[p.74]
1981 CHILD HEALTH SUPPLEMENT
NATIONAL HEALTH INTERVIEW SURVEY
Segment
Serial
Age
____ Mos
2[] Refused (explain in footnotes)
3[] Eligible respondent not available (explain in footnotes)
4[] No eligible respondent in HH (explain in footnotes)
[] Other noninterview reason (explain in footnotes)
COMPLETE REMAINING ITEMS ON HH PAGE OF HIS-1
BEGIN CALLBACK INTERVIEW WITH CHECK ITEM B1 ON PAGE 4.
[p.75]
Section A. INTRODUCTION
The next questions will be used to study the health of the Nation's children.
If more than one child in family read: The only child I will ask the rest of my questions about is --.
(These questions will go much more quickly if we can do them alone.)
Arrange to conduct supplement in private if possible.
Ask or verify for each HH member.
1. How is (Name on HIS-1) related to --?
If parent ask: Is (name of parent) -- biological (natural), adoptive, step or foster parent?
If brother/sister ask: Is (name of sibling) -- full, half, step, adoptive, or foster (brother/sister)?
Enter "sample child" on appropriate line.
Enter "unrelated" for persons not related to the sample child.
2 ____
3 ____
4 ____
5 ____
6 ____
7 ____
8 ____
9 ____
10 ____
Mark first appropriate box.
2[] Sample child 6+ years old and biological father in HH and available (Section B, page 4)
3[] Biological mother not in HH, only one adult relative in HH (Section B, page 4)
4[] Biological mother in HH not available (2)
5[] Biological mother not in HH, 2+ adult relatives in HH (2)
2. (Besides (Biological mother) which family member knows the most about the health-related matters of -- ?
Mark first appropriate box.
3[] Biological father or person in 2 available (Section B, page 4)
4[] Biological father or person in 2 not available (arrange callback and complete remaining items on HIS-1, HH page)
[p.76]
Section B. CHILD CARE
CHECK ITEM B1
Mark box and enter person number of respondent
INTRO - I will be asking questions about --. These questions will be used to study the health of the Nation's children.
(These questions will go much more quickly if we can do them alone.)
Arrange to conduct supplement in private if possible.
CHECK ITEM B2
Refer to age of sample child.
2[] 15+ years old (3)
Refer to HH composition on HIS-1.
2[] 2 + related HH members 12+ years old (1)
1. Which family member, that is, (Related HH members 12+), spends the most time taking care of -- ?
2a. Not counting occasional sitters, who (else) takes care of --? Include day care centers, nurseries, sitters, or anyone else who takes care of --.
Do not include regular school.
If non HH member, ask: Is this person related or unrelated to --?
6[] Child cares for self
2[] Unrelated HH member(s) (Indicate each person or place on a separate line in column 4 of the Child Care Table, then ask 2b.)
4[] Unrelated non HH member(s) (Indicate each person or place on a separate line in column 4 of the Child Care Table, then ask 2b.)
5[] Day care/Nursery(Indicate each person or place on a separate line in column 4 of the Child Care Table, then ask 2b.)
b. Again, not counting occasional sitters, does anyone else take care of -- either in this home or some other place?
[] N
3. Who usually takes -- to the doctor for checkups or other nonemergency visits?
44[] Never went to doctor
[p.77]
Section B. CHILD CARE - Continued
CHILD CARE TABLE
Ask questions 5 through 7 for first caretaker before proceeding to next caretaker
4. Caretaker
2[] Sitter (Related)- Specify
____
4[] Nursery (7)
5. Does (Caretaker in 4) take care of -- in this home or some other place?
8[] Some other place only
3[] Both
6. Is this (other place) in someone's home or some other place?
8[] Some other place - Specify
____
____
____
7. On the average, about how many hours per week does (Caretaker in 4) take care of -- (in this home/outside this home)?
____ Hours/week outside this home
[p.78]
Section C. RELATIONSHIPS AND RESIDENTIAL MOBILITY
CHECK ITEM C1
Refer to question 1, page 3 of CHS.
8[] Other (1)
1a. Has -- ever lived with -- biological mother for at least 3 months?
2[] N(2)
9[] DK(2)
b. How long has it been since -- last lived with her for at least 3 months?
(Number)
____ 2[] Weeks
(Number)
____ 3[] Months
(Number)
____ 4[] Years
(Number)
2. Is -- biological mother now living or deceased?
2[] Deceased (C2)
3[] DK (C2)
2[] Almost every day
3[] Several times a week
4[] About once a week
5[] 2 or 3 times a month
6[] About once a month
7[] Less than once a month
0[] Never
CHECK ITEM C2
Refer to question 1, page 3 of CHS.
8[] Other (4)
4a. Has -- ever lived with -- biological father for at least 3 months?
2[] N (5)
9[] DK (5)
b. How long has it been since -- last lived with him for at least 3 months?
(Number)
2[] Weeks
3[] Months
4[] Years
2. Is -- biological father now living or deceased?
2[] Deceased (C2)
3[] DK (C2)
2[] Almost every day
3[] Several times a week
4[] About once a week
5[] 2 or 3 times a month
6[] About once a month
7[] Less than once a month
0[] Never
[p.79]
Section C. RELATIONSHIPS AND RESIDENTIAL MOBILITY - Continued
7a. How many children has -- (Biological mother) EVER had? Do not count miscarriages or stillbirths.
____ Number
b. Of those (Number in 7a) children, was -- born first (or) second (or third, etc.)?
2[] Second
3[] Third
4[] Fourth
5[] Fifth
6[] Other - Specify ____
CHECK ITEM C3
Refer to question 1, page 3 of CHS or to question 2 on page 6 of CHS.
2[] Biological mother deceased or DK (12)
3[] Biological mother not in HH (8)
8. Is -- biological mother now married, widowed, divorced, separated or never married?
2[] Widowed
4[] Divorced
5[] Separated
3[] Never married (12)
9[] DK (12)
9. How many times altogether has -- (Biological mother) been married?
____ Number
Ask 10a-c about each marriage before proceeding to next marriage.
10a. In what year was -- (Biological mother) married (the (first/second/third) time)?
Marriage
If now married and this is last or only marriage, go to question 12. If now separated and this is last or only marriage, go to question 11.
b. In what year did this marriage end?
For divorce and annulment, record legal end.
Marriage
If now widowed or divorced and this is last or only marriage, go to question 12.
c. Was this marriage ended by death, divorce, or annulment?
Marriage
4[] Divorce
5[] Annulment
4[] Divorce
5[] Annulment
4[] Divorce
5[] Annulment
11. How long has she been separated?
(Number)
2[] Weeks
3[] Months
4[] Years
12. In what month and year did -- move to this home?
____ Month
19__ Year
[p.80]
Section C. RELATIONSHIPS AND RESIDENTIAL MOBILITY - Continued
13. About how many miles from here is the home -- lived in before -- moved to this home?
Range acceptable
____ Miles
14. How many times has -- ever moved?
15. How long has -- lived with you?
CHECK ITEM C4
8[] Other (15)
(Number)
2[] Weeks
3[] Months
4[] Years
[p.81]
Section D. Breastfeeding
CHECK ITEM D1
Refer to age of sample child.
6[] 6+ months old (2)
1. Is -- being breastfed at present time?
2[] N
2[] N (D4)
3. How old was -- when -- completely stopped breastfeeding?
____
(Number)
2[] Weeks
3[] Months
CHECK ITEM D2
Mark first appropriate box.
2[] Respondent not biological mother (D3)
1[] Respondent is biological mother (4)
4. While breastfeeding --, did you ever take any birth control pills?
2[] N
CHECK ITEM D3
Refer to age of sample child.
2[] Under 6 months old (5a)
8[] Other (5b)
5a. Has -- ever been given any formula or regular milk?
2[] N (D4)
b. How old was -- when -- was first fed formula or regular milk on a daily basis?
____
(Number)
2[] Weeks
3[] Months
CHECK ITEM D4
Refer to age of sample child.
2[] Under 6 months old (6a)
8[] Other (6b)
6a. Has -- ever been given any solid food, such as commercially prepared strained and junior foods, "table foods," or any other non-liquid foods?
2 N (Section E, page 10)
b. How old was -- when -- started eating solid food (such as strained foods or any other non-liquid foods) on a daily basis?
____
(Number)
2[] Weeks
3[] Months
[p.82]
Section E. MOTOR AND SOCIAL DEVELOPMENT
CHECK ITEM E1
Refer to age of sample child.
2[] 2-4 years old (INTRO)
3[] 5+ years old (Section F, page 14)
INTRO - Now I would like to ask a few questions about various things children do at different ages.
CHECK ITEM E2
Refer to age of sample child.
After marking the appropriate box, go to the list of questions and circle the corresponding question numbers.
Ask first sequence of questions until five consecutive "Yes" responses are given, then ask second sequence of questions until five consecutive "No" responses are given. One or more of the five consecutive "No" responses may have been given at the beginning of the first sequence, thus requiring less than five consecutive "No" responses in the second sequence.
After completing second sequence, go to Check Item E3. If 10 consecutive "No" responses are given in the first sequence, go to Check Item E3 without asking any further questions in the list.
1[] Under 4 months
2[] 4 months
3[] 5 months
4[] 6 months
5[] 7 months
6[] 8 months
7[] 9 months
8[] 10 months
9[] 11 months
10[] 12-14 months
11[] 15-17 months
12[] 18-23 months
13[] 2 years
14[] 3 years
15[] 4 years
1 (Descending order beginning with question number-)
8
10
12
14
16
18
20
22
24
28
33
36
41
44
9
11
13
15
17
19
21
23
25
29
34
37
42
45
Section E. Motor and Social Development-continued
1. When lying on -- stomach, has -- ever turned -- head from side to side?
2[] N
9[] DK
2. Have -- eyes ever followed a moving object at all?
2[] N
9[] DK
3. When lying on -- stomach on a flat surface did -- ever lift -- head off the surface for a moment?
2[] N
9[] DK
4. Have -- eyes ever followed a moving object all the way from one side to another?
2[] N
9[] DK
5a. Has -- ever smiled at someone when they talked to or smiled at -- without being touched?
2[] N
9[] DK
b. If "Yes," ask: How old was -- when -- first smiled at someone when they talked to or smiled at --?
(Number)
3[] Months
6. When lying on -- stomach, has -- ever raised -- head and chest from the surface while resting -- weight on -- lower arms or hands?
2[] N
9[] DK
7. While lying on -- back and being pulled up to a sitting position, did -- ever hold -- head stiffly so that it DID NOT hang back as -- was pulled up?
2[] N
9[] DK
8. Has -- ever laughed out loud without being tickled or touched?
2[] N
9[] DK
9. Has -- ever turned -- head around to look at something?
2[] N
9[] DK
10. Has -- ever held in one had a moderate size object such as a block or a rattle?
2[] N
9[] DK
11. Has -- ever looked around with -- eyes for a toy which was lost or not nearby?
2[] N
9[] DK
12a. Has -- ever rolled over on -- own on purpose?
2[] N
9[] DK
b. If "Yes," ask: How old was -- when -- first rolled over?
(Number)
3[] Months
13. Has -- ever been pulled from a sitting to a standing position and supported -- own weight with legs stretched out?
2[] N
9[] DK
14. Has -- ever sat alone with no help except for leaning forward on -- hands or with just a little help from someone else?
2[] N
9[] DK
15. Has -- ever seemed to enjoy looking in the mirror at (himself/herself)?
2[] N
9[] DK
16a. Has -- ever said any recognizable words, such as "mama" or "dada"?
2[] N
9[] DK
b. If "Yes," ask: How old was -- when -- first said any recognizable words?
(Number)
3[] Months
[p.84]
Section E. MOTOR AND SOCIAL DEVELOPMENT - Continued
17a. Has -- ever crawled when left lying on -- stomach?
2[] N
9[] DK
b. If "Yes," ask: How old was -- when -- first crawled?
(Number)
3[] Months
18. Did -- ever sit for 10 minutes without any support at all?
2[] N
9[] DK
19. Has -- ever pulled (himself/herself) to a standing position without help from another person?
2[] N
9[] DK
20. Has -- ever recognized -- own name when someone said it?
2[] N
9[] DK
21. Has -- ever picked up small objects, such as raisins or cookie crumbs, using only -- thumb and first finger?
2[] N
9[] DK
22a. Has -- ever waved good-bye without help from another person?
2[] N
9[] DK
b. If "Yes," ask: How old was -- when -- first waved good-bye without help from another person?
(Number)
3[] Months
23a. Has -- ever stood alone on -- feet for 10 seconds or more without holding on to anything or another person?
2[] N
9[] DK
b. If "Yes," ask: How old was -- when -- first stood alone?
(Number)
3[] Months
24. Has -- said 2 recognizable words besides "mama" and "dada"?
2[] N
9[] DK
25. Has -- ever walked at least 2 steps with one hand held or holding on to something?
2[] N
9[] DK
26. Has -- ever shown by -- behavior that -- knows that names of some common objects when somebody else names them out loud?
2[] N
9[] DK
27. Has -- ever crawled up at least 2 stairs or steps?
2[] N
9[] DK
28. Has -- ever said the name of a familiar object, such as a ball?
2[] N
9[] DK
29a. Has -- ever walked at least 2 steps without holding on to anything or another person?
2[] N
9[] DK
b. If "Yes," ask: How old was -- when -- first walked at least 2 steps?
(Number)
3[] Months
30. Has -- ever shown that -- wanted something without crying or whining? It may have been by pointing, pulling, or making pleasant sounds.
2[] N
9[] DK
31. Has -- ever made a line with a crayon or pencil?
2[] N
9[] DK
2[] N
9[] DK
33. Did -- ever walk up at least 2 stairs with one hand held or holding the railing?
2[] N
9[] DK
34. Has -- ever let someone know, without crying, that -- was bothered by -- pants or diapers being wet or soiled?
2[] N
9[] DK
35. Has -- ever fed (himself/herself) with a spoon or fork without spilling much?
2[] N
9[] DK
[p.85]
Section E. MOTOR AND SOCIAL DEVELOPMENT - Continued
36. Has -- ever walked upstairs by (himself/herself) without holding on to a rail?
2[] N
9[] DK
37. Has -- ever spoken in a partial sentence of 3 words or more?
2[] N
9[] DK
38. Has -- ever said -- first and last names together without someone's help?
Nickname may be used for first name.
2[] N
9[] DK
39. Has -- ever walked up stairs by (himself/herself) with no help, stepping on each step with only one foot?
2[] N
9[] DK
40. Has -- ever counted 3 object correctly?
2[] N
9[] DK
41. Has -- ever pedaled a tricycle at least 10 feet?
2[] N
9[] DK
42. Does -- know -- own age AND sex?
2[] N
9[] DK
43. Has -- ever washed and dried -- hands without any help except for turning the water on and off?
2[] N
9[] DK
44. Has -- ever done a somersault without help from anybody?
2[] N
9[] DK
45. Has -- ever drawn a picture of a man or woman with at least 2 parts of the body besides a head?
2[] N
9[] DK
46. Has -- ever gone to the toilet alone?
2[] N
9[] DK
47. Has -- ever played with several children at the same time?
2[] N
9[] DK
48. Has -- ever said the names of at least 4 colors?
2[] N
9[] DK
49. Has -- ever dressed (himself/herself) without any help except for tying shoes (and buttoning the back of dresses)?
2[] N
9[] DK
50. Has -- ever counted out loud up to 10?
2[] N
9[] DK
CHECK ITEM E3
Refer to age of sample child.
2[] 2 years old (51b)
3[] 3+ years old (E4)
2[] N (E4)
b. How old was -- when the first tooth came in (that is, broke through the gums)?
(Number)
3[] Months
CHECK ITEM E4
Refer to age of sample child.
2[] 1-3 years old (52a)
3[] 4 years old (52b)
2[] N (Section F, Page 14)
b. How old was -- when -- was completely toilet trained?
____
(Number)
4[] Years
[p. 86]
Section F. BIRTH
In studying the health of children, it is important to have information about their birth.
CHECK ITEM F1
Refer to question 1, page 3 of CHS.
2[] Biological mother not in HH (1)
1. How old was -- biological mother when -- was born?
CHECK ITEM F2
Refer to question 1, page 3 of CHS.
2[] Biological father not in HH (2)
2. How old was -- biological father when -- was born?
3a. Was -- born in a hospital or some other place?
CHECK ITEM F3 >
8[] Other (9)
[] Other - Specify (4) ____
b. How many nights was -- (Biological mother) in the hospital during this stay?
____ Nights
c. How many nights was -- in the hospital during this stay?
____ Nights
4a. How much did -- weigh at birth?
Probe for ounces if not reported.
____ Lbs (5)
____ Oz (5)
b. Did -- weigh more than 5 1/2 pounds or less?
2[] Less than 5 1/2 lbs. (5)
7[] DK (5)
c. Did -- weigh more than 9 pounds or less?
4[] Less than 9 lbs.
9[] DK
5a. Was -- born about when expected or was it earlier or later?
2[] When expected (6)
3[] Later than expected
9[] DK (6)
b. About how much (earlier/later) than expected was -- born?
Range acceptable
(Number)
2[] Weeks
3[] Months
6. How many hours was -- (Biological mother) in labor?
____ Hours
Refer to age of sample child.
2[] 6+ years old (11)
Section F. BIRTH - Continued
7a. Now I'm going to ask about medicine, shots, and gas given during labor AND delivery. First I'll ask about LABOR. While (Biological mother) was in LABOR, was she given any medicine, shots, or gas?
Read if necessary: Labor begins with the onset of contractions that lead to delivery. Do not include false labor but do include medication to induce labor.
2[] N (8a)
b. How was it given to (Biological mother) during labor? Was it a spinal shot, some other type of shot, gas, or some other method?
2[] Other shot/I.V.
3[] Gas
8[] Some other method - Specify ____
c. Was (Biological mother) given anything else during labor?
[] N
8a. While (Biological mother) was in DELIVERY, was she given any medicine, shots, or gas?
Read if necessary: Delivery begins when the baby starts to show, or the doctor starts to use forceps or to operate in the case of a caesarean section.
2[] N (9)
b. How was it given to (Biological mother) during delivery? Was it a spinal shot, some other type of shot, gas, or some other method?
2[] Other shot/I.V.
3[] Gas
8[] Some other method - Specify ____
c. Was (Biological mother) given anything else during delivery?
[] N
9a. Was --delivered by caesarean section?
2[] N (10)
b. Why was the caesarean performed?
________ (11c)
10. Was -- born head first or feet first?
2[] Feet first
8[] Other way - Specify ____
11a. Was it a normal delivery or were there any complications or problems?
2[] Complications/problems
b. What was the matter?
________
c. (Besides the caesarean section) Were there any other problems during delivery?
[] N
[p.88]
Section F. BIRTH - Continued
12a. Including any condition not known about immediately after delivery by found out about later, was there anything (else) wrong with -- when -- was born?
2[] N (3)
b. What (else) was wrong with --?
________
c. Was there anything else wrong with --?
[] N
13a. Did -- receive any newborn care in an intensive care unit, premature nursery, or any other type of special care facility?
2[] N (F5)
b. How many nights did -- stay in the special care facility?
____ Nights
CHECK ITEM F5
Refer to sex of sample child.
[] Female (Section G, page 17)
14. Was -- ever circumcised?
2[] N
9[] DK
[p.89]
Section G. PRENATAL CARE
CHECK ITEM G1
8[] Other (Section H, page 21)
1. The next set of questions is about the health care you may have received during your pregnancy with --.
How many weeks pregnant were you when you first thought you were pregnant with --?
2a. Did you see or talk to a doctor to find out if you were pregnant?
2[] N (2c)
b. How many weeks or months pregnant were you when you first saw or talked to a doctor to find out if you were pregnant?
(Number)
3[] Months
c. Including routine checkups, did you see or talk to a doctor about your pregnancy at any (other) time during that pregnancy?
2[] N (3)
If "Yes," in 2a, go to 3
d. How many weeks or months pregnant were you when you first saw a doctor about your pregnancy?
(Number)
3[] Months
3a. How much did you weigh just before you become pregnant with --?
b. Altogether, how many pounds did you either gain or lose during the pregnancy?
____ 2[] Lost
c. How many months pregnant were you when -- was born?
NOTE - 4a-h are conditions that may occur during pregnancy.
4. At any time during your pregnancy with --, did you have:
2[] N
2[] N (4c)
2[] Red/8-day
3[] Both
At any time in your pregnancy with -- did you have:
2[] N
2[] N (4e)
2[] Eclampsia
3[] Convulsion
At any time during your pregnancy with -- did you have:
2[] N
2[] N
2[] N
2[] N
[p. 90]
Section G. PRENATAL CARE - Continued
5a. At any time during your pregnancy with -- did you have?
2[] N (Next column)
2[] N (Next column)
2[] N (6)
b. When did you first notice it - was it during your pregnancy with -- or before?
2[] Before
2[] Before
2[] Before
c. Did you have the (Condition) for at least 3 months after -- was born?
2[] N (5a)
2[] N (5a)
2[] N (6)
6. Do you now have diabetes or sugar diabetes?
2[] N
7a. At any time during your pregnancy with -- did you stay in a hospital overnight? Do not count hospitalization for -- birth.
0[] N (8)
b. How many times?
c. For what (other) conditions did you stay in a hospital overnight?
____
____
d. Any other conditions?
[] N
e. Altogether, how many nights did you stay in a hospital for (Conditions in 7c)?
8a. (Not including the times you stayed overnight in the hospital,) Did a doctor ever tell you to remain in bed for one or more weeks during your pregnancy?
2[] N (9)
b. For what (other) conditions did the doctor tell you to remain in bed for one or more weeks?
____
____
c. Any other conditions?
[] N
d. Altogether, how long did you stay in bed for (Condition in 8b) during your pregnancy with --? (Do not include time spent in the hospital)
(Number)
2[] Weeks
3[] Months
9. During your pregnancy with -- about how many cigarettes a day did you usually smoke?
____ Number
[p.91]
Section G. PRENATAL CARE - Continued
10a. At any time during your pregnancy with --, did you take tranquilizers?
2[] N (11)
Hand Card T
[There is no Card T available]
b. Which number on that card best describes how often you took tranquilizers DURING your pregnancy?
2[] Nearly every day
3[] Once or twice a week
4[] 2 or 3 times a month
5[] About once a month
6[] Less than once a month
11a. Have you ever had a miscarriage before you became pregnant with --?
2[] N (Section H, page 21)
b. How many?
c. How long before -- was born did you have the (most recent of those) miscarriage(s)?
(Number)
____ 4[] Years
[p.92]
Section H. HOSPITALIZATIONS AND SURGERY
1a. Since -- was born, how many different times has -- stayed in the hospital overnight? Do not include the hospitalization when --was born.
____ Number of times
b. During any of these hospitalizations, was -- treated for diabetes or sugar diabetes?
2[] N (2)
c. Does -- take insulin shots?
2[] N
2a. Was surgery of any kind or were any operations performed on -- during any stays in the hospital? Include bone settings and stitches.
2[] N (3)
b. What are the names of these surgeries or operations?
If name is not known describe what was done.
c. Any others?
[] N
3a. (Excluding any operations performed on -- while -- was an overnight patient in the hospital). Has -- ever had any (other) surgery or operations? Include bone settings and stitches.
2[] N (Section I, page 22)
b. What are the names of these other surgeries or operations?
If name is not known describe what was done.
____
c. Any others?
[] N
[p.93]
Section I. SUPPLEMENTAL CONDITION LIST
Some of the following conditions were asked about earlier, but tell me whether or not -- ever had any of these conditions even if they have been mentioned before.
If "Yes," enter condition and number in Item 1, Section J.
Did -- ever have --?
2. Yellow jaundice?
3. Any other liver trouble?**
4. Colitis?
5. Any other bowel trouble?**
6. An ulcer?
7. A hernia or rupture?
8. Any other condition of the digestive system? **
9. Asthma?
10. Hay fever or allergies?
11. Tonsillitis or enlargement of the tonsils or adenoids?*
12. Tuberculosis?
13. Pneumonia?
14. Any other respiratory, lung or pulmonary condition?**
15. Arthritis of any kind or rheumatism?
16. Curvature of the spine?
17. Clubfoot?
18. Any other condition affecting the bone, cartilage, muscle or tendon?**
19. Eczema or psoriasis (so-rye-uh-sis)?
20. Trouble with acne?
21. Any kind of skin allergy?
22. Any other kind of skin trouble?**
23. Repeated ear infections?
24. Deafness in one or both ears?
25. Any other trouble hearing with one or both ears?**
26. Blindness in one or both eyes?
27. Cataracts?
28. Any other trouble seeing with one or both eyes even when wearing glasses?**
29. A cleft palate or harelip?
30. Stammering or stuttering?
31. Any other speech defect?**
32. Autism or has -- ever been autistic?
33. Palsy or cerebral palsy?
34. Paralysis of any kind?
35. Mental retardation?
36. Epilepsy?
37. Repeated convulsions, seizures, or blackouts?
38. Migraine?
39. Frequent or severe headaches?
40. Meningitis?
41. Chorea (ko-ree-uh) or St. Vitus' dance?
42. Nephritis?
43. Urinary tract infection?
44. Any other kidney trouble?**
45. Diabetes?
46. Goiter or other thyroid trouble?
47. Cystic fibrosis?
48. Anemia or sickle cell anemia?
49. A heart murmur?
50. Cancer or any kind?
51. High blood pressure?
52. Rheumatic fever?
53. Rheumatic heart disease?
54. Congenital heart disease?
55. Any other heart trouble?**
56. Does -- now have - a missing finger, hand, or arm, toe, foot, or leg?
57. Permanent stiffness or any deformity in the back, foot, or leg? (Permanent stiffness - joints will not move at all)
58. Permanent stiffness or any deformity of the fingers, hands or arm?
59. Did -- ever have any other health problem which lasted for at least 3 months which you have not mentioned?
If "Yes," ask: What was the condition?
Make no entry in Section J for cold; flu; grippe; red, sore, or strep throat; or "virus".
*1. How many times did -- have...? If 2+ enter in Section J
If only one time ask:
2. How long did it last? - If 1 month or longer, enter in Section J. If less than 1 month, do no record.
**Did this condition last for at least 3 months? If "Yes," enter in Section J.
If "No," do not record unless it is an obvious permanent condition which began less than 3 months ago.
[p.94]
Section J. SUPPLEMENTAL CONDITIONS
Condition 1
1. Item number ____
For allergy ask:
2. How does this allergy affect --?
For impairment or ulcer, ask:
3. What part of the body is affected by (Condition)?
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)
____
____
____
4a. When was (Condition) first noticed?
(Was it during the past 12 months or before that time?)
(Was it during the past 3 months or before that time?)
5[] Over 3-12 months (6)
6[] More than 12 months ago
b. How old was -- when this was first noticed?
____ 3[] Months
____ 4[] Years
0 [] Condition from 56, 57, or 58 (NC)
5. Did -- have this condition at any time during the past 12 months?
2[] N (6b)
0 [] Condition from 56, 57, or 58 (NC)
6a. Does -- still have this condition?
2[] N
b. Is this condition completely cured or is it under control?
3[] Under control
4[] Other - Specify ____
Condition 2
1. Item number ____
For allergy ask:
2. How does this allergy affect --?
For impairment or ulcer, ask:
3. What part of the body is affected by (Condition)?
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)
____
____
____
4a. When was (Condition) first noticed?
(Was it during the past 12 months or before that time?)
(Was it during the past 3 months or before that time?)
5[] Over 3-12 months (6)
6[] More than 12 months ago
b. How old was -- when this was first noticed?
____ 3[] Months
(Number)
____ 4[] Years
(Number)
0 [] Condition from 56, 57, or 58 (NC)
5. Did -- have this condition at any time during the past 12 months?
2[] N (6b)
0 [] Condition from 56, 57, or 58 (NC)
6a. Does -- still have this condition?
2[] N
b. Is this condition completely cured or is it under control?
3[] Under control
4[] Other - Specify ____
Condition 3
1. Item number ____
For allergy ask:
2. How does this allergy affect --?
For impairment or ulcer, ask:
3. What part of the body is affected by (Condition)?
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)
____
____
____
4a. When was (Condition) first noticed?
(Was it during the past 12 months or before that time?)
(Was it during the past 3 months or before that time?)
5[] Over 3-12 months (6)
6[] More than 12 months ago
b. How old was -- when this was first noticed?
____ 3[] Months
(Number)
____ 4[] Years
0 [] Condition from 56, 57, or 58 (NC)
5. Did -- have this condition at any time during the past 12 months?
2[] N (6b)
0 [] Condition from 56, 57, or 58 (NC)
6a. Does -- still have this condition?
2[] N
b. Is this condition completely cured or is it under control?
3[] Under control
4[] Other - Specify ____
Condition 4
1. Item number ____
____ Name of condition
For allergy ask:
2. How does this allergy affect --?
For impairment or ulcer, ask:
3. What part of the body is affected by (Condition)?
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)
____
____
____
4a. When was (Condition) first noticed?
(Was it during the past 12 months or before that time?)
(Was it during the past 3 months or before that time?)
5[] Over 3-12 months (6)
6[] More than 12 months ago
b. How old was -- when this was first noticed?
____
(Number)
4[] Years
0 [] Condition from 56, 57, or 58 (NC)
5. Did -- have this condition at any time during the past 12 months?
2[] N (6b)
0 [] Condition from 56, 57, or 58 (NC)
6a. Does -- still have this condition?
2[] N
b. Is this condition completely cured or is it under control?
3[] Under control
4[] Other - Specify ____
[p.95]
Section K. WEIGHT, EYES, AND TEETH
1a. For -- height, would you say -- is underweight, about the right weight, or overweight?
1[] About the right weight (K1)
[] Overweight
b. Would you say -- is extremely overweight, somewhat overweight, or only a little overweight?
3[] Somewhat overweight (K1)
4[] Only a little overweight
c. Would you say -- is extremely underweight, somewhat underweight, or only a little underweight?
6[] Somewhat underweight
7[] Only a little underweight
CHECK ITEM K1
Refer to age of sample child.
1[] 3+ years old (2)
2a. Does -- wear glasses or contact lenses?
2[] N (3)
b. Which does -- wear?
2[] Glasses only
3[] Contacts only
3a. Has -- ever had -- teeth straightened or had braces or bands on teeth?
2[] N
b. Would you say -- teeth need to be straightened?
2[] N
c. Has a doctor or dentist ever said that -- teeth need to be straightened?
2[] N
4a. Does -- have any fillings in -- teeth?
0[] N (Section L, page 26)
b. How many teeth now have fillings?
Range acceptable - exclude baby or other teeth child no longer has.
[p.96]
Section L. MEDICINE USE
Note - Ask 1a-k before asking 2-5.
Hand calendar
The next few questions refer to the use of medicines, pills or ointments.
1. During the 2 weeks outlined in red on that calendar, did -- take or use any:
[] N
[] N
[] N
[] N
[] N
[] N
[] N
[] N
[] N
[] N
[] N
K2 ____
K3 ____
Note - Ask 2-5 only for those questions in 1a-k which were answered "Yes."
2. What is the main health problem for which -- took or used the (Medication)?
3. Did anyone get a prescription from a doctor for -- to take or use the (medication)?
2[] N
4. Did a doctor recommend that -- take or use the (Medication)?
2[] N
Hand Card T
5. Which number on that card best describes how often -- took or used the (Medication) during the past 3 months?
2 Nearly every day
3 Once or twice a week
4 2 or 3 times a month
5 About once a month
6 Less than once a month
7 For one episode of illness
8 Other _________
[p. 97]
Section M. SCHOOL
CHECK ITEM M1
Refer to age of sample child.
1[] 5 years old (1)
2[] 6+ years old (M2)
1. What was -- doing most of the past 12 months - going to school or doing something else?
2[] Something else
2. In terms of health, would -- be able to go to school?
2[] N (6)
3a. Does (would) -- have to go to a certain type of school because of -- health?
2[] N
b. Is (would) -- (be) limited in school attendance because of -- health?
2[] N (M3)
CHECK ITEM M2
Refer to age of sample child and/or to SCHOOL box on HIS-1.
1[] 17 years old and SCHOOL box marked (M3)
2[] 17 years old and SCHOOL box not marked (4)
4. In terms of health, would -- be able to go to school?
2[] N (6)
5a. Does (would) -- have to go to a certain type of school because of -- health?
2[] N
b. Is (would) -- (be) limited in school attendance because of -- health?
2[] N (M3)
CHECK ITEM M3
Refer to SCHOOL box on HIS-1 and/or to question 1 above.
2[] Going to school in Q1 (8)
8[] Other (7)
7. Has -- ever attended school?
2[] N (Section N, page 31)
8. Is -- now either going to school or on vacation from school?
2[] On vacation from school
0[] Neither (11)
9. What grade { is -- in now?}
{ will -- be in? }
If child is between grades, enter grade promoted to.
22[] Kindergarten (Section N, page 31)
____ Grade
10a. Does -- go to a special class or get special help in school because of a disability or health problem?
2[] N
b. Do you think that -- needs to attend a special class or get special help in school because of a disability or health problem?
2[] N (12)
[p. 98]
Section M. SCHOOL - Continued
11a. Why did -- stop going to school?
1[] Never went - other reasons (section N page 31)
2[] Graduated
3[] Health problem
4[] Dropped out
8[] Other - Specify
____
b. How long ago did -- stop going to school?
2[] 12 months - less than 2 years (13)
3[] 2+ years (13)
12. During the past 12 months, that is, since (12 month date) a year ago, about how many days was -- absent from school because of illness?
Range acceptable
____ Days
13a. Has -- repeated any grades for any reasons?
2[] N (14)
b. What grade or grades did -- repeat?
c. Why did -- repeat the (Grades in 13b) grade(s)?
2[] Immature/acted too young
3[] Frequently absent
4[] Moved into more difficult school
8[] Other - Specify ____
d. Any other reasons?
2[] N (14d)
14a. Has -- ever been suspended, excluded, or expelled from school?
2[] N (M4)
b. How many times has this happened?
c. How long ago was the last time?
____ 2[] Weeks
____ 3[] Months
____ 4[] Years
[p.99]
Section M. SCHOOL - Continued
CHECK Item M4
Refer to question 8, page 27 of CHS
0[] Neither (Section N, page 31)
15. Overall what kind of student would you say -- is now?
Is -- one of the best in the class, above the middle, in the middle, below the middle, or near the bottom of the class?
2[] Above the middle
3[] In the middle
4[] Below the middle
5[] Near the bottom
16. How do you feel -- is doing in school? Is -- doing really well, doing about as well as -- can, or could -- be doing better?
2[] Doing about as well as he/she can
3[] Could be doing better
[p.100]
Section N. BEHAVIOR
CHECK ITEM N1
Refer to age of sample child.
8[] 3+ years old (1)
1a. During the past twelve months has -- ever wet the bed?
2[] N (2)
b. About how many times has this happened?
Range acceptable.
2. Does -- now suck -- thumb or fingers either during the day or at night?
2[] N
3a. Has -- ever run away from home? (Disappeared at a time when you thought this is what -- might be doing, and stayed away so long that you had to start searching or looking for --._)
2[] N (4)
b. How many times has -- run away?
c. How old was -- the (last) time -- ran away?
4. Does -- take any medicines or drugs to help control activity or behavior?
2[] N
5a. Has -- ever seen a psychiatrist, psychologist, or psychoanalyst about any emotional, mental, or behavioral problem?
2[] N (5d)
b. Is -- still seeing this person?
2[] N
c. When was the last time -- saw this person?
8[] Within past 12 months (Section O, page 32)
d. During the past 12 months, have you felt, or has anyone suggested that -- needed help for any emotional, mental, or behavior problem?
2[] N
[p.101]
Section O. BEHAVIOR PROBLEMS INDEX
CHECK ITEM O1
Refer to age of sample child.
2[] 4+ years old (INTRO)
Hand card B
CARD B
Sometimes true in the past 3 months
Not true in the past 3 months
INTRO - Now I am going to read some statements that describe behavior problems many children have. Please tell me whether each statement has been OFTEN true, SOMETIMES true, or NOT true of -- during the past 3 months.
The first statement is: "Has sudden changes in mood or feelings." Has that been OFTEN true, SOMETIMES true, or NOT true of -- in the past 3 months?
Record response and continue with statement 2.
Read list repeating categories and/or time reference as needed.
1. Has sudden changes in mood or feelings.
2[] Sometimes true
3[] Not true
2. Feels or complains that no one loves --.
2[] Sometimes true
3[] Not true
3. Is rather high strung, tense, or nervous.
2[] Sometimes true
3[] Not true
2[] Sometimes true
3[] Not true
2[] Sometimes true
3[] Not true
2[] Sometimes true
3[] Not true
7. Has difficulty concentrating, cannot pay attention for long.
2[] Sometimes true
3[] Not true
8. Is easily confused, seems to be in a fog.
2[] Sometimes true
3[] Not true
9. Bullies, or is cruel or mean to others.
2[] Sometimes true
3[] Not true
2[] Sometimes true
3[] Not true
2[] Sometimes true
3[] Not true
12. Does not seem to feel sorry after -- misbehaves.
2[] Sometimes true
3[] Not true
13. Has trouble getting along with other children.
2[] Sometimes true
3[] Not true
14. Has trouble getting along with teachers.
2[] Sometimes true
3[] Not true
15. Is impulsive, or acts without thinking
2[] Sometimes true
3[] Not true
16. Feels worthless or inferior.
2[] Sometimes true
3[] Not true
[p.102]
Section O. BEHAVIOR PROBLEMS INDEX - Continued
17. Is not liked by other children.
2[] Sometimes true
3[] Not true
18. Has a lot of difficulty getting -- mind off certain thoughts, has obsessions.
2[] Sometimes true
3[] Not true
19. Is restless or overly active, cannot sit still.
2[] Sometimes true
3[] Not true
20. Is stubborn, sullen or irritable.
2[] Sometimes true
3[] Not true
21. Has a very strong temper and loses it easily.
2[] Sometimes true
3[] Not true
22. Is unhappy, sad or depressed.
2[] Sometimes true
3[] Not true
23. Is withdrawn, does not get involved with others.
2[] Sometimes true
3[] Not true
If child is 12+ years old, go to 29.
24. Breaks things on purpose, deliberately destroys -- own or other's things.
2[] Sometimes true
3[] Not true
2[] Sometimes true
3[] Not true
2[] Sometimes true
3[] Not true
27. Demands a lot of attention.
2[] Sometimes true
3[] Not true
28. Is too dependent on others.
2[] Sometimes true
3[] Not true
If child is under 12 years old, go to Section P, page 34.
29. Feels others are out to get --.
2[] Sometimes true
3[] Not true
30. Hangs around with kids who get into trouble.
2[] Sometimes true
3[] Not true
31. Is secretive, keeps things to (himself/herself).
2[] Sometimes true
3[] Not true
2[] Sometimes true
3[] Not true
[p. 103]
Section P. SOCIAL EFFECTS OF ILL HEALTH
1. A child's illness or disability may cause problems for other members of the family. Tell me if any of the following things have EVER happened because of a health problem of --.
Because of a health problem of --:
2[] N
2[] N
2[] N
2[] N
2[] N
2[] N
Because of a health problem of --:
2[] N
2[] N
________
[] N
CHECK ITEM P1 :
Refer to question 1a above.
8[] Other (2)
2. When the family moved because of -- health problem, was it to be nearer to certain special services that were needed, was it because the family could not afford to stay where it was, or was it for some other reason?
Mark the most appropriate box.
2[] Could not afford
8[] Other - Specify ____
[p. 104]
Section Q. SLEEP AND SEAT BELTS
CHECK ITEM Q1
Refer to age of sample child
2[] 1+ years old (1a)
If respondent asks, question 1 refers to sleeping patterns on school days and nights.
1a. About what time does -- usually go to bed (If 5+: on school nights)?
1[] Before 8 p.m.
2[] 8-8:59 p.m.
3[] 9-9:59 p.m.
4[] 10-10:59 p.m.
5[] 11-12 midnight
6[] After midnight
b. About how many hours does -- usually SLEEP each night?
2[] 5-6 hours
3[] 7-8 hours
4[] 9-10 hours
5[] 11+ hours
c. Does -- usually take naps during the day?
2[] N (2)
d. Counting daily naps and night-time sleep, about how many hours in all does -- usually sleep each day?
2[] 8-9 hours
3[] 10-11 hours
4[] 12-14 hours
5[] 15+ hours
2a. During the past 12 months has -- walked in -- sleep?
1[] Y
2[] N (3)
b. About how many times has -- walked in -- sleep during the past 12 months?
Range acceptable
3a. Does -- usually sleep in one room or in different rooms?
2[] Different rooms
b. Does -- usually sleep in a room alone or share a room?
2[] Shares
c. Who (else) usually sleeps in the room with --?
2[] Sister(s)
3[] Father
4[] Mother
8[] Other(s)
d. Anyone else?
[] N
4. When riding in a car, does -- wear a seat belt or restraint all or most of the time, some of the time, once in a while, or never?
2[] Some of the time
3[] Once in a while
0[] Never
Complete item 7 on page 1 of CHS
(End Survey)