NHIS 2013 questions

Attachment 1- Questions to be cognitively tested

Point-prevalence of immunocompromised status in the U.S.

1. Have you been told by your doctor or your healthcare professional that your immune system is weakened? Please only respond yes if your doctor or health care provider specifically told you that your immune system is weakened, and that you believe that this would still be the case at this point in time.

Yes

No (Go to Adult Asthma questions)

Don’t know (Go to Adult Asthma questions)

Refused (Go to Adult Asthma questions)

Now I am going to ask you several question about the reason your doctor or healthcare professional thinks your immune system is weakened. There may be more than one reason, so please respond to all that apply.

2. Is it because of the effects of treatments, including medicines you are now taking or whole body radiation treatment you recently received?

* Read if necessary: These might include long term oral steroid or corticosteroid pills like prednisone, or many other immune weakening medications used to treat certain cancers, for organ or bone marrow transplantation, for treating many autoimmune or inflammatory conditions such as rheumatoid arthritis, lupus, crohn’s disease, or psoriasis. Please only respond yes if your doctor or health care provider specifically told you the medicines weaken the immune system.

Yes

No

Don’t know

Refused

3. Is it because of an illness that weakens the immune system directly, even without treatments, for instance some kinds of leukemias or lymphomas, or certain infections, or certain specific genetic conditions?

Yes

No

Don’t know

Refused

4. Did your doctor or healthcare professional say it is because of one or more chronic illnesses that cause more general problems to immunity, like kidney disease, lung disease, liver disease, diabetes, poor nutrition, or general frailty?

Yes

No

Don’t know

Refused

5. Did your doctor or healthcare provider tell you your immune system was weakened just based on the fact that you seem to get many infections or colds?

Yes

No

Don’t know

Refused

Adult Asthma Supplement

Question ID: ACN.080_00.000

Have you EVER been told by a doctor or other health professional that you had asthma?

1 Yes

2 No

7 Refused

9 Don't know

Skip Instructions: If yes, go to ACN.085_00.000. If no, go to Child Asthma section.

Question ID: ACN.085_00.000

Do you still have asthma?

1 Yes

2 No

7 Refused

9 Don't know

Question ID: ACN.090_00.000

DURING THE PAST 12 MONTHS, have you had an episode of asthma or an asthma attack?

1 Yes

2 No

7 Refused

9 Don't know

Question ID: ACN.100_00.000

DURING THE PAST 12 MONTHS, have you had to visit an emergency room or urgent care center because of asthma?

1 Yes

2 No

7 Refused

9 Don't know

Skip Instructions: If yes ACN.085 or 090, go to 100. Otherwise, done with survey.

Question ID: ACN.100_00.010

DURING THE PAST 12 MONTHS, have you stayed overnight in a hospital because of asthma?

* If in hospital for asthma AND other reasons, enter 1.

1 Yes

2 No

7 Refused

9 Don't know

Question ID: ACN.100_00.030

DURING THE PAST 12 MONTHS, HOW MANY DAYS were you UNABLE to work because of your asthma?

Read if necessary: For homemakers, this includes work around the house. Enter '996' if respondent is unable to do this activity.

000-365 000-365 days

996 Unable to do this activity

997 Refused

999 Don't know

Question ID: ACN.100_00.060

Now I'm going to ask you about two different kinds of ASTHMA medicine. One prevents symptoms over the long term. The other is for quick relief of symptoms during an attack or episode. This quick relief medicine is breathed in through your mouth using a canister inhaler or a disk inhaler.

DURING THE PAST 3 MONTHS, have you used the kind of PRESCRIPTION asthma inhaler that gives QUICK relief from asthma symptoms during an attack?

1 Yes

2 No

7 Refused

9 Don't know

Skip instructions: If yes, go to 100_00.070; If no, go to 100_00.090

Question ID: ACN.100_00.070

DURING THE PAST 3 MONTHS did you use more than three canisters or disks of this type of quick relief inhaler?

1 Yes

2 No

7 Refused

9 Don't know

Question ID: ACN.100_00.090

The second kind of asthma medication is different from inhalers used for quick relief. It is the preventive kind that is used to protect your lungs and keep you from having attacks. It can be either a pill or an inhaler.

Are you NOW taking a preventive asthma medication every day or almost every day, less often, or never?

1 Every day or almost every day

2 Less often

3 Never

7 Refused

9 Don't know

Question ID: ACN.100_00.100

An asthma action plan is a printed form that tells when to change the amount or type of medicine, when to call the doctor for advice, and when to go to the emergency room.

Has a doctor or other health professional EVER given you an asthma action plan?

*Read if necessary: include nurses and asthma educators.

1 Yes

2 No

7 Refused

9 Don't know

Question ID: ACN.100_00.110

Have you ever taken a course or class on how to manage asthma yourself?

1 Yes

2 No

7 Refused

9 Don't know

Question ID: ACN.105_01.010

Has a doctor or other health professional EVER taught you

...How to recognize early signs or symptoms of an asthma episode

1 Yes

2 No

7 Refused

9 Don't know

Question ID: ACN.105_02.020

* Read if necessary: Has a doctor or other health professional ever taught you

...How to respond to episodes of asthma

1 Yes

2 No

7 Refused

9 Don't know

Question ID: ACN.105_03.030

*Read if necessary: Has a doctor or other health professional ever taught you

… How to monitor peak flow for daily therapy?

1 Yes

2 No

7 Refused

9 Don't know

Question ID: ACN.107_00.010

Has a doctor or other health professional ever advised you to change things in your home, school, or work environment to improve your asthma?

1 Yes

2 No

3 Was told no changes needed

7 Refused

9 Don't know

Question ID: ACN.107_00.0XX

During the past 12 months how many times did you see a doctor or other health professional for a routine checkup for your asthma? Please do not include visits for acute care for an asthma episode or attack.

000 Never

001-365 time(s)

997 Refused

999 Don't know

Question ID: ACN.107_00.0XY

During the past 12 months did your doctor or other health professional ask you how often …

….you had asthma symptoms during the day?

1 Yes

2 No

7 Refused

9 Don't know

Question ID: ACN.107_00.0XW

*Read if necessary:

During the past 12 months did your doctor or other health professional ask you how often …

…. your sleep was interrupted by your asthma symptoms?

1 Yes

2 No

7 Refused

9 Don't know

Question ID: ACN.107_00.0XZ

*Read if necessary:

During the past 12 months did your doctor or other health professional ask you how often …

…. asthma symptoms limited your daily activities?

1 Yes

2 No

7 Refused

9 Don't know

Child Asthma Supplement 2013

Question ID: CHS.080_00.000

Has a doctor or other health professional EVER told you that [fill: sample child name] had asthma?

1 Yes

2 No

7 Refused

9 Don't know

Skip Instructions: If yes, go to 085_00.000; If no, done with survey.

Question ID: CHS.085_00.000

Does [fill: sample child name] still have asthma?

1 Yes

2 No

7 Refused

9 Don't know

Question ID: CHS.090_00.000

The following questions are about [fill: sample child name]'s asthma DURING THE PAST 12 MONTHS.

DURING THE PAST 12 MONTHS, has [fill: SC name] had an episode of asthma or an asthma attack?

1 Yes

2 No

7 Refused

9 Don't know

Question ID: CHS.100_00.000

DURING THE PAST 12 MONTHS, did [fill1: sample child name] have to visit an emergency room or urgent care center because of [fill2: his/her] asthma?

1 Yes

2 No

7 Refused

9 Don't know

Skip Instructions: If yes to 090_00.00, go to 100_00.000; If no, have completed the survey.

Question ID: CHS.100_00.010

DURING THE PAST 12 MONTHS, has [fill: sample child name] stayed overnight in a hospital because of asthma?

1 Yes

2 No

7 Refused

9 Don't know

Question ID: CHS.100_00.030

DURING THE PAST 12 MONTHS, that is since [12-month ref. date], HOW MANY DAYS of [fill1: daycare or preschool/fill2: school/fill3: school or work] did [fill: SC name] miss because of [fill: his/her] asthma?

*Enter 995 if child home schooled.

*Enter 996 if child did not go to [fill1: daycare or preschool/fill2: school/fill3: school or work].

000-365 000-365 days

995 Child was home schooled

996 child did not go to day care, preschool, school, or work

997 Refused

999 Don't know

Question ID: CHS.100_00.060

Now I'm going to ask you about two different kinds of ASTHMA medicine. One prevents symptoms over the long term. The other is for quick relief of symptoms during an attack or episode. This quick relief medicine is breathed in through your mouth using a canister inhaler or a disk inhaler.

DURING THE PAST 3 MONTHS, has [fill: SC name] used the kind of PRESCRIPTION asthma inhaler that gives QUICK relief from asthma symptoms during an attack?

1 Yes

2 No

7 Refused

9 Don't know

Skip Instructions: If yes, go to 100_00.070; If no, go to 100_00.090

Question ID: CHS.100_00.070

DURING THE PAST 3 MONTHS did [fill: SC name] use more than three canisters or disks of this type of quick relief inhaler?

1 Yes

2 No

7 Refused

9 Don't Know

Question ID: CHS.100_00.090

The second kind of asthma medication is different from inhalers used for quick relief. It is the preventive kind that is used to protect your lungs and keep you from having attacks. It can be either a pill or an inhaler.

Is [fill: SC name] NOW taking a preventive asthma medication every day or almost every day, less often, or never?

1 Every day or almost every day

2 Less often

3 Never

7 Refused

9 Don't know

Question ID: CHS.100_00.100

An asthma action plan is a printed form that tells when to change the amount or type of medicine, when to call the doctor for advice, and when to go to the emergency room.

Has a doctor or other health professional EVER given [fill: SC name] an asthma action plan?

*Read if necessary: Include nurses and asthma educators.

1 Yes

2 No

7 Refused

9 Don't know

Question ID: CHS.100_00.110

Has [fill: SC name] ever taken a course or class on how to manage [fill: his/her] asthma?

*Include adult(s) who took a course for the child's asthma.

1 Yes

2 No

7 Refused

9 Don't know

Question ID: CHS.100_00.116

Has a doctor or other health professional EVER taught [fill: SC name] or [fill: his/her] parent or guardian

...how to recognize early signs or symptoms of an asthma episode

1 Yes

2 No

7 Refused

9 Don't know

Question ID: CHS.100_00.117

*Read if necessary: Has a doctor or other health professional EVER taught [fill: SC name] or [fill: his/her] parent or guardian

...how to respond to episodes of asthma

1 Yes

2 No

7 Refused

9 Don't know

Question ID: CHS.100_00.118

*Read if necessary: Has a doctor or other health professional EVER taught [fill: SC name] or [fill: his/her] parent or guardian ...how to monitor peak flow for daily therapy

1 Yes

2 No

7 Refused

9 Don't know

Question ID: CHS.100_00.130

Has a doctor or other health professional EVER advised you to change things in [fill: SC name]'s home, school, or work to improve [fill: his/her] asthma?

1 Yes

2 No

3 Was told no changes needed

7 Refused

9 Don't know

Question ID: CHS.100_00.0XX

During the past 12 months how many times did [fill: SC name] see a doctor or other health professional for a routine checkup for [fill: his/her] asthma? Please do not include visits for acute care for an asthma episode or attack.

000 Never

001-365 time(s)

997 Refused

999 Don't know [RANGE CHECK: (000-365, 997, 999)] [Verify any value >50]

Question ID: CHS.100_00.0XY

During the past 12 months did [fill: SC name]'s doctor or other health professional ask how often …

….[fill: he/she] had asthma symptoms during the day?

1 Yes

2 No

7 Refused

9 Don't know

Question ID: CHS.100_00.0XW

*Read if necessary:

During the past 12 months did [fill: SC name]’s doctor or other health professional ask how often ….[fill: his/her] sleep was interrupted by asthma symptoms?

1 Yes

2 No

7 Refused

9 Don't know

Question ID: CHS.100_00.0XZ

*Read if necessary:

During the past 12 months did [fill: SC name]’s doctor or other health professional ask how often …

…. asthma symptoms limited [fill: his/her] daily activities?

1 Yes

2 No

7 Refused

9 Don't know

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