Questions for 2012

Attachment 1.

Supplements—2012 New Questions
Page 1 of 16

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

CCD.010_00.000 Instrument Variable Name:

CVSLWRD

QuestionnaireFileName:

Sample Child

How old was {fill1: S.C. name} when {fill2: he/she} spoke {fill3: his/her} first words other than “ma-ma” or “da-da”?

QuestionText:

1. 6 to 8 months
2. 9 to 11 months
3. 12 to 14 months
4. 15 to 17 months
5. 18 to 23 months
6. 24 months (2 years) or later
7. Cannot talk
Refused
Don't know

UniverseText:

Sample children 3+

SkipInstructions:

<1-7,R,D> [goto CVSLVYR]

Question ID:

CCD.015_00.000 Instrument Variable Name:

QuestionText:

CVSLVYR

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, has {fill1: S.C. name} had any problems or difficulties with {fill2: his/her} VOICE,
such as too weak, hoarse, or strained that lasted for a week or longer?

1. Yes
2. No
Refused
Don’t know

UniverseText:

Sample children 3+

SkipInstructions:

<1,2,R,D> [goto CVSLSWYR]

Page 2 of 16

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

CCD.020_00.000 Instrument Variable Name:

CVSLSWYR

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, has {fill1: S.C. name} had a problem swallowing food or beverages that lasted for a
week or longer?

QuestionText:

1. Yes
2. No
Refused
Don’t know

UniverseText:

Sample children 3+

SkipInstructions:

<1,2,R,D> [goto CVSLSPYR]

Question ID:

CCD.025_00.000 Instrument Variable Name:

CVSLSPYR

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, has {fill1: S.C. name} had a problem speaking, such as making speech sounds
correctly or stuttering that lasted for a week or longer?

QuestionText:

1. Yes
2. No
Refused
Don’t know

UniverseText:

Sample children 3+

SkipInstructions:

<1,2,R,D> [goto CVSLLGYR]

Question ID:

CCD.030_00.000 Instrument Variable Name:

QuestionText:

CVSLLGYR

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, has {fill1: S.C. name} had a problem learning, using, or understanding words or
sentences that lasted for a week or longer?

1. Yes
2. No
Refused
Don’t know

UniverseText:

Sample children 3+

SkipInstructions:

<1,2,R,D> if CVSLVYR=2,R,D and CVSLSWYR=2,R,D and CVSLSPYR=2,R,D and CVSLLGYR=2,R,D [goto
CVSLEVER]; else if CVSLVYR=1 or CVSLSWYR=1 or CVSLSPYR=1 or CVSLLGYR=1 [goto CVSLDG]

Page 3 of 16

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

CCD.035_00.000 Instrument Variable Name:

CVSLEVER

QuestionnaireFileName:

Sample Child

Has {fill1: S.C. name} EVER had a voice, swallowing, speech, or language problem that lasted a week or longer?

QuestionText:

1. Yes
2. No
Refused
Don’t know

UniverseText:

Sample children 3+ who have not had a voice, swallowing, speech, or language problem in the past 12 months

SkipInstructions:

<1> [goto CVSLDG] <2,R,D> [goto next section]

Question ID:

CCD.040_00.000 Instrument Variable Name:

QuestionText:

CVSLDG

QuestionnaireFileName:

Sample Child

Did a health or education professional EVER tell you a diagnosis or reason for {fill1: S.C. name}'s voice, swallowing,
speech, or language problem?

1. Yes
2. No
Refused
Don’t know

UniverseText:

Sample children 3+ who have ever had a voice, swallowing, speech, or language problem

SkipInstructions:

<1> [goto CVSLDGTP] <2,R,D> if CVSLVYR=1 or CVSLSWYR=1 or CVSLSPYR=1 or CVSLLGYR)=1
[goto applicable CVSLVAG, CVSLSWAG, CVSLSPAG, CVSLLGAG series]; else [goto next section]

Page 4 of 16

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

CCD.045_00.000 Instrument Variable Name:

CVSLTYP

QuestionnaireFileName:

Sample Child

For which problems(s)?

QuestionText:

*Read if necessary: Was this for problems with {fill1: S.C. name}'s voice, swallowing, speech, or language?
*Enter all that apply, separate with commas.
1. Voice problem
2. Swallowing problem
3. Speech problem
4. Language problem
Refused
Don't know

UniverseText:

Sample children 3+ who have been given a diagnosis for their voice, swallowing, speech, or language problem

SkipInstructions:

<1> [goto CVSLVDG] <2> [goto CVSLSWDG] <3> [goto CVSLSPDG] <4> [goto
CVSLLGDG] [if CVSLVYR=1 or CVSLSWYR=1 or CVSLSPYR=1 or CVSLLGYR=1
goto CVSLVAG, CVSLSWAG, CVSLSPAG, CVSLLGAG series; else goto next section]

Question ID:

CCD.050_00.000 Instrument Variable Name:

QuestionText:

CVSLVDG

QuestionnaireFileName:

Sample Child

What diagnoses or reasons were you told caused {fill1: S.C. name}'s voice problems?
*Enter all that apply, separate with commas.

1. Laryngitis or nodules caused by voice
misuse/abuse/overuse
2. Laryngitis caused by colds/strep
3. Allergies or airborne irritants
4. Tissue damage in throat (accident, intubation, ingestion
of caustic material)
5. Laryngeal growths (polyps, papillomas, laryngeal web)
6. Cancer anywhere in the head, neck or throat
7. Neurological cause (cerebral palsy, muscular dystrophy,
etc.)
8. Congenital malformation
9. Gastroesophageal reflux
10. Prescription medication or drugs
11. Other
Refused
Don’t know

UniverseText:

Sample children 3+ who have been given a diagnosis for their voice problem

SkipInstructions:

<1-11,R,D> [cycle through CVSLSWDG, CVSLSPDG, CVSLLGDG if applicable]; then if CVSLVYR=1 or
CVSLSWYR=1 or CVSLSPYR=1 or CVSLLGYR=1 [goto CVSLVAG, CVSLSWAG, CVSLSPAG,
CVSLLGAG series]; else [goto next section]

Page 5 of 16

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

CCD.055_00.000 Instrument Variable Name:

QuestionText:

CVSLSWDG

QuestionnaireFileName:

Sample Child

What diagnoses or reasons were you told caused {fill1: S.C. name}'s problems swallowing?
*Enter all that apply, separate with commas.

1. Neurological cause (cerebral palsy, muscular dystrophy,
stroke, etc.)
2. Premature birth
3. Tissues damage in mouth or throat (accident,
intubation, ingestion of caustic material)
4. Congenital malformation
5. Genetic syndrome
6. Cancer anywhere in the head, neck or throat
7. Asthma
8. Prescription medication or drugs
9. Other
Refused
Don't know

UniverseText:

Sample children 3+ who have been given a diagnosis for their swallowing problem

SkipInstructions:

<1-8,R,D> [cycle through CVSLSPDG, CVSLLGDG if applicable]; then if CVSLVYR=1 or CVSLSWYR=1 or
CVSLSPYR=1 or CVSLLGYR=1 [goto CVSLVAG, CVSLSWAG, CVSLSPAG, CVSLLGAG series]; else [goto
next section]

Page 6 of 16

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

CCD.060_00.000 Instrument Variable Name:

QuestionText:

CVSLSPDG

QuestionnaireFileName:

Sample Child

What diagnoses or reasons were you told caused {fill1: S.C. name}'s speech problems?
*Enter all that apply, separate with commas.

1. Hearing loss or deafness
2. Developmental speech sound disorder
(phonology,articulation, apraxia, dyspraxia, etc.)
3. Stuttering
4. Congenital malformation (cleft lip/palate, craniofacial
anomaly, etc.)
5. Genetic syndrome
6. Neurological cause or disease (cerebral palsy, muscular
dystrophy, stroke, etc.)
7. Head/neck injury or other type of tissue damage
8. Cancer anywhere in the head, neck or throat
9. Prescription medication or drugs
10. Other
Refused
Don't know

UniverseText:

Sample children 3+ who have been given a diagnosis for their speech problem

SkipInstructions:

<1-10,R,D> [cycle through CVSLLGDG if applicable]; then if CVSLVYR=1 or CVSLSWYR=1 or
CVSLSPYR=1 or CVSLLGYR=1 [goto CVSLVAG, CVSLSWAG, CVSLSPAG, CVSLLGAG
series]; else [goto next section]

Page 7 of 16

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

CCD.065_00.000 Instrument Variable Name:

CVSLLGDG

QuestionnaireFileName:

Sample Child

What diagnoses or reasons were you told caused {fill1: S.C. name}'s problems learning, using, or understanding words or
sentences?

QuestionText:

*Enter all that apply, separate with commas.
1. Hearing loss or deafness
2. Genetic syndrome
3. Intellectual disability, also known as mental retardation
4. Autism spectrum disorder
5. Developmental language-learning disorder (specific
language impairment, learning
disability, dyslexia)
6. Head injury, traumatic brain injury
7. Other neurological cause (stroke, seizure disorder, etc.)
8. Prescription medication or drugs
9. Other
Refused
Don’t know

UniverseText:

Sample children 3+ who have been given a diagnosis for their language problem

SkipInstructions:

<1-9,R,D> if CVSLVYR=1 or CVSLSWYR=1 or CVSLSPYR=1 or CVSLLGYR=1 [goto CVSLVAG,
CVSLSWAG, CVSLSPAG, CVSLLGAG series]; else [goto next section]

Question ID:

CCD.070_00.000 Instrument Variable Name:

QuestionText:

CVSLVAG

QuestionnaireFileName:

Sample Child

At what age did {fill1: S.C. name} FIRST begin to have any voice problems?

Allow 0-17,R,D

UniverseText:

Sample children 3+ who have had a voice problem in the past 12 months for a week or longer

SkipInstructions:

<0-Current Age,R,D> [cycle through CVSLSWAG, CVSLSPAG, CVSLLGAG if applicalbe, then goto
CVSLVPB,
CVSLSWPB, CVSLSPPB, CVSLLGPB series]

Page 8 of 16

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

CCD.075_00.000 Instrument Variable Name:

CVSLSWAG

QuestionnaireFileName:

Sample Child

At what age did {fill1: S.C. name} FIRST begin to have any problems swallowing?

QuestionText:

Allow 0-17,R,D

UniverseText:

Sample children 3+ who have had a swallowing problem in the past 12 months for a week or longer

SkipInstructions:

<0-Current Age,R,D> [cycle through CVSLSPAG, CVSLLGAG if applicable, then goto CVSLVPB,
CVSLSWPB, CVSLSPPB, CVSLLGPB series]

Question ID:

CCD.080_00.000 Instrument Variable Name:

CVSLSPAG

QuestionnaireFileName:

Sample Child

At what age did {fill1: S.C. name} FIRST begin to have any speech problems?

QuestionText:

Allow 0-17,R,D

UniverseText:

Sample children 3+ who have had a speech problem in the past 12 months for a week or longer

SkipInstructions:

<0-Current Age,R,D> [cycle through CVSLLGAG if applicable, then goto CVSLVPB, CVSLSWPB, CVSLSPPB,
CVSLLGPB series]

Question ID:

CCD.085_00.000 Instrument Variable Name:

QuestionText:

CVSLLGAG

QuestionnaireFileName:

Sample Child

At what age did {fill1: S.C. name} FIRST begin to have any problems learning, using, or understanding words or
sentences?

Allow 0-17,R,D

UniverseText:

Sample children 3+ who have had a language problem in the past 12 months for a week or longer

SkipInstructions:

<0-Current Age,R,D> [goto CVSLVPB, CVSLSWPB, CVSLSPPB, CVSLLGPB series]

Page 9 of 16

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

CCD.090_00.000 Instrument Variable Name:

CVSLVPB

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, how much of a problem did {fill1: S.C. name} have with {fill2: his/her} voice?
Would you say it was...

QuestionText:

*Read categories below
1. No problem
2. A small problem
3. A moderate problem
4. A big problem
5. A very big problem
Refused
Don't know

UniverseText:

Sample children 3+ who have had a voice problem in the past 12 months for a week or longer

SkipInstructions:

<1-5,R,D> [cycle through CVSLSWPB, CVSLSPPB, CVSLLGPB if applicable, then goto CVSLVSP,
CVSLSWSP, CVSLSPSP, CVSLLGSP series]

Question ID:

CCD.095_00.000 Instrument Variable Name:

QuestionText:

CVSLSWPB

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, how much of a swallowing problem did {fill1: S.C. name} have? Would you say it
was...
*Read categories below

1. No problem
2. A small problem
3. A moderate problem
4. A big problem
5. A very big problem
Refused
Don't know

UniverseText:

Sample children 3+ who have had a swallowing problem in the past 12 months for a week or longer

SkipInstructions:

<1-5,R,D> [cycle through CVSLSPPB, CVSLLGPB if applicable, then goto CVSLVSP, CVSLSWSP,
CVSLSPSP, CVSLLGSP series]

Page 10 of 16

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

CCD.100_00.000 Instrument Variable Name:

CVSLSPPB

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, how much of a problem did {fill1: S.C. name} have with {fill2: his/her} speech?
Would you say it was...

QuestionText:

*Read categories below
1. No problem
2. A small problem
3. A moderate problem
4. A big problem
5. A very big problem
Refused
Don't know

UniverseText:

Sample children 3+ who have had a speech problem in the past 12 months for a week or longer

SkipInstructions:

<1-5,R,D> [cycle through CVSLLGPB if applicable, then goto CVSLVSP, CVSLSWSP, CVSLSPSP,
CVSLLGSP series]

Question ID:

CCD.110_00.000 Instrument Variable Name:

QuestionText:

CVSLLGPB

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, how much of a problem did {fill1: S.C. name} have learning, using or understanding
words or sentences? Would you say it was...
*Read categories below

1. No problem
2. A small problem
3. A moderate problem
4. A big problem
5. A very big problem
Refused
Don't know

UniverseText:

Sample children 3+ who have had a language problem in the past 12 months for a week or longer

SkipInstructions:

<1-5,R,D> [goto CVSLVSP, CVSLSWSP, CVSLSPSP, CVSLLGSP series]

Page 11 of 16

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

CCD.115_00.000 Instrument Variable Name:

CVSLVSP

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, did {fill1: S.C. name} receive speech language therapy or other intervention services
for {fill2: his/her} voice problems?

QuestionText:

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 3+ who have had a voice problem in the past 12 months for a week or longer

SkipInstructions:

<1> [cycle through CVSLSWSP, CVSLSPSP, CVSLLGSP if applicable; else goto HP series] <2> [goto
CVSLVPE]
[cycle through the SP series if applicable; else goto next section CBL.010]

Question ID:

CCD.120_00.000 Instrument Variable Name:

QuestionText:

CVSLVPE

QuestionnaireFileName:

Sample Child

Did {fill1: S.C. name} EVER receive speech language therapy or other intervention services for {fill2: his/her} voice
problems?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 3+ who have not had speech language therapy for a voice problem in the past 12 months

SkipInstructions:

<1> [cycle through CVSLSWSP, CVSLSPSP, CVSLLGSP if applicable; else goto HP series] <2,R,D> [cycle
through SP series if applicable; else goto next section CBL.010]

Page 12 of 16

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

CCD.125_00.000 Instrument Variable Name:

CVSLSWSP

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, did {fill1: S.C. name} receive speech language therapy or other intervention services
for {fill2: his/her} problems swallowing?

QuestionText:

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 3+ who have had a swallowing problem in the past 12 months for a week or longer

SkipInstructions:

<1> [cycle through CVSLSPSP, CVSLLGSP if applicable; else goto HP series]
<2> [goto CVSLSWPE] [cycle through SP series if applicable;
else if CVSLVSP=’1’ or CVSLVPE=’1’ goto HP series; else goto next section CBL.010]

Question ID:

CCD.130_00.000 Instrument Variable Name:

QuestionText:

CVSLSWPE

QuestionnaireFileName:

Sample Child

Did {fill1: S.C. name} EVER receive speech language therapy or other intervention services for {fill2: his/her} problems
swallowing?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 3+ who have not had speech language therapy for a swallowing problem in the past 12 months

SkipInstructions:

<1> [cycle through CVSLSPSP, CVSLLGSP if applicable; else goto HP series] <2,R,D> [cycle through SP series
if
applicable; else if CVSLVSP=’1’ or CVSLVPE=’1’ goto HP series; else goto next section CBL.010]

Page 13 of 16

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

CCD.135_00.000 Instrument Variable Name:

CVSLSPSP

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, did {fill1: S.C. name} receive speech language therapy or other intervention services
for {fill2: his/her} speech problems?

QuestionText:

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 3+ who have had a speech problem in the past 12 months for a week or longer

SkipInstructions:

<1>[cycle through CVSLLGSP if applicable; else goto HP series] <2> [goto CVSLSPPE] [cycle through
CVSLLGSP if applicable; else if CVSLVSP=’1’ or CVSLVPE=’1’ or CVSLSWSP=’1’ or CVSLSWPE=’1’ goto
HP
series; else goto next section CBL.010]

Question ID:

CCD.140_00.000 Instrument Variable Name:

QuestionText:

CVSLSPPE

QuestionnaireFileName:

Sample Child

Did {fill1: S.C. name} EVER receive speech language therapy or other intervention services for {fill2: his/her} speech
problems?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 3+ who have not had speech language therapy for a speech problem in the past 12 months

SkipInstructions:

<1> [cycle through CVSLLGSP if applicable; else goto HP series] <2,R,D> <2,R,D> [cycle through CVSLLGSP
if
applicable; else if CVSLVSP=’1’ or CVSLVPE=’1’ or CVSLSWSP=’1’ or CVSLSWPE=’1’ goto HP series; else
goto
next section CBL.010]

Page 14 of 16

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

CCD.145_00.000 Instrument Variable Name:

CVSLLGSP

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, did {fill1: S.C. name} receive speech language therapy or other intervention services
for {fill2: his/her} problems using, learning or understanding words or sentences?

QuestionText:

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 3+ who have had a language problem in the past 12 months for a week or longer

SkipInstructions:

<1,R,D> [if CVSLVSP=1 or CVSLVPE=1 or CVSLSWSP=1 or CVSLSWPE=1 or
CVSLSPSP=1 or CVSLSPPE=1 or CVSLLGSP=1 or CVSLLGPE=1 cycle through CVSLVHP,
CVSLSWHP,CVSLSPHP, CVSLLGHP if applicable; else goto next section CBL.010] <2> [goto CVSLLGPE]

Question ID:

CCD.150_00.000 Instrument Variable Name:

QuestionText:

CVSLLGPE

QuestionnaireFileName:

Sample Child

Did {fill1: S.C. name} EVER receive speech language therapy or other intervention services for {fill2: his/her} problems
learning, using, or understanding words or sentences?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 3+ who have not had speech language therapy for a language problem in the past 12 months

SkipInstructions:

<1,2,R,D> if CVSLVSP=1 or CVSLVPE=1 or CVSLSWSP=1 or CVSLSWPE=1 or CVSLSPSP=1 or
CVSLSPPE=1 or CVSLLGSP=1 or CVSLLGPE=1 [cycle through CVSLVHP, CVSLSWHP, CVSLSPHP,
CVSLLGHP if applicable]; else [goto CBL.010]

Page 15 of 16

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

CCD.155_00.000 Instrument Variable Name:

CVSLVHP

QuestionnaireFileName:

Sample Child

Who provided this (for {fill1: S.C. name}'s voice problems)?

QuestionText:

*Enter all that apply, separate with commas.
1. Speech-Language Pathologist
2. Early Intervention Specialist/Program
3. Occupational/Physical Therapist
4. Ear, Nose & Throat Doctor (ENT, or otolaryngologist)
5. Audiologist or Hearing Aid Specialist
6. Pediatrician or Family Practice Doctor
7. Neurologist or Other Specialist
8. Nutritionist or Dietician
9. Psychiatrist or Psychologist
10. Other
Refused
Don’t know

UniverseText:

Sample children 3+ who have ever had speech language therapy or other intervention services for a voice problem

SkipInstructions:

<1-10,R,D> [cycle through CVSLSWHP, CVSLSPHP, CVSLLGHP if applicable]; else [goto CBL.010]

Question ID:

CCD.160_00.000 Instrument Variable Name:

QuestionText:

CVSLSWHP

QuestionnaireFileName:

Sample Child

Who provided this (for {fill1: S.C. name}'s problems swallowing)?
*Enter all that apply, separate with commas.

1. Speech-Language Pathologist
2. Early Intervention Specialist/Program
3. Occupational/Physical Therapist
4. Ear, Nose & Throat Doctor (ENT, or otolaryngologist)
5. Audiologist or Hearing Aid Specialist
6. Pediatrician or Family Practice Doctor
7. Neurologist or Other Specialist
8. Nutritionist or Dietician
9. Psychiatrist or Psychologist
10. Other
Refused
Don’t know

UniverseText:

Sample children 3+ who have ever had speech language therapy or other intervention services for a swallowing
problem

SkipInstructions:

<1-10,R,D> [cycle through CVSLSPHP, CVSLLGHP if applicable]; else [goto CBL.010]

Page 16 of 16

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

CCD.165_00.000 Instrument Variable Name:

CVSLSPHP

QuestionnaireFileName:

Sample Child

Who provided this (for {fill1: S.C. name}'s speech problems)?

QuestionText:

*Enter all that apply, separate with commas.
1. Speech-Language Pathologist
2. Early Intervention Specialist/Program
3. Occupational/Physical Therapist
4. Ear, Nose & Throat Doctor (ENT, or otolaryngologist)
5. Audiologist or Hearing Aid Specialist
6. Pediatrician or Family Practice Doctor
7. Neurologist or Other Specialist
8. Nutritionist or Dietician
9. Psychiatrist or Psychologist
10. Other
Refused
Don’t know

UniverseText:

Sample children 3+ who have ever had speech language therapy or other intervention services for a speech problem

SkipInstructions:

<1-10,R,D> [cycle through CVSLLGHP if applicable]; else [goto CBL.010]

Question ID:

CCD.170_00.000 Instrument Variable Name:

QuestionText:

CVSLLGHP

QuestionnaireFileName:

Sample Child

Who provided this (for {fill1: S.C. name}'s problems learning, using, or understanding words or sentences)?
*Enter all that apply, separate with commas.

1. Speech-Language Pathologist
2. Early Intervention Specialist/Program
3. Occupational/Physical Therapist
4. Ear, Nose & Throat Doctor (ENT, or otolaryngologist)
5. Audiologist or Hearing Aid Specialist
6. Pediatrician or Family Practice Doctor
7. Neurologist or Other Specialist
8. Nutritionist or Dietician
9. Psychiatrist or Psychologist
10. Other
Refused
Don’t know

UniverseText:

Sample children 3+ who have ever had speech language therapy or other intervention services for a language
problem

SkipInstructions:

<1-10,R,D> [goto CBL.010]

Page 1 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.010_00.000 Instrument Variable Name:

VSLVYR

QuestionnaireFileName:

Sample Adult

These next questions are about problems with your voice, swallowing, speech, or language. Please do not tell us about
problems that resulted from drinking alcohol or were caused by use of illicit drugs.

QuestionText:

DURING THE PAST 12 MONTHS, have you had any problems or difficulties with your VOICE, such as having a
hoarse, raspy, or strained voice, or with difficulty speaking loud enough to be heard?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto VSLSWYR]

Question ID:

ACD.015_00.000 Instrument Variable Name:

QuestionText:

VSLSWYR

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you had a SWALLOWING problem, such as difficulty eating solid food, taking
pills, or drinking beverages?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto VSLSPYR]

Page 2 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.020_00.000 Instrument Variable Name:

VSLSPYR

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you had a SPEECH problem, such as stuttering, repeating words, or not being
able to pronounce words properly?

QuestionText:

*Read if necessary: This refers to the language you are most comfortable with, not a foreign language.
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto VSLLGYR]

Question ID:

ACD.025_00.000 Instrument Variable Name:

QuestionText:

VSLLGYR

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you had a LANGUAGE problem, such as problems using or understanding
words or sentences?
*Read if necessary: This refers to the language you are most comfortable with, not a foreign language.

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto VSLSPEC]

Page 3 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.030_00.000 Instrument Variable Name:

VSLSPEC

QuestionnaireFileName:

Sample Adult

Before age 18, did you ever receive SPECIAL SERVICES or INSTRUCTION for a problem with your voice, speech, or
language, for example, pronunciation, using or understanding words or sentences, or in reading?

QuestionText:

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> if VSLVYR=1 or VSLSWYR=1 or VSLSPYR=1 or VSLLGYR=1 [goto VSLHPD]; else [goto
VSLEVER]

Question ID:

ACD.035_00.000 Instrument Variable Name:

VSLEVER

QuestionnaireFileName:

Sample Adult

Have you EVER had a voice, swallowing, speech, or language problem that lasted a week or longer?

QuestionText:

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who haven't had any voice, swallowing, speech or language problems in the past 12 months

SkipInstructions:

<1> [goto VSLHPD] <2,R,D> [gpto VSLINTYR]

Question ID:

ACD.040_00.000 Instrument Variable Name:

QuestionText:

VSLHPD

QuestionnaireFileName:

Sample Adult

Did a doctor or other health professional EVER tell you a diagnosis or reason for a voice, swallowing, speech, or language
problem?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who have had a voice, swallowing, speech or language problem in the past 12 months or who
have ever had a voice, swallowing, speech or language problem

SkipInstructions:

<1> [goto VSLDGTYP] <2,R,D> [if VSLVYR=1 or VSLSWYR=1 or VSLSPYR=1 or VSLLGYR=1 goto
VSLVDYS, VSLSWDYS, VSLSPDYS, VSLLGDYS series; else goto VSLINTYR]

Page 4 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.045_00.000 Instrument Variable Name:

VSLDGTYP

QuestionnaireFileName:

Sample Adult

For which problem(s)?

QuestionText:

*Read if necessary: Was this for problems with your voice, swallowing, speech, or language?
*Enter all that apply, separate with commas.
1. Voice problem
2. Swallowing problem
3. Speech problem
4. Language problem
Refused
Don't know

UniverseText:

Sample adults 18+ who have ever had a diagnosis for a voice, swallowing, speech or language problem that lasted
for a week or longer

SkipInstructions:

<1> [goto VSLVDG] <2> [goto VSLSWDG] <3> [goto VSLSPDG] <4> [goto VSLLGDG] [if
VSLVYR=1 or VSLSWYR=1 or VSLSPYR=1 or VSLLGYR=1 goto VSLVDYS, VSLSWDYS, VSLSPDYS,
VSLLGDYS series; else goto VSLINTYR]

Question ID:

ACD.050_00.000 Instrument Variable Name:

QuestionText:

VSLVDG

QuestionnaireFileName:

Sample Adult

What diagnoses or reasons were you told caused your voice problems?
*Enter all that apply, separate with commas.

1. Laryngitis caused by voice misuse, abuse, overuse
2. Laryngitis caused by colds/strep
3. Vocal nodules or polyps
4. Gastro-esophageal reflux disease (GERD)
5. Allergies
6. Airborne irritants or environmental pollutants
7. Head/neck injury
8. Cancer anywhere in the head, neck, or throat
9. Neurological cause (Alzheimer's, Parkinson's, dementia,
etc.)
10. Prescription medication or drugs
11. Other
Refused
Don’t know

UniverseText:

Sample adults 18+ who have ever had a diagnosis for a voice problem that lasted a week or longer

SkipInstructions:

<1-11,R,D> [cycle through VSLSWDG, VSLSPDG, VSLLGDG if applicable]; then if VSLVYR=1 or
VSLSWYR=1 or VSLSPYR=1 or VSLLGYR=1 [goto VSLVDYS, VSLSWDYS, VSLSPDYS, VSLLGDYS
series]; else [goto VSLINTYR]

Page 5 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.060_00.000 Instrument Variable Name:

QuestionText:

VSLSWDG

QuestionnaireFileName:

Sample Adult

What diagnoses or reasons were you told caused your problems swallowing?
*Enter all that apply, separate with commas.

1. Stroke
2. Neurological cause (Alzheimer’s, Parkinson’s, postpolio syndrome, dementia, etc.)
3. Cancer anywhere in the head, neck, or throat
4. Chronic obstructive pulmonary disease (COPD)
5. Congestive heart failure (CHF)
6. Head/neck injury
7. Arthritic changes in the neck (arthritis, cervical
osteophyte)
8. Advancing age (deterioration of muscle function with
age…sarcopenia)
9. Prescription medication or drugs
10. Other
Refused
Don't know

UniverseText:

Sample adults 18+ who have ever had a diagnosis for a swallowing problem that lasted a week or longer

SkipInstructions:

<1-9,R,D> [cycle through VSLSPDG, VSLLGDG if applicable]; then if VSLVYR=1 or VSLSWYR=1 or
VSLSPYR=1 or VSLLGYR=1 [goto VSLVDYS, VSLSWDYS, VSLSPDYS, VSLLGDYS series]; else [goto
VSLINTYR]

Page 6 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.065_00.000 Instrument Variable Name:

QuestionText:

VSLSPDG

QuestionnaireFileName:

Sample Adult

What diagnoses or reasons were you told caused your speech problems?
*Enter all that apply, separate with commas.

1. Hearing loss or deafness
2. Developmental speech sound disorder (phonological,
articulatory, dyspraxia)
3. Cerebral palsy
4. Cleft lip/palate, cranial-facial anomaly (structural cause)
5. Head/neck injury
6. Stuttering
7. Cancer anywhere in the head, neck, or throat
8. Neurological cause/dysarthria (Alzheimer’s
Parkinson’s, ALS, multiple sclerosis, dementia, etc.)
9. Prescription medication or drugs
10. Other
Refused
Don’t know

UniverseText:

Sample adults 18+ who have ever had a diagnosis for a speech problem that lasted a week or longer

SkipInstructions:

<1-9,R,D> [cycle through VSLLGDG if applicable]; then if VSLVYR=1 or VSLSWYR=1 or VSLSPYR=1 or
VSLLGYR=1 [goto VSLVDYS, VSLSWDYS, VSLSPDYS, VSLLGDYS series]; else [goto VSLINTYR]

Page 7 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.070_00.000 Instrument Variable Name:

VSLLGDG

QuestionnaireFileName:

Sample Adult

What diagnoses or reasons were you told caused your problems using or understanding words or sentences?

QuestionText:

*Enter all that apply, separate with commas.
1. Hearing loss or deafness
2. Genetic syndrome: Down syndrome, Fragile X
syndrome, etc.
3. Intellectual disability, also known as mental retardation
4. Autism spectrum disorder (ASD)
5. Developmental Language–Learning Disorder (e.g.,
Specific Language Impairment (SLI), learning disability,
or dyslexia)
6. Other developmental delay
7. Head injury, trauma brain injury (TBI)
8. Stroke/aphasia
9. Dementia or other neurological cause (Alzheimer’s
Parkinson’s, etc.)
10. Prescription medication or drugs
11. Other
Refused
Don't know

UniverseText:

Sample adults 18+ who have ever had a diagnosis for a language problem that lasted a week or longer

SkipInstructions:

<1-10,R,D> if VSLVYR=1 or VSLSWYR=1 or VSLSPYR=1 or VSLLGYR=1 [goto VSLVDYS, VSLSWDYS,
VSLSPDYS, VSLLGDYS series; else goto VSLINTYR]

Question ID:

ACD.075_00.000 Instrument Variable Name:

QuestionText:

VSLVDYS

QuestionnaireFileName:

Sample Adult

How many days in the past year did you have voice problems?
*Enter '7' for one week.
*Enter '30' for one month.
*Enter '365' for one year.

Allow 001-365,R,D

UniverseText:

Sample adults 18+ who had a voice problem in the past 12 months

SkipInstructions:

<1-6,R> [cycle through VSLSWDYS, VSLSPDYS, VSLLGDYS if applicable. If not applicable, goto
VSLINTYR]
[cycle through VSLSWDYS, VSLSPDYS, VSLLGDYS if applicable; else, goto VSLV1WK]
<7-365> cycle through VSLSWDYS, VSLSPDYS, VSLLGDYS if applicable; then [goto VSLVAGE,
VSLSWAGE, VSLSPAGE VSLLGAGE series]

Page 8 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.080_00.000 Instrument Variable Name:

VSLSWDYS

QuestionnaireFileName:

Sample Adult

How many days in the past year did you have problems swallowing?

QuestionText:

*Enter '7' for one week.
*Enter '30' for one month.
*Enter '365' for one year.
Allow 001-365,R,D

UniverseText:

Sample adults 18+ who had a swallowing problem in the past 12 months

SkipInstructions:

<1-6,R> [cycle through VSLSPDYS, VSLLGDYS if applicable;
else if VSLLGDYS, VSLLGDYS not applicable and VSLVDYS=1-6,R,’ ‘ goto VSLINTYR
else if VSLLGDYS, VSLLGDYS not applicable and VSLVDYS=D, goto VSLV1WK;
else goto VSLVAGE, VSLSWAGE, VSLSPAGE, VSLLGAGE series]
[cycle through VSLSPDYS, VSLLGDYS if applicable;
else goto 1WK series (VSLSW1WK)]
<7-365> cycle through VSLSPDYS, VSLLGDYS if applicable then [goto VSLVAGE, VSLSWAGE, VSLSPAGE
VSLLGAGE series]

Question ID:

ACD.082_00.000 Instrument Variable Name:

QuestionText:

VSLSPDYS

QuestionnaireFileName:

Sample Adult

How many days in the past year did you have speech problems?
*Enter '7' for one week.
*Enter '30' for one month.
*Enter '365' for one year.

Allow 001-365,R,D

UniverseText:

Sample adults 18+ who had a speech problem in the past 12 months

SkipInstructions:

<1-6,R> [cycle through VSLLGDYS if applicable;
else if VSLLGDYS not applicable and VSLVDYS=1-6,R,’ ‘ and VSLSWDYS=1-6,R,’ ‘ goto VSLINTYR;
else if VSLLGDYS not applicable and any applicable DYS variables=D, goto VSLV1WK, VSLSW1WK,
VSLSP1WK series;
else goto VSLVAGE, VSLSWAGE, VSLSPAGE VSLLGAGE series]
[cycle through VSLLGDYS if applicable;
else goto 1WK series (VSLSP1WK)]
<7-365> cycle through VSLLGDYS if applicable then [goto VSLSTUTT]

Page 9 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.085_00.000 Instrument Variable Name:

VSLLGDYS

QuestionnaireFileName:

Sample Adult

How many days in the past year did you have problems using or understanding words or sentences?

QuestionText:

*Enter '7' for one week.
*Enter '30' for one month.
*Enter '365' for one year.
Allow 001-365,R,D

UniverseText:

Sample adults 18+ who had a language problem in the past 12 months

SkipInstructions:

<1-6,R> [if 1-6,R to all applicable DYS variables, goto VSLINTYR;
else if any applicable DYS variables=D, goto VSLV1WK, VSLSW1WK, VSLSP1WK, VSLLG1WK series;
else if VSLSPDYS GE 7, goto VSLSTUTT;
else if VSLLGDYS GE 7, goto VSLLGFAM;
else goto VSLVAGE, VSLSWAGE, VSLSPAGE VSLLGAGE series]
[goto 1WK series (VSLLG1WK)]
<7-365> if VSLSPDYS GE 7 [goto VSLSTUTT];
else if VSLLGDYS GE 7 [goto VSLLGFAM];
else [goto VSLVAGE, VSLSWAGE, VSLSPAGE VSLLGAGE series]

Question ID:

ACD.090_00.000 Instrument Variable Name:

QuestionText:

VSLV1WK

QuestionnaireFileName:

Sample Adult

Altogether, did your voice problems last a week or longer?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who had a voice problem in the past 12 months who don't know how many days in the past year
they have had this problem

SkipInstructions:

<1> [cycle through VSLSW1WK, VSLSP1WK, VSLLG1WK if applicable;
else if VSLSW1WK, VSLSP1WK, VSLLG1WK not applicable and VSLSPDYS GE 7, goto VSLSTUTT;
else if VSLSW1WK, VSLSP1WK, VSLLG1WK not applicable and VSLLGDYS GE 7, goto VSLLGFAM;
else goto applicable items in VSLVAGE, VSLSWAGE, VSLSPAGE, VSLLGAGE series]
<2,R,D> [cycle through VSLSW1WK, VSLSP1WK, VSLLG1WK if applicable;
else if VSLSW1WK, VSLSP1WK, VSLLG1WK not applicable and if all applicable DYS series < 7 goto
VSLINTYR;
else if VSLSPDYS GE 7, goto VSLSTUTT;
else if VSLLGDYS GE 7, goto VSLLGFAM;
else goto applicable items in VSLVAGE, VSLSWAGE, VSLSPAGE, VSLLGAGE series]

Page 10 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.095_00.000 Instrument Variable Name:

VSLSW1WK

QuestionnaireFileName:

Sample Adult

Altogether, did your problems swallowing last a week or longer?

QuestionText:

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who had a voice problem in the past 12 months who don't know how many days in the past year
they have had this problem

SkipInstructions:

<1> [cycle through VSLSP1WK, VSLLG1WK if applicable,
else if VSLSP1WK, VSLLG1WK not applicable and VSLSPDYS GE 7, goto VSLSTUTT;
else if VSLSP1WK, VSLLG1WK not applicable and VSLLGDYS GE 7, goto VSLLGFAM;
else goto applicable items in VSLVAGE, VSLSWAGE, VSLSPAGE, VSLLGAGE series]
<2,R,D> [cycle through VSLSP1WK, VSLLG1WK if applicable;
else if VSLSP1WK, VSLLG1WK not applicable and if all applicable DYS series < 7 and VSLV1WK NE 1 goto
VSLINTYR;
else if VSLSPDYS GE 7, goto VSLSTUTT;
else if VSLLGDYS GE 7, goto VSLLGFAM;
else goto applicable items in VSLVAGE, VSLSWAGE, VSLSPAGE, VSLLGAGE series]

Question ID:

ACD.100_00.000 Instrument Variable Name:

QuestionText:

VSLSP1WK

QuestionnaireFileName:

Sample Adult

Altogether, did your speech problems last for a week or longer?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who had a speech problem in the past 12 months who don't know how many days in the past
year they have had this problem

SkipInstructions:

<1> [cycle through VSLLG1WK if applicable,
else if VSLLG1WK not applicable goto VSLSTUTT;
else if VSLLG1WK not applicable and VSLLGDYS GE 7, goto VSLLGFAM;
else then goto applicable items in VSLVAGE, VSLSWAGE, VSLSPAGE, VSLLGAGE series]
<2,R,D> [cycle through VSLLG1WK if applicable;
else if VSLLG1WK not applicable and if all applicable DYS series < 7 and VSLV1WK NE 1 and VSLSW1WK
NE 1 goto VSLINTYR;
else if VSLSPDYS GE 7, goto VSLSTUTT;
else if VSLLGDYS GE 7, goto VSLLGFAM;
else goto VSLINTYR]

Page 11 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.105_00.000 Instrument Variable Name:

VSLLG1WK

QuestionnaireFileName:

Sample Adult

Altogether, did your problems using or understanding words or sentences last for a week or longer?

QuestionText:

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who had a language problem in the past 12 months who don't know how many days in the past
year they have had this problem

SkipInstructions:

<1>if VSLSPDYS GE 7 or VSLSP1WK=1 [goto VSLSTUTT];
else [goto VSLLGFAM];
<2,R,D> if VSLSPDYS GE 7 or VSLSP1WK=1 [goto VSLSTUTT];
else if all applicable DYS series < 7 and VSLV1WK NE 1 and VSLSW1WK NE 1 and VSLSP1WK NE 1 goto
VSLINTYR;
else [goto applicable items in VSLVAGE, VSLSWAGE, VSLSPAGE, VSLLGAGE series]

Question ID:

ACD.110_00.000 Instrument Variable Name:

QuestionText:

VSLSTUTT

QuestionnaireFileName:

DURING THE PAST 12 MONTHS, have you had a problem with stuttering or stammering?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ with a speech problem in the past 12 months for a week or longer

SkipInstructions:

<1> [goto VSLSTDEG]
<2,R,D> if VSLLGDYS GE 7 or VSLLG1WK=1 [goto VSLLGFAM];
else [goto VSLVAGE, VSLSWAGE, VSLSPAGE, VSLLGAGE series]

Sample Adult

Page 12 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.115_00.000 Instrument Variable Name:

VSLSTDEG

QuestionnaireFileName:

Sample Adult

Would you describe your stuttering or stammering as mild, moderate, or severe?

QuestionText:

1. Mild
2. Moderate
3. Severe
Refused
Don't know

UniverseText:

Sample adults 18+ with a stuttering or stammering problem in the past 12 months for a week or longer

SkipInstructions:

<1-3,R,D> VSLLGDYS GE 7 or VSLLG1WK=1 [goto VSLLGFAM];
else [goto VSLVAGE, VSLSWAGE, VSLSPAGE, VSLLGAGE series]

Question ID:

ACD.120_00.000 Instrument Variable Name:

VSLLGFAM

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have your family members, friends, or associates had trouble understanding what you
say?

QuestionText:

1. Yes
2. No
Refused
Don’t know

UniverseText:

Sample adults 18+ with a language problem in the past 12 months for a week or longer

SkipInstructions:

<1,2,R,D> [goto VSLVAGE, VSLSWAGE, VSLSPAGE, VSLLGAGE series]

Question ID:

ACD.125_00.000 Instrument Variable Name:

QuestionText:

VSLVAGE

QuestionnaireFileName:

At what age did you FIRST begin to have any voice problems?

Allow 0 - Current Age

UniverseText:

Sample adults 18+ with a voice problem in the past 12 months for a week or longer

SkipInstructions:

<0-Current Age,R,D> [cycle through VSLSWAGE, VSLSPAGE, VSLLGAGE if applicable,
then goto VSLVPRB, VSLSWPRB, VSLSPPRB, VSLLGPRB series]

Sample Adult

Page 13 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.130_00.000 Instrument Variable Name:

VSLSWAGE

QuestionnaireFileName:

Sample Adult

At what age did you FIRST begin to have any problems swallowing?

QuestionText:

Allow 0 - Current Age

UniverseText:

Sample adults 18+ with a swallowing problem in the past 12 months for a week or longer

SkipInstructions:

<0-Current Age,R,D> [cycle through VSLSPAGE, VSLLGAGE if applicable,
then goto VSLVPRB, VSLSWPRB, VSLSPPRB, VSLLGPRB series]

Question ID:

ACD.135_00.000 Instrument Variable Name:

VSLSPAGE

QuestionnaireFileName:

Sample Adult

At what age did you FIRST begin to have any speech problems?

QuestionText:

Allow 0 - Current Age

UniverseText:

Sample adults 18+ with a speech problem in the past 12 months for a week or longer

SkipInstructions:

<0-Current Age,R,D> [cycle through VSLLGAGE if applicable, then goto VSLVPRB, VSLSWPRB, VSLSPPRB,
VSLLGPRB series]

Question ID:

ACD.140_00.000 Instrument Variable Name:

QuestionText:

VSLLGAGE

QuestionnaireFileName:

At what age did you FIRST begin to have any problems using or understanding words or sentences?

Allow 0 - Current Age

UniverseText:

Sample adults 18+ with a language problem in the past 12 months for a week or longer

SkipInstructions:

<0-Current Age,R,D> [goto VSLVPRB, VSLSWPRB, VSLSPPRB, VSLLGPRB series]

Sample Adult

Page 14 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.145_00.000 Instrument Variable Name:

VSLVPRB

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, how much of a problem did you have with your voice? Would you say it was...

QuestionText:

*Read categories below
1. No problem
2. A small problem
3. A moderate problem
4. A big problem
5. A very big problem
Refused
Don't know

UniverseText:

Sample adults 18+ with a voice problem in the past 12 months for a week or longer

SkipInstructions:

<1-5,R,D> [cycle through VSLSWPRB, VSLSPPRB, VSLLGPRB if applicable, then goto VSLVSLP,
VSLSWSLP VSLSPSLP, VSLLGSLP series]

Question ID:

ACD.150_00.000 Instrument Variable Name:

QuestionText:

VSLSWPRB

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, how much of a swallowing problem did you have? Would you say it was...
*Read categories below

1. No problem
2. A small problem
3. A moderate problem
4. A big problem
5. A very big problem
Refused
Don't know

UniverseText:

Sample adults 18+ with a swallowing problem in the past 12 months for a week or longer

SkipInstructions:

<1-5,R,D> [cycle through VSLSPPRB, VSLLGPRB if applicable, then goto VSLVSLP, VSLSWSLP VSLSPSLP,
VSLLGSLP series]

Page 15 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.155_00.000 Instrument Variable Name:

VSLSPPRB

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, how much of a problem did you have with your speech? Would you say it was...

QuestionText:

*Read categories below
1. No problem
2. A small problem
3. A moderate problem
4. A big problem
5. A very big problem
Refused
Don't know

UniverseText:

Sample adults 18+ with a speech problem in the past 12 months for a week or longer

SkipInstructions:

<1-5,R,D> [cycle through VSLLGPRB if applicable, then goto VSLVSLP, VSLSWSLP VSLSPSLP, VSLLGSLP
series]

Question ID:

ACD.160_00.000 Instrument Variable Name:

QuestionText:

VSLLGPRB

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, how much of a problem did you have using or understanding words or sentences?
Would you say it was...
*Read categories below

1. No problem
2. A small problem
3. A moderate problem
4. A big problem
5. A very big problem
Refused
Don't know

UniverseText:

Sample adults 18+ with a language problem in the past 12 months for a week or longer

SkipInstructions:

<1-5,R,D> [goto VSLVSLP, VSLSWSLP VSLSPSLP, VSLLGSLP series]

Page 16 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.165_00.000 Instrument Variable Name:

VSLVSLP

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you seen a speech-language pathologist (SLP) or other health care professional
about your voice problems?

QuestionText:

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ with a voice problem in the past 12 months for a week or longer

SkipInstructions:

<1,R,D> [cycle through VSLSWSLP, VSLSPSLP, VSLLGSLP if applicable, then goto VSLVTRT, VSLSWTRT,
VSLSPTRT, VSLLGTRT series]
<2> [goto VSLVPEV]

Question ID:

ACD.170_00.000 Instrument Variable Name:

QuestionText:

VSLVPEV

QuestionnaireFileName:

Sample Adult

Have you EVER seen a speech-language pathologist (SLP) or other health care professional about your voice problems?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who have not seen a speech-language pathologist or other health care professional about a voice
problem in the past 12 months

SkipInstructions:

<1,2,R,D> [cycle through VSLSWSLP, VSLSPSLP, VSLLGSLP if applicable,
then goto VSLVTRT, VSLSWTRT, VSLSPTRT, VSLLGTRT series]

Page 17 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.175_00.000 Instrument Variable Name:

VSLSWSLP

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you seen a speech-language pathologist (SLP) or other health care professional
about your problems swallowing?

QuestionText:

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ with a swallowing problem in the past 12 months for a week or longer

SkipInstructions:

<1,R,D> [cycle through VSLSPSLP, VSLLGSLP if applicable, then goto VSLVTRT, VSLSWTRT, VSLSPTRT,
VSLLGTRT series] <2> [goto VSLSWPEV]

Question ID:

ACD.180_00.000 Instrument Variable Name:

QuestionText:

VSLSWPEV

QuestionnaireFileName:

Sample Adult

Have you EVER seen a speech-language pathologist (SLP) or other health care professional about your problems
swallowing?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who have not seen a speech-language pathologist or other health care professional about a
swallowing problem in the past 12 months

SkipInstructions:

<1,2,R,D> [cycle through VSLSPSLP, VSLLGSLP if applicable,
then goto VSLVTRT, VSLSWTRT, VSLSPTRT, VSLLGTRT series]

Page 18 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.185_00.000 Instrument Variable Name:

VSLSPSLP

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you seen a speech-language pathologist (SLP) or other health care professional
about your speech problems?

QuestionText:

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ with a speech problem in the past 12 months for a week or longer

SkipInstructions:

<1,R,D> [cycle through VSLLGSLP if applicable; then goto VSLVTRT, VSLSWTRT, VSLSPTRT, VSLLGTRT
series]
<2> [goto VSLSPPEV]

Question ID:

ACD.190_00.000 Instrument Variable Name:

VSLSPPEV

QuestionnaireFileName:

Sample Adult

Have you EVER seen a speech-language pathologist (SLP) or other health care professional about your speech problems?

QuestionText:

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who have not seen a speech-language pathologist or other health care professional about a
speech problem in the past 12 months

SkipInstructions:

<1,2,R,D> [cycle through VSLLGSLP if applicable]; else [goto VSLVTRT, VSLSWTRT, VSLSPTRT,
VSLLGTRT series]

Question ID:

ACD.195_00.000 Instrument Variable Name:

QuestionText:

VSLLGSLP

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you seen a speech-language pathologist (SLP) or other health care professional
about your problems using or understanding words or sentences?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ with a language problem in the past 12 months for a week or longer

SkipInstructions:

<1,R,D> [goto VSLVTRT, VSLSWTRT, VSLSPTRT, VSLLGTRT series] <2> [goto VSLLGPEV]

Page 19 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.200_00.000 Instrument Variable Name:

VSLLGPEV

QuestionnaireFileName:

Sample Adult

Have you EVER seen a speech-language pathologist (SLP) or other health care professional about your problems using or
understanding words or sentences?

QuestionText:

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who have not seen a speech-language pathologist or other health care professional about a
language problem in the past 12 months

SkipInstructions:

<1,2,R,D> [goto VSLVTRT, VSLSWTRT, VSLSPTRT, VSLLGTRT series]

Question ID:

ACD.205_00.000 Instrument Variable Name:

QuestionText:

VSLVTRT

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you received treatments, therapy, or other rehabilitation services for your voice
problems?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ with a voice problem in the past 12 months for a week or longer

SkipInstructions:

<1> [goto VSLVTRW]
<2,R,D> [cycle through VSLSWTRT, VSLSPTRT, VSLLGTRT if applicable; else go to VSLVCOM,
VSLSWCOM, VSLSPCOM, VSLLGCOM series]

Page 20 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.210_00.000 Instrument Variable Name:

VSLVTRW

QuestionnaireFileName:

Sample Adult

Who provided this (for your voice problems)?

QuestionText:

*Enter all that apply, separate with commas.
1. Speech-Language Pathologist
2. Family Physician, General Practitioner, or Osteopath
3. Rehabilitation Specialist (Occupational or Physical
Therapist)
4. Ear, Nose, and Throat Doctor (Otolaryngologist)
5. Audiologist, Hearing Specialist, or Hearing Aid
Technician
6. Specialty doctor in Internal Medicine, Geriatrics,
Neurology, etc.
7. Nutritionist or Dietician
8. Psychiatrist or Psychologist
9. Nurse or Nurse Practitioner
10. Dentist, Orthodontist, or Oral Surgeon
11. Other
Refused
Don't know

UniverseText:

Sample adults 18+ who have received treatment/rehabilitative services for a voice problem in the past 12 months

SkipInstructions:

<1-11,R,D> [cycle through VSLSWTRT, VSLSPTRT, VSLLGTRT if applicable
else if VSLSWTRT, VSLSPTRT, VSLLGTRT not applicable and VSLVTRW=1,goto VSLVSOC;
else go to VSLVCOM, VSLSWCOM, VSLSPCOM, VSLLGCOM series]

Question ID:

ACD.215_00.000 Instrument Variable Name:

QuestionText:

VSLSWTRT

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you received treatments, therapy, or other rehabilitation services for your
problems swallowing?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ with a swallowing problem in the past 12 months for a week or longer

SkipInstructions:

<1> [goto VSLSWTRW]
<2,R,D> [cycle through VSLSPTRT, VSLLGTRT if applicable;
else if VSLSPTRT, VSLLGTRT not applicable and any TRT variables=1 goto VSLVSOC, VSLSWSOC,
VSLSPSOC, VSLLGSOC series;
else goto VSLVCOM, VSLSWCOM, VSLSPCOM, VSLLGCOM series]

Page 21 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.220_00.000 Instrument Variable Name:

VSLSWTRW

QuestionnaireFileName:

Sample Adult

Who provided this (for your problems swallowing)?

QuestionText:

*Enter all that apply, separate with commas.
1. Speech-Language Pathologist
2. Family Physician, General Practitioner, or Osteopath
3. Rehabilitation Specialist (Occupational or Physical
Therapist)
4. Ear, Nose, and Throat Doctor (Otolaryngologist)
5. Audiologist, Hearing Specialist, or Hearing Aid
Technician
6. Specialty doctor in Internal Medicine, Geriatrics,
Neurology, etc.
7. Nutritionist or Dietician
8. Psychiatrist or Psychologist
9. Nurse or Nurse Practitioner
10. Dentist, Orthodontist, or Oral Surgeon
11. Other
Refused
Don't know

UniverseText:

Sample adults 18+ who have received treatment/rehabilitative services for a swallowing problem in the past 12
months

SkipInstructions:

<1-11,R,D> [cycle through VSLSPTRT, VSLLGTRT if applicable;
else if VSLSPTRT, VSLLGTRT not applicable and any TRT variables=1 goto VSLVSOC, VSLSWSOC,
VSLSPSOC, VSLLGSOC series;
else go to VSLVCOM, VSLSWCOM, VSLSPCOM, VSLLGCOM series]

Question ID:

ACD.225_00.000 Instrument Variable Name:

QuestionText:

VSLSPTRT

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you received treatments, therapy, or other rehabilitation services for your
speech problems?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ with a speech problem in the past 12 months for a week or longer

SkipInstructions:

<1> [goto VSLSPTRW]
<2,R,D> [cycle through VSLLGTRT if applicable;
else if VSLLGTRT not applicable and any TRT variables=1 [goto VSLVSOC, VSLSWSOC, VSLSPSOC,
VSLLGSOC series;
else [goto VSLVCOM, VSLSWCOM, VSLSPCOM, VSLLGCOM series]

Page 22 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.230_00.000 Instrument Variable Name:

VSLSPTRW

QuestionnaireFileName:

Sample Adult

Who provided this (for your speech problems)?

QuestionText:

*Enter all that apply, separate with commas.
1. Speech-Language Pathologist
2. Family Physician, General Practitioner, or Osteopath
3. Rehabilitation Specialist (Occupational or Physical
Therapist)
4. Ear, Nose, and Throat Doctor (Otolaryngologist)
5. Audiologist, Hearing Specialist, or Hearing Aid
Technician
6. Specialty doctor in Internal Medicine, Geriatrics,
Neurology, etc.
7. Nutritionist or Dietician
8. Psychiatrist or Psychologist
9. Nurse or Nurse Practitioner
10. Dentist, Orthodontist, or Oral Surgeon
11. Other
Refused
Don't know

UniverseText:

Sample adults 18+ who have received treatment/rehabilitative services for a speech problem in the past 12 months

SkipInstructions:

<1-11,R,D> [cycle through VSLLGTRT if applicable;
else if VSLLGTRT not applicable and any TRT variables=1 [goto VSLVSOC, VSLSWSOC, VSLSPSOC,
VSLLGSOC series;
else go to VSLVCOM, VSLSWCOM, VSLSPCOM, VSLLGCOM series]

Question ID:

ACD.235_00.000 Instrument Variable Name:

QuestionText:

VSLLGTRT

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you received treatments, therapy, or other rehabilitation services, for your
problems using or understanding words or sentences?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ with a language problem in the past 12 months for a week or longer

SkipInstructions:

<1> [goto VSLLGTRW]
<2,R,D> if any TRT variables=1 [goto VSLVSOC, VSLSWSOC, VSLSPSOC, VSLLGSOC series];
else [goto VSLVCOM, VSLSWCOM, VSLSPCOM, VSLLGCOM series]

Page 23 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.240_00.000 Instrument Variable Name:

VSLLGTRW

QuestionnaireFileName:

Sample Adult

Who provided this (for your problems using or understanding words or sentences)?

QuestionText:

*Enter all that apply, separate with commas.
1. Speech-Language Pathologist
2. Family Physician, General Practitioner, or Osteopath
3. Rehabilitation Specialist (Occupational or Physical
Therapist)
4. Ear, Nose, and Throat Doctor (Otolaryngologist)
5. Audiologist, Hearing Specialist, or Hearing Aid
Technician
6. Specialty doctor in Internal Medicine, Geriatrics,
Neurology, etc.
7. Nutritionist or Dietician
8. Psychiatrist or Psychologist
9. Nurse or Nurse Practitioner
10. Dentist, Orthodontist, or Oral Surgeon
11. Other
Refused
Don't know

UniverseText:

Sample adults 18+ who have received treatment/rehabilitative services for a language problem in the past 12
months

SkipInstructions:

<1-11,R,D> if any TRT variables=1 [goto VSLVSOC, VSLSWSOC, VSLSPSOC, VSLLGSOC series;
else [goto VSLVCOM, VSLSWCOM, VSLSPCOM, VSLLGCOM series}

Question ID:

ACD.245_00.000 Instrument Variable Name:

QuestionText:

VSLVSOC

QuestionnaireFileName:

Sample Adult

Did the treatments or other rehabilitation services for your voice problems make your personal or social life better?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who have received treatment/rehabilitative services for a voice problem in the past 12 months

SkipInstructions:

<1,2,R,D> [cycle through VSLSWSOC, VSLSPSOC, VSLLGSOC if applicable;
else if VSLVTRT(e)='1' and (DOINGLW2 IN('1','2','4') or WRKLYR2(e)='1' or SCHOOLYR(e)='1') goto
VSLVSW, VSLSWSW, VSLSPSW, VSLLGSW series;
else goto VSLVCOM, VSLSWCOM, VSLSPCOM, VSLLGCOM series]

Page 24 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.250_00.000 Instrument Variable Name:

VSLSWSOC

QuestionnaireFileName:

Sample Adult

Did the treatments or other rehabilitation services for your problems swallowing make your personal or social life better?

QuestionText:

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who have received treatment/rehabilitative services for a swallowing problem in the past 12
months

SkipInstructions:

<1,2,R,D> [cycle through VSLSPSOC, VSLLGSOC if applicable,
else if VSLVTRT(e)='1' and (DOINGLW2 IN('1','2','4') or WRKLYR2(e)='1' or SCHOOLYR(e)='1') goto
VSLVSW, VSLSWSW, VSLSPSW, VSLLGSW series;
else goto VSLVCOM, VSLSWCOM, VSLSPCOM, VSLLGCOM series]

Question ID:

ACD.255_00.000 Instrument Variable Name:

QuestionText:

VSLSPSOC

QuestionnaireFileName:

Sample Adult

Did the treatments or other rehabilitation services for your speech problems make your personal or social life better?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who have received treatment/rehabilitative services for a speech problem in the past 12 months

SkipInstructions:

<1,2,R,D> [cycle through VSLLGSOC if applicable;
else if VSLVTRT(e)='1' and (DOINGLW2 IN('1','2','4') or WRKLYR2(e)='1' or SCHOOLYR(e)='1') goto
VSLVSW, VSLSWSW, VSLSPSW, VSLLGSW series;
else goto VSLVCOM, VSLSWCOM, VSLSPCOM, VSLLGCOM series]

Page 25 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.260_00.000 Instrument Variable Name:

VSLLGSOC

QuestionnaireFileName:

Sample Adult

Did the treatments or other rehabilitation services for your problems using or understanding words or sentences make your
personal or social life better?

QuestionText:

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who have received treatment/rehabilitative services for a language problem in the past 12
months

SkipInstructions:

<1,2,R,D> [if VSLVTRT(e)='1' and (DOINGLW2 IN('1','2','4') or WRKLYR2(e)='1' or SCHOOLYR(e)='1') goto
VSLVSW, VSLSWSW, VSLSPSW, VSLLGSW series;
else goto VSLVCOM, VSLSWCOM, VSLSPCOM, VSLLGCOM series]

Question ID:

ACD.265_00.000 Instrument Variable Name:

QuestionText:

VSLVSW

QuestionnaireFileName:

Sample Adult

Did the treatments or other rehabilitation services for your voice problems make your life at school or work better?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who have worked or attended school in the past 12 months and who received
treatment/rehabilitative services for a voice problem in the past 12 months

SkipInstructions:

<1,2,R,D> [cycle through VSLSWSW, VSLSPSW, VSLLGSW if applicable, then goto VSLVCOM,
VSLSWCOM, VSLSPCOM, VSLLGCOM series]

Page 26 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.270_00.000 Instrument Variable Name:

VSLSWSW

QuestionnaireFileName:

Sample Adult

Did the treatments or other rehabilitation services for your problems swallowing make your life at school or work better?

QuestionText:

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who have worked or attended school in the past 12 months and who have received
treatment/rehabilitative services for a swallowing problem in the past 12 months

SkipInstructions:

<1,2,R,D> [cycle through VSLSPSW, VSLLGSW if applicable, then goto VSLVCOM, VSLSWCOM,
VSLSPCOM, VSLLGCOM series]

Question ID:

ACD.275_00.000 Instrument Variable Name:

QuestionText:

VSLSPSW

QuestionnaireFileName:

Sample Adult

Did the treatments or other rehabilitation services for your speech problems make your life at school or work better?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who have worked or attended school in the past 12 months and who have received
treatment/rehabilitative services for a speech problem in the past 12 months

SkipInstructions:

<1,2,R,D> [cycle through VSLLGSW if applicable, then goto VSLVCOM, VSLSWCOM, VSLSPCOM,
VSLLGCOM series]

Page 27 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.280_00.000 Instrument Variable Name:

VSLLGSW

QuestionnaireFileName:

Sample Adult

Did the treatments or other rehabilitation services for your problems using or understanding words or sentences make your
life at school or work better?

QuestionText:

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who have worked or attended school in the past 12 months and who have received
treatment/rehabilitative services for a language problem in the past 12 months

SkipInstructions:

<1,2,R,D> [goto VSLVCOM, VSLSWCOM, VSLSPCOM, VSLLGCOM series]

Question ID:

ACD.285_00.000 Instrument Variable Name:

VSLVCOM

QuestionnaireFileName:

Sample Adult

Compared to 12 months ago, would you say your voice problems are now better, worse, or about the same?

QuestionText:

1. Better
2. Worse
3. About the same
Refused
Don't know

UniverseText:

Sample adults 18+ with a voice problem in the past 12 months

SkipInstructions:

<1-3,R,D> [cycle through VSLSWCOM, VSLSPCOM, VSLLGCOM series, then goto VSLINTYR]

Question ID:

ACD.290_00.000 Instrument Variable Name:

QuestionText:

VSLSWCOM

QuestionnaireFileName:

Compared to 12 months ago, would you say your problems swallowing are now better, worse, or about the same?

1. Better
2. Worse
3. About the same
Refused
Don't know

UniverseText:

Sample adults 18+ with a swallowing problem in the past 12 months

SkipInstructions:

<1-3,R,D> [cycle through VSLSPCOM, VSLLGCOM if applicable, then goto VSLINTYR]

Hard Edit:
Soft Edit:

Sample Adult

Page 28 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.295_00.000 Instrument Variable Name:

VSLSPCOM

QuestionnaireFileName:

Sample Adult

Compared to 12 months ago, would you say your speech problems are now better, worse, or about the same?

QuestionText:

1. Better
2. Worse
3. About the same
Refused
Don't know

UniverseText:

Sample adults 18+ with a speech problem in the past 12 months

SkipInstructions:

<1-3,R,D> [cycle through VSLLGCOM if applicable, then goto VSLINTYR]

Hard Edit:
Soft Edit:
Question ID:

ACD.300_00.000 Instrument Variable Name:

QuestionText:

VSLLGCOM

QuestionnaireFileName:

Compared to 12 months ago, would you say your problems using or understanding words or sentences are now better,
worse, or about the same?

1. Better
2. Worse
3. About the same
Refused
Don't know

UniverseText:

Sample adults 18+ with a language problem in the past 12 months

SkipInstructions:

<1-3,R,D> [goto VSLINTYR]

Hard Edit:
Soft Edit:

Sample Adult

Page 29 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.305_00.000 Instrument Variable Name:

VSLINTYR

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, did you get information from the Internet about your health, medical treatments, or
rehabilitation services?

QuestionText:

1. Yes
2. No
Refused
Don’t know

UniverseText:

Sample adults 18+

SkipInstructions:

<1> if VSLVYR=1 or VSLSWYR=1 or VSLSPYR=1 or VSLLGYR=1 then [goto VSLINTCN];
else goto next section;
<2,R,D> goto next section

Question ID:

ACD.310_00.000 Instrument Variable Name:

QuestionText:

VSLINTCN

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, did you get information from the Internet on...
{fill1:
Voice problems
Problems swallowing
Speech problems
Problems using or understanding words or sentences}

1. Yes
2. No
Refused
Don’t know

UniverseText:

Sample adults 18+ who have had a voice, swallowing, speech or language problem in the past 12 months and who
have received health information from the Internet in the past 12 months

SkipInstructions:

<1> [goto VSLINTPR] <2,R,D> [goto VSLINTHP]

Hard Edit:
Soft Edit:

Page 30 of 30

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Communication Disorders
Document Version Date: 23-Aug-11
Question ID:

ACD.315_00.000 Instrument Variable Name:

VSLINTPR

QuestionnaireFileName:

Sample Adult

Was any of this information written by doctor, other health professionals, medical associations, or other health-related
organizations?

QuestionText:

1. Yes
2. No
Refused
Don’t know

UniverseText:

Sample adults 18+ who have received information from the Internet in the past 12 months about a voice,
swallowing, speech or language problem

SkipInstructions:

<1,2,R,D> [goto VSLINTHP]

Hard Edit:
Soft Edit:
Question ID:

ACD.320_00.000 Instrument Variable Name:

QuestionText:

VSLINTHP

QuestionnaireFileName:

Sample Adult

Overall, how helpful was the health information found on the Internet? Would you say...
*Read categories below.

1. Very helpful
2. Somewhat helpful
3. Not helpful
Refused
Don’t know

UniverseText:

Sample adults 18+ who have received information from the Internet in the past 12 months about a voice,
swallowing, speech or language problem

SkipInstructions:

<1-3,R,D> [goto next section]

Hard Edit:
Soft Edit:

Page 1 of 7

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Balance
Document Version Date: 23-Aug-11
Question ID:

CBL.010_00.000 Instrument Variable Name:

CBALWLK

QuestionnaireFileName:

Sample Child

At what age did {fill1: S.C. name} take {fill2: his/her} first steps without support?

QuestionText:

1. 6 to 8 months
2. 9 to 11 months
3. 12 to 14 months
4. 15 to 17 months
5. 18 to 23 months
6. 24 months (2 years) or later
7. Cannot walk
Refused
Don't know

UniverseText:

Sample children 3+

SkipInstructions:

<1-7,R,D> [goto CBALLIMB]

Question ID:

CBL.015_00.000 Instrument Variable Name:

QuestionText:

CBALLIMB

QuestionnaireFileName:

Does {fill1: S.C. name} have any problem standing, walking, or using {fill2: his/her} arms or legs?

1. Yes
2. No
Refused
Don’t know

UniverseText:

Sample children 3+

SkipInstructions:

<1,2,R,D> [goto CBALVRTG]

Sample Child

Page 2 of 7

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Balance
Document Version Date: 23-Aug-11
Question ID:

CBL.020_00.000 Instrument Variable Name:

CBALVRTG

QuestionnaireFileName:

Sample Child

These next questions are about balance problems or disorders that children may experience such as feeling unsteady,
dizzy, light
headed, or whoozy or having body or motor coordination problems.

QuestionText:

DURING THE PAST 12 MONTHS, has {fill1: S.C. name} been bothered by episodes of any of the following dizziness or
balance problems?
Vertigo, a spinning sensation like a Merry-Go-Round?
1. Yes
2. No
Refused
Don’t know

UniverseText:

Sample children 3+

SkipInstructions:

<1,2,R,D> [goto CBALSTED]

Question ID:

CBL.025_00.000 Instrument Variable Name:

QuestionText:

CBALSTED

QuestionnaireFileName:

Sample Child

*Read if necessary.
DURING THE PAST 12 MONTHS, has {fill1: S.C. name} been bothered by episodes of any of the following dizziness or
balance problems?
Poor balance, an unsteady or whoozy feeling that makes it difficult to stand up or walk?

1. Yes
2. No
Refused
Don’t know

UniverseText:

Sample children 3+

SkipInstructions:

<1,2,R,D> [goto CBALMOTR]

Page 3 of 7

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Balance
Document Version Date: 23-Aug-11
Question ID:

CBL.030_00.000 Instrument Variable Name:

CBALFALL

QuestionnaireFileName:

Sample Child

*Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, has {fill1: S.C. name} been bothered by episodes of any of the following dizziness or
balance problems?
Frequent falls?
1. Yes
2. No
Refused
Don’t know

UniverseText:

Sample children 3+

SkipInstructions:

<1,2,R,D> [goto CBALPASS]

Question ID:

CBL.035_00.000 Instrument Variable Name:

QuestionText:

CBALPASS

QuestionnaireFileName:

Sample Child

*Read if necessary.
DURING THE PAST 12 MONTHS, has {fill1: S.C. name} been bothered by episodes of any of the following dizziness or
balance problems?
Light-headedness, fainting, or feeling {fill2: he/she} is about to pass out?

1. Yes
2. No
Refused
Don’t know

UniverseText:

Sample children 3+

SkipInstructions:

<1,2,R,D> [goto CBALOTH]

Page 4 of 7

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Balance
Document Version Date: 23-Aug-11
Question ID:

CBL.040_00.000 Instrument Variable Name:

CBALOTH

QuestionnaireFileName:

Sample Child

*Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, has {fill1: S.C. name} been bothered by episodes of any of the following dizziness or
balance problems?
Any other type of balance or dizziness problems?
1. Yes
2. No
Refused
Don’t know

UniverseText:

Sample children 3+

SkipInstructions:

<1,2,R,D> if CBALVRTG=1 or CBALSTED=1 or CBALMOTR=1 or CBALFALL=1 or CBALPASS=1 or
CBALOTH=1 [goto CBALDGHP]; else [goto CAU.CUSUALPL]

Question ID:

CBL.045_00.000 Instrument Variable Name:

QuestionText:

CBALDGHP

QuestionnaireFileName:

Sample Child

Did a doctor or other health professional EVER tell you a diagnosis or reason for {fill1: S.C. name}'s dizziness or balance
problems?

1. Yes
2. No
Refused
Don’t know

UniverseText:

Sample children 3+ who have had episodes of balance or dizziness in the past 12 months

SkipInstructions:

<1> [goto CBALDIGN] <2,R,D> [goto CBALPART]

Page 5 of 7

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Balance
Document Version Date: 23-Aug-11
Question ID:

CBL.050_00.000 Instrument Variable Name:

CBALDIGN

QuestionnaireFileName:

Sample Child

What diagnoses or reasons were you told caused {fill1: S.C. name}'s balance or dizziness problems?

QuestionText:

*Enter all that apply, separate with commas.
1. Ear infections (inner ear infection, otitis media, fluid in
ears)
2. Vision problems/Blurred vision
3. Positional dizziness or vertigo (BPPV)
4. Severe headaches or migraine
5. Head or neck injury or concussion
6. Neurologic disorders including seizures, stroke, or brain
tumors
7. Developmental motor coordination disorder (“clumsy”
child)
8. Malformation of the ear
9. Other genetic cause (Asperger Syndrome, Usher’s
Syndrome, etc.)
10. Metabolic problem, such as “low blood sugar”
(hypoglycemia)
11. Prescription medication or drugs
12. Other

UniverseText:

Sample children 3+ who have ever been told a diagnosis for their balance or dizziness problems

SkipInstructions:

<1-12,R,D> [goto CBALPART]

Question ID:

CBL.055_00.000 Instrument Variable Name:

QuestionText:

CBALPART

QuestionnaireFileName:

Sample Child

Did any of these episodes of dizziness or balance problems keep {fill1: S.C. name} from participating in home, school,
{fill2: work,} or recreational activities?

1. Yes
2. No
Refused
Don’t know

UniverseText:

Sample children 3+ who have had episodes of balance or dizziness in the past 12 months

SkipInstructions:

<1,2,R,D> [goto CBALPROB]

Page 6 of 7

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Balance
Document Version Date: 23-Aug-11
Question ID:

CBL.060_00.000 Instrument Variable Name:

CBALPROB

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, how much of a problem were these episodes of dizziness or imbalance for {fill1:
S.C. name}? Would you say it was...

QuestionText:

*Read categories below.
1. No problem
2. A small problem
3. A moderate problem
4. A big problem
5. A very big problem
Refused
Don't know

UniverseText:

Sample children 3+ who have had episodes of balance or dizziness in the past 12 months

SkipInstructions:

<1-5,R,D> [goto CBALHPYR]

Question ID:

CBL.065_00.000 Instrument Variable Name:

QuestionText:

CBALHPYR

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, has {fill1: S.C name} seen a doctor, physical or occupational therapist, or other
health care professional about these episodes of dizziness or balance problems? Include visits to the Emergency Room,
hospital, or health clinics.

1. Yes
2. No
Refused
Don’t know

UniverseText:

Sample children 3+ who have had episodes of balance or dizziness in the past 12 months

SkipInstructions:

<1,2,R,D> [goto CBALTRET]

Page 7 of 7

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Balance
Document Version Date: 23-Aug-11
Question ID:

CBL.070_00.000 Instrument Variable Name:

QuestionText:

CBALTRET

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, has {fill1: S.C. name} tried methods recommended by a doctor, physical or
occupational therapist, or other health care professional for treating {fill2: his/her} episodes of dizziness or balance
problems?

1. Yes
2. No
Refused
Don’t know

UniverseText:

Sample children 3+ who have had episodes of balance the past 12 months

SkipInstructions:

<1,2,R,D> [goto CAU.CUSUALPL]

Page 1 of 2

DRAFT 2012 NHIS Questionnaire - Sample Adult
ABCs of Heart Disease and Stroke Prevention
Document Version Date: 23-Aug-11
Question ID:

ABC.040_00.010 Instrument Variable Name:

ASPMEDEV

QuestionnaireFileName:

Sample Adult

Has a doctor or other health professional EVER told you to take a low-dose aspirin each day to prevent or control heart
disease?

QuestionText:

* If the respondent volunteers they have been told to take an aspirin every other day or “regularly” for these reasons, enter
1 for “yes.”
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 40+

SkipInstructions:

<1> [goto ASPMEDAD]
<2,R,D> [goto ASPONOWN]

Question ID:

ABC.040_00.020 Instrument Variable Name:

QuestionText:

ASPMEDAD

QuestionnaireFileName:

Sample Adult

Are you NOW following this advice?
* If the respondent provides an answer such as “sometimes,” “occasionally,” or “from time to time,” enter 1 for “yes."

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 40+ who have ever been advised to take a low-dose aspirin every day to prevent or control heart
disease

SkipInstructions:

<1,R,D> [goto AASMEV]
<2> [goto ASPMDMED]

Page 2 of 2

DRAFT 2012 NHIS Questionnaire - Sample Adult
ABCs of Heart Disease and Stroke Prevention
Document Version Date: 23-Aug-11
Question ID:

ABC.040_00.030 Instrument Variable Name:

ASPMDMED

QuestionnaireFileName:

Sample Adult

Did a doctor or other health professional advise you to stop taking a low-dose aspirin every day?

QuestionText:

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 40+ who have ever been advised to take aspirin every day, but are not currently following that advice

SkipInstructions:

goto AASMEV

Question ID:

ABC.040_00.040 Instrument Variable Name:

QuestionText:

ASPONOWN

QuestionnaireFileName:

Sample Adult

On your own, are you now taking a low-dose aspirin each day to prevent or control heart disease?
* If the respondent volunteers they are taking an aspirin every other day or “regularly” for these reasons, enter 1 for “yes.”

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 40+ who have not been advised to take aspirin every day or Ref/DK if they have been advised to
take aspirin every day

SkipInstructions:

goto AASMEV

Page 1 of 1

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date: 24-Aug-11
Question ID:

ACN.035_00.000 Instrument Variable Name:

QuestionText:

COPDEV

QuestionnaireFileName:

Sample Adult

Have you EVER been told by a doctor or other health professional that you had chronic obstructive pulmonary disease,
also called COPD?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto AASMEV]

Page 1 of 3

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Health Behaviors-Tobacco
Document Version Date: 23-Aug-11
Question ID:

AHB.085_00.010 Instrument Variable Name:

OTHCIGEV

QuestionnaireFileName:

Sample Adult

These next questions are about your use of tobacco products OTHER THAN CIGARETTES.

QuestionText:

Tobacco products OTHER THAN CIGARETTES that are smoked include cigars, pipes, water pipes or hookahs, very
small cigars that look like cigarettes, bidis (bee-dees) or cigarillos (cig-a-ril-los).
Have you ever smoked tobacco products other than cigarettes EVEN ONE TIME?
* Do not include electronic cigarettes or e-cigarettes.
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto OTHCIGED]
<2,R,D> [goto SMKLESEV]

Question ID:

AHB.085_00.020 Instrument Variable Name:

QuestionText:

OTHCIGED

QuestionnaireFileName:

Sample Adult

Do you NOW smoke tobacco products other than cigarettes every day, some days, rarely, or not at all?

1. Every day
2. Some days
3. Rarely
4. Not at all
Refused
Don't know

UniverseText:

Sample adults 18+ who have ever smoked tobacco products other than cigarettes

SkipInstructions:

goto SMKLESEV

Page 2 of 3

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Health Behaviors-Tobacco
Document Version Date: 23-Aug-11
Question ID:

AHB.085_00.030 Instrument Variable Name:

SMKLESEV

QuestionnaireFileName:

Sample Adult

Smokeless tobacco products are placed in the mouth or nose and can include chewing tobacco, snuff, dip, snus (snoose),
or dissolvable tobacco.

QuestionText:

Have you ever used smokeless tobacco products EVEN ONE TIME?
* Do not include nicotine replacement therapy products (patch, gum, lozenge, spray), which are considered smoking
cessation treatments.
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto SMKLESED]
<2,R,D> [if SMKEV=1 or OTHCIGEV=1, goto TOBLASYR; else goto VIGNO]

Question ID:

AHB.085_00.040 Instrument Variable Name:

QuestionText:

SMKLESED

QuestionnaireFileName:

Do you NOW use smokeless tobacco products every day, some days, rarely, or not at all?

1. Every day
2. Some days
3. Rarely
4. Not at all
Refused
Don't know

UniverseText:

Sample adults 18+ who have ever used smokeless tobacco products

SkipInstructions:

goto TOBLASYR

Sample Adult

Page 3 of 3

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Health Behaviors-Tobacco
Document Version Date: 23-Aug-11
Question ID:

AHB.085_00.050 Instrument Variable Name:

TOBLASYR

QuestionnaireFileName:

Sample Adult

Around this time last year, were you using ANY KIND of tobacco product?

QuestionText:

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who smoked at least 100 cigarettes in their entire life, ever smoked tobacco products other than
cigarettes, or ever used smokeless tobacco products

SkipInstructions:

<1> [goto TOBQTYR]
<2,R,D> [if SMKNOW in(1,2) or OTHCIGED in(1,2,3) or SMKLESED in(1,2,3), goto TOBQTYR; else goto
VIGNO]

Question ID:

AHB.085_00.060 Instrument Variable Name:

QuestionText:

TOBQTYR

QuestionnaireFileName:

Sample Adult

During the past 12 months, have you stopped using ALL KINDS of tobacco products for more than one day because you
were trying to quit using tobacco?
* “All kinds” means trying to quit using tobacco completely, including smoking cigarettes, smoking products other than
cigarettes, and using smokeless tobacco products.

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who were using tobacco products around this time last year or were current users of any
tobacco products (cigarettes, non-cigarette tobacco, or smokeless)

SkipInstructions:

[goto VIGNO]

Page 1 of 2

DRAFT 2012 NHIS Questionnaire - Sample Adult
Immunization Pregnancy Questions
Document Version Date: 23-Aug-11
Question ID:

PRG.310_00.010 Instrument Variable Name:

PREGFLYR

QuestionnaireFileName:

Sample Adult

[Fill1: Were you pregnant any time since August 1st, 2011?/Were you pregnant any time from August 2011 through
March 2012?/Were you pregnant any time since August 1st, 2012?]

QuestionText:

1. Yes
2. No
Refused
Don't know

UniverseText:

Female sample adults 18-49 years of age who are not currently pregnant or who don't know if they are currently
pregnant or who are currently pregnant and interviewed April-July

SkipInstructions:

<1,2,R,D> [goto MENSYR]

Question ID:

PRG.313_00.000 Instrument Variable Name:

QuestionText:

FLUSHPG1

QuestionnaireFileName:

Sample Adult

Did you get a flu shot before or during your current pregnancy?

1. Before this pregnancy
2. During this pregnancy
Refused
Don't know

UniverseText:

Female sample adults 18-49 who are currently pregnant and are interviewed January-March or August-December
and received a flu shot in the past year

SkipInstructions:

<1,2,R,D> [goto SPRFLUYR]

Page 2 of 2

DRAFT 2012 NHIS Questionnaire - Sample Adult
Immunization Pregnancy Questions
Document Version Date: 23-Aug-11
Question ID:

PRG.314_00.000 Instrument Variable Name:

QuestionText:

FLUSHPG2

QuestionnaireFileName:

Sample Adult

[Fill1: Earlier you said you were pregnant sometime since August 1st, 2011. Did you get a flu shot before, during or after
this pregnancy?/
Earlier you said you were pregnant sometime between August 2011 and March 2012. Did you get a flu shot before,
during or after this pregnancy?/
Earlier you said you were pregnant sometime between August 2011 and March 2012. Did you get a flu shot before,
during or after this pregnancy?/
Earlier you said you were pregnant sometime since August 1st, 2012. Did you get a flu shot before, during or after this
pregnancy?]

1. Before this pregnancy
2. During this pregnancy
3. After this pregnancy
Refused
Don't know

UniverseText:

Female sample adults 18-49 who are currently pregnant and were interviewed April-July or who have been
determined to be pregnant at a specific point in the past year and received a flu shot in the past year

SkipInstructions:

<1-3,R,D> [goto SPRFLUYR]

Page 1 of 4

DRAFT 2012 NHIS Questionnaire - Sample Adult
Internet and Email Usage
Document Version Date: 23-Aug-11
Question ID:

AWB.010_00.000 Instrument Variable Name:

AWEBUSE

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

The next questions are about your Internet and email use.

QuestionText:

Do you use the Internet?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto AWEBOFNO] <2,R,D> [goto AWEBEML]

Question ID:

AWB.020_01.000 Instrument Variable Name:

QuestionText:

AWEBOFNO

1 of 2
How often do you use the internet?
*Read if necessary: How many times per week, per month, or per year do you use the Internet?
*Enter number.

Allow 1-995,R,D

UniverseText:

Sample adults 18+ who use the Internet

SkipInstructions:

<1-995> [goto AWEBOFTP] [goto AWEBEML]

Page 2 of 4

DRAFT 2012 NHIS Questionnaire - Sample Adult
Internet and Email Usage
Document Version Date: 23-Aug-11
Question ID:

AWB.020_02.000 Instrument Variable Name:

AWEBOFTP

QuestionnaireFileName:

Sample Adult

2 of 2

QuestionText:

*Enter time period for how often Internet is used.
1. Per week
2. Per month
3. Per year
Refused
Don't know

UniverseText:

Sample adults 18+ who use the Internet and gave a valid value for the number portion of this question

SkipInstructions:

<1-3,R,D> [goto AWEBEML]

Question ID:

AWB.030_00.000 Instrument Variable Name:

QuestionText:

AWEBEML

QuestionnaireFileName:

Do you send or receive emails?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto AWEBEMAD] <2,R,D> [goto Back or Recontact section]

Sample Adult

Page 3 of 4

DRAFT 2012 NHIS Questionnaire - Sample Adult
Internet and Email Usage
Document Version Date: 23-Aug-11
Question ID:

AWB.040_00.000 Instrument Variable Name:

AWEBEMAD

QuestionnaireFileName:

Sample Adult

We may want to contact you to obtain additional health-related information.

QuestionText:

May I have your email address?
*Enter email address.
*Enter 'N' for none.

UniverseText:

Sample adults 18+ who send or receive email

SkipInstructions:

[goto AWBEMNO] [goto Back or Recontact section]

Question ID:

AWB.050_01.000 Instrument Variable Name:

QuestionText:

AWBEMNO

QuestionnaireFileName:

Sample Adult

1 of 2
How often do you check this email account?
*Read if necessary: How many times per week, per month, or per year do you check this email account?
*Enter number.

Allow 1-995,R,D

UniverseText:

Sample adults 18+ who gave an email address

SkipInstructions:

<1-995> [goto AWBEMTP] [goto Back or Recontact section]

Page 4 of 4

DRAFT 2012 NHIS Questionnaire - Sample Adult
Internet and Email Usage
Document Version Date: 23-Aug-11
Question ID:

AWB.050_02.000 Instrument Variable Name:

QuestionText:

AWBEMTP

QuestionnaireFileName:

Sample Adult

2 of 2
*Enter time period for how often email is checked.

1. Per week
2. Per month
3. Per year
Refused
Don't know

UniverseText:

Sample adults 18+ who gave an email address and gave a valid value for the number portion of this question

SkipInstructions:

<1-3,R,D> [goto Back or Recontact section]

Page 1 of 14

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Health Status & Limitations-Added CAM Conditions
Document Version Date: 26-Aug-11
Question ID:

CHS.105_00.010 Instrument Variable Name:

CHPYR

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, has a doctor or other health professional told you that [fill1: S.C. name] had

QuestionText:

…Hypertension, also called high blood pressure?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 6+

SkipInstructions:

<1> [goto CHYPMED] <2,R,D> [goto CCHLYR]

Question ID:

CHS.105_00.020 Instrument Variable Name:

CHYPMED

QuestionnaireFileName:

Sample Child

Does [fill: S.C. name] take prescription medication to control [fill2: his/her] blood pressure?

QuestionText:

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 6+ who were ever told they had hypertension

SkipInstructions:

<1,2,R,D> [goto CCHLYR]

Question ID:

CHS.105_00.030 Instrument Variable Name:

QuestionText:

CCHLYR

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, has a doctor or other health professional told you that [fill1: S.C. name] had
…High cholesterol?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 6+

SkipInstructions:

<1,2,R,D> [goto CFLUPNYR]

Page 2 of 14

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Health Status & Limitations-Added CAM Conditions
Document Version Date: 26-Aug-11
Question ID:

CHS.106_00.010 Instrument Variable Name:

CFLUPNYR

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, has a doctor or other health professional told you that [fill1: S.C. name] had

QuestionText:

…Influenza or pneumonia?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 4+

SkipInstructions:

<1,2,R,D> [goto CCONMED]

Question ID:

CHS.106_00.020 Instrument Variable Name:

QuestionText:

CCONMED

QuestionnaireFileName:

Sample Child

* Read if necessary.
DURING THE PAST 12 MONTHS, has a doctor or other health professional told you that [fill1: S.C. name] had
…Constipation severe enough to require medication?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 4+

SkipInstructions:

<1,2,R,D> [goto CSINYR]

Page 3 of 14

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Health Status & Limitations-Added CAM Conditions
Document Version Date: 26-Aug-11
Question ID:

CHS.106_00.030 Instrument Variable Name:

CSINYR

QuestionnaireFileName:

Sample Child

* Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, has a doctor or other health professional told you that [fill1: S.C. name] had
…Sinusitis?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 4+

SkipInstructions:

<1,2,R,D> [goto CSTREPYR]

Question ID:

CHS.106_00.040 Instrument Variable Name:

QuestionText:

CSTREPYR

QuestionnaireFileName:

Sample Child

* Read if necessary.
DURING THE PAST 12 MONTHS, has a doctor or other health professional told you that [fill1: S.C. name] had
…Strep throat or tonsillitis?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 4+

SkipInstructions:

<1,2,R,D> [goto CCONDT_1]

Page 4 of 14

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Health Status & Limitations-Added CAM Conditions
Document Version Date: 26-Aug-11
Question ID:

CHS.120_00.010 Instrument Variable Name:

CHEADYR

QuestionnaireFileName:

Sample Child

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, has [fill1: S.C name] had

QuestionText:

…Recurring headache, other than migraine?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 6+

SkipInstructions:

<1,2,R,D> [goto CABDOMYR]

Question ID:

CHS.120_00.020 Instrument Variable Name:

QuestionText:

CABDOMYR

*Read if necessary.
DURING THE PAST 12 MONTHS, has [fill1: S.C name] had
…Abdominal pain?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 6+

SkipInstructions:

<1,2,R,D> [goto CJNTSYMP]

Page 5 of 14

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Health Status & Limitations-Added CAM Conditions
Document Version Date: 26-Aug-11
Question ID:

CHS.120_00.030 Instrument Variable Name:

CJNTSYMP

QuestionnaireFileName:

Sample Child

DURING THE PAST 30 DAYS, has [fill1: S.C. name] had any symptoms of pain, aching, or stiffness in or around a joint?

QuestionText:

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 6+

SkipInstructions:

<1,2,R,D> [goto CPAINECK]

Question ID:

CHS.120_00.040 Instrument Variable Name:

QuestionText:

CPAINECK

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill1: S.C name] had
…Neck pain?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 6+

SkipInstructions:

<1,2,R,D> [goto CPAINLB]

QuestionnaireFileName:

Sample Child

Page 6 of 14

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Health Status & Limitations-Added CAM Conditions
Document Version Date: 26-Aug-11
Question ID:

CHS.120_00.050 Instrument Variable Name:

CPAINLB

QuestionnaireFileName:

Sample Child

QuestionnaireFileName:

Sample Child

* Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, has [fill1: S.C name] had
…Low back pain?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 6+

SkipInstructions:

<1,2,R,D> [goto CMUSCLYR]

Question ID:

CHS.120_00.060 Instrument Variable Name:

QuestionText:

CMUSCLYR

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill1: S.C name] had
…Other muscle or bone pain?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 6+

SkipInstructions:

<1,2,R,D> [goto CSPNYR]

Page 7 of 14

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Health Status & Limitations-Added CAM Conditions
Document Version Date: 26-Aug-11
Question ID:

CHS.120_00.070 Instrument Variable Name:

CSPNYR

QuestionnaireFileName:

Sample Child

QuestionnaireFileName:

Sample Child

* Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, has [fill1: S.C name] had
…Any severe sprains or strains?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 6+

SkipInstructions:

<1,2,R,D> [goto CDENYR]

Question ID:

CHS.120_00.080 Instrument Variable Name:

QuestionText:

CDENYR

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill1: S.C name] had
…Dental pain?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 6+

SkipInstructions:

<1,2,R,D> [goto CPNOTHYR]

Page 8 of 14

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Health Status & Limitations-Added CAM Conditions
Document Version Date: 26-Aug-11
Question ID:

CHS.120_00.090 Instrument Variable Name:

CPNOTHYR

QuestionnaireFileName:

Sample Child

QuestionnaireFileName:

Sample Child

* Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, has [fill1: S.C name] had
…Other chronic pain?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 6+

SkipInstructions:

<1,2,R,D> [goto COVRWTYR]

Question ID:

CHS.120_00.100 Instrument Variable Name:

QuestionText:

COVRWTYR

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill1: S.C name] had
…Problems with being overweight?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 6+

SkipInstructions:

<1,2,R,D> [goto CTHOTHYR]

Page 9 of 14

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Health Status & Limitations-Added CAM Conditions
Document Version Date: 26-Aug-11
Question ID:

CHS.125_00.010 Instrument Variable Name:

CTHOTHYR

QuestionnaireFileName:

Sample Child

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, has [fill1: S.C name] had

QuestionText:

…Sore throat other than strep or tonsillitis?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 4+

SkipInstructions:

<1,2,R,D> [goto CFEVRYR]

Question ID:

CHS.125_00.020 Instrument Variable Name:

QuestionText:

CFEVRYR

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill1: S.C name] had
…Fever more than 1 day?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 4+

SkipInstructions:

<1,2,R,D> [goto CCOLDYR]

Page 10 of 14

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Health Status & Limitations-Added CAM Conditions
Document Version Date: 26-Aug-11
Question ID:

CHS.125_00.030 Instrument Variable Name:

CCOLDYR

QuestionnaireFileName:

Sample Child

QuestionnaireFileName:

Sample Child

* Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, has [fill1: S.C name] had
…A head or chest cold?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 4+

SkipInstructions:

<1,2,R,D> [goto CNAUSYR]

Question ID:

CHS.125_00.040 Instrument Variable Name:

QuestionText:

CNAUSYR

* Read if necessary.
DURING THE PAST 12 MONTHS, has [fill1: S.C name] had
…Nausea and/or vomiting?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 4+

SkipInstructions:

<1,2,R,D> [goto CFATIGYR]

Page 11 of 14

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Health Status & Limitations-Added CAM Conditions
Document Version Date: 26-Aug-11
Question ID:

CHS.125_00.050 Instrument Variable Name:

CFATIGYR

QuestionnaireFileName:

Sample Child

QuestionnaireFileName:

Sample Child

* Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, has [fill1: S.C name] had
…Fatigue or lack of energy more than 3 days?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 4+

SkipInstructions:

<1,2,R,D> [goto CFATYR]

Question ID:

CHS.125_00.060 Instrument Variable Name:

QuestionText:

CFATYR

DURING THE PAST 12 MONTHS, has [fill1: S.C name]
…Regularly had excessive sleepiness during the day?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 4+

SkipInstructions:

<1,2,R,D> [goto CINSYR]

Page 12 of 14

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Health Status & Limitations-Added CAM Conditions
Document Version Date: 26-Aug-11
Question ID:

CHS.125_00.070 Instrument Variable Name:

CINSYR

QuestionnaireFileName:

Sample Child

QuestionnaireFileName:

Sample Child

DURING THE PAST 12 MONTHS, has [fill1: S.C name]

QuestionText:

…Regularly had insomnia or trouble sleeping?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 4+

SkipInstructions:

<1,2,R,D> [goto CHSTATYR]

Question ID:

CHS.370_00.010 Instrument Variable Name:

CDEPRSYR

DURING THE PAST 12 MONTHS, has a doctor or other health professional told you that [fill1: S.C. name] had

QuestionText:

…Depression?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 6+

SkipInstructions:

<1,2,R,D> [goto CANXNWYR]

Question ID:

CHS.370_00.020 Instrument Variable Name:

QuestionText:

CANXNWYR

DURING THE PAST 12 MONTHS, has [fill1: S.C name]
…Frequently felt anxious, nervous, or worried?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 6+

SkipInstructions:

<1,2,R,D> [goto CSTRESYR]

QuestionnaireFileName:

Sample Child

Page 13 of 14

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Health Status & Limitations-Added CAM Conditions
Document Version Date: 26-Aug-11
Question ID:

CHS.370_00.030 Instrument Variable Name:

CSTRESYR

QuestionnaireFileName:

Sample Child

* Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, has [fill1: S.C name]
…Frequently felt stressed?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample children 6+

SkipInstructions:

<1,2,R,D> if SEX=2 and AGE GE 10 [goto MENSTYR]; else [goto next section]

Question ID:

CHS.375_00.010 Instrument Variable Name:

QuestionText:

MENSTYR

QuestionnaireFileName:

DURING THE PAST 12 MONTHS, has [fill1: S.C name] had
…Menstrual problems such as heavy bleeding, bothersome cramping, or premenstrual syndrome (
also called PMS)?

1. Yes
2. No
Refused
Don't know

UniverseText:

Female sample children 10+

SkipInstructions:

<1,2,R,D> [goto CGYNYR]

Sample Child

Page 14 of 14

DRAFT 2012 NHIS Questionnaire - Sample Child
Child Health Status & Limitations-Added CAM Conditions
Document Version Date: 26-Aug-11
Question ID:

CHS.375_00.020 Instrument Variable Name:

QuestionText:

CGYNYR

DURING THE PAST 12 MONTHS, has [fill1: S.C name] had
…Gynecologic problems such as vaginal infection?

1. Yes
2. No
Refused
Don't know

UniverseText:

Female sample children 10+

SkipInstructions:

<1,2,R,D> [goto next section]

QuestionnaireFileName:

Sample Child

Sample Child Complementary and Alternative Medicine Supplement

[NOTE: ENTIRE CHILD CAM SUPPLEMENT for CHILDREN 4+ ONLY]
CAM.1
A personal health care provider is a health professional who knows [fill: S.C. name] well and is
familiar with [fill: his/her] health history. This can be a general doctor, a specialist doctor, a nurse
practitioner, a physician’s assistant, or another type of provider. Do you have one or more persons
you think of as [fill S.C. name]'s personal health care provider?
(1) Yes (CAM.2)
(2) No (CAM.3)
(7) Refused (CAM.3)
(9) Don’t know (CAM.3)
CAM.2
What type of provider(s) is it?
*Enter all that apply, separate with commas.
(1) Medical doctor (M.D., D.O.) including specialists
(2) Nurse, Nurse Practitioner, or Physician Assistant
(3) Chiropractor, Acupuncturist, or Naturopath
(4) Other
(7) Refused
(9) Don’t know
[ask for respondents who have place for sick care from core questionnaire]
CAM.3
Earlier you said [fill: S.C. name] has a place where [fill: he/she] usually goes when [fill: he/she]
is sick. What type of provider(s) does [fill: he/she] see there?
*Enter all that apply, separate with commas.
(1) Medical doctor (M.D., D.O.) including specialists
(2) Nurse, Nurse Practitioner, or Physician Assistant
(3) Chiropractor, Acupuncturist, or Naturopath
(4) Other
(7) Refused
(9) Don’t know
[ask for respondents who have different routine place than sick place or only have sick
place from core questionnaire]
CAM.4
Earlier you said [fill: S.C. name] has a place where [fill: he/she] usually goes when [fill: he/she]
needs routine care. What type of provider(s) does [fill: he/she] see there?
*Enter all that apply, separate with commas.
1

(1) Medical doctor (M.D., D.O.) including specialists
(2) Nurse, Nurse Practitioner, or Physician Assistant
(3) Chiropractor, Acupuncturist, or Naturopath
(4) Other
(7) Refused
(9) Don’t know
Now I am going to ask you about some health services [Fill: S.C. name] may have used.
PRT.1
Has [fill: S.C. name] EVER used any of the following therapies for [fill: his/her] health?
(1) Chiropractic (kye-row-PRAK-tik) or Osteopathic Manipulation
(2) Massage
(3) Acupuncture
(4) Energy Healing Therapy
(5) Naturopathy (nay-chur-AH-puh-thee)
(6) Hypnosis
(7) Biofeedback
(8) Ayurveda
(9) Chelation (key-LAY-shun) Therapy
(10) Craniosacral (krey-nee-oh-SEY-kruhl)Therapy
(97) Refused
(99) Don’t know

yes
yes
yes
yes
yes
yes
yes
yes
yes
yes

no
no
no
no
no
no
no
no
no
no

[IF NO TO ALL, GO TO Traditional healers]
[ask for any yes responses to PRT.1]
PRT.2
Has [fill: S.C. name]’s EVER seen a provider or practitioner for any of the following therapies
for [fill: himself/herself]?
(1) Chiropractic (kye-row-PRAK-tik) or Osteopathic Manipulation
(2) Massage
(3) Acupuncture
(4) Energy Healing Therapy
(5) Naturopathy (nay-chur-AH-puh-thee)
(6) Hypnosis
(7) Biofeedback
(8) Ayurveda
(9) Chelation (key-LAY-shun) Therapy
(10) Craniosacral (krey-nee-oh-SEY-kruhl)Therapy
(97) Refused
(99) Don’t know

yes
yes
yes
yes
yes
yes
yes
yes
yes
yes

no
no
no
no
no
no
no
no
no
no

[if any yes responses ask PRT.3 for each, else goto PRT.4 for all no responses or all Ref/DK]
PRT.3
DURING THE PAST 12 MONTHS, did [fill: S.C. name] see a practitioner for [fill: modality]?

2

(1) Yes (ALL.1 or CHI.1 or HYP.1 or BIO.1)
(2) No (PRT.4)
(7) Refused (PRT.4)
(9) Don’t know (PRT.4)

PRT.4
DURING THE PAST 12 MONTHS, did [fill: S.C. name] use [fill: modality]?
(1) Yes (for biofeedback and hypnosis goto ALL.10, else goto TRD.1)
(2) No (TRD.1)
(7) Refused (TRD.1)
(9) Don’t know (TRD.1)
[cycle through ALL.1 through ALL.11 for all modalities for which Sample Child has seen a
practitioner in past 12 months]
TRD.1
Flashcard CAM1
Has [fill: S.C. name] ever seen any of the following traditional healers?
Native American Healer/Medicine Man
Shaman (SHAH-man)
Curandero (coo-rahn-DEHR-oh), Machi (MAH-chee), or Parchero (pahr-CHEH-roh)
Yerbero (yehr-BEH-roh) or Hierbista (yehr-BEE-stah)
Sobador (so-bah-DOHR)
Huesero (weh-SEHR-oh)
(1) Yes (TRD.1a)
(2) No (VIT.1)
(7) Refused (VIT.1)
(9) Don’t know (VIT.1)
TRD.1a
Which ones?
(1) Native American Healer/Medicine Man
(2) Shaman (SHAH-man)
(3) Curandero (coo-rahn-DEHR-oh), Machi (MAH-chee), or Parchero (pahr-CHEH-roh)
(4) Yerbero (yehr-BEH-roh) or Hierbista (yehr-BEE-stah)
(5) Sobador (so-bah-DOHR)
(6) Huesero (weh-SEHR-oh)
(7) Refused
(9) Don’t know
Cycle through TRD.2 for each yes in TRD.1a
TRD.2
DURING THE PAST 12 MONTHS, did [fill: S.C. name] see [fill: each traditional healer
mentioned in TRD.1a]?
3

(1) Yes (ALL.1)
(2) No to all (VIT.1)
(7) Refused (VIT.1)
(9) Don’t know (VIT.1)
[use “traditional healers” as fill for remaining questions ALL.1 – ALL.11]
Now I am going to ask you about some health services [fill: S.C. name] may have used. The
first practice I’ll ask about is vitamins and minerals. These are pills, capsules, tablets, or
liquids that have been labeled as a VITAMIN OR MINERAL SUPPLEMENT. I’ll ask
about herbs or other non-vitamin supplements next.
VIT.1
Has [fill: S.C. name] EVER taken Multi-vitamins or Multi-minerals?
(1) Yes (VIT.2)
(2) No (VIT.3)
(7) Refused (VIT.3)
(9) Don’t know (VIT.3)
VIT.2
DURING THE PAST 12 MONTHS, did [fill: S.C. name] take Multi-vitamins or Multi-minerals?
(1) Yes
(2) No
(7) Refused
(9) Don’t know
VIT.3
[Fill: Other than in a multi-vitamin or mineral] Has [fill: S.C. name] ever taken vitamins
A,B,C,D,E,H or K?
(1) Yes (VIT.4)
(2) No (VIT.5)
(7) Refused (VIT.5)
(9) Don’t know (VIT.5)
VIT.4
DURING THE PAST 12 MONTHS, did [fill: S.C. name] take vitamins A,B,C,D,E,H or K?
(1) Yes
(2) No
(7) Refused
(9) Don’t know
VIT.5
[Fill: Other than in a multi-vitamin or mineral] Has [fill: S.C. name] ever taken calcium,
magnesium, iron, chromium, zinc, selenium, or potassium?
(1) Yes (VIT.6)
4

(2) No (HRB.1)
(7) Refused (HRB.1)
(9) Don’t know (HRB.1)
VIT.6
DURING THE PAST 12 MONTHS, did [fill: S.C. name] take calcium, magnesium, iron,
chromium, zinc, selenium, or potassium?
(1) Yes
(2) No
(7) Refused
(9) Don’t know
Herbs or other non-vitamin supplements are pills, capsules, tablets, or liquids that have
been labeled as a DIETARY SUPPLEMENT. This does NOT include vitamin or mineral
supplements, homeopathic treatments, or drinking herbal or green teas.
HRB.1

Flashcard CAM2

Has [fill: S.C. name] EVER taken any herbal or other non-vitamin supplements listed on this card
for [fill: himself/herself]?
*Tinctures are included.
Combination herb pill
Acai (pills, gelcaps)
Bee Pollen and other Bee products
Chondroitin
Co-enzyme Q10 (CoQ10)
Cranberry (pills or capsules)
Digestive Enzymes (lactaid)
Echinacea
Fish Oil or omega 3 or DHA fatty acid or EPA fatty acid supplements
Garlic supplements (pills, gelcaps)
Ginkgo Biloba
Ginseng
Glucosamine
Green tea pills (not brewed tea) or EGCG (pills)
Melatonin
Milk Thistle (silymarin)
MSM (Methylsulfonylmethane)
Probiotics or Prebiotics
SAM-e
Saw Palmetto
Valerian
Other herbs or non-vitamin supplements
(1) Yes (HRB.1a)
(2) No (if vitamins taken goto VITB.1a; else go to HOM.1)
(7) Refused (if vitamins taken goto VITB.1a; else go to HOM.1)
(9) Don’t know (if vitamins taken goto VITB.1a; else go to HOM.1)
5

HRB.1a

Flashcard CAM2

DURING THE PAST 12 MONTHS, has [fill: S.C. name] taken any herbal or other non-vitamin
supplements listed on this card for [fill: himself/herself]?
(1) Yes (HRB.1b)
(2) No (if vitamins taken in past 12 months go to VITB.1a; else go to HOM.1)
(7) Refused (if vitamins taken in past 12 months goto VITB.1a; else go to HOM.1)
(9) Don’t know (if vitamins taken in past 12 months goto VITB.1a; else go to HOM.1)

HRB.1b

Flashcard CAM2

Please tell me which of these supplements [fill: S.C. name] has taken DURING THE PAST 12
MONTHS? If [fill: he/she] took more than one herb in a single supplement, select "combination
herb pill."
*Enter all that apply, separate with commas.
(1) Combination herb pill
(2) Acai (pills, gelcaps)
(3) Bee Pollen and other Bee products
(4) Chondroitin
(5) Co-enzyme Q10 (CoQ10)
(6) Cranberry (pills or capsules)
(7) Digestive Enzymes (lactaid)
(8) Echinacea
(9) Fish Oil or omega 3 or DHA fatty acid or EPA fatty acid supplements
(10) Garlic supplements (pills, gelcaps)
(11) Ginkgo Biloba
(12) Ginseng
(13) Glucosamine
(14) Green tea pills (not brewed tea) or EGCG (pills)
(15) Melatonin
(16) Milk Thistle (silymarin)
(17) MSM (Methylsulfonylmethane)
(18) Probiotics or Prebiotics
(19) SAM-e
(20) Saw Palmetto
(21) Valerian
(22) Other herbs or non-vitamin supplements
(97) Refused
(99) Don't know

HRB.1c

Flashcard CAM2

Did [fill: S.C. name] take any of these DURING THE PAST 30 DAYS?
(1) Yes (HRB.1d)
6

(2) No (HRB.3)
(7) Refused (HRB.3)
(9) Don’t know (HRB.3)
HRB.1d

Flashcard CAM2

Which of these supplements has [fill: S.C. name] taken DURING THE PAST 30 DAYS? If [fill:
he/she] took more than one herb in a single supplement, select "combination herb pill."
*Enter all that apply, separate with commas.
(1) Combination herb pill
(2) Acai (pills, gelcaps)
(3) Bee Pollen and other Bee products
(4) Chondroitin
(5) Co-enzyme Q10 (CoQ10)
(6) Cranberry (pills or capsules)
(7) Digestive Enzymes (lactaid)
(8) Echinacea
(9) Fish Oil or omega 3 or DHA fatty acid or EPA fatty acid supplements
(10) Garlic supplements (pills, gelcaps)
(11) Ginkgo Biloba
(12) Ginseng
(13) Glucosamine
(14) Green tea pills (not brewed tea) or EGCG (pills)
(15) Melatonin
(16) Milk Thistle (silymarin)
(17) MSM (Methylsulfonylmethane)
(18) Probiotics or Prebiotics
(19) SAM-e
(20) Saw Palmetto
(21) Valerian
(22) Other herbs or non-vitamin supplements
(97) Refused
(99) Don't know
if combination herb pill chosen:
HRB.1e
How many different "combination herb pills" did [fill: S.C. name] take?
___1-50
(97) Refused
(99) Don’t know
HRB.1f and 1g:
Ask for up to 2 combination herb pills:
Which herbs or other non-vitamin supplements are included in the combination herb pill or pills?
7

Select from CAM2 card (1-22)
HRB.1e
If “other” herb or non-vitamin supplement selected from HRB.1d go to lookup table with
approximately 100 herbs not on flashcard (see Appendix I at end of this document for herb
lookup table list)

How many other herbs or non-vitamin supplements has [fill: S.C. name] taken in the past 30
days?
___1-50
(97) Refused
(99) Don’t know
(Collect specific names of up to two most important from lookup table)
HRB.2
[if more than 2 herbs chosen from any source]:
Which TWO of these herbal supplements did [fill: S.C. name] take the most in the PAST 30
DAYS?
*Enter two answers, separate with commas.
*If SC respondent cannot choose two herbs used most often, probe for the two most important for
health.
(1) Combination herb pill
(2) Acai (pills, gelcaps)
(3) Bee Pollen and other Bee products
(4) Chondroitin
(5) Co-enzyme Q10 (CoQ10)
(6) Cranberry (pills or capsules)
(7) Digestive Enzymes (lactaid)
(8) Echinacea
(9) Fish Oil or omega 3 or DHA fatty acid or EPA fatty acid supplements
(10) Garlic supplements (pills, gelcaps)
(11) Ginkgo Biloba
(12) Ginseng
(13) Glucosamine
(14) Green tea pills (not brewed tea) or EGCG (pills)
(15) Melatonin
(16) Milk Thistle (silymarin)
(17) MSM (Methylsulfonylmethane)
(18) Probiotics or Prebiotics
(19) SAM-e
(20) Saw Palmetto
8

(21) Valerian
(22) Second combination herb pill
(23) {First herb from lookup table}
(24) {Second herb from lookup table}
(97) Refused
(99) Don't know
HRB.3
Has [fill: S.C. name] EVER seen a practitioner for herbs or other non-vitamin supplements?
(1) Yes (HRB.4)
(2) No (ALL.10)
(7) Refused (ALL.10
(9) Don’t know (ALL.10

HRB.4
DURING THE PAST 12 MONTHS, did [fill: S.C. name] see a practitioner for herbs or other
non-vitamin supplements?
(1) Yes
(2) No
(7) Refused
(9) Don’t know

[ask for respondents who have taken vitamins in past 12 months]
VITB.1a
Now I am going to ask you about how much you spend on [fill1: vitamins and
minerals./vitamin and minerals, and herbs or other non-vitamin supplements for [fill: S.C. name].
First I will ask about vitamins and minerals and then about herbs or other non-vitamin
supplements.]
About how many times per week, month, or year do you or another family member buy vitamins
and minerals for [fill: S.C. name]?
*Enter number.
*Enter '0' if vitamins or minerals are not bought.

______ times per

VITB.1b

9

week/month/year

About how much did you or another family member spend the last time you bought vitamins or
minerals for [fill: S.C. name]?
*Enter '0' for none.
$ __________________
$0-$1000

*Enter 1000 for $1000 or more

[ask for respondents who have taken herbs or other non-vitamin supplements in past 12
months]
HRBB.1a
Now I am going to ask you about how much you spend on herbs or other non-vitamin
supplements for [fill: S.C. name].
About how many times per week, month, or year do you or another family member buy herbs or
other non-vitamin supplements for [fill: S.C. name]?
*Enter number.
*Enter '0' if herbs or non-vitamin supplements are not bought.
______ times per

week/month/year

HRBB.1b
About how much did you or another family member spend the last time you bought herbs or other
non-vitamin supplements for [fill: S.C. name]?
*Enter '0' for none.
$ __________________
$0-$1000

*Enter 1000 for $1000 or more

[if HRB.4 = “1” cycle through ALL.1-ALL.11; else only else ALL.10-11]

People who use homeopathy to treat health problems take small pills or drops that are often
placed under the tongue. They may be labeled as homeopathic remedies or medicine and
they may be prescribed by practitioners of homeopathy.
HOM.1
Has [fill: S.C. name] EVER used homeopathic treatment for [fill: his/her] health?
10

(1) Yes (next question)
(2) No (go to next modality)
(7) Refused (go to next modality)
(9) Don’t know (go to next modality)
HOM.2
DURING THE PAST 12 MONTHS, did [fill: S.C. name] use homeopathic treatment for [fill:
his/her] health?
(1) Yes (next question)
(2) No (go to next modality)
(7) Refused (go to next modality)
(9) Don’t know (go to next modality)
HOM.3
About how many days per week, month, or year do you or another family member buy
homeopathic medicine for [fill: S.C. name]?
______ days per

week/month/year

HOM.4
On average, how much do you or another family member spend each time you buy homeopathic
medicine for [fill: S.C. name]?
$ __________________
$0-$1000

*Enter 1000 for $1000 or more

Read if necessary: this does not include herbals or vitamins or minerals.

HOM.5
Has [fill: S.C. name] EVER seen a practitioner for homeopathic treatment?
(1) Yes
(2) No (ALL.10)
(7) Refused (ALL.10)
(9) Don’t know (ALL.10)

HOM.6
DURING THE PAST 12 MONTHS, did [fill: S.C. name] see a practitioner for homeopathic
treatment?

11

(1) Yes (ALL.1)
(2) No (ALL.10)
(7) Refused (ALL.10)
(9) Don’t know (ALL.10)

MBO.1
Has [fill: S.C. name] EVER used meditation, guided imagery, or progressive relaxation?
(1) Yes (goto MBO.2)
(2) No (go to next modality)
(7) Refused (go to next modality)
(9) Don’t know (go to next modality)

MBO.2
Has [fill: S.C. name] EVER used any of the following for [fill: his/her] own health or treatment?
Yes/No/Ref/DK
(1) Mantra Meditation, including Transcendental Meditation®, Relaxation Response, and
Clinically Standardized Meditation?
(2) Mindfulness meditation, including Vipassana (vih-PAS-sah-nah), Zen Buddhist meditation,
Mindfulness-based Stress Reduction, and Mindfulness-based Cognitive Therapy?
(3) Spiritual meditation including Centering Prayer and Contemplative Meditation?
(4) Guided imagery
(5) Progressive relaxation
[if no to all, skip to next modality]
[ Cycle through for every yes in MBO.1]
MBO.3
DURING THE PAST 12 MONTHS, did [fill: S.C. name] use [methods in MBO.2]?
(1) Yes
(2) No to all(go to next modality)
(7) Refused (go to next modality)
(9) Don’t know (go to next modality)
[IF MORE THAN ONE YES in MBO.3, ASK MBO.4; ELSE GO TO MBO.5]
MBO.4
DURING THE PAST 12 MONTHS, which of these did [fill: S.C. name] use the most:
{fill techniques from MBO. 3}?
_____________________ [TECHNIQUE]

12

MBO.5
Did [fill: S.C. name] do breathing exercises as part of {mind-body technique used the most}?
(1) Yes
(2) No
(7) Refused
(9) Don’t know

MBO.6
DURING THE PAST 12 MONTHS, did [fill: S.C. name] see a practitioner or take a class for
{mind-body technique used the most}?
(1) Yes (ALL.1)
(2) No (ALL.10)
(7) Refused (ALL.10)
(9) Don’t know (ALL.10)

YOG.1
Has [fill: S.C. name] EVER practiced any of the following?
(1) Yoga
(2) Tai Chi (TIE-CHEE)
(3) Qi Gong (CHEE-KUNG)

Yes
Yes
Yes

No,Ref/DK
No,Ref/DK
No,Ref/DK

[IF NO TO ALL, GO TO NEXT MODALITY]
[Cycle through for each yes answer in YOG.1]
YOG.2
DURING THE PAST 12 MONTHS, did [fill: S.C. name] practice [fill: exercise mentioned in
YOG.1] ?
(1) Yes
(2) No to all (go to next modality)
(7) Refused (go to next modality)
(9) Don’t know (go to next modality

[cycle through each yes in YOG.2]
YOG.3
Do you know whether [fill: S.C. name] did breathing exercises as part of [fill: type of exercise]?
Breathing exercises may involve actively controlling the way air is drawn in, or the rate or depth
of breathing.

13

(1) Yes
(2) No
(7) Refused
(9) Don’t know

[cycle through each yes in YOG.2]
YOG.4
Did [fill: S.C. name] do meditation as part of [fill: type of exercise]?
(1) Yes
(2) No
(7) Refused
(9) Don’t know
[If no to both YOG.3 and YOG.4 for all possible exercises skip to next modality]
[ask if more than one exercise mentioned in YOG.2]
YOG.5
DURING THE PAST 12 MONTHS, which exercise [fill from yes answers to YOG.2] did [fill:
S.C. name] practice the most?
__________________[EXERCISE]
YOG.6
DURING THE PAST 12 MONTHS, [fill: S.C. name] take a [fill: type of exercise] class or in
some way receive formal training? Attending only one session does not count.
(1) Yes (cycle through ALL.1 through ALL.11)
(2) No (cycle through ALL.10 through ALL.11)
(7) Refused (cycle through ALL.10 through ALL.11)
(9) Don’t know (cycle through ALL.10 through ALL.11)

DIT.1
Has [fill: S.C. name] EVER used any of the following special diets for two weeks or more for
health reasons?
(1) Vegetarian, including Vegan (for health reasons)
(2) Macrobiotic
(3) Atkins
(4) Pritikin
(5) Ornish
[IF NO TO ALL, GO TO NEXT MODALITY]
DIT.2

14

Yes
Yes
Yes
Yes
Yes

No,Ref/DK
No,Ref/DK
No,Ref/DK
No,Ref/DK
No,Ref/DK

DURING THE PAST 12 MONTHS, did [fill: S.C. name] use {fill: yes answers from DIT.1] for
two weeks or more for health reasons?
(1) Yes
(2) No to all (go to next modality)
(7) Refused (go to next modality)
(9) Don’t know (go to next modality
[use “special diets” as fill throughout section]
DIT.3
Did [fill: S.C. name] use special diets for weight control or weight loss?
(1) Yes
(2) No
(7) Refused
(9) Don’t know
DIT.4
Has [fill: S.C. name] EVER seen a practitioner for special diets?
(1) Yes
(2) No (ALL.10)
(7) Refused (ALL.10)
(9) Don’t know (ALL.10)

DIT.5
DURING THE PAST 12 MONTHS, did [fill: S.C. name] see a practitioner for special diets?
(1) Yes (ALL.1)
(2) No (ALL.10)
(7) Refused (ALL.10)
(9) Don’t know (ALL.10)

MOV.1
Has [fill: S.C. name] ever practiced any of the following movement or exercise techniques?
(1) Feldenkrais
(2) Alexander Technique
(3) Pilates
(4) Trager Psychophysical Integration

[If no to all, goto next modality]

15

Yes
Yes
Yes
Yes

No,Ref/DK
No,Ref/DK
No,Ref/DK
No,Ref/DK

[ask for each yes response in MOV.1]
MOV.2
Has [fill: S.C. name] ever seen a practitioner or teacher for [fill for yes responses to MOV.1]?
(1) Feldenkrais
(2) Alexander Technique
(3) Pilates
(4) Trager Psychophysical Integration

Yes
Yes
Yes
Yes

No,Ref/DK
No,Ref/DK
No,Ref/DK
No,Ref/DK

[Cycle through MOV.3 for each yes in MOV.2, else if all no, cycle through MOV.4 for each
yes in MOV.1]

MOV.3
DURING THE PAST 12 MONTHS, did [fill: S.C. name] see a practitioner or teacher for [fill:
type of movement therapy]?
(1) Yes (ALL.1 using “movement or exercise technique” as fill)
(2) No to all (MOV.4)
(7) Refused (MOV.4)
(9) Don’t know (MOV.4)
MOV.4
DURING THE PAST 12 MONTHS, did [fill: S.C. name] use [fill: type of movement therapy]?
(1) Yes (ALL.10)
(2) No to all (TOP.1 or TP3.1)
(7) Refused (TOP.1 or TP3.1)
(9) Don’t know (TOP.1 or TP3.1)
______________________________________________________________________________
Questions ALL.1 – ALL.11 (plus some additional modality specific questions included in this
section)
Next 3 questions for chiropractic or osteopathic manipulation ONLY:
CHI.1
Which did [fill: he/she] see, a chiropractor or an osteopathic physician?
(1) Chiropractor (goto CHI.3)
(2) Osteopathic physician (goto CHI.3)
(3) Both (goto CHI.2)
(7) Refused
(9) Don’t know
CHI.2

16

DURING THE PAST 12 MONTHS, which practitioner did [fill: S.C. name] see the most?
(1) Chiropractic (use as fill for rest of chiropractic section)
(2) Osteopathic physician (use as fill for rest of chiropractic section)
(7) Refused
(9) Don’t know

[ask if choice 3 picked in CAM.2 and choice 1 picked in CHI.2]
CHI.3
Was this the personal health care provider mentioneded earlier?
(1) Yes (ALL.1)
(2) No (ALL.1)
(7) Refused (ALL.1)
(9) Don’t know (ALL.1)

Next question for Hypnosis ONLY:
HYP.1
Do you know whether [fill: S.C. name] does breathing exercises as part of hypnosis? Breathing
exercises may involve actively controlling the way air is drawn in, or the rate or depth of
breathing.
(1) Yes (ALL.1)
(2) No (ALL.1)
(7) Refused (ALL.1)
(9) Don’t know (ALL.1)

Next question for biofeedback ONLY:
BIO.1
Did [fill: S.C. name] do breathing exercises as part of biofeedback? Breathing exercises may
involve actively controlling the way air is drawn in, or the rate or depth of breathing.
(1) Yes (ALL.1)
(2) No (ALL.1)
(7) Refused (ALL.1)
(9) Don’t know (ALL.1)
[For self-care modalities (biofeedback, hypnosis, herbs, homeopathy, mind-body therapies,
yoga/tai-chi/qi gong, special diets, and movement therapies, only ask ALL.1 through ALL.9
if saw a practitioner in past 12 months; else goto ALL.10]
ALL.1
Do you know the exact number of times [fill: S.C. name] saw a practitioner for [fill: modality] in
the past 12 months?

17

(1) Yes (ALL.2
(2) No (ALL.3)
(7) Refused (ALL.3)
(9) Don’t know (ALL.3)
ALL.2
DURING THE PAST 12 MONTHS, how many times did [fill: S.C. name] see a practitioner for
[fill: modality]?
___________________ # of times (goto ALL.4)

ALL.3
DURING THE PAST 12 MONTHS, ABOUT how many times did [fill: S.C. name] see a
practitioner for [fill: modality]? Would you say…
[read categories]
(1)
(2)
(3)
(4)
(5)
(6)
(7)

Only 1 time
2-5 times
6-10 times
11-15 times
16-20 times
21-25 times
More than 25 times
Refused
Don’t know

ALL.4
DURING THE PAST 12 MONTHS, were any of the costs of [fill: S.C. name]’s seeing a
practitioner for [fill: modality] covered by health insurance?
(1) Yes (next question)
(2) No (ALL.6)
(7) Refused (ALL.6)
(9) Don’t know (ALL.6)
ALL.5
DURING THE PAST 12 MONTHS, was all of the cost or just some of the cost of [fill: S.C.
name]'s seeing a practitioner for [fill: modality] covered by health insurance?
(1) All of the cost (ALL.10)
(2) Some of the cost
(7) Refused
(9) Don’t know

18

ALL.6
Do you know the total amount that was paid for [fill: S.C. name] to see a practitioner for [fill:
modality] in the past 12 months [fill: not including the amount covered by insurance]?
(1) Yes
(2) No (ALL.8)
(7) Refused (ALL.8)
(9) Don’t know (ALL.8)

ALL.7
What is the total amount that was paid for [fill: S.C. name] to see a practitioner for [fill: modality]
in the past 12 months [fill: not including the amount covered by insurance]?
*Enter '0' for no cost or free.
$_______________ (amount in dollars) (go to ALL.10)
*Enter zero if no cost or free
ALL.8
Do you know the average amount that was paid for each of [fill: S.C. name]'s visits for [fill:
modality] [fill1: not including the amount covered by insurance] in the past 12 months?
1. Yes (next question)
2. No (gotot ALL.10)

ALL.9
On average, how much was paid out-of-pocket for each of [fill: S.C name]'s visits to a
practitioner for [fill: modality]?
Enter '0' if no cost or free
$______________________ (amount in dollars)
($0 – 500)
*Enter zero if no cost or free

ALL.10
DURING THE PAST 12 MONTHS, did you or another family member buy a self-help book or
other materials such as a DVD, CD, or Video to learn about [fill: S.C. name]'s use of [fill:
modality]?
(1) Yes (goto ALL.11)
(2) No (next modality or continue on if one of top 3 modalities)
(7) Refused (next modality or continue on if one of top 3 modalities)
19

(9) Don’t know (next modality or continue on if one of top 3 modalities)
ALL.11
How much was paid for these materials in the past 12 months?
*Enter '200' for $200 or more.
$ ________________________
[goto next modality or continue on if one of top 3 modalities]

[If more than 3 total modalities used in past 12 months, ask this question, else go to TP3.1
for 1st modality used]
TOP.1
DURING THE PAST 12 MONTHS, which THREE of these therapies were the most important
for [fill: S.C. name]’s health?
[instrument to list all modalities used in past 12 months]
Ask Question TP3.1 – TP3.21 for top 3 modalities ONLY.
*Chelation Therapy and Ayurveda not part of top 3 due to low prevelance.
[self-care modalities will say “use” instead of “see a practitioner for”; for traditional
healers, use “see a {fill: type of tradititional healer}]
TP3.1 Did [fill: S.C. name] [fill: use/see a practitioner for] [fill: modality] for any of these
reasons?
Yes/No/Ref/DK
(1)
(2)
(3)
(4)
(5)

For general wellness or general disease prevention?
To improve [fill: his/her] energy?
To improve [fill: his/her] immune function?
To improve [fill: his/her] athletic or sports performance?
To improve [his/her] memory or concentration?

TP3.2 Do you think [fill: seeing a practitioner for/using] [fill: modality] motivated [fill: S.C.
name] to
Yes/No/Ref/DK
(1) Eat healthier?
(2) Eat more organic foods?
(3) Exercise more regularly?
TP3.3 Do you think [fill: S.C. name]’s [fill: seeing a practitioner for/using] [fill: modality] led to
any of these outcomes?
20

Yes/No/Ref/DK
(1)
(2)
(3)
(4)
(5)

Give [fill: him/her] a sense of control over [fill: his/her] health?
Help to reduce [fill: his/her] stress level or to relax?
Help [fill: him/her]to sleep better?
Make [fill: him/her] feel better emotionally?
Make it easier to cope with health problems?

TP3.4 Do you think [fill: S.C. name]’s [fill: seeing a practitioner for/using] [fill: modality] led to
any of these outcomes?
Yes/No/Ref/DK
(1) Improve [fill: his/her] overall health and make [fill: him/her] feel better?
(2) Improve [fill: his/her] relationships with others?
(3) Improve [fill: his/her] attendance at school?

[IF more than 1 reason given in TP3.1 – TP3.4 ask next question, else go to TP3.6]
TP3.5
Of these reasons, which ONE was the most important for [fill: S.C. name] [fill: using/seeing]
[fill: modality]?
*Read list below.{fill from TP3.1-TP3.4}?
[instrument to fill all choices in TP3.1- TP3.4]
TP3.6
How much do you think [fill: modality] helped [fill S.C. name] [fill: reason given in previous
question]? Would you say a great deal, some, only a little, or not at all?
(1)
(2)
(3)
(4)

A great deal
Some
Only a little
Not at all
Refused
Don’t know

[If no health conditions reported in core questionnaire, skip to TP3.13]
TP3.7
DURING THE PAST 12 MONTHS, did [fill: S.C. name] [fill: use/see a practitioner for] [fill:
modality] for one or more
specific health problems, symptoms, or conditions?

21

(1) Yes
(2) No (goto TP3.13)
(7) No (goto TP3.13)
(9) No (goto TP3.13)

TP3.8
For what health problem, symptom, or condition did [fill: S.C. name] [fill use/see a practitioner
for] [modality]?
[computer to list these from core questions; See Appendix II for list of conditions pulled
in from core]
[IF more than 1 condition, ask next question; else go to TP3.10]
TP3.9
For which ONE of these did [fill: S.C. name] [fill: use/see a practitioner for] [fill: modality] the
most?
_________________________ [CONDITION]
*If respondent cannot choose one condition, probe for condition most important for using
modality.
TP3.10
How much do you think [fill: modality] helped [fill: S.C. name]’s [fill: health problem, symptom,
or condition]? Would you say a great deal, some, only a little, or not at all?
(1)
(2)
(3)
(4)

A great deal
Some
Only a little
Not at all
Refused
Don’t know

TP3.11
Did [fill: S.C. name] receive any of these medical treatments for [fill: health problem, symptom,
or condition]?
Yes/No/Ref/DK
(1) Prescription Medications?
(2) Over-the-counter medications?
(3) Surgery?
(4) Physical therapy?
(5) Mental Health Counseling?
22

[ask this question for yes responses in TP3.11 above, else goto next question]
TP3.12
DURING THE PAST 12 MONTHS, did [fill: S.C. name] [fill: use/see a practitioner for] [fill:
modality] for any of these reasons?
Yes/No/Ref/DK
(1)
(2)
(3)
(4)

Because these medical treatments were too expensive?
Because [fill: modality] combined with these medical treatments would help?
Because these medical treatments do not work for [fill: his/her] health problem?
Because [fill: category 1 or 2 from TP3.11] causes side effects?

TP3.13
Did [fill: S.C. name] see a practitioner for [fill: modality] for any of these reasons?
Yes/No/Ref/DK
(1)
(2)
(3)
(4)
(5)

Because it can be done without help from a specialist [self-care modalities only]?
Because it is natural?
Because it focuses on the whole person, mind, body, and spirit?
Because [fill: modality] treats the cause and not just the symptoms?
Because it was part of [fill: his/her] upbringing?

TP3.14
Did [fill: S.C. name] see a practitioner for [fill: modality] because it was recommended by any of
the following people?
Yes/No/Ref/DK
(1) A medical doctor?
(2) A family member?
(3) A friend?
(4) A co-worker of you or another family member?
TP3.15
DURING THE PAST 12 MONTHS, how important do you think [fill: S.C. name]’s use of
[fill: modality] was in maintaining {his/her} health and well-being? Would you say very
important, somewhat important, slightly important, or not at all important?
(1)
(2)
(3)
(4)

23

Very important
Somewhat important
Slightly important
Not at all important
Refused

Don’t know

[ask ONLY if respondent indicated having a personal health care provider in CAM.2]
TP3.16
[[fill: Not including the practitioner [fill: S.C. name] saw for [fill: modality]] DURING THE
PAST 12 MONTHS, did you let [fill S.C. name]'s personal health care provider know about [fill:
his/her] use of [fill1: modality]?
*If practitioner for therapy is the same person as personal health care provider, enter '2'.
(1) Yes (goto TP3.18)
(2) No (goto TP3.17)
(7) Refused (goto TP3.18)
(9) Don’t know (goto TP3.18)
TP3.17
Why didn't you tell [fill: S.C. name]'s personal health care provider about [fill: his/her] use of
[fill: modalilty]?
Yes/No/Ref/DK
(1) [fill: S.C. name] was not using it at the time?
(2) They discouraged use of it in the past?
(3) You were worried they would discourage it?
(4) You were concerned about a negative reaction?
(5) You didn’t think they needed to know?
(6) They didn't ask?
(7) You don't think they know as much about it as you do?
(8) They didn't give you enough time to tell them?
TP3.18
DURING THE PAST 12 MONTHS, did you or another family member get information about
[fill: modality] from any of the following sources?
Yes/No/Ref/DK
(1) The internet?
(2) Books, magazines, or newspapers?
(3) DVDs, videos, or CDs?
(4) Television or radio?
(5) Scientific articles?
(6) Health food stores?

24

APPENDIX I: HERB LOOKUP TABLE (Used with Question HRB.1e)
01

5 HTP (5-Hydroxytryptophan)

02

Achillea (AKA Yarrowa)

03

Aloe Vera

04

Angelica (AKA Dang Gui or Dong Quai)

05

Androstenedione

06

Ashwagandha

07

Astragalus (AKA Huang Qi)

08

Ayurvedic herbs

09

Bearberry (AKA Uva Ursi)

10

Bilberry

11

Bitter Gourd (AKA Bitter Melon)

12

Bitter Melon (AKA Bitter Gourd)

13

Black cohosh

14

Black Mulberry berry or leaf (AKA Mulberry)

15

Blackroot

16

Buckthorn

17

Butterbur

18

Cactus

19

Carnitine

20

Cascara sagrada

21

Cassica senna (AKA Senna)

22

Cat’s Claw

23

Cayenne

24

Chasteberry (AKA Vitex)

25

Common Rue (AKA Rue or Ruta graveolens)

26

Curcumin (AKA Turmeric)

27

Conjugated Linolenic Acid (CLA)

28

Crataegus (AKA Hawthorn or Thornapple)

29

Creatine

30

Dandelion

31

Dang Gui (AKA Angelica or Dong Quai)

32

Devil’s Claw

33

DHEA (Dehydroepiandrosterone)

34

Dong Quai (AKA Angelica or Dang Gui)

35

Elderberry

36

Enzymes

37

Ephedra

38

Evening primrose oil

39

Feverfew

40

Fiber or Psyllium (pills or powder)

41

Flaxseed (Oil or Ground) in pill or capsule

25

42

Fenugreek

43

Garcinia (AKA Goat’s Thorn)

44

Ginger pills or gelcaps

45

Goat’s Thorn (AKA Garcinia)

46

Goji Berry in pills or capsules

47

Goldenseal (AKA Hydrastis

48

Guarana

49

Grape Seed Extract

50

Hawthorn (AKA Crataegus or Thornapple)

51

Horehound

52

Horse chestnut

53

Horny Goat Weed

54

Huang Qi (AKA Astragalus)

55

Hypericum (AKA St. Johns Wort)

56

Jin Bu Huan

57

Kava kava

58

Lavender tinctures or capsules (not oil)

59

Ligustrum (AKA Osha)

60

Linden flower (AKA Tilia)

61

Lecithin

62

Licorice root in pill or capsule

63

Lutein

64

Lycopene

65

Maca

66

Mulberry berry or leaf (AKA Black Mulberry)

67

Noni juice or extract in capsules or pills

68

Olive Leaf extract

69

Oregano in pill or capsule

70

Osha (AKA Ligustrum)

71

Pau d’arco

72

Peppermint oil capsule

73

Phido estrogens

74

Pine bark extract (AKA Pycnogenol)

75

Puncture vine (AKA Tribulus terrestris)

76

Pycnogenol (AKA Pine bark extract)

77

Rasyana herbs

78

Red yeast rice in pill or capsule

79

Rhodiola (AKA Roseroot)

80

Rose hips in pill or capsule

81

Roseroot (AKA Rhodiola)

82

Rue (AKA Common Rue or Ruta graveolens)

83

Ruta graveolens (AKA Common Rue or Rue)

84

Senna (AKA Cassica senna)

26

85

Siberian Ginseng (AKA Eleuthero, not a true Ginseng)

86

Slippery elm (AKA Ulmus)

87

Soy supplements or soy isoflavones

88

St. John’s wort (AKA Hypericum)

89

Stevia

90

Thornapple (AKA Crataegus or Hawthorn)

91

Tilia (AKA Linden flower)

92

Tribulus Terrestris (AKA Puncture vine)

93

Turmeric (Curcumin)

94

Ulmus (AKA Slippery elm)

95

Uva Ursi (AKA Bearberry)

96

Vitex (AKA Chasteberry)

97

Yarrow (AKA Achillea)

98

Yohimbe or Yohimbine

27

APPENDIX II: Conditions Pulled from Core Sample Child and CAM Added Conditions: (Used
with Question TP3.8)
Health conditions from CHS to be filled in Top 3 condition items:
01. [If CABDOMYR eq <1>] – Abdominal pain
02. [If CCONDT1_6 eq <1> or CCONDT_6 eq <1>] – Anemia
03. [if CANXNWYR eq <1>] – Felt anxious, nervous or worried
04. [If CONDL1 includes <8>] – Arthritis
05. [If CASSTILL eq <1>] – Asthma
06. [if ADD_1 eq <1>] - Attention Deficit Hyperactivity Disorder (ADHD)/Attention Deficit
Disorder (ADD)
07. [[if CONDL1 includes <6>] – Autism
08. [If CONDL1 includes <2>] - Cerebral palsy
09. [If CPOX12MO eq <1>] – Chickenpox
10. [if CCHLYR eq <1>]-High cholesterol
11. [If CONDL1 includes <9>] - Congenital heart disease
12. [If CCONMED eq <1>] - Constipation
13. [If CONDL1 includes <4>] - Cystic fibrosis
14. [If CDEPRSYR eq <1>] – Depression
15. [If CDENYR eq <1>] – Dental pain
16. [If CONDL1 includes <7>] – Diabetes
17. [If CONDL1 includes <1>] - Down syndrome
18. [If CCONDT1_4 eq <1> or CCONDT_4 eq <1>] – Eczema or skin allergy
19. [if CFATYR eq <1>] - Excessive sleepiness during the day
20. [If CFATIGYR eq <1>] – Fatigue or lack of energy more than 3 days
21. [If CFEVRYR eq <1>] – Fever more than 1 day
22. [If CCONDT1_3 eq <1> or CCONDT_3 eq <1>] – Food or digestive allergy
23. [If CCONDT1_5 eq <1> or CCONDT_5 eq <1>] – Frequent or repeated diarrhea or colitis
24. [if CGYNYR eq <1>] - Gynecologic problem
25. [If CCONDT1_1 eq <1> or CCONDT_1 eq <1>] – Hay fever
26. [If CCOLDYR eq <1>] – Head or chest cold
27. [If CHEARST1 eq <3> or CHEARST1 eq <4> or CHEARST1 eq <5> or CHEARST1 eq
<6>] – Hearing problem
28. [if CHPYR eq <1>] – Hypertension
29. [If CFLUPNYR eq <1>] – Influenza or pneumonia
30. [If CINSYR eq <1>] – Insomnia or trouble sleeping
31. [if CJNTSYMP eq <1>] - Joint pain or stiffness
32. [if CPAINLB eq <1>] – Low back pain
33. [if ADD1_2 eq <1> or ADD_2 eq <1>] – Intellectual disability, also called Mental
Retardation
34. [if MENSTYR eq <1>] – Menstrual problems
35. [If CCONDT_7 eq <1>] – Migraine headaches
36. [If CONDL1 includes <3>] - Muscular dystrophy
37. [If CNAUSYR eq <1>] – Nausea and/or vomiting
38. [if CPAINECK eq <1>] – Neck pain
39. [If CPNOTHYR eq <1>] – Other chronic pain
40. [If CMUSCLYR eq <1>] – Other muscle or joint pain
41. [if ADD1_3 eq <1> or ADD_3 eq <1>] – Other developmental delay
42. [If CONDL includes <10>] – Other heart condition
43. [If COVRWTYR eq <1>] – Problems with being overweight
28

44. [If CCONDT_7 eq <1> or CHEADYR eq <1>] – Non-migraine headaches
45. [If CCONDT1_2 eq <1> or CCONDT_2 eq <1>] – Respiratory allergy
46. [If CCONDT1_9 eq <1> or CCONDT_9 eq <1>] – Seizures
47. [If CONDL1 includes <5>] – Sickle cell anemia
48. [if CSINYR eq <1>] – Sinusitis
49. [if CTHOTHYR eq <1>] – Sore throat other than strep or tonsillitis
50. [if CSPNYR eq <1>] – Sprain or strain
51. [if CSTREPYR eq <1>] – Strep throat or tonsillitis
52. [if CSTRESYR eq <1>] – Frequent stress
53. [If CCONDT_10 eq <1>] – Stuttering or stammering
54. [If CCONDT1_8 eq <1> or CCONDT_8 eq <1>] – Three or more ear infections
55. [if CVISION eq <1>] – Vision problems
56. Other specify

29

Page 1 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.020_00.010 Instrument Variable Name:

HYPYR

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you had hypertension, also called high blood pressure?

QuestionText:

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who were ever told they had hypertention

SkipInstructions:

<1,2,R,D> [goto CHDEV]

Question ID:

ACN.031_01.010 Instrument Variable Name:

CHDYR

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS have you had

QuestionText:

... Coronary heart disease?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who were ever told they had coronary heart disease

SkipInstructions:

<1,2,R,D> [goto ANGEV]

Question ID:

ACN.031_04.010 Instrument Variable Name:

QuestionText:

HRTYR

QuestionnaireFileName:

DURING THE PAST 12 MONTHS have you had ...
Any kind of heart condition or heart disease (other than the ones I just asked about)?

UniverseText:

Sample adults 18+ who were ever told they had any other kind of heart condition

SkipInstructions:

<1,2,R,D> [goto STREV]

Sample Adult

Page 2 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.121_00.010 Instrument Variable Name:

CHLEV

QuestionnaireFileName:

Sample Adult

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

QuestionText:

…High cholesterol?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto CHLYR]
<2,R,D>[goto AFLUPNEV]

Question ID:

ACN.121_00.020 Instrument Variable Name:

QuestionText:

CHLYR

DURING THE PAST 12 MONTHS have you had
...High cholesterol?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who were ever told they had high cholesterol

SkipInstructions:

<1,2,R,D> [goto AFLUPNEV]

QuestionnaireFileName:

Sample Adult

Page 3 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.121_00.030 Instrument Variable Name:

AFLUPNEV

QuestionnaireFileName:

Sample Adult

* Read if necessary.

QuestionText:

Have you EVER been told by a doctor or other health professional that you had
…Influenza or pneumonia?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto AFLUPNYR]
<2,R,D>[goto ASTREPEV]

Question ID:

ACN.121_00.040 Instrument Variable Name:

QuestionText:

AFLUPNYR

QuestionnaireFileName:

DURING THE PAST 12 MONTHS have you had
...Influenza or pneumonia?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who were ever told they had influenza or pneumonia

SkipInstructions:

<1,2,R,D> [goto ASTREPEV]

Sample Adult

Page 4 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.121_00.050 Instrument Variable Name:

ASTREPEV

QuestionnaireFileName:

Sample Adult

* Read if necessary.

QuestionText:

Have you EVER been told by a doctor or other health professional that you had
…Strep throat or tonsillitis?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto ASTREPYR]
<2,R,D>[goto PRCIREV]

Question ID:

ACN.121_00.060 Instrument Variable Name:

QuestionText:

ASTREPYR

QuestionnaireFileName:

DURING THE PAST 12 MONTHS have you had
…Strep throat or tonsillitis?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who were ever told they had strep throat or tonsillitis

SkipInstructions:

<1,2,R,D> [goto PRCIREV]

Sample Adult

Page 5 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.121_00.070 Instrument Variable Name:

PRCIREV

QuestionnaireFileName:

Sample Adult

* Read if necessary.

QuestionText:

Have you EVER been told by a doctor or other health professional that you had
…Poor circulation in your legs?
*Include peripheral vascular disease, Intermittent Claudication or cramping.
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto PRCIRYR]
<2,R,D> [goto UREV]

Question ID:

ACN.121_00.080 Instrument Variable Name:

QuestionText:

PRCIRYR

QuestionnaireFileName:

DURING THE PAST 12 MONTHS have you had
…Poor circulation in your legs?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who were ever told they had poor circulation in their legs

SkipInstructions:

<1> [goto PRCIRYR]
<2,R,D> [goto UREV]

Sample Adult

Page 6 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.121_00.090 Instrument Variable Name:

UREV

QuestionnaireFileName:

Sample Adult

* Read if necessary.

QuestionText:

Have you EVER been told by a doctor or other health professional that you had
...Urinary problems such as incontinence, frequent or slow urination or infections?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto URYR]
<2,R,D>[goto PHOBIAEV]

Question ID:

ACN.121_00.100 Instrument Variable Name:

QuestionText:

URYR

QuestionnaireFileName:

DURING THE PAST 12 MONTHS have you had
...Urinary problems such as incontinence, frequent or slow urination or infections?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who were ever told they had urinary problems

SkipInstructions:

<1,2,R,D> [goto PHOBIAEV]

Sample Adult

Page 7 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.121_00.110 Instrument Variable Name:

PHOBIAEV

QuestionnaireFileName:

Sample Adult

* Read if necessary.

QuestionText:

Have you EVER been told by a doctor or other health professional that you had
...Phobia or fears?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto PHOBIAYR]
<2,R,D>[goto ADDHYP1]

Question ID:

ACN.121_00.120 Instrument Variable Name:

QuestionText:

PHOBIAYR

DURING THE PAST 12 MONTHS have you had
...Phobia or fears?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who were ever told they had phobia or fears

SkipInstructions:

<1,2,R,D> [goto ADDHYP1]

QuestionnaireFileName:

Sample Adult

Page 8 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.121_00.130 Instrument Variable Name:

ADDHYP1

QuestionnaireFileName:

Sample Adult

* Read if necessary.

QuestionText:

Have you EVER been told by a doctor or other health professional that you had
...Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD)?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto BIPDIS]

Question ID:

ACN.121_00.140 Instrument Variable Name:

QuestionText:

BIPDIS

QuestionnaireFileName:

* Read if necessary.
Have you EVER been told by a doctor or other health professional that you had
…Bipolar Disorder?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto ADEPRSEV]

Sample Adult

Page 9 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.121_00.150 Instrument Variable Name:

ADEPRSEV

QuestionnaireFileName:

Sample Adult

* Read if necessary.

QuestionText:

Have you EVER been told by a doctor or other health professional that you had
…Depression?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto ADEPRSYR]
<2,R,D>[goto MHDOTHEV]

Question ID:

ACN.121_00.160 Instrument Variable Name:

QuestionText:

ADEPRSYR

DURING THE PAST 12 MONTHS have you had
…Depression?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who were ever told they had depression

SkipInstructions:

<1,2,R,D> [goto MHDOTHEV]

QuestionnaireFileName:

Sample Adult

Page 10 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.121_00.170 Instrument Variable Name:

MHDOTHEV

QuestionnaireFileName:

Sample Adult

* Read if necessary.

QuestionText:

Have you EVER been told by a doctor or other health professional that you had
…Other mental health disorders?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto MHDOTHYR]
<2,R,D> [goto RESPALYR]

Question ID:

ACN.121_00.180 Instrument Variable Name:

QuestionText:

MHDOTHYR

QuestionnaireFileName:

DURING THE PAST 12 MONTHS have you had
…Other mental health disorders?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+ who were ever told they had other mental health disorders

SkipInstructions:

<1,2,R,D> [goto RESPALYR]

Sample Adult

Page 11 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.125_00.010 Instrument Variable Name:

RESPALYR

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you had

QuestionText:

…Any kind of respiratory allergy?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto DGSTALYR]

Question ID:

ACN.125_00.020 Instrument Variable Name:

QuestionText:

DGSTALYR

*Read if necessary.
DURING THE PAST 12 MONTHS, have you had
…Any kind of digestive allergy?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto SKNALYR]

Page 12 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.125_00.030 Instrument Variable Name:

SKNALYR

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

*Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, have you had
…Eczema or any kind of skin allergy?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto OTHALYR]

Question ID:

ACN.125_00.040 Instrument Variable Name:

QuestionText:

OTHALYR

*Read if necessary.
DURING THE PAST 12 MONTHS, have you had
…Allergies other than hay fever, respiratory, food, digestive, or skin allergies?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto ACIDRYR]

Page 13 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.125_00.050 Instrument Variable Name:

ACIDRYR

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

*Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, have you had
…Problems with acid reflux or heartburn?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto AFEVRYR]

Question ID:

ACN.125_00.060 Instrument Variable Name:

QuestionText:

AFEVRYR

*Read if necessary.
DURING THE PAST 12 MONTHS, have you had
…Fever more than one day?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto ACOLDYR]

Page 14 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.125_00.070 Instrument Variable Name:

ACOLDYR

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

*Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, have you had
…A head or chest cold?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto ANAUSYR]

Question ID:

ACN.125_00.080 Instrument Variable Name:

QuestionText:

ANAUSYR

*Read if necessary.
DURING THE PAST 12 MONTHS, have you had
…Nausea and/or vomiting?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto ATHOTHYR]

Page 15 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.125_00.090 Instrument Variable Name:

ATHOTHYR

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

*Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, have you had
…Sore throat other than strep or tonsillitis?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto IMMOTHYR]

Question ID:

ACN.125_00.100 Instrument Variable Name:

QuestionText:

IMMOTHYR

*Read if necessary.
DURING THE PAST 12 MONTHS, have you had
…Infectious diseases or problems of the immune system?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto AHEADYR]

Page 16 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.125_00.110 Instrument Variable Name:

AHEADYR

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

*Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, have you had
…Recurring headache, other than migraine?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto MEMLOSYR]

Question ID:

ACN.125_00.120 Instrument Variable Name:

QuestionText:

MEMLOSYR

*Read if necessary.
DURING THE PAST 12 MONTHS, have you had
…Memory loss or loss of other cognitive functions?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto NEUROYR]

Page 17 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.125_00.130 Instrument Variable Name:

NEUROYR

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

*Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, have you had
…Neurological problems?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto AABDOMYR]

Question ID:

ACN.125_00.140 Instrument Variable Name:

QuestionText:

AABDOMYR

*Read if necessary.
DURING THE PAST 12 MONTHS, have you had
…Abdominal pain?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto SPNYR]

Page 18 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.125_00.150 Instrument Variable Name:

SPNYR

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

*Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, have you had
…Any severe sprains or strains?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto DENYR]

Question ID:

ACN.125_00.160 Instrument Variable Name:

QuestionText:

DENYR

*Read if necessary.
DURING THE PAST 12 MONTHS, have you had
…Dental pain?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto AMUSCLYR]

Page 19 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.125_00.170 Instrument Variable Name:

AMUSCLYR

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

*Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, have you had
…Other muscle or bone pain?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto APNOTHYR]

Question ID:

ACN.125_00.180 Instrument Variable Name:

QuestionText:

APNOTHYR

*Read if necessary.
DURING THE PAST 12 MONTHS, have you had
…Other chronic pain?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto ALCTOBYR]

Page 20 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.125_00.190 Instrument Variable Name:

ALCTOBYR

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

*Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, have you had
…Excessive use of alcohol or tobacco?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto SUBABYR]

Question ID:

ACN.125_00.200 Instrument Variable Name:

QuestionText:

SUBABYR

*Read if necessary.
DURING THE PAST 12 MONTHS, have you had
…Substance abuse, other than alcohol or tobacco?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto AOVRWTYR]

Page 21 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.125_00.210 Instrument Variable Name:

AOVRWTYR

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

*Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, have you had
…Problems with being overweight?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto SKNYR1]

Question ID:

ACN.125_00.220 Instrument Variable Name:

QuestionText:

SKNYR1

*Read if necessary.
DURING THE PAST 12 MONTHS, have you had
…Skin problems, other than ezcema or allergies?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto AFATIGYR]

Page 22 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.125_00.230 Instrument Variable Name:

FATIGYR

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

*Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, have you had
…Fatigue or lack of energy more than 3 days?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto AFATIGYR]

Question ID:

ACN.125_00.240 Instrument Variable Name:

QuestionText:

FATYR

DURING THE PAST 12 MONTHS, have you
…Regularly had excessive sleepiness during the day?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto INSYR]

Page 23 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.125_00.250 Instrument Variable Name:

INSYR

QuestionnaireFileName:

Sample Adult

ANXNWYR

QuestionnaireFileName:

Sample Adult

*Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, have you
…Regularly had insomnia or trouble sleeping?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto ANXNWYR]

Question ID:

ACN.125_00.260 Instrument Variable Name:

QuestionText:

*Read if necessary.
DURING THE PAST 12 MONTHS, have you
…Frequently felt anxious, nervous, or worried?

1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto ASTRESYR]

Page 24 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.125_00.270 Instrument Variable Name:

ASTRESYR

QuestionnaireFileName:

Sample Adult

ARTHTYP

QuestionnaireFileName:

Sample Adult

*Read if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, have
…Frequently felt stressed?
1. Yes
2. No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto CANEV]

Question ID:

ACN.297_00.010 Instrument Variable Name:

QuestionText:

You just mentioned that you were told by a doctor or other health professional that you had some form of arthritis,
rheumatoid arthritis, gout, lupus, or fibromyalgia (fy-bro-my-AL-jee-uh). Which of these were you told you had?
*Enter all that apply, separate with commas.

1. Arthritis
2. Rheumatoid arthritis
3. Gout
4. Lupus
5. Fibromyalgia
6. Other joint condition
Refused
Don't know

UniverseText:

Sample adults 18+ who were told they had some form of arthritis, rheumatoid arthritis, gout, lupus or fibromyalgia

SkipInstructions:

<1-6,R,D> [goto PAINECK]

Page 25 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.372_00.010 Instrument Variable Name:

MENSYR

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you had any menstrual problems such as heavy bleeding, bothersome cramping,
or pre-menstrual syndrome (also called PMS)?

QuestionText:

1. Yes
2. No
Refused
Don't know

UniverseText:

Female sample adults 18-55

SkipInstructions:

<1,2,R,D> if AGE 45-55 [goto MENOYR]; else [goto GYNYR]

Question ID:

ACN.372_00.020 Instrument Variable Name:

MENOYR

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you had any menopausal problems such as hot flashes, night sweats, or other
menopausal symptoms?

QuestionText:

1. Yes
2. No
Refused
Don't know

UniverseText:

Female sample adults 45-57

SkipInstructions:

<1,2,R,D> [goto GYNYR]

Question ID:

ACN.372_00.030 Instrument Variable Name:

QuestionText:

GYNYR

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you had any gynecologic problems such as a vaginal infection, uterine fibroids,
or infertility?

1. Yes
2. No
Refused
Don't know

UniverseText:

Female sample adults 18+

SkipInstructions:

<1,2,R,D> [goto HRAIDNOW]

Page 26 of 26

DRAFT 2012 NHIS Questionnaire - Sample Adult
Adult Conditions-Added CAM Conditions
Document Version Date: 23-Aug-11
Question ID:

ACN.372_00.040 Instrument Variable Name:

QuestionText:

PROSTYR

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you had any men's health problems such as prostate trouble, or impotence?

1. Yes
2. No
Refused
Don't know

UniverseText:

Male sample adults 40+

SkipInstructions:

<1,2,R,D> [goto HRAIDNOW]

Sample Adult Complementary and Alternative Medicine Supplement
CAM.1
A personal health care provider is a health professional who knows you well and is familiar with
your health history. This can be a general doctor, a specialist doctor, a nurse practitioner, a
physician’s assistant, or another type of provider. Do you have one or more persons you think of
as your personal health care provider?
(1) Yes (CAM.2)
(2) No (CAM.3)
(7) Refused (CAM.3)
(9) Don’t know (CAM.3)
CAM.2
What type of provider(s) is it?
*Enter all that apply, separate with commas.
(1) Medical doctor (M.D., D.O.) including specialists
(2) Nurse, Nurse Practitioner, or Physician Assistant
(3) Chiropractor, Acupuncturist, or Naturopath
(4) Other
(7) Refused
(9) Don’t know
[ask for respondents who have place for sick care from core questionnaire]
CAM.3
Earlier you said you have a place where you usually go when you are sick. What type of
provider(s) do you see there?
*Enter all that apply, separate with commas.
(1) Medical doctor (M.D., D.O.) including specialists
(2) Nurse, Nurse Practitioner, or Physician Assistant
(3) Chiropractor, Acupuncturist, or Naturopath
(4) Other
(7) Refused
(9) Don’t know
[ask for respondents who have different routine place than sick place or only have sick
place from core questionnaire]
CAM.4
Earlier you said you have a place where you usually go when you need routine care. What type
of provider(s) do you see there?
*Enter all that apply, separate with commas.
(1) Medical doctor (M.D., D.O.) including specialists
(2) Nurse, Nurse Practitioner, or Physician Assistant
(3) Chiropractor, Acupuncturist, or Naturopath
1

(4) Other
(7) Refused
(9) Don’t know
Now I am going to ask you about some health services you may have used.
PRT.1
Have you EVER used any of the following therapies for your health?
(1) Chiropractic (kye-row-PRAK-tik) or Osteopathic Manipulation
(2) Massage
(3) Acupuncture
(4) Energy Healing Therapy
(5) Naturopathy (nay-chur-AH-puh-thee)
(6) Hypnosis
(7) Biofeedback
(8) Ayurveda
(9) Chelation (key-LAY-shun) Therapy
(10) Craniosacral (krey-nee-oh-SEY-kruhl)Therapy
(97) Refused
(99) Don’t know

yes
yes
yes
yes
yes
yes
yes
yes
yes
yes

no
no
no
no
no
no
no
no
no
no

[IF NO TO ALL, GO TO Traditional healers]
[ask for any yes responses to PRT.1]
PRT.2
Have you EVER seen a provider or practitioner for any of the following therapies for yourself?
(1) Chiropractic (kye-row-PRAK-tik) or Osteopathic Manipulation
(2) Massage
(3) Acupuncture
(4) Energy Healing Therapy
(5) Naturopathy (nay-chur-AH-puh-thee)
(6) Hypnosis
(7) Biofeedback
(8) Ayurveda
(9) Chelation (key-LAY-shun) Therapy
(10) Craniosacral (krey-nee-oh-SEY-kruhl)Therapy
(97) Refused
(99) Don’t know

yes
yes
yes
yes
yes
yes
yes
yes
yes
yes

no
no
no
no
no
no
no
no
no
no

[if any yes responses ask PRT.3 for each, else goto PRT.4 for all no responses or all Ref/DK]
PRT.3
DURING THE PAST 12 MONTHS, did you see a practitioner for [fill: modality]?
(1) Yes (ALL.1 or CHI.1 or HYP.1 or BIO.1)
(2) No (PRT.4)
(7) Refused (PRT.4)
(9) Don’t know (PRT.4)

2

PRT.4
DURING THE PAST 12 MONTHS, did you use [fill: modality]?
(1) Yes (for biofeedback and hypnosis goto ALL.10, else goto TRD.1)
(2) No (TRD.1)
(7) Refused (TRD.1)
(9) Don’t know (TRD.1)
[cycle through ALL.1 through ALL.11 for all modalities for which respondent has seen a
practitioner in past 12 months]
TRD.1
Flashcard CAM1
Have you ever seen any of the following traditional healers?
Native American Healer/Medicine Man
Shaman (SHAH-man)
Curandero (coo-rahn-DEHR-oh), Machi (MAH-chee), or Parchero (pahr-CHEH-roh)
Yerbero (yehr-BEH-roh) or Hierbista (yehr-BEE-stah)
Sobador (so-bah-DOHR)
Huesero (weh-SEHR-oh)
(1) Yes (TRD.1a)
(2) No (VIT.1)
(7) Refused (VIT.1)
(9) Don’t know (VIT.1)
TRD.1a
Which ones?
(1) Native American Healer/Medicine Man
(2) Shaman (SHAH-man)
(3) Curandero (coo-rahn-DEHR-oh), Machi (MAH-chee), or Parchero (pahr-CHEH-roh)
(4) Yerbero (yehr-BEH-roh) or Hierbista (yehr-BEE-stah)
(5) Sobador (so-bah-DOHR)
(6) Huesero (weh-SEHR-oh)
(7) Refused
(9) Don’t know
Cycle through TRD.2 for each yes in TRD.1a
TRD.2
DURING THE PAST 12 MONTHS, did you see [fill: each traditional healer mentioned in
TRD.1a]?
(1) Yes (ALL.1)
(2) No to all (VIT.1)
(7) Refused (VIT.1)
(9) Don’t know (VIT.1)
3

[use “traditional healers” as fill for remaining questions ALL.1 – ALL.11]
Now I am going to ask you about some additional health practices. The first practice I’ll ask
about is vitamins and minerals. These are pills, capsules, tablets, or liquids that have been
labeled as a VITAMIN OR MINERAL SUPPLEMENT. I’ll ask about herbs or other nonvitamin supplements next.
VIT.1
Have you EVER taken Multi-vitamins or Multi-minerals?
(1) Yes (VIT.2)
(2) No (VIT.3)
(7) Refused (VIT.3)
(9) Don’t know (VIT.3)
VIT.2
DURING THE PAST 12 MONTHS, did you take Multi-vitamins or Multi-minerals?
(1) Yes
(2) No
(7) Refused
(9) Don’t know
VIT.3
[Fill: Other than in a multi-vitamin or mineral] Have you ever taken vitamins A,B,C,D,E,H or K?
(1) Yes (VIT.4)
(2) No (VIT.5)
(7) Refused (VIT.5)
(9) Don’t know (VIT.5)
VIT.4
DURING THE PAST 12 MONTHS, did you take vitamins A,B,C,D,E,H or K?
(1) Yes
(2) No
(7) Refused
(9) Don’t know
VIT.5
[Fill: Other than in a multi-vitamin or mineral] Have you ever taken calcium, magnesium, iron,
chromium, zinc, selenium, or potassium?
(1) Yes (VIT.6)
(2) No (HRB.1)
(7) Refused (HRB.1)
(9) Don’t know (HRB.1)
VIT.6

4

DURING THE PAST 12 MONTHS, did you take calcium, magnesium, iron, chromium, zinc,
selenium, or potassium?
(1) Yes
(2) No
(7) Refused
(9) Don’t know
Herbs or other non-vitamin supplements are pills, capsules, tablets, or liquids that have
been labeled as a DIETARY SUPPLEMENT. This does NOT include vitamin or mineral
supplements, homeopathic treatments, or drinking herbal or green teas.
HRB.1

Flashcard CAM2

Have you EVER taken any herbal or other non-vitamin supplements listed on this card for
yourself?
*Tinctures are included.
Combination herb pill
Acai (pills, gelcaps)
Bee Pollen and other Bee products
Chondroitin
Co-enzyme Q10 (CoQ10)
Cranberry (pills or capsules)
Digestive Enzymes (lactaid)
Echinacea
Fish Oil or omega 3 or DHA fatty acid or EPA fatty acid supplements
Garlic supplements (pills, gelcaps)
Ginkgo Biloba
Ginseng
Glucosamine
Green tea pills (not brewed tea) or EGCG (pills)
Melatonin
Milk Thistle (silymarin)
MSM (Methylsulfonylmethane)
Probiotics or Prebiotics
SAM-e
Saw Palmetto
Valerian
Other herbs or non-vitamin supplements
(1) Yes (HRB.1a)
(2) No (if vitamins taken goto VITB.1a; else go to HOM.1)
(7) Refused (if vitamins taken goto VITB.1a; else go to HOM.1)
(9) Don’t know (if vitamins taken goto VITB.1a; else go to HOM.1)

5

HRB.1a

Flashcard CAM2

DURING THE PAST 12 MONTHS, have you taken any herbal or other non-vitamin supplements
listed on this card for yourself?
(1) Yes (HRB.1b)
(2) No (if vitamins taken in past 12 months go to VITB.1a; else go to HOM.1)
(7) Refused (if vitamins taken in past 12 months goto VITB.1a; else go to HOM.1)
(9) Don’t know (if vitamins taken in past 12 months goto VITB.1a; else go to HOM.1)

HRB.1b

Flashcard CAM2

Please tell me which of these supplements you have taken DURING THE PAST 12 MONTHS?
If you took more than one herb in a single supplement, select "combination herb pill."
*Enter all that apply, separate with commas.
(1) Combination herb pill
(2) Acai (pills, gelcaps)
(3) Bee Pollen and other Bee products
(4) Chondroitin
(5) Co-enzyme Q10 (CoQ10)
(6) Cranberry (pills or capsules)
(7) Digestive Enzymes (lactaid)
(8) Echinacea
(9) Fish Oil or omega 3 or DHA fatty acid or EPA fatty acid supplements
(10) Garlic supplements (pills, gelcaps)
(11) Ginkgo Biloba
(12) Ginseng
(13) Glucosamine
(14) Green tea pills (not brewed tea) or EGCG (pills)
(15) Melatonin
(16) Milk Thistle (silymarin)
(17) MSM (Methylsulfonylmethane)
(18) Probiotics or Prebiotics
(19) SAM-e
(20) Saw Palmetto
(21) Valerian
(22) Other herbs or non-vitamin supplements
(97) Refused
(99) Don't know

HRB.1c

Flashcard CAM2

Did you take any of these DURING THE PAST 30 DAYS?
(1) Yes (HRB.1d)
(2) No (HRB.3)
(7) Refused (HRB.3)
6

(9) Don’t know (HRB.3)
HRB.1d

Flashcard CAM2

Which of these supplements have you taken DURING THE PAST 30 DAYS? If you took more
than one herb in a single supplement, select "combination herb pill."
*Enter all that apply, separate with commas.
(1) Combination herb pill
(2) Acai (pills, gelcaps)
(3) Bee Pollen and other Bee products
(4) Chondroitin
(5) Co-enzyme Q10 (CoQ10)
(6) Cranberry (pills or capsules)
(7) Digestive Enzymes (lactaid)
(8) Echinacea
(9) Fish Oil or omega 3 or DHA fatty acid or EPA fatty acid supplements
(10) Garlic supplements (pills, gelcaps)
(11) Ginkgo Biloba
(12) Ginseng
(13) Glucosamine
(14) Green tea pills (not brewed tea) or EGCG (pills)
(15) Melatonin
(16) Milk Thistle (silymarin)
(17) MSM (Methylsulfonylmethane)
(18) Probiotics or Prebiotics
(19) SAM-e
(20) Saw Palmetto
(21) Valerian
(22) Other herbs or non-vitamin supplements
(97) Refused
(99) Don't know
if combination herb pill chosen:
HRB.1e
How many different "combination herb pills" did you take?
___1-50
(97) Refused
(99) Don’t know
HRB.1f and 1g:
Ask for up to 2 combination herb pills:
Which herbs or other non-vitamin supplements are included in the combination herb pill or pills?
Select from CAM2 card (1-22)
7

HRB.1e
If “other” herb or non-vitamin supplement selected from HRB.1d go to lookup table with
approximately 100 herbs not on flashcard (see Appendix I at end of this document for herb
lookup table list)
How many other herbs or non-vitamin supplements have you taken in the past 30 days?
___1-50
(97) Refused
(99) Don’t know
(Collect specific names of up to two most important from lookup table)
HRB.2
[if more than 2 herbs chosen from any source]:
Which TWO of these herbal supplements did you take the most in the PAST 30 DAYS?
*Enter two answers, separate with commas.
*If respondent cannot choose two herbs used most often, probe for the two most important for
health.
(1) Combination herb pill
(2) Acai (pills, gelcaps)
(3) Bee Pollen and other Bee products
(4) Chondroitin
(5) Co-enzyme Q10 (CoQ10)
(6) Cranberry (pills or capsules)
(7) Digestive Enzymes (lactaid)
(8) Echinacea
(9) Fish Oil or omega 3 or DHA fatty acid or EPA fatty acid supplements
(10) Garlic supplements (pills, gelcaps)
(11) Ginkgo Biloba
(12) Ginseng
(13) Glucosamine
(14) Green tea pills (not brewed tea) or EGCG (pills)
(15) Melatonin
(16) Milk Thistle (silymarin)
(17) MSM (Methylsulfonylmethane)
(18) Probiotics or Prebiotics
(19) SAM-e
(20) Saw Palmetto
(21) Valerian
(22) Second combination herb pill
(23) {First herb from lookup table}
(24) {Second herb from lookup table}
(97) Refused
8

(99) Don't know
HRB.3
Have you EVER seen a practitioner for herbs or other non-vitamin supplements?
(1) Yes (HRB.4)
(2) No (ALL.10)
(7) Refused (ALL.10
(9) Don’t know (ALL.10

HRB.4
DURING THE PAST 12 MONTHS, did you see a practitioner for herbs or other non-vitamin
supplements?
(1) Yes
(2) No
(7) Refused
(9) Don’t know

[ask for respondents who have taken vitamins in past 12 months]
VITB.1a
Now I am going to ask you about how much you spend on [fill1: vitamins and
minerals./vitamin and minerals, and herbs or other non-vitamin supplements. First I will
ask about vitamins and minerals and then about herbs or other non-vitamin supplements.]
About how many times per week, month, or year do you buy vitamins and minerals?
*Enter number.
*Enter '0' if respondent does not buy vitamins or minerals.
______ times per

week/month/year

VITB.1b
About how much did you spend the last time you bought vitamins and minerals?
$ __________________

$0-$1000

9

*Enter 1000 for $1000 or more

[ask for respondents who have taken herbs or other non-vitamin supplements in past 12
months]
HRBB.1a
Now I am going to ask you about how much you spend on herbs or other non-vitamin
supplements.
About how many times per week, month, or year do you buy herbs or other non-vitamin
supplements?
*Enter number.
*Enter '0' if respondent does not buy herbs or non-vitamin supplements.
______ times per

week/month/year

HRBB.1b
About how much did you spend the last time you bought herbs or other non-vitamin
supplements?

$ __________________
$0-$1000

*Enter 1000 for $1000 or more

[if HRB.4 = “1” cycle through ALL.1-ALL.11; else only else ALL.10-11]

People who use homeopathy to treat health problems take small pills or drops that are often
placed under the tongue. They may be labeled as homeopathic remedies or medicine and
they may be prescribed by practitioners of homeopathy.
HOM.1
Have you EVER used homeopathic treatment for your health?
(1) Yes (next question)
(2) No (go to next modality)
(7) Refused (go to next modality)
(9) Don’t know (go to next modality)

HOM.2
DURING THE PAST 12 MONTHS, did you use homeopathic treatment for your health?
10

(1) Yes (next question)
(2) No (go to next modality)
(7) Refused (go to next modality)
(9) Don’t know (go to next modality)
HOM.3
About how many days per week, month, or year do you buy homeopathic medicine?
______ days per

week/month/year

HOM.4
On average, how much do you spend each time you buy homeopathic medicine?
$ __________________
$0-$1000

*Enter 1000 for $1000 or more

Read if necessary: this does not include herbals or vitamins or minerals.

HOM.5
Have you EVER seen a practitioner for homeopathic treatment?
(1) Yes
(2) No (ALL.10)
(7) Refused (ALL.10)
(9) Don’t know (ALL.10)

HOM.6
DURING THE PAST 12 MONTHS, did you see a practitioner for homeopathic treatment?
(1) Yes (ALL.1)
(2) No (ALL.10)
(7) Refused (ALL.10)
(9) Don’t know (ALL.10)

MBO.1
Have you EVER used meditation, guided imagery, or progressive relaxation?
(1) Yes (goto MBO.2)
(2) No (go to next modality)
11

(7) Refused (go to next modality)
(9) Don’t know (go to next modality)

MBO.2
Have you EVER used any of the following for your own health or treatment? Yes/No/Ref/DK
(1) Mantra Meditation, including Transcendental Meditation®, Relaxation Response, and
Clinically Standardized Meditation?
(2) Mindfulness meditation, including Vipassana (vih-PAS-sah-nah), Zen Buddhist meditation,
Mindfulness-based Stress Reduction, and Mindfulness-based Cognitive Therapy?
(3) Spiritual meditation including Centering Prayer and Contemplative Meditation?
(4) Guided imagery
(5) Progressive relaxation
[if no to all, skip to next modality]
[ Cycle through for every yes in MBO.1]
MBO.3
DURING THE PAST 12 MONTHS, did you use [methods in MBO.2]?
(1) Yes
(2) No to all(go to next modality)
(7) Refused (go to next modality)
(9) Don’t know (go to next modality)
[IF MORE THAN ONE YES in MBO.3, ASK MBO.4; ELSE GO TO MBO.5]
MBO.4
DURING THE PAST 12 MONTHS, which of these did you use the most:
{fill techniques from MBO. 3}?
_____________________ [TECHNIQUE]
MBO.5
Did you do breathing exercises as part of {mind-body technique used the most}?
(1) Yes
(2) No
(7) Refused
(9) Don’t know

MBO.6
DURING THE PAST 12 MONTHS, did you see a practitioner or take a class for {mind-body
technique used the most}?
12

(1) Yes (ALL.1)
(2) No (ALL.10)
(7) Refused (ALL.10)
(9) Don’t know (ALL.10)

YOG.1
Have you EVER practiced any of the following?
(1) Yoga
(2) Tai Chi (TIE-CHEE)
(3) Qi Gong (CHEE-KUNG)

Yes
Yes
Yes

No,Ref/DK
No,Ref/DK
No,Ref/DK

[IF NO TO ALL, GO TO NEXT MODALITY]
[Cycle through for each yes answer in YOG.1]
YOG.2
DURING THE PAST 12 MONTHS, did you practice [fill: exercise mentioned in YOG.1] ?
(1) Yes
(2) No to all (go to next modality)
(7) Refused (go to next modality)
(9) Don’t know (go to next modality

[cycle through each yes in YOG.2]
YOG.3
Did you do breathing exercises as part of [fill: type of exercise]? Breathing exercises may involve
actively controlling the way air is drawn in, or the rate or depth of breathing.

(1) Yes
(2) No
(7) Refused
(9) Don’t know

[cycle through each yes in YOG.2]
YOG.4
Did you do meditation as part of [fill: type of exercise]?
(1) Yes
(2) No
(7) Refused
(9) Don’t know

13

[If no to both YOG.3 and YOG.4 for all possible exercises skip to next modality]
[ask if more than one exercise mentioned in YOG.2]
YOG.5
DURING THE PAST 12 MONTHS, which exercise [fill from yes answers to YOG.2] did you
practice the most?
__________________[EXERCISE]
YOG.6
DURING THE PAST 12 MONTHS, did you take a [fill: type of exercise] class or in some way
receive formal training? Attending only one session does not count.
(1) Yes (cycle through ALL.1 through ALL.11)
(2) No (cycle through ALL.10 through ALL.11)
(7) Refused (cycle through ALL.10 through ALL.11)
(9) Don’t know (cycle through ALL.10 through ALL.11)

DIT.1
Have you EVER used any of the following special diets for two weeks or more for health
reasons?
(1) Vegetarian, including Vegan (for health reasons)
(2) Macrobiotic
(3) Atkins
(4) Pritikin
(5) Ornish
[IF NO TO ALL, GO TO NEXT MODALITY]

Yes
Yes
Yes
Yes
Yes

No,Ref/DK
No,Ref/DK
No,Ref/DK
No,Ref/DK
No,Ref/DK

DIT.2
DURING THE PAST 12 MONTHS, did you use {fill: yes answers from DIT.1] for two weeks or
more for health reasons?
(1) Yes
(2) No to all (go to next modality)
(7) Refused (go to next modality)
(9) Don’t know (go to next modality
[use “special diets” as fill throughout section]
DIT.3
Did you use special diets for weight control or weight loss?
(1) Yes
(2) No
14

(7) Refused
(9) Don’t know
DIT.4
Have you EVER seen a practitioner for special diets?
(1) Yes
(2) No (ALL.10)
(7) Refused (ALL.10)
(9) Don’t know (ALL.10)

DIT.5
DURING THE PAST 12 MONTHS, did you see a practitioner for special diets?
(1) Yes (ALL.1)
(2) No (ALL.10)
(7) Refused (ALL.10)
(9) Don’t know (ALL.10)

MOV.1
Have you ever practiced any of the following movement or exercise techniques?
(1) Feldenkrais
(2) Alexander Technique
(3) Pilates
(4) Trager Psychophysical Integration

Yes
Yes
Yes
Yes

No,Ref/DK
No,Ref/DK
No,Ref/DK
No,Ref/DK

[If no to all, goto next modality]
[ask for each yes response in MOV.1]
MOV.2
Have you ever seen a practitioner or teacher for [fill for yes responses to MOV.1]?
(1) Feldenkrais
(2) Alexander Technique
(3) Pilates
(4) Trager Psychophysical Integration

Yes
Yes
Yes
Yes

No,Ref/DK
No,Ref/DK
No,Ref/DK
No,Ref/DK

[Cycle through MOV.3 for each yes in MOV.2, else if all no, cycle through MOV.4 for each
yes in MOV.1]

MOV.3
15

DURING THE PAST 12 MONTHS, did you see a practitioner or teacher for [fill: type of
movement therapy]?
(1) Yes (ALL.1 using “movement or exercise technique” as fill)
(2) No to all (MOV.4)
(7) Refused (MOV.4)
(9) Don’t know (MOV.4)
MOV.4
DURING THE PAST 12 MONTHS, did you use [fill: type of movement therapy]?
(1) Yes (ALL.10)
(2) No to all (TOP.1 or TP3.1)
(7) Refused (TOP.1 or TP3.1)
(9) Don’t know (TOP.1 or TP3.1)
______________________________________________________________________________
Questions ALL.1 – ALL.11 (plus some additional modality specific questions included in this
section)
Next 3 questions for chiropractic or osteopathic manipulation ONLY:
CHI.1
Which did you see, a chiropractor or an osteopathic physician?
(1) Chiropractor (goto CHI.3)
(2) Osteopathic physician (goto CHI.3)
(3) Both (goto CHI.2)
(7) Refused
(9) Don’t know
CHI.2
DURING THE PAST 12 MONTHS, which practitioner did you see the most?
(1) Chiropractic (use as fill for rest of chiropractic section)
(2) Osteopathic physician (use as fill for rest of chiropractic section)
(7) Refused
(9) Don’t know

[ask if choice 3 picked in CAM.2 and choice 1 picked in CHI.2]
CHI.3
Was this the personal health care provider you mentioned earlier?
(1) Yes (ALL.1)
(2) No (ALL.1)
(7) Refused (ALL.1)
(9) Don’t know (ALL.1)
16

Next question for Hypnosis ONLY:
HYP.1
Did you do breathing exercises as part of hypnosis? Breathing exercises may involve actively
controlling the way air is drawn in, or the rate or depth of breathing.
(1) Yes (ALL.1)
(2) No (ALL.1)
(7) Refused (ALL.1)
(9) Don’t know (ALL.1)

Next question for biofeedback ONLY:
BIO.1
Did you do breathing exercises as part of biofeedback? Breathing exercises may involve actively
controlling the way air is drawn in, or the rate or depth of breathing.
(1) Yes (ALL.1)
(2) No (ALL.1)
(7) Refused (ALL.1)
(9) Don’t know (ALL.1)
[For self-care modalities (biofeedback, hypnosis, herbs, homeopathy, mind-body therapies,
yoga/tai-chi/qi gong, special diets, and movement therapies, only ask ALL.1 through ALL.9
if saw a practitioner in past 12 months; else goto ALL.10]
ALL.1
Do you know the exact number of times you saw a practitioner for [fill: modality] in the past 12
months?
(1) Yes (ALL.2
(2) No (ALL.3)
(7) Refused (ALL.3)
(9) Don’t know (ALL.3)
ALL.2
DURING THE PAST 12 MONTHS, how many times did you see a practitioner for [fill:
modality]?
___________________ # of times (goto ALL.4)

ALL.3
DURING THE PAST 12 MONTHS, ABOUT how many times did you see a practitioner for [fill:
modality]? Would you say…
17

[read categories]
(1)
(2)
(3)
(4)
(5)
(6)
(7)

Only 1 time
2-5 times
6-10 times
11-15 times
16-20 times
21-25 times
More than 25 times
Refused
Don’t know

ALL.4
DURING THE PAST 12 MONTHS, were any of the costs of seeing a practitioner for [fill:
modality] covered by health insurance?
(1) Yes (next question)
(2) No (ALL.6)
(7) Refused (ALL.6)
(9) Don’t know (ALL.6)
ALL.5
DURING THE PAST 12 MONTHS, did your health insurance cover all of the cost or just some
of the cost of seeing a practitioner for [fill: modality]?
(1) All of the cost (ALL.10)
(2) Some of the cost
(7) Refused
(9) Don’t know

ALL.6
Do you know the total amount you paid for seeing a practitioner for [fill: modality] in the past 12
months [fill: not including the amount covered by insurance]?
(1) Yes
(2) No (ALL.8)
(7) Refused (ALL.8)
(9) Don’t know (ALL.8)

ALL.7
What is the total amount you paid for seeing a practitioner for [fill: modality] in the past 12
months?

18

$_______________ (amount in dollars) (go to ALL.10)
*Enter zero if no cost or free
ALL.8
Do you know the average amount you paid for each visit for [fill: modality] [fill: not including
the amount covered by insurance] in the past 12 months?
1. Yes (next question)
2. No (gotot ALL.10)

ALL.9
On average, how much did you pay out-of-pocket for each visit to a practitioner for [fill:
modality]?
$______________________ (amount in dollars)
($0 – 500)
*Enter zero if no cost or free

ALL.10
DURING THE PAST 12 MONTHS, did you buy a self-help book or other materials such as a
DVD, CD,
or Video to learn about [fill: modality]?
(1) Yes (goto ALL.11)
(2) No (next modality or continue on if one of top 3 modalities)
(7) Refused (next modality or continue on if one of top 3 modalities)
(9) Don’t know (next modality or continue on if one of top 3 modalities)
ALL.11
About how much did you pay for these materials in the past 12 months?
$ ________________________
[goto next modality or continue on if one of top 3 modalities]

[If more than 3 total modalities used in past 12 months, ask this question, else go to TP3.1
for 1st modality used]
TOP.1
DURING THE PAST 12 MONTHS, which THREE of these therapies were the most important
for your health?
19

[instrument to list all modalities used in past 12 months]
Ask Question TP3.1 – TP3.21 for top 3 modalities ONLY.
*Chelation Therapy and Ayurveda not part of top 3 due to low prevelance.
[self-care modalities will say “use” instead of “see a practitioner for”; for traditional
healers, use “see a {fill: type of tradititional healer}]
TP3.1

Did you [fill: use/see a practitioner for] [fill: modality] for any of these reasons?

Yes/No/Ref/DK
(1)
(2)
(3)
(4)
(5)

For general wellness or general disease prevention?
To improve your energy?
To improve your immune function?
To improve your athletic or sports performance?
To improve your memory or concentration?

TP3.2 Did [fill: using/seeing a practitioner for] [fill: modality] motivate you to …?
Yes/No/Ref/DK
(1) Eat healthier?
(2) Eat more organic foods?
[ask #3 for respondents who report drinking alcohol in core]
(3) Cut back or stop drinking alcohol?
[ask #4 for respondents who report smoking in core]
(4) Cut back or stop smoking cigarettes?
(5) Exercise more regularly?
TP3.3 Did [fill: using/seeing a practitioner for] [fill: modality] lead to any of these outcomes?
Yes/No/Ref/DK
(1)
(2)
(3)
(4)
(5)

Give you a sense of control over your health?
Help to reduce your stress level or to relax?
Help you to sleep better?
Make you feel better emotionally?
Make it easier to cope with health problems?

TP3.4 Did [fill: using/seeing a practitioner for] [fill: modality] lead to any of these outcomes?
Yes/No/Ref/DK
(1) Improve your overall health and make you feel better?
(2) Improve your relationships with others?
(3) Improve your attendance at a job or school?

20

[IF more than 1 reason given in TP3.1 – TP3.4 ask next question, else go to TP3.6]
TP3.5
Of the following reasons, which ONE was the most important for [fill: using/seeing a practitioner
for] [fill: modality] {fill from TP3.1-TP3.4}?
[instrument to fill all choices in TP3.1- TP3.4]

TP3.6
How much do you think [fill: modality] helped [fill: reason given in previous question]? Would
you say a great deal, some, only a little, or not at all?
(1)
(2)
(3)
(4)

A great deal
Some
Only a little
Not at all
Refused
Don’t know

[If no health conditions reported in core questionnaire, skip to TP3.13]
TP3.7
DURING THE PAST 12 MONTHS, did you [fill: use/see a practitioner for] [fill: modality] for
one or more
specific health problems, symptoms, or conditions?
(1) Yes
(2) No (goto TP3.13)
(7) No (goto TP3.13)
(9) No (goto TP3.13)

TP3.8
For what health problem, symptom, or condition did you [fill use/see a practitioner for]
[modality]?
[computer to list these from core questions; See Appendix II for list of conditions pulled
in from core]
[IF more than 1 condition, ask next question; else go to TP3.10]
TP3.9
For which ONE of these did you [fill: use/see a practitioner for] [fill: modality] the most?

21

_________________________ [CONDITION]
*If respondent cannot choose one condition, probe for condition most important for using
modality.
TP3.10
How much do you think [fill: modality] helped your [fill: health problem, symptom, or
condition]? Would you say a great deal, some, only a little, or not at all?
(1)
(2)
(3)
(4)

A great deal
Some
Only a little
Not at all
Refused
Don’t know

TP3.11
Did you receive any of these medical treatments for [fill: health problem, symptom, or
condition]?
Yes/No/Ref/DK
(1) Prescription Medications?
(2) Over-the-counter medications?
(3) Surgery?
(4) Physical therapy?
(5) Mental Health Counseling?
[ask this question for yes responses in TP3.11 above, else goto next question]
TP3.12
DURING THE PAST 12 MONTHS, did you [fill: use/see a practitioner for] [fill: modality] for
any of these
reasons?
Yes/No/Ref/DK
(1) Because these medical treatments were too expensive?
(2) Because [fill: modality] combined with these medical treatments would help you?
(3) Because these medical treatments do not work for the health problem you want to treat or
prevent?
(4) Because [fill: category 1 or 2 from TP3.11] causes side effects?

TP3.13
Did you see a practitioner for [fill: modality] for any of these reasons?
22

Yes/No/Ref/DK
(1)
(2)
(3)
(4)
(5)

Because you can do it on your own [self-care modalities only]?
Because it is natural?
Because it focuses on the whole person, mind, body, and spirit?
Because [fill: modality] treats the cause and not just the symptoms?
Because it was part of your upbringing?

TP3.14
Did you see a practitioner for [fill: modality] because it was recommended by any of the
following people?
Yes/No/Ref/DK
(1)
(2)
(3)
(4)

A medical doctor
A family member
A friend
A co-worker

TP3.15
DURING THE PAST 12 MONTHS, how important was your use of [fill: modality] in
maintaining your health and well-being? Would you say very important, somewhat important,
slightly important, or not at all important?
(1)
(2)
(3)
(4)

Very important
Somewhat important
Slightly important
Not at all important
Refused
Don’t know

[ask ONLY if respondent indicated having a personal health care provider in CAM.2]
TP3.16
[[fill1: Not including the practitioner you saw for [fill2: modality]] DURING THE PAST 12
MONTHS, did you let your personal health care provider know about your use of [fill2:
modality]?
*If practitioner for therapy is the same person as personal health care provider, enter '2'.
(1) Yes (goto TP3.18)
(2) No (goto TP3.17)
(7) Refused (goto TP3.18)
(9) Don’t know (goto TP3.18)
TP3.17

23

Why didn't you tell your personal health care provider about your use of [fill: modalilty]?
Yes/No/Ref/DK
(1) You were not using it at the time?
(2) They discouraged use of it in the past?
(3) You were worried they would discourage it?
(4) You were concerned about a negative reaction?
(5) You didn’t think they needed to know?
(6) They didn't ask?
(7) You don't think they know as much about it as you do?
(8) They didn't give you enough time to tell them?
TP3.18
DURING THE PAST 12 MONTHS, did you get information about [fill: modality] from any of
the following sources?
Yes/No/Ref/DK
(1) The internet?
(2) Books, magazines, or newspapers?
(3) DVDs, videos, or CDs?
(4) Television or radio?
(5) Scientific articles?
(6) Health food stores?

24

APPENDIX I: HERB LOOKUP TABLE (Used with Question HRB.1e)
01

5 HTP (5-Hydroxytryptophan)

02

Achillea (AKA Yarrowa)

03

Aloe Vera

04

Angelica (AKA Dang Gui or Dong Quai)

05

Androstenedione

06

Ashwagandha

07

Astragalus (AKA Huang Qi)

08

Ayurvedic herbs

09

Bearberry (AKA Uva Ursi)

10

Bilberry

11

Bitter Gourd (AKA Bitter Melon)

12

Bitter Melon (AKA Bitter Gourd)

13

Black cohosh

14

Black Mulberry berry or leaf (AKA Mulberry)

15

Blackroot

16

Buckthorn

17

Butterbur

18

Cactus

19

Carnitine

20

Cascara sagrada

21

Cassica senna (AKA Senna)

22

Cat’s Claw

23

Cayenne

24

Chasteberry (AKA Vitex)

25

Common Rue (AKA Rue or Ruta graveolens)

26

Curcumin (AKA Turmeric)

27

Conjugated Linolenic Acid (CLA)

28

Crataegus (AKA Hawthorn or Thornapple)

29

Creatine

30

Dandelion

31

Dang Gui (AKA Angelica or Dong Quai)

32

Devil’s Claw

33

DHEA (Dehydroepiandrosterone)

34

Dong Quai (AKA Angelica or Dang Gui)

35

Elderberry

36

Enzymes

37

Ephedra

38

Evening primrose oil

39

Feverfew

40

Fiber or Psyllium (pills or powder)

41

Flaxseed (Oil or Ground) in pill or capsule

25

42

Fenugreek

43

Garcinia (AKA Goat’s Thorn)

44

Ginger pills or gelcaps

45

Goat’s Thorn (AKA Garcinia)

46

Goji Berry in pills or capsules

47

Goldenseal (AKA Hydrastis

48

Guarana

49

Grape Seed Extract

50

Hawthorn (AKA Crataegus or Thornapple)

51

Horehound

52

Horse chestnut

53

Horny Goat Weed

54

Huang Qi (AKA Astragalus)

55

Hypericum (AKA St. Johns Wort)

56

Jin Bu Huan

57

Kava kava

58

Lavender tinctures or capsules (not oil)

59

Ligustrum (AKA Osha)

60

Linden flower (AKA Tilia)

61

Lecithin

62

Licorice root in pill or capsule

63

Lutein

64

Lycopene

65

Maca

66

Mulberry berry or leaf (AKA Black Mulberry)

67

Noni juice or extract in capsules or pills

68

Olive Leaf extract

69

Oregano in pill or capsule

70

Osha (AKA Ligustrum)

71

Pau d’arco

72

Peppermint oil capsule

73

Phido estrogens

74

Pine bark extract (AKA Pycnogenol)

75

Puncture vine (AKA Tribulus terrestris)

76

Pycnogenol (AKA Pine bark extract)

77

Rasyana herbs

78

Red yeast rice in pill or capsule

79

Rhodiola (AKA Roseroot)

80

Rose hips in pill or capsule

81

Roseroot (AKA Rhodiola)

82

Rue (AKA Common Rue or Ruta graveolens)

83

Ruta graveolens (AKA Common Rue or Rue)

84

Senna (AKA Cassica senna)

26

85

Siberian Ginseng (AKA Eleuthero, not a true Ginseng)

86

Slippery elm (AKA Ulmus)

87

Soy supplements or soy isoflavones

88

St. John’s wort (AKA Hypericum)

89

Stevia

90

Thornapple (AKA Crataegus or Hawthorn)

91

Tilia (AKA Linden flower)

92

Tribulus Terrestris (AKA Puncture vine)

93

Turmeric (Curcumin)

94

Ulmus (AKA Slippery elm)

95

Uva Ursi (AKA Bearberry)

96

Vitex (AKA Chasteberry)

97

Yarrow (AKA Achillea)

98

Yohimbe or Yohimbine

27

APPENDIX II: Conditions Pulled from Core Sample Adult and CAM Added Conditions: (Used
with Question TP3.8)
Health conditions from ACN to be filled in Top 3 condition items:
01. [if AABDOMYR eq <1>] – Abdominal pain
02. [if ACIDRYR eq <1>] - Acid reflux or heartburn
03. [if ANXNWYR eq <1>] - Felt anxious, nervous or worried
04. [if AASSTILL eq <1>] - Asthma
05. [if ARTHTYP includes <1>] - Arthritis
06. [if ADDHYP eq <1>] - Attention Deficit Disorder/Hyperactivity
07. [if AUTISM eq <1>] - Autism
08. [if AFLHCA includes <22>] - Benign tumors, cysts
09. [if BIPDIS eq <1>] - Bipolar Disorder
10. [if AFLHCA includes <13>] - Birth defect
11. [if CANEV eq <1>] - Cancer
12. [if CHLYR eq <1>] – High Cholesterol
13. [if CBRCHYR eq <1>] - Chronic Bronchitis
14. [if AFLHCA includes <21>] - Circulation problems (other than in the legs)
15. [if CHDYR eq <1>] - Coronary heart disease
16. [if DENYR eq <1>] - Dental pain
17. [if ADEPRSYR eq <1>] - Depression
18. [if DIBEV eq <1>] – Diabetes
19. [if DGSTALYR eq <1>] – Any kind of digestive allergy
20. [if FATYR eq <1>] - Excessive sleepiness during the day
21. [if ALCTOBYR eq <1>] - Excessive use of alcohol or tobacco
22. [if FATIGYR eq <1>] – Fatigue or lack of energy more than 3 days
23. [if AFEVRYR eq <1>] – Fever more than 1 day
24. [if ARTHTYP includes <5>] - Fibromyalgia
25. [if AFLHCA includes <5>] - Fracture, bone/joint injury
26. [if ARTHTYP includes <3>] - Gout
27. [if GYNYR eq <1>] - Gynecologic problem
28. [if AHAYFYR eq <1>] - Hay fever
29. [If ACOLDYR eq <1>] – Head or chest cold
30. [if AFLHCA includes <2> or AHEARST1 eq <3> or AHEARST1 eq <4> or AHEARST1 eq
<5> or AHEARST1 eq <6>] or HRTIN eq <1> - Hearing problem
31. [if HRTYR eq <1>] - Other heart condition or disease
32. [if AFLHCA includes <30>] - Hernia
33. [if HYPYR eq <1>] – Hypertension
34. [If IMMOTHYR eq <1> Infectious diseases or problems of the immune system
35. [if AFLUPNYR eq <1>] - Influenza or pneumonia
36. [if INSYR eq <1>] - Insomnia or trouble sleeping
37. [if PAINFACE eq <1>] - Jaw pain
38. [if JNTSYMP eq <1>] or ARTHTYP includes <6> - Joint pain or stiffness/Other joint
condition
39. [if AFLHCA includes <34>] - Knee problems (not arthritis, not joint injury)
40. [if LIVYR eq <1>] - Liver problem
41. [if AFLHCA includes <11>] - Lung/breathing problem
42. [if ARTHTYP includes <4>] - Lupus
43. [if MEMLOSYR eq <1>] - Memory loss of loss of other cognitive function
44. [if MENOYR eq <1>] - Menopause
28

45. [if MENSYR eq <1>] - Menstrual problems
46. [if AFLHCA includes <14>] – Intellectual disability, also known as Mental retardation
47. [if AFLHCA includes <19>] - Missing limbs (fingers, toes or digits), amputee
48. [If ANAUSYR eq <1>] – Nausea and/or vomiting
49. [If NEUROYR eq <1>] – Neurological problems
50. [if AFLHCA includes(<24>] - Osteoporosis, tendinitis
51. [if OTHALYR eq <1>] – Allergies other than hay fever, respiratory, food, digestive, or skin
allergies
52. [if APNOTHYR eq <1>] - Other chronic pain
53. [if AFLHCA includes <15>] - Other developmental problem
54. [if AFLHCA includes <6>] - Other injury
55. [if MHDOTHYR eq <1>] - Other mental health disorders
56. [if AMUSCLYR eq <1>] - Other muscle or bone pain
57. [if AFLHCA includes <29>] - Other nerve damage, including carpal tunnel syndrome
58. [If AFLHCA includes <18> or AOVRWTYR eq <1>] – Problems with being overweight
59. [if PHOBIAYR eq <1>] - Phobia or fears
60. [if AFLHCA includes <27>]- Polio (myelitis), paralysis, para/quadriplegia
61. [if PRCIRYR eq <1>] - Poor circulation in your legs
62. [if PROSTYR eq <1>] - Prostate trouble or impotence
63. [if AHEADYR eq <1>] – Recurring headache, other than migraine
64. [if RESPALYR eq <1>] – Any kind of respiratory allergy
65. [if RESPALYR eq <1>] – Any kind of respiratory allergy
66. [if ARTHTYP includes <2>] - Rheumatoid arthritis
67. [if AFLHCA includes <16>] - Senility
68. [if SINYR eq <1>] – Sinusitis
69. [if SKNALYR eq <1>] – Eczema or any kind of skin allergy
70. [if SKNYR1 eq <1>] - Skin problems, other than eczema or skin allergies
71. [if ATHOTHYR eq <1>] - Sore throat other than strep or tonsillitis
72. [if SPNYR eq <1>] - Sprain or strain
73. [if ASTRESYR eq <1>] – Frequent stress
74. [if ASTREPYR eq <1>] – Strep throat or tonsillitis
75. [if SUBABYR eq <1>] - Substance abuse, other than alcohol or tobacco
76. [if AFLHCA includes <90>] - fill problem from AFLHCA_S1
77. [if AFLHCA includes <91>] - fill problem from AFLHCA_S2
78. [if ULCYR eq <1>] Ulcer
79. [if URYR eq <1>] Urinary problems
80. [if AFLHCA includes <32>] – Varicose veins, hemorrhoids
81. [if AFLHCA includes <1> or AVISION eq <1>] – Vision problem
82. [if KIDWKYR eq <1>] Weak or failing kidneys
83. [if COPDEV eq <1>] - COPD
Fills that always appear (hardcoded):
84. Back pain or problem
85.Neck pain or problem
86. Severe headache or migraine
87. Stomach or intestinal illness
88. Other - specify

29

CARD CAM1
You may choose more than one.
1. Native American Healer or Medicine Man
2. Shaman
3. Curandero, Machi, or Parchero
4. Yerbero or Hierbista
5. Sobador
6. Huesero

CARD CAM2
You may choose more than one.

1. Combination herb pill
2. Acai (pills, gelcaps)
3. Bee Pollen and other Bee products
4. Chondroitin
5. Co-enzyme Q10 (CoQ10)
6. Cranberry (pills or capsules)
7. Digestive Enzymes (lactaid)
8. Echinacea
9. Fish Oil or omega 3 or DHA fatty acid or EPA fatty
acid supplements
10. Garlic supplements (pills, gelcaps)
11. Ginkgo Biloba
12. Ginseng
13. Glucosamine
14. Green tea pills (not brewed tea) or EGCG (pills)
15. Melatonin
16. Milk Thistle (silymarin)
17. MSM (Methylsulfonylmethane)
18. Probiotics or Prebiotics
19. SAM-e
20. Saw Palmetto
21. Valerian
22. Other herb(s) or non-vitamin supplement(s)