SUPPLEMENT ON AGING 1 3-4 Section N. FAMILY STRUCTURE, RELATIONSHIPS, SUPPORT, AND LIVING ARRANGEMENTS
I
8. initial status of sample person I I 0 Available (Nlbl 1 5
I
Nl
b. Supplement beginning time 1
2 0 Callback required (Next SP)
picpj { p”,;
Read to respondent - We are interested in obtaining further information about the health of people 55 years of age and older in the United States. I will also ask you some questions about your family and social actlvlties.
Enter “Sample Person” on appropriate line.
Enter “Unrelated” for persons not related to the sample person.
Enter “Deleted” for any deleted persons, except AF members living at home and babies born during interview week.
Enter ages from H/S- 1.
Refer to marital status (page 46 or 47) on HIS-1
I I q Sample person is now married fN3)
I I 2 0 Sample person is now widowed, divorced, separated 126)
I I
Number of years ---~~---~---~---~-,,,,,,,,,,---~
3. Earlier [you told me/l waa told] that you are now
Cwidowedldivorcedlseparatedl. How long have 1
you been Iwidowedldivorcedlseparatedl? I
I
I Number of years
I
a. Including step and adopted children, how many LIVING I oo ONone (61 )77--78
children do you have? I
I
I Number
~--~~-~---~---~--~---c---~~---~----
3. How many of your children are sons and how I 79-80
many are daughters? I 81-82
I
I Number of sons
Iii 83-84 I
I
I I Number of daughters
pzl Total number of children
I Compare with 3a, reconcile differences
Section N. FAMILY STRUCTURE, RELATIONSHIPS, SUPPORT, AND LIVING ARRANGEMENTS, Continued
your children/your son/your daughter]? I
I I [house/apartment] from the outside7
b. Counting basements and stepdown living araas as separate levels, does this [house/apartment] have more than one floor or level?
RT 66
Section N. FAMILY STRUCTURE, RELATIONSHIPS, SUPPORT, AND LIVING ARRANGEMENTS, Continued 3-4
11 a. Does this Ihouselapartmentl have a bathroom, bedroom, I
Section 0. COMMUNITY AND SOCIAL SUPPORT
community services. sometimes, or rarely?
I
RT 67
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6. Are you now receiving disability payments from any source?
Section P. OCCUPATION AND RETIREMENT, Continued I
Section P. OCCUPATION AND RETIREMENT, Continued I
P3 Refer to Wa/Wb boxes for SP in C 1 on the ’ I 0 Wa or Wb box marked (Section Qj (
HIS- 1 Household Composition Page I 9 0 Other fP4J
I I
P4 Mark first appropriate boxI I 1OSPis75+
’ 2 q Proxy (Section Q) I 3 0 Self response (13)
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130. Do you think there are some kinds of work ) 1 UYes
you could do now if jobs were aveileble? I zuNo
I 9 0 DK/maybe > fSection Q)
---~----~---~ 92p’
b. Do you WANT lo work at e job or business? I
I I UYes
’ ZUNO
FOOTNOTES
Section Q. CONDITIONS AND IMPAIRMENTS 3-4
Circle appropriate condition I
I 1OYes 20 No 90DK
Section Q. CONDITIONS AND IMPAIRMENTS, Continued
d. Hypertension, sometimes called high blood pressure?
e. Rheumatic fever?
13
Section Q. CONDITIONS AND IMPAIRMENTS. Continued
. During the PAST 12 MONTHS, did you have -
This information is voluntary and collected
) 999999999 0 DK ---=
I under the authority of the Public Health Ser- 1 vice Act. There will be no effect on your benefits and no information will be given to any other government or nongovernment agency.
Section RI. ACTIVITIES OF DAILY LIVING (ADL’S) Read to respondent - The next questions are about how well you are able to do certain activities -
by yourself and without using special equipment.
Bathing or showering7
Ask if “Doesn’t do”:
3 0 Doesn’t do for other reason 3 0 Doesn’t do for other reason 3 0 Doesn’t do for other reason
Anyone else?
asking if ONLY help is from spouse/children/parents.
b. Is this help paid for?
4 0 Nonrelative ’ I 0 Yes 20 No 4 0 Nonrelative ’ I 0 Yes 2 0 No
60. What lother) condition CBUSBB the trouble in freadADL(s))?
Ask or mask 66, if O-3 months injury or operation.
Otherwise, mark appropriate box
) RT 71 Condition Summary Chart, THEN next page.
,RMHlCl ,se, ,1084,,3.13-84,
1
RI Mark first appropriare box I seeninabedorchair
, 30 Telephone interview >
FOOTNOTES
Sectian ---_______-. _._____.___________-__ -- -- --__-_ -_-_.-- R2. INCIDENTAL ACTIVITIES OF DAILY LIVING flADL’S\ ___- -, I c(1”ees the troublG In IreadlADLfsjJ?
C. Is the trouble In fresdlADLfs)l caused by enY (other)
0 No f15dl iiii~iii~.~iiaii~lilii~~~~~~~~~~~~~.~~~~~~~
. . . >
Section R2. INCIDENTAL ACTIVITIES OF DAILY LIVING UADL’S), Continued
(3) I 58
(41 1 70 (51 1 82 (61 1
Managing your money, (such as keep- Reask 7 1 Doing heavy housework, (like scrub- Doing light housework, (like do-
ing track of expenses or paying bills)? Using the telephone? bing floors, or washing windows)? ing dishes, straightening up, or
light cleeningl?
to Yes 1 cl Yes 1 0 Yes 10 Yes
znNo ZUNO znNo 20 No
3 0 Doesn’t do for other reason 3 0 Doesn’t do for other reason 3 0 Doesn’t do for other reason 3 0 Doesn’t do for other reason
1 59 71 1 83 1
1 cl Some 10 Some t 0 Some 1 q Some
2 0 A lot 2 0 A lot 2 17 A lot 2 0 A lot
3 0 Unable 3 0 Unable 3 0 Unable 3 0 Unable
1 60 1 [ 84 1
1 0 Yes 1 0 Yes 10 Yes 1 0 Yes
2 0 No (72 fornextIADL with 2 0 No 172 for nextIADL with 2 0 No (12 fornextJADL with 20 No (151
“Yes” in 7 I) “Yes” in 1 7 I “Yes” in I I!
I / / I
Source of help ; Paid Source of help I Paid Source of help I Paid Source of help I Paid
14s. 14b. 14a. I 14b. 14a. I
I I I 14b. 14a. I
I 14b.
181-641 185-68 73-781 77-80
I I 185-881 189-92
I 97-100 I 1101-1(1
H member I 0 0 S/C/P HH member I 0 0 S/C/P HH member / 0 0 S/C/P HH member I cl 0 S/C/P
I 0 Relative .I I 0 Yes 2 0 No 2 0 Nonrelative I 1 0 Yes 2 0 No
I 0 Relative / I 0 Yes 2 0 No 2 0 Nonrelative I I 0 Yes 2 0 No
I 0 Relative .I I 0 Yes 2 0 No 2 0 Nonrelative I 1 0 Yes 2 q No
I 0 Relative I I 0 Yes 2 q No
2 q Nonrelative I I 0 Yes 2 0 No
I I I I
on-HH member I Non-HH member I Non-HH member I Non-HH member I
3 0 Relative .I I 0 Yes 2 0 No 3 0 Relative ,I I 0 Yes 2 0 No 3 0 Relative .I I 0 Yes 2 0 No 3 0 Relative .I 1 0 Yes 2 0 No 4 0 Nonrelative , I 0 Yes 2 n No 4 0 Nonrelative / I q Yes 2 0 No 4 0 Nonrelative I I 0 Yes 2 0 No 4 0 Nonrelative \ 1 u Yes 2 n No
I I / I
(3) [ 69 (41 1 81 (6) 1 93 (6) I 105 c-
I 0 O-3 month Inj! Op ONLY
>
I q O-3 month Ini/ Op ONLY
>
I 0 O-3 month lnjl Op ONLY
2 0 Old age > 3
I 0 O-3 month
2 0 Old age 1 2 q Old age 3
Ask 15d fornextJADL with “Yes”in 1 I Ask 15d for nextlADL with “Yes” in 7 I Ask I5d for nextIADL with “Yes” in I 7
I”i/ OP ONLY > Next page 2 0 Old age
30 30 30 30
Condition - EnterinIADL box on Condition Condition - Enter in IADL box on Condition Condition - Enter in IADL box on Condition Condition - Enter inlADL box on Condition Summary Chart, THEN ask 15d for next LAD1 Summary Chart, THEN ask 15d for nextIADL Summary Chart, THEN ask 15d for nextIADL Summary Chart, THEN next page.
with “Yes” in 1 I. with “Yes” in I I. with “Yes”in Il.
‘OOTNOTES
1
‘.
about health related matters.
1 I 0 Excellent 4 0 Fair 1
1 2 0 Sample person mentally/physically incapable of responding fExplai#
1 9 0 Other fExp/ain)
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Ailment CO”lX, DIM080 Problem
Anemia Condition Disorder RUptUr.3
Asthma Cyst Growth Trouble
Attack Defect M.X3sles Tumor
Smd IJhX,
e. What kind of lcondition in 3b) is it? (Specify) J
1 RT 73 I
Section U. SUPPLEMENT CONDITION PAGES
Except for eyes, ears, or internal organs, ask 3h if there are any of the following entries in 3b-f:
InfectIon SINS SWStlSSS
h.What pert of the (part of body in 3b-@is affected by the [infection/sore/soreness1 - the skin, muscle, bona, or soms other pert? (Specify)
For Stroke, fill remainder of this condition page for the firsr present effect. If additiona present effects, enter in CDndirion Summary Chart each one that is not a/ready in the Condition Summary Chart. l/f in C2 in HIS- 1, enter condition number and transcribe when editing; if not, fill additional supplement page(s) during-w.)
Ask 3g if there is an impairment (refer to Card CP2) or any of rhe
Abscess th”CW InfectIon Rupture
Ache (wwxspt Cramps (except Inflammation Sorel”s5s)
head o, earl menmtruall Neursl~la SGff(nes*J
SIndIng lsxcept Cyst Naurltls Tumor
ms”*t,“al, Damage Pal” UllX,
Blood clot Growth Palsy Varicc.se vain.
SOII Hamorrhags Paralysis Wsaklnessl
Ask if box 3, 4, or 5 marked in item 5
l l If multiple present effects, enter in Condition Summary Chart each one that is not the same BS 36 above or is not already in the Condition Summary Chart ill in C2 in HIS-l, enter condition-
snscribe when editing; if not. fill additional supplement pagelsl during interview.) and tr<
a. indicate status of this 1 q Transcribed from HIS-1
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1 RT 73 1Allmmnt tZ*bllXr DI#,**a Problem
An0nlla Condnlon Disorder ltuptura
Asthma CW Drowth Troubla
For Stroke, fill remainder of this condition page for the first present affect. If additions oresent effects, enter in Condition Summarv Chart each one that is not akeedv in the
‘Condition Summery Chart. f/f in C2 in H/S-i, enter condition number and transcribe when editing; if not, fill additional supplement pagels) duringxw.l ---
Ask 3g if there is an impairment (refer to Card CPZ) or any of the
mokl,phlolv~n upper, mhkwa, lower
Sh . . . .._..._...t. l&l orrlftht the Knfactlonlsorelsorenessl - the bone, or some other part? (Specify)
d
Ask if there are any of the following entries in 3b-f: 1
TUltKW cyst Growth
I. Is this ftumorlcystlgrowthl malignant or benign?
1 0 Malignant 2 0 Benign snDK
l l If multiple present effects, enter in Condition Summary Chart each one that is not the same s.s 3 above or is not already in the Condition Summary Chart. Ilf in C2 in HIS-l, enter condition numb1 and transcribe when editing; if not, fill additional supplement pagalsl during interview.1
1
I -
Ailment ClXWXr Disease Problem
Alll3lXlia Condltlon Disorder RUptWe
Asthma Cyst Growth Trouble
For Stroke, fill remainder of this condition page for the first present effect. If additiona present effects, enter in Condition Summary Chart each one that is not already in the Condition Summary Chart. f/f in C2 in HIS- 1, enter condition number and transcribe when editing; if not, fill additional supplement page(s) duringinterview.)
Ask 3g if there is an impairment Irefer to Card CP21 or any of the following entries in 3b-f:
Abscess CallCC3r Infection Rupture
Ache lexcept Cramps lexcept lnflemmetion SOIE4IlWSl
hsad or ear) menstrual) Neuralgia Stifflnessi
Bleadlng lexcspt Cyst Neuritis Tumor
menstrual) Damage PlJilI Ulcer
Blood Clot Growth Palsy varicose vein*
SOII Hemorrhage Paralysis Weekbmssl
, g. What part of the body is affected? (Specify) J
Section U. SUPPLEMENT CONDITION PAGES
CONDITIONC EC I Except for eyes, ears, or internal organs, ask 3h if there are any of
the following entries in 3b-f:
Infection SOEl Soreness
Sh. What part of the (part of body in 3b-gl is affected by the [infection/sore/soreness1 - the skin, muscle, bone, or some other part? (Specify)
l l If multiple present effects, enter in Condition Summarv Chart each one that is not the same as 3b above or is not already in the Condition Summary Chart. llf in C2 in HIS-l, enter condition number and transuibe when edding; if not, fill additional supplement pagefsi during interview.)
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1 RT 73 1Section U. SUPPLEMENT CONDITION PAGES
CONDITION D l-s
Ailment Ctl”Cer Disease Problem
Ansmia Condition Disorder RUptUre
Asthma Cpt Growth Trouble
For Stroke, fill remainder of this condition page for the first present affect. If addition:
present effects, enter in Condition Summary Chart each one that is not already in the Condition Summary Chart. f/f in C2 in H/S- I, enter condition number and transcribe when editing; if not, fi// additional supplement pagefsl duringinterview.)
Ask 3g if there is an impairment (refer to Card CP21 or any of the Sacklsplnelvertebree ... upper, middle, lower Side ... leftcrrlght the [infection/sore/soreness] - the skin, muscle, bone, or some other part? ISpecify/
l l If multiple present effects, enter in Condition Summary Chart each one that is not the same 8s 3b above or is not already in the Condition Summary Chart. (If in C2 in HIS-l, enter condition numb81 and transcribe when editing: if not, fill additional supplement page(s) during interview.)
1
CONDITION E hi2
Abscess th”CM Infection Rupture
Ache (except Cramps Iexcept Inflammation 8orelnessl
head o, ear) menstrual) Neuralgia Stiff(nessj
Bleeding (except Cyst Neuritis Tumor
ms”strualJ Damage Pai” lJlC.3,
Elood clot Growth Palsy varicose veins
Boll Hemorrhage Paralysis Weaklness)
g. Whet part of the body is effected7 fspecifyl
Section U. SUPPLEMENT CONDITION PAGES
Ask probes as necessary:
l l If multiple present effects, enter in Condition Summary Chart each one that is not the same as 3b above or is not already in the Condition Summary Chart. ilf in C2 in HIS-l, enter condition number and transcribe when editing; if not, fill additional supplement page(s) during interview.)
I ( 26
a. indicate starus of this 1 q Transcribed from HIS-l
earh.... II ~IIDDI EMFNT mwunlTmN PACF~
“V”.,“..V.W”. . --...-.w. -.v.m-...-.-. .----
CONDITION F 3-4 Except for eyes, ears, or internal organs, ask 3h if there are any of
6-6 the following entries in 3b - f:
Name of condition Infection Sore SOretteSS
3h. Whet pert of the (part of body in 3b- lis effected by
Condition Summary Chart. (If in C2 in HIS-l, eater condition number and transcribe
when editing; if not, fill additional supplement page(s) duringinterview. Ask if box 3, 4, or 5 marked in item 5
Blending (except Cyst Neurlth Tumor
msnstruall Damage Paill Ulcer
Blood clot Growth Palsy varicose veins and transcribe when editing; if not. fill additional supplement pagelsl dwng interview.l
1
Show the following detail: a. fndicate status of this 1 q Transcribed from HIS-1
Hand . . . skull, scalp, face condition page. __/T 2 aobtained in SOA Interview
gacklspinefvetiebrae upper, middle. lower
Side .,....,,,...,..,..,..,... leftorright
1
Is this [tumor/cyst/growth1 malignant or benign?
10 Yes z0No s0DK
Anemia Condition Disorder Rupture
Atihma Cpt Growth Trouble 20 Cured 8 0 Other LSpecifyJ
l l If multiple present effects, enter in Condition Summary Chart each one that is not the same as 3b above or is not already in the Condition Summary Chart. Ilf in C2 in HIS-l, enter condition numbe and transcribe when editing; if not, fill additional supplement page(s) during interview.1
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1 RT 73 1Section U. SUPPLEMENT CONDITION PAGES
CONDITION H 1
Ailment Cll”O.3I Disease Problem
Anemia Condition Disorder Rupture
Asthma Cy*t Growth Trouble
Attack Defact MEll3Sh Tumor
gad LJhXr
For Stroke, fi// remainder of this condition page for the first present effect. If addition, present effects, enter in Condition Summary Chart each one that is not a/ready in the Condition Summary Chart, (If in C2 in HIS- I, enter condition number and transcribe when editing; if not, fi// additional supplement pagelsl duringinterview.
Ask 3g if there is an impairment (refer to Card CF’2) or any of the following entries in 36-f:
Abscess CalMXr InfectIon RUptWe
Ache (except Cramps (except lnflammatlon Sorehsssl
head or ear) menstrual) Neuralgia Stlfflnslsl
Bleadlng Iexcept CYSt Neuritis Tumor
menwtruall Dalllage pain Ulcer
Blood clot Growth Palsy “arlco*e veins
GOII Hemorrhage Paralysis Weaklnessl
g. What part of the body is affected? (Specify) i
Show the following detail:
Head ,, ..,, .., ..,, skull, scalp, face
Back/splne/vsrtebree upper, middle, lower
Glde ,,...,..,...,..,..,.,,,..,.,.,,...,.... ,.... leftorrlght the [infection/sore/soreness1 - the skin, muscle.
bone, or some other part? (Specify1 and transcribe when editing: if not, fill additional supplement pagelsl during interview.~
I ( 26
CONDITION SUMMARY CHART
1 INSTRUCTIONS - If no entries in Summary Chart, complete cover page and any additional supplement booklets required.
All conditions in Summary Chart must be accounted for. Compare to C2 in HIS-l for sample person.
1. If a condition page IS already filled, enter the condition NUMBER in the diagonal space on the Summary Chart.
2. If a condition page is NOT filled, complete a LETTERED supplement condition page and enter the letter in the diagonal space.
3. If the condition wording on the HIS-1 and the Summary Chart are similar but NOT identical, probe: Is the kwdement conditionlthe same condition as the (HIS- 1 condition1 I was told about earlier?
If any doubt. fill a lettered supplement condition page.
When editing, transcribe the appropriate data items from the HIS-l Condition Page to a lettered supplement condition page for those conditions with a number in the diagonal space on the Summary Chart. Also, cross out the number in the diagonal space and indicate the lettered supplement condition page.
!YE LTR I EAR LTR I EVER LTR 112 MD LTRI .---l---~---
ADL NUMBERS IADL NUMBERS
:iii : :
!YE LTR ! EAR LTR ! EVER LTR 112 MD LTR! ADL NUMBERS IADL NUMBERS .--j---[---[---i---j---[<
3YE LTR ! EAR LTR 1 EVER LTR !I2 MD. LTR 1 ADL NUMBERS IADL NUMBERS .--r--[---i---j---i<
EYELTR ! EARLTR lEVERLTRl12MO.LTR ADLNUMBERS I HDL NUMBERS I CP
\
EYE LTR ! EAR LTR ! EVER LTR I12 MO LTRI ADLNUMBERS 1 IADLNUMBERS I CP
>
iY? L%? &i-L% %zRITx !E ii,%@ - ?,DL 6t,,iiEj7S- 7 - fiDc $j,.?bE%- 7 -CT
i
ifit L%? i%l%%i %‘&R-ifii !E i?O%Til - ID? $,iiEjS- 7 - iiiD?J N%tiiEES- ?- -C?
F