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?
5a During the past 12 months, was there any time that you did not have any health insurance or coverage? (State-added question)
6 Medicare is a coverage plan for people 65 or over and for certain disabled people. Do you have Medicare?
7a What type of health care coverage do you use to pay for most of your medical care?
7b There are some types of coverage you may not have considered. Please tell me if you have any of the following:
8 About how long have you had [fill in type (Medicare/Medicaid/this
particular health care coverage) from Q. 6, Q. 7a, or Q. 7b]?
9 Is there a book or list of doctors associated with your [fill in
type (Medicare/Medicaid/health coverage) from Q. 6, Q. 7a, or Q.
7b] plan?
10 Does your [fill in type (Medicare/Medicaid/health coverage) from
Q. 6, Q. 7a, or Q. 7b] plan require you to select a certain doctor
or clinic for all of your routine care?
11 About how long has it been since you had health care coverage?
12 Was there a time during the last 12 months when you needed to see
a doctor, but could not because of the cost?
13 About how long has it been since you last visited a doctor for a
routine checkup?
 
CDC Core
Section 3: Diabetes
14 Have you ever been told by a doctor that you have diabetes?
 
CDC Core
Section 4: Exercise
15 During the past month, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?
16 What type of physical activity or exercise did you spend the most time doing 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 during the past month?
19 And when you took part in this activity, for how many minutes or hours did you usually keep at it?
20 Was there another physical activity or exercise that you participated in during the last month?
21 What other type of physical activity gave you the next most exercise during the past month?
22 How far did you usually walk/run/jog/swim?
23 How many times per week or per month did you take part in this activity?
24 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
25 Have you smoked at least 100 cigarettes in your entire life?
26 Do you now smoke cigarettes everyday, some days, or not at all?
27 On the average, about how many cigarettes a day do you now smoke?
27a On the average, when you smoked during the past 30 days, about how many cigarettes did you smoke a day?
28 During the past 12 months, have you quit smoking for 1 day or longer?
29 About how long has it been since you last smoked cigarettes regularly, that is, daily?
 
CDC Core
Section 6: Nutrition
30 How often do you drink fruit juices such as orange, grapefruit, or tomato?
31 Not counting juice, how often do you eat fruit?
32 How often do you eat green salad?
33 How often do you eat potatoes not including french fries, fried potatoes, or potato chips?
34 How often do you eat carrots?
35 Not counting carrots, potatoes, or salad, how many servings of vegetables do you usually eat?
 
CDC Core
Section 7: Weight Control
36 Are you now trying to lose weight?
37 Are you now trying to maintain your current weight, that is to keep from gaining weight?
38 Are you eating either fewer calories or less fat to...

lose weight? [if "Yes" on Q36]

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

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

lose weight? [if "Yes" on Q36]

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

40 In the past 12 months, has a doctor, nurse, or other health professional given you advice about your weight?
 
CDC Core
Section 8: Demographics
41 What is your age?
42 What is your race?
43 Are you of Spanish or Hispanic origin?
44 Are you:
 
  • Married
  • Divorced
  • Widowed
  • Separated
  • Never been married
  • A member of an unmarried couple
45 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?
46 What is the highest grade or year of school you completed?
47 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
48
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
49 About how much do you weigh without shoes?
50 How much would you like to weigh?
51 About how tall are you without shoes?
52 What county do you live in?
53 Do you have more than one telephone number in your household?
54 How many residential telephone numbers do you have?
55 Indicate sex of respondent. Ask Only if Necessary
 
CDC Core
Section 9: Women's Health
56 A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram?
57 How long has it been since you had your last mammogram?
58 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?
59 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?
60 How long has it been since your last breast exam?
61 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?
62 A Pap smear is a test for cancer of the cervix. Have you ever had a Pap smear?
63 How long has it been since you had your last Pap smear?
64 Was your last Pap smear done as part of a routine exam, or to check a current or previous problem?
65 Have you had a hysterectomy?
66 To your knowledge, are you now pregnant?
 
CDC Core
Section 10: HIV/AIDS
67 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?
68 If you had a teenager who was sexually active, would you encourage him or her to use a condom?
69 What are your chances of getting infected with HIV, the virus that causes AIDS?
70 Have you ever had you blood tested for HIV?
71a Have you donated blood since March 1985?
72a When did you last donate blood?
71 When was your last blood test for HIV?
72 What was the main reason you had your last test for HIV?
73 Where did you have your last test for HIV?
74 Did you receive the results of your last test?
75 Did you receive counseling or talk with a health care professional about the results of your test?
76 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?
77 Due to what you know about HIV, have you changed your sexual
behavior in the last 12 months?
78 Have you:

Had sexual intercourse with only one partner?
Used condoms for protection?
Been more careful in selecting sexual partners?
 
CDC Optional
Module 4: 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 5: Arthritis
1 During the past 12 months, have you had pain, aching, stiffness or
swelling in or around a joint?
2 Were these symptoms present on most days for at least one month?
3 Are you now limited in any way in any activities because of joint
symptoms?
4 Have you ever been told by a doctor that you have arthritis?
5 What type of arthritis did the doctor say you have?
6 Are you currently being treated by a doctor for arthritis?
 
CDC Optional
Module 7: 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?
5 How far do you have to travel to see the doctor or health care provider of your choice? (State-added question)
6 How far do you have to travel to use the hospital of your choice? (State-added question)
 
CDC Optional
Module 8: Oral Health
1 How long has it been since you last visited the dentist or a
dental clinic?
2 What is the main reason you have not visited the dentist in the
last year?
3 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.
4 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?
5 Are you currently in need of any dental services such as fillings, dentures, partials, teeth pulled, caps, crowns, or root canal? (State-added question.)
 
CDC Optional
Module 9: Preventive Counseling Services
1 Has a doctor or other health professional ever talked with you
about your diet or eating habits?
2 Has a doctor or other health professional ever talked with you
about physical activity or exercise?
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?
4 (Has a doctor or other health professional ever talked with you)
about drug abuse?
5 (Has a doctor or other health professional ever talked with you)
about alcohol use?
6 (Has a doctor or other health professional) ever advised you to
quit smoking?
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?
 
State-Added
Module: Fire Safety
1 Which of the following best describes whether you have a smoke detector in your home?
2 In the past 15 years, has there ever been a fire in your home which caused any smoke or burn damage to your home?
3 Did the fire result in any major or minor burns or injuries to the hands, fingers, or other parts of the body of yourself or another person?
4 What was the cause of the most recent fire in your home?
 
State-Added
Module: Flu Knowledge
1 During the past 12 months, have you gotten information about the flu or the benefits of getting a flu shot from the:

a. Radio
b. Television
c. Newspaper
d. Insurance company

Poster or flyer in:
e. Library
f. Bus
g. Drugstore/pharmacy.
h. Civic organization
i. Church group
j. Your doctor/health clinic
k. Other (specify:_________)
2 Which of the following do you think the flu vaccine would help prevent?

a. An illness with symptoms of a runny nose and a stuffy head
b. An illness with symptoms of vomiting and diarrhea
c. An illness with symptoms of muscle aches, fever, headache, sore throat, cough
 
State-Added
Module: Disability
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 Do you now consider yourself to be a person with a disability?
4 Has a doctor or other health professional given you information about community or self-help resources that can help you manage your condition?
 
State-Added
Module: Quality of Life for Older Kansans
1 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?
2 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?
3 During the past 12 months, have you fallen?
4 During the past 12 months, have you had to see a doctor or nurse because you were injured when you fell?
5 During the past 5 years, have you been admitted to a hospital?
6 During the past 5 years, were you ever admitted to a nursing home?
7 During the past week, have you needed to change your clothes or be sheets because you lost control of your bladder?
8 During the past week, have you needed to change your clothes or be sheets because you lost control of your bowels?
 
State-Added
Module: Social Context
1 How long have you lived at your current address?
2 Do you own or rent your home?
3 What is the source of water you usually drink at home?
 
State-Added
Module: Violence and Crime
1 How afraid are you to leave your home at night?
2 When was the last time you saw a violent crime in your neighborhood (someone hurting or trying to hurt someone else)?
3 During the past year have you known or seen anyone who was beaten or otherwise hurt by their husband, wife, boyfriend, or girlfriend?