CORE SECTIONS
Section 1: Health Status
Section 2: Health Care Access
Section 3: Exercise
Section 4: Hypertension Awareness
Section 5: Cholesterol Awareness
Section 6: Asthma
Section 7: Diabetes
Section 8: Arthritis
Section 9: Immunization
Section 10: Tobacco Use
Section 11: Alcohol Consumption
Section 12: Firearms
Section 13: Demographics
Section 14: Disability
Section 15: Physical Activity
Section 16: Prostate Cancer Screening
Section 17: Colorectal Cancer Screening
Section 18: HIV/AIDS
OPTIONAL MODULES
Module 7: Asthma History
Module 12: Folic Acid
Module 13: Tobacco Indicators
1.1. Would you say that in general your health is:
1 Excellent
2 Very good
3 Good
4 Fair
5 Poor
7 Don't know/Not sure
9 Refused
1.2. 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 good?
Number of days
8 8 None
7 7 Don't know/Not sure
9 9 Refused
1.3. 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?
Number of days
8 8 None
7 7 Don't know/Not sure
9 9 Refused
1.4. 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 recreation?
Number of days
8 8 None
7 7 Don't know/Not sure
9 9 Refused
2.1. Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
2.2. During the past 12 months, was there any time that you did not have any health insurance or coverage?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
2.3. Do you have one person you think of as your personal doctor or health care provider?
1 Yes, only one
2 More than one
3 No
7 Don't know/Not sure
9 Refused
Section 3: Exercise
3.1. During the past 30 days, other than your regular job, did you participate in any physical activities or exercise such as running, calisthenics, golf, gardening, or walking for exercise?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
Section 4: Hypertension Awareness
4.1. Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
4.2. Are you currently taking medicine for your high blood pressure?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
Section 5: Cholesterol Awareness
5.1. Blood cholesterol is a fatty substance found in the blood. Have you ever had your blood cholesterol checked?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
5.2. About how long has it been since you last had your blood cholesterol checked?
1 Within the past year (1 to 12 months ago)
2 Within the past 2 years (1 to 2 years ago)
3 Within the past 5 years (2 to 5 years ago)
4 5 or more years ago
7 Don't know/Not sure
9 Refused
5.3. Have you ever been told by a doctor, nurse, or other health professional that your blood cholesterol is high?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
Section 6: Asthma
6.1. Have you ever been told by a doctor, nurse, or other health professional that you had asthma?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
6.2. Do you still have asthma?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
Section 7: Diabetes
7.1. Have you ever been told by a doctor that you have diabetes?
1 Yes
2 Yes, but female told only during pregnancy
3 No
7 Don't know/Not sure
9 Refused
Section 8: Arthritis
8.1. During the past 12 months, have you had pain, aching, stiffness or swelling in or around a joint?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
8.2. Were these symptoms present on most days for at least one month?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
8.3. Are you now limited in any way in any activities because of joint symptoms?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
8.4. Have you ever seen a doctor, nurse, or other health professional for these joint symptoms?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
8.5. Have you ever been told by a doctor that you have arthritis?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
8.6. Are you currently being treated by a doctor for arthritis?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
Section 9: Immunization
9.1. During the past 12 months, have you had a flu shot?
1 Yes
2 No
7 Don’t know/Not sure
9 Refused
9.2. Have you ever had a pneumonia shot? This shot is usually given only once or twice in a person's lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.
1 Yes
2 No
7 Don’t know/Not sure
9 Refused
Section 10: Tobacco Use
10.1. Have you smoked at least 100 cigarettes in your entire life?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
10.2. Do you now smoke cigarettes every day, some days, or not at all?
1 Every day
2 Some days
3 Not at all
9 Refused
10.3. During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
Section 11: Alcohol Consumption
11.1. A drink of alcohol is 1 can or bottle of beer, 1 glass of wine, 1 can or bottle of wine cooler, 1 cocktail, or 1 shot of liquor. During the past 30 days, how often have you had at least one drink of any alcoholic beverage?
1 __ __ Days per week
2 __ __ Days in past 30
8 8 8 No drinks in past 30 days
7 7 7 Don't know/Not sure
9 9 9 Refused
11.2. On the days when you drank, about how many drinks did you drink on the average?
Number of drinks
7 7 Don't know/Not sure
9 9 Refused
11.3. Considering all types of alcoholic beverages, how many times during the past 30 days did you have 5 or more drinks on an occasion?
Number of times
8 8 None
7 7 Don't know/Not sure
9 9 Refused
Section 12: Firearms
The next question is about firearms, including weapons such as pistols, shotguns, and rifles; but not BB guns, starter pistols, or guns that cannot fire.
12.1. Are any firearms now kept in or around your home? Include those kept in a garage, outdoor storage area, car, truck, or other motor vehicle.
1 Yes
2 No
7 Don’t know/Not sure
9 Refused
Section 13: Demographics
13.1. What is your age?
Code age in years
0 7 Don’t know/Not sure
0 9 Refused
13.2. Are you Hispanic or Latino?
1 Yes
2 No
7 Don’t know/Not sure
9 Refused
13.3. Which one or more of the following would you say is your race?
1 White
2 Black or African American
3 Asian
4 Native Hawaiian or Other Pacific Islander
5 American Indian, Alaska Native
6 Other [specify]
8 No additional choices
7 Don't know/Not sure
9 Refused
13.4. Which one of these groups would you say best represents your race?
1 White
2 Black or African American
3 Asian
4 Native Hawaiian or Other Pacific Islander
5 American Indian, Alaska Native
6 Other [specify]
7 Don’t know/Not sure
9 Refused
13.5. Are you:
1 Married
2 Divorced
3 Widowed
4 Separated
5 Never married
6 A member of an unmarried couple
9 Refused
13.6. How many children less than 18 years of age live in your household ?
Number of children
8 8 None
9 9 Refused
13.7. What is the highest grade or year of school you completed?
1 Never attended school or only attended kindergarten
2 Grades 1 through 8 (Elementary)
3 Grades 9 through 11 (Some high school)
4 Grade 12 or GED (High school graduate)
5 College 1 year to 3 years (Some college or technical school)
6 College 4 years or more (College graduate)
9 Refused
13.8. Are you currently:
1 Employed for wages
2 Self-employed
3 Out of work for more than 1 year
4 Out of work for less than 1 year
5 A Homemaker
6 A Student
7 Retired
8 Unable to work
9 Refused
13.9. Is your annual household income from all sources:
0 1 Less than $10,000
0 2 Less than $15,000 ($10,000 to less than $15,000)
0 3 Less than $20,000 ($15,000 to less than $20,000)
0 4 Less than $25,000 ($20,000 to less than $25,000)
0 5 Less than $35,000 ($25,000 to less than $35,000)
0 6 Less than $50,000 ($35,000 to less than $50,000)
0 7 Less than $75,000 ($50,000 to less than $75,000)
0 8 $75,000 or more
7 7 Don't know/Not sure
9 9 Refused
13.10. About how much do you weigh without shoes?
__ __ __ Weight
pounds
7 7 7 Don't know/Not sure
9 9 9 Refused
13.11. About how tall are you without shoes?
__/__ __ Height
ft/inches
7 7 7 Don't know/Not sure
9 9 9 Refused
13.12. What county do you live in?
__ __ __ FIPS county code
7 7 7 Don't know/Not sure
9 9 9 Refused
13.13. Do you have more than one telephone number in your household? Do not include cell phones or numbers that are only used by a computer or fax machine.
1 Yes
2 No
7 Don't know/Not sure
9 Refused
13.14. How many of these are residential numbers?
__ Residential telephone numbers
7 Don't know/Not sure
9 Refused
13.15. How many adult members of your household currently use a cell phone for any purpose?
Number of adults
8 None
7 Don't know/Not sure
9 Refused
13.16. Indicate sex of respondent.
1 Male
2 Female
13.17. To your knowledge, are you now pregnant?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
Section 14: Disability
14.1. Are you limited in any way in any activities because of physical, mental, or emotional problems?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
14.2. 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?
1 Yes
2 No
7 Don’t know/Not sure
9 Refused
Section 15: Physical Activity
15.1. When you are at work, which of the following best describes what you do?
Would you say:
1 Mostly sitting or standing
2 Mostly walking
3 Mostly heavy labor or physically demanding work
7 Don't know/Not sure
9 Refused
We are interested in two types of physical activity: vigorous and moderate. Vigorous activities cause large increases in breathing or heart rate while moderate activities cause small increases in breathing or heart rate.
15.2. Now, thinking about the moderate physical activities you do in a usual week, do you do moderate activities for at least 10 minutes at a time, such as brisk walking, bicycling, vacuuming, gardening, or anything else that causes small increases in breathing or heart rate?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
15.3. How many days per week do you do these moderate activities for at least 10 minutes at a time?
Days per week
7 7 Don't know/Not sure
9 9 Refused
15.4. 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?
: Hours and minutes per day
7 7 7 Don't know/Not sure
9 9 9 Refused
15.5. Now thinking about the vigorous physical activities you do in a usual week, do you do vigorous activities for at least 10 minutes at a time, such as running, aerobics, heavy yard work, or anything else that causes large increases in breathing or heart rate?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
15.6. How many days per week do you do these vigorous activities for at least 10 minutes at a time? Days per week
7 7 Don't know/Not sure
9 9 Refused
15.7. 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?
: Hours and minutes per day
7 7 7 Don't know/Not sure
9 9 9 Refused
Section 16: Prostate Cancer Screening
16.1. A Prostate-Specific Antigen test, also called a PSA test, is a blood test used to check men for prostate cancer. Have you ever had a PSA test?
1 Yes
2 No
7 Don't know/not Sure
9 Refused
16.2. How long has it been since you had your last PSA test?
1 Within the past year (1 to 12 months ago)
2 Within the past 2 years (1 to 2 years)
3 Within the past 3 years (2 to 3 years)
4 Within the past 5 years (3 to 5 years)
5 5 or more years ago
7 Don't know
9 Refused
16.3. A digital rectal exam is an exam in which a doctor, nurse, or other health professional places a gloved finger into the rectum to feel the size, shape, and hardness of the prostate gland. Have you ever had a digital rectal exam?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
16.4. How long has it been since your last digital rectal exam?
1 Within the past year (1 to 12 months ago)
2 Within the past 2 years (1 to 2 years)
3 Within the past 3 years (2 to 3 years)
4 Within the past 5 years (3 to 5 years)
5 5 or more years ago
7 Don't know/Not sure
9 Refused
16.5. Have you ever been told by a doctor, nurse, or other health professional that you had prostate cancer?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
16.6. Has your father, brother, son, or grandfather ever been told by a doctor, nurse, or health professional that he had prostate cancer?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
Section 17: Colorectal Cancer Screening
17.1. A blood stool test is a test that may use a special kit at home to determine whether the stool contains blood. Have you ever had this test using a home kit?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
17.2. How long has it been since you had your last blood stool test using a home kit?
1 Within the past year (1 to 12 months ago)
2 Within the past 2 years (1 to 2 years ago)
3 Within the past 5 years (2 to 5 years ago)
4 5 or more years ago
7 Don't know/Not sure
9 Refused
17.3. Sigmoidoscopy and colonoscopy are exams in which a tube is inserted in the rectum to view the bowel for signs of cancer or other health problems. Have you ever had either of these exams?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
17.4. How long has it been since you had your last sigmoidoscopy or colonoscopy?
1 Within the past year (1 to 12 months ago)
2 Within the past 2 years (1 to 2 years ago)
3 Within the past 5 years (2 to 5 years ago)
4 Within the past 10 years (5 to 10 years ago)
5 10 or more years ago
7 Don't know/Not sure
9 Refused
Section 18: HIV/AIDS
The next few questions are about the national health problem of HIV, the virus that causes AIDS. Please remember that your answers are strictly confidential and that you don't have to answer every question if you don't want to.
I'm going to read two statements about HIV, the virus that causes AIDS. After I read each one, please tell me whether you think it is true or false, or if you Don't know.
18.1. A pregnant woman with HIV can get treatment to help reduce the chances that she will pass the virus on to her baby.
1 True
2 False
7 Don't know/Not Sure
9 Refused
18.2. There are medical treatments available that are intended to help a person who is infected with HIV to live longer.
1 True
2 False
7 Don't know/Not Sure
9 Refused
18.3. How effective do you think these treatments are helping persons with HIV to live longer?
Would you say:
1 Very effective
2 Somewhat effective
3 Not at all effective
7 Don't know/Not sure
9 Refused
18.4. How important do you think it is for people to know their HIV status by getting tested?
Would you say:
1 Very important
2 Somewhat important
3 Not at all important
7 Don't know/Not sure
9 Refused
18.5. As far as you know, have you ever been tested for HIV? Do not count tests you may have had as part of a blood donation.
1 Yes
2 No
7 Don't know/Not sure
9 Refused
18.6. Not including blood donations, in what month and year was your last HIV test?
Code month and year
7 7 7 7 Don't know/Not sure
6 6 6 6 Refused
18.7. What was the main reason you had your test for HIV in …?
Reason code
0 1 For hospitalization or surgical procedure
0 2 To apply for health insurance
0 3 To apply for life insurance
0 4 For employment
0 5 To apply for a marriage license
0 6 For military
induction or military service
0 7 For immigration
0 8 Just to find out if you were infected
0 9 Because of referral by a doctor
1 0 Because of pregnancy
1 1 Referred by your sex partner
1 3 For routine check-up
1 4 Because of occupational exposure
1 5 Because of illness
1 6 Because I am at risk for HIV
8 7 Other
7 7 Don't know/Not sure
9 9 Refused
18.8. Where did you have the HIV test in …?
Facility code
0 1 Private doctor, HMO
0 2 Blood bank, plasma center, Red Cross
0 3 Health department
0 4 AIDS clinic, counseling, testing site
0 5 Hospital, emergency room, outpatient clinic
0 6 Family planning clinic
0 7 Prenatal clinic, obstetrician's office
0 8 Tuberculosis clinic
0 9 STD clinic
1 0 Community health clinic
1 1 Clinic run by employer
1 2 Insurance company clinic
1 3 Other public clinic
1 4 Drug treatment facility
1 5 Military induction or military service site
1 6 Immigration site
1 7 At home, home visit by nurse or health worker
1 8 At home using self-sampling kit
1 9 In jail or prison
8 7 Other
7 7 Don't know/Not sure
9 9 Refused
The next question is about sexually transmitted diseases other than HIV, such as syphilis, gonorrhea, chlamydia, or genital herpes.
18.9. In the past 12 months has a doctor, nurse, or other health professional talked to you about preventing sexually transmitted diseases through condom use?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
Module 7: Asthma History
Previously you said you were told by a doctor, nurse, or other health professional that you had asthma.
1. How old were you when you were first told by a doctor, nurse, or other health professional that you had asthma?
Age in years 11 or older
9 7 Age 10 or younger
9 8 Don't know/Not sure
9 9 Refused
2. During the past 12 months, have you had an episode of asthma or an asthma attack?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
3. During the past 12 months, how many times did you visit an emergency room or urgent care center because of your asthma?
Number of visits
8 8 None
9 8 Don't know/Not sure
9 9 Refused
4. Besides … emergency room visits, during the past 12 months, how many times did you see a doctor, nurse, or other health professional for urgent treatment of worsening asthma symptoms?
Number of visits
8 8 None
9 8 Don't know/Not sure
9 9 Refused
5. During the past 12 months, how many times did you see a doctor, nurse, or other health professional for a routine checkup for your asthma?
Number of visits
8 8 None
9 8 Don't know/Not sure
9 9 Refused
6. During the past 12 months, how many days were you unable to work or carry out your usual activities because of your asthma?
Number of days
8 8 8 None
7 7 7 Don't know/Not sure
9 9 9 Refused
7. Symptoms of asthma include cough, wheezing, shortness of breath, chest tightness and phlegm production when you don't have a cold or respiratory infection. During the past 30 days, how often did you have any symptoms of asthma?
Would you say:
8 Not at any time
1 Less than once a week
2 Once or twice a week
3 More than 2 times a week, but not every day
4 Every day, but not all the time
5 Every day, all the time
7 Don't know/Not sure
9 Refused
8. During the past 30 days, how many days did symptoms of asthma make it difficult for you to stay asleep?
Would you say:
8 None
1 One or two
2 Three to five
3 Six to ten
4 More than ten
7 Don't know/Not sure
9 Refused
9. During the past 30 days how often did you take asthma medication that was prescribed or given to you by doctor? This includes using an inhaler.
Would you say:
8 Didn't take any
1 Less than once a week
2 Once or twice a week
3 More than 2 times a week, but not every day
4 Once every day
5 2 or more times every day
7 Don't know/Not sure
9 Refused
10. Earlier you said there were … children age 17 or younger living in your household. How many of these children have ever been diagnosed with asthma?
Number of children
8 8 None
7 7 Don't know
9 9 Refused
11. Does this child/How many of these children still have asthma?
Number of children
8 8 None
7 7 Don't know
9 9 Refused
Module 12: Folic Acid
1. Do you currently take any vitamin pills or supplements?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
2. Are any of these a multivitamin?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
3. Do any of the vitamin pills or supplements you take contain folic acid?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
4. How often do you take this vitamin pill or supplement?
1 Times per day
2 Times per week
3 Times per month
7 7 7 Don't know/Not sure
9 9 9 Refused
5. Some health experts recommend that women take 400 micrograms of the B vitamin folic acid, for which one of the following reasons...
1 To make strong bones
2 To prevent birth defects
3 To prevent high blood pressure
4 Some other reason
7 Don't know/Not sure
9 Refused
Module 13: Tobacco Indicators
Previously you said you have smoked cigarettes.
1. How old were you the first time you smoked a cigarette, even one or two puffs?
__ __ Code age in years
7 7 Don't know/Not sure
9 9 Refused
2. How old were you when you first started smoking cigarettes regularly?
Code age in years
8 8 Never smoked regularly
7 7 Don't know/Not sure
9 9 Refused
3. About how long has it been since you last smoked cigarettes regularly?
0 1 Within the past month (0 to 1 month ago)
0 2 Within the past 3 months
0 3 Within the past 6 months
0 4 Within the past year
0 5 Within the past 5 years
0 6 Within the past 10 years
0 7 10 or more years ago
7 7 Don't know/Not sure
9 9 Refused
4. In the past 12 months, have you seen a doctor, nurse, or other health professional to get any kind of care for yourself?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
5. In the past 12 months, has a doctor, nurse, or other health professional advised you to quit smoking?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
6. Which statement best describes the rules about smoking inside your home?
1 Smoking is not allowed anywhere inside your home
2 Smoking is allowed in some places or at some times
3 Smoking is allowed anywhere inside the home
4 There are no rules about smoking inside the home
7 Don't know/Not sure
9 Refused
7. While working at your job, are you indoors most of the time?
1 Yes
2 No
7 Don't know/Not Sure
9 Refused
8. Which of the following best describes your place of work's official smoking policy for indoor public or common areas, such as lobbies, rest rooms, and lunch rooms?
1 Not allowed in any public areas
2 Allowed in some public areas
3 Allowed in all public areas
4 No official policy
7 Don't know/Not sure
9 Refused
9. Which of the following best describes your place of work's official smoking policy for work areas?
1 Not allowed in any work areas
2 Allowed in some work areas
3 Allowed in all work areas
4 No official policy
7 Don't know/Not sure
9 Refused