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c
[p. 155]

CONDITION 1

PERSON NO. ____

1. Name of condition

____

Mark "2-wk. ref. pd." box without asking if "DV" or "HS" in C2 as source.

2. When did [--/anyone] last see or talk to a doctor or assistant about [his/her] (condition)?

0[] Interview week (Reask 2)
1[] 2-wk. ref. pd.
2[] Over 2 weeks, less than 6 months
3[] 6 mos., less than 1 yr.
4[] 1yr., less than 2 yrs.
5[] 2 yrs., less than 5 yrs.
6[] 5yrs. or more
7[] Dr. seen, DK when
8[] DK if Dr. seen (3b)
9[] Dr. never seen (3b)

3a. (Earlier you told me about -- (condition)) Did the doctor or assistant call the (condition) by a more technical or specific name?

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

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

1[] Color Blindness (NC)
2[] Cancer (3e)
3[] Normal pregnancy, normal delivery, vasectomy (5)
4[] Old age (NC)
8[] Other (3c)

c. What was the cause of -- (condition in 3b)?

Specify ____

Mark the box if accident or injury.

0[] Accident/injury (Probe, then 5)

d. Did the (condition in 3b) result from an accident or injury?
Ask probes if necessary. Record responses in 3c:

1[] Yes (Probe, then 5) (How did the accident happen?)
2[] No (What was -- doing at the time of the injury?)

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

Ailment
Anemia
Asthma
Attack
Bed
Cancer
Condition
Cyst
Defect
Disease
Disorder
Growth
Measles
Problem
Rupture
Trouble
Tumor
Ulcer

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

Specify ____

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

Specify ________

For Stroke, fill remainder of this condition page for the first present effect. Enter in item C2 and complete a
separate condition page for each additional present effect.

Ask 3g if there is an impairment (refer to Card CP2) or any of the following entries in 3b-f:

Abscess
Ache (except head or ear)
Bleeding (except menstrual)
Blood clot
Boil
Cancer
Cramps (except menstrual)
Cyst
Damage
Growth
Hemorrhage
Infection
Inflammation
Neuralgia
Neuritis
Pain
Palsy
Paralysis
Rupture
Sore(ness)
Stiff (ness)
Tumor
Ulcer
Varicose veins
Weak(ness)

g. What part of the body is affected? Specify ____

Show the following detail:

Head .... skull, scalp, face
Back/spine/vertebrae ....upper, middle, lower
Side ....left or right
Ear ....inner or outer; left, right or both
Eye .... left, right, or both
Arm .... shoulder, upper, elbow, lower or wrist; left, right, or both
Hand ....entire hand or fingers only; left, right, or both
Leg ....hip, upper, knee, lower, or ankle; left, right or both
Foot .... entire foot, arch, or toes only; left, right, or both

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

Infection
Sore
Soreness

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

Specify ____

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

Tumor
Cyst
Growth

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

1[] Malignant
2[] Benign
9[] DK

5. a. When was --'s (condition in 3b/3f) first noticed?

1[] 2-wk. ref. pd.
2[] Over 2 weeks to 3 months
3[] Over 3 months to 1 year
4[] Over 1 year to 5 years
5[] Over 5 years

b. When did --'s (name if injury in 3b)?

1[] 2-wk. ref. pd.
2[] Over 2 weeks to 3 months
3[] Over 3 months to 1 year
4[] Over 1 year to 5 years
5[] Over 5 years

Ask probes if necessary:

(Was it on or since (first date of 2-week ref. period) or was it before that date)
(Was it less than 3 months or more than 3 months ago?)
(Was it less than 1 year or more than 1 year ago?)
(Was it less than 5 years or more than 5 years ago?)

[p. 156]

K1

Refer to RD and C2

1[] "Yes" in "RD" box AND more than 1 condition in C2 (6)
8[] Other (K2)
6a. During the 2 weeks outlines in red on that calendar, did -- (condition) cause[him/her] to cut down on things [he/she] usually does?

[] Yes
[] No (K2)

b. During that period, how many days did -- cut down for more than half of the day?

00[] None (K2)
Days ____

7. During those 2 weeks, how many days did -- stay in bed for more than half of the day because of this condition?

00[] None
Days ____

Ask if "Wa/Wb" box marked in C1:
8. During those 2 weeks, how many days did miss more than half of the day from --'s job or business because of this condition?

00[] None
Days ____

Ask if age 5-17:
9. During those 2 weeks, how many days did -- miss more than half of the day from school because of this condition?

00[] None
Days ____

K2

[] Condition has "CL LTR" in C2 as source (10)
[] Condition does not have "CL LTR" in C2 as source (K4)
10. About how many days since (12-month date) a year ago, has this condition kept -- in bed more than half of the day? (Include days while an overnight patient in a hospital.)

000[] None
Days ____

11. Was -- ever hospitalized for [his/her] (condition in 3b)?

1[] Yes
2[] No

K3

[] Missing extremity or organ (K4)
[] Other (12)
12a. Does -- still have this condition?

1[] Yes (K4)
2[] No

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

2[] Cured
3[] Under control (K4)
8[] Other (Specify) ____ (K4)

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

000[] Less than 1 month
OR
____ (Number)
1[] Month
2[] Years

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

1[] Yes
2[] No

K4

0[] Not an accident/injury (NC)
1[] First accident/injury for this person (14)
8[] Other (13)
13. Is this (condition in 3b) the result of the same accident you already told me about?

[] Yes (Record condition page number where accident questions first completed.) : Page No. ____ (NC)
[] No

14. Where did the accident happen?

1[] At home (inside house)
2[] At home (adjacent premises)
3[] Street and highway (includes roadway and public sidewalk)
4[] Farm
5[] Industrial place (includes premises) (Specify) ____
6[] School (includes premises)
7[] Place of recreation and sports, except at school
8[] Other (Specify) ____

Mark box if under 18 [] Under 18 (16)
15a. Was --under 18 when the accident happened?

1[] Yes (16)
[] No

b. Was -- in the Armed Forces when the accident happened?

2[] Yes (16)
[] No

c. Was -- at work at [his/her] job or business when the accident happened?

3[] Yes
4[] No

16a. Was a car truck, bus, or other motor vehicle involved in the accident in any way?

1[] Yes
2[] No (17)

b. Was more than one vehicle involved?

1[] Yes
2[] No

c. Was [it/either one] moving at the time?

1[] Yes
2[] No

17a. At the time of the accident what part of the body was hurt?
What kind of injury was it?
Anything else?

Part(s) of body * ____
Kind of injury ____

Ask if box 3, 4, or 5 marked in Q. 5:
b. What part of the body is affected now? How is --'s (part of body) affected? Is -- affected in any other way?

Part(s) of body * ____
Present effects ** ____

* Enter part of body in same detail as for 3g
** If multiple present effects, enter in C2 each one that is not the same as 3b or C2 and complete a separate condition page for it.