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: Healthy Days - Health-related Quality of Life
2.1
Data Results 2.1
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?
2.2
Data Results 2.2
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:
2.3
Data Results 2.3
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?
 
CDC Core
Section 3: Health Care Access
3.1
Data Results 3.1
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:
 
3.2
Data Results 3.2
Do you have one person you think of as your personal doctor or health care provider? (If "No", ask: "Is there more than one or is there no person who you think of?")
Crosstabulation Table:
3.3
Data Results 3.3
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 4: Exercise
4.1
Data Results 4.1
During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?
Crosstabulation Table:
 
CDC Core
Section 5: Environmental Factors
The next two questions are about things in the air you breathe that may make you ill, not about an illness you can catch from other people, such as a cold.
5.1
Data Results 5.1
Things like dust, mold, smoke, and chemicals inside the home or office can cause poor indoor air quality. In the past 12 months have you had an illness or symptom that you think was caused by something in the air inside a home, office, or other building?

Read if necessary: If you are experiencing an illness or symptom within the past 12 months that was caused by something in the air you encountered over 12 months ago, the answer is "Yes".
5.2
Data Results 5.2
Things like smog, automobile exhaust, and chemicals can cause outdoor air pollution. In the past 12 months have you had an illness or symptom that you think was caused by pollution in the air outdoors?

Read if necessary: This question does not refer to natural agents like pollen or dust in outdoor air. If respondent is experiencing an illness or symptom within the past 12 months that was caused by something in the air they encountered over 12 months ago, the answer is "Yes".
 
CDC Core
Section 6: Excess Sun Exposure
The next question is about sunburns including anytime that even a small part of your skin was red for more than 12 hours.
6.1
Data Results 6.1
Have you had a sunburn within the past 12 months?
Crosstabulation Table:
6.2
Data Results 6.2
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 7: Tobacco Use
7.1
Data Results 7.1
Have you smoked at least 100 cigarettes in your entire life?
[Interviewer: 5 packs = 100 cigarettes]
7.2
Data Results 7.2
Do you now smoke cigarettes every day, some days, or not at all?
Crosstabulation Table:
7.3
Data Results 7.3
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 8: AlcoholConsumption
8.1
Data Results 8.1
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 one drink of any alcoholic beverage?
8.2
Data Results 8.2
On the days when you drank, about how many drinks did you drink on the average?
Crosstabulation Table:
8.3
Data Results 8.3
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:
8.4
Data Results 8.4
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 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: Diabetes
10.1
Data Results 10.1
Have you ever been told by a doctor that you have diabetes?
(If "Yes" and respondent is female, ask: "Was this only when you were pregnant?")
Crosstabulation Table:
 
CDC Core
Section 11: Oral Health
11.1
  Data Results 11.1
11.1. How long has it been since you last visited a dentist or a dental clinic for any reason?
[Interviewer: Include visits to dental specialists, such as ortho-dentists.]
Crosstabulation Table:
11.2
Data Results 11.2
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.
[Interviewer: Include teeth lost due to "infection".]
Crosstabulation Table:
 
11.3
Data Results 11.3
How long has it been since you had your teeth cleaned by a dentist or dental hygienist?
 
CDC Core
Section 12: Immunization
12.1
Data Results 12.1
During the past 12 months, have you had a flu shot?
Read if necessary: We want to know if you had a flu shot injected in your arm.
Crosstabulation Table:
 
 
 
12.2
Data Results 12.2
During the past 12 months, have you had a flu vaccine that was sprayed in your nose?
12.3
Data Results 12.3
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 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?
13.11 About how tall are you without shoes?
Crosstabulation Table:
 
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 phone numbers are residential numbers?
13.15
Data Results 13.15
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.
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: Veteran's Status
14.1
Data Results 14.1
The next question relates to military service. 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?
14.2
Data Results 14.2
Which of the following best describes your service in the United States Military?
14.3
Data Results 14.3
In the last 12 months have you received some or all of your health care from VA facilities?
 
CDC Core
Section 15: Women's Health
15.1
Data Results 15.1
A mammogram is an x ray of each breast to look for breast cancer. Have you ever had a mammogram?
15.2
Data Results 15.2
How long has it been since you had your last mammogram?
Crosstabulation Table:
15.3
Data Results 15.3
A clinical breast exam is when a doctor, nurse or other health professional feels the breasts for lumps. Have you ever had a clinical breasts exam?
15.4
Data Results 15.4
How long has it been since your last breast exam?
15.5
Data Results 15.5
A Pap test is a test for cancer of the cervix. Have you ever had a Pap test?
15.6
Data Results 15.6
How long has it been since you had your last Pap smear?
Crosstabulation Table:
15.7
Data Results 15.7
Have you had a hysterectomy?
[A hysterectomy is an operation to remove the uterus (womb).]
 
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?
Crosstabulation Table:
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?
 
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?
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 colon 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: Family Planning
The next set of questions asks you about your thoughts and experiences with family planning. Please remember that all of your answers will be kept confidential.
18.1
Data Results 18.1
Some things people do to keep from getting pregnant include not having sex at certain times, using birth control methods such as the pill, implants, shots, condoms, diaphragm, foam, IUD, having their tubes tied, or having a vasectomy. Are you or your [if female, insert husband/partner, if male, insert wife/partner] doing anything now to keep [if female, insert you], if male, insert her] from getting pregnant?
[NOTE: If more than one partner, consider usual partner.]
18.2
Data Results 18.2
What are you or your [if female, insert husband/partner, if male, insert wife/partner] doing now to keep [if female, insert you, if male, insert her] from getting pregnant?
18.3
Data Results 18.3
What is the main reason for not doing anything to keep [if female, insert "you," if male, insert "your wife/partner"] from getting pregnant?
18.4
Data Results 18.4
How do you feel about having a child now or sometime in the future? Would you say:
  • You don't want to have one
  • You do want to have one
  • You're not sure if you do or don't
18.5
Data Results 18.5
How soon would you want to have a child? Would you say:
  • Less than 12 months from now
  • Between 12 months to less than two years from now
  • Between two years to less than 5 years from now
  • 5 or more years from now
 
CDC Core
Section 19: Disability
The following questions are about health problems or impairments you may have.
19.1
Data Results 19.1
Are you limited in any way in any activities because of physical, mental, or emotional problems?
Crosstabulation Table:
19.2
Data Results 19.2
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 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.
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.
20.1
Data Results 20.1
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
Have you ever been tested for HIV? Do not count tests you may have had as part of a blood donation.
[Note: Include saliva tests.]
20.4 In the past 12 months, how many times have you been tested for HIV, including times you did not get your results?
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
What type of clinic did you go to for your last HIV test?
20.9
Data Results 20.9
Was this test done by a nurse or other health worker, or with a home testing kit?
20.10
Data Results 20.10
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?
20.11
Data Results 20.11

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 Core
Section 21: Firearms
The next 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.
21.1
Data Results 21.1
Are any firearms kept in or around your home?
21.2
Data Results 21.2
Are any of these firearms now loaded?
21.3
Data Results 21.3
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:
 
State-Added
Module 11: Occupation
1
Data Results SA 11.1  
Previously, you indicated you were (a) [insert response from core, Q13.8]. On the average, how many hours per week, if any, do you work at a job or business?
2
Data Results SA 11.2
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 11.3
What kind of business or industry is this? (For example: hospital, newspaper publishing, mail order house, auto repair shop, bank)
 
This year the State of Kansas BRFSS questionnaire is a split questionnaire. That is, the core questions above and the one state-added module is asked of every respondent. However, the additional CDC modules and state-added modules that follow are seperated into two parts: Part A and Part B. Each record was pre-determined to be asked either Part A or Part B.
 
Part A
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: Diabetes Accessory
1
Data Results SA 1.1
When you go to your doctor for your diabetes, are you usually told to remove your socks and shoes before you see the doctor?
2
Data Results SA 1.2
When you go to the doctor for your diabetes, how often does your doctor tell you when to return for your next diabetes check up?
3
Data Results SA 1.3

Earlier you said that you check your blood for sugar or glucose. Please tell me what steps you take when you find that your blood sugar or glucose is elevated. Include times when you are helped by family members or friends to take those steps. [Mark all that apply]

  • Exercise
  • Take or adjust my does of insulin
  • Go to the nearest emergency room
  • Call my doctor
  • Nothing
  • Other (specify:_____)

4
Data Results SA 1.4

Knowing that you have diabetes, please tell me what steps you take to avoid having an elevated blood sugar.[Mark all that apply]

  • Control carbohydrate intake/awareness of carbohydrate intake
  • Count carbohydrates
  • Exercise
  • Test blood sugar or glucose
  • Adjust medication
  • Nothing
  • Other (specify:_____)

5
Data Results SA 1.5
How often does your doctor ask to see a record of what your blood sugars are at home?
 
State-Added
Module 2: 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.
1
Data Results SA 2.1
How often do you drink fruit juices such as orange, grapefruit, or tomato?
2
Data Results SA 2.2
Not counting juice, how often do you eat fruit?
3
Data Results SA 2.3
How often do you eat green salad?
4
Data Results SA 2.4
How often do you eat potatoes not including French fries, fried potatoes, or potatoes chips?
5
Data Results SA 2.5
How often do you eat carrots?
6
Data Results SA 2.6
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.]
 
State-Added
Module 3: Physical Activity
1
Data Results SA 3.1
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.
2
Data Results SA 3.2
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?
3
Data Results SA 3.3
How many days per week do you do these moderate activities for at least 10 minutes at a time?
4
Data Results SA 3.4
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?
5
Data Results SA 3.5
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?
6
Data Results SA 3.6
How many days per week do you do these vigorous activities for at least 10 minutes at a time?
7
Data Results SA 3.7
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 Optional
Module 3: Hypertension Awareness
1
Data Results Co 3.1
Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?
(If "Yes" and respondent is female, ask: "Was this only when you were pregnant?")
Crosstabulation Table:
2
Data Results Co 3.2
Are you currently taking medicine for your high blood pressure?
 
CDC Module
Module 4: Cholesterol Awareness
1
Data Results CM 4.1
Blood cholesterol is a fatty substance found in the blood. Have you ever had your blood cholesterol checked?
2
Data Results CM 4.2
About how long has it been since you last had your blood cholesterol checked?
3
Data Results CM 4.3
Have you ever been told by a doctor, nurse, or other health professional that your blood cholesterol is high?
Crosstabulation Table:
 
CDC Module
Module 11: Heart Attack and Stroke
Now I would like to ask you about your knowledge of the signs and symptoms of a heart attack and stroke.
1a.
Data Results CM 11.1a
Which of the following do you think is a symptom of a heart attack? For each, tell me yes, no, or you're not sure.
a. Do you think pain or discomfort in the jaw, neck, or back are symptoms of a heart attack?
1b.
Data Results CM 11.1b
b. (Do you think) feeling weak, lightheaded, or faint (are symptoms of a heart attack?)
1c.
Data Results CM 11.1c
c. (Do you think) chest pain or discomfort (are symptoms of a heart attack?)
1d.
Data Results CM 11.1d
d. (Do you think) sudden trouble seeing in one or both eyes (is a symptom of a heart attack?)
1e.
Data Results CM 11.1e
e. (Do you think) pain or discomfort in the arms or shoulder (are symptoms of a heart attack?)
1f.
Data Results CM 11.1f
f. (Do you think) shortness of breath (is a symptom of a heart attack?)
2a.
Data Results CM 11.2a
Which of the following do you think is a symptom of a stroke? For each, tell me yes, no, or you're not sure.
a. Do you think sudden confusion or trouble speaking are symptoms of a stroke?
2b.
Data Results CM 11.2b
b. Do you think sudden numbness or weakness of face, arm, leg, especially on one side, are symptoms of a stroke?
2c.
Data Results CM 11.2c
c. (Do you think) sudden trouble seeing in one or both eyes (is a symptom of a stroke?)
2d.
Data Results CM 11.2d
d. (Do you think) sudden chest pain or discomfort (are symptoms of stroke?)
2e.
Data Results CM 11.2e
e. (Do you think) sudden trouble walking, dizziness, or loss of balance (are symptoms of a stroke?)
2f.
Data Results CM 11.2f
f. (Do you think) severe headache with no known cause (is a symptom of a stroke?)
3.
Data Results CM 11.3
If you thought someone was having a heart attack or stroke, what is the first thing you would do?
 
CDC Module
Module 12: Cardiovascular Disease
1a.
Data Results CM 12.1a
To lower your risk of developing heart disease or stroke, are you.
a. Eating fewer high fat or high cholesterol foods?
1b.
Data Results CM 12.1b
(To lower your risk of developing heart disease or stroke, are you.)
b. Eating more fruits and vegetables?
1c.
Data Results CM 12.1c
(To lower your risk of developing heart disease or stroke, are you.)
c. More physically active?
2a.
Data Results CM 12.2a
Within the past 12 months, has a doctor, nurse, or other health professional told you to.
a. Eat fewer high fat or high cholesterol foods?
2b.
Data Results CM 12.2b
(Within the past 12 months, has a doctor, nurse, or other health professional told you to.)
b. Eat more fruits and vegetables?
2c.
Data Results CM 12.2c
(Within the past 12 months, has a doctor, nurse, or other health professional told you to.)
c. Be more physically active?
3a.
Data Results CM 12.3a
Has a doctor, nurse or other health professional ever told you that you had any of the following?
a. A heart attack, also called a myocardial infarction
Crosstabulation Table:
3b.
Data Results CM 12.3b
(Has a doctor, nurse or other health professional ever told you that you had any of the following?)
b. Angina or coronary heart disease
3c.
Data Results CM 12.3c
(Has a doctor, nurse or other health professional ever told you that you had any of the following?)
c. A stroke
4.
Data Results CM 12.4
At what age did you have your first heart attack?
5.
Data Results CM 12.5
At what age did you have your first stroke?
6.
Data Results CM 12.6
After you left the hospital following your [Fill in (heart attack) if "yes" to Q3a or Q3a and Q3c; fill in (stroke) if "Yes" to Q3c and "No" to Q3a], did you go to any kind of outpatient rehabilitation? This is sometimes called "rehab."
7.
Data Results CM 12.7
Do you take aspirin daily or every other day?
8.
Data Results CM 12.8
Do you have a health problem or condition that makes taking aspirin unsafe for you?
If "Yes," ask "Is this a stomach condition?" [Code upset stomach as stomach problems]
9a.
Data Results CM 12.9a
Why do you take aspirin.
a. To relieve pain?
9b.
Data Results CM 12.9b
(Why do you take aspirin.)
b. To reduce the chance of a heart attack?
9c.
Data Results CM 12.9c
(Why do you take aspirin.)
c. To reduce the chance of a stroke?
 
Part B
State-Added
Module 4: Animal Ownership
1
Data Results SA 4.1
What type of animals are kept as pets in or around your home?
Crosstabulation Table:
2a
Data Results SA 4.2a
How many dogs do you have?
2b
Data Results SA 2b
How many cats do you have?
2c
Data Results SA 2c
How many ferrets do you have?
2d
Data Results SA 2d
How many hamsters, gerbils, guinea pigs, or chinchillas do you have?
2e
Data Results SA 2e
How many prairie dogs do you have?
2f
Data Results SA 2f
How many rats or mice do you have?
2g
Data Results SA 2g
How many rabbits do you have?
2h
Data Results SA 2h
How many pet pigs do you have?
2i
Data Results SA 2i
How many pet birds do you have?
2j
Data Results SA 2j
How many wild birds do you have?
[Examples: eagles, hawks, or sparrows or birds that are being rehabilitated]
2k
Data Results SA 2k
How many wild animals do you have?
[Examples: raccoons, skunks, possums, bats, coyotes, wolves, foxes, bobcats, mountain lions, lynx, squirrels, wood chucks, or ground hogs]
2l
Data Results SA 2l
How many turtles do you have?
2m
Data Results SA 2m
How many snakes do you have?
[Examples: pythons, boa constrictors, asps, vipers, etc.]
2n
Data Results SA 2n
How many lizards do you have?
[Examples: iguanas, dragons, geckos, skinks, anoles, monitors, chameleons, or uromastyx]
2o
Data Results SA 2o
How many other reptiles or amphibians do you have?
[Examples: frogs, toads, mantellas, tortoises, salmanders, newts, or caecilians]
2p
Data Results SA 2p
How many non-human primates such as monkeys or chimpanzees do you have?
[Examples: monkeys, chimpanzees, maqueques, or capuchins]
2q
Data Results SA 2q
How many small exotic cats do you have?
[Examples: bengals, geoffroys, Asian Leopards, or African Servals]
2r
Data Results SA 2r
How many horses or livestock do you have?
[Examples of livestock: cows, goats, pigs, or sheep]
2s
Data Results SA 2s
How many (show specific other response) do you have?
 
State-Added
Module 5: Trust in Medical Providers
The following questions are about how much you trust doctors and the health care system to protect your best interests and also the interests of other people like you. Please indicate how much you agree or disagree with the following statements.
1
Data Results SA 5.1
Most doctors will try to help someone who is sick, even if the person has no way to pay for the care.
2
Data Results SA 5.2
Most doctors will take extra time with their patients when it is necessary to understand the patient's problems.
3
Data Results SA 5.3
Most doctors can be trusted to keep personally sensitive information private.
4
Data Results SA 5.4
Most doctors can be trusted to give patients information on all medical options and not just options that are covered by the health plan.
5
Data Results SA 5.5
Most doctors can be trusted to refer patients to a specialist when needed.
6
Data Results SA 5.6
Most doctors can be trusted to perform necessary medical tests and procedures regardless of cost.
7
Data Results SA 5.7
Most doctors can be trusted to offer high-quality medical care.
8
Data Results SA 5.8
Most doctors would not ask a patient to participate in medical research if they thought it might harm the patient.
 
State-Added
Module 6: Perceived Discrimination
These next questions are about experiences you may have in your day-to-day life. How often do any of the following things happen to you? Would you say this happens: almost every day, at least once a week, a few times a month, a few times a year, less than once a year or never.
1
Data Results SA 6.1
You are treated with less respect than other people are.
2
Data Results SA 6.2
People act as if they think you are not smart.
3
Data Results SA 6.3
People act as if they’re better than you are.
4
Data Results SA 6.4
You are called names or insulted.
5
Data Results SA 6.5
What do you think is the main reason for the negative experiences you have just told me about?
  • Age
  • Gender
  • Race / Ethnicity
  • Religion
  • Weight
  • Sexual Orientation
  • Education or income level
  • Physical disability status
  • Some other aspect of physical appearance
  • No particular reason / Reasons vary too much to say
  • Other (specify: _______ )
 
State-Added
Module 7: Depressive Disorders
1
Data Results SA 7.1
Has a doctor or nurse ever told you that you had depression?
Crosstabulation Table:
2
Data Results SA 7.2
Have you ever taken a prescription medication for depression?
3
Data Results SA 7.3
Have you ever had counseling therapy for depression?
4
Data Results SA 7.4
Have you ever taken any over the counter medications for depression? Over the counter medications are, for example, St. John’s Wort, ginseng, or any herbal medication.
5
Data Results SA 7.5
Have you ever had any other alternative / complementary treatments for depression? Alternative / complementary treatments are, for example, massage, acupuncture, or touch therapy.
6
Data Results SA 7.6
To your knowledge, how helpful is physical activity, such as swimming, jogging, brisk walking, or biking, in improving mood and relieving depression?
7
Data Results SA 7.7
During the past month, have you often been bothered by feeling down, depressed, or hopeless?
8
Data Results SA 7.8
During the past month, have you often been bothered by little interest or pleasure in doing things?
 
CDC Module
Module 14: Other Tobacco Products
1
Data Results CM 14.1
Have you ever used or tried any smokeless tobacco products such as chewing tobacco or snuff?
2
Data Results CM 14.2
Do you currently use chewing tobacco or snuff every day, some days, or not at all?
Crosstabulation Table:
3
Data Results CM 14.3
Do you currently use any tobacco products other than cigarettes, such as cigars, pipes, bidis, kreteks, or any other tobacco product?

NOTE: Bidis are small, brown, hand-rolled cigarettes from India and other southeast Asian countries. Kreteks are clove cigarettes made in Indonesia that contain clove extract and tobacco.
 
State-Added
Module 8: Tobacco Tax
1
Data Results SA 8.1
How much additional tax on a pack of cigarettes would you be willing to support if some or all of the money raised was used to support programs designed to reduce tobacco use?
 
CDC Module
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 CM 9.1
How old were you when you were first told by a doctor, nurse, or other health professional that you had asthma?
2
Data Results CM 9.2
During the past 12 months, have you had an episode of asthma or an asthma attack?
3
Data Results CM 9.3
During the past 12 months, how many times did you visit an emergency room or urgent care center because of your asthma?
4
Data Results CM 9.4
[If one or more visits to Q3, 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?
5
Data Results CM 9.5
During the past 12 months, how many times did you see a doctor, nurse or other health professional for a routine checkup for your asthma?
6
Data Results CM 9.6
During the past 12 months, how many days were you unable to work or carry out your usual activities because of your asthma?
7
Data Results CM 9.7
Symptoms of asthma include cough, wheezing, shortness of breath, chest tightness and phlegm production when you don't have a cold or respiratory infection. During the past 30 days, how often did you have any symptoms of asthma?
8
Data Results CM 9.8
During the past 30 days, how many days did symptoms of asthma make it difficult for you to stay asleep?
9
Data Results CM 9.9
During the past 30 days, how often did you take asthma medication that was prescribed or given to you by a doctor? This includes using an inhaler.
 
State-Added
Module 9: Childhood Asthma
1
Data Results SA 9.1
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 child - oldest, second oldest, etc.] child?
2
Data Results SA 9.2
What is the gender of this child?
3
Data Results SA 9.3
Is the [randomly selected child] child Hispanic or Latino?
4
Data Results SA 9.4
Which one of these groups would you say best represents the race of the [randomly selected child]?
5
Data Results SA 9.5
How are you related to the [randomly selected child]?
6
Data Results SA 9.6
Has the [randomly selected child] ever been diagnosed with asthma?
7
Data Results SA 9.7
Does the [randomly selected child] still have asthma?
Crosstabulation Table:
8
Data Results SA 9.8
During the past 12 months, how many days has the [randomly selected child] missed school or day care because of [his/her] asthma?
 
State-Added
Module 10: Oral Health
1
Data Results SA 10.1
During the past 12 months, was there any time when you needed dental care but did not get it?
2
Data Results SA 10.2
What was the main reason you did not receive the dental care you needed?
3
Data Results SA 10.3
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 10.4
Next, I have a question related to the oral health of children.
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?
Crosstabulation Table: