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2012 NHIS Questionnaire: Functioning And Disability
Adult Functioning and Disability

Document Version Date: 18-Jun-13

Question ID: AFD.090_00.000

Instrument Variable Name: VIS_0
Question Text:

Now I am going to ask you some questions about your ability to do different activities, and how you have been feeling.
Although some of these questions may seem similar to ones you have already answered, it is important that we ask them all.
Do you wear glasses?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who were asked the family disability questions (FDB) and were randomly selected to receive the Functioning and Disability (AFD) section
Skip Instructions: (1,2,R,D) go to VIS_SS

Question ID: AFD.100_00.000

Instrument Variable Name: VIS_SS
Question Text:

Do you have difficulty seeing, even when wearing glasses? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?

1 No difficulty
2 Some difficulty
3 A lot of difficulty
4 Cannot do at all/unable to do
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who were asked the family disability questions (FDB)
Skip Instructions: (1-4,R,D)[go to HEAR_1]

Question ID: AFD.140_00.000

Instrument Variable Name: HEAR_1
Question Text:

Do you use a hearing aid?

1 Yes
2 No
7 Refused
9 Don't know

Question ID: AFD.145_00.000

Instrument Variable Name: HEAR_2
Question Text:

How often do you use your hearing aid(s)? Would you say all of the time, some of the time, rarely, or never?

1 All of the time
2 Some of the time
3 Rarely
4 Never
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who were asked the family disability questions (FDB), were randomly selected to receive the Functioning and Disability (AFD) section, and use a hearing aid
Skip Instructions: (1,2,R,D) go to HEAR_SS

Question ID: AFD.150_00.000

Instrument Variable Name: HEAR_SS
Question Text:

Do you have difficulty hearing [fill: , even when using your hearing aid(s)]? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?

1 No difficulty
2 Some difficulty
3 A lot of difficulty
4 Cannot do at all/unable to do
7 Refused
9 Don't know

Question ID: AFD.170_00.000

Instrument Variable Name: HEAR_3
Question Text:

Do you have difficulty hearing what is said in a conversation with one other person in a quiet room [fill: even when using your hearing aid(s)]? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?

1 No difficulty
2 Some difficulty
3 A lot of difficulty
4 Cannot do at all/unable to do
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who were asked the family disability questions (FDB), were randomly selected to receive the Functioning and Disability (AFD) section, and have no difficulty, some difficulty, a lot of difficulty, or refused or don't know if they have difficulty hearing, even when using a hearing aid
Skip Instructions: (1-3,R,D) [go to HEAR_4] (4)[go to MOB_SS]

Question ID: AFD.170_00.001

Instrument Variable Name: HEAR_4
Question Text:

Do you have difficulty hearing what is said in a conversation with one other person in a noisier room [fill: even when using your hearing aid(s)]? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?

1 No difficulty
2 Some difficulty
3 A lot of difficulty
4 Cannot do at all/unable to do
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who were asked the family disability questions (FDB), were randomly selected to receive the Functioning and Disability (AFD) section, and have no difficulty, some difficulty, a lot of difficulty, or refuse or don't know if they have difficulty hearing what is said in a conversation with one other person in a quiet room (even when wearing their hearing aid(s))
Skip Instructions: (1-4,R,D)[go to MOB_SS]

Question ID: AFD.180_00.000

Instrument Variable Name: MOB_SS
Question Text:

Do you have difficulty walking or climbing steps? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?

1 No difficulty
2 Some difficulty
3 A lot of difficulty
4 Cannot do at all/unable to do
7 Refused
9 Don't know

Question ID: AFD.200_00.000

Instrument Variable Name: MOB_2
Question Text:

Do you use any equipment or receive help for getting around?

1 Yes
2 No
7 Refused
9 Don't know

Question ID: AFD.200_00.001

Instrument Variable Name: MOB_3A
Question Text:

Do you use any of the following_
Cane or walking stick?

1 Yes
2 No
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who were asked the family disability questions (FDB), were randomly selected to receive the Functioning and Disability (AFD) section, and use equipment or receive help for getting around
Skip Instructions: (1,2,R,D) go to MOB_3B

Question ID: AFD.200_00.002

Instrument Variable Name: MOB_3B
Question Text:

*Read if necessary.
Do you use any of the following_
Walker or Zimmer frame?

1 Yes
2 No
7 Refused
9 Don't know

Question ID: AFD.200_00.003

Instrument Variable Name: MOB_3C
Question Text:

*Read if necessary.
Do you use any of the following_
Crutches?

1 Yes
2 No
7 Refused
9 Don't know

Question ID: AFD.200_00.004

Instrument Variable Name: MOB_3D
Question Text:

*Read if necessary.
Do you use any of the following_
Wheelchair or scooter?

1 Yes
2 No
7 Refused
9 Don't know

Question ID: AFD.200_00.005

Instrument Variable Name: MOB_3E
Question Text:

*Read if necessary.
Do you use any of the following_
Artificial limb (leg/foot)?

1 Yes
2 No
7 Refused
9 Don't know

Question ID: AFD.200_00.006

Instrument Variable Name: MOB_3F
Question Text:

*Read if necessary.
Do you use any of the following_
Someone's assistance?

1 Yes
2 No
7 Refused
9 Don't know

Question ID: AFD.200_00.007

Instrument Variable Name: MOB_3G
Question Text:

*Read if necessary.
Do you use any of the following_
Other type of equipment or help?

1 Yes
2 No
7 Refused
9 Don't know

Question ID: AFD.210_00.000

Instrument Variable Name: MOB_4
Question Text:

Do you have difficulty walking 100 yards on level ground, that would be about the length of one football field or one city block [fill: without the use of your aid(s)]? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?

1 No difficulty
2 Some difficulty
3 A lot of difficulty
4 Cannot do at all/unable to do
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who were asked the family disability questions (FDB), were randomly selected to receive the Functioning and Disability (AFD) section, and do not use a wheelchair or scooter
Skip Instructions: (1-3,R,D) [go to MOB_5] (4)[go to MOB_6]

Question ID: AFD.220_00.000

Instrument Variable Name: MOB_5
Question Text:

Do you have difficulty walking a third of a mile on level ground, that would be the length of five football fields or five city blocks [fill: without the use of your aid(s)]? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?

1 No difficulty
2 Some difficulty
3 A lot of difficulty
4 Cannot do at all/unable to do
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who were asked the family disability questions (FDB), were randomly selected to receive the
Functioning and Disability (AFD) section, do not use a wheelchair or scooter, and have no difficulty, some difficulty, a lot of difficulty, or refused or don't know if they have difficulty walking 100 yards on level ground (without the use of their aid)
Skip Instructions: (1,2,R,D) go to MOB_6

Question ID: AFD.230_00.000

Instrument Variable Name: MOB_6
Question Text:

Do you have difficulty walking up or down 12 steps? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?

1 No difficulty
2 Some difficulty
3 A lot of difficulty
4 Cannot do at all/unable to do
7 Refused
9 Don't know

Question ID: AFD.240_00.000

Instrument Variable Name: MOB_7
Question Text:

Do you have difficulty walking 100 yards on level ground, that would be about the length of one football field or one city block, when using your aid(s)? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?

1 No difficulty
2 Some difficulty
3 A lot of difficulty
4 Cannot do at all/unable to do
7 Refused
9 Don't know

Question ID: AFD.250_00.000

Instrument Variable Name: MOB_8
Question Text:

Do you have difficulty walking a third of a mile on level ground, that would be the length of five football fields or five city blocks, when using your aid(s)? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?

1 No difficulty
2 Some difficulty
3 A lot of difficulty
4 Cannot do at all/unable to do
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who were asked the family disability questions (FDB), were randomly selected to receive the Functioning and Disability (AFD) section, use equipment or receive help for getting around but do not use a wheelchair or scooter, and who have no difficulty, some difficulty, a lot of difficulty, or refused or don't know if they have difficulty walking 100 yards on level ground, when using their aid
Skip Instructions: (1-4,R,D) go to COM_SS

Question ID: AFD.270_00.000

Instrument Variable Name: COM_SS
Question Text:

Using your usual language, do you have difficulty communicating, for example, understanding or being understood? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?

1 No difficulty
2 Some difficulty
3 A lot of difficulty
4 Cannot do at all/unable to do
7 Refused
9 Don't know

Question ID: AFD.290_00.000

Instrument Variable Name: COM_2
Question Text:

Do you use sign language?

1 Yes
2 No
7 Refused
9 Don't know

Question ID: AFD.300_00.000

Instrument Variable Name: COG_SS
Question Text:

Do you have difficulty remembering or concentrating? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?

1 No difficulty
2 Some difficulty
3 A lot of difficulty
4 Cannot do at all/unable to do
7 Refused
9 Don't know

Question ID: AFD.310_00.000

Instrument Variable Name: COG_1
Question Text:

Do you have difficulty remembering, concentrating, or both?

1 Difficulty remembering only
2 Difficulty concentrating only
3 Difficulty both remembering and concentrating
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who were asked the family disability questions (FDB), were randomly selected to receive the Functioning and Disability (AFD) section, and have some difficulty, a lot of difficulty, or are unable to remember or concentrate, or don't know or refused if they are able to remember or concentrate
Skip Instructions: (1,3,R,D)[go to COG_2] (2)[go to UB_SS]

Question ID: AFD.320_00.000

Instrument Variable Name: COG_2
Question Text:

How often do you have difficulty remembering? Would you say sometimes, often or all of the time?

1 Sometimes
2 Often
3 All of the time
7 Refused
9 Don't know

Question ID: AFD.330_00.000

Instrument Variable Name: COG_3
Question Text:

Do you have difficulty remembering a few things, a lot of things, or almost everything?

1 A few things
2 A lot of things
3 Almost everything
7 Refused
9 Don't know

Question ID: AFD.360_00.000

Instrument Variable Name: UB_SS
Question Text:

Do you have difficulty with self care, such as washing all over or dressing? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?

1 No difficulty
2 Some difficulty
3 A lot of difficulty
4 Cannot do at all/unable to do
7 Refused
9 Don't know

Question ID: AFD.370_00.000

Instrument Variable Name: UB_1
Question Text:

Do you have difficulty raising a 2 liter bottle of water or soda from waist to eye level? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?

1 No difficulty
2 Some difficulty
3 A lot of difficulty
4 Cannot do at all/unable to do
7 Refused
9 Don't know

Question ID: AFD.380_00.000

Instrument Variable Name: UB_2
Question Text:

Do you have difficulty using your hands and fingers, such as picking up small objects, for example, a button or pencil, or opening or closing containers or bottles? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?

1 No difficulty
2 Some difficulty
3 A lot of difficulty
4 Cannot do at all/unable to do
7 Refused
9 Don't know

Question ID: AFD.410_00.000

Instrument Variable Name: ANX_1
Question Text:

How often do you feel worried, nervous or anxious? Would you say daily, weekly, monthly, a few times a year, or never?

1 Daily
2 Weekly
3 Monthly
4 A few times a year
5 Never
7 Refused
9 Don't know

Question ID: AFD.420_00.000

Instrument Variable Name: ANX_2
Question Text:

Do you take medication for these feelings?

1 Yes
2 No
7 Refused
9 Don't know

Question ID: AFD.430_00.000

Instrument Variable Name: ANX_3
Question Text:

Thinking about the last time you felt worried, nervous or anxious, how would you describe the level of these feelings? Would you say a little, a lot, or somewhere in between?

1 A little
2 A lot
3 Somewhere in between a little and a lot
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who were asked the family disability questions (FDB), were randomly selected to receive the Functioning and Disability (AFD) section, and feel worried, anxious, or nervous daily, weekly, monthly, a few times a year or don't know or refused how often OR who do take medication for these feelings or don't know or refused if they take medication for these feelings
Skip Instructions: (1-3,R,D) go to DEP_1

Question ID: AFD.450_00.000

Instrument Variable Name: DEP_1
Question Text:

How often do you feel depressed? Would you say daily, weekly, monthly, a few times a year, or never?

1 Daily
2 Weekly
3 Monthly
4 A few times a year
5 Never
7 Refused
9 Don't know

Question ID: AFD.460_00.000

Instrument Variable Name: DEP_2
Question Text:

Do you take medication for depression?

1 Yes
2 No
7 Refused
9 Don't know

Question ID: AFD.470_00.000

Instrument Variable Name: DEP_3
Question Text:

Thinking about the last time you felt depressed, how depressed did you feel? Would you say a little, a lot, or somewhere in between?

1 A little
2 A lot
3 Somewhere in between a little and a lot
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who were asked the family disability questions (FDB), were randomly selected to receive the Functioning and Disability (AFD) section, and feel depressed daily, weekly, monthly, a few times a year or refused or don't know how often they feel depressed OR who do take medication or refused or don't know if they take medication for depression.
Skip Instructions: (1-3,R,D) go to PAIN_2

Question ID: AFD.500_00.000

Instrument Variable Name: PAIN_2
Question Text:

In the past 3 months, how often did you have pain? Would you say never, some days, most days, or every day?

1 Never
2 Some days
3 Most days
4 Every day
7 Refused
9 Don't know

Question ID: AFD.520_00.000

Instrument Variable Name: PAIN_4
Question Text:

Thinking about the last time you had pain, how much pain did you have? Would you say a little, a lot, or somewhere in between?

1 A little
2 A lot
3 Somewhere in between a little and a lot
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who were asked the family disability questions (FDB), were randomly selected to receive the Functioning and Disability (AFD) section, and have had pain some days, most days, every day, or refused or don't know how often they have had pain in the past 3 months
Skip Instructions: (1-3,R,D) go to TIRED_1

Question ID: AFD.540_00.000

Instrument Variable Name: TIRED_1
Question Text:

In the past 3 months, how often did you feel very tired or exhausted? Would you say never, some days, most days, or every day?

1 Never
2 Some days
3 Most days
4 Every day
7 Refused
9 Don't know

Question ID: AFD.550_00.000

Instrument Variable Name: TIRED_2
Question Text:

Thinking about the last time you felt very tired or exhausted, how long did it last? Would you say some of the day, most of the day, or all of the day?

1 Some of the day
2 Most of the day
3 All of the day
7 Refused
9 Don't know

Universe Text: Sample adults 18+ who were asked the family disability questions (FDB), were randomly selected to receive the
Functioning and Disability (AFD) section, and felt very tired or exhausted some days, most days, every day, or refused or don't know how often they felt very tired or exhausted in the past 3 months
Skip Instructions: (1-3,R,D) go to TIRED_3

Question ID: AFD.560_00.000

Instrument Variable Name: TIRED_3
Question Text:

Thinking about the last time you felt this way, how would you describe the level of tiredness? Would you say a little, a lot, or somewhere in between?

1 A little
2 A lot
3 Somewhere in between a little and a lot
7 Refused
9 Don't know

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