Form 10 Adult Epilepsy--Line 10

Attachment 3i Adult Epilepsy (1 minute)
Page 1 of 2

DRAFT 2010 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:

ACN.192_00.010 Instrument Variable Name:

QuestionText:

EPILEP1

QuestionnaireFileName:

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto EPILEP2] <2,R,D> [goto AHAYFYR]

ACN.192_00.020 Instrument Variable Name:

QuestionText:

EPILEP2

QuestionnaireFileName:

Sample Adult

Are you currently taking any medicine to control your seizure disorder or epilepsy?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who have ever been told they have epilepsy or a seizure disorder

SkipInstructions:

<1,2,R,D> [goto EPILEP3]

Question ID:

Sample Adult

Have you ever been told by a doctor that you have a seizure disorder or epilepsy?

1

Question ID:

23-Jul-09

ACN.192_00.030 Instrument Variable Name:

QuestionText:

EPILEP3

QuestionnaireFileName:

Sample Adult

Today is [fill: Current Date]. Think back to last year about the same time. About how many seizures of any type have you
had in the past year?
*Read if necessary: Some people may call it “convulsion,” “fit,” “falling out spell,” “episode,” “attack,” “drop attack,”
“staring spell,” or “out-of-touch.”.
*If the respondent mentions and counts “auras” as seizures accept the response. If a respondent indicates that he/she has
had nothing more than an aura and is unsure about counting the aura(s), do NOT count auras as seizures.

1
2
3
4
5
7
9

None
One
Two or three
Between four and ten
More than 10
Refused
Don't know

UniverseText:

Sample adults 18+ who have ever been told they have epilepsy or a seizure disorder

SkipInstructions:

<1-5,R,D> [goto EPILEP4]

Page 2 of 2

DRAFT 2010 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:

ACN.192_00.040 Instrument Variable Name:

QuestionText:

EPILEP4

23-Jul-09
QuestionnaireFileName:

In the past year have you seen a neurologist or epilepsy specialist for your epilepsy or seizure disorder?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who have ever been told they have epilepsy or a seizure disorder

SkipInstructions:

<1,2,R,D> [goto EPILEP5]

Question ID:

Sample Adult

ACN.192_00.050 Instrument Variable Name:

QuestionText:

EPILEP5

QuestionnaireFileName:

DURING THE PAST 30 DAYS, to what extent has epilepsy or its treatment interfered with your normal activities like
working, school, or socializing with family or friends? Would you say…
*Read categories below.

1
2
3
4
5
7
9

Sample Adult

Not at all
Slightly
Moderately
Quite a bit
Extremely
Refused
Don't know

UniverseText:

Sample adults 18+ who have ever been told they have epilepsy or a seizure disorder

SkipInstructions:

<1-5,R,D> [goto AHAYFYR]