CDC Core
Section 1: Health Status
1.1
Data Results 1.1
Would you say that in general your health is:
  • Excellent
  • Very good
  • Good
  • Fair
  • Poor
Crosstabulation Table:
1.2
Data Results 1.2
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?
1.3
Data Results 1.3
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?
Crosstabulation Table:
1.4
Data Results 1.4
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
2.1
Data Results 2.1
Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?
Crosstabulation Table:
2.2
Data Results 2.2
During the past 12 months, was there any time that you did not have any health insurance or coverage?
2.3
Data Results 2.3
Do you have one person you think of as your personal doctor or health care provider?
Crosstabulation Table:
 
CDC Core
Section 3: Exercise
3.1
Data Results 3.1
During the past 30 days, other than your regular job, did you participate in any physical activities or exercise such as running, calisthenics, golf, gardening, or walking for exercise?
 
CDC Core
Section 4: Hypertension Awareness
4.1
Data Results 4.1
Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?
Crosstabulation Table:
4.2
Data Results 4.2
Are you currently taking medicine for your high blood pressure?
 
CDC Core
Section 5: Cholesterol Awareness
5.1
Data Results 5.1
Blood cholesterol is a fatty substance found in the blood. Have you ever had your blood cholesterol checked?
5.2
Data Results 5.2
About how long has it been since you last had your blood cholesterol checked?
5.3
Data Results 5.3
Have you ever been told by a doctor, nurse, or other health professional that your blood cholesterol is high?
Crosstabulation Table:
 
CDC Core
Section 6: Asthma
6.1
Data Results 6.1
Have you ever been told by a doctor, nurse, or other health professional that you had asthma?
6.2
Data Results 6.2
Do you still have asthma?
Crosstabulation Table:
 
CDC Core
Section 7: Diabetes
7.1
Data Results 7.1
Have you ever been told by a doctor that you have diabetes?
Crosstabulation Table:
 
 
CDC Core
Section 8: Arthritis
8.1
Data Results 8.1
During the past 12 months, have you had pain, aching, stiffness or swelling in or around a joint?
Crosstabulation Table:
8.2
Data Results 8.2
Were these symptoms present on most days for at least one month?
8.3
Data Results 8.3
Are you now limited in any way in any activities because of joint symptoms?
8.4
Data Results 8.4
Have you ever seen a doctor, nurse, or other health professional for these joint symptoms?
8.5
Data Results 8.5
Have you ever been told by a doctor that you have arthritis?
Crosstabulation Table:
8.6
Data Results 8.6
Are you currently being treated by a doctor for arthritis?
 
CDC Core
Section 9: Immunization
9.1
Data Results 9.1
During the past 12 months, have you had a flu shot?
Crosstabulation Tables:
 
 
9.2
Data Results 9.2
Have you ever had a pneumonia shot? This shot is usually given only once or twice in a person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.
Crosstabulation Tables:
 
 
 
CDC Core
Section 10: Tobacco Use
10.1
Data Results 10.1
Have you smoked at least 100 cigarettes in your entire life?
Crosstabulation Table:
10.2
Data Results 10.2
Do you now smoke cigarettes every day, some days, or not at all?
Crosstabulation Table:
10.3
Data Results 10.3
During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?
 
CDC Core
Section 11: Alcohol Consumption
11.1
Data Results 11.1
A drink of alcohol 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. During the past 30 days, how often have you had at least one drink of any alcoholic beverage?
11.2
Data Results 11.2
On the days when you drank, about how many drinks did you drink on the average?
Crosstabulation Table:
11.3
Data Results 11.3
Considering all types of alcoholic beverages, how many times during the past 30 days did you have 5 or more drinks on an occasion?
Crosstabulation Table:
 
CDC Core
Section 12: Firearms
12.1
Data Results 12.1
Are any firearms now kept in or around your home? Include those kept in a garage, outdoor storage area, car, truck, or other motor vehicle.
 
CDC Core
Section 13: Demographics
13.1
Data Results 13.1
What is your age?
13.2
Data Results 13.2
Are you of Hispanic or Latino?
13.3
Data Results 13.3
Which one or more of the following would you say is your race?
13.4
Data Results 13.4
Which one of these groups would you say best represents your race?
13.5
Data Results 13.5
Are you:
 
  • Married
  • Divorced
  • Widowed
  • Separated
  • Never been married
  • A member of an unmarried couple
13.6
Data Results 13.6
How many children less than 18 years of age live in your household ?
13.7
Data Results 13.7
What is the highest grade or year of school you completed?
13.8
Data Results 13.8
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
13.9
Data Results 13.9
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
13.10 About how much do you weigh without shoes?
Crosstabulation Table:
13.11 About how tall are you without shoes?
13.12 What county do you live in?
13.13
Data Results 13.13
Do you have more than one telephone number in your household? Do not include cell phones or numbers that are only used by a computer or fax machine.
13.14
Data Results 13.14
How many of these are residential numbers?
13.15
Data Results 13.15
How many adult members of your household currently use a cell phone for any purpose?
13.16
Data Results 13.16
Indicate sex of respondent. Ask Only if Necessary
13.17
Data Results 13.17
To your knowledge, are you now pregnant?
 
CDC Core
Section 14: Disability
14.1
Data Results 14.1
Are you limited in any way in any activities because of physical, mental, or emotional problems?
Crosstabulation Table:
14.2
Data Results 14.2
Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?
 
 
CDC Core
Section 15: Physical Activity
15.1
Data Results 15.1
When you are at work, which of the following best describes what you do?
15.2
Data Results 15.2
Now, thinking about the moderate physical activities you do [fill in (when you are not working) if "employed" or "self-employed" to core Q13.8] in a usual week, do you do moderate activities for at least 10 minutes at a time, such as brisk walking, bicycling, vacuuming, gardening, or anything else that causes small increases in breathing or heart rate?
Crosstabulation Table:
 
15.3
Data Results 15.3
How many days per week do you do these moderate activities for at least 10 minutes at a time?
15.4
Data Results 15.4
On days when you do moderate activities for at least 10 minutes at a time, how much total time per day do you spend doing these activities?
15.5
Data Results 15.5
Now thinking about the vigorous physical activities you do [fill in (when you are not working) if "employed" or "self-employed" to core Q13.8] in a usual week, do you do vigorous activities for at least 10 minutes at a time, such as running, aerobics, heavy yard work, or anything else that causes large increases in breathing or heart rate?
Crosstabulation Table:
 
15.6
Data Results 15.6
How many days per week do you do these vigorous activities for at least 10 minutes at a time?
Crosstabulation Table:
15.7
Data Results 15.7
On days when you do vigorous activities for at least 10 minutes at a time, how much total time per day do you spend doing these activities?
Crosstabulation Table:
 
CDC Core
Section 16: Prostate Cancer Screening
16.1
Data Results 16.1
A Prostate-Specific Antigen test, also called a PSA test, is a blood test used to check men for prostate cancer. Have you ever had a PSA test?
16.2
Data Results 16.2
How long has it been since you had your last PSA test?
16.3
Data Results 16.3
A digital rectal exam is an exam in which a doctor, nurse, or other health professional places a gloved finger into the rectum to feel the size, shape, and hardness of the prostate gland. Have you ever had a digital rectal exam?
16.4
Data Results 16.4
How long has it been since your last digital rectal exam?
16.5
Data Results 16.5
Have you ever been told by a doctor, nurse, or other health professional that you had prostate cancer?
16.6
Data Results 16.6
Has your father, brother, son, or grandfather ever been told by a doctor, nurse, or health professional that he had prostate cancer?
 
 
CDC Core
Section 17: Colorectal Cancer Screening
17.1
Data Results 17.1
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?
Crosstabulation Table:
17.2
Data Results 17.2
How long has it been since you had your last blood stool test using a home kit?
Crosstabulation Table:
17.3
Data Results 17.3
Sigmoidoscopy and colonoscopy are exams in which a tube is inserted in the rectum to view the bowel for signs of cancer or other health problems. Have you ever had either of these exams?
Crosstabulation Table:
17.4
Data Results 17.4
How long has it been since you had your last sigmoidoscopy or colonoscopy?
 
 
CDC Core
Section 18: HIV/AIDS
18.1
Data Results 18.1
A pregnant woman with HIV can get treatment to help reduce the chances that she will pass the virus on to her baby. (True, False or Don't know/Not sure)
18.2
Data Results 18.2
There are medical treatments available that are intended to help a person who is infected with HIV to live longer. (True, False or Don't know/Not sure)
18.3
Data Results 18.3
How effective do you think these treatments are helping persons with HIV to live longer?
18.4
Data Results 18.4
How important do you think it is for people to know their HIV status by getting tested?
18.5
Data Results 18.5
As far as you know, have you ever been tested for HIV? Do not count tests you may have had as part of a blood donation.
18.6 Not including blood donations, in what month and year was your last HIV test?
18.7
Data Results 18.7
What was the main reason you had your test for HIV in [fill in date from Q18.6]?
18.8
Data Results 18.8
Where did you have the HIV test in [fill in date from Q18.6]?
18.9
Data Results 18.9
In the past 12 months has a doctor, nurse, or other health professional talked to you about preventing sexually transmitted diseases through condom use?
 
 
CDC Optional
Module 1: Diabetes
1
Data Results CO 1.1
How old were you when you were told you have diabetes?
2
Data Results CO 1.2
Are you now taking insulin?
3
Data Results CO 1.3
Are you now taking diabetes pills?
4
Data Results CO 1.4
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
Data Results CO 1.5
About how often do you check your feet for any sores or irritations? Include times when checked by a family member or friend, but do not include times when checked by a health professional.
6
Data Results CO 1.6
Have you ever had any sores or irritations on your feet that took more than four weeks to heal?
7
Data Results CO 1.7
About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?
8
Data Results CO 1.8
A test for hemoglobin "A one C" measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for hemoglobin "A one C"?
9
Data Results CO 1.9
About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?
10
Data Results CO 1.10
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.
11
Data Results CO 1.11
Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?
12
Data Results CO 1.12
Have you ever taken a course or class in how to manage your diabetes yourself?
 
State-Added
Module 1: Accessory Diabetes
1
Data Results SA 1.1
Is paying for your diabetes supplies a problem?
2
Data Results SA 1.2
When you go to your doctor for your diabetes, are you usually told to remove your socks and shoes before you see the doctor?
3
Data Results SA 1.3
Who decides when you need your next diabetes check-up?
4
Data Results SA 1.4
Were you hospitalized during the past two years?
5
Data Results SA 1.5
What was the reason for your most recent hospitalization?
 
State-Added
Module 2: HIV Testing in Pregnancy
1
Data Results SA 2.1
Have you been pregnant during the past two years?
2
Data Results SA 2.2
Did your doctor offer you an HIV test during your last pregnancy?
 
CDC Optional (M) & State-Added (D)
Module 15: Disability
1 (D)
Data Results SA 15.1
How often do you get the social and emotional support you need?
2 (D)
Data Results SA 15.2
In general, how satisfied are you with your life?
3 (D)
Data Results SA 15.3
Because of any impairment or health problem, do you have any trouble learning, remembering, or concentrating?
4 (D)
Data Results SA 15.4
What is the farthest distance you can walk by yourself, without any special equipment or help from others?
5 (M)
Data Results CO 15.5
What is the MAJOR impairment or health problem that limits your activities?
6 (M)
Data Results CO 15.6
For HOW LONG have your activities been limited because of your major impairment or health problem?
7 (M)
Data Results CO 15.7
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?
8 (M)
Data Results CO 15.8
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?
9 (M)
Data Results CO 15.9
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?
Crosstabulation Table:
10 (M)
Data Results CO 15.10
During the past 30 days, for about how many days have you felt SAD, BLUE, or DEPRESSED?
Crosstabulation Table:
11 (M)
Data Results CO 15.11
During the past 30 days, for about how many days have you felt WORRIED, TENSE, or ANXIOUS?
Crosstabulation Table:
12 (M)
Data Results CO 15.12
During the past 30 days, for about how many days have you felt that you did not get ENOUGH REST or SLEEP?
Crosstabulation Table:
13 (M)
Data Results CO 15.13
During the past 30 days, for about how many days have you felt VERY HEALTHY and FULL OF ENERGY?
Crosstabulation Table:
14 (D)
Data Results SA 15.14
Is there anyone [fill in (else) if "yes" to Core Q14.1 or Q14.2 or if Q(D)-3 in Disability Module is "yes"] in your household who is LIMITED in any way in any activities because of any impairment or health problem?
15a(D) How old are these people? a. person 1
15b(D) How old are these people? b. person 2
15c(D) How old are these people? c. person 3
15d(D) How old are these people? d. person 4
15e(D) How old are these people? e. person 5
 
State-Added
Module 3: Child Vehicle Safety
1
Data Results SA 3.1
Next, I have a few questions related to children’s health issues. In general, do you feel a child between 4 and 8 years of age is safer in a seat belt, child safety seat, booster seat, or without a restraining device while riding in a vehicle?
2
Data Results SA 3.2
Previously, you indicated there were [number from core, Q13.6] children under age 18 in your household. What is the age of the [randomly selected -- oldest, second oldest, etc.] child?
3
Data Results SA 3.3
What is the gender of this child?
4
Data Results SA 3.4
During the past 30 days, how often did the [randomly selected child] use a child safety seat, booster seat, or seat belt when riding in a car, van, sports utility vehicle, or truck?
5a
Data Results SA 3.5a
During that time, did the [randomly selected child] use: a child safety seat?
5b
Data Results SA 3.5b
(During that time, did the [randomly selected child] use): a booster seat?
5c
Data Results SA 3.5c
(During that time, did the [randomly selected child] use): a seat belt only?
6
Data Results SA 3.6
During the past 30 days, how often did the [randomly selected child] ride in the back seat?
 
State-Added
Module 4: Oral Health (modified)
1
Data Results SA 4.1
During the past 12 months, was there any time when you needed dental care but did not get it?
2
Data Results SA 4.2
What was the main reason you did not receive the dental care you needed?
3
Data Results SA 4.3
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?
Crosstabulation Table:
4
Data Results SA 4.4
These next few questions are about the [age of randomly-selected child]. Has the [randomly selected child] ever had any cavities or tooth decay?
5
Data Results SA 4.5
Have all the cavities that the [randomly selected child] been filled or repaired?
6
Data Results SA 4.6
How long has it been since the [randomly selected child] last visited a dentist or dental clinic for any reason?
7
Data Results SA 4.7
During the past 12 months, was there any time when the [randomly selected child] needed dental care but did not get it?
8
Data Results SA 4.8
What was the main reason the [randomly selected child] did not receive the dental care [he/she] needed?
9
Data Results SA 4.9
Does the [randomly selected child] have any kind of insurance coverage that pays for some or all of [his/her] routine dental care, including dental insurance, prepaid plans such as HMOs, or government plans such as Medicaid?
10
Data Results SA 4.10
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 from fillings, caps, crowns, and fluoride treatments. Has the [randomly selected child] ever had dental sealants placed on [her/his] teeth?
 
State-Added
Module 5: Prostate Cancer Counseling
1
Data Results SA 5.1
Previously, I asked you some questions about tests for prostate cancer you may have had. Has you physician ever discussed with you both the advantages and disadvantages of being screened for prostate cancer?
 
State-Added
Module 6: Colorectal Cancer Counseling
1
Data Results SA 6.1
I also previously asked you whether or not you have had tests for colorectal cancer. Has a doctor or other health professional ever talked to you about getting tested for colorectal cancer, or cancer of the bowel?
 
State-Added
Module 7: Workplace Smoking
1
Data Results SA 7.1
Which of the following best describes the policy about smoking at your work place?
 
State-Added
Module 8: Community Involvement
1
Data Results SA 8.1
How would you rate your community as a place to live?
2
Data Results SA 8.2
How long have you lived in the community in which you now live?
3
Data Results SA 8.3
During the past 5 years, have you been active in a coalition or civic group which attempted to address one or more community problems?
4
Data Results SA 8.4
How would you rate your community on it's... Willingness of citizens to become involved in community issues?
5
Data Results SA 8.5
(How would you rate your community on its)... Availability of effective leadership for solving community problems?
6
Data Results SA 8.6
(How would you rate your community on its)... Cooperation and communication between community organizations, including government, civic organizations, and social agencies?
7
Data Results SA 8.7
(How would you rate your community on its)... People sharing a sense of belonging to the community?
8
Data Results SA 8.8
(How would you rate your community on its)... Past history of community success at problem solving?
9
Data Results SA 8.9
(How would you rate your community on its)... Community decision making shared among community members and among community organizations?
10
Data Results SA 8.10
(How would you rate your community on its)... Community investment of financial resources in community problem-solving?
11
Data Results SA 8.11
(How would you rate your community on its)... Availability of people in the community with skills to solve community problems?
12
Data Results SA 8.12
(How would you rate your community on its)... Shared values and vision among community citizens?
13
Data Results SA 8.13
(How would you rate your community on its)... Self-honesty and ability to learn from mistakes?