ASTHMA

• Within the past 12 months have you experienced any wheezing?
• In the past 12 months, have you used any medication for breathing problems such as inhalers like Primatene Mist, Alupent, or Ventolin or taken pills such as Theo-Dur or Solbid?
• Has a health care provider ever told you that you have asthma?
• In the past 12 months, have you visited an emergency room or been hospitalized for asthma?

DEMOGRAPHICS 

• What is your race?
• Are you of Spanish or Hispanic origin?
• Marital status?
• How many children live in your household who are less than 5 years old?
• How many children live in your household who are 5 through 12 years old?
• How many children live in your household who are 13 through 17 years old?
• What is the highest grade or year of school you completed?
• Employment status?
• Is your annual household income from all sources...?
• How much do you weigh without shoes?
• How much would you like to weigh?
• About how tall are you without shoes?
• What county do you live in?
• Do you have more than one telephone number in your household?
• How many residential telephone numbers do you have?

DIABETES

• Have you ever been told by a doctor that you have diabetes? If YES AND FEMALE: "Was this only when you were pregnant?"
• How old were you when you were told you have diabetes?
• Are you now taking insulin?
• Have you ever heard of glycosylated hemoglobin [gli-KOS-ilated he-mo-glo-bin] or hemoglobin "A one C"?
• About how many times in the last year have you seen a doctor, nurse, or other health professional for your diabetes?
• About how many times in the last year has a doctor, nurse, or other health professional checked you for glycosylated hemoglobin or hemoglobin "A one C"?
• About how many times in the last year has a health professional checked your feet for any sores or irritations?
• 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.
• How much of the time does your vision limit you in recognizing people or objects across the street?
• How much of the time does your vision limit you in reading print in a newspaper, magazine, recipe, menu, or numbers on the telephone?
• How much of the time does your vision limit you in watching television?
• Have you attended any formal diabetes education sessions, either classes or one-on-one training with a diabetes educator?
• When was the last time you took a diabetes education class?
• Are you taking aspirin daily or every other day in order to reduce your risk of heart disease or other disease?
• About how long has it been since you last had your blood pressure taken by a doctor, nurse, or other health professional?
• Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?
• Have you been told on more than one occasion that your blood pressure was high, or have you been told this only once?
• Blood cholesterol is a fatty substance found in the blood. Have you ever had your blood cholesterol checked?
• About how long has it been since you last had your blood cholesterol checked?
• Have you ever been told by a doctor or other health professional that your blood cholesterol is high?

EXERCISE 

• During the past month, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?
• What type of physical activity or exercise did you spend the most time doing during the past month?
• What other type of physical activity gave you the next most exercise during the past month?
• Physical Activity Level
• Sedentary Lifestyle: Sedentary, Irregular Physical Activity
• At Risk for Inactivity

FIREARMS 

• Are any firearms now kept in or around your home? Include those kept in your home, in a garage, outdoor storage area, car, truck or other motor vehicle.
• What is the main reason that there are firearms in or around your home?
• During the past 30 days, have you had a firearm in or around your home at anytime that was both loaded and unlocked?
• During the last 30 days, have you carried a loaded firearm on your person, outside of the home for protection against people?
• In the past three years, have you attended a firearm safety workshop, class, or clinic?

FOLIC ACID

• Do you currently take any vitamin supplement with folic acid?
• Some health experts recommend that certain women consume additional daily amounts of folic acid, one of the B Vitamins. Before today, have you ever heard of this recommendation?
• To the best of your knowledge, why is folic acid recommended for certain women?
• At the time you became pregnant, did you want to become pregnant then, did you want to wait until later, or did you want to become pregnant at all?
• Did you take multivitamins or vitamins containing folic acid before you were pregnant or did you start taking them after you knew you were pregnant?

HEALTH CARE ACCESS

• Do you have any kind of health care coverage?
• Do you have Medicare?

• What type of health care coverage do you use to pay for most of your medical care?
• There are some types of coverages you may not have considered. Please tell me if you have any of the following:
• About how long have you had this particular health care coverage?
• Is there a book or list of doctors associated with your health coverage?
• Does your health care plan require you to select a certain doctor or clinic for all of your routine care?
• About how long has it been since you had health care 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?

HEALTH STATUS

• Would you say that in general your health is...?
• 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, 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?

HIV/AIDS

• If you had a child in school, at what grade do you think he or she should begin receiving education in school about HIV infection and AIDS?
• If you had a teenager who was sexually active, would you encourage him or her to use a condom?
• What are your chances of getting infected with HIV, the virus that causes AIDS?
• Have you ever had your blood tested for HIV?
• Have you donated blood since March 1985?
• What was the main reason you had your last blood test for HIV?
• Where did you have your last blood test for HIV?
• Did you receive the results of your last test?
• Did you receive counseling or talk with a health care professional about the results of your test?
• Some people use condoms to keep from getting infected with HIV through sexual activity. How effective do you think a properly used condom is for this purpose?
• Due to what you know about HIV, have you changed your sexual behavior in the last 12 months?
• Have you had sexual intercourse with only one partner?
• Have you used condoms for protection?
• Have you been more careful in selecting sexual partners?

INFLUENZA & PNEUMONIA

• During the past 12 months, have you had a flu shot?
• Have you ever had a pneumonia vaccination?

INJURY PREVENTION ISSUES

• What is the age of the oldest child in your household under the age of 16?
• What is the gender of that child?
• During the past year, how often has the oldest child worn a bicycle helmet when riding a bicycle?

INTERPERSONAL VIOLENCE

• During the past 12 months, did anyone threaten to beat you up or threaten you with a knife, gun or some other weapon?
• During the past 12 months, have you been subject to any physical violence?
• During the past 12 months, how many different occasions have you been subject to physical violence?
• On the most recent occasion, was the person who did this to you. . .?
• During the past 12 months, how many times was this same person involved in the other incidents you mentioned?
• Before this last incident occurred did this same person ever threaten to beat you or threaten you with knife, gun or other weapon?
• 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?
• Was this last incidence reported to the police or other law enforcement agency?
• There is help for domestic violence victims. Would you like the number?

NUTRITION

• Summary Index of Fruit and Vegetable Consumption

QUALITY OF LIFE

• Are you limited in any way in any activities because of any impairment or health problem?
• What is the major impairment or health problem that limits your activities?
• Because of any impairment or 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?
• 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?

SEXUAL BEHAVIOR

• During the past 12 months, with how many people have you had sexual intercourse?
• The last time you had sexual intercourse was it with your regular or steady partner or with someone else?
• Was a condom used the last time you had sexual intercourse?
• Last time you had sexual intercourse, did you use a method of birth control?
• What was the primary method of birth control?
• Was there a reason not to use a method of birth control?
• Have you used intravenous drugs in the past year?
• Have you been tested for a sexually transmitted or venereal disease in the past year?
• Have you tested positive for having HIV, the virus that causes AIDS?
• ONLY IF MALE UNDER 50: Have you had sex with another male in the past year?

SMOKE EXPOSURE

• On how many of the past 30 days has someone, including yourself, smoked in your home?
• Which of these best describes your place of work's smoking policy for work areas?
• In a typical week, about how many hours would you say you are exposed to secondhand smoke at work?
• Which of the following statements best represents your opinion on children's exposure to second hand smoke?

SMOKELESS TOBACCO USE

• Do you currently use any smokeless tobacco products such as chewing tobacco or snuff?
• On how many of the past 30 days did you use smokeless tobacco?

TOBACCO USE

• Have you smoked at least 100 cigarettes in your entire life? (5 packs = 100 cigarettes.)
• 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?
• On the average, when you smoked during the past 30 days, about how many cigarettes did you smoke a day?
• During the past 12 months, have you quit smoking for 1 day or longer?
• About how long has it been since you last smoked cigarettes regularly, that is, daily?
• At what age did you start smoking?
• Would you like to quit smoking?
• Has a doctor or other health professional advised you to stop smoking?
• Computed Smoking Status
• Smoking: Current Smokers

WEIGHT CONTROL

• Are you now trying to lose weight?
• Are you now trying to maintain your current weight, that is to keep from gaining weight?
• Are you eating fewer calories to lose weight or maintain your current weight?
• Are you using physical activity to lose weight or maintain your current weight?
• In the past 12 months, has a doctor, nurse, or other health professional given you advice about your weight?
• Obese 120% Above Median
• Obese: BMI gt 27.8(M) 27.3 (F)

WOMENS HEALTH 

• Have you ever had a mammogram?
• How long has it been since you had your last mammogram?
• Was your last mammogram done as part of a routine checkup, because of a breast problem other than cancer, or because you've already had breast cancer?
• Other than that condition, how long has it been since you had a mammogram that was part of a routine checkup?
• What was the main reason you have never had a mammogram?
• What is the main reason you have not a mammogram within the last two years?
• ALL WOMEN OVER 40: Has any doctor or health professional suggested that you have a mammogram as part of your routine health care?
• How often do you believe women your age should get a mammogram?
• Have you ever had a clinical breast exam?
• How long has it been since your last breast exam?
• Was your last breast exam done as a part of a routine checkup, because of a breast problem other than cancer, or because you've already had breast cancer?
• A breast self-exam is when a woman feels her own breasts for lumps. How often do you do a breast self-exam?
• Have you ever been instructed or trained by a professional on how to do a breast self-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?
• Was your last Pap smear done as part of a routine exam, or to check a current or previous problem?
• What is the main reason you have not had a Pap smear?
• What is the main reason you have not had a Pap smear within the last three years?
• Have you had a hysterectomy?
• To your knowledge, are you now pregnant?

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