(View in Courier new, 10 pt) 1997 Behavioral Risk Factor Surveillance System Questionnaire 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: (33) 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? (34-35) 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? (36-37) a. Number of days __ __ b. None If Q. 2 also "None," go to Q. 5 (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? (38-39) 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? (40) a. Yes 1 b. No Go to Q. 7b (p. 7) 2 Don't know/Not sure Go to Q. 12 (p. 9) 7 Refused Go to Q. 12 (p. 9) 9 6. Do you have Medicare? (41) Medicare is a a. Yes Go to Q. 8 (p. 7) 1 coverage plan for people 65 b. No 2 or over and for certain Don't know/not sure 7 disabled people Refused 9 7a. What type of health care coverage do you use to pay for most of your medical care? (42-43) Is it coverage through: Please Read a. Your employer Go to Q. 8 (p. 7) 0 1 b. Someone else's employer Go to Q. 8 (p. 7) 0 2 c. A plan that you or someone else buys on your own Go to Q. 8 (p. 7) 0 3 d. Medicare Go to Q. 8 (p. 7) 0 4 e. Medicaid or Medical Assistance [or substitute state program name] Go to Q. 8 (p. 7) 0 5 f. The military, CHAMPUS, or the VA [or CHAMP-VA] Go to Q. 8 (p. 7) 0 6 g. The Indian Health Service [or the Alaska Native Health Service] Go to Q. 8 (p. 7) 0 7 or h. Some other source Go to Q. 8 (p. 7) 0 8 Do not None Go to Q. 11 (p. 9) 8 8 read these responses Don't know/Not sure Go to Q. 8 (p. 7) 7 7 Refused Go to Q. 8 (p. 7) 9 9 7b. There are some types of coverage you may not have considered. Please tell me if you have any of the following: (44-45) Coverage through: Please Read If more a. Your employer 0 1 than one, ask "Which type b. Someone else's employer 0 2 do you use to pay for c. A plan that you or someone else buys on most of your own 0 3 your medical care?" d. Medicare 0 4 e. Medicaid or Medical Assistance [or substitute state program name] 0 5 f. The military, CHAMPUS, 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 Q. 11 (p. 9) 8 8 read these responses Don't know/Not sure Go to Q. 12 (p. 9) 7 7 Refused Go to Q. 12 (p. 9) 9 9 8. About how long have you had [fill in type (Medicare/Medicaid/this particular health care coverage) from Q. 6, Q. 7a, or Q. 7b]? (46) 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 9. Is there a book or list of doctors associated with your [fill in type (Medicare/Medicaid/health coverage) from Q. 6, Q. 7a, or Q. 7b] plan? (47) 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?" 10. Does your [fill in type (Medicare/Medicaid/health coverage) from Q. 6, Q. 7a, or Q. 7b] plan require you to select a certain doctor or clinic for all of your routine care? (48) If necessary, say "The coverage you use currently to pay for most of your medical care" a. Yes Go to Q. 12 (p. 9) 1 Do not include emergency care b. No Go to Q. 12 (p. 9) 2 or referral to a specialist Don't know/Not sure Go to Q. 12 (p. 9) 7 Refused Go to Q. 12 (p. 9) 9 11. 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 12. 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 13. About how long has it been since you last visited a doctor for a routine checkup? (51) 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 Never 8 Refused 9 Section 3: Hypertension Awareness 14. About how long has it been since you last had your blood pressure taken by a doctor, nurse, or other health professional? (52) 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 Q. 17 (p. 11) 8 Refused 9 15. Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure? (53) a. Yes 1 b. No Go to Q. 17 (p. 11) 2 Don't know/Not sure Go to Q. 17 (p. 11) 7 Refused Go to Q. 17 (p. 11) 9 16. Have you been told on more than one occasion that your blood pressure was high, or have you been told this only once? (54) a. More than once 1 b. Only once 2 Don't know/Not sure 7 Refused 9 Section 4: Cholesterol Awareness 17. Blood cholesterol is a fatty substance found in the blood. Have you ever had your blood cholesterol checked? (55) a. Yes 1 b. No Go to Q. 20 (p. 12) 2 Don't know/Not sure Go to Q. 20 (p. 12) 7 Refused Go to Q. 20 (p. 12) 9 18. About how long has it been since you last had your blood cholesterol checked? (56) 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 19. Have you ever been told by a doctor or other health professional that your blood cholesterol is high? (57) a. Yes 1 b. No 2 Don't know/Not sure 7 Refused 9 Section 5: Diabetes 20. Have you ever been told by a doctor that you have diabetes? (58) 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 6: Injury Control 21. How often do you use seatbelts when you drive or ride in a car? (59) 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 22. What is the age of the oldest child in your household under the age of 16? (60-61) Code <1 a. Code age in years __ __ yr. as "01" b. No children under age 16 Go to Q. 25 (p. 15) 8 8 Don't know/Not sure Go to Q. 25 (p. 15) 7 7 Refused Go to Q. 25 (p. 15) 9 9 23. How often does the [fill in age from Q. 22]-year-old child in your household use a... car safety seat [for child under 5] seatbelt [for child 5 or older] ...when they ride in a car? (62) 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 If oldest child is 5 years or older, continue with Q. 24. Otherwise, go to Q. 25 (p. 15). 24. During the past year, how often has the [fill in age from Q. 22]-year-old child worn a bicycle helmet when riding a bicycle? (63) 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 25. When was the last time you or someone else deliberately tested all of the smoke detectors in your home, either by pressing the test buttons or holding a source of smoke near them? (64) 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 Section 7: Tobacco Use 26. Have you smoked at least 100 cigarettes in your entire life? (65) 5 packs = 100 a. Yes 1 cigar- ettes b. No Go to Q. 31 (p. 18) 2 Don't know/Not sure Go to Q. 31 (p. 18) 7 Refused Go to Q. 31 (p. 18) 9 27. Do you now smoke cigarettes everyday, some days, or not at all? (66) a. Everyday 1 b. Some days Go to Q. 28a 2 c. Not at all Go to Q. 30 (p. 17) 3 Refused Go to Q. 31 (p. 18) 9 28. On the average, about how many cigarettes a day do you now smoke? (67-68) 1 pack = 20 Number of cigarettes Go to Q. 29 (p. 17) __ __ cigarettes Don't know/Not sure Go to Q. 29 (p. 17) 7 7 Refused Go to Q. 29 (p. 17) 9 9 28a. On the average, when you smoked during the past 30 days, about how many cigarettes did you smoke a day? (69-70) 1 pack = 20 Number of cigarettes Go to Q. 31 (p. 18) __ __ cigarettes Don't know/Not sure Go to Q. 31 (p. 18) 7 7 Refused Go to Q. 31 (p. 18) 9 9 29. During the past 12 months, have you quit smoking for 1 day or longer? (71) a. Yes Go to Q. 31 (p. 18) 1 b. No Go to Q. 31 (p. 18) 2 Don't know/Not sure Go to Q. 31 (p. 18) 7 Refused Go to Q. 31 (p. 18) 9 30. About how long has it been since you last smoked cigarettes regularly, that is, daily? (72-73) 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 Section 8: Alcohol Consumption 31. During the past month, have you had at least one drink of any alcoholic beverage such as beer, wine, wine coolers, or liquor? (74) a. Yes 1 b. No Go to Q. 36 (p. 20) 2 Don't know/Not sure Go to Q. 36 (p. 20) 7 Refused Go to Q. 36 (p. 20) 9 32. During the past month, how many days per week or per month did you drink any alcoholic beverages, on the average? (75-77) a. Days per week 1 __ __ b. Days per month 2 __ __ Don't know/Not sure Go to Q. 34 7 7 7 Refused Go to Q. 34 9 9 9 33. 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? (78-79) Number of drinks __ __ Don't know/Not sure 7 7 Refused 9 9 34. Considering all types of alcoholic beverages, how many times during the past month did you have 5 or more drinks on an occasion? (80-81) a. Number of times __ __ b. None 8 8 Don't know/Not sure 7 7 Refused 9 9 35. During the past month, how many times have you driven when you've had perhaps too much to drink? (82-83) a. Number of times __ __ b. None 8 8 Don't know/Not sure 7 7 Refused 9 9 Section 9: Demographics 36. What is your age? (84-85) Code age in years __ __ Don't know/Not sure 0 7 Refused 0 9 37. What is your race? (86) 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 38. Are you of Spanish or Hispanic origin? (87) a. Yes 1 b. No 2 Don't know/Not sure 7 Refused 9 39. Are you: (88) 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 40. How many children live in your household who are... Please Read Code 1-9 a. less than 5 years old? __ __ (89) 7 = 7 or more 8 = None b. 5 through 12 years old? __ __ (90) 9 = Refused c. 13 through 17 years old? __ __ (91) 41. What is the highest grade or year of school you completed? (92) 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 42. Are you currently: (93) 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 43. Is your annual household income from all sources: (94-95) 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 44. About how much do you weigh without shoes? (96-98) Round Weight __ __ __ fractions pounds up Don't know/Not sure 7 7 7 Refused 9 9 9 45. About how tall are you without shoes? (99-101) Round Height __ /__ __ fractions ft/inches down Don't know/Not sure 7 7 7 Refused 9 9 9 46. What county do you live in? (102-104) FIPS county code Don't know/not sure 7 7 7 Refused 9 9 9 47. Do you have more than one telephone number in your household? (105) a. Yes 1 b. No Go to Q. 49 2 Refused Go to Q. 49 9 48. How many residential telephone numbers do you have? (106) Exclude ded- Total telephone numbers [8=8 or more] __ icated fax and computer Refused 9 lines Now I have some questions about other health services you may have received. 49. Indicate sex of respondent. Ask Only if Necessary (107) Male Go to Q. 61 (p. 28) 1 Female 2 Section 10: Women's Health 50. A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram? (108) a. Yes 1 b. No Go to Q. 53 (p. 25) 2 Don't know/Not sure Go to Q. 53 (p. 25) 7 Refused Go to Q. 53 (p. 25) 9 51. How long has it been since you had your last mammogram? (109) 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 52. 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? (110) a. Routine checkup 1 b. Breast problem other than cancer 2 c. Had breast cancer 3 Don't know/Not sure 7 Refused 9 53. 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? (111) a. Yes 1 b. No Go to Q. 56 (p. 26) 2 Don't know/Not sure Go to Q. 56 (p. 26) 7 Refused Go to Q. 56 (p. 26) 9 54. How long has it been since your last breast exam? (112) 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 55. 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? (113) a. Routine Checkup 1 b. Breast problem other than cancer 2 c. Had breast cancer 3 Don't know/Not sure 7 Refused 9 56. A Pap smear is a test for cancer of the cervix. Have you ever had a Pap smear? (114) a. Yes 1 b. No Go to Q. 59 (p. 27) 2 Don't know/Not sure Go to Q. 59 (p. 27) 7 Refused Go to Q. 59 (p. 27) 9 57. How long has it been since you had your last Pap smear? (115) 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 58. Was your last Pap smear done as part of a routine exam, or to check a current or previous problem? (116) a. Routine exam 1 b. Check current or previous problem 2 Other 3 Don't know/Not sure 7 Refused 9 59. Have you had a hysterectomy? (117) a. Yes Go to Q. 61 (p. 28) 1 A hysterec- tomy is an b. No 2 operation to remove the Don't know/Not sure 7 uterus (womb) Refused 9 If respondent 45 years old or older, go to Q. 61 (p. 28). 60. To your knowledge, are you now pregnant? (118) a. Yes 1 b. No 2 Don't know/Not sure 7 Refused 9 Section 11: Immunization 61. During the past 12 months, have you had a flu shot? (119) a. Yes 1 b. No 2 Don't know/Not sure 7 Refused 9 62. Have you ever had a pneumonia vaccination? (120) a. Yes 1 b. No 2 Don't know/Not sure 7 Refused 9 Section 12: Colorectal Cancer Screening If respondent is 40 years or older, continue with Q. 63. Otherwise, go to Section 13: HIV/AIDS (p. 31). 63. 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? (121) a. Yes 1 b. No Go to Q. 65 2 Don't know/Not sure Go to Q. 65 7 Refused Go to Q. 65 9 64. When did you have your last blood stool test using a home kit? (122) 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 65. 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? (123) a. Yes 1 b. No Go to Section 13: HIV/AIDS (p. 31) 2 Don't know/Not sure Go to Section 13: HIV/AIDS (p. 31) 7 Refused Go to Section 13: HIV/AIDS (p. 31) 9 66. When did you have your last sigmoidoscopy or proctoscopy? (124) 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 Section 13: HIV/AIDS 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. 67. 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? (125-126) Code 01 a. Grade __ __ through 12 b. Kindergarten 5 5 c. Never 8 8 Don't know/Not sure 7 7 Refused 9 9 68. If you had a teenager who was sexually active, would you encourage him or her to use a condom? (127) a. Yes 1 b. No 2 Would give other advice 3 Don't know/Not sure 7 Refused 9 69. What are your chances of getting infected with HIV, the virus that causes AIDS? (128) Would you say: Please Read a. High 1 b. Medium 2 c. Low 3 or d. None 4 Not applicable Go to Q. 71 (p. 33) 5 Do not read these Don't know/Not sure 7 responses Refused 9 70. Have you ever had your blood tested for HIV? (129) a. Yes Go to Q. 71 (p. 33) 1 b. No 2 Don't know/Not sure 7 Refused 9 71a. Have you donated blood since March 1985? (130) a. Yes 1 b. No Go to Q. 76 (p. 35) 2 Don"t know/Not sure Go to Q. 76 (p. 35) 7 Refused Go to Q. 76 (p. 35) 9 72a. When did you last donate blood? (131-134) Code month and year Go to Q. 76 (p. 35) __ __/__ __ Don't know/Not sure Go to Q. 76 (p. 35) 7 7 7 7 Refused Go to Q. 76 (p. 35) 9 9 9 9 71. When was your last blood test for HIV? (135-138) Code month and year __ __/__ __ Don't know/Not sure 7 7 7 7 Refused 9 9 9 9 72. What was the main reason you had your last blood test for HIV? (139-140) 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 Q. 76 (p. 35) 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 73. Where did you have your last blood test for HIV? (141-142) 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 74. Did you receive the results of your last test? (143) a. Yes 1 b. No Go to Q. 76 2 Don't know/Not sure Go to Q. 76 7 Refused Go to Q. 76 9 75. Did you receive counseling or talk with a health care professional about the results of your test? (144) a. Yes 1 b. No 2 Don't know/Not sure 7 Refused 9 76. These next few questions are about your personal sexual behavior, and I want to remind you that your answers are confidential. Due to what you know about HIV, have you changed your sexual behavior in the past 12 months? (145) 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 77. Did you make any of the following changes in the past 12 months? Please Read Yes No Dk/Ns Ref a. Did you decrease the number of your sexual partners or become abstinent? 1 2 7 9 (146) b. Do you now have sexual intercourse with only the same partner? 1 2 7 9 (147) c. Do you now always use condoms for protection? 1 2 7 9 (148) 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.