[p. 76]
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
[] Accident or injury (A2)
[] 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]? ____
[] Accident or injury (A2)
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] 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 head or ear)
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:
2 [] Q. 3a
3 [] Q. 3b
4 [] Q. 3c
5 [] Q. 3d
6 [] Q. 3e
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?
00 [] 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]?
(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?)
2 [] Week before
3 [] Past 2 weeks - DK which
4 [] 2 weeks - 3 months
5 [] 3 - 12 months
6 [] More than 12 months ago
A3
2 [] First eye condition (under 6) (10g)
3 [] First eye cond. (6+ yrs.) (10)
4 [] Not first eye cond. (AA)
These next questions are about how well -- can see (with glasses/contacts).
10a. Can -- see well enough to read ordinary newspaper print with his
2 [] N
2 [] N
b. Can -- see well enough to recognize the features of people he knows if they are close enough?
[] N
c. Can -- see moving objects, such as cars moving or people walking?
[] N
d. Can -- see well enough to step down?
[] N
e. Can -- see well enough to recognize a friend walking on the other side of the street?
[] N
If ALL "No," ask 10f: otherwise go to 10g.
f. Can -- see well enough to tell if a light is on?
[] N (AA)
g. How much trouble would you say that -- has in seeing, a great deal, some, or hardly any at all?
[] Hardly any or none
[] Some
[] Other -- Specify ____
[p. 77]
AA
2 [] Condition in C2 does not have a letter as source (A4)
3 [] Condition in C2 has a letter as source, Doctor seen (11)
4 [] Condition in C2 has a letter as source, Doctor not seen (15)
2 [] N (12)
b. Was any of this medicine or treatment recommended by a doctor?
2 [] N
12. Has he ever had surgery for this condition?
2 [] N
13. Was he ever hospitalized for this condition?
2 [] N
14. 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
15a. About how many days during the past 12 months has this condition kept him in bed all or most of the day?
000 [] None
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
16a. 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 (A4)
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 ____
A4
[] Other (NC)
[] Before 2 years (18a)
b. When did the accident happen?
[] Week before
[] 2 weeks - 3 months
[] Over 3-12 months
[] 1-2 years
18a. At the time of the accident what part of the body was hurt? What kind of injury was it? Anything else?
Kind of injury ____
If accident happened more than 3 months ago, ask:
b. What part of the body is affected now? How is his -- affected? Is he affected in any other way?
Present effects ____
19. 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 ____
20. 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
21a. 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