Attachment 1. Adult Topical Modules (sample adult)
OMB no. 0920-0214
Expires: 12/31/2009
Notice - Information contained on this form which would permit identification of any individual or establishment has been collected with a guarantee that it will be held in strict confidence, will be used only for purposes stated for this study, and will not be disclosed or released to others without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m). Public reporting burden of this collection of information is estimated to average 18 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333. ATTN: PRA (0920-0214).
Topical Module on Asthma
Question ID ACN.100.010
Variable Name AASMHSP
Universe-text Sample adults 18+ who had episode of asthma in past year
Question Text DURING THE PAST 12 MONTHS, have you stayed overnight in a hospital
because of asthma?
FR Instruction: If in hospital for asthma AND other reasons, enter 1.
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1> [goto AASMMC]
<2,D,R> [go to AWZMSWK]
Question ID ACN.100.020
Variable Name AASMMC
Universe-text Sample adults 18+ in hospital overnight b/c of asthma, past year
Question Text After (the last time) you left the hospital, did a health professional talk with you about long term management of your asthma?
Answer Codes 1. Yes
2. No
3. Still in the hospital
Refused
Don't know
Skip Instructions <1,2, 3,D,R> [go to AWZMSWK]
Question ID ACN.100.030
Variable Name AWZMSWK
Universe-text Sample adults 18+ who had episode of asthma in past year
Question Text * Read if necessary: For homemakers, this includes work around the house.
DURING THE PAST 12 MONTHS, HOW MANY DAYS were you UNABLE to work because of
your asthma?
Answer Codes <000-365> Days
996 Unable to do this activity
Refused
Don't Know
Skip Instructions <000-365, 996,D,R> [go to AWZPIN]
Question ID ACN.100.040
Variable Name AWZPIN
Universe-text Sample adults 18+ who still have asthma
Question Text Have you ever used a PRESCRIPTION inhaler?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1> [goto AASMINST]
<2,D,R> [go to AASMED]
Question ID ACN.100.050
Variable Name AASMINST
Universe-text Sample adults 18+ who have ever used prescription inhaler
Question Text Has a health professional shown you how to use your inhaler?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,D,R> [go to AASMPMED]
Question ID ACN.100.060
Variable Name AASMPMED
Universe-text Sample adults 18+ who have ever used prescription inhaler
Question Text Now I'm going to ask you about two different kinds of ASTHMA medicine. One is for quick relief. The other does not give quick relief but protects your lungs AND PREVENTS SYMPTOMS OVER THE LONG TERM.
DURING THE PAST 3 MONTHS, have you used the kind of PRESCRIPTION
inhaler THAT YOU BREATHE IN THROUGH YOUR MOUTH, that gives QUICK
relief from asthma symptoms?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1> [goto AASMCAN]
<2,D,R> [go to AASMED]
Question ID ACN.100.070
Variable Name AASMCAN
Universe-text Sample adults 18+ who have used quick relief inhaler, past 3 mos
Question Text DURING THE PAST 3 MONTHS did you use more than three canisters of
this type of inhaler?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,D,R> [go to AASMED]
Question ID ACN.100.080
Variable Name AASMED
Universe-text Sample adults 18+ who have ever used prescription inhaler
Question Text Have you EVER taken the preventive kind of ASTHMA medicine used
every day to protect your lungs and keep you from having attacks? Include both oral
medicine and inhalers. This is different from inhalers used for quick relief.
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1> [go to AASMDTP] < 2,D,R> [goto AASWMP]
Question ID ACN.100.090
Variable Name AASMDTP
Universe-text Sample adults 18+ who have ever taken preventive asthma medicine
Question Text Are you NOW taking this medication (that protects your lungs) daily or almost daily?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,D,R> [go to AASWMP]
Question ID ACN.100.100
Variable Name AASWMP
Universe-text Sample adults 18+ who still have asthma
Question Text An asthma management plan is a printed form that tells when to change the amount or type of medicine, when to call the doctor for advice, and when to go to the emergency room.
*Read if necessary: include nurses and asthma educators
Has a doctor or other health professional EVER given you an asthma management plan?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,D,R> [go to AASCLASS]
Question ID ACN.100.110
Variable Name AASCLASS
Universe-text Sample adults 18+ who still have asthma
Question Text Have you ever taken a course or class on how to manage asthma yourself?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,D,R> [go to AAS_REC]
Question ID ACN.105_01.010
Variable Name AAS_REC
Universe-text Sample adults 18+ who still have asthma
Question Text Has a doctor or other health professional ever taught you...
...how to recognize early signs or symptoms of an asthma episode?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,D,R> [go to AAS_RES]
Question ID ACN.105_02.020
Variable Name AAS_RES
Universe-text Sample adults 18+ who still have asthma
Question Text * Read if necessary:
Has a doctor or other health professional ever taught you...
...how to respond to episodes of asthma?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,D,R> [go to AAS_MON]
Question ID ACN.105_03.030
Variable Name AAS_MON
Universe-text Sample adults 18+ who still have asthma
Question Text * Read if necessary:
Has a doctor or other health professional ever taught you...
...how to monitor peak flow for daily therapy?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,D,R> [go to AAPENVLN]
Question ID ACN.107.010
Variable Name AAPENVLN
Universe-text Sample adults 18+ who still have asthma
Question Text Has a doctor or other health professional ever advised you to change things in your home,
school, or work to improve your asthma?
Answer Codes 1. Yes
2. No
3. Was told no changes needed
Refused
Don't know
Skip Instructions <1> [goto AAPENVDO]
<2,3, D,R> [go to ULCEV]
Question ID ACN.107.020
Variable Name AAPENVDO
Universe-text Sample adults 18+ who been told to change things because of asthma
Question Text How much of this advice did you follow? Would you say none, a little, some, most, or all?
Answer Codes 0. None
1. A little
2. Some
3. Most
4. All
Refused
Don't Know
Skip Instructions <0-4,D,R> [go to ULCEV]
Question ID CHS.100.010
Variable Name CASMHSP
Universe-text Sample child <18 who had episode of asthma in past year
Question Text DURING THE PAST 12 MONTHS, has {S.C. name} stayed overnight in a hospital because of
asthma?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1> [goto CASMMC]
<2,D,R> [go to CWZMSWK]
Question ID CHS.100.020
Variable Name CASMMC
Universe-text Sample child <18 in hospital overnight b/c of asthma, past year
Question Text After (the last time) {S.C. name} left the hospital, did a health professional talk with you about
long term management of {his/her} asthma?
Answer Codes 1. Yes
2. No
3. Still in the hospital
Refused
Don't know
Skip Instructions <1,2, 3,D,R> [go to CWZMSWK]
Question ID CHS.100.030
Variable Name CWZMSWK
Universe-text Sample child <18 who had episode of asthma in past year
Question Text DURING THE PAST 12 MONTHS, that is since {12-month ref. date}, HOW MANY DAYS of [see fill instructions] did {S.C. name} miss because of {his/her} asthma?
FR Instruction: Enter 995 if child home schooled
Answer Codes <000-365> Days
995 child was home schooled
996 child did not go to day care, preschool, school, or work
Refused
Don't Know
Skip Instructions <000-365, 996,D,R> [go to CWZPIN]
Question ID CHS.100.040
Variable Name CWZPIN
Universe-text Sample child <18 who still have asthma
Question Text Has {S.C. name} EVER used a PRESCRIPTION inhaler?
(H)
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1> [goto CASMINST]
<2,D,R> [go to CASMED]
Question ID CHS.100.050
Variable Name CASMINST
Universe-text Sample child <18 who have ever used prescription inhaler
Question Text Has a health professional shown {S.C. name} how to use {his/her} inhaler? (This includes showing parents for young children).
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,D,R> [go to CASMPMED]
Question ID CHS.100.060
Variable Name CASMPMED
Universe-text Sample child <18 who have ever used prescription inhaler
Question Text Now I’m going to ask you about two different kinds of ASTHMA medicine. One is for quick
relief. The other does not give quick relief but protects your lungs AND PREVENTS SYMPTOMS OVER THE LONG TERM.
DURING THE PAST 3 MONTHS, has {S.C. name} used the kind of PRESCRIPTION inhaler
THAT YOU BREATH IN THROUGH YOUR MOUTH, that gives QUICK relief from asthma symptoms?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1> [goto CASMCAN]
<2,D,R> [go to CASMED]
Question ID CHS.100.070
Variable Name CASMCAN
Universe-text Sample child <18 who have used quick relief inhaler, past 3 mos
Question Text DURING THE PAST 3 MONTHS did {S.C. name} use more
than three canisters of this type of inhaler?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,D,R> [go to CASMED]
Question ID CHS.100.080
Variable Name CASMED
Universe-text Sample child <18 who have ever used prescription inhaler
Question Text Has {S.C.name} EVER taken the preventive kind of ASTHMA medicine used everyday to
protect {his/her} lungs and keep {him/her} from having attacks? Include both oral medicine
and inhalers. This is different from inhalers used for quick relief.
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1> [go to CASMDTP] < 2,D,R> [goto CASWMP]
Question ID CHS.100.090
Variable Name CASMDTP
Universe-text Sample child <18 who have ever taken preventive asthma medicine
Question Text Is {S.C. name} NOW taking this medication (that protects {his/her} lungs) daily or almost daily?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Skip Instructions <1,2,D,R> [go to CASWMP]
Question ID CHS.100.100
Variable Name CASWMP
Universe-text Sample child <18 who still have asthma
Question Text An asthma management plan is a printed form that tells when to change the amount or type of medicine, when to call the doctor for advice, and when to go to the emergency room.
Has a doctor or other health professional EVER given {S.C.name} an asthma management plan?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,D,R> [go to CASCLASS]
Question ID CHS.100.110
Variable Name CASCLASS
Universe-text Sample child <18 who still have asthma
Question Text Has {Sample Child’s name} ever taken a course or class on how to manage {his/her} asthma?
FR: INCLUDE ADULT(S) WHO TOOK A COURSE FOR THE CHILD’S ASTHMA
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,D,R> [go to CAS_REC]
Question ID CHS.100.120_01.010
Variable Name CAS_REC
Universe-text Sample child <18 who still have asthma
Question Text Has a doctor or other health professional EVER taught {S.C. name} or {his/her} parent or guardian...
...how to recognize early signs or symptoms of an asthma episode?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,D,R> [go to CAS_RES]
Question ID CHS.100.120_02.020
Variable Name CAS_RES
Universe-text Sample child <18 who still have asthma
Question Text ...how to respond to episodes of asthma?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,D,R> [go to CAS_MON]
Question ID CHS.100.120_03.030
Variable Name CAS_MON
Universe-text Sample child <18 who still have asthma
Question Text ...how to monitor peak flow for daily therapy?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,D,R> [go to CAPENVLN]
Question ID CHS.100.130
Variable Name CAPENVLN
Universe-text Sample child <18 who still have asthma
Question Text Has a doctor or other health professional EVER advised you to change things in {S.C. name}
home, school, or work to improve {his/her} asthma?
Answer Codes 1. Yes
2. No
3. Was told no changes needed
Refused
Don't know
Skip Instructions <1> [goto CAPENVDO]
<2,3, D,R> [go to CONDT1_1]
Question ID CHS.100.140
Variable Name CAPENVDO
Universe-text Sample child <18 who been told to change things because of asthma
Question Text How much of this advice did you follow? Would you say none, a little, some, most, or all?
Answer Codes 0. None
1. A little
2. Some
3. Most
4. All
Refused
Don't Know
Skip Instructions <0-4,D,R> [go to CCONDT1_1]
Topical Module on Cancer Screening
Question ID: NAF.020_00.000 Instrument Variable Name: SUN1_SHA
QuestionText: (book) CAN1
When you go outside on a warm sunny day for MORE than one hour, how often do you. . .
Stay in the shade? Would you say (Read categories 1-5). . .
1 Always
2 Most of the time
3 Sometimes
4 Rarely
5 Never
6 Don't go out in the sun
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1-6,R,D> [goto SUN1_CAP]
Question ID: NAF.022_00.000 Instrument Variable Name: SUN1_CAP
QuestionText: (book) CAN1
*Read if necessary.
When you go outside on a warm sunny day for MORE than one hour, how often do you. . .
Wear a baseball cap or sun visor? Would you say (Read categories 1-5). . .
1 Always
2 Most of the time
3 Sometimes
4 Rarely
5 Never
6 Don't go out in the sun
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1-6,R,D> [goto SUN1_HAT]
Question ID: NAF.023_00.000 Instrument Variable Name: SUN1_HAT
QuestionText: (book) CAN1 and CAN2
*Read if necessary.
When you go outside on a warm sunny day for MORE than one hour, how often do you. . .
Wear a hat that shades your face, ears AND neck such as a hat with a wide brim all around? Would you say (Read
categories 1-5). . .
*Do not include visors, baseball caps, or hats that do not shade the face, ears and neck. Include safari hats.
1 Always
2 Most of the time
3 Sometimes
4 Rarely
5 Never
6 Don't go out in the sun
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1-6,R,D> [goto SUN2_LGS]
Question ID: NAF.024_00.000 Instrument Variable Name: SUN2_LGS
QuestionText: (book) CAN1
*Read if necessary.
When you go outside on a warm sunny day for MORE than one hour, how often do you. . .
Wear a long sleeved shirt? Would you say (Read categories 1-5). . .
1 Always
2 Most of the time
3 Sometimes
4 Rarely
5 Never
6 Don't go out in the sun
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1-6,R,D> [goto SUN2_LGP]
Question ID: NAF.025_00.000 Instrument Variable Name: SUN2_LGP
QuestionText: (book) CAN1
*Read if necessary.
When you go outside on a warm sunny day for MORE than one hour, how often do you. . .
Wear long pants or other clothing that reaches your ankles? Would you say (Read categories 1-5). . .
1 Always
2 Most of the time
3 Sometimes
4 Rarely
5 Never
6 Don't go out in the sun
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1-6,R,D> [goto SUN2_SCR]
Question ID: NAF.026_00.000 Instrument Variable Name: SUN2_SCR
QuestionText: (book) CAN1
*Read if necessary.
When you go outside on a warm sunny day for MORE than one hour, how often do you. . .
Use sunscreen? Would you say (Read categories 1-5). . .
1 Always
2 Most of the time
3 Sometimes
4 Rarely
5 Never
6 Don't go out in the sun
7 Refused
9 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <1-4> [goto SPF] <5,6,R,D> [goto SNNUM]
Question ID: NAF.027_00.000 Instrument Variable Name: SPF
QuestionText: What is the SPF number of the sunscreen you use MOST often?
*Read if necessary: If you use more than one or different ones, pick the one used most often.
*Enter '96' if unable to pick the one used most often.
01-50 1-50
96 More than one, different ones, other
97 Refused
99 Don't know
UniverseText: Sample adults 18+ who use sunscreen at least rarely
SkipInstructions: <1-50> [goto SNNUM] <96, R, D> [goto SPFSCALE]
Question ID: NAF.028_00.000 Instrument Variable Name: SPFSCALE
QuestionText: Is the SPF usually 1-14 or 15-50?
1 1-14
2 15-50
7 Refused
9 Don't know
UniverseText: Sample adults 18+ who answered more than one, different ones, or other to SPF number, or did not know or refused
to say the SPF
SkipInstructions: <1,2,R,D> [goto SNNUM]
Question ID: NAF.033_00.000 Instrument Variable Name: SNNUM
QuestionText: DURING THE PAST 12 MONTHS, how many times have you used any of the following indoor tanning devices---a
sunlamp, sunbed or tanning booth EVEN ONE TIME? Do NOT include times you have gotten a spray-on tan.
*Enter '0' for none.
000 None
001-365 1-365 times
997 Refused
999 Don't know
UniverseText: Sample adults 18+
SkipInstructions: <000-365,R,D> [goto PAPHAD]
Question ID: NAF.130_00.000 Instrument Variable Name: PAPHAD
QuestionText: Have you EVER HAD a Pap smear or Pap test?
*Read if necessary.
A Pap smear or Pap test is a routine test for women in which the doctor examines the cervix, takes a cell sample from the cervix with a
small stick or brush, and sends it to the lab.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Female sample adults 18+
SkipInstructions: <1> [goto PAP6YR] <2> [goto PAPNOT] <R,D> [goto HYST]
Question ID: NAF.140_00.000 Instrument Variable Name: PAP6YR
QuestionText: How many Pap smears or Pap tests have you had in the LAST 6 YEARS?
*Enter '0' for none.
*Enter '95' for 95 or more exams.
00 None
01-94 1-94 times
95 95+ times
97 Refused
99 Don't know
UniverseText: Female sample adults 18+ who have ever had a Pap smear
SkipInstructions: <0-95,R,D> [goto RPAP1_MT]
Question ID: NAF.150_01.000 Instrument Variable Name: RPAP1_MT
QuestionText: 1 of 2
When did you have your MOST RECENT Pap smear or Pap test?
*Enter month of last Pap smear or Pap test test.
*Enter '96' to go to number and time period format.
01 January
02 February
03 March
04 April
05 May
06 June
07 July
08 August
09 September
10 October
11 November
12 December
96 Time period format
97 Refused
99 Don't know
UniverseText: Female sample adults 18+ who have ever had a Pap smear
SkipInstructions: <1-12,D> [goto RPAP1_YR] <R> store "R' in RPAP1_YR [goto RPAP2] <96> store "96" in RPAP1_YR [goto RPAP1N]
Question ID: NAF.150_02.000 Instrument Variable Name: RPAP1_YR
QuestionText: 2 of 2
*Enter year of last Pap smear or Pap test.
1880-2006 1880-2006
9996 Time period format
9997 Refused
9999 Don't know
UniverseText: Female sample adults age 18+ who answered month of last Pap smear test or didn't know month of last Pap smear test
SkipInstructions: <valid year> if RPAP1_MT=1-12 [goto PAPREAS]; else if RPAP1_MT=D [goto RPAP2] <R,D> [goto RPAP2] IF RPAP1_MT and RPAP1_YR = a future date [goto ERR1_RPAP1_YR]
Question ID: NAF.160_01.000 Instrument Variable Name: RPAP1N
QuestionText: 1 of 2
When did you have your MOST RECENT Pap smear or Pap test?
*Enter number for time since last Pap smear or Pap test.
*Enter '95' for 95 or more.
01-94 1-94
95 95+
97 Refused
UniverseText: Female sample adults 18+ who selected number and time period format for most recent Pap smear test from the initial month screen
SkipInstructions: <1-95> [goto RPAP1T] <R,D> store "R,D" in RPAP1T [goto RPAP2]
Question ID: NAF.160_02.000 Instrument Variable Name: RPAP1T
QuestionText: 2 of 2
*Enter time period for time since most recent Pap smear or Pap test.
1 Days ago
2 Weeks ago
3 Months ago
4 Years ago
7 Refused
9 Don't know
UniverseText: Female sample adults 18+ who answered 1-95 for number part of this 2 part question
SkipInstructions: <1-3> [goto PAPREAS]; <4> if RPAP1N and RPAP1T GT 5 years from system, fill "5" in RPAP2 [goto PAPREAS]; else [goto RPAP2]
<R,D> [goto RPAP2]
IF [RPAPIN = Number greater than person years old and RPAP1T= 4]] goto ERR1_RPAP1T
Question ID: NAF.165_00.000 Instrument Variable Name: RPAP2
QuestionText: (book) CAN3
Was it:
*Read answer categories.
1 A year ago or less
2 More than 1 year but not more than 2 years
3 More than 2 years but not more than 3 years
4 More than 3 years but not more than 5 years
5 Over 5 years ago
7 Refused
9 Don't know
UniverseText: Female sample adults 18+ who failed to give a complete date in either the month or year format or failed to give a complete date in the number and time period format, or entered years ago in the time period format (excluding those whose last Pap smear test was over 5 years ago)
SkipInstructions: <1-5,R,D> goto PAPREAS
Question ID: NAF.170_00.000 Instrument Variable Name: PAPREAS
QuestionText:
What was the MAIN reason you had this Pap smear or Pap test - was it part of a routine exam, because of a
problem, or some other reason?
1 Part of a routine exam
2 Because of a problem
3 Some other reason
7 Refused
9 Don't know
UniverseText: Female sample adults 18+ who have ever had a Pap smear or Pap test
SkipInstructions: <1-3,R,D> goto PAPABN
Question ID: NAF.180_00.000 Instrument Variable Name: PAPABN
QuestionText: Have you EVER had a Pap smear or Pap test where the results were NOT normal?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Female sample adults 18+ who have ever had a Pap smear or Pap test
SkipInstructions: <1,2,R,D> if (RPAP1_YR lt (system year - 3)) or (RPAP1_YR=(system year - 3) and RPAP1_MT lt system
month) or (RPAP1T=4 and RPAP1N gt 3) or (RPAP2=4,5) goto PAPNOT else goto MDCRECPAP
Question ID: NAF.210_00.000 Instrument Variable Name: PAPNOT
QuestionText: (book) CAN4
What is the most important reason you have [Fill1: NEVER had a Pap smear or Pap test/NOT had a Pap smear or Pap test in the LAST 3 YEARS]?
01 No reason/Never thought about it
02 Didn't need/Didn't know I needed this type of test
03 Doctor didn't order it/didn't say I needed it
04 Haven't had any problems
05 Put if off/Didn't get around to it
06 Too expensive/No insurance/Cost
07 Too painful, unpleasant, or embarrassing
08 Had hysterectomy
09 Don't have doctor
10 Had an HPV DNA test
11 Other
97 Refused
99 Don't know
UniverseText: Female sample adults 18+ who have never had a Pap smear, or who have not had a Pap smear in the last 3 years
SkipInstructions: <1,2,4-7,10,11,R,D> goto MDRECPAP <8> set HYST=1 and goto MDRECPAP
<3,9> if PAPHAD=1 goto PAPWHEN elseif PAPHAD=2 goto HYST
Question ID: NAF.215_00.000 Instrument Variable Name: MDRECPAP
QuestionText: Fill1 (IF PAPHAD=1 and most recent screening exam LE 3 years from system date)
"Was your most recent Pap smear or Pap test RECOMMENDED by a doctor or other health professional?"
Else (IF PAPHAD=2, or PAPHAD GT 3 years from system date or RPAP2=R,D)
"In the PAST 12 MONTHS, has a doctor or other health professional RECOMMENDED that you have a PAP smear or Pap test?"
1 Yes
2 No
3 Did not see a doctor in the past 12 months
7 Refused
9 Don't know
UniverseText: Female sample adults 18+ who had a doctor, who didn't answer that her doctor didn't recommend a Pap Smear, who haven't had a hysterectomy, and gave a reason for not having Pap test ever/in the last 3 years
SkipInstructions: <1-3,R,D> if PAPHAD=1 goto PAPWHEN
elseif PAPHAD=2 and AGE=18-65 goto HPVHRD
elseif PAPHAD=2 and AGE ge 66 goto HPVHAD
Question ID: NAF.216_00.000 Instrument Variable Name: PAPWHEN
When do you expect to have your next Pap smear or Pap test?
1 A year or less from now
2 1-3 Years from now
3 3-5 years from now
4 More than 5 years from now
5 When doctor recommends it
6 Never, had HPV DNA test
7 Never, had HPV vaccine
8 Never, other reason
97 Refused
99 Don't know
SkipInstructions: <1-8,R,D> if PAPNOT=8 store "1" in HYST
if AGE=18-65 goto HPVHRD; elseif AGE ge 66 goto HPVHAD
endif; elseif PAPNOT=1-7,9-11,R,D goto HYST
Question ID: NAF.220_00.000 Instrument Variable Name: HYST
QuestionText: Have you had a hysterectomy?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Female sample adults 18+ who have not already indicated they have had a hysterectomy
SkipInstructions: <1,2,R,D> [goto HPV Questions]
Question ID NAF.221
Variable Name HPVHRD
Universe-text Sample adults LT 65
Question Text Have you ever heard of HPV? HPV stands for human papillomavirus.
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1> goto HPVCAUS
<2,R,D> if SEX=1
goto SHHPVHRD
elseif SEX=2
goto HPVHAD
Question ID NAF.222
Variable Name HPVCAUS
Universe-text Sample adults LT 65 who have ever heard of HPV
Question Text These next questions are about HPV. Your best guess is fine.
Do you think HPV can cause cervical cancer?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,R,D> goto HPVSEXCN
Question ID NAF.223
Variable Name HPVSEXCN
Universe-text Sample adults LT 65 who have ever heard of HPV
Question Text Do you think you can get HPV through sexual contact?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,R,D> goto HPVTRET
Question ID NAF.224
Variable Name HPVTRET
Universe-text Sample adults LT 65 who have ever heard of HPV
Question Text Do you think HPV can go away on its own without treatment?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Skip Instructions <1,2,R,D> if SEX=2
goto HPVHAD
elseif SEX=1
goto SHHPVHRD
Question ID NAF.224.010
Variable Name HPVHAD
Universe-text Female sample adults 18-64
Question Text Have you ever been told by a doctor or other health professional that you had HPV?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,R,D> goto SHHPVHRD
Question ID NAF.225
Variable Name SHHPVHRD
Universe-text Sample adults age 18-64
Question Text A vaccine to prevent HPV infection is available and is called the HPV shot, cervical cancer vaccine, or
GARDASIL®. Before this survey, have you ever heard of the HPV shot or cervical cancer vaccine?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Skip Instructions <1,2,R,D> if SEX=2
goto SHTHPV
elseif SEX=1 and AGE ge 40
goto PSAHAD
elseif SEX=1 and AGE=18-39
goto next section
Question ID NAF.226
Variable Name SHTHPV
Universe-text Female sample adults age 18-64
Question Text Have you ever received the HPV shot or cervical cancer vaccine?
Answer Codes 1. Yes
2. No
3. Doctor refused when asked
Refused
Don't know
Question Type Yes/No
Skip Instructions <1> goto SHHPVDOS
<2,3,R,D> goto HPVINT
Question ID NAF.227
Variable Name SHHPVDOS
Universe-text Female sample adults age 18-64 who have had a HPV shot
Question Text How many HPV shots did you receive?
*Enter ‘96’ for all shots.
Answer Codes Integer
Skip Instructions <1-50,96,R,D> if AGE ge 30
goto MAMHAD
elseif AGE=18-29
goto next section
Question ID NAF.228
Variable Name HPVINT
Universe-text Female sample adults age 18+ who have never had a HPV shot or Ref/DK this information
Question Text Would you be interested in getting the HPV vaccine?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1> goto HPVCOST
<2,R,D> goto HPVNOT
Question ID NAF.229
Variable Name HPVNOT
Universe-text Female sample adults age 18+ who are not interested in getting the HPV vaccine or who Ref/DK this
information
Question Text What is the MAIN reason you would NOT want to get the vaccine?
Answer Codes 1. Does not need vaccine
2. Not sexually active
3. Too expensive
4. Too old for vaccine
5. Doctor didn't recommend it
6. Worried about safety of vaccine
7. Don't know where to get vaccine
8. My spouse/family member is against it
9. Don't know enough about vaccine
10. Already have HPV
11. Other
Refused
Don't know
Skip Instructions <1,2,4-11,R,D> if AGE ge 30
goto MAMHAD
elseif AGE=18-29
goto next section
<3> goto HPVLOCST
Question ID NAF.229.010
Variable Name HPVCOST
Universe-text Female sample adults age 18+ who are interested in getting the HPV vaccine
Question Text The cost of the vaccine may be about $360-$500. Would you get the HPV vaccine if you had to pay this
amount?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,R,D> if AGE ge 30
goto MAMHAD
elseif AGE=18-29
goto next section
<2> goto HPVLOCST
Question ID NAF.229.020
Variable Name HPVLOCST
Universe-text Female sample adults age 18+ who would not pay $360-500 for the HPV vaccine or for whom the main reason not to get the vaccine was because it was too expensive
Question Text If you could get the HPV vaccine free or at a much lower cost, would you get it?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,R,D> if AGE ge 30
goto MAMHAD
elseif AGE=18-29
goto next section
Question ID: NAF.230_00.000 Instrument Variable Name: MAMHAD
QuestionText: Have you EVER HAD a mammogram?
*Read if necessary.
A mammogram is an x-ray taken only of the breast by a machine that presses against the breast.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Female sample adults age 30+
SkipInstructions: <1> [goto MAMAGE] <2> [goto MAMNOT] <R,D> [goto HRT Questions if 40; else goto next section]
Question ID: NAF.250_00.000 Instrument Variable Name: MAM6YR
QuestionText: How many mammograms have you had in the LAST 6 YEARS?
*Enter '0' for none.
*Enter '95' for 95 or more mammograms.
00 None
01-94 1-94
95 95+
97 Refused
99 Don't know
UniverseText: Female sample adults 30+ who have ever had a mammogram
SkipInstructions: <0-95,R,D> [goto RMAM1_MT]
Question ID: NAF.260_01.000 Instrument Variable Name: RMAM1_MT
QuestionText: 1 of 2
The next few questions are about your recent mammograms. When did you have your MOST RECENT mammogram?
*Enter month of last mammogram.
*Enter '96' to go to number and time period format.
01 January
02 February
03 March
04 April
05 May
06 June
07 July
08 August
09 September
10 October
11 November
12 December
96 Time period format
97 Refused
99 Don't know
UniverseText: Female sample adults 30+ who have ever had a mammogram
SkipInstructions: <1-12,D> [goto RMAM1_YR] <R> store "R' in RMAM1_YR [goto RMAM2] <96> store "96" in RMAM1_YR [goto RMAM1N]
Question ID: NAF.260_02.000 Instrument Variable Name: RMAM1_YR
QuestionText: 2 of 2
*Enter year of last mammogram.
1880-2006 1880-2006
9996 Time period format
9997 Refused
9999 Don't know
UniverseText: Female sample adults age 30+ who answered month of last mammogram or didn't know month of last mammogram
SkipInstructions: <valid year> if RMAM1_MT=1-12 [goto MAMWHER]; else if RMAM1_MT=D [goto RMAM2] <R,D> [goto RMAM2] IF RMAM1_MT and RMAM1_YR = a future date [goto ERR1_RMAM1_YR] IF RMAM1_MT and RMAM1_YR = a date prior to birth date [goto ERR2_RMAM1_YR]
Question ID: NAF.270_01.000 Instrument Variable Name: RMAM1N
QuestionText: 1 of 2
When did you have your MOST RECENT mammogram?
*Enter number for time since last mammogram.
*Enter '95' for 95 or more.
01-94 1-94
95 95+
97 Refused
99 Don't know
UniverseText: Female sample adults 30+ who selected number and time period format for most recent mammogram from the initial month screen
SkipInstructions: <1-95> [goto RMAM1T] <R,D> store "R,D" in RMAM1T [goto RMAM2]
Question ID: NAF.270_02.000 Instrument Variable Name: RMAM1T
QuestionText: 2 of 2
*Enter time period for time since most recent mammogram.
1 Days ago
2 Weeks ago
3 Months ago
4 Years ago
7 Refused
9 Don't know
UniverseText: Female sample adults 30+ who answered 1-95 for number part of this 2 part question
SkipInstructions: <1-3> [goto MAMWHER]; <4> if RMAM1N and RMAM1T GT 5 years from system date, fill "5" in RMAM2 goto MAMWHER]; else [goto RMAM2] <R,D> [goto RMAM2] IF [RMAM1N = Number greater than person years old and RMAM1T= 4]] goto ERR1_RMAM1T
Question ID: NAF.275_00.000 Instrument Variable Name: RMAM2
QuestionText: (book) CAN3
Was it:
*Read answer categories.
1 A year ago or less
2 More than 1 year but not more than 2 years
3 More than 2 years but not more than 3 years
4 More than 3 years but not more than 5 years
5 Over 5 years ago
7 Refused
9 Don't know
UniverseText: Female sample adults 30+ who failed to give a complete date in either the month or year format or failed to give a complete date in the number and time period format, or entered years ago in the time period format (excluding those whose last mammogram was over 5 years ago)
SkipInstructions: <1-5,R,D> [goto MAMWHER]
Question ID: NAF.310_00.000 Instrument Variable Name: MAMREAS
QuestionText: What was the MAIN reason you had this mammogram -- was it part of a routine exam, because of a problem, or some other reason?
1 Part of a routine exam
2 Because of a problem
3 Other reason
7 Refused
9 Don't know
UniverseText: Female sample adults 30+ who have ever had a mammogram
SkipInstructions: <1-3,R,D> [goto MDRECMAM]
Question ID: NAF.370_00.000 Instrument Variable Name: MDRECMAM
QuestionText: Fill1 (IF MAMHAD=1 and most recent screening exam LE 2 years from system date)
[Was your most recent mammogram RECOMMENDED by a doctor or other health professional?]
Else (IF MAMHAD=2, or MAMHAD GT 2 years from system date or RMAM2=R,D)
[In the PAST 12 MONTHS, has a doctor or other health professional RECOMMENDED that you have a mammogram?]
1 Yes
2 No
3 Did not see a doctor in the past 12 months
7 Refused
9 Don't know
UniverseText: Female sample adults 30+ who have a doctor and had a mammogram in the past 2 years
SkipInstructions: <1,2,3,R,D> [goto MAMREC]
Question ID: NAF.371_00.000 Instrument Variable Name: MAMINFO
QuestionText: Have you ever read or been given conflicting information about whether you should get a mammogram?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Female sample adults 30+
SkipInstructions: <1>-[goto MAMDELAY] <2,R,D> [goto HRTEVER if age 40+; else goto next section]
Question ID: NAF.372_00.000 Instrument Variable Name: MAMDELAY
QuestionText: Did this conflicting information cause you to delay or not get a mammogram in the past year?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Female sample adults 30+ who have read or been given conflicting information on mammograms
SkipInstructions: <12,R,D> [goto HRTEVER if age 40+; else goto next section]
Question ID: NAF.380_00.000 Instrument Variable Name: HRTEVER
QuestionText: Have you EVER taken hormone replacement therapy or HRT for menopause?
*Read if necessary: This is a pill, patch or treatment that gives women more of the female hormone, estrogen.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Female sample adults 40+
SkipInstructions: <1> [goto HRTNOW <2,R,D> [goto CREHAD]
Question ID: NAF.382_00.000 Instrument Variable Name: HRTNOW
QuestionText: Are you currently taking hormone replacement therapy or HRT for menopause?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Female sample adults 40+ who have ever taken hormone replacement therapy
SkipInstructions: <1,2,R,D> [goto HRTLNG]
Question ID: NAF.385_00.000 Instrument Variable Name: HRTLNG
QuestionText: Some women go on and off hormone replacement therapy. How long have you taken HRT altogether?
*Read if necessary: Please total all the time you have taken HRT.
1 A year or less
2 More than 1 up to 2 years
3 More than 2 up to 4 years
4 More than 4 up to 8 years
5 More than 8 years
7 Refused
9 Don't know
UniverseText: Female sample adults 40+ who have ever taken hormone replacement therapy
SkipInstructions: <1,2,R,D> [goto CREHAD]
Question ID: NAF.430_00.000 Instrument Variable Name: PSAHAD
QuestionText: The following questions are about men's health.
Have you EVER HAD a PSA test?
*Read if necessary. A PSA test is a blood test to detect prostate cancer. It is also called a prostate-specific antigen test.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Male sample adults 40+
SkipInstructions: <1> [goto PSAAGE1] <2,R,D> [goto CREHAD]
Question ID: NAF.460_01.000 Instrument Variable Name: RPSA1_MT
QuestionText: 1 of 2
The next few questions are about your recent PSA tests. When did you have your MOST RECENT PSA test?
*Enter month of last PSA test.
*Enter '96' to go to number and time period format.
01 January
02 February
03 March
04 April
05 May
06 June
07 July
08 August
09 September
10 October
11 November
12 December
96 Time period format
97 Refused
99 Don't know
UniverseText: Male sample adults 40+ who have ever had a PSA test
SkipInstructions: <1-12,D> [goto RPSA1_YR] <R> store "R' in RPSA1_YR [goto RPSA2] <96> store "96" in RPSA1_YR [goto
RPSA1N]
Question ID: NAF.460_02.000 Instrument Variable Name: RPSA1_YR
QuestionText: 2 of 2
*Enter year of last PSA test.
1880-2006 1880-2006
9996 Time period format
9997 Refused
9999 Don't know
UniverseText: Male sample adults 40+ who answered month of last PSA test or didn't know month of last PSA test
SkipInstructions: <valid year> if RPSA1_MT=1-12 [goto PSAREAS]; else if RPSA1_MT=D [goto RPSA2] <R,D> goto RPSA2] IF RPSA1_MT and RPSA1_YR = a future date [goto ERR1_RPSA1_YR]
Question ID: NAF.470_01.000 Instrument Variable Name: RPSA1N
QuestionText: 1 of 2
When did you have your MOST RECENT PSA test?
*Enter number for time since last PSA test.
*Enter '95' for 95 or more.
01-94 1-94
95 95+
97 Refused
99 Don't know
UniverseText: Male sample adults 40+ who selected number and time period format for most recent PSA test from the initial month screen
SkipInstructions: <1-95> [goto RPSA1T] <R,D> store "R,D" in RPSA1T [goto RPSA2]
Question ID: NAF.470_02.000 Instrument Variable Name: RPSA1T
QuestionText: 2 of 2
*Enter time period for time since most recent PSA test.
1 Days ago
2 Weeks ago
3 Months ago
4 Years ago
7 Refused
9 Don't know
UniverseText: Male sample adults 40+ who answered 1-95 for number part of this 2 part question
SkipInstructions: <1-3> [goto PSAREAS]; <4> if RPSA1N and RPSA1T GT 5 years from system date, fill "5" in RPSA2 [goto PSAREAS]; else [goto RPSA2] <R,D> [goto RPSA2] IF [RPSA1N = Number greater than person years old and RPSA1T= 4]] goto ERR1_RPSA1T
Question ID: NAF.475_00.000 Instrument Variable Name: RPSA2
QuestionText: (book) CAN3
Was it:
*Read answer categories.
1 A year ago or less
2 More than 1 year but not more than 2 years
3 More than 2 years but not more than 3 years
4 More than 3 years but not more than 5 years
5 Over 5 years ago
7 Refused
9 Don't know
UniverseText: Male sample adults 40+ who failed to give a complete date in either the month or year format or failed to give a complete date in the number and time period format, or entered years ago in the time period format (excluding those whose last PSA test was over 5 years ago)
SkipInstructions: <1-5,R,D> [goto PSAREAS]
Question ID: NAF.480_00.000 Instrument Variable Name: PSAREAS
QuestionText: What was the MAIN reason you had this PSA test - was it part of a routine exam, because of a problem, or some other reason?
1 Part of a routine exam
2 Because of a problem
3 Other reason
7 Refused
9 Don't know
UniverseText: Male sample adults 40+ who have had a PSA test
SkipInstructions: <1-3,R,D> [goto MDRECPSA]
Question ID: NAF.485_00.000 Instrument Variable Name: MDRECPSA
QuestionText: Fill1 (IF PSAHAD=1 and most recent screening exam LE 1 years from system date)
[Was your most recent PSA test RECOMMENDED by a doctor or other health professional?]
Else (IF PSAHAD=2, or PSAHAD GT 1 years from system date or PSAM2=R,D)
[In the PAST 12 MONTHS, has a doctor or other health professional that you have a PSA test?]
1 Yes
2 No
3 Did not see a doctor in the past 12 months
7 Refused
9 Don't know
UniverseText: Male sample adults 40+ who have a doctor and had a PSA test in the past
SkipInstructions: <1,2,3,R,D> [goto MAMREC]
Question ID: NAF.540_00.000 Instrument Variable Name: CREHAD
QuestionText: Have you EVER HAD a sigmoidoscopy, colonoscopy, or proctoscopy? These are exams in which a health care professional inserts a tube into the rectum to look for signs of cancer or other problems.
*Read if necessary.
A proctoscopy is an older exam that used a rigid tube.
*Pronunciation guide: sigmoid-OS-copy, colon-OS-copy, proc-TOS-copy.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 40+
SkipInstructions: <1> [goto CRE10YR] <2> [goto CRENOT] <R,D> [goto HFOBHAD]
Question ID: NAF.560_01.000 Instrument Variable Name: RCRE1_MT
QuestionText: 1 of 2
When did you have your MOST RECENT exam?
*Enter month of last exam.
*Enter '96' to go to number and time period format.
01 January
02 February
03 March
04 April
05 May
06 June
07 July
08 August
09 September
10 October
11 November
12 December
96 Time period format
97 Refused
99 Don't know
UniverseText: Sample adults 40+ who have ever had a colorectal exam
SkipInstructions: <1-12,D> [goto RCRE1_YR] <R> store "R' in RCRE1_YR [goto RCRE2] <96> store "96" in RCRE1_YR [goto RCRE1N]
Question ID: NAF.560_02.000 Instrument Variable Name: RCRE1_YR
QuestionText: 2 of 2
*Enter year of last colorectal exam.
1880-2006 1880-2006
9996 Time period format
9997 Refused
9999 Don't know
UniverseText: Sample adults age 40+ who answered month of last colorectal exam or didn't know month of last colorectal exam
SkipInstructions: <valid year> if RCRE1_MT=1-12 [goto CRENAM]; else if RCRE1_MT=D [goto RCRE2] <R,D> [goto RCRE2] IF RCRE1_MT and RCRE1_YR = a future date [goto ERR1_RCRE1_YR]
Question ID: NAF.570_01.000 Instrument Variable Name: RCRE1N
QuestionText: 1 of 2
When did you have your MOST RECENT exam?
*Enter number for time since last exam.
*Enter '95' for 95 or more.
01-94 1-94
95 95+
97 Refused
99 Don't know
UniverseText: Sample adults 40+ who selected number and time period format for most recent colorectal exam from the initial month screen
SkipInstructions: <1-95> [goto RCRE1T] <R,D> store "R,D" in RCRE1T [goto RCRE2]
Question ID: NAF.570_02.000 Instrument Variable Name: RCRE1T
QuestionText: 2 of 2
*Enter time period for time since most recent exam.
1 Days ago
2 Weeks ago
3 Months ago
4 Years ago
7 Refused
9 Don't know
UniverseText: Sample adults 40+ who answered 1-95 for number part of this 2 part question
SkipInstructions: <1-3> [goto CRENAM]; <4> if RCRE1N and RCRE1T GT 5 years from system date but LE 10 years from system data, fill "5" in RCRE2; if RCRE1N and RCRE1T GT 10 years from system date, fill "6" in RCRE2 [goto CRENAM]; else [goto RCRE2] <R,D> [goto RCRE2] IF [RCRE1N = Number greater than person years old and RCRE1T= 4]] goto ERR1_RCRE1T
Question ID: NAF.575_00.000 Instrument Variable Name: RCRE2
QuestionText:
Was it: *Read answer categories.
1 A year ago or less
2 More than 1 year but not more than 2 years
3 More than 2 years but not more than 3 years
4 More than 3 years but not more than 5 years
5 More than 5 years but not more than 10 years
6 Over 10 years ago
7 Refused
9 Don't know
UniverseText: Sample adults 40+ who failed to give a complete date in either the month or year format or failed to give a complete date in the number and time period format, or entered years ago in the time period format (excluding those whose last colorectal exam was over 5 years ago)
SkipInstructions: <1-6,R,D> [goto CRENAM]
Question ID: NAF.580_00.000 Instrument Variable Name: CRENAM
QuestionText: For a SIGMOIDOSCOPY, a flexible tube is inserted into the rectum to look for problems. A COLONOSCOPY is SIMILAR, but uses a longer tube, and you are usually given medication through a needle in your arm to make you sleepy, and told to have someone else drive you home. A PROCTOSCOPY is an older exam that used a rigid tube. Was this MOST RECENT exam a sigmoidoscopy, colonoscopy, proctoscopy or something else?
Pronunciation guide: sigmoid-OS-copy, colon-OS-copy, proc-TOS-copy.
1 Sigmoidoscopy
2 Colonoscopy
3 Proctoscopy
4 Something else
7 Refused
9 Don't know
UniverseText: Sample adults 40+ who have had a colorectal exam
SkipInstructions: <1-4,R,D> [goto CREREAS]
Question ID: NAF.590_00.000 Instrument Variable Name: CREREAS
QuestionText: What was the MAIN reason you had this exam - was it part of a routine exam, because of a problem, or some other reason?
1 Part of a routine exam
2 Because of a problem
3 Other reason
7 Refused
9 Don't know
UniverseText: Sample adults 40+ who have had a colorectal exam
SkipInstructions: <1-3,R,D> if CREHAD=2 or last exam was more than 10 years ago [goto CRENOT] else [goto CREREC]
Question ID: NAF.610_00.000 Instrument Variable Name: CREREC
QuestionText: Fill1 (IF CREHAD=1 and most recent screening exam LE 10 years from system date)
Was your most recent test RECOMMENDED by a doctor or other health professional?
Else (IF CREHAD=2, or CREHAD GT 10 years from system date or RCRE2=R,D)
In the PAST 12 MONTHS, has a doctor or other health professional RECOMMENDED that you have a sigmoidoscopy or colonoscopy?
1 Yes
2 No
3 Did not see a doctor in the past 12 months
7 Refused
9 Don't know
UniverseText: Sample adults 40+ who have a doctor or had a colorectal exam in the past 10 years or refused or didn't know date of most recent colorectal exam
SkipInstructions: <1,2,R,D> [goto HFOBHAD]
Question ID: NAF.620_00.000 Instrument Variable Name: HFOBHAD
QuestionText: The following questions are about the blood stool or occult blood test, a test to determine whether you have blood in your stool or bowel movement. The blood stool test can be done at home using a kit. You use a stick or brush to obtain a small amount of stool at home and send it back to the doctor or lab.
Have you EVER HAD a blood stool test, using a HOME test kit?
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample adults 40+
SkipInstructions: <1> [goto HFOB3YR] <2> [goto HFOBNOT] <R,D> [goto FOBHAD]
Question ID: NAF.640_01.000 Instrument Variable Name: RHFO1_MT
QuestionText: 1 of 2
When did you have your MOST RECENT blood stool test using a kit at home?
*Enter month of last test.
*Enter '96' to go to number and time period format.
01 January
02 February
03 March
04 April
05 May
06 June
07 July
08 August
09 September
10 October
11 November
12 December
96 Time period format
97 Refused
99 Don't know
UniverseText: Sample adults 40+ who have ever had a home blood stool test
SkipInstructions: <1-12,D> [goto RHFO1_YR] <R> store "R' in RHFO1_YR [goto RHFO2] <96> store "96" in RHFO1_YR [goto RHFO1N]
Question ID: NAF.640_02.000 Instrument Variable Name: RHFO1_YR
QuestionText: 2 of 2
*Enter year of last home blood stool test.
1880-2006 1880-2006
9996 Time period format
9997 Refused
9999 Don't know
UniverseText: Sample adults age 40+ who answered month of last home blood stool test or didn't know month of last test
SkipInstructions: <valid year> if RHFO1_MT=1-12 [goto HFOBREAS]; else if RHFO1_MT=D [goto RHFO2] <R,D> [goto
RHFO2] IF RHFO1_MT and RHFO1_YR = a future date [goto ERR1_RHFO1_YR]
IF RHFO1_MT and RHFO1_YR = a date prior to birth date [goto ERR2_RHFO1_YR]
Question ID: NAF.650_01.000 Instrument Variable Name: RHFO1N
QuestionText: 1 of 2
When did you have your MOST RECENT blood stool test using a kit at home?
*Enter number for time since last test.
*Enter '95' for 95 or more.
01-94 1-94
95 95+
97 Refused
99 Don't know
UniverseText: Sample adults 40+ who selected number and time period format for most recent home blood stool test from the initial month screen
SkipInstructions: <1-95> [goto RHFO1T] <R,D> store "R,D" in RHFO1T [goto RHFO2]
Question ID: NAF.650_02.000 Instrument Variable Name: RHFO1T
QuestionText: 2 of 2
*Enter time period for time since most recent home blood stool test.
1 Days ago
2 Weeks ago
3 Months ago
4 Years ago
7 Refused
9 Don't know
UniverseText: Sample adults 40+ who answered 1-95 for number part of this 2 part question
SkipInstructions: <1-3> [goto HFOBREAS]; <4> if RHFO1N and RHFO1T GT 5 years from system date but LE 10 years from system data, fill "5" in RHFO2; if RHFO1N and RHFO1T GT 10 years from system date, fill "6" in RHFO2 [goto HFOBREAS]; else [goto RHFO2] <R,D> [goto RHFO2] IF [RHFO1N = Number greater than person years old and RHFO1T= 4]] goto ERR1_RHFO1T
Question ID: NAF.655_00.000 Instrument Variable Name: RHFO2
QuestionText:
Was it:
*Read answer categories.
1 A year ago or less
2 More than 1 year but not more than 2 years
3 More than 2 years but not more than 3 years
4 More than 3 years but not more than 5 years
5 More than 5 years but not more than 10 years
6 Over 10 years ago
7 Refused
9 Don't know
UniverseText: Sample adults 40+ who failed to give a complete date in either the month or year format or failed to give a complete date in the number and time period format, or entered years ago in the time period format (excluding those whose last home blood stool test was over 5 years ago)
SkipInstructions: <1-6,R,D> [goto MDHFOB]
Question ID: NAF.700_00.000 Instrument Variable Name: MDHFOB
QuestionText: IFill1 (IF HFOBHAD=1 and most recent screening exam LE 1 year from system date)
Was your most recent HOME blood stool test RECOMMENDED by a doctor or other health professional?
Else (IF HFOBHAD=2, or HFOBHAD GT 1 year from system date or RHFO2=R,D)
In the PAST 12 MONTHS, has a doctor or other health professional RECOMMENDED that you have a HOME blood stool
test?
1 Yes
2 No
3 Did not see a doctor in the past 12 months
7 Refused
9 Don't know
UniverseText: Sample adults 40+ who have a doctor and had a home blood stool test in the past 10 years
SkipInstructions: <1-3,R,D> [goto next section]
Child Use of Indoor Sun Tanning Devices
Question ID: CAU.350_00.010 Instrument Variable Name: CSNLAMP
QuestionText: During the PAST 12 MONTHS, has [fill1: SC name] used any of the following indoor tanning devices---a sunlamp, sunbed, or tanning booth EVEN ONE TIME? Do NOT include a spray-on tan.
1 Yes
2 No
7 Refused
9 Don't know
UniverseText: Sample children 14-17
SkipInstructions: <1> [goto CSNNUM] <2,R,D> [goto next section]
Question ID: CAU.350_00.020 Instrument Variable Name: CSNNUM
QuestionText: During the PAST 12 MONTHS, how many times has [fill1: SC name] used the following indoor tanning devices-- a sunlamp, sunbed, or tanning booth? Do NOT include times [fill1: SC name] has gotten a spray-on tan.
001-365 1-365 times
997 Refused
999 Don't know
UniverseText: Sample children 14-17 who have used a indoor tanning device in the past 12 months
SkipInstructions: <1-99,R,D> [goto next section]; {if <100-365> goto ERR1_CSNNUM}
Topical Module on Dizziness, Balance Problems, and Falls
Questions on Health Conditions.
Have you ever had …
Please say yes or no to each.
Yes No
(1) Low blood pressure
(2) Chronic fatigue syndrome
(3) Low thyroid function or hypothyroidism
(4) Chronic infection
(5) Depression
(6) Generalized anxiety
(7) Panic disorder
(8) Epilepsy or seizures
(9) Cerebral Palsy
(10) Multiple Sclerosis
(11) Muscular Dystrophy
(12) Spinal cord or neck injury
(13) Injury to head or brain
(14) Movement disorders such as Parkinson’s disease or Amyotrophic Lateral Sclerosis (ALS) or Lou Gehrig’s disease
(15) Migraine headaches
{Help Screen/FR instruction: migraine is a recurring, moderate to severe headache lasting 4 hours or longer and characterized by throbbing head pain, often greater on one side; may be preceded by a warning (aura) and accompanied by nausea, vomiting, and sensitivity to light and sound}
(16) Regular headaches, other than migraine
You just mentioned that you were told by a doctor or other health professional that you had some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia (fy-bro-my-AL-jee-ah). Which of these were you told you had?
*Enter all that apply, separate with commas.
(1) Arthritis
(2) Rheumatoid arthritis
(3) Gout
(4) Lupus
(5) Fibromyalgia
(6) Other joint condition
Questions on Tinnitus (repeated from the 2007 supplement)
Question ID: ACN.412_00.010 Instrument Variable Name: HRTIN
QuestionText: IN THE PAST 12 MONTHS, have you been bothered by ringing, roaring, or buzzing in your ears or head that lasts for 5 minutes or more?
*Read if necessary.
Tinnitus (TIN-ih-tus) is the medical term for ringing, roaring or buzzing in the ears or head.
1 Yes
2 No (goto Balance Question #1)
7 Refused
Question ID: ACN.412_00.020 Instrument Variable Name: HRTINLNG Sample Adult
QuestionText: How long have you been bothered by this ringing, roaring, or buzzing in your ears or head?
01 Less than 3 months
02 3 to 11 months
03 1 to 2 years
04 3 to 4 years
05 5 to 9 years
06 10 to 14 years
07 15 years or more
97 Refused
99 Don't know
Question ID: ACN.412_00.030 Instrument Variable Name: HRTINOFT Sample Adult
QuestionText: IN THE PAST 12 MONTHS, how often have you had this ringing, roaring, or buzzing in your ears or head? Would you say...
*Read categories below.
1 Almost always
2 At least once a day
3 At least once a week
4 At least once a month
5 Less frequently than once a month
7 Refused
9 Don't know
Question ID: ACN.412_00.040 Instrument Variable Name: HRTINMUS Sample Adult
QuestionText: Are you bothered by ringing, roaring, or buzzing in your ears or head ONLY after listening to loud sounds or loud music?
1 Yes
2 No
7 Refused
9 Don't know
Question ID: ACN.412_00.050 Instrument Variable Name: HRTINSLP Sample Adult
QuestionText: Are you bothered by ringing, roaring, or buzzing in your ears or head when going to sleep?
1 Yes
2 No
7 Refused
9 Don't know
Question ID: ACN.412_00.060 Instrument Variable Name: HRTNPROB Sample Adult
QuestionText: How much of a problem is this ringing, roaring, or buzzing in your ears or head? Would you say it is...
*Read categories below.
1 No problem
2 A small problem
3 A moderate problem
4 A big problem
5 A very big problem
7 Refused
9 Don't know
Questions on Dizziness, Balance Problems, and Falls
Do you use any of the following aids to help you get around?
Please say yes or no to each.
Yes No
(1) A cane
(2) Crutches
(3) A walker
(4) A wheelchair
(5) A scooter
(6) A brace………………………………. (Go to #2)
(7) Artificial or replacement limbs or joints…………. (Go to #3)
(8) Medically prescribed shoes or orthotics
Answers 1-6, 9, Goto #4
2. What type of brace do you use?
Mark all that apply.
neck
arm
wrist
back
knee
leg
ankle
3. What part or parts is artificial?
Mark all that apply.
arm
leg
hip
knee
other
4. During the past 12 months, have you had a problem with dizziness or balance? Do not include times when drinking alcohol.
Yes……………………………………… 1
No……………………………………….. 2
REFUSED………………………………. 3
DON’T KNOW…………………………. 4
5. During the past 12 months, have you had any of the following problems? Do not include times when drinking alcohol.
FR instruction: If respondent is unable to do this activity for reasons OTHER than dizziness or balance, enter “2”.
Please say yes or no to each.
Yes No
(1) Muscle weakness that affects walking
(2) Severe fatigue
(3) Drifting to the side when trying to walk straight
(4) Walking through a doorway without bumping into one side
(5) Difficulty walking in the dark
(6) Difficulty walking on uneven ground or surfaces
(7) Difficulty walking with bi- or trifocal or progressive lenses
(8) Blurred or fuzzy vision when moving your head
(9) Fear of heights
(10) Fear of large open spaces
(11) Difficulty walking up a flight of stairs
(12) Difficulty walking down a flight of stairs
(13) Difficulty riding an escalator or moving walkway
(14) Difficulty driving through tunnels
(15) Difficulty driving over bridges
If yes to #4 or #5 (any), goto # 6, otherwise skip to #29 ۞
This next question is about symptoms of dizziness or balance problems. Please tell me if you have had any of these in the past 12 months.
Read if necessary: Do not include times when drinking alcohol.
Please say yes or no to each.
Yes No
(1) A spinning or vertigo sensation, a rocking of yourself or your surroundings
(2) A floating, spacey, or tilting sensation
(3) Feeling lightheaded, without a sense of motion
(4) Feeling as if you are going to pass out or faint
(5) Blurring of your vision when you move your head
(6) Feeling off-balance or unsteady
Help Screen or Field Representative (FR) / Interviewer instruction: {“vertigo” is an illusion of rotation or other motion, as if riding a “carousel”}
If respondents say YES in error to a symptom before hearing the one that best fits them, our interviewers are trained to back up and correct the answer
If “NO” to each of the above six symptoms AND “NO” to question 4, SKIP to Question #29 ۞
If “NO to each of the above 6 symptoms and “YES” to question 4, ask questions 8-30 using the fill {dizziness or balance problem}
If “YES’ to more than one in question 6 goto question #7, else go to question #8
7. During the past 12 months, which ONE of these feelings of dizziness or balance problems {fill options mentioned in #6} bothered you the most?
Options mentioned in question 6 above
FILL OPTIONS: (1) feeling a sense of spinning
(2) floating or spacey feeling
(3) feeling lightheaded
(4) feeling like you are about to pass out
(5) blurred vision
(6) unsteadiness
Ask questions #8 – #30 for most bothersome [or only] feeling.
8. About how old were you when {fill most bothersome [or only] feeling} first happened?
If UNSURE, estimate as best you can.
________________ {1 to 100} years
DON’T KNOW
REFUSED
9. Altogether, about how long have you had the {fill most bothersome [or only] feeling}?
Less than 3 months……………………….. 1
3 months to less than 12 months…………. 2
12 months to less than 3 years.......….. 3
3 years to less than 5 years……………….. 4
5 years to less than 10 years......…….. 5
10 years to less than 15 years.............. 6
15 years or more………………………….. 7
REFUSED………………………………. 8
DON’T KNOW…………………………. 9
10. During the past 12 months, about how often have you had the {fill most bothersome [or only] feeling}?
Almost always……………………………. 1 (if unsteadiness, Go to #15)
3 or more times a day…………………….. 2
Once or twice a day………………………. 3
Several times a week.................................. 4
Once a week……...………………….. 5
Several times a month ............................. 6
Once a month………………………....... 7
Less than once a month….........…….. 8
REFUSED…………………………………
DON’T KNOW……………………………
How long does each spell or bout of {fill most bothersome [or only] feeling} usually last? Do not include nausea or vomiting.
Help Screen or Field Representative (FR) / Interviewer instruction: {Only count the duration of individual spells or bouts, not a whole cluster of them, and don’t include other related symptoms, such as nausea or vomiting.}
Momentary, or less than one minute……… 1
One minute to less than 20 minutes………. 2
20 minutes to less than 4 hours…………… 3
4 hours to less than 24 hours……………… 4
1 day to less than 14 days…………………. 5
2 weeks to less than 3 months…………….. 6
3 months or longer………………………… 7
REFUSED………………………………… 8
DON’T KNOW…………………………… 9
Do any of the following usually cause or trigger your {fill most bothersome [or only] feeling}?
FR instruction: If respondent is unable to do this activity for reasons OTHER than dizziness or balance, enter “2”.
Please say yes or no to each.
Yes No
(1) Turning your head side to side
(2) Looking up or down
(3) Rolling over in bed
(4) Getting up after sitting or lying down
(5) Standing or being on your feet for a long time
(6) Riding in a car, bus, airplane, boat, or train
(7) Walking down a grocery store aisle
(8) Hearing loud sounds
(9) Blowing your nose
(10) Prescription medicine or drugs
(11) Over the counter medicine such as aspirin, Tylenol, or Advil
(12) Eating too much salt
(13) Certain foods or drink, such as chocolate, coffee, or alcohol
13. Do any of the following problems happen around the same time as your {fill most bothersome [or only] feeling}?
Please say yes or no to each.
Yes No
(1) Nausea or vomiting
(2) Motion sickness or discomfort
(3) Difficulty rolling over in bed
(4) Hearing loss in one or both ears
(5) Tinnitus
(6) Ear ache or pain
(7) Fullness or pressure in the ear without pain
(8) Sinus congestion
(9) Migraine headache
(10) Headache, other than migraine
(11) Neck pain
(12) Blurred or double vision
(13) Loss of vision or blacking out
(14) Sweats or sweating
(15) Shortness of breath or trouble breathing
(16) Difficulty speaking or slurred speech
(17) Difficulty swallowing
(18) Numbness in your face, hands, or feet
(19) Weak or clumsy arms or legs
(20) High level of stress
(21) Anxiety
(22) Depression
Ask #14 for every yes response in #13
14. Do you have [fill response from #13 above] only when you have the {fill most bothersome [or only] feeling}, or do you have it regardless?
(1) Around the same time [just before, during, or following]
(2) I have this regardless
15. Have you ever gone to a hospital emergency room about your {fill most bothersome [or only] feeling}?
Yes……………………………………… 1 (Go to #16)
No……………………………………….. 2 (Go to #17)
REFUSED………………………………. 3
DON’T KNOW…………………………. 4
16. During the past 5 years, about how many times have you gone to a hospital emergency room about your {fill most bothersome [or only] feeling}?
If UNSURE, estimate as best you can.
None/zero………………………………... 1
1 time……………………………………. 2
2 times…………………………………… 3
3-4 times………………………………… 4
5-9 times………………………………… 5
10-14 times……………………………… 6
15 or more times………………………... 7
REFUSED………………………………. 8
DON’T KNOW…………………………. 9
17. Have you EVER seen a doctor or other health professional, except for an emergency room physician, about your {fill most bothersome [or only] feeling}?
Yes……………………………………… 1 (Go to #18)
No……………………………………….. 2 (If No to #15, Go to #26; Else Go to #19)
REFUSED………………………………. 3
DON’T KNOW…………………………. 4
18. Which of the following types of doctors or health professionals have you seen about your {fill most bothersome [or only] feeling}?
Please say yes or no to each.
Yes No
(1) Family doctor or general practitioner
(2) Cardiologist or doctor of internal medicine
(3) Ear, nose, and throat doctor
(4) Neurologist
(5) Eye doctor, optometrist or ophthalmologist
(6) Dentist, orthodontist, or oral surgeon
(7) Gynecologist or OB/GYN
(8) Psychiatrist, psychologist, or social worker
(9) Chiropractor
(10) Osteopath or doctor of osteopathy
(11) Occupational therapist, physical therapist or rehabilitation specialist
(12) Nurse or nurse practitioner
(13) Nutritionist or dietitian
(14) Foot doctor
(15) Radiologist or technician for MRI, CAT scan or ultrasound
(16) Some other health professional
19. During the past 5 years, about how many times have you gone to a doctor or other health professional about your {fill most bothersome [or only] feeling}?
If UNSURE, estimate as best you can.
None……………………………………... 1
1 time……………………………………. 2
2 times…………………………………… 3
3-4 times………………………………… 4
5-9 times………………………………… 5
10-14 times……………………………… 6
15 or more times………………………... 7
REFUSED………………………………. 8
DON’T KNOW…………………………. 9
20. How long ago did you FIRST see a doctor or other health professional, including emergency room physicians, about your {fill most bothersome [or only] feeling}?
Less than 12 months …………..……… 1
12 months to less than 3 years…………. 2
3 years to less than 5 years.……………….. 3
5 years to less than 10 years ……………… 4
10 years to less than 15 years .…………….. 5
15 or more years ……………………. 6
REFUSED ………………………………. 7
DON’T KNOW ………………………….. 8
21. In total, about how many separate doctors, emergency room physicians, or other health professionals have you EVER seen concerning your {fill most bothersome [or only] feeling}?
If UNSURE, estimate as best you can.
1 ………………………………………… 1
2 ………………………………………… 2
3 to 4 …………………………………… 3
5 to 9 ……………………………………. 4
10 to 14 …………………………………. 5
15 or more………………………………. 6
REFUSED ………………………………. 7
DON’T KNOW ………………………….. 9
22. Do you feel that any of these doctors or other health professionals have helped your {fill most bothersome [or only] feeling}?
Yes……………………………………… 1 (Go to #23)
No……………………………………….. 2 (Go to #24)
REFUSED………………………………. 3
DON’T KNOW…………………………. 4
23. About how long was it between the first time you saw a doctor or other health professional about your {fill most bothersome [or only] feeling} until you began to be helped by treatments or advice you received?
Please tell me the number of days, weeks, months, or years.
__________ (number) days, or
__________ (number) weeks, or
__________ (number) months, or
__________ (number) years
24. Did any of the doctors or health care professionals tell you the cause or give you a diagnosis for your {fill most bothersome [or only] feeling}?
Yes……………………………………… 1 (Go to #25)
No……………………………………….. 2 (Go to #26)
REFUSED………………………………. 3
DON’T KNOW…………………………. 4
25. What did the doctor(s) or health care professional(s) tell you was the cause or causes of your {fill most bothersome [or only] feeling}?
Interviewer: Mark all that apply. Read list if necessary.
Antibiotics given through a needle or tube (I.V.)
Arthritis
Brain tumor
(4) Cogan's syndrome or Sjogren's syndrome
(5) Loose or dislodged crystals in your ear or BPPV (benign positional vertigo)
(6) Diabetes
(7) Head or neck trauma or concussion
(8) Heart disease
(9) Inner ear infection
(10) Ménière’s disease
(11) Migraine headaches
(12) Neurological or muscular conditions (such as M.S. or M.D.)
(13) Side effect of medicines or drugs
(14) Stroke
(15) TMJ or Temporal mandibular joint disorder
(16) Other health problem(s)
26. Have you ever taken or tried anything to treat your {fill most bothersome [or only] feeling} such as physical therapy, certain exercises, avoiding certain foods, taking medicines, surgery, or wearing magnets or wristbands?
Yes ……..……………………………….. 1 (Go to #27)
No …….…………………………………. 2 (Go to #28)
REFUSED …………..………………….. 3
DON’T KNOW …………………………. 4
27. What treatments have you tried?
Please say yes or no to each.
Yes No
(1) Exercises or physical therapy
(2) Head rolling maneuver by a doctor or therapist (Epley maneuver)
(3) Steroid injections into the ear
(4) Gentamicin injection into the ear
(5) Ear surgery
(6) Head or neck surgery
(7) Bed rest for several hours or days
(8) Psychiatric treatment
(9) Chiropractic treatment or manipulation
(10) Acupuncture
(11) Massage therapy
(12) T’ai Chi, Yoga, or Qi Gong
(13) Hypnosis
(14) Low salt diet
(15) Avoiding or cutting back on certain foods or drink such as chocolate, coffee, or alcohol
(16) Quitting or reducing use of tobacco or cigarettes
(17) Prescription medicine or drugs
(18) Over the counter medicine such as aspirin, Tylenol, or Advil
(19) Herbal remedy such as feverfew leaf, ginger, or gingko biloba
(20) Meniette™ device, air pressure pulses in ear
(21) Wearing acupressure wristband or Sea-band™
(22) Wearing magnets
(23) Mouth guard
28. During the past 12 months, has your {fill most bothersome [or only] feeling} gotten worse, stayed the same, improved somewhat, or improved greatly?
Gotten worse …………………………… 1
Stayed the same ………………………... 2
Improved somewhat …………………… 3
Improved greatly ……………………….. 4
REFUSED …………..………………….. 5
DON’T KNOW …………………………. 6
۞ 29. Do you now take any medicines on a regular basis for any health problems or conditions?
Yes ……..……………………………….. 1 (Go to #30 if have dizzi-ness or balance problem; otherwise Go to #37 ◘ )
No …….…………………………………. 2 (Go to #31 if have dizzi-ness or balance problem, otherwise go to #37 ◘ )
REFUSED …………..………………….. 3
DON’T KNOW …………………………. 4
30. Do any of your medicines cause your {fill most bothersome [or only] feeling} to get worse?
Yes …………………………………... 1
No …….....…………………………... 2
REFUSED …………..………………….. 4
DON’T KNOW …………………………. 5
Ask questions #31 – #37 for any DIZZINESS OR BALANCE problems.
31. Does/do your dizziness or balance problem(s) prevent you in any way from doing things you otherwise could do?
Yes …….……………………………….. 1 (Go to #32)
No ………………………………………. 2 (Go to #33)
REFUSED ……..……………………….. 3
DON’T KNOW…………………………. 4
Have your dizziness or balance problem(s) caused you to change or cut back on any of the following activities?
FR instruction: If respondent is unable to do this activity for reasons OTHER than dizziness or balance, enter “2”.
Please say yes or no to each.
Yes No
(1) Work or school
(2) Driving a motor vehicle
(3) Riding in a car, bus, airplane, boat, or train
(4) Exercising or taking walks
(5) Standing or being on your feet for 30 minutes or longer
(6) Walking down a flight of stairs
(7) Walking or climbing up 10 steps without resting
(8) Going outside your home to shop, movies, sporting, or other events
(9) Participating in social activities such as visiting friends, attending clubs and meetings, or going to parties.
(10) Bathing yourself, dressing yourself, feeding yourself, or going to the toilet
33. Have you EVER missed any days from work or school because of your dizziness or balance problem(s)?
Yes ……..……………………………….. 1 (Go to #34)
No …….…………………………………. 2 (Go to #36)
Doesn’t work or go to school..................... 3 (Go to #36)
REFUSED …………..………………….. 7
DON’T KNOW …………………………. 9
34. During your entire life, about how many days of work or school have you missed because of your dizziness or balance problem(s)?
If UNSURE, estimate as best you can.
Please tell me the number of days, weeks, months, or years.
__________ (number) days, or
__________ (number) weeks, or
__________ (number) months, or
__________ (number) years
35. During the past 12 months, how many days of work or school have you missed because of your dizziness or balance problem(s)?
If UNSURE, estimate as best you can.
Please tell me the number of days, weeks, or months.
__________ zero or no days
__________ (number) days, or
__________ (number) weeks, or
__________ (number) months
36. During the past 12 months, how much of a problem was your dizziness or balance condition? Would you say it was no problem, a small problem, a moderate problem, a big problem, or a very big problem?
No problem ………..……………..…….. 1
A small problem …………......…………. 2
A moderate problem …………….……... 3
A big problem ……….…………………. 4
A very big problem …………………….. 5
REFUSED …….……………………….. 6
DON’T KNOW…………………………. 7
◘ 37. Have you ever taken or had any of the following medications or treatments for ANY health conditions or problems?
Please say yes or no to each.
Yes No
(1) Antibiotics given through a needle or tube (IV)
(2) Antibiotics injected into the ear
(3) Diuretics due to water retention
(4) Antivert™ (Meclizine) for dizziness, nausea, or vomiting
(5) Medicines or patches for motion sickness, nausea, or vomiting
(7) Medicines for anxiety
(8) Chemotherapy drugs
(9) X-ray, MRI, or CAT scan of the head
38. Have any of your biological, that is, BLOOD relatives such as parents, brothers, sisters, or children had a problem with dizziness, balance, or falling, NOT related to aging?
Yes……………………………….. 1
No…………………………………. 2
REFUSED……………………….. 3
DON’T KNOW…………………. 4
The next questions are about Falls or Falling. by falls or falling, we mean unexpectedly dropping to the floor or ground from a standing, walking, or bending position.
39. During the past 5 years have you fallen at least one time?
Yes……………………………….. 1
No…………………………………. 2 (Go to END of section)
REFUSED……………………….. 3
DON’T KNOW…………………. 4
40. During the past 5 years, did any of your falls occur just before or around the time you were having any of the following dizziness or balance problems?
[Computer will only display options respondent said they had previously]
Please say yes or no to each.
Yes No
(1) feeling a sense of spinning
(2) a floating or spacey feeling
(3) feeling lightheaded
(4) feeling like you are about to pass out
(5) blurred vision
(6) unsteadiness
41. During the past 12 months, have you fallen at least once a month on average?
Yes……………………………….. 1 (Go to #42) No…………………………………. 2 (Go to #43)
REFUSED……………………….. 3
DON’T KNOW…………………. 4
42. During the past 12 months, about how many times per day, week, or month have you fallen?
If UNSURE, estimate as best you can.
Please tell me how many times per day, per week, or per month.
__________ (number) days, or
__________ (number) weeks, or
__________ (number) months
If Question #42 is answered, SKIP Question #43.
43. During the past 12 months, about how many times have you fallen?
If UNSURE, estimate as best you can.
0 or no times ………………………… 1
1 time…………………………………. 2
2 times………………………………… 3
3–4 times……………………………… 4
5–7 times………………………………. 5
8 or more……………………………. 6
REFUSED…………………………….. 8
DON’T KNOW……………………….. 9
44. During the past 12 months, did you have an injury as a result of a fall? For example, with a bruise, cut or wound, sprain, dislocation, fracture, broken bones, back pain, head or neck injury.
Yes……………………………….. 1
No…………………………………. 2 (Go to #46)
REFUSED……………………….. 3
DON’T KNOW…………………. 4
45. During the past 12 months, how many days of work or school did you miss because of injury from falls?
If UNSURE, estimate as best you can.
Please tell me the number of days, weeks, months, or years.
__________ zero or no days
__________ (number) days, or
__________ (number) weeks, or
__________ (number) months, or
46. Have you fallen during the past 12 months due to any of the following reasons?
Please say yes or no to each.
Yes No
You tripped or stumbled
You slipped
You hurried too much
You were not paying attention
You had nothing to hold onto
You blacked out or fainted
You lost your balance
You were knocked over by someone or something
You were doing sports or exercise
You had a problem with hearing
You had a problem with vision
You were getting up after sitting or lying down
You were walking up or down stairs
You had slow reactions or reflexes
You had weakness or numbness in one or both legs
You had not eaten recently or you had low blood sugar
You had a problem with medicine(s)
You drank too much alcohol
You had a problem using a walker, cane, or other aid
You had a problem with shoes, sandals, or socks
You had a health condition
Some other reason
── END of Section ──
Topical Module on Heart Disease
>HYBPCK<
ACN.020.010
About how long has it been since you had your blood pressure
checked by a doctor, nurse, or health professional?
@NO Number @TP Time Period
(0) Never
(1-94) 1-94 (1) Days
(95) 95+ (2) Weeks
(97) Refused (3) Months (7) Refused
(99) Don’t know (4) Years (9) Don’t know
<Never>, goto ACN.020.030; else goto ACN.020.020
>HYBPLEV<
ACN.020.020
At that time, were you told that your blood pressure was high,
normal, or low? (H)
(1) Not told
(2) High
(3) Normal
(4) Low
(5) Borderline
(7) Refused
(9) Don’t know
>CLCK<
ACN.020.030
About how long has it been since you had your blood cholesterol
checked by a doctor, nurse, or other health professional?
@NO Number @TP Time Period
(00) Never
(1-94) 1-94 (1) Days
(95) 95+ (2) Weeks
(97) Refused (3) Months
(99) Don't know (blind) (4) Years
<Never>, goto next set of questions; else goto ACN.020.040
>CLHI<
ACN.020.040
Have you ever been told by a doctor or other health professional
that your blood cholesterol level was high? (H)
(1) Yes
(2) No
(7) Refused
(9) Don’t know
>AHA<
ACN.031.010 Which of the following would you say are the symptoms that someone may be having a
heart attack? I am going to read a list. Please say yes or no to each one.
1)Yes 2)No 7)Refused 9)DK
>AHA_JAWP< Pain or discomfort in the jaw, neck, or back
>AHA_WEA< Feeling weak, lightheaded or faint
>AHA_CHE< Chest pain or discomfort
>AHA_ARM< Pain or discomfort in the arms or shoulder
>AHA_BRTH< Shortness of breath
>AHADO<
ACN.031.020 If you thought someone was having a heart attack, what is the BEST thing to do right away? FR: SHOW FLASHCARD A3
(1) Advise them to drive to the hospital
(2) Advise them to call their physician
(3) Call 9-1-1 (or another emergency number)
(4) Call spouse or family member
(5) Other
(7) Refused
(9) Don’t know
>ACPR<
ACN.031.040 Have you ever received formal training or certification in CPR for adults?
(1) Yes (ACN.031.050)
(2) No (next set of questions)
(7) Refused (next set of questions)
(9) Don’t know (next set of questions)
>ACPRLO<
ACN.031.050 How long ago was this?
(1) 1 year or less
(2) More than 1 year but not more than 2 years
(3) More than 2 years but not more than 5 years
(4) More than 5 years
(7) Ref
(9) DK
>PAFCCI01<
CHECK ITEM PAF01. Refer to SEX and HYPEV in Adult Core, Conditions, Section II, ACN.010.
If SEX eq <2> and HYPEV eq <1> [goto HYPPREG] else if SEX eq <1> and HYPEV eq <1>[goto HLOSWGT] else [goto NAF_BEGIN]
>HYPPREG<
PAF.010 These next questions are about health conditions.
Earlier you mentioned that you had been told you had high blood pressure. Was this only during pregnancy?
(1) Yes (NAF_BEGIN)
(2) No (PAF.020)
(7) Refused (PAF.020)
(9) Don’t Know (PAF.020)
>HLOSWGT<
CAPI: IF SEX EQ <1> SHOW THE FOLLOWING:
PAF.020 These next questions are about health conditions.
Earlier you mentioned that you had been told that you had high blood pressure. Because of your high blood pressure, has a doctor or other health professional EVER advised you to go on a diet or change your eating habits to help lower your blood pressure?
ELSE IF SEX EQ <2> SHOW THE FOLLOWING:
Because of your high blood pressure, has a doctor or other health professional EVER advised you to go on a diet or change your eating habits to help lower your blood pressure?
(1) Yes (PAF.030)
(2) No (PAF.050)
(7) Refused (PAF.050)
(9) Don’t Know (PAF.050)
>WGTADEV<
PAF.030 Did you EVER follow this advice?
(1) Yes (PAF.040)
(2) No (PAF.050)
(7) Refused (PAF.050)
(9) Don’t Know (PAF.050)
>WGTADNOW<
PAF.040 Are you NOW following this advice?
(1) Yes (PAF.050)
(2) No (PAF.050)
(7) Refused (PAF.050)
(9) Don’t Know (PAF.050)
>LOWSLT<
PAF.050 Because of your high blood pressure, has a doctor or other health professional EVER advised you to cut down on salt or sodium in your diet?
(1) Yes (PAF.060)
(2) No (PAF.080)
(7) Refused (PAF.080)
(9) Don’t Know (PAF.080)
>LOWSLTEV<
PAF.060 Did you EVER follow this advice?
(1) Yes (PAF.070)
(2) No (PAF.080)
(7) Refused (PAF.080)
(9) Don’t Know (PAF.080)
>LOWSLTNW<
PAF.070 Are you NOW following this advice?
(1) Yes (PAF.080)
(2) No (PAF.080)
(7) Refused (PAF.080)
(9) Don’t Know (PAF.080)
>EXERC<
PAF.080 Because of your high blood pressure, has a doctor or other health professional EVER advised you to exercise?
(1) Yes (PAF.090)
(2) No (PAF.110)
(7) Refused (PAF.110)
(9) Don’t Know (PAF.110)
>EXERCEV<
PAF.090 Did you EVER follow this advice?
(1) Yes (PAF.100)
(2) No (PAF.110)
(7) Refused (PAF.110)
(9) Don’t Know (PAF.110)
>EXERCNW<
PAF.100 Are you NOW following this advice?
(1) Yes (PAF.110)
(2) No (PAF.110)
(7) Refused (PAF.110)
(9) Don’t Know (PAF.110)
>HBPALC<
PAF.110 Because of your high blood pressure, has a doctor or other health professional EVER advised you to cut down on alcohol use?
(1) Yes (PAF.120)
(2) No (PAF.140)
(7) Refused (PAF.140)
(9) Don’t Know (PAF.140)
>HBPALCEV<
-HBPALCEV-
PAF.120 Did you EVER follow this advice?
(1) Yes (PAF.130)
(2) No (PAF.140)
(7) Refused (PAF.140)
(9) Don’t Know (PAF.140)
>HBPALCNW<
PAF.130 Are you NOW following this advice?
(1) Yes (PAF.140)
(2) No (PAF.140)
(7) Refused (PAF.140)
(9) Don’t Know (PAF.140)
>HYPMEDEV<
PAF.140 Was any medicine EVER prescribed by a doctor for your high blood pressure?
(1) Yes (PAF.150)
(2) No (NAF_BEGIN)
(7) Refused (NAF_BEGIN){blind}
(9) Don’t Know (NAF_BEGIN){blind}
>HYPMED<
PAF.150 Are you NOW taking any medicine prescribed by a doctor for your high blood pressure?
(1) Yes (NAF_BEGIN)
(2) No (PAF.160)
(7) Refused (PAF.160)
(9) Don’t Know (PAF.160)
>HYMDMED<
PAF.160 Did a doctor advise you to stop taking the medicine?
(1) Yes
(2) No)
(7) Refused
(9) Don’t Know
[goto NAF_BEGIN]
Topical Module on Immunization
SHINGLES – Males and Females 50+
Q01. Shingles is an outbreak of a rash or blisters on the skin that may be associated with severe pain. The pain is generally on one side of the body or face. Shingles is caused by the chicken pox virus. A vaccine for shingles has been available since May 2006. Have you ever had the Zoster or Shingles vaccine, also called Zostavax®?
1 Yes
2 No
7 Refused
9 Don’t know
TD/TDAP – All adults 18+
Q01. Have you received a tetanus shot in the past 10 years?
1 Yes
2 No [SKIP BEYOND Q03]
7 Refused [SKIP BEYOND Q03]
9 Don’t know [SKIP BEYOND Q03]
Q02. Was your most recent tetanus shot given in 2005 or later?
1 Yes [SKIP TO CHECKPOINT]
2 No [SKIP BEYOND Q03]
7 Refused [SKIP TO CHECKPOINT]
9 Don’t know [SKIP BEYOND Q03]
Checkpoint: If R’s age <65 then Q03 Else skip beyond Q03 |
Q03. [PRONOUNCE “Td” TEE DEE (RHYMES WITH “SEE”). PRONOUNCE “Tdap” TEE DAP (RHYMES WITH “CAP”).]
There are currently two types of tetanus shots available today. One is the Td or tetanus-diphtheria vaccine and the other is called Tdap or Adacel™. They are similar except the Tdap shot also includes a pertussis or whooping cough vaccine. Thinking back to your most recent tetanus shot, did the doctor tell you the vaccine included the pertussis or whooping cough vaccine? The shot is often called Tdap or ADACEL™.
1 Yes – included pertussis
2 No – did not include pertussis
3 Doctor did not say
7 Refused
9 Don’t know
HEPATITIS A – All adults 18+
Q01. The hepatitis A vaccine is given as a two dose series routinely to some children starting at 1 year of age, and to some adults and people who travel outside the United States. Although it can be given as a combination vaccine with hepatitis B, it is different from the hepatitis B shot, and has only been available since 1995. Have you ever received hepatitis A vaccine?
1 Yes
2 No [SKIP TO Q03]
7 Refused [SKIP TO Q03]
9 Don’t know [SKIP TO Q03]
Q02. How many hepatitis A shots did you receive?
___ (# of hepatitis A shots)
3 All shots
7 Refused
9 Don’t know
Q03. Has a doctor or other health professional ever told you that you had any kind of chronic, or long-term liver condition?
1 Yes
2 No
7 Refused
9 Don’t know
Q04. Have you ever traveled outside of the United States to countries other than Europe, Japan, Australia, New Zealand or Canada, since 1995?
1 Yes
2 No
7 Refused
9 Don’t know
Section name: Child HPV
Question ID CHP.010
Variable Name CHPVHRD
Universe-text Female sample children 8+
Question Text A vaccine to prevent human papillomavirus or HPV infection is available and is called the HPV shot, cervical cancer vaccine, or GARDASIL®. Before this survey, have you ever heard of the HPV shot or cervical cancer vaccine?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,R,D> [goto CSHTHPV]
Question ID CHP.020
Variable Name CSHTHPV
Universe-text Female sample children 8+
Question Text Did [fill: SC name] ever receive the HPV shot or cervical cancer vaccine?
Answer Codes 1. Yes
2. No
3. Doctor refused when asked
Refused
Don't know
Skip Instructions <1> [goto CSHHPVDS] <2,3,R,D> [goto CHPVREC]
Question ID CHP.030
Variable Name CSHHPVDS
Universe-text Female sample children 8+ who have received the HPV vaccine or shot
Question Text How many HPV shots did [fill: SC name] receive?
*Enter ‘96’ for all shots.
Skip Instructions <1-50,96,R,D> [goto next section]
Question ID CHP.040
Variable Name CHPVREC
Universe-text Female sample children 8+ who have not received an HPV vaccine or shot
Question Text If [fill: SC name]'s doctor recommended the HPV vaccine,
would you have her get it?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1> [goto CHPVCOST] <2> [goto CHPVNOT] <R,D> [goto next section]
Question ID CHP.050
Variable Name CHPVNOT
Universe-text Female sample children 8+ who would not get the HPV vaccine if her doctor recommended it
Question Text What is the MAIN reason you would not want [fill: SC name] to get the vaccine?
Answer Codes 1. Does not need vaccine
2. Not sexually active
3. Too expensive
4. Too young
5. Doctor didn't recommend it
6. Worried about safety of vaccine
7. Don't know where to get vaccine
8. My spouse/family member is against it
9. Don't know enough about vaccine
10. Already has HPV
11. Other
Refused
Don't know
Skip Instructions <1,2,4-11,R,D> [goto next section] <3> [goto CHPVLOC]
Question ID CHP.060
Variable Name CHPVCOST
Universe-text Female sample children age 8+ whose respondent would be interested in getting the HPV vaccine for her
Question Text The cost of the vaccine may be about $360-$500. Would you have [fill: SC name] get the
vaccine if you had to pay this amount?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,R,D> [goto next section]; <2> [goto CHPVLOC]
Question ID CHP.070
Variable Name CHPVLOC
Universe-text Female sample children age 8+ whose respondent would not pay $360-$500 for the HPV vaccine or for whom the main reason not to get the vaccine was because it was too expensive
Question Text If [fill: SC name] could get the vaccine free or at a much lower cost, would you have her get it?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,R,D> [goto next section]
Topical Module on Oral Health
Section name: Adult Oral Health
Question ID AOH.010
Variable Name OCOND
Universe-text Sample adults 18+
Question Text How would you describe the condition of your mouth [if LUPPRT = 2,R,D, fill: and teeth]?
Would you say very good, good, fair or poor?
Answer Codes 1.Very good
2. Good
3. Fair
4. Poor
Refused
Don't Know
Skip Instructions <1-4,R,D> [go to OBTWS]
Question ID AOH.020
Variable Name OBTWS
Universe-text Sample adults 18+
Question Text Would you say the condition of your mouth and teeth is better than, the same as or not as good as other people your age?
Answer Codes 1.Better
2.Same
3.Not as good
Refused
Don't Know
Skip Instructions <1-3,R,D> [go to OEMB]
Question ID AOH.030
Variable Name OEMB
Universe-text Sample adults 18+
Question Text DURING THE PAST 6 MONTHS, how often have you been self-conscious or embarrassed
because of your teeth, mouth or dentures? Would you say often, sometimes, rarely or never?
Answer Codes 1. Often
2.Sometimes
3.Rarely
4.Never
Refused
Don't Know
Skip Instructions <1-4, R,D> and ADENLONG = 1 [go to OREAS_1];
else if <1-4, R,D> and ADENLONG ne 1 [go to OREAS_4]
Question ID AOH.040_1
Variable Name OREAS_1
Universe-text Sample adults 18+, seen a dentist, past 6 mos
Question Text I am going to read you a list of reasons people get dental care. Please tell me how many hours of work or school you have missed IN THE PAST 6 MONTHS.
. . . For emergency dental care where you saw the dentist within 24 hours or as soon as was
possible
Answer Codes 1. Less than 1 hour
2. 1 hour, less than 3 hours
3. 3 hours, less than 5 hours
4. 5 hours, less than 7 hours
5. 7 or more hours
6. Doesn't go to work or school
Refused
Don't know
Skip Instructions <1-6, R, D> [go to OREAS_2]
Question ID AOH.040_2
Variable Name OREAS_2
Universe-text Sample adults 18+, seen a dentist, past 6 mos
Question Text *Read if necessary: I am going to read you a list of reasons people get dental care. Please tell me how many hours of work or school you have missed IN THE PAST 6 MONTHS.
. . . For planned routine dental or orthodontic care
Answer Codes 1. Less than 1 hour
2. 1 hour, less than 3 hours
3. 3 hours, less than 5 hours
4. 5 hours, less than 7 hours
5. 7 or more hours
6. Doesn't go to work or school
Refused
Don't know
Skip Instructions <1-6, R, D > [go to OREAS_3]
Question ID AOH.040_3
Variable Name OREAS_3
Universe-text Sample adults 18+, seen a dentist, past 6 mos
Question Text *Read if necessary: I am going to read you a list of reasons people get dental care. Please tell me how many hours of work or school you have missed IN THE PAST 6 MONTHS.
. . . For tooth whitening or other cosmetic procedures
Answer Codes 1. Less than 1 hour
2. 1 hour, less than 3 hours
3. 3 hours, less than 5 hours
4. 5 hours, less than 7 hours
5. 7 or more hours
6. Doesn't go to work or school
Refused
Don't know
Skip Instructions <1-6, R, D > [go to OREAS_4]
Question ID AOH.040_4
Variable Name OREAS_4
Universe-text Sample adults 18+
Question Text *Read if necessary: I am going to read you a list of reasons people get dental care. Please tell me how many hours of work or school you have missed IN THE PAST 6 MONTHS.
. . . For taking someone else to a dental appointment
Answer Codes 1. Less than 1 hour
2. 1 hour, less than 3 hours
3. 3 hours, less than 5 hours
4. 5 hours, less than 7 hours
5. 7 or more hours
6. Doesn't go to work or school
Refused
Don't know
Skip Instructions <1-6, D, R > and if LUPPRT =2 [go to OPROB_01];
else if <1-6, D, R > and LUPPRT ne 2 [go to OPROB_08]
Question ID AOH.050_1
Variable Name OPROB_01
Universe-text Sample adults 18+ have not lost all lower and upper teeth
Question Text DURING THE PAST 6 MONTHS, have you had any of the following problems? Please say yes or no to each.
. . . A toothache or sensitive teeth
Answer Codes 1. Yes
2. No
Refused
Don't Know
Question Type Yes/No
Skip Instructions <1,2, R,D> [go to OPROB_02]
Question ID AOH.050_2
Variable Name OPROB_02
Universe-text Sample adults 18+ have not lost all lower and upper teeth
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, have you had any of the following
problems? Please say yes or no to each.
. . . Bleeding gums
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to OPROB_03]
Question ID AOH.050_3
Variable Name OPROB_03
Universe-text Sample adults 18+ have not lost all lower and upper teeth
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, have you had any of the following
problems? Please say yes or no to each.
. . . Crooked teeth
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1, 2, R, D> [go to OPROB_04]
Question ID AOH.050_4
Variable Name OPROB_04
Universe-text Sample adults 18+ have not lost all lower and upper teeth
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, have you had any of the following
problems? Please say yes or no to each.
. . . Broken or missing teeth
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to OPROB_05]
Question ID AOH.050_5
Variable Name OPROB_05
Universe-text Sample adults 18+ have not lost all lower and upper teeth
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, have you had any of the following
problems? Please say yes or no to each.
. . . Stained or discolored teeth
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to OPROB_06]
Question ID AOH.050_6
Variable Name OPROB_06
Universe-text Sample adults 18+ have not lost all lower and upper teeth
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, have you had any of the following
problems? Please say yes or no to each.
. . . Loose teeth not due to an injury
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to OPROB_07]
Question ID AOH.050_7
Variable Name OPROB_07
Universe-text Sample adults 18+ have not lost all lower and upper teeth
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, have you had any of the following
problems? Please say yes or no to each.
. . . Broken or missing fillings
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to OPROB_08]
Question ID AOH.055_1
Variable Name OPROB_08
Universe-text Sample adults 18+
Question Text DURING THE PAST 6 MONTHS, have you had any of the following problems that lasted more than a day? Please say yes or no to each.
. . . Pain in your jaw joint
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to OPROB_09]
Question ID AOH.055_2
Variable Name OPROB_09
Universe-text Sample adults 18+
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, have you had any of the following
problems that lasted more than a day? Please say yes or no to each.
. . . Sores in your mouth
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to OPROB_10]
Question ID AOH.055_3
Variable Name OPROB_10
Universe-text Sample adults 18+
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, have you had any of the following
problems that lasted more than a day? Please say yes or no to each.
. . . Difficulty eating or chewing
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to OPROB_11]
Question ID AOH.055_4
Variable Name OPROB_11
Universe-text Sample adults 18+
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, have you had any of the following
problems that lasted more than a day? Please say yes or no to each.
. . . Bad breath
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to OPROB_12]
Question ID AOH.055_5
Variable Name OPROB_12
Universe-text Sample adults 18+
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, have you had any of the following
problems that lasted more than a day? Please say yes or no to each.
. . . Dry mouth
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2,R,D> and([OPROB_1 =1 or OPROB_2 =1 or OPROB_3 =1 or OPROB_4 =1 or OPROB_5 =1
or OPROB_6 =1 or OPROB_7 =1 or OPROB_8 =1 or OPROB_9 =1 or OPROB_10 =1 or
OPROB_11 =1 or OPROB_12 =1]) [go to ODENT1] else if <1,2,R,D> and ((OPROB_1 or OPROB_2 through _12) ne 1) [ go to OCEXAM]
Question ID AOH.060
Variable Name ODENT1
Universe-text Sample adults 18+ have at least one problem with mouth or teeth
Question Text DURING THE PAST 6 MONTHS did you see a dentist or a medical doctor for any of the
problems with your mouth or teeth?
*Read if necessary: Include all types of dentists such as orthodontists, oral surgeons, and all
other dental specialists, as well as dental hygienists.
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1> [go to ODENT2]
<2> [goto ONODEN_1]
<R,D> [goto OINT_1]
Question ID AOH.070
Variable Name ODENT2
Universe-text Sample adults 18+ have at least one problem with mouth or teeth and saw a doctor or dentist
Question Text Which one did you see?
* Code as dentists for all types such as orthodontists, oral surgeons, and all other dental
specialists, as well as dental hygienists.
Answer Codes 1.Dentist
2.Doctor
3.Both
Refused
Don't Know
Skip Instructions <1,3, R,D> [go to OINT_1]
<2> [go to ONODEN_1]
Question ID AOH.080_1
Variable Name ONODEN_1
Universe-text Sample adults 18+ didn't see a dentist for problem with mouth or teeth
Question Text DURING THE PAST 6 MONTHS, why didn’t you see a dentist for the problems with your mouth or teeth? Please say yes or no to each.
. . . You didn’t think it was important
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to ONODEN_2]
Question ID AOH.080_2
Variable Name ONODEN_2
Universe-text Sample adults 18+ didn't see a dentist for problem with mouth or teeth
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, why didn’t you see a dentist for the
problems with your mouth or teeth? Please say yes or no to each.
. . . The problem went away
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to ONODEN_3]
Question ID AOH.080_3
Variable Name ONODEN_3
Universe-text Sample adults 18+ didn't see a dentist for problem with mouth or teeth
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, why didn’t you see a dentist for the
problems with your mouth or teeth? Please say yes or no to each.
. . . You couldn’t afford treatments or you didn’t have insurance
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to ONODEN_4]
Question ID AOH.080_4
Variable Name ONODEN_4
Universe-text Sample adults 18+ didn't see a dentist for problem with mouth or teeth
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, why didn’t you see a dentist for the
problems with your mouth or teeth? Please say yes or no to each.
. . . You didn’t have transportation
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to ONODEN_5]
Question ID AOH.080_5
Variable Name ONODEN_5
Universe-text Sample adults 18+ didn't see a dentist for problem with mouth or teeth
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, why didn’t you see a dentist for the
problems with your mouth or teeth? Please say yes or no to each.
. . . You were afraid to see a dentist
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to ONODEN_6]
Question ID AOH.080_6
Variable Name ONODEN_6
Universe-text Sample adults 18+ didn't see a dentist for problem with mouth or teeth
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, why didn’t you see a dentist for the
problems with your mouth or teeth? Please say yes or no to each.
. . . You were waiting for an appointment
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to ONODEN_7]
Question ID AOH.080_7
Variable Name ONODEN_7
Universe-text Sample adults 18+ didn't see a dentist for problem with mouth or teeth
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, why didn’t you see a dentist for the
problems with your mouth or teeth? Please say yes or no to each.
. . . You didn’t think a dentist could fix the problem
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to OINT_1]
Question ID AOH.090_1
Variable Name OINT_1
Universe-text Sample adults 18+ have at least one problem with mouth or teeth
Question Text Did the problems with your mouth or teeth interfere with any of the following. Please say yes or no to each.
. . . Your job or school
Answer Codes 1. Yes
2. No
3. Doesn't go to work or school
Refused
Don't Know
Skip Instructions <1-3, R,D> [go to OINT_2]
Question ID AOH.090_2
Variable Name OINT_2
Universe-text Sample adults 18+ have at least one problem with mouth or teeth
Question Text *Read if necessary: Did the problems with your mouth or teeth interfere with any of the
following. Please say yes or no to each.
. . . Sleeping
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to OINT_3]
Question ID AOH.090_3
Variable Name OINT_3
Universe-text Sample adults 18+ have at least one problem with mouth or teeth
Question Text *Read if necessary: Did the problems with your mouth or teeth interfere with any of the
following. Please say yes or no to each.
. . . Social activities such as going out or being with other people
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to OINT_4]
Question ID AOH.090_4
Variable Name OINT_4
Universe-text Sample adults 18+ have at least one problem with mouth or teeth
Question Text *Read if necessary: Did the problems with your mouth or teeth interfere with any of the
following. Please say yes or no to each.
. . . Your usual activities at home
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to OCEXAM]
Question ID AOH.100
Variable Name OCEXAM
Universe-text Sample adults 18+
Question Text Have you ever heard of an exam for oral or mouth cancer?
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to OCTONG]
Question ID AOH.110
Variable Name OCTONG
Universe-text Sample adults 18+
Question Text Have you ever had an exam for oral cancer in which the doctor, dentist or other health
professional pulls on your tongue,
sometimes with gauze wrapped around it, and feels under the tongue and inside the cheeks?
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to OCNECK]
Question ID AOH.120
Variable Name OCNECK
Universe-text Sample adults 18+
Question Text Have you ever had an exam for oral cancer in which the doctor, dentist or other health
professional feels your neck?
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1> or OCTONG=1 [goto OCEXWHEN]
else <2,R,D> and OCTONG ne 1 [goto next section]
Question ID AOH.130
Variable Name OCEXWHEN
Universe-text Sample adults 18+ have had oral cancer exam
Question Text When did you have your most recent oral or mouth cancer exam?
Was it within the past year, between 1 and 3 years ago, or over 3 years ago?
Answer Codes 1.Within past year
2.Between 1 and 3 years ago
3.Over 3 years ago
Refused
Don't know
Skip Instructions <1,2> [go to OCEXCHCK]
<3,R,D> next section
Question ID AOH.140
Variable Name OEXCHECK
Universe-text Sample adults 18+ have had oral cancer exam with last 3 years
Question Text Did you have your most recent oral cancer exam during a routine check-up or
because you were having a specific problem?
Answer Codes 1.Part of a routine check-up
2.For a specific problem
Refused
Don't know
Skip Instructions <1,2, R, D> [go to OCEXPROF]
Question ID AOH.150
Variable Name OCEXPROF
Universe-text Sample adults 18+ have had oral cancer exam with last 3 years
Question Text What type of health care professional performed your most recent oral cancer exam?
Answer Codes 1.Doctor/physician
2.Nurse/nurse practitioner
3.Dentist (include oral surgeons)
4.Dental Hygienist
5.Other
Refused
Don't know
Skip Instructions <1-5, R,D > [go to next section]
Section name: Child Oral Health
Question ID COH.010
Variable Name COCOND
Universe-text Sample children <18
Question Text How would you describe the condition of [fill: S.C. name]'s mouth and teeth? Would you say
very good, good, fair or poor?
Answer Codes 1.Very good
2. Good
3. Fair
4. Poor
Refused
Don't Know
Skip Instructions <1-4,R,D> [go to COBTWS]
Question ID COH.020
Variable Name COBTWS
Universe-text Sample children <18
Question Text Would you say the condition of [fill: SC name]'s mouth and teeth is better than, the same as or
not as good as other people [fill: her or his] age?
Answer Codes 1.Better
2.Same
3.Not as good
Refused
Don't Know
Skip Instructions <1-3,R,D> [if AGE GE 6 go to COEMB;
if AGE < 6 and CDENLONG = 1 go to COREAS_1;
else go to COPROB_1]
Question ID COH.030
Variable Name COEMB
Universe-text Sample children 6-17
Question Text DURING THE PAST 6 MONTHS, how often was [fill: she/he] self-conscious or embarrassed
because of [fill: her/his] teeth or mouth? Would you say often, sometimes, rarely or never?
Answer Codes 1. Often
2. Sometimes
3. Rarely
4. Never
Refused
Don't Know
Skip Instructions <1-4,R,D> [if CDENLONG = 1 go to COREAS_1;
if AGE LE 15 and CDENLONG NE 1 go to COPROB_1;
if AGE GE 16 and CDENLONG NE 1 go to COREAS_4;
else goto COPROB_1]
Question ID COH.040_1
Variable Name COREAS_1
Universe-text Sample children 1-17, seen a dentist, past 6 mos
Question Text I am going to read you a list of reasons people get dental care. Please tell me how many hours of school [fill1: or work] [fill: SC name] has missed IN THE PAST 6 MONTHS for each one.
...For emergency dental care where [fill: SC name] saw the dentist within 24 hours or as soon as was possible
Answer Codes 1. Less than 1 hour
2. 1 hour, less than 3 hours
3. 3 hours, less than 5 hours
4. 5 hours, less than 7 hours
5. 7 or more hours
6. Doesn't go to school [fill1: or work]
Refused
Don't know
Skip Instructions <1-6,R,D> [go to COREAS_2]
Question ID COH.040_2
Variable Name COREAS_2
Universe-text Sample children 1-17, seen a dentist, past 6 mos
Question Text *Read if necessary: I am going to read you a list of reasons people get dental care. Please tell me how many hours of school [fill1: or work] [fill: SC name] has missed IN THE PAST 6
MONTHS for each one.
...For planned routine dental or orthodontic care
Answer Codes 1. Less than 1 hour
2. 1 hour, less than 3 hours
3. 3 hours, less than 5 hours
4. 5 hours, less than 7 hours
5. 7 or more hours
6. Doesn't go to school [fill1: or work]
Refused
Don't Know
Skip Instructions <1-6,R,D> [if AGE LE 5 go to COPROB_1;
else go to COREAS_3]
Question ID COH.040_3
Variable Name COREAS_3
Universe-text Sample children 6-17, seen a dentist, past 6 mos
Question Text *Read if necessary: I am going to read you a list of reasons people get dental care. Please tell me how many hours of school [fill1: or work] [fill: SC name] has missed IN THE PAST 6
MONTHS for each one.
...For tooth whitening or other cosmetic procedures
Answer Codes 1. Less than 1 hour
2. 1 hour, less than 3 hours
3. 3 hours, less than 5 hours
4. 5 hours, less than 7 hours
5. 7 or more hours
6. Doesn't go to school [fill1: or work]
Refused
Don't know
Skip Instructions <1-6,R,D> [if AGE GE 16 go to COREAS_4;
else go to COPROB_1]
Question ID COH.040_4
Variable Name COREAS_4
Universe-text Sample children 16-17, seen a dentist, past 6 mos
Question Text Please tell me how many hours of school [fill1: or work] [fill: SC name] has missed IN THE
PAST 6 MONTHS for each one.
...For taking someone else to a dental appointment
Answer Codes 1. Less than 1 hour
2. 1 hour, less than 3 hours
3. 3 hours, less than 5 hours
4. 5 hours, less than 7 hours
5. 7 or more hours
6. Doesn't go to school [fill1: or work]
Refused
Don't know
Skip Instructions <1-6,R,D> [go to COPROB_1]
Question ID COH.050_01
Variable Name COPROB_01
Universe-text Sample children <18
Question Text DURING THE PAST 6 MONTHS, has [fill S.C. name] had any of the following problems? Please say yes or no to each.
...A toothache or sensitive teeth
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2,R,D> [go to COPROB_02]
Question ID COH.050_02
Variable Name COPROB_02
Universe-text Sample children <18
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, has [fill: S.C. name] had any of the
following problems? Please say yes or no to each.
...Pain in [fill: her/his] jaw joint
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to COPROB_03]
Question ID COH.050_03
Variable Name COPROB_03
Universe-text Sample children <18
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, has [fill S.C. name] had any of the
following problems? Please say yes or no to each.
...Sores in [fill: her/his] mouth
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to COPROB_04]
Question ID COH.050_04
Variable Name COPROB_04
Universe-text Sample children <18
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, has [fill S.C. name] had any of the
following problems? Please say yes or no to each.
...Bleeding gums
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to COPROB_05]
Question ID COH.050_05
Variable Name COPROB_05
Universe-text Sample children <18
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, has [fill S.C. name] had any of the
following problems? Please say yes or no to each.
...Crooked teeth
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to COPROB_06]
Question ID COH.050_06
Variable Name COPROB_06
Universe-text Sample children <18
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, has [fill S.C. name] had any of the
following problems? Please say yes or no to each.
...Broken or missing teeth other than losing baby teeth
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2,R,D> [go to COPROB_07]
Question ID COH.050_07
Variable Name COPROB_07
Universe HHSTAT4 = 'C' and AGE <18
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, has [fill S.C. name] had any of the
following problems? Please say yes or no to each.
...Stained or discolored teeth
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2,R,D> [go to COPROB_08]
Question ID COH.050_08
Variable Name COPROB_08
Universe-text Sample children <18
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, has [fill S.C. name] had any of the
following problems? Please say yes or no to each.
...Loose teeth not due to an injury or losing baby teeth
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to COPROB_09]
Question ID COH.050_09
Variable Name COPROB_09
Universe-text Sample children <18
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, has [fill S.C. name] had any of the
following problems? Please say yes or no to each.
...Decayed teeth or cavities
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to COPROB_10]
Question ID COH.050_10
Variable Name COPROB_10
Universe-text Sample children <18
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, has [fill S.C. name] had any of the
following problems? Please say yes or no to each.
...Broken or missing fillings
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to COPROB_11]
Question ID COH.050_11
Variable Name COPROB_11
Universe-text Sample children <18
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, has [fill S.C. name] had any of the
following problems? Please say yes or no to each.
...Bad breath
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to COPROB_12]
Question ID COH.050_12
Variable Name COPROB_12
Universe-text Sample children <18
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, has [fill S.C. name] had any of the
following problems? Please say yes or no to each.
...Dry mouth
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [if [COPROB_01 =1 or COPROB_02 =1 or COPROB_03 =1 or COPROB_04 =1 or
COPROB_05 =1 or COPROB_06 =1 or COPROB_07 =1 or COPROB_08 =1 or COPROB_09 =1 or
COPROB_10 =1 or COPROB_11 =1 or COPROB_12 =1 go to CODENT1;
else [go to next section]
Question ID COH.060
Variable Name CODENT1
Universe-text Sample children <18 have at least one problem mouth or teeth
Question Text DURING THE PAST 6 MONTHS did [fill S.C. name] see a dentist or a medical doctor for any of the problems with [fill: her or his] mouth or teeth?
*Read if necessary: Include all types of dentists such as orthodontists, oral surgeons, and all
other dental specialists, as well as dental hygienists.
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1> [go to CODENT2]
<2> [go to CONODEN_1]
<R,D> [go to COINT_1]
Question ID COH.070
Variable Name CODENT2
Universe-text Sample children <18 who have seen a doctor or dentist for mouth or teeth problem
Question Text Which one did [fill S. C. name] see?
*Code as dentist: orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists.
Answer Codes 1. Dentist
2. Medical Doctor
3. Both
Refused
Don't Know
Skip Instructions <1,3,R,D> [go to COINT_1] <2> [go to CONODEN_1]
Question ID COH.080_1
Variable Name CONODEN_1
Universe-text Sample children <18 didn't see a dentist for problem with mouth or teeth
Question Text DURING THE PAST 6 MONTHS, why didn’t [fill: SC name] see a dentist for the problems with
[fill: his/her] mouth or teeth? Please say yes or no to each.
...You didn’t think it was important
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2,R,D> [go to CONODEN_2]
Question ID COH.080_2
Variable Name CONODEN_2
Universe-text Sample children <18 didn't see a dentist for problem with mouth or teeth
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, why didn’t [fill: SC name] see a dentist
for the problems with [fill: his/her] mouth or teeth? Please say yes or no to each.
...The problem went away
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to CONODEN_3]
Question ID COH.080_3
Variable Name CONODEN_3
Universe-text Sample children <18 didn't see a dentist for problem with mouth or teeth
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, why didn’t [fill: SC name] see a dentist for the problems with [fill: his/her] mouth or teeth? Please say yes or no to each.
...You couldn’t afford treatments or [fill S.C. name] didn’t have insurance
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to CONODEN_4]
Question ID COH.080_4
Variable Name CONODEN_4
Universe-text Sample children <18 didn't see a dentist for problem with mouth or teeth
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, why didn’t [fill: SC name] see a dentist
for the problems with [fill: his/her] mouth or teeth? Please say yes or no to each.
...No transportation was available
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to CONODEN_5]
Question ID COH.080_5
Variable Name CONODEN_5
Universe-text Sample children <18 didn't see a dentist for problem with mouth or teeth
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, why didn’t [fill: SC name] see a dentist
for the problems with [fill: his/her] mouth or teeth? Please say yes or no to each.
...[fill S. C. name] was afraid to see a dentist
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2,R,D> [go to CONODEN_6]
Question ID COH.080_6
Variable Name CONODEN_6
Universe-text Sample children <18 didn't see a dentist for problem with mouth or teeth
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, why didn’t [fill: SC name] see a dentist for the problems with [fill: his/her] mouth or teeth? Please say yes or no to each.
...[fill: SC name] was waiting for an appointment
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2,R,D> [go to CONODEN_7]
Question ID COH.080_7
Variable Name CONODEN_7
Universe-text Sample children <18 didn't see a dentist for problem with mouth or teeth
Question Text *Read if necessary: DURING THE PAST 6 MONTHS, why didn’t [fill: SC name] see a dentist
for the problems with [fill: his/her] mouth or teeth? Please say yes or no to each.
...You didn’t think a dentist could fix the problem
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2,R,D> [go to COINT_1]
Question ID COH.090_1
Variable Name COINT_1
Universe-text Sample children <18 have at least one problem mouth or teeth
Question Text Did the problems with [fill S. C. name]'s mouth or teeth interfere with any of the following?
Please say yes or no to each.
...School or school activities
Answer Codes 1. Yes
2. No
3. Doesn't go to school
Refused
Don't Know
Skip Instructions <1-3,R,D> [if AGE = 14-17 go to COINT_2; else go to COINT_3]
Question ID COH.090_2
Variable Name COINT_2
Universe-text Sample children 14-17 have at least one problem with mouth or teeth
Question Text *Read if necessary: Did the problems with [fill S. C. name]'s mouth or teeth interfere with any of the following? Please say yes or no to each.
...Work
Answer Codes 1. Yes
2. No
3. Doesn't work
Refused
Don't Know
Skip Instructions <1-3, R,D> [go to COINT_3]
Question ID COH.090_3
Variable Name COINT_3
Universe-text Sample children <18 have at least one problem with mouth or teeth
Question Text *Read if necessary: Did the problems with [fill S. C. name]'s mouth or teeth interfere with any of the following? Please say yes or no to each.
...Eating
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2,R,D> [go to COINT_4]
Question ID COH.090_4
Variable Name COINT_4
Universe-text Sample children <18 have at least one problem with mouth or teeth
Question Text *Read if necessary: Did the problems with [fill S. C. name]'s mouth or teeth interfere with any of the following? Please say yes or no to each.
...Sleeping
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [go to COINT_5]
Question ID COH.090_5
Variable Name COINT_5
Universe-text Sample children <18 have at least one problem with mouth or teeth
Question Text *Read if necessary: Did the problems with [fill S. C. name]'s mouth or teeth interfere with any of the following? Please say yes or no to each.
...Social activities such as going out or being with other people
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2,R,D> [go to COINT_6]
Question ID COH.090_6
Variable Name COINT_6
Universe-text Sample children <18 have at least one problem with mouth or teeth
Question Text *Read if necessary: Did the problems with [fill S. C. name]'s mouth or teeth interfere with any of the following? Please say yes or no to each.
...[fill S. C. name] 's usual activities at home
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2, R,D> [if AGE GE 4 go to CMHCOPY;
else go to CSHFLUYR]
Section Name Family Health Insurance
Question ID FHI.249_02
Variable Name PRDNCOV
Universe-text All private health insurance plans
Question Text Does [fill 1: ^HIPNAM1 or ^HIPNAM2, or ^HIPNAM3, or ^HIPNAM4 or Plan 1 or Plan 2 or Plan 3 or Plan 4] pay for any of the costs for dental care?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions Loop through from FHICCI8 for any other private plans. When roster is exhausted, goto
STNAME1 to see if the family fits into the universe for this question.
Topical Module on Vision
Question ID ACN.440.010
Variable Name VIM_DREV
Universe-text Sample adults 18+
Question Text Have you EVER been told by a doctor or other health professional that you had...
Diabetic retinopathy?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1> [go to VIMLS_DR] [2,R,D> [goto VIM_CAEV]
Question ID ACN.440.020
Variable Name VIMLS_DR
Universe-text Sample adults 18+ told they have diabetic retinopathy
Question Text Have you lost any vision because of
diabetic retinopathy?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,R,D> [goto VIM_CAEV]
Question ID ACN.440.030
Variable Name VIM_CAEV
Universe-text Sample adults 18+
Question Text Have you EVER been told by a doctor or other health professional that you had...
Cataracts?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1> [go to VIMLS_CA] [2,R,D> [goto VIM_GLEV]
Question ID ACN.440.040
Variable Name VIMLS_CA
Universe-text Sample adults 18+ told they have cataracts
Question Text Have you lost any vision because of
Cataracts?
Answer Codes 1. Yes
2. No
Refused
Don't know
Question Type Yes/No
Skip Instructions [1,2,R,D> [goto VIM_GLEV]
Question ID ACN.440.050
Variable Name VIM_GLEV
Universe-text Sample adults 18+
Question Text Have you EVER been told by a doctor or other health professional that you had...
Glaucoma?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1> [go to VIMLS_GL] [2,R,D> [goto VIM_MDEV]
Question ID ACN.440.060
Variable Name VIMLS_GL
Universe-text Sample adults 18+ told they have glaucoma
Question Text Have you lost any vision because of
Glaucoma?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,R,D> [goto VIM_MDEV]
Question ID ACN.440.070
Variable Name VIM_MDEV
Universe-text Sample adults 18+
Question Text Have you EVER been told by a doctor or other health professional that you had...
Macular Degeneration?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1> [go to VIMLS_MD] <2,R,D> if VIM_CAEV=1 [goto VIMCSURG]; else goto VIMGLASS]
Question ID ACN.440.080
Variable Name VIMLS_MD
Universe-text Sample adults 18+ told they have macular degeneration
Question Text Have you lost any vision because of
Macular degeneration?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,R,D> if VIM_CAEV=1 [goto VIMCSURG]; else [goto VIMGLASS]
Question ID ACN.440.090
Variable Name VIMCSURG
Universe-text Sample adults 18+ ever had cataracts
Question Text Have you ever had cataract surgery?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1, 2,D,R> [go to VIMGLASS]
Question ID ACN.440.100
Variable Name VIMGLASS
Universe-text Sample adults 18+
Question Text Do you currently wear eyeglasses or contact lenses?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,> [go to VIMREAD]
<2,D,R> [go to AVISREH]
Question ID ACN.440.110
Variable Name VIMREAD
Universe-text Sample adults 18+ wear glasses or contacts
Question Text Do you wear eyeglasses or contact lenses to read books or newspapers, write, tasks that require you to see well close up such as cooking, sewing or fixing things?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,D,R> [go to VIMDRIVE]
Question ID ACN.440.120
Variable Name VIMDRIVE
Universe-text Sample adults 18+ wear glasses or contacts
Question Text Do you wear eyeglasses or contact lenses to drive, read road and street signs, watch TV, or see things in the distance?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1,2,D,R> [go to AVISREH]
Question ID ACN.440.130
Variable Name AVISREH
Universe-text Sample adults 18+ who have trouble seeing
Question Text Do you use any vision rehabilitation services, such as job training, counseling, or training in daily living skills and mobility?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1 2,R,D> [goto AVISDEV]
Question ID ACN.440.140
Variable Name AVISDEV
Universe-text Sample adults 18+ who have trouble seeing
Question Text Do you use any adaptive devices such as telescopic or other prescriptive lenses, magnifiers,
large print or talking materials, CCTV, white cane, or guide dog?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions if ABLIND = 2 then <1 2,R,D> [goto AVDF_NWS]; else goto AVISEXAM]
Question ID ACN.441_01.010
Variable Name AVDF_NWS
Universe-text Sample adults 18+ who are not blind
Question Text (CARD A6) Even when wearing glasses or contacts lenses, because of your eyesight, how difficult is it for you...to read ordinary print in newspapers?
Answer Codes 0.Not at all difficult
1.Only a little difficult
2.Somewhat difficult
3.Very difficult
4.Can't do at all because of eyesight
6. Do not do this activity for other reasons
Refused
Don't know
Skip Instructions <1 2,R,D> [goto AVDF_CLS]
Question ID ACN.441_02.020
Variable Name AVDF_CLS
Universe-text Sample adults 18+ who are not blind
Question Text (CARD A6) Even when wearing glasses or contacts lenses, because of your eyesight, how difficult is it for you...
To do work or hobbies that require you to see well up close such as cooking, sewing, fixing things around the house or using hand tools?
Answer Codes 0.Not at all difficult
1.Only a little difficult
2.Somewhat difficult
3.Very difficult
4.Can't do at all because of eyesight
6. Do not do this activity for other reasons
Refused
Don't know
Skip Instructions <1 2,R,D> [goto AVDF_NIT]
Question ID ACN.441_03.030
Variable Name AVDF_NIT
Universe-text Sample adults 18+ who are not blind
Question Text (CARD A6) Even when wearing glasses or contacts lenses, because of your eyesight, how difficult is it for you...to go down steps, stairs or curbs in dim light or at night?
Answer Codes 0.Not at all difficult
1.Only a little difficult
2.Somewhat difficult
3.Very difficult
4.Can't do at all because of eyesight
6. Do not do this activity for other reasons
Refused
Don't know
Skip Instructions <1 2,R,D> [goto AVDF_DRV]
Question ID ACN.441_04.040
Variable Name AVDF_DRV
Universe-text Sample adults 18+ who are not blind
Question Text (CARD A6) Even when wearing glasses or contacts lenses, because of your eyesight, how difficult is it for you...to drive during daytime in familiar places?
Answer Codes 0.Not at all difficult
1.Only a little difficult
2.Somewhat difficult
3.Very difficult
4.Can't do at all because of eyesight
6. Do not do this activity for other reasons
Refused
Don't know
Skip Instructions <1 2,R,D> [goto AVDF_PER]
Question ID ACN.441_05.050
Variable Name AVDF_PER
Universe-text Sample adults 18+ who are not blind
Question Text (CARD A6) Even when wearing glasses or contacts lenses, because of your eyesight, how difficult is it for you...to notice objects off to the side while you are walking along?
Answer Codes 0.Not at all difficult
1.Only a little difficult
2.Somewhat difficult
3.Very difficult
4.Can't do at all because of eyesight
6. Do not do this activity for other reasons
Refused
Don't know
Skip Instructions <1 2,R,D> [goto AVDF_CRD]
Question ID ACN.441_06.060
Variable Name AVDF_CRD
Universe-text Sample adults 18+ who are not blind
Question Text (CARD A6) Even when wearing glasses or contacts lenses, because of your eyesight, how difficult is it for you...To find something on a crowded shelf?
Answer Codes 0.Not at all difficult
1.Only a little difficult
2.Somewhat difficult
3.Very difficult
4.Can't do at all because of eyesight
6. Do not do this activity for other reaons
Refused
Don't know
Skip Instructions <1 2,R,D> [goto AVISEXAM]
Question ID ACN.442.010
Variable Name AVISEXAM
Universe-text Sample adults 18+
Question Text When was the last time you had an eye exam in which the pupils were dilated? This would have made you temporarily sensitive to bright light.
Answer Codes 1. Less than one month
2. 1-12 months
3. 13-24 months
4. more than 2 years
5. Never
Refused
Don't know
Skip Instructions <1 2,R,D> [goto AVISACT]
Question ID ACN.442.020
Variable Name AVISACT
Universe-text Sample adults 18+
Question Text Outside of work, do you participate in sports, hobbies, or other activities that can cause eye
injury? This includes activities such as baseball, basketball, mowing the lawn, wood working, or working with chemicals?
Answer Codes 1. Yes
2. No
Refused
Don't know
Skip Instructions <1 2,R,D> [goto AVISPROT]
Question ID ACN.442.030
Variable Name AVISPROT
Universe-text Sample adults 18+
Question Text When doing these activities, on average, do you wear eye
protection always, most of the time, some of the time, or none of the time?
Answer Codes 1.Always
2. Most of the time
3.Some of the time
4.None of the time
Refused
Don't know
Skip Instructions <1 2,R,D> [goto LUPPRT]
Section Name Child Conditions, Limitations, Health Status
Question ID CHS.270.010
Variable Name CVISTST
Universe-text Sample children <6
Question Text Has {S.C.name} EVER had {his/her} vision tested by
a doctor or other health professional?
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1> [goto CVISLT]
<2,R,D> [go to IHSPEQ]
Question ID CHS.270.020
Variable Name CVISLT
Universe-text Sample children <6 ever had vision tested
Question Text When was {his/her} vision last tested?
Answer Codes 1.in the last 12 months
2.in the last 13-24 months
3.over 24 months
Refused
Don't know
Skip Instructions <1-3,R,D> [go to CVISGLAS]
Question ID CHS.270.025
Variable Name CVISGLAS
Universe-text Sample children <18
Question Text Does {S.C. child} wear eyeglasses or contact lenses?
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1> [goto CVISDIST]
<2,R,D> [go to CVISACT ]
Question ID CHS.270.030
Variable Name CVISDIST
Universe-text Sample children <18 wear glasses or contact lenses
Question Text Does {S.C. Name} wear eyeglasses or contact lenses to read road and street signs, see the
blackboard, play sports, watch TV, or see things in the distance?
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2,R,D> [go to CVISREAD ]
Question ID CHS.270.035
Variable Name CVISREAD
Universe-text Sample children <18 wear glasses or contact lenses
Question Text Does {S.C. Name} wear eyeglasses or contact lenses to read books, write, play hand-held
games, to do other things that require {her/him} to see well up close?
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1,2,R,D> [go to CVISACT ]
Question ID CHS.270.040
Variable Name CVISACT
Universe-text Sample children 6-17
Question Text Does {S.C name} participate in sports, hobbies, or other activities that can cause eye injury?
This includes activities such as baseball, basketball, soccer and mowing the lawn.
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skip Instructions <1> [go to CVISPROT] <2,R,D> [go to IHSPEQ]
Question ID CHS.270.050
Variable Name CVISPROT
Universe-text Sample children 6-17 participate in sports that cause eye injuries
Question Text When doing these activities, on average, does {he/she} wear eye protection always, most of the time, some of the time, or none of the time?
Answer Codes 1.Always
2.Most of the time
3.Some of the time
4.None of the time
Refused
Don't know
Skip Instructions <1,2,R,D> [go to IHSPEQ]
| File Type | application/msword |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |