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[p. 58]

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.

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)

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

L

Ask Condition list ____.

C

1. Record the number of Bed Days, Doctor Visits, and Hospitalizations.

BED DAYS
[] None (NP)
____ (NP)
DV
[] None (NP)
____ (NP)
HOSP.
[] None (NP)
____ (NP)

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

Reference dates
2-week period ____, ____
12-month Bed Days and Doctor visit probe ____
Hospital probe ____

Q. no. ____
Condition ____


[MK Note: End section C]


If 17+, ask:
4. 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

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).

5a. During those 2 weeks, did -- stay in bed because of any illness or injury?

[] Y (5b)
00 [] N (If age: 17+ (6), 6-16 (7), Under 6 (9))

b. During that 2-week period, how many days did -- stay in bed all or most of the day?

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

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

WL ____ days (8)
00 [] None (9)

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

SL days ____
00 [] None (9)

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

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

[work
school]

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

Days ____
00 [] None

9a. 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 (10)

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

10a. What condition caused -- to

[stay in bed
miss work
miss school
cut down]

during the past 2 weeks? ____

Enter condition in item C. Ask 10b.

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 condition in item C (10b)

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

[p. 59]


[MK Note: Page 59 appears to be a response sheet for questions asked on page 58. It contains five identical columns in which to enter responses; only one is represented here since all columns contain the same information.]

4.

0 [] Under 17
1 [] Married - spouse present
6 [] Married - spouse absent
2 [] Widowed
4 [] Divorced
5 [] Separated
3 [] Never married
H
0 [] Under 17
1 [] At home
2 [] Not at home

5a.

[] Y (5b)
00 [] N If age: 17+ (6), 6-16 (7), Under 6 (9)

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

6.

WL days ____ (8)
00 [] None (9)

7.

SL days ____
00 [] None (9)

8.

Days ____
00 [] None

9a.

1 [] Y
2 [] N (10)

b.

Days ____
00 [] None

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

b.

[] Y
[] N (NP)

c. Enter condition in item C (10b) ____

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

[p. 60]

11a. During the past 2 weeks, did anyone in the family, that is you, your --, etc. have any (other) accidents or injuries?

[] Y
[] N (12)

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 (11b 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


12a. During the past 2 weeks, did anyone in the family go to a dentist?

[] Y
[] N (13)

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 12b 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.
Mark box or ask:
13. ABOUT how long has it been since -- LAST went to a dentist?

1 [] 2-week dental visit
2 [] Past 2 weeks not reported (12)
3 [] 2 weeks - 6 months
4 [] Over 6 - 12 months
5 [] 1 year
6 [] 2 - 4 years
7 [] 5+ years
8 [] Never

[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.]

11a.

[] Y
[] N (12)

b.

[] Accident or injury

c. Injury ____

d.

[] Y (11b and c)
[] N

e.

[] Y (Enter injury in Item C)
[] N

12a.

[] Y
[] N (13)

b.

[] Dental visit

c.

[] Y (Reask 12b and c)
[] N

d.

No. of dental visits ____ (NP)

13.

1 [] 2-week dental visit
2 [] Past 2 weeks not reported (12)
3 [] 2 weeks - 6 months
4 [] Over 6 - 12 months
5 [] 1 year
6 [] 2 - 4 years
7 [] 5+ years
8 [] Never

[p. 62]


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.

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

(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?

[] Y
[] N (16)

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

[] Doctor visit

c. Anyone else?

[] Y (15b and c)
[] N

If "Doctor visit," ask:
d. How many times did -- visit the doctor during that period?

Number of visits ____ (NP)

16a. During that period, did anyone in the family get any medical advice from a doctor over the telephone?

[] Y
[] N (17)

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 16b 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, (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?

[] Condition (item C THEN 17d)
[] Pregnancy (17e)
[] 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 17d.

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

[] Y (17c)
[] N (NP)

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

[] Y
[] N (17d)

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.)

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? Include doctors seen while a patient in a hospital.

1 [] 2-week DV
2 [] Past 2 weeks not reported (14 and 17)
3 [] 2 wks. - 6 mos.
4 [] Over 6 - 12 mos.
5 [] 1 year
6 [] 2 - 4 years
7 [] 5+ years
8 [] Never

[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.]

14.

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

15b.

[] Doctor visit

d. Number of visits ____ (NP)

16b.

[] Phone call

d. Number of calls ____ (NP)

17a.

[] Condition (item C THEN 17d)
[] Pregnancy (17e)
[] No condition

b.

[] Y
[] N (NP)

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

d.

[] Y (17c)
[] N (NP)

e.

[] Y
[] N (17d)

f. Enter condition in item C (17d)

18a.

000 [] Only when in hospital
000 [] None
Number of visits ____

b.

1 [] 2-week DV
2 [] Past 2 weeks not reported (14 and 17)
3 [] 2 wks. - 6 mos.
4 [] Over 6 - 12 mos.
5 [] 1 year
6 [] 2 - 4 years
7 [] 5+ years
8 [] Never

[p. 64]


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?

1 [] Working (24a)
2 [] Keeping house (24b)
3 [] Retired, health (23)
4 [] Retired, other (23)
5 [] Going to school (26)
6 [] 17+ something else (23)
7 [] 6-16 something else (25)

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?

1 [] Working (24a)
2 [] Keeping house (24b)
3 [] Retired, health (23)
4 [] Retired, other (23)
5 [] Going to school (26)
6 [] 17+ something else (23)
7 [] 6-16 something else (25)

If "something else," ask:

b. What was -- doing? ____


Ages under 6:

0 [] 1-5 yrs. (21)
0 [] Under 1 (22)

21a. Is -- able to take part at all in ordinary play with other children?

[] Y
1 [] N (28)

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

2 [] Y (28)
[] N

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

2 [] Y (28)
[] N (27)

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

[] Y
5 [] N (NP)

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

23a. Does -- health now keep him from working?

1 [] Y (28)
[] N

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

2 [] Y (28)
[] N

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

2 [] Y (28)
[] N

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

3 [] Y (28)
[] N (27)

24a. Does -- NOW have a job?

[] Y (24c)
[] N

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

[] Y
1 [] N (28)

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

2 [] Y (28)
[] N

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

2 [] Y (28)
[] N

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

3 [] Y (28)
[] N (27)

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

[] Y
1 [] N (28)

26a. Does (would) -- have to go to a certain type of school because of his health?

2 [] Y (28)
[] N

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

2 [] Y (28)
[] N

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

3 [] Y (28)
[] N

27a. 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 ________


28a. 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 28c

[] Old age only (NP)

c. Is this limitation caused by any other condition?

[] Y (Reask 28b 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. 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.]

19.

1 [] Working (24a)
2 [] Keeping house (24b)
3 [] Retired, health (23)
4 [] Retired, other (23)
5 [] Going to school (26)
6 [] 17+ something else (23)
7 [] 6-16 something else (25)
0 [] 1-5 yrs. (21)
0 [] Under 1 (22)

20.

1 [] Working (24a)
2 [] Keeping house (24b)
3 [] Retired, health (23)
4 [] Retired, other (23)
5 [] Going to school (26)
6 [] 17+ something else (23)
7 [] 6-16 something else (25)
0 [] 1-5 yrs. (21)
0 [] Under 1 (22)

21a.

[] Y
1 [] N (28)

b.

2 [] Y (28)
[] N

c.

2 [] Y (28)
[] N (27)

22a.

[] Y
5 [] N (NP)

b. ____ (28)

23a.

1 [] Y (28)
[] N

b.

2 [] Y (28)
[] N

c.

2 [] Y (28)
[] N

d.

3 [] Y (28)
[] N (27)

24a.

[] Y (24c)
[] N

b.

[] Y
1 [] N (28)

c.

2 [] Y (28)
[] N

d.

2 [] Y (28)
[] N

e.

3 [] Y (28)
[] N (27)

25.

[] Y
1 [] N (28)

26a.

2 [] Y (28)
[] N

b.

2 [] Y (28)
[] N

c.

3 [] Y (28)
[] N

27a.

4 [] Y
5 [] N (NP)

b. ________

28a.

000 [] Less than 1 month
1 [] Mos. ____
2 [] Yrs. ____

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

[] Old age only, Mark D box, THEN (NP)

c.

[] Y (Reask 28b and c)
[] N

d.

[] Only 1 condition
Enter main condition ____

[p. 66]

29a. 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)

30a. Was anyone in the family in a nursing home, convalescent home or similar place since (date) a year ago?

[] Y
[] N (31)

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.

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.

[] Y
[] N (NP)

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

[] Y
[] N

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

[p. 67]


[MK Note: Page 67 contains a response sheet for questions asked on page 66. The response sheet has five columns; only one is represented here since each column contains the same information.]

29a.

[] Y
[] N (Item C)

b. Times ____ (Item C)

30b.

[] Y

c. Times ____ (Item C)

31a.

[] Y
[] N (NP)

b.

[] Y
[] N

[p. 68]

1

32a. DURING THE PAST 12 MONTHS, did anyone in the family (you, your --, etc.) have --

Conditions affecting the digestive system.
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 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. During the past 12 months, did anyone else have [conditions affecting the digestive system]?

Make no entry in item C for cold, flu, or grippe even if reported in question 32.

2

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

A. Permanent stiffness or any deformity of the foot, leg, fingers, arm or back? (Permanent stiffness - joints will not move at all) ____
B. Paralysis of any kind? ____

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 affecting the joints]?

32d. DURING THE PAST 12 MONTHS, did anyone in the family (you, your --, etc.) have --

Conditions C-N and V are conditions affecting the bone and muscle.
C. Arthritis of any kind or Rheumatism? ____
D. Gout? ____
E. Lumbago? ____
F. Osteomyelitis? (os-tee-oh-my-uh-lite-iss) ____
G. A bone cyst or bone spur? ____
H. Any other disease of the bone or cartilage? ____
I. Trick knee? ____
J. A slipped or ruptured disc? ____
K. Curvature of the spine? ____
L. REPEATED trouble with neck, back, or spine? ____
M. Bursitis or Synovitis? (sin-uh-vite-iss) ____
N. Any disease of the muscles or tendons? ____

If "Yes," ask 32e and f.

e. Who was this? ____

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

f. During the past 12 months, did anyone else have [conditions affecting the bone and muscle]? ____

3

32a. DURING THE PAST 12 MONTHS, did anyone in the family (you, your --, etc.) have --

Glandular disorders
A. Goiter or other thyroid trouble? ____
B. Diabetes? ____
C. Cystic fibrosis? ____
Blood disorder
D. Anemia? ____
Conditions affecting the nervous system
E. Epilepsy? ____
F. Multiple sclerosis? ____
G. Migraine? ____

If "Yes," ask 32b 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 [glandular disorders, blood disorders, or conditions affecting the nervous system]? ____

[p. 69]

1

32a. DURING THE PAST 12 MONTHS, did anyone in the family have --

Conditions affecting the digestive system.
Q. Diverticulitis?
R. Colitis?
S. Spastic colon?
T. FREQUENT constipation?
U. Any other bowel trouble?
V. Any other intestinal trouble?
W. Cancer of the stomach, colon, or rectum?
X. During the past 12 months, did anyone in the family have any other condition of the digestive system.
If "Yes," ask: Who was this? What was the condition? (Enter in item C) ____

Make no entry in item C for cold, flu, or grippe even if reported in question 32.

If "Yes," ask 32b and c.

b. Who was this? ____

Enter in item C.

c. During the past 12 months, did anyone else have [conditions affecting the digestive system]?

2

32d. DURING THE PAST 12 MONTHS, did anyone in the family have --

Condition O-U and W-Z are conditions affecting the skin.
O. A tumor, cyst or growth of the skin? ____
P. Eczema or psoriasis? (so-rye-uh-sis) ____
Q. TROUBLE with dry or itching skin? ____
R. TROUBLE with acne? ____
S. A skin ulcer? ____
T. Any kind of skin allergy? ____
U. Dermatitis or any other skin trouble? ____
V. TROUBLE with fallen arches, flatfeet or clubfoot? ____
W. TROUBLE with ingrown toenails or fingernails? ____
X. TROUBLE with bunions, corns, or calluses? ____
Y. A disease of the hair or scalp? ____
Z. Any disease of the lymph or sweat glands? ____

If "Yes," ask 32e and f.

e. Who was this? ____

Enter in item C.

f. During the past 12 months, did anyone else have [conditions affecting the skin]? ____

3

32a. DURING THE PAST 12 MONTHS, did anyone in the family have -

Conditions affecting the nervous system
H. Neuralgia or neuritis? ____
I. Sciatica? ____
Genito-urinary conditions
J. Nephritis? ____
K. Kidney stones? ____
L. Any other kidney trouble? ____
M. Bladder trouble? ____
N. Prostate trouble? ____
O. Disease of the uterus or ovary? ____
P. Any other female trouble? ____

If "Yes," ask 32 b and c.

b. Who was this? ____

Enter in item C.

c. During the past 12 months, did anyone else have [conditions affecting the nervous system/ genito-urinary conditions]? ____

[p. 70]

4

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

A-L are conditions affecting hearing/ vision/ speech
A. Deafness in one or both ears? ____
B. Any other trouble hearing with one or both ears? ____
C. Tinnitus or ringing in the ears? ____
D. Blindness in one or both eyes? ____
E. Cataracts? ____
F. Glaucoma? ____
G. Color blindness? ____
H. A detached retina or any other condition of the retina? ____
I. Any other trouble seeing with one or both eyes even when wearing glasses? ____
J. A cleft palate or harelip? ____
K. Stammering or stuttering? ____
L. Any other speech defect? ____
M. A missing finger, hand, or arm, toe, foot, or leg? ____
N. A missing (breast), kidney or lung? ____

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 affecting hearing/vision/speech]? ____

5

32a. Has anyone in the family (you, your --, etc.) EVER had --

Conditions affecting the heart and circulatory system.
A. Rheumatic fever? ____
B. Rheumatic heart disease? ____
C. Hardening of the arteries or arteriosclerosis? ____
D. Congenital heart disease? ____
E. Coronary heart disease? ____
F. High blood pressure? ____
G. Stroke or a cerebrovascular accident? ____
H. Hemorrhage of the brain? ____
I. Angina pectoris? ____
J. Myocardial infarction? ____
K. Any other heart attack?

If "Yes," ask 32b 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. Has anyone else ever had [conditions affecting the heart and circulatory system]? ____

6

32a. DURING THE PAST 12 MONTHS, did anyone in the family (you, your --, etc.) have --

Conditions affecting the respiratory system.
A. Bronchitis? ____
B. Bronchiectasis? (brong-ke-ek-tah-sis) ____
C. Asthma? ____
D. Hay fever? ____
E. Nasal polyp? ____
F. Sinus trouble? ____
G. Deflected or deviated nasal septum? ____
H. *Tonsillitis or enlargement of the tonsils or adenoids? ____
I. *Laryngitis? ____

If "Yes," ask 32b 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 affecting the respiratory system]? ____

*If reported in question 32 only ask:

1. How many times did -- have [condition] in the past 12 months? ____

If 2+ enter in item C.

If only 1 time, ask:

2. How long did it last? ____

If 1 month or longer, enter in item C.
If less than 1 month, do not record.

If tonsils or adenoids removed during the past 12 months, enter condition causing removal in item C.

Make no entry in item C for cold; flu; red, sore, or strep throat; or "virus" reported in answer to question 32.

[p. 71]

4

32a. Does anyone in the family NOW have --

Conditions O-W are impairments.
Conditions Y and Z affect the nervous system.
O. Palsy or cerebral palsy? ____
P. Paralysis of any kind? ____
Q. Curvature of the spine? ____
R. REPEATED trouble with the back or spine? ____
S. Any TROUBLE with fallen arches or flatfeet? ____
T. A clubfoot? ____
U. PERMANENT stiffness or any deformity of the back, foot, or leg? (Permanent stiffness - joints will not move at all) ____
V. PERMANENT stiffness or any deformity of the fingers, hand, or arm? ____
W. Mental retardation? ____
X. Any condition caused by an old accident or injury?
If "Yes," ask: What is the condition?
Y. Epilepsy?____
Z. REPEATED convulsions, seizures, or blackouts? ____

If "Yes," ask 32b and c.

b. Who is this? ____

Enter in item C.

c. Does anyone else have [impairments/ conditions affecting the nervous system]? ____

5

32a. DURING THE PAST 12 MONTHS, did anyone in the family (you, your --, etc.) have --

Conditions affecting the heart and circulatory system.
L. Damaged heart valves? ____
M. Tachycardia or rapid heart? ____
N. Heart murmur? ____
O. Any other heart trouble? ____
P. Aneurysm? ____
Q. Any blood clots? ____
R. Gangrene? ____
S. Varicose veins? ____
T. Hemorrhoids or piles? ____
U. Phlebitis or thrombophlebitis? ____
V. Any other condition affecting blood circulation? ____

If "Yes," ask 32b and c.

b. Who was this? ____

Enter in item C.

c. During the past 12 months did anyone else have [conditions affecting the heart and circulatory system]? ____

6

32a. DURING THE PAST 12 MONTHS, did anyone in the family have -

Conditions affecting the respiratory system.
J. Tumor, cyst, or growth of the bronchial tube or lung? ____
K. Emphysema? ____
L. Pleurisy? ____
M. Tuberculosis? ____
N. Abscess of the lung? ____
O. Tumor, cyst, or growth of the throat, larynx, or trachea? ____
P. Any work-related respiratory condition such as dust on the lungs, silicosis or pneu-mo-co-ni-o-sis? ____
Q. During the past 12 months did anyone in the family have any other respiratory, lung, or pulmonary condition? ____
If "Yes," ask: Who was this? What was the condition? (Enter in item C) ____

If "Yes," ask 32b and c.

b. Who was this? ____

Enter in item C.

c. During the past 12 months, did anyone else have [conditions affecting the respiratory system]? ____

Make no entry in item C for cold; flu; red, sore, or strep throat; or "virus" reported in answer to question 32.

[p. 72]



33. 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


BD

Mark box(es) for item C.

1 [] 1+ Bed Days
2 [] 1+ Hospital Stays
3 [] No Bed Days

34. 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 +)


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.

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

[p. 73]


[MK Note: Page 73 contains a response sheet for questions asked on page 72. The response sheet has five columns to enter information in; only one is represented here since each column contains the same information.]

33.

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

BD

1 [] 1+ Bed Days
2 [] 1+ Hospital Stays
3 [] No Bed Days

34.

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

R

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

[p. 82]

USUAL SOURCE OF CARE


1. Is there a particular clinic, health center, doctor's office or other place that -- usually goes to if he is sick or needs advice about his health?

1 [] Y
2 [] N (7)


2. What kind of place is it -- a clinic, a health center, a hospital, a doctor's office, or some other place?
IF HOSPITAL: Is this an outpatient clinic or the emergency room?
IF CLINIC: Is this a hospital outpatient clinic, a company clinic, or some other kind of clinic?

1 [] Doctor's office (group practice or doctor's clinic)
2 [] Hospital outpatient clinic
3 [] Home
4 [] Hospital emergency room
5 [] Company or industry clinic
6 [] Health center
7 [] Other (Specify) ____


3. Is there ONE particular doctor -- usually sees at (place in 2)?

1 [] Y
2 [] N

If "Home" in 2, go to 6; otherwise ask:

4. In what city (town), county and State is the (place in 2) located?

City ____
County ____
State ____


5. About how long does it usually take -- to get to the (place in 2)?

Minutes ____

6. The LAST time -- saw a doctor was it at the SAME (place in 2) or some other place?

1 [] Same place (NP)
2 [] Other place (8)


Hand Card P

CARD P

1. Have two or more usual doctors or places depending on what is wrong.
2. Haven't needed a doctor.
3. Previous doctor no longer available.
4. Haven't been able to find the right doctor.
5. Recently moved to area.
6. Other reason - Please Specify

7. Many people do not have a particular place they usually go when they are sick or need advice about their health. Could you please give me the number of the statement which is the MAIN reason -- does not have a particular place he usually goes?

[] 1
[] 2
[] 3
[] 4
[] 5
[] 6 (Specify) ____

Mark box or ask:

8. The LAST time -- saw a doctor was it at a clinic, a health center, a hospital, a doctor's office, or some other place?

IF HOSPITAL: Is this an outpatient clinic or the emergency room?
IF CLINIC: Is this a hospital outpatient clinic, a company clinic, or some other kind of clinic?

[] 2 week DV in C1 (NP)
1 [] Doctor's office (group practice or doctor's clinic)
2 [] Hospital outpatient clinic
3 [] Home
4 [] Hospital emergency room
5 [] Company or industry clinic
6 [] Health center
7 [] Other (Specify) ____

[p. 83]


[MK Note: Page 83 contains a response sheet for questions asked on page 82. The response sheet contains 5 columns in which to enter responses; only one is represented here since each column contains the same information.]

1.

1 [] Y
2 [] N (7)

2.

1 [] Doctor's office (group practice or doctor's clinic)
2 [] Hospital outpatient clinic
3 [] Home
4 [] Hospital emergency room
5 [] Company or industry clinic
6 [] Health center
7 [] Other (Specify) ____

3.

1 [] Y
2 [] N

4.

City ____
County ____
State ____

5. Minutes ____

6.

1 [] Same place (NP)
2 [] Other place (8)

7.

[] 1
[] 2
[] 3
[] 4
[] 5
[] 6 (Specify) ____

8.

[] 2 week DV in C1 (NP)
1 [] Doctor's office (group practice or doctor's clinic)
2 [] Hospital outpatient clinic
3 [] Home
4 [] Hospital emergency room
5 [] Company or industry clinic
6 [] Health center
7 [] Other (Specify) ____

[p. 84]

BLOOD DONOR


D

1 [] 17-64 (1)
2 [] Other (NP)

1a. During the past 12 months, has -- given or sold any blood to a blood bank, a hospital, the Red Cross, or anywhere else?

1 [] Y
2 [] N (2)


b. During the past 12 months, how many times has -- given or sold blood? ____


Hand Card B

For each time reported in 1b, ask:

c. Which of the reasons listed on this card best describes why -- gave blood (the last time/the time before that, etc.)? Please give me the number of the reason.

CARD B
1. Sold blood.
2. Replaced blood used by a relative or friend.
3. Unpaid donation to a blood bank to assure free blood for this family in the future.
4. Other unpaid blood donation which was NOT for replacement and did NOT assure free blood for this family in the future.
5. Some other reason -- Specify

[The response indicates 4 rows listed in descending order from most recent to the least recent. The response choices are the same and only one row is indicated here.]

[Rows 1-4]
(Last time)

[] 1 (3)
[] 2 (3)
[] 3 (3)
[] 4 (3)
[] 5 (Specify) ____ (3)


2a. Has -- EVER given or sold blood to a blood bank, a hospital, the Red Cross or anywhere else?

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


b. About how long has it been since -- LAST gave or sold blood?

(Was it more than 5 years or less than 5 years?)
(Was it more than 10 years or less than 10 years?)

Years ____
99 [] DK


3. About how many times has -- EVER given or sold blood?

Times ____
99 [] DK


4. Has -- EVER been asked in person, either face-to-face or over the telephone, to give or sell blood?

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


R1
Q's 1-4

For persons aged 17-64, show who responded for (or was present during the asking of) Questions 1-4.

If person responded for self, show whether entirely or partly.

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

[p. 85]


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

D

1 [] 17-64 (1)
2 [] Other (NP)
1a.

1 [] Y
2 [] N (2)

b. Times ____

c.

Rows 1-4
(Last time)
[] 1 (3)
[] 2 (3)
[] 3 (3)
[] 4 (3)
[] 5 (Specify) ____ (3)

2a.

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

b.

Years ____
99 [] DK

3.

Times ____
99 [] DK

4.

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

R1

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

[p. 88]

Mark box or ask:

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

[] Under 17 (NP)
1 [] Y
2 [] N (NP)

2a. In which branch or branches of the Armed Forces did -- serve? Mark all that apply.

1 [] Air Force
2 [] Army
3 [] Navy
4 [] Marines
5 [] Coast Guard

If only one entry in 2a, mark corresponding box; otherwise ask:

b. In which did -- serve most recently?

1 [] Air Force
2 [] Army
3 [] Navy
4 [] Marines
5 [] Coast Guard

c. When did -- serve in the (entry in 2b)?
Circle code in descending order of priority. Thus if person served in Vietnam and in Korea, circle VN.

Vietnam Era (Aug. '64 to April '75) . . . VN
Korean War (June '50 - Jan. '55) . . . KW
World War II (Sept. '40 - July '47) . . . WWII
World War I (April '17 - Nov. '18) . . . WWI
Post Vietnam (May '75 to present) . . . PVN
Other Service (all other periods) . . . OS
1 [] VN
2 [] KW
3 [] WWII
4 [] WWI
5 [] PVN
6 [] OS
9 [] DK


d. In what year did -- leave the (entry in 2b)?
Year 19 _ _


e. How many total years did -- serve on active duty in the (entries in 2a)?

Years ____


f. Does -- have a service connected disability?

1 [] Y
2 [] N


3a. Does -- get retirement payments or a pension from the (entry in 2b) or the Veterans Administration?

[] Y
5 [] N (NP)

b. From which does -- get the retirement payments or the pension?

1 [] Service
2 [] VA

[p. 89]


[MK Note: Page 89 contains a response sheet for questions asked on page 88. The response sheet contains five columns to enter responses in; only one is represented here since each column contains the same information.]

1.

[] Under 17 (NP)
1 [] Y
2 [] N (NP)

2a.

1 [] Air Force
2 [] Army
3 [] Navy
4 [] Marines
5 [] Coast Guard

b.

1 [] Air Force
2 [] Army
3 [] Navy
4 [] Marines
5 [] Coast Guard

c.

1 [] VN
2 [] KW
3 [] WWII
4 [] WWI
5 [] PVN
6 [] OS
9 [] DK

d. Year 19 _ _

e. Years ____

f.

1 [] Y
2 [] N

3a.

[] Y
5 [] N (NP)

b.

1 [] Service
2 [] VA

4a. Does anyone in this family receive assistance through the "AID to Families with Dependent Children" Program, sometimes called "AFDC" or "ADC"?

1 [] Y
2 [] N (5)

b. Which (other) family members are included in the AFDC assistance payment? Mark "AFDC" box in person's column.

1 [] AFDC

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

Y [] (Reask 4b and c)
N []

5a. Does anyone in this family receive the "Supplemental Security Income" or "SSI" gold-colored check?

Y []
N []

(6)

b. Who receives this check? Mark "SSI" box in person's column.

1 [] SSI

c. Anyone else?

Y (reask 6b and c)
N

6a. There is a national program called Medicaid which pays for health care for persons in need. (In this State it is also called ___.) During the past 12 months, has anyone in this family received health care which has been or will be paid for by Medicaid (or ___)?

Y []
N [] (7)

b. Who was this? Mark "Medicaid" box in person's column.

1 [] Medicaid

c. Anyone else?

Y [] (Reask 6b and c)
N []

7a. Does anyone in this family now have a Medicaid (or ____) card which looks like this? Show Medicaid card.

Y []
N [] (8)

b. Who is this? Mark "Card" box in person's column.

1 [] Card

c. Anyone else?

Y [] (Reask 7b and c)
N []

If "Card," ask:

d. May I please see __'s (and __) card(s)?
Mark appropriate box(es) in person's column.

[] Medicaid card seen
1 [] Current
2 [] Expired
3 [] No card seen
4 [] Other card seen Specify _________

8a. During the past 12 months, has anyone in the family received health care provided or paid for by the Veteran's Administration?

Y []
N [] (9)

b. Who was this? Mark "VA" box in person's column.

1 [] VA

c. Anyone else?

Y [] (Reask 8b and c)
N []


[p. 91]


Mark box or ask:

9a. About how tall is -- without shoes?

[] Under 17 (NP)
Feet ____
Inches ____


b. About how much does -- weigh without shoes? ____

Mark box or ask:


10a. What is the highest grade or year -- attended in school?

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


Hand Card R
CARD R

1. Alaskan Native or American Indian
2. Asian or Pacific Islander
3. Black
4. White
5. Another group not listed -- Please specify

Mark box or ask:
11a. Please give me the number of the group or groups which describes --'s racial background.
Circle all that apply.

[] Under 17 (NP)
[]1
[] 2
[] 3
[] 4
[] 5 (Specify) ____

If multiple entries ask:
b. Which of those groups; that is, (entries in 11a) would you say BEST describes --'s racial background?

[] 1
[] 2
[] 3
[] 4
[] 5 (Specify) ____


Hand Card O
CARD O

1. Puerto Rican
2. Cuban
3. Mexican
4. Mexicano
5. Mexican-American
6. Chicano
7. Other Latin American
8. Other Spanish

Mark box or ask:
12a. Are any of those groups --'s national origin or ancestry? (Where did --'s ancestors come from?)

[] Under 17 (NP)
1 [] Y
2 [] N (NP)

b. Please give me the number of the group.
Circle all that apply.

[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8

[p. 93]


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

9a.

[] Under 17 (NP)
Feet ____
Inches ____

b. Pounds ____

10a.

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

Elem.
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
High
[] 9
[] 10
[] 11
[] 12
College
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6+

b.

1 [] Y
2 [] N

11a.

[] Under 17 (NP)
[] 1
[] 2
[] 3
[] 4
[] 5 (Specify) ____

b.

[] 1
[] 2
[] 3
[] 4
[] 5 (Specify) ____

12a.

[] Under 17 (NP)
1 [] Y
2 [] N (NP)

b.

[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8

[p. 94]

Mark box or ask:


13a. Did -- work at any time last week or the week before -- not counting work around the house?

[] Under 17 (NP)
1 [] Y (14)
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 (14)

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 13a, b, or c.

If "Yes" in 13c only, questions 14a through 14e apply to this person's LAST full-time civilian job.

14a. 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 14a-d; if not clear, ask:

e. Was --

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

Class of worker

1 [] P
2 [] F
3 [] S
4 [] L
5 [] I
6 [] SE
7 [] WP
8 [] NEV


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

15. 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


16a. Which (other) family members received some income during the past 12 months? ____
Mark "Income" box in person's column.

[] Income

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

[] Y (Reask 16a and b)
[] N

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

If 2 or more persons with "Income" box marked, ask 17 for each:


17. 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

[p. 95]


[MK Note: Page 95 is a response sheet for questions asked on page 58 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.]

(2-6)

1a.

First name ____
Last name ____
Age ____
Race
1 [] W
2 [] B
3 [] OT

2.

Relationship ____
Sex
1 [] M
2 [] F

3.

Month ____
Date ____
Year ____

C

BED DAYS

[] None (NP)
____ (NP)

DV

[] None (NP)
____ (NP)

HOSP.

[] None (NP)
____ (NP)

Q. No. (Rows 1-5) ____
Condition (Rows 1-5) ____

13a.

[] Under 17 (NP)
1 [] Y (14)
2 [] N

b.

1 [] Y
2 [] N

c.

1 [] Y
2 [] N (14)

d.

1 [] Looking
2 [] Layoff
3 [] Both

14a. Employer ____

b. Industry ____

c. Occupation ____

d. Duties ____

e. Class of worker

1 [] P
2 [] F
3 [] S
4 [] L
5 [] I
6 [] SE
7 [] WP
8 [] NEV

16a.

[] Income

17.

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