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[p. 146]

[] SP
[] Old age
[] Smoking asked
A. HOUSEHOLD COMPOSITION PAGE

1a. What are the names of all persons living or staying here? Start with the name of the person or one of the persons who owns or rents this home. Enter name in REFERENCE PERSON column. ________

First name ____
Mid. init. ____
Last name ____

b. What are the names of all the other persons living or staying here? Enter names in columns. ____

First name ____
Mid. init. ____
Last name ____

c. I have listed (read names). Have I missed:

-- any babies or small children?
[] Yes
[] No
-- any lodgers, boarders, or persons you employ who live here?
[] Yes
[] No
-- anyone who USUALLY lives here but is now away from home traveling or in a hospital?
[] Yes
[] No
-- anyone else staying here?
[] Yes
[] No


If "Yes," enter names in columns
d. Do all of the persons you have named usually live here?
Probe if necessary:
Does -- usually live somewhere else?

[] Yes (2)
[] No (APPLY HOUSEHOLD MEMBERSHIP RULES. Delete nonhousehold members by an "X" from 1-C2 and enter reason.)


2. What is -- relationship to (reference person)? ____

Relationship ____

Reference person


3. What is -- date of birth? (Enter date and age and mark sex.)

Date of birth
Month ___
Date____
Year___
Age___
Sex
1[] M
2[] F

C1

HOSP.
00 [] None
Number ____
WORK
1 [] Wa
2 [] Wb
RD
1 [] Yes
2 [] No
2-WK. DV
00 [] None
Number ____
C2
[] LA
[] RA
[] DV
[] INJ.
[] CL LTR HS
[] COND.
A1
Reference Periods
2--Week period ____
12--Month Date ____
13--Month Hospital Date ____
A2
ASK CONDITION LIST ____

A3
Refer to ages of all related HH members.

[] All persons 65 and over (5)
[] Other (4)
4a. Are any of the persons in this household now on full-time active duty with the armed forces?

[] Yes
[] No (5)

b. Who is this? ___
Delete column number(s) ____ by an "X" from 1-C2

c. Anyone else?

[] Yes (Reask 4b and c)
[] No

Ask for each person with in armed forces:
d. Where does -- usually live and sleep, here or somewhere else?
Mark box in person's column

[] Living at home
[] Not living at home

5. We would like to have all adult family members who are at home take part in the interview. Are (names of persons 17 and over) at home now?
If "Yes," ask: Could they join us (Allow time)

Read to respondent(s):
This survey is being conducted to collect information on the nation's health. I will ask about hospitalizations, disability, visits to doctors, illness in the family, and other health related items.

HOSPITAL PROBE
6a. Since (13-month hospital date) a year ago, was -- a patient in a hospital OVERNIGHT?

1[] Yes
2[] No (Mark "HOSP." box, THEN NP)

b. How many different times did -- stay in any hospital overnight or longer since (13 month hospital date) a year ago? ____
(Make entry in "HOSP." box THEN NP)

Ask for each child under one:
7a. Was -- born in a hospital?

1[] Yes
2[] No (NP)

Ask for mother and child:
b. Have you included this hospitalization in the number you gave me for --?

1[] Yes (NP)
2[] No (Correct 6 and "HOSP." box)

[p. 147]

B. LIMITATION OF ACTIVITIES PAGE

B1

Refer to age

1 [] 18-69 (1)
2 [] Other (NP)


1. What was -- doing MOST OF THE PAST 12 MONTHS; working a job or business, keeping house, going to school, or something else?
Priority if 2 or more activities reported: (1) Spent most time doing; (2) Considers most important.

1 [] Working (2)
2 [] Keeping house (3)
3 [] Going to school (5)
4 [] Something else (5)

2a. Does any impairment or health problem NOW keep -- from working at a job or business?

1 [] Yes (7)
[] No

b. Is -- limited in the kind OR amount of work -- can do because of any impairment or health problem?

2 [] Yes (7)
3 [] No (6)

3a. Does any impairment or health problem NOW keep -- from doing any housework at all?

4 [] Yes (4)
[] No

b. Is -- limited in the kind OR amount of housework -- can do because of any impairment or health problem?

5 [] Yes (4)
6 [] No (5)

4a. What (other) condition causes this? ____
Ask if injury or operation: When did [the (injury) occur?/ -- have the operation?]
Ask if operation over 3 months ago; For what condition did -- have the operation?
If pregnancy/delivery or 0-3 months injury or operation -
Reask question 3 where limitation reported, saying: Except for -- (condition), ...?
OR reask 4b/c.
(Enter condition in C2, THEN 4b)

1[] Old age (Mark "Old age" box, THEN 4c)

b. Besides (condition) is there any other condition that causes this limitation?

[] Yes (Reask 4a and b)
[] No (4d)

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

[] Yes (Reask 4a and b)
[] No

Mark box if only one condition
d. Which of these conditions would you say is the MAIN cause of this limitation? ____

[] Only 1 condition

5a. Does any impairment or health problem keep -- from working at a job or business?

1 [] Yes (7)
[] No

b. Is -- limited in the kind OR amount of work -- could do because of any impairment or health problem?

2 [] Yes (7)
3 [] No

B2
Refer to questions 3a and 3b

1[] "Yes" in 3a or 3b (NP)
2[] Other (6)
6a. Is -- limited in ANY WAY in any activities because of an impairment or health problem?

1 [] Yes
2 [] No (NP)

b. In what way is -- limited? Record limitation, not condition. ________

7a. What (other) condition causes this? ____
Ask if injury or operation: When did [the (injury) occur?/ -- have the operation?]
Ask if operation over 3 months ago; For what condition did -- have the operation?
If pregnancy/delivery or 0-3 months injury or operation -
Reask question 3 where limitation reported, saying: Except for -- (condition), ...?
OR reask 7b/c.
(Enter condition in C2 , THEN 7b)

1[] Old Age (Mark "Old age" box, THEN 7c)

b. Besides (condition) is there any other condition that causes this limitation?

[] Yes (Reask 7a and b)
[] No (7d)

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

[] Yes (Reask 7a and b)
[] No

Mark box if only one condition.
d. Which of these conditions would you say is the MAIN cause of this limitation? ____

[] Only 1 condition

[p. 148]

B. LIMITATIONS OF ACTIVITIES PAGE, Continued

B3

Refer to age

0 [] Under 5 (10)
1 [] 5-17 (11)
2 [] 18-69 (NP)
3 [] 70 and over (8)


8. What was -- doing MOST OF THE PAST 12 MONTHS; working at a job or business, keeping house, going to school, or something else?
Priority if 2 or more activities reported: (1) Spent the most time doing; (2) Considers the most important.

1 [] Working
2 [] Keeping house
3 [] Going to school
4 [] Something else


9a. Because of any impairment or health problem, does -- need the help of other persons with -- personal care needs, such as eating, bathing, dressing, or getting around this home?

1 [] Yes (13)
[] No

b. Because of any impairment or health problem, does -- need help of other persons in handling -- routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?

2 [] Yes (13)
3 [] No (12)

10a. Is -- able to take part AT ALL in the usual kinds of play activities done by most children -- age?

[] Yes
0 [] No (13)

b. Is -- limited to the kind OR amount of play activities -- can do because of any impairment or health problem?

1 [] Yes (13)
2 [] No (12)

11a. Does any impairment or health problem NOW keep -- from attending school?

1 [] Yes (13)
[] No

b. Does -- attend a special school or special classes because of any impairment or health problem?

2 [] Yes (13)
[] No

c. Does -- need to attend a special school or special classes because of any impairment or health problem?

3 [] Yes (13)
[] No

d. Is -- limited in school attendance because of -- health?

4 [] Yes (13)
5 [] No

12a. Is -- limited in ANY WAY in any activities because of impairment or health problem?

1 [] Yes
2 [] No (NP)

13a. What (other) condition causes this? (Enter condition in C2, THEN 13b) ____
Ask if injury or operation: When did [the (injury) occur?/ -- have the operation?]
Ask if operation over 3 months ago: For what condition did -- have the operation?
If pregnancy/delivery or 0-3 months injury or operation -
Reask question where limitation reported, saying: Except for -- (condition), ...?
OR reask 13b/c.
(Enter condition in C2, THEN 13b)

1[] Old age (Mark "Old age" box, THEN 13c)

b. Besides (condition) is there any other condition that causes this limitation?

[] Yes (Reask 13a and b)
[] No (13d)

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

[] Yes (Reask 13a and b)
[] No

Mark box if only one condition.
d. Which of these conditions would you say is the MAIN cause of this limitation? ____

[] Only 1 condition

[p. 149]

B. LIMITATION OF ACTIVITIES PAGE, Continued

B4
Refer to age

0 [] Under 5 (NP)
1 [] 5-59 (B5)
2 [] 60-69 (14)
3 [] 70 and over (NP)
B5
Refer to "Old age" and "LA" boxes. Mark first appropriate box.

[] "Old age" box marked (14)
[] Entry in "LA" box (14)
[] Other (NP)
14a. Because of any impairment or health problem, does -- need the help of other persons with -- personal care needs, such as eating, bathing, dressing, or getting around this home?

1 [] Yes (15)
[] No

If under 18, skip to next person; otherwise ask:
b. Because of any impairment or health problem, does -- need help of other persons in handling: routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?

2 [] Yes
3 [] No (NP)

15a. What (other) condition causes this? (Enter condition in C2, THEN 15b) ____
Ask if injury or operation:

When did [the (injury) occur?/ -- have the operation?]

Ask if operation over 3 months ago:

For what condition did -- have the operation?

If pregnancy/delivery or 0-3 months injury or operation -

Reask question 14 where limitation reported, saying: Except for -- (condition), ...?
OR reask 15b/c.
1 [] Old age (Mark "Old age" box, THEN 15c)

b. Besides (condition) is there any other condition that causes this limitation?

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

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

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

Mark box if only one condition.
d. Which of these conditions would you say is the MAIN cause of this limitation? ____

[] Only 1 condition

[p. 150]

D. RESTRICTED ACTIVITY PAGE PERSON 1

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

D1

Refer to age.

[] Under 5 (4)
[] 5-17 (3)
[] 18 and over (1)


1a. DURING THOSE 2 WEEKS, did -- work at any time at a job or business not counting work around the house? (Include unpaid work in the family [farm/business].)

1 [] Yes (Mark "Wa" box, THEN 2)
2 [] No

b. Even though -- did not work during those 2 weeks, did -- have a job or business?

1 [] Yes (Mark "Wb" box, THEN 2)
2 [] No (4)


2a. During those 2 weeks, did -- miss any time from a job or business because of illness or injury?

[] Yes
00 [] No (4)

b. During that 2-week period, how many days did -- miss more than half of the day from -- job or business because of illness or injury?

00 [] None (4)

No. of work--loss days ____ (4)


3a. During those 2 weeks, did -- miss any time from school because of illness or injury?

[] Yes
00 [] No (4)

b. During that 2-week period, how many days did -- miss more than half of the day from school because of illness or injury?

00 [] None

No. of school--loss days ____


4a. During those 2 weeks, did -- stay in bed because of illness or injury?

[] Yes
00 [] No (6)

b. During that 2-week period, how many days did -- stay in bed more than half of the day because of illness or injury?

00 [] None (6)

No. of bed days ____ (D2)

D2
Refer to 2b and 3b

[] No days in 2b or 3b (6)
[] 1 or more days in 2b or 3b (5)
5. On how many of the (number in 2b or 3b) days missed from [work/school] did -- stay in bed more than half of the day because of illness or injury?

00 [] None
No. of days ____


Refer to 2b, 3b and 4b.
6a. (Not counting the day(s)

[missed from work
missed from school,
(and) in bed]

was there any (OTHER) time during those 2 weeks that -- cut down on the things -- usually does because of illness or injury?

[] Yes
00 [] No (D3)

b. (Again, not counting the day(s)

[missed from work
missed from school,
(and) in bed]

During that period, how many (OTHER) days did -- cut down for more than half of the day because of illness or injury?

00 [] None

No. of cut-down days ____

D3
Refer to 2 - 6

[] No days in 2 - 6 (Mark "No" in RD, then NP)
[] 1 or more days in 2 - 6 (Mark "Yes" in RD, THEN 7)

Refer to 2b, 3b, 4b and 6b.
7a. What (other) condition caused -- to

[miss work
miss school
(or) stay in bed
(or) cut down]

during those 2 weeks?

(Enter condition in C2, THEN 7b) ____

b. Did any other condition cause -- to

[miss work
miss school
(or) stay in bed
(or) cut down]

during that period?

1 [] Yes (Reask 7a and b)
2 [] No

[p. 153]

G. HEALTH INDICATOR PAGE

1a. During the past 2-week period outlined in red on that calendar, has anyone in the family had an injury from an accident or other cause that you have not yet told me about?

[] Yes
[] No (2)

b. Who was this?____
Mark "Injury" box in person's column.

[] Injury

c. What was -- injury? ____
Enter injury(ies) in person's column.

d. Did anyone have any other injuries during that period?

[] Yes (Reask 1b, c, and d)
[] No

Ask for each injury in 1c:
e. As a result of the (injury in 1c) did (--/anyone) see or talk to a medical doctor or assistant (about --) or did -- cut down on [his/her] usual activities for more than half of a day?

[] Yes (Enter injury in C2, THEN 1e for next injury)
[] No (1e for next injury)


2. During the past 12 months, {that is, since (12-month date) a year ago} ABOUT how many days did illness or injury keep -- in bed more than half of the day? (Include days while an overnight patient in a hospital.)

000 [] None
No. of days ____


3a. During the past 12 months, ABOUT how many times did [--/anyone] see or talk to a medical doctor or assistant (about --)? (Do not count doctors seen while an overnight patient in a hospital.) (Include the (number in 2-WK DV box) visit(s) you already told me about.)

000 [] None (3b)
000 [] Only when overnight patient in hospital (NP)
No. of visits ____ (NP)

b. About how long has it been since(--/anyone) last saw or talked to a medical doctor or assistant (about --)? Include doctors seen while a patient in a hospital.

1 [] Interview week (Reask 3b)
2 [] Less than 1 yr. (Reask 3a)
3 [] 1yr., less than 2 yrs.
4 [] 2 yrs., less than 5 yrs.
5 [] 5 yrs. or more
0 [] Never


4. Would you say -- health in general is excellent, very good, fair, or poor?

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


Mark box if under 18.
5a. About how tall is -- without shoes?

[] Under 18 (NP)
Feet _ _
Inches _ _


b. About how much does -- weigh without shoes?

Pounds ____

[p. 154]

H. CONDITION LISTS 1 AND 2

Read to respondent(s) and ask list specified in A2:
Now I am going to read a list of medical conditions. Tell me if anyone in the family has had any of these conditions, even if you have mentioned them before.

1

1a. Does anyone in the family {read names} now have -- ?
If "Yes," ask 1b and c.

A. PERMENANT stiffness or any deformity of the foot, leg, fingers, arm or back? (Permanent stiffness -- joints will not move at all.) ____
B. Paralysis of any kind? ____

b. Who is this?

____

c. Does anyone else NOW have --?
Enter condition and letter in appropriate person's column.

____

1d. DURING THE PAST 12 MONTHS, did anyone in the family have:
If "Yes," ask 1e and f.

C-L are conditions affecting the bone and muscle.
M-W are conditions affecting the skin.

Enter condition and letter in appropriate person's column.

C. Arthritis of any kind or rheumatism?
D. Gout? ____
E. Lumbago? ____
F. Sciatica? ____
G. A bone cyst or bone spur? ____
H. Any other diseases of the bone or cartilage? ____
I. A slipped or ruptured disc? ____
J. REPEATED trouble with neck, back, or spine? ____
K. Bursitis? ____
L. Any disease of the muscles or tendons? ____

Reask 1d.

M. A tumor, cyst, or growth of the skin? ____
N. Skin cancer? ____
O. Eczema or Psoriasis? (ek'-sa-ma) or (so-rye'uh-sis) ____
P. TROUBLE with dry or itching skin? ____
Q. TROUBLE with acne? ____
R. A skin ulcer? ____
S. Any kind of skin allergy? ____
T. Dermatitis or any other skin trouble? ____
U. TROUBLE with ingrown toenails or fingernails? ____
V. TROUBLE with bunions, corns, or calluses? ____
W. Any disease of the hair or scalp? ____

e. Who was this? ____

f. DURING THE PAST 12 MONTHS, did anyone else have [conditions affecting the bone or muscle/ conditions affecting the skin.] ____

2

2a. Does anyone in the family {read names} NOW HAVE --
If "Yes," ask 2b and c.

A. Deafness in one or both ears? ____
B. Any other trouble hearing with one or both ears? ____
C. Tinnitus or ringing in the ears? ____
D. Blindness in one or both eyes? ____
E. Cataracts? ____
F. Glaucoma? ____
G. Color blindness? ____
H. A detached retina or any other condition of the retina? ____
I. Any trouble seeing with one or both eyes EVEN when wearing glasses? ____
J. A cleft palate or harelip? ____
K. Stammering or stuttering? ____
L. Any other speech defect? ____
M. Loss of taste or smell which has lasted 3 months or more? ____
N. A missing finger, hand, or arm; toe, foot, or leg? ____

Reask 2a

O. A missing joint? ____
P. A missing breast, kidney, or lung? ____
Q. Palsy or cerebral palsy? (ser'a-bral) ____
R. Paralysis of any kind? ____
S. Curvature of the spine? ____
T. REPEATED trouble with neck, back, or spine? ____
U. Any TROUBLE with fallen arches or flatfeet? ____
V. A clubfoot? ____
W. A trick knee? ____
X. PERMANENT Stiffness or any deformity of the foot, leg, or back? (Permanent stiffness --joints will not move at all.) ____
Y. PERMANENT stiffness or any deformity of the fingers, hand, or arm? ____
Z. Mental retardation? ____

AA. Any condition cause by an accident or injury which happened more than 3 months ago?____
If "Yes," ask: What is the condition? ____

b. Who is this? ____

c. Does anyone else NOW have --?___

Enter condition and letter in appropriate person's column.

A-L are conditions affecting Hearing, Vision, Speech
Conditions M-AA are impairments.

[p. 155]

H. CONDITION LISTS 3 AND 4

Read to respondent(s) and ask list specified in A2:
Now I am going to read a list of medical conditions. Tell me if anyone in the family has had any of these conditions, even if you have mentioned them before.

3

3a. DURING THE PAST 12 MONTHS, did anyone in the family (read names) have --
If "Yes," ask 3b and c.

Conditions affecting the digestive system.
A. Gallstones? ____
B. Any other gallbladder trouble? ____
C. Cirrhosis of the liver? ____
D. Fatty liver? ____
E. Hepatitis? ____
F. Yellow jaundice? ____
G. Any other liver trouble? ____
H. Any ulcer? ____
I. A hernia or rupture? ____
J. Any diseases of the esophagus? ____
K. Gastritis? ____
L. FREQUENT indigestion? ____
M. Any other stomach trouble? ____

Reask 3a

N. Enteritis? ____
O. Diverticulitis? (Dye-ver-tic-yoo-lye'tis) ____
P. Colitis? ____
Q. A spastic colon? ____
R. FREQUENT constipation? ____
S. Any other bowel trouble? ____
T. Any other intestinal trouble? ____
U. Cancer of the stomach, intestines, colon, or rectum? ____
V. During the past 12 months, did anyone (else) in the family have any other condition of the digestive system? ____
If "Yes," ask: Who was this? ____
What was the condition?____

Enter in item C2, THEN reask V.

b. Who was this? ____

c. DURING THE PAST 12 MONTHS, did anyone else have --? ____

Enter condition and letter in appropriate person's column.
Make no entry in item C2 for cold; flu; red, sore, or strep throat; or "virus" even if reported in this list.

4

4a. DURING THE PAST 12 MONTHS, did anyone in the family (read names) have --
If "Yes," ask 4b and c.

A - B are conditions affecting the glandular system.
C is a blood condition
D - I are conditions affecting the nervous system
J - Y are conditions affecting the genito-urinary system

A. A goiter or other thyroid trouble? ____
B. Diabetes? ____
C. Anemia of any kind? ____
D. Epilepsy? ____
E. REPEATED seizures, convulsions, or blackouts? ____
F. Multiple sclerosis? ____
G. Migraine? ____
H. FREQUENT headaches? ____
I. Neuralgia or neuritis? ____
J. Nephritis? ____
K. Kidney stones? ____
L. REPEATED kidney infections? ____
M. A missing kidney? ____

Reask 4a

N. Any other kidney trouble? ____
O. Bladder trouble? ____
P. Any disease of the genital organs? ____
Q. A missing breast? ____
R. Breast cancer? ____
S. *Cancer of the prostate? ____
T. *Any other prostate trouble? ____
U. **Trouble with menstruation? ____
V. ** A hysterectomy? ____
If "Yes," ask:
For what condition did -- have a hysterectomy?
W. ** A tumor, cyst, or growth of the uterus or ovaries? ____
X. ** Any other disease of the uterus or ovaries? ____
Y. ** Any other female trouble? ____

* Ask only if males in family
** Ask only if females in family.

b. Who was this? ____

c. DURING THE PAST 12 MONTHS, did anyone else have --? ____

Enter condition letter in appropriate person's column.
[p. 156]

H. CONDITION LISTS 5 AND 6

Read to respondents(s) and ask list specified in A2.
Now I am going to read a list of medical conditions. Tell me if anyone in the family has had any of these conditions, even if you have mentioned them before.

5

5a. Has anyone in the family {read names} EVER had --

Conditions affecting the heart and circulatory system.
A. Rheumatic fever?
B. Rheumatic heart disease?
C. Hardening of the arteries or arteriosclerosis?
D. Congenital heart disease?
E. Coronary heart disease?
F. Hypertension, sometimes call high blood pressure?
G. A stroke or cerebrovascular accident? (ser'a-bro vas ku-lar)
H. A hemorrhage of the brain?
I. Angina pectoris? (pek'to-ris)
J. A myocardial infarction?
K. Any other heart attack?

If "Yes." ask 5b and c.

b. Who was this? ____

c. Has anyone else EVER had --?

Enter condition and letter in appropriate person's column.

5d. DURING THE PAST 12 MONTHS, did anyone in the family have --

L. Damaged heart valves?
M. Tachycardia or rapid heart?
N. A heart murmur?
O. Any other heart trouble?
P. An aneurysm? (an yoo-rizm)
Q. Any blood clots?
R. Varicose veins?
S. Hemorrhoids or piles?
T. Phlebitis or thrombophlebitis?
U. Any other condition affecting blood circulation?

If "Yes," ask 5e and f.

e. Who was this? ____

f. DURING THE PAST 12 MONTHS, did anyone else have --?

Enter condition and letter in appropriate person's column.

6

6a. DURING THE PAST 12 MONTHS, did anyone in the family (read names) have--

Conditions affecting the respiratory system.
A. Bronchitis? ____
B. Asthma? ____
C. Hay fever? ____
D. Sinus trouble? ____
E. A nasal polyp? ____
F. A deflected or deviated nasal septum? ____
G. *Tonsillitis or enlargement of the tonsils or adenoids? ____
H. *Laryngitis? ____
I. A tumor or growth of the throat, larynx, or trachea? ____
J. A tumor or growth of the bronchial tube or lung? ____


Reask 6a.

K. A missing lung? ____
L. Lung cancer?____
M. Emphysema? ____
N. Pleurisy? ____
O. Tuberculosis? ____
P. Any other work-related respiratory condition, such as dust on the lungs, silicosis, asbestosis, or pneu-mo-co-ni-o-sis? ____
Q. During the past 12 months did anyone (else) in the family have any other respiratory, lung, or pulmonary condition? ____
If "Yes," ask: Who was this? ____
What was the condition? ____
Enter in item C2, THEN reask Q.

If "Yes," ask 6b and c.

b. Who was this? ____

c. DURING THE PAST 12 MONTHS, did anyone else have --? ____

Enter condition and letter in appropriate person's column.
Make no entry in item C2 for cold; flu; red sore, or strep throat; or "virus" even if reported in this list.

* If reported in this list only, ask:

1. How many times did -- have (condition) in the past 12 months? ____
If 2 or more times, enter condition in item C2.
If only 1 time, ask:

2. How long did that last? ____
If 1 month or longer, enter in item C2.
If less than 1 month, do not record

If tonsils or adenoids were removed during the past 12 months, enter the condition causing removal in item C2.

[p. 160]

L. DEMOGRAPHIC BACKGROUND PAGE

L1

Refer to age.

[] Under 5 (NP)
[] 5-17 (2)
[] 18 and over (1)


1a. Did -- EVER serve on active duty in the Armed Forces of the United States?

1 [] Yes
2 [] No (2)

b. When did -- serve?

Vietnam Era (Aug. '64 - April ' 75).... VN
Korean War (June '50 - Jan. '55)............KW
World War II (Sept. '40 - July '47)....... WWII
World War I (April '17 - Nov. '18)....... WWI
Post Vietnam(May '75 to present)........ PVN
Other Service (all other periods).......... OS

Mark box in descending order of priority. Thus if person served in Vietnam and in Korea, mark VN.

1 [] VN
2 [] KW
3 [] WWII
4 [] WWI
5 [] PVN
6 [] OS
9 [] DK

c. Was -- EVER an active member of a National Guard or military reserve unit?

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

d. Was ALL of -- active duty service related to National Guard or military reserve training?

1 [] Yes
3 [] No
9 [] DK


2a. What is the highest grade or year of regular school -- has ever attended?

00 [] Never attended or kindergarten (NP)
Elem:
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
High:
[] 9
[] 10
[] 11
[] 12
College:
[] 1
[] 2
[] 3
[] 4
[] 5
[] 6+

b. Did -- finish the (number in 2a) [grade/year]?

1 [] Yes
2 [] No

Hand Card R, Ask first alternative for first person, ask second alternative for other persons.


CARD R

1. Aluet, Eskimo or American Indian
2. Asian or Pacific Islander
3. Black
4. White
5. Another group not listed -- Specify

3a. (What is the number of the group or groups which represents -- race?)
(What is -- race?)
Circle all that apply.

[] 1 -- Aleut, Eskimo or American Indian
[] 2 -- Asian or Pacific Islander
[] 3 -- Black
[] 4 -- White
[] 5 -- Another group not listed-- Please specify ____

Ask if multiple entries:
b. Which of those groups; that is, (entries in 3a) would you say BEST represents -- race?

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

c. Mark observed race of respondent(s) only.

1 [] W
2 [] B
3 [] O

Hand Card O - Mark box or ask:


CARD O

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

4a. Are any of those groups --'s national origin or ancestry?
(Where did --'s ancestors come from?)

1 [] Yes
2 [] No (NP)

b. Please give me the number of the group
(Circle all that apply)

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

[p. 161]

L. DEMOGRAPHIC BACKGROUND PAGE, Continued

L2

Refer to "Age" and "Wa/Wb" boxes in C1.

0 [] Under 18 (NP)
1 [] Wa box marked (6a)
2 [] Wb box marked (5a)
3 [] Neither box marked (5b)


5a. Earlier you said that -- has a job or business but did not work last week or the week before. Was -- looking for work or on layoff from a job during those 2 weeks?

1 [] Yes (5c)
2 [] No (6b)

b. Earlier you said that -- didn't have a job or business last week or the week before. Was -- looking for work or on layoff from a job during those 2 weeks?

1 [] Yes
2 [] No (NP)

c. Which, looking for work or on layoff from a job?

1 [] Looking (6c)
2 [] Layoff (6b)
3 [] Both (6b)


6a. Earlier you said that -- worked last week or the week before. Ask 6b.

b. For whom did -- work? Enter name of company, business, organization or other employer ____

c. For whom did -- work at [his/her] last full-time civilian job or business lasting 2 consecutive weeks or more? ____

Enter name of company, business, organization, or other employer or mark "NEV" or "AF" box in person's column.

[] NEV (6g)
[] AF (6e)

d. What kind of business or industry is this? For example, TV and radio manufacturing, retail shoe store, State Labor Department, farm. ____

e. What kind of work was -- doing? For example, electrical engineer, stock clerk, typist, farmer. If "AF" in 6b/c, mark "AF" box in person's column without asking. ____

[] AF (NP)

f. What were -- most important activities or duties? For example, types, keeps account books, files, sells cars, operates printing press, finishing concrete ____

Complete from entries in 6b-f. If not clear ask:

g. Was --:

P [] An employee of PRIVATE company, -business, or individual for wages, salary or commission?
F [] A FEDERAL government employee?
S [] A STATE government employee?
L [] A LOCAL government employee?

Self-employed in OWN business, professional practice or farm?
If not farm, is the business incorporated?
I [] Yes
SE [] No
WP [] Working WITHOUT pay in family business or farm?
NEV [] NEVER WORKED or never worked at a full-time civilian job lasting 2 weeks or more

[p. 162]

L. DEMOGRAPHIC BACKGROUND PAGE, Continued


Mark box if under 14. If "Married" refer to household composition and mark accordingly.

7. Is -- now married, widowed, divorced, separated, or has -- never been married?

0 [] Under 14
1 [] Married -- spouse in HH
2 [] Married -- spouse not in HH
3 [] Widowed
4 [] Divorced
5 [] Separated
6 [] Never married


8a. Was the total combined FAMILY income during the past 12 months -- that is, yours, (read names, including Armed Forces members living at home) more or less than $20,000? Include money from jobs, social security, retirement income, unemployment payments, public assistance, and so forth. Also include income from interest, dividends, net income from business, farm, or rent, and any other money income received.

1 [] $20,000 or more (Hand Card I)
2 [] Less than $20,000 (Hand Card J)
CARD I
U -- 20,00-24,999
V -- 25,000-29,999
W -- 30,000-34,999
X -- 35,000-39,999
Y -- 40,000-44,999
Z -- 45,000-49,999
ZZ -- 50,000 and over
CARD J
A -- Less than 1,000 (including loss)
B -- 1,000 - 1,999
C -- 2,000 - 2,999
D -- 3,000 - 3,999
E -- 4,000 - 4,999
F -- 5,000 - 5,999
G -- 6,000 - 6,999
H -- 7,000 - 7,999
I -- 8,000 - 8,999
J -- 9,000 - 9,999
K -- 10,000 - 10,999
L -- 11,000 - 11,999
M -- 12,000 - 12,999
N -- 13,000 - 13,999
O -- 14,000 - 14,999
P -- 15,000 - 15,999
Q -- 16,000 - 16,999
R -- 17,000 - 17,999
S -- 18,000 - 18,999
T -- 19,000 - 19,999

Read if necessary: Income is important in analyzing the health information we collect. For example, this information helps us to learn whether persons in one income group use certain types of medical care services or have certain conditions more or less often than those in another group.

Read parenthetical phrase if Armed Forces member living at home or if necessary.
b. Of those income groups, which letter best represents the total combined FAMILY income during the past 12 months (that is, yours, (read names, including Armed Forces members living at home))? Include wages, salaries, and the other items we just talked about.

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

R

a. Mark first appropriate box.

0 [] Under 17
1 [] Present for all questions
2 [] Present for some questions
3 [] Not present

b. Enter person number of respondent. ____

L3
Enter person number of first parent listed or mark box. ____

00 [] None in household
L4
Enter person number of spouse or mark box. ____

00 [] None in household
[p. 163]

L. DEMOGRAPHIC BACKGROUND PAGE, Continued

L5
Refer to age. Complete a separate column for each nondeleted person aged 18 and over.

Person number ____

Read to respondent(s) --

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.

L6
Enter date of birth from question 3 on Household Composition page.

Month ____
Date ____
Year ____
9. In what State or country was -- born? ____
Print the full name of the State or mark the appropriate box if the person was not born in the United States.

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

L7
Print full name, including middle initial, from question 1 on Household Composition page.

Last ____
First ____
Middle initial ____

Verify for males; ask for females.
10. What was your father's LAST name?
Verify spelling. DO NOT write "Same."

Father's LAST name ____

Read to respondent -
We also need -- Social Security Number. This information is voluntary and collected under the authority of the Public Health Service Act. There will be no effect on -- 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.
11. What is -- Social Security Number?

999999999 [] DK
Social Security Number _ _ _-_ _-_ _ _ _

Mark if number obtained from:

1 [] Memory
2 [] Records

L8
Mark box to indicate how Social Security number was obtained.

1 [] Self -- personal
2 [] Self -- telephone
3 [] Proxy -- personal
4 [] Proxy -- telephone
[p. 164]

L. DEMOGRAPHIC BACKGROUND PAGE, Continued

Read to Hhld. Respondent - The National Center for Health Statistics may wish to contact you again to obtain additional health related information. Please give me the name, address, and telephone number of a relative or friend who would know where you could be reached in case we have trouble reaching you. (Please give me the name of someone who is not currently living in the household.) Please print items 12-15.

12. Contact Person name

Last ____
First ____
Middle initial ____

13a. Address (Number and street) ____

b.

City ____
State ____
ZIP Code ____

14. Area code/telephone number _ _ _-_ _ _-_ _ _ _

1 [] None
2 [] Refused
9 [] DK

15. Relationship to household respondent ____