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[p. 53]
[] SP
[]12 Mo. DV
[] CE

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?

1 [] Y
Col(s). ____ (Delete)
2 [] N


2. How is -- related to -- (Head of Household)?

Relationship ____

HEAD


3. What is --'s date of birth? (Enter date and Age and circle Race and Sex)

AGE ____
Month ____
Date ____
Year _ _ _ _
RACE
1 [] W
2 [] B
3 [] OT
SEX
1 [] M
2 [] F

C

1. Record the number of Doctor Visits, Hospitalizations, and Work loss days.

DR ____ (NP)
HOSP ____ (NP)
WORK LOSS
[] None (8)
[] 1+ days (7)

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 Persons; mark SP boxes.

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 ____ (Item C)
00 [] None (Item C)

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

SL days ____
00 [] None (8)

If one or more days in 4b, ask 7; otherwise go to 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 (other) days did he cut down for as much as a day?

Days ____
00 [] None

If 1 or more days in 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.

10 a. 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

If "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. 54]


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 (NP)
2 [] Past 2 weeks not reported (11)
3 [] 2 weeks -- 6 mos. (NP)
4 [] Over 6 -- 12 mos. (NP)
5 [] 1 year (NP)
6 [] 2 -- 4 years (NP)
7 [] 5+ years (NP)
8 [] Never (NP)

O


Mark one box in each person's column.

[] 25+ years (NP)
[] 5-24 years (13)
[] Under 5 years (NP)


[MK Note: End section O]


13a. Has -- ever had his teeth straightened or had bands on his teeth?

1 [] Y
2 [] N (14)


b. During the past 12 months, about how many visits did he make to an orthodontist?

00 [] None (NP)
Number of visits ____


c. How many of these visits were in the past two weeks -- that is, the two weeks outlined in red on that calendar?

00 [] None (NP)
Number of visits ____

If one or more visits in 11d, ask, otherwise, go to NP.

d. How many of these orthodontic visits were included in the -- dental visits -- had during the past 2 weeks that you told me about earlier?

00 [] None (NP)
Number of visits ____ (NP)


14a. Do you think --'s teeth need to be straightened?

1 [] Y
2 [] N


(Even though you don't think his teeth need to be straightened)

b. Have you ever been told by a dentist or orthodontist that his teeth need to be straightened?

1 [] Y
2 [] N


If "Y" circled in 14a or b, ask: otherwise, go to NP.

c. We are interested in the various reasons why people do not have their teeth straightened when they need this type of care. (Hand Card O)

CARD O
1. Don't know who to go to.
2. It costs too much.
3. No one in this area straightens teeth.
4. Cannot get appointment.
5. Thinks braces or bands would be unattractive.
6. Dentist or orthodontist advised us to wait.
7. Don't have time.
8. Too much pain and discomfort involved.
9. Other reason.

Which of those statements describes why -- is not NOW receiving this care?
Circle all reasons given

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

Any other reason?

[] Other (Specify) ____


Mark box or ask:

d. What is the MAIN reason -- is not NOW receiving this care?

00 [] Only one reason
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] Other (Specify) ____

[p. 55]


15. 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)

16 a. 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 (17)

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

[] Doctor visit

c. Anyone else?

[] Y (16b and c)
[] N

If "Doctor visit," ask:

d. How many times did -- visit the doctor during that period?

Number of visits ____ (NP)

17a. During that period, did anyone in the family get any medical advice from a doctor over the telephone?

[] Y
[] N (18)

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

[] Phone call

c. Any calls about anyone else?

[] Y (Reask 17b 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, (DR.), from 15-17 for all persons. Ask Q. 18a for each person with visits in DR box.

18a. For what condition did -- see or talk to a doctor during the past 2 weeks?

[] Condition (item C THEN 18d)
[] Pregnancy (18e)
[] 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 18d.

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

[] Y (18c)
[] N (NP)

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

[] Y
[] N (18d)

f. What was the matter? ____

Enter condition in item C (18d)

19a. 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 (Mark "12 Mo. DV" box in SP column.)
2 [] Past 2 weeks not reported (15 and 18) (Mark "12 Mo. DV" box in SP column.)
3 [] 2 wks. -- 6 mos. (Mark "12 Mo. DV" box in SP column.)
4 [] Over 6 -- 12 mos. (Mark "12 Mo. DV" box in SP column.)
5 [] 1 year
6 [] 2 -- 4 years
7 [] 5+ years
8 [] Never

[p. 56]


Ages 17+
20a. 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 (25a)
2 [] Keeping house (25b)
3 [] Retired, health (24)
4 [] Retired, other (24)
5 [] Going to school (27)
6 [] 17+ something else (24)
7 [] 6--16 something else (26)

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
21a. What was -- doing MOST OF THE PAST 12 MONTHS -- going to school or doing something else?

1 [] Working (25a)
2 [] Keeping house (25b)
3 [] Retired, health (24)
4 [] Retired, other (24)
5 [] Going to school (27)
6 [] 17+ something else (24)
7 [] 6 --16 something else (26)

If "something else," ask:

b. What was -- doing? ____


Ages under 6

0 [] 1-5 years (22)
0 [] Under 1 (23)

22a. Is -- able to take part at all in ordinary play with other children?

[] Y
1 [] N (29)

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

2 [] Y (29)
[] N

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

2 [] Y (29)
[] N (28)

23a. Is -- limited in any way because of his health?

[] Y
5 [] N (NP)

b. In what way is he limited? ________ (29)

24a. Does -- health now keep him from working?

1 [] Y (29)
[] N

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

2 [] Y (29)
[] N

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

2 [] Y (29)
[] N

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

3 [] Y (29)
[] N (28)

25a. Does -- NOW have a job?

[] Y (25c)
[] N

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

[] Y
1 [] N (29)

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

2 [] Y (29)
[] N

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

2 [] Y (29)
[] N

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

3 [] Y (29)
[] N (28)

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

[] Y
1 [] N (29)

27a. Does (would) -- have to go to a certain type of school because of his health?

2 [] Y (29)
[] N

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

2 [] Y (29)
[] N

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

3 [] Y (29)
[] N

28a. 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


29a. 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. Ask c.

[] Old age only (NP)

c. Is this limitation caused by any other condition?

[] Y (Reask 29b 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

[p. 57]

30a. 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)

31a. Was anyone in the family in a nursing home, convalescent home or similar place since (date) a year ago?

[] Y
[] N (32)

b. Who was this? ____
Circle "Y" in person's column.

[] Y

If "Y," 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.

32a. Was -- born in a hospital?

[] Y
[] N (NP)

If "Yes" and no hospitalizations entered in his and/or mother's column, enter "1" in 30b and item C.
If "Yes," and a hospitalization is entered for the mother and/or baby, ask 32b for each.

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

[] Y
[] N

If "No," correct entries in 30 and item C for mother and/or baby.


33. 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 4-33


For persons 17 years old or over, show who responded for (or was present during the asking of) Q.'s 4-33.

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. 71]


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?

1 [] Y
2 [] N (36)

b. When did he serve? Circle code in descending order of priority. Thus if person served in Vietnam and in Korea, circle VN.

1 [] Vietnam Era (Aug. '64 to present) . . . VN
2 [] Korean War (June '50 - Jan. '55) . . . KW
3 [] World War II (Sept. '40 - July '47) . . . WWII
4 [] World War I (April '17 - Nov. '18) . . . WWI
5 [] Other Service (all other periods) . . . OS
6 [] DK


36a. Did -- work at any time last week or the week before -- not counting work around the house?

1 [] Y (CE then 37a)
2 [] N

b. Even though -- did not work during these 2 weeks, does he have a job or business?

1 [] Y (CE then 36c)
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. For whom did -- work? Name of company, business, organization, or other employer

Employer ____

b. What kind of business or industry is this? For example, TV and radio manufacturing, retail shoe store, State Labor Dept., farm

Industry ____

c. What kind of work was -- doing? For example, electrical engineer, stock clerk, typist, farmer

Occupation ____

d. What were --'s most important activities or duties? For example, types, keeps account books, files, sells cars, operates printing press, finishes concrete

Duties ____

Complete from entries in 37a-d; if not clear, ask:

e. Was --

1 [] P -- an employee of PRIVATE company, business, or individual for wages, salary, or commission?
2 [] F -- a FEDERAL government employee?
3 [] S -- a STATE government employee?
4 [] L -- a LOCAL government employee?

Self-employed in OWN business, professional practice, or farm?
If not a farm, ask: Is the business incorporated?

5 [] I -- Yes
6 [] SE -- No (or farm)
7 [] WP -- working WITHOUT PAY in family business or farm?
8 [] NEV -- NEVER WORKED

[p. 74]


Hand 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 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
1 [] Married -- spouse present
6 [] Married -- spouse absent
2 [] Widowed
4 [] Divorced
5 [] Separated
3 [] Never married