part(s) of body ____
Present effects ____

22. Where did the accident happen?

1 [] At home (inside house)
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?

1 [] Y
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?

1 [] Y
2 [] N (26)

b. Was more than one vehicle involved?

[] Y
[] N

c. Was it (either one) moving at the time?

1 [] Y
2 [] N

25a. Was -- outside the vehicle, getting in or out of it, a passenger or was -- the driver?

1 [] Outside (b)
2 [] Getting in or out (c)
3 [] Passenger (c)
4 [] Driver (c)

b. What kind(s) of motor vehicle was involved?

1 [] Car (26)
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)?

1 [] Car
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?

Outside motor vehicle
1. Accident between motor vehicle and person riding on bicycle, in streetcar, on railroad train, on horsedrawn vehicle.
2. Accident between motor vehicle and person who was walking, running, or standing.
3. Other way (Specify how)
Inside motor vehicle or getting in or out
4. Accident between two or more motor vehicles on roadway
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" -

[] 1
[] 2
[] 3* (Specify) ____

If "Inside" or "Getting in or out of" -

[] 4
[] 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?

11. An injury involving an uncontrolled fire or explosion
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)
[] 11
[] 12
[] 13
[] 14* ____
[] 15
[] 16
[] 17
[] 18* ____
[] 19
[] 20
[] 22
[] 23
[] 24
[] 25
[] 26
[] 27
[] 28* ____

*(Specify)