ALCOHOL CONSUMPTION

 module tables

•  During the past 30 days, how often have you had at least one drink of any alcoholic beverage?
• Considering all types of alcoholic beverages, how many times during the past month did you have 5 or more drinks on an occasion?

ARTHRITIS

 module tables

• During the past 12 months, have you had pain, aching, stiffness in or around a joint?
• Were these symptoms present on most days for at least one month?
• Are you now limited in any way in any activities because of joint symptoms?
• Have you seen a doctor, nurse, or other health professional for these joint symptoms?
• Have you ever been told by a doctor that you have arthritis?
• Are you currently being treated by doctor for arthritis?

ASTHMA

 module tables

• Within the past 12 months, have you experienced any wheezing?
• Have you ever been told by a doctor, nurse or other health care professional that you had asthma?
• Do you still have asthma?
• Symptoms of asthma include cough, wheezing, shortness of breath, chest tightness, when you don't have a cold or respiratory infection. During the past 4 weeks, how often did you have any symptoms of asthma? Would you say:?
• During the past 4 weeks, how many days did the symptoms of asthma disturb your sleep? Would you say:?
• During the past 12 months, how many times did you see a doctor or health professional for routine treatment or evaluation of asthma?
• In the past 12 months, how many times have you visited an emergency room or been hospitalized because of asthma?
• During the past 12 months, have you had an episode or an asthma attack?
• Hospitalizations are overnight stays in the hospital for asthma, not including emergency room or urgent care visits. During the past 12 months, how many times have you been hospitalized for your asthma??
• During the past 4 weeks, how often did you take doctor-prescribed asthma medication? This includes using an inhaler. Would you say:?
• During the past 12 months, how many times did you see your doctor or health provider for urgent treatment of worsening asthma symptoms?
• Did your doctor or other health care provider ever show you how to use a peak flow meter?
• Did your doctor or health care provider ever give you information on how to avoid the things that make your asthma worse?
• Did your doctor or health care provider ever explain how to recognize the early signs of an asthma episode?
• Have you been given written directions by a doctor, nurse or other health care provider about how to take your asthma medicine?
• During the last 3 months, how much did you limit your usual activities because of your asthma?
• During the last 3 months, how many days of work, school or other daily activities did you miss because of asthma?
• Earlier you said there were children age 17 or younger living in your household. How many of these children have ever been diagnosed with asthma?
• Does this child/How many of these children still have asthma?

CARDIOVASCULAR DISEASE

 module tables

• Has a doctor ever told you that you had a heart attack or myocardial infarction?
• Has a doctor ever told you that you had angina or coronary heart disease?
• Has a doctor ever told you that you had an angina stroke?

CHOLESTEROL

 module tables

• Blood cholesterol is a fatty substance found in the blood. Have you ever had your blood cholesterol checked?
• Have you ever been told by a doctor, nurse, or other health professional that your blood cholesterol is high?
• About how long has it been since you had your blood cholesterol checked?

COLORECTAL SCREENING FOR CANCER

 module tables

• Have you ever had a Sigmoidoscopy or a colonoscopy exam?
• When did you have your last Sigmoidoscopy or a colonoscopy?
• Have you had a blood stool test using a home kit?
• When have you had a blood stool test using a home kit?

DEMOGRAPHICS

 module tables

• What county do you live in?
• Are you of Spanish or Hispanic origin?
• What is your race? (A single race from multiple races and a primary race is reported)
• What is your race? (A single race or combination with primary race reported)
• Marital status? Are you?
• How many children live in your household who are less than 18 years old?
• What is the highest grade or year of school you completed?
• Employment status? Are you currently?
• Is your annual household income from all sources?
• Do you have more than one telephone number in your household?
• Overweight and obesity prevalence among adults.
• At risk for chronic disease based on Body Mass Index (BMI) being 25.0 or higher.

DIABETES

 module tables

• Have you ever been told that you have diabetes?
• How old were you when you were told you have diabetes?
• Are you now taking insulin?
• Are you now taking pills to treat your diabetes? These are pills to lower blood sugar?
• Do you currently have a personal target for your fasting blood glucose level?
• When you test your blood glucose, about how often do you save your test results on paper, in a log, glucose memory meter or computer? Would you say:?
• When was the last time you had an eye exam in which the pupils were dilated? This would have made you temporarily sensitive to bright light.
• Have you ever attended any formal diabetes education programs, such as a class or one-on-one training with a diabetes educator?
• When was the last time you had this formal diabetes education session?
• What type of diabetes education session was this?
• Does your current health insurance coverage pay for all or part of the cost of diabetes education programs?
• Was there a time in the past 12 months when you needed to see a doctor for your diabetes or to get your medicine but could not because of cost?
• Have you ever heard of glycosyliated hemoglobin (pronounced gli-KOS-il-a-ted he-mo-glo-bin)or Hemoglobin (A one C)?
• Do you know the results of your last glycosylated hemoglobin test?
• During the past 12 months, did a doctor, nurse, or other health professional test the feeling in your feet or lower legs by touching you with something and asking if you could feel it?
• How worried are you that in the next 10 years you will get diabetes?
• This question asks about your family members who are related to you by blood (do not include diabetes during pregnancy). Do you have a parent, brother or sister related by blood, who has or has had diabetes?
• During the past 12 months, did a doctor, nurse, or other health professional talked with you about diabetes?
• In the past 12 months, have you been tested by a health care provider for diabetes?
• Are you taking aspirin daily or every other day in order to reduce your risk of heart disease or other disease?

EXERCISE AND PHYSICAL ACTIVITY

 module tables

• During the past 30 days, other than your regular job, did you participate in any physical activities or exercise such as running, calisthenics, golf, gardening, or walking for exercise?
• When you are at work, which of the following best describes what you do? Would you say:?
• Now, thinking about the moderate physical activities you do in a usual week, do you do moderate activities for at least 10 minutes at a time, such as brisk walking, bicycling, vacuuming, gardening, or anything else that causes small increases in breathing or heart rate?
• Now thinking about the vigorous physical activities you do in a usual week, do you do vigorous activities for at least 10 minutes at a time, such as running, aerobics, heavy yard work, or anything else that causes large increases in breathing or heart rate?
• At risk for no leisure time physical activity.

FAMILY PLANNING - Female

 module tables

• Have you been pregnant in the last five years?
• Thinking back to your last pregnancy, just before you got pregnant, how did you feel about becoming pregnant?
• Are you or your husband or partner using any kind of birth control now?
• What kinds of birth control are you or your husband or partner using now?
• When you have intercourse, how often do you use a method to prevent pregnancy?
• How long have you been using a method to prevent pregnancy every time you have intercourse?
• In the next six months, do you intend to use a method to prevent pregnancy every time you have intercourse?
• In the next 30 days, do you intend to use a method to prevent pregnancy every time you have intercourse?
• From your understanding, would you say the emergency birth control can be used to:?
• In the past 5 years, have you used emergency birth control pills?
• In the last year, have you used emergency birth control pills?
• What are your reasons for not using any birth control now?
• What 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?
• Have you ever used the services at a family planning clinic?
• How long has it been since you used the services at a family planning clinic?
• Have you ever used a health department clinic for female health concerns?
• How long has it been since you used a health department clinic for female health concerns?
• Earlier you said that you went to a health department clinic for female health concerns. How long has it been since you used a health department clinic for those services?
• Does your health insurance cover at least some birth control methods?
• Does your health insurance pay for the birth control method you use?
• Does your health insurance pay for the birth control method you want to use?
• Did you know there is free or low cost birth control at health departments and clinics?

FAMILY PLANNING - Male

• Have you had sexual intercourse that resulted in pregnancy in the last 5 years?
• When was the last time a sex partner became pregnant by you?
• Thinking back to just before she got pregnant how did you feel about her becoming pregnant?
• Are you or your wife or partner using any kind of birth control now?
• What kinds of birth control are you or your wife or partner using now?
• When you have intercourse, how often do you use a method to prevent pregnancy?
• How long have you been using a method to prevent pregnancy every time you have intercourse?
• What are your reasons for not using any birth control now?
• In the last year, have you gone to a health care provider for birth control or family planning services including condoms or vasectomy?
• When you went for birth control or family planning services in the last year, did you go to either a Planned Parenthood clinic or a health department clinic?
• In the next six months, do you intend to use a method to prevent pregnancy every time you have intercourse?
• In the next 30 days, do you intend to use a method to prevent pregnancy every time you have intercourse?
• Does your health insurance coverage pay for at least some of the cost of a vasectomy?
• Did you know there is free or low cost birth control at health departments and Planned Parent clinics?
• From your understanding, would you say emergency birth control can be used?
• In the last five years, did a partner of yours use emergency birth control pills?
• In the last year, did a partner of yours use emergency birth control pills?

FIREARMS

 module tables

• 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 the firearms handguns, such as pistols or revolvers?
• What is the main reason that there are firearms in or around your home?
• Is there a firearm in or around your home that is now both loaded and unlocked?
• During the last 12 months, have you confronted another person with a firearm,even if you did not fire it, to protect yourself, your property, or someone else?
• Do any of the firearms kept in or around your home belong to you, personally?

FOLIC ACID AND VITAMIN/SUPPLEMENTS

 module tables

• Currently Takes a Multivitamin or Other Supplement Containing Folic Acid.
• How Often Took Folic Acid: Daily and Weekly.
• Why is folic acid recommended?

HEALTH CARE COVERAGE & SOURCE

 module tables

• Do you have any kind of health care coverage?
• Are you currently enrolled in the Oregon Health Plan, which is the state's Medicaid Program?
• During the past twelve months, was there a time that you did not have any health insurance or coverage?
• Was there a time during the last 12 months when you needed to see a doctor, but could not because of the cost?
• About how long has it been since you last visited a doctor for a routine checkup?
• Do you have one person who you think of as your personal doctor or health care provider?

HEALTH STATUS

 module tables

• How is your general health?
• For how many days during the past 30 days was your physical health not good?
• For how many days during the past 30 days was your mental health not good?
• During the past 30 days, how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?

HIV/AIDS

 module tables

• True or false: A pregnant woman with HIV can get treatment to help reduce the chances that she will pass the virus on to her baby?
• True or false: There are medical treatments available that are intended to help a person who is infected with HIV to live longer?
• How effective do you think these treatments are in helping persons with HIV to live longer?
• Have you ever been tested for HIV?
• How important do you think it is for people to know their HIV status by getting tested?
• What was the main reason you had your last test for HIV?
• Where did you have your last blood test for HIV?
• In the past 12 months, has doctor, nurse, or other health professional talked to you about preventing sexually transmitted diseases through condom use?

HUNGER

 module tables

• The first statement is, "The food that we bought just didn?t last, and we didn?t have money to get more." Was that often, sometimes, or never true for you in the last 12 months? ?
• The second statement is, "We couldn't afford balanced meals." Was that often, sometimes, or never true for you in the last 12 months? ?
• 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?
• In the last 12 months, how often did you cut the size of your meals or skip meals because there wasn?t enough money for food?
• 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?

HYPERTENSION AWARENESS

 module tables

• Have you ever been told by a health professional that you had high blood pressure?
• Are you taking medicine for your high blood pressure?

INFLUENZA & PNEUMONIA

 module tables

• During the past 12 months, have you had a flu shot?
• At what kind of place did you get your last flu shot?
• What was the most important reason that you did not get a shot?
• Have you ever had a pneumonia shot? This shot is usually given only once or twice in a person's lifetime and is different from the flu shot. It is also called the pneumococcal [new-mo-COCK-uhl] vaccine.

INTERPERSONAL VIOLENCE

 module tables

• During the past 12 months, have you been subject to any physical violence?
• During the past 12 months, on how many different occasions have you been subject to physical violence?
• On the most recent occasion, who was the person who did this to you...?
• On the most recent occasion, were you injured?
• Did you go to an emergency room, hospital, doctor, dentist or other medical care facility to get treatment for this injury?

NUTRITION

 module tables

• Index of Fruit and Vegetable Consumption. Current recommendation is to eat five or more servings per day, to reduce the risk of chronic disease, including some types of cancer, heart disease, and stroke.

ORAL HEALTH

 module tables

• How long has it been since you last visited a dentist?
• How long has it been since you had your teeth cleaned by a dentist or dental hygienist?
• What is the main reason you have not visited the dentist in the past year?

PROSTATE CANCER SCREENING

 module tables

• A Prostate-Specific Antigen test, also called a PSA test, is a blood test used to check men for prostate cancer. Have you ever had a PSA test?
• How long has it been since you had your last PSA test?
• A digital rectal exam is an exam in which a doctor, nurse, or other health professional places a gloved finger into the rectum to feel the size, shape, and hardness of the prostate gland. Have you ever had a digital rectal exam?
• How long has it been since your last digital rectal exam?
• Have you ever been told by a doctor, nurse, or other health professional that you have prostate cancer?
• Has your father, son, brother, or grandfather ever been told by a doctor, nurse, or other health professional that he had prostate cancer?

QUALITY OF LIFE

 module tables

• How often do you get the social and emotional support you need?
• In general, how satisfied are you with your life?
• Because of any impairment or health problem, do you have any trouble learning, remembering, or concentrating?
• Are you limited in any way in any activities because of any impairment or health problems?
• Because of any impairment of health problem, do you need the help of other persons with your PERSONAL care needs, such as eating, bathing, dressing, or getting around the house?
• Because of any impairment or health problem, do you need the help of other persons in handling your ROUTINE needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?
• Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?
• What is the farthest distance you can walk by yourself, without any special equipment or help from others?
• During the past 30 days, for about how many days did PAIN make it hard for you to do your usual activities, such as self-care, work, or recreation?
• Is there anyone else in your household who is limited in any way in any activities because of any impairment or health problem?
• What is the major impairment of health problem that limits the activity of the person in your home?
• How old is this first person who is limited?
• How old is this second person who is limited?
• How old is this third person who is limited?
• How old is this fourth person who is limited?
• How old is this fifth person who is limited?
• Are you limited in the kind or amount of work you can do because of any impairment or a health problem?
• Are you concerned that you would lose your Supplemental Security Income, known as SSI, Supplemental Security Disability Income, known as SSDI, or other sources of income if you went to work?
• Are you concerned that you would lose your subsidized housing if you went to work?
• Are you concerned that you would lose your Medicare or Medicaid coverage if you went to work?
• Are you concerned that you would not be able to find a job offering affordable health insurance as a benefit?
• Are you concerned that you would lose your subsidized personal attendant services if you went to work?
• Are you concerned that you would need additional attendant care services at home if you went to work?
• Are you concerned that you would not be able to take time off for health-related reasons?
• Are you concerned that you would need work accommodations, such as accessible work space?
• Are you concerned that you wouldn't have control over the pace or scheduling of work activities?
• Are you concerned that you don't have convenient or accessible transportation?
• Are you concerned that you wouldn't earn enough money to make up for the disability-related benefits that you would lose by becoming employed?
• Are you concerned that employers have negative attitudes toward people with disabilities?
• Are you concerned that your training or skills are not adequate to be employed?
• Are you concerned that there are no jobs available that you could perform?
• 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 30 days, for about how many days have you felt you did not get enough rest or sleep?
• During the past 30 days, for about how many days have you felt very healthy and full of energy?

SMOKE EXPOSURE

 module tables

• Secondhand smoke is smoke from someone else's cigarette, cigar, or pipe that you breathe. Would you say that breathing secondhand smoke is:?
• Is there an adult living in your household who does not smoke cigarettes, cigars, or pipes?
• Is there an adult living in your household who smokes cigarettes, cigars, or pipes?
• Do you agree or disagree with the following statement: People should be protected from secondhand smoke?
• On how many of the past 30 days has someone, including yourself, smoked cigarettes, cigars, or pipes anywhere inside your home?
• Which of these best describes the rules about smoking inside your home?
• What are the rules about smoking your family's cars?
• Does your place of work have an official policy that restricts smoking in any way?
• Which of these best describes your place of work's smoking policy for indoor public or common areas, such as lobbies, rest rooms, and lunch rooms?
• Which of these best describes your place of work's smoking policy for work areas?
• Do you agree or disagree: Smoking should not be allowed in bars?
• Do you agree or disagree: Smoking should not be allowed in indoor work areas?
• Do you agree or disagree: Smoking should not be allowed in restaurants?
• How important is it that communities keep stores from selling tobacco products to minors?
• Which of the following statements best describes how you think the tobacco industry is being treated these days?
• Do you think that the tobacco companies have been honest or dishonest with the public about the dangers of tobacco use?
• Do you agree or disagree with the following statement: Store owners should be required to have a license to sell tobacco products, just like they are required to have a license to sell alcohol?
• Do you agree or disagree with the following statement: Tobacco use by adults should not be allowed on school grounds or at any school events?
• How important is it that communities keep stores from selling tobacco products to minors?
• Do you agree or disagree with the following statement: Cigarette companies deliberately advertise and promote cigarettes to encourage youth under 18 to smoke?

SMOKELESS TOBACCO USE

 module tables

• Do you currently use any smokeless tobacco products such as chewing tobacco and snuff?
• On how many of the past 30 days did you use smokeless tobacco products?
• Are you seriously considering stopping the use of smokeless tobacco within the next 6 months?
• Are you planning to stop within the next 30 days?
• At risk for smokeless tobacco-related illnesses (current users of smokeless tobacco).

SUICIDAL THOUGHTS

 module tables

• During the past 12 months, did you ever seriously consider attempting suicide?
• During the past 12 months, how many times did you actually attempt suicide?
• Did any of these attempts result in an injury, poisoning, or overdose that had to be treated by a doctor or nurse?

TOBACCO USE

 module tables

• Current smoking status.
• Have you smoked at least 100 cigarettes (5 packs = 100 cigarettes)in your entire life?
• Do you now smoke cigarettes everyday, some days, or not at all?
• On the average, about how many cigarettes a day do you now smoke (1 pack = 20 cigarettes)?
• During the last 30 days, on the average, about how many cigarettes did you smoke (1 pack = 20 cigarettes)?
• In your lifetime, have you ever quit smoking for one year or more?
• During the past 12 months, what was the longest period of time you did not smoke?
• During the past 12 months, have you quit smoking for 1 day or longer?
• Would you like to quit smoking?
• How long since you last smoked cigarettes regularly?
• At your last visit to your health care provider, did someone ask you if you smoked?
• At your last visit to your health care provider, were you advised to quit smoking?
• Has a doctor or other health care professional ever advised you to quit smoking?
• When was the last time a health care professional advised you to quit smoking?
• At your last visit to your health care provider, were you offered recommendations or assistance to quit smoking?
• If you were trying to quit smoking, how helpful do you think it would be to have assistance such as a nicotine patch or nicotine gum or a smoking cessation program?
• Are you seriously considering stopping smoking within the next 6 months?
• Are you planning to stop within the next 30 days?
• Does your health insurance coverage pay for the cost of any smoking cessation assistance such as nicotine replacement or a smoking cessation program?
• Thinking of when you successfully quit smoking, please tell me the single most important reason you had for quitting?
• When you quit smoking, did you use any other assistance such as counseling or classes?
• When you quit smoking the last time, did you use a nicotine patch, nicotine gum, or any other medication to help you?
• The last time you tried to quit smoking, did you use a nicotine patch, nicotine gum, or any other medication to help you quit?
• The last time you tried to quit smoking, did you use any other assistance such as counseling or classes?
• How soon after you awaken in the morning do you smoke your first cigarette?
• The last time you bought cigarettes, what brand did you buy?
• The last time you bought cigarettes, did you purchase them by the carton or the pack?
• In the last year, have you bought cigarettes over the Internet?
• Have you smoked a cigar in the past month?
• Do you agree or disagree with the following statement: People close to me are upset at my smoking?
• At risk for smoking-related illnesses (current smokers).

TRAVEL TO WORK

 module tables

• On at least three separate days last week, did you commute to a job outside of your residence?
• On a regular basis, do you walk part or all of the way to work?
• On a regular basis, do you bicycle part or all of the way to work?

WEIGHT CONTROL

 module tables

• Overweight and obesity prevalence among adults.
• At risk for chronic disease based on Body Mass Index (BMI) being 25.0 or higher.
• Are you trying to lose weight?
• Are you now trying to maintain your current weight, that is to keep from gaining weight?

WOMEN'S HEALTH

 module tables

• Have you ever had a mammogram?
• How long has it been since you had your last mammogram?
• A clinical breast exam is when a doctor, nurse, or other health professional feels the breast for lumps. Have you ever had a clinical exam?
• How long has it been since your last breast exam?
• A pap smear is a test for cancer of the cervix. Have you ever had a pap smear?
• How long has it been since you had your last pap smear?
• A hysterectomy is an operation to remove the uterus. Have you had a hysterectomy?
• To your knowledge, are you now pregnant?