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:
 
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
Do you have one person you think of as your personal doctor or health care provider?
Crosstabulation Table:
2.3
Data Results 2.3
When you are sick or need advice about your health, to which one of the following places do you usually go?
2.4
Data Results 2.4
Was there a time in the past 12 months when you needed medical care, but could not get it?
2.5
Data Results 2.5
What is the main reason you did not get medical care?
 
CDC Core
Section 3: Exercise
3.1
Data Results 3.1
During the past month, other than your regular job, did you participate in any physical activities or exercise such as running, calisthenics, golf, gardening, or walking for exercise?
Crosstabulation Table:
 
CDC Core
Section 4: Fruits and Vegetables
Crosstabulation Table:
4.1
Data Results 4.1
How often do you drink fruit juices such as orange, grapefruit, or tomato?
4.2
Data Results 4.2
Not counting juice, how often do you eat fruit?
4.3
Data Results 4.3
How often do you eat green salad?
4.4
Data Results 4.4
How often do you eat potatoes not including french fries, fried potatoes, or potatoes chips?
4.5
Data Results 4.5
How often do you eat carrots?
4.6
Data Results 4.6
Not counting carrots, potatoes, or salad, how many servings of vegetables do you usually eat? [Example: A serving of vegetables at both lunch and dinner would be two servings.]
 
CDC Core
Section 5: Asthma
5.1
Data Results 5.1
Have you ever been told by a doctor, nurse or other health professional that you had asthma?
Crosstabulation Table:
5.2
Data Results 5.2
Do you still have asthma?
 
CDC Core
Section 6: Diabetes
6.1
Data Results 6.1
Have you ever been told by a doctor that you have diabetes?
Crosstabulation Table:
 
 
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?
 
CDC Core
Section 7: Oral Health
7.1
Data Results 7.1
How long has it been since you last visited a dentist or a dental clinic for any reason? [Note: Include visits to dental specialists, such as orthodontists.]
Crosstabulation Table:
7.2
Data Results 7.2
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. [Note: Include teeth lost due to "infection".]
Crosstabulation Table:
 
7.3
Data Results 7.3
How long has it been since you had your teeth cleaned by a dentist or dental hygienist?
 
 
CDC Core
Section 8: Immunization
8.1
Data Results 8.1
During the past 12 months, have you had a flu shot?
Crosstabulation Table:
 
 
8.2
Data Results 8.2
At what kind of place did you get your last flu shot?
8.3
Data Results 8.3
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 9: Tobacco Use
9.1
Data Results 9.1
Have you smoked at least 100 cigarettes in your entire life?
[Note: 5 packs = 100 cigarettes.]
9.2
Data Results 9.2
Do you now smoke cigarettes every day, some days, or not at all?
Crosstabulation Table:
9.3
Data Results 9.3
During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?
 
 
CDC Core
Section 10: Alcohol Consumption
10.1
Data Results 10.1
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 many days per week or per month did you have at least 1 drink of any alcoholic beverage?
Crosstabulation Table:
 
 
10.2
Data Results 10.2
On the days when you drank, about how many drinks did you drink on the average?
10.3
Data Results 10.3
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:
10.4
Data Results 10.4
During the past 30 days, how many times have you driven when you've had perhaps too much to drink?
Crosstabulation Table:
 
CDC Core
Section 11: Seat Belts
11.1
Data Results 11.1
How often do you use seatbelts when you drive or ride in a car?
Crosstabulation Table:
 
CDC Core
Section 12: Demographics
12.1
Data Results 12.1
What is your age?
12.2
Data Results 12.2
Are you of Hispanic or Latino?
12.3
Data Results 12.3
Which one or more of the following would you say is your race?
12.4
Data Results 12.4
Which one of these groups would you say best represents your race?
12.5
Data Results 12.5
Are you:
 
  • Married
  • Divorced
  • Widowed
  • Separated
  • Never been married
  • A member of an unmarried couple
12.6
Data Results 12.6
How many children less than 18 years of age live in your household ?
12.7
Data Results 12.7
What is the highest grade or year of school you completed?
12.8
Data Results 12.8
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
12.9
Data Results 12.9
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
12.10 About how much do you weigh without shoes?
12.11 About how tall are you without shoes?
Crosstabulation Table:
12.12 What county do you live in?
12.13
Data Results 12.13
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.
12.14
Data Results 12.14
How many of these are residential numbers?
12.15
Data Results 12.15
Indicate sex of respondent. Ask Only if Necessary
12.16
Data Results 12.16
To your knowledge, are you now pregnant?
 
CDC Core
Section 13: Family Planning
13.1
Data Results 13.1
Are you or your [husband/wife/partner] doing anything now to keep [you/her] from getting pregnant? Some things people do to keep from getting pregnant include not having sex at certain times, using birth control methods such as the pill, Norplant, shots or Depo-provera, condoms, diaphragm, foam, IUD, having their tubes tied, or having a vasectomy.
13.2
Data Results 13.2
What are you or your [if female husband/partner; if male, insert wife/partner] doing now to keep [if female, insert "you"; insert "her" if male] from getting pregnant?
13.3
Data Results 13.3
What other method are you also using to prevent pregnancy?
13.4
Data Results 13.4
[Females] What is your main reason for not doing anything to keep from getting pregnant?
[Males]What is your main reason for not doing anything to keep your partner from getting pregnant?
 
CDC Core
Section 14: Women's Health
14.1
Data Results 14.1
A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram?
14.2
Data Results 14.2
How long has it been since you had your last mammogram?
Crosstabulation Table:
14.3
Data Results 14.3
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?
14.4
Data Results 14.4
How long has it been since your last breast exam?
14.5
Data Results 14.5
A Pap smear is a test for cancer of the cervix. Have you ever had a Pap smear?
14.6
Data Results 14.6
How long has it been since you had your last Pap smear?
Crosstabulation Table:
14.7
Data Results 14.7
Have you had a hysterectomy?
 
CDC Core
Section 15: Prostate Cancer Screening
15.1
Data Results 15.1
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?
15.2
Data Results 15.2
How long has it been since you had your last PSA test?
Crosstabulation Table:
15.3
Data Results 15.3
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?
15.4
Data Results 15.4
How long has it been since your last digital rectal exam?
15.5
Data Results 15.5
Have you ever been told by a doctor, nurse, or other health professional that you had prostate cancer?
 
CDC Core
Section 16: Colorectal Cancer Screening
16.1
Data Results 16.1
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:
16.2
Data Results 16.2
How long has it been since you had your last blood stool test using a home kit?
16.3
Data Results 16.3
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:
16.4
Data Results 16.4
How long has it been since you had your last sigmoidoscopy or colonoscopy?
 
CDC Core
Section 17: HIV/AIDS
17.1
Data Results 17.1
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)
17.2
Data Results 17.2
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)
17.3
Data Results 17.3
How important do you think it is for people to know their HIV status by getting tested?
17.4
Data Results 17.4
Have you ever been tested for HIV? Do not count tests you may as part of a blood donation.
17.5
Not including blood donations, in what month and year was your last HIV test? [Note: Include saliva tests.]
17.6
Data Results 17.6
I am going to read you a list of reasons why some people have been tested for HIV. Not including blood donations, which of these would you say was the MAIN reason for your last HIV test?
17.7
Data Results 17.7
Where did you have your last HIV test - at a private doctor or HMO office, at a counseling and testing site, at a hospital, at a clinic, in a jail or prison, at home, or somewhere else?
17.8
Data Results 17.8
I'm going to read you a list. When I'm done, please tell me if any of these situations apply to you. You don't need to tell me which one.
  • You have used intravenous drugs in the past year.
  • You have been treated for a sexually transmitted or venereal disease in the past year.
  • You have given or received money or drugs in exchange for sex in the past year.
  • You had anal sex without a condom in the past year.
Do any of these situations apply to you?
17.9
Data Results 17.9
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 Core
Section 18: Firearms
The next three questions are about firearms. We are asking these in a health survey because of our interest in firearm-related injuries.

Please include weapons such as pistols, shotguns, and rifles; but not BB guns, starter pistols, or guns that cannot fire. Include those kept in a garage, outdoor storage area, or motor vehicle.
18.1
Data Results 18.1
Are any firearms now kept in or around your home?
18.2
Data Results 18.2
Are any of these firearms now loaded?
18.3
Data Results 18.3
Are any of these loaded firearms also unlocked? By "unlocked" we mean you do not need a key or combination to get the gun or to fire it. We don't count a safety as a lock.
Crosstabulation Table:
 
CDC Optional
Module 5: Healthy Days - Health-Related Quality of Life
1
Data Results CO 5.1
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?
2
Data Results CO 5.2
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:
3
Data Results CO 5.3
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?
 
State-Added
Module 1: Activity Limitation
1
Data Results SA 1.1
Are you limited in any way in any activities because of physical, mental, or emotional problems?
Crosstabulation Table:
 
State-Added
Module 2: Diabetes Accessory
1
Data Results SA 2.1
Is paying for your diabetes supplies a problem?
2
Data Results SA 2.2
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 2.3
Who decides when you need your next diabetes check-up?
4
Data Results SA 2.4
Were you hospitalized during the past two years?
5
Data Results SA 2.5
What was the reason for your most recent hospitalization?
 
State-Added
Module 3: Smoke Detectors
1
Data Results SA 3.1
Which of the following best describes whether you have a smoke detector in your home? Is it
  • I don't have a smoke detector.
  • I have an installed and working smoke detector.
  • I have a smoke detector, but it is not installed.
  • I have a smoke detector, but it is broken or the battery is missing.
  • I have a smoke detector, but don't know if it works.
Crosstabulation Table:
2
Data Results SA 3.2
Do you have a functioning smoke detector on every level of your home and outside each sleeping area?
Crosstabulation Table:
3
Data Results SA 3.3
Does your family have an escape plan in case of fire in the home?
4
Data Results SA 3.4
Has your family practiced an escape plan in case of fire in the home?
 
CDC Optional
Module 15: Other Tobacco Products
1
Data Results CO 15.1
Have you ever used or tried any smokeless tobacco products such as chewing tobacco or snuff?
2
Data Results CO 15.2
Do you currently use chewing tobacco or snuff every day, some days, or not at all?
Crosstabulation Table:
3
Data Results CO 15.3
Have you ever smoked a cigar, even one or two puffs?
4
Data Results CO 15.4
Do you now smoke cigars every day, some days, or not at all?
5
Data Results CO 15.5
Have you ever smoked tobacco in a pipe, even one or two puffs?
6
Data Results CO 15.6
Do you now smoke a pipe every day, some days, or not at all?
7
Data Results CO 15.7
A bidi is a flavored cigarette from India. Have you ever smoked a bidi, even one or two puffs?
8
Data Results CO 15.8
Do you now smoke bidis every day, some days, or not at all?
 
State-Added
Module 4: Supplementary Tobacco Questions
1
Data Results SA 4.1

Which statement best describes the rules about smoking inside your home?

  • Smoking is not allowed anywhere inside your home.
  • Smoking is allowed in some places or at some times.
  • Smoking is allowed anywhere inside the home.
  • There are no rules about smoking inside the home.

2
Data Results SA 4.2
In restaurants, do you feel that smoking should be:
  • Totally banned
  • Allowed in designated areas
  • Allowed anywhere
 
State-Added
Module 5: Oral Health
1
Data Results SA 5.1
During the past 12 months, was there any time when you needed dental care but did not get it?
2
Data Results SA 5.2
What was the main reason you did not receive the dental care you needed?
3
Data Results SA 5.3
Are you currently in need of any dental services such as fillings, dentures, partials, teeth pulled, caps, crowns, or root canals?
4
Data Results SA 5.4
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?
Crosstabulation Table:
5
Data Results SA 5.5
The last time you saw your dentist for dental care, did he or she examine all surfaces of the inside of your mouth, including the back of the throat and under the tongue?
6
Data Results SA 5.6
Previously, you indicated there were [number from core] children under the age 18 in your household. What is the age of the [randomly selected -- oldest, second oldest, etc.] child?
7
Data Results SA 5.7
What is the gender of this child?
8
Data Results SA 5.8
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 6: Childhood Immunization Opinions
1
Data Results SA 6.1
The next three questions are about childhood immunizations. Have you attempted to obtain the immunizations or shots for your [child/children] that your [child's/children's] physician has recommended?
2
Data Results SA 6.2
What are the main reasons why you have not attempted to obtain immunizations for your [child/children]?
3
Data Results SA 6.3
In general, how confident are you in the safety of the routine childhood immunizations? Would you say very confident, confident, somewhat confident, or not at all confident?
 
State-Added
Module 7: Mental Health
1
Data Results SA 7.1
During the past 12 months, did you ever feel so sad or hopeless every day for two weeks or more in a row that you stopped doing some usual activites?
Crosstabulation Table:
The following questions deal with suicide. Many people feel that this subject is personal, but we would appreciate your trying to answer these questions. Remember that you don't have to answer any questions you don't want to.
2
Data Results SA 7.2
During the past 12 months, have you seriously considered taking your own life, even if you would not really do it?
Crosstabulation Table:
3
Data Results SA 7.3
During the past 12 months, did you make a plan about how you would attempt suicide?
4
Data Results SA 7.4
During the past 12 months, how many times have you made an attempt to take your own life?