Form 0920-1291 CDC Questionnaire - BRFSS subset

ATTACHMENT 1: CDC QUESTIONNAIRE

1-6. Has a doctor, nurse, or other health professional ever told you that you had any of the following? [GRID FORMAT OFFERING RESPONSE OPTIONS OF YES / NO / DON’T KNOW OR NOT SURE]

• Heart attack, also called a myocardial infarction?

• Angina or coronary heart disease?

• A stroke?

• Asthma?

• Some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?

• A depressive disorder (including depression, major depression, dysthymia, or minor depression)?

7. Has a doctor, nurse, or other health professional ever told you that you had diabetes?

• Yes

• No

• Don’t know / Not sure

8. [If “Yes” to diabetes and respondent is female]: Was this only when you were pregnant?

• Yes

• No

• Don’t know / Not sure

9. Has a doctor, nurse, or other health professional ever told you that you had high blood pressure?

• Yes

• No

• Don’t know / Not sure

10. [If “Yes” to HIGH BLOOD PRESSURE and respondent is female]: Was this only when you were pregnant?

• Yes

• No

• Don’t know / Not sure

11. Not including kidney stones, bladder infection or incontinence, were you ever told you have kidney disease?

• Yes

• No

• Don’t know / Not sure

12. Are you blind or do you have serious difficulty seeing, even when wearing glasses or contact lenses?

• Yes

• No

• Don’t know / Not sure

13. Do you have serious difficulty walking or climbing stairs?

• Yes

• No

• Don’t know / Not sure

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

• Yes

• No

• Don’t know / Not sure

15. 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?

_ _ Number of days (01-30)

• None

• Don’t know/not sure

16. [ASK ONLY IF HAVE SMOKED AT LEAST 100 CIGARETTES IN LIFE] Do you now smoke cigarettes every day, some days, or not at all?

• Every day

• Some days

• Not at all

• Don’t know / Not sure

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

• Every day

• Some days

• Not at all

• Don’t know / Not sure

18. During the past 12 months, have you had either a flu vaccine that was sprayed in your nose or a flu shot injected into your arm?

• Yes

• No

• Don’t know / Not sure

19. Do you own or rent your home?

• Own

• Rent

• Other arrangement

• Don’t know / Not sure

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

• Never attended school or only attended kindergarten

• Grades 1 through 8 (Elementary)

• Grades 9 through 11 (Some high school)

• Grade 12 or GED (High school graduate)

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

• College 4 years or more (College graduate)

21. Which one or more of the following would you say is your race? (Select all that apply.)

• White

• Black or African American

• American Indian or Alaska Native

• Asian

• Pacific Islander

• Other

22. About how tall are you without shoes?

--/-- feet/inches

23. About how much do you weigh without shoes?

_ _ _ _ pounds

24. Do you have one person or a group of doctors that you think of as your personal health care provider?

• Yes, only one

• More than one

• No

• Don’t know / Not sure

25. Was there a time in the past 12 months when you needed to see a doctor but could not because you could not afford it?

• Yes

• No

• Don’t know / Not sure

26. 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.

• Within the past year (anytime less than 12 months ago)

• Within the past 2 years (1 year but less than 2 years ago)

• Within the past 5 years (2 years but less than 5 years ago)

• 5 or more years ago

• Don’t know / Not sure