p

[p. 60]

[] SP
[] P

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.

f. Are any of the persons in this household now on full-time active duty with the Armed Forces of the United States?

2a. 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 Bed Days, Doctor Visits, and Hospitalizations.

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

[MK Note: End section C]

If 17+, ask:
4. Is -- now married, widowed, divorced, separated, or never married?

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.

[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).

5a. 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?

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

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

If one or more days in 5b, ask 8; otherwise go to 9.

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

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

9a. 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 one or more days in 5-9, ask 10 otherwise go to next person.

10a. What condition caused -- to

during the past 2 weeks? ____

Enter condition in item C. Ask 10b.

b. Did any other condition cause him to

during that period?

c. What condition? ____

Enter condition in item C (10b)

Fill item C, (BED DAYS), from 5b for all persons.

[p. 61]

[MK Note: Page 61 appears to be a response sheet for questions asked on page 60. It contains five identical columns in which to enter responses; only one is represented here since all columns contain the same information.]

4.

H

5a.

b. Days ____ (If age: 17+ (6), 6-16 (7), Under 6 (9))

6.

7.

8.

9a.

b.

10a. Enter condition in item C. Ask 10b.

b.

c. Enter condition in item C (10b)

Fill item C, (BED DAYS), from 5b for all persons.

11a. 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?

12a. During the past 2 weeks, did anyone in the family 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.

Mark box or ask:
13. ABOUT how long has it been since -- LAST went to a dentist?

[p. 63]

[MK Note: Page 63 appears to be a response sheet for questions asked on page 62. It contains five identical columns in which to enter responses; only one is represented here since all columns contain the same information.]

11b.

c. Injury ____

e.

12b.

d. No. of dental visits ____ (NP)

13.

[p. 64]

14. 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)
15a. 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?

16a. 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, (DV), from 14-16 for all persons. Ask 17a for each person with visits in DV box.

17a. 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 17d.

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 (17d)

18a. 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? Include doctors seen while a patient in a hospital.

[p. 65]

[MK Note: Page 65 appears to be a response sheet for questions asked on page 64. It contains five identical columns in which to enter responses; only one is represented here since all columns contain the same information.]

14.

15b.

d. Number of visits ____ (NP)

16b.

d. Number of calls ____ (NP)

17a.

b.

c. Enter condition in item C. Ask 17d.

d.

e.

f. Enter condition in item C (17d)

18a.

b.

[p. 66]

Ages 17+
19a. 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
20a. 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

21a. 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?

22a. Is -- limited in any way because of his health?

b. In what way is he limited? Record limitation, not condition. ________ (28)

23a. 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?

24a. 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?

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

26a. 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?

27a. Is -- limited in ANY WAY because of a disability or health?

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

28a. About how long has he
[been limited in --
been unable to --
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. Mark D box, THEN 28c

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. 67]

[MK Note: Page 67 appears to be a response sheet for questions asked on page 66. It contains five identical columns in which to enter responses; only one is represented here since all columns contain the same information.]

19.

20.

21a.

b.

c.

22a.

b. ____ (28)

23a.

b.

c.

d.

24a.

b.

c.

d.

e.

25.

26a.

b.

c.

27a.

b. ____

28a.

b. Enter condition in item C. Mark D box, THEN 28c

c.

d.

[p. 68]

29a. 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?

30a. 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.
31a. Was -- born in a hospital?

If "Yes" and no hospitalizations entered in his and/or mother's column, enter "1" in 29b and item C.

If "Yes," and a hospitalization is entered for the mother and/or baby, ask 31b for each.

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

If "No," correct entries in 29 and item C for mother and/or baby.

32a. Does anyone in the family (you, your --, etc.) HAVE-

If "Yes," ask 32b and c.

b. Who is this? ____
Enter name of condition and letter of line where reported in appropriate person's column in item C.

c. Does anyone else have [conditions A-N]? ____

33a. Does anyone in the family use -

If "Yes," ask 33b and c

b. Who is this? ____

Mark box in person's column

c. Anyone else? ____

For "hearing aid," with no hearing problem reported, enter "33, hearing trouble," in item C2

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

R

Q.'s 4-34

For persons 17 years or over, show who responded for (or was present during the asking of) Questions 4-34.

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. 69]

[MK Note: The following appears to be a response sheet for questions 29a-b, 30b-c, and 31a-b. There are five columns in which to enter responses; only one is represented here as the information contained in each column is identical.]

29a.

b. Times ____ (Item C)

30b.

c. Times ____ (Item C)

31a.

b.

[MK Note: End Response sheet]

32a. Does anyone in the family NOW have-

If "Yes," ask 32 b and c

b. Who is this? ____

Enter name of condition and letter of line where reported in appropriate person's column in item C.

c. Does anyone else have [conditions O-Z]? ____

[MK Note: The following appears to be a response sheet for questions 33b, 34, and R. There are five columns in which to enter responses; only one is represented here as the information contained in each column is identical.]

33b.

[Columns 2-6]

34.

R

[MK Note: End response sheet]

[p. 74]

BD

Mark box(es) for item C.

45. 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?)

0 [] None
1 [] 1--7
2 [] 8--30
3 [] 31--180 (6 months)
4 [] 181+ (6 months +)

46a. Does anyone in the family now use (any of the following special aids) -

If "Yes," specify: ____Enter in Table SA

b. Who is this? ____

c. Anyone else? ____

Table SA
[Rows 1-5]

a. Person No. ____

b. Type of aid ____

If 1-6 in (b), ASK:

c. Does he use one or two ____ (at a time)?

If 3-10 in (b), ASK:

d. For what condition does he need this ____? (Item C)
If "brace," Ask: On what part of the body is the brace worn? ____

[p. 75]

[MK Note: Page 75 appears to be a response sheet for questions asked on page 74. It contains five identical columns in which to enter responses; only one is represented here since all columns contain the same information.]

BD

45.

[MK Note: End response sheet]

Table SA - Continued
[Rows 1-5]

e. Is the ____ used all of the time, most of the time or only occasionally?

f. How long has he used ____?

g. How was the _____ obtained? Was it purchased, rented, borrowed or a gift?

[p. 86]

R4

6. On the average, how many hours of sleep do you usually get at night?

7. How often do you eat breakfast - almost every day, sometimes, rarely or never?

8. Including evening snacks, how often do you eat between meals - almost every day, sometimes, rarely or never?

9. Would you say that you are physically more active, less active or about as active as other persons your age?

10a. How often do you drink wine - never, occasionally, once or twice a week, or more than twice a week?

b. How often do you drink beer - never, occasionally, once or twice a week, or more than twice a week?

c. How often do you drink liquor - never, occasionally, once or twice a week, or more than twice a week?

If all "Never," go to 11

d. When you drink --, how many drinks do you usually have at one sitting?

If under 5 in 10d ask; otherwise go to 11

e. On any one occasion during the past 12 months, did you have 5 or more drinks of (wine/beer/liquor)?

11a. Have you smoked at least 100 cigarettes in your entire life?

b. Do you smoke cigarettes now?

c. On the average, ABOUT how many cigarettes a day do you smoke? ____

12a. About how tall are you without shoes?

b. About how much do you weigh without clothes or shoes? ____

13a. During the past 12 months, have you had any problems getting medical care for yourself (for any of the following reasons) --

b. Did this problem PREVENT you from getting medical care for yourself?

[p. 87]

[MK Note: Page 87 contains a response sheet for questions asked on page 86. The response sheet has five columns to enter information in; only one is represented here since each column contains the same information.]

R4

6. Hours ____

7.

8.

9.

10a.

b.

c.

d.

e.

11a.

b.

c. Cigarettes ____

12a.

b. Pounds ____

13a.
[1-5]

a. Had problem

b. Prevented care

13b.
[1-5]

a. Had problem

b. Prevented care

[p. 90]

If 17+, ask:
1a. What is the highest grade or year -- attended in school?

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

2a. 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.

c. Does -- have a service connected disability?

3a. 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 3a, b, or c.

If "Yes" in 3c only, questions 4a through 4e apply to this person's LAST full-time civilian job.


4a. 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. [Occupation] ____

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 4a-d; if not clear, ask:

e. Was --

[p. 91]

[MK Note: Page 91 has a response sheet for questions asked on page 90. The response sheet has five columns to enter responses in; only one is represented here since each column contains the same information.]

1a.

b.

2a.

b.

c.

3a.

b.

c.

d.

4a. Employer ____

b. Industry ____

c. Occupation ____

d. Duties ____

e. Class of worker

[MK Note: End response sheet]

[p. 92]

If 17+, ask:
5a. During the past 12 months, about how many months did you have a job?

b. During that period, ABOUT how many days did illness or injury keep -- from work -- not counting work around the house?

Hand Card O

CARD O
National Origin or Ancestry

If 17+, ask:
6a. Which of those groups BEST describes --'s national origin or ancestry?

If multiple entries, ask:
b. Which of those groups, that is, (entries in 6a) would you say BEST describes --'s national origin or ancestry? (Specify) ____

7a. During the past 12 months, has anyone in the family received medical care which has been or will be paid for by MEDICARE?

b. Who was this? ____

Mark "Medicare" in person's column.

c. Anyone else?

8a. There is a public program called -- (Medicaid) which provides medical assistance to persons in need. During the past 12 months, has anyone in the family received medical care which has been or will be paid for by -- (MEDICAID)?

b. Who was this? ____

Mark "Medicaid" in person's column.

c. Anyone else?

9a. During the past 12 months, has anyone in the family received medical care provided or paid for by the Veterans Administration?

b. Who was this? ____

Mark "VA" in person's column.

c. Anyone else?

[p. 93]

[MK Note: Page 93 contains a response sheet for questions asked on page 92. The response sheet has five columns to enter responses in; only one is represented here since each column contains the same information.]

5a.

b.

6a.

b. (Specify) ____

7b.

8b.

9b.

[MK Note: End response sheet]

[p. 94]

Hand Card I
CARD I

10. 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.

11a. Which (other) family members received some income during the past 12 months? ____

Mark "Income" box in person's column.

b. Did any other family members receive any income during the past 12 months?

If only one person with "Income" box marked, go to 13.

If 2 ore more persons with "Income" box marked, ask 12 for each:

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

13a. During the past 12 months, did anyone in the family receive any payments or benefits from Workmen's Compensation?

b. Who was this? ____

Mark "Workmen's Compensation" box in person's column.

c. Anyone else?

14a. During the past 12 months, did anyone in the family receive any disability payments or disability benefits from -

If "Yes," ask 14b.
b. Was this because of a disability?

If "Yes," ask 14c and d, otherwise continue with list.

c. Who was this? ____
Mark appropriate box in person's column.

d. Anyone else? ____

15a. Does anyone in this family receive assistance through the "Aid to Families with Dependent Children" Program, sometimes called "AFDC" or "ADC"?

b. Which (other) family members are included in the AFDC assistance payment? ____

Mark "AFDC" box in each person's column.

c. Are any other family members included in this program?

[p. 95]

[MK Note: Page 95 is a response sheet for questions asked on page 60 and page 94. The response sheet has five columns to enter responses in; only one is represented here since each column contains the same information.]

SP []
D []

[2-6]
1a.

2.

3.

C

BED DAYS

DV

HOSP.

Q. No. (Rows 1-5)

Condition (Rows 1-5)

11a.

12.

13b.

14b.

15b.