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"]

Is your family, friends, health care provider, clergy, or designated agent aware that you have a durable power of attorney for health care decisions?

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?

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?

Is your family, friends, health care provider, clergy, or designated agent aware that you have a health care directive or living will?

Does your health care provider or hospital have a copy of your health care directive or living will on file with your medical records?

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

Are you limited in any way in any activities because of any impairment or health problem? (Asked of all respondents.)

Are you limited in any way in any activities because of physical, mental, or emotional problems? (Asked of all respondents.)

Are you limited in the kind or amount of housework you can do because of any impairment or health problem?
(Asked of respondents who where between the ages of 18 - 64.)

Are you limited in the kind or amount of work you can do because of any impairment or health problem?
(Asked of respondents who where between the ages of 18 - 64.)

Are you limited in the kind or amount of work you can do because of any impairment or health problem?
(Asked of all respondents.)

Are you limited in the kind or amount of work you could do because of any impairment or health problem?
(Asked of respondents who where between the ages of 18 - 64.)

Because of any impairment or health problem, do you have any trouble learning, remembering, or concentrating?

Because of any impairment or health problem, do you need the help of other persons in handling your ROUTINE NEEDS, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?
(Asked of respondents who where 65 and older.)

Because of any impairment or health problem, do you need the help of other persons in handling your ROUTINE NEEDS, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?
(Asked of all respondents.)

Because of any impairment or health problem, do you need the help of other persons with your PERSONAL CARE needs, such as eating, bathing, dressing, or getting around the house?
(Asked of respondents who where 65 and older.)

Because of any impairment or health problem, do you need the help of other persons with your PERSONAL CARE needs, such as eating, bathing, dressing, or getting around the house?
(Asked of all respondents.)

Do you now consider yourself to be a person with a disability?

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?

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.

Do you still experience problems as a result of a head injury?

Does any impairment or health problem keep you from working at a job or business?
(Asked of respondents who where between the ages of 18 - 64.)

Does any impairment or health problem NOW keep you from doing any housework at all?
(Asked of respondents who where between the ages of 18 - 64.)

Does any impairment or health problem NOW keep you from working at a job or business?
(Asked of respondents who where between the ages of 18 - 64.)

During the past 12 months, have you fallen?
(Asked of respondents who where 65 and older.)

During the past 12 months, have you had to see a doctor or nurse because you were injured when you fell?
(Asked of respondents who where 65 and older.)

During the past 30 days, for about how many days did PAIN make it hard for you to do your usual activities, such as self-care, work, or recreation?

During the past 30 days, for about how many days have you felt SAD, BLUE, or DEPRESSED?

During the past 30 days, for about how many days have you felt that you did not get ENOUGH REST or SLEEP?

During the past 30 days, for about how many days have you felt VERY HEALTHY and FULL OF ENERGY?

During the past 30 days, for about how many days have you felt WORRIED, TENSE, or ANXIOUS?

During the past 5 years, have you been admitted to a hospital?
(Asked of respondents who where 65 and older.)

During the past 5 years, were you ever admitted to a nursing home?
(Asked of respondents who where 65 and older.)

During the past week, have you needed to change your clothes or bed sheets because you lost control of your bladder?
(Asked of respondents who where 65 and older.)

During the past week, have you needed to change your clothes or bed sheets because you lost control of your bowels?
(Asked of respondents who where 65 and older.)

Earlier you reported that due to your impairment you need some assistance from another person with your PERSONAL CARE needs. Who usually helps you with your personal care needs, such as eating, bathing, dressing, or getting around the house?

Earlier you reported that due to your impairment you need some assistance from another person with your ROUTINE needs. Who usually helps you with handling your routine needs, such as everyday household chores, shopping, or getting around for other purposes?

For HOW LONG have your activities been limited because of your major impairment or health problem?

Has a doctor or other health professional given you information about community or self-help resources that can help you manage your condition?

Have you ever had a head injury which caused you to lose consciousness or completely black out?

Have you ever sustained a spinal cord injury?

How often do you get the social and emotional support you need?

How old are these people?

If you use special equipment or help from others to get around, what type do you use?

In general, how satisfied are you with your life?

Including yourself, how many people in your household have received medical care or are limited in any way in any activities as a result of an injury to their head or brain?

Is the assistance you receive to meet your personal care needs:  Usually adequate, Sometimes adequate, Rarely adequate

Is the assistance you receive to meet your routine needs: Usually adequate, Sometimes adequate, Rarely adequate

Is there anyone [insert "else" if respondent already indicated that they have a limitation] in your household who is LIMITED in any way in any activities because of any impairment or health problem?

Is this impairment or health problem the result of a work-related illness or injury?

Using special equipment or help, what is the farthest distance that you can go?

What is the farthest distance you can walk by yourself, without any special equipment or help from others?

What is the MAJOR impairment or health problem that limits your activities?

What were you doing MOST of the past 12 months?
(Asked of respondents who where between the ages of 18 - 64.)

A drink of alcohol is 1 can or bottle of beer, 1 glass of wine, 1 can or bottle of wine cooler, 1 cocktail, or 1 shot of liquor. During the past 30 days, how often have you had at least one drink of any alcoholic beverage?

A drink is 1 can or bottle of beer, 1 glass of wine, 1 can or bottle of wine cooler, 1 cocktail, or 1 shot of liquor. On the days when you drank, about how many drinks did you drink on the average?

Considering all types of alcoholic beverages, how many times during the past 30 days did you have:

[WOMEN]: 4 or more drinks on an occasion?

[MEN]: 5 or more drinks on an occasion?

Considering all types of alcoholic beverages, how many times during the past month did you have 5 or more drinks on an occasion?

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?

During the past month, have you had at least one drink of any alcoholic beverage such as beer, wine, wine coolers, or liquor?

During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage?

During the past month, how many days per week or per month did you drink any alcoholic beverages, on the average?

During the past 30 days, how many times have you driven when you've had perhaps too much to drink?

During the past month, how many times have you driven when you've had perhaps too much to drink?

During the past month, how many times have you ridden with a driver who has had perhaps too much to drink?

During the past 30 days, what is the largest number of drinks you had on any occasion?

(Has a doctor or other health professional ever talked with you) about alcohol use?

On the days when you drank, about how many drinks did you drink on the average?

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?

The next question is about counseling services related to prevention that you might have received from a doctor, nurse, or other health professional.

Has a doctor or other health professional ever talked with you about alcohol use?

How many cats do you have?

How many dogs do you have?

How many ferrets do you have?

How many hamsters, gerbils, guinea pigs, or chinchillas do you have?

How many horses or livestock do you have?
[Examples of livestock: cows, goats, pigs or sheep]

How many lizards do you have?
[Examples: iguanas, dragons, geckos, skinks, anoles, monitors, chameleons or uromastyx]

How many non-human primates such as monkeys or chimpanzees do you have?
[Examples: monkeys, chimpanzees, maqueques or capuchins]

How many other reptiles or amphibians do you have?
[Examples: frogs, toads, mantellas, tortoises, salmanders, newts or caecillians]

How many pet birds do you have?

How many pet pigs do you have?

How many prairie dogs do you have?

How many rabbits do you have?

How many rats or mice do you have?

How many (show specific other response) do you have?

How many small exotic cats do you have?
[Examples: bengals, geoffroys, Asian leopards or African servals]

How many snakes do you have?
[Examples: pythons, boa constrictors, asps, vipers, etc]

How many turtles do you have?

How many wild animals do you have?
[Examples: raccoons, skunks, possums, bats, coyotes, wolves, foxes, bobcats, mountain lions, lynx, squirrels, wood chucks or ground hogs]

How many wild birds do you have?
[Examples: eagles, hawks, sparrows or birds that are being rehabilitated]

What type of animals are kept as pets in or around your home?

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?

Has a doctor or other healthcare provider EVER told you that you had an anxiety disorder (including acute stress disorder, anxiety, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, phobia, posttraumatic stress disorder, or social anxiety disorder)?

Has a doctor or other healthcare provider EVER told you that you have a depressive disorder (including depression, major depression, dysthymia, or minor depression)?

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.”
(Ever told) you have a depressive disorder (including depression, major depression, dysthymia, or minor depression)?

Over the last 2 weeks, how many days have you felt down, depressed or hopeless?

Over the last 2 weeks, how many days have you had little interest or pleasure in doing things?

Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much?

Over the last 2 weeks, how many days have you felt bad about yourself or that you were a failure or had let yourself or your family down?

Over the last 2 weeks, how many days have you felt tired or had little energy?

Over the last 2 weeks, how many days have you had a poor appetite or ate too much?

Over the last 2 weeks, how many days have you had trouble concentrating on things, such as reading the newspaper or watching the TV?

Over the last 2 weeks, how many days have you moved or spoken so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you were moving around a lot more than usual?

Are you currently being treated by a doctor for arthritis?

Are you now limited in any way in any activities because of joint symptoms?

Are you now limited in any way in any of your usual activities because of arthritis or joint symptoms?
[NOTE: If respondent question arises about medication, then interviewer should reply: "Please answer the question based on how you are when you are taking any of the medications or treatments you might use."]

Did your joint symptoms FIRST begin more than 3 months ago?

Do you currently participate in any support group to help manage problems related to your arthritis or joint symptoms?

Do you currently participate in physical activity or exercise to help manage problems related to your arthritis or joint symptoms?

During the past 12 months, have you had pain, aching, stiffness or swelling in or around a joint?

DURING THE PAST 30 DAYS, have you had
any symptoms of pain, aching, or stiffness in or around a joint? (Please do NOT include the back or neck.)

Please think about the past 30 days, keeping in mind all of your joint pain or aching and whether or not you have taken medication. DURING THE PAST 30 DAYS, how bad was your joint pain ON AVERAGE? Please answer on a scale of 0 to 10 where 0 is no pain or aching and 10 is pain or aching as bad as it can be.

During the past 30 days, to what extent has your arthritis or joint symptoms interfered with your normal social activities, such as going shopping, to the movies, or to religious or social gatherings? Would you say…

• A lot
• A little
• Not at all

INTERVIEWER INSTRUCTION: If a question arises about medications or treatments, then the interviewer should say: "Please answer the question based on your current experiences, regardless of whether you are taking any medication or treatment."

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

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

 

Has a doctor or health professional EVER suggested losing weight to help your arthritis or joint symptoms?

Has a doctor or other health professional EVER suggested physical activity or exercise to help your arthritis of joint symptoms? [NOTE: If the respondent is unclear about whether this means an increase or decrease in physical activity, this means increase.]

Has a doctor or other health professional ever suggested you participate in an Arthritis Foundation program to help manage problems related to your arthritis or joint symptoms?

Have you ever seen a doctor, nurse, or other health professional for these joint symptoms?

Have you EVER seen a doctor or other health professional for these joint symptoms?

Have you ever been told by a doctor that you have arthritis?

Have you EVER been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?

Arthritis diagnoses include:

• rheumatism, polymyalgia gheumatica
• osteoarthritis (not osteoporosis)
• tendonitis, bursitis, bunion, tennis elbow
• carpal tunnel syndrome, tarsal tunnel syndrome
• joint infection, Reiter's syndrome
• ankylosing spondylitis; spondylosis
• rotator cuff syndrome
• connective tissue disease, scleroderma, polymyositis, Raynaud's syndrome
• vasculitis (giant cell arteritis, henoch-Schonlein purpura, Wegener's granulomatosis, polyarteritis nodosa)

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.”
(Ever told) you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?
INTERVIEWER NOTE: Arthritis diagnoses include:

• rheumatism, polymyalgia gheumatica
• osteoarthritis (not osteoporosis)
• tendonitis, bursitis, bunion, tennis elbow
• carpal tunnel syndrome, tarsal tunnel syndrome
• joint infection, Reiter's syndrome
• ankylosing spondylitis; spondylosis
• rotator cuff syndrome
• connective tissue disease, scleroderma, polymyositis, Raynaud's syndrome
• vasculitis (giant cell arteritis, henoch-Schonlein purpura, Wegener's granulomatosis, polyarteritis nodosa)

Have you EVER taken an educational course or class to teach you how to manage problems related to your arthritis or joint symptoms?

In the next question we are referring to work for pay.
Do arthritis or joint symptoms now effect whether you work, the type of work you do, or the amount of work you do?
[NOTE: If respondent says he/she is retired or out-of-work, reply: "Did arthritis or joint symptoms cause you to stop working? That is, did it affect whether you work or not?"]

Please think about the past 30 days, keeping in mind all of your joint pain or aching and whether or not you have taken medication. DURING THE PAST 30 DAYS, how bad was your joint pain ON AVERAGE? Please answer on a scale of 0 to 10 where 0 is no pain or aching and 10 is pain or aching as bad as it can be.

To your knowledge, are there educational courses or classes available in your community that could teach you how to manage problems related to your arthritis or joint symptoms?

Were these symptoms present on most days for at least one month?

What type of arthritis did the doctor say you have?

A peak flow meter is a hand held device used to measure how well a person is breathing. Have you been instructed in the use of a peak flow meter?

[If one or more visits to Q1 or Q3, fill in (Besides those emergency room visits.)] During the past 12 months, how many times did you see a doctor, nurse or other health professional for urgent treatment of worsening asthma symptoms?

Did a doctor ever tell you that you had asthma?

Do you currently have asthma?

Do you still have asthma?

Does anyone, including household members or guests, smoke inside your home?

During the past 12 months, have you had an episode of asthma or an asthma attack?

During the past 12 months have you taken predisone or another steroid as a pill, capsule, or injection to help control your asthma? This does not include inhaled steroids.

During the past 12 months have you visited a hospital emergency room or urgent care center because of difficulty breathing?

During the past 12 months, how many days were you unable to work or carry out your usual activities because of your asthma?

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?

During the past 12 months, how many times did you visit an emergency room or urgent care center because of your asthma?

During the past 30 days, for about how many days did your asthma limit you in your usual activities, such as self-care, work, or recreation?

During the past 30 days, how many days did symptoms of asthma make it difficult for you to stay asleep?

During the past 30 days, how many days did you take a prescription asthma medication to PREVENT an asthma attack from occurring?

During the past 30 days, how often did you take asthma medication that was prescribed or given to you by a doctor? This includes using an inhaler.

During the past 30 days, how often did you use a prescription inhaler DURING AN ATTACK to stop it?

Has a doctor ever counseled you about how to make changes in your medication to control your asthma?

Has a doctor ever counseled you about not permitting anyone to smoke in your home?

Have you ever been told by a doctor, nurse, or other health professional that you had asthma?

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.”
(Ever told) you had asthma?

Have you ever been told by a doctor that you have asthma?

Have you taken any medications for asthma during the past twelve months?

How old were you when you were first told by a doctor, nurse, or other health professional that you had asthma?

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?

Does the [randomly selected child] still have asthma?

Does the child still have asthma?

During the past 12 months, how many days has the [randomly selected child] missed school or day care because of [his/her] asthma?

Has the [randomly selected child] ever been diagnosed with asthma?

Has a doctor, nurse, or other health professional EVER said that the child has asthma?

How are you related to the [randomly selected child]?

Is the [randomly selected child] child Hispanic or Latino?

Previously, you indicated there were [number of children from core] children under age 18 in your household. What is the age of the [randomly selected child - oldest, second oldest, etc.] child?

What is the gender of this child?

Which one of these groups would you say best represents the race of the [randomly selected child]?