PROGRAMS AND COLLECTION PROCEDURES Series 1 Number 10 b
Plan and Operation of the Health and Nutrition
ExaminationSurvey
United States-197M973
A description of a national health and nutrition examination survey of a probability sample of the U.S. population 1-74 years of age:
Part A-Development, plan, and operation.
Part B-Data collection forms of the survey.
DHEW Publication No. (PHS) 79-1310
U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service
Office of Health Research, Statistics, and Technology National Center for Health Statistics
Hyattsville, Md. January 1977
NATIONAL CENTER FOR HEALTH STATISTICS
DOROTHY P. RICE, Director
ROBERT A. ISFUEL, Deputy Director
JACOB J. FELD W, Ph.D., Associate Director for Analysis
GAIL F. FISHER, Associate Director for the Cooperative Health Skzti~tics System ELIJAH L. WHITE, Associate Director for Data Systems
ANDERS S. LUNDE, Ph.D., Associate Director for Interrzdiond Statistics ROBERT C. HUBER, Acting Associate Director for Management MONROE G. SIRKEN, Ph.D., Associate Director for Mathematical Statistics
PETER L. HURLEY, Associate Director for Operations JAMES M. ROBEY, Ph.D., Associate Director for Program Development
ALICE HAYWOOD, Information Oficer
CONTENTS
Part B
Appendix HA.
Appendix IIB.
Appendix IIC.
Appendix IID.
Appendix HE.
Appendix IIF.
Appendix IIG.
Appendix LIH.
Appendix IIJ.
Appendix IIK.
Appendix IIL.
Appendix IIM.
Appendix IIN.
Appendix 110.
Appendix IIP.
Appendix llQ.
HANES Household Questionnaire . . . . . . . . . Food Programs Questionnaire . . . . . . . . . . . Medical History Questionnaire, Ages 1-5 . . . . . . . Medical History “Questionnaire, Ages 6-11 . . . . . . Medical History Questionnaire, Ages 12-74. . . . . . General Medical History Supplement, Ages 25-74 . , . Dietary - 24-Hour Recall Questionnaire . . . . . . . Dietzuy - Frequency Questionnaire . . . . . . . . . Health Care Needs Questionnaire . . . . . . . . . General WeII-Being Questionnaire . . . . . . . . , Supplement A . . . . . . . . . . . . . . . . . Supplement B . . . . . . . . . . . . . . . . . Supplement C . . . . . . . . . . . . . . . . . Examination Forms (all exarninees) . . . . . . . . Control Record . . . . . . . . . . . . . . . . General Medical Examination, Ages 1-74 . . . . . . Body Measurements . . . . . . . . . . . . . . Dermatology Examination . . . . . . . . . . . . Ophthalmology Examination . . . . . . . . . . . Dental Examination . . . . . . . . . . . . . . Report of Dental Findings . . . . . . . . . . . . Report of Physical Findings . . . . . . . . . . . Nutritional Biochemical Lab Data Form (all examinees) . Examination Forms (additional for detailed examinees) .
Control Record .,... . . . . . . . .
General Medical Examination . . . . . . . . . . . Goniometry . . . . . . . . . . . . . . . . . . Respiratory Function Tests . . , . . . . . . . . . Audiometry . . . . . . . . . . . . . . . . . . TB Skin Test . . . . . . . . . . . . . . . . . Report of Physical Findings . . . . . . . . . . .
Page 1 4 5 7 10 14 20 22 23 27 29 35 39 42 42 43 45 46 51 56 60 61 63 64 64 65 72 73 74 75 76
...
IllAPPENDIX 11A. HANES HOUSEHOLD QUESTIONNAIRE
A
NoTICE - All ir.!m-m.tion which wn.ld pmmiL idcnli[icarion .1 ,h. individ.nl will be held in ,Lrict eodidmce
will b, umd ..IY by pcrs.m engaged in and Im b. p.rpmcu .1 Lhe .urv.y. nnd will not b. disclosed mrel=m.ed O.M.B. NO. 68-R1184
to ctb.rs 1., ,“. Durposes, APPROVAL EXPIFIES DECEMBER 31, 1973
,m HES-5 (CYCLE IV)
m.,,, 1.Stand No. 2. {~d~tific.lion 3. PSU No. 4. Segment No. 5. Serial No. 6.
..S. DEPARTMENT OFCOMMERCE ..”..” ., THE .E.,. m
Q.. stio.n. irm _ ..,,.. .s =. . ...7!.. . . Fom THc
LI.s-Pu. L’C HEALTH SE.VICE
HEALTH EXAMINATION SURVEY
Addrcns or dcsm,p!,on of locnLio. (IN.. and St., City, SL.tc, ZIP code)
city
Is,,,. IZIP cod,1 1
Is -- your CO,l.Ct mmi[ln~ ~ddr. s.?
(Wh.f is your c.nmcI mmiling .ddr...?)
n Ye.
❑
No❑❆
w.sti..nair.s
Listirt~ B. Ye.rbuilt - If ‘, A.k’3 box is “X”d, complete
sheet Lbis item b.fvm the interview
Sheet __ D}!!7____---__B?:k:_ Y-k--- NO. — Whmnw.. thi. shuci.r. .rigi..lly b.il17
L.. n Before 4-1-6o
❑
After 4-1-50- Go to Q. 12., completeNo._ Continue LIteruinu if required and end iuemiew
11.
Special placename ;Type
Type cod.1
! 1
15. Wha! is ih. tal.phon. numb.r hr.?
City’
i
SImL. 1ZIP rode1 1
Type of livin,g q.arwra
Mark onc b.m I
❑
Hou.in~ unit 2❑
Other unitA.k:
❑
. . Ar. ih.,. any .c..pi.d or vacant Ilvl.g q..rt.r. b.zid.~N~ own i. fhix building?l_J Ye. (fill Table X) n None
--- 16. INTERVIEWER
❑
b. A.. *hmr. any o...pd.d or vacanl livin~ q..rl.rs b..id.s your own . . ibis flmar?❑
Yes ([ill Table W(Ask only for hour.kolds with EP’s)
❑
No--- Th. i. form.tio. Y.U h.v. iust giv.n m. will h n c. 1. th.r. any oth.r building . . Ihi. prop.~ for p..pl. t. Iiv. i. - .ilh.r .c..pl.d or v.=.nt? .Id by th. PubIl. H~lth S.rvi=. fa d.t.nnln.
❑
Ye.(fill
Table A)❑
No which p.ra.ns will b. aik.d in pnrticipat. i. tfu--- .!h.r part of thix s.rv. . Th.t part will cov.r
❑
d. None (itemL) hcalih❑nd ..iriti.n. I[my.n. in your h.us.h.li. ..l. ct.d, . r.pr. s..t. tlv. of ih. U.S. P.bllc
!TEM L ! 2
❑
Rural (13) I❑
All other (Q. 1, p. 2) Health S.wi.. will k c.llin~ . . you wiihl. aw..k orm. t..xplai. th. s.c..d pm+. Whet
0. y.. own or r.nt this pl.c.7 I-Jowl l_JRent n Rent Ire. would b. A. hit tint. for h.r to visit y.. --
m.mlng or dt.mo. n?
How many .cr. s of Ia.d .r. in.1.d.d? 1
❑
10 or more z❑
LCSH than D.y Timemeres (b) 10 acreB (c) ■om
During th. past 12 months did s.I.s .1 =r.p., Iiv.stock, and
P.m z U YCE
(Q. 1> •~No(Q. 1,
oth.r fmm pred. =ts frotn th. pi... ri,n.unt to $50 e. mm.? Name .[renpmdem
p. 2) p. 2)
During th. p.nt 12 month. did snl.s of =rops, liv.~1..k, ❑nd 3
❑
Y., (Q. 1, s❑
No (Q. 1,.th. r fnrm p,nd. dt from thm pl. c. remountt. $250 or mom? P. .2) P. 2) LEA VE THANK YOU LETTER
RECORD OF CALLS AT HOUSEHOLO
1 cm. 2 Corn. 3 cm= 4 cm?. 5 con% 6 6nl.
❑,,,
Time mm. a.m. a.m. &m. a.m. R.UI.
p.m. p.m- P.m. p-m- P=- P.m.
REASON FOR NONINTERVIEW
TYPE A
I
lTPE B
I
TYPE CI
TVPE ZfC.c@.ta ii-a 1-14, 17-x7) (Cm@.te clone 1-12,L, (complete 11-.1411,
14, 17, 2S,and W
(Paru.r Mm-vi-v>
17, 18, and m)
. For ‘“find”’ Tm. A n.nintewiewn enter name., approxim.w .Kea, and ..x of hou~eh.ld membern. i 19b. !%. supplied tbia in form. tier.?
Yi.me AR. sex Nmme Au= sex Nun,
1. 4. Number ■r,d❑u,,,, mute. mboXnmba
2. 5.
City
3. 6.
Rmce iQ. Sigr..ture of inlmvi.wtr l’=ode
❑
W❑
N❑
OT iI
1
,, Whet isthe n.m. of th. hand of thii household? - Enter name in first column. Ye.* No ). Wfmt❑re the names of all other persons wha live hove? - Limt all persons who live hem.
:. I h.v. listed (Read names) Is there anyone .1s= staying hare now, such as hiemds, r.1.aiives, or romn.rs?
❑ ❑
1, Have I missed anyone who USUALLY lives hem buf is now
❑
way from home? . . .❑ ❑
t. Doa.yof the people in this ho.sahold hovi. home anywhere else? ., . . .
❑ ❑
H any .dult males listed, ,sk: “ Apply household membership rules.
Are may of the persons in this household now . . full-timm
active duty with the Armed Forces of the United St. tes? 0 Ye, — Col(s). _.(Dele Le) m No
H.w i. -- r.[.ted t. -- (Head .1 household)?
,. How old WE, --0. his Iosi birthday? - Enter Age and circle Race and Sex.
,. What i. *he month, day, and year of --’s bir~h? - U.. card to check birth d.te and nge far conniatency.
c1
INITlfVIEWER: Mark the box Ior each person .8. 1-74 years nnd CONTINUE DO NOT CONTINUE for perscmn under 1 or 75 ye.rs❑
f a~e or over.If no EP. m to ..=. 1. mmstion 15,
1.whoi .%te was -- born? Enter &e nameof th= St.tt or foreign country.
Ask for all EP’s 17 yews old m ovec
Is -- nowm.rried. widowed, divorced, sewm.ted, or ..v.r mami.d? - Mark❑ne box for each EP.
,k for .11 P’=6 ye.r.
d m over,
,k for ,ildre”
-5 ye.,.
d.
,kfor .11 EP ,us,holds.
$m. W1.t isthehighest gmdm or y.nr of r.g.l.ar school -- has ev.r
❑
tlmnded?--- b. Did -- finish the -- gmde (year)?
If6–18 y~,,,, ask, ., Is -- .zHending schoml now?
d, Whet is th. name o“d location of ih. school -- goes to?
---
r.zHa. -- everattended o school of any kind?
- —---
b. Whmi kind al school?
3.. Is any language other th.. English frequently
sp.ke. here in this hem.? 1
❑ y= (ah) z ❑ N.
- —--- (9)b. What Iangumge(s)? Leq.mge(s) spoken
?. Which of the groups .s. this card - (hind curd) bast dsscribas your (your husband’s; or --’.) MAIN ancestry or nm,ionol origin?
(Additional probe, what is yourMAIN ancas!ry or ..ti.n.l origin?) 3., What was -- doing MOST .f the pasf THREE m.n?h. -
(for males): working or doing something else?
(forfemales): kespi.g house, working, or doing smnethl.~ el~.?
--- -
b, What was -- doing?
---
., D,d -- work et o iob m businmss AT ANY TIME d.rinq the p.st’ THREE months?
d. When -- w.. vmrki.gr did be work full tint. ❑r part lime?
1.. Did -- work .t any time 1.4 week or th. week b. for.? ([orfemales): not. . ..fing work around Ihe house?
_________________________________________________________________ -
b. Eventhough -- did not wo,k during Ihat time, de.. he hove a id or b.sin.. s?
--- - —--- .
c._________________________________________________________________Was h.looking for work or on layoff from oi.b? .
d.Which - I.oking{orw.,k or on layoff from. iob?
Ask formll EP’~ wmh a“Yes” in 11., b, or c, If ’’Yes” inllc .-rely, q.estionB 12a throuBh 12capPly to this EP’s LAST
20.Wk. d.. s [did) -- work for? lull-time civili.n job.
---
b,What kind ofbusiness .rind. stry is !his?
., Wh. fkind.fw.rk is (was) -- doing?
d. Clmss oI worker
Fill 12d Ir.m .ntriee in 12.-12., if”ot clear ask.
---
If self-employed i“ “OWN” b“mim=ssand not a fmn, m.k:
e.Is ihc business incorporated?
1 ‘“”-fi’n’”mc o
k ---
Lam nameRelationship
2. EEAD
AGE RACE SEX
3.0. ,W2N307, M21
.- --- ---—- .-- —-
Mon~h Dmy Yea,
b.
I ❑
1-74 yea,, (EP)sbILe . .iorei,gn..un Lry
I
zElcrn . . . ...12345678,. ❑
No., (NP>3Nigh . . . . ..l 234 6..---@College,.,,12245+ —-
b, I
❑
Y,S 2DN0.--- ———--——-—-—
c,
1
1❑
Ye, (6d) 2❑
No (NP) ---d, Name and laonlian
“c
7..b. 311❑ ❑ ❑
Y,.NurseryOthersp. .Sfy 202❑
No (NPJKimder-~.,leti.-
J1
3❑
Smne,h,ng else (100 . --- —---b. 1
❑
Ret.red 2❑
Studen, 3❑
Other - S,oeclfyi
--- .: : _Q:: __-z-!!’=-w -
+-
b, i
❑ YeB
(IIC) z❑
No(n.). --- —--- c. I
❑
Yes (lldj 2D No (12) .— ---1
❑
L..~w 3❑
Bolh d. 2❑
LayoffEmplnyer
I
2:.
Business m imdust~
b. E
. — --- OccnpaLim
1 . .
--- —---
;...
o,her (NP) d. 1I ❑
Private paid (NP)?..~ FederaI(NP,
: ~;:~q ~,,
---
..
1❑
Yes (WP> 2❑
No (NP).
+
.
,
2
3. How many roams ar. ih.r. in this h..s. (th.i. livim~ q..rt.rsl? Count th. kit.h.n b.+ not Ihe hu*r..m.
Circle ~.mh.r of room. _
4., Iftihmrmpip. d vmt. r in this ho... (ih.s. living q.ati.r.)?
--- --- - --- -
b. Is Ih.r. both hot and cold pip.d wat.r?
5.. D... ihit h..s. Ohms. Iivi.g q..r!.rs) hav. th. following kit.h.. facil iti.. -
(1) A sink with pip.d--- w.t.r? .
(2)A rmgm m conk S+OV.?
--- .
(3) A r.fcig.rater?--- .
11“)’. S’” toall Lhw, dmvc. mk:
b.Am th.s. kltch.n f.cillii. s”usrdby any... NOT livin~ in thi, h.us.hold?
6. P1.a,. look at ibis card -
Which of th. s. inc.m. gr.upa r.pr.s..ts your,, your --’s .1..,1.1.1 combin.d family in..m. [m ih. post 12 month., that i., sin..
%.f~s,h.lp from r.la+iv.s, r.n,!rnm prop.tiy..d z. btb.
ate a ■ar au.? Incl. d. inc.mm hom .11sour.., such a. wag.., sml.ri. n,
&.cl.l s.cud*y or r.tir.m..t
II A-G is marked in qucntion 16, ..k: I
❑
Yen - How m.=h .hog.th.r7. Duri.o *. pant 12 months, didY.. .r any mmmb.rt of your b.for. d.du.ii.ns?
Imnily t.c.lv. ..y m...y from w.g.. or ,.l.ri. s? ZUNO
8. Dwi.a lh. mat 12 momth., dld you a any m.mb.rs of your f.mily r.c. iv. any mon.y fr.m -
. . Social h..rlty m Roilro. d R.tlr. m.nt? I n y,. - H.w m..h .l*.n.lh.r?
-.. --- _______ -__-- _--- _---z-~- N:---
b. W.lfar. puym..t. or .fh.r publi= .s,ist.nc.
(such am aid t. famlli.. with d.pnd.nf chil-
dr.n, .Id ag. as.i.tan.., or ald 10 th. blind or I
❑
Ye. — How much .It.gmlh. r?101.IIY di. abl.d)?
-_-: --- __--___---
ZUNOu--- . c. Un.mpl.ym.nt =amp.n Lotion orw.rkm..’s ..moa. s.tic+?
I a Yen - How much .It. gmth. r?
--- _________________________________________________ znNO .
d. Government .mpl.y.. pm.si.ns or I o Yen - How much alto~.lh.r?
privat* p.n.i. n.? 2nN.
--- .
., Olvid.. d.,i.t.m.t, w rant? I U Y=. - HOW m..h .l*.s=th. r?
--- 2nNo
f. M.t i..mn. from th.ir own ..nfmm ku.I . . . 1
❑
y,. — HoW much ah.gdi.r?pr.[.s~ ional prn.tic., . . nati..r.hin? lnNo ---
g. N.ti.coin. from . farm? (Nei ezpemes. lnclud. emnz”~s or .harccroppv. lf farm lost mone
“Los*” ab.w .M.,s.1 1 ---
.—... -u. .
--- ,t
ah, ...-,.. –... rati. .
I
A
❑tenantfarmer
T❑ Yes
- How much .Ir. g.th.r?!7. write . _ ~-
---- ... . ~
,.”,---
h. V. I.r.ns paym.nfs? I fl Yem - How much .l!oDmfh.r?
--- 2~No
i,Allm.n~, child ..pp.rf, w confr[bull..a from I
❑
Yen — HOW m..h .Img.th.,?p.rs~,---..1 IIVIIIE I. *IS h.ul.h.ld? ZIZND
I Any cith.r Irm.m.? I
❑
Yem - HOW m..h .h. g.th.l?ZUNO
INTERVIEWER: Enner the❑um 01 mll money received bin .I1 ..urce. in qucmticmm17 and lB, and continue interview with q.e. tion 15 . . the hon. ch.ld Fgc.
m!... m. h..
w=-,, 1=.1.d?
(En
far
....1 d..mlp110”0, 1. X.11C+7,
ad , b4.mne”f; 2nd
flm.! rear) lmc
., (If.ufddaAm.
Soernenf
bmrnd.,w
.prdfy 1“..1.., STOP Ta6fe Xand .O”,l.”. Wilil{lam 12ORL)
+=
) (2)
I
TABLE X - LIVING OUARTERS OETERkkfNATIONS AT LISTEO ADDRESS
1234.S
678 9.. mare
I
I
❑ Yes
.S❑
No (15.(2)) _______________________1
n
Ycs 2nNaI
❑
YeS 20N0---
I
❑
% 2nNo--- \--- --- .
I
❑ ye,
.--- _-s3Q!?----
--- s - AIm”n,
~i;oir s ---
--- -
h.”r,t
______________________ s -
4nlo”n,
.--- _-__-- _-- _-_---—---
Netincome
,- _,--- -______ -—_ ———. —
vet mcm.
---—-—---—————-
hlo”.t
-_- ——— ———_—-—_—. —-_ —-_
{mount
---
km”,
Total mn.””1
B SEGMENTSONLY USE OR CHARACTERISTICS CLAS51FlCATfON IF MU IN BSEGMENT ASK:
1[l,w. d, cm,, INTERVIEWER, Are Arm,h. m. OCCUPIED ALL WARTER5 N - N.t a sep.rmle Inwhat PO, (rlb.f.,. I.J)
mh=.t mnd line !hc.e qu.rlers within (.Fify unit, .dd oc. upmr.l. W.r. Ih. m. 1960J
numb,, mr,d the .pcclfic .mmplc 10C.I1MJ D. th. D. Ih.,. qa.rimrm I. ,. Lhi. q.ali o.. w.”..,
,Iop, mddr,.m■hom i. ~otior, ~~r s.. ”p..l. or (,PCIIY lcuflaI) hov.: .mir,, f.pcff” what w.. lb
c.lmr..s 2-4 01 he .m. ** thmw (.pcifr nam. af th.
[1 .nT,ntrd .r.d ~ ~=pen, ~,,? 1..,1(W)
.“.
mm., d ::::),,”0 (Complel.
● hau.. hold- B S,p.nt - ,.W,.1. *.aflOn- cr. m.d?
h.sd .1 ih.,.
G. 1. cd, 4 (If say.., ,, cm,{””. p.pl.7
mnd .mt wllh ::’~””” :~1:~ “r .,ira (., ..ch (71 1959 m q“mt. rs ml
- 4,,. T.bf. x, u Tfo,- (If -1’.,,., any .*., !nmr,ld P,,=
..1,1A 0# ●WW-.1 1%0, .p.lf” Ap,ll 1, 19607
s~p Tab]= x ..$ ll:J -= lJ.. 8,-P .f 10, .,=, ”,l,O mf.m Hy j-p,) ,,fr,, ,f ,,” f
A!,.”* .
=;R’::,-$ e.nflnua wlfh Jfmn I., math 12 ORL)
P*. PI.7 .m,mmnnh.117 “..7 --- half, or ,,LS,
#J-P) 1[ I.. fh.rf. ]
~:) ‘e~~~~’e Ir!lerbiew . . a sep.r.lc q...lian-
(3) (4) [s) (6) [7) ..,,,.
[m [9) (1OJ [111
S— L— Y N YN Y (9) N YN YN N HU 01
S— L— Y N YN Y (9) N YN YN NHUOt
s— L— Y N Y N Y (9) N YN YN N m Ot
3
DT E: Continueinterview with next item .1 the Houneh old Page.
APPENDIX IIB. FOOD PROGRAMS QUESTIONNAIRE
:~4~);{l ,,.G= 1,
I
Form APProvcd o,M. B. No. 68-RI 104
DEPARTMENT OF HEALTH, EDUCATION, ANo WELFARE A5SURANCE OF CONFIDENTIALITY
PUBLIC !!,,,.. s,..,.,
HEALTH 3.. ”!..5 AND MENTAL HEALTH AOMIN, ST RA7,0N All ,nform.d.n whleh w.uld Perml,
NAT ION.. . ..7.. .0. HEALTH 37,7,3, ,.s Ident, flcar, cm of tie ind, vldual wIII
HEALTH ANO NUTRITION EXAMINATION SURVEY he held sulccly cm fide.. ial, wIII bt
used only by persons engaged lr
FOOD PROGRAMS QUESTIONNAIRE
and fortic WC POS.S of the survey, ,nd wIII . . . be dl, cl. sed ., ,,l., s., m .fficrs for any other p.rpo,., (22 FR 16B71.
I. Name of respondent (Last. first, middle) b. Deck No. c. Segment No, d. Serial No, e. Column N(
101 ______ –. ––
FOR INTERVIEWER USE ONLY 1
Not a,bPlicoble
Mork appmPriate box before go)ng Into household.
~@ I Cl Iwn. I and 2 nonapplicable by tfES income and family size criteria - SKIP to 30
,
Applicable1 z ~ NOprogram available - SKIP to 30
, s D Food stamps available - Ask 10
1 a n Commodities available – sKIP m 20
la. Are you certified t. participate in the food Ship program?
l.-~@ i~Yes-.4skb
1 2~N0
1 }
SKIP m 30 g ~Don’r know
b, At. you buying feed st.arnps now? b. ~ @@ I ~ Yes, rwl.rb ~Klp,030
2 ~ Yes, occasionally
I }
1 z~”,No-Askc
c, What is the MAIN reason you aren’t participating in the pmgr.m?
e. j @ I r- No need
2 [J Nor enough money at the time ,
3
❑
No uansportanon on Pride 5 D Ocher - Spec!fy1 1 I
2.. Are y.. certified to porticipaie in the commodity disui bution program?
+ ,~Yes-Askb
1 2~N0
1 }
sKIP to 3a g
❑
Don’t knowb. Are you receiving ..mrmdity foods now for your family?
b.@J I
❑
Yes, regularly1 }
sKIP to 3a z~j Yes, occasionally
1 an No- Askc
1 c, Why aren’t you pmficipating in
the program?
c.\@ !DNoneed
1 2 n No transportation
I 3 ~ Pride
1 4 m Other - Spec!ly
— 1
Ask the following questions First name ,
Oeck No, Sample No.
only in households where I
there me smnpfe children or , BEGIN NEW RECORO
102
youths ottendinc school, I !
I I
b.
c.
d.
❑.
f.
9.
h.
I I 1 1— — ——-
1s there . school lunch program at the 3.. ~ @ ,DYes-Askb
school thut . , . attends? 1 z~No
1 }
SKIP to d 9 D Don’t know How many times a week does h.
usually participate? “+Zl _ Trmes
HOW much doe~ kc pay far his lunch
p-l day? c“ ~ @ - -Cents
Is thorn n special milk program at the d.1 DO~ lnYes-Aske
school *hat . . . .mt. rds?
;0
21_JN0 1
} SKIP to f 9
❑
Don’1 knowHew many times ❑week does h. usually ●. I
pnrli.ipn t.? 1
:@ _ X me.
Is th.re a school breakiast program at the f.! ~06 ,Dye~-Ask EQndh
school thml . . . attends?
/0
2mN0 1
}
Go ro next sample child 9 m Don’t know
How m.ny times a week dot h. usually
p.rtl. ipate? ‘“{ @ _Times
How much dons he pay for his breokfrist h. \
per dq? ! @ __ Cents
The same questions are aked far any further sample children or youths attcndmg school.
APPENDIX IIC. MEDICAL HISTORY QUESTIONNAIRE, AGES 1-5
1~11~ ‘..., !’
,. .,,
,.rm .,,,.,,, . ...s. N..60s.!(84
DCP. . . ..” T 0,HC.
L7H,
,.”..7! 0”,. . . ASJJUAHCE OF COHFIDENTIALIT!. ...,, .,..,. .,”. !..
“c.’. ” ,Lnb! cr. ..r . ..7.. . . . . . . . . .. . . .. . A,, ,.,.,”,., !.. which .,..,, ,.rm, ... !.... . . . .. . . i,., ,7!. s ,d..t,f, ”!l.. orLha ,.,,.,...1 .,, .,.,,” .,. “Ur.,r,am ,“A.,”A, r.”s.”,.” b.h.], ,“!<,), .=”,,,. ”,,,,. w,,, t.
.,,, ..,, b ,.,sc”, .“..m=d !, MEDICAL HISTORY QUESTIONNAIRE - AGES 1-5
,“, r., *. ,.,,.,.s or *. ..r”w .,, “,,,, . . . b. d,, c,.,, d ., ,.,,.,., r. .*=,3 for M, .U!.r p“,,.,.:
,21FR1687,.
061 _____ ____-–
,. S,,,, !N,. f. Column No, E, 5,. h. 4!, 1, Da,, .1 b.,.l
!➤lMa!, MO..*
o_
Da” Y,..
-. -- , D Female —— -— ——
How much dld . . w.igh wh.n h. . . . b...? 1. :
~ @ – - p~nds – -Ounces
,,,, u D..,, km.w
W., . . .born~r.mmIU,.ly? (Ihat 1., . ..lY or 2,~@ 1 ~ Y,!
. . . c.rrl. d ,h.{.[[ .In. m..,h, ] zCINO
, (- I Eon-c know
, How nld w., . . ‘s mm,h., wh. m . . . w., berm7 3.;@ __ Y,,,, old as cl Don.t know
a. How . . . . <hlldr, n h., , . . ,s molhmr k.dl 4.. ~ @ -- Chlld,en - ,fmore ,lm ,. As, b ,, 11 Donnrk”w - SKIP 1.S
h. How man” w.,. b.,. bml.,. ..1 b.~@ __ Ch,ld,m
,,❑0=.+, know
; @ __
BmLhe,s and SIsmrs. How . ..” .1. . . be., hm,mand .I,,.rsw.;gkmd 5. ;
!., s $h.m fw. and. . . hnll pound. .1 blrnhg ,, 0 Dm+ckn.w
H.w much dld . . . w.lgh wh. n h. . . . m 6. ; @ __ Pounds
Y..r .Id? ,, ~ Dc.+, know
Il.. Mm, . . b...,, f.d ., ,.” ,,Iw? ,,.,, (@ I,gYez-AIkb ,ONO
1’
SKIP ,.12., ~ Do”,,know
.—
b. Wk., VP. .1 m>lk .,., u,.dl b. :
r.. N. Don,, know
111 Whmlm. nw., milk, . . . (1): @) Ill ail ,II 12) CO...,,,+ pr.vr.d rn,[k -
5P?. f,hro”, !/ . . . . . M (i-J
—
13 a 13 s .:1(3)As.yh... foulmlm. . . , [11 i
@l
1(:1 2 ,x 9:;114, H.. had th. f.llowlmg lmm.nlxol; .n,, 14. Y .3
DPT (D,ph,h. r,m, whm~lng cu,qk, ad ,.1,.,s) . . B ‘ ‘:’ ,,,‘L ‘m::””
‘“l’” . . . ...!....@ “= . LI– , :,
S.dlp. . . @ I’_- 213 a —_’
Man’’”’ . . . @ ‘= “=’ ‘-’
‘“’~” M””’l”’ . . ..@ . . . ...@ ‘~ “=’ “--’
M.mp, . . . .,@ 11.7 .,= ICI Oohmr,d.n,lkn.w whalfr. r . . . @I:J–- 2 l_J 3 I..J
15. Da., ., d,d . hav.❑ny c.nd,,, om, h,w., 15.
L.,. w,oh ,hn! lnvmlv.d❑., al lh. 1.llmw,nm7 ‘r,, N. 0..,1 kn.w
,-.... .. ... .. .. ... . ..$ ::; :’; :I;
H.-I . . . ,
M.”lhat lhr..l, . . . ...8 : @ in 2’:3 3,:,
Slnm.rh a,l.,.,ll”. m . . . ...’ @ ,= XI , ~,
“d’”y’”’”’’””’y’ y’’””.”.”’.’..’....’.@ ‘~ 2 El s 1:1
M“’c’’’, bo,”’l ”’””’”” -“””” ”.-. ”-”-... @ “~ z ,3 9=
Bralnwn.wws splwa . . . ,@lm zn ,U
5
16.. Ha, . ...,.,
❑
c.ld.n,ally ,wnll.w.d 160.i @ ,mYcs-Askbany mcdlcl n., ~111, er P.1,.,7 ,UNO
\ SKIP 1. 17.
, ~ DO,,, know
b. Dld ihi, ,...11 in❑.” ..,Iou, dammg.! L @ lo Y?s-4sk.
20N0 -SKIP ,. 170
c Whm, w., l,? ,_ _-
17.. H., .“,, h.d, hd mc.ld.n,7 17., ! @ ,nYes-Askb
,ON.
} SKIP co 18.
, ~ Don, tknw
lM. H.. . .“., ,Imy.d wm,nlghl 1, lza @ ,UYcs-Askb
. h.!pll.l? 2DN. -SKIP 1OI9
b.F., what, ——
,
20., Hw many Nnu, ha, . . . had 20.. ~ @ _Tlmcs
P...,,,?.?
k. Dam, h.ha,. 1, ..w7 b.! @ InY=s
ZONO
21,. D,rlng th, p.,1 .1x m.n,h, how man” 21.. ~
cold. ham . . hmd7 , ~ _Colds
b. D.,, h.h.,. o., . ..1 b.~ @ IDY.$
ZONE
22Q. Du,lng ih. PD. I ml, m.nlhs hm. . P.*,.d w w.r.,7
..! @ ;g~-.%kb
} SKIP [o 23.
, n D.n, r know
h,WhmI Iyp., tin”whll. .,p.n.11.slz.d 7 b. ~ @ ! m TIOYwhl!c
ZU Pendl-sized
23.. Du,lng *h. PO. I .1”momlhs hw wony
,lmm,h.. ., . hod dlwh.07 2’”,! @ __ T,nles
b, D.., h.ha.. II now? b,l m , OY, S
—
24.. Dm.s . . . dl. or .1. ”, s#mr.h, 1.1 ar Plm,l.r, or . . .w,.,lal oh.,mlghl
~ co,,ld.r.d .nu,uol?
a“” ~ @ ,DY,s-Askb
,
❑
No -SKIP 1025h.Which? b.! YcS No
(l) DlrI o,@, .. . . . . . [l)~@ ,0 2U
(2) Stnr.h . . . . (z)\@ IO ,0 [3) Pol.t.r pla,t.r . . . . (3)1 @ lo ,Iz
(4)Olhmr -SpecllV (4); @ ,D 20
25. D.., . . . h... “....,1 l,wbl. smmlng 25.;@ ,
❑
YCS.1 night., 1. ~h.d.rk? ZOND
P n Don’. kn.w
Hr. . . . .W. SIIO. S nb. ut ‘s molhmr: ;
26.. HOW mu,h d.., ,h. w.l~h? 26..; @ ___ Pound.
,,s
❑
Don,, bow ,b, How10111,nhn7 b. ~
j @ ––FCCC -— Inches
s,,
❑
D..,, know H.,. ❑r.,n.m. wnllon, ❑bout . ‘s Ialkmn27.. H.. much d.., h.w.+? z7~. ~ @--- pounds
,s, ~ Don-r know
~—-–—— — ——–
b,Hw 1o11 IS h.1 b. /
b, MayI . . . you,h, al labl. salt? b.j @ I a Imd, zed
,0 NotI.dlz,d ,
❑
N.b..29.. N... .1 r.,pond.nl
6
APPENDIX IID. MEDICAL HISTORY QUESTIONNAIRE, AGES 6-11
411.9,. . . . ,) ,. .,7,
DEPARTMENT OF HEALTH. ED UC,T1. . . ANDWELFARE I-4%%+=
,.. . .,+,. .,”.! . . . AN. !4EN. AI
?4.,,. ”.. . ..7.” F.”
,ALITV ,..,. ..,., ” ,...1..
L . ...7. .. MINI JT”AT1..
I
All Inl.rmhrlm which would mnnll, .,...” ,..71 s,,., Idmnrltlemtlan .1 the Indlvldual wll
“EA., ” ANO..7.,,,0. EXAMIM. TIONsURVEY beheld SW,.+’ c- fld.nd.1, wII1 b!
u,,d mlf b“ F-=-mu CU. --A ,-
MEDICAL HISTORY QUESTIONNAIRE –AGES 6-11
,-.. .
.nd villl “.1 ii k.lasmd .r =’:%
,. .,F,,,, I., ..” mhc. WVP,=, (22 FR 1~71,
1
Name (Lasr. first, middle) b. Deck No. c. Sample No. d. Seg.menr No.
071 —-. .— —-— ———
s,,1.1 No. 1. Column N.. g, Sex h. Age 1. Date of birth
1I-J male PI..* Dar’ y,.,
zDFcrnale
—— —— —— —— —— ——
How much dld . . w.igh wh.n h. we! born? 1. \
/(3
—- Pound. — — ouncesSSSSD Don. r know
!%. . . . born pmmotur.ly? (Thet !s, .arly 2.\@ I
❑
yes❑r nnt c.rri.d th. lull .1.. months] I
ZU NO
,
, g
❑
Dmft knowI Hnw many childr.n ho> . ..s moih.r had?
3m” ~ @ __Children -I fmorc than 1. Ask b
~s fg Dan’r know - SKIP m 4
Hewmany war. born b.f.r. . ..7 +@ —_ Childlcn
1 !mn Don’t know
How man of . r
. .’s broth.rs and nis?.rs 4. ; jt.$~h$ .s. ihan fiv. and on. -hml[ po. mdt
\@ -— Brothers and .Isrcrs
S=
n
Donh kWl—
ZONO
,11 Dc$h.,kmw }
‘K’p‘07“
How old w., . . . wh.n h. s?oppmd br.nst fm.dinB7
b“!o _—Mon*s
s,
❑
Don. t know I_—.
Whd VP. ❑F milk w., UIod? b. i Yes No Don’t know
(l) Wliolac.w”, milk . . . .
:@ ‘n ‘D ‘n
(2) Commwclally pr.par.d milk -Sp+CJfr brand fknow.
@ ‘n ‘u ‘~
(3) Aswbm,cformula . . . .
:@ ‘n ‘n ?0
(4) Other - sFClf” + 013 ID an Sn
Flaw ❑ld w.. . . . wh.n ha fh,i ,fmtod E.;@
.aIln B ,nlid faed. Ilk. c.real m fruit? —- Mun,hs
INTERVIEWER: converi replies m weeks ,
10 neoresc number of months. ss
❑
Dcn.r knowDo.. or did . . hov. any c.ndilio.s h. 9.
w., b.rn with ihat invnlv=d any of tb. (
Yes No O.n”r know
{o I1.awing7
( Hmort . . . .
@ ‘m ‘n ‘n
EY*n . . . .
:0 :: ‘~ ‘D
Moulh orthroat . . . .
{f@ 20
~m
Slomach or lnl.nlin. s. . . .
;@ ‘n ‘n ::
Kidnmy. or udnwy ,y,im. . . . .
[0 ‘n ‘~
Muscl.a, bon.., or iolnts . . . .
;@ ‘n 20 ‘~
Brain .rn.wo.s,~strm . . . .
;@ ‘~ ‘~ ‘u
7
0
10.
P.c..monio, ,,, . . . .
Other chast or lung comditiar,. ., . . . .
Hamtico.d,iio., . . . ,..
D[mbetas . . . .
EP~t=PsY or cwwul>i=ms, . . . . . .
Stomach❑r iniestind d,sorder
(dXCIUdi”g dmrrh--a). . . . . . .
Kidney dls.as. ❑r infection, . . . . .
Thyroid disease -r garter . . . . . . .
Cml..ror rummr,. . . .
Other candltio.s - Specify
lm. Ho, ❑v.r hnd a bad accident? 110
b. Far what?
c, Has . .verh.d❑nop.rotl=o? .
d. For whet?
%. f, ., unobl. !. dm same things 13.
bcceu,a ❑f❑condlden ihnt has bofhmad him 1.,❑long tlm.?
A.. Owing lh.pot+ SIX men!hs how many 140
cold, hm. . . . had?
b. O.aas h. h.vm on. now? b
5., During Ihe past six months has . . 15.
p.~sad ..y w.,m~?
b. What type, ilny while or p.ncil-siz.d? b
60. OUrIng the past SIX months how many 16.
iim.s has ., hnd diarrb.a?
b, Does h. hove if now? b
7., Do. s . . .ver .-I dir! or cloy, -Iarch, 17..
point m plaster, m❑ny material ihmt might b, cnnsldermd unusual?
b. Yllich? b.
Oirlo, cl.y . . . . Starch . . . . P.aintor plcistw . . . .
~hsr - 5PClfy
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
@
l~Yes-Askb20N0
I SKIP to /20
~
❑
Don’r know@
,~Yes-Askb.,dc zmNo -SKIP co 130@j ,~,es-.
skdZn No - SKIP 1.r30
@
l~Yes-.4skb2D No-SKIP m 140
(@ —cord,
@
I❑
Tiny whimz D Penc,l-sized SD Both
@
,~Yes-Askb.n
NO-SKIP
TIJ laYes No
(@In
20(@In za
(GJ1O Za
@la 20
—.
B. Do., . h... . ..s..1 lrmubl. ,e.;ng m lB. ;i w 11-JYcs night or in !h. dark?
, ZONO
b. Was i! bun... of .Nh.r an●y. iniwy,
b. / OM I ,0 ❑
ye.in~.. tion or oih. r .y. probl mm?
(l) An.y. iniuq . . . . I ZRNO
(2 I An .y. in f.cllon or .Ih.r my. prabl.m .
\ @ ,~,e,
z ~ NO - lf “’No’- [o both (1) .~ (2) SKlp EO2~
c, Did h. s.. ❑doctor about
it? ‘-~ @ ;~::s
[11 A..y. iniuV . . . . , ,
(2 I A.●y. i. f.cti.n or❑thar V. pmblmm . . . ! @ ~0’fEs-Askd
z
❑
NO - If“’No” [O ~lh (f) ad (2J 5KIP I. ~ d. What did ha soy ibm !roubl. w..?I
0.. Has . . . .v.r had❑ .y. accidan! or q. 2%. ~ @ ,aYes-Askb Inj. w Ih.af did not ofl.ct hit vi, i..?
I zf7N0 -SKIP 10210
b. Dtd ho s.. ❑doctor about ii? b. ~ @ la Yes
I ZONO
la.
H.. . . . . worn sle, s., or 21.. [ @ ,~Yer-Askb..ni.. t 1.”,. s? ZU No - SKIP [. 22
I
b. Do.. h.,Nll w.., [h,m? b, ; @ ,a Yes
7. I-J 1*O ,
c. Wb.n do-s [did) h. war ih.m? ,. ! Yes No
Allih. lime . . . .
@ln ~n
Forr.odinB .rclos. wo,k . . . .
Fo,dista.c.visien . . . . ~~ ~~ I=
A*oth.r tim.s - specI[y ;@ln ZD
d. Do.s (did) h. ha.. 1,.ubl. wilb d. ~ @ ,OY,S
hit vision .v.. wh.n w.a,i.g s1.s..s (m <ontaet 18.,.s) ?
I ZONO
. . How old was h. wh.n b. first 1
*. ~ 06B
w.,. glass., (., COn?.cl 1.”,., ) ? —— Years
!. Hdz . . . bad !.ml,, scho.1bocaus, 22. j @ 1
❑
Yes❑f ir..bl. . ..ing or oih.r tre.bl. whh 1
biz .y.s? ZCINO
H.,. . . . some qumstlonn about 1
. . . ‘, moiha~
,,a. j m - --pounds
❑. How much do., ,hc waigh? SS9 n Don’t know
b. How tall is sh.? b. :
Hr. a. sm. q..stlms about
. . . ‘s f.th.n ; @ -––pwnds
. . Hew much do., h. w.igh? Ua. j BSS
❑
Don’tknowL
b. How tall 1, h.? b. ;
I@ _ —Feet — —Inches
I SS9 D Din-r know
b. (day I ,.. y.”, box of lnbl. ●alt? b.@ , Ig Icdlzed
I 2
❑
Not iodizedI ,D No box
1 b. R., and..?’. r.latio. ship 10 child cev.red
E by t is q..stlon.alr.
b, ~ 1
❑
~0~-1
2 n ohm NOTES
APPENDIX IIE. MEDICAL HISTORY QUESTIONNAIRE, AGES 12-74
~
0,,.”,”,”7 ❑, “l!.,,”. co”..,!.”. A“. .cLP. ”c . . . .,.”.! <.. ..0 ...,., ..,.,. . . .. .. . . .
.
...0”.,
. . . .. . .“...,. ,..7! ..,.. ,d.m,,,c.t, m d ~, ,dvld”,, M,,“m,,,” ,“0 .“,”,,,0” .?..”,”,,,.. ,“””,.
MEDICAL HISTORY QUESTIONNAIRE - AGES 12-74
NM. (L.sL [h!, middle)
~ ,.
D.,W h,. mmIll,”, ., CANI.” .hl,h l.,1“1.,1”., .Nb ,,”, “ml”g?
L Wh.l?
,.0. p“ b“. .“ Ilk.. “k.kh h., WW.!l, cot 2*
k“ p., .P,.IIW
,.wl.17
,.
D* ,.. ha.. !m.hl, AM” .,”i., C*., kwMh” N,- .“1.7
,.D. ,., h.,. ,IAt. ml”, .,,1.. “ .“.. b ,n.lbc.bl
,.
Ala Ih,t. .“,f“dm
Whl.bp“ .“ld “ml., kb-,,. hq M..u,.. .lmhY..1
,.WA, ,,. Ih. v? b,
Mom. . . . . . . .
F., . . . .
Gt”rm. . . .
24A . . . ..- l-l... ,., .....
w“ - 5VCI(”
0. “.. h- .Pl, d., (w%pdl,”.] DI pd. w 5.
41...-M [. vw.U.m- .t.-cb dm 6 1“,, 3 d.”, pa, “nihl [D.”’l ..ml .-. NMt v -mh . Ad. .“. lb-l, n“ “ [1., --.) Mn, hull ,.,M.]
0. 7,. h,,. dllll.dti 1.,-11.,.1., .1 1.s., 6.
3 i,”, pm,mwlh7 (Dal, CW,l A, 6HNc.Iv 1“ nmll”i”m I!W ,- “Ilh . ..1A ,“.
AM, ., N..]
D. . . . km. .,1.+, (w %dl,o-) .I.WHI., 7.
d “ I“,, 3 d, s F, ■,mhl [D.n,, ..~f ~“
1!
lb w .Ilh <. S, .w. Nwmmsm,11,, _ [1.,
“-.”1 ■.n.lrn,l ,“Id,.]
H.,. P. m.., M y.llm 1.1M61... ,,hkh -i. &
““r .kh “ .,.s tw” XII*W7
,. Dld . dti” .,”,.11,., ,6M ,.. h.6 pd.lm, Pm dbtmh, bind ., ,- k mm, UIM.1
b. W1l.h? .
Pml.l . . . .
al bum! . . . .
Bled, . . . .
5W.1, . . . .
1. DA, h. ,.,1,1XD9mlhm h- p“ bad 10.
prom., . .“m.
1.,.”,
,,..1,7,..
D. “.” h... lr..kl. .IN1 ,.., b-d. 11.wbl.h “t., ,.. . . .. IIPIA or ,17..
p“ dl.”h-?
b. H*” h.” & p. oh+ h“ . b
bowl m,..m,nt?
c. H.,. ,.., -.-.,, -r
b-
,,hh. rSW, h,k WA. w.,,,dd Ah b)md?
6. WTd,h7 d
WIIN . . . .
Gem . . . .
D,,kblmk. . .. . . .
%“b.d-l,hbl ad... . . . . . . . .
—
Ye, ‘No
—
e❑4., m.,. elm., idmy
@ ,mYcs-Askd z❑N. -SKIP
CO
J20Yes
@ In
2Nb
10
l%. lb. “.. bmd. . .M.mlmd
.p.r.,
kn?12+ @ ,
❑Yes - Ask 12b
z❑N.-SKIP 1. 13.
b.wht I-1 ! ‘f,, No
U1..r . . . . .
pm
Z13GallmFam.. . .
,@ln
20HI.!.. h.rml. .f fh. dl.pkqm . . . . +@ln zig
T.-. .fIk. .I*ch. b.w.l. .r =.lmn. -. . . . . \@ I❑ .0
T-”’”’’~’’ ”f”h*--* -”-’’”’ -... - j @ ~n ~n
Dm” - Sp.ec!(”
iii,n
,0h. H.. .d.”” . ..r..ld y.. h, y.. had .V 13.. I : Ilb. D. ,.”,,111 k- W
,i*. I.llmllw .“dlll.nm7
If ,. Yam.. to any O( the Mlnwi.# .Md,lims.
~i ,
Don.,
No i Y= N. ~M
ask13b n,d 13,IW II)OJ, cmd,,,an$.
‘@’nl’n ‘n ‘n Arih,l,i, . . . .
c.”! ., . . . .
~.o--...-.P---~
onan i
lig---:-P...?----
o
Amok . . . Ml z= r,0 ,D sO
~@*n!’n ~n ,0
Chmlc kr,mchl,l, M .tiphym,ma . . . .
Twbmcwl.ml, . . . . .
@bn..\
IO lo ,0 nh. m,l.r w” . . . @~o :-~ B---~-ti---=--
Homrt.wrm,r . . . ...\ @.n ; IO :gzn:!n H“tikllurm . . . .
H“ti.mck . . . ...! 051 ZO ; 10
Hlohkl~v.~~Mr.. -- . . ..-. -.. -..---..! @ .0 I 10
Efr.k . . . . . 8
;09,0; ,0
+- --- +--- U1..r. (p. pll,, ●l-cl!, d+mal) -.. . .-. . .: OH z❑ : I❑
:@,n~!n E. Irrl,ln (,mcw~M w ch,.nlc] . . . .,
,@znlln Callll. (Ipllc ..1.”, .=.”s ..1111.) . . . .;
G. HS4.M, . . . . @zn~ln
—
H.pmlltlm . . . ..!
8
DL, Zn i In SO ,0
Chrml. =.i+. . . . . . . . . .rw!--z-n-; -t---- ~-n---~ -n---
:0’0!’0 in ‘n
P1.l...lm”, ..,...,..,.. . . . .
L- blmmdp..mnw . . . . @2n:, n ,0 so
N1--~... - . . . . ..- . . . ..-. -..--...! @zO ; 10 so CO
‘@zu ! In so .0
*“ k.., . . . .
--- +---
A1l-,l.. le~m.d,. ..,.., . . . ...! @2n;1n SO .0
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, ZONE
13
