Adults-including respondents participating in re-interview with AUDADIS-V or PRISM

ATTACHMENT 3
ALCOHOL USE DISORDERS AND ASSOCIATED DISABILITIES
INTERVIEW SCHEDULE-V (AUDADIS-V)
AND FLASHCARD BOOKLET

OMB #: 0925-xxxx
Expiration Date:
Public reporting burden for this collection of information is estimated to average 60 minutes per response
including 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 NIH, Project Clearance
Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0926-xxxx).

1

Section 1 - BACKGROUND INFORMATION
These first few questions are about your background.

Statement A

How old are you as of today?

1a.
CHECK
ITEM 1.0

Does AGE = D OR R?

1b. Interviewer: Enter best guess as to respondent’s age.

_____ Age
1  Yes
2  No - SKIP to 1c
_____ Age

c. What is your date of birth? Please give me the month, day
and year.
Example: 01-20-1983
12-01-1963
Ask if not apparent. If D or R record from observation.

d. What is your sex?
e.

f.

Month

Day

Year

1  Male
2  Female

Are you of Hispanic or Latino origin?

1  Yes
2  No

(SHOW FLASHCARD 1)

1  American Indian or Alaska Native
2  Asian
3  Black or African American
4  Native Hawaiian or Other Pacific Islander
5  White

On Card 1 is a list of racial categories. Please select 1 or
more categories to describe your race.
Mark (X) all that apply.
(SHOW FLASHCARD 2)

Code

2a. Which country on the card best describes the heritage or
ancestry you identify with the most even though you may
have been born in the United States? Please just tell me
the number on the card.
(Don’t accept U.S. as response.)

b. Were you born in the United States?

1  Yes - SKIP to 2e
2  No

c. (SHOW FLASHCARD 2)
Code

In what country were you born?

d. How many years have you lived in the United States?
(Code 1 if less than 1 year.)

_____ Year(s)

e. (SHOW FLASHCARD 2)
In what country was your mother born? Please just tell
me the number on the card.

Code

f. (SHOW FLASHCARD 2)
In what country was your father born?

Code

(SHOW FLASHCARD 2)

3.

In what country was your mother’s mother born?

Code

(SHOW FLASHCARD 2)

4.

In what country was your mother’s father born?

Code

(SHOW FLASHCARD 2)

5.

In what country was your father’s mother born?

Code

(SHOW FLASHCARD 2)

6.

In what country was your father’s father born?

7a. Did you live with at least 1 of your biological or birth
parents at any time while you were growing up, that is
BEFORE you were 18 years old?

b. Did your biological father ever live in your household
while you were growing up, regardless of whether he and
your mother were married or not?

Code
1  Yes
2  No - SKIP to 7c
1  Yes - SKIP to 8a
2  No - SKIP to 8d

Page 1

Section 1 - BACKGROUND INFORMATION (Continued)
1  Adoptive parents
7c. When you were growing up, BEFORE the age of 18, were
you raised by adoptive parents, by relatives, by foster
2  Relatives
parents or in an institution like an orphanage?
3  Foster parents
4  Institution
Mark (X) all that apply.
5  Other
Is 1 marked in 7c?

CHECK
ITEM 1.1

8a.

Did your (biological/adoptive) parents get divorced or
permanently stop living together BEFORE you were 18?

b. How old were you when they first stopped living
c.

1  Yes
2  No - SKIP to 8d

together?

_____ Age

Which of your (biological/adoptive) parents did you live
with most of the time after they stopped living together?

1  Mother
2  Father
3  Both equally
4  Neither parent

d. Did you ever live with a stepparent BEFORE the age of
18, including any who may have subsequently adopted
you?

e.

1  Yes
2  No - SKIP to 9a

How old were you when that stepparent started living
with you?

1  Yes
2  No - SKIP to 8h

_____ Age

(Code earliest age if more than one stepparent.)

f.

Did your stepparent die before you were 18?

g.

How old were you when that happened?
(Code age at first death if more than one stepparent died.)

either of your (biological/adoptive) parents die
h. Did
before you were 18?

i.

(SHOW FLASHCARD 3)
What is your current marital status?

b. How many times have you been married in your life
(including your current marriage)? Do not count times when
you were living with someone as if married.
CHECK
ITEM 1.2

Does number marked in 9a equal 1 and 9b equal 1?
(Is respondent currently married?)

10a. How old were you when you got married (for the first
time)?
CHECK
ITEM 1.3

10b.

c.

_____ Age
1  Yes
2  No - SKIP to 9a

How old were you when that happened?
(Code age at first death if more than one
biological/adoptive parent died.)

9a.

1  Yes
2  No - SKIP to 8h

Does number marked in 9b equal 1 and 9a equal 3 or
4 or 5?

How did this marriage end - were you widowed,
separated or divorced from your first spouse?

How old were you when (your (first/former) spouse
died)/(you stopped living with your (first/former)
spouse)?

CHECK
ITEM 1.4

Does number marked in 9a equal 1?

10d. How old were you when you and your (CURRENT)
spouse got married?

_____ Age

1  Married
2  Living with someone as if married
3  Widowed
4  Divorced
5  Separated
6  Never married - SKIP to 11a
_____ Number

 None - SKIP to 11a
1  Yes - SKIP to 10d
2  No
_____ Age
1  Yes - SKIP to 10c
2  No
1  Widowed
2  Separated
3  Divorced
4  Other
_____ Age
1  Yes
2  No - SKIP to 11a
_____ Age

Page 2

Section 1 – BACKGROUND INFORMATION (Continued)
11a.

How many live-born children have you EVER had,
including those who are not now living? Please include
any adopted, foster or stepchildren who EVER lived with
you. (Do not include stillbirths or miscarriages.)

b. How old were you when your (FIRST) child was born
or when your (FIRST) step, adopted, or foster child
began to live with you?

_____ Number
0  None – SKIP to 12a

_____ Age

(Report earliest age if experienced more than one of these
events.)

c.

How old were you when your (LAST) child was born or
when your (LAST) adopted, foster or stepchild came to
live with you?

_____ Age

(Report latest age if experienced more than one of these
events.)
(SHOW FLASHCARD 4)

12a. Which of these statements describe your present situation?
Mark (X) all that apply.

CHECK
ITEM 1.4A

Is 6, 7, or 8 marked in 12a?

12b. For how long have you been unemployed?

CHECK
ITEM 1.4B

13.

Is 10, 11, or 12 marked in 12a?

1  Yes
2  No - SKIP to 13
_____ Weeks(s)
OR
_____ Months(s)
OR
_____ Years(s)
1  Yes – SKIP to 14a.
2  No

Are you currently or were you in the past year a full- or
part-time student? (If necessary, ask: Was that full-time
or part-time?)

1  Yes, full-time student
2  Yes, part-time student
3  No

(SHOW FLASHCARD 5)

1  No formal schooling – SKIP to 15a
2  Completed grade K, 1 or 2
3  Completed grade 3 or 4
4  Completed grade 5 or 6
5  Completed grade 7
6  Completed grade 8
7  Completed grade 9, 10 or 11
8  Completed high school
9  Graduate equivalency degree (GED)
10  Some college (no degree)
11  Completed associate or other technical 2 year degree
12  Completed college (Bachelor’s degree)
13  Some graduate or professional studies (completed
Bachelor’s degree but not graduate degree)
14  Completed Master’s degree or equivalent or higher
graduate degree

14a. What is the highest grade or year of school that you
completed?

(MARK ONE AND ONLY ONE)

b.

1  Working full time, that is, 35 hours or more per week
2  Working part time, that is, less than 35 hours per week
3  Have a job or business, but not at work because of
temporary illness or injury
4  Have a job or business, but on paid vacation
5  Have a job or business, but absent from work without
pay
6  Unemployed or laid off and looking for work
7  Unemployed or laid off and not looking for work
8  Unemployed and permanently disabled
9  Retired
10  In school, full time
11  In school, part time
12  Currently on summer break/holiday from school
13  Full-time homemaker
14  Something else

How old were you at that time?

15a. Have you ever served on ACTIVE DUTY in the U.S.

_____ Age

Armed Forces, Military Reserves, or National Guard?

1  Yes, now on active duty
2  Yes, on active duty in past, but not now

(Active duty does not include training for the Reserves or
National Guard, but DOES include activation, for example,
for the Persian Gulf War.)

3  No, training for Reserves or National Guard
only – SKIP to Check Item 1.5
4  No, never served in the military – SKIP to
Check Item 1.5
Page 3

Section 1 – BACKGROUND INFORMATION (Continued)
15b. (SHOW FLASHCARD 6)
When did you serve on ACTIVE DUTY in the U.S.
Armed Forces?
(Check all that apply even if for part of the period.)

c.

In total, how long were you in ACTIVE DUTY military
service?

CHECK
ITEM 1.5

Is “1”, “2”, “3”, “4”, “5” checked in 12a?

16a. In the last 12 months, did you work at any time at a JOB
OR BUSINESS, either full-time or part-time, even for
only a few days? Include unpaid work in a family
business or farm.

b. Have you ever worked for pay, or have you ever been an
unpaid worker in a family business or farm?

1  September 2011- Present
2  September 2009 – August 2011
3  September 2004 – August 2009
4  September 2001 – August 2004
5  August 1990 to August 2001 (including Persian
Gulf War)
6  September 1980 to July 1990
7  May 1975 to August 1980
8  Vietnam era (August 1964-April 1975)
9  March 1961 to July 1964
10  February 1955 to February 1961
11  Korean War (July 1950-January 1955)
12  January 1947 to June 1950
13  World War II (December 1941-December 1946)
14  November 1941 or earlier
_____ Months
or
_____ Years
1  Yes – SKIP to 16d
2  No
1  Yes – SKIP to 16d
2  No
1  Yes
2  No – SKIP to18a

c. How old were you when you last worked for pay or when
you were an unpaid worker in a family business or farm,
either full- time or part-time?

d. How old were you when you started your FIRST full-time
job, that is, when you worked at least 30 hours per week
for pay or without pay including in a family business or
farm?

_____ Age
_____ Age
OR
0  Never worked 30 hours/week

17a. (SHOW FLASHCARD 7)
In what kind of business or industry (is your present
job/was your most recent job)?

Kind of business/industry

b. (SHOW FLASHCARD 8)
What kind of work (do/did) you do on this job?
(SHOW FLASHCARD 9)

c. Which of the following best describes where you (work/
worked)?

Kind of work
1  A private for-profit company, business, or individual
2  A private not-for-profit, tax exempt, or
charitable organization
3  Federal government (exclude Armed Forces)
4  State government
5  Local government
6  Armed Forces
7  Unpaid in family business or farm
8  Self-employed in own business, professional
practice, or farm

(SHOW FLASHCARD 10)

18a. During the last 12 months, what was your TOTAL
PERSONAL income? Please report income from all jobs
BEFORE taxes and other deductions and net income
after business expenses. Include any tips, bonuses,
overtime pay and commissions, as well as any income
from pensions, dividends, interest, Social Security,
alimony, child support, financial aid, support from
persons living elsewhere, worker’s compensation or any
public assistance or welfare payments and any other
money income received by you from ANY OTHER
source shown on this card.

$______________

(Round amount to nearest dollar.)

Page 4

Section 1 – BACKGROUND INFORMATION (Continued)
CHECK
ITEM 1.6

Is 18a D OR R?

(SHOW FLASHCARD 11)

18b. Please tell me which category on this card best represents
your TOTAL PERSONAL income in the last 12 months.

CHECK
ITEM 1.7

(Refer to Screener.)
The number of persons related to respondent in this
household is?

1  Yes
2  No - SKIP to Check Item 1.7
0  $0 (no personal income)
1  $1 to $4,999
2  $5,000 to $7,999
3  $8,000 to $9,999
4  $10,000 to $12,999
5  $13,000 to $14,999
6  $15,000 to $19,999
7  $20,000 to $24,999
8  $25,000 to $29,999
9  $30,000 to $34,999
10  $35,000 to $39,999
11  $40,000 to $49,999
12  $50,000 to $59,999
13  $60,000 to $69,999
14  $70,000 to $79,999
15  $80,000 to $89,999
16  $90,000 to $99,999
17  $100,000 or more
1  None - SKIP to Check Item 1.9
2  One or more

(SHOW FLASHCARD 12)

19a. During the last 12 months, what was YOUR TOTAL
COMBINED FAMILY income received from jobs,
businesses, and ALL OTHER SOURCES WE JUST
TALKED ABOUT? Include ONLY related family
members living in this household including yourself and
report income before taxes and other deductions or net
income after business expenses for self-employed family
members. Include any tips, bonuses, overtime pay or
commissions.

$______________

(Round amount to nearest dollar.)
CHECK
ITEM 1.8

Is 19a D OR R?

(SHOW FLASHCARD 13)

19b. Please tell me which category on this card best represents

YOUR TOTAL COMBINED FAMILY income in the last
12 months.

1  Yes
2  No - SKIP to Check Item 1.9
1  Less than $5,000
2  $5,000 to $7,999
3  $8,000 to $9,999
4  $10,000 to $12,999
5  $13,000 to $14,999
6  $15,000 to $19,999
7  $20,000 to $24,999
8  $25,000 to $29,999
9  $30,000 to $34,999
10  $35,000 to $39,999
11  $40,000 to $49,999
12  $50,000 to $59,999
13  $60,000 to $69,999
14  $70,000 to $79,999
15  $80,000 to $89,999
16  $90,000 to $99,999
17  $100,000 to $109,999
18  $110,000 to $119,999
19  $120,000 to $149,999
20  $150,000 to $199,999
21  $200,000 or more

Page 5

Section 1 – BACKGROUND INFORMATION (Continued)
CHECK
ITEM 1.9

(Refer to Screener.)
The number of persons unrelated to respondent in this
household is?

1  None - SKIP to 21a
2  One or more

(SHOW FLASHCARD 14)

20a. During the last 12 months, what was YOUR TOTAL
COMBINED HOUSEHOLD income received from jobs,
business and ALL OTHER SOURCES mentioned earlier?
Include income from all RELATED and UNRELATED
household members including yourself before taxes and
other deductions or report net income after business
expenses for self-employed household members.

$______________

(Round amount to nearest dollar.)
CHECK
ITEM 1.10A

Is 20a D OR R?

(SHOW FLASHCARD 15)

b.

Please tell me which category on this card best represents
YOUR TOTAL COMBINED HOUSEHOLD income in
the last 12 months.

21a. Before you were 18 years old, was there ever a time
when your family received money from government
assistance programs like welfare, food stamps, general
assistance, Aid to Families with Dependent Children, or
Temporary Assistance for Needy Families?

b.

About how many years altogether between the time you
were born and the time you turned 18 did your family
receive money from a government assistance program?

1  Yes
2  No - SKIP to 21a
1  Less than $5,000
2  $5,000 to $7,999
3  $8,000 to $9,999
4  $10,000 to $12,999
5  $13,000 to $14,999
6  $15,000 to $19,999
7  $20,000 to $24,999
8  $25,000 to $29,999
9  $30,000 to $34,999
10  $35,000 to $39,999
11  $40,000 to $49,999
12  $50,000 to $59,999
13  $60,000 to $69,999
14  $70,000 to $79,999
15  $80,000 to $89,999
16  $90,000 to $99,999
17  $100,000 to $109,999
18  $110,000 to $119,999
19  $120,000 to $149,999
20  $150,000 to $199,999
21  $200,000 or more
1  Yes
2  No - SKIP to 22a

_____ Years

22a. Please tell me if YOU received any income during the
last 12 months from any of the following sources:
Did you PERSONALLY receive Social Security?

b. Did you PERSONALLY receive Supplemental Security
Income (SSI)?

c. Did YOU receive Traditional Aid to Families with
Dependent Children (TAFDC) or Employment Services
Program (ESP) or Emergency Assistance Program
(EAP)? Include all cash assistance from any state or
local public assistance or welfare office. Do not include
food stamps, SSI or energy assistance programs.

d. Did YOU receive WIC Benefits from the Women,
Infants and Children Nutritional Program?

23a. Did YOU receive food stamps during the last 12 months?
b. About how much did YOU receive in food stamps during
the last 12 months?

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No

1  Yes
2  No
1  Yes
2  No - SKIP to 24a
$______________

Page 6

Section 1 – BACKGROUND INFORMATION (Continued)
24a. At ANY time during the last 12 months were YOU
covered by…
Medicare?

b. Were you covered by Part A, hospital ONLY; Part B,
medical ONLY; or by BOTH Part A and Part B?

c.

A Medi-Gap insurance policy?

d. Medicaid or (local name)?

1  Yes
2  No - SKIP to 24c
1  Part A, Hospital ONLY
2  Part B, Medical ONLY
3  BOTH Part A and Part B
1  Yes
2  No
1  Yes
2  No

e.

TRICARE, CHAMPUS, CHAMPVA, the VA, or other
military health care?

1  Yes
2  No

f.

A private health insurance plan obtained through a
current or former employer or union?

1  Yes
2  No

g. A private health insurance plan purchased DIRECTLY

1  Yes
2  No

by you or a relative?

government or community program?

1  Yes
2  No

i.

Any OTHER government or state-sponsored health
insurance plan or program?

1  Yes
2  No

j.

Long-term care insurance?

1  Yes
2  No

h. A private health insurance plan through state or local

k. A single service plan for dental or vision?
l.

A single service plan for prescriptions ONLY?

m. Any OTHER health insurance plan?
25.

In general, would you say your health is excellent, very
good, good, fair or poor?

CHECK
ITEM 1.10B

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Excellent
2  Very good
3  Good
4  Fair
5  Poor

Is “yes” checked for 12a(8)?

1  Yes - SKIP to 26b
2  No

26a. During the last 12 months, did you have a serious

1  Yes
2  No - SKIP to 26e

PERMANENT physical disability? Do not include
serious TEMPORARY physical disabilities.

b.

(Earlier you mentioned that you were currently
unemployed and permanently disabled.) How long have
you had this PERMANENT physical disability?

_____ Day(s)
OR
_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)

c.

During the last 12 months, how many days, weeks or
months have you been totally unable to work or carry
out your day to day activities because of your
PERMANENT disability?

0  None
OR
_____ Day(s)
OR
_____ Week(s)
OR
_____ Month(s)

Page 7

Section 1 – BACKGROUND INFORMATION (Continued)
26d. During the last 12 months, how many days, weeks or
months were you able to work and carry out your day to
day activities, but had to cut down on what you did or not
get as much done as usual because of your PERMANENT
disability?

e. (Not counting your permanent disability,) During the last
12 months, did you have a serious TEMPORARY physical
disability?

0  None
OR
_____ Day(s)
OR
_____ Week(s)
OR
_____ Month(s)
1  Yes
2  No - SKIP to Check Item 1.11

f. How long have you had this temporary disability?

_____ Day(s)
OR
_____ Week(s)
OR
_____ Month(s)

g. During the last 12 months, how many days, weeks or

0  None
OR
_____ Day(s)
OR
_____ Week(s)
OR
_____ Month(s)

months have you been totally unable to work or carry out
your day to day activities because of your TEMPORARY
disability?

h. During the last 12 months, how many days, weeks or
months were you able to work and carry out your day to
day activities, but had to cut down on what you did or not
get as much done as usual because of your TEMPORARY
disability?

CHECK
ITEM 1.11

Is “1” marked in 26a OR 26e or is “Yes” marked
for 12(8)?

0  None
OR
_____ Day(s)
OR
_____ Week(s)
OR
_____ Month(s)
1  Yes
2  No - SKIP to 30a

(SHOW FLASHCARD 16)

27a. Now I’d like to know about how often you have experienced discrimination, been
prevented from doing something, or been hassled or made to feel inferior in any of the
following situations because of your disability.

(1) During the last 12 months, about how often did you
experience discrimination in your ability to obtain
health care or health insurance coverage because of
your disability?

(2) During the last 12 months, about how often did you
experience discrimination in how you were treated
when you got care because of your disability?

(3) During the last 12 months, about how often did you
experience discrimination in access to public facilities,
like bathrooms, restaurants, elevators or public
transportation because of your disability?

(4) During the last 12 months, about how often did you
experience discrimination because of your disability
in ANY other situation, like obtaining a job or on the
job, getting admitted to a school or training program,
in the courts or by the police, obtaining housing or in
public, like on the street, in stores or in restaurants?
CHECK
ITEM 1.12

Are all the items (1) – (4) in 27a AND 27b marked
“1” OR “Never” OR D OR R?

28. When you are treated unfairly because of your physical
disability, do you usually accept it as a fact of life or do
you try to do something about it?

29. When you are treated unfairly because of your physical
disability, do you usually talk to other people about it or
do you keep it to yourself?

b. About how often did this
happen BEFORE 12
months ago?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Yes - SKIP to 30a
2  No
1  Accept it
2  Try to do something about it
1  Talk to other people
2  Keep it to yourself

Page 8

Section 1 – BACKGROUND INFORMATION (Continued)
(SHOW FLASHCARD 17)

30a. The following questions are about activities you might do
during a typical day. Please tell me if your health now
limits you in these activities and if so, how much:
Moderate activities, such as moving a table, pushing a
vacuum cleaner, bowling, or playing golf.

b. Climbing several flights of stairs.

1  Yes, limited a lot
2  Yes, limited a little
3  No, not limited at all
1  Yes, limited a lot
2  Yes, limited a little
3  No, not limited at all

(SHOW FLASHCARD 18)

31a. The next few questions are about how you feel and how
things have been with you during the past 4 weeks. During
the past 4 weeks, tell me how much of the time you have
had any of the following problems with your work or other
regular daily activities as the result of your physical health:
How much of the time have you accomplished less than you
would like?

b. How much of the time have you been limited in the kind of
work or other activities you could do?

1  None of the time
2  A little of the time
3  Some of the time
4  Most of the time
5  All of the time
1  None of the time
2  A little of the time
3  Some of the time
4  Most of the time
5  All of the time

(SHOW FLASHCARD 18)

32a. During the past 4 weeks, tell me how much of the time you
have had any of the following problems with your work or
other regular daily activities as the result of any emotional
problems, such as feeling depressed or anxious:
How much of the time have you accomplished less than you
would like?

b. How much of the time have you not done work or other
activities as carefully as usual?

1  None of the time
2  A little of the time
3  Some of the time
4  Most of the time
5  All of the time
1  None of the time
2  A little of the time
3  Some of the time
4  Most of the time
5  All of the time

(SHOW FLASHCARD 18)

33a. For each of the following questions, please give the one
answer that comes closest to the way you have been
feeling. How much of the time during the past 4 weeks…
Have you felt calm and peaceful?

1  None of the time
2  A little of the time
3  Some of the time
4  Most of the time
5  All of the time

b. Did you have a lot of energy?

1  None of the time
2  A little of the time
3  Some of the time
4  Most of the time
5  All of the time

c. Have you felt downhearted and depressed?

1  None of the time
2  A little of the time
3  Some of the time
4  Most of the time
5  All of the time
Page 9

Section 1 – BACKGROUND INFORMATION (Continued)
(SHOW FLASHCARD 18)

34. During the past 4 weeks, how much of the time has your
physical health or emotional problems interfered with your
social activities like visiting with friends, relatives, and so
forth?
(SHOW FLASHCARD 19)

35. During the past 4 weeks, how much did pain interfere with
your normal work, including both work outside the home
and housework?

1  None of the time
2  A little of the time
3  Some of the time
4  Most of the time
5  All of the time
1  Not at all
2  A little bit
3  Moderately
4  Quite a bit
5  Extremely

36a. Please tell me if you have had any of the following
experiences in the last 12 months.
During the last 12 months. . .
Did you move or have anyone new come to live with you?

1  Yes
2  No

b. Were you fired or laid off from a job?

1  Yes
2  No

c. Were you unemployed and looking for a job for more

1  Yes
2  No

than a month?

d. Have you had trouble with your boss or a coworker?

1  Yes
2  No

e. Did you change jobs, job responsibilities or work hours?

1  Yes
2  No

f. Did you get separated or divorced or break off a steady

1  Yes
2  No

relationship?

g. Have you had serious problems with a neighbor, friend
or relative?

h. Have you experienced a major financial crisis, declared
bankruptcy or more than once been unable to pay your
bills on time?

1  Yes
2  No
1  Yes
2  No

i. Did you have serious trouble with the police or the law?

1  Yes
2  No

j. Was something stolen from you, including things that

1  Yes
2  No

you carry like a wallet, or something inside or outside
your home?

k. Has anyone intentionally damaged or destroyed property
owned by you or someone else in your house?

1  Yes
2  No

l. Did any of your family members or close friends die?

1  Yes
2  No

m. Were any of your family members or close friends

1  Yes
2  No

physically assaulted, attacked or mugged?

n. Did any of your family members or close friends have
serious trouble with the police or the law?

37a. Do you currently attend religious services at a church,
synagogue, mosque or other place of worship?
(SHOW FLASHCARD 20)

b. How often do you attend these services?

c. How many members of your religious group do you talk

1  Yes
2  No
1  Yes
2  No - SKIP to 37d
1  Once a year
2  A few times a year
3  1 to 3 times a month
4  Once a week
5  Twice a week or more
_____ Number

to socially at least once every 2 weeks, not counting brief
visits during services?

Page 10

Section 1 – BACKGROUND INFORMATION (Continued)
1  Very important
2  Somewhat important
3  Not very important
4  Not important at all

37d. In general, how important are religious or spiritual beliefs
in your daily life – very important, somewhat important,
not very important, or not important at all?

38. (SHOW FLASHCARD 21)
Which category on the card best describes your religion?
Please tell me the number on the card.

41a. And now, please tell me your height and weight as these

Code
Height

are important factors for this survey.

Feet
Inches

b.

Weight
Pounds

42a. When you were growing up, that is, BEFORE you were 13
years old, were you overweight (not counting when you
were pregnant)?

b. In your ENTIRE LIFE, what is the most you EVER

1  Yes
2  No
Weight

weighed?

Pounds
_____ Age

c. How old were you when you FIRST reached that weight?
CHECK
Does height in 41a and weight in 41b OR does height in
ITEM 1.14 41a and weight in 42b yield BMI ≥ 25 or is 42a = 1?

1  Yes
2  No - SKIP to 45a

(SHOW FLASHCARD 22)

b. About how often did this happen

43a. Now I’d like to know about how often you have experienced discrimination, been

BEFORE 12 months ago?

prevented from doing something, or been hassled or made to feel inferior in any of
the following situations because of your weight.
(1) During the last 12 months, about how
often did you experience discrimination
in your ability to obtain health care or
health insurance coverage because of
your weight?

(2) During the last 12 months, about how
often did you experience
discrimination in how you were
treated when you got care because of
your weight?
(3) During the last 12 months, about how
often did you experience
discrimination because of your weight
in public settings, like on the street, in
restaurants or stores, or on public
transportation like buses or airplanes?
(4) During the last 12 months, about how
often did you experience
discrimination because of your weight
in obtaining a job or on the job, or
getting admitted to a school or
training program?
(5) During the last 12 months, about how
often did you experience discrimination
because of your weight in ANY other
situation, like in the courts or by the
police or when obtaining housing?
CHECK
ITEM 1.15

0  Not overweight in last
12 months – SKIP col. a items
1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

0  Not overweight BEFORE
12 months ago – SKIP col. b
items
1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

Are all the items (1) – (5) in 43a AND 43b marked
“0”, OR blank OR “1” OR D OR R?

44a. When you are treated unfairly because of your weight, do
you usually accept it as a fact of life or do you try to do
something about it?

1  Yes - SKIP to 45a
2  No
1  Accept it
2  Try to do something about it

Page 11

Section 1 – BACKGROUND INFORMATION (Continued)
44b. When you are treated unfairly because of your weight, do
you usually talk to other people about it or do you keep it
to yourself?

1  Talk to other people
2  Keep it to yourself

(SHOW FLASHCARD 23)

45a. The next questions are about physical activities that you
may do in your leisure time or as part of your work or
during the course of your daily activities.
How often in the last 12 months did you USUALLY do
VIGOROUS activities that caused you to sweat
HEAVILY or caused LARGE increases in your breathing
or heart rate?

b. About how long did you USUALLY do these VIGOROUS
activities each time?
(SHOW FLASHCARD 23)

46a. About how often in the last 12 months did you
USUALLY do LIGHT or MODERATE activities that
caused only LIGHT sweating or a SLIGHT TO
MODERATE increase in your breathing or heart rate?

b. About how long did you USUALLY do these LIGHT or
MODERATE activities each time?

1  Every day
2  Nearly every day
3  3 to 4 times a week
4  2 times a week
5  Once a week
6  2 to 3 times a month
7  Once a month
8  7 to 11 times in the last year
9  3 to 6 times in the last year
10  1 to 2 times in the last year
11  Never in the last year – SKIP to 46a
_____ Minutes
OR
_____ Hours
1  Every day
2  Nearly every day
3  3 to 4 times a week
4  2 times a week
5  Once a week
6  2 to 3 times a month
7  Once a month
8  7 to 11 times in the last year
9  3 to 6 times in the last year
10  1 to 2 times in the last year
11  Never in the last year – SKIP to Section 2A
_____ Minutes
OR
_____ Hours

Go to Section 2A

Page 12

Section 2A – ALCOHOL CONSUMPTION
Statement B

The next questions are about drinking alcohol. This includes coolers; beer; wine; champagne; liquor such as
whiskey, rum, gin, vodka, bourbon, tequila, scotch, brandy, cognac, cordials, or liqueurs; and also any other
type of alcohol.

1.

In your entire life, have you had at least 1 drink of any
kind of alcohol, not counting small tastes or sips?

1  Yes
2  No - SKIP to Check Item 2.1 and mark as lifetime
abstainer

2.

During the last 12 months, that is, since (month one year
ago) did you have a total of at least 12 drinks of any kind
of alcohol?

1  Yes - SKIP to Check Item 2.1 and mark as
current drinker
2  No

3.

During the last 12 months, did you have at least 1 drink of
any kind of alcohol?

1  Yes - Go to Check Item 2.1 and mark as
current drinker
2  No - Go to Check Item 2.1 and mark as
former drinker

CHECK
ITEM 2.1

Mark (X) one and ONLY one.

(SHOW FLASHCARD 24)

4a. During the last 12 months, about how often did you drink
any kind of alcoholic beverage?

b. How many drinks did you USUALLY have on days when
you drank during the last 12 months?

c. During the last 12 months, what was the LARGEST
number of drinks that you drank in a single day?

d. (SHOW FLASHCARD 25)
APPROXIMATELY what was the largest number of
drinks that you drank in a single day?

(SHOW FLASHCARD 24)

e. About how often during the last 12 months did you drink
(number of drinks reported in 4c/this largest number of
drinks) in a single day?

CHECK
ITEM 2.2

(Refer to 1c, Section 1.)
Is the respondent a female (any age) or a male 65
years of age or older?

(SHOW FLASHCARD 23)

4f. During the last 12 months, about how often did you drink
FOUR OR MORE drinks in a single day?

1  Current drinker - Go to 4a
2  Former drinker - SKIP to 11
3  Lifetime abstainer - SKIP to Section 2D
1
2
3
4
5
6
7
8
9
10

 Every day
 Nearly every day
 3 to 4 times a week
 2 times a week
 Once a week
 2 to 3 times a month
 Once a month
 7 to 11 times in the last year
 3 to 6 times in the last year
 1 or 2 times in the last year

_____ Number
_____ Number – Skip to 4e
(If D or R, ask 4d)
1
2
3
4
5
6
1
2
3
4
5
6
7
8
9
10

 1-2 drinks
 3-4 drinks
 5-7 drinks
 8-11 drinks
 12-23 drinks
 24+ drinks
 Every day
 Nearly every day
 3 to 4 times a week
 2 times a week
 Once a week
 2 to 3 times a month
 Once a month
 7 to 11 times in the last year
 3 to 6 times in the last year
 1 or 2 times in the last year

1  Yes
2  No – SKIP to 4h

1
2
3
4
5
6
7
8
9
10
11

 Every day
 Nearly every day
 3 to 4 times a week
 2 times a week
 Once a week
 2 to 3 times a month
 Once a month
 7 to 11 times in the last year
 3 to 6 times in the last year
 1 or 2 times in the last year
 Never in the last year (SKIP to Statement C)

Page 1

Section 2A – ALCOHOL CONSUMPTION (Continued)
(SHOW FLASHCARD 23)

4g. And during the last 12 months, about how often did you
drink FOUR OR MORE drinks in a period of TWO
HOURS OR LESS?

(SHOW FLASHCARD 23)

h. During the last 12 months, about how often did you drink
FIVE OR MORE drinks in a single day?

(SHOW FLASHCARD 23)

i.

And during the last 12 months, about how often did you
drink FIVE OR MORE drinks in a period of TWO
HOURS OR LESS?

(SHOW FLASHCARD 23)

j.

During the last 12 months, about how often did you drink
EIGHT OR MORE drinks in a single day?

(SHOW FLASHCARD 23)

k. And during the last 12 months, about how often did you
drink TWELVE OR MORE drinks in a single day?

Statement C

1
2
3
4
5
6
7
8
9
10
11

 Every day
 Nearly every day
 3 to 4 times a week
 2 times a week
 Once a week
 2 to 3 times a month
 Once a month
 7 to 11 times in the last year
 3 to 6 times in the last year
 1 or 2 times in the last year
 Never in the last year

1
2
3
4
5
6
7
8
9
10
11

 Every day
 Nearly every day
 3 to 4 times a week
 2 times a week
 Once a week
 2 to 3 times a month
 Once a month
 7 to 11 times in the last year
 3 to 6 times in the last year
 1 or 2 times in the last year
 Never in the last year - SKIP to Statement C

1
2
3
4
5
6
7
8
9
10
11

 Every day
 Nearly every day
 3 to 4 times a week
 2 times a week
 Once a week
 2 to 3 times a month
 Once a month
 7 to 11 times in the last year
 3 to 6 times in the last year
 1 or 2 times in the last year
 Never in the last year

1
2
3
4
5
6
7
8
9
10
11

 Every day
 Nearly every day
 3 to 4 times a week
 2 times a week
 Once a week
 2 to 3 times a month
 Once a month
 7 to 11 times in the last year
 3 to 6 times in the last year
 1 or 2 times in the last year
 Never in the last year - SKIP to Statement C

1
2
3
4
5
6
7
8
9
10
11

 Every day
 Nearly every day
 3 to 4 times a week
 2 times a week
 Once a week
 2 to 3 times a month
 Once a month
 7 to 11 times in the last year
 3 to 6 times in the last year
 1 or 2 times in the last year
 Never in the last year

The next few questions are about drinking coolers. By coolers, I mean wine-based, malt-based, and liquorbased coolers, hard lemonade, hard iced tea, hard cider, alcoholic energy drinks, and any prepackaged
cocktails with the alcohol and mixer already combined in the container. Do not include mixed drinks you mix
yourself or get in a restaurant or bar.

5a. During the last 12 months, did you drink any prepackaged
alcoholic coolers?

1  Yes
2  No - SKIP to Statement D

Page 2

Section 2A – ALCOHOL CONSUMPTION (Continued)
(SHOW FLASHCARD 24)

5b. During the last 12 months, about how often did you drink
any coolers?

(SHOW FLASHCARD 26, 26A-26C)

c. What was the size of the TYPICAL bottle, can or glass of
cooler that you USUALLY drank during the last 12
months?

1  Every day
2  Nearly every day
3  3 to 4 times a week
4  2 times a week
5  Once a week
6  2 to 3 times a month
7  Once a month
8  7 to 11 times in the last year
9  3 to 6 times in the last year
10  1 or 2 times in the last year

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

 8-ounce (small) bottle or can
 12-ounce (regular) bottle or can
 16-ounce (large) bottle or can
 2-ounce can or bottle
 3-ounce glass
 4-ounce glass
 5-ounce glass
 6-ounce glass
 7-ounce glass
 8-ounce glass
 9-ounce glass
 12-ounce glass
 15-ounce glass
 18-ounce glass
 Other – Specify

Code

d. How many (units reported in 5c) of cooler did you

_____ Number

e. During the last 12 months, what was the LARGEST

_____ Number

Size and type of container

USUALLY drink on days when you drank coolers?
number of (units reported in 5c) of cooler that you drank
in a single day?

(SHOW FLASHCARD 24)

f. About how often during the last 12 months did you drink

(largest number and units reported in 5c and 5e) of cooler in
a single day?

7
8
9
10

 Every day
 Nearly every day
 3 to 4 times a week
 2 times a week
 Once a week
 2 to 3 times a month
 Once a month
 7 to 11 times in the last year
 3 to 6 times in the last year
 1 or 2 times in the last year

1
2
3
4
5
6
7
8
9
10
11

 Every day
 Nearly every day
 3 to 4 times a week
 2 times a week
 Once a week
 2 to 3 times a month
 Once a month
 7 to 11 times in the last year
 3 to 6 times in the last year
 1 or 2 times in the last year
 Never in the last year

1
2
3

4
5
6

(SHOW FLASHCARD 23)

g. About how often during the last 12 months did you drink

FIVE OR MORE (units reported in 5c) of cooler in a single
day?

h. During the last 12 months, did you USUALLY drink wine,
malt, or liquor-based coolers, hard lemonade, hard iced
tea, hard cider, alcoholic energy drinks, or prepackaged
cocktails based on a liquor such as vodka, gin or tequila?
Mark (X) one and ONLY one.

1  Wine, malt or liquor-based coolers
2  Hard lemonade
3  Hard iced tea
4  Hard cider
5  Alcoholic energy drinks
6  Prepackaged cocktails

Page 3

Section 2A – ALCOHOL CONSUMPTION (Continued)
5i. During the last 12 months, did you USUALLY drink coolers

1  In own home
2  In homes of friends or relatives
3  In public places

in your own home, in the homes of friends or relatives or in
public places such as bars, restaurants or sports arenas?
Mark (X) one and ONLY one.

j During the last 12 months, what brand of cooler, hard
lemonade, hard iced tea, hard cider, alcoholic energy drink,
or prepackaged cocktail did you drink the most often?
Statement D

____________________ Brand – Specify

Now I’d like to ask you about drinking beer, including light beer, ice beer and malt liquor.

6a. During the last 12 months, did you drink any beer or malt

1  Yes
2  No – SKIP to Statement E

liquor? Do not count nonalcoholic beers.
(SHOW FLASHCARD 24)

b. During the last 12 months, about how often did you drink
any beer or malt liquor?

(SHOW FLASHCARD 27)

c. What was the size of the TYPICAL can, bottle, or glass of
beer or malt liquor that you USUALLY drank during the
last 12 months?

1
2
3
4
5
6
7
8
9
10

 Every day
 Nearly every day
 3 to 4 times a week
 2 times a week
 Once a week
 2 to 3 times a month
 Once a month
 7 to 11 times in the last year
 3 to 6 times in the last year
 1 or 2 times in the last year

1
2
3
4
5
6
7
8
9
10

 7 or 8-ounce (pony size) can, bottle or glass
 10-ounce (small) can, bottle or glass
 12-ounce (regular size) can, bottle or glass
 16-ounce (large) can, bottle or glass
 22 to 25-ounce (extra large) can, bottle or glass
 40 to 45-ounce (jumbo) can or bottle
 Mug
 Pint
 Pitcher
 Other – Specify
Code

d. How many (units reported in 6c) of beer or malt liquor did

Size and type of container

_____ Number

you USUALLY drink on days when you drank beer?

e. During the last 12 months, what was the LARGEST

_____ Number

number of (units reported in 6c) of beer or malt liquor that
you drank in a single day?

(SHOW FLASHCARD 24)

f. About how often during the last 12 months did you drink
(largest number and units reported in 6c and 6e) of beer or
malt liquor in a single day?

(SHOW FLASHCARD 23)

g. About how often during the last 12 months did you drink

FIVE OR MORE (units reported in 6c) of beer or malt liquor
in a single day?

1
2
3
4
5
6
7
8
9
10

 Every day
 Nearly every day
 3 to 4 times a week
 2 times a week
 Once a week
 2 to 3 times a month
 Once a month
 7 to 11 times in the last year
 3 to 6 times in the last year
 1 or 2 times in the last year

1
2
3
4
5
6
7
8
9
10
11

 Every day
 Nearly every day
 3 to 4 times a week
 2 times a week
 Once a week
 2 to 3 times a month
 Once a month
 7 to 11 times in the last year
 3 to 6 times in the last year
 1 or 2 times in the last year
 Never in the last year
Page 4

Section 2A – ALCOHOL CONSUMPTION (Continued)
6h. During the last 12 months, did you USUALLY drink
Mark (X) one and ONLY one.

1  Regular beer
2  Malt liquor
3  Light, extra light, reduced calorie, low-carb beer
4  Ice beer

During the last 12 months, did you USUALLY drink beer
or malt liquor in your own home, in the homes of friends
or relatives or in public places such as bars, restaurants
or sports arenas?

1  In own home
2  In homes of friends or relatives
3  In public places

regular beer, malt liquor, light, extra light, reduced
calorie or low-carb beer, or ice beer?

i.

Mark (X) one and ONLY one.

j.

During the last 12 months, what brand of beer or malt
liquor did you drink the most often?

Statement E

____________________ Brand - Specify

Now I’d like to ask you about drinking wine, including champagne, sparkling wine, fortified wines such as
sherry, port and sake, and low-alcohol fruit-flavored wines.

7a. During the last 12 months, did you drink any type of
wine? Do not count any wine coolers you may have told
me about earlier.
(SHOW FLASHCARD 24)

b. During the last 12 months, about how often did you
drink any type of wine?

(SHOW FLASHCARD 28, 28A-28C)

c. What was the size of the TYPICAL glass or bottle of
wine that you USUALLY drank during the last 12
months? Please do not include the amount of any soda
or ice that may have been added.

1  Yes
2  No - SKIP to Statement F
1
2
3
4
5
6
7
8
9
10

 Every day
 Nearly every day
 3 to 4 times a week
 2 times a week
 Once a week
 2 to 3 times a month
 Once a month
 7 to 11 times in the last year
 3 to 6 times in the last year
 1 or 2 times in the last year

1
2
3
4
5
6
7
8
9
10
11

 3-ounce glass
 4-ounce glass
 5-ounce glass
 6-ounce glass
 7-ounce glass
 8-ounce glass
 9-ounce glass
 12-ounce glass
 15-ounce glass
 18-ounce glass
 187 ml. individual serving bottle (usually sold in 4-

packs)
12  375 ml. bottle (half bottle of wine) or ½ carafe
13  750 ml. bottle (regular size wine bottle) or full carafe
14  Other – Specify

Code

d. How many (units reported in 7c) of wine did you USUALLY

Size and type of container

_____ Number

drink on days when you drank wine?

e. During the last 12 months, what was the LARGEST

_____ Number

number of (units reported in 7c) of wine that you drank in
a single day?
(SHOW FLASHCARD 24)

f.

About how often during the last 12 months did you drink
(largest number and units reported in 7c and 7e) of wine in
a single day?

1
2
3
4
5
6
7
8
9
10

 Every day
 Nearly every day
 3 to 4 times a week
 2 times a week
 Once a week
 2 to 3 times a month
 Once a month
 7 to 11 times in the last year
 3 to 6 times in the last year
 1 or 2 times in the last year

Page 5

Section 2A – ALCOHOL CONSUMPTION (Continued)
(SHOW FLASHCARD 23)

7g. About how often during the last 12 months did you drink
FIVE OR MORE (units reported in 7c) of wine in a single
day?

h. During the last 12 months, did you USUALLY drink
wine in your own home, in the homes of friends or
relatives or in public places such as bars, restaurants or
sports arenas?

1
2
3
4
5
6
7
8
9
10
11

 Every day
 Nearly every day
 3 to 4 times a week
 2 times a week
 Once a week
 2 to 3 times a month
 Once a month
 7 to 11 times in the last year
 3 to 6 times in the last year
 1 or 2 times in the last year
 Never in the last year

1  In own home
2  In homes of friends or relatives
3  In public places

Mark (X) one and ONLY one.

i.

During the last 12 months, did you USUALLY drink
regular wine, champagne or sparkling wine, fortified wine
such as sherry, port or sake, or low-alcohol fruit-flavored
wine?
Mark (X) one and ONLY one.

1  Regular wine
2  Champagne or sparkling wine
3  Fortified wine (including sherry, port, sake)
4  Low-alcohol fruit-flavored wine

j . During the last 12 months, what brand of wine,
champagne, sparkling wine, fortified wine, or low-alcohol
fruit-flavored wine did you drink the most often?

k. Thinking about all the wine, sparkling wine, champagne,
and fortified wine you drank in the last 12 months, how
much of this was RED wine? Would you say all, most,
some, a little, or none of it?

Statement F

____________________ Brand - Specify
1  All
2  Most
3  Some
4  A little
5  None of it

The next questions are about drinking liquor, such as whiskey, rum, gin, vodka, bourbon, tequila, scotch,
brandy, cognac, cordials or liqueurs.

8a. During the last 12 months, did you drink any liquor,
including mixed drinks and liqueurs? Do not count any
liquor-based coolers or prepackaged cocktails that you
may have told me about earlier.
(SHOW FLASHCARD 24)

b. During the last 12 months, about how often did you drink
any liquor?

(SHOW FLASHCARD 29, 29A-29C)

c. How much liquor did you USUALLY have in a drink?

Please do not include the amount of any soda, water, ice,
cola, or juice that may have been added to your drink.

1  Yes
2  No - SKIP to 9

1
2
3
4
5
6
7
8
9
10

 Every day
 Nearly every day
 3 to 4 times a week
 2 times a week
 Once a week
 2 to 3 times a month
 Once a month
 7 to 11 times in the last year
 3 to 6 times in the last year
 1 or 2 times in the last year

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

 1 shot or ounce
 1 jigger
 Mini-bottle (type sold on airplanes)
 1½ shots or ounces
 2 shots or ounces (double)
 2 jiggers
 3 shots or ounces (triple)
 3 jiggers
 4 shots or ounces
 4 jiggers
 ½ pint
 Pint
 Quart
 Fifth
 ½ gallon
 Other – Specify
Code

Size and type of container
Page 6

Section 2A - ALCOHOL CONSUMPTION (Continued)
8d. How many (drinks of this size/units reported in 8c) of liquor
did you USUALLY drink on days when you drank liquor?

_____ Number

e. During the last 12 months, what was the LARGEST

f.

number of (drinks of this size/units reported in 8c) of liquor
that you drank in a single day?

_____ Number

(SHOW FLASHCARD 24)

1
2
3
4
5
6
7
8
9
10

 Every day
 Nearly every day
 3 to 4 times a week
 2 times a week
 Once a week
 2 to 3 times a month
 Once a month
 7 to 11 times in the last year
 3 to 6 times in the last year
 1 or 2 times in the last year

1
2
3
4
5
6
7
8
9
10
11

 Every day
 Nearly every day
 3 to 4 times a week
 2 times a week
 Once a week
 2 to 3 times a month
 Once a month
 7 to 11 times in the last year
 3 to 6 times in the last year
 1 or 2 times in the last year
 Never in the last year

About how often during the last 12 months did you drink
(largest number and units reported in 8c and 8e) of liquor in
a single day?

(SHOW FLASHCARD 23)

g. About how often during the last 12 months did you drink
FIVE OR MORE (units reported in 8c) of liquor in a single
day?

h. During the last 12 months, did you USUALLY drink 80proof liquor including brandy and cognac, 100-proof
liquor, greater than 100-proof liquor, or cordials or
liqueurs?
Mark (X) one and ONLY one.

i.

During the last 12 months, did you USUALLY drink
liquor in your own home, in the homes of friends or
relatives or in public places such as bars, restaurants or
sports arenas?

1  80-proof liquor, including brandy and cognac
2  100-proof liquor
3  Greater than 100-proof liquor
4  Cordials or liqueurs
1  In own home
2  In homes of friends or relatives
3  In public places

Mark (X) one and ONLY one.

j.

During the last 12 months, what brand of liquor or
liqueur did you drink the most often?
(SHOW FLASHCARD 23)

9.

10.

11.

During the last 12 months, about how often did you drink
enough alcohol of any kind to feel intoxicated or drunk,
that is, when your speech was slurred, you felt unsteady on
your feet, or you had blurred vision?

You just told me how much and how often you drank in
the last 12 months. For how many years have you been
drinking about this amount with this frequency?
Round up to nearest whole year.
How long has it been since you last had a drink of any
kind of alcohol?

____________________ Brand – Specify
1
2
3
4
5
6
7
8
9
10
11

 Every day
 Nearly every day
 3 to 4 times a week
 2 times a week
 Once a week
 2 to 3 times a month
 Once a month
 7 to 11 times in the last year
 3 to 6 times in the last year
 1 or 2 times in the last year
 Never in the last year

_____ Year(s)

_____ Hour(s) ago
OR
_____ Day(s) ago
OR
_____ Week(s) ago
OR
_____ Month(s) ago
OR
_____ Year(s) ago

Page 7

Section 2A - ALCOHOL CONSUMPTION (Continued)
12a. About how old were you when you first started drinking,
not counting small tastes or sips of alcohol?
CHECK
ITEM 2.2A

Is age reported in 12a within a year of respondent’s
current age or D or R?

12b. Was that in the last 12 months?
c. About how old were you when you first drank enough
alcohol to feel intoxicated or drunk, that is, when your
speech was slurred, you felt unsteady on your feet or you
had blurred vision?

13. Has there ever been a period of at least one year when you
drank more heavily than in the past 12 months?
CHECK
ITEM 2.3

Is “1” marked in 2?
Did respondent drink 12+ drinks in last year?

14. Has there been any one year period during your life when
you had a total of at least 12 drinks of any kind of
alcohol?

_____ Age
1  Yes
2  No - SKIP to 12c
1  Yes
2  No
_____ Age
0  Never drank enough to feel intoxicated
1  Yes
2  No - SKIP to Check Item 2.4
1  Yes - SKIP to 15
2  No
1  Yes
2  No

15. Now I would like you to think about the period in your
life when you drank the most. About how old were you
when that period began?

16. About how many years did that period last?
(SHOW FLASHCARD 30)

17a. During that period when you drank the most, about how
often did you drink?

b. Counting all types of alcohol combined, how many
drinks did you USUALLY have on days when you drank
during that period?

_____ Age

_____ Year(s)
1
2
3
4
5
6
7
8
9
10

 Every day
 Nearly every day
 3 to 4 times a week
 2 times a week
 Once a week
 2 to 3 times a month
 Once a month
 7 to 11 times a year
 3 to 6 times a year
 1 or 2 times a year

_____ Number

c. During that period when you drank the most, what was
the LARGEST number of drinks that you drank in a
single day?

d. (SHOW FLASHCARD 25)
APPROXIMATELY what was the largest number of
drinks that you drank in a single day?

(SHOW FLASHCARD 30)

e. About how often during that period did you drink
(number of drinks reported in 17c/this largest number of
drinks) in a single day?

_____ Number – Skip to 17e
(If D or R, ask 17d)
1  1 to 2 drinks
2  3 to 4 drinks
3  5 to 7 drinks
4  8 to 11 drinks
5  12 to 23 drinks
6  24 or more drinks
1  Every day
2  Nearly every day
3  3 to 4 times a week
4  2 times a week
5  Once a week
6  2 to 3 times a month
7  Once a month
8  7 to 11 times a year
9  3 to 6 times a year
10  1 or 2 times a year

Page 8

Section 2A – ALCOHOL CONSUMPTION (Continued)
(SHOW FLASHCARD 31)

17f. During that period when you drank the most, about how
often did you drink FIVE OR MORE drinks in a single
day?

(SHOW FLASHCARD 31)

g. During that period, about how often did you drink
EIGHT OR MORE drinks in a single day?

(SHOW FLASHCARD 31)

h. During that period, about how often did you drink
TWELVE OR MORE drinks in a single day?

19. During that period when you drank the most, what was
the MAIN type of alcohol you drank: coolers, beer, wine
or liquor?
Mark (X) one and ONLY one.
CHECK
ITEM 2.4

Is age in 12a=17 or younger?

20a. Now I’d like you to think back to the time when you were
drinking before you reached the age of 18. Before you
were 18, what was the LARGEST number of drinks that
you drank in a single day?
(SHOW FLASHCARD 25)

b. APPROXIMATELY what was the LARGEST number of
drinks that you drank in a single day before you were 18?

(SHOW FLASHCARD 31)

c. During that time when you were drinking before you
reached the age of 18, about how often did you drink
FIVE OR MORE drinks in a single day?

1
2
3
4
5
6
7
8
9
10
11

 Every day
 Nearly every day
 3 to 4 times a week
 2 times a week
 Once a week
 2 to 3 times a month
 Once a month
 7 to 11 times a year
 3 to 6 times a year
 1 or 2 times a year
 Never – SKIP to 19

1
2
3
4
5
6
7
8
9
10
11

 Every day
 Nearly every day
 3 to 4 times a week
 2 times a week
 Once a week
 2 to 3 times a month
 Once a month
 7 to 11 times a year
 3 to 6 times a year
 1 or 2 times a year
 Never – Skip to 19

1
2
3
4
5
6
7
8
9
10
11

 Every day
 Nearly every day
 3 to 4 times a week
 2 times a week
 Once a week
 2 to 3 times a month
 Once a month
 7 to 11 times a year
 3 to 6 times a year
 1 or 2 times a year
 Never

1  Coolers
2  Beer
3  Wine
4  Liquor
1  Yes
2  No – SKIP to Check Item 2.4A
_____ Number – SKIP to 20c
(If D or R, ask 20b)
1  1-2 drinks
2  3-4 drinks
3  5-7 drinks
4  8-11 drinks
5  12-23 drinks
6  24+ drinks
1  Every day
2  Nearly every day
3  3 to 4 times a week
4  2 times a week
5  Once a week
6  2 to 3 times a month
7  Once a month
8  7 to 11 times a year
9  3 to 6 times a year
10  1 or 2 times a year
11  Never

Page 9

Section 2A – ALCOHOL CONSUMPTION (Continued)
CHECK
ITEM 2.4A

(Refer to Q2, 4a, 4c, 4d, 4h, 14, 17a, 17c, 17d, 17f.)
Did respondent ever drink at least 12 drinks in any year
or 5+ drinks in a single day in any year?

CHECK
ITEM 2.4B

(Refer to Check Item 2.1.)
Is respondent a former drinker?

CHECK
Is 12a = current age or is 12b = 1 (did respondent start
ITEM 2.4C drinking in the past year)?

1  Yes
2  No – SKIP to Section 2D
1  Yes – Go to Section 2B and ask/fill columns a, c and d
only
2  No
1  Yes –Go to Section 2B and ask/fill columns a and b
2  No –Go to Section 2B and ask/fill columns a-d

Page 10

Section 2B - ALCOHOL EXPERIENCES
1a. Now I’m going to ask you about some experiences you may have had with your
drinking. As I read each experience, please tell me if this has ever happened to you.

b. Did this happen in the last 12
months?

In your entire life, did you EVER... (PAUSE)
(Repeat phrase frequently)

(1)

Find that your usual number of drinks had
much less effect on you than it once did?

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

(2)

Find that you had to drink much more than you
once did to get the effect you wanted?

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

(3)

Drink as much as a fifth of liquor in one day, that
would be about 20 drinks, or 3 bottles of wine, or
as much as 3 six-packs of beer in a single day?

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

(4)

Increase your drinking because the amount you
used to drink didn’t give you the same effect
anymore?

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

(5)

More than once WANT to stop or cut down on
your drinking?

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

(6)

More than once TRY to stop or cut down on
your drinking but found you couldn’t do it?

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

(7)

Have a period when you ended up drinking more
than you meant to?

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

(8)

Have a period when you kept on drinking for
longer than you had intended to?

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

(9)

The next few questions are about the bad
aftereffects of drinking that people may have
when the effects of alcohol are wearing off. This
includes the morning after drinking or in the first
few days after stopping or cutting down.
Did you EVER...
1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

(11) Feel anxious or nervous?

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

(12) Feel sick to your stomach or vomit (when

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

(13) Feel more restless than is usual for you?

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

(14) Find yourself sweating or your heart

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

Have trouble falling asleep or staying
asleep (when the effects of alcohol were
wearing off)?

(10) Find yourself shaking or your hands
trembling?

the effects of alcohol were wearing off)?

beating fast?

(15) See, feel, or hear things that weren’t really
there (when the effects of alcohol were
wearing off)?

(16) Have fits or seizures?

Page 1

Section 2B - ALCOHOL EXPERIENCES (Continued)
c. Did this happen before 12 months

d.

ago, that is before last (Month one
year ago)?

1  Yes - Mark Box B1
2  No - Go to next experience

1

1  Yes - Mark Box B1
2  No - Go to next experience

B1
Had to drink much more to get an
effect or drank the equivalent of a
fifth of liquor

1  Yes - Mark Box B1
2  No - Go to next experience
1  Yes - Mark Box B1
2  No - Go to next experience
1  Yes - Mark Box B2
2  No - Go to next experience

1

B2
Wanted or tried to stop or cut down
on your drinking

1

B3
Drank more or longer than you
meant to

1  Yes - Mark Box B2
2  No - Go to next experience
1  Yes - Mark Box B3
2  No - Go to next experience
1  Yes - Mark Box B3
2  No - Go to next experience

1  Yes
2  No

Go to next experience

1  Yes
2  No

Go to next experience

1  Yes
2  No

Go to next experience

1  Yes
2  No

Go to next experience

1  Yes
2  No

Go to next experience

1  Yes
2  No

Go to next experience

1  Yes
2  No

Go to next experience

1  Yes
2  No

Go to next experience

Page 2

Section 2B - ALCOHOL EXPERIENCES (Continued)
CHECK Are at least 2 items marked “Yes” in column b,
ITEM 2.11 item 9-16

1  Yes
2  No – SKIP to Check Item 2.12

(17) You just mentioned that you had SOME

1  Yes
2  No

bad aftereffects when stopping or
cutting down on drinking in the last 12
months. Did at least 2 of these
experiences happen around the same
time DURING the last 12 months?
CHECK Are at least 2 items marked “Yes” in column c,
ITEM 2.12
item 9-16)?

1  Yes
2  No – SKIP to (19)

(18) You (also/just) mentioned that you had
SOME bad aftereffects when stopping
or cutting down on drinking before 12
months ago. Did at least 2 of these
experiences happen around the same
time BEFORE 12 months ago?

1a. In your entire life, did you EVER... (PAUSE)

b. Did this happen in the last 12

(Repeat phrase frequently)

months?
1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

(28) Feel a very strong urge or desire to drink?

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

(29) Want a drink so badly that you couldn’t think

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

(19) Take a drink or use any drug or medicine,
other than aspirin, Advil or Tylenol, to GET
OVER any of the bad aftereffects of drinking?

(20) Take a drink or use any drug or medicine,
other than aspirin, Advil or Tylenol, to KEEP
FROM having any of these bad aftereffects of
drinking?

(21) Have a period when you spent a lot of time
drinking?

(22) Have a period when you spent a lot of time
being sick or getting over the bad aftereffects of
drinking?

(23) Give up or cut down on activities that were
important to you in order to drink - like work,
school, or associating with friends or relatives?

(24) Give up or cut down on activities that you were
interested in or that gave you pleasure in order
to drink?

(25) Continue to drink even though you knew it was
making you feel depressed, uninterested in
things, or suspicious or distrustful of other
people?

(26) Continue to drink even though you knew it was
causing you a health problem or making a
health problem worse?

(27) Continue to drink even though you had
experienced a prior blackout, that is, awakened
the next day not being able to remember some
of the things you did while drinking or after
drinking?

of anything else?

Page 3

Section 2B - ALCOHOL EXPERIENCES (Continued)

1  Yes – Mark Box B4-1
2  No

c. Did this happen before 12 months

1

B4-1
Had bad aftereffects after
stopping or cutting down on
drinking

d.

ago, that is before last (Month one
year ago)?
1  Yes - Mark Box B4-2
2  No - Go to next experience

1

B4-2
Took a drink, medicine or
drug to get over or avoid the
bad aftereffects of drinking

1  Yes - Mark Box B4-2
2  No - Go to next experience
1  Yes - Mark Box B5
2  No - Go to next experience

1

B5
Spent a lot of time drinking
or getting over being sick
from drinking

1  Yes - Mark Box B5
2  No - Go to next experience
1  Yes - Mark Box B6
2  No - Go to next experience

1

1  Yes - Mark Box B6
2  No - Go to next experience
1  Yes - Mark Box B7
2  No - Go to next experience

1

B6
Gave up or cut down on
activities that were
important to you in order to
drink

B7
Drank even though it
affected your mood or health

1  Yes - Mark Box B7
2  No - Go to next experience
1  Yes - Mark Box B7
2  No - Go to next experience

1  Yes - Mark Box B8
2  No - Go to next experience

1

B8
Had a strong desire or urge to
drink

1  Yes - Mark Box B8
2  No - Go to next
experience

Page 4

Section 2B - ALCOHOL EXPERIENCES (Continued)
1a. In your entire life, did you EVER... (PAUSE)

b. Did this happen in the last 12

(Repeat phrase frequently)

(30) Have a period when your drinking or being sick
from drinking often interfered with taking care
of your home or family?

(31) Have job or school troubles because of your
drinking or being sick from drinking – like
missing too much work, not doing your work
well, being demoted or losing a job, or being
suspended, expelled or dropping out of school?

(32) Continue to drink even though it was causing
you problems at school or at work?

(33) More than once drive a car or other vehicle
WHILE you were drinking?

(34) Drive a car, motorcycle, truck, boat or other
vehicle and have an accident WHILE you were
under the influence of alcohol?

(35) More than once drive a car, motorcycle, truck
boat, or other vehicle AFTER having too much
to drink?

(36) Get into situations while drinking or after
drinking that increased your chances of getting
hurt – like swimming, using machinery, or
walking in a dangerous area or around heavy
traffic?

(37) Have arguments or problems with your spouse
or partner or family or friends because of your
drinking?

(38) Continue to drink even though it was causing
you trouble with your family or friends?

(39) Get into physical fights while drinking or right
after drinking?

(40) More than once get arrested, held at a police
station, or have any other legal problems
because of your drinking?

months?
1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Mark “Yes”
in column c

1  Yes
2  No - Go to Check
Item 2.14

1  Yes
2  No - Mark “Yes”
in column c

Page 5

Section 2B - ALCOHOL EXPERIENCES (Continued)
c. Did this happen before 12 months

d.

ago, that is before last (Month one
year ago)?
1  Yes - Mark Box B9
2  No - Go to next experience

1

1  Yes - Mark Box B9
2  No - Go to next experience

B9
Were drunk or hung over
when you were supposed to be
doing something important

1  Yes - Mark Box B9
2  No - Go to next experience
1  Yes - Mark Box B10
2  No - Go to next experience

1

1  Yes - Mark Box B10
2  No - Go to next experience

B10
Were in a situation while
drinking or after drinking
where you could have been
hurt

1  Yes - Mark Box B10
2  No - Go to next experience
1  Yes - Mark Box B10
2  No - Go to next experience

1  Yes - Mark Box B11
2  No - Go to next experience

1

1  Yes - Mark Box B11
2  No - Go to next experience

B11
Drank even though it
affected your relationships
with other people

1  Yes - Mark Box B11
2  No - Go to next experience
1  Yes - Mark Box B12
2  No - Go to Check Item 2.14

1

B12
Got arrested or had legal problems
as the result of your drinking

Page 6

Section 2B – ALCOHOL EXPERIENCES (Continued)
CHECK
Are there AT LEAST 2 BOXES marked “Yes” for
ITEM 2.14 Boxes 1-3, (4-1 or 4-2), 5-12 in 1, column d?

2a.

You mentioned that before 12 months ago, you... (Read
ALL summary statements marked in Boxes B1, B2, B3,
B4-1, B4-2, B5-B12 in 1, column d).

1  Yes
2  No – SKIP to 3a1
1  Yes - SKIP to 2d
2  No

Before last (Month one year ago), was there EVER a
period when SOME of these experiences were
happening around the same time ON AND OFF FOR
A FEW MONTHS OR LONGER?

b. Before last (Month one year ago), was there EVER a
period when SOME of these experiences were
happening around the same time MOST DAYS FOR
AT LEAST A MONTH?

c. Before last (Month one year ago), was there EVER a
period when SOME of these experiences happened
within the same 1-year period?

d. About how old were you the FIRST time SOME of

1  Yes - SKIP to 2d
2  No

1  Yes
2  No - SKIP to 3a1
_______ Age

these experiences BEGAN to happen around the same
time?

e. In your ENTIRE LIFE, how many separate periods

_______ Number

like this did you have when SOME of these experiences
were happening around the same time?
By separate periods, I mean times that were separated
by at least 1 year when you EITHER STOPPED
drinking entirely (PAUSE) OR you didn’t have any of
the experiences you mentioned with alcohol at all.
CHECK
ITEM 2.15 Is number entered in 2e, 2 or more or unknown?

2f.

What was the LONGEST period you had when SOME
of these experiences were happening around the same
time?

g. How old were you the MOST RECENT time SOME of

1  Yes
2  No - SKIP to 2h
_______ Month(s)
OR
_______ Year(s)
_______ Age - SKIP to Check Item 2.16

these experiences BEGAN to happen around the same
time?

h. How long did this period last when SOME of these
experiences were happening around the same time?
CHECK Is at least 1 item marked in 1b, items (1) – (16) or
ITEM 2.16 (19) - (40)?

2i.

About how old were you when you FINALLY
STOPPED having ANY of these experiences with
alcohol? By finally stopped, I mean they never started
happening again.

_______ Month(s)
OR
_______ Year(s)
1  Yes - SKIP to 3a1
2  No

_______ Age

3a. In your ENTIRE LIFE, did you EVER ... (PAUSE)

b. Did this happen in c. Did this happen

(Repeat phrase frequently)

(1) Ride in a car or other vehicle WHILE the driver was
drinking?

(2) Ride in a car as a passenger while YOU were
drinking?

the last 12 months?

before 12 months
ago, that is, before
last (Month one year
ago)?

1  Yes
2  No - Go to next
experience

1  Yes
2  No – Mark “Yes”
in column c

1  Yes
2  No

1  Yes
2  No - Go to next
experience

1  Yes
2  No – Mark “Yes”
in column c

1  Yes
2  No

Page 7

Section 2B - ALCOHOL EXPERIENCES (Continued)
3a. In your ENTIRE LIFE, did you EVER ... (PAUSE)

b. Did this happen in c. Did this happen

(Repeat phrase frequently)

(3) Drive a car, motorcycle, truck or other vehicle and
injure yourself or someone else in an accident while
you were under the influence of alcohol?

(4) Accidentally injure yourself or someone else in any
way other than motor vehicle accidents, like a bad
fall or bad cut, while you were under the influence
of alcohol?

the last 12
months?

1  Yes
2  No - Go to next
experience

1  Yes
2  No – Mark
“Yes” in
column c

1  Yes
2  No - Go to
Section 2C

1  Yes
2  No – Mark
“Yes” in
column c

before 12 months
ago, that is, before
last (Month one
year ago)?
1  Yes
2  No

1  Yes
2  No

Go to
Section
2C

Page 8

Section 2C - TREATMENT UTILIZATION
1.

Have you ever gone anywhere or seen anyone for a reason that
was related in any way to your drinking - a physician,
counselor, Alcoholics Anonymous, or any other community
agency or professional?

2a. I am going to read you a list of community agencies and
professionals. For each one, please tell me if you have ever gone
there for any reason related to your drinking.

1  Yes
2  No - SKIP to 4a

b. Did you go there during the last 12
months ONLY, before the last 12
months ONLY or during both time
periods?

In your entire life, did you EVER go to (a/an) ...
(Repeat phrase frequently)

(1) Alcoholics Anonymous,
Narcotics or Cocaine
Anonymous meeting, or
any 12-step meeting?

(2) Family services or other
social service agency?

(3) Alcohol or drug
detoxification ward or
clinic?

(4) Inpatient ward of a
psychiatric or general
hospital or community
mental health program?

(5) Outpatient clinic,
including outreach
programs and day or
partial patient programs?

(6) Alcohol or drug
rehabilitation program?

(7) Emergency room for any
reason related to your
drinking?

(8) Halfway house, including
therapeutic communities?

(9) Crisis center for any
reason related to your
drinking?

(10) Employee assistance
program (EAP)?

(11) Clergyman, priest, rabbi
or any other religious
counselor for any reason
related to your drinking?

(12) Private physician,
psychiatrist, psychologist,
social worker, or any
other professional?

(13) Any other agency or
professional?

1  Yes
2  No - Go to Next Agency

1  Last 12 months only
2  Before the last 12 months only
3  Both time periods

1  Yes
2  No - Go to Next Agency

1  Last 12 months only
2  Before the last 12 months only
3  Both time periods

1  Yes
2  No - Go to Next Agency

1  Last 12 months only
2  Before the last 12 months only
3  Both time periods

1  Yes
2  No - Go to Next Agency

1  Last 12 months only
2  Before the last 12 months only
3  Both time periods

1  Yes
2  No - Go to Next Agency

1  Last 12 months only
2  Before the last 12 months only
3  Both time periods

1  Yes
2  No - Go to Next Agency

1  Last 12 months only
2  Before the last 12 months only
3  Both time periods

1  Yes
2  No - Go to Next Agency

1  Last 12 months only
2  Before the last 12 months only
3  Both time periods

1  Yes
2  No - Go to Next Agency

1  Last 12 months only
2  Before the last 12 months only
3  Both time periods

1  Yes
2  No - Go to Next Agency

1  Last 12 months only
2  Before the last 12 months only
3  Both time periods

1  Yes
2  No - Go to Next Agency

1  Last 12 months only
2  Before the last 12 months only
3  Both time periods

1  Yes
2  No - Go to Next Agency

1  Last 12 months only
2  Before the last 12 months only
3  Both time periods

1  Yes
2  No - Go to Next Agency

1  Last 12 months only
2  Before the last 12 months only
3  Both time periods

1  Yes
2  No - Go to 3a

1  Last 12 months only
2  Before the last 12 months only
3  Both time periods

Page 1

Section 2C - TREATMENT UTILIZATION (Continued)
3a. How old were you the FIRST time you went anywhere or saw

_______ Age

anyone for help with your drinking?

b. How old were you the MOST RECENT time you went
anywhere or saw anyone for help with your drinking?

4a. Was there ever a time when you thought you should see a
doctor, counselor, or other health professional or seek any other
help for your drinking, but you didn’t go?

b. Did this happen during the last 12 months?
c.

Did this happen before 12 months ago, that is, before last
(Month one year ago)?
(SHOW FLASHCARD 32)

d. What were your reasons for not getting help?
(Check all that apply.)

_______ Age
OR
0  Happened only once
1  Yes
2  No - SKIP to Section 2D

1  Yes
2  No - SKIP to 4d
1  Yes
2  No
1  Wanted to go, but health insurance didn’t cover
2  Didn’t think anyone could help
3  Didn’t know any place to go for help
4  Couldn’t afford to pay the bill
5  Didn’t have any way to get there
6  Didn’t have time
7  Thought the problem would get better by itself
8  Was too embarrassed to discuss it with anyone
9  Was afraid of what my boss, friends, family,
or others would think
10  Thought it was something I should be strong
enough to handle alone
11  Was afraid they would put me into the hospital
12  Was afraid of the treatment they would give me
13  Hated answering personal questions
14  The hours were inconvenient
15  A member of my family objected
16  My family thought I should go but I didn’t
think it was necessary
17  Can’t speak English very well
18  Was afraid I would lose my job
19  Couldn’t arrange for child care
20  Had to wait too long to get into a program
21  Wanted to keep drinking or got drunk
22  Didn’t think drinking problem was serious enough
23  Didn’t want to go
24  Stopped drinking on my own
25  Friends or family helped me stop drinking
26  Tried getting help before and it didn’t work
27  Was afraid my children would be taken away
28  My religious beliefs don’t allow me to go for treatment
29  Other reason

Page 2

Section 2D - FAMILY HISTORY

Statement G

Now I would like to ask you some questions about whether any of your relatives, regardless of whether or
not they are now living, have EVER been alcoholics or problem drinkers. By alcoholic or problem drinker,
I mean a person who has physical or emotional problems because of drinking (PAUSE); problems with a
spouse, family, or friends because of drinking (PAUSE); problems at work or school because of drinking
(PAUSE); problems with the police because of drinking - like drunk driving (PAUSE) or a person who seems
to spend a lot of time drinking or being hung over. (Repeat definition as needed.)

1.

Has your blood or natural father been an alcoholic or
problem drinker at ANY time in his life?

1  Yes
2  No

2.

Has your blood or natural mother been an alcoholic or
problem drinker at ANY time in her life?

1  Yes
2  No

3a. How many full brothers have you had who lived to be
at least 10 years old, including those who are still
living? By full brothers, I mean brothers who have the
same natural mother AND the same natural father as
you do.
CHECK
ITEM 2.17

Is number marked in 3a equal to 1?

3b. Was your full brother an alcoholic or problem drinker
at ANY time in his life?

c. How many of your full brothers are now, or were in the
past, alcoholics or problem drinkers?

4a. How many full sisters have you had who lived to be at
least 10 years old, including those who are still living?
By full sisters, I mean sisters who have the same
natural mother AND the same natural father as you do.
CHECK
ITEM 2.18

Is number marked in 4a equal to 1?

4b. Was your full sister an alcoholic or problem drinker at
ANY time in her life?

c. How many of your full sisters are now, or were in the
past, alcoholics or problem drinkers?

5a. How many natural sons have you had who lived to be
at least 10 years old, including those who are still
living? By natural son, I mean those you (biologically
fathered/gave birth to.)
CHECK
ITEM 2.19

Is number marked in 5a equal to 1?

5b. Was your natural son an alcoholic or problem drinker
at ANY time in his life?

c. How many of your natural sons are now, or were in

______ Number
0  None – SKIP to 4a

1  Yes
2  No - SKIP to 3c
1  Yes
2  No

SKIP to 4a

______ Number

______ Number
0  None - SKIP to 5a

1  Yes
2  No- SKIP to 4c
1  Yes
2  No

SKIP to 5a

______ Number

______ Number
0  None - SKIP

to 6a

1  Yes
2  No - SKIP to 5c
1  Yes
2  No

SKIP to 6a

______ Number

the past, alcoholics or problem drinkers?

6a. How many natural daughters have you had who lived to
be at least 10 years old, including those who are still
living? By natural daughters, I mean those you
(biologically fathered/gave birth to).
CHECK
ITEM 2.20

Is number marked in 6a equal to 1?

6b. Was your natural daughter an alcoholic or problem
drinker at ANY time in her life?

c. How many of your natural daughters are now, or were

______ Number
0  None - SKIP

to 7a

1  Yes
2  No – SKIP to 6c
1  Yes
2  No

SKIP to 7a

______ Number

in the past, alcoholics or problem drinkers?
Page 1

Section 2D - FAMILY HISTORY (Continued)
7a. How many full brothers did your natural father have
who lived to be at least 10 years old, including those
who are still living? By full brothers, I mean those who
had the SAME TWO natural or blood parents as your
father.
CHECK
ITEM 2.21

Is number marked in 7a equal to 1?

7b. Was your natural father’s full brother an alcoholic or
problem drinker at ANY time in his life?

c. How many of your natural father’s full brothers are
now, or were in the past, alcoholics or problem
drinkers?

8a. How many full sisters did your natural father have who
lived to be at least 10 years old, including those who are
still living? By full sisters, I mean those who had the
SAME TWO natural or blood parents as your father.
CHECK
ITEM 2.22

Is number marked in 8a equal to 1?

8b. Was your natural father’s full sister an alcoholic or
problem drinker at ANY time in her life?

c. How many of your natural father’s full sisters are now,
or were in the past, alcoholics or problem drinkers?

9a. How many full brothers did your natural mother have
who lived to be at least 10 years old, including those
who are still living? By full brothers, I mean those who
had the SAME TWO natural or blood parents as your
mother.
CHECK
ITEM 2.23

Is number marked in 9a equal to 1?

9b. Was your natural mother’s full brother an alcoholic or
problem drinker at ANY time in his life?

c. How many of your natural mother’s full brothers are
now, or were in the past, alcoholics or problem
drinkers?

10a. How many full sisters did your natural mother have
who lived to be at least 10 years old, including those
who are still living? By full sisters, I mean those who
had the SAME TWO natural or blood parents as your
mother.
CHECK
ITEM 2.24

Is number marked in 10a equal to 1?

10b. Was your natural mother’s full sister an alcoholic or
problem drinker at ANY time in her life?

c. How many of your natural mother’s full sisters are now,
or were in the past, alcoholics or problem drinkers?

11. Was your natural grandfather on your father’s side an
alcoholic or problem drinker at ANY time in his life? By
natural grandfather on your father’s side, I mean your
father’s natural or blood father.

12. Was your natural grandmother on your father’s side an
alcoholic or problem drinker at ANY time in her life?
By natural grandmother on your father’s side, I mean
your father’s natural or blood mother.

______ Number
0  None - SKIP

to 8a

1  Yes
2  No – SKIP to 7c
1  Yes
2  No

SKIP to 8a

______ Number

______ Number
0  None - SKIP to 9a

1  Yes
2  No – SKIP to 8c
1  Yes
2  No

SKIP to 9a

______ Number
______ Number
0  None - SKIP to 10a

1  Yes
2  No - SKIP to 9c
1  Yes
2  No

SKIP to 10a

______ Number

______ Number
0  None - SKIP to 11

1  Yes
2  No - SKIP to 10c
1  Yes
2  No

SKIP to 10a

______ Number

1  Yes
2  No

1  Yes
2  No

Page 2

Section 2D - FAMILY HISTORY (Continued)
13a. Was your natural grandfather on your mother’s side
an alcoholic or problem drinker at ANY time in his
life? By natural grandfather on your mother’s side, I
mean your mother’s natural or blood father.

b. Was your natural grandmother on your mother’s side
an alcoholic or problem drinker at ANY time in her
life? By natural grandmother on your mother’s side, I
mean your mother’s natural or blood mother.
CHECK
ITEM 2.24A

Refer to 7c, Section 1.
Was respondent raised by adoptive parents?
(Section1, 7c=1)

1  Yes
2  No

1  Yes
2  No - SKIP to Check Item 2.25A

drinker at ANY time in his life?

1  Yes
2  No

Was your adoptive mother an alcoholic or problem
drinker at ANY time in her life?

1  Yes
2  No

14a. Was your adoptive father an alcoholic or problem

b.

1  Yes
2  No

CHECK
ITEM 2.25A

Refer to 9a and 9b, Section 1.
Is respondent never married?
(Section 1, 9a=6 or 9b=0)

15. Were you EVER married to an alcoholic or problem
drinker?
CHECK
ITEM 2.25B

1  Yes - SKIP to 18
2  No
1  Yes
2  No - SKIP to 18

Refer to 9a, Section 1.
Is respondent currently married or separated?
(n1q9a = 1 or n1q9a = 5)

1  Yes
2  No – SKIP to 18

16. Is that your current spouse?

1  Yes
2  No - SKIP to 18

17. Would you say that person is an alcoholic or problem

1  Yes
2  No

drinker at this time?

18. Did you EVER live as if married with someone who
was an alcoholic or problem drinker?
CHECK
ITEM 2.26

Refer to 9a, Section 1.
Is respondent currently living with someone as if
married? (Code 2)

SKIP to 18

1  Yes
2  No - SKIP to Section 2E
1  Yes
2  No - SKIP to Section 2E

19. Is that the person you live with now?

1  Yes
2  No - SKIP to Section 2E

20. Would you say that person is an alcoholic or problem

1  Yes
2  No

drinker at this time?

Go to Section 2E

Page 3

Section 2E - Background Information II
Now I’d like to ask you some other questions about your background.

Statement H
CHECK
ITEM 2.27

(Refer to 1e, Section 1.)
Is respondent Hispanic?

1  Yes
2  No - SKIP to Check Item 2.29

(SHOW FLASHCARD 33)

1a. You mentioned earlier that you are of Hispanic or
Latino origin. I’d like to ask you some questions about
your heritage or ancestry.
As I read each question, please tell me what category
on the card best describes your answer.
How often do you speak English?

1  Almost never
2  Sometimes
3  Often
4  Almost always

b. How often do you speak English with your friends?

1  Almost never
2  Sometimes
3  Often
4  Almost always

c. How often do you think in English?

1  Almost never
2  Sometimes
3  Often
4  Almost always

d. How often do you speak in Spanish?

1  Almost never
2  Sometimes
3  Often
4  Almost always

e. How often do you speak in Spanish with your friends?

1  Almost never
2  Sometimes
3  Often
4  Almost always

f. How often do you think in Spanish?

1  Almost never
2  Sometimes
3  Often
4  Almost always

g. How often do you watch television programs in

1  Almost never
2  Sometimes
3  Often
4  Almost always

English?

h. How often do you listen to radio programs in English?

1  Almost never
2  Sometimes
3  Often
4  Almost always

i. How often do you listen to music in English?

1  Almost never
2  Sometimes
3  Often
4  Almost always

j. How often do you watch television programs in

1  Almost never
2  Sometimes
3  Often
4  Almost always

Spanish?

k. How often do you listen to radio programs in Spanish?

1  Almost never
2  Sometimes
3  Often
4  Almost always

l. How often do you listen to music in Spanish?

1  Almost never
2  Sometimes
3  Often
4  Almost always

Page 1

Section 2E - Background Information II (Continued)
(SHOW FLASHCARD 34)

1m. How well do you speak English?

1  Very poorly
2  Poorly
3  Well
4  Very well

n. How well do you read in English?

1  Very poorly
2  Poorly
3  Well
4  Very well

o. How well do you understand television programs in

1  Very poorly
2  Poorly
3  Well
4  Very well

English?

p. How well do you understand radio programs in
English?

1  Very poorly
2  Poorly
3  Well
4  Very well

q. How well do you write in English?

1  Very poorly
2  Poorly
3  Well
4  Very well

r. How well do you understand music in English?

1  Very poorly
2  Poorly
3  Well
4  Very well

s. How well do you speak Spanish?

1  Very poorly
2  Poorly
3  Well
4  Very well

t. How well do you read in Spanish?

1  Very poorly
2  Poorly
3  Well
4  Very well

u. How well do you understand television programs in

1  Very poorly
2  Poorly
3  Well
4  Very well

Spanish?

v. How well do you understand radio programs in
Spanish?

1  Very poorly
2  Poorly
3  Well
4  Very well

w. How well do you write in Spanish?

1  Very poorly
2  Poorly
3  Well
4  Very well

x. How well do you understand music in Spanish?

1  Very poorly
2  Poorly
3  Well
4  Very well

(SHOW FLASHCARD 35)

2a. Looking at the card, please tell me what category best
describes your level of agreement with each of the
following statements.

You have a strong sense of yourself as a person of
Hispanic or Latino origin.

1  Strongly agree
2  Agree
3  Somewhat agree
4  Somewhat disagree
5  Disagree
6  Strongly disagree

Page 2

Section 2E - Background Information II (Continued)
1  Strongly agree
2  Agree
3  Somewhat agree
4  Somewhat disagree
5  Disagree
6  Strongly disagree

(SHOW FLASHCARD 35)

2b. You identify with other Hispanics or Latinos.

c. Most of your close friends are of Hispanic or Latino
origin.

d. Your Hispanic or Latino heritage is important in your
life.

e. You are more comfortable in social situations where
other Hispanics or Latinos are present.

1  Strongly agree
2  Agree
3  Somewhat agree
4  Somewhat disagree
5  Disagree
6  Strongly disagree
1  Strongly agree
2  Agree
3  Somewhat agree
4  Somewhat disagree
5  Disagree
6  Strongly disagree
1  Strongly agree
2  Agree
3  Somewhat agree
4  Somewhat disagree
5  Disagree
6  Strongly disagree

f. You are proud of your Hispanic or Latino heritage.

1  Strongly agree
2  Agree
3  Somewhat agree
4  Somewhat disagree
5  Disagree
6  Strongly disagree

g. Your Hispanic or Latino background plays a big part

1  Strongly agree
2  Agree
3  Somewhat agree
4  Somewhat disagree
5  Disagree
6  Strongly disagree

in how you interact with others.

h. Your values, attitudes and behaviors are shared by
people of Hispanic or Latino origin.

1  Strongly agree
2  Agree
3  Somewhat agree
4  Somewhat disagree
5  Disagree
6  Strongly disagree

3a. (SHOW FLASHCARD 36)

b. About how often did this happen

Now I’d like to know about how often you have experienced discrimination, been
prevented from doing something, or been hassled or made to feel inferior in any of
the following situations because you are Hispanic or Latino.

BEFORE 12 months ago?

(1)

During the last 12 months, about how
often did you experience
discrimination in your ability to obtain
health care or health insurance
coverage because you are Hispanic or
Latino?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

(2)

During the last 12 months, about how
often did you experience
discrimination in how you were
treated when you got care because you
are Hispanic or Latino?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

Page 3

Section 2E - Background Information II (Continued)
(SHOW FLASHCARD 36)

b. About how often did this happen

3a. Now I’d like to know about how often you have experienced discrimination, been

BEFORE 12 months ago?

prevented from doing something, or been hassled or made to feel inferior in any of
the following situations because you are Hispanic or Latino.
(3)

During the last 12 months, about how
often did you experience
discrimination in public, like on the
street, in stores, or in restaurants,
because you are Hispanic or Latino?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

(4)

During the last 12 months, about how
often did you experience discrimination
because you are Hispanic or Latino in
ANY other situation, like obtaining a
job or on the job, getting admitted to a
school or training program, in the
courts or by the police, or obtaining
housing?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

(5)

During the last 12 months, about how
often were you called a racist name
because you are Hispanic or Latino?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

(6)

During the last 12 months, about how
often were you made fun of, picked on,
pushed, shoved, hit or threatened with
harm because you are Hispanic or
Latino?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

CHECK
ITEM 2.28

Are all items (1) - (6) in 3a AND 3b marked “1”
OR “Never” OR D OR R?

3c. When you are treated unfairly because you are
Hispanic or Latino, do you usually accept it as a fact of
life, or do you try to do something about it?

d. When you are treated unfairly because you are
Hispanic or Latino, do you usually talk to other people
about it, or do you keep it to yourself?
CHECK
ITEM 2.29

(Refer to 1f, Section 1.)
Is respondent Asian or Pacific Islander?

1  Yes - SKIP to 13a
2  No
1  Accept it
2  Try to do something about it
1  Talk to other people
2  Keep it to yourself

SKIP to 13a

1  Yes
2  No - SKIP to 6a

4a. You mentioned earlier that you are of Asian or Pacific
Islander origin. By Asian origin or heritage, I mean
Chinese, Japanese, Indian, Filipino, Korean,
Vietnamese and other Asian background and by
Pacific Islander, I mean native Hawaiian, Samoan,
Guamanian or other Pacific Islander. Now I’d like to
ask you some questions about your Asian or Pacific
Islander origin or heritage.
Do you currently speak an Asian language or did you
speak an Asian language when you were growing up or
do your parents, caregivers, family or other people
around you speak an Asian language now or when you
were growing up?

b. Which language is that?

1  Yes
2  No - SKIP to 9a

__________________
Specify

Page 4

Section 2E – Background Information II (Continued)
(SHOW FLASHCARD 33)

5a . As I read each question, please tell me which of the
categories on the card best describes your answer.
How often do you speak English?

1  Almost never
2  Sometimes
3  Often
4  Almost always

b. How often do you speak English with your friends?

1  Almost never
2  Sometimes
3  Often
4  Almost always

c. How often do you think in English?

1  Almost never
2  Sometimes
3  Often
4  Almost always

d. How often do you speak in (language in 4b)?

1  Almost never
2  Sometimes
3  Often
4  Almost always

e. How often do you speak in (language in 4b) with your

1  Almost never
2  Sometimes
3  Often
4  Almost always

friends?

f. How often do you think in (language in 4b)?

1  Almost never
2  Sometimes
3  Often
4  Almost always

g. How often do you watch television programs in

1  Almost never
2  Sometimes
3  Often
4  Almost always

English?

h. How often do you listen to radio programs in English?

1  Almost never
2  Sometimes
3  Often
4  Almost always

i. How often do you listen to music in English?

1  Almost never
2  Sometimes
3  Often
4  Almost always

j. How often do you watch television programs in

1  Almost never
2  Sometimes
3  Often
4  Almost always

(language in 4b)?

k. How often do you listen to radio programs in
(language in 4b)?

l. How often do you listen to music in (language in 4b)?

(SHOW FLASHCARD 34)

m. How well do you speak English?

n. How well do you read in English?

1  Almost never
2  Sometimes
3  Often
4  Almost always
1  Almost never
2  Sometimes
3  Often
4  Almost always
1  Very poorly
2  Poorly
3  Well
4  Very well
1  Very poorly
2  Poorly
3  Well
4  Very well

Page 5

Section 2E – Background Information II (Continued)
(SHOW FLASHCARD 33)

5o.

How well do you understand television programs in
English?

p. How well do you understand radio programs in
English?

1  Very poorly
2  Poorly
3  Well
4  Very well
1  Very poorly
2  Poorly
3  Well
4  Very well

q. How well do you write in English?

1  Very poorly
2  Poorly
3  Well
4  Very well

r. How well do you understand music in English?

1  Very poorly
2  Poorly
3  Well
4  Very well

s. How well do you speak (language in 4b)?

1  Very poorly
2  Poorly
3  Well
4  Very well

t. How well do you read in (language in 4b)?

1  Very poorly
2  Poorly
3  Well
4  Very well

u How well do you understand television programs in

1  Very poorly
2  Poorly
3  Well
4  Very well

(language in 4b)?

v. How well do you understand radio programs in
(language in 4b)?

1  Very poorly
2  Poorly
3  Well
4  Very well

w. How well do you write in (language in 4b)?

1  Very poorly
2  Poorly
3  Well
4  Very well

x. How well do you understand music in (language in

1  Very poorly
2  Poorly
3  Well
4  Very well

4b)?

6a. Do you or did you or your parents, caregivers, family or
other people around you speak a non-English language
associated with your origin or heritage, either now or
when you were growing up? (Do not count English as
spoken by those from England, Australia, Ireland, etc.)

b. Which language is that?

SKIP to 9a

1  Yes
2  No - SKIP to 9a

_________________________
Specify

(SHOW FLASHCARD 33)

7a. As I read each question, please tell me which of the
categories on the card best describes your answer.
How often do you speak English?

b. How often do you speak English with your friends?

1  Almost never
2  Sometimes
3  Often
4  Almost always
1  Almost never
2  Sometimes
3  Often
4  Almost always

Page 6

Section 2E – Background Information II (Continued)
(SHOW FLASHCARD 33)

7c. How often do you think in English?

1  Almost never
2  Sometimes
3  Often
4  Almost always

d. How often do you speak in (language in 6b)?

1  Almost never
2  Sometimes
3  Often
4  Almost always

e. How often do you speak in (language in 6b) with your

1  Almost never
2  Sometimes
3  Often
4  Almost always

friends?

f. How often do you think in (language in 6b)?

1  Almost never
2  Sometimes
3  Often
4  Almost always

g. How often do you watch television programs in

1  Almost never
2  Sometimes
3  Often
4  Almost always

English?

h. How often do you listen to radio programs in English?

1  Almost never
2  Sometimes
3  Often
4  Almost always

i. How often do you listen to music in English?

1  Almost never
2  Sometimes
3  Often
4  Almost always

j. How often do you watch television programs in

1  Almost never
2  Sometimes
3  Often
4  Almost always

(language in 6b)?

k. How often do you listen to radio programs in (language
in 6b)?

l. How often do you listen to music in (language in 6b)?

(SHOW FLASHCARD 34)

m. How well do you speak English?

1  Almost never
2  Sometimes
3  Often
4  Almost always
1  Almost never
2  Sometimes
3  Often
4  Almost always
1  Very poorly
2  Poorly
3  Well
4  Very well

n. How well do you read in English?

1  Very poorly
2  Poorly
3  Well
4  Very well

o. How well do you understand television programs in

1  Very poorly
2  Poorly
3  Well
4  Very well

English?

p. How well do you understand radio programs in
English?

1  Very poorly
2  Poorly
3  Well
4  Very well

Page 7

Section 2E - Background Information II (Continued)
(SHOW FLASHCARD 34)

7q. How well do you write in English?

1  Very poorly
2  Poorly
3  Well
4  Very well

r. How well do you understand music in English?

1  Very poorly
2  Poorly
3  Well
4  Very well

s. How well do you speak (language in 6b)?

1  Very poorly
2  Poorly
3  Well
4  Very well

t. How well do you read in (language in 6b)?

1  Very poorly
2  Poorly
3  Well
4  Very well

u. How well do you understand television programs in

1  Very poorly
2  Poorly
3  Well
4  Very well

(language in 6b)?

v. How well do you understand radio programs in
(language in 6b)?

1  Very poorly
2  Poorly
3  Well
4  Very well

w. How well do you write in (language in 6b)?

1  Very poorly
2  Poorly
3  Well
4  Very well

x. How well do you understand music in (language in 6b)?

1  Very poorly
2  Poorly
3  Well
4  Very well

(SHOW FLASHCARD 35)

9a. Looking at the card, please tell me what category best
describes your level of agreement with each of the
following statements.

You have a strong sense of yourself as a member of
your race/ethnic group.

b. You identify with other people from your race/ethnic
group.

c. Most of your close friends are from your race/ethnic
group.

d. Your race/ethnic heritage is important in your life.

1  Strongly agree
2  Agree
3  Somewhat agree
4  Somewhat disagree
5  Disagree
6  Strongly disagree
1  Strongly agree
2  Agree
3  Somewhat agree
4  Somewhat disagree
5  Disagree
6  Strongly disagree
1  Strongly agree
2  Agree
3  Somewhat agree
4  Somewhat disagree
5  Disagree
6  Strongly disagree
1  Strongly agree
2  Agree
3  Somewhat agree
4  Somewhat disagree
5  Disagree
6  Strongly disagree

Page 8

Section 2E - Background Information II (Continued)
(SHOW FLASHCARD 35)

9e. You are more comfortable in social situations where
others are present from your racial/ethnic group.

1  Strongly agree
2  Agree
3  Somewhat agree
4  Somewhat disagree
5  Disagree
6  Strongly disagree
1  Strongly agree
2  Agree
3  Somewhat agree
4  Somewhat disagree
5  Disagree
6  Strongly disagree

f. You are proud of your race/ethnic heritage.

g. Your race/ethnic background plays a big part in how

1  Strongly agree
2  Agree
3  Somewhat agree
4  Somewhat disagree
5  Disagree
6  Strongly disagree

h. Your values, attitudes and behaviors are shared by

1  Strongly agree
2  Agree
3  Somewhat agree
4  Somewhat disagree
5  Disagree
6  Strongly disagree

you interact with others.

most members of your race/ethnic group.

(SHOW FLASHCARD 36)

b. About how often did this happen

10a. Now I’d like to know about how often you have experienced discrimination, been

BEFORE 12 months ago?

prevented from doing something, or been hassled or made to feel inferior in any of
the following situations because of your race or ethnicity.
(Repeat phrase frequently)
(1)

During the last 12 months, about how
often did you experience
discrimination in your ability to
obtain health care or health
insurance coverage because of your
race or ethnicity?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

(2)

During the last 12 months, about how
often did you experience
discrimination in how you were
treated when you got care because of
your race or ethnicity?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

(3)

During the last 12 months, about how
often did you experience
discrimination in public, like on the
street, in stores, or in restaurants,
because of your race or ethnicity?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

(4)

During the last 12 months, about how
often did you experience
discrimination because of your race
or ethnicity in ANY other situation,
like obtaining a job or on the job,
getting admitted to a school or
training program, in the courts or by
the police, or obtaining housing?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

(5)

During the last 12 months, about how
often were you called a racist name
because of your race or ethnicity?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

Page 9

Section 2E – Background Information II (Continued)
(SHOW FLASHCARD 36)

b. About how often did this happen

10a. About how often you have experienced discrimination, been prevented from doing

BEFORE 12 months ago?

something, or been hassled or made to feel inferior in any of the following situations
because of your race/ethnicity.

(6) During the last 12 months, about how
often were you made fun of, picked on,
pushed, shoved, hit or threatened with
harm because of your race or
ethnicity?
CHECK
ITEM 2.30

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

Are all items (1) - (6) in 10a AND 10b marked “1”
OR “Never” OR D OR R?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Yes - SKIP to 13a
2  No

11.

When you are treated unfairly because of your race or
ethnicity, do you usually accept it as a fact of life, or
do you try to do something about it?

1  Accept it
2  Try to do something about it

12.

When you are treated unfairly because of your race or
ethnicity, do you usually talk to other people about it,
or do you keep it to yourself?

1  Talk to other people
2  Keep it to yourself

(SHOW FLASHCARD 36)

b. About how often did this happen

13a. Now I’d like to ask you about sex discrimination that some people experience

BEFORE 12 months ago?

because they are male or female.
I’d like to know about how often you have experienced discrimination, been
prevented from doing something, or been hassled or made to feel inferior in any of
the following situations because you are (male/female).
(1) During the last 12 months, about how
often did you experience
discrimination in your ability to
obtain health care or health insurance
coverage because you are
(male/female)?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

(2) During the last 12 months, about how
often did you experience
discrimination in how you were
treated when you got care because you
are (male/female)?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

(3) During the last 12 months, about how
often did you experience
discrimination in obtaining a job or on
the job because you are
(male/female)?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

(4) During the last 12 months, about how
often did you experience
discrimination in public, like on the
street, in stores, or in restaurants,
because you are (male/female)?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

(5) During the last 12 months, about how
often did you experience
discrimination because you are
(male/female) in ANY other situation,
like getting admitted to a school or
training program, in the courts or by
the police, or obtaining housing?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

(6) During the last 12 months about how
often were you called a sexist name
because you are (male/female)?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

Page 10

Section 2E – Background Information II (Continued)
CHECK
ITEM 2.31

Are all items (1) - (6) in 13a AND 13b marked
“1” OR “Never” OR D OR R?

1  Yes - SKIP to 16a
2  No

14.

When you are treated unfairly because you are
(male/female), do you usually accept it as a fact of life,
or do you try to do something about it?

1  Accept it
2  Try to do something about it

15.

When you are treated unfairly because you are
(male/female), do you usually talk to other people
about it, or do you keep it to yourself?

1  Talk to other people
2  Keep it to yourself

(SHOW FLASHCARD 36)

16a. In the last 12 months, how often have you…
(Repeat phrase frequently)

Felt that you were not able to control the important
things in your life?

b. Felt confident about your ability to handle your
personal problems?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often
1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

c. Felt things were going your way?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

d. Felt difficulties were piling up so high that you could

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

not overcome them?

17a. Do you have any grown children, that is, children 18
years of age or older?

b. How many of your grown children do you see or talk
to on the phone or internet at least once every 2
weeks? (If more than 15 enter 15.)

18a. Are any of your parents or other people who raised
you still living?

b. Do you see or talk on the phone or internet to any of
your parents or other people who raised you at least
once every 2 weeks?

CHECK
ITEM 2.31A

Does 9a = 1 OR 2 in Section 1?

19a. Are any of your (spouse’s/partner’s) parents or any
other people who raised your (spouse/partner) still
living?

b. Do you see or talk on the phone or internet to them at
least once every 2 weeks?

20a. How many of your other relatives, not counting
spouses, partners, children, parents, or parents-in-law,
do you feel close to?

b. How many of these relatives do you see or talk to on
the phone or internet at least once every 2 weeks?

21a. How many close friends do you have?

b. How many of these friends do you see or talk to on
the phone or internet at least once every 2 weeks?

1  Yes
2  No - SKIP to 18a
______ Number

1  Yes
2  No - SKIP to Check Item 2.31A
1  Yes
2  No
1  Yes
2  No - SKIP to 20a
1  Yes
2  No - SKIP to 20a
1  Yes
2  No
0  None - SKIP to 21a
OR
______ Number
______ Number
0  None - SKIP to 22a
OR
______ Number

______ Number

Page 11

Section 2E - Background Information II (Continued)
22a. Do you attend any classes, that is at school, a
university, technical training or adult education
classes, on a regular basis?

b. How many fellow students or teachers do you talk to
socially at least once every 2 weeks, not counting brief
encounters at school?
CHECK
ITEM 2.32

(Refer to 12, Section 1.)
Is respondent currently employed either part-time or
full-time? (12 = 1-5)?

23. How many people do you work with that you talk to
socially at least once every 2 weeks, not counting brief
encounters at work?

24. How many of your neighbors do you visit or talk to at
least once every 2 weeks, not counting brief
encounters?

25a. Are you currently involved in regular volunteer work
or community service?

b. How many people involved in this volunteer work or
community service do you talk to socially at least once
every 2 weeks, not counting brief encounters at your
volunteer work?

26a. Not counting religious groups or volunteer groups you
may have already told me about, do you belong to any
other groups, such as social clubs, recreational groups,
trade unions, commercial groups, professional
organizations, or groups concerned with children like
the PTA or Boy Scouts?

b. How many of these groups do you belong to?
c. (Thinking about ALL of these other groups together),
about how many members of (this group/these other
groups) do you talk to socially at least once every 2
weeks, not counting brief encounters at these group
meetings?

1  Yes
2  No - SKIP to Check Item 2.32

______ Number

1  Yes
2  No - SKIP to 24

______ Number

______ Number

1  Yes
2  No - SKIP to 26a
______ Number

1  Yes
2  No - SKIP to 27a

______ Number

______ Number

(SHOW FLASHCARD 37)

27a. Now I’m going to read you a few statements and I
would like to know how well they describe you.
Look at the categories on the card and tell me how true
or how false these statements are about you.
If I wanted to go on a trip for a day, like to the
country, city, mountains or beach, I would have a hard
time finding someone to go with me.

b. I feel that there is no one I can share my most private
worries and fears with.

c. If I were sick, I know I would find someone to help me
with my daily chores.

d. There is someone I can turn to for advice about
handling problems with my family.

e. If I decide one afternoon that I would like to go to a
movie that evening, I could easily find someone to go
with me.

1  Definitely false
2  Probably false
3  Probably true
4  Definitely true
1  Definitely false
2  Probably false
3  Probably true
4  Definitely true
1  Definitely false
2  Probably false
3  Probably true
4  Definitely true
1  Definitely false
2  Probably false
3  Probably true
4  Definitely true
1  Definitely false
2  Probably false
3  Probably true
4  Definitely true

Page 12

Section 2E - Background Information II (Continued)
(SHOW FLASHCARD 37)

27f. When I need suggestions on how to deal with a
personal problem, I know someone I can turn to.

1  Definitely false
2  Probably false
3  Probably true
4  Definitely true

I don’t often get invited to do things with others.

1  Definitely false
2  Probably false
3  Probably true
4  Definitely true

h. If I had to go out of town for a few weeks, it would be

1  Definitely false
2  Probably false
3  Probably true
4  Definitely true

g.

difficult to find someone who would look after my
house or apartment, like taking care of my plants,
garden or pets, getting the mail or watching the house
in general.

i.

If I wanted to have lunch with someone, I could
easily find someone to join me.

1  Definitely false
2  Probably false
3  Probably true
4  Definitely true

j.

If I were stranded 10 miles from home, someone I
know would come and get me.

1  Definitely false
2  Probably false
3  Probably true
4  Definitely true

k. If a family crisis arose, it would be difficult to find

1  Definitely false
2  Probably false
3  Probably true
4  Definitely true

someone who could give me good advice about how
to handle it.

l.

If I needed some help in moving to a new house or
apartment, I would have a hard time finding
someone to help me.

m. I am able to adapt to change.

1  Definitely false
2  Probably false
3  Probably true
4  Definitely true
1  Definitely false
2  Probably false
3  Probably true
4  Definitely true

I can deal with whatever comes.

1  Definitely false
2  Probably false
3  Probably true
4  Definitely true

I try to see the humorous side of problems.

1  Definitely false
2  Probably false
3  Probably true
4  Definitely true

p.

Coping with stress can strengthen me.

1  Definitely false
2  Probably false
3  Probably true
4  Definitely true

q.

I tend to bounce back after illness or hardship.

1  Definitely false
2  Probably false
3  Probably true
4  Definitely true

r.

I can achieve goals despite obstacles.

1  Definitely false
2  Probably false
3  Probably true
4  Definitely true

s.

I can stay focused under pressure.

1  Definitely false
2  Probably false
3  Probably true
4  Definitely true

n.

o.

Page 13

Section 2E - Background Information II (Continued)
(SHOW FLASHCARD 37)

27t.

I am not easily discouraged by failure.

1  Definitely false
2  Probably false
3  Probably true
4  Definitely true

u.

I think of myself as a strong person.

1  Definitely false
2  Probably false
3  Probably true
4  Definitely true

v.

I can handle unpleasant feelings.

1  Definitely false
2  Probably false
3  Probably true
4  Definitely true

(SHOW FLASHCARD 38)

28a.

Which category on the card best describes your
answer to the following questions?
I am always courteous even to people who are
disagreeable.

1  Definitely false
2  Mostly false
3  Don’t know
4  Mostly true
5  Definitely true

b.

I sometimes feel resentful when I don’t get my way.

1  Definitely false
2  Mostly false
3  Don’t know
4  Mostly true
5  Definitely true

c.

No matter whom I am talking to, I’m always a good
listener.

1  Definitely false
2  Mostly false
3  Don’t know
4  Mostly true
5  Definitely true

29a.

Now a few questions about your current
neighborhood.
Do you know most of the people in your
neighborhood?

1  Yes
2  No

b.

Do you usually feel safe in your neighborhood?

1  Yes
2  No

c.

Do people in your neighborhood look out for each
other?

1  Yes
2  No

d.

Are you happy about living in your neighborhood?

1  Yes
2  No

e.

Do you live in a close-knit neighborhood?

1  Yes
2  No

f.

Can people in your neighborhood be trusted?

1  Yes
2  No

g.

Do people in your neighborhood get along with each
other?

1  Yes
2  No

h.

Do people in your neighborhood share the same
values?

1  Yes
2  No

i.

How long have you lived in your neighborhood?

j.

Would you be happy if you could move to another
neighborhood?

_____ Months
or
_____ Years
1  Yes
2  No

Go to Section 3A

Page 14

Section 3A - TOBACCO USE
Now I’d like to ask you about your experiences with tobacco.

Statement I

1a. In your ENTIRE LIFE, have you ever. . .
Smoked at least 100 cigarettes? Include smoking tobacco in a
water pipe.

1  Yes
2  No

b. Smoked at least 50 cigars?

1  Yes
2  No

c. Smoked a pipe at least 50 times?

1  Yes
2  No

d. Used snuff, such as Skoal, Skoal Bandit or Copenhagen at least

1  Yes
2  No

20 times?

e. Used chewing tobacco, such as Redman, Levi Garrett or
Beechnut at least 20 times?
CHECK
ITEM 3.1

Is at least 1 tobacco category marked in 1a - e?

For each tobacco category
reported in 1, MARK EACH
TOBACCO CATEGORY
CODE BOX and ask 2
through 7 for each tobacco
category marked.

1  Yes
2  No
1  Yes
2  No - SKIP to Section 3B

1  Cigarettes

2  Cigars

3  Pipe

4  Snuff

5  Chewing
Tobacco

____ Age

____ Age

____ Age

____ Age

____ Age

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

____ Hour(s) ago
OR
____ Day(s) ago
OR
____ Week(s) ago
OR
____ Month(s) ago
OR
____ Year(s) ago

____ Hour(s) ago
OR
____ Day(s) ago
OR
____ Week(s) ago
OR
____ Month(s) ago
OR
____ Year(s) ago

____ Hour(s) ago
OR
____ Day(s) ago
OR
____ Week(s) ago
OR
____ Month(s) ago
OR
____ Year(s) ago

____ Hour(s) ago
OR
____ Day(s) ago
OR
____ Week(s) ago
OR
____ Month(s) ago
OR
____ Year(s) ago

____ Hour(s) ago
OR
____ Day(s) ago
OR
____ Week(s) ago
OR
____ Month(s) ago
OR
____ Year(s) ago

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

2a. About how old were you
when you smoked your
first FULL (cigarette/
cigar/ bowl of
tobacco)?/About how old
were you when you first
used (snuff/chewing
tobacco?)

b. During the last 12 months, 1  Yes
2  No
that is, since last (Month
one year ago), did you
smoke at least one
(cigarette/cigar/bowl of
tobacco)/use (snuff/
chewing tobacco)?

3a. When was the MOST
RECENT time you
(smoked a/used) (Name of
tobacco category)?

CHECK
ITEM 3.2

Did respondent
(smoke/use)
(tobacco product)
in the last year?
Refer to 2a or 2b, if
necessary.

Page 1

Section 3A - TOBACCO USE (Continued)

3b. (SHOW FLASHCARD 39)
About how often did you
USUALLY (smoke/use)
(Name of tobacco category)
(in the past year/in the
year right before you
stopped)?

1  Cigarettes

2  Cigars

3  Pipe

4  Snuff

5  Chewing
Tobacco

1  Every day SKIP to 5
2  5 to 6 days a
week
3  3 to 4 days a
week
4  1 to 2 days a
week
5  2 to 3 days a
month
6  Once a month
or less

1  Every day SKIP to 5
2  5 to 6 days a
week
3  3 to 4 days a
week
4  1 to 2 days a
week
5  2 to 3 days a
month
6  Once a month
or less

1  Every day SKIP to 5
2  5 to 6 days a
week
3  3 to 4 days a
week
4  1 to 2 days a
week
5  2 to 3 days a
month
6  Once a month
or less

1  Every day SKIP to 5
2  5 to 6 days a
week
3  3 to 4 days a
week
4  1 to 2 days a
week
5  2 to 3 days a
month
6  Once a month
or less

1  Every day SKIP to 5
2  5 to 6 days a
week
3  3 to 4 days a
week
4  1 to 2 days a
week
5  2 to 3 days a
month
6  Once a month
or less

____ Number

____ Number

____ Number

____ Number

____ Number

____ Day(s)
OR
____ Week(s)
OR
____ Month(s)
OR
____ Year(s)

____ Day(s)
OR
____ Week(s)
OR
____ Month(s)
OR
____ Year(s)

____ Day(s)
OR
____ Week(s)
OR
____ Month(s)
OR
____ Year(s)

____ Day(s)
OR
____ Week(s)
OR
____ Month(s)
OR
____ Year(s)

____ Day(s)
OR
____ Week(s)
OR
____ Month(s)
OR
____ Year(s)

c. (On the days that you
smoked (in the past year/
in the year right before
you stopped), about how
many (cigarettes/cigars/
bowls of tobacco) did you
USUALLY smoke?)/ (On
the days that you used
(snuff/chewing tobacco)
(in the past year/in the
year right before you
stopped) about how many
(pinches, dips or
rubs/plugs, wads or
chews) did you use?)

d. For how long (have/did)
you (smoke(d)/use(d)) this
amount?

4. Did you ever (smoke/use)
(Name of tobacco category)
every day?

1  Yes
1  Yes
1  Yes
1  Yes
1
2  No - SKIP to 2  No - SKIP to 2  No - SKIP to 2  No - SKIP to 2 
Check
Check
Check
Check
Item 3.31
Item 3.32
Item 3.33
Item 3.34

Yes
No - SKIP to
Check Item
3.3a

5. About how old were you
when you FIRST started
(smoking/using) (Name of
tobacco category) every
day?

____ Age

____ Age

____ Age

____ Age

____ Age

____ Number

____ Number

____ Number

____ Number

____ Number

____ Day(s)
OR
____ Week(s)
OR
____ Month(s)
OR
____ Year(s)

____ Day(s)
OR
____ Week(s)
OR
____ Month(s)
OR
____ Year(s)

____ Day(s)
OR
____ Week(s)
OR
____ Month(s)
OR
____ Year(s)

____ Day(s)
OR
____ Week(s)
OR
____ Month(s)
OR
____ Year(s)

____ Day(s)
OR
____ Week(s)
OR
____ Month(s)
OR
____ Year(s)

6. Thinking back over the
entire period when you
were (smoking/using snuff/
chewing tobacco) every
day, about how many
(cigarettes/cigars/ bowls of
tobacco/pinches, dips or
rubs/plugs, wads or chews)
did you USUALLY
(smoke/use) in a single
day?

7. For how long (have/did)
you (smoke(d)/use(d)) this
amount every day?

Page 2

Section 3A - TOBACCO USE (Continued)
CHECK
ITEM 3.3

Is another
tobacco category
marked?

1  Yes - Fill 2-7 1  Yes - Fill 2-7 1  Yes - Fill 2-7 1  Yes - Fill 2-7
in designated
in designated
in designated
in designated
column for
column for
column for
column for
next tobacco
next tobacco
next tobacco
next tobacco
category
category
category
category
2  No - Go to
2  No - Go to
2  No - Go to
2  No - Go to
Check Item
Check Item
Check Item
Check Item
3.32
3.33
3.34
3.3A

CHECK
ITEM 3.3A

Is at least 1
column in Check
Item 3.2 marked
“Yes”?

1  Yes - Ask 8a,
b and c as
appropriate
2  No - Ask 8a,
only

8a. The next few questions are about experiences that many

b. Did this happen in the last

people have had with using tobacco, including cigarettes,
cigars, a pipe, snuff or chewing tobacco. As I read each
experience, please tell me if it has EVER happened to you as a
result of using ANY of these types of tobacco.

12 months?

c. Did this happen before 12
months ago, that is before
last (Month one year ago)?

In your ENTIRE LIFE, did you EVER ... (PAUSE)
(Repeat phrase frequently)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

More than once WANT
to stop or cut down on
your tobacco use?

1  Yes
2  No - Go to next
experience

1
2

More than once TRY to
stop or cut down on your
tobacco use but found you
couldn’t do it?

1  Yes
2  No - Go to next
experience

1
2

Give up or cut down
on activities that you were
interested in or that gave
you pleasure because
tobacco use was not
permitted at the activity?

1  Yes
2  No - Go to next
experience

1
2

Give up or cut down on
activities that were
important to you - like
associating with friends or
relatives or attending
social activities because
tobacco use was not
permitted at the activity?

1  Yes
2  No - Go to next
experience

1
2

Continue to use tobacco
even though you knew it
was causing you a health
problem or making a
health problem worse?

1  Yes
2  No - Go to next
experience

1
2

Find yourself (chain
smoking/using one pinch
or plug of snuff or chewing
tobacco right after
another)?

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

Many people experience
the bad aftereffects of
tobacco use on occasions
when they stop or cut
down on their tobacco use.
Within a day after
stopping or cutting down
on your tobacco use, did
you EVER...
Feel depressed?

(8) Have difficulty falling
asleep or staying
asleep?

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

Page 3

Section 3A - TOBACCO USE (Continued)
(9) Have difficulty
concentrating?

(10) Eat more than usual or
gain weight (within a
day after cutting down
on your tobacco use)?

(11) Become easily irritated,
angry or frustrated?

(12) Feel anxious or
nervous?

(13) Feel your heart beating

more slowly than usual
(within a day after
cutting down on your
tobacco use)?

(14) Feel more restless than
usual?

CHECK
ITEM 3.4

Are at least 4 items
marked “Yes” in column
b, items 7-14?

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - SKIP to
Check Item 3.4

1
2

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

1  Yes
2  No – SKIP to Check Item 3.5

(15) You just mentioned

1
2

that you had SOME
bad aftereffects after
stopping or cutting
down on your tobacco
use in the last 12
months. Did at least 4
of these experiences
happen around the
same time DURING
the last 12 months?
CHECK
ITEM 3.5

 Yes
 No – Mark “Yes”

 Yes
 No

Are at least 4 items
1  Yes
marked “Yes” in column
2  No – SKIP to (17)
c, items 7-14?

(16) You (also/just)

1
2

mentioned that you
had SOME bad
aftereffects after
stopping or cutting
down on your tobacco
use BEFORE 12
months ago. Did at
least 4 of these
experiences happen
around the same time
BEFORE 12 months
ago?

(17) Use tobacco or other
sources of nicotine like
nicotine gum or a patch to
relieve or avoid any of
these bad aftereffects after
you stopped or cut down on
your tobacco use?

(18) Wake up in the middle of
the night to use tobacco?

(19) Often use tobacco just after
getting up or shortly after
getting up in the morning?

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

 Yes
 No – Mark “Yes”

 Yes
 No

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

Page 4

Section 3A - TOBACCO USE (Continued)
8a. In your ENTIRE LIFE, did you EVER ... (PAUSE)

b. Did this happen in the last c. Did this happen before 12

(Repeat phrase frequently)

(20) Find yourself using
tobacco JUST AFTER
being in a situation
where tobacco use was
not permitted - like
after being on a plane,
at a meeting, or
shopping at the mall?

(21) Find that you had to
use much more
tobacco than you once
did to get the effect
you wanted?

(22) Increase your tobacco
use because the
amount you used to
use didn’t give you the
same effect anymore?

(23) Have a period when
you often used tobacco
more or longer than
you intended to?

(24) Continue to use
tobacco even though
you knew it made you
nervous, jittery,
anxious or depressed?

(25) More than once use
tobacco in a situation
that could have been
dangerous, like
smoking in bed or
when using
combustible materials
like paint thinner, or
in any other
dangerous situation?

(26) Have arguments or
problems with your
spouse or partner or
family or friends
because of your
tobacco use?

(27) Continue to use
tobacco even if it was
causing you problems
with your family or
friends?

(28) Have job or school
problems as a result of
your tobacco use, like
problems getting your
work done, not doing
your job well, being
demoted or losing a
job or being
suspended, expelled or
dropping out of
school?

(29) Continue to use
tobacco even though it
was causing you
problems at school or
work?

12 months?
1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

 Yes
 No – Mark “Yes”

months ago, that is before
last (Month one year ago)?
1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

Page 5

Section 3A - TOBACCO USE (Continued)
8a. In your ENTIRE LIFE, did you EVER ... (PAUSE)

b. Did this happen in the last c. Did this happen before 12

(Repeat phrase frequently)

(30) Have a period when
your tobacco use often
interfered with taking
care of your home or
family?

(31) Get into serious
trouble because of
your tobacco use in a
place where it was
prohibited, like on an
airplane, in an airport
or any other place?

(32) More than once use
tobacco in prohibited
places even though
you had gotten into
serious trouble for
doing that before?

(33) Have a period when
you spent a lot of time
using tobacco?

(34) Have a period of time
when you spent a lot of
time making sure you
had enough tobacco
available?

(35) Have a very strong
desire or urge to use
tobacco?

(36) Want to use tobacco so
badly that you
couldn’t think of
anything else?

(37) Use tobacco within 30
minutes of waking up?

(38) Use tobacco MORE
FREQUENTLY
during the first hours
after waking up than
during the rest of the
day?

(39) Find that your first
use of tobacco after
waking up gave you
more satisfaction than
using tobacco at any
other time?

(40) Find it difficult to keep
from using tobacco in
places where it is
prohibited?

12 months?
1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to Check
Item 3.6

1
2

 Yes
 No – Mark “Yes”

 Yes
 No – Mark “Yes”

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c
1  Yes
2  No - SKIP to Check Item 3.8

CHECK
ITEM 3.7

Are at least 2 Boxes in Box 1-3,(Check Item 3.4 or
Box 5), Box 6-13 marked ”Yes” in 8, column b?

1  Yes
2  No - SKIP to Check Item 3.8

Mark (X) all that apply.

1  Yes
2  No

in column c

Is more than 1 item marked in 1(a) - (e)?

What type or types of tobacco were you using when you had
SOME of these experiences with tobacco you mentioned in
the last 12 months?

1  Yes
2  No

in column c

CHECK
ITEM 3.6

9.

months ago, that is before
last (Month one year ago)?

1  Cigarettes
2  Cigars
3  Pipe
4  Snuff
5  Chewing tobacco

Page 6

Section 3A - TOBACCO USE (Continued)
CHECK
ITEM 3.8

Are at least 2 Boxes in Box 1-3,(Check Item 3.5 or
Box 5), Box 6-13 marked “Yes” in 8, column c?

1  Yes
2  No - SKIP to Section 3B

10a. You just mentioned some experiences with using tobacco that
happened in the past, that is, before 12 months ago. Now I’d
like to know if SOME of the experiences you mentioned
happened around the same time in the past.
Before last (Month one year ago), was there EVER a period
when SOME of these experiences were happening around the
same time most days FOR AT LEAST A MONTH?

b. Before last (Month one year ago), was there EVER a period
when SOME of these experiences were happening around
the same time ON AND OFF FOR A FEW MONTHS OR
LONGER?

c. Before last (Month one year ago), was there EVER a time
when SOME of these experiences happened within the same
1-year period?

d. About how old were you the FIRST time SOME of these

1  Yes - SKIP to 10d
2  No
1  Yes - SKIP to 10d
2  No

1  Yes
2  No - SKIP to Section 3B

_____ Age

experiences BEGAN to happen around the same time?

e. In your entire LIFE, how many separate periods like this did
you have when some of these experiences were happening
around the same time?

_______ Number

By separate periods, I mean times that were separated by at
least 1 year when you STOPPED using tobacco entirely OR
you didn’t have any of the experiences you mentioned with
tobacco at all?
CHECK
ITEM 3.9A

Is number entered in 10e, 2 or more or unknown?

10f. What was the LONGEST period you had when SOME of
these experiences were happening around the same time?

g. How old were you the MOST RECENT time when SOME of
these experiences BEGAN to happen around the same time?

h. How long did this period last?

CHECK
ITEM 3.9B

Is at least 1 item marked in 8, column b?

10i. About how old were you when you FINALLY STOPPED
having ANY of these experiences with tobacco? By finally
stopped, I mean they never started happening again.
CHECK
ITEM 3.9C

Is more than 1 item marked in 1a-e?

11. What type or types of tobacco were you using when you had
SOME of the experiences you mentioned with tobacco
BEFORE 12 months ago?
Mark (X) all that apply.

1  Yes
2  No - SKIP to 10h
_______ Month(s)
OR
_______ Year(s)

_______ Age - SKIP to Check Item 3.9B
_______ Month(s)
OR
_______ Year(s)
1  Yes - SKIP to Check Item 3.9C
2  No
_______ Age

1  Yes
2  No - SKIP to Section 3B
1  Cigarettes
2  Cigars
3  Pipe
4  Snuff
5  Chewing tobacco

Go to Section 3B

Page 7

Section 3B - MEDICINE USE

Statement J

Now I’d like to ask you about your experiences with medicines and other kinds of drugs that you may have used
ON YOUR OWN - that is, either WITHOUT a doctor’s prescription (PAUSE); in GREATER amounts, MORE
OFTEN, or LONGER than prescribed (PAUSE); or for a reason other than a doctor said you should use them.
People use these medicines and drugs ON THEIR OWN to feel more alert, to relax or quiet their nerves, to feel
better, to enjoy themselves, or to get high or just to see how they would work.

(SHOW FLASHCARD 40)
1a. Have you EVER used any of these
medicines or drugs?
Read list. (If “YES” to any drug
category, ask: Which ones?)
Record specific drug(s) used.

1  Sedatives or tranquilizers, for example…barbs, downers, Ambien, Lunesta,
phenobarbital, pentobarbital, Halcion, Tuinal, Nembutal, Seconal, Librium,
Valium, Xanax, benzodiazepines, tranks, Ativan.
__________________________________________________________
2  Painkillers, for example…methadone, codeine, Demerol, Vicodin, Oxycontin,
opium, oxy, Percocet, Dilaudid, Percodan, morphine.
__________________________________________________________
3  Marijuana, including THC, for example…weed, pot, dope, hashish, Mary
Jane, joint, blunt.
__________________________________________________________
4  Cocaine or crack, for example…blow, rock, snow.
__________________________________________________________
5  Stimulants, for example…Adderall, Concerta, Cylert, Provigil, Ritalin or
Dexedrine, speed, amphetamine, methamphetamine, uppers, bennies, pep
pills, crystal, crank.
__________________________________________________________
6  Club drugs, for example…MDMA, ecstasy, GHB, Rohypnol, ketamine,
Special K, XTC, roofies.
__________________________________________________________
7  Hallucinogens, for example…LSD, acid, PCP, mescaline, peyote, psilocybin,
mushrooms, angel dust, cactus.
__________________________________________________________
8  Inhalants or solvents, for example…nitrous oxide, lighter fluid, gasoline,
cleaning fluid, glue, poppers, whippets.
__________________________________________________________
9  Heroin, for example…smack, black tar, poppy.
__________________________________________________________
10  Any OTHER medicines, or drugs, or substances, for example…steroids,
Elavil, Thorazine, or Haldol.
(SELECT MOST FREQUENTLY USED OTHER DRUG) - Specify ↓
__________________________________________________________

CHECK
ITEM 3.10

Is at least one category marked
in 1a?

1  Yes - Classify as ever (drug) user
2  No - Classify as non (drug) user and SKIP to Section 3E

Page 1

Section 3B - MEDICINE USE (Continued)
CHECK
For every drug
ITEM 3.11 category marked in
1a, mark the
corresponding
category below and
ask 2a - g for each
marked drug
category.

1  Sedatives or Tranquilizers

2a. How old were you
when you FIRST
used (Name of drug
category)?

b. Did you use (Name of drug category) in
the last 12 months only, before the last 12
months only, or during both time
periods?

c. During the last 12
months, about how
often did you use
(Name of drug
category)?
(SHOW
FLASHCARD 41)

______ Age

1  Last 12 months only
2  Prior to last 12 months only SKIP to column d

Code

3  Both time periods

2  Painkillers

______ Age

1  Last 12 months only
2  Prior to last 12 months only SKIP to column d

Code

3  Both time periods

3  Marijuana

______ Age

1  Last 12 months only
2  Prior to last 12 months only SKIP to column d

Code

3  Both time periods

4  Cocaine or Crack

______ Age

1  Last 12 months only
2  Prior to last 12 months only SKIP to column d

Code

3  Both time periods

5  Stimulants

______ Age

1  Last 12 months only
2  Prior to last 12 months only SKIP to column d

Code

3  Both time periods

6  Club drugs

______ Age

1  Last 12 months only
2  Prior to last 12 months only SKIP to column d

Code

3  Both time periods

7  Hallucinogens

______ Age

1  Last 12 months only
2  Prior to last 12 months only SKIP to column d

Code

3  Both time periods

8  Inhalants/Solvents

______ Age

1  Last 12 months only
2  Prior to last 12 months only SKIP to column d

Code

3  Both time periods

9  Heroin

______ Age

1  Last 12 months only
2  Prior to last 12 months only SKIP to column d

Code

3  Both time periods

10  OTHER
Specify
___________________

______ Age

1  Last 12 months only
2  Prior to last 12 months only SKIP to column d

Code

3  Both time periods

Page 2

d. When was the most recent time
you used (Name of drug category)?

Section 3B - MEDICINE (Continued)
e. Think about the time f. About how old were
when you were using
(Name of drug
category) the MOST.
At that time about
how often did you use
(it/them)?
(SHOW
FLASHCARD 42)

you when you FIRST
BEGAN using (Name
of drug category) that
frequently?

____ Day(s) ago OR
____ Week(s) ago OR
____ Month(s) ago OR

Code

______ Age

____ Year(s) ago
____ Day(s) ago OR
____ Week(s) ago OR
____ Month(s) ago OR

Code

______ Age

____ Year(s) ago
____ Day(s) ago OR
____ Week(s) ago OR
____ Month(s) ago OR

Code

______ Age

____ Year(s) ago
____ Day(s) ago OR
____ Week(s) ago OR
____ Month(s) ago OR

Code

______ Age

____ Year(s) ago
____ Day(s) ago OR
____ Week(s) ago OR
____ Month(s) ago OR

Code

______ Age

____ Year(s) ago
____ Day(s) ago OR
____ Week(s) ago OR
____ Month(s) ago OR

Code

______ Age

____ Year(s) ago
____ Day(s) ago OR
____ Week(s) ago OR
____ Month(s) ago OR

Code

______ Age

____ Year(s) ago
____ Day(s) ago OR
____ Week(s) ago OR
____ Month(s) ago OR

Code

______ Age

____ Year(s) ago
____ Day(s) ago OR
____ Week(s) ago OR
____ Month(s) ago OR

Code

______ Age

____ Year(s) ago
____ Day(s) ago OR
____ Week(s) ago OR
____ Month(s) ago OR
____ Year(s) ago

Code

______ Age

g. About how long did that period
last when you were using (Name
of drug category) that
frequently?

____ Week(s)
OR
____ Month(s)
OR
____ Year(s)

SKIP to next
marked drug
category

____ Week(s)
OR
____ Month(s)
OR
____ Year(s)

SKIP to next
marked drug
category

____ Week(s)
OR
____ Month(s)
OR
____ Year(s)

SKIP to next
marked drug
category

____ Week(s)
OR
____ Month(s)
OR
____ Year(s)

SKIP to next
marked drug
category

____ Week(s)
OR
____ Month(s)
OR
____ Year(s)

SKIP to next
marked drug
category

____ Week(s)
OR
____ Month(s)
OR
____ Year(s)

SKIP to next
marked drug
category

____ Week(s)
OR
____ Month(s)
OR
____ Year(s)

SKIP to next
marked drug
category

____ Week(s)
OR
____ Month(s)
OR
____ Year(s)

SKIP to next
marked drug
category

____ Week(s)
OR
____ Month(s)
OR
____ Year(s)

SKIP to next
marked drug
category

____ Week(s)
OR
____ Month(s)
OR
____ Year(s)

Go to Check
Item 3.12

Page 3

Section 3B - MEDICINE USE (Continued)
CHECK
ITEM 3.12

What is the time period marked in 2b for marijuana?
When did respondent use marijuana ?

3.

Now I would like to know a little more about your use of
marijuana.

1  Last 12 months only
2  Before last 12 months only - SKIP to 4
3  Both time periods
4  Never - SKIP to Check Item 3.13
______ Number

On the days that you used marijuana in the last 12 months,
about how many joints did you usually smoke in a single
day?

4.

At the time you were using marijuana the MOST, about
how many joints did you usually smoke in a single day?

CHECK
ITEM 3.13

What is the time period marked in 2b for cocaine or
crack?
When did respondent use cocaine or crack?

5.

On the days that you used cocaine or crack in the last 12
months, about how many grams, lines or rocks did you
usually use in a single day?

______ Number
1  Last 12 months only
2  Before last 12 months only - SKIP to 6
3  Both time periods
4  Never – SKIP to Check Item 3.13A
______ Gram(s)
OR
______ Line(s)
OR
______ Rock(s)

6.

At the time when you were using cocaine or crack the
MOST, about how many grams, lines or rocks did you
usually use in a single day?

______ Gram(s)
OR
______ Line(s)
OR
______ Rock(s)

7a. In which of the following ways have you used cocaine or
crack?
Read each response category.
Mark (X) all that apply.

1  IV, through the veins?
2  Injection under the skin?
3  Smoking, freebasing?
4  Snorting, sniffing, breathing?
5  By mouth, drinking?
6  Other method?

CHECK
ITEM 3.13A

Is respondent only a marijuana user?

1  Yes - SKIP to Section 3C
2  No

CHECK
ITEM 3.13B

Did respondent use stimulants in the last 12
months?

1  Yes
2  No - SKIP to Check Item 3.13C

7b. In the last 12 months, did you use Adderall, Concerta,
Cylert, Provigil, Ritalin, Dexedrine or any other
prescription stimulant ON YOUR OWN?

7c. In the last 12 months, did you use a stimulant other than a
prescription stimulant?
CHECK
ITEM 3.13C

Did respondent use stimulants before 12 months
ago?

7d. Did you use Adderall, Concerta, Cylert, Provigil, Ritalin,
Dexedrine or any other prescription stimulant ON YOUR
OWN before 12 months ago?

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No - SKIP to 8
1  Yes
2  No

before 12 months ago?

1  Yes
2  No

8.

Have you EVER taken ANY medicines or drugs ON
YOUR OWN by injection with a needle?

1  Yes
2  No – SKIP to Section 3C

9.

Did you take ANY medicines or drugs ON YOUR OWN by
injection with a needle in the last 12 months?

1  Yes
2  No– SKIP to 12

7e. Did you use a stimulant other than a prescription stimulant

Page 4

Section 3B - MEDICINE USE (Continued)
(SHOW FLASHCARD 41)

10.

About how many times in the last 12 months, did you inject
a medicine or drug with a needle?

11. Did you take ANY medicines or drugs ON YOUR OWN by
injection with a needle BEFORE 12 months ago?

(SHOW FLASHCARD 42)

12. Think about a time when you were taking a medicine or
drug by injection with a needle the MOST. At that time
about how often did you inject a medicine or drug?

13. About how long did that period last when you were taking
a medicine or drug by injection the MOST?
(If less than 1 week, code 1 week)

14. About how old were you when you first injected any
medicine or drug?

15. I would like to ask you a few questions about needle
sharing. By needle sharing, I mean using someone else’s
needles, syringes, or other injection equipment, like filters,
spoons, cookers or washers, or letting someone else use
yours.

1  Every day
2  Nearly every day
3  3 to 4 times a week
4  1 to 2 times a week
5  2 to 3 times a month
6  Once a month
7  7 to 11 times in the last year
8  3 to 6 times in the last year
9  2 times in the last year
10  Once in the last year
1  Yes
2  No – SKIP to 14
1  Every day
2  Nearly every day
3  3 to 4 times a week
4  1 to 2 times a week
5  2 to 3 times a month
6  Once a month
7  7 to 11 times a year
8  3 to 6 times a year
9  2 times a year
10 Once a year
____ Week(s)
OR
____ Month(s)
OR
____ Year(s)
______ Age
1  Yes
2  No

In the last 12 months did you take ANY medicines or drugs
using a needle or other injection equipment that you knew
or suspected had been used by someone else, or did you let
someone else use yours?

16. Did this happen BEFORE 12 months ago?
CHECK
ITEM 3.14

Is 15 or 16 marked “Yes”?

17. About how many people shared a needle or other injection
equipment the last time you shared?

1  Yes
2  No
1  Yes
2  No – SKIP to Section 3C
11
22
33
44
5  5 or more

Go to Section 3C

Page 5

Section 3C - MEDICINE EXPERIENCES
1a. Now I’m going to ask you about some experiences that people have reported in connection
with their use of medicines or drugs ON THEIR OWN that we just talked about. As I read
each experience, please tell me if this has ever happened to you.

b. Did this happen in the last
12 months?

In your entire life, did you EVER ... (PAUSE)
(Repeat phrase frequently)

(1)

(2)

(3)

Find that your usual amount of a medicine or drug
had much less effect on you than it once did?

Find that you had to use much more of a medicine
or drug to get the effect you wanted?

The next few questions are about the bad aftereffects
that people may have when the effects of a medicine
or drug are wearing off. This includes the morning
after using it or in the first few days after stopping or
cutting down on it. Did you EVER. . .

1  Yes
2  No - Go to next
experience

 Yes
2  No - Mark “Yes”

1  Yes
2  No - Go to next
experience

2

1  Yes
2  No - Go to next
experience

 Yes
2  No - Mark “Yes”

1  Yes
2  No - Go to next
experience

 Yes
2  No - Mark “Yes”

1  Yes
2  No - Go to next
experience

 Yes
2  No - Mark “Yes”

1  Yes
2  No - Go to next
experience

 Yes
2  No - Mark “Yes”

1  Yes
2  No - Go to next
experience

 Yes
2  No - Mark “Yes”

1  Yes
2  No - Go to next
experience

2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1

in column d

1

in column d

1

in column d

Sleep more than usual (when the effects of a
medicine or drug were wearing off)?

(4) Feel weak or tired?

(5) Feel depressed?

(6) Find your heart beating fast (when the effects
of a medicine or drug were wearing off)?

(7) Have nausea or vomiting?

(8) Yawn a lot?

(9) Have runny eyes or a runny nose (when the
effects of a medicine or drug were wearing
off)?

(10) Eat more than usual or gain weight?

 Yes
 No - Mark “Yes”

1

in column d

1

in column d

1

in column d

1

in column d

1

 Yes
 No - Mark “Yes”
in column d

 Yes
 No - Mark “Yes”
in column d

 Yes
 No - Mark “Yes”
in column d

Page 1

Section 3C - MEDICINE EXPERIENCES (Continued)
c. During the last 12 months, which medicines d. Did this happen before
or drugs did this happen with?
(SHOW FLASHCARD 40)
1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

12 months ago, that is
before last (Month one
year ago)?

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

e. Which medicines or drugs did this happen with
before 12 months ago?
(SHOW FLASHCARD 40)
1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

Page 2

Section 3C - MEDICINE EXPERIENCES (Continued)
1a. Did you EVER ... (PAUSE)

b. Did this happen in the last

(Repeat phrase frequently)

(11) Feel anxious or nervous?

(12) Have muscle aches or cramps (when the
effects of a medicine or drug were wearing
off)?

(13) Have a fever?

(14) Become so restless you fidgeted, paced or
couldn’t sit still?

(15) Move or talk much more slowly than usual
(when the effects of a medicine or drug were
wearing off)?

(16) Find your pupils dilating or your hair
standing up?

(17) Have unpleasant dreams that often seemed
real?

(18) See, feel or hear things that weren’t really
there (when the effects of a medicine or
drug were wearing off)?

(19) Feel shaky or have shaky or trembling hands?

(20) Have trouble falling asleep or staying asleep?

12 months?

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience,

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

 Yes
 No - Mark “Yes”
in column d

 Yes
 No - Mark “Yes”
in column d

 Yes
 No - Mark “Yes”
in column d

 Yes
 No - Mark “Yes”
in column d

 Yes
 No - Mark “Yes”
in column d

 Yes
 No - Mark “Yes”
in column d

 Yes
 No - Mark “Yes”
in column d

 Yes
 No - Mark “Yes”
in column d

 Yes
 No - Mark “Yes”
in column d

 Yes
 No - Mark “Yes”
in column d

Page 3

Section 3C - MEDICINE EXPERIENCES (Continued)
c. During the last 12 months, which medicines d. Did this happen before
or drugs did this happen with?
(SHOW FLASHCARD 40)

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

12 months ago, that is
before last (Month one
year ago)?

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

e. Which medicines or drugs did this happen with
before 12 months ago?
(SHOW FLASHCARD 40)

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

Page 4

Section 3C - MEDICINE EXPERIENCES (Continued)
1a. Did you EVER ...

b. Did this happen in the last 12

(Repeat phrase frequently)

(21) Have fits or seizures (when the effects of
a medicine or drug were wearing off)?

(22) Become more irritable than usual?

(23) Eat less than usual or lose weight?

(24) Feel angry, combative or aggressive
(when the effects of a medicine or drug
were wearing off)?

(25) Have a headache?

(26) Find yourself sweating?

(27) Have chills (when the effects of a
medicine or drug were wearing off)?

(28) Have stomach pain?

months?

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

 Yes
 No - Mark “Yes”
in column d

 Yes
 No - Mark “Yes”
in column d

 Yes
 No - Mark “Yes”
in column d

 Yes
 No - Mark “Yes”
in column d

 Yes
 No - Mark “Yes”
in column d

 Yes
 No - Mark “Yes”
in column d

 Yes
 No - Mark “Yes”
in column d

 Yes
 No - Mark “Yes”
in column d

1a. In your entire life, did you EVER ...
(Repeat phrase frequently)

(29) Take more of the same or a similar medicine or
drug to get over or avoid any of these bad
aftereffects?

 Yes
 No - Mark “Yes”
in column d

Page 5

Section 3C - MEDICINE EXPERIENCES (Continued)
c. During the last 12 months, which medicines
or drugs did this happen with?
(SHOW FLASHCARD 40)

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

d. Did this happen before
12 months ago, that is
before last (Month one
year ago)?

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

e. Which medicines or drugs did this happen
with before 12 months ago?
(SHOW FLASHCARD 40)

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

Page 6

Section 3C - MEDICINE EXPERIENCES (Continued)
1a.

b. Did this happen in the last 12

In your entire life, did you EVER ... (PAUSE)
(Repeat phrase frequently)

(30) More than once WANT to stop or cut down on
using any of these medicines or drugs?

(31) More than once TRY to stop or cut down on
using any of these medicines or drugs but
found you couldn’t do it?

(32) Often use a medicine or drug in larger
amounts or for a much longer period than you
meant to?

(33) Have a period when you spent a lot of time
using a medicine or drug or getting over its
bad aftereffects?

(34) Have a period when you spent a lot of time
making sure you always had enough of a
medicine or drug available?

(35) Give up or cut down on activities that were
important to you in order to use a medicine or
drug – like work, school, or associating with
friends or relatives?

(36) Give up or cut down on activities that you
were interested in or that gave you pleasure in
order to use a medicine or drug?

(37) Continue to use a medicine or drug even
though you knew it was making you feel
depressed, uninterested in things, or suspicious
or distrustful of other people?

(38) Continue to use a medicine or drug even
though you knew it was causing you a health
problem or making a health problem worse?

(39) Feel a very strong urge or desire to use a
medicine or drug?

(40) Want a medicine or drug so badly that you
couldn’t think of anything else?

months?

1  Yes
2  No - Go to next
experience

 Yes
2  No - Mark “Yes”

1  Yes
2  No - Go to next
experience

 Yes
2  No - Mark “Yes”

1  Yes
2  No - Go to next
experience

 Yes
2  No - Mark “Yes”

1  Yes
2  No - Go to next
experience

 Yes
2  No - Mark “Yes”

1  Yes
2  No - Go to next
experience

 Yes
2  No - Mark “Yes”

1  Yes
2  No - Go to next
experience

 Yes
2  No - Mark “Yes”

1  Yes
2  No - Go to next
experience

 Yes
2  No - Mark “Yes”

1  Yes
2  No - Go to next
experience

 Yes
2  No - Mark “Yes”

1  Yes
2  No - Go to next
experience

 Yes
2  No - Mark “Yes”

1  Yes
2  No - Go to next
experience

 Yes
2  No - Mark “Yes”

1  Yes
2  No – Go to next
experience

 Yes
2  No - Mark “Yes”

1

in column d

1

in column d

1

in column d

1

in column d

1

in column d

1

in column d

1

in column d

1

in column d

1

in column d

1

in column d

1

in column d

Page 7

Section 3C - MEDICINE EXPERIENCES (Continued)
c. During the last 12 months, which medicines d. Did this happen before
or drugs did this happen with?
(SHOW FLASHCARD 40)
1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

12 months ago, that is
before last (Month one
year ago)?
1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

e. Which medicines or drugs did this happen with
before 12 months ago?
(SHOW FLASHCARD 40)
1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SET
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

Page 8

Section 3C - MEDICINE EXPERIENCES (Continued)
1a.

b. Did this happen in the last 12

In your entire life, did you EVER ... (PAUSE)
(Repeat phrase frequently)

(41) Have arguments with your spouse or partner
or family or friends as a result of your
medicine or drug use?

(42) Continue to use a medicine or drug even
though it was causing you trouble with your
family or friends?

(43) Get into physical fights while under the
influence of a medicine or drug?

(44) Have job or school troubles as a result of your
medicine or drug use - like missing too much
work, not doing your work well, being
demoted or losing a job, or being suspended,
expelled or dropping out of school?

(45) Continue to use a medicine or drug even
though it was causing you problems at school
or work?

(46) Have a period when your medicine or drug
use or your being sick from your medicine or
drug use often interfered with taking care of
your home or family?

(47) More than once drive a car, motorcycle, truck,
boat, or other vehicle when you were under
the influence of a medicine or drug?

(48) Find yourself under the influence of a
medicine or drug or feeling its aftereffects in
situations that increased your chances of
getting hurt - like swimming, using
machinery, or walking in a dangerous area or
around heavy traffic?

(49) More than once get arrested, held at a police
station or have any other legal problems
because of your medicine or drug use?

(50) Use any medicine or drug to make you more
alert or to enhance your mental performance,
skills or abilities at work or in school?

months?

1  Yes
2  No - Go to next
experience

2

1  Yes
2  No - Go to next
experience

 Yes
2  No - Mark “Yes”

1  Yes
2  No - Go to next
experience

2

1  Yes
2  No - Go to next
experience

 Yes
2  No - Mark “Yes”

1  Yes
2  No - Go to next
experience

2

1  Yes
2  No - Go to next
experience

 Yes
2  No - Mark “Yes”

1  Yes
2  No - Go to next
experience

2

1  Yes
2  No - Go to next
experience

 Yes
2  No - Mark “Yes”

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to Check
Item 3.21

1
2

1

 Yes
 No - Mark “Yes”
in column d

1

in column d

1

 Yes
 No - Mark “Yes”
in column d

1

in column d

1

 Yes
 No - Mark “Yes”
in column d

1

in column d

1

 Yes
 No - Mark “Yes”
in column d

1

in column d

 Yes
 No - Mark “Yes”
in column d

 Yes
 No - Mark “Yes”
in column d

Page 9

Section 3C - MEDICINE EXPERIENCES (Continued)
c. During the last 12 months, which medicines d. Did this happen before
or drugs did this happen with?
(SHOW FLASHCARD 40)

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

12 months ago, that is
before last (Month one
year ago)?

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No - Go to Check
Item 3.21

e. Which medicines or drugs did this happen with
before 12 months ago?
(SHOW FLASHCARD 40)

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

Page 10

Section 3C - MEDICINE EXPERIENCES (Continued)
CHECK
ITEM 3.21

2a.
Are at least 2
boxes in Box 1,
(2 or 3), 4-13
marked “Yes” in
1a, column e?

1  Yes
2  No - SKIP to Check
Item 3.24
Mark corresponding
category below and ask 2 a-g
for each marked category.

You just mentioned some
experiences you
had with (Name of drug
category) in the past, that is,
before 12 months ago.
Before last (Month one year
ago) was there ever a
period when SOME of
these experiences with
(Name of drug category)
were happening around the
same time most days for at
least a month (PAUSE), on
and off for a few months or
longer (PAUSE) or within
the same 1-year period?

1  Sedatives or Tranquilizers

1  Yes
2  No- SKIP to next
drug category

2  Painkillers

1  Yes
2  No - SKIP to next
drug category

3  Marijuana

1  Yes
2  No - SKIP to next
drug category

4  Cocaine or Crack

1  Yes
2  No - SKIP to next
drug category

5  Stimulants

1  Yes
2  No - SKIP to next
drug category

6  Club drugs

1  Yes
2  No - SKIP to next
drug category

7  Hallucinogens

1  Yes
2  No - SKIP to next
drug category

8  Inhalants/Solvents

1  Yes
2  No - SKIP to next
drug category

9  Heroin

1  Yes
2  No - SKIP to next
drug category

10  Other

1  Yes
2  No - SKIP to
Check Item 3.24

b. About how old
were you the
FIRST time SOME
of these
experiences with
(Name of drug
category) BEGAN
to happen around
the same time?

c. In your ENTIRE LIFE how
many separate periods like this
did you have when some of
these experiences with (Name of
drug category) were happening
around the same time?
By separate periods, I mean
times separated by at least a
year when you EITHER
STOPPED using (Name of drug
category) entirely (PAUSE) OR
you didn’t have any of the
experiences you just mentioned
with (Name of drug category)?

______ Age

______ Number

______ Age

______ Number

______ Age

______ Number

______ Age

______ Number

______ Age

______ Number

______ Age

______ Number

______ Age

______ Number

______ Age

______ Number

______ Age

______ Number

______ Age

______ Number

Page 11

Section 3C - MEDICINE EXPERIENCES (Continued)
CHECK
ITEM 3.22
Is number in

2c,
2 or more or
unknown?

d. In your
ENTIRE
LIFE what
was the
LONGEST
period you
had when
SOME of
these
experiences
with (Name of
drug category)
were
happening
around the
same time?

e. About how old f. How long did this
were you the
MOST
RECENT
time when
some of these
experiences
BEGAN to
happen
around the
same time?

CHECK
ITEM 3.23

period last when some
of these experiences
with (Name of drug
Is at least 1 item
category) were
marked in
happening around the 1, column c, items (1)same time?
(49)?

g. About how old
were you when
you FINALLY
STOPPED
having ANY of
these problems
with (Name of
drug category)?
By finally
stopped, I mean
they never
started
happening
again.

______ Month(s)
1  Yes
OR
2  No - SKIP to
______
Year(s)
2f

_____ Age Go to Check
Item 3.23

______ Month(s)
OR
______ Year(s)

____ Age 1  Yes - Go to next
SKIP to next
drug category
drug category
2  No

______ Month(s)
1  Yes
OR
2  No - SKIP to
______
Year(s)
2f

_____ Age Go to Check
Item 3.23

______ Month(s)
OR
______ Year(s)

____ Age 1  Yes - Go to next
SKIP to next
drug category
drug category
2  No

______ Month(s)
1  Yes
OR
2  No - SKIP to
______ Year(s)
2f

_____ Age Go to Check
Item 3.23

______ Month(s)
OR
______ Year(s)

____ Age 1  Yes - Go to next
SKIP to next
drug category
drug category
2  No

______ Month(s)
1  Yes
OR
2  No - SKIP to
______
Year(s)
2f

_____ Age Go to Check
Item 3.23

______ Month(s)
OR
______ Year(s)

____ Age 1  Yes - Go to next
SKIP to next
drug category
drug category
2  No

______ Month(s)
1  Yes
OR
2  No - SKIP to
______
Year(s)
2f

_____ Age Go to Check
Item 3.23

______ Month(s)
OR
______ Year(s)

____ Age 1  Yes - Go to next
SKIP to next
drug category
drug category
2  No

______ Month(s)
1  Yes
OR
2  No - SKIP to
______ Year(s)
2f

_____ Age Go to Check
Item 3.23

______ Month(s)
OR
______ Year(s)

____ Age 1  Yes - Go to next
SKIP to next
drug category
drug category
2  No

______ Month(s)
1  Yes
OR
2  No - SKIP to
______ Year(s)
2f

_____ Age Go to Check
Item 3.23

______ Month(s)
OR
______ Year(s)

____ Age 1  Yes - Go to next
SKIP to next
drug category
drug category
2  No

______ Month(s)
1  Yes
OR
2  No - SKIP to
______
Year(s)
2f

_____ Age Go to Check
Item 3.23

______ Month(s)
OR
______ Year(s)

____ Age 1  Yes - Go to next
SKIP to next
drug category
drug category
2  No

______ Month(s)
1  Yes
OR
2  No - SKIP to
______
Year(s)
2f

_____ Age Go to Check
Item 3.23

______ Month(s)
OR
______ Year(s)

____ Age 1  Yes - Go to next
SKIP to next
drug category
drug category
2  No

______ Month(s)
1  Yes
OR
2  No - SKIP to
______ Year(s)
2f

_____ Age –
Go to Check
Item 3.23

______ Month(s)
OR
______ Year(s)

____ Age 1  Yes – Skip to
Go to Check
Check Item 3.24
Item 3.24
2  No

Page 12

Section 3C - MEDICINE EXPERIENCES (Continued)
CHECK
ITEM 3.24

3.

(a) When you had SOME of these experiences with
sedatives or tranquilizers in the last 12 months,
were you using them without a prescription?

1  Yes
2  No

(b) During the last 12 months when you had some of
these experiences with sedatives or tranquilizers,
were you using them in LARGER AMOUNTS,
MORE FREQUENTLY or LONGER than
prescribed or for a reason other than prescribed
by a doctor?

1  Yes
2  No

Are at least 2 Boxes, Box 1, (2 or 3), 4-13, marked in
1a, column e for sedatives/tranquilizers.

(a) During ANY of these times when you had SOME
of these experiences with sedatives or tranquilizers
BEFORE 12 months ago, were you using them
without a prescription?

1  Yes
2  No - SKIP to 4c

(b) Did ALL of these times BEFORE 12 months ago
ONLY happen when you were using sedatives or
tranquilizers without a prescription?

1  Yes -SKIP to Check Item 3.26
2  No

Did ALL of those times BEFORE 12 months ago ONLY
happen when you were using sedatives or tranquilizers in
LARGER AMOUNTS, MORE FREQUENTLY, or
LONGER than prescribed or for a reason other than
prescribed by a doctor?

CHECK
ITEM 3.26

6.

Are at least 2 Boxes, Box 1, (2 or 3), 4-13 marked in
1a, Column c for painkillers?

1  Yes
2  No - SKIP to Check Item 3.26

1  Yes
2  No

1  Yes
2  No - SKIP to Check Item 3.27

You just mentioned SOME experiences you had with
painkillers in the last 12 months.

CHECK
ITEM 3.27

7.

1  Yes
2  No - SKIP to Check Item 3.26

You just mentioned SOME experiences you had with
sedatives or tranquilizers around the same time BEFORE
12 months ago, that is, BEFORE (month one year ago).

(c) During ANY of these times when you had SOME
of those experiences with sedatives or tranquilizers
BEFORE 12 months ago, were you using them in
GREATER AMOUNTS, MORE FREQUENTLY,
or LONGER than prescribed or for a reason other
than prescribed by a doctor?

5.

1  Yes
2  No - SKIP to Check Item 3.25

You just mentioned SOME experiences you had with
sedatives or tranquilizers in the last 12 months.

CHECK
ITEM 3.25

4.

Are at least 2 Boxes, Box 1, (2 or 3), 4-13, marked in
1a, Column c for Sedatives/Tranquilizers?

(a) When you had SOME of these experiences with
painkillers in the last 12 months, were you using
them without a prescription?

1  Yes
2  No

(b) During the last 12 months when you had some of
these experiences with painkillers, were you using
them in LARGER AMOUNTS, MORE
FREQUENTLY or LONGER than prescribed or
for a reason other than prescribed by a doctor?

1  Yes
2  No

Are at least 2 Boxes, Box 1, (2 or 3), 4-13, marked in
1a, column e for painkillers?

1  Yes
2  No - SKIP to Check Item 3.28

You just mentioned SOME experiences you had with
painkillers around the same time BEFORE 12 months ago,
that is, BEFORE (month one year ago).
(a) During ANY of these times when you had SOME
of these experiences with painkillers BEFORE 12
months ago, were you using them without a
prescription?

1  Yes
2  No - SKIP to 7c

Page 13

Section 3C - MEDICINE EXPERIENCES (Continued)
7.

(b) Did ALL of these times BEFORE 12 months ago
ONLY happen when you were using painkillers
without a prescription?
(c) During ANY of these times when you had SOME
of those experiences with painkillers BEFORE 12
months ago, were you using them in GREATER
AMOUNTS, MORE FREQUENTLY, or
LONGER than prescribed or for a reason other
than prescribed by a doctor?

8.

Did ALL of those times BEFORE 12 months ago ONLY
happen when you were using painkillers in LARGER
AMOUNTS, MORE FREQUENTLY, or LONGER than
prescribed or for a reason other than prescribed by
doctor?

CHECK
ITEM 3.28

9.

Are at least 2 Boxes, Box 1, (2 or 3), 4-13, marked in
1a, Column c for stimulants?

1  Yes - SKIP to Check Item 3.28
2  No

1  Yes
2  No - SKIP to Check Item 3.28

1  Yes
2  No

1  Yes
2  No - SKIP to Check Item 3.29

You just mentioned SOME experiences you had with
stimulants in the last 12 months.

CHECK
ITEM 3.29

(a) When you had SOME of these experiences with
stimulants in the last 12 months, were you using
them without a prescription?

1  Yes
2  No

(b) During the last 12 months when you had some of
these experiences with stimulants, were you using
them in LARGER AMOUNTS, MORE
FREQUENTLY or LONGER than prescribed or
for a reason other than prescribed by a doctor?

1  Yes
2  No

Are at least 2 Boxes, Box 1, (2 or 3), 4-13, marked in
1a, column e for stimulants?

1  Yes
2  No - SKIP to Section 3D

10. You just mentioned SOME experiences you had with
stimulants around the same time BEFORE 12 months ago,
that is, BEFORE (month one year ago).
(a) During ANY of these times when you had SOME
of these experiences with stimulants BEFORE 12
months ago, were you using them without a
prescription?

1  Yes
2  No - SKIP to 10c

(b) Did ALL of these times BEFORE 12 months ago
ONLY happen when you were using stimulants
without a prescription?

1  Yes - SKIP to Section 3D
2  No

(c) During ANY of these times when you had SOME
of those experiences with stimulants BEFORE 12
months ago, were you using them in GREATER
AMOUNTS, MORE FREQUENTLY, or
LONGER than prescribed or for a reason other
than prescribed by a doctor?

11. Did ALL of those times BEFORE 12 months ago ONLY
happen when you were using stimulants in LARGER
AMOUNTS, MORE FREQUENTLY, or LONGER than
prescribed or for a reason other than prescribed by a
doctor?

1  Yes
2  No - SKIP to Section 3D

1  Yes
2  No

Go to Section 3D

Page 14

Section 3D – TREATMENT UTILIZATION
1.

Have you ever gone anywhere or seen anyone for a
reason that was related in any way to your use of
medicines or drugs - a physician, counselor, Narcotics
Anonymous, or any other community agency or
professional?

2a.

I am going to read you a list of community agencies and professionals. For each one, please
tell me if you have ever gone there for any reason related to your medicine or drug use.

1  Yes
2  No - SKIP to 4a

b. Did you go there in the last
12 months?

In your entire life, did you EVER go to a/an ...(Repeat phrase frequently)
Narcotics or Cocaine Anonymous, Alcoholics
Anonymous or any 12-Step meeting?

1  Yes
2  No - Go to next agency

2

(2)

Family services or another social service
agency?

1  Yes
2  No - Go to next agency

 Yes
2  No – Skip to column d

(3)

Drug or alcohol detoxification ward or clinic?

1  Yes
2  No - Go to next agency

 Yes
2  No – Skip to column d

(4)

Inpatient ward of a psychiatric or general
hospital or community mental health program?

1  Yes
2  No - Go to next agency

 Yes
2  No – Skip to column d

(5)

Outpatient clinic, including outreach programs
and day or partial patient programs?

1  Yes
2  No - Go to next agency

 Yes
2  No – Skip to column d

(6)

Drug or alcohol rehabilitation program?

1  Yes
2  No - Go to next agency

2

(1)

1

 Yes
 No – Skip to column d

1

1

1

1

1

 Yes
 No – Skip to column d

(7)

Methadone Maintenance Program?

1  Yes
2  No - Go to next agency

 Yes
2  No – Skip to column d

(8)

Emergency room for any reason related to
your drug use?

1  Yes
2  No - Go to next agency

 Yes
2  No – Skip to column d

(9)

Halfway house, including therapeutic
communities?

1  Yes
2  No - Go to next agency

 Yes
2  No – Skip to column d

1

1

1

Page 1

Section 3D – TREATMENT UTILIZATION (Continued)
c. For which medicines or drugs did you go
there in the last 12 months?

d. Did you go there before 12 e. For which medicines or drugs did you go there
months ago, that is before
last (Month one year ago)?

(SHOW FLASHCARD 40)

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

before 12 months ago?
(SHOW FLASHCARD 40)

1  Yes
2  No - Go to next
agency

1  Yes
2  No - Go to next
agency

1  Yes
2  No - Go to next
agency

1  Yes
2  No - Go to next
agency

1  Yes
2  No - Go to next
agency

1  Yes
2  No - Go to next
agency

1  Yes
2  No - Go to next
agency

1  Yes
2  No - Go to next
agency

1  Yes
2  No - Go to next
agency

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

Page 2

Section 3D – TREATMENT UTILIZATION (Continued)
2a.

In your entire life, did you EVER go to a/an ...(Repeat phrase frequently)

b. Did you go there in the last
12 months?

Crisis center for any reason related to your
drug use?

1  Yes
2  No - Go to next agency

2

(11)

Employee Assistance Program (EAP)?

1  Yes
2  No - Go to next agency

 Yes
2  No – Skip to column d

(12)

Clergyman, priest, rabbi or any other religious
counselor for any reason related to your drug
use?

1  Yes
2  No - Go to next agency

 Yes
2  No – Skip to column d

(13)

Private physician, psychiatrist, psychologist,
social worker or any other professional?

1  Yes
2  No - Go to next agency

 Yes
2  No – Skip to column d

(14)

Any other agency or professional?

1  Yes
2  No - Go to 3a

 Yes
2  No – Skip to column d

(10)

1

 Yes
 No – Skip to column d

1

1

1

1

Page 3

Section 3D – TREATMENT UTILIZATION (Continued)
c. For which medicines or drugs did you go
there in the last 12 months?

d. Did you go there before 12 e. For which medicines or drugs did you go there
months ago, that is before
last (Month one year ago)?

(SHOW FLASHCARD 40)
1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

before 12 months ago?
(SHOW FLASHCARD 40)

1  Yes
2  No - Go to next
agency

1  Yes
2  No - Go to next
agency

1  Yes
2  No - Go to next
agency

1  Yes
2  No - Go to next
agency

1  Yes
2  No - Go to 3a

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

1  SED
3  MAR
5  STIM
7  HAL
9  HER

2  PAN
4  COC
6  CLB
8  SOLV
10  OTH

Page 4

Section 3D - TREATMENT UTILIZATION (Continued)
3a. How old were you the FIRST time you went anywhere for
help or saw anyone for a reason that was related to your
medicine or drug use?

b. How old were you the MOST RECENT time you went
anywhere for help or saw anyone for a reason that was
related to your medicine or drug use?

4a. Was there ever a time when you thought you should see a
doctor, counselor, or other health professional or seek any
other help for your drug use, but you didn’t go?

_____ Age

_____ Age
OR
0  Happened only once
1  Yes
2  No - SKIP to Section 3E

b. Did this happen during the last 12 months?

1  Yes
2  No - SKIP to 4d

c. Did this happen before 12 months ago, that is, before last

1  Yes
2  No

(Month one year ago)?

(SHOW FLASHCARD 43)

d. What were your reasons for not getting help?
(Check all that apply.)

1  Wanted to go, but health insurance didn’t
cover
2  Didn’t think anyone could help
3  Didn’t know any place to go for help
4  Couldn’t afford to pay the bill
5  Didn’t have any way to get there
6  Didn’t have time
7  Thought the problem would get better by
itself
8  Was too embarrassed to discuss it with
anyone
9  Was afraid of what my boss, friends, family,
or others would think
10  Thought it was something I should be strong
enough to handle alone
11  Was afraid they would put me into the
hospital
12  Was afraid of the treatment they would
give me
13  Hated answering personal questions
14  The hours were inconvenient
15  A member of my family objected
16  My family thought I should go but I didn’t
think it was necessary
17  Can’t speak English very well
18  Was afraid I would lose my job
19  Couldn’t arrange for child care
20  Had to wait too long to get into a program
21  Wanted to keep using medicines or drugs
22  Didn’t think medicine or drug problem was
serious enough
23  Didn’t want to go
24  Stopped using medicines or drugs on my
own
25  Friends or family helped me stop using
medicines or drugs
26  Tried getting help before and it didn’t work
27  Was afraid my children would be taken away
28  My religious beliefs don’t allow me to go
for treatment
29  Other reason

Go to
Section
3E

Page 5

Section 3E - FAMILY HISTORY - II
Statement K

Now I would like to ask you some further questions about whether your relatives, regardless of whether or
not they are now living, have EVER had problems with drugs. By having problems with drugs I mean a
person who has physical or emotional problems because of drug use (PAUSE); problems with a spouse, family
or friends because of drug use (PAUSE); problems at work or school because of drug use (PAUSE); problems
with the police because of drug use - like driving under the influence (PAUSE) or a person who seems to
spend a lot of time using drugs or getting over their bad aftereffects. (Repeat definition frequently.)

1.

In your judgment, has your blood or natural father had
problems with drugs at ANY time in his life?

1  Yes
2  No

2.

Has your blood or natural mother had problems with
drugs at ANY time in her life?

1  Yes
2  No

3.

(Did your full brother have/How many of your full
brothers had) problems with drugs at ANY time in (his
life/their lives)?

1  Yes
2  No
OR
______ Number
0  None

4.

(Did your full sister have/How many of your full sisters
had) problems with drugs at ANY time in (her life/their
lives)?

1  Yes
2  No
OR
______ Number
0  None

5.

(Did your natural son have/How many of your natural
sons had) problems with drugs at ANY time in (his life/
their lives)?

1  Yes
2  No
OR
______ Number
0  None

6.

(Did your natural daughter have/How many of your
natural daughters had) problems with drugs at ANY time
in (her life/their lives)?

1  Yes
2  No
OR
______ Number
0  None

7.

(Did your natural father’s full brother have/How many of
your natural father’s full brothers had) problems with
drugs at ANY time in (his life/their lives)?

1  Yes
2  No
OR
______ Number
0  None

8.

(Did your natural father’s full sister have/How many of
your natural father’s full sisters had) problems with drugs
at ANY time in (her life/their lives)?

1  Yes
2  No
OR
______ Number
0  None

9.

(Did your natural mother’s full brother have/How many
of your natural mother’s full brothers had) problems with
drugs at ANY time in (his life/their lives)?

1  Yes
2  No
OR
______ Number
0  None

(Did your natural mother’s full sister have/How many of
your natural mother’s full sisters had) problems with
drugs at ANY time in (her life/their lives)?

1  Yes
2  No
OR
______ Number
0  None

10.

11. Did your natural grandfather on your father’s side have
problems with drugs at ANY time in his life?

12. Did your natural grandmother on your father’s side have
problems with drugs at ANY time in her life?

13. Did your natural grandfather on your mother’s side have
problems with drugs at ANY time in his life?

14. Did your natural grandmother on your mother’s side have
problems with drugs at ANY time in her life?

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No

Go to Section 4A

Page 1

Section 4A - LOW MOOD I
Statement L

Now I’d like to ask you some questions about moods and related experiences that many people have had.

1a. In your ENTIRE LIFE, have you ever had a time when you
felt sad, blue, depressed, or down nearly every day for at
least 2 weeks?

b. In your ENTIRE LIFE, have you ever had a time when
other people noticed that you were so sad, blue, depressed,
or down that you weren’t your normal self or that they were
concerned about you nearly every day for at least 2 weeks?

c. In your ENTIRE LIFE, have you ever had a time when you
didn’t care about the things that you usually cared about, or
when you didn’t enjoy the things you usually enjoyed nearly
every day for at least 2 weeks?

d. In your ENTIRE LIFE, have you ever had a time when
other people noticed that you no longer cared about things
or enjoyed things nearly every day for at least 2 weeks?
CHECK
ITEM 4.1

Is at least 1 item marked “Yes” in 1a-1d?

1  Yes
2  No

1  Yes
2  No
1  Yes
2  No

1  Yes
2  No
1  Yes
2  No - SKIP to Section 4B

3a. The next few questions are about experiences many people have had when they felt sad, blue,

b.

depressed, or down or didn’t care about things or enjoy things. During that time in your life
when (your mood was at its lowest/you enjoyed or cared the least about things), please tell me
if you ALSO had ANY of the following experiences NEARLY EVERY DAY for at least 2
weeks.
(Repeat entire phrase frequently)
Did you feel sad, blue, depressed or down?

b. Did you find that you didn’t care about things that you
usually cared about or you didn’t enjoy the things you
usually enjoyed?

c. Did you lose at least 2 pounds a week for several weeks
or at least 10 pounds altogether within a month, other than
when you were physically ill or dieting?

1  Yes - Mark Box 1
2  No - Go to next
experience

Box
1

1  Yes - Mark Box 2
2  No - Go to next
experience

Box
2

1  Yes - Mark Box 3
2  No - Go to next
experience

Box
3

d. Did you lose your appetite?

1  Yes - Mark Box 3
2  No - Go to next
experience

e. Did you gain at least 2 pounds a week for several weeks

1  Yes - Mark Box 3
2  No - Go to next
experience

or at least 10 pounds altogether within a month other than
when you were growing (or pregnant)?

f. Did you find that you wanted to eat a lot more than usual for
no special reason, nearly every day for at least 2 weeks?

g. Did you have trouble falling asleep?

h. Did you wake up too early nearly every day for at least 2
weeks?

i. Did you sleep more than usual nearly every day for at least 2
weeks?

j. Did you feel tired or get tired easily most days for at least 2
weeks, even though you weren’t doing more than usual?

k. Did you feel so tired that even small things took a lot of
effort?

1  Yes - Mark Box 3
2  No - Go to next
experience
1  Yes - Mark Box 4
2  No - Go to next
experience

Box

4

1  Yes - Mark Box 4
2  No - Go to next
experience
1  Yes - Mark Box 4
2  No - Go to next
experience
1  Yes - Mark Box 5
2  No - Go to next
experience

Box
5

1  Yes - Mark Box 5
2  No - Go to next
experience

Page 1

Section 4A - LOW MOOD I (Continued)
3l.

During that time in your life when (your mood was at its lowest/you enjoyed or cared the least
about things), . . .

b.

(Repeat entire phrase frequently)
Did you move or talk SO MUCH more slowly than usual that
other people noticed most days for at least 2 weeks?

1  Yes - Mark Box 6
2  No - Go to next
experience

m. Did you become so restless that you fidgeted or paced most of

1  Yes - Mark Box 6
2  No - Go to next
experience

the time?

n. Did other people notice that you were so restless that you
fidgeted or paced most of the time?

1  Yes - Mark Box 6
2  No - Go to next
experience

o. Did you become so restless that you felt uncomfortable?

1  Yes - Mark Box 6
2  No - Go to next
experience

p. Did other people notice that you were so restless that you

1  Yes - Mark Box 6
2  No - Go to next
experience

seemed uncomfortable?

q. Did you feel worthless nearly every day for at least 2 weeks?

1  Yes - Mark Box 7
2  No - Go to next
experience

r. Did you feel guilty about things you normally wouldn’t feel

1  Yes - Mark Box 7
2  No - Go to next
experience

guilty about nearly every day for at least 2 weeks?

s. Did you feel useless or good for nothing nearly every day for
at least 2 weeks?

t. Did you have trouble concentrating or keeping your mind on
things most days for at least 2 weeks?

u. Did other people notice that you were having trouble
concentrating or keeping your mind on things?

v. Did you find it harder than usual to make decisions most of
the time for at least 2 weeks?

w. Did other people notice that you found it harder than usual to
make decisions?

Box
6

Box
7

1  Yes - Mark Box 7
2  No - Go to next
experience
1  Yes - Mark Box 8
2  No - Go to next
experience

Box
8

1  Yes - Mark Box 8
2  No - Go to next
experience
1  Yes - Mark Box 8
2  No - Go to next
experience
1  Yes - Mark Box 8
2  No - Go to next
experience

x. Did you attempt suicide or try to kill yourself?

1  Yes - Mark Box 9
2  No - Go to next
experience

y. Did you think about committing suicide or killing yourself?

1  Yes - Mark Box 9
2  No - Go to next
experience

z. Did you feel like you wanted to die?

1  Yes - Mark Box 9
2  No - Go to next
experience

aa. Did you think a lot about your own death?

1  Yes - Mark Box 9
2  No - Go to Check
Item 4.3

Box
9

Page 2

Section 4A - LOW MOOD I (Continued)
CHECK
ITEM 4.3

Is Box 1 or 2 marked “Yes” and is the sum of boxes
1-9 equal to 5 or more?

1  Yes – SKIP to 5a
2  No

CHECK
ITEM 4.3A

Is Box 1 or 2 marked “Yes” and is the sum of boxes
1-9 equal to 3 or 4?

1  Yes
2  No – SKIP Section 4B

4a. Now I’d like to know about some OTHER experiences that
may have happened nearly every day when your mood was
at its lowest or you enjoyed or cared the least about things.
During ANY of those times, did you …
Worry a lot about things even though you knew it was
unreasonable?

1  Yes
2  No

b. Spend a lot of time worrying about unpleasant things?

1  Yes
2  No

c. Have trouble relaxing for at least 2 weeks?

1  Yes
2  No

d. Fear something awful might happen?

1  Yes
2  No

e. Find it difficult to sit still or find yourself fidgeting or

1  Yes
2  No

pacing?
CHECK
ITEM 4.3B

Are at least 2 items marked “Yes” in 4a-4e?

1  Yes
2  No – SKIP to Section 4B

5a. Now I’d like to ask you about some other things that might
have happened to you during that time when (your mood
was at its lowest/you enjoyed or cared the least about
things) for at least 2 weeks and you had some of the other
experiences you mentioned at the same time.
During that time...
Were you very upset by your low mood or any of these
OTHER experiences?

b. Did you have arguments or friction with friends, family,
people at work or anyone else?

c. Were you very troubled because of the way you felt at that
time, or did you often wish you could get better?

d. Did you have any trouble doing things you were supposed
to do - like working, doing your schoolwork, or taking care
of your home or family?

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No

you didn’t want to be around people as much as usual?

1  Yes
2  No

Did you find you couldn’t do the things you usually did or
wanted to do?

1  Yes
2  No

e. Did you spend more time than usual by yourself, because
f.

1  Yes
2  No

g. Did you find you did a lot less or were less active than
usual?

h. Did you depend a lot more on people to take care of
everyday things for you or to give you a lot of attention or
comfort?

1  Yes
2  No
1  Yes
2  No

Page 3

Section 4A - LOW MOOD I (Continued)
6a. About how old were you the FIRST time you BEGAN to
(feel sad, blue, depressed or down/not care about things or
enjoy things) for at least 2 weeks and when you also had
some of the other experiences you mentioned?

_____ Age

Refer to other experiences marked “Yes” in 3a – 5h, if
necessary.
CHECK
ITEM 4.4

Is respondent’s age in 6a within 1 year of
his/her present age or is present age or 6a unknown?

6b. Did this FIRST time BEGIN to happen during the last 12
months?

7.

In your ENTIRE LIFE, how many SEPARATE times
lasting at least 2 weeks were there when you (felt sad, blue,
depressed, or down/didn’t care about things or enjoy
things) and when you also had some of the other
experiences you mentioned? By separate times, I mean
times separated by at least 2 months when your mood was
much improved or back to normal and you DIDN’T have
ANY of the other experiences you mentioned.

CHECK

Is number entered in 7, 2 or more or unknown?

ITEM 4.5

1  Yes
2  No - SKIP to 7
1  Yes
2  No

_____ Number

1  Yes
2  No - SKIP to 9e

8a. How old were you the MOST RECENT time you BEGAN
to (feel sad, blue, depressed or down/not care about things
or enjoy things) for at least 2 weeks and when you also had
some of these other experiences?
CHECK
ITEM 4.6A

Is respondent’s age in 8a within 1 year of his/her
present age or is present age or 8a unknown?

8b. Did this MOST RECENT time BEGIN to happen during
the last 12 months?

9a. How long did this MOST RECENT time last when you
(felt sad, blue, depressed or down/didn’t care about things
or enjoy things)?
(Must be at least 2 weeks.)

b.

Since this MOST RECENT time BEGAN, have there been
at least 2 months when your mood was much improved or
back to normal AND when you DIDN’T have ANY of the
OTHER experiences you mentioned?

CHECK
ITEM 4.6B

Is “Yes” marked in 8b?

9c. Did this MOST RECENT time when your mood was much
improved BEGIN to happen in the last 12 months?

d.

In your ENTIRE LIFE, what was the LONGEST time you
had when you (felt sad, blue, depressed, or down/didn’t
care about things or enjoy things)?
(Must be at least 2 weeks.)

_____ Age

1  Yes
2  No - SKIP to 9a
1  Yes
2  No
_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)
1  Yes
2  No – SKIP to 9d

1  Yes - SKIP to 9d
2  No
1  Yes
2  No
_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)

SKIP to Check Item 4.8A

Page 4

Section 4A - LOW MOOD I (Continued)
9e. How long did that time last when you (felt sad, blue,
depressed or down/didn’t care about things or enjoy
things)?
(Must be at least 2 weeks.)

f.

Since that time BEGAN, have there been at least 2 months
when your mood was much improved or back to normal
AND you DIDN’T have ANY of the OTHER experiences
you mentioned?

CHECK
ITEM 4.7

Is “Yes” marked in 6b?

9g. Did this time when your mood was much improved or back
to normal BEGIN to happen in the last 12 months?
CHECK
ITEM 4.8

Is number marked in 9e, 2 months or more or is
Follow-up probe 9ep coded “Yes”?

10a. Did that time when you (felt sad, blue, depressed or
down/didn’t care about things or enjoy things) BEGIN to
happen just after someone close to you died?
CHECK
ITEM 4.8A

Is number in 9d, less than 2 months or is Follow-up
probe 9dp coded “No”?

10b. Did ALL of those times when you (felt sad, blue, depressed
or down/didn’t care about things or enjoy things) last for
at least 2 months?
CHECK
ITEM 4.9A

Is 6b marked “Yes” or 8b marked “Yes”?

10c. Think about the times in the last 12 months when you (felt
sad, blue, depressed or down/didn’t care about things or
enjoy things) for LESS than 2 months. Did ALL of those
times BEGIN to happen just after someone close to you
died?
CHECK
ITEM 4.9B

Is 6b marked “Yes”?

10d. Think about the times BEFORE 12 months ago when you
(felt sad, blue, depressed or down/didn’t care about things
or enjoy things) for LESS than 2 months. Did ALL of
those times BEGIN to happen just after someone close to
you died?
CHECK
ITEM 4.10

Refer to Check Item 2.1, Section 2A.
Is the respondent a lifetime abstainer of alcohol?

11. Did (that time/ANY of those times) when you (felt sad,
blue, depressed or down/didn’t care about things or
enjoy things) BEGIN to happen DURING or within 1
month AFTER drinking heavily or a lot more than
usual?

12. Did (that time/ANY of those times) when you (felt sad,
blue, depressed or down/didn’t care about things or
enjoy things) BEGIN to happen DURING or within 1
month AFTER experiencing the bad aftereffects of
drinking?

_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)
1  Yes
2  No - SKIP to Check Item 4.8

1  Yes - SKIP to Check Item 4.8
2  No
1  Yes
2  No
1  Yes - SKIP to Check Item 4.10
2  No
1  Yes
2  No

SKIP to Check Item 4.10

1  Yes - SKIP to Check Item 4.9A
2  No
1  Yes - SKIP to Check Item 4.10
2  No
1  Yes
2  No - SKIP to 10d
1  Yes
2  No

1  Yes - SKIP to Check Item 4.10
2  No
1  Yes
2  No

1  Yes - SKIP to 13
2  No
1  Yes
2  No

1  Yes
2  No

Page 5

Section 4A - LOW MOOD I (Continued)
13. Did (that time/ANY of those times) when you (felt sad,
blue, depressed or down/didn’t care about things or
enjoy things) BEGIN to happen DURING or within 1
month AFTER using a medicine or drug?

14. Did (that time/ANY of those times) when you (felt sad,
blue, depressed or down/didn’t care about things or enjoy
things) BEGIN to happen DURING or within 1 month
AFTER experiencing the bad aftereffects of a medicine or
drug?

1  Yes
2  No

1  Yes
2  No

CHECK
ITEM 4.11

Is at least 1 item marked “Yes” in 11, 12, 13 OR 14?

1  Yes
2  No - SKIP to 16a

CHECK
ITEM 4.12

Is Check Item 4.5 marked “No”?

1  Yes
2  No - SKIP to Check Item 4.13A

15a. During that time, did you STOP (drinking heavily/using
medicines and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs) for at least 1 month?

b. Did you CONTINUE (to feel sad, blue, depressed or
down/not to care about things or enjoy things) for at least
1 month AFTER you STOPPED (drinking heavily/using
medicines and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs)?
CHECK
ITEM 4.13A

Is 6b marked “Yes” or 8b marked “Yes”?

15c. Did ALL of the times when you (felt sad, blue, depressed
or down/didn’t care about things or enjoy things) in the
last 12 months ONLY BEGIN to happen during or within
1 month after (drinking heavily/using any medicines or
drugs/experiencing the bad aftereffects of
drinking/medicines or drugs)?

d. During ANY of those times in the last 12 months when you
(felt sad, blue, depressed or down/didn’t care about things
or enjoy things) after (drinking heavily/using any
medicine or drugs), did you STOP (drinking heavily/using
medicines and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs) for at least 1 month?

e. During ALL of those times, did you STOP (drinking
heavily/using medicines and drugs/experiencing the bad
aftereffects of drinking/medicines and drugs)?

f.

Did you CONTINUE (to feel sad, blue, depressed or
down/not to care about things or enjoy things) for at least
1 month AFTER ANY of those times in the last 12 months
when you STOPPED (drinking heavily/using medicines
and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs)?

CHECK
ITEM 4.13B

Is 6b marked “Yes”?

15g. Did ALL of the times when you (felt sad, blue, depressed
or down/didn’t care about things or enjoy things)
BEFORE 12 months ago ONLY BEGIN to happen during
or within 1 month after (drinking heavily/using any
medicines or drugs/experiencing the bad aftereffects of
drinking/medicines or drugs)?

1  Yes
2  No - SKIP to 16a
1  Yes
2  No

SKIP to 16a

1  Yes
2  No - SKIP to 15g
1  Yes
2  No - SKIP to Check Item 4.13B

1  Yes
2  No - SKIP to Check Item 4.13B

1  Yes
2  No

1  Yes
2  No

1  Yes - SKIP to 16a
2  No
1  Yes
2  No - SKIP to 16a

Page 6

Section 4A - LOW MOOD I (Continued)
15h. During ANY of those times BEFORE 12 months ago when
you (felt sad, blue, depressed or down/didn’t care about
things or enjoy things) after (drinking heavily/using any
medicines or drugs), did you STOP (drinking
heavily/using medicines and drugs/experiencing the bad
aftereffects of drinking/medicines and drugs) for at least 1
month?

i. During ALL of those times, did you STOP (drinking
heavily/using medicines and drugs/experiencing the bad
aftereffects of drinking/medicines and drugs)?

j. Did you CONTINUE (to feel sad, blue, depressed or
down/not to care about things or enjoy things) for at least
1 month AFTER ANY of those times BEFORE 12 months
ago when you STOPPED (drinking heavily/using
medicines and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs)?

16a. Did you EVER talk to any health professional like a
psychiatrist, other medical doctor, psychologist, social
worker or any other kind of counselor or therapist to help
improve your mood?

b. Did you EVER go to a self-help or support group, use a
hotline or visit an internet chat room for help to improve
your mood?

17a. Were you EVER a patient in any kind of hospital

1  Yes
2  No - SKIP to 16a

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

overnight or longer because you (felt sad, blue, depressed
or down/didn’t care about things or enjoy things)?

1  Yes
2  No

b. Did you EVER go to an emergency room for help during

1  Yes
2  No

any time when you (felt sad, blue, depressed or down/
didn’t care about things or enjoy things)?

18. Did a doctor EVER prescribe any medicines or drugs to
improve your mood?
CHECK
ITEM 4.14

Is at least 1 item marked “Yes” in 16a-18?
Did respondent ever seek help for their low mood?

1  Yes
2  No
1  Yes
2  No - SKIP to Check Item 4.16

19. About how old were you the FIRST time you went
anywhere or talked to anyone to get help for (feeling sad,
blue, depressed or down/not caring about things or
enjoying things)?
CHECK
ITEM 4.15

Is age in 19 equal to respondent’s current age?

20. Did you go anywhere or talk to anyone in the last 12
months?
CHECK
ITEM 4.15A

Is age in 19 at least 2 years less than respondent’s
current age?

21. Did you go anywhere or talk to anyone before 12 months
ago, that is, BEFORE last (Month one year ago)?
CHECK
ITEM 4.16

Is Check Item 4.5 marked “No”?

22a. Did that time when you (felt sad, blue, depressed or
down/didn’t care about things or enjoy things) BEGIN to
happen DURING a time when you were physically ill or
getting over being physically ill?

_____ Age

1  Yes - SKIP to Check Item 4.16
2  No
1  Yes
2  No - SKIP to Check Item 4.16
1  Yes - SKIP to Check Item 4.16
2  No
1  Yes
2  No
1  Yes
2  No - SKIP to Check Item 4.17
1  Yes
2  No - SKIP to 23a1

Page 7

Section 4A - LOW MOOD I (Continued)
22b. Did a doctor or other health professional tell you that this
time was related to your physical illness or medical
condition?
CHECK
ITEM 4.17

Is 6b marked “Yes” or 8b marked “Yes”?

c. Did ALL of those times when you (felt sad, blue, depressed
or down/didn’t care about things or enjoy things) in the
last 12 months ONLY BEGIN to happen DURING times
when you were physically ill or getting over being
physically ill?

d. Did a doctor or other health professional tell you that
ALL of the times like this were related to your physical
illness or medical condition?
CHECK
ITEM 4.18

Is 6b marked “Yes”?

e.

Did ALL of those times BEFORE 12 months ago when
you (felt sad, blue, depressed or down/didn’t care about
things or enjoy things) ONLY BEGIN to happen DURING
times when you were physically ill or getting over being
physically ill?

f.

Did a doctor or other health professional tell you that
ALL of the times like this were related to your physical
illness or medical condition?

CHECK
ITEM 4.18A

Is Check Item 4.3 marked “Yes”?

1  Yes
2  No

SKIP to 23a1

1  Yes
2  No - SKIP to 22e
1  Yes
2  No - SKIP to Check Item 4.18

1  Yes
2  No
1  Yes - SKIP to 23a1
2  No
1  Yes
2  No - SKIP to 23a1

1  Yes
2  No
1  Yes
2  No - SKIP to Section 4B

23a. Now I’d like to know about some other experiences that

b. Did this happen
during ANY of those
times when you (felt
sad, blue, depressed
or down/didn’t care
about things or enjoy
things) that BEGAN
in the last 12
months?

may have happened during (that time/ANY of those times)
when you (felt sad, blue, depressed or down/didn’t care
about things or enjoy things).
During (that time/ANY of these times), please tell me if you
had ANY of the following experiences nearly every day.
Did you…

c. Did this happen
during ANY of those
times that BEGAN
BEFORE 12 months
ago?

(Repeat phrase frequently.)

(1) Feel extremely excited or elated?

1  Yes
2  No - Go to next
Experience

1  Yes
2  No - Go to next
Experience

1  Yes
2  No

(2) Feel very irritable or easily annoyed?

1  Yes
2  No - Go to next
Experience

1  Yes
2  No - Go to next
Experience

1  Yes
2  No

(3) Feel extremely revved up or energetic?

1  Yes
2  No - Go to next
Experience

1  Yes
2  No - Go to next
Experience

1  Yes
2  No

(4) Need much less sleep than usual?

1  Yes
2  No - Go to next
Experience

1  Yes
2  No - Go to next
Experience

1  Yes
2  No

(5) Feel rested after getting much less sleep than

1  Yes
2  No - Go to next
Experience

1  Yes
2  No - Go to next
Experience

1  Yes
2  No

(6) Find you were more talkative than usual?

1  Yes
2  No - Go to next
Experience

1  Yes
2  No - Go to next
Experience

1  Yes
2  No

(7) Feel pressure to keep talking?

1  Yes
2  No - Go to next
Experience

1  Yes
2  No - Go to next
Experience

1  Yes
2  No

usual?

Page 8

Section 4A - LOW MOOD I (Continued)
23a. During (that time/ANY of those times), did you…

b. Did this happen
during ANY of those
times when you (felt
sad, blue, depressed
or down/didn’t care
about things or enjoy
things) that BEGAN
in the last 12 months?

(Repeat phrase frequently.)

c. Did this happen
during ANY of
those times that
BEGAN BEFORE
12 months ago?

(8)

Talk so fast that people had trouble
understanding you or couldn’t get a word in
edgewise?

1  Yes
2  No - Go to next
Experience

1  Yes
2  No - Go to next
Experience

1  Yes
2  No

(9)

Find your thoughts racing so fast that you
couldn’t keep track of them?

1  Yes
2  No - Go to next
Experience

1  Yes
2  No - Go to next
Experience

1  Yes
2  No

(10)

Find your thoughts racing so fast that it was
hard to follow your own thoughts?

1  Yes
2  No - Go to next
Experience

1  Yes
2  No - Go to next
Experience

1  Yes
2  No

(11)

Become more active than usual at work, at home,
or in pursuing other interests?

1  Yes
2  No - Go to next
Experience

1  Yes
2  No - Go to next
Experience

1  Yes
2  No

(12)

Become more sexually active than usual?

1  Yes
2  No - Go to next
Experience

1  Yes
2  No - Go to next
Experience

1  Yes
2  No

(13)

Have sex with people you normally wouldn’t be
interested in?

1  Yes
2  No - Go to next
Experience

1  Yes
2  No - Go to next
Experience

1  Yes
2  No

(14)

Do anything unusual that could have gotten you
into trouble - like buying things you couldn’t
afford or didn’t need, making foolish decisions
about money, or driving recklessly?

1  Yes
2  No - Go to next
Experience

1  Yes
2  No - Go to next
Experience

1  Yes
2  No

(15)

Do anything that you later regretted - like
spending time with people you normally
wouldn’t be interested in?

1  Yes
2  No - Go to next
Experience

1  Yes
2  No - Go to next
Experience

1  Yes
2  No

(16)

Feel that you were an unusually important
person or that you had special gifts, powers, or
abilities to do things that most other people
couldn’t do?

1  Yes
2  No - Go to next
Experience

1  Yes
2  No - Go to next
Experience

1  Yes
2  No

(17)

Have trouble concentrating because little things
going on around you got you easily off track?

1  Yes
1  Yes
1  Yes
2  No - Go to
2  No - Go to Check 2  No
Item 4.18B
Check Item 4.18B

CHECK
ITEM 4.18B

Is “Yes” marked in Check Item 4.5?

1  Yes
2  No – Skip to Section 4B

CHECK
ITEM 4.19

Are at least 3 Boxes marked “Yes” in 23 column b?

1  Yes
2  No - SKIP to Check Item 4.20

25. Did SOME of these experiences we just talked about
happen nearly every day during ANY of those times in the
last 12 months when you (felt sad, blue, depressed or
down/didn’t care about things or enjoy things)?

26. Did SOME of these experiences happen nearly every day
during ALL of those times in the last 12 months when you
(felt sad, blue, depressed or down/didn’t care about things
or enjoy things)?

1  Yes
2  No - SKIP to Check Item 4.20

1  Yes
2  No

Page 9

Section 4A - LOW MOOD I (Continued)
CHECK
ITEM 4.20

Are at least 3 Boxes marked “Yes” in 23, column c?

27. Did SOME of these experiences we just talked about happen
nearly every day during ANY of those times BEFORE 12
months ago when you (felt sad, blue, depressed or
down/didn’t care about things or enjoy things)?

28. Did SOME of these experiences happen nearly every day
during ALL of those times BEFORE 12 months ago when
you (felt sad, blue, depressed or down/didn’t care about
things or enjoy things)?

1  Yes
2  No - SKIP to Section 4B
1  Yes
2  No - SKIP to Section 4B

1  Yes
2  No

Go to Section 4B

Page 10

Section 4B - LOW MOOD II
1.

Some people have reported that they have low moods that
last for 2 years or longer.
Have you EVER had a time that lasted for at least 2 years
when more days then not you were in a low mood?

1  Yes
2  No - SKIP to Section 4C

3a. During that time when your mood was at its lowest, did you OFTEN. . .
(Repeat entire phrase frequently)

Lose your appetite?

b. Find you wanted to eat a lot more than usual for no
special reason?

c. Have trouble falling asleep, staying asleep or waking up
too early?

1  Yes - Mark Box 1
2  No - Go to next
experience

b.
Box
1

1  Yes - Mark Box 1
2  No - Go to next
experience
1  Yes - Mark Box 2
2  No - Go to next
experience

Box
2

d. Sleep more than usual?

1  Yes - Mark Box 2
2  No - Go to next
experience

e. Feel tired or feel you didn’t have much energy?

1  Yes - Mark Box 3
2  No - Go to next
experience

Box
3

f. Have trouble concentrating or keeping your mind on

1  Yes - Mark Box 4
2  No - Go to next
experience

Box
4

things?

g. Find it harder than usual to make everyday decisions?

1  Yes - Mark Box 4
2  No - Go to next
experience

h. Feel that you weren’t as good as other people?

1  Yes - Mark Box 5
2  No - Go to next
experience

i.

1  Yes - Mark Box 5
2  No - Go to next
experience

Feel down on yourself?

j. Feel that you were inadequate or a failure?

1  Yes - Mark Box 5
2  No - Go to next
experience

k. Feel like life would never work out the way you wanted?

1  Yes - Mark Box 5
2  No - Go to next
experience

l.

1  Yes - Mark Box 6
2  No - Go to next
experience

Feel that things were bad and would never get better?

m. Feel hopeless?

CHECK
ITEM 4.23

Are at least 2 boxes marked Boxes 1-6, column b?

Box
5

Box
6

1  Yes - Mark Box 6
2  No - Go to next
experience
1  Yes
2  No - Go to Section 4C

Page 1

Section 4B - LOW MOOD II (Continued)
4a. Now I’d like to ask you about some other things that
might have happened to you during that time when your
mood was at its lowest for at least 2 years and you had
some of the other experiences you mentioned around the
same time.
During those years, did you. . .
(Repeat phrase frequently)
Feel very upset by your low mood or any of those other
experiences?

1  Yes
2  No

b. Wish you could get better?

1  Yes
2  No

c. Have arguments or friction with family, friends, people at

1  Yes
2  No

work or anyone else?

d. Have difficulty doing the things you were supposed to do like working, doing your schoolwork or taking care of
your home or family?

1  Yes
2  No

e. Dwell on the past or brood about the past?

1  Yes
2  No

f. Find that you did a lot less than usual or were less active?

1  Yes
2  No

g. Spend more time by yourself because you didn’t want to

1  Yes
2  No

be around people?

getting along with them?

1  Yes
2  No

About how old were you the FIRST time you BEGAN to
have a low mood that lasted for at least 2 years and you
also had SOME of the other experiences you mentioned?

_____ Age

h. Ask people for help so much that it caused problems
5.

Refer to other experiences marked “Yes” in 3a – 4h, if
necessary.

6.

In your ENTIRE LIFE, how many SEPARATE times
lasting at least 2 years were there when your mood was
low and you often had SOME of the other experiences you
mentioned?

_____ Number

By separate times, I mean times separated by at least 2
months when your mood was much improved or back to
normal AND you didn’t have ANY of the OTHER
experiences you mentioned.
CHECK
ITEM 4.24A

Is number entered in 6, 2 or more or unknown?

1  Yes
2  No - SKIP to 8b

7a. How old were you the MOST RECENT time you
BEGAN to have a low mood that lasted for at least 2
years and you often had SOME of the other experiences
you mentioned?

b.

_____ Age

For how many years did this MOST RECENT time last?
(Must be at least 2 years.)

_____ Years

c.

Since this MOST RECENT time BEGAN, has there been
a time lasting at least 2 months when your mood was
much improved or back to normal AND you DIDN’T
have ANY of those OTHER experiences?

1  Yes
2  No - SKIP to 8a

d.

Did this MOST RECENT time when your mood was
much improved BEGIN to happen in the last 12 months?

1  Yes
2  No

Page 2

Section 4B - LOW MOOD II (Continued)
8a. In your ENTIRE LIFE, what was the LONGEST period you
had when your mood was low and you had some of those
other experiences?

_____ Years - SKIP to Check Item 4.25

(Must be at least 2 years.)

b.

For how many years did that time last when your mood was
low and you had some of the other experiences you
mentioned?

_____ Years

(Must be at least 2 years.)

c.

Since that time BEGAN, has there been a time lasting at
least 2 months when your mood was much improved or back
to normal AND you DIDN’T have ANY of those OTHER
experiences?

1  Yes
2  No - SKIP to Check Item 4.25

d.

Did this time when your mood was much improved BEGIN
to happen in the last 12 months?

1  Yes
2  No

CHECK
ITEM 4.25

Refer to Check Item 2.1, Section 2A.
Is respondent a lifetime abstainer of alcohol?

9. Did (that time/ANY of those times) when your mood was low
for at least 2 years BEGIN to happen DURING or within 1
month AFTER drinking heavily or a lot more than usual?

10. Did (that time/ANY of those times) when your mood was
low for at least 2 years BEGIN to happen DURING or
within 1 month AFTER experiencing the bad aftereffects
of drinking?

11. Did (that time/ANY of those times) when your mood was
low for at least 2 years BEGIN to happen DURING or
within 1 month AFTER using a medicine or drug?

12. Did (that time/ANY of those times) when your mood was
low for at least 2 years BEGIN to happen DURING or
within 1 month AFTER experiencing the bad aftereffects
of a medicine or drug?

1  Yes - SKIP to 11
2  No
1  Yes
2  No
1  Yes
2  No

1  Yes
2  No
1  Yes
2  No

CHECK
ITEM 4.26

Is at least 1 item marked “Yes” in 9, 10, 11 OR 12?

1  Yes
2  No - SKIP to 14a

CHECK
ITEM 4.27

Is number in 6, 2 or more or unknown?

1  Yes - SKIP to 13c
2  No

13a. During that time, did you STOP (drinking heavily/using
medicines and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs) for at least 1 month?

b. Did you CONTINUE to have a low mood for at least 1
month AFTER you STOPPED (drinking heavily/using
medicines and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs)?

c. Did the MOST RECENT time when your mood was low
for at least 2 years BEGIN to happen during or within 1
month after (drinking heavily/using any medicines or
drugs/experiencing the bad aftereffects of
drinking/medicines or drugs)?

d. During that MOST RECENT time, did you STOP
(drinking heavily/using medicines and drugs/experiencing
the bad aftereffects of drinking/medicines and drugs) for at
least 1 month?

e. Did you CONTINUE to have a low mood for at least 1
month AFTER you STOPPED (drinking heavily/using
medicines and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs)?

1  Yes
2  No - SKIP to 14a
1  Yes SKIP to 14a
2  No

1  Yes
2  No - SKIP to Check Item 4.28

1  Yes
2  No - SKIP to Check Item 4.28

1  Yes
2  No

Page 3

Section 4B - LOW MOOD II (Continued)
CHECK
ITEM 4.28

Is number entered in 6, 3 or more or D or R?

13f. Did the earlier time when your mood was low for at least 2
years BEGIN to happen during or within 1 month after
(drinking heavily/using any medicines or drugs/
experiencing the bad aftereffects of drinking/medicines or
drugs)?

g. During that earlier time, did you STOP (drinking
heavily/using medicines and drugs/experiencing the bad
aftereffects of drinking/medicines and drugs) for at least 1
month?

h. Did you CONTINUE to have a low mood for at least 1
month AFTER the earlier time when you STOPPED
(drinking heavily/using medicines and drugs/experiencing
the bad aftereffects of drinking/medicines and drugs)?

i.

Did ALL of the earlier times when your mood was low for
at least 2 years ONLY BEGIN to happen during or within
1 month after (drinking heavily/using any medicines or
drugs/experiencing the bad aftereffects of
drinking/medicines or drugs)?

j.

During ANY of those earlier times when your mood was
low for at least 2 years after (drinking heavily/using any
medicines or drugs), did you STOP (drinking
heavily/using medicines and drugs/experiencing the bad
aftereffects of drinking/medicines and drugs) for at least 1
month?

k. During ALL of those times, did you STOP (drinking
heavily/using medicines and drugs/experiencing the bad
aftereffects of drinking/medicines and drugs)?

l.

Did you CONTINUE to have a low mood for at least 1
month AFTER ANY of those earlier times when you
STOPPED (drinking heavily/using medicines and
drugs/experiencing the bad aftereffects of
drinking/medicines and drugs)?

14a. DURING (that time/ANY of those times) when your mood

1  Yes - SKIP to 13i
2  No
1  Yes
2  No - SKIP to 14a

1  Yes
2  No - SKIP to 14a

1  Yes
2  No

1  Yes
2  No - SKIP to 14a

1  Yes
2  No - SKIP to 14a

1  Yes
2  No
1  Yes
2  No

was low for at least 2 years, did you EVER talk to any
health professional like a psychiatrist, other medical
doctor, psychologist, social worker or any other kind of
counselor or therapist to help improve your mood?

1  Yes
2  No

b. DURING (that time/ANY of those times) when your mood

1  Yes
2  No

was low for at least 2 years, did you EVER go to a selfhelp or support group, use a hotline or visit an internet
chat room for help to improve your mood?

15a. DURING (that time/ANY of those times) when your mood
was low for at least 2 years, were you EVER a patient in a
hospital for at least 1 night because of your low mood?

b. Did you EVER go to an emergency room for help during
(that time/ANY of those times) when you felt low?

16. DURING (that time/ANY of those times) when your mood
was low for at least 2 years, did a doctor EVER prescribe
any medicines or drugs to improve your mood or to make
you feel better?

SKIP to 14a

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No

Page 4

Section 4B - LOW MOOD II (Continued)
CHECK
ITEM 4.29

Is at least 1 item marked “Yes” in 14a - 16?
Did respondent ever seek help for their persistent
low mood?

17.

About how old were you the FIRST time you went
anywhere or talked to anyone to get help for your low
mood that lasted for at least 2 years?

CHECK
ITEM 4.30

18.

Is age in 17 equal to respondent’s current age?

Did you go anywhere or talk to anyone in the last 12
months?

CHECK
ITEM 4.30A

Is age in 17 at least 2 years less than respondent’s
current age?

19. Did you go anywhere or talk to anyone before the last 12
months, that is, BEFORE last (Month one year ago)?
CHECK
ITEM 4.31

Is number in 6, 2 or more or unknown?

20a. Did that time when your mood was low for at least 2 years
BEGIN to happen DURING a time when you were
physically ill or getting over being physically ill?

b. Did a doctor or other health professional tell you that this
time was related to your physical illness or medical
condition?

c. Did the MOST RECENT time when your mood was low
for at least 2 years BEGIN to happen DURING a time
when you were physically ill or getting over being
physically ill?

d. Did a doctor or other health professional tell you that this
MOST RECENT time was related to your physical illness
or medical condition?
CHECK
ITEM 4.32

Is number entered in 6, 3 or more or D or R?

20e. Did the EARLIER time when your mood was low for at
least 2 years BEGIN to happen DURING a time you were
physically ill or getting over being physically ill?

f.

Did a doctor or other health professional tell you this
EARLIER time was related to your physical illness or
medical condition?

g. Did ALL of those EARLIER times when your mood was
low for at least 2 years ONLY BEGIN to happen
DURING times when you were physically ill or getting
over being physically ill?

h. Did a doctor or other health professional tell you that
ALL of the EARLIER times like this were related to your
physical illness or medical condition?

1  Yes
2  No - SKIP to Check Item 4.31

_____ Age

1  Yes - SKIP to Check Item 4.31
2  No
1  Yes
2  No - SKIP to Check Item 4.31
1  Yes - SKIP to Check Item 4.31
2  No
1  Yes
2  No
1  Yes - SKIP to 20c
2  No
1  Yes
2  No – SKIP to Section 4C
1  Yes
2  No

SKIP to Section 4C

1  Yes
2  No - SKIP to Check Item 4.32

1  Yes
2  No
1  Yes - SKIP to 20g
2  No
1  Yes
2  No - SKIP to Section 4C
1  Yes
2  No

SKIP to Section 4C

1  Yes
2  No - SKIP to Section 4C

1  Yes
2  No

Goto Section 4C

Page 5

Section 4C - FAMILY HISTORY - III
Now I would like to ask about whether any of your relatives, regardless of whether or not they are now
living, have ever been depressed for a period of AT LEAST 2 WEEKS.
(SHOW FLASHCARD 44)

Statement M

By depressed I mean they felt down, sad, blue or didn’t care about things and also ate or slept too little or
too much, moved more slowly than usual, were tired or agitated, had trouble concentrating, making
decisions or doing things, or felt worthless or thought about suicide.
(REFER TO FLASHCARD FREQUENTLY.)

1.

Was your blood or natural father depressed at ANY
time in his life?

1  Yes
2  No

2.

Was your blood or natural mother depressed at ANY
time in her life?

1  Yes
2  No

3.

(Was your full brother/How many of your full
brothers were) depressed at ANY time in (his life/their
lives)?

1  Yes
2  No
OR
_____ Number
0  None

4.

(Was your full sister/How many of your full sisters
were) depressed at ANY time in (her life/their lives)?

1  Yes
2  No
OR
_____ Number
0  None

5.

(Was your natural son/How many of your natural
sons were) depressed at ANY time in (his life/their
lives)?

1  Yes
2  No
OR
_____ Number
0  None

6.

(Was your natural daughter/How many of your
natural daughters were) depressed at ANY time in
(her life/ their lives)?

1  Yes
2  No
OR
_____ Number
0  None

7.

(Was your natural father’s full brother/How many of
your natural father’s full brothers were) depressed at
ANY time in (his life/their lives)?

1  Yes
2  No
OR
_____ Number
0  None

8.

(Was your natural father’s full sister/How many of
your natural father’s full sisters were) depressed at
ANY time in (her life/their lives)?

1  Yes
2  No
OR
_____ Number
0  None

9.

(Was your natural mother’s full brother/How many of
your natural mother’s full brothers were) depressed
at ANY time in (his life/their lives)?

1  Yes
2  No
OR
_____ Number
0  None

10. (Was your natural mother’s full sister/How many of
your natural mother’s full sisters were) depressed at
ANY time in (her life/their lives)?

11. Was your natural grandfather on your father’s side
depressed at ANY time in his life?

12. Was your natural grandmother on your father’s side
depressed at ANY time in her life?

13. Was your natural grandfather on your mother’s side
depressed at ANY time in his life?

14. Was your natural grandmother on your mother’s side
depressed at ANY time in her life?

1  Yes
2  No
OR
_____ Number
0  None
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No

Go to Section 5

Page 1

Section 5 - HIGH MOOD
Statement N

Now I’d like to ask you about OTHER moods and related experiences you may have had.

1a. In your ENTIRE LIFE, have you EVER had a time
lasting at least 1 week when you felt so extremely excited
or elated that other people thought you weren’t your
normal self or were concerned about you?

b. In your ENTIRE LIFE, have you EVER had a time
lasting a least 1 week when you were so irritable or easily
annoyed that you acted really angry and often started
fights or arguments?
CHECK
ITEM 5.1

2.

Is at least 1 item marked “Yes” in 1a or 1b?

During ANY of these times lasting at least 1 week when
you were extremely (excited or elated/irritable or easily
annoyed), were you ALSO so revved up or energetic that
other people thought you weren’t your normal self or were
concerned about you?

3a. In your ENTIRE LIFE, have you EVER had a time lasting
LESS than 1 week when you felt so extremely excited or
elated that other people thought you weren’t your normal
self or were concerned about you?

b. In your ENTIRE LIFE, have you EVER had a time lasting
LESS than 1 week when you were so irritable or easily
annoyed that you acted really angry and often started
fights or arguments?
CHECK
ITEM 5.2

4.

Is at least 1 item marked “Yes” in 3a or 3b?

During ANY of these times lasting LESS than 1 week
when you were extremely (excited or elated/irritable or
easily annoyed), were you ALSO so revved up or energetic
that other people thought you weren’t your normal self or
were concerned about you?

5a. Just AFTER ANY of those times lasting LESS than 1 week
when you felt extremely (excited or elated or irritable/
easily annoyed) AND also extremely revved up or
energetic, were you hospitalized for these mood changes?

b. Did ANY of those times lasting LESS than 1 week when
you felt extremely (excited or elated or irritable/ easily
annoyed) AND also extremely revved up or energetic last
for at least 4 days?

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No – Skip to 3a
1  Yes – Skip to 6a
2  No

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No – SKIP to Section 6
1  Yes
2  No – Skip to Section 6

1  Yes – SKIP to 6a
2  No

1  Yes
2  No – SKIP to Section 6

6a. The next few questions are about experiences many people have had when they felt

b.

extremely excited, elated, irritable or easily annoyed AND also revved up or energetic.
During that time when (you were the MOST excited or elated/you felt the MOST irritable
or easily annoyed/you were the MOST excited or elated OR you felt the MOST irritable or
easily annoyed) AND you also felt extremely revved up or energetic, did you . . .
(Repeat entire phrase frequently)
Feel extremely excited or elated?

1  Yes - Mark Box 1
2  No - Go to next
experience

Box
1

Page 1

Section 5 - HIGH MOOD (Continued)
6b. Feel extremely revved up or energetic?

1  Yes - Mark Box 2
2  No - Go to next
experience

c. Feel very irritable or easily annoyed?

1  Yes - Mark Box 3
2  No - Go to next
experience

Box
3

d. Need much less sleep than usual?

1  Yes - Mark Box 4
2  No - Go to next
experience

Box
4

e. Feel rested after getting less sleep than usual?

1  Yes - Mark Box 4
2  No - Go to next
experience

f. Find you were more talkative than usual?

1  Yes - Mark Box 5
2  No - Go to next
experience

g. Feel a pressure to keep talking?

1  Yes - Mark Box 5
2  No - Go to next
experience

h. Talk so fast that people had trouble understanding you

1  Yes - Mark Box 5
2  No - Go to next
experience

or couldn’t get a word in edgewise?

i. Have trouble concentrating because little things going on
around you easily got you off track?

j. Find your thoughts racing so fast that you couldn’t keep
track of them?

k. Find your thoughts racing so fast that it was hard to
follow your own thoughts?

l. Feel so restless that you fidgeted, paced, or couldn’t sit
still?

m. Become more active than usual at work, school, at home,
or in pursuing other interests?

Box

trouble - like buying things you couldn’t afford or didn’t
need, making foolish decisions about money, or driving
recklessly?

r. Do anything that you later regretted - like spending time
with people you normally wouldn’t be interested in?

s. Feel that you were an unusually important person or that
you had special gifts, powers, or abilities to do things that
most other people couldn’t do?

7

1  Yes - Mark Box 7
2  No - Go to next
experience
1  Yes - Mark Box 8
2  No - Go to next
experience

Box
8

1  Yes - Mark Box 8
2  No - Go to next
experience

1  Yes - Mark Box 8
2  No - Go to next
experience

q. Do anything unusual that could have gotten you into

5

1  Yes - Mark Box 7
2  No - Go to next
experience

o. Have sex with people you normally wouldn’t be

uncomfortable?

Box

Box
6

1  Yes - Mark Box 8
2  No - Go to next
experience

p. Become so physically restless that it made you

2

1  Yes - Mark Box 6
2  No - Go to next
experience

n. Become more sexually active than usual?

interested in?

Box

1  Yes - Mark Box 8
2  No - Go to next
experience
1  Yes - Mark Box 9
2  No - Go to next
experience

Box
9

1  Yes - Mark Box 9
2  No - Go to next
experience
1  Yes - Mark Box 10
2  No - Go to Check
Item 5.3

Box
10 

Page 2

Section 5 - HIGH MOOD (Continued)
CHECK
ITEM 5.3

Is Box 1 marked “No” and is Box 3 marked “Yes”?

1  Yes – Go to Check Item 5.3A
2  No - Go to Check Item 5.3B

CHECK
ITEM 5.3A

Are at least 4 Boxes 4-10 marked “Yes”?

1  Yes – SKIP to 7a
2  No - SKIP to Section 6

CHECK
ITEM 5.3B

Are at least 3 Boxes 4-10 marked “Yes”?

1  Yes
2  No - SKIP to Section 6

7a. Now I’d like to ask you about some things that might have
happened to you during that time when (you were the
MOST excited or elated/you felt the MOST irritable or
easily annoyed) and you ALSO felt extremely revved up or
energetic for (at least 1 week/4-6 days) and when you had
some of the other experiences you mentioned.
During that time. . .
Were you very upset by feeling extremely (excited or elated
/irritable or easily annoyed) and extremely revved up or
energetic or by any of those OTHER experiences?

1  Yes
2  No

b. Did you have any serious problems getting along with other

1  Yes
2  No

people - like arguing with your friends, family, people at
work or anyone else?

c. Did you have any serious problems doing things you were
supposed to do - like working, doing your schoolwork, or
taking care of your home or family?

1  Yes
2  No

d. Did you have trouble getting things done?

1  Yes
2  No

e. Did you have any legal trouble - like being arrested, held at

1  Yes
2  No

the police station or put in jail?

8a. About how old were you the FIRST time you BEGAN to
feel extremely (excited or elated /irritable or easily
annoyed) AND also extremely revved up or energetic for
(at least 1 week/less than 1 week) and when you also had
some of the other experiences you mentioned?

_____ Age

Refer to other experiences marked “Yes” in 6a – 7e, if
necessary.
CHECK
ITEM 5.4

Is respondent’s age in 8a within 1 year of his/her
present age or is present age or 8a unknown?

8b. Did this FIRST time BEGIN to happen during the last 12
months?

9.

In your ENTIRE LIFE, how many SEPARATE times
lasting (at least 1 week/4-6 days) were there when you felt
extremely (excited or elated/irritable or easily annoyed)
AND also extremely revved up or energetic and when you
also had some of the other experiences you mentioned?

1  Yes
2  No - SKIP to 9
1  Yes
2  No

_____ Number

By separate times, I mean times separated by at least 2
months when your mood was back to normal, AND you
DIDN’T have ANY of the OTHER experiences you
mentioned.
CHECK
ITEM 5.5

Is number in 9, 2 or more or unknown?

1  Yes
2  No - SKIP to 11e

10a. How old were you the MOST RECENT time you felt
extremely (excited or elated/irritable or easily annoyed)
AND also extremely revved up or energetic and when you
also had some of those other experiences?
CHECK
ITEM 5.6A

Is respondent’s age in 10a within 1 year of his/her
present age or is present age or 10a unknown?

10b. Did this MOST RECENT time BEGIN to happen during
the last 12 months?

_____ Age

1  Yes
2  No - SKIP to 11a
1  Yes
2  No

Page 3

Section 5 - HIGH MOOD (Continued)
11a. How long did this MOST RECENT time last when you felt
extremely (excited or elated/irritable or easily annoyed) AND
also extremely revved up or energetic?

b. Since this MOST RECENT time BEGAN, have there been at
least 2 months when your mood was back to normal AND you
DIDN’T have ANY of the OTHER experiences you
mentioned?
CHECK
ITEM 5.6B

Is 10b marked “Yes”?

11c. Did this MOST RECENT time when your mood was back to
normal BEGIN to happen in the last 12 months?

d. In your ENTIRE LIFE, what was the LONGEST time you
had when you felt extremely (excited or elated/irritable or
easily annoyed) AND also extremely revved up or energetic?

e. How long did that time last when you felt extremely (excited
or elated/irritable or easily annoyed) AND also extremely
revved up or energetic?

f.

Since that time BEGAN, have there been at least 2 months
when your mood was back to normal AND you DIDN’T have
ANY of the OTHER experiences that you mentioned?

CHECK
ITEM 5.6C

Is 8b marked “Yes”?

11g. Did this time when your mood was back to normal BEGIN to
happen in the last 12 months?
CHECK
ITEM 5.7

Refer to Check Item 2.1, Section 2A.
Is respondent a lifetime abstainer of alcohol?

12. Did (that time/ANY of those times) when you felt extremely
(excited or elated/irritable or easily annoyed) AND also
extremely revved up or energetic BEGIN to happen DURING
or within 1 month AFTER drinking heavily or a lot more
than usual?

13. Did (that time/ANY of those times) when you felt extremely
(excited or elated/irritable or easily annoyed) AND also
extremely revved up or energetic BEGIN to happen DURING
or within 1 month AFTER experiencing the bad aftereffects
of drinking?

14. Did (that time/ANY of those times) when you felt extremely
(excited or elated/irritable or easily annoyed) AND also
extremely revved up or energetic BEGIN to happen DURING
or within 1 month AFTER using a medicine or drug?

15. Did (that time/ANY of those times) when you felt extremely
(excited or elated/irritable or easily annoyed) AND also
extremely revved up or energetic BEGIN to happen DURING
or within 1 month AFTER experiencing the bad aftereffects
of a medicine or drug?

_____ Day(s)
OR
_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)
1  Yes
2  No - SKIP to 11d
1  Yes - SKIP to 11d
2  No
1  Yes
2  No
_____ Days(s)
OR
_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)

SKIP to Check Item 5.7

_____ Days(s)
OR
_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)
1  Yes
2  No - SKIP to Check Item 5.7
1  Yes - SKIP to Check Item 5.7
2  No
1  Yes
2  No
1  Yes - SKIP to 14
2  No
1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

CHECK
ITEM 5.8

Is at least 1 item marked “Yes” in 12, 13, 14
OR 15?

1  Yes
2  No - SKIP to 17a

CHECK
ITEM 5.9

Is Check Item 5.5 marked “No”?

1  Yes
2  No - SKIP to Check Item 5.10A

16a. During that time, did you STOP (drinking heavily/using
medicines and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs) for at least 1 month?

1  Yes
2  No - SKIP to 17a

Page 4

Section 5 - HIGH MOOD (Continued)
16b. Did you CONTINUE to feel extremely (excited or
elated/irritable or easily annoyed) AND also extremely
revved up or energetic for at least 1 month AFTER you
STOPPED (drinking heavily/using medicines and drugs/
experiencing the bad aftereffects of drinking/medicines and
drugs)?
CHECK
ITEM 5.10A

Is 8b marked “Yes” or 10b marked “Yes”?

16c. Did ALL of the times when you felt extremely (excited or
elated/irritable or easily annoyed) AND also extremely
revved up or energetic in the last 12 months ONLY BEGIN
to happen during or within 1 month after (drinking
heavily/using any medicines or drugs/experiencing the bad
aftereffects of drinking/medicines or drugs)?

d. During ANY of those times in the last 12 months when you
felt extremely (excited or elated/irritable or easily annoyed)
AND also extremely revved up or energetic after (drinking
heavily/using any medicines or drugs), did you STOP
(drinking heavily/using medicines and drugs/experiencing
the bad aftereffects of drinking/medicines and drugs) for at
least 1 month?

e. During ALL of those times, did you STOP (drinking
heavily/using medicines and drugs/experiencing the bad
aftereffects of drinking/medicines and drugs)?

f. Did you CONTINUE to feel extremely (excited or
elated/irritable or easily annoyed) AND also extremely
revved up or energetic for at least 1 month AFTER ANY of
those times in the last 12 months when you STOPPED
(drinking heavily/using medicines and drugs/experiencing
the bad aftereffects of drinking/medicines and drugs)?
CHECK
ITEM 5.10B

Is 8b marked “Yes”?

16g. Did ALL of the times when you felt extremely (excited or
elated/irritable or easily annoyed) AND also extremely
revved up or energetic BEFORE 12 months ago ONLY
BEGIN to happen during or within 1 month after
(drinking heavily/using any medicines or drugs/
experiencing the bad aftereffects of drinking/medicines or
drugs)?

h. During ANY of those times BEFORE 12 months ago when
you felt extremely (excited or elated/irritable or easily
annoyed) AND also extremely revved up or energetic after
(drinking heavily/using any medicines or drugs), did you
STOP (drinking heavily/using medicines and
drugs/experiencing the bad aftereffects of
drinking/medicines and drugs) for at least 1 month?

i. During ALL of those times, did you STOP (drinking
heavily/using medicines and drugs/experiencing the bad
aftereffects of drinking/medicines and drugs)?

1  Yes
SKIP to 17a
2  No

1  Yes
2  No - SKIP to 16g
1  Yes
2  No - SKIP to Check Item 5.10B

1  Yes
2  No - SKIP to Check Item 5.10B

1  Yes
2  No

1  Yes
2  No

1  Yes - SKIP to 17a
2  No
1  Yes
2  No - SKIP to 17a

1  Yes
2  No - SKIP to 17a

1  Yes
2  No

Page 5

Section 5 - HIGH MOOD (Continued)
16j. Did you CONTINUE to feel extremely (excited or
elated/irritable or easily annoyed) AND also extremely
revved up or energetic for at least 1 month AFTER ANY
of those times BEFORE 12 months ago when you
STOPPED (drinking heavily/using medicines and
drugs/experiencing the bad aftereffects of
drinking/medicines and drugs)?

17a. Did you EVER talk to any health professional like a
psychiatrist, other medical doctor, psychologist, social
worker or any other kind of counselor or therapist to calm
down or feel better when you felt extremely (excited or
elated/irritable or easily annoyed) AND also extremely
revved up or energetic?

b. Did you EVER go to a self-help or support group, use a
hotline or visit an internet chat room for help to feel better
when you felt extremely (excited or elated/irritable or
easily annoyed) AND also extremely revved up or
energetic?

18a. Were you EVER a patient in any kind of hospital
overnight or longer because you felt extremely (excited or
elated/irritable or easily annoyed) AND also extremely
revved up or energetic?

b. Did you EVER go to an emergency room for help at any
time when you felt extremely (excited or elated/irritable or
easily annoyed) AND also extremely revved up or
energetic?

19. Did a doctor EVER prescribe any medicines or drugs to
help you calm down or feel better?
CHECK
ITEM 5.11

Is at least 1 item marked “Yes” in 17a - 19?

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No
1  Yes
2  No - SKIP to Check Item 5.13

20. About how old were you the FIRST time you went
anywhere or talked to anyone to get help for feeling
extremely (excited or elated/irritable or easily annoyed)
AND also extremely revved up or energetic?
CHECK
ITEM 5.12

Is age in 20 equal to respondent’s present age?

21. Did you go anywhere or talk to anyone in the last 12
months?
CHECK
ITEM 5.12A

Is age in 20 at least 2 years less than respondent’s
present age?

22. Did you go anywhere or talk to anyone before 12 months
ago, that is, BEFORE last (Month one year ago)?
CHECK
ITEM 5.13

Is Check Item 5.5 marked “No”?

23a. Did that time when you felt extremely (excited or
elated/irritable or easily annoyed) AND also extremely
revved up or energetic BEGIN to happen DURING a
time when you were physically ill or getting over being
physically ill?

b. Did a doctor or other health professional tell you that
this time was related to your physical illness or medical
condition?
CHECK
ITEM 5.14

Is 8b marked “Yes” or 10b marked “Yes”?

_____ Age

1  Yes - SKIP to Check Item 5.13
2  No
1  Yes
2  No - SKIP to Check Item 5.13
1  Yes - SKIP to Check Item 5.13
2  No
1  Yes
2  No
1  Yes
2  No - SKIP to Check Item 5.14
1  Yes
2  No - SKIP to 24a1

1  Yes
2  No

SKIP to 24a1

1  Yes
2  No - SKIP to 23e

Page 6

Section 5 - HIGH MOOD (Continued)
23c. Did ALL of those times when you felt extremely (excited
or elated/irritable or easily annoyed) AND also extremely
revved up or energetic in the last 12 months ONLY
BEGIN to happen DURING times when you were
physically ill or getting over being physically ill?

d. Did a doctor or other health professional tell you that
ALL of the times like this were related to your physical
illness or medical condition?
CHECK
ITEM 5.15

Is 8b marked “Yes”?

23e. Did ALL of those times BEFORE 12 months ago when
you felt extremely (excited or elated/irritable or easily
annoyed) AND also extremely revved up or energetic
ONLY BEGIN to happen DURING times when you were
physically ill or getting over being physically ill?

f. Did a doctor or other health professional tell you that
ALL of the times like this were related to your physical
illness or medical condition?

1  Yes
2  No - SKIP to Check Item 5.15

1  Yes
2  No
1  Yes - SKIP to 24a1
2  No
1  Yes
2  No - SKIP to 24a1

1  Yes
2  No

24a. Now I’d like to know about some other experiences that may

b. Did this happen c. Did this happen
during ANY of those during ANY of those
times when you felt times that BEGAN
(excited or
BEFORE 12 months
elated/irritable or
ago?
easily annoyed) AND
also extremely
revved up or
energetic that
BEGAN in the last
12 months?

have happened during (that time/ANY of those times) when
you felt (excited or elated/irritable or easily annoyed) AND
also extremely revved up or energetic.
During (that time/ANY of those times), please tell me if you
had ANY of the following experiences nearly every day.
Did you…
(Repeat phrase frequently.)

1  Yes
1  Yes
(1) Feel sad, blue, depressed or down nearly every day? 1  Yes
2  No - Go to next 2  No - Go to next 2  No
experience

(2) Not care about things or enjoy things you usually
cared about or enjoyed?

experience

1  Yes
1  Yes
1  Yes
2  No - Go to next 2  No - Go to next 2  No
experience
experience

1  Yes
1  Yes
(3) Feel tired nearly all the time or get tired easily, even 1  Yes
though you weren’t doing more than usual?
2  No - Go to next 2  No - Go to next 2  No
experience

(4) Feel so tired nearly all the time that even small
things took a lot of effort?

(5) Move or talk MUCH more slowly than usual?

experience

1  Yes
1  Yes
1  Yes
2  No - Go to next 2  No - Go to next 2  No
experience
experience
1  Yes
1  Yes
1  Yes
2  No - Go to next 2  No - Go to next 2  No
experience
experience

Page 7

Section 5 - HIGH MOOD (Continued)
24a. During (that time/ANY of those times), did you …

b. Did this happen
c. Did this happen
during ANY of those during ANY of those
times when you felt times that BEGAN
(excited or
BEFORE 12 months
elated/irritable or
ago?
easily annoyed) AND
also extremely revved
up or energetic that
BEGAN in the last 12
months?

(Repeat phrase frequently.)

(6) Feel worthless nearly every day?

1  Yes
1  Yes
2  No - Go to next 2  No - Go to next
experience
experience

1  Yes
2  No

(7) Feel guilty about things you normally wouldn’t feel

1  Yes
1  Yes
2  No - Go to next 2  No - Go to next
experience
experience

1  Yes
2  No

(8) Feel useless or good for nothing?

1  Yes
1  Yes
2  No - Go to next 2  No - Go to next
experience
experience

1  Yes
2  No

(9) Attempt suicide?

1  Yes
1  Yes
2  No - Go to next 2  No - Go to next
experience
experience

1  Yes
2  No

(10) Think about committing suicide?

1  Yes
1  Yes
2  No - Go to next 2  No - Go to next
experience
experience

1  Yes
2  No

(11) Feel like you wanted to die?

1  Yes
1  Yes
2  No - Go to next 2  No - Go to next
experience
experience

1  Yes
2  No

(12) Think a lot about your own death?

1  Yes
2  No - Go to
Check Item
5.15A

1  Yes
2  No

guilty about?

1  Yes
2  No - Go to
Check Item 5.15A

CHECK
ITEM 5.15A

Is “Yes” marked in Check Item 5.5?

1  Yes
2  No - SKIP to 29a1

CHECK
ITEM 5.16

Are at least 3 Boxes marked “Yes” in 24 column b?

1  Yes
2  No - SKIP to Check Item 5.17

26a. Did SOME of these experiences we just talked about happen
nearly every day DURING ANY period in the last 12
months when you felt (excited or elated/irritable or easily
annoyed) AND also extremely revved up or energetic?

26b. Did SOME of these experiences happen nearly every day
DURING ALL of those periods in the last 12 months when
you felt (excited or elated/irritable or easily annoyed) AND
also extremely revved up or energetic?
CHECK
ITEM 5.17

1  Yes
2  No - SKIP to Check Item 5.17

1  Yes
2  No

Are at least 3 Boxes marked “Yes” in 24 column c?

1  Yes
2  No - SKIP to 29a1

27. Did SOME of the experiences we just talked about happen

1  Yes
2  No - SKIP to 29a1

nearly every day DURING ANY period BEFORE12 months
ago when you felt (excited or elated/irritable or easily
annoyed) AND also extremely revved up or energetic?

28. Did SOME of these experiences happen nearly every day
DURING ALL of those periods BEFORE12 months ago
when you felt (excited or elated/irritable or easily annoyed)
AND also extremely revved up or energetic?

1  Yes
2  No

Page 8

Section 5 - HIGH MOOD (Continued)
29a. Now I’d like to know about some other experiences that may

b. Did this happen
c. Did this happen
during ANY of those during ANY of those
times when you felt times that BEGAN
(excited or
BEFORE 12 months
elated/irritable or
ago?
easily annoyed) AND
also extremely revved
up or energetic that
BEGAN in the last 12
months?

have happened during (that time/ANY of these times) when
you felt (excited or elated/irritable or easily annoyed) AND
also extremely revved up or energetic.
During (that time/ANY of those times), please tell me if you
had ANY of the following experiences nearly every day.
Did you…

(Repeat phrase frequently.)

(1)

Worry a lot about things even though you knew it
was unreasonable?

1  Yes
1  Yes
2  No - Go to next 2  No - Go to next
Experience
experience

1  Yes
2  No

(2)

Feel uneasy?

1  Yes
1  Yes
2  No - Go to next 2  No - Go to next
Experience
experience

1  Yes
2  No

(3)

Feel extremely nervous?

1  Yes
1  Yes
2  No - Go to next 2  No - Go to next
Experience
experience

1  Yes
2  No

(4)

Feel like something terrible might happen?

1  Yes
1  Yes
2  No - Go to next 2  No - Go to next
Experience
experience

1  Yes
2  No

(5)

Find it difficult to sit still or find yourself fidgeting
or pacing?

1  Yes
2  No - Go to
Check Item 5.17A

1  Yes
2  No

1  Yes
2  No - Go to
Check Item 5.17A

CHECK
ITEM 5.17A

Is “Yes” marked in Check Item 5.5?

1  Yes
2  No - SKIP to Section 6

CHECK
ITEM 5.18

Are at least 2 items marked “Yes” in 29 column b?

1  Yes
2  No - SKIP to Check Item 5.19

31a. Did SOME of these experiences we just talked about happen
nearly every day DURING ANY period in the last 12 months
when you felt (excited or elated/irritable or easily annoyed)
AND also extremely revved up or energetic?

31b. Did SOME of these experiences happen nearly every day
DURING ALL of those periods in the last 12 months when
you felt (excited or elated/irritable or easily annoyed) AND
also extremely revved up or energetic?
CHECK
ITEM 5.19

1  Yes
2  No - SKIP to Check Item 5.19

1  Yes
2  No

Are at least 2 items marked “Yes” in 29 column c?

1  Yes
2  No - SKIP to Section 6

Did SOME of the experiences we just talked about happen

1  Yes
2  No - SKIP to Section 6

32. nearly every day DURING ANY period BEFORE 12 months
ago when you felt (excited or elated/irritable or easily
annoyed) AND also extremely revved up or energetic?
Did SOME of these experiences happen nearly every day

33. DURING ALL of those periods BEFORE 12 months ago

when you felt (excited or elated/irritable or easily annoyed)
AND also extremely revved up or energetic?

1  Yes
2  No

Go to Section 6

Page 9

Section 6 – ANXIETY
Statement O

Now I’d like to ask you about feelings of nervousness that you might have experienced at some time in your
life.

1.

Have you EVER had a panic attack, when ALL OF A
SUDDEN you felt extremely frightened or
uncomfortable, overwhelmed or nervous, almost as if
you were in great danger, but really weren’t?

1  Yes
2  No

2.

Were you EVER very surprised by a panic attack that
happened totally out-of-the-blue, for no real reason, or
in a situation where you didn’t expect to be frightened
or nervous?

1  Yes
2  No

3.

Did you EVER think you were having a heart attack,
but the doctor said it was just nerves or you were
having a panic attack?

1  Yes
2  No

CHECK
ITEM 6.1

4.

Is at least 1 item marked “Yes” in 1 - 3?

1  Yes
2  No - SKIP to 29

Did you have at least 2 panic attacks that happened
out-of-the-blue, for no real reason?

1  Yes
2  No – SKIP to 29

6a. Now I’d like you to think about the time when you
were having your worst panic attacks that happened
OUT-OF-THE-BLUE. By worst panic attacks, I mean
the ones that made you the most frightened,
uncomfortable, nervous, or overwhelmed.
During your worst panic attacks did you . . .
(Repeat phrase frequently)
Have trouble catching your breath, feel short of
breath, or feel like you were smothering?

1  Yes
2  No

b. Feel your heart racing, pounding or skipping?

1  Yes
2  No

c. Tremble or shake?

1  Yes
2  No

d. Perspire or sweat?

1  Yes
2  No

e. Feel as if you were choking?

1  Yes
2  No

f. Feel dizzy, lightheaded, unsteady or as if you might

1  Yes
2  No

faint?

g. Feel that things around you seemed unreal?

1  Yes
2  No

h. Feel that you were detached from the things around

1  Yes
2  No

you?

i.

Have tingling or numbness in any part of your body?

1  Yes
2  No

j. Have chills or feel hot?

1  Yes
2  No

k. Feel nauseous, have an upset stomach, or feel you

1  Yes
2  No

might vomit or have diarrhea?

l.

Have pain or pressure in your chest?

1  Yes
2  No

m. Feel like you might go crazy or lose control?

1  Yes
2  No

n. Feel like you might die?

1  Yes
2  No

Page 1

Section 6 - ANXIETY (Continued)
CHECK
ITEM 6.2

Is at least 1 item marked “Yes” in 6a – n?

1  Yes
2  No – SKIP to 29

CHECK
ITEM 6.3

Are at least 4 items marked “Yes” in 6a – 6n?

1  Yes
2  No - SKIP to 29

7. During the time you were having your worst panic
attacks, did at least 4 of the experiences you mentioned
begin suddenly and become very intense within minutes?

8a. During that worst time, did you have at least two
separate panic attacks when at least 4 of these
experiences became very intense within minutes after
they started?

8b. After your worst panic attacks did you worry for at least
1 month that you might have another one?

9. After having your worst panic attacks, did you worry a
lot for at least 1 month about what might happen if you
DID have another panic attack, like losing control,
having a heart attack or going crazy, or having some of
the other experiences related to having a panic attack?

10. Did you make any major changes in your everyday life,
usual activities, or future plans for at least 1 month after
you had your worst panic attacks, like changing your
behavior to avoid or reduce the likelihood you would
have another attack?

1  Yes
2  No
1  Yes
2  No

1  Yes
2  No
1  Yes
2  No

1  Yes
2  No

11a. Now I’d like to ask you about some other things that may
have happened to you after you had your worst panic
attacks.
After those worst panic attacks. . .
Were you very upset by your panic attacks or by any of
these other experiences?

b. Did you have any serious problems getting along with
other people - like arguing with them or avoiding them
more than usual?

c. Did you have any serious problems doing things you
were supposed to do - like working, doing your
schoolwork, or taking care of your home or family?

d. Did you restrict your usual activities in any way because
of your panic attacks?

e. Was there anything you were unable to do because of
your panic attacks?

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No

12a. About how old were you the FIRST time you BEGAN to
have panic attacks along with some of the other
experiences you told me about?

_____ Age

Refer to experiences marked “Yes” in 6(a) - (n) and 7 - 11e,
if necessary.
CHECK
ITEM 6.4

Is respondent’s age in 12a within 1 year of his/her
present age or is present age or 12a unknown?

12b. Did this FIRST time when you were having panic attacks
BEGIN to happen during the last 12 months?

c. After your first attacks, did you worry a lot about having
another one for at least 1 month (PAUSE) or make a
change in your everyday life or future plans as the result
of having a panic attack?

1  Yes
2  No - SKIP to 12c
1  Yes
2  No
1  Yes
2  No

13. In your ENTIRE LIFE, about how many SEPARATE
times were there when you were having panic attacks
along with some of those other experiences you
mentioned?

_____ Number

By separate times, I mean times separated by at least 2
months when you DIDN’T have any panic attacks.
Page 2

Section 6 - ANXIETY (Continued)
CHECK
ITEM 6.5

Is number in 13, 2 or more or unknown?

1  Yes
2  No - SKIP to 15e

14a. How old were you the MOST RECENT time you BEGAN
to have panic attacks along with some of the other
experiences you mentioned?
CHECK
ITEM 6.6A

Is respondent’s age in 14a within 1 year of his/her
present age or is present age or 14a unknown?

14b. Did this MOST RECENT time BEGIN to happen during
the last 12 months?

c. After these MOST RECENT attacks, did you worry about
having another one for at least 1 month (PAUSE) or make a
change in your everyday life or plans as the result of having
the attacks?

15a. How long did this MOST RECENT time last when you
were experiencing panic attacks, that is from the time the
most recent period began to the time the attacks completely
stopped for at least 2 months?

b. Since this MOST RECENT time when your panic attacks
BEGAN, have there been at least 2 months when you
DIDN’T have ANY panic attacks?
CHECK
ITEM 6.6B

Is 14b marked “Yes”?

15c. Did this MOST RECENT time you DIDN’T have ANY
panic attacks for at least 2 months BEGIN to happen in the
last 12 months?

d. In your ENTIRE LIFE, what was the LONGEST period
you had when you were having panic attacks, that is, from
the time that period began to the time the attacks stopped
completely for at least 2 months?

e. How long did that time last when you were having panic
attacks, that is, from the time the first panic attack
happened to the time the attacks stopped completely for at
least 2 months?

f. Since that time when your panic attacks BEGAN, have
there been at least 2 months when you DIDN’T have ANY
panic attacks?
CHECK
ITEM 6.6C

Is 12b marked “Yes”?

15g. Did that time when you DIDN’T have ANY panic attacks for
at least 2 months BEGIN to happen in the last 12 months?
CHECK
ITEM 6.7

Refer to Check Item 2.1, Section 2A.
Is respondent a lifetime abstainer of alcohol?

16. Did (that time/ANY of those times) when you were having
panic attacks BEGIN to happen DURING or within 1
month AFTER drinking heavily or a lot more than usual?

17. Did (that time/ANY of those times) when you were having
panic attacks BEGIN to happen DURING or within 1
month AFTER experiencing the bad aftereffects of
drinking?

_____ Age
1  Yes
2  No - SKIP to 14c
1  Yes
2  No
1  Yes
2  No

_____ Day(s)
OR
_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)
1  Yes
2  No - SKIP to 15d
1  Yes - SKIP to 15d
2  No
1  Yes
2  No
_____ Day(s)
OR
_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)

SKIP to Check Item 6.7

_____ Day(s)
OR
_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)
1  Yes
2  No - SKIP to Check Item 6.7
1  Yes - SKIP to Check Item 6.7
2  No
1  Yes
2  No
1  Yes - SKIP to 18
2  No
1  Yes
2  No
1  Yes
2  No

Page 3

Section 6 - ANXIETY (Continued)
18. Did (that time/ANY of those times) when you were having
panic attacks BEGIN to happen DURING or within 1 month
AFTER using a medicine or drug?

19. Did (that time/ANY of those times) when you were having
panic attacks BEGIN to happen DURING or within 1 month
AFTER experiencing the bad aftereffects of a medicine or
drug?
CHECK
ITEM 6.8
CHECK
ITEM 6.9

Is at least 1 item marked “Yes” in 16, 17, 18
OR 19?
Is Check Item 6.5 marked “No”?

20a. During that time did you STOP (drinking heavily/using
medicines and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs) for at least 1 month?

b.

Did you CONTINUE to have panic attacks for at least 1
month AFTER you STOPPED (drinking heavily/using
medicines and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs)?

CHECK
ITEM 6.10

Is 12b marked “Yes” or 14b marked “Yes”?

20c. Did ALL of the times when you were having panic attacks in
the last 12 months ONLY BEGIN to happen during or
within 1 month after (drinking heavily/using any medicines
or drugs/experiencing the bad aftereffects of
drinking/medicines or drugs)?

d.

During ANY of those times in the last 12 months when you
were having panic attacks after (drinking heavily/ using any
medicines or drugs), did you STOP (drinking heavily/using
medicines and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs) for at least 1 month?

e.

During ALL of those times, did you STOP (drinking
heavily/using medicines and drugs/experiencing the bad
aftereffects of drinking/medicines and drugs)?

f.

Did you CONTINUE to have panic attacks for at least 1
month AFTER ANY of those times in the last 12 months
when you STOPPED (drinking heavily/using medicines and
drugs/experiencing the bad aftereffects of
drinking/medicines and drugs)?

CHECK
ITEM 6.10A

Is 12b marked “Yes”?

20g. Did ALL of the times when you were having panic attacks
BEFORE 12 months ago ONLY BEGIN to happen during
or within 1 month after (drinking heavily/using any
medicines or drugs/experiencing the bad aftereffects of
drinking/ medicines or drugs)?

h.

During ANY of those times BEFORE 12 months ago when
you were having panic attacks after (drinking heavily/using
any medicines or drugs), did you STOP (drinking
heavily/using medicines and drugs/experiencing the bad
aftereffects of drinking/medicines and drugs) for at least 1
month?

1  Yes
2  No
1  Yes
2  No

1  Yes
2  No - SKIP to 21a
1  Yes
2  No - SKIP to Check Item 6.10
1  Yes
2  No - SKIP to 21a

1  Yes
SKIP to 21a
2  No
1  Yes
2  No - SKIP to 20g
1  Yes
2  No - SKIP to Check Item 6.10A

1  Yes
2  No - SKIP to Check Item 6.10A

1  Yes
2  No

1  Yes
2  No

1  Yes - SKIP to 21a
2  No
1  Yes
2  No - SKIP to 21a

1  Yes
2  No - SKIP to 21a

i.

During ALL of those times, did you STOP (drinking
heavily/using medicines and drugs/experiencing the bad
aftereffects of drinking/medicines and drugs)?

1  Yes
2  No

j.

Did you CONTINUE to have panic attacks for at least 1
month AFTER ANY of those times BEFORE 12 months ago
when you STOPPED (drinking heavily/using medicines and
drugs/experiencing the bad aftereffects of
drinking/medicines and drugs)?

1  Yes
2  No

21a. Did you EVER talk to any health professional like a
psychiatrist, other medical doctor, psychologist, social
worker or any other kind of counselor or therapist to get
help for panic attacks?

1  Yes
2  No

Page 4

Section 6 - ANXIETY (Continued)
21b. Did you EVER go to a self-help or support group, use a
hotline, or visit an internet chat room to get help for
panic attacks?

22. Did you EVER go to an emergency room to get help for
your panic attacks?

23. Were you EVER a patient in any kind of hospital
overnight or longer because of your panic attacks?

24. Did a doctor EVER prescribe any medicines or drugs for
your panic attacks?
CHECK
ITEM 6.11

25. How old were you the FIRST time you went anywhere or
talked to anyone to get help for panic attacks?
Is age in 25 equal to respondent’s current age?

26. Did you go anywhere or talk to anyone in the last 12
months?
CHECK
ITEM 6.12A

Is age in 25 at least 2 years less than respondent’s
current age?

27. Did you go anywhere or talk to anyone before 12 months
ago, that is, BEFORE last (Month one year ago)?
CHECK
ITEM 6.13

Is Check Item 6.5 marked “No”?

28a. Did your panic attacks BEGIN to happen DURING a
time when you where physically ill or getting over being
physically ill?

b.

Did a doctor or other health professional tell you that
these panic attacks were related to your physical illness
or medical condition?

CHECK
ITEM 6.14

Is 12b marked “Yes” or 14b marked “Yes”?

c. Did ALL of those panic attacks that you had in the last
12 months ONLY BEGIN to happen DURING times
when you were physically ill or getting over being
physically ill?

d. Did a doctor or other health professional tell you that
ALL of the panic attacks you had like this were related
to your physical illness or medical condition?
CHECK
ITEM 6.15

Is 12b marked “Yes”?

e. Did ALL of those panic attacks you had BEFORE 12
months ago ONLY BEGIN to happen DURING times
when you were physically ill or getting over being
physically ill?

f.

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No

Is at least 1 item marked “Yes” in 21a - 24?
Did respondent ever seek help for their panic
attacks?

CHECK
ITEM 6.12

1  Yes
2  No

Did a doctor or other health professional tell you that
ALL of the panic attacks you had like this were related
to your physical illness or medical condition?

29. Now I’d like to ask you about other times you may have
had panic attacks that did NOT happen out-of-the-blue.
That is, did you EVER have a panic attack that you
EXPECTED in a specific situation or around certain
objects that usually made you feel very frightened,
uncomfortable, overwhelmed or nervous?

1  Yes
2  No - SKIP to Check Item 6.13

_____ Age
1  Yes - SKIP to Check Item 6.13
2  No
1  Yes
2  No - SKIP to Check Item 6.13
1  Yes - SKIP to Check Item 6.13
2  No
1  Yes
2  No
1  Yes
2  No - SKIP to Check Item 6.14
1  Yes
2  No - SKIP to 29
1  Yes
2  No

SKIP to 29

1  Yes
2  No - SKIP to 28e
1  Yes
2  No - SKIP to Check Item 6.15

1  Yes
2  No
1  Yes - SKIP to 29
2  No
1  Yes
2  No - SKIP to 29

1  Yes
2  No
1  Yes
2  No – SKIP to Section 6a

Page 5

Section 6 - ANXIETY (Continued)
CHECK
ITEM 6.16

Is Item 7 marked “Yes”?

1  Yes - SKIP to Section 6a
2  No

30a. Now I’d like you to think about the time when you were
having your WORST panic attacks that were ENTIRELY
EXPECTED. By worst panic attacks, I mean the ones that
made you the most frightened, uncomfortable, nervous, or
overwhelmed and that happened when you were in specific
situations or around certain objects.
During your worst EXPECTED panic attacks did you . . .
(Repeat phrase frequently)
Have trouble catching your breath, feel short of breath, or
feel like you were smothering?

1  Yes
2  No

b. Feel your heart racing, pounding or skipping?

1  Yes
2  No

c. Tremble or shake?

1  Yes
2  No

d. Perspire or sweat?

1  Yes
2  No

e. Feel as if you were choking?

1  Yes
2  No

f. Feel dizzy, lightheaded, unsteady or as if you might faint?

1  Yes
2  No

g. Feel that things around you seemed unreal?

1  Yes
2  No

h. Feel that you were detached from the things around you?

1  Yes
2  No

Have tingling or numbness in any part of your body?

1  Yes
2  No

i.

j. Have chills or feel hot?

1  Yes
2  No

k. Feel nauseous, have an upset stomach, or feel you might

1  Yes
2  No

vomit or have diarrhea?

l. Have pain or pressure in your chest?

1  Yes
2  No

m. Feel like you might go crazy or lose control?

1  Yes
2  No

n. Feel like you might die?

1  Yes
2  No

CHECK
ITEM 6.17

Is at least 1 item marked “Yes” in 30a - n?

1  Yes
2  No - SKIP to Section 6A

CHECK
ITEM 6.18

Are at least 4 items marked “Yes” in 30a - n?

1  Yes
2  No - SKIP to Section 6A

31. During the time you were having your worst EXPECTED
panic attacks, did at least 4 of the experiences you just
mentioned begin suddenly and become very intense
within minutes?

1  Yes
2  No

Go to Section 6A

Page 6

Section 6a - SPECIFIC ANXIETY
Statement P

Now I’d like to ask you about some specific situations which may have made you nervous at some time in your
life.

1a. Some people have such a strong fear of SPECIFIC
SITUATIONS that they become extremely anxious or
frightened in such situations or they try to avoid them.
Were you EVER very anxious or frightened in any of the
following SITUATIONS?
(Repeat phrase frequently)
Being in stores?

1  Yes
2  No

b. Being at a movie or in another kind of theater?

1  Yes
2  No

c. Being outside your home alone?

1  Yes
2  No

d. Being around crowds?

1  Yes
2  No

e. Standing in lines?

1  Yes
2  No

f.

1  Yes
2  No

Being in wide open places, like a field, parking lot, or
mall?

g. Traveling on a train?

1  Yes
2  No

h. Traveling on a bus?

1  Yes
2  No

i.

Traveling on a ship?

1  Yes
2  No

j.

Traveling on a plane?

1  Yes
2  No

k. Being in any other place or situation because you might
feel extremely anxious or frightened?
CHECK
ITEM 6.20

Are at least 2 items marked “Yes” in 1a - k?

2a. When you found yourself in any of these situations, did
you ALWAYS become very anxious or frightened?

2b. When you were in any of these situations because you
3.

1  Yes
2  No

1  Yes
2  No - SKIP to Section 7
1  Yes
2  No

had to be there, were you very anxious or frightened the
whole time?

1  Yes
2  No

When you had to be in any of these situations, did you
need to bring someone along with you because you were
so anxious or frightened?

1  Yes
2  No

4a. Did you EVER avoid any of these situations because of
your anxiety or strong fear of them?

b. Did you EVER feel that your fear, anxiety or avoidance
of any of these situations was out of proportion in
relation to the actual danger of the situation?

c. Did you EVER feel that your fear, anxiety or avoidance
of any of these situations was excessive or unrealistic,
that is, in excess of the actual danger of the situation?
CHECK
ITEM 6.20A

Is “Yes” marked in Item 7 or Item 31, Section 6?

5a. When you were in any of these situations, did you EVER
have a panic attack?

Specify _______________________

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No - SKIP to Check Item 6.20B
1  Yes – SKIP to 5c
2  No – SKIP to 5b

Page 1

Section 6a - SPECIFIC ANXIETY (Continued)
CHECK
ITEM 6.20B

Is “Yes” marked in Check Item 6.2 or Check Item
6.17, Section 6?

5b. When you were in any of these situations, did you EVER
experience ANY of the symptoms of a panic attack?

c. Were you EVER very anxious or frightened of any of
these situations because you were afraid of losing control
or having a panic attack or panic symptoms?

d. Were you EVER very anxious or frightened of any of
these situations because you might not be able to find
help if you lost control or had a panic attack or panic
symptoms?

6a. Were you EVER very anxious or frightened of any of
these situations because you might not be able to get
away if you lost control or had a panic attack or panic
symptoms?

b. Did you EVER avoid any of these situations because you
were afraid of losing control or having a panic attack or
panic symptoms?

1  Yes
2  No - SKIP to 5c
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

7a. Did your fear, anxiety or avoidance of these situations
EVER . . .
(Repeat phrase frequently)
Make you feel very upset?

b. Interfere with your relationships with other people - like
arguing with them or avoiding them?

c. Make you avoid seeing or talking with people because
you didn’t want to be around them as much as usual?

d. Interfere with doing things you were supposed to do - like
working, doing your schoolwork, or taking care of your
home or family?

e. Restrict your usual activities in any way or keep you
from doing something you wanted to do?

f. Make you depend on others to take care of your everyday
responsibilities or to give you lots of attention or
comfort?

8a. About how old were you the FIRST time you BEGAN to
experience a strong fear, anxiety or avoidance of any of
these situations?
CHECK
ITEM 6.21

Is respondent’s age in 8a within 1 year of his/her
present age or is present age or age in 8a unknown?

8b. Did this FIRST time BEGIN to happen during the last 12
months?

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No

_____ Age

1  Yes
2  No - SKIP to 8c
1  Yes
2  No

c. In your ENTIRE LIFE, how many SEPARATE times
were there when you had a strong fear, anxiety or
avoidance of any of these situations?

_____ Number

By separate times, I mean times separated by at least 2
months when you WEREN’T afraid or anxious of any of
these situations and you DIDN’T try to avoid them.
If respondent says “All my life” or “There was never a time
when I didn’t fear or avoid situation”, code 1.
CHECK
ITEM 6.22

Is number entered in 8c, 2 or more or unknown?

9a. How old were you the MOST RECENT time you BEGAN
to experience a strong fear, anxiety or avoidance of any of
these situations?

1  Yes
2  No - SKIP to 11a
_____ Age

Page 2

Section 6a - SPECIFIC ANXIETY (Continued)
CHECK
ITEM 6.23

Is respondent’s age in 9a within 1 year of his/her
present age or is present age or age in 9a unknown?

9b. Did this MOST RECENT time when you were very anxious
or frightened of any of these situations or you avoided them
BEGIN to happen during the last 12 months?

10a. How long did this MOST RECENT time last when you
were very anxious or frightened of any of these situations
or tried to avoid them?

b. Since the MOST RECENT time BEGAN, have there been
at least 2 months when you WEREN’T anxious or
frightened of any of these situations and you DIDN’T try to
avoid them?
CHECK
ITEM 6.24

Is 9b marked “Yes”?

10c. Did this MOST RECENT time when you WEREN’T
anxious or frightened of any of these situations and you
DIDN’T try to avoid them BEGIN to happen during the
last 12 months?

d. In your ENTIRE LIFE, what was the LONGEST period
you had when you were anxious or frightened of any of
these situations or you tried to avoid them?

11a. How long did that period last when you were anxious or
frightened of any of these situations or you tried to avoid
them?

b. Since that time BEGAN, have there been at least 2 months
when you WEREN’T anxious or frightened of any of these
situations and you DIDN’T try to avoid them?
CHECK
ITEM 6.25

Is 8b marked “Yes”?

11c. Did that time when you WEREN’T anxious or frightened of
any of these situations and you DIDN’T try to avoid them
BEGIN to happen during the last 12 months?
CHECK
ITEM 6.26

Refer to Check Item 2.1, Section 2A.
Is respondent a lifetime abstainer of alcohol?

12. Did (that time/ANY of those times) when you had a strong
fear, anxiety or avoidance of these situations BEGIN to
happen DURING or within 1 month AFTER drinking
heavily or a lot more than usual?

13. Did (that time/ANY of those times) when you had a strong
fear, anxiety or avoidance of these situations BEGIN to
happen DURING or within 1 month AFTER experiencing
the bad aftereffects of drinking?

14. Did (that time/ANY of those times) when you had a strong
fear, anxiety or avoidance of these situations BEGIN to
happen DURING or within 1 month AFTER using a
medicine or drug?

15. Did (that time/ANY of those times) when you had a strong
fear, anxiety or avoidance of these situations BEGIN to
happen DURING or within 1 month AFTER experiencing
the bad aftereffects of a medicine or drug?

1  Yes
2  No - SKIP to 10a
1  Yes
2  No
_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)
1  Yes
2  No - SKIP to 10d

1  Yes - SKIP to 10d
2  No
1  Yes
2  No

_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)

SKIP to Check Item 6.26

_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)
1  Yes
2  No - SKIP to Check Item 6.26
1  Yes - SKIP to Check Item 6.26
2  No
1  Yes
2  No
1  Yes - SKIP to 14
2  No
1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

CHECK
ITEM 6.27

Is at least 1 item marked “Yes” in 12, 13, 14
OR 15?

1  Yes
2  No - SKIP to 17a

CHECK
ITEM 6.28

Is Check Item 6.22 marked “No”?

1  Yes
2  No - SKIP to Check Item 6.29
Page 3

Section 6a - SPECIFIC ANXIETY (Continued)
16a. During that time, did you STOP (drinking heavily/using
medicines and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs) for at least 1 month?

b. Did you CONTINUE to have a strong fear or avoidance of
any of these situations for at least 1 month AFTER you
STOPPED (drinking heavily/using medicines and
drugs/experiencing the bad aftereffects of drinking/medicines
and drugs)?
CHECK
ITEM 6.29

Is 8b marked “Yes” or 9b marked “Yes”?

16c. Did ALL of the times when you had a strong fear, anxiety or
avoidance of these situations in the last 12 months ONLY
BEGIN to happen during or within 1 month after (drinking
heavily/using any medicines or drugs/experiencing the bad
aftereffects of drinking/medicines or drugs)?

d. During ANY of those times in the last 12 months when you
had a strong fear, anxiety or avoidance of these situations
after (drinking heavily/using any medicines or drugs), did
you STOP (drinking heavily/using medicines and
drugs/experiencing the bad aftereffects of
drinking/medicines and drugs) for at least 1 month?

e.

During ALL of those times, did you STOP (drinking
heavily/using medicines and drugs/experiencing the bad
aftereffects of drinking/medicines and drugs)?

f.

Did you CONTINUE to have a strong fear, anxiety or
avoidance of any of these situations for at least 1 month
AFTER ANY of those times in the last 12 months when you
STOPPED (drinking heavily/using medicines and drugs/
experiencing the bad aftereffects of drinking/medicines and
drugs)?

CHECK
ITEM 6.30

Is 8b marked “Yes”?

16g. Did ALL of the times when you had a strong fear, anxiety or
avoidance of these situations BEFORE 12 months ago ONLY
BEGIN to happen during or within 1 month after (drinking
heavily/using any medicines or drugs/experiencing the bad
aftereffects of drinking/medicines or drugs)?

h. During ANY of those times BEFORE 12 months ago when

1  Yes
2  No - SKIP to 17a
1  Yes
2  No

SKIP to 17a

1  Yes
2  No - SKIP to 16g
1  Yes
2  No - SKIP to Check Item 6.30

1  Yes
2  No - SKIP to Check Item 6.30

1  Yes
2  No
1  Yes
2  No

1  Yes - SKIP to 17a
2  No
1  Yes
2  No - SKIP to 17a

you had a strong fear, anxiety or avoidance of these
situations after (drinking heavily/using any medicines or
drugs) did you STOP (drinking heavily/using medicines and
drugs/experiencing the bad aftereffects of drinking/medicines
and drugs) for at least 1 month?

1  Yes
2  No - SKIP to 17a

i.

During ALL of those times, did you STOP (drinking
heavily/using medicines and drugs/experiencing the bad
aftereffects of drinking/medicines and drugs)?

1  Yes
2  No

j.

Did you CONTINUE to have a strong fear, anxiety or
avoidance of any of these situations for at least 1 month
AFTER ANY of those times BEFORE 12 months ago when
you STOPPED (drinking heavily/using medicines and
drugs/experiencing the bad aftereffects of drinking/medicines
and drugs)?

17a. Did you EVER talk to any health professional like a
psychiatrist, other medical doctor, psychologist, social
worker or any other kind of counselor or therapist to get
help for your fear, anxiety or avoidance of any of these
situations?

b. Did you EVER go to a self-help or support group, use a
hotline, or visit an internet chat room to get help for your
fear, anxiety or avoidance of any of these situations?

18a. Did you EVER go to an emergency room to get help for
your fear, anxiety or avoidance of any of these situations?

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No
1  Yes
2  No

Page 4

Section 6a - SPECIFIC ANXIETY (Continued)
18b. Were you EVER a patient in any kind of hospital overnight
or longer because of your fear, anxiety or avoidance of any
of these situations?

19. Did a doctor EVER prescribe any medicines or drugs for
your fear, anxiety or avoidance of any of these situations?
CHECK
ITEM 6.31

1  Yes
2  No
1  Yes
2  No

Is at least 1 item marked “Yes” in 17a - 19?
Did respondent ever seek help for his/her fear or
avoidance of a situation?

1  Yes
2  No - SKIP to Check Item 6.33

20. About how old were you the FIRST time you went
anywhere or talked to anyone to get help for your fear,
anxiety or avoidance of any of these situations?
CHECK
ITEM 6.32

Is age in 20 equal to respondent’s current age?

21. Did you go anywhere or talk to anyone in the last 12
months?
CHECK
ITEM 6.32A

Is age in 20 at least 2 years less than respondent’s
current age?

22. Did you go anywhere or talk to anyone before 12 months
ago, that is, BEFORE last (Month one year ago)?
CHECK
ITEM 6.33

Is Check Item 6.22 marked “No”?

23a. Did your fear, anxiety or avoidance of these situations
BEGIN to happen during a time when you were physically
ill or getting over being physically ill?

b. Did a doctor or other health professional tell you that your
fear or anxiety of these situations was related to your
physical illness or medical condition?
CHECK
ITEM 6.34

Is 8b marked “Yes” or 9b marked “Yes”?

24a. Did ALL of those times when you were frightened, anxious
or avoided these situations in the last 12 months ONLY
BEGIN to happen DURING times when you were physically
ill or getting over being physically ill?

b. Did a doctor or other health professional tell you that ALL
of the times like this were related to your physical illness or
medical condition?
CHECK
ITEM 6.35

Is 8b marked “Yes”?

24c. Did ALL of those times when you were frightened, anxious
or avoided these situations BEFORE 12 months ago ONLY
BEGIN to happen DURING times when you were physically
ill or getting over being physically ill?

d. Did a doctor or other health professional tell you that ALL
of the times like this were related to your physical illness or
medical condition?

_____ Age
1  Yes - SKIP to Check Item 6.33
2  No
1  Yes
2  No - SKIP to Check Item 6.33
1  Yes- SKIP to Check Item 6.33
2  No
1  Yes
2  No
1  Yes
2  No - SKIP to Check Item 6.34
1  Yes
2  No - SKIP to Section 7
1  Yes
2  No

SKIP to Section 7

1  Yes
2  No - SKIP to 24c
1  Yes
2  No – Check Item 6.35

1  Yes
2  No
1  Yes - SKIP to Section 7
2  No
1  Yes
2  No - SKIP to Section 7

1  Yes
2  No

Go to Section 7

Page 5

Section 7 - SOCIAL SITUATIONS
Statement Q

1a.

The next few questions are about SOCIAL SITUATIONS which may have made you frightened or anxious at
some time in your life.

Some people have such a strong fear of social situations,
like doing things in front of other people, interacting with
people or being the center of attention, that they become
very frightened or anxious or they try to avoid them.
Have you EVER had a strong fear, anxiety or avoidance
of . . . (Repeat phrase frequently)
Speaking or talking in front of other people?

1  Yes
2  No

b. Having conversations with people you don’t know well?

1  Yes
2  No

c. Going to parties or other social gatherings?

1  Yes
2  No

d. Eating or drinking in public?

1  Yes
2  No

e. Writing while someone else was watching?

1  Yes
2  No

f. Dating?

1  Yes
2  No

g. Being in a small group situation?

1  Yes
2  No

h. Taking part or speaking in a class?

1  Yes
2  No

i. Being interviewed?

1  Yes
2  No

j. Taking part in or speaking at a meeting?

1  Yes
2  No

k. Performing in front of other people?

1  Yes
2  No

l. Taking an important exam?

1  Yes
2  No

m. Speaking to an authority figure - like a teacher or a boss?

1  Yes
2  No

n. Meeting new people?

1  Yes
2  No

o. Talking to people at social gatherings?

1  Yes
2  No

p. Have you EVER had a strong fear, anxiety or avoidance

1  Yes
2  No

of any other SOCIAL situation?
CHECK
ITEM 7.0

Is any item 1a – p marked yes?

Specify ____________________

1  Yes
2  No - SKIP to Section 8

2.

Did you have a STRONG FEAR, anxiety or avoidance of
any social situation because you were afraid of being
embarrassed or humiliated by what you might say or do
around other people?

1  Yes
2  No

3.

Did you have a STRONG FEAR, anxiety or avoidance of
any social situation because you were afraid you would
become speechless, have nothing to say or you might show
how anxious you were?

1  Yes
2  No

Page 1

Section 7 - SOCIAL SITUATIONS (Continued)
4.

Did you have a STRONG FEAR, anxiety or avoidance of
any social situation because you were afraid of being
rejected by other people because of what you might say or
do?

1  Yes
2  No

5.

Did you have a STRONG FEAR, anxiety or avoidance of
any social situation because you were afraid you might
offend people by what you might say or do?

1  Yes
2  No

6.

When you found yourself in any of these social situations,
were you ALWAYS very anxious or frightened?

1  Yes
2  No

7.

When you were in any of these social situations because you
had to be there, were you very frightened or anxious the
whole time?

1  Yes
2  No

8.

Did you EVER avoid any of these social situations because
of your anxiety or strong fear of them?

1  Yes
2  No

9.

Did you EVER feel that your fear, anxiety or avoidance of
any of these social situations was out of proportion in
relation to the actual danger of the social situation?

1  Yes
2  No

Did you EVER feel that your fear, anxiety or avoidance of
any of these social situations was excessive or unrealistic,
that is, in excess of the actual danger of the social situation?

1  Yes
2  No

10.

CHECK
ITEM 7.1

Is “Yes” marked in Item 7 OR Item 31, Section 6?

11. When you were in any of these social situations that made
you frightened and anxious, did you EVER have a panic
attack?
CHECK
ITEM 7.1B

Is “Yes” marked in Check Item 6.2 or Check Item
6.17, Section 6?

12. When you were in any of these social situations, did you
EVER experience some of the symptoms of a panic attack?

13. Were you EVER very anxious or frightened of any of these
social situations because you were afraid of having a panic
attack or panic symptoms?

14. Did you EVER avoid any of these social situations because
you were afraid of having a panic attack or panic
symptoms?

1  Yes
2  No - SKIP to Check Item 7.1B
1  Yes – SKIP to 13
2  No – SKIP to 12
1  Yes
2  No - SKIP to 13
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No

15a. Did your fear, anxiety or avoidance of any of these social
situations EVER . . . (Repeat phrase frequently)
Make you feel very upset?

b. Interfere with your relationships with other people - like
arguing with them or avoiding them?

c. Interfere with doing things you were supposed to do - like
working, doing your schoolwork, or taking care of your
home or family?

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No

d. Restrict your usual activities in any way?

1  Yes
2  No

e. Keep you from doing something you wanted to do?

1  Yes
2  No

16.

About how old were you the FIRST time you BEGAN to
experience a strong fear, anxiety or avoidance of any social
situation?

CHECK
ITEM 7.2A

Is respondent’s age in 16 within 1 year of his/her
present age or is present or age in 16 unknown?

_____ Age

1  Yes
2  No - SKIP to 17b

Page 2

Section 7 - SOCIAL SITUATIONS (Continued)
17a. Did this FIRST time BEGIN to happen during the last 12
months?

1  Yes
2  No

b. In your ENTIRE LIFE how many SEPARATE times were
there when you had a strong fear, anxiety or avoidance of
any social situation?

_____ Number

By separate times, I mean times separated by at least 2
months when you WEREN’T anxious or afraid of social
situations and you DIDN’T try to avoid them.
If respondent says “All my life” or “There was never a time
when I didn’t fear or avoid situation”, code 1.
CHECK
ITEM 7.2B

Is number entered in 17b, 2 or more or unknown?

18a. How old were you the MOST RECENT time you BEGAN
to experience a strong fear, anxiety or avoidance of any
social situation?
CHECK
ITEM 7.3A

Is respondent’s age in 18a within 1 year of his/her
present age or is present age or 18a unknown?

18b. Did this MOST RECENT time when you were afraid or
anxious or avoided any social situation BEGIN to happen
during the last 12 months?

19a. How long did this MOST RECENT time last when you
were afraid, anxious or avoided any social situation?

b. Since this MOST RECENT time BEGAN, have there been
at least 2 months when you WEREN’T anxious or afraid
of any social situation and you DIDN’T try to avoid them?
CHECK
ITEM 7.3B

Is 18b marked “Yes”?

19c. Did this MOST RECENT time when you WEREN’T
anxious or afraid of any social situation and DIDN’T try
to avoid them BEGIN to happen in the last 12 months?

d. In your ENTIRE LIFE, what was the LONGEST period
you had when you were afraid, anxious or avoided any
social situation?

20a. How long did that period last when you were afraid,
anxious or avoided any social situation?

b. Since that time BEGAN, have there been at least 2 months
when you WEREN’T anxious or afraid of any social
situation and you DIDN’T try to avoid them?
CHECK
ITEM 7.3C

Is 17a marked “Yes”?

20c. Did that time when you WEREN’T anxious or afraid of
social situations and DIDN’T try to avoid them BEGIN to
happen in the last 12 months?
CHECK
ITEM 7.4

Refer to Check Item 2.1, Section 2A.
Is the respondent a lifetime abstainer of alcohol?

1  Yes
2  No - SKIP to 20a
_____ Age

1  Yes
2  No - SKIP to 19a
1  Yes
2  No
_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)
1  Yes
2  No - SKIP to 19d
1  Yes - SKIP to 19d
2  No
1  Yes
2  No
_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)

SKIP to Check Item 7.4

_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)
1  Yes
2  No - SKIP to Check Item 7.4
1  Yes - SKIP to Check item 7.4
2  No
1  Yes
2  No
1  Yes - SKIP to 23
2  No

Page 3

Section 7 - SOCIAL SITUATIONS (Continued)
21. Did (that time/ANY of those times) when you had a strong
fear, anxiety or avoidance of social situations BEGIN to
happen DURING or within 1 month AFTER drinking
heavily or a lot more than usual?

22. Did (that time/ANY of those times) when you had a strong
fear, anxiety or avoidance of social situations BEGIN to
happen DURING or within 1 month AFTER experiencing
the bad aftereffects of drinking?

23. Did (that time/ANY of those times) when you had a strong
fear, anxiety or avoidance of social situations BEGIN to
happen DURING or within 1 month AFTER using a
medicine or drug?

24. Did (that time/ANY of those times) when you had a strong
fear, anxiety or avoidance of social situations BEGIN to
happen DURING or within 1 month AFTER experiencing
the bad aftereffects of a medicine or drug?
CHECK
ITEM 7.5
CHECK
ITEM 7.6A

Is at least 1 item marked “Yes” in 21, 22, 23 or 24?

Is Check Item 7.2B marked “No”?

25a. During that time, did you STOP (drinking heavily/using
medicines and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs) for at least 1 month?

b. Did you CONTINUE to have a strong fear, anxiety or
avoidance of any social situation for at least 1 month
AFTER you STOPPED (drinking heavily/using
medicines and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs)?
CHECK
ITEM 7.6B

Is 17a marked “Yes” or 18b marked “Yes”?

25c. Did ALL of the times when you had a strong fear, anxiety
or avoidance of social situations in the last 12 months
ONLY BEGIN to happen during or within 1 month after
(drinking heavily/using any medicines or drugs/
experiencing the bad aftereffects of drinking/medicines
or drugs)?

d.

During ANY of those times in the last 12 months when
you had a strong fear, anxiety or avoidance of social
situations after (drinking heavily/using any medicines or
drugs), did you STOP (drinking heavily/using medicines
and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs) for at least 1 month?

e.

During ALL of those times, did you STOP (drinking
heavily/using medicines and drugs/experiencing the bad
aftereffects of drinking/medicines and drugs)?

f.

Did you CONTINUE to have a strong fear, anxiety or
avoidance of any social situation for at least 1 month
AFTER ANY of those times in the last 12 months when
you STOPPED (drinking heavily/using medicines and
drugs/experiencing the bad aftereffects of
drinking/medicines and drugs)?

CHECK
ITEM 7.6C

Is 17a marked “Yes”?

25g. Did ALL of the times when you had a strong fear,
anxiety or avoidance of social situations BEFORE 12
months ago ONLY BEGIN to happen during or within 1
month after (drinking heavily/using any medicines or
drugs/experiencing the bad aftereffects of
drinking/medicines or drugs)?

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No - SKIP to 26a
1  Yes
2  No - SKIP to Check Item 7.6B
1  Yes
2  No - SKIP to 26a

1  Yes
2  No

SKIP to 26a

1  Yes
2  No - SKIP to 25g
1  Yes
2  No - SKIP to Check Item 7.6C

1  Yes
2  No - SKIP to Check Item 7.6C

1  Yes
2  No

1  Yes
2  No

1  Yes - SKIP to 26a
2  No

1  Yes
2  No - SKIP to 26a

Page 4

Section 7 - SOCIAL SITUATIONS (Continued)
25h. During ANY of those times BEFORE 12 months ago
when you had a strong fear, anxiety or avoidance of
social situations after (drinking heavily/using any
medicines or drugs), did you STOP (drinking
heavily/using medicines and drugs/experiencing the bad
aftereffects of drinking/medicines and drugs) for at least
1 month?

1  Yes
2  No - SKIP 26a

i.

During ALL of those times, did you STOP (drinking
heavily/using medicines and drugs/experiencing the bad
aftereffects of drinking/medicines and drugs)?

1  Yes
2  No

j.

Did you CONTINUE to have a strong fear, anxiety or
avoidance of any social situation for at least 1 month
AFTER ANY of those times BEFORE 12 months ago
when you STOPPED (drinking heavily/using medicines
and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs)?

26a. Did you EVER talk to any health professional like a
psychiatrist, other medical doctor, psychologist, social
worker or any other kind of counselor or therapist to
get help for your fear, anxiety or avoidance of social
situations?

b. Did you EVER go to a self-help or support group, use a
hotline or visit an internet chat room to get help for
your fear, anxiety or avoidance of social situations?

27. Did you EVER go to an emergency room to get help for
your fear, anxiety or avoidance of social situations?

28. Were you EVER a patient in any kind of hospital
overnight or longer because of your fear, anxiety or
avoidance of any social situation?

29. Did a doctor EVER prescribe any medicines or drugs
for your fear, anxiety or avoidance of social situations?
CHECK
ITEM 7.7

Is at least 1 item marked “Yes” in 26a - 29?
Did respondent ever seek help for fear of social
situations?

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No - SKIP to Check Item 7.9

30. About how old were you the FIRST time you went
anywhere or saw anyone to get help for your fear, anxiety
or avoidance of social situations?
CHECK
ITEM 7.8

Is age in 30 equal to respondent’s current age?

31. Did you go anywhere or talk to anyone in the last 12
months?
CHECK
ITEM 7.8A

Is age in 30 at least 2 years less than respondent’s
current age?

32. Did you go anywhere or talk to anyone before 12 months
ago, that is, BEFORE last (Month one year ago)?
CHECK
ITEM 7.9

Check Item 7.2B marked “No”?

33a. Did your fear, anxiety or avoidance of social situations
BEGIN to happen during a time when you were
physically ill or getting over being physically ill?

b. Did a doctor or other health professional tell you that
your fear, anxiety or avoidance of social situations was
related to your physical illness or medical condition?
CHECK
ITEM 7.10

Is 17a marked “Yes” or 18b marked “Yes”?

_____ Age

1  Yes - SKIP to Check Item 7.9
2  No
1  Yes
2  No - SKIP to Check Item 7.9
1  Yes - SKIP to Check Item 7.9
2  No
1  Yes
2  No
1  Yes
2  No - SKIP to Check Item 7.10
1  Yes
2  No - SKIP to Section 8
1  Yes
2  No

SKIP to Section 8

1  Yes
2  No - SKIP to 33e

Page 5

Section 7 - SOCIAL SITUATIONS (Continued)
33c. Did ALL of those times when you were afraid, anxious
or avoided social situations in the last 12 months ONLY
BEGIN to happen DURING times when you were
physically ill or getting over being physically ill?

d. Did a doctor or other health professional tell you that
ALL of the times like this were related to your physical
illness or medical condition?
CHECK
ITEM 7.11

Is 17a marked “Yes”?

e. Did ALL of those times when you were afraid, anxious
or avoided social situations BEFORE 12 months ago
ONLY BEGIN to happen DURING times when you
were physically ill or getting over being physically ill?

f. Did a doctor or other health professional tell you that
ALL of the times like this were related to your physical
illness or medical condition?

1  Yes
2  No - SKIP to Check Item 7.11

1  Yes
2  No
1  Yes - SKIP to Section 8
2  No
1  Yes
2  No - SKIP to Section 8

1  Yes
2  No

Go to Section 8

Page 6

Section 8 - SPECIFIC SITUATIONS
Statement R

The next few questions are about objects or OTHER situations which may have made you frightened or anxious
at some time in your life. Please don’t include other situations we have already talked about.

1a. Some people have such a strong fear of SPECIFIC
SITUATIONS or OBJECTS that they become very frightened
or anxious in such situations or near such objects, or they try to
avoid them.
Have you EVER had a strong fear or avoidance of . . .
(Repeat phrase frequently)
Insects, snakes, birds or other animals?

1  Yes
2  No

b. Heights - like tall buildings, bridges or mountains?

1  Yes
2  No

c. Being in storms?

1  Yes
2  No

d. Being in or on the water - like swimming or boating?

1  Yes
2  No

e. Flying in airplanes?

1  Yes
2  No

f. Seeing someone injured?

1  Yes
2  No

g. Being in closed spaces - like a cave, tunnel or elevator?

1  Yes
2  No

h. Seeing blood?

1  Yes
2  No

i. Getting a shot or injection?

1  Yes
2  No

j. Going to the dentist?

1  Yes
2  No

k. Visiting or being in a hospital?

1  Yes
2  No

l. Thunder or lightning?

1  Yes
2  No

m. Invasive medical procedures?

1  Yes
2  No

n. Driving a car?

1  Yes
2  No

o. Choking or vomiting?

1  Yes
2  No

p. Have you EVER had a strong fear, anxiety or avoidance of

1  Yes
2  No

any other SPECIFIC object or situation? Do not include any
situations we have already talked about.
CHECK
ITEM 8.0

Is at least 1 item marked “Yes” in 1a - p?

Specify _____________________

1  Yes
2  No - SKIP to Section 9

2.

When you found yourself near any of these objects or in any
of these situations, did you ALWAYS become very anxious or
frightened?

1  Yes
2  No

3.

When you were near any of these objects or in any of these
situations because you had to be, were you very anxious or
frightened the whole time?

1  Yes
2  No

4.

Did you EVER avoid any of these objects or situations because
of your anxiety or strong fear of them?

1  Yes
2  No

5.

Did you EVER feel that your fear, anxiety or avoidance of any
of these objects or situations was out of proportion in relation
to the actual danger of the object or situation?

1  Yes
2  No
Page 1

Section 8 - SPECIFIC SITUATIONS (Continued)
6.

Did you EVER feel that your fear, anxiety or avoidance of any
of these objects or situations was excessive or unrealistic, that
is, in excess of actual danger of the object or situation?

CHECK
ITEM 8.1

7.

Is “Yes” marked in Item 7 or Item 31, Section 6?

When you were near any of these objects or in any of the
situations that made you frightened or anxious, did you EVER
have a panic attack?

CHECK
ITEM 8.1A

Is “Yes” marked in Check Item 6.2 or Check Item 6.17,
Section 6?

1  Yes
2  No
1  Yes
2  No - SKIP to Check Item 8.1A
1  Yes – SKIP to 9
2  No – SKIP to 8
1  Yes
2  No - SKIP to 9

8.

When you were near any of these objects or in any of these
situations, did you EVER experience some of the symptoms of
a panic attack?

1  Yes
2  No

9.

Were you EVER very anxious or frightened of any of these
objects or situations because you were afraid of having a
panic attack or panic symptoms?

1  Yes
2  No

10. Did you EVER avoid any of these objects or situations because
you were afraid of having a panic attack or panic symptoms?

1  Yes
2  No

13a. Did your fear, anxiety or avoidance of these objects or
situations EVER . . .
(Repeat phrase frequently)
Make you feel very upset?

b. Interfere with your relationships with other people - like
arguing with them or avoiding them?

c. Interfere with doing things you were supposed to do - like
working, doing your schoolwork, or taking care of your home
or family?

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No

d. Restrict your usual activities in any way?

1  Yes
2  No

e. Keep you from doing something you wanted to do?

1  Yes
2  No

14a. About how old were you the FIRST time you BEGAN to
experience a strong fear, anxiety or avoidance of any of these
objects or situations?
CHECK
ITEM 8.2

Is respondent’s age in 14a within 1 year of his/her present
age or is present age or age in 14a unknown?

14b. Did this FIRST time BEGIN to happen during the last 12
months?

_____ Age

1  Yes
2  No - SKIP to 14c
1  Yes
2  No

c. In your ENTIRE LIFE, how many SEPARATE times were
there when you had a strong fear, anxiety or avoidance of any
of these objects or situations?

_____ Number

By separate times, I mean times separated by at least 2 months
when you WEREN’T afraid of any of these objects or
situations and you DIDN’T try to avoid them.
If respondent says “All my life” or “There was never a time when
I didn’t fear or avoid object or situation”, code 1.
CHECK
ITEM 8.2A

Is number entered in 14c, 2 or more or unknown?

15a. How old were you the MOST RECENT time you BEGAN to
experience a strong fear, anxiety or avoidance of any of these
objects or situations?
CHECK
ITEM 8.3A

Is respondent’s age in 15a within 1 year of his/her present
age or is present age or age in 15a unknown?

1  Yes
2  No - SKIP to 17a
_____ Age

1  Yes
2  No - SKIP to 16a

Page 2

Section 8 - SPECIFIC SITUATIONS (Continued)
15b. Did this MOST RECENT time when you were afraid or
anxious or avoided any of these objects or situations BEGIN to
happen during the last 12 months?

16a. How long did this MOST RECENT time last when you were
afraid, anxious or avoided any of these objects or situations?

b. Since the MOST RECENT time BEGAN, have there been at
least 2 months when you WEREN’T anxious or afraid of any of
these objects or situations and you DIDN’T try to avoid them?
CHECK
ITEM 8.3B

Is 15b marked “Yes”?

16c. Did this MOST RECENT time when you WEREN’T anxious or
afraid of any of these objects or situations and you DIDN’T try
to avoid them BEGIN to happen during the last 12 months?

d. In your ENTIRE LIFE, what was the LONGEST period you
had when you were afraid, anxious or avoided any of these
objects or situations?

17a. How long did that period last when you were afraid, anxious or
avoided any of these objects or situations?

b. Since that time BEGAN, have there been at least 2 months
when you WEREN’T anxious or afraid of any of these objects
or situations and you DIDN’T try to avoid them?
CHECK
ITEM 8.3C

Is 14b marked “Yes”?

17c. Did that time when you WEREN’T anxious or afraid of any of
these objects or situations and you DIDN’T try to avoid them
BEGIN to happen during the last 12 months?
CHECK
ITEM 8.4

Refer to Check Item 2.1, Section 2A.
Is respondent a lifetime abstainer of alcohol?

18. Did (that time/ANY of those times) when you had a strong
fear, anxiety or avoidance of these objects or situations
BEGIN to happen DURING or within 1 month AFTER
drinking heavily or a lot more than usual?

19. Did (that time/ANY of those times) when you had a strong
fear, anxiety or avoidance of these objects or situations
BEGIN to happen DURING or within 1 month AFTER
experiencing the bad aftereffects of drinking?

20. Did (that time/ANY of those times) when you had a strong
fear, anxiety or avoidance of these objects or situations
BEGIN to happen DURING or within 1 month AFTER using
a medicine or drug?

21. Did (that time/ANY of those times) when you had a strong
fear, anxiety or avoidance of these objects or situations
BEGIN to happen DURING or within 1 month AFTER
experiencing the bad aftereffects of a medicine or drug?

1  Yes
2  No
_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)
1  Yes
2  No - SKIP to 16d
1  Yes - SKIP to 16d
2  No
1  Yes
2  No
_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)

SKIP to Check Item 8.4

_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)
1  Yes
2  No - SKIP to Check Item 8.4
1  Yes - SKIP to Check Item 8.4
2  No
1  Yes
2  No
1  Yes - SKIP to 20
2  No
1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

CHECK
ITEM 8.5

Is at least 1 item marked “Yes” in 18, 19, 20
OR 21?

1  Yes
2  No - SKIP to 23a

CHECK
ITEM 8.6A

Is Check Item 8.2A marked “No”?

1  Yes
2  No - SKIP to Check Item 8.6B

22a. During that time, did you STOP (drinking heavily/using
medicines and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs) for at least 1 month?

1  Yes
2  No - SKIP to 23a

Page 3

Section 8 - SPECIFIC SITUATIONS (Continued)
22b. Did you CONTINUE to have a strong fear, anxiety or
avoidance of any of these objects or situations for at least 1
month AFTER you STOPPED (drinking heavily/using
medicines and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs)?
CHECK
ITEM 8.6B

Is 14b marked “Yes” or 15b marked “Yes”?

22c. Did ALL of the times when you had a strong fear, anxiety or
avoidance of these objects or situations in the last 12 months
ONLY BEGIN to happen during or within 1 month after
(drinking heavily/using any medicines or drugs/experiencing
the bad aftereffects of drinking/medicines or drugs)?

d.

During ANY of those times in the last 12 months when you
had a strong fear, anxiety or avoidance of these objects or
situations after (drinking heavily/using any medicines or
drugs), did you STOP (drinking heavily/using medicines and
drugs/experiencing the bad aftereffects of drinking/medicines
and drugs) for at least 1 month?

e.

During ALL of those times, did you STOP (drinking
heavily/using medicines and drugs/experiencing the bad
aftereffects of drinking/medicines and drugs)?

f.

Did you CONTINUE to have a strong fear, anxiety or
avoidance of any of these objects or situations for at least 1
month AFTER ANY of those times in the last 12 months when
you STOPPED (drinking heavily/using medicines and
drugs/experiencing the bad aftereffects of drinking/medicines
and drugs)?

CHECK
ITEM 8.6C

Is 14b marked “Yes”?

22g. Did ALL of the times when you had a strong fear, anxiety or
avoidance of these objects or situations BEFORE 12 months
ago ONLY BEGIN to happen during or within 1 month after
(drinking heavily/using any medicines or drugs/ experiencing
the bad aftereffects of drinking/medicines or drugs)?

h.

During ANY of those times BEFORE 12 months ago when you
had a strong fear, anxiety or avoidance of these objects or
situations after (drinking heavily/using any medicines or drugs)
did you STOP (drinking heavily/using medicines and
drugs/experiencing the bad aftereffects of drinking/medicines
and drugs) for at least 1 month?

i.

During ALL of those times, did you STOP (drinking
heavily/using medicines and drugs/experiencing the bad
aftereffects of drinking/medicines and drugs)?

j.

Did you CONTINUE to have a strong fear, anxiety or
avoidance of any of these objects or situations for at least 1
month AFTER ANY of those times BEFORE 12 months ago
when you STOPPED (drinking heavily/using medicines and
drugs/experiencing the bad aftereffects of drinking/medicines
and drugs)?

23a. Did you EVER talk to any health professional like a
psychiatrist, other medical doctor, psychologist, social worker
or any other kind of counselor or therapist to get help for your
fear, anxiety or avoidance of any of these objects or
situations?

b. Did you EVER go to a self-help or support group, use a
hotline, or visit an internet chat room for help for your fear,
anxiety or avoidance of any of these objects or situations?

24a. Did you EVER go to an emergency room to get help for your
fear, anxiety or avoidance of any of these objects or
situations?

1  Yes
2  No

1  Yes
2  No - SKIP to 22g
1  Yes
2  No - SKIP to Check Item 8.6C

1  Yes
2  No - SKIP to Check Item 8.6C

1  Yes
2  No

1  Yes
2  No

1  Yes - SKIP to 23a
2  No
1  Yes
2  No - SKIP to 23a

1  Yes
2  No - SKIP to 23a

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No
1  Yes
2  No

Were you EVER a patient in any kind of hospital overnight or
longer because of your fear, anxiety or avoidance of any of
these objects or situations?

1  Yes
2  No

25. Did a doctor EVER prescribe any medicines or drugs for your

1  Yes
2  No

b.

fear, anxiety or avoidance of any of these objects or
situations?

SKIP to 23a

Page 4

Section 8 - SPECIFIC SITUATIONS (Continued)
CHECK
ITEM 8.7

Is at least 1 item marked “Yes” in 23a - 25?

1  Yes
2  No - SKIP to Check Item 8.9

26. About how old were you the FIRST time you went anywhere
or talked to anyone to get help for your fear, anxiety or
avoidance of any of these objects or situations?
CHECK
ITEM 8.8

Is age in 26 equal to respondent’s current age?

_____ Age
1  Yes - SKIP to Check Item 8.9
2  No

27. Did you go anywhere or talk to anyone in the last 12 months?

1  Yes
2  No - SKIP to Check Item 8.9

CHECK
ITEM 8.8A

1  Yes- SKIP to Check Item 8.9
2  No

Is age in 26 at least 2 years less than respondent’s current
age?

28. Did you go anywhere or talk to anyone before 12 months ago,
that is, BEFORE last (Month one year ago)?
CHECK
ITEM 8.9

Is Check Item 8.2A marked “No”?

29a. Did your fear, anxiety or avoidance of these objects or
situations BEGIN to happen during a time when you were
physically ill or getting over being physically ill?

b. Did a doctor or other health professional tell you that your
fear, anxiety or avoidance of these objects or situations was
related to your physical illness or medical condition?
CHECK
ITEM 8.10

Is 14b marked “Yes” or 15b marked “Yes?

30a. Did ALL of those times when you were afraid, anxious or
avoided these objects or situations in the last 12 months
ONLY BEGIN to happen DURING times when you were
physically ill or getting over being physically ill?

b. Did a doctor or other health professional tell you that ALL of
the times like this were related to your physical illness or
medical condition?
CHECK
ITEM 8.11

Is 14b marked “Yes”?

c. Did ALL of those times when you feared or avoided these
objects or situations BEFORE 12 months ago ONLY BEGIN
to happen DURING times when you were physically ill or
getting over being physically ill?

d. Did a doctor or other health professional tell you that ALL of
the times like this were related to your physical illness or
medical condition?

1  Yes
2  No
1  Yes
2  No - SKIP to Check Item 8.10
1  Yes
2  No - SKIP to Section 9
1  Yes
2  No

SKIP to Section 9

1  Yes
2  No - SKIP to 30c
1  Yes
2  No - SKIP to Check Item 8.11

1  Yes
2  No
1  Yes - SKIP to Section 9
2  No
1  Yes
2  No - SKIP to Section 9

1  Yes
2  No

Go to Section 9

Page 5

Section 9 - GENERAL ANXIETY
Now I’d like to ask you about times in your life when you may have been extremely worried or anxious.

Statement S

1a. Have you EVER had a time lasting at least 3 months when
you felt extremely worried or anxious about many different
things?

b. Have you EVER had a time lasting at least 3 months when
most of the time you felt extremely worried or anxious about
many different things, like your family, school or work,
finances or health?

1  Yes - SKIP to 2a
2  No
1  Yes
2  No - SKIP to Section 10

2a. Now I’d like you to think of a time in your life when you were
the most worried or anxious for at least 3 months.
During that worst period, did you OFTEN . . .
(Repeat entire phrase frequently)
Get tired easily?

1  Yes
2  No

b. Have tense, aching muscles?

1  Yes
2  No

c. Become so restless that you fidgeted, paced, or couldn’t sit

1  Yes
2  No

still?

d. Feel keyed up or on edge?

1  Yes
2  No

e. Have trouble concentrating or keeping your mind on

1  Yes
2  No

things?

f. Feel irritable or easily annoyed?

1  Yes
2  No

g. Have trouble falling asleep or staying asleep?

1  Yes
2  No

h. Have such restless sleep that you woke up tired?

1  Yes
2  No

i. Have times when you forgot what you were talking about or

1  Yes
2  No

your mind went blank?
CHECK
ITEM 9.3

Is at least 1 item marked “Yes” in 2b, 2c or 2d?

1  Yes
2  No - SKIP to Section 10

3a. During your worst period of feeling worried or anxious for
at least 3 months, did you EVER . . .
Put off doing things or making decisions because of your
worry or anxiety?

b. Often seek reassurance from others because of your worry
or anxiety?

c. Avoid events or activities that could have possible negative
consequences?

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No

d. Find it difficult to stop being worried or anxious?

1  Yes
2  No

e. Think that your worrying was excessive?

1  Yes
2  No

f. Spend a lot of time and effort preparing for events or

1  Yes
2  No

activities that could have possible negative consequences?

g. Worry about what other people might do or what would
happen to them?
CHECK
ITEM 9.3A

Is “Yes” marked in Item 7 or Item 31, Section 6?

4a. During any of the times that you were very worried or
anxious for at least 3 months, did you EVER have a panic
attack?

1  Yes
2  No
1  Yes
2  No - SKIP to Check Item 9.3B
1  Yes – SKIP to 5a
2  No – SKIP to 4b

Page 1

Section 9 - GENERAL ANXIETY (Continued)
CHECK
ITEM 9.3B

Is “Yes” marked in Check Item 6.2 or Check Item
6.17, Section 6?

4b. During any of those times when you were very worried or
anxious for at least 3 months, did you EVER experience
some of the symptoms of a panic attack?

1  Yes
2  No - SKIP to 5a
1  Yes
2  No

5a. Now I’d like to ask you about some things that might have
happened to you during your worst period when you felt
worried or anxious most of the time for at least 3 months
and had some of the other experiences you just mentioned
at the same time.
During that worst period, did you. ..
(Repeat phrase frequently)
Feel very upset?

1  Yes
2  No

b. Have arguments or friction with family, friends, people at

1  Yes
2  No

c. Have difficulty doing things you were supposed to do - like

1  Yes
2  No

d. Restrict your usual activities in any way?

1  Yes
2  No

e. Find that you were unable to do something you wanted to

1  Yes
2  No

f. Depend on others to take care of your everyday

1  Yes
2  No

g. Depend on others to give you a lot of assurance and

1  Yes
2  No

h. Avoid seeing or talking to people because you didn’t want

1  Yes
2  No

work or anyone else?

working, doing your schoolwork, or taking care of your
home or family?

do?

responsibilities?

comfort?

to be around them as much as usual?

6a. About how old were you the FIRST time you BEGAN to
feel worried or anxious for at least 3 months and also had
some of the other experiences you mentioned?
CHECK
ITEM 9.4

Is respondent’s age in 6a within 1 year of his/her
present age or is present age or age in 6a unknown?

6b. Did this FIRST time BEGIN to happen during the last 12
months?

_____ Age
1  Yes
2  No - SKIP to 7
1  Yes
2  No

7. In your ENTIRE LIFE, how many SEPARATE times
lasting at least 3 months were there when you felt worried
or anxious and had some of the other experiences you
mentioned?

_____ Number

By separate times, I mean times separated by at least 2
months when you DIDN’T feel nervous or worried AND
you DIDN’T have ANY of these OTHER experiences.
CHECK
ITEM 9.5

Is number entered in 7, 2 or more or unknown?

1  Yes
2  No - SKIP to 9e

8a. How old were you the MOST RECENT time you BEGAN
to feel worried or anxious most of the time for at least 3
months and also had some of those other experiences?
CHECK
ITEM 9.6

Is respondent’s age in 8a within 1 year of his/her
present age or is present age or age in 8a unknown?

8b. Did this MOST RECENT time when you felt worried or
anxious BEGIN to happen in the last 12 months?

9a. How long did this MOST RECENT period last when you
felt worried or anxious?
(Must be at least 3 months.)

b. Since this MOST RECENT time BEGAN, have there been
at least 2 months when you DIDN’T feel worried or
anxious AND DIDN’T have any of the OTHER experiences
you mentioned?

_____ Age
1  Yes
2  No - SKIP to 9a
1  Yes
2  No
_____ Month(s)
OR
_____ Year(s)
1  Yes
2  No - SKIP to 9d

Page 2

Section 9 - GENERAL ANXIETY (Continued)
CHECK
ITEM 9.6A

Is 8b marked “Yes”?

9c. Did this MOST RECENT time when you DIDN’T feel
worried or anxious BEGIN to happen during the last 12
months?

d.

In your ENTIRE LIFE, what was the LONGEST period
you had when you felt worried or anxious most of the
time?

1  Yes - SKIP to 9d
2  No
1  Yes
2  No
_____ Months
OR
_____ Year(s)

SKIP to Check Item 9.7

(Must be at least 3 months.)

e.

How long did that period last when you felt worried or
anxious most of the time?
(Must be at least 3 months.)

f.

Since that time BEGAN, have there been at least 2 months
when you DIDN’T feel worried or anxious AND DIDN’T
have any of the OTHER experiences you mentioned?

CHECK
ITEM 9.6B

9g.

Is 6b marked “Yes”?

Did that time when you DIDN’T feel worried or anxious
BEGIN to happen during the last 12 months?

CHECK
ITEM 9.7

Refer to Check Item 2.1, Section 2A.
Is respondent a lifetime abstainer of alcohol?

10. Did (that time/ANY of those times) when you were
worried or anxious for at least 3 months BEGIN to happen
DURING or within 1 month AFTER drinking heavily or a
lot more than usual?

11. Did (that time/ANY of those times) when you were
worried or anxious for at least 3 months BEGIN to happen
DURING or within 1 month AFTER experiencing the bad
aftereffects of drinking?

12. Did (that time/ANY of those times) when you were
worried or anxious for at least 3 months BEGIN to happen
DURING or within 1 month AFTER using a medicine or
drug?

13. Did (that time/ANY of those times) when you were
worried or anxious for at least 3 months BEGIN to happen
DURING or within 1 month AFTER experiencing the bad
aftereffects of a medicine or drug?

_____ Month(s)
OR
_____ Year(s)
1  Yes
2  No - SKIP to Check Item 9.7
1  Yes - SKIP to Check Item 9.7
2  No
1  Yes
2  No
1  Yes - SKIP to 12
2  No
1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

CHECK
ITEM 9.8

Is at least 1 item marked “Yes” in 10, 11, 12 OR 13?

1  Yes
2  No - SKIP to 15a

CHECK
ITEM 9.9

Is Check Item 9.5 marked “No”?

1  Yes
2  No - SKIP to Check Item 9.10

14a. During that time, did you STOP (drinking heavily/using
medicines and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs) for at least 1 month?

b. Did you CONTINUE to feel worried or anxious for at least
1 month AFTER you STOPPED (drinking heavily/using
medicines and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs)?
CHECK
ITEM 9.10

Is 6b marked “Yes” or 8b marked “Yes”?

14c. Did ALL of those times in the last 12 months when you were
worried or anxious for at least 3 months ONLY BEGIN to
happen during or within 1 month after (drinking
heavily/using any medicines or drugs/experiencing the bad
aftereffects of drinking/medicines or drugs)?

1  Yes
2  No - SKIP to 15a

1  Yes
2  No

SKIP to 15a

1  Yes
2  No - SKIP to 14g
1  Yes
2  No - SKIP to Check Item 9.10A

Page 3

Section 9 - GENERAL ANXIETY (Continued)
14d. During ANY of those times in the last 12 months when you
were worried or anxious for at least 3 months after
(drinking heavily/using any medicines or drugs), did you
STOP (drinking heavily/using medicines and
drugs/experiencing the bad aftereffects of
drinking/medicines and drugs) for at least 1 month?

e. During ALL or those times, did you STOP (drinking
heavily/using medicines and drugs/experiencing the bad
aftereffects of drinking/medicines and drugs)?

f. Did you CONTINUE to feel worried or anxious for at least
1 month AFTER ANY of those times in the last 12 months
when you STOPPED (drinking heavily/using medicines
and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs)?
CHECK
ITEM 9.10A

Is 6b marked “Yes”?

14g. Did ALL of those times BEFORE 12 months ago when you
were worried or anxious for at least 3 months ONLY
BEGIN to happen during or within 1 month after
(drinking heavily/using any medicines or drugs/
experiencing the bad aftereffects of drinking/medicines or
drugs)?

h. During ANY of those times BEFORE 12 months ago when

1  Yes
2  No - SKIP to Check Item 9.10A

1  Yes
2  No

1  Yes
2  No

1  Yes - SKIP to 15a
2  No
1  Yes
2  No - SKIP to 15a

you were worried or anxious for at least 3 months after
(drinking heavily/using any medicines or drugs), did you
STOP (drinking heavily/using medicines and
drugs/experiencing the bad aftereffects of
drinking/medicines and drugs) for at least 1 month?

1  Yes
2  No - SKIP to 15a

i.

During ALL or those times, did you STOP (drinking
heavily/using medicines and drugs/experiencing the bad
aftereffects of drinking/medicines and drugs)?

1  Yes
2  No

j.

Did you CONTINUE to feel worried or anxious for at least
1 month AFTER ANY of those times BEFORE 12 months
ago when you STOPPED (drinking heavily/using
medicines and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs)?

15a. Did you EVER talk to any health professional like a
psychiatrist, other medical doctor, psychologist, social
worker or any other kind of counselor or therapist
because you were feeling worried or anxious?

b. Did you EVER go to a self-help or support group, use a
hotline, or visit an internet chat room because you were
feeling worried or anxious?

16a. Did you EVER go to an emergency room to get help for
feeling worried or anxious?

b. Were you EVER a patient in any kind of hospital
overnight or longer because you were feeling worried or
anxious?

17. Did a doctor EVER prescribe any medicines or drugs for
your worry or anxiety?
CHECK
ITEM 9.11

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No

Is at least 1 item marked “Yes” in 15a - 17?
Did respondent ever seek help for feeling worried or
anxious for at least 3 months?

1  Yes
2  No - SKIP to Check Item 9.13

18. About how old were you the FIRST time you went
anywhere or talked to anyone to get help for feeling
worried or anxious?
CHECK
ITEM 9.12

Is age in 18 equal to respondent’s current age?

_____ Age
1  Yes - SKIP to Check Item 9.13
2  No

Page 4

Section 9 - GENERAL ANXIETY (Continued)
19.

Did you go anywhere or talk to anyone in the last 12
months?

CHECK
ITEM 9.12A

Is age in 18 at least 2 years less than respondent’s
current age?

20. Did you go anywhere or talk to anyone before 12 months
ago, that is, BEFORE last (Month one year ago)?
CHECK
ITEM 9.13

Is Check Item 9.5 marked “No”?

21a. Did that time when you were worried or anxious for at
least 3 months BEGIN to happen DURING a time when
you where physically ill or getting over being physically
ill?

b. Did a doctor or other health professional tell you that
this time was related to your physical illness or medical
condition?
CHECK
ITEM 9.14

Is 6b marked “Yes” or 8b marked “Yes”?

21c. Did ALL of those times when you were worried or anxious
in the last 12 months ONLY BEGIN to happen DURING
times when you were physically ill or getting over being
physically ill?

d. Did a doctor or other health professional tell you that ALL
of the times like this were related to you physical illness or
medical condition?
CHECK
ITEM 9.15

Is 6b marked “Yes”?

21e. Did ALL of those times BEFORE 12 months ago when
you were worried or anxious ONLY BEGIN to happen
DURING times when you were physically ill or getting
over being physically ill?

f. Did a doctor or other health professional tell you that
ALL of the times like this were related to your physical
illness or medical condition?

1  Yes
2  No - SKIP to Check Item 9.13
1  Yes - SKIP to Check Item 9.13
2  No
1  Yes
2  No
1  Yes
2  No - SKIP to Check Item 9.14
1  Yes
2  No - SKIP to Section 10

1  Yes
2  No

SKIP to Section 10

1  Yes
2  No - SKIP to 21e
1  Yes
2  No - SKIP to Check Item 9.15

1  Yes
2  No
1  Yes - SKIP to Section 10
2  No
1  Yes
2  No - SKIP to Section 10

1  Yes
2  No

Go to Section 10

Page 5

Section 10 - USUAL FEELINGS AND ACTIONS

Statement T

The questions I’m going to ask you now are about how you have felt or acted MOST of the time since early
adulthood regardless of the situation or whom you were with. Do NOT include times when you weren’t
yourself or when you acted differently than usual because you were depressed or hyper, anxious or nervous or
drinking heavily, using medicines or drugs or experiencing their bad aftereffects, or times when you were
physically ill.

1a. Since early adulthood. . .

b. Did this ever trouble you or
cause problems at work or
school, or with your family or
other people?

(Repeat phrase frequently)
1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

(6) Have you had a lot of sudden mood changes?

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

(7) When you have gotten close to someone, have

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

(1) Have you usually gotten attached to people very
quickly?

(2) Have your relationships with people you really
care about had lots of extreme ups and downs?

(3) Have you often started out thinking that
someone was a great person only to be
disappointed when they didn’t live up to your
expectations?

(4) Have you often become very sad, anxious or
angry over little things?

(5) Have other people often wondered why you get
so upset so easily?

you needed them to reassure you that they
would never leave you?

(8) Have you put a lot of time and effort into doing
things to keep someone from leaving you?

(9) Have you often become frantic when you
thought that someone you really cared about
was going to leave you?

(10) Have you gone to extremes to keep people from
leaving you?

(11) Have you often had temper outbursts or gotten
so angry that you lose control?

(12) Have you hit people or thrown things when you
got angry?

(13) Have even little things made you angry or have
you had difficulty controlling your anger?

(14) Have there been lots of sudden changes in your
personal goals, career plans, religious beliefs, or
other important aspects of your life?

(15) Have you been so different with different
people or in different situations that you
sometimes don’t know who you really are?

(16) Has your sense of who you are often changed
depending on the situation or whom you are
with?

(17) Have you all of a sudden changed your sense of
who you are and where you are headed?

(18) Have you often felt like your life had no
purpose or meaning?

(19) Have you often felt empty inside?

Page 1

Section 10 - USUAL FEELINGS AND ACTIONS (Continued)
1a. Since early adulthood. . .

b.

(Repeat phrase frequently)

(20) When you’ve been under a lot of stress, have
you often felt that you weren’t real?

(21) When you’ve been under a lot of stress, have
you often felt like you were outside your body?

(22) When you’ve been under a lot of stress, have
you felt suspicious or distrustful of other
people?

(23) Have you ever cut, burned, or scratched
yourself on purpose?

(24) Have you tried to hurt or kill yourself, or
threatened to do so?

(25) Have you gotten into sexual relationships
quickly or without thinking about the
consequences?

(26) Have there been periods of your life when you
often spent too much money while shopping or
gambling?

(27) Have you had periods in your life when you
drank a lot more or used a lot more drugs than
you meant to?

(28) Have you had periods in your life when you
often took too many risks when driving?

(29) Have you often done things impulsively?
CHECK
ITEM 10.1

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No – SKIP to Check Item 10.1

1  Yes
2  No

About how old were you when SOME of these experiences BEGAN to

(30) happen around the same time?

About how old were you the MOST RECENT time you had ANY of

Statement U

Go to Check
Item 10.1

1  Yes
2  No- Skip to Statement U

Are at least 2 items marked “Yes” in 1a(1) – (29)?

(31) these experiences?

Did this ever trouble you or
cause problems at work or
school, or with your family
or other people?

_______ Age
_______ Age

Now I’d like to ask about some other experiences that describe how you felt or acted MOST of the time since
early adulthood regardless of the situation or whom you were with.
Since early adulthood . . .
(Repeat phrase frequently)

(32) Have you often had the feeling that things that
have no special meaning to most people are
really meant to give you a message?

(33) Have you felt suspicious of people, even if you
have known them for awhile?

(34) When you are around people, have you often
had the feeling that you are being watched or
stared at?

(35) Have you ever felt that you could make things
happen just by making a wish or thinking about
them?

(36) Have you had personal experiences with the
supernatural?

(37) Have you believed that you have a “sixth sense”
that allows you to know and predict things that
others can’t?

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

Page 2

Section 10 - USUAL FEELINGS AND ACTIONS (Continued)
1a. Since early adulthood. . .

b. Did this ever trouble you or
cause problems at work or
school, or with your family or
other people?

(Repeat phrase frequently)
1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

(42) Have people thought you act strangely?

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

(43) Have there been very few people that you’re

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

(45) Has it been unusual for you to show emotion?

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

(46) Have you had trouble expressing your emotions

1  Yes
2  No - SKIP to next experience

1  Yes
2  No

1  Yes
2  No - SKIP to Check Item 10.2

1  Yes
2  No

(38) Have you had the sense that some force is
around you, even though you cannot see
anyone?

(39) Have you often seen auras or energy fields
around people?

(40) Have you often thought that objects or shadows
are really people or animals, or that noises are
actually people’s voices?

(41) Have people thought you are odd, eccentric or
strange?

really close to outside of your immediate
family?

(44) Have you often felt nervous when you are with
other people even if you have known them for
awhile?

and feelings?

(47) Have people thought you have strange ideas?
CHECK
ITEM 10.2

1  Yes
2  No- Skip to Section 12

Are at least 2 items marked “Yes” in 1a(32) – (47)?

(48) About how old were you when SOME of these experiences BEGAN to

_______ Age

happen around the same time?

(49) About how old were you the MOST RECENT time you had ANY of

_______ Age – Go to Section 12

these experiences?

Page 3

Section 12 - Traumatic Experiences
Statement X

Now I’d like to ask you about experiences that people sometimes have following an extremely stressful or
traumatic event, that is, an event that caused or threatened death, serious injury, or sexual violation.

1a. (SHOW FLASHCARD 45)
First, I would like to ask you about stressful events that have
happened to many people. Please look at Card 45, Box A at
the top of the card. In your ENTIRE life, have any of the
stressful or traumatic events in Box A EVER happened to
YOU PERSONALLY?

b. Now look at Box B at the bottom of the Card. In your entire
life, have you EVER PERSONALLY WITNESSED any of
the traumatic or stressful events in Box B happening to a
friend, relative or ANY OTHER person?

c. In your entire life, have you EVER been REPEATEDLY
EXPOSED, for example, at work to the details of any of the
traumatic or stressful events in Box B? Please do not include
events that you saw in pictures, on television or at the movies
or in video games.

d. Did you EVER personally experience, witness, or become
exposed to the details of any other kind of traumatic or
stressful event that could have caused or threatened death,
serious injury, or sexual violation?

2a. In your entire life, did you EVER LEARN OR HEAR that
any of the events listed on Card 45, Box B happened to a
relative or close friend? Include ONLY those events that you
LEARNED or HEARD about that happened to a relative or
close friend that were especially violent or accidental.

b. Did you EVER LEARN or HEAR that any other kind of
traumatic or stressful life events like this happened to a
relative or close friend?
CHECK
ITEM 12.1

Is any item marked “Yes” in 1a-2b?

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No
1  Yes
2  No – Skip to Section 13

(SHOW FLASHCARD 45)

3.

You just mentioned some traumatic or stressful event(s)
that HAPPENED to you, that you witnessed or learned
about, or that happened to a close relative or friend or
another person.

Code 1
Code 2
Code 3

In your entire life, which of these stressful events did you
experience? Please just tell me the number to the left of the
event on the card.

Code 4

If more than 4 events, mark the 4 most severe events.
CHECK
ITEM 12.2

Is the number of events marked in 3, 2 or more?

1  Yes
2  No – SKIP to 5a

4. Which of these experiences would you single out as the
MOST stressful and upsetting to you? Please just tell me the
number to the left of the event on the card.
(Mark one and only one.)

Code

5a. Many people have reported having several reactions AFTER
experiencing a traumatic or stressful event.
AFTER (that/that worst) event happened, did you keep
remembering the event even though you didn’t want to?

1  Yes
2  No

b. Did you have distressing memories of the event?

1  Yes
2  No

c. Did you have distressing dreams about the event?

1  Yes
2  No

d. Did you feel that you were reliving (that/that worst) event or

1  Yes
2  No

that it was happening all over again?

Page 1

Section 12 - Traumatic Experiences (Continued)
5e. AFTER (that/that worst) event happened, did you find
yourself acting as if the event was happening again, for
example, reacting to sights or sounds like the ones you
heard when it happened?

f. Did you get very upset when you were reminded of
(that/that worst) event? This could happen when someone
reminded you of the event OR you were in a situation that
reminded you of it, OR it could happen around the same
time of year it happened.

g. Did you have any physical reactions when something
reminded you of (that/that worst) event, like breaking out
in a sweat, breathing fast, or feeling your heart pounding?
Again, this could happen when someone reminded you of
the event OR in a situation that reminded you of it, OR
around the same time of year it happened.

h. Did you get so upset when you were reminded of the event
that for a moment you didn’t know where you were or
what you were doing?

i. Did you avoid thinking about or feeling anything about
(that/that worst) event?

j. Did you avoid conversations or seeing people that had
anything to do with the event or reminded you of the event?

k. Did you avoid going places, doing things or objects or
situations that might bring back memories of (that/that
worst) event?

l. AFTER (that/that worst) event happened, did you find that
you couldn’t remember some important part of the event?

m. Did you feel you really couldn’t expect the future to turn
out the way you expected it to, in terms of your job, family
or length of time you would live?

n. Did you feel that the world was a completely dangerous
place?

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No

o. Did you feel that no one could ever be trusted?

1  Yes
2  No

p. Did you feel that your nerves were completely shot?

1  Yes
2  No

q. Did you feel you were to blame for the event or what

1  Yes
2  No

happened after the event?

r. Did you feel that others were to blame for the event or what
happened as the result of the event?

1  Yes
2  No

s. Did you often feel more frightened than usual?

1  Yes
2  No

t. Did you often feel more angry than usual?

1  Yes
2  No

u. Did you often feel more guilty or ashamed than usual?

1  Yes
2  No

v. Did you often feel more horrified than usual?

1  Yes
2  No

w. Did you find that you were much less interested in activities

1  Yes
2  No

you usually enjoyed or that you participated much less than
usual in such activities?

Page 2

Section 12 - Traumatic Experiences (Continued)
5x. AFTER (that/that worst) event happened, did you feel
emotionally distant from other people, or cut off from
others?

1  Yes
2  No

y. Did you feel that you couldn’t be positive about yourself?

1  Yes
2  No

z. Did you feel as though you couldn’t feel positive or loving

1  Yes
2  No

towards other people like you used to?

aa. Did you find yourself getting angry, irritable or combative
with others more often than usual?

bb. Did you find that you were more reckless, like speeding,
drinking too much, using drugs or doing anything else in
which you or someone else could be hurt?

cc. Did you find yourself being more watchful or alert even
though it probably wasn’t necessary?

dd. Did you find that you were unusually jumpy or easily
startled by sudden noises?

ee. Did you find that you were having difficulty concentrating
or keeping your mind on things?

ff. Did you have trouble falling asleep, staying asleep, or was
your sleep so restless, you often woke up tired?
CHECK
ITEM 12.3

Is at least 1 item marked “Yes” in 5a-h AND at least
1 item marked “Yes” in 5i-k AND is Box D positive
AND is Box E positive?

6a. How long after (that/that worst) event happened did you
BEGIN to experience SOME of these reactions?
(If less than 1 week, enter 1 week.)

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No - SKIP to Section 13
_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)

b. About how old were you when SOME of these reactions
c.

FIRST BEGAN to happen around the same time?

_____ Age

Did SOME of these reactions you just mentioned happen
around the same time for at least 1 month?

1  Yes
2  No

8a. Now I’d like to ask you about some other things that
might have happened to you after (that/that worst) event
when you also had some of the other reactions you
mentioned at the same time.
During that time, were you very upset by any of these
reactions?

1  Yes
2  No

b. Did any of these reactions distress you a lot?

1  Yes
2  No

c. Did any of these reactions interfere with your daily life?

1  Yes
2  No

d. Did any of these reactions make it harder for you to take

1  Yes
2  No

care of your everyday responsibilities?

Page 3

Section 12 - Traumatic Experiences (Continued)
8e. Did any of these reactions cause you problems in your
relationships or social life?

f. Did any of these reactions cause you problems at work or
school?

1  Yes
2  No
1  Yes
2  No

9. About how old were you the FIRST time (that/ANY of
these) stressful event(s) caused you to have SOME of these
reactions we talked about for at least 1 month?
CHECK
ITEM 12.4

Is respondent’s age in 9 within 1 year of his/her
present age or is present age or age in 9 unknown?

10. Did this FIRST time BEGIN to happen in the last 12
months?
CHECK
ITEM 12.5

Is “Yes” marked in Check Item 12.2?

_____ Age
1  Yes
2  No - SKIP to Check Item 12.5
1  Yes
2  No
1  Yes
2  No - SKIP to 13a

(SHOW FLASHCARD 45)

11. What was the stressful event that caused you to have
SOME of those reactions for the FIRST time? Please just
tell me the number to the left of the event on the card.

Code

(If more than 1, code the most stressful.)

12. How long after this event happened did you FIRST BEGIN
to have some of those reactions?
(If less than 1 week, enter 1 week.)

13a. Since that time BEGAN, have all of those reactions gone
away completely?
CHECK
ITEM 12.6

Is “Yes” marked in 10?

13b. Did that time when ALL of these reactions went away
completely BEGIN to happen in the LAST 12 months?

14.

Now I have some questions about different periods when
you were experiencing reactions to a stressful or traumatic
event. If more than two months passed between reactions,
this counts as the beginning of a separate period.
Reactions LESS than two months apart are part of the
SAME period. How many SEPARATE periods have you
had when you were experiencing some of these reactions
to a stressful or traumatic event?

CHECK
ITEM 12.7

Is number in 14, “2” or more or D or R?

15. How long did this time last when you were having some of
these reactions because of experiencing this stressful event?

_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)
1  Yes
2  No - SKIP to 14
1  Yes - SKIP to 14
2  No
1  Yes
2  No
_____ Number

1  Yes - SKIP to 16
2  No
_____ Month(s)
OR
_____ Year(s)

SKIP to Check Item 12.10A

16. How old were you the MOST RECENT time a stressful
event caused you to have some of those reactions you
mentioned for at least 1 month?
CHECK
ITEM 12.8

17.

Is respondent’s age in 16 within 1 year of his/her
present age or is present age or age in 16 unknown?

Did this MOST RECENT time BEGIN to happen in the
last 12 months?

CHECK
ITEM 12.9

Is “1” marked in Check Item 12.2?

_____ Age
1  Yes
2  No - SKIP to Check Item 12.9
1  Yes
2  No
1  Yes
2  No - SKIP to 20

Page 4

Section 12 - Traumatic Experiences (Continued)
(SHOW FLASHCARD 45)

18.

What was the stressful event that caused you to have
SOME of those reactions MOST RECENTLY? Please just
tell me the number to the left of the event on the card.

Code

(If more than 1, code the most stressful.)

19.

How long AFTER this event happened did you BEGIN to
have some of these reactions?
(If less than 1 week, enter 1 week.)

_____ Week(s)
OR

_____ Month(s)
OR

_____ Year(s)

20. Since that MOST RECENT time BEGAN, have ALL of
those reactions gone away completely?
CHECK
ITEM 12.10

Is “Yes” marked in 17?

21. Did that MOST RECENT time when ALL of those
reactions went away completely BEGIN to happen in the
last 12 months?

22a. How long did this MOST RECENT period last when you
had SOME of these reactions because of experiencing a
stressful event?
(If less than 1 month, enter 1 month.)

b. In your ENTIRE LIFE, what is the LONGEST period
you’ve had SOME of these reactions because of
experiencing a stressful event?
(If less than 1 month, enter 1 month.)
CHECK
ITEM 12.10A

Is “Yes” marked in Item 7 or Item 31, Section 6?

22c. During (that time /ANY of those times) when you were
having SOME of these reactions, did you EVER have a
panic attack?
CHECK
ITEM 12.10B

Is “Yes” marked in Check Item 6.2 or Check Item
6.17, Section 6?

22d. During (that time /ANY of those times) did you EVER
have some symptoms related to a panic attack?

23a. Did you EVER talk to any health professional like a
psychiatrist, other medical doctor, psychologist, social
worker or any other kind of counselor or therapist to help
get over those reactions you experienced as a result of a
stressful event?

b. Did you EVER go to a self-help or support group, use a
hotline, or visit an internet chat room to help get over
those reactions you experienced as a result of a stressful
event?

24. Were you EVER a patient in a hospital for at least 1 night
because of those reactions?

25. Did you EVER go to an emergency room for help when
you were having those reactions?

26. Did a doctor EVER prescribe any medicines or drugs to
help you get over those reactions?
CHECK
ITEM 12.11

Is at least 1 item marked “Yes” in 23a - 26?
Did respondent seek help for their reactions?

1  Yes
2  No - SKIP to 22a
1  Yes - SKIP to 22a
2  No
1  Yes
2  No
_____ Month(s)
OR
_____ Year(s)

_____ Month(s)
OR
_____ Year(s)
1  Yes
2  No - SKIP to Check Item 12.10B
1  Yes – SKIP to 23a
2  No – SKIP to 22d
1  Yes
2  No - SKIP to 23a
1  Yes
2  No
1  Yes
2  No

1  Yes
2  No

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No - SKIP Section 13

27. About how old were you the FIRST time you went
anywhere or talked to anyone to get help for your
reactions?
CHECK
ITEM 12.12

Is age in 27 equal to respondent’s current age?

_____ Age

1  Yes - SKIP to Section 13
2  No
Page 5

Section 12 - Traumatic Experiences (Continued)
28. Did you go anywhere or talk to anyone to get help for your
reactions in the last 12 months?
CHECK
ITEM 12.12A

Is age in 27 at least 2 years less than respondent’s
current age?

29. Did you go anywhere or talk to anyone to get help for your
reactions BEFORE 12 months ago, that is, BEFORE
(month on year ago)?

1  Yes
2  No - SKIP to Section 13
1  Yes - SKIP to Section 13
2  No
1  Yes
1  No

Go to Section 13

Page 6

Section 13 - BACKGROUND INFORMATION - III
Statement Y

Now I would like to ask you a few questions about your childhood and background.

1a. (SHOW FLASHCARD 46)
The next few questions are about how your parents or
caregivers treated you while you were growing up, that is,
BEFORE you were 18 years old. By parents or caregivers,
I mean your mother, father, stepmother, stepfather,
adoptive mother or father, foster parent or other adult
living in your home.
BEFORE you were 18 years old…
(Repeat phrase frequently)
How often were you made to do chores that were too
difficult or dangerous for someone your age?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

b. How often were you left alone or unsupervised when you

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

were too young to be alone, that is, before you were 10
years old?

c. How often did you go without things you needed like
clothes, shoes or school supplies because a parent or other
adult living in your home spent the money on themselves?

d. How often did a parent or other adult living in your home
make you go hungry or not prepare regular meals?

e. How often did a parent or other adult living in your home
ignore or fail to get you medical treatment when you were
sick or hurt?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often
1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often
1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

How often did a parent or other adult living in your home
swear at you, insult you or say hurtful things?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

g. How often did a parent or other adult living in your home

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

f.

threaten to hit you or throw something at you, but didn’t
do it?

h. How often did a parent or other adult living in your home
act in ANY other way that made you afraid that you would
be physically hurt or injured?

i.

How often did a parent or other adult living in your home
push, grab, shove, slap or hit you?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often
1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

Page 1

Section 13 - BACKGROUND INFORMATION - III (Continued)
1j.

(SHOW FLASHCARD 46)
How often did a parent or other adult living in your home
hit you so hard that you had marks or bruises or were
injured?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

How often did your father, stepfather, foster or adoptive
father or mother’s boyfriend do ANY of these things to
your mother, stepmother, father’s girlfriend, or your foster
or adoptive mother?

k. Push, grab, slap or throw something at her?

l.

Kick, bite, hit her with a fist, or hit her with something
hard?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often
1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

m. Repeatedly hit her for at least a few minutes?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

n. Threaten her with a knife or gun or use a knife or gun to

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

hurt her?

(SHOW FLASHCARD 46)

2a. Now I’d like to know if you had any of the following sexual
experiences with an adult or any other person BEFORE
you were 18 years old. By adult or other person I mean a
parent, stepparent, foster parent, adoptive parent, a
relative, friend, family friend, teacher or stranger.
BEFORE you were 18 years old…
(Repeat phrase frequently)
How often did an adult or other person touch or fondle
you in a sexual way when you didn’t want them to or when
you were too young to know what was happening?

b. How often did an adult or other person have you touch
their body in a sexual way when you didn’t want to or you
were too young to know what was happening?

c. How often did an adult or other person attempt to have
sexual intercourse with you when you didn’t want them to
or you were too young to know what was happening?

d. How often did an adult or other person actually have sexual
intercourse with you when you didn’t want them to or you
were too young to know what was happening?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often
1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often
1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often
1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often
Page 2

Section 13 - BACKGROUND INFORMATION - III (Continued)
3a. (SHOW FLASHCARD 47)
Now I’d like to know how true each of the following
statements was when you were growing up, that is,
BEFORE you were 18 years old.
I felt there was someone in my family who wanted me to be
a success.

1  Never true
2  Rarely true
3  Sometimes true
4  Often true
5  Very often true

b. There was someone in my family who helped me feel that I

1  Never true
2  Rarely true
3  Sometimes true
4  Often true
5  Very often true

was important or special.

c. My family was a source of strength and support.

1  Never true
2  Rarely true
3  Sometimes true
4  Often true
5  Very often true

d. I felt that I was part of a close-knit family.

1  Never true
2  Rarely true
3  Sometimes true
4  Often true
5  Very often true

e. Someone in my family believed in me.

1  Never true
2  Rarely true
3  Sometimes true
4  Often true
5  Very often true

4a. BEFORE you were 18 years old, was a parent or other
adult living in your home a problem drinker or alcoholic?

1  Yes
2  No

(By alcoholic or problem drinker, I mean a person who had
physical or emotional problems because of drinking;
problems with a spouse, family, or friends because of
drinking; problems at work or school because of drinking;
problems with the police because of drinking – like drunk
driving; or a person who seemed to spend a lot of time
drinking or being hung over.)

b. BEFORE you were 18 years old, did a parent or other
adult living in your home have some similar problems with
drugs?

5. BEFORE you were 18 years old, did a parent or other
adult living in your home go to jail or prison?

6. BEFORE you were 18 years old, was a parent or other
adult living in your home treated or hospitalized for a
mental illness?

7. BEFORE you were 18 years old, did a parent or other
adult living in your home attempt suicide?

8. BEFORE you were 18 years old, did a parent or other
adult living in your home actually commit suicide?

1  Yes
2  No

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No

Go to Section 14

Page 3

Section 14 - MEDICAL CONDITIONS AND PRACTICES
Statement Z

Now I’d like to ask some questions about your health and health practices.

1.

(Not counting hospitalization for delivery of a healthy
live born infant,) How many separate times did you stay
in a hospital overnight or longer in the last 12 months?

2.

(Again not counting hospitalization for delivery of a
healthy live born infant,) How many days altogether did
you spend in the hospital in the last 12 months?

3.

In the last 12 months, how many times did you receive
medical care or treatment in a hospital emergency room?

0  No times
OR
______ Number of times

4.

In the last 12 months, how many injuries have you had
that caused you to seek medical help or to cut down your
usual activities for more than half a day?

0  No injuries
OR
______ Number of injuries

5.

And now some questions about your health and sexual
practices.
(SHOW FLASHCARD 49)
People are different in their sexual attraction to other
people. Which category on the card best describes your
feelings?

6.

7.

(SHOW FLASHCARD 50)

1  Heterosexual (straight)
2  Gay or lesbian
3  Bisexual
3  Not sure

Which of the categories on the card best describes you?

Is “4” marked in 6?

8a. Have you had sex in the last 12 months?
b.

During the last 12 months, did you have sex with only
males, only females, or both males and females?

c.

During the last 12 months, did you have sex with
someone who you knew or suspected was an injection
drug user?
(SHOW FLASHCARD 51)
When you had sex in the last 12 months, about how often
did you use a condom?

CHECK
ITEM 14.2

11.

1  Only attracted to females
2  Mostly attracted to females
3  Equally attracted to females and males
4  Mostly attracted to males
5  Only attracted to males
1  Only males
2  Only females
3  Both males and females
4  Never had sex

Has respondent never had sex?

8e.

______ Number of days

In your entire life, have you had sex with only males,
only females, both males and females, or have you never
had sex? By sex, I mean vaginal or anal sex, but NOT
oral sex.

CHECK
ITEM 14.1

d.

0  No times - SKIP to 3
OR
______ Number of times

Is respondent a Female AND is 1 or 3 marked in 8b?

During the last 12 months, did you have sex with a male
partner who you knew or suspected had sex with other
male partners?

How old were you when you first had sex?

1  Yes - SKIP to Check Item 14.4
2  No
1  Yes
2  No – SKIP to 11
1  Only males
2  Only females
3  Both males and females
1  Yes
2  No

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often
1  Yes
2  No - SKIP to 11
1  Yes
2  No

______ Age

Page 1

Section 14 - MEDICAL CONDITIONS AND PRACTICES (Continued)
CHECK
ITEM 14.4

If sex = 1,
Is Q5 coded as 2,3,4,5,D,R
OR Q6 coded as 1,3,D,R
OR Q7 coded as 2,3, D,R?

If sex = 2,
Is Q5 coded as 1,2,3,4,D,R,
OR Q6 coded as 2,3,D,R,
OR Q7 coded as 2,3, D,R?

1  Yes
2  No - SKIP to 15a

(SHOW FLASHCARD 51)

12a. Now I’d like to know about how often you have experienced discrimination, been prevented

b. About how often did this

from doing something, or been hassled or made to feel inferior in any of the following
situations because you were assumed to be gay, lesbian or bisexual.

happen BEFORE 12
months ago?

(1) During the last 12 months, about how often did you
experience discrimination in your ability to obtain
health care or health insurance coverage because you
were assumed to be gay, lesbian or bisexual?

(2) During the last 12 months, how often did you
experience discrimination in how you were treated
when you got care because you were assumed to be
gay, lesbian or bisexual?

(3) During the last 12 months, how often did you
experience discrimination in public, like on the street,
in stores or in restaurants, because you were assumed
to be gay, lesbian or bisexual?

(4) During the last 12 months, about how often did you
experience discrimination because you were assumed
to be gay, lesbian or bisexual in ANY other situation,
like obtaining a job or on the job, getting admitted to a
school or training program, in the courts or by the
police?

(5) During the last 12 months, about how often were you
called names because you were assumed to be gay,
lesbian or bisexual?

(6) During the last 12 months, about how often were you
made fun of, picked on, pushed, shoved, hit, or
threatened with harm because you were assumed to be
gay, lesbian or bisexual?
CHECK
ITEM 14.5

Are all items (1) - (6) in 12a AND 12b marked “1”
OR “Never” OR D OR R?

13. When you are treated unfairly because you were assumed
to be gay, lesbian or bisexual, do you USUALLY accept it
as a fact of life, or do you try to do something about it?

14. When you are treated unfairly because you were assumed
to be gay, lesbian or bisexual, do you USUALLY talk to
other people about it, or do you keep it to yourself?

15a. Have you EVER been tested for HIV, the virus that
causes AIDS, or tested for AIDS?

b. Did you EVER test positive for HIV or AIDS?

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Never
2  Almost never
3  Sometimes
4  Fairly often
5  Very often

1  Yes - SKIP to 15a
2  No
1  Accept it
2  Try to do something about it
1  Talk to other people
2  Keep it to yourself
1  Yes
2  No – SKIP to 16a
1  Yes
2  No

Page 2

Section 14 - MEDICAL CONDITIONS AND PRACTICES (Continued)
b. Did a doctor or other health

16a. And now a few questions about your health.

professional tell you that you
had (Name of condition)?

During the last 12 months, did you have. . .
(Repeat phrase frequently)

(1)

Cirrhosis of the liver?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(2)

Any other form of liver disease?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(3)

Hardening of the arteries or
arteriosclerosis?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(4)

Diabetes or sugar diabetes?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(5)

High blood pressure or hypertension?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(6)

High cholesterol?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(7)

High triglycerides?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(8)

Chest pain or angina?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(9)

Rapid heart beat or tachycardia?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(10)

A heart attack or myocardial infarction?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(11)

Any other form of heart condition or heart
disease?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(12)

A stomach ulcer?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(13)

Any sexually transmitted diseases or
venereal diseases like gonarea, sifalis,
clamidia or herpeez?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(14)

Epilepsy or seizure disorder?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(15)

Arthritis?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(16)

A stroke?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(17)

Problems falling asleep or staying asleep?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(18)

Liver cancer?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(19)

Breast cancer?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

Page 3

Section 14 - MEDICAL CONDITIONS AND PRACTICES (Continued)
16a. During the last 12 months, did you have. . .

b. Did a doctor or other health

(Repeat phrase frequently)

professional tell you that you
had (Name of condition)?

(20)

Cancer of the mouth, tongue, throat or
esophagus?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(21)

Any other cancer?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(22)

Anemia?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(23)

Fibromyalgia?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(24)

Reflex sympathetic dystrophy (RSD) or
Complex Regional Pain Syndrome (CRPS)?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(25)

Any other nerve problem in your legs, arms
or back?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(26)

Bowel problems, like inflammatory bowel
disease (IBD) or irritable bowel syndrome
(IBS)?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(27)

Osteoporosis?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(28)

Lung problems like chronic bronchitis,
emphysema, pneumonia, or influenza?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(29)

Pancreatitis?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(30)

Tuberculosis?

1  Yes
2  No - SKIP to next condition

1  Yes
2  No

(31)

A serious or traumatic brain injury?

1  Yes
2  No - SKIP to 17a

1  Yes
2  No

16c. In the past 30 days, about how many hours did you sleep

_____________ Number of hours

during a typical day?

17a. During the last 12 months, have you provided personal care
or help with daily activities to another person because of a
health condition or limitation? If you provided this
assistance to more than one person, please answer the
questions for the person you assisted the MOST.
(Do not include care for others that is related to your job.)

b. Was the person to whom you provided care living in your
home, in another home or in a health care institution?

(SHOW FLASHCARD 52)

1  Yes
2  No - SKIP to 18a

1  Own home
2  Another home
3 Health care institution
Code

c. What is this person’s relationship to you?
(SHOW FLASHCARD 24)

d. During the last 12 months, about how often did you provide
care or assistance to this person?

1  Every day
2  Nearly every day
3  3 to 4 times a week
4  2 times a week
5  Once a week
6  2 to 3 times a month
7  Once a month
8  7 to 11 times in the last year
9  3 to 6 times in the last year
10  1 or 2 times in the last year
Page 4

Section 14 - MEDICAL CONDITIONS AND PRACTICES (Continued)
17e. About how long have you been providing care or assistance
to this person?

18a. In your ENTIRE life did you EVER attempt suicide?

_____ Weeks
or
_____ Months
or
_____ Years
1  Yes
2  No - SKIP to Check Item 14.6

b. How old were you the FIRST time that happened?

______ Age

c. How old were you the MOST RECENT time that

______ Age

happened?

0  Only happened once - SKIP to Check Item 14.6

d. How many times have you attempted suicide?
CHECK
ITEM 14.6

Is respondent a female aged 18 - 55?

19a. Are you pregnant at this time?

Times

1  Yes
2  No - SKIP to 20a
1  Yes - SKIP to 19c
2  No

b. Were you pregnant at any time during the last year?

1  Yes
2  No - SKIP to 20a

c. (Did you experience/Have you experienced) any

1  Yes
2  No

complications with this most recent pregnancy (or during
delivery)?
(SHOW FLASHCARD 53)

20a. Please look at the categories on the card and let me know
how much each of the following statements describes you…
When doing several things in a row, I mix up the sequence.

1  Not at all
2  A little
3  Somewhat
4  A lot
5  Very much

b. I try to plan for the future.

1  Not at all
2  A little
3  Somewhat
4  A lot
5  Very much

c. I have trouble doing two things at once, multi-tasking.

1  Not at all
2  A little
3  Somewhat
4  A lot
5  Very much

d. I’m an organized person.

1  Not at all
2  A little
3  Somewhat
4  A lot
5  Very much

e. I save money on a regular basis.

1  Not at all
2  A little
3  Somewhat
4  A lot
5  Very much

f. I only have to make a mistake once in order to learn from

1  Not at all
2  A little
3  Somewhat
4  A lot
5  Very much

it.

Page 5

Section 14 - MEDICAL CONDITIONS AND PRACTICES (Continued)
(SHOW FLASHCARD 53)

20g. I sometimes lose track of what I’m doing.

1  Not at all
2  A little
3  Somewhat
4  A lot
5  Very much

h. I think about the consequences of an action before I do it.

1  Not at all
2  A little
3  Somewhat
4  A lot
5  Very much

i. I have trouble summing up information in order to make a

1  Not at all
2  A little
3  Somewhat
4  A lot
5  Very much

decision with it.

j. I start things, but then lose interest and do something else.

1  Not at all
2  A little
3  Somewhat
4  A lot
5  Very much

k. I use strategies to remember things.

1  Not at all
2  A little
3  Somewhat
4  A lot
5  Very much

l. I monitor myself so that I can catch any mistakes.

1  Not at all
2  A little
3  Somewhat
4  A lot
5  Very much

(SHOW FLASHCARD 54)

21a. Please look at the categories on the card and let me know
how OFTEN each of the following has been a problem…
I have trouble concentrating on tasks.

1  Never
2  Sometimes
3  Often

b. I need to be reminded to begin a task.

1  Never
2  Sometimes
3  Often

c. I have trouble with tasks that have more than one step.

1  Never
2  Sometimes
3  Often

d. I forget what I’m doing in the middle of things.

1  Never
2  Sometimes
3  Often

e. I have trouble accepting different ways to solve problems

1  Never
2  Sometimes
3  Often

with work, friends or tasks.

f. I have trouble staying on the same topic when talking.

1  Never
2  Sometimes
3  Often

g. I have trouble thinking of a way to solve a problem when I

1  Never
2  Sometimes
3  Often

get stuck.

h. I have a short attention span.

1  Never
2  Sometimes
3  Often

Page 6

Section 14 - MEDICAL CONDITIONS AND PRACTICES (Continued)
(SHOW FLASHCARD 54)

21i. I am bothered by having to deal with changes.

1  Never
2  Sometimes
3  Often

j. I forget instructions easily.

1  Never
2  Sometimes
3  Often

k. I have trouble remembering things, even for a few minutes,

1  Never
2  Sometimes
3  Often

like telephone numbers or directions.

l. I get disturbed by unexpected changes in my daily routine.

1  Never
2  Sometimes
3  Often

m. After having a problem, I don’t get over it easily.

1  Never
2  Sometimes
3  Often

n. I have trouble doing more than one thing at a time.

1  Never
2  Sometimes
3  Often

Go to Section 15

Page 7

Section 15 – REPEATED THOUGHTS AND BEHAVIOR
Statement AA

Now I’m going to ask you about some repeated thoughts, urges, images or behaviors that some people have.

1. In your ENTIRE LIFE, have you EVER been bothered by persistent and
unwanted thoughts, urges or images that kept coming back, even though you
tried to block them out?

2. Were you EVER extremely distressed by these persistent and unwanted
thoughts, urges or images?

1  Yes
2  No – SKIP to 5
1  Yes
2  No

3. Did you EVER try to ignore these thoughts, urges or images?

1  Yes
2  No

4. Did you EVER try to block out these thoughts, urges or images by thinking

1  Yes
2  No

about something else or doing something else to get your mind off it?

5. In your ENTIRE life, did you EVER repeat anything like washing your hands or
checking the door locks over and over, even though you didn’t want to?

6. In your ENTIRE life, did you EVER do anything like repeating words to
yourself, praying or counting over and over, even though you didn’t want to?
CHECK
Is 5 or 6 marked “Yes”?
ITEM 15.1

7. Did you EVER repeat things over and over like this according to certain rules
that had to be followed exactly the same each time?

8. Did you EVER repeat things over and over like this to stop or keep away
unwanted thoughts, urges or images?

9. Did you EVER repeat things over and over like this as a way to reduce or
eliminate your anxiety or distress, or to keep something bad from happening?

10. Did you EVER think that these repetitive thoughts or behaviors were excessive
or unrealistic or didn’t accomplish what you wanted them to?

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No – SKIP to Check Item 15.2
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No

CHECK
Is [item 1 marked “Yes” and (item 3 or 4) marked “Yes”] OR is [(item 5 or 6)
ITEM 15.2
marked “Yes” and (item 7 or 8) marked “Yes” and (item 9 or 10) marked
“Yes”]?

1  Yes
2  No – SKIP to Section 15A

10a. Were there times in your life when you sometimes spent at least 1 hour a day

1  Yes
2  No

(having persistent thoughts, urges or images/repeating things over and over)?
CHECK
ITEM 15.3

Is “Yes” marked in Item 7 or Item 31, Section 6?

11. During ANY of these times when you (had persistent thoughts, urges or
images/repeated things over and over), did you EVER have a panic attack?
CHECK
ITEM 15.3A

Is “Yes” marked in Check Item 6.2 or Check Item 6.17, Section 6?

12. During ANY of these times when you (had persistent thoughts, urges or
images/repeated things over and over), did you EVER experience SOME of the
symptoms of a panic attack?

1  Yes
2  No – SKIP to Check Item 15.3A
1  Yes – SKIP to 13a
2  No – SKIP to 12
1  Yes
2  No – SKIP to 13a
1  Yes
2  No

13a. Now I’d like to ask you about some other things that might have happened to
you during ANY of these times when you (had persistent thoughts, urges or
images/repeated things over and over).
During that time, were you very upset by (having persistent thoughts, urges or
images/repeating things over and over)?

b. Did you have arguments or friction with friends, family, people at work or
anyone else?

c. Were you very troubled because of the way you felt at that time or did you often
wish you could get better?

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No

Page 1

Section 15 – REPEATED THOUGHTS AND BEHAVIOR (Continued)
13d. Did you have any trouble doing things you were supposed to do – like working,
doing your schoolwork, or taking care of your home or family?

e Did you spend more time than usual by yourself, because you didn’t want to be
around people as much as usual?

1  Yes
2  No
1  Yes
2  No

f. Did you find that you couldn’t do the things you usually did or wanted to do?

1  Yes
2  No

g. During that time, did you find you did a lot less than usual or were less active?

1  Yes
2  No

h. Did you depend a lot more on people to take care of everyday things for you or

1  Yes
2  No

to give you a lot of reassurance or attention?

14a. About how old were you the FIRST time you BEGAN to
(have persistent thoughts, urges or images/repeat things
over and over)?
CHECK
ITEM 15.4

Is respondent’s age in 14a within 1 year of
his/her present age or is present age or age in 14a
unknown?

14b. Did this FIRST time BEGIN to happen during the last 12
months?

c. During this FIRST time, did you spend at least 1 hour a
day for most days (having persistent thoughts, urges or
images/repeating things over and over)?

_____ Age
1  Yes
2  No - SKIP to 14c
1  Yes
2  No
1  Yes
2  No

15. In you ENTIRE LIFE, how many SEPARATE times were
there when you (had persistent thoughts, urges or
images/repeated things over and over)? By separate times,
I mean times separated by at least 2 months when you
DIDN’T (have ANY persistent thoughts, urges or
images/repeat things over and over).
CHECK

Is number entered in 15, 2 or more or unknown?

ITEM 15.5

_____ Number

1  Yes
2  No - SKIP to 17g

16a. How old were you the MOST RECENT time you BEGAN
to (have persistent thoughts, urges or images/repeat things
over and over)?
CHECK
ITEM 15.6

Is respondent’s age in 16a within 1 year of his/her
present age or is present age or age in 16a unknown?

16b. Did this MOST RECENT time BEGIN to happen during
the last 12 months?

17a. How long did this MOST RECENT time last when you
(had persistent thoughts, urges or images/repeated things
over and over)?

b. During this MOST RECENT time, did you spend at least 1
hour a day for most days (having persistent thoughts,
urges or images/repeating things over and over)?

c. Since this MOST RECENT time BEGAN, have there been
at least 2 months when you DIDN’T (have ANY persistent
thoughts, urges or images/repeat things over and over)?
CHECK
ITEM 15.7

Is “Yes” marked in 16b?

17d. Did this MOST RECENT time when you DIDN’T (have
ANY persistent thoughts, urges or images/repeat things
over and over) BEGIN to happen in the last 12 months?

e. In your ENTIRE LIFE, what was the LONGEST time
when you (had persistent thoughts, urges or
images/repeated things over and over)?

_____ Age
1  Yes
2  No - SKIP to 17a
1  Yes
2  No
_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)
1  Yes
2  No
1  Yes
2  No – SKIP to 17e
1  Yes - SKIP to 17e
2  No
1  Yes
2  No
_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)

Page 2

Section 15 – REPEATED THOUGHTS AND BEHAVIOR (Continued)
17f. During this LONGEST time, did you spend at least 1 hour
a day for most days (having persistent thoughts, urges or
images/repeating things over and over)?

g. How long did that time last when you (had persistent
thoughts, urges or images/repeated things over and over)?

h. During this time, did you spend at least 1 hour a day for
most days (having persistent thoughts, urges or
images/repeating things over and over)?

i. Since that time BEGAN, have there been at least 2 months
when you DIDN’T (have ANY persistent thoughts, urges or
images/repeat things over and over)?
CHECK
ITEM 15.8

Is “Yes” marked in 14b?

17j. Did this time when you DIDN’T (have ANY persistent
thoughts, urges or images/repeat things over and over)
BEGIN to happen in the last 12 months?
CHECK
ITEM 15.9

Refer to Check Item 2.1, Section 2A.
Is the respondent a lifetime abstainer of alcohol?

18. Did (that time/ANY of those times) when you (had ANY
persistent thoughts, urges or images/repeated things over
and over) BEGIN to happen DURING or within 1 month
AFTER drinking heavily or a lot more than usual?

19. Did (that time/ANY of those times) when you (had ANY
persistent thoughts, urges or images/repeated things over
and over) BEGIN to happen DURING or within 1 month
AFTER experiencing the bad aftereffects of drinking?

20. Did (that time/ANY of those times) when you (had ANY
persistent thoughts, urges or images/repeated things over
and over) BEGIN to happen DURING or within 1 month
AFTER using a medicine or drug?

21. Did (that time/ANY of those times) when you (had ANY
persistent thoughts, urges or images/repeated things over
and over) BEGIN to happen DURING or within 1 month
AFTER experiencing the bad aftereffects of a medicine or
drug?

1  Yes
2  No

SKIP to Check Item 15.9

_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)
1  Yes
2  No
1  Yes
2  No - SKIP to Check Item 15.9
1  Yes - SKIP to Check Item 15.9
2  No
1  Yes
2  No
1  Yes - SKIP to 20
2  No

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

CHECK
ITEM 15.10

Is at least 1 item marked “Yes” in 18, 19, 20, OR 21?

1  Yes
2  No - SKIP to 23a

CHECK
ITEM 15.11

Is Check Item 15.5 marked “No”?

1  Yes
2  No - SKIP to Check Item 15.12

22a. During that time, did you STOP (drinking heavily/using
medicines and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs) for at least 1 month?

b. Did you CONTINUE to (have persistent thoughts, urges or
images/repeat things over and over) for at least 1 month
AFTER you STOPPED (drinking heavily/using medicines
and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs)?
CHECK
ITEM 15.12

Is 14b marked “Yes” or 16b marked “Yes”?

22c. Did ALL of the times when you (had persistent thoughts,
urges or images/repeated things over and over) in the last
12 months ONLY BEGIN to happen during or within 1
month after (drinking heavily/using any medicines or
drugs/experiencing the bad aftereffects of drinking/
medicines or drugs)?

1  Yes
2  No - SKIP to 23a
1  Yes
SKIP to 23a
2  No

1  Yes
2  No - SKIP to 22g
1  Yes
2  No - SKIP to Check Item 15.13

Page 3

Section 15 – REPEATED THOUGHTS AND BEHAVIOR (Continued)
22d. During ANY of those times in the last 12 months when you
(had persistent thoughts, urges or images/repeated things
over and over) after (drinking heavily/using any medicines
or drugs), did you STOP (drinking heavily/using
medicines and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs) for at least 1 month?

e. During ALL of those times, did you STOP (drinking
heavily/using medicines and drugs/experiencing the bad
aftereffects of drinking/medicines and drugs)?

f.

Did you CONTINUE to (have persistent thoughts, urges
or images/repeat things over and over) for at least 1
month AFTER ANY of those times in the last 12 months
when you STOPPED (drinking heavily/using medicines
and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs)?

CHECK
ITEM 15.13

Is 14b marked “Yes”?

22g. Did ALL of the times when you (had persistent thoughts,
urges or images/repeated things over and over) BEFORE
12 months ago ONLY BEGIN to happen during or within
1 month after (drinking heavily/using any medicines or
drugs/ experiencing the bad aftereffects of
drinking/medicines or drugs)?

h. During ANY of those times BEFORE 12 months ago when
you (had persistent thoughts, urges or images/repeated
things over and over) after (drinking heavily/using any
medicines or drugs) did you STOP (drinking heavily/using
medicines and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs) for at least 1 month?

i.

During ALL of those times, did you STOP (drinking
heavily/using medicines and drugs/experiencing the bad
aftereffects of drinking/medicines and drugs)?

j.

Did you CONTINUE to (have persistent thoughts, urges
or images/repeat things over and over) for at least 1 month
AFTER ANY of those times BEFORE 12 months ago
when you STOPPED (drinking heavily/using medicines
and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs)?

23a. Did you EVER talk to any health professional like a
psychiatrist, other medical doctor, psychologist, social
worker or any other kind of counselor or therapist to help
you stop (having persistent thoughts, urges or
images/repeating things over and over)?

b. Did you EVER go to a self-help or support group, use a
hotline, or visit an internet chat room to help you stop
(having persistent thoughts, urges or images/repeating
things over and over)?

24a. Were you a patient in a hospital for at least one night
because of (having persistent thoughts, urges or
images/repeating things over and over)?

24b. Did you EVER go to an emergency room for help during
any time when you were (having persistent thoughts, urges
or images/repeating things over and over)?

25. Did a doctor EVER prescribe any medicines or drugs to
help you stop (having persistent thoughts, urges or
images/repeating things over and over)?
CHECK
Is at least 1 item marked “Yes” in 23a-25?
ITEM 15.14

1  Yes
2  No - SKIP to Check Item 15.13

1  Yes
2  No
1  Yes
2  No

1  Yes - SKIP to 23a
2  No
1  Yes
2  No - SKIP to 23a

1  Yes
2  No - SKIP to 23a

1  Yes
2  No
1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No - SKIP to Check Item 15.17

26. About how old were you the FIRST time you went
anywhere or saw anyone to get help for (having persistent
thoughts, urges or images/repeating things over and
over)?

_____ Age

Page 4

Section 15 – REPEATED THOUGHTS AND BEHAVIOR (Continued)
CHECK
Is age in 26 equal to respondent’s current age?
ITEM 15.15

27. Did you go anywhere or talk to anyone in the last 12
months?
CHECK
Is age in 26 at least 2 years less than respondent’s
ITEM 15.16 current age?

28. Did you go anywhere or talk to anyone BEFORE 12
months ago, that is, BEFORE last (Month one year ago)?
CHECK
Is Check Item 15.5 marked “No”?
ITEM 15.17

29a. Did that time when you (had persistent thoughts, urges or
images/repeated things over and over) BEGIN to happen
DURING a time when you were physically ill or getting
over being physically ill?

b. Did a doctor or other health professional tell you that this
time was related to your physical illness or medical
condition?
CHECK
Is 14b marked “Yes” or 16b marked “Yes”?
ITEM 15.18

29c. Did ALL of those times when you (had persistent thoughts,
urges or images/repeated things over and over) in the last
12 months ONLY BEGIN to happen DURING times when
you were physically ill or getting over being physically ill?

d. Did a doctor or other health professional tell you that ALL
the times like this were related to your physical illness or
medical condition?
CHECK
Is 14b marked “Yes”?
ITEM 15.19

29e. Did ALL of those times BEFORE 12 months ago when you
(had persistent thoughts, urges or images/repeated things
over and over) ONLY BEGIN to happen DURING times
when you were physically ill or getting over being
physically ill?

f. Did a doctor or other health professional tell you that ALL
the times like this were related to your physical illness or
medical condition?

1  Yes - SKIP to Check Item 15.17
2  No
1  Yes
2  No - SKIP to Check Item 15.17
1  Yes - SKIP to Check Item 15.17
2  No
1  Yes
2  No
1  Yes
2  No - SKIP to Check Item 15.18
1  Yes
2  No – SKIP to Section 15A

1  Yes
2  No

SKIP to Section 15A

1  Yes
2  No - SKIP to 29e
1  Yes
2  No – SKIP to Check Item 15.19

1  Yes
2  No
1  Yes - SKIP to Section 15A
2  No
1  Yes
2  No – SKIP to Section 15A

1  Yes
2  No

Go to Section 15A

Page 5

Section 15A - FAMILY HISTORY - V
Now I would like to ask about whether any of your relatives, regardless of whether or not they are now
living, have EVER had a period of feeling anxious or nervous.
(SHOW FLASHCARD 55)

Statement BB

By anxious or nervous I mean times when they were tense, nervous or anxious for at least three months
(PAUSE), had panic attacks (PAUSE), were very frightened of objects or situations or avoided them
(PAUSE), repeated things over and over (PAUSE), or had bad reactions to a traumatic or stressful event.
(REFER TO FLASHCARD FREQUENTLY.)

1.

Was your blood or natural father anxious, nervous or
frightened at ANY time in his life?

1  Yes
2  No

2.

Was your blood or natural mother anxious, nervous or
frightened at ANY time in her life?

1  Yes
2  No

3.

(Was your full brother/How many of your full brothers
were) anxious, nervous or frightened at ANY time in (his
life/their lives)?

1  Yes
2  No
OR
_____ Number
0  None

4.

(Was your full sister/How many of your full sisters were)
anxious, nervous or frightened at ANY time in (her
life/their lives)?

1  Yes
2  No
OR
_____ Number
0  None

5.

(Was your natural son/How many of your natural sons
were) anxious, nervous or frightened at ANY time in (his
life/their lives)?

1  Yes
2  No
OR
_____ Number
0  None

6.

(Was your natural daughter/How many of your natural
daughters were) anxious, nervous or frightened at ANY
time in (her life/ their lives)?

1  Yes
2  No
OR
_____ Number
0  None

7.

(Was your natural father’s full brother/How many of
your natural father’s full brothers were) anxious, nervous
or frightened at ANY time in (his life/their lives)?

1  Yes
2  No
OR
_____ Number
0  None

8.

(Was your natural father’s full sister/How many of your
natural father’s full sisters were) anxious, nervous or
frightened at ANY time in (her life/their lives)?

1  Yes
2  No
OR
_____ Number
0  None

9.

(Was your natural mother’s full brother/How many of
your natural mother’s full brothers were) anxious,
nervous or frightened at ANY time in (his life/their lives)?

1  Yes
2  No
OR
_____ Number
0  None

10. (Was your natural mother’s full sister/How many of your

1  Yes
2  No
OR
_____ Number
0  None

natural mother’s full sisters were) anxious, nervous or
frightened at ANY time in (her life/their lives)?

11. Was your natural grandfather on your father’s side
anxious, nervous or frightened at ANY time in his life?

12. Was your natural grandmother on your father’s side
anxious, nervous or frightened at ANY time in her life?

13. Was your natural grandfather on your mother’s side
anxious, nervous or frightened at ANY time in his life?

14. Was your natural grandmother on your mother’s side
anxious, nervous or frightened at ANY time in her life?

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No

Go to Section 16

Page 1

Section 16 - UNUSUAL EXPERIENCES
Statement CC

Now I’d like to ask you about some UNUSUAL experiences that people sometimes have. As I read each
experience, please tell me if it has EVER happened to you.

1a. In your ENTIRE LIFE did you EVER…(Repeat phrase frequently).

b. Did this happen in
the last 12 months?

(1) Think that people were following
you or spying on you? (Do NOT
include being followed by a detective
in a divorce or criminal case.)

(2) Think that you were being secretly
tested or experimented on?

(3) Think that anyone was going out of
their way to give you a hard time or
harm you?

(4) Think that someone was in love with
you even though he/she denied it?

(5) Think that someone was unfaithful
to you even though no one else
would believe it?

(6) Think that parts of your body had
changed or stopped working?

(7) Think that something peculiar was
inside your body or that parts of
your body were missing?

(8) Think that you had a disease even
though your doctor said you didn’t?

(9) Receive messages from the
television, internet or radio, or
newspaper that were meant only for
you? (Do NOT include message that
seems particularly relevant or timely
to respondent.)

(10) Find special meanings in street
signs, or the way in which furniture
or other things were arranged
around you?

(11) Find hidden meanings in the way
people acted around you or in other
things that were going on around
you?

(12) Often notice people talking about
you or paying particular attention
to you?

(13) Think that you were exceptionally
important in some way? (Do NOT
include if respondent is particularly
talented at something.)

(14) Think that you had extraordinary
knowledge, talents or powers?

(15) Think that you were God or some
other religious person – like Michael
the Archangel, Muhammad or an
apostle?

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No – Go to next
experience

1
2

1  Yes
2  No – Go to next
experience

1
2

1  Yes
2  No – Go to next
experience

1
2

 Yes
 No – Mark “Yes”

c. Did this happen before
12 months ago, that is
before last (Month one
year ago)?
1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

Page 1

Section 16 - UNUSUAL EXPERIENCES – (Continued)
1a. In your ENTIRE LIFE did you EVER…(Repeat phrase frequently).

b. Did this happen in
the last 12 months?

(16) Think you had a special mission in
life?

(17) Think that the world was about to
come to an end or that you were
going to die soon?

(18) Think that you did something
terrible that you should be punished
for?

(19) Think that you would end up with no
money or no way to support
yourself?

(20) Think that there was something
terribly wrong with you?

(21) Think that your thoughts, feelings or
actions were being completely
controlled by a force or power
outside yourself? (Do NOT include
persuasion and coercion of others or
having a domineering husband/wife/
partner.)

(22) Think that you were being controlled
in some unusual way by another
person?

(23) Think that your thoughts could be
heard out loud, as if they were being
broadcast on a radio?

(24) Feel convinced that strange thoughts
or thoughts that were not your own
were being put directly into your
mind?

(25) Have any other ideas that people
couldn’t understand or thought were
strange, unusual or impossible?

(26) Have visions or see things that other
people couldn’t see? (Do NOT include
exceptionally good vision.)

(27) Hear things that other people
couldn’t hear, such as noises or the
voices of people whispering or
talking? (Do NOT include
exceptionally good hearing.)

(28) Smell specific or peculiar odors that
no one else could smell? (Do NOT
include exceptionally good sense of
smell.)

(29) Have a definite or strange taste in
your mouth for no ordinary reason?

(30) Have strange or UNUSUAL
sensations on your body or under
your skin?

1  Yes
2  No – Go to next
experience

1
2

1  Yes
2  No – Go to next
experience

1
2

1  Yes
2  No – Go to next
experience

1
2

1  Yes
2  No – Go to next
experience

1
2

1  Yes
2  No – Go to next
experience

1
2

1  Yes
2  No – Go to next
experience

1
2

1  Yes
2  No – Go to next
experience

1
2

1  Yes
2  No – Go to next
experience

1
2

1  Yes
2  No – Go to next
experience

1
2

1  Yes
2  No – Go to next
experience

1
2

1  Yes
2  No – Go to next
experience

1
2

1  Yes
2  No – Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

 Yes
 No – Mark “Yes”

c. Did this happen before
12 months ago, that is
before last (Month one
year ago)?
1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

Page 2

Section 16 – UNUSUAL EXPERIENCES – (Continued)
1a. In your ENTIRE LIFE did you EVER…(Repeat phrase frequently).

b. Did this happen in
the last 12 months?

(31) Feel something was touching you
when nothing was really there?

(32) Hear voices talking to each other?

(33) Hear voices talking about what you
were doing or thinking?

(34) Have a time when people had a very
hard time making out what you
were saying or what you meant?

(35) Have people comment on your way
of speaking or the words you used?

(36) Make up your own words?

(37) Have a time when you didn’t react
to things going on around you?

(38) Have a time when you didn’t move
for a long time?

(39) Have a time when you didn’t talk
for a long time?

(40) Have a time when you didn’t show
interest in anything?

(41) Have a time when you didn’t have
feelings or had very few feelings?

(42) Have a time when you didn’t have
conversations with people?

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to next
experience

1
2

1  Yes
2  No - Go to Check
Item 16.1

1
2

 Yes
 No – Mark “Yes”
 Yes
 No – Mark “Yes”
 Yes
 No – Mark “Yes”
 Yes
 No – Mark “Yes”

1  Yes
2  No
1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c

 Yes
 No – Mark “Yes”

1  Yes
2  No

in column c
and go to
Check Item
16.1

1  Yes
2  No

CHECK
Is 2a or 2b marked “Yes”?
ITEM 16.2

1  Yes
2  No

in column c

2a. Did you EVER have a time when SOME of these

medications to stop having these UNUSUAL experiences
just after they began to happen?

1  Yes
2  No

in column c

1  Yes
2  No – SKIP to Section 11A

b. Were you EVER hospitalized or did you EVER take any

before 12 months
ago, that is before
last (Month one year
ago)?

in column c

CHECK
Are at least 2 Boxes 1-5 marked “Yes” and at least 1
ITEM 16.1 Box 1-3 marked “Yes”?

UNUSUAL experiences were happening for at least 1
month?

c. Did this happen

1  Yes
2  No
1  Yes
2  No - SKIP to Section 11A

Page 3

Section 16 – UNUSUAL EXPERIENCES – (Continued)
3a. Some people have reported some OTHER experiences that
can happen BEFORE or AFTER periods when they are
having UNUSUAL experiences.
Please tell me if you EVER had ANY of the following
OTHER experiences BEFORE or AFTER you had the
UNUSUAL experiences we just talked about. Did you…
(Repeat phrase frequently)
Find it hard to follow through on any task?

1  Yes
2  No

b. Keep to yourself more than usual?

1  Yes
2  No

c. Not care about the way you looked?

1  Yes
2  No

d. Not care if you got things done?

1  Yes
2  No

e. Stop having conversations with people?

1  Yes
2  No

f.

Often get very angry all of a sudden?

1  Yes
2  No

g. Have times when it seemed as if you had no feelings at all?

1  Yes
2  No

h. Do things that other people thought were strange?

1  Yes
2  No

i.

Believe things that other people thought were strange,
unusual or impossible?

1  Yes
2  No

j.

Did you EVER have a period when SOME of the
UNUSUAL experiences you mentioned earlier and SOME
of these OTHER experiences were happening for at least 6
months?

1  Yes
2  No

4a. At the time you were having SOME of these UNUSUAL
experiences or OTHER experiences we just talked about,
were you also…
(Repeat phrase frequently)
Very upset?

1  Yes
2  No

b. Having problems with people?

1  Yes
2  No

c. Having problems at work or school?

1  Yes
2  No

d. Having problems getting a job?

1  Yes
2  No

e. Having problems taking care of your everyday

1  Yes
2  No

responsibilities?

f.

Having problems taking care of yourself?

g. Having problems keeping your clothes clean and neat?
5a. About how old were you the FIRST TIME you BEGAN to
have some of these UNUSUAL or OTHER experiences?

1  Yes
2  No
1  Yes
2  No
_____ Age

CHECK
Is respondent’s age in 5a within 1 year of his/her present
ITEM 16.3A age or is present age or 5a unknown?

1  Yes
2  No – SKIP to 5c.

5b. Did this FIRST time BEGIN to happen during the last 12

1  Yes
2  No

months?

Page 4

Section 16 – UNUSUAL EXPERIENCES (Continued)
5c. In your ENTIRE LIFE, how many SEPARATE times
were there lasting at least 6 months when you had SOME
of these UNUSUAL experiences, including the time when
you had the OTHER experiences you mentioned?

_____ Number

By separate times, I mean times separated by at least 2
months when you didn’t have ANY of these UNUSUAL
or OTHER experiences.
CHECK
Is number entered in 5c, 2 or more or unknown?
ITEM 16.3B

6a. How old were you the MOST RECENT time you BEGAN
to have some of these UNUSUAL or OTHER experiences?
CHECK
ITEM 16.4

Is respondent’s age in 6a within 1 year of his/her
present age or is present age or 6a unknown?

6b. Did this MOST RECENT time when you had these
UNUSUAL or OTHER experiences BEGIN to happen
during the last 12 months?

7a. How long did this MOST RECENT time last when you
had these UNUSUAL or OTHER experiences, that is,
from the time you began to have any of these experiences
to the time you felt back to normal and didn’t have ANY
of these experiences?
(Must be at least 1 month)

b. Since this MOST RECENT time BEGAN, have there been
at least 2 months when you DIDN’T have any of these
UNUSUAL or OTHER experiences?
CHECK
ITEM16.5

Is 6b marked “Yes”?

7c. Did this MOST RECENT time when you DIDN’T have
ANY of these UNUSUAL or OTHER experiences BEGIN
to happen during the last 12 months?

d. In your ENTIRE LIFE, what was the LONGEST period
you had when you had ANY of these UNUSUAL or
OTHER experiences, that is, from the time you BEGAN to
have ANY of these UNUSUAL or OTHER experiences to
the time you felt back to normal and DIDN’T have ANY
UNUSUAL or OTHER experiences?
(Must be at least 1 month)

8a. How long did that period last when you had these
UNUSUAL or OTHER experiences, that is, from the time
you BEGAN to have any of these UNUSUAL or OTHER
experiences to the time you felt back to normal and
DIDN’T have ANY UNUSUAL or OTHER experiences?
(Must be at least 1 month)

b. Since that time BEGAN, have there been at least 2 months
when you DIDN’T have ANY of these UNUSUAL or
OTHER experiences?
CHECK
ITEM 16.6

Is 5b marked “Yes”?

8c. Did that time when you DIDN’T have ANY of these
UNUSUAL experiences BEGIN to happen during the last
12 months?
CHECK
ITEM 16.7

Refer to Check Item 2.1, Section 2A.
Is respondent a lifetime abstainer of alcohol?

9.

Did (that time/ANY of those times) when you had these
UNUSUAL or OTHER experiences BEGIN to happen
DURING or within 1 month AFTER drinking heavily or
a lot more than usual?

10. Did (that time/ANY of those times) when you had these
UNUSUAL or OTHER experiences BEGIN to happen
DURING or within 1 month AFTER experiencing the
bad aftereffects of drinking?

1  Yes
2  No – SKIP to 8a.
_____ Age
1  Yes
2  No - SKIP to 7a
1  Yes
2  No
_____ Month(s)
OR
_____ Year(s)

1  Yes
2  No - SKIP to 7d
1  Yes - SKIP to 7d
2  No
1  Yes
2  No
_____ Month(s)
OR
_____ Year(s)

SKIP to Check Item16.7

_____ Month(s)
OR
_____ Year(s)

1  Yes
2  No - SKIP to Check Item 16.7
1  Yes - SKIP to Check Item16.7
2  No
1  Yes
2  No
1  Yes - SKIP to 11
2  No
1  Yes
2  No

1  Yes
2  No

Page 5

Section 16 – UNUSUAL EXPERIENCES (Continued)
11. Did (that time/ANY of those times) when you had these
UNUSUAL or OTHER experiences BEGIN to happen
DURING or within 1 month AFTER using a medicine or
drug?

12. Did (that time/ANY of those times) when you had these
UNUSUAL or OTHER experiences BEGIN to happen
DURING or within 1 month AFTER experiencing the
bad aftereffects of a medicine or drug?

1  Yes
2  No

1  Yes
2  No

CHECK
ITEM16.8

Is at least 1 item marked “Yes” in 9-12?

1  Yes
2  No - SKIP to 14a

CHECK
ITEM 16.9

Is Check Item 16.3B marked “No”?

1  Yes
2  No - SKIP to Check Item 16.10

13a. During that time, did you STOP (drinking heavily/using
medicines and drugs/experiencing the bad aftereffects of
drinking/medicines and drugs) for at least 1 month?

b. Did you CONTINUE to have these UNUSUAL or OTHER
experiences for at least 1 month AFTER you STOPPED
(drinking heavily/using medicines and drugs/experiencing
the bad aftereffects of drinking/medicines and drugs)?
CHECK
ITEM 16.10

Is 5b marked “Yes” or 6b marked “Yes”?

13c. Did ALL of the times in the last 12 months when you had
these UNUSUAL or OTHER experiences ONLY BEGIN
to happen during or within 1 month after (drinking
heavily/using any medicines or drugs/experiencing the
bad aftereffects of drinking/medicines or drugs)?

d. During ANY of those times in the last 12 months when
you had these UNUSUAL or OTHER experiences after
(drinking heavily/using any medicines or drugs), did you
STOP (drinking heavily/using medicines and
drugs/experiencing the bad aftereffects of
drinking/medicines and drugs) for at least 1 month?

e. During ALL of those times, did you STOP (drinking
heavily/using medicines and drugs/experiencing the bad
aftereffects of drinking/medicines and drugs)?

f. Did you CONTINUE to have these UNUSUAL or
OTHER experiences for at least 1 month AFTER ANY of
those times in the last 12 months when you STOPPED
(drinking heavily/using medicines and drugs/experiencing
the bad aftereffects of drinking/medicines and drugs)?
CHECK
ITEM 16.11

Is 5b marked “Yes”?

13g. Did ALL of the times BEFORE 12 months ago when you
had these UNUSUAL or OTHER experiences ONLY
BEGIN to happen during or within 1 month after
(drinking heavily/using any medicines or drugs/
experiencing the bad aftereffects of drinking/medicines or
drugs)?

h. During ANY of those times BEFORE 12 months ago when
you had these UNUSUAL or OTHER experiences after
(drinking heavily/using any medicines or drugs), did you
STOP (drinking heavily/using medicines and
drugs/experiencing the bad aftereffects of
drinking/medicines and drugs) for at least 1 month?

1  Yes
2  No - SKIP to 14a
1  Yes
2  No

SKIP to 14a

1  Yes
2  No - SKIP to 13g
1  Yes
2  No - SKIP to Check Item 16.11

1  Yes
2  No - SKIP to Check Item 16.11

1  Yes
2  No

1  Yes
2  No

1  Yes - SKIP to 14a
2  No
1  Yes
2  No - SKIP to 14a

1  Yes
2  No - SKIP to 14a

Page 6

Section 16 – UNUSUAL EXPERIENCES (Continued)
13i. During ALL of those times, did you STOP (drinking
heavily/using medicines and drugs/experiencing the bad
aftereffects of drinking/medicines and drugs)?

j. Did you CONTINUE to have these UNUSUAL or OTHER
experiences for at least 1 month AFTER ANY of those
times BEFORE 12 months ago when you STOPPED
(drinking heavily/using medicines and drugs/experiencing
the bad aftereffects of drinking/medicines and drugs)?

14a. Did you EVER talk to any health professional like a
psychiatrist, other medical doctor, psychologist, social
worker or any other kind of counselor or therapist for
help because of these UNUSUAL or OTHER
experiences?

b. Did you EVER go to a self-help or support group, use a
hotline, or visit an internet chat room for help because of
these UNUSUAL or OTHER experiences?

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

15.

Did you EVER go to an emergency room because of these
UNUSUAL or OTHER experiences?

1  Yes
2  No

16.

Were you EVER a patient in any kind of hospital overnight
or longer because of these UNUSUAL or OTHER
experiences?

1  Yes
2  No

17.

Did a doctor EVER prescribe any medicines or drugs for
you because of these UNUSUAL or OTHER experiences?

1  Yes
2  No

CHECK
ITEM 16.12

18.

About how old were you the FIRST time you went
anywhere or talked to anyone for help with these
UNUSUAL or OTHER experiences?

CHECK
ITEM 16.13

19.

Is age in 18 equal to respondent’s current age?

Did you go anywhere or talk to anyone during the last 12
months?

CHECK
ITEM 16.14

20.

Is at least 1 item marked “Yes” in 14a-17?

Is age in 18 at least 2 years less than respondent’s
current age?

Did you go anywhere or talk to anyone before 12 months
ago, that is, BEFORE last (Month one year ago)?

CHECK
ITEM 16.15

Is Check Item 16.3b marked “No”?

21a. Did your UNUSUAL or OTHER experiences BEGIN to
happen DURING a time when you were physically ill or
getting over being physically ill?

b. Did a doctor or other health professional tell you that
your UNUSUAL or OTHER experiences were related to
your physical illness or medical condition?
CHECK
ITEM 16.16

Is 5b marked “Yes” or 6b marked “Yes”?

22a. Did ALL of those times when you had these UNUSUAL
or OTHER experiences in the last 12 months ONLY
BEGIN to happen DURING times when you were
physically ill or getting over being physically ill?

1  Yes
2  No - SKIP to Check Item 16.15
_____ Age

1  Yes – SKIP to Check Item 16.15
2  No
1  Yes
2  No - SKIP to Check Item 16.15
1  Yes – SKIP to Check Item 16.15
2  No
1  Yes
2  No
1  Yes
2  No - SKIP to Check Item 16.16
1  Yes
2  No - SKIP to Check Item 16.18
1  Yes
2  No

SKIP to Check Item 16.18

1  Yes
2  No - SKIP to 22c
1  Yes
2  No - SKIP to Check Item 16.17

Page 7

Section 16 – UNUSUAL EXPERIENCES (Continued)
22b. Did a doctor or other health professional tell you that
ALL of the times like this were related to your physical
illness or medical condition?
CHECK
ITEM 16.17

Is 5b marked “Yes”?

22c. Did ALL of those times when you had these UNUSUAL
or OTHER experiences BEFORE 12 months ago ONLY
BEGIN to happen DURING times when you were
physically ill or getting over being physically ill?

d. Did a doctor or other health professional tell you that
ALL of the times like this were related to your physical
illness or medical condition?
CHECK
ITEM 16.18
CHECK
ITEM 16.18A

1  Yes
2  No - SKIP to Check Item 16.18

1  Yes
2  No
1  Yes
2  No - SKIP to Check Item 16.21

Is “No” marked in Check Item 16.3B?

1  Yes
2  No - SKIP to Check Item 16.19

experiences were happening, did you EVER have a period
when you (felt sad, blue, depressed or down/didn’t care
about things or enjoy things) for at least 2 weeks?

f. During that time, did you (feel sad, blue, depressed or
down/not care about things or enjoy things) for at least half
of the time when those UNUSUAL or OTHER experiences
were happening?
Is 5b marked “Yes” or 6b marked “Yes”?

23.

During ANY of those times that BEGAN in the last 12
months when these UNUSUAL or OTHER experiences
were happening, did you EVER have a period when you
(felt sad, blue, depressed or down/didn’t care about things
or enjoy things) for at least 2 weeks?

24.

During ANY of those times that BEGAN in the last 12
months, did you (feel sad, blue, depressed or down/not care
about things or enjoy things) for at least half of the time
when those UNUSUAL or OTHER experiences were
happening?

25.

During ALL of those times that BEGAN in the last 12
months when some of these UNUSUAL or OTHER
experiences were happening, did you ALWAYS have a
period like this when you (felt sad, blue, depressed or
down/didn’t care about things or enjoy things) for at least
half of the time?

CHECK
ITEM 16.20

1  Yes - SKIP to Check Item 16.18
2  No

Is “Yes” marked in Check Item 4.3 or Check Item
4.3A, Section 4A?

22e. During that time when these UNUSUAL or OTHER

CHECK
ITEM 16.19

1  Yes
2  No

Is 5b marked “Yes”?

26.

During ANY of those times that BEGAN BEFORE 12
months ago when these UNUSUAL or OTHER
experiences were happening, did you EVER have a period
when you (felt sad, blue, depressed or down/didn’t care
about things or enjoy things) for at least 2 weeks?

27.

During ANY of those times that BEGAN BEFORE 12
months ago, did you (feel sad, blue, depressed or down/not
care about things or enjoy things) for at least half of the
time when those UNUSUAL or OTHER experiences were
happening?

1  Yes
2  No – SKIP to Check Item 16.21
1  Yes
2  No

– SKIP to Check Item 16.21

1  Yes
2  No - SKIP to 26
1  Yes
2  No – SKIP to Check Item 16.20

1  Yes
2  No – SKIP to Check Item 16.20

1  Yes
2  No

1  Yes - SKIP to Check Item 16.21
2  No
1  Yes
2  No – SKIP to Check Item 16.21

1  Yes
2  No – SKIP to Check Item 16.21

Page 8

Section 16 – UNUSUAL EXPERIENCES (Continued)
28.

During ALL of those times that BEGAN BEFORE 12
months ago when these UNUSUAL or OTHER experiences
were happening, did you ALWAYS have a period like this
when you (felt sad, blue, depressed or down/didn’t care
about things or enjoy things) for at least half of the time?

CHECK
ITEM 16.21
CHECK
ITEM 16.21A

Is “Yes” marked in Check Item 5.3A or Check
Item 5.3B, Section 5?

1  Yes
2  No - SKIP to Section 11A

Is “No” marked in Check Item 16.3B?

1  Yes
2  No - SKIP to Check Item 16.22

29a. During that time when these UNUSUAL or OTHER
experiences were happening, did you EVER have a period
when you when you felt (excited, elated, revved up, or
energetic/irritable or easily annoyed) for some of the time?

b. During that time, did you feel (excited, elated, revved up or
energetic/irritable or easily annoyed) for at least half of the
time when those UNUSUAL or OTHER experiences were
happening?
CHECK
ITEM 16.22

Is 5b marked “Yes” or 6b marked “Yes”?

30.

During ANY of those times that BEGAN in the last 12
months when these UNUSUAL or OTHER experiences
were happening, did you EVER have a period when you felt
(excited, elated, revved up, or energetic/irritable or easily
annoyed) for some of the time?

31.

During ANY of those times that BEGAN in the last 12
months, did you feel (excited, elated, revved up or
energetic/irritable or easily annoyed) for at least half of the
time when those UNUSUAL or OTHER experiences were
happening?

32.

During ALL of those times that BEGAN in the last 12
months when these UNUSUAL or OTHER experiences
were happening, did you ALWAYS have a period like this
when you felt (excited, elated, revved up or
energetic/irritable or easily annoyed) for at least half of the
time?

CHECK
ITEM 16.23

1  Yes
2  No

Is 5b marked “Yes”?

33.

During ANY of those times that BEGAN BEFORE 12
months ago when these UNUSUAL or OTHER experiences
were happening, did you ALSO have a period when you felt
(excited, elated, revved up or energetic/irritable or easily
annoyed) for some of the time?

34.

During ANY of those times that BEGAN BEFORE 12
months ago, did you feel (excited, elated, revved up or
energetic/irritable or easily annoyed) for at least half of the
time when those UNUSUAL or OTHER experiences were
happening?

35.

During ALL of those times that BEGAN BEFORE 12
months ago when these UNUSUAL or OTHER experiences
were happening, did you ALWAYS have a period like this
when you felt (excited, elated, revved up or
energetic/irritable or easily annoyed) for at least half of the
time?

1  Yes
2  No – SKIP to Section 11A
1  Yes
2  No

– SKIP to Section 11A

1  Yes
2  No - SKIP to 33
1  Yes
2  No – SKIP to Check Item 16.23

1  Yes
2  No – SKIP to Check Item 16.23

1  Yes
2  No

1  Yes - SKIP to Section 11A
2  No
1  Yes
2  No - SKIP to Section 11A

1  Yes
2  No - SKIP to Section 11A

1  Yes
2  No

Go to Section 11A

Page 9

Section 11A - BEHAVIOR
Statement V

Now I’d like to ask you some questions about experiences you may have had. As I read each experience, please
tell me if it has ever happened.

1a. In your ENTIRE life, did you. . .

b. Did this

(Repeat entire phrase frequently)

(1) Often cut class, not go to
class or go to school and
then leave without
permission?

(2) Stay out late at night even
though your parents or
caregivers told you to stay
home?

(3) Often bully or push people
around or try to make them
afraid of you?

(4) Run away from home
overnight at least twice
when you were living at
home, or run away and stay
away for a longer time?

(5) Have a time when you were
absent from work or school
a lot, other than the times
you were sick or taking care
of someone else who was
sick or on military duty?

(6) More than once quit a job
without knowing where you
would find another one?

(7) Make spur of the moment
decisions, like quitting
school, moving or changing
jobs?

(8) Travel around from place
to place for a month or
more without making any
plans ahead of time or
knowing how long you
would be gone or where you
were going to work?

(9) Have a time that lasted at
least 1 month when you had
no regular place to live –
like living on the street or in
a car?

(10) Have a time that lasted at
least 1 month when you
lived with friends,
acquaintances or relatives
because you didn’t really
have your own place to
live?

(11) Have a time in your
life when you lied a lot to
get what you wanted or
avoid something you didn’t
want to do, not counting
any times you lied to keep
from being hurt?

happen
BEFORE
you were 15?

c. Has this happened SINCE
you were 15?

1  Yes
2  No - Go to next
experience

Ask Before 13
1  Yes
2  No

Ask Since 13
1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

Ask Before 13
1  Yes
2  No

Ask Since 13
1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

Page 1

Section 11A - BEHAVIOR (Continued)
1a. In your ENTIRE life, did you. . .

b. Did this

(Repeat entire phrase frequently)

happen
BEFORE you
were 15?

c. Has this happened SINCE
you were 15?

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

(15) Have unprotected sex?

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

(16) Have your driver’s license

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

(23) Shoplift?

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

(24) Steal something from

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

(12) Use a false or made-up
name or alias?

(13) Scam or con someone for
money, to avoid
responsibility or just for
fun?

(14) Do things that could have
easily hurt you or someone
else - like speeding or
driving or using heavy
machinery while drunk or
high?

or learner’s permit
suspended or revoked for
moving violations?

(17) Destroy or damage someone
else’s property - like their
car, home, or other
personal belongings?

(18) Start a fire on purpose to
destroy someone else’s
property or just to see it
burn?

(19) Fail to pay off your debts like moving to avoid paying
rent, not making payments
on a loan, mortgage, or
credit card, or failing to
make alimony or child
support payments?

(20) Steal money or anything of
value from someone or
someplace when no one was
around?

(21) Forge a check or any other
document?

(22) Break into someone else’s
house, building or car?

someone directly, like
mugging them, threatening
them with a weapon or
snatching their purse or
wallet?

1  Yes Go to next
2  No experience

Page 2

Section 11A - BEHAVIOR (Continued)
1a. In your ENTIRE life, did you. . .

b. Did this

(Repeat entire phrase frequently)

(25) Make money illegally - like
selling stolen property or
selling drugs?

(26) Use someone else’s credit
card without their
permission?

(27) Steal using an online
method or scam or over the
telephone?

(28) Do anything that you could
have been arrested for,
regardless of whether or
not you were caught or
arrested?

(29) Force anyone to engage in
any sexual activity with you
against their will?

(30) Get into a lot of fights that
you started?

(31) Physically hurt another
person in any other way on
purpose?

(32) Harass, threaten or
blackmail someone?

(33) Get into a fight that came to
swapping blows with
someone like a husband,
wife, girlfriend or
boyfriend?

(34) Use a weapon like a stick,
knife, or gun in a fight?

(35) Hit someone so hard that
you injured them or they
had to see a doctor?

(36) Hurt or be cruel to an
animal or pet on purpose?

(37) Have a time when you
weren’t working and other
people thought you should
have been?
CHECK
ITEM 11.0

happen
BEFORE
you were 15?

you were 15?

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes Go to next
2  No experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to next
experience

1  Yes
2  No

1  Yes
2  No

Go to next
experience

1  Yes
2  No - Go to Check
Item 11.0

1  Yes
2  No

1  Yes
2  No

Go to Check
Item 11.0

Are at least 3 items marked “Yes” in 1, column a?

1d. About how old were you the FIRST time ANY of these
experiences BEGAN to happen?
CHECK
ITEM 11.1

c. Has this happened SINCE

Are at least 3 items marked “Yes” in 1, column b?
Did respondent demonstrate at least 3 behaviors
BEFORE age 15?

1  Yes
2  No - SKIP to 14a
______ Age
1  Yes
2  No - SKIP to Check Item 11.2

Page 3

Section 11A - BEHAVIOR (Continued)
2.

You just mentioned SOME experiences you had BEFORE
you were 15 years old.
Did any of these experiences you had BEFORE you were
15 years old cause any problems with your family or
friends, at school or with the law?

3a. Did ANY of these experiences you mentioned happen
BEFORE you were 10 years old?

b. Did at least 3 of these experiences you had BEFORE you
were 15 years old happen around the same time or within
a 1-year period?

c. Did you EVER talk to any kind of counselor, therapist,
doctor, psychologist or any person like that about these
experiences you had BEFORE you were 15 years old?

d. Did you EVER regret ANY of those experiences that
happened BEFORE you were 15 or wish they had never
happened?

e. Did you feel you had a right to do ANY of these things?

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No

f. Did you feel that other people deserved what they got?

1  Yes
2  No

g. BEFORE age 15, were you interested or concerned about
how well you were doing at school, work or in other
activities?

h. BEFORE age 15, did you show very little emotion or
feelings to others?

i. BEFORE age 15, would you say that you cared about how
other people felt?
CHECK
ITEM 11.1A

Refer to Check Item 2.1, Section 2A.
Is the respondent a lifetime abstainer of alcohol?

CHECK
ITEM 11.1B

Refer to Q12a, Section 2A.
Is the respondent’s age at first drink less than 15?

4a.

2  No
1  Yes
2  No
1  Yes
2  No
1  Yes - SKIP to 5a
2  No
1  Yes
2  No- SKIP to 5a

Now I’d like you to think about ALL of the experiences
you just mentioned that happened BEFORE you were 15
years old.
Did ANY of these experiences you had BEFORE you
were 15 happen WHILE you were drinking heavily, or
AFTER you had been drinking heavily?

b. Did ALL of these experiences ONLY happen WHILE you
were drinking heavily, or AFTER you had been drinking
heavily?

5a.

1  Yes

(Did/Now I’d like you to think about ALL of the
experiences you just mentioned that happened BEFORE
you were 15 years old. Did) ANY of these experiences you
had BEFORE you were 15 happen WHILE you were
using or AFTER you had used any medicines or drugs?

b. Did ALL of these experiences ONLY happen WHILE you
were using or AFTER you had used any medicines or
drugs?

1  Yes
2  No - SKIP to 5a
1  Yes
2  No
1  Yes
2  No - SKIP to Check Item 11.1C

1  Yes
2  No

Page 4

Section 11A - BEHAVIOR (Continued)
CHECK
ITEM 11.1C

Is “Yes” marked in Check Item 5.3A or
Check Item 5.3B, Section 5?
Did respondent ever have a period of high mood?

5c. Did ANY of these experiences you had BEFORE you were

d.

1  Yes
2  No - SKIP to Check Item 11.1D

15 happen during a period when you felt extremely excited,
elated, revved up or energetic or extremely irritable or
easily annoyed?

1  Yes
2  No - SKIP to Check Item 11.1D

Did ALL of those experiences ONLY happen during periods
when you felt extremely excited, elated, revved up or
energetic or extremely irritable or easily annoyed?

1  Yes
2  No

CHECK
ITEM 11.1D

Is “Yes” marked in Check Item 16.1, Section 16?

5e. Did ANY of these experiences you had BEFORE you were
15 happen during a period when you were having SOME of
the unusual experiences you mentioned?

f. Did ALL of these experiences ONLY happen during times
when you were having SOME of those unusual experiences?
CHECK
ITEM 11.2

1  Yes
2  No - SKIP to Check Item 11.2
1  Yes
2  No

Are at least 3 items marked “Yes” in 1, column c, or
“Yes” in 1(19), column a?
Did respondent demonstrate at least 3 behaviors
SINCE age 15?

CHECK
ITEM 11.2A

1  Yes
2  No - SKIP to Check Item 11.2

Refer to Check Item 2.1, Section 2A.
Is the respondent a lifetime abstainer of alcohol?

1  Yes
2  No - SKIP to 12
1  Yes - SKIP to 7a
2  No

6a. You mentioned some experiences you had SINCE you were
15 years old.
Did ANY of these experiences you had SINCE you were 15
happen WHILE you were drinking heavily, or AFTER you
had been drinking heavily?

b.

Did ALL of these experiences ONLY happen WHILE you
were drinking heavily, or AFTER you had been drinking
heavily?

7a. (Did/You mentioned some experiences you had SINCE you
were 15 years old. Did) ANY of these experiences you had
SINCE you were 15 happen WHILE you were using or
AFTER you had used any medicines or drugs?

b. Did ALL of these experiences ONLY happen WHILE you
were using or AFTER you had used any medicine or drugs?

c. Did you EVER talk to any kind of counselor, therapist,
doctor, psychologist or any person like that about these
experiences you had SINCE you were 15 years old?
CHECK
ITEM 11.2B

Is “Yes” marked in Check Item 5.3A or
Check Item 5.3B, Section 5?
Did respondent ever have a period of high mood?

1  Yes
2  No - SKIP to 7a
1  Yes
2  No
1  Yes
2  No – SKIP to 7c

1  Yes
2  No
1  Yes
2  No

1  Yes
2  No - SKIP to Check Item 11.2c

7d. Did ANY of the experiences you had SINCE you were 15
happen during a time when you felt extremely excited,
elated, revved up or energetic or extremely irritable or
easily annoyed?

e. Did ALL of those experiences ONLY happen during
periods when you felt extremely excited, elated, revved up
or energetic or extremely irritable or easily annoyed?
CHECK
ITEM 11.2C

Is “Yes” marked in Check Item 16.1, Section 16?

1  Yes
2  No - SKIP to Check Item 11.2c
1  Yes
2  No
1  Yes
2  No - SKIP to Check Item 11.3

Page 5

Section 11A - BEHAVIOR (Continued)
7f. Did ANY of those experiences you had SINCE you were 15
happen during a period when you were having SOME of the
unusual experiences you mentioned?

g. Did ALL of those experiences ONLY happen during times
when you were having SOME of these unusual experiences?
CHECK
ITEM 11.3

Is at least 1 item marked “Yes” in 1(3), (13), (14),
(17) - (35), column c, or “Yes” marked in 1(19),
column a?
Has respondent ever destroyed or stolen property or
mistreated or harmed another person?

1  Yes
2  No - SKIP to Check Item 11.3
1  Yes
2  No

1  Yes
2  No - SKIP to 9

8a. You mentioned some experiences that you’ve had in your
life when you (destroyed property/stole something/
mistreated or harmed another person).
Have you regretted ANY of these experiences or wished
they had never happened?

1  Yes
2  No

b. Did you feel you had a right to do ANY of these things?

1  Yes
2  No

c. Did you feel that other people deserved what they got?

1  Yes
2  No

9. SINCE age 15, were you interested or concerned about how
well you were doing at school, work or in other activities?

10. SINCE age 15, did you show very little emotion or feelings
to others?

11. SINCE age 15, would you say that you cared about how other
people felt?

12. Was there EVER a time when you NO LONGER had ANY of
the experiences you just mentioned, that is, a time when
NONE of the experiences EVER happened again?

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No – Go to 14a

13. About how old were you when that happened?
________Age

14a. BEFORE you were 18, were you ever in jail, prison, or a
juvenile detention center?

b. About how long altogether were you in jail or a juvenile
detention center before you were 18?

15a. SINCE you were 18, were you ever in jail, prison, or a
correctional facility?

b. About how long altogether were you in jail or a correctional
facility since you were 18?

1  Yes
2  No - SKIP to 15a
_____ Day(s)
OR
_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)
1  Yes
2  No - SKIP to Section 11B
_____ Day(s)
OR
_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)

Go to Section 11B

Page 6

Section 11B - FAMILY HISTORY - IV
Now I would like to ask you about whether any of your relatives, regardless of whether or not they are
now living, have ever had behavior problems.
(SHOW FLASHCARD 56)

Statement W

By behavior problems I mean being cruel to people or animals, fighting or destroying property, trouble
keeping a job or paying bills, being impulsive, reckless or not planning ahead, lying or conning people or
getting arrested. These people also do not seem to care if they hurt others and often have problems at an
early age such as truancy, staying out all night or running away.
(REFER TO FLASHCARD FREQUENTLY)

1.

In your judgment, did your blood or natural father have
some of these behavior problems like this at ANY time in
his life?

1  Yes
2  No

2.

Did your blood or natural mother have some of these
behavior problems like this at ANY time in her life?

1  Yes
2  No

3.

(Did your full brother have/How many of your full
brothers had) some of these behavior problems at ANY
time in (his life/their lives)?

1  Yes
2  No
OR
_____ Number
0  None

4.

(Did your full sister have/How many of your full sisters
had) some of these behavior problems at ANY time in (her
life/ their lives)?

1  Yes
2  No
OR
_____ Number
0  None

5.

(Did your natural son have/How many of your natural sons
had) some of these behavior problems at ANY time in (his
life/their lives)?

1  Yes
2  No
OR
_____ Number
0  None

6.

(Did your natural daughter have/How many of your
natural daughters had) some of these behavior problems at
ANY time in (her life/their lives)?

1  Yes
2  No
OR
_____ Number
0  None

7.

(Did your natural father’s full brother have/How many of
your natural father’s full brothers had) some of these
behavior problems at ANY time in (his life/their lives)?

1  Yes
2  No
OR
_____ Number
0  None

8.

(Did your natural father’s full sister have/How many of
your natural father’s full sisters had) some of these
behavior problems at ANY time in (her life/their lives)?

1  Yes
2  No
OR
_____ Number
0  None

9.

(Did your natural mother’s full brother have/How many of
your natural mother’s full brothers had) some of these
behavior problems at ANY time in (his life/ their lives)?

1  Yes
2  No
OR
_____ Number
0  None

10. (Did your natural mother’s full sister have/How many of

1  Yes
2  No
OR
_____ Number
0  None

11. Did your natural grandfather on your father’s side have

1  Yes
2  No

12. Did your natural grandmother on your father’s side have

1  Yes
2  No

13. Did your natural grandfather on your mother’s side have

1  Yes
2  No

14. Did your natural grandmother on your mother’s side have

1  Yes
2  No

your natural mother’s full sisters had) some of these
behavior problems at ANY time in (her life/their lives)?

some of these behavior problems at ANY time in his life?

some of these behavior problems at ANY time in her life?

some of these behavior problems at ANY time in his life?

some of these behavior problems at ANY time in her life?

Go to Section 17

Page 1

Section 17 – LOW WEIGHT
Now I’d like to ask you a few questions about your eating habits.

Statement DD

1.

What has been your LOWEST weight since you reached
your current height, not counting times when you were ill?

CHECK
ITEM 17.1

Is lowest weight in 1 less than 85% of that
expected?

Weight
Pounds
1  Yes
2  No – SKIP to Section 18

(Refer to norms for men and women.)

3.

How old were you when your weight first reached (weight
in 1) at your current height?

4.

When your weight was (weight in 1), did you restrict the
amount of food you ate in order not to gain any weight
even though other people thought you should?

1  Yes
2  No

5.

During that time when your weight was (weight in 1), were
you afraid of gaining weight or getting fat?

1  Yes
2  No

_____ Age

6a. When your weight was (weight in 1), …
Did you think that you looked fat?

b. Did you think your weight or body shape was one of the
most important things about you?

c. Did you think that your weight might have been
unhealthy?

d. Did you believe other people who thought your weight
was unhealthy?

e. Were you constantly weighing yourself or taking
measurements of various parts of your body?

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No

7a. Now I’d like to know if you did any of the following things
to lose weight BEFORE you weighed (weight in 1) or to
keep from gaining weight AFTER you reached (weight in
1).
During either of those times did you…
Eat an UNUSUALLY LARGE amount of food within a
2-hour period, not including the holidays; that is, eat
much more food than most people would eat during a 2hour period under similar circumstances?

b. Vomit, use enemas, laxatives, diuretics or other
medicines AFTER you ate an UNUSUALLY LARGE
amount of food?

c.

Diet, fast, not use solid foods, or exercise a lot AFTER
you ate an UNUSUALLY LARGE amount of food?

d. Vomit, use enemas, laxatives, diuretics or other
medicines AFTER you ate a SMALL amount or
REGULAR amount of food?

1  Yes
2  No – SKIP to 7d

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No

e.

Diet, fast, not use solid foods, or exercise a lot AFTER
you ate a SMALL amount or REGULAR amount of
food?

1  Yes
2  No

f.

Diet, fast, not use solid foods, or exercise a lot regardless
of what or how much you ate?

1  Yes
2  No

Page 1

Section 17 – LOW WEIGHT (Continued)
CHECK
ITEM 17.2

Is at least 1 item marked “Yes” in 7b-7f?

7g. Did ANY of the things we just talked about when you
were losing weight or when you were trying to keep from
gaining weight happen repeatedly for at least 3 months?

1  Yes
2  No – Go to 8a
1  Yes
2  No

8a. Now, I’d like to ask you about some other things that
might have happened to you during that time when you
weighed (weight in 1) and you had some of the other
experiences we just talked about.
During that time did your low weight…
Make you very upset?

1  Yes
2  No

b. Interfere with your normal daily activities?

1  Yes
2  No

c. Cause any serious problems getting along with other

1  Yes
2  No

people – like arguing with your friends, family, people at
work or anyone else?

d. Cause any serious problems doing the things you were
supposed to do – like working, doing your schoolwork, or
taking care of your home or family?

9.

About how old were you when you FIRST weighed less
than (85% of expected weight) and had SOME of the
other experiences you mentioned at the same time?

CHECK
ITEM 17.3

Is respondent’s age in 9 within 1 year of his/her present
age or is present age unknown?

10.

Did this FIRST time BEGIN to happen during the last 12
months?

11.

In your ENTIRE life how many separate times were
there when you weighed less than (85% of expected
weight) and had SOME of the other experiences you
mentioned at the same time?

1  Yes
2  No

_____ Age
1  Yes
2  No - SKIP to 11
1  Yes
2  No
_____ Times

By separate times, I mean times separated by at least 3
months when you weighed at least (85% of expected
weight) and DIDN’T have any of the other experiences
you mentioned at the same time?
CHECK
ITEM 17.4

12.

Is number in 11, 2 or more or unknown?

About how old were you the MOST RECENT time when
you weighed less than (85% of expected weight) and you
also had SOME of these other experiences?

CHECK
ITEM 17.5

Is respondent’s age in 12 within 1 year of his/her
present age or is present age unknown?

13.

Did this MOST RECENT time BEGIN to happen in the
last 12 months?

14.

How long did this MOST RECENT time last when you
weighed less than (85% of expected weight)?

15.

Since this MOST RECENT time BEGAN, was there a
time when you weighed at least (85% of expected weight)
and DIDN’T have ANY of the OTHER experiences you
mentioned at the same time?

CHECK
ITEM 17.6

Is 13 marked “Yes”?

1  Yes
2  No - SKIP to 18
_____ Age
1  Yes
2  No - SKIP to 14
1  Yes
2  No
_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)
1  Yes
2  No - SKIP to 17

1  Yes - SKIP to 17
2  No

Page 2

Section 17 – LOW WEIGHT (Continued)
1  Yes
2  No

16.

Did this MOST RECENT time when you weighed at least
(85% of expected weight) BEGIN to happen in the last 12
months?

17.

In your ENTIRE LIFE, what was the LONGEST time
that you had when you weighed less than (85% of
expected weight)?

_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)

18.

How long did that time last when you weighed less than
(85% of expected weight)?

_____ Week(s)
OR
_____ Month(s)
OR
_____ Year(s)

19.

Since that time BEGAN, was there a time when you
weighed at least (85% of expected weight) and DIDN’T
have ANY of the OTHER experiences you mentioned
around the same time?

CHECK
ITEM 17.7

Is 10 marked “Yes”?

1  Yes
2  No - SKIP to 21a

1  Yes - SKIP to 21a
2  No

Did this time when you weighed at least (85% of
expected weight) BEGIN to happen in the last 12
months?

1  Yes
2  No

21a. Did you EVER talk to any kind of counselor, therapist,

1  Yes
2  No

20.

doctor, psychologist or any person like that to get help
for your low weight?

21b. Did you EVER go to a self-help or support group, use a

1  Yes

hotline or visit an internet chat room to get help for
your low weight? (Do not count chat rooms/support
groups that promoted low weight or offered advice on how
to lose weight.)

2  No

22.

Were you EVER a patient in any kind of hospital
overnight or longer because of your low weight?

1  Yes
2  No

23.

Did you EVER go to an emergency room for help at
any time for your low weight?

1  Yes
2  No

24.

Did a doctor EVER prescribe any medicines or drugs to
help you with your low weight?

1  Yes
2  No

25.

Did you EVER go to Overeaters Anonymous or any
other 12-step group because of your weight or eating?

1  Yes
2  No

CHECK
ITEM 17.8

26.

About how old were you the FIRST time you went
anywhere or talked to anyone to get help for your low
weight?

CHECK
ITEM 17.9

27.

Is at least 1 item marked “Yes” in 21a-25?

Is age in 26 equal to respondent’s current age?

Did you go anywhere or talk to anyone in the last 12
months?

CHECK
ITEM 17.10

Is age in 26 at least 2 years less than respondent’s
current age?

SKIP to 21a

1  Yes
2  No - SKIP to 29
_____ Age
1  Yes - SKIP to 29
2  No
1  Yes
2  No - SKIP to 29
1  Yes - SKIP to 29
2  No

28.

Did you go anywhere or talk to anyone before 12
months ago, that is, BEFORE last (Month one year
ago)?

1  Yes
2  No

29.

Did you EVER go to a self-help or support group, use
a hotline or visit an internet chat room that
ENCOURAGED you to be extremely thin and offered
advice on methods for losing weight?

1  Yes
2  No

- Go to Section 18

Page 3

Section 18 – EATING AND OVEREATING
Statement EE

Now a few more questions about your eating habits.

1.

Have you EVER eaten an UNUSUALLY LARGE
AMOUNT of food within any 2-hour period, not including
the holidays? That is, eating more food than most people
would eat during a 2-hour period under similar
circumstances.

1  Yes
2  No - SKIP to end of interview

2.

Was there EVER a time when you ate an UNUSUALLY
LARGE AMOUNT of food on average at least once a
week for at least 3 months?

1  Yes
2  No - SKIP to end of interview

3a. During ANY time like this when you ate an UNUSUALLY
LARGE AMOUNT of food, did you . . .
(Repeat phrase often.)
Feel that you couldn’t stop eating or control how much or
what you were eating?

b. Feel that your weight or body shape was one of the most
important things about you?

1  Yes
2  No - SKIP to end of interview
1  Yes
2  No

c. Find that you ate much more quickly than usual?

1  Yes
2  No

d. Find that you ate until you felt uncomfortably full?

1  Yes
2  No

e. Eat an UNUSUALLY LARGE AMOUNT of food even

1  Yes
2  No

though you weren’t hungry?

f. Eat alone because you might be embarrassed by how
much you were eating?

g. Feel disgusted with yourself, depressed or very guilty
about eating so much?

4a. During ANY of those times when you were eating an
UNUSUALLY LARGE AMOUNT of food, did you try to
keep from gaining weight by vomiting, using enemas,
laxatives, diuretics or other medicines, or by fasting, that
is having no solid food, or exercising a lot?

b. During ALL of those times when you were eating an
UNUSUALLY LARGE AMOUNT of food, did you
ALWAYS try to keep from gaining weight by vomiting,
using enemas, laxatives, diuretics or other medicines, or
by fasting or exercising a lot?

5.

6.

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No – SKIP to 7a (Do not read parentheticals in 7a-25)

1  Yes
2  No

Did you EVER eat an UNUSUALLY LARGE AMOUNT
of food within 2-hour periods AND do SOME of the other
things we talked about to keep from gaining weight on
average at least once a week for at least 3 months?

1  Yes
2  No

When you were eating an UNUSUALLY LARGE
AMOUNT of food AND doing some of the things we
talked about to keep from gaining weight around the same
time, was your weight or body shape the most important
thing about you?

1  Yes
2  No

(Read parentheticals in 7a-25)

7a. Now I’d like to ask you about some other things that
might have happened to you during a time when you
were eating an UNUSUALLY LARGE AMOUNT of
food (AND doing some of the things we talked about to
keep from gaining weight around the same time).
During ANY of these times, did eating LARGE
AMOUNTS of food (AND doing some of the things we
talked about to keep from gaining weight) . . .
Make you very upset?

b. Interfere with your normal daily activities?

1  Yes
2  No
1  Yes
2  No

Page 1

Section 18 – EATING AND OVEREATING (Continued)
7c. Cause serious problems getting along with people at
work or anyone else?

d.

Cause any serious problems doing the things you were
supposed to do – like working, doing your schoolwork
or taking care of your home or family?

1  Yes
2  No
1  Yes
2  No

8a. About how old were you the FIRST time you BEGAN to
eat LARGE AMOUNTS of food (AND do some things to
keep from gaining weight) on average at least once a
week for at least 3 months?
CHECK
ITEM 18.1

Is respondent’s age in 8a within 1 year of his/her
present age or is present age or 8a unknown?

8b. Did this FIRST time BEGIN to happen during the last
12 months?

9.

In your ENTIRE LIFE, how many separate times were
there when you were eating LARGE AMOUNTS of
food (AND doing some things to keep from gaining
weight) on average at least once a week for at least 3
months?

_____ Age

1  Yes
2  No - SKIP to 9
1  Yes
2  No
_____ Number

By separate times, I mean times separated by at least 3
months when you WEREN’T eating LARGE
AMOUNTS of food (AND DIDN’T do ANY of the
things we talked about to keep from gaining weight)?
CHECK
ITEM 18.2

10.

How old were you the MOST RECENT time you
BEGAN to eat LARGE AMOUNTS of food (AND do
some things to keep from gaining weight)?

CHECK
ITEM 18.3

11.

Is number entered in 9, 2 or more or unknown?

Is respondent’s age in 10 within 1 year or his/her
present age or is present age or 10 unknown?

Did this MOST RECENT time BEGIN to happen
during the last 12 months?

12a. How long did this MOST RECENT time last when you
ate LARGE AMOUNTS of food (AND did some things
to keep from gaining weight)?

1  Yes
2  No - SKIP to 16
_____ Age
1  Yes
2  No - SKIP to 12a
1  Yes
2  No
_____ Month(s)
OR
_____ Year(s)

(Must be at least 3 months.)

b. Since this MOST RECENT time BEGAN, have there
been at least 3 months when you DIDN’T eat LARGE
AMOUNTS of food (AND DIDN’T do anything to keep
from gaining weight)?
CHECK
ITEM 18.4

Is “Yes” marked in 11?

13.

Did this MOST RECENT time when you STOPPED
eating LARGE AMOUNTS of food (and doing things to
keep from gaining weight) BEGIN to happen in the last
12 months?

14.

In your ENTIRE LIFE, what was the LONGEST time
you had when you ate LARGE AMOUNTS of food
(AND did some things to keep from gaining weight)?

1  Yes
2  No - SKIP to 14

1  Yes- SKIP to 14
2  No
1  Yes
2  No

_____ Month(s)
OR
_____ Year(s)

(Must be at least 3 months.)

15.

During these times, what was the usual number of days
per week that you ate LARGE AMOUNTS of food
(AND did some things to keep from gaining weight)?

_____ Number of days per week – SKIP to 20a

Page 2

Section 18 – EATING AND OVEREATING (Continued)
16.

How long did that time last when you ate LARGE
AMOUNTS of food (AND did some things to keep from
gaining weight)?
(Must be at least 3 months.)

17.

During that time, what was the usual number of days
per week that you ate LARGE AMOUNTS of food
(AND did some things to keep from gaining weight)?

18.

Since that time BEGAN, have there been at least 3
months when you DIDN’T eat LARGE AMOUNTS of
food (AND DIDN’T do anything to keep from gaining
weight)?

CHECK
ITEM 18.5

19.

Is “Yes” marked in 8b?

Did this time when you STOPPED eating LARGE
AMOUNTS of food (and doing things to keep from
gaining weight) BEGIN to happen in the last 12
months?

20a. Did you EVER go to any kind of counselor, therapist,
doctor, psychologist or any person like that to help you
stop eating LARGE AMOUNTS of food (OR doing
things to keep from gaining weight)?

b. Did you EVER go to a self-help or support group, use a
hotline or visit an internet chat room to help you stop
eating LARGE AMOUNTS of food (OR doing things to
keep from gaining weight)?

21a. Were you a patient in any kind of hospital overnight or
longer because you were eating LARGE AMOUNTS of
food (OR doing things to keep from gaining weight)?

b. Did you EVER go to an emergency room to help you
stop eating LARGE AMOUNTS of food (OR doing
things to keep from gaining weight)?

22a. Did a doctor EVER prescribe any medicines or drugs to
help you stop eating LARGE AMOUNTS of food (OR
doing things to keep from gaining weight)?

b. Did you EVER go to Overeaters Anonymous or any
other 12-step group to help you stop eating large
amounts of food (OR doing things that kept you from
gaining weight)?
CHECK
ITEM 18.6

23.

How old were you the FIRST TIME you went anywhere
or saw anyone to get help for eating LARGE
AMOUNTS of food (OR doing things to keep from
gaining weight)?

CHECK
ITEM 18.7

24.

Is age in 23 at least 2 years less than respondent’s
current age?

Did you go anywhere or talk to anyone BEFORE 12
months ago, that is, BEFORE last (Month one year ago)?

CHECK
ITEM 18.9

26.

Is age in 23 equal to respondent’s current age?

Did you go anywhere or talk to anyone in the last 12
months?

CHECK
ITEM 18.8

25.

Is at least 1 item marked “Yes” in 20a-22b?

Is “No” marked in 4b or is 4b unknown?

Were there EVER ANY OTHER times lasting at least 3
months when you ate LARGE AMOUNTS of food at
least once a week WITHOUT doing any of the things
you mentioned to keep from gaining weight?

_____ Month(s)
OR
_____ Year(s)

_____ Number of days per week
1  Yes
2  No - SKIP to 20a

1  Yes - SKIP to 20a
2  No
1  Yes
2  No

1  Yes
2  No

1  Yes
2  No

1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No

1  Yes
2  No - SKIP to Check Item 18.9
_____ Age

1  Yes - SKIP to Check Item 18.9
2  No
1  Yes
2  No - SKIP to Check Item 18.9
1  Yes - SKIP to Check Item 18.9
2  No
1  Yes
2  No
1  Yes
2  No - SKIP to 47
1  Yes
2  No - SKIP to 47

Page 3

Section 18 – EATING AND OVEREATING (Continued)
27a. During ANY time when you ate an UNUSUALLY
LARGE AMOUNT of food did this…
Make you very upset?

1  Yes
2  No

b. Interfere with your normal daily activities?

1  Yes
2  No

c. Cause serious problems getting along with people at

1  Yes
2  No

work or anyone else?

d. Cause any serious problems doing the things you were
supposed to do – like working, doing your schoolwork,
or taking care of your home or family?

28a. When you were eating an UNUSUALLY LARGE
AMOUNT of food, was your weight or body shape the
most important thing about you?

b.

About how old were you the FIRST time you BEGAN to
eat LARGE AMOUNTS of food on average at least once
a week for at least 3 months?

CHECK
ITEM 18.10

Is respondent’s age in 28b within 1 year of his/her
present age or is present age or 28b unknown?

29. Did this FIRST time BEGIN to happen during the last
12 months?

30. In your ENTIRE LIFE, how many separate times were
there when you were eating LARGE AMOUNTS of
food on average at least once a week for at least 3
months WITHOUT doing anything to keep from
gaining weight?

1  Yes
2  No
1  Yes
2  No

_____ Age
1  Yes
2  No - SKIP to 30
1  Yes
2  No
_____ Number

By separate times, I mean times separated by at least 3
months when you WEREN’T eating LARGE
AMOUNTS of food.
CHECK
ITEM 18.11

31.

How old were you the MOST RECENT time you
BEGAN to eat LARGE AMOUNTS of food?

CHECK
ITEM 18.12

32.

Is number entered in 30, 2 or more or unknown?

Is respondent’s age in 31 within 1 year or his/her
present age or is present age or 31 unknown?

Did this MOST RECENT time BEGIN to happen
during the last 12 months?

33a. How long did this MOST RECENT time last when you
ate LARGE AMOUNTS of food?

1  Yes
2  No - SKIP to 37
_____ Age
1  Yes
2  No - SKIP to 33a
1  Yes
2  No
_____ Months(s)
OR
_____ Years(s)

(Must be at least 3 months.)

b. Since this MOST RECENT time BEGAN, have there
been at least 3 months when you DIDN’T eat LARGE
AMOUNTS of food?
CHECK
ITEM 18.13

Is “Yes” marked in 32?

34.

Did this MOST RECENT time when you STOPPED
eating LARGE AMOUNTS of food BEGIN to happen
in the last 12 months?

35.

In your ENTIRE LIFE, what was the LONGEST time
that you’ve had when you ate LARGE AMOUNTS of
food)?

1  Yes
2  No - SKIP to 35
1  Yes- SKIP to 35
2  No
1  Yes
2  No
_____ Months(s)
OR
_____ Years(s)

(Must be at least 3 months.)

36.

During these times, what was the usual number of days
per week that you ate LARGE AMOUNTS of food?

_____ Number of days per week – SKIP to 41a
Page 4

Section 18 – EATING AND OVEREATING (Continued)
37.

How long did that time last when you ate LARGE
AMOUNTS of food?
(Must be at least 3 months.)

38.

During that time what was the usual number of days
per week that you ate LARGE AMOUNTS of food?

39.

Since that time BEGAN, have there been at least 3
months when you DIDN’T eat LARGE AMOUNTS of
food?

CHECK
ITEM 18.14

40.

Is “Yes” marked in 29?

Did this time when you STOPPED eating LARGE
AMOUNTS of food BEGIN to happen in the last 12
months?

41a. Did you EVER go to any kind of counselor, therapist,
doctor, psychologist or any person like that to help you
stop eating LARGE AMOUNTS of food?

b. Did you EVER go to a self-help or support group, use a
hotline or visit an internet chat room to help you stop
eating LARGE AMOUNTS of food?

42a. Were you a patient in a hospital for at least one night
because you were eating LARGE AMOUNTS of food?

1  Yes - SKIP to 41a
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No
1  Yes
2  No

Did a doctor EVER prescribe any medicines or drugs to
help you stop eating LARGE AMOUNTS of food?

1  Yes
2  No

Is at least 1 item marked “Yes” in 41a-43?

How old were you the FIRST TIME you went anywhere
or saw anyone to get help for eating LARGE
AMOUNTS of food?

CHECK
ITEM 18.16

45.

1  Yes
2  No - SKIP to 41a

1  Yes
2  No

CHECK
ITEM 18.15

44.

_____ Number of days per week

stop eating LARGE AMOUNTS of food?

b. Did you EVER go to an emergency room to help you
43.

_____ Months(s)
OR
_____ Years(s)

Is age in 44 equal to respondent’s current age?

Did you go anywhere or talk to anyone in the last 12
months?

CHECK
ITEM 18.17

Is age in 23 at least 2 years less than respondent’s
current age?

1  Yes
2  No - SKIP to 47
_____ Age
1  Yes - SKIP to 47
2  No
1  Yes
2  No - SKIP to 47
1  Yes - SKIP to 47
2  No

46.

Did you go anywhere or talk to anyone BEFORE 12
months ago, that is, BEFORE last (Month one year ago)?

1  Yes
2  No

Skip to 47

47.

Did you EVER go to a self-help or support group, use a
hotline or visit an internet chat room that
ENCOURAGED you to be extremely thin and offered
advice on methods for losing weight?

1  Yes
2  No

- GO to end of interview

Page 5

NESARC-III
FLASHCARD
BOOKLET

FLASHCARD INDEX
1

Race

29

2

Country of Heritage or Ancestry

29A-C Liquor Ounce Size

3

Marital Status

30

Frequency of Drinking

4

Current Situation

31

Frequency of Drinking

5

Education

32

Reasons

6

Service Dates

33

Frequency

7

Industry

34

How Well

8

Occupation

35

Agree – Disagree

9

Type of Employer

36

How Often

10

Your Total Personal Income

37

True – False

11

Your Total Personal Income

38

True – False

12

Your Total Combined Family Income

39

Frequency of Smoking

13

Your Total Combined Family Income

40

Types of Medicines/Drugs

14

Your Total Combined Household Income

41

Frequency of Medicine/Drug Use

15

Your Total Combined Household Income

42

Frequency of Medicine/Drug Use

16

How Often

43

Reasons

17

Activities

44

Relatives

18

How Much Time

45

Stressful Life Experiences

19

How Much Pain

46

How Often

20

Service Attendance

47

How Often True

21

Religion

48

Frequency

22

How Often

49

Attraction

23

Frequency

50

Orientation

24

Frequency

51

Frequency

25

Number of Drinks

52

Relationship to You

26

Size of Cooler

53

How Much

26A-C Cooler Ounce Size

54

How Often

27

Size of Beer

55

Relatives

28

Size of Wine

56

Relatives

57

Size/Type of Container

28A-C Wine Ounce Size

Size of Liquor

CARD 1
RACE
1

American Indian or Alaska Native

2

Asian

3

Black or African American

4

Native Hawaiian or Other Pacific Islander

5

White

CARD 2
COUNTRY OF HERITAGE OR ANCESTRY
AFRICA
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.

Algeria
Angola
Benin
Botswana
Burkina Faso
Cameroon
Cape Verde
Central African Republic
Chad
Congo
Comoros
Djibouti
Ivory Coast
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Ghana
Guinea
Guinea Bissau
Kenya
Lesotho
Liberia
Libya
Madagascar
Gambia
Mali
Mauritania
Morocco
Mozambique
Namibia
Niger
Nigeria
Republic of the Congo
Reunion
Rwanda
Senegal
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
Tanzania
Togo
Tunisia
Uganda
Western Sahara
Zambia
Zimbabwe
Malawi
Sao Tome and Principe
Wallis and Futuna
Unknown/other African

ASIA
55.
56.
57.
58.
59.
60.
61.
62.
63.

Afghanistan
Bangladesh
Bhutan
Brunei
Burma/Myanmar
Cambodia
China
Hong Kong
India

64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.

Indonesia
Japan
Laos
Malaysia
Mayotte
Mongolia
Nepal
North Korea
Pakistan
Philippines
Seychelles
Singapore
South Korea
Sri Lanka
Taiwan
Thailand
Vietnam
Unknown/other Asian

AUSTRALIA, OCEANIA
82. American Samoan
Islands
83. Australia
84. Cook Island
85. Fiji
86. French Polynesia
87. Guam
88. Kiribati
89. Maldives
90. Marshall Islands
91. Melanesia
92. Micronesia
93. New Caledonia
94. New Zealand
95. Palau
96. Papua New Guinea
97. Polynesia
98. Samoa Islands
99. Solomon Islands
100. Tonga
101. Tuvalu
102. Vanuatu
103. Unknown/other
Oceania

COMMONWEALTH OF
INDEPENDENT STATES
(RUSSIA)
104.
105.
106.
107.
108.
109.
110.
111.
112.
113.
114.
115.
116.

Armenia
Azerbaijan
Belarus
Georgia
Kazakhstan
Kyrgyzstan
Moldova
Russia
Tajikistan
Turkmenistan
Ukraine
Uzbekistan
Unknown/other
Russian

EUROPE
117.
118.
119.
120.
121.
122.
123.
124.
125.
126.
127.
128.
129.
130.
131.
132.
133.
134.
135.
136.
137.
138.
139.
140.
141.
142.
143.
144.
145.
146.
147.
148.
149.
150.
151.
152.
153.
154.
155.
156.
157.
158.
159.
160.
161.
162.
163.
164.
165.

Albania
Austria
Belgium
Bosnia and Herzegovina
Bulgaria
Channel Islands
Croatia
Cyprus
Czech Republic
Denmark
Estonia
England
Finland
France
Germany
Gibraltar
Greece
Greenland
Hungary
Iceland
Ireland
Italy
Latvia
Lithuania
Luxembourg
Monaco
Macedonia
Netherlands
New Caledonia
Norway
Poland
Portugal
Romania
San Marino
Serbia
Scotland
Slovakia
Slovenia
Spain
Sweden
Switzerland
Turkey
Montenegro
Malta
Isle of Man
Andorra
Faeroe Island
Liechtenstein
Unknown/other
European

MIDDLE EAST
166.
167.
168.
169.
170.
171.
172.
173.
174.
175.
176.
177.
178.

Gaza Strip
Iran
Iraq
Israel
Jordan
Kuwait
Lebanon
Oman
Qatar
Saudi Arabia
Syria
United Arab Emirates
West Bank

179. Yemen
180. Bahrain
181. Unknown/other Middle
Eastern

NORTH AND CENTRAL
AMERICA & CARIBBEAN
182. Anguilla
183. Antigua and Barbuda
184. Aruba
185. Barbados
186. Belize
187. Canada
188. Cayman Islands
189. Costa Rica
190. Cuba
191. Dominica
192. Dominican Republic
193. El Salvador
194. Grenada
195. Guatemala
196. Haiti
197. Honduras
198. Jamaica
199. Marie Galante
200. Martinique
201. Mexico
202. Montserrat
203. Netherlands Antilles
204. Nicaragua
205. Panama
206. Puerto Rico
207. St. Bartholomew
208. St. Kitts and Nevis
209. St. Lucia
210. St. Martin
211. St. Vincent and the
Grenadines
212. The Bahamas
213. Trinidad
214. United States
215. Virgin Islands (British)
216. Virgin Islands (U.S.)
217. Unknown/other
North/Central American
or Caribbean

SOUTH AMERICA
218.
219.
220.
221.
222.
223.
224.
225.
226.
227.
228.
229.
230.
231.

Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Falkland Islands
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Unknown/other South
American

CARD 3
MARITAL STATUS
1

Married

2

Living with someone as if married
(not currently married or separated from someone)

3

Widowed

4

Divorced

5

Separated

6

Never married

CARD 4
CURRENT SITUATION
1 Working full time, that is, 35 hours or more per week
2 Working part time, that is, less than 35 hours per week
3 Have a job or business, but not at work because of temporary
illness or injury
4 Have a job or business, but on paid vacation
5 Have a job or business, but absent from work without pay
6 Unemployed or laid off and looking for work
7 Unemployed or laid off and not looking for work
8 Unemployed and permanently disabled
9 Retired
10 In school, full time
11 In school, part time
12 Currently on summer break/holiday from school
13 Full-time homemaker
14 Something else

CARD 5
EDUCATION
1 No formal schooling
2 Completed grade K, 1, or 2
3 Completed grade 3 or 4
4 Completed grade 5 or 6
5 Completed grade 7
6 Completed grade 8
7 Completed grade 9, 10 or 11 (some high school)
8 Completed high school
9 Graduate equivalency degree (GED)
10 Some college (no degree)
11 Completed Associate or other technical 2 year degree
12 Completed college (Bachelor’s degree)
13 Some graduate or professional studies (completed Bachelor’s
degree but not graduate degree)
14 Completed Master’s degree or equivalent or higher graduate
degree

CARD 6
SERVICE DATES
1 September 2011 – Present
2 September 2009 – August 2011
3 September 2004 – August 2009
4 September 2001– August 2004
5 August 1990 to August 2001 (including Persian Gulf War)
6 September 1980 to July 1990
7 May 1975 to August 1980
8 Vietnam era (August 1964 – April 1975)
9 March 1961 to July 1964
10 February 1955 to February 1961
11 Korean War (July 1950 – January 1955)
12 January 1947 to June 1950
13 World War II (December 1941 – December 1946)
14 November 1941 or earlier

CARD 7
INDUSTRY
1 Agriculture (farming, forestry, veterinary and landscaping services)
2 Mining (metal, coal, oil and gas extraction, quarrying)
3 Construction
4 Manufacturing (food products, tobacco, textiles, chemical products, lumber, metal
industries, machinery, motor vehicles)
5 Transportation, Communications and Other Public Utilities (railroads, airlines,
bus, taxi, trucking, warehouse, postal, telephone, gas, electric, water)
6 Wholesale Trade (sales of durable and nondurable goods to retailers)
7 Retail Trade (retail stores, restaurants, drug stores, gas stations)
8 Finance, Insurance and Real Estate (banks, savings and credit, brokerage,
investment, commodities, real estate)
9 Business and Repair Services (advertising, computer and other business
services, auto renting/leasing)
10 Personal Services (hotel, laundry, barber/beauty shop, funeral services, shoe
repair, private household service)
11 Entertainment and Recreation Services (theaters, video rental, bowling)
12 Professional and Related Services (doctors’ offices, hospital, schools, libraries,
child care services, museums, labor unions, engineering and accounting firms,
religious organizations)
13 Public Administration (international, national, state and local government)
14 Armed Services

CARD 8
OCCUPATION
1 Executive, Administrative, and
Managerial
2 Professional Specialty

3 Technical and Related Support

4 Sales

5 Administrative Support, including
Clerical

6 Private Household
7 Protective Services
8 Other Services

9 Farming, Forestry and Fishing

10

Precision Production, Craft and
Repair

11

Operators, Fabricators and Laborers

12

Transportation and Material Moving

13

Handlers, Equipment Cleaners and
Laborers

14

Military

• Managers (business, financial, restaurant, hotel)
• Public administrators
• Administrators
• Teachers
• Computer system analysts
• Scientists
• Librarians
• Lawyers
• Doctors, RN’s, PA’s
• Accountants
• Writers/artists/athletes
• Health technicians & technologists, LPN’s, dental
hygienists
• Computer programmers & operators
• Other technicians/technologists (industrial)
• Sales representatives (retail, insurance, real estate)
• Sales workers, cashiers
• Supervisors of sales workers
• Shopkeepers, owners
• Computer installation & maintenance workers
• Secretaries/typists/receptionists/bank tellers
• Financial records processing (bookkeepers, clerks)
• Mail distribution
• Maids
• Housekeepers
• Butlers
• Live-in child care workers
• Police/firefighters
• Security guards/crossing guards
• Food services (cooks, waiters, bartenders)
• Health services (dental assistants, nurses’ aides)
• Cleaning and building services (janitors, etc.)
• Personal services (barbers, bellhops, child care
workers)
• Farm operators/managers
• Agricultural inspectors
• Farm workers
• Forestry and fishing operations
• Gardeners
• Manufacturing supervisors
• Mechanics and repairers (cars, machinery, aircraft)
• Construction (supervisors, skilled workers)
• Precision production (tool and die, machinists, shoe
repair, upholsterers, butchers)
• Machine operators (textile, printing, metal and
woodworking)
• Fabricators
• Assemblers
• Inspectors and samplers
• Motor vehicle and other transportation workers
(truck/bus/cab drivers, sailors)
• Material moving equipment operators (hoist, crane,
tractor operators)
• Construction laborers
• Freight stock and material handlers (garbage collectors,
vehicle washers, dock workers)
• Army, Navy, Marines, Air Force

CARD 9
TYPE OF EMPLOYER
1 A private for-profit company, business, or individual
2 A private not-for-profit, tax exempt, or charitable organization
3 Federal government (exclude Armed Forces)
4 State government
5 Local government
6 Armed Forces
7 Unpaid in family business or farm
8 Self-employed in own business, professional practice, or farm

CARD 10
YOUR TOTAL PERSONAL INCOME
INCLUDE ALL MONEY INCOME FROM:
• Jobs and/or self employment
• Social Security or Railroad Retirement
• SSI
• Veteran’s (VA) payments
• Retirement, disability, and survivor pensions
• Interest and dividend income
• Worker’s compensation
• Unemployment payments
• Child support and alimony
• Financial aid (room and board, living expenses)
• Support from persons living elsewhere
ANY public assistance program:
• TAFDC, Emergency Services Program or Emergency Assistance
Program
• WIC
• Any other public assistance/welfare payments

CARD 11
YOUR TOTAL PERSONAL INCOME

0
1

$0 (no personal income)
$1 to $4,999

2
3

$5,000 to $7,999
$8,000 to $9,999

4
5

$10,000 to $12,999
$13,000 to $14,999

6
7

$15,000 to $19,999
$20,000 to $24,999

8
9

$25,000 to $29,999
$30,000 to $34,999

10
11
12
13
14
15
16

$35,000 to $39,999
$40,000 to $49,999
$50,000 to $59,999
$60,000 to $69,999
$70,000 to $79,999
$80,000 to $89,999
$90,000 to $99,999

17

$100,000 or more

CARD 12
YOUR TOTAL COMBINED FAMILY INCOME
INCLUDE ALL MONEY INCOME FROM RELATED FAMILY MEMBERS:
• Jobs and/or self employment
• Social Security or Railroad Retirement
• SSI
• Veteran’s (VA) payments
• Retirement, disability, and survivor pensions
• Interest and dividend income
• Worker’s compensation
• Unemployment payments
• Child support and alimony
• Financial aid (room and board, living expenses)
• Support from persons living elsewhere
ANY public assistance program:
• TAFDC, Emergency Services Program or Emergency Assistance
Program
• WIC
• Any other public assistance/welfare payments

CARD 13
YOUR TOTAL COMBINED FAMILY INCOME
1

Less than $5,000

2

$5,000 to $7,999

3

$8,000 to $9,999

4

$10,000 to $12,999

5

$13,000 to $14,999

6

$15,000 to $19,999

7

$20,000 to $24,999

8

$25,000 to $29,999

9

$30,000 to $34,999

10

$35,000 to $39,999

11

$40,000 to $49,999

12

$50,000 to $59,999

13

$60,000 to $69,999

14

$70,000 to $79,999

15

$80,000 to $89,999

16

$90,000 to $99,999

17

$100,000 to $109,999

18

$110,000 to $119,999

19

$120,000 to $149,999

20

$150,000 to $199,999

21

$200,000 or more

CARD 14
YOUR TOTAL COMBINED HOUSEHOLD INCOME
INCLUDE ALL MONEY INCOME FROM ALL PERSONS LIVING IN THIS
HOUSEHOLD:
• Jobs and/or self employment
• Social Security or Railroad Retirement
• SSI
• Veteran’s (VA) payments
• Retirement, disability, and survivor pensions
• Interest and dividend income
• Worker’s compensation
• Unemployment payments
• Child support and alimony
• Financial aid (room and board, living expenses)
• Support from persons living elsewhere
ANY public assistance program:
• TAFDC, Emergency Services Program or Emergency Assistance
Program
• WIC
• Any other public assistance/welfare payments

CARD 15
YOUR TOTAL COMBINED HOUSEHOLD INCOME
1

Less than $5,000

2

$5,000 to $7,999

3

$8,000 to $9,999

4

$10,000 to $12,999

5

$13,000 to $14,999

6

$15,000 to $19,999

7

$20,000 to $24,999

8

$25,000 to $29,999

9

$30,000 to $34,999

10

$35,000 to $39,999

11

$40,000 to $49,999

12

$50,000 to $59,999

13

$60,000 to $69,999

14

$70,000 to $79,999

15

$80,000 to $89,999

16

$90,000 to $99,999

17

$100,000 to $109,999

18

$110,000 to $119,999

19

$120,000 to $149,999

20

$150,000 to $199,999

21

$200,000 or more

CARD 16
HOW OFTEN

1

Never

2

Almost never

3

Sometimes

4

Fairly often

5

Very often

CARD 17
ACTIVITIES

1

Yes, limited a lot

2

Yes, limited a little

3

No, not limited at all

CARD 18
HOW MUCH TIME

1

None of the time

2

A little of the time

3

Some of the time

4

Most of the time

5

All of the time

CARD 19
HOW MUCH PAIN

1

Not at all

2

A little bit

3

Moderately

4

Quite a bit

5

Extremely

CARD 20
SERVICE ATTENDANCE

1

Once a year

2

A few times a year

3

1 to 3 times a month

4

Once a week

5

Twice a week or more

CARD 21
RELIGION
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29

Apostolic/New Apostolic
Assemblies of God
Baha'i
Baptist
Buddhist
Catholic
Christian
Christian Reform
Christian Science
Church of God
Church of the Brethren
Church of the Nazarene
Churches of Christ
Congregational/United Church of
Christ
Disciples of Christ
Druid
Eckankar
Episcopalian/Anglican
Ethical Culture
Evangelical/Born Again
Foursquare Gospel
Full Gospel
Fundamentalist
Hindu
Holiness/Holy
Independent Christian Church
Jehovah's Witness
Jewish
Lutheran

30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52

Mennonite
Methodist/Wesleyan
Mormon/Latter-Day Saints
Muslim
Native American
New Age
Orthodox (Eastern)
Pagan
Pentecostal/Charismatic
Presbyterian
Protestant
Quaker
Rastafarian
Reformed/Dutch Reform
Salvation Army
Santeria
Scientologist
Seventh-Day Adventist
Sikh
Spiritualist
Taoist
Unitarian/Universalist
Wiccan

53 Other religion
54 No religious affiliation
55 Agnostic
56 Atheist

CARD 22
HOW OFTEN

1

Never

2

Almost never

3

Sometimes

4

Fairly often

5

Very often

CARD 23
FREQUENCY

1 Every day
2 Nearly every day
3 3 to 4 times a week
4 2 times a week
5 Once a week
6 2 to 3 times a month
7 Once a month
8 7 to 11 times in the last year
9 3 to 6 times in the last year
10 1 to 2 times in the last year
11 Never in the last year

CARD 24
FREQUENCY

1 Every day
2 Nearly every day
3 3 to 4 times a week
4 2 times a week
5 Once a week
6 2 to 3 times a month
7 Once a month
8 7 to 11 times in the last year
9 3 to 6 times in the last year
10 1 or 2 times in the last year

CARD 25
NUMBER OF DRINKS

1 1 to 2 drinks
2 3 to 4 drinks
3 5 to 7 drinks
4 8 to 11 drinks
5 12 to 23 drinks
6 24 or more drinks

CARD 26
SIZE OF COOLER

1 8-ounce (small) bottle or can
2 12-ounce (regular) bottle or can
3 16-ounce (large) bottle or can
4 2-ounce can or bottle
5 3-ounce glass
6 4-ounce glass
7 5-ounce glass
8 6-ounce glass
9 7-ounce glass
10 8-ounce glass
11 9-ounce glass
12 12-ounce glass
13 15-ounce glass
14 18-ounce glass
15 Other

If necessary, see cards
26A-26C for examples of
different glass sizes.

CARD 26A
[Insert 13a.pdf]

CARD 26B
[Insert 13b.pdf]

CARD 26C
[Insert 13c&16b.pdf]

CARD 27
SIZE OF BEER

1 7 or 8-ounce (pony size) can, bottle or glass
2 10-ounce (small) can, bottle or glass
3 12-ounce (regular size) can, bottle or glass
4 16-ounce (large) can, bottle or glass
5 22 to 25-ounce (extra large) can, bottle or glass
6 40- to 45- ounce (jumbo) can or bottle
7 Mug
8 Pint
9 Pitcher
10 Other

CARD 28
SIZE OF WINE

1 3-ounce glass
2 4-ounce glass
3 5-ounce glass
4 6-ounce glass
5 7-ounce glass
6 8-ounce glass

If necessary, see cards
28A-28C for examples of
different glass sizes.

7 9-ounce glass
8 12-ounce glass
9 15-ounce glass
10 18-ounce glass
11 187 ml. individual serving bottle (usually sold in 4-packs)
12 375 ml. bottle (half bottle of wine) or ½ carafe
13 750 ml. bottle (regular size wine bottle) or full carafe
14 Other

CARD 28A
[Insert 16a.pdf]

CARD 28B
[Insert 13c&16b.pdf]

CARD 28C
[Insert 16c.pdf]

CARD 29
SIZE OF LIQUOR

1 1 shot or ounce
2 1 jigger
3 Mini-bottle (type sold on airplanes)
4 1½ shouts or ounces
5 2 shots or ounces (double)
6 2 jiggers
7 3 shots or ounces (triple)
8 3 jiggers
9 4 shots or ounces
10 4 jiggers
11 ½ pint
12 Pint
13 Quart
14 Fifth
15 ½ gallon
16 Other

If necessary, see cards
29A-29C for examples of
different glass sizes.

CARD 29A
[Insert 17b.pdf]

CARD 29B
[Insert 17a.pdf]

CARD 29C
[Insert 17c.pdf]

CARD 30
FREQUENCY OF DRINKING

1 Every day
2 Nearly every day
3 3 to 4 times a week
4 2 times a week
5 Once a week
6 2 to 3 times a month
7 Once a month
8 7 to 11 times a year
9 3 to 6 times a year
10 1 or 2 times a year

CARD 31
FREQUENCY OF DRINKING

1 Every day
2 Nearly every day
3 3 to 4 times a week
4 2 times a week
5 Once a week
6 2 to 3 times a month
7 Once a month
8 7 to 11 times a year
9 3 to 6 times a year
10 1 or 2 times a year
11 Never

CARD 32
REASONS

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28

Wanted to go, but health insurance didn’t cover
Didn’t think anyone could help
Didn’t know any place to go for help
Couldn’t afford to pay the bill
Didn’t have any way to get there
Didn’t have time
Thought the problem would get better by itself
Was too embarrassed to discuss it with anyone
Was afraid of what my boss, friends, family, or others would think
Thought it was something I should be strong enough to handle alone
Was afraid they would put me into the hospital
Was afraid of the treatment they would give me
Hated answering personal questions
The hours were inconvenient
A member of my family objected
My family thought I should go, but I didn’t think it was necessary
Can’t speak English very well
Was afraid I would lose my job
Couldn’t arrange for child care
Had to wait too long to get into a program
Wanted to keep drinking or got drunk
Didn’t think drinking problem was serious enough
Didn’t want to go
Stopped drinking on my own
Friends or family helped me stop drinking
Tried getting help before and it didn’t work
Was afraid my children would be taken away
My religious beliefs don’t allow me to go for treatment

29 Other reason

CARD 33
FREQUENCY

1

Almost never

2

Sometimes

3

Often

4

Almost always

CARD 34
HOW WELL

1

Very poorly

2

Poorly

3

Well

4

Very well

CARD 35
AGREE - DISAGREE

1

Strongly agree

2

Agree

3

Somewhat agree

4

Somewhat disagree

5

Disagree

6

Strongly disagree

CARD 36
HOW OFTEN

1

Never

2

Almost never

3

Sometimes

4

Fairly often

5

Very often

CARD 37
TRUE - FALSE

1

Definitely false

2

Probably false

3

Probably true

4

Definitely true

CARD 38
TRUE - FALSE

1

Definitely false

2

Mostly false

3

Don’t know

4

Mostly true

5

Definitely true

CARD 39
FREQUENCY OF SMOKING

1

Every day

2

5 to 6 days a week

3

3 to 4 days a week

4

1 to 2 days a week

5

2 to 3 days a month

6

Once a month or less

CARD 40
TYPES OF MEDICINES/DRUGS

1

Sedatives or tranquilizers, for example…barbs, downers,
Ambien, Lunesta, phenobarbital, pentobarbital, Halcion, Tuinal,
Nembutal, Seconal, Librium, Valium, Xanax, benzodiazepines,
tranks, Ativan.

2

Painkillers, for example…methadone, codeine, Demerol, Vicodin,
Oxycontin, opium, oxy, Percocet, Dilaudid, Percodan, morphine

3

Marijuana, including THC, for example…weed, pot, dope,
hashish, Mary Jane, joint, blunt

4

Cocaine or crack, for example…blow, rock, snow

5

Stimulants, for example…Adderall, Concerta, Cylert, Provigil,
Ritalin or Dexedrine, speed, amphetamine, methamphetamine,
uppers, bennies, dexies, pep pills, Ritalin, Dexedrine, crystal, crank

6

Club drugs, for example…MDMA, ecstasy, GHB, Rohypnol,
ketamine, Special K, XTC, roofies

7

Hallucinogens, for example…LSD, acid, PCP, mescaline, peyote,
psilocybin, mushrooms, angel dust, cactus

8

Inhalants or solvents, for example…nitrous oxide, lighter fluid,
gasoline, cleaning fluid, glue, poppers, whippets

9

Heroin, for example…smack, black tar, poppy

10 Any OTHER medicines, or drugs, or substances, for
example…steroids, Elavil, Thorazine, or Haldol

CARD 41
FREQUENCY OF MEDICINE/DRUG USE

1 Every day
2 Nearly every day
3 3 to 4 times a week
4 1 to 2 times a week
5 2 to 3 times a month
6 Once a month
7 7 to 11 times in the last year
8 3 to 6 times in the last year
9 2 times in the last year
10 Once in the last year

CARD 42
FREQUENCY OF MEDICINE/DRUG USE

1 Every day
2 Nearly every day
3 3 to 4 times a week
4 1 to 2 times a week
5 2 to 3 times a month
6 Once a month
7 7 to 11 times a year
8 3 to 6 times a year
9 2 times a year
10 Once a year

CARD 43
REASONS

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28

Wanted to go, but health insurance didn’t cover
Didn’t think anyone could help
Didn’t know any place to go for help
Couldn’t afford to pay the bill
Didn’t have any way to get there
Didn’t have time
Thought the problem would get better by itself
Was too embarrassed to discuss it with anyone
Was afraid of what my boss, friends, family, or others would think
Thought it was something I should be strong enough to handle alone
Was afraid they would put me into the hospital
Was afraid of the treatment they would give me
Hated answering personal questions
The hours were inconvenient
A member of my family objected
My family thought I should go, but I didn’t think it was necessary
Can’t speak English very well
Was afraid I would lose my job
Couldn’t arrange for child care
Had to wait too long to get into a program
Wanted to keep using medicines or drugs
Didn’t think medicine or drug problem was serious enough
Didn’t want to go
Stopped using medicines or drugs on my own
Friends or family helped me stop using medicines or drugs
Tried getting help before and it didn’t work
Was afraid my children would be taken away
My religious beliefs don’t allow me to go for treatment

29 Other reason

CARD 44
RELATIVES

FOR AT LEAST 2 WEEKS
•

Depressed, sad or down

•

Lost interest or pleasure in usual activities

•

Slept very little or slept too much

•

Ate too little or ate too much

•

Appeared tired

•

Cried a lot

•

Seemed to move slowly

•

Seemed very restless or agitated

•

Had difficulty concentrating

•

Had difficulty making decisions

•

Felt worthless or guilty

•

Talked about suicide or tried to commit suicide

CARD 45
STRESSFUL LIFE EXPERIENCES
Box A
Traumatic Experiences That Happened to YOU
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19

Serious or life-threatening injury
Serious or life-threatening illness
Saw a dead body or body parts
Injured in a terrorist attack
Natural disaster, like flood, fire, earthquake, hurricane
Sexually abused before age 18
Sexually assaulted as an adult
Physically abused before age 18
Beaten up by spouse/romantic partner
Beaten up by someone else
Kidnapped/held hostage
Stalked
Mugged, held up, threatened with a weapon or assaulted in any other way
Active military combat
Peacekeeper/relief worker
Civilian in war zone/place of terror
Refugee
Prisoner of war
Juvenile detention or jail

20

Any other traumatic or stressful event that happened to you
Box B
Traumatic Experiences To Others That You Personally Witnessed, Learned About,
or Became Exposed to the Details

21
22
23
24
25
26
27
28
29
30
31
32
33

Other person’s serious or life-threatening injury
Other person’s serious or life-threatening illness
Other person seeing a dead body or body parts
Other person injured in a terrorist attack
Other person exposed to natural disaster, like a flood, fire, earthquake, hurricane
Other person’s sexual abuse as a child under age 18
Other person’s sexual assault as an adult
Other person’s physical abuse as a child under age 18
Other person beaten up by a spouse/romantic partner
Other person beaten up by someone else
Other person kidnapped/held hostage
Other person stalked
Other person mugged/held up, or threatened with a weapon

34

Any other traumatic or stressful event to others that you witnessed, learned about or
became exposed to the details

CARD 46
HOW OFTEN

1

Never

2

Almost never

3

Sometimes

4

Fairly often

5

Very often

CARD 47
HOW OFTEN TRUE

1

Never true

2

Rarely true

3

Sometimes true

4

Often true

5

Very often true

CARD 48
FREQUENCY

1

Never

2

Once

3

2 to 3 times

4

4 to 11 times

5

Once a month

6

More than once a month

CARD 49
ATTRACTION

1

Only attracted to females

2

Mostly attracted to females

3

Equally attracted to females and males

4

Mostly attracted to males

5

Only attracted to males

CARD 50
ORIENTATION

1

Heterosexual (straight)

2

Gay or lesbian

3

Bisexual

4

Not sure

CARD 51
FREQUENCY

1

Never

2

Almost never

3

Sometimes

4

Fairly often

5

Very often

CARD 52
RELATIONSHIP TO YOU
(The person I care for is my…)
1

Husband, wife, spouse, partner

2

Parent or step-parent

3

Child, stepchild, foster child, son-in-law
or daughter-in-law

4

Brother, sister

5

Other blood relative or in-law

6

Friend

7

Other non-relative

CARD 53
HOW MUCH

1

Not at all

2

A little

3

Somewhat

4

A lot

5

Very much

CARD 54
HOW OFTEN

1

Never

2

Sometimes

3

Often

CARD 55
RELATIVES
•

Very worried or anxious for at least 3 months
about a lot of things

•

Had panic attacks

•

Fearful or anxious about objects or situations or
tried to avoid them

•

Repeating things over and over, like washing
their hands, check the door locks, even though
they didn’t want to

•

Had a very bad reaction to a traumatic or
stressful event that happened to them, someone
else or that they witnessed

CARD 56
RELATIVES
•

Cruel to people or animals

•

Started a lot of fights

•

Destroyed someone’s property

•

Had trouble keeping a job

•

Had trouble paying the bills

•

Lied to other people or tried to con other people

•

Got arrested more than once for a crime like
stealing, destroying property, assault, or robbery

•

Didn’t care about their own safety or safety of
others

•

Ditched school or ran away from home when
younger

•

Didn’t seem to care if they had hurt, mistreated or
stolen from other people

•

Was impulsive and didn’t plan ahead

CARD 57
SIZE/TYPE OF CONTAINER
(IF EXACT SIZE NOT SHOWN, PLEASE PICK CATEGORY THAT COMES CLOSEST)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46

1 ounce or shot, shot of unspecified size
1½ ounces or shots
2 ounces or shots; double, 2-ounce can or bottle
3 ounces or shots, triple; 3-ounce glass
4 ounces or shots, 4-ounce glass
5-ounce glass, can or bottle
6-ounce glass, can or bottle
7-ounce glass, can or bottle
8-ounce glass, can or bottle
9-ounce glass, can or bottle
10-ounce glass, can or bottle
12-ounce glass, can or bottle
15-ounce glass, can or bottle
16-ounce glass, can or bottle
18-ounce glass, can or bottle
20-ounce glass, can or bottle; schooner
22- to 25-ounce can or bottle
32-ounce can or bottle
40- to 45-ounce bottle
64-ounce bottle
1 jigger
2 jiggers
3 jiggers
4 jiggers
50-milliliter mini bottle (type sold on airlines)
187- milliliter bottle (small individual wine bottle usually sold in 4-packs)
375-milliliter bottle; half bottle of wine; half carafe; split
750-milliliter bottle; regular size wine bottle; full carafe
1/2 liter bottle
1 liter bottle
1.5 liter bottle; magnum
1.75 liter bottle
3 liter bottle; double magnum
5 to 6 liter bottle or box
1/2 pint
Pint
Fifth
Quart
1/2 gallon
Gallon
Mug
Pitcher
Growler
Six-pack of pony-size beer bottles
Six pack of regular beer bottles
Six-pack of large beer bottles/cans

47

Other