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c

[p. 58]

CONDITION 1

1. Person number ____

Name of condition ____

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

1 [] In interview week (Reask 2)
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

[] Accident or injury (A2)
[] 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]?

[] Accident or injury (A2)

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

Ailment
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:

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

A2
The remaining questions will be asked as appropriate for the condition entered in:

[] Item 1
[] Q. 3a
[] Q. 3b
[] Q. 3c
[] Q. 3d
4. During the past 2 weeks, did his [condition] 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 [condition] keep him in bed all or most of the day?

Days ____
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?

Days ____ (Item C, then 9)
[] None (9)

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

Days ____
00 [] None

9. When did -- first notice his [condition]?

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 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

1 [] Not an eye cond. (A4)
2 [] First eye condition (under 6) (A4)
3 [] First eye cond. (6+ yrs.) (10)
4 [] Not first eye cond. (A4)
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

A4
a. First noticed during the past 2 weeks?
(Question 9)

[] Y
[] N (A5)

b. Doctor seen or talked to during the past 2 weeks?
(Question 2)

[] Y (Fill blue form)
[] N

c. One or more cut--down days?
(Question 5)

[] Y (Fill blue form)
[] N (A5)

[p. 59]

A5

[] Accident or injury
[] Other (NC)
11a. Did the accident happen during the past 2 years or before that time?

[] During the past 2 years
[] Before 2 years (12a)

b. When did the accident happen?

[] Last week
[] 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?

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 ____

13. 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 ____

14. 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

15a. Was a car, truck, bus, or any other motor vehicle involved in the accident in any way?

1 [] Y
2 [] N (NC)

b. Was more than one vehicle involved?

[] Y
[] N

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

1 [] Y
2 [] N