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phc
[p. 72]

HOME CARE PAGE


Some people are limited in what they can do because of physical or mental condition; that is, the cannot do some of the daily activities that other people do.

1a. Because of a disability or health problem, does anyone in the family, (that is you, your -- etc.), receive or need help from another person, or use special equipment in -
If "Yes," ask 1b and c


(1) Walking, except for using stairs?
[] Y or "doesn't do"
[] N


(2) Going outside?
[] Y or "doesn't do"
[] N


(3) Using the toilet in the bathroom including getting to the bathroom?
[] Y or "doesn't do"
[] N


(4) Bathing, including sponge baths?
[] Y or "doesn't do"
[] N


(5) Dressing?
[] Y or "doesn't do"
[] N


(6) Eating?
[] Y or "doesn't do"
[] N


(7) Getting in and out of bed or chairs?
[] Y or "doesn't do"
[] N

b. Who is this?

c. Does anyone else receive or need help or use special equipment in -- ?


The following represents the table that collects info from 1a-c. The series is repeated 4 times

(a) Person number
(b) Activity

(c) Doesn't do

[] Doesn't do (Mark H box, then 1c)


(d) If "Doesn't do," go to next line. Does -- use any special equipment in (activity)?

[] 1 Y
[] 2 N


(e) Does -- receive or need the help of another person in (activity)?
[] 1 Y
[] 2 N (next line)


(f) Does -- need help from another person in (activity) most of the time, some of the time, or once in a while?
1 [] All/most
2 [] Some
3 [] Once
4 [] Never
8 [] Other - Specify ____
(Mark H box)


2a. Because of a disability or health problem, does anyone in the family receive or need help from another person in -
If "Yes," ask 2b and c.

b. Who is this?

c. Does anyone else receive or need help in --?

(1) Preparing their own meals?
[] Y
[] N
(2) Shopping for personal items, such as magazines, toilet items or medicines?
[] Y
[] N
(3) Doing routing household chores, not including yard work?
[] Y
[] N
(4) Handling their own money?
[] Y
[] N

2b.

1 [] Meals
2 [] Shopping
3 [] Chores
4 [] Handling money
(Mark H box)


3a. Because of a disability or health problem does anyone in the family usually stay in bed all or most of the time?

[] Y
[] N (4)

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

1 [] Stays in bed (H box then 3c)

c. Anyone else?

[] Y (Reask 3b and c)
[] N


Mark box or ask:
4a. What (other) condition causes -- to (need help in activities in 1 and 2/(or) stay in bed)?

[] No H box (NP) ________

b. Does any other conditions cause -- to (need help in activities in 1 and 2/ (or) stay in bed)?

[] 1 Y (Reask 4a and b)
[] 2 N

Mark box or ask:
c. Which of these conditions would you say ins the main condition that causes -- to (need help in activities in 1 and 2/ (or) stay in bed)?

[] Old age only (NP)
[] Only one condition
Main condition ____


HC1
Refer to item C2 to determine if a condition page was completed for the main condition in 4. Enter condition number, or mark box.

HC1
____ Cond. number (NP)
[] No condition page

5. When did -- first notice his (main condition in 4)?

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

[p. 73]

Home Care Page -- Continued


6a. Does anyone in the family have a colostomy, a urinary catheter, or any other device to help control bowel movements or urination?

[] Y
[] N(7)

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

1 [] Device

c. Anyone else

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


If "Device," ask 6d and e
d. Which does -- have - a colostomy, a catheter, or another type of device?

1 [] Colostomy
2 [] Catheter
8 [] Other - Specify ____


e. Does -- receive or need help from another person in taking care of his (device in 6d)?

1[] Y (Mark H box then NP)
2[] N


7a. (Besides --) Does anyone (else) in the family have any accidents or any trouble controlling their bowel movements or urinations?

[] Y
[] N (8)

b. Who is this? (Mark "Trouble Controlling" box in person's column.)

1 [] Trouble controlling

c. Anyone else?

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


8a. Does anyone in the family (this is you, your, -- etc.) now use (any of the following special aids) -
If "Yes, " ask 8b and c


(1) An artificial arm?
[] Y
[] N


(2) An artificial leg?
[] Y
[] N


(3) A brace of any kind? (If "Yes" ask: On what part of the body is the brace worn?)
[] Y
[] N


(4) Crutches?
[] Y
[] N


(5) A cane or walking stick?
[] Y
[] N


(6) Special shoes?
[] Y
[] N


(7) A wheel chair?
[] Y
[] N


(8) A walker?
[] Y
[] N


(9) A guide dog?
[] Y
[] N


(10) Any other kind of aid for getting around?
[] Y
[] N

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

1 [] Artificial arm
2 [] Artificial leg
3 [] Brace - Part of body ____
4 [] Crutches
5 [] Can or walking stick
6 [] Special shoes
7 [] Wheel chair
8 [] Walker
9 [] Guide dog
10 [] Other -- Specify ____

c. Anyone else?


9a. Does anyone in the family use -
If "Yes," ask 9b and c

(1) Eyeglasses?
[] Y
[] N
(2) Contact lenses?
[] Y
[] N
(3) A hearing aid?
[] Y
[] N

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

1 [] Eyeglasses
2 [] Contact lenses
3 [] Hearing aid

c. Anyone else?


10a. Does anyone in the family receive help here at home with -
If "Yes," ask 10b and c


(1) Receiving injections or shots?
[] Y
[] N


(2) Physical therapy?
[] Y
[] N


(3) Changing bandages?
[] Y
[] N


(8) Any other nursing or medical treatments?
[] Y
[] N

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

1 [] Injections
2 [] Physical therapy
3 [] Bandages
8 [] Other -- Specify ____

c. Anyone else?

[p. 74]

Home Care Page - Continued


11a. During the past 12 months, (that is since (date) a year ago) has anyone in the family received meals that were prepared outside the home and brought on a fairly regular basis?

[] Y
[] N (12)

b. Who received the meals? Mark "Meals" box in person's column.

1 [] Meals

c. Anyone else?

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


If "Meals in 11b, ask 11d-e

d. Does -- now regularly receive meals that are prepared outside the home and brought in?

[] Y
[] N (NP)


e. What agency, organization or program provides these meals for--? ________


12a. During the past 12 months, has anyone in the family received any care at home from a nurse? Exclude related HH members.

[] Y
[] N (IHCP)

b. Who received the care? Mark "nurse" box in person's column.

1 [] Nurse

c. Anyone else?

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

[p. 75]

Individual Home Care Page

Complete for each person with H box

1. Person number ____

2a. Earlier you said that -- receives or needs the help of another person. Who helps --?
(Is -- helped by anyone who lives here, by any other friends or relatives, a nurse or any other health care professionals who come into the home, or is -- helped by someone else?)

1 [] Related HH members
2 [] Nurse
3 [] Other Health worker -- Specify ____
4 [] Other relatives or friends
8 [] Other - Specify ____

b. Does anyone else help --?

[] Y (Reask 2a and b)
[] N


If "Nurse" in 2a, ask:

3a. On the average, how many days per week does the nurse visit -- ?

[] Days per week ____


b. When the nurse visits, how many hours per day does he or she usually spend helping --?

[] 00 Less than 1 hour
[] Hours ____


c. Does anyone in the family, that is you, your --, etc. pay any part of the cost for the nurse?

[] 1 Y
[] 2 N


d. Does any government agency or program help pay for the nurse?

1 Y
2 N (3f)


e. What agency or program helps pay?

[] 1 Medicaid
[] 2 Medicare
[] 3 Health Insurance
[] Other -- Specify ____


f. During the past 2 weeks, how many times was -- visited by the nurse?

[] Number of times ____


If "Other health worker" in 2a, ask:
4 a. On the average, how many days per week does the (other health worker) visit --?

Days per week ____


b. When the (other health worker) visits, how many hours per day does he or she usually spend helping --?

00 [] Less than 1 hour
Hours ____


c. Does anyone in the family, that is you, your --, etc. pay any part of the cost for the (other health worker)?

1 [] Y
2 [] N


d. Does any government agency or program help pay for the (other health worker)?

1 [] Y
2 [] N (4f)


e. What agency or program helps pay?

1 [] Medicaid
2 [] Medicare
3 [] Health insurance
[] Other - specify ____


f. During the past 2 weeks, how many times was -- visited by the (other health worker)?

Number of times ____

HC2

HC2
1 [] Under 17 (NP)
2 [] 17+

5a. Does -- receive or need help from others in using public transportation, such as buses, trains, subways, or planes?

[] 1 Y (6)
[] 2 N
[] 4 Doesn't use (5c)


b. Does -- use public transportation?

[] 1 Y (6)
[] 2 N


c. If -- had to use public transportation, would [he/she] need the help of other persons?

[] 1 Y
[] 2 N


6a. Does -- drive a car?

[] 1 Y (8)
[] 2 N


b. Does -- not drive a car because of a disability or health problem or because of some other reason?

[] 1 Age
[] 2 Disability
[] 8 Other


7a. Does -- use the telephone without the help of another person?

[] 1 Y (8)
[] 2 N


b. Would -- be able to use the telephone in an emergency?

[] 1 Y
[] 2 N


8a. During the 2 weeks outlined in red on the calendar, did -- have any visits from a friend, relative or neighbor?

[] 1 Y
[] 2 N (8c)


b. How many times during that period was -- visited by friends, relatives or neighbors?
(Was it 3 or more times or less than 3 times?)
(Was it 12 or more times or less than 12 times?)

1 [] 1-3 times
2 [] 4-12 times
3 [] 13+ times


c. During these 2 weeks, did -- go out to visit a friend, relative or neighbors?

[] 1 Y
[] 2 N (9)


d. How many times during that period did -- go out to visit friends, relatives or neighbors?
(Was it 3 or more times or less than 3 times?)
(Was it 12 or more times or less than 12 times?)

1 [] 1-3 times
2 [] 4-12 times
3 [] 13+ times


9. During the past 12 months, did -- go on a vacation?

[] 1 Y
[] 2 N


10. Because of a disability or health problem, how often must someone be here with --,
most of the time, some of the time, once in a while or never?

1 [] Most/All
2 [] Some
3 [] Once
4 [] Never
8 [] Other -- Specify ____