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soa
[pg. 172]

SUPPLEMENT ON AGING

Section N: Family structure, relationships, support, and living arrangements

N1

a. Initial status of sample person
1[] Available (N1b)
2[] Callback required (Next SP)


b. Supplement beginning time
Hour ____
Minutes ____

1[] am
2[] pm

Read to respondent - We are interested in obtaining further information about the health of people 55 years of age and older in the United States. I will also ask you some questions about your family and social activities.


Ask or verify for each HH member
1. How is (name on HIS-1) related to you?
Enter "Sample Person" on appropriate line.
Enter "Unrelated" for persons not related to the sample person.
Enter "Deleted" for any deleted persons, except AF members living at home and babies born during interview week.


Enter ages from HIS-1.


Person No. on HIS-1

01
02
03
04
05
06
07
08
09
10


Age on HIS-1

____
____
____
____
____
____
____
____
____
____


Relationship to sample person

____
____
____
____
____
____
____
____
____
____


N2
Refer to marital status (Page 46 or 47) on HIS-1

1[] Sample person is now married (N3)
2[] Sample person is now widowed, divorced, separated (2b)
3[] Sample person has never been married (6)
N3
Spouse of Sample Person previously interviewed on SOA

1[] Yes (6)
2[] No (2)


2a. How long have you been married (to (name of spouse))?

00[] Less than one year (3)
Number of years ____


b. Earlier [you told me/I was told] that you are now [widowed/divorced/separated]. How long have you been [widowed/divorced/separated]?

00[] Less than one year
Number of years ____


3a. Including step and adopted children, how many living children do you have?

00[] None (6)
Number ____


b. How many of your children are sons and how many are daughters?

Number of sons ____
Number of daughters ____
Total number of children ____
(Compare with 3a, reconcile differences)


N4
Refer to relationship roster in 1

1[] Any of SP's children live in household (6)
8[] Other (4)

[pg. 173]

Section N. FAMILY STRUCTURE, RELATIONSHIPS, SUPPORT, AND LIVING ARRANGEMENTS, Continued


4a. How quickly can [any one of your children/your son/your daughter] get here?

____ Number
1[] Minutes
2[] Hours
3[] Days


b. How often do you see [any one of your children/your son/your daughter]?

000[] Less than once a year/never

____ Times per
1[] Day
2[] Week
3[] Month
4[] Year


c. How often do you talk on the telephone with [any one of your children/your son/your daughter]?

000[] Less than once a year/never

____ Times per
1[] Day
2[] Week
3[] Month
4[] Year


d. How often do you get mail from [any one of your children/your son/your daughter]?

000[] Less than once a year/never

____ Times per
1[] Day
2[] Week
3[] Month
4[] Year


5. [Do your children/Does your son/Does your daughter] routinely give you money to help with your living expenses or pay your bills?

1[] Yes
2[] No


6a. Including step and adopted brothers, how many living brothers do you have?

00[] None
Number of brothers ____


b. Including step and adopted sisters, how many living sisters do you have?

00[] None
Number of sisters ____


7. How long have you been living here, in this [house/apartment]?

00[] Less than 1 year
Number of years ____

N5
Other family member previously interviewed on SOA

1[] Yes (12)
2[] No (8)

Mark if known
8. Is this [house/apartment] in a retirement [community/building or complex]?

1[] Yes
2[] No (10)


9.Whether you use them or not, are the following services available in this retirement [community/building or complex]?


a. Group meals for residents?
1[] Yes
2[] No


b. Housekeeping or maid service?

1[] Yes
2[] No


c. Medical services?

1[] Yes
2[] No


d. Telephone call service to check on your well-being?

1[] Yes
2[] No


e. Recreational services?

1[] Yes
2[] No




10a. Is it necessary to go up or down a step to get into this [house/apartment] from the outside?

1[] No
Yes - If not mentioned, ask: Is it more than one?
2[] 1 step
3[] More than 1 step


b. Counting basements and stepdown living areas as separate levels, does this [house/apartment] have more than one floor or level?

1[] Yes
2[] No (11b)

[pg. 174]

Section N. FAMILY STRUCTURE, RELATIONSHIPS, SUPPORT, AND LIVING ARRANGEMENTS, Continued


11a. Does this [house/apartment] have a bathroom, bedroom, and kitchen ALL on the SAME floor or level?

1[] Yes
2[] No


b. Does this [house/apartment] have a walk-in shower, that is, where you don't step over the side of the tub to get into the shower?

1[] Yes
2[] No


12a. Because of a health or physical problem, do you need a bathroom, bedroom, and kitchen all on the same floor or level?

1[] Yes
2[] No


b. Because of a health of physical problem, do you need a walk-in shower?

1[] Yes
2[] No


N6
Mark first appropriate box

1[] Sample person lives along (14)
2[] Sample person lives with spouse only (N7)
3[] Sample person lives only with persons under 18 years old (and spouse) (N7)
8[] All other (13a)


13a. Do you and (read names of all other household members) live together now because you need to share living expenses?

1[] Yes
2[] No


b. Do you and (read names of all other household members) live together now because of a health or physical problem you have?

1[] Yes
2[] No


N7
Spouse of SP previously interviewed on SOA

1[] Yes (Section O)
2[] No (14)

14a. Is this [house/apartment] now -

(1) Owned or being bought by you (OR someone in the household)?

1[] Yes (14b)
[] No
(2) Rented for money?

1[] Yes (14h)
[] No
(3) Occupied without payment of money rent?

1[] Yes (Section O)


b. Who owns or is buying it?
Anyone else?
Follow skip instructions for lowest numbered box marked.

1[] Sample person (14c)
2[] Spouse (14c)
3[] Child (Section O)
4[] Grandchild (Section O)
5[] Other relative (Section O)
6[] Nonrelative (Section O)


c. Is this place fully paid for or is there a mortgage being paid?

1[] Fully paid for (14f)
2[] Mortgage being paid
9[] DK (14f)


d. Do you know about how much principal is still owed on the mortgage?

1[] Yes
2[] No/DK (14f)


e. How much principal is still owed?

Amount $ ____


f. Do you know the present value of this place, that is, about how much it would bring if you sold it on today's market?

1[] Yes
2[] No/DK (Section O)


g. What is the present value?

Amount $ ____ (Section O)


h. Who is paying rent for it?
Anyone else?

1[] Sample person
2[] Spouse
3[] Child
4[] Grandchild
5[] Other relative
6[] Nonrelative

[pg. 175]

Section O. COMMUNITY AND SOCIAL SUPPORT

O1
Refer to age

1[] Sample person is 55-59
2[] Sample person is 60 or older

Note - Ask 2 immediately after receiving a "Yes" in 1.
Read to respondent - The next questions are about community services.


1. In the past 12 months, did you -


a. Use a senior center?
1[] Yes
2[] No (next service)
9[] DK (next service)


b. Use special transportation for the elderly?

1[] Yes
2[] No (next service)
9[] DK (next service)


c. Have meals delivered to your home by an agency or organization like Meals on Wheels?

1[] Yes
2[] No (next service)
9[] DK (next service)


d. Eat meals in a senior center or in some place with a special meal program for the elderly?

1[] Yes
2[] No (next service)
9[] DK (next service)


e. Use a homemaker service for the elderly that provides services like cleaning and cooking in the home?

1[] Yes
2[] No (next service)
9[] DK (next service)


f. Use a service which makes routine telephone calls to check on the health of elderly people?

1[] Yes
2[] No (next service)
9[] DK (next service)


g. Use a visiting nurse service?

1[] Yes
2[] No (next service)
9[] DK (next service)


h. Use a health aide who comes into the home?

1[] Yes
2[] No (next service)
9[] DK (next service)


i. Use adult day care or day care for the elderly?

1[] Yes
2[] No (next service)
9[] DK (next service)


2. How often did you use it -- frequently, sometimes, or rarely?


a. Use a senior center?
1[] Frequently {Reask 1 and resume list}
2[] Sometimes {Reask 1 and resume list}
3[] Rarely {Reask 1 and resume list}


b. Use special transportation for the elderly?
1[] Frequently {Reask 1 and resume list}
2[] Sometimes {Reask 1 and resume list}
3[] Rarely {Reask 1 and resume list}


c. Have meals delivered to your home by an agency or organization like Meals on Wheels?
1[] Frequently {Reask 1 and resume list}
2[] Sometimes {Reask 1 and resume list}
3[] Rarely {Reask 1 and resume list}


d. Eat meals in a senior center or in some place with a special meal program for the elderly?
1[] Frequently {Reask 1 and resume list}
2[] Sometimes {Reask 1 and resume list}
3[] Rarely {Reask 1 and resume list}


e. Use a homemaker service for the elderly that provides services like cleaning and cooking in the home?
1[] Frequently {Reask 1 and resume list}
2[] Sometimes {Reask 1 and resume list}
3[] Rarely {Reask 1 and resume list}


f. Use a service which makes routine telephone calls to check on the health of elderly people?
1[] Frequently {Reask 1 and resume list}
2[] Sometimes {Reask 1 and resume list}
3[] Rarely {Reask 1 and resume list}


g. Use a visiting nurse service?
1[] Frequently {Reask 1 and resume list}
2[] Sometimes {Reask 1 and resume list}
3[] Rarely {Reask 1 and resume list}


h. Use a health aide who comes into the home?
1[] Frequently {Reask 1 and resume list}
2[] Sometimes {Reask 1 and resume list}
3[] Rarely {Reask 1 and resume list}


i. Use adult day care or day care for the elderly?
1[] Frequently
2[] Sometimes
3[] Rarely


3a. In the past 12 months, did you do any volunteer work for any organized group?

1[] Yes
2[] No (4)
9[] DK


b. How often did you do volunteer work - frequently, sometimes, or rarely?

1[] Yes
2[] No
9[] DK


Hand calendar
Read to respondent - The next questions refer to the 2 weeks (outlined in red on that calendar), beginning Monday (date) and ending this past Sunday (date).

4. During those 2 weeks did you -


a. Get together socially with friends or neighbors?
1[] Yes
2[] No


b. Talk with friends or neighbors on the telephone?

1[] Yes
2[] No


c. Get together with any relatives (not including household members)?

1[] Yes
2[] No


d. Talk with any relatives on the telephone (not including household members)?
1[] Yes
2[] No


e. Go to church or temple for services or other activities?
1[] Yes
2[] No


f. Go to a show or movie, sports event, club meeting, classes or other group event?
1[] Yes
2[] No


O2
Respondent

1[] Self (5)
2[] Proxy (Section P)

5. Regarding your present social activities, do you feel that you are doing about enough, too much, or would you like to be doing more?

1[] About enough
2[] Too much
3[] Would like to do more

[pg.176]

Section P. OCCUPATION AND RETIREMENT


P1
Refer to Wa/Wb boxes for SP in C1 on the HIS-1, Household Composition Page

1[] Wa or Wb marked (1d)
8[] Other (1a)

1a. Have you ever worked at a job or business?

1[] Yes
2[] No (2)


b. Have you worked at a job or business, at any time since you were 45 years old?

1[] Yes
2[] No
9[] DK


c. Did you work at all at a job or business in the past 12 months, that is, since (12 month date) a year ago?

1[] Yes
2[] No (2)


d. Since (12 month date) a year ago, in how many weeks did you work, either full or part time, not counting work aroudn the house? Include paid vacations and paid sick leave.

52[] All year- 52 weeks
Weeks ____


e. In the weeks that you worked, how many hours a week did you usually work at all jobs?

Hours ____


2a. At this time, do you consider yourself retired, partly retired, or not retired at all?

1[] Completely retired
2[] Partly retired
3[] Not retired at all {3}
4[] Never worked {3}


P2
Refer to SP's work status in 1a and 1b

1[] "No" in 1a or 1b (3)
8[] All other (2b)

2b. Have you retired more than once?

1[] Yes
2[] No


c. How long has it been since you retired (the last time)?

00[] Less than 1 year
Number of years ____


d. (The last time you retired) Did you retire mainly because of a health or physical problem you had?

1[] Yes (3)
2[] No


e. (That time) Did you retire mainly because you thought your work would cause a health problem?

1[] Yes
2[] No


Hand card SOA 1 or read sources for a telephone interview
CARD SOA 1

1. Social Security
2. Railroad Retirement
3. A private employer or union pension
4. A government employee pension -
Federal, State, or local
5. Military retirement
6. Some other source - Specify

3a. (Even though you do not consider yourself retired) Are you now receiving retirement income from any of these sources? Do not include any disability income.

1[] Yes
2[] No (6)

b. Which ones? Mark all sources given
Any other source?

1[] Social Security
2[] Railroad retirement
3[] Private employer or union pension
4[] A government employee pension (Federal, State, or local)
5[] Military retirement
6[] Some other source - Specify
____
____


Note - Ask 4 and 5 for each source marked in 3b.
4. How long have you been receiving (source in 3b)?


1[] Social Security
00[] Less than 1 year
Number of years ____


2[] Railroad retirement

00[] Less than 1 year
Number of years ____


3[] Private employer or union pension

00[] Less than 1 year
Number of years ____


4[] A government employee pension (Federal, State, or local)

00[] Less than 1 year
Number of years ____


5[] Military retirement

00[] Less than 1 year
Number of years ____


5. Do you now receive it because of your own work experience or because you are a dependent or survivor of someone else?


1[] Social Security
1[] Own
2[] Someone else
3[] Both


2[] Railroad retirement
1[] Own
2[] Someone else
3[] Both


3[] A private employer or union pension
1[] Own
2[] Someone else
3[] Both


4[] A government employee pension (Federal, State, or Local)
1[] Own
2[] Someone else
3[] Both


5[] Military retirement
1[] Own
2[] Someone else
3[] Both

[pg. 177]

Section P. OCCUPATION AND RETIREMENT, Continued


6. Are you now receiving disability from any source?

1[] Yes
2[] No (9)


7. Are you receiving disability payments because of a disability you have or because you are a dependent or survivor of someone else?

1[] Own
2[] Someone else (9)
3[] Both


8. How long have you been receiving disability payments?
If more than one, record the longest one.

00[] Less than 1 year
Number of years ____


9. Have you ever received any disability payments from Social Security?

1[] Yes
2[] No
9[] DK

Note - Ask 10a-j before asking 11 and 12.


Read to respondent -
Please tell me if you have any difficulty when you do the following activities -

10. By yourself and not using aids, do you have any difficulty -


a. Walking for a quarter of a mile (that is about 2 or 3 blocks)?
1[] Yes
2[] No
9[] NA, DK


b. Walking up 10 steps without resting?

1[] Yes
2[] No
9[] NA, DK


c. Standing or being on your feet for about 2 hours?

1[] Yes
2[] No
9[] NA, DK


d. Sitting for about 2 hours?

1[] Yes
2[] No
9[] NA, DK

Reask 10

e. Stooping, crouching, or kneeling?

1[] Yes
2[] No
9[] NA, DK


f. Reaching up over your head?

1[] Yes
2[] No
9[] NA, DK


g. Reaching out (as if to shake someone's hand)?

1 [] Yes
2 [] No
9 [] NA, DK


h. Using your fingers to grasp or handle?

1[] Yes
2[] No
9[] NA, DK


Reask 10

i. Lifting or carrying something as heavy as 25 pounds (such as two full bags of groceries)?

1 [] Yes
2 [] No
9 [] NA, DK


j. Lifting or carrying something as heavy as 10 pounds?
1 [] Yes
2 [] No
9 [] NA, DK


11. How much difficulty do you have (activity in 10), some, a lot, or are you unable to do it?


a. Walking for a quarter of a mile (that is about 2 or 3 blocks?

1[] Some
2[] A lot
3[] Unable


b. Walking up 10 steps without resting?
1[] Some
2[] A lot
3[] Unable


c. Standing or being on your feet for about 2 hours?
1[] Some
2[] A lot
3[] Unable


d. Sitting for about 2 hours?
1[] Some
2[] A lot
3[] Unable


e. Stooping, crouching, or kneeling?
1[] Some
2[] A lot
3[] Unable


f. Reaching up over your head?
1[] Some
2[] A lot
3[] Unable


g. Reaching out (as if to shake someone's hand)?
1[] Some
2[] A lot
3[] Unable


h. Using your fingers to grasp or handle?
1[] Some
2[] A lot
3[] Unable


i. Lifting or carrying something as heavy as 25 pounds (such as two full bags of groceries)?
1[] Some
2[] A lot
3[] Unable


j. Lifting or carrying something as heavy as 10 pounds?
1[] Some
2[] A lot
3[] Unable


12. For how long have you [had some difficulty/had a lot of difficulty/been unable to] (activity in 10)?


a. Walking for a quarter of a mile (that is about 2 or 3 blocks)?

00[] Less than 1 year
Number of years ____


b. Walking up 10 steps without resting?
00[] Less than 1 year
Number of years ____


c. Standing or being on your feet for about 2 hours?
00[] Less than 1 year
Number of years ____


d. Sitting for about 2 hours?
00[] Less than 1 year
Number of years ____


e. Stooping, crouching, or kneeling?
00[] Less than 1 year
Number of years ____


f. Reaching up over your head?
00[] Less than 1 year
Number of years ____


g. Reaching out (as if to shake someone's hand)?
00[] Less than 1 year
Number of years ____


h. Using your fingers to grasp or handle?
00[] Less than 1 year
Number of years ____


i. Lifting or carrying something as heavy as 25 pounds (such as two full bags of groceries)?
00[] Less than 1 year
Number of years ____



j Lifting or carrying something as heavy as 10 pounds?
00[] Less than 1 year
Number of years ____

[pg. 178]

Section P. OCCUPATION AND RETIREMENT, Continued


P3
Refer to Wa/Wb boxes for SP in C1 on the HIS-1 Household Composition Page

1[] Wa or Wb box marked (Section Q)
8[] Other (P4)
P4
Mark first appropriate box

1[] SP is 75+ (Section Q)
2[] Proxy (Section Q)
3[] Self response (13)

13a. Do you think there are some kinds of work you could do now if jobs were available?

1[] Yes
2[] No (Section Q)
9[] DK/maybe (Section Q)


b. Do you want to work at a job or business?

1[] Yes
2[] No


[pg. 179]

Section Q. CONDITIONS AND IMPAIRMENTS

Read to respondent - Now tell me if you have any of these eye conditions, even if you have mentioned them before.
1. Do you now have -

a. Cataracts?
1[] Yes
2[] No
9[] DK


b. Glaucoma?

1[] Yes
2[] No
9[] DK


c. Color blindness?

1[] Yes
2[] No
9[] DK


d. A detached retina or any other condition of the retina?
Circle appropriate condition
1[] Yes
2[] No
9[] DK


e. Blindness in one or both eyes?
If "Yes," ask: Which - one or both?
Yes
0[] One
1[] Both (Q1)


2[]No
9[]DK


f. Any other trouble seeing with one or both eyes even when wearing glasses?
1[] Yes
2[] No
9[] DK


Q1
Refer to answers in 1a-f

1[] All "No" or "DK" in 1a-f (2)
8[] Other - Enter "Yes" responses in eye ltr box on Condition Summary Chart, then Q2
Q2
Blindness in BOTH eyes reported in 1e

1[] yes (4a then 9)
2[] No (2)

2a. Do you use eyeglasses? Include eyeglasses that just magnify.

1[] Yes
2[] No (3)


b. Were these eyeglasses prescribed for you?

1[] Yes
2[] No


3. Do you use contact lenses?

1[] Yes
2[] No


4a. Have you ever had an operation for cataracts?

1[] Yes
2[] No (5)


b. Do you have a lens implant?

1[] Yes
2[] No


5. Do you use a magnifying glass to read or to do other close work?

1[] Yes
2[] No


Read to respondent - The next few questions are about how well you can see (wearing your [glasses/(or) contact lenses] if that's how you see best).


6a. Can you see well enough to recognize the features of people if they are within two or three feet?

1[] Yes
2[] No


b. Can you see well enough to watch T.V. 8 to 12 feet away?

1[] Yes
2[] No


c. Can you see well enough to read newspaper print?

1[] Yes
2[] No


7a. Can you see well enough to step off a curb or down a step?

1[] Yes
2[] No


b. Can you see well enough to recognize a friend walking on the other side of the street?

1[] Yes
2[] No


8. Which statement best describes your vision (wearing [glasses/(or) contact lenses]) - no trouble seeing, a little trouble, or a lot of trouble?

1[] No trouble
2[] Little trouble
3[] Lot of trouble

[pg. 180]

Section Q. CONDITIONS AND IMPAIRMENTS, Continued


Read to respondent - These next questions are about hearing.
9. Do you now have -


a. Tinnitus or ringing in the ears? Circle appropriate condition.
1[] Yes
2[] No
9[] DK


b. Deafness in one of both ears?
If "Yes," ask: Which - one or both?
Yes
0[] One
1[] Both (Q3)

2[]No
9[]DK


c. Any other trouble hearing with one or both ears?

1[] Yes
2[] No
9[] DK

Q3
Refer to answers in 9a-c

1[] All "No" or "DK" in 9a-c (10)
8[] Other - Enter "Yes" responses in ear ltr box on Condition Summary Chart, then 10

10a. Do you use a hearing aid?

1[] Yes
2[] No


b.(With your hearing aid) Can you hear most of the things people say?

1[] Yes (11)
2[] No


c. (With your hearing aid) Can you hear only a few words people say or loud noises?

1[] Yes
2[] No


11. Which statement best describes your hearing (with your hearing aid) - no trouble haring, a little trouble, or a lot of trouble?

1[] No trouble
2[] Little trouble
3[] Lot of trouble


Read to respondent - Please tell me if you have ever had any of the following conditions, even if you have mentioned them before.

12. Have you ever had -


a. Osteoporosis, sometimes called fragile or soft bones? (os tee o po ro' sis)
1[] Yes
2[] No
9[] DK


b. A broken hip?

1[] Yes
2[] No
9[] DK


c. Hardening of the arteriesclerosis? Circle appropriate condition
1[] Yes
2[] No
9[] DK


d. Hypertension, sometimes called high blood pressure?
1[] Yes
2[] No
9[] DK


e. Rheumatic fever?
1[] Yes
2[] No
9[] DK


f. Rheumatic heart disease?
1[] Yes
2[] No
9[] DK


g. Coronary heart disease?

1[] Yes
2[] No
9[] DK


h. Angina pectoris? (pek' to ris)
1[] Yes
2[] No
9[] DK


i. A myocardial infarction?

1[] Yes
2[] No
9[] DK


j. Any other heart attack?

1[] Yes
2[] No
9[] DK


k. A stroke or carebrovascular accident? (ser' a-bro vas ku lar) Circle appropriate condition
1[] Yes
2[] No
9[] DK


l. Alzheimer's disease? (al' zi mers)
1[] Yes
2[] No
9[] DK


m. Cancer of any kind?

1[] Yes
2[] No
9[] DK

Q4
Refer to answers in 12a-m

1[] All "No" or "DK" in 12a-m (13)
8[] Other - Enter "Yes" responses in ever ltr box on Condition Summary Chart, then 13
[pg. 181]

Section Q. CONDITIONS AND IMPAIREMENTS, Continued

13. During the past 12 months, did you have -

a. Arthritis of any kind or rheumatism?
1[] Yes
2[] No
9[] DK


b. Diabetes?

1[] Yes
2[] No
9[] DK


c. An aneurysm? (an' yoo rizm)
1[] Yes
2[] No
9[] DK


d. Any blood clots?

1[] Yes
2[] No
9[] DK


e. Varicose veins?

1[] Yes
2[] No
9[] DK

Q5
Refer to answers in 13a-e

1[] All "No" or "DK" in 13a-e (14)
8[] Other - Enter "Yes" responses in 12 - mo ltr box on Condition Summary Chart, then 14

14a. During the past 12 months, that is, since (12-month date) a year ago, have you fallen?

1[] Yes
2[] No (14d)


b. How many times?

1[] One
2[] More than one


c. [Did you fall/Were there any falls] because you felt dizzy?

1[] Yes (14)
2[] No


d. Do you sometimes have trouble with dizziness?

1[] Yes
2[] No (15)


e. Does dizziness prevent you in any way from doing things you otherwise could do?

1[] Yes
2[] No


15. Do you have trouble biting or chewing any kinds of food, such as firm meat or apples?
If asked - includes wearing false teeth/dentures.

1[] Yes
2[] No

Read to respondent -
In order to determine how health practices and conditions are related to how long people live, we would like to refer to statistical records maintained by the National Center for Health Statistics.
16a. I have your date of birth as (birthdate from item 3 on HIS-1 Household Composition page). Is that correct?

Date of birth
Month ____
Date ____
Year ____

b. In what State or country were you born?
Write in the full name of the State or mark the appropriate box if the sample person was not born in the United States.

99[] DK
State ____
01[] Puerto Rico
02[] Virgin Islands
03[] Guam
04[] Canada
05[] Cuba
06[] Mexico
98[] All other countries

c. To verify the spelling, what is your full name, including middle initial?

Last ____
First ____
Middle initial ____

Verify for males; ask for females.
d. What was your father's last name?
Verify spelling. do not write "Same."

Father's last name ____

Read to respondent -
We also need your Social Security Number. This information is voluntary and collected under the authority of the Public Health Service Act. There will be no effect on your benefits and no information will be given to any other government or nongovernment agency.

Read if necessary - The Public Health Service Act is title 42, United States Code, section 242k.
e. What is your Social Security Number?

999999999 [] DK
Social Security Number _ _ _ - _ _ - _ _ _ _
Mark if number obtained from
1[] Memory
2[] Records

[pg. 182-183]

Section R1. ACTIVITIES OF DAILY LIVING (ADL'S)

Read to respondent -
The next questions are about how well you are able to do certain activities - by yourself and without using special equipment.


1. Because of a health or physical problem, do you have any difficulty -
Ask if "Doesn't do":
Is this because of a health or physical problem?
If "Yes," mark box 1; if "No," mark box 3.


Bathing or showering?
1[] Yes
2[] No
3[] Doesn't do for other reason


Dressing?
1[] Yes
2[] No
3[] Doesn't do for other reason


Eating
1[] Yes
2[] No
3[] Doesn't do for other reason


Getting in and out of bed or chairs?
1[] Yes
2[] No
3[] Doesn't do for other reason


Walking?
1[] Yes
2[] No
3[] Doesn't do for other reason


Getting outside?
1[] Yes
2[] No
3[] Doesn't do for other reason


Using the toilet, including getting to the toilet?
1[] Yes
2[] No
3[] Doesn't do for other reason


Ask 2-5 for each ADL marked "Yes" in 1
2. By yourself and without using special equipment, how much difficulty do you have (ADL), some, a lot, or are you unable to do it?


Bathing
1[] Some
2[] A lot
3[] Unable


Dressing
1[] Some
2[] A lot
3[] Unable


Eating
1[] Some
2[] A lot
3[] Unable


Getting in and out of bed or chairs?
1[] Some
2[] A lot
3[] Unable


Walking?
1[] Some
2[] A lot
3[] Unable


Getting outside?
1[] Some
2[] A lot
3[] Unable


Using the toilet, including getting to the toilet?
1[] Some
2[] A lot
3[] Unable


3. Do you receive help from another person in (ADL)?


Bathing or showering?
1[] Yes
2[] No (5)


Dressing
1[] Yes
2[] No (5)


Eating

1[] Yes
2[] No (5)


Getting in and out of bed or chairs?
1[] Yes
2[] No (5)


Walking
1[] Yes
2[] No (5)


Getting outside?
1[] Yes
2[] No (5)



Using the toilet, including getting to the toilet?
1[] Yes
2[] No (5)


4a. Who gives this help?
Anyone else?


Bathing
Source of help
HH member
1[] Relative
2[] Nonrelative
Non-HH member
3[] Relative
4[] Nonrelative


Dressing
Source of help
HH member
1[] Relative
2[] Nonrelative
Non-HH member
3[] Relative
4[] Nonrelative


Eating
Source of help
HH member
1[] Relative
2[] Nonrelative
Non-HH member
3[] Relative
4[] Nonrelative


Getting in and out of bed or chairs?
Source of help
HH member
1[] Relative
2[] Nonrelative
Non-HH member
3[] Relative
4[] Nonrelative


Walking?
Source of help
HH member
1[] Relative
2[] Nonrelative
Non-HH member
3[] Relative
4[] Non-relative


Getting outside?
Source of help
HH member
1[] Relative
2[] Nonrelative
Non-HH member
3[] Relative
4[] Nonrelative


Using the toilet, including getting to the toilet?
Source of help
HH member
1[] Relative
2[] Nonrelative
Non-HH member
3[] Relative
4[] Nonrelative


b. Is this help paid for?
Ask if necessary: Which helpers are paid?


Bathing
0[] S/CIP (5)
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No


Dressing
0[] S/CIP (5)
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No


Eating
0[] S/CIP (5)
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No


Getting in and out of bed or chairs?

0[] S/CIP (5)
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No


Walking?
0[] S/CIP (5)
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No


Getting outside?
0[] S/CIP (5)
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No


Using the toilet, including getting to the toilet?
0[] S/CIP (5)
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No


5a. Do you use any special equipment or aide in (ADL)?


Bathing
1[] Yes
2[] No (2 for next ADL with "Yes" in 1)


Dressing
1[] Yes
2[] No (2 for next ADL with "Yes" in 1)


Eating
1[] Yes
2[] No (2 for next ADL with "Yes" in 1)


Getting in and out of bed or chairs?
1[] Yes
2[] No (2 for next ADL with "Yes" in 1)


Walking?
1[] Yes
2[] No (2 for next ADL with "Yes" in 1)


Getting outside?
1[] Yes
2[] No (2 for next ADL with "Yes" in 1)


Using the toilet, including getting to the toilet?
1[] Yes
2[] No (2 for next ADL with "Yes" in 1)


b. What special equipment or aids do you use?
Anything else?


Bathing
________
________


Dressing
________
________


Eating
________
________


Getting in and out of bed or chairs?
________
________


Walking?
________
________


Getting outside?
________
________


Using the toilet, including getting to the toilet?
________
________


Ask 6 if any ADL marked "Yes" in 1.
6a. What (other) condition causes the trouble in (read ADL(s))
Ask if injury or operation:
When did [the (injury) occur? I you have the operation?]
Enter injury if over 3 months ago.
Ask or reask 6b, if 0-3 months injury or operation.
Ask if operation over 3 months ago: For what condition did you have the operation?
Enter condition.

[] Old age
________
________
________
________
________

b. Besides (condition), is there any other condition which causes this trouble in (read ADL(s))?

[] Yes (Reask 6a and b)
[] No (6d)

c. Is this trouble in (read ADL(s)) caused by any (other) specific condition?

[] Yes (Reask 6a and b)
[] No


If multiple conditions, including old age, are listed in 6a, ask 6d for each ADL with a "Yes" in 1. Otherwise, mark appropriate box or transcribe the only listed condition for each ADL.
d. Which of these conditions, that is (read conditions in 6a) would you say is the main cause of the trouble in (ADL)?


Bathing
1[] 0-3 month Inj/Op only [Ask 6d for next ADL with "Yes" in 1]
2[] Old age [Ask 6d for next ADL with "Yes" in 1]
3[] ________
Condition- enter in ADL box on Condition Summary Chart, then ask 6d for next ADL with "Yes" in 1.


Dressing
1[] 0-3 month Inj/Op only [Ask 6d for next ADL with "Yes" in 1]
2[] Old age [Ask 6d for next ADL with "Yes" in 1]
3[] ________
Condition- enter in ADL box on Condition Summary Chart, then ask 6d for next ADL with "Yes" in 1.


Eating
1[] 0-3 month Inj/Op only [Ask 6d for next ADL with "Yes" in 1]
2[] Old age [Ask 6d for next ADL with "Yes" in 1]
3[] ________
Condition- enter in ADL box on Condition Summary Chart, then ask 6d for next ADL with "Yes" in 1.


Getting in and out of bed or chairs
1[] 0-3 month Inj/Op only [Ask 6d for next ADL with "Yes" in 1]
2[] Old age [Ask 6d for next ADL with "Yes" in 1]
3[] ________
Condition- enter in ADL box on Condition Summary Chart, then ask 6d for next ADL with "Yes" in 1.


Walking
1[] 0-3 month Inj/Op only [Ask 6d for next ADL with "Yes" in 1]
2[] Old age [Ask 6d for next ADL with "Yes" in 1]
3[] ________
Condition- enter in ADL box on Condition Summary Chart, then ask 6d for next ADL with "Yes" in 1.


Getting outside?
1[] 0-3 month Inj/Op only [Ask 6d for next ADL with "Yes" in 1]
2[] Old age [Ask 6d for next ADL with "Yes" in 1]
3[] ________
Condition- enter in ADL box on Condition Summary Chart, then ask 6d for next ADL with "Yes" in 1.


Using the toilet, including getting to the toilet?
1[] 0-3 month Inj/Op only [Ask 6d for next ADL with "Yes" in 1]
2[] Old age [Ask 6d for next ADL with "Yes" in 1]
3[] ________
Condition- enter in ADL box on Condition Summary Chart, then ask 6d for next ADL with "Yes" in 1.

[pg.184]

Section R1. ACTIVITIES OF DAILY LIVING (ADL'S), Continued


7a. Do you have difficulty controlling your bowels?

1[] Yes
2[] No (7c)


b. How frequently do you have this difficulty - daily, several times a week, once a week, or less than once a week?

1[] Daily
2[] Several times a week
3[] Once a week
4[] Less than once a week
9[] DK


c. Do you have a colostomy or a device to help control bowel movements?

1[] Yes
2[] No (8)


d. Do you need help from another person in taking care of this device?

1[] Yes
2[] No


8a. Do you have difficulty controlling urination?

1[] Yes
2[] No (8c)


b. How frequently do you have this difficulty - daily, several times a week, once a week, or less than once a week?

1[] Daily
2[] Several times a week
3[] Once a week
4[] Less than once a week
9[] DK


c. Do you have a colostomy or a device to help control bowel movements?

1[] Yes
2[] No (R1)


d. Do you need help from another person in taking care of this device?

1[] Yes
2[] No


R1
Mark first appropriate box

1[] Respondent is a proxy (9)
2[] Sample person has only been seen in a bed or chair (9)
3[] Telephone interview (9)
8[] All other (Next page)


Mark if known
9. Because of a health or physical problem, do you usually -


a. Stay in bed all or most of the time?
1[] Yes (10)
2[] No
b. Stay in a chair all or most of the time? [32]
1 [] Yes (10)
2 [] No (Next page)


10a. What (other) condition causes you to stay in [bed/a chair]?
Ask if injury or operation:
When did [the (injury) occur?/ you have the operation?]
Enter injury if over 3 months ago.
Ask of reask 10b, if 0-3 months injury or operation.
Ask if operation over 3 months ago:
For what condition did you have the operation?
Enter condition.

[] Old age (10c)
________
________
________
________

b. Besides (condition), is there any other condition which causes this?

[] Yes (Reask 10a and b)
[] No (10d)

c. Is this caused by any (other) specific condition?

[] Yes (Reask 10a and b)
[] No

Ask if multiple conditions, including old age, are listed in 10a. Otherwise, mark appropriate box or transcribe the only listed condition.
d. Which of these conditions, that is (read conditions in 10a) would you say is the main cause of your staying in [bed/a chair] all of most of the time?

1[] 0-3 month inj/op ONLY } Ask 6d for next ADL with "Yes" in 1
2[] Old age
3[] ________
Condition - Enter "9" in ADL box on Condition Summary Chart, then next page.

[pg. 185-186]

Section R2. INCIDENTAL ACTIVITIES OF DAILY LIVING (IADL'S)

Read to respondent - Now I will ask you about some other activities. Tell me about doing them by yourself.


11. Because of a health or physical problem, do you have any difficulty -
Ask if "Doesn't do":
Is this because of a health or physical problem?
If "Yes" mark box 1; If "No" mark box 3.


[1] Preparing you own meals?
1[] Yes
2[] No
3[] Doesn't do for other reason


[2] Shopping for personal items, (such as toilet items or medicines)?
1[] Yes
2[] No
3[] Doesn't do for other reason


[3] Managing your money, (such as keeping track of expenses or paying bills)?
1[] Yes
2[] No
3[] Doesn't do for other reason

Reask 11

[4] Using the telephone?
1[] Yes
2[] No
3[] Doesn't do for other reason


[5] Doing heavy housework, (like scrubbing floors, or washing windows)?
1[] Yes
2[] No
3[] Doesn't do for other reason


[6] Doing light housework, (like doing the dishes, straightening up, or light cleaning)?
1[] Yes
2[] No
3[] Doesn't do for other reason


Ask 12-14 for each ADL marked "Yes" in 11.
12. By yourself, how much difficulty do you have (IADL), some, a lot, or are you unable to do it?


[1] Preparing your own meals?
1[] Some
2[] A lot
3[] Unable


[2] Shopping for personal items, (such as toilet items or medicines)?
1[] Some
2[] A lot
3[] Unable


[3] Managing your money, (such as keeping track of expenses or paying bills)?
1[] Some
2[] A lot
3[] Unable


Reask 11

[4] Using the telephone?
1[] Some
2[] A lot
3[] Unable


[5] Doing heavy housework, (like scrubbing floors, or washing windows)?
1[] Some
2[] A lot
3[] Unable


[6] Doing light housework, (like doing dishes, straightening up, or light cleaning)?
1[] Some
2[] A lot
3[] Unable


13. Do you receive help from another person in (IADL)?


[1] Preparing your own meals?
1[] Yes
2[] No (12 for next IADL with "Yes" in 11)


[2] Shopping for personal items, (such as toilet items or medicines)?
1[] Yes
2[] No (12 for next IADL with "Yes" in 11)


[3] Managing your money, (such as keeping track of expenses or paying bills)?
1[] Yes
2[] No (12 for next IADL with "Yes" in 11)

Reask 11

[4] Using the telephone?
1[] Yes
2[] No (12 for next IADL with "Yes" in 11)


[5] Doing heavy housework, (like scrubbing floors, or washing windows)?
1[] Yes
2[] No (12 for next IADL with "Yes" in 11)


[6] Doing light housework, (like doing dishes, straightening up, or light cleaning)?
1[] Yes
2[] No (12 for next IADL with "Yes" in 11)


14a. Who gives this help?
Anyone else?


[1] Preparing your own meals?
HH member
1[] Relative
2[] Nonrelative
Non-HH member
3[] Relative
4[] Nonrelative


[2] Shopping for personal items, (such as toilet items or medicines)?
HH member
1[] Relative
2[] Nonrelative
Non-HH member
3[] Relative
4[] Nonrelative


[3] Managing your money, (such as keeping track of expenses or paying bills)?
HH member
1[] Relative
2[] Nonrelative
Non-HH member
3[] Relative
4[] Nonrelative


Reask 11

[4] Using the telephone?
HH member
1[] Relative
2[] Nonrelative
Non-HH member
3[] Relative
4[] Nonrelative


[5] Doing heavy housework, (like scrubbing floors, or washing windows)?
HH member
1[] Relative
2[] Nonrelative
Non-HH member
3[] Relative
4[] Nonrelative


[6] Doing light housework, (like doing dishes, straightening up, or light cleaning)?
HH member
1[] Relative
2[] Nonrelative
Non-HH member
3[] Relative
4[] Nonrelative


Mark the S/C/P box without asking if ONLY help is from spouse, children/parents. Then 12 for next IADL with "Yes" in 11.
b. Is this help paid for?
Ask if necessary: Which helpers are paid?


[1] Preparing your own meals?
0[] S/C/P
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No


[2] Shopping for personal items (such as toilet items or medicines)?
0[] S/C/P
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No


[3] Managing your money, (such as keeping track of expenses or paying bills)?
0[] S/C/P
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No


Reask 11

[4] Using the telephone?
0[] S/C/P
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No


[5] Doing heavy housework, (like scrubbing floors, or washing windows)?
0[] S/C/P
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No


[6] Doing light housework (like doing dishes, straightening up, or light cleaning)?
0[] S/C/P
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No
1[] Yes
2[] No


Ask 15 if any ADL marked "Yes" in 11.
15a. What (other) condition causes the trouble in (read IADL(s))?
Ask if injury or operation:
When did [the (injury) occur?/ you have the operation?]
Enter injury if over 3 months ago.
Ask of reask 15b, if 0-3 months injury or operation.
Ask if operation over 3 months ago: For what condition did you have the operation?
Enter condition.

[] Old age (15c)
________
________
________
________
________

b. Besides (condition), is there any other condition which causes this trouble in (read IADL(s))?

[] Yes (Reask 15a and b)
[] No (15d)

c. Is this trouble in (read IADL(s)) caused by any (other) specific condition?

[] Yes (Reask 15a and b)
[] No


If multiple conditions, including old age, are listed in 15a, ask 15d for each IADL with a "Yes" in 11. Otherwise, mark appropriate box or transcribe the only listed condition.
d. Which of these conditions, that is (read conditions in 6a) would you say is the MAIN cause of the trouble in (IADL)?


[1] Preparing your own meals?
1[] 0-3 month inj/ Op only (Ask 15d for next IADL with "Yes" in 11)
2[] Old age (Ask 15d for next IADL with "Yes" in 11)
3[] ________
Condition - enter in IADL box on condition summary chart, then ask 15d for next IADL with "Yes" in 11.


[2] Shopping for personal items, (such as toilet items or medicines)?
1[] 0-3 month inj/ Op only (Ask 15d for next IADL with "Yes" in 11)
2[] Old age (Ask 15d for next IADL with "Yes" in 11)
3[] ________
Condition - enter in IADL box on condition summary chart, then ask 15d for next IADL with "Yes" in 11


[3] Managing your money (such as keeping track of expenses or paying bills)?
1[] 0-3 month inj/ Op only (Ask 15d for next IADL with "Yes" in 11)
2[] Old age (Ask 15d for next IADL with "Yes" in 11)
3[] ________
Condition - enter in IADL box on condition summary chart, then ask 15d for next IADL with "Yes" in 11

Reask 11

[4] Using the telephone?
1[] 0-3 month inj/ Op only (Ask 15d for next IADL with "Yes" in 11)
2[] Old age (Ask 15d for next IADL with "Yes" in 11)
3[] ________
Condition - enter in IADL box on condition summary chart, then ask 15d for next IADL with "Yes" in 11


[5] Doing heavy housework (like scrubbing floors, or washing windows)?
1[] 0-3 month inj/ Op only (Ask 15d for next IADL with "Yes" in 11)
2[] Old age (Ask 15d for next IADL with "Yes" in 11)
3[] ________
Condition - enter in IADL box on condition summary chart, then ask 15d for next IADL with "Yes" in 11


[6] Doing light housework, (like doing dishes, straightening up, or light cleaning)?
1[] 0-3 month inj/ Op only (Ask 15d for next IADL with "Yes" in 11)
2[] Old age (Ask 15d for next IADL with "Yes" in 11)
3[] ________
Condition - enter in IADL box on condition summary chart, then ask 15d for next IADL with "Yes" in 11

[pg. 187]

Section S. NURSING HOME STAY, HELP WITH CARE, AND HOSPICE


1a. Have you ever been a resident or patient in a nursing home?

1[] Yes
2[] No (S2)
9[] DK (S2)


b. How many different times have you been a resident or patient in a nursing home?

Number of times ____


c. When were you admitted (the first time)?

Month ____
Year 19 __


d. When were you discharged (the last time)?

Month ____
Year __


e. How long were you in the nursing home (the last time)?

00[] Less than 1 months
Number of months ____

S1


Refer to 1d

1[] Date discharged is since the 12-month reference date (1f)
8[] All other (S2)

1f. How many weeks in the past 12 months, that is, since (12 month date) a year ago, were you in a nursing home?

00[] Less than 1 week
Number of weeks ____


S2
Refer to age

1[] Sample person is 55-64 (2)
2[] Sample person is 65 or older (1g)

1g. Are you now on a waiting list to go into a nursing home?

1[] Yes
2[] No
9[] DK


2a. Is there a friend, relative, or neighbor who would take care of you for a few DAYS, if necessary? (Include the people you live with.)
Mark one box only.

Yes - Who is this person

.

HH- member
3[] Relative
4[] Nonrelative

OR
Non-HH member
5[] Relative
6[] Nonrelative
2[] No


b. Is there a friend, relative, or neighbor who would take care of you for a few WEEKS, if necessary? (Include the people you live with).
Mark one box only

Yes - Who is this person.
HH- member
3[] Relative
4[] Nonrelative

OR
Non-HH member
5[] Relative
6[] Nonrelative
2[] No


Skip to Section T if a proxy
3a. Are you familiar with the term "hospice," that is, a service for the terminally ill?

1[] Yes
2[] No/DK (Section T)


b. Is there a hospice or an in-home hospice in the [metropolitan area/county] that you could use if you needed one?

1[] Yes
2[] No
9[] DK

[pg. 188]

Section T. HEALTH OPTIONS


T1
Respondent

1[] Self response (1)
2[] Proxy (T2)

Read to respondent - Now I'd like to ask your personal opinions about health related matters.
1. How good a job do you feel you are doing in TAKING CARE of you health? Would you say excellent, very good, good, fair, or poor?

1[] Excellent
2[] Very good
3[] Good
4[] Fair
5[] Poor


2. Compared with 1 year ago, would you say that your health is now better, worse, or about the same as it was then?

1[] Better
2[] Worse
3[] Same


3. During the past year, has your overall health caused you a great deal of worry, some worry, hardly any worry, or no worry at all?

1[] A great deal of worry
2[] Some worry
3[] Hardly any worry
4[] No worry at all


4a. Compared to other people your age, would you say you are physically more active, less active, or about as active?

1[] More active
2[] Less active
3[] About as active (5)


b. Is that [a lot or a little more active/a lot less or a little less active]?

1[] Lot more
2[] little more
3[] Lot less
4[] Little less


5a. Compared to your own level of physical activity 1 year ago, would you say you are now more active, less active, or about the same as you were then?

1[] More active
2[] Less active
3[] About the same (6)


b. Is that [a lot more or a little more active/a lot less or a little less active]?

1[] lot more
2[] Little more
3[] Lot less
4[] Little less


6. How much control do you think you have over your future health? Would you say you have a great deal of control, some, very little, or none at all?

1[] A great deal of control
2[] Some control
3[] Very little control
4[] Little less


7. Do you feel that you get as much exercise as you need, or less than you need?

1[] As much as needed
2[] Less than needed


8. Do you follow a regular routine of physical exercise?

1[] Yes
2[] No


9. How often do you walk a mile or more at a time, without resting?
(Note: One miles equals 8-12 blocks.). Probe if necessary: About how many days a week is that?

1[] Everyday
2[] 4-6 days a week
3[] 2-3 days a week
4[] 1 day a week
5[] Less than 1 day a week
0[] Never


10a. People find that they sometimes have more trouble remembering things as they get older. In the past year, about how often did you have trouble remembering things - frequently, sometimes, rarely, or never?

1[] Frequently
2[] Sometimes
3[] Rarely
0[] Never (11)


b. Compared with a year ago, does this now happen more often, less often, or about the same?

1[] More often
2[] Less often
3[] About the same


11a. People find that they sometimes get confused as they get older. In the past year, about how often did you get confused - frequently, sometimes, rarely, or never?

1[] Frequently
2[] Sometimes
3[] Rarely
0[] Never (T2)


b. Compared with a year ago, does this now happen more often, less often, or about the same?

1[] More often
2[] Less often
3[] About the same


T2
Type of interview

1[] Self personal (Go to condition summary chart)
2[] Self- telephone (Go to condition summary chart)
3[] Proxy personal (T3)
4[] Proxy telephone (T3)


T3
a. Proxy Reason

1 [] Sample person temporarily absent
2 [] Sample person mentally/physically incapable of responding (Explain) ________
8 [] Other (Explain) ________

b. Enter person number of proxy respondent, or mark box.

00[] Non-HH member (Go to Condition summary chart)
Proxy Person No. ________