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[p. 203]


NATIONAL HEALTH INTERVIEW SURVEY
EPIDEMIOLOGY STUDY

1. Book ____ of ____ books

2. R.O. Number

3. Sample

4. Control number

PSU ____
Segment ____
Serial ____

5. Beginning time

1 [] a.m.
2 [] p.m.

6a. FAMILY ROSTER

List all nondeleted family members 18 + by age (oldest to youngest)

b. Hispanic oversample

1[] Line
Person ____
Name ____
Age ____
[] "X" if Hisp.

Hisp No. Marked Line No

.

1 [] Hisp.
2 [] Hisp.
3 [] Hisp.
4 [] Hisp.
5 [] Hisp.
6 [] Hisp.
7 [] Hisp.
8 [] Hisp.
9 [] Hisp.

Refer to the appropriate section of the sample person selection and label and circle as applicable. THEN circle "SP1" Line No. in item 6a and mark "SP" box in HIS-1 for the selected sample person. THEN go to Section AA.

7. Final Status

0 [] No person 18+ in this family (Household Page)

Interview
1 [] Complete interview (all appropriate sections completed)
2 [] Partial interview (some but not all appropriate sections completed) - Explain ________
Noninterview
3 [] Refusal (Explain in notes)
4 [] SP temporarily absent
5 [] SP mentally or physically incapable
8 [] Other - Explain ________

8. Ending time

1 [] a.m.
2 [] p.m.

9. Interview mode

1 [] Personal
2 [] Telephone

10. Language of interview

1 [] English
2 [] Spanish
3 [] Both English and Spanish
8 [] Other

11. Interviewer identification

Name ____
Code ____

TRANSCRIPTION FROM COMPLETED HIS-1

12. Sex of SP (Page 2 or 55, question 3)

1 [] M
2 [] F

13. Education of SP (Page 42 or 43, question 2a)

00 [] Never attended or kindergarten

Elem:
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
High:
[] 9
[] 10
[] 11
[] 12
College:
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6+

Finish grade/year

1 [] Yes
2 [] No

14. Main race of SP (Page 42 or 43, question 3a/b)

[] 1
[] 2
[] 3
[] 4
[] 5 - Specify ____

15. Marital status (Page 46 or 47, question 7)

1 [] Married - spouse in HH
2 [] Married - spouse not in HH
3 [] Widowed
4 [] Divorced
5 [] Separated
6 [] Never married

16. Family income (Page 46, question 8b)

00 [] A
01 [] B
02 [] C
03 [] D
04 [] E
05 [] F
06 [] G
07 [] H
08 [] I
09 [] J
10 [] K
11 [] L
12 [] M
13 [] N
14 [] O
15 [] P
16 [] Q
17 [] R
18 [] S
19 [] T
20 [] U
21 [] V
22 [] W
23 [] X
24 [] Y
25 [] Z
26 [] ZZ
(Transcribe from 8a if 8b blank)
27 [] $20,000 or more
28 [] Less than $20,000

17. Person No. ____

18. Age ____

19. Booklet type ____

2[x] Epidemiology study

[p. 204]

Section AA - ACCULTURATION

AA1
SP Status at initial interview

1 [] Available (AA2)
2 [] Callback required (Household page)
8 [] Noninterview (Cover page)

AA2
Refer to hispanic origin from family roster and expected language for this supplement.

1 [] Hispanic/English Supp. Interview (1a)
2 [] Hispanic/Spanish Supp. Interview (1b)
8 [] Other (section BB)

Read to respondent:
I'm going to be asking questions that are related to health concerns, such as smoking, eating practices, doctor visits and so forth. Before I ask these questions I would like to ask a few questions about the language you use most often.


1a. Do you speak any Spanish?

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

Read to respondent:
I'm going to be asking questions that are related to health concerns, such as smoking, eating practices, doctor visits and so forth. Before I ask these questions I would like to ask a few questions about the language you use most often.


b. Do you speak any English?

1 [] Yes
2 [] No (4)


2. Would you say that you speak mostly Spanish, mostly English, or do you speak Spanish and English about the same?

1 [] Mostly Spanish
2 [] Mostly English
3 [] Both about the same


3. What language do you prefer: Spanish only, mostly Spanish, mostly English, English only, or Spanish and English about equally?

1 [] Spanish only
2 [] Mostly Spanish
3 [] Mostly English
4 [] English only
5 [] Spanish and English equally


4. Can you read Spanish?

1 [] Yes
2 [] No


5. Can you read English?

1 [] Yes
2 [] No


If "Yes" to both 4 and 5 ask?
6. In which language do you read better?

1 [] Spanish
2 [] English
3 [] Both the same


7. Can you write in Spanish?

1 [] Yes
2 [] No


8. Can you write in English?

1 [] Yes
2 [] No


If "Yes" to both 7 and 8 ask:
9. In which language do you write better?

1 [] Spanish
2 [] English
3 [] Both the same

If self-reported on HIS-1, mark box without asking.

HAND CARD O, read categories if telephone interview.

CARD O

1 - Puerto Rican
2 - Cuban
3 - Mexican/Mexicano
4 - Mexican American
5 - Chicano
6 - Other Latin American
7 - Other Spanish

10. Which of these groups best describes your ethnic identification?

1 [] Puerto Rican
2 [] Cuban
3 [] Mexican/Mexicano
4 [] Mexican American
5 [] Chicano
6 [] Other Latin American
7 [] Other Spanish
8 [] Other (specify) ____


11. Which of these groups best describes your mother's ethnic identification?

1 [] Puerto Rican
2 [] Cuban
3 [] Mexican/Mexicano
4 [] Mexican American
5 [] Chicano
6 [] Other Latin American
7 [] Other Spanish
8 [] Other (Specify) ____


12. Which of these groups best describes your father's ethnic identification?

1 [] Puerto Rican
2 [] Cuban
3 [] Mexican/Mexicano
4 [] Mexican American
5 [] Chicano
6 [] Other Latin American
7 [] Other Spanish
8 [] Other (Specify)

[p. 205]

Section AA - ACCULTURATION - Continued


If self-reported on HIS-1, mark box without asking.
13. In what country or state were you born?

1 [] U.S., except Puerto Rico
2 [] Puerto Rico
3 [] Cuba
4 [] Mexico
8 [] Other (Specify) ____


14. In what country or state was your father born?

1 [] U.S., except Puerto Rico
2 [] Puerto Rico
3 [] Cuba
4 [] Mexico
8 [] Other (Specify) ____




15. In what country or state was your mother born?

1 [] U.S., except Puerto Rico
2 [] Puerto Rico
3 [] Cuba
4 [] Mexico
8 [] Other (Specify) ____

[p. 206]

Section BB - FOOD FREQUENCY

Read to respondent: (I'm going to be asking questions that are related to health concerns, such as smoking, eating practices, vitamin use and so forth.) These next questions are about the foods you eat. Please tell me how often you eat each one, for example, twice a week, three times a month and so forth. Also tell me whether you usually eat a small, medium, or large portion of each food. Remember I'm only interested in the foods YOU eat.

HAND FOOD FLASHCARD BOOKLET. Please look at List 1 as I ask these first questions.

LIST 1 : Fruits and Juices

How often did you eat or drink - what size portion did you usually eat or drink?
Orange juice or grapefruit juice? Small, medium, or large?
Other fruit juices or fortified fruit drinks?
Oranges?
Grapefruit?
Cantaloupe in season? Medium (1/4 cant.)
Apples or applesauce?


During the past year or so, how often do you usually (eat/drink) -
1. Orange juice or grapefruit juice?

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

0000 [] Less than 6 a year or never (2)


Was it a small, medium or large portion?
1 [] Small
2 [] Medium (6 oz.)
3 [] Large


2. Other fruit juice or fortified fruit drinks?

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

0000 [] Less than 6 a year or never (3)


Was it a small, medium or large portion?
1 [] Small
2 [] Medium (6 oz.)
3 [] Large


3. Oranges?

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

0000 [] Less than 6 a year or never (4)


Was it a small, medium or large portion?
1 [] Small
2 [] Medium (1 med.)
3 [] Large


4. Grapefruit?

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

0000 [] Less than 6 a year or never (5)


Was it a small, medium or large portion?
1 [] Small
2 [] Medium (1/2 grapefruit)
3 [] Large


5. Cantaloupe in season?

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

0000 [] Less than 6 a year or never (6)


A medium serving is ? cantaloupe
1 [] Small
2 [] Medium (1/4 med.)
3 [] Large


6. Apples or applesauce?

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

0000 [] Less than 6 a year or never (7)


Was it a small, medium or large portion?
1 [] Small
2 [] Medium (1 med. or ? cup)
3 [] Large


Now look at List 2.
LIST 2 : Vegetables

How often did you eat - what size portion did you usually eat?
Beans, such as baked beans, pinto, kidney Small, medium or large? beans, or in chili? Do not include green beans.
Carrots or mixed vegetables containing carrots?
Tomatoes, including in salad?
Green salad?
Salad dressing or mayonnaise, Including on sandwiches?
Broccoli?
Spinach?
Collards, mustard greens, turnip greens, etc?
Cole slaw, cabbage, or sauerkraut?
Frenchfries or fried potatoes?
Potatoes, baked, boiled, or mashed?
Sweet potatoes or yams?
Rice?


During the past year or so, how often did you usually eat -
7. Beans, such as baked, pinto, kidney beans, or in chili? Do not include green beans.

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

0000 [] Less than 6 a year or never (8)


Small, medium or large?
1 [] Small
2 [] Medium (1 med. or ? cup)
3 [] Large


8. Carrots, or mixed vegetables containing carrots?

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

0000 [] Less than 6 a year or never (9)


Was it a small, medium or large portion?
1 [] Small
2 [] Medium (1 med. or ? cup)
3 [] Large


9. Tomatoes, including in salad?

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

0000 [] Less than 6 a year or never (10)


Was it a small, medium or large portion?
1 [] Small
2 [] Medium (1 tomato)
3 [] Large


10. Green salad?

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

0000 [] Less than 6 a year or never (11)


Was it a small, medium or large portion?
1 [] Small
2 [] Medium (1 med. bowl)
3 [] Large


11. Salad dressing or mayonnaise, including on sandwiches?

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

0000 [] Less than 6 a year or never (12)


Was it a small, medium or large portion?
1 [] Small
2 [] Medium (2 tbs.)
3 [] Large

[p. 207]

Section BB - FOOD FREQUENCY - Continued


12. Broccoli?

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

0000 [] Less than 6 a year or never (13)


Was it a small, medium or large portion?
1 [] Small
2 [] Medium (1/2 cup)
3 [] Large


13. Spinach?

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


0000 [] Less than 6 a year or never (14)


Was it a small, medium or large portion?
1 [] Small
2 [] Medium (1/2 cup)
3 [] Large


14. Mustard greens, turnip greens or collards?

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

0000 [] Less than 6 a year or never (15)


Was it a small, medium or large portion?
1 [] Small
2 [] Medium (1/2 cup)
3 [] Large


15. Coleslaw, cabbage or sauerkraut?

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

0000 [] Less than 6 a year or never (16)


Was it a small, medium or large portion?
1 [] Small
2 [] Medium (1/2 cup)
3 [] Large


16. French fries or fried potatoes?

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

0000 [] Less than 6 a year or never (17)


Was it a small, medium or large portion?
1 [] Small
2 [] Medium (3/4 cup)
3 [] Large


17. Potatoes, baked, boiled or mashed?

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

0000 [] Less than 6 a year or never (18)


Was it a small, medium or large portion?
1 [] Small
2 [] Medium (1 potato or 1/2 cup)
3 [] Large


18. Sweet potatoes or yams?

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

0000 [] Less than 6 a year or never (19)


Was it a small, medium or large portion?
1 [] Small
2 [] Medium (1/2 cup)
3 [] Large


19. Rice?

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

0000 [] Less than 6 a year or never (20)


Was it a small, medium or large portion?
1 [] Small
2 [] Medium (1/2 cup)
3 [] Large


Now look at List 3.
LIST 3 : Meats and mixed dishes

How often did you eat - what size portion did you usually eat?
Hamburgers, cheeseburgers, Small, medium, or large? or meatloaf?
Beef, such as steaks, or roasts?
Beef stew or potpie containing vegetables?
Liver, including chicken liver?
Pork, such as chops, Medium (2 chops or or roasts? 4oz. of roast)
Fried chicken? Medium (2 small or 1 large piece)
Chicken or turkey, baked, Medium (2 small or 1 stewed or broiled? large piece)
Fried fish or fish sandwiches?
Spaghetti, lasagna, or pasta with tomato sauce?


During the past year or so, how often did you usually eat -
20. Hamburgers, cheeseburgers, or meatloaf?

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

0000 [] Less than 6 a year or never (21)


Small, medium or large?
1 [] Small
2 [] Medium
3 [] Large


21. Beef, such as steaks or roasts?

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

0000 [] Less than 6 a year or never (22)


Small, medium or large?
1 [] Small
2 [] Medium (4 oz.)
3 [] Large


22. Beef stew or potpie with vegetables?

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

0000 [] Less than 6 a year or never (23)


Small, medium or large?
1 [] Small
2 [] Medium (1 cup)
3 [] Large


23. Liver, including chicken liver?

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

0000 [] Less than 6 a year or never (24)


Small, medium or large?
1 [] Small
2 [] Medium (4 oz.)
3 [] Large

[p. 208]

Section BB - FOOD FREQUENCY - Continued


24. Pork, such as pork chops or roasts?

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

0000 [] Less than 6 a year or never (25)


A medium service is 2 pork chops or 4 oz. of roast.
1 [] Small
2 [] Medium (2 pork chops of 4 oz. of roast)
3 [] Large


25. Fried chicken?

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

0000 [] Less than 6 a year or never (26)


A medium serving is 2 small or 1 large piece.
1 [] Small
2 [] Medium (2 sm. or 1 lg. piece)
3 [] Large


26. Chicken or turkey, baked, stewed or broiled?

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

0000 [] Less than 6 a year or never (27)


A medium serving is 2 small or 1 large piece.
1 [] Small
2 [] Medium (2 sm. or 1 lg. piece)
3 [] Large


27. Fried fish or fish sandwiches?

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

0000 [] Less than 6 a year or never (28)


Small, medium or large?
1 [] Small
2 [] Medium (4 oz.)
3 [] Large


28. Spaghetti, lasagna or pasta with tomato sauce?

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

0000 [] Less than 6 a year or never (29)


Small, medium or large?
1 [] Small
2 [] Medium (1 cup)
3 [] Large


Now look at List 4.
LIST 4 : Breakfast foods

How often did you eat - What size portion did you usually eat?
Cooked cereals like Small, medium, or large? oatmeal?
High fiber cereals like brand, granola, or shredded wheat?
Highly fortified cereals like Product 19, Total, or Most?
Other cold cereals like Rice Krispies or corn flakes?
Eggs? How many eggs?
Bacon? How many slices?
Sausage? How many patties or links?


During the past year or so, how often did you usually eat -
29. Cooked cereals like oatmeal?

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

0000 [] Less than 6 a year or never (30)


Small, medium or large?
1 [] Small
2 [] Medium (1 med. bowl)
3 [] Large


30. High fiber cereals like bran, granola, or shredded wheat?

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


0000 [] Less than 6 a year or never (31)


Small, medium or large?
1 [] Small
2 [] Medium (1 med. bowl)
3 [] Large


31. Highly fortified cereals like Product 19, Total, or Most?

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

0000 [] Less than 6 a year or never (32)


Small, medium or large?
1 [] Small
2 [] Medium (1 med. bowl)
3 [] Large


32. Other cold cereals like Rice Krispies or corn flakes?

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

0000 [] Less than 6 a year or never (33)


Small, medium or large?
1 [] Small
2 [] Medium (1 med. bowl)
3 [] Large


33. Eggs?

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

0000 [] Less than 6 a year or never (34)


How many eggs?
____ Number


34. Bacon?

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

0000 [] Less than 6 a year or never (35)


How many slices?
____ Number


35. Sausage?

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

0000 [] Less than 6 a year or never (36)


How many patties or links?
____ Number

[p. 209]

Section BB - FOOD FREQUENCY PAGE - Continued


Now look at List 5.
LIST 5: Breads, Lunches and snacks

How often did you eat - what size portion did you usually eat?
Vegetable soup, vegetable Small, medium, or large? beef, minestrone or tomato soup?
Do not include other kinds of soups.
Hot dogs? How many hot dogs?
Ham or lunch meats?
White bread, rolls, or crackers, Medium including sandwiches, bagels, (2 slices or 4 crackers) and so forth?
Dark breads like whole Medium (2 slices) wheat, rye, or pumpernickel?
Corn bread, corn muffins, corn tortillas, or grits?
Butter on bread, rolls, or Medium (2 pats) vegetables?
Margarine on breads, rolls, or Medium (2 pats) on vegetables?
Cheese or cheese spreads, not including cottage cheese?
Peanuts or peanut butter?
Salty snacks like chips or popcorn?


During the past year or so, how often did you usually eat -
36. Vegetable soup, vegetable beef, minestrone or tomato soup? Do not include other kinds of soup.

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

0000 [] Less than 6 a year or never (37)


Small, medium or large?
1 [] Small
2 [] Medium (1 med. bowl)
3 [] Large


37. Hot dogs?

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

0000 [] Less than 6 a year or never (38)


How many hot dogs?
____ Amount


38. Ham or lunch meats?

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

0000 [] Less than 6 a year or never (39)


Small, medium or large?
1 [] Small
2 [] Medium (2 slices)
3 [] Large


39. White bread, rolls or crackers, including sandwiches, bagels, and so forth? I'm going to ask about dark bread and corn bread next.

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

0000 [] Less than 6 a year or never (40)


A medium serving is 2 slices or 4 crackers.
1 [] Small
2 [] Medium (2 slices or 4 crackers)
3 [] Large


40. Dark breads like whole wheat, rye or pumpernickel?

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

0000 [] Less than 6 a year or never (41)


A medium serving is 2 slices
1 [] Small
2 [] Medium (2 slices)
3 [] Large


41. Corn bread, corn muffins, corn tortillas, or grits?

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

0000 [] Less than 6 a year or never (42)


Small, medium or large?
1 [] Small
2 [] Medium (1 piece or 1/2 cup grits)
3 [] Large


42. Butter on bread, rolls or vegetables? I'll ask about margarine next.

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

0000 [] Less than 6 a year or never (43)


A medium serving is 2 pats
1 [] Small
2 [] Medium (2 pats)
3 [] Large


43. Margarine on bread, rolls or vegetables?

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

0000 [] Less than 6 a year or never (44)


A medium serving is 2 pats.
1 [] Small
2 [] Medium (2 pats)
3 [] Large


44. Cheese or cheese spreads, not including cottage cheese?

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

0000 [] Less than 6 a year or never (45)


Small, medium or large?
1 [] Small
2 [] Medium (2 slices or 2 oz.)
3 [] Large


45. Peanuts or peanut butter?

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

0000 [] Less than 6 a year or never (46)


Small, medium or large?
1 [] Small
2 [] Medium (2 tbs.)
3 [] Large


46. Salty snacks like chips or popcorn?

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

0000 [] Less than 6 a year or never (47)


Small, medium or large?
1 [] Small
2 [] Medium (1 handful)
3 [] Large


Now look at List 6.
LIST 6: Sweets and beverages
How often did you eat or drink - what size portion did you usually eat or drink?

Ice cream? Small, medium, or large?
Pie?
Doughnuts, cookies, cakes, or pastry?
Chocolate candy?
Sugar in coffee or tea, Medium (2 tsp.) or on cereal?
Whole milk or drinks made with whole milk, NOT including on cereal?
2% milk or drinks made with
2% milk, NOT including on cereal?
Skim milk or 1% milk or buttermilk, NOT including on cereal?
Milk or cream in coffee or tea?
Soda or soft drinks containing sugar?
Beer?
Wine?
Liquor?
a. How often
b. On the days you drank it, how many cans, glasses, or drinks?
c. Small, medium or large?


During the past year or so, how often did you usually (eat/drink) -
47. Ice cream?

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

0000 [] Less than 6 a year or never (48)


A medium serving is 1 medium scoop.
1 [] Small
2 [] Medium (1 med. scoop)
3 [] Large

[p. 210]

Section BB - FOOD FREQUENCY - Continued


48. Pie?

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

0000 [] Less than 6 a year or never (49)


Small, medium or large?
1 [] Small
2 [] Medium (1 med. slice)
3 [] Large


49. Doughnuts, cookies, cake or pastry?

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

0000 [] Less than 6 a year or never (50)


A medium serving is 1 piece or 3 cookies
1 [] Small
2 [] Medium (1 piece or 3 cookies)
3 [] Large


50. Chocolate candy?

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

0000 [] Less than 6 a year or never (51)


Small, medium or large?
1 [] Small
2 [] Medium (1 oz.)
3 [] Large


51. Sugar in coffee or tea or on cereal?

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

0000 [] Less than 6 a year or never (52)


Small, medium or large?
1 [] Small
2 [] Medium (2 tsp.)
3 [] Large


52. Whole milk or drinks made with whole milk, not including on cereal? I'm going to ask about 1%, 2% and skim milk separately.

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

0000 [] Less than 6 a year or never (53)


Small, medium or large?
1 [] Small
2 [] Medium (8 oz. glass)
3 [] Large


53. 2% milk or drinks made with 2% milk, not including on cereal?

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

0000 [] Less than 6 a year or never (54)


Small, medium or large?
1 [] Small
2 [] Medium (8 oz. glass)
3 [] Large


54. Skim milk, 1% milk or buttermilk, not including on cereal?

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

0000 [] Less than 6 a year or never (55)


Small, medium or large?
1 [] Small
2 [] Medium (8 oz. glass)
3 [] Large


55. Milk or cream in coffee or tea?

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


0000 [] Less than 6 a year or never (56)


Small, medium or large?
1 [] Small
2 [] Medium (1 tbs.)
3 [] Large


56. Soda or soft drinks with sugar?

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

0000 [] Less than 6 a year or never (57)


Small, medium or large?
1 [] Small
2 [] Medium (12 oz.)
3 [] Large


57a. During the past year or so, how often did you drink beer?

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

0000 [] Less than 6 a year or never (58)


b. On the days you drank beer, how many cans, bottles or glasses did you drink?

____ Number
99 [] DK


c. Were they small, medium, or large?
1 [] Small
2 [] Medium (12 oz.)
3 [] Large (16 oz.)



[p. 211]

Section BB - FOOD FREQUENCY - Continued


58a. During the past year or so, how often did you drink wine?

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

0000 [] Less than 6 a year or never (59)


b. On the days you drank wine, how many glasses did you drink?

____ Number
99 [] DK


c. Were they small, medium, or large?
1 [] Small
2 [] Medium (1 med. wine glass)
3 [] Large


59a. During the past year or so, how often did you drink liquor?

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

0000 [] Less than 6 a year or never (60)


b. On the days you drank liquor, how many drinks did you have?
____ Number
99 [] DK


c. Were they small, medium, or large?
1 [] Small
2 [] Medium (1 shot)
3 [] Large


60a. Was there ever a period in your life when you drank five or more drinks of any alcoholic beverage almost every day?

1 [] Yes
2 [] No (61)
9 [] DK (61)


b. For how long did that period last?

____ Number

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


9999 [] DK


61. When you eat chicken or other poultry, how often do you eat it with the skin on? Would you say often, sometimes, rarely or never?

1 [] Often or always
2 [] Sometimes
3 [] Rarely
4 [] Never
0 [] Don't eat chicken or poultry


62. When you eat red meat, how often do you eat the fat? Would you say often, sometimes, rarely or never?

1 [] Often or always
2 [] Sometimes
3 [] Rarely
4 [] Never
0 [] Don't eat red meat


63a. On most weekdays, how many meals do you usually eat each day?

0 [] Less than one a day

____ Meals

9 [] DK


b. On most weekdays, how many snacks do you usually eat each day, including snacks after dinner?

0 [] Less than one a day

____ Snacks

9 [] DK


c. On most Saturdays or Sundays, how many meals do you usually eat each day?

0 [] Less than one a day

____ Meals

9 [] DK


d. On most Saturdays or Sundays, how many snacks do you usually eat each day?

0 [] Less than one a day

____ Snacks

9 [] DK


64. In a typical week, how many meals do you usually get in restaurants, cafeterias, or fast food places?

00 [] Less than one a week

____ Meals

99 [] DK

[p. 212]

Section CC - VITAMIN AND MINERAL INTAKE


1. During the past 12 months, that is, since (12 month date) a year ago, did you take any vitamin or mineral supplements of any kind?

1 [] Yes
2 [] No (section DD)


2a. During the past 12 months, that is, since (12 month date) a year ago, did you take any MULTIPLE vitamins?

1 [] Yes
2 [] No (3)


b. What is the brand name of the multiple vitamins?

If more than one brand, ask:
What is the name of the brand you took most often during the past 12 months?
____ Brand name


[] DK/Refused (Ask probe for type)

If known, mark without asking, otherwise ask:
Is that a therapeutic type, a stress-tab type or a one-a-day type?
Mark first type listed
1 [] Therapeutic
2 [] Stress-tabs
3 [] One-a-day
8 [] None of these
9 [] DK


c. For how many of the past 12 months did you take [(name in 2b)/multiple vitamins]?

00 [] Less than one
12 [] All of them

____ Number of months


d. During (the/those) (number in 2c) month(s), about how many days per months did you take [(name in 2b)/ multiple vitamins]?

98 [] Everyday
____ Number of days per month
88 [] Other


e. On the days you took [(name in 2b)/ multiple vitamins], how many pills did you take per day?

____ Pills per day
99 [] DK


If less than 12 in 2c, ask:
f. Did you take any multiple vitamins in the past month?

1 [] Yes
2 [] No


(The following questions are about vitamins not including the multiple vitamins you already told me about.)
3a. During the past 12 months, did you take any vitamin A?

1 [] Yes
2 [] No (4)


b. For how many of the past 12 months did you take vitamin A?

00 [] Less than one
12 [] All of them

____ Number of months


c. During (the/those) (number in 3b) month(s), about how many days per months did you take Vitamin A?

98 [] Everyday

___ Number of days per month

88 [] Other


d. On the days you took vitamin A, how many pills did you usually take per day?

____ Pills per day

99 [] DK


e. How many milligrams of vitamin A are in each of the pills you took?

____ Mgs.

99999 [] DK


If less than 12 in 3b, ask:
f. Did you take any vitamin A in the past month?

1 [] Yes
2 [] No


4a. During the past 12 months, did you take any vitamin C?

1 [] Yes
2 [] No (5)


b. For how many of the past 12 months did you take vitamin C?

00 [] Less than one
12 [] All of them

____ Number of months


c. During (the/those) (number in 4b) month(s), about how many days per months did you take Vitamin C?

98 [] Everyday

____ Number of days per month

88 [] Other


d. On the days you took vitamin C, how many pills did you usually take per day?

____ Pills per day

99 [] DK


e. How many milligrams of vitamin C are in each of the pills you took?

____ Mgs.

99999 [] DK


If less than 12 in 4b, ask:
f. Did you take any vitamin C in the past month?

1 [] Yes
2 [] No



[p. 213]

Section CC - VITAMIN AND MINERAL INTAKE - Continued


5a. During the past 12 months, did you take any vitamin E?

1 [] Yes
2 [] No (6)


b. For how many of the past 12 months did you take vitamin E?

00 [] Less than one
12 [] All of them

____ Number of months


c. During (the/those) (number in 5b) month(s), about how many days per months did you take Vitamin E?

98 [] Everyday

____ Number of days per month

88 [] Other


d. On the days you took vitamin E, how many pills did you usually take per day?

____ Pills per day
99 [] DK


e. How many units of vitamin E are in each of the pills you took?

____ Units

99999 [] DK


If less than 12 in 5b, ask:
f. Did you take any vitamin E in the past month?

1 [] Yes
2 [] No


6a. During the past 12 months, did you take any calcium?

1 [] Yes
2 [] No (section DD)


b. For how many of the past 12 months did you take calcium?

00 [] Less than one
12 [] All of them

____ Number of months


c. During (the/those) (number in 6b) month(s), about how many days per months did you take calcium?

98 [] Everyday

____ Number of days per month

88 [] Other


d. On the days you took calcium, how many pills did you usually take per day?

____ Pills per day
99 [] DK


e. How many milligrams of calcium are in each of the pills you took?

____ Mgs.

99999 [] DK


If less than 12 in 6b, ask:
f. Did you take any calcium in the past month?

1 [] Yes
2 [] No

[p. 214]

Section DD - FOOD KNOWLEDGE


1a. Have you ever made any LASTING and MAJOR changes in what you eat and drink for health reasons?

1 [] Yes
2 [] No (2)


b. In making these changes, what foods do you eat MORE of?
Enter responses verbatim, one food per line. Do not probe.
MORE

________
________
________
________
000 [] None
999 [] DK


c. What foods do you eat LESS of?
Enter responses verbatim, one food per line. Do not probe.
LESS

________
________
________
________
000 [] None
999 [] DK


d. Have you made these changes in what you eat and drink in the past 5 years?

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


e. Did you make these changes in the past year?

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


f. Have there been any changes in the ways your food is cooked?

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


g. What are these changes?


Baking
1 [] More
2 [] Less


Boiling
1 [] More
2 [] Less


Broiling

1 [] More
2 [] Less


Steaming

1 [] More
2 [] Less


Frying

1 [] More
2 [] Less


Stir-frying/wok

1 [] More
2 [] Less


Sauteeing

1 [] More
2 [] Less


Grilling/barbecuing

1 [] More
2 [] Less


Salting

1 [] More
2 [] Less


Microwaving

1 [] More
2 [] Less


Pressure-cooking

1 [] More
2 [] Less


Using non-stick pans

1 [] More
2 [] Less


Other

1 [] More
2 [] Less
1 [] DK


2. I am going to read two statement. Please tell me which one you agree with the most.
(a) What people eat or drink has little effect on whether they will develop major diseases.
OR
(b) By eating certain kinds of foods, people can reduce their chances of developing major diseases.

1 [] a (5)
2 [] b (3)
9 [] DK (4)


3. Which major diseases do you think may be related to what people eat and drink?

1 [] Cancer
1 [] Heart disease
1 [] Obesity/Overweight
1 [] Diabetes
1 [] Hypertension/ High Blood Pressure
1 [] Other
1 [] None
1 [] DK

[p. 215]

Section DD - FOOD KNOWLEDGE


DD1
Refer to 3

1 [] Cancer in 3 (5)
8 [] Other (4)

4. Do you think cancer may be related to what people eat and drink?

1 [] Yes
2 [] No
3 [] Probably/maybe/could be/etc.
9 [] DK


5a. Some foods contain fiber. Have you heard of fiber?

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


b. Overall, would you say your diet is high, medium, or low in fiber?

1 [] High
2 [] Medium
3 [] Low
9 [] DK


6. Overall, would you say your diet is high, medium or low in fat?

1 [] High
2 [] Medium
3 [] Low
9 [] DK


7. Have you gone on a diet for weight loss or any other medical reason during the past 12 months?

1 [] Yes
2 [] No



[p.216]

Section EE - SMOKING HABITS


These next questions are about cigarette smoking.

1. Have you smoked at least 100 cigarettes in your entire life?
If asked: approximately 5 packs

1 [] Yes
2 [] No
9 [] DK (section FF)


2. How old were you when you first tried starting smoking cigarettes fairly regularly?

____ Age
00 [] Never smoked regularly (section FF)
99 [] DK


3. Do you smoke cigarettes now?

1 [] Yes (5)
2 [] No


4. How old were you when you stopped smoking cigarettes?

____ Age
99 [] DK


5. On the average, how many cigarettes (did/do) you usually smoke a day?

00 [] Less than one cigarette per day
____ Cigarettes per day
99 [] DK


6. For how many years (have you/were you) a regular smoker, do not include the times you may have stayed off cigarettes?

00 [] Less than one year
____ Years
99 [] DK

[p. 217]

Section FF - OTHER TOBACCO USE

These next questions are about the use of other tobacco products.


1a. Have you ever used chewing tobacco, such as Redman, Levi Garrett, or Beechnut?

1 [] Yes
2 [] No (6)
9 [] DK Chewing tobacco (6)


b. Have you used chewing tobacco at least 20 times?

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


2. How old were you when you first used chewing tobacco?

____ Age

99 [] DK


3. Do you use chewing tobacco now?

1 [] Yes
2 [] No


4. Altogether, about how long (did you use/have you used) chewing tobacco?

000 [] Less than one month

______
1 [] Months
2 [] Years


999 [] DK


5a. On the average, how many days per month (did/do) you use chewing tobacco?

00 [] Less than one day a month
97 [] Never used regularly (6)
98 [] Everyday
Days per month ____
99 [] DK


b. On the days that you use(d) chewing tobacco, how many times (did/do) you use it?

Times per day ____
99 [] DK


6a. Have you ever used snuff, such as Skoal, Skoal Bandits, or Copenhagen?

1 [] Yes
2 [] No
9 [] DK Snuff (12)


b. Have you used snuff at least 20 times?

1 [] Yes
2 [] No
9 [] DK (12)


7. How old were you when you first used snuff?

Age ____
99 [] DK


8. Do you use snuff now?

1 [] Yes
2 [] No


9. Altogether, about how long (did you use/have you used) snuff?

000 [] Less than one month

______
1 [] Months
2 [] Years


999 [] DK


10a. On the average, how many days per month (did/do) you use snuff?

00 [] Less than one day a month
97 [] Never used regularly (12)
98 [] Everyday
____ Days per month
99 [] DK


b. On the days you use(d) snuff, how many times (did/do) you use it?

____ Times per day
99 [] DK


11. (Did/Do) you use snuff by sniffing it or by placing it in your mouth?

1 [] Sniffing
2 [] Mouth
3 [] Both


12a. Have you ever smoked a pipe?

1 [] Yes
2 [] No (17)


b. Have you smoked a pipe at least 50 times?

1 [] Yes
2 [] No
9 [] DK (17)


13. How old were you when you first smoked a pipe?

____ Age
99 [] DK

[p.218]

Section FF - OTHER TOBACCO USE - Continued


14. Do you smoke a pipe now?

1 [] Yes
2 [] No


15. Altogether, about how long (did you smoke/have you smoked) a pipe?

000 [] Less than one month

______
1 [] Months
2 [] Years


999 [] DK


16a. On the average, how many days per month (did/do) you smoke a pipe?

00 [] Less than one day a month
97 [] Never used regularly (17)
98 [] Everyday
____ Days per month
99 [] DK


b. On the days you smoke(d) a pipe, how many pipefuls of tobacco (did/do) you smoke?

____ Pipefuls per day
99 [] DK


17a. Have you ever smoked cigars?

1 [] Yes
2 [] No (section GG)


b. Have you smoked at least 50 cigars in your entire life?

1 [] Yes
2 [] No
9 [] DK (section GG)


18. How old were you when you first smoked cigars?

____ Age
99 [] DK


19. Do you smoke cigars now?

1 [] Yes
2 [] No


20. Altogether, about how long (did you use/have you smoked) cigars?

000 [] Less than one month

______
1 [] Months
2 [] Years


999 [] DK


21a. On the average, how many days per month (did/do) you smoke cigars?

00 [] Less than one day a month
97 [] Never smoked cigars regularly (Section GG)
98 [] Everyday
____ Days per month
99 [] DK


b. On the days you smoke(d) cigars, how many times (did/do) you smoke?

00 [] Less than one
____ Cigars per day
99 [] DK

[p. 219]

Section GG - REPRODUCTION AND HORMONE USE

GG1
Refer to sex

1 [] Male (section HH)
2 [] Female (1)

These next questions are about pregnancy and reproduction.
1a. Have you ever given birth to a liveborn infant?

1 [] Yes
2 [] No (2)


b. How many live births have you had?

____ Number


c. How old were you when your (first) child was born?

____ Age (2)
99 [] DK (1d)


d. Were you 20 or younger, or older than 20?

1 [] 20 or younger (2)
2 [] Older than 20 (1e)
9 [] DK (2)


e. Were you 21 to 24, 25 to 29, 30 to 34, or 35 or older?

1 [] 21-24
2 [] 25-29
3 [] 30-34
4 [] 35+
9 [] DK


2a. (Besides (that pregnancy/those pregnancies)), Have you ever had any (other) pregnancies that lasted six months or more?

1 [] Yes
2 [] No (GG2)


b. How many of those (other) pregnancies have you had?

____ Number


c. How old were you at the end of (that pregnancy/the first of those pregnancies)?

____ Age (GG2)
99 [] DK (2d)


d. Were you 20 or younger, or older than 20?

1 [] 20 or younger (GG2)
2 [] Older than 20
9 [] DK (GG2)


e. Were you 21 to 24, 25 to 29, 30 to 34, or 35 or older?

1 [] 21-24
2 [] 25-29
3 [] 30-34
4 [] 35+
9 [] DK

GG2
Refer to 1a

1 [] "Yes" in 1a (3)
8 [] Other (4)

3. Did you breastfeed any of your children?

1 [] Yes
2 [] No


4a. How old were you when your menstrual cycles began?

____ Age (5)
00 [] Never menstruated (7)
99 [] DK (4b)


b. Were you younger than 10, 10 to 12, 13 to 15, or 16 or older?

1 [] younger than 10
2 [] 10-12
3 [] 13-15
4 [] 16+
9 [] DK


5. Have your menstrual cycles stopped permanently?

1 [] Yes
2 [] No (8)


6a. How old were you when they completely stopped?

____ Age (7)
99 [] DK (6b)


b. Were you younger than 20, 20 to 29, 30 to 39, 40 to 44, 45 to 49, 50 to 54, or 55 or older?

1 [] Younger than 20
2 [] 20-29
3 [] 30-39
4 [] 40-44
5 [] 45-49
6 [] 50-54
7 [] 55+
9 [] DK


7. (Did they stop/Was this) due to surgery?

1 [] Yes
2 [] No

[p. 220]

Section GG - REPRODUCTION AND HORMONE USE - Continued


8a. Have you ever had an operation to remove a lump from your breast that was found to be NONCANCEROUS?

1 [] Yes (8b)
2 [] No (9)
3 [] Lumps removed that were cancerous (9)
9 [] DK (9)


b. How many of these operations have you had?

____ Number of operations
9 [] DK


c. How old were you when you had the (first) operation?

____ Age at first operation
99 [] DK


We are interested in learning about the relationship between birth control pills and health.
9. Have you ever used birth control pills?

1 [] Yes
2 [] No (GG3)


10a. How old were you when you started using birth control pills?

____ Abe (11)
99 [] DK (10b)


b. Were you younger than 25, or 25 or older?

1 [] Younger than 25 (10c)
2 [] 25+ (10d)
9 [] DK (11)


c. Were you 18 or younger, 19 to 21, or 22 to 24?

1 [] 18 or younger (11)
2 [] 19-21 (11)
3 [] 22-24 (11)
9 [] DK (11)

d. Were you 25 to 29, 30 to 34, or 35 older?

1 [] 25-29
2 [] 30-34
3 [] 35+
9 [] DK


11a. Altogether, about how long did you take birth control pills? Include any breaks in usage that lasted less than one month.

____ Number
1 [] Days (GG3)
2 [] Months (GG3)
3 [] Years (GG3)


000 [] Less than one month (GG3)
888 [] Other - Specify ____ (GG3)
999 [] DK (11b)


b. Was it less than a year, or a year or more?

1 [] Less than one year (GG3)
2 [] One year or more (11c)
9 [] DK (GG 3)


c. Was it 3 years or less, more than 3 but less than 5, or 5 or more years?

1 [] 3 years or less
2 [] More than 3, less than 5 years
3 [] 5 or more years
9 [] DK


GG3
Refer to age.

1 [] Under 40 (section HH)
2 [] 40 and over (12)

12. Estrogen is a female hormone that may be taken after a hysterectomy or during menopause. Have you ever taken estrogen pills for any reason?

1 [] Yes
2 [] No (section HH)
9 [] DK (section HH)


13a. How old were you when you started using estrogen pills?

____ Age (14)
99 [] DK (13b)


b. Were you younger than 20, 20 to 29, 30 to 39, 40 to 44, 45 to 49, 50 to 54, or 55 or older?

1 [] Younger than 20
2 [] 20-29
3 [] 30-39
4 [] 40-44
5 [] 45-49
6 [] 50-54
7 [] 55+
9 [] DK

[p. 221]

Section GG - REPRODUCTION AND HORMONE USE - Continued


14a. Altogether, about how long did you take estrogen pills? Include any breaks in usage that lasted less than one month.

____ Number
1 [] Days (15)
2 [] Months (15)
3 [] Years (15)


000 [] Less than one month (15)
888 [] Other - Specify ____ (15)
999 [] DK (14b)


b. Was it less than a year, or a year or more?

1 [] Less than one year (15)
2 [] One year or more (14c)
9 [] DK (15)


c. Was it 3 years or less, more than 3 but less than 5, or 5 or more years?

1 [] 3 years or less
2 [] More than 3, less than 5 years
3 [] 5 or more years
9 [] DK

15. What was the brand name of the estrogen pills?

____ Brand name
[] DK

[p . 222]

Section HH - FAMILY HISTORY OF CANCER

These next questions are about your natural or birth mother and father. Do not include step or adoptive parents.


Ask 1-2 for mother, then for father.
1a. In what year was your natural (mother/father) born?


Mother
____ Year
9999 [] DK


Father
____ Year
9999 [] DK


b. Is your (mother/father) still living?


Mother
1 [] Yes (2)
2 [] No (1c)
9 [] DK (2)
7 [] Never knew natural mother (1 for father)


Father
1 [] Yes (2)
2 [] No (1c)
9 [] DK (2)
7 [] Never knew natural mother (3)


c. At what age did your (mother/father) die?


Mother
____ Age
99 [] DK


Father
____ Age
99 [] DK


2a. Was your (mother/father) ever diagnosed by a doctor as having cancer?


Mother
1 [] Yes
2 [] No (1 for father)
9 [] DK (1 for father)


Father
1 [] Yes
2 [] No (3)
9 [] DK (3)


b. What kind of cancer was it?


Mother
________ (2d)
799 [] DK (2c)


Father
________ (2d)
799 [] DK (2c)


c. what part of the body was affected?


Mother
____
[] DK


Father
____
[] DK


d. Did your (mother/father) have any other kind of cancer that was diagnosed by a doctor?


Mother
1 [] Yes
2 [] No (2g)
9 [] DK (2g)


Father
1 [] Yes
2 [] No (2g)
9 [] DK (2g)


e. The FIRST time (she/he) was diagnosed with cancer, what kind of cancer was it?


Mother
000 [] Same as 2b/c (2g)
____ (2g)
799 [] DK (2f)


Father
000 [] Same as 2b/c (2g)
____ (2g)
799 [] DK (2f)


f. What part of the body was affected?


Mother
____
[] DK


Father
____
[] DK


g. how old was your (mother/father) when cancer was first diagnosed by a doctor?


Mother
____ Age (1 for father)
99 [] DK (1 for father)


Father
____ Age
99 [] DK

[p. 223]

Section HH - FAMILY HISTORY OF CANCER - Continued

Read to respondent: Now I'm going to ask about your sisters and brothers who have the same natural or birth mother AND father as you. Do not include step, half, or adoptive sisters and brothers.


3a. How many sisters do you have, including any that may have died?

00 [] None
____ Sisters
99 [] DK


b. How many brothers do you have, including any that may have died?

00 [] None
____ Brothers
99 [] DK


If "None" in 3a and 3b, skip to 9.

4. Have any of your (brothers/(or) sisters) ever been diagnosed by a doctor as having cancer?

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

5. What are the first names of your (brothers/(or) sisters) who had cancer?
Record each person in a separate column
Anyone else?

________ Name

Sex:

1 [] Male
2 [] Female
9 [] DK


________ Name
Sex:
1 [] Male
2 [] Female
9 [] DK


Ask 6-8 for the first person listed in 5 before asking 6-8 for the next person.
6a. What kind of cancer did (name in 5) have?

________ (6c)
799 [] DK (6b)

________ (6c)
799 [] DK (6b)

b. What part of the body was affected?

____
[] DK

____
[] DK


c. Did (name in 5) have any other kind of cancer that was diagnosed by a doctor?

1 [] Yes
2 [] No (7)
9 [] DK (7)

1 [] Yes
2 [] No (7)
9 [] DK (7)


d. The FIRST time (he/she) was diagnosed with cancer, what kind of cancer was it?

000 [] Same as 6a/b (7)
____ (7)
799 [] DK (6e)

000 [] Same as 6a/b (7)
____ (7)
799 [] DK (6e)

e. What part of the body was affected?

____
[] DK

____
[] DK


7. How old was (name in 5) when cancer was first diagnosed by a doctor?

____ Age
99 [] DK

____ Age
99 [] DK


8a. In what year was (name in 5) born?

____ Year
9999 [] DK

____ Year
9999 [] DK


If known, mark without asking.
b. Is (name in 5) still living?

1 [] Yes (HH1)
2 [] No (8c)
9 [] DK (HH1)

1 [] Yes (HH1)
2 [] No (8c)
9 [] DK (HH1)


c. At what age did (name in 5) die?

____ Age
99 [] DK

____ Age
99 [] DK

HH1
Refer to entries in 5.

1 [] Additional siblings (6)
2 [] No more siblings (9)

1 [] Additional siblings (6)
2 [] No more siblings (9)

[p. 224]

Section HH - FAMILY HISTORY OF CANCER - Continued

Read to respondent: These questions are about your natural or birth children. Do not include any children for whom you are an adoptive, step, or foster parent.


9a. How many daughters do you have, including any that may have died?

00 [] None
____ Daughters
99 [] DK


b. How many sons do you have, including any that may have died?

00 [] None
____ Sons
99 [] DK


If "None" in 9a and 9b, skip to section II.
10. Have any of your children ever been diagnosed by a doctor as having cancer?

1 [] Yes
2 [] No (15)
9 [] DK (15)

11. What are the first names of your children who had cancer?
Record each person in a separate column
Anyone else?

________ Name

Sex:

1 [] Male
2 [] Female


________ Name

Sex:
1 [] Male
2 [] Female


Ask 12-14 for the first person listed in 11 before asking 12-14 for the next person.

12a. What kind of cancer did (name in 11) have?

________ (12c)
799 [] DK (12b)

________ (12c)
799 [] DK (12b)

b. What part of the body was affected?

____
[] DK

____
[] DK


c. Did (name in 11) have any other kind of cancer that was diagnosed by a doctor?

1 [] Yes
2 [] No
9 [] DK (13)

1 [] Yes
2 [] No
9 [] DK (13)


d. The FIRST time (he/she) was diagnosed with cancer, what kind of cancer was it?

000 [] Same as 12a/b (13)
____ (13)
799 [] DK (12e)

000 [] Same as 12a/b (13)
____ (13)
799 [] DK (12e)

e. What part of the body was affected?

____
[] DK

____
[] DK


13. How old was (name in 11) when cancer was first diagnosed by a doctor?

____ Age
99 [] DK

____ Age
99 [] DK


14a. In what year was (name in 11) born?

____ Year
9999 [] DK

____ Year
9999 [] DK


If this child in household, mark "Yes" box without asking.
b. Is (name in 11) still living?

1 [] Yes (HH2)
2 [] No (14c)
9 [] DK (HH2)

1 [] Yes (HH2)
2 [] No (14c)
9 [] DK (HH2)


c. At what age did (name in 11) die?

____ Age
99 [] DK

____ Age
99 [] DK

HH2
Refer to entries in 11.

1 [] Additional siblings (12)
2 [] No more siblings (15)

1 [] Additional siblings (12)
2 [] No more siblings (15)


[p. 225]

Section HH - FAMILY HISTORY OF CANCER - Continued


15. Has the natural (father/mother) of (any of your (other) children/your child) ever been diagnosed by a doctor as having cancer?

1 [] Yes
2 [] No (section II)
9 [] DK (section II)


16a. What is the (father's/mother's) name?

____ Name

b. Is (name in 16a) the (father/mother) of all your (other) children?

1 [] Yes
2 [] No


17a. What kind of cancer did (name in 16a) have?

________ (17c)
799 [] DK (17b)

b. What part of the body was affected?

____
[] DK


c. Did (name in 16a) have any other kind of cancer that was diagnosed by a doctor?

1 [] Yes
2 [] No
9 [] DK (18)


d. The FIRST time (he/she) was diagnosed with cancer, what kind of cancer was it?

000 [] Same as 17a/b (18)
____ (18)
799 [] DK (17e)

e. What part of the body was affected?

____
[] DK


18. How old was (name in 16a) when cancer was first diagnosed by a doctor?

____ Age
99 [] DK


19a. In what year was (name in 16a) born?

____ Year
9999 [] DK


If person in household, mark "Yes" without asking.
b. Is (name in 16a) still living?

1 [] Yes (20)
2 [] No (19c)
9 [] DK (20)


c. At what age did (name in 16a) die?

____ Age
99 [] DK


20a. How many children did you and (name in 16a) have together, including any that may have died?

____ No. of children


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

____ No. of sons
____ No. of daughters

c. What are the children's first names?

________

HH3
Refer to 16b.

1 [] "No" in 16b (15)
8 [] "Yes" in 16b (section II)
[p. 226]

Section II - CANCER SURVIVORSHIP


1. Has a doctor or other health professional ever told you that you had cancer of any kind (including any cancer you have already mentioned)?

1 [] Yes
2 [] No (Section JJ)


2a. What kind of cancer was it?

________ (3)
799 [] DK (2b)

b. What part of the body was affected?

____


3. How old were you when this cancer was first diagnosed by a doctor?

____ Age
99 [] DK


4. Besides this cancer, has a doctor ever told you that you had any other kind of cancer?

1 [] Yes
2 [] No (Section JJ)


5a. What kind of cancer was it?

____ (6)
799 [] DK (5b)

b. What part of the body was affected?

____


6. How old were you when THIS cancer was first diagnosed by a doctor?

____ Age
99 [] DK



[p. 227]

Section JJ - OCCUPATIONAL EXPOSURE


These next questions are about the kind of work you have done the longest, not counting work around the house.

1. Thinking of all the jobs or businesses you have ever had, what kind of work have you done the longest? Include work in the Armed Forces. For example, electrical engineer, stock clerk, typist, farmer.

990 [] Never worked (section KK)
________ Occupation/kind of work

2. When you were doing this kind of work, what were your most important activities or duties? For example, types, keeps account books, files, sells cars, operates printing press, finishes concrete.

________ Duties


3a. How long did you do this kind of work?

00 [] Less than one year
____ Years
99 [] DK


b. How old were you when you started doing this kind of work?

____ Age
99 [] DK


4. What kind of business or industry did you work in the longest as (entry in 1)? (For example, TV and radio manufacturing, retail shoe store, State Labor Department, farm.)

________ Industry


Complete from entries 1, 2, and 4. If not clear ask:
5. Were you-
An employee of private company, -business, or individual for wages, salary or commission? .... P
A member of the armed forces? .... AF
A federal government employee? .... F
A state government employee? .... S
A local government employee? .... L
Self-employed in own business, professional practice or farm?
Ask: Is the business incorporated?
Yes .... I
No .... SE
Working without pay in family business or farm? ....WP

Class of worker
1 [] P
2 [] AF
3 [] F
4 [] S
5 [] L
6 [] I
7 [] SE
0 [] WP



[p. 228]

Section KK - HEIGHT, WEIGHT, RELATIONSHIPS, SOCIAL ACTIVITIES


1. About how tall are you without shoes?

____ Feet
____ Inches


2. About how much do you weigh without shoes?

____ Pounds


3. When you weighed the most, how much did you weigh (not including pregnancy)?

____ Pounds


These questions are about social activities and relationships.
4a. (Not including your [husband/wife]) Of all your friends, how many are there that you can talk to about private matters or can call on for help?

____ Friends
00 [] None


b. (Not including your [husband/wife]) Of all your relatives, how many are there that you can talk to about private matters or can call on for help?

____ Relatives
00 [] None


If None in 4a and b, skip to 5.
c. How many of these friends and relatives do you see or talk to at least once a month?

____ Friends and relatives
00 [] None


5a. How often do you participate in or attend group meetings or activities, for example, social clubs, PTA, sporting events, church groups or other community service groups?

____ Times per
2 [] Week
3 [] Month
4 [] Year
000 [] Never


b. How often do you go to church, temple, or other religious services?

____ Times per
2 [] Week
3 [] Month
4 [] Year
000 [] Never