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 as your personal doctor or health care provider?")
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?
3.4
Data Results 3.4
About how long has it been since you last visited a doctor for a routine checkup? A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.
 
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: Diabetes
5.1
Data Results 5.1
Have you EVER been told by a doctor that you have diabetes?

Note: If respondent says 'pre-diabetes or borderline diabetes', use response Code 4.

(If "Yes" and respondent is female, ask: "Was this only when you were pregnant?")
Crosstabulation Table:
 
 
CDC Core
Section 6: Hypertension Awareness
6.1
Data Results 6.1
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:
6.2
Data Results 6.2
Are you currently taking medicine for your high blood pressure?
 
 
CDC Core
Section 7: Cholesterol Awareness
7.1
Data Results 7.1
Blood cholesterol is a fatty substance found in the blood. Have you EVER had your blood cholesterol checked?
7.2
Data Results 7.2
About how long has it been since you last had your blood cholesterol checked?
7.3
Data Results 7.3
Have you EVER been told by a doctor, nurse, or other health professional that your blood cholesterol is high?
Crosstabulation Table:
 
CDC Core
Section 8: Cardiovascular Disease Prevalence
Has a doctor, nurse or other health professional EVER told you that you had any of the following? For each, tell me "Yes", "No", or you're "Not sure":
8.1
Data Results 8.1
(Ever told you had) a heart attack, also called a myocardial infarction?
8.2
Data Results 8.2
(Ever told you had) angina or coronary heart disease?
8.3
Data Results 8.3
(Ever told you had) a stroke?
 
 
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:
Summary Index Table:
 
 
CDC Core
Section 10: Immunization
10.1
Data Results 10.1
A flu shot is an influenza vaccine injected in your arm. 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:
 
 
 
10.2
Data Results 10.2
During the past 12 months, have you had a flu vaccine that was sprayed in your nose? The flu vaccine that is sprayed in the nose is also called FluMist™.
Immunization Section questions 10.4 through 10.11 were ONLY asked in the months of January and February.
10.4
 
During what month and year did you receive your most recent flu vaccination?
If "Yes" to both Question 10.1 and Question 10.2, also say: "The most recent flu vaccination may have been either the flu shot or the flu spray."
10.5
 
Where did you go to get your most recent [FILL: flu shot/vaccine that was sprayed in your nose/vaccination (whether it was a shot or spray in the nose)]?
Read only if necessary:
  • A doctor's office or health maintenance organization (HMO)
  • A health department
  • Another type of clinic or health center [Example: a community health center]
  • A senior, recreation, or community center
  • A store [Examples: supermarket, drug store]
  • A hospital [Example: in-patient]
  • An emergency room
  • Workplace
  • Some other kind of place
  • Received vaccination in Canada/Mexico (Volunteered: DO NOT READ)
  • Don't know/Not sure (Probe: How would you describe the place where you
    went to get your most recent flu vaccine)?
  • Refused
10.6
 
What is the MAIN reason you have NOT received a flu vaccination for this current flu season?
[Interviewer note: The current flu season = Sept. '04 - Mar. '05]
Do not read answer choices below.
Select category that best matches response.
  • Need: Do not need it
  • Need: Doctor did not recommend it
  • Need: Did not know that I should be vaccinated
  • Need: Flu is not that serious
  • Need: Had the flu already this flu season
  • Concern about vaccine: side effects/can cause flu
  • Concern about vaccine: does not work
  • Access: Plan to get vaccinated later this flu season
  • Access: Flu vaccination costs too much
  • Access: Inconvenient to get vaccinated
  • Vaccine shortage: saving vaccine for people who need it more
  • Vaccine shortage: tried to find vaccine, but could not get it
  • Vaccine shortage: not eligible to receive vaccine
  • Some other reason
  • Don't know/Not sure (Probe: "What was the main reason?")
  • Refused
10.7
 
Did you get a flu vaccination during the ‘last flu season’ in other words during the months of September 2003 through March 2005?
10.3
Data Results 10.3
Have you EVER had a pneumonia shot? A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person's lifetime and is different from the flu shot. Have you ever had a pneumonia shot?
Crosstabulation Tables:
 
 
10.8
 
Has a doctor, nurse, or other health professional ever said that you have any of the following health problems?

Read each problem listed below:
  • Asthma
  • Lung problems, other than asthma
  • Heart problems
  • Diabetes
  • Kidney problems
  • Weakened immune system caused by a chronic illness, such as
    cancer or HIV/AIDS, or medicines, such as steroids
  • Sickle cell anemia or other anemia
10.9
 
Do you still have (this/any of these) problem(s)?
10.10
 
Do you currently work in a health care facility, such as a medical clinic, hospital, or nursing home?
If necessary say: This includes part-time and volunteer work.
10.11
 
Do you have direct face-to-face or hands-on contact with patients as a part of your routine work?
 
 
CDC Core
Section 11: Tobacco Use
11.1
Data Results 11.1
Have you smoked at least 100 cigarettes in your entire life?
[Interviewer: 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:
Summary Index 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
During the past 30 days, have you had at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?
12.2
Data Results 12.2
During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage?
12.3
Data Results 12.3
One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor. During the past 30 days, on the days when you drank, about how many drinks did you drink on the average?
Crosstabulation Table:
12.4
Data Results 12.4
Considering all types of alcoholic beverages, how many times during the past 30 days did you have 5 or more drinks on one occasion?
Crosstabulation Table:
12.5
Data Results 12.5
During the past 30 days, what is the largest number of drinks you had on any occasion?
 
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
State-Added Module 1: Hours Worked
Skipped out of the core to ask the following question.
1.
Data Results SA1.1
Previously, you indicated you were (a) [insert response from core, Question 13.8]. On the average, how many hours per week, if any, do you work at a job or business?
Skip back into core, and continue with the survey.
13.10 About how much do you weigh without shoes?
[Round fractions up]
13.11 About how tall are you without shoes?
[Round fractions down]
Crosstabulation Table:
 
Summary Index Table:
13.12 What county do you live in?
13.13
What is your ZIP Code where you live?
13.14
Data Results 13.14
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.
13.15
Data Results 13.15
How many of these phone numbers are residential numbers?
13.16
Data Results 13.16
During the past 12 months, has your household been without telephone service for 1 week or more? Do not include interruptions of phone service due to weather or natural disasters.
13.17
Data Results 13.17
Indicate sex of respondent. Ask Only if Necessary
13.18
Data Results 13.18
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 in the United States Armed Forces, either in the regular military or in a National Guard or Reserve unit.

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?
 
CDC Core
Section 15: Disability
The following questions are about health problems or impairments you may have.
15.1
Data Results 15.1
Are you limited in any way in any activities because of physical, mental, or emotional problems?
Crosstabulation Table:
15.2
Data Results 15.2
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?
NOTE: Include occasional use or use in certain circumstances.
Crosstabulation Table:
 
CDC Core
Section 16: Arthritis Burden
The next questions refer to the joints in your body. Please do NOT include the back or neck.
16.1
Data Results 16.1
During the past 30 days, have you had symptoms of pain, aching, or stiffness in or around a joint?
16.2
Data Results 16.2
Did your joint symptoms FIRST begin more than 3 months ago?
Crosstabulation Table:
16.3
Data Results 16.3
Have you EVER seen a doctor or other health professional for these joint symptoms?
16.4
Data Results 16.4
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?

INTERVIEWER NOTE: Arthritis diagnoses includes:
  • rheumatism, polymyalgia rheumatica
  • 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:
16.5
Data Results 16.5
Are you now limited in any way in any of your usual activities because of arthritis or joint symptoms?
Note: If a respondent question arises about medication, then the 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:
 
 
CDC Core
Section 17: Fruits and Vegetables
Crosstabulation Table:
Summary Index 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.
17.1
Data Results 17.1
How often do you drink fruit juices such as orange, grapefruit, or tomato?
17.2
Data Results 17.2
Not counting juice, how often do you eat fruit?
17.3
Data Results 17.3
How often do you eat green salad?
17.4
Data Results 17.4
How often do you eat potatoes not including French fries, fried potatoes, or potatoes chips?
17.5
Data Results 17.5
How often do you eat carrots?
17.6
Data Results 17.6
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 18: Physical Activity
18.1
Data Results 18.1
When you are at work, which of the following best describes what you do? Would you say:
  • Mostly sitting or standing
  • Mostly walking
  • Mostly heavy labor or physically demanding work

[NOTE: If respondent has multiple jobs, include all jobs.]
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 1, employed, or 2, self-employed, in Question 13.8] 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:
Summary Index Table:
18.5
Data Results 18.5
Now thinking about the vigorous physical activities you do [fill in "when you are not working" if 1, employed, or 2, self-employed, in Question 13.8] 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: 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 do not have to answer every question if you do not want to. Although we will ask you about testing, we will not ask you about the results of any test you may have had.
19.1
Data Results 19.1
Have you EVER been tested for HIV? Do not count tests you may have had as part of a blood donation.
Include test using fluid from your mouth.
19.2 Not including blood donations, in what month and year was your last HIV test?
Note: If response is before January 1985, code “Don’t know.”
19.3
Data Results 19.3
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, drug treatment facility or somewhere else?
19.4
Data Results 19.4
I am going to read you a list. When I am done, please tell me if any of the situations apply to you. You do not need to tell me which one.

[Please read]:
  • 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?
 
CDC Core
Section 20: Emotional Support and Life Satisfaction
The next two questions are about emotional support and your satisfaction with life.
20.1
Data Results 20.1
How often do you get the social and emotional support you need?
20.2
Data Results 20.2
In general, how satisfied are you with your life?
 
State-Added
Module 15: Public Opinion Regarding Health
Now I would like to ask you some questions regarding your opinion on various health topics.
1
Data Results SA15.1  
How do you feel about laws that require drivers and front seat passengers to wear seat belts? Do you favor these laws a lot, do you favor them some or do you favor these laws not at all?
2
Data Results SA15.2
Do you think that seat belt laws should also apply to back seat adult passengers?
3
Data Results SA15.3
In your opinion, SHOULD police be allowed to stop a vehicle if they observe a seat belt violation when no other traffic laws are being broken?
4
Data Results SA15.4
In some schools, students have their heights and weights measured to determine their level of growth and development, and to identify children who may be overweight or underweight for their age. Do you favor this practice in Kansas schools?
 
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
Summary Index Table:
CDC Module
Module 10: Random Child Selection
If Core Question 13.6 = 88, or 99 (no children under age 18 in the household, or refused), [Go to CDC Module 9 Adult Asthma. If Core Question 13.6 = 1;

INTERVIEWER: "Previously, you indicated there was one child age 17 or younger in your household. I would like to ask you some questions about that child." [Go to Question 1. If Core 13.6 is >1 and Core Question 13.6 does not equal to 88 or 99;

INTERVIEWER: "Previously, you indicated there were [number] children age 17 or younger in your household. Think about those [number] children in order of their birth, from oldest to youngest. The oldest child is the first child and the youngest child is the last child." Please include children with the same birth date, including twins, in the order of their birth.
INTERVIEWER: "I have some additional questions about one specific child. The child I will be referring to is the "X"th child in your household. All following questions about children will be about the "Xth" child."

Note: If there are two children with the same birth date, randomly select one.
1
Data Results M10.1
What is the birth month and year of the “Xth” child?
2
Data Results M10.2
Is the child a boy or a girl?
3
Data Results M10.3
Is the child Hispanic or Latino?
4
Data Results M10.4
Which one or more of the following would you say is the race of the child?
[Check all that apply]
5
Data Results M10.5
Which one of these groups would you say best represents the child's race?
6
Data Results M10.6
How are you related to the child?
 
CDC Module
Module : Child Immunization Supplement-Flu Vaccination Shortage
This section (questions 1 through 7) were ONLY asked in the months of January and February.
1
 
Has a doctor, nurse, or other health professional ever said that [Fill: he/she] has any of the following health problems?

Read each problem listed below:
  • Asthma
  • Lung problems, other than asthma
  • Heart problems
  • Diabetes
  • Kidney problems
  • Weakened immune system caused by a chronic illness, such as cancer or HIV/AIDS, or medicines, such as steroids
  • Must take aspirin every day
  • Sickle cell anemia or other anemia
2
 
Does [Fill: he/she] still have (this/any of these) problem(s)?
3
 
If child is less than 6 months old, go to next module otherwise ask: During the past 12 months, has [Fill: he/she] had a flu shot? A flu shot is a flu vaccine injected in a child's arm or thigh.
4
 
During the past 12 months, has [Fill: he/she] had a flu vaccine sprayed in the nose? The flu vaccine that is sprayed in the nose is FluMist™ .
5
 
During what month and year did [Fill: he/she] receive the most recent flu vaccination?
If "Yes" to both Question 3 and Question 4, also say: "The most recent flu vaccination may have been either the flu shot or the flu spray."
6
 
What is the MAIN reason [Fill: he/she] has not received a flu vaccination for this current flu season?
[Interviewer note: The current flu season = Sept. '04 - Mar. '05]
7
 
If Random Child Selection Question 1 date is 06/2003 to present, go to next module; if Question 5 is 09/2003 to 03/2005 go next module, otherwise continue.: Did [Fill: he/she] get the flu vaccine during the 'last flu season' in other words during the months of September 2003 through March 2005?
 
 
CDC Module
Module 11: Childhood Asthma Prevalence
The next two questions are about the "Xth" child.
1
Data Results M11.1
Has a doctor, nurse, or other health professional EVER said that the child has asthma?
2
Data Results M11.2
Does the child still have asthma?
Crosstabulation Table:
 
 
State-Added
Module 2: Childhood Asthma
1
Data Results SA2.1
During the past 12 months, how many days has the [randomly selected child] missed school or day care because of [his/her] asthma?
 
 
CDC Module
Module 9: Adult Asthma History
Previously you said that you were told by a doctor, nurse, or other health professional that you had asthma.
1
Data Results M9.1
How old were you when you were first told by a doctor,or other health professional that you had asthma?
2
Data Results M9.2
During the past 12 months, have you had an episode of asthma or an asthma attack?
3
Data Results M9.3
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 M9.4
[If one or more visits to Question 3, 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 M9.5
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 M9.6
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 M9.7
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 M9.8
During the past 30 days, how many days did symptoms of asthma make it difficult for you to stay asleep?
9
Data Results M9.9
During the past 30 days, how many days did you take a prescription asthma medication to PREVENT an asthma attack from occurring?
10
Data Results M9.10
During the past 30 days, how often did you use a prescription asthma inhaler DURING AN ASTHMA ATTACK to stop it?

INTERVIEWER INSTRUCTION: How often (number of times) does NOT equal number of puffs. Two to three puffs are usually taken each time the inhaler is used.
 
 
CDC Module
Module 16: Osteoporosis
Osteoporosis (os-tee-oh-por-o-sis) is a condition where bones become brittle and break (fracture) more easily. It is not the same condition as osteoarthritis, a joint disease.
1
Data Results M16.1
Have you EVER been told by a doctor, nurse, or other health professional that you have osteoporosis?
Crosstabulation Table:
 
CDC Module
Module 17: Arthritis Management
1
Data Results M17.1
Earlier you indicated that you had arthritis or joint symptoms. Thinking about your arthritis or joint symptoms, which of the following best describes you TODAY?
2
Data Results M17.2
Has a doctor or other health professional EVER suggested losing weight to help your arthritis or joint symptoms?
3
Data Results M17.3
Has a doctor or other health professional EVER suggested physical activity or exercise to help your arthritis or 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 M17.4
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 3: Chronic Joint Symptoms and Possible Arthritis
Earlier you indicated that you have had pain, aching, or stiffness, in or around a joint. We have a few additional questions about your joints.
1
Data Results SA3.1
How many months or years ago did those joint symptoms first begin?
2
Data Results SA3.2
Were those symptoms present on most days for at least one month?
3
Data Results SA3.3
Over the past 7 days, how many days have you had pain, aching, or stiffness from arthritis or joint symptoms?
4
Data Results SA3.4
On a scale of 0 to 10 where 0 is no pain or aching and 10 is pain or aching as bad as it could be, over the past 7 days, how bad was your joint pain or aching ON AVERAGE.
5
Data Results SA3.5
Tell me which joints are affected?
Note to Interviewer: check all that apply - [Do not read]: Notice list of joints below goes from top of body to bottom.
  • Neck
  • Shoulder
  • Elbow
  • Wrist
  • Hand
  • Fingers/thumb
  • Back
  • Hip
  • Knee
  • Ankle
  • Foot
  • Toes
  • Other Joint (specify)
6
Data Results SA3.6
Have you taken any prescription or non-prescription medication for these joint symptoms in the past 7 days?
Interviewer instruction: If the words or concept used by the respondent do not match the categories below exactly, please code OTHER SPECIFY and record the respondent's words verbatim.
7a
Data Results SA3.7a
Earlier you said you had never seen a doctor about your joint symptoms.
Please tell me why you did not see a doctor about your joint symptoms?
  • not that bad/ not serious/ not important
  • costs too much/ no insurance
  • don't like doctors/ didn't want to go
  • self treatment works
  • just occurred/ going to doctor soon
  • no transportation/ too far
  • other specify _______________
Interviewer instruction: If the words or concept used by the respondent do not match the categories below exactly, please code OTHER SPECIFY and record the respondent's words verbatim.
7b
Data Results SA3.7b
Earlier you said you had seen a doctor for your joint symptoms. What did the doctor say was the cause of your joint symptoms?
  • injury/ work-related
  • bursitis/ tendonitis/ tennis elbow/ carpal tunnel
  • bone spurs
  • doctor didn't say/ doctor didn't know
  • cartilage
  • body weight
  • age
  • other specify ________
 
 
State-Added
Module 4: Preventive Counseling - Skin cancer
1
Data Results SA4.1
Have you ever had all of your skin from head to toe checked for cancer either by a dermatologist or some other kind of doctor?
[Interviewer note: If asked, 'A dermatologist is a doctor who specializes in skin diseases'.]
If 'Yes' probe for how long ago
2
Data Results SA4.2
When you go outside on a very sunny day, for more than one hour, how often do you stay in the shade?
3
Data Results SA4.3
When you go outside on a very sunny day, for more than one hour, how often do you wear a hat that shades your face, ears, and neck?
[READ IF NECESSARY] Do not include visors, baseball caps, or hats that do not shade the ears and neck.
4
Data Results SA4.4
When you go outside on a very sunny day, for more than one hour, how often do you wear a long sleeved shirt?
5
Data Results SA4.5
When you go outside on a very sunny day, for more than one hour, how often do you use sunscreen?
6
Data Results SA4.6
Have you used a sun lamp or tanning bed in the past 12 months?
7
Data Results SA4.7
Has a doctor, nurse, or other health professional ever advised or discussed with you about taking protective measures against skin cancer. Protective measures include use of sunscreen, protective clothing and avoiding exposure to sunlamps or tanning beds.
If 'Yes', probe for how long ago
 
State-Added
Module 5: Epilepsy and Seizure Disorder
1
Data Results SA5.1
Have you ever been told by a doctor that you have a seizure disorder or epilepsy?
 
State-Added
Module 6: 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.
1
Data Results SA6.1
In the past 3 months, have you had a fall?
2
Data Results SA6.2
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.
 
State-Added
Module 7: 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.
1
Data Results SA7.1
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".
2
Data Results SA7.2
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".
 
State-Added
Module 8: Outdoor Air Quailty and Activity
1
Data Results SA8.1
Please think of the past 12 months. How many times did you reduce or change your outdoor activity level because you thought the air quality was bad or was affecting how well you felt? For example, avoiding outdoor exercise or strenuous outdoor activity. Please do not include times when you made changes because of high pollen levels.
2
Data Results SA8.2
The government routinely collects information on air quality that may be distributed by local radio, TV and newspapers to help inform the public about air pollution levels. Have you ever heard or read about the air quality index or air quality alerts where you live? Please do not include times when you may have heard or read about high pollen counts.
3
Data Results SA8.3
Please think of the past 12 months. How many times did you reduce or change your outdoor activity level based on the air quality index or air quality alerts? For example, avoiding outdoor exercise or strenuous outdoor activity. Please do not include times when you may have heard or read about high pollen counts.
4
Data Results SA8.4
Has a doctor, nurse, or other health professional ever told you to reduce your outdoor activity level when the air quality is bad?
 
State-Added
Module 9: Seatbelts
1
Data Results SA9.1
How often do you use seat belts when you drive or ride in a car?
Crosstabulation Table:
 
State-Added
Module 10: Motor Vehicle Occupant Safety
If randomly selected child is less than 10 years of age, continue with Question 1.

If randomly selected child is 10 years of age or older, skip to Question 2.
Early, I asked you questions about the [randomly selected child]. Now I have some additional questions.
1
Data Results SA10.1
When the [randomly selected] child rides in the vehicle with you, how often does [he/she] ride in a child car seat? Child car seats include infant seats, toddler seats, and booster seats. Would you say [he/she] rides in a child car seat...

[Please read]:
  • All of the time
  • Most of the time
  • Some of the time
  • Rarely
  • Never
  • Child does not ride in vehicle / Does not ride with respondent
2
Data Results SA10.2
When the [randomly selected] child rides with you [if Q1 ="Most of the time" "Some of the time" or "Rarely" then insert] and is not riding in a child car seat how often is [he/she] buckled in a seat belt?
If child is 10 years of age or older and Question 2 = 'All of the time', 'Most of the time', 'Some of the time' or 'Rarely', then skip to Question 5.

If child is 10 years of age or older and Question 2 = 'Never' then skip to Question 6.

If child is less than 10 years of age and Question 1 = 'Never' and Question 2 = 'Never', skip to Question 6.

If child is less than 10 years of age and if Question 1 = 'Never' and Question 2 = 'All of the time', 'Most of the Time', 'Some of the time' or 'Rarely', skip to Question 5.
3
Data Results SA10.3
There are many different kinds of child safety seats. Does the child seat have harness straps that go over the shoulders and buckle between the legs? Do not count straps from seat belt.
4
Data Results SA10.4
Would you describe this seat as a booster seat? A booster seat raises the child up and the seatbelt usually goes across both the child and the seat to hold the child in place.
5
Data Results SA10.5
Does the vehicle seat belt the child usually wears go across the shoulder only, across the lap only, or across both the shoulder and lap?
[Interviewer note: Include times when child is in a booster seat]
6
Data Results SA10.6
When the [randomly selected] child rides in the vehicle with you, does [he/she] usually ride in the front seat or back seat?
 
Part B
Summary Index Table:
CDC Optional
Module 1: Diabetes
1
Data Results M1.1
How old were you when you were told you have diabetes?
2
Data Results M1.2
Are you now taking insulin?
3
Data Results M1.3
Are you now taking diabetes pills?
4
Data Results M1.4
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 M1.5
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 M1.6
Have you EVER had any sores or irritations on your feet that took more than four weeks to heal?
7
Data Results M1.7
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 M1.8
A test for "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 "A one C" ?
9
Data Results M1.9
About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?
10
Data Results M1.10
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 M1.11
Has a doctor EVER told you that diabetes has affected your eyes or that you had retinopathy?
12
Data Results M1.12
Have you EVER taken a course or class in how to manage your diabetes yourself?
 
 
State-Added
Module 11: Diabetes Accessory
1
Data Results SA11.1
When you go to your doctor or other health professional for your diabetes, are you usually told to remove your socks and shoes before you see the doctor or other health professional?
2
Data Results SA11.2
How often are you told to remove your socks and shoes before you see the doctor or other health professional for your diabetes? Would you say always, nearly always, sometimes, or seldom?
3
Data Results SA11.3
When you go to the doctor or other health professional for your diabetes, how often does your doctor or other health professional tell you when to return for your next diabetes check-up?
4
Data Results SA11.4
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:_____)
5
Data Results SA11.5
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:_____)
6
Data Results SA11.6
How often does your doctor ask to see a record of what your blood sugars are at home?
 
 
CDC Module
Module 21: Smoking Cessation
Previously you said you have smoked cigarettes:
1.
Data Results M21.1
About how long has it been since you last smoked cigarettes?
The next questions are about interactions you might have had with a doctor, nurse, or other health professional.
2.
Data Results M21.2
In the last 12 months, how many times have you seen a doctor, nurse or other health professional to get any kind of care for yourself?
3.
Data Results M21.3
In the last 12 months, on how many visits were you advised to quit smoking by a doctor or other health provider?
4.
Data Results M21.4
On how many visits did your doctor, nurse or other health professional recommend or discuss medication to assist you with quitting smoking, such as nicotine gum, patch, nasal spray, inhaler, lozenge, or prescription medication such as Wellbutrin/Zyban/Bupropion?

(Pronunciation: Well BYOU trin/ZEYE ban/byou PRO pee on)
5.
Data Results M21.5
On how many visits did your doctor or health provider recommend or discuss methods and strategies other than medication to assist you with quitting smoking?
 
 
CDC Module
Module 22: Secondhand Smoke Policy
1.
Data Results M22.1
Which statement best describes the rules about smoking inside your home?
2.
Data Results M22.2
While working at your job, are you indoors most of the time?
3.
Data Results M22.3
Which of the following best describes your place of work's official smoking policy for indoor public or common areas, such as lobbies, rest rooms, and lunch rooms?

Note: For workers who visit clients or work at home, "place of work" means their base location. For self-employed persons who work at home, the official smoking policy means the home smoking policy.
4.
Data Results M22.4
Which of the following best describes your place of work’s official smoking policy for work areas?
 
 
State-Added
Module 12: Secondhand Smoke Work Policy
If response to Core Q13.8 = 5 (homemaker), 6 (student), or 7 (retired) AND if response to State-Added Module 1 Q1 is 10 or more, ask the following questions.
1
Data Results SA12.1
While working at your job, are you indoors most of the time?
2
Data Results SA12.2
Which of the following best describes your place of work’s official smoking policy for indoor public or common areas, such as lobbies, rest rooms, and lunch rooms?

Note: For workers who visit clients or work at home, “place of work” means their base location. For self-employed persons who work at home, the official smoking policy means the home smoking policy.
3
Data Results SA12.3
Which of the following best describes your place of work’s official smoking policy for work areas?
 
 
CDC Module
Module 5: Cardiovascular Health
I would like to ask you a few more questions about your cardiovascular or heart health.
1.
Data Results M5.1
After you left the hospital following your heart attack did you go to any kind of outpatient rehabilitation? This is sometimes called "rehab."
2.
Data Results M5.2
After you left the hospital following your stroke did you go to any kind of outpatient rehabilitation? This is sometimes called "rehab."
3.
Data Results M5.3
Do you take aspirin daily or every other day?
4.
Data Results M5.4
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.
 
 
CDC Module
Module 6: Actions to Control High Blood Pressure
Are you now doing any of the following to help lower or control your high blood pressure:
1.
Data Results M6.1
(Are you) changing your eating habits (to help lower or control your high blood pressure)?
2.
Data Results M6.2
(Are you) cutting down on salt (to help lower or control your high blood pressure)?
3.
Data Results M6.3
(Are you) reducing alcohol use (to help lower or control your high blood pressure)?
4.
Data Results M6.4
(Are you) exercising (to help lower or control your high blood pressure)?
Has a doctor or other health professional EVER advised you to do any of the following to help lower or control your high blood pressure:
5.
Data Results M6.5
(Ever advised you to) change your eating habits (to help lower or control your high blood pressure)?
6.
Data Results M6.6
(Ever advised you to) cut down on salt (to help lower or control your high blood pressure)?
7.
Data Results M6.7
(Ever advised you to) reduce alcohol use (to help lower or control your high blood pressure)?
8.
Data Results M6.8
(Ever advised you to) exercise (to help lower or control your high blood pressure)?
9.
Data Results M6.9
(Ever advised you to) take medication (to help lower or control your high blood pressure)?
10.
Data Results M6.10
Were you told on two or more different visits to a doctor or other health professional that you had high blood pressure?

If “Yes” and respondent is female, ask: “Was this only when you were pregnant?”
Crosstabulation Table:
 
CDC Module
Module 7: 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.
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.
1.
Data Results M7.1

Do you think pain or discomfort in the jaw, neck, or back are symptoms of a heart attack?
2.
Data Results M7.2
Do you think feeling weak, lightheaded, or faint are symptoms of a heart attack?
3.
Data Results M7.3
Do you think chest pain or discomfort are symptoms of a heart attack?
4.
Data Results M7.4
Do you think sudden trouble seeing in one or both eyes (is a symptom of a heart attack)?
5.
Data Results M7.5
Do you think pain or discomfort in the arms or shoulder are symptoms of a heart attack?
6.
Data Results M7.6
Do you think shortness of breath (is a symptom of a heart attack)?
Which of the following do you think is a symptom of a stroke? For each, tell me yes, no, or you're not sure.
7.
Data Results M7.7
Do you think sudden confusion or trouble speaking are symptoms of a stroke?
8.
Data Results M7.8
Do you think sudden numbness or weakness of face, arm, leg, especially on one side, are symptoms of a stroke?
9.
Data Results M7.9
Do you think sudden trouble seeing in one or both eyes is a symptom of a stroke?
10.
Data Results M7.10
Do you think sudden chest pain or discomfort are symptoms of stroke?
11.
Data Results M7.11
Do you think sudden trouble walking, dizziness, or loss of balance are symptoms of a stroke?
12.
Data Results M7.12
Do you think severe headache with no known cause is a symptom of a stroke?
13.
Data Results M7.13
If you thought someone was having a heart attack or stroke, what is the first thing you would do?
 
State-Added Module
Module 13: Durable Power of Attorney for Health Care Decisions
1.
Data Results SA13.1
Have you completed a Durable Power of Attorney for Health Care Decisions? This is a legal document that allows you to name someone to make health care decisions for you if you should ever become unable to speak for yourself?

[Interviewer note: If asked “This is different from a Living Will”]

 
State-Added Module
Module 14: Chronic Pain
1.
Data Results SA14.1
Do you suffer from any type of chronic pain, that is pain that occurs constantly or flares up frequently?
Crosstabulation Table:
2.
Data Results SA14.2
Is this pain caused by cancer of any type?
3.
Data Results SA14.3
How long have you been experiencing this type of pain?
4.
Data Results SA14.4
About how often do you experience this pain? Would you say...

[Please read]:
  • It is constant, always there
  • At least once a day
  • At least once a week
  • Not ever week, but at least once a month
  • Less often
5.
Data Results SA14.5
Using a 1 to 10 scale where 1 means no pain at all and 10 means the worst pain imaginable, how severe would you say your pain has been on average over the past three months?
6.
Data Results SA14.6
Have you ever seen or talked to your doctor about your pain?
7.
Data Results SA14.7
How satisfied are you with how your doctor is helping you manage your pain?