soac

[pg. 189]

Section U. SUPPLEMENT CONDITION PAGES

CONDITION A
1. Name of condition

2. When did you last see or talk to a doctor or assistant about your (condition)?

3a. Did the doctor or assistant call the (condition) by a more technical or specific name?

Ask 3b if "Yes" in 3a, otherwise transcribe condition name from item 1 without asking:
b. What did he or she call it?

c. What is the cause of your (condition in 3b)?

Mark box if accident or injury
0[] Accident/injury (5)

d. Did the (condition in 3b) result from an accident or injury?

Ask 3a if the condition name in 3b includes any of the following words:

e. What kind of (condition in 3b) is it?

Ask 3f only if allergy or stroke in 3b-e:
f. How does the [allergy/stroke] now affect you?

For Stroke, fill remainder of this condition page for the first present effect. If additional present
effects, enter in Condition Summer Chart each one that is not already in the Condition Summary Chart. (If in C2 in HIS-1, enter condition number and transcribe when editing; if not, fill additional supplement page(s) during interview.)
Ask 3g if there is an impairment (refer to Card CP2) or any of the following entries in 3b-f:

g. What part of the body is affected?
Show the following detail:
Head .... skull, scalp, face
Back/spine/vertebrae .... upper, middle, lower
Side .... left or right
Ear .... inner or outer; left, right, or both
Eye .... left, right, or both
Arm .... shoulder, upper, elbow, lower or wrist; left, right, or both
Hand .... entire hand or fingers only; left, right, or both
Leg .... hip, upper, knee, lower, or ankle; left, right, or both
Foot .... entire foot, arch, or toes only; left, right, or both

Except for eyes, ears or internal organs, ask 3h if there are any of the following entries in 3b-f:

3h. What part of the (part of the body in 3b-g) is affected by the [infection/sore/soreness] - the skin, muscle, bone, or some other part?

Ask if there are any of the following entries in 3b-f:

4. Is this [tumor/cyst/growth] malignant or benign?

5. a. When was your (condition in 3b/3f) first noticed?
Ask probes as necessary:
(Was it on or since (first date of 2-week ref. period) or was it before that date?)
(Was it less than 3 months or more than 3 months ago?)
(Was it less than 1 year or more than 1 year ago?)
(Was it less than 5 years or more than 5 years ago?)

b. When did you (name of injury in 3b)?
Ask probes as necessary:
(Was it on or since (first date of 2-week ref. period) or was it before that date?)
(Was it less than 3 months or more than 3 months ago?)
(Was it less than 1 year or more than 1 year ago?)
(Was it less than 5 years or more than 5 years ago?)

U1 (K3)

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

c. About how long did you have this condition before it was cured?

d. Was this condition present at any time during the past 12 months?

U2 (K4)

Ask if box 3,4, or 5 marked in item 5
17b. What part of the body is affected now?
How is your (part of body) affected? Same acc. as Cond. ____
Are you affected in any other way?

* Enter part of body in same detail as for 3g.
** If multiple present effects, enter in Condition Summary Chart each one that is not the same as 3b above or is not already in the Condition Summary Chart. (If in C2 in HIS-1, enter condition number and transcribe when editing; if not, fill additional supplement page(s) during interview.)

U3
a. Indicate status of this condition page.

b. When editing, transcribe source data for this condition from the appropriate like in the Condition Summary Chart.