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[p. 58]

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

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 persons 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

2 wks.
____ (NP)
12 mos.
[] Y (NP)
[] N (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


[End section C]


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+ (6), 6-16 (7), Under 6 (9))


b. During that 2-week period, how many days did -- stay in bed all or most of the day?
Days ____ (If age: 17+ (6), 6-16 (7), Under 6 (9))


6. During those 2 weeks, how many days did illness or injury keep -- from work? (For females): not counting work around the house.

WL days ____ (8)
00 [] None (9)


7. During those 2 weeks, how many days did illness or injury keep -- from school?
SL days ____
00 [] None (9)


If "N" in Q. 5a, go to Q. 9.

8. On how many of these -- days lost from
work
school
did -- stay in bed all or most of the day?
Days ____
00 [] None

[p. 59]


9a. 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
2 [] N (10)


b. (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 ____
00 [] None

If 1 or more days in Q's. 5-9, ask 10; otherwise go to next person.

10a. What condition caused -- to

[stay in bed
miss work
miss school
cut down]

during the past 2 weeks?

Enter condition in item C. Ask 10b.

b. Did any other condition cause him to

[stay in bed
miss work
miss school
cut down]

during that period?

[] Y
[] N (NP)

c. What condition? Enter conditions in item C. Reask 10b.

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

[] Y (11b and c)
[] N (12)

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 (11b 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


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

[] Y (12b and c)
[] N (13)


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 12b 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)


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

13a. 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.)
00 [] None
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. 12)
3 [] 2 weeks - 6 mos.
4 [] Over 6 - 12 mos.
5 [] 1 year
6 [] 2 - 4 years
7 [] 5+ years
8 [] Never

[p. 60]


14. 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)
15a. 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 (15b and c)
[] N (16)


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


c. Anyone else?
[] Y (15b and c)
[] N


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


16a. During that period, did anyone in the family get any medical advice from a doctor over the telephone?
[] Y (16b and c)
[] N (17)


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


c. Any calls about anyone else?
[] Y (16b 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 14-16 for all persons. Ask Q. 17 for each person with visits in DOCTOR box.

17a. For what condition did -- see or talk to a doctor during the past 2 weeks?

[] Condition (item C THEN 17d)
[] Pregnancy (17e)
[] 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 17d.

d. During that period, did -- see or talk to a doctor about any other condition?

[] Y (17c)
[] 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)

18a. 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
000 [] None
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 14 and 17)
3 [] 2 wks. - 6 mos.
4 [] Over 6 - 12 mos.
5 [] 1 year
6 [] 2 - 4 years
7 [] 5+ years
8 [] Never

[p. 61]

M


Please look at this card (Hand respondent Card M)

Card M
Mobility


In terms of health:

1. Must stay in bed all or most of the time.
2. Must stay in the house all or most of the time.
3. Need the help of another person in getting around inside or outside the house.
4. Need the help of some special aid, such as a cane or wheelchair in getting around inside or outside the house.
5. Does not need the help of another person or a special aid but has trouble getting around freely.
6. Does not have trouble getting around freely.


Which one of these statements fits -- best in terms of health? (Circle appropriate number)
[] 1 (24a)
[] 2 (24a)
[] 3 (24a)
[] 4 (24a)
[] 5 (24a)
[] 6 (NP)


If respondent does not understand or is unable to read the card, ask questions 19-23 for each person.


[End section M]


19. In terms of health must -- stay IN BED all or most of the time?
1 [] Y (24a)
[] N


20. In terms of health must -- stay IN THE HOUSE all or most of the time?
2 [] Y (24a)
[] N


21. Does -- need the help of ANOTHER PERSON in getting around inside or outside the house?
3 [] Y (24a)
[] N


22. Does -- need help of some SPECIAL AID, such as a cane or wheelchair in getting around inside or outside the house?
4 [] Y (24a)
[] N


23. Although -- does not need the help of another person or a special aid, does he have trouble getting around freely?
5 [] Y (24a)
6 [] N (NP)


Ask for each person with a limitation reported in item M or in questions 19-23:

24a. About how long has --

(1) had to stay in bed because of health?
(2) had to stay in the house because of health?
(3-4) needed help getting around inside or outside the house?
(5) had trouble getting around freely?

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 condition?

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 ____

[p. 62]


Ages 17+
25a. 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
26a. 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
27a. Is -- able to take part at all in ordinary play with other children?

[] Y
1 [] N (34)


b. Is he limited in the kind of play he can do because of his health?
2 [] Y (34)
[] N


c. Is he limited in the amount of play because of his health?
2 [] Y (34)
[] N (33)


28a. Is -- limited in any way because of his health?
[] Y
5 [] N (NP)


b. In what way is he limited? ________ (34)

29a. Does --'s health now keep him from working?
1 [] Y (34)
[] N


b. Is he limited in the kind of work he could do because of his health?
2 [] Y (34)
[] N


c. Is he limited in the amount of work he could do because of his health?
2 [] Y (34)
[] N


d. Is he limited in the kind or amount of other activities because of his health?
3 [] Y (34)
[] N (33)


30a. Does -- NOW have a job?
[] Y (30c)
[] N


b. In terms of health, is -- NOW able to (work - keep house) at all?
[] Y
1 [] N (34)


c. Is he limited in the kind of (work - housework) he can do because of his health?
2 [] Y (34)
[] N


d. Is he limited in the amount of (work -- housework) he can do because of his health?
2 [] Y (34)
[] N


e. Is he limited in the kind or amount of other activities because of his health?
3 [] Y (34)
[] N (33)


31. In terms of health would -- be able to go to school?
[] Y
1 [] N (34)


32 a. Does (would) -- have to go to a certain type of school because of his health?
2 [] Y (34)
[] N


b. Is he (would he be) limited in school attendance because of his health?
2 [] Y (34)
[] N


c. Is he limited in the kind or amount of other activities because of his health?
3 [] Y (34)
[] N (33)


33a. 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 ________


34a. 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

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 ____

[p. 63]

35a. 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)

36a. Was anyone in the family in a nursing home, convalescent home or similar place since (date) a year ago?

[] Y
[] N (37)

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:
37a. When was -- born? If on or after the hospital reference date, ask 37b.

Month ____
Day ____
Year _ _ _ _

b. Was -- born in a hospital?

[] Y
[] N (NP)

If "Yes" and no hospitalizations entered in his and/or mother's column, enter "1" in 35b and item C.
If "Yes" and a hospitalization is entered for the mother and/or baby, ask 37c for each.

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

If "No," correct entries in Q. 35 and item C for mother and/or baby.

[] Y
[] N

38 a. Has anyone in the family (you, your --, etc.) EVER had --

A. Rheumatic fever? ____
B. Rheumatic heart disease? ____
C. Hardening of the arteries or arteriosclerosis? ____
D. Congenital heart disease? ____
E. Coronary heart disease? ____
F. High blood pressure? ____
G. Stroke or a cerebrovascular accident? ____
H. Hemorrhage of the brain? ____
I. Angina pectoris? ____
J. Myocardial infarction? ____
K. Any other heart attack? ____

If "Yes," ask b and c.

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

c. Has anyone else ever had [conditions A-K]?

[p. 64]

39a. DURING THE PAST 12 MONTHS, did anyone in the family (you, your --, etc.) have --

L. Damaged heart valves? ____
M. Tachycardia or rapid heart? ____
N. Heart murmur? ____
O. Any other heart trouble? ____
P. Aneurysm ____
Q. Any blood clots? ____
R. Gangrene? ____
S. Varicose veins? ____
T. Hemorrhoids or piles? ____
U. Phlebitis or thrombophlebitis? ____
V. Any other condition affecting blood circulation? ____


40. Compared to other persons his age, would you say that --'s health is excellent, good, fair, or poor?

1 [] E
2 [] G
3 [] F
4 [] P

R
Q.'s 5-40


For persons 17 years old or over, show who responded for (or was present during the asking of) Q.'s 5-40.

If persons responded for self, show whether entirely or partly. For persons under 17 show who responded for them.

1 [] Responded for self-entirely
2 [] Responded for self-partly
Person ____ was respondent

[p. 70]

These next questions are about health insurance.

If 65 or over ask:
1a. Is -- covered by that part of Social Security Medicare which pays for hospital bills?

[] Und. 65 (NP)
1 [] Y
2 [] N
9 [] DK

b. Is -- covered by that part of Medicare which pays for doctor's bills, that is, the Medicare plan for which he or some agency must pay a certain amount each month?

1 [] Y (NP)
2 [] N (NP)
9 [] DK (NP)

For each person with "DK" in Q. 1a or b, ask:
2. May I please see the Social Security Medicare card(s) for -- to determine the type of coverage? (Transcribe the information from the card or mark the "Card not seen" box.)

1 [] Hospital
2 [] Medical
3 [] Card not seen

We are interested in all kinds of health insurance place except those which pay only for accidents.

3a. (Not counting Medicare) Is anyone in the family covered by hospital insurance, that is, a health insurance plan which pays any part of a hospital bill?

[] Y (3b, c)
[] N (3d)

b. What is the name of the plan? (Record in Table H.I) ____

c. Is anyone in the family covered by any other hospital insurance plan?

[] Y (3b, c)
[] N (3d)

d. Is anyone in the family covered by a (any other) health insurance plan which pays any part of a doctor's or surgeon's bill?

[] Y
[] N

(Complete Table H.I. for each plan. If no plans reported, go to I)

e. What is the name of the plan? ____
(Record in Table H.I.: reask 3d)

Table H.I.

[Table H.I. gives two lines "A" and "B" for the various plans. The questions are identical for each so the extra lines have been omitted here.]

a. Name of plan ____

b. Which members of the family are covered by (name of plan)?
Is anyone else in the family covered under this policy?
Circle person number.

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

c. Was this insurance plan obtained through an employer, union, or some other group?

1 [] Y
2 [] N
9 [] DK

d. Is this plan NOW carried through a group or as an individual plan?

1 [] Group
2 [] Ind.
9 [] DK

e. To receive services under this plan must you and your family to go certain clinics or doctors?

1 [] Y
2 [] N
9 [] DK

f. Does this -- plan pay any part of hospital expenses?

1 [] Y
2 [] N
9 [] DK

g. Does this -- plan pay any part of doctor's or surgeon's bills for operations?

1 [] Y
2 [] N
9 [] DK

h. Does this plan pay any part of a doctor's bill for office visits or home calls?

1 [] Y (j)
2 [] N
9 [] DK

i. Does this plan pay any part of a doctor's bill for office visits or home calls after a certain amount has been paid by the family?

1 [] Y
2 [] N
9 [] DK

j. What do you like most about this -- plan? ________

k. What do you like least about this -- plan? ________

l. When was the last time any member of your family used this -- plan?

000 [] Nev. used
2 [] Wks. ____
3 [] Mos. ____
4 [] Yrs. ____


[End Table H.I.]

I

For each person, review Q's. 1 and 2 and Table H.I. and determine if "Covered" by either Medicare or insurance or "Not covered."

1 [] Covered (NP)
2 [] Not Covered (NP)

Ask for each person "Not covered"

(Many people do not carry health insurance for various reasons)
4. Which of these statements (Hand Card N) best describes why -- is not covered by any health insurance plan? Any other Reason?
Circle all reasons given

Card N
1. Can't obtain insurance because of age, illness, or poor health
2. Don't believe in insurance
3. Dissatisfied with previous insurance
4. Don't need health insurance because care received through welfare or Medicaid
5. Have been healthy, not much sickness in the family, haven't needed health insurance
6. Too expensive, can't afford health insurance
7. Some other reason
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7 (specify) ____

5a. Is anyone in the family covered by an insurance plan which pays any part of a dentist bill for routine or regular care?

1 [] Y
2 [] N (41)

b. Which family members are covered? ____

[] Covered

[p. 71]


If 17 years old or over, ask:

41a. What is the highest grade or year -- attended in school?

[] Und. 17 (NP)
00 [] None (42)

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:

42a. Did -- ever serve in the Armed Forces of the United States?

2 [] Y
1 [] N (43)


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


43a. Did -- work at any time last week or the week before -- (For females): not counting work around the house?

1 [] Y (44a)
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 43d)


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 43a, b, or c.

If "Yes" in 43c only, questions 44a through 44d apply to this person's LAST full-time civilian job.

44a. 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 44d from entries in 44a-44c; if not clear, ask:
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)

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


45. 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