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[p. 1]

2004 NHIS Questionnaire -- Sample Adult
Adult Identification

AID.005_00.000

Instrument Variable Name: SADULT
Question Text:

*The sample adult person is [fill: Sample Adult name]. The next questions must be answered by this person. Probe as necessary to determine the availability of [fill: Sample Adult name].
If refused enter CTRL-R

1 Available
2 Not available
3 Physical or mental condition prohibits responding
7 Refused

Universe Text: Sample adult section has not been started or completed
Skip Instructions:

(1) [if Sample Adult = demographics.hhc.RELRESP_A]
[goto beginning of adult.asd]
[elseif Sample Adult = demographics.hhc.HHRESP]
[goto beginning of adult.asd]
[else]
[goto AIDVERF_S]
[endif]
(2) [goto callbk.ACALLBK1]
(3) [goto PROX1]
(R) [store (4) in ASTAT]
[if recontact.RCIFLAG () 1]
[goto recontact.RCI_BEGIN procedure]
[else]
[goto back.OUTCOMEB1 procedure]
[endif]

AID.010_00.000

Instrument Variable Name: PROX1
Question Text:

*Proxy interviews can be done for sample adults that have a mental or physical condition that prevents them from responding for themselves.
Is a family member or caregiver that is knowledgeable about [fill: Sample Adult name]'s health available?

1 Yes
2 No

Universe Text: The Sample adult's physical or mental condition prohibits responding
Skip Instructions:

(1) [goto PROX2]
(2) [goto PROX3]

[p. 2]

AID.015_00.000

Instrument Variable Name: PROX2
Question Text:

*Ask if necessary.
What is this person's relationship to [fill: Sample Adult name]?

1 Relative who lives in household
2 Relative who doesn't live in household
3 Other caregiver
4 Other
7 Refused
9 Don't know

Universe Text: Knowledgeable proxy is available
Skip Instructions:

(1-4) [goto AIDVERF_S]

AID.020_00.000

Instrument Variable Name: PROX3
Question Text:

*Ask if necessary.
Can a callback with someone knowledgeable about [fill: Sample Adult name]'s health be arranged?

1 Yes
2 No

Universe Text: Knowledgeable proxy is not available
Skip Instructions:

(1) [goto callbk.ACALLBK1]
(2) [store (3) in ASTAT]
[if recontact.RCIFLAG () 1]
[goto recontact.RCI_BEGIN procedure]
[else]
[goto back.OUTCOMEB1 procedure]
[endif]

AID.030_00.000

Instrument Variable Name: AIDVERF_S
Question Text:

*Please verify the following information about the sample adult before proceeding:
I have recorded your sex as [fill: Sex of Sample Adult]. Is this correct?
*If respondent "refuses" or says "don't know", enter "1" for "yes".

1 Yes
2 No

Universe Text: Sample adult is not the person entered in HHRESP or RELRESP_A Or PROX1 = 'Yes'
Skip Instructions:

(1) [goto AIDVERF_A]
(2) [goto AIDSEX]

[p. 3]

AID.040_00.000

Instrument Variable Name: AIDSEX
Question Text:

*Ask if appropriate; otherwise, enter your best guess of the person's sex.
Are you Male or Female?

1 Male
2 Female

Universe Text: Respondent said his/her sex is not correct
Skip Instructions:

(1,2) [store AIDSEX in SEX]
[goto ERR_AIDSEX]
[reset AIDVERF_S]
[goto AIDVERF_S]

AID.045_00.000

Instrument Variable Name: AIDVERF_A
Question Text:

*Please verify the following information about the sample adult before proceeding:
I have recorded your age as [fill: Age of Sample Adult] old. Is this correct?
*If respondent "refuses" or says "don't know", enter "1" for "yes".

1 Yes
2 No

Universe Text: Sample adult said his/her sex is correct
Skip Instructions:

(1) [goto AIDVERF_D]
(2) [goto AIDAGE]

AID.050_00.000

Instrument Variable Name: AIDAGE
Question Text:

How old are you?

000-120 Age in years
997 Refused
999 Don't know

Universe Text: Respondent said his/her age is not correct
Skip Instructions:

(0-120, Refused, Don't know)
[if AIDAGE = Refused or AIDAGE = Don't know or AIDAGE = AGE]
[reset AIDVERF_A]
[goto ERR_AIDAGE]
[else]
[store AIDAGE in AGE]
[goto AIDDOB_M]

[p. 4]

AID.055_00.000

Instrument Variable Name: AIDVERF_D
Question Text:

*Please verify the following information about the sample adult before proceeding:
I have recorded your birthday as [fill: Birthday of Sample Adult]. Is this correct?
*If respondent "refuses" or says "don't know", enter "1" for "yes".

1 Yes
2 No

Universe Text: Sample adult said his/her age is correct
Skip Instructions:

Do not allow "Don't Know" or "Refused" as an answer.
(1) [if AGE of Sample Adult le (17)]
[goto NO_MORE]
[else]
[goto beginning of adult.asd]
[endif]
(2) [goto AIDDOB_M]

AID.060_01.000

Instrument Variable Name: AIDDOB_M
Question Text:

1 of 3
What is your birthday?
*Enter month of birth.

01 January
02 February
03 March
04 April
05 May
06 June
07 July
08 August
09 September
10 October
11 November
12 December
97 Refused
99 Don't know

Universe Text: Respondent said his/her date of birth is not correct or his/her age is not correct
Skip Instructions:

(01-12, Refused, Don't know) [goto AIDDOB_D]

[p. 5]

AID.060_02.000

Instrument Variable Name: AIDDOB_D
Question Text:

2 of 3
*Enter day of birth.

01-31 Day of the month
97 Refused
99 Don't know

Universe Text: Respondent said his/her date of birth is not correct or his/her age is not correct
Skip Instructions:

(01-31,Refused,Don't know) [goto AIDDOB_Y]
If days not valid, goto ERR_AIDDOB_D

AID.060_03.000

Instrument Variable Name: AIDDOB_Y
Question Text:

3 of 3
*Enter year of birth.

1880-2020 Year of Birth

Universe Text: Respondent said his/her date of birth is not correct or his/her age is not correct
Skip Instructions:

(1880-2020, Refused, Don't know) if AIDVERF_A = No then reset AIDVERF_A to empty
goto AIDVERF_A_
elseif AIDVERF_D = No then reset AIDVERF_D to empty
goto AIDVERF_D
endif
(if year GT current year) or (if year = current year and month GT current month) or (if year = current year and month = current month and day GT current day)
goto ERR1_AIDDOB_Y
endif
(if birth month = (02) and birth day = (29) and this is not a leap year)
goto ERR2_AIDDOB_Y
endif
(if AIDDOB_M = Ref or DK) or (if AIDDOB_D = Ref or DK) or (if AIDDOB_Y = Ref or DK)
goto ERR3_AIDDOB_Y
else
store AIDDOB_M in DOBM
store AIDDOB_D in DOBD
store AIDDOB_Y in DOBY
if AIDVERF_A = No then reset AIDVERF_A to empty
goto AIDVERF_A
elseif AIDVERF_D = No then reset AIDVERF_D to empty
goto AIDVERF_D
endif
endif
Calculate age from AIDDOB_M, AIDDOB_D, and AIDDOB_Y.
if age from AIDDOB items is ne AGE and age from AIDDOB items is valid reset AIDVERF_A or AIDVERF_D.
goto ERR4_AIDDOB_Y
endif

[p. 1]

2004 NHIS Questionnaire - Sample Adult
Adult Socio-Demographic

ASD.050_00.000

Instrument Variable Name: WRKVER
Question Text:

Earlier I recorded that in the last week you were
(Fill1: working for pay at a job or business.)
(Fill2: with a job or business but not at work.)
(Fill3: looking for work.)
(Fill4: working, but not for pay, at a family-owned job or business.)
(Fill5: not working at a job or business and not looking for work.)
Is that correct?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who were working or not working last week
Skip Instructions:

(1)if DOINGLW2 = 1,2,4 [goto WHOWRK]
else if DOINGLW2 = 3,5 [goto EVERWRK]
(2)[go to WRKCOR]
(R,D)go to EVERWRK

ASD.060_00.000

Instrument Variable Name: WRKCOR
Question Text:

? [F1]
What is your correct working status?
*Read answer categories.

1 Working for pay at a job or business
2 With a job or business but not at work
3 Looking for work
4 Working, but not for pay, at a family-owned job or business
5 Not working at a job or business and not looking for work
7 Refused
9 Don't know

Universe Text: Sample adults 18+ whose working status was incorrect or who were not the Family Respondent and with an answer of D or R to DOINGLW
Skip Instructions:

(1,4) [goto to WHOWRK]
(2,5) [goto WHYNOWK2]
(3,R,D) [goto EVERWRK]

[p. 2]

ASD.062_00.000

Instrument Variable Name: DOINGLW2
Question Text:

Corrected Employment Status Last Week: (not displayed)

Universe Text: Sample adults 18+ and also the family section respondent and said Refused or Don't know to the working last week status question in the family section
Skip Instructions:

if DOINGLW2 = Refused or Don't know then
[goto EVERWRK]
endif

ASD.065_00.000

Instrument Variable Name: WHYNOWK2
Question Text:

(Fill1: What is the main reason you did not work last week?)
(Fill2: What is the main reason you did not have a job or business last week?)

01 Taking care of house or family
02 Going to school
03 Retired
04 On a planned vacation from work
05 On family or maternity leave
06 Temporarily unable to work for health reasons
07 Have job/contract and off-season
08 On layoff
09 Disabled
10 Other
97 Refused
99 Don't know

Universe Text: Sample adults 18+ whose corrected working status last week was not working at a job or business and not looking for work or with a job or business but not at work
Skip Instructions:

(1-10,R,D) if WRKCOR = 2 then
[goto WHOWRK]
else [goto EVERWRK]

[p. 3]

ASD.066_00.000

Instrument Variable Name: EVERWRK
Question Text:

Have you ever held a job or worked at a business?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who were NOT working at a job or business and not looking for work or looking for work last week or didn't know or refused to provide their employment status last week
Skip Instructions:

(1) go to WHOWRK
(2,R,D) [goto next section]

ASD.070_00.000

Instrument Variable Name: WHOWRK
Question Text:

? [F1]
(Fill1:For whom did you work at your MAIN job or business? (Name of company, business, organization or employer))
(Fill2: Thinking about the job you held the longest, for whom did you work? (Name of company, business, organization or employer))
(Fill3: Thinking about the job you held most recently, for whom did you work? (Name of company, business, organization or employer))

7 Refused
9 Don't know
Verbatim Verbatim Response

Universe Text: Sample adults 18+ who were working last week, or who were with a job or business but not at work, or who were working but not for pay at a family-owned job or business, or who have ever worked
Skip Instructions:

(90 char long,R,D) [goto KINDIND]

ASD.080_00.000

Instrument Variable Name: KINDIND
Question Text:

? [F1]
What kind of business or industry was this? (For example: TV and radio mgt., retail shoe store, State Department of Labor)

7 Refused
9 Don't know
Verbatim Verbatim Response

(90 char long,R,D) [goto KINDWRK]

[p. 4]

ASD.090_00.000

Instrument Variable Name: KINDWRK
Question Text:

? [F1]
What kind of work were you doing? (For example: farming, mail clerk, computer specialist.)

7 Refused
9 Don't know
Verbatim Verbatim Response

(90 char long,R,D) [goto IMPACT]

ASD.100_00.000

Instrument Variable Name: IMPACT
Question Text:

? [F1]
What were your most important activities on this job or business? (For example: sells cars, keeps account books, operates printing press.)

7 Refused
9 Don't know
Verbatim Verbatim Response

(90 char long,R,D) [goto WRKCAT]

ASD.110_00.000

Instrument Variable Name: WRKCAT
Question Text:

(book) A1 ? [F1]
(Fill1: Looking at the card, which of these best describes your current job or work situation?)
(Fill2: Looking at the card, which of these best describes the job you held for the longest time?)
(Fill3: Looking at the card, which of these best describes the job you held most recently?)
*Read answer choices if necessary.

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 a family-owned business or farm
7 Refused
9 Don't know

Card A1

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-owned business or farm

(1-4,6,R,D) [goto LOCALLNO]
(5) [goto BUSINC]

[p. 5]

ASD.112_00.000

Instrument Variable Name: BUSINC
Question Text:

Is this business incorporated?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who are self-employed
Skip Instructions:

(1,2,R,D) [goto LOCALLNO]

ASD.120_00.000

Instrument Variable Name: LOCALLNO
Question Text:

(book) A2
Thinking about
(Fill1: this MAIN job or business)
(Fill2: your last week at the job you held the longest)
(Fill3: your last week at the job you held most recently)
how many people (Fill4:work/worked) at this location?
*"People" includes both FULL- and PART-time employees; "location" refers to the street address of the workplace.

01 1-9 employees
02 10-24 employees
03 25-49 employees
04 50-99 employees
05 100-249employees
06 250-499employees
07 500-999employees
08 1000 employees or more
97 Refused
99 Don't know

Card A2

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

Skip Instructions:

(1-8, R,D) [goto WRKLONGN]

[p. 6]

ASD.140_01.000

Instrument Variable Name: WRKLONGN
Question Text:

? [F1]
1 of 2
About how long
(Fill1: have you worked at this MAIN job or business?)
(Fill2: did you work at the job you held the longest?)
(Fill3: did you work at the job you held most recently?)
*Enter number.

001-365 1-365
997 Refused
999 Don't know

(1-365) [goto WRKLONGT]
(R,D) [goto HOURPD if EVERWRK eq 1 and (WHYNOWK2 eq 03 or AGE GE 65);
else goto WRKLONGH]

ASD.140_02.000

Instrument Variable Name: WRKLONGT
Question Text:

2 of 2
*Enter time period.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)

Universe Text: Sample adults 18+ (who were working last week, or who were with a job or business but not at work, or who were working but not for pay at a family-owned job or business, or who have ever worked) and who gave a number entry in WRKLONGN
Skip Instructions:

(1-4) if EVERWRK = 1 and (WHYNOWK2 = 3 or AGE ge 65) then
[goto HOURPD]_
else [goto WRKLONGH]
(4) if WRKLONGN gt AGE then
[goto ERR_WRKLONGT]

[p. 7]

ASD.146_00.000

Instrument Variable Name: WRKLONGH
Question Text:

? [F1]
(Fill1: Is this MAIN job or business the job you have held for the longest?)
(Fill2: Was your most recently held job also the job you held the longest?)

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ (who were working last week, or who were with a job or business but not at work, or who were working but not for pay at a family-owned job or business,) or (who have ever worked and are not retired and are less than 65 years of age.)
Skip Instructions:

(1,2,R,D) [goto HOURPD]

ASD.150_00.000

Instrument Variable Name: HOURPD
Question Text:

(Fill1: Are you paid by the hour at this MAIN job or business?)
(Fill2: Were you paid by the hour on the job you held the longest?)
(Fill3: Were you paid by the hour on the job you held most recently?)

1 Yes
2 No
7 Refused
9 Don't know

(1,2,R,D) [goto PDSICK]

ASD.160_00.000

Instrument Variable Name: PDSICK
Question Text:

(Fill1: Do you have paid sick leave on this MAIN job or business?
(Fill2: Did you ever have paid sick leave on the job you held the longest?
(Fill3: Did you ever have paid sick leave on the job you held most recently?

1 Yes
2 No
7 Refused
9 Don't know

(1,2,R,D) if DOINGLW2 = 1,2,4 then [goto ONEJOB]; else [goto next section]

[p. 8]

ASD.170_00.000

Instrument Variable Name: ONEJOB
Question Text:

Do you have more than one job or business?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who were working last week, or who were with a job or business but not at work, or who were working but not for pay at a family-owned job or business
Skip Instructions:

(1,2,R,D) [goto next section]

[p. 1]

2004 NHIS Questionnaire - Sample Adult
Adult Conditions

ACN.010_00.000

Instrument Variable Name: HYPEV
Question Text:

Now I am going to ask you about certain medical conditions.
Have you EVER been told by a doctor or other health professional that you had
...Hypertension, also called high blood pressure?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1) [goto HYPDIFV]
(2,R,D) [goto CHDEV]

ACN.020_00.000

Instrument Variable Name: HYPDIFV
Question Text:

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

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who were told they had hypertension
Skip Instructions:

(1,2,R,D) [goto CHDEV]

ACN.031_01.000

Instrument Variable Name: CHDEV
Question Text:

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

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D) [goto ANGEV]

[p. 2]

ACN.031_02.000

Instrument Variable Name: ANGEV
Question Text:

*Read lead-in if necessary:
Have you EVER been told by a doctor or other health professional that you had
...Angina, also called angina pectoris?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D) [goto MIEV]

ACN.031_03.000

Instrument Variable Name: MIEV
Question Text:

*Read lead-in if necessary:
Have you EVER been told by a doctor or other health professional that you had
...A heart attack (also called myocardial infarction)?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D) [goto HRTEV]

ACN.031_04.000

Instrument Variable Name: HRTEV
Question Text:

*Read lead-in if necessary:
Have you EVER been told by a doctor or other health professional that you had
...Any kind of heart condition or heart disease (other than the ones I just asked about)?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D) [goto STREV]

[p. 3]

ACN.031_05.000

Instrument Variable Name: STREV
Question Text:

*Read lead-in if necessary:
Have you EVER been told by a doctor or other health professional that you had
...A stroke?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D) [goto EPHEV]

ACN.031_06.000

Instrument Variable Name: EPHEV
Question Text:

*Read lead-in if necessary:
Have you EVER been told by a doctor or other health professional that you had
...Emphysema?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D) [goto AASMEV]

ACN.080_00.000

Instrument Variable Name: AASMEV
Question Text:

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

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1) [goto AASSTILL]
(2,R,D) [goto ULCEV]

[p. 4]

ACN.085_00.000

Instrument Variable Name: AASSTILL
Question Text:

Do you still have asthma?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who were ever told they have asthma
Skip Instructions:

(1,2,R,D) [go to AASMYR]

ACN.090_00.000

Instrument Variable Name: AASMYR
Question Text:

DURING THE PAST 12 MONTHS, have you had an episode of asthma or an asthma attack?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who were ever told they had asthma
Skip Instructions:

(1) [goto AASMERYR]
(2,R,D) [go to ULCEV]

ACN.100_00.000

Instrument Variable Name: AASMERYR
Question Text:

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

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ with asthma episode/attack in past 12 months
Skip Instructions:

(1,2,R,D) [goto ULCEV]

ACN.110_00.000

Instrument Variable Name: ULCEV
Question Text:

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.

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1) [goto ULCYR]_
(2,R,D)[goto CANEV]

[p. 5]

ACN.120_00.000

Instrument Variable Name: ULCYR
Question Text:

DURING THE PAST 12 MONTHS have you had an ulcer?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who were ever told they had an ulcer
Skip Instructions:

(1,2,R,D) [goto CANEV]

ACN.130_00.000

Instrument Variable Name: CANEV
Question Text:

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

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1) [goto CANKIND_1]
(2,R,D) [goto DIBEV]

[p. 6]

ACN.140_00.001

Instrument Variable Name: CANKIND_1
Question Text:

What kind of cancer was it?
*Enter code for the first kind of cancer.

01 Bladder
02 Blood
03 Bone
04 Brain
05 Breast
06 Cervix
07 Colon
08 Esophagus
09 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
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who were ever told they had cancer
Skip Instructions:

(1-30,R,D)[goto CANAGE_1]
IF SEX=1 (MALE) and No. (6,18,29) selected goto ERR1_CANKIND_1
IF SEX=2 (FEMALE) and No. (20,26) selected goto ERR2_CANKIND_1

ACN.140_00.002

Instrument Variable Name: CANKIND_2
Question Text:

*Enter code for the second kind of cancer.
*Enter '96' for no more.

Universe Text: Sample adults 18+ who either provided an age for one kind of cancer or didn't know how old they were when first diagnosed with that kind of cancer or else refused to provide an age but had not refused to answer CANKIND_1.
Skip Instructions:

(1-30,R,D)[goto CANAGE_2]
(96) goto DIBEV
IF SEX=1 (MALE) and No. (6,18,29) selected goto ERR1_CANKIND_2
IF SEX=2 (FEMALE) and No. (20,26) selected goto ERR2_CANKIND_2

ACN.140_00.003

Instrument Variable Name: CANKIND_3
Question Text:

*Enter code for the third kind of cancer.
*Enter '96' for no more.

Universe Text: Sample adults 18+ who either provided an age for a second kind of cancer or didn't know how old they were when first diagnosed that kind of cancer or else refused to provide an age but had not refused to answer CANKIND_2.
Skip Instructions:

(1-30,R,D)[goto CANAGE_3]
(96) [goto DIBEV]
IF SEX=1 (MALE) and No. (6,18,29) selected goto ERR1_CANKIND_3
IF SEX=2 (FEMALE) and No. (20,26) selected goto ERR2_CANKIND_3

ACN.140_00.004

Instrument Variable Name: CANKIND_4
Question Text:

*Enter '95' if respondent offers more than 3 kinds of cancer.
*Enter '96' for no more.

95 More than three kinds
96 No more

Universe Text: Sample adults 18+ who either provided an age for a third kind of cancer or didn't know how old they were when first diagnosed that kind of cancer or else refused to provide an age but had not refused to answer CANKIND_3
Skip Instructions:

(95,96) [goto DIBEV]

ACN.150_00.001

Instrument Variable Name: CANAGE_1
Question Text:

How old were you when [fill: CANKIND_1 /this cancer] was first diagnosed?

001-100 1-100 years
997 Refused
999 Don't know

Universe Text: Sample adults 18+ who were ever told they had cancer
Skip Instructions:

(1-100, D) [goto CANKIND_2]
(R) and (R) at CANKIND_1 [goto DIBEV]
(R) and CANKIND_1 NE (R) [goto CANKIND_2]
If number in CANAGE_1 greater than person years old (AGE) goto ERR_ CANAGE_1

ACN.150_00.002

Instrument Variable Name: CANAGE_2
Question Text:

How old were you when [fill: CANKIND_2/this cancer] was first diagnosed?

001-100 1-100 years
997 Refused
999 Don't know

Universe Text: Sample adults 18+ who were ever told they had cancer
Skip Instructions:

(1-100, D) [goto CANKIND_3]
(R) and (R) at CANKIND_2 [goto DIBEV]
(R) and CANKIND_2 NE (R) [goto CANKIND_3]
If number in CANAGE_2 greater than person years old (AGE) goto ERR_ CANAGE_2

ACN.150_00.003

Instrument Variable Name: CANAGE_3
Question Text:

How old were you when [fill: CANKIND_3/this cancer ] was first diagnosed?

001-100 1-100 years
997 Refused
999 Don't know

Universe Text: Sample adults 18+ who were ever told they had cancer
Skip Instructions:

(1-100, D) [goto CANKIND_4]
(R) and (R) at CANKIND_3 [goto DIBEV]
(R) and CANKIND_3 NE (R) [goto CANKIND_4]
If number in CANAGE_3 greater than person years old (AGE) goto ERR_ CANAGE_3

ACN.160_00.000

Instrument Variable Name: DIBEV
Question Text:

[fill: Other than during pregnancy, have you EVER been told by a doctor or health professional that you have diabetes or sugar diabetes?/Have you EVER been told by a doctor or health professional that you have diabetes or sugar diabetes?]

1 Yes
2 No
3 Borderline
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1) [goto DIBAGE]
(2,3,R,D) [goto AHAYFYR]

ACN.170_00.000

Instrument Variable Name: DIBAGE
Question Text:

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

01-84 1-84 years
85 85+ years
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who were told they had diabetes or sugar diabetes (other than during pregnancy)
Skip Instructions:

(1-100 R,D) [goto INSLN]
If number in DIBAGE greater than person years old (AGE) goto ERR_ DIBAGE
Note: Age is collected as 1-100 in the instrument and later top coded to 1-84 and 85+ years

[p. 11]

ACN.180_00.000

Instrument Variable Name: INSLN
Question Text:

Are you NOW taking insulin?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who were told they had diabetes or sugar diabetes (other than during pregnancy)
Skip Instructions:

(1,2,R,D) [goto DIBPILL]

ACN.190_00.000

Instrument Variable Name: DIBPILL
Question Text:

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

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who were told they had diabetes or sugar diabetes (other than during pregnancy)
Skip Instructions:

(1,2,R,D) [goto AHAYFYR]

ACN.201_01.000

Instrument Variable Name: AHAYFYR
Question Text:

DURING THE PAST 12 MONTHS, have you been told by a doctor or other health professional that you had
...Hay fever?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D) [goto SINYR]

[p. 12]

ACN.201_02.000

Instrument Variable Name: SINYR
Question Text:

*Read lead-in if necessary:
DURING THE PAST 12 MONTHS, have you been told by a doctor or other health professional that you had
...Sinusitis?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D) [goto CBRCHYR]

ACN.201_03.000

Instrument Variable Name: CBRCHYR
Question Text:

*Read lead-in if necessary:
DURING THE PAST 12 MONTHS, have you been told by a doctor or other health professional that you had
...Chronic bronchitis?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D) [goto KIDWKYR]

ACN.201_04.000

Instrument Variable Name: KIDWKYR
Question Text:

*Read lead-in if necessary:
DURING THE PAST 12 MONTHS, have you been told by a doctor or other health professional that you had
......Weak or failing kidneys? - Do not include kidney stones, bladder infections or incontinence.

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D) [goto LIVYR]

[p. 13]

ACN.201_05.000

Instrument Variable Name: LIVYR
Question Text:

*Read lead-in if necessary:
DURING THE PAST 12 MONTHS, have you been told by a doctor or other health professional that you had
......Any kind of liver condition?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D) [goto JNTSYMP]

ACN.250_00.000

Instrument Variable Name: JNTSYMP
Question Text:

The next questions refer to your joints. Please do NOT include the back or neck. DURING THE PAST 30 DAYS, have you had any symptoms of pain, aching, or stiffness in or around a joint?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1) [goto JMTHP]
(2,R,D) [goto ARTH]

[p. 14]

ACN.260_00.000

Instrument Variable Name: JMTHP
Question Text:

(book) A3
Which joints are affected?
*Enter all that apply, separate with commas.

01 Shoulder-right
02 Shoulder-left
03 Elbow-right
04 Elbow-left
05 Hip-right
06 Hip-left
07 Wrist-right
08 Wrist-left
09 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 Don't know

[Flashcard A3 shows a figure of the body (front and back) with different body parts labeled.]
Card A3
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
You may choose more than one.

Universe Text: Sample adults 18+ who had joint pain in the past 30 days
Skip Instructions:

(1-17,R,D) [goto JNTCHR]

ACN.270_00.000

Instrument Variable Name: JNTCHR
Question Text:

Did your joint symptoms FIRST begin more than 3 months ago?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ with joint pain
Skip Instructions:

(1,2,R,D) [goto JNTHP]

[p. 15]

ACN.280_00.000

Instrument Variable Name: JNTHP
Question Text:

Have you EVER seen a doctor or other health professional for these joint symptoms?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ with joint pain
Skip Instructions:

(1,2,R,D) [goto ARTH]

ACN.290_00.000

Instrument Variable Name: ARTH
Question Text:

Have you EVER been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia (fy-bro-my-AL-jee-uh)?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

If ARTH eq (1) or JNTSYMP eq (1) goto ARTHLMT; else [goto PAINECK]

ACN.295_00.000

Instrument Variable Name: ARTHLMT
Question Text:

Are you now limited in any way in any of your usual activities because of arthritis or joint symptoms?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ with joint pain or arthritis
Skip Instructions:

(1,2,R,D) [goto PAINECK]

[p. 16]

ACN.300_00.000

Instrument Variable Name: PAINECK
Question Text:

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

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D) [goto PAINLB]

ACN.310_00.000

Instrument Variable Name: PAINLB
Question Text:

*Read lead-in if necessary.
During the PAST THREE MONTHS, did you have
... Low back pain?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1) [goto PAINLEG]
(2,R,D) [goto PAINFACE]

ACN.320_00.000

Instrument Variable Name: PAINLEG
Question Text:

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

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ with low back pain in the past 3 months
Skip Instructions:

(1,2,R,D) [goto PAINFACE]

[p. 17]

ACN.331_01.000

Instrument Variable Name: PAINFACE
Question Text:

During the PAST THREE MONTHS, did you have
... Facial ache or pain in the jaw muscles or the joint in front of the ear?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D) [goto AMIGR]

ACN.331_02.000

Instrument Variable Name: AMIGR
Question Text:

*Read lead-in if neccesary:
During the PAST THREE MONTHS, did you have
...Severe headache or migraine?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D)[goto ACOLD2W]

ACN.350_00.000

Instrument Variable Name: ACOLD2W
Question Text:

*Hand calendar card
These next questions are about your recent health during the TWO WEEKS outlined on that calendar.
Did you have a head cold or chest cold that started during those TWO WEEKS?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D) [goto AINTIL2W]

ACN.360_00.000

Instrument Variable Name: AINTIL2W
Question Text:

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

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D) if SEX=2 and AGE 18-49 [goto PREGNOW]; else [goto HEARAID]

ACN.370_00.000

Instrument Variable Name: PREGNOW
Question Text:

Are you currently pregnant?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Female sample adults 18-49 years of age
Skip Instructions:

(1,2,R,D) [goto HEARAID]

ACN.410_00.000

Instrument Variable Name: HEARAID
Question Text:

These next questions are about your hearing, vision and teeth.
Have you ever worn a hearing aid?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D) [goto AHEARST]

[p. 19]

ACN.420_00.000

Instrument Variable Name: AHEARST
Question Text:

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

1 Good
2 A little trouble
3 A lot of trouble
4 Deaf
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D) [goto AVISION]

ACN.430_00.000

Instrument Variable Name: AVISION
Question Text:

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

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1) [goto ABLIND]
(2,R,D) [goto LUPPRT]

ACN.440_00.000

Instrument Variable Name: ABLIND
Question Text:

Are you blind or unable to see at all?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who have trouble seeing even when wearing glasses/contact lenses
Skip Instructions:

(1,2,R,D) [goto LUPPRT]

[p. 20]

ACN.451_00.000

Instrument Variable Name: LUPPRT
Question Text:

Have you lost all of your upper and lower natural (permanent) teeth?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D)[goto MHSAD_CK]

ACN.470_00.000

Instrument Variable Name: MHSAD_CK
Question Text:

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

1 Enter 1 to continue

Universe Text: Sample adults 18+
Skip Instructions:

(1) [goto SAD]

ACN.471_01.000

Instrument Variable Name: SAD
Question Text:

(book) A4.
During the PAST 30 DAYS, how often did you feel
...So sad that nothing could cheer you up?

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 Don't know

Card A4

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

Universe Text: Sample adults 18+
Skip Instructions:

(1-5,R,D) [goto NERVOUS]

[p. 21]

ACN.471_02.000

Instrument Variable Name: NERVOUS
Question Text:

(book) A4.
*Read lead-in if necessary:
During the PAST 30 DAYS, how often did you feel
...Nervous?

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 Don't know

Card A4

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

Universe Text: Sample adults 18+
Skip Instructions:

(1-5,R,D) [goto RESTLESS]

ACN.471_03.000

Instrument Variable Name: RESTLESS
Question Text:

(book) A4.
*Read lead-in if necessary:
During the PAST 30 DAYS, how often did you feel
... Restless or fidgety?

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 Don't know

Card A4

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

Universe Text: Sample adults 18+
Skip Instructions:

(1-5,R,D) [goto HOPELESS]

[p. 22]

ACN.471_04.000

Instrument Variable Name: HOPELESS
Question Text:

(book) A4.
*Read lead-in if necessary:
During the PAST 30 DAYS, how often did you feel
... Hopeless?

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 Don't know

Card A4

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

Universe Text: Sample adults 18+
Skip Instructions:

(1-5,R,D) [goto EFFORT]

ACN.471_05.000

Instrument Variable Name: EFFORT
Question Text:

(book) A4.
*Read lead-in if necessary:
During the PAST 30 DAYS, how often did you feel
...That everything was an effort?

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 Don't know

Card A4

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

Universe Text: Sample adults 18+
Skip Instructions:

(1-5,R,D) [goto WORTHLS]

[p. 23]

ACN.471_06.000

Instrument Variable Name: WORTHLS
Question Text:

(book) A4.
*Read lead-in if necessary:
During the PAST 30 DAYS, how often did you feel
...Worthless?

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 Don't know

Card A4

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

Universe Text: Sample adults 18+
Skip Instructions:

If SAD eq (1-3) or NERVOUS eq (1-3) or RESTLESS eq (1-3) or HOPELESS eq (1-3) or EFFORT eq (1-3) or WORTHLS eq (1-3) [goto MHAMTMO]; else [goto next section]

ACN.530_00.000

Instrument Variable Name: MHAMTMO
Question Text:

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?

1 A lot
2 Some
3 A little
4 Not at all
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who at least some of the time have felt sad, nervous, restless or fidgety, hopeless, that everything was an effort, or worthless, in the past 30 days
Skip Instructions:

(1-4,R,D) [go to next section]

[p. 1]

2004 NHIS Questionnaire - Sample Adult
Adult Health Status and Limitations

AHS.030_00.000

Instrument Variable Name: WRKLYR2
Question Text:

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

0 Had job last week
1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who were looking for work or who were not working at a job or business AND who were not looking for work in the last week
Skip Instructions:

(1) [goto WKDAYR]
(2,R,D) [goto BEDDAYR]

AHS.040_00.000

Instrument Variable Name: WKDAYR
Question Text:

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)?
*Enter '0' for None.

000 None
001-366 1-366 days
997 Refused
999 Don't know

Universe Text: Sample adults 18+ who worked or had a job or business with or without pay in the last week or who had a job or business in the past 12 months
Skip Instructions:

(0-366,R,D) [goto BEDDAYR]
(120-366) [goto ERR_WKDAYR]

AHS.050_00.000

Instrument Variable Name: BEDDAYR
Question Text:

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)?
*Enter '0' for None.

000 None
001-366 1-366 days
997 Refused
999 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(0-366,R,D) [goto AHSTATYR]
(120-366) [goto ERR_BEDDAYR]

[p. 2]

AHS.060_00.000

Instrument Variable Name: AHSTATYR
Question Text:

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

1 Better
2 Worse
3 About the same
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1-3,R,D) [goto SPECEQ]

AHS.070_00.000

Instrument Variable Name: SPECEQ
Question Text:

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?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D) [goto FLWALK]

AHS.091_01.000

Instrument Variable Name: FLWALK
Question Text:

(book) A5
By yourself, and without using any special equipment, how difficult is it for you to...
...Walk a quarter of a mile - about 3 city blocks?

0 Not at all difficult
1 Only a little difficult
2 Somewhat difficult
3 Very difficult
4 Can't do at all
6 Do not do this activity
7 Refused
9 Don't know

Card A5

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

Universe Text: Sample adults 18+
Skip Instructions:

(0-4,6,R,D) [goto FLCLIMB]

[p. 3]

AHS.091_02.000

Instrument Variable Name: FLCLIMB
Question Text:

(book) A5
*Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you to...
...Walk up 10 steps without resting?

0 Not at all difficult
1 Only a little difficult
2 Somewhat difficult
3 Very difficult
4 Can't do at all
6 Do not do this activity
7 Refused
9 Don't know

Card A5

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

Universe Text: Sample adults 18+
Skip Instructions:

(0-4,6,R,D) [goto FLSTAND]

AHS.091_03.000

Instrument Variable Name: FLSTAND
Question Text:

(book) A5
*Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you to...
...Stand or be on your feet for about 2 hours?

0 Not at all difficult
1 Only a little difficult
2 Somewhat difficult
3 Very difficult
4 Can't do at all
6 Do not do this activity
7 Refused
9 Don't know

Card A5

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

Universe Text: Sample adults 18+
Skip Instructions:

(0-4,6,R,D) [goto FLSIT]

[p. 4]

AHS.091_04.000

Instrument Variable Name: FLSIT
Question Text:

(book) A5
*Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you to...
...Sit for about 2 hours?

0 Not at all difficult
1 Only a little difficult
2 Somewhat difficult
3 Very difficult
4 Can't do at all
6 Do not do this activity
7 Refused
9 Don't know

Card A5

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

Universe Text: Sample adults 18+
Skip Instructions:

(0-4,6,R,D) [goto FLSTOOP]

AHS.091_05.000

Instrument Variable Name: FLSTOOP
Question Text:

(book) A5
*Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you to...
...Stoop, bend, or kneel?

0 Not at all difficult
1 Only a little difficult
2 Somewhat difficult
3 Very difficult
4 Can't do at all
6 Do not do this activity
7 Refused
9 Don't know

Card A5

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

Universe Text: Sample adults 18+
Skip Instructions:

(0-4,6,R,D) [goto FLREACH]

[p. 5]

AHS.091_06.000

Instrument Variable Name: FLREACH
Question Text:

(book) A5
*Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you to...
...Reach up over your head?

0 Not at all difficult
1 Only a little difficult
2 Somewhat difficult
3 Very difficult
4 Can't do at all
6 Do not do this activity
7 Refused
9 Don't know

Card A5

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

Universe Text: Sample adults 18+
Skip Instructions:

(0-4,6,R,D) [goto FLGRASP]

AHS.141_01.000

Instrument Variable Name: FLGRASP
Question Text:

(book) A5
*Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you to...
...Use your fingers to grasp or handle small objects?

0 Not at all difficult
1 Only a little difficult
2 Somewhat difficult
3 Very difficult
4 Can't do at all
6 Do not do this activity
7 Refused
9 Don't know

Card A5

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

Universe Text: Sample adults 18+
Skip Instructions:

(0-4,6,R,D) [goto FLCARRY]

[p. 6]

AHS.141_02.000

Instrument Variable Name: FLCARRY
Question Text:

(book) A5
*Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you to...
...Lift or carry something as heavy as 10 pounds such as a full bag of groceries?

0 Not at all difficult
1 Only a little difficult
2 Somewhat difficult
3 Very difficult
4 Can't do at all
6 Do not do this activity
7 Refused
9 Don't know

Card A5

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

Universe Text: Sample adults 18+
Skip Instructions:

(0-4,6,R,D) [goto FLPUSH]

AHS.141_03.000

Instrument Variable Name: FLPUSH
Question Text:

(book) A5
*Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you to...
...Push or pull large objects like a living room chair?

0 Not at all difficult
1 Only a little difficult
2 Somewhat difficult
3 Very difficult
4 Can't do at all
6 Do not do this activity
7 Refused
9 Don't know

Card A5

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

Universe Text: Sample adults 18+
Skip Instructions:

(0-4,6,R,D) [goto FLSHOP]

[p. 7]

AHS.171_01.000

Instrument Variable Name: FLSHOP
Question Text:

(book) A5
*Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you to...
...Go out to things like shopping, movies, or sporting events?

0 Not at all difficult
1 Only a little difficult
2 Somewhat difficult
3 Very difficult
4 Can't do at all
6 Do not do this activity
7 Refused
9 Don't know

Card A5

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

Universe Text: Sample adults 18+
Skip Instructions:

(0-4,6,R,D) [goto FLSOCL]

AHS.171_02.000

Instrument Variable Name: FLSOCL
Question Text:

(book) A5
*Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you to...
...Participate in social activities such as visiting friends, attending clubs and meetings, going to parties?

0 Not at all difficult
1 Only a little difficult
2 Somewhat difficult
3 Very difficult
4 Can't do at all
6 Do not do this activity
7 Refused
9 Don't know

Card A5

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

Universe Text: Sample adults 18+
Skip Instructions:

(0-4,6,R,D) [goto FLRELAX]

[p. 8]

AHS.171_03.000

Instrument Variable Name: FLRELAX
Question Text:

(book) A5
*Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you to...
...Do things to relax at home or for leisure (reading, watching TV, sewing, listening to music)?

0 Not at all difficult
1 Only a little difficult
2 Somewhat difficult
3 Very difficult
4 Can't do at all
6 Do not do this activity
7 Refused
9 Don't know

Card A5

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

Universe Text: Sample adults 18+
Skip Instructions:

(1-4 or FLWALK= 1-4 or FLCLIMB= 1-4 or FLSTAND= 1-4 or FLSIT= 1-4 or FLSTOOP= 1-4 or FLREACH= 1
4 or FLGRASP= 1-4 or FLCARRY= 1-4 or FLPUSH= 1-4 or FLSHOP= 1-4 or FLSOCL= 1-4)[goto AFLHCA]
Else goto SMKEV (next section)

[p. 9]

AHS.200_00.000

Instrument Variable Name: AFLHCA
Question Text:

(book) A6
What condition or health problem causes you to have difficulty with [fill1: condition 1, condition 2 or condition 3 (as specified in AHS.091_1 through AHS.171_3)][fill2: these activities]?
*Enter condition number for all that apply, separate with commas.
*Do not probe, except to clarify answer.

01 Vision/problem seeing
02 Hearing problem
03 Arthritis/rheumatism
04 Back or neck problem
05 Fracture, bone/joint injury
06 Other injury
07 Heart problem
08 Stroke problem
09 Hypertension/high blood pressure
10 Diabetes
11 Lung/breathing problem(e.g., asthma and emphysema)
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 Missing limbs (fingers, toes or digits), amputee
20 Kidney, bladder or renal problems
21 Circulation problems (including blood clots)
22 Benign Tumors, Cysts
23 Fibromyalgia, lupus
24 Osteoporosis, tendinitis
25 Epilepsy, seizures
26 Multiple Sclerosis (MS), Muscular Dystrophy (MD)
27 Polio(myelitis), paralysis, para/quadriplegia
28 Parkinson's disease, other tremors
29 Other nerve damage, including carpal tunnel syndrome
30 Hernia
31 Ulcer
32 Varicose veins, hemorrhoids
33 Thyroid problems, Grave's disease, gout
34 Knee problems (not arthritis (03), not joint injury(05))
35 Migraine headaches (not just headaches)
90 Other impairment/problem (Specify one)
91 Other impairment/problem (Specify one)
97 Refused
99 Don't know/Not sure

Card A6
You may choose more than one.

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 (e.g., asthma and emphysema)
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
Other impairment/problem

Universe Text: Sample adults 18+ who, without using special equipment, have at least a little difficulty walking a quarter mile; walking up 10 steps without resting; standing/being on feet for about 2 hours; sitting for about 2 hours; stooping/bending/kneeling; reaching up over head; using fingers to grasp/handle small objects; lifting/carrying 10 pounds; pushing/pulling large objects;going out for things (shopping/movies); participating in social activities; or relaxing at home (reading/sewing).

Skip Instructions:

[1- 12, 14 - 35] goto the appropriate follow up question AHCL01N-AHCL12N, AHCL14N-AHCL35N], in numerical order
(13) store "96" in AHCL13N and "6" IN AHCL13T[goto SMKEV ]
(90) [goto AFLHCA_S1]
(91) [goto AFLHCA_S2]
Roster through all AFLHCA entries. Once exhausted goto SMKEV (next section)
( R,D) [goto SMKEV (next section)]

AHS.201_90.000

Instrument Variable Name: AFLHCA_S1
Question Text:

*Enter other impairment/problem.

7 Refused
9 Don't know
Verbatim Verbatim Response

Universe Text: Sample adults 18+ whose difficulties performing activities listed in FLWALK through FLRELAX is due to at least one condition not listed in AFLHCA
Skip Instructions:

(50 chars)[goto AHCL90N]
)ENTER( only with no description [goto ERR1_AFLHCA_S1]
Else goto the appropriate follow-up questions AHCL01N-AHCL12N, AHCL14N-AHCL35N], in numerical order, as specified in AFLHCA

AHS.201_91.000

Instrument Variable Name: AFLHCA_S2
Question Text:

*Enter other impairment/problem.

7 Refused
9 Don't know
Verbatim Verbatim Response

Universe Text: Sample adults 18+ whose difficulty performing activities listed in FLWALK through FLRELAX is due to more than one condition that is not listed in AFLHCA
Skip Instructions:

(50 chars)[goto AHCL91N]
)ENTER( only with no description [goto ERR1_AFLHCA_S1]

[p. 11]

AHS.300_01.000

Instrument Variable Name: AHCL01N
Question Text:

1 of 2
How long have you had a vision problem or problem seeing?
*Enter number for time with your vision problem or problem seeing..
*Enter '95' for 95 or more.
*Enter '96' if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to a vision problem or problem seeing
Skip Instructions:

(1-95,D)[goto AHCL01T]
(R)[store "R" in AHCL01T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL01T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.300_02.000

Instrument Variable Name: AHCL01T
Question Text:

2 of 2
*Enter time period for time with vision problem or problem seeing.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL01T
[if [AHCL01N = Number greater than person years old and AHCL01T= 4]] goto
ERR1_AHCL01T

[p. 12]

AHS.301_01.000

Instrument Variable Name: AHCL02N
Question Text:

1 of 2
How long have you had a hearing problem?
*Enter number for time with a hearing problem.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to a hearing problem
Skip Instructions:

(1-95,D)[goto AHCL02T]
(R)[store "R" in AHCL02T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL02T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.301_02.000

Instrument Variable Name: AHCL02T
Question Text:

2 of 2
*Enter time period for time with hearing problem.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL02T
[if [AHCL02N = Number greater than person years old and AHCL02T= 4]] goto
ERR1_AHCL02T

[p. 13]

AHS.302_01.000

Instrument Variable Name: AHCL03N
Question Text:

1 of 2
How long have you had arthritis or rheumatism?
*Enter number for time with arthritis or rheumatism.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to arthritis or rheumatism
Skip Instructions:

(1-95,D)[goto AHCL03T]
(R)[store "R" in AHCL03T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL03T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.302_02.000

Instrument Variable Name: AHCL03T
Question Text:

2 of 2
*Enter time period for time with arthritis or rheumatism.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL03T
[if [AHCL03N = Number greater than person years old and AHCL03T= 4]] goto
ERR1_AHCL03T

[p. 14]

AHS.303_01.000

Instrument Variable Name: AHCL04N
Question Text:

1 of 2
How long have you had a back or neck problem?
*Enter number for time with back or neck problem.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to a back or neck problem
Skip Instructions:

(1-95,D)[goto AHCL04T]
(R)[store "R" in AHCL04T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL04T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.303_02.000

Instrument Variable Name: AHCL04T
Question Text:

2 of 2
*Enter time period for time with back or neck problem.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL04T
[if [AHCL04N = Number greater than person years old and AHCL04T= 4]] goto
ERR1_AHCL04T

[p. 15]

AHS.304_01.000

Instrument Variable Name: AHCL05N
Question Text:

1 of 2
How long have you had a fracture, bone, or joint injury?
*Enter number for time with a fracture, bone, or joint injury.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to a fracture, bone, or joint injury
Skip Instructions:

(1-95,D)[goto AHCL05T]
(R)[store "R" in AHCL05T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL05T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.304_02.000

Instrument Variable Name: AHCL05T
Question Text:

2 of 2
*Enter time period for time with fracture, bone, or joint injury.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL05T
[if [AHCL05N = Number greater than person years old and AHCL05T= 4]] goto
ERR1_AHCL05T

[p. 16]

AHS.305_01.000

Instrument Variable Name: AHCL06N
Question Text:

1 of 2
How long have you had the (fill: other) injury that caused your limitation?
*Enter number for time with injury that caused your limitation.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to an injury other than a fracture, bone, or joint injury
Skip Instructions:

(1-95,D)[goto AHCL06T]
(R)[store "R" in AHCL06T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL06T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.305_02.000

Instrument Variable Name: AHCL06T
Question Text:

2 of 2
*Enter time period for time with (fill: other) injury.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL06T
[if [AHCL06N = Number greater than person years old and AHCL06T= 4]] goto
ERR1_AHCL06T

[p. 17]

AHS.306_01.000

Instrument Variable Name: AHCL07N
Question Text:

1 of 2
How long have you had a heart problem?
*Enter number for time with a heart problem.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to a heart problem
Skip Instructions:

(1-95,D)[goto AHCL07T]
(R)[store "R" in AHCL07T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL07T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.306_02.000

Instrument Variable Name: AHCL07T
Question Text:

2 of 2
*Enter time period for time with heart problem.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL07T
[if [AHCL07N = Number greater than person years old and AHCL07T= 4]] goto
ERR1_AHCL07T

[p. 18]

AHS.307_01.000

Instrument Variable Name: AHCL08N
Question Text:

1 of 2
How long have you had a stroke problem?
*Enter number for time with a stroke problem.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to a stroke problem
Skip Instructions:

(1-95,D)[goto AHCL08T]
(R)[store "R" in AHCL08T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL08T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.307_02.000

Instrument Variable Name: AHCL08T
Question Text:

2 of 2
*Enter time period for time with stroke problem.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL08T
[if [AHCL08N = Number greater than person years old and AHCL08T= 4]] goto
ERR1_AHCL08T

[p. 19]

AHS.308_01.000

Instrument Variable Name: AHCL09N
Question Text:

1 of 2
How long have you had hypertension or high blood pressure?
*Enter number for time with hypertension or high blood pressure.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to hypertension or high blood pressure
Skip Instructions:

(1-95,D)[goto AHCL09T]
(R)[store "R" in AHCL09T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL09T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.308_02.000

Instrument Variable Name: AHCL09T
Question Text:

2 of 2
*Enter time period for time with hypertension or high blood pressure.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL09T
[if [AHCL09N = Number greater than person years old and AHCL09T= 4]] goto
ERR1_AHCL09T

[p. 20]

AHS.309_01.000

Instrument Variable Name: AHCL10N
Question Text:

1 of 2
How long have you had diabetes?
*Enter number for time with diabetes.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to diabetes
Skip Instructions:

(1-95,D)[goto AHCL10T]
(R)[store "R" in AHCL10T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL10T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.309_02.000

Instrument Variable Name: AHCL10T
Question Text:

2 of 2
*Enter time period for time with diabetes.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL10T
[if [AHCL10N = Number greater than person years old and AHCL10T= 4]] goto
ERR1_AHCL10T

[p. 21]

AHS.310_01.000

Instrument Variable Name: AHCL11N
Question Text:

1 of 2
How long have you had a lung or breathing problem (e.g. asthma and emphysema)?
*Enter number for time with a lung or breathing problem.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to a lung or breathing problem
Skip Instructions:

(1-95,D)[goto AHCL11T]
(R)[store "R" in AHCL11T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL11T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.310_02.000

Instrument Variable Name: AHCL11T
Question Text:

2 of 2
*Enter time period for time with lung or breathing problem (e.g. asthma and emphysema).

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL11T
[if [AHCL11N = Number greater than person years old and AHCL11T= 4]] goto
ERR1_AHCL11T

[p. 22]

AHS.311_01.000

Instrument Variable Name: AHCL12N
Question Text:

1 of 2
How long have you had cancer?
*Enter number for time with cancer.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to cancer
Skip Instructions:

(1-95,D)[goto AHCL12T]
(R)[store "R" in AHCL12T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL12T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.311_02.000

Instrument Variable Name: AHCL12T
Question Text:

2 of 2
*Enter time period for time with cancer.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL12T
[if [AHCL12N = Number greater than person years old and AHCL12T= 4]] goto
ERR1_AHCL12T

[p. 23]

AHS.313_01.000

Instrument Variable Name: AHCL14N
Question Text:

1 of 2
How long have you had mental retardation?
*Enter number for time with mental retardation.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to mental retardation
Skip Instructions:

(1-95,D)[goto AHCL14T]
(R)[store "R" in AHCL14T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL14T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.313_02.000

Instrument Variable Name: AHCL14T
Question Text:

2 of 2
*Enter time period for time with mental retardation.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL14T
[if [AHCL14N = Number greater than person years old and AHCL14T= 4]] goto
ERR1_AHCL14T

[p. 24]

AHS.314_01.000

Instrument Variable Name: AHCL15N
Question Text:

1 of 2
How long have you had a developmental problem (e.g., cerebral palsy)?
*Enter number for time with a developmental problem.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to a developmental problem
Skip Instructions:

(1-95,D)[goto AHCL15T]
(R)[store "R" in AHCL15T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL15T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.314_02.000

Instrument Variable Name: AHCL15T
Question Text:

2 of 2
*Enter time period for time with developmental problem.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL15T
[if [AHCL15N = Number greater than person years old and AHCL15T= 4]] goto
ERR1_AHCL15T

[p. 25]

AHS.315_01.000

Instrument Variable Name: AHCL16N
Question Text:

1 of 2
How long have you had senility?
*Enter number for time with senility.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to senility
Skip Instructions:

(1-95,D)[goto AHCL16T]
(R)[store "R" in AHCL16T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL16T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.315_02.000

Instrument Variable Name: AHCL16T
Question Text:

2 of 2
*Enter time period for time with senility.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL16T
[if [AHCL16N = Number greater than person years old and AHCL16T= 4]] goto
ERR1_AHCL16T

[p. 26]

AHS.316_01.000

Instrument Variable Name: AHCL17N
Question Text:

1 of 2
How long have you had depression, anxiety, or an emotional problem?
*Enter number for time with depression, anxiety, or an emotional problem.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to depression, anxiety, or an emotional problem
Skip Instructions:

(1-95,D)[goto AHCL17T]
(R)[store "R" in AHCL17T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL17T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.316_02.000

Instrument Variable Name: AHCL17T
Question Text:

2 of 2
*Enter time period for time with depression, anxiety, or emotional problem.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL17T
[if [AHCL17N = Number greater than person years old and AHCL17T= 4]] goto
ERR1_AHCL17T

[p. 27]

AHS.317_01.000

Instrument Variable Name: AHCL18N
Question Text:

1 of 2
How long have you had a weight problem?
*Enter number for time with a weight problem.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to a weight problem
Skip Instructions:

(1-95,D)[goto AHCL18T]
(R)[store "R" in AHCL18T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL18T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.317_02.000

Instrument Variable Name: AHCL18T
Question Text:

2 of 2
*Enter time period for time with weight problem.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL18T
[if [AHCL18N = Number greater than person years old and AHCL18T= 4]] goto
ERR1_AHCL18T

[p. 28]

AHS.318_01.000

Instrument Variable Name: AHCL19N
Question Text:

1 of 2
How long have you had a missing limb (finger, toe, or digit)?
*Enter number for time with a missing limb.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to a missing limb
Skip Instructions:

(1-95,D)[goto AHCL19T]
(R)[store "R" in AHCL19T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL19T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.318_02.000

Instrument Variable Name: AHCL19T
Question Text:

2 of 2
*Enter time period for time with missing limb.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL19T
[if [AHCL19N = Number greater than person years old and AHCL19T= 4]] goto
ERR1_AHCL19T

[p. 29]

AHS.319_01.000

Instrument Variable Name: AHCL20N
Question Text:

1 of 2
How long have you had a kidney, bladder or renal problem?
*Enter number for time with a kidney, bladder or renal problem.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to a kidney, bladder or renal problem
Skip Instructions:

(1-95,D)[goto AHCL20T]
(R)[store "R" in AHCL20T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL20T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.319_02.000

Instrument Variable Name: AHCL20T
Question Text:

2 of 2
*Enter time period for time with kidney, bladder or renal problem.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL20T
[if [AHCL20N = Number greater than person years old and AHCL20T= 4]] goto
ERR1_AHCL20T

[p. 30]

AHS.320_01.000

Instrument Variable Name: AHCL21N
Question Text:

1 of 2
How long have you had a circulation problem (including blood clots)?
*Enter number for time with a circulation problem.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to a circulation problem
Skip Instructions:

(1-95,D)[goto AHCL21T]
(R)[store "R" in AHCL21T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL21T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.320_02.000

Instrument Variable Name: AHCL21T
Question Text:

2 of 2
*Enter time period for time with circulation problem.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL21T
[if [AHCL21N = Number greater than person years old and AHCL21T= 4]] goto
ERR1_AHCL21T

[p. 31]

AHS.321_01.000

Instrument Variable Name: AHCL22N
Question Text:

1 of 2
How long have you had benign tumors or cysts?
*Enter number for time with benign tumors or cysts.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to benign tumors or cysts
Skip Instructions:

(1-95,D)[goto AHCL22T]
(R)[store "R" in AHCL22T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL22T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.321_02.000

Instrument Variable Name: AHCL22T
Question Text:

2 of 2
*Enter time period for time with benign tumors or cysts.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL22T
[if [AHCL22N = Number greater than person years old and AHCL22T= 4]] goto
ERR1_AHCL22T

[p. 32]

AHS.322_01.000

Instrument Variable Name: AHCL23N
Question Text:

1 of 2
How long have you had fibromyalgia or lupus?
*Enter number for time with fibromyalgia or lupus.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to fibromyalgia or lupus
Skip Instructions:

(1-95,D)[goto AHCL23T]
(R)[store "R" in AHCL23T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL23T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.322_02.000

Instrument Variable Name: AHCL23T
Question Text:

2 of 2
*Enter time period for time with fibromyalgia or lupus.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL23T
[if [AHCL23N = Number greater than person years old and AHCL23T= 4]] goto
ERR1_AHCL23T

[p. 33]

AHS.323_01.000

Instrument Variable Name: AHCL24N
Question Text:

1 of 2
How long have you had osteoporosis or tendinitis?
*Enter number for time with osteoporosis or tendinitis.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to osteoporosis or tendinitis
Skip Instructions:

(1-95,D)[goto AHCL24T]
(R)[store "R" in AHCL24T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL24T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.323_02.000

Instrument Variable Name: AHCL24T
Question Text:

2 of 2
*Enter time period for time with osteoporosis or tendinitis.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL24T
[if [AHCL24N = Number greater than person years old and AHCL24T= 4]] goto
ERR1_AHCL24T

[p. 34]

AHS.324_01.000

Instrument Variable Name: AHCL25N
Question Text:

1 of 2
How long have you had epilepsy or seizures?
*Enter number for time with epilepsy or seizures.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to epilepsy or seizures
Skip Instructions:

(1-95,D)[goto AHCL25T]
(R)[store "R" in AHCL25T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL25T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.324_02.000

Instrument Variable Name: AHCL25T
Question Text:

2 of 2
*Enter time period for time with epilepsy or seizures.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL25T
[if [AHCL25N = Number greater than person years old and AHCL25T= 4]] goto
ERR1_AHCL25T

[p. 35]

AHS.325_01.000

Instrument Variable Name: AHCL26N
Question Text:

1 of 2
How long have you had multiple sclerosis (MS) or muscular dystrophy (MD)?
*Enter number for time with multiple sclerosis (MS) or muscular dystrophy (MD).
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to multiple sclerosis or muscular dystrophy
Skip Instructions:

(1-95,D)[goto AHCL26T]
(R)[store "R" in AHCL26T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL26T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.325_02.000

Instrument Variable Name: AHCL26T
Question Text:

2 of 2
*Enter time period for time with multiple sclerosis or muscular dystrophy.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL26T
[if [AHCL26N = Number greater than person years old and AHCL26T= 4]] goto
ERR1_AHCL26T

[p. 36]

AHS.326_01.000

Instrument Variable Name: AHCL27N
Question Text:

1 of 2
How long have you had polio(myelitis), paralysis or para/quadriplegia?
*Enter number for time with polio (myelitis), paralysis or para/quadriplegia.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to polio(myelitis), paralysis or para/quadriplegia
Skip Instructions:

(1-95,D)[goto AHCL27T]
(R)[store "R" in AHCL27T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL27T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.326_02.000

Instrument Variable Name: AHCL27T
Question Text:

2 of 2
*Enter time period for time with polio(myelitis), paralysis or para/quadriplegia.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL27T
[if [AHCL27N = Number greater than person years old and AHCL27T= 4]] goto
ERR1_AHCL27T

[p. 37]

AHS.327_01.000

Instrument Variable Name: AHCL28N
Question Text:

1 of 2
How long have you had Parkinson's disease or tremors?
*Enter number for time with Parkinson's disease or tremors.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to Parkinson's disease or tremors
Skip Instructions:

(1-95,D)[goto AHCL28T]
(R)[store "R" in AHCL28T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL28T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.327_02.000

Instrument Variable Name: AHCL28T
Question Text:

2 of 2
*Enter time period for time with Parkinson's disease or tremors.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL28T
[if [AHCL28N = Number greater than person years old and AHCL28T= 4]] goto
ERR1_AHCL28T

[p. 38]

AHS.328_01.000

Instrument Variable Name: AHCL29N
Question Text:

1 of 2
How long have you had nerve damage (including carpal tunnel syndrome)?
*Enter number for time with nerver damage (including carpal tunnel syndrome).
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to nerve damage
Skip Instructions:

(1-95,D)[goto AHCL29T]
(R)[store "R" in AHCL29T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL29T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.328_02.000

Instrument Variable Name: AHCL29T
Question Text:

2 of 2
*Enter time period for time with nerve damage.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL29T
[if [AHCL29N = Number greater than person years old and AHCL29T= 4]] goto
ERR1_AHCL29T

[p. 39]

AHS.329_01.000

Instrument Variable Name: AHCL30N
Question Text:

1 of 2
How long have you had a hernia?
*Enter number for time with a hernia.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to a hernia
Skip Instructions:

(1-95,D)[goto AHCL30T]
(R)[store "R" in AHCL30T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL30T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.329_02.000

Instrument Variable Name: AHCL30T
Question Text:

2 of 2
*Enter time period for time with hernia.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL30T
[if [AHCL30N = Number greater than person years old and AHCL30T= 4]] goto
ERR1_AHCL30T

[p. 40]

AHS.330_01.000

Instrument Variable Name: AHCL31N
Question Text:

1 of 2
How long have you had an ulcer?
*Enter number for time with an ulcer.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to an ulcer
Skip Instructions:

(1-95,D)[goto AHCL31T]
(R)[store "R" in AHCL31T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL31T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.330_02.000

Instrument Variable Name: AHCL31T
Question Text:

2 of 2
*Enter time period for time with ulcer.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL31T
[if [AHCL31N = Number greater than person years old and AHCL31T= 4]] goto
ERR1_AHCL31T

[p. 41]

AHS.331_01.000

Instrument Variable Name: AHCL32N
Question Text:

1 of 2
How long have you had varicose veins or hemorrhoids?
*Enter number for time with varicose veins or hemorrhoids.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to varicose veins or hemorrhoids
Skip Instructions:

(1-95,D)[goto AHCL32T]
(R)[store "R" in AHCL32T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL32T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.331_02.000

Instrument Variable Name: AHCL32T
Question Text:

2 of 2
*Enter time period for time with varicose veins or hemorrhoids.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL32T
[if [AHCL32N = Number greater than person years old and AHCL32T= 4]] goto
ERR1_AHCL32T

[p. 42]

AHS.332_01.000

Instrument Variable Name: AHCL33N
Question Text:

1 of 2
How long have you had a thyroid problem, Grave's disease or gout?
*Enter number for time with a thyroid problem, Grave's disease or gout.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to a thyroid problem, Grave's disease or gout
Skip Instructions:

(1-95,D)[goto AHCL33T]
(R)[store "R" in AHCL33T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL33T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.332_02.000

Instrument Variable Name: AHCL33T
Question Text:

2 of 2
*Enter time period for time with thyroid problem, Grave's disease or gout.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL33T
[if [AHCL33N = Number greater than person years old and AHCL33T= 4]] goto
ERR1_AHCL33T

[p. 43]

AHS.333_01.000

Instrument Variable Name: AHCL34N
Question Text:

1 of 2
How long have you had a knee problem?
*Enter number for time with a knee problem.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to a knee problem
Skip Instructions:

(1-95,D)[goto AHCL34T]
(R)[store "R" in AHCL34T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL34T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.333_02.000

Instrument Variable Name: AHCL34T
Question Text:

2 of 2
*Enter time period for time with knee problem.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL34T
[if [AHCL34N = Number greater than person years old and AHCL34T= 4]] goto
ERR1_AHCL34T

[p. 44]

AHS.334_01.000

Instrument Variable Name: AHCL35N
Question Text:

1 of 2
How long have you had migraine headaches?
*Enter number for time with migraine headaches.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to migraine headaches
Skip Instructions:

(1-95,D)[goto AHCL35T]
(R)[store "R" in AHCL35T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL35T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.334_02.000

Instrument Variable Name: AHCL35T
Question Text:

2 of 2
*Enter time period for time with migraine headaches.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL35T
[if [AHCL35N = Number greater than person years old and AHCL35T= 4]] goto
ERR1_AHCL35T

[p. 45]

AHS.335_01.000

Instrument Variable Name: AHCL90N
Question Text:

1 of 2
How long have you had {problem in AFLHCA90}?
*Enter number for time with {problem in AFLHCA90}.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to {problem in AFLHCA90}
Skip Instructions:

(1-95,D)[goto AHCL90T]
(R)[store "R" in AHCL90T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(96)[store "6" in AHCL90T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]

AHS.335_02.000

Instrument Variable Name: AHCL90T
Question Text:

2 of 2
*Enter time period for time with {problem in AFLHCA90}.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1- 4, R,D)[[if 91 selected in AFLHCA goto AFLHCA_S2]
Else goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL90T
[if [AHCL90N = Number greater than person years old and AHCL90T= 4]] goto
ERR1_AHCL90T

[p. 46]

AHS.336_01.000

Instrument Variable Name: AHCL91N
Question Text:

1 of 2
How long have you had {problem in AFLHCA91}?
*Enter number for time with {problem in AFLHCA91}.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.

01-94 01-94
95 95+
96 Since birth
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had difficulty due to {problem in AFLHCA91}
Skip Instructions:

(1-95,D)[goto AHCL91T]
(R)[store "R" in AHCL91T] [goto SMKEV (next section)]
(96)[store "6" in AHCL91T] [goto SMKEV (next section)]

AHS.336_02.000

Instrument Variable Name: AHCL91T
Question Text:

2 of 2
*Enter time period for time with {problem in AFLHCA91}.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question
Skip Instructions:

(1-4, R,D)[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition selected, goto SMKEV (next section)]
(6) goto ERR2_AHCL91T
[if [AHCL91N = Number greater than person years old and AHCL91T= 4]] goto
ERR1_AHCL91T

[p. 1]

2004 NHIS Questionnaire - Sample Adult
Adult Health Behaviors

AHB.010_00.000

Instrument Variable Name: SMKEV
Question Text:

These next questions are about cigarette smoking.
Have you smoked at least 100 cigarettes in your ENTIRE LIFE?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1)[goto SMKREG]
(2,R,D)[goto VIGNO]

AHB.020_00.000

Instrument Variable Name: SMKREG
Question Text:

How old were you when you FIRST started to smoke fairly regularly?
*Enter '6' if less than 6 years old.
*Enter '95' if 95 years old or older.
*Enter '96' if never smoked regularly.

06-84 6 - 84 years
85 85 years or older
96 Never smoked regularly
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who ever smoked 100 cigarettes
Skip Instructions:

(6-95,96,R,D) [goto SMKNOW]
[If SMKREG gt AGE and SMKREG ne (96), goto ERR_SMKREG

AHB.030_00.000

Instrument Variable Name: SMKNOW
Question Text:

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

1 Every day
2 Some days
3 Not at all
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who ever smoked 100 cigarettes
Skip Instructions:

(1)[goto CIGSDA1]
(2) [goto CIGDAMO]
(3) [goto SMKQTNO]
(R,D) [goto VIGNO]

[p. 2]

AHB.040_01.000

Instrument Variable Name: SMKQTNO
Question Text:

1 of 2
How long has it been since you quit smoking cigarettes?
*Enter number for time since quit smoking.
*Enter '95' for 95 years old or older.

01-94 1 - 94
95 95+
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who quit smoking
Skip Instructions:

(1-95) [goto SMKQTTP]
(R,D) [goto VIGNO]

AHB.040_02.000

Instrument Variable Name: SMKQTTP
Question Text:

2 of 2
*Enter time period for time since quit smoking.

1 Day(s)
2 Week(s)
3 Month(s)
4 Year(s)
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who quit smoking
Skip Instructions:

(1-4) [goto VIGNO]
(4) [if SMKQTNO gt (AGE - (15)), goto ERR1_SMKQTTP
if (SMKREG + SMKQTNO gt AGE), goto ERR2_SMKQTTP

AHB.050_00.000

Instrument Variable Name: CIGSDA1
Question Text:

On the average, how many cigarettes do you now smoke a day?
*Enter '1' if less than 1 cigarette.
*Enter '95' if 95 or more cigarettes.

01-94 1 - 94 cigarettes
95 95+ cigarettes
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who are current every day smokers
Skip Instructions:

(1-95,R,D) [goto CIGQTYR]

[p. 3]

AHB.060_00.000

Instrument Variable Name: CIGDAMO
Question Text:

On how many of the PAST 30 DAYS did you smoke a cigarette?
*Enter '0' for None.

00 None
01-30 1-30 days
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who are current some day smokers
Skip Instructions:

(0)[goto CIGQTYR]
(1-30,R,D) [goto CIGSDA2]

AHB.070_00.000

Instrument Variable Name: CIGSDA2
Question Text:

On the average, when you smoked during the PAST 30 DAYS, about how many cigarettes did you smoke a day?
*Enter '1' if less than 1.
*Enter '95' if 95 or more cigarettes.

01-94 1-94 cigarettes
95 95+ cigarettes
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who are current some day smokers
Skip Instructions:

(1-95,R,D) [goto CIGQTYR]

AHB.080_00.000

Instrument Variable Name: CIGQTYR
Question Text:

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

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who are every day or someday smokers
Skip Instructions:

(1,2,R,D) [goto VIGNO]

[p. 4]

AHB.090_01.000

Instrument Variable Name: VIGNO
Question Text:

1 of 2
The next questions are about physical activities (exercise, sports, physically active hobbies...) that you may do in your LEISURE time.
How often do you do VIGOROUS leisure-time physical activities for AT LEAST 10 MINUTES that cause HEAVY sweating or LARGE increases in breathing or heart rate?
*Read if necessary: How many times per day, per week, per month, or per year do you do these activities?
*Enter number for vigorous leisure-time physical activities.
*Enter '0' for Never.
*Enter '996' if unable to do this type of activity.

000 Never
001-995 1-995 time(s)
996 Unable to do this type activity
997 Refused
999 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(0,996,R,D)[goto MODNO]
(1-995)[goto VIGTP]

AHB.090_02.000

Instrument Variable Name: VIGTP
Question Text:

2 of 2
*Enter time period for vigorous leisure-time physical activities.

0 Never
1 Per day
2 Per week
3 Per month
4 Per year
6 Unable to do this activity
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who do vigorous activities
Skip Instructions:

(1-4) goto VIGLNGNO
[if (VIGNO gt (4) and VIGTP eq (1)) or
(VIGNO gt (28) and VIGTP eq (2)) or
(VIGNO gt (31) and VIGTP eq (3)) or
(VIGNO gt (365) and VIGTP eq (4)) goto ERR1_VIGTP]

AHB.100_01.000

Instrument Variable Name: VIGLNGNO
Question Text:

1 of 2
About how long do you do these vigorous leisure-time physical activities each time?
*Enter number for length of vigorous leisure-time physical activities.

001-995 1-995
997 Refused
999 Don't know

Universe Text: Sample adults 18+ who do vigorous activities
Skip Instructions:

(1-995)[goto VIGLNGTP]
(R,D)[goto MODNO]

AHB.100_02.000

Instrument Variable Name: VIGLNGTP
Question Text:

2 of 2
*Enter time period for length of vigorous leisure-time physical activities.

1 Minutes
2 Hours
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who do vigorous activities
Skip Instructions:

(1,2)goto MODNO
if VIGLNGNO lt (10) and VIGLNGTP eq (1) goto ERR1_VIGLNGTP;
if (VIGLNGNO gt (90) and VIGLNGTP eq (1)) or if VIGLNGNO gt (2) and VIGLNGTP eq (2) goto
ERR2_VIGLNGTP

[p. 6]

AHB.110_01.000

Instrument Variable Name: MODNO
Question Text:

How often do you do LIGHT OR MODERATE LEISURE-TIME physical activities for AT LEAST 10 MINUTES that cause ONLY LIGHT sweating or a SLIGHT to MODERATE increase in breathing or heart rate?
*If necessary, prompt with: How many times per day, per week, per month, or per year do you do these activities?
*Enter number of light or moderate leisure-time physical activities.
*Enter '0' for Never.
*Enter '996' if unable to do this type of activity.

000 Never
001-995 1-995 time(s)
996 Unable to do this type activity
997 Refused
999 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1-995)[goto MODTP]
(0, 996, R,D)[goto STRNGNO]

AHB.110_02.000

Instrument Variable Name: MODTP
Question Text:

2 of 2
*Enter time period for light or moderate leisure-time physical activities

0 Never
1 Per day
2 Per week
3 Per month
4 Per year
6 Unable to do this activity
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who do light or moderate activities
Skip Instructions:

(1-4) goto MODLNGNO
[if (MODNO gt (4) and MODTP eq (1)) or
(MODNO gt (28) and MODTP eq (2)) or
(MODNO gt (31) and MODTP eq (3)) or
(MODNO gt (365) and MODTP eq (4))] goto ERR_MODNO

AHB.120_01.000

Instrument Variable Name: MODLNGNO
Question Text:

1 of 2
About how long do you do these light or moderate leisure-time physical activities each time?
*Enter number for length of light or moderate leisure-time physical activities.

001-995 1-995
997 Refused
999 Don't know

Universe Text: Sample adults 18+ who do light or moderate activities
Skip Instructions:

(1-995)[goto MODLNGTP]
(R,D)[goto STRNGNO]

AHB.120_02.000

Instrument Variable Name: MODLNGTP
Question Text:

2 of 2
*Enter time period for length of light or moderate leisure-time physical activities.

1 Minutes
2 Hours
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who do light or moderate activities
Skip Instructions:

(1,2) goto STRNGNO
if MODLNGNO lt (10) and MODLNGTP eq (1) goto ERR1_MODLNGTP
if MODLNGNO gt (90) and MODLNGTP eq (1) or if MODLNGNO gt (2) and MODLNGTP eq (2)goto ERR2_MODLNGTP

[p. 8]

AHB.130_01.000

Instrument Variable Name: STRNGNO
Question Text:

How often do you do LEISURE-TIME 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.)
*Read if necessary: How many times per day, per week, per month, or per year do you do these activities?
*Enter number for strengthening activities.
*Enter '0' for Never.
*Enter '996' for Unable to do this type activity

000 Never
001-995 1-995 time(s)
996 Unable to do this type activity
997 Refused
999 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1-995)[goto STRNGTP]
(0, 996,R,D)[goto ALC1YR]

AHB.130_02.000

Instrument Variable Name: STRNGTP
Question Text:

2 of 2
*Enter time period for strengthening activities

0 Never
1 Per day
2 Per week
3 Per month
4 Per year
6 Unable to do this activity
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who do strengthening activities
Skip Instructions:

(1-4) goto ALC1YR
[If (STRNGNO gt (4) and STRNGTP = (1)) or (STRNGNO gt (28) and STRNGTP = (2)) or (STRNGNO gt (31) and STRNGTP = (3)) or (STRNGNO gt (365) and STRNGTP = (4)) goto ERR_STRNGTP]

[p. 9]

AHB.140_00.000

Instrument Variable Name: ALC1YR
Question Text:

These next questions are about drinking alcoholic beverages. Included are liquor such as whiskey or gin, beer, wine, wine coolers, and any other type of alcoholic beverage.
In ANY ONE YEAR, have you had at least 12 drinks of any type of alcoholic beverage?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1) [goto ALC12MNO]
(2,R,D) [goto ALCLIFE]

AHB.150_00.000

Instrument Variable Name: ALCLIFE
Question Text:

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

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who have not had 12 drinks in any one year or don't know if they did or refused to answer
Skip Instructions:

(1) [goto ALC12MNO]_
(2,R,D) [goto AHGT_FT]

AHB.160_01.000

Instrument Variable Name: ALC12MNO
Question Text:

1 of 2
In the PAST YEAR, how often did you drink any type of alcoholic beverage?
*Read if necessary: "How many days per week, per month or per year did you drink?"
*Enter number for how often alcoholic beverages were consumed in the past year.
*Enter '0' for Never.

000 Never
001-365 1-365 day(s)
997 Refused
999 Don't know

Universe Text: Sample adults 18+ who have had at least 12 drinks in any one year or at least 12 drinks in their entire life
Skip Instructions:

(1-365)[goto ALC12MTP]
(0,R,D)[goto AHGT_FT]

AHB.160_02.000

Instrument Variable Name: ALC12MTP
Question Text:

2 of 2
*Enter time period for how often alcoholic beverages were consumed in the past year.

0 Never/None
1 Week
2 Month
3 Year
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who drank at least once in the past year
Skip Instructions:

(1-3) [goto ALCAMT]
[If (ALC12MNO gt (7) and ALC12MTP = (1)) or (ALC12MNO gt (31) and ALC12MTP = (2)) or (ALC12MNO gt (365) and ALC12MTP = (3)) goto ERR_ALC12MTP]

AHB.170_00.000

Instrument Variable Name: ALCAMT
Question Text:

In the PAST YEAR, on those days that you drank alcoholic beverages, on the average, how many drinks did you have?
*Enter '1' if less than 1 drink.
*Enter '95' if 95 or more drinks.

01-94 1-94 drinks
95 95+ drinks
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who have had at least 1 drink in the past year
Skip Instructions:

(1-95,R,D) [goto ALC5UPNO]
(10-95)[goto ERR_ALCAMT]

[p. 11]

AHB.180_01.000

Instrument Variable Name: ALC5UPNO
Question Text:

1 of 2
In the PAST YEAR, on how many DAYS did you have 5 or more drinks of any alcoholic beverage?
*Read if necessary:
How many days per week, per month or per year did you have 5 or more drinks in a single day?
*Enter number of days.
*Enter '0' for Never/None.

000 Never/None
001-365 1-365 day(s)
997 Refused
999 Don't know

Universe Text: Sample adults 18+ who have had at least 1 drink in the past year
Skip Instructions:

(1-365)[goto ALC5UPTP]
(0,R,D)[goto AHGT_FT]

AHB.180_02.000

Instrument Variable Name: ALC5UPTP
Question Text:

2 of 2
*Enter time period for days per week, per month or per year.

0 Never/None
1 Per week
2 Per month
3 Per year
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who have had 5+ drinks in one day at least once in the past year
Skip Instructions:

(1-3)goto AHGT_FT
[If (ALC5UPNO gt (7) and ALC5UPTP = (1)) or
(ALC5UPNO gt (31) and ALC5UPTP = (2)) or
(ALC5UPNO gt (365) and ALC5UPTP = (3)) goto ERR1_ALC5UPTP
[if number of days drank in the past year (calculated from ALC12MNO and ALC12MTP) lt number of days per year with 5 or more drinks (calculated from ALC5UPNO and ALC5UPTP)] goto ERR2_ALC5UPTP]

[p. 12]

AHB.190_01.000

Instrument Variable Name: AHGT_FT
Question Text:

How tall are you without shoes?
*Enter "M" to record metric measurements

02-07 2-7 feet
97 Refused
99 Don't know
M Metric

Universe Text: Sample adults 18+
Skip Instructions:

(2-7) [goto AHGT_IN]
(R,D) [goto AWGT_LB]
(M) [goto AHGT_M]
[if AHGT_FT NE(2-7,D,R,M) goto ERR1_AHGT_FT]
[if AHGT_FT = (2,3) goto ERR2_AHGT_FT]

AHB.190_02.000

Instrument Variable Name: AHGT_IN
Question Text:

How tall are you without shoes?
*Enter '0' if exactly [fill1: AHGT_FT] feet tall.

00-11 0-11 inches
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who answered their height in feet
Skip Instructions:

(0-11,R,D) [goto AWGT_LB]
(empty) [goto ERR_AHGT_IN]

AHB.190_03.000

Instrument Variable Name: AHGT_M
Question Text:

How tall are you without shoes?
*Enter height in metric.

0-2 0-2 meters
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who choose to give their height in metric measurements
Skip Instructions:

(0-2) [goto AHGT_CM]
(R,D) [goto AWGT_LB]
(empty) [goto ERR_AHGT_M]

AHB.190_04.000

Instrument Variable Name: AHGT_CM
Question Text:

*Enter centimeters.

000-241 0-241 centimeters
997 Refused
999 Don't know

Universe Text: Sample adults 18+ who answered their height in meters
Skip Instructions:

(0-241,R,D) goto AWGT_LB
[If AHGT_M eq (2) and AHGT_CM gt (41) or AHGT_M eq (1) and AHGT_CM gt (141)] goto ERR1_AHGT_CM]
( ) goto ERR2_AHGT_CM
[If AHGT_M eq (1) and AHGT_CM lt (20) or AHGT_M eq (0) and AHGT_CM lt (120)] goto ERR3_AHGT_CM]

AHB.200_01.000

Instrument Variable Name: AWGT_LB
Question Text:

How much do you weigh without shoes?
*Enter "M" to record metric measurements
*Enter '500' for 500 pounds or more

050-500 50-500 pounds
997 Refused
999 Don't know
M Metric

Universe Text: Sample adults 18+
Skip Instructions:

(50-500) [goto SLEEP]
[if AWGT_LB lt (50) or gt (500) goto ERR_AWGT_LB
(R,D)[goto SLEEP]
(M) [goto AWGT_KG]

AHB.200_02.000

Instrument Variable Name: AWGT_KG
Question Text:

How much do you weigh without shoes?
*Enter weight in kilograms

022-226 22-226 kilograms
997 Refused
999 Don't know

Universe Text: Sample adults 18+ who choose to give their weight in metric measurements
Skip Instructions:

(22-226,R,D) [goto SLEEP]
[If AWGT_KG lt (22) or K gt (226)goto ERR_AWGT_KG]

[p. 14]

AHB.210_00.000

Instrument Variable Name: SLEEP
Question Text:

On average, how many hours of sleep do you get in a 24-hour period?
*Enter hours of sleep in whole numbers, rounding 30 minutes (1/2 hour) or more UP to the next whole hour and dropping 29 or fewer minutes.

01-24 1-24 hours
97 Refused
99 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1-24,R,D) [goto next section]_
[If SLEEP eq (1-5) goto ERR_SLEEP]

[p. 1]

2004 NHIS Questionnaire - Sample Adult
Adult Access to Health Care and Utilization

AAU.020_00.000

Instrument Variable Name: AUSUALPL
Question Text:

The next questions are about health care.
Is there a place that you USUALLY go to when you are sick or need advice about your health?

1 Yes
2 There is NO place
3 There is MORE THAN ONE place
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,3) [go to APLKIND]
(2,R,D) [go to AHCPLKND]

AAU.030_00.000

Instrument Variable Name: APLKIND
Question Text:

[fill: What kind of place is it - a clinic, doctor's office, emergency room, or some other place?/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
2 Doctor's office or HMO
3 Hospital emergency room
4 Hospital outpatient department
5 Some other place
6 Doesn't go to one place most often
7 Refused
9 Don't know

Universe Text: Sample adults 18+ with 1+ usual place(s) to go when sick/need health advice
Skip Instructions:

(1 - 5) [go to AHCPLROU]
(6,R,D) [go to AHCPLKND]

AAU.035_00.000

Instrument Variable Name: AHCPLROU
Question Text:

Is that [fill: place from APLKIND] the same place you USUALLY go when you need routine or preventive care, such as a physical examination or check up?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ with 1+ usual place(s) to go when sick/need health advice who reported place goes most often as a clinic or health center, doctor's office or HMO, hospital emergency room, hospital outpatient department, or some other place
Skip Instructions:

(1) [goto AHCCHGYR]
(2,D,R) [go to AHCPLKND]

[p. 2]

AAU.037_00.000

Instrument Variable Name: AHCPLKND
Question Text:

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

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
6 Doesn't go to one place most often
7 Refused
9 Don't know

Universe Text: Sample Adults 18+ who do not have a usual source of sick care; who Ref/DK if have a usual source of sick care; who have a usual source of sick care but do not go to one place most often or Ref/DK what kind of place; who have a usual source of sick care, but it is not same place as usual source of routine/preventive care; who have a usual source of sick care but Ref/DK if it is same place as usual source of routine/preventive care.
Skip Instructions:

(0-6,R,D) if AUSUALPL = 2,D,R goto AHCDLY_1
ELSE goto AHCCHGYR

AAU.040_00.000

Instrument Variable Name: AHCCHGYR
Question Text:

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

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ with 1+ usual place(s) to go when sick/need health advice [or who reported same place as usual source of routine/preventive care]
Skip Instructions:

(1)[goto AHCCHGHI]
(2,R,D)[goto AHCDLY_1]

AAU.050_00.000

Instrument Variable Name: AHCCHGHI
Question Text:

Was this change for a reason related to health insurance?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ with 1+ usual place(s) to go when sick/need health advice who CHANGED their USUAL place for health care in past 12 months
Skip Instructions:

(1,2,R,D)[goto AHCDLY_1]

[p. 3]

AAU.061_01.000

Instrument Variable Name: AHCDLY_1
Question Text:

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?
...You couldn't get through on the telephone.

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D)[goto AHCDLY_2]

AAU.061_02.000

Instrument Variable Name: AHCDLY_2
Question Text:

*Read Lead-in if Necessary
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?
...You couldn't get an appointment soon enough.

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D)[goto AHCDLY_3]

AAU.061_03.000

Instrument Variable Name: AHCDLY_3
Question Text:

*Read Lead-in if Necessary
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?
...Once you get there, you have to wait too long to see the doctor.

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D)[goto AHCDLY_4]

[p. 4]

AAU.061_04.000

Instrument Variable Name: AHCDLY_4
Question Text:

*Read Lead-in if Necessary
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?
...The (clinic/doctor's) office wasn't open when you could get there.

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D)[goto AHCDLY_5]

AAU.061_05.000

Instrument Variable Name: AHCDLY_5
Question Text:

*Read Lead-in if Necessary
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?
...You didn't have transportation.

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D)[goto AHCAFY_1]

AAU.111_01.000

Instrument Variable Name: AHCAFY_1
Question Text:

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?
...Prescription medicines.

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D)[goto AHCAFY_2]

[p. 5]

AAU.111_02.000

Instrument Variable Name: AHCAFY_2
Question Text:

*Read Lead-in if Necessary.
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?
...Mental health care or counseling.

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D)[goto AHCAFY_3]

AAU.111_03.000

Instrument Variable Name: AHCAFY_3
Question Text:

*Read Lead-in if Necessary.
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?
...Dental care (including check ups).

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D)[goto AHCAFY_4]

AAU.111_04.000

Instrument Variable Name: AHCAFY_4
Question Text:

*Read Lead-in if Necessary.
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?
...Eyeglasses.

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D)[goto ADENLONG]

[p. 6]

AAU.135_00.000

Instrument Variable Name: ADENLONG
Question Text:

(book) A7
About how long has it been since you last saw a dentist? Include all types of dentists, such as orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists.

0 Never
1 6 months or less
2 More than 6 mos, but not more than 1 yr ago
3 More than 1 yr, but not more than 2 yrs ago
4 More than 2 yrs, but not more than 5 yrs ago
5 More than 5 years ago
7 Refused
9 Don't know

Card A7

0. Never
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 2 years ago
4. More than 2 years, but not more than 5 years ago
5. More than 5 years ago

Universe Text: Sample adults 18+
Skip Instructions:

(0-5,R,D)[ goto AHCSY1_1]

AAU.141_01.000

Instrument Variable Name: AHCSY1_1
Question Text:

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 mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker.

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D)[ goto AHCSY1_2]

AAU.141_02.000

Instrument Variable Name: AHCSY1_2
Question Text:

*Read Lead-in if Necessary.
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?
...An optometrist, ophthalmologist, or eye doctor (someone who prescribes eyeglasses).

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D)[ goto AHCSY1_3]

[p. 7]

AAU.141_03.000

Instrument Variable Name: AHCSY1_3
Question Text:

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D)[ goto AHCSY1_4]

AAU.141_04.000

Instrument Variable Name: AHCSY1_4
Question Text:

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D)[ goto AHCSY1_5]

AAU.141_05.000

Instrument Variable Name: AHCSY1_5
Question Text:

*Read Lead-in if Necessary.
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 physical therapist, speech therapist, respiratory therapist, audiologist, or occupational therapist.

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D)[ goto AHCSY1_6]

[p. 8]

AAU.141_06.000

Instrument Variable Name: AHCSY1_6
Question Text:

*Read Lead-in if Necessary.
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 nurse practitioner, physician assistant, or midwife.

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D)[if SEX=1goto AHCSY8_8; else if SEX=2 goto AHCSYR7]

AAU.200_00.000

Instrument Variable Name: AHCSYR7
Question Text:

*Read lead-in if necessary
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).

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who are female
Skip Instructions:

(1,2,R,D) [go to AHCSY8_ 8]

AAU.211_01.000

Instrument Variable Name: AHCSY8_ 8
Question Text:

*Read Lead-in if Necessary.
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 medical doctor who specializes in a particular medical disease or problem (other than obstetrician/gynecologist, psychiatrist, or ophthalmologist).

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D) [go to AHCSY8_ 9]

[p. 9]

AAU.211_02.000

Instrument Variable Name: AHCSY8_ 9
Question Text:

*Read Lead-in if Necessary.
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 general doctor who treats a variety of illnesses (a doctor in general practice, family medicine, or internal medicine)?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1) [goto AHCSYR10]
(2,R,D) [goto AHERNOYR]

AAU.230_00.000

Instrument Variable Name: AHCSYR10
Question Text:

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

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who have seen or talked to a general doctor during the past 12 months
Skip Instructions:

(1,2,R,D) [go to AHERNOYR]

AAU.240_00.000

Instrument Variable Name: AHERNOYR
Question Text:

(book) A8
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.)?

00 None
01 1
02 2-3
03 4-5
04 6-7
05 8-9
06 10-12
07 13-15
08 16 or more
97 Refused
99 Don't know

Card A8

0. None
1. 1
2. 2-3
3. 4-5
4. 6-7
5. 8-9
6. 10-12
7. 13-15
8. 16 or more

Universe Text: Sample adults 18+
Skip Instructions:

(0 - 8,R,D) [go to AHCHYR]

[p. 10]

AAU.250_00.000

Instrument Variable Name: AHCHYR
Question Text:

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

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1)[goto AHCHMOYR]
(2,R,D)[goto AHCNOYR]

AAU.260_00.000

Instrument Variable Name: AHCHMOYR
Question Text:

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

01-12 01-12 months
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who received home care from a health professional during the past 12 months
Skip Instructions:

(1-12,R,D)[goto AHCHNOYR]

AAU.270_00.000

Instrument Variable Name: AHCHNOYR
Question Text:

(book) A9
What was the total number of home visits received during [fill: that month/those months]?

01 1
02 2-3
03 4-5
04 6-7
05 8-9
06 10-12
07 13-15
08 16 or more
97 Refused
99 Don't know

Card A9

1. 1
2. 2-3
3. 4-5
4. 6-7
5. 8-9
6. 10 -12
7. 13-15
8. 16 or more

Universe Text: Sample adults 18+ who received home care from a health professional during the past 12 months
Skip Instructions:

(1-8,R,D)[goto AHCNOYR]

[p. 11]

AAU.280_00.000

Instrument Variable Name: AHCNOYR
Question Text:

(book) A8
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, dental visits, or telephone calls.

00 None
01 1
02 2-3
03 4-5
04 6-7
05 8-9
06 10-12
07 13-15
08 16 or more
97 Refused
99 Don't know

Card A8

0. None
1. 1
2. 2-3
3. 4-5
4. 6-7
5. 8-9
6. 10-12
7. 13-15
8. 16 or more

Universe Text: Sample adults 18+
Skip Instructions:

(0-8,R,D)[goto ASRGYR]

AAU.290_00.000

Instrument Variable Name: ASRGYR
Question Text:

DURING THE PAST 12 MONTHS, have you had SURGERY or other surgical procedures either as an inpatient or outpatient?
*Read if necessary: This includes both major surgery and minor procedures such as setting bones or removing growths.

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1)[goto ASRGNOYR]
(2,R,D) [goto AMDLONG].

AAU.300_00.000

Instrument Variable Name: ASRGNOYR
Question Text:

Including any times you may have already told me about, HOW MANY DIFFERENT TIMES have you had surgery during the PAST 12 MONTHS?
*Enter "95" for 95 or more times.

01-94 1-94 Times
95 95+ times
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who had surgery or surgical procedures during past 12 months
Skip Instructions:

(1-95,R,D) [goto AMDLONG].
(11-95)[goto ERR_ASGYR]

[p. 12]

AAU.305_00.000

Instrument Variable Name: AMDLONG
Question Text:

(book) A7 ? [F1]
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.

Card A7

Universe Text: Sample adults 18+
Skip Instructions:

(0-5,R,D) [goto SHTFLUYR]

AAU.310_00.000

Instrument Variable Name: SHTFLUYR
Question Text:

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.
*Read if necessary: A flu shot is injected in the arm. Do not include an influenza vaccine sprayed in the nose.

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D) [ goto SPRFLUYR ]

AAU.315_00.000

Instrument Variable Name: SPRFLUYR
Question Text:

DURING THE PAST 12 MONTHS, have you had a flu vaccine sprayed in your nose by a doctor or other health professional? A health professional may have let you spray it. This vaccine is usually given in the fall and protects against influenza for the flu season.
*Read if necessary: This influenza vaccine is called FluMist (trademark).

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D) [ goto SHTPNUYR ]

[p. 13]

AAU.320_00.000

Instrument Variable Name: SHTPNUYR
Question Text:

Have you EVER had a pneumonia shot?
This shot is usually given only once or twice in a person's lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D) [goto APOX]

AAU.330_00.000

Instrument Variable Name: APOX
Question Text:

Have you EVER had chickenpox?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1) [goto APOX12MO]
(2,R,D) [goto AHEP]

AAU.340_00.000

Instrument Variable Name: APOX12MO
Question Text:

Have you had chickenpox in the PAST 12 MONTHS?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who have ever had chickenpox
Skip Instructions:

(1,2,R,D) [goto AHEP]

[p. 14]

AAU.350_00.000

Instrument Variable Name: AHEP
Question Text:

Have you EVER had hepatitis?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1) [goto SHTHEPB]
(2,R,D) [goto AHEPLIV]

AAU.360_00.000

Instrument Variable Name: AHEPLIV
Question Text:

Have you ever lived with someone who had hepatitis?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who have never had hepatitis; Ref/DK if ever had hepatitis
Skip Instructions:

(1,2,R,D) [goto SHTHEPB]

AAU.370_00.000

Instrument Variable Name: SHTHEPB
Question Text:

Have you EVER received the hepatitis B vaccine?
*Read if necessary: This is given in three separate doses and has been available since 1991. It is recommended for newborn infants, adolescents, and people such as health care workers, who may be exposed to the hepatitis B virus.

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1) [goto SHEPDOS]
(2,R,D) [goto next section]

[p. 15]

AAU.380_00.000

Instrument Variable Name: SHEPDOS
Question Text:

Did you receive at least 3 doses of the hepatitis B vaccine, or less than 3 doses?

1 Received at least 3 doses
2 Received less than 3 doses
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who have ever received the Hepatitis B vaccine
Skip Instructions:

(1,2,R,D) [goto next section]

[p. 1]

2004 NHIS Questionnaire - Sample Adult
AIDS Knowledge and Attitudes

ADS.010_00.000

Instrument Variable Name: BLDGV
Question Text:

Now, I am going to ask about giving blood donations to a blood bank such as the American Red Cross.
Have you donated blood since March 1985?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1) [goto BLDG12M]
(2,R,D) [goto HIVTST]

ADS.020_00.000

Instrument Variable Name: BLDG12M
Question Text:

During the PAST 12 MONTHS, that is, since [fill: 12-month ref. Date], have you donated blood?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who have given blood since March 1985
Skip Instructions:

(1,2,R,D) [goto HIVTST]

ADS.040_00.000

Instrument Variable Name: HIVTST
Question Text:

The next questions are about the test for HIV (the virus that causes AIDS).
[fill: Except for tests you may have had as part of blood donations, have you ever been tested for HIV?/Have you ever been tested for HIV?]

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1) [goto TST12M_M]
(2) [goto WHYTST]
(R,D) [goto EXTST12M]

[p. 2]

ADS.050_00.000

Instrument Variable Name: WHYTST
Question Text:

(book) A10
I am going to show you a list of reasons why some people have not been tested for HIV (the virus that causes AIDS).
Which one of these would you say is the MAIN reason why you have not been tested?

01 It's unlikely you've been exposed to HIV
02 You were afraid to find out if you were HIV positive (that you had HIV)
03 You didn't want to think about HIV or about being HIV positive
04 You were worried your name would be reported to the government if you tested positive
05 You didn't know where to get tested
06 You don't like needles
07 You were afraid of losing job, insurance, housing, friends, family, if people knew you were positive for AIDS infection
08 Some other reason
09 No particular reason
97 Refused
99 Don't know

Card A10

1. It's unlikely you've been exposed to HIV
2. You were afraid to find out if you were HIV positive (that you had HIV)
3. You didn't want to think about HIV or about being HIV positive
4. You were worried your name would be reported to the government if you tested positive
5. You didn't know where to get tested
6. You don't like needles
7. You were afraid of losing job, insurance, housing, friends, family, if people knew you were positive for AIDS infection
8. Some other reason (Specify)
9. No particular reason

Universe Text: Sample adults 18+ who have not been tested for HIV
Skip Instructions:

(1-7,9,R,D) [goto EXTST12M]
(8) [goto WHYSPEC]

ADS.055_00.000

Instrument Variable Name: WHYSPEC
Question Text:

What was the main reason why you have not been tested?

7 Refused
9 Don't know
Verbatim Verbatim Response

Universe Text: Sample adults 18+ with some other reason for no HIV test
Skip Instructions:

(20 char long) [goto EXTST12M]

[p. 3]

ADS.060_01.000

Instrument Variable Name: TST12M_M
Question Text:

1 of 2
[fill: Not including blood donations, in what month and year was your last test for HIV (the virus that causes AIDS)?/In what month and year was your last test for HIV, (the virus that causes AIDS)?]
*Enter month of last HIV test.
*Enter "96" to go to the time period format.

01 January
02 February
03 March
04 April
05 May
06 June
07 July
08 August
09 September
10 October
11 November
12 December
96 Time period format
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who have been tested for HIV/AIDS
Skip Instructions:

(R,96) [goto TIMETST]
(1-12,D) [goto TST12M_Y]

ADS.060_02.000

Instrument Variable Name: TST12M_Y
Question Text:

2 of 2
*Enter year of last HIV test.

1985-2005 1985-2005
9996Time period format
9997 Refused
9999 Don't know

Universe Text: Sample adults 18+ who gave a month for their last HIV test or who didn't know the month
Skip Instructions:

(1880-2030) [goto REATST]
(R,D) [goto TIMETST]
[if TST12M_M and TST12M_Y = a future date] goto ERR1_TST12M_Y
[if TST12M_M and TST12M_Y = a date prior to birth date] goto ERR2_TST12M_Y

ADS.061_00.000

Instrument Variable Name: TIMETST
Question Text:

Was it:
*Read answer categories.

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 2 years ago
4 More than 2 years, but not more than 5 years ago
5 More than 5 years ago
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who have been tested for HIV who refused or or requested the time period format at TEST12M_M or refused or don't know the year of their last HIV test.
Skip Instructions:

(1-5,R,D) [goto REATST]

ADS.065_00.000

Instrument Variable Name: REATST
Question Text:

(book) A11.
I am going to show you a list of reasons why some people have been tested for HIV (the virus that causes AIDS).
[fill: Not including your blood donations, which of these would you say was the MAIN reason for your last HIV test?/Which of these would you say was the MAIN reason for your last HIV test?]

01 Someone suggested you should be tested
02 You might have been exposed through sex or drug use
03 You might have been exposed through your work or at work
04 You just wanted to find out if you were infected or not
05 For part of a routine medical check-up, or for hospitalization or surgical procedure
06 You were sick or had a medical problem
07 You were pregnant or delivered a baby
08 For health or life insurance coverage
09 For military induction, separation, or military service
10 For immigration
11 For marriage license or to get married
12 You were concerned you could give HIV to someone
13 You wanted medical care or new treatments if you tested positive
14 Some other reason
15 No particular reason
97 Refused
99 Don't know

Card A11

1. Someone suggested you should be tested
2. You might have been exposed through sex or drug use
3. You might have been exposed through your work or at work
4. You just wanted to find out if you were infected or not
5. For part of a routine medical check-up, or for hospitalization or surgical procedure
6. You were sick or had a medical problem
7. You were pregnant or delivered a baby
8. For health or life insurance coverage
9. For military induction, separation, or military service
10. For immigration
11. For marriage license or to get married
12. You were concerned you could give HIV to someone
13. You wanted medical care or new treatments if you tested positive
14. Some other reason (Specify)
15. No particular reason

Universe Text: Sample adults 18+ who have been tested for HIV
Skip Instructions:

(1)[goto REASWHO]
(2-13,15,R,D) [goto LASTST]
(14) [goto REASPEC]

[p. 5]

ADS.066_00.000

Instrument Variable Name: REASWHO
Question Text:

Who suggested you should be tested - a doctor, nurse or other health care professional, a sex partner, someone at the health department, or someone else?

1 Doctor, nurse or other health care professional
2 Sex partner
3 Someone at health department
4 Family member or friend
5 Other
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who have been tested for HIV because someone suggested it
Skip Instructions:

(1-4,R,D) [goto LASTST]
(5) [goto WHOSPEC]

ADS.067_00.000

Instrument Variable Name: WHOSPEC
Question Text:

Who suggested you should be tested?

7 Refused
9 Don't know
Verbatim Verbatim Response

Universe Text: Sample adults 18+ who have been tested for HIV because someone not listed in REASWHO suggested it
Skip Instructions:

(20 char long) [goto LASTST]

ADS.069_00.000

Instrument Variable Name: REASPEC
Question Text:

What was the main reason for your last HIV test?

7 Refused
9 Don't know
Verbatim Verbatim Response

Universe Text: Sample adults 18+ who have been tested for HIV for some reason not listed in REATST
Skip Instructions:

(20 char long)[goto LASTST]

[p. 6]

ADS.070_00.000

Instrument Variable Name: LASTST
Question Text:

(book) A12
[fill: Not including your blood donations, where did you have your last HIV test?/Where did you have your last HIV test?]

01 Private doctor/HMO
02 AIDS clinic/counseling/testing site
03 Hospital, emergency room, outpatient clinic
04 Other type of clinic
05 Public health department
06 At home
07 Drug treatment facility
08 Military induction or military service site
09 Immigration site
10 In a correctional facility (jail or prison)
11 Other location
97 Refused
99 Don't know

Card A12

1. Private doctor/HMO
2. AIDS clinic/counseling/testing site
3. Hospital, emergency room, outpatient clinic
4. Other type of clinic
5. Public health department
6. At home
7. Drug treatment facility
8. Military induction or military service site
9. Immigration site
10. In a correctional facility (jailor prison)
11. Other location (Specify)

Universe Text: Sample adults 18+ who have been tested for HIV
Skip Instructions:

(1-3,5,7-10,R,D) [goto GIVNAM]
(4) [goto CLINTYPE]
(6) [goto WHOADM]
(11) [goto LASTSPEC]

ADS.072_00.000

Instrument Variable Name: CLINTYP
Question Text:

What type of clinic did you go to for your last HIV test?

01 Family planning clinic
02 Prenatal clinic
03 Tuberculosis clinic
04 STD clinic
05 Community health clinic
06 Clinic run by employer or insurance company
07 Other
97 Refused
99 Don't know

Universe Text: Sample adults 18+ who have been tested for HIV at an other type of clinic
Skip Instructions:

(1-7,R,D) [goto GIVNAM]

[p. 7]

ADS.074_00.000

Instrument Variable Name: WHOADM
Question Text:

Was this test administered by a nurse or other health worker, or did you use a self-sampling kit?

1 Nurse or health worker
2 Self-sampling kit
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who have been tested for HIV at home
Skip Instructions:

(1,2,R,D) [goto GIVNAM]

ADS.076_00.000

Instrument Variable Name: LASTSPEC
Question Text:

Where did you have your last HIV test?
*This should be a specific location that is not on the list.

7 Refused
9 Don't know
Verbatim Verbatim Response

Universe Text: Sample adults 18+ who were tested at an other location
Skip Instructions:

(20 char long) [goto GIVNAM]

ADS.080_00.000

Instrument Variable Name: GIVNAM
Question Text:

The last time you were tested, did you have to give your first and last names?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who have been tested for HIV
Skip Instructions:

(1,2,R,D) [goto EXTST12M]

ADS.110_00.000

Instrument Variable Name: EXTST12M
Question Text:

[fill: Do you expect to have another test for HIV in the next 12 months, not including blood donations?/Do you expect to have a test for HIV in the next 12 months, not including blood donations?]

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,D,R) [goto CHNSADS]

[p. 8]

ADS.140_00.000

Instrument Variable Name: CHNSADS
Question Text:

What are your chances of GETTING HIV (the virus that causes AIDS)?
Would you say high, medium, low, or none?

1 High
2 Medium
3 Low
4 None
5 Already have HIV or AIDS
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1-5,R,D) [goto STMTRU]

ADS.150_00.000

Instrument Variable Name: STMTRU
Question Text:

(book) A13
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.
*Read if necessary.
(a) You have hemophilia and have received clotting factor concentrations.
(b) You are a man who has had sex with other men, even just one time.
(c) You have taken street drugs by needle, even just one time.
(d) You have traded sex for money or drugs, even just one time.
(e) You have tested positive for HIV (the virus that causes AIDS).
(f) You have had sex (even just one time) with someone who would answer "yes" to any of these statements.

Card A13

a. You have hemophilia and have received clotting factor concentrations.
b. You are a man who has had sex with other men, even just one time.
c. You have taken street drugs by needle, even just one time.
d. You have traded sex for money or drugs, even just one time.
e. You have tested positive for HIV (the virus that causes AIDS).
f. You have had sex (even just one time) with someone who would answer "yes" to any of these statements.

1 Yes, at least one statement is true
2 No, none of these statements are true
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D) [If AGE GE (50) [go to TBHRD] else [go to STD]]

[p. 9]

ADS.160_00.000

Instrument Variable Name: STD
Question Text:

The next questions are about other sexually transmitted diseases or STDs. STDs are also known as venereal diseases or VD. Examples of STDs are gonorrhea, chlamydia (CLUH-MIH-DEE-UH), syphilis, herpes, and genital warts.
In the past five years, have you had an STD other than HIV or AIDS?
*If asked, tell respondent to include newly contracted STDs and recurring flare-ups of previously contracted STDs.

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18-49
Skip Instructions:

(1) [goto STDDOC]
(2,R,D) [goto TBHRD]

ADS.170_00.000

Instrument Variable Name: STDDOC
Question Text:

The last time you had an STD other than HIV or AIDS, did you see a doctor or other health professional to get it checked?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18 - 49 who have had an STD other than HIV or AIDS in the past 5 years
Skip Instructions:

(1) [goto STDWHER]
(2,R,D) [goto TBHRD]

ADS.180_00.000

Instrument Variable Name: STDWHER
Question Text:

Where did you go to be checked?
*Read answer choices only if necessary.

1 Private doctor
2 Family planning clinic
3 STD clinic
4 Emergency room
5 Health department
6 Some other place
7 Refused
9 Don't know

Universe Text: Sample adults 18-49 who have had an STD other than HIV or AIDS who saw a doctor or other health professional
Skip Instructions:

(1-5,R,D) [goto TBHRD]
(6) [goto STDWOTH]

ADS.190_00.000

Instrument Variable Name: STDWOTH
Question Text:

Where did you go to be checked?

7 Refused
9 Don't know
Verbatim Verbatim Response

Universe Text: Sample adults 18-49 who have had an STD other than HIV or AIDS who were tested at some other place
Skip Instructions:

(20 char long) [goto TBHRD]

ADS.200_00.000

Instrument Variable Name: TBHRD
Question Text:

The next questions are about tuberculosis, or TB.
Have you ever heard of tuberculosis?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1) [goto TBKNOW]
(2,R,D) [goto HOMELESS]

ADS.210_00.000

Instrument Variable Name: TBKNOW
Question Text:

Have you ever personally known anyone who had TB?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who have heard of tuberculosis
Skip Instructions:

(1,2,R,D) [goto TB]

[p. 11]

ADS.220_00.000

Instrument Variable Name: TB
Question Text:

How much do you know about TB - a lot, some, a little, or nothing?

1 A lot
2 Some
3 A little
4 Nothing
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who have heard of tuberculosis
Skip Instructions:

(1-3) [goto TBSPRD]
(4) [goto TBCHANC]
(R,D) [goto HOMELESS]

ADS.230_00.000

Instrument Variable Name: TBSPRD
Question Text:

(book) A14
How is TB spread?
*Probe: Can TB be spread in any other way?
*Mark all that apply, separate with commas.

1 Breathing the air around a person who is sick with TB
2 Sharing eating/drinking utensils
3 Through semen or vaginal secretions shared during sexual intercourse
4 From smoking
5 From mosquito or other insect bites
6 Other
7 Refused
9 Don't know

Card A14
You may choose more than one.

1. Breathing the air around a person who is sick with TB
2. Sharing eating/drinking utensils
3. Through semen or vaginal secretions shared during sexual intercourse
4. From smoking
5. From mosquito or other insect bites
6. Other

Universe Text: Sample adults 18+ who have knowledge of tuberculosis
Skip Instructions:

(1-6,R,D) goto TBCURED

ADS.240_00.000

Instrument Variable Name: TBCURED
Question Text:

As far as you know, can TB be cured?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who have knowledge of tuberculosis
Skip Instructions:

(1,2,R,D) [goto TBCHANC]

[p. 12]

ADS.250_00.000

Instrument Variable Name: TBCHANC
Question Text:

What are your chances of getting TB? Would you say high, medium, low, or none?

1 High
2 Medium
3 Low
4 None
5 Already have TB
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who have knowledge or heard of tuberculosis or know nothing about tuberculosis
Skip Instructions:

(1-5,R,D) [goto TBSHAME]

ADS.260_00.000

Instrument Variable Name: TBSHAME
Question Text:

(Fill1: If a member of your family were diagnosed with TB, would you feel ashamed or embarrassed?)
(Fill2: If you or a member of your family were diagnosed with TB, would you feel ashamed or embarrassed?)

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who have knowledge or heard of tuberculosis or know nothing about tuberculosis
Skip Instructions:

(1,2,R,D) [goto HOMELESS]

ADS.270_00.000

Instrument Variable Name: HOMELESS
Question Text:

Have you ever spent more than 24 hours living on the streets, in a shelter, or in a jail or prison?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+
Skip Instructions:

(1,2,R,D) [goto next section]

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