1998 Behavioral Risk Factor Surveillance System
		                     Core Questionnaire and Modules

CORE SECTIONS
Introduction and Respondent Selection..............................................................................................1
Section 1:	Health Status..............................................................................................................3
Section 2:	Health Care Access.....................................................................................................5
Section 3:	Diabetes....................................................................................................................10
Section 4:	Exercise....................................................................................................................11
Section 5:	Tobacco Use.............................................................................................................14
Section 6:	Fruits and Vegetables................................................................................................18
Section 7:	Weight Control..........................................................................................................21
Section 8:	Demographics............................................................................................................24
Section 9:	Women’s Health........................................................................................................29
Section 10:	HIV/AIDS.................................................................................................................33

OPTIONAL MODULES
Module 1:	Diabetes....................................................................................................................40
Module 2:	Sexual Behavior........................................................................................................44
Module 3:	Family Planning........................................................................................................48
Module 4:	Health Care Coverage..............................................................................................53
Module 5:	Health Care Utilization.............................................................................................57
Module 6:	Oral Health...............................................................................................................62
Module 7:	Preventive Counseling Services.................................................................................64
Module 8:	Hypertension Awareness...........................................................................................67
Module 9:	Cholesterol Awareness..............................................................................................68
Module 10:	Colorectal Cancer Screening.....................................................................................69
Module 11:	Immunization............................................................................................................71
Module 12:	Injury Control...........................................................................................................72
Module 13:	Alcohol Consumption...............................................................................................75
Module 14:	Cardiovascular Disease.............................................................................................77
Module 15:	Arthritis....................................................................................................................81
Module 16:	Quality of Life..........................................................................................................83
Module 17:	Folic Acid................................................................................................................87
Module 18:	Firearms...................................................................................................................89
Module 19:	Social Context..........................................................................................................92
Module 20:	Tobacco Use Prevention.......................................................................................... 94
Module 21:	Smokeless Tobacco..................................................................................................97

HELLO,  I'm                           calling for the                                        .  We're doing a study of the health practices of                        residents.  Your phone number has been chosen randomly by the                                      to be included in the study, and we'd like to ask some questions about things people do which may affect their health.

Is this                          ?		No	Thank you very much, but I seem to have dialed the wrong number,  It's possible that your number may be called at a later time.  Stop

Is this a private residence?		No	Thank you very much, but we are only interviewing private residences.  Stop

Our study requires that we randomly select one adult who lives in your household to be interviewed.  How many members of your household, including yourself, are 18 years of age or older?

	If "1"	Are you the adult?

		If "yes"	Then you are the person I need to speak with.  Go to page 3

		If "no"	May I speak with him or her?  Go to "correct respondent" at bottom of page

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

Who is the oldest man who presently lives in this household?
Who is the next oldest man who presently lives in this household?
Etc.

Who is the oldest woman who presently lives in this household?
Who is the next oldest woman who presently lives in this household?
Etc.

The person in your household that I need to speak with is                                                                .
									If "you," go to page 3

To correct respondent	Hello, I’m                                     calling for the                             . I'm a member of a special research team. We're doing a study of                         residents regarding their health practices and day-to-day living habits. You have been randomly chosen to be included in the study from among the adult members of your household.

The interview will only take a short time, and all the information obtained in this study will be confidential.

Section 1: Health Status

1.	Would you say that in general your health is:	(35)

		Please Read

		a.  Excellent	1

		b.  Very good	2

		c.  Good	3

		d.  Fair	4
			or
		e.  Poor	5

Do not				Don't know/Not Sure	7
read these
responses			Refused	9

2.	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?	(36-37)

		a.  Number of days	         
	
		b.  None	8  8

			Don't know/Not sure	7  7

			Refused	9  9

3.	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?
				(38-39)

		a.  Number of days 	         

		b.  None  If Q2 also "None," go to Q5 (p. 5)	8  8

			Don't know/Not sure	7  7

			Refused	9  9

4.	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?	(40-41)

		a.  Number of days	         
	
		b.  None	8  8

			Don't know/Not sure	7  7

			Refused	9  9

Section 2:  Health Care Access

5.	Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?	(42)

		a.  Yes	1

		b.  No  Go to Q7a (p. 7)	2

			Don't know/Not sure  Go to Q10 (p. 8)	7

			Refused  Go to Q10 (p. 8)	9

6.	Medicare is a coverage plan for people 65 or over and for certain disabled people.  Do you have Medicare?		(43)

		a.	Yes  Go to Q10 (p. 8)	1

		b.	No	2

			Don’t know/not sure	7

			Refused	9

7.	What type of health care coverage do you use to pay for most of your medical care?
				(44-45)

Is it coverage through:         Coverage Code	         

		Please Read 

	a.  Your employer  Go to Q8 (p. 8)	0 1

		b.  Someone else’s employer  Go to Q8 (p. 8)	0 2

	c.  A plan that you or someone else buys on
			your own  Go to Q8 (p. 8)	0 3

		d.  Medicare  Go to Q10 (p. 8)	0 4

		e.  Medicaid or Medical Assistance [or substitute state program name]
		     Go to Q8 (p. 8)	0 5

	f.  The military, CHAMPUS, TriCare, or the VA
			[or CHAMP-VA]  Go to Q8 (p. 8)	0 6

		g.  The Indian Health Service [or the Alaska Native Health Service]
		     Go to Q8 (p. 8)	0 7
			or
		h.  Some other source  Go to Q8 (p. 8)	0 8	

Do not				None  Go to Q9 (p. 8)	8 8
read these
responses			Don't know/Not sure  Go to Q8 (p. 8)	7 7

			Refused  Go to Q8 (p. 8)	9 9

7a.	There are some types of coverage you may not have considered. Please tell me if you have any of the following:	(46-47)

	Coverage through:               Coverage Code	         

		Please Read 

If more than		a.  Your employer	0 1
one, ask
"Which type		b.  Someone else’s employer	0 2
do you use to
pay for most		c.  A plan that you or someone else buys on
of your				your own	0 3
medical care?"
		d.  Medicare  Go to Q10 (p. 8)	0 4

		e.  Medicaid or Medical Assistance [or substitute state program name]	0 5

	f.  The military, CHAMPUS, TriCare, or the VA [or CHAMP-VA]	0 6

		g.  The Indian Health Service [or the Alaska Native Health Service]	0 7
			or
		h.  Some other source	0 8	

Do not				None  Go to Q9 (p. 8)	8 8
read these
responses			Don't know/Not sure Go to Q10 (p. 8)	7 7

			Refused  Go to Q10 (p. 8)	9 9

8.	During the past 12 months, was there any time that you did not have any health insurance or coverage?			(48)

		a.  Yes  Go to Q10	1

		b.  No  Go to Q10	2

			Don't know/Not sure  Go to Q10	7

			Refused  Go to Q10	9

9.	About how long has it been since you had health care coverage?		(49)

		Read Only if Necessary

		a.  Within the past 6 months  (1 to 6 months ago)	1

		b.  Within the past year  (6 to 12 months ago)	2	

		c.  Within the past 2 years  (1 to 2 years ago)	3

		d.  Within the past 5 years  (2 to 5 years ago)	4

		e.  5 or more years ago	5

			Don't know/Not sure	7

			Never	8

			Refused	9

10.	Was there a time during the last 12 months when you needed to see a doctor, but could not because of the cost?		(50)

		a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

11.	About how long has it been since you last visited a doctor for a routine checkup?		(51)

		Read Only if Necessary

A routine		a.  Within the past year  (1 to 12 months ago)	1
checkup is a
general phys-		b.  Within the past 2 years  (1 to 2 years ago)	2
ical exam, not
an exam for		c.  Within the past 5 years  (2 to 5 years ago)	3
a specific
injury, ill-		d.  5 or more years ago	4
ness, or con-
dition				Don't know/Not sure	7

			Never	8

			Refused	9

Section 3:  Diabetes

12.	Have you ever been told by a doctor that you have diabetes?		(52)

If "Yes" and
female, ask		a.  Yes	1
"Was this 
only when		b.  Yes, but female told only during pregnancy	2
you were
pregnant?"		c.  No	3

			Don't know/Not sure	7

			Refused	9

Section 4:  Exercise

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

13.	During the past month, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?		(53)
	
		a.  Yes	1

		b.  No  Go to Q23 (p. 14)	2

			Don't know/Not sure  Go to Q23 (p. 14)	7

			Refused  Go to Q23 (p. 14)	9

14.	What type of physical activity or exercise did you spend the most time doing during the past month?			(54-55)

			Activity (specify): _________________________	         
		                                        See coding list A

			Refused  Go to Q18 (p. 12)	9  9

ö Ask Q15 only if answer to Q14 is running, jogging, walking, or swimming.  All others, go to Q16.

15.	How far did you usually walk/run/jog/swim?		(56-58)

See coding			Miles and tenths	         .    
list B if
response is			Don't know/Not sure	7   7   7
not in miles
and tenths			Refused	9   9   9

16.	How many times per week or per month did you take part in this activity during the past month?
					(59-61)

		a.  Times per week	1          

		b.  Times per month	2          

			Don't know/Not sure	7   7   7

			Refused	9   9   9

17.	And when you took part in this activity, for how many minutes or hours did you usually keep at it?
					(62-64)

			Hours and minutes	    :         

			Don't know/Not sure	7   7   7

			Refused	9   9   9  

18.	Was there another physical activity or exercise that you participated in during the last month?
					(65)

		a.  Yes	1

		b.  No  Go to Q23 (p. 14)	2

			Don't know/Not sure  Go to Q23 (p. 14)	7

			Refused  Go to Q23 (p. 14)	9

19.	What other type of physical activity gave you the next most exercise during the past month?
					(66-67)

			Activity (specify): __________________________ 	         
		                                           See coding list A

			Refused  Go to Q23 (p. 14)	9  9

ö Ask Q20 only if answer to Q19 is running, jogging, walking, or swimming.  All others go to Q21 (p. 13).

20.	How far did you usually walk/run/jog/swim?		(68-70)

See coding
list B if			Miles and tenths	         .    
response is
not in			Don't know/Not sure	7   7   7
miles and
tenths			Refused	9   9   9

21.	How many times per week or per month did you take part in this activity?		(71-73)

		a.  Times per week	1          

		b.  Times per month	2          

			Don't know/Not sure	7   7   7

			Refused	9   9   9

22.	And when you took part in this activity, for how many minutes or hours did you usually keep at it?
					(74-76)

			Hours and minutes	    :         

			Don't know/Not sure	7   7   7

			Refused	9   9   9

Section 5:  Tobacco Use

23.	Have you smoked at least 100 cigarettes in your entire life?		(77)

5 packs
= 100			a.  Yes	1
cigarettes
		b.  No  Go to Q28 (p. 16)	2

			Don't know/Not sure  Go to Q28 (p. 16)	7

			Refused  Go to Q28 (p. 16)	9

24.	Do you now smoke cigarettes everyday, some days, or not at all?		(78)	

		a.  Everyday	1

		b.  Some days  Go to Q25a	2

		c.  Not at all  Go to Q27 (p. 15)	3

			Refused  Go to Q28 (p. 16)	9

25.	On the average, about how many cigarettes a day do you now smoke?		(79-80)

1 pack = 20			Number of cigarettes [76 = 76 or more]
cigarettes			Go to Q26 (p. 15)	         

			Don't know/Not sure  Go to Q26 (p. 15)	 7  7

			Refused  Go to Q26 (p. 15)	 9  9

25a.	On the average, when you smoked during the past 30 days, about how many cigarettes did you smoke a day?		(81-82)

1 pack = 20 			Number of cigarettes [76 = 76 or more]
cigarettes			Go to Q28 (p. 16)	         
			
			Don't know/Not sure  Go to Q28 (p. 16)	 7  7
	
			Refused  Go to Q28 (p. 16)	 9  9

26.	During the past 12 months, have you quit smoking for 1 day or longer?		(83)

		a.  Yes  Go to Q28 (p. 16)	1

		b.  No  Go to Q28 (p. 16)	2

			Don't know/Not sure  Go to Q28 (p. 16)	7

			Refused  Go to Q28 (p. 16)	9

27.	About how long has it been since you last smoked cigarettes regularly, that is, daily?
					(84-85)

			Time code	         

		Read Only if Necessary

		a.  Within the past month (0 to 1 month ago)	0 1

		b.  Within the past 3 months (1 to 3 months ago)	0 2

		c.  Within the past 6 months (3 to 6 months ago)	0 3

		d.  Within the past year (6 to 12 months ago)	0 4

		e.  Within the past 5 years (1 to 5 years ago)	0 5

		f.  Within the past 15 years (5 to 15 years ago)	0 6

		g.  15 or more years ago	0 7

			Don't know/Not sure	7 7 

			Never smoked regularly	8 8 

			Refused	9 9

28.  Have you ever smoked a cigar, even just a few puffs?		(86)
 
Cigar =		a.  Yes	1
large cigar
cigarillo,		b.  No Go to Section 6: Fruits and Vegetables  (p. 18)	2
or small cigar	
					Don’t know/Not sure Go to Section 6: Fruits and Vegetables (p. 18)	7

			Refused Go to Section 6: Fruits and Vegetables (p. 18)	9

29.  When was the last time you smoked a cigar?		(87-88)

			Time code	         

		Read Only if Necessary

		a.  Within the past month (0 to 1 month ago)	0 1

		b.  Within the past 3 months (1 to 3 months ago)
			Go to Section 6: Fruits and Vegetables (p. 18)	0 2

		c.  Within the past 6 months (3 to 6 months ago)
			Go to Section 6: Fruits and Vegetables (p. 18)	0 3

		d.  Within the past year (6 to 12 months ago)
			Go to Section 6: Fruits and Vegetables (p. 18)	0 4

		e.  Within the past 5 years (1 to 5 years ago)
			Go to Section 6: Fruits and Vegetables (p. 18)	0 5

		f.  Within the past 15 years (5 to 15 years ago)
			Go to Section 6: Fruits and Vegetables (p. 18)	0 6

		g.  15 or more years ago  Go to Section 6: Fruits and Vegetables (p. 18)	0 7

			Don’t know/not sure  Go to Section 6: Fruits and Vegetables (p. 18)	7 7

			Refused  Go to Section 6: Fruits and Vegetables (p. 18)	9 9

30.  In the past month, did you smoke cigars:		(89)

		Please Read

		a.  Everyday	1

		b.  Several times per week	2

		c.  Once per week 	3
		     or
		d.  Less than once per week	4

Do not				Don’t know/Not sure	7
read these
responses			Refused	9

Section 6: Fruits and Vegetables

These next questions are about the foods you usually eat or drink.  Please tell me how often you eat or drink each one, for example, twice a week, three times a month, and so forth.  Remember, I am only interested in the foods you eat.  Include all foods you eat, both at home and away from home.

31.	How often do you drink fruit juices such as orange, grapefruit, or tomato?		(90-92)

		a.  Per day	1            

		b.  Per week	2            

		c.  Per month	3            
 
		d.  Per year	4            

		e.  Never	5   5   5

			Don't know/Not sure	7   7   7

			Refused	9   9   9

32.	Not counting juice, how often do you eat fruit?		(93-95)

		a.  Per day	1            

		b.  Per week	2            

		c.  Per month	3            
 
		d.  Per year	4            

		e.  Never	5   5   5

			Don't know/Not sure	7   7   7

			Refused	9   9   9

33.	How often do you eat green salad?		(96-98)

		a.  Per day	1            

		b.  Per week	2            

		c.  Per month	3            
 
		d.  Per year	4            

		e.  Never	5   5   5

			Don't know/Not sure	7   7   7

			Refused	9   9   9

34.	How often do you eat potatoes not including french fries, fried potatoes, or potato chips?
					(99-101)

		a.  Per day	1            

		b.  Per week	2            

		c.  Per month	3            
 
		d.  Per year	4            

		e.  Never	5   5   5

			Don't know/Not sure	7   7   7

			Refused	9   9   9

35.	How often do you eat carrots?		(102-104)

		a.  Per day	1            

		b.  Per week	2            

		c.  Per month	3            
 
		d.  Per year	4            

		e.  Never	5   5   5

			Don't know/Not sure	7   7   7

			Refused	9   9   9

36.	Not counting carrots, potatoes, or salad, how many servings of vegetables do you usually eat?
					(105-107)

Example:		a.  Per day	1            
A serving of
vegetables at		b.  Per week	2            
both lunch
and dinner		c.  Per month	3            
would be two
servings		d.  Per year	4            

		e.  Never	5   5   5

			Don't know/Not sure	7   7   7

			Refused	9   9   9

Section 7: Weight Control

37.	Are you now trying to lose weight?		(108)

		a.  Yes Go to Q39 	1

		b.  No 	2

			Don't know/Not sure	7

			Refused	9

38.	Are you now trying to maintain your current weight, that is to keep from gaining weight?
					(109)

		a.  Yes	1

		b.  No  Go to Q41 (p. 22)  	2

			Don't know/Not sure  Go to Q41 (p. 22) 	7

			Refused  Go to Q41 (p. 22)	9

39.	Are you eating either fewer calories or less fat to...

	lose weight? [if "Yes" on Q37]

	keep from gaining weight? [if "Yes" on Q38]		(110)

Probe			a.  Yes, fewer calories	1
for
which			b.  Yes, less fat	2

		c.  Yes, fewer calories and less fat	3

		d.  No	4

			Don't know/Not sure	7

			Refused	9

40.	Are you using physical activity or exercise to... 

	lose weight? [if "Yes" on Q37]

	keep from gaining weight? [if "Yes" on Q38]		(111)

		a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

41.	In the past 12 months, has a doctor, nurse, or other health professional given you advice about your weight?			(112)

Probe			a.  Yes, lose weight	1
for
which			b.  Yes, gain weight	2

		c.  Yes, maintain current weight	3

		d.  No	4

			Don't know/Not sure	7

			Refused	9

42.	In the past two years, have you taken any weight loss pills prescribed by a doctor?  Do not include water pills or thyroid medications.		(113)

Include only
pills taken
for the pri-
mary purpose
of losing
weight

Probe			a.  Yes, I am currently taking them	1
for
which			b.  Yes, I have taken them but I am not currently taking them 	2

		c.  No, I have not taken them  Go to Q44 (p. 24)	3

			Don’t know/Not sure  Go to Q44 (p. 24)	7

			Refused  Go to Q44 (p. 24)	9

43.	How much did you weigh just before you started taking prescription weight loss pills for the first time?				(114-116)

Round				Weight	              
fractions			 		  pounds
up
			Don't know/Not sure	 7  7  7

			Refused	 9  9  9

Section 8: Demographics

44.	What is your age?		(117-118)

			Code age in years	         

			Don't know/Not sure	 0  7

			Refused	 0  9

45.	What is your race?		(119)

	Would you say:  Please Read

		a.  White	1

		b.  Black	2

		c.  Asian, Pacific Islander	3

		d.  American Indian, Alaska Native	4
			or
		e.  Other: (specify)                             	5

Do not				Don't know/Not sure	7
read these
responses			Refused	9

46.	Are you of Spanish or Hispanic origin?		(120)

		a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9 

47.	Are you:			(121)

		Please Read

		a.  Married	1

		b.  Divorced	2

		c.  Widowed	3

		d.  Separated	4

		e.  Never been married	5
			or
		f.  A member of an unmarried couple	6

			Refused	9

48.	How many children live in your household who are...

		Please Read

Code 1-9		a.  less than 5 years old?	      (122)
7 = 7 or more
8 = None		b.  5 through 12 years old?	      (123)
9 = Refused
		c.  13 through 17 years old?	      (124)

49.	What is the highest grade or year of school you completed?		(125)

		Read Only if Necessary

		a.  Never attended school or only kindergarten	1

		b.  Grades 1 through 8 (Elementary)	2

		c.  Grades 9 through 11 (Some high school)	3

		d.  Grade 12 or GED (High school graduate)	4

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

		f.  College 4 years or more (College graduate)	6

			Refused	9

50.	Are you currently:		(126)

		Please Read

		a.  Employed for wages	1

		b.  Self-employed	2

		c.  Out of work for more than 1 year	3

		d.  Out of work for less than 1 year	4

		e.  Homemaker	5

		f.  Student	6

		g.  Retired	7
			or
		h.  Unable to work	8

			Refused	9

51.	Is your annual household income from all sources: 		(127-128)

		Read as Appropriate

		a.  Less than $25,000  If "no," ask e; if "yes," ask b
If res-				($20,000 to less than $25,000)	0 4
pondent 
refuses			b.  Less than $20,000  If "no," code a; if "yes," ask c
at any				 ($15,000 to less than $20,000)	0 3 
income
level,			c.  Less than $15,000  If "no," code b; if "yes," ask d
code				 ($10,000 to less than $15,000)	0 2
refused
		d.  Less than $10,000  If "no," code c	0 1

		e.  Less than $35,000  If "no," ask f
			($25,000 to less than $35,000)	0 5

		f.  Less than $50,000  If "no," ask g
			($35,000 to less than $50,000)	0 6

		g.  Less than $75,000  If "no," code h
			($50,000 to $75,000)	0 7

		h.  $75,000 or more	0 8

Do not				Don't know/Not sure	7 7
read these
responses			Refused	9 9

52.	About how much do you weigh without shoes?		(129-131)

Round				Weight	              
fractions				      pounds
up
			Don't know/Not sure	 7  7  7

			Refused	 9  9  9

53.	How much would you like to weigh?		(132-134)

			Weight	              
					  pounds

			Don't know/Not sure	 7  7  7

			Refused	 9  9  9

54.	About how tall are you without shoes?		(135-137)

Round				Height	    /         
fractions					  ft/inches
down
			Don't know/Not sure	 7  7  7

			Refused	 9  9  9

55.	What county do you live in?	(138-140)

			FIPS county code	              

			Don't know/not sure	 7  7  7

			Refused	 9  9  9

56.	Do you have more than one telephone number in your household?	(141)

		a.  Yes	1

		b.  No  Go to Q58 (p. 28)	2

			Refused  Go to Q58 (p. 28)	9

57.	How many residential telephone numbers do you have?	(142)

Exclude ded-			Total telephone numbers [8 = 8 or more] 	    
icated fax
and computer		Refused	9
lines

58.	Indicate sex of respondent.  Ask Only if Necessary	(143)

			Male  Go to Section 10: HIV/AIDS (p. 33)	1

			Female	2

Now I have some questions about other health services you may have received.

Section 9:  Women's Health

59.	A mammogram is an x-ray of each breast to look for breast cancer.  Have you ever had a mammogram?	(144)

		a.  Yes	1

		b.  No  Go to Q62 (p. 30)	2

			Don't know/Not sure  Go to Q62 (p. 30)	7

			Refused  Go to Q62 (p. 30)	9

60.	How long has it been since you had your last mammogram?
					(145)
		Read only if Necessary

		a.  Within the past year  (1 to 12 months ago)	1

		b.  Within the past 2 years  (1 to 2 years ago)	2

		c.  Within the past 3 years  (2 to 3 years ago)	3

		d.  Within the past 5 years  (3 to 5 years ago)	4

		e.  5 or more years ago	5
		
			Don't know/Not sure	7

			Refused	9

61.	Was your last mammogram done as part of a routine checkup, because of a breast problem other than cancer, or because you've already had breast cancer?	(146)

		a.  Routine checkup	1

		b.  Breast problem other than cancer	2

		c.  Had breast cancer	3

			Don't know/Not sure	7

			Refused	9

62.	A clinical breast exam is when a doctor, nurse, or other health professional feels the breast for lumps.  Have you ever had a clinical breast exam?	(147)

		a.  Yes	1

		b.  No  Go to Q65 (p. 31)	2

			Don't know/Not sure  Go to Q65 (p. 31)	7

			Refused  Go to Q65 (p. 31)	9

63.	How long has it been since your last breast exam?	(148)

		Read Only if Necessary

		a.  Within the past year  (1 to 12 months ago)	1

		b.  Within the past 2 years  (1 to 2 years ago)	2

		c.  Within the past 3 years  (2 to 3 years ago)	3

		d.  Within the past 5 years  (3 to 5 years ago)	4

		e.  5 or more years ago	5
		
			Don't know/Not sure	7

			Refused	9

64.	Was your last breast exam done as part of a routine checkup, because of a breast problem other than cancer, or because you've already had breast cancer?	(149)

		a.  Routine Checkup	1

		b.  Breast problem other than cancer	2

		c.  Had breast cancer	3

			Don't know/Not sure	7

			Refused	9

65.	A Pap smear is a test for cancer of the cervix.  Have you ever had a Pap smear?	(150)

		a.  Yes	1

		b.  No  Go to Q68 (p. 32)	2

			Don't know/Not sure  Go to Q68 (p. 32)	7

			Refused  Go to Q68 (p. 32)	9

66.	How long has it been since you had your last Pap smear?	(151)

		Read Only if Necessary

		a.  Within the past year  (1 to 12 months ago)	1

		b.  Within the past 2 years  (1 to 2 years ago)	2

		c.  Within the past 3 years  (2 to 3 years ago)	3

		d.  Within the past 5 years  (3 to 5 years ago)	4

		e.  5 or more years ago	5
		
			Don't know/Not sure	7

			Refused	9

67.	Was your last Pap smear done as part of a routine exam, or to check a current or previous problem?		(152)

		a.  Routine exam	1

		b.  Check current or previous problem	2

			Other	3

			Don't know/Not sure	7

			Refused	9

68.	Have you had a hysterectomy?	(153)

		a.  Yes  Go to Section 10: HIV/AIDS (p. 33)	1
A hysterec-
tomy is an		b.  No	2
operation
to remove the		Don't know/Not sure	7
uterus (womb)
			Refused	9

ö If respondent 45 years old or older, go to Section 10: HIV/AIDS (p. 33).

69.	To your knowledge, are you now pregnant?	(154)

		a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

Section 10: HIV/AIDS

ö If respondent is 65 years old or older, go to Closing Statement.

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 don't want to.

70.	If you had a child in school, at what grade do you think he or she should begin receiving education in school about HIV infection and AIDS?	(155-156)

Code 01		a.  Grade 	         
through 12
		b.  Kindergarten	5  5

		c.  Never	8  8

			Don't know/Not sure	7  7

			Refused	9  9

71.	If you had a teenager who was sexually active, would you encourage him or her to use a condom?
					(157)

		a.  Yes	1

		b.  No	2

			Would give other advice	3

			Don't know/Not sure	7

			Refused	9

72.	What are your chances of getting infected with HIV, the virus that causes AIDS?	(158)

		Would you say:  Please Read

		a.  High	1

		b.  Medium	2

		c.  Low	3
			or
		d.  None	4

			Not applicable Go to Q76a (p. 35)	5
Do not
read these			Don't know/Not sure	7
responses
			Refused	9

73.	Have you donated blood since March 1985?	(159)

			a.  Yes	1

			b.  No  Go to Q75a (p. 35)	2

			Don't know/Not sure  Go to Q75a (p. 35)	7

			Refused  Go to Q75a (p. 35)	9

74.	Have you donated blood in the past 12 months?	(160)

		a.  Yes	1

		b.  No	2

			Don"t know/Not sure	7

			Refused	9

75.	Except for tests you may have had as part of blood donations, have you ever been tested for HIV?
					(161)

Include			a.  Yes  Go to Q76 (p. 35)	1
saliva
tests			b.  No  Go to Closing Statement	2

			Don"t know/Not sure  Go to Closing Statement	7

			Refused  Go to Closing Statement	9
75a.	Have you ever been tested for HIV?	(162)

Include			a.  Yes  Go to Q76a	1
saliva
tests			b.  No  Go to Closing Statement	2

			Don"t know/Not sure  Go to Closing Statement	7

			Refused  Go to Closing Statement	9

76.	Not including your blood donations, have you been tested for HIV in the past 12 months?
					(163)

Include			a.  Yes  Go to Q77 (p. 36)	1
saliva
tests			b.  No  Go to Closing Statement	2

			Don"t know/Not sure  Go to Closing Statement	7

			Refused  Go to Closing Statement	9

76a.	Have you been tested for HIV in the past 12 months?	(164)

Include			a.  Yes	1
saliva
tests			b.  No  Go to Closing Statement	2

			Don"t know/Not sure  Go to Closing Statement	7

			Refused  Go to Closing Statement	9

77.	What was the main reason you had your last test for HIV?	(165-166)

			Reason code	         

		Read Only if Necessary

		a.  For hospitalization or surgical procedure	0 1

		b.  To apply for health insurance	0 2

		c.  To apply for life insurance	0 3

		d.  For employment	0 4

		e.  To apply for a marriage license	0 5

		f.  For military induction or military service	0 6

		g.  For immigration	0 7

		h.  Just to find out if you were infected	0 8

		i.  Because of referral by a doctor	0 9

		j.  Because of pregnancy	1 0

		k.  Referred by your sex partner	1 1

		l.  Because it was part of a blood donation process
			Go to Closing Statement	1 2

		m.  For routine check-up	1 3

		n.  Because of occupational exposure	1 4

		o.  Because of illness	1 5

		p.  Because I am at risk for HIV	1 6

		q.  Other	8 7

			Don't know/Not sure	7 7

			Refused	9 9

78.	Where did you have your last test for HIV?	(167-168)

			Facility Code	         

		Read Only if Necessary

		a.  Private doctor, HMO	0 1

		b.  Blood bank, plasma center, Red Cross	0 2

		c.  Health department	0 3

		d.  AIDS clinic, counseling, testing site	0 4

		e.  Hospital, emergency room, outpatient clinic	0 5

		f.  Family planning clinic	0 6

		g.  Prenatal clinic, obstetrician’s office	0 7

		h.  Tuberculosis clinic	0 8

		i.  STD clinic	0 9

		j.  Community health clinic	1 0

		k.  Clinic run by employer	1 1

		l.  Insurance company clinic	1 2

		m.  Other public clinic	1 3

		n.  Drug treatment facility	1 4

		o.  Military induction or military service site	1 5

		p.  Immigration site	1 6

		q.  At home, home visit by nurse or health worker	1 7

		r.  At home using self-sampling kit	1 8

		s.  In jail or prison	1 9

		t.  Other	8 7

			Don't know/Not sure	7 7

			Refused	9 9

79.	Did you receive the results of your last test?	(169)

		a.  Yes 	1

		b.  No  Go to Closing Statement	2

			Don't know/Not sure  Go to Closing Statement	7

			Refused  Go to Closing Statement  	9

80.	Did you receive counseling or talk with a health care professional about the results of your test?
					(170)

		a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

Closing Statement

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

or

Transition to Modules and/or State-added Questions

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

	Activity List for Common Leisure Activities
	Coding List A

Code Description

01. Aerobics class
02. Backpacking
03. Badminton
04. Basketball
05. Bicycling for pleasure
06. Boating (canoeing, rowing,
      sailing for pleasure or camping)
07. Bowling
08. Boxing
09. Calisthenics
10. Canoeing/rowing - in competition
11. Carpentry
12. Dancing-aerobics/ballet
13. Fishing from river bank or boat
14. Gardening (spading, weeding,
      digging, filling)
15. Golf
16. Handball
17. Health club exercise
18. Hiking - cross-country
19. Home exercise
20. Horseback riding
21. Hunting large game - deer, elk
22. Jogging
23. Judo/karate
24. Mountain climbing
25. Mowing lawn
26. Paddleball
27. Painting/papering house

28. Racketball
29. Raking lawn
30. Running
31. Rope skipping
32. Scuba diving
33. Skating - ice or roller
34. Sledding, tobogganing
35. Snorkeling
36. Snowshoeing
37. Snow shoveling by hand
38. Snow blowing
39. Snow skiing
40. Soccer
41. Softball
42. Squash
43. Stair climbing
44. Stream fishing in waders
45. Surfing
46. Swimming laps
47. Table tennis
48. Tennis
49. Touch football
50. Volleyball
51. Walking
52. Waterskiing
53. Weight lifting
54. Other______________
55. Bicycling machine exercise 
56. Rowing machine exercise

Coding List B

Lap Swimming

Size pool/Laps
(1 lap = 2 lengths) 

50 ft. pool
5 laps (10 lengths) = .1 mile
100 ft. pool
2½ laps (5 lengths) = .1 mile

50 meter pool
1½ laps (3 lengths) = .1 mile

Running/Jogging/Walking

1/2 mile = .5 mile
1/4 mile = .3 mile
1/8 mile = .1 mile
 1 block = .1 mile

Module 1:  Diabetes

1.	How old were you when you were told you have diabetes?	(171-172)

			Code age in years  [76 = 76 and older]	         

			Don't know/Not sure	7  7

			Refused	9  9

2.	Are you now taking insulin?	(173)

		a.  Yes	1

		b.  No  Go to Q4	2

			Refused  Go to Q4	9

3.	Currently, about how often do you use insulin?	(174-176)

		a.  Times per day	1           

		b.  Times per week	2           

		c.  Use insulin pump	3  3  3

			Don't know/Not sure	7  7  7

			Refused	9  9  9	

4.	About how often do you check your blood for glucose or sugar?  Include times when checked by a family member or friend, but do not include times when checked by a health professional.
				(177-179)

		a.  Times per day	1           

		b.  Times per week	2           

		c.  Times per month	3           

		d.  Times per year	4           

		e.  Never	8  8  8

			Don't know/Not sure	7  7  7

			Refused	9  9  9

5.	Have you ever heard of glycosylated hemoglobin [gli-KOS-ilated HE-mo-glo-bin] or hemoglobin "A one C"?		(180)

		a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused 	9

6.	About how many times in the last year have you seen a doctor, nurse, or other health professional for your diabetes?	(181-182)

		a.  Number of times	         

		b.  None  Go to Q9	8  8

			Don't know/Not sure  Go to Q9	7  7

			Refused  Go to Q9	9  9

ö If "No," "Dk/Ns," or "Refused" to Q5, go to Q8.

7.	About how many times in the last year has a doctor, nurse, or other health professional checked you for glycosylated hemoglobin or hemoglobin "A one C"?	(183-184)

		a.  Number of times	         

		b.  None	8 8

			Don't know/Not sure	7 7

			Refused	9 9

8.	About how many times in the last year has a health professional checked your feet for any sores or irritations?		(185-186)

		a.  Number of times	         

		b.  None	8 8

			Don't know/Not sure	7 7

			Refused	9 9

9.	When was the last time you had an eye exam in which the pupils were dilated?  This would have made you temporarily sensitive to bright light.	(187)

		Read Only if Necessary

		a.  Within the past month (0 to 1 month ago)	1

		b.  Within the past year (1 to 12 months ago)	2

		c.  Within the past 2 years (1 to 2 years ago)	3

		d.  2 or more years ago	4

		e.  Never	8

			Don't know/Not sure	7

			Refused	9

I would now like to ask you three questions about how well you see with your glasses or contacts on if you use them.

10.	How much of the time does your vision limit you in recognizing people or objects across the street?
				(188)

	Would you say:  Please Read

		a.  All of the time	1

		b.  Most of the time	2

		c.  Some of the time	3

		d.  A little bit of the time	4
			or
		e.  None of the time	5

Do not				Don't know/Not sure	7
read these
responses			Refused	9

11.	How much of the time does your vision limit you in reading print  in a newspaper, magazine, recipe, menu, or numbers on the telephone?	(189)

	Would you say:  Please Read

		a.  All of the time	1

		b.  Most of the time	2

		c.  Some of the time	3

		d.  A little bit of the time	4
			or
		e.  None of the time	5

Do not				Don't know/Not sure	7
read these
responses			Refused	9

12.	How much of the time does your vision limit you in watching television?	(190)

	Would you say:  Please Read

		a.  All of the time	1

		b.  Most of the time	2

		c.  Some of the time	3

		d.  A little bit of the time	4
			or
		e.  None of the time	5

Do not				Don't know/Not sure	7
read these
responses			Refused	9

Module 2: Sexual Behavior

ö If respondent 50 years old or older, go to next module

These next few questions are about your personal sexual behavior, and I want to remind you that your answers are confidential.

1.	During the past twelve months, with how many people have you had sexual intercourse?
				(191-192)

		a.	Number	         

		b.	None Go to Next Module	8  8

			Don't know/Not sure	7  7

			Refused	9  9

2.	Was a condom used the last time you had sexual intercourse?	(193)

		a.	Yes	1

		b.	No Go to Q4	2

			Don't know/Not sure  Go to Q4	7

			Refused  Go to Q4	9

3.	The last time you had sexual intercourse, was the condom used ...  	(194)

		Please Read

		a.  To prevent pregnancy	1

		b.  To prevent diseases like syphilis, gonorrhea,
			and AIDS	2

		c.  For both of these reasons	3
			or
		d.  For some other reason	4

Do not				Don't know/Not sure	7	
read these
responses			Refused	9

4.	Some people use condoms to keep from getting infected with HIV through sexual activity.  How effective do you think a properly used condom is for this purpose?	(195)

	Would you say:  Please Read

		a.  Very effective	1

		b.  Somewhat effective	2
			or
		c.  Not at all effective	3

			Don't know how effective	4
Do not
read these			Don't know method	5
responses
			Refused	9

5.	How many new sex partners did you have during the past twelve months?	(196-197)
A new sex
partner is		a.	Number [76 = 76 or more]	         
someone
the respon-		b.	None	8  8
dent had sex
with for the			Don't know/Not sure	7  7
first time in
the past 12			Refused	9  9
months

6.	I’m going to read you a list.  When I’m done, please tell me if any of the situations apply to you.  You don't need to tell me which one.

	You have used intravenous drugs in the past year

You have been treated for a sexually transmitted or venereal disease in the past year

	You tested positive for having HIV, the virus that causes AIDS

	You had anal sex without a condom in the past year

	Do any of these situations apply to you?	(198) 

		a.  Yes	1

		b.  No	2

			Don't know/Not sure 	7

			Refused	9

7.	In the past five years, have you been treated for a sexually transmitted or venereal disease?
				(199)

		a.  Yes	1

		b.  No  Go to Q9	2

			Don't know/Not sure  Go to Q9	7

			Refused  Go to Q9	9

8.	Were you treated at a health department STD clinic?	(200)
	
		a.  Yes	1

		b.  No	2

			Don't know/Not sure 	7

			Refused	9

9.	Due to what you know about HIV, have you changed your sexual behavior in the past 12 months?
				(201)

		a.  Yes	1

		b.  No  Go to Next Module	2

			Don't know/Not sure  Go to Next Module	7

			Refused  Go to Next Module	9

10.	Did you make any of the following changes in the past 12 months?

		Please Read	Yes	No	Dk/Ns	NA	Ref
If respon-
dent says		a.  Did you decrease the number
"abstinent,"		     your sexual partners or
ask "Are		     become abstinent?	1	 2	7		 9	(202)
you abstinent
now?"  If "no,"	
read b and c.		
If "yes," do	
not read b and
c and code b
and c 8

		b.  Do you now have sexual inter-
		     course with only the same
		     partner?	1	 2	7	8	 9	(203)

		c.  Do you now always use condoms
		     for protection?	1	 2	7	8	 9	(204)

Module 3: Family Planning

ö If respondent is male or age 45 years old or older, go to next module

The next few questions ask about pregnancy and ways to prevent pregnancy.

ö If pregnant now ("Yes" to core Q69), go to Q2a.

1.  Have you been pregnant in the last 5 years?	(205)

		a.  Yes	1

		b.  No Go to Q3	2

			Don’t know/Not sure Go to Q3	7

			Refused Go to Q3	9

2.	Thinking back to your last pregnancy, just before you got pregnant, how did you feel about becoming pregnant?	(206)

	Would you say:  Please Read

		a.  You wanted to be pregnant sooner  Go to Q3	1

		b.  You wanted to be pregnant later  Go to Q3	2

		c.  You wanted to be pregnant then  Go to Q3	3

		d.  You didn’t want to be pregnant then or
		      at anytime in the future  Go to Q3	4

		e.  You don’t know  Go to Q3	7

Do not read			Refused  Go to Q3	9

2a.	Thinking back to just before you got pregnant with your current pregnancy, how did you feel about becoming pregnant?	(207)

	Would you say: Please Read

		a.  You wanted to be pregnant sooner	1

		b.  You wanted to be pregnant later	2

		c.  You wanted to be pregnant then	3

		d.  You didn’t want to be pregnant then or at any time in the future	4

		e.	You don’t know	7

	Do not read			Refused	9

ö If respondent had hysterectomy ("Yes" to core Q68) or is pregnant now ("Yes" to core Q69), go to Q6.
ö If respondent has no sex partners ("None" to Q1 in Sexual Behavior module), go to Q6.

3.	Are you or your [fill in (husband/partner) from core Q47] using any kind of birth control now? Birth control means having your tubes tied, vasectomy, the pill, condoms, diaphragm, foam, rhythm, Norplant, shots (Depo-provera) or any other way to keep from getting pregnant.
					(208)

		a.  Yes	1

		b.  No  Go to Q5	2

		c.  Not sexually active  Go to Q6	3

			Don't know/Not sure  Go to Q6	7

			Refused  Go to Q6	9

4.	What kinds of birth control are you or your [fill in (husband/partner) from core Q47] using now?
					(209-210)

			Kind Code	         

		Read Only if Necessary

		a.  Tubes tied (sterilization)  Go to Q6	0 1

		b.  Vasectomy (sterilization)  Go to Q6	0 2

If more than		c.  Pill  Go to Q6	0 3
one, code
other and		d.  Condoms  Go to Q6	0 4
specify each
method code		e.  Foam, jelly, cream  Go to Q6	0 5

				f.  Diaphragm  Go to Q6	0 6

				g.  Norplant  Go to Q6	0 7

		h.  Shots (Depo-Provera)  Go to Q6	0 8

		i.  Withdrawal  Go to Q6	0 9

		j.  Other (specify:                          )  Go to Q6	8 7  

			Don't know/Not sure  Go to Q6	7 7

			Refused  Go to Q6	9 9

5.  What are your reasons for not using any birth control now?	(211-212)

			Reason Code	         

		Read Only if Necessary

If more than		a.  I am not having sex	0 1
one, code
other and		b.  I want to get pregnant	0 2
specify each
method code		c.  I don’t want to use birth control	0 3

		d.  My husband or partner doesn’t want to use birth control	0 4

		e.  I don’t think I can get pregnant	0 5

		f.  I can’t pay for birth control	0 6

		g.  Other (specify: ______________)	8 7

			Don't know/Not sure	7 7

			Refused	9 9

6.	Where is your usual source of services for female health concerns, such as family planning, annual exams, breast exams, tests for sexually transmitted diseases, and other female health concerns?
					(213)

	Would you say: Please Read

		a.  A family planning clinic [Example: a Planned Parenthood clinic]
			Go to Q8	1

		b.  A health department clinic	2
	
		c.  A community health center	3

		d.  A private gynecologist	4

		e.  A general or family physician	5
			or
		f.  Some other kind of place	8

Do not				Don’t know/not sure	7
read these
responses			Refused	9

7.	Have you ever used the services at a family planning clinic?	(214)

Example:		a.  Yes	1
a Planned
Parenthood		b.  No Go to Next Module	2
clinic
			Don’t know/not sure Go to Next Module	7

			Refused Go to Next Module	9

8.	How long has it been since you used the services at a family planning clinic?	(215)

		Read Only if Necessary

		a.	Within the past year (1 to 12 months ago)	1

		b.	Within the past 2 years (1 to 2 years ago)	2

		c.	Within the past 3 years (2 to 3 years ago)	3

		d.	Within the past 5 years (3 to 5 years ago)	4

		e.	5 or more years ago	5

			Don’t know/Not sure	7

			Refused	9

Module 4: Health Care Coverage

ö If not known whether respondent has health care coverage ("Dk/Ns" or "Refused" to core Q5), go to next module.

I asked you previously about your health care coverage.

ö If respondent has no health care coverage ("None" to core Q7 or Q7a), continue.  Otherwise, go to Q2.

1.	What is the main reason you are without health care coverage? 	(216-217)

			Reason Code	         

		Read Only if Necessary

		a.  Lost job or changed employers Go to Next Module	0 1

		b.  Spouse or parent lost job or changed employers [includes any person
			who had been providing insurance prior to job loss or change]
			Go to Next Module	0 2

		c.  Became divorced or separated  Go to Next Module	0 3

		d.  Spouse or parent died  Go to Next Module	0 4

		e.  Became ineligible because of age or because
			left school  Go to Next Module	0 5

	f.  Employer doesn’t offer or stopped offering
			coverage  Go to Next Module	0 6

	g.  Cut back to part time or became temporary
			employee  Go to Next Module	0 7

		h.  Benefits from employer or former employer ran
			out  Go to Next Module	0 8

		i.  Couldn't afford to pay the premiums
			Go to Next Module	0 9

		j.  Insurance company refused coverage
			Go to Next Module	1 0

		k.  Lost Medicaid or Medical Assistance eligibility
			Go to Next Module	1 1	
	
		l.  Other  Go to Next Module	8 7

	Don't know/Not sure  Go to Next Module	7 7

			Refused  Go to Next Module	9 9

2.	About how long have you had [fill in type (Medicare/Medicaid/this particular health care coverage) from core Q6, Q7, or Q7a]?	(218)

		Read Only if Necessary
	
If necessary,		a.  For less than 12 months (1 to 12 months)	1
say "The
coverage you		b.  For less than 2 years (1 to 2 years)	2
use currently
to pay for		c.  For less than 3 years (2 to 3 years)	3
most of your
medical care"	d.  For less than 5 years (3 to 5 years)	4

		e.  For 5 or more years	5

		Don't know/Not sure	7

			Refused	9

3.	Is there a book or list of doctors associated with your [fill in type (Medicare/Medicaid/health coverage) from core Q6, Q7, or  Q7a] plan?	(219)

If necessary,
say "The
coverage you
use currently
to pay for
most of your
medical care"

		a.  Yes	1

If "no" or		b.  No	2
"Dk/Ns," probe
"Is there a			Don't know/Not sure	7
certain number
you are supposed		Refused	9
to call to find a
doctor to go to?"

4.	Does your [fill in type (Medicare/Medicaid/health coverage) from core Q6, Q7, or Q7a] plan require you to select a certain doctor or clinic for all of your routine care?	(220)

If necessary,
say "The
coverage you
use currently
to pay for
most of your
medical care"
	a.  Yes	1
Do not include
emergency care	b.  No	2
or referral to
a specialist			Don't know/Not sure	7

			Refused	9	

5.	Other than [fill in type (Medicare/Medicaid/the health coverage which pays for most of your medical care) from core Q6, Q7, or Q7a], do you have any other type of health care coverage?
					(221)
Do not
include			a.  Yes	1
plans that
only cover		b.  No	2
one type of
service or 			Don't know/Not sure	7
care
			Refused	9

ö If respondent did not have coverage at some time during past 12 months ("Yes" to core Q8),
 continue.  Otherwise, go to next module. 

6.	What was the main reason you were without health care coverage during the past 12 months?
				 	(222-223)

			Reason Code	         

		Read Only if Necessary

		a.  Lost job or changed employers	0 1

		b.  Spouse or parent lost job or changed employers [includes any person
			who had been providing insurance prior to job loss or change]	0 2

		c.  Became divorced or separated	0 3

		d.  Spouse or parent died	0 4

		e.  Became ineligible because of age or because
			left school	0 5

	f.  Employer doesn’t offer or stopped offering
			coverage	0 6

	g.  Cut back to part time or became temporary
			employee	0 7

		h.  Benefits from employer or former employer ran
			out	0 8

		i.  Couldn't afford to pay the premiums	0 9

		j.  Insurance company refused coverage	1 0

		k.  Lost Medicaid or Medical Assistance eligibility	1 1
	
		l.  Other	8 7

	Don't know/Not sure	7 7

			Refused	9 9

Module 5: Health Care Utilization

Now I am going to ask you some questions about the health care you receive.

1.	How would you rate your satisfaction with your overall health care?	(224)
	
	Would you say:  Please Read
  	
		a.  Excellent	1

		b.  Very Good	2

		c.  Good	3

		d.  Fair	4
			or
		e.  Poor	5

Do not				Not applicable/don't use any health services	8
read these
responses			Don't know/Not sure	7  

			Refused	9

2.	Is there one particular clinic, health center, doctor's office, or other place that you usually go to if you are sick or need advice about your health?	(225)

		a.  Yes  Go to Q5	1

		b.  More than one place  Go to Q4	2

		c.  No	3

			Don't know/Not sure  Go to Next Module	7

			Refused  Go to Next Module	9

3.	What is the main reason you do not have a usual source of medical care?	(226-227)

			Reason Code	         

			Read Only if Necessary

		a.  Two or more usual places	0 1

		b.  Have not needed a doctor Go to Next Module	0 2

		c.  Do not like/trust/believe in doctors
			Go to Next Module	0 3

		d.  Do not know where to go  Go to Next Module	0 4

		e.  Previous doctor is not available/moved
			Go to Next Module	0 5

		f.  No insurance/cannot afford Go to Next Module	0 6

		g.  Speak a different language Go to Next Module	0 7

		h.  No place is available/close enough/convenient
			Go to Next Module	0 8

		i.	Other Go to Next Module	0 9

			Don't know/Not sure Go to Next Module	7 7

			Refused Go to Next Module	9 9

4.	Is there one of these places that you go to most often when you are sick or need advice about your health?			(228)

		a.  Yes	1

		b.  No  Go to Next Module	2

			Don't know/Not sure  Go to Next Module	7

			Refused  Go to Next Module	9

5.	What kind of place is it?	(229)

	Would you say:  Please Read

		a.  A doctor's office or HMO	1
			
		b.  A clinic or health center	2

		c.  A hospital outpatient department	3

		d.  A hospital emergency room	4

		e.  An urgent care center	5
			or
		f.  Some other kind of place	8

Do not				Don't know/Not sure	7
read these 
responses			Refused	9

6.	Thinking of the distance or time you travel to get to the place you usually go to, how would you rate the convenience of that place?	(230)

	Would you say: Please Read

	a.  Excellent	1

		b.  Very Good	2

		c.  Good	3

		d.  Fair	4
			or
		e.  Poor	5
	
Do not				Don't have usual place	6
read these
responses			Don't know/Not sure	7  

			Refused	9

7.	Is there one particular doctor or health professional who you usually go to when you need routine medical care?	(231)

If "no," ask		a.  Yes, only one	1
"Is there more
than one or is		b.  More than one  Go to Next Module	2
there no usual
doctor who you	c.  No  Go to Next Module	3
go to?"  			
				 	Don't know/Not sure  Go to Next Module	7

			Refused  Go to Next Module	9

8.	When did you last change doctors?	(232)

		Read Only if Necessary
	
"Doctors"		a.  Within the past year (1 to 12 months ago)	1
includes other
health			b.  Within the past 2 years (1 to 2 years ago)	2
professionals
		c.  Within the past 3 years (2 to 3 years ago)	3

		d.  Within the past 5 years (3 to 5 years ago)	4

		e.  5 or more years ago	5

	f.  Never  Go to Next Module	8

	Don't know/Not sure  Go to Next Module	7

			Refused  Go to Next Module	9

9.	Why did you change doctors that last time?	(233-234)

			Reason Code	         

		Read Only if Necessary
	
"Doctors"		a.  Changed residence or moved	0 1
includes other
health			b.  Changed jobs	0 2
professionals
		c.  Changed health care coverage	0 3

		d.  Provider moved or retired	0 4

		e.  Dissatisfied with former provider or liked new provider better	0 5

		f.  Former provider no longer reimbursed by my health care coverage	0 6

		g.  Owed money to former provider	0 7

		h.  Medical care needs changed	0 8

		i.  Other	8 7

	Don't know/Not sure	7 7

			Refused	9 9

Module 6:  Oral Health

1.	How long has it been since you last visited the dentist or a dental clinic?	(235)

		Read Only if Necessary

		a.  Within the past year (1 to 12 months ago)  Go to Q3	1

		b.  Within the past 2 years (1 to 2 years ago)	2

		c.  Within the past 5 years (2 to 5 years ago)	3

		d.  5 or more years ago	4

			Don't know/Not sure  Go to Q3	7

			Never	8

			Refused  Go to Q3	9

2.	What is the main reason you have not visited the dentist in the last year?	(236-237)

			Reason code	         

		Read Only if Necessary

		a.  Fear, apprehension, nervousness, pain, dislike going	0 1

		b.  Cost	0 2

		c.  Do not have/know a dentist	0 3

		d.  Cannot get to the office/clinic (too far away, no transportation,
			no appointments available)	0 4

		e.  No reason to go (no problems, no teeth)	0 5

		f.  Other priorities	0 6

		g.  Have not thought of it	0 7

		h.  Other	0 8

			Don't know/Not sure	7 7

			Refused	9 9

3.	How many of your permanent teeth have been removed because of tooth decay or gum disease?  Do not include teeth lost for other reasons, such as injury or orthodontics.	(238)

		a.  5 or fewer	1

		b.  6 or more but not all	2

		c.  All	3

		d.  None	8

			Don't know/Not sure	7

			Refused	9

4.	Do you have any kind of insurance coverage that pays for some or all of your routine dental care, including dental insurance, prepaid plans such as HMOs, or government plans such as Medicaid?
					(239) 

		a.	Yes	1

		b.	No	2

			Don't know/Not sure	7

			Refused	9

Module 7: Preventive Counseling Services

The next questions are about counseling services related to prevention that you might have received from a doctor, nurse, or other health professional.

1.	Has a doctor or other health professional ever talked with you about your diet or eating habits?
					(240)
	
If yes,			a.  Yes, within the past 12 months (1 to 12 months ago)	1
ask "About
how long ago		b.  Yes, within the past 3 years (1 to 3 years ago)	2
was it?"
		c.  Yes, 3 or more years ago	3

		d.  No	4

			Don't know/Not sure	7

			Refused	9

2.	Has a doctor or other health professional ever talked with you about physical activity or exercise?
					(241)
	
If yes,			a.  Yes, within the past 12 months (1 to 12 months ago)	1
ask "About
how long ago		b.  Yes, within the past 3 years (1 to 3 years ago)	2
was it?"
		c.  Yes, 3 or more years ago	3

		d.  No	4

			Don't know/Not sure	7

			Refused	9

3.	(Has a doctor or other health professional ever talked with you) about injury prevention, such as safety belt use, helmet use, or smoke detectors?	(242)
		
If yes,			a.  Yes, within the past 12 months (1 to 12 months ago)	1
ask "About
how long ago		b.  Yes, within the past 3 years (1 to 3 years ago)	2
was it?"
		c.  Yes, 3 or more years ago	3

		d.  No	4

			Don't know/Not sure	7

			Refused	9

4.	(Has a doctor or other health professional ever talked with you) about drug abuse?	(243)

If yes,			a.  Yes, within the past 12 months (1 to 12 months ago)	1
ask "About
how long ago		b.  Yes, within the past 3 years (1 to 3 years ago)	2
was it?"
		c.  Yes, 3 or more years ago	3

		d.  No	4

			Don't know/Not sure	7

			Refused	9

5.	(Has a doctor or other health professional ever talked with you) about alcohol use?	(244)
	
If yes,			a.  Yes, within the past 12 months (1 to 12 months ago)	1
ask "About
how long ago		b.  Yes, within the past 3 years (1 to 3 years ago)	2
was it?"
		c.  Yes, 3 or more years ago	3

		d.  No	4

			Don't know/Not sure	7

			Refused	9

ö If "No" to core Q23 or "Not at all" to core Q24, go to Q7

6.	(Has a doctor or other health professional) ever advised you to quit smoking?	(245) 
	
If yes,			a.  Yes, within the past 12 months (1 to 12 months ago)	1
ask "About
how long ago		b.  Yes, within the past 3 years (1 to 3 years ago)	2
was it?"
		c.  Yes, 3 or more years ago	3

		d.  No	4

			Don't know/Not sure	7

			Refused	9

ö If respondent 65 years old or older, go to next module

7.	(Has a doctor or other health professional) ever talked with you about your sexual practices, including family planning, sexually transmitted diseases, AIDS, or the use of condoms?
					(246)

If yes,			a.  Yes, within the past 12 months (1 to 12 months ago)	1
ask "About
how long ago		b.  Yes, within the past 3 years (1 to 3 years ago)	2
was it?"
		c.  Yes, 3 or more years ago	3

		d.  No	4

			Don't know/Not sure	7

			Refused	9

Module 8:  Hypertension Awareness

1.	About how long has it been since you last had your blood pressure taken by a doctor, nurse, or other health professional?	(247)

		Read Only if Necessary

		a.  Within the past 6 months  (1 to 6 months ago)	1

		b.  Within the past year  (6 to 12 months ago)	2	

		c.  Within the past 2 years  (1 to 2 years ago)	3

		d.  Within the past 5 years  (2 to 5 years ago)	4

		e.  5 or more years ago	5		
			Don't know/Not sure	7

			Never  Go to Next Module	8

			Refused	9

2.	Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?		(248)

		a.  Yes	1

		b.  No  Go to Next Module	2

			Don't know/Not sure  Go to Next Module	7

			Refused  Go to Next Module	9

3.	Have you been told on more than one occasion that your blood pressure was high, or have you been told this only once?	(249)

		a.  More than once	1

		b.  Only once	2

			Don't know/Not sure	7

			Refused	9

Module 9:  Cholesterol Awareness

1.	Blood cholesterol is a fatty substance found in the blood. Have you ever had your blood cholesterol checked?		(250)

		a.  Yes	1

		b.  No  Go to Next Module 	2

			Don't know/Not sure  Go to Next Module	7

			Refused  Go to Next Module	9

2.	About how long has it been since you last had your blood cholesterol checked?	(251)

		Read Only if Necessary

		a.  Within the past year  (1 to 12 months ago)	1	

		b.  Within the past 2 years  (1 to 2 years ago)	2

		c.  Within the past 5 years  (2 to 5 years ago)	3

		d.  5 or more years ago	4
		
			Don't know/Not sure	7

			Refused	9

3.	Have you ever been told by a doctor or other health professional that your blood cholesterol is high?				(252)

		a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

Module 10: Colorectal Cancer Screening

ö If respondent 40 years or older, continue with this module.  Otherwise, go to next module.

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?	(253)

		a.  Yes	1

		b.  No  Go to Q3	2

			Don't know/Not sure  Go to Q3	7

			Refused  Go to Q3	9

2.	When did you have your last blood stool test using a home kit?	(254)

		Read Only if Necessary

		a.  Within the past year  (1 to 12 months ago)	1	

		b.  Within the past 2 years  (1 to 2 years ago)	2

		c.  Within the past 5 years  (2 to 5 years ago)	3

		d.  5 or more years ago	4
		
			Don't know/Not sure	7

			Refused	9

3.	A sigmoidoscopy or proctoscopy is when a tube is inserted in the rectum to view the bowel for signs of cancer and other health problems.  Have you ever had this exam?	(255)

Do not			a.  Yes	1
include
colonoscopy		b.  No  Go to Next Module	2

			Don't know/Not sure Go to Next Module	7

			Refused  Go to Next Module	9

4.	When did you have your last sigmoidoscopy or proctoscopy?	(256)

		Read Only if Necessary

		a.  Within the past year  (1 to 12 months ago)	1	

		b.  Within the past 2 years  (1 to 2 years ago)	2

		c.  Within the past 5 years  (2 to 5 years ago)	3

		d.  5 or more years ago	4
		
			Don't know/Not sure	7

			Refused	9

Module 11:  Immunization

1.	During the past 12 months, have you had a flu shot?	(257)

		a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

2.	Have you ever had a pneumonia vaccination?	(258)

		a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

Module 12:  Injury Control

1.	How often do you use seatbelts when you drive or ride in a car?	(259)

	Would you say:  Please Read

		a.  Always	1

		b.  Nearly Always	2

		c.  Sometimes	3

		d.  Seldom	4
			or
		e.  Never	5

Do not				Don't know/Not sure	7
read these
responses			Never drive or ride in a car	8

			Refused	9

ö If core Q48a, b, and c are all "None," go to Q5

2.	What is the age of the oldest child in your household under the age of 16?	(260-261)
Code
<1 yr.			a.  Code age in years	              
as "01"
		b.  No children under age 16  Go to Q5	 8  8

			Don't know/Not sure  Go to Q5 	 7  7

			Refused  Go to Q5	 9  9

3.	How often does the [fill in age from Q2]-year-old child in your household use a...	(262)

	car safety seat [for child under 5]

	seatbelt [for child 5 or older]

	...when they ride in a car?  
	
	Would you say:  Please Read

		a.  Always	1

		b.  Nearly always	2

		c.  Sometimes	3

		d.  Seldom	4
			or
		e.  Never	5
		
Do not				Don't know/Not sure	7
read these
responses			Never rides in a car	8

			Refused	9

ö If oldest child 5 years or older, continue with Q4.  Otherwise, go to Q5.

4.	During the past year, how often has the [fill in age from Q2]-year-old child worn a bicycle helmet when riding a bicycle?	(263)

	Would you say:  Please Read

		a.	Always	1

		b.	Nearly Always	2

		c.	Sometimes	3

		d.	Seldom	4
			or
		e.	Never	5

			Don't know/Not sure	7
Do not
read these			Never rides a bicycle	8
responses
			Refused	9

5.	When was the last time you or someone else deliberately tested all of the smoke detectors in your home?			(264)

		Read Only if Necessary

		a.  Within the past month (0 to 1 month ago)	1

		b.  Within the past 6 months (1 to 6 months ago)	2

		c.  Within the past year (6 to 12 months ago)	3

		d.  One or more years ago 	4

		e.	Never	5

		f.	No smoke detectors in home	6

			Don't know/Not sure	7

			Refused	9

Module 13:  Alcohol Consumption

1.	During the past month, have you had at least one drink of any alcoholic beverage such as beer, wine, wine coolers, or liquor?	(265)

		a.  Yes	1

		b.  No  Go to Next Module	2

			Don't know/Not sure  Go to Next Module	7

			Refused Go to Next Module	9

2.	During the past month, how many days per week or per month did you drink any alcoholic beverages, on the average?	(266-268)

		a.  Days per week	1          

		b.  Days per month	2          

			Don't know/Not sure  Go to Q4	7  7  7

			Refused  Go to Q4	9  9  9

3.	A drink is 1 can or bottle of beer, 1 glass of wine, 1 can or bottle of wine cooler, 1 cocktail, or 1 shot of liquor.  On the days when you drank, about how many drinks did you drink on the average?
					(269-270)

			Number of drinks	         

			Don't know/Not sure	 7  7

			Refused	 9  9

4.	Considering all types of alcoholic beverages, how many times during the past month did you have 5 or more drinks on an occasion?	(271-272)

		a.  Number of times	         

		b.  None	 8  8

			Don't know/Not sure	 7  7

			Refused	 9  9

5.	During the past month, how many times have you driven when you've had perhaps too much to drink?			(273-274)

		a.  Number of times	         

		b.  None	 8  8

			Don't know/Not sure	 7  7

			Refused	 9  9

Module 14:  Cardiovascular Disease

1.	To lower your risk of developing heart disease or stroke, has a doctor advised you to...

		Please Read		Yes	No	Dk/Ns	Ref	
			  		
		a.  Eat fewer high fat
		     or high cholesterol foods	1	2	7	9	(275)

		b.  Exercise more		1	2	7	9	(276)

2.	To lower your risk of developing heart disease or stroke, are you?

		Please Read		Yes	No	Dk/Ns	Ref

		a.  Eating fewer high fat
	   	     or high cholesterol foods?	1	2	7	9	(277)

		b.  Exercising more?	1	2	7	9	(278)

3.	Has a doctor ever told you that you had any of the following?

		Please Read		Yes	No	Dk/Ns	Ref

		a.  Heart attack or myocardial infarction	1	2	7	9	(279)

		b.  Angina or coronary heart disease	1	2	7	9	(280)
 
		c.  Stroke	1	2	7	9	(281)

ö If respondent 35 years old or older continue with Q4.  Otherwise, go to next module.

4.	Do you take aspirin daily or every other day?	(282)

		a.  Yes  Go to Q6	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

5.	Do you have a health problem or condition that makes taking aspirin unsafe for you?
				(283)

If yes, ask		a.  Yes, not stomach related  Go to Q7	1
"Is this a
stomach con-		b.  Yes, stomach problems  Go to Q7	2
dition?"
Code upset		c.  No  Go to Q7	3
stomachs as
stomach			Don't know/Not sure  Go to Q7	7
problems
			Refused  Go to Q7	9

6.	Why do you take aspirin?

		Please Read		Yes	No	Dk/Ns	Ref	

		a.  To relieve pain	1	2	7	9	(284)

		b.  To reduce the chance of a heart attack	1	2	7	9	(285)

		c.  To reduce the chance of a stroke	1	2	7	9	(286)

ö If respondent is male or is pregnant ("Yes" to core Q69), go to next module.

The next few questions are about menopause, or what some women refer to as the "change of life."

ö If respondent had hysterectomy ("Yes" to core Q68) or if respondent is age 65 or older, go to Q8. 

7.	Have you gone through or are you now going through menopause?	(287)

Probe			a.  Yes, have gone through menopause	1
for
which			b.  Yes, now going through menopause 	2

		c.  No Go to Next Module	3

			Don't know/Not sure  Go to Next Module	7

			Refused  Go to Next Module	9

8.	Estrogens such as Premarin and progestins such as Provera are female hormones that may be prescribed around the time of menopause, after menopause, or after a hysterectomy.  Has your doctor discussed the benefits and risks of estrogen with you?	(288)

		a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

9.	Other than birth control pills, has your doctor ever prescribed estrogen pills for you?
				(289)

Do not			a.  Yes	1
include
estrogen		b.  No  Go to Next Module	2
patches
			Don't know/Not sure Go to Next Module	7

			Refused  Go to Next Module	9

10.	Are you currently taking estrogen pills?          	(290)

Do not			a.  Yes	1
include
estrogen		b.  No	2
patches
	Don't know/Not sure Go to Next Module	7
 
	Refused Go to Next Module	9

11.	Why...

		are you taking...[if "Yes" to Q10]

		did you take...[if "No" to Q10]

 		...estrogen pills?
								Never
				Please Read	Yes	No	Dk/Ns	took	Ref

		a.  To prevent a heart attack	1	2	7	8	9	(291)

		b.  To treat or prevent bone thinning,
		     bone loss, or osteoporosis	1	2	7	8	9	(292)

		c.  To treat symptoms of menopause
		     such as hot flashes 	1	2	7	8	9	(293)

Module 15: Arthritis

1.	During the past 12 months, have you had pain, aching, stiffness or swelling in or around a joint?
				(294)

		a.  Yes	1
 
		b.  No  Go to Q4	2

			Don't know/Not sure  Go to Q4	7

			Refused  Go to Q4	9

2.	Were these symptoms present on most days for at least one month?	(295)

		a.  Yes	1
 
		b.  No	2

			Don't know/Not sure	7

			Refused	9

3.	Are you now limited in any way in any activities because of joint symptoms?	(296)

		a.  Yes	1
 
		b.  No	2

			Don't know/Not sure	7

			Refused	9

4.	Have you ever been told by a doctor that you have arthritis?	(297)

		a.  Yes	1
 
		b.  No   Go to Next Module	2

			Don't know/Not sure  Go to Next Module	7

			Refused    Go to Next Module	9

5.	What type of arthritis did the doctor say you have?	(298-299)

			Type Code	         

		Read Only if Necessary

		a.  Osteoarthritis/degenerative arthritis	0 1

		b.  Rheumatism	0 2
	
		c.  Rheumatoid Arthritis	0 3

		d.  Lyme disease	0 4

		e.  Other: (specify)                              	0 7

		f.	Never saw a doctor	8 8

	  		Don't know/Not sure	7 7
		
			Refused	9 9

6.	Are you currently being treated by a doctor for arthritis?	(300)

		a.  Yes	1
 
		b.  No	2

			Don't know/Not sure 	7

			Refused	9

Module 16: Quality of Life

These next questions are about limitations you may have in your daily life.

1.	Are you limited in any way in any activities because of any impairment or health problem?
				(301)

		a.  Yes	1
	
		b.  No  Go to Q6	2

			Don't know/Not sure  Go to Q6   	7

			Refused  Go to Q6	9

2.	What is the major impairment or health problem that limits your activities?	(302-303)

			Reason Code	         

		Read Only if Necessary

		a.  Arthritis/rheumatism	0 1

		b.  Back or neck problem	0 2

		c.  Fractures, bone/joint injury	0 3

		d.  Walking problem	0 4

		e.  Lung/breathing problem	0 5

		f.  Hearing problem	0 6

		g.  Eye/vision problem	0 7

		h.  Heart problem	0 8

		i.  Stroke problem	0 9

		j.  Hypertension/high blood pressure	1 0

		k.  Diabetes	1 1

		l.  Cancer	1 2

		m.  Depression/anxiety/emotional problem	1 3

		n.  Other impairment/problem	1 4

			Don't know/Not sure	7 7

			Refused	9 9

3.	For how long have your activities been limited because of your major impairment or health problem?		(304-306)

		a.  Days	1          

		b.  Weeks	2          

		c.  Months	3          

		d.  Years	4          

			Don't know/Not Sure	7  7  7

			Refused	9  9  9

4.	Because of any impairment or health problem, do you need the help of other persons with your PERSONAL CARE needs, such as eating, bathing, dressing, or getting around the house?
				(307)	

		a.  Yes	1	

		b.  No	2

			Don't know/Not sure  	7

			Refused	9

5.	Because of any impairment or health problem, do you need the help of other persons in handling your ROUTINE needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?	(308)

		a.  Yes  	1	

		b.  No  	2

			Don't know/Not sure  	7

			Refused  	9

6.	During the past 30 days, for about how many days did pain make it hard for you to do your usual activities, such as self-care, work, or recreation?	(309-310)

		a.  Number of days	         

		b.  None	8  8

			Don't know/Not sure	7  7

 			Refused	9  9

7.	During the past 30 days, for about how many days have you felt sad, blue, or depressed?
				(311-312)

		a.  Number of days	         
	
		b.  None	8  8

			Don't know/Not sure	7  7

 			Refused	9  9

8.	During the past 30 days, for about how many days have you felt worried, tense, or anxious?
				(313-314) 

		a.  Number of days	         
	
		b.  None	8  8

			Don't know/Not sure	7  7

 			Refused	9  9

9.	During the past 30 days, for about how many days have you felt you did not get enough rest or sleep?		(315-316)

	a.  Number of days	         	

		b.  None	8  8

			Don't know/Not sure	7  7

 			Refused	9  9

10.	During the past 30 days, for about how many days have you felt very healthy and full of energy?
				(317-318)

		a.  Number of days	         
	
		b.  None	8  8

			Don't know/Not sure	7  7

 			Refused	9  9

Module 17: Folic Acid

1.	Do you currently take any vitamin pills or supplements?	(319)

Include   		a.  Yes	1
liquid
supplements		b.  No  Go to Q5	2

			Don't know/Not sure  Go to Q5 	7

			Refused  Go to Q5	9

2.	Are any of these a multivitamin?	(320)

		a.  Yes  Go to Q4	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

3.	Do any of the vitamin pills or supplements you take contain folic acid?	(321)

		a.  Yes	1

		b.  No Go to Q5	2

			Don't know/Not sure Go to Q5	7

			Refused Go to Q5	9

4.	How often do you take this vitamin pill or supplement?	(322-324)

		a.  Times per day	1          

		b.  Times per week	2          

		c.  Times per month	3          

			Don't know/Not sure	7  7  7

			Refused	9  9  9

ö If respondent 45 years old or older, go to next module

5.	Some health experts recommend that women take 400 micrograms of the B vitamin folic acid, for which one of the following reasons... 	(325)

		Please Read

		a.  To make strong bones	1

		b.  To prevent birth defects	2

		c.  To prevent high blood pressure	3
			or
		d.  Some other reason	4

Do not				Don't know/Not sure	7
read these
responses			Refused	9

Module 18: Firearms

The next questions are about safety and firearms.  Firearms include weapons such as pistols, shotguns, and rifles.  In answering the questions, do not include BB guns, starter pistols, or guns that cannot fire.

1.	Are any firearms now kept in or around your home?  Include those kept in a garage, outdoor storage area, car, truck, or other motor vehicle.	(326)

		a.  Yes	1

		b.  No Go to Next Module	2

			Don't know/Not sure Go to Next Module	7

			Refused Go to Next Module	9

2.	Are any of the firearms handguns, such as pistols or revolvers?	(327)

		a.  Yes	1

		b.  No Go to Q4	2

			Don't know/Not sure	7

			Refused	9

3.	Are any of the firearms long guns, such as rifles or shotguns?	(328)

		a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

4.	What is the main reason that there are firearms in or around your home?	(329)

	 Would you say for...

		Please Read

		a.  Hunting or sport	1

		b.  Protection	2

		c.  Work	3
			or
		d.  Some other reason	4

			Don't know/Not sure	7

			Refused	9

5.	Is there a firearm in or around your home that is now both loaded and unlocked?	(330)

		a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

ö Read the following if "Employed" or "Self-employed" on core Q50.  Otherwise, go directly to Q6.

The next three questions are about using firearms.  If you are a police officer or have another occupation that requires and authorizes you to use a firearm, do not include firearm‑use associated with your job.

6.	During the last 30 days, have you carried a loaded firearm on your person, outside of the home for protection against people?	(331)

		a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

7.	During the last 30 days, have you driven or been a passenger in a motor vehicle in which you knew there was a loaded firearm?	(332)

		a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

8.	During the last 12 months, have you confronted another person with a firearm, even if you did not fire it, to protect yourself, your property, or someone else?	(333)

		a.  Yes	1

     		b.  No	2

			Don't know/Not sure	7

			Refused	9

9.	In the past three years, have you attended a firearm safety workshop, class, or clinic?
					(334)

     		a.  Yes	1

     		b.  No	2

			Don't know/Not sure	7

			Refused	9

10.	Do any of the firearms kept in or around your home belong to you, personally?	(335)

		a.  Yes	1

		b.  No	2

			Don't know/Not sure	7

			Refused	9

Module 19: Social Context

These next questions are about your daily life.

1.	How safe from crime do you consider your neighborhood to be?	(336)

	Would you say:  Please Read

		a.  Extremely safe	1

		b.  Quite safe	2

		c.  Slightly safe	3

		d.  Not at all safe	4

			Don't know/Not sure	7

			Refused	9

2.	Do you own or rent your home?	(337)

		a.  Own	1

		b.  Rent	2

			Refused	9

3.	How long have you lived at your current address?	(338)

		Read Only if Necessary

		a.  Less than six months (1 to 6 months)	1

		b.  Less than one year (6 to 12 months)	2

		c.  Less than two years (1 to 2 years)	3

		d.  2 or more years	4

			Don't know/Not sure	7

			Refused	9

4.	How many close friends or relatives would help you with your emotional problems or feelings if you needed it?	(339)

  		a.  3 or more	1

		b.  2		2

		c.  1		3

		d.  None	4

			Don't know/Not Sure	7

			Refused	9

5.	In the past 30 days, have you been concerned about having enough food for you or your family?
					(340)

  		a.  Yes	1

		b.  No	2

			Don't know/Not Sure	7

			Refused	9

Module 20:  Tobacco Use Prevention

1.	In the past 30 days has anyone, including yourself, smoked cigarettes, cigars, or pipes anywhere inside your home?	(341)

		a.	Yes	1

		b.	No	2

			Don’t know/Not sure	7

			Refused	9

ö If "Employed," or "Self-employed" to core Q50 continue.  Otherwise, go to Q5.

2.	While working at your job, are you indoors most of the time?	(342)

		a.  Yes	1

		b.	No  Go to Q5	2
		
			Don’t know/Not sure Go to Q5	7

			Refused  Go to Q5	9

3.	Which of the following best describes your place of work’s official smoking policy for indoor public or common areas, such as lobbies, rest rooms, and lunch rooms?	(343)

		Please Read

For workers		a.	Not allowed in any public areas	1
who visit
clients,			b.	Allowed in some public areas	2
"place
of work"		c.	Allowed in all public areas	3
means their			or
base location		d.	No official policy	4

Do not				Don’t know/Not sure	7
read these
responses			Refused	9

4.	Which of the following best describes your place of work’s official smoking policy for work areas?
					(344)

		Please Read
 
For workers		a.	Not allowed in any work areas	1
who visit
clients,			b.	Allowed in some work areas	2
"place
of work"		c.	Allowed in all work areas	3
means their			or
base location		d.	No official policy	4

Do not				Don’t know/Not sure	7
read these
responses			Refused	9

5.	In the following locations, do you think that smoking should be allowed in all areas, some areas, or not allowed at all?

					All	Some	Not	
					Areas	Areas	Allowed	Dk/Ns	Ref
	Please Read
		 
	a. Restaurants		1	2	3	7	9	(345)

	b. Schools			1	2	3	7	9	(346)

	c. Day care centers		1	2	3	7	9	(347)

	d. Indoor work areas		1	2	3	7	9	(348)

6.	Do you think that billboards that advertise tobacco products should be allowed near places frequented by children, such as schools, playgrounds, and churches.	(349)

		a. Yes	1

		b.  No	2

			Don’t know/Not sure	7

			Refused	9

Module 21:  Smokeless Tobacco Use

1.	Have you ever used or tried any smokeless tobacco products such as chewing tobacco or snuff?
				(350)

Probe for		a.  Yes, chewing tobacco	1
chewing
tobacco,		b.  Yes, snuff	2
snuff,
or both			c.  Yes, both	3

		d.  No, neither  Go to Closing Statement	4

			Don't know/Not sure  Go to Closing Statement	7

			Refused  Go to Closing Statement	9  

2.	Do you currently use any smokeless tobacco products such as chewing tobacco or snuff?
				(351)

"Yes"			a.  Yes, chewing tobacco	1
includes
occa-			b.  Yes, snuff	2
sional
use			c.  Yes, both	3

		d.  No, neither	4

			Don't know/Not sure	7

			Refused	9