Adult Core--line 3

2013Q4: Attachment 3b Sample Adult Core (14 minutes)
Page 1 of 9

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Identification
Document Version Date:

Question ID:

AID.005_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

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 9

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Identification
Document Version Date:

Question ID:

AID.015_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

2

Yes
No

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

Page 3 of 9

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Identification
Document Version Date:

Question ID:

AID.030_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

AIDVERF_S

QuestionnaireFileName:

Sample Adult

* 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

Yes
No

2

UniverseText:

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

SkipInstructions:

<1> goto AIDVERF_A
<2> goto AIDSEX

Question ID:

AID.040_00.000 Instrument Variable Name:

QuestionText:

AIDSEX

Are you Male or Female?
* If don’t know or refused enter your best guess of the person's sex.

1
2

Male
Female

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

Hard Edit:

ERR_AIDSEX
*The gender will now be changed to [fill: AIDSEX].
goto AIDVERF_S (as the default goto)

QuestionnaireFileName:

Sample Adult

Page 4 of 9

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Identification
Document Version Date:

Question ID:

AID.045_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

Soft Edit:

ERR_AIDAGE
*Age of [fill1: ALIAS of Sample Adult] remains [fill2: Age of Sample Adult] years old.
goto AIDVERF_A (whether suppressed or not)

Sample Adult

Page 5 of 9

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Identification
Document Version Date:

Question ID:

AID.055_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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 6 of 9

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Identification
Document Version Date:

Question ID:

AID.060_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

AIDDOB_D

QuestionnaireFileName:

2 of 3
*Enter day of birth.

01-31
97
99

Day of the month
Refused
Don't know

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

Hard Edit:

ERR_AIDDOB_D
*[fill1: AIDDOB_D] is not a valid day for [fill2: AIDDOB_M].
*Please correct.

Sample Adult

Page 7 of 9

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Identification
Document Version Date:

Question ID:
QuestionText:

AID.060_03.000 Instrument Variable Name:
3 of 3
*Enter year of birth.

1880-2020

Year of birth

20-Aug-13

AIDDOB_Y

QuestionnaireFileName:

Sample Adult

Page 8 of 9

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Identification
Document Version Date:

20-Aug-13

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

Hard Edit:

ERR1_AIDDOB_Y
*Future date invalid: [fill1: , ]
*Please correct.
goto AIDDOB_M (whether suppressed or not)
ERR2_AIDDOB_Y
*Not a valid day: [fill1: , ]
*Please correct.
goto AIDDOB_M (whether suppressed or not)
ERR3_AIDDOB_Y
*DOB of [fill2: ALIAS of Sample Adult] remains [fill3: , ]
goto AIDVERF_A (whether suppressed or not)
ERR4_AIDDOB_Y
* Data mismatched. Please fix Age or Birthday.

Page 9 of 9

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Identification
Document Version Date:

20-Aug-13

* If still cannot reconcile, enter 'Don't know' for year of birth.
* Please correct.

Page 1 of 10

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Socio-Demographic
Document Version Date:

Question ID:

ASD.050_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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 10

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Socio-Demographic
Document Version Date:

Question ID:

ASD.062_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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 or 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 10

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Socio-Demographic
Document Version Date:

Question ID:

ASD.066_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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
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 KINDIND]

Page 4 of 10

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Socio-Demographic
Document Version Date:

Question ID:

ASD.080_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

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 KINDWRK]

Question ID:

ASD.090_00.000 Instrument Variable Name:

QuestionText:

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
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 WRKCAT]

Page 5 of 10

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Socio-Demographic
Document Version Date:

Question ID:

ASD.110_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

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

2
3
4
5

6
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:

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

Question ID:

ASD.112_00.000 Instrument Variable Name:

QuestionText:
1

2
7
9

BUSINC

Is this business incorporated?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who are self-employed

SkipInstructions:

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

QuestionnaireFileName:

Sample Adult

Page 6 of 10

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Socio-Demographic
Document Version Date:

Question ID:

ASD.120_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

LOCALLNO

QuestionnaireFileName:

Sample Adult

(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 7 of 10

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Socio-Demographic
Document Version Date:

Question ID:

ASD.140_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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]

Hard Edit:

ERR_WRKLONGT
* Number of years is greater than age.
* Please correct.

Page 8 of 10

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Socio-Demographic
Document Version Date:

Question ID:

ASD.146_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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:

1

2
7
9

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?
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> [goto PDSICK]

Page 9 of 10

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Socio-Demographic
Document Version Date:

Question ID:

ASD.160_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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?

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>
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]

Question ID:

ASD.170_00.000 Instrument Variable Name:

QuestionText:
1
2
7
9

ONEJOB

QuestionnaireFileName:

Sample Adult

Do you have more than one job or business?
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

SkipInstructions:

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

Page 10 of 10

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Socio-Demographic
Document Version Date:

Question ID:

ASD.210_00.000 Instrument Variable Name:

QuestionText:

0
1
2
7

9

20-Aug-13

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 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.010_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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 CHLYR]

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> [goto HYPYR]
<2,R,D> [goto CHLYR]

Question ID:

QuestionnaireFileName:

ACN.020_00.010 Instrument Variable Name:

QuestionText:

HYPYR

QuestionnaireFileName:

DURING THE PAST 12 MONTHS, have you had hypertension, also called high blood pressure?
*Enter '1' if respondent is taking medication to control his/her high blood pressure.

1
2

7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who were ever told they had hypertention (2+ visits)

SkipInstructions:

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

Sample Adult

Page 2 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.025_00.010 Instrument Variable Name:

QuestionText:

20-Aug-13

CHLYR

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you had high cholesterol?
*Enter '1' if respondent is taking medication to control his/her high cholesterol.

1

Yes
No
Refused
Don't know

2
7

9

UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

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 3 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.031_02.000 Instrument Variable Name:

QuestionText:

ANGEV

20-Aug-13

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:

* 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
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Sample Adult

Page 4 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.031_04.000 Instrument Variable Name:

QuestionText:

HRTEV

20-Aug-13

QuestionnaireFileName:

Sample Adult

? [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

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

ACN.031_05.000 Instrument Variable Name:

QuestionText:

STREV

QuestionnaireFileName:

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

1
2
7

9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Sample Adult

Page 5 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.031_06.000 Instrument Variable Name:

QuestionText:

EPHEV

20-Aug-13

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 COPDEV]

Question ID:

ACN.035_00.000 Instrument Variable Name:

QuestionText:

1
2

7
9

COPDEV

QuestionnaireFileName:

Sample Adult

Have you EVER been told by a doctor or other health professional that you had chronic obstructive pulmonary disease,
also called COPD?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [if AGE GE 40, goto ASPMDMED;
else goto AASMEV]

Page 6 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.040_00.010 Instrument Variable Name:

QuestionText:

20-Aug-13

ASPMEDEV

QuestionnaireFileName:

Sample Adult

Has a doctor or other health professional EVER told you to take a low-dose aspirin each day to prevent or control heart
disease?
* If the respondent volunteers they have been told to take an aspirin every other day or “regularly” for these reasons, enter
1 for “yes.”

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 40+

SkipInstructions:

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

Question ID:

ACN.040_00.020 Instrument Variable Name:

QuestionText:

ASPMEDAD

QuestionnaireFileName:

Sample Adult

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

1

2
7
9

Yes
No
Refused
Don't know

UniverseText:

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

SkipInstructions:

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

Page 7 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.040_00.030 Instrument Variable Name:

QuestionText:

20-Aug-13

ASPMDMED

QuestionnaireFileName:

Sample Adult

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

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

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

SkipInstructions:

<1,2,R,D> goto AASMEV

Question ID:

ACN.040_00.040 Instrument Variable Name:

QuestionText:

ASPONOWN

QuestionnaireFileName:

Sample Adult

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

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

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

SkipInstructions:

<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 8 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.085_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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> if AASSTILL=1 or AASMYR=1 [go to AASMHSP];
else if AASSTILL=2,R,D and AASMYR=2,R,D [go to ULCEV]

Page 9 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.100_00.010 Instrument Variable Name:

QuestionText:

20-Aug-13

AASMHSP

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you stayed overnight in a hospital because of asthma?
*If in hospital for asthma AND other reasons, enter '1'.

1

Yes
No
Refused
Don't know

2
7

9

UniverseText:

Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months

SkipInstructions:

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

Question ID:

ACN.100_00.030 Instrument Variable Name:

QuestionText:

AWZMSWK

QuestionnaireFileName:

DURING THE PAST 12 MONTHS, HOW MANY DAYS were you UNABLE to [fill1: work/get work done around the
house] because of your asthma?
*Enter '0' for none.
*Enter '996' if respondent is unable to do this activity.

000
001-365
996
997
999

None
1-365 days
Unable to do this activity
Refused
Don't know

UniverseText:

Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months

SkipInstructions:

<0-100,996,R,D> [go to AASMPMED]
<101-365> [go to ERR1_AWZMSWK]
<366-994> [go to ERR2_AWZMSWK]

Hard Edit:

if AWZMSWK = 366-994 then display ERR2_AWZMSWK:
"366-994 days not allowed in this field.
*Please correct."

Soft Edit:

Sample Adult

if AWZMSWK >100 and ne 996 then display ERR1_AWZMSWK:
"AWZMSWK is an unusually large number;
*Please verify.

Page 10 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.100_00.060 Instrument Variable Name:

QuestionText:

20-Aug-13

AASMPMED

QuestionnaireFileName:

Sample Adult

Now I'm going to ask you about two different kinds of ASTHMA medicine. One prevents symptoms over the long term.
The other is for quick relief of symptoms during an attack or episode. This quick relief medicine is breathed in through
your mouth using a canister inhaler or a disk inhaler.
DURING THE PAST 3 MONTHS, have you used the kind of PRESCRIPTION asthma inhaler that gives QUICK relief
from asthma symptoms during an attack? Include only medications prescribed by a health care professional.

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months

SkipInstructions:

<1> [goto AASMTYP]
<2,R,D> [go to AASMDTP2]

Question ID:

ACN.100_00.065 Instrument Variable Name:

QuestionText:

AASMTYP

QuestionnaireFileName:

Sample Adult

When you take your rescue prescription asthma medication, would you say that you most often use an inhaler and/or disk,
or do you most often use a nebulizer?
*Read if necessary: Both an inhaler or a disk inhaler are very portable canisters or devices used to inhale medication in
one or two breaths. A nebulizer is a machine that turns liquid medication into a mist that you inhale into the lungs over a
few minutes

1
2
7

8

Inhaler or disc
Nebulizer
Refused
Don't know

UniverseText:

Sample adults 18+ who have used a quick relief prescription asthma inhaler in the past three months

SkipInstructions:

<1> [go to AASMCAN]
<2,R,D> [go to AASMDTP2]

Page 11 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.100_00.070 Instrument Variable Name:

QuestionText:

20-Aug-13

AASMCAN

QuestionnaireFileName:

Sample Adult

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

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+ who have used a prescription asthma inhaler/disk most often in the past three months

SkipInstructions:

<1,2,R,D> [go to AASMDTP2]

Question ID:

ACN.100_00.090 Instrument Variable Name:

QuestionText:

AASMDTP2

QuestionnaireFileName:

Sample Adult

The second kind of asthma medication is different from inhalers used for quick relief. It is the preventive kind that is used
to protect your lungs and keep you from having attacks. It can be either a pill or an inhaler.
Are you NOW taking a preventive asthma medication every day or almost every day, less often, or never?

1
2
3

7
9

Every day or almost every day
Less often
Never
Refused
Don't know

UniverseText:

Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months

SkipInstructions:

<1-3,R,D> [go to AASWMP]

Page 12 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.100_00.100 Instrument Variable Name:

QuestionText:

20-Aug-13

AASWMP

QuestionnaireFileName:

Sample Adult

An asthma action plan is a printed form with specific instructions based on your asthma that tells when to change the
amount or type of medicine, when to call the doctor for advice, and when to go to the emergency room.
Has a doctor or other health professional EVER given you an asthma action plan?
*Read if necessary: Include nurses and asthma educators.

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months

SkipInstructions:

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

Question ID:

ACN.100_00.110 Instrument Variable Name:

QuestionText:

AASCLASS

QuestionnaireFileName:

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

1

Yes
No
Refused
Don't know

2

7
9

UniverseText:

Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months

SkipInstructions:

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

Question ID:

Sample Adult

ACN.105_01.010 Instrument Variable Name:

QuestionText:

AAS_REC

QuestionnaireFileName:

Has a doctor or other health professional EVER taught you
...how to recognize early signs or symptoms of an asthma episode?

1
2

7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months

SkipInstructions:

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

Sample Adult

Page 13 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.105_02.020 Instrument Variable Name:

QuestionText:

20-Aug-13

AAS_RES

QuestionnaireFileName:

Sample Adult

*Read if necessary: Has a doctor or other health professional EVER taught you
...how to respond to episodes of asthma?

1

Yes
No
Refused
Don't know

2
7

9

UniverseText:

Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months

SkipInstructions:

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

Question ID:

ACN.105_03.030 Instrument Variable Name:

QuestionText:

AAS_MON

QuestionnaireFileName:

Sample Adult

*Read if necessary: Has a doctor or other health professional EVER taught you
...how to monitor peak flow for daily therapy?

1

Yes
No
Refused
Don't know

2
7

9

UniverseText:

Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months

SkipInstructions:

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

Question ID:

ACN.107_00.010 Instrument Variable Name:

QuestionText:

1
2
3
7

9

AAPENVLN

QuestionnaireFileName:

Sample Adult

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

Yes
No
Was told no changes needed
Refused
Don't know

UniverseText:

Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months

SkipInstructions:

<1-3,R,D> [go to AAROUTIN]

Page 14 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.107_00.020 Instrument Variable Name:

QuestionText:

20-Aug-13

AAROUTIN

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, how many times did you see a doctor or other health professional for a routine
checkup for your asthma? Please do not include emergency room visits, visits to urgent care centers, or other visits for
acute care for an asthma episode or attack.
*Enter '0' for none.

000

None
1-365 times
Refused
Don’t know

001-365
997
999

UniverseText:

Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months

SkipInstructions:

<0-50,R,D> [go to AASYMPT]
<51-365> [goto ERR_AAROUTIN]

Soft Edit:

ERR_AAROUTIN
[fill4: AAROUTIN] is an unusually large number.
* Please verify.

Question ID:

ACN.107_00.030 Instrument Variable Name:

QuestionText:

AASYMPT

QuestionnaireFileName:

The next three questions are about the last time you saw a doctor or other health care professional for routine care or for
any reason.
At your last visit, did your doctor or other health professional ask HOW OFTEN
….you had asthma symptoms?

1

2
7
9

Sample Adult

Yes
No
Refused
Don’t know

UniverseText:

Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months

SkipInstructions:

<1,2,R,D> [go to AARESCUE];

Page 15 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.107_00.040 Instrument Variable Name:

QuestionText:

20-Aug-13

AARESCUE

QuestionnaireFileName:

Sample Adult

At your last visit, did your doctor or other health professional ask HOW OFTEN
….you used a quick relief inhaler?

1

Yes
No
Refused
Don’t know

2
7

9

UniverseText:

Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months

SkipInstructions:

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

Question ID:

ACN.107_00.050 Instrument Variable Name:

QuestionText:

AAACTLIM

QuestionnaireFileName:

At your last visit, did your doctor or other health professional ask HOW OFTEN
…asthma symptoms limited your daily activities?

1
2
7

9

Yes
No
Refused
Don’t know

UniverseText:

Sample adults 18+ who still have asthma or who had asthma episode/attack in past 12 months

SkipInstructions:

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

Sample Adult

Page 16 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.110_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

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

1

2
7
9

Yes
No
Refused
Don't know

UniverseText:

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

SkipInstructions:

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

QuestionnaireFileName:

Sample Adult

Page 17 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.130_00.000 Instrument Variable Name:

QuestionText:

2
7

9

QuestionnaireFileName:

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

1

CANEV

20-Aug-13

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Sample Adult

Page 18 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:
QuestionText:

ACN.140_00.001 Instrument Variable Name:
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

20-Aug-13

CANKIND_1

QuestionnaireFileName:

Sample Adult

Page 19 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

20-Aug-13

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

Hard Edit:

ERR1_CANKIND_1
* Code 6 or 18 or 29 is unavailable for males.
ERR2_CANKIND_1
* Code 20 or 26 is unavailable for females.

Page 20 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.140_00.002 Instrument Variable Name:

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

20-Aug-13

CANKIND_2

QuestionnaireFileName:

Sample Adult

Page 21 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

20-Aug-13

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

Hard Edit:

ERR1_CANKIND_2
* Code 6 or 18 or 29 is unavailable for males.
ERR2_CANKIND_2
* Code 20 or 26 is unavailable for females.

Page 22 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.140_00.003 Instrument Variable Name:

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

20-Aug-13

CANKIND_3

QuestionnaireFileName:

Sample Adult

Page 23 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

20-Aug-13

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
ERR1_CANKIND_3

Hard Edit:

* Code 6 or 18 or 29 is unavailable for males.
ERR2_CANKIND_3
* Code 20 or 26 is unavailable for females.

Question ID:

ACN.140_00.004 Instrument Variable Name:

QuestionText:

CANKIND_4

QuestionnaireFileName:

Sample Adult

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

95
96

More than three kinds
No more

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]

Page 24 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.150_00.001 Instrument Variable Name:

QuestionText:

20-Aug-13

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
ERR_ CANAGE_1

Hard Edit:

* [Fill2: CANAGE_1] years old is older than age[fill3: AGE].
* Please correct.

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

Hard Edit:

ERR_ CANAGE_2
* [Fill2: CANAGE_2] years old is older than your age[fill3: AGE].
* Please correct.

Sample Adult

Page 25 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.150_00.003 Instrument Variable Name:

QuestionText:

20-Aug-13

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
ERR_ CANAGE_3

Hard Edit:

* [Fill2: CANAGE_3] years old is older than your age[fill3: AGE].
* Please correct.

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
2

3
7
9

Yes
No
Borderline
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Page 26 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.165_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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?

1

Yes
No
Refused
Don't know

2
7
9

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 EPILEP1]

Question ID:

ACN.170_00.000 Instrument Variable Name:

QuestionText:

DIBAGE

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
85

97
99

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

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

Hard Edit:

ERR_ DIBAGE
* [Fill1: DIBAGE] years old is older than your age[fill2: AGE].
* Please correct.

Page 27 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.180_00.000 Instrument Variable Name:

QuestionText:

INSLN

20-Aug-13

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:

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.

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 pre-diabetes, impaired fasting glucose, impaired glucose tolerance, borderline diabetes, or high blood
sugar

SkipInstructions:

<1,2,R,D> [goto EPILEP1]

Question ID:

ACN.192_00.010 Instrument Variable Name:

QuestionText:
1
2
7

9

EPILEP1

QuestionnaireFileName:

Sample Adult

Have you ever been told by a doctor or other health professional that you have a seizure disorder or epilepsy?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto EPILEP2]
<2,R,D> [goto AHAYFYR]

Page 28 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.192_00.020 Instrument Variable Name:

QuestionText:

EPILEP2

20-Aug-13

QuestionnaireFileName:

Are you currently taking any medicine to control your seizure disorder or epilepsy?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+ who have ever been told they have epilepsy or a seizure disorder

SkipInstructions:

<1,2,R,D> [goto EPILEP3]

Question ID:

Sample Adult

ACN.192_00.030 Instrument Variable Name:

QuestionText:

EPILEP3

QuestionnaireFileName:

Sample Adult

Today is [fill: Current Date]. Think back to last year about the same time. About how many seizures of any type have you
had in the past year?
*Read if necessary: Some people may call it “convulsion,” “fit,” “falling out spell,” “episode,” “attack,” “drop attack,”
“staring spell,” or “out-of-touch.”.
*If the respondent mentions and counts “auras” as seizures accept the response. If a respondent indicates that he/she has
had nothing more than an aura and is unsure about counting the aura(s), do NOT count auras as seizures.

0
1
2
3
4

7
9

None
One
Two or three
Between four and ten
More than 10
Refused
Don't know

UniverseText:

Sample adults 18+ who have ever been told they have epilepsy or a seizure disorder

SkipInstructions:

<0-4,R,D> [goto EPILEP4]

Page 29 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.192_00.040 Instrument Variable Name:

QuestionText:

EPILEP4

20-Aug-13

QuestionnaireFileName:

In the past year have you seen a neurologist or epilepsy specialist for your epilepsy or seizure disorder?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+ who have ever been told they have epilepsy or a seizure disorder

SkipInstructions:

<1,2,R,D> [goto EPILEP5]

Question ID:

Sample Adult

ACN.192_00.050 Instrument Variable Name:

QuestionText:

EPILEP5

QuestionnaireFileName:

DURING THE PAST 30 DAYS, to what extent has epilepsy or its treatment interfered with your normal activities like
working, school, or socializing with family or friends? Would you say…
*Read categories below.

1
2
3

4
5
7
9

Sample Adult

Not at all
Slightly
Moderately
Quite a bit
Extremely
Refused
Don't know

UniverseText:

Sample adults 18+ who have ever been told they have epilepsy or a seizure disorder

SkipInstructions:

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

Page 30 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.201_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Page 31 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.201_03.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

ACN.201_04.000 Instrument Variable Name:

QuestionText:

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
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Page 32 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.201_05.000 Instrument Variable Name:

QuestionText:

LIVYR

20-Aug-13

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 33 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.260_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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 34 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.280_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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
2

7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Page 35 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.295_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

Yes
No
Refused
Don't know

2
7

9

UniverseText:

Sample adults 18+ with joint pain or arthritis

SkipInstructions:

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

Question ID:

ACN.300_00.000 Instrument Variable Name:

QuestionText:

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
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Page 36 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.310_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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 37 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.331_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

PAINFACE

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

2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Page 38 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.350_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ACOLD2W

QuestionnaireFileName:

Sample Adult

These next questions are about your recent health DURING THE LAST 2 WEEKS.
Did you have a head cold or chest cold that started DURING THE LAST 2 WEEKS?

1

Yes
No
Refused
Don't know

2
7

9

UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

ACN.360_00.000 Instrument Variable Name:

QuestionText:

AINTIL2W

Sample Adult

Did you have a stomach or intestinal illness with vomiting or diarrhea that started DURING THE LAST 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 if SEX=1 or AGE >49 [goto HRAIDNOW]

Question ID:

QuestionnaireFileName:

ACN.370_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

PREGNOW

QuestionnaireFileName:

Are you currently pregnant?

Yes
No
Refused
Don't know

UniverseText:

Female sample adults 18-49 years of age

SkipInstructions:

<1> if INTERVIEW_MONTH=4,5,6,7 (April-July) [goto PREGFLYR];
else [goto HRAIDNOW]
[goto HRAIDNOW]
<2,D> [goto PREGFLYR]

Sample Adult

Page 39 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.370_00.010 Instrument Variable Name:

QuestionText:

20-Aug-13

PREGFLYR

QuestionnaireFileName:

Sample Adult

[fill1: Were you pregnant any time since August 1st, [fill: LAST YEAR]?/Were you pregnant any time from August [fill:
LAST YEAR] through March [fill: CURYEAR]?/Were you pregnant any time since August 1st, [fill: CURYEAR]?]

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

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

SkipInstructions:

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

Question ID:

ACN.400_00.000 Instrument Variable Name:

QuestionText:

HRAIDNOW

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

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 40 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.420_00.000 Instrument Variable Name:

QuestionText:

AHEARST1

QuestionnaireFileName:

Sample Adult

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

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]

Question ID:

20-Aug-13

ACN.430_00.000 Instrument Variable Name:

QuestionText:
1

2
7
9

AVISION

QuestionnaireFileName:

Do you have any trouble seeing, even when wearing glasses or contact lenses?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Sample Adult

Page 41 of 41

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Conditions
Document Version Date:

Question ID:

ACN.440_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ABLIND

QuestionnaireFileName:

Are you blind or unable to see at all?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

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

SkipInstructions:

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

Question ID:

Sample Adult

ACN.451_00.000 Instrument Variable Name:

QuestionText:
1
2
7
9

LUPPRT

Have you lost all of your upper and lower natural (permanent) teeth?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

QuestionnaireFileName:

Sample Adult

Page 1 of 4

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Immunosuppression
Document Version Date:

Question ID:

AIS.010_00.010 Instrument Variable Name:

QuestionText:

20-Aug-13

AIMSUPEV

QuestionnaireFileName:

Sample Adult

Have you EVER been told by a doctor or other health professional that your immune system is weakened?
*Read if necessary: A weakened immune system is also called immune compromised or immune suppressed. It means
that you are not able to fight infections and is usually caused by an underlying illness or by various medical treatments or
prescription medications.

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

AIS.010_00.020 Instrument Variable Name:

QuestionText:
1
2

7
9

AIMSPSTL

QuestionnaireFileName:

Sample Adult

Based on what a doctor or other health professional told you, do you still have a weakened immune system?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who have ever been told by a doctor/other health professional that they had a weakened
immune system

SkipInstructions:

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

Page 2 of 4

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Immunosuppression
Document Version Date:

Question ID:

AIS.010_00.030 Instrument Variable Name:

QuestionText:

20-Aug-13

AIMSPMED

QuestionnaireFileName:

Sample Adult

The next questions are about reasons a doctor or other health professional may have told you that your immune system
was weakened. Please say yes or no to each.
DURING THE PAST 6 MONTHS, have you taken prescription medication or had any medical treatments that a doctor or
other health professional told you would weaken your immune system? Examples include steroid or corticosteroid pills,
such as prednisone, or other oral or injected medications for treating many types of autoimmune conditions or certain
cancers.

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+ who have ever been told by a doctor/other health professional that they had a weakened
immune system

SkipInstructions:

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

Question ID:

AIS.010_00.040 Instrument Variable Name:

QuestionText:

1
2
7
9

AIMSPCHC

QuestionnaireFileName:

Sample Adult

Do you currently have a health condition that a doctor or other health professional told you weakens the immune system,
even without related medications or treatments? Examples include certain kinds of leukemia, lymphoma, or HIV
infection.
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who have ever been told by a doctor/other health professional that they had a weakened
immune system

SkipInstructions:

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

Page 3 of 4

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Immunosuppression
Document Version Date:

Question ID:

AIS.010_00.050 Instrument Variable Name:

QuestionText:

20-Aug-13

AIMSPSHC

QuestionnaireFileName:

Sample Adult

Has a doctor or other health professional EVER told you that your immune system is weakened because you have kidney
disease, lung disease, liver disease, diabetes, poor nutrition, or general frailty?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+ who have ever been told by a doctor/other health professional that they had a weakened
immune system

SkipInstructions:

<1,2,R,D>
If CANKIND_1=1-30 or CANKIND_2=1-30 or CANKIND_3=1-30 or CANKIND_4=96 [goto AIMSPCAN];
else [goto AIMSPCLD]

Question ID:

AIS.010_00.060 Instrument Variable Name:

QuestionText:

AIMSPCAN

QuestionnaireFileName:

Sample Adult

Earlier you said you had {fill1: type of cancer from CANKIND_1, CANKIND_2, CANKIND_3, CANKIND_4 cancer}.
Did a doctor or other health professional EVER tell you that your immune system is weakened because of {fill2: this
cancer/these cancers}?
*Read if necessary: Please only respond yes if a doctor or health care professional told you the cancer weakens the
immune system, even if you are not now having treatments or taking prescription medicines that weaken the immune
system.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who have ever been told by a doctor/other health professional that they had a weakened
immune system and have one or more kinds of cancer

SkipInstructions:

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

Page 4 of 4

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Immunosuppression
Document Version Date:

Question ID:

AIS.010_00.070 Instrument Variable Name:

QuestionText:

1
2
7
9

20-Aug-13

AIMSPCLD

QuestionnaireFileName:

Sample Adult

Has a doctor or other health professional EVER told you that your immune system is weakened because you seem to get
many infections and colds or that you can’t seem to get over them?

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who have ever been told by a doctor/other health professional that they had a weakened
immune system

SkipInstructions:

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

Page 1 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.040_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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]

Soft Edit:

ERR_WKDAYR
* [Fill: WKDAYR] is an unusually large number.
* Please verify.

Question ID:

AHS.050_00.000 Instrument Variable Name:

QuestionText:

BEDDAYR

000
997

999

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.

001-366

QuestionnaireFileName:

None
1-366 days
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Soft Edit:

ERR_BEDDAYR
* [Fill: BEDDAYR] is an unusually large number.
* Please verify.

Page 2 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.060_00.000 Instrument Variable Name:

QuestionText:

AHSTATYR

QuestionnaireFileName:

Sample Adult

Compared with 12 MONTHS AGO, would you say your health is better, worse, or about the same?

1

Better
Worse
About the same
Refused
Don't know

2
3
7

9

UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

20-Aug-13

AHS.070_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

SPECEQ

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?

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Page 3 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.091_01.000 Instrument Variable Name:

QuestionText:

FLWALK

20-Aug-13

QuestionnaireFileName:

Sample Adult

(book) A5
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

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 FLCLIMB]

Question ID:

AHS.091_02.000 Instrument Variable Name:

QuestionText:

FLCLIMB

QuestionnaireFileName:

(book) A5
* 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
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 FLSTAND]

Sample Adult

Page 4 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.091_03.000 Instrument Variable Name:

QuestionText:

FLSTAND

20-Aug-13

QuestionnaireFileName:

Sample Adult

(book) A5
* 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

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 FLSIT]

Question ID:

AHS.091_04.000 Instrument Variable Name:

QuestionText:

FLSIT

QuestionnaireFileName:

(book) A5
* 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
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 FLSTOOP]

Sample Adult

Page 5 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.091_05.000 Instrument Variable Name:

QuestionText:

FLSTOOP

20-Aug-13

QuestionnaireFileName:

Sample Adult

(book) A5
* 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

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 FLREACH]

Question ID:

AHS.091_06.000 Instrument Variable Name:

QuestionText:

FLREACH

QuestionnaireFileName:

(book) A5
* 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
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 FLGRASP]

Sample Adult

Page 6 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.141_01.000 Instrument Variable Name:

QuestionText:

FLGRASP

20-Aug-13

QuestionnaireFileName:

Sample Adult

(book) A5
* 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

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 FLCARRY]

Question ID:

AHS.141_02.000 Instrument Variable Name:

QuestionText:

FLCARRY

QuestionnaireFileName:

(book) A5
* 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
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 FLPUSH]

Sample Adult

Page 7 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.141_03.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FLPUSH

QuestionnaireFileName:

Sample Adult

(book) A5
* 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

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 FLSHOP]

Question ID:

AHS.171_01.000 Instrument Variable Name:

QuestionText:

FLSHOP

QuestionnaireFileName:

(book) A5
* 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
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 FLSOCL]

Sample Adult

Page 8 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.171_02.000 Instrument Variable Name:

QuestionText:

FLSOCL

20-Aug-13

QuestionnaireFileName:

Sample Adult

(book) A5
* 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

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 FLRELAX]

Question ID:

AHS.171_03.000 Instrument Variable Name:

QuestionText:

FLRELAX

QuestionnaireFileName:

Sample Adult

(book) A5
* 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 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:
QuestionText:

AHS.200_00.000 Instrument Variable Name:

20-Aug-13

AFLHCA

QuestionnaireFileName:

Sample Adult

(book) A6
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, 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 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

20-Aug-13

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

Hard Edit:

$ You should enter something specific.

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]

Hard Edit:

$ You should enter something specific.

Page 11 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.300_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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
95
96

97
99

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

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)]

Page 12 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.300_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

Hard Edit:

ERR1_AHCL01T
*Time with condition cannot be greater than age.
* Please correct.
ERR2_AHCL01T
* "6" not selectable.

Page 13 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.301_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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
95
96

97
99

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

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)]

Page 14 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.301_02.000 Instrument Variable Name:

QuestionText:

AHCL02T

20-Aug-13

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

Hard Edit:

ERR1_AHCL02T
* Time with condition cannot be greater than age.
* Please correct.

ERR2_AHCL02T
* "6" not selectable.

Page 15 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.302_01.000 Instrument Variable Name:

QuestionText:

AHCL03N

20-Aug-13

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

1-94
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

Hard Edit:

ERR_AHCL03T
* Time with condition cannot be greater than age.
* Please correct.

Page 16 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.303_01.000 Instrument Variable Name:

QuestionText:

AHCL04N

20-Aug-13

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

Hard Edit:

ERR_AHCL04T
* Time with condition cannot be greater than age.
* Please correct.

Page 17 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.304_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

01-94
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

Hard Edit:

ERR_AHCL05T
* Time with condition cannot be greater than age.
* Please correct.

Page 18 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.305_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

1-94
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

Hard Edit:

ERR_AHCL06T
* Time with condition cannot be greater than age.
* Please correct.

Page 19 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.306_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

1-94
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

Hard Edit:

ERR_AHCL07T
* Time with condition cannot be greater than age.
* Please correct.

Page 20 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.307_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

1-94
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

Hard Edit:

ERR_AHCL08T
* Time with condition cannot be greater than age.
* Please correct.

Page 21 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.308_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

Hard Edit:

ERR_AHCL09T
* Time with condition cannot be greater than age.
* Please correct.

Page 22 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.309_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

Hard Edit:

ERR_AHCL10T
* Time with condition cannot be greater than age.
* Please correct.

Page 23 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.310_01.000 Instrument Variable Name:

QuestionText:

AHCL11N

20-Aug-13

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had a lung or breathing problem (e.g. 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

1-94
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 (e.g. 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

Hard Edit:

ERR_AHCL11T
* Time with condition cannot be greater than age.
* Please correct.

Page 24 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.311_01.000 Instrument Variable Name:

QuestionText:

AHCL12N

20-Aug-13

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

Hard Edit:

ERR_AHCL12T
* Time with condition cannot be greater than age.
* Please correct.

Page 25 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.313_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

AHCL14N

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/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/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

Hard Edit:

ERR_AHCL14T
* Time with condition cannot be greater than age.
* Please correct.

Page 26 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.314_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

AHCL15N

QuestionnaireFileName:

Sample Adult

1 of 2
How long have you had a developmental problem (e.g., cerebral palsy)?
* Enter number for time with a developmental 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 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

Hard Edit:

ERR_AHCL15T
* Time with condition cannot be greater than age.
* Please correct.

Page 27 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.315_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

Hard Edit:

ERR_AHCL16T
* Time with condition cannot be greater than age.
* Please correct.

Page 28 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.316_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

1-94
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

Hard Edit:

ERR_AHCL17T
* Time with condition cannot be greater than age.
* Please correct.

Page 29 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.317_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

1-94
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

Hard Edit:

ERR_AHCL18T
* Time with condition cannot be greater than age.
* Please correct.

Page 30 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.318_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

Hard Edit:

ERR_AHCL19T
* Time with condition cannot be greater than age.
* Please correct.

Page 31 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.319_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

1-94
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

Hard Edit:

ERR_AHCL20T
* Time with condition cannot be greater than age.
* Please correct.

Page 32 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.320_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

1-94
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

Hard Edit:

ERR_AHCL21T
* Time with condition cannot be greater than age.
* Please correct.

Page 33 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.321_01.000 Instrument Variable Name:

QuestionText:

AHCL22N

20-Aug-13

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

Hard Edit:

ERR_AHCL22T
* Time with condition cannot be greater than age.
* Please correct.

Page 34 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.322_01.000 Instrument Variable Name:

QuestionText:

AHCL23N

20-Aug-13

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

Hard Edit:

ERR_AHCL23T
* Time with condition cannot be greater than age.
* Please correct.

Page 35 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.323_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

01-94
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

Hard Edit:

ERR_AHCL24T
* Time with condition cannot be greater than age.
* Please correct.

Page 36 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.324_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

1-94
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

Hard Edit:

ERR_AHCL25T
* Time with condition cannot be greater than age.
* Please correct.

Page 37 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.325_01.000 Instrument Variable Name:

QuestionText:

AHCL26N

20-Aug-13

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

1-94
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

Hard Edit:

ERR_AHCL26T
* Time with condition cannot be greater than age.
* Please correct.

Page 38 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.326_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

Hard Edit:

ERR_AHCL27T
* Time with condition cannot be greater than age.
* Please correct.

Page 39 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.327_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

Hard Edit:

ERR_AHCL28T
* Time with condition cannot be greater than age.
* Please correct.

Page 40 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.328_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

1-94
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

Hard Edit:

ERR_AHCL29T
* Time with condition cannot be greater than age.
* Please correct.

Page 41 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.329_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

Hard Edit:

ERR_AHCL30T
* Time with condition cannot be greater than age.
* Please correct.

Page 42 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.330_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

01-94
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

Hard Edit:

ERR_AHCL31T
* Time with condition cannot be greater than age.
* Please correct.

Page 43 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.331_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

Hard Edit:

ERR_AHCL32T
* Time with condition cannot be greater than age.
* Please correct.

Page 44 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.332_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

Hard Edit:

ERR_AHCL33T
* Time with condition cannot be greater than age.
* Please correct.

Page 45 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.333_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

Hard Edit:

ERR1_AHCL34T
* Time with condition cannot be greater than age.
* Please correct.

Page 46 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.334_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

Hard Edit:

ERR1_AHCL35T
* Time with condition cannot be greater than age.
* Please correct.

Page 47 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.335_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

Hard Edit:

ERR_AHCL90T
* Time with condition cannot be greater than age.
* Please correct.

Page 48 of 48

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Status & Limitations
Document Version Date:

Question ID:

AHS.336_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

01-94
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

Hard Edit:

ERR_AHCL91T
* Time with condition cannot be greater than age.
* Please correct.

Page 1 of 20

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:

Question ID:

AHB.010_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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 OTHCIGEV]

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
85
96
97

99

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

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

Hard Edit:

ERR_SMKREG
* Starting age exceeded current age.
* Please correct.

Page 2 of 20

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:

Question ID:

AHB.030_00.000 Instrument Variable Name:

QuestionText:

SMKNOW

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

Do you NOW smoke cigarettes every day, some days or not at all?

1

Every day
Some days
Not at all
Refused
Don't know

2
3
7

9

UniverseText:

Sample adults 18+ who ever smoked 100 cigarettes

SkipInstructions:

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

Question ID:

20-Aug-13

AHB.040_01.000 Instrument Variable Name:

QuestionText:

SMKQTNO

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
95
97

99

1 - 94
95+
Refused
Don't know

UniverseText:

Sample adults 18+ who quit smoking

SkipInstructions:

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

Page 3 of 20

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:

Question ID:

AHB.040_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

SMKQTTP

QuestionnaireFileName:

Sample Adult

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

Hard Edit:

ERR2_SMKQTTP
* Age started ([Fill1: SMKREG]) + years since quit ([Fill2: SMKQTNO]) exceeds current age ([Fill3: AGE]).
* Please correct.
ERR1_SMKQTTP

Soft Edit:

* Respondent quit smoking before age 15?
* Please verify.
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]

QuestionnaireFileName:

Sample Adult

Page 4 of 20

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:

Question ID:

AHB.060_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

95
97
99

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

UniverseText:

Sample adults 18+ who are current some day smokers

SkipInstructions:

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

Page 5 of 20

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:

Question ID:

AHB.080_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

CIGQTYR

Sample Adult

During the PAST 12 MONTHS, have you stopped smoking for more than one day BECAUSE YOU WERE TRYING TO
QUIT SMOKING?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+ who are every day or someday smokers

SkipInstructions:

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

Question ID:

QuestionnaireFileName:

AHB.085_00.010 Instrument Variable Name:

QuestionText:

OTHCIGEV

QuestionnaireFileName:

Sample Adult

? [F1]
These next questions are about your use of tobacco products OTHER THAN CIGARETTES.
Tobacco products OTHER THAN CIGARETTES that are smoked include cigars, pipes, water pipes or hookahs, very
small cigars that look like cigarettes, bidis (bee-dees) or cigarillos (cig-a-ril-los).
Have you ever smoked tobacco products other than cigarettes EVEN ONE TIME?
* Do not include electronic cigarettes or e-cigarettes.

1
2
7

9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Page 6 of 20

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:

Question ID:

AHB.085_00.020 Instrument Variable Name:

QuestionText:

20-Aug-13

OTHCIGED

QuestionnaireFileName:

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

1

Every day
Some days
Rarely
Not at all
Refused
Don't know

2
3
4

7
9

UniverseText:

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

SkipInstructions:

<1-4,R,D> [goto SMKLESEV]

Question ID:

Sample Adult

AHB.085_00.030 Instrument Variable Name:

QuestionText:

SMKLESEV

QuestionnaireFileName:

Sample Adult

? [F1]
Smokeless tobacco products are placed in the mouth or nose and can include chewing tobacco, snuff, dip, snus (snoose),
or dissolvable tobacco.
Have you ever used smokeless tobacco products EVEN ONE TIME?
* Do not include nicotine replacement therapy products (patch, gum, lozenge, spray), which are considered smoking
cessation treatments.

1
2

7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Page 7 of 20

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:

Question ID:

AHB.085_00.040 Instrument Variable Name:

QuestionText:

20-Aug-13

SMKLESED

QuestionnaireFileName:

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

1

Every day
Some days
Rarely
Not at all
Refused
Don't know

2
3
4

7
9

UniverseText:

Sample adults 18+ who have ever used smokeless tobacco products

SkipInstructions:

<1-4,R,D> goto TOBLASYR

Question ID:

Sample Adult

AHB.085_00.050 Instrument Variable Name:

QuestionText:
1
2
7

9

TOBLASYR

QuestionnaireFileName:

Sample Adult

Around this time last year, were you using ANY KIND of tobacco product?
Yes
No
Refused
Don't know

UniverseText:

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

SkipInstructions:

<1,2,R,D> If (TOBLASYR='1' or SMKNOW in('1','2') or OTHCIGED in('1','2','3') or SMKLESED in('1','2','3'))
and CIGQTYR ne '2' [goto TOBQTYR];
Else If (TOBLASYR ne'1' & SMKNOW not in('1','2')& OTHCIGED not in('1','2','3') & SMKLESED not
in('1','2','3'))
or CIGQTYR = '2' [goto VIGNO]

Page 8 of 20

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:

Question ID:

AHB.085_00.060 Instrument Variable Name:

QuestionText:

20-Aug-13

TOBQTYR

QuestionnaireFileName:

Sample Adult

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

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

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

SkipInstructions:

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

Question ID:

AHB.090_01.000 Instrument Variable Name:

QuestionText:

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

Page 9 of 20

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:

Question ID:

AHB.090_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

VIGTP

QuestionnaireFileName:

Sample Adult

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

0

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

1
2

3
4
6
7
9

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]

ERR1_VIGTP

Soft Edit:

* [Fill1: VIGNO] times per [Fill2: VIGTP] is unusually high.
* Please verify.
Question ID:

AHB.100_01.000 Instrument Variable Name:

QuestionText:

VIGLNGNO

QuestionnaireFileName:

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
997

999

1-995
Refused
Don't know

UniverseText:

Sample adults 18+ who do vigorous activities

SkipInstructions:

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

Sample Adult

Page 10 of 20

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:

Question ID:

AHB.100_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

VIGLNGTP

QuestionnaireFileName:

Sample Adult

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

1

Minutes
Hours
Refused
Don't know

2
7

9

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
ERR1_VIGLNGTP

Hard Edit:

* Question asked for activities lasting at least 10 minutes.
* Please correct.
ERR2_VIGLNGTP

Soft Edit:

* [Fill1: VIGLNGNO] [fill2: VIGLNGTP] is unusually high.
* Please verify.
Question ID:

AHB.110_01.000 Instrument Variable Name:

QuestionText:

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

Page 11 of 20

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:

Question ID:

AHB.110_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

MODTP

QuestionnaireFileName:

Sample Adult

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

0

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

1
2

3
4
6
7
9

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

ERR_MODNO

Soft Edit:

* [Fill1: MODNO] times per [fill2: MODTP] is unusually high.
* Please verify.
Question ID:

AHB.120_01.000 Instrument Variable Name:

QuestionText:

MODLNGNO

QuestionnaireFileName:

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
997

999

1-995
Refused
Don't know

UniverseText:

Sample adults 18+ who do light or moderate activities

SkipInstructions:

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

Sample Adult

Page 12 of 20

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:

Question ID:

AHB.120_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

MODLNGTP

QuestionnaireFileName:

Sample Adult

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

1

Minutes
Hours
Refused
Don't know

2
7

9

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
ERR1_MODLNGTP

Hard Edit:

* Question asked for activities lasting at least 10 minutes.
* Please correct.
ERR2_MODLNGTP

Soft Edit:

* [Fill1: MODLNGNO] [Fill2: MODLNGTP] is unusually high.
* Please verify.
Question ID:

AHB.130_01.000 Instrument Variable Name:

QuestionText:

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 ALC1YR]

001-995
996
997

Page 13 of 20

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:

Question ID:

AHB.130_02.000 Instrument Variable Name:

QuestionText:

STRNGTP

20-Aug-13

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter time period for strengthening activities

0

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

1
2

3
4
6
7
9

UniverseText:

Sample adults 18+ who do strengthening activities

SkipInstructions:

<1-4> goto ALC1YR
[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]

Soft Edit:

ERR_STRNGTP
* [Fill1: STRNGNO] times per [Fill2: STRNGTP] is unusually high.
* Please verify.

Question ID:

AHB.140_00.000 Instrument Variable Name:

QuestionText:

ALC1YR

QuestionnaireFileName:

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
2
7
9

Sample Adult

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Page 14 of 20

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:

Question ID:

AHB.150_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ALCLIFE

QuestionnaireFileName:

Sample Adult

In your ENTIRE LIFE, 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+ 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]

Question ID:

AHB.160_01.000 Instrument Variable Name:

QuestionText:

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
001-365
997
999

Never
1-365 days
Refused
Don't know

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]

Page 15 of 20

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:

Question ID:

AHB.160_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ALC12MTP

QuestionnaireFileName:

Sample Adult

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

0

Never/None
Week
Month
Year
Refused
Don't know

1
2

3
7
9

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]
ERR_ALC12MTP

Hard Edit:

* [Fill1: ALC12MNO] days per [Fill2: ALC12MTP] exceeds number possible in this time period.
* Please correct.

Question ID:

AHB.170_00.000 Instrument Variable Name:

QuestionText:

ALCAMT

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
95
97
99

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

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]

Soft Edit:

ERR_ALCAMT
* [Fill: ALCAMT] drinks is an unusually high number.
* Please verify.
* Do not probe

QuestionnaireFileName:

Sample Adult

Page 16 of 20

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:

Question ID:

AHB.180_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ALC5UPNO

QuestionnaireFileName:

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]

Sample Adult

Page 17 of 20

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:

Question ID:

AHB.180_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ALC5UPTP

QuestionnaireFileName:

Sample Adult

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

0
1
2

3
7
9

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

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]

Hard Edit:

ERR1_ALC5UPTP
* [Fill1: ALC5UPNO] days per [Fill2: ALC5UPTP] exceeds number possible in this time period.
* Please correct.
ERR2_ALC5UPTP
* Number of days had 5 or more drinks exceeds number of days drank.
* Please correct.
* Do not probe.

Page 18 of 20

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:

Question ID:

AHB.190_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

97
99

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]

Hard Edit:

ERR1_AHGT_FT
* Only 2-7, Don't Know/Refused or M allowed in this field.
* Please correct.
ERR2_AHGT_FT

Soft Edit:

* Respondent's height in feet is [fill: AHGT_FT]?
* Please verify.
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]

Hard Edit:

ERR1_AHGT_IN
* If [fill: AHGT_FT] feet exactly, enter "0"; otherwise enter number of inches.

Soft Edit:

ERR2_AHGT_IN
* Please verify that the height was entered correctly. Probe only if necessary.

Page 19 of 20

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:

Question ID:

AHB.190_03.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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]

Hard Edit:

ERR_AHGT_M
* If height is being given in centimeters only, enter "0"; otherwise enter number of meters.

Question ID:

AHB.190_04.000 Instrument Variable Name:

AHGT_CM

QuestionnaireFileName:

Sample Adult

QuestionText:

*Enter centimeters.
000-241
997

999

0-241 centimeters
Refused
Don't know

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]

Hard Edit:

ERR1_AHGT_CM
* Total height exceeds maximum allowed.
* Please correct.
ERR2_AHGT_CM
* If [fill: AHGT_M] meters exactly, enter "0"; otherwise enter number of centimeters.

Soft Edit:

ERR3_AHGT_CM
* Please verify that the height was entered correctly. Probe only if necessary.

Page 20 of 20

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Health Behaviors
Document Version Date:

Question ID:

AHB.200_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

AWGT_LB

QuestionnaireFileName:

Sample Adult

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

050-500

50-500 pounds
Refused
Don't know
Metric

997
999
M

UniverseText:

Sample adults 18+

SkipInstructions:

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

Hard Edit:

ERR1_AWGT_LB
* Weight is out of range (50-500).
* Please correct.
ERR2_AWGT_LB

Soft Edit:

* Please verify that the weight was entered correctly. Probe only if necessary.
Question ID:

AHB.200_02.000 Instrument Variable Name:

QuestionText:

AWGT_KG

QuestionnaireFileName:

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

023-226
997
999

23-226 kilograms
Refused
Don't know

UniverseText:

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

SkipInstructions:

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

Hard Edit:

ERR1_AWGT_KG
*Weight is out of range (23-226).
* Please correct.

Soft Edit:

ERR2_AWGT_KG
* Please verify that the weight was entered correctly. Probe only if necessary.

Sample Adult

Page 1 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.020_00.000 Instrument Variable Name:

QuestionText:

AUSUALPL

QuestionnaireFileName:

Sample Adult

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

1

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

2
3
7

9

UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

20-Aug-13

AAU.030_00.000 Instrument Variable Name:

QuestionText:

APLKIND

QuestionnaireFileName:

Sample Adult

[Fill1: What kind of place is it - a clinic, doctor's office, emergency room, or some other place?
[Fill2: What kind of place do you go to most often - a clinic, doctor's office, emergency room, or some other place?]

1
2

3
4
5
6
7
9

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

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]

Page 2 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.035_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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?

1

Yes
No
Refused
Don't know

2
7
9

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]

Question ID:

AAU.037_00.000 Instrument Variable Name:

QuestionText:

0
1

2
3
4
5
6
7

9

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?
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

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

Page 3 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.040_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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?

1

Yes
No
Refused
Don't know

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 4 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.050_00.010 Instrument Variable Name:

20-Aug-13

ANOUSLPL

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.
01

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

02
03

04
05
06
07
08

09
97
99

UniverseText:

Sample adults 18+ without a usual place of care

SkipInstructions:

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

Question ID:

AAU.051_00.010 Instrument Variable Name:

QuestionText:
1
2

7
9

APRVTRYR

DURING THE PAST 12 MONTHS, did you have any trouble finding a general doctor or provider who would see you?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Page 5 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.053_00.010 Instrument Variable Name:

QuestionText:

20-Aug-13

APRVTRFD

QuestionnaireFileName:

Sample Adult

Yes
No
Refused
Don’t know

2
7
9

UniverseText:

Sample adults 18+ who had trouble finding a provider

SkipInstructions:

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

AAU.057_00.010 Instrument Variable Name:

ADRNANP

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?

QuestionText:

1

Yes
No
Refused
Don’t know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

Sample Adult

Were you able to find a general doctor or provider who could see you?

1

Question ID:

QuestionnaireFileName:

AAU.059_00.010 Instrument Variable Name:

QuestionText:

1
2
7
9

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

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto AHCDLY_1]

Page 6 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.061_01.000 Instrument Variable Name:

20-Aug-13

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

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto AHCDLY_2]

Question ID:

AAU.061_02.000 Instrument Variable Name:

QuestionText:

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

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto AHCDLY_3]

Page 7 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.061_03.000 Instrument Variable Name:

QuestionText:

20-Aug-13

AHCDLY_3

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?
...Once you get there, you have to wait too long to see the doctor.

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto AHCDLY_4]

Question ID:

AAU.061_04.000 Instrument Variable Name:

QuestionText:

AHCDLY_4

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?
...The (clinic/doctor's) office wasn't open when you could get there.

1
2
7

9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto AHCDLY_5]

Page 8 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.061_05.000 Instrument Variable Name:

QuestionText:

20-Aug-13

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

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto AHCAFY_1]

Question ID:

AAU.111_01.000 Instrument Variable Name:

QuestionText:

2
7
9

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?
...Prescription medicines.

1

AHCAFY_1

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto AHCAFY_2]

Page 9 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.111_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

AHCAFY_2

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?
...Mental health care or counseling.

1

Yes
No
Refused
Don't know

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 10 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.111_04.000 Instrument Variable Name:

QuestionText:

20-Aug-13

AHCAFY_4

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?
...Eyeglasses.

1

Yes
No
Refused
Don't know

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 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]

Page 11 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.111_06.010 Instrument Variable Name:

QuestionText:

20-Aug-13

AHCAFY_6

QuestionnaireFileName:

Sample Adult

*Read 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

Yes
No
Refused
Don’t know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

AAU.113_00.010 Instrument Variable Name:

QuestionText:

1

2
3
7
9

AWORPAY

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?
Very worried
Somewhat worried
Not at all worried
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Page 12 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.113_00.020 Instrument Variable Name:

QuestionText:

QuestionnaireFileName:

Sample Adult

Better
Worse
About the same
Refused
Don't know

2
3
7

9

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,3,R,D>[goto ARX12MO]

AAU.126_01.010 Instrument Variable Name:

QuestionText:

ARX12MO

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, were you prescribed medication by a doctor or other health professional?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto ARX12_1]
<2,R,D> [goto ARX12_5]

Question ID:

AHICOMP

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?

1

Question ID:

20-Aug-13

AAU.127_01.010 Instrument Variable Name:

QuestionText:

ARX12_1

QuestionnaireFileName:

DURING THE PAST 12 MONTHS, were 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+ who took prescription medication in the past 12 months

SkipInstructions:

<1,2,R,D>[goto ARX12_2]

Sample Adult

Page 13 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.127_02.010 Instrument Variable Name:

QuestionText:

ARX12_2

20-Aug-13

QuestionnaireFileName:

Sample Adult

*Read if necessary.
DURING THE PAST 12 MONTHS, were any of the following true for you?
…You took less medicine to save money.

1

Yes
No
Refused
Don’t know

2
7
9

UniverseText:

Sample adults 18+ who took prescription medication in the past 12 months

SkipInstructions:

<1,2,R,D>[goto ARX12_3]

Question ID:

AAU.127_03.010 Instrument Variable Name:

QuestionText:

ARX12_3

QuestionnaireFileName:

*Read if necessary.
DURING THE PAST 12 MONTHS, were any of the following true for you?
…You delayed filling a prescription to save money.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who took prescription medication in the past 12 months

SkipInstructions:

<1,2,R,D>[goto ARX12_4]

Sample Adult

Page 14 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.127_04.010 Instrument Variable Name:

QuestionText:

20-Aug-13

ARX12_4

QuestionnaireFileName:

Sample Adult

*Read if necessary.
DURING THE PAST 12 MONTHS, were any of the following true for you?
…You asked your doctor for a lower cost medication to save money.

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+ who took prescription medication in the past 12 months

SkipInstructions:

<1,2,R,D>[goto ARX12_5]

Question ID:

AAU.127_05.010 Instrument Variable Name:

QuestionText:

ARX12_5

DURING THE PAST 12 MONTHS, were any of the following true for you?
…You bought prescription drugs from another country to save money.

1

2
7
9

QuestionnaireFileName:

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[goto ARX12_6]

Sample Adult

Page 15 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.127_06.010 Instrument Variable Name:

QuestionText:

20-Aug-13

ARX12_6

QuestionnaireFileName:

Sample Adult

*Read if necessary.
DURING THE PAST 12 MONTHS, were any of the following true for you?
…You used alternative therapies to save money.

1

Yes
No
Refused
Don't know

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) A7
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 16 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.141_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

AHCSY1_1

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you seen or talked to any of the following health care providers about your own
health?
...A mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker.

1

Yes
No
Refused
Don't know

2

7
9

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[ goto AHCSY1_2]

Question ID:

AAU.141_02.000 Instrument Variable Name:

QuestionText:

AHCSY1_2

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.
DURING THE PAST 12 MONTHS, have you seen or talked to any of the following health care providers about your own
health?
...An optometrist, ophthalmologist (AHF-thal-MOL-oh-jist), or eye doctor (someone who prescribes eyeglasses).

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[ goto AHCSY1_3]

Page 17 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.141_03.000 Instrument Variable Name:

QuestionText:

20-Aug-13

AHCSY1_3

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.
DURING THE PAST 12 MONTHS, have you seen or talked to any of the following health care providers about your own
health?

...A foot doctor.
1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[ goto AHCSY1_4]

Question ID:

AAU.141_04.000 Instrument Variable Name:

QuestionText:

AHCSY1_4

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.
DURING THE PAST 12 MONTHS, have you seen or talked to any of the following health care providers about your own
health?

...A chiropractor.
1
2

7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[ goto AHCSY1_5]

Page 18 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.141_05.000 Instrument Variable Name:

QuestionText:

20-Aug-13

AHCSY1_5

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.
DURING THE PAST 12 MONTHS, 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.
1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D>[ goto AHCSY1_6]

Question ID:

AAU.141_06.000 Instrument Variable Name:

QuestionText:

AHCSY1_6

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.
DURING THE PAST 12 MONTHS, 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 19 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.200_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

AHCSYR7

QuestionnaireFileName:

Sample Adult

* Read lead-in if necessary.
DURING THE PAST 12 MONTHS, 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).

1

Yes
No
Refused
Don't know

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:

QuestionText:

AHCSY8_ 8

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.
DURING THE PAST 12 MONTHS, 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).

1
2
7

9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [go to AHCSY8_ 9]

Page 20 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.211_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

AHCSY8_ 9

QuestionnaireFileName:

Sample Adult

* Read Lead-in if Necessary.
DURING THE PAST 12 MONTHS, 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

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto AHCSYR10]
<2,R,D> [goto AHERNOYR]

Question ID:

AAU.230_00.000 Instrument Variable Name:

QuestionText:
1

2
7
9

AHCSYR10

QuestionnaireFileName:

Does that doctor treat children and adults (a doctor in general practice or family medicine)?
Yes
No
Refused
Don't know

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]

Sample Adult

Page 21 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.240_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

AHERNOYR

QuestionnaireFileName:

Sample Adult

(book) A8
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.)?

00

None
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+

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 either 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 22 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.245_00.010 Instrument Variable Name:

QuestionText:

20-Aug-13

AERHOS

Sample Adult

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

Did this emergency room visit result in a hospital admission?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+ who had at least one ER visit in the past year

SkipInstructions:

<1,2,R,D> [go to AERREAS1]

Question ID:

QuestionnaireFileName:

AAU.248_01.010 Instrument Variable Name:

QuestionText:

AERREAS1

Tell me which of these apply to your last emergency room visit?
… You didn't have another place to go

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+ who had at least one ER visit in the past year

SkipInstructions:

<1,2,R,D> [goto AERREAS2]

Question ID:

AAU.248_02.020 Instrument Variable Name:

QuestionText:

AERREAS2

*Read if necessary..
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

SkipInstructions:

<1,2,R,D> [goto AERREAS3]

Page 23 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.248_03.030 Instrument Variable Name:

QuestionText:

20-Aug-13

AERREAS3

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

*Read if necessary..
Tell me which of these apply to your last emergency room visit?
… Your health provider advised you to go

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+ who had at least one ER visit in the past year

SkipInstructions:

<1,2,R,D> [goto AERREAS4]

Question ID:

AAU.248_04.040 Instrument Variable Name:

QuestionText:

AERREAS4

*Read if necessary..
Tell me which of these apply to your last emergency room visit?
… The problem was too serious for the doctor’s office or clinic

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

SkipInstructions:

<1,2,R,D> [goto AERREAS5]

Page 24 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.248_05.050 Instrument Variable Name:

QuestionText:

20-Aug-13

AERREAS5

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

*Read if necessary..
Tell me which of these apply to your last emergency room visit?
… Only a hospital could help you

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+ who had at least one ER visit in the past year

SkipInstructions:

<1,2,R,D> [goto AERREAS6]

Question ID:

AAU.248_06.060 Instrument Variable Name:

QuestionText:

AERREAS6

*Read if necessary..
Tell me which of these apply to your last emergency room visit?
… the emergency room is your closest provider

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

SkipInstructions:

<1,2,R,D> [goto AERREAS7]

Page 25 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.248_07.070 Instrument Variable Name:

QuestionText:

20-Aug-13

AERREAS7

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

*Read if necessary..
Tell me which of these apply to your last emergency room visit?
…you get most of your care at the emergency room

1

Yes
No
Refused
Don’t know

2
7
9

UniverseText:

Sample adults 18+ who had at least one ER visit in the past year

SkipInstructions:

<1,2,R,D> [goto AERREAS8]

Question ID:

AAU.248_08.080 Instrument Variable Name:

QuestionText:

AERREAS8

*Read if necessary..
Tell me which of these apply to your last emergency room visit?
…you arrived by ambulance or other emergency vehicle

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

SkipInstructions:

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

Page 26 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.250_00.000 Instrument Variable Name:

QuestionText:

AHCHYR

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, did you receive care AT HOME from a nurse or other health care professional?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

<1>[goto AHCHMOYR]
<2,R,D>[goto AHCNOYR]

Question ID:

20-Aug-13

AAU.260_00.000 Instrument Variable Name:

QuestionText:

01-12
97
99

AHCHMOYR

QuestionnaireFileName:

Sample Adult

During how many of the PAST 12 MONTHS did you receive care AT HOME from a health care professional?

01-12 months
Refused
Don't know

UniverseText:

Sample adults 18+ who received home care from a health professional during the past 12 months

SkipInstructions:

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

Page 27 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.270_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

AHCHNOYR

QuestionnaireFileName:

Sample Adult

(book) A9
What was the total number of home visits received during {Fill1: that month/Fill2: those months}?

01

1
2-3
4-5
6-7
8-9
10-12
13-15
16 or more
Refused
Don't know

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:

AAU.280_00.000 Instrument Variable Name:

QuestionText:

AHCNOYR

QuestionnaireFileName:

Sample Adult

(book) A8
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

None
1
2-3
4-5
6-7
8-9
10-12
13-15
16 or more
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<0-8,R,D>[goto ASRGYR]

Page 28 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.290_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ASRGYR

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you had SURGERY or other surgical procedures either as an inpatient or
outpatient?
* Read if necessary: This includes both major surgery and minor procedures such as setting bones or removing growths.

1

Yes
No
Refused
Don't know

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:

QuestionText:

ASRGNOYR

QuestionnaireFileName:

Including any times you may have already told me about, HOW MANY DIFFERENT TIMES have you had surgery
during the PAST 12 MONTHS?
* Enter "95" for 95 or more times.

01-94

95
97
99

Sample Adult

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

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]

Soft Edit:

* {ASRGYR} is an unusually large number.
* Please verify.

Page 29 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.305_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

AMDLONG

QuestionnaireFileName:

Sample Adult

(book) A7 ? [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

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

1

2
3
4
5
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

<0,R,D> [goto HIT1A] <1-5> [goto AVISLAST]

Question ID:

AAU.306_00.010 Instrument Variable Name:

QuestionText:

AVISLAST

Thinking about your last visit for any type of medical care, where did you go?
*Read categories if necessary.

1
2
3
4

5
6
7
9

QuestionnaireFileName:

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

UniverseText:

Sample adults 18+ who have ever seen/talked to a doctor

SkipInstructions:

<1,2,4,6> [goto ALASTTYP]
<3,5> [goto AWAITRMN]
[goto HIT1A]

Sample Adult

Page 30 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.306_00.020 Instrument Variable Name:

QuestionText:

20-Aug-13

ALASTTYP

QuestionnaireFileName:

Sample Adult

Did you see a general doctor, a specialist, a nurse practitioner or physician assistant, or someone else?

1

General doctor
Specialist
Nurse practitioner/Physician assistant
Someone else
Refused
Don’t know

2
3
4

7
9

UniverseText:

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

SkipInstructions:

<1-3,R,D> [goto AVISAPTN] <4> [goto ALASTSPC]

Question ID:

AAU.306_00.025 Instrument Variable Name:

QuestionText:
Verbatim

ALASTSPC

QuestionnaireFileName:

What kind of health professional did you see at your last visit?
Verbatim response

UniverseText:

Sample adults 18+ who saw some other kind of provider on their last health care visit

SkipInstructions:

[goto AVISAPTN]

Sample Adult

Page 31 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.307_01.010 Instrument Variable Name:

QuestionText:

20-Aug-13

AVISAPTN

QuestionnaireFileName:

Sample Adult

1 of 2
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?
*Enter ‘0’ for same day , walk-in appointment , or no appointment made.
*Enter number for appointment wait time.
*Enter ‘96’ for routine appointment, appointment arranged during a previous visit, or received a reminder card from
provider.

00

Same day/walk-in appt/no appt made
1-95
Routine appt/appt arranged on previous visit/rec'd appt reminder card
Refused
Don't know

01-95

96
97
99

UniverseText:

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

SkipInstructions:

<0,96,R> [goto AWAITRMN]
<1-95,D> [goto AVISAPTT]

Question ID:

AAU.307_02.020 Instrument Variable Name:

QuestionText:

AVISAPTT

QuestionnaireFileName:

Sample Adult

2 of 2
*Enter time period for appointment wait time.

1
2
3
7
9

Days
Weeks
Months
Refused
Don’t know

UniverseText:

Sample adults 18+ who visited a clinic, doctor’s office/HMO, hospital outpatient department or someplace else
and gave a number or answered DK for length of time to make an appointment

SkipInstructions:

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

Page 32 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.308_01.010 Instrument Variable Name:

QuestionText:

20-Aug-13

AWAITRMN

QuestionnaireFileName:

Sample Adult

1 of 2
How long did you have to wait in the waiting room before you saw a doctor or other health professional for this visit?
*Enter ‘0’ for no wait time.
*Enter number for time in waiting room.

00

No time
1-96
Refused
Don’t know

01-96
97
99

UniverseText:

Sample adults 18+ who had a place of last medical visit

SkipInstructions:

<0,R> [goto HIT1A]
<1-96,D> [goto AWAITRMT]

Question ID:

AAU.308_02.020 Instrument Variable Name:

QuestionText:

AWAITRMT

QuestionnaireFileName:

Sample Adult

2 of 2
*Enter time period for time in waiting room.

1
2
7
9

Minutes
Hours
Refused
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]

Page 33 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.309_00.010 Instrument Variable Name:

QuestionText:

HIT1A

20-Aug-13

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you ever used computers for any of the following
…Look up health information on the Internet.

1

Yes
No
Refused
Don’t know

2
7

9

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto HIT2A]

Question ID:

AAU.309_00.020 Instrument Variable Name:

QuestionText:

HIT2A

QuestionnaireFileName:

*Read if necessary..
DURING THE PAST 12 MONTHS, have you ever used computers for any of the following
…Fill a prescription.

1

2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto HIT3A]

Sample Adult

Page 34 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.309_00.030 Instrument Variable Name:

QuestionText:

HIT3A

20-Aug-13

QuestionnaireFileName:

Sample Adult

*Read if necessary..
DURING THE PAST 12 MONTHS, have you ever used computers for any of the following
…Schedule an appointment with a health care provider.

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto HIT4A]

Question ID:

AAU.309_00.040 Instrument Variable Name:

QuestionText:

HIT4A

QuestionnaireFileName:

*Read if necessary..
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

Yes
No
Refused
Don’t know

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> [goto HIT5A]

Sample Adult

Page 35 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.309_00.050 Instrument Variable Name:

QuestionText:

20-Aug-13

HIT5A

QuestionnaireFileName:

Sample Adult

*Read if necessary..
DURING THE PAST 12 MONTHS, have you ever used computers for any of the following
…Use online chat groups to learn about health topics.

1

Yes
No
Refused
Don’t know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

AAU.310_00.000 Instrument Variable Name:

QuestionText:

SHTFLUYR

QuestionnaireFileName:

Sample Adult

?[F1]
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.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Page 36 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.312_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ASHFLU_M

1 of 2
During what month and year did you receive your most recent flu shot?

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:

Sample adults 18+ who have had a flu shot

SkipInstructions:

<1-12,D> [ goto ASHFLU_Y] [goto SPRFLUYR]

QuestionnaireFileName:

Sample Adult

Page 37 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.312_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ASHFLU_Y

QuestionnaireFileName:

Sample Adult

2 of 2
*Enter year of most recent flu shot.

Year

Year
Refused
Don't know

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 ]

Hard Edit:

ERR1_ASHFLU_Y
*Future date invalid
ERR2_ASHFLU_Y
*Date before birth
ERR3_ASHFLU_Y
*Date more than 12 months ago

Question ID:

AAU.313_00.000 Instrument Variable Name:

QuestionText:
1
2
7
9

FLUSHPG1

QuestionnaireFileName:

Sample Adult

Did you get a flu shot before or during your current pregnancy?
Before this pregnancy
During this pregnancy
Refused
Don't know

UniverseText:

Female sample adults 18-49 who are currently pregnant and are interviewed January-March or August-December

SkipInstructions:

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

Page 38 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.314_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

FLUSHPG2

QuestionnaireFileName:

Sample Adult

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

1

Before this pregnancy
During this pregnancy
After this pregnancy
Refused
Don't know

2
3
7
9

UniverseText:

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

SkipInstructions:

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

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).

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<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]

Soft Edit:

ERR1_SPRFLUYR
*Respondent says they have received both a flu shot and flu nasal vaccine.
*Please verify.
ERR2_SPRFLUYR
*Respondent says they have received a nasal vaccine to PREVENT the flu, not to TREAT symptoms of the flu.
*Please verify.

Page 39 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.318_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ASPFLU_M

QuestionnaireFileName:

1 of 2
During what month and year did you receive your most recent flu nasal spray?

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:

Sample adults 18+ who have had a flu nasal vaccine

SkipInstructions:

<1-12,D> [ goto ASPFLU_Y]
[goto SHTPNUYR]

Sample Adult

Page 40 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.318_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ASPFLU_Y

QuestionnaireFileName:

Sample Adult

2 of 2
*Enter year of most recent flu nasal spray.

Year

Year
Refused
Don't know

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

Hard Edit:

ERR1_ASPFLU_Y
*Future date invalid
ERR2_ASPFLU_Y
*Date before birth
ERR3_ASPFLU_Y
*Date more than 12 months ago

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 41 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.330_00.000 Instrument Variable Name:

QuestionText:

APOX

QuestionnaireFileName:

Sample Adult

APOX12MO

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

Have you EVER had chickenpox?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto APOX12MO]
<2,R,D> [goto AHEP]

Question ID:

AAU.340_00.000 Instrument Variable Name:

QuestionText:

Have you had chickenpox in the PAST 12 MONTHS?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+ who have ever had chickenpox

SkipInstructions:

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

Question ID:

20-Aug-13

AAU.350_00.000 Instrument Variable Name:

QuestionText:
1
2
7
9

Have you EVER had hepatitis?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto AHEPBTST]
<2,R,D> [goto AHEPLIV]

AHEP

Page 42 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.360_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

AHEPLIV

QuestionnaireFileName:

Have you ever lived with someone who had hepatitis?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+ who have never had hepatitis; Ref/DK if ever had hepatitis

SkipInstructions:

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

Question ID:

AAU.365_00.010 Instrument Variable Name:

QuestionText:

AHEPBTST

QuestionnaireFileName:

Sample Adult

SHTHEPB

QuestionnaireFileName:

Sample Adult

Have you ever had a blood test for hepatitis B?

1

Yes
No
Refused
Don’t know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

Sample Adult

AAU.370_00.000 Instrument Variable Name:

QuestionText:

Have you EVER received the hepatitis B vaccine?
* 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.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto SHEPDOS]
<2,R,D> [goto SHTHEPA]

Page 43 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.380_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

SHEPDOS

QuestionnaireFileName:

Did you receive at least 3 doses of the hepatitis B vaccine, or less than 3 doses?

1

Received at least 3 doses
Received less than 3 doses
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+ who have ever received the Hepatitis B vaccine

SkipInstructions:

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

Question ID:

AAU.390_00.010 Instrument Variable Name:

QuestionText:

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?

1

Yes
No
Refused
Don't know

2
7

9

UniverseText:

Sample adults 18+

SkipInstructions:

<1> goto SHEPANUM
<2,R,D> [goto AHEPCTST]

Question ID:

Sample Adult

AAU.400_00.010 Instrument Variable Name:

QuestionText:

SHEPANUM

How many hepatitis A shots did you receive?
*Enter '96' if all shots were received

01-95
96

97
99

01-95 shots
Received all shots
Refused
Don't know

UniverseText:

Sample adults 18+ who have had a hepatitis A vaccine

SkipInstructions:

<1-95,96,R,D> [goto AHEPCTST]

QuestionnaireFileName:

Sample Adult

Page 44 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.405_00.010 Instrument Variable Name:

QuestionText:

AHEPCTST

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

Have you ever had a blood test for hepatitis C?

1

Yes
No
Refused
Don’t know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto AHEPCRES]
<2,R,D> if AGE GE 50 goto SHINGLES
elseif AGE LT 50 goto SHTTD

Question ID:

20-Aug-13

AAU.405_00.020 Instrument Variable Name:

QuestionText:

AHEPCRES

What is the MAIN reason you were tested for hepatitis C? Was it because...
*Read answer categories below.

1
2

3
4
7
8

You or your doctor thought you were at risk of having hepatitis C because a blood tests or symptoms like fatigue, nausea,
stomach pain, yellowing of the eyes or skin indicated you might have liver disease
You were born from 1945 through 1965
You were at risk of hepatitis C infection due to exposure to blood on your job, injection drug use or receipt of transfusion
before 1992
Some other reason
Refused
Don’t know

UniverseText:

Sample adults 18+ who have had a blood test for hepatitis C

SkipInstructions:

<1-4,R,D> if AGE GE 50 [goto SHINGLES];
elseif AGE LT 50 goto SHTTD

Page 45 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.410_00.010 Instrument Variable Name:

QuestionText:

SHINGLES

Sample Adult

Yes
No
Refused
Don't know

2
7

9

UniverseText:

Sample adults 50+

SkipInstructions:

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

AAU.420_00.010 Instrument Variable Name:

QuestionText:

SHTTD

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

Have you received a tetanus shot in the past 10 years?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

<1> goto SHTTD05
<2,R,D> and AGE >64 [goto LIVEV]
Else if <2,R,D> and AGE<65 [goto SHTHPV2]

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®?

1

Question ID:

20-Aug-13

AAU.430_00.010 Instrument Variable Name:

QuestionText:
1
2
7

9

SHTTD05

Was your most recent tetanus shot given in 2005 or later?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who have had a tetanus shot in the past 10 years

SkipInstructions:

<1,R> [goto SHTTDAP]
<2,D> if AGE le 64 [goto SHTHPV2]
elseif AGE gt 64 goto LIVEV

Page 46 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.440_00.010 Instrument Variable Name:

QuestionText:

20-Aug-13

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) or Boostrix (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 your health care provider
tell you or did the vaccine information sheet say the vaccine included the pertussis or whooping cough vaccine? The shot
is often called Tdap or ADACEL (trademark) or BOOSTRIX (trademark).

1

Yes-included pertussis
No-did not include pertussis
Doctor did not say
Refused
Don't know

2
3
7
9

UniverseText:

Sample adults 18+ 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> if age le 64 [goto SHTHPV2];
else [goto LIVEV]

Question ID:

AAU.446_00.010 Instrument Variable Name:

QuestionText:

SHTHPV2

QuestionnaireFileName:

Have you ever received an HPV shot or vaccine?
*HPV stands for human papillomavirus (pap-uh-LOW-muh-vi-rus).
*The vaccines are sometimes called CERVARIX (trademark) or GARDASIL (trademark).

1
2
3

7
9

Yes
No
Doctor refused when asked
Refused
Don't know

UniverseText:

Sample adults LE 64

SkipInstructions:

<1> [goto SHHPVDOS]
<2,3,R,D> [goto LIVEV]

Sample Adult

Page 47 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.448_00.010 Instrument Variable Name:

QuestionText:

How many HPV shots did you receive?
* Enter '50' if 50 or more shots
* Enter '96' for all shots

01-49

20-Aug-13

SHHPVDOS

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

1-49 shots
50+
All shots
Refused
Don't know

50+
96

97
99

UniverseText:

Sample adults LE 64 who received an HPV shot

SkipInstructions:

<1-50,96,R,D> [goto AHPVAGE]
<51-95> [goto ERR_SHHPVDOS]

Hard Edit:

ERR_SHHPVDOS
* Shots should be in the range 1-50 or 96 for all shots.
* Please correct.

Question ID:

AAU.449_00.010 Instrument Variable Name:

QuestionText:

008-current age
997
999

AHPVAGE

How old were you when you received your first HPV shot?
8-current age
Refused
Don't know

UniverseText:

Sample adults LE 64 who received an HPV shot

SkipInstructions:

<8-120,R,D> [goto LIVEV]

Page 48 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.450_00.010 Instrument Variable Name:

QuestionText:

QuestionnaireFileName:

Sample Adult

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

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

AAU.460_00.010 Instrument Variable Name:

QuestionText:

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?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

LIVEV

Has a doctor or other health professional ever told you that you had any kind of chronic, or long-term liver condition?

1

Question ID:

20-Aug-13

AAU.465_00.010 Instrument Variable Name:

QuestionText:

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 emergency responders and public safety personnel, part-time and unpaid work in
a health care facility as well as professional nursing care provided in the home.
*Read if necessary: This includes non-health care professionals, such as administrative staff, who work in a health-care
facility.

1
2

7
9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto WRKDIR] <2,R,D> [goto APSBPCHK]

Page 49 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.470_00.010 Instrument Variable Name:

QuestionText:

20-Aug-13

WRKDIR

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+ who work or volunteer in a health-care setting

SkipInstructions:

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

AAU.500_00.010 Instrument Variable Name:

QuestionText:

APSBPCHK

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you had your blood pressure checked by a doctor, nurse, or other health
professional?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

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.

1

Question ID:

QuestionnaireFileName:

AAU.510_00.010 Instrument Variable Name:

QuestionText:

1
2
7
9

APSCHCHK

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, have you had your blood cholesterol checked by a doctor, nurse, or other health
professional?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Page 50 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.520_00.010 Instrument Variable Name:

QuestionText:

20-Aug-13

APSBSCHK

Sample Adult

Have you had a fasting test for high blood sugar or diabetes DURING THE PAST 12 MONTHS?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> and SEX=1 and AGE GE 40 [goto APSCOL]
If <1,2,R,D> and SEX=1 and AGE < 40 [goto APSDIET]
Else <1,2,R,D> and SEX=2 [goto APSPAP]

Question ID:

QuestionnaireFileName:

AAU.530_00.010 Instrument Variable Name:

QuestionText:

APSPAP

QuestionnaireFileName:

Sample Adult

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 <1,2,R,D and AGE<30 [goto APSDIET]

Page 51 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.540_00.010 Instrument Variable Name:

QuestionText:

20-Aug-13

APSMAM

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

Have you had a Mammogram DURING THE PAST 12 MONTHS?
*Read if necessary.
A mammogram is an x-ray of each breast to look for breast cancer.

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Female sample adults 30+

SkipInstructions:

<1,2,R,D> if AGE GE 40 [gotoAPSCOL];
else <1,2,R,D and AGE<40> [goto APSDIET]

Question ID:

AAU.550_00.010 Instrument Variable Name:

QuestionText:

APSCOL

DURING THE PAST 12 MONTHS, have you had any test done for colon cancer?
*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.

1
2
7
9

Yes
No
Refused
Don’t know

UniverseText:

Sample adults 40+

SkipInstructions:

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

Page 52 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.560_00.010 Instrument Variable Name:

QuestionText:

20-Aug-13

APSDIET

Sample Adult

DURING THE PAST 12 MONTHS, has a doctor or other health professional talked to you about your diet?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

<1,2,R,D> if SMKNOW in ('1','2') [goto APSSMKC];
else if (40<=AGE<=65) [goto LTCFAM];
else [goto AINDINS]

Question ID:

QuestionnaireFileName:

AAU.570_00.010 Instrument Variable Name:

QuestionText:
1
2
7

9

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

UniverseText:

Sample adults 18+ currently who smoke every day or some days

SkipInstructions:

<1,2,R,D> if (40<=AGE<=65) [goto LTCFAM];
else [goto AINDINS]

Page 53 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.580_00.010 Instrument Variable Name:

QuestionText:

LTCFAM

20-Aug-13

QuestionnaireFileName:

Sample Adult

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?
*Read if necessary.
Due to a chronic illness or disability.

1

Yes
No
Refused
Don’t know

2
7
9

UniverseText:

Sample adults 40-65

SkipInstructions:

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

Question ID:

AAU.582_00.010 Instrument Variable Name:

QuestionText:

2
3
4
7

9

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.

1

LTCHELP

Very likely
Somewhat likely
Somewhat unlikely
Very unlikely
Refused
Don't know

UniverseText:

Sample adults 40-65

SkipInstructions:

<1-4,R,D> [goto LTCWHO]

Page 54 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.584_00.010 Instrument Variable Name:

QuestionText:

20-Aug-13

LTCWHO

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

If you needed such help, who would provide this help?
*Enter all that apply, separate with commas.

1

My family
Someone I hire
Home health care organization
Nursing home/assisted living
Other
Refused
Don’t know

2
3

4
5
7
9

UniverseText:

Sample adults 40-65

SkipInstructions:

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

Question ID:

AAU.600_00.010 Instrument Variable Name:

QuestionText:

1

2
7
9

AINDINS

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

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto AINDPRCH>
<2,R,D> if age LT 65 [goto AEXCHNG]; else [goto next section]

Page 55 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.600_00.020 Instrument Variable Name:

QuestionText:

20-Aug-13

AINDPRCH

QuestionnaireFileName:

Was a plan purchased?

1

Yes
No
Refused
Don’t know

2
7
9

UniverseText:

Sample adults 18+ who tried to purchase health insurance directly in the past 3 years

SkipInstructions:

<1> [goto AINDWHO]
<2> [goto AINDNOT]
if age LT 65 [goto AEXCHNG]; else [goto next section]

Question ID:

Sample Adult

AAU.600_00.030 Instrument Variable Name:

QuestionText:
1
2
3

7
9

AINDWHO

QuestionnaireFileName:

Was this plan for yourself, someone else in your family, or both?
Self
Someone else in family
Both
Refused
Don’t know

UniverseText:

Sample adults 18+ who purchased health insurance directly in the past 3 years

SkipInstructions:

<1-3,R,D> [goto AINDDIF1]

Sample Adult

Page 56 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.600_00.040 Instrument Variable Name:

20-Aug-13

AINDDIF1

QuestionnaireFileName:

Sample Adult

How difficult was it to find a plan with the type of coverage you needed? Would you say…

QuestionText:

*Read categories below.
1

Very difficult
Somewhat difficult
Not at all difficult
Refused
Don’t know

2
3

7
9

UniverseText:

Sample adults 18+ who purchased health insurance directly in the past 3 years

SkipInstructions:

<1-3,R,D> [goto AINDDIF2]

Question ID:

AAU.600_00.050 Instrument Variable Name:

AINDDIF2

QuestionnaireFileName:

Sample Adult

How difficult was it to find a plan you could afford? Would you say…

QuestionText:

*Read categories below.
1

Very difficult
Somewhat difficult
Not at all difficult
Refused
Don't know

2

3
7
9

UniverseText:

Sample adults 18+ who purchased health insurance directly in the past 3 years

SkipInstructions:

<1-3,R,D> [goto AINDENY1]

Question ID:

AAU.600_01.060 Instrument Variable Name:

QuestionText:
1
2

7
9

AINDENY1

QuestionnaireFileName:

Did any company turn you down when you tried to buy coverage on your own ?
Yes
No
Refused
Don’t know

UniverseText:

Sample adults 18+ who purchased health insurance directly in the past 3 years

SkipInstructions:

<1,2,R,D> [goto AINDENY2]

Sample Adult

Page 57 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.600_02.060 Instrument Variable Name:

20-Aug-13

AINDENY2

QuestionnaireFileName:

Did any company charge a higher price because of {fill 1: your/your family’s/you or your family’s} health?

QuestionText:

1

Yes
No
Refused
Don’t know

2
7
9

UniverseText:

Sample adults 18+ who purchased health insurance directly in the past 3 years

SkipInstructions:

<1,2,R,D> [goto AINDENY3]

Question ID:

Sample Adult

AAU.600_03.060 Instrument Variable Name:

QuestionText:
1
2
7
9

AINDENY3

QuestionnaireFileName:

Did any company exclude a specific health problem from the coverage?
Yes
No
Refused
Don’t know

UniverseText:

Sample adults 18+ who purchased health insurance directly in the past 3 years

SkipInstructions:

<1,2,R,D> if age LT 65 [goto AEXCHNG]; else [goto next section]

Sample Adult

Page 58 of 58

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Access to Health Care & Utilization
Document Version Date:

Question ID:

AAU.601_00.070 Instrument Variable Name:

QuestionText:

20-Aug-13

AINDNOT

QuestionnaireFileName:

Sample Adult

Why did you not buy the plan?
*Enter all that apply, separate with commas.

1

Turned down
Cost
Pre-existing condition
Got health insurance from other source
Other
Refused
Don’t know

2
3

4
5
7
9

UniverseText:

Sample adults 18+ who tried but did not purchase health insurance directly in the past 3 years

SkipInstructions:

<1-4,R,D> if age LT 65 [goto AEXCHNG]; else [goto next section]
<5> [goto AINDNTSP]

Question ID:

AAU.601_00.080 Instrument Variable Name:

QuestionText:

AINDNTSP

QuestionnaireFileName:

*Specify other reason plan was not obtained.

Verbatim

Verbatim response

UniverseText:

Sample adults 18+ who had other reason plan was not purchased

SkipInstructions:

if age LT 65 [goto AEXCHNG]; else [goto next section]

Question ID:

Sample Adult

AAU.605_00.010 Instrument Variable Name:

QuestionText:

1
2
7
9

AEXCHNG

QuestionnaireFileName:

Sample Adult

Have you looked into purchasing health insurance coverage through the [Fill: Health Insurance Marketplace/Health
Insurance Marketplace, such as {fill: state plan name}]?

Yes
No
Refused
Don't know

UniverseText:

Sample adults LT age 65 years

SkipInstructions:

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

Page 1 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.032_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

SNONCE

Sample Adult

DURING THE PAST 12 MONTHS, have you used an indoor tanning device such as a sunlamp, sunbed, or tanning booth
EVEN ONE TIME? Do NOT include times you have gotten a spray-on tan.

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

<1> [goto SNNUM1]
<2,R,D> if SEX=2 and if APSPAP=1 [goto RPAP1_M1];
else if SEX=2 and APSPAP ne 1 [goto PAPHAD1];
else if SEX=1 and AGE GE 40 [goto PSAREC];
else if SEX =1 and AGE<40 [goto next section]

Question ID:

QuestionnaireFileName:

NAF.033_00.000 Instrument Variable Name:

QuestionText:

001-365

997
999

SNNUM1

QuestionnaireFileName:

Sample Adult

DURING THE PAST 12 MONTHS, how many times have you used an indoor tanning device such as a sunlamp, sunbed
or tanning booth? Do NOT include times you have gotten a spray-on tan.
1-365 times
Refused
Don't know

UniverseText:

Sample adults 18+ who have used indoor tanning device in past year

SkipInstructions:

<1-365,R,D> if SEX=2 and if APSPAP=1 [goto RPAP1_M1];
else if SEX=2 and APSPAP ne 1 [goto PAPHAD1];
else if SEX=1 and AGE GE 40 [goto PSAREC];
else if SEX =1 and AGE<40 [goto next section]

Page 2 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.130_00.000 Instrument Variable Name:

QuestionText:

PAPHAD1

20-Aug-13

QuestionnaireFileName:

Sample Adult

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

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Female sample adults 18+ who have not had a Pap test in the past 12 months

SkipInstructions:

<1> [goto RPAP1_M1]
<2> [goto MDRECP1]
[goto HYST]

Page 3 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.150_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

RPAP1_M1

1 of 2
[Fill1: Earlier you said you had a Pap test.]
When did you have your MOST RECENT Pap test?
*Enter month of last Pap test.
*Enter '96' to go to number and time period format.

01
02
03

04
05
06
07
08
09

10
11
12
96
97
99

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

UniverseText:

Female sample adults 18+ who have ever had a Pap smear

SkipInstructions:

<1-12,D> [goto RPAP1_Y1]
store 'R' in RPAP1_Y1 [goto RPAP21]
<96> store '9996' in RPAP1_Y1 [goto RPAP1N1]

QuestionnaireFileName:

Sample Adult

Page 4 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.150_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

RPAP1_Y1

QuestionnaireFileName:

Sample Adult

2 of 2
*Enter year of last Pap test.

1880-current year
9996
9997

9999

1880-current year
Time period format
Refused
Don't know

UniverseText:

Female sample adults age 18+ who answered month of last Pap smear test or didn't know month of last Pap smear
test

SkipInstructions:

if RPAP1_Y1 gt current year or (RPAP1_Y1=current year and RPAP1_M1 gt current month)
goto ERR1_ RPAP1_Y1 (future date)
elseif RPAP1_Y1 lt DOBY or (RPAP1_Y1=DOBY and RPAP1_M1 lt DOBM)
goto ERR2_ RPAP1_Y1 (prior to birth date)
elseif RPAP1_M1=D
goto RPAP21
elseif RPAP1_M1=1-12
goto PAPREA1
goto RPAP21

Hard Edit:

ERR1_ RPAP1_Y1
* Future date invalid. Please correct.
ERR2_ RPAP1_Y1
* Date before birth. Please correct.

Question ID:

NAF.160_01.000 Instrument Variable Name:

QuestionText:

RPAP1N1

QuestionnaireFileName:

Sample Adult

1 of 2
When did you have your MOST RECENT Pap test?
*Enter number for time since last Pap test.
*Enter '95' for 95 or more.

01-94
95
97
99

1-94
95+
Refused
Don't know

UniverseText:

Female sample adults 18+ who selected number and time period format for most recent Pap smear test from the
initial month screen

SkipInstructions:

<1-95> [goto RPAP1T1]
store 'R,D' in RPAP1T1 [goto RPAP21]

Page 5 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.160_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

RPAP1T1

QuestionnaireFileName:

2 of 2
*Enter time period for time since most recent Pap test.

1
2
3

4
7
9

Days ago
Weeks ago
Months ago
Years ago
Refused
Don't know

UniverseText:

Female sample adults 18+ who answered 1-95 for number part of this 2 part question

SkipInstructions:

<1-3> goto PAPREA1
<4> if RPAP1N1=4
set RPAP21=4
goto PAPREA1
elseif RPAP1N1 gt 5 and RPAP1N1 gt AGE
goto ERR_RPAP1T1 (greater than persons age)
elseif RPAP1N1 gt 5 and RPAP1N1 le AGE
set RPAP21=5
goto PAPREA1
elseif RPAP1N1=1,2,3,5
goto RPAP21
goto RPAP21

Hard Edit:

ERR_RPAP1T1
* Time since last exam cannot be greater than age.
* Please correct.

Sample Adult

Page 6 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.165_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

RPAP21

QuestionnaireFileName:

Sample Adult

Was it:
*Read answer categories.

1

A year ago or less
More than 1 year but not more than 2 years
More than 2 years but not more than 3 years
More than 3 years but not more than 5 years
Over 5 years ago
Refused
Don't know

2
3

4
5
7
9

UniverseText:

Female sample adults 18+ who failed to give a complete date in either the month or year format or failed to give a
complete date in the number and time period format, or entered years ago in the time period format (excluding
those whose last Pap smear test was over 5 years ago)

SkipInstructions:

<1-5,R,D> if answer code is grayed out [goto ERR_RPAP21];
else [goto PAPREA1]

Hard Edit:

ERR_RPAP21
*That is not a valid response.
*Please correct.

Question ID:

NAF.170_00.000 Instrument Variable Name:

QuestionText:

1
2

3
7
9

PAPREA1

QuestionnaireFileName:

Sample Adult

What was the MAIN reason you had this Pap test - was it part of a routine exam, because of a problem, or some other
reason?
Part of a routine exam
Because of a problem
Other reason
Refused
Don't know

UniverseText:

Female sample adults 18+ who have ever had a Pap smear

SkipInstructions:

<1-3,R,D> [goto MDRECP1]

Page 7 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.215_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

MDRECP1

QuestionnaireFileName:

Sample Adult

Fill1: (IF PAPHAD1=1 and most recent screening exam LE 3 years from system date)
"Was your most recent Pap test recommended by a doctor or other health professional?"
Else (IF PAPHAD1=2, or PAPHAD1=1 and GT 3 years from system date or RPAP21=R,D)
"In the PAST 12 MONTHS, has a doctor or other health professional RECOMMENDED that you have a PAP test?"

1

Yes
No
Did not see a doctor in the past 12 months
Refused
Don't know

2
3
7
9

UniverseText:

Female sample adults 18+ who did not answer refused or don't know to initial Pap test question

SkipInstructions:

<1-3,R,D>
if PAPHAD1=1 [goto PAPWHEN];
else PAPHAD ne 1 [goto HYST]

Question ID:

NAF.216_00.000 Instrument Variable Name:

QuestionText:
01
02
03
04
05

06
07
08
97
99

PAPWHEN

When do you expect to have your next Pap smear or Pap test?
A year or less from now
More than 1 year to 3 years from now
More than 3 years to 5 years from now
More than 5 years from now
When doctor recommends it
Never, had HPV DNA test
Never, had HPV vaccine
Never, other reason
Refused
Don't know

UniverseText:

Female sample adults 18+ who have ever had a Pap smear

SkipInstructions:

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

QuestionnaireFileName:

Sample Adult

Page 8 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.220_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

HYST

QuestionnaireFileName:

Sample Adult

MAMHAD

QuestionnaireFileName:

Sample Adult

Have you had a hysterectomy?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Female sample adults 18+

SkipInstructions:

<1,2,R,D>
if AGE GE 30 [goto MAMHAD];
else if AGE < 30 [goto next section]

Question ID:

NAF.230_00.000 Instrument Variable Name:

QuestionText:

Have you EVER HAD a mammogram?
*Read if necessary.
A mammogram is an x-ray taken only of the breast by a machine that presses against the breast.

1

2
7
9

Yes
No
Refused
Don't know

UniverseText:

Female sample adults 30+ who have not had a mammogram in the past 12 months

SkipInstructions:

<1> [goto RMAM1_MT]
<2> [goto MDRECMAM]
if AGE GE 40 [goto COLHAD];
else [goto next section]

Page 9 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.260_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

RMAM1_MT

1 of 2
[Fill1: Earlier you said you had a mammogram.]
When did you have your MOST RECENT mammogram?
*Enter month of last mammogram.
*Enter '96' to go to number and time period format.

01
02
03

04
05
06
07
08
09

10
11
12
96
97
99

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

UniverseText:

Female sample adults 30+ who have ever had a mammogram

SkipInstructions:

<1-12,D> [goto RMAM1_YR]
store 'R' in RMAM1_YR [goto RMAM2]
<96> store '9996' in RMAM1_YR [goto RMAM1N]

QuestionnaireFileName:

Sample Adult

Page 10 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.260_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

RMAM1_YR

QuestionnaireFileName:

Sample Adult

2 of 2
*Enter year of last mammogram.

1880-current year
9996
9997

9999

1880-current year
Time period format
Refused
Don't know

UniverseText:

Female sample adults age 30+ who answered month of last mammogram or didn't know month of last mammogram

SkipInstructions:

if RMAM1_YR gt current year or (RMAM1_YR=current year and RMAM1_MT gt current month)
goto ERR1_ RMAM1_YR (future date)
elseif RMAM1_YR lt DOBY or (RMAM1_YR=DOBY and RMAM1_MT lt DOBM)
goto ERR2_ RMAM1_YR (prior to birth date)
elseif RMAM1_MT=D
goto RMAM2
elseif RMAM1_MT=1-12
goto MAMREAS
goto RMAM2

Hard Edit:

ERR1_ RMAM1_YR
* Future date invalid. Please correct.
ERR2_ RMAM1_YR
* Date before birth. Please correct.

Question ID:

NAF.270_01.000 Instrument Variable Name:

QuestionText:

RMAM1N

QuestionnaireFileName:

Sample Adult

1 of 2
When did you have your MOST RECENT mammogram?
*Enter number for time since last mammogram.
*Enter '95' for 95 or more.

01-94
95
97
99

1-94
95+
Refused
Don't know

UniverseText:

Female sample adults 30+ who selected number and time period format for most recent mammogram from the
initial month screen

SkipInstructions:

<1-95> [goto RMAM1T]
store 'R,D' in RMAM1T [goto RMAM2]

Page 11 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.270_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

RMAM1T

QuestionnaireFileName:

2 of 2
*Enter time period for time since most recent mammogram.

1
2
3

4
7
9

Days ago
Weeks ago
Months ago
Years ago
Refused
Don't know

UniverseText:

Female sample adults 30+ who answered 1-95 for number part of this 2 part question

SkipInstructions:

<1-3> goto MAMREAS
<4> if RMAM1N=4
set RMAM2=4
goto MAMREAS
elseif RMAM1N gt 5 and RMAM1N gt AGE
goto ERR_RMAM1T (greater than persons age)
elseif RMAM1N gt 5 and RMAM1N le AGE
set RMAM2=5
goto MAMREAS
elseif RMAM1N=1,2,3,5
goto RMAM2
goto RMAM2

Hard Edit:

ERR_RMAM1T
* Time since last exam cannot be greater than age.
* Please correct.

Sample Adult

Page 12 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.275_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

RMAM2

QuestionnaireFileName:

Sample Adult

Was it:
*Read answer categories.

1

A year ago or less
More than 1 year but not more than 2 years
More than 2 years but not more than 3 years
More than 3 years but not more than 5 years
Over 5 years ago
Refused
Don't know

2
3

4
5
7
9

UniverseText:

Female sample adults 30+ who failed to give a complete date in either the month or year format or failed to give a
complete date in the number and time period format, or entered years ago in the time period format (excluding
those whose last mammogram was over 5 years ago)

SkipInstructions:

<1-5,R,D> if answer code is grayed out [goto ERR_RMAM2]
else [goto MAMREAS]

Hard Edit:

ERR_RMAM2
*That is not a valid response.
*Please correct.

Question ID:

NAF.310_00.000 Instrument Variable Name:

QuestionText:

1
2

3
7
9

MAMREAS

QuestionnaireFileName:

Sample Adult

What was the MAIN reason you had this mammogram -- was it part of a routine exam, because of a problem, or some
other reason?
Part of a routine exam
Because of a problem
Other reason
Refused
Don't know

UniverseText:

Female sample adults 30+ who have ever had a mammogram

SkipInstructions:

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

Page 13 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.370_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

MDRECMAM

QuestionnaireFileName:

Sample Adult

Fill1: (IF MAMHAD=1 and most recent screening exam LE 2 years from system date)
[Was your most recent mammogram recommended by a doctor or other health professional?]
Else (IF MAMHAD=2, or MAMHAD GT 2 years from system date or RMAM2=R,D)
[In the PAST 12 MONTHS, has a doctor or other health professional RECOMMENDED that you have a mammogram?]

1

Yes
No
Did not see a doctor in the past 12 months
Refused
Don't know

2
3
7
9

UniverseText:

Female sample adults 30+ who did not answer refused or don't know to initial mammogram question

SkipInstructions:

<1-3,R,D> if AGE GE 40 [goto COLHAD];
else [goto next section]

Question ID:

NAF.427_00.000 Instrument Variable Name:

QuestionText:

PSAREC

QuestionnaireFileName:

Sample Adult

Has a doctor EVER recommended that you have a PSA test?
*Read if necessary. A PSA test is a blood test to detect prostate cancer. It is also called a prostate-specific antigen test.

1
2
7
9

Yes
No
Refused
Don't know

UniverseText:

Male sample adults 40+

SkipInstructions:

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

Page 14 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.430_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

PSAHAD

QuestionnaireFileName:

Sample Adult

Have you EVER HAD a PSA test?
*Read if necessary. A PSA test is a blood test to detect prostate cancer. It is also called a prostate-specific antigen test.

1

Yes
No
Refused
Don't know

2
7

9

UniverseText:

Male sample adults 40+

SkipInstructions:

<1> [goto RPSA1_MT]
<2,R,D> [goto COLHAD]

Question ID:

NAF.440_00.000 Instrument Variable Name:

QuestionText:

RPSA1_MT

1 of 2
When did you have your MOST RECENT PSA test?
* Enter month of last PSA test.
* Enter '96' to go to number and time period format.

01
02
03
04

05
06
07
08
09
10

11
12
96
97
99

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

UniverseText:

Male sample adults 40+ who have had a PSA test

SkipInstructions:

<1-12,D> [goto RPSA1_YR]
store 'R' in RPSA1_YR [goto RPSA2]
<96> store '9996' in RPSA1_YR [goto RPSA1N]

QuestionnaireFileName:

Sample Adult

Page 15 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.440_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

RPSA1_YR

QuestionnaireFileName:

Sample Adult

2 of 2
* Enter year of last PSA test.

1880-current year
9996
9997

9999

1880-current year
Time period format
Refused
Don't know

UniverseText:

Male sample adults 40+ who answred month of last PSA test or didn't know month of last PSA test

SkipInstructions:

if RPSA1_YR gt current year or (RPSA1_YR=current year and RPSA1_MT gt current month)
goto ERR1_ RPSA1_YR (future date)
elseif RPSA1_YR lt DOBY or (RPSA1_YR=DOBY and RPSA1_MT lt DOBM)
goto ERR2_ RPSA1_YR (prior to birth date)
elseif RPSA1_MT=D
goto RPSA2
elseif RPSA1_MT=1-12
goto PSAREAS
goto RPSA2

Hard Edit:

ERR1_ RPSA1_YR
* Future date invalid. Please correct.
ERR2_ RPSA1_YR
* Date before birth. Please correct.

Question ID:

NAF.440_02.000 Instrument Variable Name:

QuestionText:

RPSA1N

QuestionnaireFileName:

Sample Adult

1 of 2
When did you have your MOST RECENT PSA test?
* Enter number for time since last PSA test.
* Enter '95' for 95 or more.

01-94
95
97
99

1-94
95+
Refused
Don't know

UniverseText:

Male sample adults 40+ who have selected number and time period format for most recent PSA test from the
initial month screen

SkipInstructions:

<1-95> [goto RPSA1T]
store 'R,D' in RPSA1T [goto RPSA2]

Page 16 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.440_03.000 Instrument Variable Name:

QuestionText:

20-Aug-13

RPSA1T

QuestionnaireFileName:

2 of 2
* Enter time period for time since most recent PSA test.

1
2
3

4
7
9

Days ago
Weeks ago
Months ago
Years ago
Refused
Don't know

UniverseText:

Male sample adults 40+ who answered 1-95 for number part of this 2 part question

SkipInstructions:

<1-3> goto PSAREAS
<4> if RPSA1N=4
set RPSA2=4
goto PSAREAS
elseif RPSA1N gt 5 and RPSA1N gt AGE
goto ERR_RPSA1T (greater than persons age)
elseif RPSA1N gt 5 and RPSA1N le AGE
set RPSA2=5
goto PSAREAS
elseif RPSA1N=1,2,3,5
goto RPSA2
goto RPSA2

Hard Edit:

ERR_RPSA1T
* Time since last exam cannot be greater than age.
* Please correct.

Sample Adult

Page 17 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.440_04.000 Instrument Variable Name:

QuestionText:

20-Aug-13

RPSA2

QuestionnaireFileName:

Sample Adult

Was it:
*Read answer categories.

1

A year ago or less
More than 1 year but not more than 2 years
More than 2 years but not more than 3 years
More than 3 years but not more than 5 years
Over 5 years ago
Refused
Don't know

2
3

4
5
7
9

UniverseText:

Male sample adults 40+ who failed to give a complete date in either the month or year format or failed to give a
complete date in the number and time period format, or entered years ago in the time period format (excluding
those whose last PSA test was over 5 years ago)

SkipInstructions:

<1-5,R,D> if answer code is grayed out [goto ERR_RPSA2];
else [goto PSAREAS]

Hard Edit:

ERR_RPSA2
*That is not a valid response.
*Please correct.

Question ID:

NAF.441_00.000 Instrument Variable Name:

QuestionText:

1
2

3
7
9

PSAREAS

QuestionnaireFileName:

Sample Adult

What was the MAIN reason you had this PSA test - was it part of a routine exam, because of a problem, or some other
reason?
Part of a routine exam
Because of a problem
Other reason
Refused
Don't know

UniverseText:

Male sample adults 40+ who have had a PSA test

SkipInstructions:

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

Page 18 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.540_00.000 Instrument Variable Name:

QuestionText:

COLHAD

20-Aug-13

QuestionnaireFileName:

Colonoscopy (colon-OS-copy) and sigmoidoscopy (sigmoid-OS-copy) are exams in which a doctor inserts a tube into the
rectum to look for polyps or cancer. For a colonoscopy, the doctor checks the entire colon, and you are given medication
through a needle in your arm to make you sleepy, and told to have someone drive you home. For a sigmoidoscopy, the
doctor checks only part of the colon and you are fully awake.
Have you EVER HAD a colonoscopy?
*Read if necessary:
A polyp is a small growth that develops on the inside of the colon or rectum.
Before these tests, you are asked to take a medication that causes diarrhea.

1

2
7
9

Sample Adult

Yes
No
Refused
Don't know

UniverseText:

Sample adults 40+

SkipInstructions:

<1> [goto COL_MT]
<2,R,D> [goto SIGHAD]

Page 19 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.560_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

COL_MT

1 of 2
When did you have your MOST RECENT colonoscopy?
*Enter month of last exam.
*Enter '96' to go to number and time period format.

01
02
03
04
05

06
07
08
09
10
11

12
96
97
99

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

UniverseText:

Sample adults 40+ who have ever had a colonoscopy

SkipInstructions:

<1-12,D> [goto COL_YR]
store 'R' in COL_YR [goto COL2]
<96> store '9996' in COL_YR [goto COLN]

QuestionnaireFileName:

Sample Adult

Page 20 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.560_02.000 Instrument Variable Name:

QuestionText:

COL_YR

20-Aug-13

QuestionnaireFileName:

Sample Adult

2 of 2
*Enter year of last colonoscopy.

1880-current year
9996
9997

9999

1880-current year
Time period format
Refused
Don't know

UniverseText:

Sample adults age 40+ who answered month of last colonoscopy or didn't know month of last colonoscopy

SkipInstructions:

if COL_YR gt current year or (COL_YR=current year and COL_MT gt current month)
goto ERR1_ COL_YR (future date)
elseif COL_YR lt DOBY or (COL_YR=DOBY and COL_MT lt DOBM)
goto ERR2_ COL_YR (prior to birth date)
elseif COL_MT=D
goto COL2
elseif COL_MT=1-12
goto COLREAS
goto COL2

Hard Edit:

ERR1_ COL_YR
* Future date invalid. Please correct.
ERR2_ COL_YR
* Date before birth. Please correct.

Question ID:

NAF.570_01.000 Instrument Variable Name:

QuestionText:

COLN

QuestionnaireFileName:

Sample Adult

1 of 2
When did you have your MOST RECENT colonoscopy?
*Enter number for time since last colonoscopy.
*Enter '95' for 95 or more.

01-94
95
97
99

1-94
95+
Refused
Don't know

UniverseText:

Sample adults 40+ who selected number and time period format for most recent colonoscopy from the initial
month screen

SkipInstructions:

<1-95> [goto COLT]
store 'R,D' in COLT [goto COL2]

Page 21 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.570_02.000 Instrument Variable Name:

QuestionText:

COLT

20-Aug-13

QuestionnaireFileName:

2 of 2
*Enter time period for time since most recent colonoscopy.

1
2
3

4
7
9

Days ago
Weeks ago
Months ago
Years ago
Refused
Don't know

UniverseText:

Sample adults 40+ who answered 1-95 for number part of this 2 part question

SkipInstructions:

<1-3> goto COLREAS
<4> if COLN=4
set COL2=4
goto COLREAS
elseif COLN=6,7,8,9
set COL2=5
goto COLREAS
elseif COLN gt 10 and COLN gt AGE
goto ERR_COLT (greater than persons age)
elseif COLN gt 10 and COLN le AGE
set COL2=6
goto COLREAS
elseif COLN=1,2,3,5,10
goto COL2
goto COL2

Hard Edit:

ERR_COLT
* Time since last exam cannot be greater than age.
* Please correct.

Sample Adult

Page 22 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.575_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

COL2

QuestionnaireFileName:

Sample Adult

Was it:
*Read answer categories.

1

A year ago or less
More than 1 year but not more than 2 years
More than 2 years but not more than 3 years
More than 3 years but not more than 5 years
More than 5 years but not more than 10 years
Over 10 years ago
Refused
Don't know

2
3

4
5
6
7
9

UniverseText:

Sample adults 40+ who failed to give a complete date in either the month or year format or failed to give a
complete date in the number and time period format, or entered years ago in the time period format (excluding
those whose last colonoscopy was 6-9 or over 10 years ago)

SkipInstructions:

<1-6,R,D> if answer code is grayed out [goto ERR_COL2];
else [goto COLREAS]

Hard Edit:

ERR_COL2
*That is not a valid response.
*Please correct.

Question ID:

NAF.590_00.000 Instrument Variable Name:

QuestionText:

1

2
3
4
7
9

COLREAS

QuestionnaireFileName:

Sample Adult

What was the MAIN reason you had this colonoscopy - was it part of a routine exam, because of a problem, as a followup test of an earlier test or screening exam, or some other reason?
Part of a routine exam
Because of a problem
Follow-up test of an earlier test or screening exam
Other reason
Refused
Don't know

UniverseText:

Sample adults 40+ who have had a colonoscopy

SkipInstructions:

<1-4,R,D> [goto SIGHAD]

Page 23 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.591_00.000 Instrument Variable Name:

QuestionText:

SIGHAD

QuestionnaireFileName:

Sample Adult

Recall that a sigmoidoscopy is similar to a colonoscopy but the doctor checks only part of the colon and you are fully
awake. Have you EVER HAD a sigmoidoscopy?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 40+

SkipInstructions:

<1> [goto SIG_MT]
<2,R,D> [goto HFOBHAD]

Question ID:

20-Aug-13

NAF.592_01.000 Instrument Variable Name:

QuestionText:

SIG_MT

1 of 2
When did you have your MOST RECENT sigmoidoscopy?
*Enter month of last exam.
*Enter '96' to go to number and time period format.

01
02
03
04
05

06
07
08
09
10
11

12
96
97
99

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

UniverseText:

Sample adults 40+ who have ever had a sigmoidoscopy

SkipInstructions:

<1-12,D> [goto SIG_YR]
store 'R' in SIG_YR [goto SIG2]
<96> store '9996' in SIG_YR [goto SIGN]

QuestionnaireFileName:

Sample Adult

Page 24 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.593_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

SIG_YR

QuestionnaireFileName:

Sample Adult

2 of 2
*Enter year of last sigmoidoscopy.

1880-current year
9996
9997

9999

1880-current year
Time period format
Refused
Don't know

UniverseText:

Sample adults age 40+ who answered month of last sigmoidoscopy or didn't know month of last sigmoidoscopy

SkipInstructions:

if SIG_YR gt current year or (SIG_YR=current year and SIG_MT gt current month)
goto ERR1_ SIG_YR (future date)
elseif SIG_YR lt DOBY or (SIG_YR=DOBY and SIG_MT lt DOBM)
goto ERR2_ SIG_YR (prior to birth date)
elseif SIG_MT=D
goto SIG2
elseif SIG_MT=1-12
goto SIGREAS
goto SIG2

Hard Edit:

ERR1_ SIG_YR
* Future date invalid. Please correct.
ERR2_ SIG_YR
* Date before birth. Please correct.

Question ID:

NAF.594_01.000 Instrument Variable Name:

QuestionText:

SIGN

QuestionnaireFileName:

Sample Adult

1 of 2
When did you have your MOST RECENT sigmoidoscopy?
*Enter number for time since last sigmoidoscopy.
*Enter '95' for 95 or more.

01-94
95
97
99

1-94
95+
Refused
Don't know

UniverseText:

Sample adults 40+ who selected number and time period format for most recent sigmoidoscopy from the initial
month screen

SkipInstructions:

<1-95> [goto SIGT]
store 'R,D' in SIGT [goto SIG2]

Page 25 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.595_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

SIGT

QuestionnaireFileName:

2 of 2
*Enter time period for time since most recent sigmoidoscopy.

1
2
3

4
7
9

Days ago
Weeks ago
Months ago
Years ago
Refused
Don't know

UniverseText:

Sample adults 40+ who answered 1-95 for number part of this 2 part question

SkipInstructions:

<1-3> goto SIGREAS
<4> if SIGN=4
set SIG2=4
goto SIGREAS
elseif SIGN=6,7,8,9
set SIG2=5
goto SIGREAS
elseif SIGN gt 10 and SIGN gt AGE
goto ERR_SIGT (greater than persons age)
elseif SIGN gt 10 and SIGN le AGE
set SIG2=6
goto SIGREAS
elseif SIGN=1,2,3,5,10
goto SIG2
goto SIG2

Hard Edit:

ERR_SIGT
* Time since last exam cannot be greater than age.
* Please correct.

Sample Adult

Page 26 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.596_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

SIG2

QuestionnaireFileName:

Sample Adult

Was it:
*Read answer categories.

1

A year ago or less
More than 1 year but not more than 2 years
More than 2 years but not more than 3 years
More than 3 years but not more than 5 years
More than 5 years but not more than 10 years
Over 10 years ago
Refused
Don't know

2
3

4
5
6
7
9

UniverseText:

Sample adults 40+ who failed to give a complete date in either the month or year format or failed to give a
complete date in the number and time period format, or entered years ago in the time period format (excluding
those whose last sigmoidoscopy was 6-9 or over 10 years ago)

SkipInstructions:

<1-6,R,D> if answer code is grayed out {goto ERR_SIG2]
else [goto SIGREAS]

Hard Edit:

ERR_SIG2
*That is not a valid response.
*Please correct.

Question ID:

NAF.597_00.000 Instrument Variable Name:

QuestionText:

1

2
3
4
7
9

SIGREAS

QuestionnaireFileName:

Sample Adult

What was the MAIN reason you had this sigmoidoscopy - was it part of a routine exam, because of a problem, as a followup test of an earlier test or screening exam, or some other reason?
Part of a routine exam
Because of a problem
Follow-up test of an earlier test or screening exam
Other reason
Refused
Don't know

UniverseText:

Sample adults 40+ who have had a sigmoidoscopy

SkipInstructions:

<1-4,R,D> [goto HFOBHAD]

Page 27 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.620_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

HFOBHAD

*Read if necessary:
Do not include tests done at the doctor's office.

2
7

9

Sample Adult

The following questions are about the blood stool or occult blood test, a test to determine whether you have blood in your
stool or bowel movement. The blood stool test can be done at home using a kit. You use a stick or brush to obtain a
small amount of stool at home and send it back to the doctor or lab.
Have you EVER HAD a blood stool test, using a HOME test kit?

1

QuestionnaireFileName:

Yes
No
Refused
Don't know

UniverseText:

Sample adults 40+

SkipInstructions:

<1> [goto RHFO1_MT]
<2,R,D> [goto COLPROB]

Page 28 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.640_01.000 Instrument Variable Name:

QuestionText:

20-Aug-13

RHFO1_MT

QuestionnaireFileName:

1 of 2
When did you have your MOST RECENT blood stool test using a kit at home?
*Enter month of last home blood stool test.
*Enter '96' to go to number and time period format.

01
02
03
04
05

06
07
08
09
10
11

12
96
97
99

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

UniverseText:

Sample adults 40+ who have ever had a home blood stool test

SkipInstructions:

<1-12,D> goto RHFO1_YR
store "R" in RHFO1_YR and goto RHFO2
<96> store "9996" in RHFO1_YR and goto RHFO1N

Sample Adult

Page 29 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.640_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

RHFO1_YR

QuestionnaireFileName:

Sample Adult

2 of 2
*Enter year of last home blood stool test.

1880-current year
9996
9997

9999

1880-current year
Time period format
Refused
Don't know

UniverseText:

Sample adults age 40+ who answered month of last home blood stool test or didn't know month of last test

SkipInstructions:

if RHFO1_YR gt current year or (RHFO1_YR=current year and RHRO1_MT gt current month)
goto ERR1_RHFO1_YR (future date)
elseif RHFO1_YR lt DOBY or (RHFO1_YR=DOBY and RHFO1_MT lt DOBM)
goto ERR2_RHFO1_YR (prior to birth date)
elseif RHFO1_MT=D
goto RHFO2
elseif RHFO1_MT=1-12
goto HFOBREA1
goto RHFO2

Hard Edit:

ERR1_ RHFO1_YR
* Future date invalid. Please correct.
ERR2_ RHFO1_YR
* Date before birth. Please correct.

Question ID:

NAF.650_01.000 Instrument Variable Name:

QuestionText:

RHFO1N

QuestionnaireFileName:

Sample Adult

1 of 2
When did you have your MOST RECENT blood stool test using a kit at home?
*Enter number for time since last home blood stool test.
*Enter '95' for 95 or more.

01-94
95
97
99

1-94
95+
Refused
Don't know

UniverseText:

Sample adults 40+ who selected number and time period format for most recent home blood stool test from the
initial month screen

SkipInstructions:

<1-95> [goto RHFO1T]
store 'R,D' in RHFO1T [goto RHFO2]

Page 30 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.650_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

RHFO1T

QuestionnaireFileName:

2 of 2
*Enter time period for time since most recent home blood stool test.

1
2
3

4
7
9

Days ago
Weeks ago
Months ago
Years ago
Refused
Don't know

UniverseText:

Sample adults 40+ who answered 1-95 for number part of this 2 part question

SkipInstructions:

<1-3> goto HFOBREA1
<4> if RHFO1N=4
set RHFO2=4
goto HFOBREA1
elseif RHFO1N=6,7,8,9
set RHFO2=5
goto HFOBREA1
elseif RHFO1N gt 10 and RHFO1N gt AGE
goto ERR_RHFO1T (greater than persons age)
elseif RHFO1N gt 10 and RHFO1N le AGE
set RHFO2=6
goto HFOBREA1
elseif RHFO1N=1,2,3,5,10
goto RHFO2
goto RHFO2

Hard Edit:

ERR_RHFO1T
* Time since last exam cannot be greater than age.
* Please correct.

Sample Adult

Page 31 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.655_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

RHFO2

QuestionnaireFileName:

Sample Adult

Was it:
*Read answer categories.

1

A year ago or less
More than 1 year but not more than 2 years
More than 2 years but not more than 3 years
More than 3 years but not more than 5 years
More than 5 years but not more than 10 years
Over 10 years ago
Refused
Don't know

2
3

4
5
6
7
9

UniverseText:

Sample adults 40+ who failed to give a complete date in either the month or year format or failed to give a
complete date in the number and time period format, or entered years ago in the time period format (excluding
those whose last home blood stool test was 6-9 or over 10 years ago)

SkipInstructions:

<1-6,R,D> if answer code is grayed out [goto ERR_RHFO2];
else [goto HFOBREA1]

Hard Edit:

ERR_RHFO2
*That is not a valid response.
*Please correct.

Question ID:

NAF.660_00.000 Instrument Variable Name:

QuestionText:

1

2
3
7
9

HFOBREA1

QuestionnaireFileName:

Sample Adult

What was the MAIN reason you had this home blood stool test - was it part of a routine exam, because of a problem, or
some other reason?
Part of a routine exam
Because of a problem
Other reason
Refused
Don't know

UniverseText:

Sample adults 40+ who have had a home blood stool test

SkipInstructions:

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

Page 32 of 32

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Cancer Screening
Document Version Date:

Question ID:

NAF.750_00.000 Instrument Variable Name:

QuestionText:

1
2
7
9

COLPROB

20-Aug-13

QuestionnaireFileName:

Sample Adult

In the PAST 12 MONTHS, did a doctor or other health professional RECOMMEND that you be tested to look for
problems in your colon or rectum?

Yes
No
Refused
Don't know

UniverseText:

Sample adults 40+

SkipInstructions:

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

Page 1 of 19

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Sexual Identity
Document Version Date:

Question ID:

ASI.005_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ASIINTRO

QuestionnaireFileName:

Sample Adult

*You are about to enter the Sexual Identity and Lifestyle questions section. This section includes questions on computer
use, the respondent’s neighborhood, sexual identity, financial worries, mental health, and HIV testing.
*Enter 1 to Continue.

1

Continue

UniverseText:

Sample adults 18+

SkipInstructions:

<1> goto ACICPUSE

Question ID:

ASI.130_00.000 Instrument Variable Name:

QuestionText:

These questions are about you and your neighborhood.
How often do you use a computer?
*Read answer categories.

1
2
3

4
7
9

ACICPUSE

Never or almost never
Some days
Most days
Every day
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1-4,R,D> [goto ACISATHC]

QuestionnaireFileName:

Sample Adult

Page 2 of 19

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Sexual Identity
Document Version Date:

Question ID:

ASI.140_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ACISATHC

QuestionnaireFileName:

Sample Adult

In general, how satisfied are you with the health care you received in the past 12 months?
*Read answer categories.

1

Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
You haven't had health care in the past 12 months
Refused
Don't know

2
3

4
5
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

ASI.150_00.000 Instrument Variable Name:

QuestionText:
1

2
3
4
5
7

9

ACITENUR

About how long have you lived in your present neighborhood?
Less than 1 year
1-3 years
4-10 years
11-20 years
More than 20 years
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

QuestionnaireFileName:

Sample Adult

Page 3 of 19

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Sexual Identity
Document Version Date:

Question ID:

ASI.160_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ACINHELP

QuestionnaireFileName:

Sample Adult

How much do you agree or disagree with the following statements about your neighborhood?
People in this neighborhood help each other out.
Would you say…
*Read answer categories.

1

Definitely agree
Somewhat agree
Somewhat disagree
Definitely disagree
Refused
Don't know

2
3
4
7

9

UniverseText:

Sample adults 18+

SkipInstructions:

<1-4,R,D> [goto ACINCNTO]

Question ID:

ASI.170_00.000 Instrument Variable Name:

QuestionText:

ACINCNTO

QuestionnaireFileName:

*Read if necessary.
How much do you agree or disagree with the following statements about your neighborhood?
There are people I can count on in this neighborhood.
Would you say…
*Read answer categories if necessary.

1
2
3
4

7
9

Definitely agree
Somewhat agree
Somewhat disagree
Definitely disagree
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1-4,R,D> [goto ACINTRU]

Sample Adult

Page 4 of 19

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Sexual Identity
Document Version Date:

Question ID:

ASI.180_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ACINTRU

QuestionnaireFileName:

Sample Adult

*Read if necessary.
How much do you agree or disagree with the following statements about your neighborhood?
People in this neighborhood can be trusted.
Would you say…
*Read answer categories if necessary.

1

Definitely agree
Somewhat agree
Somewhat disagree
Definitely disagree
Refused
Don't know

2
3

4
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

<1-4,R,D> [goto ACINKNT]

Question ID:

ASI.190_00.000 Instrument Variable Name:

QuestionText:

ACINKNT

QuestionnaireFileName:

*Read if necessary.
How much do you agree or disagree with the following statements about your neighborhood?
This is a close-knit neighborhood.
Would you say…
*Read answer categories if necessary.

1
2

3
4
7
9

Definitely agree
Somewhat agree
Somewhat disagree
Definitely disagree
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1-4,R,D>
[if SEX=1, goto ACISIM; elseif SEX=2, goto ACISIF]

Sample Adult

Page 5 of 19

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Sexual Identity
Document Version Date:

Question ID:

ASI.220_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ACISIM

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

(book) ASI1
Which of the following best represents how you think of yourself?

1

Gay
Straight, that is, not gay
Bisexual
Something else
I don't know the answer
Refused

2
3

4
5
7

UniverseText:

Male sample adults 18+

SkipInstructions:

<1-3,R> [goto ACIRETR]
<4> [goto ACISMELS]
<5> [goto ACISIMDK]

Question ID:

ASI.230_00.000 Instrument Variable Name:

QuestionText:

ACISMELS

(book) ASI3
What do you mean by something else?

1
2
3
4
5

6
7
9

You are not straight, but identify with another label such as queer, trisexual, omnisexual or pansexual
You are transgender, transsexual or gender variant
You have not figured out or are in the process of figuring out your sexuality
You do not think of yourself as having sexuality
You do not use labels to identify yourself
You mean something else
Refused
Don't know

UniverseText:

Male sample adults 18+ who think of themselves as something else

SkipInstructions:

<1-5,R,D> [goto ACIRETR]
<6> [goto ACIMSESP]

Page 6 of 19

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Sexual Identity
Document Version Date:

Question ID:

ASI.234_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ACISIMDK

QuestionnaireFileName:

Sample Adult

(book) ASI4
What do you mean by don't know?

1

You don't understand the words
You understand the words, but you have not figured out or are in the process of figuring out your sexuality
You mean something else
Refused
Don't know

2
3

7
9

UniverseText:

Male sample adults 18+ who answered don't know at ACISIM

SkipInstructions:

<1,2,R,D> [goto ACIRETR]
<3> [goto ACIMSESP]

Question ID:

ASI.238_00.000 Instrument Variable Name:

QuestionText:

What do you mean by something else?

7
9

verbatim

ACIMSESP

QuestionnaireFileName:

Refused
Don't know
Verbatim response

UniverseText:

Male sample adults 18+ who answered something else at ACISMELS or ACISIMDK

SkipInstructions:

[goto ACIRETR]

Sample Adult

Page 7 of 19

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Sexual Identity
Document Version Date:

Question ID:

ASI.240_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ACISIF

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

(book) ASI2
Which of the following best represents how you think of yourself?

1

Lesbian or gay
Straight, that is, not lesbian or gay
Bisexual
Something else
I don't know the answer
Refused

2
3

4
5
7

UniverseText:

Female sample adults 18+

SkipInstructions:

<1-3,R> [goto ACIRETR]
<4> [goto ACISFELS]
<5> [goto ACISIFDK]

Question ID:

ASI.250_00.000 Instrument Variable Name:

QuestionText:

ACISFELS

(book) ASI3
What do you mean by something else?

1
2
3
4
5

6
7
9

You are not straight, but identify with another label such as queer, trisexual, omnisexual or pansexual
You are transgender, transsexual or gender variant
You have not figured out or are in the process of figuring out your sexuality
You do not think of yourself as having sexuality
You do not use labels to identify yourself
You mean something else
Refused
Don't know

UniverseText:

Female sample adults 18+ who think of themselves as as something else

SkipInstructions:

<1-5,R,D> [goto ACIRETR]
<6> [goto ACIFSESP]

Page 8 of 19

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Sexual Identity
Document Version Date:

Question ID:

ASI.254_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ACISIFDK

QuestionnaireFileName:

Sample Adult

(book) ASI4
What do you mean by don't know?

1

You don't understand the words
You understand the words, but you have not figured out or are in the process of figuring out your sexuality
You mean something else
Refused
Don't know

2
3

7
9

UniverseText:

Female sample adults 18+ who answered don't know at ACISIM

SkipInstructions:

<1,2,R,D> [goto ACIRETR]
<3> [goto ACIFSESP]

Question ID:

ASI.258_00.000 Instrument Variable Name:

QuestionText:

What do you mean by something else?

7
9

verbatim

ACIFSESP

QuestionnaireFileName:

Refused
Don't know
Verbatim response

UniverseText:

Female sample adults 18+ who answered something else at ACISMELS or ACISIMDK

SkipInstructions:

[goto ACIRETR]

Sample Adult

Page 9 of 19

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Sexual Identity
Document Version Date:

Question ID:

ASI.260_00.000 Instrument Variable Name:

QuestionText:

ACIRETR

20-Aug-13

QuestionnaireFileName:

Sample Adult

The next questions ask how worried you are right now about financial matters.
How worried are you right now about not having enough money for retirement? Are you…
*Read answer categories.

1

Very worried
Moderately worried
Not too worried
Not worried at all
Refused
Don't know

2
3
4
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

<1-4,R,D> [goto ACIMEDC]

Question ID:

ASI.270_00.000 Instrument Variable Name:

QuestionText:

2
3
4
7

9

QuestionnaireFileName:

Sample Adult

How worried are you right now about not being able to pay medical costs of a serious illness or accident? Are you…
*Read answer categories if necessary.

1

ACIMEDC

Very worried
Moderately worried
Not too worried
Not worried at all
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1-4,R,D> [goto ACISTLV]

Page 10 of 19

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Sexual Identity
Document Version Date:

Question ID:

ASI.280_00.000 Instrument Variable Name:

ACISTLV

20-Aug-13

QuestionnaireFileName:

Sample Adult

How worried are you right now about not being able to maintain the standard of living you enjoy? Are you…

QuestionText:

*Read answer categories if necessary.
1

Very worried
Moderately worried
Not too worried
Not worried at all
Refused
Don't know

2
3

4
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

<1-4,R,D> [goto ACICNHC]

Question ID:

ASI.290_00.000 Instrument Variable Name:

QuestionText:

2
3
4
7
9

QuestionnaireFileName:

Sample Adult

How worried are you right now about not being able to pay medical costs for normal healthcare? Are you…
*Read answer categories if necessary.

1

ACICNHC

Very worried
Moderately worried
Not too worried
Not worried at all
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1-4,R,D> [goto ACICCOLL]

Page 11 of 19

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Sexual Identity
Document Version Date:

Question ID:

ASI.300_00.000 Instrument Variable Name:

20-Aug-13

ACICCOLL

QuestionnaireFileName:

Sample Adult

How worried are you right now about not having enough money to pay for your children's college? Are you…

QuestionText:

*Read answer categories if necessary.
1

Very worried
Moderately worried
Not too worried
Not worried at all
This does not apply to me
Refused
Don't know

2
3

4
5
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

ASI.310_00.000 Instrument Variable Name:

QuestionText:

2
3
4
7

9

QuestionnaireFileName:

Sample Adult

How worried are you right now about not having enough to pay your normal monthly bills? Are you…
*Read answer categories if necessary.

1

ACINBILL

Very worried
Moderately worried
Not too worried
Not worried at all
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<1-4,R,D> [goto ACIHCST]

Page 12 of 19

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Sexual Identity
Document Version Date:

Question ID:

ASI.320_00.000 Instrument Variable Name:

ACIHCST

20-Aug-13

QuestionnaireFileName:

Sample Adult

How worried are you right now about not being able to pay your rent, mortgage, or other housing costs? Are you…

QuestionText:

*Read answer categories if necessary.
1

Very worried
Moderately worried
Not too worried
Not worried at all
Refused
Don't know

2
3

4
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

<1-4,R,D> [goto ACICCMP]

Question ID:

ASI.330_00.000 Instrument Variable Name:

QuestionText:

2
3
4
5
7

9

QuestionnaireFileName:

Sample Adult

How worried are you right now about not being able to make the minimum payments on your credit cards? Are you…
*Read answer categories if necessary.

1

ACICCMP

Very worried
Moderately worried
Not too worried
Not worried at all
I don't have credit cards
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

Page 13 of 19

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Sexual Identity
Document Version Date:

Question ID:

ASI.340_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ACISLEEP

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

1-24 hours
Refused
Don't know

97

99

UniverseText:

Sample adults 18+

SkipInstructions:

<1-5>[goto ERR_SLEEP];
<1-24, R,D>[goto ACISLPFL]

Soft Edit:

ERR_SLEEP
*Average number of hours of sleep is [ACISLEEP].
* Please verify.

Question ID:

ASI.350_00.000 Instrument Variable Name:

QuestionText:

ACISLPFL

QuestionnaireFileName:

In the past week, how many times did you have trouble falling asleep?
*Enter '0' if respondent did not have trouble falling asleep in the past week.
*Enter '7' for 7 or more times.

00
01-06
07
97

99

Did not have trouble falling asleep in the past week
1-6 times
7 or more times
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<0-7,R,D> [goto ACISLPST]

Sample Adult

Page 14 of 19

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Sexual Identity
Document Version Date:

Question ID:

ASI.360_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ACISLPST

QuestionnaireFileName:

Sample Adult

In the past week, how many times did you have trouble staying asleep?
*Enter '0' if respondent did not have trouble staying asleep in the past week.
*Enter '7' for 7 or more times.

00

Did not have trouble staying asleep in the past week
1-6 times
7 or more times
Refused
Don't know

01-06
07
97
99

UniverseText:

Sample adults 18+

SkipInstructions:

<0-7,R,D> [goto ACISLPMD]

Question ID:

ASI.370_00.000 Instrument Variable Name:

QuestionText:

ACISLPMD

QuestionnaireFileName:

In the past week, how many times did you take medication to help you fall asleep or stay asleep?
*Enter '0' if respondent did not take medication to help sleep in the past week.
*Enter '7' for 7 or more times.

00
01-06
07
97

99

Did not take medication to help sleep in the past week
1-6 times
7 or more times
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

<0-7,R,D> [goto ACIREST]

Sample Adult

Page 15 of 19

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Sexual Identity
Document Version Date:

Question ID:

ASI.380_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ACIREST

QuestionnaireFileName:

Sample Adult

In the past week, on how many days did you wake up feeling well rested?
*Enter '0' if respondent never felt well rested in the past week.

00

Never felt rested in the past week
1-7 days
Refused
Don't know

01-07
97

99

UniverseText:

Sample adults 18+

SkipInstructions:

<0-7,R,D> [goto MHSAD_CK]

Question ID:

ASI.390_00.000 Instrument Variable Name:

QuestionText:

QuestionnaireFileName:

Sample Adult

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 ACISAD]

Question ID:

MHSAD_CK

ASI.390_01.000 Instrument Variable Name:

QuestionText:

ACISAD

(book) ASI5
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 ACINERV]

QuestionnaireFileName:

Sample Adult

Page 16 of 19

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Sexual Identity
Document Version Date:

Question ID:

ASI.390_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ACINERV

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

(book) ASI5
* 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 ACIRSTLS]

Question ID:

ASI.390_03.000 Instrument Variable Name:

QuestionText:

ACIRSTLS

(book) ASI5
* Read 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 ACIHOPLS]

Page 17 of 19

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Sexual Identity
Document Version Date:

Question ID:

ASI.390_04.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ACIHOPLS

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

(book) ASI5
* 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 ACIEFFRT]

Question ID:

ASI.390_05.000 Instrument Variable Name:

QuestionText:

ACIEFFRT

(book) ASI5
* 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 ACIWTHLS]

Page 18 of 19

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Sexual Identity
Document Version Date:

Question ID:

ASI.390_06.000 Instrument Variable Name:

QuestionText:

20-Aug-13

ACIWTHLS

QuestionnaireFileName:

Sample Adult

(book) ASI5
* 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:

<1-5,R,D> if ACISAD or ACINERV or ACIRSTLS or ACIHOPLS or ACIEFFRT or ACIWTHLS=1-3 [goto
ACIMUCH];
else [goto ACIHIVT]

Question ID:

ASI.400_00.000 Instrument Variable Name:

QuestionText:

1

2
3
4
7
9

ACIMUCH

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 ACIHIVT]

Page 19 of 19

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Sexual Identity
Document Version Date:

Question ID:

ASI.410_00.000 Instrument Variable Name:

QuestionText:

ACIHIVT

QuestionnaireFileName:

Sample Adult

The next question is about the test for HIV, the virus that causes AIDS. Except for tests you may have had as part of blood
donations, have you ever been tested for HIV?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

20-Aug-13

ASI.420_00.000 Instrument Variable Name:

QuestionText:

ACIHIVWN

QuestionnaireFileName:

Sample Adult

(book) ASI6
I am going to show you a list of reasons why some people have not been tested for HIV (the virus that causes AIDS).
Which one of these would you say is the MAIN reason why you have not been tested?

01
02

03
04
05
06
07
08

09
97
99

It's unlikely you've been exposed to HIV
You were afraid to find out if you were HIV positive (that you had HIV)
You didn't want to think about HIV or about being HIV positive
You were worried your name would be reported to the government if you tested positive
You didn't know where to get tested
You don't like needles
You were afraid of losing job, insurance, housing, friends, family, if people knew you were positive for AIDS infection
Some other reason
No particular reason
Refused
Don't know

UniverseText:

Sample adults 18+ who have never been tested for HIV

SkipInstructions:

<1-9,R,D> [goto next section]

Page 1 of 21

DRAFT 2013 NHIS Questionnaire - Functioning And Disability
Adult Functioning and Disability
Document Version Date:

Question ID:

AFD.090_00.000 Instrument Variable Name:

QuestionText:

VIS_0

20-Aug-13

QuestionnaireFileName:

Functioning And
Disability

Now I am going to ask you some questions about your ability to do different activities, and how you have been feeling.
Although some of these questions may seem similar to ones you have already answered, it is important that we ask them
all.
Do you wear glasses?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB) and were randomly selected to receive
the Functioning and Disability (AFD) section

SkipInstructions:

<1,2,R,D> goto VIS_SS

Question ID:

AFD.100_00.000 Instrument Variable Name:

QuestionText:

1
2
3
4
7

9

VIS_SS

QuestionnaireFileName:

Functioning And
Disability

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?
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 HEAR_1]

Page 2 of 21

DRAFT 2013 NHIS Questionnaire - Functioning And Disability
Adult Functioning and Disability
Document Version Date:

Question ID:

AFD.140_00.000 Instrument Variable Name:

QuestionText:

HEAR_1

20-Aug-13

QuestionnaireFileName:

Functioning And
Disability

Do you use a hearing aid?

1

Yes
No
Refused
Don't know

2
7

9

UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB) and were randomly selected to receive
the Functioning and Disability (AFD) section

SkipInstructions:

<1> [goto HEAR_2]
<2,R,D> [goto HEAR_SS]

Question ID:

AFD.145_00.000 Instrument Variable Name:

QuestionText:
1
2

3
4
7
9

HEAR_2

QuestionnaireFileName:

Functioning And
Disability

How often do you use your hearing aid(s)? Would you say all of the time, some of the time, rarely, or never?
All of the time
Some of the time
Rarely
Never
Refused
Don't know

UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB), were randomly selected to receive the
Functioning and Disability (AFD) section, and use a hearing aid

SkipInstructions:

<1,2,R,D> goto HEAR_SS

Page 3 of 21

DRAFT 2013 NHIS Questionnaire - Functioning And Disability
Adult Functioning and Disability
Document Version Date:

Question ID:

AFD.150_00.000 Instrument Variable Name:

QuestionText:

HEAR_SS

20-Aug-13

QuestionnaireFileName:

Functioning And
Disability

Do you have difficulty hearing [fill: , even when using 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 were asked the family disability questions (FDB) and were randomly selected to receive
the Functioning and Disability (AFD) section

SkipInstructions:

<1-3,R,D>[goto HEAR_3]
<4> [goto MOB_SS]

Question ID:

AFD.170_00.000 Instrument Variable Name:

QuestionText:

1
2
3
4
7

9

HEAR_3

QuestionnaireFileName:

Functioning And
Disability

Do you have difficulty hearing what is said in a conversation with one other person in a quiet room [fill: even when using
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 were asked the family disability questions (FDB), were randomly selected to receive the
Functioning and Disability (AFD) section, and 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]

Page 4 of 21

DRAFT 2013 NHIS Questionnaire - Functioning And Disability
Adult Functioning and Disability
Document Version Date:

Question ID:

AFD.170_00.001 Instrument Variable Name:

QuestionText:

HEAR_4

20-Aug-13

QuestionnaireFileName:

Functioning And
Disability

Do you have difficulty hearing what is said in a conversation with one other person in a noisier room [fill: even when
using 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 were asked the family disability questions (FDB), were randomly selected to receive the
Functioning and Disability (AFD) section, and 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]

Question ID:

AFD.180_00.000 Instrument Variable Name:

QuestionText:

1
2
3
4

7
9

MOB_SS

QuestionnaireFileName:

Functioning And
Disability

Do you have difficulty walking or climbing steps? 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) and were randomly selected to receive
the Functioning and Disability (AFD) section

SkipInstructions:

<1-4,R,D> goto MOB_2

Page 5 of 21

DRAFT 2013 NHIS Questionnaire - Functioning And Disability
Adult Functioning and Disability
Document Version Date:

Question ID:

AFD.200_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

MOB_2

QuestionnaireFileName:

Functioning And
Disability

Do you use any equipment or receive help for getting around?

1

Yes
No
Refused
Don't know

2
7

9

UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB) and were randomly selected to receive
the Functioning and Disability (AFD) section

SkipInstructions:

<1>[goto MOB_3A]
<2,R,D>[goto MOB_4]

Question ID:

AFD.200_00.001 Instrument Variable Name:

QuestionText:

MOB_3A

QuestionnaireFileName:

Functioning And
Disability

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 were asked the family disability questions (FDB), were randomly selected to receive the
Functioning and Disability (AFD) section, and use equipment or receive help for getting around

SkipInstructions:

<1,2,R,D> goto MOB_3B

Page 6 of 21

DRAFT 2013 NHIS Questionnaire - Functioning And Disability
Adult Functioning and Disability
Document Version Date:

Question ID:

AFD.200_00.002 Instrument Variable Name:

QuestionText:

MOB_3B

20-Aug-13

QuestionnaireFileName:

Functioning And
Disability

*Read if necessary.
Do you use any of the following…
Walker or Zimmer frame?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB), were randomly selected to receive the
Functioning and Disability (AFD) section, and use equipment or receive help for getting around

SkipInstructions:

<1,2,R,D> goto MOB_3C

Question ID:

AFD.200_00.003 Instrument Variable Name:

QuestionText:

MOB_3C

QuestionnaireFileName:

Functioning And
Disability

*Read if necessary.
Do you use any of the following…
Crutches?

1
2
7

9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB), were randomly selected to receive the
Functioning and Disability (AFD) section, and use equipment or receive help for getting around

SkipInstructions:

<1,2,R,D> goto MOB_3D

Page 7 of 21

DRAFT 2013 NHIS Questionnaire - Functioning And Disability
Adult Functioning and Disability
Document Version Date:

Question ID:

AFD.200_00.004 Instrument Variable Name:

QuestionText:

MOB_3D

20-Aug-13

QuestionnaireFileName:

Functioning And
Disability

*Read if necessary.
Do you use any of the following…
Wheelchair or scooter?

1

Yes
No
Refused
Don't know

2
7
9

UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB), were randomly selected to receive the
Functioning and Disability (AFD) section, and use equipment or receive help for getting around

SkipInstructions:

<1,2,R,D> goto MOB_3E

Question ID:

AFD.200_00.005 Instrument Variable Name:

QuestionText:

MOB_3E

QuestionnaireFileName:

Functioning And
Disability

*Read if necessary.
Do you use any of the following…
Artificial limb (leg/foot)?

1
2
7

9

Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB), were randomly selected to receive the
Functioning and Disability (AFD) section, and use equipment or receive help for getting around

SkipInstructions:

<1,2,R,D> goto MOB_3F

Page 8 of 21

DRAFT 2013 NHIS Questionnaire - Functioning And Disability
Adult Functioning and Disability
Document Version Date:

Question ID:

AFD.200_00.006 Instrument Variable Name:

QuestionText:

MOB_3F

20-Aug-13

QuestionnaireFileName:

Functioning And
Disability

*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 were asked the family disability questions (FDB), were randomly selected to receive the
Functioning and Disability (AFD) section, and use equipment or receive help for getting around

SkipInstructions:

<1,2,R,D> goto MOB_3G

Question ID:

AFD.200_00.007 Instrument Variable Name:

QuestionText:

MOB_3G

QuestionnaireFileName:

Functioning And
Disability

*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 were asked the family disability questions (FDB), were randomly selected to receive the
Functioning and Disability (AFD) section, and use equipment or receive help for getting around

SkipInstructions:

<1,2,R,D> if MOB_3D=1, [goto COM_SS];
else if MOB_3D=2,R,D [goto MOB_4]

Page 9 of 21

DRAFT 2013 NHIS Questionnaire - Functioning And Disability
Adult Functioning and Disability
Document Version Date:

Question ID:

AFD.210_00.000 Instrument Variable Name:

QuestionText:

MOB_4

20-Aug-13

QuestionnaireFileName:

Functioning And
Disability

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

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), were randomly selected to receive the
Functioning and Disability (AFD) section, and do not use a wheelchair or scooter

SkipInstructions:

<1-3,R,D>[goto MOB_5]
<4>[goto MOB_6]

Question ID:

AFD.220_00.000 Instrument Variable Name:

QuestionText:

1
2
3

4
7
9

MOB_5

QuestionnaireFileName:

Functioning And
Disability

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 [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?
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), were randomly selected to receive the
Functioning and Disability (AFD) section, do not use a wheelchair or scooter, and 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
(without the use of their aid)

SkipInstructions:

<1,2,R,D> goto MOB_6

Page 10 of 21

DRAFT 2013 NHIS Questionnaire - Functioning And Disability
Adult Functioning and Disability
Document Version Date:

Question ID:

AFD.230_00.000 Instrument Variable Name:

QuestionText:

MOB_6

20-Aug-13

QuestionnaireFileName:

Functioning And
Disability

Do you have difficulty walking up or down 12 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), were randomly selected to receive the
Functioning and Disability (AFD) section, and do not use a wheelchair or scooter

SkipInstructions:

<1-4,R,D> if MOB_2 IN (2,R,D) [goto COM_SS];
else if MOB_2=1 [goto MOB_7]

Question ID:

AFD.240_00.000 Instrument Variable Name:

QuestionText:

1
2
3
4

7
9

MOB_7

QuestionnaireFileName:

Functioning And
Disability

Do you have difficulty walking 100 yards on level ground, that would be about the length of one 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 were asked the family disability questions (FDB), were randomly selected to receive the
Functioning and Disability (AFD) section, and use equipment or receive help for getting around but do not use a
wheelchair or scooter

SkipInstructions:

<1-3,R,D>[goto MOB_8]
<4>[goto COM_SS]

Page 11 of 21

DRAFT 2013 NHIS Questionnaire - Functioning And Disability
Adult Functioning and Disability
Document Version Date:

Question ID:

AFD.250_00.000 Instrument Variable Name:

QuestionText:

MOB_8

20-Aug-13

QuestionnaireFileName:

Functioning And
Disability

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 were asked the family disability questions (FDB), were randomly selected to receive the
Functioning and Disability (AFD) section, use equipment or receive help for getting around but do not use a
wheelchair or scooter, 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 COM_SS

Question ID:

AFD.270_00.000 Instrument Variable Name:

QuestionText:

1
2
3

4
7
9

COM_SS

QuestionnaireFileName:

Functioning And
Disability

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) and were randomly selected to receive
the Functioning and Disability (AFD) section

SkipInstructions:

<1-4,R,D> goto COM_2

Page 12 of 21

DRAFT 2013 NHIS Questionnaire - Functioning And Disability
Adult Functioning and Disability
Document Version Date:

Question ID:

AFD.290_00.000 Instrument Variable Name:

QuestionText:

COM_2

20-Aug-13

QuestionnaireFileName:

Functioning And
Disability

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) and were randomly selected to receive
the Functioning and Disability (AFD) section

SkipInstructions:

<1,2,R,D> goto COG_SS

Question ID:

AFD.300_00.000 Instrument Variable Name:

QuestionText:

1
2
3

4
7
9

COG_SS

QuestionnaireFileName:

Functioning And
Disability

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?
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) and were randomly selected to receive
the Functioning and Disability (AFD) section

SkipInstructions:

<1>[goto UB_SS]
<2-4,R,D>[goto COG_1]

Page 13 of 21

DRAFT 2013 NHIS Questionnaire - Functioning And Disability
Adult Functioning and Disability
Document Version Date:

Question ID:

AFD.310_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

COG_1

QuestionnaireFileName:

Functioning And
Disability

Do you have difficulty remembering, concentrating, or both?

1

Difficulty remembering only
Difficulty concentrating only
Difficulty with both remembering and concentrating
Refused
Don't know

2
3

7
9

UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB), were randomly selected to receive the
Functioning and Disability (AFD) section, and 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]

Question ID:

AFD.320_00.000 Instrument Variable Name:

QuestionText:
1
2
3
7
9

COG_2

QuestionnaireFileName:

Functioning And
Disability

How often do you have difficulty remembering? Would you say sometimes, often or all of the time?
Sometimes
Often
All of the time
Refused
Don't know

UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB), were randomly selected to receive the
Functioning and Disability (AFD) section, and have difficulty remembering or don't know or refused if they have
difficulty remembering

SkipInstructions:

<1-3,R,D> goto COG_3

Page 14 of 21

DRAFT 2013 NHIS Questionnaire - Functioning And Disability
Adult Functioning and Disability
Document Version Date:

Question ID:

AFD.330_00.000 Instrument Variable Name:

QuestionText:

COG_3

20-Aug-13

QuestionnaireFileName:

Functioning And
Disability

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 were asked the family disability questions (FDB), were randomly selected to receive the
Functioning and Disability (AFD) section, and have difficulty remembering or don't know or refused if they have
difficulty remembering

SkipInstructions:

<1-3,R,D> goto UB_SS

Question ID:

AFD.360_00.000 Instrument Variable Name:

QuestionText:

1

2
3
4
7
9

UB_SS

QuestionnaireFileName:

Functioning And
Disability

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) and were randomly selected to receive
the Functioning and Disability (AFD) section

SkipInstructions:

<1-4,R,D> goto UB_1

Page 15 of 21

DRAFT 2013 NHIS Questionnaire - Functioning And Disability
Adult Functioning and Disability
Document Version Date:

Question ID:

AFD.370_00.000 Instrument Variable Name:

QuestionText:

UB_1

20-Aug-13

QuestionnaireFileName:

Functioning And
Disability

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) and were randomly selected to receive
the Functioning and Disability (AFD) section

SkipInstructions:

<1-4,R,D> goto UB_2

Question ID:

AFD.380_00.000 Instrument Variable Name:

QuestionText:

1
2
3
4
7

9

UB_2

QuestionnaireFileName:

Functioning And
Disability

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?
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) and were randomly selected to receive
the Functioning and Disability (AFD) section

SkipInstructions:

<1-4,R,D> goto ANX_1

Page 16 of 21

DRAFT 2013 NHIS Questionnaire - Functioning And Disability
Adult Functioning and Disability
Document Version Date:

Question ID:

AFD.410_00.000 Instrument Variable Name:

QuestionText:

ANX_1

20-Aug-13

QuestionnaireFileName:

Functioning And
Disability

How often do you feel worried, nervous or anxious? Would you say daily, weekly, monthly, a few times a year, or never?

1

Daily
Weekly
Monthly
A few times a year
Never
Refused
Don't know

2
3

4
5
7
9

UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB) and were randomly selected to receive
the Functioning and Disability (AFD) section

SkipInstructions:

<1-5,R,D> goto ANX_2

Question ID:

AFD.420_00.000 Instrument Variable Name:

QuestionText:
1
2
7
9

ANX_2

QuestionnaireFileName:

Functioning And
Disability

Do you take medication for these feelings?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB) and were randomly selected to receive
the Functioning and Disability (AFD) section

SkipInstructions:

<1,R,D> [goto ANX_3]
<2> if ANX_1=5 [goto DEP_1];
else [goto ANX_3]

Page 17 of 21

DRAFT 2013 NHIS Questionnaire - Functioning And Disability
Adult Functioning and Disability
Document Version Date:

Question ID:

AFD.430_00.000 Instrument Variable Name:

QuestionText:

ANX_3

20-Aug-13

QuestionnaireFileName:

Functioning And
Disability

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 were asked the family disability questions (FDB), were randomly selected to receive the
Functioning and Disability (AFD) section, and feel worried, anxious, or nervous daily, weekly, monthly, a few
times a year 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:

<1-3,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:

Functioning And
Disability

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) and were randomly selected to receive
the Functioning and Disability (AFD) section

SkipInstructions:

<1-5,R,D> goto DEP_2

Page 18 of 21

DRAFT 2013 NHIS Questionnaire - Functioning And Disability
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

20-Aug-13

QuestionnaireFileName:

Functioning And
Disability

Yes
No
Refused
Don't know

2
7

9

UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB) and were randomly selected to receive
the Functioning and Disability (AFD) section

SkipInstructions:

<1,R,D> [goto DEP_3]
<2> if DEP_1=5 [goto PAIN_2];
else [goto DEP_3]

Question ID:

AFD.470_00.000 Instrument Variable Name:

QuestionText:

1

2
3
7
9

DEP_3

QuestionnaireFileName:

Functioning And
Disability

Thinking about the last time you felt depressed, how depressed did you feel? Would you say a little, a lot, or somewhere
in between?
A little
A lot
Somewhere in between a little and a lot
Refused
Don't know

UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB), were randomly selected to receive the
Functioning and Disability (AFD) section, and feel depressed daily, weekly, monthly, a few times a year or refused
or don't know how often they feel depressed OR who do take medication or refused or don't know if they take
medication for depression.

SkipInstructions:

<1-3,R,D> goto PAIN_2

Page 19 of 21

DRAFT 2013 NHIS Questionnaire - Functioning And Disability
Adult Functioning and Disability
Document Version Date:

Question ID:

AFD.500_00.000 Instrument Variable Name:

QuestionText:

PAIN_2

20-Aug-13

QuestionnaireFileName:

Functioning And
Disability

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) and were randomly selected to receive
the Functioning and Disability (AFD) section

SkipInstructions:

<1> [goto TIRED_1]
<2,3,4,R,D> [goto PAIN_4]

Question ID:

AFD.520_00.000 Instrument Variable Name:

QuestionText:

1
2
3
7
9

PAIN_4

QuestionnaireFileName:

Functioning And
Disability

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?
A little
A lot
Somewhere in between a little and a lot
Refused
Don't know

UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB), were randomly selected to receive the
Functioning and Disability (AFD) section, and 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 TIRED_1

Page 20 of 21

DRAFT 2013 NHIS Questionnaire - Functioning And Disability
Adult Functioning and Disability
Document Version Date:

Question ID:

AFD.540_00.000 Instrument Variable Name:

QuestionText:

TIRED_1

20-Aug-13

QuestionnaireFileName:

Functioning And
Disability

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?

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) and were randomly selected to receive
the Functioning and Disability (AFD) section

SkipInstructions:

<1>[goto next section]
<2-4,R,D>[goto TIRED_2]

Question ID:

AFD.550_00.000 Instrument Variable Name:

QuestionText:

1
2
3
7
9

TIRED_2

QuestionnaireFileName:

Functioning And
Disability

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?
Some of the day
Most of the day
All of the day
Refused
Don't know

UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB), were randomly selected to receive the
Functioning and Disability (AFD) section, and 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

Page 21 of 21

DRAFT 2013 NHIS Questionnaire - Functioning And Disability
Adult Functioning and Disability
Document Version Date:

Question ID:

AFD.560_00.000 Instrument Variable Name:

QuestionText:

1
2
3

7
9

TIRED_3

20-Aug-13

QuestionnaireFileName:

Functioning And
Disability

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?
A little
A lot
Somewhere in between a little and a lot
Refused
Don't know

UniverseText:

Sample adults 18+ who were asked the family disability questions (FDB), were randomly selected to receive the
Functioning and Disability (AFD) section, and 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 next section

Page 1 of 4

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Internet and Email Usage
Document Version Date:

Question ID:

AWB.010_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

AWEBUSE

QuestionnaireFileName:

Sample Adult

QuestionnaireFileName:

Sample Adult

The next questions are about your Internet and email use.
Do you use the Internet?

1

Yes
No
Refused
Don't know

2
7

9

UniverseText:

Sample adults 18+

SkipInstructions:

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

Question ID:

AWB.020_01.000 Instrument Variable Name:

QuestionText:

AWEBOFNO

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

001-995
997
999

1-995
Refused
Don't know

UniverseText:

Sample adults 18+ who use the Internet

SkipInstructions:

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

Page 2 of 4

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Internet and Email Usage
Document Version Date:

Question ID:

AWB.020_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

AWEBOFTP

QuestionnaireFileName:

Sample Adult

2 of 2
*Enter time period for how often Internet is used.

1

Per day
Per week
Per month
Per year
Refused
Don't know

2
3

4
7
9

UniverseText:

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

SkipInstructions:

<1-4,R,D> [goto AWEBEML]

Question ID:

AWB.030_00.000 Instrument Variable Name:

QuestionText:
1
2

7
9

AWEBEML

Do you send or receive emails?
Yes
No
Refused
Don't know

UniverseText:

Sample adults 18+

SkipInstructions:

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

QuestionnaireFileName:

Sample Adult

Page 3 of 4

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Internet and Email Usage
Document Version Date:

Question ID:

AWB.040_00.000 Instrument Variable Name:

QuestionText:

20-Aug-13

AWEBEMAD

QuestionnaireFileName:

Sample Adult

We may want to contact you to obtain additional health-related information.
May I have your email address?
*Enter email address.
*Enter 'N' for none.
allow 75
Refused
Don't Know

97
99

UniverseText:

Sample adults 18+ who send or receive email

SkipInstructions:

[goto AWBEMNO] [goto next section]

Question ID:

AWB.050_01.000 Instrument Variable Name:

QuestionText:

AWEBMNO

QuestionnaireFileName:

Sample Adult

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

001-995
997
999

1-995
Refused
Don't know

UniverseText:

Sample adults 18+ who gave an email address

SkipInstructions:

<1-995> [goto AWBEMTP] [goto next section]

Page 4 of 4

DRAFT 2013 NHIS Questionnaire - Sample Adult
Adult Internet and Email Usage
Document Version Date:

Question ID:

AWB.050_02.000 Instrument Variable Name:

QuestionText:

20-Aug-13

AWEBMTP

QuestionnaireFileName:

Sample Adult

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

1
2
3

4
7
9

Per day
Per week
Per month
Per year
Refused
Don't know

UniverseText:

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

SkipInstructions:

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