A, HOU.5EHOL0 COMPOSITION PAGE

1.. Whatate th. nam** of .11 perm.sliving or ~tayins h.re? Stirt with th. nom. ef tko p.rsen . . en. of 1.the p.rsens who .W. S or . ..1s this hem.. Enter nome in REFERENCE PERSON column.

I t..wht.,., h. nmm.s of .!1 oth.r p.rsens living . . .+.ri.g hr.? Enter names in columns.

E

If “’Yes.”” ente,nanes in c.shurm

. . I have Iist.d (read names). HGV. I miss.d: Yes No

-.nybobi.s.rsm.11 child,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .00

- my Iodg. rs, b.. rd.rs, or persons you .mpl.y who Nv. her.? . . . . , . . . . . . . . . . . . ❑ u

- any. m. wh. USUALLY lives hr. but i, now .wq from fwnw tmvsling or in a hospital?. . . . 0 0

-anyone. ],, ,tOyi. S h.,. ?.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..fl D

d. Do .11 of th. p.rsons you hmv. nmn.d .s..117 [iv. hr.? ❑ Yes (2)

Probe ,f necessov:❑ No (APPLY HOUSEHOLD MEMBERSHIP

RULES. Delete nonhousehofd members

DO.. -- .s..!1. Iiv. smn.wh.t. .1s.?by on “X-S from I-C2 w!d enter reason,) I

2.

3,

cl

C2

Ask for c41 persons bq,nning with column 2:

Z. Wh.t i. -- r.1.fienship to (reference mrso”]?

3. Whet ii -- da!. of bitth? (Enter date and ace and mffk sex.)

REFERENCE PERIODS

2.WEEK PERIoD*1 ------- -------- --------- ------------ . ----- ------ . _ ., --------------------

12-MONTN DATE---------- ------------------------------------------------------------

13-MONTH HOSPITAL OATE

A2 ASK CONOITION LIST

I 1

IR.1.,lc.whIREFEREN?E PERSONDate of birthMmth ; O,!* ; Ye*r

Z55ii13

iA---,iAi,--,-,”---,”-,-.a-i,,-rii.,[, , ,,,, ,,

I I

A3 lRefertoo#esofall relaredHHmembers.A3 ❑ All ptrsc+s 65 *nd c.v.r (5J

❑ G+h., (4J1 1

4.. Ar. o.y.fth. p.rs.ns in this fomil n.wenf.ll.Nm. oetiv.L?duty wi9hth. Arm.d F.t..sefth* n,t.d Stat.s?

n Yes n No /5)----------------------- .------ _------- __-_----w-::-_---- _----------&-:: :-:--b. Who i. *hIs?

1

--

Delete column number(s) bymI, <X’. from I -C2.------- -------------------------------------------------------------------- --

c. Any... .Is.?❑ Yes (f?ea3k 4b and c) ❑ No

~;k-G;;;c~-b~~s;; ~~~k-e>-~;r;;s~ ------------------------------------------------- ~A~

d, Wh*r; dogs -~ usually live and SI*CP, hem or somewhsre A.?Mcfk tax in Dersm’s colwm.

,.-.

--------------------------------------------

—- —----❑ Livlnt atha

❑ )&at 11.1.* ●t hc.m

1 1

Ifrelotedpersons 17mdover orelisled inddillon tolhe,eswndent wdwenotpresent, sW:

5. W.w..ld lik. t. b.v. .llod.lt f.milym.mb.rs wh. .r. ethem. tik. p. fiinth. inmwl.w.Ar. (names of persons 17 ando.er)athom.new? If ‘-Yes.,. ask: C.uldth.yiain us? (Al[ow time)

Read to responded:

Thlssurv.y is being condu.t*d te.oll.ct in fomotlon onthenatl.n's health. Iwlll ask abouthospitelizatimw, diaobillsy, visits to doctors, illn.ss in tho family, and etfmr h.alth t.lawd it.ms.

HOSPITAL PROBE6.. I ❑ Y=*

6.. Since ( 13-month hospital dote) . y..r q., was -- a potl.nt i.. h.spital OVERNIGHT? 2 ❑ No~~uNkpa;HCSP. ., box,

--- . . ------- ------- ------------------ ..---------------------------------------b. How many diff.r.nt times did -- stay in any hospitml . . . ..ight or 1..s., sine.

_--_. --—-- -------------

(13-mimth hospital dote) a y... q.?

}

f~g$j!

Nurnbw of tlrms 7HEN NP

1 I

Ask f.ar each chifd.”der one: 7.. , n Y.,

7.. W.s -- born {. o hospital? 2 n N. f~p)

---------------------------------------- ----------- ------------------------ .. -------------------------Ask form.ather ondchrld:

II

b. ❑ Y., fNPJ

b. Hav. youincludcdthls hospit.lizatlon lnlhonumhr yeu~v. mo for--? ~ ~f-(ccfmcf 6 *IW “-HtX?P. “

142

B. LIMITATIONOF ACTIVITIES PAGE

B1 / Re(.?r m age.

1. Wh.tw~t --d.i.g MOST OF THE PAST 12 MONTHS; wo?kirq.ta [oborb.si..ss,kooping houio, going to school, or som+fhlng .1s.?

Priority if 2ormore octivhiesrePorfed: (l) S9cnt themosttimedaing; (2) Considers the most Impcflant.

2.. Dw8 any impairment or hcahh pr.bl.m NOW k..p -- from w.rkinn.+. i.b., b.slm..s?------------------------------------------------------------------------

b. Is -- Ilmlfad in AI. bind OR Qmou.t of work ----- d. kc . . . . .f .ny impsirm.nt ., h.alth pr.bl.m?

2a. OOGS any impairment or h.slvb pmbl.m NOW knp --- from doing ●ny houmw~k at all?-------------------------------------------------------------------------

b. Is -- Ilmltd ink kind OR mmaunt .f hou..wark -- can de b...us. of a.y impairment w hmlth problem?

da. Wfwt (ottw?) condition C@Us*. *hIs?Askiflnjury oroperation: Wh.. dld Cvfn (i.”. )..c.r?/--htfm tpomfim?]..?]

eAsk lfoperotion o.er3mwNhsa#o: Forw t.odtion did-- bv. th. .mtitn?n?If Pfe#nrncv/deliveV or O-3 months injurv or Opwatim -

Reaskrwestion 3whcrellmitation rQorted, sayin.s: Exc*ptf.r -- (sum@,. ..?OR reosk 4b/c.------------------------------------------------------------------------ .

b. B.sld*s (c-M) IS them any ethw .e.dltlon that c..... thi. Iimlzati..?

------------------------------------------------------------------------ .e.lsthls limitation .a.sdby ony(oth.c) s~.lficc.tiiti-?

-------------------------------------------------------------------------tdwk box if c+ one condition.

d. Which of th.w cmdlti..s would you my isk MAIN cause of thl. Iimit.ti.n?

II

01 , ❑ 12-70 (1)

2 m C+h.r (NPJ i

h 4 •1 y.. (4) n No---- -------------------------

b. s o Y., (4) 6 m N. (5)

40. (Enfcr cmdlllrn in C2. THEN 4bJ

t ❑ $J~Ea#~~ “Old aI# LVX,

---h.

---e.

---d.

/

-------------------------❑ Y.* (Rcask 4. ●ti b)O No (d)

------------------------

a Y.. (R.ask 44 .ti b)

❑ No------------------------

n IMY I Cdltlon

I m.,. . . . . . ‘1%. OoQs any impairmmf w health ptoblom kocp -- from working O*. lob et business? $1. t O Y., f?’) ❑ NO

------------------------------------------------------------------------- . ---- -------------------------b. fs -- Iimit.d in *h. kind OR amount .f w.rk -- could d. bwc..s. ef any impoi,awmt e, hcmlth p,.bl.m? b. 20 Y.* f?) 3UN0

BZ Refer to questions 30 and 3b.B2 1@ O,Y.sO% 3a c+ 3b ($/P)

2 m Othw M]I

6s,f.- ..

-- Itmlt.d III ANY WAY i. any acliviti.s b..,.,. .f an impaimnt o, h“lth p,.bl.m?-------------------------------------------------------------------------- _K- _:_P?-____!_~?::!::___

b. h! Wh W-y h -- Iimit.d? Record fimitotion, not condition.b.

Llfnttxh”

7.. What (.tfmr) .enditi.n c..... this?Ask If injury or operotion: When dld ~h+ (in’u ) .c.ur?/--bav. th. .potmi..?]

?Ask if operation over 3 nwnlhs ago: F.. w m .ondit,.. did -.. hav. th~ opmtio.?70. fEnt.r ctilliffl In C2. THEN 7b)

11Premancvldeli.eo’ or O-3 months Iniwv or operation - 1 n ~[E.ld7:fafk ..OW 1#8- m,Reask question Z, S, or 6 where (Imitation repined, saving: Except for -- (mWLQO), . . .?OR reosk 7blc.

, -----i - ,-;- ------------------------------------------------------------------b, f3csi&s _n) IS *h*r* anv ofher condltim that c..%*s this Ilmifof ion?

I ----------------------------------------------------------------e, Is this Ifmlfatlon ceuscd by any (AI.,) specific condition?

--..

I--------------------------------------------------------------Mark bax if only one condition.

1

d.

d. which of #h... c.nditias would yaw soy is th. fdAIN c..=. .f this Ilmivation?

I I,0”. “!s., ,,,,,, !4.,.,,,

------------------------nY.s (fl#ask 7aafdb)

DNo(7dJ------------------------

❑ Y.. (Roa$k 7. ●fd b)

❑ N.------------------------

n CMIy I .dItIm

Mm -... I

143

B. LIMITATIONOF ACTIVITIES PAGE,Cmtinurd

03 Refer to .,,.

8. ~.*wcs-- d#ln, MST OF THE PAST 12MNTHS; wocking .talobar b.si..ss, k.~ims h..,.,,.i., t. ssh”l, w sonwfhiW .1..?

Priority if20rmore actlvNiesrefwrted: (l) Swnttie mosttime doln#; (2JConsiders tiemstlwonanL

9,a, B.c.”s9 ef ●y Impd,m,”t ., hrilth pw.bltm, 4.,s -- 1A th. h.lp .f .th.r p.rsens WINI -- personalIRS amud thii fmnw?:a.r~_.~-d-~,-9-u_cy__.~-&JLRJL_~-@Jw_~_rs!s-l?lJ-!~.r-H-_ ----------------------------------------

b. B.c.us* of ●y Impaimwro .r fdth problom, d-s -- IW.d th. h.lp .f oth.r p.rs.ns i.handling -- mutin.. ..ds. such .s .v.ryJ.y hw..h.ld ch.r.s, del.s-c.. sa~bu. i...s, sh.pplq, .rg.tNns.mund far.*” p“rps..,?

100.1. -- ablo te fake p.fl AT ALL in the usual kinds .f plOv .Ct{Viti.S don. by mast childr.n -- *B.?

-------------------------------------------------------------------------b. Is -- limited in tk. kind OR amount of plcy activities -- can de beaus. of ●y imp.lrm.nt a h..lfh pr.bl.m?

11.. DMS ..y impsiraent e, fwaltk pmbl,m HOW k-p -- from .ttwtdlng school?

b. 5G;-JJ;fi;;d-~-IpZZGT;Z~0Zi;r-8;;;iZi;t;Ia:;-GJ.;~JZF;n;~;;ii;;.;F;FF.;itF;;0%To-m?---------

-------------------------------------------------------------------------c. Oe.s--n..d teatndada sp.ciol sche.lw special class.. hceus. of..yimp.irment .rheolthpr.blem?

-------------------------------------------------------------------------d. h -- Ilmit.d in school offondww. bccutc of -- health?

12.. h -- Iimit.d in ANY WAY in ..y #Cti,ihS kmc,”s. of .“ imp,i,m.”t w h..lfh prabl.m?

_------------- _---- __----- _ ----------, -------------------------------------b.lnwhtiwayi.--limitcd? Recodlimitotlon, mtcodtcton.

13.. What (.th.r) . ..di*ion cm.s.s this?Askifinjury oroperatiom Wh.. did[th(iti) o.cur?/--hlh. ~r..~r.ti.nfl

Asklfoperation over3montisaXo: Farwh.i c.wditi.. did-- fmtktp..p.ran?.n?

if we;nancvldelive~ or O-3 mmths i“jwy or operatkm _ffeos&quesNon where limitation repined, saylnc: Exaptfor--f QIJu@), . ..?

OR mask 13b/c--------------------------------------------------------------------------b. Beaid.s (c-n) istbr. anYotbr condition that caus@sthis limitation?

. . i.-tl;.-l;;;t;t;:;;,;~-~-;;.;; l;~;i~fi;fii.-c-~-iii-~-~ ‘---------------------’ -----------

------------------ ,------------------------------------------------------Atork box if only cme condit: on.

d. Which ef *h*s. cmmfitl.ns wo.ld ye. soy i, *h. kfAWf . . . . . .f this Iimifatien?

B4 Refer to “Ace,” “’Oldage,”’ end”’U’’hxes.. hfmk firstappmpriatekox.

,14.. B.c.”.. ●f .IIy i~irmgnt or halth pr.bfcm, do.s -- mosd tho help .f oh. p.rs.ns with -- pws.nal

comn.ds, suha. ”titt~ bathim,, dm,,ing, o,~wim, a,.”md this ham.?-------------------------------------------------------------------------Ask if CIP 18 and over.

b. B...uf. .f.n i-Me,.. .w-w~w~l~~h~l~ pr.bl.m, do.s--ne.d !fw h.lp .f .ffmr Pr..n. i. ha.dli.g--mutlno MA,e.. . d A,-. 4.1”. -.....”, h.., . . . .L-1.. ., -*, - .-”4 & 4,.. ..,. -..7

m1

-----------------------------b. 2 c1 -f** w 1 I-J W (12)

i

10.. ❑ Y., o p No (w

---- ------------------------b. ~ ❑ Y*s @J 2 ❑ N. (12)

11.. 1 ❑ Y.S (13) ❑ N.

---- ------------------------b. 2 fJ Y., (w ~ Ne

---- ------------------------c. 3 I-J Y*. (73) ❑ No

---- --------------- ---------d. .O Y.s (!3) saw

12*. 1Ig Y., z ❑ N. (p/P)

---- ------------------------

b.Llmitul..

129. (Enter mZIdlNM 1. C2, THEN 13b)

, ❑ Oldm .0&,k,40/dWe.ebm,THEfh3c)

1----------------

b. ❑ Yes (###,k 13, ,mj b)a N. (73d)

--- ------------------------. . Ig Y.* (R,.$k 13. SW b)

❑ No--- ------------------------

d. a Only I condit[on

1---------------------------

b. 2 ❑ v., 3rJNo

144

D. RESTRICTED ACTIVITY PAGE PERSDN1

Hand calendw.

(Th. n.xt q...tl... t.f.r t. the 2 w..ks e.din.d i. r.d m lh.t ..l.nd.rb.gl..ing M.m2r.Y, (Me) and ●riding this P..* S..d.v (Mel.)

Refer to age.

D1 fg U.de, 5 (4) ❑ 5-17 (3) O 18 and ova (1)

1.. DURING THOSE 2 WEEKS, did -- work S, any ti~ .! o iob w business

notcwntlng work .re.nd Yh. h..s.? (Incl.d. .npald work i.+h. family[farmlbuslrmst].)

tOYes(Mork “WO’’bax,THEN2) ZUNO------------------------ ------------------------ .

b, Ev.nth.ugh --did moiw.rk d.ri.gth.s.2w..ks, did --have a lob or bvsln.ss?

I ❑ Yes (Afork ‘“Wb”’ tox, THEN 2) 2 D No (4)

2u. Dutlng th.s~ 2 we.ka, did -- miss any tire. from . iobat busht.ss b.c.us. ef illnois m Iniury?

Q Y,. nom No(4)

----------------------------------------------- .

b. Du,l.9 that 2.w.,kp.,i.d, hr,wm..y d.y, did-- mis, me,.tfmnhelf .fth. day fr.m --lob eebsin.ssb.c..s. efNln... or ini.ry?

00U None (4) m {4

3e. D.rin9 thos. 2 w..ks, did -- lld SS my Nm from .cho.l b.c.u.eof llln*ss or fnlury?

❑ Yes . . Q No (4)------------------------------------------------

b. D.rtn.3th.? 2.w..kp.riod, h.wm.ny day, did-- mis. m.,.than h.lf of tb. day from school b....,. .f inn. sser i.i.ry?

00 u None mk. D.rln9 thos. 2 w.. k., did -- stay in b.d . . . . . . . of ill . . . . or i.iwy?

I_J Yes 00 ❑ No (6)------------------------------------------------

b, Ouri.g thst 2.w..k p.ri.d, how mo.y days did -- stay i. bed mm.than h.lf .f A. doy b..ous. of illness or f.@y?

00 ❑ Nc+Ie (6) m

ml” !,., ,,,,,, (,.,.,,,

D2

.i. 0“

[w

Refer to 2b and 3b.❑ No day, i“ 2b or 3b (6)D I or more days in lb w 3b (5]

. many of th. f“.mber ,“ 2b or 3b) day. mi. i.d from

‘schoo~ did -- stay in b+d m.r. than half of *h. d.yb...... of IN..%. or iniuty?

o, 0 NoneN.. of days

t?efe 10 2b, 3b, cmd4b.

[

mi,s.d from w.,k. . (Not counting th. cloy(s) 1rniss.d from ,.h.el ),

(and) in b.dW.. th.r. my (OTHER) tlrn. d.ri.~ thos. 2 w..ks that -- cut d-awnen tb. things -- .s.. IIY &.s b..o. s. of ill . . . . w ini.ry?

O Yes o, u N,I {D3)------------------------------------------------

[

mi. s.d from workb. (Again, not counting *h. day(,) 1mis..d from school ),

(end) in bed

During thot pedad, how many (OTHER) days did -- cut dawn formow than half of the day because of illn.f$ or ini.ry?

No. of ‘mtdc.wr, day, I

..0 None I IRefer to 2-6.

D3 O No days in 2-6 (dbrk “No” m RD. THEN NP)

O I or more days in 2-6 (Mark We.’” m RD. THEN 71

“ier’02b’3b’4b’””d6b” [E?dk’J~~?’hla.What (oth.r) condition caused --10

(Enter ccodition i“ C2, THEN 7b)

b. Oid ..y .th.r condition . ..s. -- ~ [i!i’%il~::;t❑ Yes (Reask 7. and b) .ONO

‘OOTNOTES

145

“. ,,&”b, ,, ,“”, - ,Wm rA-

1.. Durin9 th. Z-w-k pdod e.tlhd in r.d .n fh.t calendar, has WIY.IW in th. family hod . . iniutyfrom mo occident., A., cav,e PM y.. ha,, ,eI yet ~ld mmabout?

I-J Yes ❑ No {2)-------------------------------------------------------------------------- ---- ------------------------ .

b. Who wm. ibis? Mark “lnjwy,’ box in perx,nvs coIumn. lb. ❑ Injury

-------------------------------------------------------------------------- ____ ------------------------ .c. Wkat was -- laiwy?

Enter ;njury(ies) {n person% column. c..

d.iiii.~i~-<.;i;i~ iii~i.iii.iiiii~ &i;~~&i?-------------------------------------- ‘--.----------12LT----------.

o Yes (Remk lb. c, and d) ❑ No__________________________________________________________________________ ___ ------------------------Ask for each injury in lc:

+--. . As ● t@S”h of tfm [in u ,n Ic) did [--/. n~.n~ ,., e, tdk to m iwdical dectsr ., assi,fwit

. . ❑ Ye, (En,,, l“]u,Y !. CZ, THEN

(abwi --) s, did -- ~uj ,wn em -- usual mtiviti,, h, SW,. !hm Mf of a dcy?1. for “*, I r“l”,y)

❑ No (le 10,mxt W@

‘. Dvri.g th. past 12 m.nths, (that is, .1... (12.mnth date) d y-r q.) ABWT hew many days dld illm.s.or Iniucy knp --

2. 00. ❑ NC.M

h W MO* *.” helf of A. &y? (1..l.d. &y. Whih 0“ ●v.,ni~h! P8k”t i“ a hospital.)

—No. OFW.

m. DuriII~ th. past 12 months, ABOUT how mony !lm.. did [--/. ny]n.] s.. w talk ?s a medi.ol doctoror .Isisiwt (abc+t --)? (0. not count doctors i.e. whil... .v.might N.nt 1.. hoapltal.)

30. 000 ❑ Non. (3b]

(1.clud* ffm (numter in 2-WK DV box) visit(s) you drcdy told m. akwb r000❑ ally whenW.mi,ht

P.,8.., in ho,~ltal

}

(NP)

-------------------------------------------------------------------------- - ___ ------------------------No, of ,1s$,,

b. About how Ions has it ko.n sin.. [--/y aoa].] hst S.W . . talk.d to. Aicsl do.por or ..si.temt(okout --)? Include doctors inn whil. mIMtiont in a hospltml,

b. 1 ❑ I.t.rvh. w.k (Rwsk 3b)

‘Z ❑ Lass th.” I W. (Rusk%)3 I_J I yr., 10s. h.. 2 w*.

4 ❑ 2 y,’., 1.,, than 5 v,,.

s ❑ 5 ?,s. 0, mom0 ❑ N.v8,

Would yOU S.y -- fwlth in g.”.ml iS ●XC.it@, VCly s=Od,good, fnlr, of poor?

4. S ❑ =-11*., 4 ❑ Fak

~ ❑ Vw c.~ , ❑ Poor

3 ❑ God

Mark lwx if under 18.0. Akeut hew full is -- WilhOUt ,haas?

5., ❑ Under 18(NP)

—F**, —I.**.

b. i~iiiii;i;~i;.i-I--iil~i;iiiui;i&;?------------------------------------------- ‘-- ‘-----------------------

b. — Pwnds

FOOTNOTES

,“) 4”,, .,,,.”, ,....,,

148

H. CONDITION LISTS 1 AND 2-x

N.,you

1

-

I to respondent(s) and ask list specified in A2:lamg.lng bm.delis* .fm.fic.l condilio.s. T.llm. ifa.y... i.6. f.milyh.s .nyof6.s. .o.&*l.ns, .rn. ifWV. mqn+i.n.d th.m kdoro.

1., D..s.ny.n. i. !h. famlly(read n.mes}tfOWhav. - 2.. 0... anyon. in fh. hmllY{m.d ..mes)NOWh.v. -If ‘“Yes,” ask lb and c.

b. Wheisfhls?

c, Oo.%anyon. .ls. NOWhov. -

Enter .onditio” and letter inaPPmPriote person’s column.

A. PERMAtkENT stlffn.ss .ranyd.f.rmify .fth. fa.t, I.g,flng.rs, arm, or back? (Permanent stiffness -@ints will“*t RI*V* at all.)

----------------------------------------- -.

B, Pamlysi. .fm.y kind?

Id. OURINGTffE PAST 12 MOffTHS, did..y... i. familyilyh.v. -lf”-Yes.”’.sk Ieandf.

●. Whe w., ibis?

f. OURING THE PAST 12 MONTHS, didanye.. .lho ho..-

Enter condition tmd letter In appropriate person’s column.

Conditions C-Nond Varecondilions af{ectinz the bonea“d m“SCh

Conditions O-tJ and W-Z ore conditlo”s offecti”c the skim

C. Arthriii. ofa.ykind.t Reosk IdRh..nmti,m? P. Ecz.m. m Pswlasls?------------------- ---

(*1/% a.mo) or

O. Gout?(...rh...h.. is)

------------------ . --------------------- ---Q, TROUBLE witk dry or

E, L.mbqw? Itching skin?------------------- -------------------- . --

F. Oslwnyehlis?(.s.f..+h-mv.h-ly.’tls) R. TROUBLE with .cn.?

------------------ -- ------------------ ---

L At,ickkn..?

II IU. O.tm.liti* .r any .th.r

skin tro.bl.?------------------ -------------------- -.

J. A#p.der,.pti, ed

------------------ -- V. TROUBLE with Eon..cweh. s, flatf..t, o,

K. Cu:watur. of th. spin.? clubfoot?------------------ -.------------------ --

L. REPEAI’EOtroubl. with W. TROUBLE with i.grown

n..k, back, .. spin.? te.nails or fl”g.r”oils?------------------ -- ------------------ --

M. Bu,siIis otSynovitis? X. TROUBLE with b+nlons,

(.in.o.vy.’tls) corns, er..llvs.s?------------------ --- ------------------ -.N, Anydis..s. .f th. Y. Any dls~s. of A. h.ir

m.scl.i or t.ndo.s? or *C. I.?

O. Atumor, .yst, .rgrowth Z. Any di,.m.. of +h. lymphef th. skin?

0s2, ,4...,.!

—

2

If .“)’es,”ask 2b and C.

b. Who i, this?

. . Oo.s any... .1s. NOW h.v. -

Enter co”dirion and letter inaDDmDriate Derson’s column.

{}

Heorin~A-L ore conditions affecti”~ Vision

Speech

Cmditions O-Wore impairments.

Conditiom Y and Z .ffe

A. O., fn.s. 1....0, both..,s?

------------------ .

B. Any .th.r tm.bl. h.ari.fwith . . . or both ●m?

. - . . . ___________________ .

[. Tinnitus or ringing inth. oU,S?

------------------ .

0. Blimdn.ss i. . . . or bath.y.s?

------------------ .

E. G-,..1,?------------------ -

F, G1.a.cmm?------------------

G. Color Mind”.ss?------------------ .

H, A domch.d t.tins or my.ih.r condition .f *h*r.ti”o?

------------------ .

1. +&rtiH. sningwith ~orbathqs EVENwfmn wmrimg gf.ssm?

------------------ .

J. A .l.ft P.l.t. .rH.r.liP!------------------ .

K. Smnvn.ring or StLIII.ring?------------------ -

L, Any oth.r sp..ch dof,et?------ ------------- .

U. A missing fing.,, hand,., am; M*, foot,., l.fl?

------------------ .

N. A missing (bm.at),kidn.y, ..1..s?

,ervous system.Reask 20

0. Palsy m C.r.bml Palsy?(s.r’..b1)l)

------------------

P. Paralysis .f.ny kind?------------------

Q. C.rvafu,. of th. spin.?------------------

R. REPEATEo q,..bl. widka.k ., spi..?

------------------

S. A.y TROUBLE withf.11.m .,ch., ., flotf..t?

------------------

T. A .I.bfo.t?

U. PERMANENT stiffnessor any Af.rmiiy of th.foot, I.g, .cfmck?(Permo”e”t *tiff”es* -i.i.ls will met m.v.at .1[.)

------------------

W. PERMANENT stiffn.s.or any d. fwmity of tb.fi.g.rs, hand, . . arm?

------------------

W. M..tal ,.ta,dalio.?------------------

(. Any condition caused bya.?.cid.m or~l.ry

p;;:.;$: ;“;

* ..ondition?------------------f. Epil.psy?------------------ .

L REPEATEO C.. VUI,{O..,x.izum., or bl..kc.ui.?

149

H. CfXfDITION LIST33 AND 4

Read to respondent(s) and ask list soecified in A2:

N.ye’

3

c,M“,s.,,

If ““Yes,”’ ask 3b and c.

b. Wh. WC, this?

c. DURING THE PAST T2 MONTHS, did anyone .1.. how -

Enter condition ondletter inowmwlateperson.s column.

f/ake no entry in item C2 for cold; flu: red, sore, or strepthrc.at: o.’%lrus.-even ifrep.xwdln this list,

Comfitlons offectinc fbe digestive system.

L Gdlsteno’?------------------

L Ann:l:: gallbl.dd.r

------------------

:. Cirrhosis d III. Ii,.,?----------------- .

1. Fa~lIv.c?------------------

!. Jf.pallis?------------------

‘. Y.llow @undlc.?------------------

i. Any dim, h., trwbh?------------------

1. Any dis.a.e ef ~.FQ.crms?-----------------

An A.,?----------------- .

, A hernia w ,uphtm?----------------- .

. Amy dlsea,. of AI..,.phaws?

----------------- .

. Gastritis?----------------- .

. FREQUENT indigestion?

,,, ,44.,,,

l.mgaing mr~dalist .fmAicol ”conditi . . . . T.llm. if..yen. inth. bmily ha.!S”S mention.d th.m Wan.

So. OURING THE PAST 12 MONTNS, did .ny.m. i. Pmfamily (read norms) h... -

--1P. Oiv.ftieuliti.?(Oy..v.r.tlc-y.o.ly. Ii.]

-- ------------------

}Q. Colitis?

-- ------------------

1R. A spastic .s1..?--------------------

1S. FREQUENT.CWIIP. IIWI-- ------------------

IT. Amy dim, bowl ,twbl.1

-+------------------

IV.Cone.,of ih. stomach,..l*n, .rr..lum?-p_- -------------

w. O“ri”g fh. -St 12months, dider.y en. (.1..)--1. th. family have .ny.dl. r.ondifie” .f th.di~.stlv. S~SNM?

--

If”’Yes,’’ask: whoWE, tkis? - Whet Y/o,fh. condition? Emer

_- inllern C2. THENrens k W.

had any of th.s. .o.difi..s, .v.. if

40. OURING THE PAST 12 MONTHS, did a.y... in the family{read .omes)hov. -

If-sk fb ond C.

b. Wh. W.S !his?

c. OURING THE PAST 12 MONTHS, did my... .1s. h,.. -

E“terconditio” a”dletter inawrwriatepemo”-s column.

HA. d.my.;:~or oth.rtbyroid

------------------ --

B. Oiab,tss?

!4------------------ --

C. Cysti. fikm. i.?

41------------------ __

D. Anemia?

I

------------------ --

E. Epil.psy?------------------ __

F. M.1tipi.s.1.rosis?-------------------- --

G. Miswoin.?------------------- --

L Sciatica? (si.oti.kuh)

II------------1. H.phritis?__________________ __

K. Kid.. ysto..,?------------------ __L. An~;$orkidnoy

------------------ --

4. Bladd.rtrwbl.?

II

------------------ ---

L P,esto?. tr..bl.?------------------ _-

). A.ydisoas. oftb.“NW. .rewy?

------------------ __

‘. Any.th., f.mal. t,oubl.

44------------------- --

Glandular disorders

Blood disorde,

Condition affectin~ thenervous system

Genito.urmwy conditions

). Came., ofanyki.d?

150

H. CONOITION LISTS 5 AND 6

toresp.andent(s) .ndaskltst sPecifiedin A2.

lam~i.. *.t..li stsfmfdiealc~ dititnsns. T.llmeif anyon. inh. family he. hdrnv.f *h*s. .on&ti . . . ..v.nff. . .sw m.ntl.ned Am ‘dove.

m. Yf.s a.yor.. in tfm Ymnlly {read names) EVER bad -

(f “yes.”” ask 5b and c.

b. Who Was this?

c, Has anyono AC EVER had -

Emer condition and letter in qprop+icwe p+rs.m-s c.alunm.

Conditions affecting the heon and ci,culom-y system.

k. Rheumatic fw*r?

Ii

G. A sirok. . . .------------------ --C.r.brovasculor oceid.nt

1. Rfwumaflc hart dlsrnsw? (s.r’a-br. v.. ku.1.t)-------------- ---- -- ------------------

‘%rw$i!!%’i-llH”tkwO’*Of*”]~

.----------------- -- ------------------1. An@no P+chmis?

1. Ceng.nltml h~rt disco,. (p.k’to-ris).----------------- -- ------------------

~d. DURING THE PAST 12 bfONTHS, did OnyC+l. in #+.

family hovo -

1( ““Yes,”’ ask Se .nd f.

. . Who we, this?

f. DURING THE PAST 12 MONTHS, did Oily*. ●ls. fWO -

Enter c~didon and letter in opp@riate person”s column.

Ccnditi.ms affectinz the heart ond circulatory system.

‘“Dam”g*dh*”r’v”’v””J.-----------------1,h:eardia o, Rapid

1------------------ .

‘“A’Y”*”’’*’’’’MJ’’”’J.-----------------. Amwwxysm?

(.. y.a.rixm)

I------------------ .

. Ally ‘IA Gt.tS? I,.1)(.4.,,)

—

--

--

.-

--

—

—

i

-R:-!?!’:!??---------- -.S. V.vi.as. veins?------------------- --

T. Homonh.ids . .Pil*a?

J------------------- --

U. Phl.biti. orThrombophl.bltis?

I------------------- --

—

6

—

b. DURING THE PAST 12 MONTHS, did any... i. th. family

@@=)hOv* -

If “Yes,”’ ask bb and c.b. Who W.. this?

. . DURING THE PAST 12 MONTHS, did my..- d.. ho.. -

Enter condit ton and fetter in oppropnate person”s column.

Make no emty in item C2 for cold; flu; red. sore. or streptbmot; or ..virus-- eve. if reported m th,s list.

Conditions affecting the

L Brmdftis?------------------

B. Branchi.cto% is?(bmmg ka-~ t.h-si.)

------------------

:. Ash.?------------------

D. Hay f...r?------------------

E. A IW.1 POlyP?------------------

F. Sin.. tr..bl.?------------------

& A doflocted or d.vi.fd“.s01 a.ptum?

------------------

1. ●T.nsil fitis 0. ..lOtg.-m.ns ef i’. tonsils orwkoids?

------------------------

1. “L.iyngitis?------------------

L A tumor, cyst, or growthof *h. b,on.hi.l tub.or 1“”9?

!Spl—

---

---

--

--

--

---

---

---

---

—

tory system.

Reask 6a.(. Emphys. ma?------------------

. . Pt.ulisy?------------------

4. T.b.rc.l.. is?----------------- .

{.Am obs..s. of *h. lung?----------------- .

1. A I.mci, cyst, . . growthof NW IbIO.t, larynx, ortt.eh..?

------------------

3. Any w.rk.r.l.t.d t.splratmy condition such asdust .nih.l~s, sill.esisor p...-m.-.o.sis?. sis?

-..-____-_-------_-

I. During *h. ~St 12 MUllhSdid any... (.1s.) i. h.family h.,. any .th.,

2:%7{W’:317’?:Yask: Mm w., AIS?Who* W., t’. cendillon?

Enter i“ ttem C2. THENmosk O.

—

-.

--

-.

--

--

--

—‘If reported i“ 16is list only. ask:

1. Hew nm.y tim.s did -- h.v. (_n) i. *h. p.st 12 months?

If 2 w more times, enter condition in item CZ.

if only I tfme, ask:

L How long did iti last? If I month or longer. enter i“ item C2.

If less than 1 month, do not record.

ff tonsils or denoids were removed duri”z pust 12 momhs,emu the .cmdition causing renw.al in item C2.

151

L, DEMOGRAPHIC BACKGROUND PAGE

I

LI Refer to .8..

10. Did -- EVER s.rv. on active d.ty i. th. Atm.d Fore.s of th. Unitd Slat..?

b. Wh.n did -- smve?

{

Vietnam Era (Auz. ’64 to April ’75) . . . . . . . VN

Mark box in descending order of priority.Korean War (June .30 t. Jam ’55) KW

Thus, if person served in Vietnam .ond in Korea,World War II (Sepz. ,42 m July 047). ., WWII

mark VN.World War I (April ,!7 to Nov. ,18) . . . . . WWIPost Vietnam (May “75 to present) . . . . PVNOther Service (all other periods) . . . . . . . . . . OS

. -----------------------------------------------------------------------G We. -- EVER an activ. membar of a NaNonal Guard co militmy r.s.tv. unit?

I------------------------------------------------------------------------

d. Was ALL of -- .activ. duty s.rvic. r.latcd to 140tlon.1 Guord or military r.s.rv. training?

2.. What ii th. hish.st grad. or y.ar of r.gular school -- ho. ●v.r efi*.d.d?

------------------------------ ------------------------------------ -------b. Did -- finish th. (number in 2.) l@d./y.arI?

Hand Cord R, Ask first oltematwe for first person; ask second alternative for other persons.

Ilfmt Is --r...?30, hot 1$ tho numb.r of fh. group .r gtoups which r.pr.sents -- Inc.?

1

Circle 011 that OPPIYI - Aleut, Eskimo. or American Indian 4- Whk7, - Asia” or Pacific Islander S - Another croup not I#sted - Specify3- Black---------------------------------------------------------- -------------- .Ask of mult,ple entries:

b. Which of thes. groups; Ihat is, ($ntries in 30) w.uld you soy BEST t.pr.s..ts -- m..?

---------- ---------- ---------------------------------- -----------------c. Mark observed race of respondent(s) only.

I Hcmd Card O.

40. Are ony ef lhos. groups -- national otlgl. or anc.stry? (Wh.t. did -- .mc.seers cm. from?)---------------------------------------------------------------- ------ ---

b. P1.aw glY. m. the numb.r of tb. greup.

Circle all that apply

I - Puerto Rican 5- Chicano2- Cuba” 6- Other Latin American3- Mexican/Mexican.a 7- Other Spanish4- Mexi.a” America,.

.O”M .!s.1 !,0,21 ,4.,.,2,

Ti

1..

---b.

---..

d.

2..

b.

—

30.

b.

---..

—40.

b.

—

G Under 5 (NP)

G5-17 (2}I-J 18 .M over (r)

t ❑ Yes (Mark ,.AF.. L.3x, THEN It

2 ❑ No (2)

!(_JVN 5 u PVN

zUKw 000s>Dwwll 9~DK4 u W*I

❑ Ye, 2UNO(2) 7~DK(2J-------- -------------- -

,@Yez ,nNo ,UDK

,0 c1 Never attended wkmdwlar,en (NPJ

Elem: 12345678

H,dx 9 10 II 12

CO,!.*O: 1 2 3 4 5 6.

-----------------------

,Uy=~ ZUNO

1134‘J

specify-------------- --------1234

‘d

Swcw------------- ---------

*OW 206 3(-JO

, UY.S ,DNo(NP)----- ------- . . . . . . ----

1234567

155

L. DEMOGRAPHIC BAcKGROUND PAGE, Canti..cd

L2 Refer to ‘“A,e”” .nd ‘Wo/Wb’. tom. in c,.

Ea. ~~i.r yeu soid that -- has e ieb w busln.ss but did not wock last w..k w th. w..k b.ferc.-- leaking f- work w en layoff fceme [.b during k,. 2 w..ks?

------------------------ : ----------------------------------------------- .b. &,fi., yew ,miithat--didm,t hm. . iab S, bu,imss lest w,.k ., th. w..k hfor..

-- looking f,, work or en layoff frem a iob during tlmso 2 weeks?------------------------------------------------------------------------ .

e. Which, 100kin, for work w em iOyOff from a lob?

5.. E.rlio, ye. sold dmt -- w.rk.d last w..k .r th. w..k below. Ask bb.

------------------------------------------------------------------------ .b. Fe, ~~ did -- work? Enter nom of atr$any, business, organizalon, or other employer.

------------------------------------------------------------------------ .c.For whom did-- wwk at -- last Eull.iim. civiliw @b or buslm.ss l.stlmg 2 csns.eutfv. wtiks or mor.?

Enter name of comony, tusiness, organization, or otier emPloyer.------------------------------------------------------------------------

d. tWmt kind .f busin.ss . . indwstiy is this? For ●xample. TV ad rcdie manuf.%turinc. retoil shoe store.State Laki Dep.xtm.m, farm.

------------------------------------------------------------------------ .& What kind of wuk was -- doiws? FM ●xample, electrical enlineer, stock clerk, typist, fcrmer.

------------------------------------------------------------------------ .f. What w.re -- m.st lmpotfmtt .ctivitl.s .r duti.s at tfwt lob? For example, types, keeps account books.

files, sells cars, ODerates pfintinr press, finishes concrete.

------------------------------------------------------------------Complete fmm enlrles in 6t-f. If not clear, ask: .

*. w’s --

An .*PI . . ef . PRIVATE company, ku.rwss or7

s.lf-employ.J I. OWN ku.lc+ss, pmf.s,tcalI.Jlvld* f- -.s.s, s. f.ry. w .ommls.l..? . . . . . . . P wacllc., M Iarm?A FEDERAL ,.W”W”I ●WI. P.? . . . . . . . . . . . . . F II “d farm, ●sk: I* III. buslnc.t i..wpw.wd?ASTATE’.w,”Mn, .mPlq..7 . . . . . . . . . . . . . ..S Y., . . . . . . . . . . . . . . . . . .A LOCAL ,w.r.m.nt ●ploy”? . . . . . . . . . . . . . . . L !+a(erl.rm ) . . . . . . . . . . . .

Werkln, WITHOUT PAY 1. h+ ku.1.,ssWfmm?. . . . . . . . . . . . . . . . . . . . . . . . . . .

- NEVER WORKED ., -v.* wmksd .1. Iull.tlrm.<1”111.. I.b I.sll. g 2 w..k. or mom . . . . . . . . .

ISE

WP

N EV

00TNOTES

!0. 4I n Yes (5cJ 2 n N. (6!

-- ------------------.--- .

I-----------------.~k.Em.loy.r

d. .

t

------------------------d. Ind”*rry

I------------.,Occ.mlm

I-17 5it7.T ------------------

--- ,-----_--_--------_-_-- .C 1.,. d vm,kw

9. inP 51-Jl

zOF 6 c, SE

30s 70WP

4QL 8 n NEv

156

L. DEMOGRAPHIC BACKGROUND PAGE, ContinualMark box If under 14. If ““Momied” refer to household cm%aition and mark .ccordinzlv.

‘. IS -- new m.rri.d, wid.w.d, div.rc.d, s.p.mt.d, or has -- nav.. b... morvi.d?

1., Was th. total ..mbin.d FAMILY Inmm. during th. post 12 months - th.t IS, your., (read names, Includin=Armed Forces members livin~ at home] more or loss than $20,000? Mud. mon.y ham i.ba, social s.curify,

r. NmmwIt income, un.mploymant payments, public assistance, and s. froth. Also in.lud. in.om. froml.t.t.st, dividends, ..t inc.m. from bust . . . . . f.rm, . . r.nt, and any oth.r m...y i.c.mo c.c.iv.d.

Read if necessov: Income is important 1. armlyxing *h. hrnlth information we coil.ct. For .xompl., thisi. f.nnati.. h.lps .s w I..r. wh.th.r P.rs.n. 1. on. l.com. groq . . . c.rml. !YP.s of medical car. ..rvic.s.r h.v. .. II.I. cenditl.ns III... or 1.ss .fwn th.n th.s. in moth.. group.

. . -----------------------------------------------------------------------Read porentherlcal phrase if Armed Forces member living at home or if necessafy.

b, Of the.. in..m. reups, which I.tt.r b.st r.r.r*s.nts th. total cembin.d FAMILY income1during ih. pmst 1 m..lhs (thot IS, yours, (read names, including Armed Forces members

livinr ot home))? Include wages, I.lades, .nd the eth.r N.m$ W* lust talked obe.t.

Read if necessaw: I.c.m. IS impofi.nt in analyzing #t. h-lth In form.li.. w. c.11..t. F.r .xampl., thisinformation h.lpa us ta learn whoffwr pwsons in one income group use certain fyp.s of mdical care services

.r hav. . ..tal. . ..ditt..s mar. m 1.ss .fi.n than %s. t. .n.ihu group.

I . . M.rk firs! aPPmPriate ~x.

R _____________________________________________________________---------I b. Enterpem.”number. fmsw”de”t.

o n U“d.r 14

10 M~l*d - SW** i. HH

z ❑ Marri.d - .r.mm. not !. HH

, I_J Wld.w.d

4 m Dlvorc.d

, I-J ~$-loiy C4 mm. of-d

7, f-J L& ~t $20,cm (lid

o •l u.d*r 17* ❑ Pr8*Nlt for ,11 W.SIICIM

* D Pmsnlt t., sent. qu.stl.n,

S ❑ Not PV.SMIZ

----------------------

00TNOTES

157

CARD R

1. Aleut, Eskimo, or American Indisn

2. Asian or Pacific Islander

3. Black

4. white

CARD I

u ....... 20,000 – 24,999

v ... ... . 25,000 – 29,999

w ......30.000- 34,999

x ... ... . 35,000 – 39,999

Y .... ...40.000-44.999

z ... ....45.000 49,999

Zz .. ... . 50,000 and over

CARD O

1.Puerto Rican

2. Cuban

3. Mexican/Mexicano

4. Mexican American

5. Chicano

6. Other Latin American

7. Other Spanish

CARD J

A .... ... .. Less than 1,000 (including loss)

B . ... ... .. 1,000 – 1,999

c ... .. ... . 2,000 – 2,999.

D ......... 3,000 – 3,999

E ......... 4,000 – 4,999

F ......... 5,000 – 5,999

G .... .. ... 6,000 – 6,999

H ......... 7,000 – 7,999

1 .. .. ... .. . 6,000 – 8,999

J ... ... .. . 9,000- 9,899

K .........10.000 – 10,999

L .........11.000-11.999

M .. ... ...12.000 – 12,999

N .. .. ... .. . 13,000 – 13,999

0 .. ... ....14.000 – 14,989

P .........15.000 – 15,999

Q ... .. ....16.000 – 16,999

R .. ... ....17.000 – 17,999

s .. .. .....18.000 – 18,999

T .........19.000 – 19,999

164