CDC Core
Section A: Seatbelts
1 How often do you use seatbelts when you drive or ride in a car?
 
CDC Core
Section B: Hypertension
2 About how long has it been since you last had your blood pressure taken by a doctor, nurse, or other health professional?
3 Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?
4 Have you been told on more than one occasion that your blood pressure was high, or have you been told this only once?
5 Is any medicine currently being prescribed for your high blood pressure?
 
CDC Core
Section C: Exercise
6 During the past month, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?
7 What type of physical activity or exercise did you spend the most time doing during the past month?
8 How far did you usually walk/run/jog/swim?
9 How many times per week or per month did you take part in this activity during the past month?
10 And when you took part in this activity, for how many minutes or hours did you usually keep at it?
11 Was there another physical activity or exercise that you participated in during the last month?
12 What other type of physical activity gave you the next most exercise during the past month?
13 How far did you usually walk/run/jog/swim?
14 How many times per week or per month did you take part in this activity?
15 And when you took part in this activity, for how many minutes or hours did you usually keep at it?
 
CDC Core
Section D: Weight Control
16 Are you now trying to lose weight?
17 Are you eating fewer calories to lose weight?
18 Have you increased your physical activity to lose weight?
 
CDC Core
Section E: Tobacco Use
19 Have you smoked at least 100 cigarettes in your entire life?
20 About how old were you when you first started smoking cigarettes fairly regularly?
21 Do you smoke cigarettes now?
22 On the average, about how many cigarettes a day do you now smoke?
23 During the past 12 months, have you quit smoking for 1 day or longer?
24 About how long has it been since you last smoked cigarettes regularly?
 
CDC Core
Section F: Alcohol Consumption
25 Have you had any beer, wine, wine coolers, cocktails, or liquor during the past month, that is since (fill in appropriate date)?
26 During the past month, how many days per week or per month did you drink any alcoholic beverages, on the average?
27 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?
28 Considering all types of alcoholic beverages, that is beer, wine, wine coolers, cocktails, and liquor, as drinks, how many times during the past month did you have 5 or more drinks on an occasion?
29 And during the past month, how many times have you driven when you've had perhaps too much to drink?
 
CDC Core
Section G: Preventive Health Practices
30 About how long has it been since you last visited a doctor for a routine checkup?
31 Have you ever had your blood cholesterol checked?
32 About how long has it been since you last had your blood cholesterol checked?
33 Have you ever been told your blood cholesterol level, in numbers?
34 What is your blood cholesterol level?
35 Have you ever been told by a doctor or other health professional that your blood cholesterol is high?
36 Next, I'd like to ask you about diabetes, sometimes called sugar diabetes. Have you ever been told by a doctor that you have diabetes?
 
CDC Core
Section H: Health Insurance
37 Do you have any kind of health care plan?
38 For hospital bills, does your health care plan cover all, most, some, or none of your expenses?
39 For visits to a doctor's office when you are sick, does your health care plan cover all, most, some, or none of your expenses?
40 When you are not sick, does your health care plan cover all, most, some, or none of your checkups or other preventive services?
41 Was there a time during the last 12 months when you needed to see a doctor, but could not because of the cost?
 
CDC Core
Section I: Demographics
42 How old were you on your last birthday?
43 What is your race?
44 Are you of Hispanic origin such as Mexican American, Latin American, Puerto Rican, or Cuban?
45 What is the highest grade or year of school you completed?
46 Are you currently:
 
  • Employed for wages
  • Self-employed
  • Out of work for more than 1 year
  • Out of work for less than 1 year
  • Homemaker
  • Student
  • Retired
  • Unable to work
47 Are you:
 
  • Married
  • Divorced
  • Widowed
  • Separated
  • Never been married
  • A member of an unmarried couple
48 Which of the following categories best describes your annual household income from all sources?
  • Less than $10,000
  • $10,000 to less than $15,000
  • $15,000 to less than $20,000
  • $20,000 to less than $25,000
  • $25,000 to less than $35,000
  • $35,000 to less than $50,000
  • Over $50,000
49 About how much do you weigh without shoes?
50 About how tall are you without shoes?
51 Indicate sex of respondent.
 
CDC Core
Section J: Women's Health
52 Have you ever had a mammogram?
53 How long has it been since you had your last mammogram?
54 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?
55 Have you ever had a clinical breast exam?
56 How long has it been since your last breast exam?
57 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?
58 Have you ever had a Pap smear?
59 How long has it been since you had your last Pap smear?
60 Was your last Pap smear done as part of a routine exam, or to check a current or previous problem?
61 Have you had a hysterectomy (that is, an operation to remove the uterus/womb)?
62 To your knowledge, are you now pregnant?
63 During what month is your baby due?
 
CDC Core
Section J: AIDS
64 Have you ever heard the AIDS virus called by the name HIV?
65 To your knowledge, are there drugs available that can lengthen the life of a person infected with the AIDS virus?
66 Do you think a person who is infected with the AIDS virus can look and feel well and healthy?
67 Do you think a person can get infected with AIDS or the AIDS virus from:
a. Donating blood?
b. Being cared for by a nurse, doctor, dentist, or other health care worker who has the AIDS virus?
68 Do you think a pregnant women who has the AIDS virus can give it to her baby?
69 Do you have a child or children in kindergarten through eighth grade?
70 Would you allow your child to be in the same classroom with a child who is infected with the AIDS virus?
71 At what grade do you think your child should begin AIDS education in school?
72 Would you eat in a restaurant where the cook is infected with the AIDS virus?
73 Would you be willing to work with a person who is infected with the AIDS virus?
74a. Where could you go to be tested for the AIDS virus infection?
74b. Where else could you go?
75 Some people use condoms to keep from getting infected with HIV
through sexual activity. How effective do you think using a condom is in preventing getting the AIDS virus through sexual activity?
 
76 How many different residential telephone numbers do you have at this household?
 
CDC Optional
Module 1: County of Residence
1 What county do you live in?
 
CDC Optional
Module 2: Smokeless Tobacco Use
1 Have you ever used or tried any smokeless tobacco products such as
chewing tobacco or snuff?
2 Do you currently use any smokeless tobacco products such as
chewing tobacco or snuff?
 
CDC Optional
Module 6: Dietary Fat
1 How often do you eat hot dogs or lunch meats such as ham or other cold cuts?
2 How often do you eat bacon or sausage?
3 How often do you eat pork other than ham, bacon, or sausage?
4 How often do you eat hamburgers, cheeseburgers, or meat loaf?
5 How often do you eat beef other than hamburgers, cheeseburgers, or meat loaf?
6 How often do you eat fried chicken?
7 How often do you eat french fries or fried potatoes?
8 How often do you eat cheese or cheese spreads, not including cottage cheese?
9 How often do you eat doughnuts, cookies, cake, pastry, or pies?
10 How often do you usually eat snacks, such as chips or popcorn?
11 How often do you usually add butter or margarine to bread, rolls, or vegetables?
12 How many eggs do you usually eat?
13 How many glasses (8 oz.) of whole milk do you usually drink? Remember to include drinks made with whole milk or milk on cereal. Do not include low-fat milk, such as skim milk or 2% milk.
 
CDC Optional
Module 7: Fruits and Vegetables
1 How often do you drink fruit juices such as orange, grapefruit, or tomato?
2 Not counting juice, how often do you eat fruit?
3 How often do you eat green salad?
4 How often do you eat potatoes (not including french fries, fried potatoes, or potato chips)?
5 How often do you eat carrots?
6 Not counting carrots, potatoes, or salad, how many servings of vegetables do you usually eat? (For example, a serving of vegetables at both lunch and dinner would be two servings.)
 
State-Added
State-Added Module: Smoking in the Workplace
1 Do you work outside the home?
2 Which of the following best describes the policy about smoking at your workplace?