DEFINITIONS OF CERTAIN TERMS USED IN THIS REPORT

Terms Relating to Chronic Conditions

Condition. -A morbidity condition, or simply a con

dition, is any entry on the questionnaire which describes a departure from a state of physical or mental well-being, It results from a positive response to one of a series of “illness-recall” questions. In the coding and tabulating process, conditions are selected or classi

fied according to a number of different criteria, such as, whether they were medically attended, whether they resulted in disability; whether they were acute or chronic; or according to the type of disease, injury, impairment, or symptom reported. For the purposes of each published report or set of tables, only those con

ditions recorded on the questionnaire which satisfy certain stated criteria are included.

Except for impairments, conditions sre coded by type according to the International Classification of Dis

eases with certain modifications adopted to make the code more suitable for a household-interview-type sur

vey.

Chronic co?tdition.- A condition is considered to be chronic if (1) it is described by the respondent in terms of one of the chronic diseases on the Check List of Chronic Conditions or in terms of one of the types of im

pairments on the Check List of Impairments or (2) the condition is described by the respondent as having been first noticed more than 3 months before theweek of the interview.

Impairment. -Impairments are chronic or per

manent defects, resulting from disease, injury, or con-genital malformation. They represent decrease or loss of ability to perform various functions, particularly those of the musculoskeletal system and the sense organs. Code numbers for impairments in the Inter-national Classification of Diseases are not used. All impairments are classified by means of a special supplementary code in which they are grouped accord

ing to the type of functional impairment and etiology.

(See Series 10, No. 48.)

Condition groups.-The 25 condition groups shown in this report and the International Classification code numbers used are listed below.

P~sons with chronic conditions.- The estimated number of persons with chronic conditions is based on the number of persons who at the time of the interview were reported to have one chronic condition or more.

Prevalence of conditions.~ In general, prevalence of conditions is the estimated number of conditions of a specified type existing at a specified time or the av

erage number exfsting during a specified interval of time. The prevalence of chronic conditions is defined as the number of chronic cases reported to be present or assumed to be present at the time of the interview;

those assumed to be present at the time of the inter-view are cases described by the respondent in terms of one of the chronic diseases on the Check List of Chronic Conditions and reported to have been present at some time during the 12-month period prior to theinter

view.

Terms Relating to Disability

Chronic activity limitation.- Persons with chronic conditions are classified into four categories according to the extent to which their activities are limited at present as a result of these conditions. Since the usual activities of preschool children, school-age children, housewives, and workers and other persons differ, a activity performed (major activiq refers to ability to work, keep house, or go to school) Preschool children: limited in the amount or

kind of play with other children, e.g., need spe

cial rest periods, cannot play strenuous games, cannot play for long pe

riods at a time.

School-age children: limited to certain types of schools or in school cannot do strenuous work,

3. Persons not limited inmajor activi’ty but other-wise limited (major activity refers to ability to work, keep house, or go to school)

Preschool children: not classified in this cat

egory.

School-age children: not limited in going to school but limited in participation in athletics or other extracurricu

lar activities.

Housewives: not limited in housework but limited in other ac

tivities, such as church, clubs, hobbies, civic projects, or shopping.

Workers and all

other persons: not limited in regular work activities but lim

ited in other activities, such as church, clubs, hobbies, civic projects, sports, or games.

4. Persons not limited in activities include per-sons with chronic conditions whose activities are not limited in any of the ways described above.

Chronic mobility limitation.-Persons withchronic .conditions are classified into four (or six) categories

Demographic, Social, and Economic Terms

Age.-The age recorded for each person is theage at last birthday. Age is recorded in single years and

-- -- - --

/

grouped in a variety of distributions depending upon the

I purpose of the table.

Color.- In this report the population is subdivided I into the two groups “white” and “allother.” “All other”

I includes Negro, American Indian, Chinese, Japanese, and so forth. Mexican persons are included in “white”

unless definitely known to be Indian or of another race.

Income of family OY of unrelated individuals.-Each member of a family is classified according to the total income of the family of which he is a member. Within the household all persons related to each other by blood, marriage, or adoption constitute a family. Unrelated individuals are classified according to their own income.

The income recorded is the total of all income re

ceived by members of the family (or by an unrelated individual) in the 12-month period preceding the week of interview. Income from all sources is included, e.g., wages, salaries, rents from property,pensions, help from relatives, and so forth. else, self-employment in business, farming, or pro

fessional practice, and unpaid work in a family busi

ness or farm. ’Persons who were temporarily absent born their job or business because of a temporary illness, vacation, strike, or bad weather areconsidered as currently employed if they expected to work as soon as the particular event causing their absence no longer existed.

Free-lance workers are considered as having a job if they had a definite arrangement with one or more em

ployees to work for pay according to a weekly or monthly schedule, either full time or part time. Excluded from the currently employed population are such persons who have no definite employment schedule but who work only when their services are needed.

Also excluded from the currently employed population are (1) persons who were not working, even though having a job or business, ‘but were on layoff or looking for work, (2) persons receiving revenue from anenter

prise but not participating in its operation, (3) persons doing housework or charity work for which they re

ceived no pay, and (4) seasonal workers during the un-1 employment season.

The number of currently employed persons estimated by the Health Interview Survey (HIS) will differ from the estimates prepared by the Current Population Survey (CPS), U.S. Bureau of the Census, for several reasons.

In addition to sampling variability they include three primary conceptual differences, namely, (1) HIS esti

mates are for persons 17 years of age or over; CPS estimates are for persons 14 years of age or over;

(2) HIS uses a 2-week-reference period, while CPS uses a l-week-reference period; (3) HIS is a con

tinuing survey with separate samples taken weekly, while CPS is amonthly sample taken for the survey week which includes the 12th of the month.

Currently unemployed.- This includes persons 17 years and over who, during the 2-week period prior to children under 17, retired persons, the physically handi

capped unable to work, and housewives or charity work

ers who receive no pay.

kegfon .-For the purpose of classifying the popula

tion by geographic area, the States aregroupedinto four regions. These regions, which correspond to those used by the U.S. Bureau of the Census, are as follows:

Region States Included

Northeast--- Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, New York, New Jersey, Pennsylvania North Central--- Michigan, Ohio, Indiana, Illinois,

Wisconsin, Minnesota, Iowa, Missouri, North Dakota,

South Dakota, Nebraska, Kansas south- - -- Delaware, Maryland, District of Columbia, Virginia, West Virginia,

North Carolina, South Carolina, Georgia, Florida, Kentucky,

Tennessee, Alabama, Mississippi, Arkansas, Louisiana, Oklahoma, Texas

Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, Nevada, Washington, Alaska, Oregon, California, Hawaii

APPENDIX III. QUESTIONNAIRE

The items below showthe exact content and wording of the basic questionnaire used in the nationwide household survey of the U.S. National Health Survey. The actual questionnaire is designed for a household as a udt hnd indllhdes additional spaces for reportson more thnnone.person, condition, accident, or hospitalization. Such spaoes areomitted in (his illustration.

NOTICE . All infamofion which wouldpermit identification of the individual will beheld in strict cwfidcncc,will be used only by persons engaged inond for the purposes of tbc survey, and will not be disclosed or released to others for my purposes.

I-OAR&-+; WHENWASTHIS STRUCTUREORIGINALLYBUILT? I

iSomp'* No.

I-Jb. Not / q Befm 4-l .60-Conri”“r i”lmuiCt” l&SAMPLE CirclcDnc B-39 539 B-40 B-II 842 B-43 I

,I;; J I 0 After 4-1.60 -co 10Q. IOr. olL i~r~puir.d. and md intcwirv 4

CclPtETE ,*m,s 10.16 “T T,E END OF TM ,NTERY,m “““-~~I1..,,,1~~---I. : a.Ud.k: ARE THERE ANY OCCUPIEDOR VACANTLIVING

lDoNm/ - QUARTERSBESIDESYOUROWNIN THIS BUILDING, 5a. SEGMENTNUMBER

rtirri”.nd.wk~ i

b. SEG.TYPE +le+A B P LSDP 0 No 6. “‘“‘“x~.“E~ nlrd r---l j c.O”.k: IS THEREANY OTHERBUILDINGON THIS PROPERTYFOI

PEOPLETO LIVE IN. EITHEROCCUPIEDOR VACANT 7. SPECIALDWELLINGPLACE-T= andCode“DI~WDIcode 0 Yes-i-i,, T’oblr I 0 No

c. OURlNGTHE PAST12 MONTHSDID SALESOF CROPS,

I cl Yes (2) HOWMANYROOMSARE IN THIS- - /L’hlTP Pritc in .“d m.rk

COUNTTHEKiTCHENBUTNOTTHEBATHROOM.

To’ol I R0ms f

. HOWMANYBEDROOMSARE IN THIS- - rLafI,l

rritc m mdmnrk No. of Bedrams 1, ‘hcd dcsrrib. in ,“or”otc~

El . WHATISTHETELEPHONENUMBERHERE? nritc in and nnrk

I ::E”,’ - v ”

I I

INTERVIEWERCHECKITEM: Cbrrk pcrtionr 22a-22d8 .uc on pqcr I a 5. 0 Yea-FdI ,,omnrc.,e Supplcmcnr Is 0 ,,omc cm Suppfcnmt r.q”im.P- ,, No . L<ow Thk You ‘crrrr am drpn

‘. RECORDOF CALLS AT HOUSEHOLD ITEMSn-23 ARE TO BE FILLED AFTER THE WTER”,.w

ATEAND Date 18.NUMBEROF CALLS AT HOUSEHOLD“!;\fyT .,

IYE OF 19. DATE OF COMPLETION la” 0 *p, 0 ,“I” 0 ox 0

b.NAhlE OF OBSERVER f,zob m&d ‘)a* 120b.WASTHIS INTERVIEWOBSERVED? I.5 ho

0 0

o. INTERVIEWER NAME Irizr-in ;Zlb.lNTERVIEWERNUMBER

CQTNOTES 22. IDENTIFICATIONCODENO.

Ilark /ronI tab 0, s<p..t j&k

Tml Numbr of Hospitolmttans thtrtl.H.

~~~~-~-~----_---~---~---~--~~--~~-~-~~--~~

Total Nu&er of Dccta Visits thts H.H.

._____---__-__--.____________________-~~---~~~-~

Tom, Numberof Persons this H.H.

---~-.---~--~---Totol Persons Requrmg Horn Core

!his Household

-D

0 0

Fcrst Now 01 la. WHATISTHE NAMEOFTHE HEADOFTHlSHOUSEHOLD?

b. WHATARETHENAMESOFALLOTHERPERSONSWHOLIVEHERE?L~.~.~ Yes N O

E. IHAVELISTED rrodaomrr. ISTHEREANYONE ELSE STAYINGHERE N O W ? Cl cl -ioS,-No~~~~~~~~---~--- ~-~

d. HAVEIMlSSEDANYONEWHOUllLlVES HERE BUTISNOWAWAY FROMHOME'

e. OOANYOFTHEPEOPLEIN THISHOUSEHOLD Relotmnsh,p 1 AT

HAVEAHOMEANYWHEREELSE'

1. AREANYOFrHEPERSONSINTHlSHOUSEHOLDON Yes No HEAD

FULL-TIMEACTIVEDUTYINTHEARMED FORCES? rr "rd. drlrrr 0 0

!. H O W IS - - RELATED TO (head of household)! H

I. PERSON N U M B E R firrr column rlould hare prrwn ~~.rcrondrolnmn prrron o?. etc.

2 2

Lost Name

When Nq" Clh c. RACE llork ,r,rbour mb,nK

0 0 0

/I I7 ?rara old aI (II cr. .rL. Uar. Wd. Dir. 59 NN. "rd.,

i. IS --NOWMARRIED. WIDOWED.DIVORCED. SEPARATED.OR NEVER MARRIED? '3 fi 0 '2 I' 3 I, 17 ,cor< ",.I "I ‘II ar. *xl.

i. WHATWAS--DOlNGMOSTOFTHE PASTlZMONTHS - WI K" 5E "ohI7 "

I(orm&,l WORKINGO R DOING SOMETHINGELSE' II J II 0

fkI~m*,4 KEEPING HOUSE.WORKINGO R DOING SOMETHING ELSE?

,, 'SE' mdrd I" rJ (r and prrwn I% ,: \rwII old Or "/,I. ">I? vcr N. Y

7. IS-- RETIRED? 0 45 0

I, rcf~rrd prrronr I') >,IIrs old /(?O,cr urr ,<\Wd /a "‘,d,riw, IL. ,kr resp ."I, WEWOULDLIKETOHAVEALLADULTSWHOAREATHOMETAKEPARTINTHE I INTERVIEW. ISYOUR--.ETC..ATHOMENOW? (WOULDYOU

PLEASEASK--"OdOIP Alha ,j G

N,,h ,a

c, ETC,TOJOIN US?)

rHlSSURVEYCOVERSALLKlNDSOFILLNESSES. THESEFIRSTQUESTIONSREFERTO 0 Yes LASTWEEK ANDTHEWEEKBEFORE.THATlS.THEZ.WEEK PERlDDOUTLlNEOlN RED O N THIS CALENDAR. Hand ccdmdar IO r..pandcnr and ruk (10.

l&WAS--SlCKATANYTlME LAST W E E K O R T H E W E E K BEFOREfTHEZWEEKS S H O W NONTHAT CALENDAR)?

b.WHATWASTHEMATTER?'

c.DID--HAVEANYTHlNGiLSE DURING THAT&WEEK PERIOD?

la.LASTWEEKORTHEWEEK BEFORE.DIO--TAKEANYMEDlClNEORTReATMENT 0 Yes FOR ANY CONDlTlON(BESIDES...WHICHYOU TOLDMEABOUT)?

b. FOR WHATCONDITION!

c. DID--TAKEANYMEDlClNEFORANYOTHERCONDITION?

la. LASTWEEKORTHEWEEKBEFORE.DID--HAVEANYACClDEMSORINJURIES? 0 Yes b. WHATWERETHEY!

c. DID--HAVE ANYOTHERACCIDENTS O R INJURIES DURINGTHATZ-WEEK PERIOD?

~~__.___~~.~~~_._~~...~_.~___..__

la. DID--~HAVEANfANYOTHER)ACClDENTORlNJURYTHATSTlLLBOTHERS q Yes 0 No

HIMOR AFFECTS HIM IN ANYWAY?

b. IN W H A T W A Y O O E S IT BOTHER HIM' Rcrardprrrm, r,,or..

2. Open your Flashcord booklet to Cord A and read both sides of Card A (A-I, A-2) q Yes 0 No condition by eondirion; record in his column my cotidirims mentioned

for rhe person.

3. Turn to Cord B and read both sides of Cord B (E-1, E-2). condition by condition; 0 ‘fes 0 No record in his column any conditions mentioned for the person.

la. DOES--HAVEANYOTHERAILMENTS, CONDITIONS. O R PROBLEMS WITH q y- 0 No

HIS HEALTH?

b. W H A T IS THE CONDITION? Record rondmon irre/(~( rci,, prrsmr: otkcmtsr rrrord ,““.‘“’ +m.

c. ANYOTHERPROBLEMSWITHHISHEALTH?

I

15% HAS-- BEEN IN AHOSPITALATANY TIMESINCE AYEARAGO? 0 Yes O N I, ',".\", di:

b. HOWMANYTIMESWAS--IN A HOSPITAL DURING THATPERIOD? Tires

162. HASANYONEINTHE FAMILY BEEN IN ANURSlNGHOME.CONVALESCENTHOME. 0 Yes O N

REST H O M E ORSIMILAR PLACESINCE AYEARAGO!

/I Vcr." ark:

b. W H O ?

Far rarh person rcponcd in 16b ask:

c. H O W M A N Y TIMES WAS--IN A NURSINGH O M E O R SIMILAR PLACE DURING THAT PERIOD?

Exuminr qrs in gucslion I Ior bobrcs I ycor old or under. For soch rhzld 17a. W H E N WAS--BORN? Ifm wafer rhr d.rr sromped ,n IS.,. ark ,,b.

b. WAS--BORNINAHOSPITAL? ,f"yes" and no hospirelir.rions .nrrrrd tn bar

;;,yh.; . ;.ry: “,:: :j;,,u ” 1 es” and a korpizolization is reported IO, rbr

C. ISTHlSHOSPlTALlZATlONlNCLUDEDINTHENUMBERYOUGAVEMEFOR--?

l[ “i\o.” correct m,r, for mother and bob,.

rHESENEXTQUESTlONSAREABOUTRECENTVlSlTSTOOR FROMAMEDICALDOCTOR. q Non

18. DURINGTHEPASTZWEEKS(THE2WEEKSOUTLINEDIN REDONTHATCALENDAR) HOWMANYTIMESHAS--SEENA D O C T O R EITHERATHOMEORATA

DOCTOR'S OFFICE O R CLINIC' cr. LiSllS

193. (BESIDESTHOSEVISITS) DURING THAT2 W E E K PERIOD HAS ANYONE IN THE 0 Yes L 1.1 FAMILY BEEN TO A DOCTOR'S OFFICE O R CLINIC FOR SH0TS.X.RAYS.

TESTS.OR EXAMINATIONS?

b. iHoW& THIS? I

c. ANYONE ELSE? \ d/ark "Yes," in prrscn'r column.

For rnrh “Yes” marked, ask:

d. H O W M A N Y TIMES DID--VlSlTTHE DOCTOR?

E\CLl DE ..iai,r mod<. 01, “m.ss” burns. vism

'0% DURINGTHAT PERIOD, DIDANYONEIN THE FAMILY GETANYMEDICAL ADVICE, 0 yes q NC

FROMAOOCTOROVERTHETELEPHONE?

11 'I cs" ask:

b. WHOWASTHEPHONECALLABOUT?

I lark .)'a" in pcrso"" column.

C. ANYCALLSABOUTANYONEELSE!

I Far cord ‘Yes’ morkcd, oak:

d. HOWMANYTELEPHONECALLSWEREMAOETO GETMEDlCALADVlCEABdUT--? Telephme C&.+0 ET.

If the lust Grir us uirhin the pnsr 1.7 months oak: 01[ “k.

b. INTOTAL,ABOUTHOWMANYTlMESHAS--SEENORTALKEOTOADOCTOR 0 cl

DURINGTHE PASTlZMONTHS? g\

THE FOLLOWlNGQUESTlONSREFERTODlFFERENTKlNDSOF U&r II - UC7 0

PERSONAL CARE S O M E PEOPLE NEED AT HOME:...,..,...,...,... 1 SScrM,-Ad2e Cl 2% DOES--NEED ANY HELP IN BATHING.DRESSlNG O R PUTTING O N HIS SHOES?....t---,,T-,-,~,-~~-~IOXam, v I.1 v YR "

b. DOES--NEEDANYHELPATHOMEWliHlNJECTlONS

SHOTS O R OTHER TREATMENTS? . . . I yes sio* 0 b D M( 0 C. DOES--NEEOANYONE'SHELPWHENWALKlNG UPSTAIRS

O R GETTING F R O M R O O M TO ROOM?...

d. DOES- - NEED ANY HELP ATALL IN CARING FORHIMSELF? . . . ..~ Ye, Sk? 0 N O 0 0% 0 3a. DURlNGTHEPAST12MONTHS,HAS-- RECEIVEDANYCARE "o.-d.‘Ub~r 0 & 0 DK 0

AT H O M E F R O M A NURSE?...

b. DURING THIS12 M O N T H PERIOD, ABOUT H O W M A N Y VISITS \ DID A NURSEMAKE TO CARE FOR - -?... ,

c. W E R E ANY OF THESE VISITSDURINGTHE PAST?.-WEEKS?... IS 0 NO0 DK a

0 None

Person number CONDITION NO. 1 ~ I. Person number rri*e in and nmk

*7I

i * Enter per,.,, nunbe, and -same of eondirion- ~ Name of

: and ask question 2. condition t

i 1

2 Ask for .,I1 eondi:bnr ; 2. DID - - EVER AT ANY TIME TALK TO A D O C T O R ABOUT HIS.. .? In Nn Y

i ,:,

.&mine -Name ofs.ndirion* enq in ,ren 1 ; Accident CT ,, Cod,ticn an ,, Neither WASHINGTON USE w c r~3e Question 8 9 70 II ii I, Ti H c au KOT

and ns-k one box. tn,uy-Co 10 4 Card C-Co 10 9 0 nurrber 0 0 ,.I ” ./ cm 0 0 e-8

If-Doctor talked 18, ask: - 3a. W H M DID THE D O C T O R SAY IT WAS7 DID REGIYEIT A If ‘Doem net talked to* record / MEDICAL NAME?

Ccnd. .

adequlrre derstiption of

sondition 01 illness. w

No.d this

I 3b. W H A T W A STHE CAUSE OF.. .? condition

T&l

,ftbe my is 3s m3b inslvds. conjitions

I., IL w

Accident

Asthma ‘Ailment” F:steinjury

cyst ‘Attack’

Required ‘is. I,ir

Growth ‘Cwditim” ‘Trouble” Ask: ~

hkosles ‘Oefect” hospitalization ”

Tumor Cther Ace. T l’,.. Clh.

For ALLERGY O R STROKE. Ask: - n

Kadum cede.

n Fe, c.ndirim,nr 01 Cord E-2 md for any my I 3% W H A T PART OF THE B O D Y IS AFFECTED? Person days of disability I rbr includer de word,:

R.A.]

i’ Abscess cyst

cm Ache (except Growth ” 1

C-8 headock) Hemcxrhoge Saeness SNOl THE FOLLOUNC DETA,L: mks. B.O.1

cm’ Bleeding Infection Ear c( eye..one CT both

Bleed clot lnflommotion Ulcer Head.. skull, scalp, face u C-r6 Y

(2 Boil Neuralgia Back .uppr, middle, leer T.L.] ‘~I ~’

I Center Neuritis Arm. _. ..shoulder, upper, elbow, lower, wrst,

5, Cramps (except Pain hond; ore a both

h mnstr”ol) Pa Isy Leg .,.,...__ hip, upper, knee, lower, ankle, foot; 12 ” w

one CT both Months B.-,. \

FILL QUEST10NS4-3 FOR ALL ACCIDENTS O R INIURIES I -*

’ la. DID THE ACCIDENT HAPPEN DURING THE 0 During pxt 2 years-Ask4b Ed. W A SA CAR, TRUCK, BUS, O R OTHER

PAST 2 YEARS O R BEFORE THAT TIME? 0 M O T O R VEHICLE INVOLVED IN THE Y-. ,I, 6”IO7 i’

_._----___---.---~~~~~~~~~~~~~~~~-~~~~~~--.---. eefcre 2 yeor*-& 10 50

ACCIDENTIN ANY WAY? I~, //

b. W A SM O R E THAN O N E VEHICLE

Ask for oN ossidmu or injrrier: W H E R E DID THE ACCIDENT HAPPEN?

5a. AT THE TIME OF THE ACCIDENT W H A T PART OF THE B O D Y W A SHURT?

HAPPENED?

H O W IS HIS -- AFFECTED? Fcatnotes

I

CONDITION (Con'd.) i REFER RESPONDENT TO TWO-WEEKCALENDAR FOR QUESTlONS9-14

f drkpcstion go/or 011eondi&wr.~ 9a. LAST WEEK OR THE WEEK BEFORE DID HIS...CAUSE HIM TO CUT DOWNON Yes NE-CqL.Na "

THETHINGSHE USUALLYDOES? 0 0 0

k Na-c~~l,. Y

j b. 01DHEHAVETOC~TOOWN FORASMUCHASADAY? 0 0 0

1 A~L~ucrrimr ZOondZl if'Ym !lO. HOWMANY DAYS DID HE HAVETO CUTDOWN "

marked in pues~ian 9b. DURlNGTliATlWOWEEKPERIOD?

111. DURlNGTHATTWOWEEKPERl0D,HOWMANYDAYS tlvr Y

DIDHIS...KEEPHIMIN BEDALLORMOST OFTHEDAY?

Ask qwsrion I.2 ifperson is 112. HOWMANYDAYS0lDHIS...KEEPHIMFROM

6-16 ,vors old. SCHOOLDURlNGTHATlWOWEEKPERl0D!

Askpvcrrion 13ifperson is 113. HOWMANYDAYSOIDHIS...KEEPHIMFROMWORK 17 yeorr old or over. DURING THATTWOWEEK PERIOD? fFor+,lcs add,

NOTCOUNTlNGWORKAROUNDTHEHOUSE?

Ask question 14 Ior aI1 condikm.; 14% WHEN DID HE FIRSTNOTICE HIS...? / 0ulqJ.m. &lrc3nu..-clull Y

WASITDURlNGTHEPAST3MONTHSOR BEFORETHATTIME? 0 0

k3?*%. &lir.2*L.cow,( 0

Y q

-: b. DIDHEFlRSTNOTlCEITDURlNGTHEPASTTWOWEEKSORBEFORETHATTIME? 1 o 0 0

LGSweek K.&t&m "

I C. WHlCHWEEK,LASTWEEKORTliEWEEKBEFORE? 0 0 0

GU,6

Ask question 15 only i[ condition / I 3.12mJ. er,12m% Y .

LL,DJfirst norieed %f.rc 115. DID-- FlRSTNOTlCEITDURlNGTHE PASTIZMONTHSOR BEFORETHATTIME? 0 0 c

3 nonrhs:

:--..---.-.-...---.-~.---~---~~--..

; c. HOWMUCHTROUBLEWOULOYOUSAYTHAT--HASINSEEING: A GREATOEAL. / "dl"

SOME,ORHARDLYANYATALL? &",&a, 5- ,",L

0 0 0

M: IF THIS IS A CONDlTrbN ON CARD A OR 8, OR STARTED l EEFORE 3 MONTHS.’ ASK Q. Ii’; OTHERDISE W TO ITEM BE.

drk queslion IIb if?’ 01 more j17a. ABOUTHOWMANYDAYSDURINGTHEPAST days in pcsrion 1% and 12MONTHSHASHIS...KEPTHiMlN BED question 11 is blank or ALLORMOSTOFTHEDAY?

mlukcd -None:

/.-~..WEREl\i;l~-~~~~~~~-~-DAYSDURINGLASi ---._--- ---..- j ____ ---1, ____ ~~~~~.;;-- ____

I WEEKORTHEWEEKBEFORE?

BB: fs this rhc LAST 0 Yes - Ask 18-Z if person has -I’ or more conditions 9-t AA condition for this person? 0 No - Co to next condition

Show Card 4 E. F. 01 C, 118. PLEASELOOKATEACHSTATEMENTONTHlSCARO(CAROO,E,F,G). THEN as appropriare Boredon

octiviry status or ale. I TELL MEWHICHSTATEMENTFITS--BESTINTERMSOFHEALTH.

Mark rtohmenc number +

I 2 3 ,.c*um

0000 ”

0 n

1/1,Z,or3 marked in18 ark:* 19. ISTH~SGECAUSEOFANYOFTHECOND~T~ONSYOUHAVETOLOMEABOUT~ WASHINGTONUSE

114 marked in 18 So to 20. I

[ 0 yes + W ”IC,,? ____________-___ B;;;;~n‘~~~~~~b~;;.;s;rs ________________

Yes t&

0 0

; ~~~~~~~~~~~--~~~~~~~~~~~~~---~~~~~~~~~~--~~~~~~~~~~~~~~~~~~~~~~ 0

*p Gcn Cd, OKn

WHATDOESCAUSE 0 0 0 0

I 0 No- THIS LIMITATION? Enter EDYSC

20. PLEASELOOKATTHEBLUECARD,CARDH.WHlCH ONEOF ,231 565,op "

THOSE STATEMENTS FITS--BESTINTERMSOFHEALTH? Marksrarnenrnmbcr + 0000 00 0

121. ISTHlSBECAUSEOFANYOFTHECONDlTlONSYOU HAVETOLDMEABOUT? WASHINGTONUSE

n ---::--- 0 0 0

I{6 nnrked, emit 2, and

1 q Y~~-+WHICH~ ‘(0% Ho Y

&l10IK”prrrcn. I __________________________________ Enrrc _e&!r_rcxek~~: _____ _____

-AT can Oh CK

T ₀ ₀ 0 0

1 WHATDOESCAUSE

1 0 No- THIS LIMITATION? Enter cmue l u n

0 0

I---HOSPITAL PAGE

USE YOUR CALENDAR

USEYOURCALENOAR

OU SAID MAT- -WS IN THE(HOSPITALMJRSlNG HOYE) DURING THE PAST YEAR:

L WHEN DIO - - ENTER THE (HOSPlTAL/NURSlNG HOUE) (THE LAST TIME)?

“&s~~eYE”Rticm.~-(~~

I. HOWMANY NIGHTS WAS - - IN THE (HOSPITAlJNURSING HMO?

~~.HITNUANY OF THESE--NIGHTS

WERE IN THE PAST 12 MONTHS? Nights pust Ii! month

5, FOR WHAT CONDITION DID ENTER THE (HOSPITALMJRSING HOUEI -Do YOU KNOWME UEDICAL NAME?

pr d&vet, uk VAS THIS A NORMAL DELIVERY? , If-no- “k

MAT WAS THE MAl-fER?

~am.,,bm, uk WAS THE BABY NORMAL AT BIRTH? \ Record ir ‘C.ndicimf bar Cmiitim

Kird

-6a.WEREANYOPERATlONSPERFORMEDON--DURING

THIS STAY AT TRE (HDSPlTAL/NURSlNG HONE)? 0 Yes_~~---_----~0 No-Go lo b.WHAT !fAS THE NAME OF THE OPERATION?

Gpmtim

c.ANY OTHER OPERATIONS? [7 Yes - De,edbc abe” 0 No

7. WtlAT IS THE NAME AND ADDRESSOF THE (HOSPITAL/NURSING HOME)?

Ipe-atom

Nam d Hmpiml I

- CONTINUED ON NEXT PAGE

-2

-- HBSPfTAL PAGE (CONfO) ASK QUESTIONS 8-10 FOR ALL COMPLETED HOSPITALIZATIONS

Ask i/-No’ r.rked in quedcm .s:

T ; i.

.. ‘ WASHINGTON USE

root.Amwnt B. W H A T W A STHE TOTAL A M O U N T OF THE (HOSPITAL/NURSING HOME) BILL FOR THIS STAY?

Do NOT INCLUDE DDCTORS’O R S U R G E O H S ’BJLLS S&DID (WILL) HEALTR INSURANCE PAY ANY PART OF

THIS BILL? q yes 0 No-Co to 10 Nom of Insurance Plan

b.WHAT IS THE N A M E OF M E INSURANCE PLAN? -+

-j

^IO.

7

^{Source 1}

c.DID(WILL)ANYOTHERHEALTHlNSURANCEPLANPAY _-.~~--..--~~ .._.. -_~~~ .._______ -e---j _____

PART OF THIS (HOSPITAL/NURSING HOME) BILL? I I

_ .-I

0 Yes-Ask 10e 0 No-Co lo 1Od D 0 Relative not in household t 7

c.WHD W A STHIS? b&k cock carp,y..rmioncd . E 0 Friend d.WHAT W A STHE U M U N T PAID BY - -?

Enm ,m,x.e paid opposite eppmprinre satc6.q. F 0 Ken Mills CT otha Fed. Plans I

INTERVIEWER: G 0 Armed Fares Medicare I

(7 Total armxnt paid (to be aid) does NOT ogre T-OF ABOVE- insI& -a+

with amount d hmpitol bill - Re&ve difference paid b, krdk k-e

“itk nspmd.nr.

ASK QUESTIONSII - 13 IF PERSON I.963 YEARS OLD O R O V E R York one cirrle IrWHEN - - LEFT (Nameof imspitalhursinghe). OHwe-Co&Q.e,rio.~z

DID HE RETURN H O Y E O R G O SOYE OTHER PLACE! 17 Sam other place -Ask Que&on II)

L 5,111l”k.4. C. Y ,a 0

!. AFTER LEAVING THE (HOSPITAL/NUfiSING HOME,) H O WM A N Y DAYS DID - - HAVE TO REMAIN IN BED ALL O R M O S T OF THE DAY? rnd r*

In document ChronicConditionsand limitationsof Activity and Mobility (Page 62-75)