ch
[p.74]

1981 CHILD HEALTH SUPPLEMENT
NATIONAL HEALTH INTERVIEW SURVEY

1. Book _____ of _____ books

2. R.O number

3. Sample

4. Control number

PSU
Segment
Serial

5. Interviewer's code

6. Sample child

____ First Name
Age

____ Yrs
____ Mos

____ Person number

7. Final status of interview

1[] Supplement completed
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.

1 ____
2 ____
3 ____
4 ____
5 ____
6 ____
7 ____
8 ____
9 ____
10 ____

CHECK ITEM A1
Mark first appropriate box.

1[] Biological mother in HH and available (Section B, page 4)
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 -- ?

____ Person number(s)

CHECK ITEM A2
Mark first appropriate box.

2[] Biological mother in HH not available (arrange callback and complete remaining items on HIS-1, HH page)
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

1[] Same respondent as HIS-1

____ Person number (B2)

2[] New respondent

____Person number (INTRO)

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.

1[] Under 15 years old (B3)
2[] 15+ years old (3)

CHECK ITEM B3
Refer to HH composition on HIS-1.

1[] Only 1 related HH member 12+ years old (2)
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 -- ?

____ Person number

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 --?

1[] Related HH member(s)
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.)

____ Person number(s)

3[] Related non 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?

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

3. Who usually takes -- to the doctor for checkups or other nonemergency visits?

[] HH Member

____ Person number

31[] Non HH member - Specify

____

33[] Child takes self
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

1[] Sitter (Unrelated)
2[] Sitter (Related)- Specify

____
____

3[] Day care center (7)
4[] Nursery (7)

5. Does (Caretaker in 4) take care of -- in this home or some other place?

1[] This home only (7)
8[] Some other place only
3[] Both

6. Is this (other place) in someone's home or some other place?

1[] Someone's home
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 in 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.

1[] Biological mother in HH (C2)
8[] Other (1)

1a. Has -- ever lived with -- biological mother for at least 3 months?

1[] Y
2[] N(2)
9[] DK(2)

b. How long has it been since -- last lived with her for at least 3 months?

____ 1[] Days
(Number)
____ 2[] Weeks
(Number)
____ 3[] Months
(Number)
____ 4[] Years
(Number)

2. Is -- biological mother now living or deceased?

1[] Living
2[] Deceased (C2)
3[] DK (C2)

3. How often does -- see her?

1[] Every day
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.

1[] Biological father in HH (7)
8[] Other (4)

4a. Has -- ever lived with -- biological father for at least 3 months?

1[] Y
2[] N (5)
9[] DK (5)

b. How long has it been since -- last lived with him for at least 3 months?

____
(Number)

1[] Days
2[] Weeks
3[] Months
4[] Years

2. Is -- biological father now living or deceased?

1[] Living
2[] Deceased (C2)
3[] DK (C2)

3. How often does --see him?

1[] Every day
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.

1[] Only one (3)
____ Number

b. Of those (Number in 7a) children, was -- born first (or) second (or third, etc.)?

1[] First
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.

1[] Biological mother in HH (9)
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?

1[] Married
2[] Widowed
4[] Divorced
5[] Separated
3[] Never married (12)
9[] DK (12)

9. How many times altogether has -- (Biological mother) been married?

0[] Never married (12)
____ 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

1st Marriage

19 ____ (Yr.began)

2nd Marriage

19 ____ (Yr began)

3rd Marriage

19 ____ (Yr. began)

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

1st Marriage

19 ____ (Yr.began)

2nd Marriage

19 ____ (Yr began)

3rd Marriage

19 ____ (Yr. began)

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

1st Marriage

1[] Death
4[] Divorce
5[] Annulment

2nd Marriage

1[] Death
4[] Divorce
5[] Annulment

3rd Marriage

1[] Death
4[] Divorce
5[] Annulment

11. How long has she been separated?

____
(Number)

1[] Days
2[] Weeks
3[] Months
4[] Years

12. In what month and year did -- move to this home?

0000[] Lived here since birth (C4)
____ 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

000[] Less than 1 mile
____ Miles

14. How many times has -- ever moved?

____ Number

CHECK ITEM C4

1[] Respondent is biological mother or biological father (Section D, page 9)
8[] Other (15)

15. How long has -- lived with you?

____
(Number)

1[] Days
2[] Weeks
3[] Months
4[] Years

[p.81]

Section D. Breastfeeding

CHECK ITEM D1
Refer to age of sample child.

5[] Under 6 months old (1)
6[] 6+ months old (2)

1. Is -- being breastfed at present time?

1[] Y (D2)
2[] N

2. Was -- ever breastfed?

1[] Y
2[] N (D4)

3. How old was -- when -- completely stopped breastfeeding?

000[] Still breastfeeding
____
(Number)

1[] Days
2[] Weeks
3[] Months

CHECK ITEM D2
Mark first appropriate box.

6[] 6+ years old (Section F, page 14)
2[] Respondent not biological mother (D3)
1[] Respondent is biological mother (4)

4. While breastfeeding --, did you ever take any birth control pills?

1[] Y
2[] N

CHECK ITEM D3
Refer to age of sample child.

1[] 3+ years old (Section E, page 10)
2[] Under 6 months old (5a)
8[] Other (5b)

5a. Has -- ever been given any formula or regular milk?

1[] Y
2[] N (D4)

b. How old was -- when -- was first fed formula or regular milk on a daily basis?

000[] Never on a daily basis
____
(Number)

1[] Days
2[] Weeks
3[] Months

CHECK ITEM D4
Refer to age of sample child.

1[] 3+ years old (Section E, page 10)
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?

1 Y
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?

000[] Never on a daily basis
____
(Number)

1[] Days
2[] Weeks
3[] Months

[p.82]

Section E. MOTOR AND SOCIAL DEVELOPMENT

CHECK ITEM E1
Refer to age of sample child.

1[] Under 2 years old (INTRO)
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.

Age (Mark only one)
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

Sequences
1 (Descending order beginning with question number-)

6
8
10
12
14
16
18
20
22
24
28
33
36
41
44

2 (Ascending order beginning with question number-)

7
9
11
13
15
17
19
21
23
25
29
34
37
42
45

[p.83]

Section E. Motor and Social Development-continued

1. When lying on -- stomach, has -- ever turned -- head from side to side?

1[] Y
2[] N
9[] DK

2. Have -- eyes ever followed a moving object at all?

1[] Y
2[] N
9[] DK

3. When lying on -- stomach on a flat surface did -- ever lift -- head off the surface for a moment?

1[] Y
2[] N
9[] DK

4. Have -- eyes ever followed a moving object all the way from one side to another?

1[] Y
2[] N
9[] DK

5a. Has -- ever smiled at someone when they talked to or smiled at -- without being touched?

1[] Y
2[] N
9[] DK

b. If "Yes," ask: How old was -- when -- first smiled at someone when they talked to or smiled at --?

____
(Number)

2[] Weeks
3[] Months

6. When lying on -- stomach, has -- ever raised -- head and chest from the surface while resting -- weight on -- lower arms or hands?

1[] Y
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?

1[] Y
2[] N
9[] DK

8. Has -- ever laughed out loud without being tickled or touched?

1[] Y
2[] N
9[] DK

9. Has -- ever turned -- head around to look at something?

1[] Y
2[] N
9[] DK

10. Has -- ever held in one had a moderate size object such as a block or a rattle?

1[] Y
2[] N
9[] DK

11. Has -- ever looked around with -- eyes for a toy which was lost or not nearby?

1[] Y
2[] N
9[] DK

12a. Has -- ever rolled over on -- own on purpose?

1[] Y
2[] N
9[] DK

b. If "Yes," ask: How old was -- when -- first rolled over?

____
(Number)

2[] Weeks
3[] Months

13. Has -- ever been pulled from a sitting to a standing position and supported -- own weight with legs stretched out?

1[] Y
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?

1[] Y
2[] N
9[] DK

15. Has -- ever seemed to enjoy looking in the mirror at (himself/herself)?

1[] Y
2[] N
9[] DK

16a. Has -- ever said any recognizable words, such as "mama" or "dada"?

1[] Y
2[] N
9[] DK

b. If "Yes," ask: How old was -- when -- first said any recognizable words?

____
(Number)

2[] Weeks
3[] Months

[p.84]

Section E. MOTOR AND SOCIAL DEVELOPMENT - Continued

17a. Has -- ever crawled when left lying on -- stomach?

1[] Y
2[] N
9[] DK

b. If "Yes," ask: How old was -- when -- first crawled?

____
(Number)

2[] Weeks
3[] Months

18. Did -- ever sit for 10 minutes without any support at all?

1[] Y
2[] N
9[] DK

19. Has -- ever pulled (himself/herself) to a standing position without help from another person?

1[] Y
2[] N
9[] DK

20. Has -- ever recognized -- own name when someone said it?

1[] Y
2[] N
9[] DK

21. Has -- ever picked up small objects, such as raisins or cookie crumbs, using only -- thumb and first finger?

1[] Y
2[] N
9[] DK

22a. Has -- ever waved good-bye without help from another person?

1[] Y
2[] N
9[] DK

b. If "Yes," ask: How old was -- when -- first waved good-bye without help from another person?

____
(Number)

2[] Weeks
3[] Months

23a. Has -- ever stood alone on -- feet for 10 seconds or more without holding on to anything or another person?

1[] Y
2[] N
9[] DK

b. If "Yes," ask: How old was -- when -- first stood alone?

____
(Number)

2[] Weeks
3[] Months

24. Has -- said 2 recognizable words besides "mama" and "dada"?

1[] Y
2[] N
9[] DK

25. Has -- ever walked at least 2 steps with one hand held or holding on to something?

1[] Y
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?

1[] Y
2[] N
9[] DK

27. Has -- ever crawled up at least 2 stairs or steps?

1[] Y
2[] N
9[] DK

28. Has -- ever said the name of a familiar object, such as a ball?

1[] Y
2[] N
9[] DK

29a. Has -- ever walked at least 2 steps without holding on to anything or another person?

1[] Y
2[] N
9[] DK

b. If "Yes," ask: How old was -- when -- first walked at least 2 steps?

____
(Number)

2[] Weeks
3[] Months

30. Has -- ever shown that -- wanted something without crying or whining? It may have been by pointing, pulling, or making pleasant sounds.

1[] Y
2[] N
9[] DK

31. Has -- ever made a line with a crayon or pencil?

1[] Y
2[] N
9[] DK

32. Has -- ever run?

1[] Y
2[] N
9[] DK

33. Did -- ever walk up at least 2 stairs with one hand held or holding the railing?

1[] Y
2[] N
9[] DK

34. Has -- ever let someone know, without crying, that -- was bothered by -- pants or diapers being wet or soiled?

1[] Y
2[] N
9[] DK

35. Has -- ever fed (himself/herself) with a spoon or fork without spilling much?

1[] Y
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?

1[] Y
2[] N
9[] DK

37. Has -- ever spoken in a partial sentence of 3 words or more?

1[] Y
2[] N
9[] DK

38. Has -- ever said -- first and last names together without someone's help?
Nickname may be used for first name.

1[] Y
2[] N
9[] DK

39. Has -- ever walked up stairs by (himself/herself) with no help, stepping on each step with only one foot?

1[] Y
2[] N
9[] DK

40. Has -- ever counted 3 object correctly?

1[] Y
2[] N
9[] DK

41. Has -- ever pedaled a tricycle at least 10 feet?

1[] Y
2[] N
9[] DK

42. Does -- know -- own age AND sex?

1[] Y
2[] N
9[] DK

43. Has -- ever washed and dried -- hands without any help except for turning the water on and off?

1[] Y
2[] N
9[] DK

44. Has -- ever done a somersault without help from anybody?

1[] Y
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?

1[] Y
2[] N
9[] DK

46. Has -- ever gone to the toilet alone?

1[] Y
2[] N
9[] DK

47. Has -- ever played with several children at the same time?

1[] Y
2[] N
9[] DK

48. Has -- ever said the names of at least 4 colors?

1[] Y
2[] N
9[] DK

49. Has -- ever dressed (himself/herself) without any help except for tying shoes (and buttoning the back of dresses)?

1[] Y
2[] N
9[] DK

50. Has -- ever counted out loud up to 10?

1[] Y
2[] N
9[] DK

CHECK ITEM E3
Refer to age of sample child.

1[] Under 2 years old (51a)
2[] 2 years old (51b)
3[] 3+ years old (E4)

51a. Are any of -- teeth in yet, that is, have any teeth broken through the gums?

1[] Y
2[] N (E4)

b. How old was -- when the first tooth came in (that is, broke through the gums)?

____
(Number)

2[] Weeks
3[] Months

CHECK ITEM E4
Refer to age of sample child.

1[] Under 1 year old (Section F, page 14)
2[] 1-3 years old (52a)
3[] 4 years old (52b)

52a. Except for occasional accidents, is -- completely toilet trained? (That is, does -- go to the bathroom by (himself/herself) when -- needs to?)

1[] Y
2[] N (Section F, Page 14)

b. How old was -- when -- was completely toilet trained?

000[] Not completely toilet trained
____
(Number)

3[] Months
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.

1[] Biological mother in HH (F2)
2[] Biological mother not in HH (1)

1. How old was -- biological mother when -- was born?

____ Years

CHECK ITEM F2
Refer to question 1, page 3 of CHS.

1[] Biological father in HH (F3)
2[] Biological father not in HH (2)

2. How old was -- biological father when -- was born?

____ Years

CHECK ITEM F3 >

1[] Respondent is biological mother or biological father (3)
8[] Other (9)

3a. Was -- born in a hospital or some other place?

1[] Hospital (3b)
[] Other - Specify (4) ____

b. How many nights was -- (Biological mother) in the hospital during this stay?

0[] None
____ Nights

c. How many nights was -- in the hospital during this stay?

0[] None
____ Nights

4a. How much did -- weigh at birth?
Probe for ounces if not reported.

9999 [] DK
____ Lbs (5)
____ Oz (5)

b. Did -- weigh more than 5 1/2 pounds or less?

[] More than 5 1/2 lbs.
2[] Less than 5 1/2 lbs. (5)
7[] DK (5)

c. Did -- weigh more than 9 pounds or less?

3[] More than 9 lbs.
4[] Less than 9 lbs.
9[] DK

5a. Was -- born about when expected or was it earlier or later?

1[] Earlier than expected
2[] When expected (6)
3[] Later than expected
9[] DK (6)

b. About how much (earlier/later) than expected was -- born?
Range acceptable

____
(Number)

1[] Days
2[] Weeks
3[] Months

6. How many hours was -- (Biological mother) in labor?

00[] None (8a)
____ Hours

CHECK ITEM F4

Refer to age of sample child.

1[] Under 6 years old (7a)
2[] 6+ years old (11)

[p.87]

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.

1[]Y
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?

1[] Spinal
2[] Other shot/I.V.
3[] Gas
8[] Some other method - Specify ____

c. Was (Biological mother) given anything else during labor?

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

1[] Y
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?

1[] Spinal
2[] Other shot/I.V.
3[] Gas
8[] Some other method - Specify ____

c. Was (Biological mother) given anything else during delivery?

[] Y (Reask 8b and c)
[] N

9a. Was --delivered by caesarean section?

1[] Y
2[] N (10)

b. Why was the caesarean performed?

________ (11c)
________ (11c)

10. Was -- born head first or feet first?

1[] Head first
2[] Feet first
8[] Other way - Specify ____

11a. Was it a normal delivery or were there any complications or problems?

1[] Normal delivery (12)
2[] Complications/problems

b. What was the matter?

________
________

c. (Besides the caesarean section) Were there any other problems during delivery?

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

1[] Y
2[] N (3)

b. What (else) was wrong with --?

________
________

c. Was there anything else wrong with --?

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

13a. Did -- receive any newborn care in an intensive care unit, premature nursery, or any other type of special care facility?

1[] Y
2[] N (F5)

b. How many nights did -- stay in the special care facility?

00[] None
____ Nights

CHECK ITEM F5
Refer to sex of sample child.

[] Male (14)
[] Female (Section G, page 17)

14. Was -- ever circumcised?

1[] Y
2[] N
9[] DK

[p.89]

Section G. PRENATAL CARE

CHECK ITEM G1

1[] Under 6 years old AND biological mother respondent (1)
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 --?

____ Weeks

2a. Did you see or talk to a doctor to find out if you were pregnant?

1[] Y
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)

2[] Weeks
3[] Months

c. Including routine checkups, did you see or talk to a doctor about your pregnancy at any (other) time during that pregnancy?

1[] Y
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)

2[] Weeks
3[] Months

3a. How much did you weigh just before you become pregnant with --?

____ Pounds

b. Altogether, how many pounds did you either gain or lose during the pregnancy?

____ 1[] Gained
____ 2[] Lost

c. How many months pregnant were you when -- was born?

____ Months

NOTE - 4a-h are conditions that may occur during pregnancy.
4. At any time during your pregnancy with --, did you have:

a. A urinary tract infection?

1[] Y
2[] N

b. Measles?

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

If "yes," ask: Was it German measles, sometimes known as Rubella or 3-day measles, OR was it Red measles, sometimes known as 8-day measles?

1[] German/Rubella/3-day
2[] Red/8-day
3[] Both

At any time in your pregnancy with -- did you have:

c. Hypertension or high blood pressure?

1[] Y
2[] N

d. Preeclampsia, eclampsia (eek-lamp-see-ah), or convulsions?

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

If "Yes" ask: Which was it, preeclampsia,eclampsis, or convulsions?

1[] Preeclampsia
2[] Eclampsia
3[] Convulsion

At any time during your pregnancy with -- did you have:

e. An embolism or blood clot?

1[] Y
2[] N

f. Abnormal position of the placenta?

1[] Y
2[] N

g. Abnormal position of the cord?

1[] Y
2[] N

h. Vaginal bleeding?

1[] Y
2[] N

[p. 90]

Section G. PRENATAL CARE - Continued

5a. At any time during your pregnancy with -- did you have?

(1) Sugar in the urine?

1[] Y (5b and c)
2[] N (Next column)

(2) High sugar in the blood?

1[] Y (5b and c)
2[] N (Next column)

(3) Diabetes

1[] Y (5b and c)
2[] N (6)

b. When did you first notice it - was it during your pregnancy with -- or before?

(1) Sugar in the urine?

1[] During
2[] Before

(2) High sugar in the blood?

1[] During
2[] Before

(3) Diabetes?

1[] During
2[] Before

c. Did you have the (Condition) for at least 3 months after -- was born?

(1) Sugar in the urine?

1[] Y (5a)
2[] N (5a)

(2) High sugar in the blood?

1[] Y (5a)
2[] N (5a)

(3) Diabetes?

1[] Y (6)
2[] N (6)

6. Do you now have diabetes or sugar diabetes?

1[] Y
2[] N

7a. At any time during your pregnancy with -- did you stay in a hospital overnight? Do not count hospitalization for -- birth.

1[] Y
0[] N (8)

b. How many times?

____ Number

c. For what (other) conditions did you stay in a hospital overnight?

____
____
____

d. Any other conditions?

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

e. Altogether, how many nights did you stay in a hospital for (Conditions in 7c)?

____ Nights

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?

1[] Y
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?

[] Y (Reask 8b and c)
[] 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)

1[] Days
2[] Weeks
3[] Months

9. During your pregnancy with -- about how many cigarettes a day did you usually smoke?

00[] None
____ Number

[p.91]

Section G. PRENATAL CARE - Continued

10a. At any time during your pregnancy with --, did you take tranquilizers?

1[] Y
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?

1[] Every day
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 --?

1[] Y
2[] N (Section H, page 21)

b. How many?

____ Number

c. How long before -- was born did you have the (most recent of those) miscarriage(s)?

____ 3[] Months
(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.

00[] None (3)
____ Number of times

b. During any of these hospitalizations, was -- treated for diabetes or sugar diabetes?

1[] Y
2[] N (2)

c. Does -- take insulin shots?

1[] Y
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.

1[] Y
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?

[] Y (Reask 2b and c)
[] 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.

1[] Y
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?

[] Y (Reask 3b and c)
[] 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 --?

1. Hepatitis?
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 ____

____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?)

4[] 3 months or less (6)
5[] Over 3-12 months (6)
6[] More than 12 months ago

b. How old was -- when this was first noticed?

0 [] Less than 1 month
____ 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?

1[] Y
2[] N (6b)

0 [] Condition from 56, 57, or 58 (NC)
6a. Does -- still have this condition?

1[] Y (NC)
2[] N

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

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

Condition 2
1. Item number ____

____ Name of condition

For allergy ask:
2. How does this allergy affect --?

____
____
____
____

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?)

4[] 3 months or less (6)
5[] Over 3-12 months (6)
6[] More than 12 months ago

b. How old was -- when this was first noticed?

0[] Less than 1 month
____ 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?

1[] Y
2[] N (6b)

0 [] Condition from 56, 57, or 58 (NC)
6a. Does -- still have this condition?

1[] Y (NC)
2[] N

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

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

Condition 3
1. Item number ____

____ Name of condition

For allergy ask:
2. How does this allergy affect --?

____
____
____
____

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?)

4[] 3 months or less (6)
5[] Over 3-12 months (6)
6[] More than 12 months ago

b. How old was -- when this was first noticed?

0[] Less than 1 months
____ 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?

1[] Y
2[] N (6b)

0 [] Condition from 56, 57, or 58 (NC)
6a. Does -- still have this condition?

1[] Y (NC)
2[] N

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

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

Condition 4

1. Item number ____
____ Name of condition

For allergy ask:
2. How does this allergy affect --?

____
____
____
____

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?)

4[] 3 months or less (6)
5[] Over 3-12 months (6)
6[] More than 12 months ago

b. How old was -- when this was first noticed?

0[] Less than 1 months
____
(Number)

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?

1[] Y
2[] N (6b)

0 [] Condition from 56, 57, or 58 (NC)
6a. Does -- still have this condition?

1[] Y (NC)
2[] N

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

2[] Cured
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?

[] Underweight (1c)
1[] About the right weight (K1)
[] Overweight

b. Would you say -- is extremely overweight, somewhat overweight, or only a little overweight?

2[] Extremely overweight
3[] Somewhat overweight (K1)
4[] Only a little overweight

c. Would you say -- is extremely underweight, somewhat underweight, or only a little underweight?

5[] Extremely underweight
6[] Somewhat underweight
7[] Only a little underweight

CHECK ITEM K1
Refer to age of sample child.

0[] Under 3 years old (Section L, page 26)
1[] 3+ years old (2)

2a. Does -- wear glasses or contact lenses?

1[] Y
2[] N (3)

b. Which does -- wear?

1[] Both glasses and contacts
2[] Glasses only
3[] Contacts only

3a. Has -- ever had -- teeth straightened or had braces or bands on teeth?

1[] Y (4)
2[] N

b. Would you say -- teeth need to be straightened?

1[] Y
2[] N

c. Has a doctor or dentist ever said that -- teeth need to be straightened?

1[] Y
2[] N

4a. Does -- have any fillings in -- teeth?

[] Y
0[] N (Section L, page 26)

b. How many teeth now have fillings?
Range acceptable - exclude baby or other teeth child no longer has.

____ Number

[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:

a. Pain relievers such as aspirin (or Tylenol and the like)?

[] Y
[] N

b. Cough medicines (such as Vicks, Robitussin, or Phenergan Expectorant and the like)?

[] Y
[] N

c. Any other medicines or remedies for colds?

[] Y
[] N

d. Asthma or allergy pills or medicines (such as Benadryl, Dimetapp, or Sudafed and the like)?

[] Y
[] N

e. Topical steroids (such as hydrocortisone cream or valisone and the like)?

[] Y
[] N

f. Other skin ointments or salves (such as Desitin, Calomine Lotion, Vaseline, Clearasil and the like)?

[] Y
[] N

g. Laxatives or any other medicines or remedies for the stomach (such as Ex-Lax, Rolaids, Colace, or Donnatal and the like)?

[] Y
[] N

h. Vitamins or minerals?

[] Y
[] N

i. Tranquilizers or sedatives (such as Valium, Chloral Hydrate, or Secanol and the like)?

[] Y
[] N

j. Antibiotics (such as Penicillin, Tetracycline, Ampicillin and the like)?

[]Y
[] N

k. Are there any other pills, ointments, or other types of medicines that -- has taken or used during that 2 week period? - Specific

[] Y
[] N

Any others?

K1 ____
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)?

1[] Y (5)
2[] N

4. Did a doctor recommend that -- take or use the (Medication)?

1[] Y
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?

1 Everyday
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.

0[] Under 5 years old (Section N, page 31)
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?

1[] Going to school (3)
2[] Something else

2. In terms of health, would -- be able to go to school?

1[] Y
2[] N (6)

3a. Does (would) -- have to go to a certain type of school because of -- health?

1[] Y (6)
2[] N

b. Is (would) -- (be) limited in school attendance because of -- health?

1[] Y (6)
2[] N (M3)

CHECK ITEM M2
Refer to age of sample child and/or to SCHOOL box on HIS-1.

0[] Under 17 years old (M3)
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?

1[] Y
2[] N (6)

5a. Does (would) -- have to go to a certain type of school because of -- health?

1[] Y (6)
2[] N

b. Is (would) -- (be) limited in school attendance because of -- health?

1[] Y (6)
2[] N (M3)

CHECK ITEM M3
Refer to SCHOOL box on HIS-1 and/or to question 1 above.

1[] SCHOOL box marked (8)
2[] Going to school in Q1 (8)
8[] Other (7)

7. Has -- ever attended school?

1[] Y
2[] N (Section N, page 31)

8. Is -- now either going to school or on vacation from school?

1[] Going to 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.

21[] Nursery school (Section N, page 31)
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?

1[] Y (12)
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?

1[] Y (12)
2[] N (12)

[p. 98]

Section M. SCHOOL - Continued

11a. Why did -- stop going to school?

0[] Never went - health reasons (section N page 31)
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?

1[] Less than 12 months
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

00[] None
____ Days

13a. Has -- repeated any grades for any reasons?

1[] Y
2[] N (14)

b. What grade or grades did -- repeat?

____ Grade(s)

c. Why did -- repeat the (Grades in 13b) grade(s)?

1[] Academic failure
2[] Immature/acted too young
3[] Frequently absent
4[] Moved into more difficult school
8[] Other - Specify ____

d. Any other reasons?

1[] Y (Reask 13c and d)
2[] N (14d)

14a. Has -- ever been suspended, excluded, or expelled from school?

1[] Y
2[] N (M4)

b. How many times has this happened?

____ Number

c. How long ago was the last time?

____ 1[] Days
____ 2[] Weeks
____ 3[] Months
____ 4[] Years

[p.99]

Section M. SCHOOL - Continued

CHECK Item M4
Refer to question 8, page 27 of CHS

1[] In school or on vacation (15)
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?

1[] One of the best
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?

1[] Doing really well
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.

1[] Under 3 years old (Section P, page 34)
8[] 3+ years old (1)

1a. During the past twelve months has -- ever wet the bed?

1[] Y
2[] N (2)

b. About how many times has this happened?
Range acceptable.

____ Number

2. Does -- now suck -- thumb or fingers either during the day or at night?

1[] Y
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 --._)

1[] Y
2[] N (4)

b. How many times has -- run away?

____ Number

c. How old was -- the (last) time -- ran away?

____ Years

4. Does -- take any medicines or drugs to help control activity or behavior?

1[] Y
2[] N

5a. Has -- ever seen a psychiatrist, psychologist, or psychoanalyst about any emotional, mental, or behavioral problem?

1[] Y
2[] N (5d)

b. Is -- still seeing this person?

1[] Y (Section O, page 32)
2[] N

c. When was the last time -- saw this person?

1[] More than 12 months ago
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?

1[] Y
2[] N

[p.101]

Section O. BEHAVIOR PROBLEMS INDEX

CHECK ITEM O1
Refer to age of sample child.

1[] Under 4 years old (Section P, page 34)
2[] 4+ years old (INTRO)

Hand card B
CARD B

Often true in the past 3 months
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.