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 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: Hypertension Awareness
    14 About how long has it been since you last had your blood pressure taken by a doctor, nurse, or other health professional?
    15 Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?
    16 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
    17 Blood cholesterol is a fatty substance found in the blood. Have you ever had your blood cholesterol checked?
    18 About how long has it been since you last had your blood cholesterol checked?
    19 Have you ever been told by a doctor or other health professional that your blood cholesterol is high?
     
    CDC Core
    Section 5: Diabetes
    20 Have you ever been told by a doctor that you have diabetes?
     
    Access to CDC Optional Diabetes Module
     
    CDC Core
    Section 6: Injury Control
    21 How often do you use seatbelts when you drive or ride in a car?
    22 What is the age of the oldest child in your household under the age of 16?
    23 How often does the [fill in age from Q. 22]-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?
    24 During the past year, how often has the [fill in age from Q. 22]-year-old child worn a bicycle helmet when riding a bicycle?
    25 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
    26 Have you smoked at least 100 cigarettes in your entire life?
    27 Do you now smoke cigarettes everyday, some days, or not at all?
    28 On the average, about how many cigarettes a day do you now smoke?
    28a On the average, when you smoked during the past 30 days, about how many cigarettes did you smoke a day?
    29 During the past 12 months, have you quit smoking for 1 day or longer?
    30 About how long has it been since you last smoked cigarettes regularly, that is, daily?
     
    Access to CDC Optional Smokeless Tobacco Use Module
     
    CDC Core
    Section 8: Alcohol Consumption
    31 During the past month, have you had at least one drink of any alcoholic beverage such as beer, wine, wine coolers, or liquor?
    32 During the past month, how many days per week or per month did you drink any alcoholic beverages, on the average?
    33 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?
    34 Considering all types of alcoholic beverages, how many times during the past month did you have 5 or more drinks on an occasion?
    35 During the past month, how many times have you driven when you've had perhaps too much to drink?
     
    CDC Core
    Section 9: Demographics
    36 What is your age?
    37 What is your race?
    38 Are you of Spanish or Hispanic origin?
    39 Are you:
     
    • Married
    • Divorced
    • Widowed
    • Separated
    • Never been married
    • A member of an unmarried couple
    40 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?
    41 What is the highest grade or year of school you completed?
    42 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
    43
    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
    44 About how much do you weigh without shoes?
    45 About how tall are you without shoes?
    46 What county do you live in?
    47 Do you have more than one telephone number in your household?
    48 How many residential telephone numbers do you have?
    49 Indicate sex of respondent. Ask Only if Necessary
     
    CDC Core
    Section 10: Women's Health
    50 A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram?
    51 How long has it been since you had your last mammogram?
    52 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?
    53 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?
    54 How long has it been since your last breast exam?
    55 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?
    56 A Pap smear is a test for cancer of the cervix. Have you ever had a Pap smear?
    57 How long has it been since you had your last Pap smear?
    58 Was your last Pap smear done as part of a routine exam, or to check a current or previous problem?
    59 Have you had a hysterectomy?
    60 To your knowledge, are you now pregnant?
     
    Access to State-Added Women's Health Module
     
    CDC Core
    Section 11: Immunization
    61 During the past 12 months, have you had a flu shot?
    62 Have you ever had a pneumonia vaccination?
     
    CDC Core
    Section 12: Colorectal Cancer Screening
    63 A blood stool test is a test that may use a special kit at home to determine whether the stool contains blood. Have you ever had this test using a home kit?
    64 When did you have your last blood stool test using a home kit?
    65 A sigmoidoscopy or proctoscopy is when a tube is inserted in the rectum to view the bowel for signs of cancer and other health problems. Have you ever had this exam?
    66 When did you have your last sigmoidoscopy or proctoscopy?
     
    CDC Core
    Section 13: 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 your 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 blood test for HIV?
    73 Where did you have your last blood 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 Due to what you know about HIV, have you changed your sexual behavior in the last 12 months?
    77 Did you make any of the following changes in the last 12 months?

    a. Did you decrease the number of your sexual partners or become abstinent?
    b. Do you now have sexual intercourse with only the same partner?
    c. Do you now always use condoms for protection?
     
    CDC Optional
    Module 1: 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?
     
    CDC Optional
    Module 3: Health Care Coverage
    1 What is the main reason you are without health care coverage?
    2 Other than [fill in type (Medicare/Medicaid/the health coverage which pays for most of your medical care) from core Q. 6, Q. 7a, or Q. 7b], do you have any other type of health care coverage?
    3 During the past 12 months, was there any time that you did not have any health insurance or coverage?
    4 What was the main reason you were without health care coverage?
     
    CDC Optional
    Module 9: 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 15: Social Context
    1 How safe from crime do you consider your neighborhood to be?
    2 Do you own or rent your home?
    3 How long have you lived at your current address?
    4 How many close friends or relatives would help you with your emotional problems or feelings if you needed it?
    5 In the past 30 days, have you been concerned about having enough food for you or your family?
     
    CDC Optional
    Module 16: 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?
     
    State-Added
    Module 1: Disability
    1 Have you ever sustained a spinal cord injury?
    2 Have you ever had a head injury which caused you to lose consciousness or completely black out?
    3 Do you still experience problems as a result of a head injury?
    4 Do you now consider yourself to be a person with a disability?
     
    State-Added
    Module 2: Preventive Care
    1 Is there one particular doctor or health professional who you usually go to when you need routine medical care?
    2 During the past ten years have you received a tetanus shot?
     
    State-Added
    Module 3: Women's Health
    1 Have you ever done a self breast exam?
    2 How long as it been since you last did a self breast examination?
    3 How did you learn to do a self breast examination?
    4 What is the main reason why you have never done a self breast examination?
    5 What is the main reason why you have never had a pap smear test?
    6 What is the main reason why you did not have a pap smear test during the past two years?
    7 Do you know at what age a woman should start having a mammogram every year?
    8 What is the main reason why you have never had a mammogram?
    9 What is the main reason why you did not have a mammogram during the past two years?
    10 Why did you decide to get your last mammogram?
     
    State-Added
    Module 4: Men's Health
    1 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?
    2 When did you have your last digital rectal exam?
    3 A prostate-specific antigen blood test or PSA test is a blood test to check for prostate cancer. Have you ever had a PSA test?
    4 When did you have your last PSA test?
     
    State-Added
    Module 5: Cardiovascular Disease
    1 Has a doctor ever told you that you had any of the following?
    Heart attack or myocardial infarction
    2 Has a doctor ever told you that you had any of the following?
    Angina or coronary heart disease
    3 Has a doctor ever told you that you had any of the following?
    Stroke
    4 Has a doctor ever told you that you had any of the following?
    Heart failure
    5 Have you ever had any of the following medical procedures?
    Heart bypass surgery
    6 Have you ever had any of the following medical procedures?
    Angioplasty (balloon surgery)
     
    State-Added
    Module 6: Sexual Behavior
    1 During the past 12 months, with how many different people have you had sexual intercourse?
    2 Was a condom used the last time you had sexual intercourse?
    3 The last time you had sexual intercourse, was the condom used ..
    • To prevent pregnancy
    • To prevent diseases like syphilis, gonorrhea, and AIDS
    • For both of these reasons
    • For some other reason
    4 How many new sex partners did you have during the past 12 months?
    5 I’m going to read you a list. When I’m done, please tell me if any of the situations apply to you. You don't need to tell me which one.

    You have used injectable drugs in the past year
    You tested positive for having HIV, the virus that causes AIDS
    You had anal sex without a condom in the past year
    Do any of these situations apply to you?
    6 In the past five years, have you been treated for a sexually transmitted or venereal disease?
    7 Were you treated at a local health department?
     
    State-Added
    Module 7: Health of Children
    1 What is the age of the youngest child in your household?
    2 All of our questions will focus on the youngest child who lives in your household. How is the youngest child in your household related to you?
    3 Would you say that in general the youngest child's health is:
    4 Is the youngest child limited in any way in any activities because of any impairment or health problem?
    5 About how long has it been since the youngest child last visited a doctor for a routine checkup?
    6 Was there a time during the last 12 months when the youngest child needed to see a doctor, but could not because of the cost?
    7 Is there one particular clinic, health center, doctor's office, or other place that you usually go to if the youngest child is sick or you need advice about the youngest child's health?
    8 Does the youngest child have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?
    9 What type of health care coverage do you use to pay for most of the youngest child's medical care?
    10 There are some types of coverage you may not have considered. Please tell me if the youngest child may have any of the following:
    • Your employer
    • Someone else's employer
    • A plan that you or someone else buys on your own
    • Medicare
    • Medicaid or Medical Assistance [or substitute state program name]
    • The military, CHAMPUS, or the VA [or CHAMP-VA]
    • The Indian Health Service [or the Alaska Native Health Service]
    • Some other source
    11 Did anyone in this household get food stamps at any time during the last 12 months?
    12 Does the youngest child's father live in this household?
    13 Does the youngest child's mother live in this household?
     
    State-Added
    Module 8: Skin Cancer
    1 Have you ever been told by a doctor that you have skin cancer?
    2 Have you had any of the following skin cancers?
    Melanoma
    3 Have you had any of the following skin cancers?
    Basal cell
    4 Have you had any of the following skin cancers?
    Squamous cell
    5 Have you had any of the following skin cancers?
    Some other type of skin cancer (Specify ___)
    6 How long ago was your melanoma skin cancer diagnosed?