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?

DEMOGRAPHICS

• What county do you live in?
• 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?
• 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 concerned are you about the long term complications of diabetes?
• Do you agree or disagree with the following statement: The long term complications of diabetes are preventable?
• How serious is your diabetes?
• How important is following your self-management recommendations such as diet, exercise, and glucose testing for controlling your diabetes?
• How much has your doctor or health care provider helped you set clear, specific goals for managing your diabetes?
• How worried are you about developing complications of diabetes, like eye problems, foot ulcers, or heart attacks?
• In the past 12 months, did you cut down on things you usually do, such as going to work or working around the house, because of illness or injury?
• How many days did you cut down on the things you usually do because of illness or injury?
• In the past 12 months, did you ever stay in bed because of an illness or injury?
• How many days did you stay in bed because of illness or injury?
• How old were you when you were told you have diabetes?
• Are you now taking insulin?
• During an office visit, has a doctor, nurse, or other health professional ever watched you test your blood sugar?
• Does your health insurance coverage pay for all or part of the cost of test strips for home glucose monitoring?
• About how many times in the last year have you seen a doctor, nurse, or other health professional for your diabetes?
• 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 has a doctor, nurse, or other health professional checked you for glycosylated hemoglobin or hemoglobin "A one C"?
• Have you ever heard of a fructosamine [frook-TOE-sah-mean] determination or fructosamine test?
• About how many times in the last year has a doctor, nurse, or other health professional checked you for fructosamine?
• About how many times in the last year has a health professional asked you about numbness or tingling in your feet?
• About how many times in the last year has a health professional asked you about your foot care such as trimming your toenails or checking for infections?
• About how many times in the last year has a health professional checked your feet without your shoes and socks on?
• When, if ever, was the most recent time that a health professional tested the feeling in your feet or legs by touching you with something and asking if you could feel it?
• 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 took a diabetes education class or training?
• Does your current health insurance coverage pay for all or part of the cost of diabetes education programs?
• Are you taking aspirin daily or every other day in order to reduce your risk of heart disease or other disease?
• Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?
• 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?
• About how long has it been since you last visited a dentist or hygienist?
• As far as you know, does your health care coverage pay for the total cost of a flu shot?

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?
• Was there another physical activity or exercise that you participated in during the last month?
• What other type of physical activity gave you the next most exercise during the past month?

FAMILY PLANNING

• 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?
• Thinking back to just before you got pregnant with your current pregnancy, 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?
• 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?
• How long has it been since you used a health department clinic for those services?
• 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?
• 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?

FIREARMS

• 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?
• Are any of the firearms long guns, such as rifles or shotguns?
• 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 30 days, have you carried a loaded firearm on your person, outside of the home for protection against people?
• During the last 30 days, have you driven or been a passenger in a motor vehicle in which you knew there was a loaded firearm?
• 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?
• 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?

HEALTH CARE COVERAGE & SOURCE

• 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...
• During the past twelve months, was there a time that you did not have any health insurance or coverage?
• 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?
• How would you rate your health care?
• How would you rate the availability of information from your plan regarding eligibility, covered services, or administrative issues?
• Thinking about all your experience with your health insurance plan, how would you rate your health insurance plan now?
• Is there one particular clinic, health center, doctor's office, or other place that you usually go to if you are sick or need advice about your health?
• Thinking of the distance or time you travel to get to the place you usually go to, how would you rate the convenience of that place?
• Has a doctor or other health professional ever talked with you about your diet or eating habits?
• Has a doctor or other health professional ever talked with you about physical activity or exercise?
• Has a doctor or other health professional ever talked with you about injury prevention, such as safety belt use, helmet use, or smoke detectors?
• Has a doctor or other health professional ever talked with you about drug abuse?
• Has a doctor or other health professional ever talked with you about alcohol use?
• Has a doctor or other health professional ever talked with you about your sexual practices, including family planning, sexually transmitted diseases, AIDS, or the use of condoms?

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 been tested for HIV?
• Have you donated blood since March 1985?
• Have you donated blood in the past twelve months?
• Except for tests you may have had as part of blood donations, have you ever been tested for HIV?
• Not including your blood donations, have you been tested for HIV in the past twelve months?
• Have you been tested for HIV in the past twelve months?
• What was the main reason you had your last 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?

INFLUENZEA & PNEUMONIA

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

INTERPERSONAL VIOLENCE

• Do you currently have a boyfriend or girlfriend?
• In the last 12 months, how many times did your husband, wife, etc., kick, bite, or punch you?
• In the last 12 months, how many times did your husband, wife, etc., push, shove, or grab you?
• In the last 12 months, how many times did your husband, wife, etc., hit you with something that could hurt?
• In the last 12 months, how many times did your husband, wife, etc., slap you or hit you with an open hand?
• In the last 12 months, how many times did your husband, wife, etc., beat you up?
• In the last 12 months, how many times did your husband, wife, etc., choke you?
• Did any of these behaviors of your husband, wife, etc., result in the following? Deep scratches, cuts or bruises?
• Did any of these behaviors of your husband, wife, etc., result in the following? Broken bones or damage to your face, eyes, ears, or teeth?
• Did any of these behaviors of your husband, wife, etc., result in the following? Moderate to extreme soreness or pain?
• Did any of these behaviors of your husband, wife, etc., result in the following? Medical, dental, chiropractic or hospital treatment?
• Would you like to have a telephone number that you could use to make a free call to get referrals and information for yourself or anyone you know that has experienced violence in their relationships?

QUALITY OF LIFE

• How often do you get the social and emotional support you need?
• In general, how satisfied are you with your life?
• Are you limited in any way in any activities because of any impairment or health problem?
• Because of any impairment or health problem, do you have any trouble learning, remembering, or concentrating?
• If you use special equipment or help from others to get around, what type do you use?
• Using special equipment or help, what is the farthest distance that you can go?
• What is the farthest distance you can walk by yourself, without any special equipment or help from others?
• Are you limited in the kind or amount of work you can do 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?
• Are you concerned that you would lose your Supplemental Security Income; Supplemental Security Disability Income; 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 were no jobs available that you could perform?
• 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?
• 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?
• Is there anyone else in your household who is limited in any way in any activities because of any impairment or health problem?
• How old is this person who is disabled in your home?
• How old is this second person who is disabled in your home?
• How old is this third person who is disabled in your home?
• What is the major impairment or health problem that limits the activity of the person in your home?
• What is the major impairment or health problem that limits the activity of the second disabled person in your home?
• What is the major impairment or health problem that limits the activity of the third disabled person in your home?
• During the past two weeks, did you get together socially with friends neighbors or any relatives?
• During the past two weeks, did you talk with friends, neighbors or any relatives on the telephone?
• During the past two weeks, did you go to church, a temple, or another place of worship for services or other activities?
• During the past two weeks, did you go to a show or movie, sports event, club meeting, class or other group event?
• During the past two weeks, did you go out to eat at a restaurant?
• How many days in the past two weeks did you leave your home for any reason?
• Regarding your present social activities, do you feel that you are doing about enough, too much, or would you like to be doing more?

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?
• In which room of the house was the bat first found?
• Did the bat bite anyone?
• Did the bat scratch anyone?
• Was the bat found in the room where someone had been sleeping during the previous 12 hours?
• How many people had been sleeping in the room when the bat was found?
• Were doors open for the bat to fly into a room where someone was sleeping?
• How many people were sleeping in this room or these rooms with open doors?
• Was the bat in a room where it might have bitten or scratched someone who was awake, but who would not have been able to tell you?
• Did you or anyone in your household have physical contact with the bat?
• Did you consult anyone about the bat being in your house?
• Whom did you consult?
• Whom else did you consult?
• Was the bat alive when it was found?
• Was the bat captured?
• Was the bat tested for rabies?
• Could you have captured the bat if you wanted to?
• Was anyone in the house vaccinated for rabies after the bat was found?

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?
• 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?
• Have you had sex with another male within the last year?

SMOKE EXPOSURE

• Would you say that breathing secondhand smoke is: ?
• 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?
• Within the past 12 months, has your employer offered any stop smoking program or any other help to employees who want to quit smoking?
• 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?
• Would you like your work site to have a policy that restricts smoking in some way?
• In restaurants do you think that smoking should be allowed in all areas, in some areas, or not allowed at all?
• In indoor work areas do you think that smoking should be allowed in all areas, in some areas, or not allowed at all?
• In your opinion, how easy is it for minors to buy cigarettes and other tobacco products in your community?
• 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 both children and adults should not be allowed on school grounds or at any school events?
• Do you agree or disagree with the following statement: Advertising of tobacco products on outdoor billboards should be allowed?
• Do you agree or disagree with the following statement: Billboards that advertise tobacco products should not be allowed near places children often go?
• 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

• 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 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?

SUIDICAL THOUGHTS

• 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

• 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 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?
• 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 on how to quit smoking?
• 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?
• Have you ever smoked a cigar, even just a few puffs?
• When was the last time you smoked a cigar?
• In the past month, did you smoke cigars: ?
• Are you seriously considering stopping smoking cigars within the next 6 months?
• Are you planning to stop (smoking cigars) within the next 30 days?
• Do you currently smoke tobacco in a pipe?
• In the past month, did you smoke tobacco in a pipe: ?
• Are you seriously considering stopping smoking a pipe within the next 6 months?
• Are you planning to stop within the next 30 days?

WEIGHT CONTROL

• Are you 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 or less fat to lose weight or keep from gaining weight?
• Are you using physical activity or exercise to lose weight or keep from gaining weight?
• In the past 12 months, has a doctor, nurse, or other health professional given you advice about your weight?
• In the past two years, have you taken any weight loss pills prescribed by a doctor?

WOMEN'S HEALTH

• A mammogram is an x-ray of each breast to look for breast cancer. 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?
• 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?
• 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?
• 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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