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?
Crosstabulation Table:
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?
Crosstabulation Table:
 
 
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?
Crosstabulation Table:
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.
Crosstabulation Table:
 
CDC Core
Section 4: Exercise (Physical Activity)
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: Chronic Health Conditions
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.
5.1
Data Results 5.1
Ever told you had a heart attack, also called a myocardial infarction?
Crosstabulation Table:
5.2
Data Results 5.2
(Ever told) you had angina or coronary heart disease?
Crosstabulation Table:
5.3
Data Results 5.3
(Ever told) you had a stroke?
Crosstabulation Table:
5.4
Data Results 5.4
Have you EVER been told by a doctor, nurse, or other health professional that you had asthma?
5.5
Data Results 5.5
Do you still have asthma?
Summary Index:
5.6
Data Results 5.6
(Ever told) you had skin cancer?
Crosstabulation Table:
5.7
Data Results 5.7
(Ever told) you had any other type of cancer?
Crosstabulation Table:
5.8
Data Results 5.8
(Ever told) you have (COPD) chronic obstructive pulmonary disease, emphysema or chronic bronchitis?
Crosstabulation Table:
5.9
Data Results 5.9
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 INSTRUCTION: 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:
5.10
Data Results 5.10
(Ever told) you have a depressive disorder (including depression, major depression, dysthymia, or minor depression)?
Crosstabulation Table:
5.11
Data Results 5.11
(Ever told) you have kidney disease? DO NOT include kidney stones, bladder infection or incontinence.
Crosstabulation Table:
5.12
Data Results 5.12
Has a doctor, nurse or other health professional ever said you have a vision impairment in one or both eyes, even when wearing glasses?
Crosstabulation Table:
5.13
Data Results 5.13
(Ever told) you have diabetes?

INTERVIEWER INSTRUCTION: 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: Oral Health
6.1
Data Results 6.1
How long has it been since you last visited a dentist or a dental clinic for any reason? Include visits to dental specialists, such as orthodontists.
6.2
Data Results 6.2
How many of your permanent teeth have been removed because of tooth decay or gum disease? Include teeth lost to infection, but do not include teeth lost for other reasons, such as injury or orthodontics.

NOTE: If wisdom teeth are removed because of tooth decay or gum disease, they should be included in the count for lost teeth.
Crosstabulation Table:
Crosstabulation Table:
 
 
CDC Core
Section 7: Demographics
7.1
Data Results 7.1
What is your age?
7.2
Data Results 7.2
Are you of Hispanic or Latino?
7.3
Which one or more of the following would you say is your race? (Mark all that Apply)
If more than one response to Q7.3, continue. Otherwise, go to Q7.5.
7.4
Data Results 7.4
Which one of these groups would you say BEST represents your race?
7.5
Data Results 7.5

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.

Crosstabulation Table:
7.6
Data Results 7.6
Are you:
  • Married
  • Divorced
  • Widowed
  • Separated
  • Never been married
  • A member of an unmarried couple
7.7
Data Results 7.7
How many children less than 18 years of age live in your household ?
7.8
Data Results 7.8
What is the highest grade or year of school you completed?
7.9
Data Results 7.9
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
7.10
Data Results 7.10
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
If Q7.9 = 1 (Employed for Wages), 2 (Self-Employed), 5 (A Homemaker), 6 (A Student) or 7 (Retired); skip out of the Demographics Core Section to ask the State-Added Average Hours Worked Module.
 
State-Added
State-Added 1: Average Hours Worked
1.
Data Results SA1.1
Previously, you indicated you were (a) [insert response from core, Question 7.9, reported employment status]. On the average, how many hours per week, if any, do you work at a job or business?
 
Skip back into Demographics Core Section at Q7.11, and continue with the survey.
7.11 About how much do you weigh without shoes?
[Round fractions up]
If Q7.11 = 7777 (Don't know/Not sure) or 9999 (Refused), skip Q7.13 and Q7.11.
7.12 About how tall are you without shoes?
[Round fractions down]
Crosstabulation Table:
Summary Index Table:
7.13 What county do you live in?
7.14
 
What is your ZIP Code where you live?
QUESTIONS 7.15 THROUGH 7.20 ARE ASKED ONLY OF LANDLINE RESPONDENTS
7.15
Data Results 7.15
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.
7.16
Data Results 7.16
How many of these phone numbers are residential numbers?
7.17
Data Results 7.17
Do you have a cell phone for personal use? Please include cell phones used for both business and personal use.
If Q7.17 = 1 (Yes), skip to Q7.19
7.18
Data Results 7.18
Thinking about all the phone calls that you receive on your landline or cell phone, what percent, between 0 and 100, are received on your cell phone?
7.19
Data Results 7.19
Do you own or rent your home?

INTERVIEWER NOTE: "Other arrangement" may include group homes, staying with friends or family without paying rent.

INTERVIEWER NOTE: Home is defined as the place where you live most of the time/the majority of the year.
7.20
Data Results 7.20
Indicate sex of respondent. (Asked Only if Necessary)
If Q7.20 = 1 (Male) or Q7.20 = 2 (female) and is 45 years old or older, skip to next section.
7.21
Data Results 7.21
To your knowledge, are you now pregnant?
 
 
CDC Core
Section 8: Disability
Crosstabulation Table:
Summary Index:
The following questions are about health problems or impairments you may have.
8.1
Data Results 8.1
Are you limited in any way in any activities because of physical, mental, or emotional problems?
Crosstabulation Table:
8.2
Data Results 8.2
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?

INTERVIEWER NOTE: Include occasional use or use in certain circumstances.

 
 
CDC Core
Section 9: Tobacco Use
9.1
Data Results 9.1
Have you smoked at least 100 cigarettes in your entire life?
[NOTE: 5 packs = 100 cigarettes]
If Q9.1 = 1 (Yes); continue. Otherwise, go to Q9.5.
9.2
Data Results 9.2
Do you now smoke cigarettes every day, some days, or not at all?
Crosstabulation Table:
Summary Index Table:
If Q9.2 = 1 (Every day) or 2 (Some days); continue. Otherwise, if Q9.2 = 3 (Not at all); go to Q9.4. Else, go to Q9.5.
9.3
Data Results 9.3
During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?
Crosstabulation Table:
Go to Q9.5.
9.4
Data Results 9.4
How long has it been since you last smoked a cigarette, even one or two puffs?
9.5
Data Results 9.5
Do you currently use chewing tobacco, snuff or snus every day, some days or not at all?

INTERVIEWER INSTRUCTION: Snus (Swedish for snuff) is a moist smokeless tobacco, usually sold in small pouches that are placed under the lip against the gum.
Crosstabulation Table:
 
 
CDC Core
Section 10: Alcohol Consumption
10.1
Data Results 10.1
During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?
If Q10.1 = 888 "No drinks in past 30 days", 777 "Don't know/Not sure" or 999 "Refused"; go to next section.
10.2
Data Results 10.2
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?

INTERVIEWER NOTE: A 40 ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.
Crosstabulation Table:
Summary Index:
10.3
Data Results 10.3
Considering all types of alcoholic beverages, how many times during the past 30 days did you have X [X = 5 for men, X = 4 for women] or more drinks on one occasion?
Crosstabulation Table:
Summary Index:
10.4
Data Results 10.4
During the past 30 days, what is the largest number of drinks you had on any occasion?
 
 
CDC Core
Section 11: Immunization
11.1
Data Results 11.1

Now I will ask you questions about the seasonal flu vaccine. There are two ways to get the seasonal flu vaccine, one is a shot in the arm and the other is a spray, mist, or drop in the nose called FluMist™. During the past 12 months, have you had either a seasonal flu shot or a seasonal flu vaccine that was sprayed in your nose?

READ IF NECESSARY: A new flu shot came out in 2011 that injects vaccine into the skin with a very small needle. It is called Fluzone? Intradermal vaccine. This is also considered a flu shot.

Crosstabulation Table:
If Q11.1 = 1 (Yes); continue. Else, go to Q11.4.
11.2 During what month and year did you receive your most recent flu shot injected into your arm or flu vaccine that was sprayed in your nose?
11.3
Data Results 11.3

At what kind of place did you get your last flu shot/vaccine?

  • 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: inpatient)
  • An emergency room
  • Workplace
  • Some other kind of place
  • Received vaccination in Canada/Mexico (Volunteered – Do not read)
  • A school
11.4
Data Results 11.4
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:
 
CDC Core
Section 12: Falls
If respondent is 45 years or older continue, otherwise go to next section.
Next, I will ask about recent falls. By a fall, we mean when a person unintentionally comes to rest on the ground or another lower level.
12.1
Data Results 12.1
In the past 12 months, how many times have you fallen?
12.2
Data Results 12.2
If ONE fall reported ask: "Did this fall cause an injury?".
If MULTIPLY falls reported ask: "How many of these falls caused an injury?".

By an injury, we mean the fall caused you to limit your regular activities for at least a day or to go see a doctor.
Crosstabulation Table:
 
 
CDC Core
Section 13: Seatbelt Use
13.1
Data Results 13.1
How often do you use seat belts when you drive or ride in a car? Would you say...
  • Always
  • Nearly Always
  • Sometimes
  • Seldom
  • Never
Crosstabulation Table:
If Q13.1 = 8 (Never drive or ride in a car), go to Section 15; otherwise continue.
 
CDC Core
Section 14: Drinking and Driving
If Q10.1 = 888 (No drinks in the past 30 days); go to next section.
The next question is about drinking and driving.
14.1
Data Results 14.1
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 15: Breast and Cervical Cancer Screening
If respondent is MALE, go to the next section.
The next questions are about breast and cervical cancer.
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 breast 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 test?
Crosstabulation Table:
If response to Core Q7.23 = 1 (is pregnant); then go to next section.
15.7
Data Results 15.7
Have you had a hysterectomy?
Read only if necessary: A hysterectomy is an operation to remove the uterus (womb).
 
CDC Core
Section 16: Prostate Cancer Screening
If respondent is less than 40 years of age, or is female, go to next section.
Now, I will ask you some questions about 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. Has a doctor, nurse, or other health professional EVER talked with you about the advantages of the PSA test?
16.2
Data Results 16.2
Has a doctor, nurse, or other health professional EVER talked with you about the disadvantages of the PSA test?
16.3
Data Results 16.3
Has a doctor, nurse, or other health professional EVER recommended that you have a PSA test?
16.4
Data Results 16.4
Have you EVER HAD a PSA test?
If Q16.4 = 1 (Yes); continue. Else, go to next section.
16.5
Data Results 16.5

How long has it been since you had your last PSA test?

Crosstabulation Table:
16.6
Data Results 16.6

What was the MAIN reason you had this PSA test – was it ...?

  • Part of a routine exam
  • Because of a prostate problem
  • Because of a family history of prostate cancer
  • Because you were told you had prostate cancer
  • Some other reason
 
CDC Core
Section 17: Colorectal Cancer Screening
If respondent is < 50 years of age, go to next section.
The next questions are about 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 the 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
For a SIGMOIDOSCOPY, a flexible tube is inserted into the rectum to look for problems. A COLONOSCOPY is similar, but uses a longer tube, and you are usually given medication through a needle in your arm to make you sleepy and told to have someone else drive you home after the test. Was your MOST RECENT exam a sigmoidoscopy or a colonoscopy?
17.5
Data Results 17.5
How long has it been since you had your last sigmoidoscopy or colonoscopy?
Crosstabulation Table:
 
CDC Core
Section 18: 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.
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 testing fluid from your mouth.
If Q18.1 = 1 (Yes); continue. Otherwise, go to Q18.3.
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.”

NOTE: If the respondent remembers the year but cannot remember the month, code the first two digits 77 and the last four digits for the year.
18.4
Data Results 18.4
I'm going to read you a list. When I'm done, please tell me if any of the situations apply to you. You do not 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?
Crosstabulation Table:
 
 
CDC Optional
Module 23: Random Child Selection

If Core Question 7.7 = 88, or 99 (no children under age 18 in the household, or refused), go to next module.

If Core Question 7.7 = 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 7.7 is >1 and Core Question 7.7 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 "X"th child."

INTERVIEWER INSTRUCTION: If there are two children with the same birth date, randomly select one.
M23.1
Data Results M23.1
What is the birth month and year of the “X"th child?
M23.2
Data Results M23.2
Is the child a boy or a girl?
M23.3
Data Results M23.3
Is the child Hispanic or Latino?
M23.4
Data Results M23.4
Which one or more of the following would you say is the race of the child?
[Check all that apply]
If more than one response to M23.4, continue. Otherwise, go to M23.6.
5
Data Results M23.5
Which one of these groups would you say best represents the child's race?
6
Data Results M23.6
How are you related to the child?
 
CDC Optional
Module 24: Childhood Asthma Prevalence
If response to Core Q7.7 = 88 "No children under age 18" or 99 "Refused", go to next module.
The next two questions are about the "X"th child.
M24.1
Data Results M24.1
Has a doctor, nurse, or other health professional EVER said that the child has asthma?
If M24.1 = 1 "Yes"; continue. Otherwise, go to next module.
M24.2
Data Results M24.2
Does the child still have asthma?
Crosstabulation Table:
 
State-Added
Module 2: Childhood Diabetes
If Core Q7.7 = 88, or 99 (No children under age 18 in the household, or Refused); go to next module.
Now, I would like to ask you about the "Xth" [Fill in correct number] child.
1
Data Results SA2.1
Has a doctor, nurse or other health professional EVER said the child has diabetes?
 
 
State-Added
Module 3: Sugar Sweetened Beverage Consumption Among Children
If Core Q7.7 = 88, or 99 (No children under age 18 in the household, or Refused); go to next module.
Crosstabulation Table:
Summary Index:
These next questions are about the milk, soda and other sugar sweetened beverages the "Xth" [Fill in correct number] child drank during the past 30 days.

I will be asking how often the "Xth" [Fill in correct number] child drank each one: for example, once a day, twice a week, three times a month, and so forth.

INTERVIEWER NOTE: If respondent responds less than once per month, put "0" times per month. If respondent gives a number without a time frame, ask: "Was that per day, week, or month?"
SA3.1
Data Results SA3.1
Flavored milk is plain milk which has had a flavoring such as chocolate or strawberry added to it. During the past 30 days, how often did [Fill in: he/she] drink flavored milk?
SA3.2
Data Results SA3.2
During the past 30 days, how often did [Fill in: he/she] drink regular soda or pop that contains sugar? Do not include diet soda or diet pop.
Crosstabulation Table:
SA3.3
Data Results SA3.3
During the past 30 days, how often did [Fill in: he/she] drink sugar sweetened beverages such as punch, Kool-Aid, sports drinks, other fruit flavored drinks or sweet tea? Do not include 100% fruit juice, milk, soda or non-calorie beverages.

NOTE: Fruit flavored drinks are sweetened beverages that often contain some fruit juice or flavoring.
 
 
State-Added
Module 4: Asthma Call Back Survey Information (Asked of Landline Respondents Only)
If Q10.1 = ‘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.
SA4.1
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 Optional and state-added modules that follow are separated 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 1: Pre-Diabetes
Only asked of those not responding "Yes" (code = 1) to Core Q5.13 (if assigned qstver=11 (Part A)).
M1.1
Data Results M1.1
Have you had a test for high blood sugar or diabetes within the past three years?
If Core Q5.13 = 4 (No, pre-diabetes or borderline diabetes); answer Q2 "Yes" (code = 1).
M1.2
Data Results M1.2

Have you ever been told by a doctor or other health professional that you have pre-diabetes or borderline diabetes?

If "Yes" and respondent is female, ask: "Was this only when you were pregnant?"

Crosstabulation Table:
 
 
CDC Optional
Module 2: Diabetes
To be asked following Core Q5.13 (if assigned qstver = 11); if response is "Yes" (code=1).
M2.1
Data Results M2.1
How old were you when you were told you have diabetes?
M2.2
Data Results M2.2
Are you now taking insulin?
M2.3
Data Results M2.3
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.
M2.4
Data Results M2.4
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.
M2.5
Data Results M2.5
About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?
M2.6
Data Results M2.6
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" ?
If M2.4 = 555 “No feet”, go to M2.8.
M2.7
Data Results M2.7
About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?
M2.8
Data Results M2.8
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.
M2.9
Data Results M2.9
Has a doctor EVER told you that diabetes has affected your eyes or that you had retinopathy?
M2.10
Data Results M2.10
Have you EVER taken a course or class in how to manage your diabetes yourself?
 
 
State-Added
Module 5: Diabetes Assessment
SA5.1
Data Results SA5.1

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 INSTRUCTION: include half brother]
  • Sisters [INTERVIEWER INSTRUCTION: include half sister]
  • No one
If respondent is FEMALE; continue. Otherwise, go to next module.
SA5.2
Data Results SA5.2
Have you had a baby weighing more then 9 pounds at birth?
 
 
CDC Optional
Module 5: Sugar Sweetened Beverages and Menu Labeling
Now I would like to ask you some questions about sugary beverages.
NOTE: Please remind respondents to include regular soda that they mixed with alcohol.
M5.1
Data Results M5.1
During the past 30 days, how often did you drink regular soda or pop that contains sugar? Do not include diet soda or diet pop.
Crosstabulation Table:
M5.2
Data Results M5.2
During the past 30 days, how often did you drink sweetened fruit drinks, such as Kool-Aid, cranberry juice cocktail, and lemonade? Include fruit drinks you made at home and added sugar to.

NOTE: Fruit drinks are sweetened beverages that often contain some fruit juice or flavoring. Do not include 100% fruit juice, sweet tea, coffee drinks, sports drinks, or energy drinks.

Crosstabulation Table:
M5.3
Data Results M5.3

The next question is about eating out at fast food and chain restaurants. When calorie information is available in the restaurant, how often does this information help you decide what to order?

  • Always
  • Most of the time
  • About half the time
  • Sometimes
  • Never
Crosstabulation Table:
 
 
State-Added
Module 6: Other Sugar Sweetened Beverage Consumption Among Adults
Previously, we asked about your consumption of regular soda or pop and sweetened fruit drinks. The following question will be asking how often you drank other sugar sweetened drinks: for example, once a day, twice a week, three times a month, and so forth.
INTERVIEWER NOTE: If respondent responds less than once per month, put "0" times per month. If respondent gives a number without a time frame, ask: "Was that per day, week, or month?"
SA6.1
Data Results SA6.1
During the past 30 days, how many times per day, week or month did you drink other sugar sweetened drinks such as sports drinks, energy drinks, coffee drinks or sweet tea? Do not include regular soda or pop, diet soda or diet pop, sweetened fruit drinks, or 100% fruit juice.
Crosstabulation Table:
 
Results below are from combining answers from question M5.1, M5.2 and M6.1.
Summary Index:
Crosstabulation Table:
 
 
CDC Optional
Module 21: Chronic Obstructive Pulmonary Disease (COPD)
If core Q5.8 = 1 (Yes) then continue, else go to next module.
Earlier you said that you had been diagnosed with Chronic Obstructive Pulmonary Disease (COPD).
M21.1
Data Results for M21.1
Have you ever been given a breathing test to diagnose your COPD, chronic bronchitis, or emphysema?
M21.2
Data Results for M21.2
Would you say that shortness of breath affects the quality of your life?
M21.3
Data Results for M21.3
Other than a routine visit, have you had to see a doctor in the past 12 months for symptoms related to shortness of breath, bronchitis, or other COPD, or emphysema flare?
M21.4
Data Results for M21.4
Did you have to visit an emergency room or be admitted to the hospital in the past 12 months because of your COPD, chronic bronchitis, or emphysema?
M21.5
Data Results for M21.5
How many different medications do you currently take each day to help with your COPD, chronic bronchitis, or emphysema?
 
 
State-Added
Module 7: Aspirin Use (CVH)
I would like to ask you a few questions about aspirin use.
SA7.1
Data Results SA8.1
Do you take aspirin daily or every other day?
SA7.2
Data Results SA7.2
Do you have a health problem or condition that makes taking aspirin unsafe for you?

INTERVIEWER NOTE: If "Yes", ask "Is this a stomach condition?" Code upset stomach as 2 "Yes, stomach problems".
 
State-Added
Module 8: Hypertension Awareness
SA8.1
Data Results SA8.1Module 8
Have you EVER been told by a doctor, nurse, or other health professional that you have high blood pressure?

Read only if necessary: By "other health professional" we mean a nurse practitioner, a physician’s assistant, or some other licensed health professional.

(If "Yes" and respondent is female, ask: "Was this only when you were pregnant?")
Crosstabulation Table:
SA8.2
Data Results SA8.2
Are you currently taking medicine for your high blood pressure?
 
State-Added
Module 9: Salt Intake (CVH)
Now I would like to ask you some questions about salt intake. A small amount of the salt we eat occurs naturally in foods. Most of the salt we eat is added to foods, such as salt found in canned foods and breads. Salt also can be added in cooking or at the table.
SA9.1
Data Results for SA9.1
Within the past 30 days, did you buy food from a store or a restaurant labeled "low salt" or "low sodium." Would you say...
  • Yes
  • No
  • Did not buy food in the past 30 days
Crosstabulation Table:
SA9.2
Data Results for SA9.2
Are you currently watching or reducing your salt intake?
SA9.3
Data Results for SA9.3
How many days, weeks, months, or years have you been watching or reducing your salt intake?
SA9.4
Data Results for SA9.4
Has a doctor or other health professional ever advised you to reduce salt intake?
These next questions are about some of the food you eat. Please think about all meals, snacks, and food consumed at home and away from home.

I will be asking how often you ate each one: for example, once a day, twice a week, three times a month, five times a year and so forth.
SA9.5
Data Results for SA9.5
Processed meats are meats (beef, pork, chicken and turkey) preserved by smoking, curing, salting or by the addition of preservatives. A few examples of processed meats are deli meats or cold cuts, sausages, franks or hot dogs, bacon, and ham. Thinking of all forms of processed meats, over the past 12 months, how many times per day, week, month or year did you eat processed meats?"
SA9.6
Data Results for SA9.6
Over the past 12 months, how often did you eat salty snacks? (for example, potato or tortilla chips, popcorn, pretzels, crackers, salted nuts).
SA9.7
Data Results for SA9.7
Over the past 12 months, how often did you eat pizza?
 
State-Added
Module 10: Tobacco Related Issues
The next questions refer to tobacco issues.
SA10.1
Data Results for SA10.1
Have you ever used or tried any dissolvable tobacco products such as Ariva, Stonewall, orbs, sticks, or strips?
SA10.2
Data Results for SA10.2
Have you ever used or tried Electronic Cigarettes or E-cigarettes, such as Ruyan or NJOY?
Crosstabulation Table:
SA10.3
Data Results for SA10.3
The Kansas State Legislature passed a statewide smoking ban in 2010 that prohibits smoking in indoor public places. Do you support or oppose this law?

INTERVIEWER NOTE: The Kansas Indoor Clean Air Act bans smoking in restaurants, bars, work places and other indoor public places, but does not ban smoking in casinos, 20% of hotel rooms and some private clubs.
Crosstabulation Table:
 
 
State-Added
Module 11: Health Literacy
Now I would like to ask you some questions about medical forms or medical information.
SA11.1
Data Results for SA11.1
How confident are you in filling out medical forms by yourself? For example insurance forms, questionnaires, and doctor’s office forms. Would you say...?
  • Not at all
  • A little
  • Somewhat
  • Quite a bit
  • Extremely
Crosstabulation Table:
SA11.2
Data Results for SA11.2
How often do you have problems learning about your health condition because of difficulty in understanding written information? Would you say...?

Interviewer Probe: If respondent states they do not have a health condition, say: "This would include any routine visit to a doctor’s office for a physical exam, women’s health exam or men’s health exam."
  • Always
  • Often
  • Sometimes
  • Rarely
  • Never
Crosstabulation Table:
SA11.3
Data Results for SA11.3
How often do you have someone help you read medical materials? For example: family member, friend, caregiver, doctor, nurse or other health professional. Would you say...?
  • Always
  • Often
  • Sometimes
  • Rarely
  • Never
Crosstabulation Table:
 
State-Added
Module 12: Chronic Disease Management
If answered "Yes" to any of CDC Section 5: Chronic Health Conditions questions (5.1-5.13 = 1), then continue. Else, go to next module.
Now I would like to ask you some questions about chronic disease management.
SA12.1
Data Results for SA12.1
You said that a medical professional has told you that you have or have had [Fill in list of chronic diseases from CDC Section 5]. During the last 12 months, have you gotten information about how to take care of your [Fill in ‘illness’/’illnesses’]?
Crosstabulation Table:
SA12.2
Data Results for SA12.2
During the last 12 months, where did you get information about taking care of your [Fill in ‘illness’/’illnesses’]? Would you say from...?

[MARK ALL THAT APPLY]
  • A doctor or health professional
  • Family or friends
  • A TV show or radio program
  • The Internet
  • A book, magazine, or other publication
  • A group class
SA12.3
Data Results for SA12.3
Having an illness often means doing different tasks and activities to manage your condition. How confident are you that you can do all the things necessary to manage your [Fill in ‘condition’/’conditions’] on a regular basis? Would you say...?
  • Not at all confident
  • A little confident
  • Moderately confident
  • Very confident
Crosstabulation Table:
 
 
Part B
Summary Index Table:
 
CDC Optional
Module 7: Inadequate Sleep
I would like to ask you a few questions about your sleep patterns.
M7.1
Data Results M7.1
During the past 30 days, for about how many days have you felt you did not get enough rest or sleep?
M7.2
Data Results M7.2
On average, how many hours of sleep do you get in a 24-hour period? Think about the time you actually spend sleeping or napping, not just the amount of sleep you think you should get.
INTERVIEWER NOTE: Enter hours of sleep in whole numbers, rounding 30 minutes (1/2 hour) or more up to the next whole hour and dropping 29 or fewer minutes.
Crosstablulation Table:
M7.3
Data Results M7.3
Do you snore?
INTERVIEWER NOTE: If the respondent indicates that their spouse or someone told him/her that they snore, then the answer to the question is "Yes", the respondent snores.
M7.4
Data Results M7.4
During the past 30 days, for about how many days did you find yourself unintentionally falling asleep during the day?
M7.5
Data Results M7.5
During the past 30 days, have you ever nodded off or fallen asleep, even just for a brief moment, while driving?
Crosstabulation Table:
 
CDC Module
Module 17: Mental Illness and Stigma
Crosstabulation Table:
Summary Index Table:
Now, I am going to ask you some questions about how you have been feeling lately.
M17.1
Data Results M17.1
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?
M17.2
Data Results M17.2
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?
M17.3
Data Results M17.3
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?]
M17.4
Data Results M17.4
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?]
M17.5
Data Results M17.5
During the past 30 days, about how often did you feel that everything was an effort?

Note: If respondent asks what does "everything was an effort" means; say, "Whatever it means to you"

[IF NECESSARY: all, most, some, a little, or none of the time?]
M17.6
Data Results M17.6
During the past 30 days, about how often did you feel worthless?

[IF NECESSARY: all, most, some, a little, or none of the time?]
M17.7
Data Results M17.7
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]
M17.8
Data Results M17.8
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?
Crosstabulation Table:
These next questions ask about peoples' attitudes toward mental illness and its treatment.
M17.9
Data Results M17.9
Treatment can help people with mental illness lead normal lives.
Do you - agree slightly or strongly, or disagree slightly or strongly?
M17.10
Data Results M17.10
People are generally caring and sympathetic to people with mental illness.
Do you - agree slightly or strongly, or disagree slightly or strongly?
 
 
CDC Optional
Module 20: Veteran's Health
If Core Q7.5 = 1 (Yes) continue, else go to next module.
The next questions relate to veteran's health.
M20.1
Data Results M20.1
Did you ever serve in a combat or war zone?
M20.2
Data Results M20.2
Has a doctor or other health professional ever told you that you have depression, anxiety, or post traumatic stress disorder (PTSD)?
M20.3
Data Results M20.3
A traumatic brain injury may result from a violent blow to the head or when an object pierces the skull and enters the brain tissue. Has a doctor or other health professional ever told you that you have suffered a traumatic brain injury (TBI)?
M20.4
Data Results M20.4
In the past 12 months, did you receive any psychological or psychiatric counseling or treatment?
The next few questions are a sensitive topic and some people may feel uncomfortable with these questions. At the end of this section, I will give you a phone number for an organization that can provide information and referral for these issues. Please keep in mind that you can ask me to skip any question you do not want to answer.
M20.5
Data Results M20.5
Has there been a time in the past 12 months when you thought of taking your own life?
M20.6
Data Results M20.6
During the past 12 months, did you attempt to commit suicide? Would you say...
  • Yes, but did not require treatment
  • Yes, was treated at a VA facility
  • Yes, was treated at a non-VA facility
  • No
As I mentioned, I would give you a phone number for an organization that can provide information and referral for these issues. You can dial the National Crisis line at 1-800-273-TALK (8255). You can also speak directly to your doctor or health provider.
 
 
CDC Optional
Module 25: Childhood Immunization
If response to Core Q7.7 = 88 (No children under age 18) or 99 (Refused), go to next module.
If selected child's age is greater than or equal 6 months, continue. Otherwise, go to next module.
The next two questions are about the "Xth" [fill in correct number] child.
M25.1
Data Results M25.1
Now I will ask you questions about seasonal flu. There are two types of seasonal flu vaccinations. One is a shot and the other is a spray in the nose. During the past 12 months, has [Fill: he/she] had a seasonal flu vaccination?
If M25.1 = 1 "Yes" continue, otherwise go to next module.
M25.2
The flu vaccination may have been either the flu shot or the flu spray. The flu spray is the flu vaccination that is sprayed in the nose. During what month and year did [Fill: he/she] receive [Fill: his/her] most recent seasonal flu vaccination?
 
 
State-Added
Module 13: Parental Attitudes About Vaccines
SA13.1
Data Results SA13.1
In general, how confident are you in the safety of routine childhood vaccines? Would you say...
  • Not at all confident
  • A little confident
  • Moderately confident
  • Very confident
Crosstabulation Table:
SA13.2
Data Results SA13.2
What is your greatest concern about childhood vaccines, if any? Would you say...?

Interviewer Probe: If they give more than one answer, please say "Which ONE is your greatest concern?"
  • Too many vaccines are given
  • Vaccines are not safe
  • Vaccines cause diseases such as autism
  • Vaccines are not necessary
  • Vaccines cause short term side effects, such as fever and pain
  • I have no concerns about childhood vaccines
SA13.3
Data Results SA13.3
What is the most important source of information that has helped you make decisions about vaccinating your child? Would you say...?
  • Healthcare provider
  • Media such as magazines, television, or radio
  • Internet
  • Friends or family
SA13.4
Data Results SA13.4
The next question is about the "Xth" [Fill in correct number] child.

Have you obtained ALL age appropriate immunizations or shots for [Fill him/her] as recommended by your child’s healthcare provider? Would you say...?
  • Yes, all age appropriate
  • Yes, some age appropriate
  • No
  • Healthcare provider has not recommended any immunizations
  • Healthcare provider has specifically stated not to obtain any immunizations
 
 
State-Added
Module 14: Adolescent Meningococcal Vaccination
If Core Q7.7 = 88, or 99 (No children under age 18 in the household, or Refused), go to next module.
If selected child’s age is 11 through 17 years old, continue. Otherwise, go to next module.
If selected child’s age is not given (don’t know/not sure or refused), go to next module.
The next two questions are about the "Xth" [Fill in correct number] child.
SA14.1
Data Results SA14.1
A vaccine to prevent some types of meningitis caused by bacteria is available. Has the "Xth" [Fill in correct number] child ever had the Meningococcal vaccination?
Crosstabulation Table:
If Core SA14.1 = 1 (Yes), continue. Else, go to next module.
SA14.2
Data Results SA14.2
How many meningococcal shots did [Fill: he/she] receive?
 
 
State-Added
Module 15: Oral Health
SA15.1
Data Results SA15.1
During the past 12 months, was there any time when you needed dental care but did not get it?
Crosstabulation Table:
SA15.2
Data Results SA15.2
What was the main reason you did not receive the dental care you needed?
SA15.3
Data Results SA15.3
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:
 
 
State-Added
Module 16: Disability Issues
If Core Q8.1 = 1 (Yes), limited in any way or Q8.2 = 1 (Yes), use special equipment, continue. Otherwise go to next module.
SA16.1
Data Results SA16.1
Are you restricted in any way to health care services such as physician visit, hospital inpatient care, dental visit, or mental health services?

INTERVIEWER NOTE: Mental health services include services that are provided by a psychologist, psychiatrist, mental health counselor, social worker or other mental health professionals.
Crosstabulation Table:
If SA16.1 = 1 (Yes), continue. Else, go to next module.
SA16.2
Data Results SA16.2
Is this restriction due to physical access to buildings, offices or medical equipment needed (e.g., exam tables, scales, mammogram machines)?
SA16.3
Data Results SA16.3
[Is this restriction due to...] ...transportation?
 
 
State-Added
Module 17: Arthritis Related Issues
If Core Q5.9 = 1 (Yes), continue. Otherwise go to next module.
SA17.1
Data Results SA17.1
Have you EVER taken an educational course or class to teach you how to manage problems related to your arthritis or joint symptoms?
SA17.2
Data Results SA17.2
Have you EVER taken a physical activity class to teach you how to manage problems related to your arthritis or joint symptoms?
If Core Section Employment Question (Q7.9) equals: 1 (Employed for wages) or 2 (Self-employed), then continue.

OR

If State-Added Module Average Hours Worked Question is greater than zero and Core Section Employment Question (Q7.9) equals: 5 (A homemaker), 6 (A student) or 7 (Retired), then continue.
SA17.3
Data Results SA17.3
Is your arthritis or joint symptoms MADE WORSE by duties in your CURRENT job?
SA17.4
Data Results SA17.4
In the past 30 days, how many days of work did you miss because of arthritis or joint symptoms?
 
 
State-Added
Module 18: Fall Injuries Management
The next questions are about falling.
SA18.1
Data Results SA18.1
In the past 12 months, have you done things to reduce your chance of falling?
SA18.2
Data Results SA18.2
In the past 12 months, have you done anything to help an older person reduce his/her chance of falling?
 
 
State-Added
Module 19: Rabies Vaccination for Pets
Next I will ask a few questions about rabies vaccination for pets.
SA19.1
Data Results SA19.1
How many cats 3 months of age or older do you currently keep in or around your home? This includes any cats that live around your home or on your property that you feed or otherwise care for.
There are several different types of rabies vaccines that can be given to your cat by your veterinarian; some rabies vaccines can last up to three years. A cat with a current rabies vaccination is defined as a cat, 3 months of age or older, who has either received a rabies vaccination within the last 12 months OR your veterinarian has told you that your cat has a current rabies vaccination.
SA19.2
Data Results SA19.2
Of the cats 3 months of age or older you currently keep in or around your home, how many of them are vaccinated against rabies? Count only the ones that you know have received a rabies vaccination by a veterinarian. For example, if you have four cats but you only know that two of them have received a rabies vaccination, say "two".