[p. 1]

ADULT CORE
Section I -- IDENTIFICATION

FR: THE NEXT QUESTIONS MUST BE ANSWERED BY THE SELECTED SAMPLE ADULT - NO PROXIES ARE PERMITTED.NO EMANCIPATED MINORS ARE PERMITTED.

SADULT

(1) Available
(2) Not Available
(3) Non-interview

[If the FAMILY respondent and Sample Adult are the same person, goto ACN.010; Else goto AID.030.]

AID.030

FR: PLEASE VERIFY THE FOLLOWING INFORMATION:

AIDVERF1

Gender = {male/female} Is it correct?

(1) Yes
(2) No

AIDVERF2

Age = {3 digit format} Is it correct?

(1) Yes
(2) No

AIDVERF3

Birthday = {word format} Is it correct?

(1) Yes
(2) No

[If AIDVERF1 equals (2) go to AID.040; If AIDVERF2 equals (2) go to AID.050; If AIDVERF3 equals (2) go to AID.060; Else goto ACN.010.]

AID.040

Is {sample adult} male or female?

AIDSEX

(1) Male
(2) Female
(7) Refused
(9) DK

AID.050

How old is {sample adult}?

AIDAGE

(00-99) 0-99 years old
(997) Refused
(999) DK

[p. 2]

AID.060

What is {sample adult's} birthday?

AIDDOB_M

MONTH: __________

(1) January
(2) February
(3) March
(4) April
(5) May
(6) June
(7) July
(8) August
(9) September
(10) October
(11) November
(12) December

AIDDOB_D

DAY: __________

(01-31) 1-31
(97) Refused
(99) DK

AIDDOB_Y

YEAR: __________

(1900-1997) 1900-1997
(9997) Refused
(9999) DK

[Note: Variables in the AID section are used to verify information collected from the family respondent. They do not exist as separate variables on the analytic file.]

(Goto next section -- Conditions)

[p. 3]

Section II -- CONDITIONS

Now I am going to ask you about certain medical conditions.

ACN.010

Have you EVER been told by a doctor or other health professional that you had... Hypertension, also called high blood pressure?

HYPEV

(1) Yes (ACN.020)
(2) No (ACN.031)
(7) Refused (ACN.031)
(9) DK (ACN.031)

ACN.020

Were you told on two or more DIFFERENT visits that you had hypertension, also called high blood pressure?

HYPDIFV

(1) Yes
(2) No
(7) Refused
(9) DK

ACN.031

Have you EVER been told by a doctor or other health professional that you had ...

(1) Yes
(2) No
(7) Refused
(9) DK

CHDEV ... Coronary heart disease?
ANGEV ... Angina, also called angina pectoris?
MIEV ... A heart attack (also called myocardial infarction)?
HRTEV ... Any kind of heart condition or heart disease (other than the ones I just asked about)?
STREV ... A stroke?
EPHEV ... Emphysema?

ACN.080

Have you EVER been told by a doctor or other health professional that you had ...
... Asthma?

AASMEV

(1) Yes (ACN.090)
(2) No (ACN.110)
(7) Refused (ACN.110)
(9) DK (ACN.110)

ACN.090

During the PAST 12 MONTHS, have you had an episode of asthma or asthma attack?

AASMYR

(1) Yes (ACN.100)
(2) No (ACN.110)
(7) Refused (ACN.110)
(9) DK (ACN.110)

ACN.100

During the PAST 12 MONTHS, have you had to visit an emergency room or urgent care center because of asthma?

AASMERYR

(1) Yes
(2) No
(7) Refused
(9) DK

ACN.110

Have you EVER been told by a doctor or other health professional that you had ....
.....An ulcer?
This could be a stomach, duodenal or peptic ulcer.

ULCEV

(1) Yes (ACN.120)
(2) No (ACN.130)
(7) Refused (ACN.130)
(9) DK (ACN.130)

[p. 4]

ACN.120

During the PAST 12 MONTHS have you had an ulcer?

ULCYR

(1) Yes
(2) No
(7) Refused
(9) DK

ACN.130

Have you EVER been told by a doctor or other health professional that you had ...
... Cancer or a malignancy of any kind?

CANEV

(1) Yes (ACN.140)
(2) No (ACN.160)
(7) Refused (ACN.160)
(9) DK (ACN.160)

ACN.140

What kind of cancer was it?

FR: MARK UP TO 3 KINDS. IF RESPONDENT OFFERS MORE THAN 3, CODE '96' (CNKIND31) IN THE FOURTH BOX. ENTER 'N' FOR NO MORE.

CNKIND

(1) Bladder
(2) Blood
(3) Bone
(4) Brain
(5) Breast
(6) Cervix
(7) Colon
(8) Esophagus
(9) Gallbladder
(10) Kidney
(11) Larynx-windpipe
(12) Leukemia
(13) Liver
(14) Lung
(15) Lymphoma
(16) Melanoma
(17) Mouth/tongue/lip
(18) Ovary
(19) Pancreas
(20) Prostate
(21) Rectum
(22) Skin (non-melanoma)
(23) Skin (DK what kind)
(24) Soft Tissue (muscle or fat)
(25) Stomach
(26) Testis
(27) Throat - pharynx
(28) Thyroid
(29) Uterus
(30) Other
(96) More than 3 kinds
(97) Refused
(99) DK

[ ]
[ ]
[ ]
[ ]

ACN.150

How old were you when cancer was first diagnosed?

CANAGE_1

(001-100) 1-100 years
(997) Refused
(999) DK

CANAGE_2

(001-100) 1-100 years
(997) Refused
(999) DK

CANAGE_3

(001-100) 1-100 years
(997) Refused
(999) DK

ACN.160

[ If Female, add: ]
Other than during pregnancy,

[ Else ]
Have you EVER been told by a doctor or health professional that you have diabetes or sugar diabetes?

DIBEV

(1) Yes (ACN.170)
(2) No (ACN.201)
(3) Borderline (ACN.201)
(7) Refused (ACN.201)
(9) DK (ACN.201)

[p. 5]

ACN.170

How old were you when a doctor FIRST told you that you had diabetes or sugar diabetes?

DIBAGE

(001-100) 1-100 years
(997) Refused
(999) DK

ACN.180

Are you NOW taking insulin?

INSLN

(1) Yes
(2) No
(7) Refused
(9) DK

ACN.190

Are you NOW taking diabetic pills to lower your blood sugar? These are sometimes called oral agents or oral hypoglycemic agents.

DIBPILL

(1) Yes
(2) No
(7) Refused
(9) DK

ACN.201

During the PAST 12 MONTHS, have you been told by a doctor or other health professional that you had...

(1) Yes
(2) No
(7) Refused
(9) DK

AHAYFYR ... Hay fever?
SINYR ... Sinusitis?
CBRCHYR ... Chronic bronchitis?
KIDWKYR ... Weak or failing kidneys? - Do not include kidney stones, bladder infections or incontinence.
LIVYR ... Any kind of liver condition?

FR: HAND CARD A1

Card A1

(Note: Flashcard A1 shows a figure of the body (front and back) with different body parts labeled.)

Front

Shoulders

(1) Right
(2) Left

Elbows

(3) Right
(4) Left

Hips

(5) Right
(6) Left

Wrists

(7) Right
(8) Left

Knees

(9) Right
(10) Left

Ankles

(11) Right
(12) Left

Toes

(13) Right
(14) Left

Back

Shoulders

(1) Right
(2) Left

Fingers, Thumb

(15) Right
(16) Left

Knees

(9) Right
(10) Left

( ) = joint

ACN.250

During the PAST 12 MONTHS, have you had pain, aching, stiffness or swelling in or around a joint?

JNTYR

(1) Yes (ACN.260)
(2) No (ACN.300)
(7) Refused (ACN.300)
(9) DK (ACN.300)

ACN.260

Were these symptoms present on MOST DAYS FOR AT LEAST ONE MONTH?

JNTMO

(1) Yes
(2) No
(7) Refused
(9) DK

ACN.270

Did these symptoms begin only because of an injury?

JNTIJ

(1) Yes (ACN.280)
(2) No (ACN.290)
(7) Refused (ACN.290)
(9) DK (ACN.290)

[p. 6]

ACN.280

How many weeks or months, in the past year, did you have joint symptoms due to an injury?

JNTIJL_N

[ ] NUMBER

(01-52) 1-52 units
(96) Entire year
(97) Refused
(99) DK

JNTIJLT

[ ] TIME PERIOD

(1) Weeks
(2) Months
(7) Refused
(9) DK

ACN.290

Which joints are affected?

FR: MARK ALL THAT APPLY. ENTER 'N' FOR NO MORE.

JNTYR

(1) Shoulder-right
(2) Shoulder-left
(3) Elbow-right
(4) Elbow-left
(5) Hip-right
(6) Hip-left
(7) Wrist-right
(8) Wrist-left
(9) Knee-right
(10) Knee-left
(11) Ankle-right
(12) Ankle-left
(13) Toes-right
(14) Toes-left
(15) Fingers/thumb-right
(16)Fingers/thumb-left
(17) Other joint not listed
(97) Refused
(99) DK

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

The following questions are about pain you may have experienced in the PAST THREE MONTHS. Please refer to pain that LASTED A WHOLE DAY OR MORE. Do not report aches and pains that are fleeting or minor.

ACN.300

During the PAST THREE MONTHS, did you have.... Neck pain?

PAINECK

(1) Yes
(2) No
(7) Refused
(9) DK

ACN.310

During the PAST THREE MONTHS, did you have...Low back pain?

PAINLB

(1) Yes (ACN.320)
(2) No (ACN.331)
(7) Refused (ACN.331)
(9) DK (ACN.331)

ACN.320

Did this pain spread down either leg to areas below the knees?

PAINLEG

(1) Yes
(2) No
(7) Refused
(9) DK

[p. 7]

ACN.331

During the PAST THREE MONTHS, did you have...

(1) Yes
(2) No
(7) Refused
(9) DK

PAINFACE ... Facial ache or pain in the jaw muscles or the joint in front of the ear?
AMIGR ... Severe headache or migraine?

FR: HAND CALENDAR CARD

These next questions are about your recent health during the TWO WEEKS outlined on that calendar.

ACN.350

Did you have a head cold or chest cold that started during those TWO WEEKS?

ACOLD2W

(1) Yes
(2) No
(7) Refused
(9) DK

ACN.360

Did you have a stomach or intestinal illness with vomiting or diarrhea that started during those TWO WEEKS?

AINTIL2W

(1) Yes
(2) No
(7) Refused
(9) DK

Check item ACNCCI1: If sex is male go to ACN.410; Else go to Check item ACNCCI2.
Check item ACNCCI2: If age is less than 50 go to ACN.370; Else go to ACN.410

ACN.370

Are you currently pregnant?

PREGNOW

(1) Yes
(2) No
(7) Refused
(9) DK

These next questions are about your hearing, vision, and teeth.

ACN.410

Have you ever worn a hearing aid?

HEARAID

(1) Yes
(2) No
(7) Refused
(9) DK

ACN.420

Which statement best describes your hearing (without a hearing aid): good, a little trouble, a lot of trouble, deaf?

AHEARST

(1) Good
(2) Little trouble
(3) Lot of trouble
(4) Deaf
(7) Refused
(9) DK

ACN.430

Do you have any trouble seeing, even when wearing glasses or contact lenses?

AVISION

(1) Yes (ACN.440)
(2) No (ACN.451)
(7) Refused (ACN.451)
(9) DK (ACN.451)

[p. 8]

ACN.440

Are you blind or unable to see at all?

ABLIND

(1) Yes
(2) No
(7) Refused
(9) DK

ACN.451

Have you lost all of your....

(1) Yes
(2) No
(7) Refused
(9) DK

UPPERT ... upper natural (permanent) teeth?
LOWERT ... lower natural (permanent) teeth?

Now I am going to ask you some questions about feelings you may have experienced over the PAST 30 DAYS.

FR: HAND CARD A2

Card A2

1. All of the time
2. Most of the time
3. Some of the time
4. A little of the time
5. None of the time

ACN.471

During the PAST 30 DAYS, how often did you feel...

(1) ALL OF THE TIME
(2) MOST OF THE TIME
(3) SOME OF THE TIME
(4) A LITTLE OF THE TIME
(5) NONE OF THE TIME
(7) REFUSED
(9) DK

SAD ... So sad that nothing could cheer you up?
NERVOUS ... Nervous?
RESTLESS ... Restless or fidgety
HOPELESS ... Hopeless
EFFORT ... That everything was an effort?
WORTHLS ... Worthless?

Check item ACNCCI4: If any of the responses are 1 - 3, then go to ACN.530; Else, go to the next section.

ACN.530

We just talked about a number of feelings you had during the PAST 30 DAYS. Altogether, how MUCH did these feelings interfere with your life or activities: a lot, some, a little, or not at all?

MHAMTMO

(1) A lot
(2) Some
(3) A little
(4) Not at all
(7) Refused
(9) DK

(Goto next section -- Health Status and Limitation of Activities)

[p. 9]

Section III -- HEALTH STATUS AND LIMITATION OF ACTIVITIES

Part A -- Health Indicators

FR: VERIFY OR ASK:

AHS.010

Earlier I recorded that you were working last week. Is that correct?

AHS_CCI1

(1) Yes (AHS.040)
(2) No (AHS.030)
(7) Refused (AHS.030)
(9) DK (AHS.030)

FR: VERIFY OR ASK:

AHS.020

Earlier I recorded that you were not working last week. Is that correct?

AHS_CCI2

(1) Yes (AHS.030)
(2) No (AHS.040)
(7) Refused (AHS.030)
(9) DK (AHS.030)

AHS.030

Although you did not work last week, did you have a job or business at any time in the PAST 12 MONTHS?

WRKLYR2

(1) Yes (AHS.040)
(2) No (AHS.050)
(7) Refused (AHS.050)
(9) DK (AHS.050)

AHS.040

During the PAST 12 MONTHS, that is, since {12-month ref. date}, ABOUT how many days did you miss work at a job or business because of illness or injury (do not include maternity leave)?

WKDAYR

(000) None
(001-366) 1-366 days
(997) Refused
(999) DK

AHS.050

During the PAST 12 MONTHS, that is, since {12-month ref. date}, ABOUT how many days did illness or injury keep you in bed more than half of the day? (Include days while an overnight patient in a hospital).

BEDDAYR

(000) None
(001-366) 1-366 days
(997) Refused
(999) DK (Goto AHS.060)

AHS.060

Compared with 12 MONTHS AGO, would you say your health is better, worse, or about the same?

AHSTATYR

(1) Better
(2) Worse
(3) About the same
(7) Refused
(9) DK

[p. 10]

Part B -- Limitation of Activities

AHS.070

Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?

SPECEQ

(1) Yes
(2) No
(7) Refused
(9) DK

The next questions ask about difficulties you may have doing certain activities because of a HEALTH PROBLEM.
By "health problem" we mean any physical, mental, or emotional problem or illness (not including pregnancy).

FR: HAND CARD A3.

Card A3

0. Not difficult at all
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all

AHS.091

By yourself, and without using any special equipment, how difficult is it for you to...

(0) NOT AT ALL DIFFICULT
(1) ONLY A LITTLE DIFFICULT
(2) SOMEWHAT DIFFICULT
(3) VERY DIFFICULT
(4) CAN'T DO AT ALL
(7) REFUSED
(9) DK

FLWALK ... Walk a quarter of a mile - about 3 city blocks?
FLCLIMB ... Walk up 10 steps without resting?
FLSTAND ... Stand or be on your feet for about 2 hours?
FLSIT ... Sit for about 2 hours?
FLSTOOP ... Stoop, bend, or kneel?
FLREACH ... Reach up over your head?

AHS.141

FLGRASP ... Use your fingers to grasp or handle small objects?
FLCARRY ... Lift or carry something as heavy as 10 pounds such as a full bag of groceries?
FLPUSH ... Push or pull large objects like a living room chair?

FR: HAND CARD A4.

Card A4

0. Not difficult at all
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity

AHS.171

By yourself, and without using any special equipment, how difficult is it for you to...

(0) NOT AT ALL DIFFICULT
(1) ONLY A LITTLE DIFFICUL
(2) SOMEWHAT DIFFICULT
(3) VERY DIFFICULT
(4) CAN'T DO AT ALL
(6) DO NOT DO THIS ACTIVITY
(7) Refused
(9) DK

FLSHOP ... Go out to things like shopping, movies, or sporting events?
FLSOCL ... Participate in social activities such as visiting friends, attending clubs and meetings, going to parties...?
FLRELAX ... Do things to relax at home or for leisure (reading, watching TV, sewing, listening to music...)?

[p. 11]

Check item AHS_CCI3: If any of the above answers in AHS.091, AHS.141, or AHS.171 = 1-4 go to AHS.200;
Else go to the next section.

AHS.200

What condition or health problem causes you to have difficulty with {names of up to 3 specified activities/these activities}?

FR: HAND CARD A5. ENTER ALL THAT APPLY UP TO 5 (but do not probe).
IF OLD AGE IS REPORTED, PROBE FOR SPECIFIC CONDITION(S) CAUSED BY OLD AGE.

Card A5

1. Vision/problem seeing
2. Hearing problem
3. Arthritis/rheumatism
4. Back or neck problem
5. Fracture, bone/joint injury
6. Other injury
7. Heart problem
8. Stroke problem
9. Hypertension/high blood pressure
10. Diabetes
11. Lung/breathing problem
12. Cancer
13. Birth defect
14. Mental retardation
15. Other developmental problem (e.g. cerebral palsy)
16. Senility
17. Depression/anxiety/emotional problem
18. Weight problem
19. Other impairment/problem

AFLHCA

(1) Vision/problem seeing
(2) Hearing problem
(3) Arthritis/rheumatism
(4) Back or neck problem
(5) Fractures,bone/joint injury
(6) Other injury
(7) Heart problem
(8) Stroke problem
(9) Hypertension/high blood
(10) Diabetes
(11) Lung/breathing problem
(12) Cancer
(13) Birth defect
(14) Mental retardation
(15) Other developmental problem (as cerebral palsy)
(16) Senility
(17) Depression/anxiety/emotional problem
(18) Weight problem pressure
(19) Other impairment/problem
(20) Other impairment/problem
(97) Refused
(99) DK

[ ]
[ ]
[ ]
[ ]
[ ]

[If answers equal (1) - (12) and (14) - (18) then go to AHS.300; if answer equals (19) and/or (20) go to AHS.201; else go to next section.]

AHS.201

FR: THESE SHOULD BE NAMES OF SPECIFIC CONDITIONS THAT ARE NOT ON THE CONDITION LIST.

AFLSPEC1 First condition: ___________________
AFLSPEC2 Second condition: ___________________

AHS.300

How long have you had {name the first condition AFLHCA1}?

AFLHCLN_1

[ ] NUMBER

(01-94) 1-94
(95) 95+
(96) Since birth
(97) Refused
(99) DK

AFLHCLT_1

[ ] TIME PERIOD

(1) Days
(2) Weeks
(3) Months
(4) Years
(6) Since birth
(7) Refused
(9) DK

AHS.301

How long have you had {name the second condition AFLHCA2}?

AFLHCLN_2

[ ] NUMBER

(01-94) 1-94(97) Refused
(95) 95+(99) DK
(96) Since birth

AFLHCLT_2

[ ] TIME PERIOD

(1) Days
(2) Weeks
(3) Months
(4) Years
(6) Since birth
(7) Refused
(9) DK

AHS.302

How long have you had {name the third condition AFLHCA3}?

AFLHCLN_3

[ ] NUMBER

(01-94) 1-94
(95) 95+
(96) Since birth
(97) Refused
(99) DK

AFLHCLT_3

[ ]TIME PERIOD

(1) Days
(2) Weeks
(3) Months
(4) Years
(6) Since birth
(7) Refused
(9) DK

AHS.303

How long have you had {name the fourth condition AFLHCA4}?

AFLHCLN_4

[ ] NUMBER

(01-94) 1-94(97) Refused
(95) 95+(99) DK
(96) Since birth

AFLHCLT_4

[ ]TIME PERIOD

(1) Days
(2) Weeks
(3) Months
(4) Years
(6) Since birth
(7) Refused
(9) DK

AHS.304

How long have you had {name the fifth condition AFLHCA5}?

AFLHCLN_5

[ ] NUMBER

(01-94) 1-94
(95) 95+
(96) Since birth
(97) Refused
(99) DK

AFLHCLT_5

[ ]TIME PERIOD

(1) Days
(2) Weeks
(3) Months
(4) Years
(6) Since birth
(7) Refused
(9) DK

(Goto next section -- Health Behaviors)

[p. 14]

Section IV - HEALTH BEHAVIORS

Part A - Tobacco

These next questions are about cigarette smoking.

AHB.010

Have you smoked at least 100 cigarettes in your ENTIRE LIFE?

SMKEV

(1) Yes (AHB.020)
(2) No (AHB.090)
(7) Refused (AHB.090)
(9) DK (AHB.090)

AHB.020

How old were you when you FIRST started to smoke fairly regularly?

SMKREG

(06-94) 6-94 years of age
(95) 95 years or older
(96) Never smoked regularly
(97) Refused
(99) DK

AHB.030

Do you NOW smoke cigarettes every day, some days or not at all?

SMKNOW

(1) Every day (AHB.050)
(2) Some days (AHB.060)
(3) Not at all (AHB.040)
(7) Refused (AHB.060)
(9) DK (AHB.060)

AHB.040

How long has it been since you quit smoking cigarettes?

SMKQTNO

[ ] NUMBER

(01-94) 1-94
(95) 95+
(97) Refused
(99) DK

SMKQTTP

[ ] TIME PERIOD

(1) Days (AHB.090)
(2) Weeks (AHB.090)
(3) Months (AHB.090
(4) Years (AHB.090)
(7) Refused (AHB.090)
(9) DK (AHB.090)

AHB.045

Have you quit smoking since {current month 1 year ago)

SMKQTD2

(1) Yes (AHB.090)
(2) No (AHB.090)
(7) Refused (AHB.090)
(9) DK (AHB.090)

AHB.050

On the average, how many cigarettes do you now smoke a day?

CIGSDA1

(01-94) 1-94 cigarettes (AHB.080)
(95) 95+ cigarettes (AHB.080)
(97) Refused (AHB.080)
(99) DK (AHB.080)

AHB.060

On how many of the PAST 30 DAYS did you smoke a cigarette?

CIGDAMO

(00) None (AHB.080)
(01-30) 1-30 Days
(97) Refused
(99) DK

[p. 15]

AHB.070

On the average, when you smoked during the PAST 30 DAYS, about how many cigarettes did you smoke a day?

CIGSDA2

(01-94) 1-94 cigarettes
(95) 95+ cigarettes
(97) Refused
(99) DK

AHB.080

During the PAST 12 MONTHS, have you stopped smoking for one day or longer BECAUSE YOU WERE TRYING TO QUIT SMOKING?

CIGQTYR

(1) Yes
(2) No
(7) Refused
(9) DK

[p. 16]

Part B - Physical Activity

The next questions are about physical activities (exercise, sports, physically active hobbies...) that you may do in your LEISURE time.

AHB.090

How often do you do VIGOROUS activities for AT LEAST 10 MINUTES that cause HEAVY sweating or LARGE increases in breathing or heart rate?

VIGNO2

[ ]NUMBER OF TIMES

(000) Never
(001-995) 1-995 times
(996) Unable to do this type of activity
(997) Refused
(999) DK

VIGTP2

[ ]TIME PERIOD

(0) Never (AHB.100)
(1) Day (AHB.100)
(2) Week (AHB.100)
(3) Month (AHB.100)
(4) Year (AHB.100)
(6) Unable to do this activity (AHB.100)
(7) Refused (AHB.100)
(9) DK (AHB.100)

AHB.100

About how long do you do these vigorous activities each time?

VIGLNGN2

[ ] NUMBER

(001-720) 1-720
(997) Refused
(999) DK

VIGLNGT2

[ ] TIME PERIOD

(1) Minutes (AHB.110)
(2) Hours (AHB.110)
(7) Refused (AHB.110)
(9) DK (AHB.108)

AHB.108

Each time you do these vigorious activities, do you do them 20 minutes or more, or less than 20 minutes?

VIGLONG6

(1) Less than 20 minutes
(2) 20 Minutes or more
(7) Refused
(9) Don't know

[p. 17]

AHB.120

About how long do you do these light or moderate activities each time?

MODLNGN2

[ ] NUMBER

(001-995) 1-995
(997) Refused
(999) DK

MODLNGT2

[ ] TIME PERIOD

(1) Minutes (AHB.130)
(2) Hours (AHB.130)
(7) Refused (AHB.130)
(9) DK (AHB.128)

AHB.128

Each time you do these light or moderate activities, do you do them 20 minutes or more, or less than 20 minutes?

MODLONG6

(1) Less than 20 minutes
(2) 20 Minutes or more
(7) Refused
(9) DK

AHB.130

How often do you do physical activities specifically designed to STRENGTHEN your muscles such as lifting weights or doing calisthenics? (Include all such activities even if you have mentioned them before.)

STRNGNO

[ ] NUMBER OF TIMES per

(000) Never
(001-995) 1-995
(996) Unable to do this type activity
(997) Refused
(999) DK

STRNGTP

[ ] TIME PERIOD

(0) Never
(1) Day
(2) Week
(3) Month
(4) Year
(6) Unable to do this type activity
(7) Refused
(9) DK

[p. 18]

PART C - Alcohol

These next questions are about drinking alcoholic beverages. Included are liquor such as whiskey or gin, beer, wine, winecoolers, and any other type of alcoholic beverage.

AHB.140

In ANY ONE YEAR, have you had at least 12 drinks of any type of alcoholic beverage?

ALC1YR

(1) Yes (AHB.160)
(2) No (AHB.150)
(7) Refused (AHB.150)
(9) DK (AHB.150)

AHB.150

In your ENTIRE LIFE, have you had at least 12 drinks of any type of alcoholic beverage?

ALCLIFE

(1) Yes (AHB.160)
(2) No (AHB.190)
(7) Refused (AHB.190)
(9) DK (AHB.190)

AHB.160

In the PAST YEAR, how often did you drink any type of alcoholic beverage?

ALC12MNO

[ ] NUMBER OF DAYS per

(000) Never
(001-365) 1-365 days
(997) Refused
(999) DK

ALC12MTP

[ ] TIME PERIOD

(0) Never/None
(1) Week
(2) Month
(3) Year
(7) Refused
(9) DK

AHB.170

In the PAST YEAR, on those days that you drank alcoholic beverages, on the average, how many drinks did you have?

ALCAMT

(01-94) 1-94 drinks
(95) 95 and more
(97) Refused
(99) DK

AHB.180

In the PAST YEAR, on how many DAYS did you have 5 or more drinks of any alcoholic beverage?

ALC5UPNO

[ ] NUMBER OF DAYS per

(000) Never/none
(001-365) 1-365 days
(997) Refused
(999) DK

ALC5UPTP

[ ] TIME PERIOD

(0) Never/None
(1) Week
(2) Month
(3) Year
(7) Refused
(9) DK

[p. 19]

AHB.190

About how tall are you without shoes?

AHEIGHTF

Feet __________

(02-07) 2-7 feet
(97) Refused
(99) DK

AHEIGHTI

Inches __________

(00-11) 0-11 Inches
(97) Refused
(99) DK

AHB.200

About how much do you weigh without shoes?

AWEIGHT

(050-500) 50-500 pounds
(997) Refused
(999) DK

(Goto next section -- Health Care Access and Utilization)

[p. 20]

Section V - HEALTH CARE ACCESS AND UTILIZATION

The next questions are about health care.

AAU.020

Is there a place that you USUALLY go to when you are sick or need advice about your health?

AUSUALPL

(1) Yes (AAU.030)
(2) There is NO place (AAU.037)
(3) There is MORE THAN ONE place (AAU.030)
(7) Refused (AAU.037)
(9) DK (AAU.037)

AAU.030

[If AAU.020 equals 1 read:]

APLKIND

What kind of place is it - a clinic, doctor's office, emergency room, or some other place?

[If AAU.020 equals 3 read:]
What kind of place do you go to most often - a clinic, doctor's office, emergency room, or some other place?

(1) Clinic or health center (AAU.035)
(2) Doctor's office or HMO (AAU.035)
(3) Hospital emergency room (AAU.035)
(4) Hospital outpatient department (AAU.035)
(5) Some other place (AAU.035)
(7) Refused (AAU.037)
(9) DK (AAU.037)

AAU.035

Is that {full name from AAU.030 APLKIND} the same place you USUALLY go when you need routine or preventive care, such as a physical examination or check up?

AHCPLROU

(1) Yes (AAU.040)
(2) No (AAU.037)
(7) Refused (AAU.037)
(9) DK (AAU.037)

AAU.037

What kind of place do you go to when you need routine preventive care, such as a physical examination or check-up?

AHCPLKND

(0) Doesn't get preventive care anywhere
(1) Clinic or health center
(2) Doctor's office or HMO
(3) Hospital emergency room
(4) Hospital outpatient department
(5) Some other place
(7) Refused
(9) DK

Check item AAUCCI1: If AAU.020 equals 2, 7, or 9, then go to AAU.061; Else go to AAU.040.

AAU.040

At any time in the PAST 12 MONTHS did you CHANGE the place(s) to which you USUALLY go for health care?

AHCCHGYR

(1) Yes (AAU.050)
(2) No (AAU.061)
(7) Refused (AAU.061)
(9) DK (AAU.061)

AAU.050

Was this change for a reason related to health insurance?

AHCCHGHI

(1) Yes
(2) No
(7) Refused
(9) DK

[p. 21]

AAU.061

There are many reasons people delay getting medical care. Have you delayed getting care for any of the following reasons in the PAST 12 MONTHS?

(1) Yes
(2) No
(7) Refused
(9) DK

AHCDLYR1 You couldn't get through on the telephone.
AHCDLYR2 You couldn't get an appointment soon enough.
AHCDLYR3 Once you get there, you have to wait too long to see the doctor.
AHCDLYR4 The clinic/doctor's office wasn't open when you could get there.
AHCDLYR5 You didn't have transportation.

AAU.111

During the PAST 12 MONTHS, was there any time when you needed any of the following but didn't get it because you couldn't afford it?

(1) Yes
(2) No
(7) Refused
(9) DK

AHCAFYR1 Prescription medicines
AHCAFYR2 Mental health care or counseling
AHCAFYR3 Dental care (including check-ups)

[p. 22]

Part B - Dental Care

FR: HAND CARD T.

Card T

1. 6 months or less
2. More than 6 months, but not more than 1 year ago
3. More than 1 year, but not more than 3 years ago
4. More than 3 years
5. Never

AAU.135

About how long has it been since you last saw or talked to a dentist? Include all types of dentists, such as orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists.

ADENLONG

(1) 6 months or less
(2) More than 6 months, but not more than 1 year ago
(3) More than 1 year, but not more than 3 years ago
(4) More than 3 years
(5) Never
(7) Refused
(9) DK

[p. 23]

Part C - Health Care Provider Contacts

AAU.141

During the PAST 12 MONTHS, that is since {12 month ref.date}, have you seen or talked to any of the following health care providers about your own health?

(1) Yes
(2) No
(7) Refused
(9) DK

AHCSYR1 A mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker?
AHCSYR2 An optometrist, optician, or eye doctor (someone who prescribes eyeglasses)?
AHCSYR3 A foot doctor?
AHCSYR4 A chiropractor?
AHCSYR5 A physical therapist, speech therapist, respiratory therapist, audiologist, or occupational ...therapist?
AHCSYR6 A nurse practitioner, physician assistant, or midwife?

Check item AAUCCI2: If Male then goto AAU.211; Else goto AAU.200.

AAU.200

During the PAST 12 MONTHS, that is since {12 month ref.date}, have you seen or talked to any of the following health care providers about your own health?

A doctor who specializes in women's health (an obstetrician/gynecologist)?

AHCSYR7

(1) Yes
(2) No
(7) Refused
(9) DK

AAU.211

During the PAST 12 MONTHS, that is since {12 month ref.date}, have you seen or talked to any of the following health care providers about your own health?

(1) Yes
(2) No
(7) Refused
(9) DK

AHCSYR8 A medical doctor who specializes in a particular medical disease or problem (other than obstetrician/gynecologist, psychiatrist,or ophthalmologist)?
AHCSYR9 A general doctor who treats a variety of illnesses (a doctor in general practice, family medicine, or internal medicine)?

AAU.230

Does that doctor treat children and adults (a doctor in general practice or family medicine)?

AHCSYR10

(1) Yes
(2) No
(7) Refused
(9) DK

AAU.240

During the PAST 12 MONTHS, HOW MANY TIMES have you gone to a HOSPITAL EMERGENCY ROOM about your own health? (This includes emergency room visits that resulted in a hospital admission.)

FR: HAND CARD A6.

Card A6

0. None
1. 1
2. 2-3
3. 4-9
4. 10-12
5. 13 or more

AHERNOYR

(0) None
(1) 1
(2) 2-3
(3) 4-9
(4) 10-12
(5) 13 or more
(7) Refused
(9) DK

[p. 24]

AAU.250

During the PAST 12 MONTHS, did you receive care AT HOME from a nurse or other health care professional?

AHCHYR

(1) Yes (AAU.260)
(2) No (AAU.280)
(7) Refused (AAU.280)
(9) DK (AAU.280)

AAU.260

During how many of the PAST 12 MONTHS did you receive care AT HOME from a health care professional?

AHCHMOYR

(01-12) 1-12 months
(7)Refused
(9)DK

AAU.270

What was the total number of home visits received during {that month/those months}?

FR: HAND CARD A7.

Card A7

1. 1
2. 2-3
3. 4-9
4. 10-12
5. 13 or more

AHCHNOYR

(1) 1
(2) 2-3
(3) 4-9
(4) 10-12
(5) 13 or more
(7) Refused
(9) DK

AAU.280

During the PAST 12 MONTHS, HOW MANY TIMES have you seen a doctor or other health care professional about your own health at a DOCTOR'S OFFICE, A CLINIC, OR SOME OTHER PLACE? DO NOT INCLUDE TIMES YOU WERE HOSPITALIZED OVERNIGHT, VISITS TO HOSPITAL EMERGENCY ROOMS, HOME VISITS, OR TELEPHONE CALLS.

FR: HAND CARD A6.

Card A6

0. None
1. 1
2. 2-3
3. 4-9
4. 10-12
5. 13 or more

AHCNOYR

(0) None
(1) 1
(2) 2-3
(3) 4-9
(4) 10-12
(5) 13 or more
(7) Refused
(9) DK

AAU.290

During the PAST 12 MONTHS, have you had SURGERY or other surgical procedures either as an inpatient or outpatient?

ASRGYR

(1) Yes (AAU.300)
(2) No (AAUCCI3)
(7) Refused (AAUCCI3)
(9) DK ( AAUCCI3)

AAU.300

Including any times you may have already told me about, HOW MANY DIFFERENT TIMES have you had surgery during the PAST 12 MONTHS?

ASRGNOYR

(01-94) 1-94 times
(95) 95+ times
(97) Refused
(99) DK

Check item AAUCCI3: If the sample adult has had a doctor visit in the last two weeks as indicated in the family core (FAU.180 = 1 and FAU.190 = the adult sample person), then AAU.305 = 1 and go to AAU.310; Else got to AAU.305.

AAU.305

About how long has it been since you last saw or talked to a doctor or other health care professional about your own health? Include doctors seen while a patient in a hospital.

FR: HAND CARD T.

Card T

1. 6 months or less
2. More than 6 months, but not more than 1 year ago
3. More than 1 year, but not more than 3 years ago
4. More than 3 years
5. Never

AMDLONG

(1) 6 months or less
(2) More than 6 months but not more than 1 year ago
(3) More than 1 year, but not more than 3 years ago
(4) More than 3 years
(5) Never
(7) Refused
(9) DK

[p. 26]

Part D - IMMUNIZATIONS

AAU.310

During the PAST 12 MONTHS, have you had a flu shot? A flu shot is usually given in the fall and protects against influenza for the flu season.

SHTFLUYR

(1) Yes
(2) No
(7) Refused
(9) DK

AAU.320

Have you EVER had a pneumonia vaccination? This shot is usually given only once in a person's lifetime and is different from the flu shot.

SHTPNUYR

(1) Yes
(2) No
(7) Refused
(9) DK

(Goto next section -- Demographics)

[p. 27]

Section VI - DEMOGRAPHICS

ASD.010

Earlier I recorded that you were born in [fill state-territory in USBORN/foreign country in PLBORN, PLBORN2, PLBORN3, or PLBORN4 in words]. Is that correct?

BORNVER

(1) Yes (Check item ASDCCI1)
(2) No (ASD.020)
(7) Refused (Check item ASDCCI1)
(9) DK (Check item ASDCCI1)

ASD.020

What is your correct place of birth?

BORNCOR Birth Place: ___________________

Check item ASDCCI1: If born in US go to Check item ASDCCI2; Else go to ASD.030

ASD.030

Earlier I was told that your date of birth is {month, 2-digit day, 4-digit year}. In what year did you come to the United States to stay?

USYR

(1900-1997) 1900-1997 (ASDCCI2)
(9997) Refused (ASD.040)
(9999) DK (ASD.040)

ASD.040

Earlier I recorded that you are {AGE} years old. About how long have you been in the United States?

USLONG

(01-94) 1-94 years
(95) 95+ years
(97) Refused
(99) DK

Check item ASDCCI2: If FSD.050 in family core is 1-2 then go to ASD.050; Else go to next section -- AIDS.

ASD.050

Earlier I recorded that in the last week you were {Fill answer code description from FSD.050}. Is that correct?

WRKVER

(1) Yes (Check item ASDCCI3)
(2) No (ASD.060)
(7) Refused (ADS.010)
(9) DK (ADS.010)

Check item ASDCCI3: If FSD.050 in family core is 1-2 then go to ASD.070; Else go to next section -- AIDS.

ASD.060

What is your correct working status?

WRKCOR

(1) Working at a job or business (ASD.070)
(2) With a job or business but not at work (ASD.070)
(3) Looking for work (ADS.010)
(4) Not working at a job or business (ADS.010)
(7) Refused (ADS.010)
(9) DK (ADS.010)

ASD.070

For whom did you work at your MAIN job or business? (Name of company, business, organization or employer)

WHOWRK

Job or Business: _________________________________
(7) Refused
(9) DK

[p. 28]

ASD.080

What kind of business or industry is this? (For example: TV and radio mgt., retail shoe store, State Department of Labor)

KINDIND

Kind of Business: _________________________________
(7) Refused
(9) DK

ASD.090

What kind of work were you doing? (For example: farming, mail clerk, computer specialist.)

KINDWRK

Kind of Work: _________________________________________
(7) Refused
(9) DK

ASD.100

What were your most important activities on this job or business? (For example: sells cars, keeps account books, operates printing press.)

IMPACT

Activities: ______________________________________________
(7) Refused
(9) DK

FR: HAND CARD A8.

Card A8

1. An employee of a PRIVATE company, business, or individual for wages, salary, or commission
2. A FEDERAL government employee
3. A STATE government employee
4. A LOCAL government employee
5. Self-employed in OWN business, professional practice, or farm
6. Working WITHOUT PAY in family business or farm

ASD.110

Looking at the card, which of these best describes your current job or work situation?

WRKCAT

(1) An employee of a PRIVATE company, business, or individual for wages, salary, or commission?
(2) A FEDERAL government employee?
(3) A STATE government employee?
(4) A LOCAL government employee?
(5) Self-employed in OWN business, professional practice or farm?
(6) Working WITHOUT PAY in family business or farm?
(7) Refused
(9) DK

FR: HAND CARD A9.

Card A9

1. 1- 9 employees
2. 10 - 24 employees
3. 25 - 49 employees
4. 50 - 99 employees
5. 100 - 249 employees
6. 250 - 499 employees
7. 500 - 999 employees
8. 1000 employees or more

ASD.120

Thinking about this MAIN job or business, how many people are employed there full and part time, including employees at all locations?

LOCALLNO

(01) 1- 9 employees (ASD.140)
(02) 10-24 employees (ASD.140)
(03) 25-49 employees (ASD.140)
(04) 50-99 employees (ASD.140)
(05) 100-249 employees (ASD.140)
(06) 250-499 employees (ASD.140)
(07) 500-999 employees (ASD.140)
(08) 1000 employees or more (ASD.140)
(97) Refused (ASD.130)
(99) DK (ASD.130)

ASD.130

Thinking about the particular location or facility where you worked last week, how many people are employed there full and part time?

LOCPRTNO

(01) 1- 9 employees
(02) 10-24 employees
(03) 25-49 employees
(04) 50-99 employees
(05) 100-249 employees
(06) 250-499 employees
(07) 500-999 employees
(08) 1000 employees or more
(97) Refused
(99) DK

[p. 29]

ASD.140

About how long have you worked at this MAIN job or business?

WRKLONG1

[ ]NUMBER

(001-365) 1-365
(997) Refused
(999) DK

WRKLONG2

[ ]TIME PERIOD

(1) Day(s) (ASD.150)
(2) Week(s) (ASD.150)
(3) Month(s) (ASD.150)
(4) Year(s) (ASD.150)
(7) Refused (ASD.150)
(9) DK (ASD.145)

ASD.145

Have you worked at this MAIN job or business for one year or less, or more than one year?

WRKLONGD

(1) One year or less
(2) More than one year
(7) Refused
(9) DK

ASD.150

Are you paid by the hour on this MAIN job or business?

HOURPD

(1) Yes
(2) No
(7) Refused
(9) DK

ASD.160

Do you have paid sick leave on this MAIN job or business?

PDSICK

(1) Yes
(2) No
(7) Refused
(9) DK

ASD.170

Do you have more than one job or business?

ONEJOB

(1) Yes (ASD.180)
(2) No (ADS.010)
(7) Refused (ADS.010)
(9) DK (ADS.010)

ASD.180

In your other jobs/businesses, do you work for an employer, are you self-employed, or both?

WRKCATOT

(1) Employee only (ADS.010)
(2) Self-employed only (ASD.190)
(3) Both (ADS.010)
(7) Refused (ADS.010)
(9) DK (ADS.010)

ASD.190

Is this business incorporated?

BUSINC

(1) Yes
(2) No
(7) Refused
(9) DK

(Goto next section --AIDS)

[p. 30]

Section VII - AIDS

Now, I am going to ask about giving blood donations to a blood bank such as the American Red Cross. This does NOT include blood drawn at a doctor's office for laboratory analysis.

ADS.010

Have you given blood since March 1985?

BLDGV

(1) Yes (ADS.020)
(2) No(ADS.040)
(7) Refused (ADS.040)
(9) DK (ADS.040)

ADS.020

During the past 12 months, that is, since {12-month ref. date}, have you donated blood?

BLDG12M

(1) Yes
(2) No
(7) Refused
(9) DK

ADS.040

The next questions are about the blood test for the AIDS virus infection. No questions will ask what the results are of any tests that you may have had.

[If ADS.020 equals 1 read:]
Except for tests you may have had as part of blood donations, have you ever had your blood tested for the AIDS virus infection?

[Else read:]
Have you ever had your blood tested for the AIDS virus infection?

AIDSTST

(1) Yes (ADS.060)
(2) No (ADS.050)
(7) Refused (ADS.110)
(9) DK (ADS.110)

ADS.050

Is there any particular reason why you have not been tested?

FR: IF "YES" ASK: What is the reason? Any other?

WHYTSU

(01) No reason (ADS.110)
(02) Don't consider myself at risk of AIDS (ADS.110)
(03) Doctor/HMO did not recommend it (ADS.110)
(04) Don't believe test results are accurate (ADS.110)
(05) Don't believe anything can be done if I am positive (ADS.110)
(06) Don't like needles (ADS.110)
(07) Don't trust results to be confidential (ADS.110)
(08) Afraid of losing job, insurance, housing, friends, family, if people knew I was positive for AIDS infection (ADS.110)
(09) Other reason - specify(ADS.055)
(10) Other reason - specify(ADS.056)
(97) Refused (ADS.110)
(99) DK (ADS.110)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

ADS.055

Specify the additional reason for not having been tested.

WHYSPEC1 First reason: ________________________________

ADS.056

Specify the additional reason for not having been tested.

WHYSPEC2 Second reason: ________________________________

ADS.060

[If ADS.020 equals 1 read:]
Not including blood donations, during the past 12 months, that is, since {12-month ref. date}, have you had your blood tested?

[Else read:]
During the past 12 months, that is, since {12-month ref. date}, have you had your blood tested?

TST12M

(1) Yes (ADS.065)
(2) No (ADS.110)
(7) Refused (ADS.110)
(9) DK (ADS.110)

FR: HAND CARD A10.

Card A10

1. Just to find out/Worried that you are infected
2. Because a doctor asked you to
3. Because the health department asked you to
4. Because sex partner asked you to
5. For hospitalization or surgical procedure
6. To apply for health insurance or life insurance
7. To comply with guidelines for health workers
8. To apply for a new job
9. For military induction, separation, or during military service
10. For immigration
11. Because of pregnancy
12. For some other reason

ADS.065

[If ADS.020 equals 1 read:]
Not including your blood donations, which of these would you say were the reasons for your last AIDS blood test?

[Else read:]
Which of these would you say were the reasons for your last AIDS blood test?

REATOT

(1) Just to find out/Worried that you are infected (ADS.070)for health workers (ADS.070)
(2) Because a doctor asked you to (ADS.070)
(3) Because the Health Departmentor during military service (ADS.070) asked you to (ADS.070)
(4) Because sex partner asked you to (ADS.070)
(5) For hospitalization or surgical procedure (ADS.070)
(6) To apply for health insurance or life insurance (ADS.070)
(7) To comply with guidelines
(8) To apply for a new job (ADS.070)
(9) For military induction, separation,
(10) For immigration (ADS.070)
(11) Because of pregnancy (ADS.070)
(12) Other reason - specify (ADS.067)
(13) Other reason - specify (ADS.068)
(97) Refused (ADS.070)
(99) DK(ADS.070)

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]

ADS.067

Specify the additional reason for the last AIDS test.

REASPEC1 First reason: ________________

ADS.068

Specify the additional reason for the last AIDS test.

REASPEC2 Second reason: ________________

ADS.070

[If ADS.020 equals 1, then read:]
Not including your blood donations, where did you have your last blood test for the AIDS virus?

[Else read:]
Where did you have your last blood test for the AIDS virus?

LASTST

(01) AIDS clinic/counseling/testing site (ADS.080)
(02) Community health clinic (ADS.080)
(03) Clinic run by employer (ADS.080)
(04) STD clinic (ADS.080)
(05) Family planning (ADS.080)
(06) Prenatal clinic (ADS.080)
(07) Other clinic (ADS.080)
(08) Doctor/HMO (ADS.080)
(09) Hospital/emergency room/outpatient clinic (ADS.080)
(10) Military induction, separation or military service site (ADS.080)
(11) Immigration site (ADS.080)
(12) At home/home visits by nurse/health worker (ADS.080)
(13) At home - self testing kit (ADS.080)
(14) Other location - specify (ADS.075)
(97) Refused (ADS.080)
(99) DK (ADS.080)

ADS.075

Specify the location of the last blood test.

LASTSPEC Location: ________________

ADS.080

Did you get the results of your last blood test?

ALTST

(1) Yes (ADS.090)
(2) No (ADS.110)
(3) Only notified if there was a problem (ADS.110)
(7) Refused (ADS.110)
(9) DK (ADS.110)

ADS.090

Did a health professional talk with you about AIDS when you were GIVEN THE RESULTS of your last test?

TALKHP

(1) Yes
(2) No
(7) Refused
(9) DK

ADS.100

Were the results given in person, by telephone, by mail, or in some other way?

RSGVN

(1) In person
(2) By telephone
(3) By mail
(4) In some other way
(7) Refused
(9) DK

[p. 33]

ADS.110

[If ADS.040 equals 1, then read:]
Do you expect to have another blood test for the AIDS virus infection in the next 12 months, not including through blood donation?

[Else, read:]
Do you expect to have a blood test for the AIDS virus infection in the next 12 months, not including through blood donation?

EXTST12M

(1) Yes (ADS.120)
(2) No (ADS.140)
(7) Refused (ADS.140)
(9) DK (ADS.140)

ADS.120

I am going to read some reasons people might have the blood test for the AIDS virus infection.

FR: HAND CARD A11.

Card A11

1. Because you want to find out if you are infected
2. Because it will be part of hospitalization or surgery you expect to have
3. Because you expect to apply for life or health insurance
4. Because you expect to apply for a Job
5. Because you expect to join the military
6. Because of guidelines for health care workers
7. Because it will be a required part of some other activity that includes automatic AIDS testing
8. Because it is required in your non-health care employment
10. Because you are pregnant or expect to become pregnant
11 . For some other reason (Specify)

Tell me which of these statements explain WHY YOU expect to have the blood test in the next 12 months? (Anything else?)

WHY12U

(01) Because you want to find out if you are infected (ADS.130)
(02) Because it will be part of hospitalization or surgery you expect to have (ADS.130)
(03) Because you expect to apply for life or health insurance (ADS.130)
(04) Because you expect to apply for a job (ADS.130)
(05) Because you expect to join the military (ADS.130)
(06) Because of guidelines for health care workers (ADS.130)
(07) Because it will be a required part of some other activity that includes automatic AIDS testing (ADS.130)
(08) Because it is required in your non-health care employment (ADS.130)
(09) Because you plan to have/begin sexual relationship (ADS.130)
(10) Because you are pregnant or expect to become pregnant (ADS.130)
(11) Other reason - specify (ADS.125)
(12) Other reason - specify (ADS.126)
(97) Refused (ADS.130)
(99) DK (ADS.130)

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ADS.125

Specify the additional reason for the blood test.

W12SPEC1 First reason: ________________

ADS.126

Specify the additional reason for the blood test.

W12SPEC2 Second reason: ________________

[p. 34]

ADS.130

Where will you have a blood test for the AIDS virus infection?

WHERTST

(1) AIDS clinic/counseling/testing site (ADS.140)
(2) Community Health Clinic (ADS.140)
(3) Clinic run by employer (ADS.140)
(4) STD clinic (ADS.140)
(5) Family planning (ADS.140)
(6) Prenatal clinic (ADS.140)
(7) Other clinic (ADS.140)
(8) Doctor/HMO (ADS.140)
(9) Hospital/emergency room/outpatient (ADS.140)
(10) Military induction/separation or military service site (ADS.140)
(11) Red Cross/blood bank/blood drive (ADS.140)
(12) At home/home visit by nurse/health practitioner (ADS.140)
(13) At home - self testing kit (ADS.140)
(14) Other location (specify) (ADS.135)
(97) Refused (ADS.140)
(99) DK (ADS.140)

ADS.135

Specify the location of the blood test.

WHERSPEC Location: ________________

ADS.140

What are your chances of GETTING the AIDS virus, would you say high, medium, low, or none?

CHNSADS

(1) High
(2) Medium
(3) Low
(4) None
(5) Already have AIDS or AIDS virus
(7) Refused
(9) DK

FR: HAND CARD A12.

Card A12

A. You have hemophilia and have received clotting factor concentrations
B. You are a man who has had sex with another man at some time since 1980, even one time
C. You have taken street drugs by needle at any time since 1980
D. You have traded sex for money or drugs at any time since 1980
E. Since 1980, you are or have been the sex partner of any person who would answer "Yes" to any of the items on this card

ADS.150

Tell me if ANY of these statements is true for YOU. Do NOT tell me WHICH Statement or statements are true for you. Just IF ANY of them are.

(a) You have hemophilia and have received clotting factor concentrations.
(b) You are a man who has had sex with another man at some time since 1980, even one time.
(c) You have taken street drugs by needle at any time since 1980.
(d) You have traded sex for money or drugs at any time since 1980.
(e) Since 1980, you are or have been the sex partner of any person who would answer "Yes" to (any of the items on this card/any of the items I have read).

STMTRU

(1) Yes to at least one statement
(2) No to all statements
(7) Refused
(9) DK

(Goto next section)

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