Page 1 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.010_01.000 Instrument Variable Name: BWGT_LB QuestionnaireFileName: Sample Child
QuestionText: What was [fill: S.C. name]'s birth weight?
* Enter 'M' to record metric measurements.
01-15 1-15 pounds
97 Refused
99 Don't know
M Metric
UniverseText: Sample children <18
SkipInstructions: <1-12> [goto BWGT_OZ]
<13-15> [goto ERR1_BWGT_LB]
<R,D> [goto CHGT_FT]
<M> [goto BWGT_GR]
[If NE <1-15, M, R, D> goto ERR2_BWGT_LB]
Question ID: CHS.010_02.000 Instrument Variable Name: BWGT_OZ QuestionnaireFileName: Sample Child
QuestionText: * Enter ounces.
00-15 0-15 ounces
97 Refused
99 Don't know
Blank Blank
UniverseText: Sample children <18 who have a value entered for weight in pounds.
SkipInstructions: <0-15,R,D> [goto CHGT_FT]
[if BWGT_LB = <0-15, R, D> and BWGT_OZ = <empty> go to CHGT_FT]
Question ID: CHS.011_00.000 Instrument Variable Name: BWGT_GR QuestionnaireFileName: Sample Child
QuestionText: * Enter weight in grams.
0500-5485 500-5485 grams
9997 Refused
9999 Don't know
UniverseText: Sample children <18 whose birth weight will be entered in metric.
SkipInstructions: <500-5485,R,D> [goto CHGT_FT]
<5486-6900> [goto ERR_BWGT_GR]
Page 2 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.020_01.000 Instrument Variable Name: CHGT_FT QuestionnaireFileName: Sample Child
QuestionText: How tall is [fill: S.C. name] now (without shoes)?
* If the child's height is given in inches, press 'ENTER' at feet and enter the measure in inches (36 inches maximum).
* Enter 'M' to record metric measurements.
00-07 0-7 feet
97 Refused
99 Don't know
M Metric
UniverseText: Sample children <18
SkipInstructions: <empty> [goto CHGT_IN]
<0-7> [goto CHGT_IN]
<R,D> [goto CWGT_LB]
<M> [goto CHGT_M]
[If NE <0-7, M, R, D> go to ERR_CHGT_FT]
Question ID: CHS.020_02.000 Instrument Variable Name: CHGT_IN QuestionnaireFileName: Sample Child
QuestionText: * Enter inches.
00-36 0-36 inches
97 Refused
99 Don't know
UniverseText: Sample children <18 whose height in feet is 0-7 or is left empty.
SkipInstructions: <0-36> [goto CWGT_LB]
[If both CHGT_FT and CHGT_IN are either <empty> or <0>, display ERR1_CHGT_IN]
[If CHGT_FT = <0-7> and CHGT_IN is GE <12> display ERR2_CHGT_IN]
Question ID: CHS.021_01.000 Instrument Variable Name: CHGT_M QuestionnaireFileName: Sample Child
QuestionText: * Enter height in metric.
* If the child's height is given in centimeters, press 'ENTER' at meters and enter the measure in centimeters (241 centimeters
maximum).
0-2 0-2 meters
7 Refused
9 Don't know
Blank Blank
UniverseText: Sample children <18 whose current height will be entered in metric.
SkipInstructions: <0-2> [goto CHGT_CM]
<R,D> [goto CWGT_LB]
<empty> [go to CHGT_CM]
Page 3 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.021_02.000 Instrument Variable Name: CHGT_CM QuestionnaireFileName: Sample Child
QuestionText: * Enter centimenters.
000-241 0-241 centimeters
Blank Blank
UniverseText: Sample children <18 whose weight will be entered in metric, and who entered "0-2" for height in meters or left it
empty.
SkipInstructions: <0-241> [goto CWGT_LB]
[if CHGT_M = <empty, 0> and CHGT_CM = <empty, 0> go to ERR1_CHGT_CM]
[if CHGT_M = 2 and CHGT_CM > 41 goto ERR2_CHGT_CM]
[if CHGT_M = 1 and CHGT_CM >141 goto ERR2_CHGT_CM]
Question ID: CHS.022_00.000 Instrument Variable Name: CWGT_LB QuestionnaireFileName: Sample Child
QuestionText: How much does [fill: S.C. name] weigh now (without shoes)?
* Enter 'M' to record metric measurements.
* Enter '500' if 500 pounds or more.
001-500 1-500 pounds
997 Refused
999 Don't know
M Metric
UniverseText: Sample children <18
SkipInstructions: <1-500,R,D> [if age ge <2> goto ADD_1, else, goto ADD1_2]
<M> [goto CWGT_KG]
[if = <501-999> goto ERR1_CWGT_LB]
[if NE <1-999, M, R, D> goto ERR2_CWGT_KG]
Question ID: CHS.023_00.000 Instrument Variable Name: CWGT_KG QuestionnaireFileName: Sample Child
QuestionText: * Enter weight in kilograms.
002-226 2-226 kilograms
UniverseText: Sample children <18 whose weight will be entered in metric.
SkipInstructions: <2-226> [if AGE ge <2> goto ADD_1; else goto ADD1_2]
[if CWGT_KG > 226 goto ERR_CWGT_KG]
Page 4 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.031_02.000 Instrument Variable Name: ADD1_2 QuestionnaireFileName: Sample Child
QuestionText: Has a doctor or health professional ever told you that [fill: S.C. name] had...
Mental Retardation?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <2
SkipInstructions: <1,2,R,D> [goto ADD1_3]
Question ID: CHS.031_03.000 Instrument Variable Name: ADD1_3 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Any other developmental delay?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <2
SkipInstructions: <1,2,R,D> [goto CONDL]
Question ID: CHS.032_01.000 Instrument Variable Name: ADD_1 QuestionnaireFileName: Sample Child
QuestionText: Has a doctor or health professional ever told you that [fill: S.C. name] had...
Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 2-17
SkipInstructions: <1,2,R,D> [go to ADD_2]
Page 5 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.032_02.000 Instrument Variable Name: ADD_2 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Mental Retardation?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 2-17
SkipInstructions: <1,2,R,D> [go to ADD_3]
Question ID: CHS.032_03.000 Instrument Variable Name: ADD_3 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
Has a doctor or health professional ever told you that [fill: S.C. name] had...
Any other developmental delay?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 2-17
SkipInstructions: <1,2,R,D> [go to CONDL]
Page 6 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.060_00.000 Instrument Variable Name: CONDL QuestionnaireFileName: Sample Child
QuestionText: (book) C2
Looking at this list, has a doctor or health professional ever told you that [fill: S.C. name] had any of these conditions?
Which ones?
* Enter all that apply, separate with commas.
00 None
01 Down's syndrome
02 Cerebral palsy
03 Muscular dystrophy
04 Cystic fibrosis
05 Sickle cell anemia
06 Autism
07 Diabetes
08 Arthritis
09 Congenital heart disease
10 Other heart condition
97 Refused
99 Don't know
UniverseText: Sample children <18
SkipInstructions: <0-10,R,D> [go to CPOX]
[If <0> and <1-10> go to ERR_CONDL]
Question ID: CHS.070_00.000 Instrument Variable Name: CPOX QuestionnaireFileName: Sample Child
QuestionText: Has [fill: S.C. Name] EVER had chickenpox?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1> [go to CPOX12MO]
<2,R,D> [go to CASHMEV]
Question ID: CHS.072_00.000 Instrument Variable Name: CPOX12MO QuestionnaireFileName: Sample Child
QuestionText: Has [fill: S.C. name] had chickenpox DURING THE PAST 12 MONTHS?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18 who have had chickenpox
SkipInstructions: <1,2,R,D> [goto CASHMEV]
Page 7 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.080_00.000 Instrument Variable Name: CASHMEV QuestionnaireFileName: Sample Child
QuestionText: Has a doctor or other health professional EVER told you that [fill: S.C. name] had asthma?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1> [go to CASSTILL]
<2,R,D> [goto LUNGYR]
Question ID: CHS.085_00.000 Instrument Variable Name: CASSTILL QuestionnaireFileName: Sample Child
QuestionText: Does [fill: S.C. name] still have asthma?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18 and doctor has informed that child had asthma
SkipInstructions: <1,2,R,D> [go to CASHYR]
Question ID: CHS.090_00.000 Instrument Variable Name: CASHYR QuestionnaireFileName: Sample Child
QuestionText: The following questions are about [fill: S.C. name]'s asthma DURING THE PAST 12 MONTHS.
DURING THE PAST 12 MONTHS, has [fill: SC name] had an episode of asthma or an asthma attack?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18 and doctor has informed that child had asthma
SkipInstructions: <1> [go to CASMERYR]
<2,R,D> [goto LUNGYR]
Question ID: CHS.100_00.000 Instrument Variable Name: CASMERYR QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, did [fill1: S.C. name] have to visit an emergency room or urgent care center because of
[fill2: his/her] asthma?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18 who has had an episode of asthma or an asthma attack in the past 12 months
SkipInstructions: <1,2,R,D> [goto LUNGYR]
Page 8 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.110_01.010 Instrument Variable Name: LUNGYR QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, has a doctor or other health professional told you that [fill: SC name] had
...Lung or breathing problems, other than asthma?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1,2,R,D> [goto CANCERYR]
Question ID: CHS.110_02.020 Instrument Variable Name: CANCERYR QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has a doctor or other health professional told you that [fill: SC name] had
...Cancer?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1,2,R,D> [goto NEUROYR]
Question ID: CHS.110_03.030 Instrument Variable Name: NEUROYR QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has a doctor or other health professional told you that [fill: SC name] had
...Neurological problems?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1,2,R,D> [goto URINYR]
Page 9 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.110_04.040 Instrument Variable Name: URINYR QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has a doctor or other health professional told you that [fill: SC name] had
...Urinary problems, including urinary tract infection?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1,2,R,D> [goto GUMYR]
Question ID: CHS.110_05.050 Instrument Variable Name: GUMYR QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, has a doctor or other health professional told you that [fill: SC name] had
...Gum disease?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1,2,R,D> [goto FLUYR]
Question ID: CHS.110_06.060 Instrument Variable Name: FLUYR QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has a doctor or other health professional told you that [fill: SC name] had
...Influenza or pneumonia?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1,2,R,D> [goto SINUSYR]
Page 10 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.110_07.070 Instrument Variable Name: SINUSYR QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has a doctor or other health professional told you that [fill: SC name] had
...Sinusitus?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1,2,R,D> [goto STREPYR]
Question ID: CHS.110_08.080 Instrument Variable Name: STREPYR QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has a doctor or other health professional told you that [fill: SC name] had
...Strep throat or tonsillitis?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1,2,R,D> [if AGE LE 2 go to CCONDT1_1; if AGE >2 go to CCONDT_1]
Question ID: CHS.111_01.000 Instrument Variable Name: CCONDT1_1 QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Hay fever?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to CCONDT1_2]
Page 11 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.111_02.000 Instrument Variable Name: CCONDT1_2 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Any kind of respiratory allergy?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to CCONDT1_3]
Question ID: CHS.111_03.000 Instrument Variable Name: CCONDT1_3 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Any kind of food or digestive allergy?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to CCONDT1_4]
Question ID: CHS.111_04.000 Instrument Variable Name: CCONDT1_4 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Eczema or any kind of skin allergy?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to CCONDT1_5]
Page 12 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.111_05.000 Instrument Variable Name: CCONDT1_5 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Frequent or repeated diarrhea or colitis?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to CCONDT1_6]
Question ID: CHS.111_06.000 Instrument Variable Name: CCONDT1_6 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Anemia?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to CCONDT1_8]
Question ID: CHS.111_08.000 Instrument Variable Name: CCONDT1_8 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Three or more ear infections?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to CCONDT1_9]
Page 13 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.111_09.000 Instrument Variable Name: CCONDT1_9 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Seizures?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to ALOTHYR1]
Question ID: CHS.112_01.010 Instrument Variable Name: ALOTHYR1 QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Allergies other than hay fever, respiratory allergies, food or digestive allergies, or skin allergies?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to ABDOMYR1]
Question ID: CHS.112_02.020 Instrument Variable Name: ABDOMYR1 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Abdominal pain?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to BACKYR1]
Page 14 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.112_03.030 Instrument Variable Name: BACKYR1 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Back or neck pain?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to PNOTHYR1]
Question ID: CHS.112_04.040 Instrument Variable Name: PNOTHYR1 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Other chronic pain?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to FATIGYR1]
Question ID: CHS.112_05.050 Instrument Variable Name: FATIGYR1 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Fatigue or lack of energy?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to FEVRYR1]
Page 15 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.112_06.060 Instrument Variable Name: FEVRYR1 QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Fever?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to COLDYR1]
Question ID: CHS.112_07.070 Instrument Variable Name: COLDYR1 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Head or chest cold?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to THOTHYR1]
Question ID: CHS.112_08.080 Instrument Variable Name: THOTHYR1 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Sore throat other than strep or tonsillitis?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to ACIDYR1]
Page 16 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.112_09.090 Instrument Variable Name: ACIDYR1 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Problems with acid reflux or heartburn?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to NAUSYR1]
Question ID: CHS.112_10.100 Instrument Variable Name: NAUSYR1 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Nausea and/or vomiting?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to CONSPYR1]
Question ID: CHS.112_11.110 Instrument Variable Name: CONSPYR1 QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Recurring constipation?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to OVRWTYR1]
Page 17 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.112_12.120 Instrument Variable Name: OVRWTYR1 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Problems with being overweight?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to ACNEYR1]
Question ID: CHS.112_13.130 Instrument Variable Name: ACNEYR1 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Severe acne?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to WARTSYR1]
Question ID: CHS.112_14.140 Instrument Variable Name: WARTSYR1 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Warts?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to SKOTHYR1]
Page 18 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.112_15.150 Instrument Variable Name: SKOTHYR1 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Skin problems other than eczema, acne, or warts?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children LE 2
SkipInstructions: <1,2,R,D> [go to CHSTATYR]
Question ID: CHS.115_01.000 Instrument Variable Name: CCONDT_1 QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Hay fever?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions: <1,2,R,D> [go to CCONDT_2]
Question ID: CHS.115_02.000 Instrument Variable Name: CCONDT_2 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Any kind of respiratory allergy?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions: <1,2,R,D> [go to CCONDT_3]
Page 19 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.115_03.000 Instrument Variable Name: CCONDT_3 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Any kind of food or digestive allergy?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions: <1,2,R,D> [go to CCONDT_4]
Question ID: CHS.115_04.000 Instrument Variable Name: CCONDT_4 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Eczema or any kind of skin allergy?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions: <1,2,R,D> [go to CCONDT_5]
Question ID: CHS.115_05.000 Instrument Variable Name: CCONDT_5 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Frequent or repeated diarrhea or colitis?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions: <1,2,R,D> [go to CCONDT_6]
Page 20 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.115_06.000 Instrument Variable Name: CCONDT_6 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Anemia?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions: <1,2,R,D> [go to CCONDT_7]
Question ID: CHS.115_07.000 Instrument Variable Name: CCONDT_7 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Frequent or severe headaches, including migraines?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions: <1,2,R,D> [go to CCONDT_8]
Question ID: CHS.115_08.000 Instrument Variable Name: CCONDT_8 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Three or more ear infections?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions: <1,2,R,D> [go to CCONDT_9]
Page 21 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.115_09.000 Instrument Variable Name: CCONDT_9 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Seizures?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions: <1,2,R,D> [go to CCONDT_10]
Question ID: CHS.115_10.000 Instrument Variable Name: CCONDT_10 QuestionnaireFileName: Sample Child
QuestionText: * Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: S.C. name] had any of the following conditions...
Stuttering or stammering?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children = 3-17
SkipInstructions: <1,2,R,D> [go to ALOTHYR2]
Question ID: CHS.120_01.010 Instrument Variable Name: ALOTHYR2 QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Allergies other than hay fever, respiratory allergies, food or digestive allergies, or skin allergies?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 3-17
SkipInstructions: <1,2,R,D> [go to HEADYR2]
Page 22 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.120_02.020 Instrument Variable Name: HEADYR2 QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Recurring headache, other than migraine?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 3-17
SkipInstructions: <1,2,R,D> [go to ABDOMYR2]
Question ID: CHS.120_03.030 Instrument Variable Name: ABDOMYR2 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Abdominal pain?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 3-17
SkipInstructions: <1,2,R,D> [go to BACKYR2]
Question ID: CHS.120_04.040 Instrument Variable Name: BACKYR2 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Back or neck pain?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 3-17
SkipInstructions: <1,2,R,D> [go to PNOTHYR2]
Page 23 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.120_05.050 Instrument Variable Name: PNOTHYR2 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Other chronic pain?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 3-17
SkipInstructions: <1,2,R,D> [go to FATIGYR2]
Question ID: CHS.120_06.060 Instrument Variable Name: FATIGYR2 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Fatigue or lack of energy?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 3-17
SkipInstructions: <1,2,R,D> [go to FEVRYR2]
Question ID: CHS.120_07.070 Instrument Variable Name: FEVRYR2 QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Fever?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 3-17
SkipInstructions: <1,2,R,D> [go to COLDYR2]
Page 24 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.120_08.080 Instrument Variable Name: COLDYR2 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Head or chest cold?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 3-17
SkipInstructions: <1,2,R,D> [go to THOTHYR2]
Question ID: CHS.120_09.090 Instrument Variable Name: THOTHYR2 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Sore throat other than strep or tonsillitis?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 3-17
SkipInstructions: <1,2,R,D> [go to ACIDYR2]
Question ID: CHS.120_10.100 Instrument Variable Name: ACIDYR2 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Problems with acid reflux or heartburn?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 3-17
SkipInstructions: <1,2,R,D> [go to NAUSYR2]
Page 25 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.120_11.110 Instrument Variable Name: NAUSYR2 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Nausea and/or vomiting?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 3-17
SkipInstructions: <1,2,R,D> [go to CONSPYR2]
Question ID: CHS.120_12.120 Instrument Variable Name: CONSPYR2 QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Recurring constipation?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 3-17
SkipInstructions: <1,2,R,D> [go to INSOMYR2]
Question ID: CHS.120_13.130 Instrument Variable Name: INSOMYR2 QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Insomnia or trouble sleeping?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 3-17
SkipInstructions: <1,2,R,D> [go to OVRWTYR2]
Page 26 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.120_14.140 Instrument Variable Name: OVRWTYR2 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Problems with being overweight?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 3-17
SkipInstructions: <1,2,R,D> [go to ACNEYR2]
Question ID: CHS.120_15.150 Instrument Variable Name: ACNEYR2 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Severe acne?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 3-17
SkipInstructions: <1,2,R,D> [go to WARTSYR2]
Question ID: CHS.120_16.160 Instrument Variable Name: WARTSYR2 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Warts?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 3-17
SkipInstructions: <1,2,R,D> [go to SKOTHYR2]
Page 27 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.120_17.170 Instrument Variable Name: SKOTHYR2 QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Skin problems other than eczema, acne, or warts?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 3-17
SkipInstructions: <1,2,R,D> [go to CHSTATYR]
Question ID: CHS.210_00.000 Instrument Variable Name: CHSTATYR QuestionnaireFileName: Sample Child
QuestionText: Compared with 12 months ago, would you say [fill: S.C. name]'s health is now better, worse, or about the same?
1 Better
2 Worse
3 About the same
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1-3,R,D> [if AGE le <4> goto CCOLD2W; else goto SCHDAYR]
Question ID: CHS.220_00.000 Instrument Variable Name: SCHDAYR QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, that is, since [fill1: 12-month ref. date], about how many days did [fill2: S.C. name]
miss school because of illness or injury?
* Enter '996' if child did not go to school in the past 12 months.
000 None
001-240 1-240 days
996 Did not go to school
997 Refused
999 Don't know
UniverseText: Sample children 5-17
SkipInstructions: <0-99,996,R,D> [goto CCOLD2W]
<100-240> [go to ERR1_SCHDAYR]
<241-995> [goto ERR2_SCHDAYR]
Page 28 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.230_00.000 Instrument Variable Name: CCOLD2W QuestionnaireFileName: Sample Child
QuestionText: * Hand calendar card.
These next questions are about [fill: S.C name]'s recent health during the 2 weeks outlined on that calendar.
Did [fill: SC name] 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 children <18
SkipInstructions: <1,2,R,D> [goto CINTIL2W]
Question ID: CHS.240_00.000 Instrument Variable Name: CINTIL2W QuestionnaireFileName: Sample Child
QuestionText: Did [fill: S.C. name] 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 children <18
SkipInstructions: <1,2,R,D> [goto CHEARST]
Question ID: CHS.250_00.000 Instrument Variable Name: CHEARST QuestionnaireFileName: Sample Child
QuestionText: Which statement best describes [fill: S.C. name]'s hearing without a hearing aid: Good, a little trouble, a lot of trouble, or
deaf?
1 Good
2 A little trouble
3 A lot of trouble
4 Deaf
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1-4,R,D> [go to CVISION]
Page 29 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.260_00.000 Instrument Variable Name: CVISION QuestionnaireFileName: Sample Child
QuestionText: Does [fill1: S.C. name] have any trouble seeing [fill2: , even when wearing glasses or contact lenses]?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1> [goto CBLIND]
<2,R,D> [go to IHSPEQ]
Question ID: CHS.270_00.000 Instrument Variable Name: CBLIND QuestionnaireFileName: Sample Child
QuestionText: Is [fill: S.C. name] blind or unable to see at all?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18 having trouble seeing
SkipInstructions: <1,2,R,D> [goto IHSPEQ]
Question ID: CHS.290_00.000 Instrument Variable Name: IHSPEQ QuestionnaireFileName: Sample Child
QuestionText: Does [fill1: S.C. name] have any impairment or health problem that requires [fill2: him/her] to use special equipment, such
as a brace, a wheelchair, or a hearing aid (excluding ordinary eyeglasses or corrective shoes)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1,2,R,D> [goto IHMOB]
Question ID: CHS.300_00.000 Instrument Variable Name: IHMOB QuestionnaireFileName: Sample Child
QuestionText: Does [fill1: S.C. name] have an impairment or health problem that limits [fill2: his/her] ability to (crawl), walk, run, or play?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1> [goto IHMOBYR]
<2,R,D> [goto PROBRX]
Page 30 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.310_00.000 Instrument Variable Name: IHMOBYR QuestionnaireFileName: Sample Child
QuestionText: Is this an impairment or health problem that has lasted, or is expected to last, 12 months or longer?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18 that have limited ability to crawl, walk, run, or play
SkipInstructions: <1,2,R,D> [goto PROBRX]
Question ID: CHS.311_00.000 Instrument Variable Name: PROBRX QuestionnaireFileName: Sample Child
QuestionText: Does [fill1: S.C. name] NOW have a problem for which [fill2: he/she] has regularly taken prescription medication for at least
three months?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children <18
SkipInstructions: <1,2,R,D> [if AGE LE <1> go to CUSUALPL;
if AGE GE <3> go to LEARND;
if AGE = <2> and SEX = <1> go to CMHAGM11_1;
if AGE = <2> and SEX = <2> go to CMHAGF11_1]
Question ID: CHS.312_00.000 Instrument Variable Name: LEARND QuestionnaireFileName: Sample Child
QuestionText: Has a representative from a school or a health professional ever told you that [fill: S.C. name] had a learning disability?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 3-17
SkipInstructions: <1,2,R,D> [if AGE > 3 go to DEPRSYR;
if AGE = 3 and SEX = 1 go to CMHAGM11_1;
if AGE = 3 and SEX = 2 go to CMHAGF11_1]
Page 31 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.321_01.000 Instrument Variable Name: CMHAGM11_1 QuestionnaireFileName: Sample Child
QuestionText: (book) C3
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
HE:
Has been uncooperative?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
UniverseText: Male sample children 2-3
SkipInstructions: <0-2,R,D> [go to CMHAGM11_2]
Question ID: CHS.321_02.000 Instrument Variable Name: CMHAGM11_2 QuestionnaireFileName: Sample Child
QuestionText: (book) C3
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
HE:
Has trouble getting to sleep?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
UniverseText: Male sample children 2-3
SkipInstructions: <0-2,R,D> [go to CMHAGM11_3]
Page 32 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.321_03.000 Instrument Variable Name: CMHAGM11_3 QuestionnaireFileName: Sample Child
QuestionText: (book) C3
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
HE:
Has speech problems?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
UniverseText: Male sample children 2-3
SkipInstructions: <0-2,R,D> [go to CMHAGM11_4]
Question ID: CHS.321_04.000 Instrument Variable Name: CMHAGM11_4 QuestionnaireFileName: Sample Child
QuestionText: (book) C3
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
HE:
Has been unhappy, sad, or depressed?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
UniverseText: Male sample children 2-3
SkipInstructions: <0-2,R,D> [go to CUSUALPL]
Page 33 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.361_01.000 Instrument Variable Name: CMHAGF11_1 QuestionnaireFileName: Sample Child
QuestionText: (book) C3
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
SHE:
Has temper tantrums or a hot temper?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
UniverseText: Female sample children 2-3
SkipInstructions: <0-2,R,D> [go to CMHAGF11_2]
Question ID: CHS.361_02.000 Instrument Variable Name: CMHAGF11_2 QuestionnaireFileName: Sample Child
QuestionText: book) C3
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
SHE:
Has speech problems?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
UniverseText: Female sample children 2-3
SkipInstructions: <0-2,R,D> [go to CMHAGF11_3]
Page 34 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.361_03.000 Instrument Variable Name: CMHAGF11_3 QuestionnaireFileName: Sample Child
QuestionText: book) C3
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
SHE:
Has been nervous or high-strung?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
UniverseText: Female sample children 2-3
SkipInstructions: <0-2,R,D> [go to CMHAGF11_4]
Question ID: CHS.361_04.000 Instrument Variable Name: CMHAGF11_4 QuestionnaireFileName: Sample Child
QuestionText: book) C3
* Read if necessary.
I am going to read a list of items that describe children. For each one, tell me if it has been NOT TRUE, SOMETIMES
TRUE, or OFTEN TRUE, of [fill: S.C. name] DURING THE PAST TWO MONTHS.
SHE:
Has been unhappy, sad, or depressed?
0 Not true
1 Sometimes true
2 Often true
7 Refused
9 Don't know
UniverseText: Female sample children 2-3
SkipInstructions: <0-2,R,D> [go to CUSUALPL]
Page 35 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.370_01.010 Instrument Variable Name: DEPRSYR QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, has a doctor or other health professional told you that [fill: SC name] had
...Depression?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 4
SkipInstructions: <1,2,R,D> [goto PHOBYR]
Question ID: CHS.370_02.020 Instrument Variable Name: PHOBYR QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has a doctor or other health professional told you that [fill: SC name] had
...Phobia?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 4
SkipInstructions: <1,2,R,D> [goto ANXYR]
Question ID: CHS.375_01.010 Instrument Variable Name: ANXYR QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Anxiety or stress?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 4
SkipInstructions: <1,2,R,D> [goto INCONTYR]
Page 36 of 36
2007 NHIS Questionnaire - Sample Child
Child Health Status & Limitations
Document Version Date: 12-Jul-06
Question ID: CHS.375_02.020 Instrument Variable Name: INCONTYR QuestionnaireFileName: Sample Child
QuestionText: *Read if necessary.
DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Incontinence, including bed wetting?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children GE 4
SkipInstructions: <1,2,R,D> if age GE 10 and SEX=2 [goto MENSTYR]; else [goto next section]
Question ID: CHS.380_00.010 Instrument Variable Name: MENSTYR QuestionnaireFileName: Sample Child
QuestionText: DURING THE PAST 12 MONTHS, has [fill: SC name] had
...Menstrual problems such as heavy bleeding, bothersome cramping, or premenstrual syndrome (also called PMS)?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Female sample children GE 10
SkipInstructions: <1,2,R,D> [goto next section]
| File Type | application/msword |
| Author | Howard Riddick |
| Last Modified By | Howard Riddick |
| File Modified | 2006-09-29 |
| File Created | 2006-09-29 |