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.)

How many of these falls caused an injury? By an injury, we mean the fall caused you to limit your regular activities for at least a day or to go to see a doctor.

In the past 3 months, how many times have you fallen?

The next question asks about a recent fall. By a fall, we mean when a person unintentionally comes to rest on the ground or another lower level.

In the past 3 months, have you had a fall?

Were you injured? By injured, we mean the caused you to limit your regular activities for at least a day or to go see a doctor.

Are you or your [fill in (husband/partner)] using any kind of birth control now? Birth control means having your tubes tied, vasectomy, the pill, condoms, diaphragm, foam, rhythm, Norplant, shots (Depo-provera) or any other way to keep from getting pregnant.

Are you or your [husband/wife/partner] doing anything now to keep [you/her] from getting pregnant? Some things people do to keep from getting pregnant include not having sex at certain times, using birth control methods such as the pill, Norplant, shots or Depo-provera, condoms, diaphragm, foam, IUD, having their tubes tied, or having a vasectomy.

Are you or your [fill in (wife/partner)] using any kind of birth control now? Birth control means having your tubes tied, vasectomy, the pill, condoms, diaphragm, foam, rhythm, Norplant, shots (Depo-provera) or any other way to keep from getting pregnant.

[Females] What is your main reason for not doing anything to keep from getting pregnant?
[Males]What is your main reason for not doing anything to keep your partner from getting pregnant? 

(Has a doctor or other health professional) ever talked with you about your sexual practices, including family planning, sexually transmitted diseases, AIDS, or the use of condoms?

Have you been pregnant in the last 5 years?

Have you ever used the services at a family planning clinic?

How do you feel about having a child now or sometime in the future? Would you say:

• You don't want to have one
• You do want to have one
• You're not sure if you do or don't

How long has it been since you used the services at a family planning clinic?

How soon would you want to have a child? Would you say:

• Less than 12 months from now
• Between 12 months to less than two years from now
• Between two years to less than 5 years from now
• 5 or more years from now

Some things people do to keep from getting pregnant include not having sex at certain times, using birth control methods such as the pill, Norplant, shots or Depo-provera, condoms, diaphragm, foam, IUD, having their tubes tied, or having a vasectomy. Are you or your [husband/wife/partner] doing anything now to keep [you/her] from getting pregnant?

Thinking back to just before you got pregnant with your current pregnancy, how did you feel about becoming pregnant?

Thinking back to your last pregnancy, just before you got pregnant, how did you feel about becoming pregnant?

What are you or your [if female husband/partner; if male, insert wife/partner] doing now to keep [if female, insert "you"; insert "her" if male] from getting pregnant?

What are your reasons for not using any birth control now?

What kinds of birth control are you or your [fill in (husband/partner)] using now?

What kinds of birth control are you or your [fill in (wife/partner)] using now?

What other method are you also using to prevent pregnancy?

Where is your usual source of services for female health concerns, such as family planning, annual exams, breast exams, tests for sexually transmitted diseases, and other female health concerns?

What is the main reason for not doing anything to keep [if female husband/partner; if male, insert wife/partner] from getting pregnant?

Are all of the loaded firearms in your home stored in a locked place that can only be opened with a key or combination, or with a trigger lock that can only be opened with a key or combination?

Are all of the unloaded firearms in your home stored in a locked place that can only be opened with a key or combination, or with a trigger lock that can only be opened with a key or combination?

The next questions are about firearms. We are asking these in a health survey because of our interest in firearm related injuries. Please include weapons such as pistols, shotguns, and rifles; but not BB guns, starter pistols, or guns that cannot fire. Include those kept in a garage, outdoor storage area, or motor vehicle.

Are any firearms kept in or around your home?

Are any firearms now kept in or around your home? Include those kept in a garage, outdoor storage area, car, truck, or other motor vehicle.

Are any of these firearms now loaded?

Are any of these loaded firearms also unlocked? By "unlocked" we mean you do not need a key or combination to get the gun or to fire it. We don't count a safety as a lock.

Are there any loaded firearms in the car, van, or truck you usually drive?

Are there any loaded or unloaded firearms in your home or the car, van, or truck you usually drive? This includes firearms stored in the basement, garage, or any attached buildings.

Are there any unloaded firearms in your home?

Do you feel safer or less safe because there are firearms in your home or car, van, or truck?

Excluding firearms you carry because of work, have you carried a loaded firearm on your person outside the home for protection during the past 30 days?

Is the ammunition for any of those unloaded and unlocked firearms stored in the same room as the firearms or in closets in the same room?

Is the ammunition stored in a locked or unlocked place?

Not including firearms in a car, truck, or other vehicle, are there any loaded firearms in your home?

Did the fire result in any major or minor burns or injuries to the hands, fingers, or other parts of the body of yourself or another person?

Do you have a functioning smoke detector on every level of your home and outside each sleeping area?

Does your family have an escape plan in case of fire in the home?

Has your family practiced an escape plan in case of fire in the home?

Has your family practiced or discussed an escape plan in case of a fire at home?

In the past 15 years, has there ever been a fire in your home which caused any smoke or burn damage to your home?

Is there a working smoke detector in your household?

What was the cause of the most recent fire in your home?

When was the last time you or someone else deliberately tested all of the smoke detectors in your home, either by pressing the test buttons or holding a source of smoke near them?

When was the last time you or someone else deliberately tested all of the smoke detectors in your home?

Which of the following best describes whether you have a smoke detector in your home?

• I don't have a smoke detector
• I have an installed and working smoke detector
• I have a smoke detector, but it is not installed
• I have smoke detector, but it is broken or the battery is missing
• I have a smoke detector, but I don't know if it works

During the past 12 months, have you gotten information about the flu or the benefits of getting a flu shot from the:

• Radio
• Television
• Newspaper
• Insurance company

Poster or flyer in:

• Library
• Bus
• Drugstore/pharmacy
• Civic organization
• Church group
• Your doctor/health clinic
• Other (specify:_______)

Which of the following do you think the flu vaccine would help prevent? Would it prevent:

• An illness with symptoms of a runny nose and a stuffy head
• An illness with symptoms of vomiting and diarrhea
• An illness with symptoms of muscle aches, fever, headache, sore throat, cough

Are any of these multivitamins?

Are you currently taking 400 micrograms of the vitamin folic acid each day?

Do any of the vitamin pills or supplements you take contain folic acid?

Do you currently take any vitamin pills or supplements? Include liquid supplements.

Has a doctor or other health professional ever talked with you about use of folic acid?

How often do you take this vitamin pill or supplement?

Some health experts recommend that women take 400 micrograms of the vitamin folic acid, for which of the following reasons...

• To make strong bones
• To prevent birth defects
• To prevent high blood pressure
• Some other reason

Some health experts recommend that women take 400 micrograms of the B vitamin folic acid, for which of the following reasons...

• To make strong bones
• To prevent birth defects
• To prevent high blood pressure
• Some other reason

When is it most important that a woman take the vitamin folic acid?

Where did you hear or read that 400 micrograms of folic acid can prevent birth defects?

Has a doctor or other health professional ever talked with you about your diet or eating habits?

How often do you drink fruit juices such as orange, grapefruit, or tomato?

How often do you eat carrots?

How often do you eat green salad?

How often do you eat potatoes not including french fries, fried potatoes, or potato chips?

Not counting carrots, potatoes, or salad, how many servings of vegetables do you usually eat?

Not counting juice, how often do you eat fruit?