Historical Crosswalk

HOS Historical Crosswalk 06082018.xlsx

Medicare Health Outcomes Survey (HOS) (CMS-10203)

Historical Crosswalk

OMB: 0938-0701

Document [xlsx]
Download: xlsx | pdf

Overview

Summary
Version Crosswalk

Sheet 1: Summary
Version 3.0 History Source Use
# Question Description Star Ratings Frailty Adjustment Case Mix Adjustment Federal Partners Required S.4302 Item Future Measure Development Plan QI
1 In general, would you say your health is: Original item in Version 1.0
Item in both VR-36 and VR-12		 VR-12 Item X
X

X X
2 Health now limit you in these activities?
-Moderate activities
-Climbing several flights of stairs		 Original item in Version 1.0
Items in both VR-36 and VR-12		 VR-12 Item X
X

X X
3 Problems with your work or other regular daily activities as a result of your physical health?
-Accomplished less than you would like
-Were limited in the kind of work or other activities		 Original item in Version 1.0
Items in both VR-36 and VR-12		 VR-12 Item X
X

X X
4 Problems with your work or other regular daily activities as a result of any emotional problems ?
-Accomplished less than you would like
- Didn’t do work or other activities as carefully as usual		 Original item in Version 1.0
Items in both VR-36 and VR-12		 VR-12 Item X
X

X X
5 Pain interfere with your normal work Original item in Version 1.0
Item in both VR-36 and VR-12		 VR-12 Item X
X

X X
6 How much of the time:
-Calm and peaceful?
-Lot of energy?
-Downhearted and blue?		 Original item in Version 1.0
Items in both VR-36 and VR-12		 VR-12 Item X
X

X X
7 Physical health or emotional problems interfered with your social activities Original item in Version 1.0
Item in both VR-36 and VR-12		 VR-12 Item X
X

X X
8 Rate your physical health in general now? Updated in 2006 with Version 2.0 release
As a result of VR-36 to VR-12 change		 Change in Health X
X X
X X
9 Rate your emotional problems in general now? Updated in 2006 with Version 2.0 release
As a result of VR-36 to VR-12 change		 Change in Health X
X X
X X
10a-f Difficulty doing the following activities?
-Bathing
-Dressing
-Eating
-Getting in or out of chairs
-Walking
-Using the toilet		 Original item in Version 1.0 Activities of Daily Living (ADLs)
X X X
X X
11a-c Difficulty doing the following activities?
-Preparing meals
-Managing money
-Taking medication as prescribed		 Added in 2013 with Version 2.5
Through the TEP process		 Instrumental Activities of Daily Living (IADLs)


X
X X
12 Days physical health not good? Added in 2003 to Version 1.0 Healthy Days


X
X
13 Days mental health not good? Added in 2003 to Version 1.0 Healthy Days


X
X
14 Days physical or mental health keep you from doing your usual activities? Added in 2003 to Version 1.0 Healthy Days


X
X
15 Blind or do you have serious difficulty seeing, even when wearing glasses? Original item in Version 1.0
Updated in Version 2.5
Required by ACA Section 4302		 Vision item, S.4302 Disability


X X
X
16 Deaf or do you have serious difficulty hearing, even with a hearing aid? Original item in Version 1.0
Updated in Version 2.5
Required by ACA Section 4302		 Hearing item, S.4302 Disability


X X
X
17 Difficulty concentrating, remembering or making decisions? Added in 2013 with Version 2.5 release
Required by ACA Section 4302		 S.4302 Disability


X X X X
18 Difficulty doing errands alone such as visiting a doctor’s office or shopping? Added in 2013 with Version 2.5 release Required by ACA Section 4302
 S.4302 Disability


X X X
19 Memory problems interfere with your daily activities? Added in 2013 with Version 2.5 release
Through the TEP process		 Memory Problems


X
X X
20 Hypertension or high blood pressure Original item in Version 1.0 Chronic Conditions

X X

X
21 Angina pectoris or coronary artery disease Original item in Version 1.0 Chronic Conditions

X X

X
22 Congestive heart failure Original item in Version 1.0 Chronic Conditions

X X

X
23 Myocardial infarction or heart attack Original item in Version 1.0 Chronic Conditions

X X

X
24 Problems with heart valves or the rhythm of your heartbeat Original item in Version 1.0 Chronic Conditions

X X

X
25 Stroke Original item in Version 1.0 Chronic Conditions

X X

X
26 Emphysema, or asthma, or COPD Original item in Version 1.0 Chronic Conditions

X X

X
27 Crohn’s disease, ulcerative colitis, or inflammatory bowel disease Original item in Version 1.0 Chronic Conditions

X X

X
28 Arthritis of the hip or knee Original item in Version 1.0 Chronic Conditions

X X

X
29 Arthritis of the hand or wrist Original item in Version 1.0 Chronic Conditions

X X

X
30 Osteoporosis, sometimes called thin or brittle bones Added in 2006 with Version 2.0 release Chronic Conditions

X X

X
31 Sciatica Original item in Version 1.0 Chronic Conditions

X X

X
32 Diabetes, high blood sugar, or sugar in the urine Original item in Version 1.0 Chronic Conditions

X X

X
33 Depression Added in 2013 with Version 2.5 release
Through the TEP process		 Chronic Conditions

X X

X
34 Any cancer (other than skin cancer) Original item in Version 1.0 Chronic Conditions

X X

X
35a-d Colon or rectal cancer
Lung caner
Breast cancer
Prostate cancer 		Original item in Version 1.0 Chronic Conditions— Cancer

X X

X
35e Other cancer (other than skin cancer) Added in 2013 with Version 2.5 release
Through the TEP process		 Chronic Conditions— Cancer

X X

X
36 Pain interfere with your day to day activities? Added in 2013 with Version 2.5 release
Through the TEP process
Replaced back pain item to include global pain		 PROMIS Pain Item


X

X
37 Pain keep you from socializing with others? Added in 2013 with Version 2.5 release
Through the TEP process
Replaced back pain item to include global pain		 PROMIS Pain Item


X
X X
38 Rate your pain on average? Added in 2013 with Version 2.5 release
Through the TEP process
Replaced back pain item to include global pain		 PROMIS Pain Item


X
X X
39a-b Bothered by any of the following problems?
-Little interest or pleasure in doing things
-Feeling down, depressed, or hopeless		 Added in 2013 with Version 2.5
Through the TEP process
Replaced longer 4-item depression question		 PHQ-2 Depression


X
X X
40 Compared to other people your age, would you say that your health is: Original item in Version 1.0 General Health

X X

X
41 Smoke every day, some days, or not at all? Original item in Version 1.0 Smoking


X

X
42 Experienced leaking of urine? Added in 2003 to Version 1.0 HEDIS - Urinary Incontinence X




X
43 Leaking of urine change your daily activities or interfere with your sleep? Added in 2003 to Version 1.0 HEDIS - Urinary Incontinence X




X
44 Talked with doctor, nurse, or health care provider about leaking of urine? Added in 2003 to Version 1.0 HEDIS - Urinary Incontinence X




X
45 Talked health care provider about ways to control leaking of urine. Added in 2003 to Version 1.0 HEDIS - Urinary Incontinence X




X
46 Talk with doctor or health provider about exercise or physical activity? Added in 2005 to Version 1.0 HEDIS - Physical Activity X




X
47 Advise start, increase or maintain exercise or physical activity? Added in 2005 to Version 1.0 HEDIS - Physical Activity X




X
48 Talk about falling or problems with balance or walking? Added in 2006 with Version 2.0 release HEDIS - Fall Risk Assessment X




X
49 Fall in the past 12 months? Added in 2006 with Version 2.0 release HEDIS - Fall Risk Assessment X




X
50 Problem with balance or walking? Added in 2006 with Version 2.0 release HEDIS - Fall Risk Assessment X




X
51 Prevent falls or treat problems with balance or walking? Added in 2006 with Version 2.0 release HEDIS - Fall Risk Assessment X




X
52 Bone density test to check for osteoporosis? Added in 2006 with Version 2.0 release HEDIS - Osteoporosis X




X
53 How many hours of actual sleep? Added in 2015 with Version 3.0 release
RAND item		 Sleep quality




X
54 Overall sleep quality Added in 2015 with Version 3.0 release
RAND item		 Sleep quality




X
55 Weight Added in 2006 with Version 2.0 release Weight


X
X
56 Height Added in 2006 with Version 2.0 release Height


X
X
57 Male or female Original item in Version 1.0
Required by ACA Section 4302		 S.4302 Gender

X X X

58 Hispanic, Latino/a or Spanish origin Original item in Version 1.0
Updated in Version 2.5, required by ACA Section 4302		 S.4302 Ethnicity

X X X

59 Race Original item in Version 1.0
Updated in Version 2.5, required by ACA Section 4302		 S.4302 Race

X X X

60 Language at home Added in 2013 with Version 2.5 release
Required by ACA Section 4302
Revised in 2015 with Version 3.0 release		 S.4302 Primary Language


X X

61 Marital status Original item in Version 1.0 Marital status

X X


62 Highest grade or level of school Original item in Version 1.0 Education

X X


63 Live alone or with others Added in 2013 with Version 2.5 release
Through the TEP process		 Living arrangement, RAND


X
X
64 Where do you live? Added in 2013 with Version 2.5 release
Through the TEP process		 Living arrangement, RAND


X
X
65 House or apartment ownership Original item in Version 1.0 Living arrangement

X X
X X
66 Who completed survey form? Original item in Version 1.0 Form assist

X


67 Proxy first and last name Original item in Version 1.0 Form assist






68 Combine household income Original item in Version 1.0 Income

X X


Sheet 2: Version Crosswalk
Medicare Health Outcomes Survey Version Crosswalk (HOS)
Version 1.0 Version 2.0 Version 2.5 Version 3.0
1998-2002 2003-2004 2005 2006-2007 2008-2012 2013 2014 2015 - Present
Question Number Question Text Question Number Question Text Question Number Question Text Question Number Question Text Question Number Question Text Question Number Question Text Question Number Question Text Question Number Question Text
1 In general, would you say your health is: 1 In general, would you say your health is: 1 In general, would you say your health is: 1 In general, would you say your health is: 1 In general, would you say your health is: 1 In general, would you say your health is: 1 In general, would you say your health is: 1 In general, would you say your health is:
2 Compared to one year ago, how would you rate your health in general now 2 Compared to one year ago, how would you rate your health in general now 2 Compared to one year ago, how would you rate your health in general now









3 intro The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? 3 intro The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? 3 intro The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? 2 intro The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? 2 intro The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? 2 intro The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? 2 intro The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? 2 intro The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
3a Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports 3a Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports 3a Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports









3b Moderate activities, such as moving a
table, pushing a vacuum cleaner, bowling,
or playing golf
 3b Moderate activities, such as moving a
table, pushing a vacuum cleaner, bowling,
or playing golf
 3b Moderate activities, such as moving a
table, pushing a vacuum cleaner, bowling,
or playing golf
 2a Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
 2a Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
 2a Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
 2a Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
 2a Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
3c Lifting or carrying groceries 3c Lifting or carrying groceries 3c Lifting or carrying groceries









3d Climbing several flights of stairs 3d Climbing several flights of stairs 3d Climbing several flights of stairs 2b Climbing several flights of stairs 2b Climbing several flights of stairs 2b Climbing several flights of stairs 2b Climbing several flights of stairs 2b Climbing several flights of stairs
3e Climbing one flight of stairs 3e Climbing one flight of stairs 3e Climbing one flight of stairs









3f Bending, kneeling, or stooping 3f Bending, kneeling, or stooping 3f Bending, kneeling, or stooping









3g Walking more than a mile 3g Walking more than a mile 3g Walking more than a mile









3h Walking several blocks 3h Walking several blocks 3h Walking several blocks









3i Walking one block 3i Walking one block 3i Walking one block









3j Bathing or dressing yourself 3j Bathing or dressing yourself 3j Bathing or dressing yourself









4 intro During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? 4 intro During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? 4 intro During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? 3 intro During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? 3 intro During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? 3 intro During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? 3 intro During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? 3 intro During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
4a Cut down on the amount of time you spent on work or other activities 4a Cut down on the amount of time you spent on work or other activities 4a Cut down on the amount of time you spent on work or other activities









4b Accomplished less than you would like 4b Accomplished less than you would like 4b Accomplished less than you would like 3a Accomplished less than you would like 3a Accomplished less than you would like 3a Accomplished less than you would like 3a Accomplished less than you would like 3a Accomplished less than you would like as a result of your physical health?
4c Were limited in the kind of work or other activities 4c Were limited in the kind of work or other activities 4c Were limited in the kind of work or other activities 3b Were limited in the kind of work or other activities 3b Were limited in the kind of work or other activities 3b Were limited in the kind of work or other activities 3b Were limited in the kind of work or other activities 3b Were limited in the kind of work or other activities as a result of your physical health?
4d Had difficulty performing the work or other activities (for example, it took extra effort) 4d Had difficulty performing the work or other activities (for example, it took extra effort) 4d Had difficulty performing the work or other activities (for example, it took extra effort)









5 intro During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? 5 intro During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? 5 intro During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? 4 intro During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? 4 intro During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? 4 intro During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? 4 intro During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? 4 intro During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
5a Cut down on the amount of time you spent on work or other activities 5a Cut down on the amount of time you spent on work or other activities 5a Cut down on the amount of time you spent on work or other activities









5b Accomplished less than you would like 5b Accomplished less than you would like 5b Accomplished less than you would like 4a Accomplished less than you would like 4a Accomplished less than you would like 4a Accomplished less than you would like 4a Accomplished less than you would like 4a Accomplished less than you would like as a result of any emotional problems
5c Didn't do work or other activities as carefully as usual 5c Didn't do work or other activities as carefully as usual 5c Didn't do work or other activities as carefully as usual 4b Didn't do work or other activities as carefully as usual 4b Didn't do work or other activities as carefully as usual 4b Didn't do work or other activities as carefully as usual 4b Didn't do work or other activities as carefully as usual 4b Didn't do work or other activities as carefully as usual as a result of any emotional problems
6 During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups? 6 During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups? 6 During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?









7 How much bodily pain have you had during the past 4 weeks? 7 How much bodily pain have you had during the past 4 weeks? 7 How much bodily pain have you had during the past 4 weeks?









8 During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? 8 During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? 8 During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? 5 During the past 4 weeks, how much did pain interfere with your normal work (including both outside the home and housework)? 5 During the past 4 weeks, how much did pain interfere with your normal work (including both outside the home and housework)? 5 During the past 4 weeks, how much did pain interfere with your normal work (including both outside the home and housework)? 5 During the past 4 weeks, how much did pain interfere with your normal work (including both outside the home and housework)? 5 During the past 4 weeks, how much did pain interfere with your normal work (including both outside the home and housework)?
9 intro How much of the time during the past 4 weeks...
 9 intro How much of the time during the past 4 weeks...
 9 intro How much of the time during the past 4 weeks...
 6 intro How much of the time during the past 4 weeks: 6 intro How much of the time during the past 4 weeks: 6 intro How much of the time during the past 4 weeks: 6 intro How much of the time during the past 4 weeks: 6 intro How much of the time during the past 4 weeks:
9a did you feel full of pep? 9a Did you feel full of pep? 9a Did you feel full of pep?









9b have you been a very nervous person? 9b Have you been a very nervous person? 9b Have you been a very nervous person?









9c have you felt so down in the dumps that nothing could cheer you up? 9c Have you felt so down in the dumps that nothing could cheer you up? 9c Have you felt so down in the dumps that nothing could cheer you up?









9d have you felt calm and peaceful? 9d Have you felt calm and peaceful? 9d Have you felt calm and peaceful? 6a Have you felt calm and peaceful? 6a Have you felt calm and peaceful? 6a Have you felt calm and peaceful? 6a Have you felt calm and peaceful? 6a Have you felt calm and peaceful?
9e did you have a lot of energy? 9e Did you have a lot of energy? 9e Did you have a lot of energy? 6b Did you have a lot of energy? 6b Did you have a lot of energy? 6b Did you have a lot of energy? 6b Did you have a lot of energy? 6b Did you have a lot of energy?
9f have you felt downhearted and blue? 9f Have you felt downhearted and blue? 9f Have you felt downhearted and blue? 6c Have you felt downhearted and blue? 6c Have you felt downhearted and blue? 6c Have you felt downhearted and blue? 6c Have you felt downhearted and blue? 6c Have you felt downhearted and blue?
9g did you feel worn out? 9g Did you feel worn out? 9g Did you feel worn out?









9h have you been a happy person? 9h Have you been a happy person? 9h Have you been a happy person?









9i did you feel tired? 9i Did you feel tired? 9i Did you feel tired?









10 During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? 10 During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? 10 During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? 7 During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? 7 During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? 7 During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? 7 During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? 7 During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?






8 Compared to one year ago, how would you rate your physical health in general now? 8 Compared to one year ago, how would you rate your physical health in general now? 8 Compared to one year ago, how would you rate your physical health in general now? 8 Compared to one year ago, how would you rate your physical health in general now? 8 Compared to one year ago, how would you rate your physical health in general now?






9 Compared to one year ago, how would you rate your emotional problems (such as feeling anxious, depressed or irritable) in general now? 9 Compared to one year ago, how would you rate your emotional problems (such as feeling anxious, depressed or irritable) in general now? 9 Compared to one year ago, how would you rate your emotional problems (such as feeling anxious, depressed or irritable) in general now? 9 Compared to one year ago, how would you rate your emotional problems (such as feeling anxious, depressed or irritable) in general now? 9 Compared to one year ago, how would you rate your emotional problems (such as feeling anxious, depressed or irritable) in general now?
11 intro How TRUE or FALSE is each of the following statements for you? 11 intro How TRUE or FALSE is each of the following statements for you? 11 intro How TRUE or FALSE is each of the following statements for you?









11a I seem to get sick a little easier than other people 11a I seem to get sick a little easier than other people 11a I seem to get sick a little easier than other people









11b I am as healthy as anybody I know 11b I am as healthy as anybody I know 11b I am as healthy as anybody I know









11c I expect my health to get worse 11c I expect my health to get worse 11c I expect my health to get worse









11d My health is excellent 11d My health is excellent 11d My health is excellent









12 intro Because of a health or physical problem, do you have any difficulty doing the following activities? (Please mark one response for each activity.) 12 intro Because of a health or physical problem, do you have any difficulty doing the following activities? (Please mark one response for each activity.) 12 intro Because of a health or physical problem, do you have any difficulty doing the following activities? (Please mark one response for each activity.) 10 intro Because of a health or physical problem, do you have any difficulty doing the following activites without special equipment or help from another person? 10 intro Because of a health or physical problem, do you have any difficulty doing the following activites without special equipment or help from another person? 10 intro Because of a health or physical problem, do you have any difficulty doing the following activites without special equipment or help from another person? 10 intro Because of a health or physical problem, do you have any difficulty doing the following activites without special equipment or help from another person? 10 intro Because of a health or physical problem, do you have any difficulty doing the following activites without special equipment or help from another person?
12a Bathing 12a Bathing 12a Bathing 10a Bathing 10a Bathing 10a Bathing 10a Bathing 10a Bathing
12b Dressing 12b Dressing 12b Dressing 10b Dressing 10b Dressing 10b Dressing 10b Dressing 10b Dressing
12c Eating 12c Eating 12c Eating 10c Eating 10c Eating 10c Eating 10c Eating 10c Eating
12d Getting in or out of chairs 12d Getting in or out of chairs 12d Getting in or out of chairs 10d Getting in or out of chairs 10d Getting in or out of chairs 10d Getting in or out of chairs 10d Getting in or out of chairs 10d Getting in or out of chairs
12e Walking 12e Walking 12e Walking 10e Walking 10e Walking 10e Walking 10e Walking 10e Walking
12f Using the toilet 12f Using the toilet 12f Using the toilet 10f Using the toilet 10f Using the toilet 10f Using the toilet 10f Using the toilet 10f Using the toilet










11 intro Because of a health or physical problem, do you have any difficulty doing the following activities? 11 intro Because of a health or physical problem, do you have any difficulty doing the following activities? 11 intro Because of a health or physical problem, do you have any difficulty doing the following activities?










11a Preparing meals 11a Preparing meals 11a Preparing meals










11b Managing money 11b Managing money 11b Managing money










11c Taking medication as prescribed 11c Taking medication as prescribed 11c Taking medication as prescribed


13 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? (Please enter a number between "0" and "30" days. If no days, please enter "0" days.) 13 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? (Please enter a number between "0" and "30" days. If no days, please enter "0" days.) 11 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? (Please enter a number between "0" and "30" days. If no days, please enter "0" days.) 11 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? (Please enter a number between "0" and "30" days. If no days, please enter "0" days.) 12 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?

Please enter a number between "0" and "30" days. If no days, please enter "0" days. Your best estimate would be fine. 		12 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?

Please enter a number between "0" and "30" days. If no days, please enter "0" days. Your best estimate would be fine. 		12 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?

Please enter a number between "0" and "30" days. If no days, please enter "0" days. Your best estimate would be fine.


14 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? (Please enter a number between "0" and "30" days. If no days, please enter "0" days.) 14 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? (Please enter a number between "0" and "30" days. If no days, please enter "0" days.) 12 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? (Please enter a number between "0" and "30" days. If no days, please enter "0" days.) 12 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? (Please enter a number between "0" and "30" days. If no days, please enter "0" days.) 13 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?

Please enter a number between "0" and "30" days. If no days, please enter "0" days. Your best estimate would be fine. 		13 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?

Please enter a number between "0" and "30" days. If no days, please enter "0" days. Your best estimate would be fine. 		13 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?

Please enter a number between "0" and "30" days. If no days, please enter "0" days. Your best estimate would be fine.


15 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? (Please enter a number between "0" and "30" days. If no days, please enter "0" days.) 15 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? (Please enter a number between "0" and "30" days. If no days, please enter "0" days.) 13 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? (Please enter a number between "0" and "30" days. If no days, please enter "0" days.) 13 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? (Please enter a number between "0" and "30" days. If no days, please enter "0" days.) 14 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?

Please enter a number between "0" and "30" days. If no days, please enter “0” days. Your best estimate would be fine.		 14 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?

Please enter a number between "0" and "30" days. If no days, please enter “0” days. Your best estimate would be fine.		 14 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?

Please enter a number between "0" and "30" days. If no days, please enter “0” days. Your best estimate would be fine.
NA Now we are going to ask some questions about specific medical conditions. NA Now we are going to ask some questions about specific medical conditions. NA Now we are going to ask some questions about specific medical conditions. NA Now we are going to ask some questions about specific medical conditions. NA Now we are going to ask some questions about specific medical conditions. NA Now we are going to ask some questions about specific medical conditions. NA Now we are going to ask some questions about specific medical conditions. NA Now we are going to ask some questions about specific medical conditions.
13 intro During the past 4 weeks, how often have you had any of the following problems? 16 intro During the past 4 weeks, how often have you had any of the following problems? 16 intro During the past 4 weeks, how often have you had any of the following problems? 14 intro During the past 4 weeks, how often have you had any of the following problems? 14 intro During the past 4 weeks, how often have you had any of the following problems?





13a Chest pain or pressure when you exercise 16a Chest pain or pressure when you exercise 16a Chest pain or pressure when you exercise 14a Chest pain or pressure when you exercise 14a Chest pain or pressure when you exercise





13b Chest pain or pressure when resting 16b Chest pain or pressure when resting 16b Chest pain or pressure when resting 14b Chest pain or pressure when resting 14b Chest pain or pressure when resting





14 intro During the past 4 weeks, how often have you felt short of breath under the following conditions? 17 intro During the past 4 weeks, how often have you felt short of breath under the following conditions? 17 intro During the past 4 weeks, how often have you felt short of breath under the following conditions? 15 intro During the past 4 weeks, how often have you felt short of breath under the following conditions? 15 intro During the past 4 weeks, how often have you felt short of breath under the following conditions?





14a When lying down flat 17a When lying down flat 17a When lying down flat 15a When lying down flat 15a When lying down flat





14b When sitting or resting 17b When sitting or resting 17b When sitting or resting 15b When sitting or resting 15b When sitting or resting





14c When walking less than one block 17c When walking less than one block 17c When walking less than one block 15c When walking less than one block 15c When walking less than one block





14d When climbing one flight of stairs 17d When climbing one flight of stairs 17d When climbing one flight of stairs 15d When climbing one flight of stairs 15d When climbing one flight of stairs





15 intro During the past 4 weeks, how much of the time have you had any of the following problems with your legs and feet? (Mark one response for each item.) 18 intro During the past 4 weeks, how much of the time have you had any of the following problems with your legs and feet? (Mark one response for each item.) 18 intro During the past 4 weeks, how much of the time have you had any of the following problems with your legs and feet? (Mark one response for each item.) 16 intro During the past 4 weeks, how much of the time have you had any of the following problems with your legs and feet? 16 intro During the past 4 weeks, how much of the time have you had any of the following problems with your legs and feet?





15a Numbness or loss of feeling in your feet 18a Numbness or loss of feeling in your feet 18a Numbness or loss of feeling in your feet 16a Numbness or loss of feeling in your feet 16a Numbness or loss of feeling in your feet





15b Ankles or legs that swell as the day goes on













15c Tingling or burning sensation in your feet especially at night 18b Tingling or burning sensation in your feet especially at night 18b Tingling or burning sensation in your feet especially at night 16b Tingling or burning sensation in your feet especially at night 16b Tingling or burning sensation in your feet especially at night





15d Decreased ability to feel hot or cold with your feet 18c Decreased ability to feel hot or cold with your feet 18c Decreased ability to feel hot or cold with your feet 16c Decreased ability to feel hot or cold with your feet 16c Decreased ability to feel hot or cold with your feet





15e Sores or wounds on your feet that did not heal 18d Sores or wounds on your feet that did not heal 18d Sores or wounds on your feet that did not heal 16d Sores or wounds on your feet that did not heal 16d Sores or wounds on your feet that did not heal





16a Have you ever had paralysis or weakness on one side of the body? 19a Have you ever had paralysis or weakness on one side of the body? 19a Have you ever had paralysis or weakness on one side of the body?









16b Have you ever lost the ability to talk? 19b Have you ever lost the ability to talk? 19b Have you ever lost the ability to talk?















17 During the past 4 weeks, how would you describe any arthritis pain you usually had? 17 During the past 4 weeks, how would you describe any arthritis pain you usually had?





17 Can you see well enough to read newspaper
print (with your glasses or contacts if that's how you see best)?
 20 Can you see well enough to read newspaper
print (with your glasses or contacts if that's how you see best)?
 20 Can you see well enough to read newspaper
print (with your glasses or contacts if that's how you see best)?
 18 Can you see well enough to read newspaper print (with your glasses or contacts if that's how you see best)? 18 Can you see well enough to read newspaper print (with your glasses or contacts if that's how you see best)? 15 Are you blind or do you have serious difficulty seeing, even when wearing glasses? 15 Are you blind or do you have serious difficulty seeing, even when wearing glasses? 15 Are you blind or do you have serious difficulty seeing, even when wearing glasses?
18 Can you hear most of the things people say (with a hearing aid if that's how you hear best)? 21 Can you hear most of the things people say (with a hearing aid if that's how you hear best)? 21 Can you hear most of the things people say (with a hearing aid if that's how you hear best)? 19 Can you hear most of the things people say (with a hearing aid if that's how you hear best)? 19 Can you hear most of the things people say (with a hearing aid if that's how you hear best)? 16 Are you deaf or do you have serious difficulty hearing, even with a hearing aid? 16 Are you deaf or do you have serious difficulty hearing, even with a hearing aid? 16 Are you deaf or do you have serious difficulty hearing, even with a hearing aid?
19 Do you now have acid indigestion or heartburn?













20 Do you have difficulty controlling urination? 22 Do you have difficulty controlling urination? 22 Do you have difficulty controlling urination?



















17 Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering or making decisions? 17 Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering or making decisions? 17 Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering or making decisions?










18 Do you have serious difficulty walking or climbing stairs?













19 Do you have difficulty dressing or bathing?













20 Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? 18 Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? 18 Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?










21 In the past month, how often did memory problems interfere with your daily activities? 19 In the past month, how often did memory problems interfere with your daily activities? 19 In the past month, how often did memory problems interfere with your daily activities?
NA Has a doctor ever told you that you had: NA Has a doctor ever told you that you had: NA Has a doctor ever told you that you had: NA Has a doctor ever told you that you had: NA Has a doctor ever told you that you had: NA Has a doctor ever told you that you had: NA Has a doctor ever told you that you had: NA Has a doctor ever told you that you had:
21 Hypertension or high blood pressure 23 Hypertension or high blood pressure 23 Hypertension or high blood pressure 20 Hypertension or high blood pressure 20 Hypertension or high blood pressure 22 Hypertension or high blood pressure 20 Hypertension or high blood pressure 20 Hypertension or high blood pressure
22 Angina pectoris or coronary artery disease 24 Angina pectoris or coronary artery disease 24 Angina pectoris or coronary artery disease 21 Angina pectoris or coronary artery disease 21 Angina pectoris or coronary artery disease 23 Angina pectoris or coronary artery disease 21 Angina pectoris or coronary artery disease 21 Angina pectoris or coronary artery disease
23 Congestive heart failure 25 Congestive heart failure 25 Congestive heart failure 22 Congestive heart failure 22 Congestive heart failure 24 Congestive heart failure 22 Congestive heart failure 22 Congestive heart failure
24 A myocardial infarction or heart attack 26 A myocardial infarction or heart attack 26 A myocardial infarction or heart attack 23 A myocardial infarction or heart attack 23 A myocardial infarction or heart attack 25 A myocardial infarction or heart attack 23 A myocardial infarction or heart attack 23 A myocardial infarction or heart attack
25 Other heart conditions, such as problems with heart valves or the rhythm of your heartbeat 27 Other heart conditions, such as problems with heart valves or the rhythm of your heartbeat 27 Other heart conditions, such as problems with heart valves or the rhythm of your heartbeat 24 Other heart conditions, such as problems with heart valves or the rhythm of your heartbeat 24 Other heart conditions, such as problems with heart valves or the rhythm of your heartbeat 26 Other heart conditions, such as problems with heart valves or the rhythm of your heartbeat 24 Other heart conditions, such as problems with heart valves or the rhythm of your heartbeat 24 Other heart conditions, such as problems with heart valves or the rhythm of your heartbeat
26 A stroke 28 A stroke 28 A stroke 25 A stroke 25 A stroke 27 A stroke 25 A stroke 25 A stroke
27 Emphysema, or asthma, or COPD (Chronic Obstructive Pulmonary Disease) 29 Emphysema, or asthma, or COPD (Chronic Obstructive Pulmonary Disease) 29 Emphysema, or asthma, or COPD (Chronic Obstructive Pulmonary Disease) 26 Emphysema, or asthma, or COPD (Chronic Obstructive Pulmonary Disease) 26 Emphysema, or asthma, or COPD (Chronic Obstructive Pulmonary Disease) 28 Emphysema, or asthma, or COPD (Chronic Obstructive Pulmonary Disease) 26 Emphysema, or asthma, or COPD (Chronic Obstructive Pulmonary Disease) 26 Emphysema, or asthma, or COPD (Chronic Obstructive Pulmonary Disease)
28 Crohn’s disease, ulcerative colitis, or inflammatory bowel disease 30 Crohn’s disease, ulcerative colitis, or inflammatory bowel disease 30 Crohn’s disease, ulcerative colitis, or inflammatory bowel disease 27 Crohn’s disease, ulcerative colitis, or inflammatory bowel disease 27 Crohn’s disease, ulcerative colitis, or inflammatory bowel disease 29 Crohn’s disease, ulcerative colitis, or inflammatory bowel disease 27 Crohn’s disease, ulcerative colitis, or inflammatory bowel disease 27 Crohn’s disease, ulcerative colitis, or inflammatory bowel disease
29 Arthritis of the hip or knee 31 Arthritis of the hip or knee 31 Arthritis of the hip or knee 28 Arthritis of the hip or knee 28 Arthritis of the hip or knee 30 Arthritis of the hip or knee 28 Arthritis of the hip or knee 28 Arthritis of the hip or knee
30 Arthritis of the hand or wrist 32 Arthritis of the hand or wrist 32 Arthritis of the hand or wrist 29 Arthritis of the hand or wrist 29 Arthritis of the hand or wrist 31 Arthritis of the hand or wrist 29 Arthritis of the hand or wrist 29 Arthritis of the hand or wrist






30 Osteoporosis, sometimes called thin or brittle bones 30 Osteoporosis, sometimes called thin or brittle bones 32 Osteoporosis, sometimes called thin or brittle bones 30 Osteoporosis, sometimes called thin or brittle bones 30 Osteoporosis, sometimes called thin or brittle bones
31 Sciatica (pain or numbness that travels down
your leg to below your knee)		 33 Sciatica (pain or numbness that travels down
your leg to below your knee)		 33 Sciatica (pain or numbness that travels down
your leg to below your knee)		 31 Sciatica (pain or numbness that travels down
your leg to below your knee)		 31 Sciatica (pain or numbness that travels down
your leg to below your knee)		 33 Sciatica (pain or numbness that travels down
your leg to below your knee)		 31 Sciatica (pain or numbness that travels down
your leg to below your knee)		 31 Sciatica (pain or numbness that travels down
your leg to below your knee)
32 Diabetes, high blood sugar, or sugar in the urine 34 Diabetes, high blood sugar, or sugar in the urine 34 Diabetes, high blood sugar, or sugar in the urine 32 Diabetes, high blood sugar, or sugar in the urine 32 Diabetes, high blood sugar, or sugar in the urine 34 Diabetes, high blood sugar, or sugar in the urine 32 Diabetes, high blood sugar, or sugar in the urine 32 Diabetes, high blood sugar, or sugar in the urine










35 Depression 33 Depression 33 Depression
33 Any cancer (other than skin cancer) 35 Any cancer (other than skin cancer) 35 Any cancer (other than skin cancer) 33 Any cancer (other than skin cancer) 33 Any cancer (other than skin cancer) 36 Any cancer (other than skin cancer) 34 Any cancer (other than skin cancer) 34 Any cancer (other than skin cancer)
34 During the past 4 weeks, how would you describe the arthritis pain you usually had? (Mark one answer) 36 During the past 4 weeks, how would you describe the arthritis pain you usually had? (Mark one answer) 36 During the past 4 weeks, how would you describe the arthritis pain you usually had? (Mark one answer)









35 intro Are you currently under treatment for: 37 intro Are you currently under treatment for: 37 intro Are you currently under treatment for: 34 intro Are you currently under treatment for: 34 intro Are you currently under treatment for: 37 intro Are you currently under treatment for: 35 intro Are you currently under treatment for: 35 intro Are you currently under treatment for:
35a Colon or rectal cancer 37a Colon or rectal cancer 37a Colon or rectal cancer 34a Colon or rectal cancer 34a Colon or rectal cancer 37a Colon or rectal cancer 35a Colon or rectal cancer 35a Colon or rectal cancer
35b Lung cancer 37b Lung cancer 37b Lung cancer 34b Lung cancer 34b Lung cancer 37b Lung cancer 35b Lung cancer 35b Lung cancer
35c Breast cancer 37c Breast cancer 37c Breast cancer 34c Breast cancer 34c Breast cancer 37c Breast cancer 35c Breast cancer 35c Breast cancer
35d Prostate cancer 37d Prostate cancer 37d Prostate cancer 34d Prostate cancer 34d Prostate cancer 37d Prostate cancer 35d Prostate cancer 35d Prostate cancer










37e Other cancer (other than skin cancer) 35e Other cancer (other than skin cancer) 35e Other cancer (other than skin cancer)
36 In the past 4 weeks, how often has low back pain interfered with your usual daily activities (work, school or housework)? 38 In the past 4 weeks, how often has low back pain interfered with your usual daily activities (work, school or housework)? 38 In the past 4 weeks, how often has low back pain interfered with your usual daily activities (work, school or housework)? 35 In the past 4 weeks, how often has low back pain interfered with your usual daily activities (work, school or housework)? 35 In the past 4 weeks, how often has low back pain interfered with your usual daily activities (work, school or housework)?





37 In the past 4 weeks, how often did you have pain, numbness or tingling that travels down your leg and below your knee?













38 In the past year, have you had 2 weeks or more during which you felt sad, blue or depressed; or when you lost interest or pleasure in things that you usually cared about or enjoyed?
 39 In the past year, have you had 2 weeks or more during which you felt sad, blue or depressed; or when you lost interest or pleasure in things that you usually cared about or enjoyed?
 39 In the past year, have you had 2 weeks or more during which you felt sad, blue or depressed; or when you lost interest or pleasure in things that you usually cared about or enjoyed?
 36 In the past year, have you had 2 weeks or more during which you felt sad, blue or depressed; or when you lost interest or pleasure in things that you usually cared about or enjoyed 36 In the past year, have you had 2 weeks or more during which you felt sad, blue or depressed; or when you lost interest or pleasure in things that you usually cared about or enjoyed





39 In the past year, have you felt depressed or sad much of the time? 40 In the past year, have you felt depressed or sad much of the time? 40 In the past year, have you felt depressed or sad much of the time? 37 In the past year, have you felt depressed or sad much of the time? 37 In the past year, have you felt depressed or sad much of the time?





40 Have you ever had 2 years or more in your life when you felt depressed or sad most days, even if you felt okay sometimes? 41 Have you ever had 2 years or more in your life when you felt depressed or sad most days, even if you felt okay sometimes? 41 Have you ever had 2 years or more in your life when you felt depressed or sad most days, even if you felt okay sometimes? 38 Have you ever had 2 years or more in your life when you felt depressed or sad most days, even if you felt okay sometimes? 38 Have you ever had 2 years or more in your life when you felt depressed or sad most days, even if you felt okay sometimes?













39 How much of the time in the past week did you feel depressed?















38 In the past 7 days, how much did pain interfere with your day to day activities? 36 In the past 7 days, how much did pain interfere with your day to day activities? 36 In the past 7 days, how much did pain interfere with your day to day activities?










39 In the past 7 days, how often did pain keep you from socializing with others? 37 In the past 7 days, how often did pain keep you from socializing with others? 37 In the past 7 days, how often did pain keep you from socializing with others?










40 In the past 7 days, how would you rate your pain on average? 38 In the past 7 days, how would you rate your pain on average? 38 In the past 7 days, how would you rate your pain on average?










41 intro Over the past 2 weeks, how often have you been bothered by any of the following problems? 39 intro Over the past 2 weeks, how often have you been bothered by any of the following problems? 39 intro Over the past 2 weeks, how often have you been bothered by any of the following problems?










41a Little interest or pleasure in doing things 39a Little interest or pleasure in doing things 39a Little interest or pleasure in doing things










41b Feeling down, depressed or hopeless 39b Feeling down, depressed or hopeless 39b Feeling down, depressed or hopeless
41 In general, compared to other people your age, would you say that your health is: 42 In general, compared to other people your age, would you say that your health is: 42 In general, compared to other people your age, would you say that your health is: 39 In general, compared to other people your age, would you say that your health is: 40 In general, compared to other people your age, would you say that your health is: 42 In general, compared to other people your age, would you say that your health is: 40 In general, compared to other people your age, would you say that your health is: 40 In general, compared to other people your age, would you say that your health is:
42 Have you ever smoked at least 100 cigarettes in your entire life?













43 Do you now smoke every day, some days, or not at all? 43 Do you now smoke every day, some days, or not at all? 43 Do you now smoke every day, some days, or not at all? 40 Do you now smoke every day, some days, or not at all? 41 Do you now smoke every day, some days, or not at all? 43 Do you now smoke every day, some days, or not at all? 43 Do you now smoke every day, some days, or not at all? 41 Do you now smoke every day, some days, or not at all?
44 How long has it been since you quit smoking cigarettes?













45 In the last 6 months, on how many visits were you advised to quit smoking by a doctor or other health provider in your plan?















44 Many people experience problems with urinary incontinence, the leakage of urine. In the last 6 months, have you accidentally leaked urine? 44 Many people experience problems with urinary incontinence, the leakage of urine. In the last 6 months, have you accidentally leaked urine? 41 Many people experience problems with urinary incontinence, the leakage of urine. In the past 6 months, have you accidentally leaked urine? 42 Many people experience problems with urinary incontinence, the leakage of urine. In the past 6 months, have you accidentally leaked urine? 44 Many people experience problems with urinary incontinence, the leakage of urine. In the past 6 months, have you accidentally leaked urine? 42 Many people experience problems with urinary incontinence, the leakage of urine. In the past 6 months, have you accidentally leaked urine? 42 Many people experience leakage of urine, also called urinary incontinence. In the past six months, have you experienced leaking of urine?


45 How much of a problem, if any, was the urine leakage for you? 45 How much of a problem, if any, was the urine leakage for you? 42 How much of a problem, if any, was the urine leakage for you? 43 How much of a problem, if any, was the urine leakage for you? 45 How much of a problem, if any, was the urine leakage for you? 43 How much of a problem, if any, was the urine leakage for you? 43 During the past six months, how much did leaking of urine make you change your daily activities or interfere with your sleep?


46 Have you talked with your current doctor or other health provider about your urine leakage problem? 46 Have you talked with your current doctor or other health provider about your urine leakage problem? 43 Have you talked with your current doctor or other health provider about your urine leakage problem? 44 Have you talked with your current doctor or other health provider about your urine leakage problem? 46 Have you talked with your current doctor or other health provider about your urine leakage problem? 44 Have you talked with your current doctor or other health provider about your urine leakage problem? 44 Have you ever talked with a doctor, nurse, or other health care provider about leaking of urine?


47 There are many ways to treat urinary incontinence including bladder training, exercises, medication and surgery. Have you received these or any other treatments for your current urine leakage problem? 47 There are many ways to treat urinary incontinence including bladder training, exercises, medication and surgery. Have you received these or any other treatments for your current urine leakage problem? 44 There are many ways to treat urinary incontinence including bladder training, exercises, medication and surgery. Have you received these or any other treatments for your current urine leakage problem? 45 There are many ways to treat urinary incontinence including bladder training, exercises, medication and surgery. Have you received these or any other treatments for your current urine leakage problem? 47 There are many ways to treat urinary incontinence including bladder training, exercises, medication and surgery. Have you received these or any other treatments for your current urine leakage problem? 45 There are many ways to treat urinary incontinence including bladder training, exercises, medication and surgery. Have you received these or any other treatments for your current urine leakage problem? 45 There are many ways to control or manage the leaking of urine, including bladder training exercises, medication and surgery. Have you ever talked with a doctor, nurse, or other health care provider about any of these approaches?




48 In the last 12 months, did you talk with a doctor or other health provider about your level of exercise or physical activity? For example, a doctor or other health provider may ask if you exercise regularly or take part in physical exercise. 45 In the past 12 months, did you talk with a doctor or other health provider about your level of exercise or physical activity? For example, a doctor or other health provider may ask if you exercise regularly or take part in physical exercise. 46 In the past 12 months, did you talk with a doctor or other health provider about your level of exercise or physical activity? For example, a doctor or other health provider may ask if you exercise regularly or take part in physical exercise. 48 In the past 12 months, did you talk with a doctor or other health provider about your level of exercise or physical activity? For example, a doctor or other health provider may ask if you exercise regularly or take part in physical exercise. 46 In the past 12 months, did you talk with a doctor or other health provider about your level of exercise or physical activity? For example, a doctor or other health provider may ask if you exercise regularly or take part in physical exercise. 46 In the past 12 months, did you talk with a doctor or other health provider about your level of exercise or physical activity? For example, a doctor or other health provider may ask if you exercise regularly or take part in physical exercise.




49 In the last 12 months, did a doctor or other health provider advise you to start, increase or maintain your level of exercise or physical activity? For example, in order to improve your health, your doctor or other health provider may advise you to start taking the stairs, increase walking from 10 to 20 minutes every day or to maintain your current exercise program. 46 In the past 12 months, did a doctor or other health provider advise you to start, increase or maintain your level of exercise or physical activity? For example, in order to improve your health, your doctor or other health provider may advise you to start taking the stairs, increase walking from 10 to 20 minutes every day or to maintain your current exercise program. 47 In the past 12 months, did a doctor or other health provider advise you to start, increase or maintain your level of exercise or physical activity? For example, in order to improve your health, your doctor or other health provider may advise you to start taking the stairs, increase walking from 10 to 20 minutes every day or to maintain your current exercise program. 49 In the past 12 months, did a doctor or other health provider advise you to start, increase or maintain your level of exercise or physical activity? For example, in order to improve your health, your doctor or other health provider may advise you to start taking the stairs, increase walking from 10 to 20 minutes every day or to maintain your current exercise program. 47 In the past 12 months, did a doctor or other health provider advise you to start, increase or maintain your level of exercise or physical activity? For example, in order to improve your health, your doctor or other health provider may advise you to start taking the stairs, increase walking from 10 to 20 minutes every day or to maintain your current exercise program. 47 In the past 12 months, did a doctor or other health provider advise you to start, increase or maintain your level of exercise or physical activity? For example, in order to improve your health, your doctor or other health provider may advise you to start taking the stairs, increase walking from 10 to 20 minutes every day or to maintain your current exercise program.






47 A fall is when your body goes to the ground without being pushed. In the past 12 months, did you talk with your doctor or other health provider about falling or problems with balance or walking? 48 A fall is when your body goes to the ground without being pushed. In the past 12 months, did you talk with your doctor or other health provider about falling or problems with balance or walking? 50 A fall is when your body goes to the ground without being pushed. In the past 12 months, did you talk with your doctor or other health provider about falling or problems with balance or walking? 48 A fall is when your body goes to the ground without being pushed. In the past 12 months, did you talk with your doctor or other health provider about falling or problems with balance or walking? 48 A fall is when your body goes to the ground without being pushed. In the past 12 months, did you talk with your doctor or other health provider about falling or problems with balance or walking?






48 Did you fall in the past 12 months? 49 Did you fall in the past 12 months? 51 Did you fall in the past 12 months? 49 Did you fall in the past 12 months? 49 Did you fall in the past 12 months?






49 In the past 12 months, have you had a problem with balance or walking? 50 In the past 12 months, have you had a problem with balance or walking? 52 In the past 12 months, have you had a problem with balance or walking? 50 In the past 12 months, have you had a problem with balance or walking? 50 In the past 12 months, have you had a problem with balance or walking?






50 Has your doctor or other health provider done anything to help prevent falls or treat problems with balance or walking? Some things they might do include:
• Suggest that you use a cane or walker.
• Check your blood pressure lying or standing.
• Suggest that you do an exercise or physical therapy program.
• Suggest a vision or hearing testing.
 51 Has your doctor or other health provider done anything to help prevent falls or treat problems with balance or walking? Some things they might do include:
• Suggest that you use a cane or walker.
• Check your blood pressure lying or standing.
• Suggest that you do an exercise or physical therapy program.
• Suggest a vision or hearing testing.
 53 Has your doctor or other health provider done anything to help prevent falls or treat problems with balance or walking? Some things they might do include:
• Suggest that you use a cane or walker.
• Check your blood pressure lying or standing.
• Suggest that you do an exercise or physical therapy program.
• Suggest a vision or hearing testing.
 51 Has your doctor or other health provider done anything to help prevent falls or treat problems with balance or walking? Some things they might do include:
• Suggest that you use a cane or walker.
• Check your blood pressure lying or standing.
• Suggest that you do an exercise or physical therapy program.
• Suggest a vision or hearing testing.
 51 Has your doctor or other health provider done anything to help prevent falls or treat problems with balance or walking? Some things they might do include:
• Suggest that you use a cane or walker.
• Suggest that you do an exercise or physical therapy program.
• Suggest a vision or hearing test.






51 Have you ever had a bone density test to check for osteoporosis, sometimes thought of as “brittle bones”? This test may have been done to your back, hip, wrist, heel or finger. 52 Have you ever had a bone density test to check for osteoporosis, sometimes thought of as “brittle bones”? This test may have been done to your back, hip, wrist, heel or finger. 54 Have you ever had a bone density test to check for osteoporosis, sometimes thought of as “brittle bones”? This test may have been done to your back, hip, wrist, heel or finger. 52 Have you ever had a bone density test to check for osteoporosis, sometimes thought of as “brittle bones”? This test may have been done to your back, hip, wrist, heel or finger. 52 Have you ever had a bone density test to check for osteoporosis, sometimes thought of as “brittle bones”? This test would have been done to your back or hip.














53 During the past month, on average, how many hours of actual sleep did you get at night? (This may be different from the number of hours you spent in bed.)














54 During the past month, how would you rate your overall sleep quality?






52 How much do you weigh in pounds (lbs.)? 53 How much do you weigh in pounds (lbs.)? 55 How much do you weigh in pounds (lbs.)? 53 How much do you weigh in pounds (lbs.)? 55 How much do you weigh in pounds (lbs.)?






53 How tall are you without shoes on in feet (ft.) and inches (in.)? (If 1/2 in., please round up.) 54 How tall are you without shoes on in feet (ft.) and inches (in.)? (If 1/2 in., please round up.) 56 How tall are you without shoes on in feet (ft.) and inches (in.)? (If 1/2 in., please round up.) 54 How tall are you without shoes on in feet (ft.) and inches (in.)? Please remember to fill in both feet and inches (for example, 5ft. 00 in.) If 1/2 in., please round up. 56 How tall are you without shoes on in feet (ft.) and inches (in.)? Please remember to fill in both feet and inches (for example, 5 ft. 00 in.) If 1/2 in., please round up.
46 In what year were you born? Please provide your year of birth only. For example, if your date of birth is January 1, 1935, please answer “1935”. 48 In what year were you born? Please provide your year of birth only. For example, if your date of birth is January 1, 1935, please answer “1935”. 50 In what year were you born? Please provide your year of birth only. For example, if your date of birth is January 1, 1935, please answer “1935”. 54 In what year were you born? Please provide your year of birth only. For example, if your date of birth is January 1, 1935, please answer “1935.” 55 In what year were you born? Please provide your year of birth only. 57 In what year were you born? Please provide your year of birth only.



47 Are you male or female? 49 Are you male or female? 51 Are you male or female? 55 Are you male or female? 56 Are you male or female? 58 What is your sex? 55 Are you male or female? 57 Are you male or female?
48 Are you of Hispanic or Spanish family background? 50 Are you of Hispanic or Spanish family background? 52 Are you of Hispanic or Spanish family background? 56 Are you of Hispanic or Latino origin or descent? 57 Are you of Hispanic or Latino origin or descent? 59 Are you Hispanic, Latino/a or Spanish Origin? (One or more categories may be selected) 56 Are you Hispanic, Latino/a or Spanish Origin? (One or more categories may be selected) 58 Are you Hispanic, Latino/a or Spanish Origin? (One or more categories may be selected)
49 How would you describe your race? 51 How would you describe your race? 53 How would you describe your race? 57 How would you describe your race? Please mark one or more. 58 How would you describe your race? Please mark one or more. 60 What is your race? (One or more categories may be selected) 57 What is your race? (One or more categories may be selected) 59 What is your race? (One or more categories may be selected)










61 How well do you speak English? 58 How well do you speak English?















60 What language do you mainly speak at home?
50 What is your current marital status? 52 What is your current marital status? 54 What is your current marital status? 58 What is your current marital status? 59 What is your current marital status? 62 What is your current marital status? 59 What is your current marital status? 61 What is your current marital status?
51 What is the highest grade or level of school that you have completed? 53 What is the highest grade or level of school that you have completed? 55 What is the highest grade or level of school that you have completed? 59 What is the highest grade or level of school that you have completed? 60 What is the highest grade or level of school that you have completed? 63 What is the highest grade or level of school that you have completed? 60 What is the highest grade or level of school that you have completed? 62 What is the highest grade or level of school that you have completed?










64 Do you live alone or with others? (One or more categories may be selected) 61 Do you live alone or with others? (One or more categories may be selected) 63 Do you live alone or with others? (One or more categories may be selected)










65 Where do you live? 62 Where do you live? 64 Where do you live?
52 Is the house or apartment you currently live in: 54 Is the house or apartment you currently live in: 56 Is the house or apartment you currently live in: 60 Is the house or apartment you currently live in: 61 Is the house or apartment you currently live in: 66 Is the house or apartment you currently live in: 63 Is the house or apartment you currently live in: 65 Is the house or apartment you currently live in:
53 Is this house or apartment in a retirement community, building or complex?













54 If you answered "yes" to question 53 above, Does this retirement community/building/ facility provide medical services?























67 Do you currently provide care for someone else in your home?













68 During the past week, how many days did you provide at least some care?













69 Do you have difficulty getting to places you need to go (either by driving or by getting a ride)?



55 Who completed this survey form? 55 Who completed this survey form? 57 Who completed this survey form? 61 Who completed this survey form? 62 Who completed this survey form? 70 Who completed this survey form? 64 Who completed this survey form? 66 Who completed this survey form?
56 What is the name of the person who completed this survey form? Please print clearly. 56 What is the name of the person who completed this survey form? Please print clearly. 58 What is the name of the person who completed this survey form? Please print clearly. 62 What is the name of the person who completed this survey form? Please print clearly. 63 What is the name of the person who completed this survey form? Please print clearly. 71 What is the name of the person who completed this survey form? Please print clearly. 65 What is the name of the person who completed this survey form? Please print clearly. 67 If you completed the survey for someone else, please fill in your name. DO NOT complete this question if you completed the survey for yourself. Please print clearly.
57 Which of the following categories best represents the combined income for all family members in your household for the past 12 months? 57 Which of the following categories best represents the combined income for all family members in your household for the past 12 months? 59 Which of the following categories best represents the combined income for all family members in your household for the past 12 months? 63 Which of the following categories best represents the combined income for all family members in your household for the past 12 months? 64 Which of the following categories best represents the combined income for all family members in your household for the past 12 months? 72 Which of the following categories best represents the combined income for all family members in your household for the past 12 months? 66 Which of the following categories best represents the combined income for all family members in your household for the past 12 months? 68 Which of the following categories best represents the combined income for all family members in your household for the past 12 months?
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