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[p. 59]

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)

AGE ____
RACE
1 [] W
2 [] N
3 [] OT
SEX
1 [] M
2 [] F
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 ____


[MK Note: End section C]

Refer to Flashcard ____ to determine Sample Person(s); mark SP box(es) at top of persons' column(s).

H

If related persons 17 years old or over are listed in addition to the respondent, say:

We would like to have all adults who are at home take part in the interview. Is your --, your --, etc., at home now? If "Yes" ask: Please ask them to join us.

0 [] Under 17
1 [] At home
2 [] Not at home


[MK Note: End section H]


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).

4a. During those 2 weeks, did -- stay in bed because of any illness or injury?

[] Y (4b)
00 [] N

If age: 17+ (5), 6-16 (6), Under 6 (8)

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

Days ____


If age: 17+ (5), 6-16 (6), Under 6 (8)

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

WL days ____ (7)
00 [] None (8)

6. During those 2 weeks, how many days did illness or injury keep -- from school?

SL days ____
00 [] None (8)

If NO days in Q. 4b, go to Q. 8

7. On how many of these -- days lost from

[work
school]

did -- stay in bed all or most of the day?
_____ Days
00 [] None


8a. 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 (9)

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. 4-8, ask 9; otherwise go to next person.

9a. What condition caused -- to

[stay in bed
miss work
miss school
cut down]

during the past 2 weeks? ____ (Enter condition in item C. Ask 9b.)

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 9b.)

10a. During the past 2 weeks, did anyone in the family, that is you, your --, etc. have any (other) accidents or injuries?

[] Y
[] N (11)

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

[] Accident or injury

c. What was the injury? ____

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

[] Y (10b 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

[p. 60]


11a. During the past 2 weeks, did anyone in the family, that is you, your --, etc., go to a dentist?

[] Y
[] N (12)

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 11b 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.
12a. 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. 11)
3 [] 2 weeks - 6 mos.
4 [] Over 6 - 12 mos.
5 [] 1 year
6 [] 2 - 4 years
7 [] 5+ years
8 [] Never


13. 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)
14a. 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
[] N (15)

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

[] Doctor visit

c. Anyone else?

[] Y (14b and c)
[] N

If "Doctor visit," ask:
d. How many times did -- visit the doctor during that period?

Number of visits ____ (NP)

15a. During that period, did anyone in the family get any medical advice from a doctor over the telephone?

[] Y
[] N (16)

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

[] Phone call

c. Any calls about anyone else?

[] Y (15b 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 13-15 for all persons. Ask Q. 16a for each person with visits in DOCTOR box.

16a. For what condition did -- see or talk to a doctor during the past 2 weeks?

[] Condition (item C THEN 16d)
[] Pregnancy (16e)
[] 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 16d.)

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

[] Y (16c)
[] N (NP)

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

[] Y
[] N (16d)

f. What was the matter? ____ (Enter condition in item C (16d))

[p. 61]

17a. 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 DV
2 [] Past 2 weeks not reported (Q.'s 13 and 16)
3 [] 2 wks. -- 6 mos.
4 [] Over 6 -- 12 mos.
5 [] 1 year
6 [] 2 -- 4 years
7 [] 5+ years
8 [] Never


Ages 17+
18a. 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 (23a)
2 [] Keeping house (23b)
3 [] Retired, health (22)
4 [] Retired, other (22)
5 [] Going to school (25)
6 [] 17+ something else (22)
7 [] 6-16 something else (24)
0 [] 1-5 yrs. (20)
0 [] Under 1 (21)

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
19a. What was -- doing most of the past 12 months - going to school or doing something else?

1 [] Working (23a)
2 [] Keeping house (23b)
3 [] Retired, health (22)
4 [] Retired, other (22)
5 [] Going to school (25)
6 [] 17+ something else (22)
7 [] 6-16 something else (24)
0 [] 1-5 yrs. (20)
0 [] Under 1 (21)

If "something else," ask:

b. What was -- doing? ____


Ages under 6
20a. Is -- able to take part at all in ordinary play with other children?

[]Y
1 [] N (27)

b. Is he limited in the kind of play he can do because of his health?

2 [] Y (27)
[] N

c. Is he limited in the amount of play because of his health?

2 [] Y (27)
[] N (26)

21a. Is -- limited in any way because of his health?

[] Y
5 [] N (NP)

b. In what way is he limited? ____ (27)

22a. Does -- health now keep him from working?

1 [] Y (27)
[] N

b. Is he limited in the kind of work he could do because of his health?

2 [] Y (27)
[] N

c. Is he limited in the amount of work he could do because of his health?

2 [] Y (27)
[] N

d. Is he limited in the kind or amount of other activities because of his health?

3 [] Y (27)
[] N (26)

23a. Does -- NOW have a job?

[] Y (23c)
[] N

b. In terms of health, is -- NOW able to (work -- keep house) at all?

[] Y
1 [] N (27)

c. Is he limited in the kind of (work -- housework) he can do because of his health?

2 [] Y (27)
[] N

d. Is he limited in the amount of (work -- housework) he can do because of his health?

2 [] Y (27)
[] N

e. Is he limited in the kind or amount of other activities because of his health?

3 [] Y (27)
[] N (26)

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

[] Y
1 [] N (27)

25a. Does (would) -- have to go to a certain type of school because of his health?

2 [] Y (27)
[] N

b. Is he (would he be) limited in school attendance because of his health?

2 [] Y (27)
[] N

c. Is he limited in the kind or amount of other activities because of his health?

3 [] Y (27)
[] N (26)

26a. 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 ________


27a. 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. 62]

28a. 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)

29a. Was anyone in the family in a nursing home, convalescent home or similar place since (date) a year ago?

[] Y
[] N (30)

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)

Ask for each child 1 year old or under if date of birth is on or after reference date.
37a. Was -- born in a hospital? ____

If "Yes" and no hospitalizations entered in his and/or mother's column, enter "1" in 28b and item C.

If "Yes" and a hospitalization is entered for the mother and/or baby, ask 30b for each.

[] Y
[] N (NP)

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

[] Y
[] N

If "No," correct entries in Q. 28 and item C for mother and/or baby.

31a. DURING THE PAST 12 MONTHS, did anyone in the family (you, your --, etc.) have-

A. Goiter or other thyroid trouble? (Glandular disorder) ____
B. Diabetes? (Glandular disorder) ____
C. Cystic fibrosis? (Glandular disorder) ____
D. Anemia? ____
E. Epilepsy? ____
F. Multiple sclerosis? ____
G. Migraine? ____

If "Yes," ask b and c

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

c. During the past 12 months, did anyone else have [Glandular disorders or conditions D-G]? ____


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

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

R
Q.'s 4-32


For persons 17 years old or over, show who responded for (or was present during the asking of) Q.'s 4-32.
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


[MK Note: End section R]

[p. 63]


[MK Note: The following section appears to be a response sheet for questions asked on page 62.]

28a.

[] Y
[] N (Item C)

b. Times ____ (Item C)

29b.

[] Y

c. Times ____ (Item C)

30a.

[] Y
[] N (NP)

b.

[] Y
[] N


[MK Note: End response section]

31a. DURING THE PAST 12 MONTHS, did anyone in the family have--

H. Neuralgia or neuritis? (Condition affecting the nervous system) ____
I. Sciatica? (Condition affecting the nervous system) ____
J. Nephritis? (Genito-urinary condition) ____
K. Kidney stones? (Genito-urinary condition) ____
L. Any other kidney trouble? (Genito-urinary condition)____
M. Bladder trouble? (Genito-urinary condition) ____
N. Prostate trouble? (Genito-urinary condition) ____
O. Disease of the uterus or ovary? (Genito-urinary condition) ____
P. Any other female trouble? (Genito-urinary condition) ____

b. Who was this? ____ (Enter in Item C)

c. During the past 12 months, did anyone else have [Conditions affecting the nervous system or genito-urinary conditions?] ____


[MK Note: The following section appears to be a continuation of the response sheet for questions asked on page 62]

(Persons 2-6)

32.

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

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

[p. 71]


PREVENTIVE CARE

S1

[] 40+ years (1)
[] 17-39 years (3)
[] 3-16 years (7)
[] Under 3 years (8)


1. About how long has it been since -- had an electrocardiogram, or EKG, which involves placing wires on the chest and arms?

98 [] Never
00 [] Less than 1 year
Years ____


2. About how long has it been since -- had a test for glaucoma -- this is sometimes referred to as an eye pressure test?

98 [] Never
00 [] Less than 1 year
Years ____


3. About how long has it been since -- had a chest X-ray?

98 [] Never
00 [] Less than 1 year
Years ____


4a. Does -- have eyeglasses or contact lenses?

1 [] Y
2 [] N


b. About how long has it been since -- had his eyes examined to see if he needed (new) glasses?

98 [] Never
00 [] Less than 1 year
Years ____


Ask only of FEMALES 17+ years of age; otherwise, go to next person.
5. About how long has it been since -- had a Pap smear test for cancer?

98 [] Never
00 [] Less than 1 year
Years ____


6. About how long has it been since -- had a breast examination by a doctor?

98 [] Never (NP)
00 [] Less than 1 year (NP)
Years ____ (NP)


7a. Does -- have eyeglasses or contact lenses?

1 [] Y
2 [] N


b. About how long has it been since -- had his eyes examined to see if he needed (new) glasses? (Include any eye exams given in school.)

98 [] Never
00 [] Less than 1 year
Years ____


8a. During the past 12 months, was -- taken to a doctor for a ROUTINE physical examination, that is, not a particular illness but for a general checkup?

1 [] Y (9)
2 [] N


b. About how long has it been since -- was taken to a doctor for a routine physical examination or general checkup?

98 [] Never
Years ____


9. About how old was -- when you FIRST took him to a dentist?

98 [] Never
Years old ____

[p. 74]


If 17 years old or over, ask

33a. During the past 12 months, has -- given or sold any blood to a blood bank, a hospital, the Red Cross, or anywhere else?

0 [] Under 17 (NP)
1 [] Y
2 [] N (NP)


b. During the past 12 months, how many times has -- given or sold his blood?

Times ____


For each donation reported in Q. 33b, ask:

c. Which of these reasons listed on this card (Hand Card B) best describes why -- gave blood (the last time, the time before that, etc.)?

CARD B

1. Sold blood.
2. Replaced blood used by a relative or friend.
3. Unpaid donation to a blood bank to assure free blood for this family in the future.
4. Other unpaid blood donation which was not for replacement and did not assure free blood for this family in the future.
5. Some other reason

[Col 1-4, 1 being most recent time donated.]
[] 1
[] 2
[] 3
[] 4
[] 5 -- Specify ____


If 17 years old or over, ask:

34a. What is the highest grade or year -- attended in school?

[] Und. 17 (NP)
00 [] None (35)

Elem.
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
High
[] 9
[] 10
[] 11
[] 12
College
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6+

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

1 [] Y
2 [] N


Ask for all males 17 years or over:

35a. Did -- ever serve in the Armed Forces of the United States?

2 [] Y
1 [] N (NP)

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

[p. 75]


If 17 years old or over, ask:

36a. Did -- work at any time last week or the week before -- (For females): not counting work around the house?

[] Under 17 (NP)
1 [] Y (37a)
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 (37)

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 36a, b, or c.

If "Yes" in 36c only, questions 37a through 37d apply to this person's LAST full--time civilian job.

37a. 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 37d from entries in 37a-37c; 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)

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


38. 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

39a. Which (other) family members received some income during the past 12 months? ____

Mark "Income" box in person's column.

[] Income

b. Did any other family member receive any income during the past 12 months?

[] Y (Reask 39a and b)
[] N

If only one person with "Income" box marked, go to Q. 41.
If 2 or more persons with "Income" box marked, ask Q. 40 for each:

40. Which of these income groups represents --'s income for the past 12 months?

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


If 17 years old or over, ask:

41. Is -- now married, widowed, divorced, separated, or never married? -- Mark one box for each person.

0 [] Under 17 (NP)
1 [] Married -- spouse present
6 [] Married -- spouse absent
2 [] Widowed
4 [] Divorced
5 [] Separated
3 [] Never married (NP)


42. How many times has -- been married?

Times ____