1999 Behavioral Risk Factor Surveillance
                        System Questionnaire

CORE SECTIONS
Section 1:   Health Status . . . . . . . . . . . . . . . . . . . . . 3
Section 2:   Health Care Access. . . . . . . . . . . . . . . . . . . 5
Section 3:   Hypertension Awareness. . . . . . . . . . . . . . . . .10
Section 4:   Cholesterol Awareness . . . . . . . . . . . . . . . . .11
Section 5:   Diabetes. . . . . . . . . . . . . . . . . . . . . . . .12
Section 6:   Oral Health . . . . . . . . . . . . . . . . . . . . . .13
Section 7:   Skin Cancer . . . . . . . . . . . . . . . . . . . . . .15
Section 8:   Tobacco Use . . . . . . . . . . . . . . . . . . . . . .16
Section 9:   Alcohol Consumption . . . . . . . . . . . . . . . . . .18
Section 10:  Demographics. . . . . . . . . . . . . . . . . . . . . .20
Section 11:  Women's Health. . . . . . . . . . . . . . . . . . . . .25
Section 12:  Immunization. . . . . . . . . . . . . . . . . . . . . .29
Section 13:  Colorectal Cancer Screening . . . . . . . . . . . . . .30
Section 14:  Injury Control. . . . . . . . . . . . . . . . . . . . .32
Section 15:  HIV/AIDS. . . . . . . . . . . . . . . . . . . . . . . .34

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:    Asthma. . . . . . . . . . . . . . . . . . . . . . . . .62
Module 7:    Preventive Counseling Services. . . . . . . . . . . . .63
Module 8:    Cardiovascular Disease. . . . . . . . . . . . . . . . .66
Module 9:    Arthritis . . . . . . . . . . . . . . . . . . . . . . .70
Module 10:   Fruits and Vegetables . . . . . . . . . . . . . . . . .72
Module 11:   Exercise. . . . . . . . . . . . . . . . . . . . . . . .75
Module 12:   Weight Control. . . . . . . . . . . . . . . . . . . . .79
Module 13:   Folic Acid. . . . . . . . . . . . . . . . . . . . . . .81
Module 14:   Skin Cancer . . . . . . . . . . . . . . . . . . . . . .83
Module 15:   Social Context. . . . . . . . . . . . . . . . . . . . .86
Module 16:   Tobacco Use Prevention. . . . . . . . . . . . . . . . .88
Module 17:   Smokeless Tobacco . . . . . . . . . . . . . . . . . . .90

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

1.1.  Would you say that in general your health is:              (77)

                  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

1.2.  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?                             (78‑79)
     
              a.  Number of days                                 __ __           

              b.  None                                           8  8

                  Don't know/Not sure                            7  7

                  Refused                                        9  9

1.3.  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?          (80‑81)

              a.  Number of days                                 __ __      

              b.  None  If Q1.2 also "None," go to Q2.1 (p. 5)   8  8

                  Don't know/Not sure                            7  7

                  Refused                                        9  9

1.4.  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?        (82‑83)

              a.  Number of days                                 __ __      
      
              b.  None                                           8  8

                  Don't know/Not sure                            7  7

                  Refused                                        9  9

Section 2:  Health Care Access

2.1.  Do you have any kind of health care coverage, including health
      insurance, prepaid plans such as HMOs, or government plans such
      as Medicare?                                               (84)

              a.  Yes                                            1

              b.  No  Go to Q2.3a (p. 7)                         2

                  Don't know/Not sure  Go to Q2.6 (p. 8)         7

                  Refused  Go to Q2.6 (p. 8)                     9

2.2.  Medicare is a coverage plan for people 65 or over and for certain
      disabled people.  Do you have Medicare?                    (85)

              a.  Yes  Go to Q2.6 (p. 8)                         1

              b.  No                                             2

                  Don't know/not sure                            7

                  Refused                                        9

2.3.  What type of health care coverage do you use to pay for most of
      your medical care?                                         (86‑87)

      Is it coverage through:         Coverage Code              __ __

             Please Read 

              a.  Your employer  Go to Q2.4 (p. 8)               0 1

              b.  Someone else's employer  Go to Q2.4 (p. 8)     0 2

              c.  A plan that you or someone else buys on
                  your own  Go to Q2.4 (p. 8)                    0 3

              d.  Medicare  Go to Q2.6 (p. 8)                    0 4

              e.  Medicaid or Medical Assistance [or substitute
                  state program name]  Go to Q2.4 (p. 8)         0 5

              f.  The military, CHAMPUS, TriCare, or the VA
                  [or CHAMP‑VA]  Go to Q2.4 (p. 8)               0 6

              g.  The Indian Health Service [or the Alaska
                  Native Health Service]  Go to Q2.4 (p. 8)      0 7
                  or
              h.  Some other source  Go to Q2.4 (p. 8)           0 8  

Do not            None  Go to Q2.5 (p. 8)                        8 8
read these
responses         Don't know/Not sure  Go to Q2.4 (p. 8)         7 7

                  Refused  Go to Q2.4 (p. 8)                     9 9

2.3a. There are some types of coverage you may not have considered.
      Please tell me if you have any of the following:           (88‑89)

      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 Q2.6 (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 Q2.5 (p. 8)                        8 8
read these
responses         Don't know/Not sure Go to Q2.6 (p. 8)          7 7

                  Refused  Go to Q2.6 (p. 8)                     9 9

2.4.  During the past 12 months, was there any time that you did not
      have any health insurance or coverage?                     (90)

              a.  Yes  Go to Q2.6                                1

              b.  No  Go to Q2.6                                 2

                  Don't know/Not sure  Go to Q2.6                7

                  Refused  Go to Q2.6                            9

2.5.  About how long has it been since you had health care coverage?
                                                                 (91)
                  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

2.6.  Was there a time during the last 12 months when you needed to see
      a doctor, but could not because of the cost?               (92)

              a.  Yes                                            1

              b.  No                                             2

                  Don't know/Not sure                            7

                  Refused                                        9

2.7.  About how long has it been since you last visited a doctor for a
      routine checkup?                                           (93)

                  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:  Hypertension Awareness

3.1.  About how long has it been since you last had your blood pressure
      taken by a doctor, nurse, or other health professional?    (94)

                  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 Q4.1 (p. 11)                      8

                  Refused                                        9

3.2.  Have you ever been told by a doctor, nurse, or other health
      professional that you have high blood pressure?            (95)

              a.  Yes                                            1

              b.  No  Go to Q4.1 (p. 11)                         2

                  Don't know/Not sure  Go to Q4.1 (p. 11)        7

                  Refused  Go to Q4.1 (p. 11)                    9

3.3.  Have you been told on more than one occasion that your blood
      pressure was high, or have you been told this only once?
                                                                 (96)

              a.  More than once                                 1

              b.  Only once                                      2

                  Don't know/Not sure                            7

                  Refused                                        9

Section 4:  Cholesterol Awareness

4.1.  Blood cholesterol is a fatty substance found in the blood. Have
      you ever had your blood cholesterol checked?               (97)

              a.  Yes                                            1

              b.  No  Go to Q5.1 (p. 12)                         2  

                  Don't know/Not sure  Go to Q5.1 (p. 12)        7

                  Refused  Go to Q5.1 (p. 12)                    9

4.2.  About how long has it been since you last had your blood
      cholesterol checked?                                       (98)

                  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
                  Refused                                        9

4.3.  Have you ever been told by a doctor or other health professional
      that your blood cholesterol is high?                       (99)

              a.  Yes                                            1

              b.  No                                             2

                  Don't know/Not sure                            7

                  Refused                                        9

Section 5:  Diabetes

5.1.  Have you ever been told by a doctor that you have diabetes?
                                                                 (100)

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: Oral Health

6.1.  How long has it been since you last visited a dentist or a dental
      clinic for any reason?                                     (101)

                  Read only if necessary

Include       a.  Within the past year (1 to 12 months ago)      1
visits to
dental spec‑  b.  Within the past 2 years (1 to 2 years ago)     2
ialists, such
as ortho‑     c.  Within the past 5 years (2 to 5 years ago)     3
dontists
              d.  5 or more years ago                            4

                  Don't know/Not sure                            7

                  Never                                          8

                  Refused                                        9

6.2.  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.                  (102)

Include teeth a.  5 or fewer                                     1
lost due to
"infection"   b.  6 or more but not all                          2

              c.  All                                            3

              d.  None                                           8

                  Don't know/Not sure                            7

                  Refused                                        9

If "never" to Q6.1 or "all" to Q6.2, go to Q7.1 (p. 15).

6.3.  How long has it been since you had your teeth "cleaned" by a
      dentist or dental hygienist?                               (103)

                  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 7: Skin Cancer

7.1.  The next question is about sunburns, including any time that even
      a small part of your skin was red for more than 12 hours. Have
      you had a sunburn within the past 12 months?              (104)

              a.  Yes                                            1

              b.  No Go to Q8.1 (p. 16)                          2

                  Don't know/Not sure  Go to Q8.1 (p. 16)        7

                  Refused Go to Q8.1 (p. 16)                     9

7.2.  Including times when even a small part of your skin was red for
      more than 12 hours, how many sunburns have you had within the
      past 12 months?                                            (105)

              a.  One                                            1

              b.  Two                                            2

              c.  Three                                          3

              d.  Four                                           4

              e.  Five                                           5

              f.  Six or more                                    6

                  Don't know/Not sure                            7

                  Refused                                        9 

Section 8:  Tobacco Use

8.1.  Have you smoked at least 100 cigarettes in your entire life?
                                                                 (106)

5 packs
= 100         a.  Yes                                            1
cigarettes
              b.  No  Go to Q9.1 (p. 18)                         2

                  Don't know/Not sure  Go to Q9.1 (p. 18)        7

                  Refused  Go to Q9.1 (p. 18)                    9

8.2.  Do you now smoke cigarettes everyday, some days, or not at all?
                                                                 (107)     

              a.  Everyday                                       1

              b.  Some days Go to Q8.3a                          2

              c.  Not at all Go to Q8.5 (p. 17)                  3

                  Refused  Go to Q9.1 (p. 18)                    9

8.3.  On the average, about how many cigarettes a day do you now smoke?
                                                              (108‑109)

1 pack = 20       Number of cigarettes [76 = 76 or more]         __ __
cigarettes        Go to Q8.4 (p. 17)       

                  Don't know/Not sure  Go to Q8.4 (p. 17)        7  7

                  Refused  Go to Q8.4 (p. 17)                    9  9

8.3a. On the average, when you smoked during the past 30 days, about
      how many cigarettes did you smoke a day?                (110‑111)

1 pack = 20       Number of cigarettes [76 = 76 or more]
cigarettes        Go to Q9.1 (p. 18)       
            
                  Don't know/Not sure  Go to Q9.1 (p. 18)        7  7
      
                  Refused  Go to Q9.1 (p. 18)                    9  9

8.4.  During the past 12 months, have you quit smoking for 1 day or
      longer?                                                    (112)

              a.  Yes  Go to Q9.1 (p. 18)                        1

              b.  No  Go to Q9.1 (p. 18)                         2

                  Don't know/Not sure Go to Q9.1 (p. 18)         7

                  Refused  Go to Q9.1 (p. 18)                    9

8.5.  About how long has it been since you last smoked cigarettes
      regularly, that is, daily?                                 (113‑114)

                  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

Section 9:  Alcohol Consumption

9.1.  During the past month, have you had at least one drink of any
      alcoholic beverage such as beer, wine, wine coolers, or liquor?
                                                                 (115)

              a.  Yes                                            1

              b.  No  Go to Q10.1 (p. 20)                        2

                  Don't know/Not sure  Go to Q10.1 (p. 20)       7

                  Refused Go to Q10.1 (p. 20)                    9

9.2.  During the past month, how many days per week or per month did
      you drink any alcoholic beverages, on the average?         (116‑118)

           a.  Days per week                                  1 __ __      

           b.  Days per month                                 2 __ __     

               Don't know/Not sure  Go to Q9.4                7  7  7

               Refused  Go to Q9.4                            9  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?                                                   (119‑120)

                  Number of drinks                               __ __      

                  Don't know/Not sure                            7  7

                  Refused                                        9  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?                                                  (121‑122)
                                                                 
              a.  Number of times                                __ __      

              b.  None                                           8  8

                  Don't know/Not sure                            7  7

                  Refused                                        9  9

9.5.  During the past month, how many times have you driven when you've
      had perhaps too much to drink?                             (123‑124)

              a.  Number of times                                __ __      

              b.  None                                           8  8

                  Don't know/Not sure                            7  7

                  Refused                                        9  9

Section 10: Demographics

10.1. What is your age?                                       (125‑126)

                  Code age in years                              __ __      

                  Don't know/Not sure                            0  7

                  Refused                                        0  9

10.2. What is your race?                                         (127)

                  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

10.3. Are you of Spanish or Hispanic origin?                     (128)

              a.  Yes                                            1

              b.  No                                             2

                  Don't know/Not sure                            7

                  Refused                                        9 

10.4. Are you:                                                   (129)

                  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

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

                  Please Read

Code 1‑9      a.  less than 5 years old?                         (130)
7 = 7 or more                                                         
8 = None      b.  5 through 12 years old?                        (131)
9 = Refused
              c.  13 through 17 years old?                       (132)

10.6. What is the highest grade or year of school you completed?
                                                                 (133)
                  Read Only if Necessary

              a.  Never attended school or only attended 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

10.7. Are you currently:                                         (134)
                  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

10.8. Is your annual household income from all sources:       (135‑136)
                  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

10.9. About how much do you weigh without shoes?              (137‑139)

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

               Refused                                        9  9  9

10.10.  About how tall are you without shoes?                 (140‑142)

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

               Refused                                        9  9  9

10.11.  What county do you live in?                          (143‑145)

               FIPS county code                               __ __ __         

               Don't know/not sure                            7  7  7

               Refused                                        9  9  9

10.12.  Do you have more than one telephone number in your household?
                                                                 (146)

              a.  Yes                                            1

              b.  No  Go to Q10.14 (p. 24)                       2

                  Refused  Go to Q10.14 (p. 24)                  9

10.13.  How many residential telephone numbers do you have?      (147)

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.

10.14.  Indicate sex of respondent.  Ask Only if Necessary       (148)

                  Male  Go to Q12.1 (p. 29)                      1

                  Female                                         2

Section 11:  Women's Health

11.1. A mammogram is an x‑ray of each breast to look for breast cancer. 
      Have you ever had a mammogram?                             (149)

              a.  Yes                                            1

              b.  No  Go to Q11.4 (p. 26)                        2

                  Don't know/Not sure  Go to Q11.4 (p. 26)       7

                  Refused  Go to Q11.4 (p. 26)                   9

11.2. How long has it been since you had your last mammogram?
                                                                 (150)
                  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

11.3. 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?                                 (151)

              a.  Routine checkup                                1

              b.  Breast problem other than cancer               2

              c.  Had breast cancer                              3

                  Don't know/Not sure                            7

                  Refused                                        9

11.4. 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?                                      (152)

              a.  Yes                                            1

              b.  No  Go to Q11.7 (p. 27)                        2

                  Don't know/Not sure  Go to Q11.7 (p. 27)       7

                  Refused  Go to Q11.7 (p. 27)                   9

11.5. How long has it been since your last breast exam?          (153)

                  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

11.6. 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?                                 (154)

              a.  Routine Checkup                                1

              b.  Breast problem other than cancer               2

              c.  Had breast cancer                              3

                  Don't know/Not sure                            7

                  Refused                                        9

11.7. A Pap smear is a test for cancer of the cervix.  Have you ever
      had a Pap smear?                                           (155)

              a.  Yes                                            1

              b.  No  Go to Q11.10 (p. 28)                       2

                  Don't know/Not sure  Go to Q11.10 (p. 28)      7

                  Refused  Go to Q11.10 (p. 28)                  9

11.8. How long has it been since you had your last Pap smear?
                                                                 (156)
                  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

11.9. Was your last Pap smear done as part of a routine exam, or to
      check a current or previous problem?                       (157)

              a.  Routine exam                                   1

              b.  Check current or previous problem              2

                  Other                                          3

                  Don't know/Not sure                            7

                  Refused                                        9

11.10.  Have you had a hysterectomy?                             (158)

              a.  Yes  Go to Q12.1 (p. 29)                       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 Q12.1 (p. 29)

11.11.  To your knowledge, are you now pregnant?                 (159)

              a.  Yes                                            1

              b.  No                                             2

                  Don't know/Not sure                            7

                  Refused                                        9

Section 12:  Immunization

12.1. During the past 12 months, have you had a flu shot?        (160)

              a.  Yes                                            1

              b.  No Go to Q12.3                                 2

                  Don't know/Not sure  Go to Q12.3               7

                  Refused  Go to Q12.3                           9

12.2  At what kind of place did you get your last flu shot?   (161‑162)

                  Place code                                    __ __    
                  Read Only if Necessary

              a.  A doctor's office or health
                  maintenance organization                       0 1
      
              b.  A health department                            0 2

              c.  Another type of clinic or health center
                 [Example: a community health center]            0 3

              d.  A senior, recreation, or community center      0 4

              e.  A store [Examples: supermarket, drug store]    0 5

              f.  A hospital or emergency room                   0 6

              g.  Workplace                                      0 7
        
              h.  Other [specify] ____________                   0 8

                  Don't know/Not sure                            7 7

                  Refused                                        9 9

12.3. Have you ever had a pneumonia vaccination?                 (163)

              a.  Yes                                            1

              b.  No                                             2

                  Don't know/Not sure                            7

                  Refused                                        9

Section 13: Colorectal Cancer Screening

If respondent 40 years or older, continue with Q13.1.  Otherwise, go to
Q14.1 (p. 32).

13.1. 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?                                (164)

              a.  Yes                                            1

              b.  No  Go to Q13.3                                2

                  Don't know/Not sure  Go to Q13.3               7

                  Refused  Go to Q13.3                           9

13.2. When did you have your last blood stool test using a home kit?
                                                                 (165)

                  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

13.3. A sigmoidoscopy or colonoscopy 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?                    (166)

              a.  Yes                                            1

              b.  No  Go to Q14.1 (p. 32)                        2

                  Don't know/Not sure Go to Q14.1 (p. 32)        7

                  Refused  Go to Q14.1 (p. 32)                   9

13.4. When did you have your last sigmoidoscopy or colonoscopy?
                                                                 (167)

                  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 14:  Injury Control

If core Q10.5a, b, and c are all "None," go to Q14.3 (p. 33).

14.1. What is the age of the oldest child in your household under the
      age of 16?                                                 (168‑169)
Code
<1 yr.        a.  Code age in years                                     
as "01"
              b.  No children under age 16  Go to Q14.3 (p. 33)  8  8

                  Don't know/Not sure  Go to Q14.3 (p. 33)       7  7

                  Refused  Go to Q14.3 (p. 33)                   9  9

If oldest child 5 years or older, continue with Q14.2.  Otherwise, go
to Q14.3 (p. 33).

14.2. During the past year, how often has the [fill in age from Q14.1]‑year‑old child worn a bicycle helmet when riding a bicycle?
                                                                 (170)

                  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

14.3. When was the last time you or someone else deliberately tested
      all of the smoke detectors in your home?                   (171)

                  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 15: 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.

15.1. 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?                                        (172‑173)

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

              c.  Never                                          8  8

                  Don't know/Not sure                            7  7

                  Refused                                        9  9

15.2. If you had a teenager who was sexually active, would you
      encourage him or her to use a condom?                      (174)

              a.  Yes                                            1

              b.  No                                             2

                  Would give other advice                        3

                  Don't know/Not sure                            7

                  Refused                                        9

15.3. What are your chances of getting infected with HIV, the virus
      that causes AIDS?                                          (175)

                  Would you say:     Please Read

              a.  High                                           1

              b.  Medium                                         2

              c.  Low                                            3
                  or
              d.  None                                           4

                  Not applicable Go to Q15.7a (p. 36)            5
Do not
read these        Don't know/Not sure                            7
responses
                  Refused                                        9

15.4. Have you donated blood since March 1985?                   (176)

              a.  Yes                                            1

              b.  No  Go to Q15.6a (p. 36)                       2

                  Don't know/Not sure  Go to Q15.6a (p. 36)      7

                  Refused  Go to Q15.6a (p. 36)                  9 

15.5. Have you donated blood in the past 12 months?              (177)

              a.  Yes                                            1

              b.  No                                             2

                  Don"t know/Not sure                            7

                  Refused                                        9

15.6. Except for tests you may have had as part of blood donations,
      have you ever been tested for HIV?                         (178)

Include       a.  Yes  Go to Q15.7 (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

15.6a.  Have you ever been tested for HIV?                       (179)

Include       a.  Yes  Go to Q15.7a                              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

15.7. Not including your blood donations, have you been tested for HIV
      in the past 12 months?                                     (180)

Include       a.  Yes  Go to Q15.8 (p. 37)                       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 

15.7a.  Have you been tested for HIV in the past 12 months?      (181)

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

15.8. What was the main reason you had your last test for HIV?                                                                 (182‑183)

                  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

5.9. Where did you have your last test for HIV?               (184‑185)

                  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

15.10.  Did you receive the results of your last test?           (186)

              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

15.11.  Did you receive counseling or talk with a health care
        professional about the results of your test?             (187)

              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.

Module 1:  Diabetes

1.  How old were you when you were told you have diabetes?       (188‑189)

                  Code age in years  [76 = 76 and older]         __ __      

                  Don't know/Not sure                            7  7

                  Refused                                        9  9

2.  Are you now taking insulin?                                  (190)

              a.  Yes                                            1

              b.  No  Go to Q4                                   2

                  Refused  Go to Q4                              9

3.  Currently, about how often do you use insulin?               (191‑193)

            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.
                                                                 (194‑196)

            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"?                      (197)

              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?       (198‑199)

              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

    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"?                                     (200‑201)

              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?              (202‑203)

              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.                                                (204)

                  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?                         (205)

                  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?                                                   (206)

                  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?                                                  (207)

                  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

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?                                          (208‑209)

              a.  Number [76 = 76 or more]                       __ __      

              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?
                                                                 (210)

              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 ...  
                                                                 (211)
                  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?                             (212)

                 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?                                                   (213‑214)
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?                     (215) 

              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?                             (216)

              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?          (217)

              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?                              (218)

              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    (219)
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    (220)

           c.  Do you now always use condoms
               for protection?             1    2    7     8   9    (221)

Module 3: Family Planning

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.

If pregnant now ("Yes" to core Q11.11), go to Q2a.

1.  Have you been pregnant in the last 5 years?                  (222)

              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?          (223)

                  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
                  or
              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?         (224)

                  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
                  or
              e.  You don't know                                 7

Do not read       Refused                                        9

If respondent had hysterectomy ("Yes" to core Q11.10) or is pregnant
now ("Yes" to core Q11.11), go to Q6.
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 Q10.4] 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.                                            (225)

              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 Q10.4] using now?                (226‑227)

                  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?
                                                             (228‑229)

                  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?
                                                                 (230)
                  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?
                                                                 (231)

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?                                             (232)

                  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

    If not known whether respondent has health care coverage ("Dk/Ns"
    or "Refused" to core Q2.1), go to next module.

I asked you previously about your health care coverage.

    If respondent has no health care coverage ("None" to core Q2.3 or
    Q2.3a), continue.  Otherwise, go to Q2.

1.  What is the main reason you are without health care coverage? 
                                                              (233‑234)                    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 Q2.2, Q2.3, or Q2.3a]?
                                                                 (235)

                  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 Q2.2, Q2.3, or 
    Q2.3a] plan?                                                 (236)

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 Q2.2, Q2.3, or Q2.3a] plan require you to select a certain
    doctor or clinic for all of your routine care?               (237)

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 Q2.2, Q2.3, or
    Q2.3a], do you have any other type of health care coverage?
                                                                 (238)
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

If respondent did not have coverage at some time during past 12 months
("Yes" to core Q2.4), continue.  Otherwise, go to next module. 

6.  What was the main reason you were without health care coverage
    during the past 12 months?                                   (239‑240)

                  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?                                                        (241)
    
                  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?                                           (242)

              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?                                                     (243‑244)

                  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?                   (245)

              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?                                    (246)

                  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?                                                       (247)

                  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?            (248)

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?                            (249)

                   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?                (250‑251)

                  Reason Code                                    __ __       
    
"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: Asthma

1.  Did a doctor ever tell you that you had asthma?              (252)

              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.  Do you still have asthma?                                    (253)

              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?                            (254)
    
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?                         (255)
    
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?                                             (256)
        
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?                                            (257)
    
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?                                           (258)
    
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

If "No" to core Q8.1 or "Not at all" to core Q8.2, go to Q7

6.  (Has a doctor or other health professional) ever advised you to
    quit smoking?                                                (259) 
    
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

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?           (260)

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:  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    (261)

          b.  Exercise more                  1   2     7     9    (262)

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    (263)

          b.  Exercising more?               1   2     7     9    (264)

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    (265)  
        b.  Angina or coronary heart disease 1   2     7     9    (266)
 
        c.  Stroke                           1   2     7     9    (267)

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?                (268)

              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?                                      (269)

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   (270)

         b.  To reduce the chance of a
             heart attack                      1   2     7    9   (271)

         c.  To reduce the chance of a stroke  1   2     7    9   (272)

If respondent is male or is pregnant ("Yes" to core Q11.11), go to
next module.

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

If respondent had hysterectomy ("Yes" to core Q11.10) or if respondent
is age 65 or older, go to Q8. 

7.  Have you gone through or are you now going through menopause?
                                                                 (273)

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?
                                                                 (274)

              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?                                      (275)

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?                     (276)

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  (277)

 b.  To treat or prevent bone
       thinning, bone loss,
       or osteoporosis               1    2     7       8      9  (278)

 c.  To treat symptoms of menopause
       such as hot flashes           1    2     7       8      9  (279)

Module 9: Arthritis

1.  During the past 12 months, have you had pain, aching, stiffness or
    swelling in or around a joint?                               (280)

              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?
                                                                 (281)

              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?                                                    (282)

              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?
                                                                 (283)

              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?          (284‑285)

                  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?
                                                                 (286)

              a.  Yes                                            1
 
              b.  No                                             2

                  Don't know/Not sure                            7

                  Refused                                        9

Module 10:  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.

1.  How often do you drink fruit juices such as orange, grapefruit, or
    tomato?                                                   (287‑289)

            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

2.  Not counting juice, how often do you eat fruit?           (290‑292)

            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

3.  How often do you eat green salad?                         (293‑295)

            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

4.  How often do you eat potatoes not including french fries, fried
    potatoes, or potato chips?                               (296‑298)

            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

5.  How often do you eat carrots?                             (299‑301)

            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

6.  Not counting carrots, potatoes, or salad, how many servings of
    vegetables do you usually eat?                            (302‑304)

Example:    a.  Per day                                        1 __ __      
A serving of
vegetables  b.  Per week                                       2 __ __      
at 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

Module 11:  Exercise

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

1.  During the past month, did you participate in any physical
    activities or exercises such as running, calisthenics, golf,
    gardening, or walking for exercise?                          (305)

              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.  What type of physical activity or exercise did you spend the most
    time doing during the past month?                         (306‑307)

                  Activity [specify]: ________________                                 
                                      See coding list A

                  Refused  Go to Q. 6                            9  9

Ask Q. 3 only if answer to Q. 2 is running, jogging, walking, or
swimming.  All others, go to Q. 4.

3.  How far did you usually walk/run/jog/swim?                   (308‑310)

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

4.  How many times per week or per month did you take part in this
    activity during the past month?                           (311‑313)

            a.  Times per week                                 1 __ __     

            b.  Times per month                                2 __ __     

                Don't know/Not sure                            7  7  7

                Refused                                        9  9  9

5.  And when you took part in this activity, for how many minutes or
    hours did you usually keep at it?                         (314‑316)

               Hours and minutes                              __:__ __     

               Don't know/Not sure                            7  7  7

               Refused                                        9  9  9 

6.  Was there another physical activity or exercise that you
    participated in during the last month?                       (317)

              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

7.  What other type of physical activity gave you the next most
    exercise during the past month?                           (318‑319)

                  Activity [specify]:  _________________                                
                                       See coding list A

                  Refused  Go to Next Module                     9  9

Ask Q. 8 only if answer to Q. 7 is running, jogging, walking, or
swimming.  All others go to Q. 9.

8.  How far did you usually walk/run/jog/swim?                   (320‑322)

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

9.  How many times per week or per month did you take part in this
    activity?                                                 (323‑325)

           a.  Times per week                                 1 __ __      

           b.  Times per month                                2 __ __      

               Don't know/Not sure                            7  7  7

               Refused                                        9  9  9

10. And when you took part in this activity, for how many minutes or
    hours did you usually keep at it?                         (326‑328)

               Hours and minutes                              __:__ __     

               Don't know/Not sure                            7  7  7

               Refused                                        9  9  9

                  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

½ mile = .5 mile
1/4 mile = .3 mile
1/8 mile = .1 mile
 1 block = .1 mile

Module 12: Weight Control

1.  Are you now trying to lose weight?                           (329)

              a.  Yes Go to Q. 3                                 1

              b.  No                                             2

                  Don't know/Not sure                            7

                  Refused                                        9

2.  Are you now trying to maintain your current weight, that is to
    keep from gaining weight?                                    (330)

              a.  Yes                                            1

              b.  No  Go to Q. 6                                 2

                  Don't know/Not sure  Go to Q. 6                7

                  Refused  Go to Q. 6                            9

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

    lose weight? [if "Yes" on Q. 1]

    keep from gaining weight? [if "Yes" on Q. 2]                 (331)

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

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

    lose weight? [if "Yes" on Q. 1]

    keep from gaining weight? [if "Yes" on Q. 2]                 (332)

              a.  Yes                                            1

              b.  No                                             2

                  Don't know/Not sure                            7

                  Refused                                        9

5.  How much would you like to weigh?                         (333‑335)

               Weight                                         __ __ __  
                                                              pounds

               Don't know/Not sure                            7  7  7

               Refused                                        9  9  9

6.  In the past 12 months, has a doctor, nurse, or other health
    professional given you advice about your weight?             (336)

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

Module 13: Folic Acid

1.  Do you currently take any vitamin pills or supplements?      (337)

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?                             (338)

              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?                                                        (339)

              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?    (340‑342)

           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

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...                                                   (343)

                  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 14: Skin Cancer

The next questions are about what you do to protect your skin when you
go outside.

1.  When you go outside on a sunny summer day for more than one hour,
    how often do you use sunscreen or sunblock?                  (344)

    Would you say: Please Read

Summer means  a.  Always                                         1
June, July,
and August.   b.  Nearly always                                  2
Sunny is what
respondent    c.  Sometimes                                      3
considers
sunny         d.  Seldom                                         4
                  or
              e.  Never Go to Q3                                 5
    
Do not            Don't stay out more than an hour  Go to Q6     8
read these    
responses         Don't know/Not sure  Go to Q3                  7

                  Refused  Go to Q3                              9

2.  What is the Sun Protection Factor or SPF of the sunscreen you use
    most often?                                               (345‑346)

                  Number                                         __ __

                  Don't know/Not sure                            7 7

                  Refused                                        9 9

3.  When you go outside on a sunny summer day for more than an hour,
    how often do you stay in the shade?                          (347)

    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         Refused                                        9

4.  When you go outside on a sunny summer day for more than an hour,
    how often do you wear a wide‑brimmed hat or any other hat that
    shades your face, ears, and neck from the sun?               (348)
    
    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         Refused                                        9

5.  When you go outside on a sunny summer day for more than an hour,
    how often do you wear long‑sleeved shirts?                   (349)

    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         Refused                                        9

6.  Suppose that after several months of not being out in the sun, you
    then went out in the sun without a hat, sunscreen, or protective
    clothing for an hour.                                        (350)

    Would you: Please Read

              a.  Sunburn                                        1

              b.  Darken without sunburn Go to Next Module       2
                  or
              c.  Not have anything happen Go to Next Module     3

Do not            Don't know/Not sure Go to Next Module          7
read these
responses         Refused Go to Next Module                      9

7.  Would you: Please Read                                       (351)

              a.  Burn severely with blisters                    1

              b.  Burn severely with peeling for a few days      2
                  or
              c.  Burn mildly without peeling                    3

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

Module 15: Social Context

These next questions are about your daily life.

1.  How safe from crime do you consider your neighborhood to be?
                                                                 (352)

    Would you say:  Please Read

              a.  Extremely safe                                 1

              b.  Quite safe                                     2

              c.  Slightly safe                                  3

              d.  Not at all safe                                4

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

2.  Do you own or rent your home?                                (353)

              a.  Own                                            1

              b.  Rent                                           2

                  Refused                                        9

3.  How long have you lived at your current address?             (354)

                  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?             (355)

              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?                                 (356)

              a.  Yes                                            1

              b.  No                                             2

                  Don't know/Not Sure                            7

                  Refused                                        9

Module 16:  Tobacco Use Prevention

1.  In the past 30 days has anyone, including yourself, smoked
    cigarettes, cigars, or pipes anywhere inside your home?      (357)

              a.  Yes                                            1

              b.  No                                             2

                  Don't know/Not sure                            7

                  Refused                                        9

If "Employed," or "Self‑employed" to core Q10.7 continue.  Otherwise,
go to Q5.

2.  While working at your job, are you indoors most of the time?
                                                                 (358)

              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?                        (359)
    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?                      (360)
                  Please Read
 
For workers   a.  Not allowed in any work areas                  1
who visit
clients,      b.  Allowed in some work areas, or                 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     (361)

    b. Schools              1      2        3        7     9     (362)

    c. Day care centers     1      2        3        7     9     (363)

    d. Indoor work areas    1      2        3        7     9     (364)

Module 17:  Smokeless Tobacco Use

1.  Have you ever used or tried any smokeless tobacco products such as
    chewing tobacco or snuff?                                    (365)

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?                                    (366)

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

              d.  No, neither                                    4

                  Don't know/Not sure                            7

                  Refused                                        9