BRFSS Sample Questionnaire

HELLO, I am calling for the (health department) . My name is (name) . We are gathering information about the health of (state) residents. This project is conducted by the health department with assistance from the Centers for Disease Control and Prevention. Your telephone number has been chosen randomly, and I would like to ask some questions about health and health practices.

Is this (phone number) ?

If "No”

Thank you very much, but I seem to have dialed the wrong number. It’s possible that your number may be called at a later time. STOP

Is this a private residence?

READ ONLY IF NECESSARY: “By private residence, we mean someplace like a house or apartment.”

Yes [Go to state of residence]

No [Go to college housing]

No, business phone only

If “No, business phone only”.

Thank you very much but we are only interviewing persons on residential phones lines at this time.

STOP

College Housing

Do you live in college housing?

READ ONLY IF NECESSARY: “By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.”

Yes [Go to state of residence]

If "No”,

Thank you very much, but we are only interviewing persons who live in a private residence or college housing at this time. STOP

State of Residence

Do you reside in ____(state)____?

Yes [Go to Cellular Phone]

If “No”

Thank you very much, but we are only interviewing persons who live in the state of ______at this time. STOP

Cellular Phone

Is this a cellular telephone?

INTERVIEWER NOTE: Telephone service over the internet counts as landline service (includes Vonage, Magic Jack and other home-based phone services).

Read only if necessary: “By cellular (or cell) telephone we mean a telephone that is mobile and usable outside of your neighborhood.”

If “Yes”

Thank you very much, but we are only interviewing by land line telephones and for private residences or college housing. STOP

CATI NOTE: IF (College Housing = Yes) continue; otherwise go to Adult Random Selection

Adult

Are you 18 years of age or older?

1 Yes, respondent is male [Go to Page 6]

2 Yes, respondent is female [Go to Page 6]

3 No

If "No”,

Thank you very much, but we are only interviewing persons aged 18 or older at this time. STOP

Adult Random Selection

I need to randomly select one adult who lives in your household to be interviewed. How many members of your household, including yourself, are 18 years of age or older?

__ Number of adults

If "1,"

Are you the adult?

If "yes,"

Then you are the person I need to speak with. Enter 1 man or 1 woman below (Ask gender if necessary). Go to page 6.

If "no,"

Is the adult a man or a woman? Enter 1 man or 1 woman below. May I speak with [fill in (him/her) from previous question]? Go to "correct respondent" on the next page.

How many of these adults are men and how many are women?

__ Number of men

__ Number of women

The person in your household that I need to speak with is .

If "you," go to page 7.

To the correct respondent:

HELLO, I am calling for the (health department) . My name is (name) . We are gathering information about the health of (state) residents. This project is conducted by the health department with assistance from the Centers for Disease Control and Prevention. Your telephone number has been chosen randomly, and I would like to ask some questions about your health and health practices.

Core Sections

I will not ask for your last name, address, or other personal information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Any information you give me will be confidential. If you have any questions about the survey, please call (give appropriate state telephone number).

Section 1: Health Status

1.1 Would you say that in general your health is—

(90)

Please read:

1 Excellent

2 Very good

3 Good

4 Fair

5 Poor

Do not read:

7 Don’t know / Not sure

9 Refused

Section 2: Healthy Days — Health-Related Quality of Life

2.1 Now thinking about your physical health, which includes physical illness and injury, for

how many days during the past 30 days was your physical health not good?

(91–92)

_ _ Number of days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

2.2 Now thinking about your mental health, which includes stress, depression, and problems

with emotions, for how many days during the past 30 days was your mental health not

good?

(93–94)

_ _ Number of days

8 8 None [If Q2.1 and Q2.2 = 88 (None), go to next section]

7 7 Don’t know / Not sure

9 9 Refused

2.3 During the past 30 days, for about how many days did poor physical or mental health

keep you from doing your usual activities, such as self-care, work, or recreation?

(95-96)

_ _ Number of days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

Section 3: Health Care Access

Do you have any kind of health care coverage, including health insurance, prepaid plans

such as HMOs, government plans such as Medicare, or Indian Health Service?

(97)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

3.2 Do you have one person you think of as your personal doctor or health care provider?

If “No,” ask: “Is there more than one, or is there no person who you think of as your personal doctor or health care provider?”

(98)

1 Yes, only one

2 More than one

3 No

7 Don’t know / Not sure

9 Refused

3.3 Was there a time in the past 12 months when you needed to see a doctor but could not

because of cost?

(99)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

3.4 About how long has it been since you last visited a doctor for a routine checkup? A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.

(100)

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 5 years (2 years but less than 5 years ago)

4 5 or more years ago

7 Don’t know / Not sure

8 Never

9 Refused

Section 4: Hypertension Awareness

4.1 Have you EVER been told by a doctor, nurse, or other health professional that you have

high blood pressure?

(101)

Read only if necessary: By “other health professional” we mean a nurse practitioner, a physician’s assistant, or some other licensed health professional.

If “Yes” and respondent is female, ask: “Was this only when you were pregnant?”

1 Yes

2 Yes, but female told only during pregnancy [Go to next section]

3 No [Go to next section]

4 Told borderline high or pre-hypertensive [Go to next section]

7 Don’t know / Not sure [Go to next section]

9 Refused [Go to next section]

4.2 Are you currently taking medicine for your high blood pressure?

(102)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Section 5: Cholesterol Awareness

5.1 Blood cholesterol is a fatty substance found in the blood. Have you EVER had your blood cholesterol checked?

(103)

1 Yes

2 No [Go to next section]

7 Don’t know / Not sure [Go to next section]

9 Refused [Go to next section]

5.2 About how long has it been since you last had your blood cholesterol checked?

(104)

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 5 years (2 years but less than 5 years ago)

4 5 or more years ago

Do not read:

7 Don’t know / Not sure

9 Refused

5.3 Have you EVER been told by a doctor, nurse or other health professional that your blood cholesterol is high?

(105)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Section 6: Chronic Health Conditions

Now I would like to ask you some questions about general health conditions.

Has a doctor, nurse, or other health professional EVER told you that you had any of the following? For each, tell me “Yes,” “No,” or you’re “Not sure.”

6.1 (Ever told) you that you had a heart attack also called a myocardial infarction?

(106)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.2 (Ever told) you had angina or coronary heart disease?

(107)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.3 (Ever told) you had a stroke?

(108)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.4 (Ever told) you had asthma?

(109)

1 Yes

2 No [Go to Q6.6]

7 Don’t know / Not sure [Go to Q6.6]

9 Refused [Go to Q6.6]

6.5 Do you still have asthma?

(110)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.6 (Ever told) you had skin cancer?

(111)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.7 (Ever told) you had any other types of cancer?

(112)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.8 (Ever told) you have Chronic Obstructive Pulmonary Disease or COPD, emphysema or chronic bronchitis?

(113)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.9 (Ever told) you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?

(114)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

INTERVIEWER NOTE: Arthritis diagnoses include:

rheumatism, polymyalgia rheumatica
osteoarthritis (not osteoporosis)
tendonitis, bursitis, bunion, tennis elbow
carpal tunnel syndrome, tarsal tunnel syndrome
joint infection, Reiter’s syndrome
ankylosing spondylitis; spondylosis
rotator cuff syndrome
connective tissue disease, scleroderma, polymyositis, Raynaud’s syndrome
vasculitis (giant cell arteritis, Henoch-Schonlein purpura, Wegener’s granulomatosis,
polyarteritis nodosa)

6.10 (Ever told) you have a depressive disorder, including depression, major depression, dysthymia, or minor depression?

(115)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.11 (Ever told) you have kidney disease? Do NOT include kidney stones, bladder infection or incontinence.

INTERVIEWER NOTE: Incontinence is not being able to control urine flow.

(116)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.12 (Ever told) you have diabetes? (117)

If “Yes” and respondent is female, ask: “Was this only when you were pregnant?”

If respondent says pre-diabetes or borderline diabetes, use response code 4.

1 Yes

2 Yes, but female told only during pregnancy

3 No

4 No, pre-diabetes or borderline diabetes

7 Don’t know / Not sure

9 Refused

CATI NOTE: If Q6.12 = 1 (Yes), go to next question. If any other response to Q6.12, go to Pre-Diabetes Optional Module (if used). Otherwise, go to next section.

6.13 How old were you when you were told you have diabetes?

(118-119)

_ _ Code age in years [97 = 97 and older]

9 8 Don’t know / Not sure

9 9 Refused

CATI NOTE: Go to Diabetes Optional Module (if used). Otherwise, go to next section.

Section 7: Demographics

7.1 Indicate sex of respondent. Ask only if necessary.

(120)

1 Male

2 Female

7.2 What is your age?

(121-122)

_ _ Code age in years

0 7 Don’t know / Not sure

0 9 Refused

7.3 Are you Hispanic, Latino/a, or Spanish origin? (123-126)

If yes, ask: Are you…

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

7.4 Which one or more of the following would you say is your race?

(127-154)

INTERVIEWER NOTE: Select all that apply.

INTERVIEWER NOTE: 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategories underneath major heading.

Please read:

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

CATI NOTE: If more than one response to Q7.4; continue. Otherwise, go to Q7.6.

7.5 Which one of these groups would you say best represents your race?

INTERVIEWER NOTE: If 40 (Asian) or 50 (Pacific Islander) is selected read and code subcategory underneath major heading. (155-156)

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

77 Don’t know / Not sure

99 Refused

7.6 Are you…?

(157)

Please read:

1 Married

2 Divorced

3 Widowed

4 Separated

5 Never married

6 A member of an unmarried couple

Do not read:

9 Refused

7.7 What is the highest grade or year of school you completed?

(158)

Read only if necessary:

1 Never attended school or only attended kindergarten

2 Grades 1 through 8 (Elementary)

3 Grades 9 through 11 (Some high school)

4 Grade 12 or GED (High school graduate)

5 College 1 year to 3 years (Some college or technical school)

6 College 4 years or more (College graduate)

Do not read:

9 Refused

7.8 Do you own or rent your home?

(159)

1 Own

2 Rent

3 Other arrangement

7 Don’t know / Not sure

9 Refused

INTERVIEWER NOTE: “Other arrangement” may include group home, staying with friends or family without paying rent.

NOTE: Home is defined as the place where you live most of the time/the majority of the year.

INTERVIEWER NOTE: We ask this question in order to compare health indicators among people with different housing situations.

7.9 What county do you live in? (160-162)

_ _ _ ANSI County Code (formerly FIPS county code)

7 7 7 Don’t know / Not sure

9 9 9 Refused

7.10 What is the ZIP Code where you live? (163-167)

_ _ _ _ _ ZIP Code

7 7 7 7 7 Don’t know / Not sure

9 9 9 9 9 Refused

CATI NOTE: If cellular telephone interview skip to 7.14 (QSTVER GE 20)

7.11 Do you have more than one telephone number in your household? Do not include

cell phones or numbers that are only used by a computer or fax machine. (168)

1 Yes

2 No [Go to Q7.13]

7 Don’t know / Not sure [Go to Q7.13]

9 Refused [Go to Q7.13]

7.12 How many of these telephone numbers are residential numbers?

(169)

_ Residential telephone numbers [6 = 6 or more]

7 Don’t know / Not sure

9 Refused

7.13 Do you have a cell phone for personal use? Please include cell phones used for

both business and personal use.

(170)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

7.14 Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?

INTERVIEWER NOTE: Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.

(171)

1 Yes

2 No

Do not read:

7 Don’t know / Not sure

9 Refused

7.15 Are you currently…?

(172)

Please read:

1 Employed for wages

2 Self-employed

3 Out of work for 1 year or more

4 Out of work for less than 1 year

5 A Homemaker

6 A Student

7 Retired

8 Unable to work

Do not read:

9 Refused

7.16 How many children less than 18 years of age live in your household?

(173-174)

_ _ Number of children

8 8 None

9 9 Refused

7.17 Is your annual household income from all sources—

(175-176)

If respondent refuses at ANY income level, code ‘99’ (Refused)

Read only if necessary:

0 4 Less than $25,000 If “no,” ask 05; if “yes,” ask 03

($20,000 to less than $25,000)

0 3 Less than $20,000 If “no,” code 04; if “yes,” ask 02

($15,000 to less than $20,000)

0 2 Less than $15,000 If “no,” code 03; if “yes,” ask 01

($10,000 to less than $15,000)

0 1 Less than $10,000 If “no,” code 02

0 5 Less than $35,000 If “no,” ask 06

($25,000 to less than $35,000)

0 6 Less than $50,000 If “no,” ask 07

($35,000 to less than $50,000)

0 7 Less than $75,000 If “no,” code 08

($50,000 to less than $75,000)

0 8 $75,000 or more

Do not read:

7 7 Don’t know / Not sure

9 9 Refused

7.18 Have you used the internet in the past 30 days? (177)

Don’t know/Not sure

Refused

7.19 About how much do you weigh without shoes?

(178-181)

NOTE: If respondent answers in metrics, put “9” in column 178.

Round fractions up

_ _ _ _ Weight

(pounds/kilograms)

7 7 7 7 Don’t know / Not sure

9 9 9 9 Refused

7.20 About how tall are you without shoes?

(182-185)

NOTE: If respondent answers in metrics, put “9” in column 182.

Round fractions down

_ _ / _ _ Height

(f t / inches/meters/centimeters)

7 7/ 7 7 Don’t know / Not sure

9 9/ 9 9 Refused

If male, go to 7.22, If female respondent is 45 years old or older, go to Q7.22

7.21 To your knowledge, are you now pregnant?

(186)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

The following questions are about health problems or impairments you may have.

7.22 Are you limited in any way in any activities because of physical, mental, or emotional problems?

(187)

1 Yes

2 No

7 Don’t know / Not Sure

9 Refused

7.23 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?

(188)

NOTE: Include occasional use or use in certain circumstances.

1 Yes

2 No

7 Don’t know / Not Sure

9 Refused

7.24 Are you blind or do you have serious difficulty seeing, even when wearing glasses? (189)

1 Yes

2 No

7 Don’t know / Not Sure

9 Refused

7.25 Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? (190)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

7.26 Do you have serious difficulty walking or climbing stairs? (191)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

7.27 Do you have difficulty dressing or bathing? (192)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

7.28 Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? (193)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Section 8: Tobacco Use

8.1 Have you smoked at least 100 cigarettes in your entire life?

(194)

NOTE: 5 packs = 100 cigarettes

1 Yes

2 No [Go to Q8.5]

7 Don’t know / Not sure [Go to Q8.5]

9 Refused [Go to Q8.5]

INTERVIEWER NOTE: “For cigarettes, do not include: electronic cigarettes (e-cigarettes, NJOY, Bluetip), herbal cigarettes, cigars, cigarillos, little cigars, pipes, bidis, kreteks, water pipes (hookahs), or marijuana.”

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

(195)

1 Every day

2 Some days

3 Not at all [Go to Q8.4]

7 Don’t know / Not sure [Go to Q8.5]

9 Refused [Go to Q8.5]

8.3 During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?

(196)

1 Yes [Go to Q8.5]

2 No [Go to Q8.5]

7 Don’t know / Not sure [Go to Q8.5]

9 Refused [Go to Q8.5]

8.4 How long has it been since you last smoked a cigarette, even one or two puffs?

(197-198)

0 1 Within the past month (less than 1 month ago)

0 2 Within the past 3 months (1 month but less than 3 months ago)

0 3 Within the past 6 months (3 months but less than 6 months ago)

0 4 Within the past year (6 months but less than 1 year ago)

0 5 Within the past 5 years (1 year but less than 5 years ago)

0 6 Within the past 10 years (5 years but less than 10 years ago)

0 7 10 years or more

0 8 Never smoked regularly

7 7 Don’t know / Not sure

9 9 Refused

8.5 Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all?

Snus (rhymes with ‘goose’)

NOTE: Snus (Swedish for snuff) is a moist smokeless tobacco, usually sold in small pouches that are placed under the lip against the gum.

(199)

1 Every day

2 Some days

3 Not at all

Do not read:

7 Don’t know / Not sure

9 Refused

Section 9: Alcohol Consumption

9.1 During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?

(200-202)

1 _ _ Days per week

2 _ _ Days in past 30 days

8 8 8 No drinks in past 30 days [Go to next section]

7 7 7 Don’t know / Not sure [Go to next section]

9 9 9 Refused [Go to next section]

9.2 One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor. During the past 30 days, on the days when you drank, about how many drinks did you drink on the average?

(203-204)

NOTE: A 40 ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.

_ _ Number of drinks

7 7 Don’t know / Not sure

9 9 Refused

9.3 Considering all types of alcoholic beverages, how many times during the past 30 days did you have X [CATI X = 5 for men, X = 4 for women] or more drinks on an occasion?

(205-206)

_ _ Number of times

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

9.4 During the past 30 days, what is the largest number of drinks you had on any occasion?

(207-208)

_ _ Number of drinks

7 7 Don’t know / Not sure

9 9 Refused

Section 10: Fruits and Vegetables

These next questions are about the fruits and vegetables you ate or drank during the past 30 days. Please think about all forms of fruits and vegetables including cooked or raw, fresh, frozen or canned. Please think about all meals, snacks, and food consumed at home and away from home.

I will be asking how often you ate or drank each one: for example, once a day, twice a week, three times a month, and so forth.

INTERVIEWER NOTE: If respondent responds less than once per month, put “0” times per month. If respondent gives a number without a time frame, ask: “Was that per day, week, or month?”

10.1 During the past month, how many times per day, week or month did you drink 100% PURE fruit juices? Do not include fruit-flavored drinks with added sugar or fruit juice you

made at home and added sugar to. Only include 100% juice.

(209-211)

1 _ _ Per day

2 _ _ Per week

3 _ _ Per month

5 5 5 Never

7 7 7 Don’t know / Not sure

9 9 9 Refused

INTERVIEWER NOTE: Do not include fruit drinks with added sugar or other added sweeteners like Kool-Aid, Hi-C, lemonade, cranberry cocktail, Tampico, Sunny Delight, Snapple, Fruitopia, Gatorade, Power-Ade, or yogurt drinks.

Do not include fruit juice drinks that provide 100% daily vitamin C but include added sugar.

Do not include vegetable juices such as tomato and V8 if respondent provides but include in “other vegetables” question 10.6.

DO include 100% pure juices including orange, mango, papaya, pineapple, apple, grape (white or red), or grapefruit. Only count cranberry juice if the R perception is that it is 100% juice with no sugar or artificial sweetener added. 100% juice blends such as orange-pineapple, orange-tangerine, cranberry-grape are also acceptable as are fruit-vegetable 100% blends. 100% pure juice from concentrate (i.e., reconstituted) is counted.

10.2 During the past month, not counting juice, how many times per day, week, or month did you eat fruit? Count fresh, frozen, or canned fruit.

(212-214)

1 _ _ Per day

2 _ _ Per week

3 _ _ Per month

5 5 5 Never

7 7 7 Don’t know / Not sure

9 9 9 Refused

Read only if necessary: “Your best guess is fine. Include apples, bananas, applesauce, oranges, grape fruit, fruit salad, watermelon, cantaloupe or musk melon, papaya, lychees, star fruit, pomegranates, mangos, grapes, and berries such as blueberries and strawberries.”

INTERVIEWER NOTE: Do not count fruit jam, jelly, or fruit preserves.

Do not include dried fruit in ready-to-eat cereals.

Do include dried raisins, cran-raisins if respondent tells you - but due to their small serving size they are not included in the prompt.

Do include cut up fresh, frozen, or canned fruit added to yogurt, cereal, jello, and other meal items.

Include culturally and geographically appropriate fruits that are not mentioned (e.g. genip, soursop, sugar apple, figs, tamarind, bread fruit, sea grapes, carambola, longans, lychees, akee, rambutan, etc.).

10.3 During the past month, how many times per day, week, or month did you eat cooked or canned beans, such as refried, baked, black, garbanzo beans, beans in soup, soybeans, edamame, tofu or lentils. Do NOT include long green beans.

(215-217)

1 _ _ Per day

2 _ _ Per week

3 _ _ Per month

5 5 5 Never

7 7 7 Don’t know / Not sure

9 9 9 Refused

Read only if necessary: “Include round or oval beans or peas such as navy, pinto, split peas, cow peas, hummus, lentils, soy beans and tofu. Do NOT include long green beans such as string beans, broad or winged beans, or pole beans.”

Interviewer NOTE: Include soybeans also called edamame, tofu (bean curd made from soybeans), kidney, pinto, hummus, lentils, black, black-eyed peas, cow peas, lima beans and white beans.

Include bean burgers including garden burgers and veggie burgers.

Include falafel and tempeh.

10.4 During the past month, how many times per day, week, or month did you eat dark green vegetables for example broccoli or dark leafy greens including romaine, chard, collard greens or spinach?

(218-220)

1 _ _ Per day

2 _ _ Per week

3 _ _ Per month

5 5 5 Never

7 7 7 Don’t know / Not sure

9 9 9 Refused

INTERVIEWER NOTE: Each time a vegetable is eaten it counts as one time.

INTERVIEWER NOTE: Include all raw leafy green salads including spinach, mesclun, romaine lettuce, bok choy, dark green leafy lettuce, dandelions, komatsuna, watercress, and arugula.

Do not include iceberg (head) lettuce if specifically told type of lettuce. Include all cooked greens including kale, collard greens, choys, turnip greens, mustard greens.

10.5 During the past month, how many times per day, week, or month did you eat orange-

colored vegetables such as sweet potatoes, pumpkin, winter squash, or carrots?

(221-223)

1 _ _ Per day

2 _ _ Per week

3 _ _ Per month

5 5 5 Never

7 7 7 Don’t know / Not sure

9 9 9 Refused

Read only if needed: “Winter squash have hard, thick skins and deep yellow to orange flesh. They include acorn, buttercup, and spaghetti squash.”

FOR INTERVIEWER: Include all forms of carrots including long or baby-cut.

Include carrot-slaw (e.g. shredded carrots with or without other vegetables or fruit).

Include all forms of sweet potatoes including baked, mashed, casserole, pie, or sweet potatoes fries.

Include all hard-winter squash varieties including acorn, autumn cup, banana, butternut, buttercup, delicate, hubbard, kabocha (Also known as an Ebisu, Delica, Hoka, Hokkaido, or Japanese Pumpkin; blue kuri), and spaghetti squash. Include all forms including soup.

Include pumpkin, including pumpkin soup and pie. Do not include pumpkin bars, cake, bread or other grain-based desert-type food containing pumpkin (i.e. similar to banana bars, zucchini bars we do not include).

10.6 Not counting what you just told me about, during the past month, about how many times per day, week, or month did you eat OTHER vegetables? Examples of other vegetables include tomatoes, tomato juice or V-8 juice, corn, eggplant, peas, lettuce, cabbage, and white potatoes that are not fried such as baked or mashed potatoes.

(224-226)

1 _ _ Per day

2 _ _ Per week

3 _ _ Per month

5 5 5 Never

7 7 7 Don’t know / Not sure

9 9 9 Refused

Read only if needed: “Do not count vegetables you have already counted and do not include fried potatoes.”

INTERVIEWER NOTE: Include corn, peas, tomatoes, okra, beets, cauliflower, bean sprouts, avocado, cucumber, onions, peppers (red, green, yellow, orange); all cabbage including American-style cole-slaw; mushrooms, snow peas, snap peas, broad beans, string, wax-, or pole-beans.

Include any form of the vegetable (raw, cooked, canned, or frozen).

Do include tomato juice if respondent did not count in fruit juice.

Include culturally and geographically appropriate vegetables that are not mentioned (e.g. daikon, jicama, oriental cucumber, etc.).

Do not include rice or other grains.

Do not include products consumed usually as condiments including ketchup, catsup, salsa, chutney, relish.

Section 11: Exercise (Physical Activity)

The next few questions are about exercise, recreation, or physical activities other than your regular job duties.

INTERVIEWER INSTRUCTION: If respondent does not have a “regular job duty” or is retired, they may count the physical activity or exercise they spend the most time doing in a regular month.

11.1 During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?

(227)

1 Yes

2 No [Go to Q11.8]

7 Don’t know / Not sure [Go to Q11.8]

9 Refused [Go to Q11.8]

11.2. What type of physical activity or exercise did you spend the most time doing during the past month? (228-229)

_ _ (Specify) [See Physical Activity Coding List]

7 7 Don’t know / Not Sure [Go to Q11.8]

9 9 Refused [Go to Q11.8]

INTERVIEWER INSTRUCTION: If the respondent’s activity is not included in the Physical Activity Coding List, choose the option listed as “Other “.

11.3 How many times per week or per month did you take part in this activity during the past month?

(230-232)

1_ _ Times per week

2_ _ Times per month

7 7 7 Don’t know / Not sure

9 9 9 Refused

11.4 And when you took part in this activity, for how many minutes or hours did you usually keep at it?

(233-235)

_:_ _ Hours and minutes

7 7 7 Don’t know / Not sure

9 9 9 Refused

11.5 What other type of physical activity gave you the next most exercise during the past month?

(236-237)

_ _ (Specify) [See Physical Activity Coding List] 8 8 No other activity [Go to Q11.8]

7 7 Don’t know / Not Sure [Go to Q11.8]

9 9 Refused [Go to Q11.8]

INTERVIEWER INSTRUCTION: If the respondent’s activity is not included in the Coding Physical Activity List, choose the option listed as “Other”.

11.6 How many times per week or per month did you take part in this activity during the past month?

(238-240)

1_ _ Times per week

2_ _ Times per month

7 7 7 Don’t know / Not sure

9 9 9 Refused

11.7 And when you took part in this activity, for how many minutes or hours did you usually keep at it?

(241-243)

_:_ _ Hours and minutes

7 7 7 Don’t know / Not sure

9 9 9 Refused

11.8 During the past month, how many times per week or per month did you do physical activities or exercises to STRENGTHEN your muscles? Do NOT count aerobic activities like walking, running, or bicycling. Count activities using your own body weight like yoga,

sit-ups or push-ups and those using weight machines, free weights, or elastic bands.

(244-246)

1_ _ Times per week

2_ _ Times per month

8 8 8 Never

7 7 7 Don’t know / Not sure

9 9 9 Refused

Section 12: Arthritis Burden

If Q6.9 = 1 (yes) then continue, else go to next section.

Next, I will ask you about your arthritis.

Arthritis can cause symptoms like pain, aching, or stiffness in or around a joint.

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

(247)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

INTERVIEWER INSTRUCTION: If a question arises about medications or treatment, then the interviewer should say: “Please answer the question based on your current experience, regardless of whether you are taking any medication or treatment.”

INTERVIEWER NOTE: Q12.2 should be asked of all respondents regardless of employment. status.

12.2 In this next question, we are referring to work for pay. Do arthritis or joint symptoms now affect whether you work, the type of work you do, or the amount of work you do?

(248)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

INTERVIEWER INSTRUCTION: If respondent gives an answer to each issue (whether respondent works, type of work, or amount of work), then if any issue is “yes” mark the overall response as “yes.”

If a question arises about medications or treatment, then the interviewer should say: “Please answer the question based on your current experience, regardless of whether you are taking any medication or treatment.”

12.3 During the past 30 days, to what extent has your arthritis or joint symptoms interfered with your normal social activities, such as going shopping, to the movies, or to religious or social gatherings? (249)

Please read [1-3]:

1 A lot

2 A little

3 Not at all

Do not read:

7 Don’t know / Not sure

9 Refused

12.4 Please think about the past 30 days, keeping in mind all of your joint pain or aching and whether or not you have taken medication. DURING THE PAST 30 DAYS, how bad was your joint pain ON AVERAGE? Please answer on a scale of 0 to 10 where 0 is no pain or aching and 10 is pain or aching as bad as it can be.

(250-251)

_ _ Enter number [00-10]

7 7 Don’t know / Not sure

9 9 Refused

Section 13: Seatbelt Use

13.1 How often do you use seat belts when you drive or ride in a car? Would you say—

(252)

Please read:

1 Always

2 Nearly always

3 Sometimes

4 Seldom

5 Never

Do not read:

7 Don’t know / Not sure

8 Never drive or ride in a car

9 Refused

Section 14: Immunization

Now I will ask you questions about the flu vaccine. There are two ways to get the flu vaccine, one is a shot in the arm and the other is a spray, mist, or drop in the nose called FluMist™.

14.1 During the past 12 months, have you had either a flu shot or a flu vaccine that was sprayed in your nose?

(253)

READ IF NECESSARY:

A new flu shot came out in 2011 that injects vaccine into the skin with a very small needle. It is called Fluzone Intradermal vaccine. This is also considered a flu shot.

1 Yes

2 No [Go to Q14.4]

7 Don’t know / Not sure [Go to Q14.4]

9 Refused [Go to Q14.4]

14.2 During what month and year did you receive your most recent flu shot injected into your arm or flu vaccine that was sprayed in your nose?

(254-259)

_ _ / _ _ _ _ Month / Year

7 7 / 7 7 7 7 Don’t know / Not sure

9 9 / 9 9 9 9 Refused

14.3 At what kind of place did you get your last flu shot/vaccine?

(260-261)

Note: Read only if necessary

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

14.4 A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person’s lifetime and is different from the flu shot. Have you ever had a pneumonia shot?

(262)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Section 15: HIV/AIDS

The next few questions are about the national health problem of HIV, the virus that causes AIDS. Please remember that your answers are strictly confidential and that you don’t have to answer every question if you do not want to. Although we will ask you about testing, we will not ask you about the results of any test you may have had.

15.1 Have you ever been tested for HIV? Do not count tests you may have had as part of a blood donation. Include testing fluid from your mouth.

(263)

1 Yes

2 No [Go to optional module transition]

7 Don’t know / Not sure [Go to optional module transition]

9 Refused [Go to optional module transition]

15.2 Not including blood donations, in what month and year was your last HIV test?

(264-269)

NOTE: If response is before January 1985, code “Don’t know.”

CATI INSTRUCTION: If the respondent remembers the year but cannot remember

the month, code the first two digits 77 and the last four digits for the year.

_ _ /_ _ _ _ Code month and year

7 7/ 7 7 7 7 Don’t know / Not sure

9 9/ 9 9 9 9 Refused / Not sure

15.3 Where did you have your last HIV test — at a private doctor or HMO office, at a counseling and testing site, at an emergency room, as an inpatient in a hospital, at a clinic, in a jail or prison, at a drug treatment facility, at home, or somewhere else?

(270-271)

0 1 Private doctor or HMO office

0 2 Counseling and testing site

0 9 Emergency room

0 3 Hospital inpatient

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

Closing Statement or Transition to Modules and/or State-Added Questions

Closing Statement

Please read:

That was my last question. Everyone’s answers will be combined to help us provide information about the health practices of people in this state. Thank you very much for your time and cooperation.

Transition to modules and/or state-added questions

Please read:

Finally, I have just a few questions left about some other health topics.

Optional Modules

Module 1: Pre-Diabetes

NOTE: Only asked of those not responding “Yes” (code = 1) to Core Q6.12 (Diabetes awareness question).

Have you had a test for high blood sugar or diabetes within the past three years?

(287)

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).

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?”

(288)

1 Yes

2 Yes, during pregnancy

3 No

7 Don’t know / Not sure

9 Refused

Module 2: Diabetes

NOTE: To be asked following Core Q6.13; if response is "Yes" (code = 1) and Core Q6.12 is “Yes” (code = 1).

1. Are you now taking insulin?

(289)

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.

(290-292)

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

Interviewer Note: If the respondent uses a continuous glucose monitoring system (a sensor inserted under the skin to check glucose levels continuously), fill in ‘98 times per day.’

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.

(293-295)

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?

(296-297)

_ _ 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"?

(298-299)

_ _ 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 Q7.

6. About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?

(300-301)

_ _ 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.

(302)

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?

(303)

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?

(304)

1 Yes

2 No

7 Don't know / Not sure

9 Refused

Module 3: 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?

(305-306)

_ _ 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?

(307-308)

_ _ 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?

(309-310)

_ _ 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?

(311-312)

_ _ Number of days

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

Module 4: Caregiver

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? (313)

INTERVIEWER INSTRUCTIONS: If caregiving recipient has died in the past 30 days, say “I’m so sorry to hear of your loss.” and code 8.

Yes
No [Go to Question 9]

7 Don’t know/Not sure [Go to Question 9]

8 Caregiving recipient died in past 30 days [Go to next module]

9 Refused [Go to Question 9]

What is his or her relationship to you? For example is he or she your (mother or daughter or father or son)?

INTERVIEWER NOTE: If more than one person, say: “Please refer to the person to whom you are giving the most care.”

(314-315)

[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… (316)

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…

(317)

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?

(318-319)

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… (320)

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… (321)

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? (322)

[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 = 1 or 8, 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? (323)

1 Yes

2 No

7 Don’t know/Not sure

9 Refused

Module 5: 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—

(324)

Please read:

1 No difficulty

2 A little difficulty

3 Moderate difficulty

4 Extreme difficulty

5 Unable to do because of eyesight

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—

(325)

Please read:

1 No difficulty

2 A little difficulty

3 Moderate difficulty

4 Extreme difficulty

5 Unable to do because of eyesight

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? (326)

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?

(327-328)

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 2 (Diabetes) Q7.

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.

(329)

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?

(330)

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?

(331)

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?

(332)

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?

(333)

1 Yes

2 No

7 Don’t know / Not sure

8 Not applicable (Blind)

9 Refused

Module 6: Cognitive Decline

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? (334)

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? (335)

Please read:

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? (336)

Please read:

1 Always

2 Usually

3 Sometimes

4 Rarely [Go to Q5]

5 Never [Go to Q5]

7 Don't know [Go to Q5]

9 Refused [Go to Q5]

CATI NOTE: If Q3 = 1, 2, or 3, continue. If Q3 = 4 ,5, 7, or 9 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? (337)

Please read:

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? (338)

Please read:

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? (339)

1 Yes

2 No

7 Don't know

9 Refused

Module 7: 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? (340)

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?”

(341-343)

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? (344)

1 Yes

2 No

7 Don’t know/not sure

9 Refused

Module 8: 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?

(345-346)

_ _ 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?

(347)

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?

(348-349)

_ _ 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?

(350-351)

_ _ 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?

(352-353)

_ _ 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?

(354-356)

_ _ _ 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 —

(357)

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

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 —

(358)

Please read:

8 None

1 One or two

2 Three to four

3 Five

4 Six to ten

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?

(359)

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?

(360)

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

Module 9: 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."

(361)

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." (362)

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? (363)

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?

(364)

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? (365)

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? (366)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

7. Do you take aspirin to reduce the chance of a stroke? (367)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Module 10: 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?

(368)

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?

(369)

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?

(370)

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?

(371)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Module 11: Tetanus Diphtheria (Tdap) (Adults)

Next, I will ask you about the tetanus diphtheria vaccination.

1. Since 2005, have you had a tetanus shot? (372)

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

Module 12: 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?

(373)

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?

(374-375)

_ _ Number of shots

0 3 All shots

7 7 Don’t know / Not sure

9 9 Refused

Module 13: 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?

(376)

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.

Module 14: Breast and Cervical Cancer Screening

CATI NOTE: If respondent is male, go to the next ~~section~~ module.

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?

(377)

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?

(378)

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? (379)

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?

(380)

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? (381)

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?

(382)

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?

(383)

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

Module 15: Clinical Breast Exam for Breast Cancer Screening

CATI NOTE: If respondent is male, go to the next module.

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?

(384)

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?

(385)

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

Module 16: 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?

(386)

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?

(387)

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:

7 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?

(388)

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. 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?

(389)

Sigmoidoscopy
Colonoscopy

7 Don’t know / Not sure

9 Refused

5. How long has it been since you had your last sigmoidoscopy or colonoscopy?

(390)

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

Module 17: 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?

(391)

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? (392)

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? (393)

7 Don’t Know / Not sure

9 Refused

4. Have you EVER HAD a PSA test? (394)

Yes
No [Go to next module]

7 Don’t Know / Not sure [Go to next module

9 Refused [Go to next module]

5. How long has it been since you had your last PSA test? (395)

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 …?

(396)

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

Module 18: Prostate Cancer Screening Decision Making

CATI NOTE: If module 17, 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? (397)

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) (398-401)

8 No additional choices

7 Don’t know / Not sure

9 Refused

Module 19: 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)

(402-501)

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

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) (429-453)

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) (502-601)

[Record answer] _________________________________

99 Refused

If Core ~~Q7.9~~ Q7.15 = 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

Module 20: Social Context

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---

(602)

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---

(603)

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 Q6.

3. At your main job or business, how are you generally paid for the work you do. Are you:

(604)

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?

(605-606)

_ _ Hours (01-96 or more) [Go to next module]

9 7 Don't know / Not sure [Go to next module]

9 8 Does not work [Go to next module]

9 9 Refused [Go to next module]

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:

(607)

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?

(608-609)

_ _ Hours (01-96 or more)

9 7 Don't know / Not sure

9 8 Does not work

9 9 Refused

Module 21: 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: (610)

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? (611)

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 transgender. 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.

Module 22: Random Child Selection

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?

(612-617)

_ _ /_ _ _ _ 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?

(618)

1 Boy

2 Girl

9 Refused

3. Is the child Hispanic, Latino/a, or Spanish origin?

(619-622)

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?

(623-652)

(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?

(653-654)

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

77 Don’t know / Not sure

99 Refused

6. How are you related to the child?

(655)

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

Module 23: 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?

(656)

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?

(657)

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Module 24: 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.”

(658)

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?

(659)

Please read:

1 Very satisfied

2 Satisfied

3 Dissatisfied

4 Very dissatisfied

Do not read:

7 Don't know / Not sure

9 Refused

Module 25: 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?

(660-661)

_ _ 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? (662-663)

_ _ 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? (664-665)

_ _ 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? (666-667)

_ _ 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? ( 668-669)

_ _ 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? (670-671)

_ _ 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? (672-673)

_ _ 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? (674-675)

_ _ 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? (676)

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)? (677)

1 Yes

2 No

7 Don‘t know / Not sure

9 Refused

Asthma Call-Back Permission Script

We would like to call you again within the next 2 weeks to talk in more detail about (your/your child’s) experiences with asthma. The information will be used to help develop and improve the asthma programs in <STATE>. The information you gave us today and any you give us in the future will be kept confidential. If you agree to this, we will keep your first name or initials and phone number on file, separate from the answers collected today. Even if you agree now, you or others may refuse to participate in the future. Would it be okay if we called you back to ask additional asthma-related questions at a later time?

(678)

1 Yes

2 No

Can I please have either (your/your child’s) first name or initials, so we will know who to ask for when we call back?

____________________ Enter first name or initials.

Asthma Call-Back Selection

Which person in the household was selected as the focus of the asthma call-back? (679)

1 Adult

2 Child

Activity List for Common Leisure Activities (To be used for Section 11: Physical Activity)

Code Description (Physical Activity, Questions 11.2 and 11.5 above)

0 1 Active Gaming Devices (Wii Fit, 4 1 Rugby

Dance Dance revolution) 4 2 Scuba diving

0 2 Aerobics video or class 4 3 Skateboarding

0 3 Backpacking 4 4 Skating – ice or roller

0 4 Badminton 4 5 Sledding, tobogganing

0 5 Basketball 4 6 Snorkeling

0 6 Bicycling machine exercise 4 7 Snow blowing

0 7 Bicycling 4 8 Snow shoveling by hand

0 8 Boating (Canoeing, rowing, kayaking, 4 9 Snow skiing

sailing for pleasure or camping) 5 0 Snowshoeing

0 9 Bowling 5 1 Soccer

1 0 Boxing 5 2 Softball/Baseball

1 1 Calisthenics 5 3 Squash

1 2 Canoeing/rowing in competition 5 4 Stair climbing/Stair master

1 3 Carpentry 5 5 Stream fishing in waders

1 4 Dancing-ballet, ballroom, Latin, hip hop, zumba, etc 5 6 Surfing

1 5 Elliptical/EFX machine exercise 5 7 Swimming

1 6 Fishing from river bank or boat 5 8 Swimming in laps

1 7 Frisbee 5 9 Table tennis

1 8 Gardening (spading, weeding, digging, filling) 6 0 Tai Chi

1 9 Golf (with motorized cart) 6 1 Tennis

2 0 Golf (without motorized cart) 6 2 Touch football

2 1 Handball 6 3 Volleyball

2 2 Hiking – cross-country 6 4 Walking

2 3 Hockey 6 6 Waterskiing

2 4 Horseback riding 6 7 Weight lifting

2 5 Hunting large game – deer, elk 6 8 Wrestling

2 6 Hunting small game – quail 6 9 Yoga

2 7 Inline Skating

2 8 Jogging 7 1 Childcare

2 9 Lacrosse 7 2 Farm/Ranch Work (caring for livestock, stacking

3 0 Mountain climbing hay, etc.)

3 1 Mowing lawn 7 3 Household Activities (vacuuming, dusting, home repair,

3 2 Paddleball etc.)

3 3 Painting/papering house 7 4 Karate/Martial Arts

3 4 Pilates 7 5 Upper Body Cycle (wheelchair sports, ergometer,

3 5 Racquetball etc.)

3 6 Raking lawn 7 6 Yard work (cutting/gathering wood, trimming hedges

3 7 Running etc.)

3 8 Rock Climbing

3 9 Rope skipping 9 8 Other_____

4 0 Rowing machine exercise 9 9 Refused

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	CDC
File Modified	0000-00-00
File Created	2021-01-24