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:
Summary Index 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
Now I would like to ask you some questions about cardiovascular disease.
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?
Crosstabulation Table:
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
Summary Index Table:
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
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™.
10.3
Data Results 10.3
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 Table:
10.4
Data Results 10.4
Have you EVER received the hepatitis B vaccine? The hepatitis B vaccine is completed after the third shot is given.
INTERVIEWER NOTE: Response is "Yes" only if respondent has received the entire series of three shots.
10.5
Data Results 10.5
The next question is about behaviors related to Hepatitis B.

Tell me if ANY of these statements is true for YOU. Do NOT tell me WHICH statement or statements are true for you, just if ANY of them are:
  • You have hemophilia and have received clotting factor concentrate
  • You have had sex with a man who has had sex with other men, even just one time
  • You have taken street drugs by needle, even just one time
  • You traded sex for money or drugs, even just one time
  • You have tested positive for HIV
  • You have had sex (even just one time) with someone who would answer "yes" to any of these statements
  • You had more than two sex partners in the past year

Are any of these statements true for you?
 
 
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?
 
CDC Core
Section 12: Demographics
12.1
Data Results 12.1
What is your age?
12.2
Data Results 12.2
Are you of Hispanic or Latino?
12.3
Data Results 12.3
Which one or more of the following would you say is your race?
12.4
 
Which one of these groups would you say BEST represents your race?
12.5
Data Results 12.5
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? Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.
12.6
Data Results 12.6
Are you:
  • Married
  • Divorced
  • Widowed
  • Separated
  • Never been married
  • A member of an unmarried couple
12.7
Data Results 12.7
How many children less than 18 years of age live in your household ?
12.8
Data Results 12.8
What is the highest grade or year of school you completed?
12.9
Data Results 12.9
Are you currently:
  • Employed for wages
  • Self-employed
  • Out of work for more than 1 year
  • Out of work for less than 1 year
  • Homemaker
  • Student
  • Retired
  • Unable to work
12.10
Data Results 12.10
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 11.8]. 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.
12.11 About how much do you weigh without shoes?
[Round fractions up]
12.12 About how tall are you without shoes?
[Round fractions down]
Crosstabulation Table:
Summary Index Table:
12.13 How much did you weigh a year ago? [Female respondent: If you were pregnant a year ago, how much did you weigh before your pregnancy?]
12.14 Was the change between your current weight and your weight a year ago intentional?
12.15 What county do you live in?
12.16
 
What is your ZIP Code where you live?
12.17
Data Results 12.17
Do you have more than one telephone number in your household?
Do not include cell phones or numbers that are only used by a computer or
fax machine.
12.18
Data Results 12.18
How many of these phone numbers are residential numbers?
12.19
Data Results 12.19
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.
12.20
Data Results 12.20
Indicate sex of respondent. Ask Only if Necessary
12.21
Data Results 12.21
To your knowledge, are you now pregnant?
 
CDC Core
Section 13: Alcohol Consumption
13.1
Data Results 13.1
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?
13.2
Data Results 13.2
During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage?
13.3
Data Results 13.3
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:
13.4
Data Results 13.4
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:
13.5
Data Results 13.5
During the past 30 days, what is the largest number of drinks you had on any occasion?
 
CDC Core
Section 14: Disability
The following questions are about health problems or impairments you may have.
14.1
Data Results 14.1
Are you limited in any way in any activities because of physical, mental, or emotional problems?
Crosstabulation Table:
14.2
Data Results 14.2
Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?
Include occasional use or use in certain circumstances.
Crosstabulation Table:
 
 
CDC Core
Section 15: Arthritis Burden
The next questions refer to the joints in your body. Please do NOT include the back or neck.
15.1
Data Results 15.1
During the past 30 days, have you had 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?

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:
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 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 16: 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.
16.1
Data Results 16.1
How often do you drink fruit juices such as orange, grapefruit, or tomato?
16.2
Data Results 16.2
Not counting juice, how often do you eat fruit?
16.3
Data Results 16.3
How often do you eat green salad?
16.4
Data Results 16.4
How often do you eat potatoes not including French fries, fried potatoes, or potatoes chips?
16.5
Data Results 16.5
How often do you eat carrots?
16.6
Data Results 16.6
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 17: Physical Activity
17.1
Data Results 17.1
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.
17.2
Data Results 17.2
Now, thinking about the moderate physical activities you do [fill in "when you are not working" if "employed" or "self-employed"] 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?
17.3
Data Results 17.3
How many days per week do you do these moderate activities for at least 10 minutes at a time?
17.4
Data Results 17.4
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:
17.5
Data Results 17.5
Now thinking about the vigorous physical activities you do [fill in "when you are not working" if "employed or "self-employed"] 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?
17.6
Data Results 17.6
How many days per week do you do these vigorous activities for at least 10 minutes at a time?
17.7
Data Results 17.7
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 18: HIV/AIDS
If respondent is 65 years old or older, go to next section.
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.
18.1
Data Results 18.1
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.
18.2 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.”
18.3
Data Results 18.3
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?
18.4
Data Results 18.4
Was it a rapid test where you could get your results within a couple of hours?
 
CDC Core
Section 19: Emotional Support and Life Satisfaction
The next two questions are about emotional support and your satisfaction with life.
19.1
Data Results 19.1
How often do you get the social and emotional support you need?

INTERVIEWER NOTE: If asked, say "please include support from any source".
19.2
Data Results 19.2
In general, how satisfied are you with your life?
 
CDC Core
Section 20: Gastrointestinal Disease
Now I would like to ask you some questions about diarrhea that you may have experienced and about medical care you sought for your diarrheal illness.
20.1
Data Results 20.1
In the past 30 days, did you have diarrhea that began within the 30 day period? Diarrhea is defined as 3 or more loose stools in a 24-hour period.
20.2
Data Results 20.2
Did you visit a doctor, nurse or other health professional for this diarrheal illness?

Note: Do not answer "Yes" if you just had telephone contact with a health professional.
20.3
Data Results 20.3
When you visited your health care professional, did you provide a stool sample for testing?
 
CDC Module
Module 1: Random Child Selection

If Core Question 12.7 = 88, or 99 (no children under age 18 in the household, or refused), go to next module.

If Core Question 12.7 = 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 Q1]

If Core 12.7 is >1 and Core Question 12.7 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 M1.1
What is the birth month and year of the “Xth” child?
2
Data Results M1.2
Is the child a boy or a girl?
3
Data Results M1.3
Is the child Hispanic or Latino?
4
Data Results M1.4
Which one or more of the following would you say is the race of the child?
[Check all that apply]
5
Data Results M1.5
Which one of these groups would you say best represents the child's race?
6
Data Results M1.6
How are you related to the child?
 
CDC Module
Module 2: Childhood Asthma Prevalence
If response to Core Q12.7 = 88 (None) or 99 (Refused), go to next module.
The next two questions are about the "Xth" child.
1
Data Results M2.1
Has a doctor, nurse, or other health professional EVER said that the child has asthma?
2
Data Results M2.2
Does the child still have asthma?
Crosstabulation Table:
 
 
State-Added
Module 2: Asthma Call Back Survey Information
If Q8.1 = ‘yes” or Childhood Asthma Prevalence Module Q1 = ‘Yes’ and Random Child Selection Module Q6 = “Parent” (1) or “Foster parent or guardian” (3) then continue. Otherwise, go to next module.
1
We would like to call you again within the next 2 weeks to talk in more detail about [your/your child's] experiences with asthma. The information will be used to help develop and improve the quality of life of Kansans with asthma. The information you gave us today and any you give us in the future will be kept confidential. If you agree to this, we will keep your first name or initials and phone number on file, separate from the answers collected today. Even if you agree now, you may refuse to participate in the future.

Would it be okay if we called you back to ask additional asthma-related questions at a later time?
 
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 Optional
Module 3: Diabetes
1
Data Results M3.1
How old were you when you were told you have diabetes?
2
Data Results M3.2
Are you now taking insulin?
3
Data Results M3.3
Are you now taking diabetes pills?
4
Data Results M3.4
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 M3.5
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 M3.6
Have you EVER had any sores or irritations on your feet that took more than four weeks to heal?
7
Data Results M3.7
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 M3.8
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 M3.9
About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?
10
Data Results M3.10
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 M3.11
Has a doctor EVER told you that diabetes has affected your eyes or that you had retinopathy?
12
Data Results M3.12
Have you EVER taken a course or class in how to manage your diabetes yourself?
 
 
State-Added
Module 3: Diabetes Accessory
1
Data Results SA3.1
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?
2
Data Results SA3.2
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:_____)
3
Data Results SA3.3
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:_____)
 
 
State-Added
Module 4: Diabetes Assessment
1
Data Results SA4.1

Which of the following family members, if any, have been told by a doctor that they have diabetes? Include only blood relatives. Do not include adoptive or those related only by marriage.

  • Mother
  • Father
  • Brothers [Interviewer note: include half brother]
  • Sisters [Interviewer note: include half sister]
  • No one

If respondent is female, continue.
2
Data Results SA4.2
Have you had a baby weighing more then 9 pounds at birth?
 
 
CDC Module
Module 6: Cardiovascular Health
I would like to ask you a few more questions about your cardiovascular or heart heath.
NOTE: If Core Q8.1 = 1 (Yes), ask Q1. If Core Q8.1 = 2, 7, or 9, skip Q2.
1
Data Results M6.1
After you left the hospital following your heart attack did you go to any kind of outpatient rehabilitation? This is sometimes called "rehab."
NOTE: If Core Q8.3 = 1 (Yes), ask Q2. If Core Q8.3 = 2, 7, or 9 (No, Don't know, or Refused), go to Q3.
2
Data Results M6.2
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 M6.3
Do you take aspirin daily or every other day?
4
Data Results M6.4
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 7: Actions to Control High Blood Pressure
NOTE: If Core Q6.1 = 1 (Yes); continue. Otherwise, go to next module.
Are you now doing any of the following to help lower or control your high blood pressure?
1
Data Results M7.1
(Are you) changing your eating habits (to help lower or control your high blood pressure)?
2
Data Results M7.2
(Are you) cutting down on salt (to help lower or control your high blood pressure)?
3
Data Results M7.3
(Are you) reducing alcohol use (to help lower or control your high blood pressure)?
4
Data Results M7.4
(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 M7.5
(Ever advised you to) change your eating habits (to help lower or control your high blood pressure)?
6
Data Results M7.6
(Ever advised you to) cut down on salt (to help lower or control your high blood pressure)?
7
Data Results M7.7
(Ever advised you to) reduce alcohol use (to help lower or control your high blood pressure)?
8
Data Results M7.8
(Ever advised you to) exercise (to help lower or control your high blood pressure)?
9
Data Results M7.9
(Ever advised you to) take medication (to help lower or control your high blood pressure)?
10
Data Results M7.10
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 8: 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 M8.1
(Do you think) pain or discomfort in the jaw, neck, or back (are symptoms of a heart attack?)
2
Data Results M8.2
(Do you think) feeling weak, lightheaded, or faint (are symptoms of a heart attack?)
3
Data Results M8.3
(Do you think) chest pain or discomfort (are symptoms of a heart attack?)
4
Data Results M8.4
(Do you think) sudden trouble seeing in one or both eyes (is a symptom of a heart attack?)
5
Data Results M8.5
(Do you think) pain or discomfort in the arms or shoulder (are symptoms of a heart attack?)
6
Data Results M8.6
(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 M8.7
(Do you think) sudden confusion or trouble speaking (are symptoms of a stroke?)
8
Data Results M8.8
(Do you think) sudden numbness or weakness of face, arm, or leg, especially on one side, (are symptoms of a stroke?)
9
Data Results M8.9
(Do you think) sudden trouble seeing in one or both eyes (is a symptom of a stroke?)
10
Data Results M8.10
(Do you think) sudden chest pain or discomfort (are symptoms of a stroke?)
11
 
(Do you think) sudden trouble walking, dizziness, or loss of balance (are symptoms of a stroke?)
12
Data Results M8.12
(Do you think) severe headache with no known cause (is a symptom of a stroke?)
13
Data Results M8.13
If you thought someone was having a heart attack or a stroke, what is the first thing you would do?
  • Take them to the hospital
  • Tell them to call their doctor
  • Call 911
  • Call their spouse or a family member
  • Do something else
 
 
CDC Module
Module 16: Mental Illness and Stigma
Now, I am going to ask you some questions about how you have been feeling during the past 30 days...
1
Data Results M16.1
About how often during the past 30 days did you feel nervous - would you say all of the time, most of the time, some of the time, a little of the time, or none of the time?
2
Data Results M16.2
During the past 30 days, about how often did you feel hopeless - would you say all of the time, most of the time, some of the time, a little of the time, or none of the time?
3
Data Results M16.3
During the past 30 days, about how often did you feel restless or fidgety?

[IF NECESSARY: all, most, some, a little, or none of the time?]
4
Data Results M16.4
During the past 30 days, about how often did you feel so depressed that nothing could cheer you up?

[IF NECESSARY: all, most, some, a little, or none of the time?]
5
Data Results M16.5
During the past 30 days, about how often did you feel that everything was an effort?

[IF NECESSARY: all, most, some, a little, or none of the time?]
6
Data Results M16.6
During the past 30 days, about how often did you feel worthless?

[IF NECESSARY: all, most, some, a little, or none of the time?]
[If all answers to Q1 through Q6 = "A little" or "None", skip next question]

The next question asks if any type of mental health condition or emotional problem has recently kept you from doing your work or other usual activities.
7
Data Results M16.7
During the past 30 days, for about how many days did a mental health condition or emotional problem keep you from doing your work or other usual activities?

[INTERVIEWER NOTE: If asked, "usual activities" includes housework, self-care, care giving, volunteer work, attending school, studies, or recreation]
8
Data Results M16.8
Are you now taking medicine or receiving treatment from a doctor or other health professional for any type of mental health condition or emotional problem?
These next questions ask about peoples' attitudes toward mental illness and its treatment.
How much do you agree or disagree with these statements about people with mental illness…

[INTERVIEWER NOTE: If asked for the purpose of Q9 or Q10: Answers to these questions will be used by health planners to help understand public attitudes about mental illness and its treatment and to help guide health education programs].
9
Data Results M16.9
Treatment can help people with mental illness lead normal lives.
Do you - agree slightly or strongly, or disagree slightly or strongly?
10
Data Results M16.10
People are generally caring and sympathetic to people with mental illness.
Do you - agree slightly or strongly, or disagree slightly or strongly?
 
 
Part B
Summary Index Table:
CDC Module
Module 13: Arthritis Management
NOTE: If Core Q15.2 or Q15.4 = 1 (Yes), continue. Otherwise, go to next module.
1.
Data Results M13.1
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?
  • I can do everything I would like to do
  • I can do most things I would 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 M13.2
Has a doctor or other health professional EVER suggested losing weight to help your arthritis or joint symptoms?
3.
Data Results M13.3
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 M13.4
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 5: Chronic Pain
NOTE: If Core Q15.2 or Q15.4 = 1 (Yes), continue. Otherwise, go to next module.
1.
Data Results SA5.1
Do you suffer from any type of chronic pain, that is pain that occurs constantly or flares up frequently?
Crosstabulation Table:
2.
Data Results SA5.2
How long have you been experiencing this type of pain?
3.
Data Results SA5.3
About how often do you experience this pain? Would you say:
  • Its constant, always there
  • At least once a day
  • At least once a week
  • Over 1 year to 3 years
  • Not every week but at least once a month
  • Less often
4.
Data Results SA5.4
Using a 0 to 10 scale where 0 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?
5.
Data Results SA5.5
Have you ever seen or talked to your doctor about your pain?
6.
Data Results SA5.6
What did the doctor say was the cause of this pain?
7.
Data Results SA5.7
How satisfied are you with how your doctor is helping you manage your pain?
8.
Data Results SA5.8
What kind of medication are you currently taking to treat your pain? Are you taking:
  • Prescription medication only
  • Over the counter medication only
  • Both prescription and over the counter medication
  • Not treating your pain with medication
NOTE: If SA5.8 = 1, 3 or 7, continue. Otherwise, go to next module.
9.
Data Results SA5.9
What types of prescription medication are you taking for your pain? Are you taking:
[MARK ALL THAT APPLY]
  • Anti-inflammatory drugs such as ibuprofen or naproxen
  • Analgesic such as Paracetomol
  • Celebrx, Vioxx, or Bextra
  • Narcotic pain reliever such as Oxycontin, Percocet, or Vicodin
  • Prescription topical patch
  • Prescription topical cream
  • Prescription aspirin or Tylenol
  • OTHER (Specify:_________)
 
 
State-Added
Module 6: Cancer Survivorship
1.
Data Results SA6.1
Have you ever been told by a doctor that you have cancer?
2.
Data Results M6.2for M6.2
How long ago has it been since a doctor or other health professional first told you that you had cancer?
 
State-Added
Module 7: Skin Cancer
1.
Data Results M7.1for M7.1
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.
 
State-Added
Module 8: Clinical Trials
1.
Data Results SA8.1
A clinical trial is a type of research study that involves people to test new methods of screening, prevention, diagnosis, or treatment of a disease. Has your health care provider ever talked to you about participating in a clinical trial?
If State-Added Module 7: Cancer Survivorship, question SA7.1 = 1 "Yes" continue. Otherwise, skip to next module.
2.
Data Results SA8.2
Have you ever been enrolled in a cancer clinical trial managed by your Kansas health care provider?
 
State-Added
Module 9: Influenza
1.
Data Results M9.1
During the past 12 months, did your doctor or other healthcare provider recommend that you receive the flu vaccine?
2.
Data Results M9.2
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.
3.
Data Results M9.3
Do you have direct face-to-face or hands-on contact with patients as a part of your routine work?
 
 
State-Added
Module 10: Oral Health
1
Data Results SA10.1
During the past 12 months, was there any time when you needed dental care but did not get it?
2
Data Results SA10.2
What was the main reason you did not receive the dental care you needed?
3
Data Results SA10.3
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?
 
 
State-Added
Module 9: Influenza - Child
For the randomly selected child. If child is less than 6 months old, go to next module.
Earlier, I asked you quesitons about the [randomly slected child]. Next, I have a few questions related to that child.
1.
Data Results SA11.1
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.
2.
Data Results SA11.2
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™.
3.
Data Results SA11.3
During the past 12 months, has [Fill: his/her] doctor or other healthcare provider recommended that [Fill: he/she] receive the flu vaccine?
 
 
State-Added
Module 12: Oral Health - Child
If the randomly selected child is 7-17 years of age continue. Otherwise, skip to next module.
1
Data Results SA12.1
Earlier, I asked you questions about the [randomly selected child]. Next, I have a question related to the oral health of that child.

Dental sealants are special plastic coatings that are painted on the tops of the back teeth to prevent tooth decay. They are put on by a dentist or dental hygienist. They are different from fillings, caps, crowns, and fluoride treatments. Has the [randomly selected child] ever had dental sealants placed on [her/his] teeth?
 
 
State-Added
Module 13: Advance Care Planning
1.
Data Results SA13.1
A durable power of attorney for health care decisions is a legal document that allows an individual to appoint an agent to make all decisions regarding health care, including choices regarding health care providers, medical treatments, and end of life decisions. Do you have a durable power of attorney for health care decisions?
[Interviewer note: If asked "This is different from a living will"]
2.
Data Results SA13.2
Is your family, friends, health care provider, clergy, or designated agent aware that you have a durable power of attorney for health care decisions?
3.
Data Results SA13.3
Does your health care provider or hospital have a copy of your durable power of attorney for health care decisions on file with your medical records?
4.
Data Results SA13.4
Health care directive or living will is a formal document in which a person gives instructions regarding his or her own health care should they become unable to make decision on his or her own such as during general anesthesia, coma, or mental illness. Do you have a health care directive or living will?
5.
Data Results SA13.5
Is your family, friends, health care provider, clergy, or designated agent aware that you have a health care directive or living will?
6.
Data Results SA13.6
Does your health care provider or hospital have a copy of your health care directive or living will on file with your medical records?
7.
Data Results SA13.7
Thinking collectively of the usefulness of a durable power of attorney for health care decisions and health care directives or living will, would you say that they are:
  • Very useful
  • Somewhat useful
  • Not useful at all
 
State-Added
Module 8: COPD
1
Data Results SA14.1
Have you ever been told by a doctor or health professional that you have chronic obstructive pulmonary disease (COPD), emphysema or chronic bronchitis?
 
State-Added
Module 15: Caregiving
1.
Data Results SA15.1
People may provide regular care or assistance to someone who has a long-term illness or disability. During the past month, did you provide any such care or assistance to a family member or friend?
If answer to question 1 is not 1 ='Yes', then go to closing statement. Else, continue.
2.
Data Results SA15.2
What age is the person whom you are giving care?

(PROBE FOR AGE - IF MORE THAN ONE, ASK "WHAT IS THE AGE OF THE PERSON TO WHOM YOU ARE GIVING THE MOST CARE?")
3.
Data Results SA15.3
What is the gender of the person you are caring for?
4.
Data Results SA15.4
What is his/her relationship to you? For example is [Fill: he/she] your [Fill: mother/daughter or father/son]?

(PROBE FOR RELATIONSHIP - IF MORE THAN ONE, ASK "WHICH IS THE PERSON YOU TAKE CARE OF THE MOST OFTEN?")
5.
Data Results SA15.5
The following questions will relate to your [Fill: relationship (mother, father, etc)].

What do you think or what has a doctor said is the major health problem that your [Fill: relationship (mother, father, etc)] has? CHECK ONE CONDITION ONLY
6.
Data Results SA15.6
Given this condition, with which TWO of the following areas does your [Fill: relationship (mother, father, etc)] most need your help? CHECK UP TO TWO
  • Learning, remembering, and confusion
  • Seeing or hearing
  • Taking care of oneself, such as eating, dressing, bathing, or toileting
  • Communications with others
  • Moving around
  • Getting along with people
  • Feeling anxious or depressed
7.
Data Results SA15.7
For how long have you provided care for your [Fill: relationship (mother, father, etc)]?
8.
Data Results SA15.8
In an average week, how many hours do you provide care for your [Fill: relationship (mother, father, etc)] because of his/her long-term illness or disability?
9.
Data Results SA15.9
I am going to read a list of difficulties you may have faced as a caregiver. Please indicate which TWO of the following is the greatest difficulty you have faced in your caregiving:
  • Caregiving creates a financial burden
  • Caregiving doesn't leave enough time for yourself
  • Caregiving doesn't leave enough time for your family
  • Caregiving interferes with your work
  • Caregiving creates or aggravates health problems
  • Caregiving affects your family relationships
  • Caregiving creates stress
  • Another difficulty
  • No difficulty
10.
Data Results SA15.10
In the past 12 months have you sustained an injury while helping your [Fill: relationship (mother, father, etc)]?
11.
Data Results SA15.11
How far away do you live from your [Fill: relationship (mother, father, etc)]?
12.
Data Results SA15.12
Are you the primary caregiver for your [Fill: relationship (mother, father, etc)]; that is the one most involved in providing care for this person?