[p. 67]
Condition 1
2. When did [person] last see or talk to a doctor or assistant about his [condition]?
1 [] past 2 wks. (Item C)
2 [] 2 wks.-6 mos.
3 [] Over 6-12 mos.
4 [] 1 yr.
5 [] 2-4 yrs.
6 [] 5+ yrs.
7 [] Never
8 [] DK if Dr. ever seen
9 [] DK when Dr. seen
A1
Examine "Name of condition" entry and mark
[] Accident or injury (A2) [] Neither (3a)
If "Doctor not talked to," transcribe entry from 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 -- . . .?
If the entry in 3a or b includes the words:
Anemia
Asthma
Attack
Condition
Cyst
Defect
Disease
Disorder
Growth
Measles
Problem
Rupture
Trouble
Tumor
Ulcer
Ask c:
c. What kind of . . . is it? (What would we put for that?)
For allergy or stroke, ask:
d. How does the allergy (stroke) effect him?
If in 3a-d there is an impairment or any of the following entries:
Ache (except head or ear)
Bleeding
Blood clot
Bail
Cancer
Cramps (except menstrual)
Cyst
Damage
Growth
Hemorrhage
Infection
Inflammation
Neuralgia
Neuritis
Pain
Palsy
Paralysis
Rupture
Sore(ness)
Stiff(ness)
Tumor
Ulcer
Varicose veins
Weak(ness)
Ask e:
e. What part of the body is affected? Specify ____
Show the following detail:
Back/spine/vertebrae.................... upper, middle, lower
Side............................................... left or right
Ear................................................. inner or outer; left, right or both
Eye................................................ left, right, or both
Arm............................................... shoulder, upper, elbow, lower or wrist; left, right, or both
Hand.............................................. entire hand or fingers only; left, right, or both
Leg................................................ hip, upper, knee, lower, or ankle; left, right or both
Foot............................................... entire foot, arch, or toes only; left, right, or both
Except for eyes, ears or internal organs, ask if there are any of the following entries in 3a-d:
Sore
Soreness
f. What part of the (part of body in 3e) is affected by the [infection/sore/soreness] -- the skin, muscle, bone or some other part? Specify ____
Ask if there are any of the following entries in 3a-d:
Cyst
Growth
g. Is this (tumor/cyst/growth) malignant or benign?
2[] Benign
9[] DK
A2
Ask remaining questions as appropriate for the condition entered in:
2 [] Q. 3a
3 [] Q. 3b
4 [] Q. 3c
5 [] Q. 3d
6 [] Q. 3e
2 N (9)
5. During that period, how many days did he cut down for more than half of the day?
00 [] None (9)
6. During that 2-week period, how many days did his [condition] keep him in bed all or most of the day?
00 [] None (9)
Ask if 17+ years:
7. How many days did his [condition] keep him from work during that 2-week period? (For females): not counting work around the house?
00 [] None (9)
Ask if age 6-16:
8. How many days did his [condition] keep him from school during that 2-week period?
00 [] None
9. When did [person] first notice his [condition]?
2 [] Week before
3 [] Past weeks-DK which
4 [] 2 weeks -- 3 months
5 [] Over 3 -- 12 months
6 [] More than 12 months ago
(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 months or before that time?)
A3
2 [] First eye cond. (under 6) (AA)
3 [] First eye cond. (6+ yrs.) (10)
4 [] Not first eye cond. (AA)
2 N
2 N
[p. 68]
AA
2 [] Condition in C2 does not have a letter as source (A4)
3 [] Condition in C2 has a letter as source, Doctor seen (11)
4 [] Condition in C2 has a letter as source, Doctor not seen (15)
2 N (12)
b. Was any of this medicine or treatment recommended by a doctor?
2 N
12. Has he ever had surgery for this condition?
2 N
13. Was he ever hospitalized for this condition?
2 N
14. During the past 12 months, about how many times has -- seen or talked to a doctor about his [condition]?
(Do not count visits while a patient in a hospital.)
000 [] None
15a. About how many times during the past 12 months has this condition kept him in bed all or most of the day?
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?
000 [] None
16a. How often does his [condition] bother him -- all of the time, often, once in awhile, or never?
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?
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?
N
d. Is this condition completely cured or is it under control?
3[] Under control (A4)
4[] Other - Specify ________ (A4)
e. About how long did -- have this condition before it was cured?
____ Months
____ Years
A4
[] Other (NC)
[] Before 2 years (18a)
b. When did the accident happen?
[] Week before
[] 2 weeks -- 3 months
[] Over 3--12 months
[] 1-- 2 years
18a. At the time of the accident what part of the body was hurt?
What kind of injury was it? Anything else?
________ Kind of injury
If accident happened more than 3 months ago, ask:
b. What part of the body is affected now?
How is his -- affected? Is his -- affected in any other way?
________ Present effects
19. Where did the accident happen?
2 [] At home (adjacent premises)
3 [] Street and highway (includes roadway and public sidewalk)
4 [] Farm
5 [] Industrial place (includes premises)
6 [] School (includes premises)
7 [] Place of recreation and sports, except at school
8 [] Other - Specify ____
20. Was -- at work at his job or business when the accident happened?
[] 2 N
[] 3 While in Armed Services
[] Under 17 at time of accident
21a. Was a car truck, bus, or other motor vehicle involved in the accident in any way?
[] 2 N (NC)
b. Was more than one vehicle involved?
[] N
c. Was it (either one) moving at the time?
[] 2 N