Form 3b Adult Core

Attachment 3b Adult Core (14 minutes)
Page 1 of 5

2011 NHIS Questionnaire - Sample Adult
Adult Identification
Document Version Date:
Question ID:

AID.005_00.000 Instrument Variable Name:

QuestionText:

22-Oct-10

SADULT

QuestionnaireFileName:

Sample Adult

* The sample adult person is [fill: ALIAS of Sample Adult]. The next questions must be answered by this person. Probe
as necessary to determine the availability of [fill: ALIAS of Sample Adult].
* If refused enter CTRL-R

1

Available
Not available
Physical or mental condition prohibits responding
Refused

2
3
7
UniverseText:

This is the Sample Adult and (the Sample Adult section has not been started or completed).

SkipInstructions:

<1> if Sample Adult = demographics.hhc.RELRESP_A
goto beginning of adult.asd
elseif Sample Adult = demographics.hhc.HHRESP
goto beginning of adult.asd
else
goto AIDVERF_S
endif
<2> goto callbk.ACALLBK1
<3> goto PROX1
store '4' in ASTAT
if recontact.RCIFLAG ne '1'
goto recontact.RCI_BEGIN procedure
else
goto back.OUTCOMEB1 procedure
endif

Question ID:

AID.010_00.000 Instrument Variable Name:

QuestionText:

PROX1

QuestionnaireFileName:

Sample Adult

* Proxy interviews can be done for sample adults that have a mental or physical condition that
prevents them from responding for themselves.
Is a family member or caregiver that is knowledgeable about [fill: ALIAS of Sample Adult]'s health available?

1
2

Yes
No

UniverseText:

The Sample Adult's physical or mental condition prohibits responding.

SkipInstructions:

<1> goto PROX2
<2> goto PROX3

Page 2 of 5

2011 NHIS Questionnaire - Sample Adult
Adult Identification
Document Version Date:
Question ID:

AID.015_00.000 Instrument Variable Name:

QuestionText:

22-Oct-10

PROX2

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

* Ask if necessary.
What is this person's relationship to [fill: ALIAS of Sample Adult]?

1

Relative who lives in household
Relative who doesn't live in household
Other caregiver
Other
Refused
Don't know

2
3
4
7
9
UniverseText:

Knowledgeable proxy is available.

SkipInstructions:

<1-4> goto AIDVERF_S

Question ID:

AID.020_00.000 Instrument Variable Name:

QuestionText:

PROX3

*Ask if necessary.
Can a callback with someone knowledgeable about [fill: ALIAS of Sample Adult]'s health be arranged?

1

Yes
No

2
UniverseText:

Knowledgeable proxy is not available.

SkipInstructions:

<1> goto callbk.ACALLBK1
<2> store '3' in ASTAT
if recontact.RCIFLAG ne '1'
goto recontact.RCI_BEGIN procedure
else
goto back.OUTCOMEB1 procedure
endif

Question ID:

AID.030_00.000 Instrument Variable Name:

QuestionText:

AIDVERF_S

QuestionnaireFileName:

* Please verify the following information about the sample adult before proceeding:
I have recorded your sex as [fill: Sex of Sample Adult]. Is this correct?
*If respondent "refuses" or says "don't know", enter "1" for "yes".

1
2

Yes
No

UniverseText:

Sample Adult is not the person entered in HHRESP or RELRESP_A. Or PROX1 = 'Yes'.

SkipInstructions:

<1> goto AIDVERF_A
<2> goto AIDSEX

Sample Adult

Page 3 of 5

2011 NHIS Questionnaire - Sample Adult
Adult Identification
Document Version Date:
Question ID:

AID.040_00.000 Instrument Variable Name:

QuestionText:

22-Oct-10

AIDSEX

QuestionnaireFileName:

Sample Adult

* Ask if appropriate; otherwise, enter your best guess of the person's sex.
Are you Male or Female?

1

Male
Female

2
UniverseText:

Respondent said his/her sex is not correct.

SkipInstructions:

<1,2> store AIDSEX in SEX
goto ERR_AIDSEX
reset AIDVERF_S
goto AIDVERF_S

Question ID:

AID.045_00.000 Instrument Variable Name:

QuestionText:

AIDVERF_A

QuestionnaireFileName:

Sample Adult

* Please verify the following information about the sample adult before proceeding:
I have recorded your age as [fill: Age of Sample Adult] old. Is this correct?
*If respondent "refuses" or says "don't know", enter "1" for "yes".

1

Yes
No

2
UniverseText:

Sample Adult said his/her sex is correct.

SkipInstructions:

<1> goto AIDVERF_D
<2> goto AIDAGE

Question ID:

AID.050_00.000 Instrument Variable Name:

QuestionText:
000-120
997
999

AIDAGE

QuestionnaireFileName:

How old are you?
Age in years
Refused
Don't know

UniverseText:

Respondent said his/her age is not correct

SkipInstructions:

<0-120, Refused, Don't know>
if AIDAGE = 'Refused' or AIDAGE = 'Don't know' or AIDAGE = AGE
reset AIDVERF_A
goto ERR_AIDAGE
else
store AIDAGE in AGE
goto AIDDOB_M

Sample Adult

Page 4 of 5

2011 NHIS Questionnaire - Sample Adult
Adult Identification
Document Version Date:
Question ID:

AID.055_00.000 Instrument Variable Name:

QuestionText:

22-Oct-10

AIDVERF_D

QuestionnaireFileName:

Sample Adult

* Please verify the following information about the sample adult before proceeding:
I have recorded your birthday as [fill: Birthday of Sample Adult]. Is this correct?
*If respondent "refuses" or says "don't know", enter "1" for "yes".

1

Yes
No

2
UniverseText:

Sample Adult said his/her age is correct.

SkipInstructions:

<1> if AGE of Sample Adult le '17'
goto NO_MORE
else
goto beginning of adult.asd
endif
<2> goto AIDDOB_M

Question ID:

AID.060_01.000 Instrument Variable Name:

QuestionText:

AIDDOB_M

QuestionnaireFileName:

1 of 3
What is your birthday?
*Enter month of birth.

01
02
03
04
05
06
07
08
09
10
11
12
97
99

January
February
March
April
May
June
July
August
September
October
November
December
Refused
Don't know

UniverseText:

Respondent said his/her date of birth is not correct or his/her age is not correct

SkipInstructions:

<01-12, Refused, Don't know> goto AIDDOB_D

Sample Adult

Page 5 of 5

2011 NHIS Questionnaire - Sample Adult
Adult Identification
Document Version Date:
Question ID:

AID.060_02.000 Instrument Variable Name:

QuestionText:

22-Oct-10

AIDDOB_D

QuestionnaireFileName:

Sample Adult

2 of 3
*Enter day of birth.

01-31

Day of the month
Refused
Don't know

97
99
UniverseText:

Respondent said his/her date of birth is not correct or his/her age is not correct

SkipInstructions:

<01-31,Refused,Don't know> goto AIDDOB_Y
If days not valid, goto ERR_AIDDOB_D

Question ID:

AID.060_03.000 Instrument Variable Name:

QuestionText:

AIDDOB_Y

QuestionnaireFileName:

Sample Adult

3 of 3
*Enter year of birth.

1880-2020

Year of birth

UniverseText:

Respondent said his/her date of birth is not correct or his/her age is not correct

SkipInstructions:

<1880-2020, Refused, Don't know> if AIDVERF_A = '2' (No) then reset AIDVERF_A to empty
goto AIDVERF_A
elseif AIDVERF_D = '2' (No) then reset AIDVERF_D to empty
goto AIDVERF_D
endif
(if year GT current year) or (if year = current year and month GT current month) or (if year = current year and
month = current month and day GT current day)
goto ERR1_AIDDOB_Y
endif
(if birth month = '02' and birth day = '29' and this is not a leap year)
goto ERR2_AIDDOB_Y
endif
(if AIDDOB_M = 'Ref' or 'DK') or (if AIDDOB_D = 'Re'f or 'DK') or (if AIDDOB_Y = 'Ref' or 'DK')
goto ERR3_AIDDOB_Y
else
store AIDDOB_M in DOBM
store AIDDOB_D in DOBD
store AIDDOB_Y in DOBY
if AIDVERF_A = '2' (No) then reset AIDVERF_A to empty
goto AIDVERF_A
elseif AIDVERF_D = '2' (No) then reset AIDVERF_D to empty
goto AIDVERF_D
endif
endif
Calculate age from AIDDOB_M, AIDDOB_D, and AIDDOB_Y.
if age from AIDDOB items is ne AGE and age from AIDDOB items is valid
reset AIDVERF_A or AIDVERF_D.
goto ERR4_AIDDOB_Y
endif

Page 1 of 8

2011 NHIS Questionnaire - Sample Adult
Adult Socio-Demographic
Document Version Date:
Question ID:

ASD.050_00.000 Instrument Variable Name:

QuestionText:

21-Oct-10

WRKVER

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

Earlier I recorded that in the last week you were
(Fill1: working for pay at a job or business.)
(Fill2: with a job or business but not at work.)
(Fill3: looking for work.)
(Fill4: working, but not for pay, at a family-owned job or business.)
(Fill5: not working at a job or business and not looking for work.)
Is that correct?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who were working or not working last week

SkipInstructions:

<1>if DOINGLW2 = 1,2,4 [goto WHOWRK]
else if DOINGLW2 = 3,5 [goto EVERWRK]
<2>go to WRKCOR
go to EVERWRK

Question ID:

ASD.060_00.000 Instrument Variable Name:

QuestionText:

(book) A1

WRKCOR

? [F1]

What is your correct working status?
* Read answer categories.
1
2
3
4
5
7
9

Working for pay at a job or business
With a job or business but not at work
Looking for work
Working, but not for pay, at a family-owned job or business
Not working at a job or business and not looking for work
Refused
Don't know

UniverseText:

Sample adults 18+ whose working status was incorrect or who were not the Family Respondent and with an
answer of D or R to DOINGLW.

SkipInstructions:

<1,4> [goto to WHOWRK]
<2,5>[goto WHYNOWK2]
<3,R,D>[goto EVERWRK]

Page 2 of 8

2011 NHIS Questionnaire - Sample Adult
Adult Socio-Demographic
Document Version Date:
Question ID:

ASD.062_00.000 Instrument Variable Name:

QuestionText:

21-Oct-10

DOINGLW2

QuestionnaireFileName:

Sample Adult

Corrected Employment Status Last Week: (not displayed)

1

Working for pay at a job or business
With a job or business but not at work
Looking for work
Working, but not for pay, at a family-owned job or business
Not working at a job or business and not looking for work
Refused
Don't know

2
3
4
5
7
9
UniverseText:

Sample Adults 18+ and also the family section respondent and said Refused or Don't know to the working last
week status question in the family section

SkipInstructions:

if DOINGLW2 = Refused or Don't know then
[goto EVERWRK]
endif

Question ID:

ASD.065_00.000 Instrument Variable Name:

QuestionText:

WHYNOWK2

QuestionnaireFileName:

Sample Adult

? [F1]
(Fill1: What is the main reason you did not work last week?)
(Fill2: What is the main reason you did not have a job or business last week?)

01
02
03
04
05
06
07
08
09
10
97
99

Taking care of house or family
Going to school
Retired
On a planned vacation from work
On family or maternity leave
Temporarily unable to work for health reasons
Have job/contract and off-season
On layoff
Disabled
Other
Refused
Don't know

UniverseText:

Sample Adults 18+ whose corrected working status last week was not working at a job or business and not looking
for work or with a job or business but not at work

SkipInstructions:

<1-10,D,R> if WRKCOR = 2 then
[goto WHOWRK]
else [goto EVERWRK]

Page 3 of 8

2011 NHIS Questionnaire - Sample Adult
Adult Socio-Demographic
Document Version Date:
Question ID:

ASD.066_00.000 Instrument Variable Name:

QuestionText:

21-Oct-10

EVERWRK

QuestionnaireFileName:

Sample Adult

Have you ever held a job or worked at a business?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who were NOT working at a job or business and not looking for work or looking for work last
week or didn't know or refused to provide their employment status last week

SkipInstructions:

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

Question ID:

ASD.070_00.000 Instrument Variable Name:

QuestionText:

WHOWRK

QuestionnaireFileName:

Sample Adult

? [F1]
(Fill1:For whom did you work at your MAIN job or business? (Name of company, business, organization or
employer))
(Fill2: Thinking about the job you held the longest, for whom did you work? (Name of company, business, organization
or employer))
(Fill3: Thinking about the job you held most recently, for whom did you work? (Name of company, business,
organization or employer))

Verbatim

Verbatim response
Refused
Don't know

7
9
UniverseText:

Sample adults 18+ who were working last week, or who were with a job or business but not at work, or who were
working but not for pay at a family-owned job or business, or who have ever worked

SkipInstructions:

<90 char long,D,R> [goto KINDIND]

Question ID:

ASD.080_00.000 Instrument Variable Name:

QuestionText:

KINDIND

QuestionnaireFileName:

Sample Adult

? [F1]
What kind of business or industry was this? (For example: TV and radio mgt., retail shoe store, State Department of
Labor)

Verbatim
7
9

Verbatim response
Refused
Don't know

UniverseText:

Sample adults 18+ who were working last week, or who were with a job or business but not at work, or who were
working but not for pay at a family-owned job or business, or who have ever worked

SkipInstructions:

<90 char long,D,R> [goto KINDWRK]

Page 4 of 8

2011 NHIS Questionnaire - Sample Adult
Adult Socio-Demographic
Document Version Date:
Question ID:

ASD.090_00.000 Instrument Variable Name:

QuestionText:

21-Oct-10

KINDWRK

QuestionnaireFileName:

Sample Adult

? [F1]
What kind of work were you doing? (For example: farming, mail clerk, computer specialist.)

Verbatim

Verbatim response
Refused
Don't know

7
9
UniverseText:

Sample adults 18+ who were working last week, or who were with a job or business but not at work, or who were
working but not for pay at a family-owned job or business, or who have ever worked

SkipInstructions:

<90 char long,D,R> [goto IMPACT]

Question ID:

ASD.100_00.000 Instrument Variable Name:

QuestionText:

IMPACT

QuestionnaireFileName:

Sample Adult

? [F1]
What were your most important activities on this job or business? (For example: sells cars, keeps account books, operates
printing press.)

Verbatim

Verbatim response
Refused
Don't know

7
9
UniverseText:

Sample adults 18+ who were working last week, or who were with a job or business but not at work, or who were
working but not for pay at a family-owned job or business, or who have ever worked

SkipInstructions:

<90 char long,D,R> [goto WRKCAT]

Question ID:

ASD.110_00.000 Instrument Variable Name:

QuestionText:

WRKCAT

QuestionnaireFileName:

Sample Adult

(book) A2 ? [F1]
[If DOINGLW2 eq <1,2,4>] Looking at the card, which of these best describes your current job or work situation? [Else if
EVERWRK eq <1> and [WHYNOWK2 eq 03 or AGE ge 65] Looking at the card, which of these best describes the job
you held for the longest time?[Else if EVERWRK eq <1> and WHYNOWK2 ne 03 and AGE lt 65] Looking at the card,
which of these best describes the job you held most recently?
* Read answer choices if necessary.

1
2
3
4
5
6
7
9

Employee of a PRIVATE company for wages
A FEDERAL government employee
A STATE government employee
A LOCAL government employee
Self-employed in OWN business, professional practice or farm
Working WITHOUT PAY in a family-owned business or farm
Refused
Don't know

UniverseText:

Sample adults 18+ who were working last week, or who were with a job or business but not at work, or who were
working but not for pay at a family-owned job or business, or who have ever worked

SkipInstructions:

<1-4,6,D,R>[goto LOCALLNO]
<5> [goto BUSINC]

Page 5 of 8

2011 NHIS Questionnaire - Sample Adult
Adult Socio-Demographic
Document Version Date:
Question ID:

ASD.112_00.000 Instrument Variable Name:

QuestionText:

BUSINC

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

Is this business incorporated?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who are self-employed

SkipInstructions:

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

Question ID:

21-Oct-10

ASD.120_00.000 Instrument Variable Name:

QuestionText:

LOCALLNO

(book) A3
Thinking about [If DOINGLW2 eq <1,2,4>] this MAIN job or business [Else if EVERWRK eq <1> and [WHYNOWK2
eq 03 or AGE ge 65] your last week at the job you held the longest [Else if EVERWRK eq <1> and WHYNOWK2 ne 03
and AGE lt 65] your last week at the job you held most recently how many people work(ed) at this location?
how many people (Fill4:work/Fill5: worked) at this location?
* "People" includes both FULL- and PART-time employees; "location" refers to the street address of the workplace.

01
02
03
04
05
06
07
08
97
99

1-9 employees
10-24 employees
25-49 employees
50-99 employees
100-249 employees
250-499 employees
500-999 employees
1000 employees or more
Refused
Don't know

UniverseText:

Sample adults 18+ who were working last week, or who were with a job or business but not at work, or who were
working but not for pay at a family-owned job or business, or who have ever worked

SkipInstructions:

<1-8, R,D>[goto WRKLONGN]

Page 6 of 8

2011 NHIS Questionnaire - Sample Adult
Adult Socio-Demographic
Document Version Date:
Question ID:

ASD.140_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

WRKLONGN

QuestionnaireFileName:

Sample Adult

? [F1]
1 of 2
About how long [If DOINGLW2 eq <1,2,4>] have you worked at this MAIN job or business? [Else if EVERWRK eq <1>
and [WHYNOWK2 eq 03 or AGE ge 65] did you work at the job you held the longest? [Else if EVERWRK eq <1> and
WHYNOWK2 ne 03 and AGE lt 65] did you work at the job you held most recently?

001-365

1-365
Refused
Don't know

997
999
UniverseText:

Sample adults 18+ who were working last week, or who were with a job or business but not at work, or who were
working but not for pay at a family-owned job or business, or who have ever worked

SkipInstructions:

<1-365> [goto WRKLONGT]
if EVERWRK eq 1 and (WHYNOWK2 eq 03 or AGE GE 65)
[goto HOURPD] ;
Else if (EVERWRK eq 1 and WHYNOWK2 = 1,2,4-10, D,R," " and AGE lt 65) or (DOINGLW2 = 1,2,4)
[goto WRKLONGH]

Question ID:

ASD.140_02.000 Instrument Variable Name:

QuestionText:

WRKLONGT

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period.

1
2
3
4

Day(s)
Week(s)
Month(s)
Year(s)

UniverseText:

Sample adults 18+ (who were working last week, or who were with a job or business but not at work, or who were
working but not for pay at a family-owned job or business, or who have ever worked) and who gave a number
entry in WRKLONGN

SkipInstructions:

<4> if WRKLONGN gt AGE then [goto ERR_WRKLONGT]
<1-4> if EVERWRK = 1 and (WHYNOWK2 = 3 or AGE ge 65) then [goto HOURPD]
else if (EVERWRK eq 1 and WHYNOWK2 = 1,2,4-10, D,R," " and AGE lt 65) or (DOINGLW2 = 1,2,4)
[goto WRKLONGH]

Page 7 of 8

2011 NHIS Questionnaire - Sample Adult
Adult Socio-Demographic
Document Version Date:
Question ID:

ASD.146_00.000 Instrument Variable Name:

QuestionText:

21-Oct-10

WRKLONGH

QuestionnaireFileName:

Sample Adult

? [F1]
[If DOINGLW2 eq 1,2,4] Is this MAIN job or business the job you have held for the longest? [Else if EVERWRK eq 1
and WHYNOWK2 ne 03 and AGE lt 65] Was your most recently held job also the job you held the longest?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ (who were working last week, or who were with a job or business but not at work, or who were
working but not for pay at a family-owned job or business,) or (who have ever worked and are not retired and are
less than 65 years of age.)

SkipInstructions:

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

Question ID:

ASD.150_00.000 Instrument Variable Name:

QuestionText:

HOURPD

QuestionnaireFileName:

Sample Adult

[If DOINGLW2 eq <1,2,4>] Are you paid by the hour at this MAIN job or business? [Else if EVERWRK eq <1> and
[WHYNOWK2 eq 03 or AGE ge 65] Were you paid by the hour on the job you held the longest? [Else if EVERWRK eq
<1> and WHYNOWK2 ne 03 and AGE lt 65] Were you paid by the hour on the job you held most recently?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who were working last week, or who were with a job or business but not at work, or who were
working but not for pay at a family-owned job or business, or who have ever worked

SkipInstructions:

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

Question ID:

ASD.160_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

PDSICK

QuestionnaireFileName:

Sample Adult

[If DOINGLW2 eq <1,2,4>] Do you have paid sick leave on this MAIN job or business? [Else if EVERWRK eq <1> and
[WHYNOWK2 eq 03 or AGE ge 65] Did you ever have paid sick leave on the job you held the longest?[Else if
EVERWRK eq <1> and WHYNOWK2 ne 03 and AGE lt 65] Did you ever have paid sick leave on the job you held most
recently?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who were working last week, or who were with a job or business but not at work, or who were
working but not for pay at a family-owned job or business, or who have ever worked

SkipInstructions:

<1,2,D,R>
if DOINGLW2 = 1,2,4 then [goto ONEJOB];
else if DOINGLW2=3,5 then [goto WRKLYR2];
else if DOINGLW2=D, R then [goto next section]

Page 8 of 8

2011 NHIS Questionnaire - Sample Adult
Adult Socio-Demographic
Document Version Date:
Question ID:

ASD.170_00.000 Instrument Variable Name:

QuestionText:

21-Oct-10

ONEJOB

QuestionnaireFileName:

Sample Adult

Do you have more than one job or business?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who were working last week, or who were with a job or business but not at work, or who were
working but not for pay at a family-owned job or business

SkipInstructions:

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

Question ID:

ASD.210_00.000 Instrument Variable Name:

QuestionText:
0
1
2
7
9

WRKLYR2

QuestionnaireFileName:

Sample Adult

Although you did not work last week, did you have a job or business at any time in the PAST 12 MONTHS?
Had job last week
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who were looking for work or who were not working at a job or business AND who were not
looking for work in the last week

SkipInstructions:

<0-2,D,R> [goto next section]

Page 1 of 23

2011 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:

ACN.010_00.000 Instrument Variable Name:

QuestionText:

22-Oct-10

HYPEV

QuestionnaireFileName:

Sample Adult

Now I am going to ask you about certain medical conditions.
Have you EVER been told by a doctor or other health professional that you had
... Hypertension, also called high blood pressure?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

ACN.020_00.000 Instrument Variable Name:

QuestionText:

HYPDIFV

Sample Adult

Were you told on two or more DIFFERENT visits that you had hypertension, also called high blood pressure?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who were told they had hypertension

SkipInstructions:

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

Question ID:

QuestionnaireFileName:

ACN.031_01.000 Instrument Variable Name:

QuestionText:

2
7
9

QuestionnaireFileName:

Have you EVER been told by a doctor or other health professional that you had
... Coronary heart disease?

1

CHDEV

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Sample Adult

Page 2 of 23

2011 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:

ACN.031_02.000 Instrument Variable Name:

QuestionText:

ANGEV

22-Oct-10
QuestionnaireFileName:

Sample Adult

* Read if necessary:
Have you EVER been told by a doctor or other health professional that you had
... Angina, also called angina pectoris?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

ACN.031_03.000 Instrument Variable Name:

QuestionText:

MIEV

QuestionnaireFileName:

Sample Adult

* Read if necessary:
Have you EVER been told by a doctor or other health professional that you had
...A heart attack (also called myocardial infarction)?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

ACN.031_04.000 Instrument Variable Name:

QuestionText:

HRTEV

QuestionnaireFileName:

? [F1]
* Read if necessary:
Have you EVER been told by a doctor or other health professional that you had
...Any kind of heart condition or heart disease (other than the ones I just asked about)?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Sample Adult

Page 3 of 23

2011 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:

ACN.031_05.000 Instrument Variable Name:

QuestionText:

STREV

22-Oct-10
QuestionnaireFileName:

Sample Adult

* Read if necessary:
Have you EVER been told by a doctor or other health professional that you had
...A stroke?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

ACN.031_06.000 Instrument Variable Name:

QuestionText:

EPHEV

QuestionnaireFileName:

Sample Adult

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

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

ACN.080_00.000 Instrument Variable Name:

QuestionText:

AASMEV

QuestionnaireFileName:

? [F1]
Have you EVER been told by a doctor or other health professional that you had asthma?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto AASSTILL]
<2,R,D> [goto ULCEV]

Sample Adult

Page 4 of 23

2011 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:

ACN.085_00.000 Instrument Variable Name:

QuestionText:

22-Oct-10

AASSTILL

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

? [F1]
Do you still have asthma?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who were ever told they have asthma

SkipInstructions:

<1,2,R,D> [go to AASMYR]

Question ID:

ACN.090_00.000 Instrument Variable Name:

QuestionText:

AASMYR

? [F1]
DURING THE PAST 12 MONTHS, have you had an episode of asthma or an asthma attack?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who were ever told they had asthma

SkipInstructions:

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

Question ID:

ACN.100_00.000 Instrument Variable Name:

QuestionText:

AASMERYR

QuestionnaireFileName:

Sample Adult

? [F1]
DURING THE PAST 12 MONTHS, have you had to visit an emergency room or urgent care center because of asthma?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who were ever told they had asthma

SkipInstructions:

<1,2,R,D> [goto ULCEV

Page 5 of 23

2011 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:

ACN.110_00.000 Instrument Variable Name:

QuestionText:

22-Oct-10

ULCEV

QuestionnaireFileName:

Sample Adult

Have you EVER been told by a doctor or other health professional that you had
...An ulcer
This could be a stomach, duodenal or peptic ulcer.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

ACN.120_00.000 Instrument Variable Name:

QuestionText:

ULCYR

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS have you had
... An ulcer?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who were ever told they had an ulcer

SkipInstructions:

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

Question ID:

ACN.130_00.000 Instrument Variable Name:

QuestionText:

Have you EVER been told by a doctor or other health professional that you had
...Cancer or a malignancy of any kind?

1
2
7
9

CANEV

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto CANKIND]
<2,R,D> [goto DIBEV]

Page 6 of 23

2011 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:

ACN.140_00.001 Instrument Variable Name:

QuestionText:

22-Oct-10

CANKIND_1

QuestionnaireFileName:

What kind of cancer was it?
* Enter code for the first kind of cancer.

01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
97
99

Bladder
Blood
Bone
Brain
Breast
Cervix
Colon
Esophagus
Gallbladder
Kidney
Larynx-windpipe
Leukemia
Liver
Lung
Lymphoma
Melanoma
Mouth/tongue/lip
Ovary
Pancreas
Prostate
Rectum
Skin (non-melanoma)
Skin (DK what kind)
Soft tissue (muscle or fat)
Stomach
Testis
Throat - pharynx
Thyroid
Uterus
Other
Refused
Don't know

UniverseText:

Sample adults 18+ who were ever told they had cancer

SkipInstructions:

<1-30,R,D>[goto CANAGE_1]
IF SEX=1 (MALE) and No. <6,18,29> selected goto ERR1_CANKIND_1
IF SEX=2 (FEMALE) and No. <20,26> selected goto ERR2_CANKIND_1

Sample Adult

Page 7 of 23

2011 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:

ACN.140_00.002 Instrument Variable Name:

22-Oct-10

CANKIND_2

QuestionnaireFileName:

Sample Adult

QuestionText:

* Enter code for the second kind of cancer.
* Enter '96' for no more.
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
96
97
99

Bladder
Blood
Bone
Brain
Breast
Cervix
Colon
Esophagus
Gallbladder
Kidney
Larynx-windpipe
Leukemia
Liver
Lung
Lymphoma
Melanoma
Mouth/tongue/lip
Ovary
Pancreas
Prostate
Rectum
Skin (non-melanoma)
Skin (DK what kind)
Soft tissue (muscle or fat)
Stomach
Testis
Throat - pharynx
Thyroid
Uterus
Other
No more
Refused
Don't know

UniverseText:

Sample adults 18+ who either provided an age for one kind of cancer or didn't know how old they were when first
diagnosed with that kind of cancer or else refused to provide an age but had not refused to answer CANKIND_1.

SkipInstructions:

<1-30,R,D>[goto CANAGE_2]
<96> goto DIBEV
IF SEX=1 (MALE) and No. <6,18,29> selected goto ERR1_CANKIND_2
IF SEX=2 (FEMALE) and No. <20,26> selected goto ERR2_CANKIND_2

Page 8 of 23

2011 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:

ACN.140_00.003 Instrument Variable Name:

22-Oct-10

CANKIND_3

QuestionnaireFileName:

Sample Adult

QuestionText:

* Enter code for the third kind of cancer.
* Enter '96' for no more.
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
96
97
99

Bladder
Blood
Bone
Brain
Breast
Cervix
Colon
Esophagus
Gallbladder
Kidney
Larynx-windpipe
Leukemia
Liver
Lung
Lymphoma
Melanoma
Mouth/tongue/lip
Ovary
Pancreas
Prostate
Rectum
Skin (non-melanoma)
Skin (DK what kind)
Soft tissue (muscle or fat)
Stomach
Testis
Throat - pharynx
Thyroid
Uterus
Other
No more
Refused
Don't know

UniverseText:

Sample adults 18+ who either provided an age for a second kind of cancer or didn't know how old they were when
first diagnosed that kind of cancer or else refused to provide an age but had not refused to answer CANKIND_2.

SkipInstructions:

<1-30,R,D>[goto CANAGE_3]
<96> [goto DIBEV]
IF SEX=1 (MALE) and No. <6,18,29> selected goto ERR1_CANKIND_3
IF SEX=2 (FEMALE) and No. <20,26> selected goto ERR2_CANKIND_3

Page 9 of 23

2011 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:

ACN.140_00.004 Instrument Variable Name:

QuestionText:

22-Oct-10

CANKIND_4

QuestionnaireFileName:

Sample Adult

* Enter '95' if respondent offers more than 3 kinds of cancer.
* Enter '96' for no more.

95

More than three kinds
No more

96
UniverseText:

Sample adults 18+ who either provided an age for a third kind of cancer or didn't know how old they were when
first diagnosed that kind of cancer or else refused to provide an age but had not refused to answer CANKIND_3

SkipInstructions:

<95,96> [goto DIBEV]

Question ID:

ACN.150_00.001 Instrument Variable Name:

QuestionText:

CANAGE_1

QuestionnaireFileName:

Sample Adult

? [F1]
How old were you when [Fill1: CANKIND_1 / Fill2: this cancer] was first diagnosed?

001-100

1-100 years
Refused
Don't know

997
999
UniverseText:

Sample adults 18+ who were ever told they had cancer

SkipInstructions:

<1-100, D> goto CANKIND_2
and at CANKIND_1[goto DIBEV]
and CANKIND_1 NE [goto CANKIND_2]
If number in CANAGE_1 greater than person years old (AGE) goto ERR_ CANAGE_1

Question ID:

ACN.150_00.002 Instrument Variable Name:

QuestionText:

CANAGE_2

QuestionnaireFileName:

? [F1]
How old were you when [Fill1: CANKIND_2/Fill2: this cancer] was first diagnosed?

001-100
997
999

1-100 years
Refused
Don't know

UniverseText:

Sample adults 18+ who were ever told they had cancer

SkipInstructions:

<1-100, D> goto CANKIND_3
and at CANKIND_2goto DIBEV]
and CANKIND_2 NE [goto CANKIND_3]
If number in CANAGE_2 greater than person years old (AGE) goto ERR_ CANAGE_2

Sample Adult

Page 10 of 23

2011 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:

ACN.150_00.003 Instrument Variable Name:

QuestionText:

22-Oct-10

CANAGE_3

QuestionnaireFileName:

Sample Adult

? [F1]
How old were you when [Fill1: CANKIND_3/Fill2: this cancer ] was first diagnosed?

001-100

1-100 years
Refused
Don't know

997
999
UniverseText:

Sample adults 18+ who were ever told they had cancer

SkipInstructions:

<1-100, D> goto CANKIND_4
and at CANKIND_3[goto DIBEV]
and CANKIND_3 NE [goto CANKIND_4]
If number in CANAGE_3 greater than person years old (AGE) goto ERR_ CANAGE_3

Question ID:

ACN.160_00.000 Instrument Variable Name:

QuestionText:

DIBEV

QuestionnaireFileName:

Sample Adult

? [F1]
[Fill1:Other than during pregnancy, have you EVER been told by a doctor or other health professional that you have
diabetes or sugar diabetes?]/[Fill2:Have you EVER been told by a doctor or other health professional that you have
diabetes or sugar diabetes?]

1

Yes
No
Borderline
Refused
Don't know

2
3
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto DIBAGE]
<2,R,D> [goto DIBPRE1]
<3> [goto INSLN]

Question ID:

ACN.165_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

DIBPRE1

QuestionnaireFileName:

Sample Adult

Have you EVER been told by a doctor or other health professional that you have any of the following: prediabetes,
impaired fasting glucose, impaired glucose tolerance, borderline diabetes, or high blood sugar?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who were never told they had diabetes, or who refused or said don’t know to having been told
they had diabetes

SkipInstructions:

<1> [goto INSLN]
<2,R,D> [goto AHAYFYR]

Page 11 of 23

2011 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:

ACN.170_00.000 Instrument Variable Name:

QuestionText:

DIBAGE

22-Oct-10
QuestionnaireFileName:

Sample Adult

? [F1]
How old were you when a doctor or other health professional FIRST told you that you had diabetes or sugar diabetes?

01-84

1-84 years
85+ years
Refused
Don't know

85
97
99
UniverseText:

Sample adults 18+ who were told they had diabetes or sugar diabetes (other than during pregnancy)

SkipInstructions:

<1-100 R,D> [goto INSLN]
If number in DIBAGE greater than person years old (AGE) goto ERR_ DIBAGE

Question ID:

ACN.180_00.000 Instrument Variable Name:

QuestionText:

INSLN

QuestionnaireFileName:

Sample Adult

Are you NOW taking insulin?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who were told they had diabetes or sugar diabetes (other than during pregnancy) or who were
told they had prediabetes, impaired fasting glucose, impaired glucose tolerance, borderline diabetes, or high blood
sugar

SkipInstructions:

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

Question ID:

ACN.190_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

DIBPILL

QuestionnaireFileName:

Sample Adult

Are you NOW taking diabetic pills to lower your blood sugar? These are sometimes called oral agents or oral
hypoglycemic agents.
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who were told they had diabetes or sugar diabetes (other than during pregnancy) or who were
told they had pre-diabetes, impaired fasting glucose, impaired glucose tolerance, borderline diabetes, or high blood
sugar

SkipInstructions:

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

Page 12 of 23

2011 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:

ACN.201_01.000 Instrument Variable Name:

QuestionText:

22-Oct-10

AHAYFYR

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you been told by a doctor or other health professional that you had
...Hay fever?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

ACN.201_02.000 Instrument Variable Name:

QuestionText:

SINYR

QuestionnaireFileName:

Sample Adult

* Read if necessary:
DURING THE PAST 12 MONTHS, have you been told by a doctor or other health professional that you had
...Sinusitis?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

ACN.201_03.000 Instrument Variable Name:

QuestionText:

CBRCHYR

QuestionnaireFileName:

Sample Adult

* Read if necessary:
DURING THE PAST 12 MONTHS, have you been told by a doctor or other health professional that you had
...Chronic bronchitis?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Page 13 of 23

2011 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:

ACN.201_04.000 Instrument Variable Name:

QuestionText:

22-Oct-10

KIDWKYR

QuestionnaireFileName:

Sample Adult

* Read if necessary:
DURING THE PAST 12 MONTHS, have you been told by a doctor or other health professional that you had
......Weak or failing kidneys? - Do not include kidney stones, bladder infections or incontinence.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

ACN.201_05.000 Instrument Variable Name:

QuestionText:

LIVYR

QuestionnaireFileName:

Sample Adult

* Read if necessary:
DURING THE PAST 12 MONTHS, have you been told by a doctor or other health professional that you had
...Any kind of liver condition?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

ACN.250_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

JNTSYMP

QuestionnaireFileName:

Sample Adult

The next questions refer to your joints. Please do NOT include the back or neck. DURING THE PAST 30 DAYS, have
you had any symptoms of pain, aching, or stiffness in or around a joint?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto JMTHP]
<2,R,D> [goto ARTH]

Page 14 of 23

2011 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:

ACN.260_00.000 Instrument Variable Name:

QuestionText:

22-Oct-10

JMTHP

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

(book) A4
Which joints are affected?
* Enter all that apply, separate with commas.

01

Shoulder-right
Shoulder-left
Elbow-right
Elbow-left
Hip-right
Hip-left
Wrist-right
Wrist-left
Knee-right
Knee-left
Ankle-right
Ankle-left
Toes-right
Toes-left
Fingers/thumb-right
Fingers/thumb-left
Other joint not listed
Refused
Don't know

02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
97
99
UniverseText:

Sample adults 18+ who had joint pain in the past 30 days

SkipInstructions:

<1-17,R,D> [goto JNTCHR]

Question ID:

ACN.270_00.000 Instrument Variable Name:

QuestionText:
1
2
7
9

JNTCHR

Did your joint symptoms FIRST begin more than 3 months ago?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who had joint pain in the past 30 days

SkipInstructions:

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

Page 15 of 23

2011 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:

ACN.280_00.000 Instrument Variable Name:

QuestionText:

22-Oct-10

JNTHP

Sample Adult

QuestionnaireFileName:

Sample Adult

Have you EVER seen a doctor or other health professional for these
joint symptoms?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who had joint pain in the past 30 days

SkipInstructions:

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

Question ID:

QuestionnaireFileName:

ACN.290_00.000 Instrument Variable Name:

QuestionText:

ARTH

? [F1]
Have you EVER been told by a doctor or other health professional that you have some form of arthritis, rheumatoid
arthritis, gout, lupus, or fibromyalgia (fy-bro-my-AL-jee-uh)?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

(<1> or JNTSYMP eq <1>) [goto ARTHLMT];
else (<2,R,D> and JNTSYMP ne 1) [goto PAINECK]

Question ID:

ACN.295_00.000 Instrument Variable Name:

QuestionText:

ARTHLMT

QuestionnaireFileName:

Sample Adult

? [F1]
Are you now limited in any way in any of your usual activities because of arthritis or joint symptoms?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ with joint pain or arthritis

SkipInstructions:

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

Page 16 of 23

2011 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:

ACN.300_00.000 Instrument Variable Name:

QuestionText:

22-Oct-10

PAINECK

QuestionnaireFileName:

Sample Adult

? [F1]
The following questions are about pain you may have experienced in the PAST THREE MONTHS. Please refer to pain
that LASTED A WHOLE DAY OR MORE. Do not report aches and pains that are fleeting or minor.
DURING THE PAST THREE MONTHS, did you have
... Neck pain?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

ACN.310_00.000 Instrument Variable Name:

QuestionText:

PAINLB

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

? [F1]
* Read if necessary.
DURING THE PAST THREE MONTHS, did you have
... Low back pain?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto PAINLEG]
<2,R,D> [goto PAINFACE]

Question ID:

ACN.320_00.000 Instrument Variable Name:

QuestionText:

PAINLEG

? [F1]
Did this pain spread down either leg to areas below the knees?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ with low back pain in the past 3 months

SkipInstructions:

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

Page 17 of 23

2011 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:

ACN.331_01.000 Instrument Variable Name:

QuestionText:

22-Oct-10

PAINFACE

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

DURING THE PAST THREE MONTHS, did you have
... Facial ache or pain in the jaw muscles or the joint in front of the ear?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

ACN.331_02.000 Instrument Variable Name:

QuestionText:

AMIGR

* Read if necessary:
DURING THE PAST THREE MONTHS, did you have
...Severe headache or migraine?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto ACOLD2W]

Question ID:

ACN.350_00.000 Instrument Variable Name:

QuestionText:

ACOLD2W

These next questions are about your recent health during the past TWO WEEKS.
Did you have a head cold or chest cold that started during the past TWO WEEKS?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto AINTIL2W]

Page 18 of 23

2011 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:

ACN.360_00.000 Instrument Variable Name:

QuestionText:

22-Oct-10

AINTIL2W

QuestionnaireFileName:

Did you have a stomach or intestinal illness with vomiting or diarrhea that started during the past TWO WEEKS?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> if SEX=2 and age 18-49 [goto PREGNOW];
else <1,2,R,D> and ((SEX=1) or (SEX=2 and AGE>=50)) [goto HRAIDNOW]

Question ID:

ACN.370_00.000 Instrument Variable Name:

QuestionText:

PREGNOW

QuestionnaireFileName:

Sample Adult

HRAIDNOW

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

Are you currently pregnant?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Female sample adults 18-49 years of age

SkipInstructions:

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

Question ID:

Sample Adult

ACN.400_00.000 Instrument Variable Name:

QuestionText:

These next questions are about your hearing, vision, and teeth.
Do you now use a hearing aid(s)?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto AHEARST1]
<2,R,D> [goto HRAIDEV]

Question ID:

ACN.410_00.000 Instrument Variable Name:

QuestionText:
1
2
7
9

HRAIDEV

Have you ever used a hearing aid(s) in the past?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who do not now use a hearing aid or REF/DK whether they now use a hearing aid

SkipInstructions:

<1,2,R,D>[goto AHEARST1]

Page 19 of 23

2011 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:

ACN.420_00.000 Instrument Variable Name:

QuestionText:

QuestionnaireFileName:

Sample Adult

Excellent
Good
A little trouble hearing
Moderate trouble
A lot of trouble
Deaf
Refused
Don't know

2
3
4
5
6
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

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

ACN.430_00.000 Instrument Variable Name:

QuestionText:

AVISION

QuestionnaireFileName:

Sample Adult

Do you have any trouble seeing, even when wearing glasses or contact lenses?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto ABLIND]
<2,R,D> [goto LUPPRT]

Question ID:

AHEARST1

WITHOUT the use of hearing aids or other listening devices, is your hearing excellent, good, a little trouble hearing,
moderate trouble, a lot of trouble, or are you deaf?

1

Question ID:

22-Oct-10

ACN.440_00.000 Instrument Variable Name:

QuestionText:
1
2
7
9

ABLIND

QuestionnaireFileName:

Are you blind or unable to see at all?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who have trouble seeing even when wearing glasses/contact lenses

SkipInstructions:

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

Sample Adult

Page 20 of 23

2011 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:

ACN.451_00.000 Instrument Variable Name:

QuestionText:

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

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

ACN.470_00.000 Instrument Variable Name:

QuestionText:

MHSAD_CK

Now I am going to ask you some questions about feelings you may have experienced over the PAST 30 DAYS.

1

Enter 1 to continue

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto SAD]

Question ID:

LUPPRT

Have you lost all of your upper and lower natural (permanent) teeth?

1

Question ID:

22-Oct-10

ACN.471_01.000 Instrument Variable Name:

QuestionText:

SAD

(book) A5
DURING THE PAST 30 DAYS, how often did you feel
... So sad that nothing could cheer you up?

1
2
3
4
5
7
9

ALL of the time
MOST of the time
SOME of the time
A LITTLE of the time
NONE of the time
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

QuestionnaireFileName:

Sample Adult

Page 21 of 23

2011 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:

ACN.471_02.000 Instrument Variable Name:

QuestionText:

22-Oct-10

NERVOUS

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

(book) A5
* Read if necessary:
During the PAST 30 DAYS, how often did you feel
... Nervous?

1

ALL of the time
MOST of the time
SOME of the time
A LITTLE of the time
NONE of the time
Refused
Don't know

2
3
4
5
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

ACN.471_03.000 Instrument Variable Name:

QuestionText:

RESTLESS

(book) A5
* Read lead-in if necessary:
During the PAST 30 DAYS, how often did you feel
... Restless or fidgety?

1
2
3
4
5
7
9

ALL of the time
MOST of the time
SOME of the time
A LITTLE of the time
NONE of the time
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Page 22 of 23

2011 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:

ACN.471_04.000 Instrument Variable Name:

QuestionText:

22-Oct-10

HOPELESS

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

(book) A5
* Read if necessary:
During the PAST 30 DAYS, how often did you feel
... Hopeless?

1

ALL of the time
MOST of the time
SOME of the time
A LITTLE of the time
NONE of the time
Refused
Don't know

2
3
4
5
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

ACN.471_05.000 Instrument Variable Name:

QuestionText:

EFFORT

(book) A5
* Read if necessary:
During the PAST 30 DAYS, how often did you feel
...That everything was an effort?

1
2
3
4
5
7
9

ALL of the time
MOST of the time
SOME of the time
A LITTLE of the time
NONE of the time
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Page 23 of 23

2011 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:
Question ID:

ACN.471_06.000 Instrument Variable Name:

QuestionText:

22-Oct-10

WORTHLS

QuestionnaireFileName:

Sample Adult

(book) A5
* Read if necessary:
During the PAST 30 DAYS, how often did you feel
...Worthless?

1

ALL of the time
MOST of the time
SOME of the time
A LITTLE of the time
NONE of the time
Refused
Don't know

2
3
4
5
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

If (SAD eq <1-3> or NERVOUS eq <1-3> or RESTLESS eq <1-3> or HOPELESS eq <1-3> or EFFORTeq<1-3>
or WORTHLS
eq <1-3>) [goto MHAMTMO];
else [goto Next Section]]

Question ID:

ACN.530_00.000 Instrument Variable Name:

QuestionText:

1
2
3
4
7
9

MHAMTMO

QuestionnaireFileName:

Sample Adult

We just talked about a number of feelings you had during the PAST 30 DAYS. Altogether, how MUCH did these feelings
interfere with your life or activities: a lot, some, a little, or not at all?
A lot
Some
A little
Not at all
Refused
Don't know

UniverseText:

Sample adults 18+ who at least some of the time have felt sad, nervous, restless or fidgety, hopeless, that
everything was an effort, or worthless, in the past 30 days

SkipInstructions:

<1-4,R,D> [goto next section]

Page 1 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.040_00.000 Instrument Variable Name:

QuestionText:

21-Oct-10

WKDAYR

QuestionnaireFileName:

Sample Adult

During the PAST 12 MONTHS, that is, since {12-month ref. date}, ABOUT how many days did you miss work at a job
or business because of illness or injury (do not include maternity leave)?
* Enter '0' for None.

000

None
1-366 days
Refused
Don't know

001-366
997
999
UniverseText:

Sample adults 18+ who worked or had a job or business with or without pay in the last week or who had a job or
business in the past 12 months

SkipInstructions:

<0-366,R,D> [goto BEDDAYR]
<120-366> [goto ERR_WKDAYR]

Question ID:

AHS.050_00.000 Instrument Variable Name:

QuestionText:

BEDDAYR

QuestionnaireFileName:

Sample Adult

During the PAST 12 MONTHS, that is, since {12-month ref. date}, ABOUT how many days did illness or injury keep
you in bed more than half of the day (include days while an overnight patient in a hospital)?
* Enter '0' for None.

000

None
1-366 days
Refused
Don't know

001-366
997
999
UniverseText:

Sample adults 18+

SkipInstructions:

<0-366,R,D> [goto AHSTATYR]
<120-366> [goto ERR_BEDDAYR]

Question ID:

AHS.060_00.000 Instrument Variable Name:

QuestionText:
1
2
3
7
9

AHSTATYR

QuestionnaireFileName:

Compared with 12 MONTHS AGO, would you say your health is better, worse, or about the same?
Better
Worse
About the same
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Sample Adult

Page 2 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.070_00.000 Instrument Variable Name:

QuestionText:

QuestionnaireFileName:

Sample Adult

Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special
bed, or a special telephone?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

SPECEQ

21-Oct-10

AHS.091_01.000 Instrument Variable Name:

QuestionText:

FLWALK

QuestionnaireFileName:

Sample Adult

(book) A6
The next questions ask about difficulties you may have doing certain activities because of a HEALTH PROBLEM. By
"health problem" we mean any physical, mental, or emotional problem or illness (not including pregnancy).
By yourself, and without using any special equipment, how difficult is it for you to...
...Walk a quarter of a mile - about 3 city blocks?

0
1
2
3
4
6
7
9

Not at all difficult
Only a little difficult
Somewhat difficult
Very difficult
Can't do at all
Do not do this activity
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<0-4,6,R,D> [goto FLCLIMB]

Page 3 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.091_02.000 Instrument Variable Name:

QuestionText:

FLCLIMB

21-Oct-10
QuestionnaireFileName:

Sample Adult

(book) A6
* Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you to...
...Walk up 10 steps without resting?

0

Not at all difficult
Only a little difficult
Somewhat difficult
Very difficult
Can't do at all
Do not do this activity
Refused
Don't know

1
2
3
4
6
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<0-4,6,R,D> [goto FLSTAND]

Question ID:

AHS.091_03.000 Instrument Variable Name:

QuestionText:

FLSTAND

QuestionnaireFileName:

(book) A6
* Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you to...
...Stand or be on your feet for about 2 hours?

0
1
2
3
4
6
7
9

Not at all difficult
Only a little difficult
Somewhat difficult
Very difficult
Can't do at all
Do not do this activity
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<0-4,6,R,D> [goto FLSIT]

Sample Adult

Page 4 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.091_04.000 Instrument Variable Name:

QuestionText:

FLSIT

21-Oct-10
QuestionnaireFileName:

Sample Adult

(book) A6
* Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you to...
...Sit for about 2 hours?

0

Not at all difficult
Only a little difficult
Somewhat difficult
Very difficult
Can't do at all
Do not do this activity
Refused
Don't know

1
2
3
4
6
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<0-4,6,R,D> [goto FLSTOOP]

Question ID:

AHS.091_05.000 Instrument Variable Name:

QuestionText:

FLSTOOP

QuestionnaireFileName:

(book) A6
* Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you to...
...Stoop, bend, or kneel?

0
1
2
3
4
6
7
9

Not at all difficult
Only a little difficult
Somewhat difficult
Very difficult
Can't do at all
Do not do this activity
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<0-4,6,R,D> [goto FLREACH]

Sample Adult

Page 5 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.091_06.000 Instrument Variable Name:

QuestionText:

FLREACH

21-Oct-10
QuestionnaireFileName:

Sample Adult

(book) A6
* Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you to...
...Reach up over your head?

0

Not at all difficult
Only a little difficult
Somewhat difficult
Very difficult
Can't do at all
Do not do this activity
Refused
Don't know

1
2
3
4
6
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<0-4,6,R,D> [goto FLGRASP]

Question ID:

AHS.141_01.000 Instrument Variable Name:

QuestionText:

FLGRASP

QuestionnaireFileName:

(book) A6
* Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you to...
...Use your fingers to grasp or handle small objects?

0
1
2
3
4
6
7
9

Not at all difficult
Only a little difficult
Somewhat difficult
Very difficult
Can't do at all
Do not do this activity
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<0-4,6,R,D> [goto FLCARRY]

Sample Adult

Page 6 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.141_02.000 Instrument Variable Name:

QuestionText:

FLCARRY

21-Oct-10
QuestionnaireFileName:

Sample Adult

(book) A6
* Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you to...
...Lift or carry something as heavy as 10 pounds such as a full bag of groceries?

0

Not at all difficult
Only a little difficult
Somewhat difficult
Very difficult
Can't do at all
Do not do this activity
Refused
Don't know

1
2
3
4
6
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<0-4,6,R,D> [goto FLPUSH]

Question ID:

AHS.141_03.000 Instrument Variable Name:

QuestionText:

FLPUSH

QuestionnaireFileName:

(book) A6
* Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you to...
...Push or pull large objects like a living room chair?

0
1
2
3
4
6
7
9

Not at all difficult
Only a little difficult
Somewhat difficult
Very difficult
Can't do at all
Do not do this activity
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<0-4,6,R,D> [goto FLSHOP]

Sample Adult

Page 7 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.171_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

FLSHOP

QuestionnaireFileName:

Sample Adult

(book) A6
* Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you to...
...Go out to things like shopping, movies, or sporting events?

0

Not at all difficult
Only a little difficult
Somewhat difficult
Very difficult
Can't do at all
Do not do this activity
Refused
Don't know

1
2
3
4
6
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<0-4,6,R,D> [goto FLSOCL]

Question ID:

AHS.171_02.000 Instrument Variable Name:

QuestionText:

FLSOCL

QuestionnaireFileName:

Sample Adult

(book) A6
* Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you to...
...Participate in social activities such as visiting friends, attending clubs and meetings, going to parties?

0
1
2
3
4
6
7
9

Not at all difficult
Only a little difficult
Somewhat difficult
Very difficult
Can't do at all
Do not do this activity
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<0-4,6,R,D> [goto FLRELAX]

Page 8 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.171_03.000 Instrument Variable Name:

QuestionText:

FLRELAX

21-Oct-10
QuestionnaireFileName:

Sample Adult

(book) A6
* Read lead-in if necessary.
By yourself, and without using any special equipment, how difficult is it for you to...
...Do things to relax at home or for leisure (reading, watching TV, sewing, listening to music)?

0
1
2
3
4
6
7
9

Not at all difficult
Only a little difficult
Somewhat difficult
Very difficult
Can't do at all
Do not do this activity
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1-4 or FLWALK= 1-4 or FLCLIMB= 1-4 or FLSTAND= 1-4 or FLSIT= 1-4 or FLSTOOP= 1-4 or FLREACH=
1-4 or FLGRASP= 1-4 or FLCARRY= 1-4 or FLPUSH= 1-4 or FLSHOP= 1-4 or FLSOCL= 1-4>[goto AFLHCA]
Else goto SMKEV (next section)

Page 9 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:
QuestionText:

AHS.200_00.000 Instrument Variable Name:

21-Oct-10

AFLHCA

QuestionnaireFileName:

Sample Adult

(book) A7
What condition or health problem causes you to have difficulty with [fill1: condition 1, condition 2 or condition 3 (as
specified in AHS.091_1 through AHS.171_3)][fill2: these activities]?
* Enter condition number for all that apply, separate with commas.
* Do not probe, except to clarify answer.

01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
90
91
97
99

Vision/problem seeing
Hearing problem
Arthritis/rheumatism
Back or neck problem
Fracture or bone/joint injury
Other injury
Heart problem
Stroke problem
Hypertension/high blood pressure
Diabetes
Lung/breathing problem (for example, asthma and emphysema)
Cancer
Birth defect
Intellectual disability, also known as mental retardation
Other developmental problem (for example, cerebral palsy)
Senility
Depression/anxiety/emotional problem
Weight problem
Missing limbs (fingers, toes or digits), amputee
Kidney, bladder or renal problems
Circulation problems (including blood clots)
Benign Tumors, Cysts
Fibromyalgia, lupus
Osteoporosis, tendinitis
Epilepsy, seizures
Multiple Sclerosis (MS), Muscular Dystrophy (MD)
Polio(myelitis), paralysis, para/quadriplegia
Parkinson's disease, other tremors
Other nerve damage, including carpal tunnel syndrome
Hernia
Ulcer
Varicose veins, hemorrhoids
Thyroid problems, Grave's disease, gout
Knee problems (not arthritis (03), not joint injury(05))
Migraine headaches (not just headaches)
Other impairment/problem (Specify one)
Other impairment/problem (Specify one)
Refused
Don't know/Not sure

Page 10 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

21-Oct-10

UniverseText:

Sample adults 18+ who, without using special equipment, have at least a little difficulty walking a quarter mile;
walking up 10 steps without resting; standing/being on feet for about 2 hours; sitting for about 2 hours;
stooping/bending/kneeling; reaching up over head; using fingers to grasp/handle small objects; lifting/carrying 10
pounds; pushing/pulling large objects; going out for things (shopping/movies); participating in social activities; or
relaxing at home (reading/sewing).

SkipInstructions:

[1- 12, 14 - 35] goto the appropriate follow up question AHCL01N-AHCL12N, AHCL14N-AHCL35N], in
numerical order
<13> store "96" in AHCL13N and "6" IN AHCL13T[goto SMKEV ]
<90> [goto AFLHCA_S1]
<91> [goto AFLHCA_S2]
Roster through all AFLHCA entries. Once exhausted goto SMKEV (next section)
< R,D> [goto SMKEV (next section)]

Question ID:

AHS.201_90.000 Instrument Variable Name:

QuestionText:

AFLHCA_S1

QuestionnaireFileName:

Sample Adult

* Enter other impairment/problem.

Verbatim

Verbatim response
Refused
Don't know

7
9
UniverseText:

Sample adults 18+ whose difficulties performing activities listed in FLWALK through FLRELAX is due to at least
one condition not listed in AFLHCA

SkipInstructions:

<50 chars>[goto AHCL90N]
>ENTER< only with no description [goto ERR1_AFLHCA_S1]
Else goto the appropriate follow-up questions AHCL01N-AHCL12N, AHCL14N-AHCL35N], in numerical order,
as specified in AFLHCA

Question ID:

AHS.201_91.000 Instrument Variable Name:

QuestionText:
Verbatim
7
9

AFLHCA_S2

QuestionnaireFileName:

Sample Adult

* Enter other impairment/problem.
Verbatim response
Refused
Don't know

UniverseText:

Sample adults 18+ whose difficulty performing activities listed in FLWALK through FLRELAX is due to more
than one condition that is not listed in AFLHCA

SkipInstructions:

<50 chars>[goto AHCL91N]
>ENTER< only with no description [goto ERR1_AFLHCA_S1]

Page 11 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.300_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL01N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had a vision problem or problem seeing?
* Enter number for time with your vision problem or problem seeing..
* Enter '95' for 95 or more.
* Enter '96' if since birth.

01-94

1-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to a vision problem or problem seeing

SkipInstructions:

<1-95,D>[goto AHCL01T]
[store "R" in AHCL01T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL01T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.300_02.000 Instrument Variable Name:

QuestionText:

AHCL01T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with vision problem or problem seeing.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL01T
[if [AHCL01N = Number greater than person years old and AHCL01T= 4]] goto
ERR1_AHCL01T

Page 12 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.301_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL02N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had a hearing problem?
* Enter number for time with a hearing problem.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

1-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to a hearing problem

SkipInstructions:

<1-95,D>[goto AHCL02T]
[store "R" in AHCL02T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL02T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.301_02.000 Instrument Variable Name:

QuestionText:

AHCL02T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with hearing problem.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL02T
[if [AHCL02N = Number greater than person years old and AHCL02T= 4]] goto
ERR1_AHCL02T

Page 13 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.302_01.000 Instrument Variable Name:

QuestionText:

AHCL03N

21-Oct-10
QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had arthritis or rheumatism?
* Enter number for time with arthritis or rheumatism.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

01-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to arthritis or rheumatism

SkipInstructions:

<1-95,D>[goto AHCL03T]
[store "R" in AHCL03T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL03T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.302_02.000 Instrument Variable Name:

QuestionText:

AHCL03T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with arthritis or rheumatism.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since Birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL03T
[if [AHCL03N = Number greater than person years old and AHCL03T= 4]] goto
ERR1_AHCL03T

Page 14 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.303_01.000 Instrument Variable Name:

QuestionText:

AHCL04N

21-Oct-10
QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had a back or neck problem?
* Enter number for time with back or neck problem.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

01-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to a back or neck problem

SkipInstructions:

<1-95,D>[goto AHCL04T]
[store "R" in AHCL04T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL04T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.303_02.000 Instrument Variable Name:

QuestionText:

AHCL04T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with back or neck problem.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL04T
[if [AHCL04N = Number greater than person years old and AHCL04T= 4]] goto
ERR1_AHCL04T

Page 15 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.304_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL05N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had a fracture, bone, or joint injury?
* Enter number for time with a fracture, bone, or joint injury.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

1-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to a fracture, bone, or joint injury

SkipInstructions:

<1-95,D>[goto AHCL05T]
[store "R" in AHCL05T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL05T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.304_02.000 Instrument Variable Name:

QuestionText:

AHCL05T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with fracture, bone, or joint injury.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL05T
[if [AHCL05N = Number greater than person years old and AHCL05T= 4]] goto
ERR1_AHCL05T

Page 16 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.305_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL06N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had the (fill: other) injury that caused your limitation?
* Enter number for time with injury that caused your limitation.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

01-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to an injury other than a fracture, bone, or joint injury

SkipInstructions:

<1-95,D>[goto AHCL06T]
[store "R" in AHCL06T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL06T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.305_02.000 Instrument Variable Name:

QuestionText:

AHCL06T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with (fill: other) injury.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL06T
[if [AHCL06N = Number greater than person years old and AHCL06T= 4]] goto
ERR1_AHCL06T

Page 17 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.306_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL07N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had a heart problem?
* Enter number for time with a heart problem.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

01-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to a heart problem

SkipInstructions:

<1-95,D>[goto AHCL07T]
[store "R" in AHCL07T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL07T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.306_02.000 Instrument Variable Name:

QuestionText:

AHCL07T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with heart problem.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL07T
[if [AHCL07N = Number greater than person years old and AHCL07T= 4]] goto
ERR1_AHCL07T

Page 18 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.307_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL08N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had a stroke problem?
* Enter number for time with a stroke problem.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

01-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to a stroke problem

SkipInstructions:

<1-95,D>[goto AHCL08T]
[store "R" in AHCL08T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL08T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.307_02.000 Instrument Variable Name:

QuestionText:

AHCL08T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with stroke problem.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL08T
[if [AHCL08N = Number greater than person years old and AHCL08T= 4]] goto
ERR1_AHCL08T

Page 19 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.308_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL09N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had hypertension or high blood pressure?
* Enter number for time with hypertension or high blood pressure.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

1-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to hypertension or high blood pressure

SkipInstructions:

<1-95,D>[goto AHCL09T]
[store "R" in AHCL09T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL09T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.308_02.000 Instrument Variable Name:

QuestionText:

AHCL09T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with hypertension or high blood pressure.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL09T
[if [AHCL09N = Number greater than person years old and AHCL09T= 4]] goto
ERR1_AHCL09T

Page 20 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.309_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL10N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had diabetes?
* Enter number for time with diabetes.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

1-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to diabetes

SkipInstructions:

<1-95,D>[goto AHCL10T]
[store "R" in AHCL10T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL10T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.309_02.000 Instrument Variable Name:

QuestionText:

AHCL10T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with diabetes.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since Birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL10T
[if [AHCL10N = Number greater than person years old and AHCL10T= 4]] goto
ERR1_AHCL10T

Page 21 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.310_01.000 Instrument Variable Name:

QuestionText:

AHCL11N

21-Oct-10
QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had a lung or breathing problem (for example, asthma and emphysema)?
* Enter number for time with a lung or breathing problem.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

01-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to a lung or breathing problem

SkipInstructions:

<1-95,D>[goto AHCL11T]
[store "R" in AHCL11T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL11T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.310_02.000 Instrument Variable Name:

QuestionText:

AHCL11T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with lung or breathing problem (for example, asthma and emphysema).

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL11T
[if [AHCL11N = Number greater than person years old and AHCL11T= 4]] goto
ERR1_AHCL11T

Page 22 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.311_01.000 Instrument Variable Name:

QuestionText:

AHCL12N

21-Oct-10
QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had cancer?
* Enter number for time with cancer.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

01-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to cancer

SkipInstructions:

<1-95,D>[goto AHCL12T]
[store "R" in AHCL12T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL12T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.311_02.000 Instrument Variable Name:

QuestionText:

AHCL12T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with cancer.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL12T
[if [AHCL12N = Number greater than person years old and AHCL12T= 4]] goto
ERR1_AHCL12T

Page 23 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.313_01.000 Instrument Variable Name:

QuestionText:

AHCL14N

21-Oct-10
QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had intellectual disability, also known as mental retardation?
* Enter number for time with intellectual disability, also known as mental retardation.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

01-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to intellectual disability/mental retardation

SkipInstructions:

<1-95,D>[goto AHCL14T]
[store "R" in AHCL14T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL14T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.313_02.000 Instrument Variable Name:

QuestionText:

AHCL14T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with intellectual disability, also known as mental retardation.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL14T
[if [AHCL14N = Number greater than person years old and AHCL14T= 4]] goto
ERR1_AHCL14T

Page 24 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.314_01.000 Instrument Variable Name:

QuestionText:

AHCL15N

21-Oct-10
QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had a developmental problem (for example, cerebral palsy)?
* Enter number for time with a developmental problem.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

01-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to a developmental problem

SkipInstructions:

<1-95,D>[goto AHCL15T]
[store "R" in AHCL15T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL15T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.314_02.000 Instrument Variable Name:

QuestionText:

AHCL15T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with developmental problem.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL15T
[if [AHCL15N = Number greater than person years old and AHCL15T= 4]] goto
ERR1_AHCL15T

Page 25 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.315_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL16N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had senility?
* Enter number for time with senility.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

01-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to senility

SkipInstructions:

<1-95,D>[goto AHCL16T]
[store "R" in AHCL16T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL16T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.315_02.000 Instrument Variable Name:

QuestionText:

AHCL16T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with senility.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL16T
[if [AHCL16N = Number greater than person years old and AHCL16T= 4]] goto
ERR1_AHCL16T

Page 26 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.316_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL17N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had depression, anxiety, or an emotional problem?
* Enter number for time with depression, anxiety, or an emotional problem.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

01-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to depression, anxiety, or an emotional problem

SkipInstructions:

<1-95,D>[goto AHCL17T]
[store "R" in AHCL17T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL17T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.316_02.000 Instrument Variable Name:

QuestionText:

AHCL17T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with depression, anxiety, or emotional problem.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL17T
[if [AHCL17N = Number greater than person years old and AHCL17T= 4]] goto
ERR1_AHCL17T

Page 27 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.317_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL18N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had a weight problem?
* Enter number for time with a weight problem.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

01-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to a weight problem

SkipInstructions:

<1-95,D>[goto AHCL18T]
[store "R" in AHCL18T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL18T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.317_02.000 Instrument Variable Name:

QuestionText:

AHCL18T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with weight problem.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL18T
[if [AHCL18N = Number greater than person years old and AHCL18T= 4]] goto
ERR1_AHCL18T

Page 28 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.318_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL19N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had a missing limb (finger, toe, or digit)?
* Enter number for time with a missing limb.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

01-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to a missing limb

SkipInstructions:

<1-95,D>[goto AHCL19T]
[store "R" in AHCL19T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL19T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.318_02.000 Instrument Variable Name:

QuestionText:

AHCL19T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with missing limb.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL19T
[if [AHCL19N = Number greater than person years old and AHCL19T= 4]] goto
ERR1_AHCL19T

Page 29 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.319_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL20N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had a kidney, bladder or renal problem?
* Enter number for time with a kidney, bladder or renal problem.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

01-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to a kidney, bladder or renal problem

SkipInstructions:

<1-95,D>[goto AHCL20T]
[store "R" in AHCL20T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL20T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.319_02.000 Instrument Variable Name:

QuestionText:

AHCL20T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with kidney, bladder or renal problem.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL20T
[if [AHCL20N = Number greater than person years old and AHCL20T= 4]] goto
ERR1_AHCL20T

Page 30 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.320_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL21N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had a circulation problem (including blood clots)?
* Enter number for time with a circulation problem.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

01-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to a circulation problem

SkipInstructions:

<1-95,D>[goto AHCL21T]
[store "R" in AHCL21T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL21T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.320_02.000 Instrument Variable Name:

QuestionText:

AHCL21T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with circulation problem.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL21T
[if [AHCL21N = Number greater than person years old and AHCL21T= 4]] goto
ERR1_AHCL21T

Page 31 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.321_01.000 Instrument Variable Name:

QuestionText:

AHCL22N

21-Oct-10
QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had benign tumors or cysts?
* Enter number for time with benign tumors or cysts.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

1-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to benign tumors or cysts

SkipInstructions:

<1-95,D>[goto AHCL22T]
[store "R" in AHCL22T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL22T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.321_02.000 Instrument Variable Name:

QuestionText:

AHCL22T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with benign tumors or cysts.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL22T
[if [AHCL22N = Number greater than person years old and AHCL22T= 4]] goto
ERR1_AHCL22T

Page 32 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.322_01.000 Instrument Variable Name:

QuestionText:

AHCL23N

21-Oct-10
QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had fibromyalgia or lupus?
* Enter number for time with fibromyalgia or lupus.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

1-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to fibromyalgia or lupus

SkipInstructions:

<1-95,D>[goto AHCL23T]
[store "R" in AHCL23T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL23T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.322_02.000 Instrument Variable Name:

QuestionText:

AHCL23T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with fibromyalgia or lupus.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL23T
[if [AHCL23N = Number greater than person years old and AHCL23T= 4]] goto
ERR1_AHCL23T

Page 33 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.323_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL24N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had osteoporosis or tendinitis?
* Enter number for time with osteoporosis or tendinitis.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

1-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to osteoporosis or tendinitis

SkipInstructions:

<1-95,D>[goto AHCL24T]
[store "R" in AHCL24T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL24T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.323_02.000 Instrument Variable Name:

QuestionText:

AHCL24T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with osteoporosis or tendinitis.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL24T
[if [AHCL24N = Number greater than person years old and AHCL24T= 4]] goto
ERR1_AHCL24T

Page 34 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.324_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL25N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had epilepsy or seizures?
* Enter number for time with epilepsy or seizures.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

01-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to epilepsy or seizures

SkipInstructions:

<1-95,D>[goto AHCL25T]
[store "R" in AHCL25T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL25T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.324_02.000 Instrument Variable Name:

QuestionText:

AHCL25T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with epilepsy or seizures.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL25T
[if [AHCL25N = Number greater than person years old and AHCL25T= 4]] goto
ERR1_AHCL25T

Page 35 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.325_01.000 Instrument Variable Name:

QuestionText:

AHCL26N

21-Oct-10
QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had multiple sclerosis (MS) or muscular dystrophy (MD)?
* Enter number for time with multiple sclerosis (MS) or muscular dystrophy (MD).
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

01-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to multiple sclerosis or muscular dystrophy

SkipInstructions:

<1-95,D>[goto AHCL26T]
[store "R" in AHCL26T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL26T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.325_02.000 Instrument Variable Name:

QuestionText:

AHCL26T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with multiple sclerosis or muscular dystrophy.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL26T
[if [AHCL26N = Number greater than person years old and AHCL26T= 4]] goto
ERR1_AHCL26T

Page 36 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.326_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL27N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had polio(myelitis), paralysis or para/quadriplegia?
* Enter number for time with polio (myelitis), paralysis or para/quadriplegia.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

1-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to polio(myelitis), paralysis or para/quadriplegia

SkipInstructions:

<1-95,D>[goto AHCL27T]
[store "R" in AHCL27T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL27T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.326_02.000 Instrument Variable Name:

QuestionText:

AHCL27T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with polio(myelitis), paralysis or para/quadriplegia.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL27T
[if [AHCL27N = Number greater than person years old and AHCL27T= 4]] goto
ERR1_AHCL27T

Page 37 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.327_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL28N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had Parkinson's disease or tremors?
* Enter number for time with Parkinson's disease or tremors.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

01-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to Parkinson's disease or tremors

SkipInstructions:

<1-95,D>[goto AHCL28T]
[store "R" in AHCL28T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL28T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.327_02.000 Instrument Variable Name:

QuestionText:

AHCL28T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with Parkinson's disease or tremors.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since Birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL28T
[if [AHCL28N = Number greater than person years old and AHCL28T= 4]] goto
ERR1_AHCL28T

Page 38 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.328_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL29N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had nerve damage (including carpal tunnel syndrome)?
* Enter number for time with nerve damage (including carpal tunnel syndrome).
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

01-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to nerve damage

SkipInstructions:

<1-95,D>[goto AHCL29T]
[store "R" in AHCL29T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL29T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.328_02.000 Instrument Variable Name:

QuestionText:

AHCL29T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with nerve damage.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL29T
[if [AHCL29N = Number greater than person years old and AHCL29T= 4]] goto
ERR1_AHCL29T

Page 39 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.329_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL30N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had a hernia?
* Enter number for time with a hernia.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

1-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to a hernia

SkipInstructions:

<1-95,D>[goto AHCL30T]
[store "R" in AHCL30T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL30T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.329_02.000 Instrument Variable Name:

QuestionText:

AHCL30T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with hernia.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL30T
[if [AHCL30N = Number greater than person years old and AHCL30T= 4]] goto
ERR1_AHCL30T

Page 40 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.330_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL31N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had an ulcer?
* Enter number for time with an ulcer.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

1-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to an ulcer

SkipInstructions:

<1-95,D>[goto AHCL31T]
[store "R" in AHCL31T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL31T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.330_02.000 Instrument Variable Name:

QuestionText:

AHCL31T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with ulcer.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL31T
[if [AHCL31N = Number greater than person years old and AHCL31T= 4]] goto
ERR1_AHCL31T

Page 41 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.331_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL32N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had varicose veins or hemorrhoids?
* Enter number for time with varicose veins or hemorrhoids.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

1-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to varicose veins or hemorrhoids

SkipInstructions:

<1-95,D>[goto AHCL32T]
[store "R" in AHCL32T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL32T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.331_02.000 Instrument Variable Name:

QuestionText:

AHCL32T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with varicose veins or hemorrhoids.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL32T
[if [AHCL32N = Number greater than person years old and AHCL32T= 4]] goto
ERR1_AHCL32T

Page 42 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.332_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL33N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had a thyroid problem, Grave's disease or gout?
* Enter number for time with a thyroid problem, Grave's disease or gout.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

1-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to a thyroid problem, Grave's disease or gout

SkipInstructions:

<1-95,D>[goto AHCL33T]
[store "R" in AHCL33T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL33T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.332_02.000 Instrument Variable Name:

QuestionText:

AHCL33T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with thyroid problem, Grave's disease or gout.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL33T
[if [AHCL33N = Number greater than person years old and AHCL33T= 4]] goto
ERR1_AHCL33T

Page 43 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.333_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL34N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had a knee problem?
* Enter number for time with a knee problem.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

01-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to a knee problem

SkipInstructions:

<1-95,D>[goto AHCL34T]
[store "R" in AHCL34T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL34T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.333_02.000 Instrument Variable Name:

QuestionText:

AHCL34T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with knee problem.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL34T
[if [AHCL34N = Number greater than person years old and AHCL34T= 4]] goto
ERR1_AHCL34T

Page 44 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.334_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL35N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had migraine headaches?
* Enter number for time with migraine headaches.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

01-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to migraine headaches

SkipInstructions:

<1-95,D>[goto AHCL35T]
[store "R" in AHCL35T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL35T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.334_02.000 Instrument Variable Name:

QuestionText:

AHCL35T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with migraine headaches.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL35T
[if [AHCL35N = Number greater than person years old and AHCL35T= 4]] goto
ERR1_AHCL35T

Page 45 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.335_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL90N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had {problem in AFLHCA90}?
* Enter number for time with {problem in AFLHCA90}.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

1-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to {problem in AFLHCA90}

SkipInstructions:

<1-95,D>[goto AHCL90T]
[store "R" in AHCL90T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]
<96>[store "6" in AHCL90T] [goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this
is the last condition selected, goto SMKEV (next section)]

Question ID:

AHS.335_02.000 Instrument Variable Name:

QuestionText:

AHCL90T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with {problem in AFLHCA90}.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[[if 91 selected in AFLHCA goto AFLHCA_S2]
Else goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last condition
selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL90T
[if [AHCL90N = Number greater than person years old and AHCL90T= 4]] goto
ERR1_AHCL90T

Page 46 of 46

2011 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:
Question ID:

AHS.336_01.000 Instrument Variable Name:

QuestionText:

21-Oct-10

AHCL91N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had {problem in AFLHCA91}?
* Enter number for time with {problem in AFLHCA91}.
* Enter '95'' for 95 or more.
* Enter "96" if since birth.

01-94

1-94
95+
Since birth
Refused
Don't know

95
96
97
99
UniverseText:

Sample adults 18+ who had difficulty due to {problem in AFLHCA91}

SkipInstructions:

<1-95,D>[goto AHCL91T]
[store "R" in AHCL91T] [goto SMKEV (next section)]
<96>[store "6" in AHCL91T] [goto SMKEV (next section)]

Question ID:

AHS.336_02.000 Instrument Variable Name:

QuestionText:

AHCL91T

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for time with {problem in AFLHCA91}.

1
2
3
4
6
7
9

Day(s)
Week(s)
Month(s)
Year(s)
Since birth
Refused
Don't know

UniverseText:

Sample adults 18+ who answered 1-95, D for the "number" part of this 2-part question

SkipInstructions:

<1- 4, R,D>[goto the next condition, in numerical order, selected at AFLHCA (AHS.200). If this is the last
condition selected, goto SMKEV (next section)]
<6> goto ERR2_AHCL91T
[if [AHCL91N = Number greater than person years old and AHCL91T= 4]] goto
ERR1_AHCL91T

Page 1 of 16

2011 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:
Question ID:

AHB.010_00.000 Instrument Variable Name:

QuestionText:

23-Nov-10

SMKEV

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

These next questions are about cigarette smoking.
Have you smoked at least 100 cigarettes in your ENTIRE LIFE?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1>[goto SMKREG]
<2,R,D>[goto VIGNO]

Question ID:

AHB.020_00.000 Instrument Variable Name:

QuestionText:

SMKREG

How old were you when you FIRST started to smoke fairly regularly?
* Enter '6' if less than 6 years old.
* Enter '95' if 95 years old or older.
* Enter '96' if never smoked regularly.

06-84

6 - 84 years
85 years or older
Never smoked regularly
Refused
Don't know

85
96
97
99
UniverseText:

Sample adults 18+ who ever smoked 100 cigarettes

SkipInstructions:

<6-95,96,R,D> [goto SMKNOW]
[If SMKREG gt AGE and SMKREG ne <96>, goto ERR_SMKREG

Question ID:

AHB.030_00.000 Instrument Variable Name:

QuestionText:
1
2
3
7
9

SMKNOW

Do you NOW smoke cigarettes every day, some days or not at all?
Every day
Some days
Not at all
Refused
Don't know

UniverseText:

Sample adults 18+ who ever smoked 100 cigarettes

SkipInstructions:

<1>[goto CIGSDA1]
<2> [goto CIGDAMO]
<3> [goto SMKQTNO]
[goto VIGNO]

QuestionnaireFileName:

Sample Adult

Page 2 of 16

2011 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:
Question ID:

AHB.040_01.000 Instrument Variable Name:

QuestionText:

23-Nov-10

SMKQTNO

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

1 of 2
How long has it been since you quit smoking cigarettes?
* Enter number for time since quit smoking.
* Enter '95' for 95 years old or older.

01-94

1 - 94
95+
Refused
Don't know

95
97
99
UniverseText:

Sample adults 18+ who quit smoking

SkipInstructions:

<1-95> [goto SMKQTTP]
[goto VIGNO]

Question ID:

AHB.040_02.000 Instrument Variable Name:

QuestionText:

SMKQTTP

2 of 2
* Enter time period for time since quit smoking.

1

Day(s)
Week(s)
Month(s)
Year(s)
Refused
Don't know

2
3
4
7
9
UniverseText:

Sample adults 18+ who quit smoking

SkipInstructions:

<1-4> [goto VIGNO]
<4> [if SMKQTNO gt (AGE - <15>), goto ERR1_SMKQTTP
if (SMKREG + SMKQTNO gt AGE), goto ERR2_SMKQTTP

Question ID:

AHB.050_00.000 Instrument Variable Name:

QuestionText:

CIGSDA1

On the average, how many cigarettes do you now smoke a day?
* Enter '1' if less than 1 cigarette.
* Enter '95' if 95 or more cigarettes.

01-94
95
97
99

1 - 94 cigarettes
95+ cigarettes
Refused
Don't know

UniverseText:

Sample adults 18+ who are current every day smokers

SkipInstructions:

<1-95,R,D> [goto CIGQTYR]

Page 3 of 16

2011 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:
Question ID:

AHB.060_00.000 Instrument Variable Name:

QuestionText:

23-Nov-10

CIGDAMO

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

On how many of the PAST 30 DAYS did you smoke a cigarette?
*Enter '0' for None.

00

None
1-30 days
Refused
Don't know

01-30
97
99
UniverseText:

Sample adults 18+ who are current some day smokers

SkipInstructions:

<0>[goto CIGQTYR]
<1-30,R,D> [goto CIGSDA2]

Question ID:

AHB.070_00.000 Instrument Variable Name:

QuestionText:

CIGSDA2

On the average, when you smoked during the PAST 30 DAYS, about how many cigarettes did you smoke a day?
* Enter '1' if less than 1.
* Enter '95' if 95 or more cigarettes.

01-94

1-94 cigarettes
95+ cigarettes
Refused
Don't know

95
97
99
UniverseText:

Sample adults 18+ who are current some day smokers

SkipInstructions:

<1-95,R,D> [goto CIGQTYR]

Question ID:

AHB.080_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

CIGQTYR

QuestionnaireFileName:

Sample Adult

During the PAST 12 MONTHS, have you stopped smoking for more than one day BECAUSE YOU WERE TRYING TO
QUIT SMOKING?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who are every day or someday smokers

SkipInstructions:

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

Page 4 of 16

2011 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:
Question ID:

AHB.090_01.000 Instrument Variable Name:

QuestionText:

23-Nov-10

VIGNO

QuestionnaireFileName:

Sample Adult

1 of 2
The next questions are about physical activities (exercise, sports, physically active hobbies...) that you may do in your
LEISURE time.
How often do you do VIGOROUS leisure-time physical activities for AT LEAST 10 MINUTES that cause HEAVY
sweating or LARGE increases in breathing or heart rate?
* Read if necessary: How many times per day, per week, per month, or per year do you do these activities?
* Enter number for vigorous leisure-time physical activities.
* Enter '0' for Never.
* Enter '996' if unable to do this type of activity.

000

999

Never
1-995 time(s)
Unable to do this type activity
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<0,996,R,D>[goto MODNO]
<1-995>[goto VIGTP]

001-995
996
997

Question ID:

AHB.090_02.000 Instrument Variable Name:

QuestionText:

VIGTP

QuestionnaireFileName:

2 of 2
* Enter time period for vigorous leisure-time physical activities.

0
1
2
3
4
6
7
9

Never
Per day
Per week
Per month
Per year
Unable to do this activity
Refused
Don't know

UniverseText:

Sample adults 18+ who do vigorous activities

SkipInstructions:

<1-4> goto VIGLNGNO
[if (VIGNO gt <4> and VIGTP eq <1>) or
(VIGNO gt <28> and VIGTP eq <2>) or
(VIGNO gt <31> and VIGTP eq <3>) or
(VIGNO gt <365> and VIGTP eq <4>) goto ERR1_VIGTP]

Sample Adult

Page 5 of 16

2011 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:
Question ID:

AHB.100_01.000 Instrument Variable Name:

QuestionText:

23-Nov-10

VIGLNGNO

QuestionnaireFileName:

Sample Adult

1 of 2
About how long do you do these vigorous leisure-time physical activities each time?
* Enter number for length of vigorous leisure-time physical activities.

001-995

1-995
Refused
Don't know

997
999
UniverseText:

Sample adults 18+ who do vigorous activities

SkipInstructions:

<1-995>[goto VIGLNGTP]
[goto MODNO]

Question ID:

AHB.100_02.000 Instrument Variable Name:

QuestionText:

VIGLNGTP

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for length of vigorous leisure-time physical activities.

1
2
7
9

Minutes
Hours
Refused
Don't know

UniverseText:

Sample adults 18+ who do vigorous activities

SkipInstructions:

<1,2>goto MODNO
if VIGLNGNO lt <10> and VIGLNGTP eq <1> goto ERR1_VIGLNGTP;
if (VIGLNGNO gt <90> and VIGLNGTP eq <1>) or if VIGLNGNO gt <2> and VIGLNGTP eq <2> goto
ERR2_VIGLNGTP

Page 6 of 16

2011 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:
Question ID:

AHB.110_01.000 Instrument Variable Name:

QuestionText:

23-Nov-10

MODNO

QuestionnaireFileName:

Sample Adult

How often do you do LIGHT OR MODERATE LEISURE-TIME physical activities for AT LEAST 10 MINUTES that
cause ONLY LIGHT sweating or a SLIGHT to MODERATE increase in breathing or heart rate?
* If necessary, prompt with: How many times per day, per week, per month, or per year do you do these activities?
* Enter number of light or moderate leisure-time physical activities.
* Enter '0' for Never.
* Enter '996' if unable to do this type of activity.

000

999

Never
1-995 time(s)
Unable to do this type activity
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1-995>[goto MODTP]
<0, 996, R,D>[goto STRNGNO]

001-995
996
997

Question ID:

AHB.110_02.000 Instrument Variable Name:

QuestionText:

MODTP

QuestionnaireFileName:

2 of 2
* Enter time period for light or moderate leisure-time physical activities

0
1
2
3
4
6
7
9

Never
Per day
Per week
Per month
Per year
Unable to do this activity
Refused
Don't know

UniverseText:

Sample adults 18+ who do light or moderate activities

SkipInstructions:

<1-4> goto MODLNGNO
[if (MODNO gt <4> and MODTP eq <1>) or
(MODNO gt <28> and MODTP eq <2>) or
(MODNO gt <31> and MODTP eq <3>) or
(MODNO gt <365> and MODTP eq <4>)] goto ERR_MODNO

Sample Adult

Page 7 of 16

2011 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:
Question ID:

AHB.120_01.000 Instrument Variable Name:

QuestionText:

23-Nov-10

MODLNGNO

QuestionnaireFileName:

Sample Adult

1 of 2
About how long do you do these light or moderate leisure-time physical activities each time?
* Enter number for length of light or moderate leisure-time physical activities.

001-995

1-995
Refused
Don't know

997
999
UniverseText:

Sample adults 18+ who do light or moderate activities

SkipInstructions:

<1-995>[goto MODLNGTP]
[goto STRNGNO]

Question ID:

AHB.120_02.000 Instrument Variable Name:

QuestionText:

MODLNGTP

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for length of light or moderate leisure-time physical activities.

1
2
7
9

Minutes
Hours
Refused
Don't know

UniverseText:

Sample adults 18+ who do light or moderate activities

SkipInstructions:

<1,2> goto STRNGNO
if MODLNGNO lt <10> and MODLNGTP eq <1> goto ERR1_MODLNGTP
if MODLNGNO gt <90> and MODLNGTP eq <1> or if MODLNGNO gt <2> and MODLNGTP eq <2>goto
ERR2_MODLNGTP

Page 8 of 16

2011 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:
Question ID:

AHB.130_01.000 Instrument Variable Name:

QuestionText:

23-Nov-10

STRNGNO

QuestionnaireFileName:

Sample Adult

How often do you do LEISURE-TIME physical activities specifically designed to STRENGTHEN your muscles such as
lifting weights or doing calisthenics? (Include all such activities even if you have mentioned them before.)
* Read if necessary: How many times per day, per week, per month, or per year do you do these activities?
* Enter number for strengthening activities.
* Enter '0' for Never.
* Enter '996' for Unable to do this type activity

000

999

Never
1-995 time(s)
Unable to do this type activity
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1-995>[goto STRNGTP]
<0, 996,R,D>[goto DISHFAC]

001-995
996
997

Question ID:

AHB.130_02.000 Instrument Variable Name:

QuestionText:

STRNGTP

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for strengthening activities

0
1
2
3
4
6
7
9

Never
Per day
Per week
Per month
Per year
Unable to do this activity
Refused
Don't know

UniverseText:

Sample adults 18+ who do strengthening activities

SkipInstructions:

<1-4> goto DISHFAC
[If (STRNGNO gt <4> & STRNGTP = <1>) or (STRNGNO gt <28> & STRNGTP = <2>) or
(STRNGNO gt <31> & STRNGTP = <3>) or (STRNGNO gt <365> & STRNGTP = <4>) goto
ERR_STRNGTP]

Page 9 of 16

2011 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:
Question ID:

AHB.135_00.010 Instrument Variable Name:

QuestionText:

QuestionnaireFileName:

Sample Adult

The next questions are about health clubs, wellness programs or fitness facilities, such as the YMCA, community
recreation programs, and employer fitness programs. If you wanted to use one, is there a health club, wellness program or
fitness facility in your area that meets your needs?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,R,D> [goto ALC1YR]
<2> [goto DISHFL02]

Question ID:

DISHFAC

23-Nov-10

AHB.136_01.010 Instrument Variable Name:

QuestionText:

DISHFL02

QuestionnaireFileName:

Sample Adult

Do any of these barriers limit or prevent you from using a health club, wellness program, or fitness facility that meets your
needs? I am going to read a list. Please say yes or no to each one.
…Cost is too high.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who do not have a health club, wellness program or fitness facility in their area that meets their
needs, if they wanted to use one

SkipInstructions:

<1,2,R,D> [goto DISHFL03]

Question ID:

AHB.136_02.020 Instrument Variable Name:

QuestionText:

DISHFL03

QuestionnaireFileName:

Sample Adult

* Read if necessary.
Do any of these barriers limit or prevent you from using a health club, wellness program, or fitness facility that meets your
needs?
…Lack of staff or instructors who understand your needs.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who do not have a health club, wellness program or fitness facility in their area that meets their
needs, if they wanted to use one

SkipInstructions:

<1,2,R,D> [goto DISHFL04]

Page 10 of 16

2011 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:
Question ID:

AHB.136_03.030 Instrument Variable Name:

QuestionText:

DISHFL04

23-Nov-10
QuestionnaireFileName:

Sample Adult

* Read if necessary.
Do any of these barriers limit or prevent you from using a health club, wellness program, or fitness facility that meets your
needs?
…Lack of exercise equipment that meets your needs.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who do not have a health club, wellness program or fitness facility in their area that meets their
needs, if they wanted to use one

SkipInstructions:

<1,2,R,D> [goto DISHFL05]

Question ID:

AHB.136_04.040 Instrument Variable Name:

QuestionText:

DISHFL05

QuestionnaireFileName:

Sample Adult

* Read if necessary.
Do any of these barriers limit or prevent you from using a health club, wellness program, or fitness facility that meets your
needs?
…Difficulty getting into or moving around the building.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who do not have a health club, wellness program or fitness facility in their area that meets their
needs, if they wanted to use one

SkipInstructions:

<1,2,R,D> [goto DISHFL06]

Question ID:

AHB.136_05.050 Instrument Variable Name:

QuestionText:

DISHFL06

QuestionnaireFileName:

Sample Adult

* Read if necessary.
Do any of these barriers limit or prevent you from using a health club, wellness program, or fitness facility that meets your
needs?
…Inadequate transportation.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who do not have a health club, wellness program or fitness facility in their area that meets their
needs, if they wanted to use one

SkipInstructions:

<1,2,D,R> [goto DISHFL07]

Page 11 of 16

2011 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:
Question ID:

AHB.136_06.060 Instrument Variable Name:

QuestionText:

DISHFL07

23-Nov-10
QuestionnaireFileName:

Sample Adult

* Read if necessary.
Do any of these barriers limit or prevent you from using a health club, wellness program, or fitness facility that meets your
needs?
…Some other barrier.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who do not have a health club, wellness program or fitness facility in their area that meets their
needs, if they wanted to use one

SkipInstructions:

<1,2,R,D> [goto ALC1YR]

Question ID:

AHB.140_00.000 Instrument Variable Name:

QuestionText:

ALC1YR

QuestionnaireFileName:

Sample Adult

These next questions are about drinking alcoholic beverages. Included are liquor such as whiskey or gin, beer, wine, wine
coolers, and any other type of alcoholic beverage.
In ANY ONE YEAR, have you had at least 12 drinks of any type of alcoholic beverage?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto ALC12MNO]
<2,R,D> [goto ALCLIFE]

Question ID:

AHB.150_00.000 Instrument Variable Name:

QuestionText:
1
2
7
9

ALCLIFE

QuestionnaireFileName:

Sample Adult

In your ENTIRE LIFE, have you had at least 12 drinks of any type of alcoholic beverage?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who have not had 12 drinks in any one year or don't know if they did or refused to answer

SkipInstructions:

<1> [goto ALC12MNO]
<2,R,D> [goto AHGT_FT]

Page 12 of 16

2011 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:
Question ID:

AHB.160_01.000 Instrument Variable Name:

QuestionText:

23-Nov-10

ALC12MNO

QuestionnaireFileName:

Sample Adult

1 of 2
In the PAST YEAR, how often did you drink any type of alcoholic beverage?
* Read if necessary: "How many days per week, per month or per year did you drink?"
* Enter number for how often alcoholic beverages were consumed in the past year.
*Enter '0' for Never.

000

Never
1-365 days
Refused
Don't know

001-365
997
999
UniverseText:

Sample adults 18+ who have had at least 12 drinks in any one year or at least 12 drinks in their entire life

SkipInstructions:

<1-365>[goto ALC12MTP]
<0,R,D>[goto AHGT_FT]

Question ID:

AHB.160_02.000 Instrument Variable Name:

QuestionText:

ALC12MTP

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for how often alcoholic beverages were consumed in the past year.

0
1
2
3
7
9

Never/None
Week
Month
Year
Refused
Don't know

UniverseText:

Sample adults 18+ who drank at least once in the past year

SkipInstructions:

<1-3> [goto ALCAMT]
[If (ALC12MNO gt <7> & ALC12MTP = <1>) or (ALC12MNO gt <31> & ALC12MTP = <2>) or
(ALC12MNO gt <365> & ALC12MTP = <3>) goto ERR_ALC12MTP]

Page 13 of 16

2011 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:
Question ID:

AHB.170_00.000 Instrument Variable Name:

QuestionText:

23-Nov-10

ALCAMT

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

In the PAST YEAR, on those days that you drank alcoholic
beverages, on the average, how many drinks did you have?
* Enter '1' if less than 1 drink.
* Enter '95' if 95 or more drinks.

01-94

1-94 drinks
95+ drinks
Refused
Don't know

95
97
99
UniverseText:

Sample adults 18+ who have had at least 1 drink in the past year

SkipInstructions:

<1-95,R,D> [goto ALC5UPNO]
<10-95>[goto ERR_ALCAMT]

Question ID:

AHB.180_01.000 Instrument Variable Name:

QuestionText:

ALC5UPNO

1 of 2
In the PAST YEAR, on how many DAYS did you have 5 or more drinks of any alcoholic beverage?
* Read if necessary:
How many days per week, per month or per year did you have 5 or more drinks in a single day?
* Enter number of days.
* Enter '0' for Never/None.

000
001-365
997
999

Never/None
1-365 days
Refused
Don't know

UniverseText:

Sample adults 18+ who have had at least 1 drink in the past year

SkipInstructions:

<1-365>[goto ALC5UPTP]
<0,R,D>[goto AHGT_FT]

Page 14 of 16

2011 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:
Question ID:

AHB.180_02.000 Instrument Variable Name:

QuestionText:

23-Nov-10

ALC5UPTP

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for days per week, per month or per year.

0

Never/None
Per week
Per month
Per year
Refused
Don't know

1
2
3
7
9
UniverseText:

Sample adults 18+ who have had 5+ drinks in one day at least once in the past year

SkipInstructions:

<1-3>goto AHGT_FT
[If (ALC5UPNO gt <7> & ALC5UPTP = <1>) or
(ALC5UPNO gt <31> & ALC5UPTP = <2>) or
(ALC5UPNO gt <365> & ALC5UPTP = <3>) goto ERR1_ALC5UPTP
[if number of days drank in the past year (calculated from ALC12MNO and ALC12MTP) lt number of days per
year with 5 or more drinks (calculated from ALC5UPNO and ALC5UPTP)] goto ERR2_ALC5UPTP]

Question ID:

AHB.190_01.000 Instrument Variable Name:

QuestionText:

AHGT_FT

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

How tall are you without shoes?
* Enter "M" to record metric measurements

02-07

2-7 feet
Refused
Don't know
Metric

97
99
M
UniverseText:

Sample adults 18+

SkipInstructions:

<2-7> [goto AHGT_IN]
[goto AWGT_LB]
[goto AHGT_M]
[if AHGT_FT NE<2-7,D,R,M> goto ERR1_AHGT_FT]
[if AHGT_FT = <2,3> goto ERR2_AHGT_FT]

Question ID:

AHB.190_02.000 Instrument Variable Name:

QuestionText:

AHGT_IN

How tall are you without shoes?
* Enter '0' if exactly [fill1: AHGT_FT] feet tall.

00-11
97
99

0-11 inches
Refused
Don't know

UniverseText:

Sample adults 18+ who answered their height in feet

SkipInstructions:

<0-11,R,D> [goto AWGT_LB]
[goto ERR_AHGT_IN]

Page 15 of 16

2011 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:
Question ID:

AHB.190_03.000 Instrument Variable Name:

QuestionText:

23-Nov-10

AHGT_M

QuestionnaireFileName:

Sample Adult

How tall are you without shoes?
* Enter height in metric.

0-2

0-2 meters
Refused
Don't know

7
9
UniverseText:

Sample adults 18+ who choose to give their height in metric measurements

SkipInstructions:

<0-2> [goto AHGT_CM]
[goto AWGT_LB]
[goto ERR_AHGT_M]

Question ID:

AHB.190_04.000 Instrument Variable Name:

AHGT_CM

QuestionnaireFileName:

Sample Adult

QuestionText:

*Enter centimeters.
000-241

0-241 centimeters
Refused
Don't know

997
999
UniverseText:

Sample adults 18+ who answered their height in meters

SkipInstructions:

<0-241,R,D> goto AWGT_LB
[If AHGT_M eq <2> and AHGT_CM gt <41> or AHGT_M eq <1> and AHGT_CM gt <141>] goto
ERR1_AHGT_CM]
< > goto ERR2_AHGT_CM
[If AHGT_M eq <1> and AHGT_CM lt <20> or AHGT_M eq <0> and AHGT_CM lt
<120>] goto ERR3_AHGT_CM]

Question ID:

AHB.200_01.000 Instrument Variable Name:

QuestionText:

AWGT_LB

How much do you weigh without shoes?
* Enter "M" to record metric measurements
* Enter '500' for 500 pounds or more

050-500
997
999
M

50-500 pounds
Refused
Don't know
Metric

UniverseText:

Sample adults 18+

SkipInstructions:

<50-500> [goto SLEEP]
[if AWGT_LB lt <50> or gt <500> goto ERR_AWGT_LB
[goto SLEEP]
[goto AWGT_KG]

QuestionnaireFileName:

Sample Adult

Page 16 of 16

2011 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:
Question ID:

AHB.200_02.000 Instrument Variable Name:

QuestionText:

23-Nov-10

AWGT_KG

QuestionnaireFileName:

Sample Adult

How much do you weigh without shoes?
* Enter weight in kilograms

023-226

23-226 kilograms
Refused
Don't know

997
999
UniverseText:

Sample adults 18+ who choose to give their weight in metric measurements

SkipInstructions:

<23-226,R,D> [goto SLEEP]
[If AWGT_KG lt <22> or K gt <226>goto ERR_AWGT_KG]

Question ID:

AHB.210_00.000 Instrument Variable Name:

QuestionText:

SLEEP

QuestionnaireFileName:

Sample Adult

On average, how many hours of sleep do you get in a 24-hour period?
* Enter hours of sleep in whole numbers, rounding 30 minutes (1/2 hour) or more UP to the next whole hour and dropping
29 or fewer minutes.

01-24
97
99

1-24 hours
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1-24,R,D> [goto next section]
[If SLEEP eq <1-5> goto ERR_SLEEP]

Page 1 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.020_00.000

Instrument Variable Name: AUSUALPL

QuestionText:

Is there a place that you USUALLY go to when you are sick or need advice about your health?

Sample Adult

Yes
There is NO place
There is MORE THAN ONE place
Refused
Don't know

1
2
3
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1-3> [goto APLKIND]
<2,R,D> [goto AHCPLKND]

Question ID:

QuestionnaireFileName:

AAU.030_00.000 Instrument Variable Name:

APLKIND

QuestionnaireFileName:

Sample Adult

[Fill1: What kind of place is it - a clinic, doctor's office, emergency room, or some other place?

QuestionText:

[Fill2: What kind of place do you go to most often - a clinic, doctor's office, emergency room, or some other place?]
Clinic or health center
Doctor's office or HMO
Hospital emergency room
Hospital outpatient department
Some other place
Doesn't go to one place most often
Refused
Don't know

1
2
3
4
5
6
7
9
UniverseText:

Sample adults 18+ with 1+ usual place(s) to go when sick/need health advice

SkipInstructions:

<1-5> [go to AHCPLROU]
<6,R,D> [go to AHCPLKND]

Question ID:

AAU.035_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

AHCPLROU

QuestionnaireFileName:

Sample Adult

Is that {fill: place from (APLKIND)} the same place you USUALLY go when you need routine or preventive care, such as
a physical examination or check up?
Yes
No
Refused
Don't know

UniverseText:

Sample adults aged 18+ years having a clinic or health center, doctor's office or HMO, hospital emergency room,
hospital outpatient department, or some other place that they usually go to when they are sick or need advice about
their health

SkipInstructions:

<1> [goto AHCCHGYR]
<2,R,D> [go to AHCPLKND]

Page 2 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.037_00.000 Instrument Variable Name:

AHCPLKND

QuestionnaireFileName:

Sample Adult

What kind of place do you USUALLY go to when you need routine or preventive care, such as a physical examination or
check-up?

QuestionText:

Doesn't get preventive care anywhere
Clinic or health center
Doctor's office or HMO
Hospital emergency room
Hospital outpatient department
Some other place
Doesn't go to one place most often
Refused
Don't know

0
1
2
3
4
5
6
7
9
UniverseText:

Sample Adults 18+ who do not have a usual source of sick care; who Ref/DK if have a usual source of sick care; who
have a usual source of sick care but do not go to one place most often or Ref/DK what kind of place; who have a
usual source of sick care, but it is not same place as usual source of routine/preventive care; who have a usual source
of sick care but Ref/DK if it is same place as usual source of routine/preventive care.

SkipInstructions:

<0-6,R,D> if AUSUALPL = 2 [goto ANOUSLPL]; else if AUSUALPL=R,D goto APRVTRYR
ELSE goto AHCCHGYR

Question ID:

AAU.040_00.000 Instrument Variable Name:

AHCCHGYR

QuestionnaireFileName:

Sample Adult

At any time in the PAST 12 MONTHS did you CHANGE the place(s) to which you USUALLY go for health care?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+ with 1+ usual place(s) to go when sick/need health advice [or who reported same place as usual
source of routine/preventive care]

SkipInstructions:

<1>[goto AHCCHGHI]
<2,R,D>[goto APRVTRYR]

Question ID:

AAU.050_00.000 Instrument Variable Name:

QuestionText:
1
2
7
9

AHCCHGHI

QuestionnaireFileName:

Sample Adult

Was this change for a reason related to health insurance?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ with 1+ usual place(s) to go when sick/need health advice who CHANGED their USUAL place
for health care in past 12 months

SkipInstructions:

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

Page 3 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.050_00.010

ANOUSLPL

Instrument Variable Name:

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

Why don‟t you have a usual source of medical care?

QuestionText:

*Enter all that apply, separate with commas.
Doesn‟t need a doctor/Haven't had any problems
Doesn‟t like/trust/believe in doctors
Doesn‟t know where to go
Previous doctor is not available/moved
Too expensive/no insurance/cost
Speak a different language
No care available/Care too far away, not convenient
Put it off/Didn't get around to it
Other
Refused
Don't know

01
02
03
04
05
06
07
08
09
97
99

Sample adults 18+ without a place of usual care

UniverseText:
SkipInstructions:

Question ID:

AAU.051_00.010

Instrument Variable Name: APRVTRYR

DURING THE PAST 12 MONTHS, did you have any trouble finding a general doctor or provider who would see you?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9

Sample adults 18+

UniverseText:
SkipInstructions:

Question ID:

<1-9,R,D>[goto APRVTRYR]

<1> [goto APRVTRFD ] <2,R,D>[goto ADRNANP]

AAU.053_00.010 Instrument Variable Name:

QuestionText:
1
2
7
9
UniverseText:
SkipInstructions:

APRVTRFD

Were you able to find a general doctor or provider who could see you?
Yes
No
Refused
Don't know
Sample adults 18+ who had trouble finding a provider
<1,2,R,D>[goto ADRNANP]

QuestionnaireFileName:

Sample Adult

Page 4 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:
QuestionText:
1
2
7
9
UniverseText:

Question ID:
QuestionText:
1
2
7
9
UniverseText:

Question ID:

AAU.057_00.010

Instrument Variable Name: ADRNANP

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, were you told by a doctor‟s office or clinic that they would not accept you as a new patient?
Yes
No
Refused
Don't know
Sample adults 18+ SkipInstructions:

AAU.059_00.010

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

Instrument Variable Name:

ADRNAI

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, were you told by a doctor‟s office or clinic that they did not accept your health care coverage?
Yes
No
Refused
Don't know
Sample adults 18+ SkipInstructions:

<1,2,R,D>[goto AHCDLY_1]

AAU.061_01.000 Instrument Variable Name:

AHCDLY_1

QuestionnaireFileName:

Sample Adult

QuestionText:

There are many reasons people delay getting medical care.
Have you delayed getting care for any of the following reasons in the PAST 12 MONTHS?
...You couldn't get through on the telephone.
1
2
7
9
UniverseText:

Question ID:
QuestionText:

Yes
No
Refused
Don't know
Sample adults 18+

<1,2,R,D>[goto AHCDLY_2]

SkipInstructions:

AAU.061_02.000 Instrument Variable Name:

AHCDLY_2

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary
There are many reasons people delay getting medical care. Have you delayed getting care for any of the following reasons in
the PAST 12 MONTHS?
...You couldn't get an appointment soon enough.

1
2
7
9
UniverseText:

Yes
No
Refused
Don't know
Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto AHCDLY_3]

Page 5 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.061_03.000 Instrument Variable Name:

AHCDLY_3

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary

QuestionText:

There are many reasons people delay getting medical care. Have you delayed getting care for any of the following reasons in
the PAST 12 MONTHS?
...Once you get there, you have to wait too long to see the doctor.
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto AHCDLY_4]

Question ID:

AAU.061_04.000 Instrument Variable Name:

AHCDLY_4

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary

QuestionText:

There are many reasons people delay getting medical care. Have you delayed getting care for any of the following reasons in
the PAST 12 MONTHS?
...The (clinic/doctor's) office wasn't open when you could get there.
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto AHCDLY_5]

Question ID:

AAU.061_05.000 Instrument Variable Name:

QuestionText:

AHCDLY_5

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary
There are many reasons people delay getting medical care. Have you delayed getting care for any of the following reasons in
the PAST 12 MONTHS?
...You didn't have transportation.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto AHCAFY_1]

Page 6 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.111_01.000 Instrument Variable Name:

AHCAFY_1

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, was there any time when you needed any of the following, but didn't get it because
you couldn't afford it?

QuestionText:

...Prescription medicines.
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto AHCAFY_2]

Question ID:

AAU.111_02.000 Instrument Variable Name:

AHCAFY_2

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.

QuestionText:

DURING THE PAST 12 MONTHS, was there any time when you needed any of the following, but didn't get it because
you couldn't afford it?
...Mental health care or counseling.
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto AHCAFY_3]

Question ID:

AAU.111_03.000 Instrument Variable Name:

QuestionText:

AHCAFY_3

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.
DURING THE PAST 12 MONTHS, was there any time when you needed any of the following, but didn't get it because
you couldn't afford it?
...Dental care (including check ups).

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto AHCAFY_4]

Page 7 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.111_04.000 Instrument Variable Name:

AHCAFY_4

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.

QuestionText:

DURING THE PAST 12 MONTHS, was there any time when you needed any of the following, but didn't get it because
you couldn't afford it?
...Eyeglasses.
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto AHCAFY_5]

Question ID:

AAU.111_05.010 Instrument Variable Name:

QuestionText:

AHCAFY_5

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.
DURING THE PAST 12 MONTHS, was there any time when you needed any of the following, but didn't get it because
you couldn't afford it?
...To see a specialist.

1
2
7
9

Yes
No
Refused
Don‟t know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto AHCAFY_6]

Question ID:
QuestionText:

AAU.111_06.010

Instrument Variable Name: AHCAFY_6

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.
DURING THE PAST 12 MONTHS, was there any time when you needed any of the following, but didn't get it because
you couldn't afford it?
...Follow-up care.

1
2
7
9

Yes
No
Refused
Don‟t know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Page 8 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.113_00.010 Instrument Variable Name:

QuestionnaireFileName:

Sample Adult

If you get sick or have an accident, how worried are you that you will be able to pay your medical bills? Are you very worried, somewhat
worried, or not at all worried?

QuestionText:

Very worried
Somewhat worried
Not at all worried
Refused
Don't know

1
2
3
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

AWORPAY

AAU.113_00.020 Instrument Variable Name:

QuestionText:

1
2
3
7
9

AHICOMP

QuestionnaireFileName:

Sample Adult

In regard to your health insurance or health care coverage, how does it compare to a year ago? Is it better, worse, or about the
same?
Better
Worse
About the same
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,3,R,D>[goto ARXPR_1]

Question ID:

AAU.127_01.010

Instrument Variable Name: ARXPR_1

QuestionText:

The following questions concern the use of prescription medication DURING THE PAST 12 MONTHS, are any of the
following true for you?
…You skipped medication doses to save money

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto ARXPR_2]

QuestionnaireFileName:

Sample Adult

Page 9 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.127_02.010 Instrument Variable Name:

ARXPR_2

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary

QuestionText:

The following questions concern the use of medication DURING THE PAST 12 MONTHS, are any of the following true for
you?
…you took less medicine to save money
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto ARXPR_3]

Question ID:

AAU.127_03.010 Instrument Variable Name:

QuestionText:

ARXPR_3

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary
The following questions concern the use of medication DURING THE PAST 12 MONTHS, are any of the following true for
you?
…You delayed filling a prescription to save money

1
2
7
9
UniverseText:
SkipInstructions:

Question ID:
QuestionText:

Yes
No
Refused
Don't know
Sample adults 18+
<1,2,R,D>[goto ARXPR_4]

AAU.127_04.010

Instrument Variable Name:

ARXPR_4

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.
The following questions concern the use of medication DURING THE PAST 12 MONTHS, are any of the following true for
you?
…You asked your doctor for a lower cost medication to save money.

1
2
7
9
UniverseText:

Yes
No
Refused
Don't know
Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto ARXPR_5]

Page 10 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.127_05.010 Instrument Variable Name:

ARXPR_5

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.

QuestionText:

The following questions concern the use of medication DURING THE PAST 12 MONTHS, are any of the following true for
you?
…You bought prescription drugs from another country to save money.
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto ARXPR_6]

Question ID:

AAU.127_06.010 Instrument Variable Name:

ARXPR_6

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.

QuestionText:

The following questions concern the use of medication DURING THE PAST 12 MONTHS, are any of the following true for
you?
…You used alternative therapies to save money.
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

AAU.135_00.000 Instrument Variable Name:

QuestionText:

ADENLONG

QuestionnaireFileName:

Sample Adult

(book) A8
About how long has it been since you last saw a dentist? Include all types of dentists, such as orthodontists, oral surgeons,
and all other dental specialists, as well as dental hygienists.

0
1
2
3
4
5
7
9

Never
6 months or less
More than 6 mos, but not more than 1 yr ago
More than 1 yr, but not more than 2 yrs ago
More than 2 yrs, but not more than 5 yrs ago
More than 5 years ago
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<0-5,R,D>[ goto AHCSY1_1]

Page 11 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.141_01.000 Instrument Variable Name:

AHCSY1_1

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, that is since {12 month ref.date}, have you seen or talked to any of the following
health care providers about your own health?

QuestionText:

...A mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker.
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[ goto AHCSY1_2]

Question ID:

AAU.141_02.000 Instrument Variable Name:

AHCSY1_2

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.

QuestionText:

DURING THE PAST 12 MONTHS, that is since {12 month ref.date}, have you seen or talked to any of the following
health care providers about your own health?
...An optometrist, ophthalmologist, or eye doctor (someone who prescribes eyeglasses).
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[ goto AHCSY1_3]

Question ID:

AAU.141_03.000 Instrument Variable Name:

QuestionText:

AHCSY1_3

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.
DURING THE PAST 12 MONTHS, that is since {12 month ref.date}, have you seen or talked to any of the following
health care providers about your own health?

...A foot doctor.
1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[ goto AHCSY1_4]

Page 12 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.141_04.000 Instrument Variable Name:

AHCSY1_4

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.

QuestionText:

DURING THE PAST 12 MONTHS, that is since {12 month ref.date}, have you seen or talked to any of the following
health care providers about your own health?

...A chiropractor.
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[ goto AHCSY1_5]

Question ID:

AAU.141_05.000 Instrument Variable Name:

AHCSY1_5

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.

QuestionText:

DURING THE PAST 12 MONTHS, that is since {12 month ref.date}, have you seen or talked to any of the following
health care providers about your own health?

...A physical therapist, speech therapist, respiratory therapist, audiologist, or occupational therapist.
Yes
No
Refused
Don't know

1
2
7
9

Sample adults 18+

UniverseText:

Question ID:

SkipInstructions:

AAU.141_06.000 Instrument Variable Name:

QuestionText:

<1,2,R,D>[ goto AHCSY1_6]

AHCSY1_6

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.
DURING THE PAST 12 MONTHS, that is since {12 month ref.date}, have you seen or talked to any of the following
health care providers about your own health?

...A nurse practitioner, physician assistant, or midwife.
1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[if SEX=1goto AHCSY8_8; else if SEX=2 goto AHCSYR7]

Page 13 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.200_00.000 Instrument Variable Name:

AHCSYR7

QuestionnaireFileName:

Sample Adult

* Read lead-in if necessary.

QuestionText:

DURING THE PAST 12 MONTHS, that is since {12 month ref.date}, have you seen or talked to any of the following
health care providers about your own health?
...A doctor who specializes in women's health (an obstetrician/gynecologist).
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample female adults aged 18+ years

SkipInstructions:

<1,2,R,D> [go to AHCSY8_ 8]

Question ID:

AAU.211_01.000 Instrument Variable Name:

AHCSY8_ 8

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.

QuestionText:

DURING THE PAST 12 MONTHS, that is since {12 month ref.date}, have you seen or talked to any of the following
health care providers about your own health?
...A medical doctor who specializes in a particular medical disease or problem (other than obstetrician/gynecologist,
psychiatrist, or ophthalmologist).
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [go to AHCSY8_ 9]

Question ID:

AAU.211_02.000 Instrument Variable Name:

QuestionText:

AHCSY8_ 9

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.
DURING THE PAST 12 MONTHS, that is since {12 month ref.date}, have you seen or talked to any of the following
health care providers about your own health?
...A general doctor who treats a variety of illnesses (a doctor in general practice, family medicine, or internal medicine)?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto AHCSYR10]
<2,R,D> [goto AHERNOYR]

Page 14 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.230_00.000 Instrument Variable Name:

AHCSYR10

QuestionnaireFileName:

Does that doctor treat children and adults (a doctor in general practice or family medicine)?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+ who have seen or talked to a general doctor during the past 12 months

SkipInstructions:

<1,2,R,D> [go to AHERNOYR]

Question ID:

Sample Adult

AAU.240_00.000 Instrument Variable Name:

AHERNOYR

QuestionnaireFileName:

Sample Adult

(book) A9

QuestionText:

DURING THE PAST 12 MONTHS, HOW MANY TIMES have you gone to a HOSPITAL EMERGENCY ROOM about
your own health (This includes emergency room visits that resulted in a hospital admission.)?
None
1
2-3
4-5
6-7
8-9
10-12
13-15
16 or more
Refused
Don't know

00
01
02
03
04
05
06
07
08
97
99
UniverseText:

Sample adults 18+

SkipInstructions:

<0,R,D> [go to AHCHYR] <1-8> [goto AERVISND]

Question ID:

AAU.243_00.010 Instrument Variable Name:

QuestionText:
1
2
7
9

AERVISND

QuestionnaireFileName: Sample Adult

Thinking about your most recent emergency room visit, did you go to the emergency room at night or on the weekend?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who had at least one ER visit in the past year

SkipInstructions:

<1,2,R,D> [go to AERHOS]

Page 15 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.245_00.010 Instrument Variable Name:

AERHOS

Did this emergency room visit result in a hospital admission?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+ who had at least one ER visit in the past year

SkipInstructions:

<1,R,D> [goto AHCHYR] < 2> [go to AERREAS1]

Question ID:

QuestionnaireFileName: Sample Adult

AAU.248_01.010 Instrument Variable Name:

AERREAS1

QuestionnaireFileName: Sample Adult

Tell me which of these apply to your last emergency room visit?

QuestionText:

… You didn't have another place to go
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+ who had at least one ER visit in the past year and the last visit did not result in a hospital
admission

SkipInstructions:

<1,2,R,D> [goto AERREAS2]

Question ID:

AAU.248_02.020 Instrument Variable Name:

QuestionText:

AERREAS2

QuestionnaireFileName: Sample Adult

Tell me which of these apply to your last emergency room visit?
… Your doctor‟s office or clinic was not open

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who had at least one ER visit in the past year and the last visit did not result in a hospital
admission

SkipInstructions:

<1,2,R,D> [goto AERREAS3]

Page 16 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.248_03.030 Instrument Variable Name:

AERREAS3

QuestionnaireFileName: Sample Adult

Tell me which of these apply to your last emergency room visit?

QuestionText:

… Your health provider advised you to go
Yes
No
Refused
Don't know

1
2
7
9

UniverseText:

Sample adults 18+ who had at least one ER visit in the past year and the last visit did not result in a hospital
admission

SkipInstructions:

<1,2,R,D> [goto AERREAS4]

Question ID:

AAU.248_04.040 Instrument Variable Name:

AERREAS4

QuestionnaireFileName: Sample Adult

Tell me which of these apply to your last emergency room visit?

QuestionText:

… The problem was too serious for the doctor‟s office or clinic
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+ who had at least one ER visit in the past year and the last visit did not result in a hospital
admission

SkipInstructions:

<1,2,R,D> [goto AERREAS5]

Question ID:

AAU.248_05.050

QuestionText:

Instrument Variable Name: AERREAS5

QuestionnaireFileName: Sample Adult

Tell me which of these apply to your last emergency room visit?
… Only a hospital could help you

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who had at least one ER visit in the past year and the last visit did not result in a hospital
admission

SkipInstructions:

<1,2,R,D> [goto AERREAS6]

Page 17 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.248_06.060 Instrument Variable Name:

AERREAS6

QuestionnaireFileName: Sample Adult

Tell me which of these apply to your last emergency room visit?

QuestionText:

… the emergency room is your closest provider
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+ who had at least one ER visit in the past year and the last visit did not result in a hospital
admission

SkipInstructions:

<1,2,R,D> [goto AERREAS7]

Question ID:

AAU.248_07.070 Instrument Variable Name:

AERREAS7

QuestionnaireFileName: Sample Adult

Tell me which of these apply to your last emergency room visit?

QuestionText:

…you get most of your care at the emergency room
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+ who had at least one ER visit in the past year and the last visit did not result in a hospital
admission

SkipInstructions:

<1,2,R,D> [goto AERREAS8]

Question ID:

AAU.248_08.080

Instrument Variable Name:

AERREAS8

QuestionnaireFileName: Sample Adult

Tell me which of these apply to your last emergency room visit?

QuestionText:

…you arrived by ambulance or other emergency vehicle
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:
SkipInstructions:

Question ID:
QuestionText:
1
2
7
9
UniverseText:

Sample adults 18+ who had at least one ER visit in the past year and the last visit did not result in a hospital admission
<1,2,R,D> [goto AHCHYR]

AAU.250_00.000 Instrument Variable Name:

AHCHYR

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, did you receive care AT HOME from a nurse or other health care professional?
Yes
No
Refused
Don't know
Sample adults 18+

SkipInstructions:

<1>[goto AHCHMOYR] <2,R,D>[goto AHCNOYR]

Page 18 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.260_00.000 Instrument Variable Name:

AHCHMOYR

QuestionnaireFileName:

Sample Adult

During how many of the PAST 12 MONTHS did you receive care AT HOME from a health care professional?

QuestionText:

01-12 months
Refused
Don't know

01-12
97
99
UniverseText:

Sample adults 18+ who received home care from a health professional during the past 12 months

SkipInstructions:

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

Question ID:

AAU.270_00.000 Instrument Variable Name:

AHCHNOYR

QuestionnaireFileName:

Sample Adult

(book) A10

QuestionText:

What was the total number of home visits received during {Fill1: that month/Fill2: those months}?
1
2-3
4-5
6-7
8-9
10-12
13-15
16 or more
Refused
Don't know

01
02
03
04
05
06
07
08
97
99
UniverseText:

Sample adults 18+ who received home care from a health professional during the past 12 months

SkipInstructions:

<1-8,R,D>[goto AHCNOYR]

Question ID:
QuestionText:

AAU.280_00.000 Instrument Variable Name:

AHCNOYR

QuestionnaireFileName:

Sample Adult

(book) A9
DURING THE PAST 12 MONTHS, HOW MANY TIMES have you seen a doctor or other health care professional about
your own health at a DOCTOR'S OFFICE, A CLINIC, OR SOME OTHER PLACE? DO NOT INCLUDE TIMES YOU
WERE HOSPITALIZED OVERNIGHT, VISITS TO HOSPITAL EMERGENCY ROOMS, HOME VISITS, DENTAL
VISITS, OR TELEPHONE CALLS.

00
01
02
03
04
05
06
07
08
97
99
UniverseText:

None
1
2-3
4-5
6-7
8-9
10-12
13-15
16 or more
Refused
Don't know
Sample adults 18+

SkipInstructions:

<0-8,R,D>[goto ASRGYR]

Page 19 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.290_00.000 Instrument Variable Name:

ASRGYR

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you had SURGERY or other surgical procedures either as an inpatient or
outpatient?

QuestionText:

* Read if necessary: This includes both major surgery and minor procedures such as setting bones or removing growths.
Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1>[goto ASRGNOYR]
<2,R,D> [goto AMDLONG]

Question ID:

AAU.300_00.000 Instrument Variable Name:

ASRGNOYR

QuestionnaireFileName:

Sample Adult

Including any times you may have already told me about, HOW MANY DIFFERENT TIMES have you had surgery during
the PAST 12 MONTHS?

QuestionText:

* Enter "95" for 95 or more times.
1-94 times
95+ times
Refused
Don't know

01-94
95
97
99
UniverseText:

Sample adults 18+ who had surgery or surgical procedures during past 12 months

SkipInstructions:

<1-95,R,D> [goto AMDLONG]
<11-95> [goto ERR_ASGYR]

Question ID:

AAU.305_00.000 Instrument Variable Name:

QuestionText:

(book) A8

AMDLONG

QuestionnaireFileName:

Sample Adult

? [F1]

About how long has it been since you last saw or talked to a doctor or other health care professional about your own health?
Include doctors seen while a patient in a hospital.
0
1
2
3
4
5
7
9

Never
6 months or less
More than 6 mos, but not more than 1 yr ago
More than 1 yr, but not more than 2 yrs ago
More than 2 yrs, but not more than 5 yrs ago
More than 5 years ago
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<0,R,D> [goto HIT1A] <1-5> [goto AVISLAST]

Page 20 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.306_00.010 Instrument Variable Name:

AVISLAST

QuestionnaireFileName:

Sample Adult

Thinking about your last visit for any type of medical care, where did you go?

QuestionText:

*Read categories if necessary.
Clinic or health center
Doctor's office or HMO
Hospital emergency room
Hospital outpatient department
Urgent care center
Some other place
Refused
Don't know

1
2
3
4
5
6
7
9

UniverseText:
Sample adults 18+ who have ever seen a doctor or other health professional
SkipInstructions:
<3,5> [goto AWAITRMN] <1,2,4,6> [goto ALASTTYP] [goto HIT1A]

Question ID:

AAU.306_00.020 Instrument Variable Name:

QuestionnaireFileName:

Sample Adult

Did you see a general doctor, a specialist, or someone else?

QuestionText:

General doctor
Specialist
Someone else
Refused
Don't know

1
2
3
7
9
UniverseText:
SkipInstructions:

Question ID:

ALASTTYP

Sample adults 18+ who visited a clinic, doctor‟s office/HMO, hospital outpatient department or someplace else (not ER or urgent care center) on
their last visit
<1-3,R,D> [goto AVISAPTN]

AAU.306_01.030 Instrument Variable Name:

AVISAPTN

QuestionnaireFileName:

Sample Adult

For this visit, how long did you have to wait between the time you made the appointment and the day you actually saw the doctor or other health
professional?

QuestionText:

*Enter „0‟ for same day, walk-in appointment, or no appointment made.
*Enter number for appointment wait time.
UniverseText:
SkipInstructions:

Question ID:

Sample adults 18+ who visited a clinic, doctor‟s office/HMO, hospital outpatient department or someplace else (not ER or urgent care center)
on their last visit
<0-96,D> [goto AVISAPTT] [ AWAITRMN]

AAU.306_02.030 Instrument Variable Name:

QuestionText:
1
2
3

AVISAPTT

QuestionnaireFileName:

Sample Adult

*Enter time period for appointment wait time.
Days
Weeks
Months

7
9

Refused
Don't know

Sample adults 18+ who visited a clinic, doctor‟s office/HMO, hospital outpatient department or someplace else (not ER or urgent care center)
on their last visit and did not answer refused to appointment wait time
SkipInstructions:
<1-3,R,D> [goto AWAITRMN]
UniverseText:

Page 21 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.306_01.040 Instrument Variable Name:

AWAITRMN

QuestionnaireFileName:

Sample Adult

How long did you have to wait in the waiting room before you saw a doctor or other health professional for this visit?

QuestionText:

*Enter number for time in waiting room.
Sample adults 18+ who had a place of last medical visit

UniverseText:

Question ID:

AAU.306_02.040 Instrument Variable Name:

SkipInstructions:

AWAITRMT

<0-96,D> [goto AWAITRMT] [goto HIT1A]

QuestionnaireFileName:

Sample Adult

*Enter time period for time in waiting room.

QuestionText:

Minutes
Hours

1
2

7 Refused
9 Don't know

UniverseText:
Sample adults 18+ who had a place of last medical visit and did not refuse number portion of waiting room time
SkipInstructions:
<1,2,R,D> [goto HIT1A]

Question ID:

AAU.309_00.010

QuestionnaireFileName:

Sample Adult

…Look up health information on the Internet
Yes
No
Refused
Don't know

1
2
7
9

Sample adults 18+

UniverseText:

SkipInstructions:

AAU. 309_00.020 Instrument Variable Name:

<1,2,R,D> [goto HIT2A]

HIT2A

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you ever used computers for any of the following

QuestionText:

…Fill a prescription
Yes
No
Refused
Don't know

1
2
7
9

Sample adults 18+

UniverseText:

Question ID:

HIT1A

DURING THE PAST 12 MONTHS, have you ever used computers for any of the following

QuestionText:

Question ID:

Instrument Variable Name:

SkipInstructions:

AAU. 309_00.030 Instrument Variable Name:

QuestionText:

<1,2,R,D> [goto HIT3A]

HIT3A

DURING THE PAST 12 MONTHS, have you ever used computers for any of the following
…Schedule an appointment with a health care provider

1
2
7
9

QuestionnaireFileName:

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto HIT4A]

Sample Adult

Page 22 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:
QuestionText:

AAU. 309_00.040 Instrument Variable Name:

HIT4A

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you ever used computers for any of the following
…Communicate with a health care provider by email

1
2
7
9
UniverseText:

Question ID:
QuestionText:

1
2
7
9
UniverseText:

Question ID:
QuestionText:

Yes
No
Refused
Don't know
Sample adults 18+

SkipInstructions:

AAU. 309_00.050 Instrument Variable Name:

<1,2,R,D> [goto HIT5A]

HIT5A

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you ever used computers for any of the following
…Use online chat groups to learn about health topics
Yes
No
Refused
Don't know
Sample adults 18+

SkipInstructions:

AAU.310_00.000 Instrument Variable Name:

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

SHTFLUYR

QuestionnaireFileName:

Sample Adult

During the past 12 months, several kinds of flu vaccines have been available. I will ask you about your most recent flu vaccination.
DURING THE PAST 12 MONTHS, have you had a flu shot? A flu shot is usually given in the fall and protects against influenza for the flu
season.
* Read if necessary: A flu shot is injected in the arm. Do not include an influenza vaccine sprayed in the nose.
*Read if necessary: Your most recent flu vaccination could have been the new 2010-2011 flu vaccine available starting last fall, or either of the
two types available last season, one called “seasonal” and the other called “H1N1” or “swine” flu vaccine.

1
2
7
9
UniverseText:

Yes
No
Refused
Don't know
Sample adults 18+

SkipInstructions:

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

Page 23 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.312_01.000 Instrument Variable Name:

QuestionnaireFileName:

Sample Adult

1 of 2
During what month and year did you receive your most recent flu shot?

QuestionText:

January
February
March
April
May
June
July
August
September
October
November
December
Refused
Don't know

01
02
03
04
05
06
07
08
09
10
11
12
97
99

Sample adults 18+ who have had a flu shot

UniverseText:

Question ID:

ASHFLU_M

AAU.312_02.000 Instrument Variable Name:

ASHFLU_Y

SkipInstructions:

<1-12,D> [ goto ASHFLU_Y] [goto SPRFLUYR]

QuestionnaireFileName:

Sample Adult

2 of 2
*Enter year of most recent flu shot.

QuestionText:

Year
Refused
Don't know

Year
9997
9999
UniverseText:

Sample adults 18+ who gave a month for their last flu shot or who didn‟t know the month

SkipInstructions:

[goto SPRFLUYR] [If ASHFLU_M and ASHFLU_Y = a future date] goto ERR1_ASHFLU_Y
[If ASHFLU_M and ASHFLU_Y = a date prior to birth] goto ERR2_ASHFLU_Y
[If ASHFLU_M and ASHFLU_Y = a date before 12 months ago] goto ERR3_ASHFLU_Y

Question ID:

AAU.315_00.000 Instrument Variable Name:

QuestionText:

SPRFLUYR

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you had a flu vaccine sprayed in your nose by a doctor or other health
professional? A health professional may have let you spray it. This vaccine is usually given in the fall and protects against
influenza for the flu season.
* Read if necessary: This influenza vaccine is called FluMist (trademark).
*Read if necessary: Your most recent flu vaccination could have been the new 2010-2011 flu vaccine available starting last fall, or either of the
two types available last season, one called “seasonal” and the other called “H1N1” or “swine” flu vaccine.

1
2
7
9
UniverseText:
SkipInstructions:

Yes
No
Refused
Don't know
Sample adults 18+
<1> [goto ASPFLU_M] [if SHTFLUYR =1 and SPRFLUYR=1] goto ERR1_SPRFLUYR
[if AGE GE 50] goto ERR2_SPRFLUYR <2,D,R> [goto SHTPNUYR]

Page 24 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.318_01.000 Instrument Variable Name:

ASPFLU_M

QuestionnaireFileName:

Sample Adult

1 of 2

QuestionText:

During what month and year did you receive your most recent flu nasal spray?
January
February
March
April
May
June
July
August
September
October
November
December
Refused
Don't know

01
02
03
04
05
06
07
08
09
10
11
12
97
99

Sample adults 18+ who have had a flu nasal vaccine SkipInstructions:

UniverseText:

Question ID:

AAU.318_02.000 Instrument Variable Name:

ASPFLU_Y

<1-12,D> [ goto ASPFLU_Y] [goto SHTPNUYR]

QuestionnaireFileName:

Sample Adult

2 of 2

QuestionText:

*Enter year of most recent flu nasal spray.
Year
Refused
Don't know

Year
9997
9999
UniverseText:

Sample adults 18+ who gave a month for their flu nasal vaccine or who didn‟t know the month

SkipInstructions:

[goto SHTPNUYR][If ASPFLU_M and ASPFLU_Y = a future date] goto ERR1_ASPFLU_Y
[If ASPFLU_M and ASPFLU_Y = a date prior to birth] goto ERR2_ASPFLU_Y
[If ASPFLU_M and ASPFLU_Y = a date before 12 months ago] goto ERR3_ASPFLU_Y

Question ID:

AAU.320_00.000 Instrument Variable Name:

QuestionText:

SHTPNUYR

QuestionnaireFileName:

Sample Adult

Have you EVER had a pneumonia shot?
This shot is usually given only once or twice in a person's lifetime and is different from the flu shot. It is also called the
pneumococcal vaccine.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Page 25 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.330_00.000 Instrument Variable Name:

QuestionnaireFileName:

Sample Adult

APOX12MO

QuestionnaireFileName:

Sample Adult

AHEP

QuestionnaireFileName:

Sample Adult

AHEPLIV

QuestionnaireFileName:

Sample Adult

Have you EVER had chickenpox?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto APOX12MO]
<2,R,D> [goto AHEP]

Question ID:

APOX

AAU.340_00.000 Instrument Variable Name:

Have you had chickenpox in the PAST 12 MONTHS?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+ who have ever had chickenpox

SkipInstructions:

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

Question ID:

AAU.350_00.000 Instrument Variable Name:
Have you EVER had hepatitis?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto SHTHEPB]
<2,R,D> [goto AHEPLIV]

Question ID:

AAU.360_00.000 Instrument Variable Name:

QuestionText:
1
2
7
9

Have you ever lived with someone who had hepatitis?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who have never had hepatitis; Ref/DK if ever had hepatitis

SkipInstructions:

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

Page 26 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.370_00.000 Instrument Variable Name:

SHTHEPB

QuestionnaireFileName:

Sample Adult

Have you EVER received the hepatitis B vaccine?

QuestionText:

* Read if necessary: This is given in three separate doses and has been available since 1991. It is recommended for newborn
infants, adolescents, and people such as health care workers, who may be exposed to the hepatitis B virus.
Yes
No
Refused
Don't know

1
2
7
9

Sample adults 18+

UniverseText:

Question ID:

AAU.380_00.000 Instrument Variable Name:

QuestionnaireFileName:

Sample Adult

Sample adults 18+ who have ever received the Hepatitis B vaccine SkipInstructions: <1,2,R,D> [goto SHTHEPA]

UniverseText:

AAU.390_00.010 Instrument Variable Name:

SHTHEPA

QuestionnaireFileName:

Sample Adult

The hepatitis A vaccine is given as a two dose series routinely to some children starting at 1 year of age, and to some adults
and people who travel outside the United States. Although it can be given as a combination vaccine with hepatitis B, it is
different from the hepatitis B shot, and has only been available since 1995. Have you ever received the hepatitis A vaccine?

QuestionText:

1
2
7
9
UniverseText:
SkipInstructions:

QuestionText:

SHEPDOS

Received at least 3 doses
Received less than 3 doses
Refused
Don't know

1
2
7
9

Question ID:

<1> [goto SHEPDOS] <2,R,D> [goto SHTHEPA]

Did you receive at least 3 doses of the hepatitis B vaccine, or less than 3 doses?

QuestionText:

Question ID:

SkipInstructions:

Yes
No
Refused
Don't know
Sample adults 18+
<1> [goto SHEPANUM]; <2,R,D> if AGE GE 50 [goto SHINGLES]; else [goto SHTTD]

AAU.400_00.010 Instrument Variable Name:

SHEPANUM

QuestionnaireFileName:

Sample Adult

How many hepatitis A shots did you receive?
*Enter '96' if all shots were received

01-95
96
97
99
UniverseText:

01-95 shots
Received all shots
Refused
Don't know
Sample adults 18+ who have had a hepatitis A vaccine SkipInstructions: <1-95,96,R,D> if AGE GE 50 [goto SHINGLES]
elseif AGE LT 50 [goto SHTTD]

Page 27 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.410_00.010 Instrument Variable Name:

UniverseText:

Sample adults 50+

SkipInstructions:

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

AAU.420_00.010 Instrument Variable Name:

SHTTD

QuestionnaireFileName:

Sample Adult

Have you received a tetanus shot in the past 10 years?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9

Sample adults 18+

UniverseText:
SkipInstructions:

<1> goto SHTTD05 <2,R,D> and AGE >64 [goto LIVEV] Else if <2,R,D> and AGE<65 [goto HPVHRD]

AAU.430_00.010 Instrument Variable Name:

SHTTD05

QuestionnaireFileName:

Sample Adult

Was your most recent tetanus shot given in 2005 or later?

QuestionText:
1
2
7
9
UniverseText:
SkipInstructions:

Question ID:

Sample Adult

Yes
No
Refused
Don't know

1
2
7
9

Question ID:

QuestionnaireFileName:

Shingles is an outbreak of a rash or blisters on the skin that may be associated with severe pain. The pain is generally on
one side of the body or face. Shingles is caused by the chicken pox virus. A vaccine for shingles has been available since
May 2006. Have you ever had the Zoster (ZOSS-ter) or Shingles vaccine, also called Zostavax®?

QuestionText:

Question ID:

SHINGLES

Yes
No
Refused
Don't know
Sample adults 18+ who have had a tetanus shot in the past 10 years
<1,R> if AGE le 64 goto SHTTDAP elseif AGE gt 64 goto LIVEV<2,D> if AGE le 64 goto HPVHRD elseif AGE gt 64 goto LIVEV

AAU.440_00.010 Instrument Variable Name:

QuestionText:

1
2
3
7
9

SHTTDAP

QuestionnaireFileName:

Sample Adult

There are currently two types of tetanus shots available today. One is the Td or tetanus-diphtheria vaccine and the other is
called Tdap or Adacel (trademark). They are similar except the Tdap shot also includes a pertussis (per-TUH-sis) or
whooping cough vaccine. Thinking back to your most recent tetanus shot, did the doctor tell you the vaccine included the
pertussis or whooping cough vaccine? The shot is often called Tdap or ADACEL (trademark).
Yes-included pertussis
No-did not include pertussis
Doctor did not say
Refused
Don't know

UniverseText:

Sample adults <65 who have had a tetanus shot in 2005 or beyond or refused to say if they had a tetanus shot in
2005 or beyond

SkipInstructions:

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

Page 28 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.442_00.010 Instrument Variable Name:

HPVHRD

QuestionnaireFileName:

Sample Adult

Have you ever heard of HPV? HPV stands for human papillomavirus (pap-uh-LOW-muh-vi-rus).

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9

Sample adults LE 64

UniverseText:

<1,2,R,D> [goto SHHPVHD1]

SkipInstructions:

Question ID:

AAU.444_00.010 Instrument Variable Name:

QuestionText:

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

UniverseText:

Sample adults LE 64

SkipInstructions:

<1,2,R,D> [goto SHTHPV1]

AAU.446_00.010 Instrument Variable Name:

Sample Adult

SHTHPV1

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

Have you ever received an HPV shot or vaccine?

QuestionText:

Yes
No
Doctor refused when asked
Refused
Don't know

1
2

3
7
9
UniverseText:

Sample adults LE 64

SkipInstructions:

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

Question ID:

QuestionnaireFileName:

Yes
No
Refused
Don't know

1
2
7
9

Question ID:

SHHPVHD1

AAU.446_00.010 Instrument Variable Name:

QuestionText:

SHHPVDOS

How many HPV shots did you receive?
* Enter '50' if 50 or more shots
* Enter '96' for all shots

UniverseText:
SkipInstructions:

Sample adults LE 64 who received an HPV shot
<1,2,R,D> [goto LIVEV]

Page 29 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.450_00.010 Instrument Variable Name:

Sample Adult

Yes
No
Refused
Don't know

1
2
7
9
UniverseText:

Sample adults 18+

SkipInstructions:

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

AAU.460_00.010 Instrument Variable Name:

TRAVEL

QuestionnaireFileName:

Sample Adult

Have you ever traveled outside of the United States to countries other than Europe, Japan, Australia, New Zealand or
Canada, since 1995?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9

Sample adults 18+

UniverseText:

Question ID:

QuestionnaireFileName:

Has a doctor or other health professional ever told you that you had any kind of chronic, or long-term liver condition?

QuestionText:

Question ID:

LIVEV

SkipInstructions:

AAU.465_00.010 Instrument Variable Name:

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

WRKHLTH

QuestionnaireFileName:

Sample Adult

Do you currently volunteer or work in a hospital, medical clinic, doctor‟s office, dentist‟s office, nursing home or some other
health-care facility? This includes part-time and unpaid work in a health care facility as well as professional nursing care
provided in the home.

QuestionText:

*Read if necessary: This includes non-health care professionals, such as administrative staff, who work in a health-care
facility.
Yes
No
Refused
Don't know

1
2
7
9

Sample adults 18+

UniverseText:

Question ID:

SkipInstructions:

AAU.470_00.010 Instrument Variable Name:

QuestionText:

1
2
7
9

<1> [goto WRKDIR] <2,R,D> [goto APSBPCHK]

WRKDIR

QuestionnaireFileName:

Sample Adult

Do you provide direct patient care as part of your routine work? By direct patient care we mean physical or hands on contact
with patients.
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who work or volunteer in a health-care setting

SkipInstructions:

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

Page 30 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.500_00.010 Instrument Variable Name:

Sample Adult

Yes
No
Refused
Don't know

1
2
7
9

Sample adults 18+

UniverseText:

SkipInstructions:

AAU.510_00.010 Instrument Variable Name:

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

APSCHCHK

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you had your blood cholesterol checked by a doctor, nurse, or other health professional?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9

Sample adults 18+ SkipInstructions: <1,2,R,D> [goto APSBSCHK]

UniverseText:

AAU.520_00.010

Question ID:

Instrument Variable Name:

APSBSCHK

QuestionnaireFileName:

Sample Adult

Have you had a fasting test for high blood sugar or diabetes DURING THE PAST 12 MONTHS?

QuestionText:

Yes
No
Refused
Don't know

1
2
7
9

Sample adults 18+

UniverseText:
SkipInstructions:

Question ID:

QuestionnaireFileName:

DURING THE PAST 12 MONTHS, have you had your blood pressure checked by a doctor, nurse, or other health professional?

QuestionText:

Question ID:

APSBPCHK

<1,2,R,D> and SEX=1 and AGE GE 40 [gotoAPSCOL]
<1,2,R,D> and SEX=1 and AGE < 40 [goto APSDIET]
<1,2,R,D> and SEX=2 [goto APSPAP]

AAU.530_00.010 Instrument Variable Name:

QuestionText:

APSPAP

QuestionnaireFileName:

Sample Adult

QuestionText: Have you had a Pap smear or Pap test DURING THE PAST 12 MONTHS?
*Read if necessary.
A Pap smear or Pap test is a routine test for women in which the doctor examines the cervix, takes a cell sample from the
cervix with a small stick or brush, and sends it to the lab.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Female sample adults 18+

SkipInstructions:

<1,2,R,D> if AGE GE 30 [goto APSMAM];
else [goto APSDIET]

Page 31 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.540_00.010 Instrument Variable Name:

APSMAM

QuestionnaireFileName:

Sample Adult

Have you had a Mammogram DURING THE PAST 12 MONTHS?

QuestionText:

*Read if necessary.
A mammogram is an x-ray of each breast to look for breast cancer.
Yes
No
Refused
Don't know

1
2
7
9

Female sample adults 30+

UniverseText:

SkipInstructions:

<1,2,R,D> if AGE GE 40 [gotoAPSCOL]; else [goto APSDIET]

Question ID:

AAU.550_00.010

Instrument Variable Name:APSCOL

QuestionText:

DURING THE PAST 12 MONTHS, have you had any test done for colon cancer?

QuestionnaireFileName:

Sample Adult

*Read if necessary.
Colon cancer tests include blood stool tests, colonoscopy and sigmoidoscopy.
A blood stool test is a test that may use a special kit at home to determine whether the stool contains blood.
A sigmoidoscopy and colonoscopy are exams in which a tube is inserted in the rectum to view the colon for signs of cancer
or other health problems.
Yes
No
Refused
Don‟t know
Sample adults 40+

1
2
7
9
UniverseText:

Question ID:

SkipInstructions:

AAU.560_00.010 Instrument Variable Name:

QuestionText:
1
2
7
9

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

APSDIET

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, has a doctor or other health professional talked to you about your diet?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> if SMKNOW eq 1, 2 [goto APSSMKC]; if age GE 40 and age LE 65 [goto LTCFAM]; else [goto AINDINS]

Page 32 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:

AAU.570_00.010 Instrument Variable Name:

QuestionText:
1
2
7
9
UniverseText:
SkipInstructions:

APSSMKC

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, has a doctor or other health professional talked to you about your smoking?
Yes
No
Refused
Don‟t know
Sample adults 18+ currently who smoke every day or some days
<1,2,R,D> if age GE 40 and age LE 65 [goto LTCFAM]; else [goto AINDINS]

Question ID:

AAU.580_00.010

Instrument Variable Name: LTCFAM

QuestionText:

Do you have a parent, spouse, sibling, or adult child who has needed help for at least a year with everyday needs like bathing, dressing or eating
due to a long term condition?

QuestionnaireFileName:

Sample Adult

*Read if necessary: Due to a chronic illness or disability
1
2
7
9
UniverseText:

Question ID:
QuestionText:

Yes
No
Refused
Don‟t know
Sample adults 40-65
AAU.582_00.010

SkipInstructions:

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

Instrument Variable Name: LTCHELP

QuestionnaireFileName:

Sample Adult

How likely is it that you may someday need help with daily activities like bathing, dressing, eating, or using the toilet due to a long term
condition? Would you say…
*Read categories below.
Very likely
Somewhat likely
Somewhat unlikely
Very unlikely
Refused
Don‟t know

1
2
3
4
7
9
UniverseText:

Question ID:
QuestionText:

Sample adults 40-65

AAU.584_00.010

SkipInstructions:

<1-4,R,D> [goto LTCWHO]

Instrument Variable Name: LTCWHO

QuestionnaireFileName:

If you needed such help, who would provide this help?
*Enter all that apply, separate with commas.

1
2
3
4
5
7
9
UniverseText:

My family
Someone I hire
Home health care organization
Nursing home/assisted living
Other
Refused
Don‟t know
Sample adults 40-65

SkipInstructions:

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

Sample Adult

Page 33 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:
QuestionText:

1
2
7
9
UniverseText:

Question ID:
QuestionText:

01
02
03
04
05
06
07
97
99
UniverseText:
SkipInstructions:

Question ID:
QuestionText:

AAU.586_00.010

Instrument Variable Name: LTCPRCH

QuestionnaireFileName:

Sample Adult

Health Care Reform establishes a voluntary, government-run insurance program to pay for help with everyday needs like bathing, dressing or
eating. People will be able to enroll, and pay a monthly premium. Once they need care they would receive an average of $50 each day. Would
you be interested in purchasing this insurance?
Yes
No
Refused
Don‟t know
Sample adults 40-65
AAU.588_00.010

SkipInstructions:

<1,D> [goto LTCPAY] <2,R> [goto AINDINS]

Instrument Variable Name: LTCPAY

QuestionnaireFileName:

Sample Adult

How much would you be willing to pay per month NOW to receive this benefit later in life?
$1-$24 per month
$25-$49 per month
$50-$74 per month
$75-$99 per month
$100-$124 per month
$125 per month or more
Nothing/Not interested in the program
Refused
Don‟t know
Sample adults 40-65 who would be interested in purchasing long-term care insurance or don‟t know if they are interested
<1-7,R> [goto AINDINS] [goto LTC100M]
AAU.590_00.010

Instrument Variable Name: LTC100M

QuestionnaireFileName:

Sample Adult

How likely would it be for you to pay $100 per month for this insurance? Would you say…
*Read categories below.

1
2
3
4
7
9
UniverseText:
SkipInstructions:

Question ID:
QuestionText:

1
2
7
9
UniverseText:

Very likely
Somewhat likely
Somewhat unlikely
Very unlikely
Refused
Don‟t know
Sample adults 40-65 who don‟t know how much they would be willing to pay per month for long-term care insurance
<1-4,R,D> [goto AINDINS]

AAU.600_00.010

Instrument Variable Name: AINDINS

QuestionnaireFileName:

Sample Adult

DURING THE PAST 3 YEARS, did you try to purchase health insurance directly, that is, not through any employer, union, or government
program?
Yes
No
Refused
Don‟t know
Sample adults 18+

SkipInstructions:

<1> [goto AINDPRCH> <2,R,D> [goto HIVTST1]

Page 34 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:
QuestionText:

1
2
7
9
UniverseText:
SkipInstructions:

Question ID:
QuestionText:

1
2
3
7
9
UniverseText:
SkipInstructions:

Question ID:
QuestionText:

AAU.600_00.020

Instrument Variable Name: AINDPRCH

QuestionnaireFileName:

Sample Adult

Was a plan purchased?
Yes
No
Refused
Don‟t know
Sample adults 18+ who tried to purchase health insurance directly in the past 3 years
<1> [goto AINDWHO] <2> [goto AINDNOT] [goto HIVTST1]
AAU.600_00.030

Instrument Variable Name: AINDWHO

QuestionnaireFileName:

Sample Adult

Was this plan for yourself, someone else in your family, or both?
Self
Someone else in family
Both
Refused
Don‟t know
Sample adults 18+ who purchased health insurance directly in the past 3 years
<1-3,R,D> [goto AINDDIF1]

AAU.600_00.040

Instrument Variable Name: AINDDIF1

QuestionnaireFileName:

Sample Adult

How difficult was it to find a plan with the type of coverage you needed? Would you say…
*Read categories below.

1
2
3
7
9
UniverseText:
SkipInstructions:

Question ID:
QuestionText:

Very difficult
Somewhat difficult
Not at all difficult
Refused
Don‟t know
Sample adults 18+ who purchased health insurance directly in the past 3 years
<1-3,R,D> [goto AINDDIF2]

AAU.600_00.050

Instrument Variable Name: AINDDIF2

QuestionnaireFileName:

How difficult was it to find a plan you could afford? Would you say…
*Read categories below.

1
2
3
7
9
UniverseText:
SkipInstructions:

Very difficult
Somewhat difficult
Not at all difficult
Refused
Don‟t know
Sample adults 18+ who purchased health insurance directly in the past 3 years
<1-3,R,D> [goto AINDENY1]

Sample Adult

Page 35 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:
QuestionText:
1
2
7
9
UniverseText:
SkipInstructions:

Question ID:
QuestionText:
1
2
7
9
UniverseText:
SkipInstructions:

Question ID:
QuestionText:

1
2
7
9
UniverseText:
SkipInstructions:

Question ID:
QuestionText:

AAU.600_01.060

Instrument Variable Name: AINDENY1

QuestionnaireFileName:

Did any company turn you down when you tried to buy coverage on your own?
Yes
No
Refused
Don‟t know
Sample adults 18+ who purchased health insurance directly in the past 3 years
<1,2,R,D> [goto AINDENY2]

AAU.600_02.060

Instrument Variable Name: AINDENY2

QuestionnaireFileName:

UniverseText:
SkipInstructions:

Sample Adult

Did any company charge a higher price because of {fill: your/your family‟s/you or your family‟s} health?
Yes
No
Refused
Don‟t know
Sample adults 18+ who purchased health insurance directly in the past 3 years
<1,2,R,D> [goto AINDENY3]

AAU.600_03.060

Instrument Variable Name: AINDENY3

QuestionnaireFileName:

Sample Adult

Did any company exclude a specific health problem from the coverage?
Yes
No
Refused
Don‟t know
Sample adults 18+ who purchased health insurance directly in the past 3 years
<1,2,R,D> [goto HIVTST1]

AAU.600_00.070

Instrument Variable Name: AINDNOT

QuestionnaireFileName:

Why did you not buy a plan?
*Enter all that apply, separate with commas.

1
2
3
4
5
7
9

Sample Adult

Turned down
Cost
Pre-existing condition
Got health insurance from other source
Other reason (specify)
Refused
Don‟t know
Sample adults 18+ who tried to purchase health insurance directly in the past 3 years
<1-4,R,D> [goto HIVTST1] <5> [goto AINDNTSP]

Sample Adult

Page 36 of 36

2011 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization (Including Health Care Reform Questions)
Document Version Date: 18-November 2010

Question ID:
QuestionText:

AAU.600_00.080

Instrument Variable Name: AINDNTSP

QuestionnaireFileName:

Sample Adult

*Specify other reason plan was not obtained.

Verbatim _____________________

UniverseText:
SkipInstructions:

Question ID:
QuestionText:

1
2
7
9
UniverseText:
SkipInstructions:

Sample adults 18+ who had other reason plan was not purchased
[goto HIVTST1]

AAU.700_00.000

Instrument Variable Name: HIVTST1

QuestionnaireFileName:

Sample Adult

The next question is about the test for HIV (the virus that causes AIDS). Not including tests you have done for blood donations, have you EVER
been tested for HIV?

Yes
No
Refused
Don‟t know
Sample adults 18+
<1.2,R,D> [goto next section]

Page 1 of 2

2011 NHIS Questionnaire - Sample Adult
Adult Disability
Document Version Date:
Question ID:

ADB.020_00.000 Instrument Variable Name:

QuestionText:

25-Oct-10

P2DAHEAR

QuestionnaireFileName:

Sample Adult

With this next set of questions, we want to learn about people who have physical, mental, or emotional conditions that
cause serious difficulties with their daily activities. Though different, these questions may sound similar to ones I asked
earlier.
Are you deaf or do you have serious difficulty hearing?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ and random number generator=1

SkipInstructions:

<1,2,D,R> goto P2DASEE

Question ID:

ADB.040_00.000 Instrument Variable Name:

QuestionText:

P2DASEE

Sample Adult

Are you blind or do you have serious difficulty seeing even when wearing glasses?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ and random number generator=1

SkipInstructions:

<1,2,D,R> goto P2DACON

Question ID:

QuestionnaireFileName:

ADB.060_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

P2DACON

QuestionnaireFileName:

Sample Adult

Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or
making decisions?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ and random number generator=1

SkipInstructions:

<1,2,D,R> goto P2DAWALK

Page 2 of 2

2011 NHIS Questionnaire - Sample Adult
Adult Disability
Document Version Date:
Question ID:

ADB.080_00.000 Instrument Variable Name:

QuestionText:

P2DAWALK

Sample Adult

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ and random number generator=1

SkipInstructions:

<1,2,D,R> goto P2DADRES

ADB.100_00.000 Instrument Variable Name:

QuestionText:

P2DADRES

Do you have difficulty dressing or bathing?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ and random number generator=1

SkipInstructions:

<1,2,D,R> goto P2DAERR

Question ID:

QuestionnaireFileName:

Do you have serious difficulty walking or climbing stairs?

1

Question ID:

25-Oct-10

ADB.120_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

P2DAERR

Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a
doctor's office or shopping?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ and random number generator = 1

SkipInstructions:

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

Page 1 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Functioning and Disability
Document Version Date:
Question ID:

AFD.100_00.000 Instrument Variable Name:

QuestionText:

VIS_SS

25-Oct-10
QuestionnaireFileName:

Sample Adult

These next questions are new and we are testing them. Some may sound similar to questions you already answered.
Do you have difficulty seeing, even when wearing glasses? Would you say no difficulty, some difficulty, a lot of difficulty,
or are you unable to do this?

1

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

2
3
4
7
9
UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB)

SkipInstructions:

<1-4,R,D>[goto HEAR_SS]

Question ID:

AFD.150_00.000 Instrument Variable Name:

QuestionText:

HEAR_SS

QuestionnaireFileName:

Do you have difficulty hearing, even when using a hearing aid? Would you say no difficulty, some difficulty, a lot of
difficulty, or are you unable to do this?

1

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

2
3
4
7
9
UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB)

SkipInstructions:

<1-3,R,D>[goto HEAR_1]
<4>[goto MOB_SS]

Question ID:

Sample Adult

AFD.160_00.000 Instrument Variable Name:

QuestionText:
1
2
7
9

HEAR_1

QuestionnaireFileName:

Sample Adult

Do you use a hearing aid?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who have no difficulty, some difficulty, a lot of difficulty, or refused or don't know if they have
difficulty hearing, even when using a hearing aid

SkipInstructions:

<1>[goto HEAR_2]
<2,R,D>[goto HEAR_3]

Page 2 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Functioning and Disability
Document Version Date:
Question ID:

AFD.160_00.001 Instrument Variable Name:

QuestionText:

HEAR_2

QuestionnaireFileName:

Sample Adult

How often do you use your hearing aid(s)? Would you say all of the time, some of the time, rarely, or never?

1

All of the time
Some of the time
Rarely
Never
Refused
Don't know

2
3
4
7
9
UniverseText:

Sample adults 18+ who use a hearing aid

SkipInstructions:

<1-4,R,D>[goto HEAR_3]

Question ID:

25-Oct-10

AFD.170_00.000 Instrument Variable Name:

QuestionText:

HEAR_3

QuestionnaireFileName:

Sample Adult

Do you have difficulty hearing what is said in a conversation with one other person in a quiet room {fill: even when
wearing your hearing aid(s)}? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do
this?

1

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

2
3
4
7
9
UniverseText:

Sample adults 18+ who have no difficulty, some difficulty, a lot of difficulty, or refused or don't know if they have
difficulty hearing, even when using a hearing aid

SkipInstructions:

<1-3,R,D>[goto HEAR_4]
<4>[goto MOB_SS]

Question ID:

AFD.170_00.001 Instrument Variable Name:

QuestionText:

1
2
3
4
7
9

HEAR_4

QuestionnaireFileName:

Sample Adult

Do you have difficulty hearing what is said in a conversation with one other person in a noisier room {fill: even when
wearing your hearing aid(s)}? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

UniverseText:

Sample adults 18+ who have no difficulty, some difficulty, a lot of difficulty, or refuse or don't know if they have
difficulty hearing what is said in a conversation with one other person in a quiet room (even when wearing their
hearing aid(s))

SkipInstructions:

<1-4,R,D>[goto MOB_SS]

Page 3 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Functioning and Disability
Document Version Date:
Question ID:

AFD.180_00.000 Instrument Variable Name:

QuestionText:

MOB_SS

25-Oct-10
QuestionnaireFileName:

Do you have any difficulty walking or climbing steps? Would you say no difficulty, some difficulty, a lot of difficulty, or
are you unable to do this?

1

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

2
3
4
7
9
UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB)

SkipInstructions:

<1-4,R,D>[goto MOB_2]

Question ID:

AFD.200_00.000 Instrument Variable Name:

QuestionText:

MOB_2

QuestionnaireFileName:

Sample Adult

Do you use any equipment or receive help with walking, climbing steps, or moving around?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB)

SkipInstructions:

<1>[goto MOB_3A]
<2,R,D>[goto MOB_4]

Question ID:

Sample Adult

AFD.200_00.001 Instrument Variable Name:

QuestionText:

MOB_3A

QuestionnaireFileName:

Sample Adult

Do you use any of the following…
Cane or walking stick?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who use equipment or receive help for walking, climbing steps, or moving around

SkipInstructions:

<1,2,R,D>[goto MOB_3B]

Page 4 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Functioning and Disability
Document Version Date:
Question ID:

AFD.200_00.002 Instrument Variable Name:

QuestionText:

MOB_3B

25-Oct-10
QuestionnaireFileName:

Sample Adult

*Read if necessary.
Do you use any of the following…
Walker?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who use equipment or receive help for walking, climbing steps, or moving around

SkipInstructions:

<1,2,R,D>[goto MOB_3C]

Question ID:

AFD.200_00.003 Instrument Variable Name:

QuestionText:

MOB_3C

QuestionnaireFileName:

Sample Adult

*Read if necessary.
Do you use any of the following…
Crutches?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who use equipment or receive help for walking, climbing steps, or moving around

SkipInstructions:

<1,2,R,D>[goto MOB_3D]

Question ID:

AFD.200_00.004 Instrument Variable Name:

QuestionText:

MOB_3D

QuestionnaireFileName:

Sample Adult

*Read if necessary.
Do you use any of the following…
Wheelchair or scooter?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who use equipment or receive help for walking, climbing steps, or moving around

SkipInstructions:

<1,2,R,D>[goto MOB_3E]

Page 5 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Functioning and Disability
Document Version Date:
Question ID:

AFD.200_00.005 Instrument Variable Name:

QuestionText:

MOB_3E

25-Oct-10
QuestionnaireFileName:

Sample Adult

*Read if necessary.
Do you use any of the following…
Prosthesis?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who use equipment or receive help for walking, climbing steps, or moving around

SkipInstructions:

<1,2,R,D>[goto MOB_3F]

Question ID:

AFD.200_00.006 Instrument Variable Name:

QuestionText:

MOB_3F

QuestionnaireFileName:

Sample Adult

*Read if necessary.
Do you use any of the following…
Someone's assistance?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who use equipment or receive help for walking, climbing steps, or moving around

SkipInstructions:

<1,2,R,D>[goto MOB_3G]

Question ID:

AFD.200_00.007 Instrument Variable Name:

QuestionText:

MOB_3G

QuestionnaireFileName:

Sample Adult

*Read if necessary.
Do you use any of the following…
Other type of equipment or help?

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who use equipment or receive help for walking, climbing steps, or moving around

SkipInstructions:

<1,2,R,D>
if MOB_3D='1' [goto COM_SS]
elseif MOB_3D IN (2,R,D) [goto MOB_4]

Page 6 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Functioning and Disability
Document Version Date:
Question ID:

AFD.210_00.000 Instrument Variable Name:

QuestionText:

MOB_4

Sample Adult

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

2
3
4
7
9
UniverseText:

Sample adults 18+ who do not use a wheelchair

SkipInstructions:

<1-3,R,D>[goto MOB_5]
<4>[goto MOB_6]

AFD.230_00.000 Instrument Variable Name:

QuestionText:

MOB_6

QuestionnaireFileName:

Sample Adult

Do you have difficulty walking up or down 12 steps {fill: without the use of your aid(s)}? Would you say no difficulty,
some difficulty, a lot of difficulty, or are you unable to do this?

1

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

2
3
4
7
9
UniverseText:

Sample adults 18+ who do not use a wheelchair

SkipInstructions:

<1-4,R,D>
if MOB_2 IN '2,R,D' [goto COM_SS]
elseif MOB_2 = '1' [goto MOB_7]

Question ID:

QuestionnaireFileName:

Do you have difficulty walking 100 yards on level ground, that would be about the length of one football field or one city
block {fill: without the use of your aid(s)}? Would you say no difficulty, some difficulty, a lot of difficulty, or are you
unable to do this?

1

Question ID:

25-Oct-10

AFD.240_00.000 Instrument Variable Name:

QuestionText:

1
2
3
4
7
9

MOB_7

QuestionnaireFileName:

Sample Adult

Do you have difficulty walking 100 yards on level ground, that would be about the length of one (1) football field or one
city block, when using your aid(s)? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to
do this?
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

UniverseText:

Sample adults 18+ who use equipment or receive help for getting around but do not use a wheelchair

SkipInstructions:

<1-3,R,D>[goto MOB_8]
<4>[goto MOB_9]

Page 7 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Functioning and Disability
Document Version Date:
Question ID:

AFD.250_00.000 Instrument Variable Name:

QuestionText:

MOB_8

25-Oct-10
QuestionnaireFileName:

Sample Adult

Do you have difficulty walking a third of a mile on level ground, that would be the length of five football fields or five
city blocks, when using your aid(s)? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to
do this?

1

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

2
3
4
7
9
UniverseText:

Sample adults 18+ who use equipment or receive help for getting around but do not use a wheelchair and who
have no difficulty, some difficulty, a lot of difficulty, or refused or don't know if they have difficulty walking 100
yards on level ground, when using their aid

SkipInstructions:

<1-4,R,D>[goto MOB_9]

Question ID:

AFD.260_00.000 Instrument Variable Name:

QuestionText:

MOB_9

QuestionnaireFileName:

Sample Adult

Do you have difficulty walking up or down 12 steps, even when using your aid(s)? Would you say no difficulty, some
difficulty, a lot of difficulty, or are you unable to do this?

1

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

2
3
4
7
9
UniverseText:

Sample adults 18+ who use equipment or receive help for getting around but do not use a wheelchair

SkipInstructions:

<1-4,R,D>[goto COM_SS]

Question ID:

AFD.270_00.000 Instrument Variable Name:

QuestionText:

1
2
3
4
7
9

COM_SS

QuestionnaireFileName:

Sample Adult

Using your usual language, do you have difficulty communicating, for example understanding or being understood?
Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable to do this?
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB)

SkipInstructions:

<1-4,R,D>[goto COM_2]

Page 8 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Functioning and Disability
Document Version Date:
Question ID:

AFD.290_00.000 Instrument Variable Name:

QuestionText:

25-Oct-10

COM_2

QuestionnaireFileName:

Do you use sign language?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB)

SkipInstructions:

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

Question ID:

AFD.300_00.000 Instrument Variable Name:

QuestionText:

COG_SS

QuestionnaireFileName:

Sample Adult

Do you have difficulty remembering or concentrating? Would you say no difficulty, some difficulty, a lot of difficulty, or
are you unable to do this?

1

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

2
3
4
7
9
UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB)

SkipInstructions:

<1>[goto UB_SS]
<2-4,R,D>[goto COG_1]

Question ID:

Sample Adult

AFD.310_00.000 Instrument Variable Name:

QuestionText:
1
2
3
7
9

COG_1

QuestionnaireFileName:

Sample Adult

Do you have difficulty remembering, concentrating, or both?
Difficulty remembering only
Difficulty concentrating only
Difficulty with both remembering and concentrating
Refused
Don't know

UniverseText:

Sample adults 18+ who have some difficulty, a lot of difficulty, or are unable to remember or concentrate, or don't
know or refused if they are able to remember or concentrate

SkipInstructions:

<1,3,R,D>[goto COG_2]
<2>[goto UB_SS]

Page 9 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Functioning and Disability
Document Version Date:
Question ID:

AFD.320_00.000 Instrument Variable Name:

QuestionText:

25-Oct-10

COG_2

Sometimes
Often
All of the time
Refused
Don't know

2
3
7
9
UniverseText:

Sample adults 18+ who have difficulty remembering

SkipInstructions:

<1,2,3,R,D>[goto COG_3]

AFD.330_00.000 Instrument Variable Name:

QuestionText:

COG_3

QuestionnaireFileName:

Sample Adult

Do you have difficulty remembering a few things, a lot of things, or almost everything?

1

A few things
A lot of things
Almost everything
Refused
Don't know

2
3
7
9
UniverseText:

Sample adults 18+ who have difficulty remembering

SkipInstructions:

<1,2,3,R,D>[goto UB_SS]

Question ID:

Sample Adult

How often do you have difficulty remembering? Would you say sometimes, often or all of the time?

1

Question ID:

QuestionnaireFileName:

AFD.360_00.000 Instrument Variable Name:

QuestionText:

1
2
3
4
7
9

UB_SS

QuestionnaireFileName:

Sample Adult

Do you have difficulty with self care, such as washing all over or dressing? Would you say no difficulty, some difficulty, a
lot of difficulty, or are you unable to do this?
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB)

SkipInstructions:

<1-4,R,D>[goto UB_1]

Page 10 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Functioning and Disability
Document Version Date:
Question ID:

AFD.370_00.000 Instrument Variable Name:

QuestionText:

UB_1

25-Oct-10
QuestionnaireFileName:

Do you have difficulty raising a 2 liter bottle of water or soda from waist to eye level? Would you say no difficulty, some
difficulty, a lot of difficulty, or are you unable to do this?

1

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

2
3
4
7
9
UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB)

SkipInstructions:

<1-4,R,D>[goto UB_2]

Question ID:

AFD.380_00.000 Instrument Variable Name:

QuestionText:

UB_2

QuestionnaireFileName:

Sample Adult

Do you have difficulty using your hands and fingers, such as picking up small objects, for example, a button or pencil, or
opening or closing containers or bottles? Would you say no difficulty, some difficulty, a lot of difficulty, or are you unable
to do this?

1

No difficulty
Some difficulty
A lot of difficulty
Cannot do at all/Unable to do
Refused
Don't know

2
3
4
7
9
UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB)

SkipInstructions:

<1-4,R,D>[goto ANX_1]

Question ID:

Sample Adult

AFD.410_00.000 Instrument Variable Name:

QuestionText:
1
2
3
4
5
7
9

ANX_1

QuestionnaireFileName:

Sample Adult

How often do you feel worried, nervous or anxious? Would you say daily, weekly, monthly, a few times a year, or never?
Daily
Weekly
Monthly
A few times a year
Never
Refused
Don't know

UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB)

SkipInstructions:

<1-5,R,D>[goto ANX_2]

Page 11 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Functioning and Disability
Document Version Date:
Question ID:

AFD.420_00.000 Instrument Variable Name:

QuestionText:

ANX_2

25-Oct-10
QuestionnaireFileName:

Do you take medication for these feelings?

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB)

SkipInstructions:

<1,2,R,D>
if (ANX_1 IN (4,5) and ANX_2=2) [goto DEP_1];
elseif (ANX_1 IN (1,2,3,R,D) or ANX_2 IN (1,R,D)) [goto ANX_3]

Question ID:

Sample Adult

AFD.430_00.000 Instrument Variable Name:

QuestionText:

ANX_3

QuestionnaireFileName:

Sample Adult

Thinking about the last time you felt worried, nervous or anxious, how would you describe the level of these feelings?
Would you say a little, a lot, or somewhere in between?

1

A little
A lot
Somewhere in between a little and a lot
Refused
Don't know

2
3
7
9
UniverseText:

Sample adults 18+ who feel worried, anxious, or nervous daily, weekly, or monthly or don't know or refused how
often or who do take medication for these feelings or don't know or refused if they take medication for these
feelings

SkipInstructions:

<1,2,R,D>[goto P_ANX_4C]
<3>[goto ANX_4]

Question ID:

AFD.440_00.000 Instrument Variable Name:

QuestionText:
1
2
3
7
9

ANX_4

QuestionnaireFileName:

Sample Adult

Would you say this was closer to a little, closer to a lot, or exactly in the middle?
Closer to a little
Closer to a lot
Exactly in the middle
Refused
Don't know

UniverseText:

Sample adults 18+ who feel worried, anxious, or nervous daily, weekly, or monthly or don't know or refused how
often or who do take medication for these feelings or don't know or refused if they take medication for these
feelings and the last time they felt worried, anxious, or nervous described the level of these feelings as somewhere
in between a little and a lot

SkipInstructions:

<1-3,R,D>[goto P_ANX_4C]

Page 12 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Functioning and Disability
Document Version Date:
Question ID:

AFD.445_03.000 Instrument Variable Name:

QuestionText:

25-Oct-10

P_ANX_4C

QuestionnaireFileName:

Sample Adult

Which of the following statements, if any, describe your feelings of being worried, nervous, or anxious? Please say yes or
no to each.
…These are positive feelings that help me to accomplish goals and be productive.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who feel worried, anxious, or nervous daily, weekly, or monthly or don't know or refused how
often or who do take medication for these feelings or don't know or refused if they take medication for these
feelings

SkipInstructions:

<1,2,R,D>[goto P_ANX_4D]

Question ID:

AFD.445_04.000 Instrument Variable Name:

QuestionText:

P_ANX_4D

QuestionnaireFileName:

Sample Adult

*Read if necessary.
Which of the following statements, if any, describe your feelings of being worried, nervous, or anxious? Please say yes or
no to each.
…The feelings sometimes interfere with my life, and I wish that I did not have them.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who feel worried, anxious, or nervous daily, weekly, or monthly or don't know or refused how
often or who do take medication for these feelings or don't know or refused if they take medication for these
feelings

SkipInstructions:

<1,2,R,D>[goto DEP_1]

Question ID:

AFD.450_00.000 Instrument Variable Name:

QuestionText:
1
2
3
4
5
7
9

DEP_1

QuestionnaireFileName:

Sample Adult

How often do you feel depressed? Would you say daily, weekly, monthly, a few times a year, or never?
Daily
Weekly
Monthly
A few times a year
Never
Refused
Don't know

UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB)

SkipInstructions:

<1-5,R,D>[goto DEP_2]

Page 13 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Functioning and Disability
Document Version Date:
Question ID:

AFD.460_00.000 Instrument Variable Name:

QuestionText:

Do you take medication for depression?

1

DEP_2

25-Oct-10
QuestionnaireFileName:

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB)

SkipInstructions:

<1,2,R,D>(if DEP_1 IN (4,5) and DEP_2=2) [goto PAIN_2]
elseif (DEP_1 IN (1,2,3,R,D) or (DEP_1 IN (4,5) and DEP_2 IN (1,R,D))) [goto DEP_3]

Question ID:

Sample Adult

AFD.470_00.000 Instrument Variable Name:

QuestionText:

DEP_3

QuestionnaireFileName:

Sample Adult

Thinking about the last time you felt depressed, how depressed did you feel? Would you say a little, a lot, or somewhere in
between?

1

A little
A lot
Somewhere in between a little and a lot
Refused
Don't know

2
3
7
9
UniverseText:

Sample adults 18+ who feel depressed daily, weekly, monthly, or refused or don't know how often they feel
depressed or Sample adults 18+ who feel depressed a few times a year or never and do take medication or refused
or don't know if they take medication for depression

SkipInstructions:

<1,2,R,D>[goto P_DEP_4C]
<3>[goto DEP_4]

Question ID:

AFD.480_00.000 Instrument Variable Name:

QuestionText:
1
2
3
7
9

DEP_4

QuestionnaireFileName:

Sample Adult

Would you say this was closer to a little, closer to a lot, or exactly in the middle?
Closer to a little
Closer to a lot
Exactly in the middle
Refused
Don't know

UniverseText:

Sample adults 18+ who feel depressed daily, weekly, monthly, or refused or don't know how often they feel
depressed or Sample adults 18+ who feel depressed a few times a year or never and do take medication or refused
or don't know if they take medication for depression and the last time they felt depressed described the level of this
feeling as somewhere in between a little and a lot

SkipInstructions:

<1-3,R,D>[goto P_DEP_4C]

Page 14 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Functioning and Disability
Document Version Date:
Question ID:

AFD.485_03.000 Instrument Variable Name:

QuestionText:

P_DEP_4C

25-Oct-10
QuestionnaireFileName:

Sample Adult

Does the following statements describe your feelings of being depressed? Please say yes or no.
…The feelings sometimes interfere with my life, and I wish I did not have them.

1

Yes
No
Refused
Don't know

2
7
9
UniverseText:

Sample adults 18+ who feel depressed daily, weekly, monthly, or refused or don't know how often they feel
depressed or Sample adults 18+ who feel depressed a few times a year or never and do take medication or refused
or don't know if they take medication for depression

SkipInstructions:

<1,2,R,D>[goto PAIN_2]

Question ID:

AFD.500_00.000 Instrument Variable Name:

QuestionText:

PAIN_2

QuestionnaireFileName:

In the past 3 months, how often did you have pain? Would you say never, some days, most days, or every day?

1

Never
Some days
Most days
Every day
Refused
Don't know

2
3
4
7
9
UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB)

SkipInstructions:

<1-4,R,D>
if PAIN_2=1 [goto TIRED_1];
elseif PAIN_2 IN (2,3,4,R,D) [goto PAIN_3]

Question ID:

Sample Adult

AFD.510_00.000 Instrument Variable Name:

QuestionText:

1
2
3
7
9

PAIN_3

QuestionnaireFileName:

Sample Adult

Thinking about the last time you had pain, how long did the pain last? Would you say some of the day, most of the day, or
all of the day?
Some of the day
Most of the day
All of the day
Refused
Don't know

UniverseText:

Sample adults 18+ who have had pain some days, most days, every day, or refused or don't know how often they
have had pain in the past 3 months

SkipInstructions:

<1-3,R,D>[goto PAIN_4]

Page 15 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Functioning and Disability
Document Version Date:
Question ID:

AFD.520_00.000 Instrument Variable Name:

QuestionText:

PAIN_4

25-Oct-10
QuestionnaireFileName:

Sample Adult

Thinking about the last time you had pain, how much pain did you have? Would you say a little, a lot, or somewhere in
between?

1

A little
A lot
Somewhere in between a little and a lot
Refused
Don't know

2
3
7
9
UniverseText:

Sample adults 18+ who have had pain some days, most days, every day, or refused or don't know how often they
have had pain in the past 3 months

SkipInstructions:

<1,2,R,D>[goto TIRED_1]
<3>[goto P_PAIN5]

Question ID:

AFD.530_00.000 Instrument Variable Name:

QuestionText:

PAIN_5

QuestionnaireFileName:

Sample Adult

Would you say the amount of pain was closer to a little, closer to a lot, or exactly in the middle?

1

Closer to a little
Closer to a lot
Exactly in the middle
Refused
Don't know

2
3
7
9
UniverseText:

Sample adults 18+ who the last time they had pain it was somewhere between a little and a lot

SkipInstructions:

<1-3,R,D>[goto TIRED_1]

Question ID:

AFD.540_00.000 Instrument Variable Name:

QuestionText:

1
2
3
4
7
9

TIRED_1

QuestionnaireFileName:

Sample Adult

In the past 3 months, how often did you feel very tired or exhausted? Would you say never, some days, most days, or
every day?
Never
Some days
Most days
Every day
Refused
Don't know

UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB)

SkipInstructions:

<1>[goto QOL_1]
<2-4,R,D>[goto TIRED_2]

Page 16 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Functioning and Disability
Document Version Date:
Question ID:

AFD.550_00.000 Instrument Variable Name:

QuestionText:

TIRED_2

25-Oct-10
QuestionnaireFileName:

Sample Adult

Thinking about the last time you felt very tired or exhausted, how long did it last? Would you say some of the day, most of
the day, or all of the day?

1

Some of the day
Most of the day
All of the day
Refused
Don't know

2
3
7
9
UniverseText:

Sample adults 18+ who felt very tired or exhausted some days, most days, every day, or refused or don't know how
often they felt very tired or exhausted in the past 3 months

SkipInstructions:

<1-3,R,D>[goto TIRED_3]

Question ID:

AFD.560_00.000 Instrument Variable Name:

QuestionText:

TIRED_3

QuestionnaireFileName:

Sample Adult

Thinking about the last time you felt this way, how would you describe the level of tiredness? Would you say a little, a lot,
or somewhere in between?

1

A little
A lot
Somewhere in between a little and a lot
Refused
Don't know

2
3
7
9
UniverseText:

Sample adults 18+ who felt very tired or exhausted some days, most days, every day, or refused or don't know how
often they felt very tired or exhausted in the past 3 months

SkipInstructions:

<1,2,R,D>[goto QOL_1]
<3>[goto TIRED_4]

Question ID:

AFD.570_00.000 Instrument Variable Name:

QuestionText:
1
2
3
7
9

TIRED_4

QuestionnaireFileName:

Sample Adult

Would you say it was closer to a little, closer to a lot, or exactly in the middle?
Closer to a little
Closer to a lot
Exactly in the middle
Refused
Don't know

UniverseText:

Sample adults 18+ who felt very tired or exhausted some days, most days, every day, or refused or don't know how
often they felt very tired or exhausted in the past 3 months and the last time they felt this way the level of tiredness
was somewhere between a little and a lot

SkipInstructions:

<1-3,R,D>[goto QOL_1]

Page 17 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Functioning and Disability
Document Version Date:
Question ID:

AFD.580_00.000 Instrument Variable Name:

QuestionText:

QOL_1

25-Oct-10
QuestionnaireFileName:

Are you limited in your ability to carry out daily activities? Would you say not at all, a little, a lot, or completely limited?

1

Not at all
A little
A lot
Completely
Refused
Don't know

2
3
4
7
9
UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB)

SkipInstructions:

<1-4,R,D>[goto QOL_2B]

Question ID:

Sample Adult

AFD.590_00.002 Instrument Variable Name:

QuestionText:

QOL_2B

QuestionnaireFileName:

Sample Adult

For each of the following activities, please tell me if you do the activity, don't do the activity, or are unable to do the
activity.
Working outside the home to earn an income?

1

Do the activity
Don't do the activity
Unable to do the activity
Refused
Don't know

2
3
7
9
UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB)

SkipInstructions:

<1-3,R,D>[goto QOL_2C]

Question ID:

AFD.590_00.003 Instrument Variable Name:

QuestionText:

QOL_2C

QuestionnaireFileName:

Sample Adult

*Read if necessary.
For each of the following activities, please tell me if you do the activity, don't do the activity, or are unable to do the
activity.
Going to school or achieving your education goals?

1
2
3
7
9

Do the activity
Don't do the activity
Unable to do the activity
Refused
Don't know

UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB)

SkipInstructions:

<1-3,R,D>[goto QOL_2D]

Page 18 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Functioning and Disability
Document Version Date:
Question ID:

AFD.590_00.004 Instrument Variable Name:

QuestionText:

QOL_2D

25-Oct-10
QuestionnaireFileName:

Sample Adult

*Read if necessary.
For each of the following activities, please tell me if you do the activity, don't do the activity, or are unable to do the
activity.
Participating in leisure or social activities?

1

Do the activity
Don't do the activity
Unable to do the activity
Refused
Don't know

2
3
7
9
UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB)

SkipInstructions:

<1-3,R,D>[goto QOL_2E]

Question ID:

AFD.590_00.005 Instrument Variable Name:

QuestionText:

QOL_2E

QuestionnaireFileName:

Sample Adult

*Read if necessary.
For each of the following activities, please tell me if you do the activity, don't do the activity, or are unable to do the
activity.
Getting out with friends or family?

1

Do the activity
Don't do the activity
Unable to do the activity
Refused
Don't know

2
3
7
9
UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB)

SkipInstructions:

<1-3,R,D>[goto QOL_2F]

Question ID:

AFD.590_00.006 Instrument Variable Name:

QuestionText:

QOL_2F

QuestionnaireFileName:

Sample Adult

*Read if necessary.
For each of the following activities, please tell me if you do the activity, don't do the activity, or are unable to do the
activity.
Doing household chores such as cooking and cleaning?

1
2
3
7
9

Do the activity
Don't do the activity
Unable to do the activity
Refused
Don't know

UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB)

SkipInstructions:

<1-3,R,D>[goto QOL_2G]

Page 19 of 19

2011 NHIS Questionnaire - Sample Adult
Adult Functioning and Disability
Document Version Date:
Question ID:

AFD.590_00.007 Instrument Variable Name:

QuestionText:

QOL_2G

25-Oct-10
QuestionnaireFileName:

Sample Adult

*Read if necessary.
For each of the following activities, please tell me if you do the activity, don't do the activity, or are unable to do the
activity.
Using transportation to get to places you want to go?

1

Do the activity
Don't do the activity
Unable to do the activity
Refused
Don't know

2
3
7
9
UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB)

SkipInstructions:

<1-3,R,D>[goto QOL_2H]

Question ID:

AFD.590_00.008 Instrument Variable Name:

QuestionText:

QOL_2H

QuestionnaireFileName:

Sample Adult

*Read if necessary.
For each of the following activities, please tell me if you do the activity, don't do the activity, or are unable to do the
activity.
Participating in religious activities?

1

Do the activity
Don't do the activity
Unable to do the activity
Refused
Don't know

2
3
7
9
UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB)

SkipInstructions:

<1-3,R,D>[goto QOL_2I]

Question ID:

AFD.590_00.009 Instrument Variable Name:

QuestionText:

QOL_2I

QuestionnaireFileName:

Sample Adult

*Read if necessary.
For each of the following activities, please tell me if you do the activity, don't do the activity, or are unable to do the
activity.
Participating in community gatherings?

1
2
3
7
9

Do the activity
Don't do the activity
Unable to do the activity
Refused
Don't know

UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB)

SkipInstructions:

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