Factor Surveillance System
Indiana Statewide Survey
Core 01: Health Status
C01.01 Would you say that in general your health is:
Core 02: Healthy Days—Health-Related Quality of Life
Now thinking about your physical health, which includes physical illness and
injury, for how many days during the past 30 days was your physical health not
Now thinking about your mental health, which includes stress, depression, and
problems with emotions, for how many days during the past 30 days was your
mental health not good?
During the past 30 days, for about how many days did poor physical or mental
health keep you from doing your usual activities, such as self-care, work, or
Core 03: Health Care Access
Do you have any kind of health care coverage, including health insurance,
prepaid plans such as HMOs, or government plans such as Medicare, or Indian
Do you have one person you think of as your personal doctor or health care
Was there a time in the past 12 months when you needed to see a doctor but could
not because of cost?
About how long has it been since you last visited a doctor for a routine
checkup? [A routine checkup is a general physical exam, not an exam for a
specific injury, illness, or condition.]
Core 04: Inadequate Sleep
C04.01 On average, how many hours of sleep do you get in a
Core 05: Hypertension Awareness
C05.01 Have you ever been told by a doctor, nurse, or other health care
professional that you have high blood pressure?
Are you currently taking medicine for your high blood pressure?
Core 06: Cholesterol
C06.01 Have you ever had your blood cholesterol checked?
C06.02 About how long has it been since you last had your blood cholesterol
C06.03 Have you ever been told by a doctor, nurse, or other health care
professional that your blood cholesterol is high?
Core 07: Chronic
Ever told you that you had a heart attack also called a myocardial infarction?
C07.02 Ever told you had angina or
coronary heart disease?
C07.03 Ever told you had a stroke?
C07.04 Ever told you had asthma?
C07.05 Do you still have asthma?
C07.06 Ever told you had skin cancer?
C07.07 Ever told you had any other types of
C07.08 Ever told you have (COPD) chronic
obstructive pulmonary disease, emphysema or chronic bronchitis?
C07.09 Ever told you have some form of
arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?
C07.10 Ever told you have a depressive
disorder including depression, major depression, dysthymia, or minor depression?
C07.11 Ever told you have kidney
disease? Do NOT include kidney stones, bladder infection or incontinence.
C07.12 Ever told you have diabetes?
Module 01: Pre-Diabetes
M01.01 Have you had a test for high
blood sugar or diabetes within the past three years?
M01.02 Have you ever been told by a
doctor or other health professional that you have pre-diabetes or borderline
Module 02: Diabetes
How old were you when you were told you have diabetes?
Are you now taking insulin?
About how often do you check your blood for glucose or sugar? Include times when
checked by a family member or friend, but do NOT include times when checked by a
About how often do you check your feet for any sores or irritations? Include
times when checked by a family member or friend, but do NOT include times when
checked by a health professional.
About how many times in the past 12 months have you seen a doctor, nurse, or
other health professional for your diabetes?
About how many times in the past 12 months has a health
professional checked you for 'A one C'?
About how many times in the past 12 months has a health professional checked
your feet for any sores or irritations?
When was the last time you had an eye exam in which the pupils were dilated?
This would have made you temporarily sensitive to bright light.
Has a doctor ever told you that diabetes has affected your eyes or that you had
Have you ever taken a course or class in how to manage your diabetes yourself?
Core 8: Demographics
C08.05 Have you ever served on
active duty in the United States Armed Forces, either in the regular military or
in a National Guard or military reserve unit? Active duty does not include
training for the Reserves or National Guard, but DOES include activation, for
example, for the Persian Gulf War.
C08.13 What county do you live in?
C08.20 Do you own or rent your
C08.23 Are you
limited in any way in any activities because of physical, mental, or emotional
C08.24 Do you now have any health
problem that requires you to use special equipment, such as a cane, a wheelchair,
a special bed, or a special telephone?
C08.25 Are you
blind or do you have serious difficulty seeing, even when wearing glasses?
of a physical, mental, or emotional condition, do you have serious difficulty
concentrating, remembering or making decisions?
C08.27 Do you
have serious difficulty walking or climbing stairs?
C08.28 Do you
have difficulty dressing or bathing?
of a physical, mental, or emotional condition, do you have difficulty doing
errands alone such as visiting a doctor's office or shopping?
Core 09: Tobacco Use
Have you smoked at least 100 cigarettes in your entire life?
Do you now smoke cigarettes every day, some days, or not at all?
During the past 12 months, have you stopped smoking for one day or longer
because you were trying to quit smoking?
C09.04 How long has it been since you last smoked a
cigarette, even one or two puffs?
Do you currently use chewing tobacco, snuff, or snus every day, some days, or
not at all? (Snus (Swedish for snuff) is a moist smokeless tobacco)
Core 10: Alcohol Consumption
During the past 30 days, how many days did you have at
least one drink of any alcoholic beverage?
One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink
with one shot of liquor. During the past 30 days, on the days when you drank,
about how many drinks did you drink on the average?
Considering all types of alcoholic beverages, how many times during the past 30
days did you have 5 or more drinks for men or 4 or more drinks for women on an
C10.04 During the past 30 days, what is the
largest number of drinks you had on any occasion?
Core 13: Arthritis Burden
C13.01 Are you now limited in any way
in any of your usual activities because of arthritis or joint symptoms?
Do arthritis or joint symptoms now affect whether you work, the type of work you
do or the amount of work you do?
During the past 30 days, to what extent has your arthritis or joint symptoms
interfered with your normal social activities, such as going shopping, to the
movies, or to religious or social gatherings?
During the past 30 days, how bad was your joint pain on average? Please answer
on a scale of 0 to 10 where 0 is no pain or aching and 10 is pain or aching as
bad as it can be.
Core 14: Seatbelt Use
How often do you use seat belts when you drive or ride in a car?
Core 15: Immunization
C15.01 During the past 12 months, have you had
either a flu shot or a flu vaccine that was sprayed in your
Since 2005, have you had a tetanus shot?
C15.04 Have you ever had a pneumonia shot?
Core 16: HIV/AIDS
Have you ever been tested for HIV? Do not count tests you may have had as part
of a blood donation. Include testing fluid from your mouth.
did you have your last HIV test - at a private doctor or HMO office, at a
counseling and testing site, in the emergency room, as an inpatient in a
hospital, in a clinic, in a jail or prison, at a drug treatment facility, at
home, or somewhere else?
Calculated Variables and Risk Factors:
CLV01.01 Adults with good or better health
CLV03.01 Respondents aged 18-64 that have any form of health care coverage
CLV04.01 Adults that report doing physical activity or
exercise during the past 30 days other than their regular job
CLV05.01 Adults who have been told they have high
blood pressure by a doctor, nurse, or other health professional
CLV06.01 Cholesterol check within past five years
CLV06.02 Adults who have had their cholesterol checked
and have been told by a doctor, nurse, or other health professional that it was
CLV07.01 Adults who have ever been told they have asthma
CLV07.02 Adults who have been told they currently have
CLV07.03 Computed asthma status
CLV07.04 Respondents that have had a doctor diagnose them as having some form of
CLV07.18 Four-level categories of Body Mass Index (BMI)
CLV07.19 Adults who have a body mass index greater than
25.00 (overweight or obese)
CLV09.01 Four-level smoker
status: everyday smoker, someday smoker, former smoker, never smoked
CLV09.02 Adults who are current
CLV10.01 Adults who reported
having had at least one drink of alcohol in the past 30 days
CLV10.03 Binge drinkers (males
having five or more drinks on one occasion, females having four or more drinks
on one occasion)
total number of alcoholic beverages consumed per day
drinkers (adult men having more than two drinks per day and adult women having
more than one drink per day)
CLV10.07 Adult men who are heavy drinkers (having more than two drinks per day)
CLV10.08 Adult women who are heavy drinkers (having more than one drinks per day)
CLV11.11 Total fruits consumed per day
CLV11.12 Total vegetables consumed per day
CLV11.19 Consume fruit one or more times per day
CLV11.20 Consume vegetables one or more times per day
CLV12.23 Physical Activity Index
CLV12.24 Adults who participated in 150 minutes (or
vigorous equivalent minutes) of physical activity per week
CLV12.25 Adults who participated in 300 minutes (or
vigorous equivalent minutes) of physical activity per week
CLV12.27 Muscle strengthening recommendation
CLV12.28 Aerobic and strengthening recommendation
CLV13.01 Always or nearly always
wear seat belts
CLV13.02 Always wear seat belts
CLV15.01 Adults aged 65+ years who have had a flu shot
within the past year
CLV15.02 Adults aged 65+ years who have ever had a
Module 04: Health Care Access
M04.01 Do you have Medicare?
M04.02 Are you currently covered by any of the following types of health
insurance or health coverage plans?
M04.03 Have you delayed getting needed medical care for any of the following
reasons in the past 12 months? Select the most important reason.
M04.05 In the past 12 months, was there any time when you did not have any
health insurance or coverage?
M04.06 About how long has it been since you last had health care coverage?
M04.07 How many times have you been to a doctor, nurse, or other health
professional in the past 12 months?
M04.08 Was there a time in the past 12 months when you did not take your
medication as prescribed because of cost? Do not include over-the-counter
M04.09 In general, how satisfied are you with the health care you received?
M04.10 Do you currently have medical bills that are being paid off over time?
Module 05: Sugar Drinks
M05.01 About how often do you drink regular soda or pop that contains sugar? Do not
include diet soda or diet pop.
the past 30 days, how often did you drink sugar-sweetened fruit drinks (such as
Kool-aid and lemonade), sweet tea, and sports or energy drinks (such as Gatorade
and Red Bull)? Do not include 100 percent fruit juice, diet drinks, or
artificially sweetened drinks.
Module 06: Sodium or Salt-Related Behavior
M06.01 Are you currently watching or reducing your sodium or salt intake?
M06.02 How many
days, weeks, months, or years have you been watching or reducing your sodium or
M06.03 Has a doctor or other health professional ever advised you to reduce
sodium or salt intake?
Module 21: Childhood Asthma Prevalence
M21.01 Has a doctor, nurse or other health professional EVER said that the child
M21.02 Does the
child still have asthma?
People 2020 in Indiana
Appendix B - 2013 Behavioral Risk Factor Surveillance Survey
to BRFSS Index