Adult Asthma History
CATI NOTE: If "Yes" to Core Q6.4; continue. Otherwise, go to next module.
Previously you said you were told by a doctor, nurse or other health professional that you had asthma.
1. How old were you when you were first told by a doctor, nurse, or other health professional that you had asthma?
_ _ Age in years 11 or older [96 = 96 and older]
9 7 Age 10 or younger
9 8 Don’t know / Not sure
9 9 Refused
CATI NOTE: If "Yes" to Core Q6.5, continue. Otherwise, go to next module.
2. During the past 12 months, have you had an episode of asthma or an asthma attack?
1 Yes
2 No [Go to Q5]
7 Don’t know / Not sure [Go to Q5]
9 Refused [Go to Q5]
3. During the past 12 months, how many times did you visit an emergency room or urgent
care center because of your asthma?
_ _ Number of visits [87 = 87 or more]
8 8 None
9 8 Don’t know / Not sure
9 9 Refused
4. [If one or more visits to Q3, fill in “Besides those emergency room or urgent care center visits,”] During the past 12 months, how many times did you see a doctor, nurse or other health professional for urgent treatment of worsening asthma symptoms?
_ _ Number of visits [87 = 87 or more]
8 8 None
9 8 Don’t know / Not sure
9 9 Refused
5. During the past 12 months, how many times did you see a doctor, nurse, or other health professional for a routine checkup for your asthma?
_ _ Number of visits [87 = 87 or more]
8 8 None
9 8 Don’t know / Not sure
9 9 Refused
6. During the past 12 months, how many days were you unable to work or carry out your
usual activities because of your asthma?
_ _ _ Number of days
8 8 8 None
7 7 7 Don’t know / Not sure
9 9 9 Refused
7. Symptoms of asthma include cough, wheezing, shortness of breath, chest tightness and phlegm production when you don’t have a cold or respiratory infection. During the past 30 days, how often did you have any symptoms of asthma? Would you say —
NOTE: Phlegm (‘flem’)
Please read:
8 Not at any time [Go to Q9]
1 Less than once a week
2 Once or twice a week
3 More than 2 times a week, but not every day
4 Every day, but not all the time
Or
5 Every day, all the time
Do not read:
7 Don’t know / Not sure
9 Refused
8. During the past 30 days, how many days did symptoms of asthma make it difficult for you
to stay asleep? Would you say —
Please read:
8 None
1 One or two
2 Three to four
3 Five
4 Six to ten
Or
5 More than ten
Do not read:
7 Don’t know / Not sure
9 Refused
9. During the past 30 days, how many days did you take a prescription asthma medication
to PREVENT an asthma attack from occurring?
Please read:
8 Never
1 1 to 14 days
2 15 to 24 days
3 25 to 30 days
Do not read:
7 Don’t know / Not sure
9 Refused
10. During the past 30 days, how often did you use a prescription asthma inhaler DURING AN ASTHMA ATTACK to stop it?
INTERVIEWER INSTRUCTION: How often (number of times) does NOT equal number of puffs. Two to three puffs are usually taken each time the inhaler is used.
Read only if necessary:
8 Never (include no attack in past 30 days)
1 1 to 4 times (in the past 30 days)
2 5 to 14 times (in the past 30 days)
3 15 to 29 times (in the past 30 days)
4 30 to 59 times (in the past 30 days)
5 60 to 99 times (in the past 30 days)
6 100 or more times (in the past 30 days)
Do not read:
7 Don’t know / Not sure
9 Refused
Adult Human Papillomavirus (HPV) - Vaccination
CATI NOTE: To be asked of respondents between the ages of 18 and 49 years; otherwise, go to next module.
NOTE: Human Papillomavirus (Human Pap·uh·loh·muh virus);
Gardasil (Gar·duh· seel); Cervarix (Sir·var· icks)
1. A vaccine to prevent the human papillomavirus or HPV infection is available and is called
the cervical cancer or genital warts vaccine, HPV shot, [Fill: if female “GARDASIL or CERVARIX”; if male “ or GARDASIL”].
Have you EVER had an HPV vaccination?
Yes
2 No [Go to next module]
3 Doctor refused when asked [Go to next module]
7 Don’t know / Not sure [Go to next module]
9 Refused [Go to next module]
2. How many HPV shots did you receive?
_ _ Number of shots
0 3 All shots
7 7 Don’t know / Not sure
9 9 Refused
Adverse Childhood Experience
I’d like to ask you some questions about events that happened during your childhood. This information will allow us to better understand problems that may occur early in life, and may help others in the future. This is a sensitive topic and some people may feel uncomfortable with these questions. At the end of this section, I will give you a phone number for an organization that can provide information and referral for these issues. Please keep in mind that you can ask me to skip any question you do not want to answer.
All questions refer to the time period before you were 18 years of age. Now, looking back before you were 18 years of age—
1. Did you live with anyone who was depressed, mentally ill, or suicidal?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
2. Did you live with anyone who was a problem drinker or alcoholic?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
3. Did you live with anyone who used illegal street drugs or who abused prescription
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
4. Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
5. Were your parents separated or divorced?
1 Yes
2 No
8 Parents not married
7 Don’t know / Not sure
9 Refused
6. How often did your parents or adults in your home ever slap, hit, kick, punch, or beat each other up?
1 Never
2 Once
3 More than once
Do not read:
7 Don’t know / Not sure
9 Refused
7. Before age 18, how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Do not include spanking. Would you say---
1 Never
2 Once
3 More than once
Do not read:
7 Don’t know / Not sure
9 Refused
8. How often did a parent or adult in your home ever swear at you, insult you, or put you down?
1 Never
2 Once
3 More than once
Do not read:
7 Don’t know / Not sure
9 Refused
9. How often did anyone at least 5 years older than you or an adult, ever touch you
sexually?
1 Never
2 Once
3 More than once
Do not read:
7 Don’t know / Not sure
9 Refused
10. How often did anyone at least 5 years older than you or an adult try to make you touch them sexually?
1 Never
2 Once
3 More than once
Do not read:
7 Don’t know / Not sure
9 Refused
11. How often did anyone at least 5 years older than you or an adult force you to have sex?
1 Never
2 Once
3 More than once
Do not read:
7 Don’t know / Not sure
9 Refused
As I mentioned when we started this section, I would give you a phone number for an organization that can provide information and referral for these issues. You can dial (place state or local hotline here) to reach a referral service to locate an agency in your area. [Note: if no local or state hotline is available, give respondent the National Hotline for child abuse 1-800-422-4-A-CHILD (1-800-422-4453).
Alcohol Screening & Brief Intervention (ASBI)
If Core Q3.4 = 1, or 2 (had a checkup within the past 2 years) continue, else go to next module.
Healthcare providers may ask during routine checkups about behaviors like alcohol use, whether you drink or not. We want to know about their questions.
You told me earlier that your last routine checkup was [within the past year/within the past 2 years]. At that checkup, were you asked in person or on a form if you drink alcohol?
1 Yes
2 No
7 Don't know / Not sure
9 Refused
2. Did the health care provider ask you in person or on a form how much you drink?
1 Yes
2 No
Don't know / Not sure
9 Refused
Did the healthcare provider specifically ask whether you drank [5 FOR MEN /4 FOR WOMEN] or more alcoholic drinks on an occasion?
1 Yes
2 No
7 Don't know / Not sure
9 Refused
Were you offered advice about what level of drinking is harmful or risky for your health?
1 Yes
2 No
7 Don't know / Not sure
9 Refused
CATI: If question 1, 2, or 3 = 1 (Yes) continue, else go to next module.
Healthcare providers may also advise patients to drink less for various reasons. At your last routine checkup, were you advised to reduce or quit your drinking?
1 Yes
2 No
7 Don't know / Not sure
9 Refused
Anxiety and Depression
Now, I am going to ask you some questions about your mood. When answering these questions, please think about how many days each of the following has occurred in the past 2 weeks.
1. Over the last 2 weeks, how many days have you had little interest or pleasure in doing things?
_ _ 01–14 days
8 8 None
7 7 Don‘t know / Not sure
9 9 Refused
2. Over the last 2 weeks, how many days have you felt down, depressed or hopeless?
_ _ 01–14 days
8 8 None
7 7 Don‘t know / Not sure
9 9 Refused
3. Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much?
_ _ 01–14 days
8 8 None
7 7 Don‘t know / Not sure
9 9 Refused
4. Over the last 2 weeks, how many days have you felt tired or had little energy?
_ _ 01–14 days
8 8 None
7 7 Don‘t know / Not sure
9 9 Refused
5. Over the last 2 weeks, how many days have you had a poor appetite or eaten too much?
_ _ 01–14 days
8 8 None
7 7 Don‘t know / Not sure
9 9 Refused
6. Over the last 2 weeks, how many days have you felt bad about yourself or that you were a failure or had let yourself or your family down?
_ _ 01–14 days
8 8 None
7 7 Don‘t know / Not sure
9 9 Refused
7. Over the last 2 weeks, how many days have you had trouble concentrating on things, such as reading the newspaper or watching the TV?
_ _ 01–14 days
8 8 None
7 7 Don‘t know / Not sure
9 9 Refused
8. Over the last 2 weeks, how many days have you moved or spoken so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you were moving around a lot more than usual?
_ _ 01–14 days
8 8 None
7 7 Don‘t know / Not sure
9 9 Refused
9. Are you now taking medicine or receiving treatment from a doctor or other health professional for any type of mental health condition or emotional problem?
1 Yes
2 No
7 Don‘t know / Not sure
9 Refused
10. Has a doctor or other healthcare provider EVER told you that you have an anxiety disorder (including acute stress disorder, anxiety, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, phobia, posttraumatic stress disorder, or social anxiety disorder)?
1 Yes
2 No
7 Don‘t know / Not sure
9 Refused
Arthritis Management
CATI NOTE: If Core Q6.9 = 1 (Yes), continue. Otherwise, go to next module.
1. Earlier you indicated that you had arthritis or joint symptoms. Thinking about your arthritis or joint symptoms, which of the following best describes you today?
Please read:
1 I can do everything I would like to do
2 I can do most things I would like to do
3 I can do some things I would like to do
4 I can hardly do anything I would like to do
Do not read:
7 Don’t know / Not sure
9 Refused
2. Has a doctor or other health professional EVER suggested losing weight to help your arthritis or joint symptoms?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
3. Has a doctor or other health professional ever suggested physical activity or exercise to help your arthritis or joint symptoms?
NOTE: If the respondent is unclear about whether this means an increase or decrease in physical activity, this means increase.
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
4. Have you EVER taken an educational course or class to teach you how to manage problems related to your arthritis or joint symptoms?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
Breast and Cervical Cancer Screening
CATI NOTE: If respondent is male, go to the next section.
The next questions are about breast and cervical cancer.
A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram?
1 Yes
2 No [Go to Q3]
7 Don’t know / Not sure [Go to Q3]
9 Refused [Go to Q3]
How long has it been since you had your last mammogram?
1 Within the past year (anytime less than 12 months ago)
2 Within the past 2 years (1 year but less than 2 years ago)
3 Within the past 3 years (2 years but less than 3 years ago)
4 Within the past 5 years (3 years but less than 5 years ago)
5 5 or more years ago
7 Don’t know / Not sure
9 Refused
A Pap test is a test for cancer of the cervix. Have you ever had a Pap test?
1 Yes
2 No [Go to Q5]
7 Don’t know / Not sure [Go to Q5]
9 Refused [Go to Q5]
How long has it been since you had your last Pap test?
1 Within the past year (anytime less than 12 months ago)
2 Within the past 2 years (1 year but less than 2 years ago)
3 Within the past 3 years (2 years but less than 3 years ago)
4 Within the past 5 years (3 years but less than 5 years ago)
5 5 or more years ago
7 Don’t know / Not sure
9 Refused
An HPV test is sometimes given with the Pap test for cervical cancer screening.
Have you ever had an HPV test?
1 Yes
2 No [Go to Q7]
7 Don’t know/Not sure [Go to Q7]
9 Refused [Go to Q7]
How long has it been since you had your last HPV test?
1 Within the past year (anytime less than 12 months ago)
2 Within the past 2 years (1 year but less than 2 years ago)
3 Within the past 3 years (2 years but less than 3 years ago)
4 Within the past 5 years (3 years but less than 5 years ago)
5 5 or more years ago
7 Don’t know / Not sure
9 Refused
CATI NOTE: If response to Core Q7.21 = 1 (is pregnant); then go to next section.
Have you had a hysterectomy?
Read only if necessary: A hysterectomy is an operation to remove the uterus (womb).
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
CATI note: If Core Q6.6 or Q6.7 = 1 (Yes) or Q16.6 = 4 (Because you were told you had prostate cancer) continue, else go to next module.
You’ve told us that you have had cancer. I would like to ask you a few more questions about your cancer.
1. How many different types of cancer have you had?
1 Only one
2 Two
3 Three or more
7 Don’t know / Not sure [Go to next module]
9 Refused [Go to next module]
2. At what age were you told that you had cancer?
_ _ Code age in years [97 = 97 and older]
CATI note: If Q1= 2 (Two) or 3 (Three or more), ask: “At what age were you first diagnosed with cancer?”
INTERVIEWER NOTE: This question refers to the first time they were told about their first cancer.
CATI note: If Core Q6.6 = 1 (Yes) and Q1 = 1 (Only one): ask “Was it “Melanoma” or “other skin cancer”? then code 21 if “Melanoma” or 22 if “other skin cancer”
CATI note: If Core Q16.6 = 4 (Because you were told you had Prostate Cancer) and Q1 = 1 (Only one) then code 19.
3. What type of cancer was it?
If Q1 = 2 (Two) or 3 (Three or more), ask: “With your most recent diagnoses of cancer, what type of cancer was it?”
INTERVIEWER NOTE: Please read list only if respondent needs prompting for cancer type (i.e., name of cancer) [1-30]:
Breast
0 1 Breast cancer
Female reproductive (Gynecologic)
0 2 Cervical cancer (cancer of the cervix)
0 3 Endometrial cancer (cancer of the uterus)
0 4 Ovarian cancer (cancer of the ovary)
Head/Neck
0 5 Head and neck cancer
0 6 Oral cancer
0 7 Pharyngeal (throat) cancer
0 8 Thyroid
0 9 Larynx
Gastrointestinal
1 0 Colon (intestine) cancer
1 1 Esophageal (esophagus)
1 2 Liver cancer
1 3 Pancreatic (pancreas) cancer
1 4 Rectal (rectum) cancer
1 5 Stomach
Leukemia/Lymphoma (lymph nodes and bone marrow)
1 6 Hodgkin's Lymphoma (Hodgkin’s disease)
1 7 Leukemia (blood) cancer
1 8 Non-Hodgkin’s Lymphoma
Male reproductive
1 9 Prostate cancer
2 0 Testicular cancer
Skin
2 1 Melanoma
2 2 Other skin cancer
Thoracic
2 3 Heart
2 4 Lung
Urinary cancer:
2 5 Bladder cancer
2 6 Renal (kidney) cancer
Others
2 7 Bone
2 8 Brain
2 9 Neuroblastoma
3 0 Other
Do not read:
7 7 Don’t know / Not sure
9 9 Refused
4. Are you currently receiving treatment for cancer? By treatment, we mean surgery, radiation therapy, chemotherapy, or chemotherapy pills.
2 No, I’ve completed treatment
3 No, I’ve refused treatment [Go to next module]
4 No, I haven’t started treatment [Go to next module]
7 Don’t know / Not sure [Go to next module]
5. What type of doctor provides the majority of your health care?
INTERVIEWER NOTE: If the respondent requests clarification of this question, say: “We want to know which type of doctor you see most often for illness or regular health care (Examples: annual exams and/or physicals, treatment of colds, etc.).”
Please read [1-10]:
0 5 General Practitioner, Internist
0 6 Plastic Surgeon, Reconstructive Surgeon
6. Did any doctor, nurse, or other health professional EVER give you a written summary of all the cancer treatments that you received?
Read only if necessary: “By ‘other healthcare professional’, we mean a nurse practitioner, a physician’s assistant, social worker, or some other licensed
professional.”
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
7. Have you EVER received instructions from a doctor, nurse, or other health professional about where you should return or who you should see for routine cancer check-ups after completing your treatment for cancer?
1 Yes
2 No [Go to Q9]
7 Don’t know / Not sure [Go to Q9]
9 Refused [Go to Q9]
8. Were these instructions written down or printed on paper for you?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
9. With your most recent diagnosis of cancer, did you have health insurance that paid for all or part of your cancer treatment?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
INTERVIEWER NOTE: “Health insurance” also includes Medicare, Medicaid, or other types of state health programs.
10. Were you EVER denied health insurance or life insurance coverage because of your cancer?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
11. Did you participate in a clinical trial as part of your cancer treatment?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
12. Do you currently have physical pain caused by your cancer or cancer treatment?
1 Yes
2 No [Go to next module]
7 Don’t know / Not sure [Go to next module]
9 Refused [Go to next module]
13. Is your pain currently under control?
Please read:
Yes, with medication (or treatment)
Yes, without medication (or treatment)
No, with medication (or treatment)
No, without medication (or treatment)
Do not read:
7 Don’t know / Not sure
Cardiovascular Health
I would like to ask you a few more questions about your cardiovascular or heart health.
CATI NOTE: If Core Q6.1 = 1 (Yes), ask Q1. If Core Q6.1 = 2, 7, or 9 (No, Don’t know, or Refused),
skip Q1.
Following your heart attack, did you go to any kind of outpatient rehabilitation? This is
sometimes called "rehab."
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
CATI NOTE: If Core Q6.3 = 1 (Yes), ask Q2. If Core Q6.3 = 2, 7, or 9 (No, Don’t know, or Refused), skip Q2.
Following your stroke, did you go to any kind of outpatient rehabilitation? This is
sometimes called "rehab."
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
Interviewer NOTE: Question 3 is asked for all respondents
3. Do you take aspirin daily or every other day?
Interviewer NOTE: Aspirin can be prescribed by a health care provider or obtained as an over-the-counter (OTC) medication.
1 Yes [Go to question 5]
2 No
7 Don’t know / Not sure
9 Refused
4. Do you have a health problem or condition that makes taking aspirin unsafe for you?
If "Yes," ask "Is this a stomach condition?” Code upset stomach as stomach problems.
1 Yes, not stomach related [Go to next module]
2 Yes, stomach problems [Go to next module]
3 No [Go to next module]
7 Don’t know / Not sure [Go to next module]
9 Refused [Go to next module]
5. Do you take aspirin to relieve pain?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
6. Do you take aspirin to reduce the chance of a heart attack?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
7. Do you take aspirin to reduce the chance of a stroke?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
Caregiver Module
People may provide regular care or assistance to a friend or family member who has a health problem or disability.
During the past 30 days, did you provide regular care or assistance to a friend or family member who has a health problem or disability?
Yes
No [Go to Question 9]
7 Don’t know/Not sure
9 Refused
CATI NOTE: If caregiving recipient has died in the past 30 days, say “I’m so sorry to hear of your loss.” and skip to the next module.
What is his or her relationship to you? For example is he or she your (mother or daughter or father or son)?
[DO NOT READ; CODE RESPONSE USING THESE CATEGORIES]
Mother
Father
Mother-in-law
Father-in-law
Child
Husband
Wife
Same-sex partner
Brother or brother-in-law
Sister or sister-in-law
Grandmother
Grandfather
Grandchild
Other relative
Non-relative/Family friend
77 Don’t know/Not sure
99 Refused
For how long have you provided care for that person? Would you say…
1 Less than 30 days
2 1 month to less than 6 months
3 6 months to less than 2 years
4 2 years to less than 5 years
5 More than 5 years
7 Don’t Know/ Not Sure
9 Refused
In an average week, how many hours do you provide care or assistance? Would you say…
Up to 8 hours per week
9 to 19 hours per week
20 to 39 hours per week
40 hours or more
7 Don’t know/Not sure
9 Refused
What is the main health problem, long-term illness, or disability that the person you care for has?
IF NECESSARY: Please tell me which one of these conditions would you say is the major problem?
[DO NOT READ: RECORD ONE RESPONSE]
Arthritis/Rheumatism
Asthma
Cancer
Chronic respiratory conditions such as Emphysema or COPD
Dementia and other Cognitive Impairment Disorders
Developmental Disabilities such as Autism, Down’s Syndrome, and Spina Bifida
Diabetes
Heart Disease, Hypertension
Human Immunodeficiency Virus Infection (HIV)
Mental Illnesses, such as Anxiety, Depression, or Schizophrenia
Other organ failure or diseases such as kidney or liver problems
Substance Abuse or Addiction Disorders
Other
Don’t know/Not sure
99
Refused
In the past 30 days, did you provide care for this person by…
…Managing personal care such as giving medications, feeding, dressing, or bathing?
1 Yes
2 No
7 Don’t Know /Not Sure
9 Refused
7. In the past 30 days, did you provide care for this person by…
…Managing household tasks such as cleaning, managing money, or preparing meals?
1 Yes
2 No
7 Don’t Know /Not Sure
9 Refused
8. Of the following support services, which one do you MOST need, that you are not currently getting?
[INTERVIEWER NOTE: IF RESPONDENT ASKS WHAT RESPITE CARE IS]: Respite care means short-term or long-term breaks for people who provide care.
[READ OPTIONS 1 – 6]
Classes about giving care, such as giving medications
Help in getting access to services
Support groups
Individual counseling to help cope with giving care
Respite care
You don’t need any of these support services
[DO NOT READ]
7 Don’t Know /Not Sure
9 Refused
[If Q1 = YES, GO TO NEXT MODULE]
9. In the next 2 years, do you expect to provide care or assistance to a friend or family member who has a health problem or disability?
1 Yes
2 No
7 Don’t know/Not sure
9 Refused
Childhood Asthma Prevalence
CATI NOTE: If response to Core Q7.16 = 88 (None) or 99 (Refused), go to next module.
The next two questions are about the “Xth” [CATI: please fill in correct number] child.
1. Has a doctor, nurse or other health professional EVER said that the child has asthma?
1 Yes
2 No [Go to next module]
7 Don’t know / Not sure [Go to next module]
9 Refused [Go to next module]
2. Does the child still have asthma?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
CATI note: If Core Q7.7 = 88, or 99 (No children under age 18 in the household, or Refused), go to next module.
CATI note: If selected child’s age is ≥ 6 months, continue. Otherwise, go to next module.
1. Now I will ask you questions about seasonal flu. There are two types of seasonal flu vaccinations. One is a shot and the other is a spray in the nose. During the past 12 months, has [Fill: he/she] had a seasonal flu vaccination?
1 Yes
2 No [Go to next module]
7 Don’t know / Not sure [Go to next module]
9 Refused [Go to next module]
2. The flu vaccination may have been either the flu shot or the flu spray. The flu spray is the flu vaccination that is sprayed in the nose. During what month and year did [Fill: he/she] receive [Fill: his/her] most recent seasonal flu vaccination?
_ _ / _ _ _ _ Month / Year
7 7 / 7 7 7 7 Don’t know / Not sure
9 9 / 9 9 9 9 Refused
Clinical Breast Examination for Breast Cancer Screening
A clinical breast exam is when a doctor, nurse, or other health professional feels the breasts for lumps. Have you ever had a clinical breast exam?
Yes
2 No [Go to next module]
7 Don’t know / Not sure [Go to next module]
9 Refused [Go to next module]
How long has it been since your last breast exam?
1 Within the past year (anytime less than 12 months ago)
2 Within the past 2 years (1 year but less than 2 years ago)
3 Within the past 3 years (2 years but less than 3 years ago)
4 Within the past 5 years (3 years but less than 5 years ago)
5 5 or more years ago
7 Don’t know / Not sure
9 Refused
Chronic Obstructive Pulmonary Disease (COPD)
CATI NOTE: If core Q5.8 = 1 (Yes) then continue, else go to next module.
Earlier you said that you had been diagnosed with Chronic Obstructive Pulmonary Disease or COPD.
1. Have you ever been given a breathing test to diagnose your COPD, chronic bronchitis, or emphysema?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
2. Would you say that shortness of breath affects the quality of your life?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
3. Other than a routine visit, have you had to see a doctor in the past 12 months for symptoms related to shortness of breath, bronchitis, or other COPD, or emphysema flare?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
4. Did you have to visit an emergency room or be admitted to the hospital in the past 12 months because of your COPD, chronic bronchitis, or emphysema?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
5. How many different medications do you currently take each day to help with your COPD, chronic bronchitis, or emphysema?
_ _ Number (01-76)
7 7 Don’t know / Not sure
8 8 None
9 9 Refused
Cognitive Decline Module
CATI Note: If respondent is 45 years of age or older continue, else go to next module
Introduction: The next few questions ask about difficulties in thinking or remembering that can make a big difference in everyday activities. This does not refer to occasionally forgetting your keys or the name of someone you recently met, which is normal. This refers to confusion or memory loss that is happening more often or getting worse, such as forgetting how to do things you’ve always done or forgetting things that you would normally know. We want to know how these difficulties impact you.
1. During the past 12 months, have you experienced confusion or memory loss that is happening more often or is getting worse?
1 Yes
2 No [Go to next module]
7 Don't know [Go to Q2]
9 Refused [Go to next module]
2.
During the past 12 months, as a result of confusion or memory loss,
how often have you given up day-to-day household activities or
chores you used to do, such as cooking, cleaning, taking
medications, driving, or paying bills?
1 Always
2 Usually
3 Sometimes
4 Rarely
5 Never
7 Don't know
9 Refused
3. As a result of confusion or memory loss, how often do you need assistance with these day-to-day activities?
1 Always
2 Usually
3 Sometimes
4 Rarely [Go to Q6]
5 Never [Go to Q6]
7 Don't know
9 Refused
CATI NOTE: If Q3 = 1, 2, or 3, continue. If Q3 = 4 or 5, go to Q5.
4. When you need help with these day-to-day activities, how often are you able to get the help that you need?
1 Always
2 Usually
3 Sometimes
4 Rarely
5 Never
7 Don't know
9 Refused
5. During the past 12 months, how often has confusion or memory loss interfered with your ability to work, volunteer, or engage in social activities outside the home?
1 Always
2 Usually
3 Sometimes
4 Rarely
5 Never
7 Don't know
9 Refused
6. Have you or anyone else discussed your confusion or memory loss with a health care professional?
1 Yes
2 No
7 Don't know
9 Refused
Colorectal Cancer Screening
CATI NOTE: If respondent is < 49 years of age, go to next section.
The next questions are about colorectal cancer screening.
1. A blood stool test is a test that may use a special kit at home to determine whether the stool contains blood. Have you ever had this test using a home kit?
1 Yes
2 No [Go to Q3]
7 Don't know / Not sure [Go to Q3]
9 Refused [Go to Q3]
2. How long has it been since you had your last blood stool test using a home kit?
Read only if necessary:
1 Within the past year (anytime less than 12 months ago)
2 Within the past 2 years (1 year but less than 2 years ago)
3 Within the past 3 years (2 years but less than 3 years ago)
4 Within the past 5 years (3 years but less than 5 years ago)
5 5 or more years ago
Do not read:
Don't know / Not sure
9 Refused
3. 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. Have you ever had either
of these exams?
1 Yes
2 No [Go to next section]
7 Don’t know / Not sure [Go to next section]
9 Refused [Go to next section]
4. For a SIGMOIDOSCOPY, a flexible tube is inserted into the rectum to look for problems.
A COLONOSCOPY is similar, but uses a longer tube, and you are usually given medication through a needle in your arm to make you sleepy and told to have someone else drive you home after the test. Was your MOST RECENT exam a sigmoidoscopy or
a colonoscopy?
Sigmoidoscopy
Colonoscopy
7 Don’t know / Not sure
9 Refused
5. How long has it been since you had your last sigmoidoscopy or colonoscopy?
Read only if necessary:
1 Within the past year (anytime less than 12 months ago)
2 Within the past 2 years (1 year but less than 2 years ago)
3 Within the past 3 years (2 years but less than 3 years ago)
4 Within the past 5 years (3 years but less than 5 years ago)
5 Within the past 10 years (5 years but less than 10 years ago)
6 10 or more years ago
Do not read:
7 Don't know / Not sure
9 Refused
Diabetes
To be asked following Core Q6.12; if response is "Yes" (code = 1)
1. Are you now taking insulin?
1 Yes
2 No
9 Refused
2. About how often do you check your blood for glucose or sugar? Include times when checked by a family member or friend, but do NOT include times when checked by a health professional.
1 _ _ Times per day
2 _ _ Times per week
3 _ _ Times per month
4 _ _ Times per year
8 8 8 Never
7 7 7 Don’t know / Not sure
9 9 9 Refused
3. About how often do you check your feet for any sores or irritations? Include times when checked by a family member or friend, but do NOT include times when checked by a health professional.
1 _ _ Times per day
2 _ _ Times per week
3 _ _ Times per month
4 _ _ Times per year
5 5 5 No feet
8 8 8 Never
7 7 7 Don’t know / Not sure
9 9 9 Refused
4. About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?
_ _ Number of times [76 = 76 or more]
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
5. A test for "A one C" measures the average level of blood sugar over the past three
months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for "A one C"?
_ _ Number of times [76 = 76 or more]
8 8 None
9 8 Never heard of “A one C” test
7 7 Don’t know / Not sure
9 9 Refused
CATI NOTE: If Q3 = 555 (No feet), go to Q8.
CATI NOTE: If Q3 = 555 (No feet), go to Q8.
6. About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?
_ _ Number of times [76 = 76 or more]
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
7. When was the last time you had an eye exam in which the pupils were dilated? This would have made you temporarily sensitive to bright light.
Read only if necessary:
1 Within the past month (anytime less than 1 month ago)
2 Within the past year (1 month but less than 12 months ago)
3 Within the past 2 years (1 year but less than 2 years ago)
4 2 or more years ago
Do not read:
Don’t know / Not sure
Never
9 Refused
8. Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
9. Have you ever taken a course or class in how to manage your diabetes yourself?
1 Yes
2 No
7 Don't know / Not sure
9 Refused
Emotional Support and Life Satisfaction
The next two questions are about emotional support and your satisfaction with life.
1. How often do you get the social and emotional support you need?
INTERVIEWER NOTE: If asked, say “please include support from any source.”
Please read:
1 Always
2 Usually
3 Sometimes
4 Rarely
5 Never
Do not read:
7 Don't know / Not sure
9 Refused
2. In general, how satisfied are you with your life?
Please read:
1 Very satisfied
2 Satisfied
3 Dissatisfied
4 Very dissatisfied
Do not read:
7 Don't know / Not sure
9 Refused
1. In the past 12 months, how many times did you have a red OR painful sunburn that
lasted a day or more?
8 Zero
1 One
2 Two
3 Three
4 Four
5 Five or more
7 Don’t know / Not sure
9 Refused
General Preparedness
The next series of questions asks about how prepared you are for a large-scale disaster or emergency. By large-scale disaster or emergency we mean any event that leaves you isolated in your home or displaces you from your home for at least 3 days. This might include natural disasters such as hurricanes, tornados, floods, and ice storms, or man-made disasters such as explosions, terrorist events, or blackouts.
1. How well prepared do you feel your household is to handle a large-scale disaster or emergency? Would you say…
Please read:
1 Well prepared
2 Somewhat prepared
3 Not prepared at all
Do not read:
7 Don’t know / Not sure
9 Refused
2. Does your household have a 3-day supply of water for everyone who lives there? A 3-day supply of water is 1 gallon of water per person per day.
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
3. Does your household have a 3-day supply of nonperishable food for everyone who lives there? By nonperishable we mean food that does not require refrigeration or cooking.
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
4. Does your household have a 3-day supply of prescription medication for each person who takes prescribed medicines?
1 Yes
2 No
3 No one in household requires prescribed medicine
7 Don’t know / Not sure
9 Refused
5. Does your household have a working battery operated radio and working batteries for your use if the electricity is out?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
6. Does your household have a working flashlight and working batteries for your use if the electricity is out?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
7. In a large-scale disaster or emergency, what would be your main method or way of
communicating with relatives and friends?
Read only if necessary:
1 Regular home telephones
2 Cell phones
3 Email
4 Pager
5 2-way radios
6 Other
Do not read:
7 Don’t know / Not sure
9 Refused
8. What would be your main method or way of getting information from authorities in a large-scale disaster or emergency?
Read only if necessary:
1 Television
2 Radio
3 Internet
4 Print media
5 Neighbors
6 Other
Do not read:
7 Don’t know / Not sure
9 Refused
9. Does your household have a written disaster evacuation plan for how you will leave your home, in case of a large-scale disaster or emergency that requires evacuation?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
10. If public authorities announced a mandatory evacuation from your community due to a large-scale disaster or emergency, would you evacuate?
1 Yes [Go to next module]
2 No
7 Don’t know / Not sure
9 Refused
11. What would be the main reason you might not evacuate if asked to do so?
Read only if necessary:
0 1 Lack of transportation
0 2 Lack of trust in public officials
0 3 Concern about leaving property behind
0 4 Concern about personal safety
0 5 Concern about family safety
0 6 Concern about leaving pets
0 7 Concern about traffic jams and inability to get out
0 8 Health problems (could not be moved)
0 9 Other
Do not read:
7 7 Don’t know / Not sure
9 9 Refused
1. Do you have Medicare?
Yes
No
Don’t know/Not sure
9 Refused
Note: Medicare is a coverage plan for people age 65 or over and for certain disabled people.
2. What is the primary source of your health care coverage? Is it…
Please Read
01 A plan purchased through an employer or union (includes plans purchased through another person's employer)
02 A plan that you or another family member buys on your own
03 Medicare
04 Medicaid or other state program
05 TRICARE (formerly CHAMPUS), VA, or Military
06 Alaska Native, Indian Health Service, Tribal Health Services
Or
07 Some other source
08 None (no coverage)
Do not read:
Don't know/Not sure
99 Refused
INTERVIEWER NOTE: If the respondent indicates that they purchased health insurance through the Health Insurance Marketplace (name of state Marketplace), ask if it was a private health insurance plan purchased on their own or by a family member (private) or if they received Medicaid (state plan)? If purchased on their own (or by a family member), select 02, if Medicaid select 04.
CATI NOTE: If PPHF State, go to Core Q3.2.
3. Other than cost, there are many other reasons people delay getting needed medical care.
Have you delayed getting needed medical care for any of the following reasons in the past 12 months? Select the most important reason.
Please read
1 You couldn’t get through on the telephone.
2 You couldn’t get an appointment soon enough.
3 Once you got there, you had to wait too long to see the doctor.
4 The (clinic/doctor’s) office wasn’t open when you got there.
5 You didn’t have transportation.
Do not read:
Other ____________ (specify)
8 No, I did not delay getting medical care/did not need medical care
7 Don’t know/Not sure
9 Refused
CATI NOTE: If PPHF State, go to Core Q3.4.
CATI NOTE: If Q3.1 = 1 (Yes) continue, else go to Q4b.
4a. In the PAST 12 MONTHS was there any time when you did NOT have ANY health
insurance or coverage?
1 Yes [Go to Q5]
2 No [Go to Q5]
7 Don’t know/Not sure [Go to Q5]
9 Refused [Go to Q5]
CATI Note: If Q3.1 = 2, 7, or 9 continue, else go to next question (Q5).
4b. About how long has it been since you last had health care coverage?
1 6 months or less
2 More than 6 months, but not more than 1 year ago
3 More than 1 year, but not more than 3 years ago
4 More than 3 years
5 Never
7 Don’t know/Not sure
9 Refused
5. How many times have you been to a doctor, nurse, or other health professional in the past 12 months?
_ _ Number of times
8 8 None
7 7 Don’t know/Not sure
9 9 Refused
6. Was there a time in the past 12 months when you did not take your medication as prescribed because of cost? Do not include over-the-counter (OTC) medication.
1 Yes
2 No
Do not read:
3 No medication was prescribed.
7 Don’t know/Not sure
9 Refused
7. In general, how satisfied are you with the health care you received? Would you say—
Please read:
1 Very satisfied
2 Somewhat satisfied
3 Not at all satisfied
Do not read:
8 Not applicable
7 Don’t know/Not sure
9 Refused
8. Do you currently have any health care bills that are being paid off over time?
INTERVIEWER NOTE:
This could include medical bills being paid off with a credit card, through personal loans, or bill paying arrangements with hospitals or other providers. The bills can be from earlier years as well as this year.
INTERVIEWER NOTE: Health care bills can include medical, dental, physical therapy and/or chiropractic cost.
1 Yes
2 No
7 Don’t know/Not sure
9 Refused
CATI NOTE: If PPHF state, Go to Core Section 4.
Healthy Days (Symptoms)
The next few questions are about health-related problems or symptoms.
1. During the past 30 days, for about how many days did pain make it hard for you to do your usual activities, such as self-care, work, or recreation?
_ _ Number of days
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
2. During the past 30 days, for about how many days have you felt sad, blue, or depressed?
_ _ Number of days
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
3. During the past 30 days, for about how many days have you felt worried, tense, or anxious?
_ _ Number of days
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
4. During the past 30 days, for about how many days have you felt very healthy and full of energy?
_ _ Number of days
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
The next few questions ask about health care work and chronic illness.
1. Do you currently volunteer or work in a hospital, medical clinic, doctor’s office, dentist’s
office, nursing home or some other health-care facility? This includes part-time and
unpaid work in a health care facility as well as professional nursing care provided in the
home.
INTERVIEWER NOTE: If necessary say: “This includes non-health care professionals, such as administrative staff, who work in a health-care facility.”
1 Yes
2 No [Go to Q3]
7 Don’t know / Not sure [Go to Q3]
9 Refused [Go to Q3]
2. 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 Yes
2 No
7 Don’t know / Not sure (Probe by repeating question)
9 Refused
3. Has a doctor, nurse, or other health professional ever said that you have…
Read all items listed below before waiting for an answer:
Lung problems, other than asthma
Kidney problems
Anemia, including Sickle Cell
Or
A weakened immune system caused by a chronic illness or by medicines taken for a chronic illness?
[See Attached Health Problems List, if necessary]
1 Yes
2 No [Go to next module]
7 Don’t know / Not sure [Go to next module]
9 Refused [Go to next module]
4. Do you still have (this/any of these) problem(s)?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
HIV/AIDS
CATI NOTE: If Core Q18.1 = 1 (Yes) continue, else go to next module.
1. Where did you have your last HIV test — at a private doctor or HMO office, at a counseling and testing site, at a hospital, at a clinic, in a jail or prison, at a drug treatment
facility, at home, or somewhere else?
0 1 Private doctor or HMO office
0 2 Counseling and testing site
0 3 Hospital
0 4 Clinic
0 5 Jail or prison (or other correctional facility)
0 6 Drug treatment facility
0 7 At home
0 8 Somewhere else
7 7 Don’t know / Not sure
9 9 Refused
CATI NOTE: If Core Q18.2 = within last 12 months continue, else go to next module.
2. Was it a rapid test where you could get your results within a couple of hours?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
Inadequate Sleep
I would like to ask you a few questions about your sleep patterns.
1. During the past 30 days, for about how many days have you felt you did not get enough rest or
sleep?
_ _ Number of days
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
2. On average, how many hours of sleep do you get in a 24-hour period? Think about the
time you actually spend sleeping or napping, not just the amount of sleep you think you
should get.
INTERVIEWER NOTE: 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.
_ _ Number of hours [01-24]
7 7 Don’t know / Not sure
9 9 Refused
3. Do you snore?
INTERVIEWER NOTE: If the respondent indicates that their spouse or someone told him/her that they snore, then the answer to the question is "Yes,” the respondent snores.
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
4. During the past 30 days, for about how many days did you find yourself unintentionally
falling asleep during the day?
_ _ Number of days [01-30]
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
5. During the past 30 days, have you ever nodded off or fallen asleep, even just for a brief
moment, while driving?
1 Yes
2 No
3 Don’t drive
4 Don’t have license
7 Don’t know / Not sure
9 Refused
Industry and Occupation
If Core Q7.15 = 1 or 4 (Employed for wages or out of work for less than 1 year) or 2 (Self-employed), continue else go to next module.
Now I am going to ask you about your work.
If Core Q7.15 = 1 (Employed for wages) or 2 (Self-employed) ask,
1. What kind of work do you do? (for example, registered nurse, janitor, cashier, auto mechanic)
INTERVIEWER NOTE: If respondent is unclear, ask “What is your job title?”
INTERVIEWER NOTE: If respondent has more than one job then ask, “What is your main job?”
[Record answer] _________________________________
99 Refused
Or
If Core Q7.15 = 4 (Out of work for less than 1 year) ask,
What kind of work did you do? (for example, registered nurse, janitor, cashier, auto mechanic)
INTERVIEWER NOTE: If respondent is unclear, ask “What was your job title?”
INTERVIEWER NOTE: If respondent had more than one job then ask, “What was your main job?”
[Record answer] _________________________________
99 Refused
If Core Q7.15 = 1 (Employed for wages) or 2 (Self-employed) ask,
2. What kind of business or industry do you work in? (for example, hospital, elementary school, clothing manufacturing, restaurant)
[Record answer] _________________________________
99 Refused
Or
If Core Q7.9 = 4 (Out of work for less than 1 year) ask,
What kind of business or industry did you work in? (for example, hospital, elementary school, clothing manufacturing, restaurant)
[Record answer] _________________________________
99 Refused
CATI Note: If Q11.1 = 1 (Yes) then continue, else go to next module.
Earlier, you told me you had received an influenza vaccination in the past 12 months.
Please read only if necessary:
At what kind of place did you get your last flu shot/vaccine?
0 1 A doctor’s office or health maintenance organization (HMO)
0 2 A health department
0 3 Another type of clinic or health center (Example: a community health center)
0 4 A senior, recreation, or community center
0 5 A store (Examples: supermarket, drug store)
0 6 A hospital (Example: inpatient)
0 7 An emergency room
0 8 Workplace
0 9 Some other kind of place
1 0 Received vaccination in Canada/Mexico (Volunteered – Do not read)
1 1 A school
7 7 Don’t know / Not sure (Probe: “How would you describe the place where you went to get your most recent flu vaccine?”
Do not read:
9 9 Refused
Now, I am going to ask you some questions about how you have been feeling lately.
1. About how often during the past 30 days did you feel nervous — would you say all of the
time, most of the time, some of the time, a little of the time, or none of the time?
1 All
2 Most
3 Some
4 A little
5 None
7 Don’t know / Not sure
9 Refused
2. During the past 30 days, about how often did you feel hopeless — all of the time, most of the time, some of the time, a little of the time, or none of the time?
1 All
2 Most
3 Some
4 A little
5 None
7 Don’t know / Not sure
9 Refused
3. During the past 30 days, about how often did you feel restless or fidgety?
[If necessary: all, most, some, a little, or none of the time?]
1 All
2 Most
3 Some
4 A little
5 None
7 Don’t know / Not sure
9 Refused
4. During the past 30 days, about how often did you feel so depressed that nothing could
cheer you up?
[If necessary: all, most, some, a little, or none of the time?]
1 All
2 Most
3 Some
4 A little
5 None
7 Don’t know / Not sure
9 Refused
5. During the past 30 days, about how often did you feel that everything was an effort?
Note: If respondent asks what does “everything was an effort” means; say, “Whatever it means to you”
[If necessary: all, most, some, a little, or none of the time?]
1 All
2 Most
3 Some
4 A little
5 None
7 Don’t know / Not sure
9 Refused
6. During the past 30 days, about how often did you feel worthless?
[If necessary: all, most, some, a little, or none of the time?]
1 All
2 Most
3 Some
4 A little
5 None
7 Don’t know / Not sure
9 Refused
7. During the past 30 days, for about how many days did a mental health condition or emotional problem keep you from doing your work or other usual activities?
_ _ Number of days
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
INTERVIEWER NOTE: If asked, "usual activities" includes housework, self-care, care giving, volunteer work, attending school, studies, or recreation.
8. Are you now taking medicine or receiving treatment from a doctor or other health
professional for any type of mental health condition or emotional problem?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
These next questions ask about peoples' attitudes toward mental illness and its treatment.
9. Treatment can help people with mental illness lead normal lives. Do you –agree slightly
or strongly, or disagree slightly or strongly?
Read only if necessary:
1 Agree strongly
2 Agree slightly
3 Neither agree nor disagree
4 Disagree slightly
5 Disagree strongly
Do not read:
7 Don’t know / Not sure
9 Refused
10. People are generally caring and sympathetic to people with mental illness. Do you –
agree slightly or strongly, or disagree slightly or strongly?
Read only if necessary:
1 Agree strongly
2 Agree slightly
3 Neither agree nor disagree
4 Disagree slightly
5 Disagree strongly
Do not read:
Don’t know / Not sure
9 Refused
INTERVIEWER NOTE: If asked for the purpose of Q9 or Q10: say: “answers to these questions will be used by health planners to help understand public attitudes about mental illness and its treatment and to help guide health education programs”.
Pre-Diabetes
NOTE: Only asked of those not responding “Yes” (code = 1) to Core Q6.12 (Diabetes awareness question).
1. Have you had a test for high blood sugar or diabetes within the past three years?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
CATI note: If Core Q6.12 = 4 (No, pre-diabetes or borderline diabetes); answer Q2 “Yes” (code = 1).
2 Have you ever been told by a doctor or other health professional that you have pre-diabetes or borderline diabetes?
If “Yes” and respondent is female, ask: “Was this only when you were pregnant?”
1 Yes
2 Yes, during pregnancy
3 No
7 Don’t know / Not sure
9 Refused
Prostate Cancer Screening
CATI NOTE: If respondent is <39 years of age, or is female, go to next section.
Now, I will ask you some questions about prostate cancer screening.
A Prostate-Specific Antigen test, also called a PSA test, is a blood test used to check
men for prostate cancer. Has a doctor, nurse, or other health professional EVER talked with you about the advantages of the PSA test?
1 Yes
2 No
7 Don’t Know / Not sure
9 Refused
Has a doctor, nurse, or other health professional EVER talked with you about the
disadvantages of the PSA test?
1 Yes
2 No
7 Don’t Know / Not sure
9 Refused
3. Has a doctor, nurse, or other health professional EVER recommended that you have a PSA test?
Yes
No
7 Don’t Know / Not sure
9 Refused
4. Have you EVER HAD a PSA test?
Yes
No [Go to next section]
7 Don’t Know / Not sure [Go to next section]
9 Refused [Go to next section]
5. How long has it been since you had your last PSA test?
Read only if necessary:
1 Within the past year (anytime less than 12 months ago)
2 Within the past 2 years (1 year but less than 2 years)
3 Within the past 3 years (2 years but less than 3 years)
4 Within the past 5 years (3 years but less than 5 years)
5 5 or more years ago
Do not read:
7 Don’t know / Not sure
9 Refused
6. What was the MAIN reason you had this PSA test – was it …?
Please read:
1 Part of a routine exam
2 Because of a prostate problem
3 Because of a family history of prostate cancer
4 Because you were told you had prostate cancer
5 Some other reason
Do Not Read:
7 Don’t know / Not sure
9 Refused
Prostate Cancer Screening Decision Making Module
CATI NOTE: If module 15, question 4 = 1 (has had a PSA test) continue, else go to next module.
Which one of the following best describes the decision to have the PSA test done? Please read:
You made the decision alone [Go to next module]
Your doctor, nurse, or health care provider made the decision alone
[Go to next module]
You and one or more other persons made the decision together
4 You don’t remember how the decision was made [Go to next module]
Do not read:
9 Refused
Who made the decision with you? (Mark all that apply)
Doctor/nurse /health care provider
Spouse/significant other
Other family member
Friend/non-relative
8 No additional choices
7 Don’t know / Not sure
9 Refused
CATI NOTE: If Core Q7.16 = 88, or 99 (No children under age 18 in the household, or Refused), go to next module.
If Core Q7.16 = 1, Interviewer please read: “Previously, you indicated there was one child age 17 or younger in your household. I would like to ask you some questions about that child.” [Go to Q1]
If Core Q7.16 is >1 and Core Q7.16 does not equal 88 or 99, Interviewer please read: “Previously, you indicated there were [number] children age 17 or younger in your household. Think about those [number] children in order of their birth, from oldest to youngest. The oldest child is the first child and the youngest child is the last. Please include children with the same birth date, including twins, in the order of their birth.”
CATI INSTRUCTION: RANDOMLY SELECT ONE OF THE CHILDREN. This is the “Xth” child. Please substitute “Xth” child’s number in all questions below.
INTERVIEWER PLEASE READ:
I have some additional questions about one specific child. The child I will be referring to is the “Xth” [CATI: please fill in correct number] child in your household. All following questions about children will be about the “Xth” [CATI: please fill in] child.
1. What is the birth month and year of the “Xth” child?
_ _ /_ _ _ _ Code month and year
7 7/ 7 7 7 7 Don’t know / Not sure
9 9/ 9 9 9 9 Refused
CATI INSTRUCTION: Calculate the child’s age in months (CHLDAGE1=0 to 216) and also in years (CHLDAGE2=0 to 17) based on the interview date and the birth month and year using a value of 15 for the birth day. If the selected child is < 12 months old enter the calculated months in CHLDAGE1 and 0 in CHLDAGE2. If the child is > 12 months enter the calculated months in CHLDAGE1 and set CHLDAGE2=Truncate (CHLDAGE1/12).
2. Is the child a boy or a girl?
1 Boy
2 Girl
9 Refused
3. Is the child Hispanic, Latino/a, or Spanish origin?
If yes, ask: Are they…
Interviewer NOTE: One or more categories may be selected
1 Mexican, Mexican American, Chicano/a
2 Puerto Rican
3 Cuban
4 Another Hispanic, Latino/a, or Spanish origin
Do not read:
5 No
7 Don’t know / Not sure
9 Refused
4. Which one or more of the following would you say is the race of the child?
(Select all that apply)
Interviewer NOTE: If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading.
10 White
20 Black or African American
30 American Indian or Alaska Native
40 Asian
41 Asian Indian
42 Chinese
43 Filipino
44 Japanese
45 Korean
46 Vietnamese
47 Other Asian
50 Pacific Islander
51 Native Hawaiian
52 Guamanian or Chamorro
53 Samoan
54 Other Pacific Islander
Do not read:
60 Other
88 No additional choices
77 Don’t know / Not sure
99 Refused
5. Which one of these groups would you say best represents the child’s race?
Interviewer NOTE: If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading.
10 White
20 Black or African American
30 American Indian or Alaska Native
40 Asian
41 Asian Indian
42 Chinese
43 Filipino
44 Japanese
45 Korean
46 Vietnamese
47 Other Asian
50 Pacific Islander
51 Native Hawaiian
52 Guamanian or Chamorro
53 Samoan
54 Other Pacific Islander
Do not read:
60 Other
88 No additional choices
77 Don’t know / Not sure
99 Refused
6. How are you related to the child?
Please read:
1 Parent (include biologic, step, or adoptive parent)
2 Grandparent
3 Foster parent or guardian
4 Sibling (include biologic, step, and adoptive sibling)
5 Other relative
6 Not related in any way
Do not read:
7 Don’t know / Not sure
9 Refused
Reactions to Race
Earlier I asked you to self-identify your race. Now I will ask you how other people identify you and treat you.
1. How do other people usually classify you in this country? Would you say: White, Black or African American, Hispanic or Latino, Asian, Native Hawaiian or Other Pacific Islander, American Indian or Alaska Native, or some other group?
1 White
2 Black or African American
3 Hispanic or Latino
4 Asian
5 Native Hawaiian or Other Pacific Islander
6 American Indian or Alaska Native
8 Some other group (please specify) _________________________
7 Don’t know / Not sure
9 Refused
INTERVIEWER NOTE: If the respondent requests clarification of this question, say: “We want to know how OTHER people usually classify you in this country, which might be different from how you classify yourself.”
2. How often do you think about your race? Would you say never, once a year, once a
month, once a week, once a day, once an hour, or constantly?
1 Never
2 Once a year
3 Once a month
4 Once a week
5 Once a day
6 Once an hour
8 Constantly
7 Don’t know / Not sure
9 Refused
INTERVIEWER INSTRUCTION: The responses can be interpreted as meaning “at least” the indicated time frequency. If a respondent cannot decide between two categories, check the response for the lower frequency. For example, if a respondent says that they think about their race between once a week and once a month, check “once a month” as the response.
[CATI skip pattern: This question should only be asked of those who are “employed for wages,” “self-employed,” or “out of work for less than one year.”]
3. Within the past 12 months at work, do you feel you were treated worse than, the same as, or better than people of other races?
1 Worse than other races
2 The same as other races
3 Better than other races
Do not read:
4 Worse than some races, better than others
5 Only encountered people of the same race
7 Don’t know / Not sure
9 Refused
4. Within the past 12 months, when seeking health care, do you feel your experiences were worse than, the same as, or better than for people of other races?
1 Worse than other races
2 The same as other races
3 Better than other races
Do not read:
4 Worse than some races, better than others
5 Only encountered people of the same race
6 No health care in past 12 months
7 Don’t know / Not sure
9 Refused
INTERVIEWER NOTE: If the respondent indicates that they do not know about other people’s experiences when seeking health care, say: “This question is asking about your perceptions when seeking health care. It does not require specific knowledge about other people’s experiences.”
5. Within the past 30 days, have you experienced any physical symptoms, for example, a headache, an upset stomach, tensing of your muscles, or a pounding heart, as a result of how you were treated based on your race?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
6. Within the past 30 days, have you felt emotionally upset, for example angry, sad, or frustrated, as a result of how you were treated based on your race?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
Sexual Orientation and Gender Identity
The next two questions are about sexual orientation and gender identity.
INTERVIEWER NOTE: We ask this question in order to better understand the health and health care needs of people with different sexual orientations.
INTERVIEWER NOTE: Please say the number before the text response. Respondent can answer with either the number or the text/word.
1. Do you consider yourself to be:
Please read:
1 1 Straight
2 2 - Lesbian or gay
3 3 - Bisexual
Do not read:
4 Other
Don’t know/Not sure
9 Refused
2. Do you consider yourself to be transgender?
If yes, ask “Do you consider yourself to be 1. male-to-female, 2. female-to-male, or 3. gender non-conforming?
INTERVIEWER NOTE: Please say the number before the “yes” text response. Respondent can answer with either the number or the text/word.
1 Yes, Transgender, male-to-female
2 Yes, Transgender, female to male
3 Yes, Transgender, gender nonconforming
4 No
7 Don’t know/not sure
9 Refused
INTERVIEWER NOTE: If asked about definition of transgender:
Some
people describe themselves as transgender when they experience a
different gender identity from their sex at birth. For example,
a person born into a male body, but who feels female or lives as a
woman would be transgendered.
Some transgender people change their physical appearance so that it
matches their internal gender identity. Some transgender people take
hormones and some have surgery. A transgender person may be of any
sexual orientation – straight, gay, lesbian, or bisexual.
INTERVIEWER NOTE: If asked about definition of gender non-conforming:
Some people think of themselves as gender non-conforming when they do not identify only as a man or only as a woman.
Shingles (Zostavax or ZOS)
CATI NOTE: If respondent is < 49 years of age, go to next section.
The next question is about the Shingles vaccine.
1. Have you ever had the shingles or zoster vaccine?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
INTERVIEWER NOTE (Read if necessary): Shingles is caused by the chicken pox virus. It is an outbreak of rash or blisters on the skin that may be associated with severe pain. A vaccine for shingles has been available since May 2006; it is called Zostavax®, the zoster vaccine, or the shingles vaccine.
Now, I am going to ask you about several factors that can affect a person’s health.
If Core Q7.8 = 1 or 2 (own or rent) continue, else go to Q2.
1. How often in the past 12 months would you say you were worried or stressed
about having enough money to pay your rent/mortgage? Would you say you were worried or stressed---
Please read:
1 Always
2 Usually
3 Sometimes
4 Rarely
5 Never
Do not read:
8 Not applicable
7 Don’t know / Not sure
9 Refused
2. How often in the past 12 months would you say you were worried or stressed about having enough money to buy nutritious meals? Would you say you were worried or
stressed---
Please read:
1 Always
2 Usually
3 Sometimes
4 Rarely
5 Never
Do not read:
8 Not applicable
7 Don’t know / Not sure
9 Refused
If Core Q7.15 = 1 (Employed for wages) or 2 (Self-employed), go to Q3 and Q4.
If Core Q7.15 = 3 (Out of work for 1 year or more), 4 (Out of work for less than 1 year), or
7 (Retired), go to Q5 and Q6.
If Core Q7.15 = 5 (A homemaker), 6 (A student), or 8 (Unable to work), go to Q7.
3. At your main job or business, how are you generally paid for the work you do. Are you:
1 Paid by salary
2 Paid by the hour
3 Paid by the job/task (e.g. commission, piecework)
4 Paid some other way
7 Don’t know / Not sure
9 Refused
INTERVIEWER NOTE: If paid in multiple ways at their main job, select option 4 (Paid some other way).
4. About how many hours do you work per week at all of your jobs and businesses combined?
_ _ Hours (01-96 or more) [Go to Q7]
9 7 Don't know / Not sure [Go to Q7]
9 8 Does not work [Go to Q7]
9 9 Refused [Go to Q7]
5. Thinking about the last time you worked, at your main job or business, how were you
generally paid for the work you did? Were you:
1 Paid by salary
2 Paid by the hour
3 Paid by the job/task (e.g. commission, piecework)
4 Paid some other way
7 Don’t know / Not sure
9 Refused
6. Thinking about the last time you worked, about how many hours did you work per week
at all of your jobs and businesses combined?
_ _ Hours (01-96 or more)
9 7 Don't know / Not sure
9 8 Does not work
9 9 Refused
7. Did you vote in the last presidential election? The November 2012 election between Barack Obama and Mitt Romney.
1 Yes
2 No
8 Not applicable (I did not register, I am not a U.S. citizen, or I am not eligible to vote)
7 Don’t know / Not sure
9 Refused
Sodium or Salt-Related Behavior
Now I would like to ask you some questions about sodium or salt intake.
Most of the sodium or salt we eat comes from processed foods and foods prepared in restaurants. Salt also can be added in cooking or at the table.
1. Are you currently watching or reducing your sodium or salt intake?
1 Yes
2 No [Go to Q3]
7 Don’t know/not sure [Go to Q3]
9 Refused [Go to Q3]
2. How many days, weeks, months, or years have you been watching or reducing your sodium or salt intake?”
1_ _ Day(s)
2_ _ Week(s)
3_ _ Month(s)
4_ _ Year(s)
5 5 5 All my life
7 7 7 Don’t know/not sure
9 9 9 Refused
3. Has a doctor or other health professional ever advised you to reduce sodium or salt intake?
1 Yes
2 No
7 Don’t know/not sure
9 Refused
Sugar Sweetened Drinks and Menu Labeling
Now I would like to ask you some questions about sugary beverages.
1. During the past 30 days, how often did you drink regular soda or pop that contains
sugar? Do not include diet soda or diet pop.
Please read:
You can answer times per day, week, or month: for example, twice a day, once a week, and so forth.
1 _ _ Times per day
2 _ _ Times per week
3 _ _ Times per month
Do not read:
8 8 8 None
7 7 7 Don’t know / Not sure
9 9 9 Refused
2. During the past 30 days, how often did you drink sugar-sweetened fruit drinks (such as Kool-aid and lemonade), sweet tea, and sports or energy drinks (such as Gatorade and Red Bull)? Do not include 100% fruit juice, diet drinks, or artificially sweetened drinks.
Please read: You can answer times per day, week, or month: for example, twice a day, once a week, and so forth.
1 _ _ Times per day
2 _ _ Times per week
3 _ _ Times per month
Do not read:
8 8 8 None
7 7 7 Don’t know / Not sure
9 9 9 Refused
Tetanus Diphtheria (Tdap) (Adults)
Next, I will ask you about the tetanus diphtheria vaccination.
1. Since 2005, have you had a tetanus shot?
If yes, ask: “Was this Tdap, the tetanus shot that also has pertussis or whooping cough vaccine?”
Yes, received Tdap
Yes, received tetanus shot, but not Tdap
Yes, received tetanus shot but not sure what type
No, did not receive any tetanus since 2005
7 Don’t know/Not sure
9 Refused
CATI NOTE: If Core Q7.5 = 1 (Yes) continue, else go to next module.
The next questions relate to veteran’s health.
1. Did you ever serve in a combat or war zone?
1 Yes
2 No
Don’t know / Not sure
9 Refused
2. Has a doctor or other health professional ever told you that you have depression, anxiety, or post traumatic stress disorder (PTSD)?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
3. A traumatic brain injury may result from a violent blow to the head or when an object pierces the skull and enters the brain tissue. Has a doctor or other health professional
ever told you that you have suffered a traumatic brain injury (TBI)?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
4. In the past 12 months, did you receive any psychological or psychiatric counseling or treatment?
Please read:
1 Yes, from a VA facility
2 Yes, from a non-VA facility
3 Yes, from both VA and non-VA facilities
4 No
Do not read:
7 Don’t know / Not sure
9 Refused
The next few questions are a sensitive topic and some people may feel uncomfortable with these questions. At the end of this section, I will give you a phone number for an organization that can provide information and referral for these issues. Please keep in mind that you can ask me to skip any question you do not want to answer.
5. Has there been a time in the past 12 months when you thought of taking your own life?
1 Yes
2 No [Go to next module]
7 Don’t know / Not sure [Go to next module]
9 Refused [Go to next module]
6. During the past 12 months, did you attempt to commit suicide? Would you say---
Please read:
1 Yes, but did not require treatment
2 Yes, was treated at a VA facility
3 Yes, was treated at a non-VA facility
4 No
Do not read:
Don’t know / Not sure
9 Refused
As I mentioned, I would give you a phone number for an organization that can provide information and referral for these issues. You can dial the National Crisis line at 1-800-273-TALK (8255). You can also speak directly to your doctor or health provider.
Visual Impairment and Access to Eye Care
CATI NOTE: If respondent is less than 40 years of age go to next module.
Now I would like to ask you questions about your vision. These questions are for all respondents regardless of whether or not you wear glasses or contact lenses. If you wear glasses or contact lenses, answer questions as if you are wearing them.
1. How much difficulty, if any, do you have in recognizing a friend across the street? Would you say—
Please read:
1 No difficulty
2 A little difficulty
3 Moderate difficulty
4 Extreme difficulty
5 Unable to do because of eyesight
Or
6 Unable to do for other reasons
Do not read:
7 Don’t know / Not sure
8 Not applicable (Blind) [Go to next module]
9 Refused
2. How much difficulty, if any, do you have reading print in newspapers, magazines, recipes, menus, or numbers on the telephone? Would you say—
Please read:
1 No difficulty
2 A little difficulty
3 Moderate difficulty
4 Extreme difficulty
5 Unable to do because of eyesight
Or
6 Unable to do for other reasons
Do not read:
7 Don’t know / Not sure
8 Not applicable (Blind) [Go to next module]
9 Refused
3. When was the last time you had your eyes examined by any doctor or eye care provider?
Read only if necessary:
1 Within the past month (anytime less than 1 month ago) [Go to Q5]
2 Within the past year (1 month but less than 12 months ago) [Go to Q5]
3 Within the past 2 years (1 year but less than 2 years ago)
4 2 or more years ago
5 Never
Do not read:
7 Don’t know / Not sure
8 Not applicable (Blind) [Go to next module]
9 Refused
4. What is the main reason you have not visited an eye care professional in the past 12 months?
Read only if necessary:
0 1 Cost/insurance
0 2 Do not have/know an eye doctor
0 3 Cannot get to the office/clinic (too far away, no transportation)
0 4 Could not get an appointment
0 5 No reason to go (no problem)
0 6 Have not thought of it
0 7 Other
Do not read:
7 7 Don’t know / Not sure
0 8 Not Applicable (Blind) [Go to next module]
9 9 Refused
CATI NOTE: Skip Q5, if any response to Module 1 (Diabetes) Q8.
5. When was the last time you had an eye exam in which the pupils were dilated? This would have made you temporarily sensitive to bright light.
Read only if necessary:
1 Within the past month (anytime less than 1 month ago)
2 Within the past year (1 month but less than 12 months ago)
3 Within the past 2 years (1 year but less than 2 years ago)
4 2 or more years ago
5 Never
Do not read:
7 Don’t know / Not sure
8 Not applicable (Blind) [Go to next module]
9 Refused
6. Do you have any kind of health insurance coverage for eye care?
1 Yes
2 No
7 Don’t know / Not sure
8 Not applicable (Blind) [Go to next module]
9 Refused
7. Have you been told by an eye doctor or other health care professional that you NOW have cataracts?
1 Yes
2 No, I had them removed
3 No
7 Don’t know / Not sure
8 Not applicable (Blind) [Go to next module]
9 Refused
8. Have you EVER been told by an eye doctor or other health care professional that you had glaucoma?
1 Yes
2 No
7 Don’t know / Not sure
8 Not applicable (Blind) [Go to next module]
9 Refused
Please read:
Age-related Macular Degeneration (AMD) is a disease that affects the macula, the part of the eye that allows you to see fine detail.
NOTE: Age-related Macular Degeneration (Age-related Mak·yuh·luh r Di·jen·uh·rey·shuh n)
9. Have you EVER been told by an eye doctor or other health care professional that you had age-related macular degeneration?
1 Yes
2 No
7 Don’t know / Not sure
8 Not applicable (Blind)
9 Refused
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | CDC User |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |