About how much do you weigh without shoes?

About how tall are you without shoes?

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 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.

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?

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 ?

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 would you like to weigh?

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

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

To your knowledge, are you now pregnant?

What county do you live in?

What is the highest grade or year of school you completed?

What is your age?

What is your race?

What is your ZIP Code where you live?

Which of the following best describes your current military status?

Which of the following categories best describes your annual household income from all sources?

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?

Which one or more of the following would you say is your race?

Are you a parent or a guardian of this child?

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

How is the youngest child in your household related to you?

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 [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?

What is the age of the oldest child in your household under the age of 15?

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?

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 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?

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 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?

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"?

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"?

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

About how many times in the last year 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?

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.

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?

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?

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

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?

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?

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?

How much of the time does your vision limit you in recognizing people or objects across the street?

How much of the time does your vision limit you in watching television?

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?

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?

In general, how would you rate your vision when wearing glasses or contacts if needed?

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?