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c
[p.66]

Condition 1

1. Person number

Name of condition ____

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

1[] in interview week (Reask 2)
1[] past 2 wks. (Item C).
2[] 2 weeks,- 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 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 [condition] ?

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

If the entry in 3a or b includes the words, Ask C:

Ailment
Anemia
Asthma
Attack
Condition
Cyst
Defect
Disease
Disorder
Growth
Measles
Problem
Rupture
Trouble
Tumor
Ulcer

c. What kind of [condition] is it?

____

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: Ask e:

Abscess
Ache (except head or ear)
Bleeding
Blood clot
Boil
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)

e. What part of the body is affected? Specify ____
Show the following detail:

Head ....skull, scalp, face
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:

[] Infection
[] 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:

[] Tumor
[] Cyst
[] Growth

g. Is this (tumor/cyst/growth) malignant or benign?

1[] Malignant
2[] Benign
9[] DK

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 things he usually does?

1[] Y
2[] N (9)

5. During that period, how many days did he cut down for more than half of the 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 (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?

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

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

____ Days
00[] None (9)

9. When did -- first notice his [condition]?

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
(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?)

A3

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.67]

AA

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 and 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 [condition] 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 times 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 awhile, 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)
[] 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
____ Month
____ Years

A4

[] Accident/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 other motor vehicle involved in the accident in any way?

1[] Y
2[] N (NC)

b. Was more than one vehicle involved?

[] Y
[] N (NC)

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

1[] Y
2[] N