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[p. 1]


2005 NHIS Questionnaire - Sample Child
Child Identification

Question ID: 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]

Question ID: 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


Question ID: 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]?
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
01 Parent (Biological, adoptive, or step)
02 Grandparent
03 Aunt/Uncle
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]

Question ID: 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

Question ID: 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

Question ID: 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]

Question ID: 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

Question ID: 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]

Question ID: 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

Question ID: 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]

Question ID: 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]


2005 NHIS Questionnaire - Sample Child
Child Health Status and Limitations


Question ID: 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]


Question ID: 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]


Question ID: 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]

Question ID: 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]

Question ID: 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]

Question ID: 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]

Question ID: 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]

Question ID: 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]

Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]

[p. 16]


Question ID: 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]


Question ID: 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]


Question ID: 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]


Question ID: 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]

[p. 17]


Question ID: 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]


Question ID: 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]

Question ID: 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]

Question ID: CHS.321_03.000

Instrument Variable Name: CMHAGM11_3
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 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: Male sample children 2-3
Skip Instructions:
(0-2,R,D) [go to CMHAGM11_4]


Question ID: CHS.321_04.000

Instrument Variable Name: CMHAGM11_4
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 been unhappy, sad, or depressed?
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]

[p. 19]


Question ID: CHS.361_01.000

Instrument Variable Name: CMHAGF11_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.
SHE:
Has temper tantrums or a hot temper?
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]

Question ID: 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]

Question ID: CHS.361_03.000

Instrument Variable Name: CMHAGF11_3
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 been nervous or high-strung?
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_4]


Question ID: CHS.361_04.000

Instrument Variable Name: CMHAGF11_4
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 been unhappy, sad, or depressed?
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 CUSUALPL]

[p. 1]


2005 NHIS Questionnaire - Sample Child
Child Access to Health Care and Utilization


Question ID: CAU.020_00.000

Instrument Variable Name: CUSUALPL
Question Text:
The next questions are about health care.
Is there a place that [fill1: alias] 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,D,R) [go to CHCPLKND]


Question ID: CAU.030_00.000

Instrument Variable Name: CPLKIND
Question Text:
[fill1: What kind of place is it / What kind of place does [fill2: alias] 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,D,R) [go to CHCPLKND]


Question ID: CAU.035_00.000

Instrument Variable Name: CHCPLROU
Question Text:
Is that [fill1: CPLKIND/Question ID: CAU.030] the same place [fill2: alias] 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,D,R) [go to CHCPLKND]

[p. 2]


Question ID: CAU.037_00.000

Instrument Variable Name: CHCPLKND
Question Text:
What kind of place does [fill1: alias] 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,D,R) [ if CUSUALPL=2,D,R goto CHCDLYR_1; else goto CHCCHGYR]


Question ID: 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: alias] 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,D,R) to CHCDLYR1_1]


Question ID: 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: All sample children lt 18 that have changed their usual place of health care in the past 12 months
Skip Instructions:
(1,2,D,R) [goto CHCDLYR1_1]

[p. 3]


Question ID: CAU.080_01.000

Instrument Variable Name: CHCDLYR1_1
Question Text:
*Read if necessary.
There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the following reasons IN THE PAST 12 MONTHS...
You couldn't get through on the telephone. [fill: alias]
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: All sample children lt 18
Skip Instructions:
(1,2,D,R) [goto CHCDLYR1_2]


Question ID: CAU.080_02.000

Instrument Variable Name: CHCDLYR1_2
Question Text:
*Read if necessary.
There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the following reasons IN THE PAST 12 MONTHS...
You couldn't get an appointment for [fill: alias] soon enough.
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: All sample children lt 18
Skip Instructions:
(1,2,D,R) [goto CHCDLYR1_3]


Question ID: CAU.080_03.000

Instrument Variable Name: CHCDLYR1_3
Question Text:
*Read if necessary.
There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the following reasons IN THE PAST 12 MONTHS...
Once you get there, [fill: alias] has to wait too long to see the doctor.
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: All sample children lt 18
Skip Instructions:
(1,2,D,R) [goto CHCDLYR1_4]

[p. 4]


Question ID: CAU.080_04.000

Instrument Variable Name: CHCDLYR1_4
Question Text:
*Read if necessary.
There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] 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: All sample children lt 18
Skip Instructions:
(1,2,D,R) [goto CHCDLYR1_5]


Question ID: CAU.080_05.000

Instrument Variable Name: CHCDLYR1_5
Question Text:
*Read if necessary.
There are many reasons people delay getting medical care. Have you delayed getting care for [fill: alias] for any of the following reasons IN THE PAST 12 MONTHS...
You didn't have transportation.
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: All sample children lt 18
Skip Instructions:
(1,2,D,R) [if AGE GE (2) goto CHCAFYR1_1; else goto CHCAFYR]


Question ID: CAU.130_00.000

Instrument Variable Name: CHCAFYR
Question Text:
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] 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, D, R) [if AGE lt 1 goto CHCSYR1_2; else goto CDENLONG]

[p. 5]


Question ID: CAU.135_01.000

Instrument Variable Name: CHCAFYR1_1
Question Text:
DURING THE PAST 12 MONTHS, was there any time when {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, D, R) [goto CHCAFYR1_2]


Question ID: CAU.135_02.000

Instrument Variable Name: CHCAFYR1_2
Question Text:
*Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] 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, D, R) [goto CHCAFYR1_3]


Question ID: CAU.135_03.000

Instrument Variable Name: CHCAFYR1_3
Question Text:
*Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] 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, D, R) [goto CHCAFYR1_4]

[p. 6]


Question ID: CAU.135_04.000

Instrument Variable Name: CHCAFYR1_4
Question Text:
*Read if necessary.
DURING THE PAST 12 MONTHS, was there any time when [fill: alias] 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, D, R) [goto CDENLONG]


Question ID: CAU.160_00.000

Instrument Variable Name: CDENLONG
Question Text:
(book) C4
About how long has it been since [fill: alias] 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
6 1 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, D , R) [if AGE GE (2) goto CHCSYR_1; else go to CHCSYR1_2]


Question ID: CAU.170_01.000

Instrument Variable Name: CHCSYR1_2
Question Text:
DURING THE PAST 12 MONTHS, that is since {12-month ref. date}, has anyone in the family seen or talked to any of the following health care providers about {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 lt 2
Skip Instructions:
(1, 2, D, R) [goto CHCSYR1_3]

[p. 7]


Question ID: CAU.170_02.000

Instrument Variable Name: CHCSYR1_3
Question Text:
*Read 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: alias]'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, D, R) [goto CHCSYR1_5]


Question ID: CAU.170_03.000

Instrument Variable Name: CHCSYR1_5
Question Text:
*Read 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: alias]'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 lt 2
Skip Instructions:
(1,2, D, R) [goto CHCSYR1_6]


Question ID: CAU.170_04.000

Instrument Variable Name: CHCSYR1_6
Question Text:
*Read 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: alias]'s health?
A nurse practitioner, physician assistant or midwife?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children lt 2
Skip Instructions:
(1, 2, D, R) [goto CHCSYR8]

[p. 8]


Question ID: 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: alias]'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, D, R) [goto CHCSYR_2]


Question ID: CAU.175_02.000

Instrument Variable Name: CHCSYR_2
Question Text:
*Read 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: alias]'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, D, R) [goto CHCSYR_3]


Question ID: CAU.175_03.000

Instrument Variable Name: CHCSYR_3
Question Text:
*Read 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: alias]'s health?
A foot doctor?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children GE 2
Skip Instructions:
(1, 2, D, R) [goto CHCSYR_4]

[p. 9]


Question ID: CAU.175_04.000

Instrument Variable Name: CHCSYR_4
Question Text:
*Read 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: alias]'s health?
A chiropractor?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children GE 2
Skip Instructions:
(1, 2, D, R) [goto CHCSYR_5]


Question ID: CAU.175_05.000

Instrument Variable Name: CHCSYR_5
Question Text:
*Read 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: alias]'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, D, R) [goto CHCSYR_6]


Question ID: CAU.175_06.000

Instrument Variable Name: CHCSYR_6
Question Text:
*Read 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: alias]'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, D, R) [if SEX eq (2) and AGE GE 15 goto CHCSYR7; else goto CHCSYR8]

[p. 10]


Question ID: 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: alias]'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]


Question ID: 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: alias]'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: All sample children lt 18
Skip Instructions:
(1, 2, D, R) [goto CHCSYR8_2]


Question ID: CAU.240_02.000

Instrument Variable Name: CHCSYR8_2
Question Text:
*Read 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: alias]'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: All sample children lt 18
Skip Instructions:
(1) [goto CHCSYR10]
(2, D, R) [goto CHPEXYR]

[p. 11]


Question ID: 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, D, R) [goto CHCSYREM]


Question ID: 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: alias] 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, D, R) [goto CHPEXYR]


Question ID: CAU.270_00.000

Instrument Variable Name: CHPEXYR
Question Text:
DURING THE PAST 12 MONTHS, did [fill1: alias] 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, D, R) [goto CHERNOYR]

[p. 12]


Question ID: CAU.280_00.000

Instrument Variable Name: CHERNOYR
Question Text:
(book) C5
DURING THE PAST 12 MONTHS, HOW MANY TIMES has [fill1: alias] 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, D, R) [goto CHCHYR]


Question ID: CAU.290_00.000

Instrument Variable Name: CHCHYR
Question Text:
DURING THE PAST 12 MONTHS, did [fill1: alias] 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, D, R) [goto CHCNOYR]


Question ID: CAU.300_00.000

Instrument Variable Name: CHCHMOYR
Question Text:
DURING THE PAST 12 MONTHS, how many months did [fill: alias] 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, D, R) [goto CHCHNOYR]

[p. 13]


Question ID: CAU.310_00.000

Instrument Variable Name: CHCHNOYR
Question Text:
(book) C6
What was the total number of home visits received for [fill1: alias] 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. 10 - 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, D, R) [goto CHCNOYR]


Question ID: CAU.320_00.000

Instrument Variable Name: CHCNOYR
Question Text:
(book) C5
DURING THE PAST 12 MONTHS, HOW MANY TIMES has [fill1: alias] 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: alias] 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, D, R) [goto CSRGYR]

[p. 14]


Question ID: CAU.330_00.000

Instrument Variable Name: CSRGYR
Question Text:
DURING THE PAST 12 MONTHS has [fill1: alias] 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, D, R) [goto CMDLONG]


Question ID: 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: alias] 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: All sample children lt 18 that have undergone surgery during the past 12 months
Skip Instructions:
(1-10, D, R) [goto CMDLONG]
(11-95) [goto ERR_CMDLONG]


Question ID: 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: alias]'s health? Include doctors seen while [fill2: he/she] was a patient in a hospital.
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 lt 18
Skip Instructions:
(0-5, D, R) [if AGE 4-14 goto CMHCOPY; if AGE 14-17 go to CSNLAMP; else goto CSHFLUYR]

[p. 15]


Question ID: CAU.350_00.010

Instrument Variable Name: CSNLAMP
Question Text:
During the PAST 12 MONTHS, has [fill1: SC name] used any of the following indoor tanning devices---a sunlamp, sunbed, or tanning booth EVEN ONE TIME? Do NOT include a spray-on tan.
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children 14-17
Skip Instructions:
(1) [goto CSNNUM] (2,R,D) [goto next section]


Question ID: CAU.350_00.020

Instrument Variable Name: CSNNUM
Question Text:
During the PAST 12 MONTHS, how many times has [fill1: SC name] used the following indoor tanning devices-- a sunlamp, sunbed, or tanning booth? Do NOT include times [fill1: SC name] has gotten a spray-on tan.
001-365 1-365 times
997 Refused
999 Don't know
Universe Text: Sample children 14-17 who have used a indoor tanning device in the past 12 months
Skip Instructions:
(1-99,R,D) [goto next section]; {if (100-365) goto ERR1_CSNNUM}

[p. 1]


2005 NHIS Questionnaire - Sample Child
Child Influenza Immunization


Question ID: CFI.010_00.000

Instrument Variable Name: CSHFLUYR
Question Text:
DURING THE PAST 12 MONTHS, has {fill1: SC name} had a flu shot? A flu shot is usually given in the fall and protects against influenza for the flu season.
*Read if necessary: A flu shot is injected in the arm. Do not include an influenza vaccine sprayed in the nose.
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample Children lt 18
Skip Instructions:
(1) [goto CSHFLU_M] (2,D,R) [ goto CSPFLUYR ]


Question ID: CFI.015_01.000

Instrument Variable Name: CSHFLU_M
Question Text:
1 of 2
During what month and year did {fill1: SC name} receive {fill2: his/her} most recent flu shot?
01 January
02 February
03 March
04 April
05 May
06 June
07 July
08 August
09 September
10 October
11 November
12 December
97 Refused
99 Don't know
Universe Text: Sample children lt 18 who have had a flu shot
Skip Instructions:
(1-12,D) [ goto CSHFLU_Y] (R) [goto CSPFLUYR]

[p. 2]


Question ID: CFI.015_02.000

Instrument Variable Name: CSHFLU_Y
Question Text:
2 of 2
*Enter year of most recent flu shot.
2004 2004
2005 2005
2006 2006
9997 Refused
9999 Don't know
Universe Text: Sample children lt 18 who gave a month for their last flu shot or who didn't know the month
Skip Instructions:
(valid year,R,D) [goto CSPFLUYR]
[If CSHFLU_M and CSHFLU_Y = a future date] goto ERR1_CSHFLU_Y]
[If CSHFLU_M and CSHFLU_Y = a date prior to birth] goto ERR2_CSHFLU_Y]
[If CSHFLU_M and CSHFLU_Y = a date prior to 12 months ago] goto ERR3_CSHFLU_Y]


Question ID: CFI.020_00.000

Instrument Variable Name: CSPFLUYR
Question Text:
DURING THE PAST 12 MONTHS, has {fill1: SC name} had a flu vaccine sprayed in {fill2: his/her} nose by a doctor or other health professional? This vaccine is usually given in the fall and protects against influenza for the flu season.
*Read if necessary: This influenza vaccine is called FluMist (trademark).
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children lt 18
Skip Instructions:
(1) [goto CSPFLU_M] (2,D,R) [goto next section]
[if CSHFLUYR =1 and CSPFLUYR=1] goto ERR_CSPFLUYR

[p. 3]


Question ID: CFI.025_01.000

Instrument Variable Name: CSPFLU_M
Question Text:
1 of 2
During what month and year did {fill1: SC name} receive {his/her} most recent flu nasal spray?
01 January
02 February
03 March
04 April
05 May
06 June
07 July
08 August
09 September
10 October
11 November
12 December
97 Refused
99 Don't know
Universe Text: Sample children lt 18 who have had a flu nasal vaccine
Skip Instructions:
(1-12,D) [ goto CSPFLU_Y] (R) [goto next section]


Question ID: CFI.025_02.000

Instrument Variable Name: CSPFLU_Y
Question Text:
2 of 2
*Enter year of most recent flu nasal spray.
2004 2004
2005 2005
2006 2006
9997 Refused
9999 Don't know
Universe Text: Sample children 18+ who gave a month for their flu nasal vaccine or who didn't know the month
Skip Instructions:
(valid year,R,D) [goto next section]
[If CSPFLU_M and CSPFLU_Y = a future date] goto ERR1_CSPFLU_Y]
[If CSPFLU_M and CSPFLU_Y = a date prior to birth] goto ERR2_CSPFLU_Y]
[If CSPFLU_M and CSPFLU_Y = a date prior to 12 months ago] goto ERR3_CSPFLU_Y]

[p. 1]


2005 NHIS Questionnaire - Sample Child
Child Mental Health Brief Questionnaire

Question ID: CMB.010_00.000

Instrument Variable Name: CMHCOPY
Question Text:
*The following statements are not to be read to the respondent. They are displayed and included here for legal reasons.
*The next 6 items contained in CMHMF_1 through CMHDIFF 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 CMHMF_1]


Question ID: CMB.020_01.000

Instrument Variable Name: CMHMF_1
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: SC name] DURING THE PAST SIX MONTHS.
[fill2: He/She...]
...is generally well behaved, usually does what adults request.
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,D,R) [goto CMHMF_2]

[p. 2]


Question ID: CMB.020_02.000

Instrument Variable Name: CMHMF_2
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: SC name] DURING THE PAST SIX MONTHS.
[fill2: He/She...]
...has many worries, or often seems worried.
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,D,R) [goto CMHMF_3]


Question ID: CMB.020_03.000

Instrument Variable Name: CMHMF_3
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: SC name] DURING THE PAST SIX MONTHS.
[fill2: He/She...]
...is often unhappy, depressed, or tearful.
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 CMHMF_4]

[p. 3]


Question ID: CMB.020_04.000

Instrument Variable Name: CMHMF_4
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: SC 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,D,R) [goto CMHMF_5]


Question ID: CMB.020_05.000

Instrument Variable Name: CMHMF_5
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: SC 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,D,R) [goto CMHDIFF]

[p. 4]


Question ID: CMB.030_00.000

Instrument Variable Name: CMHDIFF
Question Text:
(book) C8
Overall, do you think that [fill1: SC 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:
(1-4,R,D) [goto SEEDIFF]

[p. 1]


2005 NHIS Questionnaire - Sample Child
Child Mental Health Services


Question ID: CMS.010_00.000

Instrument Variable Name: SEEDIFF
Question Text:
Did you ever see or talk to any health care provider or school staff/personnel about difficulties [fill1: SC name] has with emotions, concentration, behavior or being able to get along with others?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children GE 4
Skip Instructions:
(1) [goto MRVSEE] (2,R,D) [goto MEDDIFF]


Question ID: CMS.020_00.000

Instrument Variable Name: MRVSEE
Question Text:
(book) C9
When was the MOST RECENT conversation or visit?
1 In the past 6 months
2 7 to 12 months ago
3 More than 12 months ago
7 Refused
9 Don't know
Card C9
1. In the past 6 months
2. 7 to 12 months ago
3. More than 12 months ago
Universe Text: Sample children GE 4 who have seen or talked to health care provider/school/staff/personnel about child's difficulties
Skip Instructions:
(1-3,R,D) [goto MEDDIFF]


Question ID: CMS.030_00.000

Instrument Variable Name: MEDDIFF
Question Text:
Was [fill1: SC name] ever prescribed medication for difficulties with [fill2: his/her] emotions, concentration, behavior or being able to get along with others?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children GE 4
Skip Instructions:
(1) [goto MRVMED] (2,R,D) [goto TRETDIFF]

[p. 2]


Question ID: CMS.040_00.000

Instrument Variable Name: MRVMED
Question Text:
(book) C9
When was the MOST RECENT medication prescribed for these difficulties?
1 In the past 6 months
2 7 to 12 months ago
3 More than 12 months ago
7 Refused
9 Don't know
Card C9
1. In the past 6 months
2. 7 to 12 months ago
3. More than 12 months ago
Universe Text: Sample children GE 4 who have had medication prescribed for difficulties with emotion, concentration, behavior, or getting along with others
Skip Instructions:
(1-3,R,D) [goto MEDWHY]


Question ID: CMS.050_00.000

Instrument Variable Name: MEDWHY
Question Text:
Was this medication prescribed for difficulties with concentration, hyperactivity, or impulsivity?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children GE 4 who have had medication prescribed for difficulties with emotion, concentration, behavior, or getting along with others
Skip Instructions:
(1,2,R,D) [goto TRETDIFF]


Question ID: CMS.060_00.000

Instrument Variable Name: TRETDIFF
Question Text:
Has [Fill1: SC name] EVER received ANY treatment or help, [Fill2: other than medication,] for difficulties with emotions, concentration, behavior or being able to get along with others?
1 Yes
2 No
7 Refused
9 Don't know
Universe Text: Sample children GE 4
Skip Instructions:
(1) [goto MRVTRET] (2,R,D) [goto next section]

[p. 3]


Question ID: CMS.070_00.000

Instrument Variable Name: MRVTRET
Question Text:
(book) C9
When was the MOST RECENT help or treatment received?
1 In the past 6 months
2 7 to 12 months ago
3 More than 12 months ago
7 Refused
9 Don't know
Card C9
1. In the past 6 months
2. 7 to 12 months ago
3. More than 12 months ago
Universe Text: Sample children GE 4 who have received treatment or help for difficulties with emotions, concentration, behavior, or getting along with others
Skip Instructions:
(1-3,R,D) [goto TRETWHER]


Question ID: CMS.080_00.000

Instrument Variable Name: TRETWHER
Question Text:
(book) C10
Was any of this treatment or help received from any of the following?
*Enter all that apply, separate with commas.
1 A pediatric or general medical care practice
2 A mental health private practice
3 A mental health clinic or center
4 The child's school
5 Other
7 Refused
9 Don't know
Card C10
1. A pediatric or general medical care practice
2. A mental health private practice
3. A mental health clinic or center
4. The child's school
5. Other
Universe Text: Sample children GE 4 who have received treatment or help for difficulties with emotions, concentration, behavior, or getting along with others
Skip Instructions:
(1-5,R,D) [goto next section]