Survey Text

1981
top
1981
Survey form view entire document:  text  image

4a. When was (Condition) first noticed?
(Was it during the past 12 months or before that time?)
(Was it during the past 3 months or before that time?)

4[] 3 months or less (6)
5[] Over 3-12 months (6)
6[] More than 12 months ago

b. How old was -- when this was first noticed?

0[] Less than 1 month
____ 3[] Months
(Number)
____ 4[] Years
(Number)

0 [] Condition from 56, 57, or 58 (NC)
5. Did -- have this condition at any time during the past 12 months?

1[] Y
2[] N (6b)

0 [] Condition from 56, 57, or 58 (NC)
6a. Does -- still have this condition?

1[] Y (NC)
2[] N

b. Is this condition completely cured or is it under control?

2[] Cured
3[] Under control
4[] Other - Specify ____