[p. 82]

CONDITION 1

1. Person number

____

Name of condition

____

2. When did -- last see or talk to a doctor about his [condition] ?

1 [] In interview week (Reask 2)
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

[] Color blindness (NC)
[] 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] ?

________
[] On Card C (A2)
[] Accident or injury (A2)

If the entry in 3a or 3b includes the words:

Ailment
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:

Abscess
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:

Head .... skull, scalp, face
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:

1 [] Item 1
2 [] Q. 3a
3 [] Q. 3b
4 [] Q. 3c
5 [] Q. 3d
6 [] Q. 3e

4. During the past 2 weeks, did his [condition] cause him to cut down on the things he usually does?

1 [] Y
2 [] N (9)

5. During that period, how many days did he cut down for as much as a day?

Days ____
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?

Days ____
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?

Days ____ (9)
00 [] None (9)

Ask if 6-16 years:

8. How many days did his [condition] keep him from school during that 2-week period?

Days ____
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?)

1 [] Last week
2 [] Week before
3 [] Past 2 weeks - DK which
4 [] 2 weeks - 3 months
5 [] 3 - 12 months
6 [] More than 12 months ago

1 [] Not an eye cond. (AA)
2 [] First eye cond. (under 6) (AA)
3 [] First eye cond. (6+ yrs.) (10)
4 [] Not first eye cond. (AA)

10. Can -- see well enough to read ordinary newspaper print with glasses with his

left eye?

1 [] Y
2 [] N

right eye?

1 [] Y
2 [] N

[p. 83]

1 [] Missing extremity or organ (A4)
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)

11a. Does -- now take any medicine or treatment for his [condition]?

1 [] Y
2 [] N (12)

b. Was any of this medicine or treatment recommended by a doctor?

1 [] Y
2 [] N

12. Has he ever had surgery for this condition?

1 [] Y
2 [] N

13. Was he ever hospitalized for this condition?

1 [] Y
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)

Times ____
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?

Days ____
000 [] None

Ask if 17+ years:
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?

Days ____
000 [] None

16a. How often does his [condition ] bother him - all of the time, often, once in a while, or never?

1 [] All the time
2 [] Often
3 [] Once in a while
0 [] Never (16c)
8 [] Other - Specify ____

b. When it does bother him, is he bothered a great deal, some, or very little?

1 [] Great deal
2 [] Some
3 [] Very little
4 [] Other - Specify ____

[] All the time in 16a OR condition list 4 asked (A4)

c. Does -- still have this condition?

1 [] Y (A4)
2 [] N

d. Is this condition completely cured or is it under control?

2 [] Cured
3 [] Under control (A4)
4 [] Other - Specify ____ (A4)

e. About how long did -- have this condition before it was cured?

0 [] Less than one month
Months ____
Year ____

[] Accident or injury
[] Other (NC)

17a. Did the accident happen during the past 2 years or before that time?

[] During the past 2 years
[] Before 2 years (18a)

b. When did the accident happen?

[] Last week
[] 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?

Part(s) of body ____
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?

Part(s) of body ____
Present effects ____

19. Where did the accident happen?

1 [] At home (inside house)
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?

1 [] Y
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?

1 [] Y
2 [] N (NC)

b. Was more than one vehicle involved?

[] Y
[] N

c. Was it (either one) moving at the time?

1 [] Y
2 [] N

[p. 84]

CONDITION 2

1. Person number

____

Name of condition

____

2. When did -- last see or talk to a doctor about his [condition]?

1 [] In interview week (Reask 2)
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

[] Color blindness (NC)
[] 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] ?

____
[] On Card C (A2)
[] Accident or injury (A2)

If the entry in 3a or 3b includes the words:

Ailment
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:

Ask e:
e. What part of the body is affected?

____

Show the following detail:

Head .... skull, scalp, face
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:

1 [] Item 1
2 [] Q. 3a
3 [] Q. 3b
4 [] Q. 3c
5 [] Q. 3d
6 [] Q. 3e

4. During the past 2 weeks, did his [condition] cause him to cut down on the things he usually does?

1 [] Y
2 [] N (9)

5. During that period, how many days did he cut down for as much as a day?

Days ____
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?

Days ____
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?

Days ____ (9)
00 [] None (9)

Ask if 6-16 years:
8. How many days did his [condition] keep him from school during that 2-week period?

Days ____
00 [] None

1 [] Last week
2 [] Week before
3 [] Past 2 weeks - DK which
4 [] 2 weeks - 3 months
5 [] 3 - 12 months
6 [] More than 12 months ago

1 [] Not an eye cond. (AA)
2 [] First eye cond. (under 6) (AA)
3 [] First eye cond. (6+ yrs.) (10)
4 [] Not first eye cond. (AA)

10. Can -- see well enough to read ordinary newspaper print WITH GLASSES with his

left eye?

1 [] Y
2 [] N

right eye?

1 [] Y
2 [] N

[p.85]

11a. Does -- now take any medicine or treatment for his [condition] ?

1 [] Y
2 [] N (12)

b. Was any of this medicine or treatment recommended by a doctor?

1 [] Y
2 [] N

12. Has he ever had surgery for this condition?

1 [] Y
2 [] N

13. Was he ever hospitalized for this condition?

1 [] Y
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)

Times ____
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?

Days ____
000 [] None

Ask if 17+ years:
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?

Days ____
000 [] None

16a. How often does his [condition] bother him - all of the time, often, once in a while, or never?

1 [] All the time
2 [] Often
3 [] Once in a while
0 [] Never (16c)
8 [] Other - Specify ____

b. When it does bother him, is he bothered a great deal, some, or very little?

1 [] Great deal
2 [] Some
3 [] Very little
4 [] Other - Specify ____

[] All the time in 16a OR condition list 4 asked (A4)

c. Does -- still have this condition?

1 [] Y (A4)
2 [] N

d. Is this condition completely cured or is it under control?

2 [] Cured
3 [] Under control (A4)
4 [] Other - Specify ____ (A4)

e. About how long did -- have this condition before it was cured?

0 [] Less than one month
Months ____
Years ____

[] Accident or injury
[] Other (NC)

17a. Did the accident happen during the past 2 years or before that time?

[] During the past 2 years
[] Before 2 years (18a)

b. When did the accident happen?

[] Last week
[] 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?

Part(s) of body ____
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?

Part(s) of body ____
Present effects ____

19. Where did the accident happen?

20. Was -- at work at his job or business when the accident happened?

1 [] Y
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?

1 [] Y
2 [] N (NC)

b. Was more than one vehicle involved?

[] Y
[] N

c. Was it (either one) moving at the time?

1 [] Y
2 [] N

[p. 86]

CONDITION 3

1. Person number

____

Name of condition

____

2. When did -- last see or talk to a doctor about his [condition] ?

1 [] In interview week (Reask 2)
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

[] Color blindness (NC)
[] 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] ?

____
[] On Card C (A2)
[] Accident or injury (A2)

If the entry in 3a or 3b includes the words:

Ailment
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:

Ask e:
e. What part of the body is affected?

____

Show the following detail:

Head .... skull, scalp, face
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:

1 [] Item 1
2 [] Q. 3a
3 [] Q. 3b
4 [] Q. 3c
5 [] Q. 3d
6 [] Q. 3e

4. During the past 2 weeks, did his [condition] cause him to cut down on the things he usually does?

1 [] Y
2 [] N (9)

5. During that period, how many days did he cut down for as much as a day?

Days ____
00 [] None (9)

6. During that 2-week period, how many days did his -- keep him in bed all or most of the day?

Days ____
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?

Days (9) ____
00 [] None (9)

Ask if 6-16 years:
8. How many days did his [condition] keep him from school during that 2-week period?

Days ____
00 [] None

1 [] Last week
2 [] Week before
3 [] Past 2 weeks - DK which
4 [] 2 weeks - 3 months
5 [] 3 - 12 months
6 [] More than 12 months ago

1 [] Not an eye cond. (AA)
2 [] First eye cond. (under 6) (AA)
3 [] First eye cond. (6+ yrs.) (10)
4 [] Not first eye cond. (AA)

10. Can -- see well enough to read ordinary newspaper print with glasses with his

left eye?

1 [] Y
2 [] N

right eye?

1 [] Y
2 [] N

[p. 87]

11a. Does -- now take any medicine or treatment for his [condition] ?

1 [] Y
2 [] N (12)

b. Was any of this medicine or treatment recommended by a doctor?

1 [] Y
2 [] N

12. Has he ever had surgery for this condition?

1 [] Y
2 [] N

13. Was he ever hospitalized for this condition?

1 [] Y
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)

Times ____
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?

Days ____
000 [] None

Ask if 17+ years:
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?

Days ____
000 [] None

16a. How often does his [condition] bother him - all of the time, often, once in a while, or never?

1 [] All the time
2 [] Often
3 [] Once in a while
0 [] Never (16c)
8 [] Other - Specify ____

b. When it does bother him, is he bothered a great deal, some, or very little?

1 [] Great deal
2 [] Some
3 [] Very little
4 [] Other - Specify ____

[] All the time in 16a OR condition list 4 asked (A4)

c. Does -- still have this condition?

1 [] Y (A4)
2 [] N

d. Is this condition completely cured or is it under control?

2 [] Cured
3 [] Under control (A4)
4 [] Other - Specify ____ (A4)

e. About how long did -- have this condition before it was cured?

0 [] Less than one month
Months ____
Year ____

[] Accident or injury
[] Other (NC)

17a. Did the accident happen during the past 2 years or before that time?

[] During the past 2 years
[] Before 2 years (18a)

b. When did the accident happen?

[] Last week
[] 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?

Part(s) of body ____
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?

Part(s) of body ____
Present effects ____

19. Where did the accident happen?

20. Was -- at work at his job or business when the accident happened?

1 [] Y
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?

1 [] Y
2 [] N (NC)

b. Was more than one vehicle involved?

[] Y
[] N

c. Was it (either one) moving at the time?

1 [] Y
2 [] N

[p. 88]

CONDITION 4

1. Person number

____

Name of condition

____

2. When did -- last see or talk to a doctor about his [condition]?

1 [] In interview week (Reask 2)
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

Examine "Name of condition" entry and mark

[] Color blindness (NC)
[] 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] ?

____
[] On Card C (A2)
[] Accident or injury (A2)

If the entry in 3a or 3b includes the words:

Ailment
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:

Ask e:
e. What part of the body is affected?

____

Show the following detail:

Head .... skull, scalp, face
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:

1 [] Item 1
2 [] Q. 3a
3 [] Q. 3b
4 [] Q. 3c
5 [] Q. 3d
6 [] Q. 3e

4. During the past 2 weeks, did his -- cause him to cut down on the things he usually does?

1 [] Y
2 [] N (9)

5. During that period, how many days did he cut down for as much as a day?

Days ____
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?

Days ____
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?

Days ____ (9)
00 [] None (9)

Ask if 6-16 years:
8. How many days did his [condition] keep him from school during that 2-week period?

Days ____
00 [] None

9. When did -- first notice his . . . ?
(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?)

1 [] Last week
2 [] Week before
3 [] Past 2 weeks - DK which
4 [] 2 weeks - 3 months
5 [] 3 - 12 months
6 [] More than 12 months ago

1 [] Not an eye cond. (AA)
2 [] First eye cond. (under 6) (AA)
3 [] First eye cond. (6+ yrs.) (10)
4 [] Not first eye cond. (AA)

10. Can -- see well enough to read ordinary newspaper print with glasses with his

left eye?

1 [] Y
2 [] N

right eye?

1 [] Y
2 [] N

[p.89]

11a. Does -- take any medicine or treatment for his [condition] ?

1 [] Y
2 [] N (12)

b. Was any of this medicine or treatment recommended by a doctor?

1 [] Y
2 [] N

12. Has he ever had surgery for this condition?

1 [] Y
2 [] N

13. Was he ever hospitalized for this condition?

1 [] Y
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)

Times ____
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?

Days ____
000 [] None

Ask if 17+ years:
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?

Days ____
000 [] None

16a. How often does his [condition] bother him - all of the time, often, once in a while, or never?

1 [] All the time
2 [] Often
3 [] Once in a while
0 [] Never (16c)
8 [] Other - Specify ____

b. When it does bother him, is he bothered a great deal, some, or very little?

1 [] Great deal
2 [] Some
3 [] Very little
4 [] Other - Specify ____

[] All the time in 16a OR condition list 4 asked (A4)

c. Does -- still have this condition?

1 [] Y (A4)
2 [] N

d. Is this condition completely cured or is it under control?

2 [] Cured
3 [] Under control (A4)
4 [] Other - Specify ____ (A4)

e. About how long did -- have this condition before it was cured?

0 [] Less than one month
Months ____
Years ____

[] Accident or injury
[] Other (NC)

17a. Did the accident happen during the past 2 years or before that time?

[] During the past 2 years
[] Before 2 years (18a)

b. When did the accident happen?

[] Last week
[] 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?

Part(s) of body ____
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?

Part(s) of body ____
Present effects ____

19. Where did the accident happen?

20. Was -- at work at his job or business when the accident happened?

1 [] Y
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?

1 [] Y
2 [] N (NC)

b. Was more than one vehicle involved?

[] Y
[] N

c. Was it (either one) moving at the time?

1 [] Y
2 [] N

[p. 90]

CONDITION 5

1. Person number

____

Name of condition

____

2. When did -- last see or talk to a doctor about his [condition]?

1 [] In interview week (Reask 2)
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

[] Color blindness (NC)
[] 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:
3 a. 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] ?

____
[] On Card C (A2)
[] Accident or injury (A2)

If the entry in 3a or 3b includes the words:

Ailment
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:

Ask e:
e. What part of the body is affected?

____

Show the following detail:

Head .... skull, scalp, face
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:

1 [] Item 1
2 [] Q. 3a
3 [] Q. 3b
4 [] Q. 3c
5 [] Q. 3d
6 [] Q. 3e

4. During the past 2 weeks, did his [condition] cause him to cut down on the things he usually does?

1 [] Y
2 [] N (9)

5. During that period, how many days did he cut down for as much as a day?

Days ____
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?

Days ____
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?

Days ____ (9)
00 [] None (9)

Ask if 6-16 years:
8. How many days did his [condition] keep him from school during that 2-week period?

Days ____
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?)

1 [] Last week
2 [] Week before
3 [] Past 2 weeks - DK which
4 [] 2 weeks - 3 months
5 [] 3 - 12 months
6 [] More than 12 months ago

1 [] Not an eye cond. (AA)
2 [] First eye cond. (under 6) (AA)
3 [] First eye cond. (6+ yrs.) (10)
4 [] Not first eye cond. (AA)

10. Can -- see well enough to read ordinary newspaper print with glasses with his

left eye?

1 [] Y
2 [] N

right eye?

1 [] Y
2 [] N

[p. 91]

11a. Does -- now take any medicine or treatment for his [condition] ?

1 [] Y
2 [] N (12)

b. Was any of this medicine or treatment recommended by a doctor?

1 [] Y
2 [] N

12. Has he ever had surgery for this condition?

1 [] Y
2 [] N

13. Was he ever hospitalized for this condition?

1 [] Y
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)

Times ____
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?

Days ____
000 [] None

Ask if 17+ years:

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?

Days ____
000 [] None

16a. How often does his [condition] bother him - all of the time, often, once in a while, or never?

1 [] All the time
2 [] Often
3 [] Once in a while
0 [] Never (16c)
8 [] Other - Specify ____

b. When it does bother him, is he bothered a great deal, some, or very little?

1 [] Great deal
2 [] Some
3 [] Very little
4 [] Other - Specify ____

[] All the time in 16a OR condition list 4 asked (A4)

c. Does -- still have this condition?

1 [] Y (A4)
2 [] N

d. Is this condition completely cured or is it under control?

2 [] Cured
3 [] Under control (A4)
4 [] Other - Specify ____ (A4)

e. About how long did -- have this condition before it was cured?

0 [] Less than one month
Months ____
Years ____

[] Accident or injury
[] Other (NC)

17a. Did the accident happen during the past 2 years or before that time?

[] During the past 2 years
[] Before 2 years (18a)

b. When did the accident happen?

[] Last week
[] Week before
[] 2 weeks - 3 months
[] Over 3-12 months
[] 1-2 years

18 a. At the time of the accident what part of the body was hurt? What kind of injury was it? Anything else?

Part(s) of body) ____
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?

Part(s) of body ____
Present effects ____

19. Where did the accident happen?

20. Was -- at work at his job or business when the accident happened?

1 [] Y
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?

1 [] Y
2 [] N (NC)

b. Was more than one vehicle involved?

[] Y
[] N

c. Was it (either one) moving at the time?

1 [] Y
2 [] N

[p. 92]

CONDITION 6

1. Person number

____

Name of condition

___

2. When did -- last see or talk to a doctor about his [condition] ?

1 [] In interview week (Reask 2)
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

[] Color blindness (NC)
[] 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] ?

____
[] On Card C (A2)
[] Accident or injury (A2)

If the entry in 3a or 3b includes the words:

Ailment
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:

Ask e:
e. What part of the body is affected?

____

Show the following detail:

Head .... skull, scalp, face
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:

1 [] Item 1
2 [] Q. 3a
3 [] Q. 3b
4 [] Q. 3c
5 [] Q. 3d
6 [] Q. 3e

4. During the past 2 weeks, did his [condition] cause him to cut down on the things he usually does?

1 [] Y
2 [] N (9)

5. During that period, how many days did he cut down for as much as a day?

Days ____
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?

Days ____
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?

Days ____ (9)
00 [] None (9)

Ask if 6-16 years:
8. How many days did his [condition] keep him from school during that 2-week period?

Days ____
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?)

1 [] Last week
2 [] Week before
3 [] Past 2 weeks - DK which
4 [] 2 weeks - 3 months
5 [] 3 - 12 months
6 [] More than 12 months ago

1 [] Not an eye cond. (AA)
2 [] First eye cond. (under 6) (AA)
3 [] First eye cond. (6+ yrs.) (10)
4 [] Not first eye cond. (AA)

10. Can -- see well enough to read ordinary newspaper print with glasses with his

left eye?

1 Y
2 N

right eye?

1 Y
2 N

[p. 93]

11a. Does -- now take any medicine or treatment for his [condition]?

1 [] Y
2 [] N (12)

b. Was any of this medicine or treatment recommended by a doctor?

1 [] Y
2 [] N

12. Has he ever had surgery for this condition?

1 [] Y
2 [] N

13. Was he ever hospitalized for this condition?

1 [] Y
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)

Times ____
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?

Days ____
000 [] None

Ask if 17+ years:
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?

Days ____
000 [] None

16a. How often does his [condition] bother him - all of the time, often, once in a while, or never?

1 [] All the time
2 [] Often
3 [] Once in a while
0 [] Never (16c)
8 [] Other - Specify ____

b. When it does bother him, is he bothered a great deal, some, or very little?

1 [] Great deal
2 [] Some
3 [] Very little
4 [] Other - Specify ____

[] All the time in 16a OR condition list 4 asked (A4)

c. Does -- still have this condition?

1 [] Y (A4)
2 [] N

d. Is this condition completely cured or is it under control?

2 [] Cured
3 [] Under control (A4)
4 [] Other - Specify ____ (A4)

e. About how long did -- have this condition before it was cured?

0 [] Less than one month
Months ____
Years ____

[] Accident or injury
[] Other (NC)

17a. Did the accident happen during the past 2 years or before that time?

[] During the past 2 years
[] Before 2 years (18a)

b. When did the accident happen?

[] Last week
[] 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?

Part(s) of body ____
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?

Part(s) of body ____
Present effects ____

19. Where did the accident happen?

20. Was -- at work at his job or business when the accident happened?

1 [] Y
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?

1 [] Y
2 [] N (NC)

b. Was more than one vehicle involved?

[] Y
[] N

c. Was it (either one) moving at the time?

1 [] Y
2 [] N

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