CONDITION 1 PERSON NO. _____
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)
Ask 3b if "Yes" in 3a, otherwise transcribe condition name from 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 (3c)
c. What was the cause of -- (condition in 3b)? (Specify)
Mark the box if accident or injury.
d. Did the (condition in 3b) result from an accident or injury?
Ask probes if necessary. Record responses in 3c:
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:
e. What kind of (condition in 3b) is it?
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:
Ache (except head or ear)
Bleeding (except menstrual)
Cramps (except menstrual)
g. What part of the body is affected?
Show the following detail:
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:
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?
Ask if there are any of the following entries in 3b-f:
2 Over 2 weeks to 3 months
3Over 3 months to 1 year
4 Over 1 year to 5 years
5 Over 5 years
Ask probes if necessary:
(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?)
Refer to RD and C2
8 Other (K2)
 No (K2)
b. During that period, how many days did -- cut down for more than half of the day?
 Condition does not have "CL LTR" in C2 as source (K4)
 Other (12)
b. Is this condition completely cured or is it under control?
3 Under control (K4)
8 Other (Specify)
c. About how long did -- have this condition before it was cured?
d. Was this condition present at any time during the past 12 months?
1 First accident/injury for this person (14)
8 Other (13)
2 At home (adjacent premises)
3 Street and highway (includes roadway and public sidewalk)
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
b. Was -- in the Armed Forces when the accident happened?
c. Was -- at work at -- job or business when the accident happened?
2 No (17)
b. Was more than one vehicle involved?
c. Was [it/either one] moving at the time?
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?
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.