I T.a,let Eamg

Bazh, ng _ _

Oressmg _ _

Eating — —

-— —.____ —__________

Bach, ”g

~ Other - SpecifQ

~] Reported earl ie~

-_ . . .._.}____

(Mark Condtt, cm o box

~:] Enter Co”d. !. C2 THEh 44b)

~ old w on!,

Y N (44d)

Enter co.dtuon ,. C2 Reask 44b and c

~ Only I co.d,rion (NP)

2❑ Dressing 3 (_J Eacmg

~ Other - Spe.ilyi

4..

_.__}_..

1 n Reported ear! ,er x

Reask 44b and c

1 :- ~ Only I Cmdtt,.n (NPJ

Bathing _ _

Oress,ng _ —

~ Ocher – Spec!fyg

. . .._._.}___

a Reported earl ie~

(Mark

Enter condtcmn I“ C2 Reask 44b and c

;:]^{Ody I co”d,c,m (NP)}

B.thmg

Oressmg

Eat,”g

To,lec

I

Mark box(es) from item C.

BD

BD I❑ 1+ Bed Days 2 n 1+Hosp, ml Stays 3❑ NO B=d nays (date) a ye.r ago), ABOUT how many days did illness or in@ry

5. During the past 12 months (that is since keep -- in ked all or most of the day?

45. 0❑ None

(Include the day. in the post 2 week..) (Include the day. while a patient in o hospital.)

1 D I-7

(Was it more than 7 days or less than 7 days?) ^{2 n} 8-30

(Was it more then 30 days or less than 30 days?) 3 a 31-ISJ3 (6 months)

(Wos it more than half the year or less than half the year?) 4 u 181+ (6 months +)

,,

T.!,!. SA

6c.Does anyone inthe family now use (any of the following special aids)

-a

Yes No

LAnartifi.ial arm? . . . .

2. Anortificial leg? . . . .

3. Abro.eof any kind? . . . .

4. Crutches? . . . .

5. Acanec.r walking stick? . . . .

6. Special shoes? . . . .

7. Awheel.hair? . . . .

8. Awalke,? . . . .

9, Guide dog? . . . .

10. AnYother kind ofaidfor getting around? . . . . If ‘Yes,’’ spec;fy:

\

Enter in Table SA b. Who is this?

c. Anyone else?

‘OOTNOTES

,.rs.n No.

—(.)

—

.

If 7-0 in (b), ASK: If S-10 In (b), ASK?

i-y p Do., h, us. .neor Ferwhm condition d.., of aid

two_(ot a time)? hene.dthis _? (lfem C)

/f-’brace,’’ Ask: Onwh.tp.rt.f

(b) (c)

the body is th.(~ worn?

lo

20 Other

In 20 Other

to

20 Othe,

to

20 Other

10

20 Other

In 1+ Bed Days 6D 1 n 1+ Bed Days I❑ 1+ Bed Days

z D 1+ H.aspltal SWS 2❑ I + Hospital Stays 2 D !+ Hospmal StaYS

3❑ No Bed Days 3❑ No Bed Days 3❑ No Bed DaYS

0❑ None tiq I-7

2❑8-30

3❑ 31-180 (6 months)

4D 181+ (6 months +)

u

^t

BD !❑ 1+ Bed Day.

2❑ 1+ Hospital Stays 3❑ No Bed Days

45. 0❑ N~=

,01–7

2❑8-30

3❑31-180 (6 months) 40 181+ (6mo”ths+)

1 n 1+ Bad Days 2 D 1+ H.spl!al Stays 3❑ No❑ed DaYs o U NOn=

to I-7

2❑ 8-30

3❑31-180 (6 months) 4D 181+ (6 months +)

Is the_u’.d .11 d th. time, m..+ Hew w.. the_. bmi..d? W. it p.rchosed,

of the tire. or only .C..l,i.”.lly? How Iowg h.. h. used—? rented, borrowed or . gift?

(’=) (f) (g)

1 D All 2❑Most 3❑Oceaswnally ❑ Less than I month 1❑ Purchased 2❑ Rented 3❑ Borrowed 4D Gtift

_ Months _’(ears

1❑All 2❑ Most 3❑ Dccasi.nally ❑ Less than I month 1 n P.rchased 2 D Reined 3 a Borrowed 4 n Gift

— Months _Years

I D All 2❑ Most 3❑ Occasicmally U Less than I month 1 a Purchased 2❑ Re.t.d 3❑ Borrowed 4❑ Gift

_M.nths _Years

1 ~ All 2❑Most 3❑ Occasionally ❑ Less than I month 1❑ Purchased 2❑ Rented 3❑ Borrowed 4 g Gift

_ Months —Year.

! D All 2❑ Mosi 3❑ Occasionally ❑ Less than I monrh !❑ Purchased 2❑ Rented 3❑ Borrowed 4❑ Gift

—Months —Years

k.

CONDITION 1

1. Person number Name of condition

2. When did -- last see or talk to a doctor about his . . .?

I ~ In !ntervlew I n Past 2 wks. (Item Cl _{5 D} 2–4 yrs.

-week z ~ 2 wks. –6 mos.

(Reosk 2) 6 D 5+ yrs.

3❑ over 6–12 mOs. 7D Never

4Dlyr. a o DK if Dr. seen

9~ DK when Dr. seen Examine “Name of condition” entry and mark

AI •l Color blindness (NC) ❑ On Card c (A2) m Accident or injury (A2) ❑ Neither (3a) 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 O On Card C (A2)

b. What was the cause of . . .?

n Accident or injury (A2)

---If the entry in 3a or 3b includes the words:

Ailment Condition Diso, de, Tr.a. ble

Anernl.a cyst Growth TLImo,

Asthma Defect Measles ulcer

} Ask C:

AM.ack Diseose Rupture

c, What kind of . . . is it?

---For allergy or stroke, ask:

J-==1%%

^AZ Ask~~;~$,q.estions as appropriate for the condition entered in:

4. During the post 2 weeks, did hi$ . . . ~auSe him to cut down on the thin.as he usuallv does?

5. During that period, how many cloys did he cut

down for as much os a day? _ Oays

00 ;=] None {9)

6. ~~ing that Z-week period, how many days did

keep him in bed all or most of the day? _Days . . .

00 u None

Ask if 17+ years:

7. How many days did his . . .keep him from work _Oays (9j during that 2-week period? (For females): not

countina work around the house? 00 ~ None (9)

d. How does--the allergy (stroke) affect him?

I

10..

Ask if 6–16 years:

8. How many days did his . . .keep him from _ Oays

school during that Z-week period? DO ~ None

9. Wh=n did -- first notice his . . .?

I n Last week i❑ 2 weeks-3 months

20 Week before 5I_J Over 3-12 months

3❑ Past 2 weeks-DK which 6 D More than 12 months ago (Was it during the past 12 months or before thot time?)

(Was it during the past 3 months or before that time?) (Wos it during the past 2 weeks or before that time?)

t❑ Not an eye cond. (AA) a u First eye cond. (6+ yrs.)

A3

^{2 I_J} (under 6) (70g)^{First eye cond.} 4❑ Not first eye cond.⁽¹⁰⁾ (AA) These next questions are about how well -- can sw (with glassdcontacts).

---If in 3a-d there IS an Impairment or any of the fol Iowlng entries:

Abscess Domage Por.lysis

Ache (mx.q? hod o,●.,) G,owth Rupture

Biding Hemorrhage sore

Blood clot Infection sore”.%%

Boll In flmnmatl.an Turn.,

I Ask e:

con .,, Ne.r.algio ulcer

Cramps (.x.ept Neuritis Varlr.es. vein.

rn.nstrlml) Pain

cy.~

Weak

Palsy Weakness

c. What part of th. body is offcct.d?

Show the following detail:

Head. . . . .sk.ll, scolp, face Bock/spine/vwwbro . . . upper, middle, lower Eorer.ye . . . ..one.a. bath

Arm . . . ..ene .a, ko,h; shcwlde,, .p e,, elbow, lower, wri s!, he. $ Leg . . . ..onmor t-sth. hip, .pper, knee,

Can -- see well enoug~~read ordinary new.~~ prin~;th his C left I . . . .

Iright] ~e?“ . . . ..ly 2N

---Can -- see well ●nough to recognize the features of people hc knows if they are close ●nough?

Y N

---Can ---- see moving obiects, such as cars moving or people walking?

Y N

---Can -- see well enough to step down?

Y N

_________________________________________________

Can -- se= well enough to recognize a friend walking on th. other side of the street?

Y N

---If ALL “No,” ask I of: otherwise go to 10g.

f. Con -- see well enough to tell if a light is on?

Y (AA) N (AA) _________________________________________________

g. How much trouble would you say that -- has in seeing, a great deal, some, or hardly any at all?

❑ Great deal ❑ Some

..-1 u Mlsslng extremity (A4)

AA 2~ Condition in C2. does. not have a letter 2s source (A4) 3❑ Condition in C2 has a letter as source, Doctor see” (II) 4❑ condition in Q has a letter as source, Doctor not see” (IS) ha. Doss -- NOW take any medicine or treotmant lY

forhls . . .? ₂ N(12)

--- ~ ---b. Was any of this msdicinc or treatment recommwtded I Y

by a doctor? 2N

12. HCIS he●vw had surgary for this condition? lY 2N

13. Was h~●VW hospitalized for this condition? lY

I 2N

14. During th. post 12 months, about how many times ho.

-- ~acn or talked +0 ~ doctor about his . . .? _ Times

(Do not count visits while a patient in a hospital.) ocm n None

150. About how many days during the past 12 months has

this condition kapt him in bod all or most of the day? _ Days 000 u None

---Ask If 17+ years:

b. About how many days during the past 12 months has _ Days this condition kept him from work?

t==-===

For females: Not counting work around the house?

16a. How ofton doos his . . . bother him - all of the time, often,

o❑ Never (A4) e m Other - Specify

---b. Whan It dots bothm him, is he bothered o graat deal, somt, or very little?

I u Great deal 2❑ Some a n Very little

4❑ Other - Specify FOOTNOTES

A4 ~

^{Accident or i“j.ry m Other (NC)}

17a. Did the occident happen during the past 2 years or before that time?

❑ During the past 2 years ❑ Before 2 years (180) _________________________________________________

b. When did the occident happen?

D Last week o Over 3-12 months

n Week before n I -2 years

❑ 2 weeks-3 months

18., At the time of the accident what part of the body was hurt?

What kindef itr@y was it? Anything ●lse?

Part(s) of body I Kind of injury

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 Present effect.

--- 1

---I I

19. Where did the accident happm?

I u At home (inside house) 2❑ At home (adjacent premises)

30 Street and highway (includes roadway and public sidewalk) 4 I_J Farm

S❑ Industrial place (includes premises) s❑ School (includes premises)

7 n place of recreation and sports, except at school E❑ Other - $ecify~

20. Was -- at work at his iob or business when the accident happened?

lY 3 n While in Armed Services

2N 4 Q Under 17 at time of accident

21a. Was a car: truck, bus, or other motorvehicle

involved ,n the occident in any way? lY 2 N (NC)

---I I

b. Was more than OIW vehicle involved? Y N

---I

^I c. Was it (either one) moving at the time? lY 2N

,

-2-WEEKS DOCTOR VISITS PAGE

Earlier, you told me that--had seen ort.alked toa doctor during thepast2 weeks.

a. On what (other) dotes during that 2-week period did -- visit or talk to a doctor?

--- --- --- --- .. --- —---

-b. Were there a”yother doctor visits forhimdurina .that oeriod?.

Where did h= see the doctor en the (date) at a clinic, hospital, doctor’s office, or~er place?

If Hosp!tal: Was it the outpatient cllnic or the emergency room?

If Clinic Was it o hospital outpatient clinic, a company clinic, or some othet kind of clinic?

IS the doctor o general practitioner or a specialist?

i. During this visit (call) did -- actually see (talk to) thedoctor?

10.Why did he visit (call) the doctor on (date) ? Write in reason

Mark appropriate box(es)

---b. Was this for any specific condition?

---

---Mark box or ask

c. For whet condition did -- visit (call) the doctor on (date) ?

0,

.

b,

,.

b

c

‘erson number

{

7777 ~ Last week OR

8808 n Weekbefore

——

Month Date

--- . . . .

Y (Reask 2a and b) N (Ask 3-6 for eachV(S/t)

0❑Whll= #. Patient in hose., t.r (NW DV) 1 Cl Dect.r’s of f,ce (grow practice or

doctor,. cl,nlc) 2❑Telephone

3❑Hospna! O.tpauent ClImc 4 n Home

5❑Hosrxtal Emergency Room 6❑Company or Industry Cllmc 7 n Other (Specify)

7

t❑ General pra.cnioner ❑Specsal, st -Whatkindof specialist is he?

7

lY 2N

t D Oiag. or treazment (6c) 3❑General checkup (fib) 2❑Pre or Posmatal care 4❑ Eye exam. (g+..) 5❑ lmmunfzatj On

} (f 1)

6❑Other

---Y (Enter condition in 6a N (P 1) and change to “D/ag.

or treatment”)

---a Condition reported In 6a

PI I

A Condition page is required for the condition in question 6. [f there is no Condition page, enter condition in item C and fill a page for it after completing columns for all required doctor visits.

OOTNOTES

1.

8886 D Week before

——

Month Dare

r(Reask 2a andb) N(Ask 3-6 for eachvisit)

~[”lwh,le 1. P.t, e.t ,nhosP, tal(N.?xt DV) 1 1–1 Doctor’s efface iwo. D ~racuce or

doctm,s .I, nlc)

! 1: I Telephone

! [:] H.sp, tal Out!xment CII.tc 11:1 Home

; 1~1 Hos PI@ Ernerse”cy Room i cl ‘&nDa.Y or Industry Cltnlc I 1~1 Other fSpeCify)

7

1El General pr.cutmmr Q S,e.(dlst

-Whm kind .( specialist IS he?

7

IY 2N

![1 OIU. or trmment(6c) 31_l Gcncral checkup 2 l_ JPrc or Postnatal care 41:1 Ey. exam. (glmsses)

} (P1) s L–_lInmunlz.tlon

F,I:I Other

.. —._______ ——---Y (En ft?rcondif ion ln6a N (P 1)

and change to “Di.9g.

or treatment”)

\~\Condltl o”repc,rted 1.6.

1.

7?77n ^{Last week}

OR

w38e~ Week before

——

Monch Oate

.-- . . . .

3 n H.sP8tal O.mmttent Clln, c

4❑ Home

s❑ H.swtal Emergency Room 6❑ Company .< Industry Cllnlc 7 n Other (Specify]

7’

II❑ General practst, oner ~ %.ectal, st -W%Ot kind v{ specialist is he?

7

lY 2N

! ~ O,ag. or treatment (6c) 3 U General checkup (6b) 2 U Pre or Postnatal care 4 ~ Eye exam. (glasses)

.__}_

(P;

5❑ lmnwniz adon 6 a Other

Y (Enter condition in 6a N (PI)

and change to “Diag.

ortreatment”)

7777 ~ Last week OR

8088 El Week before

——

Month oat, . . .

..-Y (Reask 2a and b) N (Ask 3-6 fOr

each visit)

o n Wh(le ,nPaC, e”t 8. hosp, tal (Next Dv) I [3 Doctor’s off,<. (g.rc.up pract, ce .,

doctor,. .1,.,.) 2 [–] Telephone

3 ~ HosP#tal O.trmt, ent Cllmc 4 ~] Home

s ~] Hos!J8 Cal Emersency Room 6 ~ Company or Industry Cl,.,.

7 ~1 other(Specify) 7 3❑ General checkup (6b) 2❑ Pre or Postnatal care 4 a Eye exam. (glasses)

} [Pi,

5 CJ Immunnzatjon 6 D Ocher

_______________________________

Y (Enter condttion in 6a N (P 1)

end change to ,’D,ag.

or treatment”)

---~ Ccmdtdon reported ,. 6a

Pll

A Condition page is required for the condition in quest, on6. If there is no Condition page, enter condition In item C and fill a page for it after completing columns for all required doctor visits.

I QoTNoTES

HOSPITAL PAGE

You said that--was in the hospital (nursing home) during the past year.

Wh.ndid --enter the hospital (nursing h.ame) (the Iast time)? _Make^uSEsure the YEAR^{YOUR CALENDAR},s correct

What isthenwme andaddr*ss of this hospital (nursing home)?

Howmany nights was --in the hospital (nursing home)?

Complete 5 from entries In 2 and 4; if not clear, ask the questions.

a. How many of these -- nights were during the past 12 months?

---b. How many of these -- nights were during the past 2 weeks?

____________________________________________________________________

c. Was -- still in the hospital (nursing home) last Sunday night for this hospitalization (stay)?

—

For what condition did -- enter the hospital (nursing home) - do you know the medical name?

If medical name unknown, enter an adequate description.

For delivery ask:

}

1 Show CAUSE, KIND, and 1

Was this a normal delivery? If “NO,” ask: 1 PART OF BOOY In same

[

For newborn, ask: What was the matter? [ detail as required for the

1

Was the baby normol at birth? Condition page.

1 r

n. Were any operations performed on -- during this stay at the hospital (nursing home)?

---b. What was the name of the operation?

If name of operation---IS not known, describe what was done.

c. Any other omrations durina this stay?

1. Person number

Month Date Year

2. 19_

Name

3P---4. I _ Nmh[s

4

s.. N,shts

--- .---— —

..1

Y N

6. I n Normal delivery n Normal .1 b,:th C.a”d~cm

c-a;;e---~-taydtcyd-c ‘---n iz.j l; ii

---—----Kmd

---Pam of body

7.. Y 0 N (P2)

--- ---b.

I

--- I

Y (Describa)

7 N

c.

P2 A

Condition page is required if the condition in 6 or 7 is listed specifically in 32 and is ‘“NOW” present, or there is

“ I “ or more nights in 5b. If there is no Condition page, enter condition in item C and fill a page for it after completing columns for all rermi red hospitalizations.

FOOTNOTES

—1.

—2.

3.

—

4..

50.

b.

c.

6.

?0.

-.

b,

c.

Person number

Month Date Year

19 _ Name

Street

City (W county) state

— NIZhIS

Nights

_ Nt;hts

Y N

u Normal delwery D Normal at birth C.ndltmn

---callse ❑ On^{Card C ❑ Ac., or I.,.}

---Kknd

---Part of body

Y 0 N (P2)

--- .

Y (Describe)

-7 N

1.—

L

1.

.

L—

;.,

--b.

.-C.

,.

0.

--b,

--c.

Person number

Month Date Year

19_

Name

Street

cow(.x COu”ty) State

N,ghts

_ N!ghts

---

—---— N,thts

---—---Y N

❑ Normal delivery Q Normal at birth Condition

---Cause ~ On Card C ❑ A... or I.j.

________________________________

Kmd

---Part of body

Y 0 N (P2)

---Y (Describe)

7 N

1.

1P

^●rson number

Street 3.

I^c,,, [or.0””,,, State

I

4. — N,ghrs

50. _ Nights

-- . ---

—---b.

t

—N$eh=

---c. Y N

6. ❑ Normal delwery ❑ Normal at btirth

C.nd, w.n

,---Cause ❑ O.Card C ❑ Ac.. or I.,.

p,,d- ---

——---

—---Pam of body

7.3.

r-Y 0 N(P2)

---b.

---Y (Describa)

7N

c. I

A Condition page is required if the condition in 6 or 7 is listed specifically in 32 and is ““NOW” present, ,y there is

P2 “ I“ ormore nights in5b. If there is no Condition page, enter condition in item C and fill a page for it after completing columns for all required hospitalizations.

COOTNOTES

HEARING SUPPLEMENT

1. Has --ever useda hearing aid?

(Hand Card H)

Please look at this card

-!a. Which statement best describes --’s heoring in his LEFT ear (without a hearing aid)?

--- .

b. Which statement best describes --’s hearing in his RIGHT eor(without a hearing aid)?

If age 3+ , ask:

Io. (withouta henring aid) Can --usual ly HEAR AND UNDERSTAND whet a person says without seeing his face if that person WHISPERS to him from across a quiet room?

---b. (Without a hearing aid) Can -- usually HEAR AND UNDERSTAND what a person soys without seeing his face if that person TALKS IN A NORMAL VOICE to him from across a quiet room?

---c. (Without o hearing aid) Can -- usually HEAR AND UNDERSTAND what a person says without seeing his face if that person SHOUTS to him from across aquiet room?

---d. (Without a hearing aid) Can -- usually HEAR AND UNDERSTAND a person if that person SPEAKS LOUDLY into his better ear?

---●. (Without a hearing aid) Can -- usually tell the sound of speech from other sounds ond noises?

_______________________________________________________________________________

f. (Without a hearing aid) Can -- usually tell one kind of noise from another?

_______________________________________________________________________________

g. (Without o hearing aid) Cc” -- hear loud noises?

R2

For persons 17 years old or over, show who responded for (or was present during the asking of) Q.’s 1-3. If persons responded for self, show whether entirely or partly. For persons under 17, ).’s I-3 show who responded for thcm.

1,

—

2.3, .-.

b.

3.3.

.-.

b.

---c.

---d.

.-.

..

.-.

f.

.-.

9.

—

R2

lY ZN

Lucr[e ! Lotof

;md rrrmble ;tmut!k Deaf

D 21:1 I Sr-1~l:i ---- ——..- L__ . . . . .._

n 21:1 i31:l 4 !-1

~ Under 3 (R2)

IY(R2) 2N

!Y(H2) ZN

1Y(F12) 2N

.--- ——-— ——. ——— — .—

--IY(R2 ZN

,Y(H2) 2N

!Y(ff?) 2N

IY 2N

[~] Responded for self-e. tor~l>

1] Respmded fur se[f.partly

Pemm_w.m respondent

‘OOTNOTES

RI

lY 2N

I “

t ---

--8Y(R2) 2N b.

t ---

--IY(R2) ZN c.

---

---d.

IY(R2) 2N

--- ---

---IY(R2) 2N e.

---

---1Y(R2) ZN L

---

---!Y 2N 9.

I 1:1 Rnspondad for self-entirely z la Responded for self-partly R2

Person_was respo”dem I

1 FoOTNOTES

lY 2N

L,ttle ! Lot of

Good Deaf

trouble ;tmuble

II 2 [:1 13EI 4K;

_---:

---[:I 2CI 13U 4 !:!

1 L] Under 3 (R2)

tY(R2) 2N

--- ^-b.-.

IY[R2) 2N

--- .

I. Y (R2) 2 N

--- .

IY(R2) 2N

--- .

1Y(R2) 2N

--- .

1Y(f72) 2N

---

-lY 2N

❑ Responded for self-entirely

❑Respmded for self-pardy Person_was respondent

❑ No Hearing Problem (NP)

❑

^{.4i ~;)33 i“} RI

lY 2N

m I‘

t ---

--IY(R2J 2N b,

t --- -.

IY(R2) 2N c.

---—

^1Y(R2)

---

^2N

1 --

^d.

--- —---

--IY(R2) 2N e.

---

--1Y(R2) 2N f.

t ---

--%Y 2N 9.

❑ Responded for self-entirely a Responded for self-partly R2

Person_was respondent

tY 2N

I

;ood trouble‘ittle ‘ ‘ot;trouble‘f Deaf

El 2EII 3U ~n --- L---_—_

u ,n~,n ,D

❑Under 3 (:2)

,Y(R2) 2N

---1Y(R2) 2N

--- —

---IY(R2) 2N

---IY(R2) 2N

---IY(R2) 2N

---1 Y(R2) 2N

---BY 2N

❑ Responded for self-entirely

❑Responded for self.partly PeKo”_was mspooden!

~ NoHeari”z Problem (NP)

❑

^{:; 7;:,33 in}

lY 2N

Little ~ Lot of

;ood De,

trouble :troub!e

m Zlg ; 3U 4~

.- ___ -._- _:________

n

^{z~ ]30 4C}

~ Under 3 (,9’2)

IY(R2) 2N

---1Y(R2) 2N

---1Y(R2) 2N

---1Y(R2) ZN

---1Y(R2) 2N

---rY(R2) ZN

---IY 2N

u Responded for ,elf-en,irel:

❑ Responded for ,elf.p.xtly Person _was respondent

H 1 PAGE

la.Does -- need help from others in using public transportation, such as buses, trains, subways or planes?

---b. Does -- use public transportation?

---c.If -- hod to use public transportation would -- need the help of other persons?

Za. Does -- drive a car?

---b. Does a disability or health problem keep him from driving a car?

---c. Is the car he usually drives specially ●quipped for handicapped persons?

---d. Was the car specially ●quipped for --?

,., ,

Ask if 19+:

)IJ. ~Bides) During the past 12 months did (Sdults 19+)

~

1.Suddenparalysis or weakness of an arm and leg

If “Yes,” ask:

b. Who was this? Mark “’symptom” in 2. Sudden numbness on one side of the body?

person’s column and reask 3a and b.

If “symptom,” ask 3c-e ---

---4. Sudden loss of speech?

c. Did --’s (s~m) last more or less than 24 hours? 1

.____ --- __-_-_--- _-_- __--- ____--- _---

=---d. Did -- sce a doctor for his (sym~t.am(s]) at that time?

---e. Was -- hospitalized because of the s mptom(s) ?

la. (Besides) During the past 12 months did WCS have

-I 9+)

If “Yes, ” ask:

b. Who was this? Mark box in person’s golumn and reask 4a and b

=

2. High blood pressure or hypertension?

3. Heart disease or heart trouble?

4. Blood clots in arms, legs, or lungs?

Ask if 19+:

If ‘“stroke” in C2 go to 5b.

ja. Ha$ -- EVER had a stroke?

---b. Has o doctor EVER told -- he had a stroke?

---c. How old was -- at the time he had his first stroke?

---d. was -- hospitalized for this first stroke?

!-==-)

I0<

-.

b.

-.

c<

1 Y(2) ZN .--- ..-_ -_

—---1 Y(2) 2N

---IY 2N

1

2.. 1 Y (2c) 2 N ---

.-—---I

b. 1 Y (NP) z N [NP)

--- ___ -_-—

c. lY 2 N (NP)

---

—---d. IY 2N

3b.

,nd c.

--

--❑Par?..

❑Numb, D v,,.

❑Spe.

,---

-H thwnr-forethm L4h-am 24 hwrs

u 2U

0 2U

•1 Zcl

•1 20

---{

d.t Y 2 N (4 I 9 OK (4)

---e. lY 2N s OK

,L1❑Diab=tes 2❑High Blood PresswIJ 3 Cl Heart Disease

~❑ Blood CIOIS

I

^~ Under 19 [NP}

3❑ S1rOke in C2 fsb~

so. ! Y 2 N (NP) 9 DK (NP

---{

1). lY 2N s OK

---

,A--J=---d. IY 2N

~ Under 19 fNP)

1 {~ 121abetes

2 u High Blood Pressure

3 1 j Heart Cusease

4 L—l Blood Clots

\:l Under 19 lNP)

1❑Diabetes 2❑High Blood Pressure 3❑Heart Disease 8 ~ Blood Clots

1❑ Diabetes 2❑ High Blood Pressure 30 Heart Disease

4❑ Blood Clots

2:_ ____I Y (2C)-__: AN__________

::-!2:~_:-N---______-~ 1 Y (NP) 2 N (NP) I Y (NP) 2 N (NP)

--- .--- —___ --- —____ __________________ .

e. lY 2N OK IY 2N 9 DK

I❑ Diabetes I❑ Diabetes

4b.

2❑ High Blood Pressure 2❑H,gh Blood Pressure

3 D Heart Disease 3❑Heart Disease

4❑ Blood Clot. 4❑ Blood Clots

L On the average, how muny hours of sleep do you usually get at night?

‘. How often do you cat breakfast - almost every day, sometimes, rarely or never?

1. Including ●vening snacks, how often do you ●at between meals - almost eveyy day, sometimes, rarely or never?

~. Would you soy that you are physically more active, less active or about as active os other persons your age?

Iki.How often do you drink wine - never, occasionally, once or twice a week, or more than twice a week?

---b. HOW often do you drink beer - never, occasionally, once or twice a week, or more than twice a week?

______________________________________________________________________________

c. How often do you drink liquor - never, occasionally, once or twice a week, or more than twice a week?

---If all “Never, ” go to I I

d. When you drink -, how many drinks do you usually hove at one sitting?

---If under 5 in 10d ask; otherwise go to I I

e. On an one occasion during the post 12 months, did you hove 5 or more drinks of J

(wine beer/liquor)?

a. Have you smoked at Ienst 100 cigarettes in your entire life?

---b. Do you smoke cigarettes now?

---c. On the overage, ABOUT how mony cigarettes a doy do you smoke?

!a. About how tall are you without shoes?

______________________________________________________________________________

b. About how much do you weigh without clothes or shoes?

a. During the past 12 months, have you hod any problems getting medical care for yourself (for any of the

following reasons) - 1. Because care was not available when you

needed it?

---

---2. Because of how much it cost?

---

---3, Because you didn’t know where to go?

---

---4. Because you didn’t have a way to get there?

--- ___

5. Because the hours weren’t convenient?

L Did this problem PREVENT you from getting medical core for yourself?

R

6

,

s

9

10

11

,-12

13 ,,

1 rlL .. NOI SP or SP under 19 (NPJ 2❑SP [9+ cd I back rqmed (NP) 3 a SP l% available (6-13)

— ^HCWS

1 u Everyday L-1 Q&;,;

2 u S.mWmes

# 3 D Rarely or nevw _

1❑Evewday ~ p-m;

2❑S-metims s

3[7 Rarely or .,,., _

1 D t%. acuve El mg--g z Q Less z.ctwe 3DSMW

I n Never 4 c1 he (Wd}

2 u Occaslmally (lCd) 3 u tic. w tvvlce (W)

--- _- ——

--1 D Never 4 u We (f(M)

z n &casmally (W) 3 n GICe or w,.= (Iai) ___________________

I❑Never inhe

2❑Occaslmally 3 u %ce or twice . - —________________

_w,”e (lLW — Liquor

_=-.c@J@~________

IY 2N

IY 2N (72)

--- . - —________

lY 2 N (12)

Ct:arettes

_ Feet _ Inche,

.--- —_- ———_—

Pomds

I. Had problem ! b. Prevmt=d care

IY (b] N]1Y2N

! Y [b) ~ :,y ~N.

I Y (b) N[l YzN

I Y [b) N~!Y. N

; Y (b) N~,YzN :I

I I.-I Not 5P or SP under 19(NP) 2 I: \ SP 19t callback rewired (NP 3]_ [SP [9+ aval Iable (S-73)

I[n&.!Y day n Cxher -2➤] %xnewnes .l=ffq 3 U Rarely or never

1 ~ Never 4D tie (7W

2 ~ Ckcaslwally (1OI$

3LqChcec+tw,ce(NM) 1 ~ Never 4 U Mxe (1(M) 2 u Cccaslcdly (704 3 ~ Cklce 01 twice (10.I)

I u Ncvw 4Dt+xe

2 u Cccastmally 31~ f%ce w twwe

.

---_Wme (lOb) _ Llq”a

_ 2-?. (WC) 2D SP l% callback requir.4(NP 3 n SP 1% mailable (6-13)

1❑Every day ❑Odw

-2❑Scowims s@fY$

3❑ Rarely m never Iu Every day ❑Ool., –

2❑Scmeulms S%Cq

3 D Rarely .x never

!❑tie active ❑Other -2❑ Less active $mclfY#

3D%IG

I❑ Never 41-J7-!.W.[lLW

2❑ Occasimally (l@) 3❑ Chxe w twice (lOd)

---1❑ Nevti 4❑he (l&f) Z❑ Ouasimally (l&1) 3❑Cnce c+ twice (lOd)

---t❑Never al_Jtlme

20 Cccaslmally

m. Had Ixcblem IIt. Prevmted

1 care 2❑SP I% callback re=xmred(NP) 3❑SP 19+ ava, lab!. (>13)

I❑Every day ❑r$hhy,;

2❑%mecimes *

3❑ Rarely or never

1❑Every day ❑Ottm–

2 I-J %lTetrrrrss sP=lfYJ 3❑Rarely or “ever 1❑t%re ac[ive ❑Cnher -2❑ Less active SWUYJ 3os74ne

1❑Never 4❑me (W)

2❑ O.casicoally (7M 3❑ %.. or twice (If%)

---1❑ Nev. 4 m we (I(M)

2❑ Ckcastmally (7W) 3❑ Chce or twce [107I

1❑ Never 4❑Vore

2❑ OccasicAly 3❑ ace or twice

---_ W,ne (lObJ _LIquci

_ Beef (w

---m Had pfoblen 1

---m Had pfoblen 1

In document Current Estimates From the Health Interview Survey: (Page 77-98)