CONDITION LISTS 5 AND 6 0 respondent(s) and ask list spec;fied in A2

am going to read e ~st of medical conditions. Tell me if enyone in the femily has had any of these conditions, even if we mentioned them before.

ia. Has snyone in the femily {read names} EVER hed — If “Yes,” ask 5b and c.

b. Who WaS this?

c. Hes anyona else EVER had —

Conditions affecting the heart and circulatory system.

II

G. A stroke or a L Rhaumetic---—--—— fevar?-——— — cerebrovascular

accident?

. Rheumstic heart disease? (ser’a-bro vas ku-lar)

---

I---I---J--:. Hardening of the arteries or arteriosclerosis?

-——— —— —-— ————I

I. Congenital heart disease?

—-—————————-I

H. A hemorrhage of the brain?

---- --—-—— ———.

L Angina pactoris?

(pek’to-ris)

-——— —————— —— 1

—-d.DUfflNGTHE PAST12MONTHS, didanyoneinthe family have —

If“Yea,” ask 5e and f.

0. Who WaS this?

f. DURING THE PAST 12 MONTHS, didanyoneelsehave –

Conditions affecting the heart and circulatory system.

1

Damaged heart valves?

—————— ————— — -.

L Tachycardia or rapid haart?

—--- _____ ____

-1.Aheart murmur?

———— ————- _____

. Any other heart trouble?

————— —————- ___

. An aneurysm?

(an yoo-rizm) )(8.27401

Cl. Any blood clots?

———— ————— -——-

—-R. Varicose vains?

———- ———— —— —_- -.

S. Hemorrhoids or piles?

---- ---——— ——-

—-1. Phlebitis or thrombophlebitis?

--- ---————-

—-U. Any other condition affecting blood circulation?

6

;8. DURING THE PAST 12 MONTHS, did anyone in tha fsmily {read names] have –

If “Yes,” ask 6b and c.

b. Who waa this?

c. DURING THE PAST 12 MONTHS, did anyona elsa have — Enter condition and letter in appropriate person ‘a column.

Make no entry in item C2for cold; flu; red, sore, or atrep throat; or “virus” even if reported in this list.

Conditions affecting the respiratory system.

A. Bronchitis?

————— —————— ——

B. Asthma?

.—— ——— ——— ——— ——

C. Hay faver?

————— —————— ——

D. Sinus trouble?

—————— —___— - _—

E. A naaal polyp?

———— ——————— ——

:. A defiacted or deviated nasal septum?

———- —————— — ——

5.●Tonsillitis or enlarge-ment of the tonsils or solenoids?

————— —————— ——

1.●Laryngitis?

———— —--- —--- ——

1

. A tumor or growth of the throat, larynx, or trachea?

—-———— ———- ---1. A tumor or

growth of the bronchial tube or lung?

‘If reported in this list only, ask

Reaak 6a.

L----A missing———-lung?

———-Lung cancer?

.-— — -——— ---- -R. Emphysama?

.—— —— ———-

—-—-i. Pleurisy?

—-—— —————

——-). Tuberculosis?

.—— —— —— -- —— --1. Any other

work-ralated respiratory condition, such as dust on the lungs, silicosis, asbestosis, or pneu-mo-co-ni-o-sis?

.—— — ———— —-—— -L During the past 12

months did anyone (else] in the family haw eny other respiratory, lung, or pulmonary condition? If “Yes,”

ask:Who was this? – What wss the condi-tion?Enter in item C2,

THEN reask Q.

.

—

1. How many timas did –– have (condition) in the past 12months?

If 2 or more times, enter condition in item C2.

If only 7 time, aak:

!.How long did it lest?If 1 month or /onger, enter in item C2.

If Iesa than 1 month, do not record.

If tonsils or adenoids were removed during paat 12 months, enter the condition causing removal in item C2.

n Lsnenll-n[ DA*E

I... .... ..

^--.”.

“. ,,”er, ,J.mk rrm”w ““al-m U-L =,-, a

1.

Refer to Cl, “HOSP.” box. 1. PERSON NUMBER _____

2. You said earlier that –– was a patient in the hospital since~e) - a year ^{Month Date Year} ago. On what date did —— enter the hospital ([the Iaat time/the time before that])?

Record each entry date in a separate Hospital Stay column. 2. 19_

3. How many nighta was –– in the hospital? 3. ₀₀₀₀❑None (Next HS)

Nights

II. For what condition did –– enter the hospital? 4. 1❑Normal deliverf

●For delivery ask ●For ne wborn ask: ●For initial “No condition” ask: s❑Normal at birth

Was this a normal delivery? }

(5J

If “No,” ask:

Wasthe baby normal at birth? Why did –- enter the hospital? 3❑No condition If “No,” ask:

What was tha mattar?

●For tests, ask: ❑Condition ~

What was the matter? What were the results of the tests?

If no results, ask:

Why were the tests performed?

JI

^❑At least . . . night in 2-week

JI Refer to questions 2,3, and 2-week reference period. ^reference period (Enter condition

in C2, THEN 5)

❑No nights in Z-week reference period (5)

5a. Did -- have any kind of surgery or operation during ttria stay in the hospital, 5a.

including bona settings and stitches? 1•l Yes 2❑No (6)

b. What was the name of the surgery or operation? b.

If name of operation not known, describe what waa done. ⁽¹⁾

[21

(3)

c. Waa thera any othar surgary or operation during this stay? c.

❑Yes (Reask 5b and.) ❑No

3. What is the name and address of this hospital? 6. ^Name

Number and street

Cw or Counsy State

‘OOTNOTES

-.

155

CONDITION 1 PERSON NO._

Name of condition

!.

—

Mark “2-wk. raf. pd. ” box without asking if “DV” or “HS<’

in C2 as source.

When did [––/anyone] last see or talk to a doctor or assistant about —— (condition)?

o❑Interview week (Re.wk 2J 5❑2 yrs., less than 5 yrs.

I❑2-wk. ref. pd. 6❑5 Yrs. or more

2❑Over 2 weeks, less than a mos. 7❑Or. seen, DK when ----—————-—————

3❑6 mos., less than 1 w. 8 u DK if Dr. ss.m 4❑1 yr., less than 2 ws. 9❑Dr. never seen } (3b) la. (Earlier you told me about--lcondi(ion)) Did the doctor or assistant

call the/condition)bye more technical orspecific name?

t •! Yes 20N0 9DOK

——— ———--— —- ———-—-- ——— ——-—---— ———.

Ask 3b if “Yes” in 3a, otharwisa transcribe condition rrama from item 1 without asking:

b. What did he or she call it?

(Spacify) I❑ColorBlindness (NC) 2 El Cancer (3e) 3❑Norma! pregnancy,

}

4❑Old age (NC) normal delivery, 15)

vasectomy 8❑Other (3c)

—- ——— ——— —- —-- ——— ——— ——--— ——— ——

—---c. What was the cause of –– (condition in SW? (SPacifY) ~

————————————----——————————

--—-——-Mark box if accident or injury. o❑Accident/injury (5J d.Oid the (condition in 3b) rasult from an accident or injury?

1❑Yes(5) 2DN0

——— ——— —-- ———-— ——— ——— —---

————————-Ask 3e if the condition nama in 3b includes an y of the following words

Ailment Cancer Dis9ase Problmm

Ananda CondiNon Disorder RuPtura

Asthma cyst Growth Trouble

Attack Defect Measles Tumor

Bad Ulcer

a. What kind of (condition in 3b) is

it?

(Specify)

——— ——— ——-———— ——— ——-——-——————— ———.

Ask 3f only if allargy or stroke in 3b–a:

f. How does tha [allergy/stroke] NOW affect ––? LSpacify) ~

For Stroka, fill remainder of this condition paga for tha firat present effect. Enter in itam C2 and complata a separata condition page for each additional present effect.

IRMHIS.1 [1991) (8.27.90)

9.

h.

—

Ask 3g if there is an impairment (refer to Card CP2) or an y of the following entrias in 3b– f:

Abscess Damage Palsy

Ache (excspf head or ear) Growth Paralysis

Bhding [except mc.nstrual) Hemorrhage Rupturm

❑lood clot lnf9cti0n Sora(nesd

Boil Inflammation Stiff [n.ss)

Cancer Neuralgia Tumor

Cramps [9xcapt m*nstrual) Nmwitis Ulcat

cyst Pain Varicose vsim

Weak[nsss)

What part of the body is affected?

(Specify) Show tha following datail:

Head . . . skull, SCa!p, faca Backlspindvatiabraa . . . upper, middla, 10w~r side . . . ..leff orrWht Ear . . . innw o? outar; left, right, or both EGO . . . ..lafi. ri9ht. Orb~h Arm . . . shoulder, upper, .Ibow, lower or wrist; loft, right, or both Hand . . . entlr. hand or fingers only; Mt, right, or both L99. . . . . hip,upper, knee, Iowmr,or mkt.; loft, right, or both Foot . . . entire foot, arch, or to.s only; loft, right, or both

—————-——————- ——-————— -—.——— ———— —-—.

Except for eyes, eara, or internal organs, ask 3h If there ara any of the following entries in 3b– f:

Infactlon S0r9 Soranass

What part of the (part of bodv in 3b–a) isaffected by the Iinfactiord sora/sorenessl — tha skin, muscle, bone, or some other part?

(Spacify)

Ask if there are an y of tha following entries in 3b–f:

Tumor cyst Growth

1. Is this [tumor/cyst/growth] malignant or benign?

1❑Mdigmm 2❑Benign 9nDK

[

a. When was —— (condition in 3b/3f

‘1

I

❑2-wk. ref. pd.

. first noticed? 2 a Over 2 winks to 3 months

. [

———— ———— —-———-—————

I

b. Whan did –– (nama of injury in 3b)?

a❑Over 3 months to 1 year 4❑Over 1 year to 5 years 5❑Over 5 years Ask probes as necessary:

(waS it On or SiItCE (first date of 2-waak ref. period) orwas it befora that data?)

(Was it lasa than 3 months or more than 3 months ago?)

(Was it lass than 1 yaar or more than 1 yaar ago?) (Was it less than 5 years or more than 5 years afJo?)

Refer to RD and C2.

KI 1❑,’Ye s“ in“RD’, box AND more thm 1 mndidon in C2 (.S) 8❑Other (K2)

6a. During the 2 weeks outlined in red on that calendar, did ––

kxrnd&y:~ cause –– to cut down on the things –– usually does

❑NO(K2J

b. During that period, how many days did –– cut down for more than half of the day?

000 None fK21 — Da,,

7. During thosa 2 waaks, how many days did -– stey in bad for more than half of tha day becausa of this condition?

OOm None — Days

Ask if “Wa/Wb” box marked in Cl:

6. During thoss 2 weeks, how many days did –– miss mom than half of tha day from –– job or business because of this condition?

OOm None — Days

Ask if age 5– 17:

9. During thosa 2 waaks, how many days did –– miss mora than half of tha day from school bacausa of this condition?

00DNono — Days

❑Conditionhas ,,CL LTR,, i“ C2 as source (10) K2 I ❑cond,tlondoe.n.thave,,cL LTR,,.cz.,,our.e ,~d,

D. About how many daya ainca(l Z-month date) a yaar ago, has this condition kapt -— in bad mora than half of tha day? (include days whila an overnight patiant in a hospital.)

1❑Yes 2DN0

❑Missing extremity or organ 1K4) K3 ❑Other(,2)

I

20. Does –— stili have this condition?

1❑Yes fK4) ❑No

b. Is this condition complataly curad or is it undar controi?

2❑Cured 8❑Other(Specify} ~ 3❑Under control (K4)

__________________ __:__________~:

c. About how long did —— have this condition bef ora it was curad?

000D Lessthan 1 month OR — {

1❑Months Number 20 Years

d. Was this condition present at any tima during tha past 12 months?

1❑Yes 2nN.a

On Not an accldentllnj.ry (NCJ K4 :~~e::;tiln]uwforttis person (1~)

!M HIS. ! ,1891) {0-27 90)

3. Is this/condition in 3b)the rasuit of tha sama accident you alraady

❑Yes (Record condition page nwnber where _

acc{de.t questions first completed.) _ (NC) Paoe No.

u No

4. Where did the accident happen?

1❑At homeIin.id. house) 2D Athome (adjacent premises]

30 Street and highway Iincl.des roadway and public sidewalk) 40 Farm

50 Industrial place (includes premises) 60 School (includes premises)

70 Place of recreationand sports, except atschool 8D Other(Specify) ~

Mark box if under 18. ❑Under 18 (16) 5a. Was –– undar 18 when tha accidant happanad?

ID Yes (16) ❑No

-——— —————— ——————— —-—— ———— ———- ——-.

b. Was––inthe Armed Forces whrrntheaccidant happened?

2n Yes(76) G No

—-—- ————— ————— ———— —-—— ——-— ———— —-.

c. Was-- atworkat --job or businasswhan thaaccidant happanad7

30 Yes 40No

6a. Wasacar, truck, bus, orothermotorvaMcla involved inthaaccidant in any way?

10 Yes 2DNo(17J

b. Wasmorethan onevehicle involved?

1--——❑Yes -————— —-—————2DN0 ——-- ---- -—-- -——.

c. Was Utieither one] moving atthetime?

10 Yes 20N0

7a. Atthatimaofthe accident whatpartoftha bodywashurt?

What kind of injury was it?

Anything else?

I Parl(slof bed, ● I Kind of lnlurv

8————————————————

Al———————_—— —————-Askifbox3, 4, or5markedin Q.5:

b. Whatpartof thabody isaffectednow?

Howis–– (partofbodv]affected?

Is –– affected in anv other wav?

Part(s) of body . Pr08msffscfs ^●*

“ Enter partofbody insamedetaii as for3g.

●* lfmultiple present effects, enter in C2eachonethat isnotthe sama as 3b or C2 and complete a separate condition page for it.

157

L. umvwentarnmi wminunuuwu rnuc

LI

Refer to age.

LI

^❑Undar 5 lNP)

❑5-17 (2)

❑18 and over (1I I a. Did –– EVER serve on activa duty in the Armed Forces of the United States? la. 1•lYes

2❑No (2)

—- ____ __ —- -———————- -- -- --

--b. When did –– serve?

--{

-- -- -- —.

Vietnam Era (Aug. ’64 to April ’75) . . . VN b. lDVN 5❑PVN Korean War(June ‘50to Jan. ’55) . . . KW 2DKW 800S Mark box in descending order of priority. World War II (Sept. ’40 toJuly ’47) . . . WWII

Thus, if person served in Vietnam and in Korea World Warl(April’1 7to Nov. ’18) . . . .WWI ^{30 Wwll 9UOK}

mark VN. Post Vietnam (May ’75 to present) . . . PVN ^{40 Wwl}

Other Servica (all other periods) . . . OS

--—- -—-— -—-7 ——- -—-— -- ---- ---- --:-- —--- ---—

---c. Was —— EVER an actwe member of a National Guard or mdltary reserve unit?

--—- ——

- c-. ‘ – ---– –

❑Yes 2DNo(2) 7DOK(2)

d. ‘W~~A–Lz ~f ‘–-––a~t~=d-u~y~~rv~c= ;eia~e~ t< N=t=~ai Guard &-m~~~a~y-r&&~e_tr~~~g-?–-–– – - i.

---—- -—- ----

--InYes 3DN0 9DDK

La. What ia the bigheet grade or year of regular school –– has ever attandad? 2a. 00❑Never attended or kindergarten lNP)

Elmm 12345678

High 9 10 11 12

College: 1 2 3 4 5 a +

-— -- -—

--b. ~~ –– fini~h-t~e-(~u~~e~i~~s)~~r~d~/yearl?

--- ---- ——-— -——- ---- .—A ---- ---- ----

---b.

In Yes 2❑No

Hand Card R. Aak first alternative for first person; ask second alternative for other peraona.

[Whatis --race?

3a. What ia the number of the group or groups which reprasants –– rata?

1

^{3a. 1234 5+}

Circ/e all that apply

1 – Aleut, Eskimo, or American Indian 4– White 2 – Asian or Pacific Islander

3 – Black

5 – Another group not listed – Specify

(Specify) -— --

---‘A~k~f fiultip/e antries;

-— -- --- -——— --

---b. Which of those groups; that is,(entries in 3a)would you say BEST represents –– race?

- b. -1--2 3 -

i--5-T---(s/J6.c/fyJ

---- -——- -- —--- ---- ---- —--- -——- ---— —--- ———— — --- ---—- ---- ---— ——

--o. Mark obse~v~d-ra~~o? respondent(s) only. c.

low 2Cla 300

Hand Cerd O. 4a. 1❑Yes

la. Are any of those groups –– national origin or ancastry? (Whera dld –– ancestora come from?) 2❑No (NPJ

---- -— -- --—- ---- ---— —--- ---- ---- --—- —-- ---- ---- -- --- --- -— -- ---— —-——

b. Pleaae give me the number of the group. b.

Circ/e all that apply.

1 – Puerto Rican 5 – Chicano

2 – Cuban 6 – Other Latin American 1234567

3 – Mexican/Mexicano 7 – Other Spanish

4 – Mexican American

. . . ... . . . .. . . .. .. . . .. #.--. —.,—---- II

I

(

FC

FORM Ii,, , ,1S31, [8.27.90,

L. ufavmufwrnw tim.munuuwu f-hum, bofmnueu

on Under 18 (M?

LZ Refer to “Age’’and ‘>Wa/Wb’’boxes in Cl. ¹

❑Wa box marked (68)

‘2

;~ ~~t&;;~r~i5bJ

5a.E#iar you said that –– has a job or business but did not work last week or the week before. 5a.

-- looking for work or on Ieyoff from a job during those 2 weeks? ¹❑Yes /5.) 2❑Nof6b)

-—-— —-—— ———— —-—— .—. — —-. — ———. . . . —.-. —--- --- . . . . . . ..—. ————

b. Earlie; you said thet ––-d;dn’t have a job or business last week or the week before. b.

Was –– looking for work or on layoff from a job during those 2 weeks? 1C!Yes 2❑No (,VP)

---c.Which, io;k;ng for worko; ;n”la~off-f;orn; job?- - “ - - – -- – – - -- - - - - - “ - - - - “ -c. -1-D”Lmkm9 (.&- ~❑Both~bj 2D Layoff (6bJ

6a. Earlisr you said that –– worked last week or the week before. Ask 6b.

b. For whom-did –– work? ~n<e; ;a;;o~ ;ornpa;y~busines>, o;gan~ation~or othe;ernploy.&. - “ 6b. Ernp70~er- - - - – - ❑~Ej j6j, -— —--— .—— — ---- -—. - .-—. .--— ———— ———- -— -- --—— — and

c. For whom id -- work at -- last full-time job or business lasting 2 consecutive weeks or more?

❑AF (6,) c.

Enter name of company, bus!ness, organization, or other amplo yer, or mark “NEW or “AF” box in person’s column.

d. What kind of business or industry is thie?For example, TV and radio manufacturing, d. l“du%v----––-––

retail shoe store, State Labor Department, farm.

If “AF” in 6b/c, mark–’’A~’ box;n perso;a column w;thout asking. ~. OZc&t,&

-a. What kind of work was —— doing? For example, electrical engineer, stock clerk, typist, farmer. ❑AF lNP)

f. What w.&e –– mos< ~mp;ti-a;t;&i$;e; & duties & ;hatjob? Fo;exa-mple, ;ypes, ” - - - - i. D~t’~’

keaps account books, files, sells cars, operates printing press, finishes concrete.

---Comp[et~ %m entries i; 66 — f. if ;o; ;le;r~ ask; - - - - “- - - Clas; of worke; - – –

g.was –– 9.

An .ntploy.. of II PRIVATE company, businessor Self -employed in OWN business, pro fission.! 10P 501

individual for wag.., salary, or commission . . . P practice, or farm? 2D F 6DSE

A FEDERAL govsrnmsnt amployse? . . . F Ask: Is the business incorporated? 30 s 70WP

A STATE govwnmsnt employee? . . . S Yes, ,,, , . . I

A LOCA1.government employe.? . . . L No . . . . . . ..SE 40 L 8DNEV

Wc.rkins WITHOUT PAY in family b.simsa or farm? . . . ..WP - NEVER WORKED or new, worked at a full-time

jc.b Ias1ing2waeksor nmre . . . ..NEV

IOTNOTES

159

B.. ”c.,., ””, m”. ...” ““”.. ”..””,. “ . -“-, ““...”=”

Mark box if under 14. If “Married” refer to household composition and mark accordingly. 7.

?.

0❑Under 14

Is –– now married, widowed, divorced, separated, or has –– never been married? ¹❑Married - spouse in HH 2❑Married – spouse not in HH 3❑Widowed

4❑Divorced 5❑Separated 6❑Never married

la. Was the total combined FAMILY income during the past 12 months - that is, yours,{read names. including Armed Forces members Iivirw at home) more or lessthan $20,000? Include money from jobs, social sacurity,

8a. ₁❑$20,000 or more (Hand Card 1) retirement income, unemployment paymente, public easistence, and so forth. Aleo includa income from ²❑Less than $20,000 (Hand Card Jl interest, dividends, net income from businsss, farm, or rent, and any other money income recaivad.

Read if necessary: Income isimportant in analyzing the health information we collect. For example, this information helps us to learn whether persons in one income group use certain types of medical care services m have certain conditions more or less oftan than those in another group.

---- — --—— —— -——- ---- --—- —.. —

Read parenthetical phrasa if Armed Forces member living at home or if neceaaary. b. OOUA IODK 20DU

oIDB llDL Zlnv

b. Of those income groups, which letter beat repreaanta the total combinad FAMILY income during the past 12 months (that is, yours, (read names, inc/uding Armed Forces members

Oznc 12DM 22nw

living at home))? Include wages, salaries, and other items we just talked about. ^{03DD 13DN 23DX}

040E 1400 24DY

Read if necessary: Income is important in analyzing the health information we collect. For example, 05DF this information helps us to learn whether persons in one income group use certain types of

15CIP 2502

medical care services or have cartain conrfitiona more or less often than those in another group. 06=G 16CICI 26❑22

07DH 17DR

0801 180S

09DJ 19DT

Ra. 1 •l Present for all questions

a.Mark first appropriate box. ²❑Present for some questions

R a

❑Not present

—--- .- —- —-—— --—— -——— ———— ---- --— -——- ———— —— —— ———- - --—- .—— — ———

b.Enter person number of respondent. b.

Person number(3) of respondents)

L3

Enter person number of first parent Iistad or mark box. 13 Person number of parent

00❑None in househofd

L4

Entarperson number of spouse or mark box. 14 Person number of spouse

00❑None in household 00TNOTES

,M“r,., ,,,,,, ,8.,,.,0,

In document Health Statistics (Page 159-166)