[p. 1]
2004 NHIS Questionnaire -- Sample Adult
Adult Identification
Question Text:
If refused enter CTRL-R
2 Not available
3 Physical or mental condition prohibits responding
7 Refused
Skip Instructions:
[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
Question Text:
Is a family member or caregiver that is knowledgeable about [fill: Sample Adult name]'s health available?
2 No
Skip Instructions:
(2) [goto PROX3]
[p. 2]
Question Text:
What is this person's relationship to [fill: Sample Adult name]?
2 Relative who doesn't live in household
3 Other caregiver
4 Other
7 Refused
9 Don't know
Skip Instructions:
Question Text:
Can a callback with someone knowledgeable about [fill: Sample Adult name]'s health be arranged?
2 No
Skip Instructions:
(2) [store (3) in ASTAT]
[if recontact.RCIFLAG () 1]
[goto recontact.RCI_BEGIN procedure]
[else]
[goto back.OUTCOMEB1 procedure]
[endif]
Question Text:
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".
2 No
Skip Instructions:
(2) [goto AIDSEX]
[p. 3]
Question Text:
Are you Male or Female?
2 Female
Skip Instructions:
[goto ERR_AIDSEX]
[reset AIDVERF_S]
[goto AIDVERF_S]
Question Text:
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".
2 No
Skip Instructions:
(2) [goto AIDAGE]
Question Text:
997 Refused
999 Don't know
Skip Instructions:
[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]
Question Text:
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".
2 No
Skip Instructions:
(1) [if AGE of Sample Adult le (17)]
[goto NO_MORE]
[else]
[goto beginning of adult.asd]
[endif]
(2) [goto AIDDOB_M]
Question Text:
What is your birthday?
*Enter month of birth.
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
Skip Instructions:
[p. 5]
Question Text:
*Enter day of birth.
97 Refused
99 Don't know
Skip Instructions:
If days not valid, goto ERR_AIDDOB_D
Question Text:
*Enter year of birth.
Skip Instructions:
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
Question Text:
(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?
2 No
7 Refused
9 Don't know
Skip Instructions:
else if DOINGLW2 = 3,5 [goto EVERWRK]
(2)[go to WRKCOR]
(R,D)go to EVERWRK
Question Text:
What is your correct working status?
*Read answer categories.
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
Skip Instructions:
(2,5) [goto WHYNOWK2]
(3,R,D) [goto EVERWRK]
[p. 2]
Question Text:
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
Skip Instructions:
[goto EVERWRK]
endif
Question Text:
(Fill2: What is the main reason you did not have a job or business last week?)
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
Skip Instructions:
[goto WHOWRK]
else [goto EVERWRK]
[p. 3]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,R,D) [goto next section]
Question Text:
(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))
9 Don't know
Verbatim Verbatim Response
Skip Instructions:
Question Text:
What kind of business or industry was this? (For example: TV and radio mgt., retail shoe store, State Department of Labor)
9 Don't know
Verbatim Verbatim Response
Skip Instructions:
[p. 4]
Question Text:
What kind of work were you doing? (For example: farming, mail clerk, computer specialist.)
9 Don't know
Verbatim Verbatim Response
Skip Instructions:
Question Text:
What were your most important activities on this job or business? (For example: sells cars, keeps account books, operates printing press.)
9 Don't know
Verbatim Verbatim Response
Skip Instructions:
Question Text:
(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.
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
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
Skip Instructions:
(5) [goto BUSINC]
[p. 5]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
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.
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
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
[p. 6]
Question Text:
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.
997 Refused
999 Don't know
Skip Instructions:
(R,D) [goto HOURPD if EVERWRK eq 1 and (WHYNOWK2 eq 03 or AGE GE 65);
else goto WRKLONGH]
Question Text:
*Enter time period.
2 Week(s)
3 Month(s)
4 Year(s)
Skip Instructions:
[goto HOURPD]_
else [goto WRKLONGH]
(4) if WRKLONGN gt AGE then
[goto ERR_WRKLONGT]
[p. 7]
Question Text:
(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?)
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
(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?)
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
(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?
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 8]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 1]
2004 NHIS Questionnaire - Sample Adult
Adult Conditions
Question Text:
Have you EVER been told by a doctor or other health professional that you had
...Hypertension, also called high blood pressure?
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,R,D) [goto CHDEV]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
...Coronary heart disease?
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 2]
Question Text:
Have you EVER been told by a doctor or other health professional that you had
...Angina, also called angina pectoris?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
Have you EVER been told by a doctor or other health professional that you had
...A heart attack (also called myocardial infarction)?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
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)?
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 3]
Question Text:
Have you EVER been told by a doctor or other health professional that you had
...A stroke?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
Have you EVER been told by a doctor or other health professional that you had
...Emphysema?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,R,D) [goto ULCEV]
[p. 4]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,R,D) [go to ULCEV]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
...An ulcer? This could be a stomach, duodenal or peptic ulcer.
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,R,D)[goto CANEV]
[p. 5]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
...Cancer or a malignancy of any kind?
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,R,D) [goto DIBEV]
[p. 6]
Question Text:
*Enter code for the first kind of cancer.
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
Skip Instructions:
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
Question Text:
*Enter '96' for no more.
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
96 No more
97 Refused
99 Don't know
Skip Instructions:
(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
Question Text:
*Enter '96' for no more.
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
96 No more
97 Refused
99 Don't know
Skip Instructions:
(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
Question Text:
*Enter '96' for no more.
96 No more
Skip Instructions:
Question Text:
997 Refused
999 Don't know
Skip Instructions:
(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
Question Text:
997 Refused
999 Don't know
Skip Instructions:
(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
Question Text:
997 Refused
999 Don't know
Skip Instructions:
(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
Question Text:
2 No
3 Borderline
7 Refused
9 Don't know
Skip Instructions:
(2,3,R,D) [goto AHAYFYR]
Question Text:
85 85+ years
97 Refused
99 Don't know
Skip Instructions:
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]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
...Hay fever?
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 12]
Question Text:
DURING THE PAST 12 MONTHS, have you been told by a doctor or other health professional that you had
...Sinusitis?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
DURING THE PAST 12 MONTHS, have you been told by a doctor or other health professional that you had
...Chronic bronchitis?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
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.
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 13]
Question Text:
DURING THE PAST 12 MONTHS, have you been told by a doctor or other health professional that you had
......Any kind of liver condition?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,R,D) [goto ARTH]
[p. 14]
Question Text:
Which joints are affected?
*Enter all that apply, separate with commas.
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
(2) Left
Elbows
(4) Left
Hips
(6) Left
Wrists
(8) Left
Knees
(10) Left
Ankles
(12) Left
Toes
(14) Left
Shoulders
(2) Left
Fingers, Thumb
(16) Left
Knees
(10) Left
( ) = joint
You may choose more than one.
Skip Instructions:
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 15]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 16]
Question Text:
During the PAST THREE MONTHS, did you have
... Neck pain?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
During the PAST THREE MONTHS, did you have
... Low back pain?
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,R,D) [goto PAINFACE]
ACN.320_00.000
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 17]
Question Text:
... Facial ache or pain in the jaw muscles or the joint in front of the ear?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
During the PAST THREE MONTHS, did you have
...Severe headache or migraine?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
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?
2 No
7 Refused
9 Don't know
Skip Instructions:
ACN.360_00.000
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
Have you ever worn a hearing aid?
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 19]
Question Text:
2 A little trouble
3 A lot of trouble
4 Deaf
7 Refused
9 Don't know
Skip Instructions:
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,R,D) [goto LUPPRT]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 20]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
Skip Instructions:
ACN.471_01.000
Question Text:
During the PAST 30 DAYS, how often did you feel
...So sad that nothing could cheer you up?
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
2. Most of the time
3. Some of the time
4. A Little of the time
5. None of the time
Skip Instructions:
[p. 21]
Question Text:
*Read lead-in if necessary:
During the PAST 30 DAYS, how often did you feel
...Nervous?
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
2. Most of the time
3. Some of the time
4. A Little of the time
5. None of the time
Skip Instructions:
Question Text:
*Read lead-in if necessary:
During the PAST 30 DAYS, how often did you feel
... Restless or fidgety?
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
2. Most of the time
3. Some of the time
4. A Little of the time
5. None of the time
Skip Instructions:
[p. 22]
Question Text:
*Read lead-in if necessary:
During the PAST 30 DAYS, how often did you feel
... Hopeless?
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
2. Most of the time
3. Some of the time
4. A Little of the time
5. None of the time
Skip Instructions:
Question Text:
*Read lead-in if necessary:
During the PAST 30 DAYS, how often did you feel
...That everything was an effort?
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
2. Most of the time
3. Some of the time
4. A Little of the time
5. None of the time
Skip Instructions:
[p. 23]
Question Text:
*Read lead-in if necessary:
During the PAST 30 DAYS, how often did you feel
...Worthless?
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
2. Most of the time
3. Some of the time
4. A Little of the time
5. None of the time
Skip Instructions:
Question Text:
2 Some
3 A little
4 Not at all
7 Refused
9 Don't know
Skip Instructions:
[p. 1]
2004 NHIS Questionnaire - Sample Adult
Adult Health Status and Limitations
Question Text:
1 Yes
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,R,D) [goto BEDDAYR]
Question Text:
*Enter '0' for None.
001-366 1-366 days
997 Refused
999 Don't know
Skip Instructions:
(120-366) [goto ERR_WKDAYR]
Question Text:
*Enter '0' for None.
001-366 1-366 days
997 Refused
999 Don't know
Skip Instructions:
(120-366) [goto ERR_BEDDAYR]
[p. 2]
Question Text:
2 Worse
3 About the same
7 Refused
9 Don't know
Skip Instructions:
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
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?
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
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity
Skip Instructions:
[p. 3]
Question Text:
*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?
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
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity
Skip Instructions:
Question Text:
*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?
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
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity
Skip Instructions:
[p. 4]
Question Text:
*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?
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
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity
Skip Instructions:
Question Text:
*Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you to...
...Stoop, bend, or kneel?
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
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity
Skip Instructions:
[p. 5]
Question Text:
*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?
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
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity
Skip Instructions:
Question Text:
*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?
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
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity
Skip Instructions:
[p. 6]
Question Text:
*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?
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
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity
Skip Instructions:
Question Text:
*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?
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
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity
Skip Instructions:
[p. 7]
Question Text:
*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?
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
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity
Skip Instructions:
Question Text:
*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?
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
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity
Skip Instructions:
[p. 8]
Question Text:
*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)?
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
1. Only a little difficult
2. Somewhat difficult
3. Very difficult
4. Can't do at all
6. Do not do this activity
Skip Instructions:
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]
Question Text:
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.
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
You may choose more than one.
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
Skip Instructions:
(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
Question Text:
9 Don't know
Verbatim Verbatim Response
Skip Instructions:
)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
Question Text:
9 Don't know
Verbatim Verbatim Response
Skip Instructions:
)ENTER( only with no description [goto ERR1_AFLHCA_S1]
[p. 11]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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
Question Text:
*Enter time period for time with vision problem or problem seeing.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL01T
[if [AHCL01N = Number greater than person years old and AHCL01T= 4]] goto
ERR1_AHCL01T
[p. 12]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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
Question Text:
*Enter time period for time with hearing problem.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL02T
[if [AHCL02N = Number greater than person years old and AHCL02T= 4]] goto
ERR1_AHCL02T
[p. 13]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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
Question Text:
*Enter time period for time with arthritis or rheumatism.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL03T
[if [AHCL03N = Number greater than person years old and AHCL03T= 4]] goto
ERR1_AHCL03T
[p. 14]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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
Question Text:
*Enter time period for time with back or neck problem.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL04T
[if [AHCL04N = Number greater than person years old and AHCL04T= 4]] goto
ERR1_AHCL04T
[p. 15]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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
Question Text:
*Enter time period for time with fracture, bone, or joint injury.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL05T
[if [AHCL05N = Number greater than person years old and AHCL05T= 4]] goto
ERR1_AHCL05T
[p. 16]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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
Question Text:
*Enter time period for time with (fill: other) injury.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL06T
[if [AHCL06N = Number greater than person years old and AHCL06T= 4]] goto
ERR1_AHCL06T
[p. 17]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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
Question Text:
*Enter time period for time with heart problem.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL07T
[if [AHCL07N = Number greater than person years old and AHCL07T= 4]] goto
ERR1_AHCL07T
[p. 18]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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
Question Text:
*Enter time period for time with stroke problem.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL08T
[if [AHCL08N = Number greater than person years old and AHCL08T= 4]] goto
ERR1_AHCL08T
[p. 19]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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
Question Text:
*Enter time period for time with hypertension or high blood pressure.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL09T
[if [AHCL09N = Number greater than person years old and AHCL09T= 4]] goto
ERR1_AHCL09T
[p. 20]
Question Text:
How long have you had diabetes?
*Enter number for time with diabetes.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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
Question Text:
*Enter time period for time with diabetes.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL10T
[if [AHCL10N = Number greater than person years old and AHCL10T= 4]] goto
ERR1_AHCL10T
[p. 21]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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
Question Text:
*Enter time period for time with lung or breathing problem (e.g. asthma and emphysema).
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL11T
[if [AHCL11N = Number greater than person years old and AHCL11T= 4]] goto
ERR1_AHCL11T
[p. 22]
Question Text:
How long have you had cancer?
*Enter number for time with cancer.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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
Question Text:
*Enter time period for time with cancer.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL12T
[if [AHCL12N = Number greater than person years old and AHCL12T= 4]] goto
ERR1_AHCL12T
[p. 23]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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
Question Text:
*Enter time period for time with mental retardation.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL14T
[if [AHCL14N = Number greater than person years old and AHCL14T= 4]] goto
ERR1_AHCL14T
[p. 24]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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
Question Text:
*Enter time period for time with developmental problem.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL15T
[if [AHCL15N = Number greater than person years old and AHCL15T= 4]] goto
ERR1_AHCL15T
[p. 25]
Question Text:
How long have you had senility?
*Enter number for time with senility.
*Enter '95'' for 95 or more.
*Enter "96" if since birth.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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
Question Text:
*Enter time period for time with senility.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL16T
[if [AHCL16N = Number greater than person years old and AHCL16T= 4]] goto
ERR1_AHCL16T
[p. 26]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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
Question Text:
*Enter time period for time with depression, anxiety, or emotional problem.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL17T
[if [AHCL17N = Number greater than person years old and AHCL17T= 4]] goto
ERR1_AHCL17T
[p. 27]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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
Question Text:
*Enter time period for time with weight problem.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL18T
[if [AHCL18N = Number greater than person years old and AHCL18T= 4]] goto
ERR1_AHCL18T
[p. 28]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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
Question Text:
*Enter time period for time with missing limb.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL19T
[if [AHCL19N = Number greater than person years old and AHCL19T= 4]] goto
ERR1_AHCL19T
[p. 29]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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)]
Question Text:
*Enter time period for time with kidney, bladder or renal problem.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL20T
[if [AHCL20N = Number greater than person years old and AHCL20T= 4]] goto
ERR1_AHCL20T
[p. 30]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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
Question Text:
*Enter time period for time with circulation problem.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL21T
[if [AHCL21N = Number greater than person years old and AHCL21T= 4]] goto
ERR1_AHCL21T
[p. 31]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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
Question Text:
*Enter time period for time with benign tumors or cysts.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL22T
[if [AHCL22N = Number greater than person years old and AHCL22T= 4]] goto
ERR1_AHCL22T
[p. 32]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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)]
Question Text:
*Enter time period for time with fibromyalgia or lupus.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL23T
[if [AHCL23N = Number greater than person years old and AHCL23T= 4]] goto
ERR1_AHCL23T
[p. 33]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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)]
Question Text:
*Enter time period for time with osteoporosis or tendinitis.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL24T
[if [AHCL24N = Number greater than person years old and AHCL24T= 4]] goto
ERR1_AHCL24T
[p. 34]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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)]
Question Text:
*Enter time period for time with epilepsy or seizures.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL25T
[if [AHCL25N = Number greater than person years old and AHCL25T= 4]] goto
ERR1_AHCL25T
[p. 35]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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)]
Question Text:
*Enter time period for time with multiple sclerosis or muscular dystrophy.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL26T
[if [AHCL26N = Number greater than person years old and AHCL26T= 4]] goto
ERR1_AHCL26T
[p. 36]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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)]
Question Text:
*Enter time period for time with polio(myelitis), paralysis or para/quadriplegia.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL27T
[if [AHCL27N = Number greater than person years old and AHCL27T= 4]] goto
ERR1_AHCL27T
[p. 37]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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)]
Question Text:
*Enter time period for time with Parkinson's disease or tremors.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL28T
[if [AHCL28N = Number greater than person years old and AHCL28T= 4]] goto
ERR1_AHCL28T
[p. 38]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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)]
Question Text:
*Enter time period for time with nerve damage.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL29T
[if [AHCL29N = Number greater than person years old and AHCL29T= 4]] goto
ERR1_AHCL29T
[p. 39]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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)]
Question Text:
*Enter time period for time with hernia.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL30T
[if [AHCL30N = Number greater than person years old and AHCL30T= 4]] goto
ERR1_AHCL30T
[p. 40]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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)]
Question Text:
*Enter time period for time with ulcer.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL31T
[if [AHCL31N = Number greater than person years old and AHCL31T= 4]] goto
ERR1_AHCL31T
[p. 41]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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)]
Question Text:
*Enter time period for time with varicose veins or hemorrhoids.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL32T
[if [AHCL32N = Number greater than person years old and AHCL32T= 4]] goto
ERR1_AHCL32T
[p. 42]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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)]
Question Text:
*Enter time period for time with thyroid problem, Grave's disease or gout.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL33T
[if [AHCL33N = Number greater than person years old and AHCL33T= 4]] goto
ERR1_AHCL33T
[p. 43]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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)]
Question Text:
*Enter time period for time with knee problem.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL34T
[if [AHCL34N = Number greater than person years old and AHCL34T= 4]] goto
ERR1_AHCL34T
[p. 44]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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)]
Question Text:
*Enter time period for time with migraine headaches.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(6) goto ERR2_AHCL35T
[if [AHCL35N = Number greater than person years old and AHCL35T= 4]] goto
ERR1_AHCL35T
[p. 45]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(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
Question Text:
*Enter time period for time with {problem in AFLHCA90}.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
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]
Question Text:
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.
95 95+
96 Since birth
97 Refused
99 Don't know
Skip Instructions:
(R)[store "R" in AHCL91T] [goto SMKEV (next section)]
(96)[store "6" in AHCL91T] [goto SMKEV (next section)]
AHS.336_02.000
Question Text:
*Enter time period for time with {problem in AFLHCA91}.
2 Week(s)
3 Month(s)
4 Year(s)
6 Since Birth
7 Refused
9 Don't know
Skip Instructions:
(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
Question Text:
Have you smoked at least 100 cigarettes in your ENTIRE LIFE?
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,R,D)[goto VIGNO]
Question Text:
*Enter '6' if less than 6 years old.
*Enter '95' if 95 years old or older.
*Enter '96' if never smoked regularly.
85 85 years or older
96 Never smoked regularly
97 Refused
99 Don't know
Skip Instructions:
[If SMKREG gt AGE and SMKREG ne (96), goto ERR_SMKREG
Question Text:
2 Some days
3 Not at all
7 Refused
9 Don't know
Skip Instructions:
(2) [goto CIGDAMO]
(3) [goto SMKQTNO]
(R,D) [goto VIGNO]
[p. 2]
Question Text:
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.
95 95+
97 Refused
99 Don't know
Skip Instructions:
(R,D) [goto VIGNO]
AHB.040_02.000
Question Text:
*Enter time period for time since quit smoking.
2 Week(s)
3 Month(s)
4 Year(s)
7 Refused
9 Don't know
Skip Instructions:
(4) [if SMKQTNO gt (AGE - (15)), goto ERR1_SMKQTTP
if (SMKREG + SMKQTNO gt AGE), goto ERR2_SMKQTTP
Question Text:
*Enter '1' if less than 1 cigarette.
*Enter '95' if 95 or more cigarettes.
95 95+ cigarettes
97 Refused
99 Don't know
Skip Instructions:
[p. 3]
Question Text:
*Enter '0' for None.
01-30 1-30 days
97 Refused
99 Don't know
Skip Instructions:
(1-30,R,D) [goto CIGSDA2]
Question Text:
*Enter '1' if less than 1.
*Enter '95' if 95 or more cigarettes.
95 95+ cigarettes
97 Refused
99 Don't know
Skip Instructions:
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 4]
Question Text:
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.
001-995 1-995 time(s)
996 Unable to do this type activity
997 Refused
999 Don't know
Skip Instructions:
(1-995)[goto VIGTP]
AHB.090_02.000
Question Text:
*Enter time period for vigorous leisure-time physical activities.
1 Per day
2 Per week
3 Per month
4 Per year
6 Unable to do this activity
7 Refused
9 Don't know
Skip Instructions:
[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
Question Text:
About how long do you do these vigorous leisure-time physical activities each time?
*Enter number for length of vigorous leisure-time physical activities.
997 Refused
999 Don't know
Skip Instructions:
(R,D)[goto MODNO]
AHB.100_02.000
Question Text:
*Enter time period for length of vigorous leisure-time physical activities.
2 Hours
7 Refused
9 Don't know
Skip Instructions:
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]
Question Text:
*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.
001-995 1-995 time(s)
996 Unable to do this type activity
997 Refused
999 Don't know
Skip Instructions:
(0, 996, R,D)[goto STRNGNO]
AHB.110_02.000
Question Text:
*Enter time period for light or moderate leisure-time physical activities
1 Per day
2 Per week
3 Per month
4 Per year
6 Unable to do this activity
7 Refused
9 Don't know
Skip Instructions:
[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
Question Text:
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.
997 Refused
999 Don't know
Skip Instructions:
(R,D)[goto STRNGNO]
AHB.120_02.000
Question Text:
*Enter time period for length of light or moderate leisure-time physical activities.
2 Hours
7 Refused
9 Don't know
Skip Instructions:
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]
Question Text:
*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
001-995 1-995 time(s)
996 Unable to do this type activity
997 Refused
999 Don't know
Skip Instructions:
(0, 996,R,D)[goto ALC1YR]
AHB.130_02.000
Question Text:
*Enter time period for strengthening activities
1 Per day
2 Per week
3 Per month
4 Per year
6 Unable to do this activity
7 Refused
9 Don't know
Skip Instructions:
[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]
Question Text:
In ANY ONE YEAR, have you had at least 12 drinks of any type of alcoholic beverage?
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,R,D) [goto ALCLIFE]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,R,D) [goto AHGT_FT]
Question Text:
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.
001-365 1-365 day(s)
997 Refused
999 Don't know
Skip Instructions:
(0,R,D)[goto AHGT_FT]
AHB.160_02.000
Question Text:
*Enter time period for how often alcoholic beverages were consumed in the past year.
1 Week
2 Month
3 Year
7 Refused
9 Don't know
Skip Instructions:
[If (ALC12MNO gt (7) and ALC12MTP = (1)) or (ALC12MNO gt (31) and ALC12MTP = (2)) or (ALC12MNO gt (365) and ALC12MTP = (3)) goto ERR_ALC12MTP]
Question Text:
*Enter '1' if less than 1 drink.
*Enter '95' if 95 or more drinks.
95 95+ drinks
97 Refused
99 Don't know
Skip Instructions:
(10-95)[goto ERR_ALCAMT]
[p. 11]
Question Text:
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.
001-365 1-365 day(s)
997 Refused
999 Don't know
Skip Instructions:
(0,R,D)[goto AHGT_FT]
AHB.180_02.000
Question Text:
*Enter time period for days per week, per month or per year.
1 Per week
2 Per month
3 Per year
7 Refused
9 Don't know
Skip Instructions:
[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]
Question Text:
*Enter "M" to record metric measurements
97 Refused
99 Don't know
M Metric
Skip Instructions:
(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
Question Text:
*Enter '0' if exactly [fill1: AHGT_FT] feet tall.
97 Refused
99 Don't know
Skip Instructions:
(empty) [goto ERR_AHGT_IN]
AHB.190_03.000
Question Text:
*Enter height in metric.
7 Refused
9 Don't know
Skip Instructions:
(R,D) [goto AWGT_LB]
(empty) [goto ERR_AHGT_M]
AHB.190_04.000
Question Text:
997 Refused
999 Don't know
Skip Instructions:
[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]
Question Text:
*Enter "M" to record metric measurements
*Enter '500' for 500 pounds or more
997 Refused
999 Don't know
M Metric
Skip Instructions:
[if AWGT_LB lt (50) or gt (500) goto ERR_AWGT_LB
(R,D)[goto SLEEP]
(M) [goto AWGT_KG]
AHB.200_02.000
Question Text:
*Enter weight in kilograms
997 Refused
999 Don't know
Skip Instructions:
[If AWGT_KG lt (22) or K gt (226)goto ERR_AWGT_KG]
[p. 14]
Question Text:
*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.
97 Refused
99 Don't know
Skip Instructions:
[If SLEEP eq (1-5) goto ERR_SLEEP]
[p. 1]
2004 NHIS Questionnaire - Sample Adult
Adult Access to Health Care and Utilization
Question Text:
Is there a place that you USUALLY go to when you are sick or need advice about your health?
2 There is NO place
3 There is MORE THAN ONE place
7 Refused
9 Don't know
Skip Instructions:
(2,R,D) [go to AHCPLKND]
Question Text:
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
Skip Instructions:
(6,R,D) [go to AHCPLKND]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,D,R) [go to AHCPLKND]
[p. 2]
Question Text:
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
Skip Instructions:
ELSE goto AHCCHGYR
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,R,D)[goto AHCDLY_1]
AAU.050_00.000
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 3]
Question Text:
Have you delayed getting care for any of the following reasons in the PAST 12 MONTHS?
...You couldn't get through on the telephone.
2 No
7 Refused
9 Don't know
Skip Instructions:
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 an appointment soon enough.
2 No
7 Refused
9 Don't know
Skip Instructions:
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?
...Once you get there, you have to wait too long to see the doctor.
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 4]
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?
...The (clinic/doctor's) office wasn't open when you could get there.
2 No
7 Refused
9 Don't know
Skip Instructions:
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 didn't have transportation.
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
...Prescription medicines.
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 5]
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?
...Mental health care or counseling.
2 No
7 Refused
9 Don't know
Skip Instructions:
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?
...Dental care (including check ups).
2 No
7 Refused
9 Don't know
Skip Instructions:
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?
...Eyeglasses.
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 6]
Question Text:
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.
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
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
Skip Instructions:
Question Text:
...A mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker.
2 No
7 Refused
9 Don't know
Skip Instructions:
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?
...An optometrist, ophthalmologist, or eye doctor (someone who prescribes eyeglasses).
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 7]
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 foot doctor.
2 No
7 Refused
9 Don't know
Skip Instructions:
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?
...Achiropractor.
2 No
7 Refused
9 Don't know
Skip Instructions:
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 physical therapist, speech therapist, respiratory therapist, audiologist, or occupational therapist.
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 8]
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 nurse practitioner, physician assistant, or midwife.
2 No
7 Refused
9 Don't know
Skip Instructions:
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 doctor who specializes in women's health (an obstetrician/gynecologist).
2 No
7 Refused
9 Don't know
Skip Instructions:
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 medical doctor who specializes in a particular medical disease or problem (other than obstetrician/gynecologist, psychiatrist, or ophthalmologist).
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 9]
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 general doctor who treats a variety of illnesses (a doctor in general practice, family medicine, or internal medicine)?
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,R,D) [goto AHERNOYR]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
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.)?
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
1. 1
2. 2-3
3. 4-5
4. 6-7
5. 8-9
6. 10-12
7. 13-15
8. 16 or more
Skip Instructions:
[p. 10]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,R,D)[goto AHCNOYR]
Question Text:
97 Refused
99 Don't know
Skip Instructions:
Question Text:
What was the total number of home visits received during [fill: that month/those months]?
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
2. 2-3
3. 4-5
4. 6-7
5. 8-9
6. 10 -12
7. 13-15
8. 16 or more
Skip Instructions:
[p. 11]
Question Text:
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.
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
1. 1
2. 2-3
3. 4-5
4. 6-7
5. 8-9
6. 10-12
7. 13-15
8. 16 or more
Skip Instructions:
Question Text:
*Read if necessary: This includes both major surgery and minor procedures such as setting bones or removing growths.
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,R,D) [goto AMDLONG].
Question Text:
*Enter "95" for 95 or more times.
95 95+ times
97 Refused
99 Don't know
Skip Instructions:
(11-95)[goto ERR_ASGYR]
[p. 12]
Question Text:
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.
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
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
Skip Instructions:
Question Text:
*Read if necessary: A flu shot is injected in the arm. Do not include an influenza vaccine sprayed in the nose.
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
*Read if necessary: This influenza vaccine is called FluMist (trademark).
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 13]
Question Text:
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.
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,R,D) [goto AHEP]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 14]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,R,D) [goto AHEPLIV]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
*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.
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,R,D) [goto next section]
[p. 15]
Question Text:
2 Received less than 3 doses
7 Refused
9 Don't know
Skip Instructions:
[p. 1]
2004 NHIS Questionnaire - Sample Adult
AIDS Knowledge and Attitudes
Question Text:
Have you donated blood since March 1985?
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,R,D) [goto HIVTST]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
[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?]
2 No
7 Refused
9 Don't know
Skip Instructions:
(2) [goto WHYTST]
(R,D) [goto EXTST12M]
[p. 2]
Question Text:
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?
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
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
Skip Instructions:
(8) [goto WHYSPEC]
ADS.055_00.000
Question Text:
9 Don't know
Verbatim Verbatim Response
Skip Instructions:
[p. 3]
Question Text:
[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.
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
Skip Instructions:
(1-12,D) [goto TST12M_Y]
ADS.060_02.000
Question Text:
*Enter year of last HIV test.
9996Time period format
9997 Refused
9999 Don't know
Skip Instructions:
(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
Question Text:
*Read answer categories.
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
Skip Instructions:
Question Text:
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?]
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
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
Skip Instructions:
(2-13,15,R,D) [goto LASTST]
(14) [goto REASPEC]
[p. 5]
Question Text:
2 Sex partner
3 Someone at health department
4 Family member or friend
5 Other
7 Refused
9 Don't know
Skip Instructions:
(5) [goto WHOSPEC]
ADS.067_00.000
Question Text:
9 Don't know
Verbatim Verbatim Response
Skip Instructions:
Question Text:
9 Don't know
Verbatim Verbatim Response
Skip Instructions:
[p. 6]
Question Text:
[fill: Not including your blood donations, where did you have your last HIV test?/Where did you have your last HIV test?]
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
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)
Skip Instructions:
(4) [goto CLINTYPE]
(6) [goto WHOADM]
(11) [goto LASTSPEC]
Question Text:
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
Skip Instructions:
[p. 7]
Question Text:
2 Self-sampling kit
7 Refused
9 Don't know
Skip Instructions:
Question Text:
*This should be a specific location that is not on the list.
9 Don't know
Verbatim Verbatim Response
Skip Instructions:
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 8]
Question Text:
Would you say high, medium, low, or none?
2 Medium
3 Low
4 None
5 Already have HIV or AIDS
7 Refused
9 Don't know
Skip Instructions:
Question Text:
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.
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.
2 No, none of these statements are true
7 Refused
9 Don't know
Skip Instructions:
[p. 9]
Question Text:
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.
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,R,D) [goto TBHRD]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,R,D) [goto TBHRD]
Question Text:
*Read answer choices only if necessary.
2 Family planning clinic
3 STD clinic
4 Emergency room
5 Health department
6 Some other place
7 Refused
9 Don't know
Skip Instructions:
(6) [goto STDWOTH]
ADS.190_00.000
Question Text:
9 Don't know
Verbatim Verbatim Response
Skip Instructions:
Question Text:
Have you ever heard of tuberculosis?
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,R,D) [goto HOMELESS]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 11]
Question Text:
2 Some
3 A little
4 Nothing
7 Refused
9 Don't know
Skip Instructions:
(4) [goto TBCHANC]
(R,D) [goto HOMELESS]
Question Text:
How is TB spread?
*Probe: Can TB be spread in any other way?
*Mark all that apply, separate with commas.
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
You may choose more than one.
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
Skip Instructions:
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 12]
Question Text:
2 Medium
3 Low
4 None
5 Already have TB
7 Refused
9 Don't know
Skip Instructions:
Question Text:
(Fill2: If you or a member of your family were diagnosed with TB, would you feel ashamed or embarrassed?)
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions: