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, 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: Hypertension Awareness
9 About how long has it been since you last had your blood pressure taken by a doctor, nurse, or other health professional?
10 Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?
11 Have you been told on more than one occasion that your blood pressure was high, or have you been told this only once?
 
CDC Core
Section 4: Cholesterol Awareness
12 Blood cholesterol is a fatty substance found in the blood. Have you ever had your blood cholesterol checked?
13 About how long has it been since you last had your blood cholesterol checked?
14 Have you ever been told by a doctor or other health professional that your blood cholesterol is high?
 
CDC Core
Section 5: Diabetes
15 Have you ever been told by a doctor that you have diabetes?
 
 
CDC Core
Section 6: Injury Control
16 How often do you use seatbelts when you drive or ride in a car?
17 What is the age of the oldest child in your household under the age of 16?
18 How often does the [fill in age from Q. 17]-year-old child in your household use a ...
car safety seat [for child under 5]

seatbelt [for child 5 or older]



...when they ride in a car?
19 During the past year, how often has the [fill in age from Q. 17]-year-old child worn a bicycle helmet when riding a bicycle?
20 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?
 
CDC Core
Section 7: Tobacco Use
21 Have you smoked at least 100 cigarettes in your entire life?
22 Do you smoke cigarettes now?
23 On how many of the past 30 days did you smoke cigarettes?
24 On the average, about how many cigarettes a day do you now smoke?
24a On the average, when you smoked during the past 30 days, about how many cigarettes did you smoke a day?
25 During the past 12 months, have you quit smoking for 1 day or longer?
26 About how long has it been since you last smoked cigarettes regularly, that is, daily?
 
CDC Core
Section 8: Alcohol Consumption
27 During the past month, have you had at least one drink of any alcoholic beverage such as beer, wine, wine coolers, or liquor?
28 During the past month, how many days per week or per month did you drink any alcoholic beverages, on the average?
29 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?
30 Considering all types of alcoholic beverages, how many times during the past month did you have 5 or more drinks on an occasion?
31 During the past month, how many times have you driven when you've had perhaps too much to drink?
 
CDC Core
Section 9: Demographics
32 What is your age?
33 What is your race?
34 Are you of Spanish or Hispanic origin?
35 Are you:
 
  • Married
  • Divorced
  • Widowed
  • Separated
  • Never been married
  • A member of an unmarried couple
36 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?
37 What is the highest grade or year of school you completed?
38 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
39
Is your annual household income from all sources:
  • Less than $25,000 ($20,000 to less than $25,000)
  • Less than $20,000 ($15,000 to less than $20,000)
  • Less than $15,000 ($10,000 to less than $15,000)
  • Less than $10,000

  • or
  • Less than $35,000 ($25,000 to less than $35,000)
  • Less than $50,000 ($35,000 to less than $50,000)
  • Less than $75,000 ($50,000 to less than $75,000)
  • $75,000 or more
40 About how much do you weigh without shoes?
41 About how tall are you without shoes?
42 What county do you live in?
43 Do you have more than one telephone number in your household?
44 How many residential telephone numbers do you have?
45 Indicate sex of respondent. Ask Only if Necessary
 
CDC Core
Section 10: Women's Health
46 A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram?
47 How long has it been since you had your last mammogram?
48 About how many mammograms have you had in the last five years?
49 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?
50 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?
51 How long has it been since your last breast exam?
52 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?
53 A Pap smear is a test for cancer of the cervix. Have you ever had a Pap smear?
54 How long has it been since you had your last Pap smear?
55 Was your last Pap smear done as part of a routine exam, or to check a current or previous problem?
56 Have you had a hysterectomy?
57 To your knowledge, are you now pregnant?
 
CDC Core
Section 11: Immunization
58 During the past 12 months, have you had a flu shot?
59 Have you ever had a pneumonia vaccination?
 
CDC Core
Section 12: Colorectal Cancer Screening
60 A digital rectal exam is when a doctor or other health professional inserts a finger in the rectum to check for cancer or other health problems. Have you ever had this exam?
61 When did you have your last digital rectal exam?
62 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?
63 When did you have your last proctoscopis exam?
 
CDC Core
Section 13: HIV/AIDS
64 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?
65 If you had a teenager who was sexually active, would you encourage him or her to use a condom?
66 What are your chances of getting infected with HIV, the virus that causes AIDS?
67 Have you ever had your blood tested for HIV?
68a Have you donated blood since March 1985?
69a When did you last donate blood?
68 When was your last blood test for HIV?
69 What was the main reason you had your last test for HIV?
70 Where did you have your last test for HIV?
71 Did you receive the results of your last test?
72 Did you receive counseling or talk with a health care professional about the results of your test?
73 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?
74 Due to what you know about HIV, have you changed your sexual
behavior in the last 12 months?
75 Have you:

Had sexual intercourse with only one partner?
Used condoms for protection?
Been more careful in selecting sexual partners?
 
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 2: 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?
 
CDC Optional
Module 4: Exercise
1 During the past month, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?
2 What type of physical activity or exercise did you spend the most time doing during the past month?
3 How far did you usually walk/run/jog/swim?
4 How many times per week or per month did you take part in this activity during the past month?
5 And when you took part in this activity, for how many minutes or hours did you usually keep at it?
6 Was there another physical activity or exercise that you participated in during the last month?
7 What other type of physical activity gave you the next most exercise 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?
10 And when you took part in this activity, for how many minutes or hours did you usually keep at it?
 
CDC Optional
Module 7: Quality of Life
1 Are you limited in any way in any activities because of any impairment or health problem?
2 What is the major impairment or health problem that limits your activities?
3 For how long have your activities been limited because of your major impairment or health problem?
4 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?
5 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?
6 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?
7 During the past 30 days, for about how many days have you felt sad, blue, or depressed?
8 During the past 30 days, for about how many days have you felt worried, tense, or anxious?
9 During the past 30 days, for about how many days have you felt you did not get enough rest or sleep?
10 During the past 30 days, for about how many days have you felt very healthy and full of energy?
 
CDC Optional
Module 8: Health Care Utilization
1 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?
2 Is there one of these places that you go to most often when you are sick or need advice about your health?
3 What kind of place is it -- a clinic, a health center, a hospital, a doctor's office, or some other place?
4 What is the main reason you do not have a usual source of medical care?
 
CDC Optional
Module 10: Firearms
1 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.
2 Are there any loaded firearms in the car, van, or truck you usually drive?
3 Not including firearms in a car, truck, or other vehicle, are there any loaded firearms in your home?
4 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?
5 Are there any unloaded firearms in your home?
6 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?
7 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?
8 Is the ammunition stored in a locked or unlocked place?
9 Do you feel safer or less safe because there are firearms in your home or car, van, or truck?
10 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?
 
State-Added
Module 11: State-Added Questions (Tobacco Use)
1 Including yourself, how many persons in your household are current cigarette smokers?
2 How many smoke inside the home?
3 Do you work outside the home?
4 Which of the following best describes the policy about smoking at your work place?
 
CDC Optional
Module 3: 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?