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 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
Do you have one person you think of as your personal doctor or health care provider?
Crosstabulation Table:
2.3
Data Results 2.3
Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?
 
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: Diabetes
4.1
Data Results 4.1
Have you ever been told by a doctor that you have diabetes?
Crosstabulation Table:
 
CDC Core
Section 5: Hypertension Awareness
5.1
Data Results 5.1
Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?
Crosstabulation Table:
5.2
Data Results 5.2
Are you currently taking medicine for your high blood pressure?
Crosstabulation Table:
 
CDC Core
Section 6: Cholesterol Awareness
6.1
Data Results 6.1
Blood cholesterol is a fatty substance found in the blood. Have you ever had your blood cholesterol checked?
Crosstabulation Table:
6.2
Data Results 6.2
About how long has it been since you last had your blood cholesterol checked?
6.3
Data Results 6.3
Have you ever been told by a doctor, nurse, or other health professional that your blood cholesterol is high?
 
CDC Core
Section 7: Fruits and Vegetables
Crosstabulation Table:
These next questions are about the foods you usually eat or drink. Please tell me how often you eat or drink each one, for example, twice a week, three times a month, and so forth. Remember, I am only interested in the foods you eat. Include all foods you eat, both at home and away from home.
7.1
Data Results 7.1
How often do you drink fruit juices such as orange, grapefruit, or tomato?
7.2
Data Results 7.2
Not counting juice, how often do you eat fruit?
7.3
Data Results 7.3
How often do you eat green salad?
7.4
Data Results 7.4
How often do you eat potatoes not including French fries, fried potatoes, or potatoes chips?
7.5
Data Results 7.5
How often do you eat carrots?
7.6
Data Results 7.6
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 8: Weight Control
8.1
Data Results 8.1
Are you now trying to lose weight?
8.2
Data Results 8.2
Are you now trying to maintain your current weight that is to keep from gaining weight?
8.3
Data Results 8.3
Are you eating either fewer calories or less fat to...
lose weight?
keep from gaining weight?
8.4
Data Results 8.4
Are you using physical activity or exercise to...
lose weight?
keep from gaining weight?
8.5
Data Results 8.5
In the past 12 months, has a doctor, nurse, or other health professional given you advice about your weight?
 
CDC Core
Section 9: Asthma
9.1
Data Results 9.1
Have you ever been told by a doctor, nurse or other health professional that you had asthma?
9.2
Data Results 9.2
Do you still have asthma?
Crosstabulation Table:
 
CDC Core
Section 10: Immunization
10.1
Data Results 10.1
During the past 12 months, have you had a flu shot?
Crosstabulation Table:
 
 
10.2
Data Results 10.2
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 11: Tobacco Use
11.1
Data Results 11.1
Have you smoked at least 100 cigarettes in your entire life?
[Note: 5 packs = 100 cigarettes.]
11.2
Data Results 11.2
Do you now smoke cigarettes every day, some days, or not at all?
Crosstabulation Table:
11.3
Data Results 11.3
During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?
Crosstabulation Table:
 
CDC Core
Section 12: Alcohol Consumption
12.1
Data Results 12.1
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?
12.2
Data Results 12.2
On the days when you drank, about how many drinks did you drink on the average?
Crosstabulation Table:
12.3
Data Results 12.3
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 13: Excess Sun Exposure
13.1
Data Results 13.1
Have you had a sunburn within the past 12 months?
Crosstabulation Table:
13.2
Data Results 13.2
Including times when even a small part of your skin was red for more than 12 hours, how many sunburns have you had within the past 12 months?
 
CDC Core
Section 14: Demographics
14.1
Data Results 14.1
What is your age?
14.2
Data Results 14.2
Are you of Hispanic or Latino?
14.3
Data Results 14.3
Which one or more of the following would you say is your race?
14.4
Data Results 14.4
Which one of these groups would you say best represents your race?
14.5
Data Results 14.5
Are you:
 
  • Married
  • Divorced
  • Widowed
  • Separated
  • Never been married
  • A member of an unmarried couple
14.6
Data Results 14.6
How many children less than 18 years of age live in your household ?
14.7
Data Results 14.7
What is the highest grade or year of school you completed?
14.8
Data Results 14.8
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
14.9
Data Results 14.9
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
14.10 About how much do you weigh without shoes?
14.11 How much would you like to weigh?
14.12 About how tall are you without shoes?
Crosstabulation Table:
 
14.13 What county do you live in?
14.14
Data Results 14.14
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.
14.15
Data Results 14.15
How many of these are residential numbers?
14.16
Data Results 14.16
During the past 12 months, has your household been without telephone service for 1 week or more? Do not include when services is interrupted by weather or natural disasters.
14.17
Data Results 14.17
Indicate sex of respondent. Ask Only if Necessary
14.18
Data Results 14.18
To your knowledge, are you now pregnant?
 
CDC Core
Section 15: Arthritis
The next questions refer to your joints. Please do NOT include the back or neck.
15.1
Data Results 15.1
DURING THE PAST 30 DAYS, have you had any symptoms of pain, aching, or stiffness in or around a joint?
15.2
Data Results 15.2
Did your joint symptoms FIRST begin more than 3 months ago?
Crosstabulation Table:
15.3
Data Results 15.3
Have you EVER seen a doctor or other health professional for these joint symptoms?
15.4
Data Results 15.4
Have you EVER been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?

Arthritis diagnoses include:
  • rheumatism, polymyalgia gheumatica
  • osteoarthritis (not osteoporosis)
  • tendonitis, bursitis, bunion, tennis elbow
  • carpal tunnel syndrome, tarsal tunnel syndrome
  • joint infection, Reiter's syndrome
  • ankylosing spondylitis; spondylosis
  • rotator cuff syndrome
  • connective tissue disease, scleroderma, polymyositis, Raynaud's syndrome
  • vasculitis (giant cell arteritis, henoch-Schonlein purpura, Wegener's granulomatosis, polyarteritis nodosa)
Crosstabulation Table:
15.5
Data Results 15.5
Are you now limited in any way in any of your usual activities because of arthritis or joint symptoms?
[NOTE: If respondent question arises about medication, then interviewer should reply: "Please answer the question based on how you are when you are taking any of the medications or treatments you might use."]
Crosstabulation Table:
15.6
Data Results 15.6
In the next question we are referring to work for pay.
Do arthritis or joint symptoms now effect whether you work, the type of work you do, or the amount of work you do?
[NOTE: If respondent says he/she is retired or out-of-work, reply: "Did arthritis or joint symptoms cause you to stop working? That is, did it affect whether you work or not?"]
 
CDC Core
Section 16: Falls
The next question asks about a recent fall. By a fall, we mean when a person unintentionally comes to rest on the ground or another lower level.
16.1
Data Results 16.1
In the past 3 months, have you had a fall?
16.2
Data Results 16.2
Were you injured? By injured, we mean the caused you to limit your regular activities for at least a day or to go see a doctor.
 
CDC Core
Section 17: Disability
The following questions are about health problems or impairments you may have.
17.1
Data Results 17.1
Are you limited in any way in any activities because of physical, mental, or emotional problems?
Crosstabulation Table:
17.2
Data Results 17.2
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? Include occasional use or use in certain circumstances.
Crosstabulation Table:
 
CDC Core
Section 18: Physical Activity
18.1
Data Results 18.1
When you are at work, which of the following best describes what you do? [NOTE: If respondent has multiple jobs, include all jobs.]
Would you say:
  • Mostly sitting or standing
  • Mostly walking
  • Mostly heavy labor or physically demanding work
We are interested in two types of physical activity - vigorous and moderate. Vigorous activities cause large increases in breathing or heart rate while moderate activities cause small increases in breathing or heart rate.
18.2
Data Results 18.2
Now, thinking about the moderate physical activities you do [fill in (when you are not working) if "employed" or "self-employed" to core Q14.8] 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?
18.3
Data Results 18.3
How many days per week do you do these moderate activities for at least 10 minutes at a time?
18.4
Data Results 18.4
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?
Crosstabulation Table:
 
18.5
Data Results 18.5
Now thinking about the vigorous physical activities you do [fill in (when you are not working) if "employed" or "self-employed" to core Q14.8] 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?
18.6
Data Results 18.6
How many days per week do you do these vigorous activities for at least 10 minutes at a time?
18.7
Data Results 18.7
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 19: Veteran's Status
The next question relates to military service in the United States Armed Forces, either in the regular military or in a National Guard or Reserve unit.
19.1
Data Results 19.1
Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?
19.2
Data Results 19.2
Which of the following best describes your service in the United States military?
19.3
Data Results 19.3
In the last 12 months have you received some or all of your health care from VA facilities?
 
CDC Core
Section 20: HIV/AIDS
The next few questions are about the national health problem of HIV, the virus that causes AIDS. Please remember that your answers are strictly confidential and that you don't have to answer every question if you don't want to.
20.1
Data Results 20.1

I'm going to read two statements about HIV, the virus that causes AIDS. After I read each one, please tell me whether you think it is true or false, or if you don't know.

A pregnant woman with HIV can get treatment to help reduce the chances that she will pass the virus on to her baby.

20.2
Data Results 20.2
There are medical treatments available that are intended to help a person who is infected with HIV to live longer.
20.3
Data Results 20.3
How important do you think it is for people to know their HIV status by getting tested?
20.4
Data Results 20.4
Have you ever been tested for HIV? Do not count tests you may have had as part of a blood donation.
20.5
Not including blood donations, in what month and year was your last HIV test? (Include saliva tests.) [Note: If response is before January 1985, code "Don't know/Not sure".]
20.6
Data Results 20.6
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?
20.7
Data Results 20.7
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?
20.8
Data Results 20.8
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?
20.9
Data Results 20.9

The next question is about sexually transmitted diseases other than HIV, such as syphilis, gonorrhea, chlamydia, or genital herpes.

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?
 
CDC Optional
Module 13: Arthritis
1
Data Results CO 13.1

Earlier you indicated that you had arthritis or joint symptoms. Thinking about your arthritis or joints symptoms, which of the following best describes you TODAY?

  • I can do everything I would like to do
  • I can do most things I like to do
  • I can do some things I would like to do
  • I can hardly do anything I would like to do
 

2
Data Results CO 13.2
Has a doctor or health professional EVER suggested losing weigh to help your arthritis or joint symptoms?
3
Data Results CO 13.3
Has a doctor or other health professional EVER suggested physical activity or exercise to help your arthritis of joint symptoms? [NOTE: If the respondent is unclear about whether this means an increase or decrease in physical activity, this means increase.]
4
Data Results CO 13.4
Have you EVER taken an educational course or class to teach you how to manage problems related to your arthritis or joint symptoms?
 
State-Added
Module 1: Arthritis
1
Data Results SA 1.1
To your knowledge, are there educational courses or classes available in your community that could teach you how to manage problems related to your arthritis or joint symptoms?
2
Data Results SA 1.2
Do you currently participate in physical activity or exercise to help manage problems related to your arthritis or joint symptoms?
3
Data Results SA 1.3
Do you currently participate in any support group to help manage problems related to your arthritis or joint symptoms?
4
Data Results SA 1.4
Has a doctor or other health professional ever suggested you participate in an Arthritis Foundation program to help manage problems related to your arthritis or joint symptoms?
 
State-Added
Module 2: Diabetes Accessory
Next, I have just a few more questions about your diabetes.
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: Origin and Language
1
Data Results SA 3.1
Do you consider English to be your primary or "first" language?
2
Data Results SA 3.2
What language do you consider to be your primary or "first" language?
3
Data Results SA 3.3
In what country were you born?
4
Data Results SA 3.4
How long have you lived in the United States?
 
State-Added
Module 4: Occupation and Absenteeism
1
Data Results SA 4.1
Previously, you indicated you were (a) [insert response from core, Q14.8]. On the average, how many hours per week, if any, do you work at a job or business?
2
Data Results SA 4.2
What kind of work do you do now? (For example: registered nurse, personnel manager, supervisor of order department, auto mechanic, accountant)
3
Data Results SA 4.3
What kind of business or industry is this? (For example: hospital, newspaper publishing, mail order house, auto repair shop, bank)
The next 4 questions are about days you may have missed from work. During the past 12 months, excluding vacation days, maternity or paternity leave, or other planned days off...
4
Data Results SA 4.4
...how many days did you miss work due to a physical illness that you had?
5
Data Results SA 4.5
...how many days did you miss work due to a physical illness of another person?
6
Data Results SA 4.6
...how many days did you miss work due to your own stress, depression or problems with emotions?
7
Data Results SA 4.7
...how many days did you miss work due to another person's stress, depression, or problems with emotions?
8
Data Results SA 4.8
Not including physical illness or stress, depression, or problems with emotions, how many days, during the past 12 months, did you miss work for any other reason? This excludes vacation days, maternity or paternity leave, or other planned days off.
 
State-Added
Module 5: Health Care Coverage
Previously I asked you about your health care coverage.
1
Data Results SA 5.1
What type of health care coverage do you use to pay for most of your medical care? Is it coverage through:
  • Your employer
  • Someone else's employer
  • A plan that you or someone else buys on your own
  • Medicare
  • Medicaid or Medical Assistance
  • The military, CHAMPUS, TriCare, or the VA
  • The Indian Health Service (or the Alaska Native Health Service)
  • Some other source
 
State-Added
Module 6: Traumatic Brain Injury
The next question is about injuries you or someone in your household may have had.
1
Data Results SA 6.1
Including yourself, how many people in your household have received medical care or are limited in any way in any activities as a result of an injury to their head or brain?
 
State-Added
Module 7: Tetanus
1
Data Results SA 7.1
During the past ten years have you received a tetanus shot?
 
State-Added
Module 8: Transportation Physical Activity
The next two questions are about physical activity that you may do as part of your daily transportation to your job, the store, or other places that you go. Please include physical activity that you may have included in your previous answers.
1
Data Results SA 8.1
During the past month, did you walk for transportation, like to go to or from work, to run errands, or to go somewhere else that you wanted or needed to go?
2
Data Results SA 8.2
During the past month, did you ride a bicycle for transportation, like to go to or from work, to run errands, or to go somewhere else that you wanted or needed to go?
 
State-Added
Module 9: Adult Asthma
Previously you said that you were told by a doctor, nurse, or other health professional that you had asthma.
1
Data Results SA 9.1
During the past 12 months, how many times did you visit an emergency room or urgent care center because of your asthma?
2
Data Results SA 9.2
[If one or more visits to Q1, fill in (Besides those emergency room visits,)] During the past 12 months, how many times did you see a doctor, nurse, or other health professional for urgent treatment of worsening asthma symptoms?
3
Data Results SA 9.3
During the past 12 months, how many days were you unable to work or carry out your usual activities because of asthma?
4
Data Results SA 9.4
During the past 30 days, how often did you take asthma medication that was prescribed or given to you by a doctor? This includes an inhaler.
 
State-Added
Module 10: Childhood Asthma
1
Data Results SA 10.1
Previously, you indicated there were [number from core, Q14.6] children under age 18 in your household. What is the age of the [randomly selected child - oldest, second oldest, etc.] child?
2
Data Results SA 10.2
What is the gender of this child?
3
Data Results SA 10.3
Has the [randomly selected child] ever been diagnosed with asthma?
4
Data Results SA 10.4
Does the [randomly selected child] still have asthma?
Crosstabulation Table:
5
Data Results SA 10.5
During the past 12 months, how many days has the [randomly selected child] missed school or day care because of [his/her] asthma?