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[p. 238]

Section II- Disability -continued

Part M -- CONDITION A

1. Name of condition ____

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

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

3a. 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 form item 1 without asking:

b. What did he or she call it?

[] 1 Color Blindness (NC)
[] 2 Cancer (3e)
[] 3 Normal pregnancy, normal delivery, vasectomy (5)
[] 4 Old age (NC)
[] 8 Other (9c) -- (Specify) ____

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

(Specify) ____

Mark box if accident or injury.

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

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

[] 1 Yes (Probe, then 5)
[] 2 No

Ask as necessary. Record responses in 3c:

(How did the accident happen?)

(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
Bad
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) ________

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?
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

(Specify) ____

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

5a. When was -- (condition in 3b) 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 -- (name of 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 as necessary:
(Was it on or since (first date of 2-week ref. period) or was it ebefore 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. 239]

Section II- Disability -continued

Part M -- CONDITION A-continued

ITEM M1

[] Missing extremity or organ (M2)
[] Other (12)
12a. Does -- still have this condition?

[] 1 Yes (M2)
[] No

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

[] 2 Cured
[] 3 Under control (M2)
[] 8 Other (Specify) -- ____ (M2)

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

000[] Less than 1 month
OR
____
1[] Months
2[] Years

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

[] 1 Yes
[] 2 No

ITEM M2

[] 0 Not an accident/injury (NC)
[] 1 Accident/injury (14)
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 -- (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