2011
Behavioral
Risk Factor Surveillance System
Questionnaire
2011
Behavioral
Risk Factor Surveillance System
Questionnaire
December 4, 2010
Behavioral Risk
Factor Surveillance System
2011 Questionnaire
Section 2: Healthy Days —
Health-Related Quality of Life
Section 4: Hypertension Awareness
Section 5: Cholesterol Awareness
Section 6: Chronic Health Conditions
Section 9: Fruits and Vegetables
Section 10: Exercise (Physical
Activity)
Section 15: Alcohol Consumption
Module 5: Preconception Health/Family
Planning
Module 9: Cardiovascular Health
Module 10: Actions to Control High
Blood Pressure
Module 32: Random Child Selection
Module 33: Childhood Asthma
Prevalence
Module 34: Child Immunization
(Influenza)
1.1 Would
you say that in general your health is—?
Please read:
1 Excellent
2 Very good
3 Good
4 Fair
Or
5 Poor
Do not read:
7 Don’t know / Not sure
9 Refused
2.1 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
2.2 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 [If Q2.1 and Q2.2 = 88 (None), go to next section]
7 7 Don’t know / Not sure
9 9 Refused
2.3 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
3.1 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 Health Services?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
3.2 Do you
have one person you think of as your personal doctor or health care provider?
If
“No,” ask: “Is there more than one, or is there no person who 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
3.3 Was there a time in the past 12 months when you needed to see a doctor but could not
because of cost?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
3.4 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.
1 Within past year (anytime less than 12 months ago)
2 Within past 2 years (1 year but less than 2 years ago)
3 Within past 5 years (2 years but less than 5 years ago)
4 5 or more years ago
7 Don’t know / Not sure
8 Never
9 Refused
4.1 Have
you EVER been told by a doctor, nurse, or other health professional that you
have
high
blood pressure?
Read only if necessary: By “other health
professional” we mean a nurse practitioner, a physician’s assistant, or some
other licensed health professional.
If “Yes” and
respondent is female, ask: “Was this only when you were pregnant?”
1 Yes
2 Yes, but female told only during
pregnancy [Go to next section]
3 No [Go to next section]
4 Told
borderline high or pre-hypertensive [Go to next section]
7 Don’t
know / Not sure [Go to next section]
9 Refused
[Go to next section]
4.2 Are
you currently taking medicine for your high blood pressure?
1 Yes
2 No
7 Don’t
know / Not sure
9 Refused
5.1 Blood cholesterol is a fatty
substance found in the blood. Have you
EVER had your blood
cholesterol checked?
1 Yes
2 No [Go to next section]
7 Don’t know / Not sure [Go
to next section]
9 Refused [Go to
next section]
5.2 About how long has it been since you
last had your blood cholesterol checked?
Read only if necessary:
1 Within the past year (anytime less
than 12 months ago)
2 Within the past 2 years (1 year but
less than 2 years ago)
3 Within the past 5 years (2 years but
less than 5 years ago)
4 5 or more years ago
Do not
read:
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
Now I would like to
ask you some questions about general health conditions.
Has a doctor, nurse,
or other health professional EVER told you that you had any of the following?
For each, tell me “Yes,” “No,” or you’re “Not sure.”
6.1 (Ever
told) you that you had a heart attack also called a myocardial infarction?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
6.2 (Ever
told) you had angina or coronary heart disease?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
6.3 (Ever
told) you had a stroke?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
6.4 (Ever told) you had asthma?
1 Yes
2 No [Go to Q6.6]
7 Don’t know / Not sure [Go to Q6.6]
9 Refused [Go to Q6.6]
6.5 Do you still have asthma?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
6.6 (Ever told) you had skin
cancer?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
6.7 (Ever told) you had any other types of cancer?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
6.8 (Ever
told) you have (COPD) chronic obstructive pulmonary disease, emphysema or
chronic bronchitis?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
6.9 (Ever
told) you have some form of arthritis, rheumatoid arthritis, gout, lupus, or
fibromyalgia?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
6.10 (Ever
told) you have a depressive disorder (including depression, major depression,
dysthymia, or minor depression)?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
6.11 (Ever
told) you have kidney disease? Do NOT include
kidney stones, bladder infection or incontinence.
INTERVIEWER NOTE: Incontinence is not being able to control urine flow.
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
6.12 (Ever
told) you have vision or eye problems?
1 Yes
2 No
3 Respondent is blind
7 Don’t know / Not sure
9 Refused
6.13 (Ever
told) you have diabetes?
If “Yes” and respondent is female, ask: “Was this only when you were
pregnant?”
If respondent says pre-diabetes or borderline
diabetes, use response code 4.
1 Yes
2 Yes, but female told only during
pregnancy
3 No
4 No, pre-diabetes or borderline
diabetes
7 Don’t know / Not sure
9 Refused
7.1 Have you smoked at least 100
cigarettes in your entire life?
NOTE: 5 packs = 100 cigarettes
1 Yes
2 No [Go to Q7.5]
7 Don’t know / Not sure [Go to
Q7.5]
9 Refused [Go to Q7.5]
7.2 Do you now smoke cigarettes every day, some days, or not at all?
1 Every day
2 Some days
3 Not at all [Go to Q7.4]
7 Don’t know / Not sure [Go to Q7.5]
9 Refused [Go to Q7.5]
7.3 During
the past 12 months, have you stopped smoking for one day or longer because you
were trying to quit smoking?
1 Yes [Go
to Q7.5]
2 No [Go to Q7.5]
7 Don’t know / Not sure [Go to Q7.5]
9 Refused [Go to Q7.5]
7.4 How long has it been since you last smoked a cigarette, even one or two puffs?
0 1 Within the past month (less than 1 month ago)
0 2 Within the past 3 months (1 month but less than 3 months ago)
0 3 Within the past 6 months (3 months but less than 6 months ago)
0 4 Within the past year (6 months but less than 1 year ago)
0 5 Within the past 5 years (1 year but less than 5 years ago)
0 6 Within the past 10 years (5 years but less than 10 years ago)
0 7 10 years or more
0 8 Never smoked regularly
7 7 Don’t know / Not sure
9 9 Refused
7.5 Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all?
Snus (rhymes with ‘goose’)
NOTE: Snus (Swedish for snuff) is a moist smokeless
tobacco, usually sold in small pouches that are placed under the lip against
the gum.
1 Every day
2 Some days
3 Not at all
Do not read:
7 Don’t know / Not sure
9 Refused
8.1 What
is your age?
_ _ Code age in years
0 7 Don’t know / Not sure
0 9 Refused
8.2 Are you Hispanic or Latino?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
8.3 Which one or more of the following would you say is your race?
(Check all that apply)
Please read:
1 White
2 Black or African American
3 Asian
4 Native Hawaiian or Other Pacific Islander
5 American Indian or
Or
6 Other [specify]______________
Do
not read:
8 No additional choices
7 Don’t know / Not sure
9 Refused
8.4 Which one of these groups would you say best represents your race?
Please read:
1 White
2 Black or African American
3 Asian
4 Native Hawaiian or Other Pacific Islander
5 American Indian or
Or
6 Other [specify]______________
Do
not read:
7 Don’t know / Not sure
9 Refused
8.5 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.
1 Yes
2 No
Do not read:
7 Don’t know / Not sure
9 Refused
8.6 Are
you…?
Please read:
1 Married
2 Divorced
3 Widowed
4 Separated
5 Never married
Or
6 A member of an unmarried couple
Do not read:
9 Refused
8.7 How many children less than 18 years of age live in your household?
_ _ Number of children
8 8 None
9 9 Refused
8.8 What is the highest grade or year of school you completed?
Read only if necessary:
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)
Do not read:
9 Refused
8.9 Are you currently…?
Please read:
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
Or
8 Unable to work
Do not read:
9 Refused
8.10 Is
your annual household income from all sources—
If respondent refuses at ANY income level, code ‘99’ (Refused)
Read only if necessary:
0 4 Less than $25,000 If “no,” ask 05; if “yes,” ask 03
($20,000 to less than $25,000)
0 3 Less than $20,000 If “no,” code 04; if “yes,” ask 02
($15,000 to less than $20,000)
0 2 Less than $15,000 If “no,” code 03; if “yes,” ask 01
($10,000 to less than $15,000)
0 1 Less than $10,000 If “no,” code 02
0 5 Less than $35,000 If “no,” ask 06
($25,000 to less than $35,000)
0 6 Less than $50,000 If “no,” ask 07
($35,000 to less than $50,000)
0 7 Less than $75,000 If “no,” code 08
($50,000 to less than $75,000)
0 8 $75,000 or more
Do not read:
7 7 Don’t know / Not sure
9 9 Refused
8.11 About how much do you weigh without shoes?
Round fractions up
_
_ _ _ Weight
(pounds/kilograms)
7 7 7 7 Don’t know / Not sure
9 9 9 9 Refused
8.12 About how tall are you without shoes?
NOTE: If respondent answers in metrics, put “9” in column 130.
Round fractions down
_
_ / _ _ Height
(f t / inches/meters/centimeters)
7 7/ 7 7 Don’t know / Not sure
9 9/ 9 9 Refused
8.13 What
county do you live in?
_ _ _ ANSI County Code (formerly FIPS county code)
7 7 7 Don’t know / Not sure
9 9 9 Refused
8.14 What is the ZIP Code where you
live?
_ _ _ _ _ ZIP Code
7
7 7 7 7 Don’t know / Not sure
9
9 9 9 9 Refused
8.15 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 [Go to Q8.17]
7 Don’t know / Not sure [Go to Q8.17]
9 Refused [Go to Q8.17]
8.16 How many of these telephone numbers
are residential numbers?
_ Residential telephone numbers [6 = 6 or more]
7 Don’t know / Not sure
9 Refused
8.17 Do you
have a cell phone for personal use? Please include cell phones used for both business and personal use.
1 Yes [Go to Q8.19]
2 No
7 Don’t know / Not sure
9 Refused
8.18 Do you share a cell phone for
personal use (at least one-third of the time) with other adults?
1 Yes [Go to Q8.20]
2 No [Go to Q8.21]
7 Don’t know / Not sure [Go
to Q8.21]
9 Refused [Go to
Q8.21]
8.19 Do you
usually share this cell phone (at least one-third of the time) with any other adults?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
8.20 Thinking
about all the phone calls that you receive on your landline and cell phone,
what percent, between 0 and 100, are received on your cell phone?
_
_ _ Enter percent (1 to 100)
8
8 8 Zero
7
7 7 Don’t know / Not sure
9 9 9 Refused
8.21 Do you own or rent your home?
1 Own
2 Rent
3 Other arrangement
7 Don’t know / Not sure
9 Refused
8.22 Indicate sex of respondent. Ask only if necessary.
1 Male [Go to next section]
2 Female [If respondent is 45 years old or older, go to next section]
8.23 To your knowledge, are you now
pregnant?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
9.1 During the past month, how many times per day, week or month did you drink 100% PURE fruit juices? Do not include fruit-flavored drinks with added sugar or fruit juice you
made at home and added sugar to. Only include 100% juice.
1 _ _ Per day
2 _ _ Per week
3 _ _ Per month
5 5 5 Never
7 7 7 Don’t know / Not sure
9 9 9 Refused
9.2 During the past month, not counting juice, how many times per day, week, or month did you eat fruit? Count fresh, frozen, or canned fruit
1 _ _ Per day
2 _ _ Per week
3 _ _ Per month
5 5 5 Never
7 7 7 Don’t know / Not sure
9 9 9 Refused
9.3 During the past month, how many times per day, week, or month did you eat cooked or canned beans, such as refried, baked, black, garbanzo beans, beans in soup, soybeans, edamame, tofu or lentils. Do NOT include long green beans.
1 _ _ Per day
2 _ _ Per week
3 _ _ Per month
5 5 5 Never
7 7 7 Don’t know / Not sure
9 9 9 Refused
9.4 During the past month, how many times per day, week, or month did you eat dark green vegetables for example broccoli or dark leafy greens including romaine, chard, collard greens or spinach?
1 _ _ Per day
2 _ _ Per week
3 _ _ Per month
5 5 5 Never
7 7 7 Don’t know / Not sure
9 9 9 Refused
9.5 During the past month, how many
times per day, week, or month did you eat orange-
colored vegetables such
as sweet potatoes, pumpkin, winter squash, or carrots?
1 _ _ Per day
2 _ _ Per week
3 _ _ Per month
5 5 5 Never
7 7 7 Don’t know / Not sure
9 9 9 Refused
9.6 Not counting what you just told me about, during the past month, about how many times per day, week, or month did you eat OTHER vegetables? Examples of other vegetables include tomatoes, tomato juice or V-8 juice, corn, eggplant, peas, lettuce, cabbage, and white potatoes that are not fried such as baked or mashed potatoes.
1 _ _ Per day
2 _ _ Per week
3 _ _ Per month
5 5 5 Never
7 7 7 Don’t know / Not sure
9 9 9 Refused
10.1 During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?
1 Yes
2 No [Go to Q10.8]
7 Don’t know / Not sure [Go to Q10.8]
9 Refused [Go to
Q10.8]
10.2. What
type of physical activity or exercise did you spend the most time doing during
the past month? (172-173)
_ _
(Specify) [See Coding List A]
7
7 Don’t know / Not Sure [Go to
Q10.8]
9 9 Refused
[Go to Q10.8]
10.3 How many times per week or per month did you take part in this activity during the past month?
1_ _ Times per week
2_ _ Times per month
7 7 7 Don’t know / Not sure
9 9 9 Refused
10.4 And when you took part in this activity, for how many minutes or hours did you usually keep at it?
_:_ _ Hours and minutes
7 7 7 Don’t know / Not sure
9 9 9 Refused
10.5 What
other type of physical activity gave you the next most exercise during the past
month?
_
_ (Specify) [See
Coding List A] 8 8 No
other activity [Go to Q10.8]
7 7 Don’t
know / Not Sure [Go to Q10.8]
9
9 Refused [Go to Q10.8]
10.6 How many times per week or per month did you take part in this activity during the past month?
1_ _ Times per week
2_ _ Times per month
7 7 7 Don’t know / Not sure
9 9 9 Refused
10.7 And when you took part in this activity, for how many minutes or hours did you usually keep at it?
_:_ _ Hours and minutes
7 7 7 Don’t know / Not sure
9 9 9 Refused
10.8 During the past month, how
many times per week or per month did you do physical activities or exercises to STRENGTHEN your
muscles? Do NOT count aerobic activities like walking, running, or bicycling.
Count activities using your own body weight like yoga,
sit-ups or push-ups and those using weight machines, free weights, or elastic bands.
1_ _ Times per week
2_ _ Times per month
8 8 8 Never
7 7 7 Don’t know / Not sure
9 9 9 Refused
11.1 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
11.2 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?
NOTE: Include occasional use or use in certain circumstances.
1 Yes
2 No
7 Don’t know / Not Sure
9 Refused
If Q6.9
= 1 (yes) then continue, else go to next section.
12.1 Are you
now limited in any way in any of your usual activities because of arthritis or
joint symptoms?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
12.2 In this next question, we are referring to work for pay. Do arthritis or joint symptoms now affect whether you work, the type of work you do, or the amount of work you do?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
12.3 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?
Please read [1-3]:
1 A lot
2 A little
3 Not at all
Do not read:
7 Don’t know / Not sure
9 Refused
12.4 Please think about the past 30 days, keeping in mind all
of your joint pain or aching and whether
or not you have taken medication. 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.
_ _ Enter
number [00-10]
7 7 Don’t know / Not sure
9 9 Refused
13.1 How often do you use seat belts when you drive or ride in a car? Would you say—
Please read:
1 Always
2 Nearly always
3 Sometimes
4 Seldom
5 Never
Do not read:
7 Don’t know / Not sure
8 Never drive or ride in a car
9 Refused
14.1 Now
I will ask you questions about seasonal flu vaccine. There are two ways to get the seasonal flu
vaccine, one is a shot in the arm and the other is a spray, mist, or drop in
the nose called FluMist™. During the past 12 months, have you had either a seasonal
flu shot or a seasonal flu vaccine that was sprayed in your nose?
1 Yes
2 No [Go to Q14.4]
7 Don’t know / Not sure [Go
to Q14.4]
9 Refused [Go to
Q14.4]
14.2 During what month and year did you receive your most recent flu shot injected into your arm or flu vaccine that was sprayed in your nose?
_ _ / _ _ _ _ Month / Year
7 7 / 7 7 7 7 Don’t know / Not sure
9 9 / 9 9 9 9 Refused
14.3 At what kind of place did you get your last flu shot/vaccine?
0 1 A doctor’s office or health maintenance organization (HMO)
0 2 A health department
0 3 Another type of clinic or health center (Example: a community health center)
0 4 A senior, recreation, or community center
0 5 A store (Examples: supermarket, drug store)
0 6 A hospital (Example: inpatient)
0 7 An emergency room
0 8 Workplace
0 9 Some other kind of place
1 0 Received vaccination in Canada/Mexico (Volunteered – Do not read)
1 1 A school
7
7 Don’t know / Not sure
Do not read:
9 9 Refused
14.4 A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person’s lifetime and is different from the flu shot. Have you ever had a pneumonia shot?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
15.1 During the past 30 days, how
many days per week or per month did you have at least one drink of any
alcoholic beverage such as beer, wine, a malt beverage or liquor?
1 _ _ Days per week
2 _ _ Days in past 30 days
8 8 8 No drinks in past 30 days [Go
to next section]
7 7 7 Don’t know / Not sure [Go to next
section]
9 9 9 Refused [Go to next section]
15.2 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?
_ _ Number of drinks
7 7 Don’t know / Not sure
9 9 Refused
15.3 Considering
all types of alcoholic beverages, how many times during the past 30 days did
you have X [CATI X = 5 for men, X = 4
for women] or more drinks on an occasion?
_ _ Number of times
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
15.4 During the past 30 days, what
is the largest number of drinks you had on any occasion?
_ _ Number of drinks
7 7 Don’t know / Not sure
9 9 Refused
16.1 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.
1 Yes
2 No [Go to Q16.3]
7 Don’t know / Not sure [Go to Q16.3]
9 Refused [Go
to Q16.3]
16.2 Not
including blood donations, in what month and year was your last HIV test?
_ _ /_ _ _ _ Code month and year
7 7/ 7 7 7 7 Don’t
know / Not sure
9 9/ 9 9 9 9 Refused / Not sure
16.3 I’m going to read you a list. When I’m done, please tell me if any of the situations apply to you. You do not need to tell me which one.
§ You have used intravenous drugs in the past year.
§ You have been treated for a sexually transmitted or venereal disease in the past year.
§ You have given or received money or drugs in exchange for sex in the past year.
§ You had anal sex without a condom in the past year.
Do any of these situations apply to you?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
1. Have you had a test for high blood sugar or diabetes within the past three years?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
2. Have you ever been told by a doctor or other health professional that you have pre-diabetes or borderline diabetes?
If “Yes” and respondent is female,
ask: “Was this only when you were pregnant?”
1 Yes
2 Yes, during pregnancy
3 No
7 Don’t know / Not sure
9 Refused
1. How old were you when you were told you have diabetes?
_ _ Code age in years [97 = 97 and older]
9 8 Don’t know / Not sure
9 8Don=t know/Not sure9 9 Refused
2. Are you now taking insulin?
1 Yes
2 No
9 Refused
3. 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 health professional.
1 _ _ Times per day
2 _ _ Times per week
3 _
_ Times per month
4 _
_ Times per year
8 8 8 Never
7 7 7 Don’t know / Not sure
9 9 9 Refused
4. 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.
1 _ _ Times per day
2 _ _ Times per week
3 _
_ Times per month
4 _ _ Times per year
5 5 5 No feet
8 8 8 Never
7 7 7 Don’t know / Not sure
9 9 9 Refused
5. About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?
_ _ Number of times [76 = 76 or more]
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
6. A test for "A one C" measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, nurse, or other
health professional checked you for "A one C"?
_ _ Number of times [76 = 76 or more]
8 8 None
9 8 Never heard of “A one C” test
7 7 Don’t know / Not sure
9 9 Refused
7. About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?
_ _ Number of times [76 = 76 or more]
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
8. 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.
Read only if necessary:
1 Within the past month (anytime less than 1 month ago)
2 Within the past year (1 month but less than 12 months ago)
3 Within the past 2 years (1 year but less than 2 years ago)
4 2 or more years ago
Do not read:
7 Don’t know / Not sure
8 Never
9 Refused
9. Has a doctor ever told you
that diabetes has affected your eyes or that you had retinopathy?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
10. Have you ever taken a course or class in how to manage your diabetes yourself?
1 Yes
2 No
7 Don't know / Not sure
9 Refused
1.
Has a doctor, nurse, or other health care worker ever
talked with you about ways to prepare for a healthy pregnancy and baby?
1 Yes
2 No
7 Don’t
know / Not sure
9 Refused
The next set of
questions asks you about your thoughts and experiences with family planning.
Please remember that all of your answers will be kept confidential.
2.
Have you ever been pregnant?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
3.
Did you or your husband/partner do anything the last time you had sex to
keep you from getting pregnant?
1 Yes
2 No
[Go
to Q5]
3 No
partner/not sexually active [Go to
Q6]
4 Same
sex partner [Go to
Q6]
7 Don’t
know / Not sure [Go to Q6]
9 Refused [Go to Q6]
4.
What did you or your husband/partner do the last time you had sex to keep you from getting pregnant?
Read only if necessary:
01. Female
sterilization (ex. tubal ligation, Essure, Adiana) [Go to Q7] 02. Male sterilization (vasectomy) [Go to Q7]
03. Contraceptive
implant (ex. Implanon) [Go to Q6]
04.
Levonorgestrel(LNG) or hormonal IUD(ex. Mirena) [Go to Q6] 05. Copper-bearing IUD (ex.
ParaGard) [Go to Q6]
06. IUD, type
unknown [Go to Q6]
07. Shots (ex.
Depo-Provera) [Go to Q6]
08. Birth control
pills, any kind [Go to Q6]
09. Contraceptive
patch (ex. Ortho Evra) [Go to Q6]
10. Contraceptive
ring (ex. NuvaRing) [Go to Q6]
11. Male condoms [Go
to Q6]
12. Diaphragm, cervical
cap, sponge [Go to Q6]
13.
Female condoms [Go to Q6]
14. Not having sex at certain
times (rhythm or natural family planning) [Go to Q6]
15.
Withdrawal (or pulling out) [Go
to Q6]
16.
Foam, jelly, film, or cream [Go
to Q6]
17. Emergency
contraception (morning after pill) [Go
to Q6]
18. Other method [Go to Q6]
77. Don’t know / Not sure [Go to Q6]
99.
Refused [Go to Q6]
Some reasons for not doing anything to keep you from getting pregnant the last
time you had sex might include wanting a pregnancy, not being able to pay
for birth control, or not thinking that you
can get pregnant.
5.
What was your main reason for not doing
anything the last time you had sex to keep you from getting pregnant?
Read only if necessary:
01 You
didn’t think you were going to have sex/no regular partner
02 You
just didn’t think about it/don’t care if you get pregnant
03 You
want a pregnancy
04 You
or your partner don’t want to use birth control
05 You
or your partner don’t like birth control/side effects
06 You
couldn’t pay for birth control
07 You
had a problem getting birth control when you needed it
08 Religious
reasons
09 Lapse
in use of a method
10 Don’t
think you or your partner can get pregnant (infertile or too old)
11 You
had tubes tied (sterilization) [Go to
next module]
12 You
had a hysterectomy [Go to next module]
13 Your
partner had a vasectomy (sterilization) [Go
to next module]
14 You
are currently breast-feeding
15 You
just had a baby/postpartum
16 You
are pregnant now [Go to Q7]
17 Same
sex partner
18 Other
reason
Do not read:
77 Don’t know / Not sure
99 Refused
6.
How do you feel about having a child now or
sometime in the future? Would you say:
Please read:
1 You
don’t want to have one
2 You
do want to have one, less than 12 months from now
3 You
do want to have one, between 12 months to less than 2 years from now
4 You
do want to have one, between 2 years to less than 5 years from now
5 You
do want to have one, 5 or more years from now
Do not read:
7 Don’t know / Not sure
9 Refused
7.
How many times a week do you currently take a
multivitamin, a prenatal vitamin, or a folic acid vitamin?
1 0
times a week
2 1
to 3 times a week
3 4
to 6 times a week
4 Every
day of the week
7 Don’t know / Not sure
9 Refused
1. Following your heart attack, did you go to any kind of outpatient rehabilitation? This is sometimes called "rehab."
1 Yes
1Yes2 No
2No7 Don’t know / Not sure
7Don=t know/Not sure9 Refused
2. Following your stroke, did you go to any kind of outpatient rehabilitation? This is sometimes called "rehab."
1 Yes
1Yes2 No
2No7 Don’t know / Not sure
7Don=t know/Not sure9 Refused
3. Do you take aspirin daily or every other day?
1 Yes [Go to next module]
1Yes Go to Q92 No
2No7 Don’t know / Not sure
7Don=t know/Not sure9 Refused
4. Do you have a health problem or condition that makes taking aspirin unsafe for you?
1 Yes, not stomach related
2 Yes, stomach problems
3 No
7 Don’t know / Not sure
9 Refused
Earlier you stated that you had been diagnosed with high blood pressure.
Are you now doing any of the following to help lower or control your high blood pressure?
1. (Are you) changing your eating habits (to help lower or control your high blood pressure)?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
2. (Are you) cutting down on salt (to help lower or control your high blood pressure)?
1 Yes
2 No
3 Do not use salt
7 Don’t know / Not sure
9 Refused
3. (Are you) reducing alcohol use (to help lower or control your high blood pressure)?
1 Yes
2 No
3 Do not drink
7 Don’t know / Not sure
9 Refused
4. (Are you) exercising (to help lower or control your high blood pressure)?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
Has a doctor or other health professional ever advised you to do any of the following to help lower or control your high blood pressure?
5. (Ever advised you to) change your eating habits (to help lower or control your high blood pressure)?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
6. (Ever advised you to) cut down on salt (to help lower or control your high blood pressure)?
1 Yes
2 No
3 Do not use salt
7 Don’t know / Not sure
9 Refused
7. (Ever advised you to) reduce alcohol use (to help lower or control your high blood pressure)?
1 Yes
2 No
3 Do not drink
7 Don’t know / Not sure
9 Refused
8. (Ever advised you to) exercise (to help lower or control your high blood pressure)?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
9. (Ever advised you to) take medication (to help lower or control your high blood pressure)?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
10. Were you told on two or more different visits by a doctor or other health professional that you had high blood pressure?
If “Yes” and respondent is female, ask: “Was this only when you were pregnant?”
1 Yes
2 Yes, but female told only during pregnancy
3 No
4 Told borderline or pre-hypertensive
7 Don’t know / Not sure
9 Refused
The next questions are about exposure to secondhand smoke.
1. Now I’m
going to ask you about smoke you might have breathed at work because someone
else was smoking indoors. During the past 7 days, that is, since last [TODAY’S DAY OF THE WEEK], on how many
days did you breathe the smoke at your workplace from someone other than you who was smoking tobacco?
2. Not counting decks, porches,
or garages, during the past 7 days, that is, since last [TODAY’S DAY OF WEEK], on how many days did someone other than you smoke
tobacco inside your home
while you were at home?
_ _ Number of days [01-07]
3. During
the past 7 days, that is, since last [TODAY’S
DAY OF WEEK], on how many days did
you ride in a vehicle where someone
other than you was smoking tobacco?
The next question
asks about tobacco use in indoor public places. Examples of indoor public
places are the indoor areas of stores, restaurants, bars, casinos, clubs, and
sports arenas.
4. [If
Q8.9 = 1 (Employed) or Q8.9 = 2 (Self-employed); say “Not counting
times while you were
at work,”] during the past 7 days, that is, since last [TODAY’S DAY OF WEEK],
on how many days did you breathe the smoke from someone else who was smoking in an indoor public place?
5. Not
counting decks, porches, or garages, inside your home, is smoking…
Please read:
1 Always allowed
2 Allowed only at some times or in some
places
3 Never allowed
Do not read:
6 Family does not have a smoking policy
7 Don’t
know / Not sure
9 Refused
6. Not counting motorcycles,
in the vehicles that you or family members who live with you own or lease, is
smoking…
Please
read:
1 Always allowed in all vehicles
2 Sometimes allowed in at least one
vehicle
3 Never allowed in any vehicle
Do
not read:
6 Family does not have a vehicle smoking
policy
8 Respondent’s
family does not own or lease a vehicle
7 Don’t know / Not sure
9 Refused
7. At
workplaces, do you think smoking indoors should be…
Please read:
1 Always allowed
2 Allowed only at some times or in some
places
3 Never allowed
Do not read:
7 Don’t know / Not sure
9 Refused
1.
What
is the birth month and year of the “Xth”
child?
_ _ /_ _ _ _ Code month and
year
7 7/ 7 7 7 7 Don’t
know / Not sure
9 9/ 9 9 9 9 Refused
2. Is
the child a boy or a girl?
1 Boy
2 Girl
9 Refused
3. Is
the child Hispanic or Latino?
1 Yes
2
No
7
Don’t know / Not sure
9 Refused
4. Which one
or more of the following would you say is the race of the child?
[Check
all that apply]
Please
read:
1 White
2 Black
or African American
3 Asian
4 Native
Hawaiian or Other Pacific Islander
5
Or
6 Other
[specify] ____________________
Do
not read:
8 No
additional choices
7 Don’t
know / Not sure
9 Refused
5. Which one of these
groups would you say best represents the child’s race?
1 White
2
Black or African American
3
Asian
4
Native Hawaiian or Other Pacific
Islander
5
6
Other
7
Don’t know / Not sure
9
Refused
6. How are you related
to the child?
Please
read:
1 Parent (include biologic, step, or
adoptive parent)
2 Grandparent
3 Foster parent or guardian
4 Sibling (include biologic, step, and
adoptive sibling)
5 Other
relative
6 Not
related in any way
Do
not read:
7 Don’t
know / Not sure
9 Refused
Now, I would like to ask you about the “Xth” [CATI: please fill in correct number] child.
1. Has a doctor, nurse or other health professional EVER said that the child has asthma?
1 Yes
Number of children2 No [Go to next module]
8 8 None Go to Next Module7 Don’t know / Not sure [Go to next module]
7 7 Don=t know Go to Next Module9 Refused [Go to next module]
2. Does the child still have asthma?
1 Yes
Number of children2 No
8 8 None Go to Next Module7 Don’t know / Not sure
7 7 Don=t know Go to Next Module9 Refused