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.

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

Most doctors can be trusted to give patients information on all medical options and not just options that are covered by the health plan.

Most doctors can be trusted to keep personally sensitive information private.

Most doctors can be trusted to offer high-quality medical care.

Most doctors can be trusted to perform necessary medical tests and procedures regardless of cost.

Most doctors can be trusted to refer patients to a specialist when needed.

Most doctors will take extra time with their patients when it is necessary to understand the patient's problems.

Most doctors would not ask a patient to participate in medical research if they thought it might harm the patient.

The following questions are about how much you trust doctors and the health care system to protect your best interests and also the interests of other people like you. Please indicate how much you agree or disagree with the following statements.

Most doctors will try to help someone who is sick, even if the person has no way to pay for the care.

A digital rectal exam is when a doctor or other health professional inserts a finger in the rectum to check for cancer or other health problems. Have you ever had this exam?

A prostate-specific antigen blood test or PSA test is a blood test to check for prostate cancer. Have you ever had a PSA test?

Has your father, brother, son, or grandfather ever been told by a doctor, nurse, or health professional that he had prostate cancer?

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

How long has it been since you had your last PSA test?

How long has it been since your last digital rectal exam?

Previously, I asked you some questions about tests for prostate cancer you may have had. Has you physician ever discussed with you both the advantages and disadvantages of being screened for prostate cancer?

When did you have your last digital rectal exam?

When did you have your last PSA test?

During the past 12 months, did you ever feel so sad or hopeless every day for two weeks or more in a row that you stopped doing some usual activites?

During the past 12 months, did you make a plan about how you would attempt suicide?

During the past 12 months, have you seriously considered taking your own life, even if you would not really do it?

During the past 12 months, how many times have you made an attempt to take your own life?

During the past 30 days, for about how many days did poor physical or mental health keep you from doing 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 WORRIED, TENSE, or ANXIOUS?

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?

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

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

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.

How many close friends or relatives would help you with your emotional problems or feelings if you needed it?

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

Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

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

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

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

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

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

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

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

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

To your knowledge, how helpful is physical activity, such as swimming, jogging, brisk walking, or biking, in improving mood and relieving depression?

When the [randomly selected] child rides in the vehicle with you, how often does [he/she] ride in a child car seat? Child car seats include infant seats, toddler seats, and booster seats. Would you say [he/she] rides in a child car seat...

[Please read]:

• All of the time
• Most of the time
• Some of the time
• Rarely
• Never
• Child does not ride in vehicle / Does not ride with respondent

When the [randomly selected] child rides with you [if Question 1 ="Most of the time" "Some of the time" or "Rarely" then insert "and is not riding in a child car seat"] how often is [he/she] buckled in a seat belt?

There are many different kinds of child safety seats. Does the child seat have harness straps that go over the shoulders and buckle between the legs? Do not count straps from seat belt.

Would you describe this seat as a booster seat? A booster seat raises the child up and the seatbelt usually goes across both the child and the seat to hold the child in place.

Does the vehicle seat belt the child usually wears go across the shoulder only, across the lap only, or across both the shoulder and lap?
[Interviewer note: Include times when child is in a booster seat]

When the [randomly selected] child rides in the vehicle with you, does [he/she] usually ride in the front seat or back seat?