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[p. 58]

[] SP

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)

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

C

1. Record the number of Doctor Visits, Hospitalizations.

Doctor ____ (NP)

[] None (NP)

HOSP. ____ (NP)

[] None (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 ____
Injury 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 ____ (7)
00 [] None (8)

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. ____

10a. 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. 59]


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.
4 [] Over 6 -- 12 mos.
5 [] 1 year
6 [] 2 -- 4 years
7 [] 5+ years
8 [] Never

[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.

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

(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?

[] Y
[] N (15)

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

[] Doctor visit

c. Anyone else?

[] Y (14b and c)
[] N

If "Doctor visit," ask:

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

Number of visits ____ (NP)

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

[] Y
[] N (16)

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 15b 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, (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?

[] Condition (item C THEN 16d)
[] Pregnancy (16e)
[] 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. Ask 16d.

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

[] Y (16c)
[] N (NP)

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

[] Y
[] N (16d)

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.)

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
2 [] Past 2 weeks not reported (13 and 16)
3 [] 2 wks. -- 6 mos.
4 [] Over 6 -- 12 mos.
5 [] 1 year
6 [] 2 -- 4 years
7 [] 5+ years
8 [] Never

[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?

1 [] Working (23a)
2 [] Keeping house (23b)
3 [] Retired, health (22)
4 [] Retired, other (22)
5 [] Going to school (25)
6 [] 17+ something else (22)
7 [] 6-16 something else (24)

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?

1 [] Working (23a)
2 [] Keeping house (23b)
3 [] Retired, health (22)
4 [] Retired, other (22)
5 [] Going to school (25)
6 [] 17+ something else (22)
7 [] 6-16 something else (24)

If "something else," ask:

b. What was -- doing? ____


Ages under 6

0 [] 1-5 yrs. (20)
0 [] Under 1 (21)

20a. Is -- able to take part at all in ordinary play with other children?

[] Y
1 [] N (27)

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

2 [] Y (27)
[] N

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

2 [] Y (27)
[] N (26)

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

[] Y
5 [] N (NP)

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

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

1 [] Y (27)
[] N

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

2 [] Y (27)
[] N

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

2 [] Y (27)
[] N

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

3 [] Y (27)
[] N (26)

23a. Does -- NOW have a job?

[] Y (23c)
[] N

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

[] Y
1 [] N (27)

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

2 [] Y (27)
[] N

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

2 [] Y (27)
[] N

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

3 [] Y (27)
[] N (26)

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

[] Y
1 [] N (27)

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

2 [] Y (27)
[] N

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

2 [] Y (27)
[] N

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

3 [] Y (27)
[] N

26a. 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 ________


27a. 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 27c.

[] Old age only (NP)

c. Is this limitation caused by any other condition?

[] Y (Reask 27b 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
Enter main condition ____

[p. 62]

28a. 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)

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

[] Y
[] N (30)

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.

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.

[] Y
[] N (NP)

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.

[] Y
[] N

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

A. Gallstones? ____
B. Any other gallbladder trouble? ____
C. Cirrhosis of the liver? ____
D. Fatty liver? ____
E. Hepatitis? ____
F. Yellow jaundice? ____
G. Any other liver trouble? ____
H. Diabetes? ____
I. Any disease of the pancreas? ____
J. Ulcer? ____
K. Hernia or rupture? ____
L. A disease of the esophagus? ____
M. Gastritis? ____
N. FREQUENT indigestion? ____
O. Any other stomach trouble? ____
P. Enteritis? ____

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?

1 [] E
2 [] G
3 [] F
4 [] P


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.

1 [] Responded for self-entirely
2 [] Responded for self-partly
Person ____ was respondent


[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?

[] Und. 17 (NP)
00 [] None (34)

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:

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

1 [] Y
2 [] N (35)

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

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


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

1 [] Y (36)
2 [] N

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

1 [] Y
2 [] N

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

1 [] Y
2 [] N (36)

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 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 -- an employee of PRIVATE company, business, or individual for wages, salary, or commission?
F -- a FEDERAL government employee?
S -- a STATE government employee?
L -- a LOCAL government employee?
-- self-employed in OWN business, professional practice, or farm?
If not a farm, ask: Is the business incorporated?
I -- Yes
SE -- No (or farm)
WP -- working WITHOUT PAY in family business or farm?
NEV -- NEVER WORKED
1 [] P
2 [] F
3 [] S
4 [] L
5 [] I
6 [] SE
7 [] WP
8 [] NEV

[p. 71]


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

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.

00 [] A
01 [] B
02 [] C
03 [] D
04 [] E
05 [] F
06 [] G
07 [] H
08 [] I
09 [] J
10 [] K

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

[] Income

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?

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:

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

0 [] Under 17
1 [] Married -- spouse present
6 [] Married -- spouse absent
2 [] Widowed
4 [] Divorced
5 [] Separated
3 [] Never married