[p. 58]
CONDITION 1
2. When did -- last see or talk to a doctor about his [condition]?
1 [] Past 2 wks. (Item C)
2 [] 2 wks. - 6 mos.
3 [] Over 6 - 12 mos.
4 [] 1 yr.
5 [] 2 - 4 yrs.
6 [] 5+ yrs.
7 [] Never
8 [] DK if Dr. seen
9 [] DK when Dr. seen
A1
Examine "Name of condition" entry and mark
[] On Card C (A2)
[] 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 [condition]?
If the entry in 3a or 3b includes the words:
Anemia
Asthma
Attack
Condition
Cyst
Defect
Disease
Disorder
Growth
Measles
Rupture
Trouble
Tumor
Ulcer
Ask c:
c. What kind of [above listed condition] is it? ____
For allergy or stroke, ask:
d. How does the allergy (stroke) affect him? ________
If in 3a-d there is 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
A2
The remaining questions will be asked as appropriate for the condition entered in:
[] Q. 3a
[] Q. 3b
[] Q. 3c
[] Q. 3d
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 [condition] keep him in bed all or most of the day?
00 [] None
Ask if 17+ years:
7. How many days did his [condition] 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 [condition] keep him from school during that 2-week period?
00 [] None
9. When did -- first notice his [condition]?
2 [] Week before
3 [] Past 2 weeks -- DK which
4 [] 2 weeks -- 3 months
5 [] 3 -- 12 months
6 [] More than 12 months 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?)
A3
2 [] First eye condition (under 6) (A4)
3 [] First eye cond. (6+ yrs.) (10)
4 [] Not first eye cond. (A4)
2 [] N
2 [] N
A4
a. First noticed during the past 2 weeks?
(Question 9)
[] N (A5)
b. Doctor seen or talked to during the past 2 weeks?
(Question 2)
[] N
c. One or more cut--down days?
(Question 5)
[] N (A5)
[p. 59]
A5
[] Other (NC)
[] Before 2 years (12a)
b. When did the accident happen?
[] Week before
[] 2 weeks -- 3 months
[] Over 3 --12 months
[] 1-- 2 years
12a. 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 ____
13. 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 ____
14. 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
15a. Was a car, truck, bus, or any other motor vehicle involved in the accident in any way?
2 [] N (NC)
b. Was more than one vehicle involved?
[] N
c. Was it (either one) moving at the time?
2 [] N