Probe Questions <P H
la. What is the name of the hmid of this household? - Enter name m fwst column
b. What are the nwnes of .s11 eth.r p.rsons who Iiv. here? - L,st all persons who Itve here. Yes * N.o
c. I hav. listed (Read names). Is there anyone .Ise staying here now, such as friends, relatives, or roomers? O n ‘m” “:’’nameau ‘GE
d. Hove I missed anyone who USUALLY lives here but is now away from home?. D ~
●.DotmYof the PeoPle in this household hove .a home anywhere else? .,..,,...,.. . . . . . . . . . ❑ m
--- RACI
Last name lW
*APPly household membershm rules.
f. Are any of the persons in this household now on full-time
20
oetive duty with the Armed Forces of the United States?. , Y CoI(s). _ {Delete) 2 N 30
2. How is -- related to -- (Head of household)? 2. Relat,e.ship SEX
lM
HEAD 2F
3. Whet is --’s date of birth? (Enter date and Age, and circle Race and Sex)
3. Month Dare Year
L Ask Cmd,t,im l,st_. Use Flashcard
BED DAYS I DV _to determine Sample persons; mark SP boxes.
HOSP.
❑ par ❑ pti n p;
1. Record the number of Bed Days, Doctor Vlslts, and Hospltallzations
c c _
(NP) _ (NP) _(Nf2. Record each condition In the person’s column, wnth the quesuon number(s) where It was reported. Q. No. I Conditlm
Reference dates I \
2-week period I \
I 12.month Bed Days
and Doctor vtislt \
probe \
Hospttal probe \
I
If 17+, ask:
4. Is -- no” married, widowed, divorced, separated, or never motried?
0 n Under 17 4. 9 D Ma, r,ed - spouse p,,,,,
6❑ Marr, =d - spouse ab$en 2 ~ W,dowed
4 ~ D,vorced
5 n separated
3 0 ~=v=, m=rl=d
If related persons 17 years old or over are Ilsted In addloon to the respondent, say:
H w
0❑ Under 17 e would like to have .11 adults who are at home take part i“ the interview.
Is your --, your --, etc., at home now? If ‘“Yes,” ask: Please ask them to i.ain us.
H t❑Achorre
z D Not at horn.
This surve is being conducted to collect information o“ the Nation’s heolth. I will ask ob+ut visits to J
doctors a“ dentists, il I“ess in the fomily, and other heolth related item.. (Hand calendar) The next few questions refer to the post 2 weeks, the 2 weeks outlined in red on that calendar,
beginning Monday, [date) , and ending this past Sunday, (date) . Y (5bJ
5a. During those 2 weeks, did -- stay i“ bed because of O“Y illness w iniury? 50. 00 N
} If age, 17+ (6)
b. During that 2-week period, how many days did -- stay i. bed all .X most of the day?
6- I 6 (7)
b. _ Day, Under 6 (9)
6. During those 2 weeks, how many days did illness or iniury keep -- from “ork? 6.
(For females): not counting work around the house? WL day. (8)
00 D None (9)
7. During those 2 weeks, how many cloys did illness o, i.iury keep -- f,om school? 7.
SL days 00 n Nme (9)
If o“e m more days &n 5b, ask 8; .a[herw, se go to 9
8. On how many of these -- days lost from
{:’’:0’ }
did -- stay in bed all or most of the day? Day S
8. 00 ~ No”.
{ in bed 9., (NOT COUNTING theday(s)
}
lost from work ) 9.. IY
10St from school
Were there any (other) days during the post 2 weeks that -- cut down O.the things he usually does because of illness or iniury?
2 N ( 10)
la. During the past 2 weeks, did anyone in the family, that is you,
your - -, etc., have any (other) accidents or iniuries? Y N (12)
b. Who was this? - Mark “Acc!dent or Iniury” box in person’s column. llb. r] Acc8dent ormlurY
--- --- -- — --- — ---
—----In)ury
c. What was the injury? c.
d. Did anyone have any other accidents or iniuries during that period? Y (Reask I lb and c) N
--- —-- ---
—---If “Accident or in jury,” ask:
----Y (Enter injury h item C) e. As aresult ofthe accident, did - - see o doctor or did he cut down on the things he usually does? e. N
20. During the past 2 weeks, did anyone in the family
go to the dentist? Y N (13)
--- --- ——--- ---1
b. Who was this? - Mark “Dental visit” box in person’s column. 12b. n Demal VISII
__________________________________________________________________________ --- -— —--. _.___ e
---C. During the past 2 weeks, did anyone else in the family go to a dentist? Y (Reask 12b and c) N
--- --- ---
---If “Dental visit, ” ask:
d. During the past 2 weeks, how many times did -- go to o dentist? d. _No. of dental visits (NP)
,- .”+,.. ,, . .==%=. .. .
Do not ask for children I yr. old and under.
Mark box or ask: 13. 1❑ 2-week dental visit
3. ABOUT how long has it been since -- LAST went to a dentist?
---z D Past 2 weeks not
reported (12) 3 n 2 weeks-6 months 4 n Over 6-12 months 5❑ I year
6 n 2-4 years J Cl 5+ years
8 D Nevar/a;e I or under
‘oo-rNo-rEs
4. During the past 2 weeks (the 2 weeks outlined in red on that calendar) how many times did -- see a medical doctor? 14. 00❑ None Do not count doctors seen while a patient in a hospital.
NP _ Number of VISIIS
f i’
(Besides those visits)
50, During that 2-week period did anyone in the family go to a doctor’s office or Y
clinic for shots, X-rays, tests, or examinations? u.!’!!. ____________ _ __
---b, Who wos this? - Mark “Doctor vtslt” box In person’s column. 15b.
_—
-~ Doctor vIsIt
---c. Anyone ●lse? Y“ (Reosk 15b &d c) .,
N
--- ---If “Doctor vlslt, ” ask:’
--d. How many times did -- visit the doctor during that period? d. _ Number of v,stts (NP)
6a, During that period, did anyone in the family get any medical advice from Y
a doctor over the telephone? N (17)
. —--- . . . . . . . . .——_ —-—-—-—- --- --- --- .
b. Who was the phone call about? - Mark “Phone call” box ,n person’s column. 16b. ❑ Phone call
. . c. Any calls about anyone else?
~ ---_- .”---- --... --—. —---,
Y (Reosk 16b and c) —.— _ .—.
N ..-. .
. ..-. .——-— —--- --- : . ...---.” “--- &_. . If “Phone call, ” ask:
d. How many telephone calls were made to get medical advice about -- ? d. —Number of calls (Ivpj
} FIII Item C, (DV), from 14-16 for all Persons. a Condit,on fll:NC17d)
Ask 17a for each person with vIs Its tn DV box. (-J Preg”a”cy (17e)
70. For what condition did -- see or tolk to a doctor during the post 2 weeks? 170. Q No cond,t,on
.
b. Did -- see or talk to o doctor about any specific condition? b. Y N [NP)
c. What condition? Enter condi lion in item C
c.
--- ..-. Ask 17d
d. During that period, did -– see or talk to a doctor about any other condition? d. Y (17C) N (NP)
e. During the past 2 weeks was -- sick because of her pregnancy? e. Y N (17d)
..-. _—
--f. Whet was the matter? f. Enter condition in item C ( 17d)
Ea. During the post 12 months, (that is since (date) a year ago), about how many times did -- see or 18.. 000 a only when )n hospital talk to o medical doctor? (Do not count doctors seen while o patient in a hospital. )
(Include the
--000 D None
visits you olready told me about. ) _ Number of V,.S,CS
b. ABOUT how long has it been since
--- --- —--- ___ ____________________
LAST saw or talked to a medical doctor? b. 1 a 2~eek DV
Include doctors seen while a patient in a hosp!tal.
2 D Past 2 weeks
“ot reporred (14 and 17) 3 a 2 wks. -6 mos.
4 a t)ver 6—12 rims.
5 D I year 6❑ 2-4 years 7D 5+ years .3 n Never
Ages 17+
Ages 6-16
19a. WhetWOS -- doing MOST OF THE PAST 12 MONTHS - (For males): working or doing something else?
If “something else, ” ask: (For females): keeping house, working, or doing
b. What was -- doing? something else?
If 45+years and was not “worktng,” ‘“keeping house,” or “going to school, ” ask:
c. IS -- retired?
d. [f “’retired, ” ask: Did he retire because of his health?
20a. What was -- doing MOST OF THE PAST 12 MONTHS - going to school or doing something else?
If ‘“something else, ” ask:
b. What wos -- doing? .-. -—-- —. ——_— ——_— ——__— —_. —. ———. __ —______________
Ages under 6
)1o. Is -- gble to take port at all In ord!nary DfOYwith other children?
b. Is-he-limited i“ the kind of play he can dO because of his health?
c. Is he limited ir.the amount of bfay because of his health?
220. IS -- limited in any way because of his health?
b. In what way is he limited? Record limitation, not condition.
23a. Does -- health nowkeep him from working?
b. Is he limited in the k[nd of work he could do because of his heolth?
c. Is he limited inthe amount ofwork he could do because of his health?
d. Is he limited inthe kind or amount of other activities because of his health?
!40. Does -- NOW have o iob?
b. In term. of health, is -- NOW able to(work – keep house) at all?
-- ——--— ——————-—. -. . . . .._ —-_. ——_-_ —________
c. Is he limited in the k!nd of(work – housework) he can do because of his health?
-. ——. . . —-———.
---d. Is he limited in the amount of (work - housework) he con do because of his health?
e. Is he limited in thekind or amount of other activities because of his health?
?5. In terms of health would -- be able to go toschool?
!60. Does (would) -- have to go to a certain type of school because of his health?
b.15he (would he be) limited inschool attendance becttuse of his health?
c. Is he limited inthe kind oramount ofother activities because of his health?
!70. Is -- limited in ANY WAY because of a disability or health?
b. In what way is he limited? Record Iimltatlon, not condition.
_ __{
been limited in
--!80. About how long has he been unable to
--hod to goto a certain type of school?____}_ _____ __ _____
b. What (other) condition causes this limitation?
If “old age”’ only, ask: IS this limitation caused by any specific condition?
c. Is this limitation caused by any other condition?
.--
——---Mark box or ask:
d. Which of these conditions would you say is the MAIN cause of his limitation?
ii
I D Working (24a) 2 D Keep, nghouse (24b) 3 n Ret, red, health (23) 4❑ Retired, other (23) s a Going 10 school (26) 6 D 17+ somethm; else (23) 7 m 6–16 someth!ng else(?t
—---000 a Less than I month
-l.-H’ ?-.--.Z_-_Y.!!
Enter cQndltlon In [mm C Ash 28G D Old age only (NPJ
Y (Reask N
28b and c)
,---m Only I cond,t,on
Enter mam co”duuon
29a. Was --0 patient in a hospital at any time since (date) a year ago?
14
29.. Y N (/tern C)
---
---b. How mony times was -- in a hospital since (date) a year ego? b. _ T,mes (/fern C)
b
f I A
30a, Was Gnyo”c in the family in a nursing home, convalescent home, or similar place since (date)
a year 090? Y N (31)
--- ---- -. . ..--- .
b. Who was this? - Circle “’Y” in person’s column. 30b. Y
----7, ---
---If “Y, ask:
---c. During that period, how many times was -- in o nursing home or similar place? c. _ Tames (Item C)
Ask for each child I year old or under if date of birth is on or after reference date.
31a. %s -- born in o hospital? 31..
If “Yes, ” and no hospitalizations entered in his and/or mother’s column, enter “ I” in 29b and item C.
If “Yes, ” and a hospitalization is entered for the mother and/or baby, ask 3 I b for each.
Y N(NP)
--- .__. ____________________
b. Is this hospitalization included in the number you gave me for --?
If “No,” correct entries in 29 and item C for mother and/or baby.
b.
Y N
FOOTNOTES
Condition Page
CONDITION 1 1. Person number Name of condition
i
Examine “Name of condition” entry and mark
~, n Color blindness (NC) ~ On Card C (,42)
O Accident or injury (A2) I_J Neither (30)
If “Doctor not talked to.” transcribe entry from item 1.
If “Doctor talked to, ” ask:
3a. What did the doctor say it was? - Did he give it a medical name?
---Do not ask for Cancer ❑ On Card C (A2)
b. What was the cause of . . .?
U Accident or injury (A2)
---If the entry in 3a or 3b includes the words:
Ailment Condition Disorder Trouble
Anemia cyst Growth Tumor
Asthma Defect Measles Ulcer
}
Ask C:
Attack Disease Rupture
c. What kind of . . . is it?
---For al Iergy or stroke, ask:
d. How does the allergy (stroke) affect him?
_________________________________________________
If in 3a-d there is an impairment or any of the following entries:
Abscess Damage Paralysis
Ache (.xc.pt ha.ad or .ar) Growth Rupture
B18eding Henmrrhoge S0 r.
Blood clot Infection Soreness
Boil Inflammation Tumor
1 Ask e
Cancer Neuralgia Ulcer
cramp%(9xc*pt Neuritis Varicose veins
Inulswll.1) Pain Week
cyst Palsy Weakness
●. Whet port of the body is affoctad?
Show the following detail:
Hod . . . . . ..skull, .calp, face Back/spine/vertebra . . . upper, middle, lower Ear or eye . . . one or both
Arm . . . one or both; shoulder, up er, elbow. lower. wrist. hon J’
LqI . . . one or both; hip, upper, knee, lower. ankle, foot
42
Ayly’’l’””- ‘; &y’:y. ‘“’ “ ‘:gi: .y’d ‘n’2a Q.3a ~uQ.3c 6nQ.3e
4. During the past 2 weeks, did his . . . cause him
to cut down on the things he usuolly does? lY 2 N (9 I
5. During that period, how many days did he cut
down fo, as much as a day? _ Days
00 ; None {9)
6. During that 2-week period, how mony days did
his . . . keep him in bed all or most of the day? _Days 00 : None
Ask !f 17+ years:
7. How many days did his . . . keep him from work _Oays (9) during that 2-week period? (For females): not
countina work oround the house? 00 None 19J
Ask if 6-16 years:
8. How many days did his . . . keep him from _ Days
school during that 2-week period? 00 None
I 9. When did -- first notice his . . .?
I ~~ Last week 4::”2 weeks-3 months
2 ~] Week before 5 .:! Over 3-12 months
3 i~] Past 2 weeks-OK whl~h 6 :: ‘ More than 12 months ago (Was it during the past 12 months or before that time?)
(Was it during the post 3 months or before that time?) (Was it during the past 2 weeks or before that time?)
t❑ Not an eye cond. (AA)
A3
3❑ First eye cond. (6+ yrs.)
z❑ First eye cond. (10)
(under 6) (AA) 411 NOt first eye cond. (AA)
1 —
10. Can -- see well enough to read ordinary newspaper print
WITH GLASSES with his (Iefi ~ eye? . ..l Y 2N
\J FOOTNOTES
i u Missing extremity (A4)
AA 20 Condition in C2does not have a letter as source (A4)
A41
❑ Accident or injury n Other (NC)s U Condition in C2 has a letter as source, Ooctor see” (f f) 170. Did the accident happen during the past 2 years or before that time?
4 m Condition in C2 has a letter as source, Doctor not seen (15) m During the past 2 years ❑ Before 2 years (180)
_________________________________________________
1 la. Dots -- NOW take any medicine or treatment lY b. When did the accident happen?
for his---, , ,? 2 N (12) 4 ❑ Last week ❑ Over 3-12 months
b. Was ony of this medicine or treatment recommended I Y
I
❑ Week before n I -2 years
by a doctor? 2N n 2 weeks-3 months
12. Has h~ ●vw had surgery for this condition? lY
2N
13. Was ha ●ver hospitalized for this condition? lY 2N
14, During the past 12 months, about how many times has
-. soon or talkad to a doctor about his . . .? _ Times
(Do not count visits whila a patient in a hospital.) 000 ❑ None 150, About how many days during the past 12 months has
this condition kept him in bcd all or most of the day? _ Days 000 ❑ None
---Ask if 17+ years:
b. About how many cloys during the past 12 months has _ Days this condition kept him from work?
For females: Not counting work around the house? 000 n None
160. How often dots his . . . bother him - all of the time, often, once in a while, or never?
I o All the time z❑ Often 3 D Once in a while
o u Never (16c) e❑ Other - Specify
b. Whan it daas bother him, is he bothered a great deal, some, or very little?
I u Great deal 2 a Some 3 m Very little
4 U Other - Specify
u All the time in 16a OR condition list 4 asked (A4)
c. Does -- still have this condition?
t Y (A4) N
d. Is this condition completely cured or is it under control?
2 u Cured 30 under control (A4)
4❑ Other - Specify (A4)
---●, About how long did -- have this condition before it wos cured?
o u Less than one month — Months — Years
180. At the time of the accident what port of the body was hurt?
What kind of iniury was it? Anything else?
Part(s) of body Kind of mjwy
t t
--- —--- —---
---If accident happened more than 3 months ago, ask:
b. What part of the body is affected now?
How is his -- affected? Is he affected in any other way?
Part(s) of body Presem effects
,_- -_________l-_
---19. Where did the accident happen?
1❑ At home (inside house) z❑ At home (adjacent premises)
s❑ Street and highway (includes roadway and public sidewalk) 4 n Farm
5❑ Industrial place (includes premises) G a School (includes premises)
7❑ place of recreation and sports, except at school a❑ Other - Specify
i
20. Was -- at work at his 10b or business when the accident happened?
lY 3 m While in Armed Services
2N 4❑ Under 17 at time of accident
210. Was a car, truck, bus, or other motor vehicle
involved in the accident in any way? lY 2 N (NC)
---b. Was more than one vehicle involved? Y N
---c. Was it (either one) moving at the time? lY 2N
2-WEEKS DOCTOR VISITS PAGE 1. Person number Earlier, you told mc that--hod seen or talked to o doctor during the IMSt 2 weeks. 2..
{-7777 r~ Last week OR
‘a. On what (other) dotes during that 2-week pericd did -- visit or talk to a doctor?
8s88 r IWeek before
——
Month Date
—— -.. .
b. Were there any other doctor visits for him during that period?
Y (Reask 2a and b) N(Ask 3-6 for
b. each vk+lt)
1. Where did he sec the doctor on the (date) at a 3.
clinic, hospital, doctor’s office, or-er place?
0 D wh,le ,nPat, ent in hospital (NSWI DV) I u DocIor’s of ftice (croup pcacc, ce w
If Hospital: Was it the outpatient clinic
docror’s .Itin, c)
or the emergency mom? z O Telephone
3 El HOspllal Outpatoe”t CIIn, C
If Cl!nic: Was it a hospital outpatient 4 D Home
clinic, a company clinic, or some other kind of clinic?
$ ~ HO.Pulal Emergency R.arJrn 6 m COmpany Or Industry cl~n,c 7 n O[her (Specify)
7
L Was the doctor a general practitioner or a specialist? 4. 01 m General practitioner H Spec, al, st
-Whm kind of qmcie list is he?
-F
—
i. Ouring this visit (call) did -- actually see (talk to) the doctor? 5. lY 2N
m. Why did he visit (call) the doctor on (date) ? 60.
Write in rea~c,n
1❑ Diag. or treatment (6c)
Mark appropriate box(es) 3❑ General checkup (6b)
2 D Pre or Posmatal care 4❑ Eye exam. (glasses)
}_
(Nex
5 0 Immunization DVJ
60 Other
--- --- ___________________________
b. Was this for any specific condition? b. Y (Enter condition in 6a N (Next DVj
and change to ““DIag.
---.. ---—-- _____________________________________________________ --- _______________________________or freatman t’”)
Mark box or ask: ~ Condition reported ,n 6a
c. For what condition did -- visit (call) the doctor on (date) ? c.
‘OOTNOTES
PI
A Condition page is required for the condition in question 6. If there is no Condition page, enter condition in item C and fi II a page for it after completing columns for all required doctor visits.HOSPITAL PAGE
YOU said that -- was in the hospital (nursing home) during the past year.
2. When did -- ●nter the hospital (nursing home) (the lost time)?
uSE YOUR CALENDAR Make sure the YEAR os c.xrec
3. What isthcnama andaddrcs. ofthishospital (nursing home)?
4. Howmany .nights. was -- in th* hosoital (nursina.home)?.
Complete 5 from entries in 2 and 4; if not clear, askthe questions.
b. Howmony ofthcse --nights were during the past 12 months?
___________________________________________________________________ .
b. How many of those -- nights were during the past 2 weeks?
___________________________________________________________________ .
c. Was -- still in th~ hospitol (nursing home) last Sunday night for this hospitolizotion (stay)?
6. Fe, what condition did -- enter the hospifil (“ursi”g home) - do you Icno” the medical “ome?
If medical name unknown, enter an adequate description.
For delivery ask:
}
I
1 Show CAUSE, KIND, and
Was this a normal delivery? If “NO,” ask: 1 PART OF BODY in same
1
For newborn, ask: What was the matter? I detai I as required for the
I
Was the baby normal at birth? Condition page.
1 1 , 1
7a. Wcrt any operations performed on -- during this stay at the hospital (nursing home)?
____________________________________________________________________
b. What wos the nama of the operation?
If name of operation IS not known, describe what was done.
____________________________________________________________________
c. Any other operations during this stay?
‘OOTNOTES
—
—1.
—2.
3.
—
—4.
5..
--b.
--—c.
6.
—
_-70.
b.
.—
c.
— Street
C8ty(or county) State
N,zhts
Nazhcs _______________________________
N,;hts
_______________________________
Y N
❑ Normal del,very ❑ Normal at b,nh Cond, tti.an
_______________________________
Knnd
P-aYt-07Kd;---”
Y o N (Next Hosp)
. —_____________________________
Y (Describe)
7 N’