Form No number No number Testing NHIS and NHANES Questions

Attachment 2 – Instruments to be cognitively tested

OMB #0920-0222; Expiration Date: 03/31/2013

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Physical Activity

Universe: All adults 18+

Question ID: NAD.010_00.000 Instrument Variable Name: AD11A

The next questions are about walking for transportation. I will ask you separately about walking for other reasons like relaxation or exercise. During the past 7 days, did you walk to get some place that took you at least 10 minutes?

1 Yes

2 No

3 Unable to walk

7 Refused

9 Don't know

Question ID: NAD.040_00.000 Instrument Variable Name: SITWDAY

[Outside of work, how/How ] many hours do you spend per day during the WEEKDAYS sitting?

*Read if necessary: Include watching television or videos, working on the computer, playing video games, using the Internet, knitting, sewing, reading, fishing, taking long drives, watching ball games or doing other sitting activities.

*If person is bedridden, include only waking hours lying down

00 None

01-24 1-24 hours

97 Refused

99 Don't know

Question ID: NAD.060_00.000 Instrument Variable Name: MDEXER

DURING THE PAST 12 MONTHS, did a doctor or other health professional RECOMMEND that you BEGIN or CONTINUE to do any type of exercise or physical activity?

1 Yes

2 No

3 Did not see a doctor in the PAST 12 MONTHS

7 Refused

9 Don't know

Tobacco

Universe: All adults 18+

These next questions are about tobacco use.

Question ID: NAE.146_00.000 Instrument Variable Name: CIGEV1

Have you ever smoked a cigar EVEN ONE TIME?

1 Yes

2 No

7 Refused

9 Don't know

Question ID: NAE.174_00.000 Instrument Variable Name: LIVSMOKE

In a usual week, how many people WHO LIVE here, including yourself, smoke cigarettes, cigars, or pipes anywhere INSIDE this home?

Question ID: NAE.176_00.000 Instrument Variable Name: LVDYSMOK

Usually, about how many days per week do people WHO LIVE here smoke anywhere INSIDE this home?

Sun Protection

Universe: All adults 18+

Question ID: NAF.010_00.000 Instrument Variable Name: SUN1HR

Now, we are going to ask you about your skin's reaction to the sun. After several months of not being in the sun very much, if you went out in the sun for an hour without sunscreen, a hat, or protective clothing, which one of these best describes what would happen to your skin? (*Read choices 1-5 only)

*Read if necessary: Even if you did not go out in the sun, what would happen if you did? Use the most recent experience. If none, then think about the past.

*By "sunburn" we mean even a small part of your skin turns red or hurts for 12 hours or more.

01 Get a severe sunburn with blisters

02 Have a moderate sunburn with peeling

03 Burn mildly with some or no darkening/tanning

04 Turn darker without sunburn

05 Nothing would happen to my skin

06 Do not go out in the sun

07 Other

97 Refused

99 Don't know

Question ID: NAF.015_00.000 Instrument Variable Name: SUNTAN

Next, consider that you were out in the sun repeatedly, such as every day for two weeks, without sunscreen, a hat, or protective clothing. Which one of these best describes what your skin would LOOK like? (*Read choices 1-5 only)

*Read if necessary: Even if you did not go out in the sun, what would happen if you did? Use the most recent experience. If none, then think about the past.

*By "sunburn" we mean even a small part of your skin turns red or hurts for 12 hours or more.

01 Very dark or deeply tanned

02 Dark/Moderately tanned

03 A little dark/mildly tanned

04 Freckled but still light skinned

05 Burned repeatedly with little or no darkening or tanning---still light skinned

06 Don't go out in the sun

07 Other

97 Refused

99 Don't know

Question ID: NAF.026_00.000 Instrument Variable Name: SUN2_SCR

When you go outside on a warm sunny day for MORE than one hour, how often do you. . .

Use sunscreen? Would you say (Read categories 1-5). . .

1 Always

2 Most of the time

3 Sometimes

4 Rarely

5 Never

6 Don't go out in the sun

7 Refused

9 Don't know

Pap

Universe: Females 18+

Question ID: NAF.130_00.000 Instrument Variable Name: PAPHAD1

Have you EVER HAD a Pap smear or Pap test?

*Read if necessary: A Pap smear or Pap test is a routine test for women in which the doctor examines the cervix, takes a cell sample from the cervix with a small stick or brush, and sends it to the lab.

1 Yes

2 No

7 Refused

9 Don't know

Question ID: NAF.180_00.000 Instrument Variable Name: PAPABN3

Have you had a Pap test in the LAST 3 YEARS where the results were NOT normal?

1 Yes

2 No

7 Refused

9 Don't know

Question ID: NAF.228_03.000 Instrument Variable Name: SHHPVHRD

Two vaccines, or shots, to prevent HPV infection are available in the United States. Both vaccines prevent cervical cancer and one also prevents genital warts. The two HPV vaccines are sometimes called CERVARIX® or GARDASIL®. Before this survey, have you ever heard of HPV vaccines or shots?

1 Yes

2 No

7 Refused

9 Don't know

Question ID: NAF.228_04.000 Instrument Variable Name: SHTHPV

Have you ever received an HPV shot or vaccine?

1 Yes

2 No

3 Doctor refused when asked

7 Refused

9 Don't know

Breast Cancer Screening

Universe: Females 40+

Question ID: NAF.230_00.000 Instrument Variable Name: MAMHAD

Have you EVER HAD a mammogram?

*Read if necessary: A mammogram is an x-ray taken only of the breast by a machine that presses against the breast.

1 Yes

2 No

7 Refused

9 Don't know

Question ID: NAF.350_00.000 Instrument Variable Name: LUMPEV2

Have you EVER HAD a biopsy to test or remove a lump from your breast that was found NOT to be cancer?

*Read if necessary: A biopsy is the removal of a sample of tissue to see whether cancer cells are present.

1 Yes

2 No

3 Lump removed was cancerous

7 Refused

9 Don't know

Question ID: NAF.390_00.000 Instrument Variable Name: CBEHAD1

Have you EVER HAD a breast exam done by a doctor or other health professional to check for lumps or other signs of breast cancer?

*Read if necessary: A breast exam is when the breasts are felt by a doctor or other health professional to check for lumps or other signs of breast cancer.

1 Yes

2 No

7 Refused

9 Don't know

PSA

Universe: Males 40+

Question ID: NAF.430_00.000 Instrument Variable Name: PSAHAD

Have you EVER HAD a PSA test?

*Read if necessary: A PSA test is a blood test to detect prostate cancer. It is also called a prostate-specific antigen test.

1 Yes

2 No

7 Refused

9 Don't know

Colorectal Cancer Screening

Universe: All adults 40+

Question ID: NAF.540_00.000 Instrument Variable Name: COLHAD

Colonoscopy (colon-OS-copy) and sigmoidoscopy (sigmoid-OS-copy) are exams in which a doctor inserts a tube into the rectum to look for polyps or cancer. For a colonoscopy, the doctor checks the entire colon, and you are given medication through a needle in your arm to make you sleepy, and told to have someone drive you home. For a sigmoidoscopy, the doctor checks only part of the colon and you are fully awake.

Have you EVER HAD a colonoscopy?

Read if necessary:

A polyp is a small growth that develops on the inside of the colon or rectum.

Before these tests, you are asked to take a medication that causes diarrhea.

1 Yes

2 No

7 Refused

9 Don't know

Genetic Testing

Universe: All adults 18+

Question ID: NAG.010_00.000 Instrument Variable Name: GTHEARD

The following questions refer to “genetic testing for cancer risk.” That is, testing your blood to see if you carry genes which may predict a greater chance of developing cancer at some point in your life. This does NOT include tests to determine if you have cancer now.

Have you EVER HEARD of genetic testing to determine if a person is at greater risk of developing cancer?

1 Yes

2 No

7 Refused

9 Don't know

Question ID: NAG.020_00.000 Instrument Variable Name: GTPOSS

Have you EVER DISCUSSED the possibility of getting a genetic test for cancer risk with a doctor or other health professional?

1 Yes

2 No

7 Refused

9 Don't know

Family History

Universe: All adults 18+

Question ID: NAH.010_00.000 Instrument Variable Name: FHFCAN

We would like to ask you a few questions about your family history of cancer. Did your BIOLOGICAL FATHER EVER have cancer of any kind?

1 Yes

2 No

3 Adopted or don't know biological father

7 Refused

9 Don't know

Question ID: NAH.040_00.000 Instrument Variable Name: FHMCAN

Did your BIOLOGICAL MOTHER EVER have cancer of any kind?

1 Yes

2 No

3 Adopted or don't know biological mother

7 Refused

9 Don't know

General Wellness Questions

Universe: All adults 18+

Question ID: NAI.100_00.000 Instrument Variable Name: QOL

In general, would you say your quality of life is...

*Read categories below.

1 Excellent

2 Very good

3 Good

4 Fair

5 Poor

7 Refused

9 Don't know

Question ID: NAI.110_00.000 Instrument Variable Name: QOLPH

In general, how would you rate your physical health?

*Read categories below.

1 Excellent

2 Very good

3 Good

4 Fair

5 Poor

7 Refused

9 Don't know

Question ID: NAI.120_00.000 Instrument Variable Name: QOLMH

In general, how would you rate your mental health, including your mood and your ability to think?

*Read categories below.

1 Excellent

2 Very good

3 Good

4 Fair

5 Poor

7 Refused

9 Don't know

Question ID: NAI.130_00.000 Instrument Variable Name: QOLSAR

In general, how would you rate your satisfaction with your social activities and relationships?

*Read categories below.

1 Excellent

2 Very good

3 Good

4 Fair

5 Poor

7 Refused

9 Don't know

Question ID: NAI.140_00.000 Instrument Variable Name: COUSAR

In general, please rate how well you carry out your usual social activities and roles. This includes activities at home, at work and in your community, and responsibilities as a parent, child, spouse, employee, friend, etc.

*Read categories below.

1 Excellent

2 Very good

3 Good

4 Fair

5 Poor

7 Refused

9 Don't know

Question ID: NAI.150_00.000 Instrument Variable Name: COEPA

To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair?

*Read categories below.

1 Completely

2 Mostly

3 Moderately

4 A little

5 Not at all

7 Refused

9 Don't know

Question ID: NAI.160_00.000 Instrument Variable Name: BEP7D

IN THE PAST 7 DAYS, how often have you been bothered by emotional problems such as feeling anxious, depressed, or irritable?

*Read categories below.

1 Never

2 Rarely

3 Sometimes

4 Often

5 Always

7 Refused

9 Don't know

Question ID: NAI.170_00.000 Instrument Variable Name: RF7D

IN THE PAST 7 DAYS, how would you rate your fatigue on average?

*Read categories below.

1 None

2 Mild

3 Moderate

4 Severe

5 Very severe

7 Refused

9 Don't know

Question ID: NAI.180_00.000 Instrument Variable Name: RP7D

IN THE PAST 7 DAYS, how would you rate your pain on average? Use a scale of 0-10 with 0 being no pain and 10 being the worst imaginable pain.

Question ID:

Do you have a health problem or disability which prevents you from working or which limits the

kind or amount of work you can do?

Yes

No

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

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