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[p. 58]

[] SP

1a. What is the name of the head of this household? -- Enter name in first column.

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?

d. Have I missed anyone who USUALLY lives here but is now away from home?

e. Do any of the people in this household have a home anywhere else?

* 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?

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

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

C

1. Record the number of Doctor Visits, Hospitalizations.

Doctor ____ (NP)

HOSP. ____ (NP)

WORK LOSS

2. Record each condition in the person's column, with the question number(s) where it was reported.

[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.

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?

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

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

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

If one or more days in 4b, ask 7; otherwise go to 8.

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

did -- stay in bed all or most of the day?

8a. NOT COUNTING the day(s)

Were there any (other) days during the past 2 weeks that -- cut down on the things he usually does because of illness or injury?

b. Again, not counting the day(s)

During that period, how many (other) days did he cut down for as much as a day?

If 1 or more days in 4-8, ask 9; otherwise go to next person.

9a. What condition caused -- to

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

b. Did any other condition cause him to

during that period?

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?

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

c. What was the injury? ____

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

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?

[p. 59]

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

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

c. During the past 2 weeks, did anyone else in the family go to a dentist?

If "Dental visit," ask:

d. During the past 2 weeks, how many times did -- go to dentist?

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.)

b. ABOUT how long has it been since -- LAST went to a dentist?

[p. 60]

13. During the past 2 weeks (the 2 weeks outlined in red on that calendar) how many times did -- see a medical doctor? Do not count doctors seen while a patient in a hospital.

(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?

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

c. Anyone else?

If "Doctor visit," ask:

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

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

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

c. Any calls about anyone else?

If "Phone call," ask:

d. How many telephone calls were made to get medical advice about --?

Fill item C, (DOCTOR), from 13-15 for all persons. Ask 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?

b. Did -- see or talk to a doctor about any specific condition?

c. What condition? ____
Enter condition in item C. Ask 16d.

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

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

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

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.)

b. ABOUT how long has it been since -- LAST saw or talked to a medical doctor?

[p. 61]

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?

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?

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?

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

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

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

b. In what way is he limited? Record limitation, not condition. ________ (27)

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

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

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

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

23a. Does -- NOW have a job?

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

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

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

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

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

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

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

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

26a. Is -- limited in ANY WAY because of a disability or health?

b. In what way is he limited? Record limitation, not condition ________

27a. About how long has he

had to go to a certain type of school?

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 27c.

c. Is this limitation caused by any other condition?

Mark box or ask:

d. Which of these conditions would you say is the MAIN cause of his limitation?

[p. 62]

28a. Was -- a patient in a hospital at any time since (date) a year ago?

b. How many times was -- in a hospital since (date) a year ago?

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

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

If "Y," ask:

c. During that period, how many times was -- in a nursing home or similar place?

Ask for each child 1 year old or under if date of birth is on or after reference date.

30a. 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.

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

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

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

If "Yes," ask 31b and c.

b. Who was this? Enter name of 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 [conditions A-O]? ____

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

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.

[MK Note: End section R]

[p. 70]

If 17 years old or over, ask:

33a. What is the highest grade or year -- attended in school?

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

Ask for all males 17 years or over:

34a. Did -- ever serve in the Armed Forces of the United States?

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

35a. Did -- work at any time last week or the week before -- not counting work around the house?

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

c. Was he looking for work or on layoff from a job?

d. Which -- looking for work or on layoff from a job?

Ask for all persons with a "Yes" in 35a, b, or c.

If "Yes" in 35c only, questions 36a through 36d apply to this person's LAST full-time civilian job.

36a. For whom did -- work? Name of company, business, organization, or other employer. ____

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

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

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

Complete from entries in 36a-d; if not clear, ask:

e. Was --

[p. 71]

Hand Card I

CARD I

37. 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.

38a. Which (other) family members received some income during the past 12 months? ____
Mark "Income" box in person's column.

If only one person with "Income" box marked, go to 40.

If 2 ore more persons with "Income" box marked, ask 39 for each:

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

If 17 years old or over, ask:

40. Is -- now married, widowed, divorced, separated, or never married?