[p. 72]DIAYRSAGO
D1 PAGE
BD
Mark appropriate box(es) from C1.
2 [] 1+ Hospital Stays
3 [] No Bed Days
1. During the past 12 months (that is since (date) a year ago), ABOUT how many days did illness or injury keep -- in bed all or most of the day?
(Include the days in the past 2 weeks.) (Include the days while a patient in a hospital.)
(Was it more than 7 days or less than 7 days?)
(Was it more than 30 days or less than 30 days?)
(Was it more than half the year or less than half the year?)
1 [] 1--7
2 [] 8--30
3 [] 31--180 (6 months)
4 [] 181+ (6 months +)
E
2 [] Eye condition in C2 (NP)
3 [] No eye condition in C2
2a. Can -- see well enough to read ordinary newspaper print WITH GLASSES with his:
2 [] N
2 [] N
If "N" for either eye, ask; otherwise go to NP.
b. What was the cause of --'s eye condition?
2 [] Other
3a. How many living children does -- have? (Do not count adopted, step or foster children.)
Children ____
00 [] None
If FEMALE, ask; otherwise go to next person:
b. How many children has -- EVER had? (Do not count miscarriages or stillbirths.)
00 [] None (NP)
c. How many of these children weighed 9 pounds or more pounds at birth?
00 [] None
If 17+, ask:
4a. About how tall is -- without shoes?
Feet _ _
Inches _ _
b. About how much does -- weigh without clothes or shoes?
5a. Has -- applied for a job during the past 5 years?
1 [] Y
2 [] N (NP)
9 [] DK (NP)
b. During this period, did -- apply for a job he did not get?
2 [] N (NP)
c. Was -- turned down from any of these jobs because of a health problem?
2 [] N (NP)
[p. 73]
6a. (Besides --) Has anyone in the family (you, your --, etc.) EVER had-
2 [] Glaucoma?
3 [] Hardening of the arteries or arteriosclerosis?
4 [] High blood pressure or hypertension?
5 [] A heart attack?
6 [] Any other heart trouble?
7 [] Stroke?
8 [] Kidney stones or any other kidney trouble?
If "Yes," ask 6b.
b. Who was this? Mark box in person's column and reask 6a. ____
7a. (Besides --) Does anyone in the family (you, your --, etc.) have diabetes or sugar diabetes?
[] N (8)
b. Who is this? Mark "Diabetes" box in person's column or enter type of diabetes reported. ____
c. Does anyone (else) have diabetes or sugar diabetes?
[] N
If information is known, mark boxes without asking.
8a. How many living brothers and sisters does -- have? (Do not count adopted, step, or half brothers and sisters.)
00 [] None (8c)
b. How many of these brothers and sisters have diabetes or sugar diabetes?
00 [] None
c. How many of --'s brothers and sisters are no longer living?
00 [] None (8e)
d. How many of these brothers and sisters had diabetes or sugar diabetes?
00 [] None
e. Is --'s mother still living?
2 [] N
f. Does (did) she have diabetes or sugar diabetes?
2 [] N
g. Is --'s father still living?
2 [] N
h. Does (did) he have diabetes or sugar diabetes?
2 [] N
9a. (Besides --) Has anyone in the family (you, your --, etc.) EVER been told by a doctor that they have --
2. Prediabetes? ____
3. Potential diabetes? ____
If "Yes," ask 9b.
b. Who is this? Mark box in person's column and reask 9a. ____
2 [] Borderline
3 [] Prediabetes
4 [] Potential
5 [] ____
R3
Mark one box for each person. D2 is required for each person with some type of diabetes in question 7 or 9.
1 [] Fill D2, eligible resp. avail. (NP)
2 [] Fill D2, return call required (NP)
D2 PAGE
2 [] Borderline
3 [] Prediabetes
4 [] Potential
5 [] ____
Earlier, I was told that you have (diabetes/borderline, . . .).
2a. About how old were you when the doctor first told you that you had (diabetes/. . .)?
b. Were you a patient in a hospital at the time the doctor first told you that you had it?
2 [] N (3)
c. Were you in the hospital at the time because of symptoms of (diabetes/. . .)?
2 [] N
3. (Not counting that first time) Have you ever been hospitalized because of your (diabetes/. . .)?
2 [] N
4a. Have you EVER taken insulin injections?
2 [] N (5)
b. Have you been taking insulin injections for most of the past 12 months?
2 [] N
c. Are you NOW taking insulin injections?
2 [] N
d. How many years (have you been taking/did you take) them?
Years ____
5a. Do you know what an insulin reaction is?
2 [] N (7)
b. Have you EVER had an insulin reaction?
2 [] N (6)
c. How many insulin reactions have you had during the past 30 days?
Number ____
d. (Including these reactions,) About how many have you had during the past 12 months?
Number ____
6a. Do you think an insulin reaction can be caused by too much food?
2 [] N
9 [] DK
b. Do you think an insulin reaction can be caused by too much exercise?
2 [] N
9 [] DK
c. Do you think an insulin reaction is the same as a diabetic coma?
2 [] N
9 [] DK
7. Do you think a person with diabetes can exercise as much as other people?
2 [] N
9 [] DK
8a. Have you EVER taken diabetes pills?
2 [] N (9)
b. Have you taken them most of the past 12 months?
2 [] N
c. Are you NOW taking diabetes pills?
2 [] N
d. How many years (have you been taking/did you take) them?
Years ____
9a. Have you EVER been given a WRITTEN diet for your (diabetes/. . .)?
2 [] N (10)
b. Do you NOW follow this diet?
2 [] N
c. How many years (have you been/were you) on a diet for your (diabetes/. . .)?
Years ____
10. Do you carry or wear anything which identifies you as a (diabetic/. . .)?
2 [] N
11. When did you last see or talk to a doctor about your (diabetes/. . .)?
Weeks ____
Months ____
Years ____
Ask for persons aged 6-16:
12. If an emergency should arise, is there an adult at the school aware of --'s
(diabetes/. . .)?
2 [] N
R4
Person ____ was resp. (Footnote reason if diabetic 19+)