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[p. 161]

N. PREVENTATIVE CARE PAGE

N1
Refer to age.

0[] 17-39, available (3)
1[] 40 and over, available (1)
2[] 17 and over, callback required (NP)
3[] Other (NP)

1. About how long has it been since you had an electrocardiogram, or EKG, which involves placing wires on the chest and arms?

00[] Never
98[] Less than 1 year
Years ____


2. About how long has it been since you had a test for glaucoma, sometimes referred to as an eye pressure test?

00[] Never
98[] Less than 1 year
Years ____


3. About how long has it been since you had a chest x-ray?

00[] Never
98[] Less than 1 year
Years ____


4. About how long has it been since you had your blood pressure taken?

00[] Never
98[] Less than 1 year
Years ____


5a Have you ever been told by a doctor that you had high blood pressure?

1[] Yes (6)
2[] No


b. Have you ever been told by a doctor that you had hypertension?

1[] Yes
2[] No (N2)


6. Are you NOW taking any medicine prescribed by a doctor for your [high blood pressure/hypertension]?

1[] Yes (N2)
2[] No


7a. Do you still have [high blood pressure/hypertension]?

1[] Yes (N2)
[] No
[] DK

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

2[] Cured
3[] Under control

N2
Refer to sex.

2[] Female (8)
3[] Male (10)

8. About how long has it been since you had a Pap smear test?

00[] Never
98[] Less than 1 year
Years ____


9. About how long has it been since you had a breast examination by a medical doctor or assistant?

00[] Never
98[] Less than 1 year
Years ____


10. Do you have eyeglasses or contact lenses?

1[] Yes
2[] No


b. About how long has it been since you had your eyes examined to see if you needed glasses (or new glasses)?
Read if age 17: Include any eye exams given in school.

00[] Never
98[] Less than 1 year
Years ____

RS1

____ Pers. No. of Resp.
1[] Self Resp.
2[] Proxy (Reason)
____
[p. 162]

N. PREVENTATIVE CARE PAGE, Continued

N3
Refer to age

0[] Under 3 (12)
1[] 3-16 (11)
2[] Other (NP)

11a. Does -- have eyeglasses or contact lenses?

1[] Yes
2[] No


b. About how long has it been since -- had -- eyes examined to see if -- needed glasses (or new glasses)?
Read if age 5-16: Include any eye exams given in school.

00[] Never
98[] Less than 1 year
Years ____


12a. During the past 12 months, (that is, since (12 month date) a year ago) was -- taken to a doctor for a routine physical examination, that is, not for a particular illness but for a general checkup?
Read if age 5-16: Include routine physical examinations given in school.

1[] Yes (13)
2[] No


b. About how long has it been since -- was taken to a doctor for a routine physical examination or general checkup?
Read if age 5-16: Include routine physical examinations given in school.

00[] Never
98[] Less than 1 year
Years ____


13. About how old was -- when -- first went to a dentist?

00[] Never
____ Years old


RS2

____ Pers. No. of Resp.