Form 11 Adult Quality of Life--Line 11

Attachment 3k Adult Quality of Life (5 minutes)
Page 1 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.100_00.000 Instrument Variable Name:

QuestionText:

VIS_SS

04-Aug-09
QuestionnaireFileName:

Sample Adult

We just finished our regular questions. These next questions are new and we are testing them. Some may sound similar to
questions you already answered.
Do you have difficulty seeing, even when wearing glasses? Would you say no difficulty, some difficulty, a lot of difficulty,
or are you unable to do this?

1

9

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1-3,R,D>[goto VIS_1]
<4> [goto HEAR_SS]

2
3
4
7

Question ID:

QOL.110_00.000 Instrument Variable Name:

QuestionText:

VIS_1

Sample Adult

QuestionnaireFileName:

Sample Adult

Do you wear glasses to see far away?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who are not unable to see

SkipInstructions:

<1,2,R,D>[goto VIS_2]

Question ID:

QuestionnaireFileName:

QOL.120_00.000 Instrument Variable Name:

QuestionText:

1
2
3
4
7
9

VIS_2

Do you have difficulty clearly seeing someone’s face across a room {fill: even when wearing these glasses}? Would you
say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

UniverseText:

Sample adults 18+ who are not unable to see

SkipInstructions:

<1-4,R,D>[goto VIS_3]

Page 2 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.130_00.000 Instrument Variable Name:

QuestionText:

VIS_3

Sample Adult

QuestionnaireFileName:

Sample Adult

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who are not unable to see

SkipInstructions:

<1,2,R,D>[goto VIS_4]

QOL.140_00.000 Instrument Variable Name:

QuestionText:

VIS_4

Do you have difficulty clearly seeing the picture on a coin {fill:even when wearing these glasses}? Would you say no
difficulty, some difficulty, a lot of difficulty, or are you unable to do this?

1

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

2
3
4
7
9
UniverseText:

Sample adults 18+ who are not unable to see

SkipInstructions:

<1-4,R,D>[goto HEAR_SS]

Question ID:

QuestionnaireFileName:

Do you wear glasses for reading or to see up close?

1

Question ID:

04-Aug-09

QOL.150_00.000 Instrument Variable Name:

QuestionText:

1

9
UniverseText:

Sample adults 18+

SkipInstructions:

<1-3,R,D>[goto HEAR_1]
<4>[goto MOB_SS]

3
4
7

QuestionnaireFileName:

Sample Adult

Do you have difficulty hearing, even when using a hearing aid? Would you say no difficulty, some difficulty, a lot of
difficulty, or are you unable to do this?
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

2

HEAR_SS

Page 3 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.160_00.000 Instrument Variable Name:

QuestionText:

HEAR_1

Sample Adult

QuestionnaireFileName:

Sample Adult

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+who are not unable to hear

SkipInstructions:

<1>[goto HEAR_2]
<2,R,D>[goto HEAR_3]

QOL.160_00.001 Instrument Variable Name:

QuestionText:

HEAR_2

How often do you use your hearing aid(s)? Would you say all of the time, some of the time, rarely, or never?

1

All of the time
Some of the time
Rarely
Never
Refused
Don't know

2
3
4
7
9
UniverseText:

Sample adults 18+ who use a hearing aid

SkipInstructions:

<1-4,R,D>[goto HEAR_3]

Question ID:

QuestionnaireFileName:

Do you use a hearing aid?

1

Question ID:

04-Aug-09

QOL.170_00.000 Instrument Variable Name:

QuestionText:

1
2
3
4
7
9

HEAR_3

QuestionnaireFileName:

Sample Adult

Do you have difficulty hearing what is said in a conversation with one other person in a quiet room {fill: even when
wearing your hearing aid(s)}? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

UniverseText:

Sample adults 18+who are not unable to hear

SkipInstructions:

<1-3,R,D>[goto HEAR_4]
<4>[goto MOB_SS]

Page 4 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.170_00.001 Instrument Variable Name:

QuestionText:

HEAR_4

04-Aug-09
QuestionnaireFileName:

Sample Adult

Do you have difficulty hearing what is said in a conversation with one other person in a noisier room {fill: even when
wearing your hearing aid(s)}? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?

1

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

2
3
4
7
9
UniverseText:

Sample adults 18+ who have no difficulty, some difficulty, a lot of difficulty, or refuse or don't know if they have
difficulty hearing what is said in a conversation with one other person in a quiet room

SkipInstructions:

<1-4,R,D>[goto MOB_SS]

Question ID:

QOL.180_00.000 Instrument Variable Name:

QuestionText:

QuestionnaireFileName:

Sample Adult

Do you have any difficulty walking or climbing steps? Would you say no difficulty, some difficulty, a lot of difficulty, or
are you unable to do this?

1

9

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1-4,R,D>[goto MOB_1]

2
3
4
7

Question ID:

MOB_SS

QOL.190_00.000 Instrument Variable Name:

QuestionText:

1

9
UniverseText:

Sample adults 18+

SkipInstructions:

<1-4,R,D>[goto MOB_2]

3
4
7

QuestionnaireFileName:

Sample Adult

Do you have difficulty moving around inside your home? Would you say no difficulty, some difficulty, a lot of difficulty,
or are you unable to do this?
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

2

MOB_1

Page 5 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.200_00.000 Instrument Variable Name:

QuestionText:

QuestionnaireFileName:

Sample Adult

Do you use any equipment or receive help with walking, climbing steps, or moving around?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1>[goto MOB_3A]
<2,R,D>[goto MOB_4]

Question ID:

MOB_2

04-Aug-09

QOL.200_00.001 Instrument Variable Name:

QuestionText:

MOB_3A

QuestionnaireFileName:

Sample Adult

Do you use any of the following…
Cane or walking stick?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who use equipment or receive help for walking, climbing steps, or moving around

SkipInstructions:

<1,2,R,D>[goto MOB_3B]

Question ID:

QOL.200_00.002 Instrument Variable Name:

QuestionText:

MOB_3B

QuestionnaireFileName:

Sample Adult

Do you use any of the following…
Walker or Zimmer frame?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who use equipment or receive help for walking, climbing steps, or moving around

SkipInstructions:

<1,2,R,D>[goto MOB_3C]

Page 6 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.200_00.003 Instrument Variable Name:

QuestionText:

MOB_3C

04-Aug-09
QuestionnaireFileName:

Sample Adult

Do you use any of the following…
Crutches?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who use equipment or receive help for walking, climbing steps, or moving around

SkipInstructions:

<1,2,R,D>[goto MOB_3D]

Question ID:

QOL.200_00.004 Instrument Variable Name:

QuestionText:

MOB_3D

QuestionnaireFileName:

Sample Adult

Do you use any of the following…
Wheelchair?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who use equipment or receive help for walking, climbing steps, or moving around

SkipInstructions:

<1,2,R,D>[goto MOB_3E]

Question ID:

QOL.200_00.005 Instrument Variable Name:

QuestionText:

MOB_3E

QuestionnaireFileName:

Sample Adult

Do you use any of the following…
Prothesis(es)?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who use equipment or receive help for walking, climbing steps, or moving around

SkipInstructions:

<1,2,R,D>[goto MOB_3F]

Page 7 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.200_00.006 Instrument Variable Name:

QuestionText:

04-Aug-09

MOB_3F

QuestionnaireFileName:

Sample Adult

Do you use any of the following…
Someone's assistance?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who use equipment or receive help for walking, climbing steps, or moving around

SkipInstructions:

<1,2,R,D>[goto MOB_3G]

Question ID:

QOL.200_00.007 Instrument Variable Name:

QuestionText:

MOB_3G

QuestionnaireFileName:

Sample Adult

Do you use any of the following…
Other type of equipment or help?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who use equipment or receive help for walking, climbing steps, or moving around

SkipInstructions:

<1>[goto MOBSPEC]
<2,R,D>
if MOB_3D='1' [goto COM_SS]
else [goto MOB_4]

Question ID:

QOL.200_00.008 Instrument Variable Name:

QuestionText:
7
9
verbatim

MOBSPEC

QuestionnaireFileName:

*Specify other type of equipment or help received for getting around
Refused
Don't know
verbatim

UniverseText:

Sample adults 18+ who use an other type of equipment or help for moving around

SkipInstructions:

if MOB_3D='1' [goto COM_SS]
else [goto MOB_4]

Sample Adult

Page 8 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.210_00.000 Instrument Variable Name:

QuestionText:

MOB_4

QuestionnaireFileName:

Sample Adult

Do you have difficulty walking 100 yards on level ground, that would be about the length of one football field or one city
block {fill: without the use of your aid}? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable
to do this?

1

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

2
3
4
7
9
UniverseText:

Sample adults 18+ who do not use a wheelchair

SkipInstructions:

<1-3,R,D>[goto MOB_5]
<4>[goto MOB_6]

Question ID:

04-Aug-09

QOL.220_00.000 Instrument Variable Name:

QuestionText:

MOB_5

QuestionnaireFileName:

Sample Adult

Do you have difficulty walking a third of a mile on level ground, that would be the length of five football fields or five
city blocks {fill: without the use of your aid}? Would you say no difficulty, some difficulty, a lot of difficulty, or are you
unable to do this?

1

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

2
3
4
7
9
UniverseText:

Sample adults 18+ who do not use a wheelchair and can walk 100 (meters/yards) on level ground

SkipInstructions:

<1-4,R,D>[goto MOB_6]

Question ID:

QOL.230_00.000 Instrument Variable Name:

QuestionText:

1
2
3
4
7
9

MOB_6

QuestionnaireFileName:

Sample Adult

Do you have difficulty walking up or down 12 steps {fill: without the use of your aid}? Would you say no difficulty, some
difficulty, a lot of difficulty, or are you unable to do this?
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

UniverseText:

Sample adults 18+ who do not use a wheelchair

SkipInstructions:

<1-4,R,D>
if MOB-2='2'[goto COM_SS]
else[goto MOB_7]

Page 9 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.240_00.000 Instrument Variable Name:

QuestionText:

MOB_7

04-Aug-09
QuestionnaireFileName:

Sample Adult

Do you have difficulty walking 100 yards on level ground, that would be about the length of one (1) football field or one
city block, when using your aid? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do
this?

1

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

2
3
4
7
9
UniverseText:

Sample adults 18+ who use equipment or receive help for getting around but do not use a wheelchair

SkipInstructions:

<1-3,R,D>[goto MOB_8]
<4>[goto MOB_9]

Question ID:

QOL.250_00.000 Instrument Variable Name:

QuestionText:

MOB_8

QuestionnaireFileName:

Sample Adult

Do you have difficulty walking a third of a mile on level ground, that would be the length of five football fields or five
city blocks, when using your aid? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do
this?

1

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

2
3
4
7
9
UniverseText:

Sample adults 18+ who use equipment or receive help for getting around but do not use a wheelchair and can walk
100 yards on level ground

SkipInstructions:

<1-4,R,D>[goto MOB_9]

Question ID:

QOL.260_00.000 Instrument Variable Name:

QuestionText:

1
2
3
4
7
9

MOB_9

QuestionnaireFileName:

Sample Adult

Do you have difficulty walking up or down 12 steps, even when using your aid? Would you say no difficulty, some
difficulty, a lot of difficulty, or are you unable to do this?
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

UniverseText:

Sample adults 18+ who use equipment or receive help for getting around but do not use a wheelchair

SkipInstructions:

<1-4,R,D>[goto COM_SS]

Page 10 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.270_00.000 Instrument Variable Name:

QuestionText:

COM_SS

QuestionnaireFileName:

9

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1-4,R,D>[goto COM_1]

2
3
4
7

QOL.280_00.000 Instrument Variable Name:

QuestionText:

COM_1

QuestionnaireFileName:

Sample Adult

Do people have difficulty understanding you when you speak? Would you say no difficulty, some difficulty, a lot of
difficulty, or are you unable to do this?

1

9

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

(if COM_SS IN (1,R,D) and COM_1 IN (1,R,D)) [goto COM_2]; else [goto P_COM_1A]

2
3
4
7

Question ID:

Sample Adult

Using you usual language, do you have difficulty communicating, for example understanding or being understood? Would
you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?

1

Question ID:

04-Aug-09

QOL.285_01.000 Instrument Variable Name:

QuestionText:

P_COM_1A

QuestionnaireFileName:

Which of the following, if any, are reasons for your difficulty communicating or being understood?
to each.

Sample Adult
Please say yes or no

…Because you sometimes talk too fast, feel shy or have trouble expressing yourself?
1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who have some difficulty, a lot of difficulty, or cannot communicate, or have some difficulty, a
lot of difficulty or cannot be understood when speaking

SkipInstructions:

<1,2,R,D>[goto P_COM_1B]

Page 11 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.285_02.000 Instrument Variable Name:

QuestionText:

04-Aug-09

P_COM_1B

QuestionnaireFileName:

Sample Adult

Which of the following, if any, are reasons for your difficulty communicating or being understood? Please say yes or no
to each.
…Because of a physical problem with your mouth or tongue?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who have some difficulty, a lot of difficulty, or cannot communicate, or have some difficulty, a
lot of difficulty or cannot be understood when speaking

SkipInstructions:

<1,2,R,D>[goto P_COM_1C]

Question ID:

QOL.285_03.000 Instrument Variable Name:

QuestionText:

P_COM_1C

QuestionnaireFileName:

Which of the following, if any, are reasons for your difficulty communicating or being understood?
to each.

Sample Adult
Please say yes or no

…Because you need to understand other languages or different ways of speaking?
1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who have some difficulty, a lot of difficulty, or cannot communicate, or have some difficulty, a
lot of difficulty or cannot be understood when speaking

SkipInstructions:

<1,2,R,D>[goto P_COM_1D]

Question ID:

QOL.285_04.000 Instrument Variable Name:

QuestionText:

P_COM_1D

QuestionnaireFileName:

Which of the following, if any, are reasons for your difficulty communicating or being understood?
to each.

Sample Adult
Please say yes or no

…Because you have trouble hearing?
1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who have some difficulty, a lot of difficulty, or cannot communicate, or have some difficulty, a
lot of difficulty or cannot be understood when speaking

SkipInstructions:

<1,2,R,D>[goto P_COM_2]

Page 12 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.290_00.000 Instrument Variable Name:

QuestionText:

QuestionnaireFileName:

Sample Adult

COG_SS

QuestionnaireFileName:

Sample Adult

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

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

QOL.300_00.000 Instrument Variable Name:

QuestionText:

Do you have difficulty remembering or concentrating? Would you say no difficulty, some difficulty, a lot of difficulty, or
are you unable to do this?

1

9

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1>[goto UB_SS]
<2-4,R,D>[goto COG_1]

2
3
4
7

Question ID:

COM_2

Do you use sign language?

1

Question ID:

04-Aug-09

QOL.310_00.000 Instrument Variable Name:

QuestionText:

1
2
3
7
9

COG_1

QuestionnaireFileName:

Sample Adult

Do you have difficulty remembering, concentrating, or both? Would you say no difficulty, some difficulty, a lot of
difficulty, or are you unable to do this?
Difficulty remembering only
Difficulty concentrating only
Difficulty with both remembering and concentrating
Refused
Don't know

UniverseText:

Sample adults 18+ who have difficulty remembering or concentrating

SkipInstructions:

<1,3,R,D>[goto COG_2]
<2>[goto COG_4]

Page 13 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.320_00.000 Instrument Variable Name:

QuestionText:

04-Aug-09

COG_2

Sometimes
Often
All of the time
Refused
Don't know

2
3
7
9
UniverseText:

Sample adults 18+ who have difficulty remembering

SkipInstructions:

<1,2,3,R,D>[goto COG_3]

QOL.330_00.000 Instrument Variable Name:

QuestionText:

COG_3

QuestionnaireFileName:

Sample Adult

Do you have difficulty remembering a few things, a lot of things, or almost everything?

1

A few things
A lot of things
Almost everything
Refused
Don't know

2
3
7
9
UniverseText:

Sample adults 18+ who have difficulty remembering

SkipInstructions:

<1,2,3,R,D>[goto P_COG_3A]

Question ID:

Sample Adult

How often do you have difficulty remembering? Would you say sometimes, often or all of the time?

1

Question ID:

QuestionnaireFileName:

QOL.335_01.000 Instrument Variable Name:

QuestionText:

P_COG_3A

2
7
9

Sample Adult

Which of the following statements, if any, describe your difficulty remembering? Please say yes or no to each?
…I forget things because I am busy and have too much to remember.

1

QuestionnaireFileName:

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who have difficulty remembering

SkipInstructions:

<1,2,3,R,D>[goto P_COG_3B]

Page 14 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.335_02.000 Instrument Variable Name:

QuestionText:

04-Aug-09

P_COG_3B

QuestionnaireFileName:

Sample Adult

Which of the following statements, if any, describe your difficulty remembering? Please say yes or no to each?
…My difficulty is getting worse.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who have difficulty remembering

SkipInstructions:

<1,2,3,R,D>[goto P_COG_3C]

Question ID:

QOL.335_03.000 Instrument Variable Name:

QuestionText:

P_COG_3C

QuestionnaireFileName:

Sample Adult

Which of the following statements, if any, describe your difficulty remembering? Please say yes or no to each?
…My difficulty has put me or my family in danger.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who have difficulty remembering

SkipInstructions:

<1,2,3,R,D>[goto P_COG_3D]

Question ID:

QOL.335_04.000 Instrument Variable Name:

QuestionText:

P_COG_3D

2
7
9

Sample Adult

Which of the following statements, if any, describe your difficulty remembering? Please say yes or no to each?
…I only forget little or inconsequential things.

1

QuestionnaireFileName:

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who have difficulty remembering

SkipInstructions:

<1,2,3,R,D>[goto P_COG_3E]

Page 15 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.335_05.000 Instrument Variable Name:

QuestionText:

04-Aug-09

P_COG_3E

QuestionnaireFileName:

Sample Adult

Which of the following statements, if any, describe your difficulty remembering? Please say yes or no to each?
…I must write down important things, such as my address or when to take medicine, so that I do not forget.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who have difficulty remembering

SkipInstructions:

<1,2,3,R,D>[goto P_COG_3F]

Question ID:

QOL.335_06.000 Instrument Variable Name:

QuestionText:

P_COG_3F

QuestionnaireFileName:

Sample Adult

Which of the following statements, if any, describe your difficulty remembering? Please say yes or no to each?
…My family members or friends are worried about my difficulty remembering.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who have difficulty remembering

SkipInstructions:

<1,2,3,R,D>[goto P_COG_3G]

Question ID:

QOL.335_07.000 Instrument Variable Name:

QuestionText:

P_COG_3G

2
7
9

Sample Adult

Which of the following statements, if any, describe your difficulty remembering? Please say yes or no to each?
…My difficulty is normal for someone my age.

1

QuestionnaireFileName:

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who have difficulty remembering

SkipInstructions:

if COG_1=1 [goto UB_SS]
else [goto COG_4]

Page 16 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.340_00.000 Instrument Variable Name:

QuestionText:

04-Aug-09

COG_4

Sample Adult

How much difficulty do you have concentrating for ten minutes? Would you say a little, a lot, or somewhere in between?

1

A little
A lot
Somewhere in between a little and a lot
Refused
Don't know

2
3
7
9
UniverseText:

Sample adults 18+ who have difficulty concentrating

SkipInstructions:

<1,2,R,D>[goto UB_SS]
<3>[goto COG_5]

Question ID:

QuestionnaireFileName:

QOL.350_00.000 Instrument Variable Name:

QuestionText:

COG_5

QuestionnaireFileName:

Sample Adult

Would you say this is closer to a little, closer to a lot, or exactly in the middle?

1

Closer to a little
Closer to a lot
Exactly in the middle
Refused
Don't know

2
3
7
9
UniverseText:

Sample adults 18+ who have somewhere in between a little and a lot of difficulty concentrating for ten minutes

SkipInstructions:

<1,2,3,R,D>[goto UB_SS]

Question ID:

QOL.360_00.000 Instrument Variable Name:

QuestionText:

1

9
UniverseText:

Sample adults 18+

SkipInstructions:

<1-4,R,D>[goto UB_1]

3
4
7

QuestionnaireFileName:

Sample Adult

Do you have difficulty with self care, such as washing all over or dressing? Would you say no difficulty, some difficulty, a
lot of difficulty, or are you unable to do this?
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

2

UB_SS

Page 17 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.370_00.000 Instrument Variable Name:

QuestionText:

9

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1-4,R,D>[goto UB_2]

2
3
4
7

QOL.380_00.000 Instrument Variable Name:

QuestionText:

Sample Adult

UB_2

QuestionnaireFileName:

Sample Adult

Do you have difficulty using your hands and fingers, such as picking up small objects, for example, a button or pencil, or
opening or closing containers or bottles? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable
to do this?

1

9

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1-4,R,D>[goto LEARN_1]

2
3
4
7

Question ID:

QuestionnaireFileName:

Do you have difficulty raising a 2 liter bottle of water or soda from waist to eye level? Would you say no difficulty, some
difficulty, a lot of difficulty, or are you unable to do this?

1

Question ID:

UB_1

04-Aug-09

QOL.390_00.000 Instrument Variable Name:

QuestionText:

1

9
UniverseText:

Sample adults 18+

SkipInstructions:

<1-4,R,D>[goto LEARN_2]

3
4
7

QuestionnaireFileName:

Sample Adult

Do you have difficulty learning the rules for a new game? Would you say no difficulty, some difficulty, a lot of difficulty,
or are you unable to do this?
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

2

LEARN_1

Page 18 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.400_00.000 Instrument Variable Name:

QuestionText:

9

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1-4,R,D>[goto ANX_1]

2
3
4
7

QOL.410_00.000 Instrument Variable Name:

QuestionText:

Sample Adult

ANX_1

QuestionnaireFileName:

Sample Adult

How often do you feel worried, nervous or anxious? Would you say daily, weekly, monthly, a few times a year, or never?

1

Daily
Weekly
Monthly
A few times a year
Never
Refused
Don't know

2
3
4
5
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1-5,R,D>[goto ANX_2]

Question ID:

QuestionnaireFileName:

Do you have difficulty understanding and following instructions for example, to use a cell phone or to get to a new place?
Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?

1

Question ID:

LEARN_2

04-Aug-09

QOL.420_00.000 Instrument Variable Name:

QuestionText:
1
2
7
9

ANX_2

Do you take medication for these feelings?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

if (ANX_1 IN (4,5) and ANX_2=2) [goto DEP_1];
else [goto ANX_3]

QuestionnaireFileName:

Sample Adult

Page 19 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.430_00.000 Instrument Variable Name:

QuestionText:

04-Aug-09

ANX_3

QuestionnaireFileName:

Sample Adult

Thinking about the last time you felt worried, nervous or anxious, how would you describe the level of these feelings?
Would you say a little, a lot, or somewhere in between?

1

A little
A lot
Somewhere in between a little and a lot
Refused
Don't know

2
3
7
9
UniverseText:

Sample adults 18+ who feel worried, anxious, or nervous daily, weekly, or monthly and do not take medication for
these feelings

SkipInstructions:

<1,2,R,D>[goto P_ANX_4A]
<3>[goto ANX_4]

Question ID:

QOL.440_00.000 Instrument Variable Name:

QuestionText:

ANX_4

QuestionnaireFileName:

Sample Adult

Would you say this was closer to a little, closer to a lot, or exactly in the middle?

1

Closer to a little
Closer to a lot
Exactly in the middle
Refused
Don’t know

2
3
7
9
UniverseText:

Sample adults 18+ who feel worried, anxious, or nervous daily, weekly, or monthly and the last time they felt
worried, anxious, or nervous described the level of these feelings as somewhere in between a little and a lot

SkipInstructions:

<1-3,R,D>[goto P_ANX_4A]

Question ID:

QOL.445_01.000 Instrument Variable Name:

QuestionText:

P_ANX_4A

QuestionnaireFileName:

Sample Adult

Which of the following statements, if any, describe your feelings of being worried, nervous, or anxious? Please say yes or
no to each.
…My feelings are caused by the type and amount of work I do.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who feel worried, anxious, or nervous daily, weekly, or monthly and do not take medication for
these feelings

SkipInstructions:

<1,2,R,D>[goto P_ANX_4B]

Page 20 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.445_02.000 Instrument Variable Name:

QuestionText:

04-Aug-09

P_ANX_4B

QuestionnaireFileName:

Sample Adult

Which of the following statements, if any, describe your feelings of being worried, nervous, or anxious? Please say yes or
no to each.
…Sometimes the feelings can be so intense that my chest hurts and I have trouble breathing.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who feel worried, anxious, or nervous daily, weekly, or monthly and do not take medication for
these feelings

SkipInstructions:

<1,2,R,D>[goto P_ANX_4C]

Question ID:

QOL.445_03.000 Instrument Variable Name:

QuestionText:

P_ANX_4C

QuestionnaireFileName:

Sample Adult

Which of the following statements, if any, describe your feelings of being worried, nervous, or anxious? Please say yes or
no to each.
…These are positive feelings that help me to accomplish goals and be productive.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who feel worried, anxious, or nervous daily, weekly, or monthly and do not take medication for
these feelings

SkipInstructions:

<1,2,R,D>[goto P_ANX_4D]

Question ID:

QOL.445_04.000 Instrument Variable Name:

QuestionText:

P_ANX_4D

QuestionnaireFileName:

Sample Adult

Which of the following statements, if any, describe your feelings of being worried, nervous, or anxious? Please say yes or
no to each.
…The feelings sometimes interfere with my life, and I wish that I did not have them.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who feel worried, anxious, or nervous daily, weekly, or monthly and do not take medication for
these feelings

SkipInstructions:

<1,2,R,D>[goto P_ANX_4E]

Page 21 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.445_05.000 Instrument Variable Name:

QuestionText:

04-Aug-09

P_ANX_4E

QuestionnaireFileName:

Sample Adult

Which of the following statements, if any, describe your feelings of being worried, nervous, or anxious? Please say yes or
no to each.
…If I had more money or a better job, I would not have these feelings.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who feel worried, anxious, or nervous daily, weekly, or monthly and do not take medication for
these feelings

SkipInstructions:

<1,2,R,D>[goto P_ANX_4F]

Question ID:

QOL.445_06.000 Instrument Variable Name:

QuestionText:

P_ANX_4F

QuestionnaireFileName:

Sample Adult

Which of the following statements, if any, describe your feelings of being worried, nervous, or anxious? Please say yes or
no to each.
…Everybody has these feelings. They are part of life and are normal.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who feel worried, anxious, or nervous daily, weekly, or monthly and do not take medication for
these feelings

SkipInstructions:

<1,2,R,D>[goto P_ANX_4G]

Question ID:

QOL.445_07.000 Instrument Variable Name:

QuestionText:

P_ANX_4G

QuestionnaireFileName:

Sample Adult

Which of the following statements, if any, describe your feelings of being worried, nervous, or anxious? Please say yes or
no to each.
…I have been told by a medical prefessional that I have anxiety.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who feel worried, anxious, or nervous daily, weekly, or monthly and do not take medication for
these feelings

SkipInstructions:

<1,2,R,D>[goto DEP_1]

Page 22 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.450_00.000 Instrument Variable Name:

QuestionText:

04-Aug-09

DEP_1

Sample Adult

How often do you feel depressed? Would you say daily, weekly, monthly, a few times a year, or never?

1

Daily
Weekly
Monthly
A few times a year
Never
Refused
Don't know

2
3
4
5
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1-5,R,D>[goto DEP_2]

Question ID:

QOL.460_00.000 Instrument Variable Name:

QuestionText:

Do you take medication for depression?

1

DEP_2

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

(if DEP_1 IN (4,5) and DEP_2=2) [goto P_DEP_4A]
else [goto DEP_3]

Question ID:

QuestionnaireFileName:

QOL.470_00.000 Instrument Variable Name:

QuestionText:

1
2
3
7
9

DEP_3

Thinking about the last time you felt depressed, how depressed did you feel? Would you say a little, a lot, or somewhere in
between?
A little
A lot
Somewhere in between a little and a lot
Refused
Don't know

UniverseText:

Sample adults 18+ who feel depressed or who take medication for depression

SkipInstructions:

<1,2,R,D>[goto P_DEP_4A]
<3>[goto DEP_4]

Page 23 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.480_00.000 Instrument Variable Name:

QuestionText:

04-Aug-09

DEP_4

QuestionnaireFileName:

Sample Adult

Would you say this was closer to a little, closer to a lot, or exactly in the middle?

1

Closer to a little
Closer to a lot
Exactly in the middle
Refused
Don’t know

2
3
7
9
UniverseText:

Sample adults 18+ who feel depressed and the last time they felt depressed described the level of this feeling as
somewhere in between a little and a lot

SkipInstructions:

<1-3,R,D>[goto P_DEP_4A]

Question ID:

QOL.485_01.000 Instrument Variable Name:

QuestionText:

P_DEP_4A

QuestionnaireFileName:

Sample Adult

Which of the following statements, in any, describe your feelings of being depressed? Please say yes or no to each.
…My feelings are caused by the death of a loved one.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who feel depressed or who take medication for depression

SkipInstructions:

<1,2,R,D>[goto P_DEP_4B]

Question ID:

QOL.485_02.000 Instrument Variable Name:

QuestionText:

P_DEP_4B

QuestionnaireFileName:

Which of the following statements, in any, describe your feelings of being depressed? Please say yes or no to each
.…Sometimes the feelings can be so intense that I cannot get out of bed.

1
2
7
9

Sample Adult

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who feel depressed or who take medication for depression

SkipInstructions:

<1,2,R,D>[goto P_DEP_4C]

Page 24 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.485_03.000 Instrument Variable Name:

QuestionText:

04-Aug-09

P_DEP_4C

QuestionnaireFileName:

Sample Adult

Which of the following statements, in any, describe your feelings of being depressed? Please say yes or no to each
…The feelings sometimes interfere with my life, and I wish I did not have them.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who feel depressed or who take medication for depression

SkipInstructions:

<1,2,R,D>[goto P_DEP_4D]

Question ID:

QOL.485_04.000 Instrument Variable Name:

QuestionText:

P_DEP_4D

QuestionnaireFileName:

Sample Adult

Which of the following statements, in any, describe your feelings of being depressed? Please say yes or no to each
…If I had more money or a better job, I would not have these feelings.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who feel depressed or who take medication for depression

SkipInstructions:

<1,2,R,D>[goto P_DEP_4E]

Question ID:

QOL.485_05.000 Instrument Variable Name:

QuestionText:

P_DEP_4E

QuestionnaireFileName:

Which of the following statements, in any, describe your feelings of being depressed? Please say yes or no to each
…Everybody has these feelings. They are part of life and normal.

1
2
7
9

Sample Adult

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who feel depressed or who take medication for depression

SkipInstructions:

<1,2,R,D>[goto P_DEP_4F]

Page 25 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.485_06.000 Instrument Variable Name:

QuestionText:

04-Aug-09

P_DEP_4F

QuestionnaireFileName:

Sample Adult

Which of the following statements, in any, describe your feelings of being depressed? Please say yes or no to each
…I have been told by a medical professional that I have depression.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who feel depressed or who take medication for depression

SkipInstructions:

<1,2,R,D>[goto PAIN_1]

Question ID:

QOL.490_00.000 Instrument Variable Name:

QuestionText:

QuestionnaireFileName:

Sample Adult

PAIN_2

QuestionnaireFileName:

Sample Adult

Do you have frequent pain?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto PAIN_2]

Question ID:

PAIN_1

QOL.500_00.000 Instrument Variable Name:

QuestionText:
1
2
3
4
7
9

In the past 3 months, how often did you have pain? Would you say never, some days, most days, or every day?
Never
Some days
Most days
Every day
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

(if PAIN_1=2 and PAIN_2=1) [goto TIRED_1];
else [goto PAIN_3]

Page 26 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.510_00.000 Instrument Variable Name:

QuestionText:

PAIN_3

04-Aug-09
QuestionnaireFileName:

Thinking about the last time you had pain, how long did the pain last? Would you say some of the day, most of the day, or
all of the day?

1

Some of the day
Most of the day
All of the day
Refused
Don't know

2
3
7
9
UniverseText:

Sample adults 18+ who have frequent pain or have had pain in the past 3 months

SkipInstructions:

<1-3,R,D>[goto PAIN_4]

Question ID:

QOL.520_00.000 Instrument Variable Name:

QuestionText:

PAIN_4

QuestionnaireFileName:

Sample Adult

Thinking about the last time you had pain, how much pain did you have? Would you say a little, a lot, or somewhere in
between?

1

Closer to a little
Closer to a lot
Exactly in the middle
Refused
Don’t know

2
3
7
9
UniverseText:

Sample adults 18+ who have frequent pain or have had pain in the past 3 months

SkipInstructions:

<1,2,R,D>[goto P_PAIN5A]
<3>[goto PAIN_5]

Question ID:

Sample Adult

QOL.530_00.000 Instrument Variable Name:

QuestionText:
1
2
3
7
9

PAIN_5

QuestionnaireFileName:

Sample Adult

Would you say the amount of pain was closer to a little, closer to a lot, or exactly in the middle?
Closer to a little
Closer to a lot
Exactly in the middle
Refused
Don’t know

UniverseText:

Sample adults 18+ who the last time they had pain it was somewhere between a little and a lot

SkipInstructions:

<1-3,R,D>[goto P_PAIN5A]

Page 27 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.535_01.000 Instrument Variable Name:

QuestionText:

04-Aug-09

P_PAIN5A

QuestionnaireFileName:

Sample Adult

Which of the following statements, if any, describe your feelings of pain? Please say yes or no to each.
…It is constantly present.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who have frequent pain or have had pain in the past 3 months

SkipInstructions:

<1,2,R,D>[goto P_PAIN5B]

Question ID:

QOL.535_02.000 Instrument Variable Name:

QuestionText:

P_PAIN5B

QuestionnaireFileName:

Sample Adult

Which of the following statements, if any, describe your feelings of pain? Please say yes or no to each.
…Sometimes I'm in a lot of pain and sometimes it's not so bad.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who have frequent pain or have had pain in the past 3 months

SkipInstructions:

<1,2,R,D>[goto P_PAIN5C]

Question ID:

QOL.535_03.000 Instrument Variable Name:

QuestionText:

P_PAIN5C

QuestionnaireFileName:

Which of the following statements, if any, describe your feelings of pain? Please say yes or no to each.
…Sometimes it is unbearable and excruciating.

1
2
7
9

Sample Adult

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who have frequent pain or have had pain in the past 3 months

SkipInstructions:

<1,2,R,D>[goto P_PAIN5D]

Page 28 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.535_04.000 Instrument Variable Name:

QuestionText:

04-Aug-09

P_PAIN5D

QuestionnaireFileName:

Sample Adult

Which of the following statements, if any, describe your feelings of pain? Please say yes or no to each.
…When I get my mind on other things, I am not aware of the pain.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who have frequent pain or have had pain in the past 3 months

SkipInstructions:

<1,2,R,D>[goto P_PAIN5E]

Question ID:

QOL.535_05.000 Instrument Variable Name:

QuestionText:

P_PAIN5E

QuestionnaireFileName:

Sample Adult

Which of the following statements, if any, describe your feelings of pain? Please say yes or no to each.
…Medication can take my pain away completely.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who have frequent pain or have had pain in the past 3 months

SkipInstructions:

<1,2,R,D>[goto P_PAIN5F]

Question ID:

QOL.535_06.000 Instrument Variable Name:

QuestionText:

P_PAIN5F

QuestionnaireFileName:

Which of the following statements, if any, describe your feelings of pain? Please say yes or no to each.
…My pain is because of work.

1
2
7
9

Sample Adult

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who have frequent pain or have had pain in the past 3 months

SkipInstructions:

<1,2,R,D>[goto P_PAIN5G]

Page 29 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.535_07.000 Instrument Variable Name:

QuestionText:

P_PAIN5G

04-Aug-09
QuestionnaireFileName:

Sample Adult

Which of the following statements, if any, describe your feelings of pain? Please say yes or no to each.
…My pain is because of exercise.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who have frequent pain or have had pain in the past 3 months

SkipInstructions:

<1,2,R,D>[goto TIRED_1]

Question ID:

QOL.540_00.000 Instrument Variable Name:

QuestionText:

QuestionnaireFileName:

Sample Adult

In the past 3 months, how often did you feel very tired or exhausted? Would you say never, some days, most days, or
every day?

1

Never
Some days
Most days
Every day
Refused
Don't know

2
3
4
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1>[goto QOL_1]
<2-4,R,D>[goto TIRED_2]

Question ID:

TIRED_1

QOL.550_00.000 Instrument Variable Name:

QuestionText:

1
2
3
7
9

TIRED_2

QuestionnaireFileName:

Sample Adult

Thinking about the last time you felt very tired or exhausted, how long did it last? Would you say some of the day, most of
the day, or all of the day?
Some of the day
Most of the day
All of the day
Refused
Don't know

UniverseText:

Sample adults 18+ who feel very tired or exhausted some days, most days, or every day

SkipInstructions:

<1-3,R,D>[goto TIRED_3]

Page 30 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.560_00.000 Instrument Variable Name:

QuestionText:

04-Aug-09

TIRED_3

QuestionnaireFileName:

Thinking about the last time you felt this way, how would you describe the level of tiredness? Would you say a little, a lot,
or somewhere in between?

1

A little
A lot
Somewhere in between a little and a lot
Refused
Don't know

2
3
7
9
UniverseText:

Sample adults 18+ who feel very tired or exhausted some days, most days, or every day

SkipInstructions:

<1,2,R,D>[goto PTIRED4A]
<3>[goto TIRED_4]

Question ID:

Sample Adult

QOL.570_00.000 Instrument Variable Name:

QuestionText:

TIRED_4

QuestionnaireFileName:

Sample Adult

Would you say it was closer to a little, closer to a lot, or exactly in the middle?

1

Closer to a little
Closer to a lot
Exactly in the middle
Refused
Don’t know

2
3
7
9
UniverseText:

Sample adults 18+ who feel very tired or exhausted some days, most days, or every day and the last time they felt
this way the level of tiredness was somewhere between a little and a lot

SkipInstructions:

<1-3,R,D>[goto PTIRED4A]

Question ID:

QOL.575_01.000 Instrument Variable Name:

QuestionText:

PTIRED4A

QuestionnaireFileName:

Is your tiredness the result of any of the following? Please say yes or no to each.
…Too much work or exercise?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who feel very tired or exhausted some days, most days, or every day

SkipInstructions:

<1,2,R,D>[goto PTIRED4B]

Sample Adult

Page 31 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.575_02.000 Instrument Variable Name:

QuestionText:

04-Aug-09

PTIRED4B

QuestionnaireFileName:

Sample Adult

Is your tiredness the result of any of the following? Please say yes or no to each.
…Not getting enough sleep?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who feel very tired or exhausted some days, most days, or every day

SkipInstructions:

<1,2,R,D>[goto PTIRED4C]

Question ID:

QOL.575_03.000 Instrument Variable Name:

QuestionText:

PTIRED4C

QuestionnaireFileName:

Sample Adult

Is your tiredness the result of any of the following? Please say yes or no to each.
…A physical or health-related problem?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who feel very tired or exhausted some days, most days, or every day

SkipInstructions:

<1,2,R,D>[goto PTIRED4D]

Question ID:

QOL.575_04.000 Instrument Variable Name:

QuestionText:

PTIRED4D

QuestionnaireFileName:

Is your tiredness the result of any of the following? Please say yes or no to each.
…Something else?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who feel very tired or exhausted some days, most days, or every day

SkipInstructions:

<1> [goto PTIRED4E]
else [goto QOL_1]

Sample Adult

Page 32 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.575_05.000 Instrument Variable Name:

QuestionText:

PTIRED4E

04-Aug-09
QuestionnaireFileName:

Sample Adult

*Specify other reason for tiredness

7

Refused
Don't know
verbatim

9
Verbatim
UniverseText:

Sample adults 18+ who feel very tired or exhausted some days, most days, or every day and say something else for
reason for tiredness

SkipInstructions:

[goto QOL_1]

Question ID:

QOL.580_00.000 Instrument Variable Name:

QuestionText:

QuestionnaireFileName:

Sample Adult

Are you limited in your ability to carry out daily activities? Would you say not at all, a little, a lot, or completely limited?

1

Not at all
A little
A lot
Completely
Refused
Don't know

2
3
4
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1-4,R,D>[goto QOL_2B]

Question ID:

QOL_1

QOL.590_00.002 Instrument Variable Name:

QuestionText:

2
3
7
9

QuestionnaireFileName:

Sample Adult

For each of the following activities, please tell me if you do the activity, don't do the activity, or are unable to do the
activity.
Working outside the home to earn an income?

1

QOL_2B

Do the activity
Don't do the activity
Unable to do the activity
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1-3,R,D>[goto QOL_2C]

Page 33 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.590_00.003 Instrument Variable Name:

QuestionText:

QOL_2C

04-Aug-09
QuestionnaireFileName:

Sample Adult

For each of the following activities, please tell me if you do the activity, don't do the activity, or are unable to do the
activity.
Going to school or achieving your education goals?

1

Do the activity
Don't do the activity
Unable to do the activity
Refused
Don't know

2
3
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1-3,R,D>[goto QOL_2D]

Question ID:

QOL.590_00.004 Instrument Variable Name:

QuestionText:

QOL_2D

QuestionnaireFileName:

Sample Adult

For each of the following activities, please tell me if you do the activity, don't do the activity, or are unable to do the
activity.
Participating in leisure or social activities?

1

Do the activity
Don't do the activity
Unable to do the activity
Refused
Don't know

2
3
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1-3,R,D>[goto QOL_2E]

Question ID:

QOL.590_00.005 Instrument Variable Name:

QuestionText:

2
3
7
9

QuestionnaireFileName:

Sample Adult

For each of the following activities, please tell me if you do the activity, don't do the activity, or are unable to do the
activity.
Getting out with friends or family?

1

QOL_2E

Do the activity
Don't do the activity
Unable to do the activity
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1-3,R,D>[goto QOL_2F]

Page 34 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.590_00.006 Instrument Variable Name:

QuestionText:

QOL_2F

04-Aug-09
QuestionnaireFileName:

Sample Adult

For each of the following activities, please tell me if you do the activity, don't do the activity, or are unable to do the
activity.
Doing household chores such as cooking and cleaning?

1

Do the activity
Don't do the activity
Unable to do the activity
Refused
Don't know

2
3
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1-3,R,D>[goto QOL_2G]

Question ID:

QOL.590_00.007 Instrument Variable Name:

QuestionText:

QOL_2G

QuestionnaireFileName:

Sample Adult

For each of the following activities, please tell me if you do the activity, don't do the activity, or are unable to do the
activity.
Using transportation to get to places you want to go?

1

Do the activity
Don't do the activity
Unable to do the activity
Refused
Don't know

2
3
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1-3,R,D>[goto QOL_2H]

Question ID:

QOL.590_00.008 Instrument Variable Name:

QuestionText:

2
3
7
9

QuestionnaireFileName:

Sample Adult

For each of the following activities, please tell me if you do the activity, don't do the activity, or are unable to do the
activity.
Participating in religious activities?

1

QOL_2H

Do the activity
Don't do the activity
Unable to do the activity
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1-3,R,D>[goto QOL_2I]

Page 35 of 35

DRAFT 2010 NHIS Questionnaire - Sample Adult
Quality of Life
Document Version Date:
Question ID:

QOL.590_00.009 Instrument Variable Name:

QuestionText:

2
3
7
9

QuestionnaireFileName:

Sample Adult

For each of the following activities, please tell me if you do the activity, don't do the activity, or are unable to do the
activity.
Participating in community gatherings?

1

QOL_2I

04-Aug-09

Do the activity
Don't do the activity
Unable to do the activity
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1-3,R,D>[goto next section]