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[p.463]

POLIO SURVIVORS

Earlier, we were told that you had polio. The following questions deal with the time when you were first sick with polio, that is the first week or two of the illness.
1. How old were you when you got polio?

000[] Less than 1 month

____ (Age)
1[] Months
2[] Years

888[] Never had polio (End Interview)
999[] DK

2. In what year did you get polio?

1 9 __ __ Year
99[] DK

3. In what month of the year did this illness start?
Enter number in 2-digit numerals: 01-January through 12-December

__ __ Month
99[] DK

ITEM P1
Refer to question 1 above.
(Age when respondent got polio)

1[] Less than 5 years old (Read intro to question 4)
2[] Five years or more (Ask question 4 without intro)
9[] DK (Read intro to question 4)

I'm going to ask some questions about the first two weeks of your illness. Because you may have been too young to remember much, just answer the best you can based on what your parents or other family members and friends told you.
4. During the first two weeks you had polio, did you experience --

a. Fever?
1[] Yes
2[] No
9[] DK


b. Headache?
1[] Yes
2[] No
9[] DK


c. Stiff neck?
1[] Yes
2[] No
9[] DK


d. Diarrhea?
1[] Yes
2[] No
9[] DK


e. Muscle pains?
1[] Yes
2[] No
9[] DK


f. Skin rash?
1[] Yes
2[] No
9[] DK

[p.464]

POLIO SURVIVORS - Continued

5. During the first month you had polio, did you experience WEAKNESS in the following parts of your body --

a. Right arm or hand?
1[] Yes
2[] No
9[] DK


b. Left arm or hand?
1[] Yes
2[] No
9[] DK


c. Right leg or foot?
1[] Yes
2[] No
9[] DK


d. Left leg or foot?
1[] Yes
2[] No
9[] DK


e. Swallowing muscles?
1[] Yes
2[] No
9[] DK


f. Face muscles?
1[] Yes
2[] No
9[] DK


g. Neck muscles?
1[] Yes
2[] No
9[] DK


h. Breathing muscles?
1[] Yes
2[] No
9[] DK


i. Back or stomach muscles?
1[] Yes
2[] No
9[] DK

6. During the first month of your illness, did you have any difficulty passing urine?

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

7. Were you admitted to a hospital at the time you were first diagnosed with polio?

1[] Yes (Go to 8)
2[] No (Skip to 9)
9[] DK (Skip to 9)

8. Did you receive a spinal tap at the time you were diagnosed with polio?

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

9. At the time you were diagnosed with polio, did you experience problems with breathing?

1[] Yes (Go to 10)
2[] No (Skip to 12 on page 5)
9[] DK (Skip to 12 on page 5)

10. Did you require help with breathing?

1[] Yes (Go to 11)
2[] No (Skip to 12 on page 5)
9[] DK (Skip to 12 on page 5)

11. What kind of help did you need?
Mark (X) all that apply.

1[] Occasional assistance with a hand held device
2[] Medical ventilation (iron lung or respirator)
3[] Something else -- Specify
____

[p.465]

POLIO SURVIVORS - Continued

12a. Beginning about one month after you got polio, did you go through a period of rehabilitation? This would include a time when you might have physical therapy, doctor's checkups, and/or surgical procedures to help you recover from polio.

1[] Yes (Go to 12b)
2[] No (Skip to 20 on page 8)
9[] DK (Skip to 20 on page 8)

b. About how long would you say this period of rehabilitation lasted?

000[] Less than 1 month

___ (Number)
1[] Months
2[] Years

999[] DK

HAND CARD P1.
The next few questions deal with this period of REHABILITATION.
13. Beginning approximately two months after you got polio, that is, after the initial phase of your illness had passed:

a. How weakened was your right hip, thigh and knee? Would you say -- (Read all categories)?
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


b. How weakened was your right calf, ankle and foot? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


c. How weakened was your left hip, thigh and knee? Would you say -- (Read all categories)?
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


d. How weakened was your left calf, ankle and foot? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


e. How weakened was your right shoulder, upper arm and elbow? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


f. How weakened was your right forearm, wrist and hand? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


g. How weakened was your left shoulder, upper arm and elbow? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


h. How weakened was your left forearm, wrist and hand? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


i. How weakened were your breathing muscles? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


j. How weakened were your swallowing muscles? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


k. How weakened were your face muscles? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


l. How weakened were your back muscles? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


m. How weakened were your stomach muscles? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK

[p.466]

POLIO SURVIVORS - Continued

ITEM P2
Refer to question 1 on page 3.
(Age when respondent got polio)

1[] Less than 12 months old (Skip to 18 on page 7)
2[] 12 months or older (Go to 14)
3[] DK (Go to 14)

HAND CARD P2.
14. Beginning approximately two months after you got polio, how well could you walk? Would you say you were -- (Read all categories)

1[] Able to walk without a limp,
2[] Able to walk WITH a limp,
3[] Unable to walk without leg braces or other assistive devices, or
4[] Unable to walk at all?
5[] Can't remember
9[] DK

HAND CARD P3. Read categories if telephone interview.
15. During your rehabilitation, what kind of physical therapy or exercise did you use to strengthen your muscles?
(Anything else?)
Mark (X) all that apply.

00[] No exercise or physical therapy (Skip to 20 on page 8)
01[] Stretching exercises (Go to 16)
02[] Massage/heat (Go to 16)
03[] Yoga (Go to 16)
04[] Swimming (Go to 16)
05[] Weight lifting/medicine ball (Go to 16)
06[] Push-ups/pull-ups (Go to 16)
07[] Other - Specify
___
___
08[] Too young to remember (Go to 16)
99[] DK (Skip to 20 on page 8)

16. During your rehabilitation, how often did you do physical therapy or exercise to stretch or strengthen your muscle? Would you say -- regularly or only occasionally, such as less than twice a month?

1[] Regularly (Go to 17)
2[] Occasionally (Go to 17)
9[] DK (Skip to 20 on page 8)

17. For how many years did you continue your physical therapy or exercise schedule?

00[] Less than 1 year
____ (Number) Years
99[] DK

[p.467]

Polio Survivors - Continued

18. During your rehabilitation, did you have surgery on your arms, legs, or spine which was intended to correct a limitation or weakness caused by polio?

1[] Yes (Go to 19)
2[] No (Skip to 20 on page 8)
9[] DK (Skip to 20 on page 8)

19. Please tell me each surgical procedure you had and your age at the time of the procedure?
Any others?
Enter age in whole years. If less than 1 year old, enter "00".
Enter a description of the procedure if the exact name is not known

__ __ (Years) Age

99[] DK age
Surgical procedure description
____
____
99[] DK Surgical procedure

[p.468]

POLIO SURVIVORS - Continued

20. For the next few questions, please think about the period when you were at your PHYSICAL BEST after having polio. By physical best we mean the period when you had the greatest strength and endurance and were in the best condition to carry on the various activities of daily living such as working, housework, walking, driving, dressing, bathing, and so forth.
After having polio, at what age, or between what ages, were you at your physical best?
Enter age(s) in whole years or mark (X) box.

__ __ to __ __ Years of age (Go to 21)
9977[] Presently at physical best (Go to 21)
9988[] Never had a physical best (Skip to 41 on page 15)
9999[] DK (Skip to 41 on page 15)

HAND CARD P4.

(card P4 not found)
21. During the period of your physical best AFTER THE ONSET OF POLIO, which phrase best describes the extent of your disability? Would you say -- (Read all categories)
Mark (X) only one.

1[] No disability, (Skip to 29 on page 10)
2[] No noticeable disability, (Go to 22)
3[] Mild disability, (Go to 22)
4[] Moderate disability, or (Go to 22)
5[] Severe disability? (Go to 22)
9[] DK (Go to 22)

HAND CARD P2.

(card P2 not found)
22. During the period of your physical best after the onset of polio, how well could you walk?
If telephone interview, read: Would you say you were -- (Read all categories)
Mark (X) only one.

1[] Able to walk without a limp (Go to 23)
2[] Able to walk WITH a limp (Go to 23)
3[] Unable to walk WITHOUT leg braces or other assistive devices (Skip to 24)
4[] Unable to walk at all (Skip to 26 on page 9)
5[] Can't remember (Go to 23)
9[] DK (Go to 23)

HAND CARD P5.

(card P5 not found)
23. During the period of your physical best after the onset of your polio, what was the farthest you could walk WITHOUT using assistive devices and WITHOUT stopping?
If telephone interview, read: Would you say you -- (Read all categories)
Mark (X) only one.

1[] Couldn't walk at all (Go to 24)
2[] Could walk across a room (Go to 24)
3[] Could walk up and down the street (Go to 24)
4[] Could walk around the block (Go to 24)
5[] Could walk a mile or more (Skip to 25 on page 9)
9[] DK (Go to 24)

HAND CARD P5.

(card P5 not found)
24. How about WITH a leg brace or assistive devices such as a cane or walker? What was the farthest you could walk WITHOUT stopping during the period of your physical best?
If telephone interview, read: Would you say you -- (Read all categories)
Mark (X) only one.

1[] Couldn't walk at all (Skip to 26)
2[] Could walk across a room (Go to 25 on page 9)
3[] Could walk up and down the street (Go to 25 on page 9)
4[] Could walk around the block (Go to 25 on page 9)
5[] Could walk a mile or more (Go to 25 on page 9)
9[] DK (Go to 25 on page 9)

[p.469]

POLIO SURVIVORS - Continued

25. During the period of your physical best after the onset of your polio, how well could you climb stairs? Would you say you -- (Read all categories)
Mark (X) only one.

1[] Could climb stairs easily, without using a railing
2[] Could climb stairs using a railing, or
3[] Could not climb stairs at all?
9[] DK

26. During the period of your physical best after the onset of your polio, how easily would you tire while performing your usual daily activities? Would you say you -- (Read all categories)
Mark (X) only one.

1[] Tired VERY easily during the day, requiring five or more rest periods,
2[] Tired easily during the day, requiring two to four rest periods,
3[] Tired slowly and required one rest period a day, or
4[] Tired only after strenuous exercise or before bedtime?
9[] DK

27. I am going to read a list of assistive devices. Please tell me if you used each device at any time during the period of physical best.
Read list.
Mark (X) an answer for each type of device.

a. A cane or canes?
1[] Yes
2[] No
9[] DK


b. A crutch or crutches?
1[] Yes
2[] No
9[] DK


c. Walker?
1[] Yes
2[] No
9[] DK


d. Wheel chair or electric cart?
1[] Yes
2[] No
9[] DK


e. Left leg brace?
1[] Yes
2[] No
9[] DK


f. Right leg brace?
1[] Yes
2[] No
9[] DK


g. Left arm splint or brace?
1[] Yes
2[] No
9[] DK


h. Left hand splint or brace?
1[] Yes
2[] No
9[] DK


i. Right arm splint or brace?
1[] Yes
2[] No
9[] DK


j. Right hand splint or brace?
1[] Yes
2[] No
9[] DK


k. Breathing aids?
1[] Yes
2[] No
9[] DK


l. Back brace or corset?
1[] Yes
2[] No
9[] DK


m. Special shoes, or shoe lifts?
1[] Yes
2[] No
9[] DK


n. Another type of device?
1[] Yes
Specify
____
____
2[] No
9[] DK

[p.470]

POLIO SURVIVORS - Continued

HAND CARD P1.

(card P1 not found)
28. At the time of your physical best:

a. How weakened was your right hip, thigh and knee? Would you say -- (Read all categories)?
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


b. How weakened was your right calf, ankle and foot? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


c. How weakened was your left hip, thigh and knee? Would you say -- (Read all categories)?
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


d. How weakened was your left calf, ankle and foot? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


e. How weakened was your right shoulder, upper arm and elbow? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


f. How weakened was your right forearm, wrist and hand? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


g. How weakened was your left shoulder, upper arm and elbow? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


h. How weakened was your left forearm, wrist and hand? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


i. How weakened were your breathing muscles? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


j. How weakened were your swallowing muscles? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


k. How weakened were your face muscles? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


l. How weakened were your back muscles? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


m. How weakened were your stomach muscles? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK

29. About how much did you weigh during the time of your physical best?
Enter weight in whole pounds only.

____ Pounds
999[] DK

Now I am going to ask some questions about the period AFTER your physical best.
30. At the present time, do you feel you are STILL at your physical best?

1[] Yes (Skip to 41 on page 15)
2[] No (Go to 31 on page 11)
3[] DK (Go to 31 on page 11)

[p.471]

POLIO SURVIVORS - Continued

31. Since the period when you were at your physical best have you experienced any DECREASE in your ability to carry out your routine activities of daily living such as working, housework, walking, driving, dressing, bathing, and so forth?
If "Yes," ask: Would you say that your ability has decreased some or a lot?

1[] Yes, decreased some
2[] Yes, decreased a lot
3[] No, no decrease
9[] DK

32. Since the time of your physical best, do you NOW weigh more, less, or about the same?

1[] More (Go to 33)
2[] Less (Go to 33)
3[] About the same (Skip to 34)
9[] DK (Skip to 34)

33. How many pounds have you [gained/lost]?
Enter gain or loss in whole pounds only.

____ Pounds
999[] DK

34. Since the time of your physical best, have you had any severe injuries which have limited your ability to carry out your daily activities?

1[] Yes (Go to 35)
2[] No (Skip to 36)
9[] DK (Skip to 36)

35. What were the injuries and how old were you when they occurred?
Any others?
Enter age in whole years.
Describe the injury, not the accident.
(Example: Enter "Broken hip" not "fell")

__ __ (Years) Age
99[] DK age

Injury
____
799[] DK injury

36. Compared with your physical best, has your ability to swallow solid food gotten better, gotten worse, or stayed about the same?

1[] Gotten better
2[] Gotten worse
3[] Stayed about the same
9[] DK

[p.472]

POLIO SURVIVORS - Continued

37. Since reaching your physical best, have you experienced any new polio related difficulties?
If "Yes", ask: How many new polio-related difficulties have you experienced?
Mark (X) only one.

1[] Yes, one new polio-related difficulty (Go to 38)
2[] Yes, more than one new polio-related difficulty (Go to 38)
3[] New difficulties, BUT not sure they are polio-related (Go to 38)
4[] No (Skip to 41 on page 15)
9[] DK (Skip to 41 on page 15)

38. How old were you when [this/your MAIN] new polio-related difficulty began?
Enter age in whole years only.

____ Years of age
99[] DK

39. About how quickly did [this/your MAIN] NEW polio-related difficulty develop? Was it over a period of -- (Read all categories)
Mark (X) only one.

1[] Less than one month
2[] One month, but less than a year,
3[] One year, but less than 5 years,
4[] 5 years, but less than 10 years, or
5[] 10 or more years?
6[] Other - Specify
___
9[] DK

40a. Compared with your physical best, have you experienced any NEW muscle WEAKNESS?

1[] Yes (Go to 40b)
2[] No (Skip to 40c)
9[] DK (Skip to 40c)

HAND CARD P6.

(card P6 not found)
b. Which of the following muscles are involved?

(1) Left arm or hand?
1[] Yes
2[] No
9[] DK


(2) Right arm or hand?
1[] Yes
2[] No
9[] DK


(3) Left leg or foot?
1[] Yes
2[] No
9[] DK


(4) Right leg or foot?
1[] Yes
2[] No
9[] DK


(5) Stomach, back or torso?
1[] Yes
2[] No
9[] DK


(6) Neck or face?
1[] Yes
2[] No
9[] DK

[p.473]

POLIO SURVIVORS - Continued

40c. Compared with your physical best, have you experienced any NEW muscle PAIN?

1[] Yes (Go to 40d)
2[] No (Skip to 40e)
9[] DK (Skip to 40e)

HAND CARD P6

(card P6 not found)
d. Which of the following muscles are involved?

(1) Left arm or hand?
1[] Yes
2[] No
9[] DK


(2) Right arm or hand?
1[] Yes
2[] No
9[] DK


(3) Left leg or foot?
1[] Yes
2[] No
9[] DK


(4) Right leg or foot?
1[] Yes
2[] No
9[] DK


(5) Stomach, back or torso?
1[] Yes
2[] No
9[] DK


(6) Neck or face?
1[] Yes
2[] No
9[] DK

e. Compared with your physical best, have you experienced any NEW JOINT pains?

1[] Yes (Go to 40f)
2[] No (Skip to 40g)
9[] DK (Skip to 40g)

HAND CARD P7.

(card P7 not found)
f. Which of the following joints are involved?

(1) Left shoulder, elbow, or wrist?
1[] Yes
2[] No
9[] DK


(2) Right shoulder, elbow, or wrist?
1[] Yes
2[] No
9[] DK


(3) Left hip, knee, or ankle?
1[] Yes
2[] No
9[] DK


(4) Right hip, knee, or ankle?
1[] Yes
2[] No
9[] DK


(5) Neck or spine?
1[] Yes
2[] No
9[] DK

[p.474]

POLIO SURVIVORS - Continued

40g. Compared with your physical best, have you noticed any change in the size of muscles FORMERLY WEAKENED by polio?

1[] Yes (Go to 40h)
2[] No (Skip to 41 on page 15)
9[] DK (Skip to 41 on page 15)

h. Have the muscles increased or decreased in size?
Mark (X) only one.

1[] Increased in size
2[] Decreased in size
3[] Some increased/some decreased
9[] DK

HAND CARD P6.

(card P6 not found)
i. Which of the following muscles are involved?

(1) Left arm or hand?
1[] Yes
2[] No
9[] DK


(2) Right arm or hand?
1[] Yes
2[] No
9[] DK


(3) Left leg or foot?
1[] Yes
2[] No
9[] DK


(4) Right leg or foot?
1[] Yes
2[] No
9[] DK


(5) Stomach, back or torso?
1[] Yes
2[] No
9[] DK


(6) Neck or face?
1[] Yes
2[] No
9[] DK

[p.475]

POLIO SURVIVORS - Continued

HAND CARD P1.

(card P1 not found)
The following questions deal with the PRESENT TIME that is, over the past few weeks.
41. At the present time,

a. How weakened was your right hip, thigh and knee? Would you say -- (Read all categories)?
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


b. How weakened was your right calf, ankle and foot? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


c. How weakened was your left hip, thigh and knee? Would you say -- (Read all categories)?
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


d. How weakened was your left calf, ankle and foot? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


e. How weakened was your right shoulder, upper arm and elbow? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


f. How weakened was your right forearm, wrist and hand? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


g. How weakened was your left shoulder, upper arm and elbow? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


h. How weakened was your left forearm, wrist and hand? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


i. How weakened were your breathing muscles? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


j. How weakened were your swallowing muscles? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


k. How weakened were your face muscles? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


l. How weakened were your back muscles? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK


m. How weakened were your stomach muscles? (Would you say -- (Read all categories)?)
1[] Not weakened
2[] Mildly weakened
3[] Moderately weakened
4[] Severely weakened
5[] Completely paralyzed
9[] DK

HAND CARD P8.

(card P8 not found)
42. At the present time, what is the farthest you can walk WITHOUT using assistive devices and WITHOUT stopping? Would you say -- (Read all categories)

1[] Cannot walk at all,
2[] Can walk across a room,
3[] Can walk up and down the street,
4[] Can walk around the block, or
5[] Can walk a mile or more?
9[] DK

43. At the present time, how well can you climb stairs? Would you say you -- (Read all categories)

1[] Can climb stairs easily without using a railing,
2[] Can climb stairs with a railing, or
3[] Cannot climb stairs at all?
9[] DK

[p.476]

POLIO SURVIVORS - Continued

44. Do you now use any of the following assistive devices?
Mark (X) an answer for each type of device.
Read list.

a. A cane or canes?
1[] Yes
2[] No
9[] DK


b. A crutch or crutches?
1[] Yes
2[] No
9[] DK


c. Walker?
1[] Yes
2[] No
9[] DK


d. Wheel chair or electric cart?
1[] Yes
2[] No
9[] DK


e. Left leg brace?
1[] Yes
2[] No
9[] DK


f. Right leg brace?
1[] Yes
2[] No
9[] DK


g. Left arm splint or brace?
1[] Yes
2[] No
9[] DK


h. Left hand splint or brace?
1[] Yes
2[] No
9[] DK


i. Right arm splint or brace?
1[] Yes
2[] No
9[] DK


j. Right hand splint or brace?
1[] Yes
2[] No
9[] DK


k. Breathing aids?
1[] Yes
2[] No
9[] DK


l. Back brace or corset?
1[] Yes
2[] No
9[] DK


m. Special shoes, or shoe lifts?
1[] Yes
2[] No
9[] DK


n. Another type of device?
1[] Yes
Specify
____
____
2[] No
9[] DK

45. During the past few weeks, how easily did you tire while performing your usual daily activities? Would you say you -- (Read all categories)
Mark (X) only one.

1[] Tire VERY easily during the day, requiring five or more rest periods,
2[] Tire easily during the day, requiring two to four rest periods,
3[] Tire slowly and required one rest period a day, or
4[] Tire only after strenuous exercise or before bedtime?
9[] DK

[p.477]

POLIO SURVIVORS - Continued

46. At present, do you feel your general health is improving, declining, or staying about the same?

1[] Improving (Skip to 50 on page 18)
2[] Declining (Go to 47)
3[] About the same (Skip to 50 on page 18)
9[] DK (Skip to 50 on page 18)

47. What do you think is the main cause of this decline?
Mark (X) only one.

1[] Aging (Skip to 50 on page 18)
2[] Sedentary lifestyle (Skip to 50 on page 18)
3[] Return of old problems/conditions (Skip to 50 on page 18)
4[] New chronic conditions (Skip to 50 on page 18)
5[] Other new illness (Skip to 50 on page 18)
6[] Late effects of polio (Go to 48)
7[] Other (Skip to 50 on page 18)
9[] DK (Skip to 50 on page 18)

Mark (X) box "0" or ask.
HAND CARD P9. Read categories if telephone interview.
48. Which statement best describes how you feel about your physical condition?

0[] Proxy (Skip to 50 on page 18)
1[] I do not feel disabled
2[] I feel disabled for the first time in my life
3[] Now I feel like I have a second disability
4[] None of the above
9[] DK

49. To what extent do you feel that your earlier experience with polio has prepared you to deal with this decline? Would you say -- (Read all categories)

1[] Not at all,
2[] Somewhat, or
3[] A lot?
9[] DK

[p.478]

POLIO SURVIVORS - Continued

50. Now I want to ask some questions about other health problems.
Read each condition and mark (X) box. Then proceed to question 51.
Has a doctor ever told you that you had --

a. Diabetes?
1[] Yes
2[] No
9[] DK


b. Emphysema?
1[] Yes
2[] No
9[] DK


c. Chronic bronchitis?
1[] Yes
2[] No
9[] DK


d. Asthma?
1[] Yes
2[] No
9[] DK


e. Heart problems?
1[] Yes
2[] No
9[] DK


f. Circulation problems in your arms and legs?
1[] Yes
2[] No
9[] DK


g. Hypertension?
1[] Yes
2[] No
9[] DK


h. A stroke?
1[] Yes
2[] No
9[] DK


i. Stomach ulcers?
1[] Yes
2[] No
9[] DK


j. Gallbladder problems?
1[] Yes
2[] No
9[] DK


k. Urinary tract problems?
1[] Yes
2[] No
9[] DK


l. Kidney stones?
1[] Yes
2[] No
9[] DK


m. Arthritis?
1[] Yes
2[] No
9[] DK


n. Other joint problems?
1[] Yes
2[] No
9[] DK


o. Cancer or leukemia?
1[] Yes
2[] No
9[] DK


p. A nerve or muscle disorder other than polio?
1[] Yes
2[] No
9[] DK


q. A sleep disorder?
1[] Yes
2[] No
9[] DK


r. (Males only) Prostate problems?
1[] Yes
2[] No
9[] DK

Ask for each condition marked "Yes" in 50.
51. Are you currently taking medication for your (condition)?

a. Diabetes
1[] Yes
2[] No
9[] DK


b. Emphysema?
1[] Yes
2[] No
9[] DK


c. Chronic bronchitis
1[] Yes
2[] No
9[] DK


d. Asthma
1[] Yes
2[] No
9[] DK


e. Heart problems?
1[] Yes
2[] No
9[] DK


f. Circulation problems in your arms and legs
1[] Yes
2[] No
9[] DK


g. Hypertension
1[] Yes
2[] No
9[] DK


h. A stroke?
1[] Yes
2[] No
9[] DK


i. Stomach ulcers
1[] Yes
2[] No
9[] DK


j. Gallbladder problems?
1[] Yes
2[] No
9[] DK


k. Urinary tract problems
1[] Yes
2[] No
9[] DK


l. Kidney stones
1[] Yes
2[] No
9[] DK


m. Arthritis
1[] Yes
2[] No
9[] DK


n. Other joint problems
1[] Yes
2[] No
9[] DK


o. Cancer or leukemia
1[] Yes
2[] No
9[] DK


p. A nerve or muscle disorder other than polio
1[] Yes
2[] No
9[] DK


q. A sleep disorder
1[] Yes
2[] No
9[] DK


r. (Males only) Prostate problems
1[] Yes
2[] No
9[] DK

[p.479]

POLIO SURVIVORS - Continued

52. Has a doctor ever told you that you are suffering from post-polio syndrome

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

53. Post-polio syndrome is NEW weakness, NEW pain or NEW tiredness in people who previously had polio? Do YOU think you have post-polio syndrome?

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

If proxy interview, skip to 56, otherwise read the appropriate statement.
If personal visit, HAND CARD P10 and read:

(card P10 not found)
Please read the statements on this card.
If telephone interview, read: Now, I am going to read some statements
54. For each one, please tell me whether it is not true, somewhat true, or very true for you.

a. I've always felt that I could make of my life pretty much what I wanted to make of it. Is that not true, somewhat true, or very true for you?
1[] Not true
2[] Somewhat true
3[] Very true
9[] DK


b. Once I make up my mind to do something, I stay with it until the job is completely done. (Is that not true, somewhat true, or very true for you?)
1[] Not true
2[] Somewhat true
3[] Very true
9[] DK


c. I don't let my personal feelings get in the way of getting a job done. (Is that not true, somewhat true, or very true for you?)
1[] Not true
2[] Somewhat true
3[] Very true
9[] DK


d. It's important for me to be able to do things in the way I want to do them rather than in the way other people want me to do them. (Is that not true, somewhat true, or very true for you?)
1[] Not true
2[] Somewhat true
3[] Very true
9[] DK


e. Sometimes I feel that if anything is going to be done right, I have to do it myself. (Is that not true, somewhat true, or very true for you?)
1[] Not true
2[] Somewhat true
3[] Very true
9[] DK


f. I like doing things that other people thought could not be done. (Is that not true, somewhat true, or very true for you?)
1[] Not true
2[] Somewhat true
3[] Very true
9[] DK


g. I feel like I am the kind of person who stands for what she/he believes in, regardless of the consequences. (Is that not true, somewhat true, or very true for you?)
1[] Not true
2[] Somewhat true
3[] Very true
9[] DK


h. Hard work is the best possible way for a young person to get ahead in life. (Is that not true, somewhat true, or very true for you?)
1[] Not true
2[] Somewhat true
3[] Very true
9[] DK


i. People have made fun of me because of the physical effects of polio. (Is that not true, somewhat true, or very true for you?)
1[] Not true
2[] Somewhat true
3[] Very true
9[] DK


j. I have been discriminated against because of the physical effects of polio. (Is that not true, somewhat true, or very true for you?)
1[] Not true
2[] Somewhat true
3[] Very true
9[] DK

55. On a scale from 1 to 7, with 1 being VERY SATISFIED and 7 being VERY UNSATISFIED, how satisfied or unsatisfied are you with your life as a whole these days?
Repeat if necessary. Mark (X) only one.

1[] 2[] 3[] 4[] 5[] 6[] 7[]
Very satisfied Very unsatisfied

[p.480]

POLIO SURVIVORS - Continued

ITEM P3
Refer to other DFS questionnaires for this sample person.

1[] Any DFS 1, 2, 3 completed (Skip to 58a on page 21)
2[] None completed (Go to intro)
Intro The National Center for Health Statistics may wish to contact you again to obtain additional health related information.

ITEM P4
Refer to CP on label.

1[] CP on label (Ask 56a)
2[] No CP on label (Ask 56b)
56a. The last time a Census Bureau interviewer talked to you or your family, we were told that (CP on label) will always know how to get in touch with you if we want to contact you again. Is (CP on label) still the best person to contact if we are unable to reach you?

1[] Yes (Verify CP's address and phone number. If incorrect, enter correct information in 57 below.)
2[] No (Go to 56b)

b. The National Center for Health Statistics would like the name, address, and telephone number of a relative or friend who would know where you could be reached in case we need additional health information in the future but cannot reach you. Please give me the name of someone who is not currently living in the household.
(Record information in 57.)

57. Contact Person Information

Last name _____
First name _____
MI _____
Number and street _____
City _____
State _____
ZIP Code _____

Telephone
Area code _____
Number _____
1[] None
7[] Refused
9[] DK

[p.481]

POLIO SURVIVORS - Continued

READ: The last few questions deal with locating medical records.
58a. The physicians who designed this questionnaire have a special interest in post-polio syndrome and would like to review the past medical records of as many polio survivors as possible. Could we have your permission to get copies of your medical records?

1[] Yes (Go to 58b)
2[] No (END Interview)
9[] DK (Go to 58b)

b. What is the name and address of the hospital to which you were first admitted when you got polio?

0[] None (Go to 58c)
1[] Name of hospital/facility _____
Address (Number and street) _____
City/Town _____
State _____
ZIP Code _____
9[] DK

c. What are the name and addresses of any other hospitals or medical facilities to which you were admitted for rehabilitation or surgery related to your illness?
Any others?

0[] None (Go to 59)
1[] Name of hospital/facility _____
Address (Number and street) _____
City/Town _____
State _____
ZIP Code _____
9[] DK

59a. Are there additional persons, physicians, physical therapists, and so forth, who may have records of your polio illness?

1[] Yes (Go to 59b on page 22)
2[] No (Skip to Item P5a on page 22)
9[] DK (Skip to Item P5a on page 22)

[p.482]

POLIO SURVIVORS - Continued

59b. What are their names and addresses?
Any other?

0[] None
1[] Name ____
Address (Number and street) _____
City/Town _____
State _____
ZIP Code _____
Telephone number
Area code ( )
Number ___

ITEM P5a
Mode of interview

1[] Telephone
2[] Personal visit
ITEM P5b
Respondent status

1[] Adult self response (Go to 60)
2[] Adult - Proxy (END Interview)
60. So that we might obtain your records, will you sign a form consenting to the release of your records relating to your polio illness? Your confidentiality will be carefully safeguarded and no personal information will be made available at any time.

1[] Yes (Provide form on page 23 for signature. If telephone interview, mail page 23 to respondent for signature)
2[] No (END Interview)