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hhs
[ p. 84]

H1 PAGE

R3

[] Under 19 (NP)
[] 19+ (1-2)

1a. Does -- need help from others in using public transportation, such as buses, trains, subways or planes?

1 [] Y (2)
2 [] N


b. Does -- use public transportation?

1 [] Y (2)
2 [] N


c. If -- had to use public transportation would -- need the help of other persons?

1 [] Y
2 [] N


2a. Does -- drive a car?

1 [] Y (2c)
2 [] N


b. Does a disability or health problem keep him from driving a car?

1 [] Y (NP)
2 [] N (NP)


c. Is the car he usually drives specially equipped for handicapped persons?

1 [] Y
2 [] N (NP)

d. Was the car specially equipped for --?

1 [] Y
2 [] N


Ask if 19+
3a. (Besides) During the past 12 months did (adults 19+) have-

1. Sudden paralysis or weakness of an arm and leg on the same side of the body? ____
2. Sudden numbness on one side of the body? ____
3. Sudden loss of vision? ____
4. Sudden loss of speech? ____

If "Yes," ask:

b. Who was this? ____

Mark "symptom" in person's column and reask 3a and b.

[] Und. 19 (NP)
1 [] Para.
1 [] Less than 24 hours
2 [] More than 24 hours
2 [] Numb.
1 [] Less than 24 hours
2 [] More than 24 hours
3 [] Vis.
1 [] Less than 24 hours
2 [] More than 24 hours
4 [] Spe.
1 [] Less than 24 hours
2 [] More than 24 hours

If "symptom," ask 3c-e


c. Did --'s (symptom) last more or less than 24 hours?

[] Und. 19 (NP)
1 [] Para.
1 [] Less than 24 hours
2 [] More than 24 hours
2 [] Numb.
1 [] Less than 24 hours
2 [] More than 24 hours
3 [] Vis.
1 [] Less than 24 hours
2 [] More than 24 hours
4 [] Spe.
1 [] Less than 24 hours
2 [] More than 24 hours


d. Did -- see a doctor for his (symptom(s)) at that time?

1 [] Y
2 [] N (4)
9 [] DK (4)


e. Was -- hospitalized because of the (symptom(s))?

1 [] Y
2 [] N
9 [] DK


4a. (Besides) During the past 12 months did (adults 19+) have-

1. Diabetes or sugar diabetes? ____
2. High blood pressure or hypertension? ____
3. Heart disease or heart trouble? ____
4. Blood clots in arms, legs, or lungs? ____

If "Yes," ask:
b. Who was this? ____

Mark box in person's column and reask 4a and b

1 [] Diabetes
2 [] High Blood Pressure
3 [] Heart Disease
4 [] Blood Clots


Ask if 19+:
If "stroke" in C2 go to 5b.

5a. Has -- EVER had a stroke?

[] Under 19 (NP)
3 [] Stroke in C2 (5b)
1 [] Y
2 [] N (NP)
9 [] DK (NP)

b. Has a doctor EVER told -- he had a stroke?

1 [] Y
2 [] N
9 [] DK


c. How old was -- at the time he had his first stroke?

Years ____


d. Was -- hospitalized for this first stroke?

1 [] Y
2 [] N

[p. 85]


[MK Note: Page 85 contains a response sheet for questions asked on page 84. The response sheet has five columns; only one is represented here since each column contains the same information.]

R3

[] Under 19 (NP)
[] 19+ (1-2)
1a.

1 [] Y (2)
2 [] N

b.

1 [] Y (2)
2 [] N

c.

1 [] Y
2 [] N

2a.

1 [] Y (2c)
2 [] N

b.

1 [] Y (NP)
2 [] N (NP)

c.

1 [] Y
2 [] N (NP)

d.

1 [] Y
2 [] N

3b

[] Und. 19 (NP)
1 [] Para.
1 [] Less than 24 hours
2 [] More than 24 hours
2 [] Numb.
1 [] Less than 24 hours
2 [] More than 24 hours
3 [] Vis.
1 [] Less than 24 hours
2 [] More than 24 hours
4 [] Spe.
1 [] Less than 24 hours
2 [] More than 24 hours

c.

[] Und. 19 (NP)
1 [] Para.
1 [] Less than 24 hours
2 [] More than 24 hours
2 [] Numb.
1 [] Less than 24 hours
2 [] More than 24 hours
3 [] Vis.
1 [] Less than 24 hours
2 [] More than 24 hours
4 [] Spe.
1 [] Less than 24 hours
2 [] More than 24 hours

d.

1 [] Y
2 [] N (4)
9 [] DK (4)

e.

1 [] Y
2 [] N
9 [] DK

4b.

1 [] Diabetes
2 [] High Blood Pressure
3 [] Heart Disease
4 [] Blood Clots

5a.

[] Under 19 (NP)
3 [] Stroke in C2 (5b)
1 [] Y
2 [] N (NP)
9 [] DK (NP)

b.

1 [] Y
2 [] N
9 [] DK

c. Years ____

d.

1 [] Y
2 [] N