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

lose weight? [if "Yes" on Q37]

keep from gaining weight? [if "Yes" on Q38]

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

lose weight? [if "Yes" on Q37]

keep from gaining weight? [if "Yes" on Q38]

41 In the past 12 months, has a doctor, nurse, or other health professional given you advice about your weight?
42 In the past two years, have you taken any weight loss pills prescribed by a doctor? Do not include water pills or thyroid medications.
43 How much did you weigh just before you started taking prescription weight loss pills for the first time?
 
CDC Core
Section 8: Demographics
44 What is your age?
45 What is your race?
46 Are you of Spanish or Hispanic origin?
47 Are you:
 
  • Married
  • Divorced
  • Widowed
  • Separated
  • Never been married
  • A member of an unmarried couple
48 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?
49 What is the highest grade or year of school you completed?
50 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
51
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
52 About how much do you weigh without shoes?
53 How much would you like to weigh?
54 About how tall are you without shoes?
55 What county do you live in?
56 Do you have more than one telephone number in your household?
57 How many residential telephone numbers do you have?
58 Indicate sex of respondent. Ask Only if Necessary
 
CDC Core
Section 9: Women's Health
59 A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram?
60 How long has it been since you had your last mammogram?
61 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?
62 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?
63 How long has it been since your last breast exam?
64 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?
65 A Pap smear is a test for cancer of the cervix. Have you ever had a Pap smear?
66 How long has it been since you had your last Pap smear?
67 Was your last Pap smear done as part of a routine exam, or to check a current or previous problem?
68 Have you had a hysterectomy?
69 To your knowledge, are you now pregnant?
 
CDC Core
Section 10: HIV/AIDS
70 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?
71 If you had a teenager who was sexually active, would you encourage him or her to use a condom?
72 What are your chances of getting infected with HIV, the virus that causes AIDS?
73 Have you donated blood since March 1985?
74 Have you donated blood in the past 12 months?
75 Except for tests you may have had as part of blood donations, have you ever been tested for HIV?
75a Have you ever been tested for HIV?
76 Not including your blood donations, have you been tested for HIV in the past 12 months?
76a Have you been tested for HIV in the past 12 months?
77 What was the main reason you had your last test for HIV?
78 Where did you have your last test for HIV?
79 Did you receive the results of your last test?
80 Did you receive counseling or talk with a health care professional about the results of your test?
 
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: Family Planning
1 Have you been pregnant in the last 5 years?
2 Thinking back to your last pregnancy, just before you got pregnant, how did you feel about becoming pregnant?
2a Thinking back to just before you got pregnant with your current pregnancy, how did you feel about becoming pregnant?
3 Are you or your [fill in (husband/partner) from core Q47] using any kind of birth control now? Birth control means having your tubes tied, vasectomy, the pill, condoms, diaphragm, foam, rhythm, Norplant, shots (Depo-provera) or any other way to keep from getting pregnant.
4 What kinds of birth control are you or your [fill in (husband/partner) from core Q47] using now?
5 What are your reasons for not using any birth control now?
6 Where is your usual source of services for female health concerns, such as family planning, annual exams, breast exams, tests for sexually transmitted diseases, and other female health concerns?
7 Have you ever used the services at a family planning clinic?
8 How long has it been since you used the services at a family planning clinic?
 
State-Added
Module 1: Disability
1 How often do you get the social and emotional support you need?
2 In general, how satisfied are you with your life?
3 Are you limited in the kind or amount of work you can do because of any impairment or health problem?
4 Because of any impairment or health problem, do you have any trouble learning, remembering, or concentrating?
5 If you use special equipment or help from others to get around, what type do you use?
6 Using special equipment or help, what is the farthest distance that you can go?
7 What is farthest distance that you can walk by yourself, without any special equipment or help from others?
 
 
CDC Optional
Module 16: 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?
 
State-Added
Module 1: Disability (continued)
8 Is there anyone/anyone else in your household who is limited in any activities because of any impairment or health problem?
9 How old are these people?
 
State-Added
Module 2: Injury
1 During the past year, have you suffered an injury serious enough to keep you from doing your regular activities for at least one day?
2 Did your injury occur while you were at work?
3 Where did your injury occur?
4 What was the main cause of your injury?
5 Was your injury inflicted on purpose by yourself or someone else?
6 Did you receive treatment from a health professional for your injury?
7 Where did you receive treatment for your injury?
 
State-Added
Module 3: Asthma
1 Have you ever been told by a doctor that you have asthma?
2 Do you currently have asthma?
3 During the past 30 days, for about how many days did your asthma limit you in your usual activities, such as self-care, work, or recreation?
4 Have you taken any medications for asthma during the past twelve months?
5 During the past 12 months have you taken predisone or another steroid as a pill, capsule, or injection to help control your asthma? This does not include inhaled steroids.
6 Has a doctor ever counseled you about how to make changes in your medication to control your asthma?
7 During the past 12 months have you visited a hospital emergency room or urgent care center because of difficulty breathing?
8 A peak flow meter is a hand held device used to measure how well a person is breathing. Have you been instructed in the use of a peak flow meter?
9 Does anyone, including household members or guests, smoke inside your home?
10 Has a doctor ever counseled you about not permitting anyone to smoke in your home?
 
State-Added
Module 4: Passive Smoke Exposure
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?
 
State-Added
Module 5: Children's Lead Exposure
1 Do you live in a residence built before 1950?
2 Does your residence have peeling or chipping paint, or has it undergone any remodeling within the past 6 months?
3 Do any of the children under age 5 in your household regularly visit a residence built before 1978?
4 Does that residence have peeling or chipping paint, or has it undergone any remodeling within the past 6 months?
5 Has any health care provider ever talked to you about childhood lead poisoning?
6 Have any of the children in your household ever been tested for lead poisoning?
7 Where was the lead testing done?
8 Were the results of the test normal?
 
State-Added
Module 6: Dental Sealants
1 How many of the children in your household are aged 7 to 17?
2 Dental sealants are special plastic coatings that are painted on the tops of the back teeth to prevent tooth decay. They are put on by a dentist or dental hygienist. They are different form fillings, caps, crowns, and fluoride treatments. How many of the children aged 7 to 17 living in your household, ever had dental sealants placed on their teeth?
 
State-Added
Module 7: Chickenpox
1 How many of the children ages 0 to 4, living in your household have ever had chickenpox?
2 The varicella vaccine is a vaccine given to children to prevent chickenpox. How many of the children ages 1 to 4, living in your household have had the varicella vaccine (or chickenpox vaccine)?
 
State-Added
Module 8: Folic Acid
1 Some health experts recommend that women take 400 micrograms of the vitamin folic acid, for which of the following reasons...
  • To make strong bones
  • To prevent birth defects
  • To prevent high blood pressure
  • Some other reason
2 When is it most important that a woman take the vitamin folic acid?
3 Are you currently taking 400 mg of the vitamin folic acid each day?
 
State-Added
Module 9: Male Family Planning
1 Are you or your [fill in (wife/partner) from core Q47] using any kind of birth control now? Birth control means having your tubes tied, vasectomy, the pill, condoms, diaphragm, foam, rhythm, Norplant, shots (Depo-provera) or any other way to keep from getting pregnant.
2 What kinds of birth control are you or your [fill in (wife/partner) from core Q47] using now?
 
State-Added
Module 10: Lack of Health Care Coverage
1 What is the main reason you are without health care coverage?
2 What was the main reason you were without health care coverage during the past 12 months?
 
State-Added
Module 11: Hand Washing
1 To the following questions please answer very important, somewhat important, or not important. How important is it that a person wash their hands:

a. After using the toilet?
b. After handling raw meat?
c. After working outdoors?
d. Before eating?
e. After reading the newspaper?
f. Before preparing food?
2 After using the toilet, how often do you wash your hands with soap and water?
3 After the oldest child in your household, between the ages of 5 and 17, uses the toilet, how often do they wash their hands with soap and water?
4 Besides meals prepared for yourself and your family, do you prepare or handle food to be eaten by other persons on a regular basis?
5 During the past three months, have you had diarrhea with at least three loose stools in a single day?