- 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?
- 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?
HEALTH CARE ACCESS
INFLUENZA & PNEUMONIA
INJURY PREVENTION ISSUES
- 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?
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?
SMOKELESS TOBACCO USE
Return to the top of the page.