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[p. 212]


NATIONAL HEALTH INTERVIEW SURVEY : 1991 SELF ENUMERATION SUPPLEMENT

1. Book ____ of ____books

2. R.O. No. ____

3. Sample ____

4. Control number

PSU ____
Segment ____
Serial ____

5. Family number ____

6. Sample person number ____

7. Field Representative's code ____

Introduction
This questionnaire obtains information that will be extremely useful in understanding one of the country's major health issues. However, some of the questions may be considered personal; for that reason we are asking that you complete this questionnaire yourself. If you need any assistance, please ask me for help.

[p. 213]

The first few questions are about drinking alcoholic beverages. Included are beer, wine, and liquor such as whiskey or gin, and any other type of alcoholic beverage. Please put an "X" in the box next to the answer that fits you best or write in your answer on the line.


1. Have you had at least one drink of beer, wine, or liquor in your entire life?

1[] Yes
2[] No


2. In how many months out of the past 12 months did you drink beer, wine, or liquor?

Number of months I drank beer, wine, or liquor in the past 12 months: Months ____
00[] I did not drink beer, wine, or liquor in the past 12 months.
98[] I have never drunk beer, wine, or liquor; not even once.


3. During the months that you drank beer, wine, or liquor in the past 12 months, about how often did you drink on average?

1[] Every day
2[] 5 or 6 days each week
3[] 3 or 4 days each week
4[] 1 or 2 days each week
5[] 1 to 3 days a month
6[] I did not drink beer, wine, or liquor in the past 12 months
8[] I have never drunk beer, wine, or liquor; not even once


4. On the days that you drank beer, wine, or liquor in the past 12 months, about how many drinks per day did you drink?

Number of drinks per day in the past 12 months: Drinks per day ____
00[] I did not drink beer, wine, or liquor in the past 12 months
98[] I have never drunk beer, wine, or liquor; not even once


5. During the past 12 months, what is the largest number of drinks of beer, wine, or liquor that you drank in a single day?

Number of drinks: ____
00[] I did not drink beer, wine, or liquor in the past 12 months
98[] I have never drunk beer, wine, or liquor; not even once


6. About how often did you drink that amount in the past 12 months?

01[] Every day
02[] Nearly every day
03[] 3 to 4 days per week
04[] 1 to 2 days per week
05[] 2 to3 days per month
06[] Once a month
07[] 7 to 11 days in the past 12 months
08[] 3 to 6 days in the past 12 months
09[] 2 days in the past 12 months
10[] 1 day in the past 12 months
11[] None in the past 12 months
98[] I have never drunk beer, wine, or liquor; not even once.

[p. 214]


The next few questions are about your use of some drugs and medications. Please mark the "Yes" or "No" boxes to indicate if you have or have not used the drugs in the lists.

IN YOUR ENTIRE LIFE, have you ever used:


7. Sedatives, such as barbiturates, sleeping pills, and Seconal ("downers")?

1[] Yes
2[] No


8. Sedatives, such as barbiturates, sleeping pills, and Seconal ("downers") WITHOUT a doctor telling you to?

1[] Yes
2[] No


9. Tranquilizers, such as Librium, Valium, and Xanax?

1[] Yes
2[] No


10. Tranquilizers, such as Librium, Valium, and Xanax WITHOUT a doctor telling you to?

1[] Yes
2[] No


11. Stimulants, such as amphetamines, Preludin, uppers, and speed?

1[] Yes
2[] No


12. Stimulants, such as amphetamines, Preludin, uppers, and speed WITHOUT a doctor telling you to?

1[] Yes
2[] No


13. Pain killers, such as Darvon, Demerol, Percodan, and Tylenol with codeine?

1[] Yes
2[] No


14. Pain killers, such as Darvon, Demerol, Percodan, and Tylenol with codeine WITHOUT a doctor telling you to?

1[] Yes
2[] No


Now think about the past 12 months.
During those 12 months, have you used:


15. Sedatives, such as barbiturates, sleeping pills, and Seconal ("downers")?

1[] Yes
2[] No


16. Sedatives, such as barbiturates, sleeping pills, and Seconal ("downers") WITHOUT a doctor telling you to?

1[] Yes
2[] No


17. Tranquilizers, such as Librium, Valium, and Xanax?

1[] Yes
2[] No


18. Tranquilizers, such as Librium, Valium, and Xanax WITHOUT a doctor telling you to?

1[] Yes
2[] No


19. Stimulants, such as amphetamines, Preludin, uppers, and speed?

1[] Yes
2[] No


20. Stimulants, such as amphetamines, Preludin, uppers, and speed WITHOUT a doctor telling you to?

1[] Yes
2[] No


21. Pain killers, such as Darvon, Demerol, Percodan, and Tylenol with codeine?

1[] Yes
2[] No


22. Pain killers, such as Darvon, Demerol, Percodan, and Tylenol with codeine WITHOUT a doctor telling you to?

1[] Yes
2[] No


IN YOUR ENTIRE LIFE, have you ever used:


23. Inhalants, such as glue, amyl nitrite, poppers, and aerosol sprays?

1[] Yes
2[] No


24. Hallucinogens, such as LSD, PCP, peyote, and mescaline?

1[] Yes
2[] No


25. Heroin?

1[] Yes
2[] No

[p. 215]


Now, think about the past 12 months,
During those 12 months, have you used:


26. Inhalants, such as glue, amyl nitrite, poppers, and aerosol sprays?

1[] Yes
2[] No


27. Hallucinogens, such as LSD, PCP, peyote, and mescaline?

1[] Yes
2[] No


28. Heroin?

[] 1 Yes
[] 2 No


In the following set of questions, "marijuana" refers to both marijuana and hashish (hash). Hashish is a concentrated form of marijuana. Please put an "X" in the box next to the answer that fits you best or write in your answer on the line.


29. About how old were you the first time you used marijuana, even once?

Age when I first used marijuana: ____ Years
00[] I HAVE NEVER used marijuana, not even once


30. About how many times in your life have you used marijuana?

0[] 1 or 2 times
1[] 3 to 5 times
2[] 6 to 10 times
3[] 11 to 49 times
4[] 50 to 99 times
5[] 100 to 199 times
6[] 200 or more times
8[] I HAVE NEVER used marijuana, not even once


31. When was the most recent time that you used marijuana?

1[] Within the past week (7 days)
2[] More than 1 week but less than 1 month (30 days) ago
3[] 1 or more months ago but less than 1 year ago
4[] 1 or more years ago
8[] I HAVE NEVER used marijuana, not even once


32. In how many months out of the past 12 months did you use marijuana?

Number of months I have used marijuana in the past 12 months: Months ____
00[] I did not use marijuana in the past 12 months.
98[] I HAVE NEVER used marijuana, not even once


33. During the months that you used marijuana in the past 12 months, about how often did you use it on average?

1[] Every day
2[] 5 or 6 days each week
3[] 3 or 4 days each week
4[] 1 or 2 days each week
5[] 1 to 3 days a MONTH
6[] I did not use marijuana in the past 12 months
8[] I HAVE NEVER used marijuana, not even once


34. On the days that you used marijuana in the past 12 months, about how many times per day did you use it?

Number of times per day I used marijuana in the past 12 months: Times ____
00[] I did not use marijuana in the past 12 months
98[] I HAVE NEVER used marijuana, not even once

[p. 216]

IF YOU HAVE NEVER USED MARIJUANA, NOT EVEN ONCE, GO TO QUESTION 73 ON PAGE 9.

IF YOU HAVE USED MARIJUANA AT LEAST ONE TIME IN YOUR LIFE, CONTINUE WITH QUESTION 35 ON THE NEXT PAGE.

[p. 217]


Please mark the "Yes" or "No" boxes to indicate if the following things have or have not ever happened to you in YOUR ENTIRE LIFE. Mark "Yes" even if something only happened once in your entire life.

IN YOUR ENTIRE LIFE, have you ever


35. Ended up using marijuana more often than you thought you would?

1[] Yes
2[] No


36. Tried to cut down or stop using marijuana but found that you couldn't?

1[] Yes
2[] No


37. Used marijuana every day for two weeks or more?

1[] Yes
2[] No


38. Been high on marijuana while you were at work or at school?

1[] Yes
2[] No


39. Been high on marijuana while you were at home taking care of your home or family?

1[] Yes
2[] No


40. Skipped going to work or school because you were high on marijuana?

1[] Yes
2[] No


41. Had problems with work, school, or with the police because of using marijuana?

1[] Yes
2[] No


42. Continued to use marijuana even when you knew it was causing you problems with work, school, or with the police?

1[] Yes
2[] No


43. Failed to take care of your home or family because you were high on marijuana?

1[] Yes
2[] No


44. Had problems with your family or friends because of using marijuana?

1[] Yes
2[] No


45. Continued to use marijuana even when you knew it was causing you problems with your family or friends?

1[] Yes
2[] No


46. Driven a car or other vehicle within 3 hours after using marijuana?

1[] Yes
2[] No


47. Spent less time on activities that used to be important to you, like playing sports, hobbies, or other interests, so that you could use marijuana?

1[] Yes
2[] No


48. Felt depressed, anxious, or uninterested in things because of marijuana?

1[] Yes
2[] No


49. Continued to use marijuana even though you knew it made you feel depressed, anxious, or uninterested in things?

1[] Yes
2[] No


50. Built up a tolerance to marijuana so that the same amount of marijuana had less effect than before?

1[] Yes
2[] No


51. Felt sick or irritable because you stopped or cut down on your marijuana use?

1[] Yes
2[] No


52. Used alcohol or drugs because you felt sick or irritable when you stopped or cut down on your marijuana use?

1[] Yes
2[] No


53. Gone to a self-help group, counselor, doctor, or other professional to get help because of your marijuana use?

1[] Yes
2[] No

[p. 218]

IF YOU HAVE NOT USED MARIJUANA DURING THE PAST 12 MONTHS, NOT EVEN ONCE, GO TO QUESTION 73 ON PAGE 9.

IF YOU HAVE USED MARIJUANA AT LEAST ONE TIME DURING THE PAST 12 MONTHS, CONTINUE WITH QUESTION 54 ON THE NEXT PAGE.

[p. 219]

In the next set of questions, please mark the "Yes" or "No" boxes to indicate if the following things have or have not happened to you DURING THE PAST 12 MONTHS. Mark "Yes" even if something only happened once during the past 12 months.

DURING THE PAST 12 MONTHS, have you:

54. Ended up using marijuana more often than you thought you would?

1[] Yes
2[] No


55. Tried to cut down or stop using marijuana but found that you couldn't?

1[] Yes
2[] No


56. Used marijuana every day for two weeks or more?

1[] Yes
2[] No


57. Been high on marijuana while you were at work or at school?

1[] Yes
2[] No


58. Been high on marijuana while you were at home taking care of your home or family?

1[] Yes
2[] No


59. Skipped going to work or school because you were high on marijuana?

1[] Yes
2[] No


60. Had problems with work, school, or with the police because of using marijuana?

1[] Yes
2[] No


61. Continued to use marijuana even when you knew it was causing you problems with work, school, or with the police?

1[] Yes
2[] No


62. Failed to take care of your home or family because you were high on marijuana?

1[] Yes
2[] No


63. Had problems with your family or friends because of using marijuana?

1[] Yes
2[] No


64. Continued to use marijuana even when you knew it was causing you problems with your family or friends?

1[] Yes
2[] No


65. Driven a car or other vehicle within 3 hours after using marijuana?

1[] Yes
2[] No


66. Spent less time on activities that used to be important to you, like playing sports, hobbies, or other interestsm, so that you could use marijuana?

1[] Yes
2[] No


67. Felt depressed, anxious, or uninterested in things because of marijuana?

1[] Yes
2[] No


68. Continued to use marijuana even though you knew it made you feel depressed, anxious, or uninterested in things?

1[] Yes
2[] No


69. Built up a tolerance to marijuana so that the same amount of marijuana had less effect than before?

1[] Yes
2[] No


70. Felt sick or irritable because you stopped or cut down on your marijuana use?

1[] Yes
2[] No


71. Used alcohol or drugs because you felt sick or irritable when you stopped or cut down on your marijuana use?

1[] Yes
2[] No


72. Gone to a self-help group, counselor, doctor, or other professional to get help because of your marijuana use?

1[] Yes
2[] No

[p. 220]


The next set of questions are about cocaine. This includes powder cocaine, crack cocaine, free base, and coca paste. Again, please answer every question -- even if you've never used cocaine. Please put an "X" in the box next to the answer that fits you best or write in your answer on the line.


73. About how old were you the first time you used cocaine, even once?

Age when I first used cocaine: Years ____
00[] I HAVE NEVER used cocaine, not even once


74. About how many times in your life have you used cocaine?

0[] 1 or 2 times
1[] 3 to 5 times
2[] 6 to 10 times
3[] 11 to 49 times
4[] 50 to 99 times
5[] 100 to 199 times
6[] 200 or more times
8[] I HAVE NEVER used cocaine, not even once


75. When was the most recent time that you used cocaine?

1[] Within the past week (7 days)
2[] More than 1 week but less than 1 month (30 days) ago
3[] 1 or more months ago but less than 1 year ago
4[] 1 or more years ago
8[] I HAVE NEVER used cocaine, not even once


76. In how many of the past 12 months did you use cocaine?

Number of months I have used cocaine in the past 12 months: Months ____
00[] I did not use cocaine in the past 12 months
98[] I HAVE NEVER used cocaine, not even once


77. During the months that you used cocaine in the past 12 months, about how often did you use it on average?

1[] Every day
2[] 5 or 6 days each week
3[] 3 or 4 days each week
4[] 1 or 2 days each week
5[] 1 to 3 days a MONTH
6[] I did not use cocaine in the past 12 months
8[] I HAVE NEVER used cocaine, not even once


78. On the days that you used cocaine in the past 12 months, about how many times per day did you use it?

Number of times per day I used cocaine in the past 12 months: Times ____
00[] I did not use cocaine in the past 12 months
98[] I HAVE NEVER used cocaine, not even once


79. Please put an "X" in the box next to each of the ways you have used cocaine in the past 12 months.

1[] Sniffing through the nose (snorting)
2[] Swallowing or drinking
3[] Injecting in a vein or muscle with a needle
4[] Smoking or free basing
5[] Some other way -- Specify ____
6[] I did not use cocaine in the past 12 months
8[] I HAVE NEVER used cocaine, not even once

[p. 221]


80. When was the most recent time you used the form of cocaine known as "crack"?

1[] Within the past week (7 days)
2[] More than 1 week but less than 1 month (30 days) ago
3[] 1 or more months ago but less than 1 year ago
4[] 1 or more years ago
5[] I HAVE NEVER used crack, not even once
8[] I HAVE NEVER used cocaine, not even once

[p. 222]

IF YOU HAVE NEVER USED COCAINE, NOT EVEN ONCE, PLEASE TURN TO QUESTION 123 ON PAGE 15.

IF YOU HAVE USED COCAINE AT LEAST ONE TIME IN YOUR LIFE, CONTINUE WITH QUESTION 81 ON THE NEXT PAGE.

[p. 223]


Please mark the "Yes" or "No" boxes to indicate if the following things have or have not ever happened to you IN YOUR ENTIRE LIFE. Mark "Yes" even if something only happened once in your entire life.

IN YOUR ENTIRE LIFE, have you ever:


81. Ended up using cocaine more often than you thought you would?

1[] Yes
2[] No


82. Tried to cut down or stop using cocaine but found that you couldn't?

1[] Yes
2[] No


83. Used cocaine every day for two weeks or more?

1[] Yes
2[] No


84. Been high on cocaine or feeling its after effects while you were at work or school?

1[] Yes
2[] No


85. Been high on cocaine or feeling its after effects while you were at home taking care of your home or family?

1[] Yes
2[] No


86. Skipped going to work or school because you were high on cocaine or feeling its after effects?

1[] Yes
2[] No


87. Had problems with work, school, or with the police because of using cocaine?

1[] Yes
2[] No


88. Continued to use cocaine even when you knew it was causing you problems with work, school, or with the police?

1[] Yes
2[] No


89. Failed to take care of your home or family because you were high on cocaine or feeling its after effects?

1[] Yes
2[] No


90. Had problems with your family or friends because of using cocaine?

1[] Yes
2[] No


91. Continued to use cocaine even when you knew it was causing you problems with your family or friends?

1[] Yes
2[] No


92. Driven a car or other vehicle within 1 hour after using cocaine?

1[] Yes
2[] No


93. Spent less time on activities that used to be important to you -- like playing sports, hobbies, or other interests -- so that you could use cocaine?

1[] Yes
2[] No


94. Had health problems caused by using cocaine?

1[] Yes
2[] No


95. Continued to use cocaine even though you knew it was causing you health problems?

1[] Yes
2[] No


96. Felt depressed or uninterested in things, or suspicious or distrustful of people because of using cocaine?

1[] Yes
2[] No


97. Continued to use cocaine even though you knew it made you feel depressed or uninterested in things, or suspicious or distrustful of people?

1[] Yes
2[] No


98. Built up a tolerance to cocaine so that the same amount of cocaine had less effect than before?

1[] Yes
2[] No


99. Felt sick or irritable because you stopped or cut down on your cocaine use?

1[] Yes
2[] No


100. Used alcohol or drugs because you felt sick or irritable when you stopped or cut down on your cocaine use?

1[] Yes
2[] No


101. Gone to a self-help group, counselor, doctor, or other professional to get help because of your cocaine use?

1[] Yes
2[] No

[p. 224]

IF YOU HAVE NOT USED COCAINE DURING THE PAST 12 MONTHS, NOT EVEN ONCE, PLEASE TURN TO QUESTION 123 ON PAGE 14.

IF YOU HAVE USED COCAINE AT LEAST ONE TIME DURING THE PAST 12 MONTHS, CONTINUE WITH QUESTION 102 ON THE NEXT PAGE.

[p. 225]


In the next set of questions, please mark the "Yes" or "No" boxes to indicate if the following things have or have not happened to you DURING THE PAST 12 MONTHS. Mark "Yes" even if something only happened once during the past 12 months.

DURING THE PAST 12 MONTHS, have you:


102. Ended up using cocaine more often than you thought you would?

1[] Yes
2[] No


103 Tried to cut down or stop using cocaine but found that you couldn't?

1[] Yes
2[] No


104. Used cocaine every day for two weeks or more?

1[] Yes
2[] No


105. Been high on cocaine or feeling its after effects while you were at work or school?

1[] Yes
2[] No


106. Been high on cocaine or feeling its after effects while you were at home taking care of your home or family?

1[] Yes
2[] No


107. Skipped going to work or school because you were high on cocaine or feeling its after effects?

1[] Yes
2[] No


108. Had problems with work, school, or with the police because of using cocaine?

1[] Yes
2[] No


109. Continued to use cocaine even when you knew it was causing you problems with work, school, or with the police?

1[] Yes
2[] No


110. Failed to take care of your home or family because you were high on cocaine or feeling its after effects?

1[] Yes
2[] No


111. Had problems with your family or friends because of using cocaine?

1[] Yes
2[] No


112. Continued to use cocaine even when you knew it was causing you problems with your family or friends?

1[] Yes
2[] No


113. Driven a car or other vehicle within 1 hour after using cocaine?

1[] Yes
2[] No


114. Spent less time on activities that used to be important to you -- like playing sports, hobbies, or other interests -- so that you could use cocaine?

1[] Yes
2[] No


115. Had health problems caused by using cocaine?

1[] Yes
2[] No


116. Continued to use cocaine even though you knew it was causing you health problems?

1[] Yes
2[] No


117. Felt depressed or uninterested in things, or suspicious or distrustful of people because of using cocaine?

1[] Yes
2[] No


118. Continued to use cocaine even though you knew it made you feel depressed or uninterested in things, or suspicious or distrustful of people?

1[] Yes
2[] No


119. Built up a tolerance to cocaine so that the same amount of cocaine had less effect than before?

1[] Yes
2[] No


120. Felt sick or irritable because you stopped or cut down on your cocaine use?

1[] Yes
2[] No


121. Used alcohol or drugs because you felt sick or irritable when you stopped or cut down on your cocaine use?

1[] Yes
2[] No


122. Gone to a self-help group, counselor, doctor, or other professional to get help because of your cocaine use?

1[] Yes
2[] No

[p. 226]

123. Please use this space to record any comments you may have about this questionnaire or your participation in this survey. ____

Thank you very much for your cooperation. Please put this questionnaire into the envelope and return it to the interviewer.