CDC Core
Section 1: Health Status
1 Would you say that in general your health is:
  • Excellent
  • Very good
  • Good
  • Fair
  • Poor
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?
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?
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?
 
CDC Core
Section 2: Health Care Access
5 Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs (health maintenance organizations), or government plans such as Medicare?
6 About how long has it been since you had health care coverage?
7 Was there a time during the last 12 months when you needed to see a doctor, but could not because of the cost?
8 About how long has it been since you last visited a doctor for a routine checkup?
 
CDC Core
Section 3: Diabetes
9 Have you ever been told by a doctor that you have diabetes?
 
 
CDC Core
Section 4: Exercise
10 During the past month, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?
11 What type of physical activity or exercise did you spend the most time doing during the past month?
12 How far did you usually walk/run/jog/swim?
13 How many times per week or per month did you take part in this activity during the past month?
14 And when you took part in this activity, for how many minutes or hours did you usually keep at it?
15 Was there another physical activity or exercise that you participated in during the last month?
16 What other type of physical activity gave you the next most exercise during the past month?
17 How far did you usually walk/run/jog/swim?
18 How many times per week or per month did you take part in this activity?
19 And when you took part in this activity, for how many minutes or hours did you usually keep at it?
 
CDC Core
Section 5: Tobacco Use
20 Have you smoked at least 100 cigarettes in your entire life?
21 Do you smoke cigarettes now?
22 On how many of the past 30 days did you smoke cigarettes?
23 On the average, about how many cigarettes a day do you now smoke?
23a On the average, when you smoked during the past 30 days, about how many cigarettes did you smoke a day?
24 During the past 12 months, have you quit smoking for 1 day or longer?
25 About how long has it been since you last smoked cigarettes regularly, that is (that if, daily)?
 
CDC Core
Section 6: Nutrition
26 How often do you drink fruit juices such as orange, grapefruit, or tomato?
27 Not counting juice, how often do you eat fruit?
28 How often do you eat green salad?
29 How often do you eat potatoes not including french fries, fried potatoes, or potato chips?
30 How often do you eat carrots?
31 Not counting carrots, potatoes, or salad, how many servings of vegetables do you usually eat?
 
CDC Core
Section 7: Weight Control
32 Are you now trying to lose weight?
33 Are you now trying to maintain your current weight, that is to keep from gaining weight?
34 Are you eating either fewer calories or less fat to...

lose weight? [if "Yes" on Q36]

keep from gaining weight? [if "Yes" on Q37]

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

lose weight? [if "Yes" on Q36]

keep from gaining weight? [if "Yes" on Q37]

36 In the past 12 months, has a doctor, nurse, or other health professional given you advice about your weight?
 
CDC Core
Section 8: Demographics
37 What is your age?
38 What is your race?
39 Are you of Spanish or Hispanic origin?
40 Are you:
 
  • Married
  • Divorced
  • Widowed
  • Separated
  • Never been married
  • A member of an unmarried couple
41 How many children live in your household who are..

a. less than 5 years old?
b. 5 through 12 years old?
c. 13 through 17 years old?
42 What is the highest grade or year of school you completed?
43 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
44 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
  • $50,000 to less than $75,000
  • Over $75,000
45 About how much do you weigh without shoes?
46 How much would you like to weigh?
47 About how tall are you without shoes?
48 What county do you live in?
49 Do you have more than one telephone number in your household?
50 How many residential telephone numbers do you have?
51 Indicate sex of respondent. Ask Only if Necessary
 
CDC Core
Section 9: Women's Health
52 A mammogram is an x-ray of each breast to look for breast cancer. 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 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?
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 A Pap smear is a test for cancer of the cervix. 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?
 
CDC Core
Section 10: AIDS Knowledge and Testing
63 Would you be willing to work next to or near a person who you know is infected with the AIDS virus?
64 If you had a child in school, would you allow him or her to be in the same classroom with another child who is infected with the AIDS virus?
65 If you had a child in school, at what grade do you think he or she should begin AIDS education in school?
66 If you had a teenager who was sexually active, would you encourage him or her to use a condom?
67 What are your chances of getting the AIDS virus?
68 In the past year, have your chances of getting the AIDS virus increased, decreased, or stayed the same?
69 Have you ever had your blood tested for the AIDS virus infection?
70a Have you donated blood since March 1985?
71a When did you last donate blood?
70 When was your last AIDS blood test?
71 What was the main reason you had your last AIDS blood test?
72 Where did you have your last blood test for the AIDS virus?
73 Did you receive the results of your last test?
74 Did you receive counseling or talk with a health care professional about the results of your test?
75 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?
76 Have you personnally ever known anyone with AIDS or the AIDS virus?
 
CDC Optional
Module 1: 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
Module 5: Activity Limitations
  Section A: Ages 18-64
1 What were you doing MOST of the past 12 months?
2 Does any impairment or health problem NOW keep you from working at a job or business?
3 Are you limited in any way in any activities because of any impairment or health problem?
4 Does any impairment or health problem NOW keep you from doing any housework at all?
5 Are you limited in the kind or amount of housework you can do because of any impairment or health problem?
6 Does any impairment or health problem keep you from working at a job or business?
7 Are you limited in the kind or amount of work you could do because of any impairment or health problem?
8 Are you limited in any way in any activities because of any impairment or health problem?
9 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?
10 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?
  Section B: Ages 65 or older
11 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?
12 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?
13 Are you limited in any way in any activities because of an impairment or health problem?
 
CDC Optional
Module 9: Immunization
1 During the past 12 months, have you had a flu shot?
2 Have you ever had a pneumonia vaccination?
 
CDC Optional
Module 11: Injury Control
1 How often do you use seatbelts when you drive or ride in a car?
2 What is the age of the oldest child in your household under the age of 15?
3 How often does the oldest child (of children under age 15) in your household use a ... car safety seat [for child under 5] or seatbelt [for child 5 or older] ... when they ride in a car?
4 Can you swim or tread water for 5 minutes in water that is over your head?
5 Has your family practiced or discussed an escape plan in case of a fire at home?
6
State-Added
Is there a working smoke detector in your household?
 
CDC Optional
Module 12: Alcohol Consumption
1 During the past month, have you had at least one drink of any alcoholic beverage such as beer, wine, wine coolers, or liquor?
2 During the past month, how many days per week or per month did you drink any alcoholic beverages, on the average?
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?
4 Considering all types of alcoholic beverages, how many times during the past month did you have 5 or more drinks on an occasion?
5 During the past month, how many times have you driven when you've had perhaps too much to drink?
 
State-Added
State-Added Questions
1 Do you work outside the home?
2 Which of the following best describes the policy about smoking at your work place?
 
CDC Optional
Module 4: Diabetes
1 How old were you when you were told you have diabetes?
2 Are you now taking insulin?
3 Currently, about how often do you use insulin?
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.
5 Have you ever heard of glycosylated hemoglobin [gli-KOS-ilated HE-mo-glo-bin] or hemoglobin "A one C"?
6 About how many times in the last year have you seen a doctor, nurse, or other health professional for your diabetes?
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"?
8 About how many times in the last year has a health professional checked your feet for any sores or irritations?
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.
10 How much of the time does your vision limit you in recognizing people or objects across the street?
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?
12 How much of the time does your vision limit you in watching television?