BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM			
                               (Project Title)	

                           1995 - Final Layout			Page            
           		          (Project Year)        	     Date 08-16-96

Field
Size	

Columns	

	Question	

	Comments	

  28	
  1-28	
IDENTIFICATION INFORMATION	

   2	
   1-2	
Fips State Code	

   1	
     3	
Stratum Code	

   5	
   4-8	
PSU Number	

   1	
     9	
Record Number	

   6	
 10-15	
Date of Interview	

   2	
 16-17	
Interviewer Identification	

   8	
 18-25	
Telephone Number	
First Eight Digits of Telephone Number	

   2	
 26-27	
Final Disposition of Telephone Call	
01=	Completed Interview
02=	Refused Interview
03=	Non-Working Number
04=	No Answer
05=	Business Telephone
06=	No Eligible Respondent at this number
07=	No Eligible Respondent could be reached during time period
08=	Language barrier prevented completion of interview
09=	Interview terminated within questionnaire
10=  Line Busy
11=	Selected respondent unable to respond because of physical or mental impairment	
K:\share\bsb\brfs95\layout95.fin
Rev. 08/16/96 

Field
Size

Columns	

	Questions	

	Comments	

1
	
   28	
Winddown	
Blank= Regular Mode
    9= Winddown Mode	

2
	
  29-30  	
Number of Adults in Household	
01-18= Number of adults,
       18 years plus in
       household	

1	
 31	
Number of Adult Men in Household	
0-9= Number of adult men,
     18 years plus in
     household	

1	
   32  	
Number of Adult Women in Household	
0-9=	Number of adult
      women, 18 years plus
      in household	

	
 SECTION 1:  HEALTH STATUS	

1	
   33	
Q1:  Would you say that in general your health is: 	
1= Excellent
2= Very good
3= Good
4= Fair
5= Poor
7= Don't know/Not sure
9= Refused	

2	
34-35	
Q2:  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?	
01-30= Number of days
   88= None
   77= Don't know/Not sure
   99= Refused

	

2	
  36-37     	
Q3:  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?	
01-30= Number of days
   88= None
   77= Don't know/Not sure
   99= Refused	

2	
38-39	
Q4:  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?	
01-30= Number of days
   88= None
   77= Don't know/Not sure
   99= Refused

SECTION 2:  HEALTH CARE ACCESS				

1	
40	
Q5:  Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
41	
Q6:  About how long has it been since you had health care coverage?	
1= Within the past 6
   months (1 to 6 months
   ago)
2= Within the past year 
   (6 to 12 months ago)
3= Within the past 2 years
   (1 to 2 years ago)
4= Within the past 5 years     (2 to 5 years ago)
5= 5 or more years ago
7= Don't know/Not sure
8= Never
9= Refused	

1	
42	
Q7:  Was there a time during the last 12 months when you needed to see a doctor, but could not because of the cost?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
43	
Q8:  About how long has it been since you last visited a doctor for a routine checkup?	
1= Within the past year
   (1 to 12 months ago)
2= Within the past 2 years
   (1 to 2 years ago)
3= Within the past 5 years
   (2 to 5 years ago)
4= 5 or more years ago
7= Don't know/Not sure
8= Never
9= Refused	

SECTION 3:  HYPERTENSION AWARENESS				

1	
44	
Q9:  About how long has it been since you last had your blood pressure taken by a doctor, nurse, or other health professional?	
1= Within the past 6
   months
   (1 to 6 months ago)
2= Within the past year 
   (6 to 12 months ago)
3= Within the past 2 years
   (1 to 2 years ago)
4= Within the past 5 years
   (2 to 5 years ago)
5= 5 or more years ago
7= Don't know/Not sure
8= Never
9= Refused	

1	
45	
Q10:  Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
46	
Q11:  Have you been told on more than one occasion that your blood pressure was high or have you been told only once?

	
1= More than once
2= Only once
7= Don't know/Not sure
9= Refused	

SECTION 4:  CHOLESTEROL AWARENESS				

1	
47	
Q12:  Blood cholesterol is a fatty substance found in the blood.  Have you ever had your blood cholesterol checked?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
48	
Q13:  About how long has it been since you last had your blood cholesterol checked?	
1= Within the past year 
   (1 to 12 months ago)
2= Within the past 2 years
   (1 to 2 years ago)
3= Within the past 5 years
   (2 to 5 years ago)
4= 5 or more years ago
7= Don't know/Not sure
9= Refused	

1	
49	
Q14:  Have you ever been told by a doctor or other health professional that your blood cholesterol is high?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

SECTION 5:  DIABETES				

1	
50	
Q15:  Have you ever been told by a doctor that you have diabetes?  			
1=	Yes
2=	Yes, but female told
   only during pregnancy
3=	No
7=	Don't know/Not sure
9=	Refused	

SECTION 6:  INJURY CONTROL				

1	
51	
Q16: How often do you use seatbelts when you drive or ride in a car?	
1= Always
2= Nearly always
3= Sometimes
4= Seldom
5= Never
7= Don't know/Not sure
8= Never drive or ride in
   a car
9= Refused	

2	
52-53	
Q17: What is the age of the oldest child in your household under the age of 16?	
01-15= Code age in years
   88= No children under
       age 16
   77= Don't know/Not sure
   99= Refused	

1	
54	
Q18:  How often does the oldest child in your household use a car safety seat or seatbelt when they ride in a car?	
1= Always
2= Nearly always
3= Sometimes
4= Seldom
5= Never
7= Don't know/not sure
8= Never rides in a car
9= Refused	

1	
55	
Q19:  During the past year, how often has the oldest child worn a bicycle helmet when riding a bicycle?	
1= Always
2= Nearly always
3= Sometimes
4= Seldom
5= Never
7= Don't know/not sure
8= Never rides in a car
9= Refused	

1	
56	
Q20:  When was the last time you or someone else deliberately tested all of the smoke detectors in your home, either by pressing the test buttons or holding a source of smoke near them?

	
1= Within the past month 
   (0 to 1 month ago)
2= Within the past 
   6 months (1 to 6 months
   ago)
3= Within the past year 
   (6 to 12 months ago)
4= One or more years ago
5= Never
6= No smoke detectors in
   home
7= Don't know/Not sure
9= Refused	

SECTION 7:  TOBACCO USE				

1	
57	
Q21:  Have you smoked at least 100 cigarettes in your entire life?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
58	
Q22:  Do you smoke cigarettes now?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

2	
59-60	
Q23:  On how many of the past 30 days did you smoke cigarettes?	
01-30= Code number of days
   88= None
   77= Don't know/Not sure
   99= Refused	

2	
61-62	
Q24:  On the average, about how many cigarettes a day do you now smoke?	
01-76= Code number of
       cigarettes
   77= Don't know/Not sure
   99= Refused	

2	
63-64	
Q24a.  On the average, when you smoked during the past 30 days, about how many cigarettes did you smoke a day?	
01-76= Code number of
       cigarettes
   77= Don't know/Not sure
   99= Refused	

1	
65	
Q25.  During the past 12 months, have you quit smoking for 1 day or longer?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

2	
66-67	
Q26.  About how long has it been since you last smoked cigarettes regularly, that is, daily?	
01= Within the past month
    (0 to 1 month ago)
02= Within the past 3
    months (1 to 3 months
    ago)
03= Within the past 6
    months (3 to 6 months
    ago)
04= Within the past year 
(6 to 12 months ago)
05= Within the past 5
    years (1 to 5 years
    ago)
06= Within the past 15
    years (5 to 15 years
    ago)
07= 15 or more years ago
77= Don't know/Not sure
88= Never smoked regularly
99= Refused	

SECTION 8:  ALCOHOL CONSUMPTION				

1	
68	
Q27.  During the past month, have you had at least one drink of any alcoholic beverage such as beer, wine, wine coolers, or liquor?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

3	
69-71	
Q28.  During the past month, how many days per week or per month did you drink any alcoholic beverages?	
101-107= Days per week 
201-231= Days per month
    777= Don't know/Not
         sure
    999= Refused	

2	
72-73	
Q29.  A drink is 1 can or bottle of beer, 1 cocktail, or 1 shot of liquor.  On the days when you drank, about how many drinks did you drink on the average?	
01-76= Number of drinks
   77= Don't know/Not sure
   99= Refused	

2	
74-75	
Q30.  Considering all types of alcoholic beverages, how many times during the past month did you have 5 or more drinks on an occasion?	
01-76= Number of times
   88= None
   77= Don't know/Not sure
   99= Refused	

2	
76-77	
Q31.  During the past month, how many times have you driven when you've had perhaps too much to drink?	
01-76= Number of times
   88= None
   77= Don't know/Not sure
   99= Refused	

SECTION 9:  DEMOGRAPHICS				

2	
78-79	
Q32.  What is your age?	
18-99= Code in years
   07= Don't know/Not sure
   09= Refused	

1	
80	
Q33.  What is your race?	
1= White
2= Black
3= Asian, Pacific Islander
4= American Indian, 
   Alaskan Native
5= Other
7= Don't know/Not sure
9= Refused	

1	
81	
Q34.  Are you of Spanish or Hispanic origin?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
82	
Q35.  Are you:	
1= Married
2= Divorced
3= Widowed
4= Separated
5= Never been married
6= A member of an
   unmarried couple
9= Refused	

1	
83	
Q36a.  How many children live in your household who are less than 5 years old?  	
1-6= Code number of
     children
  7= 7 or more children
  8= None
  9= Refused	

1	
84	
Q36b.  How many children live in your household who are 5 through 12 years old?	
1-6= Code number of
     children
  7= 7 or more children
  8= None
  9= Refused	

1	
85	
Q36c.  How many children live in your household who are 13 through 17 years old?	
1-6= Code number of
     children
  7= 7 or more children
  8= None
  9= Refused	

1	
86	
Q37.  What is the highest grade or year of school you completed?	
1= Never attended school
   or kindergarten only
2= Grades 1 through 8
   (Elementary)
3= Grades 9 through 11
   (Some high school)
4= Grade 12 or GED (High
   school graduate)
5= College 1 year to 
   3 years (some college
   or technical school)
6= College 4 years or more
   (college graduate)
9= Refused 	

1	
87	
Q38.  Are you currently?	
1= Employed for wages
2= Self-employed
3= Out of work for more
   than 1 year
4= Out of work for less
   than 1 year
5= Homemaker
6= Student
7= Retired
8= Unable to work
9= Refused	

2	
88-89	
Q39.  Is your annual household income from all sources:	
01= Less than $10,000
02= $10,000 to $14,999
03= $15,000 to $19,999
04= $20,000 to $24,999
05= $25,000 to $34,999
06= $35,000 to $49,999
07= $50,000 to $74,999
08= $75,000 or more
77= Don't know/Not sure
99= Refused	

3	
90-92	
Q40.  About how much do you weigh without shoes?	
050-776= Pounds
    777= Don't know/Not
         sure
    999= Refused	

3	
93-95	
Q41.  About how tall are you without shoes?	
200-805= Code in inches
    777= Don't know/Not
         sure
    999= Refused	

3	
96-98	
Q42.  What county do you live in?	
XXX= FIPS county code
777= Don't know/Not sure
999= Refused	

1	
99	
Q43.  Do you have more than one telephone number in your household?	
1= Yes
2= No
9= Refused	

1	
100	
Q44.  How many residential telephone numbers do you have?	
1-8= Total residential
     telephone numbers
  9= Refused	

1	
101	
Q45.  Indicate sex of respondent.

	
1= Male
2= Female	

SECTION 10:  WOMEN'S HEALTH				

1	
102	
Q46.  A mammogram is an x-ray of each breast to look for breast cancer.  Have you ever had a mammogram?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
103	
Q47.  How long has it been since you had your last mammogram?	
1= Within the past year 
   (1 to 12 months ago)
2= Within the past 2 years
   (1 to 2 years ago)
3= Within the past 3 years
   (2 to 3 years ago)
4= Within the past 5 years
   (3 to 5 years ago)
5= 5 or more years ago
7= Don't know/Not sure
9= Refused	

2	
104-105	
Q48.  About how many mammograms have you had in the last 5 years?	
01-60= Number of
       mammograms
   88= None
   77= Don't know/not sure
   99= Refused	

1	
106	
Q49.  Was you 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?	
1= Routine checkup
2= Breast problem other
   than cancer
3= Had breast cancer
7= Don't know/Not sure
9= Refused	

1	
107	
Q50.  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?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
108	
Q51.  How long has it been since your last breast exam?	
1= Within the past year 
   (1 to 12 months ago)
2= Within the past 2 years
   (1 to 2 years ago)
3= Within the past 3 years
   (2 to 3 years ago)
4= Within the past 5 years
   (3 to 5 years ago)
5= 5 or more years ago
7= Don' know/Not sure
9= Refused	

1	
109	
Q52.  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?	
1= Routine checkup
2= Breast problem other
   than cancer
3= Had breast cancer
7= Don't know/Not sure
9= Refused	

1	
110	
Q53.  A pap smear is a test for cancer of the cervix.  Have you ever had a pap smear?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
111	
Q54.  How long has it been since you had your last pap smear?	
1= Within the past year 
   (1 to 12 months ago)
2= Within the past 2 years
   (1 to 2 years ago)
3= Within the past 3 years
   (2 to 3 years ago)
4= Within the past 5 years
   (3 to 5 years ago)
5= 5 or more years ago
7= Don' know/Not sure
9= Refused	

1	
112	
Q55.  Was your last pap smear done as part of a routine exam, or to check a current or previous problem?	
1= Routine exam
2= Check current or
   previous problem
3= Other
7= Don't know/Not sure
9= Refused	

1	
113	
Q56.  Have you had a hysterectomy?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
114	
Q57.  To you knowledge, are you now pregnant?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

SECTION 11.  IMMUNIZATION				

1	
115	
Q58.  During the past 12 months, have you had a flu shot?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
116	
Q59.  Have you ever had a pneumonia vaccination?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

SECTION 12:  COLORECTAL CANCER SCREENING				

1	
117	
Q60.  A digital rectal exam is when a doctor or other health professional inserts a finger in the rectum to check for cancer and other health problems.  Have you ever had this exam?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
118	
Q61.  When did you have your last digital rectal exam?	
1= Within the past year 
   (1 to 12 months ago)
2= Within the past 2 years
   (1 to 2 years ago)
3= Within the past 5 years
   (2 to 5 years ago)
4= 5 or more years ago
7= Don' know/Not sure
9= Refused	

1	
119	
Q62.  A proctoscopic exam is when a tube is inserted in the rectum to check for cancer and other health problems.  Have you ever had this exam?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
120	
Q63.  When did you have your last proctoscopic exam?  	
1= Within the past year 
   (1 to 12 months ago)
2= Within the past 2 years
   (1 to 2 years ago)
3= Within the past 5 years
   (2 to 5 years ago)
4= 5 or more years ago
7= Don' know/Not sure
9= Refused	

SECTION 13:  HIV/AIDS				

2	
121-122	
Q64.  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?	
01-12= Code grade
   55= Kindergarten
   88= Never
   77= Don't know/Not sure
   99= Refused	

1	
123	
Q65.  If you had a teenager who was sexually active, would you encourage him or her to use a condom?	
1= Yes
2= No
3= Would give other advice
7= Don't know/Not sure
9= Refused	

1	
124	
Q66.  What are you chances of getting infected with HIV, the virus that causes AIDS? 	
1= High
2= Medium
3= Low
4= None
5= Not applicable
7= Don't know/Not sure
9= Refused	

1	
125	
Q67.  Have you ever had your blood tested for HIV?	
1= Yes
2= Not
7= Don't know/Not sure
9= Refused	

1	
126	
Q68a.  Have you donated blood since March 1985?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

4	
127-130	
Q69a.  When did you last donate blood?	
0385-1295= Code month and
           year
7785-7795= Code unknown
           month and year
9985-9995= Code refused
           month and year
     7777= Don't know/Not
           sure
     9999= Refused	

4	
131-134	
Q68.  When was your last blood test for HIV?	
0180-1295= Code month and
           year
7780-7795= Code unknown
           month and year
9980-9995= Code refused
           month and year
     7777= Don't know/Not
           sure
     9999= Refused	

2	
135-136	
Q69.  What was the main reason you had your last blood test for HIV?	
01=	For hospitalization
     or surgical
     procedure
02= 	To apply for health insurance
03=	To apply for life insurance
04=	For employment
05=	To apply for a  marriage license
06=	For military induction or military service
07=	For immigration
08=	Just to find out if you were infected
09=	Because of referral by a doctor
10=	Because of pregnancy
11=	Referred by your sex partner
12=	Because it was part of a blood donation process
13=	For routine check-up
14=	Because of occupational exposure
15=	Because of illness
87=	Other
77=	Don't know/Not sure
99=	Refused	

2	
137-138	
Q70.  Where did you have your last blood test for HIV?	
01=	Private doctor, HMO
02=	Blood bank, plasma
      center, Red Cross
03=	Health department
04=	AIDS clinic, counseling, testing site
05=	Hospital, emergency room, outpatient clinic
06=	Family planning clinic
07=	Prenatal clinic
08=	Tuberculosis clinic
09=	STD clinic
10=	Community health clinic
11=	Clinic run by employer
12=	Insurance company clinic
13=	Other public clinic
14=	Drug treatment facility
15=	Military induction or military service site
16=	Immigration site
17=	At home, home visit by nurse or health worker
18=	At home using self-testing kit
87=	Other
77=	Don't know/Not sure
99=	Refused	

1	
139	
Q71.  Did you receive the results of your last test?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
140	
Q72.  Did you receive counseling or talk with a health care professional about the results of your test?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
141	
Q73.  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?	
1= Very effective
2= Somewhat effective
3= Not at all effective
4= Don't know how
   effective
5= Don't know method
9= Refused	

1	
142	
Q74.  Due to what you know about HIV, have you changed your sexual behavior in the last 12 months?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
143	
Q75a.  Have you had sexual intercourse with only one partner?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
144	
Q75b.  Have you used condoms for protection?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
145	
Q75c.  Have you been more careful in selecting sexual partners?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

MODULE 1:  SMOKELESS TOBACCO USE				

1	
146	
Q1.  Have you ever used or tried any smokeless tobacco products such as chewing tobacco or snuff?	
1= Yes, chewing tobacco
2= Yes, snuff
3= Yes, both
4= No, neither
7= Don't know/Not sure
9= Refused	

1	
147	
Q2.  Do you currently use any smokeless tobacco products such as chewing tobacco or snuff?	
1= Yes, chewing tobacco
2= Yes, snuff
3= Yes, both
4= No, neither
7= Don't know/Not sure
9= Refused	

MODULE 2:  FRUITS AND VEGETABLES				

3	
148-150	
Q1.  How often do you drink fruit juices such as orange, grapefruit, or tomato?	
101-199= Times per day
201-299= Times per week
301-399= Times per month
401-499= Times per year
    555= Never
    777= Don't know/Not
         sure
    999= Refused	

3	
151-153	
Q2.  Not counting juice, how often do you eat fruit?	
101-199= Times per day
201-299= Times per week
301-399= Times per month
401-499= Times per year
    555= Never
    777= Don't know/Not
         sure
    999= Refused	

3	
154-156	
Q3.  How often do you eat green salad?	
101-199= Times per day
201-299= Times per week
301-399= Times per month
401-499= Times per year
    555= Never
    777= Don't know/Not
         sure
    999= Refused	

3	
157-159	
Q4.  How often do you eat potatoes not including french fries, fried potatoes, or potato chips?	
101-199= Times per day
201-299= Times per week
301-399= Times per month
401-499= Times per year
    555= Never
    777= Don't know/Not
         sure
    999= Refused	

3	
160-162	
Q5.  How often do you eat carrots?	
101-199= Times per day
201-299= Times per week
301-399= Times per month
401-499= Times per year
    555= Never
    777= Don't know/Not
         sure
    999= Refused	

3	
163-165	
Q6.  Not counting carrots, potatoes, or salad, how many servings of vegetables do you usually eat?	
101-199= Times per day
201-299= Times per week
301-399= Times per month
401-499= Times per year
    555= Never
    777= Don't know/Not
         sure
    999= Refused	

MODULE 3:  DIABETES				

2	
166-167	
Q1.  How old were you when you were told you have diabetes?	
01-76= Code age in years
   77= Don't know/Not sure
   99= Refused	

1	
168	
Q2.  Are you now taking insulin?	
1= Yes
2= No
9= Refused	

3	
169-171	
Q3.  Currently, about how often do you use insulin?	
101-106= Times per day
201-242= Times per week
    333= Use insulin pump
    777= Don't know/Not
         sure
    999= Refused	

3	
172-174	
Q4.  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?	
101-109= Times per day
201-263= Times per week
301-399= Times per month
401-499= Times per year
    888= Never
    777= Don't know/Not
         sure
    999= Refused	

1	
175	
Q5.  Have you ever heard of glycosylated hemoglobin or hemoglobin "A one C"?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

2	
176-177	
Q6.  About how many times in the last year have you seen a doctor, nurse, or other health professional for your diabetes?	
01-52= Code number of
       times
   88= None
   77= Don't know/Not sure
   99= Refused	

1	
178	
Q7.  About how many times in the last year has a doctor, nurse, or other health professional checked you for glycosylated hemoglobin or hemoglobin "A and C"?	
1-6= Code number of times
  8= None
  7= Don't know/Not sure
  9= Refused	

1	
179	
Q8.  About how many times in the last year has a health professional checked your feet for any sores or irritations?	
1-6= Number of times
  8= None
  7= Don't know/Not sure
  9= Refused	

1	
180	
Q9.  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?	
1= Within the past month
   (0 to 1 month ago)
2= Within the past year 
   (1 to 12 months ago)
3= Within the past 2 years
   (1 to 2 years ago)
4= 2 or more years ago
8= Never
7= Don't know/Not sure
9= Refused	

1	
181	
Q10.  How much of the time does your vision limit you in recognizing people or objects across the street?	
1= All of the time
2= Most of the time
3= Some of the time
4= A little bit of the
   time
5= None of the time
7= Don't know/Not sure
9= Refused	

1	
182	
Q11.  How much of the time does your vision limit you in reading print in a newspaper, magazine, recipe, menu, or numbers on the telephone?	
1= All of the time
2= Most of the time
3= Some of the time
4= A little bit of the
   time
5= None of the time
7= Don't know/Not sure
9= Refused	

1	
183	
Q12.  How much of the time does your vision limit you in watching television?	
1= All of the time
2= Most of the time
3= Some of the time
4= A little bit of the
   time
5= None of the time
7= Don't know/Not sure
9= Refused	

MODULE 4:  EXERCISE				

1	
184	
Q1.  During the past month, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

2	
185-186	
Q2.  What type of physical activity or exercise did you spend the most time doing during the past month?	
XX= See last page, coding
    list for activity code
99= Refused	

3	
187-189	
Q3.  How far did you usually walk/run/jog/swim?	
001-150= Code Miles and  
         Tenths (one
         implied decimal
         place)
    777= Don't know/Not
         sure
    999= Refused	

3	
190-192	
Q4.  How many times per week or per month did you take part in this activity during the past month?	
101-199= Times per week
201-299= Times per month
    777= Don't know/Not
         sure
    999= Refused	

3	
193-195	
Q5.  And when you took part in this activity, for how many minutes or hours did you usually keep at it?	
001-959= Code in hours and
         minutes
    777= Don't know/Not
         sure
    999= Refused	

1	
196	
Q6.  Was there another physical activity or exercise that you participated in during the last month?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

2	
197-198	
Q7.  What other type of physical activity gave you the next most exercise during the past month?	
XX= See last page, coding
    list A for activity
    code
99= Refused	

3	
199-201	
Q8.  How far did you usually walk/run/jog/swim?	
001-150= Code Miles and
         Tenths (one
         implied decimal
         place)
    777= Don't know/Not
         sure
    999= Refused	

3	
202-204	
Q9.  How many times per week or per month did you take part in this activity?	
101-199= Code times per
         week
201-299= Code times per
         month
    777= Don't know/Not
         sure
    999= Refused	

3	
205-207	
Q10.  And when you took part in this activity, for how many minutes or hours did you usually keep at it?

	
001-959= Code hours and
         minutes
    777= Don't know/Not
         sure
    999= Refused	

MODULE 5:  WEIGHT CONTROL				

1	
208	
Q1.  Are you trying to lose weight?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
209	
Q2.  Are you now trying to maintain your current weight, that is to keep from gaining weight?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
210	
Q3.  Are you eating either fewer calories or less fat to either lose weight or keep from gaining weight?	
1= Yes, fewer calories
2= Yes, less fat
3= Yes, fewer calories and
   less fat
4= No
7= Don't know/Not sure
9= Refused	

1	
211	
Q4.  Are you using physical activity or exercise to lose weight or keep from gaining weight?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

3	
212-214	
Q5.  How much would you like to weigh?	
050-776= Code in pounds
    777= Don't know/Not
         sure
    999= Refused	

1	
215	
Q6.  In the past 12 months, has a doctor, nurse, or other health professional given you advice about your weight?

	
1= Yes, lose weight
2= Yes, gain weight
3= Yes, maintain current
   weight
4= No
7= Don't know/Not sure
9= Refused	

MODULE 6:  YEARS OF HEALTHY LIFE				

1	
216	
Q1.  What were you doing most of the past 12 months?	
1= Working at a job or
   business
2= Keeping house
3= Going to school
4= Something else
7= Don't know/Not sure
9= Refused	

1	
217	
Q2.  Does any impairment or health problem now keep you from working at a job or business?	
1- Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
218	
Q3.  Are you limited in the kind or amount of work you can do because of any impairment or health problem?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
219	
Q4.  Does any impairment or health problem now keep you from doing any housework at all?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
220	
Q5.  Are you limited in the kind or amount of housework you can do because of any impairment or health problem?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
221	
Q6.  Does any impairment or health problem keep you from working at a job or business?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
222	
Q7.  Are you limited in the kind or amount of work you could do because of any impairment or health problem?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
223	
Q8.  Are you limited in any way in any activities because of any impairment or health problem?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
224	
Q9.  Because of any impairment or health problem, do you need the help of other persons with your PERSONAL CARE needs, such as eating, bathing, dressing, or getting around the house?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
225	
Q10. Because of any impairment or health problem, do you need the help of other persons in handling your ROUTINE needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
226	
Q11.  Because of any impairment or health problem, do you need the help of other persons with your PERSONAL CARE needs, such as eating, bathing, dressing, or getting around the house?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
227	
Q12.  Because of any impairment or health problem, do you need the help of other persons in handing your ROUTINE needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
228	
Q13.  Are you limited in any way in any activities because of an impairment or health problem?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

MODULE 7:  QUALITY OF LIFE				

1	
229	
Q1.  Are you limited in any way in any activities because of any impairment or health problem?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

2	
230-231	
Q2.  What is the major impairment or health problem that limits your activities?	
01= Arthritis/rheumatism
02= Back or neck problem
03= Fractures, bone/joint
    injury
04= Walking problem
05= Lung/breathing
    problem
06= Hearing problem
07= Eye/vision problem
08= Heart problem
09= Stroke problem
10= Hypertension/high
    blood pressure
11= Diabetes
12= Cancer
13= Depression/anxiety/
    emotional problem
14= Other impairment/
    problem
77= Don't know/Not sure
99= Refused	

3	
232-234	
Q3.  For how long have your activities been limited because of your major impairment or health problem?	
101-199= Days
201-299= Weeks
301-399= Months
401-499= Years
    777= Don't know/Not
         sure
    999= Refused	

1	
235	
Q4.  Because of any impairment or health problem, do you need the help of other persons with your PERSONAL CARE needs, such as eating, bathing, dressing, or getting around the house?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
236	
Q5.  Because of any impairment or health problem, do you need the help of other persons in handling your ROUTINE needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

2	
237-238	
Q6.  During the past 30 days, for about how many days did pain make it hard for you to do your usual activities, such as self-care, work, or recreation?	
01-30= Code number of days
   88= None
   77= Don't know/Not sure
   99= Refused	

2	
239-240	
Q7.  During the past 30 days, for about how many days have you felt sad, blue, or depressed?	
01-30= Number of days
   88= None
   77= Don't know/Not sure
   99= Refused	

2	
241-242	
Q8.  During the past 30 days, for about how many days have you felt worried, tense, or anxious?	
01-30= Number of days
   88= None
   77= Don't know/Not sure
   99= Refused	

2	
243-244	
Q9.  During the past 30 days, for about how many days have you felt you did not get enough rest or sleep?	
01-30= Number of days
   88= None
   77= Don't know/Not sure
   99= Refused	

2	
245-246	
Q10.  During the past 30 days, for about how many days have you felt very healthy and full of energy?	
01-30= Number of days
   88= None
   77= Don't know/Not sure
   99= Refused	

MODULE 8:  HEALTH CARE UTILIZATION				

1	
247	
Q1.  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?	
1= Yes
2= More than one place
3= No
7= Don't know/Not sure
9= Refused	

1	
248	
Q2.  Is there one of these places that you go to most often when you are sick or need advice about your health?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

2	
249-250	
Q3.  What kind of place is it--a clinic, a health center, a hospital, a doctor's office, or some other place?	
01= Doctor's office or
    private clinic
02= Company or school
    health clinic/center
03= Community/migrant/
    rural clinic/center
04= County/city/public
    hospital outpatient
    clinic
05= Private/other
    hospital outpatient
    clinic
06= Hospital emergency
    room
07= HMO/prepaid group
08= Psychiatric hospital
    or clinic
09= VA hospital or clinic
10= Military health care
    facility
11= Some other kind of
    place
77= Don't know/Not sure
99= Refused	

2	
251-252	
Q4.  What is the main reason you do not have a usual source of medical care?	
01= Two or more usual
    places
02= Have not needed a
    doctor
03= Do not like/trust/
    believe in doctors
04= Do not know where to
    go
05= Previous doctor is
    not available/moved
06= No insurance/cannot
    afford
07= Speak a different
    language
08= No place is 
    available/close
    enough/convenient
09= Other
77= Don't know/Not sure
99= Refused	

MODULE 9:  ORAL HEALTH				

1	
253	
Q1.  How long has it been since you last visited  the dentist or a dental clinic?	
1= Within the past year 
   (1 to 12 months ago)
2= Within the past 2 years
   (1 to 2 years ago)
3= Within the past 5 years
   (2 to 5 years ago)
4= 5 or more years ago
7= Don't know/Not sure
8= Never
9= Refused	

2	
254-255	
Q2.  What is the main reason you have not visited the dentist in the last year?	
01= Fear, apprehension,
    nervousness, pain,
    dislike going
02= Cost
03= Do not have/know a
    dentist
04= Cannot get to the
    office/clinic (too far
    away, no transpor-
    tation, no appoint- 
    ments available)
05= No reason to go (no
    problems, no teeth)
06= Other priorities
07= Have not thought of it
08= Other
77= Don't know/Not sure
99= Refused	

1	
256	
Q3.  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?	
1= 5 or fewer
2= 6 or more, but not all
3= All
8= None
7= Don't know/Not sure
9= Refused	

1	
257	
Q4.  Do you have any kind of insurance coverage that pays for some or all of your routine dental care, including dental insurance, prepaid plans such as HMOs, or government plans such as Medicaid?

	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

MODULE 10:  FIREARMS				

1	
258	
Q1.  Are there any loaded or unloaded firearms in your home or the car, van, or truck you usually drive?  This includes firearms stored in the basement, garage, or any attached buildings.	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
259	
Q2.  Are there any loaded firearms in the car, van, or truck you usually drive?	
1= Yes
2= No
7= Don't know/Not sure
8= Don't drive
9= Refused	

1	
260	
Q3.  Not including firearms in a car, truck, or other vehicle, are there any loaded firearms in your home?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
261	
Q4.  Are all of the loaded firearms in your home stored in a locked place that can only be opened with a key or combination, or with a trigger lock that can only be opened with a key or combination?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
262	
Q5.  Are there any unloaded firearms in your home?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
263	
Q6.  Are all of the unloaded firearms in your home stored in a locked place that can only be opened with a key or combination, or with a trigger lock that can only be opened with a key or combination?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

1	
264	
Q7.  Is the ammunition for any of those unloaded and unlocked firearms stored in the same room as the firearms or in closets in the same room?	
1= Yes
2= No
7= Don't know/Not sure
8= Don't own any
   ammunition
9= Refused	

1	
265	
Q8.  Is the ammunition stored in a locked or unlocked place?	
1= Locked
2= Unlocked
7= Don't know/Not sure
9= Refused	

1	
266	
Q9.  Do you feel safer or less safe because there are firearms in your home or car, van, or truck?	
1= Safer
2= Less safe
3= Neither
7= Don't know/Not sure
9= Refused	

1	
267	
Q10.  Excluding firearms you carry because of work, have you carried a loaded firearm on your person outside the home for protection during the past 30 days?	
1= Yes
2= No
7= Don't know/Not sure
9= Refused	

7	
268-274	
BLANK	

176	
275-450	
STATE ADDED QUESTIONS	

2	
451-452	
New race code	
01= White, Non-Hispanic
02= Black, Non-Hispanic
03= Hispanic, White
04= Hispanic, Black
05= Other Hispanic
06= Asian or Pacific
    Islander, non-hispanic
07=American Indian/Alaskan 
   Native, non-hispanic
08= Other
99= Unknown/Refused	

1	
453	
Computed smoking status(2)	
1= Current smoker--smoked       all of past 30 days
2= Current smoker--smoked       1-29 days in past 30         days
3= Current smoker--smoked       0 days in past 30 days 
4= Current smoker--unknown      number of days smoked in     past 30 days 
5= Former smoker
6= Never smoked
9= Refused	

4	
454-457	
Total number drinks a month	
0001-1000= # of Drinks
     8888= Did not drink in
           the past month
     9999= Refused	

5	
458-462	
Weight for Height Percent of Median	
#####= (2 implied decimal
       places)
99999= Unknown	

3	
463-465	
Body mass index	
###= (1 implied decimal
     place)
999= Unknown	

1	
466	
Physical activity level	
1= Physically inactive 
   (Yr. 2000 Obj. 1.5)
2= Irregular and/or not
   sustained activity
3= Regular and not
   intensive
4= Regular and intensive
   (Yr. 2000 Obj. 1.4)
9= Unknown

Note: Prior to 1992, code 4 represented a measure of a 1990 Objective for physical activity.

1	
467	
Computed smokeless status	
1= Current user
2= Former user
3= Never used
9= Unknown	

5	
468-472	
Total number of servings of fruits and vegetables consumed per day	
#####= (2 implied decimal
        places)
99999= Unknown	

1	
473	
Summary index for fruits and vegetables	
1= Less than once per day
   or never
2= Once but less than 3
   times per day
3= 3 but less than 5 times
   per day
4= 5 or more times per day
9= Unknown	

12	
474-485	
Risk factors	
0= Not at risk
1= At risk
9= Unknown	

1	
474	
At risk for seatbelt use (2) (sometimes, seldom, or never)	
0= Not at risk
1= At risk
9= Unknown	

1	
475	
At risk for seatbelt use (3) (nearly always, sometimes, seldom, or never)	
0= Not at risk
1= At risk
9= Unknown	

1	
476	
At risk for hypertension (2) (told blood pressure high)	
0= Not at risk
1= At risk
9= Unknown	

1	
477	
At risk for smoking (2)
(all current smokers)	
0= Not at risk
1= At risk
9= Unknown	

1	
478	
At risk for acute drinking (reported having 5+ drinks at least once on an occasion)	
0= Not at risk
1= At risk
9= Unknown	

1	
479	
At risk for drinking and driving (reported having driven at least once when perhaps had too much to drink)	
0= Not at risk
1= At risk
9= Unknown	

1	
480	
At risk for chronic drinking (having 60+ drinks a month)	
0= Not at risk
1= At risk
9= Unknown	

1	
481	
At risk for sedentary lifestyle (sedentary or irregular physical activity profile)	
0= Not at risk
1= At risk
9= Unknown	

1	
482	
Physical activity level - Frequent Regular
(Yr. 2000 Obj. 1.3)	
0= Does not engage in very
   regular and sustained
   activity
1= Engages in very regular
   and sustained activity
9= Unknown	

1	
483	
At risk for obesity (greater than 120% of weight for height percent median)	
0= Not at risk
1= At risk
9= Unknown	

1	
484	
At risk for overweight based on BMI (at risk defined as
>27.8 for males and
>27.3 for females)	
0= Not at risk
1= At risk
9= Unknown	

1	
485	
At risk for smokeless tobacco (current user)	
0= Not at risk
1= At risk
9= Unknown	

7	
486-492	
Blank	

4	
493-496	
Raw weighting factor unequal selection probability weight (number of adults in household/the number of phone # reaching houshold)	
####= (2 implied decimal
      places)
9999= Unknown	

4	
497-500	
Cluster size adjustment (CSA) (Expected cluster size divided by the actual cluster size)	
####= (2 implied decimal
      places)
9999= Unknown	

4	
501-504
	
WT1 (Raw * CSA)
The product of unequal selection probability weight and cluster size adjustment	
####= (2 implied decimal
      places)
9999= Unknown	

10	
505-514	
Post stratification (Population estimate for age/sex/race categories divided by the weighted sample frequency by age/race/sex)	
##########= (2 implied
            decimal places)
9999999999= Unknown	

10	
515-524	
Final weight:  Post stratifi-cation multiplied by the product of stratum adjustment and the product of unequal selection probability weight and cluster size adjustment	
##########= (2 implied
            decimal places)
9999999999= Unknown	

1	
525	
Age group codes used in post-stratification	
1= 18 - 24
2= 25 - 34
3= 35 - 44
4= 45 - 54
5= 55 - 64
6= 65+

NOTE:  If cell sizes are too small, age categories may have been collapsed.	

1	
526	
Race group codes used in post-stratification	
1= White
2= Other than white

NOTE:  If cell sizes are too small, race categories may have been collapsed.	

1	
527	
Sex group codes used in post-stratification	
CODES 1-2
1= Male
2= Female	

2	
528-529	
Age value used to determine age groups	
18-99= Reported or imputed
       ages*

*This value is the reported age or an imputed age, if the respondent refused to give an age.

The imputed age value is only used to estimate the age group used to compute the final weight.  It will not be recorded as the respondent's age.

The value of the imputed age will be an average age computed from the sample if the respondent refused to give an age.	

20	
530-549	
Filler - CDC reserved columns	

1	
550	
End of file marker 	
1= End of File Marker	

k:\share\bsb\brfs95\layout95.fin