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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 -- (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?


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:


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)
Blood clot
Cramps (except menstrual)
Varicose veins

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

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:


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

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

5. [a. When was -- (condition in 3b/3f) first noticed?]
[b. When did -- (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?)


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 -- to cut down on things -- 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 -- 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


[] 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 -- (condition in 3b)?

1[] Yes
2[] No


[] 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
________ Number

1[] Months
2[] Years

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

1[] Yes
2[] No


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.)
_____ (NC)
Page No.

[] 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 -- 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
** 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.