Adult Component of the Complementary and Alternative Medicine Topical Module
CONDITIONS ADDED TO ACN SECTION
Have you EVER been told by a doctor or other health professional that you had ... [READ LIST]
... Attention Deficit Disorder/Hyperactivity?
... Autism
... Bipolar Disorder
... Dementia, including Alzheimer’s disease
... Mania or psychosis
... Schizophrenia
... Seizures
... Some form of arthritis, rheumatoid arthritis, gout, lupus, fibromyalgia, other joint
condition
“Ever had” and 12 month follow-up questions (if yes response to EVER question ask: During the past 12 months, have you had):
... High cholesterol
... Gum disease
... Phobia or fears
... Influenza or pneumonia
... Poor circulation in your legs (peripheral vascular disease, including Intermittent
Claudication (cramping))
... Urinary problems, such as incontinence, frequent or slow urination or infections
12 month follow-up questions to existing “Ever” questions:
...Hypertension
... Coronary heart disease
... Angina, also called angina pectoris
... A heart attack (also called myocardial infarction)
... Other heart condition
... A stroke
... Emphysema
During the past 12 months have you had...
... Problems with Acid reflux or heartburn
... Excessive use of alcohol or tobacco
... Regular Headaches
... Memory loss or loss of other cognitive functions
... Substance abuse, other than alcohol or tobacco
... Any severe sprains and strains
...Dental pain
...Skin problems
...Regularly had insomnia or trouble sleeping
...Regularly had excessive sleepiness during the day
... Been frequently depressed or anxious
... Menstrual problems such as heavy bleeding, bothersome cramping, or premenstrual
syndrome (also called PMS)
... Menopausal problems such as hot flashes, night sweats, or other menopausal
symptoms
... Gynecologic problems such as a vaginal infection, uterine fibroids, or infertility
... Prostrate trouble or impotence
Complementary and Alternative Medicine Supplement
Now I am going to ask you about some health services you may have used. First I will ask you about some services for which you would have seen a practitioner. Then I will ask you about some other health practices you may have done on your own.
Modalities that Require Practitioner
SHOW HAND CARD (PRACTITIONER MODALITIES)
PRT.1 Have you EVER seen a provider or practitioner for any of the following therapies for your self? Please say yes or no to each.
(1) Acupuncture yes no
(2) Ayurveda yes no
(3) Biofeedback yes no
(4) Chelation Therapy yes no
(5) Chiropractic or Osteopathic Manipulation yes no
(6) Energy Healing Therapy yes no
(7) Hypnosis yes no
(8) Massage yes no
(9) Naturopathy yes no
[IF NO TO ALL, GO TO PRT.16 ]
PRT.2 DURING THE PAST 12 MONTHS, did you see a practitioner for (modality)?
(1) Yes (next question)
(2) No (GO TO NEXT MODALITY )
PRT.3 DURING THE PAST 12 MONTHS, how many times did you see a practitioner for (modality)? Would you say… [READ CATEGORIES]
(1) Only one time
(2) 2-5 times
(3) 6-10 times
(4) 11-15
(5) 16-20
(6) More than 20 times
[For Chelation Therapy add the following categories after (5) :
(6) 21-30 times
(7) 31-40 times
(8) 41 or more times]
PRT.4 On average, how much do you pay out-of-pocket for each visit to a practitioner for (modality)?
$ __________________
PRT.5 Did you use (modality) for a specific health problem or condition?
(1) Yes (next question)
(2) No (GO TO PRT.12)
PRT.6 For what health problems or conditions did you use [modality]?
_______________________________
_______________________________
_______________________________
_______________________________
[IF more than 1 condition, ask PRT.8; else go to PRT.10]
PRT.8 For which ONE of these health conditions did you use (modality) the most?
_________________________ [CONDITION]
[HELP SCREEN WILL LIST TYPES OF OTC MEDS]
HAND CARD
PRT.10 Did you receive any of these conventional medical treatments for [condition for which modality used the most]? Please say yes or no to each.
(1) Prescription Medications
(2) Over-the-counter medications
(3) Surgery
(4) Physical therapy
(5) Mental Health Counseling
{IF NO to all, Skip to PRT.12}
PRT.11 Did you receive {filll from treatments above} for [condition for which modality used the most] before, at about the same time, or after trying (modality)?
(1) Before trying modality
(2) At about the same time you began receiving modality treatments
(3) After trying modality
PRT.12 DURING THE PAST 12 MONTHS, did you use (modality) for any of these reasons? Please say yes or no to each.
To improve or enhance energy yes no
For general wellness or general disease prevention yes no
To improve or enhance immune function yes no
(4) Medical treatments did not help yes no
(5) Medical treatments were too expensive yes no
(6) It was recommended by a health care provider yes no
(7) It was recommended by family, friends, or co-workers yes no
SHOW HAND CARD (CONVENTIONAL MEDICAL PROFESSIONALS)
PRT.14 DURING THE PAST 12 MONTHS, did you let any of these CONVENTIONAL medical professionals know about your use of (modality)?
(1) Yes (next question)
(2) No (GO TO NEXT MODALITY)
PRT.15 Which ones? [MARK ALL THAT APPLY]
Medical Doctor (including specialists)
Nurse Practitioner/Physician Assistant
Psychiatrist
Dentist (including specialists)
Doctor of Osteopathy (D.O.)
Psychologist/Social Worker
Pharmacist
[Ask PRT.17 – 20 for acupuncture and chiropractic or osteopathic manipulation]
[FOR RESPONDENTS WHO HAVE NEVERS USED –GOTO PRT.17, IF USED BUT NOT IN PAST 12 MONTHS GOTO PRT.18, ELSE GOTO NEXT MODALITY]
SHOW HAND CARD
PRT.17 Please tell me the reasons why you have never used [modality].
1) Never heard of it/don’t know much about it
2) Never thought about it
3) No reason
4) Don’t need it
5) Don’t believe in it/it doesn’t work
6) It costs too much
7) It is not safe to use
8) A health care provider told me not to use it
9) Medical science has not shown that it works
10) Some other reason
[All Goto next modality]
SHOW HANDCARD
PER.18 Please tell me the reasons why you have not used [modality] in the past 12 months.
1) Never thought about it
2) No reason
3) Didn’t need it in the last 12 months
4) It didn’t work for me before
5) It costs too much
6) I had side effects last time (go to PER.19; otherwise PER.21)
7) A health care provider told me not to use it
8) Medical science has not shown that it works
9) Some other reason
PER.19 What kinds of side effects did you have?
_________________________
_________________________
PER.20 Did any of these require medical attention?
Yes
No
Traditional Healers
[HAND CARD]
TRD.1 Have you ever seen any of the following practitioners? Please say yes or no to each.
(note: pronunication guide)
(1) Curandera
(2) Espiritstas
(3) Hierbero or Yerbera
(4) Shaman
(5) Botanica
(6) Native American Healer/Medicine Man
(7) Sobador
[If no to all, goto next modality]
Cycle through TRD.2 for each yes in TRD.1
TRD.2 DURING THE PAST 12 MONTHS, did you see {fill: types of traditional healer}?
(1) Yes (next question)
(2) No (GO TO NEXT MODALITY)
[IF MORE THAN ONE YES in TRD.2, ASK TRD.2a; ELSE GO TO TRD.3]
TRD.2a During the past 12 months, which practitioner {fill from TRD.2} did you use the most?
_____________________ [TECHNIQUE]
TRD.3 DURING THE PAST 12 MONTHS, how many times did you see {fill: type of traditional healer from TRD.2 or TRD.2a}? Would you say… [READ CATEGORIES]
(1) Only one time
(2) 2-5 times
(3) 6-10 times
(4) 11-15
(5) 16-20
(6) More than 20 times
TRD.4 On average, how much do you pay out-of-pocket for each visit to {fill: type of traditional healer}?
$ __________________
TRD.5 Did you see {fill: type of traditional healer} for a specific health problem or condition?
(1) Yes (next question)
(2) No (GO TO PRT.12)
TRD.6 For what health problems or conditions did you see {fill: type of traditional healer}?
_______________________________
_______________________________
_______________________________
_______________________________
[IF more than 1 condition, ask PRT.8; else go to PRT.9]
TRD.8 For which ONE of these health conditions did you see {fill: type of traditional healer}the most?
_________________________ [CONDITION]
HAND CARD
[HELP SCREEN FOR OTC MEDS]
TRD.10 Did you receive any of these conventional medical treatments for [condition for which you saw {fill: type of traditional healer} used the most]? Please say yes or no to each.
(1) Prescription Medications
(2) Over-the-counter medications
(3) Surgery
(4) Physical therapy
(5) Mental Health Counseling
[IF NO TO ALL, SKIP TO TRD.12]
TRD.11 Did you receive {filll from treatments above} for [condition for which you saw {fill: type of traditional healer} used the most] before, at about the same time, or after seeing [{fill: type of traditional healer}?
(1) Before seeing [{fill: type of traditional healer}
(2) At about the same time you began seeing {fill: type of traditional healer}
(3) After seeing [{fill: type of traditional healer}
TRD.12 DURING THE PAST 12 MONTS, did you see {fill: type of traditional healer} for any of these reasons? Please say yes or no to each.
(1) To improve or enhance energy yes no
(2) For general wellness or general disease prevention yes no
(3) To improve or enhance immune function yes no
(4) Medical treatments did not help yes no
(5) Medical treatments were too expensive yes no
(6) It was recommended by a health care provider yes no
(7) It was recommended by family, friends, or co-workers yes no
SHOW HAND CARD (CONVENTIONAL MEDICAL PROFESSIONALS)
TRD.14 DURING THE PAST 12 MONTHS, did you let any of these CONVENTIONAL medical professionals know about your use of (modality)?
(1) Yes (next question)
(2) No (GO TO NEXT MODALITY)
TRD.15 Which ones? [MARK ALL THAT APPLY]
Medical Doctor (including specialists)
Nurse Practitioner/Physician Assistant
Psychiatrist
Dentist (including specialists)
Doctor of Osteopathy (D.O.)
Psychologist/Social Worker
Pharmacist
Movement Therapies
MOV.1 Have you ever seen a practitioner or teacher for any of the following? Please say yes or no to each.
(1) Feldenkreis yes no
(2) Alexander Technique yes no
(3) Pilates yes no
(4) Trager Psychophysical Intergration yes no
[If no to all, goto next modality]
Cycle through MOV.2 for each response in MOV.1
MOV.2 DURING THE PAST 12 MONTHS, did you see a practitioner or teacher for {fill: type of movement therapy}?
(1) Yes (next question)
(2) No (GO TO NEXT MODALITY)
[IF MORE THAN ONE YES in MOV.2, ASK MOV.2a; ELSE GO TO MOV.3]
MOV.2a During the past 12 months, which practitioner or teacher {fill from MOV.2} did you use the most?
_____________________ [TECHNIQUE]
MOV.3 DURING THE PAST 12 MONTHS, how many times did you see a practitioner or teacher for {fill: from MOV.2 or MOV.2a}? Would you say… [READ CATEGORIES]
(1) Only one time
(2) 2-5 times
(3) 6-10 times
(4) 11-15
(5) 16-20
(6) More than 20 times
MOV.4 On average, how much do you pay out-of-pocket for each visit to a practitioner or teacher for {fill: type of movement therapy}?
$ __________________
MOV.5 Did you use {fill: type of movement therapy} for a specific health problem or condition?
(1) Yes (next question)
(2) No (GO TO PRT.12)
MOV.6 For what health problems or conditions did you use {fill: type of movement therapy}?
_______________________________
_______________________________
_______________________________
_______________________________
[IF more than 1 condition, ask PRT.8; else go to PRT.9]
MOV.8 For which ONE of these health conditions did you use {fill: type of movement therapy} the most?
_________________________ [CONDITION]
HAND CARD
[HELP SCREEN FOR OTC MEDS]
MOV.10 Did you receive any of these conventional medical treatments for [condition for which you used {fill: type of movement therapy} the most]? Please say yes or no to each.
(1) Prescription Medications
(2) Over-the-counter medications
(3) Surgery
(4) Physical therapy
(5) Mental Health Counseling
[IF NO TO ALL, SKIP TO MOV.12]
MOV.11 Did you receive {fill treatment from above} for [condition for which you used {fill: type of movement therapy} the most] before, at about the same time, or after seeing {fill: type of traditional healer}?
(1) Before using {fill: type of movement therapy}
(2) At about the same time you began using {fill: type of movement therapy}
(3) After using {fill: type of movement therapy}
MOV.12 DURING THE PAST 12 MONTS, did you use {fill: type of movement therapy}
for any of these reasons? Please say yes or no to each.
(1) To improve or enhance energy yes no
(2) For general wellness or general disease prevention yes no
(3) To improve or enhance immune function yes no
(4) Medical treatments did not help yes no
(5) Medical treatments were too expensive yes no
(6) It was recommended by a health care provider yes no
(7) It was recommended by family, friends, or co-workers yes no
SHOW HAND CARD (CONVENTIONAL MEDICAL PROFESSIONALS)
MOV.14 DURING THE PAST 12 MONTHS, did you let any of these CONVENTIONAL medical professionals know about your use of (modality)?
(1) Yes (next question)
(2) No (GO TO NEXT MODALITY)
MOV.15 Which ones? [MARK ALL THAT APPLY]
Medical Doctor (including specialists)
Nurse Practitioner/Physician Assistant
Psychiatrist
Dentist (including specialists)
Doctor of Osteopathy (D.O.)
Psychologist/Social Worker
Pharmacist
HERBS and Other Non-vitamin/non-mineral Dietary Supplements
Now I am going to ask you about some additional health practices. The first practice I’ll ask about is herbal supplements, then later I’ll ask about vitamins and minerals.
People take herbs and other non-vitamin supplements for a variety of reasons. By herbal supplement we mean pills, capsules or tablets that have been labeled as a dietary supplement. This does NOT include drinking herbal or green tea.
SHOW HAND CARD HRB#1 (HERB LIST)
HRB.1 Have you EVER taken any herbal supplements listed on this card for your self?
(1) Yes (2) No (HRB.17)
HRB.2 DURING THE PAST 12 MONTHS have you taken any herbal supplements listed on this card for your self?
(1) Yes (2) No (HRB.17)
HRB.5 DURING THE PAST 30 DAYS did you take any herbal supplements?
yes
no [HRB.17]
HRB.5a Please tell me which supplements you took in the past 30 days. If you take more than one herb in a single supplement, select “combination herb pill.”
[MARK ALL THAT APPLY]
_______________________
_______________________
_______________________
_______________________
[IF COMBO HERB PILL SELECTED, ASK 5b, OTHERWISE GO TO HRB.6]
HRB.5b How many “combination herb pills” did you take?
__________ [NUMBER]
HRB.5c What herbs are included in [combination herb pill #1?] …#2? …#3?
_______________________
_______________________
_______________________
_______________________
[IF MORE THAN 2 HERBS LISTED IN HRB.5a ASK HRB. 6, OTHERWISE GOTO HRB.7]
HRB.6 Which 2 of these did you take the most in the past 30 days?
________________________
________________________
HRB.7 Which of these are the main reasons you took [herb]? Please say yes or no to each.
[MARK ALL THAT APPLY]
(1) For general health or wellness yes no
(2) prescription or over-the-counter drugs are too expensive yes no
(3) to treat or cure a specific disease or health problem yes no
(4) to prevent a specific disease or health problem yes no
(5) to improve physical performance yes no
(6) to improve sports performance yes no
(7) to improve immune system function yes no
(8) to improve sexual performance yes no
(9) to improve mental ability or memory yes no
(10) Medical treatments did not help yes no
(11) Medical treatments were too expensive yes no
(12) It was recommended by a health care provider yes no
(13) It was recommended by family, friends, or co-workers yes no
(14) Same reason as for previous herb (on screen only) yes no
[IF #3 GOTO HRB.8, IF #4 (but not #5) GOTO HRB.13, ELSE GOTO HRB. 15]
HRB.8 For what specific health problem or conditions did take [herb]?
____________________________
____________________________
____________________________
____________________________
[if more than 1 condition, ask HRB.9; else If only 1 condition go to HRB.10]
HRB.9 For which ONE of these health problems or conditions did you take [herb] the most?
__________________________ [CONDITION]
HAND CARD
[HELP SCREEN FOR OTC MEDS]
HRB.11 Did you receive any of these conventional medical treatments for [condition for which modality used the most]? Please say yes or no to each.
(1) Prescription Medications
(2) Over-the-counter medications
(3) Surgery
(4) Physical therapy
(5) Mental Health Counseling
[IF NO TO ALL, SKIP TO HRB.15]
HRB.12 Did you receive {fill from treatment above} before, at the same time, or after you began taking [herb]?
(1) Before (HRB.15)
(2) At the same time (HRB.15)
(3) After you began (HRB.15)
HRB.13 For what specific health problem or conditions did you take [herb] to prevent?
____________________________
____________________________
____________________________
____________________________
[if more than 1 condition, ask HRB.14; else If only 1 condition go to HRB.15]
HRB.14 For which ONE of these health problems or conditions did you take
[herb] the most to prevent?
__________________________ [CONDITION]
HRB.15 Have you EVER seen a practitioner for herbal medicines?
(1) Yes (HRB.16)
(2) No (HRB.17)
HRB.16 DURING THE PAST 12 MONTHS, did you see a practitioner for herbal medicines?
(1) Yes (HRB.16a)
(2) No (HRB.17)
HRB.16b DURING THE PAST 12 MONTHS, how many times did you see a practitioner for herbal medicines?
(1) Only one time
(2) 2-5 times
(3) 6-10 times
(4) 11-15
(5) 16-20
(6) More than 20 times
HRB.16c On average, how much do you pay out-of-pocket for each visit to a practitioner for herbal medicines?
$ ______________ [PER VISIT]
SHOW HAND CARD (CONVENTIONAL MEDICAL PROFESSIONALS)
HRB.16d DURING THE PAST 12 MONTHS, did you let any of these CONVENTIONAL medical professionals know about your use of (modality)?
(1) Yes (next question)
(2) No (GO TO NEXT MODALITY)
HRB.16e Which ones? [MARK ALL THAT APPLY]
Medical Doctor (including specialists)
Nurse Practitioner/Physician Assistant
Psychiatrist
Dentist (including specialists)
Doctor of Osteopathy (D.O.)
Psychologist/Social Worker
Pharmacist
[FOR RESPONDENTS WHO HAVE NEVERS USED –GOTO HRB.18, IF USED BUT NOT IN PAST 30 DAYS GOTO HRB.19, ELSE GOTO next modality]
SHOW HANDCARD
HRB.18 Please tell me the reasons why you have never used natural herbs.
1) Never heard of it/don’t know much about it
2) Never thought about it
3) No reason
4) Don’t need it
5) Don’t believe in it/it doesn’t work
6) It costs too much
7) It is not safe to use
8) A health care provider told me not to use it
9) Medical science has not shown that it works
10) Some other reason
[All Goto HRb.22]
SHOW HANDCARD
HRB.19 Please tell me the reasons why you have not used natural herbs in the past {fill 30 days or 12 months, whichever is more recent}.
1) Never thought about it
2) No reason
3) Didn’t need it in the past 30 days
4) It didn’t work for me before
5) It costs too much
6) I had side effects last time (go to HRB.20; otherwise HRB.22)
7) A health care provider told me not to use it
8) Medical science has not shown that it works
9) Some other reason
HRB.20 What kinds of side effects did you have?
_________________________
_________________________
HRB.21 Did any of these require medical attention?
Yes
No
VITAMINS
The next questions are about any vitamins and minerals you may take.
SHOW HAND CARD VIT#1 (VITAMIN LIST)
VIT.1 Thinking of the examples on this card, have you EVER taken any vitamins or minerals for your self?
(1) Yes (2) No (next modality)
VIT.2 DURING THE PAST 12 MONTHS, have you taken any vitamins or minerals for your self?
(1) Yes (2) No (next modality)
VIT.5 During the past 30 days did you take any vitamins or minerals?
yes
no (GO TO NEXT MODALITY)
VIT.5a Please tell me which items on this list you took in the past 30 days. If you take a multi-vitamin or mineral, include it as one supplement.
________________________
________________________
________________________
________________________
________________________
________________________
[IF NONE GO TO NEXT MODALITY; IF MORE THAN 2 ASK VIT. 6, OTHERWISE GOTO VIT.7]
VIT.6 Which 2 of these did you take the most in the past 30 days?
________________________
________________________
________________________
VIT.7 Which of these are the main reasons you took [vitamin/mineral]? Please say yes or not to each. [MARK ALL THAT APPLY]
(1) For general health or wellness yes no
(2) prescription or over-the-counter drugs are too expensive yes no
(3) to treat or cure a specific disease or health problem yes no
(4) to prevent a specific disease or health problem yes no
(5) to improve physical performance yes no
(6) to improve sports performance yes no
(7) to improve immune system function yes no
(8) to improve sexual performance yes no
(9) to improve mental ability or memory yes no
(10) Medical treatments did not help yes no
(11) Medical treatments were too expensive yes no
(12) It was recommended by a health care provider yes no
(13) It was recommended by family, friends, or co-workers yes no
(14) All the same reasons as for previous vitamin (on screen only) yes no
[IF #3 GOTO VIT.8, IF #4 (but not #3) GOTO VIT.13, ELSE GOTO VIT. 15]
VIT.8 For what specific health problems or conditions did you take [vitamin/mineral]?
____________________________
____________________________
____________________________
____________________________
[if more than 1 condition, ask VIT.9; else If only 1 condition go to VIT.10]
VIT.9 For which ONE of these health problems or conditions did you take [vitamin/mineral] the most?
__________________________ [CONDITION]
HAND CARD
[HELP SCREEN FOR OTC MEDS]
VIT.11 Did you receive any of these conventional medical treatments for [condition for which modality used the most]? Please say yes or no to each.
(1) Prescription Medications
(2) Over-the-counter medications
(3) Surgery
(4) Physical therapy
(5) Mental Health Counseling
[IF NO TO ALL, SKIP TO VIT.15]
VIT.12 Did you receive this [fill from treatment above} before, at the same time, or after you began taking [vitamin/mineral]?
(1) Before (VIT.15)
(2) At the same time (VIT.15)
(3) After you began (VIT.15)
VIT.13 For what specific health problem or conditions did you take [vitamin/mineral] to prevent?
____________________________
____________________________
____________________________
____________________________
[if more than 1 condition, ask VIT.14; else If only 1 condition go to VIT.15]
VIT.14 For which ONE of these health problems or conditions did you take
[vitamin/mineral] the most to prevent?
__________________________
SHOW HAND CARD (CONVENTIONAL MEDICAL PROFESSIONALS)
VIT.15 DURING THE PAST 12 MONTHS, did you let any of these CONVENTIONAL medical professionals know about your use of (modality)?
(1) Yes (next question)
(2) No (GO TO NEXT MODALITY)
VIT.16 Which ones? [MARK ALL THAT APPLY]
Medical Doctor (including specialists)
Nurse Practitioner/Physician Assistant
Psychiatrist
Dentist (including specialists)
Doctor of Osteopathy (D.O.)
Psychologist/Social Worker
Pharmacist
Cost of Herbs and Vitamins
Now I am going to ask you about how much you spend on herbs and vitamins. First I will ask about herbs and then about vitamins. [Tailor fills to respondent use].
COS.1 About how often do you buy herbal supplements?
______ times per week/month/year
COS.2 About how much did you spend the last time you bought herbal supplements? Would you say… [READ CATEGORIES]
Under $15
$15-29
$30-59
$60-89
$90-119
$120 or more
COS.3 About how often do you buy vitamins and minerals?
_____ times a week/month/year
COS.4 About how much did you spend the last time you bought vitamins and minerals? Would you say… [READ CATEGORIES]
Under $15
$15-29
$30-59
$60-89
$90-119
$120 or more
HOMEOPATHIC TREATMENT
People who use homeopathy to treat health problems take small pills or drops that are placed under the tongue. These pills or drops are often prescribed by practitioners of homeopathy.
HOM.1 Have you EVER used homeopathic treatment for your self?
(1) Yes (next question)
(2) No (GO TO NEXT MODALITY - DIETS)
HOM.2 DURING THE PAST 12 MONTHS, did you use homeopathic treatment for your self?
(1) Yes (next question)
(2) No (GO TO NEXT MODALITY - DIETS)
HOM.3 About how often do you buy homeopathic medicine?
_____ times a week/month/year
HOM.4 And about how much did you spend the last time you bought homeopathic medicine?
$ __________________
HOM.5 Did you use homeopathic treatment for a specific health problem or condition?
(1) Yes (next question)
(2) No (GO TO HOM.11)
HOM.6 For what health problems or conditions did you use homeopathic treatment?
__________________________________
__________________________________
__________________________________
__________________________________
[IF MORE THAN 1 CONDITION ASK HOM.7; ELSE GO TO HOM.8]
HOM.7 For which ONE of these health problems or conditions did you use homeopathic treatment the most?
__________________________________ [CONDITION]
HAND CARD
HOM.9 Did you receive any of these conventional medical treatments for [condition for which modality used the most]? Please say yes or no to each.
(1) Prescription Medications
(2) Over-the-counter medications
(3) Surgery
(4) Physical therapy
(5) Mental Health Counseling
[IF NO TO ALL, SKIP TO HOM.11]
HOM.10 Did you receive {fill from treatments above} for [condition for which homeopathic treatment used the most] before, at about the same time, or after trying homeopathic treatment?
(1) Before trying homeopathy
(2) At about the same time you began receiving homeopathy
(3) After trying homeopathy
HOM.11 DURING THE PAST 12 MONTHS, did you use homeopathic treatment for any of these reasons? Please say yes or no to each.
(1) To improve or enhance energy yes no
(2) For general wellness or general disease prevention yes no
(3) To improve or enhance immune function yes no
(4) Medical treatments did not help yes no
(5) Medical treatments were too expensive yes no
(6) It was recommended by a health care provider yes no
(7) It was recommended by family, friends, or co-workers yes no
HOM.12 Have you EVER seen a practitioner for homeopathic treatment?
(1) Yes (next question)
(2) No (GO TO HOM.17)
HOM.13 DURING THE PAST 12 MONTHS, did you see a practitioner for homeopathic treatment?
(1) Yes (next question)
(2) No (GO TO HOM.17)
HOM.14 DURING THE PAST 12 MONTHS, how many times did you see a practitioner for homeopathic treatments?
(1) Only one time
(2) 2-5 times
(3) 6-10 times
(4) 11-15
(5) 16-20
(6) More than 20 times
HOM.16 On average, how much do you pay out-of-pocket for each visit to a practitioner for homeopathic treatments?
$ ______________ [PER VISIT]
SHOW HAND CARD (CONVENTIONAL MEDICAL PROFESSIONALS)
HOM.17 DURING THE PAST 12 MONTHS, did you let any of these CONVENTIONAL medical professionals know about your use of (modality)?
(1) Yes (next question)
(2) No (GO TO NEXT MODALITY)
HOM.18 Which ones? [MARK ALL THAT APPLY]
Medical Doctor (including specialists)
Nurse Practitioner/Physician Assistant
Psychiatrist
Dentist (including specialists)
Doctor of Osteopathy (D.O.)
Psychologist/Social Worker
Pharmacist
SPECIAL DIETS
DIT.1 Have you EVER used any of the following special diets for two weeks or more for your self? Please say yes or no to each.
(note: insert pronunciation guide)
(1) Vegetarian (for health reasons) yes no
(2) Macrobiotic yes no
(3) Atkins yes no
(4) Pritikin yes no
(5) Ornish yes no
(6) Zone yes no
(7) South Beach yes no
[IF NO TO ALL, GO TO NEXT SECTION – YOGA]
DIT.2 DURING THE PAST 12 MONTHS, did you use [diets mentioned in DIT.1] for two weeks or more for your self? [MARK ALL THAT APPLY]
yes
no [GO TO NEXT MODALITY]
[IF ONLY ONE DIET USED, GO TO DIT.5; ELSE ASK DIT.4]
DIT.4 During the past 12 months, which diet did you use the most?
_____________________ [DIET]
DIT.5 Did you use this diet for weight control or weight loss?
(1) Yes
(2) No
DIT.6 Did you use this diet to treat a specific health problem or condition (other than weight control or weight loss)?
(1) Yes (next question)
(2) No (GO TO DIT.12)
DIT.7 For what health problems or conditions did you use this diet?
___________________________
___________________________
___________________________
___________________________
[IF MORE THAN 1 CONDITION ASK DIT.8; ELSE GO TO DIT.9]
DIT.8 For which ONE of these health problems or conditions did you use this diet the most?
___________________________ [CONDITION]
HAND CARD
[HELP SCREEN FOR OTC MEDS]
DIT.10 Did you receive any of these conventional medical treatments for [condition for which modality used the most]? Please say yes or no to each.
(1) Prescription Medications
(2) Over-the-counter medications
(3) Surgery
(4) Physical therapy
(5) Mental Health Counseling
[IF NO TO ALL, SKIP TO DIT.12]
DIT.11 Did you receive {fill from treatments above} before, at about the same time, or after trying this diet?
(1) Before trying diet
(2) At about the same time you began using diet
(3) After trying diet
DIT.12 DURING THE PAST 12 MONTHS, did you use this diet for any of these reasons? Please say yes or no to each.
(1) To improve or enhance energy yes no
(2) For general wellness or general disease prevention yes no
(3) To improve or enhance immune function yes no
(4) Medical treatments did not help yes no
(5) Medical treatments were too expensive yes no
(6) It was recommended by a health care provider yes no
(7) It was recommended by family, friends, or co-workers yes no
[ASK DIT.13a IF R HAS HEALTH INSURANCE; ELSE GO TO DIT.14]
DIT.13 Have you EVER seen a practitioner for this diet?
(1) Yes (next question)
(2) No (GO TO DIT.18)
DIT.14 DURING THE PAST 12 MONTHS, did you see a practitioner for this diet?
(1) Yes (next question)
(2) No (GO TO DIT.18)
DIT.14a What type of practitioner did you see?
medical doctor (GO TO DIT.18)
nurse (GO TO DIT.18)
dietician/nutritionist (GO TO DIT.18)
alternative provider such as Acupuncturist, Chiropractor, Massage Therapist, Naturopath, etc. (next question)
DIT.15 DURING THE PAST 12 MONTHS, how many times did you see a practitioner for this diet?
(1) Only one time
(2) 2-5 times
(3) 6-10 times
(4) 11-15
(5) 16-20
(6) More than 20 times
(7) Refused
(9) Don’t know
DIT.17 On average, how much do you pay out-of-pocket for each visit to a practitioner for this diet?
$ ______________ [PER VISIT]
SHOW HAND CARD (CONVENTIONAL MEDICAL PROFESSIONALS)
DIT.18 DURING THE PAST 12 MONTHS, did you let any of these CONVENTIONAL medical professionals know about your use of (modality)?
(1) Yes (next question)
(2) No (GO TO NEXT MODALITY)
DIT.19 Which ones? [MARK ALL THAT APPLY]
Medical Doctor (including specialists)
Nurse Practitioner/Physician Assistant
Psychiatrist
Dentist (including specialists)
Doctor of Osteopathy (D.O.)
Psychologist/Social Worker
Pharmacist
YOGA/TAI CHI/QI GONG
YOG.1 Have you EVER practiced any of the following ? Please say yes or no to each.
(1) Yoga YES NO
(2) Tai Chi (TIE-CHEE) YES NO
(3) Qi Gong (CHEE-KUNG) YES NO
[IF NO TO ALL, GO TO YOG.18]
Cycle through for each yes answer in YOG.1
YOG.2 DURING THE PAST 12 MONTHS, did you practice [methods mentioned in YOG.1] for your self?
(1) Yes
(2) No [GO TO YOG.18]
[IF MORE THAN ONE EXERCISE MENTIONED in YOG.2, ASK YOG.4; OTHERWISE GO TO YOG.5]
YOG.4 During the past 12 months, which exercise {fill from YES responses to YOG.2} did you practice the most?
_____________________ [EXERCISE]
YOG.5 Did you practice (exercise) for a specific health problem or condition?
(1) Yes (next question)
(2) No (GO TO YOG.11)
YOG.6 For what health problems or conditions did you practice (exercise)?
_______________________________
_______________________________
[IF MORE THAN 1 CONDITION ASK YOG.7; ELSE GO TO YOG.8]
YOG.7 For which ONE of these health problems or conditions did you practice(exercise) the most?
_______________________________ [CONDITION]
HAND CARD
[HELP SCREEN FOR OTC MEDS]
YOG.9 Did you receive any of these conventional medical treatments for [condition for which modality used the most]? Please say yes or no to each.
(1) Prescription Medications
(2) Over-the-counter medications
(3) Surgery
(4) Physical therapy
(5) Mental Health Counseling
[IF NO TO ALL, SKIP TO YOG.11]
YOG.10 Did you receive{fill from treatments above} before, at about the same time, or after trying (exercise)?
(1) Before trying (exercise)
(2) At about the same time you began (exercise)
(3) After trying (exercise)
YOG.11 DURING THE PAST 12 MONTHS, did you use (exercise) for any of these reasons? Please say yes or no to each.
(1) To improve or enhance energy yes no
(2) For general wellness or general disease prevention yes no
(3) To improve or enhance immune function yes no
(4) Medical treatments did not help yes no
(5) Medical treatments were too expensive yes no
(6) It was recommended by a health care provider yes no
(7) It was recommended by family, friends, or co-workers yes no
YOG.12 DURING THE PAST 12 MONTHS, did you take a (exercise) class or in some way receive formal training? Attending only one session does not count.
(1) Yes (next question)
(2) No (GO TO YOG.16)
YOG.13 DURING THE PAST 12 MONTHS, on average, how often did you take a class or in some way receive formal training for (exercise)?
(1) 2-11 times a year
(2) monthly
(3) 2-3 times per month
(4) WEEKLY
(5) 2-3 TIMES PER WEEK
(6) 4-5 TIMES PER WEEK
(7) Daily
YOG.15 On average, how much do you pay out-of-pocket for each class or other formal training for (exercise)?
$ ____________ [PER VISIT]
[FOR RESPONDENTS WHO HAVE NEVERS USED –GOTO YOG.19, IF USED BUT NOT IN PAST 12 MONTS GOTO YOG.20, ELSE GOTO YOG.23]
SHOW HANDCARD
YOG.19 Please tell me the reasons why you have never used yoga.
1) Never heard of it/don’t know much about it
2) Never thought about it
3) No reason
4) Don’t need it
5) Don’t believe in it/it doesn’t work
6) It costs too much
7) It is not safe to use
8) A health care provider told me not to use it
9) Medical science has not shown that it works
10) Some other reason
[All Goto YOG.23]
SHOW HANDCARD
YOG.20 Please tell me the reasons why you have not used yoga in the past 12 months.
1) Never thought about it
2) No reason
3) Didn’t need it in the last 12 months
4) It didn’t work for me before
5) It costs too much
6) I had side effects last time (go to YOG.21; otherwise YOG.23)
7) A health care provider told me not to use it
8) Medical science has not shown that it works
9) Some other reason
YOG.21 What kinds of side effects did you have?
_________________________
_________________________
YOG.22 Did any of these require medical attention?
Yes
No
SHOW HAND CARD (CONVENTIONAL MEDICAL PROFESSIONALS)
YOG.23 DURING THE PAST 12 MONTHS, did you let any of these CONVENTIONAL medical professionals know about your use of (modality)?
(1) Yes (next question)
(2) No (GO TO NEXT MODALITY)
YOG.24 Which ones? [MARK ALL THAT APPLY]
Medical Doctor (including specialists)
Nurse Practitioner/Physician Assistant
Psychiatrist
Dentist (including specialists)
Doctor of Osteopathy (D.O.)
Psychologist/Social Worker
Pharmacist
RELAXATION and STRESS MANAGEMENT TECHNIQUES
REL.1 Have you EVER used any of the following relaxation or stress management techniques for your self? Please say yes or no to each.
(1) Meditation YES NO
(2) Guided imagery YES NO
(3) Progressive relaxation YES NO
(4) Deep breathing exercises YES NO
(5) Support group meeting YES NO
(6) Stress management class YES NO
[IF NO TO ALL, GO TO REL.20]
Cycle through for every yes in REL.1
REL.2 DURING THE PAST 12 MONTHS, did you use [methods mentioned in REL.1] for your self?
(1) Yes
(2) No (GO TO REL.20)
[IF MORE THAN ONE YES in REL.2, ASK REL.4; ELSE GO TO REL.5]
REL.4 During the past 12 months, which relaxation techniques {fill techniques from REL. 2} did you use the most?
_____________________ [TECHNIQUE]
REL.5 Did you use (relaxation technique) for a specific health problem or condition?
(1) Yes (next question)
(2) No (GO TO REL.11)
REL.6 For what health problems or conditions did you use (relaxation technique)?
____________________________________
____________________________________
____________________________________
[IF MORE THAN 1 CONDITION ASK REL.7; ELSE GO TO REL.8]
REL.7 For which ONE of these health problems or conditions did you use (relaxation technique) the most?
____________________________________ [CONDITION]
HAND CARD
[HELP SCREEN FOR OTC MEDS]
REL.9 Did you receive any of these conventional medical treatments for [condition for which modality used the most]? Please say yes or no to each.
(1) Prescription Medications
(2) Over-the-counter medications
(3) Surgery
(4) Physical therapy
(5) Mental Health Counseling
[IF NO TO ALL, SKIP TO REL.11]
REL.10 Did you receive {fill from treatments above} before, at about the same time, or after trying (relaxation technique)?
(1) Before
(2) At about the same time you began relaxation techniques
(3) After
REL.11 DURING THE PAST 12 MONTHS, did you use (relaxation technique) for any of these reasons? Please say yes or no to each.
(1)To improve or enhance energy YES NO
(2)For general wellness or general disease prevention YES NO
(3)To improve or enhance immune function YES NO
(4)To cope with having an illness YES NO
(5) Medical treatments did not help yes no
(6) Medical treatments were too expensive yes no
(7) It was recommended by a health care provider yes no
(8) It was recommended by family, friends, or co-workers yes no
REL.12 DURING THE PAST 12 MONTHS, did you see a practitioner or take a class for (relaxation technique)?
(1) Yes (next question)
(2) No (GO TO REL.16)
REL.13 DURING THE PAST 12 MONTHS, how often did you see a practitioner or take a class for (relaxation technique)
(1) Only 1 time
(2) 2-5 times
(3) 6-10 times
(4) 11-15 times
(5) 16-20 times
(6) more than 20 times
REL.15 On average, how much do you pay out-of-pocket for each visit to a practitioner or to take a class for (relaxation technique)?
$ _______________ [PER VISIT]
REL.16 Did you buy a self-help book or other materials to learn about (relaxation technique)?
(1) Yes (next question)
(2) No (GO TO REL.18)
REL.17 How much did you pay for these materials?
$ ________________________
SHOW HAND CARD (CONVENTIONAL MEDICAL PROFESSIONALS)
REL.17a DURING THE PAST 12 MONTHS, did you let any of these CONVENTIONAL medical professionals know about your use of (modality)?
(1) Yes (next question)
(2) No (GO TO NEXT MODALITY)
REL.17b Which ones? [MARK ALL THAT APPLY]
Medical Doctor (including specialists)
Nurse Practitioner/Physician Assistant
Psychiatrist
Dentist (including specialists)
Doctor of Osteopathy (D.O.)
Psychologist/Social Worker
Pharmacist
[FOR RESPONDENTS WHO HAVE NEVERS USED –GOTO REL.21, IF USED BUT NOT IN PAST 12 MONTS GOTO REL.22, ELSE GOTO REL.25]
SHOW HANDCARD
REL.21 Please tell me the reasons why you have never used meditation.
1) Never heard of it/don’t know much about it
2) Never thought about it
3) No reason
4) Don’t need it
5) Don’t believe in it/it doesn’t work
6) It costs too much
7) It is not safe to use
8) A health care provider told me not to use it
9) Medical science has not shown that it works
10) Some other reason
[All Goto REL.25]
SHOW HANDCARD
REL.22 Please tell me the reasons why you have not used meditation in the past 12 months.
1) Never thought about it
2) No reason
3) Didn’t need it in the last 12 months
4) It didn’t work for me before
5) It costs too much
6) I had side effects last time (go to REL.23; otherwise REL.25)
7) A health care provider told me not to use it
8) Medical science has not shown that it works
9) Some other reason
REL.23 What kinds of side effects did you have?
_________________________
_________________________
REL.24 Did any of these require medical attention?
Yes
No
PRAYER FOR YOUR OWN HEALTH
Now I am going to ask you about your use of prayer for your own health.
PRY.1 Have you EVER prayed specifically for the purpose of your OWN health?
(1) Yes (next question)
(2) No (GO TO PRY.3)
PRY.2 DURING THE PAST 12 MONTHS, did you pray specifically for the purpose of your OWN health?
(1) Yes
(2) No
PRY.3 Have you EVER asked or had OTHERS pray for your OWN health?
(1) Yes
(2) No [GO TO PERCEPTIONS]
PRY.4 DURING THE PAST 12 MONTHS, did you ask or have others pray for your OWN health?
(1) Yes
(2) No
Topical Module on Hearing Problems (Questions)
These next questions are about your hearing WITHOUT the use of hearing aids or other assistive listening devices:
Is your hearing excellent, good, a little trouble hearing, moderate trouble, a lot of trouble, or are you deaf?
EXCELLENT 1 [Go To #15.]
GOOD 2
A LITTLE TROUBLE 3
MODERATE HEARING TROUBLE 4
A LOT OF TROUBLE 5
DEAF 6
REFUSED 7
DON’T KNOW 9
2. Is your hearing WORSE in one ear than the other?
YES……………………………………………………………………………………………………………………………1 [Go to #2a]
NO…………………………………………………………………………………………………………………………….2 [Go to #5]
REFUSED 7
DON’T KNOW 9
2a. Which ear is worse?
THE RIGHT EAR 1
THE LEFT EAR 2
REFUSED 7
DON'T KNOW 9
3. Is your hearing in your RIGHT ear excellent, good, a little trouble, moderate trouble, a lot of trouble, or are you deaf?
EXCELLENT 1
GOOD 2
A LITTLE TROUBLE 3
MODERATE HEARING TROUBLE 4
A LOT OF TROUBLE 5
DEAF 6
REFUSED 7
DON’T KNOW 9
4. Is your hearing in your LEFT ear excellent, good, a little trouble, moderate trouble, a lot of trouble, or are you deaf?
EXCELLENT 1
GOOD 2
A LITTLE TROUBLE 3
MODERATE HEARING TROUBLE 4
A LOT OF TROUBLE 5
DEAF 6
REFUSED 7
DON’T KNOW 9
↔ 5. 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?
YES 1 [Go To #9.]
NO 2
REFUSED 7
DON’T KNOW 9
6. 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?
YES 1 [Go To #9.]
NO 2
REFUSED 7
DON’T KNOW 9
7. 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?
YES 1 [Go To #9.]
NO 2
REFUSED 7
DON’T KNOW 9
8. Can you usually HEAR AND UNDERSTAND what a person says without seeing his face if that person SPEAKS LOUDLY into your better ear?
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
9. 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…
ALWAYS 1
USUALLY 2
ABOUT HALF THE TIME 3
SELDOM 4
NEVER 5
REFUSED 7
DON'T KNOW 9
10. How often does your hearing cause you to feel frustrated when talking to members of your family or to friends? Would you say…
ALWAYS 1
USUALLY 2
ABOUT HALF THE TIME 3
SELDOM 4
NEVER 5
REFUSED 7
DON'T KNOW 9
11. How often does your hearing cause you to worry about your safety while working or doing other activities? Would you say…
ALWAYS 1
USUALLY 2
ABOUT HALF THE TIME 3
SELDOM 4
NEVER 5
REFUSED 7
DON'T KNOW 9
IF GOOD HEARING TO QUESTION 1, AND HEAR THE SAME IN BOTH EARS,
SKIP TO Q15
12. How old were you when you began to have ANY permanent hearing loss (in either ear)?
AT BIRTH 1
0 TO 2 YEARS OF AGE 2
3 TO 5 YEARS OF AGE 3
6 TO 11 YEARS OF AGE 4
12 TO 19 YEARS OF AGE 5
20 TO 39 YEARS OF AGE 6
40 TO 59 YEARS OF AGE 7
60 TO 69 YEARS OF AGE 8
70 OR MORE YEARS OF AGE 9
REFUSED 97
DON’T KNOW 99
13. Was your hearing loss sudden or gradual?
*Read if necessary: Sudden means less than 3 months.
SUDDEN 1
GRADUAL 2
REFUSED 7
DON’T KNOW 9
14. What was the MAIN cause of your hearing loss?
PRESENT AT BIRTH BECAUSE MOTHER HAD GERMAN MEASLES (RUBELLA)
OR CYTOMEGALOVIRUS (CMV) 1
PRESENT AT BIRTH FOR A GENETIC REASON 2
PRESENT AT BIRTH FOR SOME OTHER REASON, NOT INCLUDING
GENETIC OR INFECTIOUS DISEASE 3
INFECTIOUS DISEASE AFTER BIRTH (MEASLES, MENINGITIS, ETC.)……. 4
EAR INFECTIONS OR OTITIS MEDIA 5
EAR INJURY (HOLES IN EARDRUM, ETC.) 6
EAR SURGERY 7
EAR DISEASES, SUCH AS MENIERE’S DISEASE OR OTOSCLEROSIS 8
BRAIN TUMOR (ACOUSTIC NEUROMA, ETC.)………………………………………………… 9
LOUD, BRIEF NOISE FROM GUNFIRE/BLASTS/EXPLOSIONS 10
NOISE EXPOSURE FROM MACHINERY, AIRCRAFT, POWER TOOLS, LOUD MUSIC,
APPLIANCES, PERSONAL STEREOS OR MP3 PLAYERS, HAIR DRYERS, ETC.. 11
GETTING OLDER/AGING 12
OTHER 13
REFUSED 97
DON’T KNOW 99
↔ 15. Have any of your friends or relatives ever told you that you have a hearing problem?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
16. When was the LAST time you saw a doctor or other health care professional about any hearing or ear problems?
IN THE PAST YEAR 1
1 TO 2 YEARS AGO 2
3 TO 4 YEARS AGO 3
5 TO 9 YEARS AGO 4 [GO TO #18.]
10 TO 14 YEARS AGO 5 [GO TO #18.]
15 OR MORE YEARS AGO 6 [GO TO #18.]
NEVER 7 [GO TO #18.]
REFUSED 97
DON’T KNOW 99
17a.In the past 5 years, were you ever 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]
YES…………………………………………………………………………………………………………………… 1
NO 2
REFUSED 7
DON'T KNOW 9
17b. (Read lead-in if necessary):
…an audiologist or hearing aid dispenser?
YES…………………………………………………………………………………………………………………… 1
NO 2
REFUSED 7
DON'T KNOW…………………………………………………………………………………………………… 9
↔ 18. When was the last time you had your hearing tested?
IN THE PAST YEAR 1
1 TO 2 YEARS AGO 2
3 TO 4 YEARS AGO …………………………………………………………………………………………. 3
5 TO 9 YEARS AGO 4
10 TO 14 YEARS AGO 5
15 OR MORE YEARS AGO ……………………………………………………………………………….. 6
NEVER 7
REFUSED 97
DON’T KNOW 99
19. Do you now use a cochlear implant?
YES 1 [GO TO 20]
NO . 2 [GO TO 19A]
REFUSED 7 [GO TO 19A]
DON'T KNOW 9 [GO TO 19A]
19a. Has a hearing specialist, your doctor, or other health care professional ever recommended…
…a cochlear implant to you?
YES…………………………………………………………………………………………………………………… 1 [ALL GO TO 20]
NO 2
REFUSED 7
DON'T KNOW 9
20. Do you now use a hearing aid?
YES 1 [GO TO 21]
NO . 2 [GO TO 23]
REFUSED 7 [GO TO 23]
DON'T KNOW 9 [GO TO 23]
21. How long have you worn a hearing aid(s)?
LESS THAN 6 WEEKS …………………………………………………………………………………….. 1
6 WEEKS TO 11 MONTHS 2
1 TO 2 YEARS 3
3 TO 4 YEARS …………………………………………………………………………………………. 4
5 TO 9 YEARS 5
10 TO 14 YEARS 6
15 OR MORE YEARS ……………………………………………………………………………….. 7
REFUSED 97
DON’T KNOW 99
22. In the past 12 months, how often did you use a hearing aid? Would you say…
ALWAYS 1 [GO TO #27.]
USUALLY 2 [GO TO #27.]
ABOUT HALF THE TIME 3 [GO TO #27.]
SELDOM 4 [GO TO #27.]
NEVER 5 [GO TO #26]
REFUSED 7
DON'T KNOW 9
↔ 23. Have you ever used a hearing aid in the past?
YES 1 [GO TO 24]
NO 2 [GO TO #23A]
REFUSED 7 [GOTO #23A]
DON'T KNOW 9 [GOTO #23A]
23a. Has a hearing specialist, your doctor, or other health care professional ever recommended…
…a hearing aid to you?
YES…………………………………………………………………………………………………………………… 1 [GO TO 26]
NO 2 [GO TO 27]
REFUSED 7 [GO TO 27]
DON'T KNOW 9 [GO TO 27]
24. How long did you use a hearing aid(s) in the past?
LESS THAN 6 WEEKS …………………………………………………………………………………….. 1
6 WEEKS TO 11 MONTHS 2
1 TO 2 YEARS 3
3 TO 4 YEARS …………………………………………………………………………………………. 4
5 TO 9 YEARS 5
10 TO 14 YEARS 6
15 OR MORE YEARS ……………………………………………………………………………….. 7
REFUSED 77
DON’T KNOW 99
25. During this time, how often did you use a hearing aid(s) Would you say…?
ALWAYS 1
USUALLY 2
ABOUT HALF THE TIME 3
SELDOM 4
NEVER 5
REFUSED 7
DON'T KNOW 9
26. Why have you decided not to use a hearing aid? [Mark all that apply.]
IT DIDN’T HELP 1
DIDN’T LIKE THE WAY IT SOUNDED/TOO LOUD/NOISY ..………………………….2
WHISTLING SOUNDS 3
IT WAS UNCOMFORTABLE 4
IT HAD FREQUENT BREAKDOWNS/NEEDED REPAIRS 5
DIDN’T LIKE THE WAY IT LOOKED 6
IT COST TOO MUCH 7
DON’T THINK I NEED A HEARING AID……………………………………………….…………8
OTHER …………………………………………………………………………………………..………………9
REFUSED 97
DON'T KNOW 99
If Hearing is Excellent, skip 27,28 or if hearing is Good and hear the same in both ears skip 27, 28; else go to 27↔
27. Because of your hearing, have you ever used assistive listening devices (ALDs), such as FM systems, closed-captioned television, or amplified telephone or relay services?
YES 1
NO 2 [Go To #29.]
REFUSED 7
DON’T KNOW 9
28. Which of the following assistive listening devices have you ever used?
FR: SHOW FLASHCARD [MARK ALL THAT APPLY.]
POCKET TALKER OR OTHER PERSONAL LISTENING DEVICE……………………….. 1
AMPLIFIED TELEPHONE…………………………………………………………………………………… 2
AMPLIFIED OR VIBRATING ALARM CLOCK……………………………………………………… 3
NOTIFICATION OR SIGNALING SYSTEM (LIGHT SIGNALER FOR DOORBELL,
BABY CRY MONITOR, ETC.)……………………………………………………………………. 4
TELEVISON/THEATER HEADSET OR CLOSED CAPTIONED TV…………………………… 5
TTY (TELETYPEWRITER), TDD (TELECOMMUNICATIONS DEVICE FOR THE DEAF), OR TELEPHONE RELAY SERVICE ……………………………………………… 6
VIDEO RELAY SERVICE …………………………………………………………………………………… 7
SIGN LANGUAGE INTERPRETER...................................................... 8
OTHER 9
REFUSED 97
DON'T KNOW…………………………………………………………………………………………………… 99
↔ 29. 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?
*Help screen: Definition of tinnitus as ringing, roaring, or buzzing.
YES 1
NO 2 [Go To #36.]
REFUSED 7
DON'T KNOW 9
30. How long have you been bothered by this ringing, roaring, or buzzing in your ears or head?
LESS THAN 3 MONTHS 1
3 TO 11 MONTHS 2
1 TO 2 YEARS 3
3 TO 4 YEARS 4
5 TO 9 YEARS 5
10 TO 14 YEARS 6
15 YEARS OR MORE 7
REFUSED 97
DON’T KNOW 99
31. In the past 12 months, how often have you had this ringing, roaring, or buzzing in your ears or head? Would you say…
ALMOST ALWAYS 1
AT LEAST ONCE A DAY 2
AT LEAST ONCE A WEEK 3
AT LEAST ONCE A MONTH 4
LESS FREQUENTLY THAN ONCE A MONTH 5
REFUSED 7
DON’T KNOW 9
32. Are you bothered by ringing, roaring, or buzzing in your ears or head only after listening to loud sounds or loud music?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
33. Are you bothered by ringing, roaring, or buzzing in your ears or head when going to sleep?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
34. How much of a problem is this ringing, roaring, or buzzing in your ears or head? Would you say it is…
NO PROBLEM 1
A SMALL PROBLEM 2
A MODERATE PROBLEM 3
A BIG PROBLEM 4
A VERY BIG PROBLEM 5
REFUSED 7
DON’T KNOW 9
35. Have you ever discussed this ringing, roaring or buzzing in your ears or head with your doctor or other health care professional?
YES 1 [Go To 35a]
NO 2 [Go To 36]
REFUSED 7 [Go To 36]
DON'T KNOW 9 [Go to 36]
35a. Have you ever tried any remedies or treatments for
the ringing, roaring, or buzzing in your ears or head?
YES…………………………………………………………………………………………… 1 [Go To 35b]
NO……………………………………………………………………………………………. 2 [Go To 36]
REFUSED…………………………………………………………………………………. 3 [Go To 36]
DON’T KNOW…………………………………………………………………………… 4 [Go To 36]
35b. Which of the following treatments have you tried? [SHOW FLASHCARD] [ENTER ALL THAT APPLY]
AMPLIFICATION/HEARING AIDS………..……………………………………… 1
MASKING WITH WEARABLE DEVICE (WITH OR WITHOUT
HEARING AIDS)……………………………………………..………..………………. 2
MASKING WITH NON-WEARABLE DEVICE (SOUND
GENERATORS TO HELP WITH SLEEP)…………………………..…………… 3
COGNITIVE THERAPY WITH COUNSELING………………………………… 4
STRESS REDUCTION OR RELAXATION METHODS………….…………. 5
BIOFEEDBACK…………………………………………………………………………….. 6
TINNITUS RETRAINING THERAPY (TRT)………….………………………… 7
PSYCHIATRIC TREATMENT………………………….……………………………… 8
SURGERY TO CUT THE HEARING NERVE…………………………………… 9
DRUGS OR MEDICATIONS…………………………………………………………. 10
NUTRITIONAL SUPPLEMENTS………………………..………………………….. 11
MUSIC THERAPY………………….……………………………………………………… 12
TEMPORAL MANDIBULAR JOINT TREATMENT………….………………… 13
ALTERNATIVE METHODS/HYPNOSIS, ACUPUNCTURE…….…….... 14
OTHER………………………………………………………………………………………… 15
REFUSED……………………………………………… ………………………………….. 97
DON’T KNOW………………………………………………… …………………………. 99
THE NEXT FEW QUESTIONS ARE ABOUT YOUR CURRENT OR PREVIOUS EXPOSURE TO LOUD
SOUNDS OR NOISES.
↔
36. Have you ever used firearms for any reason?
*Read if necessary: Include target shooting, hunting, your job including military service.
* Read if necessary: Firearms include pistols, shotguns, rifles, and other type of guns. Do not include BB or pellet guns.
YES 1
NO 2 [GO TO #40.]
REFUSED 7
DON'T KNOW 9
36a. Was this for work, leisure, or both?
WORK……………………………………………………………………………………………….………… 1
LEISURE…………………………………………………………………………………………….………. 2
BOTH WORK AND LEISURE………………………………………………………..…………….. 3
REFUSED 7
DON'T KNOW 9
37. How many TOTAL rounds have you ever fired?
*Read if necessary: Include target shooting, hunting, your job, including military service
*One round equals one shot.
1 TO LESS THAN 100 ROUNDS 1
100 TO LESS THAN 1000 ROUNDS 2
1000 TO LESS THAN 10,000 ROUNDS 3
10,000 TO LESS THAN 50,000………………………………………………………………………. 4
50,000 ROUNDS OR MORE………………………………………………………………………… … 5
REFUSED 7
DON'T KNOW 9
38. In the past 12 months, about how many rounds have you fired?
*Read if necessary: Include target shooting, hunting, your job, including military service
*One round equals one shot.
NONE 0 [GO TO #40]
1 TO LESS THAN 100 ROUNDS 1
100 TO LESS THAN 1000 ROUNDS 2
1000 TO LESS THAN 10,000 ROUNDS 3
10,000 ROUNDS OR MORE 4
REFUSED 7
DON'T KNOW 9
39. In the past 12 months, when shooting firearms how often have you worn ear plugs or ear muffs? Would you say…
ALWAYS 1
USUALLY 2
ABOUT HALF THE TIME 3
SELDOM 4
NEVER 5
REFUSED 7
DON'T KNOW 9
↔ 40. 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.
YES 1 [Go To #40a]
NO 2 [Go To #44.]
REFUSED 7 [Go To #44]
DON'T KNOW 9 [Go To #44]
40a. 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.
LESS THAN 3 MONTHS 1
3 MONTHS TO 11 MONTHS 2
1 TO 4 YEARS 3
5 TO 9 YEARS 4
10 TO 14 YEARS 5
15 YEARS OR MORE 6
REFUSED 7
DON’T KNOW 9
41. Was this in the past 12 months?
YES 1 [Go To #42]
NO 2 [Go To #44.]
REFUSED 7 [Go To #44]
DON’T KNOW 9 [Go To #44]
42. 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…
ALWAYS 1
USUALLY 2
ABOUT HALF THE TIME 3
SELDOM 4
NEVER 5
REFUSED 7
DON'T KNOW 9
44. 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?
*Read if necessary: Loud means so loud that you must speak in a raised voice to be heard.
YES 1
NO 2 [Go To END]
REFUSED 7
DON’T KNOW 9
45. Which of the following activities have you been ever been exposed to at least once a month for a year?
FR: SHOW FLASHCARD [Mark all that apply.]
MOTORCYCLES/AUTO RACING/SNOWMOBILE/MOTOR BOAT………………………… 1
OPERATING FARM MACHINERY 2
WOOD CUTTING, WOODWORKING, OR OTHER WORKSHOP POWER TOOLS 3
USING LAWN MOWER/ELECTRIC TRIMMER/LEAF/SNOW BLOWER 4
FIREARMS………………………………………………………………………………………………………… 5
HOUSEHOLD APPLIANCES: BLENDER/MIXER, FOOD PROCESSOR,
VACUUM CLEANER, HAIR DRYER, ETC.………………………………. 6
MP3 PLAYER/iPOD……………………………………………………………………………………………. 7
PLAYING IN A MUSIC GROUP………………………………………………………………………….. 8
OTHER MUSIC RELATED ACTIVITIES: ROCK CONCERTS/STEREOS/
DISCO/CLUBS OR BARS 9
OTHER NOISY, NON-WORK-RELATED ACTIVITIES……………………………………….. 10
REFUSED 97
DON'T KNOW 99
46. Was this in the past 12 months?
YES 1
NO 2 [Go To END.]
REFUSED 7
DON'T KNOW 9
47. In the past 12 months, when exposed to loud noise or music outside of work, how often have you worn ear plugs or ear muffs?
ALWAYS 1
USUALLY 2
ABOUT HALF THE TIME 3
SELDOM 4
NEVER 5
REFUSED 7
DON'T KNOW 9
Topical Module on Hearing Problems (Questions)
These next questions are about your hearing WITHOUT the use of hearing aids or other assistive listening devices:
Is your hearing excellent, good, a little trouble hearing, moderate trouble, a lot of trouble, or are you deaf?
EXCELLENT 1 [Go To #15.]
GOOD 2
A LITTLE TROUBLE 3
MODERATE HEARING TROUBLE 4
A LOT OF TROUBLE 5
DEAF 6
REFUSED 7
DON’T KNOW 9
2. Is your hearing WORSE in one ear than the other?
YES……………………………………………………………………………………………………………………………1 [Go to #2a]
NO…………………………………………………………………………………………………………………………….2 [Go to #5]
REFUSED 7
DON’T KNOW 9
2a. Which ear is worse?
THE RIGHT EAR 1
THE LEFT EAR 2
REFUSED 7
DON'T KNOW 9
3. Is your hearing in your RIGHT ear excellent, good, a little trouble, moderate trouble, a lot of trouble, or are you deaf?
EXCELLENT 1
GOOD 2
A LITTLE TROUBLE 3
MODERATE HEARING TROUBLE 4
A LOT OF TROUBLE 5
DEAF 6
REFUSED 7
DON’T KNOW 9
4. Is your hearing in your LEFT ear excellent, good, a little trouble, moderate trouble, a lot of trouble, or are you deaf?
EXCELLENT 1
GOOD 2
A LITTLE TROUBLE 3
MODERATE HEARING TROUBLE 4
A LOT OF TROUBLE 5
DEAF 6
REFUSED 7
DON’T KNOW 9
↔ 5. 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?
YES 1 [Go To #9.]
NO 2
REFUSED 7
DON’T KNOW 9
6. 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?
YES 1 [Go To #9.]
NO 2
REFUSED 7
DON’T KNOW 9
7. 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?
YES 1 [Go To #9.]
NO 2
REFUSED 7
DON’T KNOW 9
8. Can you usually HEAR AND UNDERSTAND what a person says without seeing his face if that person SPEAKS LOUDLY into your better ear?
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
9. 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…
ALWAYS 1
USUALLY 2
ABOUT HALF THE TIME 3
SELDOM 4
NEVER 5
REFUSED 7
DON'T KNOW 9
10. How often does your hearing cause you to feel frustrated when talking to members of your family or to friends? Would you say…
ALWAYS 1
USUALLY 2
ABOUT HALF THE TIME 3
SELDOM 4
NEVER 5
REFUSED 7
DON'T KNOW 9
11. How often does your hearing cause you to worry about your safety while working or doing other activities? Would you say…
ALWAYS 1
USUALLY 2
ABOUT HALF THE TIME 3
SELDOM 4
NEVER 5
REFUSED 7
DON'T KNOW 9
IF GOOD HEARING TO QUESTION 1, AND HEAR THE SAME IN BOTH EARS,
SKIP TO Q15
12. How old were you when you began to have ANY permanent hearing loss (in either ear)?
AT BIRTH 1
0 TO 2 YEARS OF AGE 2
3 TO 5 YEARS OF AGE 3
6 TO 11 YEARS OF AGE 4
12 TO 19 YEARS OF AGE 5
20 TO 39 YEARS OF AGE 6
40 TO 59 YEARS OF AGE 7
60 TO 69 YEARS OF AGE 8
70 OR MORE YEARS OF AGE 9
REFUSED 97
DON’T KNOW 99
13. Was your hearing loss sudden or gradual?
*Read if necessary: Sudden means less than 3 months.
SUDDEN 1
GRADUAL 2
REFUSED 7
DON’T KNOW 9
14. What was the MAIN cause of your hearing loss?
PRESENT AT BIRTH BECAUSE MOTHER HAD GERMAN MEASLES (RUBELLA)
OR CYTOMEGALOVIRUS (CMV) 1
PRESENT AT BIRTH FOR A GENETIC REASON 2
PRESENT AT BIRTH FOR SOME OTHER REASON, NOT INCLUDING
GENETIC OR INFECTIOUS DISEASE 3
INFECTIOUS DISEASE AFTER BIRTH (MEASLES, MENINGITIS, ETC.)……. 4
EAR INFECTIONS OR OTITIS MEDIA 5
EAR INJURY (HOLES IN EARDRUM, ETC.) 6
EAR SURGERY 7
EAR DISEASES, SUCH AS MENIERE’S DISEASE OR OTOSCLEROSIS 8
BRAIN TUMOR (ACOUSTIC NEUROMA, ETC.)………………………………………………… 9
LOUD, BRIEF NOISE FROM GUNFIRE/BLASTS/EXPLOSIONS 10
NOISE EXPOSURE FROM MACHINERY, AIRCRAFT, POWER TOOLS, LOUD MUSIC,
APPLIANCES, PERSONAL STEREOS OR MP3 PLAYERS, HAIR DRYERS, ETC.. 11
GETTING OLDER/AGING 12
OTHER 13
REFUSED 97
DON’T KNOW 99
↔ 15. Have any of your friends or relatives ever told you that you have a hearing problem?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
16. When was the LAST time you saw a doctor or other health care professional about any hearing or ear problems?
IN THE PAST YEAR 1
1 TO 2 YEARS AGO 2
3 TO 4 YEARS AGO 3
5 TO 9 YEARS AGO 4 [GO TO #18.]
10 TO 14 YEARS AGO 5 [GO TO #18.]
15 OR MORE YEARS AGO 6 [GO TO #18.]
NEVER 7 [GO TO #18.]
REFUSED 97
DON’T KNOW 99
17a.In the past 5 years, were you ever 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]
YES…………………………………………………………………………………………………………………… 1
NO 2
REFUSED 7
DON'T KNOW 9
17b. (Read lead-in if necessary):
…an audiologist or hearing aid dispenser?
YES…………………………………………………………………………………………………………………… 1
NO 2
REFUSED 7
DON'T KNOW…………………………………………………………………………………………………… 9
↔ 18. When was the last time you had your hearing tested?
IN THE PAST YEAR 1
1 TO 2 YEARS AGO 2
3 TO 4 YEARS AGO …………………………………………………………………………………………. 3
5 TO 9 YEARS AGO 4
10 TO 14 YEARS AGO 5
15 OR MORE YEARS AGO ……………………………………………………………………………….. 6
NEVER 7
REFUSED 97
DON’T KNOW 99
19. Do you now use a cochlear implant?
YES 1 [GO TO 20]
NO . 2 [GO TO 19A]
REFUSED 7 [GO TO 19A]
DON'T KNOW 9 [GO TO 19A]
19a. Has a hearing specialist, your doctor, or other health care professional ever recommended…
…a cochlear implant to you?
YES…………………………………………………………………………………………………………………… 1 [ALL GO TO 20]
NO 2
REFUSED 7
DON'T KNOW 9
20. Do you now use a hearing aid?
YES 1 [GO TO 21]
NO . 2 [GO TO 23]
REFUSED 7 [GO TO 23]
DON'T KNOW 9 [GO TO 23]
21. How long have you worn a hearing aid(s)?
LESS THAN 6 WEEKS …………………………………………………………………………………….. 1
6 WEEKS TO 11 MONTHS 2
1 TO 2 YEARS 3
3 TO 4 YEARS …………………………………………………………………………………………. 4
5 TO 9 YEARS 5
10 TO 14 YEARS 6
15 OR MORE YEARS ……………………………………………………………………………….. 7
REFUSED 97
DON’T KNOW 99
22. In the past 12 months, how often did you use a hearing aid? Would you say…
ALWAYS 1 [GO TO #27.]
USUALLY 2 [GO TO #27.]
ABOUT HALF THE TIME 3 [GO TO #27.]
SELDOM 4 [GO TO #27.]
NEVER 5 [GO TO #26]
REFUSED 7
DON'T KNOW 9
↔ 23. Have you ever used a hearing aid in the past?
YES 1 [GO TO 24]
NO 2 [GO TO #23A]
REFUSED 7 [GOTO #23A]
DON'T KNOW 9 [GOTO #23A]
23a. Has a hearing specialist, your doctor, or other health care professional ever recommended…
…a hearing aid to you?
YES…………………………………………………………………………………………………………………… 1 [GO TO 26]
NO 2 [GO TO 27]
REFUSED 7 [GO TO 27]
DON'T KNOW 9 [GO TO 27]
24. How long did you use a hearing aid(s) in the past?
LESS THAN 6 WEEKS …………………………………………………………………………………….. 1
6 WEEKS TO 11 MONTHS 2
1 TO 2 YEARS 3
3 TO 4 YEARS …………………………………………………………………………………………. 4
5 TO 9 YEARS 5
10 TO 14 YEARS 6
15 OR MORE YEARS ……………………………………………………………………………….. 7
REFUSED 77
DON’T KNOW 99
25. During this time, how often did you use a hearing aid(s) Would you say…?
ALWAYS 1
USUALLY 2
ABOUT HALF THE TIME 3
SELDOM 4
NEVER 5
REFUSED 7
DON'T KNOW 9
26. Why have you decided not to use a hearing aid? [Mark all that apply.]
IT DIDN’T HELP 1
DIDN’T LIKE THE WAY IT SOUNDED/TOO LOUD/NOISY ..………………………….2
WHISTLING SOUNDS 3
IT WAS UNCOMFORTABLE 4
IT HAD FREQUENT BREAKDOWNS/NEEDED REPAIRS 5
DIDN’T LIKE THE WAY IT LOOKED 6
IT COST TOO MUCH 7
DON’T THINK I NEED A HEARING AID……………………………………………….…………8
OTHER …………………………………………………………………………………………..………………9
REFUSED 97
DON'T KNOW 99
If Hearing is Excellent, skip 27,28 or if hearing is Good and hear the same in both ears skip 27, 28; else go to 27↔
27. Because of your hearing, have you ever used assistive listening devices (ALDs), such as FM systems, closed-captioned television, or amplified telephone or relay services?
YES 1
NO 2 [Go To #29.]
REFUSED 7
DON’T KNOW 9
28. Which of the following assistive listening devices have you ever used?
FR: SHOW FLASHCARD [MARK ALL THAT APPLY.]
POCKET TALKER OR OTHER PERSONAL LISTENING DEVICE……………………….. 1
AMPLIFIED TELEPHONE…………………………………………………………………………………… 2
AMPLIFIED OR VIBRATING ALARM CLOCK……………………………………………………… 3
NOTIFICATION OR SIGNALING SYSTEM (LIGHT SIGNALER FOR DOORBELL,
BABY CRY MONITOR, ETC.)……………………………………………………………………. 4
TELEVISON/THEATER HEADSET OR CLOSED CAPTIONED TV…………………………… 5
TTY (TELETYPEWRITER), TDD (TELECOMMUNICATIONS DEVICE FOR THE DEAF), OR TELEPHONE RELAY SERVICE ……………………………………………… 6
VIDEO RELAY SERVICE …………………………………………………………………………………… 7
SIGN LANGUAGE INTERPRETER...................................................... 8
OTHER 9
REFUSED 97
DON'T KNOW…………………………………………………………………………………………………… 99
↔ 29. 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?
*Help screen: Definition of tinnitus as ringing, roaring, or buzzing.
YES 1
NO 2 [Go To #36.]
REFUSED 7
DON'T KNOW 9
30. How long have you been bothered by this ringing, roaring, or buzzing in your ears or head?
LESS THAN 3 MONTHS 1
3 TO 11 MONTHS 2
1 TO 2 YEARS 3
3 TO 4 YEARS 4
5 TO 9 YEARS 5
10 TO 14 YEARS 6
15 YEARS OR MORE 7
REFUSED 97
DON’T KNOW 99
31. In the past 12 months, how often have you had this ringing, roaring, or buzzing in your ears or head? Would you say…
ALMOST ALWAYS 1
AT LEAST ONCE A DAY 2
AT LEAST ONCE A WEEK 3
AT LEAST ONCE A MONTH 4
LESS FREQUENTLY THAN ONCE A MONTH 5
REFUSED 7
DON’T KNOW 9
32. Are you bothered by ringing, roaring, or buzzing in your ears or head only after listening to loud sounds or loud music?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
33. Are you bothered by ringing, roaring, or buzzing in your ears or head when going to sleep?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
34. How much of a problem is this ringing, roaring, or buzzing in your ears or head? Would you say it is…
NO PROBLEM 1
A SMALL PROBLEM 2
A MODERATE PROBLEM 3
A BIG PROBLEM 4
A VERY BIG PROBLEM 5
REFUSED 7
DON’T KNOW 9
35. Have you ever discussed this ringing, roaring or buzzing in your ears or head with your doctor or other health care professional?
YES 1 [Go To 35a]
NO 2 [Go To 36]
REFUSED 7 [Go To 36]
DON'T KNOW 9 [Go to 36]
35a. Have you ever tried any remedies or treatments for
the ringing, roaring, or buzzing in your ears or head?
YES…………………………………………………………………………………………… 1 [Go To 35b]
NO……………………………………………………………………………………………. 2 [Go To 36]
REFUSED…………………………………………………………………………………. 3 [Go To 36]
DON’T KNOW…………………………………………………………………………… 4 [Go To 36]
35b. Which of the following treatments have you tried? [SHOW FLASHCARD] [ENTER ALL THAT APPLY]
AMPLIFICATION/HEARING AIDS………..……………………………………… 1
MASKING WITH WEARABLE DEVICE (WITH OR WITHOUT
HEARING AIDS)……………………………………………..………..………………. 2
MASKING WITH NON-WEARABLE DEVICE (SOUND
GENERATORS TO HELP WITH SLEEP)…………………………..…………… 3
COGNITIVE THERAPY WITH COUNSELING………………………………… 4
STRESS REDUCTION OR RELAXATION METHODS………….…………. 5
BIOFEEDBACK…………………………………………………………………………….. 6
TINNITUS RETRAINING THERAPY (TRT)………….………………………… 7
PSYCHIATRIC TREATMENT………………………….……………………………… 8
SURGERY TO CUT THE HEARING NERVE…………………………………… 9
DRUGS OR MEDICATIONS…………………………………………………………. 10
NUTRITIONAL SUPPLEMENTS………………………..………………………….. 11
MUSIC THERAPY………………….……………………………………………………… 12
TEMPORAL MANDIBULAR JOINT TREATMENT………….………………… 13
ALTERNATIVE METHODS/HYPNOSIS, ACUPUNCTURE…….…….... 14
OTHER………………………………………………………………………………………… 15
REFUSED……………………………………………… ………………………………….. 97
DON’T KNOW………………………………………………… …………………………. 99
THE NEXT FEW QUESTIONS ARE ABOUT YOUR CURRENT OR PREVIOUS EXPOSURE TO LOUD
SOUNDS OR NOISES.
↔
36. Have you ever used firearms for any reason?
*Read if necessary: Include target shooting, hunting, your job including military service.
* Read if necessary: Firearms include pistols, shotguns, rifles, and other type of guns. Do not include BB or pellet guns.
YES 1
NO 2 [GO TO #40.]
REFUSED 7
DON'T KNOW 9
36a. Was this for work, leisure, or both?
WORK……………………………………………………………………………………………….………… 1
LEISURE…………………………………………………………………………………………….………. 2
BOTH WORK AND LEISURE………………………………………………………..…………….. 3
REFUSED 7
DON'T KNOW 9
37. How many TOTAL rounds have you ever fired?
*Read if necessary: Include target shooting, hunting, your job, including military service
*One round equals one shot.
1 TO LESS THAN 100 ROUNDS 1
100 TO LESS THAN 1000 ROUNDS 2
1000 TO LESS THAN 10,000 ROUNDS 3
10,000 TO LESS THAN 50,000………………………………………………………………………. 4
50,000 ROUNDS OR MORE………………………………………………………………………… … 5
REFUSED 7
DON'T KNOW 9
38. In the past 12 months, about how many rounds have you fired?
*Read if necessary: Include target shooting, hunting, your job, including military service
*One round equals one shot.
NONE 0 [GO TO #40]
1 TO LESS THAN 100 ROUNDS 1
100 TO LESS THAN 1000 ROUNDS 2
1000 TO LESS THAN 10,000 ROUNDS 3
10,000 ROUNDS OR MORE 4
REFUSED 7
DON'T KNOW 9
39. In the past 12 months, when shooting firearms how often have you worn ear plugs or ear muffs? Would you say…
ALWAYS 1
USUALLY 2
ABOUT HALF THE TIME 3
SELDOM 4
NEVER 5
REFUSED 7
DON'T KNOW 9
↔ 40. 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.
YES 1 [Go To #40a]
NO 2 [Go To #44.]
REFUSED 7 [Go To #44]
DON'T KNOW 9 [Go To #44]
40a. 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.
LESS THAN 3 MONTHS 1
3 MONTHS TO 11 MONTHS 2
1 TO 4 YEARS 3
5 TO 9 YEARS 4
10 TO 14 YEARS 5
15 YEARS OR MORE 6
REFUSED 7
DON’T KNOW 9
41. Was this in the past 12 months?
YES 1 [Go To #42]
NO 2 [Go To #44.]
REFUSED 7 [Go To #44]
DON’T KNOW 9 [Go To #44]
42. 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…
ALWAYS 1
USUALLY 2
ABOUT HALF THE TIME 3
SELDOM 4
NEVER 5
REFUSED 7
DON'T KNOW 9
44. 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?
*Read if necessary: Loud means so loud that you must speak in a raised voice to be heard.
YES 1
NO 2 [Go To END]
REFUSED 7
DON’T KNOW 9
45. Which of the following activities have you been ever been exposed to at least once a month for a year?
FR: SHOW FLASHCARD [Mark all that apply.]
MOTORCYCLES/AUTO RACING/SNOWMOBILE/MOTOR BOAT………………………… 1
OPERATING FARM MACHINERY 2
WOOD CUTTING, WOODWORKING, OR OTHER WORKSHOP POWER TOOLS 3
USING LAWN MOWER/ELECTRIC TRIMMER/LEAF/SNOW BLOWER 4
FIREARMS………………………………………………………………………………………………………… 5
HOUSEHOLD APPLIANCES: BLENDER/MIXER, FOOD PROCESSOR,
VACUUM CLEANER, HAIR DRYER, ETC.………………………………. 6
MP3 PLAYER/iPOD……………………………………………………………………………………………. 7
PLAYING IN A MUSIC GROUP………………………………………………………………………….. 8
OTHER MUSIC RELATED ACTIVITIES: ROCK CONCERTS/STEREOS/
DISCO/CLUBS OR BARS 9
OTHER NOISY, NON-WORK-RELATED ACTIVITIES……………………………………….. 10
REFUSED 97
DON'T KNOW 99
46. Was this in the past 12 months?
YES 1
NO 2 [Go To END.]
REFUSED 7
DON'T KNOW 9
47. In the past 12 months, when exposed to loud noise or music outside of work, how often have you worn ear plugs or ear muffs?
ALWAYS 1
USUALLY 2
ABOUT HALF THE TIME 3
SELDOM 4
NEVER 5
REFUSED 7
DON'T KNOW 9
2007
NHIS Alternative Health Supplement -
| File Type | application/msword |
| File Title | While the officer has shown some promise in the area of data analysis, a more concentrated effort in focusing on items in the |
| Author | hcr8 |
| Last Modified By | Howard Riddick |
| File Modified | 2006-09-29 |
| File Created | 2006-09-29 |