QUESTIONNAIRE-CONDITION APPROACH

APPENDIX IV. QUESTIONNAIRE-CONDITION APPROACH

The items helou shw the psact rontcnt and nording of the hasir questionnaire used in thr nstionuidc housrhold survry of Lhc t1.S. National Health Survq. The nctusl questionnaire is designed for n houechold a+ a unit and includcn nddilionul sonces for rcnortson more than OIIP person, condition, accident, or hospitnlization. Such spaces aroamitlcd in this illusirntion

NOT,CE . A,, ,nfam.,ian which would perm,, ,dcnti,,cation of the individual will beheld ,n s,,ic, conlidcncc, will be used only by pe,sanr engaged inend to, he pu,porcr of ,hc rurvcy, and will not b. d&oscd or released lo othcrr for any purposes.

F.,nn NH&HIS-I IFY67l U.S. DEPARTMENT OF COMMERCE-&“~~A” 06 THECENSUS 1.

REWSED 9-30-B

Budget Rvrcou No. 68.R1600 ^ACTlNG ^ASCOLLECTING AGENT FOR THE US PUBLIC HEALTH SERVICE

Approval Expwes 3-31-68 U.S. HEALTH INTERVIEW SURVEY 23.3:1 Bc% CI B-1:;

,-3. 0 ,rl+ WHENWASTHISSTRUCTUREORIGINALLYt3UILTg -. -__ ! 4.1.60~C*nrrour L”,l~~ll”

IRE ANY OTHERBUlLDlNtib%THlS PROPERTYFOR PEOPLETO LIVE IN. EITHEROCCUPIEDOR VACANT’

12.3.DOES THIS PLAcEHAvElooe;laREncRES,.. _._._..._. f ,, Yes- qrk I.‘?

h. DOESTHE PLACE YOU RENT HAVE 10 OR MOREACRES’..I 0 No.4<l I&

c. DURINGTHE PAST12 MONTHSDID SALESOF CROPS.

I 0 Yes I21 LIVESTOCK,AND OTHERFARMPRODUCTSFROM

THlS PLACE AMOUNTTO $50 OR MORE’... _._.._...’ q No 14) d. DURlNGTHE PAST12 MONTHSDID SALESOF CROPS. / 0 Yes 13)

LIVESTOCK.AND OTPIER FARMPRODUCTSFROM

2lo.lNTERYIEPER IIAI.‘E t!nrr.,n ‘,Plb.INTERVIEWERNUMBER

FCUTldTES 22. ,DENTlFlCATlDNCDDENO.

!,.rk,m rd a,-‘rf”cnr,dLr n

23. REGIONALOFFICENUMBER

Frst Nom 01 Fwst Nom 02 la. WHATISTHENAMEOFTHEHEAOOFTHlSHOUSEHOLD?

b. WHATARETHE NAMESOFALLOTHER PERSONSWHO LIVE HERE?rw.lr Yes NI

C. IHAVELISTEO rradnomcs. ISTHERE ANYONE ELSE ST Los? Nom Lost Nore

d. HAVEIMISSED ANYONE WHO USUALLY LIVES HERE BUT IS NOWAWAY FROM HOIE'

C. DOANYOFTHEPEOPLEINTHISHOUSEHOLD Relofmnsh,p Aqe

HAVEAHOMEANYWHERE ELSE?

I. AREANYOFrtlE PERSONSIN THISHOUSEHOLOON Yes Nr HEAD

FULL-TIME ACTIVE DUTYINTHEARMED FORCES? /I',d, drlrtc 0 c

2. HOW IS--RELATED TO (head of hausehold)~ ir

-5. IS - - NOWMARRIED.WlD0WED. DIVORCED.SEPARATED.OR NEVER MARRIED'

I-

If 1: ,cor\ "ld 111111I,,, .i\b

6. WHAT WAS-- DOINGMOSTOF THE PAST12 MONTHS ({mm&r, WORKINGOR DOING SCMETHING ELSE?

II~rf~~~of~~I KEEPING HOUSE, WORKINGOR DOING SOMETHING ELSE' I,'.%" mdrdm (' rr undprrron I3 Ji lC"lr old ur "1L1. ".A

7. IS--RETIRED?

I,nlurrtf pI'""".< I9 ,lil73 old or o,er ‘Jr* hrwd 111Oddl,i<," l" ,hc 'I'.,, .‘,b WEWOULDLIKETOHAVEALLADULTSWHOAREATHOMETAKEPARTINTHE

I

^Ii INTERVIEW. ISYOUR--.ETC., AT HOMENOW? (WOULDYOU PLEASE ASK--, ETC., TOJOIN US?)

THISSURVEYCOVERSALLKINDSOFILLNESSES. THESE FIRSTQUESTIONSREFER TO LASTWEEK ANDTHEWEEK BEFORE.THATIS.THEZ.WEEK PERIODOUTLINEDIN RED ON THIS CALENDAR. Hand c&n&r LOrespondent and ark 80.

b&WAS--SlCKATANYTlMELAST WEEKDRTHEWEEKBEFORE(THE2WEEKS SHOWNONTHAT CALENDAR)?

I

b.WHATWASTHEMATTER?

e.DID-- HAVE ANYTHING ELSE DURING THATZ.WEEK PERIOD' 9a.LASTWEEKORTHEWEEK BEFORE.DID--TAKEANYMEDlClNEORTReATMENT

FOR ANY CONDlTlON(BESIDES...WHlCH YOU TOLDMEABOUn' b. FOR WHATCONDITION'

c. DID --TAKE ANY MEDICINE FOR ANY OTHER CONDITION?

1Oa. LASTWEEKORTHEWEEKBEFORE.DID--HAVEANYACClDENTSORINJURIES?

b. WHATWERETHEY?

_...~

C. DID--HAVE ANY OTHER ACCIDENTS OR INJURIES DURING THATZ-WEEK PERIOD I

1la. DID--EVERHAVEAN(ANYOTHER)ACClDENTORlNJURYTHATSTlLLBOTHER!

HIMOR AFFECTSHIMIN ANYWAY?

b. INWHATWAY DOES IT BOTHER HIM? ~ccord,m.wr t,,e<,s.

1‘2. Open par Floshcord booklet to Cord A and mod both sides o/Card A (A-l, A-2) condition by condition; record in his column any conditions mentioned [or the person.

J‘3. Turn 10 Cord 8 and mod both sides of Cord B (B-l, B-Z), eondicion by condition;

record in his column my conditions menrioned for the person.

1; 4% DOES--HAVEANYOTHERAILMENTS.CONDITIONS,ORPROBLEMSWlTH HISHEALTH?

b. WHAT IS THE CONDITION' Rrrord rondwon irsr/(r(srirr presmr. urkrnrtsr rwurd (In \I n, ,Pff, I I\.

c. ANYOTHERPROBLEMSWITHHISHEALTH?

-J Responded fcr selfenfmlv 1 Responded fn self-portly

'erson 'was respondent

1%. HAS-- BEEN IN A HOSPITALATANY TIMESINCE AYEARAGO?

I( 'I Cb", ask:

b. H O W M A N Y TIMES WAS--IN A HOSPITAL DURING THAT PERIOD?

6a. HASANYONEINTHEFAMlLYBEENINANURSlNGHOME.CONVALESCENTHOME.

REST H O M E ORSIMILAR PLACESINCE AYEARAGO?

I/ 'Its," ark:

b. W H O ?

For car* person reporred in ,a* ask:

c. H O W M A N Y TIMES WAS-- IN A NURSING H O M E O R SIMILAR PLACE OURING THATPERIOD?

.la. W H E N WAS--BORN? l/m OI+, tkr dote stomped in 150, ask 17b.

b. WAS-- B O R N IN A HOSPITAL? ,,'I es” and no kospiralimions rnrerrd m his column, enter ‘I” in 15. If “Yes” and o korpitalizorion is reported for tkc marker and bob, as6 17~.

~HESENEXTQUESTlONSAREABOUTRECENTVlSlTSTOOR FROMAMEDICALOOCTOR.

18. DURINGTHEPASTZWEEKS(THEZWEEKSOUTLINEDIN RED O N THATCALENDAR HOWMANYTIMESHAS--SEENADDCTORElTHERATHOMEORATA

DOCTOR'S OFFICE O R CLINIC?

19% [BESIDESTHOSE VISITS) DURINGTHAT W E E K PERIOD HAS ANYONE IN THE FAM~LYBEENTOA DDCTOR~OFFICEORCLINIC FORSHOTS,~.RAYS, TEST&OR EXAMINATIONS?

II ‘Icr.” ask:

b. vjHOWASTHIS? /

c. ANYONE ELSE?1 ^lark ^‘Yes.” in person’s column.

~---.-...__________________________---~-~~~~~~-~~.

For cock Yes” marked. ark:

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

E.\CLL DE vasils mode on “moss” bostr.

!Oa. DURINGTHAT PERIOD, DID ANYONE IN THE FAMILY GET ANY MEDICAL ADVICE FROMADOCTOROVERTHETELEPHONE?

,f ‘I CI’ ask:

b. WHOWASTHEPHONECALLABOUT! I

c. ANY CALLS ABOUT ANYONE ELSE? 1 ""' ')“'" in person'r co'umn.

For enck ‘Yes- m.,rkrd ask:

d. HOWMANYTELEPHONECALLSWEREMADETO

GETMEOlCALADVlCEABOUT--If no visrrr reported in pcstions 18.20 Ark:

Zla. =HOWLONGHASITBEENSlNCE--SAWORTALKEDTOADOCTOR'

Esrimntc is ocrcproble. ,, less tk.n I p,,, mark oppropriorr circle; if m m ,kon , ,m,, mark nmbcr oflrkolc p,rs.

/[ rkc lost visit UIIS within the pczsr I? monrks ark:

b. INTOTAL.ABOUTHOWMANYTlMESHAS--SEENORTALKEDTOADOCTOR DURINGTHE PASTUMONTHS?

THE FOLLDWlNGQUESTiONSREFERTDDlFFERENTKlNDSOF

PERSONAL C A R E S O M E PEOPLE NEED ATHOME:...

!Za. DOES--NEED ANY HELP IN BATHING. DRESSINGOR PUTTING O N HISSHOES?...

b. DOES--NEEDANYHELPATHOMEWlTHINJECTIONS.

SHOTS O R OTHER TREATMENTS? . . . c. DOES--NEEDANYONE'SHELPWHENWALKlNG UPSTAIRS

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

d. DOES-- NEED ANY HELPATALLIN CARING FORHIMSELF? . . . .._...

___-____________________________________---~~-~---~~---.

!3a. DURlNGTHEPASTlZMONTHS.HAS-- RECEIVEDANYCARE 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 OFTHESE VISITS DURING THE PAST%WEEKS?...

m<t _,us

Person number CONDITION NO. 1 / I. Person number

Enter pcrm nvnhar and ~n.me of eondirion’ / Nome of

and ask pe.rion 2. , condition

A.k ,or all conditiou I2. DID--EVERATANY TlMETALKTOAOOCTORABOUTHIS...! Y*r N O Y

T Emm,ks *Name o, condition’ enq in Iti* I I Accident a ,, Cordmon on ,-, Neither

and ma& one Lox. : 0 mpry-Co IO 4 Cord C-Co IO 9 Go ‘0 30I. : -_ I, ‘Doctor talked I.‘, ask: 2 3a. W H A T DID THE D O C T O R SAY IT WAS? DIDIEZlVEIT A

,,%eror not ralked to* record MEDICAL NAME? Cond.

.&quote dearrip& of

condi&,n or illness. i

No. of this I 3b. W H A T W A S THE CAUSE OF.. .! condition

C.,m. AC”!.

Accident or Injury _{H-k osc}

0 3

ia car.31

Total

,f the my in 30 or Sk includes tke wards: I 3~. W H A T KIND OF.. . IS IT? corditiom

Accident Yes N O

Asthma ‘Ail0X”t” ‘Disease” First inlury 0 3

Cyst ‘Attack’ “Disorder” /4 code Yes Na

Growth TX&~,” “Trouble” Ask: ~ Required c

Measles ‘Defect” haspitalirotion ”

TJlii. cm.

Tumw Cther Act. 1 c

For ALLERGY OR STROKE, Ask: - ~ M. H O W D O E S THE ALLERGY (STROKE) AFFECT HIM?

IC CTdum cc&.

For conditions on Card B-2 and for oar cny I 3e. W H A T PART OF THE B O O Y IS AFFECTED? I-Person’dws of disabilih, ”

rhor in&de. rb luordr: - 0

i.- ^R.A.]

Abscess Cyst Par0 lys is

ACk&;g Grawth Sme

Hemwrhage Screcess _i _j SHOV THE FOLLOWING DETAIL: B.D. j 0

Bleeding Infection Tuma

\ ₁~ Ear OTeye.. one OTboth

Blaad clot lnflommatlol Ulcer ^/Ask: Heod skull, scalp, face ^“lll.6 ^Y

Boil Neurolgio Weak Bock .upper, mldd le. Iwar T.L.[ 0 0

CWtCer Neuritis Weakness Arm ._._... shoulder, uppr, elbow, lower, wrist,

Cramps (except Pain hand; one c( both

m ”5t’“Ol) Palsy Leg hip, uppr, knee, lower, ankle, fwt; 12 ₀

one CT both Month! B.D. ’

FILL QUESTlONS 4-S FOR ALL ACCIDENTS OR INJURIES /

-la. DID THE ACCIDENT HAPPEN DURING THE @_ n,,r,m__ .= ~.. ?-veorc-r(rk a,.- ~. / 6a. W A S A CAR. TRUCK. BUS, O R DT R

PAST 2 YEARS O R BEFORE THAT TIME? L 1 D-‘,.-- ?^Iyears-co ‘0 50 M O T O R VEHICLE INVOL.VED IN THE “es No-Co,‘, Y lb. W H E N DID THE ACCIDENT HAPPEN? Enter nonth M I ~ec~u;n.rk one lox ACCIDENT IN ANY WAY?

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

INVOLVED?

1 Mon+h ~ “Or 1 i ;j?i;hy?hs ~:~~~~~~~~~~~~~~~111111111

c. W A S IT (EITHER ONE) MOVING AT YPI N O Y

0 3 0

years

Ask for oil accidents or injuries: 7. W H E R E DID THE ACCIDENT HAPF‘EN?

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

W H A T KIND OF INJURY W A S IT? ANYTHING ELSE?

Pm(s) of bcdy 1 Kmd of qury(lnjuries)

1 1 ‘. ““&&~~“T’H;‘~;C”;~;~ YesNo “.:‘:i7A.“% ,.,Y

ljoscidenr happened BEFORE 3 months, a.k:

5b. W H A T PART OF THE B O D Y IS AFFECTED N O W ? HAPPENED? 0 c 0 0 0

H O W IS HIS -- AFFECTED? FC0t”DtE.s

Port(s) of body Present effects

-- CONOITION ICon'd.) 1 REFER RESPONDENT 70 ~~-~~KCALENDAR F ~ R Q U E ~ T ~ O N S W ~

: Aak question h,m 011 candirions. 9% LASTWEEKORTHEWEEKBEFOREDIDHIS...CAUSEHIMTO C U T D O W N O N ; YCS N C C.U ,<e I

THETHINGSHE USUALLYDOES?

I--m-mm ~~~ ~~~~~ ~~- ~. ~~ ~. .~. ~~ -~ (8

k N;-C..,Io i / b. DIOHEHAVETOCUTDOWN FORASMUCHASAOAY!

* Ask rl~.st"na 10 a&l, if-yea' 110. H O W M A N Y DAYS DID HE HAVE TO CUT D O W N

morkd in quearion 9b. DUAINGTHATTWOYEEK PERIOD?

11. DURlNGTHATTWOWEEKPEFiIOD,HOWMANY DAYS Dl0HIS...KEEPHlMINBEDALLOAMOST OFTHE DAY?

Ark gu~rtien 12 if person is 112. H O W M A N Y DAYS DID HIS...KEEPHlM F R O M Under uorr Y

6-16 years old. SCHOOL DURINGTHATTWOWEEKPERIOD!

13. H O W M A N Y DAYSDIDHIS...KEEP HIM F R O M W O R K DURING THAT T W O W E E K PERIOD? /For{elndc~ add) NOTCOUNTINGWORKAROUNDTHEHOUSE?

Rsk pcrrion 14 ,or 00 CO"di,iOW. 14a. W H E N DID HE FIRST NOTICE HIS . ..? Cr,r3nor &iaclnca.-Celoll Y

WASITLIURlNGTH~PAST3MONTHSOR BEFORETHATTIME' ) Pw2xuwae2*<r.CI,.,d,I L) n”

1 b. DIDHEFIRST NOTICEITDURINGTHEPASTTWQ W E E K S O R BEFORETHATTIME? ~ ) (I

LX. *eeli Weeikh "

1 c. WHlCHWEEK,LASTWEEKORTHEWEEKBEFORE, ._

C mto16

Ask qucarion IS only i[c.ndirion 3 Ii mol. a,xe 12na. y n

was ,im no&ed %/or. 15. DID--FIRST NOTICE IT DURING THE PAST12 M O N T H S O R BEFORE THAT TIME? ' -> <

I AA: IF THISLA CONDITIONON cm A oRR,oR~TARTE~~EEFoRE~~~NT~~,-IsKQ.~~;~THER*~sE co T~ITENER.

(~ Ark question I?b if 'I- or Iwe 117% ABOUTHOWMANYOAYSOURINGTHEPAST Nme~C.mRB nY

BB: Is this rkr LAST 0 Yes - Ark 18.22 ifpersm k.s '1. or mare conditions pas* AA c.ndirion ,or ‘hia prr.on? 0 No - Co to nezt condition

Show Cord D. E, F, or G, 118. PLEASE LOOK AT EACH STATEMENTONTHISCARD(CAR0 0, E,F,G). THEN

(II appropriou basedon , TELL M E WHICH STATEMENT FITS--BESTINTERMSOFHEALTH.

number cc,: n :,

ad&y *tat”‘orqe. dlmk‘L(IIemenl + I ? 3 4.c.*m ” n

,,I. 2, or3 norkId in 18 ask:- 19. ISTHlSBECAUSEOFANYOFTHECONDlTlONSYOUHAVETOLDMEABOUT? WASHINGTONUSE

W H A T DOESCAUSE ,I ,, I> 0

/ 0 No- THIS LIMITATION? ~____ Enter caLwe

20. PLEASELOOKATTHEBLUECARD.CARDH.WHlCH ONEOF I? 31 5 611.1 d

THOSE STATEMENTSFITS--BESTINTERMSOF HEALTH? Y.rksroren.nrnumbrr --t ,' i> 2 ? c' c

~ 21. ISTHISBECAUSEOFANYOFTHE CONDITIONSYOU HAVETOLDMEABOUT? WASHINGTONUSE n

. in 20. ark:

"es NO Y

> ‘>

WHATDOESCAUSE

0 No- THIS LIMITATION? Enr.r E~YSC l m w

(I \a

HOSPITAL PAGE

USEYOURCALENDAR

Y O U SAID THAT--WAS IN THE (HOSPITAL/NURSING HOME) DURING THE PAST YEAR:

I?. W H E N DID - - ENTER THE (HOSPITAUNU HOME) (THE LAST TIME)?

3. H O WM A N Y NIGHTS WAS--IN THE (HOSPITAL’NURSING HOME)?

4a.HOW M A N Y OF THESE - - NIGHTS W E R E IN THE PAST 12 MONTHS?

I J

c.WAS - - STILL IN THE (HOSPITAL/NURSING HOME) LAST SUNDAVNIGHT FOR

THIS HOSPITALIZATION (STAY)? 0 Yes ONo

5. FOR W H A T CONDITION DID ENTER THE (HOSPITAL/NURSING HOME) -D O Y O U K N O W THE ME-DICAL NAME?

For deliveT ask: W A STHIS A NORMAL DELIVERY? , If ‘No’ ark:

W H A T W A S THE MATTER?

For newborn, ark W A S THE BABY NORMAL AT BIRTH? i Record in ‘Condition’ box Cadition

Kind

Pan of body I

6a.WERE ANY OPERATIONS PERFORMED O N --DURING THIS STAY AT THE (HOSPITAVNURSING HCME.)? 0 Yes ---~---~~~~~~~~~~~.~~~.~~~~~~~~~...~~~~..~.~~~!~~

b.WHAT W A S THE N A M E OF THE OPERATION?

c.ANY OTHER OPERATIONS? 0 No

7. W H A T IS THE N A M E AND ADDRESSOF THE (HOSPITAVNURSING HOME)?

Nom of Hospital

- CONTINUED O N NEXT PAGE

-Person numb9

WASHINGTON USE

CpYat Ion 2

Oprotion 3

l H

0 0

HOSPITAL PAGE (CONT’O) ASK QUESTIOXS R-10 FOR ALL COUPLETED HOSPITALIZATlOM Ma,k one *it9 8”0. d- .a I# I4 ~, SidP---+ 1 “N O ”in4. h ..,,‘,.,O 8-j

7 -

WASHINGTON USE

Ask if “No* mrkrd in gucrrion 4c:

T 0,. AT-W!

;. W H A T W A S THE TOTAL A M O U N T OF THE (HOSPITAL/NURSING HOME) BILL FOR THIS STAY?

D O NOT INCLUDE DDCTDRS’O R S U R G E O N S ’BILLS.

Ia.DIO (WILL) HEALTH INSURANCE PAY ANY PART OF

THIS BILL? 0 Yes 0 No-Co to JO Nom af insurance Plan Oollm I Cents

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

-c.DID(WILL)ANYDTHERHEALTHlNSURANCEPLANPAY _- . . ~~~~~~~~~___---_~__--- ____._.__ j..._

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

For r.sh Health ,nrumnce Plan noned, uk:

d. W H A T W A S(WILL.BE) THE A M O U N T PAID BY (Name of Plan)?

la.WHO PAID (WILL PAY) THE (REMAINDER OF THE)

HOSPITAL BILL? Uark roeh e~te~on neruioned B 0 Scciol Security Medicare - .

I I

b.DID ANY OTHER PERSON O R AGENCY PAY ANY

OTHER PART OF THE HOSPITAL BILL? C 0 Self and/or Family

0 0 Relative not in household

____----__~-~~~__..-.__-____________________

c.WHO W A STHIS? Mark eoeh cnregoty mentioned

E [7 Friend d.WHAT W A S THE A M O U N T PAID BY - -?

Enter mount paid opposite qpmptiate category. F 0 Kerr Mtlls cr other Fed. Plans

__-_-_--__--____________________________---INTERVIEWER: G 0 Armd Fwces Medicare

Add mmnts entered&&de any mamt paid by health

intt,,me, and enter in TOTAL bm, then mark one of de I

follodn~ boxes. H 0 State cx Local Welfare Agency

ASK QORSTIONSII - IS IF PERSON IS55 YEARS OLD O R O V E R Mark one circle l&WHEN - - LEFT (Name of hospital/nursing home), 0 Horn-Co b Quertion I.2

DID HE RETURN H D M E D R G O S O M E OTHER PLACE? q

________________-_______________________---~~~.---Some other place -Ask Question 116

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

b.WHAT KIND OF PLACE DID - - G O TO? Specify

--1

-1

U&r 51 ‘.. II I4 I: 7 i- A,‘,,

13 ,:,

WASHINGTON USE

i,,,, ,“k4. co,o* 0

!. AFTER LEAVING THE(HOSPITAL/NURSING HOME,) H O WM A N Y DAYS fi-3 c

DID - - HAVE TO REMAIN IN BED ALL O R M O S T OF THE DAY? Mmk entq 0

fl.1,rml.ir,, 1sk.,l 0

I. (ALTOGETHER) H O W M A N Y DAYS W A S- - CONFINED TO THE H O U S E AFTER i,Ye L

RETURNING H O M E F R O M THE(HOSPITAL/NURSING HOME.)? Mark entry

DOCTOR VISITS P A G E (1) See q”c”tionr 18.21. on Pager 4 and 5 Record roch dote on w.hich a Docror was visited in LI rrpomre Question 20 o/the Dorm Visits Querrions.

, . Person number

Ewe in and mark

I EARLIERYOUTOLDMETHAT--HADSEENORTALKEDTOA

~ DOCTOR DURING THE PAST2 WEEKS. lrite in and mark

‘2a. O N WHAT D A T E S DURING THAT 2.WEEK

-I PERIOD DIO - VISIT O R TALK TO A DOCTOR?

~~~t~~~~~~~~~ ~~ ~~~~~

dsk and record the answer to Qucrrion 2b on b. W E R E THERE A N Y OTHER DCCTOR VISITS FOR :- DURING~THAT PERIOD? I

rhr lost set of Doctor Visits Questions

/LX rock person. ,, Yes-Reosk Q. 20 q No-Ask Q. 35 for cock visit

W H E R E DID --SEE THE DOCTOR O N THE lDore,? Bark one circle * I_...

WASHINGTON U S E

,, bill not received. ask:

H O W M U C H D O Y O U EXPECTTHEDOCTOR ’S BILL TO B E FOR THAT VISIT (CALL)?

;.--- ~~~~~~~~~~~ I

~5. IS THE DOCTOR A GENERAL PRACTlTlONEi? 6R A SPECIALIST?

0 General Prcctitwer 0 Spcmlis.

~ ,, ‘Speci.lisr’ ark: WHAT KIND OF SPECIALIST IS HE?

DOCTOR VISITS P A G E (2)

I I. Person number Wrire in and mark

Person number

Pcrord each dote on which o Docror wa.s 1 EARLIERYDUTOLDMETHAT--HADSEENORTALKEDTOA -I

visited in D rcpuotc Question 20 of the I DOCTOR DURING THE PAST2 WEEKS. Ftite in and mark Doctor visits Qucskms.

;2a. O N WHAT D A T E S DURING THAT 2.WEEK

~~~

trk and rerard the answer IO Question 26 on I b. W E R E THERE A N Y OTHER DOCTOR VISITS FOR - - DURING THAT PERIOD?

I the fart ret of Doctor Visits Qucrrionr /

0 Yes-Reosk Q. 20 0 No-Ark Q. 3.5 for cash visit [or each pormn.

WTNOTES: / 3. W H E R E DID--SEE THE DOCTOR O N THE @.a)? lnrk one circle

I

^I If bill not received. ask:

; H O W M U C H D D Y O U E X P E C T T H E D D C T O R ’S I BILL TO B E FOR THAT VISIT&ALL)?

,..._-__~~~~~~~~~~-~~-__..._....~~~~~____-~~~~~~~~~~-~~.

I 5. IS THE DOCTOR A GENERAL PRACTITIONER O R A SPECIALIST?

I 0 General Practitioner 0 Spxialis!

j ,,~Spcci.list~ ask: WHAT KIND OF SPECIALIST IS HE?

WASHINGTON U S E

-I

Dum.Code I

SpX.

l m I

I I

57 I

Ask /or af1 prrsonr 1, pm old .,I OYII. Elementary 4a.WHAT ISTHEHlGHESTGRADE(YEAR)--ATTENDEOINSCHOOL? High schw Cd lege

b. OID--FINISH THE-GRADEIYEAR)?

5a.OlO~WOR~ATANY~lMELASTWEEKORTHEWEEK BEFORE?

Forfcm&r.dd: NOTCOUNTINGWORK A R O U N D THEHOUSE? n

b.EVENTHOUGH--DIDNOTWORK DURINGTHOSEZWEEKS, DOESHEHAVE A J O B O R BUSINESS?

c.WASHELOOKlNG F O R W O R K O R O N LAYOFFFROMAJOB!

d.WHICH-LOOKING F D R W O R K O R O N LAYOFFFROMAJOB? n

If 'Yes. in 25c ."l~,~ Ask ior 011pcrrons witk a ‘Yes” in 2.50, Eb, or 25s.

gverrions 260 ~26a.W H O DOES(DID)-WORK FOR?

~ c.WHAT KIND OFWORKIS(WAS)-DOING?

Fill Id/mm entries in 260-26s: i,not clear, ask.

d.CLASS CFWORKER n

Ask /or all mole. 17 7ewr otd or over.

‘2 7a.DID-EVERSERVEINTHEARMEDFORCESOFTHEUNlTEDSTATES?

-b.WASANY OF HISSERVICEDURINGAWAR?

- n

d.WAS ANYOF HIS SERVICE AFTER JANUARY31.1955!

28. WHICHOFTHESEINCOMEGROUPSREPRESENTSYDURTDTALCOMBINED FAMILY n

INCOMEFORTHE PASTlZMONTHS-THATIS.YOURS.YOUR--'S,ETC.?

SHO~CARDI. INCLUDEINCOMEFRDMALLSOURCESSUCHASWAGES,

I SALARIES,SOClAL ICURITYORRETIREMENT BENEFITS,HELPFROM RELATIVES.RENl 'ROMPROPERTY,ANDSOFORTH.

F:OCTNCTES WASHINGTON USE n WASHINGTONUSE n

'Transcribe codes fcr I Respandent hem R (Respondent)

0 - Self*ntirely ~ Age of respondent I - Self-pwly

2 -Spouse

~ Family relationship

3 - hlotkr 3 -Father Y-k income pu, each r&cd person’s column.

n I

I Cccuptim

-- represents your total combined family income for the past 12 months? In

clude income from all sources such OS wages, solaries, social security or retirement benefits, help from relo

4. TROUBLE wi:ilhvaricose veins?

5. Hemorrhoids et piles? amount of other activities.

4. Not limited in any of the above ways.

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individual ---- ---

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In document Current Estimates (Page 57-67)