sc
[p. 1]

2004 NHIS Questionnaire -- Sample Child
Child Identification

CID.001_00.000

Instrument Variable Name: CURRES
Question Text:

*Enter the line number of the person to whom you are speaking.

01-25 Person number of the respondent for Sample Child

Universe Text: Sample child section not started or not completed
Skip Instructions:

if CSTAT () empty and CSTAT () 2 THEN
if ASTAT = empty or ASTAT = 2 THEN
goto adult.aid.SADULT
elseif recontact.RCIFLAG () 1 THEN
goto recontact.RCI_BEGIN procedure
else
goto back.OUTCOMEB1 procedure
endif
goto back.OUTCOMEB1 procedure
endif
(01-25) if this is NOT an allowable line number
goto ERR_CURRES
elseif CURRES = a line number entered in KNOWSC2
store CURRES in CSPAVAIL and CSRESP
goto CSRELTIV
elseif KNOWSC2 = 'Don't know' or 'Refused' or empty (no line numbers in KNOWSC2)
goto KNOAVAIL
else
goto CSPAVAIL
endif

[p. 2]

CID.010_00.000

Instrument Variable Name: CSPAVAIL
Question Text:

The next questions are about [fill1: S.C. name].
Is [fill2:KNOWSC2 names] available to answer some questions about [fill3: HISHER] health?
*Enter line number of available respondent from list or enter '96' if no one is available.
*If refused enter CTRL_R.

01-25 Person # of person available to answer questions about Sample Child
96 No person available

Universe Text: Someone identified as knowledgeable about child's health and knowledgeable person(s) not entered in CURRES
Skip Instructions:

(01-25) if line number not equal one of the line numbers in KNOWSC2
goto child.cid.ERR_CSPAVAIL
else
store child.cid.CSPAVAIL in child.cid.CSRESP
goto child.cid.CSRELTIV
endif
(96) store child.cid.CSPAVAIL in child.cid.CSRESP
goto cbk.CCALLBK1
(R) store (4) in CSTAT(FAMINT)
if ASTAT = empty or ASTAT = 2 THEN
goto adult.aid.SADULT
elseif recontact.RCIFLAG () 1 THEN
goto recontact.RCI_BEGIN procedure
else
goto back.OUTCOMEB1 procedure
endif

CID.030_00.000

Instrument Variable Name: CSRELTIV
Question Text:

(book) C1
[fill1: The next questions are about [fill2: S.C. name]
What is your relationship to [fill2: S.C. name]?

01 Parent (Biological, adoptive, or step)
02 Grandparent
03 Aunt/Uncle

Card C1

1. Parent (Biological, adoptive or step)
2. Grandparent
3. Aunt/Uncle
4. Brother/Sister
5. Other relative
6. Legal guardian
7. Foster parent
8. Other non-relative

Universe Text: Someone identified as knowledgeable about child's health
Skip Instructions:

(1-8,R,D) If CSRESP = demographics.hhc.RELRESP_A
goto child.chs.BWGT_LB
elseif CSRESP = demographics.hhc.HHRESP
goto child.chs.BWGT_LB
else]
goto CSPVERF_S
endif]

[p. 3]

CID.040_00.000

Instrument Variable Name: CSPVERF_S
Question Text:

*Please verify the following information about the sample child before proceeding:
I have recorded [fill1: S.C. name]'s sex as [fill2: Sex of Sample Child]. Is this correct?
*If respondent "refuses" or says "don't know", enter "1" for "yes".

1 Yes
2 No

Universe Text: Respondent is not the person entered in HHRESP or RELRESP_A.
Skip Instructions:

(1) goto CSPVERF_A
(2) goto NEWSEX

CID.041_00.000

Instrument Variable Name: NEWSEX
Question Text:

*Ask if appropriate; otherwise, enter your best guess of the person's sex.
Is [fill: S.C. name] Male or Female?

1 Male
2 Female

Universe Text: Respondent said child's sex is not correct.
Skip Instructions:

(1,2) store NEWSEX in SEX
goto ERR_NEWSEX
reset CSPVERF_S
goto CSPVERF_S

CID.042_00.000

Instrument Variable Name: CSPVERF_A
Question Text:

*Please verify the following information about the sample child before proceeding:
I have recorded [fill1: S.C name]'s age as [fill2: Age of Sample Child] old. Is this correct?
*If respondent "refuses" or says "don't know", enter "1" for "yes".

1 Yes
2 No

Universe Text: Respondent verified child's sex
Skip Instructions:

(1) goto CSPVERF_D
(2) goto NEWAGE

[p. 4]

CID.043_00.000

Instrument Variable Name: NEWAGE
Question Text:

How old is [fill1: S.C. name]?
*If age given in months, weeks, or days, convert age to appropriate year. If less than one year old, enter "0".

000-120 Age in years

Universe Text: Respondent said child's age is not correct
Skip Instructions:

(0-120, Refused, Don't know)
if NEWAGE = Refused or NEWAGE = Don't know or NEWAGE = AGE
reset CSPVERF_A
goto ERR_NEWAGE
else
store NEWAGE in AGE
goto NEWDOB_M

CID.044_00.000

Instrument Variable Name: CSPVERF_D
Question Text:

*Please verify the following information about the sample child before proceeding:
I have recorded [fill1: S.C. name]'s birthday as [fill2: Birthday of Sample Child]. Is this correct?
*If respondent "refuses" or says "don't know", enter "1" for "yes".

1 Yes
2 No

Universe Text: Respondent verified child's sex
Skip Instructions:

(1) if AGE of Sample Child ge (18)
goto CNO_MORE
else
goto child.chs.BWGT_LB
endif
(2) goto NEWDOB_M

[p. 5]

CID.046_01.000

Instrument Variable Name: NEWDOB_M
Question Text:

1 of 3
What is [fill: S.C. name]'s birthday?
*Enter month of birth.

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

Universe Text: Respondent said child's date of birth is not correct or child's age is not correct
Skip Instructions:

(01-12, Refused, Don't know) goto NEWDOB_D

CID.046_02.000

Instrument Variable Name: NEWDOB_D
Question Text:

2 of 3
*Enter day of birth.

01-31 Day of the month

Universe Text: Respondent said child's date of birth is not correct or child's age is not correct
Skip Instructions:

(01-31,Refused,Don't know) goto NEWDOB_Y
If days not valid, goto ERR_NEWDOB_D

[p. 6]

CID.046_03.000

Instrument Variable Name: NEWDOB_Y
Question Text:

3 of 3
*Enter year of birth.

1880-2020 Year of birth

Universe Text: Respondent said child's date of birth is not correct or child's age is not correct
Skip Instructions:

(1880-2020, Refused, Don't know) if CSPVERF_A = No then reset CSPVERF_A to empty
goto CSPVERF_A
elseif CSPVERF_D = No then reset CSPVERF_D to empty
goto CSPVERF_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_NEWDOB_Y
endif
(if birth month = (02) and birth day = (29) and this is not a leap year)
goto ERR2_NEWDOB_Y
endif
(if NEWDOB_M = Ref or DK) or (if NEWDOB_D = Ref or DK) or (if NEWDOB_Y = Ref or DK)
goto ERR3_NEWDOB_Y
else
store NEWDOB_M in DOBM
store NEWDOB_D in DOBD
store NEWDOB_Y in DOBY
if CSPVERF_A = No then reset CSPVERF_A to empty
goto CSPVERF_A
elseif CSPVERF_D = No then reset CSPVERF_D to empty
goto CSPVERF_D
endif
endif
Calculate age from NEWDOB_M, NEWDOB_D, and NEWDOB_Y.
if age from NEWDOB items is ne AGE and age from NEWDOB items is valid
reset CSPVERF_A or CSPVERF_D
goto ERR4_NEWDOB_Y
endif

[p. 1]

2004 NHIS Questionnaire - Sample Child
Child Health Status and Limitations

CHS.010_01.000

Instrument Variable Name: BWGT_LB
Question Text:

What was [fill: S.C. name]'s birth weight?
*Enter 'M' to record metric measurements.

01-15 1-15 pounds
97 Refused
99 Don't know
M Metric

Universe Text: Sample children lt 18
Skip Instructions:

(1-12) [goto BWGT_OZ]
(13-15) [goto ERR1_BWGT_LB]
(R,D) [goto CHGT_FT]
(M) [goto BWGT_GR]
[If NE (1-15, M, R, D) goto ERR2_BWGT_LB]

CHS.010_02.000

Instrument Variable Name: BWGT_OZ
Question Text:

*Enter ounces.

00-15 0-15 ounces
97 Refused
99 Don't know
Blank Blank

Universe Text: Sample children lt 18 who have a value entered for weight in pounds.
Skip Instructions:

(0-15,R,D) [goto CHGT_FT]
[if BWGT_LB = (0-15, R, D) and BWGT_OZ = (empty) go to CHGT_FT]

CHS.011_00.000

Instrument Variable Name: BWGT_GR
Question Text:

*Enter weight in grams.

0500-5485 500-5485 grams
9997 Refused
9999 Don't know

Universe Text: Sample children lt 18 whose birth weight will be entered in metric.
Skip Instructions:

(500-5485,R,D) [goto CHGT_FT]
(5486-6900) [goto ERR_BWGT_GR]

[p. 2]

CHS.020_01.000

Instrument Variable Name: CHGT_FT
Question Text:

How tall is [fill: S.C. name] now (without shoes)?
*If the child's height is given in inches, press 'ENTER' at feet and enter the measure in inches (36 inches maximum).
*Enter 'M' to record metric measurements.

00-07 0-7 feet
97 Refused
99 Don't know
M Metric

Universe Text: Sample children lt 18
Skip Instructions:

(empty) [goto CHGT_IN]
(0-7) [goto CHGT_IN]
(R,D) [goto CWGT_LB]
(M) [goto CHGT_M]
[If NE (0-7, M, R, D) go to ERR_CHGT_FT]

CHS.020_02.000

Instrument Variable Name: CHGT_IN
Question Text:

*Enter inches.

00-36 0-36 inches
97 Refused
99 Don't know

Universe Text: Sample children lt 18 whose height in feet is 0-7 or is left empty.
Skip Instructions:

(0-36) [goto CWGT_LB]
[If both CHGT_FT and CHGT_IN are either (empty) or (0), display ERR1_CHGT_IN]
[If CHGT_FT = (0-7) and CHGT_IN is GE (12) display ERR2_CHGT_IN]

CHS.021_01.000

Instrument Variable Name: CHGT_M
Question Text:

*Enter height in metric.
*If the child's height is given in centimeters, press 'ENTER' at meters and enter the measure in centimeters (241 centimeters maximum).

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

Universe Text: Sample children lt 18 whose current height will be entered in metric.
Skip Instructions:

(0-2) [goto CHGT_CM]
(R,D) [goto CWGT_LB]
(empty) [go to CHGT_CM]

[p. 3]

CHS.021_02.000

Instrument Variable Name: CHGT_CM
Question Text:

*Enter centimenters.

000-241 0-241 centimeters
Blank Blank

Universe Text: Sample children lt 18 whose weight will be entered in metric, and who entered "0-2" for height in meters or left it empty.
Skip Instructions:

(0-241) [goto CWGT_LB]
[if CHGT_M = (empty, 0) and CHGT_CM = (empty, 0) go to ERR1_CHGT_CM]
[if CHGT_M = 2 and CHGT_CM gt 41 goto ERR2_CHGT_CM]
[if CHGT_M = 1 and CHGT_CM gt 141 goto ERR2_CHGT_CM]

CHS.022_00.000

Instrument Variable Name: CWGT_LB
Question Text:

How much does [fill: S.C. name] weigh now (without shoes)?
*Enter 'M' to record metric measurements.
*Enter '500' if 500 pounds or more.

001-500 1-500 pounds
997 Refused
999 Don't know
M Metric

Universe Text: Sample children lt 18
Skip Instructions:

(1-500,R,D) [if age ge (2) goto ADD_1, else, goto ADD1_2]
(M) [goto CWGT_KG]
[if = (501-999) goto ERR1_CWGT_LB]
[if NE (1-999, M, R, D) goto ERR2_CWGT_KG]

CHS.023_00.000

Instrument Variable Name: CWGT_KG
Question Text:

*Enter weight in kilograms.

002-226 2-226 kilograms

Universe Text: Sample children lt 18 whose weight will be entered in metric.
Skip Instructions:

(2-226) [if AGE ge (2) goto ADD_1; else goto ADD1_2]
[if CWGT_KG gt 226 goto ERR_CWGT_KG]

[p. 4]

CHS.031_02.000

Instrument Variable Name: ADD1_2
Question Text:

Has a doctor or health professional ever told you that [fill: S.C. name] had...
Mental Retardation?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 2
Skip Instructions:

(1,2,R,D) [goto ADD1_3]

CHS.031_03.000

Instrument Variable Name: ADD1_3
Question Text:

*Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Any other developmental delay?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 2
Skip Instructions:

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

CHS.032_01.000

Instrument Variable Name: ADD_1
Question Text:

Has a doctor or health professional ever told you that [fill: S.C. name] had...
Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD)?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children 2-17
Skip Instructions:

(1,2,R,D) [go to ADD_2]

[p. 5]

CHS.032_02.000

Instrument Variable Name: ADD_2
Question Text:

*Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Mental Retardation?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children 2-17
Skip Instructions:

(1,2,R,D) [go to ADD_3]

CHS.032_03.000

Instrument Variable Name: ADD_3
Question Text:

*Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Any other developmental delay?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children 2-17
Skip Instructions:

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

[p. 6]

CHS.060_00.000

Instrument Variable Name: CONDL
Question Text:

(book) C2
Looking at this list, has a doctor or health professional ever told you that [fill: S.C. name] had any of these conditions?
Which ones?
*Enter all that apply, separate with commas.

00 None
01 Down's syndrome
02 Cerebral palsy
03 Muscular dystrophy
04 Cystic fibrosis
05 Sickle cell anemia
06 Autism
07 Diabetes
08 Arthritis
09 Congenital heart disease
10 Other heart condition
97 Refused
99 Don't know

Card C2
You may choose more than one.

1. Down syndrome
2. Cerebral palsy
3. Muscular dystrophy
4. Cystic fibrosis
5. Sickle cell anemia
6. Autism
7. Diabetes
8. Arthritis
9. Congenital heart disease
10. Other heart condition

Universe Text: Sample children lt 18
Skip Instructions:

(0-10,R,D) [go to CPOX]
[If (0) and (1-10) go to ERR_CONDL]

CHS.070_00.000

Instrument Variable Name: CPOX
Question Text:

Has [fill: S.C. Name] EVER had chickenpox?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 18
Skip Instructions:

(1) [go to CPOX12MO]
(2,R,D) [go to CASHMEV]

CHS.072_00.000

Instrument Variable Name: CPOX12MO
Question Text:

Has [fill: S.C. name] had chickenpox DURING THE PAST 12 MONTHS?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 18 who have had chickenpox
Skip Instructions:

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

[p. 7]

CHS.080_00.000

Instrument Variable Name: CASHMEV
Question Text:

Has a doctor or other health professional EVER told you that [fill: S.C. name] had asthma?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 18
Skip Instructions:

(1) [go to CASSTILL]
(2,R,D) [if AGE LE 2 go to CCONDT1; if AGE gt 2 go to CCONDT]

CHS.085_00.000

Instrument Variable Name: CASSTILL
Question Text:

Does [fill: S.C. name] still have asthma?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 18 and doctor has informed that child had asthma
Skip Instructions:

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

CHS.090_00.000

Instrument Variable Name: CASHYR
Question Text:

The following questions are about [fill: S.C. name]'s asthma DURING THE PAST 12 MONTHS.
DURING THE PAST 12 MONTHS, has [fill: SC name] had an episode of asthma or an asthma attack?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 18 and doctor has informed that child had asthma
Skip Instructions:

(1) [go to CASMERYR]
(2,R,D) [if AGE LE 2 go to CCONDT1; if AGE gt 2 go to CCONDT]

CHS.100_00.000

Instrument Variable Name: CASMERYR
Question Text:

DURING THE PAST 12 MONTHS, did [fill1: S.C. name] have to visit an emergency room or urgent care center because of [fill2: his/her] asthma?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 18 who has had an episode of asthma or an asthma attack in the past 12 months
Skip Instructions:

(1,2,R,D) [if AGE LE 2 go to CCONDT1_1; if AGE gt 2 go to CCONDT_1]

[p. 8]

CHS.111_01.000

Instrument Variable Name: CCONDT1_1
Question Text:

DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Hay fever?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children LE 2
Skip Instructions:

(1,2,R,D) [go to CCONDT1_2]

CHS.111_02.000

Instrument Variable Name: CCONDT1_2
Question Text:

*Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Any kind of respiratory allergy?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children LE 2
Skip Instructions:

(1,2,R,D) [go to CCONDT1_3]

CHS.111_03.000

Instrument Variable Name: CCONDT1_3
Question Text:

*Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Any kind of food or digestive allergy?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children LE 2
Skip Instructions:

(1,2,R,D) [go to CCONDT1_4]

[p. 9]

CHS.111_04.000

Instrument Variable Name: CCONDT1_4
Question Text:

*Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Eczema or any kind of skin allergy?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children LE 2
Skip Instructions:

(1,2,R,D) [go to CCONDT1_5]

CHS.111_05.000

Instrument Variable Name: CCONDT1_5
Question Text:

*Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Frequent or repeated diarrhea or colitis?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children LE 2
Skip Instructions:

(1,2,R,D) [go to CCONDT1_6]

CHS.111_06.000

Instrument Variable Name: CCONDT1_6
Question Text:

*Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Anemia?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children LE 2
Skip Instructions:

(1,2,R,D) [go to CCONDT1_8]

[p. 10]

CHS.111_08.000

Instrument Variable Name: CCONDT1_8
Question Text:

*Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Three or more ear infections?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children LE 2
Skip Instructions:

(1,2,R,D) [go to CCONDT1_9]

CHS.111_09.000

Instrument Variable Name: CCONDT1_9
Question Text:

*Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Seizures?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children LE 2
Skip Instructions:

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

CHS.115_01.000

Instrument Variable Name: CCONDT_1
Question Text:

DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Hay fever?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children = 3-17
Skip Instructions:

(1,2,R,D) [go to CCONDT_2]

[p. 11]

CHS.115_02.000

Instrument Variable Name: CCONDT_2
Question Text:

*Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Any kind of respiratory allergy?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children = 3-17
Skip Instructions:

(1,2,R,D) [go to CCONDT_3]

CHS.115_03.000

Instrument Variable Name: CCONDT_3
Question Text:

*Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Any kind of food or digestive allergy?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children = 3-17
Skip Instructions:

(1,2,R,D) [go to CCONDT_4]

CHS.115_04.000

Instrument Variable Name: CCONDT_4
Question Text:

*Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Eczema or any kind of skin allergy?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children = 3-17
Skip Instructions:

(1,2,R,D) [go to CCONDT_5]

[p. 12]

CHS.115_05.000

Instrument Variable Name: CCONDT_5
Question Text:

*Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Frequent or repeated diarrhea or colitis?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children = 3-17
Skip Instructions:

(1,2,R,D) [go to CCONDT_6]

CHS.115_06.000

Instrument Variable Name: CCONDT_6
Question Text:

*Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Anemia?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children = 3-17
Skip Instructions:

(1,2,R,D) [go to CCONDT_7]

CHS.115_07.000

Instrument Variable Name: CCONDT_7
Question Text:

*Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Frequent or severe headaches, including migraines?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children = 3-17
Skip Instructions:

(1,2,R,D) [go to CCONDT_8]

[p. 13]

CHS.115_08.000

Instrument Variable Name: CCONDT_8
Question Text:

*Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Three or more ear infections?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children = 3-17
Skip Instructions:

(1,2,R,D) [go to CCONDT_9]

CHS.115_09.000

Instrument Variable Name: CCONDT_9
Question Text:

*Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Seizures?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children = 3-17
Skip Instructions:

(1,2,R,D) [go to CCONDT_10]

CHS.115_10.000

Instrument Variable Name: CCONDT_10
Question Text:

*Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Stuttering or stammering?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children = 3-17
Skip Instructions:

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

[p. 14]

CHS.210_00.000

Instrument Variable Name: CHSTATYR
Question Text:

Compared with 12 months ago, would you say [fill: S.C. name]'s health is now better, worse, or about the same?

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

Universe Text: Sample children lt 18
Skip Instructions:

(1-3,R,D) [if AGE le (4) goto CCOLD2W; else goto SCHDAYR]

CHS.220_00.000

Instrument Variable Name: SCHDAYR
Question Text:

DURING THE PAST 12 MONTHS, that is, since [fill1: 12-month ref. date], about how many days did [fill2: S.C. name] miss school because of illness or injury?
*Enter '996' if child did not go to school in the past 12 months.

000 None
001-240 1-240 days
996 Did not go to school
997 Refused
999 Don't know

Universe Text: Sample children 5-17
Skip Instructions:

(0-99,996,R,D) [goto CCOLD2W]
(100-240) [go to ERR1_SCHDAYR]
(241-995) [goto ERR2_SCHDAYR]

CHS.230_00.000

Instrument Variable Name: CCOLD2W
Question Text:

*Hand calendar card.
These next questions are about [fill: S.C name]'s recent health during the 2 weeks outlined on that calendar.
Did [fill: SC name] 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 children lt 18
Skip Instructions:

(1,2,R,D) [goto CINTIL2W]

[p. 15]

CHS.240_00.000

Instrument Variable Name: CINTIL2W
Question Text:

Did [fill: S.C. name] 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 children lt 18
Skip Instructions:

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

CHS.250_00.000

Instrument Variable Name: CHEARST
Question Text:

Which statement best describes [fill: S.C. name]'s hearing without a hearing aid: Good, a little trouble, a lot of trouble, or deaf?

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

Universe Text: Sample children lt 18
Skip Instructions:

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

CHS.260_00.000

Instrument Variable Name: CVISION
Question Text:

Does [fill1: S.C. name] have any trouble seeing [fill2: , even when wearing glasses or contact lenses]?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 18
Skip Instructions:

(1) [goto CBLIND]
(2,R,D) [go to IHSPEQ]

[p. 16]

CHS.270_00.000

Instrument Variable Name: CBLIND
Question Text:

Is [fill: S.C. name] blind or unable to see at all?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 18 having trouble seeing
Skip Instructions:

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

CHS.290_00.000

Instrument Variable Name: IHSPEQ
Question Text:

Does [fill1: S.C. name] have any impairment or health problem that requires [fill2: him/her] to use special equipment, such as a brace, a wheelchair, or a hearing aid (excluding ordinary eyeglasses or corrective shoes)?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 18
Skip Instructions:

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

CHS.300_00.000

Instrument Variable Name: IHMOB
Question Text:

Does [fill1: S.C. name] have an impairment or health problem that limits [fill2: his/her] ability to (crawl), walk, run, or play?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 18
Skip Instructions:

(1) [goto IHMOBYR]
(2,R,D) [goto PROBRX]

CHS.310_00.000

Instrument Variable Name: IHMOBYR
Question Text:

Is this an impairment or health problem that has lasted, or is expected to last, 12 months or longer?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 18 that have limited ability to crawl, walk, run, or play
Skip Instructions:

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

[p. 17]

CHS.311_00.000

Instrument Variable Name: PROBRX
Question Text:

Does [fill1: S.C. name] NOW have a problem for which [fill2: he/she] has regularly taken prescription medication for at least three months?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 18
Skip Instructions:

(1,2,R,D) [if AGE LE (1) go to CUSUALPL;
if AGE GE (3) go to LEARND;
if AGE = (2) and SEX = (1) go to CMHAGM11_1;
if AGE = (2) and SEX = (2) go to CMHAGF11_1]

CHS.312_00.000

Instrument Variable Name: LEARND
Question Text:

Has a representative from a school or a health professional ever told you that [fill: S.C. name] had a learning disability?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children 3-17
Skip Instructions:

(1,2,R,D) [if AGE gt 3 go to CUSUALPL;
if AGE = 3 and SEX = 1 go to CMHAGM11_1;
if AGE = 3 and SEX = 2 go to CMHAGF11_1]

CHS.321_01.000

Instrument Variable Name: CMHAGM11_1
Question Text:

(book) C3
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
HE:
Has been uncooperative?

0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know

Card C3

0. Not true
1. Sometimes true
2. Often true

Universe Text: Male sample children 2-3
Skip Instructions:

(0-2,R,D) [go to CMHAGM11_2]

CHS.321_02.000

Instrument Variable Name: CMHAGM11_2
Question Text:

(book) C3
*Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
HE:
Has trouble getting to sleep?

0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know

Card C3

0. Not true
1. Sometimes true
2. Often true

Universe Text: Male sample children 2-3
Skip Instructions:

(0-2,R,D) [go to CMHAGM11_3]

CHS.321_03.000

Instrument Variable Name: CMHAGM11_3
Question Text:

0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know

Card C3

0. Not true
1. Sometimes true
2. Often true

Universe Text: Male sample children 2-3
Skip Instructions:

(0-2,R,D) [go to CMHAGM11_4]

[p. 19]

CHS.321_04.000

Instrument Variable Name: CMHAGM11_4
Question Text:

0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know

Card C3

0. Not true
1. Sometimes true
2. Often true

Universe Text: Male sample children 2-3
Skip Instructions:

(0-2,R,D) [go to CUSUALPL]

CHS.361_01.000

Instrument Variable Name: CMHAGF11_1
Question Text:

0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know

Card C3

0. Not true
1. Sometimes true
2. Often true

Universe Text: Female sample children 2-3
Skip Instructions:

(0-2,R,D) [go to CMHAGF11_2]

CHS.361_02.000

Instrument Variable Name: CMHAGF11_2
Question Text:

book) C3
*Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
SHE:
Has speech problems?

0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know

Card C3

0. Not true
1. Sometimes true
2. Often true

Universe Text: Female sample children 2-3
Skip Instructions:

(0-2,R,D) [go to CMHAGF11_3]

CHS.361_03.000

Instrument Variable Name: CMHAGF11_3
Question Text:

0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know

Universe Text: Female sample children 2-3
Skip Instructions:

(0-2,R,D) [go to CMHAGF11_4]

[p. 21]

CHS.361_04.000

Instrument Variable Name: CMHAGF11_4
Question Text:

0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know

Universe Text: Female sample children 2-3
Skip Instructions:

(0-2,R,D) [go to CUSUALPL]

[p. 1]

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

CAU.020_00.000

Instrument Variable Name: CUSUALPL
Question Text:

The next questions are about health care.
Is there a place that [fill1: S.C. name] USUALLY goes when [fill2: he/she] is sick or you need advice about [fill3: his/her] health?

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

Universe Text: Sample Children lt 18
Skip Instructions:

(1,3) [go to CPLKIND]
(2,R,D) [go to CHCPLKND]

CAU.030_00.000

Instrument Variable Name: CPLKIND
Question Text:

[fill1: What kind of place is it / What kind of place does [fill2: S.C. name] 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 children lt 18 with one or more usual places to go when sick or need health advice
Skip Instructions:

(1-5) [go to CHCPLROU]
(6,R,D) [go to CHCPLKND]

CAU.035_00.000

Instrument Variable Name: CHCPLROU
Question Text:

Is that [fill1: CPLKIND/CAU.030] the same place [fill2: S.C. name] USUALLY goes when [fill3: he/she] needs routine or preventive care, such as a physical examination or (well baby/child) check-up?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 18 with one or more usual places to go when sick or need health advice who reported that place as a clinic or health center, doctor's office or HMO, hospital emergency room, hospital outpatient department, or some other place
Skip Instructions:

(1) [go to CHCCHGYR]
(2,R,D) [go to CHCPLKND]

[p. 2]

CAU.037_00.000

Instrument Variable Name: CHCPLKND
Question Text:

What kind of place does [fill1: S.C. name] USUALLY go to when [fill2: he/she] needs routine or preventive care, such as a physical examination or (well baby/child) check-up?

0 Doesn't get preventive care anywhere
1 Clinic or health center
2 Doctor's office of 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 Children lt 18 who do not have a usual source of sick care; who Ref/NA/DK if have a usual source of sick care; who have a usual source of sick care but does not go to one place most often; who have a usual source of sick care but Ref/NA/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/NA/DK if it is same place as usual source of
routine/preventive care.
Skip Instructions:

(0-6,R,D) [ if CUSUALPL=2,R,D goto CHCDLYR_1; else goto CHCCHGYR]

CAU.040_00.000

Instrument Variable Name: CHCCHGYR
Question Text:

At any time IN THE PAST 12 MONTHS did you CHANGE the place(s) to which [fill: S.C. name] USUALLY goes for health care?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 18 with one or more place to go when sick/need advice [or who reported same place as usual source of routine/preventive care]
Skip Instructions:

(1) [go to CHCCHGHI]
(2,R,D) [go to CHCDLYR1_1]

CAU.050_00.000

Instrument Variable Name: CHCCHGHI
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 children lt 18 that have changed their usual place of health care in the past 12 months
Skip Instructions:

(1,2,R,D) [goto CHCDLYR1_1]

[p. 3]

CAU.080_01.000

Instrument Variable Name: CHCDLYR1_1
Question Text:

There are many reasons people delay getting medical care. Have you delayed getting care for [fill: S.C. name] 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 children lt 18
Skip Instructions:

(1,2,R,D) [goto CHCDLYR1_2]

CAU.080_02.000

Instrument Variable Name: CHCDLYR1_2
Question Text:

*Read lead-in if necessary.
There are many reasons people delay getting medical care. Have you delayed getting care for [fill: S.C. name] for any of the following reasons IN THE PAST 12 MONTHS...
You couldn't get an appointment for [fill: S.C. name] soon enough.

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 18
Skip Instructions:

(1,2,R,D) [goto CHCDLYR1_3]

CAU.080_03.000

Instrument Variable Name: CHCDLYR1_3
Question Text:

*Read lead-in if necessary.
There are many reasons people delay getting medical care. Have you delayed getting care for [fill: S.C. name] for any of the following reasons IN THE PAST 12 MONTHS...
Once you get there, [fill: S.C. name] has to wait too long to see the doctor.

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 18
Skip Instructions:

(1,2,R,D) [goto CHCDLYR1_4]

[p. 4]

CAU.080_04.000

Instrument Variable Name: CHCDLYR1_4
Question Text:

*Read lead-in if necessary.
There are many reasons people delay getting medical care. Have you delayed getting care for [fill: S.C. name] 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 children lt 18
Skip Instructions:

(1,2,R,D) [goto CHCDLYR1_5]

CAU.080_05.000

Instrument Variable Name: CHCDLYR1_5
Question Text:

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 18
Skip Instructions:

(1,2,R,D) [if AGE GE (2) goto CHCAFYR1_1; else goto CHCAFYR]

CAU.130_00.000

Instrument Variable Name: CHCAFYR
Question Text:

DURING THE PAST 12 MONTHS, was there any time when [fill: S.C. name] 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 children lt 2
Skip Instructions:

(1,2,R,D) [if AGE lt 1 goto CHCSYR1_2; else goto CDENLONG]

[p. 5]

CAU.135_01.000

Instrument Variable Name: CHCAFYR1_1
Question Text:

DURING THE PAST 12 MONTHS, was there any time when [fill: S.C. name] 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 children GE 2
Skip Instructions:

(1,2,R,D) [goto CHCAFYR1_2]

CAU.135_02.000

Instrument Variable Name: CHCAFYR1_2
Question Text:

*Read lead-in if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: S.C. name] 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 children GE 2
Skip Instructions:

(1,2,R,D) [goto CHCAFYR1_3]

CAU.135_03.000

Instrument Variable Name: CHCAFYR1_3
Question Text:

*Read lead-in if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: S.C. name] 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 children GE 2
Skip Instructions:

(1,2,R,D) [goto CHCAFYR1_4]

[p. 6]

CAU.135_04.000

Instrument Variable Name: CHCAFYR1_4
Question Text:

*Read lead-in if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: S.C. name] 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 children GE 2
Skip Instructions:

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

CAU.160_00.000

Instrument Variable Name: CDENLONG
Question Text:

(book) C4
About how long has it been since [fill: S.C. name] 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 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

Card C4

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 children GE 1
Skip Instructions:

(0-5,R,D) [if AGE GE (2) goto CHCSYR_1; else go to CHCSYR1_2]

CAU.170_01.000

Instrument Variable Name: CHCSYR1_2
Question Text:

DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], has anyone in the family seen or talked to any of the following health care providers about [fill2: S.C. name]'s health?
An optometrist, ophthamologist, or eye doctor (someone who prescribes eyeglasses)?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 2
Skip Instructions:

(1,2,R,D) [goto CHCSYR1_3]

[p. 7]

CAU.170_02.000

Instrument Variable Name: CHCSYR1_3
Question Text:

*Read lead-in if necessary.
DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], has anyone in the family seen or talked to any of the following health care providers about [fill2: S.C. name]'s health?
A foot doctor?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 2
Skip Instructions:

(1,2,R,D) [goto CHCSYR1_5]

CAU.170_03.000

Instrument Variable Name: CHCSYR1_5
Question Text:

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 2
Skip Instructions:

(1,2,R,D) [goto CHCSYR1_6]

CAU.170_04.000

Instrument Variable Name: CHCSYR1_6
Question Text:

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 2
Skip Instructions:

(1,2,R,D) [goto CHCSYR8]

[p. 8]

CAU.175_01.000

Instrument Variable Name: CHCSYR_1
Question Text:

DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], have you seen or talked to any of the following health care providers about [fill2: S.C. name]'s 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 children GE 2
Skip Instructions:

(1,2,R,D) [goto CHCSYR_2]

CAU.175_02.000

Instrument Variable Name: CHCSYR_2
Question Text:

*Read lead-in if necessary.
DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], have you seen or talked to any of the following health care providers about [fill2: S.C. name]'s health?
An optometrist, ophthalmologist, or eye doctor (someone who prescribes eyeglasses)?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children GE 2
Skip Instructions:

(1,2,R,D) [goto CHCSYR_3]

CAU.175_03.000

Instrument Variable Name: CHCSYR_3
Question Text:

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children GE 2
Skip Instructions:

(1,2,R,D) [goto CHCSYR_4]

[p. 9]

CAU.175_04.000

Instrument Variable Name: CHCSYR_4
Question Text:

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children GE 2
Skip Instructions:

(1,2,R,D) [goto CHCSYR_5]

CAU.175_05.000

Instrument Variable Name: CHCSYR_5
Question Text:

*Read lead-in if necessary.
DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], have you seen or talked to any of the following health care providers about [fill2: S.C. name]'s 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 children GE 2
Skip Instructions:

(1,2,R,D) [goto CHCSYR_6]

CAU.175_06.000

Instrument Variable Name: CHCSYR_6
Question Text:

*Read lead-in if necessary.
DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], have you seen or talked to any of the following health care providers about [fill2: S.C. name]'s health?
A nurse practitioner, physician assistant or midwife?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children GE 2
Skip Instructions:

(1,2,R,D) if SEX eq (2) and AGE GE 15 [goto CHCSYR7]; else [goto CHCSYR8_1]

[p. 10]

CAU.230_00.000

Instrument Variable Name: CHCSYR7
Question Text:

DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], have you seen or talked to a doctor who specializes in women's health (an obstetrician/gynecologist) about [fill2: S.C. name]'s health?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children GE 15 who are female
Skip Instructions:

(1,2,R,D) [goto CHCSYR8_1]

CAU.240_01.000

Instrument Variable Name: CHCSYR8_1
Question Text:

DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], have you seen or talked to the following about [fill2: S.C. name]'s health?
A medical doctor who specializes in a particular medical disease or problem (fill3:other than obstetrician/ gynecologist, psychiatrist or ophthalmologist?/fill4: other than psychiatrist or ophthalmologist)?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 18
Skip Instructions:

(1,2,R,D) [goto CHCSYR8_2]

CAU.240_02.000

Instrument Variable Name: CHCSYR8_2
Question Text:

*Read lead-in if necessary.
DURING THE PAST 12 MONTHS, that is since [fill1: 12 month reference date], have you seen or talked to the following about [fill2: S.C. name]'s health?
A general doctor who treats a variety of illnesses (a doctor in general practice, pediatrics, family medicine, or internal medicine)?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 18
Skip Instructions:

(1) [goto CHCSYR10]
(2,R,D) [goto CHPEXYR]

[p. 11]

CAU.260_00.000

Instrument Variable Name: CHCSYR10
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 children lt 18 who have seen or talked to a general doctor during the past 12 months
Skip Instructions:

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

CAU.265_00.000

Instrument Variable Name: CHCSYREM
Question Text:

Did you see or talk to this general doctor because of an emotional or behavioral problem that [fill1: S.C. name] may have?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 18 who have seen a general doctor in the past 12 months
Skip Instructions:

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

CAU.270_00.000

Instrument Variable Name: CHPEXYR
Question Text:

DURING THE PAST 12 MONTHS, did [fill1: S.C. name] receive a well-child check-up, that is a general check-up, when [fill2: he/she] was not sick or injured?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample children lt 18
Skip Instructions:

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

[p. 12]

CAU.280_00.000

Instrument Variable Name: CHERNOYR
Question Text:

(book) C5
DURING THE PAST 12 MONTHS, HOW MANY TIMES has [fill1: S.C. name] gone to a HOSPITAL EMERGENCY ROOM about [fill2: his/her] 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 C5

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 children lt 18
Skip Instructions:

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

CAU.290_00.000

Instrument Variable Name: CHCHYR
Question Text:

DURING THE PAST 12 MONTHS, did [fill1: S.C. name] 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 children lt 18
Skip Instructions:

(1) [goto CHCHMOYR]
(2,R,D) [goto CHCNOYR]

CAU.300_00.000

Instrument Variable Name: CHCHMOYR
Question Text:

DURING THE PAST 12 MONTHS, how many months did [fill: S.C. name] receive care AT HOME from a health care professional?

01-12 1-12 months
97 Refused
99 Don't know

Universe Text: Sample children lt 18 that have received home care from health professional during the past 12 months
Skip Instructions:

(01-12,R,D) [goto CHCHNOYR]

[p. 13]

CAU.310_00.000

Instrument Variable Name: CHCHNOYR
Question Text:

(book) C6
What was the total number of home visits received for [fill1: S.C. name] during [fill2: 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 C6

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

Universe Text: Sample children lt 18 that have received home care from health professional during the past 12 months
Skip Instructions:

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

CAU.320_00.000

Instrument Variable Name: CHCNOYR
Question Text:

(book) C5
DURING THE PAST 12 MONTHS, HOW MANY TIMES has [fill1: S.C. name] seen a doctor or other health care professional about [fill2: his/her] health at A DOCTOR'S OFFICE, A CLINIC, OR SOME OTHER PLACE? Do not include times [fill1: S.C. name] was 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 C5

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 children lt 18
Skip Instructions:

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

[p. 14]

CAU.330_00.000

Instrument Variable Name: CSRGYR
Question Text:

DURING THE PAST 12 MONTHS has [fill1: S.C. name] 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 children lt 18
Skip Instructions:

(1) [goto CSRGNOYR]
(2,R,D) [goto CMDLONG]

CAU.340_00.000

Instrument Variable Name: CSRGNOYR
Question Text:

Including any times you may have already told me about, HOW MANY DIFFERENT TIMES has [fill1: S.C. name] 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 children lt 18 that have undergone surgery during the past 12 months
Skip Instructions:

(1-10,R,D) [goto CMDLONG]
(11-95) [goto ERR_CMDLONG]

CAU.345_00.000

Instrument Variable Name: CMDLONG
Question Text:

(book) C4
About how long has it been since anyone in the family last saw or talked to a doctor or other health care professional about [fill1: S.C. name]'s health? Include doctors seen while [fill2: he/she] was a patient in a hospital.

Card C4

Universe Text: Sample children lt 18
Skip Instructions:

(0-5,R,D) if AGE le (3) store (1) in CSTAT [goto next section]; else [goto CSCLCOPY]

[p. 1]

2004 NHIS Questionnaire - Sample Child
Child Mental Health

CMH.005_00.000

Instrument Variable Name: CSCLCOPY
Question Text:

*The following statements are not to be read to the respondent. They are displayed and included here for legal reasons.
*The next 25 items contained in CSCL1_S1 through CSCL5_H5 are included in this survey with permission as indicated below.
*The SDQ questions are copyrighted by Robert Goodman, Ph.D., FRCPSYCH, MRCP. State and local agencies may use these questions without charge and without seeking separate permission provided the wording is not modified, all the questions are retained, and Dr. Goodman's copyright is acknowledged.
*Enter 1 to Continue.

1 Enter 1 to continue

Universe Text: Sample children GE 4
Skip Instructions:

(1) [goto CSCL1_S1]

CMH.010_01.000

Instrument Variable Name: CSCL1_S1
Question Text:

(book) C7
I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE, SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: S.C. name] DURING THE PAST SIX MONTHS.
[fill2: He/She...]
...is considerate of other people's feelings.

1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know

Card C7

1. Not true
2. Somewhat true
3. Certainly true

Universe Text: Sample children GE 4
Skip Instructions:

(1-3,R,D) [goto CSCL1_H1]

[p. 2]

CMH.010_02.000

Instrument Variable Name: CSCL1_H1
Question Text:

(book) C7
*Read if necessary.
I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE, SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: S.C. name] DURING THE PAST SIX MONTHS.
[fill2: He/She...]
...is restless, overactive, cannot stay still for long.

1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know

Card C7

1. Not true
2. Somewhat true
3. Certainly true

Universe Text: Sample children GE 4
Skip Instructions:

(1-3,R,D) [goto CSCL1_E1]

CMH.010_03.000

Instrument Variable Name: CSCL1_E1
Question Text:

(book) C7
*Read if necessary.
I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE, SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: S.C. name] DURING THE PAST SIX MONTHS.
[fill2: He/She...]
...often COMPLAINS of headaches, stomach-aches or sickness.

1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know

Card C7

1. Not true
2. Somewhat true
3. Certainly true

Universe Text: Sample children GE 4
Skip Instructions:

(1-3,R,D) [goto CSCL1_S2]

[p. 3]

CMH.010_04.000

Instrument Variable Name: CSCL1_S2
Question Text:

(book) C7
*Read if necessary.
I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE, SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: S.C. name] DURING THE PAST SIX MONTHS.
[fill2: He/She...]
...shares readily with other [fill 3: children; for example, toys, treats, pencils/youth; for example, CDs, games, food].

1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know

Card C7

1. Not true
2. Somewhat true
3. Certainly true

Universe Text: Sample children GE 4
Skip Instructions:

(1-3,R,D) [goto CSCL1_C1]

CMH.010_05.000

Instrument Variable Name: CSCL1_C1
Question Text:

1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know

Card C7

1. Not true
2. Somewhat true
3. Certainly true

Universe Text: Sample children GE 4
Skip Instructions:

(1-3,R,D) [goto CSCL2_P1]

[p. 4]

CMH.020_01.000

Instrument Variable Name: CSCL2_P1
Question Text:

(book) C7
*Read if necessary.
I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE, SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: S.C. name] DURING THE PAST SIX MONTHS.
[fill2: He/She...]
...[fill3: is rather solitary, prefers to play alone/would rather be alone than with other teenagers].

1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know

Card C7

1. Not true
2. Somewhat true
3. Certainly true

Universe Text: Sample children GE 4
Skip Instructions:

(1-3,R,D) [goto CSCL2_C2]

CMH.020_02.000

Instrument Variable Name: CSCL2_C2
Question Text:

1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know

Card C7

1. Not true
2. Somewhat true
3. Certainly true

Universe Text: Sample children GE 4
Skip Instructions:

(1-3,R,D) [goto CSCL2_E2]

[p. 5]

CMH.020_03.000

Instrument Variable Name: CSCL2_E2
Question Text:

1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know

Card C7

1. Not true
2. Somewhat true
3. Certainly true

Universe Text: Sample children GE 4
Skip Instructions:

(1-3,R,D) [goto CSCL2_S3]

CMH.020_04.000

Instrument Variable Name: CSCL2_S3
Question Text:

1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know

Card C7

1. Not true
2. Somewhat true
3. Certainly true

Universe Text: Sample children GE 4
Skip Instructions:

(1-3,R,D) [goto CSCL2_H2]

[p. 6]

CMH.020_05.000

Instrument Variable Name: CSCL2_H2
Question Text:

1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know

Card C7

1. Not true
2. Somewhat true
3. Certainly true

Universe Text: Sample children GE 4
Skip Instructions:

(1-3,R,D) [goto CSCL3_P2]

CMH.030_01.000

Instrument Variable Name: CSCL3_P2
Question Text:

1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know

Card C7

1. Not true
2. Somewhat true
3. Certainly true

Universe Text: Sample children GE 4
Skip Instructions:

(1-3,R,D) [goto CSCL3_C3]

[p. 7]

CMH.030_02.000

Instrument Variable Name: CSCL3_C3
Question Text:

(book) C7
*Read if necessary.
I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE, SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: S.C. name] DURING THE PAST SIX MONTHS.
[fill2: He/She...]
...often fights with other [fill3: children/youth] or bullies them.

1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know

Card C7

1. Not true
2. Somewhat true
3. Certainly true

Universe Text: Sample children GE 4
Skip Instructions:

(1-3,R,D) [goto CSCL3_E3]

CMH.030_03.000

Instrument Variable Name: CSCL3_E3
Question Text:

1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know

Card C7

1. Not true
2. Somewhat true
3. Certainly true

Universe Text: Sample children GE 4
Skip Instructions:

(1-3,R,D) [goto CSCL3_P3]

[p. 8]

CMH.030_04.000

Instrument Variable Name: CSCL3_P3
Question Text:

1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know

Card C7

1. Not true
2. Somewhat true
3. Certainly true

Universe Text: Sample children GE 4
Skip Instructions:

(1-3,R,D) [goto CSCL3_H3]

CMH.030_05.000

Instrument Variable Name: CSCL3_H3
Question Text:

1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know

Card C7

1. Not true
2. Somewhat true
3. Certainly true

Universe Text: Sample children GE 4
Skip Instructions:

(1-3,R,D) [goto CSCL4_E4]

[p. 9]

CMH.040_01.000

Instrument Variable Name: CSCL4_E4
Question Text:

(book) C7
*Read if necessary.
I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE, SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: S.C. name] DURING THE PAST SIX MONTHS.
[fill2: He/She...]
...[fill3: is nervous or clingy in new situations/is nervous in new situations, easily loses confidence].

1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know

Card C7

1. Not true
2. Somewhat true
3. Certainly true

Universe Text: Sample children GE 4
Skip Instructions:

(1-3,R,D) [goto CSCL4_S4]

CMH.040_02.000

Instrument Variable Name: CSCL4_S4
Question Text:

1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know

Card C7

1. Not true
2. Somewhat true
3. Certainly true

Universe Text: Sample children GE 4
Skip Instructions:

(1-3,R,D) [goto CSCL4_C4]

[p. 10]

CMH.040_03.000

Instrument Variable Name: CSCL4_C4
Question Text:

1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know

Card C7

1. Not true
2. Somewhat true
3. Certainly true

Universe Text: Sample children GE 4
Skip Instructions:

(1-3,R,D) [goto CSCL4_P4]

CMH.040_04.000

Instrument Variable Name: CSCL4_P4
Question Text:

1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know

Card C7

1. Not true
2. Somewhat true
3. Certainly true

Universe Text: Sample children GE 4
Skip Instructions:

(1-3,R,D) [goto CSCL4_S5]

[p. 11]

CMH.040_05.000

Instrument Variable Name: CSCL4_S5
Question Text:

(book) C7
*Read if necessary.
I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE, SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: S.C. name] DURING THE PAST SIX MONTHS.
[fill2: He/She...]
...often offers to help others (parents, teachers, other children).

1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know

Card C7

1. Not true
2. Somewhat true
3. Certainly true

Universe Text: Sample children GE 4
Skip Instructions:

(1-3,R,D) [goto CSCL5_H4]

CMH.050_01.000

Instrument Variable Name: CSCL5_H4
Question Text:

1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know

Card C7

1. Not true
2. Somewhat true
3. Certainly true

Universe Text: Sample children GE 4
Skip Instructions:

(1-3,R,D) [goto CSCL5_C5]

[p. 12]

CMH.050_02.000

Instrument Variable Name: CSCL5_C5
Question Text:

1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know

Card C7

1. Not true
2. Somewhat true
3. Certainly true

Universe Text: Sample children GE 4
Skip Instructions:

(1-3,R,D) [goto CSCL5_P5]

CMH.050_03.000

Instrument Variable Name: CSCL5_P5
Question Text:

(book) C7
*Read if necessary.
I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE, SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: S.C. name] DURING THE PAST SIX MONTHS.
[fill2: He/She...]
...gets along better with adults than with other [fill3: children/youth].

1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know

Card C7

1. Not true
2. Somewhat true
3. Certainly true

Universe Text: Sample children GE 4
Skip Instructions:

(1-3,R,D) [goto CSCL5_E5]

[p. 13]

CMH.050_04.000

Instrument Variable Name: CSCL5_E5
Question Text:

1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know

Card C7

1. Not true
2. Somewhat true
3. Certainly true

Universe Text: Sample children GE 4
Skip Instructions:

(1-3,R,D) [goto CSCL5_H5]

CMH.050_05.000

Instrument Variable Name: CSCL5_H5
Question Text:

(book) C7
*Read if necessary.
I am going to read a list of items that describe children. For each item, please tell me if it has been NOT TRUE, SOMEWHAT TRUE, or CERTAINLY TRUE for [fill1: S.C. name] DURING THE PAST SIX MONTHS.
[fill2: He/She...]
...has good attention span, sees chores or homework through to the end.

1 Not true
2 Somewhat true
3 Certainly true
7 Refused
9 Don't know

Card C7

1. Not true
2. Somewhat true
3. Certainly true

Universe Text: Sample children GE 4
Skip Instructions:

(1-3,R,D) [goto CSCL6]

[p. 14]

CMH.060_00.000

Instrument Variable Name: CSCL6
Question Text:

(book) C8
Overall, do you think that [fill: S.C. name] has difficulties in any of the following areas: emotions, concentration, behavior, or being able to get along with other people?

1 No
2 Yes, minor difficulties
3 Yes, definite difficulties
4 Yes, severe difficulties
7 Refused
9 Don't know

Card C8
Overall, do you think that this child has difficulties in any of the following areas: emotions, concentration, behavior, or being able to get along with other people?

1. No
2. Yes, minor difficulties
3. Yes, definite difficulties
4. Yes, severe difficulties

Universe Text: Sample children GE 4
Skip Instructions:

(2-4) [goto CSCL8]
(1,R,D) [store 1 in CSTAT; goto next section]

CMH.070_00.000

Instrument Variable Name: CSCL7
Question Text:

How long have these difficulties been present?

1 Less than a month
2 1-5 months
3 6-12 months
4 Over 12 months
7 Refused
8 Not Ascertained
9 Don't know

Universe Text: Sample children GE 4 who have difficulties with emotions, concentration, behavior, or getting along
Skip Instructions:

(2-4) [goto CSCL8]
(1,R,D) [store 1 in CSTAT; goto next section]

CMH.080_00.000

Instrument Variable Name: CSCL8
Question Text:

(book) C9
Do the difficulties upset or distress your child?

1 Not at all
2 A little
3 A medium amount
4 A great deal
7 Refused
9 Don't know

Card C9

1. Not at all
2. A little
3. A medium amount
4. A great deal

Universe Text: Sample children GE 4 who have had difficulties in emotions, concentration, behavior, or getting along one month or more
Skip Instructions:

(1-4,R,D) [goto CSCL9_HL]

[p. 15]

CMH.090_01.000

Instrument Variable Name: CSCL9_HL
Question Text:

(book) C9
Do the difficulties interfere with your child's everyday life in the following areas...
...Home life?

1 Not at all
2 A little
3 A medium amount
4 A great deal
7 Refused
9 Don't know

Card C9

1. Not at all
2. A little
3. A medium amount
4. A great deal

Universe Text: Sample children GE 4 who have had difficulties in emotions, concentration, behavior, or getting along one month or more
Skip Instructions:

(1-4,R,D) [goto CSCL9_FR]

CMH.090_02.000

Instrument Variable Name: CSCL9_FR
Question Text:

(book) C9
*Read if necessary.
Do the difficulties interfere with your child's everyday life in the following areas...
...Friendships?

1 Not at all
2 A little
3 A medium amount
4 A great deal
7 Refused
9 Don't know

Card C9

1. Not at all
2. A little
3. A medium amount
4. A great deal

Universe Text: Sample children GE 4 who have had difficulties in emotions, concentration, behavior, or getting along one month or more
Skip Instructions:

(1-4,R,D) [goto CSCL9_CL]

[p. 16]

CMH.090_03.000

Instrument Variable Name: CSCL9_CL
Question Text:

(book) C9
*Read if necessary.
Do the difficulties interfere with your child's everyday life in the following areas...
...Classroom learning?

1 Not at all
2 A little
3 A medium amount
4 A great deal
7 Refused
9 Don't know

Card C9

1. Not at all
2. A little
3. A medium amount
4. A great deal

Universe Text: Sample children GE 4 who have had difficulties in emotions, concentration, behavior, or getting along one month or more
Skip Instructions:

(1-4,R,D) [goto CSCL9_LA]

CMH.090_04.000

Instrument Variable Name: CSCL9_LA
Question Text:

(book) C9
*Read if necessary.
Do the difficulties interfere with your child's everyday life in the following areas...
...Leisure activities?

1 Not at all
2 A little
3 A medium amount
4 A great deal
7 Refused
9 Don't know

Card C9

1. Not at all
2. A little
3. A medium amount
4. A great deal

Universe Text: Sample children GE 4 who have had difficulties in emotions, concentration, behavior, or getting along one month or more
Skip Instructions:

(1-4,R,D) [goto CSCL10]

[p. 17]

CMH.100_00.000

Instrument Variable Name: CSCL10
Question Text:

(book) C9
Do the difficulties put a burden on you or the family as a whole?

1 Not at all
2 A little
3 A medium amount
4 A great deal
7 Refused
9 Don't know

Card C9

1. Not at all
2. A little
3. A medium amount
4. A great deal

Universe Text: Sample children GE 4 who have had difficulties in emotions, concentration, behavior, or getting along one month or more
Skip Instructions:

(1-4,R,D) store (1) in CSTAT [goto next section]

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