[p. 1]
2005 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]
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]
2005 NHIS Questionnaire - Sample Adult
Diet and Nutrition
Question Text:
First, I would like to ask about the language you use most often. In general, what language do you speak?
2 Mostly Spanish
3 Spanish and English about the same
4 Mostly English
5 Only English
6 Other
7 Refused
9 Don't know
2. Mostly Spanish
3. Both Spanish and English about the same
4. Mostly English
5. Only English
6. Other language
Skip Instructions:
Question Text:
9 Don't know
Verbatim Verbatim Response
Skip Instructions:
[p. 2]
Question Text:
These questions are about the different kinds of foods you ate or drank during the PAST MONTH, that is, the past 30 days. When answering, please include meals and snacks eaten at home, at work or school, in restaurants, and anyplace else.
During the past month, how often did you eat HOT OR COLD CEREALS?
*Read if necessary: Include cereals eaten at any time of the day.
01 1-3 times last month
02 1-2 times per week
03 3-4 times per week
04 5-6 times per week
05 1 time per day
06 2 times per day
07 3 times per day
08 4 times per day
09 5 or more times per day
97 Refused
99 Don't know
1. 1-3 times last month
2. 1-2 times per week
3. 3-4 times per week
4. 5-6 times per week
5. 1 time per day
6. 2 times per day
7. 3 times per day
8. 4 times per day
9. 5 or more times per day
Skip Instructions:
Question Text:
*Read if necessary: During the past month . . .
When you ate cereal, which kinds did you usually eat?
*Enter one or two types. Separate with a comma.
2 All bran cereals (such as All Bran, Fiber One, 100% Bran, or Bran Buds)
3 Cereals with some bran or fiber (such as Cheerios, Raisin Bran, Shredded Wheat, Total, Wheaties, 40% Bran flakes, Granola, Grape Nuts, Muselix, etc.)
4 Cereals with little bran or fiber (such as Corn Flakes, Honey Nut Cheerios, Froot Loops, Rice Krispies, Kix, Frosted Flakes, Special K, Cap'n Crunch, Blueberry Morning, Product 19, etc.)
5 Other
7 Refused
9 Don't know
You may choose up to two.
2. All bran cereals (such as All Bran, Fiber One, 100% Bran, or Bran Buds)
3. Cereals with some bran or fiber (such as Cheerios, Raisin Bran, Shredded Wheat, Total, Wheaties, 40% Bran Flakes, Granola, Grape Nuts, Muselix, etc.)
4. Cereals with little bran or fiber (such as Corn Flakes, Honey Nut Cheerios, Froot Loops, Rice Krispies, Kix, Frosted Flakes, Special K, Cap'n Crunch, Blueberry Morning, Product 19, etc.)
5. Other
Skip Instructions:
[p. 3]
Question Text:
*Read if necessary: During the past month . . .
How often did you have MILK, either to drink or on cereal? Do NOT include small amounts of milk in coffee or tea.
*Read if necessary: Do NOT include cream or soy milk . INCLUDE skim, no-fat, low-fat, whole milk, buttermilk, and lactose-free milk. Also INCLUDE chocolate or other flavored milks.
01 1-3 times last month
02 1-2 times per week
03 3-4 times per week
04 5-6 times per week
05 1 time per day
06 2 times per day
07 3 times per day
08 4 times per day
09 5 or more times per day
97 Refused
99 Don't know
1. 1-3 times last month
2. 1-2 times per week
3. 3-4 times per week
4. 5-6 times per week
5. 1 time per day
6. 2 times per day
7. 3 times per day
8. 4 times per day
9. 5 or more times per day
Skip Instructions:
Question Text:
During the past month, how often did you drink regular, carbonated SODA OR SOFT DRINKS that contain sugar? Do NOT include diet soda.
*Read if necessary: Do NOT include diet or sugar-free fruit drinks. Do NOT include juices or tea in cans. DO NOT include diet mineral water or diet flavored waters.
01 1-3 times last month
02 1-2 times per week
03 3-4 times per week
04 5-6 times per week
05 1 time per day
06 2 times per day
07 3 times per day
08 4 times per day
09 5 or more times per day
97 Refused
99 Don't know
1. 1-3 times last month
2. 1-2 times per week
3. 3-4 times per week
4. 5-6 times per week
5. 1 time per day
6. 2 times per day
7. 3 times per day
8. 4 times per day
9. 5 or more times per day
Skip Instructions:
[p. 4]
Question Text:
During the past month, How often did you drink 100% FRUIT JUICE, such as orange, mango, apple, and grape juices? Do NOT count fruit drinks.
*Read if necessary: INCLUDE only 100% pure juices. Do NOT include fruit drinks with added sugar, like Kool-aid, Hi-C, lemonade, cranberry cocktail, Gatorade, Tampico, and Sunny Delight.
01 1-3 times last month
02 1-2 times per week
03 3-4 times per week
04 5-6 times per week
05 1 time per day
06 2 times per day
07 3 times per day
08 4 times per day
09 5 or more times per day
97 Refused
99 Don't know
1. 1-3 times last month
2. 1-2 times per week
3. 3-4 times per week
4. 5-6 times per week
5. 1 time per day
6. 2 times per day
7. 3 times per day
8. 4 times per day
9. 5 or more times per day
Skip Instructions:
Question Text:
NOW we are going to ask about FRUIT-FLAVORED drinks WITH ADDED SUGAR. How often did you drink FRUIT-FLAVORED DRINKS with sugar (such as Kool-aid, Hi-C, lemonade, or cranberry cocktail)? Do NOT include diet drinks.
*Read if necessary: INCLUDE Gatorade and other sports drinks with added sugar. INCLUDE Tampico, Sunny Delight and Twister. Do NOT include 100% fruit juices or soda. Do NOT include yogurt drinks or carbonated water.
01 1-3 times last month
02 1-2 times per week
03 3-4 times per week
04 5-6 times per week
05 1 time per day
06 2 times per day
07 3 times per day
08 4 times per day
09 5 or more times per day
97 Refused
99 Don't know
1. 1-3 times last month
2. 1-2 times per week
3. 3-4 times per week
4. 5-6 times per week
5. 1 time per day
6. 2 times per day
7. 3 times per day
8. 4 times per day
9. 5 or more times per day
Skip Instructions:
[p. 5]
Question Text:
*Read if necessary: During the past month . . .
How often did you eat FRUIT? COUNT fresh, frozen, or canned fruit. Do NOT count juices.
*Read if necessary: Include fruits such as apples, bananas, applesauce, melon, berries, fruit salad, mangos, papayas, oranges, and grapes.
01 1-3 times last month
02 1-2 times per week
03 3-4 times per week
04 5-6 times per week
05 1 time per day
06 2 times per day
07 3 times per day
08 4 times per day
09 5 or more times per day
97 Refused
99 Don't know
1. 1-3 times last month
2. 1-2 times per week
3. 3-4 times per week
4. 5-6 times per week
5. 1 time per day
6. 2 times per day
7. 3 times per day
8. 4 times per day
9. 5 or more times per day
Skip Instructions:
Question Text:
During the past month, how often did you eat a green leafy or lettuce SALAD, with or without other vegetables?
*Read if necessary: INCLUDE spinach salads
01 1-3 times last month
02 1-2 times per week
03 3-4 times per week
04 5-6 times per week
05 1 time per day
06 2 times per day
07 3 times per day
08 4 times per day
09 5 or more times per day
97 Refused
99 Don't know
1. 1-3 times last month
2. 1-2 times per week
3. 3-4 times per week
4. 5-6 times per week
5. 1 time per day
6. 2 times per day
7. 3 times per day
8. 4 times per day
9. 5 or more times per day
Skip Instructions:
[p. 6]
Question Text:
*Read if necessary: During the past month . . .
How often did you eat FRENCH FRIES, home fries, or hash brown potatoes?
01 1-3 times last month
02 1-2 times per week
03 3-4 times per week
04 5-6 times per week
05 1 time per day
06 2 times per day
07 3 times per day
08 4 times per day
09 5 or more times per day
97 Refused
99 Don't know
1. 1-3 times last month
2. 1-2 times per week
3. 3-4 times per week
4. 5-6 times per week
5. 1 time per day
6. 2 times per day
7. 3 times per day
8. 4 times per day
9. 5 or more times per day
Skip Instructions:
Question Text:
*Read if necessary: During the past month . . .
How often did you eat other WHITE POTATOES? COUNT baked potatoes, boiled potatoes, mashed potatoes and potato salad.
*Read if necessary: Do NOT include yams or sweet potatoes. INCLUDE red-skinned and Yukon Gold potatoes.
01 1-3 times last month
02 1-2 times per week
03 3-4 times per week
04 5-6 times per week
05 1 time per day
06 2 times per day
07 3 times per day
08 4 times per day
09 5 or more times per day
97 Refused
99 Don't know
1. 1-3 times last month
2. 1-2 times per week
3. 3-4 times per week
4. 5-6 times per week
5. 1 time per day
6. 2 times per day
7. 3 times per day
8. 4 times per day
9. 5 or more times per day
Skip Instructions:
[p. 7]
Question Text:
*Read if necessary: During the past month . . .
How often did you eat COOKED DRIED BEANS, such as refried beans, baked beans, bean soup, and pork and beans? Do NOT include green beans.
01 1-3 times last month
02 1-2 times per week
03 3-4 times per week
04 5-6 times per week
05 1 time per day
06 2 times per day
07 3 times per day
08 4 times per day
09 5 or more times per day
97 Refused
99 Don't know
1. 1-3 times last month
2. 1-2 times per week
3. 3-4 times per week
4. 5-6 times per week
5. 1 time per day
6. 2 times per day
7. 3 times per day
8. 4 times per day
9. 5 or more times per day
Skip Instructions:
Question Text:
*Read if necessary: During the past month . . .
Not counting what you just told me about (lettuce salads, white potatoes, cooked dried beans), and not counting rice, how often did you eat OTHER VEGETABLES?
*Read if necessary: Examples of other vegetables include tomatoes, string beans, carrots, corn, sweet potatoes, cabbage, bean sprouts, collard greens, and broccoli.
01 1-3 times last month
02 1-2 times per week
03 3-4 times per week
04 5-6 times per week
05 1 time per day
06 2 times per day
07 3 times per day
08 4 times per day
09 5 or more times per day
97 Refused
99 Don't know
1. 1-3 times last month
2. 1-2 times per week
3. 3-4 times per week
4. 5-6 times per week
5. 1 time per day
6. 2 times per day
7. 3 times per day
8. 4 times per day
9. 5 or more times per day
Skip Instructions:
[p. 8]
Question Text:
*Read if necessary: During the past month . . .
How often did you have TOMATO SAUCES such as spaghetti sauce or pizza with tomato sauce?
01 1-3 times last month
02 1-2 times per week
03 3-4 times per week
04 5-6 times per week
05 1 time per day
06 2 times per day
07 3 times per day
08 4 times per day
09 5 or more times per day
97 Refused
99 Don't know
1. 1-3 times last month
2. 1-2 times per week
3. 3-4 times per week
4. 5-6 times per week
5. 1 time per day
6. 2 times per day
7. 3 times per day
8. 4 times per day
9. 5 or more times per day
Skip Instructions:
Question Text:
*Read if necessary: During the past month . . .
How often did you have SALSA?
01 1-3 times last month
02 1-2 times per week
03 3-4 times per week
04 5-6 times per week
05 1 time per day
06 2 times per day
07 3 times per day
08 4 times per day
09 5 or more times per day
97 Refused
99 Don't know
1. 1-3 times last month
2. 1-2 times per week
3. 3-4 times per week
4. 5-6 times per week
5. 1 time per day
6. 2 times per day
7. 3 times per day
8. 4 times per day
9. 5 or more times per day
Skip Instructions:
[p. 9]
Question Text:
*Read if necessary: During the past month . . .
How often did you eat RED MEAT?
01 1-3 times last month
02 1-2 times per week
03 3-4 times per week
04 5-6 times per week
05 1 time per day
06 2 times per day
07 3 times per day
08 4 times per day
09 5 or more times per day
97 Refused
99 Don't know
1. 1-3 times last month
2. 1-2 times per week
3. 3-4 times per week
4. 5-6 times per week
5. 1 time per day
6. 2 times per day
7. 3 times per day
8. 4 times per day
9. 5 or more times per day
Pork, bacon
Lamb
Hotdogs and coldcuts made with those meats
Mixtures with those meats, like sandwiches, lasagna, stew . . .
Fish or seafood
Skip Instructions:
Question Text:
*Read if necessary: During the past month . . .
How often did you eat WHOLE GRAIN BREAD including toast, rolls and in sandwiches? Whole grain breads include whole wheat, rye, oatmeal and pumpernickel. Do NOT include white bread.
*Read if necessary: INCLUDE cracked wheat, multi-grain and bran breads.
01 1-3 times last month
02 1-2 times per week
03 3-4 times per week
04 5-6 times per week
05 1 time per day
06 2 times per day
07 3 times per day
08 4 times per day
09 5 or more times per day
97 Refused
99 Don't know
1. 1-3 times last month
2. 1-2 times per week
3. 3-4 times per week
4. 5-6 times per week
5. 1 time per day
6. 2 times per day
7. 3 times per day
8. 4 times per day
9. 5 or more times per day
Skip Instructions:
[p. 10]
Question Text:
During the past month, how often did you eat DOUGHNUTS, sweet rolls, Danish, muffins, or pop-tarts? Do NOT include sugar-free items.
*Read if necessary: INCLUDE low-fat kinds.
01 1-3 times last month
02 1-2 times per week
03 3-4 times per week
04 5-6 times per week
05 1 time per day
06 2 times per day
07 3 times per day
08 4 times per day
09 5 or more times per day
97 Refused
99 Don't know
1. 1-3 times last month
2. 1-2 times per week
3. 3-4 times per week
4. 5-6 times per week
5. 1 time per day
6. 2 times per day
7. 3 times per day
8. 4 times per day
9. 5 or more times per day
Skip Instructions:
Question Text:
*Read if necessary: During the past month . . .
How often did you eat COOKIES, CAKE, PIE, or BROWNIES? Do NOT include sugar-free kinds.
*Read if necessary: INCLUDE low-fat kinds. Do NOT include ice cream and other frozen desserts or candy.
01 1-3 times last month
02 1-2 times per week
03 3-4 times per week
04 5-6 times per week
05 1 time per day
06 2 times per day
07 3 times per day
08 4 times per day
09 5 or more times per day
97 Refused
99 Don't know
1. 1-3 times last month
2. 1-2 times per week
3. 3-4 times per week
4. 5-6 times per week
5. 1 time per day
6. 2 times per day
7. 3 times per day
8. 4 times per day
9. 5 or more times per day
Skip Instructions:
[p. 11]
Question Text:
*Read if necessary: During the past month . . .
How often did you eat any kind of CHEESE? Include cheese as a snack, cheese on burgers, sandwiches, or pizza, and cheese mixed into such foods as lasagna, enchiladas or casseroles.
*Read if necessary: Do NOT count cream cheese.
01 1-3 times last month
02 1-2 times per week
03 3-4 times per week
04 5-6 times per week
05 1 time per day
06 2 times per day
07 3 times per day
08 4 times per day
09 5 or more times per day
97 Refused
99 Don't know
1. 1-3 times last month
2. 1-2 times per week
3. 3-4 times per week
4. 5-6 times per week
5. 1 time per day
6. 2 times per day
7. 3 times per day
8. 4 times per day
9. 5 or more times per day
Skip Instructions:
Question Text:
During the PAST 12 MONTHS, did you take any vitamin or mineral supplements of ANY kind?
*Read if necessary: INCLUDE vitamin or mineral pills, liquids, or tinctures. Do NOT include vitamin-fortified foods.
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 12]
Question Text:
*If multi-vitamins were already mentioned, enter "1" for yes without asking.
*Read if necessary: There are a number of vitamin and mineral combinations now available. The ways in which nutrients can be combined into pill form is almost infinite. Any combination of 3 or more vitamins and minerals should be included in the MULTI-vitamin category. Combinations labeled as "stress" or "antioxidant" supplements are common and should be included as MULTI-vitamins. Do NOT include combinations of herbal or botanical substances, or combinations of just 2 nutrients (e.g., calcium with vitamin D, etc.) in this question.
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
*Enter '12' for all 12 months.
97 Refused
99 Don't know
Skip Instructions:
Question Text:
During [fill1: the month/those months] about how many [fill2: DAYS/DAYS PER MONTH] did you take MULTI- vitamins?
*Enter number of days taking multi-vitamins.
*Enter '30' for all days in the month.
*Enter '95' for other.
95 Other
97 Refused
99 Don't know
Skip Instructions:
(30) store '2' in VITMULDT [goto BETAC] (95) store '3' in VITMULDT [goto BETAC]
(R,D) store 'R', 'D' in VITMULDT [goto BETAC]
[p. 13]
Question Text:
*Enter time period for days taking multi-vitamins.
2 Days per month
3 Other
7 Refused
9 Don't know
Skip Instructions:
else
(1-3,R,D) [goto BETAC]
Question Text:
During the PAST 12 MONTHS, did you take any beta carotene (BAY-tuh KAR-uh-teen)? [fill1: Do NOT include any beta carotene in the MULTI-vitamins you told me about.]
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
*Enter '12' for all 12 months.
97 Refused
99 Don't know
Skip Instructions:
[p. 14]
Question Text:
During [fill1: the month/those months] about how many [fill2: DAYS/DAYS PER MONTH] did you take beta carotene?
*Enter number of days taking beta carotene.
*Enter '30' for all days in the month.
*Enter '95' for other.
95 Other
97 Refused
99 Don't know
Skip Instructions:
(30) store '2' in BETACDT [goto VITE] (95) store '3' in BETACDT [goto VITE]
(R,D) store 'R', 'D' in BETACDT [goto VITE]
Question Text:
*Enter time period for days taking beta carotene. (Probe as necessary for a 'don't know' answer)
2 Days per month
3 Other
7 Refused
9 Don't know
Skip Instructions:
else
(1-3,R,D)[ goto VITE]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 15]
Question Text:
*Enter '12' for all 12 months.
97 Refused
99 Don't know
Skip Instructions:
Question Text:
During [fill1: the month/those months] about how many [fill2: DAYS/DAYS PER MONTH] did you take vitamin E?
*Enter number of days taking vitamin E.
*Enter '30' for all days in the month.
*Enter '95' for other.
95 Other
97 Refused
99 Don't know
Skip Instructions:
(30) store '2' in VITEDT [goto CALC] (95) store '3' in VITEDT [goto CALC]
(R,D) store 'R', 'D' in VITEDT [goto CALC]
Question Text:
*Enter time period for days taking vitamin E.
2 Days per month
3 Other
7 Refused
9 Don't know
Skip Instructions:
else
(1-3,R,D) [goto CALC]
[p. 16]
Question Text:
*Read if necessary: Include Tums. Do NOT include milk or calcium-fortified orange juice.
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
*Enter '12' for all 12 months.
97 Refused
99 Don't know
Skip Instructions:
Question Text:
During [fill1: the month/those months] about how many [fill2: DAYS/DAYS PER MONTH] did you take calcium?
*Enter number of days taking calcium.
*Enter '30' for all days in the month.
*Enter '95' for other.
95 Other
97 Refused
99 Don't know
Skip Instructions:
(30) store '2' in CALCDT [goto SELN] (95) store '3' in CALCDT [goto SELN]
(R,D) store 'R', 'D' in CALCDT [goto SELN]
[p. 17]
Question Text:
*Enter time period for days taking calcium.
2 Days per month
3 Other
7 Refused
9 Don't know
Skip Instructions:
else
(1-3,R,D) [goto SELN]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
*Enter '12' for all 12 months.
97 Refused
99 Don't know
Skip Instructions:
[p. 18]
Question Text:
During [fill1: the month/those months] about how many [fill2: DAYS/DAYS PER MONTH] did you take selenium?
*Enter number of days taking selenium.
*Enter '30' for all days in the month.
*Enter '95' for other.
95 Other
97 Refused
99 Don't know
Skip Instructions:
(30) store '2' in SELNDT [goto HERBSUPP] (95) store '3' in SELNDT [goto HERBSUPP]
(R,D) store 'R', 'D' in SELNDT [goto HERBSUPP]
Question Text:
*Enter time period for days taking selenium.
2 Days per month
3 Other
7 Refused
9 Don't know
Skip Instructions:
else
(1-3,R,D) [goto HERBSUPP]
[p. 19]
Question Text:
This next question is about herbal supplements. During the PAST 12 MONTHS, did you take any MIXED or single herbal or botanical supplements?
*Read if necessary: Include pills, capsules, liquid tinctures and extracts. Do NOT include teas or food. Do not include garlic or ginger used in cooking.
2. Astragalus
3. Bilberry
4. Cascara Sagrada
5. Cat's Claw
6. Cayenne
7. Cranberry
8. Dong Quai
9. Echinacea
10. Evening primrose oil
11. Feverfew
12. Garlic pills
13. Ginger pills
14. Ginkgo (biloba)
15. Ginseng (Amer., Asian)
16. Ginseng (Siberian)
17. Goldenseal
18. Grapeseed extract
19. Kava Kava
20. Lecithin
21. Melatonin
22. Milk Thistle
23. Saw Palmetto
24. St. John's Wort
25. Valerian
26. Another herbal
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. 20]
Question Text:
People may take medication to treat pain, headache, or arthritis; to relax muscles; or to prevent heart attacks and other diseases.
Typical medications are shown on this card:
Note that this list does NOT include Tylenol. Do you now take any of these medications regularly, that is, at least 3 times a week?
*Read list only if necessary.
Aspirin, Advil, Aleve, Bayer, Bufferin, Celecoxib, Excedrin, Ibuprofen, Motrin, Naprosyn (Naproxen), Nuprin, Vioxx
2 No
7 Refused
9 Don't know
Skip Instructions:
NAC.442_00.000
Question Text:
Have you taken any of these kinds of medications regularly for the last 3 months?
Advil
Aleve
Bayer
Bufferin
Celecoxib
Excedrin
Ibuprofen
Motrin
Naprosyn (Naproxen)
Nuprin
Vioxx
2 No
7 Refused
9 Don't know
Skip Instructions:
NAC.450_00.000
Question Text:
*Enter all that apply, separate with commas.
02 Advil
03 Aleve
04 Bayer
05 Bufferin
06 Celecoxib
07 Excedrin
08 Ibuprofen
09 Motrin
10 Naprosyn (Naproxen)
11 Nuprin
12 Vioxx
13 Other (specify)
97 Refused
99 Don't know
Skip Instructions:
NAC.455_00.000
Question Text:
9 Don't know
Verbatim Verbatim Response
Skip Instructions:
Question Text:
Skip Instructions:
[p. 22]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 1]
2005 NHIS Questionnaire - Sample Adult
Physical Activity
Question Text:
2 No
3 Unable to walk
7 Refused
9 Don't know
Skip Instructions:
Question Text:
*Enter '7' for all days per week.
97 Refused
99 Don't know
Skip Instructions:
Question Text:
[fill1: How much time did you spend walking to get from place to place on that day?/
How much time did you usually spend on one of those days walking to get from place to place?]
*Enter number for length of walk for transportation.
997 Refused
999 Don't know
Skip Instructions:
(R,D)[goto AD14]
NAD.012_02.000
Question Text:
*Enter time period for length of walking for transportation.
2 Hours
7 Refused
9 Don't know
Skip Instructions:
(IF AD13NO gt (90) and AD13TP eq (1) ) or ( if AD13NO gt (2) and AD13TP eq (2) ) goto ERR2_ AD13TP
(1,2,R,D)goto AD14
If AD13NO= 'R', 'D' store 'R', 'D' in AD13TP
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
*Enter '7' for all days per week.
97 Refused
99 Don't know
Skip Instructions:
[p. 3]
Question Text:
[fill1: How much time did you spend walking on that day for FUN, RELAXATION, OR EXERCISE?/
fill2: How much time did you usually spend on one of those days walking for FUN, RELAXATION, OR EXERCISE?]
*Enter number for length of walk for fun, relaxation, or exercise.
997 Refused
999 Don't know
Skip Instructions:
(IF AD16NO gt (90) and AD16TP eq (1) ) or ( if AD16NO gt (2) and AD16TP eq (2) ) goto ERR2_ AD16TP
(1-995)[goto AD16TP]
(R,D)[goto MOVE1]
[If AD16NO= 'R', 'D' store 'R', 'D' in AD16TP]
NAD.015_02.000
Question Text:
*Enter time period for length of walking for fun, relaxation, or exercise.
2 Hours
7 Refused
9 Don't know
Skip Instructions:
[If AD16NO= 'R', 'D' store 'R', 'D' in AD16TP]
[p. 4]
Question Text:
Which one of the following BEST describes your usual daily activities related to moving around? Do NOT include exercises, sports, or physically active hobbies done in your leisure time.
Do you (read categories below):
*Read if necessary: Pick the one you do MOST often
*If respondent is bedridden, enter '1'
2 STAND during MOST of the day
3 WALK AROUND MOST of the day
7 Refused
9 Don't know
2. You STAND during MOST of the day
3. You WALK AROUND MOST of the day
Skip Instructions:
Question Text:
Which one of the following BEST describes your usual daily activities related to lifting or carrying things? Do NOT include activities done in your leisure time.
Do you (read categories 1-4 below):
*Read if necessary: Pick the one you do MOST often.
2 LIFT or carry LIGHT loads
3 LIFT or carry MODERATE loads
4 LIFT or carry HEAVY loads
5 Unable to lift or carry loads
6 Other
7 Refused
9 Don't know
2. You LIFT or carry LIGHT loads
3. You LIFT or carry MODERATE loads
4. You LIFT or carry HEAVY loads
Skip Instructions:
[p. 5]
Question Text:
*Read if necessary: Include watching television or videos, working on the computer, playing video games, using the Internet, knitting, sewing, reading, fishing, taking long drives, watching ball games or doing other sitting activities.
*If person is bedridden, include only waking hours lying down
01-24 1-24 hours
97 Refused
99 Don't know
Skip Instructions:
Question Text:
*Read if necessary: Include watching television or videos, working on the computer, playing video games, using the Internet, knitting, sewing, reading, fishing, taking long drives, watching ball games or doing other sitting activities. Weekend means any days off, not necessarily Saturday and Sunday.
*If person is bedridden, include only waking hours lying down.
01-24 01-24 hours
97 Refused
99 Don't know
Skip Instructions:
Question Text:
2 No
3 Did not see a doctor in the PAST 12 MONTHS
7 Refused
9 Don't know
Skip Instructions:
[p. 1]
2005 NHIS Questionnaire - Sample Adult
Tobacco
Question Text:
2 Non menthol
3 No usual type
7 Refused
9 Don't know
Skip Instructions:
Question Text:
*Read if necessary.
1 pack equals 20 cigarettes.
*Enter '95' if varied.
*Enter '96' if never smoked cigarettes regularly.
95 Varied
96 Never smoked cigarettes regularly
97 Refused
99 Don't know
Skip Instructions:
if AMDLONG=1,2,R,D or ADENLONG = 1,2,R,D [goto MDTOB1A]; else if
AMDLONG=0,3,4,5 or ADENLONG = 0,3,4,5 [goto PIPEEV]
(95) [goto NUMCVAR]
Question Text:
*Read if necessary: 1 pack equals 20 cigarettes.
97 Refused
99 Don't know
Skip Instructions:
[p. 2]
Question Text:
A nicotine gum?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
Thinking back to when you stopped smoking completely, did you use ANY of the following PRODUCTS:
A nicotine patch?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
Thinking back to when you stopped smoking completely, did you use ANY of the following PRODUCTS:
Any of these other nicotine products---nasal spray, inhaler, lozenge or tablet?
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 3]
Question Text:
Thinking back to when you stopped smoking completely, did you use ANY of the following PRODUCTS:
A prescription pill, such as Zyban, Buproprion, or Wellbutrin?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
A telephone help line or quit line?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
Thinking back to when you stopped smoking completely, did you use ANY of the following:
A stop smoking clinic, class, or support group?
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 4]
Question Text:
Thinking back to when you stopped smoking completely, did you use ANY of the following:
One-on-one counseling?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
Thinking back to when you stopped smoking completely, did you use ANY of the following:
Help or support from friends or family?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
Thinking back to when you stopped smoking completely, did you use ANY of the following:
The Internet or World Wide Web?
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 5]
Question Text:
Thinking back to when you stopped smoking completely, did you use ANY of the following:
Books, pamphlets, videos, or other materials?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
Thinking back to when you stopped smoking completely, did you use ANY of the following:
Acupuncture or hypnosis?
2 No
7 Refused
9 Don't know
Skip Instructions:
if AMDLONG=0,3,4,5 or ADENLONG = 0,3,4,5 [goto PIPEEV]
Question Text:
Is your usual cigarette brand menthol or non-menthol?
2 Non menthol
3 No usual type
7 Refused
9 Don't know
Skip Instructions:
[p. 6]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
A nicotine gum?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
Thinking back to when you tried to QUIT smoking in the PAST 12 MONTHS, did you use ANY of the following PRODUCTS:
A nicotine patch?
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 7]
Question Text:
Thinking back to when you tried to QUIT smoking in the PAST 12 MONTHS, did you use ANY of the following PRODUCTS:
Any of these other nicotine products---nasal spray, inhaler, lozenge or tablet?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
Thinking back to when tried to QUIT smoking in the PAST 12 MONTHS, did you use ANY of the following PRODUCTS:
A prescription pill, such as Zyban, Buproprion, or Wellbutrin?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
A telephone help line or quit line?
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 8]
Question Text:
Thinking back to when you tried to QUIT smoking in the PAST 12 MONTHS, did you use ANY of the following:
A stop smoking clinic, class, or support group?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
Thinking back to when you tried to QUIT smoking in the PAST 12 MONTHS, did you use ANY of the following:
One-on-one counseling?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
Thinking back to when you tried to QUIT smoking in the PAST 12 MONTHS, did you use ANY of the following:
Help or support from friends or family?
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 9]
Question Text:
Thinking back to when you tried to QUIT smoking in the PAST 12 MONTHS, did you use ANY of the following:
The Internet or World Wide Web?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
Thinking back to when you tried to QUIT smoking in the PAST 12 MONTHS, did you use ANY of the following:
Books, pamphlets, videos, or other materials?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
Thinking back to when you tried to QUIT smoking in the PAST 12 MONTHS, did you use ANY of the following:
Acupuncture or hypnosis?
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 10]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
In the PAST 12 MONTHS, has a medical doctor, dentist, or other health professional ASKED you about whether you smoke cigarettes or use other kinds of tobacco?
2 No
3 Did not see a doctor in the past 12 months
7 Refused
9 Don't know
Skip Instructions:
Question Text:
2 No
3 Varies from doctor to doctor
7 Refused
9 Don't know
Skip Instructions:
[p. 11]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
In the PAST 12 MONTHS, which health professional(s) advised you to quit smoking or quit using other kinds of tobacco?
*Enter all that apply, separate with commas.
2 Dentist
3 Nurse
4 Dental Hygienist
5 Other health professional (specify)
7 Refused
9 Don't know
2. Dentist
3. Nurse
4. Dental Hygienist
5. Other health professional
Skip Instructions:
Question Text:
9 Don't know
verbatim Verbatim response
Skip Instructions:
[p. 12]
Question Text:
Have you ever smoked tobacco in a pipe EVEN ONE TIME?
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 Some days
3 Not at all
7 Refused
9 Don't know
Skip Instructions:
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 13]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
2 Some days
3 Not at all
7 Refused
9 Don't know
Skip Instructions:
Question Text:
*Enter '0' for none.
*Enter '30' for all days in the month.
01-30 1-30 days
97 Refused
99 Don't know
Skip Instructions:
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:
Question Text:
2 Some days
3 Not at all
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. 15]
Question Text:
2 Some days
3 Not at all
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:
Question Text:
2 Some days
3 Not at all
7 Refused
9 Don't know
Skip Instructions:
[p. 16]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
(2,R,D) [if SEX = 2 and AGE = 18-49 [goto LIVEBTH]]; else goto next section
Question Text:
*Enter '0' for none.
*Enter '96' for 96 or more smokers.
01-95 01-95 persons
96 96+
97 Refused
99 Don't know
Skip Instructions:
(0,R,D) [if SEX = 2 and AGE = 18-49 [goto LIVEBTH]]; else goto next section
Question Text:
*Enter '0' for less than 1 day per week/rarely/none
*Enter '7' for all days per week
01-07 01-07 days
97 Refused
99 Don't know
Skip Instructions:
[p. 17]
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:
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 18]
Question Text:
02 Second
03 Third
04 Fourth
05 Fifth
06 Sixth
07 Seventh
08 Eighth
09 Ninth
97 Refused
99 Don't know
Skip Instructions:
Question Text:
2 Started again
3 Never started again
7 Refused
9 Don't know
Skip Instructions:
[p. 1]
2005 NHIS Questionnaire - Sample Adult
Cancer Screening
Question Text:
Now, we are going to ask you about your skin's reaction to the sun. After several months of not being in the sun very much, if you went out in the sun for an hour without sunscreen, a hat, or protective clothing, which one of these best describes what would happen to your skin?
*Read if necessary: Even if you did not go out in the sun, what would happen if you did? Use the most recent experience. If none, then think about the past.
*By "sunburn" we mean even a small part of your skin turns red or hurts for 12 hours or more.
02 Have a moderate sunburn with peeling
03 Burn mildly with some or no darkening/tanning
04 Turn darker without sunburn
05 Nothing would happen to my skin
06 Do not go out in the sun
07 Other
97 Refused
99 Don't know
2. Have a moderate sunburn with peeling
3. Burn mildly with some or no darkening/tanning
4. Turn darker without sunburn
5. Nothing would happen to my skin
Skip Instructions:
Question Text:
Next, consider that you were out in the sun repeatedly, such as every day for two weeks, without sunscreen, a hat, or protective clothing . Which one of these best describes what your skin would LOOK like?
*Read if necessary: Even if you did not go out in the sun, what would happen if you did? Use the most recent experience. If none, then think about the past.
*By "sunburn" we mean even a small part of your skin turns red or hurts for 12 hours or more.
02 Dark/Moderately tanned
03 A little dark/mildly tanned
04 Freckled but still light skinned
05 Burned repeatedly with little or no darkening or tanning---still light skinned
06 Don't go out in the sun
07 Other
97 Refused
99 Don't know
2. Dark/Moderately tanned
3. A little dark/Mildly tanned
4. Freckled but still light skinned
5. Burned repeatedly with little or no darkening or tanning--still light skinned
Skip Instructions:
[p. 2]
Question Text:
When you go outside on a warm sunny day for MORE than one hour, how often do you. . .
Stay in the shade? Would you say (Read categories 1-5). . .
2 Most of the time
3 Sometimes
4 Rarely
5 Never
6 Don't go out in the sun
7 Refused
9 Don't know
2. Most of the time
3. Sometimes
4. Rarely
5. Never
Skip Instructions:
Question Text:
*Read if necessary.
When you go outside on a warm sunny day for MORE than one hour, how often do you. . .
Wear a baseball cap or sun visor? Would you say (Read categories 1-5). . .
SUN1_CAP
2 Most of the time
3 Sometimes
4 Rarely
5 Never
6 Don't go out in the sun
7 Refused
9 Don't know
2. Most of the time
3. Sometimes
4. Rarely
5. Never
Skip Instructions:
[p. 3]
Question Text:
*Read if necessary.
When you go outside on a warm sunny day for MORE than one hour, how often do you. . .
Wear a hat that shades your face, ears AND neck such as a hat with a wide brim all around? Would you say (Read categories 1-5). . .
*Do not include visors, baseball caps, or hats that do not shade the face, ears and neck. Include safari hats.
2. Most of the time
3. Sometimes
4. Rarely
5. Never
Flashcard CAN13 shows images of different kinds of hats that shade the face, ears, and neck (e.g., sunhat, cowboy hat, safari hat).
2 Most of the time
3 Sometimes
4 Rarely
5 Never
6 Don't go out in the sun
7 Refused
9 Don't know
Skip Instructions:
Question Text:
*Read if necessary.
When you go outside on a warm sunny day for MORE than one hour, how often do you. . .
Wear a long sleeved shirt? Would you say (Read categories 1-5). . .
2 Most of the time
3 Sometimes
4 Rarely
5 Never
6 Don't go out in the sun
7 Refused
9 Don't know
2. Most of the time
3. Sometimes
4. Rarely
5. Never
Skip Instructions:
[p. 4]
Question Text:
*Read if necessary.
When you go outside on a warm sunny day for MORE than one hour, how often do you. . .
Wear long pants or other clothing that reaches your ankles? Would you say (Read categories 1-5). . .
2 Most of the time
3 Sometimes
4 Rarely
5 Never
6 Don't go out in the sun
7 Refused
9 Don't know
2. Most of the time
3. Sometimes
4. Rarely
5. Never
Skip Instructions:
Question Text:
*Read if necessary.
When you go outside on a warm sunny day for MORE than one hour, how often do you. . .
Use sunscreen? Would you say (Read categories 1-5). . .
2 Most of the time
3 Sometimes
4 Rarely
5 Never
6 Don't go out in the sun
7 Refused
9 Don't know
2. Most of the time
3. Sometimes
4. Rarely
5. Never
Skip Instructions:
[p. 5]
Question Text:
*Read if necessary: If you use more than one or different ones, pick the one used most often.
*Enter '96' if unable to pick the one used most often.
96 More than one, different ones, other
97 Refused
99 Don't know
Skip Instructions:
Question Text:
2 15-50
7 Refused
9 Don't know
Skip Instructions:
Question Text:
*Read if necessary: By "sunburn" we mean even a small part of your skin turns red or hurts for 12 hours or more. Also include burns from sunlamps and other indoor tanning devices.
*Enter '0' for none.
001-365 1-365 times
997 Refused
999 Don't know
Skip Instructions:
[p. 6]
Question Text:
*Enter '0' for none.
001-365 1-365 times
997 Refused
999 Don't know
Skip Instructions:
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 7]
Question Text:
When did you have your MOST RECENT skin exam to check for cancer?
*Enter month of last skin exam.
*Enter '96' to go to the number and 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:
Question Text:
*Enter year of last skin exam.
9996 Time period format
9997 Refused
9999 Don't know
Skip Instructions:
[p. 8]
Question Text:
When did you have your MOST RECENT skin exam?
*Enter number for time since last skin exam.
*Enter '95' for 95 or more.
95 95+
97 Refused
99 Don't know
Skip Instructions:
Question Text:
*Enter time period for time since most recent skin exam.
2 Weeks ago
3 Months ago
4 Years ago
7 Refused
9 Don't know
Skip Instructions:
Question Text:
Was it (read answer categories):
2 More than 1 year but not more than 2 years
3 More than 2 years but not more than 3 years
4 More than 3 years but not more than 5 years
5 Over 5 years ago
7 Refused
9 Don't know
2. More than 1 year but not more than 2 years
3. More than 2 years but not more than 3 years
4. More than 3 years but not more than 5 years
5. Over 5 years ago
Skip Instructions:
[p. 9]
Question Text:
2 Because of a problem
3 Other reason
7 Refused
9 Don't know
Skip Instructions:
Question Text:
*Enter '0' for haven't started.
06-60 6-60 years
97 Refused
99 Don't know
Skip Instructions:
Question Text:
Have you EVER used any of the following birth control methods?
*Enter all that apply, separate with commas.
1 Oral Contraception (birth control pills)
2 Patch
3 Ring
4 Injection
5 IUD (Intrauterine Device)
6 Implant
7 Refused
9 Don't know
You may choose more than one.
2. Patch
3. Ring
4. Injection
5. IUD (Intrauterine Device)
6. Implant
Skip Instructions:
[p. 10]
Question Text:
Altogether, about how long did you use birth control?
*Enter number for time using birth control.
*Enter '95' for 95 or more.
95 95+
97 Refused
99 Don't know
Skip Instructions:
Question Text:
*Enter time period for time using birth control.
2 Months
3 Years
7 Refused
9 Don't know
Skip Instructions:
if [BCNO = Number greater than person years old and BCTP= 3]] goto
ERR1_BCTP
Question Text:
Have you EVER given birth to a live born infant?
*Read if necessary.
A live born infant is an infant born alive.
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 11]
Question Text:
97 Refused
99 Don't know
Skip Instructions:
Question Text:
97 Refused
99 Don't know
Skip Instructions:
Question Text:
9997 Refused
9999 Don't know
Skip Instructions:
Question Text:
*Read if necessary. A Pap smear is a routine test for women in which the doctor examines the cervix, takes a cell sample from the cervix with a small stick or brush, and sends it to the lab.
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 12]
Question Text:
*Enter '0' for none.
*Enter '95' for 95 or more exams.
01-94 1-94 times
95 95+ times
97 Refused
99 Don't know
Skip Instructions:
Question Text:
*Enter month of last Pap smear test.
*Enter '96' to go to number and 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:
[p. 13]
Question Text:
*Enter year of last Pap smear test.
9996 Time period format
9997 Refused
9999 Don't know
Skip Instructions:
IF RPAP1_MT and RPAP1_YR = a future date [goto ERR1_RPAP1_YR]
IF RPAP1_MT and RPAP1_YR = a date prior to birth date [goto ERR2_RPAP1_YR]
Question Text:
When did you have your MOST RECENT Pap smear test?
*Enter number for time since last Pap smear test.
*Enter '95' for 95 or more.
95 95+
97 Refused
Skip Instructions:
Question Text:
*Enter time period for time since most recent Pap smear test.
2 Weeks ago
3 Months ago
4 Years ago
7 Refused
9 Don't know
Skip Instructions:
(4) if RPAP1N and RPAP1T GT 5 years from system, fill "5" in RPAP2 [goto PAPREAS]; else [goto RPAP2]
(R,D) [goto RPAP2]
IF [RPAPIN = Number greater than person years old and RPAP1T= 4]] goto ERR1_RPAP1T
[p. 14]
Question Text:
Was it:
*Read answer categories.
2 More than 1 year but not more than 2 years
3 More than 2 years but not more than 3 years
4 More than 3 years but not more than 5 years
5 Over 5 years ago
7 Refused
9 Don't know
2. More than 1 year but not more than 2 years
3. More than 2 years but not more than 3 years
4. More than 3 years but not more than 5 years
5. Over 5 years ago
Skip Instructions:
Question Text:
2 Because of a problem
3 Other reason
7 Refused
9 Don't know
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:
What is the most important reason you have [Fill1: NEVER had a Pap smear/NOT had a Pap smear in the LAST 3 YEARS]?
02 Didn't need/Didn't know I needed this type of test
03 Doctor didn't order it/didn't say I needed it
04 Haven't had any problems
05 Put if off/Didn't get around to it
06 Too expensive/No insurance/Cost
07 Too painful, unpleasant, or embarrassing
08 Had hysterectomy
09 Don't have doctor
10 Other
97 Refused
99 Don't know
2. Didn't need it/didn't know I needed this type of test
3. Doctor didn't order it/didn't say I needed it 4. Haven't had any problems
5. Put it off/didn't get around to it
6. Too expensive/no insurance/cost
7. Too painful, unpleasant, or embarrassing
8. Had hysterectomy
9. Don't have a doctor
Skip Instructions:
[p. 16]
Question Text:
"Was your most recent Pap smear recommended by a doctor or other health professional?"
Else (IF PAPHAD=2, or PAPHAD GT 3 years from system date or RPAP2=R,D)
"In the PAST 12 MONTHS, has a doctor or other health professional RECOMMENDED that you have a PAP smear?"
2 No
3 Did not see a doctor in the past 12 months
7 Refused
9 Don't know
Skip Instructions:
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 17]
Question Text:
When was your hysterectomy?
*Enter month of hysterectomy.
*Enter '96' to go to number and 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:
Question Text:
*Enter year of hysterectomy.
9996 Time period format
9997 Refused
9999 Don't know
Skip Instructions:
IF RHYS1_MT and RHYS1_YR = a future date [goto ERR1_RHYS1_YR]
IF RHYS1_MT and RHYS1_YR = a date prior to birth date [goto ERR2_RHYS1_YR]
[p. 18]
Question Text:
When was your hysterectomy?
*Enter number for time since hysterectomy.
*Enter '95' for 95 or more.
95 95+
97 Refused
99 Don't know
Skip Instructions:
Question Text:
*Enter time period for time since hysterectomy.
2 Weeks ago
3 Months ago
4 Years ago
7 Refused
9 Don't know
Skip Instructions:
(4) if RHYS1N and RHYS1T GT 5 years from system date fill "5" in RHYS2 [goto MAMHAD if AGE GE 30, else goto next section]; else [goto RHYS2] (R,D) [goto RHYS2]
IF [RHYS1N = Number greater than person years old and RHYS1T= 4]] goto ERR1_RHYS1T
[p. 19]
Question Text:
Was it:
*Read answer categories.
2 More than 1 year but not more than 2 years
3 More than 2 years but not more than 3 years
4 More than 3 years but not more than 5 years
5 Over 5 years ago
7 Refused
9 Don't know
2. More than 1 year but not more than 2 years
3. More than 2 years but not more than 3 years
4. More than 3 years but not more than 5 years
5. Over 5 years ago
Skip Instructions:
Question Text:
*Read if necessary. A mammogram is an x-ray taken only of the breast by a machine that presses against the breast.
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
About how old were you when you had your first mammogram? Were you:
*Read answer categories.
2 30-39
3 40-49
4 50-59
5 60 years or older
7 Refused
9 Don't know
2. 30-39
3. 40-49
4. 50-59
5. 60 years or older
Skip Instructions:
[p. 20]
Question Text:
*Enter '0' for none.
*Enter '95' for 95 or more mammograms.
01-94 1-94
95 95+
97 Refused
99 Don't know
Skip Instructions:
Question Text:
The next few questions are about your recent mammograms. When did you have your MOST RECENT mammogram?
*Enter month of last mammogram.
*Enter '96' to go to number and 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:
[goto RMAM1N]
[p. 21]
Question Text:
*Enter year of last mammogram.
9996 Time period format
9997 Refused
9999 Don't know
Skip Instructions:
Question Text:
When did you have your MOST RECENT mammogram?
*Enter number for time since last mammogram.
*Enter '95' for 95 or more.
95 95+
97 Refused
99 Don't know
Skip Instructions:
Question Text:
*Enter time period for time since most recent mammogram.
2 Weeks ago
3 Months ago
4 Years ago
7 Refused
9 Don't know
Skip Instructions:
IF [RMAM1N = Number greater than person years old and RMAM1T= 4]] goto ERR1_RMAM1T
[p. 22]
Question Text:
Was it:
*Read answer categories.
2 More than 1 year but not more than 2 years
3 More than 2 years but not more than 3 years
4 More than 3 years but not more than 5 years
5 Over 5 years ago
7 Refused
9 Don't know
2. More than 1 year but not more than 2 years
3. More than 2 years but not more than 3 years
4. More than 3 years but not more than 5 years
5. Over 5 years ago
Skip Instructions:
Question Text:
2 Because of a problem
3 Other reason
7 Refused
9 Don't know
Skip Instructions:
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 23]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
2 No
3 Lump removed was cancerous
7 Refused
9 Don't know
Skip Instructions:
Question Text:
97 Refused
99 Don't know
Skip Instructions:
[p. 24]
Question Text:
What is the most important reason why you have [fill1: NEVER had a mammogram/NOT had a mammogram in the PAST 2 YEARS]?
02 Didn't need it/didn't know I needed this type of test
03 Doctor didn't order it/didn't say I needed it
04 Haven't had any problems
05 Put it off/Didn't get around to it
06 Too expensive/no insurance/cost
07 Too painful, unpleasant or embarrassing
08 I'm too young
09 Don't have doctor
10 Other
97 Refused
99 Don't know
2. Didn't need it/didn't know I needed this type of test
3. Doctor didn't order it/didn't say I needed it
4. Haven't had any problems
5. Put it off/didn't get around to it
6. Too expensive/no insurance/cost
7. Too painful, unpleasant, or embarrassing
8. I'm too young
9. Don't have a doctor
Skip Instructions:
Question Text:
[Was your most recent mammogram recommended by a doctor or other health professional?]
Else (IF MAMHAD=2, or MAMHAD GT 2 years from system date or RMAM2=R,D)
[In the PAST 12 MONTHS, has a doctor or other health professional RECOMMENDED that you have a mammogram?]
2 No
3 Did not see a doctor in the past 12 months
7 Refused
9 Don't know
Skip Instructions:
Question Text:
Hormone replacement therapy?
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 25]
Question Text:
Are you currently taking any of the following medications?
Tamoxifen, also known as Nolvadex?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
Are you currently taking any of the following medications?
Raloxifen, also known as Evista?
*Pronunciation guide: rah-LOX-ih-fen
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
Are you currently taking any of the following medications?
Birth control pills, birth control implants, or birth control shots?
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 26]
Question Text:
2 To reduce the chance I may develop breast cancer
3 Other
7 Refused
9 Don't know
Skip Instructions:
Question Text:
*Read if necessary.
A breast exam is when the breasts are felt by a doctor or other health professional to check for lumps or other signs of breast cancer.
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 27]
Question Text:
When did you have your MOST RECENT breast exam?
*Enter month of last breast exam.
*Enter '96' to go to number and 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:
Question Text:
*Enter year of last breast exam.
9996 Time period format
9997 Refused
9999 Don't know
Skip Instructions:
[goto RCBE2] (R,D) [goto RCBE2]
IF RCBE1_MT and RCBE1_YR = a future date [goto ERR1_RCBE1_YR]
IF RCBE1_MT and RCBE1_YR = a date prior to birth date [goto ERR2_RCBE1_YR]
[p. 28]
Question Text:
When did you have your MOST RECENT breast exam?
*Enter number for time since last breast exam.
*Enter '95' for 95 or more.
95 95+
97 Refused
99 Don't know
Skip Instructions:
Question Text:
*Enter time period for time since most recent breast exam.
2 Weeks ago
3 Months ago
4 Years ago
7 Refused
9 Don't know
Skip Instructions:
(4) if RCBE1N and RCBE1T GT 5 years from system date, fill "5" in RCBE2 [goto CREHAD if AGE GE 40; else goto next section]; else [goto RCBE2] (R,D) [goto RCBE2]
IF [RCBEIN = Number greater than person years old and RCBE1T= 4]] goto ERR1_RCBE1T
[p. 29]
Question Text:
Was it:
*Read answer categories.
2 More than 1 year but not more than 2 years
3 More than 2 years but not more than 3 years
4 More than 3 years but not more than 5 years
5 Over 5 years ago
7 Refused
9 Don't know
2. More than 1 year but not more than 2 years
3. More than 2 years but not more than 3 years
4. More than 3 years but not more than 5 years
5. Over 5 years ago
Skip Instructions:
Question Text:
Have you EVER HAD a PSA test? *Read if necessary. A PSA test is a blood test to detect prostate cancer. It is also called a prostate-specific antigen test.
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 30]
Question Text:
How old were you when you had your first PSA test? Were you:
*Read answer categories.
02 40-44
03 45-49
04 50-54
05 55-59
06 60-64
07 65-69
08 70 years and older
97 Refused
99 Don't know
2. 40-44
3. 45-49
4. 50-54
5. 55-59
6. 60-64
7. 65-69
8. 70 years or older
Skip Instructions:
Question Text:
*Enter '0' for none.
*Enter '95" for 95 or more PSA tests.
01-94 1-94 times
95 95+
97 Refused
99 Don't know
Skip Instructions:
[p. 31]
Question Text:
The next few questions are about your recent PSA tests. When did you have your MOST RECENT PSA test?
*Enter month of last PSA test.
*Enter '96' to go to number and 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:
Question Text:
*Enter year of last PSA test.
9996 Time period format
9997 Refused
9999 Don't know
Skip Instructions:
IF RPSA1_MT and RPSA1_YR = a future date [goto ERR1_RPSA1_YR]
IF RPSA1_MT and RPSA1_YR = a date prior to birth date [goto ERR2_RPSA1_YR]
[p. 32]
Question Text:
When did you have your MOST RECENT PSA test?
*Enter number for time since last PSA test.
*Enter '95' for 95 or more.
95 95+
97 Refused
99 Don't know
Skip Instructions:
Question Text:
*Enter time period for time since most recent PSA test.
2 Weeks ago
3 Months ago
4 Years ago
7 Refused
9 Don't know
Skip Instructions:
IF [RPSA1N = Number greater than person years old and RPSA1T= 4]] goto ERR1_RPSA1T
[p. 33]
Question Text:
Was it:
*Read answer categories.
2 More than 1 year but not more than 2 years
3 More than 2 years but not more than 3 years
4 More than 3 years but not more than 5 years
5 Over 5 years ago
7 Refused
9 Don't know
2. More than 1 year but not more than 2 years
3. More than 2 years but not more than 3 years
4. More than 3 years but not more than 5 years
5. Over 5 years ago
Skip Instructions:
Question Text:
2 Because of a problem
3 Other reason
7 Refused
9 Don't know
Skip Instructions:
Question Text:
*Read if necessary. A proctoscopy is an older exam that used a rigid tube.
*Pronunciation guide: sigmoid-OS-copy, colon-OS-copy, proc-TOS-copy.
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 34]
Question Text:
*Enter '0' for none.
*Enter '95' for 95 or more exams.
01-94 1-94 times
95 95+
97 Refused
99 Don't know
Skip Instructions:
Question Text:
When did you have your MOST RECENT exam?
*Enter month of last exam.
*Enter '96' to go to number and 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:
[p. 35]
Question Text:
*Enter year of last colorectal exam.
9996 Time period format
9997 Refused
9999 Don't know
Skip Instructions:
IF RCRE1_MT and RCRE1_YR = a future date [goto ERR1_RCRE1_YR]
IF RCRE1_MT and RCRE1_YR = a date prior to birth date [goto ERR2_RCRE1_YR]
Question Text:
When did you have your MOST RECENT exam?
*Enter number for time since last exam.
*Enter '95' for 95 or more.
95 95+
97 Refused
99 Don't know
Skip Instructions:
Question Text:
*Enter time period for time since most recent exam.
2 Weeks ago
3 Months ago
4 Years ago
7 Refused
9 Don't know
Skip Instructions:
IF [RCRE1N = Number greater than person years old and RCRE1T= 4]] goto ERR1_RCRE1T
[p. 36]
Question Text:
Was it:
*Read answer categories.
2 More than 1 year but not more than 2 years
3 More than 2 years but not more than 3 years
4 More than 3 years but not more than 5 years
5 More than 5 years but not more than 10 years
6 Over 10 years ago
7 Refused
9 Don't know
2. More than 1 year but not more than 2 years
3. More than 2 years but not more than 3 years
4. More than 3 years but not more than 5 years
5. More than 5 years but not more than 10 years
6. Over 10 years ago
Skip Instructions:
Question Text:
For a SIGMOIDOSCOPY, a flexible tube is inserted into the rectum to look for problems. A COLONOSCOPY is SIMILAR, but uses a longer tube, and you are usually given medication through a needle in your arm to make you sleepy, and told to have someone else drive you home. A PROCTOSCOPY is an older exam that used a rigid tube.
Was this MOST RECENT exam a sigmoidoscopy, colonoscopy, proctoscopy or something else?
Pronunciation guide: sigmoid-OS-copy, colon-OS-copy, proc-TOS-copy.
- You are able to drive yourself home
- You are able to resume your normal activities
- You need someone to drive you home
- You may
2 Colonoscopy
3 Proctoscopy
4 Something else
7 Refused
9 Don't know
Skip Instructions:
[p. 37]
Question Text:
2 Because of a problem
3 Other reason
7 Refused
9 Don't know
Skip Instructions:
Question Text:
What is the most important reason you have [fill1: NEVER had one of these exams/NOT had one of these exams in the LAST 10 YEARS]?
02 Didn't need it/Didn't know I needed this type of test
03 Doctor didn't order it/didn't say I needed it
04 Haven't had any problems
05 Put if off/Didn't get around to it
06 Too expensive/No insurance/Cost
07 Too painful, unpleasant, or embarrassing
08 Had another type of colorectal exam
09 Don't have doctor
10 Other
97 Refused
99 Don't know
2. Didn't need it/didn't know I needed this type of test
3. Doctor didn't order it/didn't say I needed it
4. Haven't had any problems
5. Put it off/didn't get around to it
6. Too expensive/no insurance/cost
7. Too painful, unpleasant, or embarassing
8. Had another type of colorectal exam
9. Don't have a doctor
Skip Instructions:
[p. 38]
Question Text:
Was your most recent test recommended by a doctor or other health professional?
Else (IF CREHAD=2, or CREHAD GT 10 years from system date or RCRE2=R,D)
In the PAST 12 MONTHS, has a doctor or other health professional RECOMMENDED that you have a sigmoidoscopy or colonoscopy?
2 No
3 Did not see a doctor in the past 12 months
7 Refused
9 Don't know
Skip Instructions:
Question Text:
Have you EVER HAD a blood stool test, using a HOME test kit?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
*Enter '0' for none.
*Enter '95' for 95 or more exams.
01-94 1-94 times
95 95+
97 Refused
99 Don't know
Skip Instructions:
[p. 39]
Question Text:
When did you have your MOST RECENT blood stool test using a kit at home?
*Enter month of last test.
*Enter '96' to go to number and 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:
Question Text:
*Enter year of last home blood stool test.
9996 Time period format
9997 Refused
9999 Don't know
Skip Instructions:
IF RHFO1_MT and RHFO1_YR = a future date [goto ERR1_RHFO1_YR]
IF RHFO1_MT and RHFO1_YR = a date prior to birth date [goto ERR2_RHFO1_YR]
[p. 40]
Question Text:
When did you have your MOST RECENT blood stool test using a kit at home?
*Enter number for time since last test.
*Enter '95' for 95 or more.
95 95+
97 Refused
99 Don't know
Skip Instructions:
Question Text:
*Enter time period for time since most recent home blood stool test.
2 Weeks ago
3 Months ago
4 Years ago
7 Refused
9 Don't know
Skip Instructions:
[p. 41]
Question Text:
Was it:
*Read answer categories.
2 More than 1 year but not more than 2 years
3 More than 2 years but not more than 3 years
4 More than 3 years but not more than 5 years
5 More than 5 years but not more than 10 years
6 Over 10 years ago
7 Refused
9 Don't know
2. More than 1 year but not more than 2 years
3. More than 2 years but not more than 3 years
4. More than 3 years but not more than 5 years
5. More than 5 years but not more than 10 years
6. Over 10 years ago
Skip Instructions:
Question Text:
2 Because of a problem
3 Other reason
7 Refused
9 Don't know
Skip Instructions:
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 42]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
*Enter all that apply, separate with commas.
1 Another Fecal Occult Blood Test
2 Sigmoidoscopy
3 Colonoscopy
4 Barium enema
5 Surgery
7 Refused
9 Don't know
Skip Instructions:
[p. 43]
Question Text:
What is the most important reason you have [fill1: NEVER had a HOME blood stool test/NOT had a HOME blood stool test in the LAST YEAR]?
02 Didn't need it/Didn't know I needed this type of test
03 Doctor didn't order it/didn't say I needed it
04 Haven't had any problems
05 Put it off/Didn't get around to it
06 Too expensive/No insurance/Cost
07 Too painful, unpleasant, or embarrassing
08 Had another type of colorectal exam
09 Don't have doctor
10 Other
97 Refused
99 Don't know
2. Didn't need it/didn't know I needed this type of test
3. Doctor didn't order it/didn't say I needed it
4. Haven't had any problems
5. Put it off/didn't get around to it
6. Too expensive/no insurance/cost
7. Too painful, unpleasant, or embarassing
8. Had another type of colorectal exam
9. Don't have a doctor
Skip Instructions:
Question Text:
Was your most recent HOME blood stool test recommended by a doctor or other health professional?
Else (IF HFOBHAD=2, or HFOBHAD GT 1 year from system date or RHFO2=R,D)
In the PAST 12 MONTHS, has a doctor or other health professional RECOMMENDED that you have a HOME blood stool test?
2 No
3 Did not see a doctor in the past 12 months
7 Refused
9 Don't know
Skip Instructions:
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
(2, R, D) [goto Genetic Test]
[p. 44]
Question Text:
When did you have your MOST recent OFFICE blood stool test?
*Enter month of last test.
*Enter '96' to go to number and 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:
Question Text:
9996 Time period format
9997 Refused
9999 Don't know
Skip Instructions:
IF RFOB1_MT and RFOB1_YR = a future date [goto ERR1_RFOB1_YR]
IF RFOB1_MT and RFOB1_YR = a date prior to birth date [goto ERR2_RFOB1_YR]
[p. 45]
Question Text:
When did you have your MOST recent OFFICE blood stool test?
*Enter number for time since last test.
*Enter '95' for 95 or more.
95 95+
97 Refused
99 Don't know
Skip Instructions:
Question Text:
*Enter time period for time since most recent office blood stool test.
2 Weeks ago
3 Months ago
4 Years ago
7 Refused
9 Don't know
Skip Instructions:
IF [RFOB1N = Number greater than person years old and RFOB1T= 4]] goto ERR1_RFOB1T
[p. 46]
Question Text:
Was it:
*Read answer categories.
2 More than 1 year but not more than 2 years
3 More than 2 years but not more than 3 years
4 More than 3 years but not more than 5 years
5 More than 5 years but not more than 10 years
6 Over 10 years ago
7 Refused
9 Don't know
2. More than 1 year but not more than 2 years
3. More than 2 years but not more than 3 years
4. More than 3 years but not more than 5 years
5. More than 5 years but not more than 10 years
6. Over 10 years ago
Skip Instructions:
[p. 1]
2005 NHIS Questionnaire - Sample Adult
Genetic Testing
Question Text:
Have you EVER HEARD of genetic testing to determine if a person is at greater risk of developing cancer?
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. 2]
Question Text:
*Read if necessary. This does not include any test to see whether you had cancer in the PAST or have cancer NOW.
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
Breast?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
Please think about your MOST RECENT genetic test for cancer risk. Which kinds of cancer was it for?
Ovarian?
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 3]
Question Text:
Colon or rectal?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
Please think about your MOST RECENT genetic test for cancer risk. Which kinds of cancer was it for?
Another type of cancer?
2 No
7 Refused
9 Don't know
Skip Instructions:
Question Text:
9 Don't know
verbatim Verbatim response
Skip Instructions:
[p. 4]
Question Text:
When did you have this genetic test done?
*Enter month of genetic test.
*Enter '96' to go to number and 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:
Question Text:
*Enter year of genetic test.
9996 Time period format
9997 Refused
9999 Don't know
Skip Instructions:
IF GTRSK_MT and GTRSK_YR = a date prior to birth date [goto ERR2_GTRSK_YR]
[p. 5]
Question Text:
When did you have this genetic test done?
*Enter number for time since genetic test.
*Enter '95' for 95 or more.
95 95+
97 Refused
99 Don't know
Skip Instructions:
Question Text:
*Enter time period for time since genetic test.
2 Weeks ago
3 Months ago
4 Years ago
7 Refused
9 Don't know
Skip Instructions:
Question Text:
*Read if necessary. Effects include losing your health insurance coverage or not being eligible for health insurance if you change jobs or move.
2 No
7 Refused
9 Don't know
Skip Instructions:
[p. 6]
Question Text:
*Read if necessary.
For a cancer survivor, this means getting another cancer in the future.
2 Less likely
3 About as likely
7 Refused
9 Don't know
Skip Instructions:
Question Text:
*Read if necessary.
For a cancer survivor, this means getting another cancer in the future.
2 Less likely
3 About as likely
7 Refused
9 Don't know
Skip Instructions:
Question Text:
*Read if necessary.
For a cancer survivor, this means getting another cancer in the future.
2 Less likely
3 About as likely
7 Refuse
9 Don't know
Skip Instructions:
[p. 1]
2005 NHIS Questionnaire - Sample Adult
Family History
Question Text:
2 No
3 Adopted or don't know biological father
7 Refused
9 Don't know
Skip Instructions:
(2,3,R,D) [goto FHMCAN]
[p. 2]
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:
(6,18,29) goto ERR_FHFTYP_1
[p. 3]
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 FHMCAN]
(6,18,29) [goto ERR1_FHFTYP_2]
[p. 4]
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 FHMCAN]
(6,18,29) [goto ERR1_FHFTYP_3]
[p. 5]
Question Text:
*Enter '96' for no more.
96 No more
Skip Instructions:
(1-30) [goto ERR_FHFTYP_4]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
(R) and (R) at FHFTYP_1 [goto FHMCAN]
(R) and FHFTYP_1 NE (R) [goto FHFTYP_2]
NAH.030_00.002
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
(R) and (R) at FHFTYP_2 [goto FHMCAN]
(R) and FHFTYP_2 NE (R) [goto FHFTYP_3]
NAH.030_00.003
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
(R) and (R) at FHFTYP_3 [goto FHMCAN]
(R) and FHFTYP_3 NE (R) [goto FHFTYP_4]
Question Text:
2 No
3 Adopted or don't know biological mother
7 Refused
9 Don't know
Skip Instructions:
(2,3,R,D) [goto FHBNUM]
[p. 7]
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:
(20,26) [goto ERR_FHMTYP_1]
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 FHBNUM]
(20,26) [goto ERR1_FHMTYP_2]
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 FHBNUM]
(20,26) [goto ERR1_FHMTYP_3]
Question Text:
*Enter '96' for no more.
96 No more
Skip Instructions:
(1-30) [goto ERR_FHMTYP_4]
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
(R) and (R) at FHMTYP_1 [goto FHBCAN]
(R) and FHMTYP_1 NE (R) [goto FHMTYP_2]
NAH.060_00.002
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
(R) and (R) at FHMTYP_2 [goto FHBCAN]
(R) and FHMTYP_2 NE (R) [goto FHMTYP_3]
NAH.060_00.003
Question Text:
2 No
7 Refused
9 Don't know
Skip Instructions:
(R) and (R) at FHMTYP_3 [goto FHBNUM]
(R) and FHMTYP_3 NE (R) [goto FHMTYP_4]]
Question Text:
*Enter '0' for none.
*Enter '21' for 21 or more brothers.
01-20 1-20 brothers
21 21+
97 Refused
99 Don't know
Skip Instructions:
(1-21)[goto FHBCAN]
[p. 12]
Question Text:
*Enter '0' if brother has not had any kind of cancer.
*Enter '1' if brother has had cancer.]
[Fill2: How many of your BROTHERS have EVER had cancer of any kind?
*Enter '0' for none.
*Enter '21' for 21 or more brothers.]
01-20 1-20 brothers
21 21+
97 Refused
99 Don't know
Skip Instructions:
(1-21) if FHBCAN GT FHBNUM [goto ERR_FHBCAN]; else [goto FHBTYP_1]
[p. 13]
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:
(6,18,29) [goto ERR_FHBTYP_1]
[p. 14]
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 FHSNUM]
(6,18,29) [goto ERR1_FHBTYP_2]
[p. 15]
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 FHSNUM]
(6,18,29) [goto ERR1_FHBTYP_3]
[p. 16]
Question Text:
*Enter '96' for no more.
96 No more
Skip Instructions:
(1-30) goto [ERR_FHBTYP_4]
Question Text:
*Enter '21' for 21 or more brothers.
21 21+
97 Refused
99 Don't know
Skip Instructions:
(R,D) [goto FHBAGE1]
[p. 17]
Question Text:
*Enter '0' if brother was not under 50.
*Enter '1' if brother was under 50.]
[Fill2: How many of these brothers were under 50 years of age when [Fill3: FHBTYP_1] was first diagnosed?
*Enter '0' for none.
*Enter '21' for 21 or more brothers.]
01-20 1-20 brothers
21 21+
97 Refused
99 Don't know
Skip Instructions:
(D) [goto FHBTYP_2]
(R) and (R) at FHBTYP_1 [goto FHSNUM]
(R) and FHBTYP_1 NE (R) [goto FHBTYP_2]
Question Text:
*Enter '21' for 21 or more brothers.
21 21+
97 Refused
99 Don't know
Skip Instructions:
(R,D) [goto FHBAGE2]
[p. 18]
Question Text:
*Enter '0' if brother was not under 50.
*Enter '1' if brother was under 50.]
[Fill2: How many of these brothers were under 50 years of age when [Fill3: FHBTYP_2] was first diagnosed?
*Enter '0' for none.
*Enter '21' for 21 or more brothers.]
01-20 1-20 brothers
21 21+
97 Refused
99 Don't know
Skip Instructions:
(D) [goto FHBTYP_3]
(R) and (R) at FHBTYP_2 [goto FHSNUM]
(R) and FHBTYP_2 NE (R) [goto FHBTYP_3]
Question Text:
*Enter '21' for 21 or more brothers.
21 21+
97 Refused
99 Don't know
Skip Instructions:
(R,D) [goto FHBAGE3]
[p. 19]
Question Text:
*Enter '0' if brother was not under 50.
*Enter '1' if brother was under 50.]
[Fill2: How many of these brothers were under 50 years of age when [Fill3: FHBTYP_3] was first diagnosed?
*Enter '0' for none.
*Enter '21' for 21 or more brothers.]
01-20 1-20 brothers
21 21+
97 Refused
99 Don't know
Skip Instructions:
(D) [goto FHBTYP_4]
(R) and (R) at FHBTYP_3 [goto FHSNUM]
(R) and FHBTYP_3 NE (R) [goto FHBTYP_4]
Question Text:
*Enter '0' for none.
*Enter '21' for 21 or more sisters.
1-20 1-20 sisters
21 21+
97 Refused
99 Don't know
Skip Instructions:
(1-21) [goto FHSCAN]
[p. 20]
Question Text:
*Enter '0' if sister has not had any kind of cancer.
*Enter '1' if sister has had cancer.]
[Fill2: How many of your SISTERS have EVER had cancer of any kind?
*Enter '0' for none.
*Enter '21' for 21 or more sisters.]
01-20 1-20 sisters
21 21+
97 Refused
99 Don't know
Skip Instructions:
(1-21) if FHSCAN gt FHSNUM [goto ERR_FHSCAN]; else [goto FHSTYP_1]
[p. 21]
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:
(20,26) [goto ERR_FHSTYP_1]
[p. 22]
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)
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 FHNNUM]
(20,26) [goto ERR1_FHSTYP_2]
[p. 23]
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 FHNNUM]
(20,26) [goto ERR1_FHSTYP_3]
[p. 24]
Question Text:
*Enter '96' for no more.
96 No more
Skip Instructions:
(1-30) [goto ERR_FHSTYP_4]
Question Text:
*Enter '21' for 21 or more sisters.
21 21+
97 Refused
99 Don't know
Skip Instructions:
(R,D) [goto FHSAGE1]
Question Text:
*Enter '0' if sister was not under 50.
*Enter '1' if sister was under 50.]
[Fill2: How many of these sisters were under 50 years of age when [Fill3: FHSTYP_1] was first diagnosed?
*Enter '0' for none.
*Enter '21' for 21 or more sisters.]
01-20 1-20 sisters
21 21+
97 Refused
99 Don't know
Skip Instructions:
(D) [goto FHSTYP_2]
(R) and (R) at FHSTYP_1 [goto FHNNUM]
(R) and FHSTYP_1 NE (R) [goto FHSTYP_2]
[p. 25]
Question Text:
*Enter '21' for 21 or more sisters.
21 21+
97 Refused
99 Don't know
Skip Instructions:
(R,D) [goto FHSAGE2]
Question Text:
*Enter '0' if sister was not under 50.
*Enter '1' if sister was under 50.]
[Fill2: How many of these sisters were under 50 years of age when [Fill3: FHSTYP_2] was first diagnosed?
*Enter '0' for none.
*Enter '21' for 21 or more sisters.]
01-20 1-20 sisters
21 21+
97 Refused
99 Don't know
Skip Instructions:
(D) [goto FHSTYP_3]
(R) and (R) at FHSTYP_2 [goto FHNNUM]
(R) and FHSTYP_2 NE (R) [goto FHSTYP_3]
[p. 26]
Question Text:
*Enter '21' for 21 or more sisters.
21 21+
97 Refused
99 Don't know
Skip Instructions:
(R,D) [goto FHSAGE3]
Question Text:
*Enter '0' if sister was not under 50.
*Enter '1' if sister was under 50.]
[Fill2: How many of these sisters were under 50 years of age when [Fill3: FHBTYP_3] was first diagnosed?
*Enter '0' for none.
*Enter '21' for 21 or more sisters.]
01-20 1-20 sisters
21 21+
97 Refused
99 Don't know
Skip Instructions:
(D) [goto FHSTYP_4]
(R) and (R) at FHSTYP_3 [goto FHNNUM]
(R) and FHSTYP_3 NE (R) [goto FHSTYP_4]
[p. 27]
Question Text:
*Enter '0' for none.
*Enter '21' for 21 or more biological sons.
*Enter '96' for no biological children.
01-20 1-20 sons
21 21+
96 No biological children
97 Refused
99 Don't know
Skip Instructions:
(1-21)[goto FHNCAN]
(22-95) [goto ERR_FHNNUM]
(96) [goto next section]
Question Text:
*Enter '0' if son has not had any kind of cancer.
*Enter '1' if son has had cancer.]
[Fill2: How many of your SONS have EVER had cancer of any kind?
*Enter '0' for none.
*Enter '21' for 21 or more sons.]
01-20 1-20 sons
21 21+
97 Refused
99 Don't know
Skip Instructions:
(1-21) if FHNCAN gt FHNNUM [goto ERR_FHNCAN]; else [goto FHNTYP_1]
[p. 28]
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:
(6,18,29) [goto ERR_FHNTYP_1]
[p. 29]
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 [FHDNUM] (6,18,29) [goto ERR1_FHNTYP_2]
[p. 30]
Question Text:
*Enter '96' for no more.
96 No more
Skip Instructions:
(1-30) [goto ERR_FHNTYP_3]
Question Text:
*Enter '21' for 21 or more sons.
21 21+
97 Refused
99 Don't know
Skip Instructions:
[p. 31]
Question Text:
*Enter '0' if son was not under 50.
*Enter '1' if son was under 50.]
[Fill2: How many of these sons were under 50 years of age when [Fill3: FHNTYP_1] was first diagnosed?
*Enter '0' for none.
*Enter '21' for 21 or more sons.]
01-20 1-20 sons
21 21+
97 Refused
99 Don't know
Skip Instructions:
ERR1_FHNAGE1]; elseif AGE LE 55 and(FHNMAN1 = R or FHNMAN1 = D) and FHNAGE1 = 0 [goto ERR1_FHNAGE1] else [goto FHNTYP_2] (D) [goto FHNTYP_2]
(R) and (R) at FHNTYP_1 [goto FHDNUM]
(R) and FHNTYP_1 NE (R) [goto FHNTYP_2]
Question Text:
*Enter '21' for 21 or more sons.
21 21+
97 Refused
99 Don't know
Skip Instructions:
(R,D) [goto FHNAGE2]
[p. 32]
Question Text:
*Enter '0' if son was not under 50.
*Enter '1' if son was under 50.]
[Fill2: How many of these sons were under 50 years of age when [Fill3: FHNTYP_2] was first diagnosed?
*Enter '0' for none.
*Enter '21' for 21 or more sons.]
01-20 1-20 sons
21 21+
97 Refused
99 Don't know
Skip Instructions:
(D) [goto FHNTYP_3]
(R) and (R) at FHNTYP_2 [goto FHDNUM]
(R) and FHNTYP_2 NE (R) [goto FHNTYP_3]
Question Text:
*Enter '0' for none.
*Enter '21' for 21 or more biological daughters.
01-20 1-20 daughters
21 21+
97 Refused
99 Don't know
Skip Instructions:
(1-21) goto [FHDCAN]
[p. 33]
Question Text:
*Enter '0' if daughter has not had any kind of cancer.
*Enter '1' if daughter has had cancer.]
[Fill2: How many of your DAUGHTERS have EVER had cancer of any kind?
*Enter '0' for none.
*Enter '21' for 21 or more daughters.]
01-20 1-20 daughters
21 21+
97 Refused
99 Don't know
Skip Instructions:
(1-21) if FHDCAN gt FHDNUM [goto ERR_FHDCAN]; else [goto FHDTYP_1]
[p. 34]
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:
(20,26) [goto ERR_FHDTYP_1]
[p. 35]
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 next section]
(20,26) [goto ERR_FHDTYP_2]
[p. 36]
Question Text:
*Enter '96' for no more.
96 No more
Skip Instructions:
(1-30) [goto ERR_FHDTYP_3]
Question Text:
*Enter '21' for 21 or more daughters.
21 21+
97 Refused
99 Don't know
Skip Instructions:
(R,D) [goto FHDAGE1]
[p. 37]
Question Text:
*Enter '0' if daughter was not under 50.
*Enter '1' if daughter was under 50.]
[Fill2: How many of these daughters were under 50 years of age when [Fill3: FHDTYP_1] was first diagnosed?
*Enter '0' for none.
*Enter '21' for 21 or more daughters.]
01-20 1-20 daughters
21 21+
97 Refused
99 Don't know
Skip Instructions:
(D) [goto FHDTYP_2]
(R) and (R) at FHDTYP_1 [goto next section]
(R) and FHDTYP_1 NE (R) [goto FHDTYP_2]
Question Text:
*Enter '21' for 21 or more daughters.
21 21+
97 Refused
99 Don't know
Skip Instructions:
(R,D) [goto FHDAGE2]
[p. 38]
Question Text:
*Enter '0' if daughter was not under 50.
*Enter '1' if daughter was under 50.]
[Fill2: How many of these daughters were under 50 years of age when [Fill3: FHDTYP_2] was first diagnosed?
*Enter '0' for none.
*Enter '21' for 21 or more daughters.]
01-20 1-20 daughters
21 21+
97 Refused
99 Don't know
Skip Instructions:
(D) [goto FHDTYP_3]
(R) and (R) at FHDTYP_2 [goto next section]
(R) and FHDTYP_2 NE (R) [goto FHDTYP_3]
sac