Demographics, Adult
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
About how much do you weigh without shoes?
1993c, 1994c, 1995c, 1996c, 1997c, 1998c, 1999c, 2000c, 2001c, 2002c, 2003c, 2004c, 2005c, 2006c, 2007c, 2008c, 2009c, 2010c, 2011c, 2012c
 
About how tall are you without shoes?
1993c, 1994c, 1995c, 1996c, 1997c, 1998c, 1999c, 2000c, 2001c, 2002c, 2003c, 2004c, 2005c, 2006c, 2007c, 2008c, 2009c, 2010c, 2011c, 2012c
 
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

 
Are you Hispanic or Latino?
 
Are you of Spanish or Hispanic origin?
 
Are you:
  • Married
  • Divorced
  • Widowed
  • Separated
  • Never been married
  • A member of an unmarried couple

 
Do you have a cell phone for personal use? Please include cell phones used for both business and personal use.
 
Do you have more than one telephone number in your household?
1993c, 1994c, 1995c, 1996c, 1997c, 1998c, 1999c, 2000cfor Do you have more than one telephone number in your household?
 
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.
2001cfor 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., 2002cfor 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., 2003cfor 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., 2004cfor 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., 2005cfor 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., 2006cfor 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., 2007cfor 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., 2008cfor 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., 2009cfor 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., 2010cfor 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., 2011cfor 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., 2012c for 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.
 
Do you own or rent your home?

Home is defined as the place where you live most of the time/the majority of the year.
 
Do you share a cell phone for personal use (at least one-third of the time) with other adults?
 
Do you usually share this cell phone (at least one-third of the time) with any other adults?
 
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.
 
During the past 12 months, has your household been without telephone service for 1 week or more? Do not include when services is interrupted by weather or natural disasters.
 

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?

 

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 inlcude training for the Reserves or National Guard, but does inlcude activation, for example, for the Persian Gulf War.

2007cfor 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 inlcude training for the Reserves or National Guard, but does inlcude activation, for example, for the Persian Gulf War., 2008cfor 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 inlcude training for the Reserves or National Guard, but does inlcude activation, for example, for the Persian Gulf War., 2009cfor 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 inlcude training for the Reserves or National Guard, but does inlcude activation, for example, for the Persian Gulf War., 2010cfor 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 inlcude training for the Reserves or National Guard, but does inlcude activation, for example, for the Persian Gulf War., 2011cfor 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 inlcude training for the Reserves or National Guard, but does inlcude activation, for example, for the Persian Gulf War., 2012c for 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 inlcude training for the Reserves or National Guard, but does inlcude activation, for example, for the Persian Gulf War.
 
How many adult members of your household currently use a cell phone for any purpose?
 
How many children less than 18 years of age live in your household ?
1993c, 2001cfor How many children less than 18 years of age live in your household ?, 2002cfor How many children less than 18 years of age live in your household ?, 2003cfor How many children less than 18 years of age live in your household ?, 2004cfor How many children less than 18 years of age live in your household ?, 2005cfor How many children less than 18 years of age live in your household ?, 2006cfor How many children less than 18 years of age live in your household ?, 2007cfor How many children less than 18 years of age live in your household ?, 2008cfor How many children less than 18 years of age live in your household ?, 2009cfor How many children less than 18 years of age live in your household ?, 2010cfor How many children less than 18 years of age live in your household ?, 2011cfor How many children less than 18 years of age live in your household ?, 2012c for How many children less than 18 years of age live in your household ?
 
How many children live in your household who are...
a. less than 5 years old?

 

How many children live in your household who are...
b. 5 through 12 years old?

 

How many children live in your household who are...
c. 13 through 17 years old?

 
How many of these are residential numbers?
 
How many of these phone numbers are residential numbers?
 
How many residential telephone numbers do you have?
 
How much did you weigh a year ago?
2008c
 
How much would you like to weigh?
1994c, 1996c, 1998c, 2000c
 
In the last 12 months have you received some or all of your health care from VA facilities?
 
Indicate sex of respondent. Ask Only if Necessary
1993c, 1994c, 1995c, 1996c, 1997c, 1998c, 1999cfor Indicate sex of respondent. Ask Only if Necessary, 2000cfor Indicate sex of respondent. Ask Only if Necessary, 2001cfor Indicate sex of respondent. Ask Only if Necessary, 2002cfor Indicate sex of respondent. Ask Only if Necessary, 2003cfor Indicate sex of respondent. Ask Only if Necessary, 2004cfor Indicate sex of respondent. Ask Only if Necessary, 2005cfor Indicate sex of respondent. Ask Only if Necessary, 2006cfor Indicate sex of respondent. Ask Only if Necessary, 2007cfor Indicate sex of respondent. Ask Only if Necessary, 2008cfor Indicate sex of respondent. Ask Only if Necessary, 2009cfor Indicate sex of respondent. Ask Only if Necessary, 2010cfor Indicate sex of respondent. Ask Only if Necessary, 2011cfor Indicate sex of respondent. Ask Only if Necessary, 2012c for Indicate sex of respondent. Ask Only if Necessary
 
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
  • 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
1995c, 1996c, 1997c, 1998c, 1999cfor Is your annual household income from all sources:, 2000cfor Is your annual household income from all sources:, 2001cfor Is your annual household income from all sources:, 2002cfor Is your annual household income from all sources:, 2003cfor Is your annual household income from all sources:, 2004cfor Is your annual household income from all sources:, 2005cfor Is your annual household income from all sources:, 2006cfor Is your annual household income from all sources:, 2007cfor Is your annual household income from all sources:, 2008cfor Is your annual household income from all sources:, 2009cfor Is your annual household income from all sources:, 2010cfor Is your annual household income from all sources:, 2011cfor Is your annual household income from all sources:, 2012cfor Is your annual household income from all sources:
 
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?
 
To your knowledge, are you now pregnant?
 
Was the change between your current weight and your weight a year ago intentional?
 
What county do you live in?
1993c, 1994c, 1995c, 1996c, 1997c, 1998c, 1999c, 2000c, 2001c, 2002c, 2003c, 2004c, 2005c, 2006c, 2007c, 2008c
 
What is the highest grade or year of school you completed?
1993c, 1994c, 1995c, 1996c, 1997c, 1998c, 1999cfor What is the highest grade or year of school you completed?, 2000cfor What is the highest grade or year of school you completed?, 2001cfor What is the highest grade or year of school you completed?, 2002cfor What is the highest grade or year of school you completed?, 2003cfor What is the highest grade or year of school you completed?, 2004cfor What is the highest grade or year of school you completed?, 2005cfor What is the highest grade or year of school you completed?, 2006cfor What is the highest grade or year of school you completed?, 2007cfor What is the highest grade or year of school you completed?, 2008cfor What is the highest grade or year of school you completed?, 2009cfor What is the highest grade or year of school you completed?, 2010cfor What is the highest grade or year of school you completed?, 2011cfor What is the highest grade or year of school you completed?, 2012cfor What is the highest grade or year of school you completed?
 
What is your age?
 
What is your race?
1993c, 1994c, 1995c, 1996c, 1997c, 1998c, 1999cfor What is your race?, 2000cfor What is your race?
 
What is your ZIP Code where you live?
2005c, 2006c, 2007c, 2008c
 
Which of the following best describes your current military status?
 
Which of the following categories best describes your annual household income from all sources?
1993c, 1994c
 
Which of the following best describes your service in the United States Military?
 
Which one of these groups would you say best represents your race?
2001cfor Which one of these groups would you say best represents your race?, 2002cfor Which one of these groups would you say best represents your race?, 2003cfor Which one of these groups would you say best represents your race?, 2004cfor Which one of these groups would you say best represents your race?, 2005cfor Which one of these groups would you say best represents your race?, 2006cfor Which one of these groups would you say best represents your race?, 2007cfor Which one of these groups would you say best represents your race?, 2008cfor Which one of these groups would you say best represents your race?, 2009cfor Which one of these groups would you say best represents your race?, 2010cfor Which one of these groups would you say best represents your race?, 2011cfor Which one of these groups would you say best represents your race?, 2012c for Which one of these groups would you say best represents your race?
 
Which one or more of the following would you say is your race?
2001cfor Which one or more of the following would you say is your race?, 2002cfor Which one or more of the following would you say is your race?, 2003cfor Which one or more of the following would you say is your race?, 2004cfor Which one or more of the following would you say is your race?, 2005cfor Which one or more of the following would you say is your race?, 2006cfor Which one or more of the following would you say is your race?, 2007cfor Which one or more of the following would you say is your race?, 2008cfor Which one or more of the following would you say is your race?, 2009cfor Which one or more of the following would you say is your race?, 2010cfor Which one or more of the following would you say is your race?, 2011cfor Which one or more of the following would you say is your race?, 2012cfor Which one or more of the following would you say is your race?
 
Demographics, Child
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
Are you a parent or a guardian of this child?
 

How are you related to the child?

 

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

 
How is the youngest child in your household related to you?
1997s
 
How many children less than 18 years of age live in your household?
 
How many children live in your household who are...
a. less than 5 years old?

 

How many children live in your household who are...
b. 5 through 12 years old?

 

How many children live in your household who are...
c. 13 through 17 years old?

 
How many of the children in your household are aged 7 to 17?
 

Is the child Hispanic or Latino?

 

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

 

Is the child a boy or a girl?

 

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?

2001sfor 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?, 2002sfor 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?, 2003sfor 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?, 2004sfor 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 age of the oldest child in your household under the age of 15?
1993c, 1994o
 
What is the age of the oldest child in your household under the age of 16?
 
What is the age of the oldest child in your household under the age of 18?
 
What is the age of the youngest child in your household?
1997s
 
What is the age of the youngest child under age 18 in your household?
 
What is the birth month and year of the “Xth” child?
 

What is the gender of this child?

 
Which one or more of the following would you say is the race of the child?
[Check all that apply]
 

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

 
Would you say you are the parent or guardian who spends the most time caring for the [age] year old child?
 
Dental Sealants
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
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?
2001sfor 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?, 2002sfor 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?, 2004sfor 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?, 2006sfor 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?
 

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. How many of the children aged 7 to 17 living in your household, ever had dental sealants placed on their teeth?

 
How many of the children in your household are aged 7 to 17?
 
Depressive Disorders (also see Anxiety & Depression)
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question

During the past month, have you often been bothered by feeling down, depressed, or hopeless?During the past month, have you often been bothered by feeling down, depressed, or hopeless?

 
During the past month, have you often been bothered by little interest or pleasure in doing things?
 
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)?
 
Has a doctor or nurse ever told you that you had depression?
 

Have you ever had any other alternative / complementary treatments for depression? Alternative / complementary treatments are, for example, massage, acupuncture, or touch therapy.

 
Have you ever had counseling therapy for depression?
 

Have you ever taken a prescription medication for depression?

 
Have you ever taken any over the counter medications for depression? Over the counter medications are, for example, St. John’s Wort, ginseng, or any herbal medication.
 
To your knowledge, how helpful is physical activity, such as swimming, jogging, brisk walking, or biking, in improving mood and relieving depression?
 
Depression Treatment (also see Anxiety & Depression)
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
About how long has it been since you were diagnosed with depression?
 
During the past 12 months, have you had a period of two weeks or longer when you felt sad, discouraged or uninterested?
 
Did you receive any treatment for your sadness, discouragement or lack of interest at any time in the past 12 months by a medical doctor or other health professionals? (By health professional we mean psychologists, counseolors, spiritual advisors, herbalists, acupuncturists, and other healing professionals.)
 
During the past 12 months, did you get a precscription medicine for your sadness, discouragement or lack of interest?
 
During the past 12 months, did you receive counseling or therapy from a medical doctor or other health professional for your sadness, discouragement or lack of interest? (By health professional we mean psychologists, counseolors, spiritual advisors, herbalists, acupuncturists, and other healing professionals.)
 
What was the main reason you did not receive treatment that you needed for your sadness, discouragement or lack of interest in the past 12 months?
 
During the past 12 months, how many different times have you stayed overnight or longer in a hospital to receive treatment for your sadness, discouragement or lack of interest?
 
Diabetes
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
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"?
2005ofor A test for hemoglobin "A one C" measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for hemoglobin "A one C"?, 2006o, 2007ofor A test for hemoglobin "A one C" measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for hemoglobin "A one C"?, 2008ofor A test for hemoglobin "A one C" measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for hemoglobin "A one C"?, 2009ofor A test for hemoglobin "A one C" measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for hemoglobin "A one C"?, 2010ofor A test for hemoglobin "A one C" measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for hemoglobin "A one C"?, 2011ofor A test for hemoglobin "A one C" measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for hemoglobin "A one C"?, 2012ofor A test for hemoglobin "A one C" measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for hemoglobin "A one C"?
 
A test for hemoglobin "A one C" measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for hemoglobin "A one C"?
2000ofor A test for hemoglobin "A one C" measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for hemoglobin "A one C"?, 2001ofor A test for hemoglobin "A one C" measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for hemoglobin "A one C"?, 2002ofor A test for hemoglobin "A one C" measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for hemoglobin "A one C"?, 2003ofor A test for hemoglobin "A one C" measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for hemoglobin "A one C"?, 2004ofor A test for hemoglobin "A one C" measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for hemoglobin "A one C"?
 
About how many times in the last year has a doctor, nurse, or other health professional checked you for hemoglobin "A one C"?
1994o, 1995o, 1997o, 1998o
 

About how many times in the last year has a health professional checked your feet for any sores or irritations?

1994o, 1995o, 1997o, 1998o
 
About how many times in the last year have you seen a doctor, nurse, or other health professional for your diabetes?
1994o, 1995o, 1997o, 1998o
 
About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?
 
About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?
2000ofor About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?, 2001ofor About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?, 2002ofor About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?, 2003ofor About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?, 2004ofor About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?, 2005ofor About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?, 2006o, 2007ofor About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?, 2008ofor About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?, 2009ofor About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?, 2010ofor About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?, 2011ofor About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?, 2012ofor About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?
 
About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?
2000ofor About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?, 2001ofor About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?, 2002ofor About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?, 2003ofor About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?, 2004ofor About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?, 2005ofor About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?, 2006o, 2007ofor About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?
 
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.
1994o, 1995o, 1997o, 1998o, 2000ofor 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., 2001ofor 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., 2002ofor 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., 2003ofor 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., 2004ofor 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., 2005ofor 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., 2006o, 2007ofor 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., 2008ofor 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., 2009ofor 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., 2010ofor 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., 2011ofor 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., 2012ofor 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.
 
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.
2000ofor 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., 2001ofor 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., 2002ofor 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., 2003ofor 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., 2004ofor 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., 2005ofor 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., 2006ofor 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., 2007ofor 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., 2008ofor 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., 2009ofor 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., 2010ofor 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., 2011ofor 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., 2012ofor 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.
 
Are you now taking diabetes pills?
 
Are you now taking insulin?
 
Currently, about how often do you use insulin?
1994o, 1995o, 1997o, 1998o
 
Do you take insulin injections, diabetes pills, or both?
 

Earlier you said that you check your blood for sugar or glucose. Please tell me waht 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:_____)

 
Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?
2000ofor Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?, 2001ofor Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?, 2002ofor Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?, 2003ofor Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?, 2004ofor Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?, 2005ofor Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?, 2006ofor Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?, 2007ofor Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?, 2008ofor Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?, 2009ofor Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?, 2010ofor Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?, 2011ofor Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?, 2012ofor Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?
 
Have you ever been told by a doctor that you have diabetes?
1993c, 1994c, 1995c, 1996c, 1997c, 1998o, 1999cfor Have you ever been told by a doctor that you have diabetes?, 2000cfor Have you ever been told by a doctor that you have diabetes?, 2001cfor Have you ever been told by a doctor that you have diabetes?, 2002cfor Have you ever been told by a doctor that you have diabetes?, 2003cfor Have you ever been told by a doctor that you have diabetes?, 2004cfor Have you ever been told by a doctor that you have diabetes?, 2005cfor Have you ever been told by a doctor that you have diabetes?, 2006cfor Have you ever been told by a doctor that you have diabetes?, 2007cfor Have you ever been told by a doctor that you have diabetes?, 2008cfor Have you ever been told by a doctor that you have diabetes?, 2009cfor Have you ever been told by a doctor that you have diabetes?
 
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 diabetes?

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

If respondent says pre-diabetes or borderline diabetes, use response code 4.
 
Have you ever heard of glycosylated hemoglobin (gli-KOS-ilated he-mo-glo-bin) or hemoglobin "A one C"?
 
Have you ever taken a course or class in how to manage your diabetes yourself?
2000ofor Have you ever taken a course or class in how to manage your diabetes yourself?, 2001ofor Have you ever taken a course or class in how to manage your diabetes yourself?, 2002ofor Have you ever taken a course or class in how to manage your diabetes yourself?, 2003ofor Have you ever taken a course or class in how to manage your diabetes yourself?, 2004ofor Have you ever taken a course or class in how to manage your diabetes yourself?, 2005ofor Have you ever taken a course or class in how to manage your diabetes yourself?, 2006ofor Have you ever taken a course or class in how to manage your diabetes yourself?, 2007ofor Have you ever taken a course or class in how to manage your diabetes yourself?, 2008ofor Have you ever taken a course or class in how to manage your diabetes yourself?, 2009ofor Have you ever taken a course or class in how to manage your diabetes yourself? , 2010ofor Have you ever taken a course or class in how to manage your diabetes yourself?, 2011ofor Have you ever taken a course or class in how to manage your diabetes yourself? , 2012ofor Have you ever taken a course or class in how to manage your diabetes yourself?
 
Have you had a baby weighing more then 9 pounds at birth?
 
Have you had any sores or irritations on your feet that took more than four weeks to heal?
2000ofor Have you had any sores or irritations on your feet that took more than four weeks to heal?, 2001ofor Have you had any sores or irritations on your feet that took more than four weeks to heal?, 2002ofor Have you had any sores or irritations on your feet that took more than four weeks to heal?, 2003ofor Have you had any sores or irritations on your feet that took more than four weeks to heal?, 2004ofor Have you had any sores or irritations on your feet that took more than four weeks to heal?, 2005ofor Have you had any sores or irritations on your feet that took more than four weeks to heal?, 2006ofor Have you had any sores or irritations on your feet that took more than four weeks to heal?, 2007ofor Have you had any sores or irritations on your feet that took more than four weeks to heal?
 
Have you talked to a dietician (diet specialist), or nutritionist about your diabetes during the past 5 years?
 
How much of the time does your vision limit you in reading print in a newspaper, magazine, recipe, menu, or numbers on the telephone?
1994o, 1995o, 1997o, 1998o
 
How much of the time does your vision limit you in recognizing people or objects across the street?
1994o, 1995o, 1997o, 1998o
 
How much of the time does your vision limit you in watching television?
1994o, 1995o, 1997o, 1998o
 
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?
 
How often do you have trouble telling the difference between a one dollar bill and a five dollar bill?
1993o
 
How often does your doctor ask to see a record of what your blood sugars are at home?
 
How old were you when you were told you had diabetes?
1993o, 1994o, 1995o, 1997o, 1999sfor How old were you when you were told you had diabetes?, 2000ofor How old were you when you were told you had diabetes?, 2001ofor How old were you when you were told you had diabetes?, 2002ofor How old were you when you were told you had diabetes?, 2003ofor How old were you when you were told you had diabetes?, 2004ofor How old were you when you were told you had diabetes?, 2005ofor How old were you when you were told you had diabetes?, 2006ofor How old were you when you were told you had diabetes?, 2007ofor How old were you when you were told you had diabetes?, 2009ofor How old were you when you were told you had diabetes?, 2010ofor How old were you when you were told you had diabetes?, 2011ofor How old were you when you were told you had diabetes?, 2012ofor How old were you when you were told you had diabetes?
 
How old were you when you were told you have diabetes?
 
In general, how would you rate your vision when wearing glasses or contacts if needed?
1993o
 
Is paying for your diabetes supplies a problem?
 

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:_____)

 
Please answer yes or no to the following questions. Has your diabetes caused you any of the following health problems?
a. Permanent loss of vision
b. Loss of kidney function
c. Skin sores or ulcers
d. Amputation
e. Heart disease
f. Numbness, tingling, or pain in feet or legs
g. Lose protein in urine
 
Were you hospitalized during the past two years?
 
What was the reason for your most recent hospitalization?
 
When you go to the doctor for your diabetes, how often does your doctor tell you when to return for your next diabetes check up?
 
When you go to your doctor or other health professional for your diabetes, are you usually told to remove your socks and shoes before you see the doctor or other health professional?
 
When you go to your doctor for your diabetes, are you usually told to remove your socks and shoes before you see the doctor?
1999sfor When you go to your doctor for your diabetes, are you usually told to remove your socks and shoes before you see the doctor?, 2000sfor When you go to your doctor for your diabetes, are you usually told to remove your socks and shoes before you see the doctor?, 2001sfor When you go to your doctor for your diabetes, are you usually told to remove your socks and shoes before you see the doctor?, 2002sfor When you go to your doctor for your diabetes, are you usually told to remove your socks and shoes before you see the doctor?, 2003sfor When you go to your doctor for your diabetes, are you usually told to remove your socks and shoes before you see the doctor?, 2004sfor When you go to your doctor for your diabetes, are you usually told to remove your socks and shoes before you see the doctor?
 
When you last visited your doctor for your diabetes did he or she examine your feet?
 
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.
1994o, 1995o, 1997o, 1998o, 2000ofor 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., 2001ofor 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., 2002ofor 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., 2003ofor 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., 2004ofor 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., 2005ofor 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., 2007ofor 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., 2008ofor 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., 2009ofor 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., 2010ofor 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., 2011ofor 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., 2012ofor 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.
 
When you go to the doctor or other health professional for your diabetes, how often does your doctor or other health professional tell you when to return for your next diabetes check-up?
 
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.
2006s , 2007sfor 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. , 2008sfor 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. , 2008sfor 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. , 2009sfor 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. , 2010sfor 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. , 2011sfor 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.
 
While stopped in a vehicle at a traffic light, how often do you have trouble reading the license plate on the care in front of you?
1993o
 
Who decides when you need your next diabetes check-up?
 
Diabetes, Child
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
Now, I would like to ask you about the "Xth" [CATI: Fill in correct number] child.

Has a doctor, nurse or other health professional EVER said the child has diabetes?
 
Diabetes, Pre-
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
Have you had a test for high blood sugar or diabetes within the past three years?
 
Have you ever been told by a doctor or other health professional that you have pre-diabetes or borderline diabetes?
 
Diabetes Assessment
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
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.
2008sfor 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., 2009sfor 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., 2010sfor 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., 2011sfor 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., 2012sfor 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.
 
Have you had a baby weighing more then 9 pounds at birth?
 
Dietary Fat
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
How often do you eat hot dogs or lunch meats such as ham or other cold cuts?
1992o
 
How often do you eat bacon or sausage?
1992o
 
How often do you eat pork other than ham, bacon, or sausage?
1992o
 
How often do you eat hamburgers, cheeseburgers, or meat loaf?
1992o
 
How often do you eat beef other than hamburgers, cheeseburgers, or meat loaf?
1992o
 
How often do you eat fried chicken?
1992o
 
How often do you eat french fries or fried potatoes?
1992o
 
How often do you eat cheese or cheese spreads, not including cottage cheese?
1992o
 
How often do you eat doughnuts, cookies, cake, pastry, or pies?
1992o
 
How often do you usually eat snacks, such as chips or popcorn?
1992o
 
How often do you usually add butter or margarine to bread, rolls, or vegetables?
1992o
 
How many eggs do you usually eat?
1992o
 
How many glasses (8 oz.) of whole milk do you usually drink? Remember to include drinks made with whole milk or milk on cereal. Do not include low-fat milk, such as skim milk or 2% milk.
1992o
 
Disability
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
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.)
2001cfor Are you limited in any way in any activities because of physical, mental, or emotional problems?, 2002sfor Are you limited in any way in any activities because of physical, mental, or emotional problems?, 2003cfor Are you limited in any way in any activities because of physical, mental, or emotional problems?, 2004cfor Are you limited in any way in any activities because of physical, mental, or emotional problems?, 2005cfor Are you limited in any way in any activities because of physical, mental, or emotional problems?, 2006cfor Are you limited in any way in any activities because of physical, mental, or emotional problems?, 2007cfor Are you limited in any way in any activities because of physical, mental, or emotional problems?, 2008cfor Are you limited in any way in any activities because of physical, mental, or emotional problems?, 2009cfor Are you limited in any way in any activities because of physical, mental, or emotional problems?, 2010cfor Are you limited in any way in any activities because of physical, mental, or emotional problems?, 2011cfor Are you limited in any way in any activities because of physical, mental, or emotional problems?, 2012cfor Are you limited in any way in any activities because of physical, mental, or emotional problems?
 
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.)
1993o, 1994o
 
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.)
1993o, 1994o
 
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.)
1993o, 1994o
 
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.
2009s
 
Are you restricted in any way to services you need such as doctor, counseling, case management, or financial?
 
Because of an impairment or health problem do you have problems with any of the following:

....thinking, remembering or controlling emotions?
 
[Because of an impairment or health problem do you have problems]:

....seeing, hearing or communicating?
 
[Because of an impairment or health problem do you have problems]:

....heart, blood pressure or breathing?
 
[Because of an impairment or health problem do you have problems]:


....digestive system?
 
[Because of an impairment or health problem do you have problems]:

....nerves, muscles or joints?
 
[Because of an impairment or health problem do you have problems]:


....other bodily functions which are affected?
 
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.)
1996s
 
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.)
1996s
 
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?
1996s, 1997s
 
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.
2003cfor 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., 2004cfor 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., 2005cfor 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., 2006cfor 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., 2007cfor 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., 2008cfor 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., 2009cfor 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., 2010cfor 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., 2011c for 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., 2012c for 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?
1997s
 
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.)
1993o, 1994o
 
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.)
1993o, 1994o
 
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.)
1993o, 1994o
 
Does your impairment or health problem affect your ability with any of the following

....go to school or work?
 
[Does your impairment or health problem affect your ability to]:

....perform personal care activities including bathing, dressing, grooming, using the toilet or getting in and out of bed?
 
[Does your impairment or health problem affect your ability to]:

....perform household activities including paying bills, shopping, cooking, or cleaning the house?
 
[Does your impairment or health problem affect your ability to]:

....participate in physical activity?
 
[Does your impairment or health problem affect your ability to]:

....move around including walking, using stairs, lifting or carrying objects?
 
During the past 12 months, have you fallen?
(Asked of respondents who where 65 and older.)
1996s
 
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.)
1996s
 
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.)
1996s
 
During the past 5 years, were you ever admitted to a nursing home?
(Asked of respondents who where 65 and older.)
1996s
 
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.)
1996s
 
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.)
1996s
 
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?
1996s
 
Have you EVER been treated unfairly by a health-care provider or the provider's staff because of a disability?
 
Have you ever had a head injury which caused you to lose consciousness or completely black out?
1997s
 
Have you ever sustained a spinal cord injury?
1997s
 
How often do you get the social and emotional support you need?
 
How old are these people?
1998s, 1999s, 2000s, 2001s
 
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?
 
Is this restriction due to any of the following?

....lack of transportation?
 
[Is this restriction due to]:

....cost of services?
 
[Is this restriction due to]:

...physical access to buildings, offices or medical equipment needed (e.g., exam tables, scales, mammogram machines)?
 
[Is this restriction due to]:

....physical access to buildings, offices or tools needed?
 
[Is this restriction due to]:

....restriction by another person such as a personal attendant or family member?
 
[Is this restriction due to]:

....lack of communication aids such as interpreters or alternate formats?
 
Is your ability to move around due to any of the following:... paralysis?

Note: If asked "Paralysis is defined as loss of function or feeling that affects the ability to move your arms or legs but does not include amputation or missing limbs"
 
[Is your ability to move around due to]:
... amputation or missing limb?
 
[Is your ability to move around due to]:
...a chronic disease such as diabetes or arthritis?
 
[Is your ability to move around due to]:
...something else?
 
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 main reason for the restriction due to a personal attendant or family member? Is this due to the personal attendant or family member's...
  • Lack of training or knowledge
  • Crossing your personal boundaries
  • Refusing to provide requested services
  • Availability
  • Level of assistance
  • Willingness to do what you ask
  • Reliability
  • Trustworthiness
  • Way of treating you
 
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.)
1993o, 1994o
 
Disability Issues
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
If response to CDC Section: Disability Q1 or Q2 is "Yes"; continue. Otherwise skip to next module.

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.
 
[Is this restriction due to...]

...physical access to buildings, offices or medical equipment needed (e.g., exam tables, scales, mammogram machines)?
 
[Is this restriction due to...]

...transportation?
 
Disability Barrier to Attend Work or School
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
Previously, you indicated you were limited in your activities or use special equipment due to an impairment or health problem.

Does your impairment or health problem affect your ability to go to school or work?
 
Discrimination, Perceived
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
These next questions are about experiences you may have in your day-to-day life. How often do any of the following things happen to you? Would you say this happens: almost every day, at least once a week, a few times a month, a few times a year, less than once a year or never.

You are treated with less respect than other people are.
 
People act as if they think you are not smart.
 
People act as if they’re better than you are.
 
You are called names or insulted.
 
What do you think is the main reason for the negative experiences you have just told me about?
  • Age
  • Gender
  • Race / Ethnicity
  • Religion
  • Weight
  • Sexual Orientation
  • Education or income level
  • Physical disability status
  • Some other aspect of physical appearance
  • No particular reason / Reasons vary too much to say
  • Other (specify: _______ )
 
Drinking and Driving
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
During the past month, how many times have you driven when you've had perhaps too much to drink?
 
During the past 30 days, how many times have you driven when you've had perhaps too much to drink?
2002cfor Link to 2002 Data Table for During the Past 30 Days, How Many Times Have You Driven When You Have Had Perhaps Too Much To Drink , 2004cfor Link to 2004 Data Table for During the Past 30 Days, How Many Times Have You Driven When You Have Had Perhaps Too Much To Drink , 2006cfor Link to 2006 Data Table for During the Past 30 Days, How Many Times Have You Driven When You Have Had Perhaps Too Much To Drink , 2008cfor Link to 2008 Data Table for During the Past 30 Days, How Many Times Have You Driven When You Have Had Perhaps Too Much To Drink , 2010cfor Link to 2010 Data Table for During the Past 30 Days, How Many Times Have You Driven When You Have Had Perhaps Too Much To Drink , 2012cfor Link to 2012 Data Table for During the Past 30 Days, How Many Times Have You Driven When You Have 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?
1993c
 
Durable Power of Attorney for Health Care Decisions
c = CDC Core Question, o = CDC Optional Question, s = State-Added Question
Have you completed a Durable Power of Attorney for Health Care Decisions? This is a legal document that allows you to name someone to make health care decisions for you if you should ever become unable to speak for yourself?

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