2017 NHIS Questionnaire - Functioning And Disability
Adult Functioning and Disability
Document Version Date: 05-Jun-18

Question ID: AFD.090_00.000

Instrument Variable Name: VIS_0
Questionnaire File Name: Functioning And Disability
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) goto VIS_SS

Question ID: AFD.100_00.000

Instrument Variable Name: VIS_SS
Questionnaire File Name: Functioning And Disability
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) and were randomly selected to receive the Functioning and Disability (AFD) section
Skip Instructions:

(1-4,R,D)[goto HEAR_1]

Question ID: AFD.140_00.000

Instrument Variable Name: HEAR_1
Questionnaire File Name: Functioning And Disability
Question Text:

Do you use a hearing aid?

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) [goto HEAR_2]
(2,R,D) [goto HEAR_SS]

Question ID: AFD.145_00.000

Instrument Variable Name: HEAR_2
Questionnaire File Name: Functioning And Disability
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) goto HEAR_SS

Question ID: AFD.150_00.000

Instrument Variable Name: HEAR_SS
Questionnaire File Name: Functioning And Disability
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

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:

(1-3,R,D)[goto HEAR_3]
(4) [goto MOB_SS]

Question ID: AFD.170_00.000

Instrument Variable Name: HEAR_3
Questionnaire File Name: Functioning And Disability
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)[goto HEAR_4]
(4)[goto MOB_SS]

Question ID: AFD.170_00.001

Instrument Variable Name: HEAR_4
Questionnaire File Name: Functioning And Disability
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)[goto MOB_SS]

Question ID: AFD.180_00.000

Instrument Variable Name: MOB_SS
Questionnaire File Name: Functioning And Disability
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

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:

(1-4,R,D) goto MOB_2

Question ID: AFD.200_00.000

Instrument Variable Name: MOB_2
Questionnaire File Name: Functioning And Disability
Question Text:

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

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)[goto MOB_3A]
(2,R,D)[goto MOB_4]

Question ID: AFD.200_00.001

Instrument Variable Name: MOB_3A
Questionnaire File Name: Functioning And Disability
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) goto MOB_3B

Question ID: AFD.200_00.002

Instrument Variable Name: MOB_3B
Questionnaire File Name: Functioning And Disability
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

(1,2,R,D) goto MOB_3C

Question ID: AFD.200_00.003

Instrument Variable Name: MOB_3C
Questionnaire File Name: Functioning And Disability
Question Text:

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

1 Yes
2 No
7 Refused
9 Don't know

(1,2,R,D) goto MOB_3D

Question ID: AFD.200_00.004

Instrument Variable Name: MOB_3D
Questionnaire File Name: Functioning And Disability
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

(1,2,R,D) goto MOB_3E

Question ID: AFD.200_00.005

Instrument Variable Name: MOB_3E
Questionnaire File Name: Functioning And Disability
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

(1,2,R,D) goto MOB_3F

Question ID: AFD.200_00.006

Instrument Variable Name: MOB_3F
Questionnaire File Name: Functioning And Disability
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

(1,2,R,D) goto MOB_3G

Question ID: AFD.200_00.007

Instrument Variable Name: MOB_3G
Questionnaire File Name: Functioning And Disability
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

(1,2,R,D) if MOB_3D=1, [goto COM_SS];
else if MOB_3D=2,R,D [goto MOB_4]

Question ID: AFD.210_00.000

Instrument Variable Name: MOB_4
Questionnaire File Name: Functioning And Disability
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)[goto MOB_5]
(4)[goto MOB_6]

Question ID: AFD.220_00.000

Instrument Variable Name: MOB_5
Questionnaire File Name: Functioning And Disability
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) goto MOB_6

Question ID: AFD.230_00.000

Instrument Variable Name: MOB_6
Questionnaire File Name: Functioning And Disability
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

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 did not use any equipment or receive help with getting around or did not use a wheelchair or scooter
Skip Instructions:

(1-4,R,D) if MOB_2 IN (2,R,D) [goto COM_SS];
else if MOB_2=1 [goto MOB_7]

Question ID: AFD.240_00.000

Instrument Variable Name: MOB_7
Questionnaire File Name: Functioning And Disability
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

(1-3,R,D)[goto MOB_8]
(4)[goto COM_SS]

Question ID: AFD.250_00.000

Instrument Variable Name: MOB_8
Questionnaire File Name: Functioning And Disability
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) goto COM_SS

Question ID: AFD.270_00.000

Instrument Variable Name: COM_SS
Questionnaire File Name: Functioning And Disability
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

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:

(1-4,R,D) goto COM_2

Question ID: AFD.290_00.000

Instrument Variable Name: COM_2
Questionnaire File Name: Functioning And Disability
Question Text:

Do you use sign language?

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)
goto COG_SS

Question ID: AFD.300_00.000

Instrument Variable Name: COG_SS
Questionnaire File Name: Functioning And Disability
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

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)[goto UB_SS]
(2-4,R,D)[goto COG_1]

Question ID: AFD.310_00.000

Instrument Variable Name: COG_1
Questionnaire File Name: Functioning And Disability
Question Text:

Do you have difficulty remembering, concentrating, or both?

1 Difficulty remembering only
2 Difficulty concentrating only
3 Difficulty with 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)[goto COG_2]
(2)[goto UB_SS]

Question ID: AFD.320_00.000

Instrument Variable Name: COG_2
Questionnaire File Name: Functioning And Disability
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

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 had some difficulty, a lot of difficulty, or were unable to remember or concentrate, or refused to answer or didn't know if they had difficulty remembering or concentrating AND they had difficulty remembering only, difficulty both remembering and concentrating, or refused to answer or didn't know if they had difficulty remembering, concentrating, or both
Skip Instructions:

(1-3,R,D) goto COG_3

Question ID: AFD.330_00.000

Instrument Variable Name: COG_3
Questionnaire File Name: Functioning And Disability
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

(1-3,R,D) goto UB_SS

Question ID: AFD.360_00.000

Instrument Variable Name: UB_SS
Questionnaire File Name: Functioning And Disability
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

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:

(1-4,R,D) goto UB_1

Question ID: AFD.370_00.000

Instrument Variable Name: UB_1
Questionnaire File Name: Functioning And Disability
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

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:

(1-4,R,D) goto UB_2

Question ID: AFD.380_00.000

Instrument Variable Name: UB_2
Questionnaire File Name: Functioning And Disability
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

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:

(1-4,R,D) goto ANX_1

Question ID: AFD.410_00.000

Instrument Variable Name: ANX_1
Questionnaire File Name: Functioning And Disability
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

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:

(1-5,R,D) goto ANX_2

Question ID: AFD.420_00.000

Instrument Variable Name: ANX_2
Questionnaire File Name: Functioning And Disability
Question Text:

Do you take medication for these feelings?

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,R,D) [goto ANX_3]
(2) if ANX_1=5 [goto DEP_1];
else [goto ANX_3]

Question ID: AFD.430_00.000

Instrument Variable Name: ANX_3
Questionnaire File Name: Functioning And Disability
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) goto DEP_1

Question ID: AFD.450_00.000

Instrument Variable Name: DEP_1
Questionnaire File Name: Functioning And Disability
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

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:

(1-5,R,D) goto DEP_2

Question ID: AFD.460_00.000

Instrument Variable Name: DEP_2
Questionnaire File Name: Functioning And Disability
Question Text:

Do you take medication for depression?

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,R,D) [goto DEP_3]
(2) if DEP_1=5 [goto PAIN_2];
else [goto DEP_3]

Question ID: AFD.470_00.000

Instrument Variable Name: DEP_3
Questionnaire File Name: Functioning And Disability
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) goto PAIN_2

Question ID: AFD.500_00.000

Instrument Variable Name: PAIN_2
Questionnaire File Name: Functioning And Disability
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

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) [goto TIRED_1]
(2,3,4,R,D) [goto PAIN_4]

Question ID: AFD.520_00.000

Instrument Variable Name: PAIN_4
Questionnaire File Name: Functioning And Disability
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) goto TIRED_1

Question ID: AFD.540_00.000

Instrument Variable Name: TIRED_1
Questionnaire File Name: Functioning And Disability
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

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)[goto next section]
(2-4,R,D)[goto TIRED_2]

Question ID: AFD.550_00.000

Instrument Variable Name: TIRED_2
Questionnaire File Name: Functioning And Disability
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) goto TIRED_3

Question ID: AFD.560_00.000

Instrument Variable Name: TIRED_3
Questionnaire File Name: Functioning And Disability
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

(1-3,R,D) goto next section

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