If only one fall then ask: "Did this fall cause an injury?"

If more than one fall then ask: "How many of these falls caused an injury?"

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

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.)

If only one fall from Q1 then ask "Did this fall cause an injury?", instead. If "yes" code as 01, if "no" code as 88.

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.

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.

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, 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?

In the last 12 months, did you or other adults in your household ever cut the size of your meals or skip meals because there wasn't enough money for food?

How often did this happen?

In the last 12 months, did you ever eat less than you felt you should because there wasn't enough money to buy food?

In the last 12 months, were you ever hungry but didn't eat because you couldn't afford enough food?

Now I'm going to read you 2 statements that people have made about their food situation. For these statements, please tell me whether the statement was often, sometimes, or never true for you or other members of your household in the last 12 months.

The first statement is, "The food that I or we bought just didn't last, and I or we didn't have money to get more." Was that often, sometimes or never true for you in the last 12 months?

Now I'm going to read you 2 statements that people have made about their food situation. For these statements, please tell me whether the statement was often, sometimes, or never true for you or other members of your household in the last 12 months.

The first statement is, "I or we couldn't afford to eat balanced meals." Was that often, sometimes or never true for you in the last 12 months?

Would you support or oppose removing the sales tax on fresh fruits and vegetables?

During the past month, how many times per day, week or month did you drink 100% PURE fruit juices? Do not include fruit-flavored drinks with added sugar or fruit juice you made at home and added sugar to. Only include 100% juice.

INTERVIEWER NOTE: Do not include fruit drinks with added sugar or other added sweeteners like Kool-aid, Hi-C, lemonade, cranberry cocktail, Tampico, Sunny Delight, Snapple, Fruitopia, Gatorade, Power-Ade, or yogurt drinks. Do not include fruit juice drinks that provide 100% daily vitamin C but include added sugar.

Do not include vegetable juices such as tomato and V8 if respondent provides but include in "other vegetables" question.

DO include 100% pure juices including orange, mango, papaya, pineapple, apple, grape (white or red), or grapefruit. Only count cranberry juice if the R perception is that it is 100% juice with no sugar or artificial sweetener added. 100% juice blends such as orange-pineapple, orange-tangerine, cranberry-grape are also acceptable as are fruit-vegetable 100% blends. 100% pure juice from concentrate (i.e., reconstituted) is counted.

During the past month, not counting juice, how many times per day, week, or month did you eat fruit? Count fresh, frozen, or canned fruit.

Read only if necessary: "Your best guess is fine. Include apples, bananas, applesauce, oranges, grape fruit, fruit salad, watermelon, cantaloupe or musk melon, papaya, lychees, star fruit, pomegranates, mangos, grapes, and berries such as blueberries and strawberries."

INTERVIEWER NOTE: Do not count fruit jam, jelly, or fruit preserves.

Do not include dried fruit in ready-to-eat cereals.

Do include dried raisins, cran-raisins if respondent tells you - but due to their small serving size they are not included in the prompt.

Do include cut up fresh, frozen, or canned fruit added to yogurt, cereal, jello, and other meal items.

Include culturally and geographically appropriate fruits that are not mentioned (e.g. genip, soursop, sugar apple, figs, tamarind, bread fruit, sea grapes, carambola, longans, lychees, akee, rambutan, etc.).

During the past month, how many times per day, week, or month did you eat cooked or canned beans, such as refried, baked, black, garbanzo beans, beans in soup, soybeans, edamame, tofu or lentils? Do NOT include long green beans.

Read only if necessary: "Include round or oval beans or peas such as navy, pinto, split peas, cow peas, hummus, lentils, soy beans and tofu. Do NOT include long green beans such as string beans, broad or winged beans, or pole beans."

INTERVIEWER NOTE: Include soybeans also called edamame, TOFU (BEAN CURD MADE FROM SOYBEANS), kidney, pinto, hummus, lentils, black, black-eyed peas, cow peas, lima beans and white beans. Include bean burgers including garden burgers and veggie burgers.

Include falafel and tempeh.

During the past month, how many times per day, week, or month did you eat dark green vegetables for example broccoli or dark leafy greens including romaine, chard, collard greens or spinach?

INTERVIEWER NOTE: Each time a vegetable is eaten it counts as one time.

INTERVIEWER NOTE: Include all raw leafy green salads including spinach, mesclun, romaine lettuce, bok choy, dark green leafy lettuce, dandelions, komatsuna, watercress, and arugula.

Do not include iceberg (head) lettuce if specifically told type of lettuce. Include all cooked greens including kale, collard greens, choys, turnip greens, mustard greens.

During the past month, how many times per day, week, or month did you eat orange-colored vegetables such as sweet potatoes, pumpkin, winter squash, or carrots?

Read only if needed: "Winter squash have hard, thick skins and deep yellow to orange flesh. They include acorn, buttercup, and spaghetti squash."

FOR INTERVIEWER: Include all forms of carrots including long or baby-cut.

Include carrot-slaw (e.g. shredded carrots with or without other vegetables or fruit).

Include all forms of sweet potatoes including baked, mashed, casserole, pie, or sweet potatoes fries.

Include all hard-winter squash varieties including acorn, autumn cup, banana, butternut, buttercup, delicate, hubbard, kabocha (Also known as an Ebisu, Delica, Hoka, Hokkaido, or Japanese Pumpkin; blue kuri), and spaghetti squash. Include all forms including soup.

Include pumpkin, including pumpkin soup and pie. Do not include pumpkin bars, cake, bread or other grain-based desert-type food containing pumpkin (i.e. similar to banana bars, zucchini bars we do not include).

Not counting what you just told me about, during the past month, about how many times per day, week, or month did you eat OTHER vegetables? Examples of other vegetables include tomatoes, tomato juice or V-8 juice, corn, eggplant, peas, lettuce, cabbage, and white potatoes that are not fried such as baked or mashed potatoes.

Read only if needed: "Do not count vegetables you have already counted and do not include fried potatoes."

INTERVIEWER NOTE: Include corn, peas, tomatoes, okra, beets, cauliflower, bean sprouts, avocado, cucumber, onions, peppers (red, green, yellow, orange); all cabbage including American-style cole-slaw; mushrooms, snow peas, snap peas, broad beans, string, wax-, or pole-beans.

Include any form of the vegetable (raw, cooked, canned, or frozen).

Do not include products consumed usually as condiments including ketchup, catsup, salsa, chutney, relish.

Do include tomato juice if respondent did not count in fruit juice.

Include culturally and geographically appropriate vegetables that are not mentioned (e.g. daikon, jicama, oriental cucumber, etc.).

Do not include rice or other grains.

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?