BRFSS Core Questionnaire

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.

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

Exercise

4.1 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?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

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?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

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

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.3 (Ever told) you had a stroke?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.4 (Ever told) you had asthma?

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?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.6 (Ever told) you had skin cancer?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

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

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?

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?

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?

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.

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

6.12 (Ever told) you have diabetes?

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 next section.

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

_ _ 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.

Demographics

7.1 Indicate sex of respondent. Ask only if necessary.

1 Male

2 Female

7.2 What is your age?

_ _ Code age in years

0 7 Don’t know / Not sure

0 9 Refused

7.3 Are you Hispanic, Latino/a, or Spanish origin?

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?

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.

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

7.6 Are you…?

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?

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?

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?

_ _ _ 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?

_ _ _ _ _ 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.

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?

_ 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.

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.

1 Yes

2 No

Do not read:

7 Don’t know / Not sure

9 Refused

7.15 Are you currently…?

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?

_ _ Number of children

8 8 None

9 9 Refused

7.17 Is your annual household income from all sources—

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?

Don’t know/Not sure

Refused

7.19 About how much do you weigh without shoes?

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?

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?

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?

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?

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?

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?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

7.26 Do you have serious difficulty walking or climbing stairs?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

7.27 Do you have difficulty dressing or bathing?

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?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Seatbelt Use

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

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

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?

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?

_ _ / _ _ _ _ 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?

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?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

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.

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?

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?

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

Tobacco Use

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

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]

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

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?

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?

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.

1 Every day

2 Some days

3 Not at all

Do not read:

7 Don’t know / Not sure

9 Refused

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?

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?

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?

_ _ 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?

_ _ Number of drinks

7 7 Don’t know / Not sure

9 9 Refused

Even Numbered Years Rotating Core

Falls

CATI NOTE: If respondent is 45 years or older continue, otherwise go to next section.

Next, I will ask about recent falls. By a fall, we mean when a person unintentionally comes to rest on the ground or another lower level.

12.1 In the past 12 months, how many times have you fallen?

_ _ Number of times [76 = 76 or more]

8 8 None [Go to next section]

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

9 9 Refused [Go to next section]

12.2 [Fill in “Did this fall (from Q12.1) cause an injury?”]. If only one fall from Q12.1 and response is “Yes” (caused an injury); code 01. If response is “No,” code 88.

How many of these falls caused an injury? By an injury, we mean the fall caused you to limit your regular activities for at least a day or to go see a doctor.

_ _ Number of falls [76 = 76 or more]

8 8 None

7 7 Don’t know / Not sure

9 9 Refused

Drinking and Driving

CATI note: If Q10.1 = 888 (No drinks in the past 30 days); go to next section.

The next question is about drinking and driving.

14.1 During the past 30 days, how many times have you driven when you’ve had perhaps too much to drink?

_ _ Number of times

8 8 None

7 7 Don’t know / Not sure

9 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.

15.1 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 Q15.3]

7 Don’t know / Not sure [Go to Q15.3]

9 Refused [Go to Q15.3]

15.2 How long has it been since you had your last mammogram?

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

15.3 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?

1 Yes

2 No [Go to Q15.5]

7 Don’t know / Not sure [Go to Q15.5]

9 Refused [Go to Q15.5]

15.4 How long has it been since your last breast exam?

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

15.5 A Pap test is a test for cancer of the cervix. Have you ever had a Pap test?

1 Yes

2 No [Go to Q15.7]

7 Don’t know / Not sure [Go to Q15.7]

9 Refused [Go to Q15.7]

15.6 How long has it been since you had your last Pap 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 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

CATI note: If response to Core Q8.22 = 1 (is pregnant); then go to next section.

15.7 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

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.

16.1 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

16.2 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

16.3 Has a doctor, nurse, or other health professional EVER recommended that you have a PSA test?

7 Don’t Know / Not sure

9 Refused

16.4. 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]

16.5. 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

16.6. 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

Colorectal Cancer Screening

CATI note: If respondent is < 49 years of age, go to next section.

The next questions are about colorectal cancer screening.

17.1 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 Q17.3]

7 Don't know / Not sure [Go to Q17.3]

9 Refused [Go to Q17.3]

17.2 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:

7 Don't know / Not sure

9 Refused

17.3 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]

17.4 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

17.5 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

Inadequate Sleep

I would like to ask you about your sleep pattern.

5.1 On average, how many hours of sleep do you get in a 24-hour period?

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

Oral Health

7.1 How long has it been since you last visited a dentist or a dental clinic for any reason? Include visits to dental specialists, such as orthodontists.

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

8 Never

9 Refused

7.2 How many of your permanent teeth have been removed because of tooth decay or gum disease? Include teeth lost to infection, but do not include teeth lost for other reasons, such as injury or orthodontics.

NOTE: If wisdom teeth are removed because of tooth decay or gum disease, they should be included in the count for lost teeth.

1 1 to 5

2 6 or more but not all

3 All

8 None

7 Don’t know / Not sure

9 Refused

Odd Numbered Years Rotating Core

Hypertension Awareness

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

high blood pressure?

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?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

Cholesterol Awareness

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

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?

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?

1 Yes

2 No

7 Don’t know / Not sure

9 Refused

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.

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

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.

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?

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?

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.

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.

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?

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?

_ _ (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?

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?

_:_ _ 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?

_ _ (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?

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?

_:_ _ 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.

1_ _ Times per week

2_ _ Times per month

8 8 8 Never

7 7 7 Don’t know / Not sure

9 9 9 Refused

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?

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?

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?

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

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	CDC
File Modified	0000-00-00
File Created	2021-01-23