nL Cg, Py snigidion AN >. 4 2 NCHS ES & NW he STAT > CER CERT ORT 1957-1974 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Health Resources Administration Library of Congress Cataloging in Publication Data United States. National Center for Health Statistics. Health interview survey, 1957-1974. (Its Vital and health statistics: Series 1, Programs and collection procedures; no. 11) (DHEW publication no. (HRA) 75-1311) 1. Health surveys—United States. I. Title. II. Series. III. Series: United States. Dept. of Health, Education and Welfare. DHEW publication no. (HRA) 75-1311. RA409.U44 no. 11 312°.07°23s [312°.07°23] 74-32057 ISBN 0-8406-0037-2 PROGRAMS AND COLLECTION PROCEDURES Series 1 Number 11 Health Interview Survey Procedure 1957-1974 DHEW Publication No. (HRA) 75-1311 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Health Resources Administration National Center for Health Statistics Rockville, Md. April 1975 NATIONAL CENTER FOR HEALTH STATISTICS EDWARD B. PERRIN, Ph.D., Director PHILIP S. LAWRENCE, Sc.D., Deputy Director GAIL F. FISHER, Associate Director for the Cooperative Health Statistics System ELIJAH L. WHITE, Associate Director for Data Systems IWAO M. MORIYAMA, Ph.D., Associate Director for International Statistics EDWARD E. MINTY, Associate Director for Management ROBERT A. ISRAEL, Associate Director for Operations QUENTIN R. REMEIN, Associate Director for Program Development ALICE HAYWOOD, Information Officer DIVISION OF HEALTH INTERVIEW STATISTICS ROBERT R. FUCHSBERG, Director PETER RIES, Ph.D., Chief, Illness and Disability Statistics Branch KINZO YAMAMOTO, Ph.D., Chief, Utilization and Expenditure Statistics Branch CLINTON E. BURNHAM, Chief, Survey Planning and Development Branch COOPERATION OF THE BUREAU OF THE CENSUS Under the legislation establishing the National Health Survey, the Public Health Service is authorized to use, insofar as possible, the services or facilities of other Federal, State, or private agencies. In accordance with specifications established by the National Center for Health Statistics, the Bureau of the Census, under a contractual arrangement, participated in planning the survey and collecting the data. Vital and Health Statistics-Series 1-No. 11 DHEW Publication No. (HRA) 75-1311 Library of Congress Catalog Card Number 74-32057 Introduction History of the Interview Survey Background of the Survey :us:.evsnss wssinssvasnss nen Concepts Used in the Health Interview Survey ............. Technical Aspects of the Survey Statistical Design scsvss avne sa Lobed@ ans sbans a anehs buen Estimating Procedures ««cesocisrssad brtsnnd srsndn sss Reliability of Estimates .......vviiiiereennrreennnnann Errors Due to Sampling Variability scxvvnrsnsvvrsnnn rons Questionnaire Development History of the Questionnaire Format ..........c.ovuuenn. The Basic Questionnaire . ccosvsrosrnss errors ssnsses res Supplements to the Basic Questionnaire .........ccc0evnn. Appendix I. Rotating Supplements CONTENTS Health Insurance Coverage, FY 1960 (July-December 1959) ........... c.count. FY 1963 .uucecencrunnnvernnonne nuesnnvnunns orn FYandCY 1968 .uiiiveviinonennsnnunssnanen nee CY 1970 coc iviiiirimsinsasbted noaninsnoyin ins OY 1072 iow vunsnsruneinvitatnntt rundus nubiis va CY 1974 cucicrvnnvusonmernvennmennusmunrunnvns Hearing Ability, BY 1063 ,ivntviventvmesintnsbinssdmis nbnids ni LO A Loss of Income, FYMACY 1968 cuniircunirnsnensnunoncnuvsns as CY 1874 cisivinssavimissiiissiicnssss bbmpusns Nursing Care and/or Special Aids, FY 1989 ,cunvevenovsnonatonannsnuennsnnsennns FY 1967-68 iucvvennvusunsnsnnunasrounnsvonnnnss CY 1869 cincivcrissmsvnnsnsnnvoniinnsinshuinimens Personal Health Expenses, FY 1963 (July-December 1962) ..............onn. BY 1066 .vvucvvnnsonumnnn rrnsnnsnusns suannns CY 1971 suuiavvnvssnnnnnnenssnws sonne saonennss © © 5 © 0 0 0 0 0 0 0 0 0 es 0 0 es es ss S00 ee es EE Ee eee eee eee ee ese © oe 6 00 000000000000 000000 000 eo 0 00000 00 e000 00000 eee e000 000 © © 0 0 0 ec 0 0 00 0 0 ss 00 0 esse 0 000 eee 0 ee es ss 00000 ee 00 000000 eo e000 0000 eos 0 000000 so 00000000 Page NN Oe op NO bt pt 11 39 41 41 41 42 42 43 44 45 49 5] 52 54 54 57 58 61 64 iii CONTENTS.—Con. Prescribed and Nonprescribed Medicines, FY 1988 .cvuvnninemons siossmsvsosses snus sinssasnsmnase CY 1973 iicvviicioniosniomssssoiiissvenansnnssnniosnnssiv Smoking Habits, FY 196886 .cucnvcronmenrannnsununsnsorsnnennsnnns rasnns CY 1070 cicivniucsnnninsnsnsesussssvnssnnmsnanesss onan Vision Impairment and Use of Corrective Lenses, FY JOB3 ivevumsesnnnsnnsnnnenvanssvnennsrasssssrsnnnns FY 1980 .iocicitecosnsrnsmcnensesscsnnssnsnvsssssrnnens CY 1971 .icrsnnvrsnnneprspinonnssiisnsbivitusnasimnnsns X-Ray Visits, FY 1981 .ivinenivsnune invnonevrnessisvonsneounsnnssmnnssee FY 1964 {April-June 1964) .. cvvcvcusisirsnsvasnssnonssnsnns CY 1970 (April-September 1970) ........ciiiiiiiiennennnnn. Appendix II. One-Time or Single Supplements .............cce0vivvnnn, Acute Conditions: CF 1974 cu convinsinvvnsnssvnnmeinssnnn nossne Artis: CY 1909 oi. covnnuivsianssrpnsosrnsnnss husvasinnnsss Blood Donorship: CY 1973 .....civivvrinrrrrnnrnnnrsrannsssnnnss Diabetes: FY 19680 vous srrunvsnvsussss rrmennevusnnnsrnssnssvonses Hypertension: CY 1974 .uveunvrvsvssnvssennonnssnmvsnsssnsansnns Medical Care Availability: CY 1974 .......ciiiiiiiiiiiiiennnnnnn. Motor Vehicle Accidents: CY 1968 .........cciiiiiiiiiiiiinnnnn.. OrthodonticCare: CY 1974 ..... vii iiiiininirennnneennnennnnsnnns Pregnancy: CY 1973 .uvcunncurnvnnsuennnmrevunnerensenssanssnse Preventive Care: CY 1973 ius iivunnrnvennnsvsnsnssnnsssonsnvsnes Specialists’ Services and Routine Checkups: FY 1964 ................. Appendix III. Definition of Certain Terms Used in the Health INIEIVIEW SUIVEY su snsu isi divcvsbuwonnssssssassans Rasunnesnnnon oe Terms Relating to Conditions ..ceveecervectsrnecrrrensssessnssns Terms Relating to Disability ...cccccenssrrreeennrvvnnsvesssnnsns Terms Relating to Persons Injured «uu coven scrvnsnsrsennsnnnnnns es Terms Relating to Class of Accident ....ccvccscncsvnssnnsvnvsnmens Terms Relating to Hospitalization ........... cc... Terms Relating to Dental VISHS cous vuvsmssnvmsnovsnnnsnsusvens rus Terms Relating to Physician Visits .........coiiiiiiiiiiiiinnennnnn. Terms Relating to Special Aids .....cvivniivrinnrennsnsrnessnrsns Terms Relatingto Home Care ............cc0iiiiiiiiiiennnnn. Family and Related Terms « ccovcnnsnvnsnsvvsnnsvunsnevrsnssnerns Terms Relating to Health Insurance .......... civ. Terms Relating to Acquisition and Cost of Medicines ................. Terms Relating to Corrective Lenses .......coviiiiiiiiiiennnnnnnnn Terms Relating to Cigarette Smoking ............ciiiiiiin., Demographic TEMS vvvess sevsnns nranervonsun ennusnsrovsnes sans CONTENTS.—Con. Page Appendix IV. Checklists for Selected Chronic Conditions: 1968-73 .......... 148 Conditions of the Digestive System: 1968 ...............ccvuuun.... 148 Conditions of the Bones, Joints, Muscles, and Skin: 1969 .............. 149 Conditions of the Respiratory System: 1970 ..........cccvveurunnn... 150 Impairments: 1971 ...vvevrvronsnsssnssnmasnsnsnsvosisvssssss 151 Conditions of the Cardiovascular System: 1972 ............ccvvuu.n.... 152 Conditions Affecting the Nervous System, Glandular Disorders, and Conditions of the Genitourinary System: 1978 ................. 153 HEALTH INTERVIEW SURVEY PROCEDURE 1957-1974 INTRODUCTION The Health Interview Survey, one of a variety of programs conducted by the National Center for Health Statistics to gather information on the health of the American people, has been in ~ operation since July 1957. The survey consists of a continuous sampling and interviewing of the civilian, United States. In addition to the collection of information and the production of health statistics, research studies relating to survey methodology and improved techniques in data collection have been carried out since the beginning of the survey. As a result of these studies and of the experience gained in the collection process, many changes have occurred in the format, content, and administration of the question- naire, the collection document used in the survey. This report outlines the changes that have led to the improvement of data collection in the household survey since its inception. The expan- sion of the survey is also examined to provide for the gathering of information on supple- mental health-related topics. An earlier report! published in 1964 covers the measurement concepts, the questionnaire development, and definitions used during the first 7 years of the survey. Certain components of the survey, particularly those dealing with the structure of the interview, the respondent, and noninstitutional population of the. the time references of the interview, are described in great detail. Since the present report is not directed primarily to the ideo- logical and behavioral aspects of the survey, the reader with interests in these areas is referred to the earlier report and to some of the methodo- logical studies2-1% released by the National Center for Health Statistics. However, in order to present a chronological description of changes in the survey, the timespan 1957-74 will be covered in the present report. HISTORY OF THE INTERVIEW SURVEY Background of the Survey Legislation authorizing the U.S. Public Health Service to conduct surveys of illness and dis- ability was enacted in July 1956 (Public Law 652, 84th Congress). The Health Interview Survey, the first of a number of data-collection systems implementing the legislation, was organized during the fall and winter of 1956. The resources of the Bureau of the Census were obtained through contractual arrangement to prepare a sample design and to provide services for the collection and processing phases of the program. During February 1957, the procedures were pretested in the Washington, D.C., area and in Charlotte, N.C. From the findings of this pretesting, revisions were made in the collection procedures, and a national sample was pretested during May and June 1957. Collection of data started officially on July 1, 1957, and has continued without interruption since that time. However, prior to the planning of the inter- view questionnaire and the construction of a sample design, it was necessary to develop some concepts relating to the kinds of information to be collected. In the development of concepts, survey personnel relied heavily on the experi- ences of researchers who had used the interview as a data-collection method. Early in the 1920s, certain populations in Hagerstown, Md., were selected for epidemiological studies and the measurement of levels of selected health char- acteristics in a local population. These studies continued during the next several decades. Dur- ing 1935-36, a major nationwide health survey was carried out with 737,000 urban households visited by interviewers. Both of these studies contributed to the knowledge concerning the basic kinds of health data that can be collected by household interview. Since 1936, with the development and refinement of sampling tech- niques and procedures, the interview method has been used as a means of data collection in a number of local studies of morbidity. Foremost among these are surveys conducted in Baltimore, Md.; Pittsburgh, Pa.; Hunterdon County, N.]J.; Kansas City, Mo.; New York City; and the State of California. Concepts Used in the Health Interview Survey Even though plans for the Health Interview Survey could be based on the experience and findings of many researchers, concepts and definitions have continued to develop with the expansion and growth of the survey. From information gathered in interviews, an attempt is made to describe the social, demographic, and economic aspects of illness, disability, and the use of medical services. Since interview data measure these health items in terms of the impact they have on the lives of individuals rather than in terms of medical criteria, the concepts of morbidity, disability, and the use of services differ basically from those used in scientific and medical studies. Morbidity.—Morbidity is considered as a departure from a state of physical or mental well-being, resulting from disease or injury, of which the affected individual is aware. Aware- ness connotes a degree of measurable impact on the individual or his family in terms of the restrictions and disabilities caused by the morbidity. Morbidity includes not only active or progressive disease but also impairments, that is, chronic or permanent defects that are static in nature, resulting from disease, injury, or con- genital malformation. The existence of morbidity in an individual caused by a particular disease, injury, or impairment is called a “mor- bidity condition,” or simply a “condition.” During the course of this condition, there may be one or more periods when the affected individual considers himself to be “sick” or “injured.” These periods are spoken of as episodes of illness. The period or periods of illness may coincide with the period during which the condition exists, or they may cover only a part of that period. A condition may involve no illness, in the usual sense of the word. Hence, illness is only one form of evidence of the existence of a morbidity condition. Other evidence might be a decrease in, or complete loss of, ability to perform various functions, par- ticularly those of the musculoskeletal system or the sense organs; or a change in the appearance of the body, such as a rash or lump, believed to be abnormal by the person affected. For the purposes of this survey, the concept of a morbidity condition is usually further limited by specifying that it includes only conditions as a result of which the person has taken one or more various actions. Such actions might be the restricting of usual activities, bed disability, work loss, the seeking of medical advice, or the taking of medicines. The start, or onset, of the condition is conceived to be the time when the person first becomes aware of it. If there is an illness associated with the condition, the start, or onset, is usually the time when the illness begins or the injury occurs. In many instances, it may be the time when a physician tells the person that he has a condition of which he was previously unaware. In the statement of this concept, there has been reference to the individual’s awareness of his condition and to the individual’s actions as a - result of the condition. Obviously, in the case of children, the statement must be modified. It is not always the child’s awareness or the child’s action that establishes the existence of a mor- bidity condition. Instead, it is the awareness and action of the people responsible for the care of the child, usually the parents. A similar modifi- cation applies to adults who are not competent to care for themselves. Disability.—The term “disability” has several common uses. For example, a “disability” often means a condition that interferes with ability to work. Also, conditions are frequently classified as producing temporary partial, temporary total, permanent partial, or permanent total ‘dis- ability.” In this sense, the various degrees of “disability” have some legal or official definition that is related to compensation. There is also the term ‘‘disabling,” which has been used in illness surveys for many years to describe a condition that prevents the individual from carrying on his usual activities for 1 or more days. It has been observed that speaking of a ‘disabling condition,” as the term has been used in surveys, meant to some people no less than severe chronic disability, despite the fact that the range of conditions covered might include such minor disability as the case of the common cold that laid the person up for a day or two. Because the other uses had gained such wide acceptance in certain fields, it was decided not to employ the term “disability” in this survey except in a very general sense where it is intended to cover the whole field of interference with activities caused by disease, injury, or impairment (in much the same way that the term “morbidity” is used for a generic rather than a specific concept) and also where other words used with it make clear the desired meaning, as in “bed disability.” For other specific indexes of disability, new terms that are more descriptive of the concepts of the survey have been and will be introduced. Furthermore, it was decided that the Health Interview Survey needed not one, but several different, specifi- cally defined indexes of disability to serve different purposes. These are presented in appendix III. The disability terms used in this survey may be grouped into the following three categories: (1) terms describing the individual’s status dur- ing a specified day, or number of days, which are equally applicable to acute conditions or chronic conditions, to all members of the population, and to any day of the week, for example, restricted-activity day and bed-disabil- ity day; (2) terms describing the individual’s status during a specified day, or number of days, which apply to both acute and chronic condi- tions but only to certain members of the population on days when they would have been working at a job or business, or going to school, if it had not been for their condition, for example, work-loss day and school-loss day; and (3) terms applying only to chronic conditions, or persons with one or more chronic conditions, which describe their usual status ‘““at the present time,” meaning in this case during recent months, for example, “chronic activity limita- tion” and “chronic mobility limitation.” Since these terms were devised for use in this survey and have special meanings, it is especially important that the user of statistics from the survey become familiar with the concepts that the terms represent. Medical services and facilities. —The personal interview can be used as a medium for determin- ing how illnesses, injuries, and impairments affect people—the restrictions and disabilities they suffer and the medical care they receive. This latter term may be broadly interpreted to encompass the concept of utilization of medical services and facilities. It might be so broadly defined as to include everything that people use to care for their well-being, including such items as health sanitation, personal hygiene, and food intake. The Health Interview Survey measures the utilization of medical services and facilities in terms of medical attention, dental care, and hospitalization; use of X-ray facilities, preventive care services, nursing care services, and pros- thetic appliances and devices; self-treatment; and other similar components of medical care or services. The use of the concept of medical attendance necessitates defining the term “physician” and also defining what is meant by “talking to” or consulting a physician. The definitions are con- tained in appendix III. Medical attendance is broadly defined; it does not imply continued attendance or consultation, nor does it require that the physician give the advice in person. The emphasis is on the fact that the condition was brought to the attention of a physician and that the initial action necessary to set in motion the procedure of diagnosis and treatment was taken. Any definition more restrictive than this would involve the question of what constitutes ade- quate care—a question that is not a part of the subject matter of the survey. Two of the principal concepts in the area of medical care included in the interview are the physician visit and the classification of visits by type of service. These are closely paralleled by similar concepts in the area of dental care. In both of these areas, the following rules apply: (1) Included in the statistics are visits during which the service is given, not by the physician or dentist himself, but by some other person such as a nurse or dental hygienist acting under the physician’s or dentist’s supervision, and (2) excluded are visits during which the service consisted of a single procedure administered identically to a number of people who all came for the same purpose, as in a glaucoma or diabetes screening program. The first rule was adopted because it was believed to give a more useful measure of the total volume of care provided and because the concept as defined corresponded more closely to what the layman thinks of as a visit to the physician or dentist. The second rule, on the other hand, was introduced because certain types of service, particularly in the field of mass preventive care, seemed remote from the personalized care that is implied by the terms “physician visit” and “dental visit.” If a physician administered a test of hearing to every child in a school classroom, 1t hardly seemed appropriate that every child be counted as having had one “physician visit.” Therefore, it was decided that the counting of such services could be better handled as a separate inquiry into the volume and type of preventive care services. The average layman responding in an inter- view cannot give accurate detailed information about the nature of the service performed at each visit. Consequently, visits have been classi- fied in broad groups according to the type of service. The definitions and method of classify- ing physician visits and the terms dealing with the classification of hospitalization are presented in appendix III. The use of X-ray facilities has been measured in terms of visits to X-ray facilities, the part-of-body X-rayed, and the place of service. The extent of personal and nursing care received at home has been the subject of inquiry in terms of the condition causing the require- ment, the duration of the care, who performed the service, and whether it was constant or part time. The use of prosthetic appliances and other devices has been concerned with the use of hearing aids, artificial limbs, braces, and wheel chairs. The condition causing the use of the appliance was determined, as was the extent of use. The use of home remedies and other forms of self-treatment, the extent of preventive care, the availability of medical care, and attitudes regarding medical care are items that have recently been added to the survey questionnaire. TECHNICAL ASPECTS OF THE SURVEY Statistical Design The sampling plan of the survey follows a multistage probability design, which permits a continuous sampling of the civilian, noninstitu- tionalized population of the United States. The sample is designed in such a way that the sample of households interviewed each week is repre- sentative of the target population and that weekly samples are additive over time. This feature of the design permits both continuous measurement of characteristics of samples and more detailed analysis of less common character- istics and smaller categories of health-related items. The continuous collection has administra- tive and operational advantages as well as tech- nical assets since it permits fieldwork to be handled with an experienced, stable staff. In the first stage of the sampling process, primary sampling units (PSU’s) are selected from a universe of 1,900 such units, which are geographically defined and collectively cover the 50 States and the District of Columbia. Each, PSU consists of a standard metropolitan statistical area (SMSA) or one or two contiguous counties. In a series of successive sampling steps, a final sampling unit is selected, which consists typically of a cluster of neighboring households, called a “segment.” (Segments of 4, 6, and 9 households have been used at various times.) A basic design has persisted throughout the existence of the survey, but among the modifica- tions, four have been sufficiently distinct to be identified by design dates: the designs of 1957, 1959, 1963, and 1973. In the original 1957 design, 372 PSU’s were selected from the uni- verse. Approximately 36,000 households within these sampling units were assigned for interview- ing, with the average size of assignment being 12 households per interviewer. In the 1959 design, the number of selected PSU’s was increased to 503, with a corresponding increase to 38,000 ° households per year and to 13.5 households per average assignment. Both the 1957 and the 1959 designs were based on population figures from the 1950 Decennial Census. In 1963, when population data from the 1960 census became available, many changes were made to increase the efficiency of design. The number of PSU’s was decreased from 372 to 357. The structure of segments and assignments was modified in three important respects: (1) segment size was changed from an expected six households to an expected nine households; (2) the nine households were alternate ones in a cluster of about 18 neighboring households, whereas, earlier, the six had been a compact cluster of six adjacent households; and (3) assignments in a given week consisted of paired neighboring segments in 1963, while, earlier, an assignment attempted to pair unlike segments. In the new design, heterogeneity is obtained by giving the same interviewer different types of segments in successive weekly assignments. One result accompanying these changes was an increase in the average size of assignment from 13.5 households to 16 households. The manner of selecting specific segments was changed for about two-thirds of the total sample, from area sampling to list sampling, using the 1960 census registers as the list frame. Most of the remaining third of the sample continued as an area sample. Finally, the evidence from better estimates of eomponents of variance, plus the above changes, together with the benefits from joint designing with the Census/Bureau of Labor Statistics Current Population Survey led to a reduction from 503 to 357 PSU’s and an increase from 38,000 to 42,000 sample households. In July 1968, segment size was changed to six house- holds. In January 1973, the sample design was modified to reflect the 1970 Decennial Census. The number of PSU’s was increased from 357 to 376, and segment size was changed from six adjacent households to four adjacent households. Estimating Procedures Since the design of the interview survey is a complex multistage probability sample, it is necessary to use complex procedures in the derivation of estimates. The following four basic operations are involved: 1. Inflation by the reciprocal of the prob- ability of selection.—The probability of selection is the product of the probabilities of selection from each step of selection in the design (PSU, segment, and household). 2. Nonresponse adjustment.—The estimates are inflated by a multiplication factor, which has as its numerator the number of sample house- holds in a given segment and as its denominator the number of households interviewed in that segment. 3. First-stage ratio adjustment.—Sampling theory indicates that the use of auxiliary infor- mation that is highly correlated with the vari- ables being estimated improves the reliability of the estimates. To reduce the variability between PSU’s within a region, the estimates are ratio adjusted to the, 1960 populations within six color-residence classes. 4. Poststratification by age-sex-color.—The estimates are ratio adjusted within each of 60 age-sex-color cells to an independent estimate of the population of each cell for the survey period. These independent estimates are pre- pared by the Bureau of the Census. Both the first-stage and poststratified ratio adjustments take the form of multiplication factors applied to the weight of each elementary unit (person, household, condition, and hospitalization). The contribution of decedents to a total inventory of events, conditions, or services can be estimated. Since the sample of households is preselected for an entire collection year, it can be assumed that the continuous sampling pro- duces results that are analogous to those that would be obtained (with adjustment for seasonal variation) if all sample persons were interviewed on a single day during the year. If it is also assumed that the death rate throughout the year is fairly constant and that the vast majority of deaths occur in the civilian, noninstitutionalized population, a complete survey conducted on July 1, for example, would include the experi- ence of approximately one-half of the decedents during a given year. Thus, the conditions, events, and services for the remaining half of the decedents are missing from the interview data regardless of whether the reference period of the interview item is 2 weeks or a complete year. In 1972, there were 1,962,000 deaths in the united States. Estimates of the experience attributable to approximately 981,000 of these persons are missing from the interview survey. It has been established through methodological studies and from statistics provided by the Hospital Discharge Survey that individuals experience higher rates of disability and hospital episodes and receive a greater number of medical services during the last year of life than do persons in the general population.1%,16,17 On the basis of these findings, it can be estimated that as a maximum the rates among the decedents missed in the survey might be three times as high as those for the surveyed popula- tion. Table A provides, for selected items, a rough estimate of the underestimation caused by the exclusion from the survey of the experience of decedents. In 1972, there were approximately 28 million discharges from short-stay hospitals, a rate of 13.9 discharges per 100 persons. If the rate of discharges among decedents were three times that in the general population, or 40 discharges per 100 persons, then 392,000 were omitted from the survey. The inclusion of these would have increased the rate of discharges to 14.1 per 100 persons. The effect of the ratio-estimating process is to make the sample more closely representative of the civilian, noninstitutionalized population by age, sex, color, and residence, which thereby reduces sampling variance. As noted, each week’s sample represents the population living during that week and charac- teristics of the population. Consolidation of samples over a time period, for example, a calendar quarter, produces estimates of average characteristics of the U.S. population for the calendar quarter. Similarly, population data for a year are averages of the four quarterly figures. For prevalence statistics, such as number of persons with speech impairments or number of persons classified by time interval since last physician visit, figures are first calculated for each calendar quarter by averaging estimates for all weeks of interviewing in the quarter. Preva- lence data for a year are then obtained by averaging the four quarterly figures. For other types of statistics—namely, those measuring the number of occurrences during a specified time period—such as incidence of acute conditions, number of disability days, or number of visits to a doctor or dentist, a similar computational procedure is used, but the sta- tistics are interpreted differently. For these items, the questionnaire asks for the respon- dent’s experience over the 2 calendar weeks prior to the week of interview. In such instances, the estimated quarterly total for the statistic is 6.5 times the average 2-week estimate produced by the 13 successive samples taken during the period. The annual total is the sum of the four quarters. Thus, the experience of persons inter- viewed during a year—experience that actually Table A. Estimation of the effect of the exclusion of decedent experience on interview survey data (1972 estimates) Survey data Decedent data Survey rate Estimated adjusted to Interview item Number Rate Estimated number include (in per rate per missed in decedent thousands) | person decedent survey data experience (in thousands) Bed-disability days .............0itiiiiiiiii iia 1,319,566 6.5 19.5 19,130 6.6 Physician Visits ...vve viii inine nn innneennnennnnens 1,016,548 5.0 15.0 14,715 6.1 PErSONSINIUIBE. wiv 5 0 + 510 550m» wat 3 40% & B00 500 BW & 90% & M0 6006 3 64,259 0.3 0.9 883 0.3 occurred for each person in a 2-calendar-week interval prior to week of interview—is treated as though it measured the total of such experience during the year. Such interpretation leads to no significant bias. Rounding of numbers.—The original tabula- tions on which the data in reports are based show all estimates to the nearest whole unit. All consolidations were made from the original tabulations using the estimates to the nearest unit. In the final published tables, the figures are rounded to the nearest thousand, although these are not necessarily accurate to that detail Devised statistics such as rates and percent distributions are computed after the estimates on which these are based have been rounded to the nearest thousand. Population figures.—Some of the published tables include population figures for specified categories. Except for certain overall totals by age, sex, and color, which are adjusted to independent estimates, these figures are based on the sample of households in the Health Interview Survey. These are given primarily to provide denominators for rate computation, and for this purpose are more appropriate for use with the accompanying measures of health characteristics than other population data that may be available. With the exception of the overall totals by age, sex, and color mentioned above, the population figures differ from figures (which are derived from different sources) pub- lished in reports of the Bureau of the Census. Official population estimates are presented in Bureau of the Census reports in Series P-20, P-25, and P-60. Reliability of Estimates There are limitations to the accuracy of diagnostic and other information collected in household interviews. For diagnostic informa- tion, the household respondent can usually pass on to the interviewer only the information the physician has given to the family. For conditions not medically attended, diagnostic information ‘is often no more than a description of symptoms. However, other facts, such as the number of disability days caused by the condi- tion, can be obtained more accurately from household members than from any other source, since only the persons concerned are in a position to report this information. The population covered by the sample for the Health Interview Survey is the civilian, non- institutionalized population of the United States living at the time of the interview. The sample does not include members of the Armed Forces or U.S. nationals living in foreign countries. It should also be noted that the estimates shown do not represent a complete measure of any given topic during the specified calendar period, since data are not collected in the interview for persons who died during the reference period. For many types of statistics collected in the survey, the reference period covers the 2 weeks prior to the interview week. For such a short period, the contribution by decedents to a total inventory of conditions or services should be very small. However, the contribution by decedents during a long reference period (e.g., 1 year) might be sizable, especially for older persons. Since about 38 percent of all deaths are attributable to diseases of the heart, at least 373,000 cases of heart diseases are missed in the survey. The prevalence estimates of other causes of death, with lower mortality rates, may be affected to a lesser extent by the exclusion of decedents. Errors Due to Sampling Variability Since the statistics presented in a report are based on a sample, they will differ somewhat from the figures that would have been obtained if a complete census had been taken using the same schedules, instructions, and interviewing personnel and procedures. As in any survey, the results are also subject to reporting and processing errors and errors due | to nonresponse. To the extent possible, these types of errors were kept to a minimum by methods built into survey procedures. Although it is very difficult to measure the extent of bias in the Health Interview Survey, a number of studies have been conducted to examine this problem. The results have been published in several reports. The standard error is primarily a measure of sampling variability; that is, the variations that might occur by chance because only a sample of the population is surveyed. As calculated for a report, the standard error also reflects part of the variation that arises in the measurement process. It does not include estimates of any biases that might be in the data. The chances are about 68 out of 100 that an estimate from the | sample would differ from a complete census by less than the standard error. The chances are about 95 out of 100 that the difference would be less than twice the standard error and about 99 out of 100 that it would be less than 2% times as large. The relative standard error of an estimate is obtained by dividing the standard error of the estimate by the estimate itself and is expressed as a percentage of the estimate. For a report, asterisks are shown for any cell with more than a 30-percent relative standard error. Included in the appendix of all HIS reports are charts from which the relative standard errors can be deter- mined for estimates shown in the report. In order to derive relative errors that would be applicable to a wide variety of health statistics and that could be prepared at a moderate cost, a number of approximations were required. As a result, the charts provide an estimate of the approximate relative standard error rather than the precise error for any specific aggregate or percentage. The following three classes of statistics for the health survey are identified for purposes of estimating variances: 1. Narrow range.—This class consists of (1) statistics that estimate a population attribute, for example, the number of persons in a particular income group and (2) statistics for which the measure for a single individual during the reference period used in data collection is usually either 0 or 1, or on occasion may take on the value 2 or, very rarely, 3. ’ 2. Medium range.—This class consists of other statistics for which the measure for a single individual during the reference period used in data collection will rarely lie outside the range 0-5. 3. Wide range.—This class consists of statistics for which the measure for a single individual during the reference period used in data collec- tion can range from 0 to a number in excess of 5, for example, the number of days of bed disability. : 8 In addition to classifying variables according to whether they are narrow, medium, or wide range, statistics in the survey are further defined as: Type A. Statistics on prevalence and incidence for which the period of reference in the questionnaire is 12 months. Type B. Incidence-type statistics for which the period of reference in the question- naire is 2 weeks. Type C. Statistics for which the reference period is 6 months. Type D. Statistics for which the reference pe- riod is 3 months. QUESTIONNAIRE DEVELOPMENT The health interview questionnaire consists of a core of questions concerning items about which information has been collected each year. These basic items include acute conditions and injuries, chronic conditions, days of disability due to acute or chronic conditions, limitation of activity caused by chronic conditions or impair- ment, hospitalization, and the social, economic, and demographic characteristics of the inter- viewed sample persons. During recent years, medical care provided by physicians and dental care have become core items. Information on certain other health-related items has been collected in the survey periodi- cally, usually at intervals from 2 to 5 years. In the early years of the survey, these topics were described as rotating items and consisted of measures such as mobility limitation due to chronic illness, dental care, and the proportion of hospital bills paid by insurance. As the survey developed, there was an increasing demand for more detailed information about some of the core items, such as detailed data on types of injuries, the duration of activity limitation, the accessibility of physicians’ services, and conva- lescence following hospitalization. The need for this information led to the expansion of certain areas of the basic questionnaire to provide for the collection of these data at periodic intervals, introducing a slightly different category of rotating items. In addition, the questionnaire for a given year has usually included one or more special supple- ments. While most of the supplements were originally planned for a 1-year collection period, some of them deal with topics for which trend information is needed. Since the interview is the most efficient method of collecting this type of data, certain items are added to the basic questionnaire on a planned schedule. These items, which might be described as rotating supplements, include such topics as smoking habits, health insurance coverage, X-ray ex- posure, home care, the use of special aids, and personal health expenses. Other supplements, particularly those dealing with specific chronic conditions or impairments, have been added to the questionnaire on a less regular basis. This arrangement of expanded core items, rotating items, and supplements allows the survey to respond to changing needs for data and to cover a greater variety of topics, and at the same time provide for continuous informa- tion on certain fundamental topics. History of Questionnaire Format y During the planning phase of the interview survey in 1956-57, two general questionnaire formats were considered. The one referred to as “alternative B” was designed to elicit informa- tion about conditions through the reporting of actions a person might have to take as a result of illness. For example, a respondent would be asked if he had to (1) cut out or reduce all or part of his activities regularly or from time to time, (2) change his activities, (3) change his diet, (4) take medicine or treatment over a long period of time, or (5) wear or use some special device. After a positive response to any of the above statements, the respondent would be asked, “What was the matter?” While the original intent of this proposed format was to elicit information about chronic conditions, the same general approach was applicable to both chronic and acute conditions. The other format, the one actually used during the first 10 years of the Health Interview Survey (July 1957-June 1967), provided for the reporting of all kinds of morbidity conditions through a series of direct questions designed to encourage the reporting of illnesses and injuries. In contrast to alternative B, no attempt at the time the condition was initially reported was made to determine if some action had been taken by the person because of the condition. This format was used to maximize the number of conditions reported regardless of their impact or severity and to apply the criteria of medical attention, restricted activity, or limitation of activity during the coding and transcribing of the collected data. The selection of this questionnaire format, which is usually identified as the condition approach, was influenced by its general accept- ance in earlier health surveys. Illness-recall questions, which had been formulated and used successfully in the collection of health data in earlier surveys, served as a prototype for the first questionnaire used in the Health Interview Survey. Using a tested collection procedure made it possible to begin the interviewing phase of the survey much earlier than would have been the case if a completely untested procedure such as alternative B had been adopted. The wording of the introduction to the illness-probe questions—*“We are interested in all kinds of illness, whether serious or not”— indicates the comprehensive nature of this section of the questionnaire. These questions were structured to elicit information about any departure from a state of physical or mental well-being resulting from disease or injury, that is, a morbidity condition. The questions that were limited to occurrences during the last week or the week before were designed primarily to aid in the reporting of acute conditions. All reported conditions were recorded regardless of which type of question had prompted the reply. Whether these conditions were chronic was established later in the interview on the basis of a series of questions relating to the nature of the disease and its duration. During the succeeding years of the interview survey, the section of the questionnaire dealing with acute and chronic illness underwent certain changes. Progressive experience in survey collec- tion procedures on the part of the Health Interview Survey staff and the findings produced from continuing studies on survey methodology led to periodic changes, which in turn led to some improvement in the reporting of illness by the respondent. These changes included varia- tions in the order in which illness-recall ques- tions were asked, introduction of. a small calendar outlining the recall period for the convenience of the respondent, restructuring of 9 the checklists of chronic diseases and impair- ments, the identification of the condition(s) causing either limitation of activity or limitation of mobility, and format changes to accommo- date revised data-processing procedures. Despite these changes in the questionnaire, certain kinds of health-related information con- tinued to be underreported in the survey, although to a lesser extent than in the first years of the survey when, on the basis of research studies comparing interview data with medical records, it had been established that chronic conditions were not completely reported in the interview. For example, the prevalence of selected chronic conditions has increased with changes in the questionnaire formats. Early in 1963, after 6 years of data collection and in accordance with a long-range plan set up during the early years of the survey, a general evaluation of the design and format of the survey was undertaken. A timetable was pre- pared, which provided for considering proposed changes, deciding whether to accept, reject, or modify the proposed changes, and pretesting and evaluating the approved changes. A target date of July 1, 1967, was established for the completion of the evaluation and for the intro- duction of any new procedures in the collection phase of the survey. During the 4-year evaluative period 1963-67, the ongoing survey continued in line with collection procedures developed during the early years of the survey. Evaluation of the survey in terms of questionnaire content and format led to major changes that were introduced in July 1967. The new questionnaire introduced as a data- collection instrument in July 1967 resembled the approach suggested by the alternative B method of data collection considered at the beginning of the interview survey. The illness- recall questions, with a 2-week reference period, were replaced with probe questions pertaining to health-related actions during the period—for example, cutting down on usual activities, spending days in bed, losing time from work or school, or seeking medical attention. Informa- tion about conditions responsible for such actions was obtained from persons with positive response to the health-related action-probe questions. 10 Methodological studies, which had been conducted since the beginning of the survey, showed that chronic conditions are generally underreported in interviews. They also indicated that the expansion of a checklist of chronic conditions to include as many descriptive titles as possible will increase the probability of a person reporting a condition, assuming that he is aware of its existence. These findings led to the decision to restrict the collection of prevalence data on chronic conditions to specific types of conditions during a given collection year. This change in collection procedure was independent of the approach suggested by the alternative B method of data collection. However, since both procedural changes were experimental during the collection year July 1967-June 1968, they were tested on the new questionnaire introduced in the field. Concentrating on a group of chronic condi- tions involving a specific system of the body (e.g., those affecting the digestive system) rather than on the entire spectrum of chronic condi- tions not only improves the quality of response but also permits the collection of more detailed diagnostic information related to that body system. The survey plan calls for the collection of different types of conditions each year, so that within 5 or 6 years after the initiation of this plan, information on the prevalence of virtually all chronic conditions will have been obtained. Once the decision had been made to modify the collection procedure for chronic conditions by emphasizing a specific type of condition during a given year, it was necessary to develop, at the same time, procedures that would provide comparable data for other measures of morbid- ity that had been derived previously from data collected on all types of chronic conditions. One of these measures, the number of persons with limitation of activity (long-term disability), had previously been generated by consolidating the data on activity limitation attributable to specific chronic conditions reported by an indi- vidual to represent the activity limitation status of that individual. The most obvious alternative to this consolidation was to build a person-data foundation in terms of the degree of activity limitation and then ascertain the conditions responsible for the activity limitation status of the individual. The Basic Questionnaire The many procedural changes in the format and administration of the questionnaire during the course of the survey preclude a discussion of the content according to the sequence of the interview. For this reason, the description of the changes that have occurred will be presented on a topical basis covering the major areas of the questionnaire. Social, economic, and demographic character- istics.—After the interviewer identifies herself as a representative of the Bureau of the Census, the agency that serves as collection agent for the interview survey, she verifies the address as the one assigned on the first page of the question- naire and then starts the interview by asking questions to determine the social, economic, and demographic characteristics of the sample persons. Since the beginning of the survey, many changes in the wording of the questions designed to elicit this type of information have been made in order to improve their specificity and to increase the accuracy of the information obtained (figure 1). The transferring of questions relating to education, military service, employment, and marital status to a later section of the interview, as indicated by the numbering of the questions in the 1974 ques- tionnaire, made it possible to obtain data on health-related items nearer the beginning of the interview. Questions on personal characteristics that have been added, deleted, or included on an irregular basis follow: 1. Place of birth was asked for fiscal years 1958 and 1959 only. 2. Current activity status was added as a basic item to the questionnaire beginning in fiscal year 1960. 3. Questions relating to occupation and industry were included in the questionnaire for fiscal years 1962 and 1963 and were incorporated as a continuing item beginning in fiscal year 1966. 4. During calendar years 1968 and 1969, the question on income status was expanded to obtain information about the receipt of public assistance, relief, or welfare pay- ments to any of the family members. 5.0n the calendar year 1973 and 1974 questionnaires, an attempt was made to check the accuracy of the questions on age and income by ascertaining the year of birth and the amount of income for each family member. 6. During calendar year 1973, information on the number of times married was obtained for all persons who had ever been married. Illness and injury recall. —Because of the new approach in eliciting information on acute and chronic conditions introduced during the interim period, July 1967-December 1968, it is necessary to divide the description of the de- velopment of the illness-recall questions into two chronological periods: (1) the first 10 years of the survey, ending in June 1967, and (2) the following years beginning in July 1967 and continuing through calendar year 1974. 1. July 1957-June 1967: From a comparison of the illness and injury recall for fiscal years 1958 and 1967, it becomes obvious that several changes in questionnaire format occurred (figure 2). During the introduction to the probe questions in the later questionnaire, the respon- dent was given a small calendar on which the 2-week period referred to in the succeeding questions was outlined in red. This innovation was introduced on the fiscal year 1965 question- naire to aid the respondent in identifying the reference period for all “2-week questions.” Minor changes in wording and emphasis were made to stress the reference period and the presence of recurrent or seasonal conditions. A revision of the checklists of chronic condi- tions and impairments and the division of cards A and B into two parts were initiated on the fiscal year 1966 questionnaire and retained during fiscal year 1967. These changes were made in an effort to increase the reporting of chronic illness, an area of underreporting that had been identified by methodological studies conducted since the beginning of the survey. 2. July 1967-December 1974: As described earlier, the questionnaire introduced as a data- collection instrument in July 1967 resembled 11 zl FY 1958 Cy 1974 L (8) Wat 1s the same of the head of this heuscheld? (Eater nase ia first colua) Last meme le. What is the nome of the head of this household? — Enter name in first column. Te.| Furst name AGE b. What are the names of all other persons whe live here? — List all persons who live here. s* No c. | have listed (Read names.) Is one else staying here now, such as friends, relatives, or reomers? © oO — (©) om (other) lodgrs ov roms live beret Cle CO Ton (dt d. Hove | missed anyone whe USUALLY lives # ope gop iigm bowed 7 osmnenses OV CLV 5... oo me Cal 9 13 tore ste Sit RIVALS Bt? Dm Owe User ppp seme «. Do any of the people in this household have o home onywhere else? . ......... ree. 0 O Lait name "ow Ferily ia 4 Mpitaly If any adult males isisd ask * Apply household membership rules. 28 sd g¥50 41 Vahyiag Aare oot) SR Di f. Are any of the per is household now on full-time » or] (1) Bo my of these people have & home slsesbere? active duty with the be Armed Forces of the United States? . . . Y Col(s). (Delete) 2 N sex] One (leave on C0 ves (1f sot » npshold nuber, dniste) + . 2 Bow are you related to the head of the bomecho ld? (Enter relatiosshis head, fur 2. How is ~~ reloted to —— (Head of household)? onship, "tM eee. Thee eta ieniter: rasan, aother. 1a. lue. Pariser. ledger, lodgers ieee [TH oO 3. Whet is —="s dote of birth? (Enter date and Age, and circle Race and Sex) 3. | Date [™~ 3 Mace (Check ome box for sach persrs) Shoe If 17 years old or over, ask: 0) Under 17 (NP) © B01 (Eheck sae ben for sack paresn) Omi © aie 34a. What is the highest grade or year —= attended in school? Te Elem: 12345678 a © mbar 5 Bow old vers you ou your last bribe 1 year High: 910 11 12 ———— College: | 23 456+ & Where were you bom? (Recerd state or foreigm cowstry) TREAT RRS Wwityy a he —— (year)? - ~ - = = a 17 14 years old or over, ask: TO oder 14 years Ask for all males | 7 years or over: 7. Are you mow married, widowed, divorced, Separated or never married? Dim Baier 35a. Did ~~ ever serve in the Armed Forces of the United States? (Coach sae box for each perace) ar rest - A So RR i ee b. When did he serve? Vietnam Era (Aug. “64 to present. . » - VN B53 Iware- old or aver, AST Conder 14 yours Circle code in descending order of priority. Thus if Korean War (June '50—Jan. '55) ..... KW 5 Wat 1s the highest grade you completed a schoel? (Circle highest grade completed or check Nese™) Be 1233485878 ma: 1334 College: 1 33 ¢ © none If Wale asd 14 years oid or over. ask: 5. (8) Did you ever serve in the Armed Porces of the United States? It Yes," ak: Crea or wed. 14 rn. (9) Sua my of your service between Jame 7. 1950 aad Jussary 31. 19837 TT 8 years old or over, sak M. (8) Wat vers you doing most of the past II semths -- (Por males over 16): wrking. lesking for wrk, or doing ssmething elm? (Por temles over 16): working. looking for work, heaping house. of doing smething ol se? (Por children 6 - 16): ing to scheel or doing mmething elec? If “Something else” checked. aad person is 30 years old or over. ask: (W) Are you retired? OO vortine 12 athe in hich Grow 414 Gu total income of your family fall, (how Card ¥) lnclede income from all sources, . pemsiens, help from relatives. ete. person served in Vietnam and in Korea, circle VN. World War || (Sept. "40—July 47) .... WWI World War | (April *17-Nov. *18). . ... WWI Other Service (all other periods). . . 3 wwii & DK If 17 years old or over, ask: 36a. Di work at any time lo c. Was he looking for work or on layoff from o job? d. Which —- looking for work or on layoff from e job? [0] Under 17 (NP) 1Y(3%)_ __2N Ask for all 376. Who does (did) =~ work for? 362. 5, 9c. b. Whet kind of business or industry is this? If ““Yes™ in 36c only, questions 37a through 37d full-time civilian Fill 374 fr [vig ill 37d from entries in 37a~3' [7] Non-pd. 2] Gov. Fed. & [7] Nev. whe. d. Class of worker 4 301 Gov. oth. 4[JOwn — If not o form, ask 1 Y N - La no S 5 Please look at this card —— (Show Card I) Gow 03(]0 or JH 38. Which of these income groups represents your total combined family income for the past 12 months ~ that is Borja oe ae uy Co , your —='s etc.? Include income from all sources such os wages, salaries, social security or rotirement = 3 fits, help from rel ent from property, and se forth. ale esCJE of) oz]C o6(]G 10K 39a. Which (other) family members received some income during the post 12 month? 39. Mark “Income” box in pecson’s columa. [1 ircome members receive any income during the past 12 menths? Y (Reask a andb) N If only one person with “‘Income’* box marked, go to Q. 41. Grows ea(J0 oi] If 2 or more persons with “Income” box marked, ask Q. 40 for each: (1A os[JE os[ |i 40. Which of these income groups income for the past 12 months? w [o1[)8 osCIF os} o2(7]C o[1G 10[]K as ali If 17 years old or over, 0 [T] Under 17 (NP) 41. 1s == now married, widowed, divorced, separated, or never married? — Mark one box for each person, a, | 1 Elramed - spouse present [Married — spouse absent 2] Widowed 4} Divorced $C] Separated [7] Never married (NP) 42. How many times hes —= been married? a Times Figure 1. Questions relating to social, economic, and demographic characteristics, fiscal year 1958 and calendar year 1974. FY 1958 ntarvion ouch adult poreen for Masel for ometions 11:34 4nd Toles 1. 3 hasponded tor alt oie is erty wr bs or omit DLs | om ur Wo are interested Tn IT Vind of [1Teves, Wether sorioes ov sot -- Sve Tn Li. ore yeu sich ot my tise LAS EN 08 THE SE SVR? () Bat ree he setter 3) layaing sine? 18 Last week or the week Defers did ave Ores Om Last re or he you bare wy accidents or lajuries, either at (8) at vere thar? (3) tay thing soe? 18. Lest week or the Week before #14 you foul my (11 effects fram an earlier Ores Owe mliomt or jerry (8) Wat vere these ffocta? (3) aything sise? 16 Last week or the west Store 414 you take my medicine or Lrestaent for sey Cres One andi (lem (banides +. ich rou (ald me shont)] ar seat cotitione (3) Mything sie? 1s 11 1 remem rim hve my ailmmts or conditions that have cea. Sree Ce Ulaed Tore Teme tar (HT 0 Bren though (boy ds bother on S11 the time? (0) Wat are hay? (8) dything sim? Me. Bae sayens in the family - your, ote. - hud sy of these conditions MAD Ores [ST Err a - ™ (Bead Card A. condition by condition: record aay conditions Sent ioned 1h the ulemm for The perisns Er Ome 11. Boss myeee in the family have my of these conditiems? (head Curd 1. condition by condition: record say eomditions went icaed 1a (he column for the pu NATIONAL WEALTM SURVEY Cheek List of Chronic Conditions 1. Athen 14. Stomach ulcer 2. Any allergy 3. Twerculosis 4. Chronic bronchitis 3. Repeated attacks of sinus trouble . Rheumatic fever 7. Mardening of the arteries Nigh blood pressure Meart trouble 10. Stroke 11. Trouble with varicose veins 12. Wesorrhoids or piles 13. Gallbladder or liver trouble Prostate trouble Diabetes . Mental or nervous . Tueor or cancer Mernia or rupture . Any other chronic stomach trowsle Kidney tones or other kidney trouble Arthritis or rheusstism roid trouble or goiter + Evilepsy or convulsions of say kind rouble . Repeated trouble with back or spine . Chronic skin trouble c's NATIONAL WEALTH SURVEY Check List of Ispairseants 1. Deafness or serious trouble with hearing. Serious trouble with seeing. even vith glasses. Stamsering or other trouble with speech Missing fingers, band, or arm Missing toes, foot, or leg Cerebral palay Mralysis of aay kind. Pesaro. am, or 3. Condition present since birth, such as cleft palate or club foot. Any permanent stiffasss or deformity of the foot or leg. fingers, FY 1967 IN THIS CALENDAR. (Hand calendar.) SHOWN ON THAT CALE! b. WHAT WAS THE MATTER? THIS SURVEY COVERS ALL KINDS OF ILLNESSES. THESE FIRST QUESTIONS REFER TO THAT IS, THE 2-WEEK PERIOD OUTLINED IN RED Ba. WAS _ . SICK AT ANY TN YEE TR THE WEEX BEFORE (THE 2 WEEKS 8 c. DID . HAVE ANYTHING ELS™ DURING THAT 2-WEEK PERIOD? OVYes One b. FOR WHAT CONDITION? 9a. LAST WEEK OR THE WEEK BEFORE, DID .. . TAKE ANY MEDICINE OR TREATMENT FOR ANY CONDITION (BESIDES... WHICH YOU TOLD ME ABOUT) ¢. DID ~~ TAKE ANY MEDICINE FOR ANY OTHER CONDITION” Ove One b. WHAT WERE THEY? 100. LAST WEEK OR THE WEEK BEFCRE, DID . . RAVE ANY ACCIDENTS OR INJURIES? €. DID - HAVE ANY OTHER ACCIDENTS OR INJURIES DURING THAT 2-WEEK PERIOO?| O ves 10. 1a. HIM OR AFFECTS HIM IN ANY WA 01D. EVER HAVE AN (ANY ii ACCIOENT OR INJURY THAT STILL BOTHERS 8. IN WHAT WAY DOES IT BOTHER HIM? rt pnt tc OYes (Owe for the person, 12. Open your Floshcord booklet to Cord A ond Reod both s des of Cord A (A-1, A-2), by condition; recerd in hrs column any conditions mentioned 13. Tun to Cord.B ond Read both sides of Cord B (B-1, B-2), condition by condition; record a k13 Column ny conditions mentioned lor the person. 0 Yes HIS HEALTH? ¢. ANY OTHER PROBLEMS WITH HIS HEALTHY 14a. DOES _ _ HAVE ANY OTHER AILMENTS, CONDITIONS, OR PROBLEMS WITH B. WHAT IS THE CONDITION? (Record condition itself if still present; otherwise record |14. present effects.) Dyes Question 12: Now I'm going te read a list of conbiiont - Please tell me if you, your hod any of these conditions DURING THE PAST 12 MONTHS? 1. Asthma? 2. CHRONIC bronchitis? 3. REPEATED attacks of sinus trouble? 4. TROUBLE with varicose veins? S. Hemorrhoids or piles? 6. Hay fever? 7. Tumor, cyst, or growth? 8. CHRONIC gallbladder or liver trouble? 9. Stomach ulcer? 10. Any other CHRONIC stomach trouble? 11. Kidney stones or CHRONIC kidney trouble? Question 12: A-2 Have you, your ——, etc., conditions DURING THE a Tuon MONTHS? 12. Thyroid trouble or goiter? 13. Any allergy? 14. CHRONIC nervous trouble? 1S. CHRONIC skin trouble? 16. P: 17. Paralysis of any kind? 18. REPEATED trouble with back or spine? 19. Cleft palate? 20. Any speech defect? 21. Hemia or rupture? 22. Prostate trouble? Question 13: B-1 Hove you, your ——, etc., EVER hod ony of these conditions? 1. Tuberculosis? 2. Emphysema? Hardening of the arteries? . High blood pressure? (Exclude if only during pregnancy) 5. Cancer? 6. Heart trouble? 7. Stroke? 8. Rheumatic fever? 9. Arthritis or rheumatism? 10. Mental illness? 11. Diabetes? 12. Epilepsy? Question 13: B-2 Do you, your =, etc., HAVE any of these conditions? 1. Deafness or SERIOUS trouble hearing with one or both ears 2. SERIOUS trouble seeing with one or both eyes even when wearing glasses? 3. Missing fingers, hand or arm — toes, foot or leg? 4. Missing lung or kidney (or breast)? S. Club foot? 6. PERMANENT stiffness or any deformity of foot, leg, fingers, arm or back? Figure 2. Questions relating to illness and injury recall, fiscal years 1958 and 1967. 13 the approach suggested by the alternative B method of collection considered at the beginning of the survey. The illness and injury recall questions, with a 2-week reference period, were replaced with questions pertaining to health-related actions taken during the reference period. Information about conditions respon- sible for such actions was obtained from persons giving positive responses to these questions (figures 3a and 3b). The 18-month period, July 1967-December 1968, was considered as a trial period for the new “person” approach in data collection. Because of this decision, it was felt that informa- tion on one-half of the sample population should be collected on the new questionnaire and that information on the other half should be elicited by means of the “condition” approach used in the first 10 years of the survey. Estimates based on the two samples are described and compared in Vital and Health Statistics report, Series 2, Number 4811. It was found that no drastic changes in levels and relationships of health measures resulted from the adoption of the “person” approach. The designation of these 18 months as an interim experimental period made it possible for re- visions to be made during this time by adding, deleting, or rewording questions. It also pro- vided for an orderly transfer of the data-collec- tion period for a given questionnaire from a fiscal to a calendar year basis (beginning in January 1969). This change in the collection period was initiated in order to make the data from the interview survey more comparable to other health-related statistics. During the interim period, two new areas were added to the 2-week recall questions in an attempt to elicit certain kinds of conditions: one related to dental visits for the treatment of oral conditions and the other was directed to hospitalization during the 2-week period for emergency or other types of care. However, neither of these areas produced a sufficient number of reportable conditions to justify including them on a permanent basis; the dental probe question relating to conditions was dropped from the questionnaire for calendar year 1971, and the hospital probe question was deleted on the calendar year 1970 questionnaire. Other revisions in the illness recall area during 14 the trial period, shown in figure 4, included (1) the expansion of the introduction to the 2-week recall questions to inform the respondent of the purpose of the survey, the areas of questioning, and the beginning and concluding dates of the period outlined on the calendar, (2) the re- arrangement of questions relating to disability caused by reportable conditions to obtain infor- mation on work- and school-loss days prior to information on activity-restricting days, and (3) an addition in the area of 2-week physician visits to elicit illnesses due to pregnancy. All of these three changes in format proved to be quite effective and have remained practically unchanged through 1974. A gradual decline in the number of injuries reported in the survey during the late 1960’s and during 1970 led to the addition of a specific area related to injury recall on the calendar years 1971-74 questionnaires. The decision to restrict the collection of prevalence data to specific types of chronic con- ditions during a given collection year was imple- mented by the collection of data on digestive conditions during the interim period July 1967- December 1968. The collection schedule for this type of information during succeeding years follows: Calendar year 1969—Conditions of the bones, joints, muscles, and skin Calendar year 1970—Conditions of the res- piratory system Calendar year 1971—Impairments Calendar year 1972—Conditions of the cardio- vascular system Calendar year 1973—Conditions affecting the nervous system, glandular disorders, and conditions of the genitourinary system Calendar year 1974—No chronic condition list The specific conditions and illnesses included for each of these are shown in appendix IV. Description of conditions and related dis- ability.—During the first 8 years of the survey, fiscal years 1958-65, the format of the question- naire provided for the entering of each illness or injury on a separate line of questionnaire table I HAND CALENDAR TO RESPONDENT During any iliness or injury? or injury? During that Tw weak period, did he have to cut down on the things he vavelly does becouse of illness Se. the pest twe weeks (the 2 weeks outlined in red on thet colender) did — ~ stay in bed oll or mest of the doy becouse of year i ines or Injury keep — ~ from schoo! during these twe weeks? [Yes-ter a [[INo—Go to 6a FC Wera == === _ J0o( Neo-Geo 6a | Twarra-. 00 None br ar oe 4000 02 i wh Ask t sae TY days — Go 10 60 1 1+ days recorded in Q. Se, ask. 66. What condition couted = = fo cut down an the things he usually dees during the &. During the past twe weeks, did any ether condition couse him te cut down on the things he vavelly dees? at twe weeks? — Eater condition ia C above [INo cut down days to next [INo—Go te next person either at home or ot @ doctor's office, or clinic? 7. During the pest 2 weeks (the 2 weeks outlined in red on thet colondor) how many times hot — ~ seen o doctor [Nene Number of visits Ba. (Besides those visits) During that 2-week period has @ in the family been to « dec Be. elinic for shets, x-rays, tests, or exominations? Yes — Ask bandc [Ne 5. Who was this? Mark “Yeu™ in person's colama b| [JYes Doctor's visite « Anyone []Yes — Reask b and [Ne ~ Ge red “ Number of visita 9a. During thet peried, did enyene in the family got ny medicel edvice from o doctor over the telephone? [Yes — Ask band c| Ia BI “Yes anki Whe was the phone call cbout?— Mark **Yen'" in person's column. [CINe - Ge te 10 o| Ove © Any colls chout anyone else? [Yes — Reask b and c [Ne -GCe tee -~ =i i a wr a: om a A ©. How many telephane calls were mode te got medical advice shout — 7 ony 0 “ Number of calla If doctor was sees or talked to during the past twe weeks, ask: 10a. [JNe 2-week visita—Ask 11 [Yes—Reask 108 [TINo—Go to next persen Mow I'm going to reed o list of conditions: 12a PUrian Roe pun 2 mets, Ie ens the family (you, your = —, ote.) had any of the following conditions 1 Yen,” ask b Yes| No 1. Gellstones? 1. 2 Any other gollbladder trouble? 2 3. Hemorrhoids or piles? 2 4 Cirrhosis of the liver? [ 5. Whe wes ist 1] 5. Pomy liver? | © During the past 12 months has anyone else hed... [| 5 6 Hepotitia? . 7. Yellow joundice? ” Paley oto Hl wor sro) . @ During the post 12 manths, hee anyone in the family hed — 1 “Yes," ask b aad _— Yes| No Ye 9. A disease of the pencreas? 9. 10. A di f the esophagus? 10. 11. Any other disease thet effects | b. Whe wes this? | 1. 12 Peptic lear? | « During the past 12 months has anyone else hed . 12 13. Duedensl ulcer? 13 14 Sromech or gesic vicar? « 15 Any other ulcer? Is During the past 12 months, hes anyone in the fomily hod — "Yen," ask band ¢ _- Yes No Yes 16. Miotel homie? 16. 7. Umbilicel hernia? 1”. 18. Any ether homies or rupture? 8. 19. Gastritis? | 5 Whe was his? | 19. 20. Frequent indigestion? c. During the past 12 menthe hes anyone slse hed... | | 20. 21. Concer of the sromech? a 22. Any other stomach wovble? 2 23. Esteritia? 21 24. Diverticulitis? 2 @ During the past 12 menthe, hes anyone in the family hod — 1 “You,” ask band c ean Yes| No Yeo 25 Colitis? 25. x other bowel trouble? 2 27. Spastic colon? | 5 Who wes this? | lz. 28 Cancer of the colon or rectum? |< wing me post 12 months hes anyone else hed. a 29. Any other cancer of the digestive system? ». 30. Any other Intestingl trouble? 2. 31. hay, shir suns of the dguarive my ment, an Figure 3a. Questions relating to illness and injury recall, fiscal year 1968. 16 FY 1974 This survey is being conducted to collect information on the Nation's health. | will ask about visits te. doctors end dentivrn, illness in the family, end other health related items. (HAND CALENDAR) The next few questions refer to the past 2 we the 2 weeks outlined in red on thot calender, beginning Monday, ___ (date), and ending this past Sunday, date 3 . b. During thet 2-week period, how many days did —— stay in bed al} or most of the doy? Y (4b) If age: 0 N La —16 (6) b| —— Days) Underé (8) During thet period, how many (other) days did he cut down for es much es a doy? S. During theta 2 weeks, how mony doya did ness of injury keep == from work? (For ns: not counting ey | 5 WL days (7) 00 (J None (8) 6. During those 2 weeks, how many days did illness or injury keep —- from school? . — 00 [7] None (8) If NO days in Q. 4b, g0 10 Q. 8 — Days 7. On how mony of these —- days lost from { yok, } did == stay in bad all or most of the day? 7. [oo ene Sa. (NOT COUNTING the day(s) {& fori from work ow } ) MN _— lost from school Were there any (other) days during the post 2 weeks that == cut down on the things Tr NW he usually does because of illness ory? n bed b. (Agel t ting the day(s) {i lost from work } . Ugtis, not ouing the dey lost from school I Ou 00 [] None If one of more days in Q's. 4-8, ask 9; otherwise £o to next person. soy in bed Enter condition in item C 9a. What condition caused —— to miss work during the past 2 weeks? 9a. Ask 9b miss school cut down stay in ig y miss worl b. Did any other condition couse him to { pei during thet peried? b . oe) cut ©. What condition? 10a. During the * post 2 weeks did anyone in the family, thet is you, , have any (other) accidents or injuries’ Enter condition in item C Reask 9b b. Whe was this? — Mark ‘'Accident or injury’* box in person's column. c. What wos the injury? d. Did enyone have any other accidents or injuries during thet peried? Y (Reask 10b and c) N For each person with *‘Accident or i ©. As o result of the accident, did ~~ jury," ask: © doctor or did he cut down on the things he vsvelly does? Y (Enter injury in item C) ~ 13. During the past 2 weeks (the 2 weeks outlined in red on that calendar) how many imes did ~~ see « medical docter? 13. [00 [7] None Foe Number of visits b. Whe was this? — Mark “Doctor visit’ box in person's column, ry A ESE Sn I KOH (Besides those Yan) Y 14a. During that 2-week period did anyone in se oily 90 to a doctor's office or clinic for shots, X-rays, tests, or exomine! N (15) e. Anyone i: If “Doctor visit,’ 1 d. How mony times did —~ visit the doctor during thet period? d.| —— Number of visits (NP) 150. During thet period, did anyone in the fomily get any medical advice from Y ii § Sa al © doctor over one? N (16) vd b. Who was the phone call about? ~ Mark **Phone call” box in person's column. 156. [7] Phone call <. Any calls about anyone else? Y (Reask 15b and c) N If “Phone cal : d. How many telephone calls were made to get medical advice about —— ? d Number of calls (NP) Condition (I1em C A. Goiter or other 31a. DURING THE PAST 12 MONTHS, did anyone in the family Syed trouble? Fill item C, (DOCTOR), from Q's 13-15 for all gute, rom €, Ask Q. 16a for each person with visits in DOCTOR o pi 6d) 16a. For what condition did —- see or talk to @ doctor fred the past 2 weeks? too| Epona! b. Did ~~ see or tulk te @ doctor about any specific condition? » Y N (NP) €. What condition? . Enter condition in item C osk 16d od. During that period, did ~~ see or talk to a doctor about any other condition? .“ Y (16) N (NP) ©. During the post 2 weeks wes —— sick because of her pregnoncy? . Y N (16d) f. Whet was the matter? +. | Enter condition in item C (16d) JRE PRA you, your ==, etc.) have — Diabetes? If *“Yes," ask b and c 5. Whe was this? Enter name of condition and letter of line C. Cystic fibrosis? where reported in appropriate person's column in item D. Anemia? c. During the past 12 months, did anyone else have . . . 7 E. Epilepsy? F. Multiple sclerosis? G. Migraine? H. Neur 1. Sciatica? J. Nephritis? K. Kidney stones? L. Any other kidney trouble? Glandular disorder Condition affecting the nervous system M. Bladder trouble? N. Prostate trouble? P. Any other female trouble? condition Figure 3b. Questions relating to illness and injury recall, fiscal year 1974. dentists, illness in (This survey is being conducted to collect information on the Nation's health. | wil ask about visits to doctors and WASHINGTON he family, and other health related items.) (HAND CALENDAR) The first few questions refer to the past two weeks, that is, the 2 weeks outlined in red on that calendar, beginning Monday, ond ending this past Sunday, | [CJ Yes (50) Sa. During those two weeks, did —— stay in bed because of any illness or injury? 5a. CiNoGeord) [TTT b. During that two-week period, how many days did —= stay in bed all or most of the day? b) d ays (Scord) ~~" T17 years old or overask: TTT T~~ % ¢. During those two weeks, how many days did illness or injury keep == from work? c. [None | rem For female add: Not counting work around the house. _ days J * TT 16-16 years old ask: "TT ™~° [None (50 | _d: During those two weeks, how many days did illness or injury keep —= from school? _ _ __ __________ | Sd days ___ Ask only if bed days AND work loss or school loss. 0 Reed), 5¢ - BESibE _#-_ On how many of these — days lost from work (school) did == stay in bed all or most of the day? _ _ [_e ——— days _ J °° _ f. (BESIDES the days in bed and days lost from work, school) were there any days during the past 2 weeks f — — — hat == had to cut down on the things he usually does because of health? __ __~° "| ap ELE 08 [Mega = 9: (Again, not counting the days in bed and days lost from work, school), how many 9. [J None (6a or (other) days did he have to cut down for as much as a day? days (6a) NP) SE BD TLD RAD If 1+ days in Q.5, ask 6, otherwise go to next person cut down c. What condition? stay in bed miss work 6a. What condition caused —- to miss sehool during the past 2 weeks? Enter conditions in Item C 6a. Ask 6b and c Reask 6b Figure 4. Questions relating to illness and injury recall, as revised during the interim period July 1967-December 1968. (see figure 5). Questions in table I were designed to elicit information relating to (1) whether the condition had ever been attended by a physician, (2) the most accurate description the respondent could give about the nature of the condition, (3) days of restricted activity, bed disability, and work- or school-loss days caused by the condition, and (4) certain facts about the onset of the condition to determine whether it was acute or chronic. The principal change in this portion of the questionnaire through fiscal year 1965 was not in the wording of the specific questions in the table, but in the interviewers’ instructions included in the heading of the table. These instructions were expanded in the questionnaires for fiscal years 1960 and 1961 and were then unchanged through fiscal year 1965. In the computer processing of the data for fiscal years 1966 and 1967, a photographic process, identified as FOSDIC,* was used by the Bureau of the Census, the agency that carried out the statistical processing of the interview data through fiscal year 1968. With this pro- cedure, it was not feasible to use the question- naire table I format, so each reported condition was carried through a separate “condition page,” which also included questions on accidents @Filmed Optical Sensing Device for Input to Computers. resulting in injury and on activity and mobility limitation. The wording of the questions relating to conditions and the interviewers’ instructions were not changed to a great extent, but the questionnaire format was quite different. The “condition page” concept has been continued through calendar year 1974. With the introduction of restricting the collec- tion of information on chronic conditions to those affecting a specific system (beginning in July 1967), it was felt that the amount of data relating to the history, treatment, and develop- ment of such conditions should be increased. Since the new “person approach” called for the collection of information on activity and mobil- ity limitation on a person basis, as described earlier, the questions relating to limitation were transferred to another area on the questionnaire, and detailed information on specific chronic conditions was obtained by adding a section identified as AA to each condition page. Section AA was revised to some extent during the trial period (July 1967-December 1968) and has remained as an integral part of the condition page through calendar year 1973 (figure 6). Limitation of activity.—During the first 8 years of the survey, through June 1965, infor- mation on limitation of activity due to chronic conditions was obtained from questions at the end of questionnaire table I. After completing 17 81 SOURCE DETERMINATION OF DIAGNOSIS DISABILITY DAYS IN 2 WEEKS ONSET FY 1958 Table I - ILLNESSES, INPAIRNENTS AND ACCIDENTS Table I - ILLNESSES, INPAIRNENTS AND Did | mat did the docto 1t If an impairment , ask: wa How | Now mamy you first sotice ... r say an impsirseat or symptom, asl Nas aie of trouble AL part at tae body amy of Sete THE PAST 3 MONTHS Wat was the cause of (If eye on li ll or before that time? Fist 2 ms pa rounte of | (1f nina of trowle (11 part of body c ing | in bed Check one | D1... start OF Before tal —~ siresds entered in col. | decernined fron entries Bel Me Siring thie past . i, SORE, | Senne oi | wea confound Before ar dariae pant col. (IT 111-affects of earlier See hen i SALINE Lhe quent ion) ? fw i 3 accident also £111 Table 4) | Westie j (If during past Wich month? g po t or injury, Go |= [2 veers. ssi): 3 oon Ao) esl. Which week, last (=) or week before? (Also, 7111 Table A) wl» €) 1) (0-3) 3) 4 (a5) ® ™ om) o) ® | a = 0 vee | Oye x x — Oars | yey | — Dus] 0 Last [3 petore] wo. or or 3a. Ws sme 1 Owe Owe bays | COvose | Ode | Dinos before Clsetore Clair OMITT=D ON FY 1958 AND FY 1962 1959 ONLY REPLACED AND 1963 BY CURRENT ACTIVITY QUESTIONS ONLY MINOR CHANGES IN INTERVENING YEARS SUBDIVIDED FY 1960 ET. SEQ. FY 1965 ) ' Table | — ILLNESS | ES IMPAIRMENTS, AND INJURIES — Continved Toble | — ILLN PAIRMENT = d Col. [Ques-| Did son Card C, enter CAUSE KIND PART OF BODY LASTWEEK| Did you [How |During [1 6-16 __ ” we If col. m) | Te No. [tion | you king 0 wad If the entry in col. (1) is | For any entry in col. (d-1) or [Ask oly for: or THE [hoveto [mony |that two |yearsold,|in Q. Sa DE as mot ischecked,| inter of |No. | ever Forumas ED. py ‘ col. (d-2) that includes the | IMPAIRMENTS, “CURRENT” EEK cut down [days [week ask: or 5b, 5 month or before thet rime? | ask: viewer ol AT go to columas (e) FEN ATINPARMEST words: INJURIES, aad PRESENT EFFECTS [BEFORE | for os did period, | How many #sk: Did you wd ANY ETT Ales [oF ue" INJURIES did... much as 0 [you how mony| days did [How ns first ON- TIME present effects Asay TER a Palen Iaflemastion couse you | day? hove to +++ keep| mony ! Did you first | it during [TINUE valk injuries — or “Cyst “Disease Ache (except Neuralgi vo cut cut you from | days did © [oot the past [if col. toa I If doctor talked to, ask Growth “Trouble” headache) Neuritis down on the| down school |... keep 3 |ing | (did it happen) | 12 months |‘m) is doctor] What did the doctor say it was — Sezoke® Blending Pais things you during during | you from months) 3 during the past | or before 4 bout Kid he give it a medical nome? ASYMPTON [mw mreme—— Boil Soreness usually do? thot thot two | work (Go |mos. | 2 weeks or thot time? |or the your - If doctor NOT talked to, record ask: Cancer Tumor two week during to before that time?) condi- eel? priginal entry and ask (eh — What kind of . . . is it? Cyst Ulcer week period? [thot twe col. |——s-| If "During tion is ) as required. pe. Srowh Weak period? jy ») past 2 weeks," on Card TT rp ve *For an ALLERGY or Hiemonbase Weakness — pix oo 7 i : For all in SH ich ame fro Question 9 or | STROKE, ask: Fig J od? oh ern BEFORE, ask: How does the ollergy Show detail for: 1 (Check one) | (Check one) lost week or pair What port fry the body was hurt? [What was the couse of . (stroke) effect you! Ear or eye - (one or both) the week before?| iment; No |Yes [No [Yes 5 [What kind of injury was it? Heod -(skull, scalp, face) a - (If ‘Cause’ is an injury, Bock -(upper, middle, lower (Go |——3](Go |= x For injuries or accidents which emer “Acci or Arm - (shoulder, upper, elbow, lower, to to Wise, 5 d before the past Injury’ and Till Table A.) wrist, hand; one or both) ool. ool. STOP . lweeks, enter the present effects. Leg Gi ty knee. lower, aakle, = 0 ot = | ® | (1) (2) (¢3) (4) @|o|w|m®f eo [0] k) [0] =) | = ©) ® (a0) Figure 5. Development of segments of questionnaire table I, fiscal years 1958-1965. [ CONDITION 2 1. Person number | Name of condition When did —— Tost see or talk to a doctor about his . . .7 0 hd % Mnterview 1 [0] Past 2 wks. (Item C) $[J2-4 yrs. 2 2 wks. 6 mos. «5 yrs. Rees 2) 3 (0) Over 6-12 mos. 73 Never # [JJ DK if Dr. seen Oly = » [J DK when Dr. seen [C] Not an eye cond. (A4) A3 [C] First eye condition (under 6) (A4) ([C) First eye cond. (6+ yrs.) (10) [CO] Not first eye cond. (Ad) 70. Can —= see wall enough fo read ordinary newspaper print WITH GLASSES with his left eye? 1 Y aN ght J LLL VY iN Al [= Accident or injury (A2) Examine “Name of condition’ entry and mark [Z) On Card C (A2) [J Neither (3a) 3a. If "Doctor not talked to," record adequate description of condition. If “Doctor talked to," ask: Whet did the doctor say it was? ~ Did he give it « medical name? If the entry in 3a or 3b includes the words: Ailment Condition Disorder Trouble Anemia Cyst Growth Tomer Asthma Defect Measles Ulcer Ask c: Anock Dissose Rupture . What kind of . . . is it? For allergy or stroke, ask: How does the allergy (stroke) affect him? For an impairment or any of the following entries: a First noticed during the past 2 weeks? (Question 9)... vvvvuuuns y N (AA) b. Doctor seen or talked to during the past 2 weeks? (Question 2)... ..uuuu.n. Y (Fill Ad buff form) <. One or more cut-down days? (Question 5). ......uu.s Y (Fin N (AA) blue FOOTNOTES Continue for conditions listed or reported in probe question 31, LAA | otherwise, zo to AS. For missing extremities or organs, go to AS. (7) Doctor seen (12) [7] Doctor not seen (11) . During the post 12 months what did —~ do or take for his .. .7 (Write in) Anythingelse? (8 13. BEFORE -- talked to o doctor about his . . ., 2. After —= first noticed something was wrong, about how long was it before he talked to o doctor about it? (Probe: Was it a matter of days, weeks, or months?) 000 [7] Discovered by doctor (I40) 3____Weeks 100 [7] Less than one day Months Days s___ Years did he do or take anything for it? vv Y 2 N 14a. Does ~~ NOW take any medicine or treatment for his . . .7 VY Nay) b. Was any of this medicine or treatment recommended by a doctor? LY 2 N 15. Has he ever had surgery for this condition? +X 2 N T6. War 3 ever hospitalized for his condition? v Y 2 N 7. During the past 12 months, “bout Tow many fimes has —— seen or talked to to a doctor about his . . .? (Do not count visits while a patient in a hospital.) Times 000 [7] None 18. About how many days during the past 12 months has this condition kept Rim in bed ol ot mast of the doy? ___ Days 000 [7] None Abscass Damage Paralysis Ache (except heedache) Growth Rupture Bleeding Homorhage Sore Blood clot Infection Soreness Beil Inflammation Tumer Ask e: Cancer Nevrelgie Ulcer Cromps (except Neuritis Varicose veins menstrual) Pain Wook “ Paley Wesknoss «. What part of the body Is affected? Show the following detail: skull, scalp, foce +. upper, middle, lower .. one or ost nr on Bd The remaining Questions will be asked as appropriate for the condition entered in: A2 [J Item | 0Q 3d 00.3 4. During the past 2 weeks, did his . . . to cut down on the things he usually TY aN® 5. During that period, how many days did he cut fits Amant hr Days 00 [7] None (9) During that 2-week pared, how many days did keep him in bed oil or most of the day? | Si Ask if 17+ years: 7. How many days did his . . . keep him from work during that Zoweek parisd?" (For females): met —Days 9) counting work around the hou: 00 [7] None (9) Ask If 6-16 years: 8. How many days did his . . . keep him from ___Days school during that 2-week period? 00 C] None (Was it during the past 2 weeks or before thet time?) When did —— first notice his ...? 1 [0] Last week 2] Week before 3 [] Past 2 weeks—DK which 4 [J 2 weeks—3 months s [] Over 3-12 months © [) More than 12 months ago (Was it during the past 12 months or before that time?) (Was it during the pest 3 months or before that time?) 9a. How often does his . . . bother him — all of the time, often, once In & while, or never? 1 CJ All the time 2 [7] Often 3) Once in a while o[) Never (19) 4 [7] Other — Specify b. When it does bother him, is he bothered a great deal, some, or very little? 1) Great deal 27) Some 3] Very lintle 4 [7] Other — Specify. "DI All the time in 19a (AS) c. Does ~~ still have this condition? d. Is this condition completely cured or is it under control? 1 [J Cured 3 [0] Under control (AS) CARD C Conditions reported for which questions 30-3e need not be asked: Acne Appendicitis Arteriosclerosis Athlete's foot Bronchitis (any kind) Bunions Bursitis Calluses Chickenpox Cold Corns Croup Diabetes Epilepsy Gallstones Goiter Hardening of the arteries Hay fever Hemorrhoids or piles Hernia (All types) Kidney stones Laryngitis Migraine Migraine headache Mumps Normal delivery Phlebitis (Thrombophlebitis) Pneumonia Pregnancy Sciatica Sinus Sinus trouble (Sinusitis) Strep (Streptococcus) throat Tonsillitis Ulcer (duodenal, stomach, peptic or gastric only) Vasectomy Warts Whooping cough Figure 6. Sample ‘‘condition page,” calendar year 1973. (Excluded are questions on accidents resulting in injury, which appear in Figure 15.) questionnaire table I for the final condition re- ported for a sample individual, the interviewer handed a card to the respondent and asked her to look at the statements printed thereon. She was then asked to select the degree of limitation that was most descriptive of the sample person (figure 7). By means of interviewer instructions keyed to the duration of conditions and check- lists of conditions, these questions were limited to those persons for whom chronic conditions were reported. The respondent was then asked to identify the reported condition(s) that caused the specific degree of activity limitation. During the period July 1965-June 1967, the questions remained virtually unchanged, but the transfer in format from questionnaire table I to the “condition page” led to a corresponding change in the format of the questions on limitation of activity. During the entire period, July 1957- June 1967, estimates of the number of limited 19 oc CARDS C-F (FY 1958 AND FY 1959) OR D-G (FY 1967) FY 1959 CARD D: Persons other than housewives and children CARD F: Children 6-16 years To Ask after completing last | FY 1958 Inter- condition for each person: earl [FT (Ploase 161,2 [0 viewer: |look at Ysa. oj won ee 1. NOT ABLE TO WORK AT ALL. 1. NOT ABLE TO GO TO SCHOOL AT ALL. 1f col. eard checked, cord ond | oh Gheckaa ac or ihe [rend woh | becouss[® Condition mets ion [Thoms 1257 lsc 2. ABLE TO WORK BUT LIMITED IN 2. ABLE TO GO TO SCHOOL BUT LIMITED Ee cither | sroramens | Cond: AMOUNT OF WORK OR KIND OF WORK. TO CERTAIN TYPES OF SCHOOLS OR of Cares | state” | coc of [fir yeu [Ment | IN SCHOOL ATTENDANCE. continue. | you bes! Cards best. oor er X | A 2B: (Show told ma 2 oer Sls Ct fobout? Tor 3. ABLE TO WORK BUT LIMITED IN KIND Prise) vise fappeo- feeds OR AMOUNT OF OTHER ACTIVITIES. 3. ABLE TO GO TO SCHOOL BUT LIMITED STOP [peiate) onea IN OTHER ACTIVITIES. (- p= 4. NOT LIMITED IN ANY OF THE ABOVE WAYS. 4. NOT LIMITED IN ANY OF THE ABOVE (an) (r) (s) (1) WAYS. Cove CINe CARD E: Housewife CARD G: Children under 6 years 1. NOT ABLE TO KEEP HOUSE AT ALL. 1. NOT ABLE TO TAKE PART AT ALL IN FY 1967 ORDINARY PLAY WITH OTHER Show Cord D,E, For G. 05 | 18. PLEASE LOOK AT EACH STATEMENT ON THIS CARD (CARD D, E, F, G). CHILDREN, oppropriate based onoctivity | THEN TELL ME WHICH STATEMENT FITS _ _ BEST IN TERMS OF HEALTH, y 2. ABLE TO KEEP HOUSE BUT LIMITED stotus or oge. (Mork statement number) IN AMOUNT OR KIND OF HOUSEWORK. 11,2, or 3 morked in 18 osk: If 4 morked in 18 go to 20. 19.15 THIS BECAUSE OF ANY OF THE CONDITIONS YOU HAVE TOLD ME ABOUT? 2. ABLE TO PLAY WITH OTHER CHILDREN Yo Yo v BUT LIMITED IN AMOUNT OR KIND OF | DO ves — WHICH? gies condition nimbess) gl ® r 8 3. ABLE TO KEEP HOUSE BUT LIMITED PLAY. IN KIND OR AMOUNT OF OTHER > © ACTIVITIES. WHAT DOES CAUSE 4. NOT LIMITED IN ANY OF THE ABOVE OJ No — THIS LIMITATION? Enter cause] WAYS 4. NOT LIMITED IN ANY OF THE ABOVE WAYS. Figure 7. Questions relating to limitation of activity, fiscal years 1958, 1959, and 1967. persons and the number of conditions causing limitation were derived during the data-process- ing phase of the survey. In the questionnaire format adopted in July 1967, the restriction regarding the presence of chronic condition(s) was removed, and questions relating to the degree of activity limitation were asked for all sample persons. This change was necessary because it was no longer possible to derive complete estimates of limitation status from previously reported conditions when only specific body systems were included in the checklists of chronic conditions. Other major changes in administering the questions relating to activity limitation were as follows: (1) instead of asking the respondent to select the appropri- ate limitation status from a printed card, the interviewer read the options to the respondent, and (2) the questions relating to the usual activ- ity of the sample persons were moved from the section on personal characteristics to an area immediately preceding the limitation of activity questions. The latter change was necessary because the options from which the respondent selects the appropriate limitation status are keyed to the usual activity of the sample person (figure 8). During the 18-month period ending in Decem- ber 1968, many changes were made in the word- ing, format, and arrangement of the questions on limitation of activity. The interviewing prob- lems and data-processing difficulties were not completely resolved until 1970 when a satisfac- tory series of questions was obtained. Unlike other health-related items, such as physician or dental visits that are objective by nature, limita- tion of activity represents an opinion or attitude on the part of the respondent. Because the questions require a subjective judgment by the respondent, even minor changes in the wording or the sequence of the questions may cause marked variation in response. The format used in the questionnaire fielded in January 1970 has been retained with few changes through December 1974. During fiscal years 1960 and 1961, informa- tion on the duration of limitation of activity was obtained for all persons who were either unable to carry on their usual activity or limited in the amount or kind of usual activity. In addition, those 17 years or over were asked if they had been working up until the time the limitation started. Questions relating to the duration of limitation of activity were not asked again until January 1969. During that year, all persons with any degree of limitation were asked: About how long has he: Been limited in Been unable to Had to go to a certain type of school? [J Less than 1 month months years This question has continued to be on the questionnaire through December 1973. Hospitalization.—Similar to the procedure used in recording illness and injury, questions on hospitalization are asked in two stages: (1) hospitalization recall questions asked during the early part of the interview (figure 9) and (2) questions regarding the cause, duration, and place of hospitalization. Changes in format for recording information on hospitalizations are also quite similar to those for recording illness data in that an area of questionnaire table II (see figure 10), analogous to questionnaire table I, was used during the fiscal years 1958-65, and a hospital page, comparable to the condition page, has been used during fiscal year 1966 through calendar year 1974. An early methodological study, the findings of which were published in Vital and Health Statistics report, Series 2, Number 7, revealed that hospitalizations during the year prior to the week of interview are underreported in the household interview. In an attempt to improve the completeness and accuracy of reporting, the following two major changes were made in the hospitalization recall area: (1) an additional question, inserted for fiscal year 1961 and retained thereafter, reminds the interviewer to inquire about hospitalizations for deliveries when a child under 1 year of age is listed as a household member, and (2) beginning in fiscal year 1963, there was a change in the time reference for the recall questions. This latter change consisted of the addition of an extra period of recall extending the period to the 1st of the month preceding the 12-month period prior to interview. For example, respondents 21 zz Fv 1968 [130 Wher wes = = doing mest of the post 12 montna — |r or males). working. or doing something sive? TC) Working (18) eo ani Sea cot Qn [ Mhorking cia) 2 Keeping house (18) If “something clas” and 45+ years of age, sak: 3 Retired (17) = retired? ‘something else” md under 45 years of age or “ne” in O. 13, ask: 14a. What wes = — doing mest of the past 12 menths — going te schoel or doing something slse? If “something else” ask: & Whot wes = — deing? + [C] Going to school (20) 5 [117 + something else (17) ¢ [)6-16 something cle (19) 156. In terms of health, is = ~ eble to take port ot oll in ordinary ploy with ether children? B18 he limited in the kind or amount of ploy becouse of his hosith? Yes as) [Ne 21) wf2[0Yes 21) [Ne = Go to next persen 16a. Is — = limited in any wey becouse of his health? In whet wey is he limited? — Specily 10 Yes (268) 4 [Ne — Go to next peracn Geo te 21 176. In terms of hasith, is — — sble te work? 17a] | Ove any [Ne 21) | 2(Yes 21) [Ne (18c) [Yes (288) [Ne (28) 2 Yes 21) [Ne (21) “Dv any 4 [Ne — Ge to next parsen 19. ln terms of hooith, is — ~ shie te go to school? [Yes 20) 1[ Ne (21) 20a Does (wovid) he hove to go 10 © cortein type of schosl becouse of his hesith? cen 20a. Whet was —- doiig MOST OF THE PAST 12 MONTHS - (For males): ed EY —— - For females): keeping house, e. vorkiog, or doing | & i oT sameihing S132, 5 dass 21. | 20 Kesping house (250) If 45+ years and was not “working,” ‘'keeping house,’ or ‘going 1 school,” ask: 2) Rativad, haalth (24) cls —- retired? 4 [0] Retired, other (24) 4. If “retired,” ask: Did he retire because of his health? 3] Going 10 school (27) I 21a. What was —— doing MOST OF THE PAST 12 MONTHS — going to scheol or doing something else? $3) 17+ something wise (24) ui If “something else,” ask: 7] 6-16 something eise (26) 5 b. What wes —— doing? H TS years 23] 25 oJ Under | (23) 220. ¥ VN 29) al 2Y (29 ~ €. amount of play e| 2Y (29) N_ (28) 23a. Is — limited in any way because of his health? 2a] 1 ¥ 5 N (WP) - esata. $20) VY (29) N bo 2Y (29 N « 2 Y (29) N “sym n (28) 25a. Y (25) N bo Y 1 N (29) [3 2 Y (29) ~N ALLY We «. 13 he limited in the kind or amount of other activities because of his health? «| sv em N (28) In terms of health would —— be able to go to school? 26. v "ON (29) 27a. Does (would) ~~ have to go to a cortin type of school becouse of his heolth? 2e.| =v 29) ™ bl 2Y (29 N c. Is he limited in the kind or amount of other activities because of his health? | sym N 28a. Is ~~ limited in ANY WAY because of o disability or health? 28a. | « ¥ 5 N (NP) b. In what way is he limited? Record limitation, not condition. oo een limited in —— ine 296. About how long hes he waoble to — } 00.) 20 LT nes sham 4 hed to go to o certain type of school? Ves 2 vn] b. What (other) condition couses this limitation? » Enter condition in tem C 1 "old age" only, ask: Is this limitation cased by emy specific condition? [0] 01d age only (NP) €. Is this limitation coused by any other condition? of TW, * Mark box or ask J 0ty | condition 4. Which of these conditions would you sey is the MAIN couse of his limitation? vr Figure 8. Questions relating to limitation of activity, fiscal year 1968 and calendar year 1974. FY 1958 HOSPITAL CARE 23. PAST 12 a TT I oe © 5 Tm Toni w+ Br weno PE . oT ham am Pe TYwansre nase Sawn (b) How my times were you in the hospital? No. of times Be eS mle 8 Se 18 8 IRL Re wpe fw mle Swen on] ye (b) Bow amy tines were you in & narsisg home or sanitarim? No. of tises CY 1974 28a. Was —— a patient in a hospital at any time since (date) a year ago? 28a. Y N (Item C) b. How many times was in a hospital since __ (date) a year ago? 29a. Was anyone in the family in a nursing home, convalescent home, or similar place since __(date) _ a year ago? a yr For each “‘Y"’ circled, ask: . During that period, how many times was —— in a nursing home or similar place? n Times (Item C) Y +| —— Times (Item C) Ask for each child | year old or under if date of birth is on or after reference date. 30a. Was —~ born in a hospital? If ““Yes,’* and no hospitalizations entered in his and/or mother’s column, enter *‘1** in 28b and item C. If “Yes, and a hospitalization is entered for the mother and/or baby, ask 30b for each. Y . Is this hospitalization included in the number you gave me for —— ? If “No,” correct entries in Q. 28 and item C for mother and/or baby. Figure 9. Recall questions relating to hospitalization, fiscal year 1958 and calendar year 1974. interviewed during July 1963 were asked about hospitalizations occurring since June 1, 1962. However, only hospitalizations within the 12- month period were used for the derivation of estimates for hospital episodes. These revisions have continued with only minor wording changes through December 1974 (figure 9). The wording in questionnaire table II, deal- ing with the cause, duration, and place of hospitalization, remained virtually unchanged from July 1958 through June 1965 (figure 10). However, the instructions to the interviewer pertaining to the administration of this area of the questionnaire were expanded in order to increase their specificity. In keeping with the format change from questionnaire table II to the “hospital page,” to accommodate the FOSDIC method of data processing in fiscal years 1966 and 1967, the hospital page has been retained on the questionnaire through December 1974 with only minor changes in question location and interviewer instructions (figure 11). During the period January 1968 through December 1970, a question was added to ascertain if the hospital episode was the first admission for the designated cause of hospitali- zation. This question was not retained because it was confusing to the respondent and the information obtained was of questionable value. During certain years of the survey, either questionnaire table II or the ‘hospital page” has been expanded to obtain information on topics specifically related to hospitalizations. These topics—the portions of the hospital and/ or surgical bills paid by insurance and convales- cence following hospitalization—were not planned originally as rotating items. However, their importance and timeliness have led to their inclusion on a rotating basis. Questions pertaining to the part of the bill paid by insurance were asked during fiscal years 1959, 1960, 1964, 1967, and 1968 (figure 12). During the years 1959, 1960, and 1964, the questions relating to insurance cover- 23 144 FY 1958 Table II - BOSPITALIZATION DURING PAST 11 BONTES Table II - BOSPITALIZATION DURING PAST 11 NONTES To iatervisver: - on the Bat perstioms performed “ring Jl Saran San hi thin: sien eter ta toe oevialy hat 15 the nase wd adiress of the teapital yeu Tore ta? hi [Past 13 moathe?|the past 3 Bay SO? | orerg gach contition 1a same detail as called for 1a ble I. It “Tee: (ater same, ity or comsty. aad State) i por [rosks. ending If conditice 1s result of secidest or iajury, alse fill Table A) (a) Wat vas the eperation? t= last sunday? | She () fay other eperatiemet wm | (0) “) ) on (o) ™ (£1) uy - [=r [=I'™Y Dre —e 1 ——____ oo | me owe | Ome One FY 1965 AN \ yt Yable IT — HOSPITALIZATIONS USE YOUR CALENDAR For what condition did you enter the Were any operations performed on you during Whet is the name and oddress of the hospital you were in? No. [tion | yo, yaid that you were in the How many Complete from entries in cols. (c) and (d); | hoPitel = = do you know the medical name? | this stay ot the hospital? of |No. | hospital (once, twice, etc.) during | nights were of, if not clear ask the questions. per the past yeor — — you in the (Qf medical name sot knows, eater 1 “Yes, ask: (Enter full name of ospital, street or highway on which it is located, [sen hospital? hi The | respondent's description.) city and State; if city mot known, enter county.) . Xx When did you enter the hospitel hospital on a. Whet wos the name of the operstion? > § (the last time)? (1f exact (Entry must show CAUSE, KIND, AND b. Any oth rations? § e number night the PART OF BODY in same detail as 7-oHeraperetions| z « (Enter month, day and year; il required ia Table I) : & exact date not known, obtain accept best 2 od estimate.) ? E ! (©) 9) @® oh) @) QD Over J Yes TJ No | Name of hospual 1 Month Day Year Nights Nights Nighs | [No SOURCE DATE OF ADMISSION LENGTH OF STAY CAUSE OF ADMISSION (DIAGNOSIS) OPERATIONS NAME OF HOSPITAL Figure 10. Questions relating to hospitalization (table 11), fiscal years 1958 and 1965. HOSPITAL PAGE 1. | Person number c. Any other operations during this stay? You said that == was in the hospital (nursing home) during the past year. USE YOUR CALENDAR i Lay Year 2. When did —— enter the hospital (nursing home) (the last time)? Make sure the YEAR is correct| 2. |; — Name 3. What is the nome ond address of this hospital (nursing home)? 3, [Sweet City (or county) State 4. How many nights was —— in the hospital (nursing home)? 4. Nights Complete Q. 5 from entries in Q.'s 2 and 4; if not clear, ask the questions. 50. How many of these —— nights were during the past 12 months? Sa. Nights b. How many of these ~~ nights were during the past 2 weeks? > assis c. Was —— still in the hospital (nursing home) last Sunday night for this hospitalization (stay)? c. Y N 6. For what condition did —~ enter the hospital (nursing home) — do you know the medical name? 6. [CO] Normal delivery [J Normal at birth If medical name unknown, enter an adequate description. Condition For delivery ask: | Show CAUSE, KIND, and Cause TTT Tj OnCard C TTT Was this a normal delivery? If “*No," ask: ! PART OF BODY insame For newborn, ask: What was the matter? | poh as required for the Kind Was the baby normal at birth? ! ORCTUOR FREE [rrp ————————— RE ) Part of body | 7a. Were any operations performed on —- during this stay at the hospital (nursing home)? 70 rem rm sh ® b. What was the nome of the operation? B. If name of operation is not known, describe what was done. ~~~ | | Y (Dasciibe)—p N 8. NOTE: If the condition in Q.6 or 7 is in Q.31 or there is *‘I** or more nights in Q.5b, a Condition page is required. If there is no Condition page, fill one after completing columns for all required hospitalizations. Figure 11. Questions on the “hospital page,” calendar year 1974. age were comparatively simple and straight- forward. In fiscal year 1967, an attempt was made to determine the actual sources of pay- ment and the amount paid by each source. The information obtained was found to be incom- plete and of questionable accuracy since many respondents did not have records available or had never been informed about the sources or amounts of payment. Nevertheless, the same format was continued during fiscal year 1968. Since the period July-December 1968 was a part of the experimental period for the “person approach” method of data collection, it was felt that a new format on insurance payments could be tested during that period. As a result, the source options, as shown in figure 12, were combined into four groups, but the questions were further complicated by the addition of questions pertaining to surgical bills. During this period, the information was collected on a supplemental document to the questionnaire. The data collected on this topic during 1967 and 1968 did not provide ade- quate information for the derivation of reliable estimates. During calendar year 1972, the most recent year for which data on hospital expense have been collected, information on the actual amount of payment for the hospital stay was limited to that paid by the family (out-of- pocket expense). By returning to the concept used in the early years of the survey, informa- tion was elicited about the proportion of the bill paid by insurance. To obtain information on the sources of payment, the respondent was handed card H and was asked to select those sources that had paid any part of the hospital bill. The options on card H, which were much more definitive than those on the 1967 questionnaire, consisted of the following: 1. Total or partial payment by sell or family 2. Social Security Medicare 25 9 FY 1950 AND 1960 For compieved ry Was smr ol | WMeTue | HMette | What pur whe haspirel col. (k), bork cols. of the Sil paid for -le 0) wad 0) Mespirel Whe caries the soot of this lnswence—thet ie, whe by omy bind De you spect | $11 wen (wit | Pere the premipm? of insurance? | Or, by wmy a) token ind of vy wh she hy “1 phon thet | 1 he paid for perso | by mewenae oy oid of this kind? ® a = w “ eo . © Under %5 | C0) Family memberts) (2) uber pei) a 0 % wp re X | 0) Employer Qe CO OMe 500) |) X ar mare | (3 Union, clubs, mre. FY 1964 Ask Cel. (j) - (a) ONLY for completed hospitalizations (“"Ne*" ia Col. (8) AND delivery or operation shown ia Col. (b) or Col. (i) Wos any pert |If "No" to [Did (will) |Did (will) [What is the neme of the insur o askithe insur- |the insur [ance o plan? Tor 3/0 ae | tt matte 10 antomine whether or more of the | nel ineumnce deceribe im footnote x pace beiow) (datror's) will? = ® (Yes 0s | [J Yes | Yes inswance to Co. Nec (m)) Amed Forces Medicare No (Ge te| [J Ne Free care Col. (w)) Othe (Spocity in Sootmoton) FY 1967 Ask if “No® morked in question 4c FS DID (WILLY HEALTH INSURANCE PAY ARY PART OF THSBILL? [Yes [J No/Cete 10) B. WHAT IS THE NAME OF THI 8. WHAT WAS THE TOTAL AMOUNT OF THE (HOSPITAL / NURSING HOME) BILL FOR THIS STAY? [= oF) Nome of insuronce Plon Doliors Cents THE INSURANCE €. DID (WILL) ANY OTHER HEALTH INSURANCE PUN PAY PART OF THIS (HOSPITAL /NURSING HOME) BILL! (IF "YES" REASK %) For each Heolth Inswonce Plan nomed, Ask WHAT WAS (WILL BE) THE AMOUNT PAID BY (Name of Plan)? Enter tot! amount paid by health insurance in line A Enter ANY amount poid by Medicare in line B- Dollors' Cents Fewom coeoe oe All Ide) i AL] Health insurance (41) Plons-exc! ! WHO PAID (WILL PAY) THE (REMAINDER OF THE) HOSPITAL BILL? each category mentioned) IB] Social Security Medicare b. DID ANY OTHER PERSON OR AGENCY PAY ANY OTHER PART OF THE HOSPITAL BILL? O Yes - dak 10e 0 No-Cewiod ICO] Self and/or Fomily D0] Relotive not in household &. WHAT WAS THE AMOUNT PAID BY __? (Enter omount oid opposite approgriote cotegary.) “NTERV EWER: Add amounts entered (inc lude ony amount po d by heath nuance) ond enter n TOTAL box, then ork one of the fol lowing bores. [ Tere! amount poid (10 be poid) ogrees with amount of hospital bill - (Co te 0.11) DJ Tos! aroum gus (tobe god) does NOT ogee ol bi (Resolve a) Serre re “160 Armed Forces Medicore ED) Friend IF] Kerr Mills or other Fed. Plons 10. Source IHC] Store or Lecol Welfore Agency 100 Orher (specify) TOTAL OF ABCVE (include amount —e=| od by hea'th insurance) Fon JULY- 1968 Eater the person number and the date of entry Year 12. Ask questions 13 through 18 for each completed hospitalization ' $ Dollars [Cents 13. What was the total amount 2% the hospital § ik for this stey? Do not include any doctor's er surgeon's bi [) Estimate, bill received ~~ [] Estimate, bill act received [] From bill 14a. Did (will) hesith insurance pay any part of the hospital bill? Brus __ Name of insurance plas Dollars [Cents c. Did other health insurance plon ‘es (Reask 145) pay part he this hospital bill? Rak for cach kedlih masrance plas named hen goo 150 plan)? d. What was (will be) the amount paid by (name of Enter total amount paid by healh insurance io line A. amount paid by Social Security Medicare in line B. 15a. Vie o poid (will Leys be Bose ol bill? ______ b. Did (you or) ony other or agency pay Yes (15c and reask 155) any other part of the al bill? _ CI No (15d or Int. Check liam) Who was this? d. Whot wes the mount paid by —-? 5 plans xsiviing Neitsare) Social Security Medicare c SC) Self nd fami in household | INTERVIEWER CHECK rou ©] No operation (19) 1 [] Operation or delivery (16s) Dollars Cents 6a. What was the amount of the surgeon's (doctor's) bill for this operation (delivery)? [CO] Estimate, bill receiv, for the surgeon's (doctor's) bill included in the § ote indicate the actual amouat of the hospital bil after deducts i in he mous pais by be health in fond Wath Fe Paymenis for expenses other than the mount you gave for the hospital bill? th d. What was (will be) the amos HT paid 17. Did (wilh) brah insurance pay any part of the surgeon's bill? Ask for each healt Name of insurance plan Dollars Cents Eater total amount paid by healt insurance in line A id by Social Security Medicare in line B. Too. Von o paid (will pay) the oy Th d. Whet wes the amount paid by —- ? excluding Medicare) 2] Social Security Medicare CY 1972 (See text: for Card H.) The following questions are chest the bill for th hospital sty — net shout any separate bill rem or surgeon. Please look ef this cord (Show Card H). Ba. Which of those seurces peid or wil! pay any of this hospital bill? 10 (Specify) — 4 567 89 b. Did or will any other source pay any of this hospital bill? 2 N(@ Circle odditionel sources In 8a c. Which source? Reosk 8b and c "1" is circled in 8a (e) d. Did or will you or your family pay any part of this hospital bill out of your own pocket? 2 N (A) ©. How much of this hospital bill did or will you or your family pay out of your own pocket? If hospital insurance reported (*‘3" circled in 8a), ask: 1 [C] Less than haif (9) f. What port of the hospital bill wes or will be paid by hospital insurance, less than half or one holf or mors? | 1. |2 [71/2 or more If only 3" is circled in 8a, ask: 9- Did or will hospital FA of the hospital bill? 2 N Figure 12. Questions relating to portion of hospital (and/or surgical) bill paid by insurance, fiscal years 1959 and 1960, 1964, 1967, July-December 1968, and calendar year 1972. 3. Hospital insurance or doctor visit insurance 4. Workmen’s Compensation 5. Accident insurance carried by family or someone outside the family 6. Armed Forces Dependent (CHAMPUS) 7. Veteran’s benefits 8. Medicaid 9. Welfare 0 . Other (some other source) Care The questionnaire format of the hospital bill payment items on the 1972 questionnaire seems to be the most satisfactory to date; the questions are set up to elicit the kind of infor- mation that can be collected on this topic in a household interview with some degree of accuracy. Supplementary questions pertaining to con- valescence following hospitalization were added to the survey questionnaire during fiscal years 1961 and 1967, and during the interim period, July 1967-December 1968 (figure 13). In 1961, only those persons who had undergone surgery, had a child, or had a fracture set were asked the convalescence questions that were added to hospital table II. Only the following FY 1961 For completed hospitalizations (‘'No'’ in Col. (g)) of persons 6 years old and over who show an operation, a setting of a fracture, or a delivery in Cols. (h)or(i): i in the hospital, be- pital, re you had your opera- tion (delivery, etc.) ? How mony nights were After You left the hos- w many days was it before you returned to your usual activities full-time? GQ) (k) If *'still unable’ in (k) ask: How long has it been since you left the hospital? m No. of nights No. of days [] Still unable Over 6 months under 6 moaths: — Days Months: FY 1967 ASK QUESTIONS 11 - 13 IF PERSON IS 55 YEARS OLD OR OVER Under 55 (Goto le) 55 or over (Mark one circle) ——— ° ° 11a. WHEN _ _ LEFT (Name of hospital / nursing home), DID HE RETURN HOME OR GO SOME OTHER PLACE? a Hore - Co to Question 12 [3 Some other place - Ask Question 116 Ne. WASHINGTON USE b. WHAT KIND OF PLACE DID — — GO TO? (Specify) ~ INTERVIEWER: If the “Place” in 11b is a Hospital, Nursing Home or a similar ploce, was o Hospital Page filled for that stoy? (Mark one box.) [J Hospital Page Filled (stop) OJ Hospital Page not filled (Fill Hosp. page for unreported stay.) Blonk (end 55) O Unser 88 O rere O Some ever piace O 12. AFTER LEAVING THE (HOSPITAL / NURSING HOME,) HOW MANY DAYS DID — — HAVE TO Still in bed (Go ve 14) O REMAIN IN BED ALL OR MOST OF THE DAY? (Mark entry) cof oR 13. (ALTOGETHER) HOW MANY DAYS WAS __ CONFINED TO THE HOUSE AFTER RETURNING HOME FROM Sill confined 19 house O THE ( HOSPITAL / NURSING HOME.)? (Mark entry) of oR 14.NOTE TO INTERVIEWER: completing all required Hospital pages. If the condition in question 5 or 6 is on Card A (A-1, A-2) or B (B-1, B-2) or there is “1" or more nights in question 4b, the condition must have a completed Condition page. If the condition does not have a Condition page, fill one after CY 1968 9a. When ~~ left (name of hospital/nursing home) did he return home or 2 3 [] Home (10) 4[] Some other place (9b b. What kind of place did =- go to? (Specify) 2 soma other place? Interviewer: If the place in 9b is a hospital, nursing home or similar place, was a hospital page filled for that stay? [J Hospital page filled (Stop) [] Hospital page not filled (Fill hospital page for unreported stay) 10. After leaving the hospital (nursing home) how many days did —— have to remain in bed all or most of the day? _ 000[] None xx1[] Still in bed 11, ALTOGETHER how many days was ~= confined to the house after returning home from the hospital (nursing home)? 000] None xx1[] Still confined to house Cees Figure 13. Questions relating to convalescence following hospitalization, fiscal years 1961 and 1967, and calendar year 1972. 27 two items of information about the conva- lescence were obtained: (1) the number of days before a person returned to his usual activities full time after he left the hospital, and (2) for a person still unable to pursue his usual activities, the number of days since he was discharged from the hospital. During the interim period July 1967-December 1968, this area of the questionnaire was administered to all persons 55 years of age and older for each hospital discharge during the year prior to interview. In addition, information was obtained on place of convalescence, number of days spent in bed, and number of days con- fined to the house following discharge from the hospital. Accidents resulting in injury.—During the interview, injuries due to accidents are usually reported in response to the illness and injury recall questions. From July 1957 through June 1967, there were specific recall questions re- lating to injuries occurring during the 2 weeks prior to interview week and to the presence of effects of old injuries. Through fiscal year 1965, in addition to entering each injury on a separate line in table I of the questionnaire, the interviewer also completed for each injury a “table A,” which described the class and FY 1958 TABLE A (Accidents and Injuries) Line No. | 1, What part of the body wos hurt? What kind of injury was It? Anything else? [) Accident happened during Table 1 past 2 weeks 2. When did it happen? Year (Enter month also if the year is 1957 or 1958) J Accident happened during Month past 2 weeks 3. Where did the accident happen? (inside or outside the house) [CJ Ac home (oun home or someone else's) [| While in Armed Services [) Some other place 4. Was a cor, truck, bus or other moter vehicle involved in the accident in any wey? [C] Yes [No 5. Were you at work at your fob or business when the occident happened? [Yes CINe [J Under 14 years at time of accident FY 1965 Table A - ACCIDENTS AND INJURIES Lie No: 1. When did the accident happen? | 2. At the time of the accident, what part of the body was hurt? What kind of injury was it? Anything else? Table I Year Part(s) of body Kind of injury (injuries) [Ll (If 1963, 1964, or 1965 also enter month): Accident happened 0 last week Month or week before (Go to Q. 3) 3, o. Was a cor, truck, bus or other motor vehicle involved in the accident inany way? .........ccovvuneeunen [1 Yes [CJ No (Go to Q. 4) b. Was more than one motor vehicle involved? « . «oi viii initio eenee sonneannns [J Yes (More than one) [J] No ©. Was It (either one) moving at the Hime? . . «otitis tonnenaee anne enennnnnnnnnnnees [3] Yes (J No 4. o. Where did the accident happen — at home or some other place? 10 At home (inside house) If *‘Some other place,” ask: b. What kind of place was it? 3] Street and highway (includes roadway) 4] Farm 8 [_] Industrial place (includes premises) 2[_] At home (adjacent premises) 6 [] School (includes school premises) 7] Place of recreation and sports, except at school 8] Other (Specify the place where accident h d [C] Some other place 5. Were you ot work at your job or business when the accident happened? 1] Yes 2[] No INTERVIEWER: Retum to Table I and complete the rest of this line. 3[] While in Armed Services 4[] Under 17 at time of accident Figure 14. Questions relating to accidental injuries (table A), fiscal years 1958 and 1965. 28 place of accident (figure 14). Essentially the same information needed to classify the injury was obtained each year. However, the questions on the 1965 questionnaire were more specific and more detailed than those on the 1958 document. Beginning in July 1965, the equivalent of ques- tionnaire table A, a section on each condition page, was completed if an injury was reported. The questions on the condition page were worded quite similarly to those on questionnaire table A, and this same format has been used through De- cember 1974 (figure 15). AS [) Accident or injury [J Other (NC) 20a. Did the accident happen during the past 2 years or before that time? [7] During the past 2 years (20b) [7] Before 2 years (21a) b. When did the accident happen? [) Last week [[]) Week before [1] 2 weeks—3 months 21a. At the time of the accident what part of the body was hurt? What kind of injury was it? Anything else? [J Over 3-12 months [1-2 years Part(s) of body Kind of injury If accident happened more than 3 months ago, ask: o . What part of the body is affected now? How is his —— affected? Is he affected in any other way? Part(s) of body Present effects 22. Where did the accident happen? 1 [1] At home (inside house) 2 [7] At home (adjacent premises) 3 [] Street and highway (includes roadway and public sidewalk) a] Farm s [] Industrial place (includes premises) 6 [] School (includes premises) 7 [) Place of recreation and sports, except at school 8 [] Other — Specify —g 23. Was —- at work at his job or business when the accident happened? 1 Y 3 [J] While in Armed Services 2 N 4 [] Under 17 at time of accident 24a. Was a car, truck, bus, or other motor vehicle involved in the accident in any way? 1 Y 2 N (NC) b. Was more thon one vehicleinvelved? YN ___ c. Was it (either one) moving at the time? 1 Y 2 N Figure 15. Questions on the ‘‘condition page’ which relate to accidental injury, calendar year 1973 (first part of this page is shown in Figure 6). As in other areas of the questionnaire, the section describing accidents resulting in injury has been expanded during certain years of the survey in order to obtain detailed information on acci- dents. During calendar years 1969 and 1970, a question relating to objects causing accidents or injuries was added. In fiscal years 1960 and 1961, and again in calendar years 1971 and 1972, this area of the questionnaire was extended to obtain information on the circumstances of the accident and the resulting injury (figure 16). While the questions for the two collection periods were quite similar, the format differed slightly. During both periods, the classification of the type of accident was made by the interviewer on the basis of the description and details provided by the respondent. Physician Visits.—Two types of information on physician visits are collected in the survey. One, the number of visits to a physician during the 2-week period prior to the week of the interview, is used to derive estimates of the total number of visits during the year for which the questionnaire is administered. The other, number of visits dur- ing the year prior to the interview and/or the length of time since a physician was seen, is the basis for estimates of frequency distributions of the population according to the annual number of physician visits (excluding hospital patient visits) and according to the interval since the physician was last seen. The development of the question- naire area on medical attention from fiscal year 1958 through fiscal year 1964 is shown in figure 17, While information on physician visits during the 2 weeks prior to interview is usually consid- ered as a basic core item in the survey, it has not been collected continuously in the survey. During fiscal years 1960-63, 1965, and the first half of 1966, no data on physician visits were collected. (January-June 1966 data were collected as a sup- plement. See Vital and Health Statistics, Series 10-Number 49, p. 4.) However, in January 1968, when the person approach method of data collec- tion was introduced for the recall of illness and injury, recent medical attention (during the 2 weeks prior to interview) was established as a necessary continuing item and thus became a part of the basic core of questions. While the informa- tion on annual visits and the interval since last physician visit is not required for the person ap- 29 30 FY 1960 AND 1961 Table A - (Accidents and Injuries) Line No. 1. When did the accident happen? 2. At the time of the accident, what part of the body was hurt? What kind of injury was it? from Anything else? Table I ‘ or Year: Part(s) of body Kind of injury(s) (If 1960 or 1961 also enter the month) Accident happened last Moath: week or week before (Go to q. 3) 3. (a) Was a cor, truck, bus or other motor vehicle involved in the accident in any way? [Yes [CI No (Ge to Section B) (b) Was more than one motor vehicle involved? [J Yes (more than one) [_]No (c) Was it (either one) moving at the time? [J Yes [CJ No (Go to Section B) 2. [] Getting in or out (Go to 4. Were you outside the vehicle, getting in or out of it, a passenger or were you the driver? 1.[[] Outside 3. [[] Passenger Section A (Go to Section q. 6) A q.5) 4. [] Driver Section A - (Motor Vehicle Accidents) Section B - (Non-Motor Vehicle Accidents) If “Outside” in q. 4, ask: 5. (a) How did the occident happen? 1. [J Accident between motor vehicle and person riding on bicycle, in streetcar, on railroad train, on horse- drawn vehicle 2. [J Accident between motor vehicle and person who was walking, running, or standing 3. [] Other (Specify how the accident happened) (b) What kind(s) of motor vehicle was involved? 1. [JCar 2. [J Taxi 3.[]Bus 4. [] Truck 5. [] Motorcycle 6. [] Other (specity) If “Getting in or out’ ‘'Passenger’’ or “Driver,” in q. 4, ask: 6. (a) How did the accident happen? 1. [C] Accident between two oc more motor vehicles on roadway 2. [[] Accident between motor vehicle and some other object on roadway (Specify object) 3. [CJ Motor vehicle came to sudden stop on roadway 4. [] Motor vehicle ran off roadway 5. [[] Other (Specify how the accident happened) [J] Acc. on roadway [1 Acc. not on roadway (b) What kind of motor vehicle were you in (getting in) (getting out of) when the accident happened? 1. [JCar 2. []) Taxi 3.[] Bus 4. [] Truck 5. [J Motoccycle 6. [] Other (Specify) 7. How did the accident happen? A.l. [[] Any injury involving an uncontrolled fire or explosion 2. [] Aay injury involving the discharge of a firearm 3. [] Any injury from an accident involving a non-motor vehicle in motion (streetcar, railroad train, airplane, boat, bicycle, horse-drawn vehicle) B.4. [] Any injury caused by machinery (belt or motor driven) while in operation (Specily kind of 5. [] Any injury caused by edge or point of knife, scissors, nail or other cutting or piercing implement 6. [] Any injury caused by foreign body in eye, windpipe, or other orifices 7. [J Any injury caused by animal or insect 8. [] Any injury caused by poi b llowed (Specify ). C.9. [] Fell on stairs or steps or from a height 10. [] All other falls 11. [T] Bumped into object or person (covers all collisions between persons including striking, punching, kicking, etc.) 12. [] Struck by moving object (include objects held in own hand or hand of other person, also falling, flying, or thrown objects) 13. [[] Handling or stepping on sharp or rough objects such as stoaes, splinters, broken glass, rope etc. 14. [C] Caught in, pinched or crushed between two moving objects or between a moving and a stationary object 15. [J Came in contact with hot object or substance oc open flame 16. [] One-time lifting or other one-time exertion 17. [] Twisting, stumbling, etc. D.18. [_] Other (Specify how ASK FOR ALL ACCIDENTS 8. (0) Where did the accident happen-- at home or some other place? 1. [C] At home (inside house) If “Some other place,’ ask: (b) What kind of place was it? 3. [[] Street and highway (includes roadway) 4. [] Farm 5. [] Industrial place (includes premises) 2. [C] At home (adjacent premises) [C] Some other place 6. [] School (includes school premises) 7. [] Place of recreation and sports, except at school 8. [[] Other (Specify the place where 1d. 9. Were you ot work at your job or business when the accident happened? 1 [) Yes 2. [JNo 3. [[] While in Armed Services 4. [] Under 17 at time of accident Figure 16. Questions relating to accidental injury as revised for fiscal years 1960 and 1961, and calendar years 1971 and 1972. CY 1971 AND 1972 > “1A2 [) Accident or injury [) Other (43) 16a. Did the accident happen during the past 2 years or before that time? [J During the past 2 years (16b) [] Before 2 years (17a) b. When did the accident happen? [C] Last week } What time of day ~~ [] Over 3—12 months [] Week before was it? [J 1-2 years [CJ 2 weeks—3 months 17a. At the time of the accident what part of the body was hurt? What kind of injury was it? Anything else? Part(s) of body Kind of injury If accident happened more than 3 months ago, ask: b. What part of the body is affected now? How is his —— affected? Is he affected in any other way? Part(s) of body Present effects 18. Where did the accident happen? 1 [CJ At home (inside house) 2 [] At home (adjacent premises) 3 [[] Street and highway (includes roadway and public sidewalk) a [] Fam s [] Industrial place (includes premises) 6 [] School (includes premises) 7 [[] Place of recreation and sports, except at school e [] Other (Specify) — CARD Y MOTOR VEHICLE ACCIDENTS How did the accident happen? Outside motor vehicle I. Accident between motor vehicle and person riding on bicycle, in streetcar, on railroad train, on horsedrawn vehicle 2. Accident between motor vehicle and person who was walking, running, or standing 3. Other way (Specify how) Inside motor vehicle or getting in or out 4. Accident between two or more motor vehicles on roadway 5. Motor vehicle came to sudden stop on roadway 6. Motor vehicle ran off roadway 7. Accident between motor vehicle and some other object on roadway (Specify object) 8. Other way (Specify how) 19. Was —— at work at his job or business when the accident happened? 1Y 3[] While in Armed Services 2N 4] Under 17 at time of accident 200. Was a cor, truck, bus, or other motor vehicle involved in the accident in any way? 1Y 2N (22) b. os misre bon ons VILE NTEOAE oes Y en o c. Was it (either one) moving at the time? v'Y 2 N 21a. Was —- outside the vehicle, getting in or out of it, a passenger or was —= the driver 1 [[] Outside (b) 3 [[] Passenger (c) 2 [] Getting in or out (c) 4 [] Driver (c) b. Whot kind(s) of motor vehicle wos involved? 1 [) Car (22) 2 [C) Taxi (22) 3 [] Bus (22) 4 [7] Truck (22) s [] Motorcycle (22) 6 [] Other (Specify) . What kind of motor vehicle was —— 1 [J Car 2 [] Taxi 3 [] Bus a [] Truck s [] Motorcycle 6 [] Other (Specify) 22. How did the accident happen? For motor vehicle accident, refer to Card Y and circle number for answer given. If “Outside "’ — 1 2 3% (Specify) If “Inside’’ or “Getting in or out of’ — 4 5 6 7* (Specify object) 8 [] Accident on roadway i [CJ Accident not on roadway (Specify how) For nonmotor vehicle accident, refer to Card Z and circle number for answer given. 11 12 13 14* 15 16 17 18* 19 20 21 22 23 24 25 26 27 28° *(Specify) CARD Z NONMOTOR VEHICLE ACCIDENTS How did the accident happen? II. Any injury involving an uncontrolled fire or explosion 12. Any injury involving the discharge of a firearm 13. Any injury from an accident involving a nonmotor vehicle in motion (streetcar, railroad train, airplane, boat, bicycle, horse-drawn vehicle) 14. Any injury inflicted by machinery (belt or motor driven) while in operation (Specify machinery) 15. Any injury inflicted by edge or point of knife, scissors, nail or other cutting or piercing implement 16. Any injury inflicted by foreign body in eye, windpipe, or other orifices 17. Any injury inflicted by animal or insect 18. Any injury inflicted by poisonous substance swallowed (Specify substance) 19. Fell on stairs or steps or from a height 20. All other falls 21. Bumped into object or person (covers all collisions between persons including striking, punching, kicking, etc.) 22. Struck by moving object (include objects held in own hand or hand of other person, also falling, flying or thrown objects) 23. Handling or stepping on sharp or rough object (include wounds from splinters, broken glass, etc.) 24. Caught in, pinched or crushed (i.e., between two moving objects or between a moving and a stationary object) 25. Came in contact with hot object or substance or open flame 26. 2 28. Other (Specify how accident happened) o Lifting or other exertion = . Twisting or stumbling Figure 16. Questions relating to accidental injury as revised for fiscal years 1960 and 1961, and calendar years 1971 and 1972—Con. 31 FY 1958 20. LAST WEEK OR THE WEEK BEFORE did anyone in the fomily talk to a INTERVIEWER: DO NOT COUNT doctors seen || 2X cco aN doctor or go to a doctor's office or clinic? while an inpatient in a hospital No. of times Last Week If “Yes, ask: * : . i We B (a) Who was this? Place Purpose No. of times Week Before (b) Anyone else? Home = At home D/T = Diag. or treat= | |— 1 Place _L __ Dopme_ For EACH person with *Yes"" box checked, ask Questions 20(c) through (f): Off. = At office ment 1 Clin. = Outpatient Nat. = Pre/post natal (c) How many times did you see or talk to a doctor LAST WEEK? Hospital G care heck 2 Clini en. = fH) (d) How many times did you see or talk to a doctor the WEEK BEFORE LAST? Co © Company or w= Tee 3 Ask for EACH visit to a doctor in last 2 weeks: Tel Sndesny Eye = Ive Exam. 4 el. = er telephone glasses) (e) Where did you talk to the doctor (the last time, the time before, etc.)? Or. = Other (spectty) 01. = Other (specity] | 5 (f) Why did you go to (call) the doctor (that time)? 6 If **No '’ to Question 20, ask: [) Under 6 mos. (J 6-12 mos. 21. ABOUT how long has it been since you have seen or talked to a doctor? No. of years [] Never FY 1964 MEDICAL CARE 18. (8) LAST EEX OR THE WEEX BEFORE did anyone in the family - you, your--, etc.- talk to a doctor or go to a doctor's office or clinic? Aayone else? If “Yes” (b) How many times during the past 2 weeks? (€) Were did you talk to the doctor? (d) How many times at -- (home, office, clialc, etc.)? (Record totsl ausber of times for each type of place) EINE] 19. What did you have done? Diag. or treatment If more than one visit or telephone call: Pre/post natal care Gen’ | check-up first Immun. /Vecc. hat did you have done on the { cone visit (or telephone call)? Eye exam. (glasses) ete. Other (Speci fy) 20. If “No” to q. 18s, ask: — Nos. or Yrs. How long bas {t been since you last talked to a doctor? (J Less than | mo. TJ mever Figure 17. Development of questions relating to medical attention, fiscal years 1958-1964. proach, both items continue to be included on the 2. Did have an appointment for that questionnaire since January 1969. visit? In a similar format to that for conditions, 3. Once he got there, about how long did injuries, and hospitalizations, questions relating —_ wait to see the doctor? to medical attention are asked in two stages: (1) the recall of visits fairly early in the inter- During calendar year 1972, a complete page view and (2) the circumstances of the visit on was included in the questionnaire to obtain the “doctor visit” page. This format, which has information on the most recent physician visit been in general use since fiscal year 1967, is during the past 12 months for all persons who shown as it appears on the questionnaire for had not seen a physician during the 2-week calendar year 1974 (figure 18). period prior to week of interview (figure 19). During several years of the survey, the An additional question was included on the “doctor visit” page has been expanded to doctor visit page during 1974 to determine if include questions on related items. From July the respondent’s blood pressure was taken dur- 1966 through December 1968, information was ing the visit. This question was in conjunction elicited on the amount of the bill (or expected with a special supplement on hypertension that bill) for each physician visit during the 2 weeks ~~ was administered to respondents in 1974. prior to week of interview. In calendar year Dental visits.—During the first 10 years of 1969, the following three questions pertaining the survey, questions regarding dental visits to the availability of medical care were added: were on the questionnaire only during fiscal years 1958, 1959, and 1964. Information 1. About how long did it take to get about dental care during the 2 weeks prior to there for the visit? week of interview was elicited for all 3 years. 32 RECALL QUESTIONS 13. Ruring the past 2 weeks (the 2 weeks outlined in red on that calendar) how many mes did ~~ see a medical doctor? (Besides those visits) 14a. During that 2-week period did anyone in the fomily go to a doctor's office or clinic for shots, X-rays, tests, or examinations? b. Whe was this? ~ Mark ‘Doctor visit’ box in person's column. € Anyone sise? 00 [7] None J (NP) Number of visit; Y N (15) Y (Reask /4b ond c) N i" “Doctor visit," ask: d. How meny times did —- visit the doctor during that period? 156. During that period, did anyone in the family get any medical edvice from a doctor the telephone? b. Who was the phone call about? ~ Mark *‘Phone call’ box in person's column. ©. Any calls about anyone else? Y N (16) Y (Reask 5b and c) N If ‘Phone call," 4. How weny telephone calls were els to got medical dient sedos -—1 eo item C, (DOCTOR). from oy s 13-15 for all persons. sk Q. 16a for each person with visits in DOCTOR box. Con (1rem C o THEN 16d) 16a. eo rnin hale? tai I TETANY wi EIFeewe fen b. Did ~~ see or talk to @ doctor about any specific condition? be Y N (NP) ©. During the past 2 weeks was —— sick because of her pregnancy? c. What condition? S Enter condition in item C and ask 16d d. During that period, did —— see or talk to a doctor about any other condition? 4 Y (16) N (NP) Ps Y N (16d) f. What wos the matter? 7a. Dori past 12 months, (that is since __ (date) tolk to a medical doctor? (Do not count doctors seen (Include the == visits you already told me about.) ogo), about le a patient in a hospital. § | Enter condition in item C (16d) 17a. | 000 [] Only when in hospital 000 [7] None. Number of visits b. ABOUT how long has if been since —— LAST saw or folked to a medical doctor? [Past 2 wesks mo. TLS ont 16) [OV ep bon 3) 2 wks.~6 mos. | column. 4 [J Over 6=12 mos. $s] year 602-4 years 7(T] 5+ years 8) Never DOCTOR VISITS 2-WEEKS DOCTOR VISITS PAGE 1. | Person number Earlier, you told me that —— had seen or talked to a 7777 [J Last week doctor during the past 2 weeks. LC [0] Week before 20. On what (other) dotes during that 2-week period did —~ visit or talk to a doctor? eveov-] Y (Reask 20 ond b) on Write in Mark appropriate box(es) b. Were th that period? N (Ask 3-6 for each visit) 3. Where did he see the docto th 3. 0 [[] While inpatient in hospital (Next DV) clinic, h hol, doctor's offic 1 J Doctor's office (group practice or If Hospital: Was it the outpatient clinic 4ost8¢'3 iris or the emergency room? 2] Telephone 3 [C] Hospital Outpatient Clinic If Clinic: Was it a hospital outpatient [Home clinic, a company clinic, or some kind of clinic? 8 [[] Hospital Emergency Room 6 [] Company or Industry Clinic 700 Other Specity —p 4. Is the doctor a general practitioner or a specialist? 4. | o1 [J] General practitioner CI specia Whet kind of speci 5. During this visit (call) did —— actually see (talk to) 5. the doctor? LY 2 N 60. Why did he visit (call) the doctor on _ (date) 7? 6a. 1 [J Diag. or treatment (6c) 3 [CJ General checkup (6b) 2 [J] Pre or Postnatal care 4] Eye exam. (glasses) r 8 [J Immunization ei BV) 6 [C) Other i _ Was this for any specific condition? Y (Enter condition in 6a N (Next DV) ond change to *'Diog. or treatment’) Mark box or ask: c. For what condition did —— visit the doctor on _ (date) _ ? [C] Condition reported in 6a Figure 18. Questions relating to medical attention, calendar year 1974. 33 12-MONTHS DOCTOR VISITS PAGE [) 2-week D.V. (NP) [J No I 2-month D.V. (NP) Eorlier, you told me that —— had seen or talked to a doctor during the past 12 months. 19 2. In what month during the past 12 months did —— last visit or talk to a doctor? 2 Month Year 3. Where did he last see the doctor in___ (month) __, ata 3. [x0 [CJ While inpatient clinic, hospital, doctor's office, or some other place? in hospital } (stop) 01 [] Doctor's office If Hospital: Was it the outpatient clinic (group practice or or the emergency room? Doctor's Clinic) 10 [[] Telephone If Clinic: Was it a hospital outpatient clinic, a company clinic, or some other 200 Hospital Outpatient kind of clinic? 30 [_] Home 40 [_] Hospital Emergency Room 50 [_] Company or Industry Clinic 60 [] Other Brecilyl— 4. Is the doctor a general practitioner or a specialist? 4. |01 [[] General practitioner [J Specialist — What kind of specialist is he’ 5a. Was this visit for emergency care? Sa. | 1 Y 2 N b. Was this visit for surgery or pre or postsurgical care? b.| 1 Y 2 N 6a. Why did he visit (call) the doctor in___(month) _ ? 6a. Write in reason lm mm om A A A OO [of we mma msi sitio or oi Mark appropriate box(es) 1 [] Diag. or treatment (6c) 3 [[] General checkup (6b) 2] Pre or Postnatal care 4] Eye exam. (glasses) (7) s [[] Immunization 6 [_] Other Y (Enter cond. in 6a, N (7) rings hy be Wel WSOP ONY IPRONEIIRININ, «ee tn iim mmm mre memes mm mses 51]... SEHGAL] en] Mark Box oF asks [C] Condition reported in 6a c. For what condition did —— visit the doctor in __ (month) _ ? rN Please look at this card — (Show Card H) I 2 3 4 5 6 7 8 9 7a. Which of those sources did or will pay any of the doctor's bill for this visit? 7a.| 10 (Specify) 7 b. Did or will ony other Source poy ony oie dosrarabili for tia vial? ooo ali X Ih c. Which source? c.| Circle additional sources in 7a CARD H . Total or partial payment by self or family ~ . Social Security Medicare w . Hospital insurance or Doctor Visit insurance > Workmen's Compensation om Accident insurance carried by family or some- one outside the family . Armed Forces Dependent Care (CHAMPUS) . Veteran's Benefits . Welfare 6 7 8. Medicaid 9 0 . Other (Some other source) Figure 19. Format of the ‘’12-months doctor visits page,” calendar year 1972. In addition, information about the interval since last dental visit was obtained in fiscal years 1958 and 1964, and about the frequency of dental visits during the past 12 months in fiscal year 1959 (figure 20). Information about dental visits during the 2-week period prior to the week of interview became a standard item in calendar year 1968 and has been used through December 1974, From responses to these questions, it was possible to derive estimates of the total number of dental visits made during the year. During calendar year 1968, with the new “person approach” on illness recall, an addi- tional question was added to the 2-week dental section for the purpose of eliciting oral or dental conditions. These questions were re- tained through calendar year 1970. The 1971 questionnaire included questions relating to the type of dental service received. During calendar years 1970-74, data were collected that pro- vided estimates relating to the interval since the last dental visit and the frequency of visits during the 12 months prior to the interview. During 2 years of the survey, fiscal year 1958 and calendar year 1971, a question that provided information relating to edentulous persons was added to the questionnaire. During 1958 a single question, “Is there anyone in the family who has lost all of his teeth?” elicited this kind of information. During 1971, this question was followed by additional ones per- taining to ownership, use, and adequacy of upper and/or lower dentures (figure 21.) Limitation of mobility.—Information on the ability of sample persons to get around freely FY 1958 — _ _ DENTAL CARE _ 21. (a) Last weekor the week before did anyomein the family go to a dentist? Anyome else? Ove Dg CA | Hn» 00000 ees ses. : (b) Now wemy times during the past 2 weeks? No, of tines 22. Wat did you have done? If more than one visit: first Wat €10 yo bare done en the { siina} visit? (1D (3) 3 BE Bios or tre SREESE- If “No” to q. 21s, ask: 23. How long has it been since you went to a demtist? ins YO Eto. OC never 18. LAST WEEK OR THE WEEK BEFORE did anyone in the family go to a dentist? If “Yes,” ash: (a) Who was this? (b) Anyone else? For each person with '‘Yes'’ checked, ask: (d) What did you have done (the last time, the time before, etc.)? (e) Anything else? 24. Is there sayome in the family who bas lost all of his teeth? Ove Ome FY 1959 19. (0) Lest week or the week before did anyone in the family go te a dentist? Anyone else? OI) Yes CO Ne RoYes® eee ——— "to" (b) How many times during the past 2 weeks? Wo. of is » [J One [2 Three 20. How many times altogether in the past 12 months did yeu ga te a dentist? CC Twe [2 Fou oc more None FY 1964 C] Yes CC No (c) How many times did you visit the dentist LAST WEEK OR THE WEEK BEFORE? en nm. Sn. en in} 1) @ 3) (OJ [1 (Fillings [J [3 [OJ Extractions or other surgery Straig on 3 Snes onta [OJ [J [ Treatment for gums [J OO [J Cleaning teeth (OJ J [OJ Examination [J [J [1] Denture work 0 OJ [J Other (pect) If “No'’ to Question 18, ask: 19. ABOUT how long has it been since you went to a dentist? [CO] Under 6 mos. [] 6-12 mos. No. of years. [J Never Figure 20. Questions relating to dental visits, fiscal years 1958, 1959, and 1964. 35 has been collected on a rotating basis. During the first 4 years of the survey, fiscal years 1958-61, a single question regarding mobility limitation was asked at the end of question- naire table I (figure 22). This question was asked only for those persons for whom some degree of activity limitation had been reported. During the period July 1964 through June 1967, the next interval during which mobility limitation data were collected, this restriction was removed and all persons with one or more chronic conditions were queried about their ability to move about; also, a question pertain- ing to the cause of the limitation was added. In keeping with the introduction of the “con- dition page” in July 1965, the format of this question changed but the wording remained essentially the same through June 1967. During calendar year 1971, a concerted effort was made to obtain definitive information on mobility limitation. Instead of asking the respondent to select the appropriate statement from a card, the interviewer read the options to the respondent and recorded the most suit- able degree of limitation for each sample person. However, this procedure produced inconsistent results; therefore, a modified flash- card version was used again in 1972 (figure 23). Control items.—At the completion of the health interview, the interviewer turns to page 1 of the survey questionnaire to ask certain questions about the living quarters in the sample household. The front page of the questionnaire serves the following purposes: (1) to provide space for a record of the calls made to obtain the interview and the length of the completed interview; (2) to obtain information about the size of the place and the annual amount of produce, data that are necessary in classifying the sample persons by place of residence (farm, nonfarm, etc.); (3) to record the number of rooms in the home (not all years); (4) to record the telephone number in case additional information is needed later by the interviewer; and (5) to provide information regarding the reason for noninterview in those assigned households where no interview was conducted. For certain years, additional items have been 11a. Is there anyone in the family who has lost ALL of his teeth? Y N (12) b. Who is this? Anyone else? 11b.| [C] No teeth | For each person with ‘No teeth,” ask: 1 - c. Does —— have false teeth? “ Y N (NP) [CJ Upper [] Both d. Does —= have an upper plate, a lower plate, or both? d.| [Lower the upper e. Does —— usually wear the lower 5 plate(s) while eating? e| Y N both weary TTT = mR f. Does —— usually wear fie lower plate(s) when not eating? tly N ot! g. Does —— need new false teeth? 9 Y (NP) N h. Do the ones he has need refitting? wm vy " Figure 21. Questions relating to loss of teeth and use of dentures, calendar year 1971. 36 FY 1958-61 If 1,” or 12" or "3" ia col. (r) ask: Card G 3 Line number FY 1966-67 getting around outside. w freely. - . Not limited in any of these ways. NATIONAL HEALTH SURVEY 1. Confined to the house all the time, except in emergencies. 2. Can go outside but need the help of another person in . Can go outside alone but have trouble in getting around 20. PLEASE LOOK AT THE BLUE CARD, CARD H. WHICH ONE OF wm aN THE TIME. . MUST STAY IN THE HOUSE ALL OR MOST OF THE TIME. . NEED THE HELP OF ANOTHER PERSON IN GETTING AROUND INSIDE OR OUTSIDE THE HOUSE. . NEED THE HELP OF SOME SPECIAL AID, SUCH AS A CANE OR WHEELCHAIR, IN GETTING AROUND INSIDE OR OUTSIDE THE HOUSE. . DOES NOT NEED THE HELP OF ANOTHER PERSON OR A SPECIAL AID BUT HAS TROUBLE IN GETTING AROUND FREELY. . NOT LIMITED IN ANY OF THE ABOVE WAYS THOSE STATEMENTS FITS — ~ BEST IN TERMS OF HEALTH? Mark statement number —»— 0000 00 o If1,2,3,4, or 5 marked | 21. IS THIS BECAUSE OF ANY OF THE CONDITIONS YOU HAVE TOLD ME ABOUT? WASHINGTON USE ~% in 20, ask: ¢ [i Yes v If 6 marked, omit 21 and t [Yes —— WHICH? —-------ommmme Fr eT aL es erent o o 80 to next person. i TTT TTT TTT TTT Tree Age Gen oh oK i [} o o o ! WHAT DOES CAUSE t ONo— "rus LiiTATION? Eoier em: ‘| CARDH For: Mobility 1. MUST STAY IN BED ALL OR MOST OF Figure 22. Questions relating to limitation of mobility, fiscal years 1958-1961, and 1966-1967. 37 . M ; L 2 3 (240) Please look at this card (Hand respondent Card M) 4 Which ons of fuess stetoments fits == bas) ID OE SHHOOIND enn SEE SpprepTim NiOO)__ M: 5 If respondent does not understand or is unable to read the card, ask questions 17-23 for each person. 6 (NP) 19. In terms of health must —~ stay IN BED all or most of the time? 19. 1 Y (240) N 20. In terms of health must —— stay IN THE HOUSE all or most of the time? 20. 2 Y (240) N 21. Does ~~ need the help of ANOTHER PERSON in getting around inside or outside the house? 2. 3 Y (240) N 22. Does —— need the help of some SPECIAL AID, such as a cane or wheelchair in getting around 22 inside or outside the house? 4 Y (240) N 23. Although —~ does not need the help of another person or a special aid, does he have trouble 23. getting around freely? $s Y (24a) 6 N (NP) Ask for each person with a limitation reported in item M or in questions 19-23: (1) had to stay in bed because of health? 000 [[] Less than | month (2) had to stay in the house because of health? 240. About how long hos = (3-4) needed help getting around inside or outside the house? a) 4 mgs: 2 rs (5) had trouble getting around freely? b. What (other) condition causes this? b. Enter condition in item C ond ask c If “old age’’ only, ask: Is this caused by any specific condition? [C] Old age only (NP) Y (Reask N c. Is this caused by any other condition? ‘ ond) Mark box or ask: [CJ Only | condition d. Which of these conditions would you say is the MAIN cause of his limitation? d. - — Enter main condition In terms of health: THE TIME. MOST OF THE TIME. OUTSIDE THE HOUSE. OUTSIDE THE HOUSE wv AROUND FREELY. AROUND FREELY. CARD M I. MUST STAY IN BED ALL OR MOST OF 2. MUST STAY IN THE HOUSE ALL OR 3. NEED THE HELP OF ANOTHER PERSON IN GETTING AROUND INSIDE OR 4. NEED THE HELP OF SOME SPECIAL AID, SUCH AS A CANE OR WHEELCHAIR, IN GETTING AROUND INSIDE OR . DOES NOT NEED THE HELP OF ANOTHER PERSON OR A SPECIAL AID BUT HAS TROUBLE IN GETTING 6. DOES NOT HAVE TROUBLE GETTING Figure 23. Questions relating to limitation of mobility, calendar year 1972. included on the covering page. In most instances, these items were added to remind the interviewer to check certain areas of the questionnaire, such as table I, the condition 38 pages, or table A on accidents and injuries, to determine if appropriate supplements had been completed for persons with conditions that required supplements for a specific year. In calendar year 1970, during which the collec- tion of prevalence data on chronic conditions was limited to those affecting the respiratory system, a household item relating to the type of heating and air conditioning in the home was added to the first page of the question- naire. Supplements to the Basic Questionnaire Supplements to the questionnaire used in the Health Interview Survey are of the follow- ing two types: (1) rotating supplements, de- fined as those on the same general topic that have appeared during more than one collection interval, and (2) one-time or single supple- ments, described as those that have appeared during a single collection interval. As pre- viously noted, some of the rotating supple- ments were included according to a planned schedule; others, originally intended as one- time items, became rotating supplements when their timeliness and importance indicated a need for trend data. In table B, the special supplements are out- lined according to type of supplement and the period during which data were collected. Some of the supplements were included within the format of the basic questionnaire, while others were on separate documents. In appendixes I and II, the actual configuration of the supple- ments is shown. Table B. Supplements to the basic questionnaire used in the Health Interview Survey Fiscal year Calendar year Type of supplement 1959 | 1960 | 1961 | 1963 | 1964 | 1965 1967 | 1968 | 1969 | 1970 | 1971 | 1972 | 1973 | 1974 Rotating supplements . Health insurance .. X X . Hearing impairment X . Loss of income ... . Nursing care and/or special aids... X . Personal health expenses ..... X 6. Prescribed and nonprescribed medicines .... X 7. Smoking habits ... X 8. Vision impairment and use of corrective enses ........ X HB WN = oa One-time supplements . Acute condition .. . Arthritis ........ . Blood donorship .. . Diabetes ........ X . Hypertension .... . Medical care availability .... . Motor vehicle accidents ..... 8. Orthodontic care 9, Pregnancy ....«us 10. Preventive care ... 11. Specialists’ services and routine checkups ..... X OHA WN= ~N 000 39 REFERENCES INational Center for Health Statistics: Health Survey Pro- cedure: Concepts, Questionnaire Development, and Definitions in the Health Interview Survey. Vital and Health Statistics. PHS Pub. No. 1000-Series 1-No. 2. Public Health Service. Washington. U.S. Government Printing Office, May 1964. 2National Center for Health Statistics: Measurement of Personal Health Expenditures. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 2. Public Health Service. Washing- ton. U.S. Government Printing Office, June 1963. National Center for Health Statistics: Reporting of Hospitalization in the Health Interview Survey. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 6. Public Health Service. Washington. U.S. Government Printing Office, July 1965. 4National Center for Health Statistics: Health Interview Responses Compared With Medical Records. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 7. Public Health Service. Washington. U.S. Government Printing Office, July 1965. 5National Center for Health Statistics: Interview Response on Health Insurance Compared With Insurance Records, U.S., 1960. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 18. Public Health Service. Washington. U.S. Government Printing Office, Aug. 1966. 6National Center for Health Statistics: Interview Data on Chronic Conditions Compared With Information Derived From Medical Records. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 23. Public Health Service. Washington. U.S. Government Printing Office, May 1967. "National Center for Health Statistics: The Influence of Interviewer and Respondent Psychological and Behavioral Variables on the Reporting in Household Interviews. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 26. Public Health Service. Washington. U.S. Government Printing Office, Mar. 1968. 8National Center for Health Statistics: Development and Evaluation of an Expanded Hearing Loss Scale Questionnaire. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 37. Public Health Service. Washington. U.S. Government Printing Office, Apr. 1970. 9National Center for Health Statistics: Effect of Some Experimental Interviewing Techniques on Reporting in the Health Interview Survey. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 41. Public Health Service. Washington. U.S. Government Printing Office, May 1971. 10National Center for Health Statistics: Reporting Health Events in Household Interviews: Effects of Reinforcement, 40 Question Length, and Reinterviews. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 45. Public Health Service. Washington. U.S. Government Printing Office, Mar. 1972. National Center for Health Statistics: Interviewing Methods in the Health Interview Survey. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 48. Public Health Service. Washington. U.S. Government Printing Office, Apr. 1972. 12National Center for Health Statistics: Reporting Health Events in Household Interviews: Effects of an Extensive Questionnaire and a Diary Procedure. Vital and Health Statistics, PHS Pub. No. 1000-Series 2-No. 49. Public Health Service. Washington. U.S. Government Printing Office, Apr. 1972. 13National Center for Health Statistics: Optimum Recall Period for Reporting Persons Injured in Motor Vehicle Acci- dents. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 50. Public Health Service. Washington. U.S. Government Printing Office, Apr. 1972. 14National Center for Health Statistics: Net Differences in Interview Data on Chronic Conditions and Information Derived From Medical Records. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 57. Public Health Service. Washington. U.S. Government Printing Office, June 1973. 15National Center for Health Statistics: Hospital Utilization in the Last Year of Life. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 10. Public Health Service. Washington. U.S. Government Printing Office, July 1965. 16National Center for Health Statistics: Hospitalization in the Last Year of Life, United States, 1961. Vital and Health Statistics. PHS Pub. No. 1000-Series 22-No. 1. Public Health Service. Washington. U.S. Government Printing Office, Sept. 1965. 17National Center for Health Statistics: Episodes and Duration of Hospitalization in the Last Year of Life, United States, 1961. Vital and Health Statistics. PHS Pub. No. 1000-Series 22-No. 2. Public Health Service. Washington. U.S. Government Printing Office, June 1966. 18National Center for Health Statistics: Eighth Revision International Classification of Diseases, Adapted for Use in the United States. PHS Pub. No. 1693. Public Health Service. Washington. U.S. Government Printing Office, 1967. 19National Center for Health Statistics: Impairments Due to Injury, United States, 1971. Vital and Health Statistics. Series 10-No. 87. DHEW Pub. No. (HRA) 74-1514. Public Health Service. Washington. U.S. Government Printing Office, Dec. 1973. APPENDIX | ROTATING SUPPLEMENTS The health insurance supplements were included within the format of the basic questionnaire in fiscal years 1960, 1963, and 1968 and calendar years 1968, 1970, 1972, and 1974. HEALTH INSURANCE COVERAGE Fy 1960 (July-December 1959) 18. (a) | have some questi about health insurance. We don't want te include insurance that pays (b) What is the name of the plan (or plans) ? Any other plons? (c) Who is covered by this plan (each plan) ? (Check "Yes," in 19(a) for each person covered) ONLY for accidents, but we are interested in all other kinds... De you, your---, have [J] Yes (Ne Jo insuronce that pays all or port of the bills when you go to the hospital? N ame(s) If “Yes,” (b) Whot is the name of the plan (or plans)? Any other plans? (€) Who is covered by this plan (each plan) ? (Check “Yes,” in 18(a) for each person covered) (d) Does the plan (sither plan) pay ony port of the surgeon's bill for on operation? [Yes [No (Jok 19. (0) Again excluding insurance that pays ONLY for accidents, do you, your--- have insurance [1] Yes [JNo (JpK thet pays all or part of the bill for doctors’ visits at home or at his office? If Yes," Name(s) Enter in each person's column whether or not he responded for himself for questions 18 and 19 a. 18, 19 [fact that a Form NHS-3(a) which covered him was left. [7] Responded for self R: aod if he did aot, (1) show the column number of the person who responded for him of (2) the Col. No.____was respondent (] Form NHS-3 (a) left FY 1963 18. (a) | have some questions about health insurance. We don't want to include insurance that pays ONLY for accidents, but we are interested in all other kinds. Do you, your ==, etc. have insurance that pays all or part of the bills when you go to the hospital? If “Yes,” ask: (b) Who is covered by hospital insurance? (Check the * ‘Yes’ box in 18(a) for each person covered) (c) What is the nome of the plon (or plans)? Any other plans? Name of plan(s) 19. (0) Excluding insurance that pays ONLY for accidents, do you, your - =, etc, have insurance that pays all or part of the surgeon's bill for an operation? If “Yes,” ask: (b) Who is covered by insurance for surgeons’ bills? (Check the 'Yes’® box in 19(a) for each person covered) (c) Whot is the name of the plan (or plans)? Any other plans? Name of plan(s) 20. (a) Do you, your--, etc., have insurance that pays any part of doctors’ bills for home calls and office visits? If “Yes,” ask: (b) Who is covered by insurance for doctors’ bills? (Check the ‘‘Yes’’ box in 20(a) for each person covered) (c) What is the name of the plan (or plans)? Any other plans? (d) Does it (each plan) pay for home calls and office visits for most kinds of sickness? Name of plan(s) 41 FY and CY 1968" These next questions are about health insurance. We are interested in all kinds of health insurance plans except those which pay only for accidents. 32a. (Not counting Social Security Medicare), is anyone in the family covered by hospital [Yes (32b,¢c) [J No (32d) insurance, that is, a health insurance plan which pays any part of a hospital bill? b. What is the name of the plan? (Record in Table H.1.) “c. (Again not counting Medicare), is anyone in the family covered by any oth REI He Which boys Shy pon of hespitl BATE or Ec AR us SET d. (Besides Medicare and the —= plan(s) you already told me about)is anyone in the family [Yes (32e,f) [J No (If no plans covered by any health insurance plan which pays any part of a doctor's or surgeon's bill? in Q. 32a-d (Complete go to Q.33) Table Jr e. What is the name of the plan? (Itecord in Table ILL) for ese f. Does anyone in the family have any other health insurance plan (besides Medicare)? [1 Yes (32e,f) CJNo If 65 or over, ask: 0] Und.65(NP) 33. These next questions are about Social Security Medicare. Does —— have a Medicare card? 33] [CJYes(wp) [JNo(NP) If “Yes” for one or more persons in Q. 33, ask: From 1 [JHospital card: 2[JMedical J NP 34. 1t would be helpful if | could see == (and ==) Medicare card (s) to determine what type Up -—————-—- a of coverage he has (they have). May | please see this (those) card(s)? No 4 JCan’tloc. NP card: 5 Refused (Transcribe the information from the card or check the appropriate ‘No card” box.) 6[] Other For each person with ““No’” in Q.33 or “No card’’ in Q.34, ask: 35a. Is == covered by that part of Social Security Medicare which pays for hospital bills? 350 [Yes (hb b. Is —= covered by that part of Medicare which pays for doctor's bills, | - NI that is, the Medicare plan for which he or some agency must pay $3.00 a month? C1Yes(wP) []No(NP) | For each person check Table H.I. and Q. 34 and 35 and determine OJ Covered (NP) if “Covered” by insurance or Medicare or “Not Covered’ by either. [CJ Not covered (36) 36. (Many people do not carry health insurance for various reasons). 3%. Would you mind telling me why —— does not have health insurance? (NP) CY 1970 These next questions are about health insurance. [Jund. 65 @P) ER 31a. Is —— covered by that part of Social Security Medicare which pays for hospital bills? Ile. "3 Y TaN sok] ASK: | b.ls —= covered by that part of Medicare which pays for doctor's bills, TY TTT 2N DK that is, the Medicare plan for which he or some agency must pay $5.30 a month? b.| VP) (NP) (VP) For each person with “‘DK’* in Q. 31a or b, ask: 32. May | please see —~ (and ~~ ) Social Security Medicare card(s) to determine 32. 1 [J Hospital the type of coverage? 2[ Medical | (NP) (Transcribe the information from the card or mark the ‘‘Card not seen’ box.) 3[] Card not seen We are interested in all kinds of health insurance plans except those which pay only for accidents. (Not counting Medicare) 33a. Is anyone in the family covered by hospital insurance, that is, a health insurance plan which pays any part of a hospital bill? Y (33b, c) N (33d) b. What is the name of the plan? (Record in TableHI) c. Is anyone in the family covered by any other hospital insurance plan? Y (335, c) N (33d) d. Is anyone in the family covered by a (any other) health insurance plan which pays any part of a doctor's or surgeon's bill? Y N (Complete Table H.I. for each plan. If no plans reported, go to Q.34.) e. What is the name of the plan? (Record in Table H.L; reask 33d) TTT TABLE H.I. Which members of the family Was this Does —— pay | Does —~ pay | Does this plan| Does this plan are covered by (name of insurance any part of a | any port of a | pay any part pay any part of plan)? plan hospital bill? | surgeon's bill?| of a doctor's a doctor's bill obtained bill for slice for ollie yi its Circle col bers through an visits or home | or home calls Name of plan re em me Seis golin? Sa sin Is anyone else in the family place of been paid by covered under this policy? work? the family? (1) (2) (3) (4) (5) 6) 7) Y A 12345678910] Y N]|Y Nf oy Nf eRe yy Y B t234s5678910[Y N|Y N[y ON|g@eret yy ! The format of this supplement on health insurance was revised several times during the experimental period, July 1967-December 1968. The format shown here was according to the final revision dated April 25, 1968. 42 CY 1972 These next questions are about health insurance. [J Und. 65 (NP) IF &8 ER la. Is == covered by that part of Social Security Medicare which pays for hospital bills? la. 1 2 N 9 DK ASK: b. Is == covered by that fo of Medicare which pays for doctor's bills, 1Y N 9 DK that is, the Medicare plan for which he or some agency must pay a certain amount each month? b.| (NP) (NP) (NP) For each person with ‘‘DK’’ in Q. la or b, ask: 1 [] Hospital 2. May | please see the Social Security Medicare card(s) for —— (and == ) to determine 2, the type of coverage? 2 [] Medical (NP) (Transcribe the information from the card or mark the ‘Card not seen’’ box.) 3 [CJ Card not seen We are interested in all kinds of health insurance plans except those which pay only for accidents. 3a. (Not counting Medicare) Is anyone in the family cavered by hospital insurance, that is, a health insurance plan which pays any part of a hospital bill? Y (3b, ¢) N (3d) b. What is the name of the plan? (Record in Table H.I.) c. Is anyone in the family covered by any other hospital insurance plan? Y (3b, ¢) N (3d) Y N (Complete Table H.I. d. Is anyone in the family covered by a (any other) health insurance plan which for each plan. If no pays any part of a doctor’ sor surgeon's bill? plans reported, go to) e. What is the name of the plan? (Record in Table H.I.; reask 3d) Which members of the family Was this Insurance plan Is this plan NOW carried through To recelve services under TABLE HI are covered by (name of plan)? | obtained through an a group or as an Individual plan? | this plan must you and your a Sy | TR Ha ne Name of plan covered under this policy? (a) (b) (c) (d) (e) A 12345678910] 1Y 2N DK [1[JGroup 2[JInd.s[JDK|1 ¥Y 2 N so DK B 1 2345678910] 1Y 2 N 9 DK 1 [C] Group 2[]Ind. 9[JDK|1 Y 2 N 9 DK C 1 2345678910] 1Y 2 N 9 DK 1 [C] Group 2[JInd. 9 [JDK|1 Y 2 N 9 DK D 12345678910[1Y 2N 9 DK 1[JGroup 2[JInd. 9[JDK|1 ¥Y 2 N 9 DK E 12345678910|1Y 2N DK [1[JGoup 2[JInd.s[JOK|1 ¥Y 2 N » DK Dees this — Dees this — plan | Does this plan pay any | Does his plo pay What do you (does ——) What do you (does —) When was the last time any pay any part of pay - part of a doctor's bill any part of a like most about this — like least about this member of your family used hospital expenses? doctor's or or office visits or doctor's blll for plan? — plan? this == plan? surgeon's bills home calls? office visits or for operations? home calls after a certain amount has been paid by the family? N (2) (h) (i) (J) (k) (1) 000 [[] Nev. used 2___ Wks. 1Y 2N 9DK[1Y 2N 9 DK|1 Y()2N9DK|1Y 2N 9 DK 3__Mos. 4___ Yrs, 000 [[] Nev. used 2___ Wks. 1Y 2N9DKf1Y 2N 9DK[1Y() 2NS9DK|1Y 2N29 DK 3__Mos. 4___ Yrs. 000 [J] Nev. used 2___ Wks. 1Y 2N9DK|1Y 2N 9DK|[1 Y()2N29 DK[t Y 2N 9 DK 3__Mos. 4___ Yrs. 000 [[J'Nev. used 2___ Wks. 1Y 2N9DK[1tY 2N9DK|1Y()2N9 DK(tY 2N ss DK 3_ Mos. 4___Yrs. 000 [] Nev. used 2___ Wks. 1Y 2N 9DK|1Y 2N 9DK|1 Y()2No9DK[1tY 2NSs DK 3_Mos. a___ Yrs. TE BT TIT WIE TR ibs SAE © 1 For each person, review Q's. | and 2 and Table H.I. and determine if 1 |! [J Covered (NP) ‘‘Covered”’ by either Medicare or insurance or ‘‘Not covered.’ 2 [] Not covered (NP) Ask for each person ‘‘Not covered’ I 2 3 4 5 6 (Many people do not carry health insurance for various reasons) 4, Which of these statements (Hand Card N) best describes why ~~ 4. 7 Bpaciiyl—y is not covered by any health insurance plan? Any other reason? Circle all reasons given Sa. Is anyone in the family covered by an insurance plan which pays any part eV .d ad 3 of a dentist bill for routine egular care? 1Y 2 N (41) f- he b. Which members of the family are covered? — Anyone else? Sb. | [J] Covered 43 CY 1974 HEALTH INSURANCE PAGE These next questions are about health insurance. yr [TJ Und. 65 (NP) . Is anyone in the family covered by any other hospital insurance plan? d. Is anyone in the family covered by any.(other) health insurance plan which pays any part of a DOCTOR'S or SURGEON'S bill? e. What is the name of the plan? (Record in Table H.I., reask 3d) Y (Reask 3b and c) N e. DEDUCTIBLE IF 65 la. Is —— covered by that part of Social Security Medicare which pays for hospital bills? 1a. tY 2N 90DK Oh fo mmm mnie mn mer de ret rte 2 Er Dd et tm tm Efe sets m mi OVER b. Is —— covered by that part of Medicare which pays for doctor's bills, that is, b. 1¥Y 2N DK ASK: the Medicare plan for which he or some agency must pay a certain amount each month? (NP) (NP) (NP) For each person with *‘DK’’ in la or b, ask: 2 1 [] Hospital 2. May | please see the Social Security Medicare card(s) for —— (and =~) to determine the type of coverage? 2 [] Medical NP (Transcribe the information form the card or mark the ‘‘Card not seen’’ box.) 3 [] Card not seen We are interested in all kinds of health insurance plans except those which pay only for accidents. : TABLE H.L ; : 3a. (Not counting Medicare) Is anyone in the family covered by hospital insurance, | | PLAN y 1 [] Covered (NP) that is, a health insurance plan which pays any part of a hospital bill? : 1 2 [] Not covered (NP) Y N (3d) 5a. GROUP 1Y 2 N s DK a PLAN 1 [] Covered (NP) | 5a. GROUP Ask for each Plan listed in Table H.I If no plans, gotoL 4. |s —— covered under this (name) Plan? 50. Was this __ (name) Plan obtained through an employer, union, or some other group? 2 [_] Not covered (NP) or surgeon's bills for operations? office visits or home calls? . Does this plan pay any part of a doctor's bill for office visits or home calls AFTER A CERTAIN AMOUNT has been paid by the family? d. Does this plan pay any part of a doctor's bill for | bm - e. DEDUCTIBLE 1 Y 2 N 9 DK Ao. sis il Riis Shopollvonsinttinntl. os. SO e. DEDUCTIBLE 1Y 2 N 9 DK Co N b. Does this plan pay any part of hospital expenses? Pas ; 5 Soveren IND) 5) c. Does this plan pay any part of doctor's | 5a. GROUP mn" 2N s DK I For each person, review | and 2 and 4 for each plan and determine if ‘Covered Medicare or insurance, or ‘‘Not covered.” " by either 1 [[] Covered (NP) 2 [] Not covered (NP) Ask for each person ‘‘Not covered.” Many people do not carry health insurance for various reasons (Hand Card N) 6a. Which of those statements describes why —— is not covered by any health insurance plan? Any other reason? Mark box or ask: b. What is the MAIN reason —— is not covered by any health insurance plan? Circle all reasons given mV I 2 3 4 5 6 Other (Specity) 5 [C] Only one reason 1 2 3 4 5 6 Other (Specify) 5 HEARING ABILITY FY 1963 HEARING ABILITY SUPPLEMENTARY QUESTIONNAIRE Buress No. 68-R620.58; al E; s x CONFIDENTIAL - This information is Sileend, for the U.S. Public Health Service under authority of Public Law 632 of the B4th Congress (70 Stat 4 U.S. ). All information which would permit identification of the individual will be held strictly confidential, will be used only by persoas a in aad for the purposes of the survey aad will not be disclosed or released to others for any othet purposes (22 FR 1687). romm NHS-D-1 (9-28-02) U.S. DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS ACTING AS COLLECTING AGENT FOR THE U.S. PUBLIC REALTH SERVICE NATIONAL HEALTH SURVEY SEGMENT (Hearing Ability) SERIAL col Name of person for whom this form should be filled ont GENERAL INSTRUCTIONS Please answer all of the questions in this form that apply to you. Most of the questions can be answered by checking one of the boxes, like this: . In some of the questions, more than one box may be checked for your answer. In a few questions, a number (such as age) is asked for. In a few others, a written description or explanation is required. If the person for whom the information is requested is a child, a parent or guardian should answer the questions for him or her. SECTION A (Please do not omit any part of Questions | and 2 even though one or more of the statements may not appear to be directly related to your present ability to forty 1. WITHOUT using a heor (Please check the ‘Yes ald, what con you hear? Yes No or ‘“No’' box alter each statement.) I can hear loud noises. Most of the time I can tell one kind of noise from another. If I hear a sound, most of the time I can tell if it is a person's voice or not. I can heor ond understand a few words a person says if I can see his face and lips. I can heor and understand a few words a person says without seeing his face and lips. I can heer and understand most of the things a person says if I can see his face and lips. I can heer and understond most of the things a person says without seeing his face and lips. Most of the time I can heer and understond a discussion between several people without seeing their faces and lips. I can heor and understand a telephone conversation on an ordinary telephone (that is a telephone without an amplifier). 2. Please describe how well you can hear, without using a hearing oid, by checking one of the statements below for each ear. For example, a person who is deaf in his left ear and has good hearing in his right ear would check the following: In left ear- box (d); In right ear-box (e). In loft ear (2) [J My hearing is good (b) [JI have a little trouble hearing In right eer (¢) [My hearing is good (f) [11 have a lietle trouble hearing (8) [C1 have a lot of trouble hearing (h) []1 am deaf (c) [JI have a lot of trouble hearing (d) C1 am deaf Hf you have checked that your hearing is goed in both ears — (1) and (e) checked, skip the questions on Pages 2 and 3 and tum to Section D on Page 4. If you have any trouble hearing at all, please go on and answer the questions that follow on Pages 2 and 3. USCOMM-DC 30203-Pa2 45 46 3. How old were you when you began to have hearing trouble or grow deaf? (Please check the first box that applies ond enter year as appropriate.) [J At birth [(COJlwasaboue _______ years old. [CJ 1 was less than one year old. [J 1 am not sure, but I know it was before Iwas _ years old. 4.(a) Since your hearing trouble began, has your hearing gotten WORSE, has it improved, or is it just about the some? (Please check one box.) J My hearing is now worse than when I first began to have hearing trouble. {My hearing is now better than when I first began to have hearing trouble. [C0 My hearing is just about the same as when I first began to have hearing trouble. (If you have checked that your hearing has @otten worse, please sanawer the following question.) (b) How old were you when it got as poor as it is now? (Please check the first box that applies and enter year as appropriate.) [JIwasabout_______years old. [CJT am not sure, but I know it was before I was _____years old. [CJ Neither of the above applies -- it is getting worse all the time. 5. What was the cause of your hearing trouble or deafness? [J It was caused by a sickness, illness or disease. "21 vas born deaf or with roor hearing. What illness? [_ Semething else caused it. [C1 It was caused by an accident or injury. (Pleas: ‘escribe it: What kind of injury was it? Mow did it happen? 7 Laon’t bev what caused it. 6. Besides your hearing trouble or deafness, do you have any other trouble with your ears? Yes [_INo H“Ves,* Whot kind of trouble? Please check as many boxes as apply.) [C) Noises or ringing in the head or ear (CT) Dizziness [C] Faraches or pains in the ear [CT] Any other trouble. What kind? J Running ears 7.(a) At work or school and at home, what are all the ways you use to tell other people what you want? (Please check each way that you use.) (CII calk to them. [J I use sign language. (1 write notes. [) Some other way. How? 1 spell with my fingers. (b) Please put a circle around the way you use the most. 8.(a) At work or school and at home, what are all the ways other people use to te|l you what they want? (Please check each way that they use.) —_] They talk to me. [C] They use sign language. _) They writs notes. [C] Some other way. How? {0 They spell with their fingers. (b) Pleose put a circle around the way they use the most. 9. Have you ever attended a school or class for those with poor hearing or a school or class for the deaf? [Yes [J Ne 10. Have you ever had any training in lip reading (speech reading)? [CO] Yes CI Ne 11. Have you ever had any training in speech or speech correction because of your poor hearing or deafness? Ove Clk 12. Fave you ever had any training in hearing (lessons to help you understand better what you hear)? C3 Yes CI FORM NMS-O-1 (8-20-62) (The questions in this section refer to the use of hearing aids.) 13. Have you ever tried a hearing aid? CJYes [Ne GL pit skip to Section D on age 14. Have you ever hod a hearing aid for your own use? [Yes [JNo (Bt No skip to Section D on age 15. (a) If you have a hearing aid NOW, please check here AND check one of the boxes below to indicate when you got it. a 1f you do NOT have a hearing aid NOW, plecse check here —————— [7] AND check one of the boxes below to indicate when you got the last one you hod. When did you get it? [) This year (1962) [J 6-10 years ago [] Last year (1961) [T] More than 10 years ago [J 2-5 years ago The remaining parts of Question 15 apply to your present hearing aid if you have one new. If you do not have a hearing aid now, they apply to the last hearing aid you had. (b) What kind of hearing aid is (was) it? (Please check one box) \ [] Fits into one ear [J Fits against one side i duets of the head Air conduction [1 Fits into both ears Mone'conduction [71 Fits against both sides of at the same time the head at the same time (c) Where ore (were) the amplifier and batteries wom when you use (used) the hearing aid? (Please check one box) [7] Above the neck [7] Relo'v the neck (4) Why did you choose this (that) particular kind of hearing oid? (Please check one box) It was prescribed by a medical doctor [] It was advised by a hearing nid dealer [J It was prescribed by a hearing clinic [_] Some other reason (Please explain) [J A friend or relative told me about it [JI saw it advertised (e) About how long did it take to get used to it? (Please check one box) [] Less than one month [1] More than six months [] One to six months [] Never have gotten used to it 16.(a) Do you use a hearing aid now? [] Yes [TJ No (If “No, skip to Section D on page 4) (b) How much do you use it? (Please check one box on each line) Does Most Once (If you do not work, go to school, etc., check the ‘Does not " of the | ina Never apply’ column.) no! rt A apply time while AUWOTKY os v viuiuin somminin wonivn © viwiwin wees WHEE wan — Ae 300NZ...0 suri vives 3 nas wens veins See see AUChUTEIZ, oo vivioin.s smimm vincwanin wma © Kxine RRA EBS At tRe MOVIESD, ... . vviv vinivis « miwiwin wwiwwin Kiwini Huis» Listeningtoradio or TV? .............0vuivnnnn. AUDOMEL., 1inin:n 1ioin mm cincmm hiwcnsmmmwonsmm wo. wa * . (c) How well satisfied ore you with the hearing aid you are now using? (Presse check one box) ™] Very well satisfied [] Fairly well satisfied [J Not satisfied at all Question 17 of Section C on Page 4 USCOMM-DC 36302-P02 47 17. WITH your heoring eid, what con you heer? (Please check the ‘Yea’ or ‘N."" box alter Yes No each statement) I can hear loud noises. Most of the time I can tell one kind of noise from another. If I hear a sound, most of tie time I can tell if it is a person's voice or not. 1 can heor end understond a few words a person says if I can see his face and lips. I can heer ond understond a few words a person says without seeing his face and lips. 1 can hear and understand most of the things a person says if I can see his face and lips. 1 can hoor ond wnderstand most of the things a person says without seeing his face and lips. Most of the time I can hear ond understond a discussion betveen several people without seeing their faces and lips. 1 can heor ond understond a telephone conversation on any telephone. SECTION D 18. Has your hearing ever been tested by @ medical doctor? [J Yes [No (If “No,” go to Question 19) (a) About how long age was your heering LAST tested by @ medical doctor? (Please check one box) [7] This year (1962) [4-5 yenrs ago [CT] Last year (1961) [6-10 years ago [12-3 years ago [7] More than 10 years ago (b) Was the doctor whe last tested your hearing an ear specialist or was he a general family doctor? (Please check one box). [J Doctor who was an ear specialist [J 1 don’t know [) General family doctor (c) About how old were you when your hearing was FIRST tested by @ medical doctor? 1 was about years old. 1 don't know, but it was before | was years old. 19. Is your heoring tested regulorly, for example, once or twice @ yeor? [Yes [Ne 20. Mas your heering ever been tested with an oudiometer (with earphones)? Yes IN Comments - (Please use this space or attach an additional sheet of paper for any additional remarks you may have about your hearing.) Name of petson who filled out this form Telephoae No. FORM NMS-D-1 (5-28-02) CY 1971 1. Record the number of Doctor Visits and Hospitalizations. DOCTOR HOSP. (NP) (NP) 2. Record each condition in the person’s column, with the question number(s) where it was reported. Reference dates 2-week period Dentist and Doctor visit probe Hospital probe Condition ° —|— == == =|-=|==]5 For persons 19 years old or over, show who responded for (or was present during the asking of) Q.’s 5-37. R1 If persons responded for self, show whether entirely or partly. For persons under 19 show who responded 1 [[] Responded for self-entirely 2 [_] Responded for self-partly Q.'s 5-37 for them. Person .was respondent For each person with an entry of ‘‘A,”” “‘B,”’or *'37"’ in C2, ask Q.’s 38-41. 38. Has —— ever used a hearing aid? 38. Y N Please look at this card ~ (Show Card H) Good Laie Log Deal 39a. Which statement best describes ——'s hearing in his LEFT ear (without a hearing aid)? Wa. [1] 200 133s ss os ot oo a a a a ea eh a moms me ds b. Which statement best describes —— 's hearing in his RIGHT ear (without a hearing aid)? b|1[J 2[7] 's[]JS a(S If under 3, go to 41a 40a. (Without a hearing aid) Can =~ usually HEAR AND UNDERSTAND what a person says without 40a. Y (41a) N Seeing lis foc IF thet person WHISPERS 16 bi from 061633 6 GUISHIOOME oe cummins RE b. (Without a hearing aid) Can —— usually HEAR AND UNDERSTAND what a person says without b. Y (41a) N ~~ seeing his foce if thet person TALKS IN A NORMAL VOICE to bim fromuersssaquierroom? = | A c. (Without a hearing aid) Can ~~ usually HEAR AND UNDERSTAND what a person says without - Y (410) N seeing bis ocw if thet person SHOUTS to lim Hemectoss CQUICIIOOMD cima TRE NARA d. (Without a hearing aid) Can —= usually HEAR AND UNDERSTAND a person if that person d. Y (41b) N SPEAKS LOUDLY into his better ear? oo] elias * (Without o hearing aid) Con =m vivally tell thw sound of speech from other seundsond noises? 8 XD LE. f. (Without @ hearing oid) Can —- usually tell one kind of noise fromanother? | el Yup) _ N___ g. (Without a hearing aid) Can ~~ hear loud noises? 9 Y (41b) N (41b) [CO] At birth [CJ] Less than 1 year 3 Years old 41a. How old was —= when he began to have trouble hearing? az. Cok b. How old was —— when he began to have serious trouble hearing or became deaf? | Lo | CIN trouble Lm Complete Q. 41c from entry in 41a and b or age. If 'DK’’ in Q.’s 41a and b AND 21 or older, ask: [J Before 21 c. Was it before or after —— 's twenty-first birthday? o.| [OO After21 (R2) Yo |A. “'S” in BOTH ears in Q. 39? Y N B. “Nin Q. 40b? = Y N If *'Y’"’ in A or B fill Hearing Supplement after the interview. [[] Hearing Supplement For persons 19 years old or over, show who responded for (or was present during the asking of) Q.’s 38-41. If persons responded for self, show whether entirely or partly. For persons under 19 show who responded for them. Q.'s 38-41 1 [J Responded for self-entirely 2 [] Responded for self-partly Person was respondent HEARING SUPPLEMENT CHECK ITEM | Number of supplements. Enter number here and in Item N on Household page. 49 50 CARD H Which statement best describes your hearing in your LEFT ear (without a hearing aid)? HEARING IS GOOD LITTLE TROUBLE HEARING LOT OF TROUBLE HEARING DEAF wn —- Which statement best describes your hearing in your RIGHT ear (without a hearing aid)? HEARING IS GOOD LITTLE TROUBLE HEARING LOT OF TROUBLE HEARING DEAF BD LOSS OF INCOME FY and CY 1968 | Ask for all persons with a *‘Yes’’ in 36a, 36b, or 36¢c. 37a. Who does (did) = — work for? If “Yes” in 36c only, questions 37a | through 37d apply to | this person's LAST | full-time civilian job. | Fill 37d from entries in 37a-37c, if not clear, ask: a . Class of worker 37a. o- Employer Occupation —_— o[ JPvepd. 3 JOwn 1[JGov. Fed. a[_]Non-pd. 2[_1Gov. Oth. s[_INev. worked INTERVIEWER CHECK ITEM: If person is under 17 years, or not in Labor Force (Q. 37 a-d blank) check ‘Not in Labor Force.” If in Labor Force (Q. 37 filled) refer to Question 5e and make appropriate entry. a[_]Not in Labor Force or Under 17 o[INo work -loss days-in LF Go to next person Work-loss days UE to 38a Earlier you said that — — lost — — days from work during the past 2 weeks — (If self-employed, ask b; for other workers, ask a) 38a. Was — — paid any wages by his employer for the days that he lost? _* Is this before or after taxes? h. Did — — receive this income for these days through a sick leave plan, loss-of-pay insurance, or some other way? 1 | h. 1 [CIYes-ask [OINo-ask 2[]Yes—Ask 3[JNo—-Ask —-———————~—— —- 1 [I¥es-Agk 2[INo—dsk | [Before 2 2[ JAfter _ Fe Em mm mm mm mm ——— 1 [Before \ 2[JAfter 1 [Sick leave plan 2[]Loss-ol-pay insurance 3[JOther - Specify 51 Cy 1974 CURRENTLY EMPLOYED PERSON PAGE Person number E + [CJ Not SP (E2) 1 2 [] Eligible respondent avail. (E2) 3 [J Return call required (Next CE Page) E2 Mark one box: o [C] No work-loss days (2) 1 [] I+ work-loss days (I) Earlier it was reported that —— lost time from work during the past 2 weeks. (Hand calendar) 1. On which days during that 2-week period outlined in red did he lose time from work because of illness or injury or because he wasn't feeling well? (Circle all days reported in Table WL-I) Hand calendar 2a. During the past 2 weeks (the 2-week period outlined in red on that calendar) did —— lose any (other) time from work because he was sick or injured or because he wasn’t feeling well? 1 Y 2 N (3) b. On which days did he lose time from work? (Circle all days reported in Table WL-| and reask 2a.) 3a. (Besides this time) During the past 2 weeks, did he lose any (other) time from work to visit a doctor, dentist, or other medical person for himself? 1 Y 2 N (WL-I) b. On which days did he lose time from work for this reason? (Circle all days reported in Table WL-| and reask 3a.) WL-1 Days circled in WL-1? TABLE WL-1 Y N (7) Week before Last week For EACH circled day, ask 4a and b Mon | Tue | Wed | Thu Fri Sat | Sun | Mon | Tue | Wed | Thu | Fri Sat | Sun 4a. How many hours did he lose from workon _(day) ?....00000000nnnn ena | essen) |. onmi Ol Self employed (Ask 4a only) Hours | Hours | Hours | Hours | Hours | Hours | Hours | Hours | Hours | Hours | Hours | Hours | Hours | Hours 1] Full I b. Will his employer pay himin | ____}____ | ____}\____{____ | ___ tL ___ + ___& LL ___ i i sm Il, in part, or not at all for P this time lost from work? 2 are a1 +r +r 1 1 14x rd of Nane | 5a. (In addition to his employer) Did or will —— receive any income from loss of pay insurance or income from any other source for all or part of this time lost from work? oY oN (6) | b. What source is this? (Specify) > If ONLY ‘““Full’’ marked in 4b, go to 7; otherwise ask: 6. How much income did he lose BEFORE DEDUCTIONS because of this bollars ens time lost from work? $ | 0000 [] None FOOTNOTES 52 Ta. (Besides this time you have just told me about) During the past 2 weeks, did he lose any time from work because someone else was sick or to take someone else to a doctor, dentist, or for other health care? 1 Y 2 N (11) b. On which days did he lose time from work for this reason? (Circle all days reported in Table WL-2.) c. During the past 2 weeks did he lose any other time from work for this reason? Y (Reask 7b) N TABLE WL-2 Week before Last week For EACH circled day, ask 8a and b Mon Tue Wed Thu Fri Sat Sun Mon Tue | Wed Thu Fri Sat Sun 8a. How many hours did he lose from work on _(day) ? ........ CEE — | — | — [| ——— | — pan; J, oom SE | i: 0 Hours | Hours | Hours | Hours | Hours | Hours | Hours | Hours | Hours | Hours | Hours | Hours | Hours | Hours 1[] Self employed (ask 8a only) 1 | Full b. Will his employer pay him in Lili oii fm oe mm em of mF em ee tft ed ee Jr in full, in part, or not at all for 2) pan this time lost from work? seem sees es ei Je ete er pe sn pt er a rt ed 0 3 None 9a. (In addition to his employer) Did or will —— receive any income from loss of pay insurance or income from any other source for all or part of this time lost from work? Y o N (10) b. What source is this? (Specify) ee If ONLY ‘Full’ marked in 8b, go to Il; otherwise ask: T Dollars | Cents 10. How much income did he lose BEFORE DEDUCTIONS because of this | time lost from work? $ \ 0000 [] None If days circled in Table WL-1 or WL-2 ask; otherwise go to |2. 11a. How many days per week does —— USUALLY work? ————— Days ee b. How many hours per week does he USUALLY work? Hours Dollars T Cents c. When he works —— hours, how much does he earn per week BEFORE DEDUCTIONS? $ | If ‘Self employed,’ go to next CE; otherwise ask: 12a. When —— is ill and loses time from work does he continue to receive any wages or salary directly from his employer? ZN ND) mmm) b. Under this arrangement is he entitled to a certain number of days of sick leave each year? Y o N (NP) c. How many days of sick leave is he allowed each year? Days 53 NURSING CARE AND/OR SPECIAL AIDS FY 1959 SUPPLEMENTARY QUESTION ON PERSONAL CARE AT HOME 23. Is there onyone in the family who requires constant help or nursing care? Is there anyone in the [] Yes - Constant CJ No family who requires help or nursing care only part of the time, such as help in dressing, eating, [J Yes - Part-time toilet activities, etc.? Condition: (Do not record *Yes® for normal care for infants or children) (a) For what condition? Years Months (b) How long has he required this care? (Years; or months if less than 1 year) [CZ] Household members (c) Who helps with this care? [J Other relative [J Trained (registered) nurse [J Practical nurse [J Other (Specity) (Check all boxes that apply. If “Other” specify in footnotes) SUPPLEMENTARY QUESTION ON SPECIAL AIDS 24. Does anyone in the family have a hearing aid? An artificial arm or leg? A brace of ony kind? [1] Yes [No A wheel chair? Type of Aid: (0) For what condition? Condition: (b) Is it used all the time, most of the time, only occasionally, or never used now? = Sn [3 Occasionally If "Occasionally”® or "Never used now,” ask: C3 Most CJ Never used (c) Why is it thot you never use it? Verbatim or Why is it that you use it only ocaasionally? FY 1967-68 If person is 55 years old or over, ask: THE FOLLOWING QUESTIONS REFER TO DIFFERENT KINDS OF PERSONAL CARE SOME | [J Under 55 (Stop) PEOPLE NEED AT HOME: 22a. DOES — _ NEED ANY HELP IN BATHING, DRESSING OR PUTTING ON HIS SHOES? [3 Yes (Stop) CO No b. DOES _ _ NEED ANY HELP AT HOME WITH INJECTIONS, SHOTS OR OTHER TREATMENTS? [J Yes (Stop) ONo ¢. DOES — _ NEED ANY ONE'S HELP WHEN WALKING UP STAIRS OR GETTING _____FROMROOMTOROOM? [J Yes (Stop) ONo If questions 220, 22b and 22c are all ““No’* ask: d. DOES — NEED ANY HELP AT ALL IN CARING FOR HIMSELF? OYes(sop) ~~ ONo 23a. DURING THE PAST 12 MONTHS, HAS- -RECEIVED ANY CARE ATHOME FROM A NURSE? [J Yes (4sk 23b, ¢) [JNo (Stop b. DURING THIS 12 MONTH PERIOD, ABOUT HOW MANY VISITS DID A NURSE VISITS MAKE TO CARE FOR _ _? — 4 ¢. WERE ANY OF THESE VISITS DURING THE PAST 2-WEEKS? OYes [ONo [JDK 54 FORM NHS-HIS-2 (FY 67) Budget Bureau No. 68-R1600 (12-12-66) U.S. DEPARTMENT OF COMMERCE Approval Expires March 31, 1968 BUREAU OF THE CENSUS ACTING AS COLLECTING AGENCY FOR THE U.S. PUBLIC HEALTH SERVICE HOME CARE SUPPLEMENT Name of person Person No. [Age PSU Segment No. Serial No. Sample FOOTNOTES Name of interviewer Code Respondent No. NOTICE - All information which would permit identification of the individual will be held in strict confidence, will be used only by persons engaged in and for the purposes of the survey, and will not be disclosed or released to others for any purposes. For each ‘Yes, answer to la, Ask: Earlier in the interview you mentioned that — — needed help of | No|Yes some kind here at home. | am going to read a list of different 1b. Who helps = --? | Does anyone else help — - ? kinds of personal care some people need in the home. Please § tell me if — — needs help in any of the following ways. ! la. Does — — need help — | in walking up stairs or getting from room to room? — | in dressing or putting on shoes? ........... [rani | Does — — need help — | in bathing (shaving) or other toilet activities? |—> ! in eating or having meals served in bed? . ..... fr | Does — — need help — | with changing bandages? . ........ Cee — 1 in receiving injections? . ..... Ni YO § eo — ! with other treatments? . . ................ } If ““Yes,"" ask: What kinds of treatment? Jr—p ) Specify ! Does — —need help — | in changing bed positions? . .............. — | in exercising or physical therapy? .......... be ! in cutting toenaibs? .............. LL. _— | Does — — get any OTHER help or care here at home? | If ‘Yes,’ ask: What kinds of other help or care? | | | Specify | IF PERSON IS NOT RECEIVING CARE (All ““No’s”" to question la), reconcile differences between answers in Q. 22 or 23c and Q. Ia above or describe the situation on the front of this form. 2. For what condition(s) does — — receive this help or care? ————-! Specify condition(s) 55 3. How long has — ~ received help or care at home? Mark one box: [J | month or less [J Over | to 3 years [J Over | to 6 months [J Over 3 to5 years [1 Over 6 to 12 months [J Over 5 years needed help or care? 4. Because of — ='s health, must someone be in the house with him all of the time, part of the time, or only when providing the [J All of the time [] Part of the time [J Only when providing the needed help or care If “‘Nurse’’ reported in Q. Ib or 5a, ask: For each person, other than a nurse, listed in Ib, ask: 5a. Is — ~ a nurse, a physical therapist, or some other kind of health worker? 5b. I's the nurse that cares for — — a registered nurse, a practical nurse, or some other kind of nurse? Determine the type(s) of person(s) providing the care in question 5 and mark appropriate box in column (1) of Table H. TABLE H During the past two weeks, on about how many days About how many hours a day does — — receive help or care from (relative, nurse, etc.)? Is (relative, nurse, etc.) paid for these did — — receive help or care services? Type of persons providing care from (relative, nurse, etc.)? (2) (3) (4) om Days Don’t know Hours Less than | hour | Don't know Yes No NON-HEALTH WORKERS A. [] Related household members B. [J] Related persons not in household C. [] Friend or neighbor D. [J] Other Specify HEALT NEALTH E. [J Nurse — Registered F. [J Nurse — Practical or other G. [) Physical therapist H. [] Other - 3+ fv Specify INTERVIEWER: Mark the to Q's 6-8. [7] Person 65 + and ‘‘Yes'' in column (4). Ask Q's 6, 7, and 8. appropriate box before going. [] Person 55-64 and *‘Yes'" in column (4). Ask Q's 7 and 8. CJ All **No’s"* in column (4) or only *‘A" checked in column (1) of Table H. Skip to question 8. 6. Are any of these services paid for by Medicare? [J Yes CONo ' [J Don't know b. Anyone else? 7a. Who pays (the remainder of the bill) for these services? [J Self or family [ Other relative or friend [J Health insurance [_] Agency or organization (Visiting Nurses Association, etc.) [] Welfare [C7] Other — Specify 8a. During the past 12 months, has — — received any care at home from a nurse? b. During the past 12 months, ABOUT how many visits did a nurse make to care for — —? [J Yes — Ask 8b [No —- STOP Number of visits FORM NHS-HIS-2 (FY 67) (12-12-66) 56 - USCOMM-DC CY 1969 37a. Does anyone in the family now use any of the following special aids — 1. An artificial arm? ovveennnnnnn 2. An artificial leg? covvuennnnen. 3. A brace of any kind? .iievaenen 4. Crutches? cevevvvreneeeenenns 5. A cone or walking stick?....... 6. Special shoes? ....uu. 7. A wheel chair?. 8B. Awalker?.ooseessnrsnenannees 9. Any other kind of aid for getting around? c.esiiianennnns If “Yes,” specify: 7 Table SA Yes No Person No. (a) Type of a (b) If 1-6 in (b), ASK: 13-9 in (b) ASK: For what condition does Does he use one or tWooor @ He)? he need this? (item C) (c) (d) 0 2] Other ad 27] Other b. Who is this? Enter in Table SA c. Anyone else? dd 2] Other Table SA — Continued Is the used all the time, most of the time or only occasionally? How long has he used _? How was the___obtained? Was it purchased, rented, borrowed or a gift? (e) (f) (8) 1JAl 2[] Most 3[] Occasionally [] Less than 1 month 1] Purchased 2[] Rented 3[_] Borrowed 4[] Gift Months Years 1 AN 2[ 1 Most 3[] Occasionally [J Less than 1 month 1[] Purchased 2[] Rented 3[] Borrowed 4[_] Gift Months Years 1] Al 2] Most 3[] Occasionally [J Less than 1 month 1[T] Purchased 2[] Rented 3[_] Borrowed 4[_] Gift Months Years 57 58 PERSONAL HEALTH EXPENSES FY 1963 (July-December 1962) orricror U.S. DEPARTMENT OF COMMERCE Budget Bureau No. 68-R620.6 THE DIRECTOR BUREAU OF THE CENSUS Approval Expites July 19, 1963 WASHINGTON 25, D.C. Form NHS-6(e) (4-2-62) Dear Friend: The Bureau of the Census, as collecting agent for the U.S. Public Health Service, is conducting a special survey on the cost of medical care. This study, when combined with other information, will serve to answer important questions about health and medical care costs in our Nation. The Census interviewer who called at your household was asked to leave this form in order that all of the family members can take part in answering these questions, and that bills, receipts, and other records can be consulted. If you cannot supply exact amounts from bills or records, please give the best estimate you can. We would appreciate your completing this form and mailing it back to us within five days. A self-addressed envelope which requires no postage has been provided for your convenience. Your cooperation in answering these questions will be a definite public service. The information will be given confidential treatment by the Bureau of the Census and the 11.S. Public Health Service. Nothing will be published except statistical summaries. Thank you. Sincerely yours, Please return completed Seasccairs form to: U.S. Bureau of the Census i 1st F1. NW Section Riehaitil. Seannon 536 S. Clark Street Chicago 5, Illinois Phone: Harrison 7-7523, Ext. 523 Director Bureau of the Census CONFIDENTIAL - This information is collected for the U.S. Public Health Service under authority of Public Law 652 of the 84th Congress (70 Stat. 489; 42 U.S.C. 305). All information which would per mit identification of the individual will be held strictly confidential, will be used only by persons engaged in and for the purposes of the survey, and will not be disclosed or released to others for any other purposes (22 FR 1687). USCOMM-DC 11711 P-e2 © oo GENERAL INSTRUCTIONS The name of each related member of the household has been entered on a separate page of this form. Please fill all sections of each page for each person listed. The specific period we are asking about is the 12 month period from to , In entering the total medical expenditures, count all bills paid (or to be paid) by the person himself, his family or friends and also any part paid by insurance, whether paid directly to the hospital or doctor, or paid to the person himself, or to his family. If you do not know exactly the amount paid by insurance, estimate it, and include it in the total bill. Please do not count any amounts paid (or to be paid) by: Workmen's compensation Non-profit organizations such as the “Polio Foundation” Charitable or Welfare Organizations Military Services, including Medicare Veterans Administration Federal, State, City, or County Government If there are any babies in the household who were born dur- ing the past 12 months, the hospital and doctor bills relating to the baby’s birth should be reported on the page for the mother. All other medical expenditures relating to the baby’s health should be reported on the page for the baby. After completing all sections of this form for each person in the household, please indicate below the name of the person or persons who filled it out. Name Name FOR OFFICE USE ONLY FORM NHS-g(a) (4-2-62) 59 60 COSTS FOR MEDICAL AND DENTAL CARE DURING THE PAST 12 MONTHS FROM: TO: PLEASE ANSWER THE QUESTIONS IN EACH SECTION BELOW FOR: Name of person IF EXACT AMOUNTS ARE NOT KNOWN, PLEASE ENTER YOUR BEST ESTIMATE. DOCTORS’ BILLS 1. How much did all of the doctors’ (including surgeons’) bills for this person come to during the past 12 months? Be sure to count all doctors’ bills for: Operations Check-ups Pregnancy care Laboratory fees Immunizations or shots Treatments Deliveries X-rays Eye examinations Any other doctors’ services [_'] No doctors’ bills HOSPITAL BILLS 2. (a) Was this person in a hospital (nursing home, rest home, sanitarium, etc.) overnight or longer during the past 12 months? 3 Yesy (b) How much did all of the hospital bills come to for this person for the past 12 months? Be sure to count all hospital bills for: J No (Go to Question 3) Room and Operating and Anesthesia X-rays Any other s board delivery room Special treatments Tests hospital services MEDICINE COSTS 3. About how much was spent for medicine for this person during the past 12 months? Be sure to count costs for all kinds of medicine whether [1 No costs or not prescribed by a doctor, such as: for medicine Tonics Prescriptions Ointments Any other Pills Salves Vitamins medicine s DENTISTS' BILLS 4. How much did all of the dentists’ bills for this person come to for the past 12 months? Be sure to count all dental bills for: [] No dentists’ bills Fillings Cleanings Bridgew ork Straightening Any other Extractions X-rays Dental plates of teeth denial services $ SPECIAL MEDICAL EXPENSES 5. How much did the bills come to for this person during the past 12 months for: [] None [] None [] None Specie] Nursing, Chiropractors’ sical therapy, Eye glasses? |[§$ 9 ysie evar $ fees? $ [] None [] None Special braces [J None or tr , Corrective wheel chairs or Hearing Aids? $ shoes? $ artificial limbs? | $ OTHER MEDICAL EXPENSES 6. Enter any other medical expenses incurred during the past 12 months which are not included [] None above, showing the kind and amount of expenditure (for example, emergency or outpatient treatment in a hospital or clinic). (If no other medical expenses, check the ‘“None’’ box.) Kind: $ FOR OFFICE PSU No. Segment No. Serial No. Column No. USE ONLY FORM NHS-6(a) (4-2-62) FY 1966 U.S. DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS WASHINGTON, D.C. 20233 4 BUDGET BUREAU NO. 68-R620.12 OFFICE OF THE DIRECTOR APPROVAL EXPIRES AUGUST 31, 1966 PSU Seg. No. Ser. No. The Bureau of the Census, acting as collecting agent for the U.S. Public Health Service, is conducting a special survey on the cost of medical care. This study, when combined with the other information which you have just given our Census interviewer, will serve to answer important questions about health and medical care costs in our Nation. The Census interviewer who called at your household was asked to leave this form in order that all of the family members can take part in answering these questions, and that bills, receipts, and other records can be consulted. If you cannot supply exact amounts from bills or records, please give the best estimate you can. Please read the instructions on page 2 before completing this form. We would appreciate your completing this form and mailing it back to us within five days. A self- addressed envelope which requires no postage has been provided for your convenience. Your cooperation in answering these questions will be a definite public service. The information will be given confidential treatment by the Bureau of the Census and the U.S. Public Health Service. Nothing will be published except statistical summaries. Thank you. Sincerely yours, A. Ross Eckler Director Bureau of the Census NOTICE - All information which would permit identification of the individual will be held strictly confi- dential, will be used only by persons engaged in and for the purposes of the survey, and will not be disclosed or released to others for any other purpose. FORM NHS-HIS-1C (FY 1968) USCOMM-DC (12-6-65) 61 62 GENERAL INSTRUCTIONS 1. The name of each related member of the household has been entered on a separate page of this form. Please fill the 4 questions on each page for each person listed. If you cannot give the exact amount from bills or records please enter the best estimate you can. 2. In entering the medical expenditures in questions 1 through 3, count all bills paid (or to be paid) by the person himself, his family or friends. Also include any part paid by insurance, whether paid directly to the hospital or doctor or paid to the person himself, or to his family. If you do not know exactly the amount paid by insurance, estimate it, and include it in the total bill. 3. In figuring the total doctor, hospital, or dentist bills, do not count any amounts paid (or to be paid) by: Workmen’s compensation Non-profit organizations such as the ‘Polio Foundation’ Charitable or Welfare Organizations Military Services Veterans Administration Federal, State, City, or County Government 4. If there are any babies in the household who were born during the past 12 months, the hospital and doctor bills relating to the baby’s birth should be reported on the page for the mother. All other medical expenditures relating to the baby’s health should be reported on the page for the baby. FOR CENSUS USE FORM NHS-HIS-1C (12-6-65) USCOMM-DC Name of person Please answer the following questions for ——— The 12-month period referred to below is from to IF EXACT AMOUNTS ARE NOT KNOWN, PLEASE ENTER YOUR BEST ESTIMATE DOCTORS’ BILLS 1. How much did all of the doctors’ (including surgeons’) bills Be sure to count all doctors’ bills for: Check-ups Deliveries Operations Treatments Pregnancy care Laboratory fees X-rays Eye examinations Dollars \Cents s : [1 No doctors’ bills Immunizations or shots Any other doctor’s services HOSPITAL BILLS 2a. Was this person in a hospital (nursing home, rest home, sanitarium, etc.) overnight or longer during the past 12 months? [JYes b. How much did all of the hospital bills come to for this person for the [JNo (Go to question 3) Be sure to count all hospital bills for: Room and Operating and board delivery room Anesthesia X-rays Special treatments Tests past 12months? . . ... iii i i tei Dollars | Cents $ Any other hospital services DENTISTS’ BILLS 3. How much did all of the dentists’ bills for this person come to for the Be sure to count all dental bills for: Fillings Extractions Cleanings X-rays Bridgework Dental plates of teeth Straightening Dollars {Cents $ [J No dentists’ bills Any other dental services DOCTOR VISITS 4. During the past 12 months, how many times has this person visited or Count: 1. All visits to a doctor’s office or clinic for consultation, shots, x-rays, or for any other medical purpose. 2. All doctor visits made to the home. Do NOT count: 1. Visits to dentists. should be included in question 1 above.) been visited by a medical doctor?. . . .. oo... iii Doctor visits [1 None 2. Any visits made to this person while he was an inpatient for one or more nights in a hospital. (However, please note that the bills for such visits 5. Name of person completing this page Comments FOR CENSUS USE FORM NHS-HIS-IC (12-6-63) USCOMM-DC 63 Cy 1971 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION ROCKVILLE, MARYLAND 20852 NATIONAL CENTER FOR HEALTH STATISTICS SURVEY OF FAMILY MEDICAL EXPENSES ASSURANCE OF CONFIDENTIALITY: All information which would permit identification of an individual, or of an establishm. nt, will be held confidential, will be used only by persons engaged in and for the purpose of the survey, and will be protected against disclosure in accordance with provisions of 42 CFR Part 1. HSM-503-2 0.M.B. No. 68-571011 3 Approval Expires: 9-30-71 is READ AND FILL THIS PAGE FIRST Please list below the names of each family member NOW living at home beginning with the Head of the family. Relationship to Sex Person's age on Names of Fomily Members Family Head (Check one) last birthday: [Z] Male 1 Head ["] Female years old [JMale 2 [[] Female years old [1] Male 3 [[] Female years old TiMale 4, [[] Female years old 5 [J Mole [] Female years old TiMale 6. [| Female years old TIMale 7. [J] Female years old TiMole 8. [_] Female years old TMale 9. [C] Female years old Mele 10. [[] Female years old Are any family members now living at this household on full-time active duty with the Armed Forces of the United States? (Check one box) [I No [CI Yes ] Who is this? Name of Family Member Nome ot Family Member What is the highest grade or year the HEAD of the family completed in school? (Circle one) Elementary: 12345678 High School: 9 10 11 12 College: 12345: ITEM B Besides the family members that you have listed above, is there anyone else living with you now, such as friends or roomers? (Check one box) [C1 No (Go to next page) [Yes Please list below the name of each person not related to you who is now living at this household. Names of Other Persons 65 The term “THIS FAMILY’ in each of the questions on the following pages refers to all members of your family that you have listed in Item A on the page to the left. © HEALTHINSURANCE 1. During 1970, that is, from January 1, 1970, to December 31, 1970, how much did THIS FAMILY spend on health insurance premiums for plans that pay for any part of a hospital bill or a doctor's bill? Include: DOLLARS CENTS | Amount deducted from paycheck for health insurance premiums or Amount deducted from Social Security check for Medicare [T] This family did not pay any Amount paid directly to health insurance plans or to Social Security for Medicare insurance premiums Do pot include: Health insurance plans that pay only in the case of accidents Employer or union contributions PAYMENTS MADE FOR PERSONS NOT LISTED IN ITEM A ON THIS QUESTIONNAIRE =: } . a 2. During 1970, did THIS FAMILY pay any medical expenses for any person who is NOT listed in Item A on th2 page to the left? This might include expenses for children now away at school or parents, other relatives or friends now in nursing homes or elsewhere, or who are deceased. These expenses may include bills from doctors, dentists, optometrists, hospitals, nursing homes, health insurance premiums, cost of prescription medicine, eye glasses, and so forth. (Check one box) [J Ne [Yes Amount This Family TYPE OF MEDICAL EXPENSE Paid DOLLARS [CENTS $ | DOLLARS TCENTS $ | 1 DOLLARS ICENTS $ | 3. What income group best describes THIS FAMILY'S total combined income during 1970? (Check one box) [Less than $3,000 [47,000 - $9,999 [1 $3,000 - 14,999 110,000 - $14,999 [[] $5,000 - $6,999 1 $15,000 - $24,999 1 $.25,000+ 4. Please print below the name of the person or persons who are completing this form. Nome None FILL ONE PAGE FOR EACH FAMILY MEMBER NOW LIVING IN THIS HOUSEHOLD WRITE IN THE PERSON'S NAME BELOW BEFORE ANSWERING THE QUESTIONS ABOUT HIM: p The following medical and dental expenses were for Write in Name of Family Member All questions on this page should be answered even though the person may not have had any medical or dental expenses in 1970. If the person did not have any expense of a certain kind during 1970, be sure to make a mark in the “no bills paid’’ box. The amounts you give below should only include what THIS FAMILY paid, NOT any payments made by health insurance or some other person or agency. Do not include payments you made if health insurance has or will reimburse you. IF EXACT AMOUNTS ARE NOT KNOWN, PLEASE ENTER YOUR BEST ESTIMATE. DENTAL BILLS PAID 1. How much did THIS FAMILY spend on dental bills for this person during 1970, that is, from January 1, 1970, to December 31, 1970? INCLUDE amounts spent for: Cleanings Straightening Fillings X-rays Other services fram a dentist or hygienist Dental surgery Bridgework Extractions Dental laboratory fees a a DOCTORS’ BILLS PAID 2. How much did THIS FAMILY spend on doctor bills for this person during 1970? INCLUDE amounts spent for: Routine doctor visits Treatments Check-ups Deliveries Shots Pregnancy care Other services by a Laboratory fees medical doctor Doctor fees while a patient in a hospital Operations ; i i : HOSPITAL BILLS PAID 3. How much did THIS FAMILY spend on hospital bills for this person during 1970? INCLUDE amounts spent for: Room and board Anesthesia Operating and Tests delivery rooms X-rays Special treatments Any other hospital services PAYMENTS MADE FOR PRESCRIPTION MEDICINE 4. About how much did THIS FAMILY spend on medicine for this person during 1970 that was purchased on a DOCTOR'S OR DENTIST'S PRESCRIPTION? INCLUDE amounts spent for: Medicines only if they were prescribed by a doctor or dentist PAYMENTS MADE FOR EYEGLASSES, CONTACT LENSES OR OPTOMETRIST'S 5. During 1970 how much did THIS FAMILY spend on eyeglasses, contact lenses, or optometrists’ fees for this person? : PAYMENTS MADE FOR ““OTHER'* MEDICAL BILLS 6a. How much did THIS FAMILY spend on other medical expenses for this person during 1970? Do not include any expenses which you have already recorded. Do not include amounts spent for medicines of any kind. INCLUDE amounts spent for such expenses as: Chiropractors’ or Podiatrists’ fees Hearing aid end braces, trusses, wheelchair or artificial limbs Physical or Speech Therapy Special nursing care Nursing Home or Convalescent Home care 6b. What type of medical expense did this person have? Type of Medical Expense dis | CENTS or OC No dental bills paid for this person DOLLARS CENTS $ or I No doctor bills paid for this person 20LLARS | CENTS or [TJ No hospital bills paid for this person DOLLARS J CENTS $ or Od No prescribed medi- cines bought for this person BILLS oLLARS | CENTS or O No amount paid for these items DOLLARS CENTS or Od No amount paid for these items 7. Check one of the following boxes: 0 Referred to records for all dollar amounts entered on this page. O Referred to records for some but not all dollar amounts entered on this page. C Did not refer to any records. 67 PRESCRIBED AND NONPRESCRIBED MEDICINES FY 1965 Now | have some questions about purchases of medicine. First, | wont to ask you about medicines prescribed by o doctor — — 16. a. LAST WEEK OR THE WEEK BEFORE, did anyone in the family buy or obtain any kind of medicine prescribed by o doctor? [J Yes [CJ No (Go to @. 17) If "Yes," ask: b. What is the nome of the medicine? (Enter name of medicine in column (a) of Table P. If name is unknown, enter *'DK"’ in column (a) and ask: What condition is it for? Then enter the condition in column (b).) c. LAST WEEK OR THE WEEK BEFORE, did anyone buy or obtain any OTHER medicine prescribed by o doctor? [] Yes (Re-ask Q. 165) (TJ No (Fill remaining columns of Table P for each medicine reported) Turn to Card J, and ask: 17. a. LAST WEEK OR THE WEEK BEFORE, did onyone in the family buy or obtain any medicine NOT prescribed by a doctor? This (Show Card ]) is a list of SOME of the items in which we are interested. [] Yes If "Yes," ask: [CJ No (Go to ©. 18) b. What is the name of the medicine? (Enter name or kind of medicine in column (a) of Table NP.) c. LAST WEEK OR THE WEEK BEFORE, did anyone buy or obtain any OTHER medicine NOT prescribed by a doctor? [J Yes (Re-ask Q. 175) [CJ No (Fill remaining columns of Table NP for each medicine reported) INTERVIEWER: “‘Impairments’’ or ‘‘conditions’’ on Card A reported in question 16 or 17, should be carried back to Table I if they do not already appear there. Table P — PRESCRIBED MEDICINES Name of medicine Who was it prescribed for? Which k was the — — bought, i {it valu Js volomn eg) What condition is the -- for? (Enter Soli Seas bpp WEEK or the WEEK How mhvdid it cost’ 7 . (b). of person, 4 (a) (b) (©) BEFORE LAST? Dollars _| Cents 1 [feinmwed 1 Ld Mask buivse, [) Before 2 weeks (STOP) 3 : [0 Last week _ [] Week before [] Before 2 weeks (§TOP) ~~ ~~~ ~~ 3 2 ig os F3 Wasi ower i [Before 2 weeks (STOP) $ | 4 [Last week (C] Week before T [) Before 2 weeks (STOP) “Cs i Toble NP — NONPRESCRIBED MEDICINES : What is the -- Teh mem- 5 Name of medicine tare damerally [rs of the | Which week wos the ——bought, | How much (If name is unknown, enter family? ly use LAST WEEK — or the WEEK did it cost? Where was it bought? & the kind of medicine) (Enter col. nos BEFORE LAST? (e) = (a) ®) © (d) Dollars (Cents [) [CC] Last week [C) Week before | [C) Drug store [) Other (specity) vf | pFemmeme= Tea ! [J Grocery store [7] Before 2 weeks (STOP) s ! [0] Mail order house + 2 [CO Last week [) Week before | (2) Drug store [2] Other (Specity) mem mee ee te a a 1 0 Grocery store [0] Before 2 weeks (STOP) 3 | () Mail order house s | Last week [0] Week before ) (] Drug store (] Other (Specify) = | [2] Grocery store [] Before 2 weeks (STOP) $ 1 [] Mail order house 4 | ()Lastweek [Week before 1 (2) Drug store (] Other (Specify) i ata | [0 Grocery store [] Before 2 weeks (STOP) $ | (] Mail order house Cord J Medicines for eye, ear, or nose conditions Pain relievers, such as aspirin, headache powders, etc. Remedies for colds and other respiratory conditions, such as cough medicine, nose drops or sprays, etc. Medicine for digestive conditions or upsets, such as antacids, laxatives, etc. Remedies for skin or muscular conditions, such as ointments, salves, liniments, etc. Vitamins Antiseptics Tonics or blood builders First aid items Allergy remedies Nonprescription tranquilizers, sleeping pills, or ‘stay awake’’ pills Any other nonprescription medicines CY 1973 PRESCRIBED MEDICINES Ta. During the past 2 weeks, (the 2 weeks outlined in red on that calendar) did anyone in the tamily, (that is you, your ==, etc.) buy or obtain any (other) kind of medicine prescribed by a doctor? Y N (2) (Besides the prescriptions you have already told me about) 2a. During the past 2 weeks did anyone in the family get any (other) medicine from a pharmacist or drugstore at was prescribed by a telephone call from a doctor? (Besides the prescriptions you have already told me about) 3a. During the past 2 we: Y_ N (4 b. What is the name of the - 4a. Fn end NTiem b. What is the name of the medicine? Enter name of medicine in col. (b) of Table M and ask: What condition is it for? Enter name of condition in col. (c) and reask 4a, TABLE M: Complete columns d—k as appropriate for each prescription listed. If none listed, go to next page. Enter name of medicine. Enter name of condition and Was the —— obtained last How was this medicine obtained ~ through reask part a of appropriate week or the week before? a written prescription, a refill, a call to Line Ques. question. the pharmacist from the doctor, given No. by the doctor to take at home, or was it obtained in some other way? (a) (b) (c) (d) (e) I 1 [J Last week 1 Written prescription 2 [J D0K 2 [_] Week before 2 Refill A 3 [J In past 2 weeks, DK which| 3 [C] Call to the pharmacist 3 4] In interview week (NM) 4 H Given by Dr, to take at home s [|] Before 2 weeks (NM) 8 Dr. recommended (not prescribed) 4 s [] Other — Specify TABLE M - Continued Who was this During the past| How much did or will you or your | Did or will any| What (other) source paid or will What was the total cost of this prescribed for? 2 weeks, how | family pay for this medicine? other source | pay any part of this medicine? medicine, including the amount Enter appropriate many different | If two or more times in col. (g), y any of the to be paid by all sources? person number, times was add: Include the total amount for | bill for this this medicine [the —= times this medicine was medicine? obtained? obtained. (f) (2) (h) (i) 1) (k) 0000 None (j 1 [] Free from doctor (NM) by a DK @ ry 2 [] Private health insurance 9999 [J DK N (N 3 Medicare Dollars ! Cents 2 (NM) 4 [] Welfare (incl. Medicaid) Person No. Times $ 1 9 DK (k) [J Other ~ Specify g SMOKING HABITS FY 1965-66 Now | have a few questions about smoking — — For each person 17 years old or over, ask: [C] Under 17 years . a. Have you smoked at least one hundred cigarettes during your entire life? [C) Yes [CJ No (Go to 21) If “Yes,ask: FEE EEE mE EEE b. During the period when you were smoking the most, how many cigarettes a day did you usually smoke? per day OR per week 19. o. Do you smoke cigarettes now? CC) Yes [CJ No (Go to 20) If "Yes," ask questions 19b AND 19c. If *'No,’’ go to question 20: b. On the average, about how many cigarettes a day do you smoke? c. Twelve months ago, how many cigarettes a day were you smoking? 20. If *'No’’ to question 19a, ask BOTH questions 20a AND 20b: a. On the average, about how many cigarettes a day were you smoking 12 months ago? b. How long has it been since you smoked cigarettes fairly regularly? “months OR “years For each male 17 years old or over ask questions 21 AND 22: [C] Fem. or under 17 21. a. Have you smoked at least 10 cigars during your entire life? Yes ~~ [No(Goto22 | b. Do you smoke cigars now? [[] Yes (Ask c) [] No (Ask d) If “Yes” to 2lb, ask: ITT TTT TTT per TT] €. About how many cigars a day do you usually smoke? OR week —— If No" to 21b, ask: months OR years d. About how long has it been since you smoked 3 or more cigars a week? [J] NEVER smoked 3 or more a week 22. a. Have you smoked at least 3 packages of pipe tobacco during your entire life? [C) No (sTOP) b. Do you smoke a pipe now? If *'Yes' to 22b, ask: c. About how many pipefuls of tobacco a day do you usually smoke? If *'No’’ to 22b, ask: d. About how long has it been since you smoked 3 or more pipefuls a week? OR years [—) NEVER smoked 3 or more a week months 70 CY 1970 SMOKING PAGE Person No. Complete Smoking Page for each person 17+ years of age. . How long has it been since —— smoked cigarettes fairly regularly? —No. of completed years (4,9) 99 [JDK (8) 98 [_] Never smoked regularly (11) oo [] Under | year (8) Now, | have a few questions about smoking: 11. Has —- smoked at least 50 cigars during his entire life? 1. Has —- smoked at least 100 cigarettes during his entire life? TY 2 N (17) o DK 1 Y 2 N (1) 9 DK 12. Does —~ smoke cigars now? 2. Does —— smoke cigarettes now? 1 Y 2 N (14) 9 DK (14) 1 Y (5) 2 N 9 DK 13. About how many cigars a day does —~ usually smoke? If less than 1 per day: 96 [] 3 to 6 per week (15) 97 [] Less than 3 per week ——No. per day (15) 99 [JDK (15) . For years |—-10 ask: Which of these statements (Hand Card S) were reasons —- decided to stop smoking cigarettes? Please give me the number of any statement that applies. Circle number. 1234567891011 1213 (Specify)— Any other reason? If more than one circled, ask: What was the main reason —— decided to stop smoking cigarettes? . About how long has it been since —— smoked 3 or more cigars a week? ——No. of completed years (17) 97 [_] Never smoked 3 or more per week (17) 00 [] Under | yen} 99 [_] Don’t know (16) 15. What size cigars does —— usually smoke: full-sized cigars, the small cigars sometimes called cigarillos, or the very small cigars about the size of a cigarette? 1 [J] Full-sized 2 [J Cigarillos 3[] Cigarette size 9 [JDK fairly regularly? 98 [] Never smoked regularly — Age started smoking 99 [] DK Enter the number of the main reason (9) 16. Twelve months ago, about how many cigars a day did —— usually smoke? 5. On the average, about how many cigarettes a day does —— smoke? If less than 1 per day: ——No. per day 99 DK —No. per day 96 [] 3 to 6 per week 97 [_] Less than 3 per week 6. What size cigarette does —— usually smoke: regular size, king size, 99 [J DK 98 [] Did not smoke or extra long? : - Regular King Size 3 [] Extra lon DK iin z - LD A 2] Kine Ll $ 20 17. Has —— smoked at least 3 packages of pipe tobacco during his entire life? 7. Does —- usually smoke filter or nonfilter cigarettes? Y N (ID - 1 [] Filter 2] Nonfilter 9 [J DK : 2 NY > 8. On th bout how many cigarettes a day wa 18. Does ww smoke o pips now? . On the average, abou many ci y was —— smoking 12 months ago? 1 Y 2 N (20) s DK (20) —No. per da 98 [_] Did not smoke 99 [] DK 19. About how many pipefuls of tobacco a day does —- usually smoke? bh pe y J [a 9. During the period when —— was smoking the most, about how many ——No. per day (21) If less than 1 per day: cigarettes a day did he usually smoke? 96 [] 3 to 6 per week (21) No. per day 99 DK 99 [J] DK (21) 97 [[] Less than 3 per week 10. About how old was —— when he first started smoking cigarettes 20. About hw long has it been since —— smoked 3 or more pipefuls a week? ——No. of completed years (22) 97 [_] Never smoked 3 or more per week (22) 00 [J] Under | year 99 [] DK 21. Twelve months ago, about how many pipefuls a doy did -- usually smoke? If less than 1 per day: —No. per day 96 [] 3 to 6 per week 97 [] Less than 3 per week 99 [] DK 98 [_] Did not smoke 22. Does —— presently use any other form of tobacco, such as snuff or chewing tobacco? = | Respondent for Q's. 1-22 1 [] Snuff 4 [] Other ke NTERVIEWER | 1 [J Responded for self-entirely 2 [] Chewing tobacco 9 [JDK . NTT : 2 [] Responded for self-partly Person was resp. 3[] No Fill Interviewer Check Item 3 } CY 1974 (See Hypertension Supplement, Appendix Il, p. 114.) 7 72 VISION IMPAIRMENT AND USE OF CORRECTIVE LENSES FY 1963 Budget Bureau No. 68-R620.8; Approval Expires July 15, 1964 FORM sHIS- Hi US DE ray on THEE Ens0s | Name of person Age PSU Segment Serial No. | Sample VISION SUPPLEMENT B- NATIONAL HEALTH SURVEY [7] Responded for self OR Column number of respondent . . . .... vv. INTERVIEWER: Complete either Section A or B Complete Section A (buff Pages 2-0), if: (a) Both "Yes and '"No'’ in answer to Columns (c), (d), and (e) of Table B OR (b) "Great deal’ or "'Some’’ in answer to Column (j) of Table B. Complete Section B (blue Pages 7-10), if: “'No'’" in answer to all of Columns {c), (d), and (e) of Table B. RESPONDENT RULES FOR VISION SUPPLEMENT If the person for whom tie Vision Supplement is to be completed is an eligible respondent according to the regular eligible respon- dent rules, he is to respond for himself. If he is not at home or otherwise not available, make arrangements for a return call to interview him. (Two additional calls to contact him may be made.) If the person is not an eligible respondent, or is unable to respond for himself because of disability or illness, complete the inter view with any eligibles respondent for Lim. EXCEPTION TO RESPONDENT RULES FOR VISION SUPPLEMENT If the person is an eligible respondent for himself, but definitely is not going to be available for interview at any time during interview week, complete the interview with any other eligible respondent for him. In such a case, explain the teason for the use of the other respondent in a footnote. Footnotes and comments 1 Com- 2 Com= pleted pleted RECORD OF RETURN CALLS TO COMPLETE Date SUPPLEMENT [J None Time Name of interviewer Code CONFIDENTIAL - This information is collected for the U.S. Public Health Service under authority of Public Law 652 of the 84th Congress (70 Stat. 489; 42 U.S.C. 305). All information which would permit identification of the individual will be held strictly confidential, will be used only by persons engaged in and for the purposes of the survey, and will not be disclosed or released to others for any other purposes (22 FR 1687). USCOMM.DC 185188 P-63 Section A QUESTIONS DEFINITIONS la. Did your trouble with seeing come suddenly or did it come gradually? [] Suddenly [] Gradually J At birth (Go to Question 2) ‘‘Suddenly’’ would be either instantaneously or in a very short time, usually associated with an injury. b. If “Suddenly” or *‘Gradually,’’ ask: Age How old were you when your trouble with seeing FIRST began to interfere with your daily activities, that is, your work, recreation, education, ortravel? . . ci iti i tiie ee nee ee na (Under 17 - Go to Question 2) [] Never interfered (Go to Question 2) “Daily activities’ means the person's usual activities, depending on the age of the person at the time. If age in 1b is 17 or over, ask: c. Were you working at a job or business before you began to have trouble with seeing? [] Yes [J No 2. When were your eyes last examined by a physician eye specialist? [] During the past 12 months Years [] Never If over 12 months, round to nearest year; round % years upward, e.g., "1%" years should be recorded as ''2”* years. If person is wearing glasses mark this box [] and ask 3b. If person is not wearing glasses, ask: 3a. At the present time do you use any glasses -- that is, ordinary glasses or special glasses or lenses? [] Yes (Ask 35) [C1 No (Go to Question 4) If ‘““Yes”’ or if person is wearing glasses, ask: b. What types of glasses do you use or wear? [] Ordinary glasses for distance and for reading [] Ordinary glasses for distance alone [] Ordinary glasses for reading alone [] Spectacles with strong reading additions (such as bifocals) [] Hand magnifying lenses [] Protection glasses (dark or frosted) [1 Any other type (Specify) Mark each type reported. If unable to classify by type, mark last box and describe. Footnotes and comments FORM NHS-HIS-1(b) (8.3.63) USCOMM-DC 15108 P63 73 74 QUESTIONS DEFINITIONS 4. Do yeu see things as if you were looking through a tube or a gun barrel? [C] Yes [J No Persons with this type of visual defect (“Tunnel Vision’) will understand the question 50. Because of your trouble seeing, do you ever use any aids either in getting around the house or in traveling outside the house; such as a cane, guide dog, or a person with sight? [1] Yes [C1 No (Go to Question 6) If “Yes,” ask: b. Which do you use? (Mark each one mentioned) [J] A cane (If marked ask Questiom 5b(1) [C1 A guide dog (If marked ask Question 5b(2) [] A person with sight [] Other (specity) If cane used, ask: (1) Have you ever had any special instructions in using or getting around with a cane? [] Yes [C1 No If guide dog used, ask: (2) Have you ever had any special instructions in traveling with guide dogs? [] Yes [1 No ‘‘Special instructions’® means training by a trained instructor 6a. Have you ever heard of talking book records? [] Yes [1 No (Go to Question 7) If ““Yes,” ask: b. At the present time are you getting talking book records of any kind th Py mail? You going 9 myn [] Yes [No If the supplement person is a child, Ga refers to whether the respondent ever heard of talk- ing book records; 6b to whether the child is receiving them. 7a. Have you ever had any instruction in reading braille? [] Yes [CJ No (Go to Question 8) If Yes,” ask: b. Can you read braille? [C] Yes [CJ No (Go to Question 8) If “Yes,” ask: c. At the present time are you reading books in braille? [] Yes [J No Footnotes and comments POMM NNS-HIS-1(b) (8-3-63) USCOMM=DC 15188 P-63 QUESTIONS DEFINITIONS 8a. During an average week, about how many hours do you spend No. of hours watching or listening to television?. ..... Crete resr reese [] Don’t watch or listen (Go to Question 9) If answer is not reported i in hours, «convert to hours. ‘An average week’ is whatever the person considers to be a typical week. No. of feet If some hours reported, ask: (Approximately) b. When you are watching television, how close to the screen do you have to sit in order to see the picture? CE © TI IIT [] Only listen If the answer is “Quite close’’ or something similar, ask about how many feet that would be. 9. During an average week, about how many hours do you spend No. of hours listening to the radio? . . . [] Don't listen If answer is not reported i in hours, convert to hours. ‘An average week'’ is whatever the person considers to be a typical week. 10a. During an average week, about how many hours do you #pend reading No. of hours or listening to books? . ........ GWG OE Ye CE. wi. we ewe [] None (Ask 10b) (Go to ahem, 11) If ““None,’* ask: o . Is this because of your trouble with seeing? [] Yes [J No Include printed books, books in braille and recorded books. Do not include time spent reading comic books, magazines or news papers. If answer is not reported in hours, convert to hours. 11. Do you attend any school or take any courses? [] Yes [J No Include correspondence courses and night school. Report students on summer vacation as ''Yes.' INTERVIEWER, MARK ONE BOX. [] Person is under 17 years of age (Skip to Question 20) [] Person is 17 years old or over (Continue with Question 12) 12. Because of your trouble with seeing have you ever had any special vocational or job training? [C] Yes [] No Training received through any formal program designed co aid or rehabilitate persons with visual defects. 13a. Do you have a job or business? [] Yes [1] No (Go to Question 14) If ““Yes,”’ ask: Occupation b. What kind of work are you doing? . . ........ Industry c. What kind of business or industry is this? .... .| Accept the person’s answers to Questions 13b and ¢ without probing. Examples: Farmer, seamstress, sales clerk. Examples: Farm, dress manu- facturing, candy and tobacco stand. d. Class of worker: (Mark one box) If not indicated by entries in (b) and (c), ask additional questions. [7] Private = paid (works for private concern) |] Own (owns or shares ownership in own business) [] Federal Government [] Government - other than Federal [] Non-paid (works only for room and board, etc.) e. On the whole, would you say you are very satisfied with your present job, fairly satisfied or not satisfied at all? [] Very satisfied [J Fairly satisfied [] Not satisfied at all Mark the box for the statement most neatly corresponding to the person's answer. Footnotes and comments FORM NHS-HIS-1(b) (5.3.63) USCOMMeDC 15188 P63 75 76 QUESTIONS DEFINITIONS No. of hours 14a. On the average, about how many hours a week do you spend visiting with friends, either in your home or theirs? . o.oo viv vinnie nuns [] Don’t visit yr Has your trouble with seeing made any difference at all in how often you get together with friends? [] Yes [J No Include time spent in physical visits only, not telephone conversations. If answer is not in hours, convert to hours. 150. Do you belong to any clubs or organizations? [] Yes (Ask 155) [I No (Ask 15¢) If ““Yes’’ to Question 15a, ask: b. Has your trouble with seeing made any difference at all in your activity in clubs or organizations? [] Yes [No If “*“No’’ to Question 15a, ask: c. Is this because of your trouble with seeing? [] Yes [J No Include any social, civic, fraternal, or religious organiza- tions. 16. Do you go to stores to do any shopping for yourself or your household? [] Yes [No Either alone or with someone else. If person lives with related member(s), skip to Question 18. If person does not live with any related member(s), ask: 17a. Do you have any relatives who live within ten miles of your home? [C] Yes [No b. About how often do you visit with your relatives, either in your home or theirs? [] Every day [1 At least once a week [] At least once a month Oa Other (Specify) c. Do you own your own home, rent or board? [] Owas [] Boards [C] Rents [1 Other (specify) 17c refers to sample unit, i.e., person’s present living quarters. 18. How long have you lived at your present address? [] Less than a year [] One year but less than two [] Two years but less than five [] Five years but less than ten [] Ten years or over Footnotes and comments FORM NHS-HIS-1(b) (5.3.63) USCOMM.DC 15188 P-63 QUESTIONS DEFINITIONS 19. How long have you lived in (this area)? (City or town) [] Less than a year [] One year but less than two [J Two years but less than five [] Five years but less than ten [] Ten years or over Insert name of city or town == if in rural area, substitute “‘this area.’ 20. Because of your trouble with seeing, are you presently receiving any financial help or other services from public or private agencies? [J Yes [CJ No Include all types of services, such as, aid in shopping, receipt of free ror) books, etc. Footnotes and comments FORM NHS-HIS-1(b) (8.3.63) USCOMMDC 185188 P83 77 78 Section B to interfere with your daily activities, that is, your work, recreation, education, ortravel? . oo... iii ieee If age in Question 2b is: under 6, go to Question 3; 17 or over, skip to Question 4; 6—~16, skip to Question 5. QUESTIONS DEFINITIONS 1. Can you see well enough to tell if a light is on or off? [] Yes [J No 2a. Did your trouble with seeing come suddenly or did it come gradually? *'Suddenly’’ would be either in- stantaneously or in a very short [] Suddenly time, usually associated with an injury. [] Gradually [] At birth (Skip to Question 5) If “*Suddenly’® or ‘‘Gradually,'’ ask: ‘Daily activities’’ means the ! person's usual activities, depending on the age of the Age (years) person at the time. b. How old were you when your trouble with seeing FIRST began 3a. If age in Question 2b is under 6, ask: Could you see anything besides light when you were an infant? [TC] Yes [C] No (Skip to Question 5) If ““Yes,”” ask: . Do you remember seeing colors? [] Yes [No . Do you remember seeing moving objects or people's features? [Yes [No (Skip to Question 5) If age in Question 2b is 17 or over, ask: specialist? [TC] During the past 12 months Years [] Never 4. Were you working at a job or business before you began to have trouble with seeing [CT] Yes [J No 5. When were your eyes last examined by a physician eye If over 12 months, round to nearest year; round Y; years opward, e.g., "14" years should be recorded as **2"* years. Footnotes and comments FORM NHS-HIS-1(b) (5.3.83) USCOMM-DC 15188 P.63 QUESTIONS DEFINITIONS 6a. Because of your treuble seeing, do you ever use any aids either in tting around the house or in voli outside the house; such as a cane, guide dog, or a person with sight? [] Yes 0 No (Go to Question 7) If “*Yes,* ask: b. Which do you use? (Mark each one mentioned) [CJ] A cane (If marked, ask Question 65(1)) [] A guide dog (If marked, ask Question 6b(2)) [CJ A person with sight [] Other (Specify) If cane used, ask: (1) Have you ever had any special instructions in using or getting around with a cane? [] Yes [J No If guide dog used, ask: (2) Have you ever had any special instructions in traveling with guide dogs? [] Yes [J No *'Special instructions’’ means training by a trained instructor. Ta. Have you ever heard of talking book records? [J Yes [CJ No (Go to Question 8) If “Yes,” ask: b..At the present time are you getting talking book records of any kind through the mail? [J Yes [J No If the supplement person is a child, 7a refers to whether the respondent ever heard of talking book records; 7b to whether the child is receiving them. 8a. Have you ever had any instructions in reading braille? [C] Yes [CJ No (Go to Question 9) If ““Yes,"’” ask: b. Can you read braille? [C] Yes [CJ No (Go to Question 9) If “Yes,” ask: c. At the present time are you reading books in braille? [] Yes [C1 No 9. During an average week, about how many hours do you spend reading or listeningto books? . . . oo. iii ii iii iii [] None No. of hours ‘An average week'’ is what- ever the person considers to be a typical week. Include books in braille, recorded books and printed books read by or to the person, but not including magazines or newspapers. If answer not reported in hours, convert to hours 10. During an average week, about how many hours do you spend listening to the radio or television? ............... Ws Ee ea [] Don’t listen No of hours If answer not reported in hours, convert to hours. Footnotes and comments FORM NHS-HIS-1(b) (5.3.63) USCOMMeDC 15188 P-63 79 80 QUESTIONS DEFINITIONS 11. Do you attend any school or take any courses? [C1 Yes [J No Include correspondence courses and night school. Report students on summer vacation as “Yes.” INTERVIEWER, MARK ONE BOX. [C] Person is under 17 years of age (Skip to Question 20) [T] Person is 17 years old or over (Continue with Question 12) 12, Because of your trouble with seeing have you ever had any special vocational or job training? [CT] Yes [No Training received through any formal program designed to aid or rehabilitate persons with visual defects. 130. Do you have a job or business? [C] Yes [C1 No (Go to Question 14) “If “Yes,” ask: Occupation b. What kind of work are you doing? . . ... 0 uuu. Industry c. What kind of business or industry is this? ..... Accept the person’s answers to Questions 13b and c¢ without probing. Examples: Farmer, seamstress, sales clerk. Examples: Farm, dress manu- facturing, candy and tobacco stand. d. Class of worker: (Mark one box) If not indicated by entries in (b) and (c), ask additional questions. [] Private - paid (works for private concern) [CJ] Own (owns or shares ownership in own business) [C] Federal Government [] Government = other than federal [C) Non-paid (works only for room and board, etc.) e. On the whole, would you say you are very satisfied with your present job, fairly satisfied or not satisfied at all? [] Very satisfied [] Fairly satisfied [] Nort satisfied at all Mark the box for the statement most nearly corresponding to the person's answer. No. of hours 14a. On the average, about how many hours a week do you spend visiting with friends, either in your home or theirs? .......cco0eveunnnn [] Don’t visit b. Has your trouble with seeing made any difference at all in how often you get together with friends? [] Yes [J No Include time spent in physical visits only, not telephone conversations. 15a. Do you belong to any clubs or organizations? [CJ Yes (Ask 156) [No (Ask 15¢c) If ““Yes *’ to Question 15a, ask: b. Has your trouble with seeing made any difference at all in your activity in clubs or organizations? [C] Yes [I No If “No” to Question 15a, ask: c. Is this because of your trouble with seeing? [] Yes [CJ No Include any social, civic, fraternal, or religious organiza- tions. Footnotes and comments FORM NHS-HIS-1(b) (5.3.63) USCOMALDC 18188 Pees QUESTIONS *DEFINITIONS 16. Do you go to stores to do any shopping for yourself or your household? [] Yes [No Either alone or with someone else. If person lives with related member(s), skip to Question 18. : If person does not live with any related member(s), ask: 17a. Do you have any relatives who live within ten miles of your home? [] Yes [1No b. About how often do you visit with your relatives, either in your home or theirs? [] Every day [] At least once a week [] At least once a month [] Other (specity), c. Do you own your own home, rent or board? [] Owns [] Boards 1 Rents [] Other (Specify) 17c refers to sample unit, i.e., person's present living quarters. 18. How long have you lived at your present address? [] Less than a year [] One year but less than two [] Two years but less than five J Five years but less than ten [] Ten years or over (this area)? (City or town) 19. How long have you lived in [] Less than a year [] One year but less than two [C] Two years but less than five [] Five years but lessthan ten [] Ten years or over Insert name of city or town == if in rural area, substitute “this area®’ 20. Because of your trouble with seeing, are you presently receiving any financial help or other services from public or private agencies? [C] Yes [JNo Include all types of. services, such as, aid in shopping, receipt of free recorded books, etc. Footnotes and comments FORM NHS-HIS-1(b) (8.3.63) USCOMM.DC 15188 P«63 81 FY 1966 EYEGLASS PAGE Tem 0 must be asked for all persons 3 years old or over. If under 3 years mark the “under 3" circle. Item 0. These next question: bout eyeglasses ond contoct lenses. Does ve or comtoct lenses? Mark for each person.) Person | Person | Person | Person | Person | Person | Person | Person | Person | Person 01 0” 0 04 08 06 07 [} ® _10 Yes | - Yes | © Yes Yes | = Yes Yes Yes Yes Yes No < © No © No “No No = No No No : Und3| = Ued3| = Und3| © Und3 Und3| - Und3| ~ Und3| . Und3 Und3| = Und3 oou > z FILL ONE EYEGLASS PAGE (QUESTIONS 1-6) FOR EACH PERSON WITH “YES MARKED IN ITEM 0 FOR EYEGLASSES OR CONTACT LENSES 2 Which dees — _ hove: eyoglosses, contact lenses or both? 1. Person number Write tn and mark Eyegonses Comoct lenses Boh V Question 3 refers to all — v Nv Ty 3e. doe ony a4 eyeglasses (or contact lenses) prescribed for reading ond - lenses which a person hae.____ TTT TUT0 "saves = b. Are ony of — — oy o! You Ne v distant objects pamer? . 1 Ne Jobe 3a and © . ho es CTT Te &. What are his eyeglasses 3b. ask 3 (or contact lenses) - ‘ bed for “Yes in Ya ih aki la, —>; da. How often does — — vee his eyeglasses (ond contact lenses) while reading ail Mou Hordly Never v oc doing close wo! {1 of the time, mest of the time, hardly ever, or never? 7% 3 If “Yes in 3b Jr Team Lae > b. How shen dees only. ask ib. distont objects All ne Lh Al Most Hardly Wows Por guy other, | : RR A combination c. How oft — use ses (ond contoct lenses): Al of ' gues in Btn Som akon dors sara fod toast low Wt ny 4 Question 5 refers to the FIRST visual aid (eye- glosses or contact lens that the person got. 5. About how old was _ _ when he got his FIRST pair of eye- s (or contact le ? write in v and mark Question 6 refers to the LAST visual aid (eye- glasses or contact lenses) | that the person got. Ask 6b, ¢, and d for all persons examined for eyeglasses during ’ past 2 years. During lost 2 yeors -- dub 6b 6a. Did — — obtain his LAST pair of eyeglasses (or contact lenses) < during the last 2 years or before that time? More than 2 yeon -- Sup (0) © Not examined - STOP (9) fo of doctor of person | “] €. Where was he da? ‘Name of place WASHINGTON USE ONLY Kind of place d. 1s the doctor (person) who examined — _ on ophthalmologist er an optometrist? © Ophthalmologist (1) Q Optometrist (4) © Other (Describe) —————= FILL AFTER COMPLETING | INTERVIEW, If person was ex v a doctor or other person | not connected with a com-i mercial company, check | the telephone directory © and mark appropriate circle based on the tele- phone listing. : Trem V: a Not verifiable because — Verified and listed as - © Address in 6Cnot m i © Optonetrist (4) local area (V) i © Ophthalmologist (MD) (1) © Nome wo listed in : © General Practitioner (MD) (2 local directory : © Other specialist (MD) (2) © Moentry of name ! © MD, bu specialty DK (3) 6b. (V) } © “Doctor” but OK whether MD or Optometrist (5) ! © co © CY 1971 37a. Does anyone in the family use ~ If **Yes,” ask band ¢ b. Who is this? Circle person’s number c. Anyone else? 1. Contact lenses? ..Y N.........1 2 3 4 5 6 7 8 9 10 2. Eyeglasses? .... Y Nivwsswwawl 2 3 4 5 6 72 8 9 0 3. A hearingaid?...Y N.........1 2 3 4 5 6 7 8 9 10 For ‘hearing aid,” with no hearing problem reported, ask: For what condition does he need this? Enter condition in item C 82 X-RAY VISITS FY 1961 X-RAY QUESTIONS 21. (a) We are interested in all kinds of X-rays - Did have teeth X- d during th + Yi N w od months - (that is, from-- through last Sunday) ? ve your fseth X-rayed dining the pas [Yes Ove es, : (b) How many times? NO. Of HIVES commer 22. During the past 3 months did you have a CHEST X-ray? [7] Yes-Chest CINo 23. (a) Did you have any (other) kind of X-ray at all during the past 3 months? [C] Yes [CINo If “Yes,” (b) What part of the body was X-rayed? Part(s) of body: 24. (a) During the pee 3 months, did anyone in the family have any X-rays for the treatment of a condition If “Yes,” (b) What part of the body was treated? (c) Was this included in the X-ray(s) you told me about before? [C] Yes [INo Part(s) of body: . (a) Did anyone in the family have a fluoroscope during the past 3 months? i “Yes,” (b) What part of the body was this for? (c) Was this included in the X-ray(s) you told me about before? [J Yes [No [] Yes []No Table X - FILL ONE LINE FOR EACH PART OF BODY ENTRY FROM QUESTIONS 22-25 | How many Where did you What was this X-ray(s) for-- a |If “‘both’’ in col. | If ‘both’’ or ‘treatment’ in col. (f) ask: 5 5 2 Yisidzent, have the X-ray(s)?| check-up or an examination or (f) ask: E A Ymes id you | How man X-rays for treatment? 3 $ 8 ave your... | Lore of the (hos- How many of o |Z al & Part of body Fags Sin pol, dosiers these. .. X-ray(s)| For what condition were you being treated? £ | 3 3 months? office, etc. were for treat- =O 5 < ment? (@) | (b) (c) d) (e) 0 (8) (h) Hospital [C] Check-up/examination 1 Dr. office [] Treatment Other | [T] Both 83 FY 1964 (April-June 1964) Sheet of sheets Budget Bureau No. 68-R620.8; Approval Expires July 15, 1964 A. PSU No. |B. Segment No. | C. Serial NoJ E. 3-month reference period G. Telephone No. Name @ Mr. LL III eel _ Interview status F. Address of sample unit (Item 2(b) or (a) of NHS-HIS-1) Miss (] Interview (Fill items E, F, and G) ™ - LE La Rg OR [J No telephone Relationship asi Type A Age Race White [Sex (J Type B City State Negro (J Type C [=] Other MF X-RAY QUESTIONS 1. (Exposure to all kinds of X-rays is a matter of particular interest to the Public Health Service, and | have a few final questions about [J Yes [J No X-rays and fluoroscopes.) Did you have your teeth X-rayed during the past 3 months (that is from through last Sunday)? (If “Yes,” check the ‘‘Yes'’ box and enter ‘‘Teeth.’’) 2. During the past 3 months did you have a chest X-ray? [] Yes [No (If ““Yes,"’ check the ‘‘Yes’’ box and enter ‘‘Chest.’’) 3. (a) Did you have any (other) kind of X-ray at all during the past 3 months? [] Yes [J No If "Yes," ask: (b) What part of the body was X-rayed? (Enter part of body in person’s column) 4. (a) Did you have a fluoroscope during the past 3 months? . [1] Yes [J No If Yes," ask: (b) What part of the body was it for? (Enter part of body in person's column) If “X-rays’’ in question 2 or 3 for the person, ask: ~~ (c) Was this included in the X-rays you told me about before? [C] Yes [] No 5. (a) Did anyone in the family, that is, you, your — —, etc., have any X-rays for the TREATMENT of a condition during the 3-month eriod from y through last Sunday night? y 9 CC] Yes 3% If "Yes," ask: (b) Who was this? (c) What part of the body was treated? (Enter part of body in person’s column) If X-rays in questions 2—4 for the person, ask: ~~ ee mm — (d) Was this included in the X-rays you told me about before? [] Yes 1 [] No Height i Weight 6. What is your height and weight? gFest) (Inches) (Pounds) | A Table X — FILL ONE LINE FOR EACH ‘PART OF BODY'' ENTRY FROM QUESTIONS 1-5 Col. | Ques- How many For dental X-rays, ask: What is the name and address of the (dentist, doctor, hospital, etc.) Neo. tion different Where did you have the X-rays taken — at the den- where the X-rays were taken? of No. times did tist's office or some other place INTERVIEWER — per- you have For X-rays other than dental, ask: . LC . I as Where did you have the Xoroys token: or fhe For Xeeays taken at hospitals, clinics, etc., ALSO enter the name of 2 X d doctor's office, a hospital, or some other place? § goetor, o 4 2 Past -raye re ee face tt Bororpimernl For X-rays taken at mobile units, enter: 2 of during the oneiherplace,” deeming p ace.) ‘Mobile unit’ on name line; v body past 3 If more than one place given and more than one location of unit at time of X-ray on address line; and - months? X-ray taken, ask: Dare and address of sponsoring organization and date How many X-rays were taken at the (hospital, ol X-ray in lootnote. doctor's office, etc.)? Verify name and address in telephone directory. Enter the telephone number. Check ““Verified'’ box. If unable to verify, give reason in a footnote. (a) (b) (c) (d) (e) [0] [C] Dentist’s office «vv vo (Times)| Name and title [J Doctor's office. ..... ‘en (Times)| Address 1 [[] Hospital . ........ .“. (Times) Ciry State rn Other (s Hy) « wow ves Ti Times | peciy, Fn ero To T] Verified [) Dentist’s office . . . Tr (Times) Nanigiand tle [C] Doctor's office. . .. . SET (Times)| Address 2 [C] Hospital . .. .. vA EY —(Times)[ City State [7] Other (Specify). vv vv vues (Times) Times Telephone No. (J Verified : N Jol (C7) Dentist’s office ......... (Times) Bnean tile [) Doctor's office. «ave vue (Times)| Address 3 [J Hospital . ..... BE ppe— TT] [OFTTY State Other (Specify). . . . Ce ( ) Times (] Ocher cspecity) Times, Telephone No. [J Verified Use reverse side if more lines are needed. INTERVIEWER ~ Ask after completing Table X for all related persons with X-rays. . May we contact the (doctor, dentist, hospital, etc.) you have mentioned to obtain (Present form for signature) Will you please sign this form? additional information about the X-rays? (C7 Signed (JNot signed (Enter re. ason) 84 TABLE X — Continued INTERVIEWER — DO NOT ASK FOR DENTAL X-RAYS What was this X-ray for — If “Both” in column (g), ask: If “Treatment” or ‘Both’ in column (g), ask: INTERVIEWER - Ask for each person with } 2 or more lines in Table X after all X-rays A checkup or an examination or How mony of these — = X-rays For what condition were you being treated? for a treatment? were for treatment? » 5 have been recorded for a person. - (Enter condition) (DO NOT include dental X-rays in number of 3 X-ray visits.) € Altogether you had — — X-rays during the past 5 3 months. How many separate visits did you 2 moke to have these — — X-rays? (8) (h) (i) ) [] Checkup/Examination Treatment LH (Skip to column (i)) 1 [] Both (Ask columns (h) and (i)) Number Number of visits [C] Checkup/Examination Treatment La (Skip to column (i) 2 Both (Ask columns (h) and (i) Number Number of visits [C] Checkup/Examination [] Treatment (Skip to column (i)) 3 [J Both ‘Ask columns (h) and (i)) ¢ (h) and (i), Number Number of visits 8. INTERVIEWER - After completing X-ray Supplement, check appropriate box. [] No X-rays reported X-rays reported and No problems (release signed, no missing information, etc.) Problems (release not signed, missing information, etc.) (Enter problem in footnote.) FOOTNOTES FORM NHS-HIS-1 (X-ray Supp.) (FY-64) (2-19-64) X-RAY SUPPLEMENT FOR NHS-HIS-1 (FY-1964) U.S. DEPARTMENT OF Toe] BURE A F TH 85 CY 1970 (April-September) Exposure to all kinds of X-rays is a matter of particular interest to the Public Health Service, and | have some questions about Yroys and fluoroscopes. 39b.|[] Dental [C] Other (Specify) 39a. Did anyone in the family have his teeth X-rayed during the past 3 months, that is from (date) through last Sunday? Y N (40) b. Who was this? Mark “Dental in person’s column c. Anyone else? Part of body 40a. During the past 3 months did anyone in the family have a chest X-ray? Y N (41) 40b.{[] Chest [] Other (Specify. b. Who was this? Mark ‘“‘Chest’’ in person's column c. Anyone else? Part of body 41a. Did — — have ony (other) kind of X-ray at all during the past 3 months? If ‘‘Yes," ask: 41a, Y N (NP) b. What part of the body was X-rayed? Enter part of body in person’s column €. c.-Did — = have any other X-ray during the past 3 months? b. TT Part of body 42a. Did — — have a fluoroscope during the past 3 months? If “Yes,” ask: 42a, Y N (NP) b. What part of the body was it for? Enter part of body in person’s column € c. Did — — have any other fluoroscope during the past 3 months? b. Part of body 43a. During those 3 months, did anyone in the family have any X-rays for the TREATMENT of a condition? Y N (43d,44)| 43b.|[] Treatment b. Who was this? Mark ‘‘Treatment’’ in person’s column c. Anyone else? d. What part of the body was treated? Enter part of body in person’s column d. Part of body For each person with X-rays, fluoroscopes, or treatment in 39-43, ask: WL Weight (Lbs.) 44. What is ——'s height and weight? 44. Table R — FILL ONE LINE FOR EACH ‘PART OF BODY" ENTRY FROM QUESTIONS 39-43 Col.| Ques- How many | For dental X-rays, ask: If more than | What is the name and address of the (dentist, doctor, hospital, etc.) No. [tion different Where did he have the X-rays taken — at a one time at where the X-rays were taken? of |No. times did |dentist's office or some other place? 2h) She place, per- - ~ have . asks For X-rays taken at hospitals, clinics, or similar places, % | son his. . . For Xoraysiother than'dental, ask: all these | ALSO enter the name of the doctor who took the X-rays. £ Part X-rayed Where did he have the X-rays taken — at a taken | For X-rays taken at mobile units, enter: 3 doctor's office, a hospital, or some other place? i; " 2 of during the me Mobile unit'' on name line; location of unit at time © body past 3 (If “‘Some other place,’’ determine place.) (dentist's office, of X-ray on address line; and name and address of £ months? if \ , « Socrers office, sponsoring organization and date of X-ray in footnote. more than one place given; as <) Verify name and address in telephone directory. for each place: .“ ve i H " ne th 1 Check ‘‘Verified'' box. If unable to verify, give reason in a footnote. op Bd taken at the (hospital, Enter the telephone number if available. @ | ® (©) (9) ' (e) 0 (2) [] Dentist's office. . . . . Times Name and title [] Doctor's office ..... Times Y Address | [TI HOSPHAL + 5 « 4:54 04 + ieee TIMES Thy Sore [zP — Times [C] Other (Specify) . .... Times N (81, 82) [] Verified | Telephone No. [] Dentist’s office. . . . . Times Name and title [] Doctor's office . . ... Times y. Address 2 al a weiss» v Ti [J Hospita Times oS 5s TP rs Times [] Other (Specify) . . . .. Times N (81, 82) [] Verified [¥«/sphave No. [] Dentists office. . . . . Times Name and title [] Doctor's office . .... Times Y Address 3 Hospital ..... sin 5 Ti [C] Hospital Times Se os [zr oon “Times | [] Other (Specify) ..... Times N (81, 2) [] Verified fF s/ephens No. Ask after completing Table R for all related persons with X-rays. 45. May we contact the (doctor, dentist, hospital, etc.) you have mentioned to obtain additional information about the X-rays? [signed Od Not signed (Enter (Present form for signature) Will you please sign this form? reaacn) Table R = Continued Use for additional name and address DO NOT ASK FOR DENTAL X-RAYS What was this X-ray for — a How many of Ask for each person with 2 or more lines in checkup, an examination, or these —~ X-rays Table R after all X-rays have been recorded for a treatment? were for treatment? | for a person. DO NOT include dental X-rays in number of visits. (Not counting his dental X-rays) Altogether he had — — X-rays during the past 3 months. How many separate visits did he make to have these — — X-rays? (22) (h) (1) (k) [C] Checkup/Examination (k) Line number Name and title Address City TState [ze code " a ! | Number Number of visits [] Verified [ Telephone No. [] Both (i) 0O0O0 86 APPENDIX II ONE-TIME OR SINGLE SUPPLEMENTS ACUTE CONDITIONS: CY 1973 and 1974 O.M.B. No. 68-R1600; Approval Expires March 31, 1975 ron HIS. 1A (1974) porice Sl information which oud pernir iden fication of the individual wi e held in strict confidence, wi e used only by persons engaged in and aE MER for the purposes of the survey, and will not be disclosed or released to others for any purposes. ADMINISTRATION TI eT A ORTH a. PSU [b. Segment fe. Serial d. Sample e. Person|f. Sample U.S. PUBLIC HEALTH SERVICE number « number number| person U.S. HEALTH INTERVIEW SURVEY 1Y 2N CONDITION SUPPLEMENT g. Name of condition h. Name of person (Medically Attended) i. Determine if eligible respondent is available: [CJ Eligible respondent available [] Telephone call or return visit required (AS, Condition page) j» RECORD OF TELEPHONE CALLS ONLY k. Reason for noninterview Beginning Ending Dats time time Completed 1 [J Refused a.m. a.m. | p.m. pom. 2 [J] Not at home — repeated calls a.m. a.m. 2 p.m. pom. 3 [[] Temporarily absent a.m. a.m. 3 p.m. p.m. [J Other (Specify) a.m. a.m. 4 p.m. p.m. a.m. a.m. b ; us RE mors wo— - error In an interview at your household today (earlier this week) it was reported that you recently Fu INTRODUCTION: had. ... The following questions refer t6 that condition. 88 1. Please look at the calendar (HAND CALENDAR) and tell me on what date you first noticed (had) the... . Month Day 2. At that time when you first noticed (had) the « + + , how serious did you think it was — very serious, somewhat serious, or not serious at all? 1 [] Very serious 2["] Somewhat serious 3 [J Not serious at all 3a, After you first Aaticd Ged) the comition on won ; about how long was it before you visited or talked to a doctor about it? b. We are interested in the various reasons why people wait before going to a doctor. Please tell me whether any of the following statements were reasons why you waited (time see or talk to a doctor about this condition ~ PROBE IF RESPONSE IS INAPPROPRIATE: PROBE IF RESPONSE IS INAPPROPRIATE: If two or more reasons given in statements A-K, ask; otherwise mark box: c. Which of these reasons would you say was the MAIN reason for waiting to see a doctor for this condition? Circle the appropriate statement letter in the space to the right. 000 [_] Discovered by doctor (5) 100 [_] Under 4 hours (4) 2 Hours 3 Days 4 Weeks A. Did you wait because you couldnt get an appointment or the doctor was not available? 1Y 2N B. Because you didn’t have the money? 1Y 2N C. Because you didn't have a way to get to the doctor? 1Y 2N D. Did you wait because you felt the doctor couldn't do anything for the condition? 1Y 2N E. Because you felt you could treat the condition yourself? 1Y 2N F. Because you didn’t want to bother the doctor? 1Y 2N G. Did you wait because you didn't think it was serious enough? 1Y 2N H. Because you feel uncomfortable with doctors or have a fear of doctors? 1Y 2N I. Did you wait for any other reason? 1Y 2 N(K) J. What was the reason? frm rn ET TT TT TT TT Tr TT me re nt vee sul se eu sm To rm m (Reask I) (2) (Reask I) If all “*“N’s"* in A—I, ask; otherwise, go to Q. 3c: K. Why did you wait_(time) to see or talk to a doctor about this . . .? Any other reasons? 0} [CJ Only | reason otA 04D 07G 10 J(2) 13K(l) 16 K(4) 02 B osE osH 1 J(3) 14 K(2) 03 C os F 09 J(I) 12)(4) 15 K(3) FORM HIS-1A (10-11-73) 4a. Before you talked to a | doctor about this condition, did you ask anyone for i advice about it, suchas a | nurse, druggist, relative, | friend or someone else? | | | | c. Did you ask anyone else | for advice? i Y (Reask 4b N and c) ! Ask for each column | marked in Q. 4b: i I I ) d. Did —— advise you to see 3[_] Relative (Household member) 4 [1 Relative (Non- household member) s[_] Friend some other type of eaten? WY aN aN] YN | LY aN | g. Did —- give you any other | ¥ oN (Next oN (Next oN (Next Y o N(5) advice? | col.) col.) col.) ———————————— em 0 ———————————— h. What advice did =~ give | you? | | | (Reask g) (Reask g) (Reask g) (Reask g) 5. Please look at the calendar. (HAND CALENDAR) On what date did you first visit or talk to —_— a doctor about this condition? Month Date 6. On (date) here did you Fai 7s or o [] While inpatient in hospital (RA) talk to the doctor — at a clinic, hospita , : i doctor's office, or some other place? ! 0 Doctor's Sie Sp practice of If hospital: Was it a hospital outpatient 2] Telephone (20) clinic or the emergency room? 3 [_] Hospital outpatient clinic (10) If clinic: Was it a hospital outpatient clinic, 4] Home (7) a company clinic, or some other kind of clinic? s [] Hospital emergency room (10) 6 [J Company or industry clinic (10) 7 [] Other — Specify (10) 7. Had you ever gone to this doctor before this visit? 1Y 2N 8. How did you choose this doctor — through another doctor, a relative or friend, a medical bureau, from a telephone directory, or in some other way? 1 (C] Another doctor 2 [] Relative/friend 3 [] Medical bureau a] Telephone directory [] Other — Specify z 9a. Is this doctor you visited on_(d2t€) the doctor you would usually go to for this type of condition? b. Why didn't you use the doctor or place that you would usually go to for this type of condition? mmm pm e me errr —ee RE) N FORM HIS-1A (10-11-73) 89 90 10. Had you ever gone to this place before this visit? 'Y 2N 11. How did you choose this place — through another doctor, a relative or friend, a medical bureau, from a telephone directory, or in some other way? 1 [J Another doctor 2 [] Relative/friend 3 [] Medical bureau 4] Telephone directory s [] Other — Specify 120. Is this place you visited on (date) the place you would usually go to for this type of condition? b. Why didn’t you use the doctor or place that you would i, go to for this type of condition? 0Y(13) N If *“Home"* in Q.6, go to Q. 16. 13a. Did you make an appointment for this visit? b. Did you have any problem making this appointment? 1Y 2 N(14) 14a. When you visited the doctor on (date) , how difficult was it for you to get there — was it very difficult, somewhat difficult, or not at aH difficult? sl es 1 [[] Very difficult 2 [] Somewhat difficult 3 [C] Not at all difficult (c) b. Why was it difficel? TT TTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT i Ls on oo a, ew i | ¢. About how long did it take you to get there? i 3 Minutes 2 Hours 150. After getting there, did you feel that the time V1 [J Much too long ou had to wait to see this doctor was much too | S h | ong, somewhat too long, or not too long? | 2] Somewhat too long } 3 [J Not too long Se rm HR RA A SR b. About how long did you have to wait after | getting there? Io Minutes Rees: HOUTS I 16. During this visit on_(date) , did the | h ti doctor spend enough time with you or not : * CISpent enough time enough time? | 2[C] Did not spend enough time 17a. During this visit did the doctor advise you to | come back and see him for the . . .? 4 1Y 2 N(18) oro mero er ee a A ee et et | b. Did or will you go back to see him for this ) condition? I 1Y(I8) 2N 9 DK c. Why not? TTmhe meme no ee | | (\ | PORM HIS=1A (10-11-73) 18a. During this visit on _(date) did the doctor prescribe or advise you to get any medicine for this . . .? 1 Y 2N(19) Ee femme b. Did you get this medicine? Io Y(I9) N e Why not? ~~ TTTTTTTTTTTIT Imm pe remaster m——] I | I 19a. During this visit did the doctor refer you to | another doctor? L 1 Y 2 N(28) | b. Did or will you see this other doctor? | 1Y(28) 2N 9 DK Riga Tm mm ann mma anna mT ed (28) 20. Had you ever gone to this doctor or place before this call? 1Y 2N | | i | I | T | | 21. How did you choose this doctor or place — | Anoth through another doctor, a relative or friend, | ! CJ Anot er doctor a medical bureau, from a telephone directory, p20 Relative/friend or in some other way? | 2 (CJ Medical bureau | 4[_] Telephone directory | [J Other — Specify 3 | : 22a. Is this doctor or place you called on _(date) ! the doctor or place you would usually go to for | this type of condition? ; 0 Y(23) N b. Why didn’t you use the doctor or place that Er you would usually go to for this type of | condition? i | 23a. How difficult was it for you to reach the doctor : 1 [J Very difficult by telephone on_(date) " — was it very | s hat ditficu) difficult, somewhat difficult, or not at ! 2] Somewhat difficult all difficult? ! 3 [] Not at all difficult (24) b. Why was it difficolt? TT Te | i 24. During this call on _(date) , did the doctor | 1 Spent enough time spend enough time with you or not enough time? | 2[] Did not spend enough time 25a. During this call did the doctor advise you to ! come in and see him for the . . . ? bay 2 N(26) El A Ale eM A A bos i eee b. Did or will you go in to see him for this condition? 1Y(26) 2N 9 DK c. Why not? —— mmm ——— FORM HIS-1A (10.11.73) 26a. During this call on_(date) , did the doctor | | prescribe or advise you to get any medicine for this . . .? 1Y 2 N27) } b. Did you get this medicine? Io Y(27) N e Why not? TTT TTT] | | | 1 | } I 27a. During this call, did this doctor refer you to ) another doctor? Po Y 2 N(28) mm a =] | b. Did or will you see this other doctor? I 1Y(28 2N 9 DK ey me ot fro RE om ei el al i ee eee) c. Why not? ! | | | | | | 28a. In your opinion, were you satisfied or - dissatisfied with the treatment or care you | [J Satisfied (b) received from this doctor on _(date) ? [] Dissatisfied (c) ee ee ee b. Would you say that you were very satisfied or | 1)Vey satisfied a9 just somewhat satisfied? | 2 [0] Somewhat satisfied (d) ti te meee we ee ee im ee a | a c. Would you say that you were very dissatisfied ! 4] Very dissatisfied or just somewhat dissatisfied? Le [C] Somewhat dissatisfied d. Why is that? TTT TTT TTT TTT TTT | | i | ; | 29. Do you still have the. . .? ! ay 2N Show who responded for this supplement. ! 1 [C] Responded for self If other than self-respondent, show who | RA responded for him. ! Person________was respondent ve om os mr mr me cm oop oo ee If other than self-respondent, give RESPONDENT| reason for accepting a proxy. © [J Under 17 1 [J] Mentally incompetent 2[] Physically incompetent | Show how the information on this 1 [J Completed during initial interview supplement was obtained. TYPE OF 2 [] Completed by return visit INTERVIEW 3 [J] Completed by a telephone callback GO TO AS, CONDITION PAGE FORM HIS-1A (1011.73) 0.M.B. No. 68-R1600; Approval Expires March 31, 1975 FORM HIS-1B (1974) (10-11-73) U.S. DEPARTMENT OF COMMERCE SOCIAL AND ECONOMIC STATISTICS NOTICE — All information which would permit identification of the individual will be held in strict confidence, will be used only by persons engaged in and for purposes of the survey, and will not be disclosed or released to others for any purposes. Tir ARON a. PSU Bb. Segment c. Serial d. Sample e. Person f. Sample ACTING AS COLLECTING AGENT FOR THE number number number person U.S. PUBLIC HEALTH SERVICE 1 Y 2 N U.S. HEALTH INTERVIEW SURVEY g. Name of condition h. Name of person CONDITION SUPPLEMENT (Nonmedically Attended) i. Determine if eligible respondent is available: [C1 Eligible respondent available [_] Telephone call or return visit required (AS, Condition page) js RECORD OF TELEPHONE CALLS ONLY 1 [] Refused Date Beginning Ending Completed time time a.m. a.m. ! p.m. p.m. a.m. a.m. 2 p.m. p.m. a.m. a.m. 3 p.m. p.m. a.m. a.m. 4 p.m. p.m. a.m. a.m. 5 p.m. p.m. k. Reason for noninterview 2 [] Not at home — repeated calls 3[_] Temporarily absent [C] Other (Specify) a 1 In an interview at your household today (earlier this week) it was reported that you recently had . . . . : I INTRODUCTION: Th e following questions refer to that condition. 1. Please look at the calendar (HAND 1 [_] Respondent denies having condition (RB) | | CALENDAR) and tell me on what date | Ha you first noticed (had) the... . ; Month id 2. At that time when you first noticed YY [T] Very serious (had) the . . ., how serious did you ! 2 [] Somewhat serious think it was — very serious, somewhat | N : I serious, or not serious at all? | 3 [[] Not serious at a 3a. Did you ask anyone for advice | about this condition, such as a nurse, | druggist, relative, friend, or | someone else? Izy 2 N(4) RR fm a. 0 A a SE a a I [Z] Nurse 2] Druggist 3[_] Relative [C] Other — Specify b. Who was this? | (Household member) i ————— — ——— a ———————— 4 i c. Did you ask anyone else for advice? J 4 Ba, Y (Reask 3b and c) N : 5] Friend ——— a — ——————————— ————————_————— om em nf ee en, ss te te ts ws tS te, em ns a se le i Ask for each column marked in Q. 3b: ! d. Did —— advise you to see a doctor? 1 1Y 2N 1Y 2N AY 2N 1'Y 2N e. Did ——advise you to take some medicine? i Y 2N 1Y 2N 1 Y 2N ay ELI N f. Did —— advise you on some other type | of treatment? Ly 2N 1Y 2N 1Y 2N 1Y 2N g- Did == give you any other advice? Ly oN (Next | Y oN (Next| Y oN (Next | Y o N(4) y col.) col.) col.) h. What advice did —- give you? i I i (Reask g) (Reask g) (Reask g) (Reask g) Footnotes 93 94 4. Do you expect to see or talk to a doctor about this . . .? 1 Y(5b) 2N 9 DK INTERVIEW 1 | | ! 5a. We are interested in the various reasons why i people do not go to doctors. Please tell me ' whether any of the following statements were | A. Did you not see a doctor (did you wait) reasons why you didn t see or talk to a because you couldn't get an appoint doctor about this condition — 4 ment or the doctor was not available? 1Y 2N b. We are interested in the various reasons why i Jeiple wait before going i] : dakton. Please ] t hether any of the following state- | Cy phi co) why you waite: time iB. Because you didn’t have the money? 1Y 2N to see or talk to a doctor about this condition — ! | C. Because you didn’t have a way to ! get to the doctor? 1Y 2N | D. Did you not see a doctor (did you wait) because you felt the doctor couldn't do | anything for the condition? *Y 2N | | E. Because you felt you could treat ' the condition yourself? 1Y 2N I | IF. Because you didn't want to bother i the doctor? 1Y 2N | G. Did you not see a doctor (did you ! wait] because you didn't think it | was serious enough? iY 2N i | H. Because you feel uncomfortable with \ doctors or have a fear of doctors? 1Y 2N | | i 1. Did you not see a doctor (did you | wait) for any other reason? 1 Y 2 N(K) J. What was the reason? | PROBE IF RESPONSE IS INAPPROPRIATE: | Mm (Reask I) I | : | (2) (Reask I) | If all “‘N’s"* in AI ask; otherwise, go to Q.5c¢: | K. Why did you (not/wait to) see or talk to a ! doctor about this . . .? Any other reason? | PROBE IF RESPONSE IS INAPPROPRIATE: ! m ] | ! (2) a pS bmi TT TT TTT If 2 or more reasons given in statements | A-K, ask; otherwise mark box: : c. Which of these reasons would you say was the i [CJ Only I reason MAIN reason for (not seeing/waiting to see) | a doctor for this condition? i 01 A 0a D 07 G 10 J(2) 13 K(1) 16 K(4) Circle the appropriate statement letter in | 02B os E os H 1 J(3) 14 K(2) the space to the right. 4 03 C os F 09 J(I) 12 J(4) 15 K(3) 6. Do you still have this condition? HEE 4 2N Show who responded for this supplement. i 1 [_] Responded for self If other than self-respondent, show ' be B who responded for him. | __ Person____was respondent If other than self-respondent, give ! 0 [] Under 17 RESPONDENT reason for accepting a proxy. | | 1 [J Mentally incompetent | | 2[] Physically incompetent 1 1 Show how the information on this | 1 [J Completed during initial interview TYPE OF supplement was obtained. ! 2 [] Completed by return visit 1 | 3] Completed by a telephone callback GO TO AS5, CONDITION PAGE FORM HIS-1B (10-11-73) ARTHRITIS: CY 1969 FORM HIS-2A (1969) (12-3-68) U.S. DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS ACTING AS COLLECTING AGENT FOR THE U.S. PUBLIC HEALTH SERVICE U.S. HEALTH INTERVIEW SURVEY ARTHRITIS SUPPLEMENT BUDGET BUREAU NO. 68-R1600 APPROVAL EXPIRES MARCH 31, 1970 PSU Segment Serial No. [Sample B- Name of sample person Person No. Name of interviewer Code 1 [_] Responded for self : OR ! Person number of respondent--! Footnotes NOTICE ~ All information which would permit identification of the individual will be held in strict confidence, will be used only by persons engaged in and for the purposes of the survey, and will not be disclosed or released to others for any purpose. 95 Earlier in the interview you told me about —-'s arthritis ! a.m. (rheumatism, . . .). This is a matter of special interest to the Starting ’ p.m. U.S. Public Health Service, and | have some additional questions tarting time. . . | about it. 1a. During the past 12 months, have you had any STIFFNESS in your joints when first getting out of bed in the moming? 1[]Yes 2[JNo (2) a.m. b. What time of day does this stiffness usually go away? p.m. [C1 Never c. During the past 12 months, have your WRISTS been stiff when first getting out of bed in the moming? 1[JYes 2[]No 2a. During the past 12 months, have you had PAIN in your joints when moving them? 1] Yes 2[JNo (3) b. During that period, have your WRISTS been painful when you moved them? 1[]Yes 2[JNo 3a. (During the past 12 months) have you had SWELLING in any joints except in the ankles or feet? 1] Yes 2 No (4) b. During that period, have you had any swelling .in your WRISTS? 1] Yes 2[JNo 4a. (During the past 12 months) have you had PAIN or SORENESS when you touch or press on your joints? 1] Yes 2] No (5 b. During that period, have you had any pain or soreness when you touched or pressed on your WRISTS? 1] Yes 2[ No If ““Yes’* in questions lc, 2b, 3b, or 4b ask: ) 5. Which wrist is bothered or affected by arthritis? 1 [J Right 2[JLeft 3[_] Both 6a. During the past 12 ths, he f the joints in your PINCERS teen bothered or affected by arthritis? 1d Yes 2[INo (7) b. Please look at this picture of a hand. (HAND CARD D TO [1]! Red [1 4 Gray RESPONDENT) Tell me what colors on this card match [C2 Blue [J None the joints of your RIGHT hand that are bothered or affected [3 Yellow by arthritis. c. Now your LEFT hand. What colors match the joints of your [1]! Red [] 4 Gray LEFT hand that are bothered or affected by arthritis? C2 Blue J None [C3 Yellow d. Are you right-handed or left-handed? 1 [J Right 2[JLeft 3[_]Both Footnotes 7a. During the past 12 months, have your ELBOWS been bothered or affected in any way by arthritis? [Yes 1ONo (8) b. Which elbow is affected? 2[JRight s[JLeft a4["] Both 8a. During the past 12 months, have your KNEES been affected in any way by arthritis? [J Yes 1CINo (9) b. Which knee is affected? 2[J Right 3[JLeft a] Both 9a. Do you presently have pain, swelling, or stiffness in 1 [J Yes 2] No (10) any joint as a result of an old accident or injury? b. Did this accident or injury happen during the past 1 [_] During past 12 months (10) 12 months or before that time? 2 [More than 12 months ago c. Which joints were hurt in this accident or injury? Right | Left [1 Neck Ankle . . [1 Upper back Elbow. . [J Middle back Foot. . . [] Lower back Hand. .. Hip. . . . Knee .. Shoulder. Wrist. . . 10. Who was the FIRST person to tell you that you had arthritis? 1 [] Medical doctor 2 [] Chiropractor 3 [Friend a [] Relative [J Other (Specify) 11. When did a doctor first tell you that you had arthritis? o [] Less than 12 months ago 8 [_] Doctor never said it was arthritis Years 9 [] Doctor never seen 12. When did your arthritis bother you the most—during the past 1 [_] During the past |2 months 12 months, when you first noticed it, or at some other time? 2 [] When first noticed it 3[] Some other time 13. Have you ever been treated by any of the following people for your ARTHRITIS - a. a foot doctor (chiropodist or podiatrist)? 1] Yes 2[ No b. a physical therapist? 1] Yes 2[J No c. an occupational therapist? 1[JYes 2[]No 14a. Have you ever seen a social worker for your arthritis? [J Yes 1 [J No (15) b. Was the social worker from a hospital? 2[]Yes 3s[INo 97 98 TABLE | A ing == 15. Have you EVER used (any of the following) for Fr A your arthritis — om Oy Where are the splints or eS —> casts worn? (Specify) a. Any splints or casts? 1 [No (b) 2[]Yes 3[JNo(b Wheré are the braces worn? [J Yes— (Specify) b. Braces of any kind? 1 [No (co) 2[JYes 3[_JNo(c []Yes—> c. Diathermy or paraffin? 1 [J No (d) 2[]Yes 3[ No d. Hot packs, hot baths, C1 Yes or a heating pad? 1 [J No(e) 2[JYes 3[ No C1 Yes—> e. Cold packs or ice treatment? 1 [J No(f) 2[JYes 3[ No [J] Yes => f. Rest recommended by a doctor? 1 [J No (g) 2[]Yes 3[ No . g. Exercises recommended by a doctor [(JYes —> or physical therapist? 1t[JNo (16) |2[]Yes 3[_JNo 16a. Are you now taking Aspirin, Anacin, or Bufferin for your arthritis? 1 Yves z[C1Ne (17) b. Do you take it every day? 1[]Yes 2 No (17) c. About how many do you usually take each day? Number per day d. Do you usually take the same amount every day? 1] Yes 2] No o [_] Less than one month e. How long have you been taking aspirin every day? Months Years 17a. Are you presently taking any injections or shots for your arthritis? 1] Yes 2] No (18) b. Are any of these injections ‘‘gold’’ shots? 1[]Yes 2[] No Footnotes 18a. Are you presently taking any (other) drugs or medicines that were recommended by a medical doctor for your arthritis? 1[] Yes 2[JNo (19) 1 [J Butazolidin, Sterazolidin, Tandearil 2 [] Aristocort, Cortisone, Decadron, Medrol, Prednisone A icines? —mm——m——_~— b. What are the names of these medicines a] Darvon; Soma, Tyleno) [7] Other (Specify) 19a. Have you EVER used any remedies or medicines for your arthritis either on your own or that were recommended by someone OTHER than a medical doctor? 1] Yes 2[] No (20) b. What kind of remedies or medicines did you use? : (Enter name or description of remedies or medicines in column (a) of Table II below.) c. Anything else? [CJ Yes (Reask (19b) [J No TABLE II Have you used —- at Did you ever talk to Remedies or medicines any time during the a medical doctor past 12 months? about using =? (a) (b) (c) 1] Yes 2[]No 1] Yes 2] No 1[]Yes 2] No 1] Yes 2] No 2. 3 1[]Yes 2[JNo 1] Yes 2[ J No 1[]Yes 2[]No 1] Yes 2] No 4. 1[]Yes 2[]No 1[] Yes 2[] No 5. 1[]Yes 2] No 1] Yes 2] No 6. 1[JYes 2[]No 1] Yes 2[]No 7. Footnotes 100 Some people need help because of arthritis— For each ‘“Yes’’ answer, ask: What kind of help is this — a person or some kind of aid? What time do you USUALLY get up in the morning? 20. Do you use the help of another person or special aid- (a) when getting in or out of an automobile? [Yes 1[JNo(b) 2[J Person 3] Aid (b) when going up or down stairs? [Yes 1[JNo(q) 2[ Person 3[_]Aid (c) when getting in or out of a tub or shower? [Yes 1[JNo(d 2[ J Person 3[]Aid Do you use the help of another person or special aid— (d) in order to completely dress yourself? [Yes 1[JNo(e) 2[ Person 3[]Aid (e) in order to feed yourself a complete meal? [Yes 1[JNo(f) 2[ Person s[]Aid (f) when rolling onto your side in bed? [JYes 1[JNo(2l) [2[JPerson 3[]Aid 21a. Does your ARTHRITIS cause you to sit or lie down to rest at any time during the day? 1 [Yes 2] No (e) Time am. b. At what time do you usually sit or lie down to rest? p.m. c. Do you rest some every day? 1[]Yes 2] No (e) Hours 3 Minutes d. How long do you usually rest each day? ! Time a.m. Footnotes 22a. Type of person mip Are you PRESENTLY seeing anyone for your arthritis?. .. ............. 1[JYes(c) 2] No (b) Could you tell me why you aren’t presently seeing anyone for your arthritis? 1 [] Arthritis not severe enough (23) [] Other (Record response verbatim) (23) 2 [] No one can do anything for it (23) . Who are you seeing? . Are you now seeing anyone else for your arthritis? Check all categories in Table Ill that apply. Then ask the appropriate questions for each category marked. TABLE Ill [] Medical doctor [] Medical doctor [] Other (Specify) 7 1 [He's a family doctor 2 [] Referred by doctor 3 [] Referred ‘by some- one else 4 [] He's an arthritis specialist [J] Other Greciiy) specialist is he? 1. What is the name Name and address Name and address and address of the doctor you see? 2. Why did you decide 1 [J He's a family doctor [1 [_JHe’s a family doctor to go to this —— 2 [] Referred by doctor 2 [] Referred by doctor for your arthritis? 3 [] Referred by some- 3 [] Referred by some- one else one else 4] He's an arthritis a[_] He's an arthritis specialist specialist Speci Speci [J Other (Specify) 7 [] Other ( pecify) — 3a. Is the doctor a 1 [] General practitioner (4) 1 [_] General practitioner (4) | general practitioner or a specialist? [) Specialist [] Specialist b. Whatkind of | | TTT 1 [] Past 2 weeks and from the —-? 2 [] Taxi 3 [] Private car [] Other (Specify)— 2 [] Taxi 3 [_] Private car [1 Other (Specify) 4. When was the LAST | 1 [] Past 2 weeks 1 [] Past 2 weeks time you saw —— for Weeks — Weeks Weeks your arthritis? Months Months Months 5. Where did you see 1 [] Doctor's office 1 [] Doctor's office the ~~. 8} his attics 2 [] Home (Next column) | 2[] Home (Next column) 2 [] Home (Stop) Tass [2] Other (Specify) — [J Other (Specify) [J Other (Specify) 6. About how long did — Minutes Minutes Minutes it take you to get to the —-? Hours Hours Hours 7. How did you get to 1 [] Bus or subway 1 [_] Bus or subway 1 [] Bus or subway 2[] Taxi 3 [] Private car [1 Other pecifyy2 101 102 23a. Have you ever had any special job training because of your arthritis? 1[JYes 2[_]No (24) Name of place b. Where did you receive this training? 24a. Have you ever changed or left a job because of your arthritis? 1[]Yes(c) 2[JNo b. Have you worked at any time since you had arthritis— (For females add: not counting work around the house)? 1[JYes 2[_]No(25) c. In general has your own income decreased because of your arthritis? 1] Yes 2] No 1] Yes 2[] No (STOP) 25a. Have you ever heard of the Arthritis Foundation? 3] Don’t know (STOP) Describe b. How did you first learn about the Arthritis Foundation? c. Have you ever received any personal help, treatment, referral, or other information from the Arthritis Foundation? 1[] Yes 2[] No (STOP) Describe d. What did the Arthritis Foundation do for you? Footnotes H | a.m. Ending time p.m. BLOOD DONORSHIP: CY 1973 If 17 years old or over, ask: 33a. During the past 12 months, has —— given or sold any blood to a blood bank, a hospital, the Red Cross, or anywhere else? For each donation reported in Q. 33b, ask: c. Which of the reasons listed on this card (Hand Card B) best describes why —= gave blood (the last time, the time before that, etc.)? 33a. 1Y 2 N (NP) b. Times Tes [TTT TTT TTT TTT time) 0 [J Under 17 (NP) I 2 3 4 5 = Specifyy I 2 3 4 5 Specify, I 2 3 4 5~ Specify y 1 2 3 4 5 = Specify g 103 DIABETES: FY 1965 FORM NHS-HIS-1(d) (FY-1965) BUDGET BUREAU NO. 68-R620.10 APPROVAL EXPIRES JULY 15, 1965 U.S. DEPARTMENT OF COMMERCE PSU Segment Serial No. | Sample BUREAU OF THE CENSUS ACTING AS COLLECTING AGENT FOR THE B U.S. PUBLIC HEALTH SERVICE NATIONAL HEALTH SURVEY Name of person with diabetes Age DIABETES SUPPLEMENT RESPONDENT RULES FOR DIABETES SUPPLEMENT If the person for whom the Diabetes Supplement is to be completed is an eligible respondent according to the regular eligible respondent rules, he is to respond for himself. If he is not at home or otherwise not available, make arrangements for a return call to interview him. (Two additional calls to contact him may be made.) If the person is not an eligible respondent, or is unable to respond for himself because of disability or illness, complete the interview with the respondent who knows most about the person’s diabetes. If the person is not going to be available for interview at any time during interview week, complete the interview with the respondent who knows most about his condition. In either case, explain in a footnote the reason for the use of the proxy respondent. Footnotes and comments Hn Returns Date Time Completed RECORD OF RETURN CALLS TO ihn 1 COMPLETE SUPPLEMENT calls (| 2 Name of interviewer Code [CT] Responded for self OR Column number of respondent—ap- CONFIDENTIAL - This information is collected for the U.S. Public Health Service under authority of Public Law 652 of the 84th Congress (70 Stat. 489; 42 U.S.C. 305). All information which would permit identification of the individual will be held strictly confidential, will be used only by persons engaged in and for the purposes of the survey, and will'not be disclosed or released to others for any other purposes (22 FR 1687). USCOMM-DC 25036 P-64 104 QUESTIONS DEFINITIONS In the interview you (your--, etc.) told me about your diabetes.. This is a matter of continu- ing interest to the Public Health Service and | have some additional questions about it — 1. About how old were you when a doctor first told you that you had diabetes? Age Estimate is acceptable 2a. Before you were . had you ever (Age in question 1) been told by a doctor that you MIGHT HAVE, or MIGHT BE GETTING diabetes? (IVes [J No [] Yes [J No b. Have you ever had a glucose tolerance test? A glucose tolerance test is a sweet drink followed by one or more blood tests taken the same day. Hand respondent Card NHS-HIS-1(c) 3a. Please look at that card and tell me which of those symptoms you had at the time you first found out that you had diabetes. (Check ‘“Yes’’ or ““No’’ for each symptom listed under ‘“At time of diagnosis’’) 1] ed No Yes No Yes No Thirst. .eeeeeseerseensssenssanssanssanness ’ [| J J —_ Larger appetite than usual. ...ccvvvinnennenss 1 O (I _ Smaller appetite than usual ....... sem 8 1 3 [| 3 Leg pait..cccvsisiess rasan aan cvnnsrrssanens 4 Oa 1. Extreme tiredness........ verevass verses . J - 1 [| Eye ttouble....ceversnrennsnsnnnnnnnssnnnnn [| it) OO J BORING ev vn sassnnmnnnn veonmewmmesnamnsmenie [| [| [| 4 Sudden weakness (associated with trembling, shakiness, and cold sweats). coeeueaneennnns e OO = OO _ Loss of weight....... ses eee tesssasrreeesans ci 3 — J Frequent urination «..eeeeeeeeessceccennacens Ta 3 i 3 Boils or carbuncles ...... www wean Bowmore 3 — (I b. Please look at the card again. Did any of those symptoms bother you at any time during the past 30 days? [No Which symptoms did you have? (Check each ““Yes’’ or ‘“No’’ under ‘‘Present during past month’’) NOTE TO INTERVIEWER When the respondent mentions one or more symptoms, check the ow ” Yes” box for each symptom mentioned and then ask ‘Any others?'’ Continue to ask until an answer of ''No’’ is given. Either the **Yes’’ or *'No’’ box must be checked for each symptom. 4a. Were you in the hospital at the time the doctor found out that you had diabetes? [C1 Yes [C1 No (Go to question 5) b. Were you there because you had symptoms of diabetes? [J Yes (Go to [1 No(Go to question 6a) question 6a) As an inpatient FORM NHS-HIS-1(d) (FY-1965) (4-27-64) 105 QUESTIONS DEFINITIONS (Ask only if ‘““No’’ in question 4a) 5. At the time your diabetes was first discovered, were you sent to the hospital for regulation of your As an inpatient c. Have you ever been hospitalized -- (Ask all 4 parts) -- for diabetic coma?......civuieieneecnsasecnanss[] Yes --for insulin reaction? .ccceteciiaiaitaicecacececes[] Yes --for gangrene? ....cciieiciiiiiietiiiitnceneieee[] Yes -- for regulation? cuuerniiuiiiaiiniaiiiieie senees[T] Yes diabetes? [] Yes [No 6a. (Not counting that first time) Have you ever been Poopiraieed baceorve of your diabetes? [] Yes [CJ No (Go to question 7a) b. About how many times? Number [CJ No [No [J No [J No Estimate acceptable. Several reasons may be given for any single hospital stay. 7a. Have you ever had a nurse come to your home to help you in taking care of your diabetes? [J Yes [CJ No(go to question 7c) b. About how many times has she visited you during the past 12 months? Number [J] None c. Where do you usually go for care of your diabetes -- a clinic; a doctor's office; or some other place? [] Clinic [] Doctor's office [] Some other place (Specity) d. Does the doctor you go to for your diabetes SPECIALIZE in the treatment of diabetes? [] Yes [CINo e. How long have you been going to him [J Less than for your diabetes Years one year 8a. How many brothers and sisters have you had nie living or dead? Number [J None (Go to question 8c) b. Did any of these brothers or sisters have diabetes Number [] None c. Did your mother have diabetes? [] Yes [I No d. Did your father have diabetes? [] Yes [J No (If “‘ever married,’’ ask) — 9a. How many children have you ever had? Exclude stepchildren, adopted children, and Number J None (Gaus foster children (If number entered in question 9a, ask) — 4. 7. Accept estimate, b. How much did each of your children N weigh at birth - - starting with the 2. 5. 8. enter answer in pounds oldest? and ounces. If pounds only are given, 3 6. 9- this is acceptable (If ““1’’ or more in question 9a, ask) — c. Did any of your children have diabetes? Number [] None 106 USCOMM-DC 25036 P-64 QUESTIONS DEFINITIONS 10a. Have you ever taken insulin injections? [C] Yes [CJ No(Go to Question 14) b. How many years have you taken Round to nearest whole year. insulin injections? Number OJ Less thay Estimate acceptable. y 4 If the respondent is not takin c. Have you been taking insulin injections daily Insulin at che present time ask: for most of the past 12 months? [J Yes [CI No How many years did you take it?" d. Are you NOW taking insulin injections? [] Yes [J] No(Go to question 14) 11a. What kinds of insulin are you NOTE TO INTERVIEWER now using? i i How was information for 11a and [] Regular, plain, or crystalline 11b obtained? [] Semi-lente [J Globin [CJ NPH (Check all that apply) ] [] Respondent gave information [J Protamine [] Ultra- [J Lente [] Other family members gave zinc lente information [C] Information obtained from . [J Other (Describe) bottle or some other source b. What strength insulin are you [Ju 40 Juso now using? [CC] Other (Specity strength) . Do you usually take your insulin injection before meals? Y J Yes [J No(Go to question 1le, d. Which meals? (Check all that [CJ Breakfast ~~ [] Lunch [J Supper apply and go to question 11f) (Noon) (Evening) e. When do you usually take your insulin? " (Enter time of day and go to question 11f) Time f. If you delay taking your insulin for an hour or more does it make [| Yes [No [J Never delay (Go to you feel sick? question 11h) . When was the last time you y delayed taking Jour insulin for [J boas than [] 2 Seps [CJ Never delay an_hour or more ys * h. Do you inject the insulin yourself? [J Yes(Goto [JNo question 12) Who wiser he insulin? [1 Relative [CJ] Nutse [] Other person (Check all that apply and go to question 13a) 12. Who taught you how to inject the [] Doctor [J Nurse [C1] Relative insulin? (Check appropriate box and ask question 13a) [J Other [C1 Not taught person 130. During the past week, in what [] One arm [] Both arms [1 One leg parts of the body have you been injecting the insulin? [J Both legs [] Abdomen [J Buttocks (Check all that apply) Anywhere else? LI Other pevarniay The “‘past week’’ is the y week ending last Sunday night. b. How are your syringes and [1] Alcohol [J Use disposable needle needles cleaned and sterilized? [1 Boil [1 Use disposable syringe Check all that apply) ¢ [J Other (Specity) 14. Do you usually carry candy or fruit or sugar or similar items with you? [C1 Yes [J No FORM NHS-HIS-1(d) (FY-1968) (4-27-64) 107 108 QUESTIONS DEFINITIONS 150. Do you know what an insulin reaction is? Yes [CJ No (Go to question 17) . Have you ever had an insulin reaction? [J Yes [J No (Go to question 16a) Sudden weakness, trembling, shakiness, cold sweats c. How many insulin reactions have you had during the past 30 days? Number [] None d. About how many have you had during the past 12 months? Number [C] None e. Have you ever used Glucagon? [J Yes JNo [J] Don’t know Glucagon: what it is A drug sometimes used by persons with diabetes 16a. Can an insulin reaction be to counteract insulin caused by too much food? [1 Yes [INo [] Don’t know shock. . Can an insulin reaction be caused by too much exercise? [] Yes [JNo [J Don’t know c. Is an insulin reaction the same as a diabetic coma? [] Yes [No [] Don’t know 17. Can a person with diabetes [1 Yes [INo [] Don’t know exercise as much as other people? 18a. Have you ever taken diabetes pills? [J Yes [C1 No (Go to question 20a) b. How many years have you been taking Nunlber Od [5 than Roundito the nearest | whole year, estimate c. Have you taken them most of the past 12 months? [J Yes [J No acceptable. . If respondent is not taking pills at present d. Are you now taking diabetes pills? [J Yes [CJ No (Go ta time ask: question 20a)] ‘How many years 19a. How many pills do you take each day? Number did you take them? b. Do you usually take your pills before meals? Yes [J No (Go to question 19d) : Breakfast [J Lunch Supper c. Which meals? Cl (Noon) - (Evening) d. If you delay taking your pills for an hour or more does it make you [] Yes [J No [] Never delay feel sick? (Go to question 20a) e. When was the last time you delayed 0 1okcing your pills for an boot or OJ 1555 chen J 30 Says [J Never delay 20a. Do you test your urine for sugar? J Yes [J No (Go to question 21) Testing by person himself or close relative not a physician, pharmacist, etc. oo . What test do you use? [] Benedict's test [] Clinistix [] Testape [] Other (Specify [1 Clinitest NOTE TO INTERVIEWER How was information for 20b obtained? (Check all that apply) [J] Respondent gave information [C1 Other family members gave information [J Information obtained from bottle or some other source USCOMM-DC 25036 P-64 QUESTIONS DEFINITIONS 20c. How many times did you test your urine last week? Number None ‘Last week”’ is the week (If number is entered, go to question 20e) ending last Sunday night y d. When was the last time you tested it? (Enter verbatim) e. Do you write down any of the results of these tests? Yes [J] No(Go to question 20g) This means the record or notes f. Do you show this to your doctor? [] Yes [J No of the results of the tests g- Did you test your urine for anything else besides sugar at any time during the past 12 months? Yes [1 No What did you test it for? 21. About how tall are you? (Feet) (Inches) 22a. About how much do you weigh? — Ponds) b. What is the most you have weighed during the past . . 12 months? (Pounds) Not counting pregnancies c. What is the least you have weighed during the past 12 months? (Pounds) 23a. When you were a youngster were you ever overweight? (Ask this question if person is 25 years old or over (if under 25, go to question 24)) [] Yes [CJ No Youngster is a person 0 —25 years Overweight is weighing more than the person himself or his doctor thinks that he should weigh. b. What is the most you have weighed since you were 25 years old? (Pounds) Not counting pregnancies c. What is the least you have weighed since you were 25 years old? (Pounds) few calories? (Enter first two mentioned) 24. Were either of your parents overweight? [] Yes [No 25a. Who prepares most of your meals? [] Spouse [] Other (specity) (Check one) or other relative [] Self b. Do you or the person who fixes your meals, use any wl recipes prepared for persons with diabetes? [3 Yes CIN 26a. Can you name some foods that can be substituted for meat? (Enter first two mentioned) b. Can you name some drinks which have very Drinks mean non-alcoholic drinks. c. Can you name some vegetables which have very few calories? (Enter first two mentioned) 27a. During the past 30 days have you eaten any pastries? [] Yes [1 No Pastry made with sugar - During the past 30 days have you eaten any candy made with sugar? [] Yes [No FORM NHS-HIS-1(d) (FY-1965) (4-27-64) 109 QUESTIONS DEFINITIONS Y 28. During the past week did you The ‘past week’’ is the --drink any dietetic soft drinks?.cceeeesseeesecees[ | Yes [J No week ending last --eat any dietetic canned fruits? c.ieceieieancenas[] Yes [CJ No Sunday night --use any artifical sweeteners such as saccharin?..[] Yes [CJ No -- eat any other dietetic foods? ceceeceneccneceasss[] Yes [CJ No (If ““Yes,”’ specify below) “‘Dietetic’’ means food specially prepared with little or no sugar 29. How many calories a day are you allowed? Number 0a. H b i diet f Y N Written, typed, or printed 0s toy en given o clet lor your [} Yes - io instruction about food b. Who taught you how to use [] Doctor [J Nurse [] Parent this diet? [] Dietitian or nutritionist 5 Not taught [] Other (Specify) Who gave you the diet? (Enter person’s occupation) c. How long have you had this [JLess [] 3 months [] Over diet? than to one one 3 months year year d. Do you follow this diet? [1 Yes J No Y ‘“Yes'’ means usually or Why? (Go to tion 35a) most of the time e. Is the diet list used as a guide in the [CJYes (Goto [JNo preparation of your meals? question 31a) f. When did you last look at your [] Under J1-6 [] Over 6 ‘‘You’’ means respondent or diet list? 1 month months months person preparing the meals 31a. Does your diet give the size of food portions? CJ Yes [CJ No (Go to ¥ question 32) b. Do you measure, weigh, or : 2 estimate the portions? [J Measure [] Weigh [J Estimate (Check all that apply) 32. Do you have to follow your diet carefully in order to feel well? [] Yes [J No 33a. Do you ever eat away from home? J Yes [CJ No (Go to question 34a) me how many bread exchanges you are allowed each day? (If ““No”’ or “DK, ’’ go to question 35. If number is given, enter it and ask about the remaining food exchanges listed below.) or aumbse in diet each day (If one or more, ask yp How many of these did you have yesterday? How many vegetable exchanges are in your diet?... How many fruit exchanges are in your diet? .,..... How many milk exchanges are in your diet? ..c.cc0s How many meat exchanges are in your diet? sceaes. How many fat exchanges are in your diet?.ccceeeas b. Do you have trouble following » our diet when eating away LY Yes 0 Some: [%e rom home? 34a. Does your diet include a list of food [] Yes No (Go « : exchanges? 1 Rito) 35a) A food exchange list arranges foods in groups b. Without looking at the list can you tell Eater **No," *'DK,"" according to their food values permitting substitu- tion within each group c. Do you have any problems in using your exchange list? What are they? [1 Yes [No (Enter verbatim resp e) 110 USCOMM-DC 25036 P-64 QUESTIONS DEFINITIONS 35a. Here are the covers of three pamphlets. (Show Special Diabetes pamphlets) Have you ever had a copy of any of these pamphlets? J Yes [J No b. Which? (Check all that apply) Oa CB Jc 36a. Were you taught how to take care of your feet [CC] Yes [CINo (Go to to avoid infection? Question 36¢) b. How do you take care of your feet? (Enter verbatim response) . During the past 12 months have you visited a foot doctor? [CC] Yes [1 No Podiatrist or Chiropodi st 37a. Have yeu been to a doctor to have your eyes examined during the past two years? [Yes [J No b. Do you see better in the morning Morni Afi or in the afternoon? [] Morming [J Ahern SHference 38a. If you had a bad cold, would you talk to your doctor? [J Yes [J No b. If you had a skin infection, would you talk to your doctor? [C] Yes [CI No c. If you had thrown-up, would you talk to your doctor? [] Yes CJ No 394. Have you ever attended classes to learn about diabetes? [Yes [CJ No (Go to Y question 40a) b.. Who gave the classes? [] Hospital 3] Clute mans out-patient clinic [CJ] Health department [_] Other (Specify) [C] Diabetes association 40a. Are you a member of a diabetes association or similar group? C1 Yes [J No(Go to J Question 41) b. What is the nome of this group? 41. What are your most difficult problems in caring for your diabetes? (Enter verbatim response) LEAVE “THANK YOU” LETTER AND DEPART FORM NHS-HIS-1(d) (FY-1968) (4-27-64) USCOMM-DC 25036 P-64 111 HYPERTENSION: CY 1974 Person number 1[C) SP under 17 (Medical Care Page) HYPERTENSION PAGE H P1 2[T] Eligible resp. avail. (1) (SAMPLE PERSONS ONLY) 3 [] Return call required —— a ———" (Next Hypertension Page) lo, Have you EVER been old by o doctor hot you hed igh blood pressered oo eens LY.) aN] b. Another name for high blood pressure is hypertension. Have you EVER been told by a doctor that you had hypertension? _______________________________________________|_ J NT. 1... S_. c. About how long ago were you FIRST told by a doctor that you had (high blood 000 [7] Less than | month pressure/hypertension)? \ — Months 2 Years 2, During the past 12 months about how many times have you seen or talked to a Virmes doctor about your (high blood pressure/hypertension)? 000 [] None 3. Has a doctor EVER advised you to lose weight BECAUSE OF (HIGH BLOOD PRESSURE/HYPERTENSION)? vy 2 N 4a. Do you now use more salt, less salt, or about the same amount of salt since 1 [J More you learned you had (high blood pressure/hypertension)? 2[] Less EAR Se Er REE BLADE emesis 0. Were you EVER advised by a doctor, nurse, or other medical person to use less salt? ry 2 N S0. Has a doctor EVER prescribed medicine for your (high blood pressure/hypertension)? | CPTI, %.. 1. EA b. Are you now taking any medicine prescribed by a doctor for your (high blood presture/hypertension? LL meen] LY smn mien c. How often are you supposed to take this medicine — more than once a day, once a day, 1 [J More than once a day or less than once a day? 27] Once a day SjLesstanonceadsy 000000] d. How often do you take your medicine when you are supposed to — all the time, often, 1 [CJ All the time once in a while, or never? 2] Often 3[] Once in a while 0] Never [C] Other (Specity) ¥ f. Why did you stop taking the medicine? Any other reason? 1 [[] Doctor's advice (5h) 2["] No longer has high blood pressure 3 [C] Side effects [C] Other (Specity) ¥ Mark all that apply v If “*Side effects’’ in 5f, go to 6; otherwise ask: h. When you were taking this medicine did it cause any side effects or make you feel funny in any way? 1Y 2 N 112 6. ABOUT how many days during the past 12 months has (high blood pressure/hypertension) kept you in bed all or most of the day? Days 000 [T] None If ““No longer has high blood pressure’” in 5f, go to 7d; otherwise ask: 7a. How often does your (high blood pressure/hypertension) bother you — all the time, often, once in a while, or never? o a 3 = a ° ° “w o ° 2 g ° S ~< ° = o 8 a ~ ° c o ° = a 2 a a o 1 [[] Great deal 2[] Some 3[] Very little [] Other (Specity) FZ If “All the time” in 7a, go to 8; otherwise ask: c. Do you still have (high blood pressure/hypertension)? 1Y (8) 2 N SDK d. Is this condition completely cured or is it under control? 1 [7] Cured (10) 2] Under control 8. Can you tell when your blood pressure is high — that is, do you have any symptoms? 1Y 2 N 9. Have you ever been refused life insurance or health insurance coverage because you had (high blood pressure/hypertension)? ry 2 N 10a. Has a doctor EVER talked to you about problems that can be caused by high blood Sp A pressure or hypertension? | 'Y(MHP) 2 ro ee or a ti b. Has a nurse or other medical person EVER talked to you about problems that can be caused by high blood pressure or hypertension? 1y 2 N (HP2) . What type of medical person was this? 0 1 [J] Nurse [] Other (Specity) ¥ [] No 2-week DV in CI (11) H P2 Refer to THIS PERSON'S doctor visit columns. [] 2-week DV in a} If ““Y’" in 7a in ANY column, go to |4; otherwise goto ll. 11. ABOUT how long has it been since you LAST had your blood pressure taken? 998 [| Never (16) 000 [] Less than | month 1 Months 2_______ Years (16) 12. Who took your blood pressure the LAST time? 1 [] Doctor 2[] Nurse 3[] Friend or relative 4[] Druggist 5] Self (13b) [C] Other (Specify) = 13a. Were you told that your reading was high, low, normal, or were you not told? b. Was your reading high, low, or normal? 1] High 2] Low 3 [7] Normal 4] Not told (14) [] Other (Specify) Z (15) 14. During the past 12 months, have you taken your own blood pressure? 15. During the past 12 months, how many times was your blood pressure taken? (Do not count times while a patient in a hospital.) Times 113 16a. ABOUT how long has it been since you had an electrocardiogram, which involves 98 [] Never placing wires on the chest and arms? 00 [] Less than | year Years b. ABOUT how long has it been since you had a chest X-ray? 98 [] Never 00 [] Less than | year Years 17a. ABOUT how much do you weigh? Pounds b. ABOUT how tall are you? Feet Inches c. Do you consider yourself overweight, underweight, or just about right? 1 [[] Overweight 2 [] Underweight (18) 3 [] About right (17e) d. Are you now trying to lose weight? rY (171) 2 N ®. Are you now trying to keep from goiningweight? iy ZN 09) f. 15 this based on advice from u doctor, nurse, or other medicol person? 13 = 9. What are you doing to (lose/control your) weight — watching what you eat, 1 [[] Diet exercising, or something else? Anything else? 2] Exercise 3 [] Medication A [7] Other (Specity) > Mark all that apply 18. Have you EVER been told by a doctor that you had diabetes? ry 2 N 19. Have you EVER been told by a doctor that you had heart trouble? 1Y 2 N 20. Have you EVER had a stroke? 1Yy 2 N 21a. Have you smoked at least 100 cigarettes in your entire life? iY 2 N (Medical Care Page) b. Do you smoke cigarettes now? 1Y 2 N (21e) c. On the average, ABOUT how many cigarettes a day do you smoke? ed cisarenes d. Have you EVER tried to stop smoking? 'y 2N e. Have you EVER been advised by a doctor to stop smoking? 1y 2 N (Medical Care Page) f. Was this because of a specific condition you had at that time? iy 2 N fuaiical Care age, g. What condition was it? h. Any other condition? Y (Reask 21g) N FOOTNOTES 114 MEDICAL CARE AVAILABILITY: CY 1974 MEDICAL CARE PAGE (SAMPLE PERSONS ONLY) Person number 1. Is there ONE particular doctor or place ~~ usually goes to when he is sick or when ou need advice about his health? 1y 2 N (17) 20. Where do you go for this care or advice for ——, to a clinic, hospital, doctor's office, or some other place? If Hospital: Is this an outpatient clinic or the emergency room? If Clinic: Is this a hospital outpatient clinic, a company clinic, or some other kind of clinic? 1 [[] Private doctor's office (5) 2 [J] Home (5) 3 [] Doctor's clinic (2b) 4] Group practice s [_] Hospital Outpatient Clinic 6 [|] Hospital Emergency Room 7 [_] Company or Industry Clinic (3) [C] Other (Specity) 2 b. Is this a group practice clinic — that 5, dows it consist oi three or more doctors who share the same equipment? ry 2 N 9 DK 3a. What is the name of this (place) ? b. During the past 12 months, that is, since (date) a year ago, how many fimes did | TTT TTT TTTTTTTooomoomooood you see or talk to a doctor at this place about —=? Visits 000 [] None c. If something bothered you about —~'s health, would you first go to (name of place) , or would you try to determine what was wrong and go to the type of place most appropriate for this kind of trouble? 1 [[] Go to regular place first 2] Select most appropriate place [C] Other (Specity) = b. Is this doctor a general practitioner or a specialist? 01 [T] General practitioner (M7) [C] Specialist — What kind of specialist is he? (M1) 5a. What is the name of this doctor? b. During the past 12 months, that is, since _(date) a year ago, how many times did you see or talk to (name of doctor) ebowt--? ~ ~~ ~~ c. Is this doctor part of a group practice — that is, does he work with two or more other doctors and share the same equipment? [7] 2+ Doctors (2b) 1yY 2 N 9 DK 6. Is this doctor a general practitioner or a specialist? 01 [_] General practitioner [C] Specialist — What kind of specialist is he? 115 7. If something bothered you about —='s health, would you first go to _ (name of doctor) _, or 1 [7] Go to regular doctor first would you try to determine what was wrong and select the most appropriate specialist? 2 [7] Select most appropriate specialist [] Other (Specify) 7 M 1 Refer to ‘‘12 Mo. DV’ box at top of person’s column and mark as appropriate: 1 [] 12-month DV (8) 2] No 12-month DV (17) 8a. (Besides _name of doctor _) During the past 12 months has —— seen a (any other) doctor ot a private doctor's office? | YEN 1 [7] One . . _ n , uD b. During that period, how many (other) doctors has seen at a private doctor's office? Doctors (60) c. Did _(name of doctor/place) EVER refer —— to this doctor? 1Y (9) 2 N (9) d. Did _(name of doctor/place) EVER refer —— to ANY of these other doctors? 1yY 2 N (9) e. Did _(name of doctor/place) refer —— to ALL of these other doctors? 1yY 2 N Did _(name of doctor/place) refer him to this place? 9. During the past 12 months has —— seen a doctor at (any of the 4D) following places) — a. (A/any other) hospital emergency room? 1Y (Col. 1) 2 N (9b) TY 2 N b. (A/any other) hospital outpatient clinic? 1Y (Col. 1) 2 N (9) 1yY 2 N c. (A/any other) company or industry clinic? 1Y (Col. 1) 2 N (9d) 1Y 2 N d. (A/any other) public health clinic? 1Y (Col. 1) 2 N (9) ty 2 e. (A/any other) neighborhood health center? © ly (Col. 7 - ZN (10) 1 y 2 N - 10a. During the past 12 months has —— seen a doctor at any other type of place? (Do not include doctors seen while a patient in a hospital.) 1Y 2 N (14) b. What type of place was this? | Typeof place |] 1Y (Reask 10a) (Col. 1) 2 N | Typeofplace | NT 1 Y (Reask 10a) (Col. 1) 2 N 116 11. Many people do not have ONE particular doctor. (Hand Card D) Which of those statements best describes why you don't have one particular doctor or place for medical care for —-? I 2 3 Other (Specify) M2 Refer to ‘12 Mo. DV’’ box at top of person's column and mark as appropriate: 1 [J 12 Month DV (12) 2] No 12 Month DV (17) 12. During the past 12 months, has —— seen a doctor at any of the following places — Bh PINE BONS BBY eee tee me eed Xe eer 4. b. A hospital emergency room? ry 2 N c. A hospital outpatient clinic? 1yY 2 N d. A company or industry clinic? ry 2 N _ e. A public health clinic? ry 7 dN f. A neighborhood health center? 1yY 2 N 13a. During the past 12 months, has —— seen a doctor at any other type of place? (Do not include doctors seen while a patient in a hospital.) 1 Y 2 N (14) b. What type of place was this? Type of place (Reask 13a) 14. During the past 12 months did you get medical advice for —— from ANY doctor over the telephone? 15. During the past 12 months has ANY doctor come to your home to give —— medical care? 1Y 2 N Hand Card H 16a. During the past 12 months, which of those sources paid any part of —='s doctor bills? If ““I"" is circled in 16a, go to 17; otherwise ask: c. During the past 12 months, did you or your family pay any part of —='s doctor bills? I 23 456789 10 Other (Specify) 117 During the past 12 During the past 12 months, did this months, did this problem problem ever DELAY you in ever PREVENT you from 17. During the past 12 months, have you had any problems getting medical care getting medical care getting medical care for —— (for any of the following for —-? OF we? reasons) — (1) (2) a. Because no doctor was available when you needed one? 1 Y (Col.1) 2 N (17b) ry 2 N ry 2 N b. Because of how much it cost? 1 Y (Col.1) 2 N (17c) vy 2 N ry 2 N c. Because you didn't know where to go? 1Y (Col.1) 2 N (17d) 1Y 2 N 1Y 2 N d. Because you didn’t have a way to get to the doctor? VY (Col.1) 2 N (17e) 1Y aN YY dN | e. Because the office hours weren't convenient? 1 Y (Col.7) 2 N (18) 1Y 2 N ry 2 N 18. During the past 12 months, have you had any problem getting an appointment for —— as soon as you felt he needed one? 1 Y (Col.1) 2 N (19) I 2 N VY 2 N 19a. During the past 12 months, have you had any other problem getting medical care for —=? 1Y 2 N (20) b. What problem did you have? CTT rrr Cy NTT 1 Y 2 N } (Reask 19a) rm (Col. 1) he 1 TY 2 N } (Reask 19a) (col. 1) 2 20a. In general do you feel —~ is getting as much medical care as he needs? 1Y (21) 2 N ee oA A AS TB cm 75m aR ER RR RE Lc me ee rr Hand Card M I 2 3 4 5 b. Which of those statements describes why —— isn't getting enough medical care? A Any other reason? Circle all reasons given 21. During the past 12 months, has —— received any services from any of the following persons — a. A chiropractor? ry 2 N | oom me Amt 8 A eo 8 JG some mmm ew ef pe SEI b. An optometrist? 1Y 2 N c. A podiatrist or chiropodist? TY 2 N d. A physical therapist? 1Y 2 N Show who responded for the Hypertension and Medical Care Pages. 1 [CJ Responded for self R M | Person was respondent RESPONDENT If other than self respondent, give reason for accepting a proxy. 0 [7] Under 17 1 [[] Mentally incompetent 2 [] Physically incompetent 118 MOTOR VEHICLE ACCIDENTS: CY 1968 Budget Bureau No. 685-66048, Approval Expires March 31, 1969 NOTICE - All information which would permit identification of the indi- vidual will be held in strict confidence, will be used only by persons en- gaged in and for the purposes of the survey, and will not be disclosed or released to others for any purposes. Form NHS-MIS-3 (1968) (1-18-60) U.S. DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS ACTING AS COLLECTING AGENT FOR THE 1. PSU U.S. PUBLIC HEALTH SERVICE U.S. HEALTH INTERVIEW SURVEY MOTOR VEHICLE ACCIDENT SUPPLEMENT 4. Semple sumber 15. B- Book — of books BEGIN SUPPLEMENT WITH QUESTION 1 ON PAGE 2 2. Segment number | 3. Serial number 21a. What was the main purpose of the trip — working, going to or from work, or some 2la.| 1 [] Working 22) other purpose? 2[] Going to or from work 3[] Other (b) b. What was the purpose? b. Record verbatim response 22a. Did the accident happen on the road, on the shoulder of the road or somewhere else? 22a. 1[] On road c) 2[_] On shoulder i 3] Other (b) b. c. Did this accident happen within an intersection? i c.| []Yes (ad 1[JNo (23) |” ~ 0. Did the intersection have a traffic control, such as a policeman, o traffic light, Taf TTT TTTTT TTT a stop or yield sign or something else? [JYes ce) 2[]No (23) o. What kind of traffic control was it? e.[ 3[] Policeman 4[] Traffic light s [_] Stop sign 6] Yield sign Check all that apply 7 [] Other (Specify) 23a. Did the accident happen during daylight, dusk, dark, or dawn? 23a.| 1 [_] Daylight 2[] Dusk 3[] Dark 4[_] Dawn b. About what time was it? b. AM. 0 [J Midnight P.M. 4] Noon 24. Did the accident happen in a residential or business district, in the open country, 24. | 1[J Residential 2] Business or somewhere else? 3] Open country 4] Other (Specify) 25. What was the condition of the road at the time of the accident; was it wet, 25. [1[JWet 2[]Dry 3[Jley dry, icy or something else? 4] Other (Specify) 26. What was the weather like at the time of the accident; was it clear, rainy, foggy, 26. | 1[JClear 2[ Foggy 3[_]Cloudy snowy, cloudy, or something else? 4[ J Rainy 5[]Snowy 6 [_] Other (Specify) 27. About how many miles from home did the accident happen? 27. | 0[] Less than 1 mile Miles WASHINGTON USE 119 COMPLETE A SEPARATE COLUMN FOR EACH PERSON INVOLVED IN THIS ACCIDENT Person number Age Enter the person number, age and name —————» Record the date of the accident below. You said that = = (and —~ were) Month Day Year Name of person 1 | was in a motor vehicle accident on (date). | | Interviewer: Check one box - Number of related persons in household in accident . . . [J 1 person (1b) la. Were they in the same accident? [| Yes (1b) [] 2+ persons (1a) (| No (Fill separate supplement for each different accident) oo . Besides —— was anyone else in the family in this accident? [No (2-4 for each [Yes (Fill column for each person listed) person and reask b) 2a. Was = = hurt or injured in any way in this accident? b. At the time of the accident, what part of his body was hurt? c. What kind of injury was it? d. Did —- have any other injuries in this accident? 1 [J Injured (26) 2] Not injured (3) 3a. Did =~ ever see or talk to a doctor because of this injury (accident)? b. How long after the accident did —— see the doctor? If less than 1 hour, enter number of minutes. 4a. Did the (injury from this) accident keep —— in bed all or most of a day? b. How many days did the (injury from this) accident keep —— in bed all or most of the day c. Even though —— didn’t have to remain in bed, did this injury (accident) cause him to cut down on the things he usually does for as much as a day? d. In total, how many days did —— have to cut down on the things he usually does for as much as a day? If 6 — 16 years of age, ask: e. How many days did the injury (accident) keep —— from school? If 17+ years of age, ask: f. How many days did the injury (accident) keep —— from work? (for females, add) not counting work around the house? If “no injury’’ AND 1 or more ‘“‘cut down’’ days, ask: g. What condition caused —— to cut down on the things he usually does? Record verbatim response in appropriate column | Partofbody | _ Kind of injury _ 1. es mir oT Wh omni mio Yes No (3) (Reask b—d) 0 [JYes (b) X0 [No (4) i. mT gs. pw i Si Minutes 1 Hours | Days T 1 1 | | l [CJYes (b) CT JNo (o [J Yes (d) 000 [| No (NP) | Number of cut down days | (e, f, or 8) | 000 [| None (8) Number of work loss days |= ~~~ ~~ 1 [] Related household member injured (6) If “no injuries” were reported, ask: 5a. Even though —= (or your husband, etc.) was not injured, was ANYONE else who was in your vehicle, in another vehicle, or a pedestrian, hurt or injured in any way in this accident? b. Did an ambulance come to the scene of the accident? 2] Yes (6) o[JNo 0[]No J If “No” in 5a, STOP; do not fill remainder of Supplement. 1) ww} If ‘Yes’ in 5a, go to 9. 120 Ask for each injured household member: Did —- receive any first aid treatment or other care at the scene of the accident? What kind of care did he receive? Who provided this care — a doctor, an ambulance attendant, or some other person? o | .| oJ No (NP) bm i] [Yes (b) 1 [] Doctor 2] Ambulance attendant (NP) 3 [] Other person Spacitsly 7a. Did an ambulance come to the scene of the accident? 7a. 1] Yes (b) 0 ]No (8 |b. Did the ambulance take ( ——, —-, etc.) from the | er, scene of the accident? [Yes (o) [CINo (8) c. Who was taken? CT TTT TTT TTTTTTTT TTT ee Mark ‘‘Taken by ambulance’ box in appropriate column for each injured person. c.| [CJ Taken by ambulance Ask for each injured person ‘‘Taken by ambulance’: 1 [7] Hospital ospita d. Where did the ambulance take ——, to a hospital, d. , 5 a doctor's office, home, or some other place? 2[] Doctor's office (NP) 3] Home 4] Some other place Bpecitdy, Ask for each injured person NOT taken by ambulance: 5] Hospital 8. Where did —— go from the scene of the accident — to a 8. 6 D 's offi hospital, a doctor's office, home, or some other place? [J Doctor's office (NP) 7] Home 8 [| Some other place (Specttily Page 4 121 90. How many motor vehicles were involved in this accident? --- [J One (&) [J Two or more (11) — Enter number —1 TTT TT 77 Th. Was the motor vehicle moving af the time of the accident? 0] Yes (11) 1 [J No (10) 10. How did the accident happen? 1 [J Moving (11) 2[_] Caught in door [CJ Non-moving, 3[] Fell getting in or out Fi Cah 4] Injured while repairing vehicle DO NOT fill TE ! s [_] Other (Specify) If 14 years or over ask: [] Outside (12) 11. At the time of the accident, was —— outside the vehicle, getting in or out of it, 11. | 3] Getting in or out (NP) a passenger, or was he the driver? P 13. If under 14 years, ask: [] Passenger (13a) At the time of the accident, was —~ outside the vehicle, getting in or out of it, 4] Driver (13b) or was he a passenger? If motorcycle, go to 14 12. Was —- on foot, on a bicycle or in some other vehicle? 12. [0 [J On foot 1 [] Bicycle (NP) 2] Other (Specity), 13a. Was —- sitting in the front or back seat? e. Was there a shoulder strap or harness where he was sitting? 13a J 1] Yes (d) [I No (ce) 4] Motorcycle (14) T2Yes@ ~~ s[Ne(@ | {s[] Yes (NP) [CINo (& 4 me er mr mr — _——————————— 16] Yes (NP) 7[_]No (NP) {| 5] Front (b) 6 [| Back (b) 7 [_] Motorcycle (14) 8 [_] Other ll a If on a motorcycle, ask: 14, Was —- wearing a helmet at the time of the accident? 1] Yes 2[ No WASHINGTON USE INTERVIEWER CHECK BOX | Refer to questions 9 and 11 and check the appropriate box below: [J One motor vehicle with 1 or more family members inside (19) [C] Two or more motor vehicles with 1 or more family members inside (16) [J] All family members outside motor vehicle (15) 122 If all related household members outside motor vehicle, ask: Year 4 Hake | 15a. What was the year and make of the motor vehicle involved? 15a. | om: ol 1. TS ST SLI Bl. ems mi mom mar oir. seredi i 1 b. Was it a sedan, a convertible, a hardtop, a station wagon, b.|0 [] Sedan 1 [_] Convertible or some other type of motor vehicle 2] Hardtop 3] Station wagon If truck, determine type: pickup, dump, etc. 4] Other (Specify) ¢. In what State was this vehicle registered? c.| State (22) If inside, and 2 or more motor vehicles, ask: 16a. Was the motor vehicle ~~ was (they were) in moving at the time of the accident? 16a. 1 [] Yes(c) [CINo (B) b. Was it moving the instant before the accident happened? b. 2] Yes(c) 3[JNo(c) 7 |” “c. Was the other vehicle moving of the time of the accident? TTT T~ 1 COvesan™ ~~~" Ne ~~" d. Was the other vehicle moving the instant before the accident happened? d.|2[] Yes (17) 3[JNo(17) To Hand respondent motor vehicle flash card— Family member motor vehicle 17a. Assunin this is thy mae vehicle ~= was in, in what lettered 17a. 1[JA 2[]B 3[]cC a[]D area of the motor vehicle did the impact occur s[]E s[(JF 70]¢ 8 H ee rh gio SE SO 8 Er Stree een een = TS TD JIE _eUIF [16 el CH b. In what lettered area of the other motor vehicle did the impact occur? b. Other motor vehicle CJA 2038 s[3C «JD sCJE s(JF 70J¢ s(n (18) T 18a. What was the year and make of the other motor vehicle involved? 18a. Year | Make | | fo 0. see sum sm, eS, SA Si A i oe] _ 1 b. Was it a sedan, a convertible, a hardtop, a station wagon b.[|0 [] Sedan 1 [J Convertible or some other type of motor vehicle? 2] Hardtop 3[] Station wagon 4] Other (Specify) ¢. In what State was this vehicle registered? c.| State (20) If inside and 1 motor vehicle, ask: 1 [] Collision with object (c) 19a. How did the accident happen; was it a collision with some other 19a object or did it happen in some other way [1 Other way (5) Ee — b. How did the accident happen? TT TW) Tamedover "3 "77 3] Sudden stop — No collision % (20) 4] Other (Specify) y c. What type of object was it? c.| Object (20) 20a. What was the year and make of motor vehicle —— was (they were) in? 200} Year : Make | I oe om i a SRR Fs TTR SHI Rl RRR, wl, ost, rtm mo SRT TE | _ | b. Was it a sedan, a convertible, a hardtop, a station wagon, b.| 0 [] Sedan 1 [] Convertible or some other type of motor vehicle 2 [J Hardtop 3 [] Station wagon If truck, determine type: pickup, dump, etc. 4] Other (Specify) c. In what State was this vehicle registered? c.| State d. In terms of dollars, about how much damage was a TTT TTT TT one to the motor vehicle —— was (they were) in? $ CONTINUE WITH QUESTION 21 ON PAGE 1 GPO : 1068 O - 288-696 123 124 [C] 25t years (NP) [[] 5-24 years (13) [] Under 5 years (NP) 130. | 1 00 . b i 00 [_] None (NP) Y 2 N (14) [J None (NP) Number of visits c. c Number of visits If one or more v in ll sk; otherwise, go to NP, d. How many of these orthodontic visits were included in the —— dental visits —— had during the past 2 weeks 00 [J Nene NP that you told me about earlier? d. Number of visits 14a. Do you think —='s teeth need to be straightened? ldo. | 1 Y 2 N b.| 1 Y 2 N : otherwise, go to NP. | 2 3 45678 c. We are interested in the various reasons why people do not have their teeth straightened when they need = this type of care. (Hand Card 0) Other (Specify) Which of those statements describes why —— is not NOW receiving this care? A Any sther reason? ee Circle all reasons given v Mark box or ask: 00 [] Only one reason d. What is the MAIN reason —— is not NOW receiving this care? dl 1 23 45678 Other (Specify) PREGNANCY INTERVIEWER [CO] No Females 17-44 yrs, old (Next page) CHECK ITEM: [C] + Females 17-44 yrs. old (1) la. During the past 12 months, has anyone in the family been pregnant or had a miscarriage? Y N (Next page) b. Who is this? Mark ‘‘Was pregnant’ box in person's column. 1b. Y (Reask N Ib and ¢) c. During the past 12 months, has anyone else in the family been pregnant or had a miscarriage? [C] Was pregnant TE Ga A — a If *‘Was pregnant,’’ ask: 2a. Is == now pregnant? 2a. (Not counting —="s current pregnancy) b. During the past 12 months, how many times has —- been pregnant, including miscarriages? b. (Not counting s current pregnancy) c. How many times has == EVER been pregnant, including miscarriages? & d. How many of these —— pregnancies resulted in live births? d. 01 [] Once (NP) Pregnancies PTR Pre ee Ce RA Sere I Sein 00 [| None (NP) Live births (NP) TABLE P: Complete a line of Table P for each terminated pregnancy reported in Q. 2b. If no terminated pregnancies reported, go to next page. Did —-'s (last pregnancy /pregnancy before Did she see a doctor [How many months About how many visits |Did a doctor ever tell Person that) end in a full-term live birth, a premature [at any time during pregnant was —— did —~ make to a ~~ to remain in bed Number live birth, a miscarriage, or what? that pregnancy? when she first saw doctor BEFORE that [for two weeks or more a doctor? pregnancy ended? during that pregnancy? (a) (b) (c) (d) (e) (f) 1+ [J Full term 2 [] Premature 3 [[] Miscarriage ry I § « [7] Stillbirth s [] Abortion 2 N (g) ——Months Visits 2 N 6 [] Other — Specify. TABLE P — Continued How many months pregnant was —— Did —- have a check- up a month or two How long has it been since that pregnancy Does ~~ intend to have a check-up for NOTES Months 2 N when that pregnancy | after that pregnancy ended? that pregnancy? ended? ended? (2) (h) (i) 1 Y (NP) 1[] Less than 2 months 2[T] 2+ months (NP) PREVENTIVE CARE: CY 1973 S1 | o[TINot SP (NP) 1 [TJ Eligible resp. avail. (S52) 2 [7] Return call required (NP) PREVENTIVE CARE $2 [140+ years (1) [C] 17-39 years (3) [(]3=16 years (7) [C]Under 3 years (8) 1. About how long has it been since —— had an electrocardiogram, or EKG, which involves 1. | 98] Never placing wires on the chest and arms? 00 [] Less than | year Years 2. About how long has it been since —= had a test for glaucoma - this is sometimes 2. | 98] Never referred to as an eye pressure test? 00 [7] Less than | year Years 3. About how long has it been since —— had a chest X-ray? 3. | 98 [7] Never 00 [] Less than | year Years 4a. Does —— have eyeglasses or contact lenses? 4a. 1Y 2 N b. About how long has it been since —~ had his eyes examined to see if he needed (new) glasses? b. | 98 [T] Never 00 [] Less than | year Years Ask only of FEMALES 17+ years of age; otherwise, go to next person. 5. | 98] Never 5. About how long has it been since —— had a Pap smear test for cancer? 00 [TJ Less than | year Years 6. About how long has it been since —- had a breast examination by a doctor? 6. | 98 [ | Never 00 [7] Less than | year (NP) Years 7a. Does —~ have eyeglasses or contact lenses? 7a. b. About how long has it been since —~ had his eyes examined to see if he needed (new) glasses? b. | 98 [T] Never (Include any eye exams given in school.) 00 [T] Less than | year Years 8a. During the past 12 months, was —~ taken to a doctor for a ROUTINE physical examination, 8a. that is, not for a particular illness but for a general checkup? TY (9) 2 N b. About how long has it been since ~~ was faken fo a doctor for a routine physical examination Cb | sa INever or general checkup? - Years 9. About how old was —— when you FIRST took him to a dentist? 9. | 98] Never Years old 125 SPECIALISTS’ SERVICES! AND ROUTINE CHECKUPS: FY 1964 If any children under 17 years in household, ask: ( 1 ) 22. DURING THE PAST 12 MONTHS was-- (were --, - -, etc.) taken to a doctor for a ROUTINE physical examination, that is, not for a particular illness but for a general check-up? [1] 17 years or over If “Yes,” and more than one child under 17 years, ask: (a) Who wos this? 0 Yes CI Ne (b) Any of the other children? 23. DURING THE PAST 12 MONTHS has ANYONE in the family — that is, you, your =, efc., — received any ¥ (Mark (X) Specialist) | Times services from ony of the persons listed on this card? Please check ““Yes'’ or ‘*No'’ for each one listed. Pediatrician A Hand respondent pencil and card (NHS-HIS-1(a)) Obstetrician or For each "Yes" box checked on the card, ask: Gynecologist B (a) Who saw the (specialist)? (Mark (X) for each specialist in person's column.) Ophthalmologist C (b) About how many times did you see a (specialist) during the past 12 months (not counting Otolaryngologist | D any visits while you were in the hospital)? —— tai 12 ns? Psychiatrist E (c) Did anyone else see a (specialist) during the past 12 months Dermatologist ~ «“ "ok 3 If “Yes," ask: or roy G (d) Who was this? Chiropractor H (e) About how many times did you see a (specialist) during the past 12 months (not counting - T any visits while you were in the hospital)? Optometrist Podiatrist or Check the ‘“None’’ box for each person who did not see a specialist. Chiropodist J [J None ! Beginning in July 1966, information on specialists’ services has been elicited by a single question on the doctor visits page, thus becoming a continuing item as of that date. 000 126 APPENDIX lI DEFINITIONS OF CERTAIN TERMS USED IN THE HEALTH INTERVIEW SURVEY’ Terms Relating to Conditions Condition.—A morbidity condition, or simply a condition, is any entry on the questionnaire that describes a departure from a state of physical or mental well-being. It results from a positive response to one of a series of “medical-disability impact” or “illness-recall” questions. In the coding and tabulating process conditions are selected or classified according to a number of different criteria such as whether they were medically attended, whether they resulted in disability, or whether they were acute or chornic; or according to the type of disease, injury, impairment, or symptom reported. For the purposes of each published report or set of tables, only those conditions recorded on the questionnaire that satisfy cer- tain stated criteria are included. Conditions except impairments are classified by type according to the Eighth Revision of the International Classification of Diseases, Adapted for Use in the United States, with certain modifications adopted to make the code more suitable for a household interview survey. Acute condition.—An acute condition is de- fined as a condition that has lasted less than 3 months and that has involved either medical attention or restricted activity. Because of the bThe definitions shown in this report are those used in CY 1973 reports. Some of the definitions have been modified through the years to improve clarity and to reflect minor methodological changes. NOTE—-A list of references follows the text. procedures used to estimate incidence, the acute conditions included in this report are the conditions that had their onset during the 2 weeks prior to the interview week and that involved either medical attention or restricted activity during that 2-week period. However, certain conditions are always classified as chronic regardless of onset (see list under the definition of chronic condition). Acute condition groups.—In this report all tables that have data classified by type of condition employ a five-category regrouping plus several selected subgroups (Table I). Chronic condition.—A condition is con- sidered chronic if (1) the condition is described by the respondent as having been first noticed more than 3 months bef ore the week of the interview or (2) it is one of the conditions listed below that are always considered chronic regardless of the date of onset. Allergy, any Arthritis or rheumatism Asthma Cancer Cleft palate Clubfoot Condition present since birth Deafness or serious trouble with hearing Diabetes Epilepsy Hardening of the arteries Hay fever Heart trouble Hemorrhoids or piles Hernia or rupture 127 Table I. Acute condition groups and International Classification code numbers included in each category Condition group International Classification code number Infective and parasitic diseases ..........covivieinennnnnnennns Common childhood diseases Virus not otherwise specified ...........cciiiiuieenrnannnns Other infective and parasitic diseases Respiratory CONGItIONS vu coe e vvm s wwe s suis 5 510 4 55500 & Bwin #50 6 $50 5 Upper respiratory conditions Common cold Other upper respiratory conditions Influenza .........cciiiiiiriiiiiiiieennennnsanansnnnnns Influenza with digestive manifestations Otherinfluenza ..........ciiiiiiinnrenerennnnannnnns Other respiratory conditions Pneumonia BrONCRITIS & iain vain « wii » wid # 900 4» 450 § Sale # sli § WIN. 4 ST # Wide # Other respiratory conditions sees sess ses as sess e ness senna. Sess e ssa sacs eases asta sss ese naseeenen tees ses sree s senses tse s ests essseescnns Sees s certs stars ress senses sense Digestive system conditions Dental cONAIIONS «cvs sows vias s sins sods vinim » S008 § G06 406 8 Vike» Functional and symptomatic upper gastrointestinal disorders not elsewhere classifiable sees es errs esate saat tenes Other digestive system conditions INJUNIES titi itei iinet ieeneeennosenesnssnensoanasannnnns Fractures, dislocations, sprains, and strains Fractures and dislocations Sprains and strains ........ccoeeeiiriirtiiiatarataaaas Open wounds and lacerations ...........eeeeveneenaeennans Contusions and superficial injuries Other current injuries AH Other aoUtB CONKILIONS 4uu suv v ssw a svi s mien 550s www» wives in's s Diseases of the ear HEBUACHSS vu» wiv + siete » as 8 0 § Win » WHR 2 WL6E § S008 BOHR § INR 3 WE 8 4 Genitourinary disorders .........ceeeeeenerrnannnenannnnns Deliveries and disorders of pregnancy and the puerperium Diseasesof the skin .........c.ccitiiiiinennernennnannnnnns Diseases of the musculoskeletal system All other acute conditions 000-136 033, 052, 055, 056, 072 079.9 000-032, 034-051, 053, 054, 057-071, 073-136 460-486, 501, 508-516, 519, 783 460-465, 501, 508 460 461-465, 501, 508 470-474 473 470-472,474 466, 480-486, 510-516, 519, 783 480-486 466 510-516, 519, 783 520.6-521.5, 5621.7-5623.9, 525-5630, 5635-543, 6560, 561, 564- 677,784, 785 520.6-521.5, 5621.7-623.9, 526 536, 784.0, 784.1, 784.3, 784.7, 785.4 pt. 526-530, 535, 537, 540-543, 560, 561, 564-577, 784.2, 784.4- 784.6, 785 pt. N800-N870, N872-N884, N890-N894, N900-N994, N996-N999 N800-N848 N800-N839 N840-N848 N870, N872-N884, N890-N894, N900-N907 N910-N929 N850-N869, N930-N994, N996-N999 All other acute code numbers 380-387, 745.0-745.3, 781.3 791 580-629, 786, 789 630-678 680-709 717-733, 787 Other acute code numbers High blood pressure Kidney stones Mental illness Missing fingers, hand, or arm-toes, foot, or leg Palsy Paralysis of any kind Permanent stiffness or deformity of the foot, leg, fingers, arm, or back Prostate trouble Repeated trouble with back or spine Rheumatic fever Serious trouble with seeing, even when wearing glasses 128 Sinus trouble, repeated attacks of Speech defect, any Stomach ulcer Stroke Thyroid trouble or goiter Tuberculosis Tumor, cyst, or growth Varicose veins, trouble with Chronic condition groups.—The 30 condition groups shown in this report and the Inter- national Classification code numbers used are listed in table II. Table II. Chronic condition groups and the International Classification code numbers included in each category Condition causing activity limitation International Classification code number Tuberculosis, all forms Malignant neoplasms Benign and unspecified neoplasms Diabetes Mental and nervous conditions Heart conditions Cerebrovascular disease Hypertension without heart involvement Varicose veins Hemorrhoids Other conditions of circulatory system Chronic bronchitis Emphysema Asthma, with or without hay fever Hay fever, without asthma Chronic sinusitis Other conditions of respiratory system Peptic ulcer Hernia Other conditions of digestive system Diseases of kidney and ureter Other conditions of genitourinary system Arthritis and rheumatism Other musculoskeletal disorders Visual impairments Hearing impairments Paralysis, complete or partial Impairments (except paralysis) of back or spine Impairments (except paralysis and absence) of upper extremities and shoulders Impairments (except paralysis and absence) of lower extremities and hips Condition not specified: Old age Other Impairment.—Impairments are chronic or permanent defects, usually static in nature, resulting from disease, injury, or congenital malformation. They represent decrease or loss of ability to perform various functions, par- ticularly those of the musculoskeletal system and the sense organs. All impairments are classified by means of a special supplementary code for impairments. Hence, code numbers for impairments in the International Classifica tion of Diseases are not used. In the Supple- mentary Code, impairments are grouped according to type of functional impairment and etiology. The impairment classification is shown in Vital and Health Statistics, Series 10, Number 87.19 Prevalence of conditions.—In general, preva- lence of conditions is the estimated number of conditions of a specified type existing at a 010-018 140-209 210-239 250 290-304, 305.0, 305.3, 305.5, 305.6, 306-309, 780.6, 781.5, 785.6, 786.2, 790.0, 790.2 390-398, 402, 404, 410-429, 782.1, 782.2, 782.4 430-438 400, 401, 403 454, 456 455 440-453, 457, 458, 782.0, 782.3, 782.5-.9 490, 491 492 493 507 503 470-486, 500-502, 504-506, 508-519, 783 531-5634 550-553 520.3, 520.4, 520.6-521.5, 521.7-523, 525-530, 535-543, 560- 577, 784, 785.0-785.5, 785.7, 785.8 581-584, 590-5693 594-611, 613-629, 786.0, 786.1, 786.3-786.7, 789 710-716, 717.0,717.1,717.9, 718 720-723, 725, 728-732, 733.0, 733.2, 733.3, 733.6, 733.9, 734 See definition of impairment specified time or the average number existing during a specified interval of time. The preva- lence of chronic conditions is defined as the number of chronic cases reported to be present or assumed to be present at the time of the interview. Those assumed to be present at the time of the interview are cases described by the respondent in terms of one of the diseases on the list of conditions always considered chronic (see definition of chronic condition above) and reported to have been present at some time during the 12-month period prior to the interview. Incidence of conditions.—The incidence of conditions is the estimated number of condi- tions having their onset in a specified time period. As previously mentioned, minor acute conditions involving neither restricted activity nor medical attention are excluded from the 129 statistics. The incidence data shown in some reports are further limited to various subclasses of conditions, such as “incidence of conditions involving bed disability.” Onset of condition.—A condition is con- sidered to have had its onset when it was first noticed. This could be the time the person first felt sick or became injured, or it could be the time when the person or his family was first told by a physician that he had a condition of which he was previously unaware. Persons with chronic conditions.—The esti- mated number of persons with chronic condi- tions is based on the number of persons who at the time of the interview were reported to have one or more chronic conditions. Activity-restricting condition.—An activity- restricting condition is one that had its onset in the past 2 weeks and that caused at least 1 day of restricted activity curing the 2 calendar weeks before the interview week. (See ‘“Re- stricted-activity day” under “Terms Relating to Disability.”) Bed-disabling condition.—A condition with onset in the past 2 weeks involving at least 1 day of bed disability is called a bed-disabling condition. (See ‘“Bed-disability day” under “Terms Relating to Disability.”) Medically attended condition.—A condition with onset in the past 2 weeks is considered medically attended if a physician has been consulted about it either at its onset or at any time thereafter. However, when the first medical attention for a condition does not occur until after the end of the 2-week period, the case is treated as though there was no medical attention. Medical attention includes consultation either in person or by telephone for "treatment or advice. Advice from the physician transmitted to the patient through the nurse is counted as well as visits to physicians in clinics or hospitals. If during the course of a single visit the physician is con- sulted about more than one condition for each of several patients, each condition of each patient is counted as medically attended. Discussions of a child’s condition by the physician and a responsible member of the household are considered as medical attention even if the child was not seen at that time. 130 For the purpose of this definition, the term “physician” includes doctors of medicine and osteopathic physicians. Terms Relating to Disability Disability. —Disability is the general term used to describe any temporary or long-term reduction of a person’s activity as a result of an acute or chornic condition. Disability day.—Short-term disability days are classified according to whether they are days of restricted activity, bed days, hospital days, work-loss days, or school-loss days. All hospital days are, by definition, days of bed disability; all days of bed disability are, by definition, days of restricted activity. The con- verse form of these statements is, of course, not true. Days lost from work and days lost from school are special terms that apply to the working and school-age populations only, but these too are days of restricted activity. Hence, “days of restricted activity” is the most inclu- sive term used to describe disability days. Restricted-activity day.—A day of restricted activity is one on which a person cuts down on his usual activities for the whole of that day because of an illness or an injury. The term “usual activities” for any day means the things that the person would ordinarily do on that day. For children under school age, usual activities depend on whatever the usual pattern is for the child’s day, which will in turn be affected by the age of the child, weather conditions, and so forth. For retired or elderly persons, usual activities might consist of almost no activity, but cutting down on even a small amount for as much as a day would constitute restricted activity. On Sundays or holidays, usual activities are the things the person usually does on such days—going to church, playing golf, visiting friends or relatives, or staying at home and listening to the radio, reading, watching television, and so forth. Persons who have permanently reduced their usual activities because of a chronic condition might not report any restricted-activity days during a 2-week period. Therefore, absence of restricted-activity days does not imply normal health. Restricted activity does not imply complete inactivity, but it does imply only the minimum of usual activities. A special nap for an hour after lunch does not constitute cutting down on usual activities, nor does the elimination of a heavy chore such as cleaning ashes out of the furnace or hanging out the wash. If a farmer or housewife carries on only the minimum of the day’s chores, however, this is a day of restricted activity. A day spent in bed or a day home from work or school because of illness or injury is, of course, a restricted-activity day. Bed-disability day.—A day of bed disability is one on which a person stays in bed for all or most of the day because of a specific illness or injury. All or most of the day is defined as more than half of the daylight hours. All hospital days for inpatients are considered to be days of bed disability even if the patient was not actually in bed at the hospital. Work-loss day.—A day lost from work is a day on which a person did not work at his job or business for at least half of his normal workday because of a specific illness or injury. The number of days lost from work is deter- mined only for persons 17 years of age and over who reported that at any time during the 2-week period covered by the interview they either worked at or had a job or business. (See “Currently employed persons” under ‘‘Demo- graphic Terms.”) School-loss day.—A day lost from school is a normal school day on which a child did not attend school because of a specific illness or injury. The number of days lost from school is determined only for children 6-16 years of age. Person-day.—Person-days of restricted activ- ity, bed disability, and so forth are days of the various forms of disability experienced by any one person. The sum of days for all persons in a group represents an unduplicated count of all days of disability for the group. Condition-day.—Condition-days of restricted activity, bed disability, and so forth are days of the various forms of disability associated with any one condition. Since any particular day of disability may be associated with more than one condition, the sum of days for conditions may add to more than the total number of person-days. Chronic activity limitation.—Persons arc classified into four categories according to the extent to which their activities are limited at present as a result of chronic conditions. Since the usual activities of preschool children, school-age children, housewives, and workers and other persons differ, a different set of criteria is used for each group. There is a general similarity between them, however, as will be seen in the following descriptions of the four categories: 1. Persons unable to carry on major activity for their group (major activity refers to ability to work, keep house, or engage in school or preschool activities). Preschool children: Inability to take part in" ordinary play with other children. School-age children: Inability to go to school. Housewives: Inability to do any housework. Workers and all other persons: Inability to work at a job or business. 2. Persons limited in amount or kind of major activity performed (major activity refers to ability to work, keep house, or engage in school or preschool activities). Preschool children: Limited in amount or kind of play with other children, e.g., need special rest periods, cannot play strenuous games, or cannot play for long periods at a time. School-age children: Limited to certain types of schools or in school attendance, e.g., need special schools or special teaching or cannot go to school full time or for long periods at a time. Housewives: Limited in amount or kind of housework, e.g., cannot lift children, wash or iron, or do housework for long periods at a time. Workers and all other persons: Limited in amount or kind of work, e.g., need special working aids or special rest periods at work, cannot work full time or for long periods at a time, or cannot do strenuous work. 131 8. Persons not limited in major activity but otherwise limited (major activity refers to ability to work, keep house, or engage in school or preschool activities). Preschool children: Not classified in this category. School-age children: Not limited in going to school but limited in participation in athletics or other extra- curricular activities. Housewives: Not limited in housework but limited in other activities such as church, clubs, hobbies, civic projects, or shopping. Workers and all other persons: Not limited in regular work activities but limited in other activities such as church, clubs, hobbies, civic projects, sports, or games. 4. Persons not limited in activities (includes persons whose activities are not limited in any of the ways described above). Chronic mobility limitation.—Persons are classified into the following five categories according to the extent to which their mobility is limited at present as a result of chronic conditions: 1. Stays in bed. Must stay in bed all or most of the time. 2. Stays in the house. Must stay in the house, but not in bed, all or most of the time. 3. Needs help getting around. Able to go out- side but needs the help of another person or of a special aid such as a cane or wheelchair in getting around. 4. Has trouble getting around freely. Does not need the help of another person or a special aid but has trouble in getting around freely. 5.Is not limited in mobility. Not limited in any of the ways described above. Terms Relating to Persons Injured Injury condition.—An injury condition, or simply an injury, is a condition of the type that is classified according to the nature of injury code numbers (N800-N999) in the Inter- national Classification of Diseases. In addition 132 to fractures, lacerations, contusions, burns, and so forth, which are commonly thought of as injuries, this group of codes includes effects of exposure, such as frostbite, adverse reactions to immunization and other medical procedures, and poisonings. Unless otherwise specified, the term “injury” is used to cover all of these. Since a person may sustain more than one injury in a single accident, e.g., a broken leg and laceration of the scalp, the number of injury conditions may exceed the number of persons injured. Statistics of acute injury conditions include only those injuries that involved at least 1 full day of restricted activity or medical attend- ance. Person injured.—A person injured is one who has sustained one or more injuries in an accident or in some type of nonaccidental violence. (See definition of injury condition.) Each time a person is involved in an accident or in nonaccidental violence causing injury that results in at least 1 full day of restricted activity or medical attention, he is included in the statistics as a separate person injured; hence, one person may be included more than once. The number of persons injured is not equiva- lent to the number of accidents for several reasons: (1) the term ‘“‘accident” as commonly used may not involve injury at all, (2) more than one injured person may be involved in a single accident, so the number of accidents resulting in injury would be less than the number of persons injured in accidents, and (3) the term ‘‘accident” ordinarily implies an accidental origin, whereas “persons injured” as used in the Health Interview Survey includes persons whose injuries resulted from certain nonaccidental violence. The number of persons injured in a specified time interval is always equal to or less than the incidence of injury conditions, since one person may incur more than one injury in a single accident. Place of accident.—Persons injured are classi- fied according to the type of place where the injury occurred. 1. Home. The place of accident is considered as “home” if the injury occurred either inside or outside the home but within the property boundaries. “Home” includes not only the person’s own home but also any other home (vacant or occupied) in which he may have been when he was injured. “Home” includes any structure that has the primary function of a dwelling unit and includes the structure and premises of such places as apartment houses and house trailers. Inside the house: Includes any room, attic, cellar, porch, or steps leading to an entrance of the house. However, inside the garage is not con- sidered as inside the house. Outside the house: Includes the yard, driveway, garage, patio, gardens, or walks. On a farm, only the premises adjacent to the house are considered as part of the home. Injuries due to accidents occurring on cultivated land, in barns, or other similar farm buildings would not be considered home injuries. 2. Street or highway. ‘Street or highway” means the entire area between property lines of which any part is open for the use of the public as a matter or right or custom. It includes the roadway, shoulder, curb, or public sidewalk; excluded are private drive- ways, lanes, or sidewalks. 3. Farm. “Farm” as a place of accident refers to accidents occurring in farm buildings or on cultivated land but does not include accidents occurring in the farm home or premises. A ranch is considered a farm. 4. Industrial place. “Industrial place” is the term applied to accidents occurring in an industrial place or on the premises. Included are such places as factories, railway yards, warehouses, workshops, logging camps, shipping piers, oil fields, shipyards, sand and gravel pits, canneries, and auto repair garages. Construction projects such as houses, buildings, bridges, and new roads are included in this category. Buildings under- going remodeling, with the exception of private homes, are classified as industrial places or premises. . School. “School” as a place of accident includes all accidents occurring in school buildings or on the premises. This classifica- tion includes elementary schools, high wt schools, colleges, and trade and business schools. 6. Place of recreation. “Place of recreation” is used to describe accidents occurring in places organized for sports and recreation other than recreational areas located at a place already defined as “home,” “industrial place,” or “school.” Bowling alley, amuse- ment park, football stadium, and dance hall are examples of “place of recreation.” In “place of accident” classification of injuries the place is significant rather than the activity in which the person was engaged at the time of accident. Hence, an injury sus- tained by a person at a dance hall while he was at work is classified as a “place of recreation” injury. Likewise, an injury occurring while a person was engaged in a sport in an industrial place is classified as an “industrial place” injury. 7. Other. Accidents that cannot be classified in any of the above groups or for which the place is unknown are classified as “other.” Included in the classification are such places as restaurants, churches, business and pro- fessional offices, and open or wooded country. Classification of injured persons by activity restriction or medical attendance.—The classifi- cation of injured persons by activity restriction or medical attendance is based on the classi- fication of the injury. (See definitions for activity-restricting injury, bed-disabling injury, work- or schoolloss injury, and medically attended injury.) For example, a person may have received several injuries in a single acci- dent; if one of the injuries involved 1 or more days of restricted activity, 1 or more days in bed, or medical attendance, the person injured would correspondingly be classified as with restricted activity, with bed disability, or medically attended. Activity-restricting ~~ injury.—An activity- restricting injury is an injury that has caused at least 1 day of restricted activity. (See defini- tion of restricted-activity day.) The incidence of activity-restricting injuries is estimated from the number of such injuries reported as having occurred in the 2 weeks before the interview week. For this reason, an injury that did not result in restricted activity until after the end 133 of the 2-week period in which it occurred is not classified as an activity-restricting injury. Bed-disabling injury.—An injury resulting in at least 1 day of bed disability is called a bed-disabling injury. (See also definition of activity-restricting injury.) Work- or school-loss injury.—An injury re- sulting in at least 1 day of work or school loss is called a work-loss injury or a school-loss injury. (See also definition of activity-restrict- ing injury.) Medically attended injury.—An injury for which a physician was consulted is called a medically attended injury. Consulting a physician includes consultation in person or by telephone for treatment or advice. Advice from the physician transmitted to the patient through the nurse is counted as medical con- sultation as well as visits to physicians in clinics or hospitals. If at one visit the physician is consulted about more than one injury for each of several patients, each injury is counted as medically attended. A parent consulting a physician about a child’s injury is counted as medical consulta- tion about that injury even if the child was not seen by the physician at that time. For the purpose of this definition, “physician” includes doctors of medicine and osteopathic physicians. The term “doctor” is used in the interview rather than “physician” because of popular usage. However, the concept toward which all instructions are directed is that which is described here. An injury is counted as medically attended if a physician was consulted about it at its onset or at any time thereafter. However, the first medical attention for an injury that was experienced during the 2-week period prior to the household interview may not occur until after the interview. Such cases are treated as though there was no medical attention. An injury is counted as medically attended if a physician was consulted about it at its onset or at any time thereafter. However, the first medical attention for an injury that was experienced during the 2-week period prior to the household interview may not occur until after the end of the 2-week period. Such cases are treated as though there was no medical attention. 134 Terms Relating to Class of Accident Class of accident.—Injuries, injured persons, and resulting days of disability may be grouped according to class of accident. This is a broad classification of the types of events that re- sulted in personal injuries. Most of these events are accidents in the usual sense of the word, but some are other kinds of mishap, such as overexposure to the sun or adverse reactions to medical procedures, and others are nonacci- dental violence, such as attempted suicide. The classes of accident are (1) moving motor vehicle accidents, (2) accidents occurring while at work, (3) home accidents, and (4) other accidents. These categories are not mutually exclusive. For example, a person may be injured in a moving motor vehicle accident that occurred while the person was at home or at work. The accident class ‘moving motor vehicle” includes ‘“home-moving motor vehicle” and “while at work-moving motor vehicle.” Similarly, the classes “while at work” and “home” include duplicated counts, e.g., “moving motor vehicle-while at work” is included under “while at work.” Motor vehicle.—A motor vehicle is any mechanically or electrically powered device, not operated on rails, upon which or by which any person or property may be transported or drawn upon a land highway. Any object, such as a trailer, coaster, sled, or wagon, being towed by a motor vehicle is considered a part of the motor vehicle. Devices used solely for moving persons or materials within the con- fines of a building and its premises are not counted as motor vehicles. Moving motor vehicle accident.—The acci- dent is classified as “moving motor vehicle” if at least one of the motor vehicles involved in the accident was moving at the time of the accident. This category is subdivided into “traffic” and “nontraffic” accidents. 1. Traffic moving motor vehicle accident. The accident is in the “traffic” category if it occurred on a public highway. It is con- sidered to have occurred on the highway if it occurred wholly on the highway, if it originated on the highway, if it terminated on the highway, or if it involved a vehicle partially on the highway. A public highway is the entire width between boundary lines of every way or place of which any part is open to the use of the public for the pur- poses of vehicular traffic as a matter of right or custom. 2. Nontraffic moving motor vehicle accident. The accident is in the “nontraffic” category if it occurred entirely in any place othe than a public highway. Nonmouving motor vehicle accident.—If the motor vehicle was not moving at the time of the accident, the accident is considered a “non- moving motor vehicle” accident and is classi- fied in the “other accident” category. Accident while at work.—The class of acci- dent is “while at work” if the injured person was 17 years of age or over and was at work at a job or a business at the time the accident happened. Home accident.—The class of accident is “home” if the injury occurred either inside or outside the house. “Outside the house” refers to the yard, buildings, and sidewalks on the property. “Home” includes not only the person’s own home but also any other home in which he may have been when he was injured. Other accident.—The class of accident is “other” if the occurrence of injury cannot be classified in one or more of the first three class-of-accident categories (i.e., moving motor vehicle, while at work, or home). This category therefore includes persons injured in public places (e.g., tripping and falling in a store or on a public sidewalk) and also nonaccidental injuries such as homicidal and suicidal attempts. The survey does not cover the mili- tary population, but current disability of various types resulting from prior injury occurring while the person was in the Armed Forces is covered and is included in this class. The class also includes mishaps for which the class of accident could not be ascertained. Terms Relating to Hospitalization Hospital. —For this survey a hospital is de- fined as any institution meeting one of the following criteria: (1) named in the listing of hospitals in the current Guide Issue of Hospitals, the Journal of the American Hospital Association, (2) named in the listing of hospitals in the Directories of the American Osteopathic Hospital Association, or (3) named in the annual inventory of non-Federal hospitals submitted by the States to the Health Care Facilities Service, Health Services and Mental Health Administration, in conjunction with the Hill-Burton program. Short-stay hospital.—A short-stay hospital is one in which the type of service provided by the hospital is general; maternity; eye, ear, nose, and throat; children’s; or osteopathic; or it may be the hospital department of an institution. Hospital ownership.—Hospital ownership is a classification of hospitals according to the type of organization that controls and operates the hospital. The category to which an individual hospital is assigned and the definition of these categories follows the usage of the American Hospital Association. Hospital day.—A hospital day is a day on which a person is confined to a hospital. The day is counted as a hospital day only if the patient stays overnight. Thus a patient who enters the hospital on Monday afternoon and leaves Wednesday noon is considered to have had 2 hospital days. Hospital days during the year.—The number of hospital days during the year is the total number for all hospital episodes in the 12-month period prior to the interview week. For the purposes of this estimate, episodes overlapping the beginning or end of the 12-month period are subdivided so that only those days falling within the period are included. Hospital episode.—A hospital episode is any continuous period of stay of 1 night or more in a hospital as an inpatient except the period of stay of a well newborn infant. A hospital episode is recorded for a family member when- ever and part of his hospital stay is included in the 12-month period prior to the interview week. Hospital discharge.—A hospital discharge is the completion of any continuous period of stay of 1 or more nights in a hospital as an inpatient except the period of stay of a well newborn infant. A hospital discharge is recorded whenever a present member of the 135 household is reported to have been discharged from a hospital in the 12-month period prior to the interview week. (Estimates were based on discharges which occurred during the 6-month period prior to the interview.) Length of hospital stay.—The length of hospital stay is the duration in days, exclusive of the day of discharge, of a hospital discharge. (See definition of “hospital discharge.”) Average length of stay.—The average length of stay per discharged patient is computed by dividing the total number of hospital days for a specified group by the total number of dis- charges for the same group. Type of hospital service.—Type of hospital service is a classification of hospitals according to the predominant type of cases for which they provide care. The category to which an individual hospital is assigned and the defini- tion of these categories follows the usage of the American Hospital Association. Terms Relating to Dental Visits Dental visit.—A dental visit is defined as any visit to a dentist’s office for treatment or advice, including services by a technician or hygienist acting under a dentist’s supervision. Interval since last dental visit.—The interval since the last dental visit is the length of time prior to the week of interview since a dentist or dental hygienist was last visited for treat- ment or advice of any type. Edentulous persons.—Persons who have lost all their permanent teeth are classed as edentu- lous persons. An edentulous person may have dentures but does not have any natural teeth. Type of dental service.—A dental service is a service received when a dentist or dental hygienist is visited. For purposes of this survey, dental services have been categorized into a number of broad types. If a single dental visit involves more than one type of dental service, each type of service is recorded. If a particular type of service is rendered more than once during a single visit, the type of service is nevertheless recorded only once. For example, if during a single dental visit one tooth is extracted and three teeth are filled, the types of services rendered during that visit are recorded as ‘‘extractions” and “fillings,” each 136 category being recorded only once. The categories of type of dental service are defined as follows: 1. Fillings include temporary fillings, perma- nent fillings, inlays, crowns, and similar pro- cedures. 2. Extractions include any dental surgery and related activity such as removal of stitches. 8. Cleaning or examination includes all forms of dental prophylaxis, checkup, consultation, and X-rays. 4. Straightening includes orthodontic treatment and brace work and also fitting or repair of braces. 5. Gum treatment includes all peridontal work except prophylaxis. 6. Denture work includes taking impressions for false teeth, plate fitting or repair, and bridge work. 7. Other includes all types of dental service not listed above. Terms Relating to Physician Visits Physician visit.—A physician visit is defined as consultation with a physician, in person or by telephone, for examination, diagnosis, treat- ment, or advice. The visit is considered to be a physician visit if the service is provided directly by the physician or by a nurse or other person acting under a physician’s supervision. For the purpose of this definition, “physician” includes doctors of medicine and osteopathic physicians. The term “doctor” is used in the interview rather than “physician” because of popular usage. However, the concept toward which all instructions are directed is that which is described here. Physician visits for services provided on a mass basis are not included in the tabulations. A service received on a mass basis is defined as any service involving only a single test (e.g., test for diabetes) or a single procedure (e.g., smallpox vaccination) when this single service was administered identically to all persons who were at the place for this purpose. Hence ob- taining a chest X-ray in a tuberculosis chest X-ray trailer is not included as a physician visit. However, a special chest X-ray given in a physician’s office or in an outpatient clinic is considered a physician visit. Physician visits to hospital inpatients are not included. If a physician is called to a house to see more than one person, the call is considered a separate physician visit for each person about whom the physician was consulted. A physician visit is associated with the person about whom the advice was sought, even if that person did not actually see or consult the physician. For example, if a mother consults a physician about one of her children, the physician visit is ascribed to the child. Interval since last physician visit.—The in- terval since the last physician visit is the length of time prior to the week of interview since a physician was last consulted in person or by telephone for treatment or advice of any type whatever. A physician visit to a hospital in- patient may be counted as the last time a physician was seen. Place of visit.—The place of visit is a classifi- cation of the types of places at which a physician visit occurs. Definitions of the various categories are as follows: 1. Home is defined as any place in which the person was staying at the time of the physi- cian’s visit. It may be his own home, the home of a friend, a hotel, or any other place the person may have been staying (except as an overnight patient in a hospital). 2. Office is defined as the office of a physician in private practice only. This may be an office in the physician’s home, an individual office in an office building, or a suite of offices occupied by several physicians. For purposes of this survey, physicians con- nected with prepayment-group-practice plans are considered to be in private practice. 3. Hospital clinic is defined as an outpatient clinic or emergency room in any hospital. 4. Company or industry health unit refers to treatment received from a physician or under a physician’s supervision at a place of business (e.g., factory, store, office building). This includes emergency or first-aid rooms located in such places if treatment was received there from a physician or trained nurse. 5. Telephone contact refers to advice given in a telephone call by the physician directly or through a nurse. (Calls for appointments are excluded.) 6. Other refers to advice or treatment received from a physician or under a physician’s general supervision at a school, at an insur- ance office, at a health department clinic, or any other place at which a physician consul- tation might take place. Type of medical service.—A medical service is a service received when a physician is con- sulted. For the purposes of this survey, medical services have been categorized into several broad types. A single physician visit may result in the recording of more than one type of medical service (though a particular type is not recorded more than once for any one physician visit). Definitions of the types of medical service are as follows: 1. Diagnosis and treatment include (1) exami- nations and tests in order to diagnose an illness regardless of whether the examina- tions and tests resulted in a diagnosis and (2) treatment or advice given by the physician or under the physician’s super- vision. The category includes diagnosis alone, treatment alone, and both combined. X-rays either for diagnostic purposes or for treat- ment are included in this class. 2. Prenatal and postnatal care include consulta- tions concerning the care of the mother during pregnancy and in the postpartum period. It excludes consultations for illnesses not related to pregnancy or delivery. 3. General checkup includes checkups for general purposes and also those for a specific purpose such as employment or insurance. If a diagnosis or diagnoses are made in the course of a general checkup, the physician visit is classified to ‘diagnosis and treat- ment” as well as to “general checkup.” If the consultation is for checking up on a specific condition, as, for example, when a person goes at regular intervals for a check on a tuberculous or heart condition, this is classified as “diagnosis and treatment” and not as ‘general checkup.” 137 4, Immunization includes this preventive service when provided by a physician or under a physician’s supervision. A physician service which is for the sole purpose of receiving immunization against a particular disease given at the same time and place that many other persons are receiving the identical immunization is excluded because of the rule for exclusion of such services in the definition of a physician visit. 5. Other includes eye refractions and specific preventive-care services (such as vitamin injections) not embraced by the above type of service categories. Also included are all visits where an unknown type of service was reported. Terms Relating to Special Aids Special aid.—A special aid is a device used to compensate for defects resulting from disease, injury, impairment, or congenital malforma- tion. Aids included in this survey are artificial limbs, braces, crutches, canes or walking sticks, special shoes, wheelchairs, walkers, and any other kind of aid for getting around, as follows: 1. Artificial limb is a device to replace a miss- ing leg, arm, hand, or foot. It does not have to have moving parts, but a device employed only for lengthening a leg where the whole leg or foot is present is not counted. 2. Brace is defined as any kind of supportive device for the arms, hands, legs, feet, back, neck, or head, exclusive of temporary casts, slings, bandages, trusses, belts, or crutches. Dental braces are excluded. 8. Crutch is a staff with a crosspiece at the top to support a person in walking. The point of support may be the axilla, upper arm, or forearm. For each crutch a second support is at hand level. 4. Cane or walking stick is a short staff, either straight or curved at upper end, used to provide some support at hand level in walk- ing. 5. Special shoes are shoes of special construc- tion or design which are used to help a person in getting around. Oversized shoes of normal or usual construction are excluded. 138 6. Wheelchair is a chair mounted on wheels and usually propelled by the occupant by means of handrims attached to the two large side wheels. 7. Walker is a four-legged stand which provides support for a person. It is moved by lifting or by wheeling on casters. Terms Relating to Home Care Home care.—Care received at home is de- fined as any personal assistance or personal services received by a person at home as a result of illness, injury, impairment, or ad- vanced age. The person providing the care may have received a fee for his service or the service may have been provided free. Excluded from the definition of home care is any care pro- vided by a physician. However, care by all other persons whether the latter are profes- sional health workers or not is included. The amount of care varies from constant care for bedridden persons to only partial or inter- mittent. Type of care provided.—Type of care pro- vided has been classified into three general categories. These categories with the specific inclusions are as follows: 1. Personal care Walking up stairs or getting from room to room: Includes assistance either in walking from one room to another or in going up and down stairs. This would include cases where someone must watch or stand behind a person as he walks up the steps in case he falls or stumbles. If the person is bedridden or never attempts to walk from one room to another or to walk up and down stairs, this type of care is ex- cluded since this kind of service is not rendered by anyone. Dressing or putting on shoes: Includes any care a person receives in dressing and the like because he is unable to dress himself without the help of another person because of some health problem. Not included is help in dressing that is not health related such as the wife who ties her husband’s ties because he never learned how to do it property or the husband who hooks the back of his wife’s dress because it is difficult for her to reach. Bathing (shaving) or other toilet activities: Includes any assistance the person need in washing or shaving himself or in using a bedpan and so forth. Eating or having meals served in bed: Includes help if the person is unable to eat without assistance or has to have his meals served to him in bed. Not included in this definition is help in preparation of meals. 2. Medically related care Changing bandages: Includes assistance in changing dressing or bandages. Receiving injections: Includes injections received at home from someone other than a doctor. Other treatments: Includes all other treatments received from some other person at home such as the application of salves or ointments, wetpacks, etc. 3. Other types of care Changing bed positions: Includes assistance of another person in order to sit up or turn over in bed. Exercising or physical therapy: Includes receipt of physical therapy at home or in any exercise performed because of some illness, injury, or impair- ment. Cutting toenails. Any other type of care not specified above. Specifically excluded from types of care pro- vided are (1) any care received by the person outside his home, e.g., physical therapy at an outpatient clinic, (2) any care received from a physician either at the person’s home or at the doctor’s office, a clinic, a hospital, etc., and (3) maid service for cleaning, laundry, or preparation of meals. Duration of care.—Duration of care is the length of time prior to the week of interview that a person received home care. Extent of care.—Two major categories used to describe the extent of care received are constant care and partial or intermittent care. 1. Constant care was provided when the person was never left unattended or alone in the house even for short intervals or during the night. Although the person providing the care was immediately available at all times, the care did not have to be provided at all times. 2. Part-time care includes any care on a part- time basis. This includes care for persons who required constant care during inter- mittent episodes of a condition. Provider of care.—Three categories are used to classify provider of home care. 1. Related household member included any medical or paramedical personnel who were related to the individual requiring care. How- ever, related physicians were excluded from this category as well as the remaining ones. 2. Registered nurse who came to the home to provide care. 3. All other persons providing care included practical nurses, physical therapists, and social workers. Nurse visits.—Home visits by nurses include visits from nurses in the past 12 months by any kind of nurse, registered or otherwise. Family and Related Terms The definitions of families and unrelated individuals (family units) are the same as those used in the 1970 census. Family refers to a group of two persons or more related by blood, marriage, or adoption who are living together in the same household. Although the usual household contains only the primary family, a household can contain secondary families as well as individuals unre- lated to the family. A lodger and his family who are not related to the head of the house- hold or a resident employee and his wife living in are considered a secondary family and not 139 part of the primary family. However, if the son of the head of the household and the son’s wife and children are members of the house- hold, this subfamily is treated as part of the primary family. Individuals are persons (other than inmates of institutions) who are not living with any relatives. An unrelated individual can be (1) a household head living alone or with non- relatives, (2) a lodger or resident employee with no relatives in the household, (3) a staff member of an institution who has no relatives living with him, or (4) a resident of a dormi- tory, lodging house, or other shared-residence facility who has no relative living with him. Head of family is usually the person re- garded as the “head” by the members of the group. Married women are never classified as heads if their husbands are living with them at the time of the survey except when the husband is a member of the Armed Forces. Only one person in each family can be desig- nated as the head. Therefore the number of heads of families is equal to the number of families. Other family members are all persons who are related to the head of the family by blood, marriage, or adoption. The category ‘child under 17,” used as a classifier of husband-wife families, refers to a child of these parents and includes an adopted child, a foster child, or a ward but excludes a grandchild. Terms Relating to Health Insurance Health insurance is any plan specifically designed to pay all or part of the medical or hospital expenses of the insured individual. The insurance can be either a group or an indi- vidual policy with the premiums paid by the individual, his employer, a third party, or a combination of these. Benefits received under the plan can be in the form of payment to the individual or to the hospital or doctor. How- ever, the plan must be a formal one with defined membership and benefits rather than an informal one. For example, an employer simply paying the hospital bill for an employee would not constitute a health insurance plan. For the Health Interview Survey, health insurance excludes the following kinds of 140 plans: (1) plans limited to the “dread diseases” such as cancer and polio, (2) free care such as public assistance, public welfare, and Medicaid, care given free of charge to veterans, care given under Uniformed Services Dependents Medical Care Program, care given under the Crippled Children Program or similar programs, and care of persons admitted to a hospital for research purposes, (3) insurance that pays bills only for accidents, such as liability insurance held by a car or property owner, insurance that covers children for accidents at school or camp, and insurance for a worker that covers him only for accidents, injuries, or diseases incurred on the job, and (4) insurance that pays only for loss of income. Hospital insurance.—Insurance that pays all or part of the hospital bill for the hospitalized person is called hospital insurance. The hospital bill is limited to the bill submitted by the hospital itself, not the doctor’s or surgeon’s bill or the bill for special nurses. Such a bill always includes the cost of room and meals and may also include the cost of other services such as operating room, laboratory tests, and X-rays. Surgical insurance.—Insurance that pays in whole or part the bill of the doctor or surgeon for an operation whether performed in a hospital or in the doctor’s office is surgical insurance. Insurance that pays the cost of visits to a doctor’s office for postoperative care is included as surgical insurance. Terms Relating to Acquisition and Cost of Medicines In order to obtain accurate and complete information relating to the acquisition and cost of medicines, the reference period is limited to the 2-week period prior to interview. The collected data are then appropriately weighted to provide annual estimates for medicine items. Prescribed medicine.—Prescribed medicine is defined as (1) any medicine obtained on a doctor’s written prescription, (2) any medicine which has been prepared on the basis of a doctor’s telephone call to a pharmacist, or (3) any medicine given by the doctor (or nurse) to a person to take home. Medicine obtained as a refill of a previous prescription is considered prescribed medicine. Medicines and injections administered in a medical facility are excluded. Acquisition of prescribed medicine.—Each time the medicine is actually obtained on the basis of a prescription is considered an acquisi- tion. If the medicine is specifically prescribed for two persons, it is counted as two acquisi- tions. Each time the prescription is refilled is considered a separate acquisition. Cost per acquisition of prescribed medicine. —The amount paid (or to be paid) by a person, his family, or friends and any part paid by health insurance is recorded for each acquisi- tion of medicine for each person. If the medi- cine was obtained without cost, the source from which the medicine was obtained free of charge is recorded. If the medicine was ob- tained for two persons, half of the cost is allocated to each person. Similarly if the medi- cine was obtained twice for one person, half the total cost is allocated per acquisition. Nonprescribed medicine.—Nonprescribed med- icine is defined as medicines obtained with- out a prescription. The term includes tonics, pills, salves, ointments, vitamins, first-aid items, and other medicines or medications. Users of nonprescribed medicine.—Persons in the family who used or might use each non- prescribed medicine are recorded. Cost of mnonprescribed medicine during period per user.—The amount paid (or to be paid) for a given type of nonprescribed medi- cine actually obtained during a period of time is allocated equally among each user (or poten- tial user) of the medicine. Nonprescribed medi- cine obtained “free from doctor” (or other source) is recorded as having no cost. Terms Relating to Corrective Lenses Corrective lenses.—Corrective lenses include eyeglasses and contact lenses. The term is lim- ited to visual aids worn to correct or improve vision and therefore excludes sunglasses worn only to filter light, safety glasses worn only for protection of the eyes, hand magnifying glasses, and other such devices. However, if the safety glasses are worn also for correction or improvement of vision, they are considered corrective lenses as are prescription sunglasses. Type of correction.—Lenses are used for the correction of near vision, distance vision, and defective vision due to specific eye conditions. Lenses prescribed for the correction of near vision aid the person in reading or doing close work. For persons who cannot read, the term “close work” is defined as seeing small objects clearly enough to recognize what they are. Lenses prescribed for the correction of distance vision aid the person in seeing distance objects and are used in such activities as driving a car, watching a moving, or seeing entries on a blackboard. Persons who reported having bi- focals are considered as having correction for both near and distance vision, but the use of both types of lenses is verified by the inter- viewer. When the respondent reported only in terms of an eye condition such as astigmatism or strabismus, the type of correction is classified as other than correction of near or distance vision. For persons who obtained their corrective lenses without a prescription, the respondent’s reply regarding type of correction is accepted. Frequency of use of corrective lenses.—The options read to the respondent, “all of the time, most of the time, hardly ever, never” represent a descending scale of frequency of use. For persons who use their lenses for the correction of near vision only or distance vision only, the scale refers only to the pur- pose for which the lenses were prescribed or intended, e.g., if a person uses his lenses to read only the daily newspaper each morning and does no other reading or close work, he is considered as a person who uses his glasses “all of the time” for “reading or close work.” If a person has both eyeglasses and contact lenses or more than one pair of either, the question on frequency of use applies to all lenses used, e.g., if a person wears contact lenses at work and eyeglasses at all other times, he is con- sidered as wearing corrective lenses “all of the time.” Source of optical prescription.—Prescriptions for corrective lenses are usually obtained from either an ophthalmologist or an optometrist. An ophthalmologist is a physician who spec- ializes in the medical and surgical care of the eyes and may prescribe drugs or other treat- ment as well as lenses. An optometrist per- forms visual analysis by examining the eyes, 141 prescribing lenses and other vision aids, visual training, and orthoptics or other optical aids. The optometrist does not treat eye diseases or perform surgery. Terms Relating to Cigarette Smoking Nonsmoker.—A person who has never smoked more than 100 cigarettes (five packs) during his entire life is considered to have never smoked cigarettes. Persons who have never smoked cigarettes are also referred to as “never smokers.” Ever smoked cigarettes.—Persons who have smoked more than 100 cigarettes (five packs) in their entire lives are classified as having ever smoked and are further described as present smokers and former smokers. They also are referred to as “ever smokers.” Present cigarette smoker.—Any person who reported a current rate of cigarette smoking is classified as a present smoker. The rate may range from less than one cigarette per day to 99 or more cigarettes per day. If a person has stopped smoking cigarettes only temporarily because of illness, economic reasons, or the like, he is still considered a present smoker. Former cigarette smoker.—Any person who has smoked at least 100 cigarettes during his entire life but reports smoking no cigarettes at the time of the interview is classified as a former smoker. Heaviest smoking rate.—A person’s heaviest smoking rate is the daily rate of consumption during the period when he was smoking the most. The period of heaviest smoking can range from a short time to many years. Present smoking rate.—A person’s present smoking rate is the number of cigarettes he reports to be smoking per day at the time of the interview. Time since last smoked.—This is a measure of the interval of time since a former smoker last smoked cigarettes fairly regularly. Demographic Terms Age.—The age recorded for each person is the age at last birthday. Age is recorded in single years and grouped in a variety of distributions depending on the purpose of the table. 142 Color.—The population is divided into two color groups, “white” and “all other.” “All other” includes Negro, American Indian, Chi- nese, Japanese, and any other race. Mexican persons are included with “white” unless defi- nitely known to be Indian or of another race. Income of family or of unrelated individ- uals.—Each member of a family is classified according to the total income of the family of which he is a member. Within the household all persons related to each other by blood, marriage, or adoption constitute a family. Un- related individuals are classified according to their own income. The income recorded is the total of all in- come received by members of the family (or by an unrelated individual) in the 12-month period preceding the week of interview. In- come from all sources is included, e.g., wages, salaries, rents from property, pensions, and help from relatives. Education.—The categories of education status show the years of school completed. Only years completed in regular schools, where persons are given a formal education, are included. A “regular” school is one which ad- vances a person toward an elementary or high school diploma or a college, university, or pro- fessional school degree. Thus education in vocational, trade, or business schools outside the regular school system is not counted in determining the highest grade of school completed. 1. Education of head of family or of unrelated individuals. Each member of a family is classified according to the education of the head of the family of which he is a member. Within the household all persons related to each other by blood, marriage, or adoption constitute a family. Unrelated individuals are classified according to their own education. 2. Education of individual. Each person aged 17 years or older is classified by education in terms of the highest grade of school completed. Marital status.—Marital status is recorded only for persons 17 years of age or older. The marital status categories in this report are as follows: 1. Under 17 includes all persons aged 0-16 regardless of their marital status. 2. Married includes all married persons not separated from their spouses. Persons with common-law marriage are considered as married. 3. Never married includes persons who were never married and persons whose only marriage was annulled. 4. Separated includes married persons who have a legal separation or who have parted because of other reasons. This does not in- clude persons separated from their spouses because of the circumstances of their employment or service in the Armed Forces; these persons are considered married. 5. Widowed and divorced include, respectively, all persons who said they were either widowed or legally divorced. Living arrangement.—The four categories of living arrangements shown in this report are as follows: 1. Living alone. Living alone is defined as living in a one-member household. 2. Living with nonrelatives. Living with non- relatives is defined as living in a household with another person or persons none of whom are related to the person by blood, marriage, or adoption. 38. Living with relatives—married. This category includes married persons who are living in a household with another person or persons one or more of whom are related to them by blood, marriage, or adoption. Persons with common-law marriages are considered to be married. For purposes of this category, “married” excludes widowed, divorced, or separated. Persons whose only marriage was annulled are counted as “never married.” 4, Living with relatives—other. This category includes children living with parents or relatives; it also includes persons who are widowed, divorced, separated, or never married who are living in a household with another person or persons one or more of whom are related to them by blood, mar- riage, or adoption. Persons whose only mar- riage was annulled are counted as “never married.” “Separated” refers to married per- sons who have a legal separation or who have parted because of marital discord. Usual activity.—All persons in the population are classified according to their usual activity during the 12-month period prior to the week of interview. The “usual” activity, in case more than one is reported, is the one at which the person spent the most time during the 12-month period. Children under 6 years of age are classified as “preschool.” All persons aged 6-16 years are classified as “school age.” The categories of usual activity used in this report for persons aged 17 years and over are usually working, usually going to school, usually keeping house, retired, and other activ- ity. For several reasons these categories are not comparable with somewhat similarly named categories in official Federal labor force statis- tics. First, the responses concerning usual activ- ity are accepted without detailed questioning since the objective of the question is not to estimate the numbers of persons in labor force categories but to identify crudely certain popu- lation groups that may have differing health problems. Second, the figures represent the usual activity status over the period of an en- tire year, whereas official labor force statistics relate to a much shorter period, usually 1 week. Third, the minimum age for usually working persons is 17 in the Health Interview Survey, and the official labor force categories include all persons aged 14 or older. Finally, in the definitions of specific categories which follow, certain marginal groups are classified differently to simplify procedures. 1. Usually working includes persons 17 years of age or older who are paid employees; self- employed in their own business, profession, or in farming; or unpaid employees in a family business or farm. Work around the house or volunteer or unpaid work such as for a church is not counted as working. 2. Usually going to school includes persons 17 years of age or older whose major activity is going to school. 3. Usually keeping house includes female persons 17 years of age or older whose major activity is described as “keeping house” and who cannot be classified as “working.” 4. Retired includes persons 45 years old and over who consider themselves to be retired. In case of doubt, a person 45 years of age or older is counted as retired if he or she has either voluntarily or involuntarily stopped working, is not looking for work, 143 and is not described as ‘keeping house.” A retired person may or may not be able to work. 5. Other activity includes all persons 17 years of age or older not classified as “working,” “retired,” or “going to school,” and females 17 years of age or older not classified as “keeping house.” Geographic region.—For the purpose of classifying the population by geographic area, the States are grouped into four regions. These regions, which correspond to those used by the U.S. Bureau of the Census, are shown below. Region States included Northeast ..... Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, New York, New Jersey, Pennsylvania North Central .. Michigan, Ohio, Indiana, Illinois, Wisconsin, Minnesota, Iowa, Missouri, North Dakota, South Dakota, Kansas, Nebraska South evens Delaware, Maryland, District of Columbia, Virginia, West Virginia, North Carolina, South Carolina, Georgia, Florida, Kentucky, Texas, Tennessee, Alabama, Mississippi, Arkansas, Louisiana, Oklahoma West ......... Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, Nevada, Washington, Alaska, Oregon, California, Hawaii Place of residence.—The place of residence of a member of the civilian, noninstitutionalized population is classified as inside a standard metropolitan statistical area (SMSA) or outside an SMSA either farm or nonfarm. 1. Standard metropolitan statistical areas. The definitions and titles of SMSA’s are estab- lished by the U.S. Office of Management and 144 Budget with the advice of the Federal Com- mittee on Standard Metropolitan Statistical Areas. There were 212 SMSA’s defined for the 1960 decennial census. The definition of an individual SMSA involves two considerations: first, a city or cities of specified population which constitute the central city and identify the county in which it is located as the central county; second, economic and social relation- ships with contiguous counties (except in New England) which are metropolitan in character so that the periphery of the specific metropolitan area may be determined. SMSA’s are not limited by State boundaries. In New England SMSA’s consist of towns and cities, rather than counties. The metropolitan population in this report is based on SMSA’s as defined in the 1960 census and does not include any subsequent additions or changes. . Central cities. Each SMSA must include at least one central city. The complete title of an SMSA identifies the central city or cities. If only one central city is designated, then it must have 50,000 inhabitants or more. The area title may include, in addition to the largest city, up to two city names on the basis and in the order of the following criteria: (1) the additional city has at least 250,000 inhabitants or (2) the additional city has a population of one-third or more of that of the largest city and a minimum population of 25,000. An exception occurs where two cities have contiguous boundaries and constitute, for economic and social purposes, a single community of at least 50,000, the smaller of which must have a population of at least 15,000. . Farm and nonfarm residence. The population residing outside SMSA’s is subdivided into the farm population, which comprises all non- SMSA residents living on farms, and the nonfarm population, which comprises the remaining outside SMSA population. The farm population includes persons living on places of 10 acres or more from which sales of farm products amounted to $50 or more during the previous 12 months or on places of less than 10 acres from which sales of farm products amounted to $250 or more during the preceding 12 months. Other persons living outside an SMSA were classified as nonfarm if their household paid rent for the house but their rent did not include any land used for farming. Sales of farm products refer to the gross receipts from the sale of field crops, vegetables, fruits, nuts, livestock and livestock products (milk, wool, etc.), poultry and poul- try products, and nursery and forest products produced on the place and sold at any time during the preceding 12 months. Occupation.—A person’s occupation may be defined as his principal job or business. For the purposes of this survey, the principal job or business is defined in one of the following ways. If the person worked during the 2-week refer- ence period of the interview, or had a job or business, the question concerning his occupation (or what kind of work he was doing) applies to his job during that period. If the respondent held more than one job, the question is directed to the one at which he spent the most time. For an unemployed person, this question refers to the last full-time civilian job he had. A person who has a job to which he has not yet reported, and has never had a previous job or business, is classified as a “new worker.” Shown below are the occupation classes pre- sented in this report and their code numbers as Occupation Classification Census Code White-collar workers Professional, technical, and kindred workers w Fm ow EE 001-195, N Managers and administrators, except farm 201-245 Sales workers . . . . . 260-280 Clerical and kindred workers 301-395, P,Q Blue-collar workers Craftsmen and kindred workers 401-580, R, S Operatives, except transport . . . . 601-696, T Transport equipment operatives . . . 701-715, U Laborers, except farm . . . . . 740-785, V Farm workers Farmers and farm managers . . . . 801-802, W Farm laborers and farm foremen . . . 821-824 Service workers Service workers, except private household 901-965, X,Y Private household workers . . . . . . | 980-984,2Z Unknown. . . . . . + +. . . . | 990,995 found in the Classified Index of Occupations and Industries, U.S. Bureau of the Census (June 1971). Industry.—The industry in which a person was reportedly working is classified by the major activity of the establishment in which he worked. The only exceptions, the few establish- ments classified according to the major activity of the parent organization, are as follows: laboratories, warehouses, repair shops, and storage facilities. The industry categories presented in this report are shown below with the corresponding codes found in the Classified Index of Occupa- tions and Industries, U.S. Bureau of the Census, and the Standard Industrial Classification Manuals (SIC), U.S. Office of Management and Budget, (1967). Industry Classification Census Code SIC Code Agriculture 017-019, A 01,07 (except 0713) Forestry and fisheries 027-028 08, Mining : 047-057 10-14 Construction . 067-077,8 15-17 Manufacturing 107-398, C 19-39, 0713 Transportation and public utilities 407-479, D 40-49 Wholesale and retail trade . . 507-698,E,F,G | 50-59 Finance, insurance, and real estate 707-718 60-67 Services and miscel- laneous . 727-897, H,J,K 70-89 Public administration 907-937, L, M 91-94 Unknown 996-999 99 In labor force.—All persons 17 years and over who worked at or had a job or business or were looking for work or on layoff from work during the 2-week period prior to the week of interview are in the labor force. The labor force consists of persons currently employed and currently unemployed. Definitions of these categories, similar to those used by the Current Population Survey, are as follows: 1. Currently employed. Persons 17 years of age and over who reported that at any time during the 2-week period covered by the interview they either worked at or had a job or business are currently employed. Current employment includes paid work as an employee of someone else; self-employment in business, farming, or professional practice, and unpaid work in a family business or far.... 145 Freelance workers are considered currently employed if they had a definite arrangement with one employer or more to work for pay according to a weekly or monthly schedule; those without a definite employment schedule are counted as employed, unem- ployed, or not in the labor force depending upon their activity during the 2-week period covered by the interview. Persons temporarily absent from a job or business because of illness, vacation, strike, or bad weather are considered employed. Excluded from the currently employed population are (1) persons receiving revenue from an enterprise but not participating in its operation, (2) persons doing housework or charity work for which they receive no pay, (8) seasonal workers during the portion of the year they were not working, and (4) persons not working even though they had a job or business but who were on layoff or looking for work. 2. Currently unemployed. Persons 17 years and over who during the 2-week period prior to interview did not work or had no job or business but were looking for work and those who had a job but were on layoff or looking for work are considered currently unemployed. The number of currently employed and currently unemployed persons estimated from the Health Interview Survey (HIS) will differ from the estimates prepared from the Current Population Survey (CPS) of the U.S. Bureau of the Census. This occurs because of sampling variability and the following primary conceptual differences: (1) HIS estimates are for persons 17 years of age and over, while CPS estimates are for persons 16 years of age and over; (2) HIS uses a 2-week reference period, while CPS uses a 1-week reference period; and (3) HIS is a continuing survey with separate samples taken weekly, while CPS is a monthly sample taken for the survey week that includes the 12th of the month. Not in labor force.—Persons not in the labor force are all persons under 17 years of age and other persons who did not at any time during the 2-week period covered by the interview have 146 a job or business, were not looking for work, and were not on layoff from a job. In general, persons excluded from the labor force are youths under 17, retired persons, physically handicapped persons unable to work, and house- wives or charity workers who receive no pay. Also excluded are persons receiving revenue from but not participating in a business and seasonal or freelance workers not looking for work. Class of worker.—Persons in the labor force are classified according to class of worker as follows: 1. Private paid workers are persons working for a private employer for wages, salary, or commissions. This includes compensation by tips; piece rates or pay in kind; and wages or salary from settlement houses, churches, unions, and other nonprofit organizations. 2. Federal Government workers are persons who work for any branch of the Federal Govern- ment including employees of Government- owned bus lines and utilities, civilian employees of the Armed Forces, and persons elected to Federal offices. 3. Other government workers are persons who work for any branch of government other than the Federal Government, e.g., State, city, or county. Included in this group are civilian employees of the National Guard, persons elected to paid offices, employees of international organizations such as the United Nations, and employees of foreign govern- ments. 4. Self-employed workers are persons working for profit or fees in their own business, farm, shop, or office. “Own business” includes persons who have their own tools or equip- ment and provide services on a contract, subcontract, or job basis. Officers of corpora- tions are not classified as owning their own business, even though they do own all or part of the corporation stock; such persons are considered as “private paid.” A person who operates a farm for himself, regardless of whether he owns or rents the land, is considered self-employed. 5. Other class of worker includes (1) persons working without pay on a farm or in a business operated by a relative, (2) persons who have never worked in the past but have a job or business which will begin in the near future, (3) persons who have not worked in the past but are presently looking for work, and (4) persons for whom no information as to class of worker is available. Quarter.—The quarters used by the Health Interview Survey are actually 13-week periods rather than 3 calendar months. Since each 13-week period begins on a Monday and ends on a Sunday, the actual dates of the beginning and end of each 13-week period may overlap into another calendar quarter. 000 147 APPENDIX IV CHECKLISTS FOR SELECTED CHRONIC CONDITIONS: 1968-73 CONDITIONS OF THE DIGESTIVE SYSTEM: 1968 Now I'm going to read a list of conditions: 16a. During the past 12 months, has anyone in the family (you,your ==, etc.) had any of the following conditions = If “Yes,” ask b and ¢ A. Gallstones? b. Who was this? B. Any other gallbladder trouble? c. During the past 12 months has anyone else had . . . ? C. Hemorrhoids or piles? (Enter name of condition and letter of line where D. Cirrhosis of the liver? reported in appropriate persons column(s) in Item C.) E. Fatty liver? in the family had any other condition L. Hernia or rupture? Colitis? of the digestive system? F. Hepatitis? During the past 12 months has anyone in During the past 12 months has anyone in During the past 12 months has anyone in the family had — If “Yes,” ask band ¢ |Yes| No | the family had = If “Yes,” ask band ¢ |Yes| No | the family had — If “Yes,” ask band ¢ G. Yellow jaundice? N. Gastritis? U. Frequent constipation? H. Any other liver trouble? 0. Frequent indigestion? V. Any other bowel trouble? |. Diabetes? P. Any other stomach trouble? W. Any other intestinal trouble? J. Any disease of the pancreas? Q. Enteritis? X. Cancer of the stomach, colon or rectum? K. Ulcer? R. Diverticulitis? Y. During the past 12 months has anyone $. T If “Yes,” ask: Who was this? — What M. A disease of the esophagus? is the condition? (Enter in [tem C) . Spastic Colon? 148 CONDITIONS OF THE BONES, JOINTS, MUSCLES, AND SKIN: 1969 17. Now I'm going to read a list of conditions. Does anyone in the family (you, your ——, A-2 etc.) HAVE any of these conditions... Missing fingers, hand or arm— toes, foot or leg? Permanent stiffness or any deformity of the foot, leg, fingers, arm or back? Paralysis of any kind? If “Yes' ask: Who is this? Does anyone else have...? 17. DURING THE PAST 12 MONTHS did anyone in the family have... Arthritis of any kind or Rheumatism? Gout? Lumbago? Osteomyelitis? (o%-tee-oh-my-uh-lité-iss) A bone cyst or bone spur? Any other disease of the bone or cartilage? Trick knee? A slipped or ruptured disc? Curvature of the spine? Repeated trouble with neck, back or spine? Bursitis or synovitis? (siff-uh-vite-iss) Any disease of the muscles or tendons? If ““Yes,” ask Who was this? During the past 12 months, did anyone else have... 17. DURING THE PAST 12 MONTHS, did anyone in the family have... A tumor, cyst or growth of the skin? Eczema or psoriasis? (so-ryé-uh-sis) Trouble with dry or itching skin? Trouble with acne? A skin ulcer? Any kind of skin allergy? Dermatitis or any other skin trouble? Trouble with fallen arches, flatfeet OT clubfoot? Trouble with bunions, corns or calluses? A disease of the hair or scalp? If “Yes,” ask Who was this? During the past 12 months, did anyone else have... Trouble with ingrown toenails or fingernails? Any disease of the lymph or sweat glands? A-3 17. AA. 88. cc. DO. fe Exclude persons who have arthritis or other “arthritis’* conditions. (Resides —) During the past 12 months, did anyone (else) in the family have any of the following... Any stiffness in the joints when first getting out of bed in the morning?* Pain in the joints when they are moved?* Swelling in any of the joints, except in the ankles or feet?* Any pain or soreness in the joints when they are touched or pressed on?* ‘Yes,' ask: Whot was the cause of this? Record letters and cause in item C-2. need not be asked. Acne Appendicitis Arteriosclerosis Athlete's foot B Bronchitis (any kind) r Bursitis ! Chickenpox ! Cold ' | | ' ' Corns, calluses, bunions or warts Croup Diabetes Epilepsy Interviewer information: Other *arthritis’’ conditions . Lupus (erythematosus) . Scleroderma . Dermatomyositis . Polyarteritis . Periarteritis . Psoriatic arthritis . Rheumatism . Gout © NVA WN —- Gallstones Goiter Hardening of the arteries J 1 1 1 | | 1 | | } Hay fever | Hemorrhoids or piles , Hemia , (all types) | \ 4 3 i Conditions reported for which questions 3a-3e High blood pressure Hypertension Kidney stones Laryngitis Migraine headache Mumps Phlebitis (Thrombophlebitis) Pneumonia Pregnancy Sciatica Sinus trouble (Sinusitis) Strep (Streptococcus) CY p-———— Tonsillitis Ulcer (duodenal, stomach, peptic or gastric only) Whooping cough 149 CONDITIONS OF THE RESPIRATORY SYSTEM: 1970 16a. Now I'm going to read a list of conditions; If “Yes,” ask b and c b. Who was this ? — Enter name of condition and letter of line where reported in appropriate persons column(s) in item C. c. During the past 12 months did anyone else have . . .? During the past 12 months, did anyone in the family (you, your —~ , etc.) have any of these conditions — A. Bronchitis? B. Bronchiectasis? C. Asthma? D. Hay fever? E. Nasal polyp? or ‘‘virus’' reported in answer to question |6. Do not circle **Y’’ and make no entryin item C for cold; flu; red, sore, or strep throat; During the past 12 months did anyone in the family have . . .? If ‘Yes,’ ask b and ¢ H. *Tonsillitis or enlargement of the tonsils or adenoids? Y L. Pleurisy? J. Tumor, cyst, or growth of the 0. Tumor, cyst, or growth of the F. Sinus trouble? Y bronchial tube or lung? throat, larynx, or trachea? P. Any work-related respiratory condition K. Emphysema? such as dust on the lungs, G. Deflected or deviated nasal septum? Y silicosis or pneurmorco*ni-o+sis? I *Loryngitis? Y M. Tuberculosis? N. Abscess of the lung? . During the past 12 months did anyone in the family have any other respiratory, lung, or pulmonary condition? If “Yes,” ask: Who was this? ~ What was the condition? (Enter in item C) *|f reported in question |6 only, ask: If only | time, ask: If less than | month, do not record. or “‘virus’’ reported in answer to question |6, 1. How many times did —~ have . . . in the past 12 months? ~ If 2+, enter in item C. 2. How long did it last? = If | month or longer, enter in item C. If tonsils or adenoids removed during the past |2 months, enter in item C. Do not circle *“Y** and make no entry in item C for cold; flu; red, sore, or strep throat; 150 IMPAIRMENTS: 1971 36a. Does anyone in the family (you, your ——, etc.) NOW have — A. Deafness in one or both ears? N If “Yes,” ask band ¢ . Any other trouble hearing with one or both ears? N b. Who is this? — Enter name of condition and letter of line where reported in appropriate person’s column(s) in item C. C. Tinnitus or ringing in the ears? N c. Does anyone else have . . . ? D. Blindness in one or both eyes? N E. Cataracts? N F. Glaucoma? N Does anyone in the fomily NOW have . . . ? If “Yes,” ask b and ¢ M. A missing finger, hand, or arm, toe, S. Any TROUBLE with fallen G. Color blindness? Y foot, or leg? N arches or flatfeet? N H. A detached retina or any other condition of the retina? Y N. A missing (breast), kidney, or lung? N |T. A clubfoot? N I. Any other trouble seeing with one or both U. Permanent stiffness or any deformity eyes even when wearing glasses? Y 0. Palsy or cerebral palsy? N of the back, foot, or leg? N V. Permanent stiffness or any deformity J. A cleft palate or harelip? Y P. Paralysis of any kind? N of the fingers , hand, or arm? N K. Stommering or stuttering? Q. Curvature of the spine? N |W. Mental retardation? N X. Any condition caused by an old accident or inn? L. Any other speech defect? Y R. REPEATED trouble with back or spine? N If *'Yes,” ask: What is the condition? N 151 CONDITIONS OF THE CARDIOVASCULAR SYSTEM: 1972 38a. Has anyone in the family (you, your —~, etc.) EVER had - If “Yes,” ask b and c. b. Who was this? Enter name of condition and letter of line where reported in appropriate person's column(s) in item C. c. Has anyone else ever had . . .? > . Rheumatic fever? . Rheumatic heart disease? . Hardening of the arteries or arteriosclerosis? oO | 0 |w . Congenital heart disease? . Coronary heart disease? mm . High blood pressure? . Stroke or a cerebrovascular accident? x | © . Hemorrhage of the brain? . Angina pectoris? . Myocardial infarction? = . Any other heart attack? 390. DURING THE PAST 12 MONTHS, did anyone in the family (you, your —=—, etc.) have — If ““Yes,” ask b and c b. Who was this? Enter name of condition and letter of line where reported in appropriate person's column(s) in item Ce c. During the past 12 months did anyone else have . . 2? - . Damaged heart valves? . Tachycardia or rapid heart? . Heart murmur? oO |Z |X . Any other heart trouble? . Aneurysm . Any blood clots? 00 . Gangrene? w . Varicose veins? . Hemorrhoids or piles? . Phlebitis or thrombophlebitis? . Any other condition affecting blood circulation? 152 CONDITIONS AFFECTING THE NERVOUS SYSTEM, GLANDULAR DISORDERS, AND CONDITIONS OF THE GENITOURINARY SYSTEM: 1973 3la. . During the past 12 months, did anyone else have . . . DURING THE PAST 12 MONTHS, did anyone in the family (you, your ——, etc.) have — If “Yes,” ask b and ¢ . Who was this? Enter name of condition and letter of line where reported in appropriate person's column in item C, ? A. Goiter or other thyroid trouble? B. Diabetes? C. Cystic fibrosis? D. Anemia? E. Epilepsy? F. Multiple sclerosis? G. Migraine? Glandular disorder 3la. oo DURING THE PAST 12 MONTHS, did anyone in the family have — If “Yes,” ask b and c . Who was this? Enter in item C . During the past 12 months, did anyone else have . . . ? x . Neuralgia or neuritis . Sciatica? Condition affecting the nervous system . Nephritis? . Kidney stones? . Any other kidney trouble? . Bladder trouble? Genito-urinary condition . Prostate trouble? . Disease of the uterus or ovary? 0 |0O |Z X IF [XR |= |— . Any other female trouble? 000 # U,S, GOVERNMENT PRINTING OFFICE: 1975 O - 573-998 163 Series 1. Series 2. Series 3. Series 4. Series 10. Series 11. Series 12. Series 13. Series 14, Series 20. Series 21, Series 22, VITAL AND HEALTH STATISTICS PUBLICATION SERIES Formerly Public Health Service Publication No. 1000 Programs and collection procedures.— Reports which describe the general programs of the National Center for Health Statistics and its offices and divisions, data collection methods used, definitions, and other material necessary for understanding the data. Data evaluation and methods reseavch.— Studies of new statistical methodology including: experi- mental tests of new survey methods, studies of vital statistics collection methods, new analytical techniques, objective evaluations of reliability of collected data, contributions to statistical theory. Analytical studies.—Reports presenting analytical or interpretive studies based on vital and health statistics, carrying the analysis further than the expository types of reports in the other series. Documents and committee reports.—Final reports of major committees concerned with vital and health statistics, and documents such as recommended model vitdl registration laws and revised birth and death certificates. Data from the Health Interview Survev.—Statistics on illness, accidental injuries, disability, use of hospital, medical, dental, and other services, and other health-related topics, based on data collected in a continuing national household interview survey, Data from the Health Examination Survey.—Data from direct examination, testing, and measure- ment of national samples of the civilian, noninstitutional population provide the basis for two types of reports: (1) estimates of the medically defined prevalence of specific diseases in the United States and the distributions of the population with respect to physical, physiological, and psycho- logical characteristics; and (2) analysis of relationships among the various measurements without reference to an explicit finite universe of persons. Data from the Institutional Population Surveys. .— Statistics relating to the health characteristics of persons in institutions, and their medical, nursing, and personal care received, based on national samples of establishments providing these services and samples of the residents or patients. Data from the Hospital Discharge Survey.—Statistics relating to discharged patients in short-stay hospitals, based on a sample of patient records in a national sample of hospitals. Data on health resources: manpower and facilities. —Statistics on the numbers, geographic distri- bution, and characteristics of health resources including physicians, dentists, nurses, other health occupations, hospitals, nursing homes, and outpatient facilities. Data on mortality.—Various statistics on mortality other than as included in regular annual or monthly reports—special analyses by cause of death, age, and other demographic variables, also geographic and time series analyses. Data on natality, marriage, and divorce,—Various statistics on natality, marriage, and divorce other than as included in regular annual or monthly reports—special analyses by demographic variables, also geographic and time series analyses, studies of fertility. Data from the National Natality and Mortality Surveys.— Statistics on characteristics of births and deaths not available from the vital records, based on sample surveys stemming from these records, including such topics as mortality by socioeconomic class, hospital experience in the last year of life, medical care during pregnancy, health insurance coverage, etc. For a list of titles of reports published in these series, write to: Office of Information National Center for Health Statistics Public Health Service, HRA Rockville, Md. 20852 DHEW Publication No. (HRA) 75-1311 Series 1-No. 11 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service HEALTH RESOURCES ADMINISTRATION 5600 Fishers Lane Rockville, Md. 20852 OFFICIAL BUSINESS Penalty for Private Use, $300 POSTAGE AND FEES PAID U.S. DEPARTMENT OF H.E.W. HEW 390 THIRD CLASS BLK. RATE Series 1-Number and HEALTH STATISTI Tole: VN VEN NTooloTHE Jog {ToT NH Tao ol] V1: pL Cg, 7 y ~~ = o NCHS % wa First followup: June B, 1974 ,.....cisniivismssnasnsnmasmsnssnooe 6,790 3,531 34.2 Second followup: June 20,1974 . ....... iii 4,709 5,612 54.4 Telephone followup: July 20,1974 ......... iii ' 568 7,726 74.9 Total rECRIVEA . . oo ttt tt tee eee 8,980 87.0 Total unusable (out-of-business, out-of-scope, PMR, etc.) ......... 910 8.8 Additional facilities identified: RESPONGBNES. vows ams @es sss sey Be CRM wv aims m0 28 0® sbi 100 NONESPONDENTS ....ccsovssesrsinspaipnavus mes wos sss seers 270 ! Telephone followup to nonrespondents was conducted with the projects, not the individual medical clinics. This was necessitated by the fact that the projects functioned as intermediaries in the mailing process. for subsequent return to the contractor. In this way, receipt control of the individual forms could be facilitated. Nine States— Arkansas, Colorado, Louisiana, Michigan, Oklahoma, Rhode Island, Tennessee, Washington, and West Virginia—requested that all medical provider questionnaires be sent to a central office at the State level since, in these cases, the State maintained statistics on medical family planning in that office. For each of these States, the questionnaires were grouped by project and inserted into mailing envelopes in the standard manner, but these mailing envelopes were then boxed together for mailing in bulk to the designated office. By using the project mailing envelopes, the State office could forward the questionnaires to the projects, if necessary, for completion of items not available through the State office. Nonmedical providers.—In developing the uni- verse for the National Inventory, it became apparent that the nonmedical providers were single units, and could not be aggregated under projects in the way the medical providers were. In these cases, the actual service location was also the headquarters; that is, for each non- medical provider the project headquarters and the service site were the same place. The process of mailing questionnaires to nonmedical pro- viders simply involved mailing each question- naire to the name and address indicated on the form’s identification label. Since the States are concerned primarily with statistics on medical family planning services, none of the question- naires for the nonmedical providers were mailed through State government offices. Some of the presumed providers of nonmedical services re- turned the forms indicating that they did not provide family planning services of any nature. In some cases this response appeared questiona- ble, and these forms were remailed with a special note defining the scope of nonmedical family planning services in the hope of clarifying any misunderstanding of definitions that may have occurred. The first followup mailing also utilized this note. As a further effort, a special cover letter was included in the second followup mailing to emphasize the importance of the information requested of the nonmedical pro- viders. Information collected on the medical pro- viders included physical location; operating responsibility; primary purpose; funding sources; patient load; total visits; medical, ancillary, and contraceptive services offered; and staffing. For the nonmedical providers, information was ob- tained on physical location; operating responsi- bility; whether referrals are provided; whether space, supplies, etc., are provided to others; and whether they contract or pay others for the provision of medical family planning services. Manual Editing and Coding Procedures As the questionnaires were received, they were clerically sorted according to type of provider. Forms returned by the post office and those returned by respondents indicating out-of- business, duplicate form, and so forth, were coded for deletion from the universe and received no further editing. Good returns, that is, returns from facilities in operation within the scope of the National Inventory, were carefully edited by trained clerks following specific writ- ten editing and coding instructions based on NCHS specifications. The editing and coding procedures were designed to: ® Identify forms with incomplete or missing data items which would require further contact with the facility to complete. ® Verify that the facility for which the questionnaire was completed was within the scope of the National Inventory. ® Detect any inconsistencies or unreasonable entries. ® Assure that the form contained informa- tion for only one facility. ® Provide uniformity of the data in prepara- tion for keypunching and computerization. ® Develop codes for the “open end” re- sponses. Each questionnaire which failed to pass one or more of the manual edits was separated from the other forms as a “fail edit.” In most instances, the service site which completed the form that failed during editing was contacted by telephone for verification and/or correction of the data reported; in the few instances where a major portion of the questionnaire was involved, the contact was made by mail. For those facilities not responding to the fail-edit inquiry, data were imputed during the machine editing stage. Once a questionnaire had passed through the manual edit, the data were keypunched and subsequently placed on computer tape for further processing. The effective cutoff date for survey returns was August 1, 1974. All editing, . coding, and keypunching, however, was not completed until October 1, 1974, and question- naires received during this period were processed if possible. Georgia and Tennessee presented special prob- lems in editing due to their incomplete data on nearly every facility. Telephone contact was made with the State health department office responsible for family planning programs in each State. Through these telephone contacts, general information applying to all service sites in each State was obtained along with some additional information on specific service sites. The types of data obtained on the nonrespondents from these States can be described as follows: Georgia: General data: funding, type of and patient percentage of receipt of services offered, ancillary services, type of and percentage of “use of contraceptive methods. Specific data: total patients, new patients, and total visits. Tennessee: General data: funding, primary purpose, loca- tion, ancillary services, patient/new patient ratio, patient/visit ratio. Specific data: total patients, total IUD users, total users of oral contraceptives A questionnaire was completed for each non- responding facility based on these data provided. No additional fail-edit procedures were em- ployed during editing. Because of the large volume of data still missing on each question- naire, no imputation during machine editing as described later was performed on these forms. Applying such a process in these cases would have created statewide data which would have been primarily imputed and statistically ques- tionable. Keypunching Specifications for keypunching were designed on the basis of the manual editing and coding procedures. Nonmedical providers were re- quested to complete a substantially smaller portion of the questionnaire than medical pro- viders, therefore requiring fewer cards to be punched. To provide for more effective use of keypunching time and more efficient sight- scanning for format and structure, the question- naires were batched for punching according to provider classification. Keypunching was 100- percent key-verified for 99.5-percent accuracy. After punching, the data were put on computer tape for implementation of the machine-edit program. Machine Editing Machine editing included range and ratio checks, cross-checks between question re- sponses, and imputation for item nonresponse, if desired. Any questionnaire from the first annual survey of the National Inventory which was only partially completed was subject to followup verification and/or imputation of a response for the missing item(s). If major por- tions of the form were not completed when they should have been, telephone or mail followup to the responding clinic was performed to solicit answers. In instances where only one or two items required a response, or when there was no response to the fail-edit inquiry, the response was imputed based on NCHS specifications. For all questions except items 15, 17, and 18, a “hot deck” process was used for imputation of responses. In using ‘hot decking,” two or three key criteria questions are identified for each item to be imputed. These key criteria are used to sort the records in the data file and group together all facilities whose responses are similar in nature. Once the file is sorted by the key criteria for a particular question, the entry for that item is taken from the record immediately preceding the one to be imputed. For questions 15 and 17, the percentages which were missing were obtained by using a modification of the “hot deck.” The data file is sorted by the key criteria questions; however, instead of using the particular response of the preceding record, the average percentage across all records in the sort for that item is obtained and entered as the imputed response. The imputation of question 18 responses was also performed in a different manner. Thirteen ratio tables of staff type to staff hours were formulated and utilized for completion of missing items. The criteria questions upon which the imputa- tion process was based are itemized in table C. As indicated previously, two States—Georgia and Tennessee—presented special problems due to their substantial amount of nonreporting. In order not to lose the minimal information obtained, but at the same time not inflate the figures, no imputation of missing items was 12 Table C. Criteria questions used to impute for nonresponse in the first annual survey: National Inventory of Family Planning Services, 1974 Question to be imputed Criteria questions Bp eg my wwe wns wns wwe oo ch § 5,7 i EEL EUG FFE 0 HAE A i eet ord 4,7,8 T ies re EEE AE ER eww ww ie 4,5,8 Re 4,5,7 TY rrr wa EIRENE HE SERED EEE 57,8 WD! owe vw cve wow oe 9008 ELE ES © AE 4,5,7 PA | sins wows win own 2 000 0 wiki WE £0 R956 8 yo 15 iriver saata reer araaaas 4,5,7 UT wns mms uses saree wwe wee wn some 4,5,7 18 viva H Es EIR RATE Eee 12, 14a performed on questions 12-18 of questionnaires from these States. Once the data file passed all required edits, it was considered clean, and tabulations based on these data could be generated. Table Generation The 1974 annual survey was the first survey to be conducted on the universe of the National Inventory. Because of the lack of previous information on the facilities in the listing, no attempt was made to “weight up” the reported data to arrive at an estimate for the total universe. It is not statistically valid at this point in time to assume that the characteristics ob- tained from the reporting facilities would occur in the same proportion in the nonreporting facilities. Until further data are received on the nonresponding facilities and the universe cover- age is validated, all data presented will be solely that of the reporting facilities and will be identified as such. RESPONSE TO THE FIRST ANNUAL SURVEY Completion of the processing of the survey data yielded further changes in the universe of the National Inventory. Those facilities identi- fied as nonproviders, out-of-business, duplicates, etc., were deleted from the universe; and newly identified sites were added. There were also changes in service-provider status. Some facilities originally classified as nonmedical providers were actually medical providers, and were trans- ferred to this listing. In other instances, the opposite was true, and supposed medical pro- viders were changed to nonmedical providers. The result of these deletions and additions was a revised universe of 9,781 service sites—5,719 medical and 4,062 nonmedical. A total of 8,170 service sites responded to this first survey, for an overall response rate of 83.5 percent based on the revised universe of 9,781 sites. These 8,170 responding sites included 4,607 medical providers and 3,563 nonmedical providers. The 4,607 medical providers included 113 service sites for which minimal data were availa- ble due to the following reasons. Eighty-nine of these sites began operation in 1974 and were therefore unable to supply answers to most of the questionnaire items which applied to the 1973 calendar year. Another 24 sites may have been operational prior to 1974 but their responses did not permit clear-cut categorization either as medical or nonmedical providers. Responses given, however, indicate that their provision of medical services was at best a minimal effort. These 113 sites were excluded from the main data base used for computing all tabulations generated from this survey, thus reducing the data base of responding medical clinics to 4,494. As mentioned previously, no attempt has been made to “weight up” the data of the reporting facilities to the total universe figure of 9,781. Two reasons for this are: (1) As a new program, no previous information is readily available on the nonresponding facilities. Thus, applying the same proportion of responses to the nonrespondents as occurred with the respondents is totally unacceptable. Therefore, it was decided to use only the data obtained from the reporting sites in any tabulations generated. (2) There is no way of knowing that the total of 9,781 facilities is accurate. As of now, there has been no statistical measurement of its validity or the scope of its coverage. It is anticipated that in the near future a comple- ment survey will be completed which will measure the validity of the National Inventory universe. RESULTS OF THE FIRST ANNUAL SURVEY Tables D and E show the breakdown of responding facilities by census region and also by State (see appendix III for a breakdown of the geographical classification). The South con- tains nearly half of the 4,494 medical providers who responded, with Georgia and Texas being the southern States with the largest number of such facilities. For the nonmedical providers, the North Central contained the most responding sites, with Indiana, Iowa, and Minnesota being the States with the largest number. Only about 10 percent of the nonmedical providers were operated by nongovernment agencies or organizations, as illustrated in table F. Taking the actual responses, 1,690 of the 3,121 State/locally operated sites (47.4 percent Table D. Number of responding family planning service sites in the first annual survey, by census region and division and type of service provided: National Inventory of Family Planning Services, 1974 survey , SS on Medical Nonmedical Region and division s ; providers providers All locations ......... 4,494 3,563 United States ........... 4,410 3,563 Regions: Northeast .....ixeuivvinvens 646 381 North Central ............. 700 1,641 South .................... 2,210 1,066 West .......ooviiiinn.. 854 474 Northeast: New England .............. 193 134 Middle Atlantic ............ 453 247 North Central: East North Central .......... 430 735 West North Central ......... 270 906 South: South Atlantic ............. 1,065 524 East South Central .......... 544 273 West South Central ......... 601 269 West: Mountain ................. 288 294 Pacific ,....vnssninimemisnims 566 180 Puerto RICO iv ivimiuns mms mmm 81 Outlyingareas ................ 13 Table E. Number of responding family planning service sites in the first annual survey, by State or geographic location and type of service provided: National Inventory of Family Planning Services, 1974 survey Location Medical | Nonmedical Location Medical | Nonmedical All locations ........... 4,494 3563 J MISSOUIT 5 eis viwsmmsmusinns wesw sone 111 158 MONTana ,.: vs wnsmaswes mes ws vw 20 77 United States . ............. 4,410 3563 || Nebraska ...w: ee: uesmosnspmsmes 23 81 NEVEAD: «om: oms mes was aru s om: ves 15 13 AlEDAINE i: vus vm + ois s ws 08 20 ¥ wi 131 38 || New Hampshire ................. 13 18 ABSA 0. ain bie 0 98 3 HSE TES Be 19 2 || Newdersey .......... ooo... 85 46 AUZONG «ove vim sin smn 5 0d 3 15 5% 3 908 87 16 || New Mexico .............cooouunn 72 34 Arkansas ..........cenuiineenanns 98 B50 lH NewYork ..wsmssassmsmmswnsens 222 95 CallfOrNIa vivo vies vies ws pms ase miw «wo 392 00 || North Caroling ; c..ossmsnmsmasmon 95 104 COIOTAO0. ov ovin smn sw 4 06 # 00m 6 mn 3 wi 52 91 | North Dakota ....ivivmanssmassmes 8 88 CONNBCHCUT ov. vis 5 40 & 3iW 6 0d» wiv 38 8||Ohio ......viii i 165 162 Delaware ...........ccvveeeeennn 16 5 || Oklahoma ..................... 135 34 District of Columbia ............. 28 1] Oregon .uvivisssvmsnssvssmarmen 63 39 FIOPTOB iv 5 os» 0 5 ss 970 5 wim: 5 wow 200 0p owiw 221 71 Pennsylvania ....ccsveivesmsnune 146 106 Georgia ..covivmssms mus sss ms wwe 248 140 | Rhode 181and ... ons wesmssmsrmen 22 - Hawa consi isms was mas ergo 27 5 || South Carolina .................. 108 41 Idaho ........c0iiiiiiinnnrnnnn 23 17 || South Dakota ................... 6 82 NOIS viii ieee ieiinnnnn 57 148 | Tennessee , ..v ews wes mswmm enw ovis w 193 88 INGIBNG + wis 5 win 2 wi 0 wo 3 wip 4 wre ww wim w 54 179 | Texas .: so omsnmivismemmopnsmnses 247 76 HOWE oc uivawimusmosmusmesmassssms 32 177 {AED imcinusnisoimapsmes ase 13 14 Kansas ..::uusvmrmazmasnsmms mes 54 147 I Vekmont .....-ines sims mispase 13 10 IKBIVIUCKY. cvs ai smnain se wn sins te 8 118 72 || Virginia ....... 170 96 Louisiana ........ xo snes nsimsnvs 121 109 || Washington .................... 65 44 Maine .......ooviiiiiiinnneannnn 31 11 || West Virginia ................... 60 28 Maryland ...........coiiiiinnnn 119 29 ij Wisconsin ....cisnsvwsmnenvrmann 23 122 Massachusetts ................... 76 B7 (j Wyoming us. suiewsnnswrswasnene 6 32 Michigan ..ciswismsmasvmivrswas 131 126 MINNESOLE iin isnsmmimiasmesmsy 36 173 1 Pusrto BICD: . ... ems wis as ams bas ai 81 - Mississippi EERE AIR ME AMEE 102 75 || Outlyingareas .................. - Table F. Number and percent distribution of service sites responding to the first annual survey, by operating responsibility and type of service provided: National Inventory of Family Planning Services, 1974 survey Medical Nonmedical Operating responsibility Number | Percent | Number | Percent TOMB ov oun wm win om w wsvim wow 3 tio B04 35 F890 2 90 F W000 E000 3 WEG 6 WB WB WH WI BEIGE WE Ee 4,494 100.0 3,563 100.0 GOV MMII: ov ot tt te te tee te eee tte e ete eee eas 2,966 66.0 3,204 89.9 EI I I I TT I TO ee a 386 8.6 93 23 SIAENOCl 5.00 016 5 hk ¥ ow 4 5,5 5005 5 0 6 B01 3 VIF § SUE $050 B00 6 64 BH 4 BUR ¥ ERR WOE NE 2,580 57.4 3,121 87.6 PrOPYIBLATY vv cv nvm nim vmins www sms oom smn s duns pion 5 wot 8 0060 9 8 495 8 ie ¥ 00 80.5 8 04% wie 28 0.6 19 0.5 INOIVDTORILD 4 ove tn v5 58 90% 50 8 #0 6 8.20058 [5 8 8 36 § JX & W100 006% 0000 3 40 #9 Io WOE» wi. % Colt 5 0190 93 40m 0 1,500 33.4 340 9.5 CIVUIICHY «comes vo ams Has Ma PE NSW 2 00 F 0/0 4 WI § IEE Wa B® 5 MNS SHS Wins He Wasa bs ws 6 0.1 4 0.1 RIIVBIBITY. wv crn rman sit sw SR ERA ARE ABH TH I MAR FAR 8 WH SH FOES SS MASE RRB 171 3.8 33 0.9 HHOBPIEBE + vos viv viv wwe ww iat wie swims coin ook & nn HRB ERS ER RW BREE 245 5.5 63 1.8 COPPOTALION, 7 vou v wiv cfers om vam vam 4 wins om nos 200 9 4a ® Hin 0 Chim % Ps 09 0 0 0% 0 #0 80% 1,051 23.4 210 5.9 OIE ©: ivi viw & wits & ith 5.90% 4 81% 000-8 BV 3050) § 59 05505 § 06 4 3 4) 4) WTR 5.0061 & SN: 3 Soin ® Colm MW #0 #1 C 27 0.6 30 0.8 14 of the total) were county operated and in all probability were social service or welfare depart- ments. For the medical providers, 66 percent were government operated, again with the county government operating the largest portion (1,308). Inquiry into the services provided by the nonmedical sites consisted of three questions: 1. Do you refer patients to any other site for medical family planning services? 2. Do you provide space, equipment, contra- ceptive supplies, and/or staff to others who provide medical family planning services? 3. Do you contract or pay others for the provision of medical family planning serv- ices? The question on patient referral received the largest number of affirmative responses—3,474, or about 98 percent. In a substantial number of instances—1,031, or 29 percent—the nonmedical providers also contracted or paid others for the provision of medical family planning services. The smallest number—372, or 10 percent— provided space or equipment to others who provided the medical family planning services. Data collected on the medical providers but not on the nonmedical providers included pri- mary purpose, number of patients and patient visits, medical services provided, and staffing. Responses of the 4,494 reporting medical pro- viders indicated that nearly three-fourths of the respondents provided medical family planning as their primary purpose, as illustrated in the following table: Primary purpose Number | Percent Medical family planning ............ 3,237 72.0 Sterilization. ewes vine amen saad we 8 0.2 Venereal disease testing ............. 14 0.3 Postpartum and/or prenatal care ...... 64 1.4 Comprehensive healthcare .......... 1,028 229 Other (mainly general gynecological SEIVIOBSY ou iv ds vib wins 408 5 wow & 2iv 3 80 143 32 The categories contained in the question on medical services provided revealed a wide range of provision—from 98.8 percent for the taking of blood pressure down to 14.4 percent for male sterilization. A clear division in the type of services provided can be seen in table G. Medical services that are usually considered as standard or normal had 80 percent or more of the service sites providing each service. The split occurred when the more unusual or specialized types of services were provided. The 4,494 responding medical providers served a total of nearly 4.4 million patients in 1973 with over 7 million visits. Table H shows the breakdown of patients served and visits by State. The question on staffing was difficult for many service sites due to the fact that their sessions may not have been set up on a formal basis with only paid workers. Also, comprehen- Table G. Number and percent distribution of medical facilities responding to the first annual survey, by medical service provided: National Inventory of Family Planning Services, 1974 survey Number Medical service of Percent sites Total sites .................. 4,494 100.0 Record of pertinent medical history 4,408 98.1 Record of reproductive history ....... 4,351 96.8 Record of pertinent social history ..... 3,856 85.8 Papsmear ....................... 4,420 98.4 Pelvic examination ................ 4,377 97.4 Breast examination ................ 4,336 96.5 Taking of blood pressure ............ 4,439 98.8 Contraceptive prescription .......... 4,284 95.3 Insertionof IUD .................. 3,936 87.6 Testing for syphilis ................ 3,689 82.1 Testing for gonorrhea. ............. 4,262 94.8 Pregnancy testing «usw «wesw ssi mms 3,630 80.8 Routine lab test .................. 4,092 91.1 Infertility diagnosis ................ 1,008 224 Infertility counseling ............... 1,729 38.5 Female sterilization ................ 849 18.9 Male sterilization .... csv ivivivisns 648 14.4 Sickle cell screening ............... 1,866 41.5 Other medical services .............. 1.712 24.7 Table H. Total patients served and number of visits reported by service sites responding to the first annual survey, by State or geographic location: National Inventory of Family Planning Services, 1974 survey Location Patients Patient Location Patients Petia visits visits AN IOCBRIONS 300s us emsans 4,301,880 | 7188018 1 IMISSOUIT wiv» wow + wiv » 05 5% % wiki & 310 § ik 5 106,838 129,944 MOTVEBING «vs wiv i win v wim 5 v8 0% 3 # He & 24,173 28,273 United States .............. 4,304,005 | 7,008,785 1] Nebraska ...:s:ewsniswrsmismenis 15,923 22,256 Nevada ..........coiiiiinnnnnn. 16,927 23,778 Alabama ....................... 80,656 176,828 || New Hampshire .................. 5,684 11,686 AIBSKE oy wie s wis 8 5 8 vig 50 5900 5 308 HIE 20,202 33.908) New Jersey ...u.smsmes es ows wns aes 96,059 167,831 ArZONE voi unismivisoesn isms wins 63,194 110,201 (1 New MeXICO' «ix «xiv «asst vive ows wins 34,290 54,045 Arkansas ...........c.00iiianeann 82,687 1228421 NeW YOrk ..coovssmnimsnvsnmsmns 333,748 541,588 California ............c.viiuurnn 630,609 967,396 || North Carolina .................. 76,382 124,697 Colorado ...........cciiiuunnunn. 49,082 78,960 || North Dakota ................... 3,739 4,626 Connecticut sien spvsmssmisms sims 34,112 42,719 || Ohio «ove ieee ean 150,852 249,567 Delaware co.uvsvveovsmssvssmiovns 12,349 21,647 OKIBhOMB oo avs wins eins sens wns wes 110,894 172,148 District of Columbia vxcvvivsvninss 64,291 107.9081 IOT0GON + ou 5 iw» wiv & me 5 53 wi9 5 590 5 5590 8 46,850 66,135 Florida ..sivesnassvavnsmesmanes 199,991 317,768 i] Pennsylvania .....:svsvvons sms vis 147,193 235,359 GOOPOI woe «wun 5 50 5 908 5 50 5 4 4 5.508 51% + 169,285 280644 || Rhode island +.....c.cuviveivnnvins 14,365 31,163 Hawall «:ovsnsransansndrmer nonin 61,663 76,261 South Caroling ....s:sssamsvmsnns 116,730 157,462 VOBNO 5 5 wns i 3 wn 0 woh Sl 3 0 9 90 6 id 4 14,241 34.002 1) South DaROta ...u.0:vxsis vis mom sss 6,095 7.427 HENOIS «ove e eee ieee ieee eens 121,028 187,242 || Tennessee ..........ccoveennennnn 113,551 154,975 Indiana ...........iiiiiiin, 51,613 71,028 || TeXas ovine 257,318 387,827 IOWA tiie 28,149 51,245 || Utah... 21,373 23,878 Kansas ........c.ououiiieennnnnnnn. 49,856 65948 || Vermont .............iiiiinn.. 7,621 11,080 RemtuokY ..susmmssnsswisvionswns 47,804 D1Y804: 1% 'Virglnid ovis wows mvs ms sms ows ums wns 105,048 160,157 Louisiana «.:vessme wes mman as ws nes 118,271 308.977 || Washington ..u.sessasms sms sissies 76,813 120,558 Maine ...c:osssmisnsnasmeimenms 17,879 20.773 )| West Virginia «ie vai » wos 5 + wie » ws we 0 21,220 31,401 MAEVIBI oo i von smo hmm wis bom is i 5 di 8 107,598 205,260 || Wisconsin ......ouvuvniennnenn. 16,532 22,237 Massachusetts ................... 92,314 146,310 || Wyoming ..........ouuuiennnnnn. 2,797 3,984 Michigan ...........c.coiiiuennn. 142,711 332,981 MINDESOE ..cnivvinnsmnswiss anne 37,473 62,243 || PuertoRicO .........civuinnnn. 86,488 145,161 MISSISSIPPI wuss wins ssnamesms sins 78,092 131,718 || Outlying areas wu. isa sw sss sms ows 1,036 4,069 sive care facilities or facilities not exclusively offering family planning services found it diffi- cult to determine the number of staff and amount of time spent in providing family planning services when these services are incor- porated into other services. As stated previously, special editing instruc- tions had to be devised for two States (Georgia and Tennessee) due to the fact that the staffing question was not completed for the majority of their service sites. Therefore, the staff figures in table J are based only on data received from the other States. This first annual survey of the National Inventory of Family Planning Services yielded a substantial amount of information on sites providing family planning services in the United States and selected territories. More detailed reports on the characteristics of these sites can be found in Series 14 of Vital and Health Statistics. 16 Table J. Staff division breakdowns for medical service sites responding to the first annual survey: National Inventory of Family Planning Services, 1974 survey Category of personnel Total gory OF iD employees Total professional and technical ....... 139,061 Medical personnel: PRYSICION, iv i wiv + 510 8 © 5 bo 5 208 © 6% 4 WE 2 556 § & 6,957 Physician’s assistant, nurse midwife/nurse practitioner ............c.0. iia... 2,071 Nursing personnel: RogiStored IWIFSe' + vw » wm + wim « o0 bwin & 4 6 5 #8 7,586 Licensed practical nurse ................ 1,930 Therapeutic personnel: Health @dUCaIOr ....v ivvrncsncsminsss 1,064 NUIFHIONISE cvs osomsiiinmimusmormerwes 514 Outreach worker ...................... 2,798 Social worker ........... ee. 1,418 All other professional and technical .......... 14,723 Based on 4,053 sites open in 1973 and responding to the personnel portion of the questionnaire. *Mr APPENDIX | PERSONS CONTACTED FOR COMMENTS ON THE PRETEST QUESTIONNAIRES . Theodore Woolsey, National Center for Health Statistics Dr. Philip Lawrence, National Center for Health Statistics *Mr . E. Earl Bryant, National Center for Health Statistics *Mrs. Gail Fisher, National Center for Health Statistics Mr . Noah Sherman, National Center for Health Statistics Dr. Robert Mugge, National Center for Health Statistics *Miss Judy Carpenter, National Center for Family Planning Services Dr. Frank Beckles, National Center for Family Planning Services *Mr. Don Trauger, Maternal and Child Health Service Mr. *Dr. Dr. Otis Turner, Maternal and Child Health Service Louis Spekter, Maternal and Child Health Service Alice Chenoweth, Maternal and Child Health Service *Mr. Mozart Spector, Indian Health Service *Mr. Royal Crystal, Community Health Service *Dr. Gooloo Wunderlich, Department of Health, Education, and Welfare *Mr. Arthur Campbell, Department of Health, Education, and Welfare *Dr. Carl Tyler, Center for Disease Control Mr. Dr. Gerald Sparer, Office of Economic Opportunity George Contis, Office of Economic Opportunity *Mr. Fred S. Jaffee, Planned Parenthood-World Population Dr. Eleanor Snyder, Planned Parenthood-World Population Mr. Alan Stone, American Hospital Association *PDr. Dr. Lt. *Dr. Dr. Dr. Dr. Dr. Dr. *Dr. Dr. Dr. Jack Reynolds, Columbia University Samuel Wishick, Columbia University Col. Russel, O’'CHAMPUS (Department of Defense) Ronald Freedman, University of Michigan Myron Wegman, University of Michigan Leslie Corsa, Jr., University of Michigan Oscar Harkavy, Ford Foundation Charles Schultze, Brookings Institution Andre Hellegers, Georgetown University Mary C. Calderone, Sex Information and Education Council of the United States Ansley J. Coale, Princeton University Philip Hauser, University of Chicago Mr. Nathan Hershey, University of Pittsburgh *Dr. Edward R. Schlesinger, University of Pittsburgh Dr. J. Richard Udry, University of North Carolina Dr. Elbridge Sibley, Social Science Research Council 17 18 Dr. Frank Nolestein, Population Council *Dr. Christopher Tietze, Population Council Mr *Mr Mr. Mr. Mr. *Mr. *Mr. Mr. *Mr. Mr . Harold Putnam, Regional Director, Department of Health, Education, and Welfare s. Bernice Bernstein, Regional Director, Department of Health, Education, and Welfare Bernard V. McCusty, Regional Director, Department of Health, Education, and Welfare Frank J. Grosshelle, Regional Director, Department of Health, Education, and Welfare Richard E. Friedman, Regional Director, Department of Health, Education, and Welfare H. D. McMahan, Regional Director, Department of Health, Education, and Welfare Max Milo Mills, Regional Director, Department of Health, Education, and Welfare William T. Van Orman, Regional Director, Department of Health, Education, and Welfare Fernando E. C. DeBaca, Regional Director, Department of Health, Education, and Welfare . Bernard E. Kelly, Regional Director, Department of Health, Education, and Welfare *Responded APPENDIX II ATTENDEES OF OCTOBER 1973 MEETING OF TECHNICAL ADVISORS Mr. Martin Bloom, Applied Management Sciences Mr. Grover Chamberlain, District of Columbia Department of Human Resources Dr. Cyril Crocker, Director, Howard University Center for Family Planning Services Ms. Jean Frink, Los Angeles Regional Family Planning Council Mr. Fred Jaffee, Planned Parenthood-World Population Mrs. Doris Malin, Bureau of Community Health Services, Department of Health, Education, and Welfare ) Ms. Helen Chiaruttini, Bureau of Community Health Services, Department of Health, Education, and Welfare Dr. Vestal Parrish, Tulane University Ms. K. Ryon, District of Columbia Department of Human Resources Mr. Ernest Raymond, Office of Population Affairs, Department of Health, Education, and Welfare Dr. Carl Schultz, Director, Office of Population Affairs, Department of Health, Education, and Welfare Mrs. Edna Smith, Director, Boston Family Planning Project Ms. Suzanne Ollivier, Boston Family Planning Project Dr. Eleanor Snyder, Director of Research, Planned Parenthood-World Population Mr. Mozart Spector, Indian Health Service, Department of Health, Education, and Welfare Ms. Louise Okada, Office of Program Planning and Evaluation Dr. William Tash, Director, Office of Evaluation, Health Services Administration Mr. Donald Trauger, Bureau of Community Health Services, Department of Health, Education, and Welfare Dr. Carl Tyler, Center for Disease Control Dr. Louise Tyrer, American College of Obstetrics and Gynecology Dr. Richard Udry, University of North Carolina Dr. Daniel Weintraub, Planned Parenthood-World Population Mr. John Wells, Director, Illinois Family Planning Council Ms. Barbara Wood, Geomet, Inc. Ms. Joann Langston, Geomet, Inc. Dr. Gooloo Wunderlich, Office of Policy Development and Planning, Department of Health, Educa- tion, and Welfare Dr. William Pratt, Division of Vital Statistics, National Center for Health Statistics Ms. Carolyn Warren, Bureau of Health Services Research and Development, Department of Health, Education, and Welfare Ms. Nancy Wiley, Applied Management Sciences Mrs. Gloria Hollis, Division of Health Resources Statistics, National Center for Health Statistics Mr. Siegfried Hoermann, Division of Health Resources Statistics, National Center for Health Statistics Mr. Peter Hurley, Division of Health Resources Statistics, National Center for Health Statistics Ms. Jessie Tabb, Division of Health Resources Statistics, National Center for Health Statistics 000 APPENDIX HI GEOGRAPHIC REGION CLASSIFICATION Census Region and Division Northeast New England Middle Atlantic North Central East North West North South South Atlantic East South Central West South West Mountain Pacific . Puerto Rico Outlying areas 20 Central Central Central © eee + es se a + es + + = = ee Territories ee ss se se + + es se + es se a se = eo = States Included (excludes territories) Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut New York, New Jersey, Pennsylvania Ohio, Indiana, Illinois, Michigan, Wisconsin Minnesota, Iowa, Missouri, North Dakota, South Dakota, Nebraska, Kansas Delaware, Maryland, District of Columbia, Virginia, West Virginia, North Carolina, South Carolina, Georgia, Florida Kentucky, Tennessee, Alabama, Mississippi Arkansas, Louisiana, Oklahoma, Texas Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, Nevada Washington, Oregon, California, Alaska, Hawaii Areas Included Puerto Rico American Samoa, Canal Zone, Guam, Virgin Islands APPENDIX IV FORMS AND QUESTIONNAIRES REQUEST FOR CLINIC LISTINGS DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION ROCKVILLE, MARYLAND 20852 NATIONAL CENTER FOR HEALTH STATISTICS Dear The National Center for Health Statistics (NCHS) of the U. S. Department of Health, Education, and Welfare is creating a Family Planning Facilities Inventory, which will include all locations in the country where family planning services are provided. We would appreciate your sending us any directories or listings that contain family planning facilities or any lists of projects or agencies that operate or fund family planning facilities. Please send your current listings or directories to: Chief, Health Facilities Statistics Branch Division of Health Resources Statistics National Center for Health Statistics - HSMHA 5600 Fishers Lane Rockville, Maryland 20852 If you have any questions, please let me know. Our telephone number is (301) 443-1524. Your help and time in fulfilling this request is greatly appreciated. Sincerely yours, " (Mrs.) Gloria Hollis Chief, Health Facilities Statistics Branch Division of Health Resources Statistics 21 MFI FACILITY SURVEY LETTER DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION ROCKVILLE, MARYLAND 20852 Janua 197 NATIONAL CENTER FOR ry, '3 HEALTH STATISTICS Dear Administrator: The National Center for Health Statistics of the U., S. Public Health Service is compiling a list of all facilities in the United States that provide family planning services. (Family planning services are those medical, social, and educational services which are primarily concerned with the regulation of conception.) It has been brought to our attention that increased emphasis has been placed on providing these services to residents of facilities such as yours. In order to help us in compiling our list of facilities, will you please complete the bottom portion of this letter and return the letter in the enclosed postage-paid envelope within 10 days to: Chief, Health Facilities Statistics Branch Division of Health Resources Statistics National Center for Health Statistics, HSMHA 5600 Fishers Lane, Room 12-33 Rockville, Maryland 20852 Thank you for your cooperation. Yours truly, Meer Fol. (Mrs.) Gloria Hollis Chief, Health Facilities Statistics Branch Please check one: /[ __/ No family planning services provided [___/ Some type of family planning service provided at this site / No family planning service provided at this site--patients referred to other source for family planning service Other (Specify) { / / COLLEGE HEALTH SERVICE SURVEY LETTER DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION ROCKVILLE, MARYLAND 20852 NATIONAL CENTER FOR January, 1973 HEALTH STATISTICS Dear Director: The National Center for Health Statistics of the U. S. Public Health Service is compiling a list of all facilities in the United States that provide family planning services. (Family planning services are those medical, social, and educational services which are primarily concerned with the regulation of conception.) It has been brought to our attention that increased emphasis has been placed on providing these services to college students through facilities such as student health centers or infirmaries. In order to help us in compiling our list of facilities, will you please complete the bottom portion of this letter and return the letter in the enclosed postage- paid envelope within 10 days to: Chief, Health Facilities Statistics Branch Division of Health Resources Statistics National Center for Health Statistics, HSMHA 5600 Fishers Lane, Room 12-33 Rockville, Maryland 20852 Thank you for your cooperation. Yours truly, (Mrs.) Gloria Hollis Chief, Health Facilities Statistics Branch Please check one: / No family planning services provided / / / Some type of family planning service provided at this site No family planning service provided at this site--patients referred to other source for family planning service [J / __/ Other (Specify) 23 PRETEST—PROJECT RECORD DEPARTMENT OF HEALTH, EDUCATION AND WELFARE Public Health Service Health Services and Mental Health Administration National Center for Health Statistics NATIONAL INVENTORY OF FAMILY PROJECT NO. PLANNING CLINICS PROJECT RECORD Dear Project Director: The rapid expansion of family planning services in the United States since the mid-sixties has brought to the fore- front the need for accurate and current information on the extent to which theseservices are available nationally. On January 1, 1972, the National Center for Health Statistics implemented the National Reporting System for Family Planning Services to collect data on family planning patients seen in public facilities and the services they receive. However, there is no comprehensive inventory of all family planning clinics in the United States and the services available through them. The National Center for Health Statistics is therefore conducting this survey to obtain current information about each family planning clinic such as name, location, caseload, services offered and staff size. This National Inventory of Family Planning Clinics expands upon and replaces previous surveys of this nature conducted by Planned Parenthood-World Population. The information from this survey will be used by the National Center for Health Statistics for statistical reports on the characteristics: of family planning clinics. In addition, the data will be made available to other agencies to compile directories of available clinics, to plan for needed additional clinics,"and to plan for future manpower needs. We are therefore asking your cooperation in completing sections B and C of this Project Record. Please be sure to fill out a separate block in Section B of this form for every location at which your project, agency or program provides medical family planning services. For ach location listed in Section B, one of the enclosed Clinic Records also should be completed. If additional Clinic Record forms are needed, please indicate on the enclosed post- card the number of additional forms needed and return the card to us as soon as possible. (Note: this postcard is also to be returned to us if you provide no family planning services or have received a duplicate request from us for these data.) None of the data will be considered confidential except in the following situation: if you feel that some of these questions should be kept confidential, please write the number of each question you wish to be so designated in the “Confidential” box which follows. Your responses to these “confidential” questions will be used only in aggregated statistics and will not be released in any manner in which your project, agency or program can be identified. Questions to be Considered nfidential” Page & Question Number Page & Question Number Page & Question Number 2 nasion Lume i i 1 1 1 1 _— _— | | dT — | ! Please complete all questions whether or not they are to be considered confidential. Before completing these forms, however, you should familiarize yourself with the definitions on the next page. If you wish to have the individual clinics complete the Clinic Record Forms, please have them return the completed forms to you so that the forms for all clinics under your direction can be returned together in the enclosed postage-paid envelope. All forms should be returned within three weeks to: Chief, Health Facilities Statistics Branch Division of Health Resources Statistics National Center for Health Statistics 5600 Fishers Lane, Room 12-33 Rockville, Maryland 20852 Thank you for your cooperation. Sincerely yours, TTR, W solye { Theodore D. Woolsey Director, National Center for Health Statistics HSM-711-1 (Page 1) 0.M.B. NO 68572185 373 APPROVAL EXPIRES: 4-30-74 (a) SECTION A — DEFINITIONS FAMILY PLANNING SERVICES Family planning services may be medical, social, and/or educational. Medical family planning services consist of a medical history, physical examination, laboratory testing, consultation, treatment including continuing medical supervision, issuance of drugs and contraceptive supplies, and appropriate medical referral when indicated. Social and educational family planning services include services such as outreach, sex education and the provision of transportation, or babysitting when these services are provided to enable a person to attend a family planning clinic or to otherwise obtain family planning services. CLINIC LOCATION A clinic location is a place or facility at which any family planning services are provided on a regularly scheduled basis. It may be a hospital, health center, mobile unit, free-standing site, church, or store front. For mobile units, each stop is considered a clinic location; therefore, a separate Clinic Record Form should be filled for each stop or location. Physicians’ offices should be considered as clinic locations only when there is a formal relationship with some project or agency which is responsible for providing family planning services. Physicians, nurses, vol- unteers, etc. who make home visits for the purpose of delivering a family planning service should count their home base of operations as the clinic location. PROJECT OR AGENCY OR PROGRAM A family planning project is a specifically designed set of activities and services intended to advance achievement of the program’s family planning objectives. It may be funded through general revenue or specific grants from either public or private sources. A family planning agency is an administrative mechanism to carry out family planning programs through family planning projects which deliver family planning services. Family planning programs are activities that provide the services which enable individuals effectively to practice family planning. These activities are provided by commercial, governmental, or non-profit institutions and indi- vidual practitioners. SECTION B — CLINIC IDENTIFICATION 1. Did your project, agency or program participate in the provision of medical family planning services during any part of calendar year 1972? a Yes 0 No (Skip to Section C. question 6) NOTE: If the only family planning services provided were social and/or educational as defined under “Family Planning Services" in Section A of this form, check box marked “No”. 2. For each location at which your project, agency or program provides medical family planning services, please complete one of the following blocks: Name of clinic: Number Street Room Number P.O. Box, Route, etc. Location: - City or town County See | Zip Administrator: Number or percentage of all your project, agency or program's patients served at this location in 1972: Number — ~~ orPercentage —______% Agency or organization responsible for operation of this clinic. HSM-711-1 (Page 2) 373 25 SECTION B — CLINIC IDENTIFICATION (Cont.) (b) Name of clinic: Number Street Room Number P.O. Box, Route, etc. Location: : City or town County State | Zip Administrator: Number or percentage of all your project, agency or program's patients served at this location in 1972: Number or Percentage % Agency or organization responsible for operation of this clinic. (c) Name of clinic: Number Street Room Number P.O. Box, Route, etc. Location: City or town County State | Zip Administrator: Number or percentage of all your project, agency or program's patients served at this location in 1972: Number or Percentage % Agency or organization responsible for operation of this clinic. (d) Name of clinic: Number Street Room Number P.O. Box, Route, etc. Location: * ! City or town County State | Zip Administrator: Number or percentage of all your project, agency or program's patients served at this location in 1972: Number or Percentage % Agency or organization responsible for operation of this clinic. (e) Name of clinic: Number Street Room Number P.O. Box, Route, etc. Location: - ation City or town County State Zip Administrator: Number or percentage of all your project, agency or program's patients served at this location in 1972: Number or Percentage % Agency or organization responsible for operation of this clinic. (f) Name of clinic: Number Street Room Number P.O. Box, Route, etc. Location: City or town County State | Zip Administrator: Number or percentage of all your project, agency or program's patients served at this location in 1972: Number or Percentage % Agency or organization responsible for operation of this clinic. HSM-711-1 (Page 3) 3-73 26 SECTION B — CLINIC IDENTIFICATION (Cont.) (9) [Name of clinic: Number Street Room Number P.O. Box, Route, etc. Location: City or town 1a State | Zip Administrator: Number or percentage of all your project, agency or program's patients served at this location in 1972: Number or Percentage % Agency or organization responsible for operation of this clinic. (h) Name of clinic: Number Street Room Number P.O. Box, Route, etc. Location: City or town T= State Zip Administrator: Number or percentage of all your project, agency or program's patients served at this location in 1972: Number orPercentage ______________ % Agency or organization responsible for operation of this clinic. If more space is needed, please use additional sheets of paper and attach trem to this form. Thank you. SECTION C — PROJECT, AGENCY OR PROGRAM INFORMATION — CALENDAR YEAR 1972 1. The following operational data are requested for Calendar Year 1972. If the period for which you are reporting is NOT the 12-month period from January 1, 1972 through December 31, 1972, please indicate below the period used. of days Beginning date Ending date month/day/yr month/day/yr Were you in operation 12 months at the ending date noted above? O Yes [J No —= How long?. months (a) How many patients received medical family planning services from your agency in the period for which you are reporting? New patients Continuing patients Total patients A new family planning patient is one who registered and received medical family planning services through your agency for the first time during the period for which you report. A continuing family planning patient is one who registered for and received medical family planning services prior to the period for which you report and who made at least one return visit to your program during the period for which you report. (b) How many medical family planning visits were recorded by your agency in the period for which you are reporting? (Do not include visits or mailings whereby a previously registered patient received suppliesonly.) initial visits return visits total visits (should equal new patients in 1a. above) An initial vist for medical family planning services is defined as a visit during the period for which you report at which a patient is registered for and receives these services for the first time through your agency. A return visit is defined as a visit by a previously registered patient who is seen by a physician or nurse or other authorized personnel for medical consultation, examination and [or lab tests during the period for which you report. It may be a routine annual revisit or a problem visit by both new and continuing patients. Exclude initial visits and visits for supplies only. HSM-711-1 (Page 4) 373 27 SECTION C — PROJECT, AGENCY OR PROGRAM INFORMATION — CALENDAR YEAR 1972 (Cont.) 2; How many days were one or more of the clinics operated by this project, agency or program in operation during 1972? (Include only those days that the clinics were actually open for and receiving patients for medical family planning services.) Number of days 3 Are there any special groups of people that this project, agency or program cannot or does not serve based on: (a) Sex? CO ves — [Serves females only Oserves m only a No (skip to question 3b) (b) Age? Oves —» Cannot or does not serve persons under 16 years of age Cannot or does not serve persons 16-20 years of age [Cannot or does not serve persons 21 years of age or older [ICannot or does not serve minors without parental consent Ccannot or does not serve persons of other age group (Specify) O No (skip to question 3c) (c) Income? [OJ Yes = Piease specify income level of persons this facility cannot or does not serve. [J No (Skip to question 3d) (d) Any other physical or social characteristic? [3 Yes (specify) 0 No a. Is this project, agency, or program especially trying to reach certain population groups (target populations) based on: (a) Sex? Ovyes —= ([J Females only —s[ 0 All femates 0 Postpartum or recently pregnant females O Ever-pregnant females 0 Other (Specify) [J Males only [TINO (skip to question ab) (b) Age? [OJ Yes— [J Persons under 16 years of age [J Persons 16-20 years of age [J Persons 21 years of age and older [1 Minors with parental consent [0 Other age groups (Specify) Ono (Skip to question 4c) (c) Income? [J Yes — Piease specify income level Ono (Skip to question 4d) (d) Ethnic origin? OYes— [] Whites [J Negroes or Blacks J O American indians [J Mexican-Americans (J Puerto Ricans { Oother(specity) ___________ [J No (skip to question ae) (e) Geographic area? [O Yes — , O Rural area 0 Town or unincorporated city 0 Small city (not included in a larger metropolitan area) [J Metropolitan ares m——— 4 [J Entire metropolitan area 0 Inner city a 0 Model cities area [J Other area within metropolitan area (Specify) 0 County [J Other geographic area (Specify, i.e. State, region, etc.), [INO (skip to question a1) (f) Any other physical or social characteristic? [J Yes (Specify) 0 No HSM-711-1 (Page 5) 3-73 28 SECTION C — PROJECT, AGENCY OR PROGRAM INFORMATION — CALENDAR YEAR 1972 (Cont.) 5. (a) What were the total number of hours all clinics operated by your agency were open for medical family planning services during: (1) A typical week last month (2) Last week Hours Hours (b) For the typical week last month reported in Question 5 (a) (1) above please complete the following staff table. (Include only those staff who were in d family ing services during this typical week. If data are unavailable please estimate the number of, and hours for each staff type.) (1 (2) (3) (4) Number of Number of Number of Total staff staff staff staff hours Staff type working assigned assigned worked during this to work to work during this typical the full part of the typical week schedule* schedule** week Physician (administrative only) Physician (clinical services only) Physician (both administrative and clinical) Registered nurse (administrative only) Registered nurse (clinical services only) Registered nurse (both administrative and clinical) Licensed practical nurse (or vocational nurse) Social worker (administrative only) Social worker (counseling only) Social worker (both administrative and counseling) Administrator (not included above) Paraprofessional community or outreach worker Clerk, secretary, receptionist Health educator Nurse midwife, or physician's assistant Other (Specify) TOTAL * For example, if clinics were open for family planning services for 30 hours, these people worked the total 30 hours. ** For example, if clinics were open for family planning services for 30 hours, these people worked less than 30 hours. 6. Name of person completing this form: (Please print) Job title: Telephone number: COMMENTS: HSM-711-1 (Page 6) 373 PRETEST— CLINIC RECORD DEPARTMENT OF HEALTH, EDUCATION AND WELFARE Public Health Service Health Services and Mental Health Administration National Center for Health Statistics NATIONAL INVENTORY OF FAMILY PROJECT NO. PLANNING CLINICS CLINIC RECORD Dear Director: The rapid expansion of family planning services in the United States since the mid-sixties has brought to the forefront the need for accurate and current information on the extent to which these services are available nationally. On January 1, 1972, the National Center for Health Statistics implemented the National Reporting System for Family Planning Services to collect data on family planning patients seen in public facilities and the services they receive. However, there is no comprehensive inventory of all family planning clinics in the United States and the services available through them. The National Center for Health Statistics is therefore conducting this survey to obtain current information about each family planning clinic such as name, location, caseload, services offered, and staff size. This National Inventory of Family Planning Clinics expands upon and replaces previous surveys of this nature conducted by Planned Parenthood- World Population. The information from this survey will be used by the National Center for Health Statistics for statistical reports on the characteristics of family planning clinics. In addition, the data will be made available to other agencies to compile directories of available clinics, to plan for needed additional clinics, and to plan for future manpower needs. None of the data will be considered confidential except in the following situation: if you feel that some of these questions should be kept confidential, please write the number of each question you wish to be so designated in the “Confidential” box which follows. Your responses to these “confidential” questions will be used only in aggregated statistics and will not be released in any manner in which your individual facility can be identified. Questions to be Considered “Confidential” Page & Question Number Page & Question Number Please complete all questions whether or not they are to be considered confidential. Before completing this form, however, you should familiarize yourself with the definitions in Section A. If you are an individual clinic completing this Clinic Record Form, please return the completed form to your Project so that the forms for all clinics under the Project's direction can be returned together. All forms should be returned within three weeks. Thank you for your cooperation. Sincerely yours, anes” SN MKaodow 9. wets Theodore D. Woolsey Director, National Center for Health Statistics HSM - 711-2 (Page 1) 0.M.8. NO 68572185 3-73 APPROVAL EXPIRES: 4-30-74 SECTION A. DEFINITIONS: For this survey, the following definitions apply: FAMILY PLANNING SERVICES Family planning services provide the means which enable individuals to meet their family planning objectives. These services are medical, social, and educational. Medical family planning services consist of a medical history, physical examination, laboratory testing, testing, consultation, treatment including continuing medical supervision, issuance of drugs and contraceptive supplies and appropriate medical referral when indicated. Other services such as outreach, the provision of transportation, or babysitting are included as social and educational family planning services when these services are provided to enable a person to attend a family planning clinic or to otherwise obtain family planning services. CLINIC LOCATION A clinic location is a place or facility at which any family planning services are provided on a regularly scheduled basis. It may be a hospital, health center, mobile unit, free-standing site, church, or store front. For mobile units each stop is considered a clinic location; therefore, a separate Clinic Record Form should be filled for each stop or location. Physicians’ offices should be considered as clinic locations only when there is a formal relationship with some project or agency which is responsible for providing family planning services. Physicians, nurses, volunteers, etc. who make home visits for the purpose of delivering a family planning service should count their home base of operations as the clinic location. PROJECT OR AGENCY OR PROGRAM A family planning project is a specifically designed set of activities and services intended to advance achievement of the program's family planning objectives. It may be funded through general revenue or specific grants from either public or private sources. A family planning agency is an administrative mechanism to carry out family planning programs through family planning projects which deliver family planning services. Family planning programs are activities that provide the services which enable individuals effectively to practice family planning. These activities are provided by commercial, governmental, or non-profit institutions and individual practitioners. HSM - 711-2 (Page 2| 3-73 4‘ ) 31 32 SECTION B. IDENTIFICATION 1a. Znter below the name and actual location of the clinic: (Please type or print.) NAME OF CLINIC oo “| Number Street Room No. P. O. Box, Route, etc. im ADDRESS City or town County State Zip TT [AreaCode Number TELEPHONE 1b. Enter below the area(s) served by this clinic: or or counties or States 1c. Enter the date this clinic first began its family planning services: MONTH 1 DAY YEAR 2 How many different individuals visited this clinic to obtain family planning services during 1972? Number of individuals 3 How many days was this clinic in operation during 1972? (Include only those days that the clinic was actually open for family plan- ning services and receiving patients.) Number of days 4. For every day in Column (1) that this clinic is open for family planning services, enter in Column (2) the actual hours it is open and providing these services. If the clinic is not open for a particular day, enter “0” in Column (2). (Example: If this clinic is open from 10:00 a.m. until 2:00 p.m., enter “10:00 — 2:00" under Column (2).) For each day the clinic is open and Column (2) is filled, mark “X" in the appropriate box under Column (3) that describes the frequency of these sessions. (Complete schedule for sessions you are now operating.) Column (1) Column (2) Hours Open and Providing Family DAY Planning Services (Enter “0” if not open this day.) Co Frequency of lumn (3) Sessions (Mark “X") Every Other Weekly Week ~ Other Monthly (s fy) Monday Tuesday Wednesday Thursday Friday Saturday Sunday 5. Is this clinic located in a: (Check (X) one box only) Oo Hospital OJ state or local health department building 0 church OO community house, school, etc. 0 Office building or store 0 Physician's office 0 Other (Specify) 0 Mobile unit a. Principal location of unit: Address: 6. Please read ALL of the following categories, (1) PUBLIC then check all applicable box (es) for the type(s) | OJ Federal 0 city of organization(s) which operate(s) this clinic. 0 state 0 School District (Include only those organizations actually 0 Interstate 0 special Unit responsible for this clinic's operations and not those organizations involved only with the fund- ing of the clinic.) HSM - 711-2 (P; 3] sy age 3) 0 Metropolitan OJ County (2) PUBLIC SPONSORED 0 Community Action [J sponsored Organization O Other (Specify) (4) NONPROFIT 0 Hospital 0 Church O Voluntary agency 0 university 0 Other (Specify) 0 Other (Specify) (3) PROFIT O Hospital 0 Private clinic O Private physician 0 Other (Specify) (6) OTHER OWNERSHIP 0 (Specify) 7a. Which of the following services or functions does this clinic ~~ 7b. provide for family planning patients? (Check all that apply.) 0 Record of pertinent medical, reproductive and social history [J Pap smear and pelvic examination OJ Breast examination 0 Taking of blood pressure 0 Routine lab tests (hematocrit, urine for sugar and albumin) OJ Infertility diagnosis or counseling O sickle cell screening 0 Male sterilization OJ Female sterilization 0 V-D testing O Pregnancy testing OJ Contraceptive prescription [OJ Other medical service (Specify) Please enter below the approximate percentage of your patients who received these services in 1972 on initial* visit. (Include only those services provided at this site.) Percentage IHN *An initial visit for medical family planning services is defined as a visit at which a patient is registered for and receives medical family planning services for the “first time” through your clinic. 7c. Which ot the following other ancillary services or functions does this clinic provide? O Outreach Program (Outreach activities are those which inform prospective patients of family planning services and assist them in availing themselves of the services.) O Followup Program (Follow-up activities include contacting persons who have missed appointments and the scheduling of reappointments.) 0 Classroom or group sessions about family planning 0 Classroom or group sessions on sex education (in addition to family planning and contraceptive education) 0 Individual counseling about family planning CI Referral to private physicians for family planning or medical services not provided at this clinic. 0 Referral to other clinic for family planning or medical services not provided at this clinic. 0 Babysitting (while patient is at clinic) 0 Transportation to the clinic (provided or subsidized) 0 Other (Specify) 0 None Which of the following types of contraceptive methods are 8b. offered by this clinic? O oral (Pil) Ovo 0 injection 0 Diaphragmijelly 0 Foam 0 condom 0 Rhythm method 0 Other (Specify) Please enter below the approximate percentage of your patients who received this method in 1972 visits. (Include only those methods provided at this site.) Percentage I 0 None Is the primary purpose of this clinic to provide family plan- ning services? 0 Yes (Skip to question 10.) 0 Nos=What is the primary purpose of this clinic? Name of person completing this form: Job title: Telephone: Area Code: Number: HSM - 711-2 (Page 4) 3-73 f ) 33 UNIVERSE VERIFICATION LETTER DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HEALTH RESOURCES ADMINISTRATION Rockville, Maryland 20852 National Center For Health Statistics October 1973 Dear Administrator: The rapid increase of family planning programs across the nation over the last decade has highlighted the need for current and accurate information on the extent and nature of these services. Therefore, the National Center for Health Statistics has planned an extensive National Family Planning Services Data Collection System. This system when fully operational will provide health planners at all levels of government with timely statistics not only on the number and characteristics of patients but also facility and staff characteristics and extent of services available at the many varied facilities — both public and privately funded - - which provide family planning services nationally. The Center is now in the process of verifying its listing of all facilities in the U.S. and its outlying territories which provide some type of Family Planning services. We are therefore asking your cooperation in completing the back page of this letter and returning it to us in the enclosed self-addressed postage-paid envelope within five (5) days. The infor- mation requested will assist us in insuring that all projects, agencies, or programs which participate in the provisions of family planning services are included in our listing. We sincerely appreciate your support in this developmental period which is so important to the success of the full-scale National Family Planning Services Data Collection System. Sincerely yours, (Mrs.) Gloria Hollis Chief Health Facilities Statistics Branch Division of Health Resources Statistics In case we need to contact you, please enter your phone number / Area Code Phone Number For the purpose of this data collection system, Family planning services are those medical, social and/or education services which are primarily concerned with the regulation of conception. CHECK ONE BOX ONLY [O Addressee does not participate in the provision of family planning services. OO Addressee maintains a clinic on site which provides family planning services. Our whose address is program is part of a more extensive system for delivering family planning which is coordinated/operated/funded by agency name OJ Addressee is an administrative unit which does participate in the provision of family planning services at the following locations: Name of service site Number Street Room Number| P.O. Box, Route, etc. (a) |, ' City or Town County State Zip Name of service site b) Number Street Room Muir] P.O. Box, Route, etc. Beal Kieaon City or Town [Coun [iss Zip Name of service site (c) Number Street Room Number | P.O. Box, Route, etc. c . Location City or Town County i Zip Name of service site Number Street Room Number | P.O. Box, Route, etc. (dd) || oe City or Town County State Zip If more space is needed, please complete this information on a separate piece of paper and attach to this letter. Thank you. COMMENTS 35 36 NATIONAL SURVEY OMB Clearance No. 068R-1393 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE Health Resources Administration National Center for Health Statistics JATIONAL INVENTORY OF FAMILY PROJECT NO. PLANNING SERVICES (NOTE: Clinic name and 1974 address ‘label goes here ANNUAL SURVEY Dear Director: The rapid expansion of family planning services in the United States since the mid-sixties has brought to the forefront the need for accurate and current information on the extent to which these ser- vices are available nationally. On January 1, 1972, the National Center for Health Statistics implemented the National Reporting System for Family Planning Services to collect monthly data on family planning patients seen in public facilities and the services they receive. However, there is currently no comprehensive inven- tory available of all facilities providing family planning services in the United States and the services available through them. The National Center for Health Statistics is therefore conducting this annual survey to obtain current information about each family planning clinic or service site such as name, location, caseload, services offered, and staff size. This National Inventory of Family Plarning Services expands upon previous surveys of this nature conducted by Planned Parenthood-World Population. The information from this survey will be used by the National Center for Health Statistics for statistical reports on the characteristics of facilities providing family planning services. In addition, the data will be made available to other agencies to compile directories of available clinics or service sites, to plan for needed additi- tional facilities, and to plan for future manpower needs. One of these questionnaires 1s to be completed for each clinic or service site at which your project, agency, or program provides family planning services. Before completing this questionnaire, you should familiarize yourselt with the definitions at the top of page 2. If this is one of a group of clinics or service sites administered or directed by a central agency, project, or program, please return the completed questionnaire to your Project so that the questionnaires for all clinics under the Project's direction can be returned together. All questionnaires should be returned within three weeks. Thank you for your cooperation. Sincerely, Edward B. Perrin, Ph.D. Director National Center for Health Statistics For this survey, the following definitions apply: FAMILY PLANNING SERVICES Family planning services provide the means which enable indivi- duals to meet their family planning objectives. These services are medical, social, and educational. Medical family planning services refer to the following services provided by a physician, nurse-midwife, registered nurse, or other authorized personnel: medical history; physical examination; laboratory testing; testing, consultation, and treatment including continuing medical supervision; issuance of drugs and contraceptive supplies; and appropriate medical referral when indicated. Social and educational family planning services are such services as outreach, the provision of transportation, or babysitting, which are provided to enable a person to attend a family planning clinic or to otherwise obtain medical family planning services. CLINIC SITE A clinic site is a place or facility at which any family planning services are provided on a regularly scheduled basis. It may be a hospital, health center, mobile unit, free-standing site, church, or store front. For mobile units each stop is considered a clinic location; therefore, a separate questionnaire should be completed for each stop or location. Physicians' offices should be con- sidered as clinic locations only when there is a formal relation- ship with some project or agency which is responsible for pro- viding family planning services. Physicians, nurses, volunteers, etc., who make home visits for the purpose of delivering a family planning service should count their home base of operations as the clinic location. FAMILY PLANNING PATIENT A family planning patient is a client who meets one of the follow- ing conditions during her/his visit: (1) The client is provided a method of contraception by the clinic; (2) The client receives contraceptive, infertility, or sterilization counseling in conjunction with a medical service which is not V.D. or pregnancy testing. 37 Card 1 9-1 1. WHAT IS YOUR AREA CODE AND TELEPHONE NUMBER? . gel0-12 13-19 2a. IS THE CORRECT (name on label) NAME FOR YOUR CLINIC OR SERVICE SITE? J Yes 1 NO west. WHAT IS THE CORRECT NAME? wis 3a. IS THE CORRECT (address on label) LOCATION FOR YOUR CLINIC OR SERVICE Number Street P.0.Box,Route SITE? City or town Count [1 Yes y y [] No ===b. WHAT IS THE ENTIRE State Zip Code CORRECT LOCATION 4 IS THIS CLINIC OR SERVICE SITE LOCATED IN A: (Mark (X) one box only) oo State or local health v , 20-1 [J department building -¢[] store -7 [] Mobile unit » x n Physician's a. WHAT IS THE 2 [J Zoepital -s 1 Office MAILING ADDRESS? , School or community . -2 [J building -6 Church 21- [| Other (Specify) 5. PLEASE CHECK THE BOX WHICH BEST INDICATES THE TYPE OF ORGANIZATION WHICH HAS OPERATING RESPONSIBI- LITY (e.g., THAT PROVIDES MOST, IF NOT ALL, OF THE STAFF, SUPPLIES, AND SPACE) FOR THIS CLINIC OR SERVICE SITE. (DO NOT INCLUDE ORGANIZATIONS INVOLVED ONLY WITH FUNDING.) : Governmental Non-governmental: 2-1 00-1 Planned Parenthood-World Population 22-1] state 29-1073 ¢1inte Affiliation fo. Ge30-33 28-1] County 34-1] University 24-1 City or Metropolitan area 26-1] Church 256-1] Health District 6- [[] Hospital memset |[] Profit -1 26-1] Indian Health Service [] Nonprofit : Other Federal Government 25 _ 2 272- (Speci fy) g7- COPPOTALLON mum— = Profit I= Nonprofit 28- [J Other nonfederal =2 of government (Specify) 38-1] Individual, profit 39-1 Partnership, profit 40- [_] Other non-government (Specify) 6. DOES ANY OTHER AGENCY OR ORGANIZATION ALSO PROVIDE FAMILY PLANNING SERVICES AT THIS SITE? 38 41-1] No -2 [CJ Yes 6a. WHAT IS THEIR NAME? 7. ARE MEDICAL FAMILY PLANNING SERVICES (AS DEFINED AT THE TOP OF PAGE 2) PROVIDED AT THIS CLINIC OR SERVICE SITE FOR WHICH YOU ARE REPORTING? IMPORTANT - THIS QUESTION DOES NOT PERTAIN TO THE AGENCY OR ORGANIZATION NAMED IN QUESTION 6b BUT TO YOUR OWN AGENCY OR ORGANIZATION. 42-2 Yes -1 No a. WHAT IS YOUR PRIMARY SERVICE b. DOES THIS CLINIC OR SERVICE SITE: OR PURPOSE? (1) REFER PATIENTS TO ANY OTHER SITE FOR MEDICAL FAMILY PLANNING SERVICES? 7 Medical family 43-1 [7] planning 44-1 [J no -i0] Yes -2 [] Sterilization . (a) WHAT IS THEIR NAME AND -3 [] Vv-D Testing ADDRESS: [J Postpartum and/or (¥ame) Prenatal Care (Street) 5 Comprehensive oe Health Care (City) (zip) - Other (Specify) (2) PROVIDE SPACE, EQUIPMENT, CONTRACEPTIVE SUPPLIES, AND/OR STAFF TO OTHERS WHO PROVIDE MEDICAL FAMILY PLANNING SERVICES? 45-1 No -2 Yes (a) WHAT IS THEIR NAME AND ADDRESS : (Name) (Street) (City) (Zip) (3) CONTRACT OR PAY OTHERS FOR THE PROVISION OF MEDICAL FAMILY PLANNING SERVICES? 46-1 (] Wo -2 Yes (a) WHAT IS THEIR NAME AND ADDRESS? (Name) (Street) (City) (Zip) E N ND 7a ERED, UE BE UE N 7b (1) - (3) ANSWERED, SKIP TO QUESTION 18 ON THE LAST PAGE. 8. DO YOU REPORT TO THE NATIONAL REPORTING SYSTEM FOR FAMILY PLANNING SERVICES? 47-1 No -2 Yes 8a. WHAT IS YOUR CLINIC NUMBER? ce 48-51 9. WHEN DID THIS CLINIC OR SERVICE SITE FIRST BEGIN OFFERING MEDICAL FAMILY PLANNING SERVICES? month year ce 52,53 54,55 10. PLEASE ENTER BELOW THE NAME OF EACH COUNTY SERVED BY THIS CLINIC OR SERVICE SITE AND THE PERCENTAGE Card & OF YOUR TOTAL PATIENTS FROM EACH COUNTY. 9-2 Name of Count % of patients Name of County % of patients eclo eels ccl8 eedl celé cell ced ced? ced cols eed0 cedd 39 0-2 11. WHAT PERCENTAGE OF YOUR BUDGET FOR FAMILY PLANNING SERVICES WAS RECEIVED IN 1973 FROM THE (THE PERCENTAGES SHOULD ADD TO 100 PERCENT.) FOLLOWING SOURCES? a. Department of Health, Education, and Welfare Other Federal agencies (Specify) FQ 0 A 60 City government State government County government Planned Parenthood-World Population Special Research Grant (Specify) Other source(s) than above (Specify) Total of a - h cecdd cab? cebd ecb8 cebl cabd cc? ae?0 47- 78- RW WR AW WR WR AWW 100 12. WE WOULD LIKE SOME INFORMATION ON YOUR FAMILY PLANNING CLINIC SESSIONS. THESE ARE REGULARLY SCHEDULED PERIODS OF TIME DURING WHICH MEDICAL FAMILY PLANNING SERVICES ARE PROVIDED AT THIS SITE. DO NOT FILL IN — FOR AGENCY USE ONLY Card ¢ 9-4 40 In column (1), check the box to indicate the daye of the week during which medical family planning services are provided. In column (2), enter the time period during which medical family planning services are provided (e.g., 9-11 a.m.; 3-5 p.m.). If a split session is operated on any day, enter both time periods in the same box for that day. If thie is a comprehensive health center or HMO where family planning is provided only on an "as needed" basis, check the "as needed" box in column (2). In column (3), check the box which best describes the type of clinic session being held. For the purposes of this study, a clinic session may be specialized (5) (where only services related to medical family planning are provided) or combined (C) (where family planning services are offered in conjunction with other health services such as maternity, post-partum, maternal and child health, obstetrice and gynecology, comprehensive or other health care). In column (4), check the box which describes the frequency of these sessions - W for weekly, B for bimonthly (e.g., every other week), M for monthly, or 0 for other. 1 pays of Week Medical Family Planning Provided From (2) (3) (4) Type of Freauency of Time Period Clinic Session Sessions To As Needed | Specialized] Combined | Weekly |[Bimonthly| Monthly [Other foo OJ Oo | o|o|loao|la|da fuesaay [7 - Oo |o| o|lo|o Mesnester [7] oO Oo |ao|lo|lolo|d Thurseay [7] = oO |lo|lolalal|la Frieey [J = Oo |o|lolao|lo|a baturoay . [7] Ol Oo |lo | ola a|da sinter [] 0 Oo | o|o|lo|lala 13a. WAS THIS CLINIC OR SERVICE SITE CLOSED AT LEAST ONE MONTH (FOUR CONSECUTIVE WEEKS) DURING ANY PART OF 19737? 10-1 [] No -2 Yes b. Closed from / to / LIONEH day month day ec / to / month day month day eld / to A month day month day cel L to / : month day month day cel tn on 14a. HOW MANY PATIENTS RECEIVED MEDICAL FAMILY PLANNING SERVICES AT THIS SITE FROM JANUARY 1, 1973 THROUGH DECEMBER 31, 1973? Total Patients ccdd b. HOW MANY OF THESE TOTAL PATIENTS WERE ENTITLED TO SUBSIDIZED FAMILY PLANNING SERVICES IN 1973 UNDER: (1) Title IV-A (AFDC)? ccd8 (2) Title XIX (Medicaid)? ceb3 €. HOW MANY OF THESE TOTAL PATIENTS WERE NEW PATIENTS (e.g. , THOSE WHO REGISTERED AND RECEIVED MEDICAL FAMILY PLANNING SERVICES AT THIS SITE FOR THE FIRST TIME) FROM JANUARY 1, 1973 THROUGH DECEMBER 31, 1973? New Patients ec58 d. HOW MANY MEDICAL FAMILY PLANNING VISITS WERE RECORDED AT THIS SITE FROM JANUARY 1, 1973 THROUGH DECEMBER 31, 1973? (DO NOT INCLUDE VISITS OR MAILINGS WHEREBY A PREVIOUSLY REGISTERED PATIENT RECEIVED SUPPLIES ONLY.) Total Visits cc63 15a. WHICH OF THE FOLLOWING SERVICES OR 15b. WHAT PERCENTAGE OF YOUR PATIENTS FUNCTIONS ARE PROVIDED AT THIS SITE RECEIVED THESE SERVICES IN 1973 ON FOR FAMILY PLANNING PATIENTS? THEIR INITIAL* VISIT FOR MEDICAL (Check all that apply.) FAMILY PLANNING SERVICES? Percentage (1) [] Record of pertinent medical history ecll (2) C3 Record of reproductive history celd (3) [I] Record of pertinent social history celé (4) [] Pap emear eel (5) [] Pelvic examination ec? (6) Breast examination ces (7) OC Taking of blood pressure cel (8) [] Contraceptive prescription ced? (9) [] Insertion of IUD cecdd (10) [] v-D testing for syphilis eel? (11) [] V-D testing for gonorrhea ecdl (12) [] Pregnancy testing ccd Routine lab tests (hematocrit, (13) [3 urine for sugar and albumin) wTe (14) [] Infertility diagnosis cc4dd (15) [] Infertility counseling . ees (16) [] Female sterilization acess (17) [J] Male sterilization ccb8 (18) [] Sickle cell screening caebl (19) [] other medical service (Specify) *An initial visit for medical family planning services is defined as a visit at which a patient is registered for and receives medical family planning services for the "first time" at this site. DO NOT FILL IN — Boe eecb8 FOR AGENCY USE ONLY wl 41 Card 6 16. WHICH OF THE FOLLOWING OTHER ANCILLARY SERVICES OR FUNCTIONS ARE PROVIDED AT THIS SITE 3-8 (Check all that apply) 10-1[_] Individual counseling about family planning 17-1] Follow-up Program (Follow-up activities include contacting persons who have missed appointments and the scheduling of reappointments.) 12-17] Referral to other clinic for family planning or medical services not ° provided at this site 13-1] Referral to appropriate agency for social services Outreach Program (Outreach activities are those which inform prospective 14-1] patients of family planning services and assist them in availing them- selves of the services.) 15-1] Classroom or group sessions about family planning 16-1] Classroom or group sessions on sex education (in addition to family 6- planning and contraceptive education) 17-1[_] Transportation to the clinic or service site (provided or subsidized) 16-1[_] Babysitting (while patient is at clinic or service site) 19- [[] other (Specify) 20-1] None 17. WHAT PERCENTAGE OF ALL YOUR PATIENTS USED OR RECEIVED THE FOLLOWING TYPES OF CONTRACEPTIVE METHODS IN 1973? (Include only those methods provided at this site.) Percentage (a) [] oral (Pill) ce?1 (vb) [] vp co? (e) —_ Foam eel? (d) [] condom cdo te) [_] Diaphragm/jelly cc33 (f) [_] Basal Temperature Rhythm cedb (g) [_] cervical-Mucus Rhythm cedd (h) 1 Sterilization (female) ced? (i) [] Sterilization (male) cods (3) [] Injection ccdd (k) J Morning after pill cebl (1) [_] other (Specify) cose (m) [_] None offered Y Infertility coungeling only) ees? - DO NOT FILL IN— ecél FOR AGENCY USE ONLY ¢e?5 Card 7 18 -7 19, PLEASE INDICATE BELOW THE NUMBER OF STAFF USUALLY INVOLVED IN THE DELIVERY OF MEDICAL FAMILY PLANNING SERVICES AT THIS CLINIC OR SERVICE SITE DURING A TYPICAL WEEK. VOLUNTEERS, CONTRACT, AND PAID EMPLOYEES AT WHICH HE/SHE SPENDS MOST TIME. INCLUDE Total Staff Total staff hours Staff Type delivering family usually worked planning services per week Administrator/Director eell cel? Clerk/Secretary cel eel? Clinic Aide cel0 ce? Health Educator eels ce? i d Licensed Practical Nurse 2030 cel? Nurse Midwife/Nurse Practitioner ceds ced? Nutritionist codl ced? Outreach Worker coeds ccd? Physician ees0 cel Physician's Assistant cess ces? Registered Nurse ecb0 cab Social Worker ra65 ceé? Other (Specify) ca?0 ac?l NAME OF PERSON COMPLETING THIS FORM: (Please print) | JOB TITLE: TELEPHONE NUMBER: COMMENTS : COUNT EACH PERSON ONLY ONCE, IN THE OCCUPATION ce?65- DO NOT FILL IN FOR INTERNAL USE ONLY cell cclé cel? # U.S. GOVERNMENT PRINTING OFFICE: 1976—210-981:32 43 n - . = y . . hed en og mood cae oh alll ll sa dey fh = ILE Ee ee 13 cit ER ay ay El ans ee Series 1. Series 2. Series 3. Series 4. Series 10. Series 11. Series 12. Series 13. Series 14. Series 20. Series 21. Series 22. Series 23. VITAL AND HEALTH STATISTICS PUBLICATIONS SERIES Formerly Public Health Service Publication No. 1000 Programs and Collection Procedures.—Reports which describe the general programs of the National Center for Health Statistics and its offices and divisions, data collection methods used, definitions, and other material necessary for understanding the data. Data Evaluation and Methods Research.—Studies of new statistical methodology including experimental tests of new survey methods, studies of vital statistics collection methods, new analytical techniques, objective evaluations of reliability of collected data, contributions to statistical theory. Analytical Studies. —Reports presenting analytical or interpretive studies based on vital and health statistics, carrying the analysis further than the expository types of reports in the other series. Documents and Committee Reports.—Final reports of major committees concerned with vital and health statistics, and documents such as recommended model vital registration laws and revised birth and death certificates. Data from the Health Interview Survey.—Statistics on illness; accidental injuries; disability; use of hospital, medical, dental, and other services; and other health-related topics, based on data collected in a continuing national household interview survey. Data from the Health Examination Survey.—Data from direct examination, testing, and measurement of national samples of the civilian, noninstitutionalized population provide the basis for two types of reports: (I) estimates of the medically defined prevalence of specific diseases in the United States and the distributions of the population with respect to physical, physiological, and psychological charac- teristics; and (2) analysis of relationships among the various measurements without reference to an explicit finite universe of persons. Data from the Institutionalized Population Surveys.—Discontinued effective 1975. Future reports from these surveys will be in Series 13. Data on Health Resources Utilization.—Statistics on the utilization of health manpower and facilities providing long-term care, ambulatory care, hospital care, and family planning services. Data on Health Resources: Manpower and Facilities. —Statistics on the numbers, geographic distrib- ution, and characteristics of health resources including physicians, dentists, nurses, other health occu- pations, hospitals, nursing homes, and outpatient facilities. Data on Mortality. —Various statistics on mortality other than as included in regular annual or monthly reports. Special analyses by cause of death, age, and other demographic variables; geographic and time series analyses; and statistics on characteristics of deaths not available from the vital records, based on sample surveys of those records. Data on Natality, Marriage, and Divorce.—Various statistics on natality, marriage, and divorce other than as included in regular annual or monthly reports. Special analyses by demographic variables; geographic and time series analyses; studies of fertility; and statistics on characteristics .of births not available from the vital records, based on sample surveys of those records. Data from the National Mortality and Natality Surveys.—Discontinued effective 1975. Future reports from these sample surveys based on vital records will be included in Series 20 and 21, respectively. Data from the National Survey of Family Growth.—Statistics on fertility, family formation and disso- lution, family planning, and related maternal and infant health topics derived from a biennial survey of a nationwide probability sample of ever-married women 15-44 years of age. For a list of titles of reports published in these series, write to: Scientific and Technical Information Branch National Center for Health Statistics Public Health Service, HRA Rockville, Md. 20852 DHEW Publication No. (HRA) 76-1312 For publications in the Vital and Health Statistics Series call 301-443-NCHS. Series 1-No. 12 PO A D D 90 » D:ABCD 0 R LD D1 IR n » A R Q () (NY ch % NCHS 4, wh Tn TSA N, Background and Development of the National Reporting System for Family Planning Services U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Library of Congress Cataloging in Publication Data United States. National Center for Health Statistics. Background and development of the National Reporting System for Family Planning Services. (Vital and health statistics: Series 1, Programs and collection procedures; no. 13) (DHEW publication; (PHS) 78-1 313) “Data from the data evaluation and methods research” 1. Birth control clinics—United States—Statistical services—History. I. Title II. Series: United States. National Center for Health Statistics. Vital and health statistics: Series 1, Programs and collection procedures; no. 13. III. Series: United States. Dept. of Health, Education, and Welfare. DHEW publication; (PHS) 78-1313. RA409.U44 No. 13 [HQ766.5.U] 312°.07°23s [362.82] ISBN 0-8406-0117-4 77-17379 For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, D.C. 20402 Stock No. 017-022-00612-0 PROGRAMS AND COLLECTION PROCEDURES Series 1 Number 13 Background and Development of the National Reporting System for Family Planning Services The development and operation of the National Reporting System for Family Planning Services are presented from its origin in 1968 through its status in 1975. This presentation includes a description of the predecessor of the National Reporting System—the Provi- sional Reporting System for Family Planning Services. A brief dis- cussion of the legislative and historical background concerning the involvement of the Federal Goverment in the provision of family planning services is also given. The last section of the report in- cludes a discussion of the growth of the reporting system during the first 6 full years of its operation as well as a brief description of the conversion of the 100-percent system to a sample survey during 1977. DHEW Publication No. (PHS) 78-1313 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service National Center for Health Statistics Hyattsville, Md. April 1978 NATIONAL CENTER FOR HEALTH STATISTICS DOROTHY P. RICE, Director ROBERT A. ISRAEL, Deputy Director JACOB J. FELDMAN, Ph.D., Associate Director for Analysis GAIL F. FISHER, Associate Director for the Cooperative Health Statistics System ELIJAH L. WHITE, Associate Director for Data Systems JAMES T. BAIRD, JR., Ph.D., Associate Director for International Statistics ROBERT C. HUBER, Associate Director for Management MONROE G. SIRKEN, Ph.D., Associate Director for Mathematical Statistics PETER L. HURLEY, Associate Director for Operations JAMES M. ROBEY, Ph.D., Associate Director for Program Development PAUL E. LEAVERTON, Ph.D., Associate Director for Research ALICE HAYWOOD, Information Officer DIVISION OF HEALTH RESOURCES UTILIZATION STATISTICS SIEGFRIED A. HOERMANN, Director STEWART C. RICE, JR. Acting Chief, Family Planning Statistics Branch W. EDWARD BACON, Ph.D., Chief, Hospital Care Statistics Branch JAMES E. DeLOZIER, Chief, Ambulatory Care Statistics Branch JOAN F. VAN NOSTRAND, Chief, Long-Term Care Statistics Branch MANOOCHEHR K. NOZARY, Chief, Technical Services Branch Vital and Health Statistics-Series 1-No. 13 DHEW Publication No. (PHS) 78-1313 Library of Congress Catalog Card Number 77-17379 CONTENTS Introduction BaCKBIoUNd....ceeiirieriinnsensnnnunnnnennnemeeraneeensenesssiisssssssssssssssssssssasansansssssssssssssassnnns Legislative BaCKBIOUNd......cceieiersueierrueenssnnissneesssenssssnesssanssessessssnsssssssssssnesssassssssssssssesssssssssssssssssessnsssnsas Historical Background...... The Provisional Reporting SYStemM....ccuuuiiiiiiieeiiiiiueeeiiisrunnienssisssneeessissenesissssssessssssnssssssssssesssssssssesssssssssns The Report Form Operational Procedures OULPUL TADULAtIONS cceeeeererrererrerrrrnsnsereensneeseeeseaesssssrsssssssssssssssssssssssessnasesssasssssassssssssasasssssssnsssasssessnsnsnns The National Reporting System The Report Forms i OPETATIONAL PrOCCAUTES coiirviitinris iris sa tassiasiahssssssssivassss ssa a sasssss sat 4AS TAIL SSSI IAAI AILSA HAIR IIIT OAT IIIS Output Tabulations Growth and Future of the Reporting SysStem.....c.cccecvueeennriisuenicssnnsssnessneecsnessnnes Appendixes I. Abbreviations Used in This REPOTt......ccceerererrererereeresersesesessesesersesesssssssesssessesessssssesessesessssasessssnses 1 II. Agencies and Persons From Whom Comments and Input Were Received Regarding the Family Planning Reporting SYStems.......cccceersrnirisenccsenissenecsssenesssnsssssnsssssnssssssssnsens III. Sample REPOrt FOIMS...uuuuuieieriiiiiieieisiscrssssnnnennsseaseseenssessssssssssssssssssnssnsssnans IV. Sample Enrolment Forms. msmssrersiessistessssssssiiserstiomsssins sistas sss issss sa iainssssss ss ss sss ts sss sassssissssasosensss V. Sample Processing ReEDOTIS..cumsicummmnsronmrossssrsrmsmnssurommsssssnpsrsssssspssnsssprspissseesy VI. Standard Table Shells.......... LIST OF TEXT TABLES Comparison of items on the Provisional Report Form for Family Planning Services (PRF) and the Clinic Visit Record for Family Planning Services (CVR) by type of information obtained, accord- ing to whether item remained the same, was modified, deleted, or added.............. aansehnins sessraensense Summary of major differences in operating procedures between the PRSFPS and the NRSFPS, by LYPE OF PLOCEAUTE wcvisrinisininiscsininsiristinmsrmss sss iaasss sss sa EER RS EAA RATS AAA aan AAs SASF i eas As Saas Summary of major differences in the output tabulations between the PRSFPS and the NRSFPS...... Number of participating service sites, family planning patients seen, and clinic visits made for fam- ily planning services as reported to the NCHS family planning reporting systems: United States, ELL CL eC EE EE PRA Percent increase in the number of participating service sites, family planning patients seen, and visits made for family planning services as reported to the NCHS family planning reporting sys- tems: United States, 1970-75 cuimmsimirmimssmimssssssssssansssasonssnsssssromsissesssssassstsstmmsssnresess Percent of records submitted to the NRSFPS by automated and nonautomated submitters: United SALES, 1978-75. srmurisstcssnnninsssns iss nssmrasssssssss sass asin oar SAA AAT SHAT H ORAS SEATS SA SAS SAS SSS SR ~N Ov Ov Ov © NN N © © © 10 12 13 1 BACKGROUND AND DEVELOPMENT OF THE NATIONAL REPORTING SYSTEM FOR FAMILY PLANNING SERVICES Barbara J. Haupt, Division of Health Resources Utilization Statistics INTRODUCTION The National Center for Health Statistics (NCHS) has been operating a reporting system for family planning clinic services since May 1969. Through this system, data are col- lected about persons who receive family plan- ning services from participating family planning service sites throughout the United States and some of its territories. The information obtained is useful for research purposes as well as for program planning and evaluation, primarily at the national level. The data are reported to NCHS by the participating family planning clinics and service sites. Although all of the sites that provide family planning services in the United States do not report to NCHS, most of the facilities that receive Federal funds for family planning serv- ices from the Bureau of Community Health Services (BCHS) in the Department of Health, Education, and Welfare (DHEW) do report.? In addition, many nonfederally funded family plan- ning programs also report data to NCHS. Included in the latter category are some clinics and service sites that are affiliated with Planned Parent- hood/World Population (PP/WP), are operated aRefers mainly to sites receiving project grants for family planning services. Also included are some sites that receive other health services grants, such as maternal and child health services or comprehensive health serv- ices. Many sites also receive matching funds under the Medicaid program and the Aid to Families With Depend- ent Children program, both also operated by DHEW. by State health departments, or are privately owned and operated. The information obtained through the Na- tional Reporting System may be divided into four general types: data about the participating facilities, data about the sociodemographic characteristics of the individuals being served, data about the types of services being provided, and data about the visits made. Because the National Reporting System is mainly concerned with the individuals being served, the data collected about the participating facilities are very limited. The only facility information collected is that which is necessary for the participation of the clinics and service sites. This includes the name and address of each facility, each clinic director’s name, a minimum amount of funding information, and the ex- pected patient load. Information collected about the individuals being served consists of identification informa- tion and the sociodemographic characteristics of each person. Since the name and address of an individual are never obtained by the National Reporting System, the identification informa- tion is limited to a unique nine-digit number assigned by the service site personnel. As long as the individual continues to receive services from the same family planning project, the informa- tion about that person should be reported to NCHS under the same number. The sociodemo- graphic characteristics collected about the in- dividual served include each person’s date of birth, sex, ethnic designation, pregnancy history (for women only), and Medicaid and welfare status. Data about the family planning services provided refer to the medical, counseling, and referral services that each person receives at a particular visit. Information about the type of contraceptive method adopted by each person, as well as any previous contraceptive use, is also obtained. The visit data collected are limited to the date and type of visit made. Because each person is uniquely identified within a given family planning project, the number of visits made by an individual over time can also be determined. The data gathered through the National Reporting System are used to provide baseline statistics on the status of family planning serv- ices in the United States. In addition, these data are used for program planning, evaluation, and monitoring, as well as for research purposes. However, NCHS never meant this system to be the sole source of family planning data; it was intended to provide only a part of the total picture. In order to obtain a comprehensive view of family planning activities and the effects of such activities in the United States, the data available from the National Reporting System must be used in conjunction with data from other sources. BACKGROUND Legislative Background The involvement of the Federal Government in the provision of family planning services has grown rapidly since the 1960s. The first Federal grants designated specifically for family planning services were made available through the Eco- nomic Opportunity Act of 1964 (Public Law 88-452) and administered by the Office of Economic Opportunity (OEO). By the mid- 1960’s, DHEW also made a limited amount of money available for family planning services through the reimbursement programs under titles IV-A (Aid to Families With Dependent Children) and XIX (Medicaid) of the Social Security Act.’ Later, the 1967 amendments to bUnder these titles, family planning service pro- viders were able to obtain reimbursement for some of the Social Security Act (Public Law 90-248) made more family planning service money avail- able through DHEW. These amendments not only established categorical project grants for family planning services under title V (Maternal and Child Health Services) but also required that at least 6 percent of the total money appropri- ated under sections 503, 508, and 512 of title V be available for family planning services.© Three years later Public Law 91-572, the Family Planning Services and Population Research Act of 1970 (title X of the Public Health Service Act), was passed.d The purpose of this act was to assist in making comprehensive voluntary family planning services available to all persons desiring such services. Lastly, the passage of the 1972 amendments to the Social Security Act (Public Law 92-603) strengthened the family planning service aspects of titles IV-A and XIX. These amendments made it mandatory that all recipients of Aid to Families With Dependent Children (AFDC) be informed of the availability of family planning services and that such services be provided to all eligible persons desiring them. States failing to meet these requirements would be penalized by a reduction of 1 percent per year of the Federal share of AFDC funds. In addition, the amendments increased the Federal share of matching funds for family planning services to 90 percent under both titles IV-A and XIX.e the medical services received by their eligible clients. The available funds, however, were not used extensively for family planning services until the mid-1970’s. €Title V provided for both formula grants to States for Maternal and Child Health Services (section 503) and special project grants for Maternity and Infant Care (section 508). Title V specifically included family planning as part of the maternal health services to be provided and allowed the establishment of projects specifically for family planning services. Section 512 authorized research projects relating to maternal and child health services. This act expired in 1975 but was extended for an additional 2 years under Public Law 94-63, the Family Planning Services and Population Research Act of 1975 (title II of the Public Health Service Act). €The previous Federal share was 75 percent under title IV-A and a variable formula with a range from 50 to 83 percent under title XIX. Historical Background The DHEW family planning services system.—Although DHEW has had categorical family planning service grant money available for some time through titles V, X, and later, II of the Public Health Service Act, these grants have been administered by different agencies within the Department over the years. A brief history of the succession of these administering agencies is presented in this section. Originally the Children’s Bureau (CB) in DHEW was responsible for the programs funded through title V of the Public Health Service Act. However, during 1969 two new agencies were created in DHEW’s Health Services and Mental Health Administration (HSMHA): the National Center for Family Planning Services (NCFPS) and the Maternal and Child Health Service (MCHS). These two agencies subsequently were made responsible for administering the title V programs: MCHS operated the service programs that concerned maternal and child health such as the children and youth projects, the crippled children programs, the maternal and child health programs, and the maternity and infant care projects. On the other hand, NCFPS was re- sponsible for the development and operation of the categorical family planning service programs as well as the coordination of family planning service efforts in the United States. Therefore, NCFPS was responsible for administering the family planning service aspects of title X of the Public Health Service Act after it was passed in 1970. During 1973, the OEO family planning service grants were transferred to NCFPS. This process was completed by September of that year. In addition, 1973 also saw the reorganiza- tion of the Public Health Service, that segment of DHEW dealing with health. One result of this reorganization, still in effect, was the abolish- ment of HSMHA and the creation of the Health Resources Administration (HRA) and the Health Services Administration (HSA). The reorganiza- tion also abolished both NCFPS and MCHS; the prograrns operated by these agencies were in- corporated into the newly created Bureau of Community Health Services in HSA, along with a number of other health service programs in DHEW. Within BCHS the title V programs are coordinated by the Associate Bureau Director for Maternal and Child Health, and the title X (now title II) programs are coordinated by the Associate Director for Family Planning. The family planning information system.— The rapid expansion of family planning service programs since the mid-1960’s, especially in the public sector, made apparent the lack of current and accurate information on the extent to which family planning services were being provided. This information was urgently needed to provide a rational basis for the expansion of family planning service programs throughout the United States and would continue to be needed on a timely basis to provide data for the evaluation of the effectiveness of such programs. Because these data needs were recognized by both Federal and private agencies involved in the delivery of family planning services, the Inter- agency Committee for the Development of a Uniform Data Collection System for Family Planning Services was established in February 1968. This Committee, which was chaired by the DHEW Deputy Assistant Secretary for Health and Scientific Affairs, was made up of representatives of DHEW, OEO, PP/WP, and other interested parties. The Committee met throughout 1968 with the purpose of defining the requirements of a uniform national family planning services reporting system. After much hard work and frequently acrimonious debate, a set of basic data elements was agreed upon late in 1968. The Committee felt that these were the crucial data items for good program planning, evaluation, and monitoring, as well as for research purposes. Meanwhile, in May 1968, the Bureau of the Budget in the Executive Office delegated focal responsibility for Federal Government family planning activities to the Office of the Assistant Secretary for Health and Scientific Affairs, DHEW. This delegation gave the Assistant Secre- tary the following responsibilities: To take the leadership in the development of a coordinated program of statistics on family planning. To develop standard classifications and ter- minology. To keep the Bureau of the Budget informed of relevant data collection plans of Federal agencies. To obtain, as much as possible, the coopera- tion of both State and local governmental and private agencies. To assure the assembly, analysis, and pub- lication of statistical information on all aspects of family planning programs in the United States, covering all activities of the Federal Government and including, to the extent possible, those of other public and private organizations. In the letter of acceptance from DHEW, it was specifically pointed out that the Interagency Committee, meeting since February 1968, had “actively participated” in the “first job under- taken in this direction... the development of a uniform reporting system for family planning services in the United States... we anticipate continuing the use of this satisfactory instru- ment and... later [including in the reporting system] other agencies who have responsibility for family planning services.”f In November 1968 the Office of the Assist- ant Secretary, DHEW, gave NCHS the responsi- bility for developing and operating a national statistical system for family planning services. This statistical system, when completed, was to provide data “on all aspects of family planning programs in the U.S., covering all activities of the federal government, and including to the extent possible those of other public and of private organizations.” The Center was also told to “work ... [on] the development of standard classification and terminology” in the field of family planning. This entire assignment, how- ever, was to be done “under the policy direc- tion” and ‘“‘together with” the Office of the Deputy Assistant Secretary for Health and Scientific Affairs.8 fCorrespondence between the Secretary of DHEW and the Assistant Director for Statistical Standards, Bureau of the Budget, Executive Office of the President, dated May 29, 1968, and June 13, 1968. Memorandum from the Secretary of DHEW to the Assistant Secretary for Health and Scientific Affairs, Because the need for family planning data had become extremely urgent, both NCHS and the Interagency Committee felt that some sort of interim data collection activity should be undertaken immediately, based on the data elements that had already been developed. It was, therefore, decided that a computer system, originally designed for the DHEW Children’s Bureau programs, would be used as an interim system until the “final” system was developed. The operation of this interim system, therefore, met two needs: (1) It provided data for the immediate administrative and research needs of the major family planning programs, and (2) it developed a body of data and experience that were used in planning the national statistical system. This interim system became known as the Provisional Reporting System for Family Planning Services (PRSFPS). In July 1970, NCHS sent a description of the proposed National Family Planning Services Statistical System to a number of family plan- ning experts for comments. This description pointed out that the total statistical program would be made up of three different data collection mechanisms: an inventory of family planning clinics, a patient contact reporting program, and special ad hoc surveys. The comments that were received were analyzed and used for revising the proposal. Besides the reviews received from experts in the field, NCHS solicited and obtained comments from the major Federal family planning funding agencies (OEO and DHEW) as well as from PP/WP. In 1971 the National Reporting System for Family Planning Services (NRSFPS), the second of the three data collection mechanisms pro- posed, was completed and approved for use. Subsequently, on January 1, 1972, the NRSFPS began operation, replacing the PRSFPS. During 1976, work was begun on developing a sample system to replace the 100-percent reporting system. The conversion to a sample DHEW, dated October 18, 1968; and memorandum from the Assistant Secretary for Health and Scientific Affairs, DHEW, to the Acting Administrator, Health Services and Mental Health Administration, DHEW, dated November 5, 1968. survey became unavoidable because of the tre- mendous growth in the number of visits re- ported to the NRSFPS (from less than 1 million in 1970 to almost 6 million in 1975). Although the original target date for implementing the sample was January 1977, it soon became evident that this date did not allow enough lead time for the sample survey. As a result, it was decided that the NRSFPS would continue on a 100-percent basis through June 1977 and that the sample would be implemented in July. THE PROVISIONAL REPORTING SYSTEM The Provisional Reporting System for Fam- ily Planning Services operated from May 1969 through December 1971. The PRSFPS func- tioned as an interim data collection mechanism while NCHS worked on developing the “final” family planning reporting system, the NRSFPS. The PRSFPS also functioned as a learning mechanism for NCHS, since many of the modifi- cations made for the National Reporting System were based on the experience and knowledge gained from operating the Provisional Reporting System. The Report Form The data collection form used by the PRSFPS, the Provisional Report Form for Fam- ily Planning Services (PRF), was designed by the Interagency Committee and was the basis for the system (see appendix III-A). This form consisted of 24 data items (some of which were optional) and was to be completed each time a person visited a participating service site for family planning services. All of the items were com- pleted the first time a form was filled out for an individual; however, the questions asked during revisits were limited to those that changed over time. Three different kinds of information were collected on this report form: identification information, demographic information, and serv- ice information. Although there was a place on the form to collect the name and address of each patient, that portion of the form was for the service site’s use only and remained at each site. For the purposes of the Provisional Reporting System, the patients were identified only by a combina- tion of the facility and patient numbers. The facility numbers were assigned by NCHS and were unique within the PRSFPS. The patient numbers, on the other hand, were assigned by the service site personnel, usually on a case basis, and were meaningful only to the facility provid- ing the services. Items of a demographic nature included each patient’s date of birth, ethnic designation, edu- cation, pregnancy history, income and family size,b and welfare status. It was assumed that all of the patients were women. Service and administrative data included the patient type; types of medical, counseling, and referral services given; the contraceptive method adopted; the date and session of the visit; and the date and type of the next appointment. Information about the individual’s contraceptive history within the previous 2 years was also collected. The PRF also included two items that were used at the discretion of the local agencies. One item pertained to the patient’s current resi- dence; the other item was open and allowed the participating facilities to obtain information that was relevant to their specific operations but was not required for the larger data system. Operational Procedures Enrollment and training of participants.— Lists of the organizations that were to partici- pate in the PRSFPS were supplied to NCHS by OEO and DHEW, the two major Federal funding agencies. These organizations were called ‘“‘proj- ects” and received grants that were designated either specifically for family planning services or for other health services, but with the stipula- tion that a certain percent of the grant funds be spent on family planning services. Planned Parenthood-affiliated service sites were also invited to participate in the PRSFPS; however, PP/WP decided that its affiliates not receiving Federal funds for family planning services could hThis item was not completed at all service sites: It was mandatory only for the sites funded by OEO and optional for the rest of the sites. postpone their participation until the “final” system was implemented. As a result, only one of these nonfederally funded affiliates decided to enroll and participate in the PRSFPS. The projects that were to participate in the PRSFPS were contacted by both NCHS and their funding agencies, told of the need to report, and asked to complete the Project Enrollment Form (reproduced in appendix IV-A). This form provided NCHS with a list of each project’s service sites, expected patient load, family planning funding data, and other necessary administrative information. Upon re- ceipt of the completed enrollment forms and the assignment of the project and service site identi- fication numbers, each site was sent a supply of report forms, instruction manuals, and all mate- rials necessary for their participation in the Provisional Reporting System. Training the site personnel began in May 1969; most of the classes were held during May, June, and July of that year. The training was conducted at each project site; a full day was allowed for each session. The report form and the instruction manual, as well as the administra- tive details about joining the system and obtain- ing the reporting materials, were discussed at each training session. Ideally, everyone who was to handle the report form was to be trained with respect to that person’s specific function, but unfortunately, this objective was not always met. An additional problem encountered was the rapid turnover of personnel at the sites; because of this turnover, the person who attended a training session was not always the one who carried out the necessary reporting procedures. A very detailed, self-explanatory instruction manual was, therefore, developed in an attempt to solve this problem. Because the PRSFPS operated for 2% years, the enrollment process was an ongoing function. New enrollments consisted of service sites that were newly opened during this time period and those that had been previously operating but were not included in the first enrollment phase because they were not family planning service grantees at that time. Ongoing training of new site personnel was found to be totally impracti- cal; the constant need for training due to the rapid turnover of clinic personnel would have resulted in excessive costs for both the travel involved and the maintenance of a staff of trainers by NCHS. The training manual was, therefore, relied on to fill this gap. Clinic personnel were also encouraged to call or write to NCHS about any reporting problems they encountered. In addition, a second major train- ing program of representatives of all the enrolled sites was carried out during 1970. Data collection and processing. —The PREF, the contents of which were discussed in the section, “The Report Form,” was the data collection instrument for the PRSFPS. This form was completed for each patient visit at which family planning services were provided, except for those visits for which the sole purpose was to pick up contraceptive supplies. The PRF was a two-part form consisting of an original and one carbon copy. The original was sent to NCHS for processing; the carbon remained at the reporting service site. In this way, the service site would keep a record of the information that was sent to the PRSFPS; many service sites also used the carbon copy as a part of each patient’s medical record. The completed PRF’s were sent to NCHS from each service site either weekly or biweekly, depending on the volume of patient visits to the site. In addition, personnel at the sites were asked to collect and send to NCHS, on the last working day of each month, all of the report forms for that month that had not yet been submitted. This procedure was adopted in order to ensure both timely data and an evenly distributed workload for data processing. Upon receipt, the PRF’s were logged in, counted, and sent on for data processing. After the data had been put onto computer tape they were edited for both the consistency and the validity of the information. Two types of consistency checks were made: The data were edited for internal consistency (for example, the same patient should not have received both contraceptive services and infertil- ity services) and for consistency with any previous data that had been submitted (for example, the highest grade of school completed by a person could not decrease over time). The second type of consistency check was possible because the PRSFPS was developed under the “patient string” concept. According to this concept, all of the data reported for a patient were kept together on the computer file. This was possible as long as the patient continued to receive services from the same family planning project, since the service sites assigned each patient an identification number that was unique to their project. The maintenance of the patient string made it possible to collect certain sociodemographic information about each pa- tient only once rather than at each visit, thus reducing the reporting burden of personnel at the service sites. In addition, it greatly enhanced the research potential of the data in the Provi- sional Reporting System by making longitudinal studies possible. Upon completion of the editing process, a processing report was produced for each service site (see appendix V-A). This report consisted of three parts: (1) the error report that provided a list of all of the “errors” (that is, invalid codes or inconsistent data) found during the editing procedures; (2) the summary report that pre- sented a tabular summary of the records sub- mitted, accepted, and rejected, the error condi- tions found, and the acceptance rates; and (3) the list of visit forms processed that was simply a list of the patient numbers for which forms were processed. Each processing report, along with the appli- cable source documents, was reviewed by the data processing personnel; transcription, coding, and other errors were sent back to the computer for reprocessing. Each annotated processing re- port was then sent to the proper service site along with the forms that had been rejected and that NCHS had been unable to correct. Person- nel at the service sites were instructed to examine their reports and the forms, make the necessary corrections, and resubmit the cor- rected forms to NCHS for reprocessing. Files and maintenance.—There were two basic files in the PRSFPS:i (1) the Address File, which contained the name, address, and some funding information of each enrolled facility; and (2) the Patient Record File, which con- iOther files were created and used in the operation of the PRSFPS, but the Address File and the Patient Record File were the basic two. tained the current sociodemographic informa- tion, a pregnancy history, and all of the service and visit information reported for each patient. Both files were updated periodically, either by adding new facility or patient records or by correcting information that had been incorrectly entered or had changed over time. The Patient Record File was also kept current by periodically deleting all of the re- cords of patients who had become inactive by not making a visit for family planning services for 15 months. The inactive patient records were not destroyed; rather, they were maintained on an Inactive Patient Record File so they would be available for longitudinal research studies. Output Tabulations The PRSFPS regularly produced monthly, quarterly, and annual tables, all at the service site, project, State, region, funding agency, and national levels. The tables showed summaries of the activities that had been reported to NCHS and that had occurred during the time period specified on each table. These tables were distributed to various levels of administration throughout the national family planning service program.j : The eight table formats that were used are shown in appendix VI-A. Tables 1 and 2 gave basic patient and visit data by type of patient and medical services provided. These two tables were produced monthly, quarterly, and annual- ly. They were distributed monthly to the service sites, projects, State agencies, Federal regional offices, and agency headquarters and quarterly and annually to the projects, State agencies, Federal regional offices, agency headquarters, and the Deputy Assistant Secretary for Popula- tion Affairs, DHEW. Tables 3-6 were produced and distributed both quarterly and annually; they were sent to the projects, State agencies, Federal regional offices, agency headquarters, and the Deputy Assistant Secretary for Population Affairs. These tables included detailed cross-tabulations of se- iEach table recipient received only the tables that applied to the particular area or agency in question. However, NCHS retained copies of all tables. lected sociodemographic characteristics of the patients served as well as the source of referral of the new patients. Information about the contraceptive method used at the last visit was also given. Tables 7 and 8 were produced and distrib- uted annually, and the distribution was the same as that used for tables 3-6. These tables showed additional cross-tabulations of selected sociodemographic characteristics of the patients served. THE NATIONAL REPORTING SYSTEM During the time in which the PRSFPS was operating, NCHS had begun to work on devel- oping the “final” reporting system. This system, the National Reporting System for Family Plan- ning Services, was implemented in January 1972. Since the NRSFPS is primarily a revised form of its predecessor, there are more simi- larities between the two systems than there are differences. The changes that were made were based on what was learned from operating the PRSFPS and were made in order to improve the collection, processing, and use of the data. The Report Forms The major data collection form used in the NRSFPS through 1976 was the Clinic Visit Record for Family Planning Services (CVR), shown in appendix III-B. This form contained 18 data items (2 of which were optional) and, like the Provisional Report Form, was to be completed each time a person made a visit to a participating service site for family planning services. The information collected on the CVR was similar to that collected on the PRF; in fact, Table A. Comparison of items on the Provisional Report Form for Family Planning Services (PRF) and the Clinic Visit Record for Family Planning Services (CVR) by type of information obtained, according to whether item remained the same, was modified, deleted, or added Type of information and item Item Same | Modified | Deleted! | Added? Identification information: ChnC/Service Site NUMDBTE canis sms imssssvasmmny PALISNT NUITIDRY cosssrssssssssnsaratesssssssssssssssviasssnionssssssss ssi ankossssssisny Demographic information: BACT AAT! (vs ivvsreoremprmreersnsssss sss estes sensssnssssassasssmss ones tRessisssssasssniuansing Ethnic designation/race . EJUCAtION crrssssasinss Pregnancy history .......... Income and family size.. WeITAre STBtUS x rurrronavms seria ses a Ta EE ATS AAS ATI SAT SAS RAT Service and administrative information: VASTUABE scorrrnronvisssmasssns sna sa mons ions aE a Sra TT ARR TRA SAAT Visit session Patient type Visit tyPRu.inisivees MBBOICEl SBIVICRE sivsvunssisssssssssnsssininnesnssivinivissssessssvunsuinsvamsesssipnssnmsns Counseling services Referral services... ummm Date and type of next appointment.. Source of referral.......ccccceveeeeneennn. Contraceptive method adopted... Contraceptive NISLONY wiwmisrssrssnmmimmeissrasssvs soars en iss Ser HOES XX XX XXX litem was on the PRF but was not on the CVR. Item was on the CVR but was not on the PRF. most of the items on the CVR were taken from the PRF either unchanged or slightly modified (see table A). Again, the entire CVR was completed the first time the form was filled out for a patient, and the items completed during revisits were limited to those that changed over time. The CVR also contained a section for agency use only. This section greatly increased the flexibility of the NRSFPS because it allowed the participating agencies and service sites to record information relevant to their specific operations but not required for the national data system. Summary information about the provision of nonmedical family planning services and medical services provided to nonfamily planning patients was collected on the Monthly Counts of Ancillary Services Sheet (MCAS), reproduced in appendix III-B. By using this mechanism, the participating family planning service sites were able to report and “get credit” for services they provided that could not be reported on the CVR. Operational Procedures The operating procedures of the NRSFPS were very similar to those of the PRSFPS; refinements and revisions were made where necessary in order to improve the efficiency and utility of the system. Table B summarizes the major differences between the operating proce- dures of the PRSFPS and the NRSFPS. Enrollment and training of participants.— Any site providing family planning services was eligible to enroll and participate in the NRSFPS. A major effort in 1972, however, was made to enroll those programs that received family plan- ning service funds from NCFPS, MCHS, or OEO or were affiliated with PP/WP because it was felt that these four agencies provided the bulk of the family planning clinic services in the United States. Later, when time and resources per- mitted, the other few remaining sites would be encouraged to enroll and participate in the NRSFPS.k kQther sites were identified through the National Inventory of Family Planning Service Sites, another survey conducted by NCHS. For more information on The primary list of participants in the NRSFPS was obtained from the PRSFPS; all of the service sites enrolled in the Provisional Reporting System were contacted and asked to “reenroll” in the National Reporting System. In addition, the names and addresses of new grantees were supplied to NCHS by MCHS, NCFPS, and OEO. Planned Parenthood also gave NCHS the names and addresses of its affiliates. All of these organizations were contacted by NCHS, and either their funding agency or PP/WP; informed of the necessity to participate in the National Reporting System; and asked to enroll their service sites that were not already in the system. Upon receipt of the completed enrollment forms and the assignment of the project and service site identification numbers, NCHS sent each site a supply of the new report forms, instruction manuals, and the other administra- tive materials needed for reporting to the NRSFPS. In most cases, the sites that were “reenrolled” were reassigned the same numbers they had used in the PRSFPS. Training for the NRSFPS was conducted late in 1971 and was carried out a little differently from what had been done in the past. For the Provisional Reporting System, an attempt had been made to personally train every individual who was to come into contact with the form. Because this procedure was found to be imprac- tical, it was decided, for the National Reporting System, to train ‘‘trainers.” That is, the intent was to train a few selected people, probably from the larger projects, in each area. These people, in turn, would be available to help others in the same region, State, or local area with their participation in the National Report- ing System. Therefore, NCHS contacted each this survey see Development of the National Inventory of Family Planning Services, by Gloria H. Kapantais and Donna Morrow, Vital and Health Statistics, Series 1, No. 12, DHEW Pub. No. (HRA) 76-1312, Jan. 1976. Only those service sites receiving funds through title X were required to participate in the NRSFPS. All other sites were urged to participate in order that the National Reporting System would reflect the actual state of family planning clinic services in the United States. In addition, participating service sites did receive feedback from the NRSFPS that could be used for their own administrative and evaluative purposes. Table B. Summary of major differences in operating procedures between the PRSFPS and the NRSFPS, by type of procedure Operating p rocedure PRSFPS NRSFPS Enrollment and training Data collection and processing...........cceeeeees Files and maintenance... Only certain family planning service pro- grams eligible to participate—those funded by DHEW title V or X, those funded by OEO, or those affiliated with PP/WP. Emphasis on training each indi- vidual who was to handle the report form. Reporting done primarily on hard copy (Provisional Report Form). Very little imputation done resulting in many forms being rejected for incom- plete or inconsistent reporting. Two basic data files. Inactive patient re- cords removed from file on an irregular All family planning service programs in the United States and territories eligible to participate regardless of funding or affil- jation status. Emphasis on training a few select individuals who would then be able to help others learn how to partici- pate in the system. Reporting done on both hard copy (Clinic Visit Record) and machine-readable form (computer cards or tape), with increasing emphasis on machine-readable form. Many imputations done resulting in an increase in the acceptance rate. Forms no longer rejected for incomplete responses to noncritical items. Five basic data files. Inactive patient records removed from file on a regular basis. basis. regional office (MCHS, NCFPS, OEO, and PP/WP), informed them of the type of training that was to be provided, and asked them to get in touch with their grantees or affiliates to help in assuring that the appropriate people were sent to the training sessions. The training procedure used for the National Reporting System was similar to that used for the Provisional Reporting System—the defini- tions, report forms, and instruction manual were reviewed, as well as other administrative details about joining and participating in the NRSFPS. The most valuable sessions were those which were attended by clinic personnel who had previously participated in the Provisional Re- porting System. These people had experience in reporting to NCHS and were able to share this experience with the group. Data collection and processing. —The patient visit data were submitted to the NRSFPS in one of two ways: on the CVR itself (hard copy) or on computer cards or tape (machine-readable form). The data collection and processing proce- dures used in the NRSFPS for the submitters of hard copy were very similar to those used in the PRSFPS; for example, the CVR’s were sub- mitted weekly or biweekly, and all of the remaining forms for a given month were sent in on the last working day of the month. As with the PRF, the CVR was a two-part form consist- 10 ing of an original, which was sent to NCHS, and a carbon copy, which was retained at the service site. The receipt and control procedures, as well as the conversion of the data into machine- readable form, were also very similar in the two systems. The family planning programs that reported their data in machine-readable form through local computerized systems were instructed to report monthly. As the cards and tapes were received by NCHS, they were logged in and sent directly for computer processing. Such data, however, were accepted for the NRSFPS only after NCHS had determined that the definitions, data collection and processing procedures, and record formats of the local systems accorded with the standards and requirements of the NRSFPS. This clearance procedure was neces- sary because most of the local computerized systems used their own forms rather than the CVR. In these cases, the data items required by NCHS were incorporated into the local report form; only the required data items were sub- mitted to NCHS. The MCAS, the other data collection instru- ment used by the NRSFPS, was completed and submitted to NCHS monthly along with the last shipment of CVR’s for the applicable month. Initially, card and tape submitters also had to report their ancillary services on the MCAS; this was later changed, however, to allow these sites to ‘report the ancillary services data, as well as the patient visit data, in machine-readable form. All data, regardless of the form in which they were submitted, were subject to the same editing procedures once they were received by NCHS. As with the Provisional Reporting Sys- tem, one result of the editing procedure was a processing report, similar to the one obtained from the Provisional Reporting System, for each site (a sample of this report is shown in appendix V-B). Each report that was produced for the submitters of hard copy was reviewed, annotated if necessary, and returned to the applicable site with any rejected records that could not be reprocessed by NCHS. Again, personnel at the sites were instructed to examine the reports for accuracy, make the necessary corrections, and resubmit any corrected forms to NCHS for reprocessing. The processing reports for those sites report- ing on cards or tape were sent back to the submitters without review by NCHS. This was necessary because NCHS did not have the original source documents with which to verify the data. Although the general kinds of edits for the NRSFPS were the same as those used for the PRSFPS, specific edits had been modified where necessary. One major modification, for example, was the change that allowed the NRSFPS to make imputations and accept records that had failed selected edits. This is in contrast with the procedure that was used in the PRSFPS where every edit failure resulted in the total Visit Record being rejected; the valid information in the record, therefore, was not added to the data file until the record had been manually cor- rected and resubmitted by the service site or, more rarely, by NCHS. For example, in the Provisional Reporting System the pregnancy history information, such as the number of live births, could not decrease over time. If a decrease was reported, the record with that information on it would be rejected and re- turned to the reporting service site for correc- tion and resubmission. In the National Report- ing System, on the other hand, it would be assumed that the larger of the two numbers was correct; an ‘error’ message would be printed on the processing report giving the patient number, the edit, and the imputation made; the record would be accepted, and all of the information on it would be added to the data file. The service site would then be sent the processing report and, if the imputation made by NCHS was incorrect, could submit a ‘“‘correction form” to the NRSFPS so the data file could be corrected. If the imputation was valid, no further action on the part of the service site was necessary. Files and maintenance.—The following were the basic files used by the NRSFPS:™ The Facility Master File The Skeleton Master File The Patient Master File The Purged Patients Master File The Activity Master File The Facility Master File was similar to the Address File in the PRSFPS; this was the file that contained the name, address, funding and Planned Parenthood affiliation data, the ancil- lary services data, and some other administrative data for each facility enrolled in the NRSFPS. This File was updated monthly by adding records for new facilities, deleting records of inactive facilities, or correcting information that had been incorrectly entered or had changed over time. The Skeleton Master File consisted of one record for each active patient in the NRSFPS. Fach record contained the most current infor- mation about each patient in terms of the individual’s sociodemographic characteristics, most recent contraceptive method used, con- traceptive usage before enrollment in the report- ing family planning project, and the most recent visit date. This File was used primarily in the editing process and was updated constantly as new or corrected patient visit records were received and processed by the NRSFPS. In addition, the inactive patient records were de- leted from this File every 3 months. The Patient Master File contained all of the information on each CVR submitted to and M Again, as with the PRSFPS, other files were created and used in the operation of the NRSFPS, but these five were the basic files. 11 accepted by the NRSFPS for the active patients. These records were kept in a consecutive “visit string” for each patient; therefore, as long as a patient remained active, all visit records for each patient were stored together in this File. This File was updated quarterly by adding new records, changing incorrect data, and deleting the records of the patients who had become inactive. The deleted records were stored on the Purged Patients Master File. The Activity Master File contained a histori- cal record of facility participation in terms of its submission of patient visit data to the NRSFPS for each enrolled service site. This File was used for administrative and monitoring purposes and was updated monthly, based on each site’s submission of patient visit data to the NRSFPS. Output Tabulations As table C indicates, the regular output tabulations from the NRSFPS were much more extensive than those of the PRSFPS (see appen- dix VI-B for the NRSFPS table formats). The output was again produced on a monthly, quarterly, and annual basis; however, unlike the Provisional Reporting System, different sets of tables were developed for the different time periods. In addition, different types of tabula- tions were produced for each level of participant—service site, project, State, region, and funding agency or Planned Parenthood—and they were intended to be useful for program planning and evaluation at each level. Tables Table C. Summary of major differences in the output tabulations between the PRSFPS and the NRSFPS PRSFPS NRSFPS Eight different table formats | Twenty-seven different table formats Some of the same table for- | Different table formats were mats were used in producing used in producing the the monthly, the quarterly, monthly, the quarterly, and and the annual tabulations the annual tabulations Service sites received only monthly tabulations Service sites received monthly, quarterly, and annual tabula- tions No tables were regularly avail- able for the general public Some of the tables were pro- duced quarterly and annual- ly for the general public 12 were not sent to service sites and projects that reported through automated systems, however, because it was felt that such systems had been developed originally to meet the data needs of their family planning programs and, therefore, already provided them with the necessary tables. By eliminating feedback to these projects and service sites, unnecessary duplication of both effort and expense was avoided. Both the monthly and the quarterly tabula- tions were designed for administrative and management purposes rather than research pur- poses. The monthly tables contained only basic patient counts and service information and were distributed to the participating service sites and projects, States, and regional offices. Distribu- tion was usually completed within 4 weeks after the end of the given month. The quarterly tables contained, in addition to basic patient and service counts, some demo- graphic information about the patients served during the particular quarter. These tables were sent to the participating service sites, projects, States, regional offices, and national offices. Because an additional month was allowed for data collection for the quarterly tables, these tables were mailed within 2 months after the end of the particular quarter. More detailed information about the demo- graphic characteristics of the persons served and the services they had received was available from the annual tabulations. Because both research and management needs were considered in de- signing these tables, a much larger set of tabulations was distributed to the service sites, projects, States, regional offices, and national offices. Distribution of these tables was com- pleted within 3 months after the end of the year. Some of the tabulations from the NRSFPS were also regularly available for public distri- bution to persons requesting information about family planning clinic services and patients. Although no monthly data were distributed to the general public, basic patient counts by quarter were sent. In addition, since the annual tabulations were heavily oriented toward re- search needs, a much larger set of tables, containing both national and State data, was available to the general public. Besides the regular tabulations, special tabu- lations from the NRSFPS have been produced and used for both research and management needs. Such tabulations have been requested by Federal, State, and local agencies for their own research, administrative, or management use. Costs for these tabulations, unless minimal, have generally been borne by the requester. All such requests are reviewed by NCHS to assure that the confidentiality of the data is protected before the tabulations are released. GROWTH AND FUTURE OF THE REPORTING SYSTEM The 100-percent family planning reporting system® has grown rapidly during the 7 full years of its operation. As can be seen in table D, during 1970 some 890 service sites reported serving 415,000 patients who made 640,000 visits for family planning services; these figures have increased to 4,940 service sites reporting 3,248,000 patients who made 5,853,000 visits during 1975. Table E shows the percent change from one year to the next of the number of participating service sites, patients served, and visits made as reported to NCHS. Although the increase in the number of participating sites seems to have leveled off, the number of patients served has consistently grown 20 to 30 percent each year since 1973. In addition, the number of family planning visits made by these persons has con- currently increased 30 to 40 percent each year over the same period of time. The percent of records submitted to the NRSFPS through local automated data systems has also continued to increase over the 4 years for which this information is available. As can be seen in table F, approximately 65 percent of the records were received through these partici- pating systems during 1975, up from the 47 percent submitted during 1973. During 1976, work was undertaken to revise both the basic data collection document used by NRSFPS (the CVR) and the National Reporting Mncludes both the PRSFPS and the NRSFPS. Table D. Number of participating service sites, family planning patients seen, and clinic visits made for family planning services as reported to the NCHS family planning reporting systems: United States, ! 1970-75 Service . LL Year S108 Patients Visits Number 19702... 390 415,000 640,000 19712 1,800 798,000 | 1,268,000 19723 3,270 | 1,633,000 2,480,000 19733... 4,090 | 2,138,000 3,469,000 19743... 4,830 | 2,608,000 4,414,000 19753 4,940 | 3,248,000 5,853,000 includes Puerto Rico, Virgin Islands, and Guam. 2PRSFPS. SNRSFPS. Table E. Percent increase in the number of participating service sites, family planning patients seen, and visits made for family planning services as reported to the NCHS family planning reporting systems: United States,! 1970-75 Percent increase from prior year Year Botice Patients | Visits 19702 3) (3) (3) 19712... 102.2 92.3 98.1 19724 81.7 104.6 95.6 19734 25.1 30.9 39.9 19744 ... 18.1 22.0 27.2 19754 2.3 24.5 32.6 Jincludes Puerto Rico, Virgin Islands, and Guam. PRSFPS. Base year. 4NRSFPS. Table F. Percent of records submitted to the NRSFPS by auto- mated and nonautomated submitters: United States,! 1973-75 Submitter Y - ear Total Auto- Non ota ated auto- mated Percent of records submitted 100.0 47.2 52.8 100.0 56.5 43.5 100.0 65.4 34.6 includes Puerto Rico, Virgin Islands, and Guam. 13 System itself. This revision was necessitated by the decision to convert the 100-percent National Reporting System to a sample survey in 1977. A sample survey would allow DHEW to take advantage of the benefits of sampling in terms of the efficiency, economy, and better quality control of the data and the data collection. In addition, sampling would allow resources pre- viously directed toward 100-percent reporting to be redirected toward obtaining data from sample family planning service sites not previously in the NRSFPS. Since these sites are mostly those which are neither federally funded nor affiliated with PP/WP, the data from the National Report- ing System would thus become representative of the total picture of family planning services in the clinic setting in the United States and its territories. Although the data collected through the sample survey will be submitted to NCHS mainly in machine-readable form (punched cards or magnetic tape), sample sites may use the NCHS report form to collect the information required. As with the 100-percent NRSFPS, data will be accepted from local automated systems that are not using the NCHS report form only if their definitions, data collection and processing systems, and record formats are in accordance with the standards and requirements of the national survey. Sampling will be done in two stages. First, a representative sample of about 1,500 service sites will be drawn from the total universe of all family planning service sites that could be identified in the United States and its territories. Second, a subsample of family planning visits made to these sites will be drawn, and the size of each subsample will depend on the size and location of each service site. Automated systems could submit all of the visit data for their sample service sites to NCHS; NCHS would then draw these subsamples. Alternatively, each subsample could be drawn at the site by use of a log attached to the CVR’. The log will not be submitted to NCHS but will remain at the service site. Since the new CVR is based on the old form, many of the items on the two forms are the same or similar (see appendix III-C for a sample of the new report form). The items on the new form can be categorized into three types: identification information, social and demo- graphic information, and family planning service or clinical information. The identification information consists only of two numbers—the service site number assigned to the site by the NCHS and the patient number assigned to the patient by the service site. Both of these numbers will be used only for purposes of quality control. Moreover, the only link between the patient number and the name of the patient will exist at the service site, as was previously the case. Social and demographic information in- cludes data on each person’s birth date, race, sex, education, pregnancy history, income, and family size. Family planning service information refers to patient status, date of the visit, and the medical services provided at the service sites. Information pertaining to the contraceptive usage of the patient, both prior to and as a result of the particular visit, is also collected. Estimates at the national, regional, and State levels will be produced from the sample NRSFPS. Although the tabulation plans have not yet been finalized, it is anticipated that the estimates produced from the sample data will be used for the overall planning and evaluation of the family planning program at the national level. In addition, the data collected also will be useful for research purposes. 000 14 IL. IIL. VIL Abbreviations Used in This Report Agencies and Persons From Whom Comments and Input Were Received Regarding the Family APPENDIXES CONTENTS Planning Reporting Systems Sample Report Forms A. Provisional Reporting System for Family Planning Services: Provisional Report Form for Family Planning Services B. National Reporting System for Family Planning Services (100-Percent Survey) Clinic Visit Record for Family Planning Services (HRA-63) Rev. 1-76......ccccueuene. FE — Monthly Counts of Ancillary Services Sheet C. National Reporting System for Family Planning Services (Sample Survey): Clinic Visit Record for Family Planning Services, HRA-192-2, 6/77 Sample Enrollment Forms A. Provisional Reporting System for Family Planning Services: Project Enrollment Form............. B. National Reporting System for Family Planning Services (100-Percent Survey) Project Data Sheet Service Site Data Sheet Sample Processing Reports A. Provisional Reporting System for Family Planning Services Sample: Error Conditions or Possible Oversights Sample: Summary of Records Submitted Sample: List of Forms Processed...... B. National Reporting System for Family Planning Services (100-Percent Survey) Sample: Error Conditions or Inconsistencies Sample: Summary of Records Submitted......ccceereeerrnneannnnenan Sample: List of Forms Processed Standard Table Shells A. Provisional Reporting System for Family Planning Services: Tables 1-8 1 and 2. Number and percent of patients receiving family planning services, by type of patient and type of service provided and number and percent of visits for family planning services, by type of service provided during visit nation and age of school completed and age live births and contraceptive method adopted . Number and percent of patients receiving family planning services, by ethnic desig- . Number and percent of patients receiving family planning services, by highest rede . Number and percent of contraceptive patients receiving family Planning services, by Number and percent of new patients receiving family planning services, by age and source of referral Number and percent of patients receiving family planning services, by age and by public welfare status Number and percent of patients receiving family planning services, by live births and highest grade of school completed 17 18 20 20 23 24 26 26 29 31 33 33 34 34 35 36 37 40 41 42 43 44 15 B. National Reporting System for Family Planning Services (100-Percent Survey) Monthly Tables: M-1-M-3 M-1. Family planning services and contraceptive method by type of visit and summary re- ports M-2. Number of family planning patient visits by type of visit: each service site and project within State M-3. Number of family planning patient visits by type of visit, by funding agency: each project and State within region............ Quarterly Tables: Q-1—Q-9 Q-1. Activity status of patients by selected patient characteristics.....cceoceereerrniericnnesecesennns Q-2. New female contraceptive patients by selected characteristics Q-3. Patient visits by type of visit and type of services provided............ erases Q-4. Number and percent distribution of all patients by selected characteristics: each State, project, and service site Q-5. Number and percent distribution of new patients by selected characteristics: each State, project, and service site Q-6. Number of sterilization patients by selected characteristics: each State, project, and service SHte..mmensorseeesisres Q-7. Number of infertility patients by selected characteristics: each State, project, and service site Q-8. Number and percent distribution of female patients by type of patient and live births: each State, project, and service site Q-9. Number of patients and visits for each project, State, and region, United States........ v Annual Tables: A-1—A-7 and A-20—A-90 series A-1. Number of patients and visits for the United States, each region and State...... FeaTivenuses A-2. Number of patients and visits by State and funding source for each participating project A-3. Number of patients and visits for each project and its SETVICe SiteSs......ccererrenrreerrrnneerens A-3P. Number of patients and visits for each Planned Parenthood affiliate A4. Number of service sites, patients, and visits by project funding source for the United States A-5. Number of service sites, patients, and visits by project funding source for each A-6. Number of service sites, patients, and patient visits by funding agency, each region, and the United States A-7. Number of service sites, patients, and patient visits by region, State, and project for each funding agency A-20. Number of female patient visits by type of service provided for the United States....... A-30(N). Number of (new) female patients by age according to selected characteristics for the United StateS...ueeeeierreriiieirriiiiersrssssssssnaeessssessssassssssssssssssssessesssses arose A-40(N). Number of (new) patients by patient characteristics according to sex and age for the United States A-50. Characteristics of patients receiving public assistance by age and parity for the United States A-60. Number of method changes by type of method after change according to type of method before change and type of patient: female patients for the United States........ A-70-1. Number of new female patients by method prior to clinic enrollment and method at last visit, and source of method prior to clinic enrollment for the United States...... A-70-2. Number of female patients by method prior to clinic enrollment, method at end of initial visit, and method at end of last visit according to type of patient and type of method for the United States. vou A-80. Female contraceptive patients by contraceptive use prior to clinic enrollment accord- ing to age and number of live births for the United States.......cccecuerrereererereeerecerneernnene A-90. Number of new female patients who are under 19 years by selected characteristics for the United States.. 55 56 56 57 58 59 60 61 62 62 63 64 APPENDIX | ABBREVIATIONS USED IN THIS REPORT AFDC BCHS CB CVR DHEW HRA HSA HSMHA MCAS MCHS NCFPS NCHS NRSFPS OEO PP/WP PRF PRSFPS Aid to Families With Dependent Children Bureau of Community Health Services Children’s Bureau Clinic Visit Record for Family Planning Services Department of Health, Education, and Welfare Health Resources Administration Health Services Administration Health Services and Mental Health Administration Monthly Counts of Ancillary Services Sheet Maternal and Child Health Service National Center for Family Planning Services National Center for Health Statistics National Reporting System for Family Planning Services Office of Economic Opportunity Planned Parenthood/World Population Provisional Report Form for Family Planning Services Provisional Reporting System for Family Planning Services 18 APPENDIX II AGENCIES AND PERSONS FROM WHOM COMMENTS AND INPUT WERE RECEIVED REGARDING THE FAMILY PLANNING REPORTING SYSTEMS Although this list may not be complete, it is representative of the agencies and persons contacted who had input into the development of both the Provisional Reporting System for Family Planning Services and the National Reporting System for Family Planning Services. Agencies Office of Economic Opportunity Planned Parenthood/World Population Department of Health, Education, and Welfare Office of the Secretary Children’s Bureau Center for Disease Control Food and Drug Administration Indian Health Service Maternal and Child Health Service National Center for Family Planning Services National Center for Health Statistics Persons David T. Allen, M.D., Tennessee State Department of Health Samuel Baum, Bureau of the Census Joseph Beasley, M.D., Louisiana Family Planning Program Donald Bogue, Ph.D., University of Chicago Arthur Campbell, Public Health Service, Department of Health, Education, and Welfare Leslie Corsa, M.D., University of Michigan Edwin Daily, M.D., New York City Health Department Ralph Frankowski, Ph.D., Tulane University School of Medicine Roberto Fuentes, District of Columbia Health Department Louis M. Hellman, M.D., Downstate Medical Center, New York Frederick S. Jaffe, Planned Parenthood/World Population Schuyler Kohl, M.D., Downstate Medical Center, New York Stephen Polgar, Ph.D., Planned Parenthood/World Population Margaret Pratt, George Washington University Jack Reynolds, Ph.D., Columbia University Jeannie Resoff, Planned Parenthood/World Population Carl S. Shultz, M.D., Department of Health, Education, and Welfare, Office of the Secretary Eleanor Snyder, Ph.D., Planned Parenthood/World Population Sheri Tepper, Rocky Mountain Planned Parenthood Christopher Tietze, M.D., Population Council George Varkey, Planned Parenthood/World Population H. Bradley Wells, Ph.D., University of North Carolina Charles Westoff, Ph.D., Princeton University Gooloo S. Wunderlich, Ph.D., Department of Health, Education, and Welfare, Office of the Secretary 19 20 APPENDIX 111 SAMPLE REPORT FORMS A. PROVISIONAL REPORTING SYSTEM FOR FAMILY PLANNING SERVICES NATIONAL CENTER FOR HEALTH STATISTICS, PHS, DEPARTMENT OF HEALTH, EDUCATION AND WELFARE PROVISIONAL REPORT FORM FOR FAMILY PLANNING SERVICES *(________1For Continuation Patients: Shaded Items Should be Completed Every Visit. Other Items (except Nos. 6, 7, 8, 9) Should be Completed Only at “Annual” Medical Examination. Prepared | Checked Change By By ? NAME PHONE [] ADDRESS PATIENT NO AGE All information which would permit identification of an individual or of a clinic will be held in strict confidence, will be used only by per- sons engaged in and for the purpose of the survey and will not be disclosed or released to others except for statistical purposes. (DETACH THIS PART AND RETAIN AT THE CLINIC) OMIT FOR CONTINUATION PATIENTS 1. CLINIC NUMBER 15 ON WHAT DATE DID YOUR LAST PREGNANCY {NUMBER} TERMINATE ? MO. | DAY | YR. | 1 le 2. PATIENT NUMBER 16. WHAT WAS THE OUTCOME OF (NUMBER) YOUR LAST PREGNANCY? (CODE) tld 3. PATIENT TYPE 17. TYPES OF MEDICAL SERVICE (CODE) (CODES) 4. DATE AND SESSION OF VISIT 18. CONTRACEPTIVE METHOD [Fess MO. | DAY | YR. ADOPTED AT THIS VISIT (CODE) 5. BIRTH DATE ! ! INFERTILITY SERVICES (CODES) 6. ETHNIC DESIGNATION COUNSELING & REFERRALS (Except Infertility Services) (CODES) a. Counseling 7. WHO REFERRED YOU TO US? b. Referrals (CODES) DATE OF NEXT 8. HAVE YOU RECEIVED FAMILY APPOINTMENT MO. YR. PLANNING SERVICES FROM A DOCTOR OR CLINIC WITHIN IYESOR NO) THE LAST TWO YEARS? 22. TYE DE NeRY 9. CONTRACEPTIVE METHOD USED OIVIMEN (CODE) IN THE LAST TWO YEARS (CODE) 23. CURRENT RESIDENCE 10. WHAT IS THE HIGHEST GRADE a. County Code (CODES) OF SCHOOL COMPLETED? (CODE) , i (CODES) 11. INCOME AND FAMILY SIZE b Location Code Ll a. How Much is Your Family's (WHOLE DOLLARS) 24. LOCAL USE Weekly Income? > b. How Many People In Your Family (NUMBER) 1 Iq L 1 Are Supported By This Income? 24. b. 12. 1S YOUR FAMILY RECEIVING ASSISTANCE FROM A PUBLIC (CODES) WELFARE AGENCY ? 24. c. 13. AREYOU REGISTERED FOR MEDICAID ? (YES OR NO) 24. d. 14. HAVE YOU EVER BEEN PREGNANT? (YES OR NO) If Yes, Provide: a. Number of Children Born Dead (NUMBER) REMARKS: (Anytime After Conception) (NUMBER) b. Number of Live Births c. Number of Children Who Were Born (NUMBER) Live But Died Before One Month (NUMBER) d. Number of Children Now Living Bureau of the Budget Approval 68-R-11371 CODES FOR COMPLETING PROVISIONAL REPORT FORM FAMILY PLANNING SERVICE ® Patient Type: What was the Outcome of Your (Code) (Code) NOW. .veveeeeacessesees 0 Continuation .eeessesese 6 Last Pregnancy? New-To-System......... 3 Readmission ceeesesrees B BORN LIVE: BORN DEAD: (Code) (Code) Term (5% Ibs. or more).. 1 Term (5% Ibs. or more).. 6 Low Weight ............ 4 Other.....ceenesssnsess 9 Session of Visit: {lesz tha SY. bs} ® (Code) (Code) Morning «vevescescecess 5 AHEMOON cevesescannss 7 Evening...coosueeeeeess 8 @ Types of Medical Service: (There may be up to Six Codes entered.) (Code) (Code) ; 7 Foon Breast Exam... . 1 PAP Smear. we B ® Ethnic D esgnation; (Code) Pelvic Exam ens 2 Serology.... we 7 White....oeee .. 0 Other Spanish Surname... § OtherMedical Exams.... 3 Other Lab Tests.. . 8 Black...... -~ . 2 American Indian........ 7 No Exams or Tests Given............. ceeees «0 Contraceptive Method Adopted at this Visit: ? ® Who Referred You to Us: (Select Only One Code) (Select Only One Code) (Code) (Code) Program Personnel. ....... vessenvanseniransrinniiirn No Change From Previous Method Other Social Welfare Agency ........ anv {Comey | [TP | Hospital, Medical, or Other Health Sources... Other Clinic Patient, Friend or Relative....... Public Welfare Agency ....cecessessnccncnsas Other Source or Self .. Oral... Infertility Services: . (Code) (Code) ® Contraceptive Method Used in the Treatment. .... 1 Raterialoiesvornes we 3 Last Two Years: Counseling. 2 (Select Code for Most Frequently Used Method) No Infertility Services Provided. .....covvvviinninnnns 0 (Code) (Code) None ..... «ooo 1 Diaphragm....covveeeee 5 Counseling and Referrals: (Except Infertility) Oral vies 2 Foam........ 6 wo..... «eee 3 Rhythm... +17 Contraceptive Counseling Condom wees & Other..evevesevascacnss 8 Other Counseling ....... . . No Counseling Provided .........cooviviniinianninnne What is the Highest Grade of School Completed? Referral From This Clinic for: None Elementary School High School Medical Services.......ccovvriiirrniinrnrnnnrnnnn (Code) 0 1,2,3,4,56,7,0r8 8,10,11, 0r12 Social Services ... cee College More Than 4 Years College No Referrals... ovvvvsusvnnssmnsviassnimusmsvvsnive (code) 13,14, 15, or 16 7 @ Type of Next Appointment: ’ - 2 (Code) (Code) @ Is Your Family Receiving Assistance from Annual Medical......... 1 Supplylnly...ccovnnnns 5 a Public Welfare Agency? Othar Medical.......... 3 Counseiing............. 7 (Code) (Code) No Appointment Made. ..coveuvrnrreiinnrninrasninias 9 NO: nsvsnsavasansangy 0 Other Public Welfare.... 9 AFDC......ccivnvvvrene 5 21 22 B. NATIONAL REPORTING SYSTEM FOR FAMILY PLANNING SERVICES U.S. DEPARTMENTOF HEALTH, EDUCAT IOI (100-PERCENT SURVEY) CLINIC VISIT RECORD FOR FAMILY PLANNING SERVICES AND WELFARE NAME (FIRST) (MIDDLE) (LAST) (MAIDEN) PUBLIC HEALTH SERVICE WEALTH RESOURCES ADMINISTRATION | ADDRESS NATIONAL CENTER FOR (STREET) PATIENT NO. NEALTN STATISTICS (CITY) (STATE) (ZIP CODE) (PHONE NO.) rere ereees PREPARED | CHECKED BY BY CONFIDENTIALITY ASSURANCE: All information which would permit identification of an individual willbe held In strict confidence, will be used only by persons engaged In and for the purpose of the survey, and will not be disclosed or released by NCHS to others except for statistical purposes. The provision of services is in no way contingent upon the patient's providing any Information on this form. (DETACH THIS PART AND RETAIN AT SERVICE SITE) . SERVICE SITE NUMBER System for Family Planning Services for this patient during the last 15 months? Has a Clinic Visit Record been submitted to the NCHS National b. If None, give reasor No - Complete items 10 through 18 below | NUMBER Yes - then: YES NO | | Is this the first Record completed for this patient this year? 2. PATIEN B TNUMBER | | TT | Yes - Complete only Items 10, 11, 12 below YES NO No - Stop here 3. DATE OF VISIT MO. DAY YR. 10. Pregnancy History NUMBER a. Number of Live Births 4. TYPE OF VISIT BER [1 Initial Visit b. Number of Fetal Deaths NUM (2) Revisit (first visit this year) (Stillbirths, Abortions & Miscarriages) [8] Revisit (not first visit this year) NUMBER (4) Readmission Visit c. Number of Children New Living 5. DATE OF BIRTH MO. DAY Welfare Status 6. Services Provided Are You or Anyone in Your Family YES NO MEDICAL SERVICES Receiving Public Assistance? a. b. Are You or Anyene in Your Family YES NO (0) Pap. Smear Registered for Medicaid? [2] Pelvic Exam [@ Urinalysis (n.e.s.) (3) Breast Exam (8) Blood Test(n.e.s.) [@ Blood Pressure [§ Sterilization eS 12. Highest Grade of School (5] Pregnancy Testing (©) Infertility Treatment] Completed Oth ® V.D. Testing ar None Elementary School High School b. COUNSELING Code 0 1,2,3,4,5,6,7,8, 9,10,11, 12, n nferti| CODES College More Than 4 Years College CODE [0 Sterilizatio: (3) Infertility [2] Contraception [@ Other Code 13, 14, 15 or 16 17 7. Referred Elsewhere 13. Place of City & State (Country if not U.S.) [© None [3] Infertility Services Birth (OPTIONAL) [1] Abortion (4) Other Medical Services CODES 14. Latin-American O [2] Sterilization (8) Social Services Ji Sotin American rigin YES NO 8. Contraceptive Method at the End of This Visit Il 15 Race @ Whi @ Am. 1nd CODE . le m. Ind. ®. Method; [RI [@ Other [@ Oral (Pi) [@D Injection 16. Sex CODE 2 1UD g Sterilization [@ Female @ Male Diephragm Other 3 roam [@ None 17. Source of Referral Rhythm t h Work [# condom (x) Interim Method {33 uitrench Weirker (2) Other FP Clinic ® (3) Hospital, or @ Other Health Agency (® © © Another Clinic Patient Family or Friend TV, Radio, Paper Ad. (4) Private Doctor or Nurse Other | [1] Pregnant (3) Seeking Pregnancy (5) Welfare Agency Unknown CODE [2] Other Medical Reason [4] Other 9. Next Appeintment 18. Contraceptive History [YES NO | b. Purpose (OPTIONAL) a. Have You Ever Used Any Method to Prevent Pregnancy? (J Supply Only [@ Other [2] Annual Medical (8) No Next Appointment PURPOSE CODE b. Are You Currently Using Contraception? Y£§ NO [3] Other Medical c. What is the Last Method Used? (Check One) [1 Oral (8) Rhythm AGENCY USE @ 1uo [# Condom (3) Diaphragm (3 Injection CODE NCFPS OEO MCHS PP-WP NCHS | LOCAL (4) Foam (8) Other * d. Who Prescribed that Method: (J Clinic Drug Store (non-prescription) CODE b. [2] Private Doctor [4] Other d. e. 1 HRA-83 REV. 1-76 FORM APPROVED OMB NO. - 68-R-1137 MONTHLY COUNTS OF ANC ILLARY SERVICES SHEET NATIONAL REPORTING SYSTEM FOR FAMILY PLANNING SERVICES Date Service Site Number Project Number i Y City S\N State The month in which ancillary services were provided The total monthly counts of ancillary services provided at this service site: Medical Services Supply Visits Outreach Contacts Attendees at Lecture Sessions Telephone Contacts ii Other Services NOTE: Please refer to the Administrative Manual, Section VI. Reporting Ancillary Services to NCHS, for detailed instructions. Send all shipments to: INFORMATICS INC. 6425 Landover Road Cheverly, Maryland 20785 ATTENTION: FAMILY PLANNING DIVISION 23 C. NATIONAL REPORTING SYSTEM FOR FAMILY PLANNING SERVICES (SAMPLE SURVEY) 3 002131 FAMILY PLANNING VISIT LOG Ask the patient: “Are you here to see a family planning provider (physician, nurse, allied health personnel) about obtaining health services related to contraception, infertility treatment, or sterilization?’ If the patient says “yes,” enter his/her name on the lines below. Complete the clinic Visit Record for the last name entered on the log. FOR SERVICE SITE USE ONLY Record Items 1-14 for this patient. DETACH HERE AND RETAIN AT SERVICE SITE Vv CONTINUE LISTING PATIENTS ON NEXT PAGE. U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HEALTH RESOURCES ADMINISTRATION NATIONAL CENTER FOR HEALTH STATISTICS Clinic Visit Record for Family Planning Services O.M.B. 68-R1137 EXPIRATION DATE 12/31/77 » 002131 ASSURANCE OF CONFIDENTIALITY-AIl information which would permit identi- fication of an individual, a practice, or an establishment will be held confidential, will be used only by persons engaged in and for the purposes of the survey and will not be disclosed or released to other persons or used for any other purpose. Provision of services is in no way contingent on the patient's providing any information for this form. SERVICE NUMBER CIT TTT T] Number Number 3. DATE OF THIS VISIT 1] Month Day Year 4. PATIENT'S SEX + [hitemin o [lwwe 5 ARE YOU OF HISPANIC ORIGIN OR DESCENT? HAND CARD A a [] ves b [J No 6. PATIENT'S RACE (Check one box) a [] white ¢ [] Asian or Pacific Islander d [] American Indian or Alaskan Native b [] Black 11. PREGNANCY HISTORY (Females only) A. Have you ever heen pregnant” a [J ves b [| No—=Gotor12 B. How many live births have you had? C. Of these, how many are now living? D. How many of your pregnancies were ended by stillbirth, induced abortion, or miscarriage? (If “zero,” go to F ) E. How many of these pregnancies were ended by induced abortion since January 1973? F. In what month and year did your last pregnancy end (regardless of how it ended)? Month Year WHAT IS YOUR BIRTH DATE? LJ Month Day Year a Date —————ee b [] if unknown ask “How old are you"? (No. of Years) PATIENT STATUS Have you been a patient of this or any other clinic for family lcal services? planning m b [J No a [J ves If “Yes,” when were you last a patient af any clinic for family planning medical services” —am month Year EDUCATION A. What is the highest grade (or year) of regular school you have completed?) (Circle one number) 01 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17+ (If “zero,” go to 10) B. Are you presently a student in a regular school? a [] ves b [| No FAMILY INCOME AND FAMILY SIZE 12. CONTRACEPTIVE HISTORY A. Have you ever used a method of birth control regularly? a 0 Yes b ( ¥ HAND CARD D B. What method did you last use regularly? (Check all methods that apply) t [[] condom gs [] Foam/eiy/cream n |] Natural (including rhythm) i [J otner ] No — Go to 13 a [] sterinization bo [J oral (Pi) ¢ (Jo a [] oiaphragm [7] 1niection C. Do you currently use that method (primary method checked in 128)? a [] ves—~GotoE b [no . In what month and year did you stop using that method? Month Year m How long did you use that method? — Days (if less than a month) — Months (if less than a year) Years F. Where was the method prescribed or obtained? a [] This service site e [] Orug store (nonprescription) b [] Clinic (if other than this site) t [] other ¢ [] Hospital (if other than this site) g [|] Unknown a [] private physician HAND CARD B and HAND CARD C A. Which of the following groups represents your total combined gross (before deductions) family income for the past 12 months? s [J] s18.750+ n [J unknown a [J 0-51,249 b []s1.250-33.749 c [7] $3.750-56.249 a [[] s6.250-38,7a9 e [] s8.750-313.749 + [] s13.750-518.749 B. How many people are in your family, that is, the number supported by this income? 13. MEDICAL SERVICES PROVIDED AT THIS VISIT a [J urinalysis (n.e.s.) n [] Blood test (n.es.) i [J sterinization x [J intertitity tr m [] other medical services a a Pap smear b [J Pelvic exam < Od Breast exam a a Blood pressure e [] Pregnancy testing t [J v.0. testing tment C. Does this income include any public assistance? a [] ves b [J No D. What is your relationship to the chief earner? ¢ [] paugnter/son a [[] other relative a [[] chief earner b [] wife/Husbana AGENCY USE ONLY A 8 C Oo Eg F 14. CONTRACEPTIVE METHOD AT THE END OF THIS VISIT A. Method (Check all that apply) a [J steritization + [] condom o [] oral (ei) 9 [] Foam/Jeily/Cream ¢ (J wo n [[] Natural (including rhythm) a [] oiaphragm i [[] other e [] injection x [] None B. If “‘None," give reason (Check one only) a [J pregnant a [[] other medical reasons b [] intertinty patient ¢ [[] seeking pregnancy e [] Relying on partner's method t [J other HRA-192-2 6/77 25 26 APPENDIX IV SAMPLE ENROLLMENT FORMS A. PROVISIONAL REPORTING SYSTEM FOR FAMILY PLANNING SERVICES PROJECT ENROLLMENT FORM Name of Project: ("Project" refers to the program receiving a grant. A number of family planning clinics may be funded by one project grant.) Name of Project Director: Address of Project: Street Address Telephone Number: Area Code How many clinic sites are part=Q¥\Your project? Include project headquarters if a clinic is operated at that location. Number ("Clinic site" is used to refer to the smallest unit directly providing family planning services to patients.) How many family planning staff members are in each of the following cate- gories in your project? Laboratory Assistants: Social Workers: Administrative Personnel: Clerical Personnel: M.D.: PN/LPN: Nursing Assistants: Laboratory Technicians: SQ HD QO TQ — rr rr GO TO QUESTION 6 Page 2 6. 10. 11. 12. 13. 14. Does your family planning project receive funds from the following organi- zations? Nat'l Center for Family Planning Services . . ( ) Yes % (1) No Maternal Child Health Services . . . . .. . () Yes __% () No Office of Economic Opportunity . . . . . . . () Yes % () No Other Federal Agency (Specify) , % Planned Parenthood-World Population . . . . . () Yes % () No State + + + + eee eee eee ee ee ee) Yes % () No Local Area . + + « + + «vv vv vv www () Yes % () No Other (Specify) " % % Does your program have an automated reporting system supporting Family Planning? ( ) Yes ( ) No (If yes, please send copies of the forms d and any reports together with the completed enrollment form.) Does each family planning clinic j WN ect have a method for number- ing patients? ( ) Yes ( ) No (If no, skip to Question IER Do any patient number contain alphabetic characters? () Yes ( ) No Can two patients within a project have the same patient number? () Yes ( ) No If a patient transfers from one clinic to another in your project, does she retain her old patient number? ( ) Yes ( ) No Are any patient numbers more than 6 digits long? () Yes ( ) No Your project will receive computer processing reports from us each week. Please list the names of project staff members who can be contacted regard- ing these reports: Should clarification or correction of the weekly computer processing report be necessary, we would prefer to notify only the project which in turn would contact the person marking the form. Should you prefer that we com- municate directly with the clinic concerned, please mark this box. () GO TO QUESTION 15 27 Page 3 15. Fill in the following information for each clinic in your project offer- ing family planning services (if more space is needed, please give the specified information on separate pages): 1. Name of Clinic: Name of Administrator: Street Address: City and State: Zip: No. of Clinic Sessions per month: No. of patient visits per month: 2. Name of Clinic: Name of Administrator: Street Address: City and State: Zip: No. of Clinic Sessions per month: % No. of patient visits per month: NY 3. Name of Clinic: Name of Administrator: Street Address: D City and State: Zip: No. of Clinic Sessions per month: No. of patient visits per month: 4, Name of Clinic: Name of Administrator: Street Address: City and State: Zip: No. of Clinic Sessions per month: No. of patient visits per month: 5. Name of Clinic: Name of Administrator: Street Address: City and State: 2ip: No. of Clinic Sessions per month: No. of patient visits per month: 9 9 (Signature) Name Title Date 28 B. NATIONAL REPORTING SYSTEM FOR FAMILY PLANNING SERVICES (100-PERCENT SURVEY) Department of Health, Education and Welfare Public Health Service Health Resources Administration National Center for Health Statistics National Reporting System for Family Planning Services PROJECT DATA SHEET a. Name of Project: b. Project Mailing Address: Number Street City or Town State Zip Code < % Teleph (Area Code) De NS elephone rea Code rem Nm / \ AR ed by or received any part of their N(A service site data sheet must be ove.) Enter the name of the Project Director: Extension How many family planning service site funds from this project? ser completed for each service site in Does this project have a method > numbering patients? No; Yes If there is more than one service site in this project, would a patient use the same identification number in all of the service sites within this project? No; Yes a. In what format will this project's patient visit data be sent to NCHS? (Check one) NCHS Clinic Visit Record and Monthly Counts of Ancillary Services NCHS Monthly Counts of Ancillary Services only Punched cards in NCHS format and Monthly Counts of Ancillary Services Magnetic tapes in NCHS format | b. If punched cards or magnetic tapes are checked above, please enter the name of the data system: Is this project affiliated with Planned Parenthood/World Population? Nos; Yes If YES, enter the name of the Planned Parenthood Affiliate to which the project belongs: NAME Indicate the number of "Guidelines from the NRSFPS" this project should receive: Number 29 30 8. Please indicate, within the appropriate categories below, the percentage of funding for this project's total budget for family planning services, and list all corres- ponding grant numbers where applicable: Federal Funds Percent Grant No. (s) DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE National Center for Family Planning Services (Title X). . Maternal and Child Health Services (Title V) Other DHEW Funds (specify source, Title IV-A, Title XIX, Title XX, etc.): Other Federal Agencies (specify Sa Covernment Funds Other Than Federal: SN > \ State Government local Government . + « + 5 + + « o « & + + » Private (specify source): Source Total + « = + 100% Person supplying this information: Name Job Title Telephone (Area Code) Number Extension Date Completed: Month Day Year RETURN TO: INFORMATICS INC. 6425 LANDOVER ROAD CHEVERLY, MARYLAND 20785 (301) 772-3222 Department of Health, Education and Welfare Public Health Service Health Resources Administration National Center for Health Statistics National Reporting System for Family Planning Services SERVICE SITE DATA SHEET a. Name of Service Site: b. Service Site Address: No. Street P.O. Box, Route, etc. City or Town State Zip Code c. Enter mailing address for this service site if different from the above address: d. Is this service site part of a progr led in the National Reporting System For Family Planning Servi No; Yes % \ —————— ~~ ld NCHS Project Number e. Is this service site a mobile unit? No; Yes Enter the name of the service site person to contact concerning the National Reporting System: Name Telephone Number (Area Code) Extension Is this service site affiliated with Planned Parenthood/World Population? No; Yes If YES, enter the name of the Planned Parenthood affiliate to which this service belongs: If this service site will be using the NCHS Clinic Visit Record and the Monthly Counts of Ancillary Services Sheet, please enter the estimated patient visit load expected per month: Number a. In what format will this service site's patient visit data be sent to NCHS? (Check one) NCHS Clinic Visit Record and Monthly Counts of Ancillary Services NCHS Monthly Counts of Ancillary Services Only Punched Cards in NCHS Format and Monthly Counts of Ancillary Services Magnetic Tapes in NCHS Format 11 31 5. b. If punched cards or magnetic tape are checked above, please enter the name of the data system: 6. Please indicate, within the appropriate categories below, the percentage of funding for this service site's total budget for family planning services, and list all correspond- ing grant numbers where applicable: FEDERAL FUNDS PERCENT GRANT NO. (s) DEPARTMENT OF HEALTH, EDUCATION AND WELFARE National Center for Family Planning Services (Title X) Maternal and Child Health Service (Title V) Other DHEW Funds (specify source, Title IV-A, Title XIX, Title XX, etc.) " ~~ ™S \ € ~ yy A Other Federal Agencies (specify source) g IN RNY - A LA RS Wr Government Funds Other Than Fede State Government Local Government Private (specify source): Source Total . . 100% Person supplying this information: Name Job Title Telephone (Area Code) Number Extension Date: Month Day Year RETURN TO: INFORMATICS INC. 6425 LANDOVER ROAD CHEVERLY, MARYLAND 20785 (301) 772-3222 32 APPENDIX V SAMPLE PROCESSING REPORTS A. PROVISIONAL REPORTING SYSTEM FOR FAMILY PLANNING SERVICES CLINIC YYYY (REGION 01, STATE 00, PROGRAM XXXX) THE FOLLOWING ERROR CONDITIONS OR POSSIBLE OVERSIGHTS WERE FOUND IN THE RECORDS SUBMITTED: PATIENT INPUT FIELD IS RECORD CONTENTS NUMBER ORDER NUMBER CONDITION ENCOUNTERED AND ACTION TAKEN ACCEPTED OF FIELD 52 3 14 A FIELD REQUIRED FOR THIS TYPE OF PATIENT IS OMITTED OR INCOMPLETE. NO 23 THE FIELD (OR A PORTION OF THE FIELD) IS OMITTED OR MISCODED. 000000 18 ADOPTED METHOD GIVES THE SAME METHOD AS ITEM 9, YET "CHANGE" IS INDICATED. 9 22 "NONE" CODED FOR NEXT APPOINTMENT TYPE, YET ITEM 21 HAS AN APPOINTMENT DATE. 0169 53 31 14 "YES" GIVEN TO EVER PREGNANT, YET THE HISTORY IS MISCODED OR INCOMPLETE. NO 1m 22 "NONE" CODED FOR NEXT APPOINTMENT TYPE, YI. EM 21 HAS AN APPOINTMENT DATE. 0169 54 12 14 "YES" GIVEN TO EVER PREGNANT, YET TH S MISCODED OR INCOMPLETE. NO 111 23 THE FIELD (OR A PORTION OF THE FI A ) OR MISCODED. 00000X 55 13 22 THE FIELD IS MISCODED. NO 3 THE FIELD (OR A PORTION O 3 PREVIOUSLY RECORDED FOR THIS PATIENT. RP 122549 249, BIRTH DATE=12/25/49, BIRTHS=1, LIVING ; FETAL=0, NEONATAL=0, LAST VISIT IN 08/68. 249 a 2 THIS BIRTH DATE DOES PREVIOUS RECORD: PATI CHILDREN=Tg 1003 44 4 LIVE BIRTHS MUST BE EQUAL T0 OR GREATER THAN THAT PREVIOUSLY RECORDED. NO 0 PREVIOUS RECORD: PATIENT NO.=0001003, BIRTH DATE=7/2/38, BIRTHS=7, LIVING CHILDREN=7, DEATHS; FETAL=0, NEONATAL=0, LAST VISIT IN 05/69. 2229 64 2 THIS BIRTH DATE DOES NOT MATCH THAT PREVIOUSLY RECORDED FOR THIS PATIENT. NO 042547 PREVIOUS RECORD: PATIENT NO.=0002229, BIRTH DATE=4/25/41, BIRTHS=4, LIVING CHILDREN=3, DEATHS; FETAL=0, NEONATAL=1, LAST VISIT IN 06/68. 33 Type of Record New Patient Visits New-to-System Visits 100 Cont. Pat. Visits Correction Forms Clinic YYYY Agency 1, Region 01, State 00, Program XXXX Summary of Records Submitted for the Period Ending February 4, 1969 Records Records Records Number of Acceptance Submitted Accepted Rejected _Error Conditions Rate 100 48 52 70 487% 72 28 40 72% % 50 41 A: 32 80% Readmis, Pat. Visits 0 Wf 0 0 0% 0 ¢ 0 0 0% 250 161 89 142 68% 34 Total Records Patient Number on Form 0000007 0000010 0000011 0000016 0000029 0000035 0000036 0000048 0000051 0000052 0000053 0000054 * 0000055 0000056 0000058 0000059 0000069 0000070 0000072 0000078 0000090 0000092 0000099 0000101 0000112 0000117 0000119 0000125 Forms reprocessed 1 Forms returned 89 Clinic YYYY (Agency 1, Region 0l, State 00, Program XXXX) List of Forms Processed for the Period Ending February 4, 1969 Patient Number Patient Number Patient Number on Form on Form on Form 0000129 0000145 0000146 0000151 0000249 0000256 0000876 0001003 0001334 0001556 NS 0002229% 0002557 0002559 0003446 2 0003449 D 0003567 etc. Patient Number on Form PATIENT NUMBER 000020346 000021439 000026305 000026331 000026348 000030480 000033136 000033159 B. NATIONAL REPORTING SYSTEM FOR FAMILY PLANNING SERVICES DATE OF VISIT 051376 050376 052576 052076 052776 050476 050476 051176 ITEM NUMBER 5 (100-PERCENT SURVEY) CLINIC YYYY IN PROJECT XXXx THE FOLLOWING ERROR CONDITIONS OR INCONSISTENCIES WERE FOUND IN THE RECORDS SUBMITTED. IF ANY ASSUMPTIONS ARE IN ERROR SUBMIT A CORRECTION FORM---SEE SECTION I OF HANDBOOK. VIS ITEM ITEM CHECK RECORD CONTENTS CONTENTS NUMBER CONDITION ENCOUNTERED ACCEPTED BEFORE EDIT AFTER EDIT (1) YEAR AND MONTH OF BIRTH DATE DOES NOT MATCH PRIOR RECORD YES 090956 010956 000 PRIOR RECORD: BIRTH DATE=5601, BIRTHS= 0, LIVING CHILDREN=0, FETAL DEATHS=0, VISIT DATE=7603. CONTRACEPTIVE METHOD IS ORAL YEAR AND MONTH OF BIRTH DATE DOES NOT MATCH PRIOR RECORD RP 020552 120552 000 PRIOR RECORD: BIRTH DATE=5212, BIRTHS= 0, LIVING CHILDREN= TAL DEATHS=0, VISIT DATE=7510. CONTRACEPTIVE METHOD IS ORAL YEAR AND MONTH OF BIRTH DATE DOES NOT MATCH PRIO YES 071547 051547 000 PRIOR RECORD: BIRTH DATE=4705, BIRTHS= 4, LIVIN DEATHS=1, VISIT DATE=7505. CONTRACEPTIVE MET YEAR AND MONTH OF BIRTH DATE DOES NO Ti YES 080359 080358 000 PRIOR RECORD: BIRTH DATE=5808, BIRTH v DEATHS=0, VISIT NATE=7505. CONT ¥ YEAR AND MONTH OF BIRTH DATE TOR RECORD YES 070557 070556 000 PRIOR RECORD: BIRTH DATE=5617, B ING CHILDREN=0, FETAL DEATHS=0, VISIT DATE=7505. CONTRA THOD IS ORAL YEAR AND MONTH OF BIRTH DATE DOES NOT MATCH PRIOR RECORD YES 022460 052460 000 PRIOR RECORD: BIRTH DATE=6005, BIRTHS= 0, LIVING CHILDREN=0, FETAL DEATHS=0, VISIT DATE=7604. CONTRACEPTIVE METHOD IS ORAL AGE OF PATIENT INVALID NO 042576 000 HIGH GRADE TOO HIGH FOR PATIENTS AGE 12 03 AGE OF PATIENT INVALID RP 031756 000 HIGH GRADE TOO HIGH FOR PATIENTS AGE 14 03 1 THE CHECK NUMBER COLUMN IS FOR COMPUTER CENTER USE ONLY. RP=REPROCESSED 35 36 CLINIC YYYY IN PROJECT XXXX SUMMARY OF RECORDS SUBMITTED FOR THE PERIOD ENDING 07/07/76 TYPE OF NUMBER OF NUMBER OF NUMBER OF ACCEPTANCE RECORD RECORDS SUBMITTED RECORDS ACCEPTED RECORDS REJECTED RATES INITIAL VISITS 251 250 1 99.2 READMISSIONS 0 0 0 .0 REVISITS-TYPE 2 OR 3-NEW TO SYSTEM 24 24 0 100.0 REVISITS-TYPE 2 OR 3-OTHER 381 380 1 99.7 VISITS UNCLASSIFIED/UNPROCESSED 0 U 0 .0 TYPE-1 MAINTENANCE 0 [ \ 0 .0 TYPE-2 MAINTENANCE 0 0 0 .0 VISIT DELETIONS 0 .0 PATIENT DELETIONS 0 0 .0 TOTAL RECORDS 654 2 99.5 FORMS REPROCESSED 1 FORMS RETURNED 2 NRSFPS SYSTEM MESSAGES HR, RAR REAR CHECK FORMS FOR CORRECT CLINIC NUMBER BEFORE SUBMITTING. CHECK FORMS FOR CORRECT BIRTHDATES BEFORE SUBMITTING. WHEN CORRECTING AN ITEM ON A REJECTED FORM PLEASE DO NOT FILL OUT A NEW FORM FOR THAT PATIENT. SIMPLY MARK THROUGH THE INCORRECT INFORMATION. WRITE IN THE CORRECT INFORMATION AND RESUBMIT THE FORM. THANK YOU-HAVE A NICE DAY * . * 1? CLINIC YYYY IN PROJECT XXXX PAGE LIST OF FURMS PROCESSED FOR THE PERIOC ENDING 07/07/16 PATIFENI DATE PATIENT CATE FATIENT DATE PATIENT DATE PATIENT CATE PATIENT DATE NUMHBEKS CF NUMBERS C$ NUMBERS af NUMBERS CF NUMPERS OF NUMBERS OF CN FCSMS VISIT CN FORMS VISIT CN FORMS VISIT ON FORMS VISIT ON FCRMS VISIT ON FORMS VISIT geeeaccue usuate (CLCC3635 C52117¢ CCCCO91SS 050876 000014819 051876 00C01586€& 050676 €00021933 052776 GCCCCCCu3 0%2C76 CCCn03999 051276 €00009207 150€76 100014836 051376 J0C015868 051776 000022014 060176 cCeocecrl us29176 (CLCY4032 CS5217¢ €C0009273 051C76 000014865 050676 00CC16894 05C876 000022146 052976 CCO00C176 051776 CCCCO4289 CEClTe €C0C0%281 051276 000014951 060176 00€019897 050676 000022155 050676 €0N10C249 050476 COCCI45€66 052476 0C0006824 050476 000015012 051176 00CC19907 051876 000022256 052076 CCCOOC249 052LT06 (CCCCa61f CS1576 €CCco9828 051876 00C015057 060176 00C016951 050176 000022282 052076 CCCOCC3bYS USLISI6 CCCNI4E49 05176 000009879 050376 1170015131 051676 00CI19951 052476 000022285 052276 CLCCCCalC UE25T76 (CCCC476C GCR267€ €CCO010007 051C76 000015187 051776 00CC1SS7T1 050876 000022475 051576 CCOOCCaby 052816 (CC(N4808 C5267€ CCLO10V08 0526176 000015311 052576 00C016994* 050476 000022507 051876 0C000C492 J5)4176 CCCCO5107 082576 600010077 051576 000015376 C50676 00€02C018 050476 000022576 050476 GCUOCCEb4 (G42CT0 (CeCo5122 C52Che CCU010515 051576 000015377 C€50176 00€02z0037 050476 000022586 050676 CLOCCOT66 05276 C0)1)5213 05227¢€ €CJ017603 252176 300015496 051876 00€020040 051176 000022774 051576 CCeoocsz? 052216 (CCC053C2 CS1l4ale 000010620. 051776 000015585 052676 00CC2C043 051076 000022780 051176 ccooccss? uSLoeTe €0Ced5354 CeC1T6 CCCOl11058 050476 C00015713 05107¢ 00€020086 052276 €00022857 051576 C00Jd4u1C61 051176 C10C0%5453 052176 000011159 051176 000015781 051876 00C02C092 051876 000022882 051576 CO00VLCE2 051476 (CCC05487 CS1il6 ¢Cee11s558 052C76 000015782 052076 00C02C097 052576 000022887 042076 C00)J1119 0503706 C00rIS5646 1515176 000011940 J50176 000015818 050176 J0C020099 052276 000022892 060176 CCOLCLIT4 0UH2T76 CCCLOSKEB? C51176 0CCCl1688 052576 000015907 051576 00cc2€122 05C176 000022935 052776 C00u01521 052570 (cceosu2? CeClie CCCOL316G 051676 000015626 050876 000020145 052476 000023003 052976 000791530 051776 cceces1L 1c C51C6 000013301 0521776 0017037 040576 00€020172 051076 000023090 051876 0C0001632 0518176 CCCCCh2S1 (CS52E5176 cco013418 0 0017037 052476 00C020186 052276 €000230S0 052676 070091739 053676 COC I63I53 (51%517¢ 3CJ0136 0017230 051376 00CC20215 0£2276 €00023097 052276 CLOVVLT3s 082476 (CCCO6353 C€52C16 cooc13 017340 C51776 0CCC2C232 052976 000023098 052576 0CHGCLI%4 051eT6 CuCC06443 CE1376 cceel3r 000917428 0597176 00020235 0€1876 000023149 050876 00101626 uv426io (CCCa6587 CO11176 0coo138 051076 000017609 051376 00€02C24C 050476 0000231¢4 060176 CCuUC1ST1l ULS24T70 COCCU6712 C1876 CCOCL3910 0511776 000017631 052976 00C020241 052776 €00C23307 050576 €00202911 0%5)4l6 CCCCCoBnC 33257¢ CCCO1396% 05C¢€76 00017723 051476 00C02C242 051876 000023309 051976 CCu0u2d21 052570 COCC06552 C511176 CCO0014144 060176 000017732 051476 00€020301 052776 000023390 060176 CLeouCels0 051676 COCLCTCCS CS1ET6 cCCOl4al66 05117€ 007017970 051776 00020346 051376 000024445 052076 C00002300 052¢76 (CCCaT053 C511 7¢ 000014219 041776 000018086 050376 00CC20400 052576 000024455 (C51776 (0GIOZ83n 0S1nTo {CCecrIC? C5116 0CC0143C3 0525176 000018086 050676 00C0z048€6 050476 0000244175 (52176 CIN002¢al ISLITO CCCHIT755 O51ETE CC30144C7 DJ51E7€ 000019148 051776 00€02C0551 0521776 000024476 050876 CCO0C28%u (60170 CUCCLTATL CHZ1T€ 0C0C14421 051476 0000193586 £52676 00CCZC661 051576 000024478 050376 CCOuC2¢y 050610 CCCONT8IL CHZa1¢ CCCCl4a44s 052616 100019359 05J47¢€ 00C02076€ 053576 000024455 060176 CCOGC INKL Ub2TT76 CGCCCTS3C GS1116 ¢C0014472 051276 0C0019379 051376 00CC?20768 052576 €00024456 (€50876 CO0d02N16 USGaT0 (CCLCI956 C4a2it¢ CC0014525 051176 000019414 051476 00C020775 060176 000024499 050176 C2033224/ 151376 CeLIIAN2E JIB2T0E 0C0014%€) JS1ETE 000015445 05187¢ 00€02C813 050876 000026002 050876 CCOC022yl USGLTTG cCLenatda €52¢16 COCCl4606 050476 C00015561 05107¢ 0CC02CS57 00476 000C260C7 050876 CCCN03 49 UHCaTa COLLOR0BT 05247€ CCCOl461T 0522176 )00J)19599 05)87¢ 00C020976 052676 000026028 050376 CLLOC236s VSll/o coecosler CS51176 00G0l14678 05C8176 00001672 051776 00(CC2i225 052076 000026C38 050676 COoGC2433 05116 CCCONBs%S CS51CT6 CCO00146E9 050576 000019736 052276 00C021231 05087¢ CC0026067 050476 COIN HY 152716 (36314651 25117¢ CCCCl47%3 051176 000019756 050176 00C02143S 050376 C00026070 050676 Cecon0in2 CHOETS CLCLO8ECS QECLTE CCGCl14793 060176 0cee1980s 051176 00CC21506 051776 000026071 051176 COOUGC3TLS 0DU4aTH cCCccoLiIs? CeClie 0J0C14804 )S0ET6 3230019823 051076 00C021741 052576 030026072 0526176 ccoccisul €S52570 (CLCORBLY C5CaT€ 000C148C5 050€76 €Cc0019826 050176 0ccc21781 050676 000026C80 050376 CCe0L2341 051170 CCCOUL 324 CR2676 CCOC14815 051576 00C01$834 05C376 00CCz180& 0€2576 000026081 050376 * INGICATES FORMS REJFCTFL PECALSE CF FRKCRS CFTECTEDR DURING PROCESSING. RESUBMIT KFCOGRES AS SOON AS FOSSIPLE. 37 APPENDIX VI STANDARD TABLE SHELLS A. PROVISIONAL REPORTING SYSTEM FOR FAMILY PLANNING SERVICES Tables 1 and 2. Number and percent of patients receiving family planning services, by type of patient and type of service provided and number and percent of visits for family planning services, by type of service provided during visit Type of service provided Patients! Visits Percent Number by type of service provided Number Percent Total New Continuation Total New Cont. All patients Contraceptive patients Infertility patients Medical exam or Lab test, total? Breast Pelvic Other medical exam Pap smear Serology Other lab test 1Unduplicated count of patients who received one or more services at this clinic during the report period. Total may be less than the sum of the parts if more than one service was provided to a patient or at more than one visit. Total may be less than total number of patients served or visits if no exam or test was performed for one or more patients. 2 38 Table 3. Number and percent of patients receiving family planning services, by ethnic designation and age Agel (in years) All groups White Black Ethnic designation Other Spanish surname American Indian Puerto Rican Other Number All ages Under 15 16-19 20-24 25-29 30-34 35-39 40-44 45 and over Percent by ethnic designation All ages Under 15 16-19 24 25-29 30-34 35-39 40-44 45 and over Iage of the patient at the patient’s last visit of this report period. 39 Table 4. Number and percent of patients receiving family planning services, by highest grade of school completed and age Highest grade of school completed Total No Grade school High school College ; Agel formal (in years) education Total 1-3 4-6 7-8 Total 1-3 4 Total 1 2 Number All ages Under 15 15-19 20-24 25-29 30-34 35-39 40 or more Percent by highest grade of school completed All ages Under 15 15-19 20-24 25-29 30-34 35-39 40 or more Tage of the patient at the patient’s last visit of this report period. 40 Table 5. Number and percent of contraceptive patients receiving family planning services, by live births and contraceptive method adopted Number of live births . Total Type of contraceptive None 1 2 34 Sor method adopted more Number Total, contraceptive patients! Oral uD Foam Diaphragm Rhythm Condom Other None Percent by contraceptive method adopted Total, contraceptive patients! Oral IUD Foam Diaphragm Rhythm Condom Other None 1Excludes all patients receiving infertility services. 41 Table 6. Number and percent of new patients receiving family planning services, by age and source of referral Source of referral All ages Age (in years)! Under 4549 2024 2520 3034 3539 40or 15 more Number All new patients Program personnel Hospital, medical, or other health sources Public welfare agency Other social welfare agency Other clinic patient, friend, or relative Other source or self Unknown Percent by source of referral All new patients 42 Program personnel Hospital, medical, or other health sources Public welfare agency Other social welfare agency Other clinic patient, friend, or relative Other source or self Unknown Iage of the patient at the patient’s last visit of this report period. Table 7. Number and percent of patients receiving family planning services, by age and by public welfare status Age (in years)! Public welfare program AY. 5ges Under 15-19 20-24 25-29 30-34 35:39 40.0r 1 more Number All patients served Total receiving publ. welf. AFDC Other publ. welf. Both AFDC and other New patients served Total receiving publ. welf. AFDC Other publ. welf. Both AFDC and other Percent by public welfare assistance All patients served Total receiving publ. welf. AFDC Other publ. welf. Both AFDC and other New patients served Total receiving publ. welf. AFDC Other publ. welf. Both AFDC and other lage of the patient at the patient’s last visit of this report period. Table 8. Number and percent of patients receiving family planning services, by live births and highest grade of school completed Number of live births Total Highest grade of school completed No formal education Grade school High school College Total 1-3 4-6 7-8 Total 1-3 Total 1 2 or more Number Totall None 34 5+ Percent by highest grade of school completed Totall None 3-4 5+ Percent by live births LUnduplicated count of patients who received one or more services at this clinic during report period. 44 B. NATIONAL REPORTING SYSTEM FOR FAMILY PLANNING SERVICES Monthly Tables Table M-1. Family planning services and contraceptive method by type of visit and summary reports Reporting period (Mo/Day/Yr to Mo/Day/Yr) Service site (number) Project (number) PP affiliate (number) (Service site name) (City) (State) Patient visits accepted this month by the NRSFPS Services Summary of visits on file year to date and First (by type of patient visit) contraceptive Initial revisit Subsequent Readmission Total method visits for year revisits visits visits Type of visit Number TV=1 TV=2 TV=3 TV=4 TV=1+2+3+4 All visits Initial visits (TV=1) Medical services First revisit for year (TV=2) Pap smear Pelvic exam Breast exam Blood pressure Pregnancy testing V.D. testing Urinalysis (n.e.s.) Blood test (n.e.s.) Sterilization Infertility treatment Other Visits received this month Reprocess input op Subsequent revisits (TV=3) Readmission visits (TV=4) Total visits (TV=1+2+3+4) Current month processing summary Counseling services Sterilization Total visits input = Contraception Visits rejected = Infertility Other Net visits processed this month = Referrals Abortion Sterilization Infertility Other medical services Social services Contraceptive patients Method presently used Oral (pill) IUD Diaphragm Foam Rhythm Condom Injection Sterilization Other None Interim method Duplicate visits merged This mor:ths visits deleted Visits deleted from master 45 Table M-2. Number of family planning patient visits by type of visit: each service site and project within State (State name) Region (number) Reporting period (Mo/Day/Yr to Mo/Day/Yr) Patient visits accepted this month by the NRSFPS Projects Responsible . and City agency (s) First ; . . Initial revisit Subsequent Readmission Total service sites . fy bu hi visits for year revisits visits visits TV=1 TV=2 TV=3 TV=4 TV=1+2+3+4 State totals Project xxxx City Service site xxxx City Project xxxx City Service site xxxx City Service site xxxx City Service site xxxx City Etc. Table M-3. Number of family planning patient visits by type of visit, by funding agency: each project and State within region Funding agency Region (number) Reporting period (Mo/Day/Yr to Mo/Day/Yr) Patient visits accepted this month by the NRSFPS States Responsible i and City agency (s) ied First cai r . Initial revisit Subsequent ~~ Readmission Total projects visits for year revisits visits visits TV=1 TV=2 TV=3 TV=4 TV=1+2+3+4 Region totals State name Project xxxx City Project xxxx City Project xxxx City State name Project xxxx City Project xxxx City Project xxxx City Project xxxx City Etc. 46 Project (number) Quarterly Tables Table Q-1. Activity status of patients by selected patient characteristics (City) Funding agency Reporting period (Mo/Day/Yr to Mo/Day/Yr) Patient characteristics Patients seen this period Total New Continuation Patients discontinued this period Active patients end of period Total patients Sex Female Male Age groups Under 18 18-19 20-24 25-29 30-34 35+ Live births None 1 2 3 4 5+ Unknown/male Latin American descent Yes No Race White Negro American Indian Other Unknown Education None 1-8 years 9-11 years 12 13+ Unknown Welfare recipient Yes No Unknown Registered for Medicaid Yes No Unknown 47 Project (number) Service site (number) Table Q-1. Activity status of patients by selected patient characteristics (City) Funding agency Reporting period (Mo/Day/yr to Mo/Day/yr) PP affiliate (number) Patient characteristics Patients seen this period Total New Continuation Ancillary services provided Total patients Sex Female Male Age groups Under 18 18-19 20-24 25-29 30-34 35+ Live births None 1 2 3 4 5+ Unknown/male Latin American descent Yes No Race White Negro American Indian Other Unknown Education None 1-8 years 9-11 years 12 13+ Unknown Welfare recipient Yes No Unknown Registered for Medicaid Yes No Unknown Medical services Supply visits Outreach contacts Attendees at lecture sessions Telephone contacts Other services Project (number) Service site (number) (City) Table Q-2. New female contraceptive patients by selected characteristics Funding agency Reporting period (Mo/Day/Yr to Mo/Day/Yr) PP affiliate (number) A. Patient characteristics Total all ages Age groups Number | Percent -18 | 18-19 20-24 25-29 | 30-34 | 35+ B. Contraceptive method prior to service site enrollment Total new female contraceptive patients Live births None 1 2 3 a4 5+ Unknown Source of referral Outreach worker Other FP clinic Hosp., oth. hith. agency Private phy. or nurse Welfare agency Cl. Pt., family, friend Mass media Other Unknown and not reported Ever used any method Yes No Unknown Education None 1-8 years 9-11 years 12 years 13+ years Unknown Latin American descent Yes No Race White Negro American Indian Other Unknown Patients Method Number |Percent Total Oral (pill) IUD Diaphragm Injection Condom Foam Rhythm Other None Unknown C. Contraceptive method at end of initial visit Patients Method Number | Percent Total Oral (pill) IUD Diaphragm Injection Condom Foam Rhythm Sterilized Other ## interim ## patients prescribed methods for an interim period are also included in the figures for each method listed above. 49 Table Q-3. Patient visits by type of visit and type of services provided Project (number) Service site (number) (City) Funding agency PP affiliate (number) Reporting period (Mo/Day/Yr to Mo/Day/Yr) Type of services Total visits Type of visit Number Percent Initial First revisit Subsequent revisit visit this year this year Total visits Medical services No medical services One or more medical services Pap smear Pelvic exam Breast exam Blood pressure Pregnancy testing VD testing Urinalysis (n.e.s.) Blood test (n.e.s.) Sterilization Infertility treatment Other Counseling services No counseling services One or more counseling services Sterilization Contraception Infertility Other Referrals No referrals One or more referrals Abortion Sterilization Infertility Other medical services Social services Method at end of visit Oral (pill) IUD Diaphragm Injection Condom Sterilization Foam Rhythm Other None (reasons given below) Pregnant Other medical reason Seeks pregnancy Other Interim 1S ion of all patients by selected characteristics: each State, project, and service site Reporting period (Mo/Day/Yr to Mo/Day/Yr) Funding agency Region (number) State Sex Age groups Race Latin project number All American serv. site, funding patients | pore | Female || -18 | 18-19 | 2024 | 25-20 | 30-38 | 35+ || White | Negro | Am.iInd. | Other [| descent service site city Region ___ # % State name # % Project number # % SS. number City # % Etc. Table Q-5. Number and percent distribution of new patients by selected characteristics: each State, project, and service site Funding agency Region (number) Reporting period (Mo/Day/Yr to Mo/Day/Yr) State Sex Age groups Race Latin project number All American serv. Site, funding patients | ote | Female || -18 | 18-19 | 20-24 | 25-29 | 30-34 | 35+ || White | Negro | Am.ind. | Other [| descent service site city Region ___ # % State name # % Project number # % SS. number City Wt % Etc. Zs Table Q-6. Number of sterilization patients by selected characteristics: each State, project, and service site Reporting pericd (Mo/Day/Yr to Mo/Day/Yr) Funding agency Region (number) State Sex Age groups Race Latin project number All American serv. Site, funding Patients | male | Female || -18 | 18-19 | 20-24 | 25-29 | 30-38 | 35+ | White | Negro | Am.lInd. | Other || descent service site city Region State name Project number SS. number City Etc. Funding agency Table Q-7. Number of infertility patients by selected characteristics: each State, project, and service site Region (number) Reporting period (Mo/Day/Yr to Mo/Day/Yr) project number serv. site, funding service site city State All patients Sex Age groups Race Male Female 18-19 20-24 25-29 30-34 35+ White Negro Am. Ind. Other Latin American descent Region State number Project number SS. number SS. number Etc, £9 Table Q-8. Number and percent distribution of female patients by type of patient and number of live births: each State, project, and service site Funding agency Region (number) Reporting period (Mo/Day/Yr to Mo/Day/Yr] A. B. C. State All patients New patients Sterilized patients project number Total | service site, funding ota Number of live births Yor Number of live births ios Number of live births service site city 1 2 3 4+ 0 1 2 3 4+ 0 1 2 3 4+ Region __ # % State name # % Project number # % SS. number City # % Etc. Table Q-9 . Number of patients and visits for each project, State, and region, United States Reporting period (Mo/Day/Yr to Mo/Day/Yr) Geographical location Number of patients reported Number of Total New Continuation visits reported Project reported ancillary services United States total Region ___ State name Proj number Proj number Proj number Etc. Annual Tables Table A-1. Number of patients and visits for the United States: each region and State Reporting period (Mo/Day/Yr to Mo/Day/Yr) Region and states No. of service sites A Act. pts. at begin. of year B New patients C Cont. patients D Discont. patients E Act. pts. not seen this year F Act. pts. at end of year G Subsequent revisits H Total visits | Total ancillary services US total Region ____ State name State name State name State name Region __ State name State name State name Etc. (State name) | Table A-2. Number of patients and visits by State and funding source for each participating project Reporting period (Mo/Day/Yr to Mo/Day/Yr) Proi A B Cc D E E G H | Yolset Act. pts Act. pts Act. pts Total Project funding sn : New Cont. Discont. HLS: . 8 t Subsequent Total in agencies #1 begin, patients patients patients not Seen ALeNd.0 revisits visits anc ary of year this year year services State total Project _ Project Project __ Project ____ Etc: Table A-3. Number of patients and visits for each project and its service sites Project (number) Reporting period (Mo/Day/Yr to Mo/Day/Yr) A B Cc D E F G H | Project ond Funding Ack. Di New Cont. Discont. Act. pts. Act. ore, Subsequent Total Joss rvice sites agencies at begin. patients patients patients Not; seen a1 8d.o revisits visits no)! acy of year this year year services Project number Service site number Service site number Service site number Service site number Service site number Etc. 54 Table A-3P. Number of patients and visits for each Planned Parenthood affiliate Affiliate (number) Reporting period (Mo/Day/Yr to Mo/Day/Yr) A 8 Cc D E F G H | Affiliates Funding Act. pts. New Cont. Discont. Act. pts. Rep Subsequent Total Joa agencies at begin. patients patients patients not seen atenc.o revisits visits ancl | y of year this year year services Affiliate number Service site number Etc. Table A4. Number of service sites, patients, and visits by project funding source for the United States Reporting period (Mo/Day/Y to Mo/Day Yr) No. of A A B Cc D A E A F G H 7 | , service oh fas New Cont. Discont. 5%: p1s. ct. pre Subsequent Total ora sites Bt.begin patients patients patients not Seen stendo revisits visits anct lid of year this year year services US total MCHS OEO NCFPS PP MCHS, OEO MCHS, NCFPS MCHS, PP OEO, NCFPS OEO, PP NCFPS, PP MCHS, OEO, NCFPS MCHS, OEO, PP MCHS, NCFPS, PP OEO, NCFPS, PP MCHS, OEO, NCFPS, PP Other Uriknown Region (number) Table A-6. Number of service sites, patients, and visits by project funding source for each region Reporting period (Mo/Day/Yr to Mo/Day/Yr) Project funding source A Act. pts. at begin. of year No. of service sites B New patients Cc Cont. patients D Discont. patients E Act. pts. not seen this year F Act. pts. at end of year G Subsequent revisits H Total visits | Total ancillary services Region total MCHS OEO NCFPS PP VICHS, OEO NVICHS, NCFPS NICHS, PP QEO, NCFPS CEO, PP NCFPS, PP MCHS, OEO, NCFPS MCHS, OEO, PP NCHS, NCFPS, PP CEO, NCFPS, PP MCHS, OEO, NCFPS, PP Other Unknown 56 Table A-6. Number of service sites, patients, and patient visits by funding agency, each region, and the United States Funding agency Reporting period (Mo/Day/Yr to Mo/Day/Yr) No. of A B Cc D E F G H | Seryicy Aa Ps; New Cont. Discont. Act. pis. pet pre Subsequent Total Tou Stes at begin. patients patients patients not: seen atendo revisits visits ancillary funded of year this year year services US total Region Region Table A-7. Number of service sites, patients, and patient visits by region, State, and project for each funding agency Agency Region (number) Reporting period (Mo/Day/Yr to Mo/Day/Yr) A B Cc D E F G H | Seats No.of | Act. pt Act. pt Total project number service ct. (18; New Cont. Discont. Ct. pis; Ct. pts. Subsequent Total ancillary agency codes sites at begin. patients patients patients of Seen at end of revisits visits . of year this year year services Region ___ State name Proj number Proj number Proj number Proj number Proj number Proj number Proj number Proj number Proj number Proj number Proj number - Proj number Proj number Proj number State name Proj number Proj number Proj number Proj number Etc. 56 Table A-20. Number of female patient visits by type of service provided for the United States (Level of aggregation)? Reporting period (Mo/Day/Yr to Mo/Day/Yr) T § Initial First revisit Subsequent Total ype of service igi i visits visits this year this year Total number of visits Medical services No med. serv. One or more serv. Total med. serv. Pap smear Pelvic exam Breast exam Blood pressure Preg. testing VD testing Urinalysis (nes) Blood test (nes) Sterilization Infertility tr. Other Counseling services No counseling One or more serv. Total coun. serv. Sterilization Contraception Infertility Other Referrals No referrals One or more ref. Total referrals Abortion Sterilization Infertility Other medical Social services Source of referral Outreach Qther FP clinic Hosp. etc. Private MD or RN Welfare agency Other clinic pt. Family or friend Radio, TV, paper ad. Other Unknown 1p evel of aggregation will be either United States, agency, region, project (or affiliate), or service site. 57 Table A-30(N). Number of (new) female patients by age according to selected characteristics for the United States (Level of aggregation)?! Reporting period (Mo/Day/Yr to Mo/Day/Yr) Toul 35 and Patient characteristics female Under 18 18-19 20-24 25-29 30-34 over patients Total patients Live births None 1 2 3 4 5+ Unknown Living children None 1 2 3 4 5+ Unknown Number of pregnancies None 1 2 3 4 5+ Unknown Method at end of year Oral IUD Diaphragm Foam Rhythm Condom Injection Sterilization Other None Interim (not in total) Ever used any method Yes No Unknown Level of aggregation will be either United States, agency, region, State, project (or affiliate), or service site. 58 6S (Level of aggregation)! Tahle A40(N). Number of (new) patients by patient characteristics according to sex and age for the United States Reporting period (Mo/Day/Yr to Mo/Day/Yr) Patient characteristics Age of women Age of men Total -18 18-19 20-24 25-29 30-34 35+ Total -24 25-29 30-34 35-39 40+ Total Race White Negro Amer. Indian Other Unknown Latin Am origin Yes No Education None 1-8 yrs 9-11 yrs 12 yrs 13+ yrs Unknown Public assist. Yes No Unknown Medicaid regis. Yes No Unknown Sterilization Medical serv. Counseling Referral Males only: Method Steril. Condom None Other 1 evel of aggregation will be either United States, agency, region, State, project (or affiliate), or service site. Table A-50. Characteristics of patients receiving public assistance by age and parity for the United States (Level of aggregation)?! Reporting period (Mo/Day/Yr to Mo/Day/Yr) Total Percent Percent in each age group Percent by number of live births Patient characteristics t Patignts Women Men -18 18-19 20-24 25-29 30-34 35+ 0 1 2 3 4 5+ Unk Total patients Contraceptive method Oral IUD Diaphragm Foam Condom Sterilization Other + injection Rhythm None Race White Negro Am. Indian Other " Unknown Latin American origin Education None 1-8 yrs. 9-11 yrs. 12 yrs. 13+ yrs. Unknown Fetal deaths None 1 2 3+ Unknown Referrals None Abortion Sterilization Infertility Other medical Social services 1p evel of aggregation will be either United States or agency. Table A-60. Number of method changes by type of method after change according to type of method before change and type of patient: female patients (Level of aggregation)! for the United States Reporting period (Mo/Day/Yr to Mo/Day/Yr) Method before change Total changes Method after change Oral IUD Diaphragm Foam Rhythm | Condom Inject. Steril. Other None New patients Number patients with no method change Total number of method changes Oral IUD Diaphragm Foam Rhythm Condom Injection Sterilization Other No method Continuation pats. Number patients with no method change Total number of method changes Oral IUD Diaphragm Foam Rhythm Condom Injection Sterilization Other No method 1 evel of aggregation will be either United States or agency. 61 Table A-70-1. Number of new female patients by method prior to clinic enrollment and method at last visit, and source of method prior to clinic : enrollment for the United States (Level of aggregation)! Reporting period (Mo/Day/Yr to Mo/Day/Yr) Total new Method prior to clinic enrollment Method at last visit female patients Oral IUD Diaphragm Foam | Rhythm [Condom | Injection Other None* Total patients Oral IUD Diaphragm Foam Rhythm Condom Injection Sterilization Other None Source of prior method Clinic Private doctor Drug store Other Unknown No prior method ILevel of aggregation will be either United States, agency, region, or project (or affiliate). *Includes patients with unknown prior methods. Table A-70-2. Number of female patients by method prior to clinic enrollment, method at end of initial visit, and method at end of last visit according to type of patient and type of method for the United States (Level of aggregation)! Reporting period (Mo/Day/Yr to Mo/Day/Yr) Type of contraceptive Prior to Bndof £nd of Type of contraceptive Priol tg End of Ed of method clinic initial last method clinic initial last enrollment visit visit enrollment visit** visit Total new patients Total continuation patients Oral Oral IUD IUD Diaphragm Diaphragm Foam Foam Rhythm Rhythm Condom Condom Injection Injection Sterilization Sterilization Other Other None None Unknown Unknown ILevel of aggregation will be either United States, agency, region, or project (or affiliate). **Does not include patients for which initial visits are not on file. 62 Table A-80. Female contraceptive patients by contraceptive use prior to clinic enroliment according to age and number of live births for the United States (Level of aggregation)! Reporting period (Mo/Day/Yr to Mo/Day/Yr) Contraceptive use prior to clinic enrollment Total number patients Percent in each age group Percent by number of live births -18 18-19 20-24 24-29 30-34 35+ 1 2 3 4 5+ Unk Total number of patients Ever used a method Yes No Unknown Currently using a method Yes No Unknown Last method used prior to clinic enrollment Oral IUD Diaphragm Foarn Rhythm Condom Injection Other Unknown No prior method Source of last method Clinic Private doctor Drug store Other Unknown No prior method Level of aggregation will be either United States, agency, or region. Table A-90. Number of new female patients who are under 19 years by selected characteristics for the United States (Level of aggregation)! Reporting period (Mo/Day/Yr to Mo/Day/Yr) Patient characteristics Age groups Total -16 | 16 18 Patient characteristics Age groups Total -15 16 17 18 Total patients Number of live births None 1 2 3 4 5+ Unknown No. of living children None 1 2 3 4 5+ Unknown Number of pregnancies None 1 2 3 4 5+ Unknown Method at end of visit Oral IUD Diaphragm Foam Rhythm Condom Injection Sterilization Other None Interim (not in total) Ever used any method Yes No Unknown Total patients Race White Negro American Indian Other Unknown Latin Amer. origin Yes No Education None 1-8 years 9-11 years 12 years 13+ years Unknown Public assistance Yes No Unknown Medicaid registrant Yes No Unknown Referrals None Abortion Sterilization Infertility Other medical ser. Social services Unknown Reason for no method Pregnant Other med. Seeking preg. Other 1 evel of aggregation will be either United States or agency. Series 1. Series 2. Series 3. Series 4. Series 10. Series 11. Series 12. Series 13. Series 14. Series 20. Series 21. Series 22. Series 23. VITAL AND HEALTH STATISTICS PUBLICATIONS SERIES Formerly Public Health Service Publication No. 1000 Programs and Collection Procedures.—Reports which describe the general programs of the National Center for Health Statistics and its offices and divisions, data collection methods used, definitions, and other material necessary for understanding the data. Data Evaluation and Methods Research.—Studies of new statistical methodology including experimental tests of new survey methods, studies of vital statistics collection methods, new analytical techniques, objective evaluations of reliability of collected data, contributions to statistical theory. Analytical Studies.—Reports presenting analytical or interpretive studies based on vital and health statistics, carrying the analysis further than the expository types of reports in the other series. Documents and Committee Reports.—Final reports of major committees concerned with vital and health statistics, and documents such as recommended model vital registration laws and revised birth and death certificates. Data from the Health Interview Survey.—Statistics on illness; accidental injuries; disability; use of hospital, medical, dental, and other services; and other health-related topics, based on data collected in a continuing national household interview survey. Data from the Health Examination Survey.—Data from direct examination, testing, and measurement of national samples of the civilian, noninstitutionalized population provide the basis for two types of reports: (1) estimates of the medically defined prevalence of specific diseases in the United States and the distributions of the population with respect to physical, physiological, and psychological charac- teristics; and (2) analysis of relationships among the various measurements without reference to an explicit finite universe of persons. Data from the Institutionalized Population Surveys. —Discontinued effective 1975. Future reports from these surveys will be in Series 13. Data on Health Resources Utilization.—Statistics on the utilization of health manpower and facilities providing long-term care, ambulatory care, hospital care, and family planning services. Data on Health Resources: Manpower and Facilities. —Statistics on the numbers, geographic distrib- ution, and characteristics of health resources including physicians, dentists, nurses, other health occu- pations, hospitals, nursing homes, and outpatient facilities. Data on Mortality. —Various statistics on mortality other than as included in regular annual or monthly reports. Special analyses by cause of death, age, and other demographic variables; geographic and time series analyses; and statistics on characteristics of deaths not available from the vital records, based on sample surveys of those records. Data on Natality, Marriage, and Divorce.—Various statistics on natality, marriage, and divorce other than as included in regular annual or monthly reports. Special analyses by demographic variables; geographic and time series analyses; studies of fertility; and statistics on characteristics of births not available from the vital records, based on sample surveys of those records. Data from the National Mortality and Natality Surveys. —Discontinued effective 1975. Future reports from these sample surveys based on vital records will be included in Series 20 and 21, respectively. Data from the National Survey of Family Growth.—Statistics on fertility, family formation and disso- lution, family planning, and related maternal and infant health topics derived from a biennial survey of a nationwide probability sample of ever-married women 15-44 years of age. For a list of titles of reports published in these series, write to: Scientific and Technical Information Branch National Center for Health Statistics Public Health Service Hyattsville, Md. 20782 DHEW Publication No. (PHS) 78-1313 Series 1-No. 13 Plan and Operation of the CLLR TT Ee ~ Survey of Adults 25-74 Years INCRE CO EYER ETE g U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Library of Congress Cataloging in Publication Data United States. National Center for Health Statistics. Division of Health Examination Statistics. Plan and operation of the Hanes I augmentation survey of adults 25-74 years. (Vital and health statistics: Series 1, Programs and collection procedure; no. 14) (DHEW publication; (PHS) 78-1314) Includes bibliographical references. Supt. of Docs. no.: HE 20.6209:1/14 1. Health and Nutrition Examination Survey. I. Engel, Arnold. II. Title. III. Series: United States. National Center for Health Statistics. Vital and health statistics: Series 1, Pro- grams and collection procedures; no. 14. IV. Series: United States. Dept. of Health, Educa- tion, and Welfare. DHEW publication; (PHS) 78-1314. RA409.U44 no. 14 [RA407.3] 312'.07'23s 78-606016 ISBN 0-8406-0124-7 (312'.07'23) PROGRAMS AND COLLECTION PROCEDURES Series 1 Number 14 HANES | Augmentation Survey of Adults 25-74 Years United States, 1974-1975 | DHEW Publication No. (PHS) 78-1314 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service National Center for Health Statistics Hyattsville, Md. June 1978 NATIONAL CENTER FOR HEALTH STATISTICS DOROTHY P. RICE, Director ROBERT A. ISRAEL, Deputy Director JACOB J. FELDMAN, Ph.D., Associate Director for Analysis GAIL F. FISHER, Ph.D., Associate Director for the Cooperative Health Statistics System ELIJAH L. WHITE, Associate Director for Data Systems JAMES T. BAIRD, JR., Ph.D., Associate Director for International Statistics ROBERT C. HUBER, Associate Director for Management MOWROE G. SIRKEN, Ph.D., Associate Director for Mathematical Statistics PETER L. HURLEY, Associate Director for Operations JAMES M. ROBEY, Ph.D., Associate Director for Program Development PAUL E. LEAVERTON, Ph.D., Associate Director for Research ALICE HAYWOOD, Information Officer DIVISION OF HEALTH EXAMINATION STATISTICS MICHAEL A. W. HATTWICK, M.D., Director JEAN ROBERTS, Chief, Medical Statistics Branch SIDNEY ABRAHAM, Chief, Nutritional Statistics Branch « LINCOLN OLIVER, Chief, Psychological Statistics Branch ROBERT S. MURPHY, Chief, Survey Planning and Development Branch 7 S [LY ~ gos 3 J) S50 Under the legislation establishing the National Health Survey, the Public Health Service is authorized to use, insofar as possible, the services or facilities of other Federal, State, or private agencies. In accordance with specifications established by the National Center for Health Statis- tics, the U.S. Bureau of the Census participated in the design and selection of the sample and carried out the household interview stage of the data collection and certain parts of the statis- tical processing. The Center for Disease Control acted as laboratory consultants and performed a series of biochemical, hematological, and serological assessments on blood speciments of persons partici- pating in the survey. The U.S. Environmental Protection Agency supervised the chemical analyses of the water samples collected at each household. Vital and Health Statistics-Series 1-No. 14 DHEW Publication No. (PHS) 78-1314 Library of Congress Catalog Card Number 78-606016 dled el ne rn well) S——— ——— ACKNOWLEDGMENTS Special acknowledgment is due Mr. Arthur J. McDowell, former Director of the Division of Health Examination Statis- tics, and Dr. Jean-Pierre Habicht, former Special Assistant to the Director, for their guidance in the formulation of the HANES I Augmentation Survey. CONTENTS Acknowledgments ii Introduction 1 New Procedures 2 Hearing Test for Speech 2 Vision Testing. 3 Water Sample Collaborative Study (HANES-National Institutes of Health-Environment Protection Agency) 3 Additional Questionnaire Material 3 Additional Laboratory Procedures 4 Sample Design 4 Selection of Primary Sampling Units 4 Sample Selection Within Primary Sampling Units 5 Data Collection 5 Plans for Analysis and Publication of Data 9 References 10 Appendixes I. Technical Notes on the Sample Design 12 II. Sample Locations of the Health and Nutrition Examination Survey of Adults, by Region, County, State, and Probability Design 14 III. Questionnaires and Examination Forms 16 LIST OF FIGURES 1. Sample Person Selection Sheet 6 2. Quality control review form 7 SYMBOLS Data not available-----------nnnnmrmemmcoeea Category not applicable----------esserrerereeeeeeee Quantity zero Quantity more than 0 but less than 0.05------ Figure does not meet standards of reliability or precision-------------oemeeoemmemnnes = PLAN AND OPERATION OF THE HANES | AUGMENTATION SURVEY OF ADULTS 25-74 YEARS Arnold Engel, M.D., Robert S. Murphy, Kurt Maurer, and Everette Collins, Division of Health Examination Statistics INTRODUCTION > In the Health Examination Survey (HES), a “major program of the National Center for Health Statistics (NCHS), data are collected by direct physical examination, tests, and measurements performed on the sample population studied. *The National Health Survey was authorized under the National Health Survey Act of 1956 ‘by the 84th Congress to be a continuous public rhealth service activity to monitor the health | status of the American population. Information has been obtained on the prevalence of certain medically defined illnesses and the distribution sof a variety of physical, physiological, and psychological measurements. The Survey pro- vides this information for the U.S. civilian noninstitutionalized population and simultane- ously provides the demographic and socioeco- nomic data necessary for analysis. In recent years, procedures to measure either directly or indirectly the impact of the environment on tindividuals and to delineate met and unmet , health care needs have been employed in the Survey. The first three national surveys conducted between 1959 and 1970 had specific age group- ings as their target populations. These were adults ages 18-79 years, children ages 6-11, and youths ages 12-17.1-3 The fourth survey pro- gram, the first Health and Nutrition Examina- tion Survey (HANES I) was conducted between , April 1971 and June 1974 on a probability sample of the U.S. noninstitutionalized civilian ~ population, ages 1-74. An extensive nutrition examination and special examinations by ophthalmologists, dermatologists, and dentists were given to every sample person who was examined. Additional examination components focused on other aspects of health were adminis- tered to a subsample of adults (25-74 years), about one-fifth of all the examinees. These additional components were designated as the “detailed” components, in contrast with the somewhat simpler nutrition examinations. A reduction in the magnitude of resources available for conducting the field operation made it necessary to cut back the number of field teams from three to two in January 1973. It had originally been anticipated that the detailed components would be continued into a second HANES program. Due to the reduction in field teams, HANES I required 3 years instead of 2. In order to speed up the availability of the data from detailed components, it was decided to devote the 15-month period, July 1974 through September 1975, to approximately double the number of people examined for the detailed health component. The larger sample size would facilitate analysis of the examination findings by smaller demographic groupings. In addition, the prolonged period of data collection would also provide more time for planning the design of the next projected Health and Nutri- tion Examination Survey (HANES II) so as to take greater advantage of information and expe- rience gained from HANES I. This 15-month operation was referred to as the “Augmentation Survey” for the detailed component. For the 15-month augmentation phase of the detailed component of HANES I, a number of changes were made in both the content of the examination and the sample design. The opera- tion of the survey proceeded in roughly the same manner as it did in the first part of HANES I. The purpose of this report is to supplement the program description of HANES I4 by describing the modifications in procedures, program con- tent, sampling, and other data collection activ- ities that were made for the augmentation phase of HANES I. Stand sequencing, scheduling, professional and public relations, logistical arrangements, household interviewing, appoint- ment procedures, quality control, examination procedures, and the composition of the field staff are described in the HANES I program report. Most of the components of the detailed examination were continued with little or no modification. For a detailed discussion of the components in the following listing, reference to the HANES I program description? is advised. A description of the nutrition and special examina- tions given in HANES I and copies of the forms used in HANES I are also included. Copies of the forms used in the HANES I Augmentation Survey are found in appendix III of this report. Detailed instructions and procedures used in HANES I and the HANES I Augmentation Sur- vey are described in the staff instruction man- uals, which are available upon request.5-7 Components of the HANES I Detailed Ex- amination Survey that were continued in the HANES I Augmentation Survey include: 1. A physician’s examination. 2. Spirometry. 3. Single-breath carbon monoxide test for pulmonary diffusion. 4. A 12-lead electrocardiogram (ECG). 5. Pure-tone audiometry at 500, 1,000, 2,000, and 4,000 cycles. 6. Anthropometric measurements. 7. Medical History, General Medical His- tory Supplement, Health Care Needs, Arthritis, Respiratory, and Cardiovascu- lar questionnaires. 8. A schedule for measuring psychologica# well-being. 9. Hand-wrist X-rays processed for bone density and cortical thickness and hip and knee X-rays assessed for the presence of arthritis. 4 10. Laboratory tests—Serum: Measurements of SGOT, alkaline phosphatase, biliru- bin, uric acid, folates, cholesterol, cal- cium, phosphorus, and serology tests for measles, German measles, polio, —— diphtheria, and amebiasis were per® formed. Whole blood: Hematocrit, hemoglobin, red and white cell counts, | and white cell differential count were continued. Hemoglobinopathy screening] that was instituted during the conduct of] HANES 1 was also continued in the Augmentation Survey. | NEW PROCEDURES * Hearing Test for Speech | The purpose of this test was to provide ay measure of the ability of the U.S. population to! hear and understand conversational speech. Recommendations for the addition of the test came from a number of speech and hearing authorities who attended an advisory meeting at NCHS. These included Hallowell Davis, Central Institute for the Deal; Leo Doeffler, Stanley Zerling, and Ralph Nauton, University of Chicd- go; and Eldon Eagles, Associate Director for the National Institute of Neurological and Com- municative Disorders and Stroke, National Insti-” tutes of Health. The stimuli used in the test consisted of the revised Central Institute for the Deaf Sentences supplied by Dr. Davis. The material was devel- oped by a working group of the Committee on Hearing and Bioacoustics of the National Re- scarch Council. The following criteria were followed in developing 10 lists of 10 sentences cach: 1 Vocabulary appropriate to adults. Words that appear with high frequency as cited in one or more of the well-known word counts of the English language. “ a: cree — > Exclusion of proper names and proper nouns. Free use of common nonslang idioms and constructions. Avoidance of phonetic loading and tongue twisting. High redundancy. Low level of abstraction. Grammatical construction that varies freely. The sentences in each list contained 50 keywords (appendix III, forms Q and R). The keywords are shown in capital letters in each of the sentences. The recordings of the sentences made under contract at the University of Mary- land by Dr. G. Donald Causey were examined at the National Bureau of Standards and judged to be of excellent technical quality. In the test format, the initial list of sen- tences was presented at a level 10-15 decibels (dB) below the 100-cycle pure-tone threshold unless that threshold was 25 dB or lower. In that case, testing always began at the 20-dB level. Depending on the results of the initial presenta- tion, the next list was presented at either 10 dB higher or 10 dB lower. The end-point for terminating the test was the correct identifica- tion of 90 percent of the keywords in a particu- lar list. A different list was presented at each 10- dB level within the range of 20 dB to 80 dB, as A determined by the degree of hearing loss. Vision Testing The inclusion of visual acuity tests in the HANES I Augmentation Survey was for the pu: pose of comparing objective tests of visual disability with a series of questions designed for + the same purpose. The near-vision test used in the examination was designed to measure one’s ability to read printed selections. Keeney and Sloan cards had different style typefaces and different reading selections. Using both Keeney and Sloan cards together provided a wide range of type sizes for testing near-vision acuity. An adaptation of the test provided some informa- tion on near vision for illiterate persons. Distance visual acuity was measured in previ- ous examination programs by using devices that simulated the recommended 20-foot distance— by optical methods such as the use of mirrors. Since some inaccuracies are introduced by the use of distance simulation devices, it was decided to use Good-lite charts at an actual 20-foot distance. Carefully controlled direct and background lighting was used to ensure accu- racy. Both binocular and monocular distance vision were tested. Water Sample Collaborative Study (HANES- National Institutes of Health-Environmental Protection Agency) This study was undertaken to evaluate the possible relationships among bulk constituents, hardness, and trace metals in household tap- water with certain risk factors of cardiovascular disease. Water samples were collected from taps or wells and from public water distribution supplies. The samples are being analyzed by the Environmental Protection Agency to measure their hardness, alkalinity, and the total amount of solute present. They are also being tested for the presence and concentration of sizable num- bers of trace minerals. In addition to the water sample collection, a questionnaire (appendix III, form C) was administered to the sample persons detailing personal consumption of water and the source of the water supplied to the household. The water pipes under the sink were examined to determine their composition. Additional Questionnaire Material During the Health Interview Survey (HIS), conducted annually by NCHS, approximately 40,000 households are interviewed to obtain a wide variety of health information. Sets of questions on vision and hearing developed for HIS were included in the HANES exam. This would enable HIS to provide a better basis for interpretation of the relationship of a person’s answers to questionnaires in these fields to clinical findings. In short, the questionnaire items provide a scaled index of impairment for hearing, distance visual acuity, and reading ability (appendix III, form B). A portion of the 1975 HIS schedule on hypertension was included so that it could be correlated with the clinical data obtained in the HANES I Augmentation Survey. A final addition was a 20-question depression scale that the National Institute of Mental Health recom- mended to be included. This scale had been used in two large community studies. Since depres- sion is an exceedingly common and important condition for study, the epidemiological rela- tionship of it to various other health factors is of considerable interest. Additional Laboratory Procedures Because of continuous interest in monitoring the prevalence of venereal disease in the U.S. population, serological tests for syphilis were added to the survey. These tests, performed at the Center for Disease Control consisted of the ART, VDRL, and FTA. Another study subject was hemoglobinopathies. Tests for hemoglobino- pathies were actually begun on a special pilot basis at the 37th location of HANES I. Although considerable information is available from local studies, interest was shown in developing esti- mates for the U.S. population. The laboratory procedure performed involved the phenotyping of red cells. On the SMA 12/60, the additional determinations of blood urea nitrogen (BUN), creatinine, sodium, and potassium were done. The BUN and serum creatinine levels served as indicators of kidney impairment in the popula- tion. SAMPLE DESIGN The sample design for the HANES I Aug- mentation Survey of Adults had two basic requirements: The sample of persons selected for examination in locations 66-100 would constitute a national probability sample of the target population and, when considered jointly with those receiving the detailed examination in HANES I locations 1-65, the sample would be a 100-PSU (primary sampling unit), national prob- ability sample. All 100 of the HANES sample locations are listed in appendix II by geographic region and probability design. As indicated in appendix II, 10 of the PSU’s were included in both the Augmentation Survey sample and in the initial 65-PSU design, so that actually there were only 90 distinct sample PSU’s. The sample design specifications, selection procedures, and data collection procedures for the first 65 PSU’s are described elsewhere.* Definitions relating to the sample design and selection of locations re- mained constant throughout the 100 survey locations. 1 The HANES I Augmentation Survey sample was designed to meet the following goals: 4 1. To examine a national probability sample of adults 25-74 years of age which repre- sents the civilian noninstitutionalized population of the contiguous United States, excluding those living on lands « set aside for use by American Indians. 2. To complete the survey of approxi- mately 4,300 sample persons in a 12- to 15-month period. 3. To sample the target population in pro-« portion to its representation in the popu- lation—with no oversampling of special groups. ’ 4. To produce two kinds of estimates from the survey: (a) distributions of the popu- lation by specified characteristics such as blood pressure and selected biochemical determinations; and (b) prevalence in the population of selected chronic condi- tions, particularly arthritic, respiratory, and cardiovascular conditions. 5. To set maximum tolerances for variabil- ity for these key statistics permitting a general analysis by broad geographic regions and by other major demographic subgroups such as income, race, age, and ! sex. Selection of Primary Sampling Units The program description of HANES I* de- scribes the contiguous United States as divided into 1,900 geographic areas or PSU’. These 1,900 PSU’s were collapsed into 357 strata for’ HIS and collapsed again into 40 superstrata for HANES. Of these 40 superstrata, 15 are com- posed of only 1 very large metropolitan area of more than 2 million people and were drawn into the HANES 65-PSU design with certainty. How- ever, in the Augmentation Survey only five of ° ,them were drawn into the sample with cer- tainty: Essex, Morris, Union, Somerset, Hudson, Middlesex, N. J. Essex, Middlesex, Norfolk, Plymouth, Suf- > folk, Mass. Allegheny, Beaver, Washington, Westmore- land, Pa. Macomb, Oakland, Wayne, Mich. Alameda, Contra-Costa, San Mateo, San Francisco, Solano, Calif. The other 10 superstrata that were drawn “into the 65-PSU design with certainty were collapsed into 5 groups of two each, only 1 of , Which was chosen for the Augmentation Survey with a probability of 0.5: Nassau, Queens, Suffolk, N.Y. Bronx, N.Y. Bucks, Chester, Philadelphia, Pa. Lake, Porter, Cook, Will, Kane, Ill. Delaware, Montgomery, Orange, Los Angeles, Calif. However, when these five locations are considered as part of the 100-PSU design they k.are selected with certainty. In each of the 25 remaining noncertainty strata, defined as they were for the HANES I + 65-PSU design,* a selection of a PSU was made with probability proportional to size in a con- trolled selection procedure, independent of its » selection status in the 65-PSU design. Only two ~ PSU’s in the noncertainty strata were included in both surveys: | St. Bernard, Jefferson, Orleans, La. « Hancock, Hamblen, Hawkins, Claiborne, Tenn. Sample Selection Within Primary Sampling Units Within PSU’s, using 1970 census data, enu- y meration districts (ED’s) were divided into seg- ments of an expected eight housing units each. In urban areas where listing units were well de- fined in 1979, tiris division was quite accurate, since the simpli; frame was comprised of list- ings that resulied from the 1970 census. For ED’s not covered by the listing books, area sam- pling was employed, and consequently, some variation in segment size occurred. To make the sample representative of the current population of the United States, the listed segments were supplemented by a sample of housing units that had been constructed since 1970. Then a sys- tematic sample of segments in each PSU was selected. Randomly selected reserve segments were drawn to provide a minimum of 105 sam- ple persons per PSU. After the sample segments had been iden- tified, a list of all current addresses within the segment boundaries was made, and the house- hold interviews were conducted to determine the age of each household member, as well as to obtain other demographic and socioeconomic information required for the survey. After listing the household members according to specified rules of relationship to the head of the house- hold, those 25-74 years of age were then added to the appropriate Sample Person Selection Sheet (figure 1) from which one of every two eligible persons was selected for participation in the survey. The sheet illustrates one of two possible sampling patterns with selection of the first listed person in the segment, third, and so forth. The patterns were randomly assigned to segments in order to effectively remove sampling bias from the selection process. The census interviewer proceeded to arrange an examination appointment for all sample persons who indi- cated a willingness to be examined. Logistical arrangements, household inter- viewing procedures, appointment and transpor- tation procedures, and general mobile examina- tion center procedures are described elsewhere. DATA COLLECTION Census interviewers replaced Health Exami- nation Representatives in administering most of the material in the medical history forms as a part of the initial household interview phase of the survey. Because of this change in inter- viewers, the task of asking certain “sensitive” questions (e.g., those relating to kidney and Form HES-28A (Cycle IV (5-13-74) SAMPLE PERSON SELECTION SHEET HEALTH EXAMINATION SURVEY U.S. DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS a. HES Stand Name b. HES Stand Number Part | — SAMPLE PERSON SELECTION c. Interviewer’'s Name Line HH EP's | Serial Segment Line HH EPs Serial Segment Line HH EP's | Serial Segment No. Line No. No. No. No. Line No. No. No. No. Line No. No. No. (1) (2) 3) (4) (n) (2) (3) (4) (nh) (2) (3) (4) 2 16 30 4 18 32 6 20 34 @ @ 6 8 22 36 10 24 38 12 26 40 28 42 Part Il — CALL BACK HOUSEHOLDS (Cross off when household is interviewed) © Segment Serial EP's Segment Serial EP's Segment Serial EP's Remarks No. No. (Est.) No. No. (Est.) No. No. (Est.) (n) (2) 3) (lh) (2) (3) (1) (2) (3) Figure 1. Sample Person Selection Sheet bowel function) was given to the examining physician. There were also small modifications in the mobile units, such as the installation of special lighting and recording equipment. In place of scheduling 10 examinees (2 for the detailed and 8 for the nutrition exams scheduled for each of the 2 daily sessions of HANES I), 6 examinees, all for the detailed, were scheduled for each session. The average number of ex- aminees scheduled at each location in the Aug- mentation Survey was 120. The lengths of time spent in different locations were roughly equal, wn contrast to HANES I in which some locations had a much larger sample size than others and so required a longer stay. Because of the dropping wf the dental, dermatological, and ophthalmolog- ical exams, none of the personnel responsible for these parts of the exam was present in the mletailed Augmentation Survey. Nutritionists were also not needed, since the Augmentation Survey did not include a dietary history. R Quality control measures were in general similar to those outlined in Plan and Operation of the Health and Nutrition Examination Survey, Series 1, No. 10a.* Some additional procedures had been worked out during HANES I and were applied in the detailed exam for the Augmenta- tion Survey sample as follows: 1. X-ray technique: Chest X-ray films were reviewed by a supervisory technician who furnished a checklist of particular errors of technique (figure 2). These were used for further instruction of the technicians. The hip and knee X-rays were graded for quality by one of the expert readers at the same time the film was being examined for pathology. In addition, listings of errors in technique in hip and knee films and in the hand- wrist X-ray films were also provided by the respective contractors on a regular Sample number Tech number Apices not shown or cut off Costophrenic angles not shown or cut off Rotation of examinee Exposure not on full inspir. (no 10 ribs) Underexposed Overexposed 1 2 3 4 5 6 7 8 POSTERIOR-ANTERIOR CHEST FILM Movement or breathing Artifacts Marker not shown or number incorrect 2 films taken 3 films taken WORKSHEET A For Chief Health Technician COMMENTS Technician signature , Figure 2. Quality control review form basis. Field evaluations of the X-ray units included checking the horizontal accuracy of the X-ray beams at the beginning of a stand and using metal wedges and bone phantoms for checking the calibration of the X-ray machines for the hand and wrist bone density deter- minations. Spirometry: The spirometry output was monitored on an oscilloscope. Based on morphology and reproducibility of the forced expiration trials, various correc- tive actions were undertaken by the technician. About 4 months after the continuation exams began, the acquisi- tion of two-channel Gould Records pro- vided the means of ensuring a more accurate check on the quality of the recordings. Carbon monoxide (CO) diffusion test: The tracings from the test were reviewed to determine whether the trials were acceptable. The trials were reviewed for such items as inspiration time, breath- holding time, inspired volume/vital capacity ratio, minimum dead space washout, minimum volume of gas col- lected, presence of inhalation artifacts. ECG tracings: These tracings were checked for “noise,” correct lead place- ment, machine problems, calibration standards, and baseline shift in the field, and also on a spot basis at headquarters. Body measurements: Body measure- ments were replicated as in the first 65 locations of HANES I. In addition, a random assignment of examinees to technicians within a field team was coupled with computer monitoring to compare results among technicians for body measurements. Audiometry: The random assignment of examinees to technicians and the moni- toring of technician differences were also used to compare pure-tone audiometry results. In addition, the results of the speech test were reviewed at head- quarters for each stand on a regular basis and compared with the results of the | pure-tone audiometry. 7. Leg length measurements: This X-ray determination was part of the arthritis exam. In order to ensure the accuracy of leg length determinations by X-ray, a metal stand on which the examinee * stood was verified as level every day by means of two spirit levels. A computer program was used for monitoring this by comparing left and right leg measure- ments for each stand. - 8. General Well-Being Schedule: Each copy of the General Well-Being (GWB) ques- tionnaire was reviewed at headquarters.. In addition, every form was checked in the field, and an examiner’s observation sheet was filled out giving reasons fom not obtaining a full, acceptable GWB. Also included was the interviewer’s im- pression of the degree of comprehensions of the interviewee in filling out the GWB. 9. Laboratory procedures: Generally, a 10-* percent nonrandom sample of blind duplicates was selected for all blood chemistries and serologies. The single eaception was the T3T, determinations for which the 10-percent sample of blind duplicates was chosen in a random fash- ion. (The nonrandom selection was froma the first batch of blood specimens in the first daily session.) The quality control procedures in hematology included the use of Coulter controls. Control results were plotted daily. Blood indices were calculated and used in quality control. The data collection of the Augmentation Survey was completed in September 1975 with medical histories and household information completed on 94 percent of the 4,288 sample persons; 71 percent of sample persons werg examined. The nonexamined sample persons are of major concern in interpreting the results of the survey. The potential biasing effects of exclud- ing information for nonexamined sample per- sons are evaluated in the development of each freport, and the findings are presented in pub- lished reports. In the development of national estimates, imputation procedures to estimate missing data are selected to minimize potential bias in the final results. Imputation procedures used on the data are presented in substantive reports to inform the user of the amount of missing data for which estimated values were substituted and how the values were estimated. PLANS FOR ANALYSIS AND PUBLICATION OF DATA v Analytical and descriptive reports published rby NCHS on HANES findings are usually writ- ten by the analytical staff of the Division of Health Examination Statistics, often in collabo- “ration with experts in particular fields. Before the data are ready for analysis, several preliminary steps must be taken. In some fcases, such as reading X-rays, further processing of a data unit is necessary. Data must then be reduced to machine-readable form. A consid- *erable amount of time is usually spent editing data to detect errors in data collection and preparation. For example, examination of cho- lesterol data in HANES I revealed a large number of greatly elevated cholesterol values in one location. An extra serum vial for these fo persons was used to repeat the tests; the original values were found to be erroneous, and the repeated tests values were used instead. Editing may also involve comparison of results for variables that are highly correlated, such as body measurements or hematocrit-hemoglobin deter- minations. Because of the large amount of data availa- ble, it is to be expected that everything cannot be analyzed and published very soon after the end of the survey. Priorities for analyses are governed by such factors as the importance of the data, the necessity of timeliness of publica- tion of particular data, the degree of interest of different groups in the data, and the relative difficulties involved in editing data. Some re- ports involving the relationships of several data items will require processing of all the involved items before analysis. Most of them should be published in the 5 years following completion of the survey. As in other HES cycles, a set of computer tapes containing the edited data is being prepared for the use of investigators at organizations other than NCHS, for example, universities and other Government agencies. In general, NCHS publishes the results in the Vital and Health Statistics Series 2 and 11 reports. To a lesser extent, information is made available in journal articles and in papers presented at professional meetings. 000 REFERENCES National Center for Health Statistics: Plan and initial program of the Health Examination Survey. Vital and Health Statistics. PHS Pub. No. 1000-Series 1-No. 4. Public Health Service. Washington. U.S. Government Printing Office, July 1965. 2National Center for Health Statistics: Plan, opera- tion, and response results of a program of children’s examinations. Vital and Health Statistics. Series 1-No. 5. DHEW Pub. No. (HSM) 73-1251. Health Services and Mental Health Administration. Washington. U.S. Govern- ment Printing Office, Oct. 1967. National Center for Health Statistics: Plan and operation of a Health Examination Survey of U.S. youths, 12-17 years of age. Vital and Health Statistics. PHS No. 1000-Series 1-No. 8. Public Health Service. Washington. U.S. Government Printing Office, Sept. 1969. #National Center for Health Statistics: Plan and operation of the Health and Nutrition Examination Survey, United States, 1971-1973. Vital and Health Statistics. Series 1-Nos. 10a and 10b. DHEW Pub. No. (HSM) 73-1310. Health Services and Mental Health Administration. Washington. U.S. Government Printing Office, Feb. 1973. 5National Center for Health Statistics: HANES, examination staff procedures manual for the Health and Nutrition Examination Survey, 1971-1973. NCHS In- 10 struction Manual, Part 15a. Health Services and Mental Health Administration. Washington. U.S. Government 4 Printing Office, June 1972. 6National Center for Health Statistics: Field staff operations manual. NCHS Instruction Manual, Part 15b. Health Services and Mental Health Administration. » Washington. U.S. Government Printing Office, Sept. 1972. "National Center for Health Statistics: Examination staff procedures manual for the Health Examination | Survey, 1974-1975. NCHS Instruction Manual, Part 15c. ' Health Resources Administration. Washington. U.S. | Government Printing Office, Apr. 1975. 1 8U.S. Bureau of the Census: Standard metropolitan statistical areas in the United States as defined on May 1, 1967, with populations in 1960 and 1950. Current Population Reports. Series P-23, No. 23. Washington. ¥ U.S. Government Printing Office, Oct. 9, 1967. 9 National Center for Health Statistics: Sample design and estimation procedures for a national health examina- tion survey of children. Vital and Health Statistics. Series 2-No. 43. DHEW Pub. No. (HISM) 72-1005. Health Services and Mental Health Administration. Washington. U.S. Government Printing Office, Aug. 1971. 0Goodman, R., and Kish, L.: Controlled selection—a technique in probability sampling. J.A4 m.Stat. Assoc.” 45(251): 350-373, Sept. 1950. APPENDIXES CONTENTS I. Technical Notes on the Sample Design 12 Definition of Terms 12 II. Sample Locations of the Health and Nutrition Examination Survey of Adults, by Region, County, State, and Probability Design 14 III. Questionnaires and Examination Forms 16 A. Household Card 16 B. Sample Person Supplement 18 C. Water Usage Supplement 34 D. Health Care Needs Questionnaire 38 E. General Well-Being Questionnaire 46 F. Supplement A— Arthritis 52 G. Supplement B— Respiratory 64 H. Supplement C—Cardiovascular 72 J. Body Measurements 78 K. General Medical Examination 79 L. Audiometry (Air)........ 88 M. Respiratory Function Tests 89 N. Physician’s Supplement 90 O. Report of Physical Findings 93 P. Vision Test 95 Q. Speech Test (20-60 decibels) 101 R. Speech Test (70-80 decibels) 106 LIST OF APPENDIX TABLES I. State groups by geographic region 12 II. Ranges for rate-of-population-change control groups by geographic region, 1950-1960............ccuee.. 13 APPENDIX | TECHNICAL NOTES ON THE SAMPLE DESIGN Definition of Terms Standard ~~ metropolitan statistical areca (SMSA).—An SMSA consists of a county or group of contiguous counties (except in New England) which contains at least one central city of 50,000 people or more, or “twin cities’ with a combined population of at least 50,000 population. In addition, other contiguous counties are included in an SMSA if, according to certain criteria, they are socially and eco- nomically integrated with the central city. Definitions of SMSA’s which identify the com- position and structure of each appear in a U.S. Bureau of the Census publication.® Geographic regions.—For purposes of HES, the 48 contiguous States and the District of Columbia are divided into 4 regions of about the same population size, shown in table I. Controlled selection.—This term refers to a scheme that permits some element of subjective determination in obtaining a “better balanced” or “more representative’ sample, while retaining all the elements of true probability sampling. The procedure is described in a number of publications.?»19 The control variables used for this sample design are “State groups” and “rate of population change” and are defined as fol- lows: Separate groups were formed within geo- graphic regions, as shown in table I. To form the State groups, the HIS design strata were classified as belonging to the State in which the HIS sample PSU was located. If a sample PSU was within two States, it was put in the State with the greater proportion of the population. NOTE: A list of references follows the text. 4 Table |. State groups by geographic region « State Region gor States in group . ber Northeast........... 1 New York 2 | Pennsylvania and New Jersey 3 Maine, New Hampshire, Vermont, Massachusetts, Connecticut, and Rhode Island ' Midwest .......cuue.0 1 Ohio 2 | Michigan 3 Indiana and Illinois 4 Missouri 1 5 Kansas, Nebraska, lowa, and North Dakota 6 | Wisconsin and Minnesota South ..oumimis 1 Maryland, Delaware, and Dis- trict of Columbia 2 | Virginia and West Virginia 3 Kentucky and Tennessee 4 North Carolina and South Carolin: 5 | Georgia 1 6 | Alabama and Mississippi 7 Florida 8 Arkansas, Louisiana, and Texas 1 [ACES ST 1 California and Nevada 2 | Texas 3 | Washington, Oregon, Idaho, and Montana 1 4 | Oklahoma, Arkansas, and Louisiana 5 | Wyoming, Utah, Colorado, New Mexico, and Arizona 6 North Dakota, South Dakota, Nebraska, Kansas, Minnesota, and Missouri v Rate of population change. —Groups were defined differently for each region as indicated it table II. In the Northeast Region, for example PSU's with less than a 3-percent increase nn population between 1950 and 1960 were clas sified in group 1, while this class in the Midwes' — Table II. Ranges for rate-of-population-change control groups by geographic region, 1950-60 Region Rate-of-population-change group number Northeast Midwest South West Percent population change, 1950-60 3 and under | 0 and under | -10 and under | -5 and under 5-11 1-15 -9-0 -2-0 12-23 16-23 1-8 4-21 25-58 24-30 9-16 24-39 - 34-81 19-26 40-59 - 27-36 73-167 3747 - 50-301 Region included only those PSU’s with a loss or with no gain in population. Population density groups.—In general, this term refers to the proportion of the population that lives in urban areas. The density groups are defined somewhat differently for each geo- graphic region.* For the very large SMSA’s, except those in the South Region, the criterion for inclusion was population size; these SMSA’s were chosen for the sample with certainty. In the South Region, the largest SMSA’s were defined in the same way as ‘other large SMSA’s,” but were put in a different stratum for sampling puposes. 13 APPENDIX II SAMPLE LOCATIONS OF THE HEALTH AND NUTRITION EXAMINATION SURVEY OF ADULTS, BY REGION, COUNTY, STATE, AND PROBABILITY DESIGN ’ Probability design Region, county! and State Hite es — 1-35 1-65 66-100 TT Northeast Essex, Morris, Union, Somerset, Hudson, Middlesex, N.J. ... Nassau, Queens, Suffolk, N.Y xX X X xX X X KINGS, RICHMOND, N.Y ......cimmiiiimmtisis mses srs sss sersess sass srseessssnessss se sress sms esssmssesssss ress sErsssmseesssmmmsesssserseessssnes Westchester, Rockland, N.Y.: Bergen, Passaic, N.J. ....... Bucks, Chester, Delaware, Montgomery, Philadelphia, Pa. Philadelphia, Pa: Camden, Gloucester, Burlington, N.J. ... .. Essex, Middlesex, Norfolk, Plymouth, SUTTOIR, ESS. ........ccccommiumsinissssminsnsssmpnsntsnrntaenss rns trdne mst satis ss ssnensosssapnasos Allegheny, Beaver, Washington, Westmoreland, Pa. Albany, Schenectady, Rensselaer, Saratoga, N.Y. ... Lackawanna, Pa. ................ Holyoke, Chicopee, Springfield, Mass. ... va Bristol, Newport, Providence, Kent, Washington, R.l. ooo eee eee | ETa 4 ee FR Ie] H Fa To JR Oo 11 Lo FAO PPPPPPRN X Chemung, Tioga, Tompkins, N.Y vas MBIT, PB. covviciirmivissirmmmcesmvnismmerssss sovessnerssssisss suns ss son sssnsnsns ss miss ses sssn sss ss sae sss ses sss sess pos sine massa posses ven sssssvaes X Bator, FULTON, PH. comms iiss st ir sn a a i iS an San Son ns Rn SU A a Rt Monroe, N.Y. ......... Blair, Pa. .ceeeveeieieiiieeiineeienens Middlesex, New Haven, Conn. vi A T= TA FR PPP PPR PSPPPPPIN xX X X XXXXXXXXXXXXXXXXX x xX X XX Midwest Lake, Porter, Cook, Will, Kang, Wl. «ummm mimi is sna ess sonia sass ravens sa erase suave i visa nies X Cook, DuPage, Kane, Lake, McHenry, III —n Macomb, Oakland, Wayne, Mich. .....ccccoeiiiiiiiiiiiiiiiiiciiiieceieciiis ee eae aaa X Milwaukee, WEUReSIE, WIS. vuivnimmissmsmss mis sions sui wins sits vis ssa mms so isns nis X Hennepin, Ramsey, Anoka, Dakota, Washington, MIN. ceases sissies iessssmmvsssessss sss sess sams sis pom sess Lake, CUYBNOGA, ONTO tuuiuuuiieieiiiiiiiitiee eset eee etree teeta eee e sate e sees tees teste eats ease esate tees ease esas ee ebe ethane tases n eee X Franklin, Ohio we BUCHAN, MOL, sivsiminsssoos sms snomss sss sss ses ea Ee i A sy EES TOE A SE CHET TEAS AS Aras X Cu55, IN. Dak: CIay., MINTE, suissnmsorssssnsss wm issimmmesseoss masses ss misms seess ses 13. oy gs mina ss sss sh ros ie eS eas s Svar vs Jefferson, St. Charles, St. Louis, Mo.: Madison, St. Clair, Ill. ... BEY, MIG, ovninnnnnnninssines sod ss Seiiesvis ss sans LURE eR SAT Eh HA IES DeKalb-Stueben, Ind.: Branch, Mich . £a85, St. JOSEPN, IVIICI. L.uiiitiiiiiiiieti eerste eee eee eee eee e eee eee ease era eee teen eee e ee nees FAYEIIE, ROUSE, OHI ..vesssmbiiihrmisi ss ioe eh aA ss UE As SS ER Aa SS SR AR EA AY RE AR A YAN ARRAS LaPorte, Marshall, Starke, Ind. . BOONE, GrEENE, LOWE oiuniiiniitiiiiee ieee eee e ete e eee eee tease tetas eet eat eee sete ease aaa ete ete e see e a tees tae eee a ana aa eas X XXXXXXXX XXXXXXXX Icounty, parish, or borough. Region, county,! and State Probability design 1-35 1-65 66-100 Midwest—Con. Howard, 10Wa: FillMOre, MINN. ...cciiiiicieieieiiiereeeeeeiiree eee esne ee sesassesessseeeesssssssssassesseeseesessnsesassssesssssssasessessssnnens ‘Cass, Clay, Jackson, Platte, Mo. ... Marion, Ind. ..ccccevveiiciieeeneeeeeeennienenns Montgomery, Greene, Miami, Ohio . Jackson, MCh. .....cvcvevieeeeeeieeeeeeccinnsnnnanenens Jefferson, Leavenworth, Kans.: Platt, Mo. .. Brown; Clinton; OhIO s..vsssissrismiinisisss I. IL IIIT » South St. Bernard, Jefferson, Orl@ANS, La. ......vecieieiieriuuiuiiieeereeereestarsssssseetteeesesstanneaessssesssenssnnnssmasassssssesssssssnsssesssees Washington, D.C.: Fairfax, Arlington, Va.: Prince Georges, Montgomery, Md. . PRIChIaNd, LexINGON, S.C. cnumivisiisiiis isos erases mins ss vasa s ssa Re F 0599 530 1000000480 ERA E ES 4SRRI IS POS SAS SS Knox, Anderson, Blount, Tenn. Roanoke, Va. .......... Chatham, Ga. ..... Hillsborough, Pinellas, Fla. .. Palm Beach, Fla. ...... Natchitoches, La. .. Lamar, Marion, Miss. .... FCabarrus, Stanley, Union, N.C. .... ve Hancock, Hamblen, Hawkins, Claiborne, TENN. ......uuuiiieiieeiiieieeeeistiie cease eeeeeenasseesessessenensnnnesennsasasseseessnsnsnnaaaes Barbour, Ala. .uussecnsssassssssssrimissnses Bullock. Jenkins, Ga. ..... WSUSSEX, DEl.: WOFOBSTEE, MIO. covviseismmmsrinssnssisunsnnsus mrasennsnnrs senssnse sessnsnsssassnnsoss setessssssssne asses bessssmssssensssssrsumesss FAVRE, Wh V8, sirsuisnnimnstrionsinissre intone adios ras ss mms hbase ST Si ER A TERETE snr RAR ERS AAAS BAT PARRA Greenville, S.C. .. NEWCASHE, D8. aivsrisesitrrrssmmrmmsmrssrsssesnsssnssnsnnsmssmssammsmsmmressisssssssnmmmnsnsrmrrrsess seas ns saa sa arrsrrasyemssssss sss JOFFOISON, MAID: survrvmrvmtri cones sess sires AR A ET A a AAA ES aaa Fann h Renan ban shasnssess Volusia, Fla. ...... a Edgefield, Saluda, S.C. ..uuuuiiiiiiiiiiiiiieeiiete reste secre eres eee sete ee ear essa rae eee eeae eas s ar rae eae etter erent tana teeeterarenra rans Clay, Calhoun, Roane, W, Via wun irises teases easiness is si os sais Shae Ga SE ania ss satan West q Orange, Los ANGEIES, Calif. .....uueueeiiieiiiiieeieieriiiisetratatatater es eaeee ae aes ee assasasssee seas sees este sssesesssesssseseseeessseesesenseeses Los Angeles, Calif. wunumnnmasnimsnmmiie Alameda, Contra-Costa, San Mateo, San Francisco, S0IaN0, Calif. ...eeeeeeeeeeeeeeeeieeieeeeee sees esses eee k Collin, Denton, Dallas, EIS, TeX. .ueeeeeeeereerrrenrneeeeeeeeeessessesseseeens BOXEAE, TOR: svvensunsusmissnsns susan sumss oi 3 Er ST EER a At AROS SE POTS A STARS ESTERASES PRET TE SAREE PIMA, ATIZ. cities eee setae steer teeta esate ee nar eee ereeetreeeeeeeesreain Douglas, Nebr.: Pottawattamie, lowa .. S30 DIRQ0, Calif: cuvnrsms cnmisiss cosa sem ssa seman dass masa rasan os ss R RAISERS FESS 3 AR HISAR PEA SSIS Frese, Call. uv mame rs rr EE Ts EET SE EG i sadn a essa res Monterey, Calif. .......... Clallum, San JU, WEBI. ..ciivininssimmmesassimmresssssnmsssnsss piss sesssrsserasssyssssssnn Brant, Washi. ucussserresmssrsn tins sae a Bs EASE ean Sone pra sa wean Gila, Ariz. ....... AVOYBHES, LA. .ciciiiisisnsssircersrsensmmmmmsssssssssssrvssssvavavassenmnerererressssssass Ottertall, MInm. summertime amare assis 35 va sas saan NAdams, Arapahoe, Denver, Jefferson, Boulder, Colo Sacramento, Calif. ......cccccvvveriieeeerieeeeeeeianreeer rere Hunt, Rains, Tex. suemsmseimms iiss Mason, Thurston, Wash. . Greeley, Nance, Nebr. ......ccovcuvveeeeiiereeeeieeeee cee ws Camadian, Cleveland, OKIGNOMA, OKIA. ..cccuvieeeiuurrreieeiieiieeieitreeeseeeeessesseseeesssasesssessssssses see sssnsseesssssesssesseees essai XXXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XX XX XXX X XX XXX XX XX XX 1county, parish, or borough. 15 16 APPENDIX 11I QUESTIONNAIRES AND EXAMINATION FORMS A. Household Card FORM HES-5A (CYCLE IV) artes U.S. DEPARTMENT OF COMMERCE SOCIAL. AND ECONOMIC STATISTICS ADMINISTRATION BUREAU OF THE CENSUS NOTICE — All information which would permit identification of the individual will be held in strict confidence, will be used only by persons engaged in and for the purposes of the survey, and will not be disclosed or released to others for any purposes. ACTING AS COLLECTING AGENT FOR THE 1. Stand 2. Identification 3. Control number 4. Car¢ U.S. PUBLIC HEALTH SERVICE number code bP cane ga HOUSEHOLD CARD PSU Segment | Serial cll HEALTH EXAMINATION SURVEY cards L 5a. What is your exact address? (Include House No., Apt. No., or other identification and | | isting 14. Noninterview reason ZIP cove) | Sheet ,TYPEA To Se TT 77 Sheet Refusal - Desclive in a tootnote JNO No one at home - repeated calls Fill items TR f= -T ; City | State : Li Temporarily absent — Footnote i) an No. applica oo ' | Other (Specity) 7 13-15 and 18 b. Is this your mailing address? Mark box or specify if different. Include ZIP code State 1 2IP code i o . Special place name do a is 1 Sample unit number Type code | [ | TYPE B Vacant - nonseasonal Vacant - seasonal oo YEAR BUILT Ask When was this structure originally built? Before 4-1-70 Continue interview Do NOT Ask After 4-170 (Go 10 8c, comprete if required and ena interview: Type of hing quarters + Housing unit 2° OTHER unit 8. Area segments ONLY “a. Are there any occupied or vacant living quarters besides your own in this building? Y Table X) N b. Are there any occupied or vacant living quarters besides your own on this floor? Y (till Table Xi N c. Is there any other building on this property for people to live in - either occupied or vacant? Usual residence elsewhere Flt items 6-8 1la—c as Aimed Forces applicable, 13-15 Other (Spec. rz TYPE C Unused line of listing sheet ~ Demolished Merged Aart Fill items Outside segment } ns “Built after Apnl 1, 1970 and 13-15 Other Seecity: 5 15. Record of calls A Me a PE Time Date Y tii Tavie X N 8 SEE Si _ i sme Sharada tine — \ d. None feet 3 i 9. Land use «RURAL ‘Goto 10 ALL OTHER (19, back) 4 « Regular units coded 82 or 84 in item 2. a! i) «Special place units coded 82 or 84 in item 2 AND coded 85-89 in item Sc. = TT Ec eee ees 10. Do you own or rent this place? Own Rent fent for tiee 6 | ! Bo y tl { ) 11a. Does this place you (own rent rent for free) have 10 acres or more? © Y 2N 11er 16. List line numbers of sample parsers o . During the past 12 months did sales of crops, livestock, and other farm products from this place amount to $50 or more? . During the past 12 months did sales of crops, livestock, and other farm products from this place amount to $250 or more? ty eN VY (19 back) 2 N 119 back) o nat interviewed during initial interview, None tert | |] | 17. Record of additional persenal calls GO TU QUESTION 19 ON THE REVERSE SIDE Time T T 12. What is the telephone number here? v Ares cone ; Number None | i Date - Line Nos, Beginning | Ending completed T 13. interviewer's nance | Coge | | NOTE: BEFORE LEAVING HOUSEHOLD, CHECK THAT 16 HAS AN ENTRY. Determine the best time for callbacks for Supplements and sample persons. NOTE: Footnote reason for noninterviews for sample persons in same detail ag in item 14, FOOTNOTES 18. For “final” Type A noninterviews enter names, approximate ages, and sex of household meribers, Name | Age I Sex 1] 2 | | —— me oof 3 | | RR! aE aps 4 | 5 | - sain 5 | J Total number WASHINGTON | of persons USE ONLY Total number of sampled persons ! Ll If this questionnaire is for an E EXTRA unit, enter Control Number of original sample unit —— 5 also enter for FIRST unit If in AREA SEGMENT, listed on property —- Sheet number LISTING SHEET Line number TABLE X — LIVING QUARTERS DETERMINATIONS AT LISTED ADDRESS LOCATION OF UNIT ef listed, © f outside AREA SEGMENT | Are these USE OR CHARACTERISTICS CLASSIFICATION enter sheet boundary; mark box below, | (specify location, N — Not a separate unit — and line STOP Table X, and go to Quarters for more OccuPIED De Be TUARTERS Add occupants to this Where are these quarters located? number, STOP| Household Page, item 8 or | than one group | Dg the occupants of these] (specify location) have: questionnaire. Table X, and 9; or Medical History, of people? (specify location) quarters " (Complete a separate Line Enter exact description or location, continue question 1 (as applicable). - ” live and eat with any Direct secors ote er arate or ool No. | e.g., basement, 2nd ficor, rear. interview for resol | other group of people? the out- | kitchen unrelated person or original ach group side or through | facilities for tamil group.) S3Mple uot. a common hall? | this unit only? of unlisted, HU Separate unit — goto 4. Bf interview on a separate estionnaire. iY @ 3) * (5) (6) om 8 qestiongd: Yes — Go to © 1 S__L Outside segment boundary] Yes No and circle N Yes No Yes No N HU oT i Yes —Goto9 Ni 2 $__L ~ Outside segment boundary] Yes No andorcien” | Yes No | ves mo N HU oT 3 s__L Outside segment boundary] Yes No | Yes=Sofo8 | No | ves No | ves No N HU or NOTE: Be sure to continue interview for original sample unit. Te — —rr— ye yp ——— ye How is —— related to—— (head House- How old What is the month, Enter | Enter | Is — now married, | Mark (X) the box | Refer to HES-28 for all of household)? hold was — on | date, and year of code | code | widowed, divorced, | for all Persons EP's to determing " member his last —="s birth? wW— separated, or aged 25-74 there are any Sample NCHS Name: Last, Just) birthday? | Use card ro check - M-1 | never married? Persons. Enter SP Serial birth date and age or3 | rz M-2 5-6 on the line for each Number . for consistency. pm w-3 N-4 Sample Person, then 3 0-5 £0 to HES-5B g (200) (20c) (204) (20e) 20 | 20g) (20h) Q (20a) Relationship Age Month] Cate] vear | Race | Sex Marital Status (201) (20)) 1 Y N |EP 1 2 Y N EP 2 3 Y N TEP 3 4 Y N {EP 4 5 Y N 1EP 5 6 Y N EP 6 7 Y N EP 7 8 YN (EP : 9 Y N EP 9 10 Y N EP 10 19a. What is the name of the head of this household? — Enter name in first column. Footnoter b. What are the names of all other persons who live here? — List all persons who live here. c. | have listed (Read names) Is there anyone else staying here now, such as friends, relatives, or roomers? d. Have | missed anyone who USUALLY lives here but is now away from home? e. Do any of the people in this household have a home anywhere else? If any adult males listed, ask: f. Are any of the persons in this household now on full-time - active duty with the Armed Forces of the United States? . . .. . Yes —» line(s) (Delete) _|No FORM HES-SA (CYCLE IV! (5-15-74) 18 B. Sample Person Supplement FORM ES-58 (CYCLE IV) Form Approved (10-28-7 «M.B. . 1184 U.S. DEPARTMENT OF COMMERCE DU. S11 19 SOCIAL AND ECONOMIC STATISTICS ADMINISTRATION BUREAU OF THE CENSUS NOTICE — All information which would ACTING AS COLLECTING AGENT FOR THE permit identification of the individual U.S. PUBLIC HEALTH SERVICE will be held in strict confidence, will be used only by persons engaged in and SAMPLE PERSON SUPPLEMENT for the purposes of the survey, and will HEALTH EXAMINATION SURVEY not be disclosed or released to others for any purposes. a. PSU b. Segment number [c. Serial number d. Person number e. NCHS SERIAL NUMBER Comments 1. In what State were you born? I State or foreign country Enter the name of the State or foreign country. ! | [11] l 2a. What is the highest grade or year of regular 2a. i o [] None school you have ever attended? ! | Elementary | 2 3 4 5 6 7 8 I ! High School 9 10 II 12 1@3) College I 2 3 4 54 b. Did you finish the —- grade (year)? be! 1 4 Yes | 2 o 3. What is your origin or descent? 3. 109) o[] German 8 [] Mexican | 2] Italian 8] Mexicano ) 1] Irish 7] Puerto Rican y 3] French 7 [[] Cuban , a [_] Polish 7] Central or : s [] Russian . South Arserizen | . 7 er Spanisl ! sJ English 12 [] Negro | 15 [_] Scottish 12 [] Black ' 1s [] Welsh 1s [] Other ~ Specify 5 : 8 [_] Mexican-American | 8 [] Chicano 4a. What were you doing MOST of the past 4a. | 3 months = ’ ? 1 [7] Working (4d) (For males): working or doing something else? ' 2] Keeping house (4c) (For females): keeping house, working, or | 3 doing something else? ! 3 [] Something else b. What were you doing? b.| (©) o [J Layoff : @ 1 [] Retired 4 2] Sudan | «(JIN ! s [] Staying home | 6 [] Looking for work | 7 [] Unable to work ! 3 [] Other — Specify | c. Did you work at a job or business AT ANY c.| 1] Yes TIME during the past 3 months? ! 2 No (5b) | d. When you were working, did you usually work d.! 1 [J Full time full time or part time? | 2] Part time 5a. Did you work at any time last week or the 50.110) 1 [CO] Yes (6) week before? | 2] No (For females): not counting work around the house? I b. Even though you did not work during that time, b.|@) 1] Yes do you have a job or business? \ 20] No 1 c. Were you looking for work or on layoff from a job? el © 1] Yes I 2[] No (Instructions for Q-6) d. Which — looking for work or on layoff from a job? di) 1 [) Looking ! 2[] Layoff I y 3[] Both Ask for all 6a. For whom did you work? Name 6a. Employer persons with of company, business, organi- | a ‘Yes in zation, or other employer. ! Say bs ore, b. What kind of business orindustry b.i Industry “ "i is this? For example, TV and | If “*Yes" in ) : | Scion! radio manufacturing, retail shoe 1 oo bo store, State Labor Department, farm. ' © | Yirough 6d c. What kind of work were you doing? c.! Occupation id ji For example, electrical engineer, , foll-time stock clerk, typist, farmer. / @ TT] civilian job. ! d. Class of worker (Fill from d 1 [] Private paid entries in ba—c; if not clear, read list.) If self-employed in ““OWN"’ busi- ness and not a farm, ask: e.ls the business incorporated? 2[] Gov. Federal » (7) 3] Gov. other 4] Own s[] Nonpaid } 7) 6] Never worked 1] Yes 2[] No 19 20 Now | have some questions about your medical history. deafness — (Read list) Bor infection... ss me 535 400 58 3 wim + Born with The vo smw vvsasouesnwves Loud noise such as that from machinery, gunfire blasts, or explosions ....... Bor surgery cio vs sin vs vor vx 3 wine + Bor INJUry « cov vo avo 43 5 90% 5 5 3 woe ¥ Other ~ Specify ® * Yes No DK 0 0 21 x 27] x 2) J 3] 3] 4 a] a sO) s() s(] 6] se] s[] | 1 | 7. Would you say your health in general is 7 | 1[ 7] Excellent excellent, very good, good, fair, or poor? 2) Very good | 3] Good | a[ | Fair : s[_] Poor 1 | 8a. Do you have any health problems now that 8a. | 1{_] Yes you would like to talk to a doctor about? i 2 0 No (9) \ = b. What are the problems? b. P>DATA PREPARATION USE ONLY ® 0 @o @0 @ 0 pox 20) x 2) T20) + 2) : 3] 3] 3] al) +0) a) in 9a. Have you had a cold, flu, or ‘the virus" 9a. | (29) 1] Yes during the past month? y 2] No (10) b. Do you still have it? b. i @) 1] Yes | 2] No + 10. IN THE PAST 5 YEARS have you had a 0. | 17] Yes back injury? | 2[ No | kad Now | have some questions about HEARING. | 11a. At any time over the past few years, have you 1la. | Co ever noticed ringing in your ears, or have you d @ 10] Yes been bothered by other funny noises in your ears? J 2[]No (12) 1 b. How often — every few days or less often? b. | 1] Every few days y 2[ | Less often c. When it does occur, does it bother you quite ei 1[_] Quite a bit a bit, just a little, or not at all? ! 2[] Justa little ! 3[ ] Not at all 12a. Have you EVER had a running ear or any 120. | 10] Yes discharge from your ears (not counting wax ! 2] No 13) i ? in the ears)? a [10K b. How often have you had a running ear or b. i ®) 1] Once only any discharge from your ears? ) 2] Twice : 3[ ]3 or more times : 910K c. Did you visit a doctor because of 32 1] Yes this condition? ! 2[] No 13 : sok f 1 d. Did a doctor give you anything for d. | (®) 1] Yes this condition? : 2[] No | s[[] DK 1 13a. Have you EVER had deafness or trouble 130. | hearing with one or both ears? Do not ! 39) 1] Yes include any problems which lasted just a i 2[ | No (14) short period of time such as colds. ! - 1 b. Did you ever see a doctor about it? b. | (3 17] Yes y 2(] No r c. How old were you when you first began c 1] 0-4 years old having trouble hearing? 1 2() 5-9 years old | 3[] 10-19 years old : 4[] 20-29 years old ! s[] 30-39 years old ! 6 [] 40-49 years old y 7] 50 years old or older i d. Since this trouble began, has it gotten worse, d. J ©) 1 [_] Gotten worse better, or stayed about the same? ; 2[] Gotten better } 3[] Stayed about the same e. Was the cause of your hearing trouble or e. i 1 | i | | | | | | | | | | | 1 HEARING — Continued | 1 13f. How would you rate your hearing in your RIGHT 3, | 1 [] Good ear - good, a little decreased, a lot decreased, | 2] A little decreased or are you deaf? | 3[] A lot decreased ! 4] Deaf g. How would you rate your hearing in your LEFT 9. ! 1 [] Good ear — good, a little Jeereased, a lot decreased, | 2] A little decreased or are you deaf? | 3] A lot decreased : 4] Deaf | h. Have you ever attended d school or class for h.! (©) 1] Yes those with poor hearing or a school for the deaf? ) 2] No 1, I i. Have you ever had any training in i.) ® 1 Yes lip reading? ! 2] No 1 I i. Have you ever had any training in speech or in i @ 1) Yes speech correction because of poor hearing? | 2] No | k. Have you ever had any training in how to k.! @) 1) Yes use your hearing? | 2] No i I. Have you ever had an operation on your ears? I () 1] Yes ! 2[J No I m. Have you ever had your hearing tested? m. | 1 Yes ! 2] No (13p) I n. How old were you when your hearing was ni @@ 1] 0-9 years old first tested? ! 2[] 10-19 years old ! 3] 20-29 years old : 4] 30 years old or older o. How often do you now have your 0. @) 1 []) Twice a year hearing tested? ! 2] Once a year : 3[] Once every 2 years ] a [] Less often than once every 2 years ee I p. Have you ever used a hearing aid? Pp. 1] Yes ! 2] No (14) Whi | i q. Which ear? q. | 1 [J Right | 2] Left ! 3] Both r. Do you use a hearing aid now? r. (sD) 17] Yes | 2] No (14) s. How well satisfied are you with your present w.) 1 Helps a lot hearing aid? Does it help a lot, a little, | © 2 Ea Helps a little very little, or not at all? 3] Helps very little ! 4 [_] Does not help at all ® If Yes’ in 13p ask |4a—g using the parenthetical ! phrase ‘‘Without a hearing aid.’ ! 14a. (Without a hearing aid) Can you usually HEAR AND 14a. | UNDERSTAND what a person says without seeing his ! face if that person WHISPERS to you from across a | (@) 1] Yes (15) quiet room? : 2] No I b. (Without a hearing aid) Can you usually HEAR AND b. i UNDERSTAND what a person says without seeing his ! face if that person TALKS IN A NORMAL VOICE to | (9 1) Yes (15) you from across a quiet room? ) 2] No c. (Without a hearing aid) Can you usually HEAR AND c.! UNDERSTAND what a person says without seeing his ' face if that person SHOUTS to you from across | (59) 1] Yes (15) a quiet room? 2] No d. (Without a hearing aid) Can you usually HEAR AND 4. UNDERSTAND a person if that person SPEAKS (39) 1 Yes (15) LOUDLY into your better ear? ! 2] No i e. (Without a hearing aid) Can you usually tell the sound . Y 5 of speech from other sounds and noises? o @ = = Us I f. (Without a hearing aid) Can you usually tell one kind f. | of noise from another? i (©) 1] Yes (15) ! 2] No i g. (Without a hearing aid) Can you hear loud noises? 9 1 [0] Yes ! 2] No 21 22 15a. o a a al x 3 ° ° o - [3 < The following series of questions will be about specific medical problems or conditions you might have had in the past or might even have at the present time. Please Pein: dvi : answer “Yes” or ‘‘No’’ to each question. Have you EVER had - Pain or aching in any of your joints on most days for AT LEAST | MONTH? . Pain in your neck or back on most days for AT LEAST 1 MONTH? . Pain in or around either hip joint including the buttock, groin, and side of the upper thigh on most doys for AT LEAST 1 MONTH? . Pain in or around the knee including the back of the knee on most days for AT LEAST 1 MONTH? . Swelling at a joint, with pain present in the joint when touched on most days for AT LEAST 1 MONTH? . Stiffness in the joints and muscles when getting out of bed in the morning lasting for AT LEAST 15 MINUTES? Have you EVER had - . Trouble with recurring persistent cough attacks? . A cough first thing in the morning in the winter? (Count a cough with first smoking or on first going out of doors; exclude clearing of throat or a single cough.) . A cough first thing in the morning in the summer? . Any phlegm from your chest first thing in the morning in the winter? (Count phlegm with the first smoke or on going out of doors; exclude phlegm from the nose. Count swallowed phlegm.) . Any phlegm from your chest the first thing in the morning in the summer? . During the past 3 years have you had a period of increased cough and phlegm lasting for 3 weeks or more? Have you EVER had - . Trouble with shortness of breath, when hurrying on the level or walking up a slight hill? . Wheezy or whistling sounds in your chest? . Trouble with any pain or discomfort in your chest? . Trouble with any pressure or heavy sensation in your chest? . Severe pain across the front of your chest lasting for half an hour or more? . Pains in either leg when walking? . Heart failure, or ‘weak heart’’ of any degree of severity? . Infections of the kidneys or bladder? . Loss of vision or blindness lasting from several minutes to several days? . Difficulty in speaking or very slurred speech lasting from several minutes to several days? 15a. < 17] Yes 2 No 1] Yes oo , 2 No (8) 1] Yes ! 2 | No FE Pl eS ——————————— | (13) 177] Yes : 27 | No sim ——— i os inert ete (169) 1{ 1 Yes 2” | No (69) 1 Yes 2 | No (168) 17] Yes . 2 No 1) 17] Yes Bh ! 2] | No (168) 1{7] Yes ’ 2 1 No er er (169) 17] Yes ! 2! 7 No “ 11] Yes 2! J No me im ] many times? D1 time 2[ ]2times 3" ] More than 2 times | (73) 1] Yes ! 2] No (79) 1] Yes 2[ |] No be (19) 1] Yes ! 2[ | No | (179) 1] Yes | 2[] No (7) 1] Yes | 2] No (@) 1] Yes J 2] No ®) 1] Yes | 2[] No 1 (159) 1] Yes | 2] No lst (08) ves ! 2(] No (® 17] Yes [No Have you EVER had — T i 15w. Prolonged weakness or paralysis of one or both 15w. | ® 1] Yes sides of the body lasting up to several months? ! 2] No | x. Loss of sensation or numbness or tingling sensations x | (189 1] Yes lasting several minutes to several days? | 2] No | ; | y. A severe head injury leading to unconsciousness yeu @ 1] Yes lasting for more than 5 minutes? ! 20] No 1 DIABETES 16a. Do you have any reason to think that you may have 16a. | 1] Yes diabetes, sometimes called sugar diabetes or ; 2] No (17) sugar disease? : 1 b. Did a doctor tell you that you had it? b. | 1] Yes ! 2[] No (17) | c. How long ago did you start having it? c | 1[] Less than | year ago \ 2[] |-4 years ago : 3[] 5 or more years ago I, I d. Do you take insulin shots? d. | 1] Yes : 2] No I e. Do you take any medicine by mouth for diabetes? e.! 1] Yes ! 2] No (17) f. What is the name of the medicine? GOITER/THYROID ! 17a. Hove you ever had a goiter or any other 7a. | 1] Yes thyroid trouble? | No (18, j 2] No (18) | b. Who told you that you had goiter or b. | 1 [] A doctor thyroid trouble? | 2[] A nurse i y 3] Other I c. Is, or was, your thyroid: Overactive (hyperactive) or c. ! 1 [_] Overactive v ive)? | underactive (hypoactive)? | 2[] Underactive : 3[] Neither i 9 [DK d. How long ago did you first have this trouble? d. i 1[] Less than | year ago ! 2[C] I-4 years ago i 3] 5-9 years ago 1 ! 4] 10 or more years ago 1 e. Have you been treated by a doctor for goiter or e. | 1 Yes i ? for thyroid trouble? ! 20] No (18) i f. Were you treated for this condition by a fo 1 [[] Medicines doctor with — (Read list and mark all li S that apply) 2[[] Surgery : 3] Radiation ) 4] Anything else — Specify 2 | 1 | I 9. Are you currently being treated for this problem? 9. } 1] Yes i 2] No i h. Are you currently taking any pills or medicine h.! 1] Yes to help you lose or gain weight? 20] No . When was the last time you saw a doctor about goiter or thyroid trouble? 1 [] Less than | month ago 2[] |-3 months ago 3 [] 4-6 months ago a] 7=11 months ago s[] | or more years ago 9 [DK 23 24 Naw Luuld bike to ask you some questions about 18a. Have you lost all your teeth from your upper jaw? o n . Do you have a plate for your upper jaw? . How long have you had your plate? 18a. ! 1] Yes 2[)No (19) | b. | 1] Yes | | 2[ | No (/8d) 1[] Less than | year i 1 2] 1-4 years | | | | J 3[ 5-9 years (19) a] 10-19 years | s [120 or more years | r d. Have you ever had a dental plate for your upper jaw? d. | 1[] Yes 2] No r e. How long has it been since you had any natural or false o. 1 [] Less than | year teeth to chew with in your upper jaw? : 2) 1-4 years l 3 ]5-9 years J a ]10-19 years | s[ ] 20 or more years . 19a. Have you lost all your teeth from your lower jaw? 19. | 1] Yes | 2] No (20) i b. Do you have a plate for your lower jaw? “ 1] Yes 2] No (19d) c. How long have you had your plate? a) 1 [] Less than | year y 2[ 1-4 years 3[ ]5-9 years (20) | | a . Have you ever had a dental plate for your lower jaw? . How long has it been since you had any natural or false teeth to chew with in your lower jaw? a ]10-19 years s [120 or more years 1 TT Yes 2( No ® 1] Less than | year ® 2[ ] 1-4 years 3[ ]5-9 years a ]10-19 years s[ ]20 or more years ef ‘““Yes’ in 18b or |9b ask question 20; otherwise skip to instructions above question 2/. 20a. Do you usually wear your plate(s) while eating? a b. Do you usually wear your plate(s) when not eating? c. Do you usually use denture powder or cream to help keep your plate(s) in place? . Do you think you need a new plate or that the one(s) you have ve) refitting? 20a. @9 1] Yes ; 2[ No L bo @D) 1 (Yes | 2] No | c. I) 1[)Yes ] 2 | No d 1 @) 1[ No | i ‘ 2[] Yes, one ! 3[ |] Yes, both ! s[] OK ® [f ‘Yes’ to questions /8a and /9a, GO to question 32; otherwise ask: @9 1 [] Excellent your teeth? 21. How would you describe the condition of your TEETH — 1 excellent, good, fair, or poor? : 2] Good ! 3 [Fair : a[ | Poor ! 1 22. How would you describe the condition of your GUMS — 2. | i) 1 [[] Excellent excellent, good, fair, or poor? | 2] Good | ! 3) Fair ! 4[ |] Poor 1 23. How many times a day do you usually brush n. | I ! @ Times (1) First condition . . . oc v vv vine nennnnnnn (2) Second condition. .......... x 3 wrradies Bere (3) Third condition .......... J p TEETH — Continued 1@D) 1] Yes 24. Do you think that you ought to go to a dentist now 24. | 2[] No ? or very soon for a checkup? [J DK | 25. Do you now have an appointment to see a dentist? 25. y 1] Yes 2] No 26. Do you think you have any teeth that need filling? 26. 1] Yes 2] No ! 9 [DK 27a. Do you think you have any teeth that need to be pulled? 27a. | 1] Yes ! 2[J No | 2 ! s [7] wt (28) b. Do you think that all of them need to be pulled? b. @) [Yes | 2] No : | 28a. Have Jo Lu had your teeth cleaned by a dentist 28a. | @ 1] Yes or dental hygienist? : No (28 | 2] No (28¢) b. When was the last time they were cleaned? b.| @ 1 [] Less than | year ago | 2[] |=2 years ago : 3] 3-4 years ago | 4] 5 or more years ago 1 c. Do you think that your teeth need cleaning now ci @) 1] Yes by a dentist or dental hygienist? J 20] No i 9 [JDK d 29. Do you have a dentist you usually go to? 29. @ 10] Yes ] 2[] No i 30. How long has it been since you last saw a 30. | Months OR dentist about yourself? ) @) " 2 | ears (32) | o [] Less than | month | 77 [7] Never (32) 31. Do you go to a dentist AS OFTEN as once 31. | @ 1] Yes every year? ! 2] No i 32a. Do you have an illness which has recently cut 32. @ 1] Yes down your appetite? 2] No (33) b. What is the name of the illness? 33. Do you have difficulty in swallowing at least 3 days x per month? (Don't count the difficulty in swallowing i 10 Yes that goes with a cold, sore throat, or flu.) | 2] No 34. Have you ever had yellow jaundice (which made 34. | your skin or eyes turn yellow)? : @ 10] Yas il 2] No ee 35a. Have you ever had an abdominal operation for 35. | @ 1 [J Ulcers (Read list and mark all that apply) J 2] Gallstones ! 3 [] Hiatus hernia of the diaphragm | 4] Any other condition — Specify» | | [J None es 36a. In the past year have you stayed in a 36a. | @ 13 Yes hospital overnight or longer? ! 2 [J No (37) b. For what condition? bl D> DATA PREPARATION USE ONLY (1) First (2) Second (3) Third c. How long were you in the hospital? cv Weeks o[] Less than | week Weeks oT] Less than | week ® ® ©ced® — 2K 0] Less than | week 25 37a. Has a doctor ever told you 37a. | 37b. Do you still have it? |37c. How many that you had any of the f years ago did following conditions? 1 you first ! have it? ® If “Yes” to any of the following | conditions, ask 37b and 37c¢ for , those conditions. | i Yes No Yes No Dk I APBIIIS ¢ 5 5 5 hi 58 8 BU 65 66 C068 8 mas ! 0 27] 10d 3 [7] Ga) a 1 GOUY Lei Le 0 1 3 | GD) — I 1 = ani = ACEI wo. 5 3 5 oi 46% 4 S300 % 8 ook 0 8» 4 tom ! D) a! 2] J 3) s[) @) fie Chronic bronchitis or emphysema . . ..... 0 2) 1] $M 9) (a) pai | Tuberculosis .................... ! Oa 20 1 3] 9 Qo) | Rheumatic fever . ................. i M 2] 1] 3] oe] @s) — I ro semi mri srs ms i Srp ——————————p sr s———— I Heart murmur ............ LL... J @%) MM 2] 1] 3] s(] @s) er I Heart failure... ................ L@ 0 0 | 0 0) sl | @ | ; Heartattack .................... : Derg] | 1 Stroke . LL... | [Gre 2) A peptic, stomach, or duodenal ulcer. . . . . | J 2] I Recurrent or chronic enteritis. . ........ ! Od 2) 1 Colitis (spastic colon, | mucous Colitis). . + von vv nmi vs 0s aes ! O 2[C COSIones. + vows vn 3a 0 5 min 6 5 4 & 0 4 y M 2] | Hepatitis. ooo... Oo 20) | Chronic coughs iss sw sss vins fase | 3 2 | I PIOUIIBY, 1: 6 4 3 GE 2 25 5 508 Hin 5 minh 0 wom y @) J 2) I Low blood pressure . . .............. ! @ 0 2) 0 0 0 0 ® | Otherollergies « ov von uw uiinmmessns ! Polio or paralysis ................. | Hiatus hernia of the diaphragm. ........ 1 Malignant tumor or growth . ........... | Benign tumor, growth, or cyst (except fat or skin). . ............... J OJ 2) 1] 3] sO) 293) Trouble with blood not J clotting properly . ................. | Nervous breakdown. . .. ............. ! Froeturs of Hip + wove ovo viv vs nim so ven | ET WO os sy | @® —— Fracture of wrist s sive miv isp vmn vain | ot EY \[ 3] es) Go) Fracture of spine. ................. OO =O Oa) sr) | GR) —— Fracture of any other bone... ......... : 0 20) 0 sO os) | Ge — ANEMIA } (29 1] Yes 38a. Have you ever had anemia, sometimes called 38a. 2] No “low blood?" 9 [7] OK (39) b. How long ago did you first have it? b. (©) Years 00 [] Less than | year 99 [] Don't remember c. Did a doctor ever tell you that you had anemia? c. (9 1] Yes 2] No (39) d. Was the anemia caused by — (Read list) d. Yes No DK Poordiet............000ut Ceraaaaas 10 @ 10 ®@). 0 Childbirth .....covvvrvvirnnvvanannes * 2) * 2] = 2 Accidental loss of bloed . .. .............. 3] [J 1] Hiness + oivsimuvermmors swam sss ern «J «0 a] SUIGOTY uv sri E sa EE ee MES ee s(] s[]) s[] Any other cause — Specify 6] se] 6] e. Were you treated for this condition by a doctor? e. 1] Yes 2] No (39) f. Was the treatment you used a — (Read list and mark f. @ 1 [7] Better diet all that apply) 3 2] Iron pills 3] Iron shots 4] Vitamin pills 5] Vitamin shots 6 [] Transfusions 7 [_] Any other treatment — Specify 3 g- Are you still being treated for this condition? 9. @ 1] Yes 2] No Now | have some questions about HYPERTENSION @) 1] Yes (39) 39a. Have you EVER been told by a doctor that you had 39a. 2[] No high blood pressure? b. Another name for high blood pressure is hypertension. b. @) 1] Yes Have you EVER been told by a doctor that you No (47 had hypertension? 2] No (47) c. About how long ago were you FIRST told by a doctor & @ Months that you had (high blood pressure/hypertension)? @ Years 0 [] Less than | month 40. During the past 12 months about how many times have 40. you seen or talked to a doctor about your (high blood @) Times pressure/hypertension)? 0 [J] None 41. Has a doctor EVER advised you to lose weight 41. @ 1 [J Yes BECAUSE OF (HIGH BLOOD PRESSURE 200 No HYPERTENSION)? 420. Do you now use more salt, less salt, or about the same 42a. @ 1 [] More amount of salt since you learned you had (high blood 20] Less pressure/hypertension)? Sse 3 me b. Were you EVER advised by a docter, nurse b. 1] Yes or other medical person to use less salt? ’ 200 No 43a. Has a doctor EVER prescribed medicine for 430. (D) 1] Yes your (high blood pressure /hypertension)? 20 No (44) b. Are you now taking any medicine prescribed by a b. 1 Yes doctor for your (high fy pressure/hypertensign)? @ 3 = No (44) 3] No longer has high blood pressure (44) @®@ 1 [7] More than once a day 27] Once a day 3] Less than once a day c. How often are you supposed to take this c. medicine — more than once a day, ence a day, or less than once a day? d. How often do you take your medicine when d. @) 1 J All the time ou are supposed to ~ all the time I once In a while, or never? ! 2] Often 3] Once in a while 4] Never 8 [7] Other = Specify 5 28 HYPERTENSION — Continued 44. ABOUT how many Hogs during the past 12 months has 44. | 325 Days (high blood pressure /hypertension) kept you in bed all 1 ¥ or most of the day? ] o[ | None ® /f “No longer has high blood pressure’ in 43b, 4 GO to 45d; otherwise ask: | 45a. How often does your (high blood pressure/hypertension) 45a. 1] All the time bother you ~ all the time, often, once in a while, i 2] Often or never? ! i 3 ] Once in a while : a) Never (45¢) s[ | Other — Specify I b. When it does bother you, are you bothered a great b.! @27) 1] Great deal deal, some, or very little? i = 2[ |] Some 3 ] Very little a | Other — Specify » | eo m—, ® If “All the time’* in 450, GO to 46; otherwise ask: ! c. Do you still have (high blood pressure /hypertension)? ad 1] ] Yes (46) | 2[ No 5 JDK d. Is this condition completely cured or is it under control? d.! ) 1] Cured (47) | 2 ] Under control | 46. Can you tell when your blood pressure is high — 46. | 1] Yes that is, do you have any symptoms? | =5 | 2( J No 470. Has a doctor EVER talked to you about problems that 47a.! Gm) 1] Yes (48) can be caused by high blood pressure or hypertension? ! 211 No b. Has a nurse or other medical person EVER talked to b.! 6G») “y - you about problems that can be caused by high blood ' Ll. Yes pressure or hypertension? : 2[] No (48) | c. What type of medical person was this? c.| @) 1] Nurse i 2[ | Other — Specify » | | 48. ABOUT how long has it been since you LAST had your 48. o[ J Less than | month blood pressure taken? (339) Months (ED) — Years (51) 77] Never (51) 49. Were you told that your reading was high, low, normal, or were you not told? 2[] Low 3[ Normal a] Not told s[_] Other — Specify » | 1 50. During the past 12 months, how many times was your 50. | blood pressure taken? (Do not count times while y a patient in a hospital.) | G0) Times 51a. ABOUT how long has it been since jou had an 5la.| o[] Less than | year electrocardiogram, which involves placing wires | on the chest and arms? ! \ 6» Years | 77] Never — b. ABOUT how long has it been since you had a b o[ |] Less than | year chest X-ray? Years 77 [] Never b> Now, | have some questions about VISION. T | 52. Are you blind in one or both eyes? 52. y 1] Yes | 2[] No | T 53a. Do you now have any of the following conditions: 53a. | Go) 1 [7] Cataracts Cataracts, glaucoma, detached retina, or | = 2[] Glaucoma any other condition of the retina? ! 3 [7] Detached retina ) 4 [_] Other condition of retina y s [_] No condition 1 b. Do you now have any (other) trouble seeing in one b. ! Go 1] Yes or both eyes even when wearing eyeglasses? : 2] No 1 54a. Do you wear eyeglasses? 54a. | Go 1] Yes ! 2[] No b. Do you wear contact lenses? b. ! (D) 1] Yes @ If BOTH 54a and 54b are ‘No,’ enter B-2 in box J 2[J No in upper right corner and SKIP to Check Item I; | otherwise continue with question 55. ! 55. How often do you use your (eyeglasses/contact lenses), 55. | @D) 1 [J All of the time (Enter A-1 in box all of the time, most of the time, some of the time, | in upper right corner and GO to hardly ever, or never? ! Check Item I.) | 2] Most of the time i 3] Some of the time } a[] Hardly ever i s[] Never (Enter B-2 in box and i GO to Check Item I.) l T 56. Do you use your (eyeglasses/contact lenses) for reading 56. | (® 1] Yes —A and other close work? | 2[JNo-B 1 57. Do you use your (eyeglasses/contact lenses) for seeing 87. | Go) 1] Yes = 1 distant objects better? ! 2[JNo-2 ® If both 56 and 57 are ‘‘No’’ enter B-2 in the box and ask 58; otherwise record the letter and number from 56 and 57 in the box in upper right corner and GO to Check Item I. 58. Why do you wear (eyeglasses/contact lenses)? 1 > CHECK ITEM | 4 } ® If A-l, or A-2, or B-| is entered in upper right box, READ: ! These first questions are about how well you can see ! even when wearing eyeglasses or contact lenses. | (Read the phrase ‘‘When wearing eyeglasses/contact : lenses*® in each of the following questions.) | ® If B-2 READ: ! These first questions are about how well you can see. \ 59a. (When wearing eyeglasses/contact lenses) How much 59%. | G9 a A jor 8 ookle trouble do you have seeing with your LEFT eye — | 27] A little trouble (60) a lot of trouble, a little trouble, or no trouble at all? : 3] No trouble b. Are you blind in the left eye? b. | Go 1] Yes ' 2[] No 60a. (When wearing eyeglasses/contact lenses) How much 60a. ! A lot of troubl trouble do you have seeing with your RIGHT eye — : hi A oe ab & a lot of trouble, a little trouble, or no trouble at all? | (61) ! 3] No trouble | b. Are you blind in the right eye? b. | @s) 1] Yes y 2] No ® If ““Yes" in 59b and 60b, GO to question 62; otherwise ask: | (©) 1 [J A lot of trouble 61a. (When wearing eyeglasses/contact lenses) In terms of 6la. | 2] A little trouble (62) total vision, how much trouble do you have seeing — ) 3 [] No trouble (Check Item Il) a lot of trouble, a little trouble, or no trouble at all? | b. Are you blind? b. | @s) 1] Yes | 20M | 62a. About how long have you had trouble seeing? 62a. | (@) Months | i (@) Years } (Check Item 11) ! 1 [J Since birth ! @% 9 [J DK | | b. Has it been less than 3 months, or 3 months or more? b. | 1 [J Less than 3 months 1 1 2] 3 months or more 29 30 Pp CHECK ITEM II ® If A-l or B-| in upper right box on page 2, READ: The next questions are about how well you can see in recognizing a friend from different distances. (Read the phrase ‘When wearing eyeglasses/contact |enses’’ in each of the following questions.) eo If A-2 or B-2 in box, READ: The next questions are about how well you can see in recognizing a friend from different distances. | 63. (When wearing eyeglasses/contact lenses) Can you SEE 63. ! well enough to recognize a friend if you get close to . ! C J Yes his face? [ 2[ J No 64. (When wearing eyeglasses/contact lenses) Can you SEE 64. | - well enough to recognize a friend who is an arms ! 1C07es length away? y 2[ | No (Check Item Il) T 65. (When wearing eyeglasses/contact lenses) Can you SEE 65. well enough to recognize a friend across a room? : ! 0) Yes y 2[ | No (Check Item Ill) 66a. (When wearing eyeglasses/contact lenses) Can you SEE 66a. | 1] Yes well enough to recognize a friend across a street? ! 2] No (Check Item I11) . b. Do you have any problems seeing distant objects? b. 1] Yes ! 2[ ] No (Check Item Il) c. What types of problems do you have in seeing © distant objects? 1 > CHECK ITEM III « ! ® If A-1 or A-2 in the box, READ: | Now I'm going to ask about how well you can see things 1 that are near to you. Please answer these questions in ! terms of when you are wearing glasses. (Read the phrase | ‘‘When wearing eyeglasses/contact lenses*’ in each of the following questions where appropriate.) ® If B-] or B-2 in box, READ: Now I'm going to ask about how well you can see things ; that are near to you. ! CI¥ 67a. Do you read any newspapers, magazines, or books? 67a. ! , C ] re) b. (When wearing eyeglasses /contact lenses) Do you have b. | 1[ 1] Yes (68) any trouble at all seeing the print? | 2[ | No (70) c. Is this because you have trouble seeing? Ey 1] Yes 2[ ] No 68a. (When wearing eyeglasses /contact lenses) Can you SEE 68a. | 1] Yes (69) well enough to read ordinary newspaper print? 2 F1 No b. (When wearing eyeglasses /contact lenses) Can you b. 3 SEE well enough to recognize letters in ordinary | ! Lo Ney newspaper print? 2] No (69b) 69a. In order to (read/recognize) ordinary newspaper print, 69a. 1 [1] Yes (73) must you use a hand magnifying glass? | 27 1 No (70) b. Can you see well enough to read or recognize ordinary b. 1] Yes (71) newspaper print if you use a hand magnifying glass? d 2[ No (71) ef 67c is “Yes,” GO to 70b; otherwise ask: | 70a. Do you have any problem seeing ORDINARY NEWS- 70a. 1] Yes PAPER print (even when wearing eyeglasses)? 2[ No (73) b. What types of problems do you have in seeing the print? b. i i (73) 71. (When you are wearing eyeglasses/contact lenses) 71. Can you see large letters in a newspaper, such as : Gn 1] Yes (73) the headlines? 2[ J] No 72a. If you are in a room, can you see well enough to tell 72a. | @m) 1] Yes if a light is on or off? : 2 ] No (73) b. Can you see well enough to tell where the light is b. | mn) 1] Yes coming from? y 2] No fairly regularly? Years (77f) 77 [] Under one year 88 [_] Never smoked cigarettes regularly (78) 73. During the past 6 months, have you used any medicine, 73. | drugs, or pills internally for the following? (Include 1 any over-the-counter medicine or prescription drugs.) ! Regularly Occasionally No | Sleep problems or insomnia . .............. ! @n a 2] 3] I Headache. . . ....... iii ! @D) 10 2} 3) | OMErPOINS 5 «4 5 ww bw wii 4 # 30000% % & BREW » ) 10 203 3] | Upset stomach or indigestion. . ............ | @n 1 2] 3) 1 Wonk bomthus ¢ wovis 3 8 8 mie 5 0 ion 5 3 8 gown 4 1G) Od 2) OJ I Allergies. . ovo v viii iii ' Gn» 10 2] 3] OPES: 4 wove wo immo % 5 NDE © § § IW» # & Boe ¥ | ) 1] 2] 3) Lack of pep (except thyroid pills). .......... | 1] 2] 3] Convulsions. « + « wu ¢ 3 5 non 4» ¢ wrwiw « % www ¥ 10 2] 3] Skin conditions. « svv oa aiid dk MEK 88 LE | 10 2) Lim Fluid pills for water loss . ............... i 10 2) 3] | Weight loss (except fluid pills). ............ ' OJ 20] 3] | Infection (antibiotic or sulfa pills or shots only) . : 10d 2) 3s) | 74a. Are you on a special diet? 74a. 1 Yes i 2[] No (75) : I +. b. Is this diet — (Read list and mark all that apply) b. | (a 1] To lose weight i * 2 [CJ] For diabetes 3] For kidney failure y a[] For ulcers s[] For allergies | 6 [] For heart trouble or high ! blood pressure ! 1 [] For pregnancy | % 2[] For any other reason — Specify 7 I I | I c. Is this diet ~ (Read list and mark all that apply) c | a) 1] Low fat ' * 2] Low protein : 3] Low salt y a] Low carbohydrate / s(] Low calorie ! 6 [] Some other type — Specifyz 1 | I d. Was this diet ordered by a doctor? d | ® 1 Yes i 2] No 715. bn you sue! day, aside i nenetion, are you 75. | @ 1] Very active physically very active, moderately active, or | quite nective) ’ 2] Moderately active | 3 [J Quite inactive 76. ir ings you do for ecrsation, for example: Jee 76. | ® 1 [] Much exercise iking, dancing, and so fort 0 you get muc exercise, moderate exercise, or little or no exercise? 2] Moderate exercise | 3 [] Little or no exercise . These next questions are about the use of TOBACCO. : 77a. Have you smoked at least 100 cigarettes during your 77a. | ®) 17] Yes entire life? ) 2["] No (78) | b. Do you smoke cigarettes now? b. | ® 10] Yes ! 2] No (77d) | | c. On the average, about how many a day do you smoke? c. (99) Cigarettes per day (77e) d. How long has it been since you smoked cigarettes d. | @® I | | | I I ! 99 [] DK 31 32 all that apply) 77¢. On the average, about how many cigarettes a day te. | were you smoking 12 months ago? ! ™ Cigarettes per day : 88 (] Did not smoke 99 [] OK Le f. During the period when you were smoking the fo mest) about how many cigarettes a day did you ' D) Cigarettes per day usually smoke? ! | 99 [DK L 9. About how old were you when you first started 9 | smoking cigarettes fairly regularly? ! Years oid | 88 [_) Never smoked regularly | 99 [] DK L 1 78a. Have you smoked at least 50 cigars during 78a. | 1[] Yes your entire life? | 2] No (79) | b. Do you smoke cigars now? by | 1] Yes ) 2] No (78d) | 1 c. About how many cigars a day do you smoke? c | Cigars per day (78e) 1 ! (IF LESS THAN 1 PER DAY) | ! 88 [] 3 to 6 per week (78e) ! 99 [] Less than 3 per week d. About how long has it been since you smoked d. ! three or more cigars a week? ! Years (79) ! 77 [] Under | year 1 ! 88 [_] Never smoked 3 or more \ cigars a week (79) | 99 [DK I e. Yauive Mant 83s, shout how many cigars a day e. id you usually smoke? . Cigars per day 1 ; (IF LESS THAN 1 PER DAY) i 77 [] 3 to 6 per week i 88 [|] Less than 3 per week | 99 [] Did not smoke cigars | 79a. Have you smoked at least three packages of pipe 79%. | 1] Yes tobacco during your entire life? ) 2] No (80) b. Do you smoke a pipe now? b. 1 [] Yes | 2] No (79d) 1 I c. About how many pipesful of tobacco a day do you c. | ; usually smoke? ___Pipesful per day (79e) | I (IF LESS THAN 1 PER DAY) 1 ! 77] 3 to 6 per week (79e) ! 88 [ | Less than 3 per week | I i i k i Ning by Sow | 77 [_] Under | year \ 88 [| Never smoked 3 or more pipesful ) a week (80) | 99 [|] DK | e. Twelve months ago, about how many e | p pipesful a day did you smoke? / ipesul per day I | (IF LESS THAN 1 PER DAY) i ' | 77] 3 to 6 per week | 88 [| Less than 3 per week 99 [] Did not smoke a pipe 80. Do you presently use — (Read list and mark 80. @ 1 [_] Snuff | | 1 i | 2[] Chewing tobacco 3 (] Any other form of tobacco — Specify = [] None I 81. How important do you think it is for people to have a 81. ! © 1[] Very important regular physical check-up, very important, fairly 1 2[] Fairly important important, or hardly important at all? ! 4 3] Hardly important ; s[] DK 82. Is there ONE particular doctor or place you usually 82, ! go to when you are sick or when you need advice : @ 10 Yes about your health? ! 2] No (84) ¥ 83. Where do you go for this care or advice, to a clinic, 83. | @ 1 [] Private doctor's office hospital, doctor's office, or some other place? 2] Home If Hospital: Is this an outpatient clinic or the ! 3] Doctor's clinic emergency room? ! 4] Group practice If Clinic: Is this a hospital outpatient clinic, | s[] Hospital Outpatient Clinic a company clinic, or some other kind of clinic? y 6 [7] Hospital Emergency Room ) 7 [] Company or Industry Clinic | J 8 [] Other — Specify 3 | i 84. How long has it been since you last talked to any 84. | doctor about yourself? i @ —— Months OR i y @9 Years : o[] Less than | month ' 77] Never (Check Item IV) | T 85. Do you get check-ups from a doctor AS OFTEN 85. y @ 1] Yes as once every 2 years? | 20] No Pp CHECK ITEM IV «4 y Ask questions 86, 87, and 88 only once for each ) family. If already asked for this household, | mark (X) the box and end questions. O : 86a. Is any language other than English frequently spoken 86a. i @ 1] Yes here in this home? 20] No (87) 1 b. What language(s)? s.! Language(s) spoken I | | @) 87. Please look at this card ~ (Show Flashcard) 87. | Group Which of these income groups represents yours, your —='s | etc., total combined family income for the past 12 months; ! ml JE vw! that is, since a year ago? Include income ! 12] 8B (JF 20) from all sources such as wages, salaries, social security Cc G K or retirement benefits, help from relatives, rent from | ni] D vi] H 21 L property, and so forth. ! w(]) 18] 22] 88. May | see your box of table salt? 88. | 1] lodized | ! 27) Not iodized | 3] No box Comments ®6®ee 66 6 33 34 C. Water Usage Supplement Form HES-SC U.S. DEPARTMENT OF COMMERCE NOTICE - All information which SOCIAL AND ECONOMIC STATISTICS ADMINISTRATION would permit identification of the BUREAU OF THE CENSUS individual will be held strictly ACTING AS COLLECTING AGENT FOR THE confidential, will be used only by U.S. PUBLIC HEALTH SERVICE persons engaged in and for purposes of the survey, and will WATER USAGE SUPPLEMENT not be disclosed or released HEALTH EXAMINATION SURVEY others for any other purposes. a. PSU b. Segment number |[c. Serial number d. Person number e. NCHS Serial number READ — The kind of water a person drinks may affect his health. Each house has different water depending on such things as the pipes in the house and the service line to the house. | would like to ask you about your use of drinking water. e These pet four questions are about water and drinks that la. you make from a faucet at this house. Do NOT include drinks made from water at other locations. — glassias) la. About how many glasses of water do you drink here per day? 5 [Noms b. About how many glasses of cold drinks made from water b. such as powdered milk, Kool aide, Tang, frozen juice, glass(es) iced tea, whiskey with water, etc.,do you drink per day? 0 1 None bed c. About how many cups of coffee do you drink per day? < @ (03) cup(s) o[_] None d. About how many cups of other hot drinks such as tea, soup, d. etc.,do you drink per day? cup(s) o[ | None e. How long have you lived at this address? e. onthe) year(s) © Now we have some questions about drinks made from faucets 2a. at other locations such as work, restaurants, and so forth. glass(es) 2a. About how many glasses of water do you drink per day at 0.1 None these places? eet b. About how many glasses of cold drinks made from water such ~~ b. as powdered milk, Kool aide, Tang, frozen juice, iced tea, glass(es) whiskey with water, etc.,do you drink per day? o [] None c. About how many cups of coffee do you drink per day? €s DO @) cup(s) o[ |] None d. About how many cups of other hot drinks such as tea, soup, d. etc.,do you drink per day? cup(s) o[_] None If an entry of glasses or cups in item 2a through d ask questions e and f; otherwise go to item 3. e. What is the address of the place that you used most in the e. Address last month? (Include number, street, city, State, and ZIP code) ? f. f. How long have you used water at . . . ? @ —— Wy) year(s) © Now we have some questions about drinks made from 3a. commercial bottled water. a) glass(es) 3a. About how many glasses of commercial bottled water do you o [] None drink per day? b. About how many glasses of cold drinks made from commercial b. bottled water such as powdered milk, Kool aide, Tang, frozen Wy glass(es) juice, iced tea, whiskey with water, etc.,do you drink per day? o [J None c. About how many cups of coffee do you drink per day? c. cup(s) o [] None d. About how many cups of other hot drinks such as tea, soup, d. etc.,do you drink per day? @) cup(s) o [] None If an entry of glasses or cups in item 3a through d ask questions e, f, and g; otherwise to to item 4. e. What brand of bottled water do you use? e. Brand name f. What type of water is this (e.g., mineral, distilled, etc.)? f 1 [J Mineral 2] Distilled 3 [_] Other (Specify) 7 g. How long have you used this type of water? I's 3 y Y month(s) year(s) o The next questions are about drinks made from other sources 4a. such as a well, cistern, spring, etc., on the property but not @) glass(es) connected to the house. sJNone 4a. How many glasses of water do you drink per day? b. About how many glasses of cold drinks made from water such b. as powdered milk, Kool aide, Tang, frozen juice, iced tea, (2) glass(es) whiskey with water, etc.,do you drink per day? 0 [] None c. About how many cups of coffee do you drink per day? c. ®@ — cup(s) o [] None d. About how many cups of other hot drinks such as tea, soup, d. etc., do you drink per day? cup(s) o [J] None If an entry of glasses or cups in item 4a through d ask questions e and f; otherwise go to item 5. e. What type of source not connected to a faucet have you eo. (29) 1] Well used most in the last month (e.g., well, cistern, spring, etc.) 2] Cistern 3 [] Spring 4 [_] Other (Specify) ¥ f. Is this source located at home? { (20) 1 [7 Yes 2] No 35 36 CHECK ITEM | Ask questions 5 through 10 once for a household. If already asked for this [] household, mark (X) the box, end questions and go to Check Item Il. 5. Does your faucet water come from a public water system 5. 1 [J No faucet water in structure (10) or your own water supply? 25] Public water 3] Own supply (7) 6a. What is the name of the water company that supplies 6a. (128) Name of company your house? b. How long have you used water from this company? b. month(s) 0B semua . year(s) 7. What type of water line runs from your own water supply 7 a) 1 [] Black iron 7 [] Cement to the house? 2 ] Galvanized 8 [_] Other Mark (X) one box after reading list. 3[] Plastic (Specify) g 4[ Lead 5s [| Brass 9 [] Don’t know 6 [|] Copper 8a. Do you have a water softener or conditioner connected 8a. (32) 1 []Yes to the hot or cold water? 2 [No (9) 9 [ ] Don’t know (9) b. Which one? b. (3) [] Hot 2[ ]Coid 3[ ] Both 9 [_] Don’t know where connected c. What brand is it? i Brand name 9a. | would like to check the pipes where they are not 9a. 3 Kitchen painted or chrome-plated. May | check under the [J h kitchen sink? 2 [J At water heater 3 [|] Other location (Specify) ¥ (39) 4 [1 Not checked (Enter reason) 7 b. Mark (X) the type of pipe. b. (136) 1 [] Black iron 2] Galvanized 3 ] Plastic a |Lead 5 [ ] Brass 6 [ |] Copper 7 [] Other (Specify) ¥ 9 [] Don’t know 10. We will be analyzing the water available to people for 10. SAMPLE OBTAINED drinking or cooking in their homes. Mey | take a sample of ©) [") Household faucet the water from your kitchen faucet (wel cistern, spring, etc)? SAMPLE NOT OBTAINED 3] Use bottled water only 4 [_] Other (Specify) y 2 [] Source not connected to a faucet CHECK ITEM II READ THE FOLLOWING: Thank you very much for answering the questions about yourself. To determine more completely and precisely the health status and needs of the adult U.S. population, the U.S. Public Health Service also needs actual measurements and tests that can only be obtained by a health examina- tion. For this, a special examination center has been set up and examinations will be conducted on the dates and times indicated on the sheet | will give you. The examination that is given is very thorough and there are no procedures, such as an internal examination, that are in any way embarrassing. We very carefully select a sample of people to be representative of all parts of the population. You have been selected from many thousands of people similar to you with respect to your age, race,and sex, and the fact that we cannot substitute any other person for you makes your participa- tion in the examination very important. The examination is entirely free and you will receive a fee of $10.00 as an expression of appreciation for your help in this important survey and as compensation for your time and for any inconvenience. We provide transportation to and from the examination center or we reimburse you if you decide to drive your own car. None of the results from the examination or answers to the questions | have just asked, will ever be disclosed to anyone for any purpose without the individual's written consent; this is required by law. However, since a valuable examination is being given, most people do request that the examination results be sent to their physician. | would very much like to make an appointment for you at a time that is convenient. [J Appointment made [J] Appointment not made (Specify) 7 Notes 37 38 D. Health Care Needs Questionnaire HRA-11-6 (FORMERLY HSM-411-6) 8-75 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HEALTH RESOURCES ADMINISTRATION NATIONAL CENTER FOR HEALTH STATISTICS HEALTH AND NUTRITION EXAMINATION SURVEY HEALTH CARE NEEDS Form Approved O.M.B. No. 68-R 1184 ASSURANCE OF CONFIDENTIALITY All information which would permit identification of the individual will be held strictly confidential, will be used only by persons engaged in and for the purposes of the survey, and will not be disclosed or released to others for any other purposes (22 FR 1687). a. Name (Last, first, middle) b. Deck No. 181 c. Sample No. d. Segment No. e. Serial No. f. Column No. READ —- | need to ask you a number of questions about doctors, dentists, hospitals, and other people who might give you medical care, just how you use them, and what your opinion is on some questions about health care. Your answers will be kept confidential. i | > DOCTORS ' Less Week's 6 but 2 5 1. When was the last time you talked 1.1 Never a through Wrote less wirsigh or to a doctor about your own health . . ears Ly oe = ye rrs id ' ago ago ago iy ago ago I I I at a private doctor's office? . .. 1] 20) 3) al] 5s) 6] 70] I at a hospital outpatient clinic? . .. | 1] 2) 3] a) 5s) 6] 7] | at a city clinic? . ....... . | (003) 1 2] 3) a) s[) 6) 71 1 | at a clinicat work? . ......... 1 (00d) 1] 2} 3) a] s(]) 6) 70) | at another type clinic? . ..... 1] 2] 30] a] s(] 6] 7] | | = at a hospital emergency room? . . J 2] 3] a] s(] 6] 7] I ? ! a ot home? . ........ Crees & [J 2] 3] i 6") 6] 70) over the telephone? . . . . ... 10) 2) a] a] s[] 6) i) I in another way? — Specify I | 0 | 20 | sO | «sO | sO | sD | 70 if only one.) 2. What was the MAIN reason for your 2. last visit with a doctor? (Check ®|® 1 [7] A sickness or illness --What was the problem? 2] An injury-- What was the problem? 3] A follow-up visit 4] A regular checkup s [J] An injection 6 [|] For a prescription 7 [_] Some other reason this visit? 2 [_] Not completely satisfied 3 [] Dissatisfied 4 [_] No opinion 3a. For this last visit, how long was it 3a. ! 1 [O] Less than one day from the time you decided you should ! » . | 2[] 1-6 days see a doctor until you actually saw him: | | 3] | but less than 2 weeks | a[] 2-3 weeks s [] 1-2 months 6 [_] 3 months or more j 9 [_] Don’t remember b. Did you have an appointment to see him? b. | 1[] Yes — Ask ¢ | 2[JNo — SKIP to 4 1 c. How long was it from the time you made c Less than one da the appointment until you saw him? 0 1% Ay 9 4 I 3] |! but less than 2 weeks : a] 2-3 weeks s [J] |-2 months J 6 [_] 3 months or more 9 [_] Don't remember d. Was this time longer than you would d. | 1] Yes have liked? 2] No 9 [] Don’t remember 4. From what place did you leave to go 4. | @3 1 [] From home to the doctor? I \ 2 [_] From work ; 3] From some other place 1 o I 5. How did you get from there to the doctor? 5. ! 1 [] Walked 2] Bus , 3[] Own car : 4 [] Someone else's car s[_] Cab 6 [7] Ambulance | 7 [[] Other means 6. How long did it take to get there? 6. 1 [] Less than 15 minutes 2] 15-29 minutes 3] 30-59 minutes a [_] | hour or more 9 [_] Don’t remember 7a. At this last visit, about how mony 7a. ’ minutes did you hogs to wait before : being seen by the doctor? ——— MINULES I b. Do you think this wait was too long? b. | 1] Yes 2] No 8. How well satisfied were you with 8. 1 [7] Satisfied | | I | | I 1 39 40 9a. During the past 12 months, have you had a health problem which you would have liked to see a doctor about but did not for some reason? 9a. I I ® 1[)Yes — Ask b 2) No — SKIP to 10 I | b. What was the reason you did not see b.i a doctor? ; Yes No Lack of confidence in available ! BOOIOIS 45 526d cA BBE Raihain vn ous [1] 2) Didn't have time . . ................. | 1 [7] 2[] Would $100 MUCH. ns cu mms sss ss 508% | 1 20 cos v ! 4 J | Couldn't get an appointment. . . ......... 1) [0] Would have to travel too far... ......... | 1 [(O) 2) . ’ | Didn't have a way to get there . . ........ : 1 [7] 2] Was ofraid of finding out what : WOS WIOIZVG «vv ovmwmminma soo is inns | 1 [(] 2] | Didn't have anyone to care for | children or other family members . . . . . 1 [7] 2] I Other — Specify | 17] 2] | . 10a. When did you last have a general checkup 10. | 1[ J Never — SKIP to 13 or examination, not counting exams made 2[] Less than 6 months ago during a visit for an illness? i ' 5 | 5 ! 3[ ] 6-11 months ago / a[] | but less than 2 years ago s[ 12 years ago or more 9 [ ] Don't remember 11. Where did you get this general examination ? 11. 1 [_] Doctor's office 2 J] Hospital clinic 3] Another clinic | 4 ] Some other place — Specify 12. During this last general examinction, were 12. you given — a cardiogram? a blood pressure check? achest x-ray? ...... LL... LL... blood tests? . . .................... a urinalysis? vision tests? an internal examination (FEMALES ONLY)? . BEREERR®E® Yes No 1] 2[] 1] 2[] OJ 2(] 1 2] 1] 27] '[] 2] 1] 2] x2] 2 [] 1] 2] 8 (_] Not applicable 13a. When was the last time you received any shots, immunizations or vaccinations to prevent an illness, excluding shots for allergy? . Why did you get this shot? 13a. 1 [J Never — SKIP to |4 2] Less than 6 months ago 3[] 6-11 months ago a[] 1-2 years ago s[] 3-5 years ago 6 [] 6-9 years ago 7 [] 10 years ago or more 9 [] Don’t remember 4-H —— 1 [] Foreign travel 2 [_] During military service 3] Participation in community or work- sponsored immunization campaign (for example, polio or flu) a [_] Other — Specify 14a. Is there a particular doctor you see regularly or whom you ols to if something were bothering you? . If you couldn't see this doctor, is there some other particular ductor you would want to see if something were bothering you? 14a. ® 1[]Yes — Ask b 2[JNo — SKIP to IS 1] Yes 2] No 9 [] Don’t know 15. Except in on emergency, do you need to 15. ! have an appointment in order to see a | ! O Yes doctor? 2] No 1 16. When you go to a doctor, do you like the 16. | doctor to talk to you about your condition | 1) Talk : : 15, ad or do you like him just to treat it? 2 [7] Just treat I | T 17. Do the ducts you vsually see talk 17. 1048) 1] Yes to you about your condition? | 2] No 18. Do you try out home remedies or any 18. | a that you can get without a prescription ! ¥(] Yes, often before going to your doctor about a : 2[_] Yes, sometimes problem? J 3[]No | NOTES 41 42 > DENTIST 19. Do you have a dentist you it from the time you decided you needed or wanted to see a dentist until you actually saw him? 2] 1-6 days 3] | week but less than 2 weeks a] 2-3 weeks s[] |-2 months 6 [_] 3 months or more 9 [] Don’t remember i | 19. 1] Yes usually go to? ) 2] No | 1 20. When was the last time you 0. | | visited or talked with a | Less 6 Jog 2 5 dentist about yourself. . . .. Tiever i LL i through | months months 2 years years ago ago years ago ago ago | | ot & dentist's oificel . . 22 0ens | @) [J 2] 3] eo] s(] | sO) | at a hospital dental clinic? ] 1) 2[7] 3] a] sO) 6] | at a hospital emergency | clinic? sisisssiisans 1) 1 [0 2) a] a) 5s) 6) | | at another clinic (work, school, eC.) ieee iD) 1] 2) 3) a] 57 s3 | over the telephone? . . . ...... j 10) 2] 3) a] s(] 6 [J] i : . | in another way? — Specify ! 1] 2] 3] a] s[] 6] | | de | 21. What was the MAIN reason for 21. 1 [] Adjustment or repair of dental plate your last visit or talk with a | dentist at either his office or 2 [7] To have a dental plate made at a clinic? | 3] Toothache | a] Tooth pulled or other surgery : 5] Trouble with gums 6 [] Regular checkup visit | \ 7 [] For cleaning teeth ! 8 [_] To have teeth filled ) 9 [] For a prescription : o [_] Some other reason — Specify I 1 I | I | | + I 22. For this last visit, how | - 2. or this last visit, how long was 1 [] Less than one day I | | I | | | I I I | | | I | I | | | 23a. At the time of this last visit or 23a. | Yes — Ask 23b talk with a dentist did you have 4 tL] Yes $ 2] No — SKIP to 24 an oppointment? b. How long was it from the time b. 1 [J Less than one day you made the appointment until 2] 1-6 days you xaw him? 3] | week but less than 2 weeks 4] 2-3 weeks s[] 1-2 months 6 [_] 3 months or more 9 [_] Don’t remeinber c. Was this wait longer then you c. would have liked it? ©) 1] Yes 2] No 9 [C] Don’t remember 1 [] Walked 2 [] Bus or subway 3] Car a[] Cab s [_] Other means — Specify - 24. How did you get to the dentist's 24. office? 25. How long did it take to get there? 25. 1 [J] Less than 15 minutes 2] 15-29 minutes 3 [J] 30-59 minutes a] | hour or more 9 [] Don’t remember I A TE Ry a Sg 26a. At this last visit with o dentist, 26a. about how many minutes did you have to wait before being seen by the dentist? __ __ __ minutes be b. Do you think this wait was too long? b. | 1] Yes | 2 [J No de I 27. How well satisfied were you with this 7. | 1 [J Satisfied visit? 2 [] Not completely satisfied 3] Dissatisfied | a [J No opinion 28. Does your dentist or dental clinic call 28. 1[] Yes you or send you a note to remind you when your next regular checkup is due? 2] No 9 [J] Don’t know | I | | | | 29a. During the past 12 months, have you had Ma. | a dental problem which you would have I (069) Yes — Ask 29b liked to see a dentist cbout but you didn't tL Yes * I I I | I | | | see the dentist? 2] No — SKIP to 30 44 29b. Why didn’t you see him? 29b Yes No . ’ . | Didn't have time . . . .............. 1] 2) Would costtoo much . .:ccuwnuwsnnns ! (070) | © 10 2 Couldn't get an appointment - 9 ppointment . ........ ! 10) 20) Ww Itoo far ......... : ould have to travel too far 1] 2) Didn't have a way to get there . . . ..... | 1] 23 Didn't have anyone to care for I children or other family members . . . . ! 10) 2 I Some otherreason . . . ............. ! 1 [0] 2[] Pp HOSPITAL | I 1 Never — SKIP to 36 30. When was the last time you stayed in 30. ! L ° a hospital overnight or longer? 2 [| Less than | month ago ; 3] I-5 months ago J 4] 6-11 months ago J s [|] One year ago or more : 9 [_] Don’t remember 31. Was this stay in the hospital on account 3. of an emergency or was it planned in / ' [Planned advance? | 2 [_] Emergency A 32. What was theMAIN reason you went into 32. | ; ; the hospital that time? | = Sickness ar Wess 2 [J Injury J 3] Surgery J a [_] Child birth | — | o [1] Checker } SKIP to 34 : 6 [_] Some other reason — Specify and SKIP to 34 I 33a. When you went into the hospital for { this , just what was the problem? : ( | b ( i F b. How long was it from the time it was b. | 1 [_] Less than one day decided you needed to go into the | 2] 1-6 days hospital until you went in? ! but | han 2 " 3] | but less than 2 weeks 4 4] 2-3 weeks : 5s] 1-2 months | 6 [_] 3 months or more ¢ 9 [_] Don’t remember de 34a. What part of the doctor's bill did you 34a. 1 [C] None — SKIP to 35 or your family have to pay out of your J L han half own pocket for the treatment the doctor | 2] Less than ha gave you while you were in the hospital? J 3 [_) More than half, but not all | al] All J 9 [] Don’t know — SKIP to 35 b. Did you get any of this money back b.! from your health insurance? ao Yen J 350. What part of this hospital 35a. bill did you or your family have to pay out of your own pocket? . Did you get any of this money b. back from your health insurance? 1 [7] None — SKIP to 3 2] Less than half 3] More than half, but not all a] Al 9 [_] Don’t know — SKIP to 36 1[J Yes 2] No 3a. When you see a doctor at his 36a. office or at a clinic, what part of the cost do you or your family usually have to pay out of your own pocket? . Do you get any of this money b. back from your health insurance? 1 [_] Never been to a doctor — SKIP to 37 2] None — SKIP to 37 3] Less than half a [J More than half, but not all s[] All 9 [] Don’t know — SKIP to 37 1[J Yes 2] No Ia. Whenever you see a dentist Ia. at either his office or at a clinic, what part of the cost do you or your family have to pay out of your own packet? . Do you get any of this money b. back from your health insurance? 1 [] Never been to a dentist — SKIP to 38 2] None — SKIP to 38 3[] Less than half a [|More than half, but not all s[] All 9 [_] Don’t know — SKIP to 38 1[JYes 2] No . What part of the cost of drugs 38a. and medicines prescribed by your doctor do you pay out of your own pocket? . Do you get any of this money b. back from your health insurance? 1 [C] No drugs or medicines ever prescribed — SKIP to 39 2] None — SKIP to 39 3[] Less than half 4 [_] More than half, but not all s[] All 9 [_] Don’t know — SKIP to 39 ) 1[] Yes : 2] No Do you have insurance ot 39. coverage for medical care under . . . . Medicare (for elderly)? ....... Private medical insurance? . . ... Insurance through your place of work? Retired military privileges?. . . Veterans medical care? ....... Some other govemment assistance program? — Specify Some other way? ............ 39b. What port of your medical bills does it pay? ) Less More than Don't know | | | | | ) Yes No than half but All | | | half not all oe = @ 0 0 @ 0 0 @ 0 0 @) 0 2 @ 0 0 1] 2] 3) 1 2] 3] OJ 2] Ln 10 2] 3] 1 2] 3) a 2] s(d 0 2(] 3] BEREBRE OO 0 ® OJ 2] sd s 5s) s os] os [7] a [J oJ E. General Well-Being Questionnaire HRA-11-7 (Formerly HSM-411-7) Form Approved /-74 O.M.B. No. 68-R1184 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE ASSURANCE OF CONFIDENTIALITY HET a HEAL TH SERN ICE Tio All information which would permit N identificat f the indivi | I NATIONAL CENTER FOR HEALTH STATISTICS Gh i mls She Jndivioual wil . HEALTH EXAMINATION SURVEY : used only by persons engaged in and for the purposes of the survey, GENERAL WELL-BEING oa le) (22 FR 1687). a. Name (Last, first, middle) b. Deck No. |c. Sample No. d. Sex e. Age 1] Male VY | cs ioe we om 2[ |] Female — READ — This section of the examination contains questions about how you feel and how things have been going with you. For each question, mark (X) the answer which best applies to.you. 1] In excellent spirits 2] In very good spirits 3[] In good spirits mostly 1. How have you been feeling in general? (DURING 1. THE PAST MONTH) a] 1 have been up and down in spirits a lot 5s] In low spirits mostly 6] In very low spirits 1 [_] Extremely so -- to the point where | could not work or take care of things 2] Very much so 2. Have you been bothered by nervousness or your 2. ‘‘nerves’’? (DURING THE PAST MONTH) a] Some -- enough to bother me s[] Alittle 6 [| Not at all 1 [] Yes, definitely so 2[] Yes, for the most part 3] Generally so a[ | Not too well s[ |] No, and | am somewhat disturbed 3. Have you been in firm control of your behavior, 3. thoughts, emotions OR feelings? (DURING THE PAST MONTH) I | | I | | | | I | I I I I | I | I | I I 3] Quite a bit I | | | ! I | T I | I I | | | | | I ! ; 6 | No, and | am very disturbed I 1 [] Extremely so -- to the point that | have just about given up 2] Very much so 3[ ] Quite a bit a] Some - - enough to bother me s[] A little bit 6] Not at all 4. Have you felt so sad, discouraged, hopeless, or 4. had so many problems that you wondered if anything was worthwhile? (DURING THE PAST MONTH) strain, stress, or pressure? (DURING THE PAST or stand MONTH 2[_] Yes -- quite a bit of pressure 3[ ] Yes -- some - more than usual 4] Yes -- some - but about usual s[_] Yes - alittle | | I | I | | | | | | | | T 5. Have you been under or felt you were under any 5. J 1] Yes -- almost more than | could bear | | I | | | | I | | i 6 [_] Not at all | | 6. How happy, satisfied, or pleased have you been with your personal life? (DURING THE PAST MONTH) 1 [_] Extremely happy — could not have been more satisfied or pleased 2] Very happy 3] Fairly happy 4] Satisfied -- pleased 5s [_] Somewhat dissatisfied 6 [] Very dissatisfied . Have you had any reason to wonder if you were losing your mind, or losing control over the way you act, talk, think, feel, or of your memory? (DURING THE PAST MONTH) eS te: ns: 1 [J] Not at all 2[] Only alittle 3[] Some -- but not enough to be concerned or worried about 4] Some and | have been a little concerned s[_] Some and | am quite concerned 6 [_] Yes, very much so and | am very concerned Have you been anxious, worried, or upset? (DURING THE PAST MONTH) 1 [_] Extremely so -- to the point of being sick or almost sick 2] Very much so 3] Quite a bit 4] Some -- enough to bother me s[_] A little bit 6 [_] Not at all Have you been waking up fresh and rested? (DURING THE PAST MONTH) 9. 1 [] Every day 2] Most every day 3 [] Fairly often a] Less than half the time s [_] Rarely 6 [_] None of the time 10. Have you been bothered by any illness, bodily disorder, pains, or fears about your health? (DURING THE PAST MONTH) 10. 1 [] All the time 2 [] Most of the time 3] A good bit of the time 4] Some of the time s [J] A little of the time 6 [_] None of the time . Has your daily life been full of things that were interesting to you? (DURING THE PAST MONTH) 11. 1 [_] All the time 2 [] Most of the time 3] A good bit of the time a] Some of the time s [] A little of the time 6 [_] None of the time 12. Have you felt down-hearted and blue? THE PAST MONTH) (DURING 12. | | | I | | | | i | I I | T I | | I I I | 1 I | I | 4 | | | | I I | | | | | | | -- I | | | | | I | | I | I | | | 1 [J All of the time 2 [J] Most of the time 3] A good bit of the time a [_] Some of the time s [_] A little of the time 6 [_] None of the time 47 48 13. Have you been feeling emotionally stable 13. | 1 [] All of the time and sure of yourself? (DURING THE PAST 2 [J Most of the time MONTH) 3 [] A good bit of the time I 4] Some of the time s[_] A little of the time 6 [_] None of the time | | 14. Have you felt tired, worn out, used-up, or 14. | 1 [CJ All of the time exhausted? (DURING THE PAST MONTH) 2 [] Most of the time 3[_] A good bit of the time J a] Some of the time s[_] A little of the time 6 [_] None of the time For each of the four scales below, note that the | words at each end of the 0 to 10 scale describe opposite feelings. Circle any number along the | bar which seems closest to how you have gen- erally felt DURING THE PAST MONTH. | | 15. How concerned or worried about your HEALTH 15. | @3 0 1 2 3 4 5s 6 7 8 9 1 have you been? (DURING THE PAST MONTH) | @ 0 | I OO Not Very | concerned concerned at all 1 | 16. How RELAXED or TENSE have you been? 16. | 0 1 2 3 4 5 6 7 8 9 10 (DURING THE PAST MONTH) I | | | I I ' Very Very | relaxed tense | ' - 17. How much ENERGY, PEP, VITALITY have 7. | o 1 2 3 4 5 & 7 8 9 10 you felt? (DURING THE PAST MONTH) | I ; No energy Very | AT ALL, ENERGETIC, | listless dynamic I 18. How DEPRESSED or CHEERFUL have 18. 0 1 2 3 4 5s 4% 7 8 9 10 have you been? (DURING THE PAST MONTH) | | | Very Very depressed cheerful 19. Have you had severe enough personal, 19. 1 [] Yes, and | did seek professional help emotional, behavior, or mental problems that you felt you needed help DURING THE PAST YEAR? | | | | | | | | | | i | | | | | | | | | I I | | | | | I | 2] Yes, but | did not seek professional help 3] | have had (or have now) severe personal problems, but have not felt | needed professional help a[ | have had very few personal problems of any serious concern s[] | have not been bothered at all by personal problems during the past year at a mental hospital, a mental health ward of a hospital, or a mental health clinic, for any personal, emotional, behavior, or mental problem. 20. Have you ever felt that you were going to 20. 1 [] Yes -- during the past year have, or were close to having, a nervous -. breakdown? 2[] Yes -- more than a year ago 3[] No 21. Have you ever had a nervous 2. 1 [] Yes -- during the past year breakdown? 2[] Yes -- more than a year ago 3] No 22. Have you ever been a patient (or outpatient) 22. 1[] Yes -- during the past year 3] No or psychoanalyst about any personal, emotional, behavior, or mental problem concerning yourself? . Have you ever seen a psychiatrist, psychologist, 23. 1[] Yes -- during the past year 2[] Yes -- more than a year ago 3[J No 24. Have you talked with or had any connection with any of the following about some personal, emotional, behavior, mental problem, worries, or ‘‘nerves’’ CONCERNING YOURSELF DURING THE PAST YEAR? a. Regular medical doctor (except for definite physical conditions or routine check-ups) . . . ...... b. Brain or nerve specialist ............. c. Nurse (except for routine medical conditions) . . ... iii d. Lawyer (except for routine legal services) . ........ iii e. Police ( except for simple traffic violations) . ................. f. Clergyman, minister, priest, rabbi, etc. . . oii iii ee g. Marriage Counselor . ......... WTR. AEE h. Social Worker . . . .. civ iiiin.. i. Other formal assistance: . . ............ 24a. i I I I | | 1 | I | | I I | | 1 | | | 2[] Yes -- more than a year ago | | | T | | | | | l | | | | I | | | | | | | | (020) 1 [0] Yes 2] No A @ Oves 2 No 1 @ ves 2 No | @) 1 OO) ves 2] No '@ +O ves 2] No | @) 1 [0] Yes 2] No T@) 1 ves 2] No ©) 1 [J Yes 2] No 1 [] Yes — What kind? 2] No 25. Do you discuss your problems with any members 25. of your family or friends? 2] Yes - and it helps some - 3[] Yes - but it does not help at all a] No - | do not have anyone | can talk with about my problems 5s [_] No - no one cares to hear about my problems 6 [J No - | do not care to talk about my problems with anyone 7 [] No - | do not have any problems I I | r | I | I | | | 1 [J Yes - and it helps a lot I | I I I I | | | | | | | | I | I 49 50 Circle the number for each statement which best describes how often you felt or behaved this way—DURING THE PAST WEEK. Rarely or Occasionally None of Some or a ora Most or the Time Little of Moderate All of the Time Amount of the Time (Less than Time 1 Day) (1-2 Days) (3-4 Days) (5-7 Days) DURING THE PAST WEEK: 26. | was bothered by Pings that sally don't bother me . w v v ® 3 0 1 2 3 27. | did not feel like Sating; r my SpPeiieN was poor 0 1 2 3 28. | felt that | could not shake off the blues even with help from my family or friends 0 1 2 3 29. | felt that | was just as good as other people 0 1 2 3 30. | had trouble kes ping my mind on what | was doing : 0 1 2 3 31. | felt depressed. 0 1 2 3 32. | felt that everything | did was an effort . 0 1 2 3 33. | felt hopeful about the future 0 1 2 3 34. | thought my life had been a failure 0 1 2 3 35. | felt fearful . 0 1 2 3 36. My sleep was restless 0 1 2 3 37. | was happy . 0 1 2 3 38. | talked less than usual 0 1 2 3 39. | felt lonely . 0 1 2 3 40. People were unfriendly 0 1 2 3 41. | enjoyed life 0 1 2 3 42. | had crying spells 0 1 2 3 43. | felt sad . 0 1 2 3 44. | felt that people disliked me 0 1 2 3 45. | could not get “‘going” 0 1 2 3 | 46. Filled out by: 10 Examinee 2 O Interviewer 3 0 Mixed 1 Form Approved HRA-11-7A O.M.B. No. 68-R118 12/74 EXAMINER OBSERVATION SHEET SL Circle the number for the most appropriate observation for cach alphabet set) 47. A. Test qualifications NAME: Last, First, Middle 1. Refused at least one item 2. Couldn’t comprehend at least one item 3. Simple error - missed item, skipped page, etc. 4, Time called, page missing, other non-examince factor 5. Feel this is a poor quality record of questionable value (other than above) 6. Other (describe) *7. None - record complete, no qualifications SAMPLE NO. SEX M F B. Reasons for not obtaining full, acceptable GWB (assessment limitations) . Lack of interviewers AGE: . Lack of time 5 . Examinee failed to return to complete exam ’ Examinee too ill, drunk, etc. Foregin language barrier COmImenLs: Seemed to be mentally retarded GWB examiner number (If no examiner number, leave blank) . Mental functioning or verbal comprehension too limited (o/t 5, 6) . Confused mental state, senile, etc. . Too emotionally disturbed or upset . Refused, non-cooperative, “difficult” . Other (describe) . None: obtained full, acceptable GWB — 19. Technician Observation — — * ro C. Indications of current problems from examinee C. 1. Direct reference to a current psychologic problems, i.e., under treatment for “nerves”, taking tranquilizers, sedatives, sleeping pills, memory loss, delusions, senile. brain damage, retarded 1. 2. Death of someone mentioned as negative affect or distressing “ 3. Distressing or limiting medical problem or condition mentioned 3. 4. Medical or psychologic problem of someone else mentioned +. 5. Reference to problems of living, i.e., money, drug use or reaction, alcohol, limited physical movement, lonely, unhappy, job loss, unhappy love/sex condition, problems with children or spouse, etc. 5. 6. Reference to problems of other family members, close friends, close associates 6. 7. More than 2 year history mentioned for questions 20-23 7. 8. Other (describe) 8. *Qa, No apparent problems *9, D. Interviewer impression of subjective distress or state (Any personal, situation, D. or condition mentioned or behavior, appearance, suggesting well being - distress) 0. Mentally or emotionally disturbed 0. 1. Severely distressed 1. 2. Moderately distressed 9. 3. Mild distress 3. 4. Some problems but apparently coping well or not distressed 4. Comments: 5. Overly euphoric, hyperactive, or “pushing” 5. 6. Highly restrained, tense, apprehensive, uncertain g. 7. Other (describe) 7. *8. Mild positive affect (feeling tone or state) 8. 9. Strong positive affect 9. E. Interviewer impression of comprehension of task (filling-out GWB) E 0. Could not do task (do not consider negative refusal) 0. 1. Comprehension low 1 2. Comprehension questionable 0 3. Translator used or foreign language noted 5 4. Literacy level seemed low 4. 5. Dialect or non-mainstream American-English 5. 6. Mental processes seemed slow, uncertain 6. 7. Speech slurred or hardly audible-difficult to understand 7. 8. Some other problem (describe) 8. i 9. No apparent limitations *9. 50. Technician’s Examiner No. F. Supplement A—Arthritis HRA-11 2 (FORMERLY HSM 411-2) 5 Form Approved bar O.M.B. No. 68 KI I84 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE ASSURANCE OF CONFIDENTIALITY PUBLIC HEALTH SERVICE All information which would permit HEALTH RESOURCES ADMINISTRATION identification of the individual will N FOR HEALTH STATISTICS be held strictly confidential, will be NATIONAL CENTER FC used only by persons engaged an HEAL TIHTAND NUTRITION EXAMINATION SURVEY and tor the purposes of the survey, and will not bes disclosed or released SUPPLEMENT A - ARTHRITIS te elie dr any other puree (22 FR Is8/). ‘ w frst, imiadie eck No. ample No. Name (Last, first ddle) Deck N Sample N READ — Earlier you mentioned having had either pain in a joint or in the back or neck, swelling of a joint, or morning stiffness in the joints or muscles. Here are some additional questions about it. ¥ la. Have you had pain in either the back or neck la. ' “]Yes — Ask b on most days for at least one month? 2] No — SKIP to 2a b. Has this pain in the back or neck been b. tJYes present on any one occasion for at least ; 2 [J No six weeks? c. Where is the pain usually located? c. Yes No ET TNT RE FF rT (003) y 59 2] Upperback « o.oo ssi ismmanssssesomn (009) 3 - A Mid-back. ......... (003) 3 2 Lower Boek ov. vo 2 4 i vv imme nner ee 1 2] . When you have this pain, where is it most intense? d. Yes Neck . (007) ' [J 2 No OJ Upperbaek , . . cus os iis smmmman ess 008) '[ J] 2 [7 Ol 0 a. Mid-back . . 009) ' [J 2 Lower back . ..... . . ... . (010) 1 2 owe ke ww ® Ee 010 ] 2 e. Is the pain present when you are resting e. aD [Yes at night? Tr 2[JNo f. When you have the pain, does it awaken {: ©) tJ Ye: you from sleep at night? 2] No g. Does the pain in the back ever seem g. (013) 1[JVYes to spread? - 2[J No 3[] Not applicable, no pain in back h. Where does it spread to? h. Yes No To the back of the right leg . ... . .... . . 014 21 J To the back of the left leg . .......... . . 0s) [J 2 To the back of both legs . . ........ .. . | [J 2 [J To the top of the head . . . . .... ... .. . . | 1 [7] 2] J 2] To the sides of the body .. . ......... .. . 018) Item | (Continued) Has pain in the neck ever seemed to spread? Where does it spread to? To the top and back of the head. . . . . .. To either shoulderarea . . .......... Tothe arms or hands. . . ........... Other — Specify Is your back or neck pain made worse — by coughing, sneezing, or deep breathing? . . . with bending or twisting motion? . . .... after prolonged activity? .. ......... after prolonged sitting? . . .......... after prolonged standing? . . ......... How old were you when you first experienced this recurring back or neck pain? . When was the last time you had this pain? What is the longest episode of back or neck pain you have ever had? . Does this back or neck pain occur more frequently now than it used to occur? Have you ever had a sprained back due to some type of physical activity? Have you ever had a of the neck? ‘whiplash’’ injury 1[J Yes 2 [J No 3] Not applicable, no pain in neck ~ S @®O®® Yes No 1] 2] 121 2] 3d Ly 13 (J Yes No a 20 a 2d a 20 a 20 1d 20 BOAO ® 1 [J Less than 20 years old 2[] 20 — 29 years old 3 (130 — 39 years old 4] 40 — 49 years old 5s [] 50 — 59 years old 6 [_] 60 years old or older ® 1 [J Now 2 [1 Less than | year ago but not now 3[J | — 2 years ago a[]3 — 5years ago 5s [] 6 years ago or more 1 [J Less than one month 2] One but less than two months 3[]2 - 3 months a[_]4 - 5 months [J 6 months or more 9 [J Don't remember 1] Yes 2 [J No 1[] Yes 2] No 1[] Yes 2[] No 53 54 Ir. Have you ever had a ruptured disc in either I. 1 [J Yes —- Ask s your back or neck? : 2 [No - SKIP tov I s. At what age? LO (030) __ __ years i t. Were you in traction? fo 1 [J Yes | 2 [] No heeeninnenee NO u. Was surgery necessary? v. | 1 [Yes ; 2 [No — a Seer EO pr v. Have you ever stayed overnight in a hospital vo | + [J Yes for back or neck pain? ! 2 [J No 2a. Have you had pain in or around eithe: hip joint 2a. | + [Yes — Ask b (including the buttock, groin, and side of the ! BN upper thigh) on most days for at least one . 2 [IN ~-3KIF 1 30 month? L— b. Has this pain in the hip area been present on b. | 1 [Yes any one occasion for at least six weeks? | 2 [No — c. Where did you first notice it? c! 1 [J Left hip ; 2 [] Right hip 3 [_] Both hips d. In the hip area, where is the pain usually d. | most intense? Yes No Right buttock . . . ...... viii J VO 2 [7] Leff buttock wu mmsmnss ss smmummmmuis » : yO 2] | Both buttocks. «vv vei viii | y [0 2) | Right groin ..... ARERR EE SRE : [OO 2] I Loft groin s cv svn mmnrs ss snmwmmns vv [O) 2) | Both groins ..... 2 000 258 50% C(0a8) 2] I Side of right thigh ................. | [OO] 2 | Side of left thigh. . . . . GI RERMEAEELS & | I 2] Sides of both upper thighs. . ........... v [] 2] | Other — Specify ) of 2) e. Frem the hip, has the pain tended to spread to — e. Yes No the inside of your leg?. . ............. : ' [) : [J the front of your leg? ............... 1D) [J 2] the outside of your leg? . ............. C05) 0 [] 27 the back of your leg? ............... ! | 2] f. Have you had pain in or around the hip when fo | 1 [Yes either coughing or sneezing? 2 [I g. Yhen this hip pain is present, does it g. 1 Yes hurt at rest as well as when moving? 2 [No 2h. How old were you when you first 2h. i 1 [J Less than 20 years old experienced this recurring pain | _ a Id in the hip? 2128-29 years 0 : 3) 30 — 39 years old ; a] 40 — 49 years old ) 5s [] 50 — 59 years old J 6 [_] 60 years old or older i. When was the last time you had the pain? pal 1 [] Now 2] Less than | year ago but not now | 3[] | — 2 years ago a[_]3 — 5years ago 5s [_] 6 years ago or more i. What is the longest episode of hip pain is | 1 [] Less than one month you have ever had? 2] One but less than 2 months 3[]2 - 3 months 4[_]4 - 5 months : 5 [_] 6 months or more J 9 [] Don’t remember k. Have you ever had a fractured hip? ks } 1 [J Yes — Ask | 2[JNo — SKIP to p I. Which hip was broken? be | 1 [J Right 2] Left 3[] Both | m. How old were you when it happened? m. | 064) _ — Years r n. Was the hip in traction? n. | 1[J Yes 2] No - o. Was there surgery? o. 1] Yes 2] No 1 p. Have you ever had a dislocated hip? poi 1[]Yes — Ask g | 2) No — SKIP to 3a ( q. Which hip was dislocated? q. 068) 1 |] Right 2 [7] Left ; 3] Both | | r. How old were you when it happened? ro _ __ Years s. Was the hip in traction? s. © (070) 1 Yes @) 0 | 2] No t. Was there surgery? % | 1] Yes 2[ No 3a. Have you had pain in or around the knee 3a. | 1[JYes — Ask b (including the back of the knee) on most ! 2M] No — SKIP to 4a days for at least one month? | amt b. Has this pain in the knee area been present b. | 1 [J Yes on any one occasion for at least six weeks? 2] No | 55 3c. In which knee did you first have it? How old were you when you first experienced recurring pain in the knee? When this knee pain is present, where is it most intense? Right knee Left knee Both knees Behind the right knee Behind the left knee Behind both knees . When this knee pain is present, does it hurt at rest as well as when moving? When this knee pain is present, is there also swelling of the knee joint? When this pain is present, have you every had "locking" of the knee? Has either knee ever ‘‘given way'' under you? Which knee? When was the last time you had this knee pain? What was the longest episode of knee pain you have ever had? Have you ever had a fractured knee? Which knee? T i. 1 [] Left knee ! 2 [] Right knee | 3 [_] Both knees | 9 [] Don't remember d. 1 [] Less than 20 years old } 2 [120-29 years old 3 [130-39 years old | a [] 40-49 years old 5 [] 50-59 years old 6 [160 years old or older e. Yes No | & Bw 2 “en v 2 [J I ee I | Oe . ie 1 [J 2 [J I r “ns 1 J 2 7] SC I f. | 1 [J Yes ; 2 [No 9 v [J Yes | 2 [J No h. 1 [Yes | 2 7] No io ©) 1 [Yes — Ask 2 [No — SKIP to k is 086 1 [] Right 2 TT Left 3 7 Both k. 1 Now 2 "1 Less than | year ago but not now 3 [11-2 years ago a [13-5 years ago s 7 6 years ago or more I. 088 1 [1 Less than one month 2 71 0ne but less than 2 months 3] 2-3 months 4 714-5 months 5 16 months or more 9 [] Don't remember m. 089 1 Yes — Ask n 2 71 No —SKIP too n. 1 7] Right 2 Len 3 [7] Both T 30. Have you ever had a severe twisting of 3o. | 1] Yes — Ask p either knee with resultant sprain or swelling | 2[ No — SKIP to q lasting more than two weeks? y | ; p. Which knee? Pe | 1 [7] Right 2] Left I 3 [| Both = q. Have you ever had any other knee injury? q. | 1] Yes — Ask r 2] No — SKIP to 4a | r. Which knee? r | 1 [] Right 2] Left 3[] Both 4a. Have you ever had hip, knee, or back 4o. | 1) Yes — Ask b disease treated by an operation? 2] No — SKIP to 5a | | . ' b. Which joint? b. : + [J Hip a] Hip and knee I 2 [] Knee s [_] Back and knee I 3] Back 6 [J Hip and back I 7 ALL IF HIP: | Ul (1) Which hip? | 1 [J Right 2] Left Both IF KNEE: 3] (2) Which knee? 2 | 1 [7] Right 2] Left : 3] Both c. What was the operation or procedure? r Specify : 5a. Have you had pain or aching in any joint 5a. ! 1[]Yes — Ask band c other than the hip, back, or knee on most | 2] No — SKIP to 6a days for at least six weeks? y ich joi inful? | Sc. If “Yes,” — Which? b. Which joints were painful? .& ¢ ; — ce If es, ic | Yes No Right Left Both Fingers: cus s:cromummmass sss smano 10 2) TO 20 1d Wrist - (02) OJ 2] OJ 2030 3(™ ELBOW. + «ove eee Co) J 20 [OJ 20 3 Shoulder . «vv vee (oe) O20 yO 200 3 | Ankle. . .. (108) [J 2] OJ 23 sO I Foote usiwmus s 5 1 sR MBE HRI 8 ¥ 2M E0 [J 2] am a 200 J 6a. Have you ever had any swelling of joints 6a. (112) 1 )Yes — Askb with pain present when the joint was touched I 2 [J No — SKIP to 7a on most days for at least one month? b. Has this swelling been present on any one b. Mm) 1] Yes occasion for at least six weeks? 2 No | 57 58 i 6c. Which joints are usually involved whenever 6¢c.&d. | 6d. If “Yes. — Which? you have this swelling and tenderness on ! ¢ ’ eh touching? | Yes No Right Left Both I PINgers. oc uss: 5523 inGHETLRS 2 4 8 dimmu 1 2 10 21 3 ingers : Od Od my ed OO | Wrists. . LL (ne) OJ 20 (7) 1 20 s™ I Blows. ooo iiiimminiossssmmmnnns ] (118) 10 27 9) [OJ 2] 3] I Shoulders . ........................ : (2) Od 20 120 + 2] 3] | | Hips. © oe C2) OO 2] ® OO 20 sO I Knees ........«covewsssssnamanmsss 0 20 (29) J 23 a | Ankles : . : ¢ 55 bmn one nem mms n PQ) vO 2 (27) OJ 20 3 I Feet . LL OO 20 1 20 3@Q | r be. How old were you when you first experienced e. | 1 [J] Less than 20 years old this swelling of the joints? | 2[]20 - 29 years old | 3] 30 — 39 years old \ a []40 — 49 years old | 5 []50 — 59 years old 6 [160 years old or older [- f. When was the last time you had this? f.! @D) 1 [] Now 2 _1l.ess than | year ago but not now 3] I — 2 years ago ; a ]3- Syears ago 5 [16 years ago or mote 7a. Have you had stiffness in your joints and 7a. 132) '[ Yes — Ask b muscles when first getting out of bed in | 27 No — SKIP io 8a the morning on most mornings for ot least = ’ ) one month? b. Has this morning stiffness been present on bh. (33) 1 Yes any one occasion for at least six weeks? I — c. Which joints are usually involved whenever c.&d. i . ; you have this morning stiffness? 76, if “Yes.” ~ Which? Yes No Right left Both Fingers... (130) [2 ED) = 2 3] Wrists... (136) iC 2 (137) 13 2 ad BHBOWS.. + 3 5 5 4 5 3 55 tthe rn en mn uD) 1 2 (139) OJ 273 ss Shoulders... | (140) i a Qa) 17] TT a £7 A : (42) 1 2 TD) 10 27 1 i oo _ _ _ Knees : (140) 10 a D) 1 20 OJ Ha — Ankles... AD) OO 230 (0) vO Og 13 FEM osmvis 55 5 5 5 28 Situmut nn nv oomon (9) 1 20 (149) J 23 3] Back ....... LL : (150) [O 2 Te. How long after getting up and moving Te. around does the morning stiffness last? (52) 1 [| Less than |5 minutes 2 [1 15 minutes to one half hour 3 [|More than one half hour but less T | | | | | | than all day | : a [] All day | f. How old were you when you first experienced fo 153) 1 [1 Less than 20 years old . . iH oS this morning stiffness of joints 2] 20 = 29 yours old | 3130 — 39 years old | 4] 40 — 49 years old : s [50 — 59 years old ! 6 [1 60 years old or older . When was the last time you had this? ol + [] Now 9 y 9-! ; 2 [| Less than | year ago but not now 3] | — 3 years ago : a[ 14-9 years ago | : 5s [] 10 years ago or more 8a. Have you ever had pain, swelling, or stiffness 8a. (159) 1[JYes — Ask b in a joint as the result of an accident or injury? 2] No — SKIP to 9 L b. Was this the cause of the pain, swelling, ul ®) 1 Yes or stiffness mentioned previously, do JN you think? : ZL... No 9 [] Don’t know | c. Is this the cause of any pain, swelling, or (5) 1} Yes stiffness which might still be present, do [ Nn you think? 2 No 9 Don't kriow 1 9. Have you ever been treated by any of the 9. following people for your joint troubles? Yes No General practitioner. . . . ............... (158) 17] 2] INY@IMISY & . ys cmv RB Es EAMG AMEE Es Rheumatologist . .................... Orthopedisy: . : suwsnnss cs su@rmmpas es Chiropractor . . . .. i Osteoputh: : « c sommes ssn sv amwmuns 3» Foot doctor (chiropodist or podiatrist). . . . . .. Physical therapist . .................. Occupational therapist. . . .............. Other — Specify Never been treated . . . . ................ \ ® 0 223 @ 3 eC 16) (J 2] @ 2 = (63) +O 2] ed CC 27 @ = ez (60) — Ge) +3 2 SKIP 10 Ila 59 60 10a. oo 0 Are you currently being treated by a doctor 10a. 1] Yes — Ask b for the troubles you have just described? | 217) Wo = SEIP to lig . What type of doctor is he? b. | 1[ | General practitioner 2 | | Internist | 3| | Rheumatologist a | | Orthopedist | s | | Chiropractor ! 6 [ | Osteopath 7 |_| Other specialist | 8 | | Other — Specify | Lo — . What did he say the problem was? Si | DATA PREPARATION USE ONLY I f ig | 9 - | (an) vl 175) 1] @ (7) 11] d. When was the last time you saw him? d. | (77) 1| ] Less than | month ago | I 2| | 1 — 3 months ago | 3 |4 —~ 6 months ago : a! |7 ~ 11 months ago | s| || year ago or more | 9 | Don't know Lucas Ha Seeman srr ————————— e. Who originally referred you to this doctor? el 1 [No one : 2[ | He's the regular doctor 3[ | Another doctor | al | Family | s' | Clinic 6 | 1 Health nurse 7, Friend 8 | | Other - Specify | | orm mms ——, Se ——————————ee eee eo] f. Where do you usually see him? ) (9 1 His office 2 lArachnic , 3 | At hone | a, | Other g. How long will it be until your next . (180) 1. [less than | month visit to him? 21711 — 2 months | 3. 13 - 6 months al '7 - 11 months s| || year or more : 9! "Don't know I 11a. Have you ever used any of the following 1a i — | 11b. Did it do you kinds of treatment for your joint troubles? any good? Yes No Yes No . I = - - Splints orcasts . ................... | 1 [7] 2] 11] 2] Broces css ssi mmanpnss ss samunmus : 1) 2] v[] 2[] | Diathermy or paraffin. . . .............. 1] 2] | 17] 2( | | ks or heati BS... v3 5 shame ny } : : Hot packs or heating pads © 1] 2] | (89) LJ 2(] Cold packs orice. .........couuur.n. 1] 2] 1 [0] 2[7) RESY vn str rtm mss sd bd MT aa ! 10) 2) 1) 27) I Traction . o.oo i : [7] 27} 17) 2[] I Exerci ical therapy . .......... | - : xercises or physical therapy 17] 2] 1] 2] ASPirin. «vv eee eee | [0] 27) 1 [7] 2[ 7) I Cane . oii (99) (7) 2) 1) 27) | Croteh oo visi isanmvnmusissn@Rmas - 0 Bn 2 rute 1 27] [0 7) Stiff mattress... LL... | 17) 2] 17) 2] Bedboard . . ................. iu... (05) 1] 27] 117] 2( | c. If “Yes to llaor IIb — Do you use it regularly? c. Yes No . I a Splints orcasts . ................... 1 [] 2 BOCES +... i tv idk RE ARE EER EWES ! 17] 2( | Diathermy or paraffin. . . .............. LC Go9) vl] 27] | Hot packs or heating pads. . . ........... : @0) 1] 2 | Coldpocks orige ci vumuns s 3s s ewmanna 2M) 1) 2| | | Rest «ov FP @) 1 z2{ J | THORION 5.0.5 3 2 sida T mahi bf La AEE el raction @)) | 2| | Exercises or physical therapy . . ......... | aD) 1 2] | Aspirin. . ii ee | @9 1) 2| | CONE wvimns it FLNNAMNED 3 51 50 0 Eh § | @) 1 2] | Crutch . o.oo : (1) 17] 2 | | ) SHEf mattress. .. LL. IQ 2 iff mattress | ID) 1) 2f | Bedboord. :. « s sswvmmuvs ss ssmmummens J 17] ef | 12a. Have you ever had injections into any 120. (2) 1| | Yes ~ Ask b of your joints? 2| |No — SKIP to I3a L or — b. Did they do you any good? b. | (2) 1] | Yes ) 2 |No 61 62 T 13a. Have you ever taken any of the following 13a. | Yes No Don’t know medications for your joints? I Any cortisone-like medicine by mouth . . . . . : 17) 2 9 | y @ Butazolidin . . . ................... | 1) 2] | 9 | | @ Darvon or Tylenol... ............... 1) 2] 9 | | Indocin. ........................ : @) 1] 2] | 9 | b. If Yes’ — Did it do any good? b. | Yes No Any cortisone-like medicine by mouth . . . . . 11] 2] | | Butazolidin . . . ................... 1 2] @) | | i Dorvonor Tylenol. ov ous is 55 snnmn ves ] 1 2) Indocin. ........................ | 17) 2{") 14. Can you do the following things without 4. | the help of someone else or the help of | vy N some special device? €s 0 Go upordown stairs . . .............. [7] 2] | Get into oroutofacar .............. @) 17] 2] | Use washing facilities. .............. @) 1 [(] 2 | Dress yourself . . covov iss vaummmunn ss : @) 1) 2 | | Feed yourself ................ .... 1” 2 | | Get into or out of bed. . . . ............ | @) 17) 2{ | 15. At the present time, does your joint 15. | 1[] Very little condition restrict your physical activity | 2] Quite a bit very little, quite a bit, or a whole lot? / Eee 3[ ]A whole lot 16. Have you ever had to stay in bed at home for 16. | @3) 17] Yes long periods of time because of your joints? 2 No | T 17. Have you ever stayed overnight in a 17. 1] Yes hospital because of joint problems? : 2071 No | bod 18. With respect to your joint trouble, would 18. | 1 Mild you say your condition is mild, moderate, | 2 0 Moderate or severe? ] io | 3[ | Severe Jd. 19. What was your job status one month before 19. | (240) + | J Retired because of age you first developed your joint condition? 2 [ L Retired because of disability 3| | Unemployed a| | Working full-time s| | Working part-time 6 | | Housewife with full duties 7 [ | Housewife with partial or no duties 8 | | Other — Specify 20a. As a result of your joint condition, has there been a change in your job status? b. What is it now? 20a. 1[]Yes — Ask b 2 [J No — SKIP to 21 1 [) Retired because of disability 2 [J] Unemployed 3[ ] Changed to easier job a [ | Working s [_] Housewife with partial duties 6 [_) Housewife with no duties 7 [] Other — Specify 21. How many work days do you estimate that you lost during the past 12 months as a result of your joint condition? 21. 1 [] None 2] | — 4days 3[] 5- 9days a[ 110 — 14 days s[]15- 19 days 6] 20 — 29 days 7 [130 days or more a) 63 64 G. Supplement B—Respiratory HRA-11-3 (Formerly HSM-L11-3) Form Approved 4/75 0.M.B. No. 68-R1 184 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE ASSURANCE OF CONFIDENTIALITY PUBLIC HEALTH SERVICE All information which would permit HEALTH RESOURCES ADMINISTRATION identification of the individual will NATIONAL CENTER FOR HEALTH STATISTICS be held strictly confidential, will be used only by persons engaged in HEALTH AND NUTRITION EXAMINATION SURVEY and for the purposes of the survey, and will not be disclosed or released SUPPLEMENT B - RESPIRATORY to others for any other purposes (22 FR 1687). a. Name (Last, first, middle) b. Deck No. c. Sample No. 13 | READ — Earlier you mentioned having had either persistent cough, phlegm, wheezing, shortness of breath, asthma, or hay fever. Here are some additional questions about this trouble. P> PERSISTENT COUGHING @D 1 1 Yes — Ask b la. Was your problem that of persistent coughing? la. 2 | No — SKIP to 2a b. How long have you had this condition? b. 1 [] Less than | year 2 [ ]1-3 years 3[ ]4-9 years a [ 110 years or more c. Have you been bothered by this within the c. (@3) v[] Yes t year? pest y 2 No d. When you have this trouble, do you also d. (004) 1[ | Yes — Ask e have chest pains? ) 27 No—-SKIPtof — mmm e. Where? e. Yes No Upperback : cvvwawssrersmmpmennss 1 [7] 2 [7] Lowerboack : . cai s ssi ivmnnnasass ! 2 [] Upperchest. coos vev ss vnvamsmvnsn ss Vid 2 [7] Along the rib edge ................ 1 2] Onthe sides . .................... vl 2] f. Do you bring up phelgm with the cough? f. ¥ {Yes 2 [| No re Ci —— a — g. Do you cough persistently like this on 9g. @w 1 71 Yes most days for as much as THREE TON ? 2, | No months each year? h. Do any medicines you take help relieve h. 1 ]1Yes the cough? . 2 I No i. What time of year do these coughing i (ID) 1 | Winter attacks seem at their worst? 2 [] Summer 3 [ 1 No difference 2a. Have you had trouble with coughing spells when 2a. you first get up in the early morning? (Count a cough with first smoke or on first going out of doors; exclude clearing of throat or a single cough.) 1 [J Yes — Ask b 2 [J] No — SKIP to 3a a [10 years or more 9 [] Don't know T I I I I I b. How long have you had this particular condition? b. 1 [] Less than | year I 2 [] 1-3 years 3 [] 4-9 years 4 [] 10 years or more 9 [J Don’t know c. Do you have chest pains when you have c. | 1 [J] Yes — Ask d morning coughing spells? : 2[JNo-SKIPtoe d. Where? d.! Yes No I Upperback cvousversvosvsvrssmonmnns ! 1 [J 2) I Lowerbgek sos wnnnvss seve mess snme 1] 2] I I Upperchest. .........covuiuvnennn 1] 2) | Along the ribedge. . ................ : 1 [OJ 2) I On the sides «covvvunsssrcsomnmess n the sides } 1 [IB 2 O L i e. What time of year are these morning coughing e.! 1 [] Winter i ? spells at their worst? | 2 [= Summer 3 [_] No difference | f. Do you have a morning cough like this on fo 023) 1 Yes most days for as much as THREE months : @) 0 each year? | 2 [J No I | g. Do you usually have a persistent cough at g. | other times during the day or at night in the : 1 [J Yes winter? (IGNORE AN OCCASIONAL COUGH.) 2 [No | h. Do you usually have a persistent cough at hi other times during the day or at night in the ! 1 [] Yes summer? (IGNORE AN OCCASIONAL COUGH.) ! I 2 [No | | PHILEGM i 3a. Do you usually bring up any phlegm from your 3a. | 1 [[] Yes — Ask b chest first thing in the morning? (Count phelgm | with the first smoke or on going out of doors. | 2 [[JNo — SKIP to 4a Exclude phlegm from the nose. Count swallowed phlegm.) I / 1 Less than | year b. How long have you had this condition? b. | LJ | 2 [] I-3 years | 3 [] 4-9 years | | | | 1 65 66 On the sides. T c. What color is the phlegm? cs! Yes No Groen vo wwmnis s 5 +s CREME mbit snes vo 1 [1] 2 [7] | Yellow. cow mans pamupunrrre 12 13 1 : 1 [O] 2 [7] | Closk wowwmess ssemmannnioses sina [0] 2] | Blood-streaked. . . . ................. 1 [O]) 2] — d. Do you also bring up any phlegm from your chest d. | at other times during the day or at night, in the I 1 [Yes winter? (At least two times or more) | 2 [No | | e. Do you also bring up any phlegm from your chest ce. | during the day, or at night, in the summer? | 1 [Yes (At least two times or more) : 2 []No I L | f. What time of year do you seem to bring up the fo! 1 [] Winter most phlegm from your chest? i 2 [7] Summer \ i; 3 [J No difference r g. If you have brought up phlegm, do you bring it g.' 1 [] Yes up on most days for as much as THREE months 2 [No each year? | SHORTNESS OF BREATH 1 [7] Yes — Ask b 4a. Have you had shortness of breath either when 4a. 2 ol No — SKIP to So hurrying on the level or walking up a slight hill? I w= b. Have you had this problem most days for as much b. | 1 []Yes as THREE months each year? ¢ [I No : _ i c. Do you get short of breath when walking with c! ' [Yes other people at an ordinary pace on the level? | 2 [No ' » d. Do you have to stop for breath when walking d. | 1] Yes at your own pace on the level? ; 2 [7] No e. Do you have to stop for breath after walking e.| 1 ]Yes about 100 yards or after a few minutes on the i 2 1 No level? | LJ f. How long ago did you first have this trouble f.! 1 [] Less than | year ago with shortness of breath? — 2 [] 1-3 years ago 3 [14-9 years ago | 4 [10 years ago or more 9 [] Don't know | g- Have you gotten chest pains along with the g.! 1 []Yes — Ask h ? i y= shortness of breath? | 2[JNo-SKIP toi h. Where? hoi Yes No Upperchesy: : sc su wmmns sss s 2 imu mmus 177] - 5 Upperback ....................... 1 [7] 2 | Lowerbock ; s cvmmuwmames 835 tadmiiommnn rv [1] 2] | Along the lower ribs . ................ 1 [1] 2 [7] | 1 [1] 2 [7] 4i. Do you develop wheezing as well as shortness 4i. | (048) 1 [J Yes of breath? 2 [] No i- Have you ever felt like you were going to pass i. 1 [] Yes out from the shortness of breath? I | 2 [J No 1 WHEEZING 1 [] Yes — Ask b 5a. Has your chest ever sounded wheezy or Sa. N SKIP to 6 whistling? 2 [J No ~ SKIP to 60 b. How long have you had this condition? b. 1 [J] Less than | year 2 [] 1-3 years 3 [] 4-9 years a [7] 10 years or more T I | i | i I I I I I I | I I c. Do you get this wheezing or whistling with colds? , | 1 [] Yes ; 2 [] No rern d. Do you get this occasionally apart from colds? d. | 1 [7] Yes 2 [J No I e. Does this usually occur daily? . | 1 [J Yes | 2 [J No | I f. What time of year does it seem worst? f. ! 1 [] Winter 2 [] Summer 3 [_] No difference g. Is this wheeziness present on most days for as g. 1 [] Yes much as THREE months each year? ; 2 [J No } h. Do you take any medicines for wheezing? h. (057) 1 Yes — Ask I J 2 [J] No — SKIP to 6a i. Do they help relieve the wheezing? Ta + [CJ Not at all : 2 [] A small amount ’ 3 [_] A great deal | ASTHMA ! 1 [] Yes — Ask b 6a. Have you had, or do you now have asthma? 6a. 2 [J No = SKIP to 7a b. What is it related to or due to? b. | Yes No I Dust... evenwrssenmunenrss ssnwnns : 1d 2] | Y 2 Foods ............ iii... Od I i 1 Animal contacts . ....... iL, = 2] I Drugs «ieee J 2] | 1 2 PollEns: cuvnts saummains vv re emmmunin OJ Ol I 1 2 Molds ....covnssemnnanuisssvamuus OJ [m) - ; : J 2] Other — Specify ) | ' 9 Don’t know ! I) | | 67 68 6c. How long have you had this condition? 6c.1 (068) 1 [] Less than | year — SKIP to e ! (. | 2 ]1-3 years — SKIP to e | 3 [ ]4-9 years ago — SKIP to e a[ | 10 years or more — Go to d r d. Since you were a child? Jd. Vives 2] No | e. Do you have asthma symptoms on most days for e.! Yi 1Yes as much as THREE months each year? | 1 : 2 [|] No f. What time of year is it worst? fu! Yes No SPRING «eee ee eens | 1) 2] | Summer ...i ee 1 [7] 2} I Fodlicmnn s « + nomoammn os vow men mn a FC @ 0 2 [7] . | Winter wwsssesveimunmusss ismnmons | 1 [7] 2) g. Do you take any medicines for it? g. 1] Yes 4 2 [ | No b UAVERVER : 1 [Yes — Ask b a. Have you had, or do you now have, hayfever? 7a. 2 [No — SKIP to 80 L | b. What is it related to or due to? b.! Yes No BUSI oss smenumnnnts ct sansn nis vO) 2 [] | Foods ............ ci... ; 1 [OC 2 | C) C) Animal OCIS os wp mmmive sp ARE BBE WEE 8 | r } nimal contacts ! 1 [1] 2] | Drugs ...ccnuumummmsssssmummasss is ! (080) '[] 2] | Pollens. . ........................ 1 [1 2) Molds «oui 1 [7] 2 [7] Ai ditioners . . .............. C . ir conditioners 10) 2] Other — Specify 1] 2] | Don't know . ..... / 9] |, | c. How long have you had this condition? c., (086) 1 [Less than | year — SKIP to e : 2 ]I-3 years — SKIP toe 3 ]4-9 years — SKIP to e : a |] 10 years or more — Ask d ke... aie d. Since you were a child? d. 1 ]Yes : 2" No d. How long ago were you last tested? 7e. Do you have hayfever symptoms on most days | (088 1 7 Yes for as much as THREE months each year? J. | 2 [ | No fn f. What time of the year is it worst? b. Yes No | ~ : Spring. « «tiv t tii i iia SE ® 1 [] 2) | —— — . “eee 1 2 SUMMEE. «ss hs ssa suns C0 0 | - - FREE se sanwewe | 1 2 [ Poll auuunns ran © ] ] | - ws i on | 1 2 | Winter «conse seme ro mown bk Bok ER -@ J ] Fim g. Do you take any medicines for it? g. |! ' [7] Yes | 2] No MEDICAL CARE ; 1 [] Yes — Ask b 8a. Have you ever been tested for TB (tuberculosis)? 8a. | 2 [ ]No — SKIP to 9a L b. How were you tested? b.! Yes No Askin test vovuvscnnvussnn pele 1) 2 [7] Chest x-ray « «ovo vv vv PEI aww vv [) 2] | Sputum examination ........... seswmnwy | 1 [1] 2) Don't know «vv vv viii inne 098) 9 | c. How often are you tested? c. “] Once every year “] Once every two years “] Once every 3-5 years “| Less often than once every 5 years r r r [ 1 1 [] Less than | year ago 2 [] 1-2 years ago 3 [ ]3-5 years ago 4 [16-9 years ago s [] 10 years ago or more 9 [|] Don’t know 9a. Have you seen a doctor or anyone else about the chest or lung conditions you mentioned previously? b. What is the name of the doctor you see? c. What type of doctor is he? a Who initially referred you to this doctor? 1 []Yes — Ask b 2 1No—-SKIPt I0 1" ] General Practitioner 2 [1] Internist 3] Osteopath 4 "Surgeon s 71 Lung specialist 6 [| Allergist 7 [] Other — Specify ["] No one "1 He's the regular doctor [7] Another physician ] Health nurse “] Clinic “] Family "| Other — Specify ( ( , 69 70 9e. How long after you first developed the problem Ye. did you see him? f. What did he say the condition or conditions f. affecting your chest were? 1 [] 1-6 days 2 [] 1-7 weeks 3 [_] 2-6 months a ]7-11 months s [_] One year or more 9 [_] Don't know DATA PREPARATION USE ONLY [OJ 0 @ 0 TO) 0) 0 @ 0) 0 @ 0 1 VO g. When you see the doctor about your chest g. condition, how often do you receive a chest x-ray? h. Does he prescribe the medicine for h. the condition? i. How is the medicine taken? ¥ Swallowed. . ....... sr R ATR bs ad Breathed ...... PES LIMB EW es Le Injected ici wiisiiinunnnnsiisian Other — Specify. i. Has he told you to do any of these other things |. for it? Breathing exercises. . . . o.oo vv viii Use a breathing machine ............... Stop smoking vos sv remmmwnes tt smn mms Decrease smoking ................... Regular checkup. . cove viii vin Lots of rest . . .... iii. Decrease activity .............. Other — Specify k. When was the last time you saw him? k. SIEI6IONeI6) [ v [J Atevery visit 2 [] At every other visit 3 [J Less often than every other visit 1 [] Yes — Ask i 2 [JNo — SKIP to j @) Yes No Cy Ol 2 1d 2] @ 2 [] @ iO 2) Yes No C@ 2 [] @ 0) 2 [J gO a0 (2 0] 2] = 2] "Qa [0] z [7] C® 0) 2 [7] 1 [O) 2 [0] [ ® 1 [] Less than | month ago 2 [] 1-3 months ago 3 [| 4-6 months ago a []7-11 months ago s [_] | year ago or more 9 [] Don't know 91. Where do you usually see him? 9l. 131 1 [] At his office 2 [] Ataclinic 3 [_] At home a [] Other — Specify m. How long will it be until your next m. (32) 1 [] Less than | month appointment? | : 2 [] 1-3 months 3 [] 4-6 months a [ ]7-11 months ) s [_]| year or more ) 9 [] Don’t know 10. Within the past 12 months, has your chest 10. | (3) 1 [_] Gotten worse condition gotten worse, gotten better, or | 2 [] Gotten better stayed about the same? — | 3 [7] Stayed about the same | 11. Have you ever been disabled because of any 11. 1 [] Yes chest condition? 2 [J No 12. Have you ever stayed overnight in a hospital 12. 1 (39) * spit ’ 1 Yes because of a chest condition? 0 | 2 [7] No 13. What was your job status one month before 13. | 1 [] Retired because of age you first had a problem with a chest or I } ) . lung condition? 2 [] Retired because of disability 3 [ ] Unemployed 4 [] Working full-time s [] Working part-time : 6 [_] Housewife with full duties 7 [] Housewife with partial or no duties ) 8 [|] Other — Specify TP I 14a. As a result of your chest or lung condition, 14a. | 3) 1 [) Yes — Ask b . 2 = has there been a change in your job status? 2 T] No — SKIP to IS b. What is it now? b. | 1 [] Retired because of disability I | 2 [] Unemployed | : 3 [_] Working only part-time a [] Changed to easier job ; s [|] Housewife with partial duties : 6 [ | Housewife with no duties y 7 [] Other — Speci _] fr—s | 15. How many work days would you estimate you 15. | 1] None have lost during the past 12 months because I 2 [1] 1-4 days of your chest or lung condition, excluding y colds or flu? | 3 []5-9 days a []10-14 days i s [] 15-19 days | 6 []20-29 days : 7 [] 30 days or more 71 72 H. Supplement C—Cardiovascular HSM-411-4 pace 1 REV. 5/71 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION NATIONAL CENTER FOR HEALTH STATISTICS HEALTH AND NUTRITION EXAMINATION SURVEY SUPPLEMENT C — CARDIOVASCULAR Form Approved O.M.B. No. 68-R 1184 ASSURANCE OF CONFIDENTIALITY All information which would permit identification of the individual will be held strictly confidential, will be used only by persons engaged in and for the purposes of the survey, and will not be disclosed or released to others for any other purposes (22 FR 1687). a. Name (Last, first, middle) b. Deck No. c. Sample No. 141 SE READ — Earlier you mentioned having a history of either chest pains, chest discomfort or heaviness, leg pains while walking, or heart failure. Here are some additional questions about it. 8 la. Was the problem that of chest pains, chest la 1[ ]Yes — Ask b | :) discomfort, pressure, or heaviness? 2 | No — SKIP to 2a I b. How would you best describe this pain b. | or discomfort? i Yes Ng . | 7 ; Heaviness. ............. RW 5 G5 343 dasa 1] 2{] | Burning sensation. . . vou viii conver 17) 2) | TighthesS wu vmpvwunus ss samen FREE 1] 2] | Stabbing pain... Loo oi Badia ¥ | 17] FAI | PP I (1) 17) 2) | | Shotp pain. cu summa mans ss sammmmv ss cee 1] 2) | Shooting pains +... ..... ven w EEE. 1] 2] | | c. Have you had it more than THREE times? cl 1] Yes 2 J No ! cr ——— d. Have you been bothered by this within the d. 1] Yes past 12 months? : 21 No \ LJ or hurry? | e. How old were you when you first had it? e.| 1] 10 — 19 years old | ! 2[ 120 — 29 years old 3[ ]30 — 39 years old a 140 — 49 years old | ! 5] 50 — 59 years old | 6 | | 60 years old or older | f. Do you get it if you walk at an ordinary $1 1 1Yes pace on level ground? = : 2 | No | | g. Do you get it if you walk uphill q. 1[ ]Yes — Ask h 2[ | No — SKIP to k . Ww . . . . ? : ! Th. What do you do if you get it while walking? 1h Yes No | I Stops» coven mmmmnn nes Pew Nm END) 1] 2) I Slowdown. ......... verre evees | 1] 2] Conti $SOME POCE vv snr ss ssibinmwmns : 1 2 ontinue at same pace ! O J I Toke medicine uv wnvvwrrrrsssnnemnmen : 1) 2] i. If you do stop or slow down, is it relieved io 1 [] Relieved — Ask j ? 1 wld J 2 [J Not relieved — SKIP to k ij. How soon? ie 1 [] Less than 10 minutes : 2 [] 10 minutes or more 1 k. When you get pain or discomfort, where k. | is it located? : Yes No 1 Upper middle chest . .......... 5 ou ch EW ; 1] 2) 1 Lower middle chest. .......... cane E 1) 2] 1 Left side of chest. .......... EE . 10) 2] I Leftarm...ovuenerennnns cere (0) 1] 2] Right cide of chest ii cuus i inessarmnsunus | ight side of chest 1] 2] ther — Speci Other — Specify 1) 2) _ |. Do any of these things tend to bring it on? l. : Yes No I Excitement or emotion . . . ... Cereeeareaas 1] 2] $1o0ping Over ww s unm mve re rrr eee 1] 2) I Eating a heavy meal . .......... vow 1] FA I Coughing spells « «ove ivi vein ei enn 1 [J FA I Coldwind......ovovvnn HIRI AARE RATE | (030) 1 [J 2] 1 Exertion . .. ov... cere aaas cera . | 1 2) 2a. Have you ever had severe pain across the 2a. \ [JYes — Ask b front of your chest lasting for half an hour ! 2] No — SKIP to 3a or more? | b. How many of these attacks have you had? b. ! 1 [] One 2[]2-3 ! 3[ ] 4 or more ? 1 c. What was the date of your last attack? c Month Year d. What was the duration of the pain during d. 1 []30 — 59 minutes your last attack? 2] | = 2 hours 3] 3 - 5hours a] 6 — Il hours 5s [] 12 — 23 hours 6 ]24 — 47 hours 7 [] 2 days or more 73 74 | " 2e. Did you see a doctor about this last attack? 2e. 1] Yes — Ask f i 2 ]No — SKIP to 3a | r mrtotes eee veer - f. What did he say it was? f. j DATA PREPARATION USE ONLY @ i a | J. HO @) 0 ' | | 00) [0 ' | T 3a. Do you get pain or discomfort in either leg 3a. 1[ Yes — Ask b while walking? | 2 No — SKIP to 4a b. Do you also get this pain in your legs b.! [Yes while standing still? 2 NG LJ c. In what parts of your leg do you feel €s i 171 Lower part (calf) this pain? | 2 | | Upper part (thigh) 3 | Both lower and upper parts d. Do you get the pain in your legs while d. | 1 Yes quiet or while sitting? 2 No : e. Do you get it when you walk up a hill e. | 1] Yes in a hurry? 20 No I bs f. Do you get it when you walk at an f! (050) 'L.iYes ordinary pace on level ground? | I 2 [No | g. Does the pain in your legs come on after 9. 17] Yes you have taken a few steps? 2[ I No h. Does the pain disappear while you are ho! 17] Yes still walking? i 21 1No [1 i. What do you do when you get it while iv! you are walking? | Yes No 1 (053 Mops rs RE BEE ARES Fe REE MEE a. 1] 2 | Slow doWniv ui smve ss ss som EERE & HE 4 EEE. 2 | | | Continue at same pace. . vo... vu. oo © 17] 2] | Take medicine . + vv vv viii enn. cols) 1] 2] jo If top, is it relieved 1? iv 1 | Relieved — Ask k i you stop, is it relieved or no i 3 | | 2( | Not relieved — SKIP to | k. How soon after stopping? k. 1 Less than 10 minutes | 2[ | 10 minutes or more I. Is the pain more likely to occur when you kL (059) 11 Yes are hurrying than when you are walking ®) IN i at a slower, more even pace? : 2i.1Ne 4a. Have you ever seen a doctor about chest pains, chest discomfort, pains in the legs while walking, or heart failure? b. What is the name of the doctor? 4a. c. What type of doctor is he? d. Who initially referred you to this doctor? NOONE + cs cvmmummmersres ors smnmmi He's the regular doctor ...... vv. Another doctor . . Family «vv viii iii ieee Clintes » vs con unumains HEF RITE . Heolth AUISe vena mn wwmmon 5665 piniw Other — Specify started did it? e. How long after this trouble first you first visit your doctor about f. At that time, what did he say the problem was? g. Did you have a cardiogram at the first visit? h. Did you have one at a later visit? i. How long was it from the time of the first visit? 1[]Yes — Ask b 2[JNo— SKIP to 5 ® 1 [_] General practitioner 2 [] Osteopath 3] Heart specialist a[_] Other specialist s [_] Other — Specify 9 { ] Don’t know Yes No | — | 10) 2[] | — . | [J 2] ©) 0, 2] | @) 20] I 1) 2(] | | — | 1) 2] ! - = | (08) 1] 2] 1] Less than | day 2] — 2days | 3 ]3 — 6 days a] — 3 weeks : s{ |] 1 — 5 months ; 6 16 — Il months 7] 1 year or more 9 [| Don't remember | | | 1] Yes ; 2 "No nD, 1 Yes — Ask i : 2. [No — SKIP to 4j 1111 = 2days ; 2! |3- 6 days y 3] ]1 — 3 weeks a || — 5 months s| |6 — || months 6 || year or more 9 [ | Don’t know 75 76 4j. Did you have a chest X-ray at the first visit? 4j. k. Did you have one at a later visit? k. I. How long was it from the time of the y, first visit? m. Have you had any other tests for this m. condition? (such as blood or urine) n. Did the doctor prescribe medicines to take n. for your condition? o. How do you take the medicine? o. Swallowed. .. .... von mmm demand gr % Era mre owan Under the tongue i: cvianmammas sass esi Injected 5 vss ess sss ranma mwvss ss nisns Other - Specify EE p. Has he told you to do any of these other things? p. | Make regular visits... ..... Have regular cardiograms Decrease activity . . Increase activity Rest .... Doexercises ssnwvus ss ss sumpumums vs 5933 Stop smoking Other — Specify q. When was the last time you saw him? q. r. Where do you usually see him? r. | J 1[]Yes j 2 | No ey 1[ Yes — Ask | 2] No —SKIPtom J ————————— i ————————————— ———— SBSUNSSSS—— ! 1 ]1 — 2 days @ | 2! |3 — 6 days 30 JI — 3 weeks : a| J 1 — 5 months | s{ |6 — 11 months | 6 || year or more | 9 | | Don't know ncenygy gyrase ites HES Aspaste siesta aes rd] | 1! 1¥es | 2] No gE Ec oh tana tess — . I ! ©) 1 Yes — Ask o ! 2! 'No-SKIPtop Yes No 0 2 | ¢ | ! 1 2 | (080) 1 zl | | J 2] Yes No 21 : . 086 1 2] 088 1 2 089) 1 2 1 Less than | month ago | 2 | I — 3 months ago ! 3 4 — 6 months ago a 7 — || months ago ! s' | year ago or more 3 Don’t remember —— es _————————eeee—— 11 Athis office 2 Ata clinic 3 | At home 2 [7] Other — SPOtify cece scsi 1 4s. How long will it be until your next visit? 4s. | 1 [_] Less than | month 2[]1 — 3 months : 3[ ]4- 6 months I a[ ]7 — || months s[ 1 year or more 9 [|] Don’t know t. Would you say that the treatments you have to | 1 [_] No, not at all had have done you any good? 2[] Yes, partly | I 3[ ] Yes, quite a bit | T - 5. Within the past 12 months, would you say that 5. 1 1 [] Gotten worse your condition has gotten worse, gotten better, 2 [7] Gotten better or stayed about the same? | i 3 |] Stayed about the same 6. Have you ever been Hisshied heeause of chest 6. | 1] Yes pain, leg pain, or heart failure? ! 2] No 7. Have you ever stayed overnight in a hospital 7. 1 1[]Yes because of chest pain, leg pain, or heart 2 [No failure? | 1 8. What was your job status one month before you 8. 1 [] Retired because of age first developed chest pain, leg pain, or ' Reti f disabi li heart fotlora? J 2 [|] Retired because of disability : 3] Unemployed a [ | Working full-time s [| Working part-time 6 [|] Housewife with full duties J 7 [] Housewife with partial or no duties : 8 [] Other — Specify | | I i 9a. As a result of your condition, has there been 9a. | (098) 1 []Yes — Ask b a change in your job status? 2] No — SKIP to 10 L i b. What is it now? b. | 1 [] Retired because of disability 2[ J Unemployed ' 3[_] Working only part-time ) a[ ] Changed to easier job 5 [| Housewife with partial duties : 6 |] Housewife with no duties : 7[] Other — Specify | i 10. How many work days would you estimate you 10. 1 [] None have lost during the past 12 months because 2(7] | — 4 days of your heart condition? 3] 5- 9 days a[ 10 — 14 days s[ ]15— 19 days 6 120 — 29 days 7 []30 days or more 77 J. Body Measurements HR 127A (f ormerly '4SM-425-7A) Form Approved 111 7-74 0.M.B. No. 68-R 1184 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE ASSURANCE OF CONFIDENTIALITY All information which would permit HEALTEOELIS LEAL TH BER Y ICE rion identification of the individual will S be held strictly confidential, will be NATIONAL CENTER FOR HEALTH STATISTICS used only by persons engaged in HEALTH EXAMINATION SURVEY and for the purposes of the survey, and will not be disclosed or released BODY MEASUREMENTS to others for any other purposes (22 FR 1687). a. Deck No. b. Examiner No. c. Recorder No. wore > Measurement in cm. unless otherwise specified. Measure left side also if the last digit of examinee's sample number is 3 or 6. I | 1. Bitrochanteric breadth Ln (009) oo | RIGHT SIDE LEFT S{DE 2. Elbow breadth 2. 100) _ _ ) _ _. _ ) RIGHT SIDE LEFT SIDE 3. Upper arm girth 3. (00) _—— — ©) _ _. _ T Chest circumference | 4a. Full expiration 40. (O08) T | b. Full inspiration b. | a | RIGHT SIDE LEFT SIDE 5. Triceps skinfold (mm.) 5. | — i Rr are vim | | RIGHT SIDE LEFT SIDE 6. Subscapular skinfold (mm.) 6. | a, gs a T | 7. Sitting height 7. | rr oy 3 tomer When both sides are measured | ©), [} Right handed 8. Is examinee right or left handed? 8. | 2 [] Left handed : 3 [] Uses both hands about the same a [_] Not sure 8 [] Not applicable | r | 9. Weight (Ibs.) 9. @y _ | 10a. Standing height (cm.) 10a. oe _ | | b. Standing height (inches) b. | a at sl NOTES Sample Number N? 98743 78 K. General Medical Examination HRA-12-3 Form Approved FORMERLY HSM-425-3 0.M.B. No. 68-R|184 74) DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE ASSURANCE OF CONFIDENTIALITY PUBLIC HEALTH SERVICE All information which would permit HEALTH RESOURCES ADMINISTRATION identification of the individual will NATIONAL CENTER FOR HEALTH STATISTICS be held strictly confidential will be » used only by persons engaged in GENERAL MEDICAL EXAMINATION —- AGES 25-74 and for ins purposes of ihe Sarva, HEALTH EXAMINATION SURVEY Be a Aeiaoye: (22 FR 1687). a. Name (Last, first, middle) b. Deck No. | c. Pulse d. Blood pressure Systolic Diastolic 231 | @) _ _ _ _ _ 1. HEAD, EYES, EARS, NOSE, AND THROAT: 1 | 1 [_] Findings 4. ABDOMINAL EVALUATION: (048) 1 [J Findings | If findings, mark applicable ) | | | | 2] No If findings, mark applicable 2[JNo box and continue with a. findings box ip dng Wi ’ findings If ro findings, SKIP to 2a. Yes tf na findings, SKiP 6 5. Yes 1] a. Hepatomegaly. . «evo ven a. Conjunctival injection . ..... \ b. Filiform papillary atrophy ! 1] b. Splenomegaly............ 1[] of tongue ..evvvee nn ' c. Uterine enlargement ....... 10 w Pugitom gaiitian pare 4 GB 417] 1. Uriel hemi. «ous s ve x | @ 0) d. Fissures of tongue « .. .... (02) OJ e.Mass(es). coin | 1] e. Serrations or swelling of tongue 1 [J (1) Area(s) — Enter number(s) | Q3) — — — — — f. Scarlet beefy tongue ....... | (029) 1[O) (2) Other findings — Describey 1] g. Other — Specify 2a. THYROID EVALUATION: 1 [] Group 0 (1) Area(s) — Enter number(s) 1 | | 1 | | | 1 | RR) | OJ f. Surgical scars ....co00enn ' 10 | | 1 1 1 | | | | | 1 1 | WHO Classificati ) ( Clazsification) | 3 Sau ; (2) Other findings — Describe gy 1 | 4[_] Group 3 b. OTHER THYROID 1 [7] Findings : FINDINGS: | = gy | 2TINe Yq | findings vA yg ! (GO to 3) } ! RL Both (1) Tenderness. «oc ocuuunn ; 1[J201 ™N 1 (DH Nodule...ovnsnnnnnas | 0) (Jz: 1 2 3 (3) Isthmus «o.oo iiennn. 10 | . (4) Other — Describe ! 4 pein 6 — 1 @®O 71 81° 3. CARDIOVASCULAR EVALUATIONS: 1] Findings 21 No ! ] indin box and continue with a. findings If no findings, SKIP to 4. Yes | 1 | If findings, mark applicable ! | J SAMPLE NUMBER a. Cyanosis ...veesennanen 1 b. Irregular pulse. .......... 10) N? 98743 80 b. Absent ankle jerks c. Other findings — Describe 5 MUSCULOSKELETAL (062) 1 [7 Findings EVALUATION: : - \ 0 If findings, mark applicable | 2 nT box and describe. findings If no findings, SKIP to 6. J Yes | Findings — Describe 5 y [1] i. | | | — | I L | NEUROLOGICAL t (067) 1 [7] Findings EVALUATION: | \ If findings, mark applicable : 2] , box and continue with a. If no findings, SKIP to 7. \ Yes | a. Absent knee jerks ....... i (068) 1 [7] @9) 1) @ 0 SKIN EVALUATION: If findings, mark applicable box and continue with a. If no findings, SKIP to 8. . Petechiae — Describe 5 . Ecchymoses — Describe . Other findings — Describep , 1 [_] Findings 2 [J No findings Yes @) 0) © 1] oF — —— oo Ho so 8a. Obesity +.vuunnen..... [1] bo NOODESItY ....vcuiuninns i i A 9. Name of physician Comments SAMPLE NUMBER N? 98743 HRA-12-4 (Page 1) (Formerly HSM-425-4 (Page 1)) 7-74 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HEALTH RESOURCES ADMINISTRATION NATIONAL CENTER FOR HEALTH STATISTICS Form Approved 0.M.B. No. 68-R| 184 ASSURANCE OF CONFIDENTIALITY All information which would permit identification of the individual will be held strictly confidential, will be used only by persons engaged in and for the purposes of the survey, eee HEALTH EXAMINATION SURVEY and will not be disclosed or released to others for any other purposes (22 FR 1687). GENERAL MEDICAL EXAMINATION Deck No. 232 P A. EXTERNAL EAR = DRUM — Continued | Right Left (Eee canal) | Right Left W. Red susnnesss 10. | 0 @) 0 . No findings — . SKIPtoB ...... 1. | 0 3 11. Other discolorations 11. | ___ 20d 20] | 12. Fluid 12. | 020) OJ @)O 2 findings with 3 2 | 2M) 2] BR eee «ke | i me a oe om 13, 8cars ...vosun 13. 1 J 1 3. Operative scar... 3. ! 1 (00d + J V4. Pediorated |B ter SA ; . Perfor 4. Other — Describe . 4. ' fron + 1 72x «| 0 a. With discharge 4a. OJ ©) dO Ha b. Without discharge . b.. 2] 2] ; bem mmm mm D. NARES | Right Left 5. Pierced ears ....5. | 1 1Yes 2[ No Co ! rem 1. No findings — B. AUDITORY CANAL | Right Left SKIPtoE ...... Lo Oo @)o 1. No findings — ! 2. Findings — [ Ros Co %. | 1 1 3 Continue with 3 ..2. | 20 20 2. Findings — | 3. Obstruction r Continue with 3 .. 2. poi” SR 2 a. Acute ....... 3a. | 1 (DE O 3. Occluded: b. Chronic . ..... b. ! 2 20) : imeem ls i some etn o. Partially ..... Jo. oo (1 vO) 4. Other significant i b. Completely. ... b.| 2) 2 [0 findings — . 4. Occluded by: Be a. Deviated septum . 4a. _@9 0 @.o I I a. Cerumen ..... 40 J J b. Swollen turbinates b. | 10) ©, a) b. Other — Describe b.! 2 2 ~~ rs rr] ‘ | Co L c. Chronic inflammationc. | ( (DE OJ To d. Other —Describe . d. | [OO 0) O C. DRUM Right Left | 1. No findings — 019) [OO 1 : SKIPoD wovmaw 1. E. NECK 2. Findings - 2 [0 | 1. No findings — : Continue with 4... 2. SKIP to F Bo ' OJ 3. Not visible ..... 3. _ 0 sO 2. Findings — 4. Dull (Opaque). . . . 4. ' OJ OJ ori with 3 . . iy ® p= 5. Transparent . . . . . 5. , 2] 2] . Adenopathy . .... og (TD) 1 Re . | 6. Bulging ....... 6. (ow) [J vO 4. Tracheal deviation. 4. : y 3 7. Retracted ...... 7. ! 2 [1 2] 5. Other — Describe. . 5. | 'O) 8. Calcium plaques . . 8. @ "J yO | 9. Other findings — me TTT TTT TT TTT Sample Number Describe . ...... 9. ! | y [0 N? 98743 81 | pF. CHEST Cn Absent Bonen! Rales Rhonchi Wheeze 1. Auscultation sounds | °% = _ Right chest y _ 1 [] No findings — 1 | eC 1d 1 | 1] @) SKIP to 8 7 Upper lobe ! | 2 [] Findings Middle lobe 0:0 20] ©) + © ©) [Es I | ” — Lower lobe @ 0:00 ©) C1] ©) + C1] ©) 1 (1|@ed) + Left chest ! oo 3 Upper lobe ©) (1 20) © + 0) |@9) TI] ©) Is) T Lower lobe | (069) ' (J | 2] OE) DE) Ded) O 2. Other chest findings 1 [_] None 2 [] Findings G. HEART PMY svessasiscmmmmmmvens 1. 1 [Felt 2 [7] Not felt ! QO QO I 2. Interspace . ................. 2. ! 40 SO 61 70) { 3. Midclavicular line . ............ 3 (DD) 1 [At 2 [] Inside 3 [] Outside | | ATheills Loi 4 + [7] Absent 2 [7] Present | a.Systolic. ...ovuvienn.... a. | 1 [] Base 2 [] Apex | I b. Diastolic csv uvnsnsnmsnnsss b. | 1 [] Base 2 [|] Apex | 5. Heart sounds ; a. Istheart sound ............ S50. | 1 [] Normal 2 [] Accentuated 3 [| Diminished : ; | b. 2nd heart sound ............ b. : + J] Normal 2 [] Accentuated 3 [_] Diminished | 6. Murmurs . ... LL... LLL... 6. | 1 [] None — Skip to? ee io 7 ss ss se 1. ! SYSTOLIC MURMURI(S) DIASTOLIC MURMUR(S) Type, « , cuvvwpmsnnssns ama a. | + (_] Functional 1 _] Functional | 2 [] Organic 2 [] Organic : 9 1 Don’t know 9 ~ 1 Don't know b. Location rT eracE cracE |] | (1) Apex «ooo... b(1): 1 Tes Tle Is Tle] (08D) 1 21s le ls ls os. ss ogo RR i es A Sa (2) Midprecordium . .......... (2) "(JJ Jea Js Je] (89) + Je sje 3s le be tt ti em mm AN 8 a mt mae er eer I (3) Leftbase. . ............. (3) 1012s CIs Cle @): J Ja Je Js "Je be me - | (4) Right base ............. (4)! 102s Teds Tle 0 @)r 2 ale Ts le 1 Sample Number Continue with 6c, ‘Origin’ on Page 3 N? 98743 Pe HEART - Continved 6. Murmurs — Continued c. Origin (MMitral . ovine 6c.(1) (D AGRIC. » « cova ssiv iis (2) (3) Tricuspid. . .....oovvnnn (3) (4) Pulmonic ............. (4) (5)ASD ... iii (5) BYVYSD ...ivenrenrannas (6) (7)Other . . ov v vi ieee (7) BY Dont Know ....camsswws (8) Systolic 00000000 Diastolic 2 [J 2 [J 2 [J 23 2d 2] 27 Both 33d 3d sd 3d sd 3] 3 7. Other cardiac or EER BERERRRG® Sample Number N? 98743 I | | I | | | | | | | | | | | | | | | | | | | | | y cardiovascular findings 1[] No — Skip to H 2[] Yes — Continue with7a a. Edema ................. 7a | 1d b. Other — Describe .......... b : | | | | c. Neck vein distension . . ...... c. | 1 (J | H. PULSE — ARTERIAL EVALUATION Sclarotic and 1. Palpation Normal Sclerotic Tortuous Tortuous a. Rightradial .............. la. | OJ 2] a0) 0 b. Right femoral . ............ b. | [OJ 2) 10) a c. Right dorsalis pedis ........ c. | OO 2 sO +O d. Leftradial ............... d. | (oe) +O 20 30 «0 e. Left femoral ............. e. | 1.) 2) 3) «JJ f. Left dorsalis pedis . ........ f. am OJ 2] sO) +3 2. Pulsations | Normal Diminished Bounding Absent a. Rightradial ........c..... 20. | ) 1 [O) 2) 3) «0 b. Right femoral ............. b. | @ OJ 2] a) +3 c. Right dorsalis pedis ........ c | a) 1 [OJ 2) 3) «0 d. Other — Describe .......... d. J @) 1 [J 2] sO) «0 | | o Leftralidlc annus anna mms e. + (ho OD 2 [0 3) «OJ f. Left femoral ............. ho 0 20 » OJ «0 g. Left dorsalis pedis ......... 9 | (hw) 1 OJ 20) sO) 7 h. Other — Describe . . . ........ h. | vy 2] 3] a] | | | | | | | | 83 > I. KNEES | | 1 [] Findings — Continue with 1 2 [] No findings — Skip to J Sample Number N© 98743 | | | 1. Bony irregularity R L Both | a. Genu varum .. LL... la. | @) ro 2] 3] b. Genu valgum ............... b. | (2) 1 [1] 2 [1] 3) c. Genu recurvatum . ............ c. | (2) 1 [1] 2] 3] d. Fixed flexion . .............. ds) (129) 1 [OJ 2] 3] Oth D ib | 9 e. Other escribe............. e | (29) 1 3 2 [) 3 [J | | 2. Pain on motion Act. Pas Both Tenderness | o. Right medial o.cwmuwmvmmmenes 2a. | 1 [1] 2) 3: (2) ' [O) b. Right lateral «vn wmwwemwens b. | 1) 2) 3 [) 1 [) I c. Right diffuse .............. c | yO 2) 1) G3) +O d. Leftmedial ............... d. | (32) 1 Od 2 Od 3 O (@®) 1 IE e. Leftlateral ............... e. | yO) 2) 3) (39) 1 [() f. Left diffuse ............... foo i 2 [] 3] (3) v [] g. Right suprapatellar .......... GH] wm mariin wig 418 408 iF Fis 3p eli #in oem dam ®) Vv [O) h. Left suprapatellar h | 1 . Left suprapatellar . . ......... *1 WN ER ELE RE Ee Ee EE Ae EEE ee (139) 1 J i. Right infrapatellar........... Is rion Wachee as Whe 44 ams Bs Wie 4% ene side ensn tenn sermon bed ve i (140) 1) i. Left infrapatellar. ........... el ee trea 1 J " @) 3. Other findings | R L Both ! a AuSWEHIING vn nnnmmmmmom mmo we 3a. (@) 1) 2] 3 [CO Be PIN oom cmmmammensnmnn be! 1 [0 2 [J 1 [J c. Soft tissue proliferation ....... c. | (49) 1.7 2] 3 [J d. Subpatellar crepitus. ......... d.! $y 2 [1] 3d] e. Muscular wasting thigh . ....... e.| 1 [0] 2] 3 (] f. Other — Describe ........... f. | 1 [] 2] 3] | | > J. HIPS | 1 [[] Findings — Continue with 1 2 [] No findings — Skip to K | ) ACTIVE PASSIVE 1. Pain on motion | R L Both R L Both | bs oS 0. EXEENSiOn «oot la. C1 200 30 0 20 0) b. Flexion... .. cov v viii... b. | ®) i 2] [1] (52) [J 200 (J c. Abduction ................ ei @) 101 20 a0) [Od 0 sO d. Adduction . .... LL... d! (59 +) 201 3] 1d 2:0 +03 € EX MOt teeta ei (5) (1 2 a) [OJ 200 J | i. ~ font. rot oe fo (sp) 10) 2] 3[] [J 2000 (OJ | 1 | | I S8 PJ. HIPS _ Continued 1. Other findings : R L Both a. Muscle wasting (gluteal) . .. ovine nee. la. | 1 2] 3] b. Trochanter tenderness. «wo «vv vv vv vee eve eee eens b. | OJ 2] 3] C.Groin1enderness «vs: ss cv sev REP EBR FEB ELE 8 oy dhe c. J 2] 3] d. Other — Describe ___ | vO) 2] 3 pr JOINTS ! 1 [] No findings — Skip to L 2 [] Findings — Describe and continue with 1 MANIFESTATIONS Other : joints Tender Swelling Deformity Limitation Heberden's Pain on motion Other “(JR 3[ JB R B 1 [JR B VCR BI : 1 [CIR 8 R B 1. Shoulder 00 (ep LR +0 CONSE @9 00 CHS @) Or 0 R B 1 [ 2 Ew @ R08 Gy CIR 20 [9 LR +008 | (9 JR > L° (29, JR »00R | @) LR +00e B 1 1 1 1 3. Wrist Se BLL (eg; Lr 200° Qu): LI sL1 Ge): L° Le (wy, Jf =e RIGHT LEFT RIGHT LEFT RIGHT LEFT RIGHT LEFT RIGHT LEFT RIGHT LEFT - 188 tress |@|®, 0 @®\®® ®@ @.®, 8 |® (No. involved) 2[] 2] 2] 2] 2] 2] 2] 2] 2] 2] 2] 2] 3] 3] 3] 3] 3] 3] 3] 3] 3] 3] +] 3(] a] a] a] a] a] a] a] a] a] a] a] a] s(] s(] s[] s(] 5s] s(] s(C]| ss] s[] s[] s[] s(] (199) @9) @9 | @) ooimn. || @ | © ® @® |@ @ |@ & @®@ @ @ inter- 2[] 2] 2] 2) 2] 2) 2) 2] 2) 2) 2] 2] phalangeal 3} 3] 3] 30) 3] 3) 3) 3) 3) 3] 3] 3) (No. involved) a] a] a] a] a] a] a] a] a] a] a a] s|] s[] s[) s[] s[] ss] ss] ss] s(] ss] s[] s[] @ |@ |[@ |@ |\@ @ 6. Distalinter- J 10] 1] J 1 +] 1) 1] OJ OJ 1] 1 phalangeal 2] 2] 21] 2] 2(] 20] 2) 20] 2] 2] 2] 2] (No. involved) 3) 3] sl] 3] 3] 3] 3] 3] 3] 3] s[) 3] a] a] a] a] a] a] a] a] a] a] a] a] s[] s(] s[] s[] s() s[] s(] s(] s[] s[) s(] s[] Ra JR R B 8B : 1 R rae [@ HC @) Lr Cel @ LR @, Ln +1 @, Hoe |@, He BL B JR B R B 1 8. Feet HD @) He Of @, U0 | @ re 0e @) LF LP | @), re 86 > L. BACK 1 [] No findings — Skip to M 2 [] Findings — Continue with 1 | | | | 1. Scoliosis vvvunennnn LL @9) 2. KyphoSis ,ssuwonwnms 2 | y IC} | 3. Lordosis , wessman nna 3. @) 1 [1] 4. Tenderness J a. Sciatic notch ....... 4a. | [IR 2[JL 2 [] Both b. Sacroiliac .ovsvsess b. | + (JR 2 3 [] Both . Other — Describe 1) : | | | 5. Limitation of motion | a. Cervical spine ...... Sa. | 1 b. Thoracic spine... ... b.! 1] c. Lumbar spine flexion .. c.| @D) v[] d. Lumbar spi ight | . Lumbar spine, rig | lateral flexion... .. DD) [1 e. Lumbar spine, left lateral flexion .... . @ 1 [1] f. Full extension ...... f. ; 1 [0] 6. Pain on motion . . ...... 6. | @a) 1 [] Negative 2 [] Positive Cervical Thoracic Low back Diffuse Uncertain 7. Flexion ............ 7. (2%) io ! @®) @) 0 2%) + UJ @) @2) 8. Extension ........... 8. @5) 1 [0 (254) vO] @s3) 1 [0] 59) 1 Oo @ 0 9. Right lateral bending ... 9. | (258) rv [] (259) [1] (260) ! J (261) 1 [] (28d) = 10. Left lateral bending 10. | (263) vO (269) ' 13 (266) * J (267) Wil | — 11. Right rotation. . ....... 1. (28) J [I] @)" 3 DD} J (272) 1] 12. Left rotation ......... 12. @)' OC @) OC @y' @9' UO @)' OJ M. STRAIGHT-LEG-RAISING TEST | 1. Righeleg. vovsnsnunns 1. 1 [[]Neg. 2[] Pos. 2. Lefrleg suvannsnnnny 2. | 1["]Neg. 2[ ) Pos. | 3. Increase — | a. On ankle (right leg) . . . 3a. | 1[C]Yes 2[]No | _— b. Dorsiflexion (Left leg) ; (28) 1 [Yes 2] No Jd N. OTHER SYSTEMS (Reticulo endcthelial, G.I., etc.) @82) [] No findings — Skip to O 2 [] Findings — Describe — Sample Number N? 98743 po BLOOD PRESSURE : TIME sysToLIC DIASTOLIC | YT. Recumbent. « » sos mens eww 1. 1 [AM ps i sae —— 2.SIttNE vee 2. TTT TPM oo 28) _ _ P. SUMMARY OF DIAGNOSTIC | 1 [_] Normal; no abnormal findings IMPRESSIONS 2 [] Abnormal; significant findings noted below | Severity Certainty ICD code 1. Cardiovascular : Min. Mod. Sev. (0-9) | oe @®.O 0 sO @— @- b nl ®0 0 a0 @) — @_— — — | | c. . @ 0 =] 73 @) — @9) — — — | | 2. Musculoskeletal | o wi ®.0 0 0 Go) — Go) — — — | | : LL @0 0 0 @— @——- — c L@o 0 0 @—- @- | | 3. Respiratory | “sl @0 .0 0 @®— @-- - | : Wl @®0 0 0 @- @--- | | “€ eo 2] 3d 3D) B10) = == | 4. Other systems — Specify | oo 4 @E 2 sl i) — @)—— — . bo @ 0 a ar @_ @__— | LT L@ 0 0 T @— @--- 5. | Wl @ 0 @— @--- | b Lo @ 0 a0 sO @— @)——— | | Or ————— | @ 0) 2[]] 3) @) — BD == Name of physician Sample Number N? 98743 87 88 L. Audiometry (Air) 241 HRA-12-10 Form Approved FORMERLY HSM-425-10 O.M.B. No. 68-R1184 (7-74) DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE I REE ASSURANCE OF CONFIDENTIALITY IC HEALTH SERVI f HEALTH RESOURCES ADMINISTRATION All information which would permit NATIONAL CENTER FOR HEALTH STATISTICS identification of the individual will be held strictly confidential, will be used only by persons engaged in and AUDIOMETRY (AIR) for the purposes of the survey, and will not be disclosed or released HEALTH EXAMINATION SURVEY to others for any other purposes (22 FR 1687). a. Deck No. b. Audio No. . Examiner No. @) START HERE IF SAMPLE NUMBER EVEN 1. AIR CONDUCTION - RIGHT EAR START HERE IF SAMPLE NUMBER ODD 2. AIR CONDUCTION - LEFT EAR nto ogo] pron | mtn [se] sone (a) (b) (©) (a) (b) (c) 1000 1000 |@ ® 3. CONDITION AFFECTING TEST RESULTS Mark (X) only one 1] None 2 [ | Cold or sinusitis now 3 ( | Ear discharge 4 | | Ringing or other noises in ears s [| Equipment defect ** 6 [ | Cold or sinusitis within one week 7 [|] Earache within week 8 [| Other — Descriic ** * Retest poorer ear with A/C masking on better ear only if differences in A/C-HL between the two ears is 40 dB or more ** Specify frequencies affected and describe 2 F _ Comments SAMPLE NUMBER NO 98743 M. Respiratory Function Tests 7-74 HRA-12-9 (Formerly HSM-425-9) DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HEALTH RESOURCES ADMINISTRATION NATIONAL CENTER FOR HEALTH STATISTICS HEALTH EXAMINATION SURVEY RESPIRATORY FUNCTION TESTS Form Approved 0.M.B. No. 68-R| 184 ASSURANCE OF CONFIDENTIALITY All information which would permit identification of the individual will be held strictly confidential, will be used only by persons engaged in and for the purposes of the survey, and will not be disclosed or released to others for any other purposes (22 FR 1687). Deck No. Room temperature 251 — oC A. SPIROMETER ! 1. Was test satisfactory? ............... = 1] Yes 2 [J No- Explain — | | | | | | : p> B. SINGLE BREATH DIFFUSING CAPACITY : | l.Inspired Cove vv vv vv vee eens . | 100% | 2. Small spirometer temperature . . . ....... 2. | ian vay OC | 3a. Uncorrected barometric pressure . . ..... 3a. P00) — — —. — mm. Hg. b. Barometer temperature . . ........... b. _ _oC | ! TRIAL #1 TRIAL #2 TRIAL #3 4. Inspired helium. . o.oo... 4 0 ©) — — — |) — — —[@)— —. — — 5. Expired helium percent. . . ........... 5. | i Br i? a P | @9 6. Expired Co meter reading . . .......... 6. | |: i © — a ©@7) ay i 7. Breath holding time *cm . . ........... 7. | 55 one 013) et co rps ~~ si 1s FE 8. Volume inspired V.C. (ATPS) ml ....... 8. | — a — 019) -— 019) ee 9. Was test satisfactory? .............. 9. | 1 [7] Yes 2 [[) No — Explain — | | * From tracing — %: inspiration point measured to onset of expiration ! NOTES Sample Number N? 98743 N. Physician's Supplement HRA-12-24 (7/74) PUBLIC HEALTH SERVICE HEALTH RESOURCES ADMINISTRATION NATIONAL CENTER FOR HEALTH STATISTICS PHYSICIAN'S SUPPLEMENT HEALTH EXAMINATION SURVEY DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Form Approved O.M.B. No. 68-R|184 ASSURANCE OF CONFIDENTIALITY All information which would permit identification of the individual will be held strictly confidential, will be used only by persons engaged in and for the purposes of the survey, and will not be disclosed or released to others for any other purposes (22 FR 1687). Deck No. 082 1. Ocular fundi | Right Left Both a. Normal la. | 1] 2] 3] 3 oes marked, I | ¥ ’ | If box(es) I, 2, or 3 b. Fundus not visualized b. | 1] 2) 3] hoki Yate By | c. Globe absent c | 10 2] a[ > So Tarked, | | d. Increased light reflex d. 1] 2) 3] | e. Narrow arterioles e. | 1) 2] 3) f. Tortuous arterioles f. | 1 2] 3a] I . AY i . g. AY compression 9 | 1 2) 3] h. Hemorrhage he | 1 2] a] | i. Exudate TO 1] 2) 3] | ij. Yenous engorgement i | 1 2] 3] k. Papilled co C apilledema k am 1] 2] 3] I. Di b | 3 isc abnorma aD) 1] 2] 3] m. Lens opacities mo @D) 1] 2] 3) | . Iriti . | n. lritis n | 9 1) 2] 3) o. Other — Speci ” 1 r fry oe 10) 107 2] 33 2a. Did a doctor ever tell you that you had 2a. | protein, albumin, blood or sugar in | 1] Yes - Ask b your urine? : 2[ J No — SKIP to 3 L b. Which? b. | ! Yes No Protein suv vrmsvic st isdamansds aD) 1] 2] | Album, wu vrs ars ress sma B ARES 1) 2) | Blood ....................... 1 2) | SUGOr «isin tera FR 1] 2] 3. During the past 6 months have you had 3. | Y SAMPLE NUMBER parasites or worms in your stools? | @ 1] Yes J 2] No 0 9 [] Don’t know N¢ 98743 90 4a. Do you have trouble with your bowels 4a. (22) 1 [] Yes — constipated which makes you constipated or gives 4 . you diarrhea? | 2[] Yes — diarrhea | ! 3] No b. How often do you usually have a b | (2) 1 [] Once a week or less often bowel movement? } 2[] 2-3 times a week ! 3] 4-6 times a week | 4] Once a day | s [] 2-3 times a day 6] 4 or more times a day c. Have your movements ever been white, cn | (29) 1[]Yes — Ask d gray, dark black, or streaked with blood? J | 2[] No = SKIP to 5a 1p d. Which? d. Yes No White inc vimanmm momma bhssio : (29) 1 20) Gray wuswmuws MEME NTE RE CE ; 1 2] I Dark black «vv vvvevnennenenn.. 1G) OJ 2] I Streaked with blood ............. 10 2] 5a. Has a doctor ever told you that you had 5a. | 2) 1[] Yes — Ask b loss of blood from the stomach or bowels? 2[] No — SKIP to 6a I b. Do you still have it? b. | 1] Yes | 2[J No 9 [] Don’t know | | c. How many years ago did you first have it? c | @ __ —Years ago 6a. Have you ever had an abdominal operation? 6a. 32 1] Yes — Ask b 2[JNo =SKIP to 7 b. Was it for. . b. | You No Tumor of the stomach, bowel, or colon? (3 1] 2] I Tumor or cyst of the womb or ovaries? 1 2] 7. Do you have episodes (or ‘‘spells’’) of pain 7. 1 or discomfort in your shaman 1 stomach of ! at least 3 days per month? (Don't count | ones that go with a cold, sore throat, flu, 39 1] Yes or (for women) menstrual periods.) 2] No 8. Do you have episodes (or “'spells'’) of 8. 3 SAMPLE NUMBER vomiting of at least 3 days per month? | (Don't count ones that go with colds, 1] Yes sore throats, flu, or (for women) | N° 98 74 3 menstrual periods.) : 2[J No . I 9a. During the past year, have you had at least 9a. | 3») 1[] Yes — Ask b one drink of beer, wine, or liquor? 2[] No — SKIP to Check Item I f b. How often do you drink? b. | 1[ 7] Every day 2] Just about every day 3[_] About 2 or 3 times a week a[_] About |—4 times a month s[ | More than 3 but less than 12 | times a year 6 ] No more than 2 or 3 times a year — : SKIP to Check Item c. Which do you most frequently drink -— a | 1] Beer beer, wine, or liquor? ! 2] Wine 3] Liquor [ d. When you drink (beer/wine/liquor), how much A do you usually drink over 24 hours? (Enter — —Glasses of beer an amount only for the one marked in 9c.) | Glasses of wine - | __ ___Drinks of liquor | 1[] Female — Ask 10a CHECK ITEM | 2) Male — END OF QUESTIONNAIRE 10a. How old were you when your periods or 10a. | menstrual cycles started? — Years — Ask b | 02 [ |] Haven't started yet — END OF QUESTIONNAIRE | b. Have they entirely stopped? b. | 1] Yes — Ask ¢ 2[ J No = SKIP to Ila L | c. At what age? \ c. | — Years T 11a. Have you taken birth control pills during 1a. 1] Yes — Ask b the past 6 months? ! 2] No = SKIP to I2a I. b. Are you taking them now? b. | 1] Yes | 2] No I [ 12a. Are you or have you ever been pregnant? 12a. 1] Yes — Ask b 2[ J No — END OF QUESTIONNAIRE b. What is the total number of pregnancies b you have had? ; — — Number c. What is the total number of miscarriages ee | you have had? — —— Number d. What is the total number of live births d. | you have had? __ Number i e. Are you pregnant now? eo | (1s) 1] Yes — Ask f : 2( | No 9 | | Don’t know I a — go — i | SAMPLE NUMBER ! 10 ! ] f. Which month of pregnancy are you in? f. (152) Month N ‘ 98743 92 0. Report of Physical Findings Confidentiality has been assured examinees as set forth in 22 F.R. 1687 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Dear Doctor: PUBLIC HEALTH SERVICE ROCKVILLE, MD. NATIONAL CENTER FOR HEALTH STATISTICS 208852 HEALTH EXAMINATION SURVEY REPORT OF PHYSICAL FINDINGS Recently the person named below was a sample person who voluntarily participated as an examinee in the Health Examination Survey conducted at special facilities of the U.S. Public Health Service. The objectives of the Survey are to obtain information on the health status of the U.S. population. The examination is not, and was not intended to be, a substitute for a visit to the examinee’s physician, nor was it intended to be a complete examination. At the request of the examinee, however, we do send a report of certain selected procedures to his/her physician. Reported below are physical findings which our physicians thought were significant and should be brought to your attention (i.e., for which no treatment had been sought and/or no history given). Also reported are some test reports and/or laboratory data. Although we are not engaged in follow-up or treatment of our findings, we appreciate the cooperation of our examinees and hope that we can contribute to their medical care by making this information available to you. In addition to items listed below a separate letter will be sent reporting any significant conditions found on knee and hip X-rays if any are present. Sincerely, Oronetd EL Arnold Engel, M.D. Medical Advisor Date of Age Height | Chest X-ray | EKG Examinee’s examination name and g oe [CJ Encl. [CJ Encl. ei address x 8 [C] Not done | [_] Not done MEDICAL VISUAL ACUITY BLOOD PRESSURE [C] No new significant findings R Eye L Eye Systolic Diastolic 20 / — WM foe [I Without glasses AUDIOGRAM — Decibels [] With glasses CPS 500 1000 2000 4000 [] With contacts Right [] Not tested Left URINE Ne TR Hematocrit vol % : § i 2 3 4 ) Albumin Hemoglobin em % Sagar RBC count mill/ce Ph (JS [16 [J7 [18 [9 SAMPLE NUMBER 7 WBC count thou/cc Blood [[] Pos [J Neg NO 98743 J SEE REVERSE SIDE FOR NOTES ON TESTS AND PROCEDURES 93 94 NOTES ON TESTS AND PROCEDURES Medical Examination — The physician’s examination included the head and neck, chest (cardiopulmonary), abdomen, and extremities (musculoskeletal and neurological) — however, rectal, pelvic, and breast examinations were excluded. - A 12 lead EKG and A—P plus Lateral Chest X-rays were taken unless contraindicated. Knee and hip plus low back A—P X-rays were taken except on females age 49 or less. Copies enclosed are without interpretation — HES interpretations will be made later and used only as survey data. X-Rays and EKG Hematology — Screening limits * Micro- Cyanmet- Coulter Coulter Determination hematocrit hemoglobin counter counter Vol. % Hgb Gm % RBC/cc WBC/cc Adult Males 41 - 52 14.0 - 16.5 4.6 — 6.2 mill. 4.3 — 10 thou. Adult Females 36 — 48 12.0 — 14.5 4.2 = 5.4 mill. 4.3 — 10 thou. Pregnant Females 33-42 10.5 — 14.0 3.7 — 4.9 mill. 5.0 = 12 thou. Urinalysis - Dip and read method using Ames Multistix. Audiometry — Air conduction readings are reported in decibels with respect to audiometric zero (ISO — 1964), which is considered normal. ROUGH GUIDELINES FOR dB REPORT AT 500 — 2000 cps. 25 dB or less - Hearing normal or more acute 30 - 40 dB - Near normal (difficulty with faint speech) 45 - 55 dB - Mild (difficulty with normal speech) 60 — 70 dB — Moderate (difficulty with loud speech) 75 - 100 dB ~ Severe (hears only amplified speech) 105 or more — Profound (usually cannot understand amplified speech) Clinical Chemistry ~ Laboratory tests on blood are performed by a central laboratory. Results shown below, if any, are those received from the laboratory prior to the time this report was mailed. Additional results, if any, will be forwarded to you promptly when received. BLOOD Test Result Screening limits * Test Result Screening limits * Folate (s) mug’ 5 — 30 mug% Ty 3.0-7.5mcg% Murphy—Pattee Test Vitamin C (P) mg% 0.2-4.0mg% (if indicated) 5.0 — 14.5 mcg% Cholesterol mg % 260 or less Total bilirubin (S) mg % 0.2-10mg% BUN mg % 30 mg% or less SGOT (S) units 10 — 40 units Creatinine mg % 1.50 mg % or less Alk. phos. (S) 1.0. 30 — 80 1.U. (SMA) Sodium mEg/1 135 — 155 Uric acid (S) mg % 2.5-7.0mg% Potassium mEg/1 3.5-5.0 Calcium (S) mg % 9.0 — 11.0 mg% T3 Euthy. 0.88 — 1.10 Phosphrous (SorP) mg% | 2.5-4.8mg% Hypo. Over — 1.10 Hyper. Less — 0.88 (P) = Plasma (S) = Serum * Results outside the screening limits are considered to warrant further investigation of the examinee. S6 22 ASSURANCE OF CONFIDENTIALITY — All information which would permit identification of the individual will be held strictly confidential, will only be used only by persons engaged in and for the purposes of the DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE survey, and will not be disclosed or released to others for any other purposes (22 FR 1687). PUBLIC HEALTH SERVICE a. Deck No. b. Name (Last, first, middle) HEALTH RESOURCES ADMINISTRATION 163 NATIONAL CENTER FOR HEALTH STATISTICS c. Age d. Sex e. Sample No. _ i (_JMale 2[] Female VISION TEST f. Examiner No. (Distance) g. Name of Examiner (Distance) HEALTH EXAMINATION SURVEY Ne (ie h. Examiner No. (Near) i. Name of Examiner (Near) A. DISTANCE VISION 1. With or without correction 1 [ ] Wears glasses for test 3 [ ] Forgot (glasses, contact lenses) Mark (X) one 2 [ ] Wears contact lenses for test a [_] Does not wear either glasses or contact lenses 2. INSTRUCTION — Draw a diagonal line through each letter missed. Draw a horizontal line through sections of line not attempted and through top full line not attempted. a. With correction b. Without correction c. With usual correction Both eyes Both eyes (1) Left eye — (Odd numbers first) (2) Right eye — (Even numbers first) Number Score : x Number Score Number Score F Number Score of Mark (X) of Mark (X) of Mark (X) oof Mark (X) Chart Line | ors | ‘only one Chart Line | Tors | ‘only one Chart Line | tors only he Chart Line | tors only oe allowed box 2 | allowed box ~ |allowed box ~~ |allowed box (a) (b) (c) (d) (a) (b) (c) (d) (a) (b) (<) (d) (a) (b) c) 2 (d) Big L BigL |. ; Big L Big L i ¥ K 40 | © oo jIK 400 0 oo jIK 400 0 oo | IK 400 0 oo] K 200 0 or” IK 200 0 or IK 200 1] or KK: 200 0 or] ov 160 0 02’ ||pv 160 0 o2| |jpv 160 0 02 j|oVv 160 0 02] zs 125 0 03” 'lzs | 125 0 oz J|zs -125 0 o3[] 128 125 0 03) ORN |—kH| 100 2 os JORN ikH| 100 | 2 oa |ORN ~~ Lkw| 100 2 oa ||ORN |-KH| 100 2 0a] Dv 80 0 os lov 80 0 os. ||pv 80 0 os] |pv 80 0 os] HVC 2) 1 os _}|HVC 60 | 06 || HVC 60 1 0s [| | HVC 60 1 o6 [| ZHVD 50 1 07. lj zHvD 50 1 07" 1| zZHVD 50 1 07] | zHvD 50 1 07] OCVR 40 I os | |JOCVR 40 1 os’ 1|OCVR 40 1 os | | OCVR 40 i os [ | HOCRDS 30 2 03 ||HOCRDS 30 2 0s || HOCRDS 30 2 09 |] | HOCRDS 30 2 os [] KDVRZCOS | 25 2 10 |kDVRZCOS | 25 2 10. | KDVRZCOS 25 2 10] | KDVRZCOS 25 2 10] VRNHZDCSKO 20 3 11 | JJ VRNHZDCSKO | 20 3 11 | VRNHZDCSKO 20 3 11 7] | VRNHZDCSKO 20 3 un) ZSVDKHNORC { 16 3 12[7)| zsvokrnore | 16 3 12 ]| ZSVDKHNORC | 16 3 12] | zsvokHNORC | 16 3 127] 3. Test results: 1 [] Test not done — Specify Mark (X) one 2 [] Test unsatisfactory — Specify 158] UOISIA “d 1. With or without correction: 1 [| Wears glasses for test 2 | Wears contact lenses for test B. NEAR VISION 3| | Forgot (glasses, contact lenses) a | Does not wear either glasses cr contact lenses 2. Test using Sloan reading cards (both eyes) — Put horizontal line through words read correctly. Smaliest selection Selection Attempted Distance (cm) read satisfactorily Number wrong Mark (X) one (a) (b) (c) (d) (e) 500 VY + [C 109 _ 350 10) 1 a (2 10) wy 250 09 Ms) ne) 1] a) r= 200 @ Gy _ (2) +7 (oy 150 @ (2 107] B&B) 125 126) 2 1] 9) 100 130) Gy (32 +0] mm 75 OR CH (39) ww 0 | @ ® | @ wo b 3. Test using Keeney reading cards (both eyes) — Put horizontal line through words read correctly. Smallest selection Selection Attempted Distance (cm) read satisfactorily Number wrong Mark (X) one (a) ’ thy (c) (d) (e) a em | ® ® 120 (146) wy) (48) (49) wv ei 85 150) 1 sy 152) sy) o | @® ® @ —— 50 (158 i 6) © | @ ® | @ © 30 v! I 4 wt 20 170) an (79) 79) 2 4. Conditions interfering with test: 1 [|] Cannot read English ( ~] Cannot read sw ' Difficulty speaking Other — Specify C. NEAR VISION (FOR NON-ENGLISH OR ILLITERATES) h or without correction: (9 1 [] Wears glasses for test 2 [] Wears contact lenses for test 3 [| Forgot (glasses, contact lenses) 4 [] Does not wear either glasses or contact lenses b 2. Test using Sloan letters (both eyes) Sloan letters Selarion | Bisanc lon) |, Sys sme) In Samba Sm byiastion | Gives | ekg one (2) (b) (c) (d) (e) 500 (a IT IS VY HT IN TE SN TY 4 a) 1] 350 G9) _ _ _ CR TE TP WH CR CS AD BN 4 10) 250 (8) __ _ _| HE YU MD TE LR YU WE TO 1 J 200 (8) _ _ __ OE IN LG WE AS GT TT HE 4 10 150 (8) — _ __ TE WR BU FS CR TS FR TT 4 10 125 (86) — _ __ TE FS AE ED TO CE FM TE 4 10 100 188) OE DY MY NR AD ME IF HD 4 10) 75 7. VS TO FA CS GE AE ON AD 4 10 50 oi vi BW TS AE OF TO KS TE TT 4 [J 3. Test using Keeney letters (both eyes) Keeney letters Errors | Score Seton | Bisa) | i thy lost, Soni fe, | sitowes | Work 0 ons (2) (b) (0) (d) (e) 130 98) WN IN TE CE GF HN ES IT 4 1] 120 (96) _ _ __ OE PE TO DE TE PL BS WH 4 [0] 85 9) WH AR AD TO AE AG TE PS ‘4 1 [O) 60 200 __ __ __ WH TE LS OF NE AD OF NS 4 10 50 @)__ _ _ CS WH IL TM TO TE SN WE 4 10 40 200) RS TT AG TE AE LE LY AD 4 1) 30 09 _ TT WR AY FO OF GT BS DE 4 @) 1 [0] 20 08) _ __ __ ET TR SY AD HS PE ID WL 4 10 97 NAME 130 120 98 85 60 50 40 30 20 SAMPLE NUMBER NEAR VISION TEST CARD WHEN IN THE COURSE OF HUMAN EVENTS, IT BECOMES NECESSARY FOR ONE PEOPLE TO DISSOLVE THE POLITICAL BANDS WHICH HAVE CONNECTED THEM WITH ANOTHER, AND TO ASSUME AMONG THE POWERS OF THE EARTH, THE SEPARATE AND EQUAL STATION TO WHICH THE LAWS OF NATURE AND OF NATURE'S GOD ENTITLE THEM, A DECENT RESPECT TO THE OPINIONS OF MANKIND REQUIRES THAT THEY SHOULD DECLARE THE CAUSES WHICH IMPEL THEM TO THE SEPARATION. WE HOLD THESE TRUTHS TO BE SELF-EVIDENT, THAT ALL MEN ARE CREATED EQUAL, THAT THEY ARE ENDOWED BY THEIR CREATOR WITH CERTAIN UNALIENABLE RIGHTS, THAT AMONG THESE ARE LIFE, LIBERTY, AND THE PURSUIT OF HAPPINESS. THAT TO SECURE THESE RIGHTS, GOVERNMENTS ARE INSTITUTED AMONG MEN, DERIVING THEIR JUST POWERS FROM THE CONSENT OF THE GOVERNED THAT, WHENEVER ANY FORM OF GOVERNMENT BECOMES DESTRUCTIVE OF THESE ENDS, IT IS THE RIGHT OF THE PEOPLE TO ALTER OR TO ABOLISH IT, AND TO INSTITUTE NEW GOVERNMENT, LAYING ITS FOUNDATION ON SUCH PRINCIPLES AND ORGANIZING ITS POWERS IN SUCH FORM, AS TO THEM SHALL SEEM MOST LIKELY TO EFFECT THEIR SAFETY AND HAPPINESS. PRUDENCE INDEED, WILL DICTATE THAT GOVERNMENTS LONG ESTABLISHED SHOULD NOT BE CHANGED FOR LIGHT AND TRANSIENT CAUSES, AND ACCORDINGLY ALL EXPERIENCE HATH SHOWN, THAT MANKIND ARE MORE DISPOSED TO SUFFER, WHILE EVILS ARE SUFFERABLE, THAN TO RIGHT THEMSELVES BY ABOLISHING THE FORMS TO WHICH THEY ARE ACCUSTOMED. BUT WHEN A LONG TRAIN OF ABUSES AND USURPATIONS JAME >00 350 250 200 150 125 100 SAMPLE NUMBER ————————— SLOAN NEAR VISION TEST CARD IT IS VERY HOT IN THE SUN TODAY COVER THE TOP WITH CRACKER CRUMBS AND BROWN IN A HOT OVEN. HAVE YOU MAILED THE LETTER YOU WROTE TO YOUR NEPHEW? HE WILL EXPECT TO HEAR FROM YOU TOMORROW. ONCE IN A LONG WHILE, AS A GREAT TREAT, HE TOOK ME DOWN TO HIS OFFICE. THIS COULD HAPPEN ONLY ON A SATURDAY MORNING WHEN THERE WAS NO SCHOOL. THE WEATHER BUREAU FORECASTS COLDER TEMPERATURES FOR TONIGHT AND TOMORROW, WITH A WARMING TREND SETTING IN BY THURSDAY. LOW TEMPERATURES TONIGHT WILL BE IN THE LOW 30'S IN THIS AREA. TOMORROW'S HIGH WILL HIT ABOUT 37 DEGREES. THE FUNDS ARE EXPECTED TO COME FROM THE SALE OF A TRACT OF LAND IN HERRING PARK. tHE MONEY WILL NOT BECOM: AVAILABLE UNTIL THE FIRST OF NEXT YEAR BUT OFFICIALS STATE THAT THEY CAN BEGIN ON SOME PARTS OF THE PROJECT AT ONCE. ONE DAY MY NEIGHBOR ASKED ME IF I HAD MET THE WIDOW WHO HAD JUST MOVED INTO THE NEXT BLGCK. THAT NIGHT IT HOBBLED DOWN THE STREET AND KNOCKED UPON HER DOOR. 1 EXPECIED TO FIND SOME SWEET, ALTHOUGH TOTTERING, LADY OF 80, BUT WIAT OPENED THE DOCR WAS THIS BLONDE. I PROPOSED TO HER IMMEDIATELY. SHE HAD A BETTER TELEVISION SET IN HER HOUSE THAN THE ONE 1 HAD IN MY COTTAGE. VISITORS TO A FLORIDA CITRUS GROVE ARE OFTEN AMAZED TO SEE FULLY RIPE ORANGES BEING PICKED FROM A TREE WHICH 1S ALSO FILLED WITH CLUSTERS OF FRAGRANT WHITE ORANGE BLOSSOMS--A GRAPHIC ILLUSTRATION OF THE TIME NATURE REQUIRES TO PRODUCE CITRUS FRUIT. UNLIKE MOST OTHER TYPES OF FRUIT, WHICH USUAT.LY NEED ONLY THREE TO FOUR MONTHS TO COMPLETE THETR CYCLE FROM BLOSSOM TO MATURITY, CITRUS FRUITS REQUIRE TEN TO TWELVE MONTHS--AND THEY HAVE TO BE MONTHS OF SUNSHINE. THAT IS WHY A RELATIVELY SMALL SECTION, KNOWN AS THE "CITRUS BELT," WIICH EXTENDS ACROSS THE WAIST OF FLORIDA--AND WHERE THE SUN SHINES AIMOST EVERY DAY IN THE YEAR--PRODUCES NEARLY TWO-THIRDS OF ALL THE CITRUS FRUIT CONSUMED IN THE U.S. 99 100 BOW TIES ARE OF TWO KINDS, THOSE THAT ARE READY TIED AND THOSE THAT HAVE TO BE TIED. BOW TIES THAT HAVE TO BE TIED ARE PREFERRED, SINCE THE READY TI1ED ARE TOO PERFECT. IMPERFECTIONS IN THE TIE THAT HAS TO BE TIED SHOW THAT IT IS NOT MACHINE-MADE BUT HAND-WROUGHT. WHILE THE TIE THAT HAS T0 BE TIED IS IMPERFECT IT SHOULD NOT BE TOO IMPERFECT. THAT IS TO SAY, ONE SIDE SHOULD NOT BE LONGER THAN THE OTHER SIDE, AND THE TIE SHOULD SIT HORIZONTALLY AND NOT AT AN ANGLE OF 45 DEGREES. TYING A BOW TI! DOLS NOT COME NATURALLY. 10L (7/74 PUBLIC HEALTH SERVICE HEALTH RESOURCES ADMINISTRATION NATIONAL CENTER FOR HEALTH STATISTICS DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE ASSURANCE OF CONFIDENTIALITY All information which would permit identification of rhe individual will be held strictly confidential, will be used only by persons engaged in and for the purposes of this survey, SPEECH TEST and will not be disclosed or released h f ther p HEALTH EXAMINATION SURVEY = 2 Is or any other purposes a. Name (Last, first, middle) b. Deck No. INSTRUCTIONS 242 c. Sample No. d. Segment No. e. Serial No. [f. Column No. Draw a horizontal line through all correct words. If after completing a list six or more words are missed, proceed to next list and increase decibel level by 10 until level 70 is reached. When 70 is reached go to Deck 243 (Blue paper). g. List No. |h. Decibels — Mark (X) cne i. Ear tested (0): 12 3140 s:760 | (103) [Right 01 2. 30 a 150 2] Left j. List No. |k. Decibels — Mark (X) one |. Ear tested @) (@) 17120 340 s 160 1 [|] Right 02 Q9 2130 4150 2 Left (I FP I 1. WALKING'S MY FAVORITE EXERCISE. * Po “HB Z E mT the WATER'S TOO COLD for SWIMMING. ®T TF TF T TT 2. HERE'S a NICE QUIET PLACE to REST. 1. 9 +[' [2 IF F I 5 4 2. WHY SHOULD | GET up SO EARLY? «|! F Lt ED Ss 6 OUR JANITOR SWEEPS the FLOORS EVERY NIGHT. ® w @T F IT TF T 3. SHINE YOUR own SHOES THIS TIME. Fi" FFE OT «I it WOULD be MUCH EASIER IF EVERYONE would HELP. ® = @ 1 7 IT’ T ITTF 4. IT'S RAINING right HERE in the ROOM. * EF Tb Pl = WE say GOOD MORNING and BEGIN to WORK. @T FT IF 5. WHERE ARE you GOING this MORNING? * ML. k E IT TF OPEN the WINDOW BEFORE you GO to BED. @T IT 1 © IT 6. YOU SHOULD COME HERE WHEN i CALL. | 1 : 2 3 4 Ss 6 DO you THINK SHE SHOULD STAY HERE? (29) =|" E 1 4 Is 6 7. DON'T TRY to GET OUT OF IT. > F' FFT TF HOW DO you FEEL about CHANGING? @T TF FT TF 8. WE LET LITTLE CHILDREN GO to the ™OQOVIES. ~ FTF TF Tr WHEN the TIME comes WE will GO. 9 L£ & & 8) (2) |" i £ L EI 9. THERE ISN'T ENOUGH PAINT to FINISH. FF TF TF TT 10. IT'S too LATE to MOVE OUT of the WAY. ® @T TFT TF 10. DO you WANT EGGS for BREAKFAST? I Ba Mark (X) only if this is the 1 Enter number of 1, | «tinal level given. | words missed —» RECORDER: Mark (X) only if this is the 1 1 Enter number v \ [_] «final level given. ! words nitssec — (s18q198p 09-02) 3521 yoeads DO 2ol n. Decibels — Mark (X)} one o. Ear tested 03 ! ] 2 trl s. 60 ®) 1] Right 2 2 Left p. List No. @ oa > @ | CT 1. EVERYBODY should BRUSH TEETH BEFORE MEALS. 1. IF you q. Decibels — Mark (X) one r. Ear tested @) 1 {7120 3740 s 160 a [150 2 2.730 1d IT'S all right. WANT to GO @ If 7 1 ONCE a YEAR EVERYTHING'S al! RIGHT. @-| a Is i 2. THROW THESE OLD TIME MAGAZINES OUT. Tr TTT 3. DON'T USE UP ALL the LETTER PAPER. 1 DO you oT STREAM? er OF WANT to WASH UP in the > TT TT TT ANYTHING like THAT'S ali RIGHT with me. mm rr ry it's a REAL DARK NIGHT SO WATCH your ORIVING. T TZ I a 5 1s OUTSIDE OUGHT to SEE a 1 I 3 a i an LL CARRY YCUR PACKAGE for YOU. . (42) | «< inal lesa! given. . words missed —» = 1 L_| «final level given. words missed —» DOCTOR. v = T ¥ 1 13 f TP? r 6 [ . T1 I 3 F I I 5 a bo | “| ] 6. the WINDOWS are SO DIRTY this MONTH i CAN'T see. 6. DON'T YOU FORGET to SHUT OFF the WATER. 7 ee — . - 5 lz i is a 5 1 2 2 1 3 {a 5 ». 7] | ®- gel jk 7. PLEASE PASS we OREAD and BUTTER FIRST. 7. MOUNTAIN FISHING is my IDEA of a GOOD TIME. iE ! T Ie 1 2 1s a oN y IE ‘ i® i g : © | Pd | | | (53) - : od ht 8. UDKN'T FORGET two WRITE and PAY YOUR BILL. 8. FATHERS USED to SPEND more TIME with their CHILDREN. i y 2 | i IE 1B 1 2 3 Ie Ts §. DON'T LET te DOG OUT of the HOUSE. 9. BE CAREFUL NOT to BREAK the GLASSES. . Y 12 T3 a TY z 3 T a ” @- TF }1 @/ FT 7 Eis 115. THERE'S = GOCL BALLGAME this AFTERNOON. 10. I'M SORRIER THAN you for “the mistake. RECORDER RECORDER: he Mark (X) calv if this is the ! Enter number of Mark (X) only it this is the Enter number of 4 £01 s. List No. [t. Decibels — Mark (X) one uv. Ear tested v. List No. |w. Decibels — Mark (X) one x. Ear tested 17.120 3 140 s[ 160 1 [_] Right 1120 3/740 s[ ]60 (731 [J Right ©) 05 G12 a 750 2 [] Left 06 @ 230 «150 2 [] Left TF EFT FF Br OT 1. YOU CAN CATCH the BUS ACROSS the STREET. 1. MUSIC ALWAYS MAKES me CHEER UP. —T TF EET @ TT IF TTT 2. TELL HER the NEWS on the PHONE. my BROTHER'S in TOWN for a SHORT WHILE. 1 I I | a ’ ®. 1 2 | ’ 4 . [ 2 i 6 3. I'LL CATCH UP "with YOU LATER. WE LIVE a FEW MILES off the MAIN ROAD. 1 2 3 2 5 © 1 2 3 Z I 1 [ @. [|] @. Tr 4. I'LL THINK it OVER AND CALL HER. 4. THIS SUIT NEEDS to GO to the CLEANERS. 1 2 3 5 4 4S 2 3 a 5 5. | DON'T WANT to GO to the MOVIES. . THEY ATE ENOUGH GREEN APPLES. 1 2 3 Ja 5 © 2 3 Tz 5 © ®@.] |] | 5 ] 6. SEE a DENTIST IF YOUR TOOTH HURTS. 6. have YOU BEEN SICK ALL THIS WEEK? Ti I I’ [ ] = T ®.[ 2 3 5 7. PUT THAT COOKIE BACK in the BOX. WHERE HAVE YOU been WORKING LATELY? i | I? {® a @). 2 3 a “¥ i | ] 2 8 you OUGHT to STOP FOOLING AROUND so MUCH. 8. there’s NOT ENOUGH TABLE ROOM in the KITCHEN? @ [| [| 7 9. TONIGHT THAT extra a TIME'S UP. 3 a it's HARD to see WHERE HE IS. @ [T'FT T 10. HOW do you a SPELL YOUR NAME? - I’ ’ b ’ 10. LOOK OUT FOR NEW BUSINESS. RECORDER: Mark (X) only if this is the 1 « final level given. Enter number of words missed —» RECORDER: ar Mark (X) only if this is the 1 [_] « tinal level given. Enter number of words missed —» vol y. ist Ne. lz. Decibels — Mark (X) one aa. Ear tested PA —y — £54 i Ose) 11120 3 140 5s 160 @) 1 Right E30 a 150 2] Left @® o7 - bb. List No.| cc. Decibels — Mark (X) one 08 Be E35 dd. Ear tested s [160 1 [1 Right 2] Left @- | Bl I ’ I i 1. i'll. SEE YOU RiGHT AFTER LUNCH. 7 IT — BELIEVE ME it's TOO LATE. * ¥ TTT TT i'll SEE YOU LATER this AFTERNOON. 5 * 1 2 3 [ LET'S GET THAT CUP of COFFEE. T° 2 = a Ss i | 3. WHITE SHOES are AWFUL to ® -@ KEEP CLEAN. * BF ETT LET'S get OUT of HERE BEFCRE long. IT a Fr rr Ir YOU STAND OVER THERE UNTIL | MOVE. * * TF FF HATE DRIVING IF IT'S at NIGHT. x ® -G wn THERE'S a PIECE of CAKE LEFT for DINNER TONIGHT. I Fr LET | i THERE WAS WATER in the CELLAR YESTERDAY. 5 * TF iF TF Fad F TFT IETTRET T DON'T WAIT for ME AT the FRONT CORNER. on * ~ TET BY SHE'LL ONLY be GONE a .9].0.0].0].0]-0 |s [ FEW MINUTES * r'TT Tr Er IT'S NO TROUBLE at ALL to TELL. rr 7 * IN) HOW do YOU KNOW WE'LL HAVE it SCON’ € erred I i 4 1 2 2 3 4 HURRY UP with the MORNING PAPER. 1 2 3 4 x 9-® 8. CHILDREN LIKE CANDY AFTER 5 HEAVY wens. 1 2 3 2 5 * B-0]-@ it DIDN'T SAY ANYTHING about a BIG RAIN. 1 2 3 LE i | @| NO GRASS grows “when we DON'T GET RAIN, 1 2 3 10. that DRUGSTORE PHONE CALL'S for YOU. ® i i * i FIT Bl 10. THEY'RE NOT LISTED in the 4 NEW PHONE BOOK. Enter number of Mark (X) only if this is the words missed —» 1 [_1«final level given. ® RECORDER: 7 I | 1 HRA-12-23A (7/74) RECORDER: oo Mark (X) only if this is the @2) 1 [| «final level given. I ! i I | Enter number ct WOPds MISSeq — » Sol ee. List No. | #f. Decibels — Mark (X) one gg. Ear tested @) 09 ASE 13 s [160 @ 1 [J Right 21 4] { hh. List No. | ii. Decibels — Mark (X) one ji. Ear tested 1 [J Right 120 3] 40 s [60 2 [] Left 10 2130 a []50 oo @ [II FF 1. WHERE CAN | FIND a PLACE to PARK? @- I TT BUT we WON'T be READY to START. 5 6 @ I I T 2. | LIKE THOSE BIG RED APPLES. rr * @ [TIT T 3. YOU'LL get FAT by EATING CANDY. > it SURE TAKES a SHARP KNIFE to CUT MEAT. ell I I FIT 4. the COLOR SHOW'S OVER in the FALL. 3 4 I i HAVEN'T READ a NEWSPAPER SINCE we got TELEVISION. * @ IT I | T 5. WHY DON'T they PAINT THEIR OTHER WALLS? 1 2 3 4 5 * the WEEDS ARE SPOILING THIS YARD. @ TT _T ITT 6. HOW COME you ALWAYS GET to GO FIRST? LL CALL ME a LITTLE LATER for BREAKFAST. @ T IT _T TT 7. WHAT ARE you HIDING UNDER your COAT? 3 5 * ET [ DO you HAVE CHANGE for a FIVE-DOLLAR BILL? @[ [ |] | 8. | SHOULD ALWAYS buy NEW cars. a * “FT HOW ARE the things WE BOUGHT? @-| 9. WHAT'S wrong with SUGAR and CREAM in my COFFEE? .9|-0].0]-0].0].0].0].0]- 2 3 * i'd LIKE SOME ICE cream WITH MY PIE. 1 4 5 @| CP ® ot eo I 3 a s DON'T THINK I'LL HAVE DESSERT. I'LL WAIT JUST ONE MINUTE. RECORDER: Mark (X) only if this is the Enter number of 1 [| 4 final level given. w ords missed —j rrr o] RECORDER: Mark (X) only if this is the 1 [_]« final level given. 901 HRA-12-238 (7 74) DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEAL TH SERVICE HEALTH RESOURCES ADMINISTRATION NATIONAL CENTER FOR HEALTH STATISTICS SPEECH TEST HEALTH EXAMINATION SURVEY ASSURANCE OF CONFIDENTIALITY All information which would permit identification of the individual will be held strictly confidential, will be used only by persons engaged in and for the purposes of the survey, and will not be disclosed or released to others for any other purposes (22 FR 1687). a. Name (Last, first, middie) b. Deck No. 243 INSTRUCTIONS Draw a horizontal line through all correct words. If after completing a c. Sample No. d. Segment No. e. Serial No. |f. Column No. list six or more words are missed, proceed to next list and increase decibel level by 10 until level 80 is reached. After 80 is complete Co a _ _ (END TEST). g. List No. h. Decibels — Mark (X) one i. Ear tested j- List No. k. Decibels — Mark (X) one I. Ear tested 1770 1 Right 1 [170 1 [7] Right 01 2 180 2 [Left 280 2 1 uate @) [i L P I Go) 8 2 {* a _ WALKING'S MY FAVORITE EXERCISE. 1. the WATER'S TOO COLD for SWIMMING. TT z 3 7 1 z T8 Ts 5 - | ot J] PF | Gs) HERE'S a NICE QUIET PLACE to REST. &; WHY SHOULD | GET up SO EARLY? | I | PF TT IF IF @); 7 12 3 T* PF cn JANITOR SWEEPS the FLOORS EVERY NIGHT. 3. SHINE YOUR own SHOES THIS TIME. Gu) i Yr 2 3 4 Ss 8 Ga)" 1 2 z - 3 : GE a 4. it WOULD be MUCH EASIER IF EVERYONE would HELP. 4. IT'S RAINING right HERE in the ROOM. TT FT rT & TF FT 5. WE ¥ GOOD MORNING and BEGIN to WORK. 5. WHERE ARE you GOING this MORNING? @) Go) | P £ ET @ I I T= T= Ti . or be. WINDOW BEFORE you GO to BED. CALL. 6. YOU SHOULD COME HERE WHEN i a 2 3 4 S 6 Le THINK SHE SHOULD STAY HERE? ®, 12 3 4 Ss 6 7 DON'T TRY to GET OUT OF IT. @y — IE | 1: I E DO you FEEL about CHANGING? G29)" | £1 I Is 8. re LET LITTLE CHILDREN GO to the MOVIES. @T 1 rr v.rF G+ |’ SIS Fr 9 WHEN the TIME comes WE will GO. 9. THERE ISN'T ENOUGH PAINT to FINISH. a) | I PE I LE I I 1 I G2)” I i I I? T 1 10. |T'S too LATE to MOVE OUT of the WAY. 10. DO you WANT EGGS for BREAKFAST? RECORDER: ] Enver number of RECORDER: 1 _ «final level given. Mark (X) only if this is the ) ] words missed —p 1 y Enter number of Mark (X) only if this is the " 1 [1 «tinal level given. ! words missed —» (s19q199p 08-0) 3581 Ydeads "YH m. List No. n. Decibels — Mark (X) one o. Ear tested p. List No. q. Decibels — Mark (X) one r. Ear tested 03 170 @) 1 [J Right 04 @D) 170 @D) 1 [] Right 1 1 280 2 [] Left 2[]80 2 [] Left @2+ 5 1. EVERYBODY should BRUSH TEETH BEFORE MEALS. ®@-| 2. ONCE a YEAR EVERYTHING'S all RIGHT. * IF you WANT to GO IT'S all right. TT | THROW THESE OLD TIME MAGAZINES OUT. 3 * 6 4 * @-| 3. DON'T USE UP ALL "LETTER PAPER. DO you WANT to WASH UP in the STREAM? 4 S @-| 4. ANYTHING like THAT'S all RIGHT with me. FT i's a REAL DARK NIGHT SO WATCH your DRIVING. 1 1 2 3 4 : 5 * @ [ [| T 5. THOSE PEOPLE OUTSIDE OUGHT to SEE a DOCTOR. * — DON'T YOU FORGET to SHUT OFF the WATER. 6. the WINDOWS are SO DIRTY this MONTH | CAN'T see. 2 * @. ] | T 7. PLEASE PASS the BREAD and BUTTER FIRST. .®.0.0).0].0.6.0| 6 MOUNTAIN FISHING is @.[ RR 8. DON'T and PAY YOUR BILL. -®.0 1 9. DON'T LET the the HOUSE. BE CAREFUL NOT to BREAK the GLASSES. 1 4 1 2 3 Ga. | 10. THERE'S a GOOD BALLGAME this AFTERNOON. 10. I'M SORRIER THAN you for the mistake. RECORDER: RECORDER: v Mark (X) only if this is the ; Enter number of Mark (X) only if this is the | Enter number of Go) 1 [_] «tinal level given. | words missed —» 1 [J] «tinal level given. , words missed —» I 1 LOL 801 @- | [ IT 2. TELL HER the NEWS on the PHONE. @3) TT 2. my BROTHER'S in TOWN @! F TT [IF 3.1'LL CATCH UP with YOU LATER. 3. WE LIVE a FEW MILES off the MAIN ROAD. I s. List No. t. Decibels — Mark (X) one u. Ear tested v. List No. w. Decibels — Mark (X) one x. Ear tested 1170 1 [] Right 1 [(]70 @) 1 [J Right Gs) 0s B.A @ Lx @) 06 @ 280 2 [J Left 1 2 3 2 Ss 1 2 2 Ss @[ [[ [TI | E @:| | | 1. YOU CAN CATCH the BUS ACROSS the STREET. 1. MUSIC ALWAYS MAKES me CHEER UP. for a SHORT WHILE. 6 @ FF [FT IF 4. I'LL THINK it OVER AND CALL HER. 1 2 3 Ir 4. THIS SUIT NEEDS tw GO 5 to the CLEANERS. @- IF Ir 5.1 DON'T WANT to TTT 5. THEY ATE ENOUGH GREEN APPLES. Ii @ IT TF T 6. SEE a DENTIST IF YOUR TOOTH HURTS. TTT 6. have YOU BEEN SICK ALL THIS WEEK? 3 4 6 ° @ FF F [ T1F 7. PUT THAT COOKIE BACK in the BOX. 1 2 3 * ila 7. WHERE HAVE YOU been $ WORKING LATELY? @ | TFT 7 IF | 8. you OUGHT to STOP FOOLING AROUND so MUCH. 2 8. there's 3 NOT ENOUGH TABLE ROOM in the KITCHEN. — TIF ®l I TT T 9. TONIGHT THAT extra TIME'S UP. TTT] 9. it's HARD to see ; WHERE HE IS. 3 4 2 3 a @ 1 1] 10. HOW do you SPELL YOUR NAME? 10. LOOK OUT FOR NEW BUSINESS. 1 2 3 * 4 5 RECORDER: ; | Mark (X) only if this is the , Enter number of (310) 1 «< final level given. y words missed —» REC ORDER: Mark (X) only if this is the 1 [_] «final level given. Enter number of words missed —» 601 y. List No. z. Decibels — Mark (X) one aa. Ear tested bb. List No. |cc. Decibels — Mark (X) one |dd. Ear tested ' [770 G8) +O Right 1 [170 1 [J Right 07 2180 2 [] Left 08 280 2 [] Left 2 3 0 5 1 2 2 1.i'll SEE YOU RIGHT AFTER LUNCH. 1. BELIEVE ME it's TOO LATE. 1 2 3 1 2 3 4 2.i'll SEE YOU LATER this AFTERNOON. 2. LET'S GET THAT CUP of COFFEE. 1 2 4 5 1 4 3. WHITE SHOES are AWFUL to KEEP CLEAN. 3 . LET'S get OUT of HERE BEFORE long. ® * N w >» I'S wl Q c wv — > = oO o < m x XI m x m CG z S r Ti 2 3 [a eS ® & i HATE DRIVING IF IT'S at NIGHT. a ® 5. THERE'S a PIECE of CAKE LEFT for DINNER TONIGHT. 1 2 3 ® (3, . THERE WAS WATER in the CELLAR YESTERDAY. TT 6. DON'T WAIT ® ds 6 FRONT CORNER. ® on . SHE'LL ONLY be GONE a FEW MINUTES. 1 2 3 ® ™ IT'S NO TROUBLE at ALL to TELL. 3 4 5 6 ® ~N . HOW do YOU KNOW WE'LL HAVE it SOON? ® ® il 1 2 3 4 5 ® CHILDREN LIKE CANDY AFTER HEAVY meals. 9.it DIDN'T SAY ANYTHING about a BIG RAIN. ® | § 3 4 s 9. NO GRASS grows when we DON'T GET RAIN. 1 2 3 4 10. that DRUGSTORE PHONE CALL'S for YOU. 1 2 3 4 5 6 * 10. THEY'RE NOT LISTED in the NEW PHONE BOOK. RECORDER: Mark (X) only if this is the 1 [J<«—tinal level given. Enter number of words missed —> RECORDER: @ Mark (X) only if this Is the Enter number of 1 [J tinal level given. wi ords missed —» oLtL $ 3JI1440 DONILNIMd INIWNHIAOD 'S ‘Nn # 1/L€6-09T RLBIT ee. List No. ff. Decibels — Mark (X) one gg. Ear tested hh. List No. ii. Decibels — Mark (X) one ji- Ear tested @) 1170 @3) 1 [] Right (@D) 170 (a9) 1 [] Right 09 2180 2] Left 10 2[]80 2 [] Left @ 1 2 3 [a 6 1. WHERE CAN | FIND a PLACE tw PARK? 1. BUT we WON'T be READY to START. TZ 3 © T @- 2.1 LIKE THOSE BIG RED APPLES. the CAR. 1 Ta 5 6 3. YOU'LL get FAT by EATING CANDY. 3. it SURE TAKES a SHARP KNIFE to CUT MEAT. 2 3 a i Z 3 3 5 @ ro @: || Lb 4. the COLOR SHOW'S OVER in the FALL. 4. i HAVEN'T READ a NEWSPAPER SINCE we got TELEVISION. ® T TT TT WEEDS ARE SPOILING THIS YARD. @a)+ 5. the * 6. HOW COME yo FT TT ALWAYS GET to 6 GO FIRST? @: FE 6. CALL ME a LITTLE LATER for BREAKFAST. * ~ I I WHAT ARE you oo . 1 SHOULD ALWAYS 1 2 [ a x 9. WHAT'S wrong with SUGAR HIDING UNDER your and CREAM in COAT? T I rT : HAVE CHANGE for a 7. DO you FIVE-DOLLAR BILL? 1 2 the things WE BOUGHT? my COFFEE? TF] ICE cream WITH MY PIE. 9.i'd LIKE SOME * ol © ®] ® © rrr Er 4 5 2 I 10. I'LL WAIT JUST ONE MINUTE. 10. i DON'T THINK I'LL HAVE DESSERT. RECORDER: 0 RECORDER: \ i i I Enter number of if this i I Enter number of Mark (X) only if this is the Mark (X) only if this is the 1 le ie 2 on. 3 words missed —» 1 [| « final level given. ) words missed —» ls ! VITAL AND HEALTH STATISTICS PUBLICATIONS SERIES Formerly Public Health Service Publication No. 1000 Series 1. Programs and Collection Procedures.—Reports which describe the general programs of the National Center for Health Statistics and its offices and divisions, data collection methods used, definitions, and other material necessary for understanding the data. Series 2. Data Evaluation and Methods Research.—Studies of new statistical methodology including experimental tests of new survey methods, studies of vital statistics collection methods, new analytical techniques, objective evaluations of reliability of collected data, contributions to statistical theory. Series 3. Analytical Studies. —Reports presenting analytical or interpretive studies based on vital and health statistics, carrying the analysis further than the expository types of reports in the other series. Series 4. Documents and Committee Reports.—Final reports of major committees concerned with vital and health statistics, and documents such as recommended model vital registration laws and revised birth and death certificates. Series 10. Data from the Health Interview Survey.—Statistics on illness; accidental injuries; disability; use of hospital, medical, dental, and other services; and other health-related topics, based on data collected in a continuing national household interview survey. Series 11. Data from the Health Examination Survey.—Data from direct examination, testing, and measurement of national samples of the civilian, noninstitutionalized population provide the basis for two types of reports: (1) estimates of the medically defined prevalence of specific diseases in the United States and the distributions of the population with respect to physical, physiological, and psychological charac- teristics; and (2) analysis of relationships among the various measurements without reference to an explicit finite universe of persons. Series 12. Data from the Institutionalized Population Surveys.—Discontinued effective 1975. Future reports from these surveys will be in Series 13. Series 13. Data on Health Resources Utilization.—Statistics on the utilization of health manpower and facilities providing long-term care, ambulatory care, hospital care, and family planning services. Series 14. Data on Health Resources: Manpower and Facilities. —Statistics on the numbers, geographic distrib- ution, and characteristics of health resources including physicians, dentists, nurses, other health occu- pations, hospitals, nursing homes, and outpatient facilities. Series 20. Data on Mortality. —Various statistics on mortality other than as included in regular annual or monthly reports. Special analyses by cause of death, age, and other demographic variables; geographic and time series analyses; and statistics on characteristics of deaths not available from the vital records, based on sample surveys of those records. / Series 21. Data on Natality, Marriage, and Divorce.—Various statistics on natality, marriage, and divorce other than as included in regular annual or monthly reports. Special analyses by demographic variables; geographic and time series analyses; studies of fertility; and statistics on characteristics of births not available from the vital records, based on sample surveys of those records. Series 22. Data from the National Mortality and Natality Surveys.—Discontinued effective 1975. Future reports from these sample surveys based on vital records will be included in Series 20 and 21, respectively. Series 23. Data from the National Survey of Family Growth.—Statistics on fertility, family formation and disso- lution, family planning, and related maternal and infant health topics derived from a biennial survey of a nationwide probability sample of ever-married women 15-44 years of age. For a list of titles of reports published in these series, write to: Scientific and Technical Information Branch National Center for Health Statistics Public Health Service Hyattsville, Md. 20782 DHEW Publication No. (PHS) 78-1314 Series 1-No. 14 NCHS U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service National Center for Health Statistics HEW-396 3700 East-West Highway Hyattsville, Maryland 20782 THIRD CLASS POSTAGE AND FEES PAID U.S. DEPARTMENT OF HEW OFFICIAL BUSINESS BLK. RATE PENALTY FOR PRIVATE USE, $300 For publications in the Vital and Health Statistics Series call 301-436-NCHS. U.C. BERKELEY LIBRARIES ARM (021205915