Attachment 2 – Instrument to be cognitively tested.
OMB #0920-0222; Expiration Date: 03/31/2013
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Adults (18 years and older) NHIS Voice, Swallowing, Speech, & Language
These next questions are about disorders or problems with voice, swallowing, speech, or language.
VSL.010 Have you ever had, or been told by a doctor, nurse, or other health professional, you have any chronic illnesses, conditions, surgeries, or injuries that affected your voice, swallowing, speech, or language?
Answer Codes 1. Yes (Go to VSL.020)
2. No (Go to VSL.030)
Refused (Go to VSL.030)
Don't Know (Go to VSL.030)
VSL.020
Which ones? (Do not read categories)
* Enter all that apply, separate with commas.
Answer Codes 1. Allergies (seasonal; e.g. hay fever)
2. Amyotrophic lateral sclerosis (ALS or Lou Gehrig’s Disease)
3. Anxiety or Panic Disorder
4. Attention Problems or ADD or ADHD
5. Asperger Syndrome
6. Asthma
7. Autism
8. Bell’s Palsy
9. Brain Cancer or Tumor
10. Cerebral Palsy
11. Cerebral or Brain Hemorrhage
12. Chronic Bronchitis
13. Cleft Lip or Palate or Cranial-Facial Anomaly
14. Congestive Heart Failure
15. Dementia or Alzheimer’s Disease
16. Dental Problems
17. Depression
18. Diabetes
19. Emphysema
20. Encephalitis
21. Esophageal Reflux or Heartburn
22. Epilepsy or Other Seizure Disorder
23. Friedreich’s Ataxia
24. Head or Neck Injury (e.g., Concussion)
25. Hypoglycemia
26. Injury (e.g., spinal cord); specify: _________________
27. Laryngitis
28. Meningitis
29. Migraine headaches
30. Multiple Sclerosis
31. Muscular Dystrophy
32. Myasthenia Gravis
33. Myoclonus
34. Narcolepsy
35. Neurofibromatosis-2
36. Parkinson’s Disease
37. Polymyositis
38. Post-Traumatic Stress Disorder (PTSD)
39. Schilder’s Disease
40. Scleroderma
41. Sjogren’s Syndrome
42. Stroke
43. Surgery to Ear, Nose, Throat, Face, etc.
44. Thyroid Cancer
45. Vomiting
46. Wilson’s Disease
47. Other, specify: _____________________________________________
Refused
Don't Know
VSL.030 Have you ever used drugs or medications that have affected your voice, swallowing, speech, or language?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.040 Have you ever used drugs or medications to treat or improve your voice, swallowing, speech, or language?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.050 DURING THE PAST 12 MONTHS, have you had any of the following conditions for one day or more?
Please say yes or no to each.
Answer Codes 1. Yes
2. No
Refused
Don't Know
...Hoarse voice
...Breathy or whispery voice
...Raspy, creaky, crackling, croaking, rough, or harsh voice
...Strained or strangled voice, breaks while speaking
...Unable to raise voice loud enough to be understood (i.e., trouble projecting your voice)
...Lost your voice (unable to speak for a time)
...Fatigued, tired, or worn-out voice
...Physical discomfort when using your voice to talk
...Sensation of a lump in the throat or a sore throat (usually)
...Need to cough or clear your throat frequently
...Changes or disruptions in loudness, pitch, or quality of your voice
...Voice change to a deeper pitch
...Voice change to a higher pitch
...Swallowing difficulty
...Choking frequently while eating or drinking
...Slurring of words
...Mispronunciation of words (a persistent problem with “articulation”, i.e., leaving out sounds where they should occur or substituting an incorrect sound for a correct one)
...Distortion of speech sounds
...Monotonous speech tone
...Explosive speech (words spoken with more force than necessary)
...Staccato speech with each syllable uttered separately
...Pauses too long between words or syllables
...Failure to complete words
...Head jerking while talking
...Eye blinking while talking
...Stuttering (or repetition of sounds, words, or phrases)
...Unable to find words to express your thoughts
...Difficulty understanding spoken or written words
...Frustrated with attempts to communicate
...Embarrassed with speech (while attempting to communicate)
VSL.060 During the past 12 months, have you had any problems or difficulties with your VOICE, for example with the way your voice sounds?
*Read if necessary: Your voice may have been hoarse, raspy, breathy, strained, fatigued, or you may have lost your voice altogether for a period of time.
*Read if necessary: Do not include times when drinking alcohol or taking recreational drugs
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.061 During the past 12 months, have you had a SWALLOWING problem, difficulty eating solid food, taking pills, or drinking beverages?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.062 During the past 12 months, have you had a...SPEECH problem, that is, stuttering, mispronouncing words, or distorting speech sounds?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.063 During the past 12 months, have you had a... LANGUAGE problem, for example, unable to express your thoughts in words or to understand spoken or written language?
Answer Codes 1. Yes
2. No
Refused
Don't Know
Skips: If problems with voice, speech, swallowing and language identified, skip to appropriate section, starting with voice
VOICE
VSL.085 In the past 12 months, how often have you had a problem with your VOICE?
*Probe if needed.
Answer Codes 1. Every day, or almost every day
2. Three to 5 days a week
3. One or 2 days a week
4. Two or 3 days a month
5. Three to 12 days in the past year
6. One or 2 days in the past year
7. None (Never or No Days)
Refused
Don't Know
VSL.090 In the past 12 months, how often has your voice been hoarse, raspy, or breathy?
*Probe if needed
Answer Codes
1. Every day, or almost every day
2. Three to 5 days a week
3. One or 2 days a week
4. Two or 3 days a month
5. Three to 12 days in the past year
6. One or 2 days in the past year
7. None (Never or No Days)
Refused
Don't Know
VSL.100 In the past 12 months, how often have you had difficulty being heard or trouble projecting your voice?
*Probe if needed.
Answer Codes 1. Every day, or almost every day
2. Three to 5 days a week
3. One or 2 days a week
4. Two or 3 days a month
5. Three to 12 days in the past year
6. One or 2 days in the past year
7. None (Never or No Days)
Refused
Don't Know
VSL.110 During the past 12 months, in your opinion, do you think your voice was ever difficult to hear or understand?
Answer Codes 1. Extremely difficult
2. Very difficult
3. Moderately difficult
4. Slightly difficult
5. Not at all difficult
Refused
Don't Know
VSL.120 During the past 12 months, did other people (for example, close family or friends) ever comment that your voice is difficult to hear or understand? Would you say...
Answer Codes 1. Almost always made comments
2. Frequent comments
3. Moderate number of comments
4. Occasional comments
5. None, never made comments
Refused
Don't Know
VSL.130 In the past 12 months, how often has a problem with your voice limited or affected your personal or social functioning at home, school, or work?
*Probe if needed.
Answer Codes 1. Every day, or almost every day
2. Three to 5 days a week
3. One or 2 days a week
4. Two or 3 days a month
5. Three to 12 days in the past year
6. One or 2 days in the past year
7. None (Functioning was never limited or affected)
Refused
Don't Know
VSL.140 How long has it been since you FIRST began to have any problems with your voice?
Answer Codes 1. Less than 2 weeks ago
2. At least 2 weeks, but less than 3 months ago
3. Three to 11 months ago
4. During the past 1 to 2 years
5. Three to 4 years
6. Five to 9 years
7. Ten to 14 years
8. 15 years or more
Refused
Don't Know
VSL.150 Have you EVER seen a speech-language pathologist (SLP), doctor, or other health professional about your VOICE problem?
Answer Codes 1. Yes (Go to VSL.160)
2. No (Go to VSL.170)
Refused (Go to VSL.170)
Don't Know (Go to VSL.170)
VSL.160 Which of the following kinds of health professionals have you seen about your VOICE problem?
Please say yes or no to each.
Answer Codes 1. Yes
2. No
Refused
Don't Know
...Acupuncturist
...Audiologist or Hearing Aid Specialist
...Chiropractor
...Dentist, Orthodontist or Oral Surgeon
...ENT or Ear, Nose, and Throat Doctor or Otolaryngologist
...Family Doctor or General Practitioner
...Internist or Internal Medicine Doctor
...Neurologist
...Nurse or Nurse Practitioner
...Nutritionist or Dietician
...Psychiatrist or Psychologist
...Occupational or Physical Therapist
...Osteopath (Doctor of Osteopathy)
...Radiologist or Technician for MRI, CAT scan, or Ultrasound
...Speech-Language Pathologist
...Other, specify: ________________________________________
VSL.165 During the past 12 months, did you see {fill health professionals selected from list in previous question} about your VOICE problem?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.170 During the past 12 months, how has your VOICE problem changed? Has it…
Answer Codes 1. Gotten a lot worse
2. Gotten a little worse
3. Stayed the same, not improved at all
3. Improved a little or somewhat
2. Improved greatly
Refused
Don't Know
VSL.190 During the past 12 months, what have you been told by a health care professional, or what do you think, caused your VOICE problem?
Answer Codes 1. Overuse of your voice
2. Acute illness (e.g., flu
3. Chronic illness or condition
4. Surgical procedure, specify
5. Injury, specify
6. Other cause(s), specify:
Refused
Don't Know
VSL.200 Have you EVER received treatment, rehabilitation or other intervention services for your VOICE problem from a speech-language pathologist (SPL), doctor, or other health professional?
Answer Codes 1. Yes (Go to VSL.220)
2. No (Go to Swallowing section if applicable)
Refused (Go to Swallowing section if applicable)
Don't Know (Go to Swallowing section if applicable)
VSL.220 Was this in the past 12 months?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.230 How did your participation in treatment, rehabilitation or other intervention services for your VOICE problem by a speech-language pathologist (SLP), doctor, or other health provider during the past year affect your PERSONAL OR SOCIAL FUNCTIONING at home, school, or work?
Answer Codes 1. Gotten a lot worse
2. Gotten a little worse
3. Stayed the same, no improvement at all
4. Improved a little
5. Improved greatly
Refused
Don't Know
SWALLOWING
VSL.240 In the past 12 months, how often have you had a problem SWALLOWING?
*Probe if needed.
Answer Codes 1. Every day, or almost every day
2. Three to 5 days a week
3. One or 2 days a week
4. Two or 3 days a month
5. Three to 12 days in the past year
6. One or 2 days in the past year
7. None (Never or No Days)
Refused
Don't Know
VSL.250 Does your SWALLOWING problem result in choking and coughing?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.260 Does your SWALLOWING problem feel like food is getting “stuck” in your throat?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.270 Does your SWALLOWING problem feel like you have heartburn or heaviness or pressure in the neck or upper or lower chest when eating?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.280 Does your SWALLOWING problem vary by what you are swallowing… for example, liquid, solid (chewable food), pills, or something else?
Answer Codes 1. Yes (Go to VSL.290)
2. No (Go to VSL.300)
Refused (Go to VSL.300)
Don't Know (Go to VSL.300)
VSL.290 Which of the following are more difficult for you to SWALLOW —liquid, solid (chewable food), pills, or something else?
Answer Codes 1. Liquid (drinks or fluids)
2. Solid or chewable food
3. Pills
4. Other, specify:
Refused
Don't Know
VSL.300 Have you modified your diet or life style because of your SWALLOWING problem?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.310 How long has it been since you FIRST began to have your SWALLOWING problem?
Answer Codes 1. Less than 2 weeks ago
2. At least 2 weeks, but less than 3 months ago
3. Three to 11 months ago
4. During the past 1 to 2 years
5. Three to 4 years
6. Five to 9 years
7. Ten to 14 years
8. 15 years or more
Refused
Don't Know
VSL.320 Have you EVER seen a speech-language pathologist (SPL), doctor, or other health professional about your SWALLOWING problem?
Answer Codes 1. Yes (Go to VSL.325)
2. No (Go to VSL.350)
Refused (Go to VSL.350)
Don't Know (Go to VSL.350)
VSL.325 Which of the following kinds of health professionals have you seen about your SWALLOWING problem?
Please say yes or no to each.
Answer Codes 1. Yes
2. No
Refused
Don't Know
...Acupuncturist
...Audiologist or Hearing Aid Specialist
...Chiropractor
...Dentist, Orthodontist or Oral Surgeon
...ENT or Ear, Nose, and Throat Doctor or Otolaryngologist
...Family Doctor or General Practitioner
...Internist or Internal Medicine Doctor
...Neurologist
...Nurse or Nurse Practitioner
...Nutritionist or Dietician
...Psychiatrist or Psychologist
...Occupational or Physical Therapist
...Osteopath (Doctor of Osteopathy)
...Radiologist or Technician for MRI, CAT scan, or Ultrasound
...Speech-Language Pathologist
...Other, specify: ________________________________________
VSL.330 During the past 12 months, did you see {fill health professionals selected from list in previous question} about your SWALLOWING problem?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.340 During the past 12 months, what have you been told by a health care professional, or what do you think caused your problem SWALLOWING?
Answer Codes 1. Narrowings (e.g., “strictures” due to radiation, chemicals, medications, chronic inflammation, or ulcers), specify
2. Acute illness (e.g., flu), specify
3. Chronic illness or condition, specify
4. Surgical procedure (e.g., tumors), specify
5. Injury, specify
6. Emotional or anxiety disorder, specify
7. Other cause(s), specify:
Refused
Don't Know
VSL.350 During the past 12 months, how has your SWALLOWING problem changed? Would you say it has…
Answer Codes 1. Gotten a lot worse
2. Gotten a little worse
3. Stayed the same, not improved at all
3. Improved a little or somewhat
2. Improved greatly
Refused
Don't Know
VSL.360 Have you EVER received treatment, rehabilitation or other intervention services for your SWALLOWING problem from a speech-language pathologist (SLP), doctor, or other health professional?
Answer Codes 1. Yes (Go to VSL.370)
2. No (Go to Speech Section if applicable)
Refused (Go to VSL.350)
Don't Know (Go to VSL.350)
VSL.370 Was this in the past 12 months?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.380 How did your participation in treatment, rehabilitation or other intervention services for your SWALLOWING problem by a speech-language pathologist (SPL), doctor, or other health provider during the past year affect your PERSONAL OR SOCIAL FUNCTIONING at home, school, or work? Would you say it has…
Answer Codes 1. Gotten a lot worse
2. Gotten a little worse
3. Stayed the same, no improvement at all
4. Improved a little
5. Improved greatly
Refused
Don't Know
SPEECH
VSL.390 In the past 12 months, how often have you had a problem with your SPEECH, for example, stuttering, mispronouncing words, or distorting speech sounds?
*Probe if needed.
Answer Codes 1. Every day, or almost every day
2. Three to 5 days a week
3. One or 2 days a week
4. Two or 3 days a month
5. Three to 12 days in the past year
6. One or 2 days in the past year
7. None (Never or No Days)
Refused
Don't Know
VSL.400 In the past 12 months, have you had a problem with stuttering or stammering?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.410 How would you describe your stuttering or stammering at this time?
Answer Codes 1. Mild {Read if necessary}– I tend to stutter only a few times a day, only when tired, or only in stressful situations
2. Moderate {Read if necessary} – I stutter often, but I can generally communicate effectively.
3. Severe {Read if necessary}– Stuttering is a major problem to my communication, I stutter frequently in every conversation.
Refused
Don't Know
VSL.420 In the past 12 months, have you had any other problem with your SPEECH {SPEAKING} , such as difficulty pronouncing or saying speech sounds such as “l”, “r”, or “s”?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.430 Do other people have trouble understanding you when you are speaking?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.440 Can other people understand you on the telephone as clearly as when you are speaking to them face-to-face?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.450 How long has it been since you FIRST began to have problems with your SPEECH, for example, stuttering or pronunciation {articulation}?
Answer Codes 1. Less than 2 weeks ago
2. At least 2 weeks, but less than 3 months ago
3. Three to 11 months ago
4. During the past 1 to 2 years
5. Three to 4 years
6. Five to 9 years
7. Ten to 14 years
8. 15 years or more
Refused
Don't Know
VSL.460 Have you EVER seen a speech-language pathologist (SLP), doctor, or other health professional about your SPEECH {SPEAKING} problem?
Answer Codes 1. Yes (Go to VSL.470)
2. No (Go to VSL.480)
Refused (Go to VSL.480)
Don't Know (Go to VSL.480)
VSL.470 Which of the following kinds of health professionals have you seen about your SPEECH {SPEAKING} problem?
Please say yes or no to each.
Answer Codes 1. Yes
2. No
Refused
Don't Know
...Acupuncturist
...Audiologist or Hearing Aid Specialist
...Chiropractor
...Dentist, Orthodontist or Oral Surgeon
...ENT or Ear, Nose, and Throat Doctor or Otolaryngologist
...Family Doctor or General Practitioner
...Internist or Internal Medicine Doctor
...Neurologist
...Nurse or Nurse Practitioner
...Nutritionist or Dietician
...Psychiatrist or Psychologist
...Occupational or Physical Therapist
...Osteopath (Doctor of Osteopathy)
...Radiologist or Technician for MRI, CAT scan, or Ultrasound
...Speech-Language Pathologist
...Other, specify: ________________________________________
VSL.475 During the past 12 months, have you seen {fill health professional from previous question} about your SPEECH {SPEAKING} problem?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.480 What have you been told by a health care professional, or what do you think is the cause your SPEECH {SPEAKING} problem?
Answer Codes 1. Birth anomaly (e.g., cleft lip or palate), specify
2. Acute illness, specify
3. Chronic illness or condition, specify
4. Surgical procedure (e.g., tumors), specify
5. Injury, specify
6. Emotional or anxiety disorder, specify
7. Other cause(s), specify:
Refused
Don't Know
Question Type Pick All That Apply
VSL.490 Have you EVER received treatment, rehabilitation or other intervention services for your SPEECH {SPEAKING} problem from a speech-language pathologist (SPL), doctor, or other health professional?
Answer Codes 1. Yes (Go to VSL.495)
2. No (Go to VSL.510)
Refused (Go to VSL.510)
Don't Know (Go to VSL.510)
VSL.495 Was this in the past 12 months?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.510 In the past 12 months, how often has a problem with your voice limited or affected your personal or social functioning at home, school, or work?
*Probe if needed.
Answer Codes 1. Every day, or almost every day
2. Three to 5 days a week
3. One or 2 days a week
4. Two or 3 days a month
5. Three to 12 days in the past year
6. One or 2 days in the past year
7. None (Functioning was never limited or affected)
Refused
Don't Know
Question Type Pick One Answer
VSL.520 During the past 12 months, how has your SPEECH {SPEAKING} problem changed?
Answer Codes 1. Gotten a lot worse
2. Gotten a little worse
3. Stayed the same, not improved at all
3. Improved a little or somewhat
2. Improved greatly
Refused
Don't Know
Question Type Pick One Answer
VSL.540 How has your participation in treatment, rehabilitation or other intervention services for your SPEECH {SPEAKING} problem by a speech-language pathologist (SPL), doctor, or other health provider during the past year affected your PERSONAL OR SOCIAL FUNCTIONING at home, school, or work?
Answer Codes 1. Gotten a lot worse
2. Gotten a little worse
3. Stayed the same, no improvement at all
4. Improved a little
5. Improved greatly
Refused
Don't Know
Question Type Pick One Answer
LANGUAGE
VSL.550 In the past 12 months, how often have you had a problem with LANGUAGE, for example, unable to express your thoughts in words or to understand spoken or written words?
*Probe if needed.
*Do not include as having language problems, unless it exists in their native language; e.g., a child who first learned Spanish may have problems with English, but probably does not have a language problem in using Spanish.
Answer Codes 1. Every day, or almost every day
2. Three to 5 days a week
3. One or 2 days a week
4. Two or 3 days a month
5. Three to 12 days in the past year
6. One or 2 days in the past year
7. None (Never or No Days)
Refused
Don't Know
VSL.560 In the past 12 months, have you had a serious problem expressing your thoughts with words or in forming sentences?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.570 In the past 12 months, have you had a serious problem understanding spoken or written words?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.580 Do you have difficulty understanding and using sentences so that family members, friends, or associates understand?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.590 Do you have serious difficulty learning how to do things that most people your age are able to learn?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.600 Do you have difficulty communicating your BASIC needs, such as hunger and thirst to family members, friends, or associates?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.610 How long has it been since you FIRST began to have a problem with LANGUAGE, for example, expressing your thoughts in words or in understanding spoken or written words?
Answer Codes 1. Less than 2 weeks ago
2. At least 2 weeks, but less than 3 months ago
3. Three to 11 months ago
4. During the past 1 to 2 years
5. Three to 4 years
6. Five to 9 years
7. Ten to 14 years
8. 15 years or more
Refused
Don't Know
VSL.620 Have you EVER seen a speech-language pathologist (SLP), doctor, or other health professional about your problem with LANGUAGE?
Answer Codes 1. Yes (Go to VSL.630)
2. No (Go to VSL.640)
Refused (Go to VSL.640)
Don't Know (Go to VSL.640)
VSL.630 Which of the following kinds of health professionals have you seen about your LANGUAGE problem?
Please say yes or no to each.
Answer Codes 1. Yes
2. No
Refused
Don't Know
...Acupuncturist
...Audiologist or Hearing Aid Specialist
...Chiropractor
...Dentist, Orthodontist or Oral Surgeon
...ENT or Ear, Nose, and Throat Doctor or Otolaryngologist
...Family Doctor or General Practitioner
...Internist or Internal Medicine Doctor
...Neurologist
...Nurse or Nurse Practitioner
...Nutritionist or Dietician
...Pediatrician
...Psychiatrist or Psychologist
...Occupational or Physical Therapist
...Osteopath (Doctor of Osteopathy)
...Radiologist or Technician for MRI, CAT scan, or Ultrasound
...Speech-Language Pathologist
...Other, specify: ________________________________________
VSL.635 During the past 12 months, have you seen {fill health professional from previous question} about your LANGUAGE problem?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.640 What have you been told by a health care professional, or what do you think is the cause your LANGUAGE problem?
Answer Codes 1. Mental retardation, e.g., Down Syndrome, specify
2. Specific language impairment from childhood
3. Autism Spectrum Disorder (ASD)
4. Aphasia
5. Deaf or severely hearing impaired, specify
6. Dementia
7. Acute or infectious illness, e.g., meningitis,
8. Chronic illness or condition
9. Surgical procedure (e.g., tumors
10. Injury, e.g., traumatic brain injury (TBI),
11. Emotional or anxiety disorder, specify
12. Other cause(s), specify:
Refused
Don't Know
VSL.650 Have you EVER received treatment, rehabilitation or other intervention services for your LANGUAGE problem from a speech-language pathologist (SPL), doctor, or other health professional?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.655 Was this in the past 12 months?
Answer Codes 1. Yes
2. No
Refused
Don't Know
VSL.670 In the past 12 months, how often has a LANGUAGE problem limited or affected your personal or social functioning at home, school, or work?
*Probe if needed.
Answer Codes 1. Every day, or almost every day
2. Three to 5 days a week
3. One or 2 days a week
4. Two or 3 days a month
5. Three to 12 days in the past year
6. One or 2 days in the past year
7. None (Functioning was never limited or affected)
Refused
Don't Know
VSL.680 During the past 12 months, how has your LANGUAGE problem changed? Would you say it has…
Answer Codes 1. Gotten a lot worse
2. Gotten a little worse
3. Stayed the same, not improved at all
3. Improved a little or somewhat
2. Improved greatly
Refused
Don't Know
VSL.700 How has your participation in treatment, rehabilitation or other intervention services for your LANGUAGE problem by a speech-language pathologist (SPL), doctor, or other health provider during the past year affected your PERSONAL OR SOCIAL FUNCTIONING at home, school, or work?
Answer Codes 1. Gotten a lot worse
2. Gotten a little worse
3. Stayed the same, no improvement at all
4. Improved a little
5. Improved greatly
Refused
Don't Know
VSL.705 Did anyone in your immediate family ever have voice, speech, swallowing, or language problem?
Answer Codes 1. Yes
2. No
Refused
Don't Know
INTERNET RESOURCES FOR ENT–VSL HEALTHCARE
VSL.710 During the past 12 months, have you ever used the Internet to look up information, send email, or any other purpose?
Answer Codes 1. Yes (Go to VSL.720)
2. No (Go to next section)
Refused (Go to next section)
Don't Know (Go to next section)
VSL.720 During the past 12 months, have you ever used the Internet to look up information about health, illnesses or other conditions, medicine or vitamins, search for doctors or other health professionals, or search for on-line support groups?
Answer Codes 1. Yes (Go to VSL.730)
2. No (Go to next section)
Refused (Go to next section)
Don't Know (Go to next section)
VSL.730 Was this for yourself or someone else?
Answer Codes 1. Yourself
2. Someone Else
Refused
Don't Know
Question Type Pick All Answers that Apply
VSL.740 During the past 12 months, when searching the Internet for these reasons, did you search for information about disorders or problems with hearing loss, tinnitus, dizziness or balance, smell, taste, voice, swallowing, speech, or language?
Answer Codes 1. Yes (Go to VSL.750)
2. No (Go to next section)
Refused (Go to next section)
Don't Know (Go to next section)
VSL.750 For which of the following disorders or problems did you search… hearing loss, tinnitus, dizziness or balance impairment, smell disorder, taste disorder, voice problem, swallowing problem, speech problem, or language problem?
Answer Codes 1. Hearing Loss
2. Tinnitus
3. Dizziness or Balance Impairment
4. Smell Disorder
5. Taste Disorder
6. Voice Problem
7. Swallowing Problem
8. Speech Problem, including stuttering
9. Language Problem
Refused
Don't Know
Question Type Pick All Answers that Apply
VSL.760 How useful was the health information you found on the Internet regarding{fill items selected from previous question}? Would you say…
Answer Codes 1. Extremely useful
2. Very useful
3. Moderately useful
4. Somewhat useful
5. Not at all useful
Refused
Don't Know
VSL.770 In which of the following sources of health information about disorders or problems with hearing loss, tinnitus, dizziness or balance impairment, smell disorder, taste disorder, voice problem, swallowing problem, speech problem, or language problem do you have the most trust?
Please say 1, 2, 3, 4, or 5 to each.
Answer Codes 1. Highest trust
2. Very trustworthy
3. Moderately trustworthy
4. Somewhat trustworthy
5. Lease trust
Refused
Don't Know
...Family Doctors or General Practitioners
...Audiologist or Hearing Aid Specialist
...ENT or Ear, Nose, and Throat Doctor or Otolaryngologist
...Speech-Language Pathologists
...Occupational or Physical Therapists
...Neurologists
...Internist (Internal Medicine Doctor)
...Osteopaths (Doctors of Osteopathy)
...Nurse or Nurse Practitioner
...Nutritionist or Dietician
...Other Health professionals
...Internet
...Television
...Family or Friends
...Magazines
...Newspapers
...Radio
Adult- Voice, Swallowing, Speech, & Language (VSL)
Children 18 months- 5 years
CVSL.010 Has your child begun to combine words yet, such as “nother cracker” or “doggie bite?” Would you say not yet, sometimes, or often?
Not yet (If child younger than 18 months, end section; if child 3 or older Go to CVSL.050.01)
Sometimes
Often
Refused
Don’t know
CVSL.020 On the whole, which of these statements best describes the way your child communicates? {He/She is}:
1. mostly talking in one-word sentences, such as “milk” or “down”
2. talking in 2 to 3 word phrases, such as “give doll” or “me got ball”
3. talking in fairly complete, short sentences, such as “I got a doll” or “can I go
outside?”
4. talking in long and complicated sentences, such as “when we went to the park,
I went on the swings” or “I saw a man standing on the corner”
Refused
Don’t know
CVSL.030 To talk about more than one thing, we add an “s” to many words. Examples include cars (for more than one car), shoes, dogs, and keys. Has your child begun to do this?
1. Yes
2. No
Refused
Don't Know
CVSL.040 To talk about ownership, we add an “s”, for example, Daddy’s keys, kitty’s dish, and baby’s bottle. Has your child begun to do this?
1. Yes
2. No
Refused
Don't Know
CVSL.045 To talk about activities, we sometimes add “ing” to verbs. Examples include looking, running, and crying. Has your child begun to do this?
1. Yes
2. No
Refused
Don't Know
CVSL.047 To talk about things that happened in the past, we often add “ed” to the verb. Examples include kissed, opened, and pushed. Has your child begun to do this?
1. Yes
2. No
Refused
Don't Know
Children 3-7
CVSL.050.01 Please rate your child’s language and social skills compared to other children his/her age, with 1 being Very Low, 5 being Normal for Age, and 10 being Very High.
{Child’s name}’s ability to ASK questions properly is…
1-10
Refused
Don’t know
CVSL.050.01 {Child’s name}’s ability to say sentences clearly enough to be understood by strangers is…
1-10
Refused
Don’t know
CVSL.050.02 The number of WORDS {child’s name} knows is
1-10
Refused
Don’t know
CVSL.050.03 {Child’s name}’s ability to use his/her words correctly is…
1-10
Refused
Don’t know
CVSL.050.04 {Child’s name}’s ability to use get his/her message across to others when talking is…
1-10
Refused
Don’t know
CVSL.050.05 {Child’s name}’s ability to use proper words when talking to others is…
1-10
Refused
Don’t know
CVSL.050.06 {Child’s name}’s ability to get what he/she wants by talking is…
1-10
Refused
Don’t know
CVSL.050.08 {Child’s name}’s ability to start a conversation, or start talking with other children is…
1-10
Refused
Don’t know
CVSL.050.09 The length of {child’s name} sentences is…
1-10
Refused
Don’t know
CVSL.050.10 {Child’s name}’s ability to make “grown up” sentences is…
1-10
Refused
Don’t know
CVSL.050.11 {Child’s name}’s ability to correctly say the sounds in individual words is…
1-10
Refused
Don’t know
AGE 2-8
CVSL.060.01 How old was {Child’s name} when he/she spoke his/her first words other than “ma-ma” or “da-da”?
6-8 months
9-12 months
13-18 months
19-24 months
After 24 months
Has not yet begun (Go to CVSL.070.01)
Refused
Don't Know
CVSL.060.01 How old was {Child’s name} when he/she began to use two-word sentences?
9-12 months
13-18 months
19-24 months
25-30 months
31-36 months
Has not yet begun (Go to CVSL.070.01)
Refused
Don't Know
CVSL.060.01 In your opinion, does {Child’s name} have a problem in any of the following areas?
Pays attention, listens.
Would you say this is…
No problem
A small problem
A moderate problem
A big problem
A very big problem
Refused
Don’t know
CVSL.060.02 Can hear speech and other sounds?
Would you say this is…
No problem
A small problem
A moderate problem
A big problem
A very big problem
Refused
Don’t know
CVSL.060.03 Makes the speech sounds correctly?
Would you say this is…
No problem
A small problem
A moderate problem
A big problem
A very big problem
Refused
Don’t know
CVSL.060.04 Talks without stuttering?
Would you say this is…
No problem
A small problem
A moderate problem
A big problem
A very big problem
Refused
Don’t know
CVSL.060.05 Understands what people mean?
Would you say this is…
No problem
A small problem
A moderate problem
A big problem
A very big problem
Refused
Don’t know
CVSL.060.06 Knows the right words to use?
Would you say this is…
No problem
A small problem
A moderate problem
A big problem
A very big problem
Refused
Don’t know
CVSL.060.07 Puts the right endings on words?
Would you say this is…
No problem
A small problem
A moderate problem
A big problem
A very big problem
Refused
Don’t know
CVSL.060.08 Knows how to put words together to say sentences?
Would you say this is…
No problem
A small problem
A moderate problem
A big problem
A very big problem
Refused
Don’t know
All children 18 month age 8
CVSL.070.01 Has {Child’s name} EVER…
…Had a lot of coughing and throat clearing?
…Had a hoarse, raspy, or breathy voice?
…Talked too loud?
…Talked too softly?
…Had a problem chewing?
…Had a problem swallowing?
…Stuttered?
…Had difficulty expressing himself/herself for his/her age?
…Not paid attention to spoken language?
…Experienced a sudden interruption in speech/language development?
1. Yes
2. No
Refused
Don't Know
If EVER to any of the above ask:
CVSL.070.02 Does {Child’s name} Currently…
…Have a lot of coughing and throat clearing?
…Have a hoarse, raspy, or breathy voice?
…Talk too loud?
…Talk too softly?
…Have a problem chewing?
…Have a problem swallowing?
…Stutter?
…Have difficulty expressing himself/herself for his/her age?
…Not paid attention to spoken language?
…Experienced a sudden interruption in speech/language development?
CVSL.080 Do you think that {Child’s name} has a speech, language, or hearing problem?
Answer Codes 1. Yes
2. No
Refused
Don't Know
CVSL.100 Have you ever been told by a health or education professional that {Child’s name} has a speech, language, or hearing problem?
Answer Codes 1. Yes
2. No
Refused
Don't Know
{if yes}
CVSL.110 What kind of problem was it?
A problem speaking?
A problem learning language?
A problem hearing?
Answer Codes 1. Yes
2. No
Refused
Don't Know
CVSL.120 Has {Child’s name} ever received speech language therapy?
Answer Codes 1. Yes
2. No
Refused
Don't Know
{if yes}
CVSL.130 How old was he/she when speech-language therapy began?
Answer Codes 1.0-2 years
2. 3-4 years
3. 5-8 years
Refused
Don't Know
CVSL.130 How long did he/she receive speech-language therapy?
Answer Codes 1.Less than 1 year
2. 1-2 years
3. 3-4 years
4. More than 4 years
Refused
Don't Know
CVSL.140 {Did/does} {Child’s name} have any of the following abnormalities of the face or head? Please say yes or no to each.
Cleft lip?
Cleft palate
Any other (specify)_______________
Answer Codes 1. Yes
2. No
Refused
Don't Know
CVSL.150 As an infant, did {Child’s name} have difficulty sucking or swallowing?
Answer Codes 1. Yes
2. No
Refused
Don't Know
CVSL.300 Does your child now or did your child ever take medication for seizures?
Answer Codes 1. Yes, now
2. Yes, in the past
3. No
Refused
Don't Know
CVSL.400 Does your child now or did your child ever take medication for hyperactivity disorder or attention deficit disorder (ADD)?
Answer Codes 1. Yes, now
2. Yes, in the past
3. No
Refused
Don't Know
CVSL.300 Did you or anyone in your immediate family ever have voice, speech, swallowing, or language problem as a child?
Answer Codes 1. Yes
2. No
Refused
Don't Know
NHANES Creatine Questionnaire
CKQ.010 In the past 3 days, did you do any strenuous exercise or heavy
physical work?
PROBE IF NEEDED: Strenuous exercise or heavy physical work is exercise or work that causes large increases in breathing or heart rate if they are done for at least 10 minutes continuously.
YES ............................................................... 1
NO................................................................. 2 (CKQ.030)
REFUSED ..................................................... 7 (CKQ.030)
DON’T KNOW ............................................. 9 (CKQ.030)
CKQ.020 Did it make your muscles sore or painful?
YES ............................................................... 1 (CKQ.065)
NO................................................................. 2
REFUSED ..................................................... 7
DON’T KNOW ............................................. 9
CKQ.030 In the past 3 days, did you injure or bruise any muscles?
YES ............................................................... 1
NO................................................................. 2 (CKQ.050)
REFUSED ..................................................... 7 (CKQ.050)
DON’T KNOW ............................................. 9 (CKQ.050)
CKQ.040 Did it make your muscles sore or painful?
YES ............................................................... 1 (CKQ.065)
NO................................................................. 2
REFUSED ..................................................... 7
DON’T KNOW ............................................. 9
CKQ.060 In the last 3 days, have you had any muscle pain or soreness?
YES ............................................................... 1 (CKQ.070)
NO................................................................. 2 (END SECTION)
REFUSED ..................................................... 7 (END SECTION)
DON’T KNOW ............................................. 9 (END SECTION)
CKQ.065 In the last 3 days, have you had any other muscle pain, aching or
soreness?
YES ............................................................... 1 (CKQ.070)
NO................................................................. 2 (END SECTION)
REFUSED ..................................................... 7 (END SECTION)
CKQ.070 For how long have you had this pain, aching or soreness?
|___|___|___|___| ENTER NUMBER (OF DAYS, WEEKS, MONTHS OR YEARS)
REFUSED ..................................................... 777
DON'T KNOW ............................................... 999
ENTER UNIT
DAYS............................................................. 1
WEEKS ......................................................... 2
MONTHS....................................................... 3
YEARS .......................................................... 4
NHANES Medical Conditions/Lifestyle
Note to Reviewers: Half of the respondents will receive MCQ.new1 and half of the respondents will receive MCQ.new2
MCQ.new1
To lower your risk for certain diseases, during the past 12 months have you ever been told by a doctor or health professional to:
PROBE IF NEEDED: CONTROLLING YOUR WEIGHT MIGHT BE RECOMMENDED TO HELP PREVENT HIGH BLOOD PRESSURE, DIABETES, HIGH CHOLESTEROL AND OTHER CONDITIONS.
1.a. control your weight or lose weight?
YES ............................................................... 1
NO................................................................. 2
REFUSED ..................................................... 7
DON’T KNOW ............................................. 9
1.b. increase your physical activity or exercise?
YES ............................................................... 1
NO................................................................. 2
REFUSED ..................................................... 7
DON’T KNOW ............................................. 9
1.c. reduce the amount of sodium in your diet?
YES ............................................................... 1
NO................................................................. 2
REFUSED ..................................................... 7
DON’T KNOW ............................................. 9
1.d. reduce the amount of fat or calories in your diet?
YES ............................................................... 1
NO................................................................. 2
REFUSED ..................................................... 7
DON’T KNOW ............................................. 9
MCQ.new2
To lower your risk for certain diseases, are you now doing any of the following:
PROBE IF NEEDED: CONTROLLING YOUR WEIGHT MIGHT BE RECOMMENDED TO HELP PREVENT HIGH BLOOD PRESSURE, DIABETES, HIGH CHOLESTEROL AND OTHER CONDITIONS.
2.a. controlling your weight or losing weight?
YES ............................................................... 1
NO................................................................. 2
REFUSED ..................................................... 7
DON’T KNOW ............................................. 9
2.b. increasing your physical activity or exercise?
YES ............................................................... 1
NO................................................................. 2
REFUSED ..................................................... 7
DON’T KNOW ............................................. 9
2.c. reduce the amount of sodium in your diet?
YES ............................................................... 1
NO................................................................. 2
REFUSED ..................................................... 7
DON’T KNOW ............................................. 9
2.d. reduce the amount of fat or calories in your diet?
YES ............................................................... 1
NO................................................................. 2
REFUSED ..................................................... 7
DON’T KNOW ............................................. 9
| File Type | application/msword |
| Author | ktm8 |
| Last Modified By | krs0 |
| File Modified | 2010-04-21 |
| File Created | 2010-04-21 |