Page 1 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.010_00.000 Instrument Variable Name: HYPEV QuestionnaireFileName: Sample Adult
QuestionText: Now I am going to ask you about certain medical conditions.
Have you EVER been told by a doctor or other health professional that you had
... Hypertension, also called high blood pressure?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto HYPDIFV]
<2,R,D> [goto CHDEV]
Question ID: ACN.020_00.000 Instrument Variable Name: HYPDIFV QuestionnaireFileName: Sample Adult
QuestionText: Were you told on two or more DIFFERENT visits that you had hypertension, also called high blood pressure?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who were told they had hypertension
SkipInstructions: <1,2,R,D> [goto HYPYR]
Question ID: ACN.020_00.010 Instrument Variable Name: HYPYR QuestionnaireFileName: Sample Adult
QuestionText: DURING THE PAST 12 MONTHS, have you had hypertension, also called high blood pressure?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D> [goto CHDEV]
Question ID: ACN.031_01.000 Instrument Variable Name: CHDEV QuestionnaireFileName: Sample Adult
QuestionText: Have you EVER been told by a doctor or other health professional that you had
... Coronary heart disease?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto CHDYR] <2,R,D> [goto ANGEV]
Page 2 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.031_01.010 Instrument Variable Name: CHDYR QuestionnaireFileName: Sample Adult
QuestionText: DURING THE PAST 12 MONTHS have you had
...Coronary heart disease?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who were ever told they had coronary heart disease
SkipInstructions: <1,2,R,D> [goto ANGEV]
Question ID: ACN.031_02.000 Instrument Variable Name: ANGEV QuestionnaireFileName: Sample Adult
QuestionText: * Read lead-in if necessary:
Have you EVER been told by a doctor or other health professional that you had
... Angina, also called angina pectoris?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto ANGYR] <2,R,D> [goto MIEV]
Question ID: ACN.031_02.020 Instrument Variable Name: ANGYR QuestionnaireFileName: Sample Adult
QuestionText: DURING THE PAST 12 MONTHS have you had
...Angina, also called angina pectoris?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who were ever told they had angina
SkipInstructions: <1,2,R,D> [goto MIEV]
Page 3 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.031_03.000 Instrument Variable Name: MIEV QuestionnaireFileName: Sample Adult
QuestionText: * Read lead-in if necessary:
Have you EVER been told by a doctor or other health professional that you had
...A heart attack (also called myocardial infarction)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto MIEVYR] <2,R,D> [goto HRTEV]
Question ID: ACN.031_03.030 Instrument Variable Name: MIEVYR QuestionnaireFileName: Sample Adult
QuestionText: DURING THE PAST 12 MONTHS have you had
...A heart attack (also called myocardial infarction)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who were ever told they had a heart attack
SkipInstructions: <1,2,R,D> [goto HRTEV]
Question ID: ACN.031_04.000 Instrument Variable Name: HRTEV QuestionnaireFileName: Sample Adult
QuestionText: * Read lead-in if necessary:
Have you EVER been told by a doctor or other health professional that you had
...Any kind of heart condition or heart disease (other than the ones I just asked about)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto HRTYR] <2,R,D> [goto STREV]
Page 4 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.031_04.040 Instrument Variable Name: HRTYR QuestionnaireFileName: Sample Adult
QuestionText: DURING THE PAST 12 MONTHS have you had
...Any kind of heart condition or heart disease (other than the ones I just asked about)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who were ever told they had any kind of heart condition not previously mentioned
SkipInstructions: <1,2,R,D> [goto STREV]
Question ID: ACN.031_05.000 Instrument Variable Name: STREV QuestionnaireFileName: Sample Adult
QuestionText: * Read lead-in if necessary:
Have you EVER been told by a doctor or other health professional that you had
...A stroke?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto STRYR] <2,R,D> [goto EPHEV]
Question ID: ACN.031_05.050 Instrument Variable Name: STRYR QuestionnaireFileName: Sample Adult
QuestionText: DURING THE PAST 12 MONTHS have you had
...A stroke?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who were ever told they had a stroke
SkipInstructions: <1,2,R,D> [goto EPHEV]
Page 5 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.031_06.000 Instrument Variable Name: EPHEV QuestionnaireFileName: Sample Adult
QuestionText: * Read lead-in if necessary:
Have you EVER been told by a doctor or other health professional that you had
...Emphysema?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto EPHYR] <2,R,D> [goto AASMEV]
Question ID: ACN.031_06.060 Instrument Variable Name: EPHYR QuestionnaireFileName: Sample Adult
QuestionText: DURING THE PAST 12 MONTHS have you had
...A stroke?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who were ever told they had emphysema
SkipInstructions: <1,2,R,D> [goto AASMEV]
Question ID: ACN.080_00.000 Instrument Variable Name: AASMEV QuestionnaireFileName: Sample Adult
QuestionText: Have you EVER been told by a doctor or other health professional that you had asthma?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto AASSTILL]
<2,R,D> [goto ULCEV]
Page 6 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.085_00.000 Instrument Variable Name: AASSTILL QuestionnaireFileName: Sample Adult
QuestionText: Do you still have asthma?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who were ever told they have asthma
SkipInstructions: <1,2,R,D> [go to AASMYR]
Question ID: ACN.090_00.000 Instrument Variable Name: AASMYR QuestionnaireFileName: Sample Adult
QuestionText: DURING THE PAST 12 MONTHS, have you had an episode of asthma or an asthma attack?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who were ever told they had asthma
SkipInstructions: <1> [goto AASMERYR]
<2,R,D> [go to ULCEV]
Question ID: ACN.100_00.000 Instrument Variable Name: AASMERYR QuestionnaireFileName: Sample Adult
QuestionText: DURING THE PAST 12 MONTHS, have you had to visit an emergency room or urgent care center because of asthma?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ with asthma episode/attack in past 12 months
SkipInstructions: <1,2,R,D> [goto ULCEV]
Question ID: ACN.110_00.000 Instrument Variable Name: ULCEV QuestionnaireFileName: Sample Adult
QuestionText: Have you EVER been told by a doctor or other health professional that you had
...An ulcer? This could be a stomach, duodenal or peptic ulcer.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto ULCYR]
<2,R,D>[goto CHLEV]
Page 7 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.120_00.000 Instrument Variable Name: ULCYR QuestionnaireFileName: Sample Adult
QuestionText: DURING THE PAST 12 MONTHS have you had an ulcer?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who were ever told they had an ulcer
SkipInstructions: <1,2,R,D> [goto CHLEV]
Question ID: ACN.121_01.010 Instrument Variable Name: CHLEV QuestionnaireFileName: Sample Adult
QuestionText: Have you EVER been told by a doctor or other health professional that you had
...High cholesterol?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto CHLYR] <2,R,D> [goto GUMDISEV]
Question ID: ACN.121_02.020 Instrument Variable Name: CHLYR QuestionnaireFileName: Sample Adult
QuestionText: DURING THE PAST 12 MONTHS have you had
...High cholesterol?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who were ever told they had high cholesterol
SkipInstructions: <1,2,R,D> [goto GUMDISEV]
Question ID: ACN.121_03.030 Instrument Variable Name: GUMDISEV QuestionnaireFileName: Sample Adult
QuestionText: Have you EVER been told by a doctor or other health professional that you had
...Gum disease?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto GUMDISYR] <2,R,D> [goto PHOBIAEV]
Page 8 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.121_04.040 Instrument Variable Name: GUMDISYR QuestionnaireFileName: Sample Adult
QuestionText: DURING THE PAST 12 MONTHS have you had
...Gum disease?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who were ever told they had gum disease
SkipInstructions: <1,2,R,D> [goto PHOBIAEV]
Question ID: ACN.121_05.050 Instrument Variable Name: PHOBIAEV QuestionnaireFileName: Sample Adult
QuestionText: Have you EVER been told by a doctor or other health professional that you had
...Phobia or fears?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto PHOBIAYR] <2,R,D> [goto AFLUPNEV]
Question ID: ACN.121_06.060 Instrument Variable Name: PHOBIAYR QuestionnaireFileName: Sample Adult
QuestionText: DURING THE PAST 12 MONTHS have you had
...Phobia or fears?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who were ever told they had phobia or fears
SkipInstructions: <1,2,R,D> [goto AFLUPNEV]
Page 9 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.121_07.070 Instrument Variable Name: AFLUPNEV QuestionnaireFileName: Sample Adult
QuestionText: Have you EVER been told by a doctor or other health professional that you had
...Influenza or pneumonia?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto AFLUPNYR] <2,R,D> [goto PRCIREV]
Question ID: ACN.121_08.080 Instrument Variable Name: AFLUPNYR QuestionnaireFileName: Sample Adult
QuestionText: DURING THE PAST 12 MONTHS have you had
...Influenza or pneumonia?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who were ever told they had influenza or pneumonia
SkipInstructions: <1,2,R,D> [goto PRCIREV]
Question ID: ACN.121_09.090 Instrument Variable Name: PRCIREV QuestionnaireFileName: Sample Adult
QuestionText: Have you EVER been told by a doctor or other health professional that you had
...Poor circulation in your legs?
*Include peripheral vascular disease, Intermittent Claudication or cramping.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto PRCIRYR] <2,R,D> [goto UREV]
Page 10 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.121_10.100 Instrument Variable Name: PRCIRYR QuestionnaireFileName: Sample Adult
QuestionText: DURING THE PAST 12 MONTHS have you had
...Poor circulation in your legs?
*Include peripheral vascular disease, Intermittent Claudication or cramping.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who were ever told they had poor circulation in their legs
SkipInstructions: <1,2,R,D> [goto UREV]
Question ID: ACN.121_11.110 Instrument Variable Name: UREV QuestionnaireFileName: Sample Adult
QuestionText: Have you EVER been told by a doctor or other health professional that you had
...Urinary problems such as incontinence, frequent or slow urination or infections?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto URYR] <2,R,D> [goto ADDHYP]
Question ID: ACN.121_12.120 Instrument Variable Name: URYR QuestionnaireFileName: Sample Adult
QuestionText: DURING THE PAST 12 MONTHS have you had
...Urinary problems such as incontinence, frequent or slow urination or infections?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who were ever told they had urinary problems
SkipInstructions: <1,2,R,D> [goto ADDHYP]
Page 11 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.123_01.010 Instrument Variable Name: ADDHYP QuestionnaireFileName: Sample Adult
QuestionText: Have you EVER been told by a doctor or other health professional that you had
...Attention Deficit Disorder or Hyperactivity?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D> [goto AUTISM]
Question ID: ACN.123_02.020 Instrument Variable Name: AUTISM QuestionnaireFileName: Sample Adult
QuestionText: *Read if necessary.
Have you EVER been told by a doctor or other health professional that you had
...Autism?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D> [goto BIPDIS]
Question ID: ACN.123_03.030 Instrument Variable Name: BIPDIS QuestionnaireFileName: Sample Adult
QuestionText: *Read if necessary.
Have you EVER been told by a doctor or other health professional that you had
...Bipolar Disorder?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D> [goto DEMENTIA]
Page 12 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.123_04.040 Instrument Variable Name: DEMENTIA QuestionnaireFileName: Sample Adult
QuestionText: *Read if necessary.
Have you EVER been told by a doctor or other health professional that you had
...Dementia, including Alzheimer's disease?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D> [goto MANIAPSY]
Question ID: ACN.123_05.050 Instrument Variable Name: MANIAPSY QuestionnaireFileName: Sample Adult
QuestionText: Have you EVER been told by a doctor or other health professional that you had
...Mania or psychosis?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D> [goto SCHIZPHN]
Question ID: ACN.123_06.060 Instrument Variable Name: SCHIZPHN QuestionnaireFileName: Sample Adult
QuestionText: *Read if necessary.
Have you EVER been told by a doctor or other health professional that you had
...Schizophrenia?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D> [goto SEIZURES]
Page 13 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.123_07.070 Instrument Variable Name: SEIZURES QuestionnaireFileName: Sample Adult
QuestionText: *Read if necessary.
Have you EVER been told by a doctor or other health professional that you had
...Seizures?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D> [goto BOWLEV]
Question ID: ACN.125_00.010 Instrument Variable Name: BOWLEV QuestionnaireFileName: Sample Adult
QuestionText: Have you EVER been told by a doctor or other health professional that you had inflammatory bowel disease, irritable bowel,
or constipation severe enough to require medication?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto BOWLYR] <2,R,D> [goto ACIDRYR]
Question ID: ACN.125_00.020 Instrument Variable Name: BOWLYR QuestionnaireFileName: Sample Adult
QuestionText: DURING THE PAST 12 MONTHS, have you had inflammatory bowel disease, irritable bowel, or constipation severe
enough to require medication?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have ever had bowel problems
SkipInstructions: <1> [goto BOWLTYP] <2,R,D> [goto ACIDRYR]
Page 14 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.125_00.030 Instrument Variable Name: BOWLTYP QuestionnaireFileName: Sample Adult
QuestionText: Which of these did you have in the past 12 months?
*Enter all that apply, separate with commas.
1 Inflammatory bowel disease
2 Irritable bowel
3 Constipation severe enough to require medication
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have had bowel problems in the past year
SkipInstructions: <1-3,R,D,> [goto ACIDRYR]
Question ID: ACN.126_00.010 Instrument Variable Name: ACIDRYR QuestionnaireFileName: Sample Adult
QuestionText: DURING THE PAST 12 MONTHS, have you had
...Problems with acid reflux or heartburn?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D,> [goto HACHEYR]
Question ID: ACN.126_00.020 Instrument Variable Name: HACHEYR QuestionnaireFileName: Sample Adult
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, have you had
...Regular headaches?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D,> [goto MEMLOSYR]
Page 15 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.126_00.030 Instrument Variable Name: MEMLOSYR QuestionnaireFileName: Sample Adult
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, have you had
...Memory loss or loss of other cognitive functions?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D,> [goto SPNYR]
Question ID: ACN.126_00.040 Instrument Variable Name: SPNYR QuestionnaireFileName: Sample Adult
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, have you had
...Any severe sprains or strains?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D,> [goto DENYR]
Question ID: ACN.126_00.050 Instrument Variable Name: DENYR QuestionnaireFileName: Sample Adult
QuestionText: DURING THE PAST 12 MONTHS, have you had
...Dental pain?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D,> [goto ALCTOBYR]
Page 16 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.126_00.060 Instrument Variable Name: ALCTOBYR QuestionnaireFileName: Sample Adult
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, have you had
...Excessive use of alcohol or tobacco?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D,> [goto SUBABYR]
Question ID: ACN.126_00.070 Instrument Variable Name: SUBABYR QuestionnaireFileName: Sample Adult
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, have you had
...Substance abuse, other than alcohol or tobacco?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D,> [goto SKNYR]
Question ID: ACN.126_00.080 Instrument Variable Name: SKNYR QuestionnaireFileName: Sample Adult
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, have you had
...Skin problems?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D,> [goto INSYR]
Page 17 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.128_00.010 Instrument Variable Name: INSYR QuestionnaireFileName: Sample Adult
QuestionText: DURING THE PAST 12 MONTHS, have you...
...Regularly had insomnia or trouble sleeping?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D,> [goto FATYR]
Question ID: ACN.128_00.020 Instrument Variable Name: FATYR QuestionnaireFileName: Sample Adult
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, have you...
...Regularly had excessive sleepiness during the day?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D,> [goto DEPYR]
Question ID: ACN.128_00.030 Instrument Variable Name: DEPYR QuestionnaireFileName: Sample Adult
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, have you...
...Been frequently depressed?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D,> [goto ANXYR]
Page 18 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.128_00.040 Instrument Variable Name: ANXYR QuestionnaireFileName: Sample Adult
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, have you...
...Been frequently anxious?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D,> [goto CANEV]
Question ID: ACN.130_00.000 Instrument Variable Name: CANEV QuestionnaireFileName: Sample Adult
QuestionText: Have you EVER been told by a doctor or other health professional that you had
...Cancer or a malignancy of any kind?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto CANKIND_1]
<2,R,D> [goto DIBEV]
Page 19 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.140_00.001 Instrument Variable Name: CANKIND_1 QuestionnaireFileName: Sample Adult
QuestionText: What kind of cancer was it?
* Enter code for the first kind of cancer.
01 Bladder
02 Blood
03 Bone
04 Brain
05 Breast
06 Cervix
07 Colon
08 Esophagus
09 Gallbladder
10 Kidney
11 Larynx-windpipe
12 Leukemia
13 Liver
14 Lung
15 Lymphoma
16 Melanoma
17 Mouth/tongue/lip
18 Ovary
19 Pancreas
20 Prostate
21 Rectum
22 Skin (non-melanoma)
23 Skin (DK what kind)
24 Soft tissue (muscle or fat)
25 Stomach
26 Testis
27 Throat - pharynx
28 Thyroid
29 Uterus
30 Other
97 Refused
99 Don't know
UniverseText: Sample adults 18+ who were ever told they had cancer
SkipInstructions: <1-30,R,D>[goto CANAGE_1]
IF SEX=1 (MALE) and No. <6,18,29> selected goto ERR1_CANKIND_1
IF SEX=2 (FEMALE) and No. <20,26> selected goto ERR2_CANKIND_1
Page 20 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.140_00.002 Instrument Variable Name: CANKIND_2 QuestionnaireFileName: Sample Adult
QuestionText:
* Enter code for the second kind of cancer.
* Enter '96' for no more.
01 Bladder
02 Blood
03 Bone
04 Brain
05 Breast
06 Cervix
07 Colon
08 Esophagus
09 Gallbladder
10 Kidney
11 Larynx-windpipe
12 Leukemia
13 Liver
14 Lung
15 Lymphoma
16 Melanoma
17 Mouth/tongue/lip
18 Ovary
19 Pancreas
20 Prostate
21 Rectum
22 Skin (non-melanoma)
23 Skin (DK what kind)
24 Soft tissue (muscle or fat)
25 Stomach
26 Testis
27 Throat - pharynx
28 Thyroid
29 Uterus
30 Other
96 No more
97 Refused
99 Don't know
UniverseText: Sample adults 18+ who either provided an age for one kind of cancer or didn't know how old they were when first
diagnosed with that kind of cancer or else refused to provide an age but had not refused to answer CANKIND_1.
SkipInstructions: <1-30,R,D>[goto CANAGE_2]
<96> goto DIBEV
IF SEX=1 (MALE) and No. <6,18,29> selected goto ERR1_CANKIND_2
IF SEX=2 (FEMALE) and No. <20,26> selected goto ERR2_CANKIND_2
Page 21 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.140_00.003 Instrument Variable Name: CANKIND_3 QuestionnaireFileName: Sample Adult
QuestionText:
* Enter code for the third kind of cancer.
* Enter '96' for no more.
01 Bladder
02 Blood
03 Bone
04 Brain
05 Breast
06 Cervix
07 Colon
08 Esophagus
09 Gallbladder
10 Kidney
11 Larynx-windpipe
12 Leukemia
13 Liver
14 Lung
15 Lymphoma
16 Melanoma
17 Mouth/tongue/lip
18 Ovary
19 Pancreas
20 Prostate
21 Rectum
22 Skin (non-melanoma)
23 Skin (DK what kind)
24 Soft tissue (muscle or fat)
25 Stomach
26 Testis
27 Throat - pharynx
28 Thyroid
29 Uterus
30 Other
96 No more
97 Refused
99 Don't know
UniverseText: Sample adults 18+ who either provided an age for a second kind of cancer or didn't know how old they were when
first diagnosed that kind of cancer or else refused to provide an age but had not refused to answer CANKIND_2.
SkipInstructions: <1-30,R,D>[goto CANAGE_3]
<96> [goto DIBEV]
IF SEX=1 (MALE) and No. <6,18,29> selected goto ERR1_CANKIND_3
IF SEX=2 (FEMALE) and No. <20,26> selected goto ERR2_CANKIND_3
Page 22 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.140_00.004 Instrument Variable Name: CANKIND_4 QuestionnaireFileName: Sample Adult
QuestionText: * Enter '95' if respondent offers more than 3 kinds of cancer.
* Enter '96' for no more.
95 More than three kinds
96 No more
UniverseText: Sample adults 18+ who either provided an age for a third kind of cancer or didn't know how old they were when first
diagnosed that kind of cancer or else refused to provide an age but had not refused to answer CANKIND_3
SkipInstructions: <95,96> [goto DIBEV]
Question ID: ACN.150_00.001 Instrument Variable Name: CANAGE_1 QuestionnaireFileName: Sample Adult
QuestionText: How old were you when [fill: CANKIND_1 /this cancer] was first diagnosed?
001-100 1-100 years
997 Refused
999 Don't know
UniverseText: Sample adults 18+ who were ever told they had cancer
SkipInstructions: <1-100, D> [goto CANKIND_2]
<R> and <R> at CANKIND_1 [goto DIBEV]
<R> and CANKIND_1 NE <R> [goto CANKIND_2]
If number in CANAGE_1 greater than person years old (AGE) goto ERR_ CANAGE_1
Question ID: ACN.150_00.002 Instrument Variable Name: CANAGE_2 QuestionnaireFileName: Sample Adult
QuestionText: How old were you when [fill: CANKIND_2/this cancer] was first diagnosed?
001-100 1-100 years
997 Refused
999 Don't know
UniverseText: Sample adults 18+ who were ever told they had cancer
SkipInstructions: <1-100, D> [goto CANKIND_3]
<R> and <R> at CANKIND_2 [goto DIBEV]
<R> and CANKIND_2 NE <R> [goto CANKIND_3]
If number in CANAGE_2 greater than person years old (AGE) goto ERR_ CANAGE_2
Page 23 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.150_00.003 Instrument Variable Name: CANAGE_3 QuestionnaireFileName: Sample Adult
QuestionText: How old were you when [fill: CANKIND_3/this cancer ] was first diagnosed?
001-100 1-100 years
997 Refused
999 Don't know
UniverseText: Sample adults 18+ who were ever told they had cancer
SkipInstructions: <1-100, D> [goto CANKIND_4]
<R> and <R> at CANKIND_3 [goto DIBEV]
<R> and CANKIND_3 NE <R> [goto CANKIND_4]
If number in CANAGE_3 greater than person years old (AGE) goto ERR_ CANAGE_3
Question ID: ACN.160_00.000 Instrument Variable Name: DIBEV QuestionnaireFileName: Sample Adult
QuestionText: [fill: Other than during pregnancy, have you EVER been told by a doctor or health professional that you have diabetes or
sugar diabetes?/Have you EVER been told by a doctor or health professional that you have diabetes or sugar diabetes?]
1 Yes
2 No
3 Borderline
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto DIBAGE]
<2,3,R,D> [goto AHAYFYR]
Question ID: ACN.170_00.000 Instrument Variable Name: DIBAGE QuestionnaireFileName: Sample Adult
QuestionText: How old were you when a doctor FIRST told you that you had diabetes or sugar diabetes?
01-84 1-84 years
85 85+ years
97 Refused
99 Don't know
UniverseText: Sample adults 18+ who were told they had diabetes or sugar diabetes (other than during pregnancy)
SkipInstructions: <1-100 R,D> [goto INSLN]
If number in DIBAGE greater than person years old (AGE) goto ERR_ DIBAGE
Note: Age is collected as 1-100 in the instrument and later top coded to 1-84 and 85+ years
Page 24 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.180_00.000 Instrument Variable Name: INSLN QuestionnaireFileName: Sample Adult
QuestionText: Are you NOW taking insulin?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who were told they had diabetes or sugar diabetes (other than during pregnancy)
SkipInstructions: <1,2,R,D> [goto DIBPILL]
Question ID: ACN.190_00.000 Instrument Variable Name: DIBPILL QuestionnaireFileName: Sample Adult
QuestionText: Are you NOW taking diabetic pills to lower your blood sugar? These are sometimes called oral agents or oral hypoglycemic
agents.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who were told they had diabetes or sugar diabetes (other than during pregnancy)
SkipInstructions: <1,2,R,D> [goto AHAYFYR]
Question ID: ACN.201_01.000 Instrument Variable Name: AHAYFYR QuestionnaireFileName: Sample Adult
QuestionText: DURING THE PAST 12 MONTHS, have you been told by a doctor or other health professional that you had
...Hay fever?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D> [goto SINYR]
Page 25 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.201_02.000 Instrument Variable Name: SINYR QuestionnaireFileName: Sample Adult
QuestionText: * Read lead-in if necessary:
DURING THE PAST 12 MONTHS, have you been told by a doctor or other health professional that you had
...Sinusitis?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D> [goto CBRCHYR]
Question ID: ACN.201_03.000 Instrument Variable Name: CBRCHYR QuestionnaireFileName: Sample Adult
QuestionText: * Read lead-in if necessary:
DURING THE PAST 12 MONTHS, have you been told by a doctor or other health professional that you had
...Chronic bronchitis?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D> [goto KIDWKYR]
Question ID: ACN.201_04.000 Instrument Variable Name: KIDWKYR QuestionnaireFileName: Sample Adult
QuestionText: * Read lead-in if necessary:
DURING THE PAST 12 MONTHS, have you been told by a doctor or other health professional that you had
......Weak or failing kidneys? - Do not include kidney stones, bladder infections or incontinence.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D> [goto LIVYR]
Page 26 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.201_05.000 Instrument Variable Name: LIVYR QuestionnaireFileName: Sample Adult
QuestionText: * Read lead-in if necessary:
DURING THE PAST 12 MONTHS, have you been told by a doctor or other health professional that you had
......Any kind of liver condition?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D> [goto JNTSYMP]
Question ID: ACN.250_00.000 Instrument Variable Name: JNTSYMP QuestionnaireFileName: Sample Adult
QuestionText: The next questions refer to your joints. Please do NOT include the back or neck. DURING THE PAST 30 DAYS, have
you had any symptoms of pain, aching, or stiffness in or around a joint?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto JMTHP]
<2,R,D> [goto ARTH]
Page 27 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.260_00.000 Instrument Variable Name: JMTHP QuestionnaireFileName: Sample Adult
QuestionText: (book) A4
Which joints are affected?
* Enter all that apply, separate with commas.
01 Shoulder-right
02 Shoulder-left
03 Elbow-right
04 Elbow-left
05 Hip-right
06 Hip-left
07 Wrist-right
08 Wrist-left
09 Knee-right
10 Knee-left
11 Ankle-right
12 Ankle-left
13 Toes-right
14 Toes-left
15 Fingers/thumb-right
16 Fingers/thumb-left
17 Other joint not listed
97 Refused
99 Don't know
UniverseText: Sample adults 18+ who had joint pain in the past 30 days
SkipInstructions: <1-17,R,D> [goto JNTCHR]
Question ID: ACN.270_00.000 Instrument Variable Name: JNTCHR QuestionnaireFileName: Sample Adult
QuestionText: Did your joint symptoms FIRST begin more than 3 months ago?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ with joint pain
SkipInstructions: <1,2,R,D> [goto JNTHP]
Page 28 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.280_00.000 Instrument Variable Name: JNTHP QuestionnaireFileName: Sample Adult
QuestionText: Have you EVER seen a doctor or other health professional for these
joint symptoms?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ with joint pain
SkipInstructions: <1,2,R,D> [goto ARTH]
Question ID: ACN.290_00.000 Instrument Variable Name: ARTH QuestionnaireFileName: Sample Adult
QuestionText: Have you EVER been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis,
gout, lupus, or fibromyalgia (fy-bro-my-AL-jee-uh)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions:
If ARTH eq <1> or JNTSYMP eq <1> goto ARTHLMT; else [goto PAINECK]
Question ID: ACN.295_00.000 Instrument Variable Name: ARTHLMT QuestionnaireFileName: Sample Adult
QuestionText: Are you now limited in any way in any of your usual activities because of arthritis or joint symptoms?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ with joint pain or arthritis
SkipInstructions: <1,2,R,D> if ARTH=1 [goto ARTHTYP]; else [goto PAINECK]
Page 29 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.297_00.010 Instrument Variable Name: ARTHTYP QuestionnaireFileName: Sample Adult
QuestionText: You just mentioned that you were told by a doctor or other health professional that you had some form of arthritis,
rheumatoid arthritis, gout, lupus, or fibromyalgia. Which of these were you told you had?
*Enter all that apply, separate with commas.
1 Arthritis
2 Rheumatoid arthritis
3 Gout
4 Lupus
5 Fibromyalgia
6 Other joint condition
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who were told they had some form of arthritis, rheumatoid arthritis, gout, lupus or fibromyalgia
SkipInstructions: <1-6,R,D> [goto PAINECK]
Question ID: ACN.300_00.000 Instrument Variable Name: PAINECK QuestionnaireFileName: Sample Adult
QuestionText: The following questions are about pain you may have experienced in the PAST THREE MONTHS. Please refer to pain
that LASTED A WHOLE DAY OR MORE. Do not report aches and pains that are fleeting or minor.
During the PAST THREE MONTHS, did you have
... Neck pain?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D> [goto PAINLB]
Question ID: ACN.310_00.000 Instrument Variable Name: PAINLB QuestionnaireFileName: Sample Adult
QuestionText: * Read lead-in if necessary.
During the PAST THREE MONTHS, did you have
... Low back pain?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto PAINLEG]
<2,R,D> [goto PAINFACE]
Page 30 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.320_00.000 Instrument Variable Name: PAINLEG QuestionnaireFileName: Sample Adult
QuestionText: Did this pain spread down either leg to areas below the knees?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ with low back pain in the past 3 months
SkipInstructions: <1,2,R,D> [goto PAINFACE]
Question ID: ACN.331_01.000 Instrument Variable Name: PAINFACE QuestionnaireFileName: Sample Adult
QuestionText: During the PAST THREE MONTHS, did you have
... Facial ache or pain in the jaw muscles or the joint in front of the ear?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D> [goto AMIGR]
Question ID: ACN.331_02.000 Instrument Variable Name: AMIGR QuestionnaireFileName: Sample Adult
QuestionText: * Read lead-in if neccesary:
During the PAST THREE MONTHS, did you have
...Severe headache or migraine?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D>[goto ACOLD2W]
Page 31 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.350_00.000 Instrument Variable Name: ACOLD2W QuestionnaireFileName: Sample Adult
QuestionText: * Hand calendar card
These next questions are about your recent health during the TWO WEEKS outlined on that calendar.
Did you have a head cold or chest cold that started during those TWO WEEKS?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D> [goto AINTIL2W]
Question ID: ACN.360_00.000 Instrument Variable Name: AINTIL2W QuestionnaireFileName: Sample Adult
QuestionText: Did you have a stomach or intestinal illness with vomiting or diarrhea that started during those TWO WEEKS?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D> if SEX=1 and age GE 40 [goto PROSTYR]; else if SEX=2 and AGE 18-49 [goto PREGNOW]; else if
SEX=2 and AGE 50-55 [goto MENSYR]; else if SEX=2 and AGE 56-57 [goto MENOYR]; else if SEX=2 and AGE
GE 58 [goto GYNYR] else [goto AHEARST1]
Question ID: ACN.370_00.000 Instrument Variable Name: PREGNOW QuestionnaireFileName: Sample Adult
QuestionText: Are you currently pregnant?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Female sample adults 18-49 years of age
SkipInstructions: <1,2,R,D> [goto MENSYR]
Page 32 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.372_00.010 Instrument Variable Name: MENSYR QuestionnaireFileName: Sample Adult
QuestionText: DURING THE PAST 12 MONTHS, have you had any menstrual problems such as heavy bleeding, bothersome cramping,
or pre-menstrual syndrome (also called PMS)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Female sample adults 18-55
SkipInstructions: <1,2,R,D> if AGE 45-55 [goto MENOYR]; else [goto GYNYR]
Question ID: ACN.372_00.020 Instrument Variable Name: MENOYR QuestionnaireFileName: Sample Adult
QuestionText: DURING THE PAST 12 MONTHS, have you had any menopausal problems such as hot flashes, night sweats, or other
menopausal symptoms?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Female sample adults 45-57
SkipInstructions: <1,2,R,D> [goto GYNYR]
Question ID: ACN.372_00.030 Instrument Variable Name: GYNYR QuestionnaireFileName: Sample Adult
QuestionText: DURING THE PAST 12 MONTHS, have you had any gynecologic problems such as a vaginal infection, uterine fibroids,
or infertility?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Female sample adults 18+
SkipInstructions: <1,2,R,D> [goto AHEARST1]
Question ID: ACN.372_00.040 Instrument Variable Name: PROSTYR QuestionnaireFileName: Sample Adult
QuestionText: DURING THE PAST 12 MONTHS, have you had any men's health problems such a prostate trouble, or impotence?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Male sample adults 40+
SkipInstructions: <1,2,R,D> [goto AHEARST1]
Page 33 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.400_00.010 Instrument Variable Name: AHEARST1 QuestionnaireFileName: Sample Adult
QuestionText: These next questions are about your hearing WITHOUT the use of hearing aids or other listening devices.
Is your hearing excellent, good, a little trouble hearing, moderate trouble, a lot of trouble, or are you deaf?
1 Excellent
2 Good
3 A little trouble
4 Moderate hearing trouble
5 A lot of trouble
6 Deaf
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto HRFAM]
<2-6,R,D> [goto HRWORS]
Question ID: ACN.400_00.020 Instrument Variable Name: HRWORS QuestionnaireFileName: Sample Adult
QuestionText: Is your hearing WORSE in one ear than the other?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have other than excellent hearing
SkipInstructions: <1> [goto HRWHICH]
<2,R,D> [goto HRWHISP]
Question ID: ACN.400_00.030 Instrument Variable Name: HRWHICH QuestionnaireFileName: Sample Adult
QuestionText: Which ear is worse?
1 The right ear
2 The left ear
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who hear worse in one ear than the other
SkipInstructions: <1,2,R,D> [goto HRRIGHT]
Page 34 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.400_00.040 Instrument Variable Name: HRRIGHT QuestionnaireFileName: Sample Adult
QuestionText: Is your hearing in your RIGHT ear excellent, good, a little trouble, moderate trouble, a lot of trouble, or are you deaf?
1 Excellent
2 Good
3 A little trouble
4 Moderate hearing trouble
5 A lot of trouble
6 Deaf
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have other than excellent hearing
SkipInstructions: <1-6,R,D> [goto HRLEFT]
Question ID: ACN.400_00.050 Instrument Variable Name: HRLEFT QuestionnaireFileName: Sample Adult
QuestionText: Is your hearing in your LEFT ear excellent, good, a little trouble, moderate trouble, a lot of trouble, or are you deaf?
1 Excellent
2 Good
3 A little trouble
4 Moderate hearing trouble
5 A lot of trouble
6 Deaf
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have other than excellent hearing
SkipInstructions: <1-6,R,D> [goto HRWHISP]
Question ID: ACN.400_00.060 Instrument Variable Name: HRWHISP QuestionnaireFileName: Sample Adult
QuestionText: Can you usually HEAR AND UNDERSTAND what a person says without seeing his face if that person WHISPERS to you
from across a quiet room?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have other than excellent hearing
SkipInstructions: <1> [goto HRBACK]
<2,R,D> [goto HRTALK]
Page 35 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.400_00.070 Instrument Variable Name: HRTALK QuestionnaireFileName: Sample Adult
QuestionText: Can you usually HEAR AND UNDERSTAND what a person says without seeing his face if that person TALKS IN A
NORMAL VOICE to you from across a quiet room?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who cannot hear whispers across a quiet room
SkipInstructions: <1> [goto HRBACK]
<2,R,D> [goto HRSHOUT]
Question ID: ACN.400_00.080 Instrument Variable Name: HRSHOUT QuestionnaireFileName: Sample Adult
QuestionText: Can you usually HEAR AND UNDERSTAND what a person says without seeing his face if that person SHOUTS to you
from across a quiet room?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who cannot hear a normal voice across a quiet room
SkipInstructions: <1> [goto HRBACK]
<2,R,D> [goto HRSPEAK]
Question ID: ACN.400_00.090 Instrument Variable Name: HRSPEAK QuestionnaireFileName: Sample Adult
QuestionText: Can you usually HEAR AND UNDERSTAND what a person says without seeing his face if that person SPEAKS LOUDLY
into your [fill: ear/better ear]?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who cannot hear a shouting voice across a quiet room
SkipInstructions: <1,2,R,D> [goto HRBACK]
Page 36 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.400_00.100 Instrument Variable Name: HRBACK QuestionnaireFileName: Sample Adult
QuestionText: How often do you find it difficult to follow a conversation if there is background noise, for example, when other people are
talking, TV or radio is on, or children are playing? Would you say...
*Read categories below.
1 Always
2 Usually
3 About half the time
4 Seldom
5 Never
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have other than excellent hearing
SkipInstructions: <1-5,R,D> [goto HRFRUST]
Question ID: ACN.400_00.110 Instrument Variable Name: HRFRUST QuestionnaireFileName: Sample Adult
QuestionText: How often does your hearing cause you to feel frustrated when talking to members of your family or to friends? Would you
say...
*Read categories below.
1 Always
2 Usually
3 About half the time
4 Seldom
5 Never
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have other than excellent hearing
SkipInstructions: <1-5,R,D> [goto HRSAFETY]
Question ID: ACN.400_00.120 Instrument Variable Name: HRSAFETY QuestionnaireFileName: Sample Adult
QuestionText: How often does your hearing cause you to worry about your safety while working or doing other activities? Would you
say...
*Read categories below.
1 Always
2 Usually
3 About half the time
4 Seldom
5 Never
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have other than excellent hearing
SkipInstructions: <1-5,R,D> if AHEARST1=2,R,D and HRWORS=2,R,D [goto HRFAM];
else [goto HEARAGE1]
Page 37 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.400_00.130 Instrument Variable Name: HEARAGE1 QuestionnaireFileName: Sample Adult
QuestionText: How old were you when you began to have ANY permanent [fill: hearing loss/hearing loss in either ear]?
1 At birth
2 0 to 2 years of age
3 3 to 5 years of age
4 6 to 11 years of age
5 12 to 19 years of age
6 20 to 39 years of age
7 40 to 59 years of age
8 60 to 69 years of age
9 70 or more years of age
97 Refused
99 Don't know
UniverseText: Sample adults 18+ whose hearing is not excellent, or who reported good hearing, but hear worse in one ear than the
other
SkipInstructions: <1-9,R,D> [goto HRSUDDEN]
Question ID: ACN.400_00.140 Instrument Variable Name: HRSUDDEN QuestionnaireFileName: Sample Adult
QuestionText: Was your hearing loss sudden or gradual?
*Read if necessary: Sudden means less than 3 months.
1 Sudden
2 Gradual
7 Refused
9 Don't know
UniverseText: Sample adults 18+ whose hearing is not excellent, or who reported good hearing, but hear worse in one ear than the
other
SkipInstructions: <1,2,R,D> [goto HRCAUS1]
Page 38 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.400_00.150 Instrument Variable Name: HRCAUS1 QuestionnaireFileName: Sample Adult
QuestionText: What was the MAIN cause of your hearing loss?
01 Present at birth because mother had German Measles (Rubella) or Cytomegalovirus (CMV)
02 Present at birth for a genetic reason
03 Present at birth for some other reason, not including genetic or infectious disease
04 Infectious disease after birth (measles, meningitis, etc.)
05 Ear infections or Otitis Media
06 Ear injury (holes in eardrum, etc.)
07 Ear surgery
08 Ear disease, such as Meniere's Disease or Otosclerosis
09 Brain tumor (Acoustic Neuroma)
10 Loud, brief noise from gunfire, blasts, or explosions
11 Noise exposure from machinery, aircraft, power tools, loud music, appliances, personal stereos or MP3 players, hair dryers,
etc.
12 Getting older/aging
13 Some other cause
97 Refused
99 Don't know
UniverseText: Sample adults 18+ whose hearing is not excellent, or who reported good hearing, but hear worse in one ear than the
other
SkipInstructions: <1-13,R,D> [goto HRFAM]
Question ID: ACN.400_00.160 Instrument Variable Name: HRFAM QuestionnaireFileName: Sample Adult
QuestionText: Have any of your friends or relatives ever told you that you have a hearing problem?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D> [goto HRPROBHP]
Page 39 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.400_00.170 Instrument Variable Name: HRPROBHP QuestionnaireFileName: Sample Adult
QuestionText: When was the LAST time you saw a doctor or other health care professional about any hearing or ear problems?
0 Never
1 In the past year
2 1 to 2 years ago
3 3 to 4 years ago
4 5 to 9 years ago
5 10 to 14 years ago
6 15 or more years ago
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <0,4-6,R,D> [goto HRTEST]
<1-3> [goto HRENT]
Question ID: ACN.405_01.010 Instrument Variable Name: HRENT QuestionnaireFileName: Sample Adult
QuestionText: In the past 5 years, were you referred by your doctor or other health care professional to a
...Hearing specialist, such as an Ear, Nose, and Throat doctor?
*Read if necessary: Include an Otolaryngologist or Otologist
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who saw a doctor or other health care professional about hearing or ear problems 1-4 years ago
SkipInstructions: <1,2,R,D> [goto HRAUD]
Question ID: ACN.405_02.020 Instrument Variable Name: HRAUD QuestionnaireFileName: Sample Adult
QuestionText: *Read if necessary.
In the past 5 years, were you referred by your doctor or other health care professional to
...An audiologist or hearing aid dispenser?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who saw a doctor or other health care professional about hearing or ear problems 1-4 years ago
SkipInstructions: <1,2,R,D> [goto HRTEST]
Page 40 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.410_00.010 Instrument Variable Name: HRTEST QuestionnaireFileName: Sample Adult
QuestionText: When was the last time you had your hearing tested?
0 Never
1 In the past year
2 1 to 2 years ago
3 3 to 4 years ago
4 5 to 9 years ago
5 10 to 14 years ago
6 15 or more years ago
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <0-6,R,D> [goto HRCOCREC]
Question ID: ACN.410_00.020 Instrument Variable Name: HRCOCREC QuestionnaireFileName: Sample Adult
QuestionText: Has a hearing specialist, your doctor, or other health care professional ever recommended a cochlear implant to you?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto HRCOCNOW]
<2,R,D> [goto HRAIDNOW]
Question ID: ACN.410_00.030 Instrument Variable Name: HRCOCNOW QuestionnaireFileName: Sample Adult
QuestionText: Do you now use a cochlear implant?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have had a cochlear implant recommended
SkipInstructions: <1,2,R,D,> [goto HRAIDNOW]
Page 41 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.410_00.040 Instrument Variable Name: HRAIDNOW QuestionnaireFileName: Sample Adult
QuestionText: Do you now use a hearing aid?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto HRAIDLNG] <2,R,D> [goto HRAIDEV]
Question ID: ACN.410_00.050 Instrument Variable Name: HRAIDLNG QuestionnaireFileName: Sample Adult
QuestionText: How long have you used a hearing aid(s)?
1 Less than 6 weeks
2 6 weeks to 11 months
3 1 to 2 years
4 3 to 4 years
5 5 to 9 years
6 10 to 14 years
7 15 or more years
97 Refused
99 Don't know
UniverseText: Sample adults 18+ who now use a hearing aid
SkipInstructions: <1-7,R,D> [goto HRAIDYR]
Question ID: ACN.410_00.060 Instrument Variable Name: HRAIDYR QuestionnaireFileName: Sample Adult
QuestionText: In the past 12 months, how often did you use a hearing aid? Would you say...
*Read categories below.
1 Always
2 Usually
3 About half the time
4 Seldom
5 Never
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who now use a hearing aid
SkipInstructions: <1-4,R,D> if AHEARST1=1 or AHEARST1=2,R,D and HRWORS=2,R,D [goto HRTIN];
else [goto HRALDS]
<5> [goto HRAIDNOT]
Page 42 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.410_00.070 Instrument Variable Name: HRAIDEV QuestionnaireFileName: Sample Adult
QuestionText: Have you ever used a hearing aid in the past?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who do not now use a hearing aid or REF/DK whether they now use a hearing aid
SkipInstructions: <1> [goto HRAIDLGP]
<2,R,D> [goto HRAIDREC]
Question ID: ACN.410_00.080 Instrument Variable Name: HRAIDREC QuestionnaireFileName: Sample Adult
QuestionText: Has a hearing specialist, your doctor, or other health care professional ever recommended a hearing aid to you?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who do not now use a hearing aid or who have not used one in the past or who refused to answer
whether they use or have used a hearing aid
SkipInstructions: <1> [goto HRAIDNOT]
<2,R,D> if AHEARST1=1 or AHEARST1=2,R,D and HRWORS=2,R,D [goto HRTIN];
else [goto HRALDS]
Question ID: ACN.410_00.090 Instrument Variable Name: HRAIDLGP QuestionnaireFileName: Sample Adult
QuestionText: How long did you use a hearing aid(s) in the past?
1 Less than 6 weeks
2 6 weeks to 11 months
3 1 to 2 years
4 3 to 4 years
5 5 to 9 years
6 10 to 14 years
7 15 or more years
97 Refused
99 Don't know
UniverseText: Sample adults 18+ who have used a hearing aid in the past, but not currently
SkipInstructions: <1-7,R,D> [goto HRAIDOFT]
Page 43 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.410_00.100 Instrument Variable Name: HRAIDOFT QuestionnaireFileName: Sample Adult
QuestionText: During this time, how often did you use a hearing aid? Would you say...
*Read categories below.
1 Always
2 Usually
3 About half the time
4 Seldom
5 Never
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have used a hearing aid in the past, but not currently
SkipInstructions: <1-5,R,D> [goto HRAIDNOT]
Question ID: ACN.410_00.110 Instrument Variable Name: HRAIDNOT QuestionnaireFileName: Sample Adult
QuestionText: Why have you decided not to use a hearing aid?
*Enter all that apply, separate with commas.
1 It didn't help
2 Didn't like the way it sounded/Too loud/noisy
3 Whistling sounds
4 It was uncomfortable
5 It had frequent breakdowns/Needed repairs
6 Didn't like the way it looked
7 It cost too much
8 Don't think I need a hearing aid
9 Other
97 Refused
99 Don't know
UniverseText: Sample adults 18+ who said they currently use a hearing aid but have not used one in the past 12 months, or who
have ever used a hearing aid, but not currently, or who have had a hearing aid recommended
SkipInstructions: <1-9,R,D> if AHEARST1=1 or AHEARST1=2,R,D and HRWORS=2,R,D [goto HRTIN];
else [goto HRALDS]
Question ID: ACN.410_00.120 Instrument Variable Name: HRALDS QuestionnaireFileName: Sample Adult
QuestionText: Because of your hearing, have you ever used assistive listening devices (ALDs), such as FM systems, closed-caption
television, or amplified telephone or relay services?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ whose hearing is not excellent, or who reported good hearing, but hear worse in one ear than the
other
SkipInstructions: <1> [goto HRALDTYP] <2,R,D> [goto HRTIN]
Page 44 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.410_00.130 Instrument Variable Name: HRALDTYP QuestionnaireFileName: Sample Adult
QuestionText: (book) A5
Which of the following assistive listening devices have you ever used?
*Enter all that apply, separate with commas.
1 Pocket talker or other personal listening device
2 Amplified telephone
3 Amplified or vibrating alarm clock
4 Notification or signaling system (light signaler for doorbell, baby cry monitor, etc.)
5 Television/Theater headset or closed-captioned TV
6 TTY (teletypewriter), TDD (telecommunications device for the deaf) or telephone relay service
7 Video relay service
8 Sign language interpreter
9 Other
97 Refused
98 Don't know
UniverseText: Sample adults 18+ who have ever used assistive listening devices
SkipInstructions: <1-9,R,D> [goto HRTIN]
Question ID: ACN.412_00.010 Instrument Variable Name: HRTIN QuestionnaireFileName: Sample Adult
QuestionText: In the past 12 months, have you been bothered by ringing, roaring, or buzzing in your ears or head that lasts for 5 minutes
or more?
Read if necessary: Tinnitus is the medical term for ringing, roaring or buzzing in the ears or head.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto HRTINLNG]
<2,R,D> [goto HRFIRE]
Page 45 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.412_00.020 Instrument Variable Name: HRTINLNG QuestionnaireFileName: Sample Adult
QuestionText: How long have you been bothered by this ringing, roaring, or buzzing in your ears or head?
1 Less than 3 months
2 3 to 11 months
3 1 to 2 years
4 3 to 4 years
5 5 to 9 years
6 10 to 14 years
7 15 years or more
97 Refused
99 Don't know
UniverseText: Sample adults 18+ who have been bothered by ringing, roaring, or buzzing in their ears or head in the past 12 months
SkipInstructions: <1-7,R,D> [goto HRTINOFT]
Question ID: ACN.412_00.030 Instrument Variable Name: HRTINOFT QuestionnaireFileName: Sample Adult
QuestionText: In the past 12 months, how often have you had this ringing, roaring, or buzzing in your ears or head? Would you say...
*Read categories below.
1 Almost always
2 At least once a day
3 At least once a week
4 At least once a month
5 Less frequently than once a month
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have been bothered by ringing, roaring, or buzzing in their ears or head in the past 12 months
SkipInstructions: <1-7,R,D> [goto HRTINMUS]
Question ID: ACN.412_00.040 Instrument Variable Name: HRTINMUS QuestionnaireFileName: Sample Adult
QuestionText: Are you bothered by ringing, roaring, or buzzing in your ears or head ONLY after listening to loud sounds or loud music?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have been bothered by ringing, roaring, or buzzing in their ears or head in the past 12 months
SkipInstructions: <1,2,R,D> [goto HRTINSLP]
Page 46 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.412_00.050 Instrument Variable Name: HRTINSLP QuestionnaireFileName: Sample Adult
QuestionText: Are you bothered by ringing, roaring, or buzzing in your ears or head when going to sleep?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have been bothered by ringing, roaring, or buzzing in their ears or head in the past 12 months
SkipInstructions: <1,2,R,D> [goto HRTNPROB]
Question ID: ACN.412_00.060 Instrument Variable Name: HRTINPROB QuestionnaireFileName: Sample Adult
QuestionText: How much of a problem is this ringing, roaring, or buzzing in your ears or head? Would you say it is...
*Read categories below.
1 No problem
2 A small problem
3 A moderate problem
4 A big problem
5 A very big problem
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have been bothered by ringing, roaring, or buzzing in their ears or head in the past 12 months
SkipInstructions: <1-5,R,D> [goto HRTINDIS]
Question ID: ACN.412_00.070 Instrument Variable Name: HRTINDIS QuestionnaireFileName: Sample Adult
QuestionText: Have you ever discussed this ringing, roaring or buzzing in your ears or head with your doctor or other health care
professional?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have been bothered by ringing, roaring, or buzzing in their ears or head in the past 12 months
SkipInstructions: <1> [goto HRTINRM] <2,R,D> [goto HRFIRE]
Page 47 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.412_00.072 Instrument Variable Name: HRTINRM QuestionnaireFileName: Sample Adult
QuestionText: Have you ever tried any remedies or treatments for this ringing, roaring, or buzzing in your ears or head?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have discussed the ringing, roaring, or buzzing in their ears or head with a doctor or other
health care professional
SkipInstructions: <1> [goto HRREMTYP] <2,R,D> [goto HRFIRE]
Question ID: ACN.412_00.074 Instrument Variable Name: HRREMTYP QuestionnaireFileName: Sample Adult
QuestionText: (book) A6
Which of the following treatments have you tried?
*Enter all that apply, separate with commas.
01 Amplification/Hearing aids
02 Masking with wearable device (with or without hearing aids)
03 Masking with non-wearable device (sound generators to help with sleep)
04 Cognitive therapy with counseling
05 Stress reduction or relaxation methods
06 Biofeedback
07 Tinnitus retraining therapy (TRT)
08 Psychiatric treatment
09 Surgery to cut the hearing nerve
10 Drugs or medications
11 Nutritional supplements
12 Music therapy
13 Temporal mandibular joint treatment
14 Alternative methods (hypnosis, acupuncture, etc.)
15 Other
97 Refused
99 Don't know
UniverseText: Sample adults 18+ who have tried remedies or treatments for the ringing, roaring, or buzzing in their ears or head
SkipInstructions: <1-15,R,D> [goto HRFIRE]
Page 48 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.413_00.010 Instrument Variable Name: HRFIRE QuestionnaireFileName: Sample Adult
QuestionText: The next few questions are about your current or previous exposure to loud sounds or noises.
Have you ever used firearms for any reason?
*Include target shooting, hunting, your job (including military service).
*Firearms include pistols shotguns, rifles, and other types of guns. Do not include BB or pellet guns.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto HRFIRTYP] <2,R,D> [goto HRWRKNOS]
Question ID: ACN.413_00.020 Instrument Variable Name: HRFIRTYP QuestionnaireFileName: Sample Adult
QuestionText: Was this for work, leisure, or both?
1 Work
2 Leisure
3 Both work and leisure
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have ever used firearms
SkipInstructions: <1-3,R,D> [goto HRTOTR]
Question ID: ACN.413_00.030 Instrument Variable Name: HRTOTR QuestionnaireFileName: Sample Adult
QuestionText: How many TOTAL rounds have you ever fired?
*Read categories if necessary.
*Include target shooting, hunting, your job (including military service).
*One round equals one shot.
1 1 to less than 100 rounds
2 100 to less than 1000 rounds
3 1000 to less than 10,000 rounds
4 10,000 to less than 50,000 rounds
5 50,000 rounds or more
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have ever used firearms
SkipInstructions: <1-5,R,D> [goto HR12MR]
Page 49 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.413_00.040 Instrument Variable Name: HR12MR QuestionnaireFileName: Sample Adult
QuestionText: In the past 12 months, about how many rounds have you fired?
*Read categories if necessary.
*Include target shooting, hunting, your job (including military service).
*One round equals one shot.
0 None
1 1 to less than 100 rounds
2 100 to less than 1000 rounds
3 1000 to less than 10,000 rounds
4 10,000 rounds or more
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have ever used firearms
SkipInstructions: <0,R,D> [goto HRWRKNOS] <1-4> [goto HRFRPROT]
Question ID: ACN.413_00.050 Instrument Variable Name: HRFRPROT QuestionnaireFileName: Sample Adult
QuestionText: In the past 12 months, when shooting firearms how often have you worn ear plugs or ear muffs? Would you say...
*Read categories below.
1 Always
2 Usually
3 About half the time
4 Seldom
5 Never
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have used firearms in the past 12 months
SkipInstructions: <1-5,R,D> [goto HRWRKNOS]
Question ID: ACN.414_00.010 Instrument Variable Name: HRWRKNOS QuestionnaireFileName: Sample Adult
QuestionText: Have you ever had a job, or combination of jobs, where you were exposed to loud sounds or noise for 4 or more hours a day,
several days a week? Loud means so loud that you must speak in a raised voice to be heard.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have ever worked
SkipInstructions: <1> [goto HRWRKTOT] <2,R,D> [goto HRLESNOS]
Page 50 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.414_00.020 Instrument Variable Name: HRWRKTOT QuestionnaireFileName: Sample Adult
QuestionText: For how many months or years have you been exposed at work to loud sounds or noise for 4 or more hours a day, several
days a week?
*Read if necessary: Loud means so loud that you must speak in a raised voice to be heard.
1 Less than 3 months
2 3 months to 11 months
3 1 to 4 years
4 5 to 9 years
5 10 to 14 years
6 15 years or more
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have ever had a job that exposed them to loud noise 4 or more hours a day, several days a
week
SkipInstructions: <1-6,R,D> [goto HRWRKYR]
Question ID: ACN.414_00.030 Instrument Variable Name: HRWRKYR QuestionnaireFileName: Sample Adult
QuestionText: Was any of this exposure to loud sounds or noise in the past 12 months?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have ever had a job that exposed them to loud noise 4 or more hours a day, several days a
week
SkipInstructions: <1> [goto HRWKPROT] <2,R,D> [HRLESNOS]
Question ID: ACN.414_00.040 Instrument Variable Name: HRWKPROT QuestionnaireFileName: Sample Adult
QuestionText: In the past 12 months, how often did you wear ear plugs or ear muffs when exposed to loud sounds or noise at work?
Would you say...
*Read categories below.
1 Always
2 Usually
3 About half the time
4 Seldom
5 Never
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have had a job that exposed them to loud noise 4 or more hours a day, several days a week
in the past 12 months
SkipInstructions: <1-5,R,D> [goto HRLESNOS]
Page 51 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.415_00.010 Instrument Variable Name: HRLESNOS QuestionnaireFileName: Sample Adult
QuestionText: [Fill: Outside of work, have you ever been exposed to loud sounds or noise for at least once a month for a year? This
includes noise from power tools, loud music, racing or speedways, household appliances, or other things/Have you ever been
exposed to loud sounds or noise for at least once a month for a year? This includes noise from power tools, loud music,
racing or speedways, household appliances, or other things]?
*Read if necessary: Loud means so loud that you must speak in a raised voice to be heard.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto HRLESTYP] <2,R,D> [goto AVISION]
Question ID: ACN.415_00.020 Instrument Variable Name: HRLESTYP QuestionnaireFileName: Sample Adult
QuestionText: (book) A7
Which of the following activities have you ever been exposed to at least once a month for a year?
*Enter all that apply, separate with commas.
01 Motorcycles/Auto racing/Snowmobile/Motor boat
02 Operating farm machinery
03 Wood cutting, woodworking, other workshop power tools
04 Lawn mower, electric trimmer, leaf/snow blower
05 Firearms
06 Household appliances: Blender/Mixer, food processor, vacuum cleaner, hair dryer, etc.
07 MP3 Player/iPod
08 Playing in a music group
09 Other music-related activities: Rock concerts, stereos, disco/clubs or bars
10 Other noise, non-work-related activities
97 Refused
99 Don't know
UniverseText: Sample adults 18+ who have ever been exposed to leisure-time noise at least once a month for a year
SkipInstructions: <1-10,R,D> [goto HRLESYR]
Question ID: ACN.415_00.030 Instrument Variable Name: HRLESYR QuestionnaireFileName: Sample Adult
QuestionText: Were any of these activities in the past 12 months?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have ever been exposed to leisure-time noise at least once a month for a year
SkipInstructions: <1> [goto HRLSPROT] <2,R,D> [goto AVISON]
Page 52 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.415_00.040 Instrument Variable Name: HRLSPROT QuestionnaireFileName: Sample Adult
QuestionText: In the past 12 months, when exposed to loud noise or music [fill: outside of work], how often have you worn ear plugs or
ear muffs? Would you say...
*Read categories below.
1 Always
2 Usually
3 About half the time
4 Seldom
5 Never
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have been exposed to leisure-time noise in the past 12 months
SkipInstructions: <1-5,R,D> [goto AVISION]
Question ID: ACN.430_00.000 Instrument Variable Name: AVISION QuestionnaireFileName: Sample Adult
QuestionText: Do you have any trouble seeing, even when wearing glasses or contact lenses?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto ABLIND]
<2,R,D> [goto LUPPRT]
Question ID: ACN.440_00.000 Instrument Variable Name: ABLIND QuestionnaireFileName: Sample Adult
QuestionText: Are you blind or unable to see at all?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who have trouble seeing even when wearing glasses/contact lenses
SkipInstructions: <1,2,R,D> [goto LUPPRT]
Page 53 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.451_00.000 Instrument Variable Name: LUPPRT QuestionnaireFileName: Sample Adult
QuestionText: Have you lost all of your upper and lower natural (permanent) teeth?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1,2,R,D>[goto MHSAD_CK]
Question ID: ACN.470_00.000 Instrument Variable Name: MHSAD_CK QuestionnaireFileName: Sample Adult
QuestionText: Now I am going to ask you some questions about feelings you may have experienced over the PAST 30 DAYS.
1 Enter 1 to continue
UniverseText: Sample adults 18+
SkipInstructions: <1> [goto SAD]
Question ID: ACN.471_01.000 Instrument Variable Name: SAD QuestionnaireFileName: Sample Adult
QuestionText: (book) A8
During the PAST 30 DAYS, how often did you feel
... So sad that nothing could cheer you up?
1 ALL of the time
2 MOST of the time
3 SOME of the time
4 A LITTLE of the time
5 NONE of the time
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1-5,R,D> [goto NERVOUS]
Page 54 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.471_02.000 Instrument Variable Name: NERVOUS QuestionnaireFileName: Sample Adult
QuestionText: (book) A8
* Read lead-in if necessary:
During the PAST 30 DAYS, how often did you feel
... Nervous?
1 ALL of the time
2 MOST of the time
3 SOME of the time
4 A LITTLE of the time
5 NONE of the time
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1-5,R,D> [goto RESTLESS]
Question ID: ACN.471_03.000 Instrument Variable Name: RESTLESS QuestionnaireFileName: Sample Adult
QuestionText: (book) A8
* Read lead-in if necessary:
During the PAST 30 DAYS, how often did you feel
... Restless or fidgety?
1 ALL of the time
2 MOST of the time
3 SOME of the time
4 A LITTLE of the time
5 NONE of the time
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1-5,R,D> [goto HOPELESS]
Page 55 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.471_04.000 Instrument Variable Name: HOPELESS QuestionnaireFileName: Sample Adult
QuestionText: (book) A8
* Read lead-in if necessary:
During the PAST 30 DAYS, how often did you feel
... Hopeless?
1 ALL of the time
2 MOST of the time
3 SOME of the time
4 A LITTLE of the time
5 NONE of the time
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1-5,R,D> [goto EFFORT]
Question ID: ACN.471_05.000 Instrument Variable Name: EFFORT QuestionnaireFileName: Sample Adult
QuestionText: (book) A8
* Read lead-in if necessary:
During the PAST 30 DAYS, how often did you feel
...That everything was an effort?
1 ALL of the time
2 MOST of the time
3 SOME of the time
4 A LITTLE of the time
5 NONE of the time
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1-5,R,D> [goto WORTHLS]
Page 56 of 56
2007 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 17-Jul-06
Question ID: ACN.471_06.000 Instrument Variable Name: WORTHLS QuestionnaireFileName: Sample Adult
QuestionText: (book) A8
* Read lead-in if necessary:
During the PAST 30 DAYS, how often did you feel
...Worthless?
1 ALL of the time
2 MOST of the time
3 SOME of the time
4 A LITTLE of the time
5 NONE of the time
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: If SAD eq <1-3> or NERVOUS eq <1-3> or RESTLESS eq <1-3> or HOPELESS eq <1-3> or EFFORT eq <1-3>
or WORTHLS eq <1-3> [goto MHAMTMO]; else [goto next section]
Question ID: ACN.530_00.000 Instrument Variable Name: MHAMTMO QuestionnaireFileName: Sample Adult
QuestionText: We just talked about a number of feelings you had during the PAST 30 DAYS. Altogether, how MUCH did these feelings
interfere with your life or activities: a lot, some, a little, or not at all?
1 A lot
2 Some
3 A little
4 Not at all
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who at least some of the time have felt sad, nervous, restless or fidgety, hopeless, that everything
was an effort, or worthless, in the past 30 days
SkipInstructions: <1-4,R,D> [go to next section]
| File Type | application/msword |
| Author | Howard Riddick |
| Last Modified By | Howard Riddick |
| File Modified | 2006-09-29 |
| File Created | 2006-09-29 |