Survey Text

2018 2012 2006 2000
2017 2011 2005 1999
2016 2010 2004 1998
2015 2009 2003 1997
2014 2008 2002
2013 2007 2001
top
2018

No questionnaire text is available for this sample.


top
2017

No questionnaire text is available for this sample.


top
2016

No questionnaire text is available for this sample.


top
2015

No questionnaire text is available for this sample.


top
2014

No questionnaire text is available for this sample.


top
2013

No questionnaire text is available for this sample.


top
2012

No questionnaire text is available for this sample.


top
2011

No questionnaire text is available for this sample.


top
2010

No questionnaire text is available for this sample.


top
2009

No questionnaire text is available for this sample.


top
2008

No questionnaire text is available for this sample.


top
2007

No questionnaire text is available for this sample.


top
2006

No questionnaire text is available for this sample.


top
2005

No questionnaire text is available for this sample.


top
2004

No questionnaire text is available for this sample.


top
2003
Survey form view entire document:  text  image

FHS.280

How long {have/has}{you/subject name} had {fill condition entered in FHS.270}?

FR: ENTER NUMBER, PRESS RETURN, AND ENTER TIME PERIOD.
LCTIME#
[ ] NUMBER(ENTER "96" IF SINCE BIRTH)

(01-94) 1-94
(95) 95+
(96) Since birth
(97) Refused
(99) Don't know
LCUNIT#
[ ] TIME PERIOD

(1) Days(s)
(2) Week(s)
(3) Month(s)
(4) Year(s)
(6) Since Birth
(7) Refused
(9) Don't know

[Go back to Check item FHSCCI3 for next family member. If no more family members go to FHS.310]

FHS.290

What condition or health problem causes {subject's name} limitations?

FR: SHOW FLASHCARD F2. DO NOT READ. MARK ALL THAT APPLY, BUT DO NOT PROBE. ENTER (N) FOR NO MORE.
Card F2
You may choose more than one.

1. Vision/problem seeing
2. Hearing problem
3. Arthritis/rheumatism
4. Back or neck problem
5. Fracture, bone/joint injury
6. Other injury
7. Heart problem
8. Stroke problem
9. Hypertension/high blood pressure
10. Diabetes
11. Lung/breathing problem (e.g., asthma and emphysema)
12. Cancer
13. Birth defect
14. Mental retardation
15. Other developmental problem (e.g., cerebral palsy)
16. Senility
17. Depression/anxiety/emotional problem
18. Weight problem
Other impairment/problem
LAHCA1 (1) Vision/ problem seeing
LAHCA2 (2) Hearing problem
LAHCA3 (3) Arthritis / rheumatism
LAHCA4 (4) Back or neck problem
LAHCA5 (5) Fracture, bone / joint injury
LAHCA6 (6) Other injury
LAHCA7 (7) Heart problem
LAHCA8 (8) Stroke problem
LAHCA9 (9) Hypertension / high blood pressure
LAHCA10 (10) Diabetes
LAHCA11 (11) Lung / breathing problem (e.g. asthma and emphysema)
LAHCA12 (12) Cancer
LAHCA13 (13) Birth defect
LAHCA14 (14) Mental retardation
LAHCA15 (15) Other developmental problem (e.g. cerebral palsy)
LAHCA16 (16) Senility
LAHCA17 (17) Depression / anxiety / emotional problem
LAHCA18 (18) Weight problem
(M) More conditions
(97) Refused
(99) Don't know/not sure

FHS.290

(What condition or health problem causes your limitations?)

FR: MARK ALL THAT APPLY, BUT DO NOT PROBE. ENTER (N) FOR NO MORE

(19) Missing limbs (fingers, toes or digits), amputee
(20) Kidney, bladder or renal problems
(21) Circulation problems (including blood clots)
(22) Benign tumors, cysts
(23) Fibromyalgia, lupus
(24) Osteoporosis, tendonitis
(25) Epilepsy, seizures
(26) Multiple sclerosis (MS), Muscular Dystrophy (MD)
(27) Polio (myelitis), paralysis, para/quadriplegia
(28) Parkinson's disease, other tremors
(29) Other nerve damage, including carpal tunnel syndrome
(30) Hernia
(31) Ulcer
(32) Varicose veins, hemorrhoids
(33) Thyroid problems, Graves disease, gout
(34) Knee problems (not arthritis (03), not joint injury (05)
(35) Migraine headaches (not just headaches)
(36) Other impairment/problem (Specify one) (LAHCA@S1)
(37) Other impairment/problem (Specify one) (LAHCA@S2)
(B) Back-up to previous screen

FR: SPECIFY CONDITION CAUSING LIMITATION. THIS SHOULD BE THE NAME OF A SPECIFIC CONDITION THAT IS NOT ON THE CONDITION LIST.
LAHCA@S1 Condition: __________________________________________
FR: SPECIFY CONDITION CAUSING LIMITATION. THIS SHOULD BE THE NAME OF A SPECIFIC CONDITION THAT IS NOT ON THE CONDITION LIST.
LAHCA@S2 Condition: __________________________________________

top
2002
Survey form view entire document:  text  image

FHS.280

How long {have/has}{you/subject name} had {fill condition entered in FHS.270}?

FR: ENTER NUMBER, PRESS RETURN, AND ENTER TIME PERIOD.
LCTIME#
[ ] NUMBER(ENTER "96" IF SINCE BIRTH)

(01-94) 1-94
(95) 95+
(96) Since birth
(97) Refused
(99) Don't know
LCUNIT#
[ ] TIME PERIOD

(1) Days(s)
(2) Week(s)
(3) Month(s)
(4) Year(s)
(6) Since Birth
(7) Refused
(9) Don't know

[Go back to Check item FHSCCI3 for next family member. If no more family members go to FHS.310]

FHS.300

How long {have/has}{you/subject name} had [fill condition(s) entered in FHS.290]?

FR: ENTER NUMBER, PRESS RETURN, AND ENTER TIME PERIOD.
LATIME#
[ ] NUMBER

(01-94) 1-94
(95) 95+
(96) Since birth
(97) Refused
(99) Don't know
LAUNIT#
[ ] TIME PERIOD

(1) Days(s)
(2) Week(s)
(3) Month(s)
(4) Year(s)
(6) Since Birth
(7) Refused
(9) Don't know

[Go back to Check item FHSCCI3 for next family member. If no more family members go to FHS.310]

top
2001
Survey form view entire document:  text  image

FHS.280

How long {have/has}{you/subject name} had {fill condition entered in FHS.270}?

FR: ENTER NUMBER, PRESS RETURN, AND ENTER TIME PERIOD.
LCTIME#
[ ] NUMBER(ENTER "96" IF SINCE BIRTH)

(01-94) 1-94
(95) 95+
(96) Since birth
(97) Refused
(99) Don't know
LCUNIT#
[ ] TIME PERIOD

(1) Days(s)
(2) Week(s)
(3) Month(s)
(4) Year(s)
(6) Since Birth
(7) Refused
(9) Don't know

[Go back to Check item FHSCCI3 for next family member. If no more family members go to FHS.310]

FHS.300

How long {have/has}{you/subject name} had [fill condition(s) entered in FHS.290]?

FR: ENTER NUMBER, PRESS RETURN, AND ENTER TIME PERIOD.
LATIME#
[ ] NUMBER

(01-94) 1-94
(95) 95+
(96) Since birth
(97) Refused
(99) Don't know
LAUNIT#
[ ] TIME PERIOD

(1) Days(s)
(2) Week(s)
(3) Month(s)
(4) Year(s)
(6) Since Birth
(7) Refused
(9) Don't know

[Go back to Check item FHSCCI3 for next family member. If no more family members go to FHS.310]

top
2000
Survey form view entire document:  text  image

FHS.280

How long {have/has}{you/subject name} had {fill condition entered in FHS.270}?

FR: ENTER NUMBER, PRESS RETURN, AND ENTER TIME PERIOD.
LCTIME#
[ ] NUMBER(ENTER "96" IF SINCE BIRTH)

(01-94) 1-94
(95) 95+
(96) Since birth
(97) Refused
(99) Don't know
LCUNIT#
[ ] TIME PERIOD

(1) Days(s)
(2) Week(s)
(3) Month(s)
(4) Year(s)
(6) Since Birth
(7) Refused
(9) Don't know

[Go back to Check item FHSCCI3 for next family member. If no more family members go to FHS.310]

FHS.300

How long {have/has}{you/subject name} had [fill condition(s) entered in FHS.290]?

FR: ENTER NUMBER, PRESS RETURN, AND ENTER TIME PERIOD.
LATIME#
[ ] NUMBER

(01-94) 1-94
(95) 95+
(96) Since birth
(97) Refused
(99) Don't know
LAUNIT#
[ ] TIME PERIOD

(1) Days(s)
(2) Week(s)
(3) Month(s)
(4) Year(s)
(6) Since Birth
(7) Refused
(9) Don't know

[Go back to Check item FHSCCI3 for next family member. If no more family members go to FHS.310]

top
1999
Survey form view entire document:  text  image

FHS.280

How long {have/has}{you/subject name} had {fill condition entered in FHS.270}?

FR: ENTER NUMBER, PRESS RETURN, AND ENTER TIME PERIOD.
LCTIME#
[ ] NUMBER(ENTER "96" IF SINCE BIRTH)

(01-94) 1-94
(95) 95+
(96) Since birth
(97) Refused
(99) Don't know
LCUNIT#
[ ] TIME PERIOD

(1) Days(s)
(2) Week(s)
(3) Month(s)
(4) Year(s)
(6) Since Birth
(7) Refused
(9) Don't know

[Go back to Check item FHSCCI3 for next family member. If no more family members go to FHS.310]

FHS.300

How long {have/has}{you/subject name} had [fill condition(s) entered in FHS.290]?

FR: ENTER NUMBER, PRESS RETURN, AND ENTER TIME PERIOD.
LATIME#
[ ] NUMBER

(01-94) 1-94
(95) 95+
(96) Since birth
(97) Refused
(99) Don't know
LAUNIT#
[ ] TIME PERIOD

(1) Days(s)
(2) Week(s)
(3) Month(s)
(4) Year(s)
(6) Since Birth
(7) Refused
(9) Don't know

[Go back to Check item FHSCCI3 for next family member. If no more family members go to FHS.310]

top
1998
Survey form view entire document:  text  image

FHS.280

How long {have/has}{you/subject name} had {fill condition entered in FHS.270}?

FR: ENTER NUMBER, PRESS RETURN, AND ENTER TIME PERIOD.
LCTIME#
[ ] NUMBER(ENTER "96" IF SINCE BIRTH)

(01-94) 1-94
(95) 95+
(96) Since birth
(97) Refused
(99) Don't know
LCUNIT#
[ ] TIME PERIOD

(1) Days(s)
(2) Week(s)
(3) Month(s)
(4) Year(s)
(6) Since Birth
(7) Refused
(9) Don't know

[Go back to Check item FHSCCI3 for next family member. If no more family members go to FHS.310]

FHS.300

How long {have/has}{you/subject name} had [fill condition(s) entered in FHS.290]?

FR: ENTER NUMBER, PRESS RETURN, AND ENTER TIME PERIOD.
LATIME#
[ ] NUMBER

(01-94) 1-94
(95) 95+
(96) Since birth
(97) Refused
(99) Don't know
LAUNIT#
[ ] TIME PERIOD

(1) Days(s)
(2) Week(s)
(3) Month(s)
(4) Year(s)
(6) Since Birth
(7) Refused
(9) Don't know

[Go back to Check item FHSCCI3 for next family member. If no more family members go to FHS.310]

top
1997
Survey form view entire document:  text  image

FHS.280

How long {have/has}{you/subject name} had {fill condition entered in FHS.270}?

FR: ENTER NUMBER, PRESS RETURN, AND ENTER TIME PERIOD.
LCTIME#
[ ] NUMBER(ENTER "96" IF SINCE BIRTH)

(01-94) 1-94
(95) 95+
(96) Since birth
(97) Refused
(99) Don't know
LCUNIT#
[ ] TIME PERIOD

(1) Days(s)
(2) Week(s)
(3) Month(s)
(4) Year(s)
(6) Since Birth
(7) Refused
(9) Don't know

[Go back to Check item FHSCCI3 for next family member. If no more family members go to FHS.310]

FHS.300

How long {have/has}{you/subject name} had [fill condition(s) entered in FHS.290]?

FR: ENTER NUMBER, PRESS RETURN, AND ENTER TIME PERIOD.
LATIME#
[ ] NUMBER

(01-94) 1-94
(95) 95+
(96) Since birth
(97) Refused
(99) Don't know
LAUNIT#
[ ] TIME PERIOD

(1) Days(s)
(2) Week(s)
(3) Month(s)
(4) Year(s)
(6) Since Birth
(7) Refused
(9) Don't know

[Go back to Check item FHSCCI3 for next family member. If no more family members go to FHS.310]