11a. Is there anyone in the family who has lost ALL of his teeth?

[] Y
[] N (12)

b. Who is this? Anyone else? ____

[] No teeth

For each person with "No teeth," ask:

c. Does -- have false teeth?

f. Does -- usually wear

when not eating?

g. Does -- need new false teeth?

h. Do the ones he has need refitting?

12. During the past 2 weeks (the 2 weeks outlined in red on that calendar) how many times did -- see a medical doctor?

(Besides those visits)
13a. During that 2-week period did anyone in the family go to a doctor's office or clinic for shots, X-rays, tests, or examinations?


b. Who was this? -Mark "Doctor visit" box in person's column. ____


c. Anyone else?


If "Doctor visit," ask:
d. How many times did -- visit the doctor during that period?


14a. During that period, did anyone in the family get any medical advice from a doctor over the telephone?


b. Who was the phone call about? ________
Mark "Phone call" box in person's column.


c. Any calls about anyone else?


If "Phone call," ask:
d. How many telephone calls were made to get medical advice about --?


Fill item C, (DOCTOR), from Q.'s 12-14 for all persons. Ask Q. 15a for each person with visits in DOCTOR box.

15a. For what condition did -- see or talk to a doctor during the past 2 weeks?


b. Did -- see or talk to a doctor about any specific condition?


c. What condition? ____

Enter condition in item C and ask 15d.

d. During that period, did -- see or talk to a doctor about any other condition?


e. During the past 2 weeks was -- sick because of her pregnancy?


f. What was the matter? ____
Anything else?

Enter condition in item C (NP)