[p. 63]
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," transcribe entry form item 1. 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 [condition above] 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
Ask remaining questions 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. (AA)
2 [] N
2 [] N
AA
2 [] Condition not listed or reported in probe question 31 (A4)
[] Condition listed or reported in probe question 31
3 [] Doctor seen (12)
4 [] Doctor not seen (11)
11. During the past 12 months what did -- do or take for his [condition]? (Write in) ____
Anything else? ____ (18)
12. After -- first noticed something was wrong, about how long was it before he talked to a doctor about it -- was it a matter of days, weeks, or months?)
100 [] Less than one day
2 [] Days ____
3 [] Weeks ____
4 [] Months ____
5 [] Years ____
13. BEFORE -- talked to a doctor about his [condition], did he do or take anything for it?
2 [] N
If "Diabetes," ask 14a; otherwise go to 14c.
14a. Does -- take insulin injections for his diabetes?
2 [] N
b. Does he take diabetes pills?
2 [] N
c. Does -- NOW take any medicine or treatment for his [condition]?
2 [] N (15)
d. Was any of this medicine or treatment recommended by a doctor?
2 [] N
15. Has he ever had surgery for this condition?
2 [] N
16. Was he ever hospitalized for this condition?
2 [] N
17. During the past 12 months, about how many times has -- seen or talked to a doctor about his [condition]? (Do not count visits while a patient in a hospital)
000 [] None
18a. About how many days during the past 12 months has this condition kept him in bed all or most of the day?
000 [] None
Ask if 17+ years:
b. About how many days during the past 12 months has this condition kept him from work? For females: Not counting work around the house?
000 [] None
19a. How often does his [condition] bother him -- all of the time, often, once in a while, or never?
2 [] Often
3 [] Once in a while
0 [] Never (19c)
8 [] Other -- Specify ____
b. When it does bother him, is he bothered a great deal, some, or very little?
2 [] Some
3 [] Very little
4 [] Other -- Specify ____
[] All the time in 19a (A4)
c. Does -- still have this condition?
[] N
d. Is this condition completely cured or is it under control?
3 [] Under control (A4)
4 [] Other -- Specify ____ (A4)
e. About how long did -- have this condition before it was cured?
Months ____
Years ____
A4
[] Other (NC)
[] Before 2 years (21a)
b. When did the accident happen?
[] Week before
[] 2 weeks -- 3 months
[] Over 3 --12 months
[] 1 -- 2 years (21a)
21a. At the time of the accident what part of the body was hurt? What kind of injury was it?
Kind of injury ____
Anything else? ____
If accident happened more than 3 months ago, ask:
b. What part of the body is affected now? How is his -- affected?
Present effects ____
Is he affected in any other way? ____
22. 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 ____
23. 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
24a. 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