APPENDIX Ill QUESTIGNNAIRE
1.~. What I$ thr n.m. of th. h..d of this hou..hold? (Enter “am. in ootumn for ~st.06 01) PERSON@
b. whet a,. the nom.‘ of alI othrr p.r.ons who liv. her.? (Lint all pw.on. who five hare)
LAST NAME C, I hovr 1lrt.d (rsad n.m.8). I. th.r. any.“. .I.. staying her. now such .I friands,
q Yes* q No
r.l.tiv.1, 01 raomw8? . . . . . . ..I...
d. Hav. I mhnmd onyon. wh. USUALLY 11v.s h.rm but Is now away from horn.? . . . .
. . Da .ny of th. pa.& In thi. hous.h.ld hav. D horn. anywher. .Is.? . . . . @f 911: _______--___________
FIRSTNAME
If my .dull males JMsd, auk: *Apply household membership de*
f. An my of th. g.r.on. In thl. hour.hold n.w on full-tim. ecflv. duty with OYas (nsleq th. An.d For.., of th. Un1t.d Stat.s? nNo
RELATIQNSHIP 2. How I. - - nlat.d to - - (head of household)?
Head
AGE RACE.nmite SF
3. HOW old was - - M hi. Iart btrthdoy? (Afw msrk R.ce and Ssx) mw; EF
ll
If 1, year. old o, “vsr, ..k: 0 Und. 17 q Nevermarried
,. Is - - new mmrtmd, widow.d, dtvorcrd, s.par.t.d, o, n.vsr mnrried? (Mark one box for each person) 0 Married 17 Divorced If parraw under 17 &I. or h.v. bsbn mnrtisd mark tke ‘Wnd. 17” b& snd Siv. marital stetus I” (I footnot.. 0 Widowed 0 Separated If 17 y..r. old of ovsq aek:
5. Wh.t w.. - -doing most of th. part.lZmonthr - ; i%i;
(for males) working or doing som.thing .I%.? 0 Keepinghouse
(for females) k..ping hour., working w doing som.thing .I%.? 0 Something else If n1.f.d p.r.ons 19 ~a.*. old of 0v.r a. Ifatsd in sdditio” to tbs res9onde”t. say:
We would Ilk. t. hav. all adult. who .I. at horn. (ok. p.rt in th. 1nt.rvi.w. Is your - -, et.., .t horn. now7 0 At hme(rntcWi~~ for ..lfJ 0 Under19
H if other eli6ible t..p,d.“te (LI. at horns, aak:
Wouldyou ploar. a.k - -, - -, .t.., to i.ln u.? 0 Not at home
Thin that I., th.Z.w..k p.riod WV.~ .av.ts alI klnds of tlln..r.s. ouflin.d In r.d on tht. eol.ndar. Th.8. first qv..tt... (Hand c.Js”d.r) rabr io LAST WEEK AND THE WEEK BEFORE, UYes @ UN0 6.0. Wo. - - sick at any tlm. LAST WEEK OR THE WEEK BEFDRE? (th. 2 weeks shown on that s.l.nd.,)?
b. Wbot wa. th. m.tt.,?
G Did - - hov. anything .I#. during that 2-w..k p.rlod?
---_---7.0. LAST WEEK OR THE WEEK BEFORE, did - - tat. any m.dtcin. or tr..tm.nt for any condition (bsslder . . . 0 Yes ON0 which you tcld m. about)?
b. For what erndifia?
C. Did - - tok. any m.dtcin. for .ny oth., eondttion?
‘L----L--l---‘_-_---_c--=~---~---__----_____
6.0, LAST WEEK OR THE WEEK BEFORE, did - - hav. .ny aceidonrs .I inivri.s? 0 Yes ON0
b. What w.,. th.y?
L. Did - - hav. any othrr ossld.nts or in(urf.s during that 2.w..k p.riod?
-d---“ --__--__^--_---_---
-____________--_____---9.0. Did I - EVER h.v. cm(any oth.r) accid.nt .I Injury that .till bDth.rr him or affects him in .nyw.y? 0 Yes UN0 b, In what way d.u it bothrt hlm7 (Record pt.s.“faff.cfa)
0p.n your Fbrhc.td Booklet to Cat.3 A. q Yes a)
id. R..d bolh aid.. of Cc”3 A, condition by oo”dificn; rsco”, I” hi. colrmu, .“y co”d,t,c,,. “,.“t,,,“.d for tb. per.on.
---___c_-___-
~---~---_--___-______________________________________________---___
Turn IO Cud 8.
11. R..d bdh aid.. of Ct B, condIllon by condition: rscotd f” hi. cokmm any conditions mentioned for tha p.r.o”. OYes EiNo
Il... Do.. - - hnv. any .th.r allm.ntr, conditiona, .I problim. with ht. h..lth? OYes q tNo
b. What I. th. sonditlonl (R.cord co”dl:lm ftsalf if .tilt pr...“f; otksrwi.. record present effect..)
I%.. H.. - - k.n In . hospital .t any tin,. sins. a y.0, q.7 I”c,ud. stay. in nvrsing horns., q Yes ON0
________ ______________ - _____
-e. I. this hospltaltxatlon In&d.d Iti th. number y.. g.v. m. for - -7 (If “No,” OYes @ 130
for self-entirely For p.r.cn. 19 year. old 02 DVOI, show who respmdsd for (or w.. pr.s.“t during ths asking of) Q, 6-14. 0 Responded
If wr.m. t..pand.d for ..lf. .how whethsr snfitely or partly. For ~sr.o”s under 19 show who r..,,o”d.d 0 Respondedfor self-partly 0.6-14 forth..,. N .IUibt. r..pbnd.“t ir “et ho”,.” but did not reapad for adf, enter ,be f...o” m . foofnofa.
Perscil _ was respondent
---
CONDITION L 1. Pusmnutu ygtk,III ./-.
---..---- i ---__--__--:
L___-_______--_-__-_---, Enter pcmon number .nd
nome of condition from Work&et : NameOf I pUettion 6 7 8 9 10 II I2 tbta. E. 07
and ask question 2. /C-dilim ____ - _____________________________________ 1 nbd+f O ” ooooo o”“bo
Ask for all conditions : 2. Did _- .v.r AT MY TIME t.lk to a doctor &we his . . . ? Y.r No ”
~---: 3b.Wbot rr. tb. cws. of.. . ?
How does the ollwgy (stroke) affect him?
For conditions on Card B-2 and for 1 3d.whot port of tb. bodp is aff.ct.d? Y
any cntq that includes the words: ; 0
C.ll.2.Z
Abscess Pltidbody
Ache (cxccpt Inflammation ”
headache) Neural.+ X 0
Blcedin Neuritis
Blood c&
Boil
Pain
Palsy show detail for: w-6 ”
Pmly*i*
Ear 0, eye (me 0, aon) 0 0
Cnmp~kxccpt sore
men.tnl.l) Sacnc.. Head(skull. scalp. Ire) ”
Cyst Tumor Es& (wper, middle. lomr)
Growth Ulcer An (shoulder. upper, eltwt. lwmr, wrist. had; a-a w ton)
fti; me or talh)
Hemorrhage We& Leg (hip, upper. knee, lower. nkle,
Itdection Lak.c.s
401. Did the acclknt kppnduring the pest 2 pm. at b&n that time?
________________________________________---4b. W-n did tlw accld.nt hppp.n? EMU nontb and ycar. narlr one sir&
Ask for all accidents or injuries
50. At the time of the occidwtt whmt pert of th. k-&p was hurt?
What kind of in/up we‘ it? Anpthlnp .I,.?
Pall(s) Of tcdy I Kind cl injuqfinjurics)
I I
-_______________________________________---~--~~.
If accident happened & 3 monthr. ask:
5b. Whd pm* ef th* body is affected now?
Hew is his - - sffimd?
Prlfs) of body I Pwsml effects
FOOt”Ote,
60. Was m car, truck, bus, or othw
mot01 whisl. Inrolwd in th. Y.S tbc.*r ”
occid.nt in 0-y ray? 0 0 0
b. Was me,. them on. whicl. Yar No
involved? 0 0
_-______________________________________---C. War it (either one) moving at Yes No ”
tha time? 0 0 0
7. !Jfh.r. did th. accid.nt happ.n?
A1 h ,i.d* b.4 . . . 0
64
--
1 CONOITION fCont'd.l i REFERRESPONDEWT TOTWO-WEEK CAl.bNDAR FORr?"E.wIONS9- I4 I
Ask qucm+ion 9a lo, at1 I, 9ca. Las+ weok or the reek before did his . . . CO”.. him +o .a+ down on th. Ye, NoC.u,,‘a ”
condi+tons. 1 thing. h. uw.lly do.,? 0 r, Ij
I_______________________________________---..--- yes ~oCo*,‘o ”
j b. Did he hwc to EU+ down 1.x as mush 0% a day? 0 3 0
hmk quea+ionm 10 and 11 ’
II “Yes” marked in :, 10. How many days did h. hw. to cut
quem+ton 9b. I down during rho+ +v,o w..k p.,iod?
j 11. During that two week period, how many j days did his . keep him in bad oil
; or meat of th. day?
h*L lUP”‘ion I2 if Pc,r8,,, / 12. How many d.ys did his.. keep him I. 6- I6 ! cIIr” 0111. I from school during +h.,+ two
B r0.k period?
,\A quu+ion I3 il ~pwsw, I 13. How many days did his . . keep him ir4 17 ycurs nld 0, IMP,. I from votk during that +v,o week p.riod?
; (For lemafes add) not counting I wwk .,ound +h. house?
“.a. Owing 3 “ws. Bcfors 3 m01. co I ,$ ”
” Aek question 14 lo, oil ;I 140. Wh.n did he first no+& his . .,du,ing rhe pa, 3 month, o,
0 5 C’ n
“dI. conditions. b.fo,. that tim.?
,a,, b. Did he lirst notice it during the pm*+ Port z “A% Bslrrs 2 rlu..6.10 16 ”
..“I. two wcakr or before that time? ; 2 c7
Lo,, -ark
c7 bcrn rcpnr1cd. : b. Can - - se well enough +o recognize o friend walking on the othe, Ye,. 0.u 16r NO-1“ Ibr n
I ride of the r+rw+? c‘ :
I________-____-_________________________--~.~~..~~-~.---~-..-~---.---~~-~---/C/ Hod”
(__________-_______-~~~~~~-~~~~~~~~~~~.~--~~~~.---~~~~~~~~~~~~~~~~~~~~~~~~~-~~~~~-~~~~~~~~
>:I C. How much trouble would you say +h.+ - _ has in stcing:a g,e~+ d.o,, chat deal son* my or “am
I Mom., o, ho,dly .any o+ all?
is
AA; IF T,,,S IS A COND,T,DN ON CARD 4 OR B. OR STARTED “REFORE I MONTHS.” ASK 17-18. OT,,ER”‘,SE GO TO WEDI UB. n
I ,,a. ABOUT how many day. during +h* par+ None ‘0 to II ”
I 12 month. ha, his.. . k.p+ him in b.d
n I all o, mar, of th. day?
123 4-c.ln21 Y
I. appmprlo+a bnacd on : 19. PI..,. look a+ .och s+d.m.n+ on this card (Card E, P, G, H).
mctlvity l +e.+umor sp. I Thm+ 1.11 me which s+a+wnen+ Ii+% be,+ in +wms of health.
1
If 1. 2. o, 3 marked 1 20. Is this brcwrc of any of the conditions you hove told me about? w*S”fHtTOH “SE
in 19, ssk: H 4 Yar ND n
I I f
I
Lrd A I :ard E :ord G :ord I
I
i-1 Now I’m going to read o list of 1 A-2 Have you, your , etc., had For: For: For: Mobility
conditions-Please tell me if you, your , etc., have hod
any of these conditions
DUR-ING THE PAST 12 MONTHS? Workers and Housewives
other persons and Children
except Children fmm 6 thmugh 16 years old
my of these conditions
DUR-ING THE PAST 12MONTHS? 1
I.. Asthma? I 12. Thyroid tmuble or goiter? I. Not able to work at all. 1. Not able to go to school at all. 1. Must stay in bed all or most of
2. CHRONIC bronchitis? I 13. Any allergy? the time.
3. REPEATED attacks of sinus 14. CHRONIC nervous trouble? 2. Able to work but limited in amount of 2. Able to go to school but limited to
tmuble? I 15. CHRONIC skin trouble? work OI kind of work. certain types of schooIs or in 2. Must stay in the house all or
school attendance. m0.s of the time.
4. TROUBLE with varicose veins? 16. Hernia or rupture? 3. Able to wotk but limited in kind or
5. Hemorrhoids or piles? 1 17. Prostate trouble? amount of other activities. 3. Able to go to school but limited in 3. Need the help of another person in
6. day fever? other activities. getting amund inside or outside
4. Not limited in any of the above ways. the house.
7. Tumor, cyst, or growth? i :i: E:zisis of any kind?
4. Not limited in any of the above ways.
8. CHRONIC gallbladder or liver 1 20. REPEATED trouble with bad 4. Need the help of some special aid,
trouble?
I 01 spine? such as a cane ot wheelchair, in
9. Stomach ulcer? 21. Cleft palate? getting around inside or outside
0. Any other CHRONIC stomach 22. Any speech defect? the house.
trouble? I
5. Does not need the help of another
I. Kidney stones or CHRONIC person or a special aid but has
kidney trouble? I trouble in getting around freely.
I
6. Not limited in any of the above ways.
:ord B :ord F :ard H :ord J
t I t-1 Have you, your
EVER had any of , etc., these
f B-2 Do you, your , etc., crny of these conditions?
HAVE For: Housewife For: Children under 6 years old For: Total combined family
during past 12 months income conditions?
I
1. Tuberculosis? 1. Not able to keep house at all. 1. Not able to take part at al1 in ordinary Under $500 (indudiug loss) . . Group 1
2. Hardening of the artedes?
i
pIay with other children.
2. Able to keep house but limited in amount
3. High blood pressure? 2. SERIOUS tmuble seeing with on or kind of hxxsework. 2. Able to play with other children but
$500- $999. ... . Group I
4. Cancer? or both eyes even when wearing limited in amount or kind of play. $l,OOO- $1.999. ... . Group (
5. Heart trouble? I &SSCS? 3. Able to keep house but limited in kind or
6. Smke? i 3. Missing fingers, hand or arm-- aumunr of other activilies. 4. Not limited in any of the above ways. $2,000- t2.999. ... . Group I
7. Rheumatic fever? toes, foot or leg?
4. Not limited in any of the above ways. $3,Qao- $3.999. ... . Group I
B. At&iris or rheumatism?
9. Neatal illness? ; $4,000- $4,999 ... . Group I
D. Diabetes?
1. Epilepsy? ( 5. Club foot? $5,000- $6.999. ... _ Group (
I
6. PERMANENT stiffness ot any $7,OoO- $9,999 ... . G&up I
deformity of foot, leg, fiigers,
$10,ooo-$14.999 ... . Group I urn or back?
i
I Sl5,CQO and over. ... . Group ]
f
I -.
___-Series 1.
Series 2.
Series 3.
Series 4.
Series 10.
Series 11.
Series 12.
Series 13.
Series 20.
Series 21.
Series 22.
OUTLINE OF REPORT SERIES FOR VITAL AND HEALTH STATlSTiCS
Public Health Service Publication No. 1000
Programs and collection procedures.- Reports which describe the general programs of the National Center for Health Statistics and its offices and divisions, data collection methods used, definitions, and other material necessary for understanding the data.
Data evaluation and methods research. - Studies of new statistical methodology including: experi
mental tests of new survey methods, studies of vital statistics collection methods, new analytical techniques, objective evaluations of reliability of collected data, contributions to statistical theory.
Analytical studies.- Reports presenting analytical or interpretive studies based on vital and health statistics, carrying theanalysis further than the expository types of reports in the other series.
Documents and committee reports.-Final reports of major committees concerned with vital and health statistics, and documents such as recommended model vital registration laws and revised birth and death certificates.
Data from the Health Interview Survey.- Statistics on illness, accidental injuries, disability, use of hospital, medical, dental, andother services, andother health-related topics, based on data collected in a continuing national household interview survey.
Data from the Health Examination Survey.- Data from direct examination, testing, and measure
ment of national samples of the population provide the basis for two types of reports: (1) estimates of the medically defined prevalence of specific diseases in the United States and the distributions of the population with respect to physical, physiological, and psychological characteristics: and (2) analysis of relationships among the various measurements without reference to an explicit finite universe of persons.
Data from the kstitutionat Population Surveys.- Statistics relating to the health characteristics of persons in institutions, and on medical, nursing, and personal care received, based on national samples of establishments providing these services and samples of the residents or patients.
Data from the Hospital Discharge Survey.- Statistics relating to discharged patients in short-stay hospitals, based on a sample of patient records in a national sample of hospitals.
Data on mortality.-Various statistics on mortality other than as included in annual or monthly reports- special analyses by cause of death, age, andother demographic variables, also geographic and time series analyses.
Data on natality, marriage, anddivorce. -Various statistics onnatality, marriage, and divorce other than as included in annual or monthly reports-special analyses by demographic variables, also geographic and time series analyses, studies of fertility.
Data from the National Natality and Mortality Surveys. -Statistics on characteristics of births and deaths not available from the vital records, basedon sample surveys stemming from these records, including such topics as mortality by socioeconomic class, medical experience in the last year of life, characteristics of pregnancy, etc.
For a list of titles of reports published in these series, write to: Office of Information
National Center for Health Statistics