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?

ASTHMA

• Within the past 12 months, have you experienced any wheezing?
• In the past 12 months, have you used any medication for breathing?
• Has a health care provider ever told you that you have asthma?
• In the past 12 months, how many times have you visited an emergency room or been hospitalized because of asthma?

CHOLESTEROL SCREENING

• Have you ever had your blood cholesterol checked?
• Have you ever been told by an 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

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

DEMOGRAPHICS

• What county do you live in?
• What is your race?
• Are you of Spanish or Hispanic origin?
• Marital status? Are you:
• 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? Are you currently:
• What is your annual household income from all sources?
• Do you have more than one telephone number in your household?

DIABETES

• When you visit a health professional for routine care, is diabetes discussed?
• In the past 12 months, has a health professional talked with you about diabetes?
• In the past 12 months, have you been tested for diabetes?
• When you were tested for diabetes in the past 12 months, was this for a routine screening or because you had symptoms?
• 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?
• How concerned are you about the long term complications of diabetes?
• Are you now taking insulin?
• Currently, about how often do you use insulin?
• About how often do you check your blood for glucose or sugar?
• About how many times in the last year have you seen a health professional for your diabetes?
• 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?
• In the past 12 months, has a health professional explained to you the importance of testing your blood glucose?
• In the past 12 months, has a health professional explained to you how and when to test your blood glucose?
• In the past 12 months, has a health professional explained how to adjust your food choices to help manage your blood glucose?
• In the past 12 months, has a health professional explained to you about getting exercise?
• In the past 12 months, has a health professional explained to you about the long-term consequences of diabetes?
• In the past 12 months, has a health professional watched you test your blood glucose?
• 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?
• How important is following your self-management recommendations such as diet, exercise and glucose testing for controlling your diabetes?
• On a daily basis, how difficult is it for you to eat the right kinds of foods to help you manage your blood glucose test levels?
• On a daily basis, how difficult is it for you to get the right amount of exercise you need to help you manage your blood glucose levels?
• On a daily basis, how difficult is it for you to eat meals and snacks when you should to help you manage your blood glucose levels
• 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?
• What type of diabetes education was this?
• Does your current health insurance coverage pay for all or part of the cost of diabetes education programs?
• Do you currently have a personal target for your fasting blood glucose level?
• Are you taking aspirin daily or every other day in order to reduce your risk of heart disease or other disease?

FAMILY PLANNING - Females

• 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?
• 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?
• 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 - Males

• 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?
• When you have intercourse, how often do you use a method to prevent pregnancy?
• How long have you been using a method to prevent pregancy 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?
• 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

• 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? Is it coverage through:?
• There are some types of coverages you may not have considered. Please tell me if you have any of the following coverage through:?
• 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?

HEALTH STATUS

• 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

• 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?
• 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?

HYPERTENSION

• About how long has it been since you last had your blood pressure taken by a health professional?
• Have you ever been told by a health professional that you had high blood pressure?
• Have you ever been told on more than one occasion that your blood pressure was high?

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?
• In the past year, has this child worn a helmet when riding?
• When was the last time all of the smoke detectors in your house were tested?

ORAL HEALTH

• How long has it been since you last visited a dentist?
• How many of your permanent teeth have been removed because of tooth decay or gum disease?
• How long has it been since you have had your teeth cleaned by a dentist or hygienist?

QUALITY OF LIFE

• Are you limited in any way in any activities because of any impairment or health problems?
• Because of any impairment or health problem, do you have any trouble learning, remembering, or concentrating?
• For how long have your activities been limited because of a major impairment or health problem?
• Because of any impairment of health problem, do you need the help of other persons with your personal are needs?
• 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?
• 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 a health problem?
• 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 work accomodations, 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 you would not be able to take time off for health-related reasons?
• 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 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 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?
• What is the major impairment or health problem that limits the activity of the fourth disabled person in your home?
• 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?

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's presence in your house; e.g. a doctor, nurse or the health department?
• 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

• 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?

SMOKE EXPOSURE

• Secondhand smoke is smoke from someone else's cigarette, cigar, or pipe that you breathe. 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 indoor work areas, do you think that smoking should be allowed in all areas, or not allowed at all?
• Considering that restaurants are worksites for waiters and waitresses, do you think that smoking should be allowed in all areas of restaurants?
• In restaurants when customers are smoking, workers are exposed to secondhand smoke.
  Should smoking be allowed in restaurants?
• Do you agree or disagree with the following statement: Smoking should not be allowed in restaurants?
• In restaurants do you think that smoking should be allowed in all areas?
• 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 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?

SUICIDAL 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?

SUN EXPOSURE/SUNBURN HISTORY

• Have you had a sunburn within the past 12 months?
• How many sunburns have you had in the past 12 months?

TOBACCO USE

• 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)?
• During the past 12 months, have you quit smoking for 1 day or longer?
• How long since you last smoked cigarettes regularly?
• How soon after you awaken in the morning do you smoke your first cigarette?
• 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?
• On how many of those visits were you advised to quit smoking?
• At your last visit to your health care provider, were you offered recommendations or assistance to quit smoking?
• In the past 12 months, has a health professional provided information or help 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?
• When you quit smoking the last time, did you use a nicotine patch, nicotine gum, or any other medication to help you?
• When you quit smoking, did you use any other assistance such as counseling or classes?
• 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?
• 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?
• Have you smoked a cigar in the past month?

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?
• What was the main reason that you never had a mammogram?
• What is the main reason that you have not had 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 exam?
• How long has it been since your last breast exam?
• Was your last 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 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?
• A hysterectomy is an operation to remove the uterus. Have you had a hysterectomy?
• To your knowledge, are you now pregnant?