Q1.1 Would you say that in general your health is:
Q1.2 For how many days during the past 30 days was your physical health not good?
Q1.3 For how many days during the past 30 days was your mental health not good?
Q1.4 During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities?

Section 2: Health Care Access

Q2.1 Do you have any kind of health care coverage?
Q2.2 During the past 12 months, was there any time that you did not have any health insurance or coverage?
Q2.3 Do you have one person you think of as your personal doctor or health care provider?

Section 3: Exercise

Q3.1 During the past 30 days, did you participate in any physical activities or exercise?

Section 4: Hypertension Awareness

Q4.1 Have you ever been told by a health professional that you have high blood pressure?
Q4.2 Are you currently taking medicine for your high blood pressure?

Section 5: Cholesterol Awareness

Q5.1 Have you ever had your blood cholesterol checked?
Q5.2 About how long has it been since you last had your blood cholesterol checked?
Q5.3 Have you ever been told by a health professional that your blood cholesterol is high?

Section 6: Asthma

Q6.1 Have you ever been told by a health professional that you had asthma?
Q6.2 Do you still have asthma?

Section 7: Diabetes

Q7.1 Have you ever been told by a doctor that you have diabetes?

Section 8: Arthritis

Q8.1 During the past 12 months, have you had pain, aching, stiffness or swelling in or around a joint?
Q8.2 Were these symptoms present on most days for at least one month?
Q8.3 Are you limited in any way in any activities because of joint symptoms?
Q8.4 Have you ever seen a health professional for these joint symptoms?
Q8.5 Have you ever been told by a doctor that you have arthritis?
Q8.6 Are you currently being treated by a doctor for arthritis?

Section 9: Immunization

Q9.1 During the past 12 months, have you had a flu shot?
Q9.2 Have you ever had a pneumonia shot?

Section 10: Tobacco Use

Q10.1 Have you smoked at least 100 cigarettes in your entire life?
Q10.2 Do you now smoke cigarettes every day, some days, or not at all?
Q10.3 During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?

Section 11: Alcohol Consumption

Q11.1 During the past 30 days, how often have you had a least one drink of any alcoholic beverage?
Q11.2 On the days when you drank, about how many drinks did you drink on the average?
Q11.3 How many times during the past 30 days did you have 5 or more drinks on an occasion?

Section 12: Firearms

Q12.1 Are any firearms now kept in or around your home?

Section 13: Demographics

Q13.12 What county do you live in?
Q13.17 To your knowledge, are you now pregnant?

Section 14: Disability

Q14.1 Are you limited in any activities because of physical, mental, or emotional problems?
Q14.2 Do you now have any health problem that requires you to use special equipment?

Section 15: Physical Activity

Q15.1 When you are at work, which of the following best describes what you do?
Q15.2 Do you do moderate activities for at least 10 minutes at a time?
Q15.3 How many days per week do you do these moderate activities for at least 10 minutes at a time?
Q15.4 On days when you do moderate activities for at least 10 minutes at a time, how much total time per day do you spend doing these activities?
Q15.5 Do you do vigorous activities for at least 10 minutes at a time?
Q15.6How many days per week do you do these vigorous activities for at least 10 minutes at a time?
Q15.7 On days when you do vigorous activities for at least 10 minutes at a time, how much total time per day do you spend doing these activities?

Section 16: Prostate Cancer Screening

Q16.1 Have you ever had a prostate-specific antigen (PSA) test?
Q16.2 How long has it been since you had your last PSA test?
Q16.3 Have you ever had a digital rectal exam?
Q16.4 How long has it been since your last digital rectal exam?
Q16.5 Have you ever been told by a health professional that you had prostate cancer?
Q16.6 Has your father, brother, son, or grandfather ever been told by a health professional that he had prostate cancer?

Section 17: Colorectal Cancer Screening

Q17.1 Have you ever had a blood stool test using a home kit?
Q17.2 How long has it been since you had your last blood stool test using a home kit?
Q17.3 Have you ever had a sigmoidoscopy or colonoscopy exam?
Q17.4 How long has it been since you had your last sigmoidoscopy or colonoscopy?

Section 18: HIV/AIDS

Q18.1 Can a pregnant woman with HIV get treatment to help reduce the changes that she will pass the virus on to her baby?
Q18.2 Are there medical treatments available that are intended to help a person who is infected with HIV to live longer.
Q18.3 How effective do you think these treatments are in helping persons with HIV to live longer?
Q18.4 How important do you think it is for people to know their HIV status by getting tested?
Q18.5 Have you ever been tested for HIV? Do not count tests you may have had as part of a blood donation.
Q18.7 What was the main reason you had your last HIV test?
Q18.8 Where did you have your last HIV test?
Q18.9 In the past 12 months has a health professional talked to you about preventing sexually transmitted diseases through condom use?

Module 7: Asthma History

M7.1 How old were you when you were first told by a health professional that you had asthma?
M7.2 During the past 12 months, have you had an episode of asthma or an asthma attack?
M7.3 During the past 12 months, how many times did you visit an emergency room or urgent care center because of your asthma?
M7.4 During the past 12 months, how many times did you see a health professional for urgent treatment of worsening asthma symptoms?
M7.5 During the past 12 months, how many times did you see a health professional for a routine checkup for your asthma?
M7.6 During the past 12 months, how many days were you unable to work or carry out your usual activities because of your asthma?
M7.7 During the past 30 days, how often did you have any symptoms of asthma?
M7.8 During the past 30 days, how many days did symptoms of asthma make it difficult for you to stay asleep?
M7.9 During the past 30 days, how often did you take asthma medication that was prescribed or given to you by doctor?
M7.10 How many children, age 17 or younger living in your household, have ever been diagnosed with asthma?
M7.11 How many of these children still have asthma?

Module 12: Folic Acid

M12.1 Do you currently take any vitamin pills or supplements?
M12.2 Are any of these a multivitamin?
M12.3 Do any of the vitamin pills or supplements you take contain folic acid?
M12.4 How often do you take this vitamin pill or supplement?
M12.5 Some health experts recommend that women take 400 micrograms of the B vitamin folic acid, for which one of the following reasons:

Module 13: Tobacco Indicators

M13.1 How old were you the first time you smoked a cigarette, even one or two puffs?
M13.2 How old were you when you first started smoking cigarettes regularly?
M13.3 About how long has it been since you last smoked cigarettes regularly?
M13.4 In the past 12 months, have you seen a health professional to get any kind of care for yourself?
M13.5 In the past 12 months, has a health professional advised you to quit smoking?
M13.6 Which statement best describes the rules about smoking inside your home?
M13.7 While working at your job, are you indoors most of the time?
M13.8 Which of the following best describes your place of work's official smoking policy for indoor public or common areas?
M13.9 Which of the following best describes your place of work's official smoking policy for work areas?

Calculated Risk Factors:

RF1.31 _BMI2 Categorized
RF1.32 Risk Factor for being overweight or obese
RF1.33 Risk Factor for being told blood pressure is high
RF1.34 Preventive health measure for cholesterol checked
RF1.35 Risk Factor for having had cholesterol checked and told it was high
RF1.36 Risk Factor for having chronic joint symptoms
RF1.37 Risk Factor for having chronic joint symptoms and limitations due to symptoms
RF1.38 Risk Factor for having chronic joint symptoms or being told had arthritis
RF1.39 Computed smoking status
RF1.40 At risk for smoking (all current smokers)
RF1.43 At risk for binge drinking (greater than or equal to 5 or more drinks consumed on one or more occasion)
RF1.44 At risk for heavy alcohol consumption (greater than 2 drinks/day for men and greater than 1 drink/day for women)
RF1.45 At risk for heavy alcohol consumption in men (greater than 2 drinks/day)
RF1.46 At risk for heavy alcohol consumption in women (greater than 1 drink/day)
RF1.51 Meet recommendations for physical activity
RF1.52 Risk factor for meeting Healthy People, 2010 Objective #22-2 - Moderate Physical Activity
RF1.53 Risk factor for meeting Healthy People, 2010 Objective #22-3 - Vigorous Physical Activity

Appendices:

Appendix A - Healthy People 2010 in Indiana

Appendix B - Definitions of BRFSS Risk Factors

Appendix C - 2001 Behavioral Risk Factor Surveillance Survey Questionnaire