ALCOHOL CONSUMPTION

• During the past month, have you had at least one drink of any alcoholic beverage such as beer wine, wine coolers, or liquor?
• A drink is 1 can or bottle of beer, 1 glass of wine, 1 can or bottle of wine cooler, 1 cocktail, or 1 shot of liquor. On the days when you drank, about how many drinks did you drink on the average?
• Considering all types of alcoholic beverages, how many times during the past month did you have 5 or more drinks on an occasion?
• During the past month, how many times have you driven when you've had perhaps too much to drink?
• Acute Drinker
• Chronic Drinker
• Drinking and Driving

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?

CHOLESTEROL AWARENESS

• 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?

COLORECTTAL CANCER SCREENING

• A blood stool test is a test that may use a special kit at home to determine whether the stool contains blood. Have you ever had this test using a home kit?
• When did you have your last blood stool test using a home kit?
• A sigmoidoscopy or proctoscopy is when a tube is inserted in the rectum to view the bowel for signs of cancer and other health problems. Have you ever had this exam?
• When did you have your last sigmoidoscopy or proctoscopy?

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?
• What is your annual household income from all sources?
• What county do you live in?
• Do you have more than one telephone number in your household?

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 had formal diabetes education?
• Are you taking aspirin daily or every other day in order to reduce your risk of heart disease or other disease?

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?
• Do any of the firearms kept in or around your home belong to you personally?

FOLIC ACID

• Do you currently take any vitamin pills or supplements?
• Are any of these a multivitamin?
• Do any of the vitamin pills or supplements you take contain folic acid?
• Some health experts recommend that women take 400 micrograms of the B vitamin folic acid, for which one of the following reasons...

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?

HEATH 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?
• Due to what you know about HIV, have you changed your sexual behavior in the last 12 months?
• In the past twelve months did you decrease the number of your sexual partners or become abstinent?
• Do you now have sexual intercourse with only the same partner?
• Do you now always use condoms for protection?

HYPERTENSION AWARENESS

• 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?
• At Risk for Hypertension

INFLUENZA & PNEUMONIA

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

INJURY PREVENTION ISSUES

• How often do you use seatbelts when you drive or ride in a car?
• What is the age of the oldest child in your household under the age of 16?
• For the oldest child in your household, how often are seatbelts used when riding in a car? (If oldest child under 5 years old, how often is a car safety seat used?)
• During the past year, how often has the oldest child worn a bicycle helmet when riding a bicycle?
• When was the last time you or someone else deliberately tested all of the smoke detectors in your home, either by pressing the test buttons or holding a source of smoke near them?
• At Risk for Non-Seatbelt Use (Not at Risk = nearly always or always wears a seatbelt)
• At Risk for Non-Seatbelt Use (No Risk = always wears a seatbelt)

RABIES EXPOSURE

• My next question is about rabies. Some animals, including bats, can carry rabies. During the past 12 months, did anyone see a bat inside your home?

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 illegal injection 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?

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 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?
• At your last visit to your health care provider, did someone ask you if you smoked, either by questionnaire or in person?
• At your last visit to your health care provider, were you advised to quit smoking?
• Has a doctor or other health professional ever advised you to quit smoking?
• About how long ago was it that a health care professional advised you to quit smoking?
• At your last visit to your health care provider, were you offered recommendations or assistance on how to quit smoking?
• At Risk for Smoking
• Computed Smoking Status
• Smoking: Current smokers

WEIGHT CONTROL

• At Risk for Overweight/BMI
• Obese: BMI greater than 27.8 (for Males) or 27.3 (for Females)

WOMEN'S 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?
• A clinical breast exam is when a doctor, nurse, or other health professional feels the breast for lumps. 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 within the last three years?
• Have you had a hysterectomy?
• To your knowledge, are you now pregnant?