0 M B No, 68. R160U, APPrLJ,al EYIMres 1 larch ;( 1974
~OTICE . 4!, ,,, for,na,, on wh, ch would Perm,, ,dent,l,’a,, m of the ,,, d,v, dual w,II be held ,“ s,,,., c,mf, dcn,ze, “,, !Sbe used ml, 1.
3Y Pe,50ns cnr. sed ‘. and for the P.r Doses .f !h~ s., ”e> J.d wdl not be d!sclosed or released 10 others for any P.r Poses Book of books o.t, Hts.1 (1973)
, ,,, ,<, 2DCC 3.Sample 4.Segment type 5,Control number
number
U : DC P. R7ME. T 0, COMMERCE Area
,,C14L A.. OE, ON GMIL 3TAT!STICS Psu Segment %rlal
.OMI.15TRATION
u.. . ...! !., [ ,..,, .s Pecmlc
... ,,,. .S. ,LL, CT,.>, ... ,!/, ,0. ,.,
“ > PuB,!. HFALTH. E.VICE Address
U.S. HEALTH INTERVIEW SURVEY Special place
6. What ,s your exact oddressz (Include House No Apc No or ocher [denctflcatlon and ZIP code] ; L!stong
~ Sheet 1 Sheet
;No I
clly ISta[e I Line
~. / ZIP code
1 ; No
—.! l—
b. Whet ,s y.., ma,l, ng address a“d ZIP code? Same as 6a
Clly ~State [ZIP code
( I
r 1
I
c Special place name ~ Sample un!t number I TYPe co<
7. Year bu,lt
‘Sk ~ Do NOT Ask
When w., th, s struct. rc ortgi”.ally b.ilte
Before 4.1.70 After 4.1.70 (Go m Q,9c, complete
(Con f)n. e inter.few) ,f requ! red and end !“tervlew)
8 Type of I,v, ng quarters _ I Hous, ”g U“II 2 OTHER untt
9 Area segments ONLY
Y (f,ll Toble X) N
. . .
b Arc ther. any o.cupi.d or vacant I,vtng quarters besides yo.c OW” . . this fl.aor~
Y (011 Table X] N
c Is there any .thcr building .“ this property for people to 1(.. in - either occupied or vacant?
Y (f,ll Toble X) N
d. None
) GO TO PROBE PAGE 2
0, Land use 2 RURAL 1 URBAN [/3)
–- Regular u“Irs and Specrol Place un!ts coded 85-88 ). 6c, go m Q, I 1, -– Spec!ol P1.ce umts not coded 85-88 III 6c, go to Q 13
1 D. y.. own ., rent th, s place? Owned Rented Renred for free
2., Y.. told me yo.r I)ving q.orters are (.w”ed r.”ted’rent. d {or fr.e),
Do.. the ~[.ce ~o. (own’,,.+ ‘rent for f,..) hove 10 ..,. s ., mor.~ I Y (b) 2 N (C)
b D.rtng the past 12 months did sales of crops, livestock, a“d
c.thcr farm prod. c?s from this place omount t.a $50 or more? 2 Y (13) 4 N (13)
c D.ring the post 12 months did sales of crops, livestock, and
other farm products from th, s place amount to $250 or more? 3Y SN
3. How many rooms are in thi~ -- [Un, t)? / Tmal moms
Count the kntche. but not the bathroom !
4, How muoy bedrooms are t“ th, s -- (Un,l)? , Number of bed, ooms
If “None” descr, be In footnotes ,
5 What ,s the tclepho”c number b, Area code , Number 16, Was th, s ,nterwew obsewed~
here? ! 1
2 None ~ 1
lY 2N
7. Interviewer’s name ~ Code
, NOTE: Before Ieovtng household, check thot ,tem 20 has on .“try, Determine the best timo for collback~ for Condition Supplements,
FOOTNOTES
8. Non!ncerv!ew reason
TYPE A
1 Refusaf - Descrtbe in a foomole
2 No one at home - repeated calls 3i Temporarl Iy absent
4. Orher - Spec!fy ~
TYPE B
I Vacant - nonseasonal 2’ Vacant - seasonal 3 Usual residence elsewhere
4: Armed Forces 5; Other - Spec, fy ~
TYPE C
1: Unused Ilne of I,stlng sheet
2! Oemohshed 31 Merged 4’ Ourslde segment 5 BudI after April 1, 1970 6, Other - Specify ~
9. Record of calfs
m
II ;;:, ;:.,:,
*
O. List column numbers of family member;
requ, ring telephone or persorial cal I backs for Condnuon Supplements
NONE
1. Record of additional personal cd Is
Date Beg, nn, nz End, ng CO(. Nos.
t,me LInle mmle!ed
,,, ”. a.m.
p,rn p.m.
a.m. a ,“
P., n. P m.
a.m. a,,”,
p.m. m
a,,” a.m.
p.m. P ..7
20. Number of [b, Tom telephone
telephone calls I ,nrerv[ew time
1
.-la. What is the nameof the hemd of this household? - Enter name In first column.
b, What arc the names of all other persons who live here? - List all persons who live here. Yes* No
c. I have listed (Read names. ) IS there anyone else staying here now, such as friends, relatives, or roomers? r ~, d. Have I missed anyone who USUALLY lives here but is now oway from home? . . . . r:, ~
●. Do any of the people in this household haven home anywhere else? . . . . . . . . . . . . r: [: 1
If any adult mates Ilstcd, ask: ‘Apply household membership rules.
f. Arc any of the persons in this household now on full-time
active duty with the Armed Forces of the United Stotes?. . . . . Y CoI(s). _(Delete) N
2. How is --related to -- (Head of household)?
3. What is --’s date of birth? (Enter date and Age, and c,rcle Race and Sex)
1 1. Record the number of Doctor V!sIts and Hospatallzattons.
c ~. . . . . . . .
--~2. Record each cond,t!on in the person’s column, w,th the quest,.. number(s) where It was reported.
I Reference dates
! z-week permd
Dentist and Doctor VIS,L probe 1
Hospital probe
, Refer to Flashcard to determ;ne .%mpfe Pem.a”(s); mark SP &x(es) at fop of persms” colunm(s).
I If related persons 17 years old or over are listed In addltton to the respondent, say:
We would like to have 011adults who are at home take port in tbe interview.
H ~ IS y.., -- , your --, ●tc., at bmne now? if “Yes” ask: Please ask them to ioin us.
,
This survey is being conducted to collect information on the Nation’s health. I will ask about visits to doctors o“d dentist~, illness in tbe family, and other h.eelth related items. (HAND CALENDAR) The next few questions refer to the past Z weeks, the 2 weeks outlined in red on that calendar,
beginning Monday, (date) _ ,and ending this past Sunday, (date) .
4a. During those 2 weeks, did -- stoy in bed becau~e ofg“y illness or iniury?
. . . . . . . .
b.During that 2-week period, how many days did -- stoy in bed all or most of the day?
5. During those 2 weeks, how many days did illness or iniury keep -- from work?
(For females): not counting wo,k oro.nd the house?
6. During those 2 week,, how many days did illness or ini.ry keep -- from school?
If NO days ,n Q. 4b, go toQ. 8
7. Dnhow many of these -- days lost from
{ :J.1 }
did -- stay in bed all or most of the day?
80. (NOT COUNTING the day(s) {
i n bed 10S+ from work lost from school }
)
Wrre there any (othw) days during tbe pn-t 2 weeks that -- cut down on the things he usually does because of illness or iniury?
--- --- . . . . . . . . . . . . . . . . . . . . . . . . . ..—
{ inbed
b. (Again, not counting the day(s) lost from work }
) lost from school
During that period, how many (other) days did he cut down for as much os a day?
If one or more days !n Q’s. 4-8, ask 9; otherwtse go to next person.
‘Uwb’’’c”ntionca”ad’’d--t” --....--- { i!i’iiz } ‘“ringthep’’st’we”ks’
b. Did any other condition cause him to
{ !!%:’} ‘Uringth”’peri”:’
--. . . --- . --- .--.-—- --- --- .----—
c. What condition?
On. During the past 2 weeks did anyone in the family, that is you,
your --, etc., have .my (ether) accidents or i“iuries? Y N (11)
--- --- . --.-—---- --- ..-. -. —- . - —- —---
-b. Who wos this? - Mark “Accldcnt or Injury” box In pcrscm’s column.
---- . . . .
c. What was the iniury?
--- . --- --- .
d. Did anyone have any other accidents or iniuries during that ptriod? Y (Reosk 10b and c) N
--- --- --- --- --- --- --- . . .
----For each person with “Acc:dcnt or In jury,” ask:
-.
e. As o result of the accident, did -- see a doctor or did he cut down on the things he usually does?
10
Firstname
a ‘GE
...__ ______ .--:-
RACELast name
lW 2N 3 01
SEX
R=lauonsh,b IM
HEAD 2F
~omh Day Y’●ar
011 None i<!
— Oa?s
la. During the past 2 weeks, did ony.me in the fmnily,
14 “
, .,.,.
,.., ,,, . &Jj#j
that is you, your --, etc., go to a dentist?
‘,*; ,.’; , ,,.%, .
Y N (12) ;4 ‘“ $ ;;$,;
_______________________________________________________________________________ &“..’2&~L__
b. Who wns this? - Mark “Dental visit “ box in person’s column.
_____________________________________________________________ __________________
c. During the past 2 weeks, did anyone else in the family go to a dentist? Y (i7eask I lb and c) N _______________________________________________________________________________
If “Dental visit, ” ask:
d. During the past 2 weeks, how many times did -- go to a dentist? _NO. ofdental visits (N,
.,1
Do not ask for children I yr. old and under.
2a. During the post 12 months (that is, since (date) a year ago), about how many visits did -- make to a dentist?
II
00❑ None(Include the -- visits you already told me about.) 12a. _Numbm of *
--- -- _________________
b. ABOUT how long has it bee” since --LAST went to a dentist? b. I❑ 2.we.sk dental VISit
_________________
visits
3❑ 2weeks-d months 4D Over 6-12 rnon ItIs 5❑ I ye=
6❑2-4 years 7❑5+ years 8❑ Never
‘OOTNOTES
3. During the past 2 weeks (the 2 weeks outlined in red on that calendar) how many 13, 00❑ None
times did -- see o medical doctor?
}
_Number of“,:;,,s “
(Besides those visits)
&. During that 2.week period did anyone in the family go to a doctor’s office or T
clinic for shots. X-rcws. tests. orexaminations? N (l 5) w%
--- :_--r----~- :--—-: _____ _ -: ____________________
b. Who was this? - Mark “Doctor vmit” box in person’s column.
1 14b
--- ---
--c. Anyone else? Y (Reask /4b ahc)
N
--- ::---
--If “Doctor Vlslt. ”SSk
d. How many times” did -“- visit tho doctor during that period? d. _ Number of visits (NP
k. Dining thot period, did anyone in the fo”i Iy get any mwfical advice from Y
a doctor over the telephme? N (16)
---
---b. Wlm was the phone call about? - Mark “Phone call” box in person’s column. 15b. n Pjl.”e call
---
---c. Any calls about anyone else? Y (Reask f5b and c)
N
---
---If “Phone call,” ask:
d. How many telephone coll~ were made to get medical advice about -- ? ‘d. _ Number of cal Is (NP)
m .,-. $k .,, =
) Fill item C, (DOCTOR), from Q.’s 13-15 for all persons. q!%%%%&c, ~d)
Ask Q. 16a for each person with visits inDOCTOR box.
6a. For what condition did -- see or talk to a doctor duriq the pqst 2 weeks?
❑ Pregnancy (16.)
‘6”” ❑ No condlcmn
--- - --- ____________ .. --__,
b. Did -- see or talk to a dwtor about any specific condition? b. Y N (NP)
--- . --- ---
~---C.What condition? c. Enter condlt!on In item C
--- --- ---ond c.sk I bd .
d. During that period, did -- see or talk to a doctor❑bout any other condition? d. Y (16.) N (NP)
__________________________________________________________ ___
_-e. During the past 2 weeks was --______________________________________sick because of her pregnmncy? ___e. Y N (16d)
-f. What was the matter? f. Enter conditkm in Hem C ()
% ~.~,.i.w ,,,:. .,, .,, ,, ., .,./, ,..+
..-, ,, .+8
~zz%
7.s. During the past 12 months, (thnt is since [date) a year ago), about how nmn times did -- see or 17.. 000 \:} Only when ,“ hosp, w.1 talk to a medical doctor? (Do not count doctors seen while a patient in a hospitol. r
(Include the -- visits you slreody *old me about.)
000 ::’ None _ NurnFJw of .,s,, %
---b. ABOUT how long has it been since -- LAST saw or talked to a medical doctor?
. . --- _ - —-—______
b. 1 T I 2.wc.k D“
-- —---
---2 ‘- Pas., 2 weeks q ,y,rced
,-., 1,
3 :::1 wks. -b mos..
4 ;“1 Over 6-12 mos.
5 ..- [ war
6 — 24 years
7:, 5. je.rs
— 8 :1 N,..,
—— .——
18a. What was -- doing most of the past 12 months - (For males): working or doing something ●lse?
If “something else, ” ask.
18.
(For females) keeping house, working, or doing I n Working (7?<.’
.S
Ages b. What was -- doing? something el se? 19. 2❑ Keewng house [:jb)
17+ If 45+ years a“d was “m ,Sworkl”g,,, ‘Skeepnng house,,, or ‘Sgcx”g to schoo l.,, ask 3❑ Ret, red. health 22)
c. IS -- retired?
d. If “reure d,” ask: Did he retire becouse of his health?
4 a R=r, red. Other 2.,
--- --- s❑ G.a, nz m school :51
Ages 19a. What was -- doing most of the past 12 months - going to school or doing something else?
If ‘“something else,” ask:
6 n 17+ smneth, ng else (22)
6-16
b. What WOS -- doing?
7 a 6-16 scmwh,ng else (;J
--- --- . --- ___________________
Ages on l—5years ,121
under 6 o= Underl (711
On. Is -- able to toke port at all In ordtnory Play with other children?
--- !’5 - ___Y_---’-!
-Yi-b. Is helimited in [he ktnd of play he can do because of his heolth? b. 2 Y !.71
--- ---- --- N
c. Is helimited in the amount of Ploy becuuse of his health? c. 2 Y (:71 N (:6)
la. Is limited in any woy bece.se of his health?
--II-_ ---. ---___ --L--- ??: - -:-L.---:-!-V!!
b. [“ what way is hc limit-d? Record Itmltat! on, not cond!tton. b. (>7)
20. Does -- health now keep him from working? 22.. , Y (:71 N
--- ----
---b. Is he limited in the kind of work he could dobecause of his health? b.
--- ____ ---2 Y (271 N
-c. Is he limited in the amount of work he could dobecause of his health?
--- ----c. ---2 Y (:7) N
d. Is helimited in thekind or amount ofother actlvttles because of his health? d. 3Y (27J N (;6)
3a. Doe. -- NOW have a job? 23..
---*--- --- ---Y (23 :J N
b. In terms of health, is -- NOW able to (work - keep house) at all? b.
--- --- ---Y I N (271
c. Is he limited inthe kind of (work - housework) he cando because of his heolth?
--- -=: - ---2 Y r:~l N
d. Is helimited in the amount of (work - housework] he can dobecause of his health? d. 2 Y (:7)
--- --- --- N
●. Is he limited in the kind or amount ofother acttwues because of his health? . . 3 Y i:-) N (:,)
d. In terms of health would -- be able to go to school? 24. Y t N ,,:-)
Se. Does (would) -- have to go to a certain type of school because of his health? 25.. 2 Y (:’J
--- ___ ___________________ N
b. Is he (would--- he be) limited inschool attendance____________________________because of his health? ________________ _-b. -:-: -(;; --- __
y----C. Is helimited in the kind or amount of other acttwtles because of his heolth? c. 3 Y ,:71 N (:6)
60. Is -- Iimitcd in ANY WAY because of a disability or health?
---_ ---:---.----____________________---! ?:. -2-T---2_!2!!i
b. [n what way is he limited? Record Ilmltat!on, not condluon. b.
{
been limited i.
--7.. About how long has he been unable to
--}
0 00❑ Less than t month 2 70.
had to go to a certain type of school?
--- --- ---~— Mos. 2_ Yrs,
b. What (other) condition causes this limitation? b. E.fer c:-i ,!>. ,. ,fc..Y C
If “’old age” only, ask: Is this limitation caused by any specific condition?
*“3 .,b c
❑ O!d age only (NP)
--- ---
---c. Is this limitation caused by any other condition?
Y Ge,s.k N
--- .---. --_____ - . - —--- ___. . ---Lmdcl
Mark box or ask:
m Only I c.nd$t,o”
d. Which of these conditions would you say is the MAIN cause of his limitation? d. Enter Tam condmcm
61
280.Was --0 patient in o hospital O+ any time since (date) ❑year ago?
II
N (l*em C) 28.. ---~_---.
---
--b. How many times was -- in a h.spitnl since (date) a year ago? b. _ Times (Item C)
I !
29a. Was o“y.ane in the fmmily in a nursing home, c.mvalescent home, or
similar place since (date) a yeor ago? Y N (30)
1
--- --- --- . --- ””.”--- .
b. Who was this? - Circle “Y” (n person’s column.
--- j:q--- ---y .
For each “Y” ctrcled, ask:
c. During that period, how many times was -- in o nurs,. g home or similar place? =. — Times (Item C)
Ask for each chdd I year old or under ,f date of b,rth IS on or after reference date.
300. Was -- born i“ . hospital? 30.a.
If “Yes,” andno hosp!tahzat, ons entered !n hls and’or mother’s column, enter “1” ,“ 28b and ,[em C. Y N (NP)
If ‘Yes, ” anda hospital I zatlon IS entered for the morher and for baby, ask 30b foreach.
______________________________________________________________________________
b. Is this hospitalization included in the number you gave me for -- ?
---b.
If “No,” correct entr, es In Q. 28 and ,tem C for mother and ‘or baby. Y N
A. Goiter or other
310. DURING THE PAST 12 MONTHS, did anyone in the family thyroid trouble?
(You, your --, et..) hove
-I Glandular
B. Diabetes? disorder
If “Yes, ” ask b and c
b. Who was this? Enter name of cond, tlon and letter of Ilne where reported In appropr[ ate person’s column !n !tem C.
c. During the post 12 months, did any One else have . . . ?
=
F. Multiple sclerosis?
I I
G. Migraine?
o
32. Compared to other pcrs.ms --’s age, would you soy that his health IS excellent, good, fair, or poor? 32. IE2G3F4P
R
For persons 17 years old or over, show who responded for (or was p;esent dur,ng the asking of) Q.’s 4-32. 1❑ Responded for self-entirely If persons responded for self, show whether ent,rely or partly. For persons under 17 show who responded 2❑ Responded for self-partly Q.,, 4-32 for them.Pe,s.an _ was re.$po”denc
FOOTNOTES
r
Y N (Iwn C) 28.. Y N (I f-m C) Y N fl?wn Cl 28.. Y N <1?..- Cl Y N ‘. .1
--- . ---- --- --- --- --- ---
—---_ T,mcs (Ifcm Cl b. — T#mes (Item C) Ttmes {h-m Cl b. . Tomes ([.<” C) — T,mes , IV.. - ,:1
I I
--- --- --- - --- --- ---
---Y 29b. Y Y 29b. ‘( Y
--- ---- --- - . --, --- - --- --- --- .
— T,mes (Ikm C) c. _ Tlmcs (If..m C) — Ttmes (Iwn Cl c. _ Tames (Jr.. - <~ _ Ttmes ,1,,. - ,:1
30.. 30..
Y N (NP) Y N (NP) Y N (NPJ Y N (API Y N P.;)
--- . ---- --- --- - --- --- --- .
b- b.
Y N Y N Y N Y’ N Y N
H. Neuralgia or neuritis
Ha. DURING THE PAST 12 MONTHS, did anyone in the family hove - Condltlon affecting the
1. Sci.stica?
nervous system
If “Yes, ” ask b and c J. Nephritis?
b. Who was this? Enter In Item C K. Kidney stones?
L. Any other kidney trouble?
c. Owing the past 12 months, did anyone else have . . . ?
~ 1
Genlto-urlnarY
M. Bladder trouble? cond, uon
N. Prostate trouble?
O. Disease of the uterus or ovary?
p. Any other female trouble?
@ o @ @ @
E 2G3F ,4P 32. 1E2G3F 4P !E2G3F 4P 32. IE2G3F 4P 1E2G 3Fa P
❑ ResPondcd for self-e.tnr.ly I m Responded for sc!f-e.t,rely I❑ Responded for self-enttrely I❑ Responded for self-en! !re!y , ~ Responded far 5.1I-ent!ml >
!❑ Responded for self-partly 2 ~1 Responded for self-pakly z❑ Responded for self-parlly 2 Q Responded for self-partly 2 D ResPonded for self -p.ml Y
Person _ was respcmde”t Person _was respondent Person _ was <espond.e”c Person _ was respmdenc Per,.. _ *AS respond,.
.
63
CONDITION 1
1. Person number Name oi condition
1
2. When did -- last see or tolk to a doctor about his . . .?
1-, In lnxervlew I Past 2 wks. (Item C] s I “J 2-4 yrs.
week 2 2wks. -6 mos.
(Reask 21
6; ;5’ yrs.
3 Over 6-12 mos. 7 INever
4 I yr. e, : DK ,f Dr. seen
9 [ OK when Dr. seen
Al
Examine “Name of cond!tlon” entry and mark
Accidem or ,n,ury (A2) I On Card C (A2) I ‘: Netther (3a)
If“Doctor not talked to,,, record adequate description of condltl on.
If “Doctor talked to, ” ask:
3..
b.
c.
d.
Whet did the doctor soy it WCS? - Did he give it a medical name?
Donot ask for Cancer What was the cause of . . .?
Accident or ,njury (A2)
[f the entry !n 3a or 3b includes the words:
Allmont Condi ti.x Disorder
Anemia cyst Growth
Asthma Def.cl Moo,lcs
Al?. .k Dl, o.,. RIM...
What kind of , . . is it?
.
For allergy or stroke, ask:
How does the allergy (stroke) of foct him?
-. .-.
Trouble Turner ulcer
} Ask c:
For a“ Impairment or any of the follow!ng entries:
--- _.-. --. -.__—_
Absce. s Dmnogo
Acho (cxccpt headache) Growth
Bleeding Hemorrhage
Blood dot In fcdi. ”
Boll In f!mmmo,i.ml
cm.., No.rolgio
cramps (mcept Ne.,ltls
men.tr..l) Pal.
cyst P.l,y
e. What parf of the body is affected?
P.raly*i S R.pt. ,.
s.,.
so,.”...
Tumor UI <0, V.rlco,. “,;. s Wa.ak W.okn e,.
Show the followlng detail:
Head ., . . . ..skull, scalp, faco
%ck,spl.o’vertebra . . . . . upper, middle, Iowor E.arc.royc . . . ..oneor bo?hneorbo?h
Arm . . . . . . . ..onoor hth; shoulder, up or, .Ibow, low.,, wrist, ho. i Lo ~ . . . . . . . . . . . . . . one or both; hip, upper, knee,
lower, mtklo, foot
The remaining questions wi II be asked as appropriate for the condition entered In:
A2 ~] Item I ~ Q. 3b n Q. 3d
In Q. 3a m Q. 3.
4. During the post 2 weeks, did his . . . ccuse him
to cut down on the things he usually does? lY 2 N (9)
5. During thot period, how many days did he cut
down for as much as a day? _ Days
0011 None (9)
6. ~~i.g that 2-week period, how ninny days did
keep him in bed all or most of the d~y? _ Days
. . .
. . m None
~
during that 2-wook period? (For females): not counting work around the house?
school during that 2-week period?
9. When did -- first notice his . . .?
I ~ I Last week 4❑ 2 weeks-3 months
z CJ Week before 5 n Over 3-12 months
3 rJ Past 2 weeks–DK which 6 u More than 12 months ago
(Was it during the past 12 months or before that time?) (Was it during the past 3 months or before that time?) (W.. it during the past 2 weeks or before thot time?)
I ~1 Not an eye cond. (.44) 8 u First eye cond. (6+ yrs. ) (/O
A3 20 First eye condition 4❑ Not first eye cond. (A4)
(under 6) (A4)
i
10, Can -- sco well enough to read c.rdima;~~wspaper print WITH GLASSES with his
I 1 ‘Ye’..’y ‘N
A4
‘OOT
~ right J . . . .lY 2N
a. First noticed during the past 2 weeks?
(Qu-tlOn 9) . . . . Y N (AA) D.Doctor seen or talked to during the past 2 weeks?
(Question 2) . . . . Y (Fill N
buff form)
c. One or more cut-down days?
(Question ) . . . . Y (Fill N (AA)
blue form)
3TES
Continue for conditions Ilsted or reported ,n probe quest, on 31, 4A otherwise, go to A5. For missing extremities or organs, go to A5.
A5 Accldenc or tnjury Other iNCt
m Doctor seen (12) !: I Doctor not seen (1 I J
1. During the past 12 months what did -- do or take for his . . .? (Wrtte In) 200. Did the accident hoppcn during the post 2 years or before that time?
Anything else? (18)
During the past 2 years (20b) Before 2 years 12[01
2. After -- first noticed something was wrong, about how long w05 it before he talked to a doctor about it?
b. Whc~ ~id the accident happen?
(Probe: Was it a matter of days, weeks, or months?) Last week over 3-( 2months
Weeks
000 ~1 Discovered by doctor (l%) 3_ Week before I -1 (ears
loo m Less than one day 4_ Months
210. At the time of the accident whet part of the body was hurt?
z_Days s_Years Wh.ai kind of infury was it? Anything else?
13. BEFORE -- talked to a do.ior about his . . ., did be do or take anything for it?
IY 2N
[4. Does -- NOW take any medicine or treatment for his . . .?
IY 2 N (15)
--- --- . . . . .—
b. Was any of this medicine or tre.atmcnt recommended by o doctor?
-.
‘-- ‘- =’”
IY ZN If acc,denr happened more than 3,omhs W% ash.
15. Has he●ver had surgery for this condition? b. What part of the body is affected now?
lY 2N How is his -- affcctcd? Is hc affcctcd i“ any other way?
16. Was he●ver hospitalized for this condition?
.—
Pan(, ) or body ~KXC”X .Fi..,.
lY 2N
17. During the post 12 months, about how many times has -- seen or talked to n doctor about bis . . .?
(Do not count visits while o patient in o hospital.)
_Times 000 ~ I None
18. About how many days during the past 12 months has this condition kept him in bed all or most of the day?
22. Where did the accident happen?
I .1At home (inside house)
—Days 000 m None 21”! At home (adjacent premises)
19a. How often does his . . . bother him - all of the time, often, c.ncc in a
3 ~ I Street and hlghwwf (tncludes roadway ond publ~c S,dewalhl
while, or never? 4 I:] Farm
I u All the time z❑ Often 3 u Once in a while s I ; Industrial place (Includes premtses)
G ;: I School (Includes prem]ses)
o ~ Never (19c) s a Other - Specify 7 c I Place of recreation and sports, except at school
--- . . . . --- ..-
——---b. When it does bother him, is he bothered a great deal, some, or very little?
a ICI Other - SXCIfY ~
I L1 Great deal 2 r~ Some 3 ~] Very little
~ ~ Other - Specify
--- --- .. - . --- —--- .- _— —--- - 23. Was -- nt work at his job or business when the accident bappcncd?
u All the t,me in 19a (AS) IY Wh]lc xnArmed Ser, rccs
c. Does -- still have this condition?
3
2N
I Y (A51 N
a Und*r 17 m trm+- of Jcc, km
--- 2&. Was a car, truck, bus, or other motor vehicle
d. Is this condition completely c.md or is it under control? involved in the accident in any way? ,Y N (I, L
2 u Cured j ~1 Under control (AS] . . . ..--. —
4 ~ Other - SPeci(y (A5)
-.. —— —--- b. Was more than one vehicle involved? Y
c. About how long did -- have this condition before it was cured?
N
00 Less than one month —Mend-is , —Years c. Was it (either one) moving at ibe time> ,Y N
65
2-WEEKS DOCTOR VISITS PAGE 1. Person number Person number
Earlierp youtoldmeth.at -- hod seen ortolked too
doctor during the past 2 weeks. OR
{
7777 ~] Last week
OR {
7777 ~ Last week
8888 [j] Week before 8888 u Week before
2..0. what (other) dates during that 2-week period dld -- 2..
visit or tnlk to a doctor? ___ _~~~t~___D_a~e ____________________
——
. . .. ---- . . . . tjg”&_ -_-DA~e_
-b. Were there any other doctor visits for him during b. y (Re.sk 2. .nd b] Y (Reosk 20md b)
that period? N (AsP 3-0 forwch v,sf) N (Ask 3-6 for e.a<h .,s,1)
3. Where did hesee the doctor on the (date,,h O+ o 3, 0 [ i Wh,le ,npat, ent ,. h.sp, tal (N.. ? cvl clinic, hosp, tal, doctor’s office, or some ot et place?
o L) ‘wh,le ,npar lent m ho$p$tal iN~xt DW
~ -; Doctc.r. s of fnce (zro. p pra.t, ce or I ~ Doctor-s of ft.e (group pract, ce or
~ -; Doctc.r. s of fnce (zro. p pra.t, ce or I ~ Doctor-s of ft.e (group pract, ce or